cover newMAY-JUNE
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ISSN 0377-2551
M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3
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ETO™ 2001
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TOMO™ 64
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π. §ÂˆÓ›‰·˜
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ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË
EDITORIAL 197
J.C. Leonidas
ANA™KO¶H™H
∏ ÂͤÏÈÍË Ù˘ ıÂڷ›·˜ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰È· ̤ÛÔ˘ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ CCG Î·È BFM
REVIEW ARTICLE 202
∞. ∫·ÙÙ¿Ì˘, ∂. °Ô˘Û¤Ù˘
1Ô ¶∞¡∂§§∏¡πO ™À¡∂¢ƒπO À¶O∂π¢π∫O∆∏∆ø¡ ∆∏™ ¶∞π¢π∞∆ƒπ∫∏™ ÿÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·. ◊ Ì‹ˆ˜ Î·È Ù· ‰‡Ô;
CONTINUING MEDICAL EDUCATION 207 208
211 215
∞naphylaxis: clinical manifestations and treatment T. Papastavrou - Mavroudi
219
ª. ∆Ú›Áη
ÃÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (Staphylococcus aureus). O ÚfiÏÔ˜ ÙÔ˘ ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·
What is, what is not asthma? K. N. Priftis
£. ¶··ÛÙ·‡ÚÔ˘ - ª·˘ÚÔ˘‰‹
∞ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË
1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES Jaundice in the breast fed infant C. Costalos
∫. ¡. ¶Ú›ÊÙ˘
∞Ó·Ê˘Ï·Í›·: ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ·ÓÙÈÌÂÙÒÈÛË
Progress in the therapy of childhood acute lymphoblastic leukemia through the CCG and BFM protocols A. Kattamis, E. Goussetis
X. ∫ÒÛÙ·ÏÔ˜
∆È Â›Ó·È, ÙÈ ‰ÂÓ Â›Ó·È ¿ÛıÌ·;
Magnetic resonance imaging in prenatal diagnosis
∞llergy to cow’s milk: diagnosis and management M. Triga
223
M. Valari
¶AI¢IATPIKH
●
ª. µ·Ï¿ÚË
The role of Staphylococcus aureus in atopic dermatitis
ªË¯·ÓÈÛÌÔ› ·˘ÙÔ·ÓÔÛ›·˜
229
ª. °. ∫·Ó¿ÚÈÔ˘
™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·
M. G. Kanariou 233
Ÿ. µÔ˘ÁÈԇη
¢È·ÈÙËÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù·
237
Dietary approach in autoimmune rheumatic diseases A. Siamopoulou-Mavridou
241
∫. ¢. ∫ÔÏÏÈfi˜
NÂfiÙÂÚ˜ ·fi„ÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·
Spondyloarthropathies in childhood O. Vougiouka
A. ™È·ÌÔÔ‡ÏÔ˘-M·˘Ú›‰Ô˘
¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘: ÂÎÙ›ÌËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË
Autoimmune mechanisms
Prenatal diagnosis of hydronephrosis: fetal assessment and postnatal follow-up K. D. Kollios
247
New aspects in the treatment of nephrotic syndrome in childhood
∂. ¡. °ÂˆÚÁ¿ÎË - ∞ÁÁÂÏ¿ÎË
H. N. Georgaki - Angelaki
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
May - June 2001 . Volume 64 . No 3
MAY- JUNE '01 TELIKO
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ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔÌ¤ÓˆÓ I‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÛÙ· ·È‰È¿
Continuation of table of contents 255
∫. π. ™ÙÂÊ·Ó›‰Ë˜
AÙ˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·
C. J. Stefanidis 261
∫. ∆ÛÔ˘Ì¿Î·˜
∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡
268 272
276
280
285
290
293
300
304 308
The pediatrician and the patient with cystic fibrosis S. Doudounakis
312
Hypospadias D. Keramidas
¢. ∫ÂÚ·Ì›‰·˜
∫ÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ
Dental injuries L. Papagiannouli - Laskaridi
™. ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘
ÀÔÛ·‰›·˜
Breastfeeding in Greece. What has been done - Targets for the future T. Zachou
§. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë
O ·È‰›·ÙÚÔ˜ Î·È ÙÔ ·È‰› Ì ÙËÓ ÈÓÔ΢ÛÙÈ΋
Cholestasis of infancy: diagnosis and treatment K. Spiroglou
£. ∑¿¯Ô˘
∆Ú·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ‰ÔÓÙÈÒÓ
Recent developments in pediatric gastroenterology S. Nousia - Arvanitakis
K. ™‡ÚÔÁÏÔ˘
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÛÙËÓ ∂ÏÏ¿‰·. ∆È ¤¯ÂÈ Á›ÓÂÈ - ªÂÏÏÔÓÙÈΤ˜ ÚˆÙÔ‚Ô˘Ï›Â˜
Modern treatment of thalassaemia. Principles and effectiveness V. A. Ladis
™. ¡Ô‡ÛÈ· - ∞Ú‚·ÓÈÙ¿ÎË
ÃÔÏfiÛÙ·ÛË ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË
Training in Pediatric Hematology - Oncology M. Kalmanti
µ. ∞. §·‰‹˜
∂ÍÂÏ›ÍÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ Á·ÛÙÚÂÓÙÂÚÔÏÔÁ›·
Haematopoietic stem cell transplantation for the treatment of haematological malignant, and genetic diseases S. Graphakos
ª. ∫·ÏÌ·ÓÙ‹
™‡Á¯ÚÔÓË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. µ·ÛÈΤ˜ ·Ú¯¤˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·
Infections in immunosuppressed patients: from the 20th to the 21st century E. Roilides
™. °Ú·Ê¿ÎÔ˜
ªÂÙÂη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·
Management of the child with multiple trauma K. Papazoglou
∂. ƒÔËÏ›‰Ë˜
∞ÓÙÈÌÂÙÒÈÛË ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ
Accidents in childhood and adolescence C. Tsoumakas
∫. ¶·¿˙ÔÁÏÔ˘
§ÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜: ·fi ÙÔÓ 20Ô ÛÙÔÓ 21Ô ·ÈÒÓ·
Idiopathic hypercalciuria
315
Criteria for referral of children to the ophthalmologist
∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË
A. Koidou-Tsiligianni
™˘Ó¯›˙ÔÓÙ·È
Continued
ªay - June 2001 . Volume 64 . No 3
MAY- JUNE '01 TELIKO
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ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
¶∞ƒOƒ∞ª∞
318
ERRATUM
¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ µÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· Î·È Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH Û ·È‰È¿ Ì ›ÌÔÓË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi
201
LITERATURE ABSTRACTS Bronchoalveolar lavage and esophageal p∏ monitoring data in children with “difficult to treat” respiratory symptoms
Sacco O, Fregonese B, Silvestri M, Sabatini F, Mattioli G, Rossi GA ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.π. ∫·ÊÚ›ÙÛ·
™¯¤ÛË ÌÂٷ͇ ·ÏÌÈ΋˜ Ô͢ÌÂÙÚ›·˜ Î·È ÎÏÈÓÈÎÔ‡ score Û ·È‰È¿ Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 24 ÌËÓÒÓ
Sacco O, Fregonese B, Silvestri M, Sabatini F, Mattioli G, Rossi GA Greek translation: G.I. Kafritsa 214
Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. OÈÎÔÓfiÌÔ˘
O ÚfiÏÔ˜ Ù˘ ÙÚÔÊÈ΋˜ ‰˘Û·ÓÂÍ›·˜ Û ‚Ú¤ÊË Ì ›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ ÔÈÛÔÊ·Á›Ùȉ·˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË
Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G Greek translation: G. Oikonomou 228
Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.π. ∫·ÊÚ›ÙÛ·
ŸÙ·Ó Ô “Û˘ÚÈÁÌfi˜” ‰ÂÓ Â›Ó·È Û˘ÚÈÁÌfi˜: ·ÎÔ˘ÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ ÛÙ· ‚Ú¤ÊË
254
260
Effect of long-term treatment with inhaled budesonide on adult height in children with asthma Agertoft L, Pedersen S Greek translation: K. Hatzis
∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∫. ÷Ù˙‹˜ 284
de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al. ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ™. ºˆÙfiÔ˘ÏÔ˜
¢ÂÓ ˘¿Ú¯ÂÈ ·ÓÙÈÎÂÈÌÂÓÈο ÌÂÙÚ‹ÛÈÌÔ fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Ì ·ÂÚÔı¿Ï·ÌÔ Û ‚Ú¤ÊË Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·
When a “wheeze” is not a wheeze: acoustic analysis of breath sounds in infants Elphick HE, Ritson S, Rogers H, Everard ML Greek translation: M. Anthrakopoulos
Agertoft L, Pedersen S
∂ÈÏÔÁ¤˜ ıÂڷ›·˜ ÁÈ· ÂÍ·ÈÚÂÙÈο ÚfiˆÚ· ÓÂÔÁÓ¿: Ì›· ‰ÈÂıÓ‹˜ ÚÔÔÙÈ΋
Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al Greek translation: G.I. Kafritsa
Elphick HE, Ritson S, Rogers H, Everard ML ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
∏ ›‰Ú·ÛË Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË Û ·È‰È¿ Ì ¿ÛıÌ·
Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age
Treatment choices for extremely preterm infants: an international perspective de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al. Greek translation: S. Fotopoulos
311
Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
No objective benefit from steroids inhaled via a spacer in infants recovering from bronchiolitis Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H Greek translation: M. Anthrakopoulos
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xvii
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xxi
Abbreviations
ªay - June 2001 . Volume 64 . No 3
MAY- JUNE '01 TELIKO
30-05-03
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M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001
. ∆fiÌÔ˜
64
. ∆‡¯Ô˜
3
¢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
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18:55
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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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MAY- JUNE '01 TELIKO
30-05-03
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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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Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.
elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995.
™˘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 EÈÎfiÓ˜ 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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EDITORIAL
∞ƒ£ƒO ™À¡∆∞•∏™
Magnetic resonance imaging in prenatal diagnosis J.C. Leonidas
ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË π. §ÂˆÓ›‰·˜
Abstract: Recent technological advances, and in particular the development of ultrafast pulse sequences in magnetic resonance imaging (MRI) permit good quality images of the fetus, with important implications for post-natal management. There is no evidence of any adverse effects on the fetus, although currently the procedure is being withheld during the first trimester. The information obtained supplements prenatal ultrasound (US), which remains the principal method of prenatal evaluation. In many instances however US may be inconclusive or unable to answer specific questions and MRI can become a useful alternative. Experience with MRI is yet limited but its ability to offer good, easily understood anatomic information and precise volumetric assessment without exposure to radiation is an important asset of this newly introduced application of MRI.
¶ÂÚ›ÏË„Ë: ∆· Û‡Á¯ÚÔÓ· Ù¯ÓÔÏÔÁÈο ÂÈÙ‡ÁÌ·Ù· ÛÙÔÓ ÙÔ̤· Ù˘ ·ÂÈÎfiÓÈÛ˘ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (ª∆), Î·È È‰È·›ÙÂÚ· ÔÈ Ù·¯Â›Â˜ ª∆ ·ÎÔÏÔ˘ı›Â˜, ·Ú¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÈηÓÔÔÈËÙÈ΋˜ ·ÂÈÎfiÓÈÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∆· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ÂͤٷÛ˘ ª∆ ÌÔÚÔ‡Ó Ó· ·›ÍÔ˘Ó Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ÌÂÙ¤ÂÈÙ· ÎÏÈÓÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÁÓˆÛÙ¤˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ª∆ ÛÙÔ ¤Ì‚Ú˘Ô, ÂÓÙÔ‡ÙÔȘ, Ë ÂͤٷÛË ·˘Ù‹ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·Ú·Ì¤ÓÂÈ Ë ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô˜ ÂÈÏÔÁ‹˜ ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. ∂ÓÙÔ‡ÙÔȘ, Ë ª∆ ÌÔÚ› Ó· ‰ÒÛÂÈ ¯Ú‹ÛÈ̘ Û˘ÌÏËڈ̷ÙÈΤ˜ ÏËÚÔÊÔڛ˜ Î·È ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÂÓ·ÏÏ·ÎÙÈ΋ ̤ıÔ‰Ô Û ÂÚÈÙÒÛÂȘ fiÔ˘ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‰ÂÓ ÌÔÚ› Ó· ‰ÒÛÂÈ Û·Ê‹ ·¿ÓÙËÛË Û ÔÚÈṲ̂ӷ ÂÚˆÙ‹Ì·Ù·. ∏ ÂÌÂÈÚ›· ÛÙËÓ ª∆ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙȘ ̤Ú˜ Ì·˜ Â›Ó·È ·ÎfiÌ· ÂÚÈÔÚÈṲ̂ÓË. ∂ÓÙÔ‡ÙÔȘ, Â›Ó·È Ì›· ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË Ì¤ıÔ‰Ô˜ ηıÒ˜ ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÂÈÎfiÓˆÓ Î·Ï‹˜ ÔÈfiÙËÙ·˜ ÛÙȘ Ôԛ˜ ÌÔÚ› Ó· ÌÂÏÂÙËı› Ë ·Ó·ÙÔÌ›· Î·È Ó· Á›ÓÔ˘Ó ÌÂÙÚ‹ÛÂȘ ¯ˆÚ›˜ ÙÔ ¤Ì‚Ú˘Ô Ó· ÂÎÙ›ıÂÙ·È Û ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·.
Key words: prenatal magnetic imaging, prenatal diagnosis.
resonance
§¤ÍÂȘ ÎÏÂȉȿ: ÚÔÁÂÓÓËÙÈ΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË.
Ultrasound (US) is a powerful diagnostic tool in the evaluation of pregnancy. It can detect congenital defects with precision and it is extremely important for postnatal care and parental counseling. There are, however, limitations to the
information provided by US, including inherent limits to tissue transmission of sound, such as oligohydranios, body habitus, fetal position etc. Even under the best circumstances the sensitivity and specificity of US are less than perfect, a fact
Division of Pediatric Radiology Schneider Children’s Hospital, New Hyde Park, NY Albert Einstein College of Medicine Bronx, New York, USA
∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÎÙÈÓÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “Schneider”, New Hyde Park, ¡¤· ÀfiÚÎË π·ÙÚÈ΋ ™¯ÔÏ‹ Albert Einstein, Bronx, ¡¤· ÀfiÚÎË, ∏.¶.∞.
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that may at times lead to serious consequences, such as termination of pregnancy of a normal fetus (1,2). Magnetic Resonance Imaging (MRI) shares, along with US, the advantage of not delivering ionizing radiation, and it can serve as an additional mode of obstetrical and fetal evaluation. Early concerns regarding safety of the fetus from a strong static magnetic field, time-varying magnetic field, and the heat generated by the high frequency electromagnetic waves failed to be substantiated (3-6). Past MRI technology precluded image acquisition fast enough to eliminate the effects of motion. Recent developments of ultra fast MRI techniques, however, have virtually eliminated the problem of fetal motion and maternal breathing, and alleviated concerns of fetal overheating resulting from long application of electromagnetic energy. Although no harmful effects on the fetus attributable to MRI have been reported, scanning during the active organogenesis of the first trimester has been avoided as an extra precaution (6-10). The purpose of the present short communication is to acquaint professionals in perinatal and neonatal care in the rapidly expanding ultra-fast MRI applications in a spectrum of maternal and fetal abnormalities (3,6-10). Experience at our center Since the beginning of 1999 we performed close to 50 MRI examinations for evaluation of suspected fetal abnormalities, in which the information provided by US was either incomplete or raised serious concerns regarding the need for prenatal or immediate neonatal intervention. In each case the expected benefit from the MRI was thought to be much higher that the possible risk, as the information was deemed critical for management, and in each instance a complete informed consent was obtained from both parents. All MR images were obtained on a 1.5 Tesla EchoSpeed system (GE Medical Systems, Milwaukee, WI) using a torso phased array surface coil with four coil elements. This system is equipped with ultra fast gradient system, which has a slew rate of 120 T/m/sec for maximum of 23 mT/m gradient amplitude. Due to short rise and fall time of these gradients one can enhance the existing fast gradient echo sequences to obtain ultra fast sequences appropriate for imaging under breath holding. T2 pulse sequences were obtained with half fourier sampling, as simple shot fast spin echo
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sequences (SSFSE). As with any T2 weighted pulse sequence fluid has high signal intensity and appears white on the images. Other tissues present with an intermediate signal intensity producing a range of gray densities, with bone occupying the lowest level of signal intensity (black). In the majority of the cases MRI was performed to exclude additional brain malformations suspected on the basis of isolated mild venticulomegaly, which had been detected on prenatal sonograms usually performed during the second trimester (Figure 1). In 2 cases MRI was performed for evaluation of the placenta (suspected placenta accreta). In both instances it identified invasion of the myometrium, but not beyond the serosa, a valuable information for the obstetrician. In 3 cases US defined a left congenital diaphragmatic hernia (CDH) and MRI was requested for additional information. In two instances the position of viscera herniated through the defect was far more obvious with MRI, including the position of the liver, information which has been recently shown to be of significant prognostic value (12) (Figure 2). In the third findings are less clear, as the MRI was performed at an earlier gestational age (23 weeks). Nevertheless there is evidence a lesser degree of pulmonary hypoplasia and a better prognosis. This case is still unconfirmed since the fetus has not yet been delivered. Other findings included agenesis of the corpus callosum (Figure 3a, 3b), aqueductal stenosis and a Dandy Walker variant. The little existing experience in this area makes prognostic conclusions difficult and offers at the same time unique opportunities for expanding information until now impossible. Using computer assisted delineation of areas of different signal intensity we can accurately measure lung volume. In the two cases of CDH and complete data the combined lung volume was less than 20% of expected volume for gestational age. Preliminary standards of lung volumes appropriate for gestational age, based on limited number of fetuses have been recently published (13). Both our infants could not be resuscitated immediately postpartum (Figure 4a,4b). Information is currently being gathered regarding the critical lung volume necessary for the immediate postpartum survival. One fetus with prenatally detected bilateral hydrothorax and trisomy 21 survived after
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Figure 1. Parasagittal view of the fetal brain at 30 weeks of gestation. There is appropriate for gestational age formation of cortical sulci. The atrium of the lateral ventricle is wide. Additional images confirmed isolated colpocephaly.
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Figure 3a. Callosal agenesis: In a coronal view there is the typical separation of the anterior horns of the lateral ventricles (short arrows) and continuity of the interhemispheric fissure (curved arrow) with the elevated third ventricle.
having been done for reasons unrelated to the head) and compare them with those with the US standard of ventricular size, i.e. ventricular dimension at the atria.
Figure 2. Coronal view of fetus with large left CDH. Practically the entire liver (L) is intrathoracic.
immediate postpartum thoracentesis, but prenatal lung volume was 33% of that expected. This degree of accurate volume determination is not currently possible with US. There were two cases of lymhangiomas, presenting as intraperitoneal cysts. We currently measure the volume of the lateral ventricles of fetuses with normal heads (the MRI
Overall assessment The earliest application of MRI in pregnancy appeared in 1983 (14). Subsequently, taking advantage of the development of fast imaging techniques, several centers reported further experience with the application of MRI in Obstetrics (6-11). An important consideration of using MRI on the fetus is that of any possible harmful effect. Although this issue has not been settled entirely, studies have failed to show any injury to the fetus during the second and third trimester of pregnancy (3-6). It is universally accepted nevertheless that MRI examinations should be performed only when the expected benefits justify the potential small risk, and only after detailed review of all aspects with the parents has convinced everyone that the study is appropriate. The value of prenatal MRI is very promising for the fetuses with restrictive thoracic abnormalities. As noted, MRI can define the volume of the fetal lungs at various gestational ages, establish normal values, and with accumulated experience will undoubtedly be of prognostic value and affect management.
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Figure 4b. Left CDH. Axial image at the level of the thorax showing stomach (S) and liver (diamond) adjacent to the heart (arrow) and the small lung with high signal (bright) posteriorly. Anteroposterior and left/right orientation varies because of fetal position. Figure 3b. Callosal agenesis: Sagittal SSFSE image of the fetal head shows absence of the corpus callosum. At this midline section the hemispheric sulci converge towards the thalami.
essentially bypassing the obstacles preventing US from providing full information. Cost considerations, and to a lesser extent safety, dictate that US remain the main imaging modality during pregnancy. References
Figure 4a. Left CDH. A coronal SSFSE image showing bowel filling the left hemithorax (arrow). The heart (H) has been displaced to the right, and there is a small left lung (L) preserved. K=Kidneys.
The rapid technological advances in imaging, especially the development of high strength MRI scanners and of fast acquisition pulse sequences allow us to obtain high quality images of the fetus, which supplement US findings in certain areas,
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1. Boyd PA, Chamberlain P, Hicks NR. 6-year experience of prenatal diagnosis in an unselected population in Oxford, UK. Lancet 1998;352:1577-1581. 2. Steinhorn RH. Prenatal ultrasonography: first do no harm. Lancet 1998;352:1568. 3. Baker PN, Johnson IR, Harvey PR, Gowland PA, Mansfield PA. A three year follow up of children imaged in utero using echo-planar magnetic resonance. Am J Obstet Gynecol 1994;170:32-34. 4. The National Radiological Protection Advisory Board ad hoc group advisory group on magnetic resonance clinical imaging. Revised guidelines on acceptable limits of exposure during magnetic resonance clinical imaging. Br J Radiol 1983;56:974-977. 5. Kanal E, Gillen J, Evans JA, Savitz DA, Shellock FG. Survey of reproductive health among female MR workers. Radiology 1993;187:395-399. 6. Garel C, Brisse H, Sebag G et al. Magnetic resonance imaging of the fetus. Pediatr Radiol 1998;28:210-211. 7. Levine D, Barnes PD, Edelman RE. Obstetric MR imaging. Radiology 1999;211:209-217. 8. Yamashita Y, Namimoto A, Abe Y et al. MR imaging of the fetus by a HASTE sequence. AJR 1997;168:513-519. 9. Levine D, Barnes PD, Sher S et al. Fetal fast MR imaging: reproducibility, technical quality, and conspicuity of
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anatomy. Radiology 1998;206:549-554. 10. Levine D, Barnes PD, Madsen JR et al. Fetal CNS anomalies revealed on ultrafast MR imaging. AJR 1998;172:813-818. 11. Hubbard AM, Adzick NS, Crombleholme TM. Congenital chest lesions: diagnosis and characterization with prenatal MR imaging. Radiology 1999;212:43-48. 12. Albanese CT, Lopoo J, Goldstein RB, Filly RA, Feldstein VA, Callen PW et al. Fetal liver position and perinatal outcome for congenital diaphragmatic hernia. Prenatal Diagnosis 1998;18:1138-1142. 13. Coakley FV, Lopoo JB, Lu Y, Albanese CT, Harrison MR, Filly R. Normal and hypoplastic fetal lungs: volumetric assessment with prenatal single-shot rapid acquisition with relaxation enhancement MR imaging. Radiology 2000;216:107-111.
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14. Smith SW, Adam AH, Philips WDP. NMR imaging in pregnancy. [letter] Lancet 1983;1:61-62
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 14-03-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: John C. Leonidas, M.D. Division of Pediatric Radiology Schneider Children’s Hospital 270-05 76th Ave New Hyde Park, NY, 11042, USA e-mail: leonidas@lij.edu
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· µÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· Î·È Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH Û ·È‰È¿ Ì ›ÌÔÓË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi1 ∂ÈÛ·ÁˆÁ‹: H Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ÌÔÚ› Ó· ÂΉËψı› Ì ¯ÚfiÓÈ· ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ŒÎÏ˘ÛË ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ ̤ۈ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ‹ Î·È ÂÈÛÚfiÊËÛË Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÚÈÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜. ∏ ·ÚÔ˘Û›· ÏȈ‰ÒÓ Ì·ÎÚÔÊ¿ÁˆÓ ÛÙȘ ΢„ÂÏ›‰Â˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û·Ó ¤Ó‰ÂÈÍË ÂÈÛÚfiÊËÛ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË Ù˘ 24ˆÚ˘ ¯·ÌÂÙÚ›·˜ Ì ÙËÓ ·ÚÔ˘Û›· ÏȈ‰ÒÓ Ì·ÎÚÔÊ¿ÁˆÓ ÛÙȘ ΢„ÂÏ›‰Â˜ Û ·È‰È¿ Ì ÂÈ̤ÓÔ˘Û· Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: 20 ·È‰È¿ Ì ÂÈ̤ÓÔ˘Û·, ·Ú¿ ÙËÓ ·ÁˆÁ‹, Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÈÛÙÔÚÈÎfi ‡ÔÙÔ ÁÈ· °O¶ ˘Ô‚Ï‹ıËÎ·Ó Û 24ˆÚË Â¯·ÌÂÙÚ›· Î·È Û ‚ÚÔÁ¯ÔÛÎfiËÛË Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË. ∏ ÔÛfiÙËÙ· Ï›Ô˘˜ ·Ó¿ Ì·ÎÚÔÊ¿ÁÔ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ËÌÈÔÛÔÙÈ΋ ̤ıÔ‰Ô (Nile - Red ¯ÚÒÛË) Î·È ˘ÔÏÔÁ›ÛÙËΠ‰Â›ÎÙ˘ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ. ∞ÔÙÂϤÛÌ·Ù·: ŒÓÙÂη ·È‰È¿ ›¯·Ó ıÂÙÈ΋ ÁÈ· °O¶ ¯·ÌÂÙÚ›·, ÂÓÒ Û 9 Ë Â¯·ÌÂÙÚ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. T· ·È‰È¿ Ì ıÂÙÈ΋ ¯·ÌÂÙÚ›· ›¯·Ó ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ, ηıÒ˜ Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·, Û˘ÁÎÚÈÙÈο Ì ٷ ·È‰È¿ Ì ·ÚÓËÙÈ΋ ¯·ÌÂÙÚ›·. ¢ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË
ÙÔ˘ ‚·ıÌÔ‡ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙËÓ Â¯·ÌÂÙÚ›· Ì ÙÔ ‰Â›ÎÙË ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙÔ ÔÛÔÛÙfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·. ™˘ÌÂÚ¿ÛÌ·Ù·: ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÂȂ‚·ÈˆÌ¤ÓË Ì ¯·ÌÂÙÚ›· °O¶, ·ÚÔ˘ÛÈ¿˙ÂÈ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·. ∞˘Ùfi ˘Ô‰ËÏÒÓÂÈ ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ÂÈÛÚfiÊËÛË Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ∂ÓÙÔ‡ÙÔȘ, Ô ‚·ıÌfi˜ Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ fiˆ˜ ÔÚ›˙ÂÙ·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯·ÌÂÙÚ›·˜, ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÓÙÔÙ Ì ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜.
1Sacco O, Fregonese B, Silvestri M, Sabatini F Mattioli G, Rossi GA Bronchoalveolar lavage and esophageal p∏ monitoring data in children with "difficult to treat" respiratory symptoms Pediatr Pulmonol 2000;30:313-319
°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜ - °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ
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∞¡∞™∫O¶∏™∏
Paediatriki 2001;64:202-206
REVIEW ARTICLE
∏ ÂͤÏÈÍË Ù˘ ıÂڷ›·˜ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰È· ̤ÛÔ˘ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ CCG Î·È BFM ∞. ∫·ÙÙ¿Ì˘1, ∂. °Ô˘Û¤Ù˘2
Progress in the therapy of childhood acute lymphoblastic leukemia through the CCG and BFM protocols A. Kattamis1, E. Goussetis2
¶ÂÚ›ÏË„Ë: ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ë ıÂڷ›· Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÂÍÂÏ›¯ıËΠ·fi ÙË ÌÔÓÔıÂڷ›· Û ÔÏ˘Ê·ÛÈο ÚˆÙfiÎÔÏÏ· Û˘Ó‰˘·ÛÙÈ΋˜ ¯ËÌÂÈÔıÂڷ›·˜. ∆· ÂÚÈÛÛfiÙÂÚ· Û‡Á¯ÚÔÓ· ÚˆÙfiÎÔÏÏ· ‰È·ÎÚ›ÓÔ˘Ó ÙË ¯ËÌÂÈÔıÂڷ›· Û ʿÛÂȘ ÂÊfi‰Ô˘, ÚÔʇϷ͢ ∫¡™, Û˘ÓÙ‹ÚËÛ˘ Î·È Â·ÓÂÊfi‰Ô˘. OÈ ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ ·Ó¿ÏÔÁ· Ì ηϿ ÙÂÎÌËÚȈ̤ӷ ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·. ªÂ ÛÙ·‰È·Î¤˜ ‚ÂÏÙÈÒÛÂȘ Û ‰È·‰Ô¯Èο ÚˆÙfiÎÔÏÏ·, Ë ·ÌÂÚÈηÓÈ΋ ÔÌ¿‰· ÌÂϤÙ˘ CCG Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ÁÂÚÌ·ÓÈ΋ ÔÌ¿‰· BFM ¤¯Ô˘Ó ÂÈÙ‡¯ÂÈ ›·ÛË Û ÔÛÔÛÙfi >80% ÙˆÓ ·ÛıÂÓÒÓ.
Abstract: The treatment of childhood acute lymphoblastic leukemia has progressed enormously in the last decades and has evolved from monotherapy to complicated protocols of combined chemotherapy. Most of the current protocols identify therapy in various phases that include induction, CNS-directed consolidation, maintenance and late intensification phase. Patients are classified into risk groups according to well-established prognostic criteria. With gradual improvements in sequential protocols the American study group CCG and the German group BFM have succeeded in curing >80% of the patients.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÚˆÙfiÎÔÏÏ· ıÂڷ›·˜ Ù˘ O§§.
Key words: acute lymphoblastic leukemia, treatment protocols of ALL.
™˘ÓÙÔÌÔÁڷʛ˜
›Ù¢ÁÌ· Ù˘ ·È‰È·ÙÚÈ΋˜ ÔÁÎÔÏÔÁ›·˜. ™ÙË Û˘Ó¤¯ÂÈ·, ı· ·Ó·ÊÂÚıԇ̠ÛÙ· ‚‹Ì·Ù· ·˘Ù¿ ΢ڛˆ˜ ̤۷ ·fi ÙË Û˘ÏÏÔÁÈÛÙÈ΋ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ÙˆÓ ÔÌ¿‰ˆÓ Children’s Cancer Group (CCG) ÙˆÓ ∏.¶.∞. Î·È Berlin-Frankfurt-Muenster (BFM) Ù˘ °ÂÚÌ·Ó›·˜.
√§§ CCG BFM ∫¡™ ∂FS π∆ªtx
ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Children’s Cancer Group Berlin-Frankfurt-Muenster ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿Ó (event-free survival) ÂÓ‰ÔÚ·¯È·›Â˜ ÂÁ¯‡ÛÂȘ ÌÂıÔÙÚÂÍ¿Ù˘
∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ηÎÔ‹ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ÂÙ‹ÛÈ· ›وÛË Ù˘ ÓfiÛÔ˘ ·Ó¤Ú¯ÂÙ·È ÂÚ› ÙȘ 4 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 15 ÂÙÒÓ. ∏ ıÂڷ›· Ù˘ O§§ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛËÌ›ˆÛ ÛËÌ·ÓÙÈο ‚‹Ì·Ù· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È ıˆÚÂ›Ù·È ˆ˜ ÙÔ ‚·ÛÈÎfiÙÂÚÔ
1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ √ÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
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OÈ ÚÒÙ˜ ÂÏ›‰Â˜ ª¤¯ÚÈ Ù· ̤۷ ÙÔ˘ 20Ô‡ ·ÈÒÓ· ‰ÔÎÈÌ¿˙ÔÓÙ·È ‰È¿ÊÔÚ˜ ıÂڷ›˜ ÛÙËÓ ·È‰È΋ O§§, fiˆ˜ ÂÓÈÎÈÏÏ›ÓË, ·Ú¿ÁˆÁ· ·ÚÛÂÓÈÎÔ‡ Î·È ·Ê·ÈÌ¿ÍÂȘ, ¯ˆÚ›˜ fï˜ ·ÔÙ¤ÏÂÛÌ·. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì O§§ ηٷϋÁÔ˘Ó Û ۇÓÙÔÌÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ‰È¿ÁÓˆÛË. OÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ ‰ÔÎÈÌ¿˙ÔÓÙ·È Û·Ó ¯ËÌÂÈÔıÂڷ¢ÙÈο ÌÂÙ¿ ÙȘ ·Ú·ÙËÚ‹ÛÂȘ ÁÈ·
1 A’ Pediatric Clinic of the University of Athens 2 Division of Bone Marrow Transplantation “St. Sophia” Children’s Hospital, Athens
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·ÈÌ·ÙÔÏÔÁÈ΋ ÙÔÍÈÎfiÙËÙ· Ì ÙË ¯Ú‹ÛË ÙÔ˘ ·ÂÚ›Ô˘ ÌÔ˘ÛÙ¿Ú‰·˜ ηٿ ÙÔÓ ÚÒÙÔ ·ÁÎfiÛÌÈÔ fiÏÂÌÔ Î·È ÌÂÙ¿ ÙÔ ·Ù‡¯ËÌ· ÙÔ˘ Bari Harbor ηٿ ÙÔ ‰Â‡ÙÂÚÔ ·ÁÎfiÛÌÈÔ fiÏÂÌÔ (1). ∏ ·Ú·Ù‹ÚËÛË fiÙÈ ÙÔ Ê˘ÏÏÈÎfi Ô͇ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÌÔÔ›ËÛË Ô‰ËÁ› ÛÙË ¯Ú‹ÛË ÙÔ˘ Î·È ÛÙË Ï¢¯·ÈÌ›·, Ô˘ fï˜, fiˆ˜ ·Ó·ÌÂÓfiÙ·Ó, ʤÚÓÂÈ ·ÓÙ›ıÂÙÔ ÙÔ˘ ÂÈı˘ÌËÙÔ‡ ·ÔÙ¤ÏÂÛÌ·, ÚÔηÏÒÓÙ·˜ ·‡ÍËÛË ÙÔ˘ Ï¢¯·ÈÌÈÎÔ‡ ÊÔÚÙ›Ô˘. ∆Ô 1947, Ô Sidney Farber ¯ÚËÛÈÌÔÔÈ› ¤Ó·Ó ·ÓÙÈÌÂÙ·‚ÔÏ›ÙË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÙËÓ ·ÌÈÓÔÙÂÚ›ÓË (·Ó·ÛÙÔϤ·˜ Ù˘ ‰È¸‰ÚÔÊ˘ÏÏÈ΋˜ ·Ó·ÁˆÁ¿Û˘) Î·È ÂÙ˘¯·›ÓÂÈ ·ÚÔ‰È΋ ‡ÊÂÛË Û 10 ·fi 16 ·ÛıÂÓ›˜ (2). ∆Ô 1949, Ô Seeger Û˘Óı¤ÙÂÈ ÙË ÌÂıÔÙÚÂÍ¿ÙË Ô˘ ¤¯ÂÈ ·ÚfiÌÔÈ· ‰Ú¿ÛË Ì ÙËÓ ·ÌÈÓÔÙÂÚ›ÓË ·ÏÏ¿ Â›Ó·È ÏÈÁfiÙÂÚÔ ÙÔÍÈ΋. §›ÁÔ ·ÚÁfiÙÂÚ·, Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È ·ÔÙÂÏÂÛÌ·ÙÈο, ·Ú¯Èο ÛÙÔ˘˜ fiÁÎÔ˘˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Î·È ÛÙË Ï¢¯·ÈÌ›· (1950) (3). ∆Ô 1951, ÔÈ Elion Î·È Hitchings Û˘Óı¤ÙÔ˘Ó Ì›· ·ÓÙÈÔ˘Ú›ÓË, ÙËÓ 6-ÌÂÚηÙÔÔ˘Ú›ÓË, Ë ÔÔ›· ηٷ‰ÂÈÎÓ‡ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ï¢¯·ÈÌ›· (4,5). ∞ÓÙ›ÛÙÔÈ¯Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÂÌÊ·Ó›˙ÂÈ Î·È ¤Ó·˜ Ó¤Ô˜ ·Ï΢ÏȈÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë. ∆Ô 1963, Ô µroome ÛÙËÚÈ˙fiÌÂÓÔ˜ ÛÙȘ ·Ú·ÙËÚ‹ÛÂȘ ÙÔ˘ Kidd fiÙÈ Ô ÔÚfi˜ ·fi ÈÓ‰Èο ¯ÔÈÚ›‰È· Â›Ó·È ÙÔÍÈÎfi˜ ÁÈ· Ù· Ï¢¯·ÈÌÈο ·ÙÙ·Ú·, ·Ó·Î·Ï‡ÙÂÈ ÙËÓ L-·Û·Ú·ÁÈÓ¿ÛË. ™ÙËÓ ÚÔÛ¿ıÂÈ· ·Ó‡ÚÂÛ˘ ·ÓÙȉȷ‚ËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Î·Ï‡ÙÂÙ·È ·fi ÙÔ Âί‡ÏÈÛÌ· ÙˆÓ Ê‡ÏÏˆÓ Ù˘ ‚›Óη˜ Ë ‚ÈÓÎÚÈÛÙ›ÓË. ∆· ·ÏηÏÔÂȉ‹ Ù˘ ‚›Óη˜ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È ‰Ú·ÛÙÈο ÛÙÔ˘˜ ÏÂÌÊÔÁÂÓ›˜ fiÁÎÔ˘˜ Î·È ÛÙË Ï¢¯·ÈÌ›· (6). ∏ ¯Ú˘Û‹ ÂÔ¯‹ ∏ Ê·Ú¤ÙÚ· ÙˆÓ È·ÙÚÒÓ ·Ú¯›˙ÂÈ Ó· ÁÂÌ›˙ÂÈ Î·È ÍÂÎÈÓÔ‡Ó ÔÈ ÚÒÙ˜ ÌÂϤÙ˜ ÌÂ Û˘Ó‰˘·ÛÌfi Ê·ÚÌ¿ÎˆÓ Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (7). ∏ ¯Ú‹ÛË Ù˘ L-·Û·Ú·ÁÈÓ¿Û˘ Ì·˙› Ì ÙË ‚ÈÓÎÚÈÛÙ›ÓË Î·È Ù· ÎÔÚÙÈÎÔÂȉ‹ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ›Ù¢Í˘ ‡ÊÂÛ˘ ·fi 85% Û >93%. O Û˘Ó‰˘·ÛÌfi˜ 6-ÌÂÚηÙÔÔ˘Ú›Ó˘ Î·È ÌÂıÔÙÚÂÍ¿Ù˘ Â›Ó·È Î·Ï‡ÙÂÚÔ˜ ÁÈ· ÙË Û˘Ó¤¯ÈÛË Ù˘ ıÂڷ›·˜. ¶·Ú¿ ÙËÓ Î·Ï‹ ·Ú¯È΋ ·¿ÓÙËÛË, fï˜, Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË Â›Ó·È ·ÎfiÌ· ȉȷ›ÙÂÚ· ¯·ÌËÏ‹. ∆Ô˘Ï¿¯ÈÛÙÔÓ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ˘ÔÙÚÔÈ¿˙ÂÈ ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· (∫¡™). ∏ ·Ó¿ÁÎË ÁÈ· ÚÔʇϷÍË ÙÔ˘ ∫¡™, ‹ ηχÙÂÚ· ÁÈ· ÚÔ-Û˘Ìو̷ÙÈ΋ ıÂڷ›· ÙÔ˘ ∫¡™ Á›ÓÂÙ·È ÂÈÙ·ÎÙÈ΋. ∆Ô 1968, ÔÈ Pinkel Î·È Simone ÛÙÔ “St. Jude Children’s Research Hospital” ÚÔÙ›ÓÔ˘Ó Ù· ÚˆÙfiÎÔÏÏ· “ÔÏÔÎÏËڈ̤Ó˘” ıÂڷ›·˜, Ô˘ Û˘Ó‰˘¿˙Ô˘Ó ¯ËÌÂÈÔıÂڷ¢ÙÈο Ê¿Ú̷η Û ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË. ¶ÂÙ˘¯·›ÓÔ˘Ó Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ-
Paediatriki 2001;64:202-206
‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿Ó (event-free survival - ∂FS) ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Î·È ı¤ÙÔ˘Ó ÙË ‚¿ÛË ÙˆÓ Û‡Á¯ÚÔÓˆÓ ÚˆÙÔÎfiÏÏˆÓ Ô˘ ‰È·ÎÚ›ÓÔ˘Ó ÙË ıÂڷ›· Ù˘ Ï¢¯·ÈÌ›·˜ Û ʿÛË ÂÊfi‰Ô˘, ÛÙ·ıÂÚÔÔ›ËÛ˘ / ÚÔʇϷ͢ ∫¡™ Î·È Û˘ÓÙ‹ÚËÛ˘ (8). µ¿ÛÂÈ ÂÓfi˜ ıˆÚËÙÈÎÔ‡ ΢ÙÙ·ÚÔÎÈÓËÙÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘, οı ʿÛË ÌÂÈÒÓÂÈ ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô Î·Ù¿ ¤Ó· Û˘ÁÎÂÎÚÈ̤ÓÔ ÎÏ¿ÛÌ·. £ÂˆÚÂ›Ù·È fiÙÈ ÛÙË ‰È¿ÁÓˆÛË, ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ·ÓÙÈÛÙÔȯ› Û 1012 ·ÙÙ·Ú· Î·È ÌÈ· Ì›ˆÛË Î·Ù¿ 99% Ô‰ËÁ› Û ÊÔÚÙ›Ô 1010 ΢ÙÙ¿ÚˆÓ, Ô˘ ÎÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ‡ÊÂÛË. ª¤¯ÚÈ ÙËÓ ÔÏÔÎÏËÚˆÙÈ΋ ÂÍ¿ÏÂÈ„Ë ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ë ıÂڷ›· ¯ÚÂÈ¿˙ÂÙ·È Ó· Û˘Ó¯ÈÛÙ› Ì ·ÚÎÂÙÔ‡˜ ·ÎÏÔ˘˜ (9). ∆· ÚˆÙfiÎÔÏÏ· CCG ™Ù·ıÂÚ‹ ÚfiÔ‰Ô˜ ∆· ÚˆÙfiÎÔÏÏ· ıÂڷ›·˜ CCG ·Ô‚Ï¤Ô˘Ó È· fi¯È ÌfiÓÔ ÛÙËÓ ›·ÛË ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Î·È ÛÙË Û‡ÁÎÚÈÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È ÙÔÍÈÎfiÙËÙ·˜ ‰È·ÊfiÚˆÓ Û˘Ó‰˘·ÛÌÒÓ Ê·ÚÌ¿ÎˆÓ ‚¿ÛÂÈ ÌÂÁ¿ÏˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÌÂÏÂÙÒÓ. ∆Ô ÚˆÙfiÎÔÏÏÔ CCG101 ÙÔ˘ 1970 ıÂڷ‡ÂÈ ÙÔ 40-50% ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Î·È Î·Ù·‰ÂÈÎÓ‡ÂÈ ˆ˜ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi Û¯‹Ì· ÚÔʇϷ͢ ÙÔ˘ ∫¡™ ÙÔ Û˘Ó‰˘·ÛÌfi ·ÎÙÈÓÔ‚ÔÏ›·˜ ÙÔ˘ ÓÂ˘Ú¿ÍÔÓ· Ì 2400 cGy Î·È 6 ÂÓ‰ÔÚ·¯È·›ˆÓ ÂÁ¯‡ÛÂˆÓ ÌÂıÔÙÚÂÍ¿Ù˘ (π∆ªtx) (10). ∏ ‰È¿ÚÎÂÈ· Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ ÌÂÈÒÓÂÙ·È ·fi Ù· 5 ÛÙ· 3 ¤ÙË (ÚˆÙfiÎÔÏÏÔ CCG 141) (11). ™ÙÔ ÚˆÙfiÎÔÏÏÔ CCG 143 ÙÔ˘ 1973, Ë ·ÎÙÈÓÔ‚ÔÏ›· ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· 1800 cGy ¯ˆÚ›˜ Ó· ÂËÚ·ÛÙ› ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘. ∞˘Ù‹ Ë Ì›ˆÛË Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋, ·ÊÔ‡ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ·ÎÙÈÓÔ‚ÔÏ›· Ì 2400 cGy ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ˘„ËÏfi ÔÛÔÛÙfi Ì·ıËÛȷο Î·È Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (12). OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ∆·˘Ùfi¯ÚÔÓ·, ‰È·Ê·›ÓÂÙ·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË. ∏ ¯Ú‹ÛË ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ¤¯ÂÈ ÍÂÎÈÓ‹ÛÂÈ. ∏ ËÏÈΛ·, ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô, Ô ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ‚Ï·ÛÙÒÓ, ÙÔ Ê‡ÏÔ, ÔÈ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ·ÔÙÂÏÔ‡Ó ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Î·È ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ∆· ÚˆÙfiÎÔÏÏ· CCG 161, 162, 163 ηٷӤÌÔ˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô Î·È Î·Ù·‰ÂÈÎÓ‡Ô˘Ó fiÙÈ 2 ¤ÙË Û˘ÓÙ‹ÚËÛ˘ Â›Ó·È ·ÚÎÂÙ¿ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· ηıÒ˜ Î·È fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ë ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ ∫¡™ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ·ı› ·fi ITMtx (13). ™ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980, ÔÈ ·ÛıÂÓ›˜ ‰È·ÎÚ›ÓÔÓÙ·È È· Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘: ¯·ÌËÏÔ‡,
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ÂӉȿÌÂÛÔ˘ Î·È ˘„ËÏÔ‡. OÈ ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ıÂڷ‡ÙËÎ·Ó Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ CCG104 ÙÔ˘ 1983, ·ÚÔ˘ÛÈ¿˙Ô˘Ó 8ÂÙ‹ EFS 70%. ∆Ô ‰È¿‰Ô¯Ô ÚˆÙfiÎÔÏÏÔ Î·Ù·‰ÂÈÎÓ‡ÂÈ fiÙÈ Ë ÚÔÛı‹ÎË Ê¿Û˘ ·ÓÂÊfi‰Ô˘ ·Ó‚¿˙ÂÈ ÙÔ ÔÛÔÛÙfi 5ÂÙÔ‡˜ ∂FS ÛÙÔ 80% (14). ªÂ ÙË ÌÂϤÙË CCG105 ÂȂ‚·ÈÒÓÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÌ¿‰·˜ BFM ÁÈ· ηχÙÂÚË ÚfiÁÓˆÛË Û ·ÛıÂÓ›˜ ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ ‹Ú·Ó Ê¿ÛË Â·ÓÂÊfi‰Ô˘, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ηٷ‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ë ·ÎÙÈÓÔ‚ÔÏ›· ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË Û ·ÛıÂÓ›˜ οو ÙˆÓ 10 ÂÙÒÓ (14,15). ™ÙȘ ÂfiÌÂÓ˜ ÌÂϤÙ˜ Ô˘ ÍÂÎÈÓÔ‡Ó ÙÔ 1989 Î·È 1995 Ê·›ÓÂÙ·È fiÙÈ Ë ÚÔÛı‹ÎË ‰Â‡ÙÂÚ˘ ·ÓÂÊfi‰Ô˘ ʤÚÂÈ ·ÎfiÌ· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù·. ∏ ÌÂϤÙË CCG106 ÁÈ· ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ó··Ú¿ÁÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ BFM ÛÂ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË (16). ∂ȉÈο, fï˜, ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÛËÌ›· ÏÂÌÊÒÌ·ÙÔ˜ (Ì¿˙· ÌÂÛÔıˆÚ·Î›Ô˘, ÛÏËÓÔÌÂÁ·Ï›·, ÂÎÛÂÛËÌ·Ṳ̂Ó˜ ÏÂÌÊ·‰ÂÓÈΤ˜ ‰ÈÔÁÎÒÛÂȘ), ÙÔ ÚˆÙfiÎÔÏÏÔ New York Ê·›ÓÂÙ·È Ó· ˘ÂÚÙÂÚ› ÙÔ˘ BFM (ÚˆÙfiÎÔÏÏÔ CCG123). OÈ ·ÛıÂÓ›˜ ÌÂ Ì˘ÂÏÈ΋ ‰È‹ıËÛË ·fi ‚Ï¿ÛÙ˜ ¿Óˆ ·fi 25% ηٿ ÙËÓ 7Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, Ô˘ ÈÛÙÔÚÈο ·ÚÔ˘Û›·˙·Ó EFS 30%, ÂÙ˘¯·›ÓÔ˘Ó EFS 67,7% Ì ÙË ¯Ú‹ÛË “ÂÓÙ·ÙÈÎÔÔÈË̤ÓÔ˘ BFM” (ÚˆÙfiÎÔÏÏÔ CCG1882) (17). ∏ ‰ÂηÂÙ›· ÙÔ˘ ’90 OÈ ÌÂϤÙ˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’90 ·ÔÛÎÔÔ‡Ó Ó· ‚ÂÏÙÈÒÛÔ˘Ó Ù· ‹‰Ë ˘¿Ú¯ÔÓÙ· ÚˆÙfiÎÔÏÏ·, ÂÓۈ̷ÙÒÓÔÓÙ·˜ Ù· ηÈÓÔ‡ÚÁÈ· ‰Â‰Ô̤ӷ Î·È Ù· ÓÂfiÙÂÚ· ÂÈÙ‡ÁÌ·Ù· Ù˘ È·ÙÚÈ΋˜ Î·È ‚ÈÔÙ¯ÓÔÏÔÁ›·˜ (fiˆ˜ Ë PEG-·Û·Ú·ÁÈÓ¿ÛË, ÔÈ Î˘ÙÙ·ÚÔΛÓ˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î.¿.). O Ï‹Ú˘ ¯·Ú·ÎÙËÚÈÛÌfi˜ ÙÔ˘ Ù‡Ô˘ Ù˘ Ï¢¯·ÈÌ›·˜ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Ë Ù·ÍÈÓfiÌËÛ‹ Ù˘ Ì ‚¿ÛË Ù· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, ·ÔÙÂÏ› ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ ıÂڷ¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ™‡Ìʈӷ Ì ÙËÓ ÔÌ¿‰· CCG, ÂÎÙfi˜ ·fi ÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ Ô˘ ·Ó·Ê¤Ú·ÌÂ, ‰È·ÊÔÚÂÙÈÎfi ÚˆÙfiÎÔÏÏÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ù· ‚Ú¤ÊË ËÏÈΛ·˜ οو ÙÔ˘ 1 ¤ÙÔ˘˜, ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ʤÚÔ˘Ó ÙËÓ ·ÓÙÈÌÂÙ¿ıÂÛË 9,22 ‹ Ô˘ ‰ÂÓ ‚Ú›ÛÎÔÓÙ·È Û ‡ÊÂÛË ÙËÓ 28Ë Ë̤ڷ Î·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÎÏÈÓÈο ÛËÌ›· ÏÂÌÊÒÌ·ÙÔ˜. ∏ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ¤¯ÂÈ È· EFS ¿Óˆ ÙÔ˘ 70%, ÂÓÒ Û ÂȉÈΤ˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÙÔ EFS ÍÂÂÚÓ¿ ÙÔ 90%. ∏ ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ ∫¡™ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ Û ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (18). ¶ÚfiÛÊ·Ù·, Ë ÔÌ¿‰· CCG ÂÓÒıËΠ̠ÙËÓ ÔÌ¿‰· POG (Pediatric Oncology Group)
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Î·È ‰ËÌÈÔ˘ÚÁ‹ıËÎÂ Ë ÔÌ¿‰· COG (Children’s Oncology Group), ÛÙ· ÚˆÙfiÎÔÏÏ· Ù˘ ÔÔ›·˜ ·Ó·Ì¤ÓÔÓÙ·È Ó· ÂÚÈÏËÊıÔ‡Ó >95% ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ÛÙȘ ∏.¶.∞. ∆· ÚˆÙfiÎÔÏÏ· BFM ª¤Û· ·fi Ù· 8 ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 30 ¯ÚfiÓˆÓ, Ë ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ O§§ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ BFM (Berlin-FrankfurtMuenster), Û‹ÌÂÚ·, ÂÙ˘¯·›ÓÂÈ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿ÓÙ· (EFS) ÛÙÔ 80% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ıÂڷ›· ‰È·ÎÚ›ÓÂÙ·È Û ʿÛÂȘ ÂÊfi‰Ô˘, ÛÙ·ıÂÚÔÔ›ËÛ˘, ·ÓÂÊfi‰Ô˘ Î·È Û˘ÓÙ‹ÚËÛ˘ Î·È ÚÔÛ·ÚÌfi˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (risk-adapted treatment). ∏ ÂͤÏÈÍË ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ BFM ‰È·ÎÚ›ÓÂÙ·È Û¯ËÌ·ÙÈο Û ÙÚÂȘ ÂÔ¯¤˜ Ì ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÛÙÔȯ›·, Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·fiÏ˘ÙË ·ÓÙÈÛÙÔȯ›· Ì ٷ ÂÈÙ‡ÁÌ·Ù· ÙˆÓ ‚ÈÔ˚·ÙÚÈÎÒÓ ÂÈÛÙËÌÒÓ (19-21). ∏ ÚÒÙË ÂÔ¯‹ (1970-1981) ∆· ÚˆÙfiÎÔÏÏ· ALL-BFM 70, 76, 79 Î·È 81 ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙË ‰ËÌÈÔ˘ÚÁ›· ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ÂÚȤ¯Ô˘Ó Û˘Ó‰˘·ÛÌÔ‡˜ 5 ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ Ê·Ú̿ΈÓ, ·fi ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰· ¯·ÌËÏÔ‡ ‹ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‚Ï·ÛÙÒÓ ÛÙË ‰È¿ÁÓˆÛË (>25000/Ìl ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘) Î·È ·fi ÙËÓ ÚÔÛı‹ÎË Ù˘ Ê¿Û˘ ·ÓÂÊfi‰Ô˘ (¶ÚˆÙfiÎÔÏÏÔ ππ) ÛÙË ıÂڷ›· Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. °È· ÙËÓ ÂÔ¯‹ ÙÔ˘˜, Ù· ÚˆÙfiÎÔÏÏ· Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈο ·ÊÔ‡ ÂÙ˘¯·›ÓÔ˘Ó EFS 62% ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Î·È EFS 45% ÁÈ· ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∏ ÂÔ¯‹ ÙÔ˘ ‰Â›ÎÙË ÎÈÓ‰‡ÓÔ˘ (1983-1986) ∆· ÚˆÙfiÎÔÏÏ· ALL-BFM-83 Î·È 86 ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ “‰Â›ÎÙË ÎÈÓ‰‡ÓÔ˘” (Risk Factor), Ô˘ ηٷٿÛÛÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜ (20). O ‰Â›ÎÙ˘ ·˘Ùfi˜ ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ Û˘ÓÔÏÈÎfi Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ÛÙË ‰È¿ÁÓˆÛË Î·È ˘ÔÏÔÁ›˙ÂÙ·È ‚¿ÛË ÙÔ˘ ·ÚÈıÌÔ‡ ‚Ï·ÛÙÒÓ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Ú‰ÓÈ˙fiÓ˘ ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ıÂڷ›·˜ ηıÈÂÚÒÓÂÙ·È ˆ˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. ∫·ÏÔ› “··ÓÙËÙ¤˜” ıˆÚÔ‡ÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÙËÓ 8Ë Ë̤ڷ ıÂڷ›·˜ ·fiÏ˘ÙÔ ·ÚÈıÌfi ΢ÎÏÔÊÔÚÔ‡ÓÙˆÓ ‚Ï·ÛÙÒÓ <1Ã109/L. ™ÙÔ ÚˆÙfiÎÔÏÏÔ ALLBFM-86, ηϋ ·¿ÓÙËÛË ÛÙËÓ Ú‰ÓÈ˙fiÓË ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 90% ÙˆÓ ·ÛıÂÓÒÓ Î·È Û˘Óԉ‡ÂÙ·È ·fi EFS 80%. ™Â ·ÓÙ›ıÂÛË, ·ÛıÂÓ›˜ Ì η΋ ·¿ÓÙËÛË ÛÙËÓ Ú‰ÓÈ˙fiÓË ·ÚÔ˘ÛÈ¿˙Ô˘Ó EFS 45% (22).
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∏ ‰ÂηÂÙ›· ÙÔ˘ ’90 ∏ ÙÚ›ÙË ÂÔ¯‹ Ì ٷ ÚˆÙfiÎÔÏÏ· ALL-BFM90, 95 ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÚÔÛ¿ıÂÈ· Ì›ˆÛ˘ Ù˘ ¯ËÌÂÈÔıÂڷ›·˜, ȉȷ›ÙÂÚ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ Î·È Î˘Ú›ˆ˜ ÁÈ· ÙËÓ ÔÌ¿‰· ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÚÔÊ˘Ï·ÎÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›·, ÂÓÒ ÛÙ· ·ÁfiÚÈ· Ù˘ ÔÌ¿‰·˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ë Ê¿ÛË Û˘ÓÙ‹ÚËÛ˘ ·˘Í¿ÓÂÈ Î·Ù¿ ¤Ó· ¤ÙÔ˜. ªÂ ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM-90 ÂÈÙ˘Á¯¿ÓÂÙ·È 6ÂÙ‹˜ EFS 84% ÁÈ· ÙȘ ÔÌ¿‰Â˜ ¯·ÌËÏÔ‡ Î·È ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (23). ™ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Á›ÓÂÙ·È ·ÓÙÈηٿÛÙ·ÛË Ù˘ Ê¿Û˘ ·ÓÂÊfi‰Ô˘ Ì ·ӷϷ̂·ÓfiÌÂÓ· ‚Ú·¯¤· Û¯‹Ì·Ù· ¤ÓÙÔÓ˘ ¯ËÌÂÈÔıÂڷ›·˜ (blocks). ∏ ·ÏÏ·Á‹ ·˘Ù‹ ‰ÂÓ ·ÔʤÚÂÈ fï˜ ‚ÂÏÙ›ˆÛË ÙÔ˘ EFS Û ۇÁÎÚÈÛË Ì ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ÚˆÙfiÎÔÏÏÔ (6ÂÙ‹˜ EFS: 34% ¤Ó·ÓÙÈ 45%). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ë ıÂڷ›· Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ fiÙ·Ó Â›Ó·È Û˘Ó¯‹˜ ·Ú¿ fiÙ·Ó Â›Ó·È ‰È·ÏÂ›Ô˘Û· Î·È ÈÔ ÂÓÙ·ÙÈ΋ Î·È ·ÎfiÌ· fiÙÈ Ù· ÂÚÈÛÛfiÙÂÚÔ Ì˘ÂÏÔÙÔÍÈο Ê¿Ú̷η fiˆ˜ Ù· ·Ï΢ÏȈÙÈο, ¤¯Ô˘Ó Î·È ÌÂÁ·Ï‡ÙÂÚË ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË. °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, ÛÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (ALL-BFM-95) ·ӤگÂÙ·È Ë Â·Ó¤ÊÔ‰Ô˜ Î·È ÌÂÈÒÓÔÓÙ·È Ù· Û¯‹Ì·Ù· Ù˘ ¤ÓÙÔÓ˘ ¯ËÌÂÈÔıÂڷ›·˜. ™ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÂÓÙ¿ÛÛÔÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ì η΋ “·¿ÓÙËÛË” ÛÙËÓ Ú‰ÓÈ˙fiÓË ‹ Ì ¯ÚˆÌÔÛˆÌÈ΋ ÌÂÙ¿ıÂÛË 4;11 ‹ 9;22, ‹ Ì ÌË Ì˘ÂÏÈ΋ ‡ÊÂÛË ÙËÓ 33Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜. ™ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM 99, Ë ·Ó›¯Ó¢ÛË ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈfiÌÂÓ˘ ÓfiÛÔ˘ ÙËÓ 5Ë Î·È ÙË 12Ë Â‚‰ÔÌ¿‰· ·ÔÙÂÏ› ηıÔÚÈÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÈÏÔÁ‹ Ù˘ ıÂڷ›·˜. ∂›ÏÔÁÔ˜ ∏ ıÂڷ›· Ù˘ O§§ ¤¯ÂÈ ÂÍÂÏȯı› Ù· ̤ÁÈÛÙ· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È Ë ›·ÛË ·ÔÙÂÏ› ÂÊÈÎÙfi ÛÙfi¯Ô ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ. ª¤Û· Û ̛· ÙÂÛÛ·Ú·ÎÔÓÙ·ÂÙ›· ÂÚ¿Û·Ì ·fi ÙËÓ ·ÚËÁÔÚËÙÈ΋ ÌÔÓÔıÂڷ›· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ Î·È ¯Ú‹ÛË ÔχÏÔÎˆÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ, ÙˆÓ ÔÔ›ˆÓ ÙÔ ˘„ËÏfi ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È Ë ÌÂȈ̤ÓË ¿ÌÂÛË Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ÙÔÍÈÎfiÙËÙ· ¤¯ÂÈ Î·Ù·‰Âȯı› ·fi ÂÎÙÂÓ›˜ ÌÂϤÙ˜ (24). ∏ ÛËÌ·ÓÙÈ΋ ·˘Ù‹ ÚfiÔ‰Ô˜ ¤¯ÂÈ ÂÈÙ¢¯ı› ̤۷ ·fi ÙË Û˘Ó¯‹ ÚÔÛ¿ıÂÈ· ÙˆÓ ÏÂÈÙÔ˘ÚÁÒÓ ˘Á›·˜ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜, Ô˘ Ù·˘Ùfi¯ÚÔÓ· ÚÔÛʤÚÔ˘Ó Û˘ÛÙËÌ·ÙÔÔÈË̤ÓË ıÂڷ›· Î·È Û˘ÁÎÚ›ÓÔ˘Ó ıÂڷ¢ÙÈΤ˜ ÂÓ·ÏÏ·ÎÙÈΤ˜.
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O ‚·ıÌfi˜ Ù˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ˘Â‡ı˘ÓˆÓ È·ÙÚÒÓ, ηıÒ˜ Î·È ÌÂٷ͇ ÙˆÓ ÔÁÎÔÏÔÁÈÎÒÓ ÔÌ¿‰ˆÓ Â›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ˜. ™ÙȘ ∏.¶.∞. Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ù˘ ∂ӈ̤Ó˘ ∂˘ÚÒ˘, Ë ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÂÓÙ¿ÛÛÂÙ·È Û ÂÚ¢ÓËÙÈο ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ·, ÌÈ· Î·È ÔÏÏÔ› ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤¯Ô˘Ó ηχÙÂÚ· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜ ·fi ·˘ÙÔ‡˜ Ô˘ ıÂڷ‡ÔÓÙ·È ‚¿ÛÂÈ ÌÂÌÔÓˆÌ¤ÓˆÓ ÚÔÛˆÈÎÒÓ ÂÌÂÈÚÈÒÓ ÙÔ˘ ÂȂϤÔÓÙÔ˜ È·ÙÚÔ‡ (25,26). ∞fi ÙÔ˘˜ 60 ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ Ô˘ ¤¯Ô˘Ó ηٿ ηÈÚÔ‡˜ ·Ó·Ï˘ı›, ÌfiÓÔ Ë ËÏÈΛ·, Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Ô Î·Ú˘fiÙ˘Ô˜ ¤¯Ô˘Ó ·ÓÂÈÏËÌ̤ӈ˜ ‰Â›ÍÂÈ ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· Û ÔÏ˘·Ú·ÁÔÓÙÈΤ˜ ÌÂϤÙ˜ (27). ¡¤· ÎÚÈÙ‹ÚÈ·, fiˆ˜ Ô ÁÔÓÔÙ˘ÈÎfi˜ ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ Ï¢¯·ÈÌ›·˜ Î·È Ë ·Ó›¯Ó¢ÛË Ù˘ ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈfiÌÂÓ˘ ÓfiÛÔ˘, ÌÔÚ› Ó· ·Ô‰ÂȯıÔ‡Ó ÛËÌ·ÓÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜. ∏ ηχÙÂÚË Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÈÙÚ¤„ÂÈ ÙËÓ ÂÚ·ÈÙ¤Úˆ ÚÔÛ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜. ¶ÚfiÛÊ·Ù·, ÚÔÙ¿ıËÎÂ Ë Î·ıȤڈÛË Ó¤·˜ ÔÌ¿‰·˜ ·ÛıÂÓÒÓ È‰È·›ÙÂÚ· ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜, Ô˘ ı· Ï·Ì‚¿ÓÂÈ ÌÂȈ̤ÓË ¯ËÌÂÈÔıÂڷ›· (28). ∏ ηٷÓfiËÛË ÙˆÓ ÁÔÓȉȷÎÒÓ Ì˯·ÓÈÛÌÒÓ Ù˘ Ï¢¯·ÈÌÔÁ¤ÓÂÛ˘ Î·È Ù˘ ·ÓıÂÎÙÈÎfiÙËÙ·˜ ÛÙË ıÂڷ›· ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË Ó¤ˆÓ ıÂڷ¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ. ™ÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ, Ô Û¯Â‰È·ÛÌfi˜ Ù˘ ıÂڷ›·˜ ı· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ¿ÏÏ· ÛÙÔȯ›· fiˆ˜ ÙË ÁÔÓȉȷ΋ ıÂڷ›·, ÙÔ˘˜ ·ÓÙÈ·ÁÁÂÈÔÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ÚfiÏÔ˘ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞Ó Î·È ÛÙËÓ È·ÙÚÈ΋ ÔÈ ÚԂϤ„ÂȘ Â›Ó·È ¿ÓÙ· ÂÈÛÊ·Ï›˜, ÈÛÙ‡ÂÙ·È fiÙÈ ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ı· Á›ÓÔ˘Ó Î·È Ù· ÌÈÎÚ¿ ‚‹Ì·Ù· ÚÔfi‰Ô˘ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÁÈ· ÙËÓ Â›Ù¢ÍË ›·Û˘ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, Ì ٷ˘Ùfi¯ÚÔÓË ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ¿ÌÂÛˆÓ Î·È ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Goodman LS, Wintrobe NM, Dameshek W, Goodman MJ, Gilman A, McLennan MT. Nitrogen mustard therapy. Use of methyl-bis-(beta-chloroethyl)amine hydrochloride and tris(beta-chloroethyl)amine hydrochloride for Hodgkin’s disease, lymphosarcoma, and certain allied and miscellaneous disorders. JAMA 1946;132:126-132. 2. Farber S, Diamond LK, Mercer RD, Wolff JA. Temporary remissions in acute leukemia in children produced by folic acid antagonist 4-aminopteroly-glutamic acid (aminopterin). N Engl J Med 1947;23:787. 3. Stickney JM, Heck FJ, Watkins CH. Cortisone and ACTH in the management of leukemia and lymphoblastoma. Proc Mayo Clin 1950;25:488.
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4. Elion GB, Hitchings GH, Vanderwerff H. Antagonists of nucleic acid derivatives. J Biol Chem 1951;192:505-518. 5. Burchenal JH, Murphy ML, Ellison RR et al. Clinical evaluation of a new antimetabolite, 6-mercaptopurine in the treatment of leukemia and allied diseases. Blood 1953;8:965-999. 6. Karon M, Freireich EJ, Frei E, Taylor R, Wolman IJ, Djerassi I, et al. The role of vincristine in the treatment of childhood acute leukemia. Pediatrics 1962;30:791-796. 7. Henderson ES. Combination chemotherapy of acute lymphocytic leukemia of childhood. Cancer Res 1967;27:2570-2572. 8. Pinkel D. Five year follow up of "total therapy" of childhood lymhocytic leukemia. JAMA 1971;216:648-655. 9. Skipper HE, Schabel FM, Wilcox W. Experimental evaluation of potential tumor agents: on the criteria and kinetics associated with curability of experimental leukemia. Cancer Chemother 1964;35:1. 10. Ortega JA, Nesbit ME, Sather HN, Robison LL, D'Angio GJ, Hammond GD. Long-term evaluation of a CNS prophylaxis trial-treatment comparisons and outcome after CNS relapse in childhood ALL: a report from the Children’s Cancer Study Group. J Clin Oncol 1987;5:1646-1654. 11. Miller DR, Leikin SL, Albo VC, Sather H, Hammond GD. Three versus five years of maintenance therapy are equivalent in childhood acute lymphoblastic leukemia: a report from the Children’s Cancer Study Group. J Clin Oncol 1989;7:316-325. 12. Packer RJ, Meadows AT, Rorke LB, Goldwein JL, D’Angio G. Long-term sequelae of cancer treatment in the central nervous system in childhood. Med Pediatr Oncol 1987;15:241. 13. Bleyer WA, Sather HN, Nickerson HJ, Coccia PF, Finklestein JZ, Miller DR et al. Monthly pulses of vincristine and prednisone prevent bone marrow and testicular relapse in low-risk childhood acute lymphoblastic leukemia: a report of the CCG-161 study by the Children’s Cancer Study Group. J Clin Oncol 1991;9:1012-1021. 14. Tubergen DG, Gilchrist GS, O'Brien RT, Coccia PF, Sather HN, Waskerwitz MJ et al. Prevention of CNS disease in intermediate-risk acute lymphoblastic leukemia: comparison of cranial radiation and intrathecal methotrexate and the importance of systemic therapy: a Children’s Cancer Group report. J Clin Oncol 1993;11:520-526. 15. Tubergen DG, Gilchrist GS, O’Brien RT, Coccia PF, Sather HN, Waskerwitz MJ et al. Improved outcome with delayed intensification for children with acute lymphoblastic leukemia and intermediate presenting features: a Children’s Cancer Group phase III trial. J Clin Oncol 1993;11:527-537. 16. Gaynon PS, Steinherz PG, Bleyer WA, Ablin AR, Albo VC, Finklestein JZ et al. Improved therapy for children with acute lymphoblastic leukemia and unfavorable presenting features: a follow-up report of the Children’s Cancer Group Study CCG-106. J Clin Oncol 1993;11:2234-2242. 17. Nachman J, Sather HN, Gaynon PS, Lukens JN, Wolff L,
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24. 25.
26. 27.
28.
Trigg ME. Augmented BFM therapy abrogates the adverse prognostic significance of slow early response to induction chemotherapy for children and adolescents with acute lymphoblastic leukemia and unfavorable presenting features: a report from the Children’s Cancer Group. J Clin Oncol 1997;15:2222-2230. Nachman J, Sather HN, Cherlow JM, Sensel MG, Gaynon PS, Lukens JN et al. Response of children with high risk acute lymphoblastic leukemia treated with and without cranial irradiation: a report from the Children’s Cancer Group. J Clin Oncol 1998;16:920-930. Riehm H, Gadner H, Henze G, Langermann HJ, Odenwald E. The Berlin childhood acute lymphoblastic leukemia therapy study 1979-76. Am J Pediatr Hematol Oncol 1980;2:299-308. Riehm H, Gadner H, Henze G, Kornhuber B, Lampert F, Niethammer D et al. Results and significance of six randomized trials in four consecutive ALL-BFM studies. Haematol Blood Transfus 1990;33:439. Riehm H, Feickert HJ, Schrappe M, Henze G, Schellong G. Therapy results in five ALL-BFM studies since 1970. Implications of risk factors for prognosis. Haematol Blood Transfus 1987;30:139-142. Reiter A, Schrappe M, Ludwig WD, Hiddemann W, Sauter S, Henze G et al. Chemotherapy in 998 unselected childhood acute lymphoblastic leukemia patients. Results and conclusions of the multicenter trial ALL-BFM 86. Blood 1994;84:3122-3133. Schrappe M, Reiter A, Ludwig WD, Harbott J, Zimmermann M, Hiddemann W et al. Improved outcome in childhood acute lymphoblastic leukemia despite reduced use of anthracyclines and cranial radiotherapy: results of trial ALL-BFM 90. Blood 2000;95:3310-3321. Pui CH, Evans WE. Acute lymphoblastic leukemia. N Engl J Med 1998;339:605-610. Meadows AT, Kramer S, Hepson R, Lustboden E, Jarrett P, Evans AE. Survival in childhood acute lymphocytic leukemia. Cancer Invest 1983;1:49-57. Kersey JH. Fifty years of studies of the biology and therapy of childhood leukemia. Blood 1997;90:4243-4251. Smith M, Arthur D, Camitta B, Carroll AJ, Crist W, Gaynon P et al. Uniform approach to risk classification and treatment assignment for children with acute lymphoblastic leukemia. J Clin Oncol 1996;14:18-24. Lange BJ. The ultra low risk child with acute lymphoblastic leukemia. Hematology 2000-Educational Program Book, 42nd Annual Meeting of the American Society of Hematology; San Francisco: 2000. p. 286-291.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 09-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÒÓÈÔ˜ ∫·ÙÙ¿Ì˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È §Â‚·‰›·˜, 115 27, °Ô˘‰› e-mail: ckatamis@cc.uoa.gr
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Paediatriki 2001;64:207-317
CONTINUING MEDICAL EDUCATION
1Ô ¶∞¡∂§§∏¡π√ ™À¡∂¢ƒπO À¶√∂π¢π∫√∆∏∆ø¡ ∆∏™ ¶∞π¢π∞∆ƒπ∫∏™
1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES
∆Ô 1Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙËÓ ∞ı‹Ó· ÛÙȘ 1 & 2 ∞ÚÈÏ›Ô˘ 2000, ·ÔÙ¤ÏÂÛ ¤Ó· ·fi Ù· ÎÔÚ˘Ê·›· ÂÈÛÙËÌÔÓÈο ÁÂÁÔÓfiÙ· ÙÔ˘ ÎÏ¿‰Ô˘ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙË ¯ÒÚ· Ì·˜. ∏ ·Ó¿ÁÎË Ù˘ Û˘ÓÂÚÁ·Û›·˜ Î·È ·ÓÙ·ÏÏ·Á‹˜ ÂÈÛÙËÌÔÓÔÎÒÓ ÏËÚÔÊÔÚÈÒÓ ÌÂٷ͇ ÙˆÓ ÁÂÓÈÎÒÓ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ·È‰È¿ÙÚˆÓ Û¯ÂÙÈο Ì ÙȘ ÚfiÛÊ·Ù˜ È·ÙÚÈΤ˜ ÂÍÂÏ›ÍÂȘ, Â›Ó·È ÂÈÙ·ÎÙÈ΋ Î·È ı· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÚ·ÈÙ¤Úˆ ÚfiÔ‰Ô Î·È ·Ó¿Ù˘ÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∂ÈÛÙ‹Ì˘. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ¢¯·ÚÈÛÙ› ıÂÚÌ¿ fiÛÔ˘˜ ·fi ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ÂȉÈÎÔ‡˜ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙËÓ ÚfiÛÎÏËÛ‹ Ì·˜ Ó· ‰ËÌÔÛÈ¢ıÔ‡Ó ÔÈ ÂÈÛËÁ‹ÛÂȘ ÙÔ˘˜.
The 1st Panhellenic Meeting of the Pediatric Subspecialties which was held in Athens on April 1 & 2 2000, proved to be one of the most significant events in the field of Pediatrics in our country. The need for cooperation and for exchange of scientific information among pediatric professionals and experts in regards to the latest medical developments, is absolutely essential and will contribute to the overall progress in the development of Pediatrics. The Scientific Editorial Board wishes to thank those participants who kindly responded to our invitation to publish their presentations.
™ÙÔ ∆‡¯Ô˜ ·˘Ùfi Ù˘ "¶∞π¢π∞∆ƒπ∫∏™" ‰ËÌÔÛȇÔÓÙ·È ÔÈ ÂÈÛÙËÌÔÓÈΤ˜ ÂÈÛËÁ‹ÛÂȘ ÙˆÓ Î¿ÙˆıÈ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜:
This issue of the Journal includes scientific presentations of the following Pediatric subspecialties:
1. ¡ÂÔÁÓÔÏÔÁ›· 2. ∞ÏÏÂÚÁÈÔÏÔÁ›· - ¢ÂÚÌ·ÙÔÏÔÁ›· 3. ∞ÓÔÛÔÏÔÁ›· - ƒÂ˘Ì·ÙÔÏÔÁ›· 4. ¡ÂÊÚÔÏÔÁ›· 5. ∂›ÁÔ˘Û· Î·È ∂ÓÙ·ÙÈ΋ ¶·È‰È·ÙÚÈ΋ 6. §ÔÈÌÒÍÂȘ 7. ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· 8. °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· - ∏·ÙÔÏÔÁ›· - ¢È·ÙÚÔÊ‹ 9. ™˘ÓÂÚÁ·˙fiÌÂÓ˜ ∂ȉÈÎfiÙËÙ˜
1. 2. 3. 4. 5. 6. 7. 8. 9.
Neonatology Allergiology - Dermatology Immunology - Rheumatology Nephrology Emergency and Intensive Care Pediatrics Infections Hematology - Oncology Gastroenterology - Hepatology - Nutrition Associated Subspecialties
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¡∂O°¡O§O°π∞
Paediatriki 2001;64:208-210
NEONATOLOGY
ÿÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·. ◊ Ì‹ˆ˜ Î·È Ù· ‰‡Ô; X. ∫ÒÛÙ·ÏÔ˜
Jaundice in the breast fed infant C. Costalos
¶ÂÚ›ÏË„Ë: ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó ¤¯Ô˘Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÈÎÙ¤ÚÔ˘ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ·›ÚÓÔ˘Ó Í¤ÓÔ Á¿Ï·. °‡Úˆ ·fi ÙËÓ ·ıÔÁ¤ÓÂÈ· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηٿÛÙ·Û˘ ·˘Ù‹˜ ÂÈÎÚ·Ù› Û‡Á¯˘ÛË Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙfi fiÙÈ Ô ›ÎÙÂÚÔ˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó ‰ÂÓ ·ÔÙÂÏ› ÂÓÈ·›· ÔÓÙfiÙËÙ· ·ÏÏ¿ ˘¿Ú¯Ô˘Ó ‰‡Ô ÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ÙÔ˘, Ë ÚÒÈÌË Î·È Ë fi„ÈÌË. ∏ ÚÒÈÌË ÔÊ›ÏÂÙ·È Û ·Ó·Ú΋ ÚfiÛÏË„Ë ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, ÂÓÒ Ë fi„ÈÌË ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Û ÓÂÔÁÓ¿ ·fiÏ˘Ù· Ê˘ÛÈÔÏÔÁÈο Ô˘ ıËÏ¿˙Ô˘Ó Â·ÚÎÒ˜. ∆Ô ¿ÚıÚÔ ·˘Ùfi ·Ó·ÛÎÔ› ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰‡Ô Ù‡ˆÓ ÈÎÙ¤ÚÔ˘ ÌÂ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜.
Abstract: It is well known that breastfed newborns have an increased incidence of jaundice. The epidemiology, physiologic basis and management of this situation has been confusing to many clinicians, primarily from failure to distinguish between the two different causes of exaggerated neonatal jaundice in breastfed infants, namely: 1. Early onset exaggeration of physiologic unconjugated hyperbilirubinemia associated with inadequate breastfeeding, which is the neonatal equivalent of starvation jaundice in the adult, and is designated as “breast feeding jaundice” and 2. Late-onset prolonged unconjugated hyperbilirubinemia associated with ingestion of breast milk, which begins at the end of the first week of life and may continue for several weeks and even months thereafter in healthy, thriving infants. This type is designated as “breast milk jaundice”. This article reviews the etiologic mechanisms of the two types of jaundice, with recommendations on their prevention and management.
§¤ÍÂȘ ÎÏÂȉȿ: ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ›ÎÙÂÚÔ˜.
Key words: breast feeding, hyperbilirubinemia, jaundice.
∞Ó Î·È Ô ›ÎÙÂÚÔ˜, Û ‚Ú¤ÊË Ô˘ ·›ÚÓÔ˘Ó Ê˘ÛÈ΋ ‰È·ÙÚÔÊ‹, ·ÔÙÂÏ› ·Ó¿Ú¯·ÈÔ Ê·ÈÓfiÌÂÓÔ, ÔÏÏ¿ ÂÚˆÙ‹Ì·Ù· ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Î·È Û‹ÌÂÚ· Ó· ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο Ì ÙËÓ ·ıÔÁ¤ÓÂÈ·, ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹˜ Ù˘ ÌÔÚÊ‹˜ ÙÔ˘. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ê·›ÓÂÙ·È ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, Û‡Ìʈӷ Ì ÙȘ Ôԛ˜ ÙÔ 13% ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÂÌÊ·Ó›˙Ô˘Ó ›ÎÙÂÚÔ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ (¤Ó·ÓÙÈ ÔÛÔÛÙÔ‡ 2,2-4% ÛÂ
ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó Í¤ÓÔ Á¿Ï·). ™Â fiÙÈ ·ÊÔÚ¿ ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÈÎÙ¤ÚÔ˘, ÔÚÈṲ̂ÓÔÈ ıˆÚÔ‡Ó fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÌÔÚʤ˜ ÈÎÙ¤ÚÔ˘, Ô ÚÒÈÌÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Î·È Ô fi„ÈÌÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·, ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ·ÈÙÈÔÏÔÁ›· Î·È ··ÈÙÔ‡Ó ‰È·ÊÔÚÂÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË (1). ÕÏÏÔÈ, ¿ÏÈ, ÂÚ¢ÓËÙ¤˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÔÈ ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘ Û ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó, ·ÔÙÂÏÔ‡Ó ‰‡Ô
¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ÏÂÍ¿Ó‰Ú·, ∞ı‹Ó·
Division of Neonatal Medicine Alexandra General Hospital, Athens
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‰È·ÊÔÚÂÙÈΤ˜ fi„ÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÌ›ÛÌ·ÙÔ˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ı· ·Ó·ÊÂÚıԇ̠ͯˆÚÈÛÙ¿ ÛÙȘ ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘, ÙÔÓ›˙ÔÓÙ·˜ fï˜ Î·È ÔÚÈṲ̂ӷ ÎÔÈÓ¿ ÛÙÔȯ›· Ô˘ ÙÔ˘˜ Û˘Ó‰¤Ô˘Ó. ¶ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi O ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÙȘ ÚÒÙ˜ 3-4 Ë̤Ú˜ ˙ˆ‹˜ Î·È ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Î·È ıÂÚÌ›‰ˆÓ. ™ÙÔ Û˘Ì¤Ú·ÛÌ· ·˘Ùfi Ô‰ËÁÔ‡Ó ÌÂϤÙ˜ Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ: ·) fiÏ· Ù· ÓÂÔÁÓ¿ Ì ÚÒÈÌÔ ›ÎÙÂÚÔ Â›¯·Ó ÌÂÁ¿ÏË ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Û ۇÁÎÚÈÛË Ì ¿ÏÏ· ÓÂÔÁÓ¿ Ô˘ ¤·ÈÚÓ·Ó ÌËÙÚÈÎfi Á¿Ï· Î·È ‰ÂÓ ¤Î·Ó·Ó ›ÎÙÂÚÔ ‹ Ì ·˘Ù¿ Ô˘ ¤·ÈÚÓ·Ó Í¤ÓÔ Á¿Ï·, ‚) ˘‹Ú¯Â ¿ÌÂÛË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜ Î·È Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È Á) Ë ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·fi 6 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Û 12 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Ì›ˆÛ ٷ ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ Û’ ÂΛӷ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ¤·ÈÚÓ·Ó Í¤ÓÔ Á¿Ï·. ∏ ·Ï·ÈfiÙÂÚ· ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë fiÙÈ Ô ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ÔÊ›ÏÂÙ·È Û ·Ê˘‰¿ÙˆÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¢ÛÙ·ı›, ·ÊÔ‡ Ë ÂÈϤÔÓ ¯ÔÚ‹ÁËÛË ÓÂÚÔ‡ ‹ ˙·¯·ÚfiÓÂÚÔ˘ Û ÓÂÔÁÓ¿ Ô˘ ı‹Ï·˙·Ó, fi¯È ÌfiÓÔ ‰ÂÓ Ì›ˆÛ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘, ·ÏÏ¿ ·ÓÙ›ıÂÙ· Ô‰‹ÁËÛ Û ˘„ËÏfiÙÂÚ· ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘. ™¯ÂÙÈο Ì ÙÔ Ì˯·ÓÈÛÌfi ̤ۈ ÙÔ˘ ÔÔ›Ô˘ Ë ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Ô‰ËÁ› Û ›ÎÙÂÚÔ, ‚Ú¤ıËΠfiÙÈ ·˘Ùfi˜ ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹, ÚfiÛÏË„Ë ‹ Û‡˙¢ÍË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙÔ ‹·Ú, ·ÏÏ¿ Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ. ∞˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ: ·) Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‹Ù·Ó ‰ÈÏ¿ÛÈ· Û ÓÂÔÁÓ¿ Ô˘ ·¤‚·ÏÏ·Ó ÌËÎÒÓÈÔ ÌÂÙ¿ ÙȘ ÚÒÙ˜ 8 ÒÚ˜ ˙ˆ‹˜, Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ¤‚Á·Ï·Ó ÌËÎÒÓÈÔ ÓˆÚ›ÙÂÚ· Î·È ‚) Ë ÔÛfiÙËÙ· Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙ· ÎfiÚ·Ó· ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË Û ÓÂÔÁÓ¿ Ì ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›Ì·ÙÔ˜ <5 mg/dL, Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ›¯·Ó ¯ÔÏÂÚ˘ıÚ›ÓË >10 mg/dL. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ Ë ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Ô‰ËÁ› Ì οÔÈÔ ¿ÁÓˆÛÙÔ Ì˯·ÓÈÛÌfi Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ (2). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ ÛËÌ›·: ·) ™ˆÛÙ‹ Âη›‰Â˘ÛË Ù˘ ÌËÙ¤Ú·˜ ÁÈ· Ù· ÔʤÏË Î·È ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∏ Âη›‰Â˘ÛË ·˘Ù‹ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Î·È Ó· Û˘Ó¯›˙ÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ·È‰ÈÔ‡, ‚) O ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜ (1 ÒÚ·) ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜, Á) ¡· ÌË ¯ÔÚËÁÂ›Ù·È ÓÂÚfi ‹ ˙·¯·ÚfiÓÂÚÔ ÛÙ· ÂӉȿÌÂÛ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ‰) ∆Ô ÓÂÔÁ¤ÓÓËÙÔ Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÛÙÔ ÛÙ‹ıÔ˜ 10 ‹ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, Â) ∫·Ù¿ ÙËÓ ·-
Paediatriki 2001;64:208-210
Ú·ÌÔÓ‹ ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ, ÙÔ ÓÂÔÁÓfi ÓÔÛËχÂÙ·È ÎÔÓÙ¿ ÛÙË ÌËÙ¤Ú· ÙÔ˘, ÛÙ) ∞Ó ÙÔ ÓÂÔÁ¤ÓÓËÙÔ ‰ÂÓ ¤¯ÂÈ Î·Ï¤˜ ıËÏ·ÛÙÈΤ˜ ÎÈÓ‹ÛÂȘ ‹ Â›Ó·È ÓˆıÚfi, Ë ÌËÙ¤Ú· Ú¤ÂÈ Ó· ·‰ÂÈ¿˙ÂÈ ÙÔ ÛÙ‹ıÔ˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ ıËÏ·ÛÌÔ‡ Î·È ÙÔ ÂÈϤÔÓ Á¿Ï· Ó· ¯ÔÚËÁÂ›Ù·È ÛÙÔ ‚Ú¤ÊÔ˜ Ì ÌÔ˘Î¿ÏÈ. ∞Ó Î·È Ô ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Â›Ó·È Û˘Ó‹ıˆ˜ ·ıÒÔ˜, ÂÈ‚¿ÏÏÂÙ·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂȤ‰ˆÓ ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›Ì·ÙÔ˜ Ù· ÚÒÙ· ÙÚ›· 24ˆÚ· ˙ˆ‹˜, ‰ËÏ·‰‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÌÔÓ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘¿Ú¯ÂÈ Ë Ù¿ÛË, ÙfiÛÔ ÛÙË µ. ∞ÌÂÚÈ΋ fiÛÔ Î·È ÛÙË ¢. ∂˘ÚÒË, Ó· ‰›ÓÂÙ·È ÂÍÈÙ‹ÚÈÔ ÛÙË ÌËÙ¤Ú· Î·È ÙÔ ‚Ú¤ÊÔ˜ ̤۷ ÛÙȘ ÚÒÙ˜ 2448 ÒÚ˜ ·fi ÙÔÓ ÙÔÎÂÙfi. ∆Ô Ì¤ÙÚÔ ·˘Ùfi ¤¯ÂÈ Û›ÁÔ˘Ú· ÔÚÈṲ̂ӷ ÔÈÎÔÓÔÌÈο Î·È ÎÔÈÓˆÓÈο ÏÂÔÓÂÎÙ‹Ì·Ù·, ÂÓ¤¯ÂÈ fï˜ Î·È ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜, ·ÊÔ‡ ÌÔÚÔ‡Ó ¤ÙÛÈ Ó· ‰È·Ï¿ıÔ˘Ó ÛÔ‚·Ú¤˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· ·ÏÏ¿ Î·È ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·. ¶Ú¿ÁÌ·ÙÈ, Ô ·ÚÈıÌfi˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÛÔ‚·Ú‹ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· (¯ÔÏÂÚ˘ıÚ›ÓË >30 mg/dL) ÂÙ·Ï·ÛÈ¿ÛÙËΠٷ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™ÙËÓ ÂÍ·ÂÙ›· 1990-1996 ÂÈÛ‹¯ıËηÓ, Û ‰È¿ÊÔÚ· ÓÔÛÔÎÔÌ›· ÙˆÓ ∏¶∞, 31 ÓÂÔÁÓ¿ Ì ˘ÚËÓÈÎfi ›ÎÙÂÚÔ, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ù· 30 ¤·ÈÚÓ·Ó ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ŸÏ· ·˘Ù¿ Ù· ÓÂÔÁÓ¿ ›¯·Ó ¿ÚÂÈ ÂÍÈÙ‹ÚÈÔ ·fi ÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ ÚÈÓ Û˘ÌÏËÚÒÛÔ˘Ó 72 ÒÚ˜. ŸÏ· Ù· ÓÂÔÁÓ¿ ›¯·Ó ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Ô˘ ÍÂÂÚÓÔ‡Û ÙÔ 10% ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘. °È· ÙÔ˘˜ ·Ú·¿Óˆ ÏfiÁÔ˘˜, Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ Û˘ÓÈÛÙ¿: “∞Ó ÙÔ ÓÂÔÁ¤ÓÓËÙÔ ÂͤÏıÂÈ ÙÔ˘ Ì·È¢ÙËÚ›Ô˘ ÚÈÓ Û˘ÌÏËÚÒÛÂÈ 72 ÒÚ˜ ˙ˆ‹˜, ÂÈ‚¿ÏÏÂÙ·È Â·ÓÂÎÙ›ÌËÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘ ·ÏÏ¿ Î·È Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡ ̤۷ Û 2-3 Ë̤Ú˜ ·fi ÙËÓ ¤ÍÔ‰Ô”. ¶ÚÔÁÓˆÛÙÈο ¤¯ÂÈ ‚ÚÂı› fiÙÈ ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·›Ì·ÙÔ˜ ÛÙȘ 24 ÒÚ˜ ˙ˆ‹˜ Â›Ó·È <5 mg/dL, ÙfiÙÂ Ë Èı·ÓfiÙËÙ· Ó· ˘Âڂ› Ë ÙÈÌ‹ Ù˘ Ù· 17 mg ÛÙȘ 7296 ÒÚ˜ ˙ˆ‹˜ Â›Ó·È ·Û‹Ì·ÓÙË. Ÿ„ÈÌÔ˜ ›ÎÙÂÚÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï· Ÿ„ÈÌÔ˜ ›ÎÙÂÚÔ˜ oÓÔÌ¿˙ÂÙ·È Ë ÂÌÊ¿ÓÈÛË ÈÎÙ¤ÚÔ˘ ÌÂÙ¿ ÙËÓ 4Ë Ë̤ڷ ˙ˆ‹˜ Î·È Ë ÂÈÌÔÓ‹ ÙÔ˘ ÁÈ· 1, 2 ‹ Î·È ÂÚÈÛÛfiÙÂÚÔ˘˜ Ì‹Ó˜. ∆Ô 1/3 ÂÚ›Ô˘ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÌÊ·Ó›˙ÂÈ ›ÎÙÂÚÔ ÙËÓ 3Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜. O ›ÎÙÂÚÔ˜ ·˘Ùfi˜ ıˆÚÂ›Ù·È fiÙÈ ‰È·Ê¤ÚÂÈ ·fi ÙÔÓ ÚÒÈÌÔ ›ÎÙÂÚÔ. ¶·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÈÎÙ¤ÚÔ˘. To 1963 Ô ∞rias Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ·ÔÌfiÓˆÛ·Ó Ì›· Ô˘Û›· ÛÙÔ Á¿Ï· (ÚÂÁÓ·Ó‰ÈfiÏË), Ë ÔÔ›· ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰Ú¿ÛË Ù˘ ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿Û˘, ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‰ËÏ·‰‹ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙË Û‡˙¢ÍË Ù˘ ¯ÔÏÂÚ˘-
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¶·È‰È·ÙÚÈ΋ 2001;64:208-210
ıÚ›Ó˘ ÛÙÔ ‹·Ú Ì ‰ÈÁÏ˘ÎÔ˘ÚÔÓ›‰È·. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜, fï˜, ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ÙËÓ ·Ó·Î¿Ï˘„Ë ·˘Ù‹. ™ÙË Û˘Ó¤¯ÂÈ·, ‚Ú¤ıËΠfiÙÈ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË ÔÛfiÙËÙ· ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, Ù· ÔÔ›· ·‰Ú·ÓÔÔÈÔ‡Ó ÙË ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿ÛË. O‡ÙÂ Î·È Ë ıˆڛ· ·˘Ù‹ fï˜ ÂȂ‚·ÈÒıËΠ·fi ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜. ªÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·‰Ú·ÓÔÔ›ËÛË Ù˘ ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿Û˘ ÛÙÔ ‹·Ú, ·ÏÏ¿ Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ. ∏ ·˘ÍË̤ÓË ·˘Ù‹ ·ÔÚÚfiÊËÛË ·Ô‰fiıËΠ·Ú¯Èο Û ·˘ÍË̤ӷ ›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‚ÁÏ˘ÎÔ˘ÚÔÓȉ¿Û˘ ÛÙÔ ¤ÓÙÂÚÔ. ∆Ô ¤Ó˙˘ÌÔ ·˘Ùfi, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, ‰È·Û¿ ÙËÓ ¤ÓˆÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Ì ٷ ‰ÈÁÏ˘ÎÔ˘ÚÔÓ›‰È·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÂÏ¢ıÂÚÒÓÂÙ·È Ë ¤ÌÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË, Ë ÔÔ›· ÛÙË Û˘Ó¤¯ÂÈ· ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ¤ÓÙÂÚÔ. O‡Ù ÎÈ ·˘Ù‹ Ë ¿Ô„Ë, fï˜, ÂȂ‚·ÈÒıËΠÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ. ∏ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Û‹ÌÂÚ· Â›Ó·È fiÙÈ Ù· ·˘ÍË̤ӷ ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ Ì fi„ÈÌÔ ›ÎÙÂÚÔ ÔÊ›ÏÔÓÙ·È Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ÂÙÈÎfi, Û·Ó Û˘Ó¤ÂÈ· ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· (3). ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fi„ÈÌÔ˘ ÈÎÙ¤ÚÔ˘. ∆· ‚Ú¤ÊË Ì ÙÔÓ fi„ÈÌÔ˘ Ù‡Ô˘ ›ÎÙÂÚÔ Â›Ó·È Î·ı’ fiÏ· Ê˘ÛÈÔÏÔÁÈο ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·È Î·ÓÔÓÈο, ÎÂÚ‰›˙Ô˘Ó ‚¿ÚÔ˜ Î·È Ë ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ÙÔ˘˜ Â›Ó·È ¤ÌÌÂÛÔ˘ Ù‡Ô˘. ∂Ô̤ӈ˜, ·Ó ÙÔ ‚Ú¤ÊÔ˜ ÛÙȘ 14 Ë̤Ú˜ ˙ˆ‹˜ Â›Ó·È ˙ˆËÚfi, ‰ÂÓ ¤¯ÂÈ Ë·ÙÔÛÏËÓÈÎfi, Ù· Ô‡Ú· ÙÔ˘ ‰ÂÓ Â›Ó·È ÛÎÔ˘Úfi¯ÚˆÌ· Î·È Ù· ÎfiÚ·Ó¿ ÙÔ˘ ‰ÂÓ Â›Ó·È ·Ô¯ÚˆÌ·ÙÈṲ̂ӷ, ÙfiÙ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·Ì›· ¤̂·ÛË Î·È Û˘ÓÈÛÙ¿Ù·È Â·ÓÂͤٷÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ∞Ó fï˜ ÙÔ ÓÂÔÁÓfi ÛÙȘ 21 Ë̤Ú˜ ˙ˆ‹˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÌÊ·Ó›˙ÂÈ ›ÎÙÂÚÔ, ÙfiÙ ··ÈÙÂ›Ù·È ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÙ›·˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘. ª›· ÂÓ·ÏÏ·ÎÙÈ΋ χÛË Â›Ó·È Ë ‰È·ÎÔ‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· 24 ÒÚ˜, ÔfiÙ ‰È·ÈÛÙÒÓÂÙ·È ¿ÌÂÛË ÙÒÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÌÂÙ¿ ·fi 24 ÒÚ˜, Ë ÔÔ›· Êı¿ÓÂÈ ÙÔ 50% ̤۷ Û 2-3 Ë̤Ú˜. ∞˘Ù‹ Ë ÂÓ¤ÚÁÂÈ·, fï˜, ‰ÂÓ Û˘ÓÈÛٿٷÈ, ·Ú¿ ÌfiÓÔ ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·›Ì·ÙÔ˜ ˘Âڂ› Ù· 20 mg/dL.
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™¯¤ÛË ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Î·È ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi Á¿Ï· ∏ ‚·ÛÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ·˘ÙÒÓ Ù‡ˆÓ ÈÎÙ¤ÚÔ˘ Â›Ó·È fiÙÈ Ô ÌÂÓ ÚÒÈÌÔ˜ ÔÊ›ÏÂÙ·È Û ·Ó·Ú΋ ÚÔÛÊÔÚ¿ ‹ Ï‹„Ë Á¿Ï·ÎÙÔ˜, ÂÓÒ Ô fi„ÈÌÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Û ÓÂÔÁÓ¿ Ô˘ ÙÚ¤ÊÔÓÙ·È ÈηÓÔÔÈËÙÈο. Œ¯ÂÈ ‚ÚÂı›, fï˜, fiÙÈ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÓÂÔÁÓÒÓ Ì fi„ÈÌÔ ›ÎÙÂÚÔ Â›¯Â ˘„ËÏ¿ ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ÙȘ ÚÒÙ˜ 4 Ë̤Ú˜ ˙ˆ‹˜ (ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜). ∫·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ, ÂÍ¿ÏÏÔ˘, ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓÔ˜ ÂÓÙÂÚÔË·ÙÈÎfi˜ ·ÎÏÔ˜ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÔÈ ‰‡Ô ·˘ÙÔ› ›ÎÙÂÚÔÈ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙ˜ ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜, ·ÏÏ¿ ‰È·ÊÔÚÂÙÈΤ˜ fi„ÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÌ›ÛÌ·ÙÔ˜. °È· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ›Ûˆ˜, ı· Ú¤ÂÈ Ó· ÂÍ·ÎÔÏÔ˘ı‹ÛÂÈ Ó· ˘Ê›ÛÙ·Ù·È ·˘Ù‹ Ë ‰È·ÊÔÚÔÔ›ËÛË ÁÈ· Ó· ‰›‰ÂÙ·È ¤ÌÊ·ÛË ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·, ·ÏÏ¿ Û ·Ó·Ú΋ ıËÏ·ÛÌfi. ∂Ô̤ӈ˜, Â›Ó·È Ï¿ıÔ˜ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ‰È·ÎÔ‹ ÙÔ˘ ÛÙ‹ıÔ˘˜ Î·È Î·Ù·Ê˘Á‹ ÛÙÔ ÌÔ˘Î¿ÏÈ. ∞ÓÙ›ıÂÙ·, Û˘ÛÙ‹ÓÂÙ·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ÚÔÛ¿ıÂÈ·˜ ÁÈ· ηχÙÂÚÔ ıËÏ·ÛÌfi ÛÙÔ ÛÙ‹ıÔ˜. ∫·Ù·Ï‹ÁÔÓÙ·˜, ÌÔÚԇ̠ӷ ԇ̠fiÙÈ Ô ›ÎÙÂÚÔ˜ Û ‚Ú¤ÊÔ˜ Ô˘ ıËÏ¿˙ÂÈ ÛˆÛÙ¿ ·ÔÙÂÏ› ·ıÒÔ Ê·ÈÓfiÌÂÓÔ Î·È Û¯Â‰fiÓ ÔÙ¤ ‰ÂÓ Ú¤ÂÈ Ó· ·ÔÙÂÏ› ·ÈÙ›· ‰È·ÎÔ‹˜ ÙÔ˘ ıËÏ·ÛÌÔ‡. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gartner LM, Lee K. Jaundice in the breast fed infant. Clin Perinatol 1999;26:431-445. 2. Maisels MJ, Newman TB. Jaundice in full term and near term babies who leave the hospital within 36 hours. Clin Perinatol 1998;25:295-302. 3. Johnson L, Bhutani VK. Guidelines for management of the jaundiced term and near term infants. Clin Perinatol 1998;25:555-574.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: X. ∫ÒÛÙ·ÏÔ˜ ∞ÚÙ¤ÌȉԘ 130, ¶. º¿ÏËÚÔ, 175 62
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∞§§∂ƒ°π√§√°π∞ - ¢∂ƒª∞∆√§√°π∞
Paediatriki 2001;64:211-214
ALLERGIOLOGY -
∆È Â›Ó·È, ÙÈ ‰ÂÓ Â›Ó·È ¿ÛıÌ·; ∫. ¡. ¶Ú›ÊÙ˘
What is, what is not asthma? K. N. Priftis
¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÂ Û˘ÓÙÔÌ›· Ô ÔÚÈÛÌfi˜ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Î·È ÔÈ Î·ıËÌÂÚÈÓ¤˜ ‰È·ÁÓˆÛÙÈΤ˜ ‰˘ÛÎÔϛ˜. ∂Í·ÈÙ›·˜ ÙˆÓ ÔÏÏÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ÔÚÈÛÌfi ·ÏÏ¿ Î·È Ù˘ ÔÈÎÈÏ›·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘ ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ÙÔ ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ ·ÔÙÂÏ› ÙË ‚¿ÛË ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ “‡ÔÙÔ˘” Ó·ÚÔ‡ ·ÛıÂÓÔ‡˜. OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÏËÚÔÊÔڛ˜ ¤¯Ô˘Ó Û˘ÌÏËڈ̷ÙÈÎfi ÚfiÏÔ.
Abstract: The definition of bronchial asthma and the every day diagnostic dificulties are briefly described. The complex nature of asthma itself and the phenotypic variety of childhood asthma have lead to the use of the clinical approach as the main diagnostic tool in paediatric practice. Laboratory investigation has a complementary role.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ¿ÛıÌ·, ÔÚÈÛÌfi˜, ‰È¿ÁÓˆÛË.
Key words: diagnosis.
∂ÈÛ·ÁˆÁ‹ ™ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ, Ë ˘ÔÙÚÔÈ¿˙Ô˘Û· ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î·È ÂȉÈÎfiÙÂÚ· Ô ˘ÔÙÚÔÈ¿˙ˆÓ ‚‹¯·˜ Î·È Û˘ÚÈÁÌfi˜ ¤¯Ô˘Ó ηٷÛÙ› ·fi ÙȘ ÚÒÙ˜ ·Èٛ˜ ›Û΄˘ ·ÛıÂÓÒÓ ÛÙ· ·È‰È·ÙÚÈο È·ÙÚ›·. ∫·Ù¿ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÈÔ ¿Óˆ Û˘Ìو̿وÓ, Ôχ Û˘¯Ó¿ Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó Ù· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ı· Ú¤ÂÈ Ó· ÂÎÏËÊıÔ‡Ó ˆ˜ ‰ËψÙÈο ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÓÙ·ÂÙ›· ˘‹ÚÍ ÌÂÁ¿ÏË ÚfiÔ‰Ô˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ¢ÂÓ ˘‹ÚÍÂ, fï˜, ·Ó¿ÏÔÁË ÚfiÔ‰Ô˜ ÛÙËÓ ÚÔÙÂÈÓfiÌÂÓË ‰È·ÁÓˆÛÙÈ΋ Ú·ÎÙÈ΋. ∞ÓÙ›ıÂÙ·, ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·‰Ô¯Èο Ú‡̷ٷ Ù¿ÛÂˆÓ ˘Ô‰È¿ÁÓˆÛ˘ Î·È ÙÂÏÂ˘Ù·›·, ˘ÂډȿÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘. ø˜ ·Ó¿ÁÎË Ï¤ÔÓ, ·fi ÙȘ ·Ú¯¤˜ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ‰ÂηÂÙ›·˜, ¤ÁÈÓ·Ó ·fiÂÈÚ˜ ‰È·Ù‡ˆÛ˘ ÎÔÈÓ¿ ·Ô‰ÂÎÙÔ‡ ÔÚÈÛÌÔ‡ ÙÔ˘ ¿ÛıÌ·ÙÔ˜. O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ηÏÂ›Ù·È Ó· ηχ„ÂÈ
·Ó¿ÁΘ, fi¯È ÌfiÓÔ ÛÙÔ Â›Â‰Ô Ù˘ ηıËÌÂÚÈÓ‹˜ ‰È·ÁÓˆÛÙÈ΋˜ Ú·ÎÙÈ΋˜, ·ÏÏ¿ Î·È ÛÙÔ ÂÚ¢ÓËÙÈÎfi ›‰Ô. ™˘Ó¤ÂÈ· ·˘ÙÔ‡ Â›Ó·È Î·È Ë ÚÔ‚ÔÏ‹ ÙˆÓ ÔÈÎ›ÏˆÓ ÎÚÈÙËÚ›ˆÓ ·Ó¿ÏÔÁ· Ì ÙÔ ÛÎÔfi ÁÈ· ÙÔÓ ÔÔ›Ô ‰È·Ù˘ÒÓÂÙ·È (1). ¢È·ÊÔÚÂÙÈÎfi Â›Ó·È ÙÔ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi Ô˘ ÂÎÙÈÌ¿ ÙÔ ÌÂÌÔӈ̤ÓÔ ·ÛıÂÓ‹ ÙÔ˘ Î·È ‰È·ÊÔÚÂÙÈÎfi ÁÈ· ÙÔÓ ÂȉËÌÈÔÏfiÁÔ Ô˘ ‚·Û›˙ÂÙ·È Û οÔÈÔ ·Ïfi ÎÔÈÓfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘ (Û˘ÚÈÁÌfi˜), ÙÔÓ Ê˘ÛÈÔÏfiÁÔ Ô˘ ·Ó·˙ËÙ¿ ÌÂÙÚ‹ÛÈ̘ ·Ú·Ì¤ÙÚÔ˘˜ (Ì›ˆÛË Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú· ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜), ÙÔÓ ·ÓÔÛÔÏfiÁÔ Ô˘ ¯ÚËÛÈÌÔÔÈ› ·ÓÔÛÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ‹ ÙÔÓ ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ Ô˘ ¯ÚËÛÈÌÔÔÈ› ÈÛÙÔÏÔÁÈο ‰Â›ÁÌ·Ù· ÁÈ· Ó· ÂÓÙÔ›ÛÂÈ ÙË ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ·È‰È¿ÙÚÔ˘ Ô˘ ηÏÂ›Ù·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ Úfi‚ÏËÌ· ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓÔ‡˜, ·ÛÊ·ÏÒ˜ ÚÔ¤¯ÂÈ ÙÔ ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ, ·ÏÏ¿ Î·È ·˘Ùfi ‰ÂÓ ‰È·ÛÊ·Ï›˙ÂÈ ÙË ‰È¿ÁÓˆÛË. ∂ÈϤÔÓ,
∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·
Division of Allergy Penteli Children’s General Hospital, Athens
childhood
asthma,
definition,
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ÂÎÊÚ¿˙ÂÙ·È ÂÈÊ˘Ï·ÎÙÈÎfiÙËÙ·, fiÙ·Ó Û˘ÌÂÚ¿ÛÌ·Ù· ·fi ·Ú·ÙËÚ‹ÛÂȘ Û ·ÛıÌ·ÙÈÎÔ‡˜ ÂÓ‹ÏÈÎÔ˘˜ ÌÂٷʤÚÔÓÙ·È ÛÙ· ·È‰È¿ Î·È ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÛÙ· ‚Ú¤ÊË (2). OÚÈÛÌfi˜ O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ô˘ ÚoÙ¿ıËΠÙÔ 1995 ·fi ÙË GINA (Global Initiative for Asthma) Î·È Â›Ó·È Û‹ÌÂÚ· Ô Ï¤ÔÓ ·Ô‰ÂÎÙfi˜, ‰È·Ù˘ÒÓÂÙ·È ˆ˜ ·ÎÔÏÔ‡ıˆ˜ (3,4): “∆Ô ¿ÛıÌ· ·ÔÙÂÏ› ¯ÚfiÓÈ· ÊÏÂÁÌÔÓÒ‰Ë ‰È·Ù·Ú·¯‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ¤¯Ô˘Ó ‰È¿ÊÔÚ· ·ÙÙ·Ú·, ȉȷ›ÙÂÚ· Ì·ÛÙÔ·ÙÙ·Ú·, ˈÛÈÓfiÊÈÏ· Î·È ∆ ÏÂÌÊÔ·ÙÙ·Ú·. ™Â ¢·ÈÛıËÙÔÔÈË̤ӷ ¿ÙÔÌ·, Ë Î·Ù¿ÛÙ·ÛË Ô‰ËÁ› Û ·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi Û˘ÚÈÁÌfi, ‰‡ÛÓÔÈ·, Û˘ÛÊÈÎÙÈÎfi ¿ÏÁÔ˜ ÛÙÔ ıÒڷη Î·È ‚‹¯·, ȉȷ›ÙÂÚ· ηٿ ÙȘ Ó˘ÎÙÂÚÈÓ¤˜ Î·È ÚÒÙ˜ ÚˆÈÓ¤˜ ÒÚ˜. ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ Û˘Ó‹ıˆ˜ ÔÊ›ÏÔÓÙ·È Û ÛËÌ·ÓÙÈÎfi (·ÏÏ¿ ‰È¿ÊÔÚÔ˘ ‚·ıÌÔ‡) ÂÚÈÔÚÈÛÌfi Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú·, ÂÓ Ì¤ÚÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ·Ó·ÛÙÚ¤„ÈÌÔ, ›Ù ·˘ÙfiÌ·Ù·, ›Ù Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÁˆÁ‹. ∏ ÊÏÂÁÌÔÓ‹ Ô‰ËÁ›, ›Û˘, Û ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ”. ¢ËÏ·‰‹, ÁÈ· ÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û ÙÚ›· ›‰·: ÙÔ ÈÛÙÔÏÔÁÈÎfi (ÊÏÂÁÌÔÓ‹), ÙÔ ÎÏÈÓÈÎfi (Û˘ÌÙÒÌ·Ù·, ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·), ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (‚ÚÔÁ¯È΋ ·ÓÙȉڷÛÙÈÎfiÙËÙ·). ∞Ó Î·È Ô ÔÚÈÛÌfi˜ ·˘Ùfi˜ ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ Ô‰ËÁfi, Ë ·Í›· ÙÔ˘ ·Ú·Ì¤ÓÂÈ ÂÚÈÔÚÈṲ̂ÓË ÁÈ· ‰‡Ô ·ÚÈÔ˘˜ ÏfiÁÔ˘˜: ¶ÚÒÙÔÓ, ‰ÈfiÙÈ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋ ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈ̘ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ˘¿Ú¯Ô˘Û˜ ÌÂıfi‰Ô˘˜ ÂϤÁ¯Ô˘ ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜, Ù˘ ‚ÚÔÁ¯ÔÛÙ¤ÓˆÛ˘ Î·È Ù˘ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜. ¢Â‡ÙÂÚÔÓ, ‰ÈfiÙÈ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ ‰ÂÓ Â›Ó·È ÙÂÎÌËÚȈ̤ÓË Ë ÈÛ¯‡˜ fiÏˆÓ ÙˆÓ ÈÔ ¿Óˆ ÛÙÔȯ›ˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ÔÚÈÛÌfi. ™Ù· ‚Ú¤ÊË, ÔÈ ÁÓÒÛÂȘ Ì·˜ ÁÈ· ÙËÓ ˘ÔΛÌÂÓË ·ıÔÊ˘ÛÈÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ Â›Ó·È ÂÏÏÈ›˜ Î·È Ë ‰È¿ÁÓˆÛË Î·Ù¿ ‚¿ÛË ·Ú·Ì¤ÓÂÈ ÎÏÈÓÈ΋. ∆Ô ‚ÚÂÊÈÎfi ¿ÛıÌ· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÂÈÛfi‰È· ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌÔ‡ ηÈ/‹ ›ÌÔÓÔ˘ ‚‹¯·, Û ¤‰·ÊÔ˜ Ô˘ ‰È¢ÎÔχÓÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (.¯. Û˘ÓÔ‰fi˜ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·ÙÔÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi) ·ÊÔ‡ ¤¯Ô˘Ó ·ÔÎÏÂÈÛÙ› ÔÈ ¿ÏϘ Èı·Ó¤˜ ·Èٛ˜ (5-8). ™Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο ۷ʤÛÙÂÚ· ‰Â‰Ô̤ӷ, ¤ÙÛÈ ÒÛÙ ӷ ıˆÚÂ›Ù·È Ì›· ÂӉȿÌÂÛË Î·Ù¿ÛÙ·ÛË. ∂ÓÒ, Ì ÙËÓ ÚfiÔ‰Ô Ù˘ ËÏÈΛ·˜ (Û¯ÔÏÈ΋ ËÏÈΛ·) ÈÛ¯‡ÂÈ Â˘Ú¤ˆ˜ Ô ÎÏ·ÛÈÎfi˜ ÔÚÈÛÌfi˜ (2).
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ÀÔÙÚÔÈ¿˙ˆÓ Û˘ÚÈÁÌfi˜ ‚ÚÂÊÈ΋˜ Î·È ÌÈÎÚ‹˜ ·È‰È΋˜ ËÏÈΛ·˜ ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ ÙÔ˘ F. Martinez (9-11) Ô‰‹ÁËÛ·Ó ÛÙËÓ Ù·ÍÈÓfiÌËÛË 3 ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi: ·) ™Ù· ·È‰È¿ Ì ·ÚÔ‰ÈÎfi ÚÒÈÌÔ Û˘ÚÈÁÌfi Ô˘ ÂΉËÏÒÓÔ˘Ó ÙÔ Û‡Ìو̷ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ·ÏÏ¿ ˆ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ Â›Ó·È ÂχıÂÚ·. ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ Ì ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó, ‚) ™Ù· ·È‰È¿ Ì fi„ÈÌÔ Û˘ÚÈÁÌfi Ô˘ ÂΉËÏÒÓÔ˘Ó ÙÔ Û‡Ìو̷ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ. ¶·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË Ì ÙÔ ÌËÙÚÈÎfi ¿ÛıÌ· Î·È Á) ™Â ÂΛӷ Ì ›ÌÔÓÔ Û˘ÚÈÁÌfi Ô˘ ÙÔ Û‡Ìو̷ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Î·È ‰È·ÚΛ. ∫·È Â‰Ò ·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË Ì ÙÔ ÌËÙÚÈÎfi ¿ÛıÌ·, ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜, ÙËÓ ÂΉ‹ÏˆÛË Û˘ÚÈÁÌÔ‡ ¯ˆÚ›˜ ÈÒÛÂȘ Î·È ÙËÓ ·ÚÔ˘Û›· Û˘ÓÔ‰Ô‡ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ë ÔÏÈ΋ πgE ÙÔ˘ ÔÚÔ‡ Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙ· ·È‰È¿ Ì ›ÌÔÓÔ Û˘ÚÈÁÌfi, ÂÓÒ ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ (¢·ÈÛıËÙÔÔ›ËÛË) ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ì fi„ÈÌÔ Î·È Â›ÌÔÓÔ Û˘ÚÈÁÌfi. º·›ÓÂÙ·È, ‰ËÏ·‰‹, fiÙÈ Ë ‰È¿ÁÓˆÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ÌÔÚ› Ó· Û˘˙ËÙÂ›Ù·È “·ÛʷϤÛÙÂÚ·” ÛÙ· ·È‰È¿ Ì ÙÔÓ fi„ÈÌÔ Î·È Â›ÌÔÓÔ Û˘ÚÈÁÌfi. EÙÂÚÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ∆Ô ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ¤Ó· Ê·ÈÓÔÙ˘Èο ÂÙÂÚÔÁÂÓ¤˜ ÓfiÛËÌ·. ∞˘Ùfi Á›ÓÂÙ·È Úfi‰ËÏÔ ·fi ÙÔ ÌÂÁ¿ÏÔ Â‡ÚÔ˜ Ù˘ ËÏÈΛ·˜ ¤Ó·Ú͢, Ù˘ ÎÏÈÓÈ΋˜ ÚÔ‚ÔÏ‹˜ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ηÈ, Ù¤ÏÔ˜, Ù˘ ‰È·ÊÔÚÂÙÈ΋˜ ·¿ÓÙËÛ˘ ÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ (1). ∂ȉÈÎfiÙÂÚ˜ ÌÔÚʤ˜, fiˆ˜ ÙÔ ‚ÚÂÊÈÎfi ¿ÛıÌ·, ÙÔ ¿ÛıÌ· ÌÂÙ¿ ·fi ¿ÛÎËÛË, ÙÔ Ó˘ÎÙÂÚÈÓfi ¿ÛıÌ·, ÙÔ ÏÔÈÌ҉˜ ¿ÛıÌ· ·ÔÙÂÏÔ‡Ó ‰È·ÊÔÚÂÙÈΤ˜ ÂÎÊÚ¿ÛÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ¶·Ú¿ÏÏËÏ·, ˘¿Ú¯Ô˘Ó ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ Ô˘ ·ÁÁ›˙Ô˘Ó ÙÔ ·È‰ÈÎfi ¿ÛıÌ· Ì ‰˘Û‰È¿ÎÚÈÙ· fiÚÈ·, fiˆ˜ Â›Ó·È Ô ÌÂÙ·‚ÚÔÁ¯ÈÔÏÈÙȉÈÎfi˜ Û˘ÚÈÁÌfi˜, Ô ‚‹¯·˜ ÈÛÔ‰‡Ó·ÌÔ˜ ¿ÛıÌ·ÙÔ˜, Ë °O¶ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î.¿. ™ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È¿ÊÔÚ· ÂÚÁ·Ï›· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÓfiÛÔ˘. ∞˘Ù¿ ›ӷÈ: 1) ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, fiÔ˘ ÌÂ Ù˘ÔÔÈË̤Ó˜ ÂÚˆÙ‹ÛÂȘ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ·ÓȯÓ‡ÂÙ·È Ë ÓfiÛÔ˜ ·fi ÙËÓ ÂΉ‹ÏˆÛË ·ÛıÌ·ÙÈÎÒÓ Û˘Ìو̿وÓ, ‹ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÁÈ·ÙÚÔ‡ Ô˘ ÌÔÚ› Ó· ¤ÁÈÓ Û οÔÈ· Ê¿ÛË Ù˘ ̤¯ÚÈ ÙÒÚ· ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡, 2) OÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜
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ÙˆÓ Ó¢ÌfiÓˆÓ, fiˆ˜ Â›Ó·È Ë ‰ÔÎÈÌ·Û›· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜, Ô ¤ÏÂÁ¯Ô˜ ÁÈ· Ù˘¯fiÓ ‚ÚÔÁ¯È΋ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·, 3) O ¤ÏÂÁ¯Ô˜ ·ÙÔ›·˜ (‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜, Rast). ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·È Ù· ÙÚ›· ÈÔ ¿Óˆ ÂÚÁ·Ï›·, ·ÏÏ¿ fiÏ· ¤¯Ô˘Ó ·‰˘Ó·Ì›Â˜ ÒÛÙ ӷ ·Ú·Ì¤ÓÂÈ Úfi‚ÏËÌ· Ô ÙÚfiÔ˜ ·ÎÚÈ‚Ô‡˜ ÂÚÌËÓ›·˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Î·È ·Ó›¯Ó¢Û˘ Ù˘ ÓfiÛÔ˘ ÏfiÁˆ Ù˘ Ê·ÈÓÔÙ˘È΋˜ ÂÙÂÚÔÁ¤ÓÂÈ·˜ (12). ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋, Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ‚·Û›˙ÂÙ·È ÚˆÙ›ÛÙˆ˜ ÛÙÔ ÈÛÙÔÚÈÎfi. ™ÙË Û˘Ó¤ÓÙ¢ÍË Ì ÙÔ˘˜ ÁÔÓ›˜ ¯ÚÂÈ¿˙ÂÙ·È Î·Ïfi Îϛ̷ Î·È ÈηÓfi˜ ¯ÚfiÓÔ˜, ÒÛÙ Ì ÙȘ ηٿÏÏËÏ· ‰È·Ù˘ˆÌ¤Ó˜ Î·È Î·Ù·ÓÔËÙ¤˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÚˆÙ‹ÛÂȘ Ô ·È‰›·ÙÚÔ˜ Ó· Â›Ó·È Û ı¤ÛË Ó· Û¯ËÌ·Ù›ÛÂÈ ¿Ô„Ë. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ÛÙËÓ ÔÍ›· ‹ ·ÎfiÌ· Î·È ÛÙËÓ ÂӉȿÌÂÛË Ê¿ÛË ÌÔÚ› Ó· ÚÔÛı¤ÛÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜. øÛÙfiÛÔ ‰ÂÓ ¤¯ÂÈ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ηÏÔ‡ ÈÛÙÔÚÈÎÔ‡. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ·ÓÙÏÔ‡ÓÙ·È Û˘ÌÏËڈ̷ÙÈΤ˜ ÏËÚÔÊÔڛ˜. ∞Ó ¯ÚÂÈ¿˙ÂÙ·È Ì›· ÌfiÓË ÂͤٷÛË, ı· Ú¤ÂÈ Ì¿ÏÏÔÓ Ó· Â›Ó·È Ë ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∫·Ïfi Â›Ó·È Ó· ˘¿Ú¯ÂÈ Û οı ·È‰› Ô˘ Ï·Ì‚¿ÓÂÈ Û˘ÛÙËÌ·ÙÈο Ì·ÎÚÔ¯ÚfiÓÈ· ÚÔÏËÙÈ΋ ·ÁˆÁ‹. ∏ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ÔÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ (IgG, IgM, IgA, IgE) ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈ̘ Û ÂÚÈÙÒÛÂȘ ÂÚ·ÈÙ¤Úˆ ÂÈÌÔÓ‹˜ ÙˆÓ Û˘Ìو̿وÓ, ¿ÓÙÔÙ ηٿ ÙËÓ ÎÚ›ÛË ÙÔ˘ ıÂÚ¿ÔÓÙ· È·ÙÚÔ‡. ŒÏÂÁ¯Ô˜ Ì ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ Ó¢ÌfiÓˆÓ ÌÔÚ› Ó· ˙ËÙËı› Û ·È‰È¿ ¿Óˆ ÙˆÓ 6-7 ÂÙÒÓ. ∞Ï‹ Î·È ¯Ú‹ÛÈÌË Â›Ó·È Ë ‰ÔÎÈÌ·Û›· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ Ô˘ ÌÔÚ› Ó· Á›ÓÂÈ ÛÙÔ Î¿ı ·È‰È·ÙÚÈÎfi È·ÙÚÂ›Ô Ì ÙÔ ÚÔfiÌÂÙÚÔ. ™Â ÂÈÏÂÁ̤ӷ ·È‰È¿ Ú¤ÂÈ Ó· ˙ËÙÂ›Ù·È Î·È Ë ‰ÔÎÈÌ·Û›· ȉÚÒÙ·. O ÁÂÓÈÎfi˜ ηÓfiÓ·˜ Ù˘ È·ÙÚÈ΋˜ ÈÛ¯‡ÂÈ Î·È ÛÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÙÔ˘ Èı·ÓÔ‡ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, fiÙÈ ‰ËÏ·‰‹ ÔÈ ‰È·ÁÓˆÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ú¤ÂÈ Ó· ˙ËÙÔ‡ÓÙ·È ÌfiÓÔ fiÙ·Ó Ô ÁÈ·ÙÚfi˜ ÂÚÈ̤ÓÂÈ Ó· ·ÍÈÔÔÈ‹ÛÂÈ ‰È·ÁÓˆÛÙÈο Ù· ·ÔÙÂϤÛÌ·Ù·. ∆¤ÏÔ˜, ȉȷ›ÙÂÚ˘ ÛËÌ·Û›·˜ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ Â›Ó·È ÙÔ ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ÃÔÚËÁÂ›Ù·È ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Î·È ÂÎÙÈÌ¿Ù·È Ë ·¿ÓÙËÛË, ÒÛÙ ·Ó¿ÏÔÁ· Ó· ÂÓÈÛ¯‡ÂÙ·È ‹ Ó· ·Ô‰˘Ó·ÌÒÓÂÙ·È Ë ·Ú¯È΋ ÎÏÈÓÈ΋ ˘Ô„›·. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÓÙ·ÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó Û ÂÚÈÛÛfiÙÂÚÔ ÔÍ›˜ ÂÚÈÙÒÛÂȘ “·Ó·ÎÔ˘ÊÈÛÙÈο” Ê¿Ú̷η, fiˆ˜ Â›Ó·È ÔÈ ÂÈÛÓÂfiÌÂÓÔÈ ‚2-·ÁˆÓÈÛÙ¤˜, ÙÔ ‚ÚˆÌÈÔ‡¯Ô ÈÚ·ÙÚfiÈÔ, ·ÎfiÌ· Î·È ‚Ú·¯˘¯ÚfiÓÈÔ Û¯‹Ì· ÛÙÂÚÔÂȉÒÓ (Û˘Ó‹ıˆ˜ ·fi ÙÔ˘
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ÛÙfiÌ·ÙÔ˜). ™Â ¯ÚÔÓÈfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÌÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó “Ú˘ıÌÈÛÙÈο” Ê¿Ú̷η ηٿ ÙËÓ ÂfiÌÂÓË ÂÚ›Ô‰Ô ÙˆÓ 4-8 ‚‰ÔÌ¿‰ˆÓ Ì ¯ÚˆÌfiÓ˜ ‹ ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÌÂ/‹ ¯ˆÚ›˜ ‚2-·ÁˆÓÈÛÙ‹ Ì·ÎÚ¿˜ ‰Ú¿Û˘. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË, ·ÍÈÔÏÔÁÂ›Ù·È ÙÔ ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. πηÓÔÔÈËÙÈ΋ ·¿ÓÙËÛË ÂÓÈÛ¯‡ÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÂÓÒ Ë ÂÈÌÔÓ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ˘Ô‰ËÏÒÓÂÈ ·Ó¿ÁÎË Â·Ó·‰Ú·ÛÙËÚÈÔÔ›ËÛ˘ Ù˘ ‰È·ÊÔÚԉȷÁÓˆÛÙÈ΋˜ ÛΤ„˘ (13). ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋, › ˘Ô„›·˜ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ηٿ ÙËÓ ÎÚ›ÛË ÙÔ˘ È·ÙÚÔ‡. ∫·Ïfi Â›Ó·È Ó· ÂÍËÁÂ›Ù·È ÛÙÔ˘˜ ÁÔÓ›˜ Ô ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Î·È Ó· ·ÔʇÁÔÓÙ·È ·fiÏ˘Ù˜ ÂÎÊÚ¿ÛÂȘ, fi¯È ÁÈ· ÏfiÁÔ˘˜ ÂÈÎÔÈÓˆÓÈ·ÎÔ‡˜ ·ÏÏ¿ ÁÈ·Ù› Ë ›‰È· Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È “ηı' Ô‰fiÓ”. ¶ÔÏϤ˜ ÊÔÚ¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÓ·ÏÏ·ÎÙÈο ¿ÏϘ ‰È·ÁÓÒÛÂȘ, fiˆ˜ ·ÛıÌ·ÙÔÂȉ‹˜ ‚ÚÔÁ¯›Ùȉ·, Û·ÛÙÈ΋ ‚ÚÔÁ¯›Ùȉ· Î.¿. ∏ ÛËÌÂÚÈÓ‹ Ù¿ÛË Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÚÚÈÙÈ΋ ÚÔ˜ ·˘Ù¤˜ ÙȘ ÂÎÊÚ¿ÛÂȘ Û ۯ¤ÛË Ì ÙÔ ÚfiÛÊ·ÙÔ ·ÚÂÏıfiÓ, ·ÏÏ¿ Î·È ¿ÏÈ Ë ¯Ú‹ÛË ÙÔ˘˜ ÎÈÓ‰˘Ó‡ÂÈ Ó· Ô‰ËÁ‹ÛÂÈ ÛÙÔ ‰È·ÁÓˆÛÙÈÎfi ÂÊËÛ˘¯·ÛÌfi Î·È ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÒıËÛË (ÁÈ· fiÔÈÔ˘˜ ÏfiÁÔ˘˜), fi¯È ÌfiÓÔ ÙÔ˘ fiÚÔ˘ ¿ÛıÌ· ·ÏÏ¿ Î·È Ù˘ ›‰È·˜ Ù˘ ÓfiÛÔ˘. EÈϤÔÓ, Ô fiÚÔ˜ “‚ÚÔÁ¯›Ùȉ·” ÎÈÓ‰˘Ó‡ÂÈ Ó· Ô‰ËÁ‹ÛÂÈ ›Ûˆ Û ·Ï·ÈfiÙÂÚ˜ ·ÓÙÈÏ‹„ÂȘ ·ÓÙÈÌÂÙÒÈÛ˘ fiÏˆÓ ÙˆÓ ‚ÚÂÊÒÓ ‹ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· ‹ ›ÌÔÓÔ Û˘ÚÈÁÌfi Ì ·ÓÙÈ‚ÈÔÙÈο. ∞ÓÙ›ıÂÙ·, Ë Â‡ÎÔÏË ˘ÈÔı¤ÙËÛË ÙÔ˘ fiÚÔ˘ ¿ÛıÌ· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ê·Ú̿ΈÓ, ·Ú·Î¿ÌÙÔÓÙ·˜ ÙÔÓ ··ÈÙÔ‡ÌÂÓÔ ‰È·ÁÓˆÛÙÈÎfi ÚÔ‚ÏËÌ·ÙÈÛÌfi. ∞Ó ˘¿Ú¯ÂÈ ‰È·ÁÓˆÛÙÈ΋ ·‰˘Ó·Ì›·, ÚÔÎÂÈ̤ÓÔ˘ Ó· Ù›ıÂÙ·È ·Û·Ê‹˜ ‰È¿ÁÓˆÛË, Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ÂÚÈÁÚ¿ÊÂÙ·È ÙÔ Û‡Ìو̷ (.¯. ˘ÔÙÚÔÈ¿˙ˆÓ ‹ ›ÌÔÓÔ˜ Û˘ÚÈÁÌfi˜). ∂Ó·ÏÏ·ÎÙÈο, ÌÔÚ› Ó· ‰ËÏÒÓÂÙ·È Ô ‰È·ÁÓˆÛÙÈÎfi˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Ì ÙËÓ ¤ÎÊÚ·ÛË “Èı·Ófi ·È‰ÈÎfi ¿ÛıÌ·”. ™˘ÓÂÒ˜, ‚¿ÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔۤϷÛ˘ ÛÙÔ ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË. OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ‚ÔËıÔ‡Ó ÏÈÁfiÙÂÚÔ Î·È Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÂÈÏÂÁ̤ӷ, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÎÏÈÓÈÎfi ÚÔ‚ÏËÌ·ÙÈÛÌfi. ∏ ‰ÔÎÈÌ·ÛÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ÌÔÚ› Ó· ‰È¢ÎÔχÓÂÈ ÙËÓ ÂÍ·ÁˆÁ‹ Ô˘ÛÈ·ÛÙÈÎÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù· ∞) O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ Î·È ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈ̤ÓË ÈÛ¯‡ ÛÙ· ‚Ú¤ÊË Î·È Ù· ÌÈÎÚ¿ ·È‰È¿.
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µ) ∆Ô ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› Ê·ÈÓÔÙ˘Èο ÂÙÂÚÔÁÂÓ¤˜ ÓfiÛËÌ·. ∏ ‰È¿ÁÓˆÛ‹ ÙÔ˘ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ·Ï‹ Î·È ·ÛÊ·Ï‹˜. ™˘¯Ó¿, ‰ÂÓ Ù›ıÂÙ·È ·fi ÙËÓ ÚÒÙË ÂͤٷÛË ·ÏÏ¿ “ηı’ Ô‰fiÓ”. °) µ¿ÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔۤϷÛ˘ ·ÔÙÂÏÔ‡Ó ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Koppelman GH, Meijer GG, Postma DS. Defining asthma in genetic studies. Clin Exp Allergy 1999;29(Suppl 4):1-4. 2. Third international pediatric consensus statement on the management of childhood asthma. Pediatr Pulmonol 1998;25:1-17. 3. ¡ational Heart, Lung and Blood Institute and World Health Organization. Global initiative for asthma. Bethesda: National Institutes of Health, publ no 95-3659; 1995. 4. ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ∫·Ú‰È¿˜, ¶Ó‡ÌÔÓÔ˜ Î·È ∞›Ì·ÙÔ˜. ¢ÈÂıÓ‹˜ ÛÙÚ·ÙËÁÈ΋ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÚfiÏË„Ë ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (∂ÏÏËÓÈ΋ ÌÂÙ¿ÊÚ·ÛË. ∂È̤ÏÂÈ·: °ÂˆÚÁ¿ÙÔ˘ ¡, °Î¿Áη ª, °ÎÚ¿ÙÛÈÔ˘ Ã, ¢ËÌ¿‰Ë ª, ªÈÙÛ¿ÎÔ˘ Ã.), publ no 95-3659; 1995. 5. Carlsen KH. What distinguishes the asthmatic amongst the infant wheezers? Pediatr Allergy Immunol 1997;8(Suppl 10):40-45. 6. Silverman M, Wilson NM. Wheezing disorders in infancy. In: Silverman M, ed. Childhood asthma and other wheezing disorders. London: Chapman and Hall; 1995. p. 375-400.
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7. ∏Ôgg C, Bush A. Childhood asthma - all that wheezes is not inflammation. Clin Exp Allergy 1997;27:991-994. 8. Go RO, Martin TR, Lester MR. A wheezy infant unresponsive to bronchodilators. Ann Allergy Asthma Immunol 1997;78:449-455. 9. Martinez FD, Wright AL, Taussing LM, Holberg CJ, Halonen M, Morgan WJ. The Group Health Medical Associates. Asthma and wheezing in the first six years of life. N Engl J Med 1995;332:133-138. 10. Hopp RJ. Recurrent wheezing in infants and young children: a perspective. J Asthma 1999;36:547-553. 11. Martinez FD, ∏elms PJ. Types of asthma and wheezing. Eur Respir J 1998;12(Suppl 27):3s-8s. 12. Joseph CLM, Foxman B, Leickly FE, Peterson E, Ownby D. Sensitivity and specificity of asthma definition and symptoms used in a survey of childhood asthma. J Asthma 1999;36:565-573. 13. ¶Ú›ÊÙ˘ ∫. √ Û˘ÚÈÁÌfi˜ ÛÙÔ ‚Ú¤ÊÔ˜ ÌÂÙ¿ ÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ¶·È‰È·ÙÚÈ΋˜ 1999. ¢È·ÁÓˆÛÙÈο Î·È ıÂڷ¢ÙÈο ÚÔ‚Ï‹Ì·Ù·. µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∞ı‹Ó·; 1999. ÛÂÏ. 309-320.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ¡. ¶Ú›ÊÙ˘ ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ 152 36, ¶. ¶ÂÓÙ¤ÏË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ™¯¤ÛË ÌÂٷ͇ ·ÏÌÈ΋˜ Ô͢ÌÂÙÚ›·˜ Î·È ÎÏÈÓÈÎÔ‡ score Û ·È‰È¿ Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 24 ÌËÓÒÓ1 ™ÎÔfi˜: ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë Û¯¤ÛË ÌÂٷ͇ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ Ô˘ ÌÂÙÚ‹ıËΠ̠·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Î·È ÙˆÓ ÙÈÌÒÓ ÎÏÈÓÈÎÒÓ score Û 138 ‚Ú¤ÊË (̤Û˘ ËÏÈΛ·˜ ±SD, 6,6±5,5 ÌËÓÒÓ) Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜, Ô˘ ÚÔÛ‹Ïı·Ó Û·Ó Â͈ÙÂÚÈÎÔ› ·ÛıÂÓ›˜ Û ΤÓÙÚÔ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŒÓ·˜ ÂÚ¢ÓËÙ‹˜ ÂÎÙÈÌÔ‡Û ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ÔͤˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÎÏÈÓÈÎÔ‡ score ¯ˆÚ›˜ Ó· ÁÓˆÚ›˙ÂÈ ÙȘ ÙÈ̤˜ ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ. ŒÓ·˜ ¿ÏÏÔ˜ ÂÚ¢ÓËÙ‹˜ ÌÂÙÚÔ‡Û ÙÔÓ ÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ Û fiÏ· Ù· ·È‰È¿. ∞ÔÙÂϤÛÌ·Ù·: ∏ ̤ÛË ÙÈÌ‹ (±SD) ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ‹Ù·Ó 98,2±1,1% ÁÈ· ·È‰È¿ Ì ÎÏÈÓÈο scores 2-5 (n=32), 95,4±1,5% ÁÈ· ÂΛӷ Ì scores 6-7 (n=82) Î·È 92,9±2% ÁÈ· ·È‰È¿ Ì scores 8-10 (n=24), (p<0,001 ·fi Bonferroni’s ÔÏÏ·Ï‹ Û‡ÁÎÚÈÛË fiÙ·Ó ÔÈ Û˘ÁÎÚ›ÛÂȘ Á›ÓÔÓÙ·È Ì ‰‡Ô ÙÚfiÔ˘˜ ÁÈ· οı ˙‡ÁÔ˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ). ∆Ô ÎÏÈÓÈÎfi score ¤‰ÂÈÍ ̛· ηϋ Û˘Û¯¤ÙÈÛË ÌÂ
214
ÙÔÓ ÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ (r=–0,76; 95% Cl, –0,83 se –0,68). ™˘ÌÂÚ¿ÛÌ·Ù·: ∂¿Ó ‰ÂÓ Â›Ó·È ‰È·ı¤ÛÈÌÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, Â›Ó·È ÛÎfiÈÌÔ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ÛÙË ıÂڷ›· ÙˆÓ ‚ÚÂÊÒÓ ÌÂ Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, fiÙ·Ó ÙÔ ÎÏÈÓÈÎfi ÙÔ˘˜ score Â›Ó·È ≥8.
1Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G. Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age Pediatr Pulmonol 1999;27:423-427
°ÂÒÚÁÈÔ˜ √ÈÎÔÓfiÌÔ˘ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ
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∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞
Paediatriki 2001;64:215-218
ALLERGIOLOGY - DERMATOLOGY
∞Ó·Ê˘Ï·Í›·: ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ·ÓÙÈÌÂÙÒÈÛË £. ¶··ÛÙ·‡ÚÔ˘ - ª·˘ÚÔ˘‰‹
Anaphylaxis: clinical manifestations and treatment T. Papastavrou - Mavroudi
¶ÂÚ›ÏË„Ë: ∏ ·Ó·Ê˘Ï·Í›· Â›Ó·È Ì›· ÂÈΛӉ˘ÓË ÁÈ· ÙË ˙ˆ‹ ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË, ÁÈ· ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È Â›ÁÔ˘Û· ·ÓÙÈÌÂÙÒÈÛË. OÈ ÁÂÓÈÎÂ˘Ì¤Ó˜ ·ÓÙȉڿÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·, fiˆ˜ ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ηډÈÔ·ÁÁÂÈ·Îfi, Á·ÛÙÚÂÓÙÂÚÈÎfi, ‰¤ÚÌ· ‹ Î·È ÙÔ Û˘Ó‰˘·ÛÌfi ·˘ÙÒÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ. ∏ ¤ÁηÈÚË ¯Ú‹ÛË ·‰ÚÂÓ·Ï›Ó˘, ÂÈÛÓÂfiÌÂÓˆÓ ‚‹Ù· ‰ÈÂÁÂÚÙÒÓ, ηıÒ˜ Î·È ¿ÏÏ· ̤ÙÚ·, Â›Ó·È ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·Í›·˜ Ú¤ÂÈ Ó· ʤÚÔ˘Ó Ì·˙› ÙÔ˘˜ ¿ÓÙÔÙ ¤Ó· kit ¿ÌÂÛ˘ ·ÓÙÈÌÂÙÒÈÛ˘.
Abstract: Anaphylaxis is a life threatening allergic reaction which needs emergency treatment. The generalized reactions involve different systems such as the respiratory, cardiovascular and gastrointestinal system and also the skin, singly or in combination. Early use of adrenaline, inhaled beta-2 agonists as well as other measures, is crucial for successful treatment. A kit containing adrenaline for self treatment must be carried by all patients with a history of anaphylaxis.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ó·Ê˘Ï·Í›·, ·ÓÙÈÌÂÙÒÈÛË.
Key words: anaphylaxis, treatment.
∏ ·Ó·Ê˘Ï·Í›· ‹ ·Ó·Ê˘Ï·ÎÙÈÎfi shock ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È Ì¤¯ÚÈ Û‹ÌÂÚ· ÙÔ ÈÔ ‰Ú·Ì·ÙÈÎfi Ê·ÈÓfiÌÂÓÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÁÈ· ÙÔ ÔÔ›Ô ··ÈÙÂ›Ù·È ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË (1). ∏ ·Ó·Ê˘Ï·Í›· Â›Ó·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ì›· Ù‡Ô˘ π ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Ì Ì˯·ÓÈÛÌfi IgE, ηٿ ÙËÓ ÔÔ›· ÌÂÙ¿ ÙËÓ ÚÒÙË Â·Ê‹ Ì ÙÔ ·ÓÙÈÁfiÓÔ Î·È ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ·ÙfiÌÔ˘ Â›Ó·È Ï¤ÔÓ Û˘Ó‰Â‰Â̤ÓË ÛÙ· ÛÈÙ¢ÙÈο Î·È ‚·ÛÂfiÊÈÏ· ·ÙÙ·Ú·, Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ, ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ÌÂÙ¿ ·fi οı Ӥ· ·ʋ Ì ÙÔ ›‰ÈÔ ·ÓÙÈÁfiÓÔ (2). ∆· ›‰· Ù˘ ÈÛÙ·Ì›Ó˘ Â›Ó·È ˘„ËÏ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. ªÂ Ì˯·ÓÈÛÌfi ¯ˆÚ›˜ Û˘ÌÌÂÙÔ¯‹ Ù˘ IgE ÌÔÚ› Ó· ÚÔÎÏËı› ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÛÈÙ¢ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·fi ÙȘ
·Ó·Ê˘Ï·ÙÔ͛Ә C3·, C4· Î·È C5·. OÚÈṲ̂ӷ Ê¿Ú̷η, fiˆ˜ Ù· ·Ú¿ÁˆÁ· ÙÔ˘ ÎÔ˘Ú·Ú›Ô˘ Î·È ·ÎÙÈÓÔÛÎÈ·ÛÙÈΤ˜ Ô˘Û›Â˜, ÌÔÚÔ‡Ó Ó· ‰Ú¿ÛÔ˘Ó ÛÙ· ÛÈÙ¢ÙÈο ·ÙÙ·Ú· Î·È Ó· ·ÂÏ¢ıÂÚÒÛÔ˘Ó ÌÂÛÔÏ·‚ËÙ¤˜ ¯ˆÚ›˜ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi. OÈ ·ÓÙȉڿÛÂȘ ·˘Ù¤˜ ÔÓÔÌ¿˙ÔÓÙ·È ·Ó·Ê˘Ï·ÎÙÔÂȉ›˜ (3). ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ (4,5) OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÔÈΛÏÔ˘Ó Û ‚·Ú‡ÙËÙ· ·fi ÙË ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· Î·È ÙÔÓ ÎÓËÛÌfi ̤¯ÚÈ ·ÎfiÌË Î·È ÙÔ ı¿Ó·ÙÔ. ∆Ô ÚÒÙÔ Û‡Ìو̷ ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È ¤Ó· ÁÂÓÈÎfi ·›ÛıËÌ· “fiÙÈ ‰ÂÓ ·ÈÛı¿ÓÂÙ·È Î·Ï¿”. ™‡ÓÙÔÌ· ÂÌÊ·Ó›˙ÂÙ·È ÎÓËÛÌ҉˜ ÂÍ¿ÓıËÌ· ‰È¿¯˘ÙÔ, Ì ·›ÛıËÌ· ˙¤ÛÙ˘, ÂÚ‡ıËÌ·, Êfi‚Ô Î·È Ù¿ÛË ÏÈÔı˘Ì›·˜. ™Â ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ ÂÌÊ·Ó›˙ÂÙ·È ·ÒÏÂÈ· ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, Û˘Ó›‰ËÛ˘, Ô‡ÚˆÓ Î·È ÎÔÚ¿ÓˆÓ.
3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË
3rd Pediatric Department of Aristotelion University Ippokration General Hospital, Thessaloniki
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¢ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ O ·Ú¯ÈÎfi˜ ÎÓËÛÌfi˜ Î·È Ë ÂÚ˘ıÚfiÙËÙ· ÂÍÂÏ›ÛÛÔÓÙ·È Û ÎÓȉˆÙÈÎfi ÂÍ¿ÓıËÌ· Î·È ·ÁÁÂÈÔÔ›‰ËÌ·, Ù· ÔÔ›· Â›Ó·È ·ÚÔ‰Èο Î·È Û¿ÓÈ· ‰È·ÚÎÔ‡Ó ÁÈ· Ï›Á˜ ‚‰ÔÌ¿‰Â˜. ™˘ÌÙÒÌ·Ù· ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∆· 2/3 ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ı·Ó¿ÙˆÓ ÔÊ›ÏÔÓÙ·È Û ·ÛÊ˘Í›·. ∆˘Èο, Ë ·fiÊÚ·ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÚÔηÏ› ÂÈÛÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi, ÂÓÒ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÎÓ¢ÛÙÈ΋ ‰‡ÛÓÔÈ·. ∆· ÚÒÙ· ÛÙ¿‰È· ÙÔ˘ Ï·Ú˘ÁÁÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÂΉËÏÒÓÔÓÙ·È Ì ‚Ú¿Á¯Ô˜ ʈӋ˜ Î·È ·›ÛıËÌ· ‰˘ÛÎÔÏ›·˜ Ù˘ ·Ó·ÓÔ‹˜. ∆Ô Â‡ÚËÌ· Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ‰ÈfiÙÈ ÙÔ Ô›‰ËÌ· ÙÔ˘ Ï·Ú˘ÁÁÔÊ¿Ú˘ÁÁ· Ù˘ ÂÈÁψٛ‰·˜ Î·È ÙÔ˘ Ï¿Ú˘ÁÁ· ÌÔÚ› ÁÚ‹ÁÔÚ· Ó· Ô‰ËÁ‹ÛÂÈ Û ı¿Ó·ÙÔ ·fi ·ÛÊ˘Í›·. ∏ ·fiÊÚ·ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂΉËÏÒÓÂÙ·È Ì ·›ÛıËÌ· Û‡ÛÊÈ͢ ÙÔ˘ ıÒڷη, ÂÎÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi Î·È Û‡ÓÙÔÌ· ÂÍÂÏ›ÛÛÂÙ·È Û ÛÔ‚·Úfi Ô͇ ¿ÛıÌ·. ∏ ·fiÊÚ·ÍË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ Û˘Óԉ‡ÂÙ·È Ì ˘ÔÍ·ÈÌ›·. ∫·Ú‰È·ÁÁÂȷο Û˘ÌÙÒÌ·Ù· ∏ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙÔ 1/3 ÙˆÓ ı·Ó¿ÙˆÓ. ∏ ˘fiÙ·ÛË Î·È ÙÔ shock ÔÊ›ÏÔÓÙ·È ÛÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹, ÙËÓ ÂÚÈÊÂÚÈ΋ Ï›ÌÓ·ÛË ÙÔ˘ ·›Ì·ÙÔ˜, ÙËÓ ·˘ÍË̤ÓË ·ÁÁÂȷ΋ ‰È·‚·ÙfiÙËÙ· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∏ ΢ÎÏÔÊÔÚÈ΋ ηٷÏËÍ›· (collapse) ÂÏ·ÙÙÒÓÂÈ ÙË ÚÔ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ Î·È Ë ˘ÔÍ·ÈÌ›·, Ë ÔÔ›· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ˘fiÙ·ÛË, ÂÏ·ÙÙÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÙÔ˘ Ì˘Ôηډ›Ô˘ Ì ·ÔÙ¤ÏÂÛÌ· ·ÚÚ˘ı̛˜, ·ÎfiÌË Î·È ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ™˘ÌÙÒÌ·Ù· Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∆· ÎÔÈÏȷο ¿ÏÁË, Ë Ó·˘Ù›· Î·È ÔÈ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙË Û‡Û·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÙȘ ·˘ÍË̤Ó˜ ÂÎÎÚ›ÛÂȘ. ¢È¿ÁÓˆÛË ∏ ‰È¿ÁÓˆÛË ÛÙËÚ›˙ÂÙ·È ÛÙÔ ÈÛÙÔÚÈÎfi Î·È ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ: ·) ·fi ÙÔ ‰¤ÚÌ· (ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·), ‚) ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (‰‡ÛÓÔÈ· ÂÈÛÓ¢ÛÙÈ΋-ÂÎÓ¢ÛÙÈ΋, ΢¿ÓˆÛË), Á) ·fi ÙÔ Î˘ÎÏÔÊÔÚÈÎfi (˘fiÙ·ÛË, ·ÚÚ˘ıÌ›·) Î·È ‰) ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (¤ÌÂÙÔÈ, ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ, ÎÔÈÏȷο ¿ÏÁË). ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ÌÔÚÔ‡Ó Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÌÔӈ̤ӷ ‹ Î·È ÛÂ Û˘Ó‰˘·ÛÌfi ·fi Ù· ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·.
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£Âڷ›· ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock Â›Ó·È Ì›· ÂÍ·ÈÚÂÙÈο ›ÁÔ˘Û· È·ÙÚÈ΋ Ú¿ÍË Î·È Ë ÂÈÙ˘¯›· Ù˘ ıÂڷ›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Ù·¯Â›· ¤Ó·ÚÍ‹ Ù˘. ∂È‚¿ÏÏÂÙ·È Ë ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ Û ÌÔÚÊ‹ ˘‰·ÙÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ·‰ÚÂÓ·Ï›Ó˘ 1:1000 Û ‰fiÛË 0,3-0,5 ml (ÛÙ· ·È‰È¿ Ë ‰fiÛË ˘ÔÏÔÁ›˙ÂÙ·È 0,01-0,02 ml/Kg µ™ ·Ó¿ ‰fiÛË). ∏ ̤ÁÈÛÙË ‰fiÛË Â›Ó·È 0,5 ml. À¿Ú¯ÂÈ Î·È ·˘ÙÔÂÓ¤ÛÈÌË (∞uto-injector) ·‰ÚÂÓ·Ï›ÓË Ì›·˜ ¯Ú‹Û˘ (Fastjekt 0,23-0,37 mg, Epipen 0,3 mg Î·È 0,15 mg, Anapen Adult 0,3 mg Î·È Anapen junior 0,15 mg) ÁÈ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (6). EÂȉ‹ Ë ·‰ÚÂÓ·Ï›ÓË ¤¯ÂÈ ÌÈÎÚ‹ ËÌÈÂÚ›Ô‰Ô ˙ˆ‹˜, Ë ·Ú¯È΋ ‰fiÛË ÌÔÚ› Ó· ·ӷÏËÊı› οı 15-20 min ÁÈ· 3-4 ÊÔÚ¤˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ÔÈ Ôԛ˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, Ë ·‰ÚÂÓ·Ï›ÓË 0,25 ml ·Ú·ÈÒÓÂÙ·È Û 10 ml Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ Î·È ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÊÏ‚›ˆ˜ Û ¯ÚfiÓÔ 1-2 ÏÂÙÒÓ Ì ¿ÌÂÛË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ∏ ·‰ÚÂÓ·Ï›ÓË ‰ÈÂÁ›ÚÂÈ ÙÔ˘˜ ·-˘Ô‰Ô¯Â›˜ Î·È ÚÔηÏ› ·ÁÁÂÈÔÛ·ÛÌfi ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ›ÂÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜. ∞ÓÙ‰›ÎÓ˘Ù·È Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Ì ·ÚÚ˘ıÌ›· ‹ Ì ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ‰ÈfiÙÈ ¤¯ÂÈ ·Ú·ÙËÚËı› ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹, ·ÎfiÌË Î·È ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ (3). ∂È‚¿ÏÏÂÙ·È Ë ÙÔÔı¤ÙËÛË ›Û¯·ÈÌ˘ ÂÚ›‰ÂÛ˘ ÎÂÓÙÚÈÎfiÙÂÚ· ÙÔ˘ ÛËÌ›Ԣ Ù˘ ÂÓ¤Ûˆ˜ ‹ ÙÔ˘ ‰‹ÁÌ·ÙÔ˜ ÂÓÙfiÌÔ˘, Ë ÔÔ›· ı· ηı˘ÛÙÂÚ‹ÛÂÈ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ‚Ï·ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ÃÔÚËÁÂ›Ù·È ¿ÌÂÛ· Ô͢ÁfiÓÔ fiÙ·Ó ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó·ÓÔ‹ ‹ ΢¿ÓˆÛË. ÃÔÚËÁÔ‡ÓÙ·È ∂º ˘ÁÚ¿ ‹ Î·È ˘ÔηٿÛٷٷ Ï¿ÛÌ·ÙÔ˜ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚ·, ÒÛÙ ӷ ÚÔÏËÊı› Ë ‚·ÚÈ¿ ΢ÎÏÔÊÔÚÈ΋ ·Ó¿ÚÎÂÈ·. ∞Ó Ë ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ Î·È Ë ∂º ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·, ÙfiÙ ¯ÔÚËÁÔ‡ÓÙ·È ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÌÂÙ·Ú·ÌÈÓfiÏË (Aramine) 0,4 mg/Kg µ™ ‚Ú·‰¤ˆ˜ Û 500 ml ˘ÁÚÒÓ, ‹ ÓÙÔ·Ì›ÓË 100-1000 Ìg/mm, ‹ ÓÔÚ·‰ÚÂÓ·Ï›ÓË 8-20 mg/min. O ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫°, ̤ÙÚËÛË ∞¶, ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË, ·¤ÚÈ· ·›Ì·ÙÔ˜. ∆· ·ÓÙÈÈÛÙ·ÌÈÓÈο, fiˆ˜ ÔÈ ∏1 ·ÓÙ·ÁˆÓÈÛÙ¤˜, ¯ÔÚËÁÔ‡ÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ¯Ú‹ÛË Ù˘ ·‰ÚÂÓ·Ï›Ó˘. ªÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó ∂º, Eª ‹ ·fi ÙÔ ÛÙfiÌ· ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘. ŸÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ·
MAY- JUNE '01 TELIKO
30-05-03
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¶·È‰È·ÙÚÈ΋ 2001;64:215-218
‰ÚÔ˘Ó Û 15-30 min. ∫·Ó¤Ó· fï˜ ·ÓÙÈÈÛÙ·ÌÈÓÈÎfi ‰ÂÓ ÌÔÚ› Ó· Â›Ó·È ˘ÔηٿÛÙ·ÙÔ Ù˘ ·‰ÚÂÓ·Ï›Ó˘, ‰ÈfiÙÈ Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÌfiÓÔ ÙË ‰Ú¿ÛË Ù˘ ÈÛÙ·Ì›Ó˘ ÛÙÔ˘˜ ˘Ô‰Ô¯Â›˜ Ù˘. ∆· ∏1 ·ÓÙÈÈÛÙ·ÌÈÓÈο ÂÌÔ‰›˙Ô˘Ó ÙË Û‡Û·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙˆÓ ‚ÚfiÁ¯ˆÓ Î·È ÙË ¯¿Ï·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ¤ÙÛÈ ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ·ÁÁÂȷ΋ ‰È·‚·ÙfiÙËÙ· (∫ÏÂÌ·ÛÙ›ÓË 2 mg). ∆· ∏2 ·ÓÙÈÈÛÙ·ÌÈÓÈο ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙË ‰È¤ÁÂÚÛË ÙˆÓ ÂÎÎÚ›ÛˆÓ, Ë ÔÔ›· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÈÛÙ·Ì›ÓË (ƒ·ÓÈÙȉ›ÓË 100 mg, ÛÙ· ·È‰È¿ 15 mg/Kg µ™) (4,5). ∂È‚¿ÏÏÂÙ·È Ó· ‰È·ÙËÚÔ‡ÓÙ·È ÂχıÂÚÔÈ ÔÈ ·Ó·Ó¢ÛÙÈÎÔ› Ô‰Ô›. ∏ ·fiÊÚ·ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·fi Ô›‰ËÌ· Ù˘ ÂÈÁψÙÙ›‰·˜, ÙÔ˘ ˘ÔÊ¿Ú˘ÁÁ· Î·È ÙÔ˘ Ï¿Ú˘ÁÁ· ÌÔÚ› Ó· ·ÔÊÚ¿ÍÂÈ Ù·¯‡Ù·Ù· ÙËÓ ·Ó·Ó¢ÛÙÈ΋ Ô‰fi. ∏ ·‰ÚÂÓ·Ï›ÓË Î·È Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο ÚÔÏ·Ì‚¿ÓÔ˘Ó ÙËÓ Âȉ›ӈÛË ÙÔ˘ Ôȉ‹Ì·ÙÔ˜. Œ¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· Ó· ÌËÓ Î·ı˘ÛÙÂÚ› Ë ÂÈÛ·ÁˆÁ‹ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎÔ‡ ηıÂÙ‹Ú· Î·È ÌÔÚ› Ó· ·ÚΛ fiÙ·Ó ÙÔ Ô›‰ËÌ· Â›Ó·È Î˘Ú›ˆ˜ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎfi. ∞Ó fï˜ Ë ·fiÊÚ·ÍË Â›Ó·È ¿Ú· Ôχ ÚÔ¯ˆÚË̤ÓË ÒÛÙ ӷ ÌËÓ ÂÈÙÚ¤ÂÈ ÙË ‰È·ÛˆÏ‹ÓˆÛË, ÙfiÙ Á›ÓÂÙ·È ÙÔÌ‹ ÛÙËÓ ÚfiÛıÈ· ÙÚ·¯ËÏÈ΋ ¯ÒÚ·, ‰È¿ÓÔÈÍË Ù˘ ÙÚ·¯Â›·˜ Î·È ÙÔÔı¤ÙËÛË ÌÈÎÚÔ‡ ÂÓ‰ÔÙÚ·¯ÂÈ·ÎÔ‡ ۈϋӷ. ™Â ÌÂÁ¿ÏË ·Ó¿ÁÎË ÌÔÚ› Ó· ÙÔÔıÂÙËı› Ì›· ‚ÂÏfiÓË Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ‰È¿ÌÂÙÚÔ, ÒÛÙ ӷ Á›ÓÂÙ·È ·ÂÚÈÛÌfi˜ ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ̤¯ÚÈ Ó· Á›ÓÂÈ ÙÚ·¯ÂÈÔÙÔÌ‹ ·fi ÂȉÈÎfi ¯ÂÈÚÔ˘ÚÁfi (4). ∏ ·fiÊÚ·ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÌÔÚ› Ó· Â›Ó·È ¿ÌÂÛË Ì ÙËÓ ÂΉ‹ÏˆÛË Û˘ÌÙˆÌ¿ÙˆÓ ¿ÛıÌ·ÙÔ˜. ∂›Ó·È ÛËÌ·ÓÙÈÎfi, Ë ¯ÔÚ‹ÁËÛË Ù·¯Â›·˜ ‰Ú¿Ûˆ˜ ‚2 ‰ÈÂÁÂÚÙÒÓ Û ÂÈÛÓÔ¤˜ Ó· ·Ú¯›˙ÂÈ ¤ÁηÈÚ·. ∞Ó Ô ·ÛıÂÓ‹˜ ‰ÂÓ ÌÔÚ› Ó· Û˘ÓÂÚÁ·ÛÙ› ‹ ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· ¯ÔÚ‹ÁËÛ˘, ÙfiÙ ÌÔÚ› Ó· ¯ÔÚËÁËı› ∂º ·ÌÈÓÔÊ˘ÏÏ›ÓË Û ‰fiÛË 1 mg/Kg ·Ó¿ ÒÚ·. ™ÙË Û˘Ó¤¯ÂÈ·, Ë ·ÌÈÓÔÊ˘ÏÏ›ÓË ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 6 mg/kg µ™ οı 6 ÒÚ˜. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ·Ú’fiÏÔ Ô˘ Ë ‰Ú¿ÛË ÙÔ˘˜ ·Ú¯›˙ÂÈ ÌÂÙ¿ 4-6 ÒÚ˜. Œ¯Ô˘Ó ¤Ó‰ÂÈÍË, ‰ÈfiÙÈ ÛÙ·ıÂÚÔÔÈÔ‡Ó ÙËÓ Î·Ù¿ÛÙ·ÛË Î·È ÚÔÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ˘ÔÙÚÔ‹ Ù˘ (‰ÈÊ·ÛÈ΋ ·ÓÙ›‰Ú·ÛË). ∏ ˘‰ÚÔÎÔÚÙÈ˙fiÓË Â›Ó·È ‰Ú·ÛÙÈ΋ Û ‰fiÛË 200 mg (3 mg/Kg) ‹ ÚÔÙÈÌ¿Ù·È Ë ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË Û ‰fiÛË 40 mg οı 3-4 ÒÚ˜, Û ·ÛıÂÓ›˜ Ì ԛ‰ËÌ· Î·È ˘ÔηÏÈ·ÈÌ›·. ∏ ÂÓ‰ÔÁÂÓ‹˜ ·Ú·ÁˆÁ‹ ÙˆÓ ·‰ÚÂÓÔÎÔÚÙÈÎÔÂȉÒÓ ÔÚÌÔÓÒÓ Â›Ó·È ·Ó·Ú΋˜ Û fiϘ ÙȘ ÌÔÚʤ˜ Ù˘ ·Ó·Ê˘Ï·Í›·˜, ·ÏÏ¿ ΢ڛˆ˜ ÛÙÔ ÛÔ‚·Úfi ·Ó·Ê˘Ï·-
Paediatriki 2001;64:215-218
ÎÙÈÎfi shock. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·ÂÏ¢ı¤ÚˆÛË Ì›·˜ Ô˘Û›·˜ - Ù˘ ÏÈÔÎÔÚÙ›Ó˘ - Ë ÔÔ›· ÂÌÔ‰›˙ÂÈ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ ÓÂÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ·Ó·Ê˘Ï·Í›·˜ Î·È ÂÌÔ‰›˙ÂÈ ÙË Û‡ÓıÂÛË ÎÈÓ›ÓˆÓ. ∏ ∂º ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÚÔηÏ› ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ ÌÂÙ¿ ·fi 1-4 ÒÚ˜. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÈ‚¿ÏÏÂÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙËÓ Î·Ù·ÛÙÔÏ‹ Ù˘ ÂÈ‚Ú·‰˘ÓfiÌÂÓ˘ IgE ·ÓÙ›‰Ú·Û˘ ·fi ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È ‰ÂÓ ¤¯ÂÈ Â›‰Ú·ÛË ÛÙËÓ ÂÈ‚›ˆÛË ·fi ÔÍ›· ·Ó·Ê˘Ï·Í›· (4,6). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock ÛÙ· ÓÔÛÔÎÔÌ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ Ì ÙËÓ ÂÍ‹˜ ÛÂÈÚ¿: ·) ÃÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ ·ÚÂÓÙÂÚÈο, ˘Ô‰fiÚÈ· ‹ ÂÓ‰ÔÌ˘˚ο Î·È ÛÙȘ ÛÔ‚·ÚfiÙÂÚ˜ ηٷÛÙ¿ÛÂȘ Û˘ÓÈÛÙ¿Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË, ‚) ÃÔÚ‹ÁËÛË ∏1 Î·È ∏2 ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜, Á) ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ∏∫°, Ï‹„Ë ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ›ÂÛ˘, ÚÔÛ‰ÈÔÚÈÛÌfi ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜, ‰ÈfiÚıˆÛË ÙÔ˘ p∏, ¯ÔÚ‹ÁËÛË ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜, ‰È·ÛˆÏ‹ÓˆÛË ÁÈ· Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ¯Ú‹ÛË ·ÈÓȉˆÙ‹. ªÂÙ¿ ÙËÓ Ï‹ÚË ·Ó¿ÓË„Ë, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·Ú·Ì¤ÓÂÈ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â› 24 ÒÚ˜ ÁÈ· ·Ú·ÎÔÏÔ‡ıËÛË, ‰ÈfiÙÈ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È ‰ÈÊ·ÛÈ΋ ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË. ™Â ÔÚÈṲ̂Ó˜ ηٷÛÙ¿ÛÂȘ ·Ó·Ê˘Ï·Í›·˜ ÂÈ‚¿ÏÏÂÙ·È Ì›· ȉȷ›ÙÂÚË ÛÙÚ·ÙËÁÈ΋: ™ÙËÓ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·, ··ÈÙÂ›Ù·È Ë ·Ó‡ÚÂÛË ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ·ÏÏÂÚÁÈÔÁfiÓÔ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰›‰ÔÓÙ·È ÔÈ Î·Ù¿ÏÏËϘ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ Ï‹ÚË ·ÔÊ˘Á‹ ÙÔ˘ (7). ∏ ÎÓ›‰ˆÛË Ë ÔÔ›· ÚÔηÏÂ›Ù·È ÌÂÙ¿ ·fi ¤ÎıÂÛË ÛÙÔ ÎÚ‡Ô (8), ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ÌÔÚ› Ó· Â›Ó·È ÂÈΛӉ˘ÓË ÁÈ· ÙË ˙ˆ‹ ‰ÈfiÙÈ ÌÔÚ› Ó· ÌÂÙ·¤ÛÂÈ Û ·Ó·Ê˘Ï·ÎÙÈÎfi shock. ∏ ÚÔʇϷÍË Î·È Ë ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Ê·›ÓÂÙ·È fiÙÈ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· ·˘ÙÒÓ ÙˆÓ ·ÓÙȉڿÛˆÓ. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·ÚȤ˜ ·ÓÙȉڿÛÂȘ ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘. ∏ ·Ó·Ê˘Ï·Í›· ÌÂÙ¿ ·fi ¿ÛÎËÛË (9) ·ÔÙÂÏ› ȉȷ›ÙÂÚ· ÂÈΛӉ˘ÓË ÌÔÚÊ‹ Ê˘ÛÈ΋˜ ·ÏÏÂÚÁ›·˜. ∏ ¿ÛÎËÛË Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È ·ÎfiÌË Î·È fiÙ·Ó ÂÌÊ·Ó›˙ÂÙ·È ÂÏ·ÊÚfi˜ ÎÓËÛÌfi˜. ™˘ÓÈÛÙ¿Ù·È Ë ÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ì ·ÓÙÈÈÛÙ·ÌÈÓÈο Î·È ÛÙȘ ‚·ÚȤ˜ ÂΉËÏÒÛÂȘ ··ÈÙÂ›Ù·È ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘. À¿Ú¯ÂÈ Ì›· ȉȷ›ÙÂÚË ÔÌ¿‰· ·ÛıÂÓÒÓ ÔÈ ÔÔ›ÔÈ ÂÌÊ·Ó›˙Ô˘Ó ÂΉËÏÒÛÂȘ ·Ó·Ê˘Ï·Í›·˜, ÌfiÓÔ fiÙ·Ó Ë ¿ÛÎËÛË Û˘Ó‰˘¿˙ÂÙ·È Ì ϋ„Ë ÔÚÈṲ̂Ó˘ ÙÚÔÊ‹˜ fiˆ˜ Ù· ÔÛÙÚ·ÎÔÂȉ‹ (10), ‹ Î·È ¿ÏϘ ÙÚÔʤ˜ (11). °È· ÙËÓ ·Ó·Ê˘Ï·Í›· ÛÙ· ˘ÌÂÓfiÙÂÚ·, ÂÎÙfi˜ ·fi ÙÔ ÈÛÙÔÚÈÎfi, ··ÈÙÂ›Ù·È Ë ÂȂ‚·›ˆÛË ÙÔ˘
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·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ tests ·ÏÏÂÚÁ›·˜ Î·È ÙÔ˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂȉÈÎÒÓ IgE ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙ· ‰È¿ÊÔÚ· ˘ÌÂÓfiÙÂÚ· (̤ÏÈÛÛ·, ÛʋΘ), ÒÛÙ ÛÙȘ ÂÚÈÙÒÛÂȘ ÔÈ Ôԛ˜ Â›Ó·È ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹ ÔÈ ·ÛıÂÓ›˜ Ó· ʤÚÔ˘Ó ¿ÓÙ· Ì·˙› ÙÔ˘˜ ·˘ÙÔÂÓ¤ÛÈÌË ·‰ÚÂÓ·Ï›ÓË Î·È Ó· ÚÔÁÚ·ÌÌ·ÙÈÛÙÔ‡Ó ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÂȉÈ΋˜ ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ (12). ∏ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙ· Ê¿Ú̷η Â›Ó·È ›Ûˆ˜ ·fi Ù· ϤÔÓ ‰‡ÛÎÔÏ· ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ È·ÙÚÈ΋ Ú¿ÍË (13). OÈ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÙȉڿÛÂȘ Â›Ó·È ÂÏ·ÊÚ¤˜, ·ÏÏ¿ ¿ÓÙ· ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ Ù˘ ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚÔ˘ ·ÓÙ›‰Ú·Û˘. ™’ ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È Ë Ï‹Ú˘ ·ÔÊ˘Á‹ ·˘ÙÔ‡ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∂¿Ó Ú¤ÂÈ, fiˆ˜ Â›Ó·È ·Ó·ÓÙÈηٿÛÙ·ÙÔ, ÌÔÚ› Ó· ¯ÔÚËÁËı› Ì ÂȉÈÎfi ÙÚfiÔ ·Â˘·ÈÛıËÙÔÔ›ËÛ˘, Ì ‚·ıÌÈ·›· ·˘Í·ÓfiÌÂÓ˜ ‰fiÛÂȘ Û ¡ÔÛÔÎÔÌ›Ô. O ·Ú¿ÁÔÓÙ·˜ Ô ÔÔ›Ô˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙ· Ê¿Ú̷η Â›Ó·È ÙÔ ıÂÙÈÎfi ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ Û οÔÈ· Ê¿Ú̷η. ∞ÏÏ¿ ·ÎfiÌË Î·È fiÙ·Ó ÙÔ ÈÛÙÔÚÈÎfi Â›Ó·È ·ÚÓËÙÈÎfi, Ô Î¿ı ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· Â›Ó·È ¿ÓÙ· ¤ÙÔÈÌÔ˜ Ó· ·Ó·ÁÓˆÚ›ÛÂÈ Î·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙË Ê·Ú̷΢ÙÈ΋ ˘ÂÚ¢·ÈÛıËÛ›·. ∂›Û˘, ηٿ ÙË ¯ÔÚ‹ÁËÛË ·ÎÙÈÓÔÛÎÈ·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. ŸÙ·Ó ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi Ê·Ú̷΢ÙÈ΋˜ ·ÏÏÂÚÁ›·˜ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ Ù· ÔÔ›· ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ·Ó·Áη›·. ™ÙËÓ È‰ÈÔ·ı‹ ·Ó·Ê˘Ï·Í›·, Ë ·ÈÙÈÔÏÔÁ›· Â›Ó·È ¿ÁÓˆÛÙË Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹, ÔÈ Ôԛ˜ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÔÓÙ·È ·fi ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·, ·fiÊÚ·ÍË ·ÓÒÙÂÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ, ‚ÚÔÁ¯fiÛ·ÛÌÔ ‹ ˘fiÙ·ÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÂÈ‚¿ÏÏÂÙ·È Ë ·ÔÊ˘Á‹ ÙÚÔÊÒÓ ÔÈ Ôԛ˜ ÂÚȤ¯Ô˘Ó Û˘ÓÙËÚËÙÈο Î·È ¯ÚˆÛÙÈΤ˜ Î·È Û ÔÚÈṲ̂Ó˜ ηÎÔ‹ıÂȘ ÌÔÚʤ˜ ȉÈÔ·ıÔ‡˜ ·Ó·Ê˘Ï·Í›·˜ ÂÈ‚¿ÏÏÂÙ·È Ë Ì·ÎÚ¿ ıÂڷ›· Ì ۇÁ¯ÚÔÓË ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (14). ¶ÚfiÏË„Ë O ΛӉ˘ÓÔ˜ ÙÔ˘ ı·Ó¿ÙÔ˘ ÌÔÚ› Ó· ÚÔÏËÊı› ‹ Ó· ÂÏ·ÙÙˆı› fiÙ·Ó ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛˆÛÙ¿ ÔÈ ·Ú·Î¿Ùˆ Ô‰ËÁ›Â˜: 1) §‹„Ë ÚÔÛÂÎÙÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ Ê·ÚÌ¿ÎÔ˘, 2) ™ˆÛÙ¤˜ Î·È Û·Ê›˜ Ô‰ËÁ›Â˜ ÛÙË ¯Ú‹ÛË Ê·Ú̿ΈÓ, 3) ¡· ÚÔÙÈÌ¿Ù·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ·fi ÙÔ ÛÙfiÌ· ·ÓÙ› Ù˘ ·ÚÂÓÙÂÚÈ΋˜ Ô‰Ô‡, 4) ¡· ·Ú·ÎÔÏÔ˘-
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ıÂ›Ù·È Ô ·ÛıÂÓ‹˜ ÁÈ· 90 ÏÂÙ¿ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÂÓfi˜ ÂÓ¤ÛÈÌÔ˘ Û΢¿ÛÌ·ÙÔ˜, 5) ¡· Â›Ó·È ¤ÙÔÈÌÔ˜ Ô ÁÈ·ÙÚfi˜ ÁÈ· Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ ·Ó·Ê˘Ï·ÎÙÈÎfi shock, 6) ¡· Û˘ÛÙ‹ÛÂÈ ÛÙÔÓ ·ÛıÂÓ‹ Ô˘ ›¯Â οÔÈ· ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË Ó· ʤÚÂÈ ¿ÓÙ· Ì·˙› ÙÔ˘ ·‰ÚÂÓ·Ï›ÓË Î·È Ì¿ÏÈÛÙ· Û ·˘ÙÔÂÓ¤ÛÈÌË ÌÔÚÊ‹. BÈ‚ÏÈÔÁÚ·Ê›· 1. Becker E. Elements of the history of our present concepts of anaphylaxis hay fever and asthma. Clin Exp Allergy 1999;29:875-895. 2. Coombs RRA, Gell PGH. Classification of allergic reactions responsible for clinical hypersensitivity and disease. In: Gell PGH, Coombs RRA, Lackman PJ, eds. Clinical aspects of immunology. 3rd ed. Oxford: Blackwell Scientific Publications; 1975. p. 761. 3. Middleton JRE, Reed CE, Ellis EF. Allergy: principles and practice. 2nd ed. Saint Louis: The CV Mosby Company; 1983. 4. Sheffer AL. Anaphylaxis. J Allergy Clin Immunol 1985;75:227-233. 5. ¶··ÛÙ·‡ÚÔ˘-ª·˘ÚÔ˘‰‹ £. ∏ ·Ó·Ê˘Ï·Í›· (‹ ·Ó·Ê˘Ï·ÎÙÈÎfi shock) Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1992;4:127-133. 6. Grabenstein J, Smith L. Incidence of anaphylactic selftreatment in an outpatient population. Ann Allergy 1998; 63:184-188. 7. Metcalfe DD. Food hypersensitivity. J Allergy Clin Immunol 1984;73:749-762. 8. Champion RH, Greaves MW, Kobza Black A, Pye RJ. The urticarias. London: Churchil Livingstone; 1985. 9. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol 1984;73:699-703. 10. Maulitz RM, Pratt DS, Schocket AL. Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol 1979; 63:433-434. 11. Kidd J, Cohen S, Sosman A, Fink J. Food-dependent exercise-induced anaphylaxis. J Allergy Clin Immunol 1983; 71:407-411. 12. Valentine MD. Insect venom allergy: diagnosis and treatment. J Allergy Clin Immunol 1984;73:299-304. 13. Jick H. Adverse drug reactions: the magnitude of the problem. J Allergy Clin Immunol 1984;74(Suppl):555-557. 14. Wiggins CA, Dykewicz MS, Patterson R. Corticosteroiddependent idiopathic anaphylaxis: A report of five cases. J Allergy Clin Immunol 1989;84:311-315.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: £. ¶··ÛÙ·‡ÚÔ˘ - ª·˘ÚÔ˘‰‹ 3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49, 546 42, £ÂÛÛ·ÏÔÓ›ÎË
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¶·È‰È·ÙÚÈ΋ 2001;64:219-222
∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞
Paediatriki 2001;64:219-222
ALLERGIOLOGY - DERMATOLOGY
AÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ª. ∆Ú›Áη
Allergy to cow’s milk: diagnosis and management M. Triga
¶ÂÚ›ÏË„Ë: ø˜ ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰o˜ ÔÚ›˙ÂÙ·È Ì›· ÛÂÈÚ¿ ·ÓÂÈı‡ÌËÙˆÓ ÂΉËÏÒÛÂˆÓ Ô˘ ÚÔηÏÔ‡ÓÙ·È Ì ÙË ÌÂÛÔÏ¿‚ËÛË ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜. ™Â Û¯¤ÛË Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜, ÔÈ ·ÓÙȉڿÛÂȘ ·˘Ù¤˜ ¿ÏÏÔÙÂ Â›Ó·È ¿ÌÂÛ˜ Î·È Û˘¯Ó¿ ÛÔ‚·Ú¤˜ (·Ó·Ê˘Ï·Í›·, ·ÁÁÂÈÔÔ›‰ËÌ·, ÎÓ›‰ˆÛË Î.Ï.) Î·È ¿ÏÏÔÙ ÂÌÊ·Ó›˙ÔÓÙ·È Î·ı˘ÛÙÂÚË̤ӷ, ÌÂÙ¿ ÌÂÚÈΤ˜ ÒÚ˜ ‹ ·ÎfiÌ· Î·È ÌÂÙ¿ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· >24 ˆÚÒÓ (Û˘Ó‹ıˆ˜ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi). H Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È 2-2,5% Î·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌÊ·Ó›˙ÂÙ·È Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜. ∏ ÓfiÛÔ˜ Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› Î·È Ê·›ÓÂÙ·È fiÙÈ ÙÔ 85% ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È ÂχıÂÚÔ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ 3Ô˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (·ÓÔÈÎÙ‹ ‹ ‰ÈÏ‹-Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì placebo) ·ÔÙÂÏ› ÙË ¯Ú˘Û‹ ÛÙ·ıÂÚ¿ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î¿ı ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. ™ÙȘ ·Ì¤ÛÔ˘ Ù‡Ô˘ ·ÓÙȉڿÛÂȘ Ë ‰È¿ÁÓˆÛË Â›Ó·È Û¯ÂÙÈο ‡ÎÔÏË ·fi ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙË ‰È·›ÛÙˆÛË Ù˘ ÂȉÈ΋˜ IgE in vivo (‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡) Î·È in vitro (RAST). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰o˜ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ Ï‹ÚË ·ÔÊ˘Á‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙˆÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘. ∂› ·‰˘Ó·Ì›·˜ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ¯ÔÚËÁÂ›Ù·È ÙÔ Î·Ù¿ÏÏËÏÔ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi - Ì ˘‰ÚÔÏ˘Ì¤ÓË ÚˆÙ½ÓË - Á¿Ï·. ∞Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ˘‰ÚfiÏ˘Û˘ Î·È ÙËÓ ËÁ‹ ÚÔ¤Ï¢Û˘ Ù˘ ÚˆÙ½Ó˘, ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎÒÓ Á·Ï¿ÙˆÓ, ÒÛÙ ӷ ÂÈϤÁÂÙ·È ÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ ÁÈ· ÙÔÓ Î¿ı ·ÛıÂÓ‹.
Abstract: Cow’s milk allergy is defined as a set of immunologically mediated adverse reactions to one or more milk proteins. Following the ingestion of milk, the adverse reactions may be immediate and sometimes severe (anaphylaxis, angioedema, urticaria, etc), or delayed occurring within hours or even over a period of days (usually gastrointestinal symptoms). The incidence of cow’s milk allergy in infancy is about 2-3%, and the majority of patients develop symptoms within the first months of life. The prognosis is regarded as very good with a remission rate of 85% by the age of 3 years. The diagnosis is established by the milk challenge test (open or double-blind, placebo-controlled). In patients with immediate-type reactions the diagnosis is usually based on a careful history and detection of specific IgE antibody to cow’s milk in vivo (skin prick test) and in vitro (RAST). The effective treatment of cow’s milk allergy consists of complete avoidance of cow’s milk protein. When breast-feeding is not possible, a hypoallergenichydrolyzed formula should be given. Based on the source of proteins and the degree of hydrolysis there are several types of hydrolyzed formulas among which the physician may choose the most suitable one for the patient.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜,
Key words: cow’s milk allergy, specific IgE to cow’s
∂ÈÌÂÏ‹ÙÚÈ· ∞’, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
Senior Registrar, Department of Pediatrics University of Patras
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¶·È‰È·ÙÚÈ΋ 2001;64:219-222
Paediatriki 2001;64:219-222
ÂȉÈ΋ IgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜, ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì Á¿Ï· ·ÁÂÏ¿‰Ô˜, ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi Á¿Ï· Ì ˘‰ÚÔÏ˘Ì¤ÓË ÚˆÙ½ÓË.
milk proteins, cow’s milk challenge test, hypoallergenic-hydrolyzed milk formula.
H ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· ¢ڇ Ê¿ÛÌ· ·ÓÂÈı‡ÌËÙˆÓ ·ÓÙȉڿÛˆÓ, Ô˘ ÔÊ›ÏÔÓÙ·È Û ·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ¤Ó·ÓÙÈ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜. ∆Ô Ê¿ÛÌ· ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂΉËÏÒÛÂˆÓ Â›Ó·È Â˘Ú‡Ù·ÙÔ Î·È Î˘Ì·›ÓÂÙ·È ·fi ·Ï¤˜ Î·È ·ÚÔ‰ÈΤ˜ ̤¯ÚÈ Ôχ ÛÔ‚·Ú¤˜, ¯ÚfiÓȘ, ÂÓÔ¯ÏËÙÈΤ˜ Î·È - Û¿ÓÈ· - ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ‹ ·ÎfiÌ· Î·È ı·Ó·ÙËÊfiÚ˜ ·ÓÙȉڿÛÂȘ. OÈ ·ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› (ηٿ Gell Î·È Coombs) Ô˘ ÂÌϤÎÔÓÙ·È, Â›Ó·È Î˘Ú›ˆ˜ Ô Ù‡Ô˘ π (πg E) Ì˯·ÓÈÛÌfi˜, Ô ÂÚÈÛÛfiÙÂÚÔ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜ Î·È Î·Ù·ÓÔËÙfi˜, ηıÒ˜ ›Û˘ Ô Ù‡Ô˘ πππ (·ÓÔÛÔ- Û˘ÌÏÂÁÌ¿ÙˆÓ) Î·È Ô Ù‡Ô˘ πV (΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜). ∏ ‰˘Û·ÓÂÍ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ·ÓÂÈı‡ÌËÙ˜ ÂΉËÏÒÛÂȘ Ô˘ ÚÔηÏÔ‡ÓÙ·È Ì ÙË ÌÂÛÔÏ¿‚ËÛË ÌË-·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ‹ ¿ÏÏˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜ (1,2).
·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û 3 ÔÌ¿‰Â˜ (2): ™ÙËÓ ÚÒÙË ÔÌ¿‰· ·Ó‹ÎÔ˘Ó ÂΛÓÔÈ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË, ̤۷ Û ÂÏ¿¯ÈÛÙ· ÏÂÙ¿ - 1 ÒÚ· ÌÂÙ¿ Ï‹„Ë ÌÈÎÚÒÓ Û˘Ó‹ıˆ˜ ÔÛÔÙ‹ÙˆÓ Á¿Ï·ÎÙÔ˜. ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·Ó·Ê˘Ï·Í›·, ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·, ¿ÌÂÛË Âȉ›ӈÛË ÂÎ˙¤Ì·ÙÔ˜. ŸÙ·Ó ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (‚Ú¿Á¯Ô˜ ʈӋ˜, ÂÈÛÓ¢ÛÙÈÎfi˜ ÛÈÁÌfi˜, Û˘ÚÈÁÌfi˜, ‰‡ÛÓÔÈ·) ‹ ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (¤ÌÂÙÔ˜, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ‰È¿ÚÚÔÈ·), ·ÔÙÂÏÔ‡Ó Ì¤ÚÔ˜ Ù˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. O ˘ÔΛÌÂÓÔ˜ ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È Ù‡Ô˘ π (πg E). ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰· ·Ó‹ÎÔ˘Ó ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‰È¿ÚÚÔÈ· ‹/Î·È ¤ÌÂÙÔ ÌÂÚÈΤ˜ ÒÚ˜ (Û˘Ó‹ıˆ˜ <20 ÒÚ˜) ÌÂÙ¿ ·fi Ï‹„Ë Ì¤ÙÚÈ·˜ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜ (60-200 ml). ¶ÚfiÎÂÈÙ·È ÁÈ· ÌÈ· ÌË-πgE ÂÓÙÂÚÔ¿ıÂÈ·, fiÔ˘ Ô ˘ÔΛÌÂÓÔ˜ Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. ™ÙËÓ ÙÚ›ÙË ÔÌ¿‰· Ë ·ÓÙ›‰Ú·ÛË ÂÌÊ·Ó›˙ÂÙ·È Î·ı˘ÛÙÂÚË̤ӷ (>20 ÒÚ˜ - ÌÂÚÈΤ˜ Ë̤Ú˜) ÌÂÙ¿ ·fi Ï‹„Ë Î·ÓÔÓÈ΋˜ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜ (>300 ml ËÌÂÚËÛ›ˆ˜ ‹ ÈÛÔ‰‡Ó·Ì· Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ). ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¯ÚfiÓÈ· ‰È¿ÚÚÔÈ· ¯ˆÚ›˜ Â̤ÙÔ˘˜, ·Ó¿ÚÎÂÈ· ·‡ÍËÛ˘, ÎÔÈÏȷ΋ ‰È¿Ù·ÛË, ‰˘Û·ÔÚÚfiÊËÛË (ÂÓÙÂÚÔ¿ıÂÈ·), ÎÔÏ›Ùȉ·, ‰˘ÛÎÔÈÏÈfiÙËÙ·, ‚ÚÂÊÈÎÔ‡˜ ÎÔÏÈÎÔ‡˜, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË. ∆· ·ÓˆÙ¤Úˆ ¿ÏÏÔÙÂ Û˘Óԉ‡ÔÓÙ·È Î·È ¿ÏÏÔÙ fi¯È, ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (¿ÛıÌ·) ‹ ÙÔ ‰¤ÚÌ· (¤Î˙ÂÌ·). OÈ ·ÓÙȉڿÛÂȘ ΢ڛˆ˜ Ù‡Ô˘ πV (΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜) ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ ÙÚ›ÙË ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜. ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ¤¯Ô˘Ì ·ÎfiÌ· Î·È πgE ·ÓÙȉڿÛÂȘ ¯ˆÚ›˜ ·˘ÍË̤ӷ ›‰· ÔÏÈ΋˜ ‹ ÂȉÈ΋˜ ÁÈ· ÙȘ ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ πgE.
™˘¯ÓfiÙËÙ· Î·È ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, Ë Û˘¯ÓfiÙËÙ· Â›Ó·È 2-2,5% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 16% ÌÂٷ͇ ÙˆÓ ‚ÚÂÊÒÓ Ì ‰‡Ô ·ÙÔÈÎÔ‡˜ ÁÔÓ›˜. ∏ ·ÔÚÚfiÊËÛË ÌÂÁ·ÏÔÌÔÚÈ·ÎÒÓ ÚˆÙÂ˚ÓÒÓ ÙˆÓ ÙÚÔÊÒÓ (fiˆ˜ .¯. ·˘ÙÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜) Î·È Ô Û¯ËÌ·ÙÈÛÌfi˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·˘ÙÒÓ, ·ÔÙÂÏ› Ê˘ÛÈÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∏ ·Ó¿Ù˘ÍË fï˜ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Ê·›ÓÂÙ·È fiÙÈ ÂÍ·ÚÙ¿Ù·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘Ú›ˆ˜ ·fi ÙË ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ·ÙÔ›·˜ Î·È ÙËÓ ÚÒÈÌË ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ ÛÙÔ ÌÈÎÚfi ‚Ú¤ÊÔ˜, Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤ÙÛÈ Ó¤· ·ÓÙÈÁfiÓ· Ì ÙÔ ·ÓÒÚÈÌÔ ·ÓÔÛÔÔÈËÙÈÎfi ÙÔ˘ Û‡ÛÙËÌ· Î·È ÙËÓ ·˘ÍË̤ÓË, ÏfiÁˆ ·ÓˆÚÈÌfiÙËÙ·˜, ‰È·ÂÚ·ÙfiÙËÙ· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ‚ÚÂÊÒÓ ÂÌÊ·Ó›˙ÂÈ Ù· Û˘ÌÙÒÌ·Ù· ̤۷ ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ (82% ̤¯ÚÈ ÙÔÓ 4Ô Ì‹Ó· Î·È 90% ̤¯ÚÈ ÙÔ 1Ô ¤ÙÔ˜ ˙ˆ‹˜). OˆÛ‰‹ÔÙÂ, ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙËÓ ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ô ¯ÚfiÓÔ˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ ÙÔ˘ ‚Ú¤ÊÔ˘˜. ∂›Ó·È ¢ÓfiËÙÔ fiÙÈ Ù· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ÂÌÊ·Ó›˙Ô˘Ó Ù· Û˘ÌÙÒÌ·Ù· Ôχ ·ÚÁfiÙÂÚ· (1,3,4). ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∞Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ·ÓÙ›‰Ú·ÛË Î·È ÙÔÓ ˘ÔΛÌÂÓÔ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi, ÔÈ ·ÛıÂÓ›˜ ÌÂ
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¶ÚfiÁÓˆÛË ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙË Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÔÈΛÏÏÔ˘Ó Â˘Ú¤ˆ˜. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Â›Ó·È Ì›· ·ÚÔ‰È΋ ÓfiÛÔ˜ Î·È ÙÔ 85% ÙˆÓ Â˘·›ÛıËÙˆÓ ‚ÚÂÊÒÓ ··ÏÏ¿ÛÛÂÙ·È ·fi Ù· Û˘ÌÙÒÌ·Ù¿ ÙÔ˘ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ 3Ô˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. ÕÏÏÔÈ fï˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÏÏÔ› ·ÛıÂÓ›˜ (ÂÚ›Ô˘ ÙÔ 40%) ·Ú·Ì¤ÓÔ˘Ó Û˘Ìو̷ÙÈÎÔ› ÌÂÙ¿ ÙÔÓ 4Ô ¯ÚfiÓÔ ˙ˆ‹˜ (3,5). ∏ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ·ÙÔ›·˜
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Ê·›ÓÂÙ·È fiÙÈ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÈÌÔÓ‹ Ù˘ ·ÏÏÂÚÁ›·˜. °ÂÓÈο, Ë ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› ̤۷ ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Û ·È‰È¿ Ì ÂΉËÏÒÛÂȘ ·fi ÙÔ ‰¤ÚÌ· (¤Î˙ÂÌ·) ‹ ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· (‰È¿ÚÚÔȘ, ¤ÌÂÙÔÈ, ÎÔÈÏȷο ¿ÏÁË, ·Ó¿ÚÎÂÈ· ·‡ÍËÛ˘), ÂÓÒ Ù›ÓÂÈ Ó· ÂÈ̤ÓÂÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Û ÂÚÈÙÒÛÂȘ Ù‡Ô˘ π (πgE) ÂΉËÏÒÛˆÓ. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ì ÙËÓ ÔÔ›· ÚˆÙÔÂÌÊ·Ó›˙ÂÙ·È Ë ÓfiÛÔ˜, Û˘Ó‹ıˆ˜ ·Ú·Ì¤ÓÂÈ Ë ›‰È· ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÈÌÔÓ‹˜ Ù˘. ªÂÚÈΤ˜ ÊÔÚ¤˜, fï˜, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· ·ÏÏ¿˙ÂÈ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÛÙÔ ›‰ÈÔ ¿ÙÔÌÔ Î·È ÙfiÙ ·˘Ùfi Ô˘ Û˘Ì‚·›ÓÂÈ Â›Ó·È Ë ÌÂٿوÛË Û ÌÔÚʤ˜ Ì ÂÚÈÛÛfiÙÂÚÔ Î·ı˘ÛÙÂÚË̤ÓË ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Û ۯ¤ÛË Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜. ¶·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Î·È Î˘Ú›ˆ˜ ÂΛӷ Ì ÂÈÌÔÓ‹ Ù˘ ÓfiÛÔ˘, ¤¯Ô˘Ó Ôχ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ·ÏÏÂÚÁ›·˜ Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· (·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· - ¿ÛıÌ·) ηıÒ˜ Î·È ·ÏÏÂÚÁ›·˜ Û ÔÏÏ·Ï¿ ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· (6,7). ¢È¿ÁÓˆÛË Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÕÌÂÛË ·ÓÙ›‰Ú·ÛË (πgE) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¿ÌÂÛË Ù‡Ô˘ π ·ÓÙ›‰Ú·ÛË, Ë ‰È¿ÁÓˆÛË Â›Ó·È Û˘Ó‹ıˆ˜ ‡ÎÔÏË. ™ÙÔ ÈÛÙÔÚÈÎfi ˘¿Ú¯ÂÈ Û·Ê‹˜ Û˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜. ∏ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡ Ì Á¿Ï· ·ÁÂÏ¿‰Ô˜ ‹ Ì ÂȉÈο ‰È·Ï‡Ì·Ù· ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Â›Ó·È ¤ÓÙÔÓ· ıÂÙÈ΋ Î·È Ë ÂȉÈ΋ πgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (RAST) Â›Ó·È Ôχ ·˘ÍË̤ÓË. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (·ÓÔÈÎÙ‹ ‹ ‰ÈÏ‹ Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì placebo DBPC - Ô˘ ·ÔÙÂÏ› ÙË ¯Ú˘Û‹ ÛÙ·ıÂÚ¿ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜) Û˘Ó‹ıˆ˜ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·È Û ÂÚÈÙÒÛÂȘ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó·Ê˘Ï·Í›·˜ ηÏfi Â›Ó·È Ó· ·ÔʇÁÂÙ·È. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û ·È‰È¿ Ì ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ Ù‡Ô˘ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ¿ÚÔ‰Ô ÔÚÈṲ̂ÓÔ˘ ¯ÚfiÓÔ˘ ·fi ÙË ‰È¿ÁÓˆÛË, ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘¯fiÓ ˘Ô¯ÒÚËÛ˘ Ù˘ ˘ÂÚ¢·ÈÛıËÛ›·˜ (2,4). ∫·ı˘ÛÙÂÚË̤ÓË ·ÓÙ›‰Ú·ÛË ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË. ∆Ô ÈÛÙÔÚÈÎfi ‰ÂÓ ‚ÔËı¿ÂÈ ÁÈ·Ù› Û˘Ó‹ıˆ˜ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Ï‹„Ë Á¿Ï·ÎÙÔ˜. ∏ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡ Î·È Ë ÂȉÈ΋ πgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (RAS∆) Û˘Ó‹ıˆ˜ ·Ô‚·›ÓÔ˘Ó ·ÚÓËÙÈΤ˜. OÈ ·fi„ÂȘ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ˜, fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÚfiÏÔ Ù˘ ‰ÔÎÈÌ·Û›·˜ patch ÛÙË ‰È¿ÁÓˆÛË ÙˆÓ Î·ı˘ÛÙÂÚË̤ÓÔ˘ Ù‡Ô˘ ·ÓÙȉڿÛˆÓ. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ·ÔÙÂÏ› ÙËÓ ·ÎÚÈ‚¤-
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ÛÙÂÚË Ì¤ıÔ‰Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË, ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ™Â ·È‰È¿ <1 ¤ÙÔ˘˜, ·ÓÔÈÎÙ‹ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ¤¯ÂÈ ‰Âȯı› fiÙÈ Â›Ó·È ·ÍÈfiÈÛÙË (4,8,9). ¶ÚÔ¸Ôı¤ÛÂȘ ‰ÔÎÈÌ·Û›·˜ ÚfiÎÏËÛ˘: ¶Ú¤ÂÈ ¿ÓÙ· Ó· Á›ÓÂÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·fi ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi, ΢ڛˆ˜ ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÌÙˆÌ¿ÙˆÓ ·Ó·Ê˘Ï·Í›·˜ ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ÂÚÌËÓ›· ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜. ∂È‚¿ÏÏÂÙ·È Ë Ï‹„Ë ÏÂÙÔÌÂÚÔ‡˜ ÈÛÙÔÚÈÎÔ‡ Î·È Ë Ï‹Ú˘ Ê˘ÛÈ΋ ÂͤٷÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙÔÓ ÔÔ›Ô ÙÔÔıÂÙÂ›Ù·È ÊÏ‚ÔηıÂÙ‹Ú·˜. °›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ηٷÁÚ·Ê‹ Ûʇ͈Ó, ∞¶, ÎÔÚÂÛÌÔ‡ O2 (SaO2), ÌÂÁ›ÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ (PEF) fiÙ·Ó ÙÔ ·È‰› Â›Ó·È >5 ÂÙÒÓ. À¿Ú¯Ô˘Ó Ê¿Ú̷η ·Ó¿Ó˄˘ Î·È ·ÚÔ¯‹ O2 ‰›Ï· ·fi ÙÔÓ ·ÛıÂÓ‹. ∆¯ÓÈ΋ ‰ÔÎÈÌ·Û›·˜ ÚfiÎÏËÛ˘: ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ÛÙ·‰È·Î‹ ¯ÔÚ‹ÁËÛË - ·Ó¿ 20-30 min - ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓˆÓ ÔÛÔÙ‹ÙˆÓ Á¿Ï·ÎÙÔ˜. ∏ ‰ÔÎÈÌ·Û›· ıˆÚÂ›Ù·È ÂÈÙ˘¯‹˜ fiÙ·Ó Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Ó¯ı› Û˘ÓÔÏÈο 15-20 gr ÚˆÙ½Ó˘ Á¿Ï·ÎÙÔ˜ Î·È 8-10 gr Û·Ó Ì›· ÙÂÏÈ΋ ÌÔÓ·‰È΋ ‰fiÛË. ∞Ó¿ 20-30 min Á›ÓÂÙ·È Ï‹Ú˘ Ê˘ÛÈ΋ ÂͤٷÛË (¤ÏÂÁ¯Ô˜ ÁÈ· ·ÚÔ˘Û›· ÂÍ·Óı‹Ì·ÙÔ˜, ÊÙ·ÚÓÈÛÌ¿ÙˆÓ, ÛÈÁÌÔ‡, Û˘ÚÈÁÌÔ‡, Â̤وÓ, ‰È¿ÚÚÔÈ·˜, ¢ÂÚÂıÈÛÙfiÙËÙ·˜), ηٷÁÚ·Ê‹ Ûʇ͈Ó, ∞¶, SaO2 PEF. ∂¿Ó ÂÌÊ·ÓÈÛÙ› ÔÔÈ·‰‹ÔÙ ·ÓÙ›‰Ú·ÛË, Ë ‰ÔÎÈÌ·Û›· ‰È·ÎfiÙÂÙ·È Î·È Ô ·ÛıÂÓ‹˜ ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· 12-24 ÒÚ˜. ∂¿Ó ‰ÂÓ ÂÌÊ·ÓÈÛÙ› ·ÓÙ›‰Ú·ÛË, Ô ·ÛıÂÓ‹˜ ÂͤگÂÙ·È ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ 23 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ‰ÔÎÈÌ·Û›·˜. ∞ÓÙÈÌÂÙÒÈÛË ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ∞) ™Ù· ‚Ú¤ÊË Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Û˘ÓÈÛÙ¿Ù·È Ï‹Ú˘ ·ÔÊ˘Á‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙˆÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘. ∂¿Ó Â›Ó·È ÂÊÈÎÙfi, ÂÓı·ÚÚ‡ÓÂÙ·È Ë Û˘Ó¤¯ÈÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ‰È·ÊÔÚÂÙÈο ÂÈϤÁÂÙ·È ÚÔÛÂÎÙÈο ÙÔ Î·Ù¿ÏÏËÏÔ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi Á¿Ï·. ™‹ÌÂÚ·, ˆ˜ ηٷÏÏËÏfiÙÂÚ· ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈο Á¿Ï·Ù· ıˆÚÔ‡ÓÙ·È ÂΛӷ Ì ÂÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ÚˆÙ½Ó˘ (ÂÚȤ¯Ô˘Ó ÂÙ›‰È· <8000 Da). AÓ¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ Ù˘ ÚˆÙ½Ó˘ ‰È·ÎÚ›ÓÔÓÙ·È Û Á¿Ï·Ù· ÌÂ: ∂ÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË Î·˙½Ó˘ (Pregestimil, Nutramigen), EÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ÏÂ˘ÎˆÌ·Ù›Ó˘ (Alfa-Re, Pepti-junior, Nutrilon Pepti), ∂ÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ¿ÏÏ˘ ÚˆÙ½Ó˘ (˙ˆ˚΋˜ ‹ Ê˘ÙÈ΋˜) (Pre- gomin, Peptide 0-2, Peptide 2+). ŒÓ· ÌÈÎÚfi ÔÛÔÛÙfi ‚ÚÂÊÒÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜ ·ÎfiÌË Î·È ÛÙ· ·Ú·¿Óˆ Á¿Ï·Ù·, ÔfiÙÂ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ Ì ·ÌÈÓÔͤ· fiˆ˜: ¡utri-junior, Neocate (ÁÈ· ‚Ú¤ÊË), Neocate Advance (ÁÈ· ·È‰È¿ >1 ¤ÙÔ˘˜). ∆Ô
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Á¿Ï· ÛfiÁÈ·˜ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È ÛÙ· ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜, ÂÂȉ‹ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·fi ·˘Ù¿ (17-47%) ·Ó·Ù‡ÛÛÂÈ ·ÏÏÂÚÁ›· ÛÙË ÛfiÁÈ·. ∆Ô Á¿Ï· ÙÔ˘ ÚÔ‚¿ÙÔ˘ Î·È Ù˘ ηÙۛη˜ ¤¯ÂÈ ÔÏϤ˜ ÎÔÈÓ¤˜ ÚˆÙ½Ó˜ Ì ·˘Ùfi Ù˘ ·ÁÂÏ¿‰Ô˜ Î·È ıˆÚÂ›Ù·È ·Î·Ù¿ÏÏËÏÔ ˆ˜ ˘ÔηٿÛÙ·ÙÔ. ∆¤ÏÔ˜, ·Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· Á¿Ï·Ù· Ì ÌÂÚÈ΋ ˘‰ÚfiÏ˘ÛË Ù˘ ÚˆÙ½Ó˘ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏË ·Ó·ÏÔÁ›· ÚˆÙÂ˚ÓÒÓ 8-40 kD·), fiˆ˜ .¯. ¡∞N ∏∞, ∞ptamil HA, ·ÓÙÂӉ›ÎÓ˘ÓÙ·È Ï‹Úˆ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË - ·ÏÏÂÚÁÈÎÒÓ ÛÙÔ Á¿Ï· - ‚ÚÂÊÒÓ. ÿÛˆ˜ ¤¯Ô˘Ó ı¤ÛË ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· ÚfiÏ˄˘ Ù˘ ·ÙÔ›·˜ (7,10). µ) OÈ ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ ·ÏÏ¿ Î·È ÔÈ ›‰ÈÔÈ ÔÈ ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ (ȉȷ›ÙÂÚ· ÂΛÓÔÈ Ì ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ Ù‡Ô˘ ·ÓÙȉڿÛÂȘ) Ú¤ÂÈ Ó· Â›Ó·È Ôχ ηϿ ÂÓËÌÂڈ̤ÓÔÈ Î·È Ó· ·ÔʇÁÔ˘Ó, fi¯È ÌfiÓÔ ÙÔ Á¿Ï· Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘, ·ÏÏ¿ Î·È ‰È¿ÊÔÚ˜ ÙÚÔʤ˜ Ô˘ ÂÚȤ¯Ô˘Ó ÚˆÙ½ÓË Á¿Ï·ÎÙÔ˜. ŒÙÛÈ, Ú¤ÂÈ Ó· Ì¿ıÔ˘Ó Ó· ‰È·‚¿˙Ô˘Ó ÚÔÛÂÎÙÈο ÙÔ˘˜ ηٷÏfiÁÔ˘˜ Ì ٷ Û˘ÛÙ·ÙÈο ÙˆÓ ‰È·ÊfiÚˆÓ ÙÚÔÊÒÓ Î·È Ó· ÁÓˆÚ›˙Ô˘Ó fiÙÈ Ë ÚˆÙ½ÓË ÙÔ˘ Á¿Ï·ÎÙÔ˜ ÌÔÚ› Ó· ÎÚ‡‚ÂÙ·È ›Ûˆ ·fi fiÚÔ˘˜ fiˆ˜ Ï·ÎÙfi˙Ë, ηڷÌÂÏfi¯ÚˆÌ·, Ê˘ÛÈÎfi ¿ÚˆÌ· Î.Ù.Ï. (4). °) À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ ÔÈ ÚÔ‚ÈÔÙÈÎÔ› ÔÚÁ·ÓÈÛÌÔ› - ÌÈÎÚԂȷο ·ÙÙ·Ú· ‹ ÙÌ‹Ì·Ù· ·˘ÙÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙ· Á¤ÓË lactobacilli ‹ bifidobacteria - ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. ª¤¯ÚÈ ÛÙÈÁÌ‹˜, fï˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ (11). ¢) ∆¤ÏÔ˜, Ù· ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Ú¤ÂÈ ·Ó¿ 1-2 ¯ÚfiÓÈ· Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘, ÁÈ·Ù› ˘¿Ú¯ÂÈ ÙÔ ÂӉ¯fiÌÂÓÔ ˘Ô¯ÒÚËÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·Ó¿Ù˘Í˘ ·ÓÔ¯‹˜ ÛÙÔ Á¿Ï· Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘ (3-5).
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µÈ‚ÏÈÔÁÚ·Ê›· 1. Host A, Halken S. Epidemiology and prevention of cow’s milk allergy. Allergy 1998; 53(Suppl 46):111-113. 2. Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunological findings. J Pediatr 1986;109:270-276. 3. Host A. Cow’s milk protein allergy and intolerance in infancy. Pediatr Allergy Immunol 1994;5:5-36.8. 4. Metcalfe DD, Sampson HA, Simon RA. Food Allergy: Adverse reaction to foods and food additives. 2nd Edition. Blackwell Science; 1997. 5. Bishop JM, Hill DJ, Hosking CS. Natural history of cow milk allergy: Clinical outcome. J Pediatr 1990;116:862-867. 6. Iacono G, Cavataio F, Montalto G, Soresi M et al. Persistent cow’s milk protein intolerance in infants: The changing faces of the same disease. Clin Exp Allergy 1998;28:817-823. 7. Businco L, Giuseppe F, Bruno G. State of the art in prevention of allergy to milk. ACI Internat 1998;10:69-75. 8. Majamaa H, Moisio P, Holm K, Kautiainen H et al. Cow’s milk allergy: diagnostic accuracy of skin prick and patch tests and specific IgE. Allergy 1999;54:346-351. 9. Vanto T, Juntunen-Backman K, Kalimo K, Klemola T et al. The patch test, skin prick test and serum milk-specific IgE as diagnostic tools in cow’s milk allergy in infants. Allergy 1999;54:837-842. 10. Halken S, Host A. How hypoallergenic are hypoallergenic cow’s milk - based formulas? Allergy 1997;52:1175-1183. 11. Kirjavainen PV, Apostolou E, Salminen SJ, Isolauri E. New aspects of probiotics - a novel approach in the management of food allergy. Allergy 1999;54:909-915.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ∆Ú›Áη ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ ¶ÂÚ. ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·ÙÚÒÓ 265 00, ƒ›Ô-¶¿ÙÚ·
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∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞
Paediatriki 2001;64:223-228
ALLERGIOLOGY - DERMATOLOGY
XÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (Staphylococcus aureus). O ÚfiÏÔ˜ ÙÔ˘ ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ª. µ·Ï¿ÚË
The role of Staphylococcus aureus in atopic dermatitis M. Valari
¶ÂÚ›ÏË„Ë: ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ‰ÂÚÌ·ÙÔ¿ıÂÈ· ÙˆÓ ·È‰ÈÒÓ. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Â›Ó·È ·ÎfiÌË ¿ÁÓˆÛÙË, ·ÏÏ¿ ÈÛÙ‡ÂÙ·È ÔÙÈ Â›Ó·È Û‡ÌÏÂÁÌ· ·ÏÏËÏ›‰Ú·Û˘ ÁÂÓÂÙÈ΋˜ ¢·ÈÛıËÛ›·˜, ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÊÚ·ÁÌÔ‡ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜, ·ÏÏÂÚÁ›Â˜ Î·È ÌÈÎÚfi‚È·. O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÈΛ˙ÂÈ ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ˘„ËÏ¿ ›‰·, Ù· ÔÔ›· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÂÏ¢ıÂÚÒÓÂÈ ÙÔ͛Ә Ô˘ ‰ÚÔ˘Ó Û·Ó ˘ÂÚ·ÓÙÈÁfiÓ·, Ù· ÔÔ›· ÌÔÚ› Ó· ÚÔηÏÔ‡Ó ÙË ÊÏÂÁÌÔÓ‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÛÙÔ ·ÙÔÈÎfi ¤Î˙ÂÌ·. ™Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿, Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÌÔÚ› Ó· ıÂڷ¢Ù› Ì ÙËÓ Î·Ï‹ ÊÚÔÓÙ›‰· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙË ¯Ú‹ÛË ÙÔÈÎÒÓ ÛÙÂÚÔÂȉÒÓ Î·È Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈ΋ ıÂڷ›·.
Abstract: Atopic dermatitis is the most common skin disease affecting children. The etiology of atopic dermatitis is still unknown, but it is believed to be a complex interplay between genetic susceptibility, immune dysregulation, epidermal barrier dysfunction and environmental factors such as irritants, allergies and bacteria. The skin of patients with atopic dermatitis is colonized with high levels of Staphylococcus aureus, depending on the severity of the eczema. Staphylococcus aureus releases toxins that act as superantigens which can induce skin inflammation in patients with atopic eczema. In most children, atopic dermatitis can be controlled with good skin care, the use of topical steroids and the appropriate anti-staphylococcal treatment.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ¤Î˙ÂÌ·, ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ˘ÂÚ·ÓÙÈÁfiÓ·, ·ÓÙÈ‚ÈÔÙÈο, ·È‰È¿.
Key words: atopic dermatitis, eczema, Staphylococcus aureus, superantigens, antibiotics, children.
ªÂϤÙ˜ ÁÈ· ÙÔ ÚfiÏÔ ÙˆÓ ÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ÍÂΛÓËÛ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi 100 ¯ÚfiÓÈ· ÚÈÓ (1-3). ∞fi ÙfiÙÂ, Ë ÁÓÒÛË, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÌÂٷ͇ ÌÈÎÚÔ‚›ˆÓ Î·È ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Î·È Û‹ÌÂÚ· Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ÛÔ˘‰·›Ô˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁˆÓ ÁÈ· ÙËÓ ÔÍ›· Âȉ›ӈÛË ·ÏÏ¿ Î·È ÙË ‰È·Ù‹ÚËÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜.
∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, Ô˘ ÔÓÔÌ¿˙ÂÙ·È Î·È ·ÙÔÈÎfi ¤Î˙ÂÌ·, Â›Ó·È Ì›· ¯ÚfiÓÈ· ˘ÔÙÚÔÈ¿˙Ô˘Û· ÎÓËÛÌ҉˘ ‰ÂÚÌ·ÙÔ¿ıÂÈ· Ô˘ ÚÔÛ‚¿ÏÏÂÈ ¿ÙÔÌ· Ì ÁÂÓÂÙÈ΋ Úԉȷı¤ÛË. ™˘¯Ó¿ ÙË Û˘Ó·ÓÙԇ̠۠·ÛıÂÓ›˜ Ì ¿ÛıÌ· ‹ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· (4). ∂›Ó·È Ë ÈÔ Û˘¯Ó‹ ‰ÂÚÌ·ÙÔ¿ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ™˘Ó‹ıˆ˜ ÚˆÙÔÂÌÊ·Ó›˙ÂÙ·È fiÙ·Ó ÙÔ ·È‰› Â›Ó·È ‚Ú¤ÊÔ˜ Î·È ÂÚ›Ô˘ ÙÔ 90% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÂΉËÏÒÓÂÈ ÙË ÓfiÛÔ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ¯ÚfiÓˆÓ (5).
∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
Division of Pediatric Dermatology “St. Sophia” Children’s Hospital, Athens
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O ÎÓËÛÌfi˜ Â›Ó·È ÙÔ ·ıÔÁÓˆÌÔÓÈÎfi Û‡Ìو̷ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Û fiϘ ÙȘ ËÏÈ˘. ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÛÙËÓ ÔÍ›· ÌÔÚÊ‹ Ù˘ ÂΉËÏÒÓÂÙ·È Ì ÂÚ‡ıËÌ·, Ô›‰ËÌ·, ‰È·‚ÚÒÛÂȘ Î·È ÂΉÔÚ¤˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÂÓÒ Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÔÚÔÚÚÔ‹ Î·È Ó· Û¯ËÌ·ÙÈÛÙÔ‡Ó ÂÊÂÏΛ‰Â˜. °ÓÒÚÈÛÌ· Ù˘ ¯ÚfiÓÈ·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Â›Ó·È Ë ÏÂȯËÓÔÔ›ËÛË, ‰ËÏ·‰‹ Ë ¯·Ú·ÎÙËÚÈÛÙÈ΋ ¿¯˘ÓÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Ì ·˘ÍË̤ÓË ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÁÚ¿Ì̈ÛË Î·È ·˘ÍË̤ÓË Û˘Ó‹ıˆ˜ ÌÂÏ¿¯ÚˆÛË. ™Ù· ‚Ú¤ÊË, Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÂÓÙÔ›˙ÂÙ·È ÛÙȘ ·ÚÂȤ˜, ÙÔ Ì¤ÙˆÔ, ÙÔ ÎÂÊ¿ÏÈ, ÙÔÓ ÎÔÚÌfi Î·È ÙȘ ¤Íˆ ÂÈÊ¿ÓÂȘ ÙˆÓ ¿ÎÚˆÓ, ÂÓÒ ÎÏÈÓÈο ¤¯Ô˘Ì ÂÈÎfiÓ· ÔÍ›·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÔÈ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÂÓÙÔ›˙ÔÓÙ·È ÛÂ Ù˘¯¤˜, fiˆ˜ ÛÙÔ˘˜ ·ÁÎÒÓ˜ Î·È ÛÙ· ÁfiÓ·Ù·, ·ÏÏ¿ Î·È ÛÙÔ˘˜ ηÚÔ‡˜, ÛÙÔ˘˜ ÌËÚÔ‡˜, ÁÏÔ˘ÙÔ‡˜ Î·È Ù· ¯¤ÚÈ·. ∫ÏÈÓÈο, ηıÒ˜ ÙÔ ·È‰› ÌÂÁ·ÏÒÓÂÈ, ÔÈ ‚Ï¿‚˜ Á›ÓÔÓÙ·È ÍËÚfiÙÂÚ˜, ÈÔ ‚Ï·Ùȉ҉ÂȘ Î·È ÏÂȯËÓÔÔÈË̤Ó˜, ÂÓÒ Û˘Ó˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ˜ ÎÓËÛÌfi˜. ¶·ıÔÁ¤ÓÂÈ· ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ·Ú·Ì¤ÓÂÈ ·ÎfiÌË ¿ÁÓˆÛÙË. £ÂˆÚÂ›Ù·È fiÙÈ Â›Ó·È Û‡ÌÏÂÁÌ· ·ÏÏËÏ›‰Ú·Û˘ ÁÂÓÂÙÈ΋˜ ¢·ÈÛıËÛ›·˜, ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÊÚ·ÁÌÔ‡ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Â›‰Ú·Û˘ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (6). ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ÁÂÓÂÙÈ΋ ÓfiÛÔ˜, ·Ó Î·È ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜ Ô ÙÚfiÔ˜ ÌÂÙ·‚›‚·Û˘. ∞˘Ùfi Ê·›ÓÂÙ·È ·fi ÙÔÓ ÔÈÎÔÁÂÓ‹ ¯·Ú·ÎÙ‹Ú· Ù˘ ÓfiÛÔ˘ Î·È ·fi ÙËÓ ˘„ËÏ‹ Û˘Ó‡·ÚÍË Û ÌÔÓÔˆÁÂÓ‹ ‰›‰˘Ì· (7). ∏ ÎÏËÚÔÓÔÌÈ΋ ·ÓˆÌ·Ï›· Ê·›ÓÂÙ·È Ó· ÌÂٷʤÚÂÙ·È ÛÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· Î·È Ó· Â›Ó·È ÔÏ˘ÁÔÓȉȷ΋ (8). ∞Ó Î·È Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û˘Ó‰˘¿˙ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏ›· ·ÓÔÛÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ‰‡Ô ‚·ÛÈΤ˜ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ê·›ÓÂÙ·È Ó· ÙËÓ ¯·Ú·ÎÙËÚ›˙Ô˘Ó: ÚÒÙÔÓ, Ë ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ IgE Î·È ‰Â‡ÙÂÚÔÓ, Ë ‹È· ηٷÛÙÔÏ‹ Ù˘ ·ÓÙ›‰Ú·Û˘ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ÂÈ‚Ú·‰˘ÓfiÌÂÓÔ˘ Ù‡Ô˘. ŒÚ¢Ó˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ˘ÔÏËı˘ÛÌfi˜ ∆∏2 ÙˆÓ ∆-
Paediatriki 2001;64:223-228
΢ÙÙ¿ÚˆÓ Ô˘ ˘¿Ú¯Ô˘Ó Û ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·Ú¿ÁÔ˘Ó ·˘ÍË̤ӷ ÔÛ¿ ÈÓÙÂÚÏ¢ΛÓ˘ IL-4 Ô˘ ‰ÚÔ˘Ó ¿Óˆ ÛÙ· µÎ‡ÙÙ·Ú· Î·È ÚÔ¿ÁÔ˘Ó ÙËÓ ˘ÂÚ·Ú·ÁˆÁ‹ IgE. ∞ÎfiÌË, ‚Ú¤ıËΠfiÙÈ ˘¿Ú¯ÂÈ ÌÂȈ̤ÓÔ˜ Ô ∆∏1 ˘ÔÏËı˘ÛÌfi˜ ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ, ÏfiÁˆ ˘ÂÚ·Ú·ÁˆÁ‹˜ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ (PGE ·Ô Ù· ÌÔÓÔ·ÙÙ·Ú·) Î·È ÙÔ˘ TNF (·fi Ù· Ì·ÛÙÔ·ÙÙ·Ú·) Î·È Ô˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ Á-ÈÓÙÂÚÊÂÚfiÓ˘ (IFN). øÛÙfiÛÔ, Ô ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÚÔηÏ› ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ ‰ÂÓ ¤¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ ‰È¢ÎÚÈÓÈÛÙ› (6,9). ∏ ÍËÚÔ‰ÂÚÌ›· Û ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÔÊ›ÏÂÙ·È ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ÏÈȉ›ˆÓ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Û ·˘ÍË̤ÓË ‰È·‰ÂÚÌÈ΋ ·ÒÏÂÈ· ÓÂÚÔ‡. ∞˘Ù¿ ¤¯Ô˘Ó Û·Ó Û˘Ó¤ÂÈ· ÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÊÚ·ÁÌÔ‡ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∏ ÍËÚfiÙËÙ· ‰ËÌÈÔ˘ÚÁ› ‰È·‚ÚÒÛÂȘ, ÔÈ Ôԛ˜ ÂÎı¤ÙÔ˘Ó ÙÔ ˘ÔΛÌÂÓÔ ‰¤ÚÌ· Û ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜, ·ÏÏÂÚÁÈÔÁfiÓ· Î·È ÌÈÎÚfi‚È· Ô˘ ÚÔηÏÔ‡Ó ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ (9). ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ¯ÚfiÓÈ· ÓfiÛÔ˜ Ì ÂÍ¿ÚÛÂȘ Ô˘ ÂÎχÔÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ (10). OÈ ÛÔ˘‰·ÈfiÙÂÚÔÈ ·fi ·˘ÙÔ‡˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÂÏ¿¯ÈÛÙ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ·ÏÏÂÚÁ›· ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÂȉÂÈÓÒÓÂÙ·È ·fi ·˘Ù‹ (11). O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (S. aureus), ¤Ó· ÎÔÈÓfi ·ıÔÁfiÓÔ ÌÈÎÚfi‚ÈÔ Ô˘ Û¿ÓÈ· ·ÔÈΛ˙ÂÈ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‰¤ÚÌ·, ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Û·Ó ÂÚÈ‚·ÏÏÔÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔηÏ› Âȉ›ӈÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ (12). ™Ù· ˘ÁÈ‹ ¿ÙÔÌ·, Ù· ÛËÌ›· Ô˘ Û˘Ó‹ıˆ˜ ·ÔÈΛ˙ÔÓÙ·È Ì S. aureus Â›Ó·È Ë Ì‡ÙË (35% ÙÔ˘ ÏËı˘ÛÌÔ‡), ÔÈ Ù˘¯¤˜, fiˆ˜ Ì·Û¯¿ÏË Î·È Ù˘¯¤˜ Ô‰ÈÒÓ (5% - 10%) Î·È ÙÔ ÂÚ›ÓÂÔÓ (20%) (13). ∞ÓÙ›ıÂÙ·, ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ÌÂϤÙ˜ Ô˘ ÍÂοı·Ú· ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÈΛ˙ÂÈ ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ÔÛÔÛÙfi Ô˘ ÌÔÚ› Ó· Î˘Ì·›ÓÂÙ·È ·fi 70% ÛÙȘ ÌË ÚÔۂ‚ÏË̤Ó˜ ÂÚÈÔ¯¤˜ Î·È Êı¿ÓÂÈ Ì¤¯ÚÈ 100% ÛÙȘ ÂÍȉڈ̷ÙÈΤ˜ ‚Ï¿‚˜
¶›Ó·Î·˜ 1. ∂ÎÏ˘ÙÈο ·›ÙÈ· ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜
∂ÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜ (Û·Ô‡ÓÈ·, Û·ÌÔ˘¿Ó, ·ÔÚÚ˘·ÓÙÈο, ·ʋ Ì ӿ˘ÏÔÓ Î·È Ì¿ÏÏÈÓ·) ∫ϛ̷ (¯ÂÈÌÒÓ·˜ Î·È ¯·ÌËÏ‹ ˘ÁÚ·Û›·) ÕÁ¯Ô˜ ∆ÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· (·˘Á¿, Á¿Ï·, ÍËÚÔ› ηÚÔ›, „¿ÚÈ Î·È ‰ËÌËÙÚȷο) ∂ÈÛÓÂfiÌÂÓ· ·ÏÏÂÚÁÈÔÁfiÓ· (¿Î·ÚÈ Ù˘ ÔÈÎȷ΋˜ ÛÎfiÓ˘, ÁÚ·Û›‰È, ÙÚ›¯ˆÌ· ·fi ηÙÔÈΛ‰È· ˙Ò·) ªÈÎÚfi‚È· (¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÈÙ˘ÚfiÛÔÚÔ)
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¶·È‰È·ÙÚÈ΋ 2001;64:223-228
(14,15). ∏ ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Â›Ó·È Ôχ ˘„ËÏfiÙÂÚË ÛÙȘ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ Û ۯ¤ÛË Ì ÙÔ ˘ÁȤ˜ ‰¤ÚÌ·, fiˆ˜ ›Û˘ Â›Ó·È ·Ó¿ÏÔÁ· Û¯ÂÙÈ˙fiÌÂÓË Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. Œ¯ÂÈ ‚ÚÂı› fiÙÈ Û ÂÍȉڈ̷ÙÈΤ˜ ‚Ï¿‚˜, ‰ËÏ·‰‹ ÔÍ›·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·, Ë Ì¤ÛË ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ‹Ù·Ó (ÌÂÁ¿ÏË) 14x106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2, Û ¯ÚfiÓÈ· ÏÂȯËÓÔÔÈË̤ÓÔ ‰¤ÚÌ· (̤ÙÚÈ·) 5x106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 Î·È Û ˘ÁȤ˜ (ÌÈÎÚ‹) 1,3x103 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 (14). ∞˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·fi ·ÚÎÂÙÔ‡˜ ÂÚ¢ÓËÙ¤˜ (16,17). ∞›ÙÈ· ·ÔÈÎÈÛÌÔ‡ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· O ÏfiÁÔ˜ ÙÔ˘ ˘„ËÏÔ‡ ·ÔÈÎÈÛÌÔ‡ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ¿ÁÓˆÛÙÔ˜. ªÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ÍËÚfiÙËÙ· Ô˘ ‰ËÌÈÔ˘ÚÁ› ‰È·‚ÚÒÛÂȘ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÔÈ Ôԛ˜ ÂÈÙÚ¤Ô˘Ó ÙË ‰È›ۉ˘ÛË ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘. ∂›Û˘, ¤¯ÂÈ ·Ô‰Ôı› ÛÙËÓ ·˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, Ô˘ ÔÊ›ÏÂÙ·È Û ÔÚÈṲ̂Ó˜ ÚˆÙ½Ó˜ ÚÔÛÎfiÏÏËÛ˘, fiˆ˜ Ë ÊÈÌÚÔÓÂÎÙ›ÓË (18,19). ∞ÎfiÌË, ¤¯ÂÈ ·Ô‰Ôı› ÛÙË ÌÂȈ̤ÓË ·ÓÙÈÌÈÎÚԂȷ΋ ‰Ú¿ÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÏfiÁˆ Ì›ˆÛ˘ ÙÔ˘ ÛÌ‹ÁÌ·ÙÔ˜ Î·È ÙÔ˘ ȉÚÒÙ·, ·ÏÏ¿ Î·È ÏfiÁˆ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ÏÈȉ›ˆÓ Ù˘ ÂȉÂÚÌ›‰·˜ (17). ™Ù·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ¶ÂÚ›Ô˘ Ù· 2/3 ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎˆÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Û ηÏÏȤÚÁÂȘ ·fi ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·Ú¿ÁÔ˘Ó Â͈ÙÔ͛Ә, ΢ڛˆ˜ ÙȘ ˘ÂÚ·ÓÙÈÁÔÓÈΤ˜ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ÂÓÙÂÚÔÙÔ͛Ә ∞ Î·È µ (SEA, SEB) Î·È ÙËÓ ÙÔÍ›ÓË ÙÔ˘ ÙÔÍÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (TSST-1) (20). ∏ ˘ÂÚ·ÓÙÈÁÔÓÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ô Î˘ÚÈfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÚÔηÏ› Âȉ›ӈÛË Î·È ‰È·Ù‹ÚËÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›‰·˜, ·Ó Î·È ÔÈ ¤Ú¢Ó˜ Â›Ó·È ·ÎfiÌË ÛÙËÓ ·Ú¯‹ (21-23). ÀÂÚ·ÓÙÈÁfiÓ· ∆· ˘ÂÚ·ÓÙÈÁfiÓ· Â›Ó·È Ì›· Û¯ÂÙÈο ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈṲ̂ÓË ÔÌ¿‰· ·ÓÙÈÁÔÓÈÎÒÓ ÌÔÚ›ˆÓ, Ù· ÔÔ›· ‰È·Ê¤ÚÔ˘Ó ·fi Ù· ÎÏ·ÛÈο ·ÓÙÈÁfiÓ· ÛÙÔ fiÙÈ ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ó· ÂÓÂÚÁÔÔÈÔ‡Ó ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (5-30%) Û ۯ¤ÛË Ì ٷ Û˘Ì‚·ÙÈο ·ÓÙÈÁfiÓ· (0,01-0,0001%) (1,22,23). OÈ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ¤¯ÂÈ ÚÔÙ·ı›
Paediatriki 2001;64:223-228
fiÙÈ ÚÔηÏÔ‡Ó Âȉ›ӈÛË Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ›Ù ‰ÚÒÓÙ·˜ Û·Ó ·ÏÏÂÚÁÈÔÁfiÓ· Ì ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ Ù‡Ô˘ π ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ (IgE ‰È·ÌÂÛÔÏ·‚Ô‡ÌÂÓË ˘ÂÚ¢·ÈÛıËÛ›·), ›Ù ‰ÚÒÓÙ·˜ Û·Ó ˘ÂÚ·ÓÙÈÁfiÓ· Ì ÙËÓ ¤ÓÓÔÈ· Ù˘ ÌË ÂȉÈ΋˜ ‰È¤ÁÂÚÛ˘ ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ (24). ∆· ˘ÂÚ·ÓÙÈÁfiÓ· Ê·›ÓÂÙ·È fiÙÈ ÚÔηÏÔ‡Ó ‹ ÚÔ¿ÁÔ˘Ó ‚Ï¿‚˜ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Ì ‰È¿ÊÔÚÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜. ŒÙÛÈ, ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì¤Ûˆ ‰È·Û˘Ó‰¤Ûˆ˜ Ù˘ V ÂÚÈÔ¯‹˜ Ù˘ ‚ ·Ï˘Û›‰·˜ ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-΢ÙÙ¿ÚÔ˘ TCR Ì ٷ ÌfiÚÈ· ÙÔ˘ ªÂ›˙ÔÓÔ˜ ™˘ÌϤÁÌ·ÙÔ˜ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ MHC-II, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ¤ÎÎÚÈÛË ÏÂÌÊÔÎÈÓÒÓ Î·È ÙË ÊÏÂÁÌÔÓ‹ (22,23). ∞ÎfiÌË, Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó ·Â˘ı›·˜ ·ÙÙ·Ú· ÙÔ˘ Langerhans, Ì·ÎÚÔÊ¿Á·, ÌÔÓÔ·ÙÙ·Ú· Î·È ÎÂÚ·ÙÈÓÔ·ÙÙ·Ú· Î·È Ó· ÚÔηϤÛÔ˘Ó ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ fiˆ˜ IL-1 (ÈÓÙÂÚÏ¢ΛÓ˘) Î·È TNF-· (·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ fiÁÎÔ˘) Î·È ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Ì¤Û· ÛÙÔ ‰¤ÚÌ· (23). ∂ȉÈο IgE ·ÓÙÈÛÒÌ·Ù· ÂÓ·ÓÙ›ÔÓ ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘, fiˆ˜ ÙȘ ÂÓÙÂÚÔÙÔ͛Ә ∞ Î·È µ Î·È ÙËÓ ÙÔÍ›ÓË ÙÔ˘ ÙÔÍÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (SEA, SEB, TSST-1), ¤¯Ô˘Ó ·ÓȯÓ¢ı› Û ÔÈΛϷ ˘„ËÏ¿ ÔÛÔÛÙ¿ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (24-26). ∆· ›‰· ÙˆÓ ÂȉÈÎÒÓ ·˘ÙÒÓ IgE ·ÓÙÈÛˆÌ¿ÙˆÓ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘. ™Â ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜ ‚Ú¤ıËΠfiÙÈ ÔÈ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó Ù· µ ÏÂÌÊÔ·ÙÙ·Ú· Ó· ·Ú¿ÁÔ˘Ó ÂȉÈο IgE ·ÓÙÈÛÒÌ·Ù· (27). ∞ÔÈÎÈÛÌfi˜ ‹ Ïԛ̈ÍË •·ÊÓÈ΋ Âȉ›ӈÛË Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÔÚÔÚÚÔ‹˜, ÂÊÂÏΛ‰ˆÓ, ÊÏ˘ÎÙ·ÈÓȉ›ˆÓ ‹ ˘Ò‰Ô˘˜ ¤ÎÎÚÈÛ˘ Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ (S. aureus), ·ÏÏ¿ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ‚ÔÏ‹ Î·È ÌÈÎÚÔ‚È·ÈÌ›· Â›Ó·È ·Û˘Ó‹ı˘. ∏ Ïԛ̈ÍË Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ÛÙ· ·È‰È¿ (28). ∏ ‰È¿ÎÚÈÛË ÌÂٷ͇ ·ÔÈÎÈÛÌÔ‡ Î·È Ïԛ̈͢ Â›Ó·È ‰‡ÛÎÔÏË ‚¿ÛÂÈ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜. ∏ ·ÚÔ˘Û›· ÔÚÔÚÚÔ‹˜ ‹ ÂÊÂÏΛ‰ˆÓ ÌÔÚ› Ó· Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ ·ÏÏ¿ Î·È ·Ï‹˜ ¤Í·ÚÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ·fi ¿ÏÏ· ·ÏÏÂÚÁÈÔÁfiÓ·. ∂›Û˘, ·Ú¿ ÙÔÓ Ôχ ˘„ËÏfi ·ÚÈıÌfi ÛÙ·Ê˘ÏÔÎfiÎÎˆÓ Ô˘ ˘¿Ú¯Ô˘Ó Û ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜, ·˘Ù¤˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÂÈÌÔÏ˘Ṳ̂Ó˜ ‹ Ù· ÎÏÈÓÈο ÛËÌ›· Ù˘ Ïԛ̈͢ Ó· ÌËÓ Â›Ó·È ÂÌÊ·Ó‹. ŒÙÛÈ, ¤¯ÂÈ ÚÔÙ·ı› fiÙÈ ˘ÎÓfiÙËÙ· ÙÔ˘ ÌÈÎÚÔ‚›Ô˘
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¿Óˆ ·fi 106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 Û ηÏÏȤÚÁÂȘ Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Ïԛ̈ÍË (14). ∞ÓÙÈÌÂÙÒÈÛË O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ê·›ÓÂÙ·È Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Î·È ÙÔ ÁÂÁÔÓfi˜ Ù˘ ıÂÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Î·È ÙÔ˘ ·ÔÈÎÈÛÌÔ‡ Ì ÛÙ·Ê˘ÏfiÎÔÎÎÔ Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈ΋ ıÂڷ›· Û ·È‰È¿ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·. ŒÙÛÈ, ÛÙÔ˘˜ ÚˆÙ·Ú¯ÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Âȉ›ӈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ¤Ú·Ó Ù˘ ÂÓ˘‰¿ÙˆÛ˘ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜, Ú¤ÂÈ Ó· Â›Ó·È Î·È Ë ÂÎÚ›˙ˆÛË ÙˆÓ ÌÈÎÚÔ‚›ˆÓ. ∂›Û˘, ÂÈ‚¿ÏÏÂÙ·È Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ıÂڷ›·˜, ÁÈ·Ù› Ì ·˘Ù‹ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ·Ó¿ÎÙËÛË Ù˘ ÂÏ·ÛÙÈÎfiÙËÙ·˜ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È ÚÔÏ·Ì‚¿ÓÂÙ·È Ë ‰ËÌÈÔ˘ÚÁ›· ‰È·‚ÚÒÛˆÓ. ªÂ ÙËÓ ÚfiÏË„Ë Ù˘ ÍËÚfiÙËÙ·˜ ‚ÂÏÙÈÒÓÂÙ·È Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÊÚ·ÁÌfi˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ¤ÙÛÈ ÌÂÈÒÓÂÙ·È Ë ‰È›ۉ˘ÛË ÙÔ˘ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Î·È ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘. ∏ ÂÓ˘‰¿ÙˆÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙÔ Ì¿ÓÈÔ Î·È ÙȘ ÂÓ˘‰·ÙÈΤ˜ Îڤ̘. ∆Ô Ì¿ÓÈÔ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î·ıËÌÂÚÈÓ¿ Û ¯ÏÈ·Úfi ÓÂÚfi Ì ÙËÓ ÚÔÛı‹ÎË ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ Ï·‰ÈÔ‡ Ì¿ÓÈÔ˘. ∂Ó˘‰·ÙÈΤ˜ Îڤ̘ Û˘ÓÈÛÙ¿Ù·È Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ Ì¿ÓÈÔ Î·È ÌÂ Û˘¯ÓfiÙËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ (5,29). OÈ ·ÓÙÈÊÏÂÁÌÔÓÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, ‰ËÏ·‰‹ Ù· ÙÔÈο ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Â›Ó·È ÙÔ ‚·ÛÈÎfi ̤ÚÔ˜ Ù˘ ıÂڷ›·˜ Ù˘ ÔÍ›·˜ ¤Í·ÚÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™Â ‹È˜ ÂÚÈÙÒÛÂȘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÂÊ·ÚÌfi˙ÔÓÙ·È ¯·ÌËÏ‹˜ ÈÛ¯‡Ô˜ ÙÔÈο ÛÙÂÚÔÂȉ‹, fiˆ˜ Ë ˘‰ÚÔÎÔÚÙÈ˙fiÓË, ÂÓÒ Û ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ, ̤ÙÚÈ·˜ ‹ ÈÛ¯˘Ú‹˜ ÈÛ¯‡Ô˜. ™Ù· ‚Ú¤ÊË, fiˆ˜ ›Û˘ ÛÙÔ ÚfiÛˆÔ Î·È ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚÈÔ¯‹, Ù· ÈÛ¯˘Ú‹˜ ÈÛ¯‡Ô˜ ÛÙÂÚÔÂȉ‹ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È. ∆· ÙÔÈο ÛÙÂÚÔÂȉ‹ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙËÓ ¿Û¯Ô˘Û· ÂÚÈÔ¯‹ ÁÈ· ÂÚ›Ô˘ 1 ¤ˆ˜ 2 ‚‰ÔÌ¿‰Â˜ (5,29). ªÈÎÚԂȷ΋ ÂÈÌfiÏ˘ÓÛË Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ˘¿Ú¯ÂÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ Âȉ›ӈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ∂¿Ó Ë Ïԛ̈ÍË Â›Ó·È ÂÎÙÂٷ̤ÓË ÂӉ›ÎÓ˘Ù·È Ë Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ÛÙÔ ÔÔ›Ô Ó· Â›Ó·È Â˘·›ÛıËÙÔ˜ Ô ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÁÈ· 7 ¤ˆ˜ 14 ̤Ú˜ (5,28,30). ∫·ıÒ˜ ÂÚ›Ô˘ ÙÔ 88% ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎˆÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Â›Ó·È
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·ÓıÂÎÙÈÎÔ› ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Î·È ÂÚ›Ô˘ ÙÔ 30% ÛÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË, Ê¿ÚÌ·ÎÔ ÂÎÏÔÁ‹˜ Â›Ó·È ÔÈ ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ÂÓÈÎÈÏϛӘ, ÙÔ ÊÔ˘ÛȉÈÎfi Ô͇ ‹ ÎÂÊ·ÏÔÛÔÚ›Ó˜ (15,30-32). ∞ÓÙÈ‚ÈÔÙÈο ‰Ú·ÛÙÈο, ΢ڛˆ˜ ÂÓ·ÓÙ›ÔÓ ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘, ÌÂÈÒÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ. ∂¿Ó Ë Ïԛ̈ÍË Â›Ó·È ÂÓÙÔÈṲ̂ÓË ÂӉ›ÎÓ˘Ù·È Î·È Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ë ıÂڷ›· Ì ÙÔÈο ·ÓÙÈ‚ÈÔÙÈο, fiˆ˜ ÊÔ˘ÛȉÈÎfi Ô͇ (fusidic acid), ÌÔ˘ÈÚÔÛ›ÓË (mupirocin) ÌfiÓÔ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (33-36). ∆ÔÈο ·ÓÙÈ‚ÈÔÙÈο Û ÌÔÚÊ‹ Îڤ̷˜ Â›Ó·È Î·Ï‡ÙÂÚ·, ÁÈ·Ù› ÔÈ ·ÏÔÈʤ˜ ÂÚÂı›˙Ô˘Ó ÙÔ ‰¤ÚÌ· Ô˘ ÊÏÂÁÌ·›ÓÂÈ. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Ô˘ Â›Ó·È ·ÔÈÎÈṲ̂ÓÔÈ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ¯ˆÚ›˜ Ó· ¤¯Ô˘Ó ÔÚ·Ù¿ Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ Ïԛ̈͢, ‰Â›¯ÓÔ˘Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ì ÙÔÈο ·ÓÙÈ‚ÈÔÙÈο ‹ ¿ÏÏ· ıÂڷ¢ÙÈο ̤ÙÚ·, Ù· ÔÔ›· ÌÂÈÒÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ì ÙËÓ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ‹ ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÌÂÈÒÓÂÙ·È Î·Ù¿ Ôχ Ô ·ÚÈıÌfi˜ ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ (2,33-35). ŸÌˆ˜, ‚Ú¤ıËΠfiÙÈ Î·È Ë ÂÊ·ÚÌÔÁ‹ ÙÔÈο ÌfiÓÔ ÈÛ¯˘ÚÒÓ ÙÔÈÎÒÓ ÛÙÂÚÔÂȉÒÓ ÌÂÈÒÓÂÈ ÙËÓ ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ (37). O Û˘Ó‰˘·ÛÌfi˜ ÙÔÈÎÔ‡ ÛÙÂÚÔÂȉԇ˜ Ì ·ÓÙÈ‚ÈÔÙÈÎfi Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Î·Ï‡ÙÂÚ· ·ÔÙÂϤÛÌ·Ù· (23,33-34). ∆· ·ÓÙÈ‚ÈÔÙÈο, ÂÂȉ‹ ÂÎÚÈ˙ÒÓÔ˘Ó ÙÔ ÛÙ·Ê˘ÏfiÎÔÎÎÔ, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·¯‡ÙÂÚË ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· Î·È ¤ÙÛÈ ÌÂÈÒÓÂÙ·È Î·È Ë ÔÛfiÙËÙ· ÙˆÓ ÛÙÂÚÔÂȉÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È (23). ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÊ·ÚÌÔÁ‹ ÙÔÈÎÒÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë. ∏ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ÓÂÔÌ˘Î›Ó˘ ‹ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ·ÔʇÁÂÙ·È ÛÙ· ·È‰È¿ (38). ŸÛÔÓ ·ÊÔÚ¿ Ù· ·ÓÙÈÛËÙÈο ˘ÂÚÌ·ÁÁ·ÓÈÎfi οÏÈÔ, ¯ÏˆÚÂÍȉ›ÓË Î·È Ù· ‚ÚˆÌÈÔ‡¯·, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎΈÓ, ÏËÓ fï˜, ÂÚÂı›˙Ô˘Ó Î·È ÍËÚ·›ÓÔ˘Ó ÙÔ ‰¤ÚÌ· Î·È ¤ÙÛÈ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û¿ÓÈ· Û ·È‰È¿ (39). ∞ÔÈÎÈÛÌfi˜ - Í·Ó¿ - ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È Ì fiϘ ÙȘ ·Ó·ÊÂÚı›Û˜ ıÂڷ›˜ Û οÔÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. µ·ÛÈÎfi ̤ÚÔ˜ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Â›Ó·È Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Âȉ›ӈÛ˘ Ô˘ ÚԷӷʤÚıËÎ·Ó (5,29). ¶ÚfiÁÓˆÛË ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. °ÂÓÈο, ˘¿Ú¯ÂÈ Ì›· Ù¿ÛË ÁÈ· ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ηıÒ˜ ÙÔ ·È‰› ÌÂÁ·ÏÒÓÂÈ.
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OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ˘Ô¯ˆÚÔ‡Ó Ì¤¯ÚÈ ÙËÓ ÂÊ˂›·, ·Ó Î·È Ë ÓfiÛÔ˜ ÌÔÚ› Ó· ÂÈ̤ÓÂÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·Ô 25 ¤ˆ˜ Î·È 40% (40). ™˘Ì¤Ú·ÛÌ·Ù· ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÔÏ˘¿ÚÈı̘ ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Âȉ›ӈÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. ÃÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÌÔÓÒÓÂÙ·È ·fi ÙȘ ‚Ï¿‚˜ Û ÂÚÈÛÛfiÙÂÚÔ ·fi 90% ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·. ∆· ·ÓÙÈ‚ÈÔÙÈο ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·¯‡ÙÂÚË ˘Ô¯ÒÚËÛ‹ ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Noble WC. The role of staphylococci in dermatology. J Eur Acad Dermatol Venereol 1996;7(Suppl):12-14. 2. Svejgaard E. The role of microorganisms in atopic dermatitis. Sem Dermatol 1990;9:255-261. 3. Zeisler J. Note on the antiparasitic treatment of eczema. J Cutan Genito-Urin Dis 1885;13:507-511. 4. Champion RH, Parish WE. Atopic Dermatitis. In: Rook, Wilkinson, Ebling, editors. Textbook of Dermatology. 5th ed. Oxford: Blackwell Scientific Publications; 1992. p. 589-610. 5. Hanifin JM. Atopic dermatitis in infants and children. Pediatr Clin North Am 1991;38:763-789. 6. Cooper KD. Atopic Dermatitis: recent trends in pathogenesis and therapy. J Invest Dermatol 1994;102:128-137. 7. Larsen FS. Atopic Dermatitis: A genetic-epidemiologic study in a population-based twin sample. J Am Acad Dermatol 1993;28:719-723. 8. Coleman R, Trembath RC, Harper JI. Genetic studies of atopy and atopic dermatitis. Br J Dermatol 1997;136:1-5. 9. Bos JD, Kapsenberg ML, Sillevis Smitt JH. Pathogenesis of atopic eczema. Lancet 1994;343:1338-1341. 10. Morren MA, Przybilla B, Bamelis M, Heykants B, Reynaers A, Degreef H. Atopic dermatitis: triggering factors. J Am Acad Dermatol 1994;31:467-473. 11. Halbert AR, Weston WL, Morelli JG. Atopic dermatitis: Is it an allergic disease? J Am Acad Dermatol 1995;33:1008-1018. 12. Dahl MV. Staphylococcus aureus and atopic dermatitis. Arch Dermatol 1983;119:840-846. 13. Noble WC, Valkenburg HA, Wolters CHL. Carriage of Staphylococcus aureus in random samples of a normal population. J Hyg 1967;65:567-573. 14. Leyden JJ, Marples RR, Kligman AM. Staphylococcus aureus in the lesions of atopic dermatitis. Br J Dermatol 1974;90:525-530. 15. Goodyear HM, Watson PJ, Egan SA, Price EH, Kenny PA, Harper JI. Skin microflora of atopic eczema in first time hospital attenders. Clin Exp Dermatol 1993;18:300-304. 16. Hoeger PH, Lenz W, Boutonnier A, Fournier JM. Staphylococcal skin colonization in children with atopic dermatitis: prevalence, persistence and transmission of toxigenic and nontoxigenic strains. J Inf Dis
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1992;165:1064-1068. 17. Abeck D, Mempel M. Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications. Br J Dermatol 1998;139(Suppl):13-16. 18. Cole GW, Silverberg NL. The adherence of Staphylococcus aureus to human corneocytes. Arch Dermatol 1986;122:166-169. 19. Bibel DJ, Aly R, Shinefield HR, Maibach HI. The Staphylococcus aureus receptor for fibronectin. J Invest Dermatol 1983;80:494-496. 20. McFadden JP, Noble WC, Camp RDR. Superantigenic exotoxin-secreting potential of staphylococci isolated from atopic eczematous skin. Br J Dermatol 1993;128:631-632. 21. Strange P, Skov L, Lisby S, Lovgreen P, Baadsgaard O. Staphylococcal enterotoxin B applied on intact normal and intact atopic skin induces dermatitis. Arch Dermatol 1996;132:27-33. 22. Skov L, Baadsgaard O. The potential role of Staphylococcus aureus superantigens in atopic eczema. J Eur Acad Dermatol Venereol 1996;7(Suppl):8-11. 23. Leung DYM, Hauk P, Strickland I, Travers JB, Norris D. The role of superantigens in human diseases: therapeutic implications for the treatment of skin diseases. Br J Dermatol 1998;139(Suppl):17-29. 24. Nomura I, Tanaka K, Tomita H, Katsunuma T, Ohya Y et al. Evaluation of the staphylococcal exotoxins and their specific IgE in childhood atopic dermatitis. J Allergy Clin Immunol 1999;104:441-446. 25. Campbell DE, Kemp AS. Production of antibodies to staphylococcal superantigens in atopic dermatitis. Arch Dis Child 1998;79:400-404. 26. Bunikowski R, Mielke M, Skarabis H, Herz U, Bergmann RL et al. Prevalence and role of serum IgE antibodies to the Staphylococcus aureus-derived superantigens SEA and SEB in children with atopic dermatitis. J Allergy Clin Immunol 1999;103:119-124. 27. Hofer MF, Harbeck RJ, Schlievert PM, Leung DYM. Staphylococcal toxins augment specific IgE responses by atopic patients exposed to allergen. J Invest Dermatol 1999;112:171-176. 28. David DJ, Cambridge GC. Bacterial infection and atopic eczema. Arch Dis Child 1986;61:20-23. 29. Przybilla B, Eberlein-Konig B, Rueff F. Practical management of atopic eczema. Lancet 1994;343:13421346. 30. Valari M, Zachariadou L, Skarmoutsou C, Pangalis A, Iordanidou A. Fusidic acid suspension in the treatment of skin infections in children. J Eur Acad Dermatol Venereol 1999;12(Suppl 2):293. 31. Veien NK. The clinician’s choice of antibiotics in the treatment of bacterial skin infection. Br J Dermatol 1998;139(Suppl):30-36. 32. Espersen F. Resistance to antibiotics used in dermatological practice. Br J Dermatol 1998;139(Suppl):4-8. 33. Ramsay CA, Savoie JM, Gilbert M, Gidon M, Kidson P. The treatment of atopic dermatitis with topical fusidic acid and hydrocortisone acetate. J Eur Acad Dermatol Venereol 1996;7(Suppl):15-22. 34. Hjorth N, Schmidt H, Thomsen K. Fusidic acid plus
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35.
36.
37.
38.
betamethasone in infected or potentially infected eczema. Pharmatherapeutica 1985;4:126-131. Lever R, Hadley K, Downey D, Mackie R. Staphylococcal colonization in atopic dermatitis and the effect of topical mupirocin therapy. Br J Dermatology 1988;119:189-198. Poyner TF, Dass BK. Comparative efficacy and tolerability of fusidic acid/hydrocortisone cream (Fucidin H cream) and miconazole/hydrocortisone cream (Daktacort cream) in infected eczema. J Eur Acad Dermatol Venereol 1996;7(Suppl):23-30. Nilsson EJ, Henning CG, Magnusson J. Topical corticosteroids and Staphylococcus aureus in atopic dermatitis. J Am Acad Dermatol 1992;27:29-34. Griffiths WAD, Wilkinson. Topical therapy. In: Rook, Wilkinson, Ebling, editors. Textbook of Dermatology. 5th
Paediatriki 2001;64:223-228
ed. Oxford: Blackwell Scientific Publications; 1992. p. 3037-3084. 39. Stalder JF, Fleury M, Sourisse M, Allavoine TH, Chalamet C et al. Comparative effect of two topical antiseptics (Chlorhexidine vs KMnO4) on bacterial skin flora in atopic dermatitis. Acta Derm Venereol (Stockh) 1992;176(Suppl):132-134. 40. Linna O, Kokkonen J, Lahtela P, Tammela O. Ten year prognosis for generalized infantile eczema. Acta Pediatr 1992;81:1013-1016
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª. µ·Ï¿ÚË ªÂÛÔÏÔÁÁ›Ô˘ 81, 162 31, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· O ÚfiÏÔ˜ Ù˘ ÙÚÔÊÈ΋˜ ‰˘Û·ÓÂÍ›·˜ Û ‚Ú¤ÊË Ì ›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ ÔÈÛÔÊ·Á›Ùȉ·˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË1 ™ÎÔfi˜: ∏ ›ÌÔÓË ·ÓËÛ˘¯›· Â›Ó·È ¤Ó· Û˘¯Ófi Û‡Ìو̷ Û ‚Ú¤ÊË Î·È Û˘¯Ó¿ ·Ô‰›‰ÂÙ·È Û Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ‹ Û ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ÌÂÏÂÙËı› Ë Â›‰Ú·ÛË ˘Ô·ÏÏÂÚÁÈ΋˜ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ Û ‚Ú¤ÊË Ì ›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ °O¶ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙË Û˘Ó‹ıË ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ·ÁˆÁ‹. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: 19 ‚Ú¤ÊË (9 ·ÁfiÚÈ· Î·È 10 ÎÔÚ›ÙÛÈ·, ‰È¿ÌÂÛË ËÏÈΛ· 5 Ì‹Ó˜) ˘Ô‚Ï‹ıËÎ·Ó Û 24ˆÚË Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ p∏ (¯·ÌÂÙÚ›·) Î·È Á·ÛÙÚÔÛÎfiËÛË. ™ÙË Û˘Ó¤¯ÂÈ·, ¤ÁÈÓ ‰ÈÏ‹ Ù˘ÊÏ‹ ‰ÔÎÈÌ·Û›·, ·Ú¯Èο Ì ÛÙÔȯÂÈ·Îfi Á¿Ï· ‚·ÛÈṲ̂ÓÔ Û ·ÌÈÓÔͤ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÙÔ Á¿Ï· Ô˘ ¤·ÈÚÓ·Ó Ù· ·È‰È¿ ÚÈÓ ÙË ÌÂϤÙË. ∞ÔÙÂϤÛÌ·Ù·: 9 ‚Ú¤ÊË Â›¯·Ó ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÔÈÛÔÊ·Á›Ùȉ·˜ Î·È 9 ›¯·Ó ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ÛÙÔÌ¿¯È ‹/Î·È ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ. ∆· Û˘ÌÙÒÌ·Ù· ˘Ê¤ıËÎ·Ó Û fiÏ· Ù· ·È‰È¿ ÂÓÙfi˜ 2 ‚‰ÔÌ¿‰ˆÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜. ªÂÙ¿ ·fi 3 Ì‹Ó˜, ¤ÁÈÓ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì ÙÔ Á¿Ï· Ô˘ ¤·ÈÚÓ οı ·È‰› ÚÈÓ ÙË ÌÂϤÙË. 12 ·fi Ù· 19 ‚Ú¤ÊË ‰ÂÓ ·Ó¤¯ÙËÎ·Ó ÙÔ Î·ÓÔÓÈÎfi Á¿Ï· Î·È Â·ÓÂÌÊ¿ÓÈÛ·Ó Ù· ·Ú¯Èο Û˘ÌÙÒÌ·Ù· (‰È¿ÚÎÂÈ· ·ÓËÛ˘¯›·˜: 580 ¤Ó·ÓÙÈ 287 ÏÂÙ¿/‚‰ÔÌ¿‰·, p=0,01 Î·È score Û˘-
228
ÌÙˆÌ¿ÙˆÓ 36,1 ¤Ó·ÓÙÈ 23,1, p=0,03). ∆· ˘fiÏÔÈ· ‚Ú¤ÊË ‰ÂÓ Â·ÓÂÌÊ¿ÓÈÛ·Ó Û˘ÌÙÒÌ·Ù· (‰È¿ÚÎÂÈ· ·ÓËÛ˘¯›·˜: 581 ¤Ó·ÓÙÈ 470 ÏÂÙ¿/‚‰ÔÌ¿‰·, p=0,77 Î·È score Û˘ÌÙˆÌ¿ÙˆÓ 20,2 ¤Ó·ÓÙÈ 29,5, p=0,89). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯ÔÚ‹ÁËÛË ˘Ô·ÏÏÂÚÁÈ΋˜ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙË Û˘¯ÓfiÙËÙËÙ· ›ÌÔÓ˘ ·ÓËÛ˘¯›·˜ Î·È ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û ‚Ú¤ÊË Ì ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·.
1Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis J Pediatr 2000;136:641-647
°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜ - °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ
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∞¡O™O§O°π∞ - ƒ∂Àª∞∆O§O°π∞
Paediatriki 2001;64:229-232
IMMUNOLOGY - RHEUMATOLOGY
ªË¯·ÓÈÛÌÔ› ·˘ÙÔ·ÓÔÛ›·˜ ª. °. ∫·Ó¿ÚÈÔ˘
Autoimmune mechanisms M. G. Kanariou
¶ÂÚ›ÏË„Ë: µ·ÛÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÔÙÂÏ› Ë ÈηÓfiÙËÙ¿ ÙÔ˘ Ó· ‰È·ÎÚ›ÓÂÈ Ù· ›‰È· ·fi Ù· ͤӷ ·ÓÙÈÁfiÓ·. ∞˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜ ‰ËÌÈÔ˘ÚÁÂ›Ù·È fiÙ·Ó ·Ó·Ù‡ÛÛÂÙ·È ÂȉÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ, ·˘ÙÔ·ÓÙÈÁfiÓˆÓ Î·È Â›Ó·È ÔÈ ›‰ÈÔÈ ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ·ÓÔÛÔ‰Ú·ÛÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘, ÌË ‰˘Ó¿ÌÂÓÔÈ Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙÔ ·˘ÙÔ·ÓÙÈÁfiÓÔ, Û˘Ó¯›˙Ô˘Ó ÙË ‰Ú¿ÛË ÙÔ˘˜ Î·È ÚÔηÏÔ‡Ó ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, ÈÛÙÈ΋ ‚Ï¿‚Ë Î·È ÓfiÛÔ. ∏ ·ÓÔ¯‹ ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ˆÚ›Ì·ÓÛ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∞fi ·˘Ù‹ ÙËÓ ÔχÏÔÎË ‰È·‰Èηۛ· ÂÈ‚ÈÒÓÔ˘Ó Ù· ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ı· Â›Ó·È Èηӿ Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ÙÔ Ï‹ıÔ˜ Î·È ÙËÓ ÔÈÎÈÏÔÌÔÚÊ›· ÙˆÓ Í¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ Ô˘ Â›Ó·È Èı·Ófi Ó· Û˘Ó·ÓÙ‹ÛÂÈ Ô ÔÚÁ·ÓÈÛÌfi˜, ·ÏÏ¿ Î·È Î¿ÔÈÔÈ ·˘ÙÔ‰Ú·ÛÙÈÎÔ› ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ÎÏÒÓÔÈ, ÔÈ ÔÔ›ÔÈ ˘fi ÔÚÈṲ̂Ó˜ Û˘Óı‹Î˜ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Î·È ·˘ÙÔ·ÓÙȉÚÔ‡Ó. ŒÙÛÈ, ÔÈ ·˘ÙÔ¿ÓÔÛ˜ ··ÓÙ‹ÛÂȘ Â›Ó·È ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi Ê·ÈÓfiÌÂÓÔ, ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ·ÓÔÈÎÙÔ‡ “ÚÂÂÚÙÔÚ›Ô˘” ÙˆÓ ∆ Î·È µ ΢ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ Ô˘ ÙÔ˘˜ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó·ÁÓÒÚÈÛË ÔÔÈÔ˘‰‹ÔÙ ·ıÔÁfiÓÔ˘ Î·È ›Ûˆ˜ Ó· Â›Ó·È Ì›· ÂΉ‹ÏˆÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÓÔÛÔÚÚ‡ıÌÈÛ˘. ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ Ë ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È ÂÌϤÎÔÓÙ·È ·ÌÊfiÙÂÚÔÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ŸÌˆ˜, ·ÎfiÌË ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ ÙÈ ‰ÈÂÁ›ÚÂÈ ÙËÓ ·˘ÙÔ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË Î·È ÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ÙË ÌÔÓÈÌÔÔÈÔ‡Ó, ÒÛÙ ӷ ÂÁηı›ÛÙ·Ù·È ÓfiÛÔ˜.
Abstract: The main function of the immune system is the capacity to distinguish between a self and a non-self antigen. Autoimmune disease occurs when a specific adaptive immune response is mounted against self-antigens, autoantigens, resulting in tissue damage from direct attack on the cells bearing the antigen, from immune-complex formation, or from local inflammation. ∞utoimmune diseases can be mediated by autoantibodies or by autoreactive T cells. The mechanisms of damage are essentially the same as those which operate in protective immunity and hypersensitivity diseases. The current challenge in autoimmunity is to identify the autoantigens recognized by T cells, and to use this information to control the activity of these T cells, or to prevent their activation in the first place. It remains unclear, however, as to what induces the autoimmune response and which are the factors that stabilize it thus resulting in disease development.
§¤ÍÂȘ ÎÏÂȉȿ: ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜, ·˘ÙÔ·Óٛۈ̷, ·˘ÙÔ‰Ú·ÛÙÈÎÔ› ÏÂÌÊÔ·ÙÙ·ÚÈÎÔ› ÎÏÒÓÔÈ, ÈÛÙÈ΋ ‚Ï¿‚Ë.
∫ey words: autoimmune disease, autoantibody, autoeffector lymphocyte clones, tissue damage.
¶·È‰›·ÙÚÔ˜ - ∞ÓÔÛÔÏfiÁÔ˜ ¢È¢ı‡ÓÙÚÈ· ∂™À, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
Pediatric Immunologist Children’s Hospital “Aghia Sophia”, Athens
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18:55
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¶·È‰È·ÙÚÈ΋ 2001;64:229-232
∂ÈÛ·ÁˆÁ‹ ∆Ô ·ÓÔÛÔÔÈËÙÈÎfi Ì·˜ Û‡ÛÙËÌ· Â›Ó·È ¤Ó· ÔχÏÔÎÔ Û‡ÓÔÏÔ ÂȉÈÎÒÓ Î·È ÌË ÂȉÈÎÒÓ ÂÍ·ÈÚÂÙÈο Û˘Ó‰˘·ÛÌ¤ÓˆÓ ÛÙÔȯ›ˆÓ-„ËÊ›‰ˆÓ, Ô˘ ÛÎÔfi ¤¯ÂÈ ÙËÓ ÚÔÛÙ·Û›· Ì·˜ ·fi ÔÔÈÔ‰‹ÔÙ ͤÓÔ ÂÈÛ‚ÔϤ·. ª¤¯ÚÈ ÚÈÓ ÌÂÚÈο ¯ÚfiÓÈ·, ·ÔÙÂÏÔ‡Û ‰fiÁÌ· Ë ÏÔÁÈ΋ ȉ¤· fiÙÈ Ô ÔÚÁ·ÓÈÛÌfi˜ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙȉڿ ¤Ó·ÓÙÈ ÙÔ˘ ·˘ÙÔ‡ ÙÔ˘. ŸÌˆ˜ ÛÙË Û˘Ó¤¯ÂÈ·, ·Ô‰Â›¯ıËΠfiÙÈ ÛÙ· Ï·›ÛÈ· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ¿Ì˘Ó·˜ ¢ԉÒÓÂÙ·È ˆ˜ ¤Ó· ‚·ıÌfi ·˘ÙÔ·ÓÔÛÔ·¿ÓÙËÛË, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ‰ËÏ·‰‹ ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Î·È ·˘ÙÔ·ÓÙȉÚÒÓÙ· ∆ ΢ÙÙ·ÚÔÙÔÍÈο ·ÙÙ·Ú· (CD8+) (1-4). ∆· Ê˘ÛÈÔÏÔÁÈο ÏÂÌÊÔ·ÙÙ·Ú· ¤¯Ô˘Ó ÂÎ·È‰Â˘Ù› Ì ٤ÙÔÈÔ ÙÚfiÔ, ÒÛÙ ӷ ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· “›‰È·” ·ÓÙÈÁfiÓ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, Ù· ‰Èο ÙÔ˘, Î·È Ó· Ù· ·Ó¤¯ÔÓÙ·È, ÂÓÒ ·Ú¿ÏÏËÏ· ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· “ÌË ›‰È·” / ͤӷ, ¤Ó·ÓÙÈ ÙˆÓ ÔÔ›ˆÓ Ì¿¯ÔÓÙ·È, ·ÓÔÛÔ·ÓÙȉÚÔ‡Ó. ∞˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ· ‰ËÌÈÔ˘ÚÁÂ›Ù·È fiÙ·Ó ÂȉÈ΋ ›ÎÙËÙË ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ, ‰ËÏ·‰‹ ÙˆÓ ·˘ÙÔ·ÓÙÈÁfiÓˆÓ. ø˜ ·˘ÙÔ·ÓÙÈÁfiÓ· ÌÔÚÔ‡Ó Ó· Û˘ÌÂÚÈÊÂÚıÔ‡Ó ÔÏÏ¿ ·fi Ù· Û˘ÛÙ·ÙÈο ÌfiÚÈ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÌÂ Û˘Ó¤ÂÈ· Ó· ÂÓÂÚÁÔÔÈ‹ÛÔ˘Ó ÂÓ¿ÓÙÈ¿ ÙÔ˘˜ ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË, ¯˘ÌÈ΋ ‹ ΢ÙÙ·ÚÈ΋, Î·È Ô ÔÚÁ·ÓÈÛÌfi˜ Ó· ·Ó·Ù‡ÍÂÈ ÓfiÛÔ (1-4). °È· ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È ÛÎfiÈÌÔ Ó· ‰È¢ÎÚÈÓ›ÛÔ˘Ì fiÙÈ Ë ·ÓÔÛÔ·Ó·ÁÓÒÚÈÛË ÙˆÓ ‰ÈÎÒÓ Ì·˜ ·ÓÙÈÁfiÓˆÓ Â›Ó·È ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ Â‡Ú˘ıÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ·ÓÔÛÔ·¿ÓÙËÛË ·ÔÙÂÏ› ̤ÚÔ˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·‰Èηۛ·˜ ¿Ì˘Ó·˜, ÂÓÒ Ë ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÓfiÛÔ. √È ÂÚÈÛÛfiÙÂÚ˜ ÚˆÙ½Ó˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÂÎÊÚ¿˙ÔÓÙ·È Û ›‰· Ôχ ¯·ÌËÏ¿ ÁÈ· Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ ÛÙfi¯ÔÈ ·Ó·ÁÓÒÚÈÛ˘ ·fi Ù· ∆ ·ÙÙ·Ú· Î·È ¿Ú· ‰ÂÓ Û˘ÌÂÚÈʤÚÔÓÙ·È Î·È ‰ÂÓ ÚÔÛʤÚÔÓÙ·È ˆ˜ ·˘ÙÔ·ÓÙÈÁfiÓ·. ŸÌˆ˜, ¤Ó·˜ ÂÏ¿¯ÈÛÙÔ˜ ·ÚÈıÌfi˜ ÚˆÙÂ˚ÓÒÓ ÂÚȤ¯ÂÈ ÂÙ›‰È·, Ù· ÔÔ›· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·fi Û˘ÁÎÂÎÚÈ̤ӷ MHC ÌfiÚÈ· ÛÂ Â›Â‰Ô ÈηÓfi Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË Î·È Èı·Ó‹ ÓfiÛÔ. ªË¯·ÓÈÛÌÔ› ÚfiÎÏËÛ˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ µ·ÛÈο ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ›ӷÈ: ·) fiÙÈ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› Û ÂÈÚ·Ì·Ùfi˙ˆ· Ì ÙË ¯ÔÚ‹ÁËÛË Û ·˘Ù¿ ÙˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ÙˆÓ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ ÎÏÒÓˆÓ ·Û¯fiÓÙˆÓ Î·È ‚) fiÙÈ ÚÔηÏ› ÈÛÙÈ΋ ‚Ï¿‚Ë Î·È Î·Ù·ÛÙÚÔÊ‹ ̤ۈ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ Î·È Ì˯·ÓÈÛÌÒÓ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ÈÔ ¿ÌÂÛË ·fi‰ÂÈÍË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·ÈÙÈÔÏÔÁ›·˜ ÂÓfi˜ ÓÔÛ‹Ì·ÙÔ˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙȘ in vivo ηٷÛÙ¿ÛÂȘ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÛÂ Ê˘ÛÈÔÏÔÁÈ-
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ο ¿ÙÔÌ· Ì ¿ÌÂÛË ÌÂÙ·ÊÔÚ¿ ·˘ÙÔ·ÓÙÈۈ̿وÓ. ∆¤ÙÔÈÔ ·Ú¿‰ÂÈÁÌ· Â›Ó·È ÙÔ Â›Ú·Ì· Ô˘ ¤Î·ÓÂ Ô Harrington, Ô ÔÔ›Ô˜ ‰ÈÔ¯¤Ù¢Û Ì ¤ÓÂÛË ÛÙÔÓ Â·˘Ùfi ÙÔ˘ Ï¿ÛÌ· ·fi ¿ÚÚˆÛÙÔ Ì ȉÈÔ·ı‹ ıÚÔÌ‚ÔÂÓ›·, ÌÂ Û˘Ó¤ÂÈ· Ó· ¿ıÂÈ Ô ›‰ÈÔ˜ ıÚÔÌ‚ÔÂÓ›· Î·È ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·ÁÈ΋ ‰È·Ù·Ú·¯‹ (4). ÕÏÏ· Ù¤ÙÔÈ· ·Ú·‰Â›ÁÌ·Ù· Â›Ó·È Ë ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ·ÊÔÚ¿ ·ıÔÁfiÓˆÓ IgG ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂΉ‹ÏˆÛË Ì˘·Ûı¤ÓÂÈ·˜ ‹ ÓfiÛÔ ÙÔ˘ Graves ÛÙÔ ÓÂÔÁÓfi. ¶ÂÈÚ¿Ì·Ù· Ô˘ Ó· ·ÊÔÚÔ‡Ó ÙË ÌÂÙ¿‰ÔÛË ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ̤ۈ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ Â›Ó·È ÈÔ ‰‡ÛÎÔÏÔ Ó· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó Î·È Û˘Ó‹ıˆ˜ ˆ˜ ÂÈÚ·Ì·Ùfi˙ˆ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˙Ò· Ì ‚·ÚÈ¿ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·. ∏ ÈÛÙÈ΋ ‚Ï¿‚Ë ÛÙȘ ·˘ÙÔ¿ÓÔÛ˜ ηٷÛÙ¿ÛÂȘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È ·fi ÛÙÔȯ›· Ô˘ Â›Ó·È Ù· ›‰È· Ù· Ê˘ÛÈÔÏÔÁÈο ÚÔ˚fiÓÙ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ‚Ï¿‚Ë ‰ËÏ·‰‹, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰Ú¿Û˘ ÙˆÓ ·ÓÙÈۈ̿وÓ, ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ÙˆÓ ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ, ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙˆÓ Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ Î˘ÙÙ¿ÚˆÓ. ¶ÈÔ ÌÂÏÂÙË̤ÓÔ˜ Â›Ó·È Ô ÙÚfiÔ˜ ‰Ú¿Û˘ ÙˆÓ ·˘ÙÔ·ÓÙÈۈ̿وÓ. ∞Ó Ô ÛÙfi¯Ô˜ Â›Ó·È ˘Ô‰Ô¯¤·˜ ΢ÙÙ¿ÚÔ˘, ÙÔ ·˘ÙÔ·Óٛۈ̷ ·ÚÂÌ‚·›ÓÂÈ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ΢ÙÙ¿ÚÔ˘, ÙËÓ ÔÔ›· Î·È ÙÚÔÔÔÈ› Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜. ™ÙË ÓfiÛÔ Graves .¯. ‰ÈÂÁ›ÚÂÈ ÙÔ ı˘ÚÂÔÂȉÈÎfi ·ÙÙ·ÚÔ, ÛÙË Ì˘·Ûı¤ÓÂÈ· Gravis Ô‰ËÁ› ÛÙËÓ “·Ô‰fiÌËÛË” ÙÔ˘ ˘Ô‰Ô¯¤·, ÂÓÒ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ™·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ÙÔ ·˘ÙÔ·Óٛۈ̷ ·ÔÎÏ›ÂÈ ÙÔÓ ˘Ô‰Ô¯¤· Ù˘ ÈÓÛÔ˘Ï›Ó˘ Î·È ÙË ‰Ú¿ÛË Ù˘. ∞Ó Ô ÛÙfi¯Ô˜ Â›Ó·È Î˘ÙÙ·ÚÈ΋ ÌÂÌ‚Ú¿ÓË, ̤ۈ ÙˆÓ ›‰ÈˆÓ Ì˯·ÓÈÛÌÒÓ, ·Ó·Ù‡ÛÛÂÙ·È ÊÏÂÁÌÔÓ‹ Î·È Î·Ù·ÛÙÚÔÊ‹ Ù˘ ÌÂÌ‚Ú¿Ó˘, fiˆ˜ ÛÙÔ Û‡Ó‰ÚÔÌÔ Goodpasture. ™ËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÌÈÎÚÔ‚È·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ Î·È ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ Â›Ó·È fiÙÈ ÙÔ ÚÒÙÔ Â›Ó·È ÂÂÚ·Ṳ̂ÓÔ, ÂÓÒ ÙÔ ‰Â‡ÙÂÚÔ Â›Ó·È ÛÙ·ıÂÚ¿ ·ÚfiÓ Î·È ¿Ú· Û˘Ó¯‹˜ ·Ú¿ÁˆÓ ‰È¤ÁÂÚÛ˘ ·˘ÙÔ·ÓÙ›‰Ú·Û˘, ÌÂ Û˘Ó¤ÂÈ· ÙË ¯ÚÔÓÈfiÙËÙ·. ∞Ó Ù· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Û¯ËÌ·Ù›˙Ô˘Ó ‰È·Ï˘Ù¿ ·ÓÔÛÔÛ˘ÌϤÁÌ·Ù· Î·È ‰ÂÓ Á›ÓÂÙ·È Ë Ê˘ÛÈÔÏÔÁÈ΋ οı·ÚÛË ·fi ÙÔ ¢∂™, ·ÏÏ¿ ÂÓ·fiıÂÛË ·˘ÙÒÓ ÙˆÓ ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ, ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÊÏÂÁÌÔÓ‹ Î·È ÈÛÙÈ΋ ‚Ï¿‚Ë (̤ۈ ÙˆÓ Ì˯·ÓÈÛÌÒÓ ˘ÂÚ¢·ÈÛıËÛ›·˜ Ù‡Ô˘ πππ), fiˆ˜ ÛÙÔ ™˘ÛÙËÌ·ÙÈÎfi ∂Ú˘ıËÌ·ÙÒ‰Ë §‡ÎÔ (1-4). ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞˘Ù¿ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·ÊÔÚÔ‡Ó ·˘Ùfi Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙÔÓ ÈÛÙfi ÛÙfi¯Ô, ÛÙÔ ÛËÌÂ›Ô Ù˘ ‚Ï¿‚˘. ¶ÔÈ· ›ӷÈ, fï˜, Ë ·Ú¯È΋ ·ÈÙ›·; ∆È Â›Ó·È ÂΛÓÔ Ô˘
MAY- JUNE '01 TELIKO
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¶·È‰È·ÙÚÈ΋ 2001;64:229-232
ÙÚÔÔÔÈ› ÙËÓ ÂÈı˘ÌËÙ‹ ·ÓÔÛȷ΋ ·¿ÓÙËÛË; ∂›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ë ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. æ˘¯ÔÏÔÁÈÎÔ›, ÔÚÌÔÓÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¢ԉÒÓÔ˘Ó ·˘Ù‹ ÙË ÛÙÚÔÊ‹ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÁÈ· ·˘ÙÔ¿ÓÔÛË ·fiÎÚÈÛË Î·È ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÈÛÙÒÓ (3). ¶Ï‹ıÔ˜ ÂÈÚ·Ì·ÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ˘Ô‰ÂÈÎÓ‡ÂÈ ÙË ÛÙÂÓ‹ ·ÏÏËÏÂÍ¿ÚÙËÛË ÌÂٷ͇ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Î·È ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ÔÚÌÔÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›, ÁÈ·Ù› Ù· ıËÏ˘Î¿ ˘ÁÈ‹ ÂÈÚ·Ì·Ùfi˙ˆ· ·ÔÎÚ›ÓÔÓÙ·È Û ·ÓÙÈÁÔÓÈο ÂÚÂı›ÛÌ·Ù· ÈÔ ¤ÓÙÔÓ· ·’ fiÙÈ Ù· ·ÚÛÂÓÈο Î·È ÛÙÔÓ ¿ÓıÚˆÔ Ù· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ÚÔÛ‚¿ÏÏÔ˘Ó ÈÔ Û˘¯Ó¿ Á˘Ó·›Î˜ ·Ú¿ ¿Ó‰Ú˜. ¶ÂÈÚ·Ì·ÙÈÎÒ˜, Ë ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· ¤¯ÂÈ Û˘Ó‰Âı› Ì ÙËÓ ¤Í·ÚÛË ÙÔ˘ ™∂§. ∏ ˘ÂÚÈ҉˘ ·ÎÙÈÓÔ‚ÔÏ›· ÙÚÔÔÔÈ› ÙÔ DNA ÙˆÓ Î˘ÙÙ¿ÚˆÓ, οÓÔÓÙ¿˜ ÙÔ ÈÔ ·ÓÙÈÁÔÓÈÎfi. OÈ ÏÔÈÌÔÁfiÓÔÈ, ÁÂÓÈÎÒ˜, ·Ú¿ÁÔÓÙ˜ Î·È È‰È·ÈÙ¤Úˆ˜ ÔÈ ÈÔ›, η٤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ù˘ ·˘ÙÔ·ÓÔÛ›·˜. OÈ ÂÍ¿ÚÛÂȘ Î·È ˘Ê¤ÛÂȘ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ ÌÔÈ¿˙Ô˘Ó Ì ÂΛӘ ÙˆÓ ÈÒÛˆÓ. ™ÙÔÓ ÔÚfi ÙÔ˘ ·›Ì·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ‚Ú¤ıËÎ·Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ÈÒÓ. O Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÔÈΛϘ ·˘ÙÔ¿ÓÔÛ˜ ÂΉËÏÒÛÂȘ. ™ÙÔÓ ÔÚfi ÙˆÓ ·ÚÚÒÛÙˆÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ΢ÎÏÔÊÔÚÔ‡Ó ·˘ÍË̤ӷ ÔÛ¿ ÈÓÙÂÚÊÂÚfiÓ˘, ¤Ó·˜ ·ÎfiÌË ¤ÌÌÂÛÔ˜ ‰Â›ÎÙ˘ Ïԛ̈͢ ·fi ÈÔ‡˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÁÂÓÂÙÈÎfi ˘fiÛÙڈ̷, Û·ÊÒ˜ ˘¿Ú¯Ô˘Ó Ù· ÁÔÓ›‰È· Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Î·È Ú˘ıÌ›˙Ô˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘. Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Û˘ÁÁÂÓ›˜ ÚÒÙÔ˘ ‚·ıÌÔ‡ ·ÚÚÒÛÙˆÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ˘„ËÏfi ÔÛÔÛÙfi ÎÏÈÓÈΤ˜ Î·È ÔÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·˘ÙÔ·ÓÔÛ›·˜. ∞Ó¿ÌÂÛ· Û ·˘Ù¿ Ù· ÁÔÓ›‰È· ÛËÌ·ÓÙÈ΋ ı¤ÛË Î·Ù¤¯Ô˘Ó ÂΛӷ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC/HLA), ·ÏÏ¿ Û·ÊÒ˜ ÂÌϤÎÔÓÙ·È Î·È ÂΛӷ Ô˘ ηıÔÚ›˙Ô˘Ó ÙȘ ΢ÙÙ·ÚÔΛÓ˜, Ù· ÁÔÓ›‰È· ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-΢ÙÙ¿ÚÔ˘ Î·È Ù· ÁÔÓ›‰È· ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ. ∏ ·Ó‡ÚÂÛË ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ÔÚÈÛÌ¤ÓˆÓ HLA ·ÓÙÈÁfiÓˆÓ (B8, DR3, DR4) ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘fiıÂÛË Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘. ∞fi ÙȘ ÈÔ ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ Â›Ó·È ÂΛÓË ÙÔ˘ µ27 Ì ÙËÓ ∞Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· Î·È Ôχ ·ÛıÂÓ¤ÛÙÂÚ· Ù˘ ÂÙÂÚÔ˙˘ÁˆÙ›·˜ DR3/DR4 Ì ÙÔÓ ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ ‰È·‚‹ÙË (2,4). ªË¯·ÓÈÛÌÔ› ¢fi‰ˆÛ˘ ·˘ÙÔ·ÓÔÛÔ·ÓÙ›‰Ú·Û˘ ¶·Ú¿ Ù· fiÛ· ͤÚÔ˘Ì ÁÈ· ÙÔ ÙÈ Û˘Ì‚·›ÓÂÈ in situ Î·È Ù· fiÛ· ˘Ô„È·˙fiÌ·ÛÙ ÁÈ· ÙȘ ·Èٛ˜, ÙÔ
Paediatriki 2001;64:229-232
ÎÔ˘Ù› ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·Ú·Ì¤ÓÂÈ ÎÏÂÈÛÙfi. ∏ Âη›‰Â˘ÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙËÓ ÂÌ‚Ú˘˚΋ ¤ˆ˜ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ÙËÓ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ Û ·ÓÙ›ıÂÛË Ì ÙËÓ Â›ıÂÛË ¤Ó·ÓÙÈ ÙˆÓ Í¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ, ·›˙ÂÈ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ “ȉ·ÓÈ΋” ·ÓÔÛÔ·¿ÓÙËÛË. °È· ÙÔ Ò˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ·˘Ù‹ Ë Âη›‰Â˘ÛË ¤¯Ô˘Ó ·Ó·Ù˘¯ı› ‰È¿ÊÔÚ˜ ıˆڛ˜. ∏ ıˆڛ· ÙˆÓ ··ÁÔÚÂ˘Ì¤ÓˆÓ ÎÏÒÓˆÓ, ‰ËÏ·‰‹ Ù˘ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ Î˘ÙÙ¿ÚˆÓ, ÂΛÓË Ù˘ ·ÂÓÂÚÁÔÔ›ËÛ˘ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ, Ù˘ ‡·Ú͢ ÂȉÈÎÒÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÂΛÓË ÙÔ˘ ‰ÈÎÙ‡Ô˘ ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈ-ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ¿ÏϘ (5-7). ∆È fï˜, ‰È·Û¿ ·˘Ù‹ ÙËÓ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ Î·È Â˘Ô‰ÒÓÂÈ ÙËÓ ·˘ÙÔ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ¤Ó·ÓÙ› ÙÔ˘˜; £ÂˆÚËÙÈο, fiÙ·Ó ˘¿Ú¯ÂÈ ÌÂÈÔÓ¤ÎÙËÌ· ‹ ‰ËÌÈÔ˘ÚÁËı› Ú‹ÁÌ· ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔÛÔ·fiÎÚÈÛË ı· ÚÔÎÏËı› ÓfiÛÔ˜. OÈ ÂÍËÁ‹ÛÂȘ ÁÈ· ÙË ‰È¿Û·ÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Â›Ó·È ‰È¿ÊÔÚ˜. OÈ ÂÈÎÚ·Ù¤ÛÙÂÚ˜ ·fi ·˘Ù¤˜ ›ӷÈ: Ë ¤ÎıÂÛË ·ÔÌÔÓˆÌ¤ÓˆÓ “ÂÁÎψ‚ÈṲ̂ӈӔ ·ÓÙÈÁfiÓˆÓ ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, fiˆ˜ Â›Ó·È ÂΛӷ ÙÔ˘ Û¤ÚÌ·ÙÔ˜ Î·È ÙÔ˘ Ê·ÎÔ‡Ø Ë ·ÚfiÛÊÔÚË ¤ÎÊÚ·ÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù¿Í˘ ππ, ‰ËÏ·‰‹ Ë ¤ÎÊÚ·Û‹ ÙÔ˘˜ ·fi ·ÙÙ·Ú· Ô˘ Ê˘ÛÈÔÏÔÁÈο ‰ÂÓ ÂÎÊÚ¿˙Ô˘Ó ÌfiÚÈ· MHC Ù¿Í˘ πI, fiˆ˜ Û˘Ì‚·›ÓÂÈ ·fi ·ÙÙ·Ú· ÙÔ˘ ı˘ÚÂÔÂȉ‹ ·‰¤Ó· Û ·ÛıÂÓ›˜ Ì ı˘ÚÂÔÂȉ›Ùȉ· Hashimoto, ‹ ÛÙ· ‚-·ÙÙ·Ú· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ π, ‹ ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ÙˆÓ Â͈ÎÚÈÓÒÓ ·‰¤ÓˆÓ Û ·ÛıÂÓ›˜ Ì ™. SjogrenØ Ë ÔÏ˘ÎψÓÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓØ Ë ·ıÔÏÔÁÈ΋ ·ÓÔÛÔÚÚ‡ıÌÈÛË ·fi Ù· ∆ ÏÂÌÊÔ·ÙÙ·Ú·, fiˆ˜ ıˆÚÂ›Ù·È fiÙÈ Á›ÓÂÙ·È ÛÙÔ ™ÎÏËÚfi‰ÂÚÌ· ÏfiÁˆ ˘ÂÚÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚ÔËıËÙÈÎÒÓ Â·ÁˆÁÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD4) ‹ ˘ÔÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD8) ÛÙÔÓ ™∂§Ø Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ‰ÈÎÙ‡Ô˘ ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈ-ȉÈÔÙ˘ÈÎÒÓ ·ÓÙÈۈ̿وÓ, ‰ËÏ·‰‹ Ë Â·ÁˆÁ‹ ·Ú·ÁˆÁ‹˜ ·ÓÙÈ-·ÓÙÈۈ̿وÓ, ·ÓÙÈ-·ÓÙÈ-·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ô ·˘ÙÔÂÚÈÔÚÈÛÌfi˜ ÙÔ˘˜ Î·È Ù¤ÏÔ˜, ÂΛÓË Ù˘ ÙÚÔÔÔ›ËÛ˘ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ‹ Ù˘ ÌÔÚȷ΋˜ Ì›ÌËÛ˘ ·fi ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜. OÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÌÔÚÔ‡Ó Ó· ‰È·Û¿ÛÔ˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ Ì ÔÏÏÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ŒÓ·˜ ·fi ÙÔ˘˜ ÈÔ ÌÂÏÂÙË̤ÓÔ˘˜ Î·È Ô Î·Ï‡ÙÂÚ· ηٷÓÔËÙfi˜ Â›Ó·È ÂΛÓÔ˜ Ù˘ ÌÔÚȷ΋˜ Ì›ÌËÛ˘, fiÔ˘ ͤӷ ·ÓÙÈÁfiÓ· ÌÈÌÔ‡ÓÙ·È ·˘ÙÔ·ÓÙÈÁfiÓ·. ŸÌˆ˜, Ù· ·ÓÙÈÁfiÓ· ·˘Ù¿, ·Ó Î·È ÚÔÛÔÌÔÈ¿˙Ô˘Ó ·ÚÎÂÙ¿ Ì ÂΛӷ ÙÔ˘ ·˘ÙÔ‡, ‰È·Ê¤ÚÔ˘Ó ÙfiÛÔ fiÛÔ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· Ó· ÍÂʇÁÔ˘Ó ÙËÓ ·ÓÔ¯‹ Î·È Ó· ÚÔηϤÛÔ˘Ó ·ÓÙ›‰Ú·ÛË
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·fi ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ·. £· ·Ó·Ê¤ÚÔ˘Ì ÙÔ ·Ú¿‰ÂÈÁÌ· Ù˘ ∫ÏÂÌÛȤÏÏ·, Ë ÌfiÏ˘ÓÛË ·fi ÙËÓ ÔÔ›· ı· ¢ԉÒÛÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘, ·ÏÏ¿ ·Ú¿ÏÏËÏ· Î·È ¤Ó·ÓÙÈ ÙÔ˘ ÌÔÚ›Ô˘ HLA-B27, Ì ÙÔ ÔÔ›Ô ¤¯ÂÈ ·Ó¿ÏÔÁË ‰ÔÌ‹. ∆Ô Î‡ÚÈÔ Úfi‚ÏËÌ· ÛÙË ÌÂϤÙË Ù˘ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È Ò˜ Ó· ÙÔÔıÂÙËıÔ‡Ó ÔÈ ÂÈ̤ÚÔ˘˜ ÂÌÏÂÎfiÌÂÓÔÈ ·Ú¿ÁÔÓÙ˜ Û ̛· ·ÈÙÈÔÏÔÁÈ΋ Û˘Ó¤¯ÂÈ·. ∆È ÚÔËÁÂ›Ù·È Î·È ÙÈ ¤ÂÙ·È; ∂›Ó·È ÙÔ ¤Ó·˘ÛÌ· ¤Ó· ÙÚÔÔÔÈË̤ÓÔ ·ÓÙÈÁfiÓÔ ·fi ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜; ∂›Ó·È Ë ·Ó¿ÚÎÂÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ ‹ ÙˆÓ Ô˘ÛÈÒÓ; ∂›Ó·È Ë ÌÂÈÔÓÂÎÙÈ΋ ÙÔ˘˜ ÂÈÎÔÈÓˆÓ›·; ª¤ÓÔ˘Ó ·ÎfiÌË ÔÏÏ¿ Ó· Ì¿ıÔ˘ÌÂ. ¶Èı·Ófiٷٷ ‰ÂÓ Â›Ó·È Ì›· ÛÂÈÚ¿ ÁÂÁÔÓfiÙˆÓ, ·ÏÏ¿ ¤Ó· ÔχÏÔÎÔ Û‡ÛÙËÌ· ·ÏÏËÏÔÂÍ·ÚÙÒÌÂÓˆÓ ·Ú·ÁfiÓÙˆÓ Î·È Ì˯·ÓÈÛÌÒÓ. ∏ ‡·ÚÍË fiÏˆÓ Î·È Ë ¿ÚÈÛÙË ·ÏÏËÏÔÚ‡ıÌÈÛ‹ ÙÔ˘˜ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË Î·È ÙËÓ Â‡Ú˘ıÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. OÈ ıÂڷ¢ÙÈΤ˜ ÚÔÔÙÈΤ˜ ‚·Û›˙ÔÓÙ·È ÛÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ›ÙÔÔ˘ ÙÔ˘ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘, ÛÙË ÁÓÒÛË ÌÔÚ›ˆÓ Î·È Ì˯·ÓÈÛÌÒÓ Ù˘ ·ÓÔÛÔ·¿ÓÙËÛ˘, ÒÛÙ ӷ ·Ó·Ù˘¯ı› Ë Î·Ù¿ÏÏËÏË ·ÓÔÛÔıÂڷ›·, ›Ûˆ˜ ÂÌ‚ÔÏÈÔıÂڷ›·, Î·È Â˘fi‰ˆÛË Ù˘ ·ÓÔ¯‹˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ per os ÌÔÚ› Ó· ‰Ú¿ÛÂÈ ÚÔÛٷ٢ÙÈο ÁÈ· ÙÔ ·˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ· (8). °ÓˆÚ›˙ÔÓÙ·˜ ÙËÓ ‰ÔÌ‹ ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ô˘ ‰›‰Ô˘Ó ÙÔ ¤Ó·˘ÛÌ· ‹ ·ÔÙÂÏÔ‡Ó ÙËÓ ·ÈÙ›· Ù˘ ÓfiÛÔ˘ Î·È Ù· ‰È¿ÊÔÚ· ÛÙ¿‰È· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÓÔÛÔ·¿ÓÙËÛ˘, ı· ÌÔÚԇ̠ӷ ·Ú¤Ì‚Ô˘Ì ‹ ÛÙË ‰ÔÌ‹ ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ‹, ·ÎfiÌË Î·Ï‡ÙÂÚ·, ÛÙËÓ ÂÓ›Û¯˘ÛË Û˘ÁÎÂÎÚÈ̤-
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ÓÔ˘ ÎÏ¿‰Ô˘ ÙˆÓ ·ÓÔÛÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ô˘ÛÈÒÓ ‹ Ì˯·ÓÈÛÌÒÓ, ÒÛÙ ӷ ¢ԉÒÛÔ˘Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ÚÔÛٷ٢ÙÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË, Ë ÔÔ›· ı· Ô‰ËÁ‹ÛÂÈ ÛÙË ıÂڷ›· Ù˘ ÓfiÛÔ˘ÛÙfi¯Ô˘ ̤ۈ ÙÔ˘ ηٿÏÏËÏÔ˘ ۯ‰ȷÛÌÔ‡ ÛÙÚ·ÙËÁÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. °ÂÚÌÂÓ‹˜ ∞∂, §˘Ì¤ÚË ¶. ∞˘ÙÔ·ÓÔÛ›·. ™ÙÔ: °ÂÚÌÂÓ‹˜ ∞∂, π·ÙÚÈ΋ ∞ÓÔÛÔÏÔÁ›·. ¶··˙‹Û˘; 2000. ÛÂÏ. 237-265. 2. Janeway CA, Travers P, Walport M, Capra JD. Immunobiology. The immune system in health and disease. 4th ed. Elsevier Science Ltd, Garland Publishing; 1999. p. 490-509. 3. ªÔ˘ÙÛfiÔ˘ÏÔ˜ ê. ∞ÓÔÛÔÏÔÁ›·. ∞˘ÙÔ¿ÓÔÛ· ƒÂ˘Ì·ÙÈο ¡ÔÛ‹Ì·Ù·. §›ÙÛ·˜; 1990. 4. Roitt I. Autoimmunity and autoimmume disease. In: Roitt I, Brosfoff J, Male D, eds. Immunology. 5th ed. Mosby; 1998. p. 367-380. 5. Kumar V, Sercarz EE. Regulation of autoimmunity. Cur Opin Immunol 1991;3:888-895. 6. Fowlkes, Ramsdell F. T-cell tolerance. Cur Opin Immunol 1993;5:873-879. 7. Todd JA, Steinman L. Autoimmunity - Editorial overview. The environment strikes back. Cur Opin Immunol 1993;5:863-865. 8. Cooke A, Wraith DC. Immunotherapy of autoimmune disease. Cur Opin Immunol 1993;5:925-933.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· °. ∫·Ó¿ÚÈÔ˘ §. ∫ËÊÈÛ›·˜ 51, 115 23, ∞ı‹Ó·
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∞¡O™O§O°π∞ - ƒ∂Àª∞∆O§O°π∞
Paediatriki 2001;64:233-236
IMMUNOLOGY - RHEUMATOLOGY
™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ÿ. µÔ˘ÁÈԇη
Spondyloarthropathies in childhood O. Vougiouka
¶ÂÚ›ÏË„Ë: OÈ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·ÔÙÂÏÔ‡Ó Ì›· ÔÌ¿‰· HLA-B27 Û¯ÂÙÈ˙fiÌÂÓˆÓ ÓÔÛËÌ¿ÙˆÓ, Ù· ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÊÏÂÁÌÔÓ‹ ÙÔ˘ ·ÚıÚÈÎÔ‡ ˘Ì¤Ó·, ÙˆÓ Ì˘˚ÎÒÓ ı˘Ï¿ÎˆÓ, ÂχÙÚˆÓ Î·È ·ÔÓ¢ÚÒÛˆÓ, ηıÒ˜ Î·È ÙˆÓ ÛËÌ›ˆÓ ÚfiÛÊ˘Û˘ ÙˆÓ ÙÂÓfiÓÙˆÓ ÙˆÓ Ì˘ÒÓ ÛÙ· ÔÛÙ¿ ΢ڛˆ˜ ÂÚÈÊÂÚÈÎÒÓ ·ÚıÚÒÛˆÓ. ¶·Ú¿ÏÏËÏ·, Û˘Ó˘¿Ú¯Ô˘Ó Â͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ. ∞ÔÙÂÏÔ‡Ó ÂÚ›Ô˘ ÙÔ 20% Ù˘ ¡Â·ÓÈ΋˜ π‰ÈÔ·ıÔ‡˜ ∞ÚıÚ›Ùȉ·˜. ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÎÂÓÙÚÈÎÒÓ ·ÚıÚÒÛÂˆÓ ÙÔ˘ ÎÔÚÌÔ‡ Û˘Ì‚·›ÓÂÈ Û’ ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ·fi ¯ÚfiÓÈ·, ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÚ›˙ÂÙ·È Û ÎÚÈÙ‹ÚÈ· ÌË ‰È·ÊÔÚÔÔÈË̤Ó˘ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·˜, fiˆ˜ ÂΛӷ Ù˘ ·ÚıÚ›Ùȉ·˜ Û¯ÂÙÈ˙fiÌÂÓ˘ ÌÂ Î·Ù·Ê˘Û›Ùȉ· ‹ Ù˘ ∂˘Úˆ·˚΋˜ OÌ¿‰·˜ ªÂϤÙ˘ ™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·˜.
Abstract: Childhood onset spondyloarthropathies are a group of HLA-B27 related diseases which are characterized by inflammation of joint synovium, entheses, tendon sheaths and bursae that predominantly involve the lower extremities. Extraarticular manifestations may develop concurrently. They acount for about 20% of the group of juvenile idiopathic arthritis seen in pediatric rheumatology clinics. Axial skeleton involvement occurs later on in early adulthood in a great proportion of affected children. Prompt recognition is based on the criteria of undifferentiated spondyloarthropathies such as Seronegativity - Arthropathy - Enthesopathy Syndrome or the European Spondyloarthropathy Study Group Criteria.
§¤ÍÂȘ ÎÏÂȉȿ: Ó·ÓÈ΋ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·, Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, Ó·ÓÈ΋ „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, ·ÚıÚ›Ùȉ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘, Û‡Ó‰ÚÔÌÔ Reiter.
Key words: juvenile spondyloarthropathy, juvenile ankylosing spondylitis, ankylosing spondylitis, juvenile psoriatic arthritis, arthritis of inflammatory bowel diseases, Reiter’s syndrome.
O fiÚÔ˜ “¡Â·ÓÈ΋ ™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·” ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÈ· ÔÌ¿‰· ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ÚÔÛ‚¿ÏÏÔ˘Ó ·ÚıÚÒÛÂȘ, ÙfiÛÔ ÙÔ˘ ÎÔÚÌÔ‡ fiÛÔ Î·È ÙˆÓ ¿ÎÚˆÓ, ÂÓÒ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·ÊÔÚ¤˜ ·fi ÙË ¡Â·ÓÈ΋ π‰ÈÔ·ı‹ ∞ÚıÚ›Ùȉ·. Àfi ÙÔÓ fiÚÔ ·˘Ùfi ·Ó·Ê¤ÚÔÓÙ·È Ë ¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ·, Ë ¡Â·ÓÈ΋ æˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, Ë ·ÚıÚ›Ùȉ· ÙÔ˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Reiter (¶›Ó·Î·˜ 1).
∫ÔÈÓ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È (¶›Ó·Î·˜ 2): ·) Ë ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÚıÚÒÛÂˆÓ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ÙˆÓ ÈÂÚÔÏ·ÁÔÓ›ˆÓ ·ÚıÚÒÛÂˆÓ Î·È ÙˆÓ ÛËÌ›ˆÓ ÚfiÛÊ˘Û˘ ÙÂÓfiÓÙˆÓ, Û˘Ó‰¤Û̈Ó, ·ÚıÚÈÎÒÓ ı˘Ï¿ÎˆÓ Î·È ÂÚÈÙÔÓ›ˆÓ ÛÙ· ÔÛÙ¿, ‚) Ë ·Û‡ÌÌÂÙÚË ÂÚÈÊÂÚÈ΋ ·ÚıÚ›Ùȉ·, Û˘¯ÓfiÙÂÚ· ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, Á) Ë ÔÈÎÔÁÂÓ‹˜ ›وÛË Î·È Ë ·˘ÍË̤ÓË ·Ó›¯Ó¢ÛË ÙÔ˘ HLA-B27, ‰) Ë ˘ÂÚÔ¯‹ ÙˆÓ ·ÚÚ¤ÓˆÓ Î·È Ë fi„ÈÌË ¤Ó·ÚÍË ÛÙËÓ
µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
2nd Department of Pediatrics of Athens University Medical School, Children’s Hospital “P. & A. Kyriakou”
233
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·È‰È΋ ËÏÈΛ·, Â) ‰È¿ÊÔÚ˜ Â͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜, ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ Ô˘ ¿ÏÏÔÙ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ¿ÏÏË Û˘¯ÓfiÙËÙ· Î·È ÛÙ) Ë ·Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ· ηıÒ˜ Î·È Ë ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ¿ÏÏˆÓ ·˘ÙÔ·ÓÙÈۈ̿وÓ, fiˆ˜ Ù· ∞¡∞. ∏ ÂÙ‹ÛÈ· ›وÛË Ù˘ Ó·ÓÈ΋˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·˜ ÂÎÙÈÌ¿Ù·È ÛÙÔ 5/100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡, ÌÂ Û˘¯ÓfiÙËÙ· Û ‰Â‰Ô̤ÓË ÛÙÈÁÌ‹ 0,2ò. ™˘¯ÓfiÙÂÚË Â›Ó·È Ë Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·. ¶ÔÏÏ¿ ·È‰È¿ ¤¯Ô˘Ó ÌÂÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ì›·˜ ·fi ÙȘ Ó·ÓÈΤ˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂȘ, ‰ÂÓ ¤¯Ô˘Ó ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÛÎÂÏÂÙÔ‡ ÙÔ˘ ÎÔÚÌÔ‡ Î·È ‰ÂÓ ÏËÚÔ‡Ó ÎÚÈÙ‹ÚÈ· ÒÛÙ ӷ ηٷٷÁÔ‡Ó Û ̛· ·fi ·˘Ù¤˜. ŒÙÛÈ ÚԤ΢„Â Ô fiÚÔ˜ “Û‡Ó‰ÚÔÌÔ ÔÚÔ·ÚÓËÙÈ΋˜ ·ÚıÚÔ¿ıÂÈ·˜-Î·Ù·Ê˘Û›Ùȉ·˜” (seronegativity enthesopathy-arthropathy, SEA, syndrome). ∆Ô Û‡Ó‰ÚÔÌÔ ·ÊÔÚ¿ ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 17 ¯ÚfiÓˆÓ, ÔÚÔ·ÚÓËÙÈο, ÌÂ Â˘Ú‹Ì·Ù· ÊÏÂÁÌÔÓ‹˜ ·fi ÙȘ ÔÛÙÈΤ˜ ÚÔÛʇÛÂȘ Î·È ·ÚıÚ·ÏÁ›· ‹ ·ÚıÚ›Ùȉ· (¶›Ó·Î·˜ 3). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂͤÏÈ͢ ÚÔ˜ ÔÚÈÛÙÈ΋ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·, ·ÔÙÂÏ› Ô‰ËÁfi ÛËÌÂ›Ô ÁÈ· ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î·È ÚfiÁÓˆÛË Î·È ˘Ô‰ËÏÒÓÂÈ Â·ÁÚ‡ÓÈÛË ÁÈ· ÙËÓ ÂͤÏÈÍ‹ ÙÔ˘. ∆Ô ÚfiÙ˘Ô ÙˆÓ Ó·ÓÈÎÒÓ ÛÔÓ‰˘Ï·ÚıÚÔ·ıÂÈÒÓ ·ÔÙÂÏ› Ë ¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ·. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ Û ÚÔ¯ˆÚË̤Ó˜ ηٷÛÙ¿ÛÂȘ Â›Ó·È Â‡ÎÔÏË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì fiÓÔ Ú¿¯ÂÔ˜, Â˘Ú‹Ì·Ù· ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· Î·È ·ÚÔ˘Û›· Û˘Ó‰ÂÛÌfiÊ˘ÙˆÓ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË. °È· ÙË ‰È¿ÁÓˆÛ‹ Ù˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ÎÚÈÙ‹ÚÈ·. ∞fi ·˘Ù¿, Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ¡.ÀfiÚ΢ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∏ ‰È·‚¿ıÌÈÛË Ù˘ ·ÎÙÈÓÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ Ù˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ·Ó·ÁÚ¿ÊÂ-
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Ù·È ÛÙÔÓ ¶›Ó·Î· 5. ŸÌˆ˜, ÛÙ· ·È‰È¿ Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈÌ·, ‰ÈfiÙÈ Ê˘ÛÈΤ˜ ÌÂÙÚ‹ÛÂȘ ‹ ‰ÂÓ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ‹ ·Ó ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› Û ÂÚÈÔÚÈṲ̂ÓÔ ÏËı˘ÛÌfi, ‰ÂÓ ¤¯Ô˘Ó ÂÎÙÈÌËı› Â˘Ú¤Ô˜. ∞ÎfiÌ·, Ë Û˘ÌÌÂÙÔ¯‹ ÎÂÓÙÚÈÎÒÓ ·ÚıÚÒÛÂˆÓ ÛÙ· ·È‰È¿ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÔÙÂÏ› ı¤Ì· ¯ÚfiÓÔ˘. ™Â ÔÛÔÛÙfi ÂÚ›Ô˘ 80% Ë ÓfiÛÔ˜ ÍÂÎÈÓ¿ Û·Ó ÂÚÈÊÂÚÈ΋ ·Û‡ÌÌÂÙÚË ÔÏÈÁÔ·ÚıÚ›Ùȉ·, ΢ڛˆ˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ. ∆Ô 20% ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ fiÓÔ, ‰˘Ûη̄›· ‹ ÂÚÈÔÚÈÛÌfi ΛÓËÛ˘ ÛÙË ıˆÚ·ÎÔÔÛÊ˘˚΋ ÌÔ›Ú· ‹ ηٿ ÙȘ ÈÂÚÔÏ·ÁfiÓȘ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. O ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ó¿Ù˘Í˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ÂÎÙÈÌ¿Ù·È ÛÙ· 6,5 ¯ÚfiÓÈ·, ÂÓÒ Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ·›ÚÓÂÈ Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ó· ·Ó·Ù˘¯ı›, Ì ·ÓÒÙÂÚÔ ·Ó·ÊÂÚfiÌÂÓÔ Ù· 30 ¯ÚfiÓÈ·. ∆Ô 1/4 ÙˆÓ ·ÛıÂÓÒÓ ‰›ÓÂÈ ÈÛÙÔÚÈÎfi fiÓÔ˘ ÂÚ› ÙËÓ Ù¤ÚÓ·, ÏfiÁˆ ÂÏÌ·ÙÈ·›·˜ ·ÔÓÂ˘ÚˆÛ›Ùȉ·˜ ‹ ÏfiÁˆ ı˘Ï·Î›Ùȉ·˜ ÙÔ˘ ·¯ÈÏ›Ԣ Ù¤ÓÔÓÙ·. ∂͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ Â›Ó·È Ë ÈÚȉÔ΢ÎÏ›Ùȉ· Û ÔÛÔÛÙfi 14-27% ÂÚ›Ô˘. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÚ˘ıÚfiÙËÙ·, fiÓÔ Î·È ÊˆÙÔÊÔ‚›·. ∂Í·ÈÚÂÙÈο Û¿ÓÈ·, ÚÔËÁÂ›Ù·È ÙˆÓ ÂΉËÏÒÛÂˆÓ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡. ∞Û˘Ó‹ıÈÛÙ˜ ÛÙ· ·È‰È¿ Â›Ó·È ÔÈ ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi, ÙÔ ∫¡™ Î·È ÙÔ˘˜ ÓÂÊÚÔ‡˜. ∞ÙÏ·ÓÙÔ˚Óȷ΋ ˘ÂÍ¿ÚıÚˆÛË Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ì‚Â›, ÂΉËÏÔ‡ÌÂÓË Ì ‰˘Ó·Ùfi fiÓÔ ÛÙÔÓ ·˘¯¤Ó· Î·È ÛÙÔ ÈÓ›Ô. À¿Ú¯ÂÈ ÂÓÙ˘ˆÛȷ΋ ÔÈÎÔÁÂÓ‹˜ ›وÛË Ù˘ ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜, Ë ÔÔ›· Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙÔ˘ HLA-B27, ÙÔ ÔÔ›Ô ·Ó¢ڛÛÎÂÙ·È Û ÔÛÔÛÙfi 95%. ∆Ô 2-10% ¶›Ó·Î·˜ 3. ∫ÚÈÙ‹ÚÈ· ηٿٷ͢ Û. SEA 1. 2. 3. 4.
ŒÓ·ÚÍË Û˘ÌÙˆÌ¿ÙˆÓ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ <17 ÂÙÒÓ ∞Ô˘Û›· RF Î·È ANA ™ËÌ›· ÊÏÂÁÌÔÓ‹˜ ÔÛÙÈÎÒÓ ÚÔÛʇÛÂˆÓ ∞ÚıÚ·ÏÁ›· ‹ ·ÚıÚ›Ùȉ·
¶›Ó·Î·˜ 1. ¡Â·ÓÈ΋ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ· 1. 2. 3. 4.
¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ· ¡Â·ÓÈ΋ æˆÚÈ·ÛÈ΋ ∞ÚıÚ›Ùȉ· ∞ÚıÚÔ¿ıÂÈ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ ™‡Ó‰ÚÔÌÔ Reiter
¶›Ó·Î·˜ 2. ∫ÔÈÓ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÛÔÓ‰˘Ï·ÚıÚÔ·ıÂÈÒÓ 1. 2. 3. 4. 5. 6.
∞ÚıÚ›Ùȉ· ™.™., ÈÂÚÔÏ·ÁÔÓ›Ùȉ·, Î·Ù·Ê˘Û›Ùȉ· ∞Û‡ÌÌÂÙÚË ÂÚÈÊÂÚÈ΋ ·ÚıÚ›Ùȉ· OÈÎÔÁÂÓ‹˜ ›وÛË. HLA-B 27 ÀÂÚÔ¯‹ ·ÚÚ¤ÓˆÓ ∂͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ ∞Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ·
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¶›Ó·Î·˜ 4. ∫ÚÈÙ‹ÚÈ· ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜ (¡¤·˜ ÀfiÚ΢) 1. ¶ÂÚÈÔÚÈÛÌfi˜ ΛÓËÛ˘ Oª™™ Û 3 ›‰· 2. ¶fiÓÔ˜ ηٿ ÙË ıˆÚ·ÎÔÔÛÊ˘˚΋ Û˘Ì‚ÔÏ‹ 3. ¶ÂÚÈÔÚÈÛÌfi˜ ıˆÚ·ÎÈ΋˜ ‰È¿Ù·Û˘ ≤2,5 cm ¢π∞°¡ø™∏: - ÔÚÈÛÙÈ΋: - ∞ÌÊÔÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 + ¤Ó· ÎÚÈÙ‹ÚÈÔ - ∂ÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 ‹ ·ÌÊÔÙÂÚfiÏ¢ÚË Ù¿Í˘ 2 + ÎÚÈÙ‹ÚÈÔ 1 ‹ ÎÚÈÙ‹ÚÈ· 2 Î·È 3 - Èı·Ó‹: - ∞ÌÊÔÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 ¯ˆÚ›˜ ÎÚÈÙ‹ÚÈÔ
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ÙˆÓ µ27 ·ÙfiÌˆÓ ¿Û¯Ô˘Ó ·fi ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·. ∏ ÓfiÛÔ˜ Â›Ó·È 10-20 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È 50-80 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ ·‰ÂÏÊÔ‡˜ ÙÔ˘˜. O ΛӉ˘ÓÔ˜ ÂÙÂÚÔ˙˘ÁÒÙË µ27 ·Ù¤Ú· ¿Û¯ÔÓÙ· Ó· ·ÔÎÙ‹ÛÂÈ ¿ÚÚÂÓ Ù¤ÎÓÔ ¿Û¯ÔÓ, Â›Ó·È 20% Û µ27 Ù¤ÎÓÔ. ¢È¿ÊÔÚÔÈ ˘fiÙ˘ÔÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ µ27 ¤¯Ô˘Ó ÌÂÏÂÙËı› ÁÈ· ÙÔ ıÂÙÈÎfi ‹ ·ÔÙÚÂÙÈÎfi ÙÔ˘˜ ÚfiÏÔ, ÂÓÒ ¿ÏϘ ÔÌ¿‰Â˜ ÌÔÚ›ˆÓ Ù¿Í˘ ∏LA I, ÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ ÙÔ˘ µ60, ·›˙Ô˘Ó ÚfiÏÔ. ¶·Ú’ fiÏÔ Ô˘ ÙÔ µ27 Ê·›ÓÂÙ·È ÈÛ¯˘ÚfiÙÂÚÔ, ÙÔ ∞2 ·ÓÙÈÁfiÓÔ Â›Û˘ ÂÌϤÎÂÙ·È. OÈ ÏfiÁÔÈ Û‡Ó‰ÂÛ˘ ÙÔ˘ HLA-B27 Ì ÙËÓ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· Û˘Ì˘ÎÓÒÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ∆Ô HLA-B27 ·Ú¤¯ÂÈ ˘ÔÛÙËÚÈÎÙÈÎfi ÚfiÏÔ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Û ·Ú¯È΋ Ê¿ÛË. ∆· ÛÙÔȯ›· ÁÈ· ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ÂÏÏÈ‹. ∏ η΋ ÚfiÁÓˆÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘, Ë ÔÔ›· Á›ÓÂÙ·È ÛˆÛÙ¿ ÌfiÓÔ ÛÙÔ 2% Ù˘ ∞™. ∏ ∞™ ÙˆÓ ÂÓËÏ›ÎˆÓ ·Ú¯›˙ÂÈ ÛÙË Ó·ÓÈ΋ ËÏÈΛ· Û ÔÛÔÛÙfi 15%. OÏÈ΋ ·ÚıÚÔÏ·ÛÙÈ΋ ÈÛ¯›ˆÓ ˘Ê›ÛÙ·Ù·È ÙÔ 17% Ù˘ ¡∞™ Î·È ÙÔ 4% Ù˘ ∞™ ÙˆÓ ÂÓËϛΈÓ. ∏ ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ÚÔÛ‚¿ÏÏÂÙ·È Û 8,5 ¯ÚfiÓÈ· (8,3±6,4). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ··Û¯fiÏËÛË Ì ̤ÛË ‰È¿ÚÎÂÈ· ÓfiÛÔ˘ 24 ¯ÚfiÓÈ·, 74% Ù˘ ¡∞™ ›¯Â Ï‹ÚË ··Û¯fiÏËÛË Û ۯ¤ÛË Ì ÙÔ 56% ÙˆÓ ÂÓËϛΈÓ. OÈ ·Ú¯¤˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È ÙÔ˘ fiÓÔ˘ Ô˘ ÚÔηÏ›ٷÈ, ÙË ‰È·Ù‹ÚËÛË Î·È ·ÔηٿÛÙ·ÛË ÙÔ˘ ‡ÚÔ˘˜ ΛÓËÛ˘ ÙˆÓ ·ÚıÚÒÛˆÓ, ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ·Ú·ÌÔÚÊÒÛˆÓ, ÙË ‰È·Ù‹ÚËÛË Î·È ·ÔηٿÛÙ·ÛË Ù˘ Ì˘˚΋˜ ÈÛ¯‡Ô˜, ÙË ‰È·Ù‹ÚËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ ·ÚıÚÒÛˆÓ, ÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ·Û¯fiÓÙˆÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜, ÙË ÌfiÚʈÛË Î·È Âη›‰Â˘ÛË, ÙÔÓ Â·ÁÁÂÏÌ·ÙÈÎfi ÚÔÛ·Ó·ÙÔÏÈÛÌfi (¶›Ó·Î·˜ 7).
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¡Â·ÓÈ΋ „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ· OÚ›˙ÂÙ·È ˆ˜ Ë ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ҉˘ ·ÚıÚ›Ùȉ·, Ë ÔÔ›· ·Ú¯›˙ÂÈ ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 16 ¯ÚfiÓˆÓ Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ·, ÙÔ ÔÔ›Ô ÚÔËÁ›ٷÈ, Û˘Óԉ‡ÂÈ ‹ ¤ÂÙ·È Ù˘ ·ÚıÚ›Ùȉ·˜. ∂Âȉ‹ ÙÔ ÂÍ¿ÓıËÌ· ÌÔÚ› Ó· ÌËÓ ÂÌÊ·ÓÈÛÙ› ÔÏÏ¿ ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ·ÚıÚ›Ùȉ·˜ (̤¯ÚÈ Î·È 15), ÙÔ 1981 ÚÔÙ¿ıËÎ·Ó Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Vancounver (¶›Ó·Î·˜ 8). ∏ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È fiÛÔ Î·Ï‹ ›¯Â ·Ú¯Èο ıˆÚËı›, ‰ÈfiÙÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi (66%) ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ÔÏ˘·ÚıÚÈ΋ ÔÚ›·. ∞ÎÚˆÙËÚÈ·ÛÙÈ΋ ·ÚıÚ›Ùȉ· Î·È ·Ì˘ÏÔ›‰ˆÛË ¤¯Ô˘Ó ÂÚÈÁÚ·Ê›. ™‡Ó‰ÚÔÌÔ Reiter ∂Í ÔÚÈÛÌÔ‡ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÙÚÈ¿‰· ÊÏÂÁÌÔÓˆ‰ÒÓ ·ÏÏÔÈÒÛÂˆÓ ·fi ÙÔÓ ·ÚıÚÈÎfi ˘Ì¤Ó·, ÙÔÓ ÂÈÂÊ˘ÎfiÙ· Î·È ÙËÓ Ô˘Ú‹ıÚ·. ∂›Ó·È ۯ‰fiÓ ‚¤‚·ÈÔ fiÙÈ ·ÔÙÂÏ› ÌÂÙ·ÏÔÈÌÒ‰Ë ‹ ·ÓÙȉڷÛÙÈ΋ ·ÚıÚ›Ùȉ· ·ÏÏ¿ ÂÚÈÁÚ¿ÊÂÙ·È Ì ÙȘ ÔÚÔ·ÚÓËÙÈΤ˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂȘ ÂÍ·ÈÙ›·˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÔÌÔÈÔÙ‹ÙˆÓ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ·Ó‡ÚÂÛ˘ ÙÔ˘ HLA-B27. ™Ù· ·È‰È¿, ÔÈ ·ÏÏÔÈÒÛÂȘ ·fi ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ Â›Ó·È Û¿ÓȘ, ÂÓÒ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Â›Ó·È Û˘¯Ó¿ Ù· ¤ÏÎË ÛÙfiÌ·ÙÔ˜ Î·È Ë ‚ÏÂÓÓÔ·ÈÌÔÚÚ·ÁÈ΋ ÎÂÚ·ÙÔ‰ÂÚÌ›·. ∞ӷʤÚÂÙ·È fiÙÈ ÛÙ· ·È‰È¿ ÙÔ Û. Reiter Â›Ó·È ·˘ÙÔ˚ÒÌÂÓÔ. ∏ ¤Î‚·ÛË ·˘Ù‹ ·ÊÔÚ¿ ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ. ¶ÈÔ ÚfiÛÊ·Ù·, Û ÌÂϤÙË 20 ·È‰ÈÒÓ Ì ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 29 Ì‹Ó˜, ÙÔ 21% ›¯Â ÛËÌ›· ÚÔÛ‚ÔÏ‹˜ ÈÂÚÔÏ·ÁÔÓ›ˆÓ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ∂Ӊ¯Ô̤ӈ˜ ÙÔ ¶›Ó·Î·˜ 7. ∞ÓÙÈÌÂÙÒÈÛË ∞.™.
∞ÓÙÈÌÂÙÒÈÛË fiÓÔ˘-ÊÏÂÁÌÔÓ‹˜ º·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ º˘ÛÈÎÔıÂڷ›· ∂ÚÁ·ÛÈÔıÂڷ›· æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ™¯ÔÏÈ΋ Âη›‰Â˘ÛË ∂·ÁÁÂÏÌ·ÙÈÎfi˜ ÚÔÛ·Ó·ÙÔÏÈÛÌfi˜
¶›Ó·Î·˜ 5. ∞ÎÙÈÓÔÏÔÁÈ΋ ‰È·‚¿ıÌÈÛË ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ µ·ıÌfi˜ µ·ıÌfi˜ µ·ıÌfi˜ µ·ıÌfi˜
π : ππ : πππ: πV:
∞Û¿ÊÂÈ· ˘Ô¯fiÓ‰ÚÈˆÓ ÔÚ›ˆÓ ¢È‡ڢÓÛË ¿ÚıÚˆÛ˘, ‰È·‚ÚÒÛÂȘ ™ÎÏ‹Ú˘ÓÛË, ÂÎÛÂÛËÌ·Ṳ̂Ó˜ ‰È·‚ÚÒÛÂȘ ∞Á·ψÛË
¶›Ó·Î·˜ 6. ∞›ÙÈ· Û‡Ó‰ÂÛ˘ ∏LA-µ27-∞.™. 1. ∞ÓÈÛÔ˙˘Á›· Û‡Ó‰ÂÛ˘ 2. ªÔÚȷ΋ ·ÔÌ›ÌËÛË, ∞˘ÙÔ·ÓÔÛ›·, ∞ÓÔ¯‹ 3. §ÂÈÙÔ˘ÚÁÈÎfi˜ ÚfiÏÔ˜ HLA ÌÔÚ›ˆÓ, ∞ÓÔÛÔ·Ó·ÁÓÒÚÈÛË, ªÂÌ‚Ú·ÓÈÎÔ› ˘Ô‰Ô¯Â›˜ ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ
¶›Ó·Î·˜ 8. ∫ÚÈÙ‹ÚÈ· Vancouver ¡æ∞ OÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË -∞ÚıÚ›Ùȉ· + Ù˘ÈÎfi „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ· ‹ -∞ÚıÚ›Ùȉ· + 3 ·fi 4 ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·: ñ¢·ÎÙ˘Ï›Ùȉ· ñµÔıÚ›· ÔÓ‡¯ˆÓ ‹ ÔÓ˘¯fiÏ˘ÛË ñÕÙ˘Ô „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ· ñOÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi „ˆÚ›·Û˘ (1Ô˘ & 2Ô˘ ‚·ıÌÔ‡ Û˘ÁÁ¤ÓÂÈ·) ¶Èı·Ó‹ ‰È¿ÁÓˆÛË -∞ÚıÚ›Ùȉ· + 2 ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·
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¶›Ó·Î·˜ 9. ∞ÚıÚ›Ùȉ· Û¯ÂÙÈ˙fiÌÂÓË ÌÂ Î·Ù·Ê˘Û›Ùȉ· ∞ÚıÚ›Ùȉ· Î·È Î·Ù·Ê˘Û›Ùȉ· ‹ ∞ÚıÚ›Ùȉ· Î·È 2 ·fi Ù· ÂÍ‹˜: 1. ∂˘·ÈÛıËÛ›· ÈÂÚÔÏ·ÁÔÓ›ˆÓ 2. ºÏÂÁÌÔÓ҉˘ fiÓÔ˜ ™.™. 3. HLA B 27 4. OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÂÓfi˜ ·fi Ù· ·Ú·Î¿Ùˆ: ·) ÚfiÛıÈ· ÈÚȉÔ΢ÎÏ›Ùȉ· Ì fiÓÔ, ÂÚ˘ıÚfiÙËÙ·, ʈÙÔÊÔ‚›· ‚) ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ· Á) ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÂÓÙ¤ÚÔ˘ 5. ¶ÚfiÛıÈ· Ú·ÁÔÂȉ›Ùȉ· Ì fiÓÔ, ÂÚ˘ıÚfiÙËÙ·, ʈÙÔÊÔ‚›· *∞Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ·, ∞¡∞, „ˆÚÈ·ÛÈ΋˜ ·ÚıÚ›Ùȉ·˜ Î·È ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÓfiÛÔ˘ ÂÓÙ¤ÚÔ˘.
Û. Reiter Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ó· ·ÔÙÂÏ› ÚÒÈÌË ÂΉ‹ÏˆÛË ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜. ∞ÚıÚÔ¿ıÂÈ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ OÚ›˙ÂÙ·È Î¿ı ¿ÛËÙË ÊÏÂÁÌÔÓ҉˘ ·ÚıÚ›Ùȉ· Ô˘ Û˘Ì‚·›ÓÂÈ ÚÈÓ ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ ‹ Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn. ™˘Ì‚·›ÓÂÈ ÛÙÔ 7-20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ‰‡Ô Ù‡Ô˘˜ ·ÚıÚ›Ùȉ·˜: ÂÚÈÊÂÚÈ΋ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·. ∏ ‰È¿ÚÎÂÈ· Ù˘ ·ÚıÚ›Ùȉ·˜ Â›Ó·È Û‡ÓÙÔÌË, ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜, ‰ÂÓ Ô‰ËÁ› Û ÔÛÙÈΤ˜ ‰È·‚ÚÒÛÂȘ Î·È ‰ÂÓ ·ÎÔÏÔ˘ı› ··Ú·›ÙËÙ· ÙȘ ÂΉËÏÒÛÂȘ ·fi ÙÔ ÂÙÈÎfi, ÙÔ ‰¤ÚÌ· ‹ ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜. ∞Û˘Ìو̷ÙÈ΋ ÂÓÙÂÚÈ΋ Û˘ÌÌÂÙÔ¯‹ ¤¯ÂÈ ·Ó¢ÚÂı› ÛÙË Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, fiˆ˜ Î·È ÛÙËÓ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· ÙˆÓ ÂÓËϛΈÓ.
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™˘ÌÂÚ¿ÛÌ·Ù· ™˘ÓÔ„›˙ÔÓÙ·˜ ÙË Û‡ÓÙÔÌË ·Ó·ÊÔÚ¿ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ù˘ Ó·ÓÈ΋˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·˜ ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘˜ ··ÈÙÔ‡ÓÙ·È ÎÔÈÓ¿ ÎÚÈÙ‹ÚÈ·, fiˆ˜ ÂΛӷ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ SE∞ ‹ ¿ÏÏ· ÈÔ ÚfiÛÊ·Ù·, fiˆ˜ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÙÔ̤· Ù˘ ¢ÈÂıÓÔ‡˜ ƒÂ˘Ì·ÙÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (¶›Ó·Î·˜ 9). §ÂÙÔ̤ÚÂȘ ÂÈ̤ÚÔ˘˜ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ‰È·¯ˆÚ›˙Ô˘Ó ÙȘ ˘ÔÔÌ¿‰Â˜. ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÛÎÂÏÂÙÔ‡ ÙÔ˘ ÎÔÚÌÔ‡ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ HLA-B27. µÈ‚ÏÈÔÁÚ·Ê›· 1. Jacobs JC, Bardon WE, Johnston AD. HLA-B27 associated spondyloarthritis and enthesopathy in childhood. Clinical pathologic and radiologic observations in 58 patients. J Pediatr 1982;100:521-528. 2. Burgos-Vargas R, Vazquez-Mallado J. The early clinical recognition of juvenile onset ankylosing spondylitis and its differentation from juvenile rheumatoid arthritis. Arthr Rheum 1995;38:835-844. 3. Burgos-Vargas R, Pacheo-Tena C, Vazquez-Mellado J. Juvenile onset spondyloarthropathies. Rheum Dis Clin N Am 1997;23:569-598. 4. Kayser FD, Elewaut D, De Vos M, De Valm K, Cuvelier C, Mielants H et al. Bowel inflammation and the spondyloarthropathies. Rheum Dis Clin N Am 1998;24: 785-810. 5. Van der Linden S, Van der Heijde D. Ankylosing spondylitis, clinical features. Rheum Dis Clin N Am 1998;24:663-675.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ŸÏÁ· µÔ˘ÁÈԇη ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
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Paediatriki 2001;64:237-240
IMMUNOLOGY-RHEUMATOLOGY
¢È·ÈÙËÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· A. ™È·ÌÔÔ‡ÏÔ˘-M·˘Ú›‰Ô˘
Dietary approach in autoimmune rheumatic diseases A. Siamopoulou-Mavridou
¶ÂÚ›ÏË„Ë: TËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ˘¿Ú¯ÂÈ ÌÂÁ¿ÏÔ È·ÙÚÈÎfi ÂӉȷʤÚÔÓ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ‰È·ÈÙËÙÈÎfi ˘fiÛÙڈ̷ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ŒÓ· ÌÂÁ¿ÏÔ Â‡ÚÔ˜ ‰È·ÈÙËÙÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ, ·fi ÌÂÌÔӈ̤ӷ ÛÙÔȯ›· ̤¯ÚÈ ÚˆÙ½Ó˜, ÌÔÚ› Ó· ÙÚÔÔÔÈ‹ÛÂÈ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ¶ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·ÏÏ¿ Î·È Û ·ÓıÚÒÔ˘˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÌÈÎÚ¤˜ ‰fiÛÂȘ ‰È·ÈÙËÙÈÎÒÓ Û˘ÏËÚˆÌ¿ÙˆÓ ÌÔÚ› Ó· ‰Ú¿ÛÔ˘Ó Â·ÁˆÁÈο ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË, ÂÓÒ ·ÓÙ›ıÂÙ· ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÌÔÚ› Ó· ¤¯Ô˘Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË. ¢È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ê·›ÓÂÙ·È ·fi ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ÚÂ˘Ì·ÙÔÂȉ‹ ·ÚıÚ›Ùȉ· (PA) fiÙÈ ·Ó·¯·ÈÙ›˙ÂÈ ÙÚÂȘ Ô‰Ô‡˜ Û‡ÓıÂÛ˘ ÏÈȉÈÎÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜: ·) ÙËÓ Ô‰fi Û‡ÓıÂÛ˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PAF), ‚) ÙËÓ Ô‰fi Ù˘ ΢ÎÏÔ-ÔÍÂÈÁÂÓ¿Û˘ Î·È Á) ÙËÓ Ô‰fi Ù˘ ÏÈÔÍÂÈÁÂÓ¿Û˘. EÚˆÙËÌ·ÙÈο ·Ú·Ì¤ÓÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ Î·Ù¿ÏÏËÏË ‰fiÛË Î·È ÙË ‰È¿ÚÎÂÈ· ·ÁˆÁ‹˜, ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó Ù· ηχÙÂÚ· ‰˘Ó·Ù¿ ·ÔÙÂϤÛÌ·Ù·. H Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· (NIA) Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÓfiÛÔ˜ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ ÛÙ· ·È‰È¿. ŒÓ· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi (2050%) ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÔıÚ„›· ÚˆÙÂïÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (PEM), Ë ÔÔ›· Û˘Óԉ‡ÂÙ·È, ÂÎÙfi˜ ·fi ÂÏ¿ÙÙˆÛË ÙˆÓ ·ÔıËÎÒÓ Ï›Ô˘˜ Î·È ·fi ÂÏ¿ÙÙˆÛË Ù˘ Ì˘˚΋˜ Ì¿˙·˜. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ˘ÔıÚ„›·˜ ÛÙ· ·È‰È¿ Ì NIA Î·È ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ›ӷÈ: ·) Ë ·ÓÔÚÂÍ›·, ‚) Ë ·Ó·ÈÌ›· (¯ÚfiÓÈ·˜ ÓfiÛÔ˘), Á) Ù· Ê¿Ú̷η, ‰) Ë ÌÂȈ̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Â) ÔÈ Ì˯·ÓÈΤ˜ ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘ Î·È ÛÙ) Èı·ÓfiÓÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜. EÂȉ‹ Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÂÈÂÏÂÁ̤Ó˘ ·˘Ù‹˜ ·ÛÈÙ›·˜ Â›Ó·È Ôχ ÌÂÁ¿ÏÔ˜
Abstract: The past decade has witnessed a resurgence of interest in nutrition and rheumatic diseases. A wide spectrum of nutritional deficiencies, ranging from trace elements to protein, can impair normal immunologic functions. Under some experimental conditions, single nutrient supplementation boosts immunity; however, some mega-dose therapies have been shown to suppress the immune response. Dietary supplementation of ˆ-3 polyunsaturated fatty acids may inhibit three pathways of the synthesis of lipid mediators of inflammation: a) the plateletactivating factor synthesis pathway, b) the cyclooxygenase pathway and c) the 5-lipoxygenase pathway. Investig·tions today focus on the proper dose and duration of therapy with fish-oil supplementation in order to obtain optimum clinical effects. Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease. The occurrence of protein-energy malnutrition (PEM) has been reported in 20% to 50% of the JIA population. The factors contributing to increased nutritional risk are: anorexia, anemia, drugs and nutritional implications, limitation of physical activity, mechanical feeding difficulties and food allergies. Because the risk for the development of complicated malnutrition pro- blems is great in the JIA population, especially since it is often characterized by the absence of sensitive visual cues that could support the clinical diagnosis of malnutrition, it is imperative that routine clinical and nutritional assessment be performed at regular intervals.
TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ, Iˆ¿ÓÓÈÓ·
Department of Pediatrics University of Ioannina Medical School, Ioannina
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¶·È‰È·ÙÚÈ΋ 2001;64:237-240
Paediatriki 2001;64:237-240
Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÂÓÂÚÁfi NIA, ı· Ú¤ÂÈ ÂÚÈÔ‰Èο Ó· Á›ÓÂÙ·È ÎÏÈÓÈ΋, ÂÚÁ·ÛÙËÚȷ΋ Î·È ‰È·ÈÙÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ù˘ ˘ÔıÚ„›·˜. §¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÈÙËÙÈο ÂÏÏ›ÌÌ·Ù·, ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË, ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜, Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ·, ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·.
Key words: nutritional deficiences, immunoresponse, protein-energy malnutrition (PEM), juvenile idiopathic arthritis, ˆ-3 polyunsaturated fatty acid.
™ÎÂÙÈÎÈÛÌÔ› ·Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË ‰›·ÈÙ·˜ ·ÚıÚ›Ùȉ·˜ ·Ó·Ê¤ÚÔÓÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ IÔÎÚ¿ÙË. K·Ù¿ ÙÔÓ 20fi ·ÈÒÓ· Î·È Î˘Ú›ˆ˜ ̤¯ÚÈ ÙÔ 1980, Ë Û˘Û¯¤ÙÈÛË ‰›·ÈÙ· - ·ÚıÚ›Ùȉ· ¤¯ÂÈ ÂÈÛÙËÌÔÓÈο ÌÂÏÂÙËı› Î·È ·¤‰ÂÈÍ fiÙÈ Î·Ó¤Ó· ›‰Ô˜ ‰È·ÙÚÔÊ‹˜ ‰ÂÓ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ¯ÚfiÓÈ· ·ÚıÚ›Ùȉ·, Ô‡Ù Âȉڿ ÛÙË ıÂڷ›· ‹ ÙËÓ “›·ÛË” Ì›·˜ ·ÚıÚ›Ùȉ·˜. ¶·Ú’ fiÏ· ·˘Ù¿, ÔÈ ·ÛıÂÓ›˜ “‰ÂÓ Ì·˜ ÈÛÙ‡ԢӔ Î·È ÍÔ‰Â‡Ô˘Ó ¿Óˆ ·fi ¤Ó· ‰ÈÛÂηÙÔÌ̇ÚÈÔ ‰ÔÏÏ¿ÚÈ· ÂÙËÛ›ˆ˜ ÛÙËÓ AÌÂÚÈ΋ ÁÈ· ‰È·ÈÙËÙÈο ‹ ¿ÏÏ· “ÌË ·Ú·‰ÔÛȷο” Ê¿Ú̷η. ¶ÔÏÏÔ› ¿ÚÚˆÛÙÔÈ ÛÙÚ¤ÊÔÓÙ·È ÛÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ È·ÙÚÈ΋ ÈÛÙ‡ÔÓÙ·˜ fiÙÈ ı· ¤¯Ô˘Ó ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ·' fiÙÈ Ì ÙËÓ ·Ú·‰ÔÛȷ΋ ÎÏ·ÛÈ΋ ·ÁˆÁ‹. ŒÙÛÈ, Ô ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· Â›Ó·È ÁÓÒÛÙ˘ ·˘ÙÒÓ ÙˆÓ ‰ÈÏËÌÌ¿ÙˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ó· ‰Â›¯ÓÂÈ Û˘Ì¿ıÂÈ· Î·È Î·Ù·ÓfiËÛË ÛÙ· ¯ÚfiÓÈ· Î·È Â›ÔÓ· ·˘Ù¿ ÓÔÛ‹Ì·Ù·. T· ÙÂÏÂ˘Ù·›· 15 ¯ÚfiÓÈ· Ë ¤Ú¢ӷ ÂÈÎÂÓÙÚÒıËΠÛÙÔ ‰È·ÈÙËÙÈÎfi ˘fiÛÙڈ̷ ÙˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ∂›Ó·È ¤Ó· ÂÚ¢ÓËÙÈÎfi ‰›Ô Ì ÌÂÁ¿Ï˜ ÚÔÛ‰Ô˘ Î·È ÔʤÏË. ŒÙÛÈ, Ë Û˘Û¯¤ÙÈÛË ‰È·ÙÚÔÊ‹˜ Î·È ·˘ÙÔ¿ÓÔÛ˘ ÚÂ˘Ì·ÙÈ΋˜ ÓfiÛÔ˘ Â›Ó·È ¤Ó· ·Ú¿‰ÂÈÁÌ· Ì›·˜ Û‡Á¯ÚÔÓ˘ ÚÂ˘Ì·ÙÔÏÔÁÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ (1). TÚ›· ÂӉȷʤÚÔÓÙ· È·ÙÚÈο ‰›· ›ӷÈ: ·) Ë Û˘Û¯¤ÙÈÛË ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ Ì ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË, ‚) Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ Î·È Ë ÌÂÛÔÏ¿‚ËÛ‹ ÙÔ˘˜ ÛÙË ÊÏÂÁÌÔÓ‹ Ù˘ ÚÂ˘Ì·ÙÔÂȉԇ˜ ·ÚıÚ›Ùȉ·˜ (PA) Î·È Á) Ù· ÔÏÏ·Ï¿ ‰È·ÈÙËÙÈο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ Ì Ó·ÓÈ΋ ȉÈÔ·ı‹ ·ÚıÚ›Ùȉ· (NIA). ∞Ó·Ï˘ÙÈÎfiÙÂÚ·: ∞) H Û˘Û¯¤ÙÈÛË ˘ÔıÚ„›·˜ Î·È ·˘ÍË̤Ó˘ ¢·ÈÛıËÛ›·˜ Û ÓÔÛ‹Ì·Ù· ·Ó·Ê¤ÚÂÙ·È ‹‰Ë ·fi ÙÔ˘˜ IÓ‰Ô‡˜ ·fi ÙÔ 5.000 .Ã. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 20Ô‡ ·ÈÒÓ· ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·Ú·ÙËÚ‹ÛÂȘ ·Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË Ïԛ̈ÍË - ˘ÔıÚ„›·, ·ÏÏ¿ ÌfiÏȘ Ù· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· ¤ÁÈÓ·Ó Î·Ù·ÓÔËÙÔ› ÔÈ Ì˯·ÓÈÛÌÔ› ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Û ηٷÛÙ¿ÛÂȘ ˘ÔıÚ„›·˜. H ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (Protein Energy Malnutrition, PEM) Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ ÛÙÔÓ ÎfiÛÌÔ (2). MÂϤÙ˜ Û ·È‰È¿ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘
‰Â›¯ÓÔ˘Ó fiÙÈ ·˘Ù¿ Âı·›ÓÔ˘Ó ·fi ÏÔÈÌÒÍÂȘ, ÏfiÁˆ Ù˘ ˘¿Ú¯Ô˘Û·˜ ηٷÛÙÔÏ‹˜ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. KÔÈÓ¿ ÏÔÈÌÒ‰Ë ·È‰È·ÙÚÈο ÓÔÛ‹Ì·Ù·, fiˆ˜ ·ÚˆÙ›Ùȉ· Î·È ÈÏ·Ú¿, Â›Ó·È ı·Ó·ÙËÊfiÚ· Û ·È‰È¿ ˘Ô·Ó¿Ù˘ÎÙˆÓ ¯ˆÚÒÓ. ™˘ÓÔÙÈο, Ù· ·ÓÔÛÔÏÔÁÈο ·ÎfiÏÔ˘ı· ÏfiÁˆ PEM Â›Ó·È Ù· ÂÍ‹˜ (3): i) AÙÚÔÊ›· ÙÔ˘ ı‡ÌÔ˘, ii) M›ˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ÛÏ‹Ó·, iii) EÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ T-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, iv) A‡ÍËÛË ÙˆÓ ÊÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, v) ¢È·Ù·Ú·¯‹ ·Ú·ÁˆÁ‹˜ ÏÂÌÊÔÎÈÓÒÓ, vi) K·ı˘ÛÙÂÚË̤ÓË ‰ÂÚÌ·ÙÈ΋ ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜, vii) EÏ·Ùو̤ÓË ·Ú·ÁˆÁ‹ ı˘ÌÈÎÒÓ ÔÚÌÔÓÒÓ. MÂÌÔӈ̤Ó˜ ıÚÂÙÈΤ˜ Ô˘Û›Â˜ ¤¯Ô˘Ó ÌÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· ÙË ÛˆÛÙ‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. H ¤ÏÏÂÈ„‹ ÙÔ˘˜ ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙË ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ŒÙÛÈ, ÌÔÚ› Ó· Û˘Ì‚Â› ÚˆÙÔ·ı‹˜ ·ÓÔÛÔÏÔÁÈ΋ ‚Ï¿‚Ë ·fi ÌÂÌÔӈ̤ӷ ‰È·ÈÙËÙÈο ÂÏÏ›ÌÌ·Ù·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó Ù· ÂÈÚ·Ì·Ùfi˙ˆ·, ÁÈ·Ù› ÌÔÚ› ÈÔ Â‡ÎÔÏ· Ó· ·Ê·ÈÚÂı› ·fi ÙÔ ‰È·ÈÙÔÏfiÁÈfi ÙÔ˘˜ Ì›· ‚ÈÙ·Ì›ÓË ‹ ¤Ó· ȯÓÔÛÙÔȯ›Ô. Y¿Ú¯Ô˘Ó, fï˜, ÏËÚÔÊÔڛ˜ Î·È Û¯ÂÙÈο Ì ÙÔÓ ¿ÓıÚˆÔ. °È· ·Ú¿‰ÂÈÁÌ·, Ë ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ A ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÏ·Ùو̤ÓË ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ‹ ‰È·Ù·Ú·¯¤˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ (4,5). ™Â ÌÂϤÙ˜ ·È‰ÈÒÓ ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ A ¤‰ÂÈÍ ӷ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒ͈Ó. H ÛȉËÚÔÂÓ›· Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi (6). ¶ÔÏϤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÙËÓ ·‡ÍËÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·fi ÏÔÈÌÒÍÂȘ Û ÛȉËÚÔÂÓÈÎÔ‡˜ ·ÛıÂÓ›˜ (7,8). ¶ÂÚÈÏËÙÈο, ÌÂϤÙ˜ ÛÙÔÓ ¿ÓıÚˆÔ Î·È Ù· ˙Ò· ¤‰ÂÈÍ·Ó: ·) MÂÌÔӈ̤Ó˜ ‹ ÔÏϷϤ˜ ÂÏÏ›„ÂȘ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó Ì¤ÙÚȘ - ‚·ÚȤ˜ ‚Ï¿‚˜ ÛÙËÓ ·ÓÔÛÔ·ÓÙ·fiÎÚÈÛË. ‚) ¢ÂÓ Â›Ó·È ÙÂÎÌËÚȈ̤ÓÔ Â¿Ó ÙÔ ÂÈϤÔÓ ıÚÂÙÈÎfi Û˘Ìϋڈ̷ ÚÔÛʤÚÂÈ Î¿ÙÈ ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË, ÂÊ’ fiÛÔÓ ‰ÂÓ ˘¿Ú¯ÂÈ ‰È·ÈÙËÙÈÎfi ¤ÏÏÂÈÌÌ·.
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Á) ¢ÂÓ Â›Ó·È ·Û‡ÓËı˜ ÁÈ· ¤Ó· ·ÓÔÛÔÊ·Ú̷΢ÙÈÎfi ·Ú¿ÁˆÁÔ Ó· ÌÔÚ› Ó· ¤¯ÂÈ ‰ÈÏ‹ ‰Ú¿ÛË. ¢ËÏ·‰‹, Û ̛· ‰fiÛË Ó· Â›Ó·È ·ÓÔÛÔ‰ÈÂÁÂÚÙÈÎfi Î·È Û ̛· ˘„ËÏfiÙÂÚË ‰fiÛË Ó· Â›Ó·È ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi (3). B) OÈ ÚÒÙ˜ ·Ú·ÙËÚ‹ÛÂȘ Ù˘ Ô˘ÛÈ·ÛÙÈ΋˜ ÚÔÛÊÔÚ¿˜ ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ¤ÁÈÓ·Ó ÙÔ 1981, fiÙ·Ó Û NZB Î·È NZW ÔÓÙ›ÎÈ· Ì ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· ÙÔ˘ χÎÔ˘ ¯ÔÚËÁ‹ıËΠ‰È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÏÈ·Ú¿ Ôͤ·. T· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (9). AÎÔÏÔ‡ıËÛ·Ó ÂÈÚ¿Ì·Ù· Û ÌÔÓ٤Ϸ ÔÓÙÈÎÈÒÓ Ì ·ÚıÚ›Ùȉ· Ì ÙÔ ›‰ÈÔ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙË ÊÏÂÁÌÔÓ‹. T· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·, ÌÂϤÙ˜ in vivo Î·È in vitro Û ·ÛıÂÓ›˜ Ì PA ΢ڛˆ˜, ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ‰È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÏÈ·Ú¿ Ôͤ· ÌÔÚ› Ó· ·Ó·¯·ÈÙ›ÛÂÈ ÙÚÂȘ Ô‰Ô‡˜ Û‡ÓıÂÛ˘ ÏÈȉÈÎÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜: ·) ÙËÓ Ô‰fi Û‡ÓıÂÛ˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PAF), ‚) ÙËÓ Ô‰fi Ù˘ ΢ÎÏÔÔ͢ÁÂÓ¿Û˘, Á) ÙËÓ Ô‰fi Ù˘ 5-ÏÈÔÍÂÈÁÂÓ¿Û˘ (10). ¶·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌË, fï˜, ÂÚˆÙËÌ·ÙÈο ÁÈ· ÙÔ˘˜ ·ÎÚȂ›˜ Ì˯·ÓÈÛÌÔ‡˜ ‰Ú¿Û˘ ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ, fiˆ˜ ›Û˘ ÁÈ· ÙËÓ È‰·ÓÈ΋ ‰fiÛË, ÙË ‰È¿ÚÎÂÈ· ·ÁˆÁ‹˜ Î·È ÙÔ Û··ÛÌ·. OÈ ÌÂϤÙ˜ Û˘Ó¯›˙ÔÓÙ·È Î·È ›Ûˆ˜ ·Ô‰Âȯı› ÌÂÏÏÔÓÙÈο Ë ÛËÌ·Û›· Ù˘ Ú·ÎÙÈ΋˜ ÙÔ˘˜ ¯Ú‹Û˘ ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· (1,11). °) H Ó·ÓÈ΋ I‰ÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· (NIA) Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÓfiÛÔ˜ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ ÛÙ· ·È‰È¿. AÓ Î·È ÂÚ›Ô˘ ÚÈÓ 100 ¯ÚfiÓÈ· ›¯Â ÂÈÛËÌ·Óı› Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙÔ ‡„Ô˜ ÙÔ˘˜ ·fi ÙÔÓ Dr. Still, ÂÓÙÔ‡ÙÔȘ, Û¯ÂÙÈο ÚfiÛÊ·Ù· Û˘Û¯ÂÙ›ÛÙËÎÂ Ë ÓfiÛÔ˜ Ì ÙË ‰È·ÈÙËÙÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË (12,13). T· ‰È·ÈÙËÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·È‰È¿ Ì NIA ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Î·È Û ·È‰È¿ Ì ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÂÂȉ‹ ˘¿Ú¯ÂÈ ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ Î·È Û˘ÌÌÂÙÔ¯‹ ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ. ™˘ÓÔÙÈο, ÔÈ Î‡ÚÈÔÈ ·Ú¿ÁÔÓÙ˜ (14,15) Ô˘
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Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·‡ÍËÛË ÎÈÓ‰‡ÓÔ˘ ˘ÔıÚ„›·˜ Û ·È‰È¿ Ì NIA Â›Ó·È ÔÈ ·ÎfiÏÔ˘ıÔÈ: ·) ·ÓÔÚÂÍ›· (ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›·), ‚) ·Ó·ÈÌ›· (¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹), Á) Ê¿Ú̷η Î·È ‰È·ÈÙËÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ, ‰) Ì˯·ÓÈΤ˜ ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘ Î·È Â) ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜. H ·ÓÔÚÂÍ›· Â›Ó·È ÙÔ Î‡ÚÈÔ ‰È·ÈÙËÙÈÎfi Úfi‚ÏËÌ·, ΢ڛˆ˜ Û ÂÚÈfi‰Ô˘˜ ·˘ÍË̤Ó˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÚıÚÒÛˆÓ. ¶ÂÈÚ¿Ì·Ù· Û ˙Ò·, ·ÏÏ¿ Î·È ÛÙÔÓ ¿ÓıÚˆÔ, ¤‰ÂÈÍ·Ó fiÙÈ Û˘ÌÌÂÙ¤¯Ô˘Ó ÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜, fiˆ˜ IL-1 Î·È TNF (16). M›· ÛËÌ·ÓÙÈ΋ ·Ú·Ù‹ÚËÛË Â›Ó·È fiÙÈ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Ù· ÔÔ›· ‰ÂÓ ÚÔÛÏ·Ì‚¿ÓÔ˘Ó ıÂÚÌ›‰Â˜, ¯¿ÓÔ˘Ó ÌfiÓÔ ÏÈÒ‰Ë ÈÛÙfi. H ‰ÈÂÚÁ·Û›· ·˘Ù‹ ϤÁÂÙ·È ÌË ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›· (uncomplicated starvation). ™Ù· ·È‰È¿, fï˜, Ì ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, ÙÔ 50% ÙÔ˘ ¯·Ì¤ÓÔ˘ ‚¿ÚÔ˘˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ Ì˘˜ Î·È ÙÔ ˘fiÏÔÈÔ 50% ·fi ÙÔ Ï›Ô˜. H ÔÓÙfiÙ˘ ·˘Ù‹ ϤÁÂÙ·È ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›· (complicated starvation) (17). H ·Ó·ÈÌ›· ÂÌÊ·Ó›˙ÂÙ·È Û˘¯Ó¿, ÔÏϤ˜ ÊÔÚ¤˜ Û ‚·ÚÈ¿ ÌÔÚÊ‹, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙË ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹. ™˘Ì‚¿ÏÏÂÈ Ë ÊÙˆ¯‹ ‰›·ÈÙ· Û ۛ‰ËÚÔ, Ë ‰Â˘ÙÂÚÔ·ı‹˜ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ·fi ÙÔ °E™ ÏfiÁˆ Ù˘ ¯Ú‹Û˘ ÙˆÓ M™Aº ·ÏÏ¿ Î·È ÏfiÁˆ ÂÓ·fiıÂÛ˘ Ûȉ‹ÚÔ˘ ÛÙÔ˘˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÚıÚÈÎÔ‡˜ ÈÛÙÔ‡˜. H Û˘ÌÌÂÙÔ¯‹ Ù˘ ÎÚÔÙ·ÊÔÁÓ·ıÈ΋˜ ¿ÚıÚˆÛ˘, Ë ˘ÔÏ·Û›· Ù˘ οو ÁÓ¿ıÔ˘ ·ÏÏ¿ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÙˆÓ Î·ÚÒÓ ÂÈ‚·Ú‡ÓÔ˘Ó ÙȘ ‰˘ÛÎÔϛ˜ Ù˘ Û›ÙÈÛ˘ (18). H ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (PEM) ·ÁÁ›˙ÂÈ ÙÔ 50% ÙˆÓ ·È‰ÈÒÓ Ì NIA Î·È ÂÌÊ·Ó›˙ÂÙ·È Û ·È‰È¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ΢ڛˆ˜ ÌÔÚÊ‹ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ÂÓÂÚÁfiÙËÙ· Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÈÂÏÂÁ̤Ó˘ ˘ÔıÚ„›·˜ Â›Ó·È ÌÂÁ¿ÏÔ˜, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÂÌÊ·Ó‹ ÛËÌ›· ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘ÔıÚ„›·˜. OÈ ÌÂÙÚ‹ÛÂȘ Ù˘ ÚÔ·Ï‚Ô˘Ì›Ó˘ Î·È Ù˘ Û˘Ó‰Â‰Â̤Ó˘ ÚÂÙÈÓfiÏ˘ Â›Ó·È ÚÒÈÌÔÈ Î·È Â˘·›ÛıËÙÔÈ ‰Â›ÎÙ˜ Ì›·˜ ÂÌÊ·ÓÈ˙fiÌÂÓ˘ ¤ÏÏÂȄ˘ ÚˆÙ½Ó˘. E›Ó·È ηχÙÂÚÔÈ ‰Â›ÎÙ˜ ·' fiÙÈ Ë Ì¤ÙÚËÛË ·Ï‚Ô˘Ì›Ó˘.
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OÈ ÙÈ̤˜ Ù˘ ÚÂÙÈÓfiÏ˘ Î·È Ù˘ ÚÔ·Ï‚Ô˘Ì›Ó˘ Â›Ó·È ¯·ÌËϤ˜ Û ˘ÔıÚÂÊfiÌÂÓ· ·È‰È¿ Ì NIA Î·È Ë ÊÏÂÁÌÔÓ‹ Ù˘ ÓfiÛÔ˘ Â›Ó·È ÂÓ Ì¤ÚÂÈ ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ÂÎÙÚÔ‹ Ù˘ Û‡ÓıÂÛ˘ ÚˆÙÂ˚ÓÒÓ ·fi ÙÔ ‹·Ú ÚÔ˜ ÙËÓ ·Ú·ÁˆÁ‹ ÔÍ›·˜ Ê¿Ûˆ˜ ·ÓÙȉڷÛÙÈÎÒÓ Ô˘ÛÈÒÓ (19). °È· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi ¯ˆÚ›˜ ȉȷ›ÙÂÚ˜ ÁÓÒÛÂȘ ‰È·ÈÙËÙÈ΋˜, Ì›· ·Ï‹ ÏËı˘ÛÌȷ΋ ‰ÔÎÈÌ·Û›· (screening test) Ì ÙȘ ·Ú·Î¿Ùˆ 4 ·Ú·Ì¤ÙÚÔ˘˜ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÂÈÛ‹Ì·ÓÛË Ì›·˜ ˘ÔıÚ„›·˜: (·) B¿ÚÔ˜ (·ıÔÏÔÁÈÎfi < 5Ë E£), (‚) B¿ÚÔ˜/‡„Ô˜ (·ıÔÏÔÁÈÎfi <80%), (Á) ¶ÂÚ›ÌÂÙÚÔ˜ ‚Ú·¯›ÔÓ· (·ıÔÏÔÁÈÎfi <5Ë E£), (‰) §Â˘ÎˆÌ·Ù›ÓË ÔÚÔ‡ (<3,5 g%). ∏ ·ÚÔ˘Û›· ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·Ú·Ì¤ÙÚˆÓ ·ıÔÏÔÁÈÎÒÓ ‰ËÏÒÓÂÈ ˘ÔıÚ„›·. TÔ ∞ÌÂÚÈηÓÈÎfi ÎÔÏϤÁÈÔ Ù˘ PÂ˘Ì·ÙÔÏÔÁ›·˜ (20) ¤¯ÂÈ ¿ÚÂÈ ÔÚÈṲ̂Ó˜ ı¤ÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ‰›Ô “‰›·ÈÙ· - ·ÚıÚ›Ùȉ·”. AӷʤÚÂÈ fiÙÈ, ÂÓÒ ÌÂÚÈο ‰È·ÈÙËÙÈο ·Ú¿ÁˆÁ· ÌÔÚ› Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹, ÂÓÙÔ‡ÙÔȘ ‰È·ÈÙËÙÈΤ˜ ıÂڷ›˜ ÁÈ· ·ÚıÚ›Ùȉ· Â›Ó·È Û ÂÈÚ·Ì·ÙÈÎfi ·ÎfiÌË ÛÙ¿‰ÈÔ. °È’ ·˘Ùfi ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È Û ÈÛÔÚÚÔË̤Ó˜ Î·È ˘ÁÈÂÈÓ¤˜ ‰›·ÈÙ˜ Î·È Ó· ·ÔʇÁÔ˘Ó Ù· ÂÍ·ÓÙÏËÙÈο Î·È “ȉÈfiÙ˘·” ‰È·ÈÙÔÏfiÁÈ·. ∞˘Ùfi ÙÔ Â‰›Ô Ù˘ I·ÙÚÈ΋˜ ÂÈÛÙ‹Ì˘ Â›Ó·È ¤Ó·˜ ·ÓÔȯÙfi˜ ÔÚ›˙ÔÓÙ·˜ Ì ÌÂÁ¿Ï˜ ÚÔÔÙÈΤ˜, fiÛÔÓ ·ÊÔÚ¿ ÙË Û˘Û¯¤ÙÈÛË ÙÚÔÊÈÎÒÓ ·ÓÙÈÁfiÓˆÓ ‹ ‰È·ÈÙËÙÈÎÒÓ ÚÔÙ‡ˆÓ Ì ÙË ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ Î·È ÙËÓ Î·Ï‡ÙÂÚË ÁÓÒÛË ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Henderson JC, Panuch SR. Diets, dietary supplements and nutritional therapies in rheumatic diseases. Rheum Dis Clin North Am 1999;25:937-968. 2. Corman LC. Effects of specific nutrients on the immune response. Med Clin North Am 1985;69:759-791. 3. Delafuente CJ. Nutrients and Immune responses. Rheum Dis Clin North Am 1991;17:203-212. 4. Cohen BE, Elin RJ. Vitamin A induced nonspecific resistance to infection. J Infet Dis 1974;129:597-600. 5. Krishman S, Bhuyan UN, Talwar GP, Ramalingaswami V. Effect of vitamin A and protein-calorie undernutrition on immune responses. Immunology 1974;27:383-392. 6. Hussey GD, Klein M. A randomized controlled trial of vitamin A in children with severe measles. N Engl J Med 1990;323:160-164.
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7. De Sousa MD. Immune cell functions in iron overload. Clin Exp Immunol 1989;75:1-6. 8. Dhur A, Galan P, Hercberg S. Iron status, immune capacity and resistance to infections. Comp Biochem Physiol 1989:94:11-19. 9. Robinson RD. Alleviation of autoimmune disease by dietary lipids containing omega-3 fatty acids. Rheum Dis Clin North Am 1991;17:213-222. 10. Von Schacky C, Siess W, Fischer S, Weber PC. A comparative study of eicosapentaenoic acid metabolism by human platelets in vivo and in vitro. J Lipid Res 1985;26:457-464. 11. Van der Tempel H, Tulleken JE, Limbury PC, Muskief FA, van Rijswijk MH. Effects of fish-oil supplementation in rheumatoid arthritis. Ann Rheum Dis 1990;49:76-80. 12. Hangen MA, Hoyeraal HM, Larsen S, Gilboe IM, Trygg K. Nutrient intake and nutritional status in children with juvenile chronic arthritis. Scand J Rheumatol 1992;21:165-170. 13. Ostrov BE. Nutrition and pediatric rheumatic diseases. Hypothesis: cytokines modulate nutritional abnormalities in rheumatic diseases. J Rheumatol 1992;19(33 Suppl):49-53. 14. Knops N, Wulffraat N, Lodder S, Honwen R, Kees de Meer. Resting energy expenditure and nutritional status in children with juvenile rheumatoid arthritis. J Rheumatol 1999;26:2039-2043. 15. Henderson CJ, Lovell JD. Nutritional aspects of juvenile rheumatoid arthritis. Rheum Dis Clin North Am 1991;17:403-413. 16. Tracey KJ, Wei H, Manogue KR. Cachectin/tumor necrosis factor induces cachexia, anemia and inflammation. J Exp Med 1988;167:1211. 17. Miller ML, Chacko JA, Young EA. Dietary deficiencies in children with juvenile rheumatoid arthritis. Arthritis Care Res 1989;2:22-24. 18. Garceau AO, Dwyer JT, Holland M. A practical approach to nutrition in the patient with juvenile rheumatoid arthritis. Clinical Nutrtition 1989;8:55-64. 19. Henderson CJ, Lovell JD. Assesment of protein-energy malnutrition in children and adolescents with juvenile rheumatoid arthritis. Arthritis Care Res 1989;2:108-113. 20. Panuch SR. American College of Rheumatology. Position statement: Diet and arthritis. Rheum Dis Clin North Am 1991;17:443-447.
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NEPHROLOGY
¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘: ÂÎÙ›ÌËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË ∫. ¢. ∫ÔÏÏÈfi˜
Prenatal diagnosis of hydronephrosis: fetal assessment and postnatal follow-up K. D. Kollios
¶ÂÚ›ÏË„Ë: °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ÂÌ‚Ú˘˚΋˜ ˘Ó‰ÚÔÓ¤ÊÚˆÛ˘ Î·È ÂÍÂÙ¿˙ÂÙ·È Ë Û˘¯ÓfiÙËÙ·, Ë ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÔÈ ‰È¿ÊÔÚ˜ ·Èٛ˜ Ô˘ ÙËÓ ÚÔηÏÔ‡Ó. ∂ÍÂÙ¿˙ÔÓÙ·È Í¯ˆÚÈÛÙ¿ Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ËÏÈΛ· Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ ÙˆÓ ÓÂÊÚÒÓ (̤ÙÚËÛË Ù˘ ÚÔÛıÈÔ-Ô›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘). °›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙÔÓ ·Ú¯ÈÎfi ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ηıÒ˜ Î·È ÛÙÔÓ ÙÚfiÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· Ù· ÂfiÌÂÓ· ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË. °È· ÙȘ ÂÚÈÙÒÛÂȘ ÂÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ·Ó·Ù‡ÛÛÔÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· Ì ‚¿ÛË Ù· ÔÔ›· ı· ÂÈÏÂÁ› Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË. AÓÙ›ıÂÙ·, ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ÂÈÛËÌ·›ÓÔÓÙ·È ÔÈ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È Û˘˙ËÙÔ‡ÓÙ·È ÔÈ ÚfiÛÊ·Ù˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ Î·È ÙȘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘ (΢ÛÙÂÔ·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›·).
Abstract: A review of the incidence, pathophysiology and the underlying etiologic factors of fetal hydronephrosis is presented. A detailed analysis follows regarding the criteria that are used to establish the diagnosis during fetal life and in the postnatal period, which are primarily based on the ultrasonographic measurements of the anteroposterior diameter of the renal pelvis. The initial radiologic evaluation that must be performed at birth and the studies required during follow-up are fully discussed. Finally, the criteria for selecting between conservative or surgical intervention during fetal life are presented. For cases of unilateral hydronephrosis the indications for surgical intervention after birth are clear-cut and easy to follow. However, for bilateral fetal hydronephrosis, the adverse effects of hydronephrosis on the fetal kidney and the lungs are underlined, and the current knowledge on the limitations as well as the reservations regarding the efficacy of fetal surgical intervention (vesicoamniotic shunt) are discussed.
§¤ÍÂȘ ÎÏÂȉȿ: ÂÌ‚Ú˘˚΋ ˘‰ÚÔÓ¤ÊÚˆÛË, ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË, ˘¤Ú˯ÔÈ, ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË.
Key words: fetal hydronephrosis, prenatal diagnosis, ultrasonography, prenatal intervention.
∏ ¢Ú›· ÂÊ·ÚÌÔÁ‹ ÙˆÓ ˘ÂÚ‹¯ˆÓ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 ÛËÌ·ÙÔ‰fiÙËÛ ÙËÓ ··Ú¯‹ Ì›·˜ Ó¤·˜ ÂÔ¯‹˜ ÛÙË ‰È¿ÁÓˆÛË Î·È ÚÔÛ¤ÁÁÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÓÂÊÚÔ‡ Î·È Ù˘ ·Ô¯ÂÙ¢ÙÈ-
΋˜ Ô˘ÚÔÊfiÚÔ˘ Ô‰Ô‡. ªÂ ÙË Û˘ÓÂÚÁ·Û›· ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ (Ì·ÈÂ˘Ù‹ÚˆÓ, ÓÂÔÁÓÔÏfiÁˆÓ, ·È‰ÔÓÂÊÚÔÏfiÁˆÓ, ·È‰ÔÔ˘ÚÔÏfiÁˆÓ, ·ÎÙÈÓÔÏfiÁˆÓ Î·È ˘ÚËÓÈÎÒÓ È·ÙÚÒÓ) ¤¯ÂÈ ·ÔÎÙËı›
∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ
Department of Pediatrics Division of Pediatric Nephrology University of Ioannina Medical School
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ÛËÌ·ÓÙÈ΋ ÂÌÂÈÚ›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ Î¤ÓÙÚÔ ‚¿ÚÔ˘˜ Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Ó· ¤¯ÂÈ Ï¤ÔÓ ÌÂÙ·ÙÔÈÛÙ› ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· ÛÙÔ ¤Ì‚Ú˘Ô Î·È ÙÔ ÓÂÔÁÓfi. ∆· ‚·ÛÈο ÂÚˆÙ‹Ì·Ù· Ô˘ Ù›ıÂÓÙ·È ÛÙȘ ÂÚÈÙÒÛÂȘ ÚÔÁÂÓÓËÙÈ΋˜ Î·È ÓÂÔÁÓÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Â›Ó·È Ù· ·Ú·Î¿Ùˆ (1): ·) ªÂ ÔÈ· ÎÚÈÙ‹ÚÈ· ÔÚ›˙ÂÙ·È Ë ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘; ‚) ¶ÔȘ Â›Ó·È ÔÈ ÂÈÙÒÛÂȘ ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÔÈ· Â›Ó·È Ë Ê˘ÛÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘; Á) ¶fiÙ ¯ÚÂÈ¿˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË Î·È fiÙ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ‰) À¿Ú¯ÂÈ ÙÚfiÔ˜ ‰È¿ÎÚÈÛ˘ ÌÂٷ͇ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ı· ‚ÂÏÙȈıÔ‡Ó ¯ˆÚ›˜ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË Î·È ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ı· ÂȉÂÈÓˆıÔ‡Ó ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈο; ™ÙËÓ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ı· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ·, ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÙË Ê˘ÛÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÛÙÔÓ ÚÔÙÂÈÓfiÌÂÓÔ ‰È·ÁÓˆÛÙÈÎfi ¤ÏÂÁ¯Ô, ηıÒ˜ Î·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË Ô˘ ··ÈÙ›ٷÈ. ∆¤ÏÔ˜, ı· ÂÈÛËÌ·ÓıÔ‡Ó, Ì ‚¿ÛË Ù· Û‡Á¯ÚÔÓ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ÔÈ ÂӉ›ÍÂȘ ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘. ™˘¯ÓfiÙËÙ· ∏ ˘‰ÚÔÓ¤ÊÚˆÛË Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÓˆÌ·Ï›· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (50%) ·fi ·˘Ù¤˜ Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È Ì ˘¤ÚË¯Ô˘˜ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ËÏÈΛ· (2). ™‡Ìʈӷ Ì ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ ·Ó¤Ú¯ÂÙ·È Û 1 ·Ó¿ 100 ΢‹ÛÂȘ, ÔÈ ÛÔ‚·Ú¤˜ fï˜ ÂÚÈÙÒÛÂȘ Â›Ó·È Ôχ ÏÈÁfiÙÂÚ˜ Î·È ÊÙ¿ÓÔ˘Ó ÙȘ 1 ·Ó¿ 500 ΢‹ÛÂȘ (3,4). ∞ÎfiÌË, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ù· Â˘Ú‹Ì·Ù· Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÂÈ̤ÓÔ˘Ó Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÛÙȘ ÌÈÛ¤˜ ÂÚ›Ô˘ ÂÚÈÙÒÛÂȘ (5). ¶·ıÔÊ˘ÛÈÔÏÔÁ›· OÈ Û˘Ó¤ÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› ÂÚÈÛÛfiÙÂÚÔ Û ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ·. ∏ Û˘ÌÌÂÙÔ¯‹ Ù˘ ·˘ÍË̤Ó˘ ˘‰ÚÔÛÙ·ÙÈ΋˜ ›ÂÛ˘, ÏfiÁˆ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ‰ÂÓ ÂÍËÁ› ÈηÓÔÔÈËÙÈο ÙË ÓÂÊÚÈ΋ ‚Ï¿‚Ë Ô˘ ÚÔ·ÙÂÈ. ™ÙÔ ÓÂÊÚfi Ì ˘‰ÚÔÓ¤ÊÚˆÛË ¤¯ÂÈ ÂÈÛËÌ·Óı› Ô ÚfiÏÔ˜ Ù˘ ÚÂÓ›Ó˘, ·ÁÁÂÈÔÙÂÓÛ›Ó˘ Î·È ıÚÔÌ‚ÔÍ¿Ó˘ ∞2, ÂÓÒ ÛÙÔÓ ˘ÁÈ‹ ÓÂÊÚfi ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙˆÓ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ Ô˘ÛÈÒÓ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ PG∂2 Î·È PGI2, ÙˆÓ ÎÈÓÈÓÒÓ Î·È ÙÔ˘ ÎÔÏÈÎÔ‡ Ó·ÙÚÈÔÔ˘ÚËÙËÚÈÎÔ‡ ÂÙȉ›Ô˘ (6).
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OÈ ÂȉڿÛÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÊÔÚÔ‡Ó ÙfiÛÔ ÙÔ ÓÂÊÚÈÎfi Û›ڷ̷, ÌÂ Û˘Ó¤ÂÈ· ÙË ÌÂȈ̤ÓË ÓÂÊÚÔÁ¤ÓÂÛË Î·È ÙË Û˘Ó·ÎfiÏÔ˘ıË ÌÂȈ̤ÓË ·‡ÍËÛË ÙÔ˘ ÓÂÊÚÔ‡, fiÛÔ Î·È ÙÔ ÓÂÊÚÈÎfi ÛˆÏËÓ¿ÚÈÔ, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂÙ·ÌfiÚʈÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ÌÂÛÂÁ¯˘Ì·ÙÈο, ÙËÓ ·fiÙˆÛË ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ (7). °È· ÙËÓ ÂΉ‹ÏˆÛË ·˘ÙÒÓ ÙˆÓ ÂȉڿÛÂˆÓ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÂÙ·ÌfiÚʈÛ˘ ‚1 (TGF - ‚1), ηıÒ˜ ¤¯ÂÈ ‚ÚÂı› ·˘ÍË̤ÓË ¤ÎÊÚ·Û‹ ÙÔ˘ Û ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ·, ÛÙ· ÔÔ›· ÚÔÎÏ‹ıËΠ·fiÊÚ·ÍË ÙÔ˘ Ô˘ÚËÙ‹Ú· (7). ∞ÈÙÈÔÏÔÁ›· ¢Â‰Ô̤ÓÔ˘ fiÙÈ Ë ·ÚÔ˘Û›· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È ¿ÓÙÔÙ Ì ÙËÓ ‡·ÚÍË ·fiÊڷ͢, ÌÔÚԇ̠ӷ Ù·ÍÈÓÔÌ‹ÛÔ˘Ì ÙȘ ‰È¿ÊÔÚ˜ ·Èٛ˜ Û ÌË ·ÔÊÚ·ÎÙÈΤ˜ Î·È Û ·ÔÊÚ·ÎÙÈΤ˜. ¶·Ú·‰Â›ÁÌ·Ù· ÙˆÓ ÌË ·ÔÊÚ·ÎÙÈÎÒÓ ·ÈÙÈÒÓ Â›Ó·È: Ë Ê˘ÛÈÔÏÔÁÈ΋ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ·ÚÔ˘Û›· ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (∫O¶) Î·È Ë ÌÂÁ·Î·Ï‡ÎˆÛË (2). ™ÙȘ ·ÔÊÚ·ÎÙÈΤ˜ ·Èٛ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È, Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ·, Ë ÛÙ¤ÓˆÛË Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ (44%) Î·È Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜ (21%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó, Ì ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ·, Ô ÏÂÈÔ΢ÛÙÈÎfi˜ ÓÂÊÚfi˜, Ë Ô˘ÚËÙËÚÔ΋ÏË Î·È Ô ¤ÎÙÔÔ˜ Ô˘ÚËÙ‹Ú·˜, ÔÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ (9%) Î·È Ë ·ÙÚËÛ›· Ù˘ Ô˘Ú‹ıÚ·˜ (2). ∞fi ÙËÓ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÚÔ·ÙÂÈ fiÙÈ Ë ∫O¶ ¢ı‡ÓÂÙ·È ÁÈ· ¤Ó· ÔÛÔÛÙfi ÂÚ›Ô˘ 20% ÙˆÓ ÚÔÁÂÓÓËÙÈÎÒÓ ‰È·Ù¿ÛˆÓ, ÂÓÒ ¿ÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (·ÔÊÚ·ÎÙÈ΋˜ ‹ ÌË ·ÔÊÚ·ÎÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜) ηχÙÔ˘Ó ¤Ó· ÔÛÔÛÙfi ÂÚ›Ô˘ 40% Ì 50%, Ì ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÙË ÛÙ¤ÓˆÛË Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜. ªÂϤÙË Ô˘ ¤ÁÈÓ ÛÙËÓ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ Î·Ù¿ ÙËÓ ÙÂÙÚ·ÂÙ›· 1996-1999, ÂÚȤϷ‚ 51 ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Î·È ‚ÚÂÊÒÓ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘ (8). ¢È·ÈÛÙÒıËÎ·Ó Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û ÔÛÔÛÙfi 37%, ÂÓÒ ∫O¶ ‰È·ÈÛÙÒıËΠÛÙÔ 24% ÙˆÓ ÂÚÈÙÒÛˆÓ. ÕÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ÂÎÙfi˜ Ù˘ ∫O¶, ‰È·ÈÛÙÒıËÎ·Ó Û 20 ·fi ÙȘ 51 ÂÚÈÙÒÛÂȘ (ÔÛÔÛÙfi 39%) (8). º˘ÛÈ΋ ÔÚ›· ∏ Ê˘ÛÈ΋ ÔÚ›· Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ù· ·ÎfiÏÔ˘ı·: ·) ˘Ô¯ÒÚËÛË, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ,
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¶·È‰È·ÙÚÈ΋ 2001;64:241-246
Paediatriki 2001;64:241-246
‚) Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·fiÊÚ·ÍË, Û ÌÈÎÚfi ÔÛÔÛÙfi, Á) ·fiÊÚ·ÍË, ·Ú’ fiÏÔ Ô˘ Ô ·Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÌÔÚ› Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜. ™Â ÌÂϤÙ˜, ηٿ ÙȘ Ôԛ˜ ¤ÁÈÓ ٷÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Û ÓÂÔÁÓ¿ Ô˘ ηٿ ÙË Á¤ÓÓËÛË ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡, ‰È·ÈÛÙÒıËΠfiÙÈ Û ̷ÎÚÔ¯ÚfiÓÈ· ‚¿ÛË ¯ÚÂÈ¿ÛÙËΠӷ Á›ÓÂÈ ˘ÂÏÔÏ·ÛÙÈ΋ ÛÙÔ 7% ¤ˆ˜ 23% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÏfiÁˆ Ì›ˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ÂÍÂÏ›¯ıËΠÌÂÙ·ÁÂÓ¤ÛÙÂÚ· (9,10). ∂Ô̤ӈ˜, ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ Î·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Û fiÏ· Ù· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË, ÛÙ· ÔÔ›· ¤¯ÂÈ ÙÂı› ÚÔÁÂÓÓËÙÈο Ë ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘. ¶ÚÔÁÂÓÓËÙÈ΋ ˘‰ÚÔÓ¤ÊÚˆÛË: ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ ∆· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ‚·Û›˙ÔÓÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ Ì ÙË Ì¤ÙÚËÛË Ù˘ ÚÔÛıÈÔ›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘. ™‡Ìʈӷ Ì ÙÔÓ Corteville Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ (11), ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Ì ˘¤ÚË¯Ô˘˜ ı· Ú¤ÂÈ Ë ÚÔÛıÈÔ›ÛıÈ· ‰È¿ÌÂÙÚÔ˜ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ Ó· ›ӷÈ: i) >4 mm, ÚÈÓ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ ‹ ii) >7 mm, ÌÂÙ¿ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘. ∫·Ù’ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ, ·ÓȯÓ‡ÔÓÙ·È fiϘ ÔÈ ÂÚÈÙÒÛÂȘ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ (¢·ÈÛıËÛ›· 100%). ¶·Ú’ fiÏ· ·˘Ù¿, ÙÔ ÔÛÔÛÙfi „¢‰ÒÓ ıÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 55% Î·È 21% ·ÓÙ›ÛÙÔȯ·, ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ (11). ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ∏ ·Ú¯È΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ Î¿ÙˆıÈ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô: 1) À¤ÚË¯Ô˘˜ (U/S), ÙËÓ 4Ë - 7Ë Ë̤ڷ ˙ˆ‹˜ Î·È fi¯È ÓˆÚ›ÙÂÚ·, ¤ÙÛÈ ÒÛÙ ӷ ·ÔÊ¢¯ıÔ‡Ó „¢-
‰Ò˜ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ‰ÈÔ‡ÚËÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ (12). H ÂÎÙ›ÌËÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Á›ÓÂÙ·È Ì ‚¿ÛË: ·) ÙËÓ ÚÔÛıÈÔ›ÛıÈ· ‰È¿ÌÂÙÚÔ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘, ‚) ÙË ‰È¿Ù·ÛË ÙˆÓ Î·Ï‡ÎˆÓ Î·È Á) ÙËÓ ·ÚÔ˘Û›· ·ÙÚÔÊ›·˜ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì·. ™ÙËÓ ÚfiÛÊ·ÙË Ù·ÍÈÓfiÌËÛË ÙÔ˘ Rascher 1998 (¶›Ó·Î·˜ 1), Ô ÌÈÎÚfiÙÂÚÔ˜ ‚·ıÌfi˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÓÙÈÛÙÔȯ› Û ‰È¿Ù·ÛË Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ¤ˆ˜ 10 mm, ÂÓÒ Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ (‚·ıÌfi˜ V) ·ÓÙÈÛÙÔȯ› Û ‰È¿Ù·ÛË >15 mm, Ô˘ ÂÈϤÔÓ Û˘Óԉ‡ÂÙ·È Ì ‚·ÚÈ¿ ‰È¿Ù·ÛË ÙˆÓ Î·Ï‡ÎˆÓ Î·ıÒ˜ Î·È ·ÙÚÔÊ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÊÏÔÈÔ‡ (13). 2) ∫˘ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›·, ÙËÓ 4Ë - 6Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜. ™‡Ìʈӷ Ì ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜, Ô ¤ÏÂÁ¯Ô˜ Ì ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ÂӉ›ÎÓ˘Ù·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ÂÓÒ Î·Ù’ ¿ÏÏÔ˘˜ ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ fiÙ·Ó Ô ÚÒÙÔ˜ ÌÂÙ·ÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ˘¤ÚË¯Ô˘˜ Â›Ó·È ·ıÔÏÔÁÈÎfi˜ (12). 3) ¢ÈÔ˘ÚËÙÈÎfi ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DTPA ‹ Mag-3), ÂÎÙÈÌÒÓÙ·˜ ÙȘ ·ÎfiÏÔ˘ı˜ ·Ú·Ì¤ÙÚÔ˘˜: ·) ÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ηıÒ˜ Î·È ÙËÓ ÂηÙÔÛÙÈ·›· Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ οı ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ‚) ÙËÓ ·ÚÔ˘Û›· ·fiÊڷ͢, ÌÂÏÂÙÒÓÙ·˜ ÙËÓ Î·Ì‡ÏË ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜ (Lasix). Œ¯ÂÈ ÚÔÙ·ı› ÔÌfiʈӷ ·fi fiÏÔ˘˜ ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ fiÙÈ ˆ˜ ‚·ÛÈΤ˜ Û˘Óı‹Î˜ Î·È ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙË ÛˆÛÙ‹ ÂÚÌËÓ›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ıˆÚÔ‡ÓÙ·È: ·) Ë Â·Ú΋˜ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ‚) Ë ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜ ÛÙ· 20 min ÌÂÙ¿ ÙËÓ ¤ÓÂÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È Á) Ë ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË, fiÙ·Ó ˘¿Ú¯ÂÈ ˘Ô„›· ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ‹ ÌÂÁ·Ô˘ÚËÙ‹Ú· (14). ™ÙÔÓ ¶›Ó·Î· 2 ÂÚÈÁÚ¿ÊÂÙ·È ÙÔ ÚˆÙfiÎÔÏÏÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÓÂÔÁÓÒÓ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘, fiˆ˜ ·˘Ùfi ÚÔÙ›ÓÂÙ·È Î·È ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ O˘ÚÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Great Ormond Street ÙÔ˘ §ÔÓ‰›ÓÔ˘ (15) Î·È ÙÔ ÔÔ›Ô ‚·Û›˙ÂÙ·È
¶›Ó·Î·˜ 1. T·ÍÈÓfiÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Rascher, 1998) (13) µ·ıÌfi˜
M¤ÁÂıÔ˜ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ (mm)
¢È¿Ù·ÛË Î·Ï‡ÎˆÓ
NÂÊÚÈÎfi ·Ú¤Á¯˘Ì·
π
10
-
ÎÊ
ππ
10-15
-
>>
πππ
>15
∂Ï·ÊÚ¿
>>
IV
>>
ª¤ÙÚÈ·
>5 mm
V
>>
µ·ÚÈ¿
<5 mm ·ÙÚÔÊ›· ÊÏÔÈÔ‡
243
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·244
¶·È‰È·ÙÚÈ΋ 2001;64:241-246
Paediatriki 2001;64:241-246
¶›Ó·Î·˜ 2. ¶ÚˆÙfiÎÔÏÏÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÛÙ· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ·Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ‰È¿Ù·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ηٿ ÙË Á¤ÓÓËÛË (¶ÚˆÙfiÎÔÏÏÔ Great Ormond Street Hospital) (15) XÚfiÓÔ˜ Î·È ÙÚfiÔ˜ ÂͤٷÛ˘ ¶ÚÔÛıÈÔ-Ô›ÛıÈ· ‰È¿ÌÂÙÚÔ˜ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘
U/S ÓÂÊÚÒÓ
¢˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Tc-DTPA ‹ Mag-3
<12 mm
3Ô˜ Ì‹Ó·˜ Î·È 1Ô, 2Ô, 5Ô, & 10Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜
+/-*
13-19 mm
>>
3Ô˜ Ì‹Ó·˜ Î·È 1Ô, 2Ô, 5Ô, & 10Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜
>20 mm
1Ô˜, 3Ô˜, 6Ô˜ Ì‹Ó·˜ Î·È 1Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜. ™ÙË Û˘Ó¤¯ÂÈ· οı 12 Ì‹Ó˜
1Ô˜, 3Ô˜, 6Ô˜ Ì‹Ó·˜ Î·È 1Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜. ™ÙË Û˘Ó¤¯ÂÈ· οı 12 Ì‹Ó˜
* ™Â ‰È¿Ù·ÛË <12mm, Ùo Mag-3 ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ ÂÎÙfi˜: ·) ·Ó ·Ú·ÙËÚËı› ·‡ÍËÛË Ù˘ ‰È¿Ù·Û˘ Î·È ‚) fiÙ·Ó Ë ¯Ú‹ÛË Ù˘ Á›ÓÂÙ·È ˆ˜ ‚·ÛÈ΋ ÂͤٷÛË.
ÛÙȘ ‰È·ÛÙ¿ÛÂȘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘: ·) ¤ÏÂÁ¯Ô˜ ÌfiÓÔ Ì U/S, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ Â›Ó·È <12 mm, ‚) ¤ÏÂÁ¯Ô˜ Ì U/S Î·È ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÓ 3Ô Ì‹Ó· ˙ˆ‹˜, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ˘¤ÏÔ˘ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 13-19 mm, Á) ¤ÏÂÁ¯Ô˜ Ì U/S Î·È ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÓ 1Ô Ì‹Ó· ˙ˆ‹˜, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ˘¤ÏÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi 20 mm. ∞ÓÙÈÌÂÙÒÈÛË °È· ÙËÓ ÚfiÏË„Ë Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Û˘ÓÈÛÙ¿Ù·È ·ÓÙÈ‚ÈÔÙÈ΋ ÚÔʇϷÍË. ∞Ú¯Èο, Ë ·ÌÔ͢ÎÈÏÏ›ÓË Â›Ó·È ÙÔ ·ÓÙÈ‚ÈÔÙÈÎfi ÂÎÏÔÁ‹˜, Ô˘ ÌÂÙ¿ ·fi ÙÔ 2Ô Ì‹Ó· ˙ˆ‹˜ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ·ı› Ì ÙÚÈÌÂıÔÚÚ›ÌË - ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË (12). ∫·Ù¿ Ù· ¿ÏÏ·, Ë ·ÓÙÈÌÂÙÒÈÛË ı· ÂÍ·ÚÙËı› ·fi ÙËÓ ·ÈÙ›· Ô˘ ÚÔηÏ› ÙËÓ ˘‰ÚÔÓ¤ÊÚˆÛË. ™ÙȘ ·Èٛ˜ Ô˘ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ¿ÌÂÛË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, Ì ÛÎÔfi Ó· ·ÔηٷÛÙ·ı› Ë ÚÔ‹ ÙˆÓ Ô‡ÚˆÓ Î·È Ó· ÚÔÏËÊı› Ë ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. EÙÂÚfiÏ¢ÚË ˘‰ÚÔÓ¤ÊÚˆÛË ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰‡Ô ·ÚÈˆÓ ·ÈÙ›ˆÓ ÂÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ‹ÙÔÈ Ù˘ ÛÙ¤ÓˆÛ˘ Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Î·È Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, ÛÙËÚ›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Ô˘ ı· ‰ÒÛÂÈ ·¿ÓÙËÛË: ·) ÛÙËÓ ‡·ÚÍË ‹ ÌË ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ η̇Ï˘ ÙÔ˘ ÓÂÊÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ‚) ÛÙÔ ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ŸÙ·Ó Ë Î·Ì‡ÏË ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È ·ÔÊÚ·ÎÙÈ-
244
ÎÔ‡ Ù‡Ô˘, ÙfiÙ ·Ó¿ÏÔÁ· Ì ÙÔ ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÚÔÙ¿ÛÛÂÙ·È Ë ·ÎfiÏÔ˘ıË ·ÓÙÈÌÂÙÒÈÛË (15): ·) ÓÂÊÚÂÎÙÔÌ‹, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È <10% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ‚) ˘ÂÏÔÏ·ÛÙÈ΋, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È ÌÂٷ͇ 10% Î·È 30% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Á) ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È >30% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™ÙËÓ ÔÚ›· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓfi˜ ·È‰ÈÔ‡ Ì ˘‰ÚÔÓ¤ÊÚˆÛË fiÙ·Ó Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È ·ÌÊ›‚ÔÏ· ‹ ·Û·Ê‹, Ë ÂÈÏÔÁ‹ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· Û˘Ìو̿وÓ, fiˆ˜ .¯. Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÎÔÈÏÈ·Îfi˜ fiÓÔ˜ ‹ ÎÔÏÈÎfi˜, ·Ó·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜, ·ÈÌ·ÙÔ˘Ú›·, ÏÈı›·ÛË ‹ ˘¤ÚÙ·ÛË (1). ∞ÌÊÔÙÂÚfiÏ¢ÚË ˘‰ÚÔÓ¤ÊÚˆÛË ™ÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÚÔ·ÙÔ˘Ó ‰È¿ÊÔÚ· ‰È·ÁÓˆÛÙÈο ÂÚˆÙ‹Ì·Ù· Î·È ıÂڷ¢ÙÈο ‰ÈÏ‹ÌÌ·Ù·, ηıÒ˜ Ú¤ÂÈ Ó· ‰Ôı› ·¿ÓÙËÛË ÛÙ· ·ÎfiÏÔ˘ı· (16): i) ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, ii) ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ·ÓˆÌ·Ï›·, iii) ·Ó ˘¿Ú¯Ô˘Ó Û˘ÓÔ‰¤˜ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜, iv) ·Ó ÔÈ ÓÂÊÚÔ› Â›Ó·È ‰˘ÛÏ·ÛÙÈÎÔ› Î·È v) ·Ó ¯ÚÂÈ¿˙ÂÙ·È ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË. OÈ Î‡ÚȘ ÂÈÏÔΤ˜ Ù˘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ÂÚ›Ô‰Ô Â›Ó·È: ·) ‚·ÚÈ¿ ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· Î·È ‚) ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ. ¢È¿ÊÔÚ˜ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Û ÂÚÈÙÒÛÂȘ
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·245
¶·È‰È·ÙÚÈ΋ 2001;64:241-246
·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜, Ô ‚·ıÌfi˜ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏ·Û›·˜ ηıÒ˜ Î·È Ù˘ ˘ÔÏ·Û›·˜ ÙˆÓ Ó¢ÌfiÓˆÓ Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· Ù˘ ·fiÊڷ͢. O ΢ÚÈfiÙÂÚÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·ÚÔ˘Û›· Ù˘ ˘ÔÏ·Û›·˜ ÙˆÓ Ó¢ÌfiÓˆÓ Â›Ó·È Ë ‡·ÚÍË ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘ ÛÙÔ 2Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ Â›Ó·È ÙÔ Î‡ÚÈÔ ·›ÙÈÔ ıÓËÛÈÌfiÙËÙ·˜ Û ÓÂÔÁÓ¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·. ∏ ÂÈ‚›ˆÛË ÛÙ· ÓÂÔÁÓ¿ ·˘Ù¿ Â›Ó·È Ìˉ·ÌÈÓ‹, fiÙ·Ó Ë ·ÚÔ˘Û›· ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘ Û¯ÂÙ›˙ÂÙ·È Ì ·fiÊÚ·ÍË Ù˘ Ô˘Ú‹ıÚ·˜ (17). ∂Ô̤ӈ˜, Û ÂÚÈÙÒÛÂȘ ‚·ÚÈ¿˜ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ Ô˘ ÂÓÙÔ›˙ÂÙ·È Î·Ù¿ ÙÔ 2Ô ÙÚ›ÌËÓÔ Î‡ËÛ˘, ÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Î·È ÙÔ ÔÔ›Ô ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ, Â›Ó·È ÙÔ Î‡ÚÈÔ Âȯ›ÚËÌ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ó· ‰ÈηÈÔÏÔÁ‹ÛÂÈ, ·fi ËıÈ΋˜ ÏÂ˘Ú¿˜, ÙË ¯Ú‹ÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ ·Ú¿ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ Â›Ó·È Èı·Ófi Ó· ÚÔ·„Ô˘Ó ·fi ·˘Ù‹. ¶ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË Û ¤Ì‚Ú˘· Ì ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ· ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·, fï˜ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ·ÌÊÈÛ‚‹ÙËÛË Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘. ∏ ̤ıÔ‰Ô˜ Ô˘ ΢ڛˆ˜ ÂÊ·ÚÌfi˙ÂÙ·È Â›Ó·È Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ‰ÈÏÔ‡ pig-tail ηıÂÙ‹Ú· ÌÂٷ͇ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ¯ÒÚÔ˘ (΢ÛÙÂÔ-·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›·). ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÁÈ· ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË ÛÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÔÙÂÏÔ‡Ó (16): ·) Ë ‡·ÚÍË ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘: ‰Â›ÎÙ˘ fiÁÎÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ <5 cm, ‚) Ë ·Ô˘Û›· ÛÔ‚·ÚÒÓ ·ÓˆÌ·ÏÈÒÓ ·fi ¿ÏÏ· fiÚÁ·Ó·, Á) Ë ·Ô˘Û›· ¯ÚˆÌÔÛˆÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (ÂÎÙ›ÌËÛË Î·Ú˘fiÙ˘Ô˘ ÌÂÙ¿ ·fi ·ÌÓÈÔΤÓÙËÛË ‹ Ï‹„Ë ‰Â›ÁÌ·ÙÔ˜ ¯ÔÚÈ·ÎÒÓ Ï·¯ÓÒÓ), ‰) Ë ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÛÙ· Ô‡Ú· ÙÔ˘ Ó·ÙÚ›Ô˘, ÙÔ˘ ¯ÏˆÚ›Ô˘ Î·È ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, ηıÒ˜ Î·È Ì ¤ÏÂÁ¯Ô Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ÙˆÓ Ô‡ÚˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘. °È· ηχÙÂÚ· Î·È ÈÔ ·ÛÊ·Ï‹ ·ÔÙÂϤÛÌ·Ù·, ¤¯ÂÈ ÚÔÙ·ı› Ó· Á›ÓÂÙ·È Ë ·Ú·¿Óˆ ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Ì ‚¿ÛË ÙË Ï‹„Ë 3 ‰È·‰Ô¯ÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ Ô‡ÚˆÓ. ø˜ ηÏÔ› ÚÔÁÓˆÛÙÈÎÔ› ÓÂÊÚÈÎÔ› ‰Â›ÎÙ˜ ıˆÚÔ‡ÓÙ·È Ù· οوıÈ Â˘Ú‹Ì·Ù· ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ Ô‡ÚˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘: ¡¿ÙÚÈÔ <100 mEq/I, ÃÏÒÚÈÔ <90 mEq/l,
Paediatriki 2001;64:241-246
øÛ̈ÙÈÎfiÙËÙ· <210 m√sm/I (18). ÕÏÏÔÈ ‰Â›ÎÙ˜ Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙ· Ô‡Ú· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ›ӷÈ: Ë ‚2-ÌÈÈÎÚÔÛÊ·ÈÚ›ÓË, Ë ·1-ÌÈÎÚÔÛÊ·ÈÚ›ÓË, Ë Û˘Ó‰ÂÙÈ΋ ÚˆÙ½ÓË Ù˘ ÚÂÙÈÓfiÏ˘, Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÌÂÙ·ÌfiÚʈÛ˘ - ‚1 (TGF-‚1) Î·È Ô ÂȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (EGF). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ Ì ΢ÛÙÂÔ·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›· (∫-∞ ÂÈÎÔÈÓˆÓ›·) ÂÎÙÈÌ‹ıËΠ·fi ÙÔÓ Freedman Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ Û ̛· ÌÂϤÙË 55 ÂÌ‚Ú‡ˆÓ Ì ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, 22 ·fi Ù· ÔÔ›· ˘Ô‚Ï‹ıËÎ·Ó Û ∫-∞ ÂÈÎÔÈÓˆÓ›· (17). TÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ ¯ÂÈÚÔ˘ÚÁËÌ¤ÓˆÓ ÂÌ‚Ú‡ˆÓ ‹Ù·Ó 61% Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ 55 ÂÌ‚Ú‡ˆÓ (ÌÂ Î·È ¯ˆÚ›˜ ∫-∞ ÂÈÎÔÈÓˆÓ›·) Ô˘ ‹Ù·Ó 40%. Ÿˆ˜ ¤‰ÂÈÍ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ú·¿Óˆ ÌÂϤÙ˘, ÔÈ Î›Ó‰˘ÓÔÈ ·fi ·Ú¤Ì‚·ÛË Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· Â›Ó·È ·˘ÍË̤ÓÔÈ. ∏ ÔÌ¿‰· ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· ‰È¤ÙÚ¯ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÚÔˆÚfiÙËÙ·˜ (71%) Î·È ÚfiˆÚ˘ ڋ͢ ˘Ì¤ÓˆÓ (31%), Û ۇÁÎÚÈÛË Ì ٷ ¤Ì‚Ú˘· Ô˘ ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û ∫-∞ ÂÈÎÔÈÓˆÓ›·. EÈϤÔÓ, ·Ú·ÙËÚ‹ıËÎ·Ó Ì˯·ÓÈΤ˜ ÂÈÏÔΤ˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·Ú¤Ì‚·Û˘, Û ÔÛÔÛÙfi 48% ÙˆÓ ÂÌ‚Ú‡ˆÓ, ÔÈ Ôԛ˜ fï˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ·ÔÙÂÏÂÛÌ·ÙÈο ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ ÂÈÏÔΤ˜. ¶·Ú¿ ÙȘ Ì˯·ÓÈΤ˜ ÂÈÏÔΤ˜, Ë ·ÒÏÂÈ· ÂÌ‚Ú‡ˆÓ ÏfiÁˆ Ì·È¢ÙÈÎÒÓ ÂÈÏÔÎÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË (16%) Û ۇÁÎÚÈÛË Ì ٷ ¤Ì‚Ú˘· Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙÔÔı¤ÙËÛË ∫-∞ ÂÈÎÔÈÓˆÓ›·˜ (38%). TÔ ÛÔ‚·ÚfiÙÂÚÔ Úfi‚ÏËÌ· Ô˘ ÂÈÛËÌ¿ÓıËΠ·fi ·˘Ù‹ ÙË ÌÂϤÙË ‹Ù·Ó ÔÈ Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·Ù¿ ÙË ÌÂÁ¿ÏË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ (>2 ¤ÙË) 14 ·È‰ÈÒÓ, Ô˘ ÂÈ‚›ˆÛ·Ó ÌÂÙ¿ ·fi ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· (16). ∏ ·‡ÍËÛË ÙÔ˘ ‡„Ô˘˜ ‹Ù·Ó ÌÈÎÚfiÙÂÚË Ù˘ 5˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ Ë ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ‹Ù·Ó ›Û˘ ÌÈÎÚfiÙÂÚË Ù˘ 5˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÛÙÔ 36% ÙˆÓ ÂÚÈÙÒÛˆÓ. º˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ›¯·Ó ÌfiÓÔ Ù· 6 ·fi Ù· 14 ·È‰È¿ (ÔÛÔÛÙfi 43%). ∆Ô ·ÓËÛ˘¯ËÙÈÎfi ‡ÚËÌ· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ (8 ·fi Ù· 14) Ô˘ ‚Ú›ÛÎÔÓÙ·Ó Â›Ù Û ‰È¿ÊÔÚ· ÛÙ¿‰È· ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ‹ Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (Û˘ÓÔÏÈÎfi ÔÛÔÛÙfi 57%). ™˘ÌÂÚ¿ÛÌ·Ù· ™˘ÓÔ„›˙ÔÓÙ·˜, ÂÈÛËÌ·›ÓÔÓÙ·È Ù· ·Ú·Î¿Ùˆ: ∞) ∏ ·ÚÔ˘Û›· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ÓÂÊÚÒÓ ‰ÂÓ Û˘ÓËÁÔÚ› ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ‡·ÚÍË ·fiÊڷ͢. µ) H ·ÚÔ˘Û›· Î·È Ô ‚·ıÌfi˜ Ù˘ ‰È¿Ù·Û˘ ηıÔÚ›˙ÔÓÙ·È Ì ÙÔ˘˜ ˘¤ÚË¯Ô˘˜, Ì ‚¿ÛË ÙȘ
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ÌÂÙÚ‹ÛÂȘ Ù˘ ÚÔÛıÈÔ›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ηٿ ÙËÓ ÚÔÁÂÓÓËÙÈ΋ Î·È ÙËÓ ÚÒÈÌË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. ∂ÈÛËÌ·›ÓÂÙ·È fiÙÈ ÔÈ ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜ ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Ô ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ ÚÔÁÂÓÓËÙÈο ‹ ÌÂÙ·ÁÂÓÓËÙÈο. °) ∏ ÂȂ‚·›ˆÛË Èı·ÓÔ‡˜ ·fiÊڷ͢ ‚·Û›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ, Ë ÂÚÌËÓ›· ÙˆÓ ÔÔ›ˆÓ ÚÔ¸Ôı¤ÙÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Û˘Óı‹Î˜ ÛˆÛÙ‹˜ ÚÔÂÙÔÈÌ·Û›·˜ Î·È ÂϤÁ¯Ô˘. ¢) ∏ ÚÔÁÂÓÓËÙÈ΋ ˘‰ÚÔÓ¤ÊÚˆÛË ˘Ô¯ˆÚ› Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ. OÈ ÂÚÈÙÒÛÂȘ Ô˘ ı· ¯ÂÈÚÔ˘ÚÁËıÔ‡Ó ı· ÂÈÏÂÁÔ‡Ó Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· ·fi: ·) ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ ÓÂÊÚÒÓ Î·È ‚) ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ ÁÈ· ÙË ‰È·›ÛÙˆÛË Ù˘ ·ÚÔ˘Û›·˜ ·fiÊڷ͢ ηıÒ˜ Î·È Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∂) Y¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ÂÈÊ˘Ï¿ÍÂȘ Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ Û ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘. OÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÈηÓÔÔÈËÙÈο (60%) Î·È fiÙÈ Ë Èı·ÓfiÙËÙ· ·ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· ·Ó¤Ú¯ÂÙ·È ÌfiÓÔ ÛÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Trip BM, Homsy YL. Neonatal hydronephrosis - The controversy and the management. Pediatr Nephrol 1995;9:503-509. 2. Reddy PP, Mandell J. Ureteropelvic Junction obstruction: Prenatal diagnosis. Urol Clin N Am 1998;25:171-180. 3. Housley HT, Harrison MR. Fetal urinary tract abnormalities: Natural history, pathophysiology, and treatment. Urol Clin N Am 1998;25:63-73. 4. Thomas DF. Fetal Uropathy. Br J Urol 1990;66:225-231. 5. Grignon A, Fillion R, Filiatrault D, Robitaille P, Homsy Y, Boutin H et al. Urinary tract dilatation in Utero: classification and clinical applications. Radiology 1986;160:645-647. 6. Klahr S, Harris K, Purkerson ML. Effects of obstruction on renal functions. Pediatr Nephrol 1998;2:34-42. 7. Chevalier RL. Molecular and cellular pathophysiology of obstructive nephropathy. Pediatr Nephrol 1999;13:612-619.
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8. Sionti I, Pavlou M, Kollios K, Daskas N, Papadopoulou L. Antenatal ultrasonographic diagnosis of fetal urinary tract anomalies and postnatal follow-up. Proceedings of the First Joint Congress of the UNEPSA and CESP (Europediatrics 2000); 2000 March 18-21; Rome: UNEPSA and CESP; 2000. p. 169. 9. Ransley PG, Dhillon HK, Gordon I, Duffy PG, Dillon MJ, Barratt TM. The postnatal management of hydronephrosis diagnosed by prenatal ultrasound. J Urol 1990;144:584-587. 10. Koff SA, Canlell KD. The non operative management of unilateral neonatal hydronephrosis: natural history of poorly functioning kidneys. J Urol 1994;152:593-595. 11. Corteville JE, Gray DL, Crane JP. Congenital hydronephrosis: Correlation of fetal ultrasonograhpic findings with infant outcome. Am J Obstet Gynecol 1991;165:384-388. 12. Elder JS. Antenatal hydronephrosis: Fetal and neonatal management. Pediatr Clin N Am 1997;44:1299-1321. 13. Rascher W, Meyer-Schwickerath, Olbing H. Congenital anomalies of the urinary tract. In: Davison AM, Cameron JS, Grünfeld J-P, Kerr DNS, Ritz E, Winearls CG, eds. Oxford Textbook of Clinical Nephrology. 2nd ed. New York: Oxford University Press; 1998. p. 2543-2563. 14. O’ Reilly P, Aurell M, Britton K, Kletter K, Rosenthal L, Testa T. Consensus on Diuresis Renography for investigating the dilated Upper urinary tract. J Nucl Med 1996;37:18721876. 15. Dhillon HK. Prenatally diagnosed hydronephrosis: the Great Ormond Street experience. Br J Urol 1998;81(2 Suppl):39-44. 16. Freedman AL, Johnson MP, Gonzalez R. Fetal therapy for obstructive uropathy: Past, present ... future? Pediatr Nephrol 2000;14:167-176. 17. Freedman AL, Bukowski TP, Smith CA, Evans MI, Johnson MP, Gonzalez R. Fetal therapy for obstructive uropathy: specific outcomes diagnosis. J Urol 1996;156:720-724. 18. Glick PL, Harrison MR, Golbus MS, Adrick NS, Filly RA, Callen PW et al. Management of the fetus with congenital hydronephrosis. II. Prognostic criteria and selection for treatment. J Pediatr Surg 1985;20:376-387.
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NEPHROLOGY
¡ÂfiÙÂÚ˜ ·fi„ÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∂. ¡. °ÂˆÚÁ¿ÎË - ∞ÁÁÂÏ¿ÎË
New aspects in the treatment of nephrotic syndrome in childhood H. N. Georgaki - Angelaki
¶ÂÚ›ÏË„Ë: ∆Ô È‰ÈÔ·ı¤˜ ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ (¡™) Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Ì ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· 27 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡, ·Ó‹ÎÂÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÛÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ıÂڷ›· Ì ÎÔÚÙÈÎÔÂȉ‹. ∏ ¢ÈÂıÓ‹˜ ªÂϤÙË ÙˆÓ ¡ÂÊÚÈÎÒÓ ¶·ı‹ÛÂˆÓ Ù˘ ¶·È‰È΋˜ ËÏÈΛ·˜ (ISDC) ıÂÌÂÏ›ˆÛ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 ÙȘ ‚·ÛÈΤ˜ ·Ú¯¤˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¡™, ÔÏϤ˜ ·fi ÙȘ Ôԛ˜ ÈÛ¯‡Ô˘Ó ¤ˆ˜ Û‹ÌÂÚ·. ∆· ÓÂfiÙÂÚ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο ‹ ·ÓÔÛÔÙÚÔÔÔÈËÙÈο Ê¿Ú̷η Ù· ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ÎÔÚÙÈÎÔÂȉ‹ ¤¯Ô˘Ó Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘, ÙË ‚ÂÏÙ›ˆÛË ÛÙËÓ ÚfiÁÓˆÛË Î·È ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ. ∆Ô ¡™ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·Ó‹ÎÂÈ Û˘Ó‹ıˆ˜ ÈÛÙÔÏÔÁÈο ÛÙÔÓ Ù‡Ô Ù˘ ∂ÛÙȷ΋˜ ™ÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Î·È Î·Ù¿ ηÓfiÓ· ÂËÚ¿˙ÂÙ·È Ôχ Ï›ÁÔ ·fi Ù· ÓÂfiÙÂÚ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù·. ¶·Ú¿ ÙȘ ‰È¯ÔÁÓˆÌÔ‡ÌÂÓ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·fi„ÂȘ, Ê·›ÓÂÙ·È fiÙÈ Ô Ù‡Ô˜ ·˘Ùfi˜ ¡™ Ô‰ËÁ› Û ¿ÏÏÔÙ ¿ÏÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÔ›·˜ ··ÈÙÂ›Ù·È ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË.
Abstract: The idiopathic Nephrotic Syndrome (NS) of childhood, with an annual incidence of 2-7 new cases in 100.000 children’s population, is by histology due primarily to the type of minimal change disease which is characterized by response to steroid treatment. Most of our current knowledge is attributed to the fundamental principles of the International Study of Kidney Disease in Childhood (ISKDC) started in 1970, most of which are operative even today. The new therapeutic regimens consist of immunosuppressive or immunoregulatory agents which, in combination with corticosteroids, have contributed significantly to the better management of nephrotic children. µased on the above regimens, and the prevention of previously fatal complications, the prognosis of the disease is now better. The type of NS resistant to steroids and to the other more aggressive immunosuppressive agents is com- monly due to Focal Segmental Glomerulosclerosis (FSGS). Although, according to the literature, there is conflicting data regarding the effectiveness of the new therapeutic agents and the outcome of this disease, many children progress to chronic renal failure and need treatment with renal trans- plantation.
§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ıÂڷ›·.
Key words: nephrotic syndrome, treatment.
∆Ô È‰ÈÔ·ı¤˜ ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ Ì ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· 2-7 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ οو ÙˆÓ 16 ¯ÚfiÓˆÓ (1), ·ÔÙÂÏ› ÎÔÈÓfi ·È‰È·ÙÚÈÎfi ÓfiÛËÌ· Ì ·ÚÈ· ›وÛË ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘, ·ÊÔ‡ ÙÔ 90% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ Î·È Ì¿ÏÈÛÙ· ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛˆÓ, ·ÊÔÚ¿ Û ·È‰È¿ οو
ÙˆÓ 7 ¯ÚfiÓˆÓ (2). O ·È‰È·ÙÚÈÎfi˜ ÎfiÛÌÔ˜ ·Ó¿ ÙËÓ ˘Ê‹ÏÈÔ ÔÊ›ÏÂÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ÁÓÒÛ˘ Î·È Ù˘ ÂÌÂÈÚ›·˜ ÁÈ· ÙÔ ÓfiÛËÌ· ·˘Ùfi ÛÙËÓ ÂÔÓÔÌ·˙fiÌÂÓË ¢ÈÂıÓ‹ ªÂϤÙË. ∏ ÌÂϤÙË ·˘Ù‹, ÁÓˆÛÙ‹ ˆ˜ ¢ÈÂıÓ‹˜ ÌÂϤÙË ÙˆÓ ¡ÂÊÚÈÎÒÓ ¡ÔÛËÌ¿ÙˆÓ Ù˘ ¶·È‰È΋˜ ËÏÈΛ·˜ (ISKDC), ÍÂΛÓËÛ ÙË ‰ÂηÂÙ›·
¢È¢ı‡ÓÙÚÈ· ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
Director of Paediatric Nephrology Unit “Agia Sophia” Children’s Hospital, Athens
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MAY- JUNE '01 TELIKO
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18:55
™ÂÏ›‰·248
¶·È‰È·ÙÚÈ΋ 2001;64:247-254
ÙÔ˘ ’70 (2) Î·È ‰ÈÂÓÂÚÁ‹ıËΠ·fi 27 ¶·È‰ÔÓÂÊÚÔÏÔÁÈο ΤÓÙÚ· Û 24 Û˘ÓÔÏÈο ¯ÒÚ˜ ·fi ÙË ¢. ∂˘ÚÒË, ÙË µ. ∞ÌÂÚÈ΋ Î·È ÙÔ Hong Kong (2). ªÂÚÈΤ˜, ÏÔÈfiÓ, ·fi ÙȘ ϤÔÓ ·ÍÈÔÛËÌ›ˆÙ˜ ÁÓÒÛÂȘ Ô˘ ÚԤ΢„·Ó ·fi ÙË ¢ÈÂıÓ‹ ªÂϤÙË Î·È Ô˘ ÈÛ¯‡Ô˘Ó ¤ˆ˜ Î·È Û‹ÌÂÚ· Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜: ∆Ô ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘ ȉÈÔ·ı¤˜, ·Ó‹ÎÂÈ ÈÛÙÔÏÔÁÈο ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È Î·Ù¿ ηÓfiÓ· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ıÂÙÈο ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·fi Ù· 561 ·È‰È¿ Ì ÙÔ ÓfiÛËÌ· ·˘Ùfi, 430 (76,6%) Ù·ÍÈÓÔÌ‹ıËÎ·Ó ÌÂÙ¿ ·fi ‚ÈÔ„›· ÓÂÊÚÔ‡ fiÙÈ ·Ó‹Î·Ó ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È ·fi ·˘Ù¿, ÙÔ 94% ·ÚÔ˘Û›·Û ‡ÊÂÛË ÌÂÙ¿ ÙË ıÂڷ›· Ì ÎÔÚÙÈÎÔÂȉ‹ (¶ÚÂ˙ÔÏfiÓË, ¶Ú‰ÓÈ˙ÔÏfiÓË), ÂÓÒ Ù· 41 (7,3%,) ·Ó‹Î·Ó ÛÙÔÓ Ù‡Ô Ù˘ ÂÛÙȷ΋˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Ì ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ÌfiÓÔÓ ÙÔ 19,5% ÂÍ’ ·˘ÙÒÓ Î·È ·ÓıÂÎÙÈÎfiÙËÙ· fiÏˆÓ ÙˆÓ ˘ÔÏÔ›ˆÓ. ∏ ‚·ÛÈ΋ ·˘Ù‹ ÁÓÒÛË Ù˘ ¿ÌÂÛ˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Ì ÙË ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Û ÔÛÔÛÙfi 94%, ıÂÌÂÏ›ˆÛ ÙË ÁÓˆÛÙ‹ Î·È ÈÛ¯‡Ô˘Û· ¤ˆ˜ Û‹ÌÂÚ· ¿Ô„Ë fiÙÈ Î¿ı ·È‰› ËÏÈΛ·˜ ÌÂٷ͇ 1 Î·È 10 ¯ÚfiÓˆÓ ÌÔÚ› - ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ - Ó· ˘Ô‚ÏËı› Û ıÂڷ›· Ì ÎÔÚÙÈÎÔÂȉ‹ ·ÊÔ‡ Ë Èı·ÓfiÙËÙ·, fiˆ˜ ÚÔ·ÙÂÈ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¢ÈÂıÓÔ‡˜ ªÂϤÙ˘, Ó· ¿Û¯ÂÈ ·fi ÙË ÓfiÛÔ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Â›Ó·È Ù˘ ٿ͈˜ ÙÔ˘ 76,6% Î·È Ë ·ÓÙ·fiÎÚÈÛË ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ÛÙË ıÂڷ›· Ì ÎÔÚÙÈÎÔÂȉ‹ 94%. ∆· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· Ô˘ ¤¯Ô˘Ó ÚÔÙ·ı› ·fi ÙfiÙ ÛÙËÓ ÔÚ›· ÙÚÈÒÓ ‰ÂηÂÙÈÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È ·ÚÎÂÙ¿. ªÂ ÌÈÎÚ¤˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜, Ô˘ÛÈ·ÛÙÈο fiÏ· ÚÔÙ›ÓÔ˘Ó ÙËÓ ¿ÌÂÛË ¤Ó·ÚÍË Ù˘ ÚÂ˙ÔÏfiÓ˘ ‹ Ú‰ÓÈ˙ÔÏfiÓ˘ Û ‰fiÛË 2 mg/kg Û 34 ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ ËÌÂÚËÛ›ˆ˜, ˘ÔÏÔÁ›˙ÔÓÙ·˜ ÙÔ È‰·ÓÈÎfi ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‚¿ÛÂÈ ÙÔ˘ ‡„Ô˘˜ ÙÔ˘ Î·È fi¯È ÙÔ ÔȉËÌ·Ù҉˜ ‚¿ÚÔ˜. ∏ ·ÁˆÁ‹ ·˘Ù‹ ‰›‰ÂÙ·È Â› ¤Ó· Ì‹Ó· Î·È ·ÎÔÏÔ˘ı› ·Ú‹ÌÂÚË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ‰fiÛË 1,5-2 mg/kg ÙÔ Úˆ›, Ì ÛÙfi¯Ô ÙË ÛÙ·‰È·Î‹ Ì›ˆÛË Î·È ‰È·ÎÔ‹ ÙÔ˘ Û’ ¤Ó· Ì‹Ó· (3). ªÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË ‰‡Ô ÌËÓÒÓ ıÂڷ›·˜ Ì ÎÔÚÙÈÎÔÂȉ‹, ÙÔ 93,8% ÙˆÓ ·È‰ÈÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ¢ÈÂıÓ‹ ªÂϤÙË Â›¯·Ó ·ÓÙ·ÔÎÚÈı› Û’ ·˘Ù¿ (2). ∞ÎÔÏÔ‡ıËÛÂ, ÂÓÙÔ‡ÙÔȘ, Ï‹ıÔ˜ ÂÚÁ·ÛÈÒÓ Ô˘ ÙÂÎÌËÚ›ˆÛ·Ó ÙËÓ ¿Ô„Ë fiÙÈ Û¯Â‰fiÓ ÙÔ 85% ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ú¯Èο ›¯·Ó ·ÓÙ·ÔÎÚÈı› ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·ÚÔ˘Û›·Û·Ó ÂÓ Û˘Ó¯›· ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘, ›Ù ηٿ ÙË Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Â›Ù Û ‚Ú·¯‡
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¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ‰È·ÎÔ‹ ÙÔ˘˜ (4-6). OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È fiÙÈ ¿Û¯Ô˘Ó ·fi ÙÔÓ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô Î·È ·Ó·ÏfiÁˆ˜ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ˘ÔÙÚÔÒÓ Ô˘ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, Ù·ÍÈÓÔÌÔ‡ÓÙ·È Â›Ù ˆ˜ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓÙ˜ (‰‡Ô ˘ÔÙÚÔ¤˜ ÙÔ ÂÍ¿ÌËÓÔ ‹ ÙÚÂȘ ÙÔ ¯ÚfiÓÔ), ›Ù ˆ˜ ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔÈ ·fi ÌÈÎÚ‹ ‹ ÌÂÁ¿ÏË ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ, ÂÊfiÛÔÓ ˘ÔÙÚÔÈ¿˙Ô˘Ó ÛÙËÓ ÚÔÛ¿ıÂÈ· Ì›ˆÛ˘ ‹ ‰È·ÎÔ‹˜ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ. ∏ ÔÌ¿‰· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ·˘ÙÒÓ ·ÛıÂÓÒÓ ·ÔÙÂÏ› Û˘¯Ó¿ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ¤Ó· Úfi‚ÏËÌ· ‰‡ÛÎÔÏ· ·ÓÙÈÌÂÙˆÈ˙fiÌÂÓÔ. ∞fi ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û˘ÁÎÚ›ÓÔÓÙ·˜ ÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙËÓ ÎÏ·ÛÈ΋ ‰›ÌËÓË ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ÚÔ˜ ¿ÏÏË ÔÌ¿‰· ÛÙËÓ ÔÔ›· ¯ÔÚËÁ‹ıËÎ·Ó Ù· ÎÔÚÙÈÎÔÂȉ‹ Û ϤÔÓ Ì·ÎÚfi¯ÚÔÓË ‰È¿ÚÎÂÈ· ÌÂ Û˘ÓÔÏÈ΋ ¯ÔÚ‹ÁËÛË ¤ÍÈ ÌËÓÒÓ Û ۯ‹Ì· ÛÙ·‰È·Î‹˜ Î·È Û ·ÚÁfi Ú˘ıÌfi ÌÂÈÔ‡ÌÂÓ˘ ‰fiÛ˘, ‰›¯ıË fiÙÈ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰·, ÙfiÛÔ ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ˘ÔÙÚÔÒÓ fiÛÔ Î·È ˆ˜ ÚÔ˜ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÚÔ˘Û›·˙·Ó ÎÔÚÙÈÎÔÂÍ¿ÚÙËÛË, ¯ˆÚ›˜ ÔÈ Ì·ÎÚfi¯ÚÔÓ˜ ·ÚÂÓ¤ÚÁÂȘ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÂÚÈÛÛfiÙÂÚ˜ (6). ∏ ıÂڷ¢ÙÈ΋ ·˘Ù‹ ¿Ô„Ë ¤¯ÂÈ Ï¤ÔÓ ˘ÈÔıÂÙËı› Î·È ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·ÚÎÂÙ¿ ·È‰ÔÓÂÊÚÔÏÔÁÈο ΤÓÙÚ·, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È ÂΛÓÔ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∞ıËÓÒÓ. ¶ÏËÓ Ù˘ ¢·ÈÛıËÛ›·˜ ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ȉÈÔ·ı¤˜ ¡™ ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛˆÓ, ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏ· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ηıÔ‰ËÁÔ‡Ó ÙÔ ıÂÚ¿ÔÓÙ· ÛÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ∏ Èı·ÓfiÙËÙ· ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÌÂÈÒÓÂÙ·È ÛÙÔ ÔÛÔÛÙfi ÙˆÓ 50% - 60% › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™, Â¿Ó ÛÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÔÛÙÂı› ˘¤ÚÙ·ÛË ‹ ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›·. ™ÙËÓ ÂÚ›ÙˆÛË ‰Â, Û˘Ó‡·Ú͢ Î·È ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î·Ù·ÛÙ¿ÛˆÓ, Ë Èı·ÓfiÙËÙ· ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÌÂÈÒÓÂÙ·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ·ÊÔ‡ ··ÓÙ¿Ù·È ÌfiÓÔ ÛÙÔ 20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ (3). ¶ÏËÓ Ù˘ ‚·ÛÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ÎÔÚÙÈÎÔÂȉ‹, ÛËÌ·ÓÙÈ΋ ·Í›· ¤¯ÂÈ Î·È Ë ÁÓÒÛË ÌÂÚÈÎÒÓ ¿ÏÏˆÓ ıÂڷ¢ÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÙˆÓ ·È‰ÈÒÓ Ì ¡™ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÂȉÈ΋ ̤ÚÈÌÓ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤Á¯˘Û˘ Ù˘ ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘. ∏ ·ÚÔ˘Û›· ÙÔ˘ Ôȉ‹Ì·ÙÔ˜, Ô˘ ·ÔÙÂÏ› ·ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘, ‰ÂÓ ·ÔÙÂÏ› ˘Ô¯ÚˆÙÈο ·fiÏ˘ÙË ¤Ó‰ÂÈÍË
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·249
¶·È‰È·ÙÚÈ΋ 2001;64:247-254
ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘, Ë ÔÔ›· ·ÓÙ›ıÂÙ· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÈÏÂÎÙÈο Û fiÛÔ˘˜ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ÛËÌ›· ˘ÔÔÁηÈÌ›·˜, Ô˘ Û˘ÓÔÙÈο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∂Ê’fiÛÔÓ ÏÔÈfiÓ ÎÚÈı› ÛÎfiÈÌË ‚¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ Ë ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘, ·˘Ù‹ Ú¤ÂÈ Ó· Â›Ó·È Î·Ù¿ ÚÔÙ›ÌËÛË ÂχıÂÚË NaCl Î·È ·fi ÙÔ ‰È¿Ï˘Ì· 20% Ó· ¯ÔÚËÁÂ›Ù·È 1 gr/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Û ‰È¿ÛÙËÌ· ÙÂÛÛ¿ÚˆÓ ˆÚÒÓ. ∆Ô ‰ÈÔ˘ÚËÙÈÎfi ÊÔ˘ÚÔÛÂÌ›‰Ë ÌÔÚ› Ó· ÚÔÛÙÂı› ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ÒÚ˜, ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË Â›Ù ÂÊ¿·Í ηٿ ÙÔ Ù¤ÏÔ˜ Ù˘ ¤Á¯˘Û˘ Û ‰fiÛË 1 mgr/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (7). ™ÙȘ ÂÚÈÙÒÛÂȘ ˘ÔÔÁηÈÌÈÎÒÓ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ‰ÈÔ˘ÚËÙÈÎfi ÚÔ Ù˘ ¤Á¯˘Û˘ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ÎÈÓ‰‡ÓÔ˘ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ‹ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ∏ Ù·¯‡ÙÂÚË ¤Á¯˘ÛË ÙÔ˘ ·ÓˆÙ¤Úˆ ‰È·Ï‡Ì·ÙÔ˜ ÂÓ¤¯ÂÈ ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Û ÔÛÔÛÙfi 11% Î·È ˘ÂÚÙ·ÛÈÎÒÓ ÎÚ›ÛÂˆÓ 46% (7). ÕÏÏ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ ·È‰› Ì ¡™ Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ù· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È·. ø˜ ÚÔ˜ ÙȘ ÏÔÈÌÒÍÂȘ, Â›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ ÔÊ›ÏÔÓÙ·È Û ÌÂÁ¿ÏË ·ÒÏÂÈ· ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ πgG Î·È ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ µ Î·È D ÛÙ· Ô‡Ú·. ∞fi ÙȘ ÏÔÈÌÒÍÂȘ ·˘Ù¤˜, Ë ÂÚÈÙÔÓ›Ùȉ· ·fi gram ·ÚÓËÙÈο ‚·ÎÙËÚ›‰È· ‹ Ó¢ÌÔÓÈfiÎÔÎÎÔ Û ÔÛÔÛÙ¿ 28% Î·È 50% ·ÓÙÈÛÙÔ›¯ˆ˜, Â›Ó·È ·fi ÙȘ ÛÔ‚·ÚfiÙÂÚ˜. Ÿ¯È Û¿ÓÈ·, Ë Ïԛ̈ÍË ·˘Ù‹ ÂÚÌËÓ‡ÂÙ·È Ï·Óı·Ṳ̂ӷ ˆ˜ Ú‹ÍË ÛΈÏËÎÔÂȉԇ˜ ·fiÊ˘Û˘ Î·È ‰ÈÂÓÂÚÁÂ›Ù·È Î·Ù’ ¤ÎÙ·ÛË Ì›· ¯ˆÚ›˜ ÏfiÁÔ ÛΈÏËÎÔÂȉÂÎÙÔÌ‹, Ô˘ ‚‚·›ˆ˜ ˆ˜ ¤̂·ÛË Î·Ù·ÔÓ› › ϤÔÓ ÙÔÓ ‹‰Ë ¢¿ÏˆÙÔ ·ÛıÂÓ‹ Ì ÂÓ ÂÓÂÚÁ›· ¡™. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·˘ÙÔ‡ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 6% (28). ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· ·ÊÔÚÔ‡Ó Û˘Ó‹ıˆ˜ Û ÌÂÁ¿Ï· ·ÁÁ›·, fiˆ˜ οو ÎÔ›ÏË ÊϤ‚·, ÓÂÊÚÈΤ˜ Î·È Ë·ÙÈΤ˜ ÊϤ‚˜, ÌËÚÈ·›· ·ÁÁ›· Î·È ÂÓ Ùˆ ‚¿ıÂÈ ·ÁÁ›· οو ¿ÎÚˆÓ ‹ Ù¤ÏÔ˜ Î·È ÂÁÎÂÊ·ÏÈΤ˜ ÊϤ‚˜, Ë ‰Â Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙ¿ Î˘Ì·ÈÓfiÌÂÓ· ·fi 1,8-5%. ∂ÎÙfi˜ Ù˘ ÎÏ·ÛÈ΋˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ô˘ Û˘Óԉ‡ÂÈ Ù· ÂÂÈÛfi‰È· ·˘Ù¿, ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ˘ÔÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ÂÈÏÔÎÒÓ ÂÎ ÙˆÓ ·ÓˆÙ¤Úˆ ·ÁÁ›ˆÓ ÛÂ Û˘¯ÓfiÙËÙ· Ô˘ ·Ó¤Ú¯ÂÙ·È Û 28% (28). µÂ‚·›ˆ˜, ÔÈ Î·Ù·ÛÙ¿ÛÂȘ ·˘Ù¤˜ Û˘Ì‚·›ÓÔ˘Ó Û¯Â‰fiÓ ¿ÓÙÔÙ Û ¤‰·ÊÔ˜ ÛÔ‚·Ú‹˜ Î·È ·Ú·ÙÂٷ̤Ó˘ ˘ÔÔÁηÈÌ›·˜. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Û˘Ó›ÛÙ·Ù·È ÛÙË ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË, ÂÓÒ ·fi ÌÂÚÈÎÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÚÔÙ›ÓÂÙ·È Û ̷ÎÚfi¯ÚÔÓË ‚¿ÛË Ë Î·ıËÌÂÚÈ-
Paediatriki 2001;64:247-254
Ó‹ ¯ÔÚ‹ÁËÛË Warfarin ÁÈ· ÚÔÊ˘Ï·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ¶ÚÔÏËÙÈο ÚÔÙ›ÓÂÙ·È Â›Û˘ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ‰ËÏ·‰‹ ÂΛÓÔ˘˜ Ì ›‰· ÈÓˆ‰ÔÁfiÓÔ˘ ¿Óˆ ÙˆÓ 6 gr/L ‹ ›‰· ·ÓÙÈıÚÔÌ‚›Ó˘ πππ ÏÈÁfiÙÂÚ· ·fi 70%, Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÛÈÚ›Ó˘ (50 mg ‰‡Ô ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜) Î·È ‰È˘Úȉ·ÌfiÏ˘, ÂÓÒ ÁÂÓÈÎfiÙÂÚ· ÚÔÏËÙÈο ̤ÙÚ· ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÓ ÂÓÂÚÁ›· ¡™ ·ÔÙÂÏÔ‡Ó Ë ¤ÁηÈÚË Î·È ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÔÁηÈÌ›·˜ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ (28). ∞fi ÙȘ ·Ó·ÌÂÓfiÌÂÓ˜ ·ÚÂÓ¤ÚÁÂȘ ÂÎ Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ ÛÙÔ ˘ÔÙÚÔÈ¿˙ˆÓ ¡™ Â›Ó·È Ë ÔÛÙÂÔÂÓ›·, Ë ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ¯ÚfiÓÈ· ·ÒÏÂÈ· ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ µÈÙ·Ì›Ó˘ D ÛÙ· Ô‡Ú· ··ÈÙ› ÙËÓ Î·Ù¿ ÂÚ›ÙˆÛË ¯ÔÚ‹ÁËÛË ·Û‚ÂÛÙ›Ô˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ (500 mg/Ë̤ڷ) Î·È µÈÙ·Ì›Ó˘ D, 2000-4000 ÌÔÓ¿‰Â˜ ËÌÂÚËÛ›ˆ˜ ‹ 1,·-O∏VitD, Û ‰fiÛË 0,25-0,50 Ìg/Ë̤ڷ (28). ∞ÓÂÍ·Úًو˜ ÙˆÓ ·Ú·¿Óˆ ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ Î·È Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ·Ó·Ê¤ÚıËηÓ, ÙÔ È‰ÈÔ·ı¤˜ ¡™ ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Ô˘ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ÎÔÚÙÈÎÔÂȉ‹, ¤¯ÂÈ, ‚¿ÛÂÈ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ¢ÈÂıÓÔ‡˜ ªÂϤÙ˘, ηϋ ÚfiÁÓˆÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·fi 389 ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· 9,4 ¯ÚfiÓÈ·, ÙÔ 75% ·ÚÔ˘Û›·Û ÌfiÓÈÌË ‡ÊÂÛË ‹ ˘ÔÙÚÔ›·Û ۷ӛˆ˜, ÂÓÒ ÌfiÓÔ ÙÔ 4% ›¯Â Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜. ∆ËÓ Î·Ï‡ÙÂÚË ÚfiÁÓˆÛË ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Â›¯·Ó ÂΛӷ Ô˘ ‰ÂÓ ˘ÔÙÚÔ›·Û·Ó ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ÂÍ·Ì‹ÓÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ªË Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜ ·ÚÔ˘Û›·Û ÙÔ 20-34% ÙˆÓ ·Û¯fiÓÙˆÓ. ∫·Ù¿ ÙËÓ ÙÂÏÈ΋ ÂÎÙ›ÌËÛË, ÙÔ 95% ·fi ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ›¯Â ηϋ ÂͤÏÈÍË, ·ÏÏ¿ ¤Ó· ÔÛÔÛÙfi 4-5% ·Â‚›ˆÛ ·fi Ïԛ̈ÍË ‹ η٤ÏËÍ Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (3,8,28). ™Ù· ·È‰È¿ ÌÂ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓ ¡™ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ›Ù ηٿ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Â›Ù ηٿ ÙË Ê¿ÛË Ù˘ ÛÙ·‰È·Î‹˜ Ì›ˆÛ˘ ·˘ÙÒÓ, ÚÔÙ›ÓÂÙ·È ÙÔ ·ÎfiÏÔ˘ıÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·: ¶Ú‰ÓÈ˙fiÓË 40-60 mg/m2 ¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ˘ÔÔÁηÈÌ›·˜ ñ∫ÏÈÓÈο - ∫ÔÈÏȷο ¿ÏÁË, ¤ÌÂÙÔÈ, Ù·¯˘Î·Ú‰›·, „˘¯Ú¿ ¿ÎÚ·, ÔÏÈÁÔ˘Ú›·, ˘¤ÚÙ·ÛË ‹ ˘fiÙ·ÛË - ¢È·ÊÔÚ¿ ÎÂÓÙÚÈ΋˜-ÂÚÈÊÂÚÈ΋˜ ıÂÚÌÔÎÚ·Û›·˜ >3oC ñ∂ÚÁ·ÛÙËÚȷο - ·ÈÌ·ÙÔÎÚ›ÙË, Ô˘Ú›·˜, ·ÏÏ¿ fi¯È ÎÚ·ÙÈÓ›Ó˘, Na Ô‡ÚˆÓ <5 moml/L* *ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ ÌÂÙÚ¿Ù·È Û ‰Â›ÁÌ· Ì›·˜ Ô‡ÚËÛ˘ Î·È ·ÍÈÔÏÔÁÂ›Ù·È ÌfiÓÔ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ‰ÈÔ˘ÚËÙÈÎÒÓ
249
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·250
¶·È‰È·ÙÚÈ΋ 2001;64:247-254
Paediatriki 2001;64:247-254
ËÌÂÚËÛ›ˆ˜, ¤ˆ˜ fiÙÔ˘ ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Î·È ·Ú¤ÏıÔ˘Ó ÙÚÂȘ ¤ˆ˜ ¤ÓÙ › ϤÔÓ Ë̤Ú˜. ∞ÎÔÏÔ˘ı› ÛÙ·‰È·Î‹ Ì›ˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·Ú¯Èο Û ηıËÌÂÚÈÓ‹ Î·È ÂÓ Û˘Ó¯›· Û ·Ú‹ÌÂÚË ‚¿ÛË, Ì ÛÙfi¯Ô Ù· ÎÔÚÙÈÎÔÂȉ‹ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ‰fiÛË 15-20 mg/m2 ̤ڷ ·Ú¿ ̤ڷ. ∏ ‰fiÛË ·˘Ù‹ ı· Ú¤ÂÈ Ó· ·ÓÙÈÚÔۈ‡ÂÈ ÛÙËÓ Ú¿ÍË ÙË ‰fiÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ˘fi ÙËÓ ÔÔ›· Ô ·ÛıÂÓ‹˜ ˘ÔÙÚÔ›·ÛÂ Î·È Â› ϤÔÓ 5 mg Î·È Ì ÙÔ ıÂڷ¢ÙÈÎfi ·˘Ùfi Û¯‹Ì· Ó· Û˘Ó¯ÈÛÙ› Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ › 12-18 Ì‹Ó˜. ∆fiÙ ı· ÂȯÂÈÚËı› Ë ÛÙ·‰È·Î‹ ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ (6). OÈ Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÙÒÛÂȘ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ÁÂÓÈο ÁÓˆÛÙ¤˜, Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. O ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ Ô˘ ΢ڛˆ˜ ·ÊÔÚÔ‡Ó ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÓËÏ›ÎˆÓ ·ÏÏ¿ Î·È ·È‰ÈÒÓ Ì ÙÔÓ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Ù‡Ô ÙÔ˘ ¡™, Ô‰ËÁ› Û˘¯Ó¿ ÙÔ ıÂÚ¿ÔÓÙ· ÁÈ·ÙÚfi ÛÙËÓ ·Ó·˙‹ÙËÛË ¿ÏÏˆÓ ıÂڷ¢ÙÈÎÒÓ Ï‡ÛˆÓ, ÔÈ Ôԛ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¿ÊÔÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù·, fiˆ˜ ı· ·Ó·ÊÂÚı› ÏÂÙÔÌÂÚÒ˜ ÛÙË Û˘Ó¤¯ÂÈ·. °È· ÙÔÓ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, ÚÒÙ˘ ÂÈÏÔÁ‹˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Ê¿ÚÌ·ÎÔ Â›Ó·È Ë ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (Endoxan), Ë ÔÔ›· ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 2 mg/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ › 2,5-3 Ì‹Ó˜, ˘fi ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÈÌ·ÙÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÏfiÁˆ ΢ڛˆ˜ Ù˘ ·ÚÂÓ¤ÚÁÂÈ·˜ Ù˘ Ï¢ÎÔÂÓ›·˜ Ô˘ ÌÔÚ› Ó· ·Ú·ÙËÚËı›, Â˘Ù˘¯Ò˜ fi¯È Û˘¯Ó¿ (9,11,12). ∏ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹ ·˘Ù‹ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÚÔËÁËı›۷ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ 75% ÙˆÓ ·È‰ÈÒÓ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ - Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓÙ· - Ù‡Ô ¡™ ·ÚÔ˘Û›·Û ̷ÎÚfi¯ÚÔÓË ‡ÊÂÛË ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜, ÂÓÒ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙÔ Ê¿ÚÌ·ÎÔ ÌÂÈÒıËΠ۠30% fiÙ·Ó ¯ÔÚËÁ‹ıËΠ۠·È‰È¿ Ì ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ Î·È È‰È·›ÙÂÚ· ·fi ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÂȉÒÓ Ù‡Ô ¡™. ™‡Ìʈӷ Ì ÙË ¢ÈÂıÓ‹ ªÂϤÙË, ·ÏÏ¿ Î·È ·fi ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ, Ê·›ÓÂÙ·È fiÙÈ ‡ÊÂÛË ÙÔ˘ ¡™ ‰È¿Ú-
ÎÂÈ·˜ 2 ¯ÚfiÓˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ 67% ÙˆÓ ·È‰ÈÒÓ fiÙ·Ó ÙÔ˘˜ ¯ÔÚËÁÂ›Ù·È Ë ∫˘ÎÏÔʈÛÊ·Ì›‰Ë › ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ Î·È 30% ÌÂÙ¿ ¯ÔÚ‹ÁËÛË 2 ÌËÓÒÓ, ·ÓÙÈÛÙÔȯ· (8,9). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ÃÏˆÚ·Ì‚Ô˘Î›ÏË Û ‰fiÛË 0,2 mg/kg ËÌÂÚËÛ›ˆ˜ › 2 Ì‹Ó˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¡™ ›ӷÈ, Û‡Ìʈӷ Ì ٷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, fiÌÔÈ· Ì ÂΛӷ Ù˘ ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜ (5,10). ∆· ‰‡Ô ÚÔ·Ó·ÊÂÚı¤ÓÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ¯ÔÚËÁÔ‡ÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÎÔÚÙÈÎÔÂȉ‹, Ë ‰fiÛË ÙˆÓ ÔÔ›ˆÓ ÛÙ·‰È·Î¿ ÌÂÈÒÓÂÙ·È ·Ú¯Èο Û ËÌÂÚ‹ÛÈÔ Î·È ÂÓ Û˘Ó¯›· Û ·Ú‹ÌÂÚÔ Û¯‹Ì·, ¤ˆ˜ ÙËÓ Ï‹ÚË ‰È·ÎÔ‹ ÙÔ˘˜, Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ‰È·ÎÔ‹ ÙˆÓ ˘fi Û˘˙‹ÙËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ. ÕÌÂÛ· ıÂÙÈο Î·È ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ıÂڷ¢ÙÈ΋ ·˘Ù‹ ·Ú¤Ì‚·ÛË ÂÊ`fiÛÔÓ ÎÚÈı› ÂÈÙ˘¯‹˜ Â›Ó·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Û ‡„Ô˜, Ë ·ÒÏÂÈ· Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ÙÔ˘ ·ÓÛÂÏËÓÔÂȉԇ˜ ÚÔÛˆÂ›Ô˘ Î·È Ë ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘. ∞fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ, ÛÔ‚·ÚfiÙÂÚË ıˆÚÂ›Ù·È Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂ Û˘Ó¤ÂÈ· ΢ڛˆ˜ ÙË Ï¢ÎÔÂÓ›·. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, › ·ÚÈıÌÔ‡ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ <3000mm3, Ù· ·Ó·ÊÂÚı¤ÓÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ‰È·ÎfiÙÔÓÙ·È ¤ˆ˜ ÙËÓ Â¿ÓÔ‰Ô ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·, ÔfiÙ ·ӷ¯ÔÚËÁÔ‡ÓÙ·È Ì¤¯ÚÈ ÙË Û˘ÌÏ‹ÚˆÛË Ù˘ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜ Ô˘ ¤¯ÂÈ ÚÔηıÔÚÈÛÙ› ÁÈ· ÙÔÓ ·ÛıÂÓ‹. ∂›Û˘, Ù· Ê¿Ú̷η ·˘Ù¿ ‰È·ÎfiÙÔÓÙ·È ·ÚÔ˘Û›· ÛÔ‚·Ú‹˜ Ïԛ̈͢, ȉȷ›ÙÂÚ· ·ÓÂÌ¢ÏÔÁÈ¿˜, ÁÈ· ÙËÓ ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ Ë ¤Ó·ÚÍË ·ÁˆÁ‹˜ Ì ·Û˘ÎÏÔ‚›ÚË ıˆÚÂ›Ù·È ÂȂ‚ÏË̤ÓË. §ÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ Â›Ó·È Ë ·ÏˆÂΛ· Î·È Ë ·ÈÌÔÚÚ·ÁÈ΋ ΢ÛÙ›Ùȉ·. ø˜ ÚÔ˜ ÙÔ ı¤Ì· Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ÁÔÓ¿‰ˆÓ, Ô Î›Ó‰˘ÓÔ˜ Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ıˆÚÂ›Ù·È Èı·ÓfiÙÂÚÔ˜ ÁÈ· Ù· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·. ∂ȉÈÎfiÙÂÚ·, ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÛÙËÓ ˘ÎÓfiÙËÙ·
¶›Ó·Î·˜ 2. ™˘ÓÔÙÈ΋ ηٷÁÚ·Ê‹ ·ÚÂÓÂÚÁÂÈÒÓ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ™ Cushing ∫·Ù·ÚÚ¿ÎÙ˘ ™ÎÂÏÂÙÈÎfi ™. ∫¡™ ™·Î¯·Ú҉˘ ¢È·‚‹Ù˘ ∫·Ú‰È·ÁÁÂÈ·Îfi ™.
250
7,5 mg/ËÌ <10 mg/ËÌ 12% Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ 3% 20 mg
ªÂÙ¿ ‰›ÌËÓÔ ∂› 1 ¯ÚfiÓÔ 1Ô ¯ÚfiÓÔ ∫¿ı › ϤÔÓ ¯ÚfiÓÔ ∫·Ù¿ıÏÈ„Ë 10% ÀÔÌ·Óȷ΋ Û˘ÌÂÚÈÊÔÚ¿ 30% 10 mg/ËÌ 1,5 ÊÔÚ¿ ·‡ÍË̤ÓË Èı·ÓfiÙËÙ· 40 mg/ËÌ 8 ÊÔÚ¤˜ ·‡ÍË̤ÓË Èı·ÓfiÙËÙ· §fiÁˆ ·˘ÍË̤Ó˘ Û‡ÓıÂÛ˘ VLD ÏÈȉ›ˆÓ
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·251
¶·È‰È·ÙÚÈ΋ 2001;64:247-254
ÙÔ˘ Û¤ÚÌ·ÙÔ˜ ·Ó‰ÚÒÓ Î·Ù¿ ÙËÓ ËÏÈΛ· ·Ó··Ú·ÁˆÁ‹˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ›¯Â ¯ÔÚËÁËı› ΢ÎÏÔʈÛÊ·Ì›‰Ë ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ¤‰ÂÈÍ Ì›ˆÛË Î·Ù¿ 35% Ù˘ ˘ÎÓfiÙËÙ·˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜ ÌÂÙ¿ ‰›ÌËÓË Î·È 50% ÌÂÙ¿ ÙÂÙÚ¿ÌËÓË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. °ÂÓÈο, ˆ˜ ÚÔ˜ ÙËÓ ÙÔÍÈÎfiÙËÙ· ÙˆÓ ÁÔÓ¿‰ˆÓ Î·È ÙËÓ ÚfiÏË„Ë ÂÎ Ù˘ ·˙ˆÔÛÂÚÌ›·˜ ¤¯ÂÈ ıˆÚËı› ·ÛʷϤ˜ fiÙ·Ó Ë Û˘ÓÔÏÈο ¯ÔÚËÁÔ‡ÌÂÓË ∫˘ÎÏÔʈÛÊ·Ì›‰Ë ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 200-300 mg/kg Î·È Ë ÃÏˆÚ·Ì‚Ô˘Î›ÏË Ù· 8-10 mg/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (10,11). ∏ ıÂÙÈ΋ ‹ fi¯È ıÂڷ¢ÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ·˘Ù¿ Ê¿Ú̷η ·Ó·Ê¤ÚÂÙ·È fiÙÈ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔ‚ÏÂÊı› Ì ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ∏L∞. ∞Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÛÙÔ ı¤Ì· ·˘Ùfi › 54 ·È‰ÈÒÓ ·Û¯fiÓÙˆÓ ·fi ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ¡™, ¤‰ÂÈÍ fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ ∏L∞-Dr 7 ·ÓÙÈÁfiÓÔ˘ ‰ÂÓ Û˘ÓËÁÔÚÔ‡Û ˘¤Ú Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ‡ÊÂÛ˘ ÙÔ˘ ¡™, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Â› ıÂÙÈÎÔ‡ Dr7 Ë ÙÚÈÂÙ‹˜ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ ∫˘ÎÏÔʈÛÊ·Ìȉ˘ ·ÊÔÚÔ‡Û ÔÛÔÛÙfi 36% ÌfiÓÔ ÙˆÓ ·Û¯fiÓÙˆÓ ¤Ó·ÓÙÈ 81% › ·ÚÓËÙÈÎÔ‡ Dr 7 (13). ∞fi Ù· ÓÂfiÙÂÚ· Î·È ÏÈÁfiÙÂÚÔ ÁÓˆÛÙ¿ Ê¿Ú̷η Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È Ë §È‚·ÌÈ˙fiÏË, Ô˘Û›· ·fi Ì·ÎÚÔ‡ ÁÓˆÛÙ‹ ˆ˜ ·ÓıÂÏÌÈÓıÈÎfi Ê¿ÚÌ·ÎÔ. ™ÙÔ ¡™ ‰ÔÎÈÌ¿ÛÙËΠ̠ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ‹‰Ë ·fi ÙÔ 1984 (14), ·ÏÏ¿ ÂÚÁ·Û›· ˘fi ÌÔÚÊ‹ ÔÏ˘ÎÂÓÙÚÈ΋˜ ÌÂϤÙ˘ ‰ËÌÔÛȇÙËΠ·fi ÙË µÚÂÙ·ÓÈ΋ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ·ÚÎÂÙ¿ ·ÚÁfiÙÂÚ· (15). ∞fi Ù· ‰Â‰Ô̤ӷ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜, Ë ÔÔ›· ÂÚÈÂÏ¿Ì‚·Ó 61 ·È‰È¿ Î·È ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠ›Ù §È‚·ÌÈ˙fiÏË Û ‰fiÛË 2,5 mg/kg ȉ·ÓÈÎÔ‡ ‚¿ÚÔ˘˜ Û ·Ú‹ÌÂÚÔ Û¯‹Ì· ›Ù placebo, ·Ú·ÙËÚ‹ıËΠ‡ÊÂÛË ÙÔ˘ ¡™ Û 14 ÂÍ ·˘ÙÒÓ Ô˘ ¤Ï·‚·Ó §È‚·ÌÈ˙fiÏË Û ۯ¤ÛË Ì 4 ·fi ÙËÓ ÔÌ¿‰· placebo. ∏ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ‰È‹ÚÎÂÛ ÌfiÓÔÓ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ·ÏÏ¿ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÔÈ ·ÛıÂÓ›˜ ˘ÔÙÚÔ›·Û·Ó ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ §È‚·ÌÈ˙fiÏ˘, Ë ÔÔ›· fï˜ ‰ÂÓ Â›¯Â ¯ÔÚËÁËı› ¤Ú·Ó ÙˆÓ 6 ÌËÓÒÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·˘ÙÔ‡, › Û˘ÓfiÏÔ˘ 140 ·Û¯fiÓÙˆÓ ‰È·ÈÛÙÒıËÎ·Ó 3 ÂÚÈÙÒÛÂȘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ·Ó·ÛÙÚ¤„ÈÌ˘ (14,15). ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ §È‚·ÌÈ˙fiÏ˘ Û 36 ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™ ÁÈ· ‰È¿ÛÙËÌ· ·fi 6 Ì‹Ó˜ ¤ˆ˜ 7 ¯ÚfiÓÈ·, ¤‰ÂÈÍ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÂÍ¿ÚÙËÛË ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹ Û ÔÛÔÛÙfi 53,6% (16). ™Â Û˘Ìʈӛ· Ì ÙË µÚÂÙ·ÓÈ΋ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Î·È ÛÙË
Paediatriki 2001;64:247-254
‰È΋ Ì·˜ ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ Ê¿ÚÌ·ÎÔ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi fiÙ·Ó ÛÙË ‰È¿ÚÎÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¡™ ¤¯ÂÈ ÚÔËÁËı› Ë ıÂڷ›· Ì ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (15). ŒÓ· ¿ÏÏÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Ê¿ÚÌ·ÎÔ Ô˘ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Â˘Ú‡Ù·Ù· ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÓÙ·ÂÙ›· Î·È ¤¯ÂÈ ·ÔÎÙËı› ÌÂÁ¿ÏË ÂÌÂÈÚ›· ˆ˜ ÚÔ˜ ÙË ‰Ú¿ÛË ÙÔ˘ ÛÙÔ ¡™, Â›Ó·È Ë ∫˘ÎÏÔÛÔÚ›ÓË (28). ∆Ô Ê¿ÚÌ·ÎÔ ·˘Ùfi ·Â˘ı‡ÓÂÙ·È Î·Ù¿ ‚¿ÛË Û ¿Û¯ÔÓÙ˜ ·fi ÎÔÚÙÈÎÔ¢·›ÛıËÙÔÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ Ù‡Ô ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ôχ ÏÈÁfiÙÂÚÔ ÛÙÔÓ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô, fiÔ˘ Ë ·ÓÙ·fiÎÚÈÛË Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·ÚÎÂÙ¿ ÂÚÈÔÚÈṲ̂ÓË. ÃÔÚËÁÔ‡ÌÂÓÔ Û ‰fiÛË 150 mg/m2 ËÌÂÚËÛ›ˆ˜ Û ‰‡Ô ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ Î·È Ì ÛÙfi¯Ô Ó· ÂÈÙ¢¯ıÔ‡Ó Â›Â‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ÔÏÈÎfi ·›Ì· ÌÂٷ͇ 100-200 mg/kg, ‰È·ÈÛÙÒıËΠ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Û ÔÛÔÛÙfi 85% › Û˘ÓfiÏÔ˘ 129 ·È‰ÈÒÓ (17,20,21). ∏ ÛÔ‚·Ú‹ ˘ÂÚ¯ÔÏËÛÙÂÚÈÓ·ÈÌ›· Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ Ù· ·È‰È¿ ·˘Ù¿ Ì ÙȘ Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜ ‹ ÙÔ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô ÙÔ˘ ¡™, ·ÔÙÂÏ› Û˘¯Ó¿ ÂÌfi‰ÈÔ ÛÙË ‰Ú¿ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ÙÔ ÔÔ›Ô ˆ˜ ÏÈÔÊÈÏÈ΋ Ô˘Û›· ÌÂٷʤÚÂÙ·È ÛÙÔ ·›Ì· ̤ۈ ÙˆÓ HDL Î·È LDL. ¶·Ú·Ì¤ÓÔÓÙ·˜ ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Ë ∫˘ÎÏÔÛÔÚ›ÓË ‰ÂÛÌÂ˘Ì¤ÓË, ÏfiÁˆ ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ ÙˆÓ ÏÈȉ›ˆÓ ·˘ÙÒÓ, ‰ÂÓ ·Ô‰›‰ÂÈ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ıÂڷ¢ÙÈο ›‰·. ™Â ‰fiÛÂȘ ÂÓÙÔ‡ÙÔȘ, ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÌÔÚÔ‡Ó Ó· ÂÈÙ¢¯ıÔ‡Ó ıÂڷ¢ÙÈο ›‰· ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ‡ÊÂÛË ÙÔ˘ ¡™, ·ÏÏ¿ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÂÎ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Â›Ó·È Ôχ Èı·Ó‹ Î·È Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Â›Ó·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜. AÙ˘¯Ò˜, ÔÈ ·ÛıÂÓ›˜ Ô˘ ı· ·ÓÙ·ÔÎÚÈıÔ‡Ó ÛÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ˘ÔÙÚÔÈ¿˙Ô˘Ó Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ Î·È Ë ·Ó·ÁηÛÙÈ΋ ·ӷ¯ÔÚ‹ÁËÛ‹ Ù˘ ‰ÂÓ ÚÔ‰Èο˙ÂÈ ¿ÓÙÔÙ ¢ÓÔ˚Îfi ·ÔÙ¤ÏÂÛÌ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÌÈÎÚ‹ ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ (0,5 mg/kg Û ·Ú‹ÌÂÚÔ Û¯‹Ì·) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ∫˘ÎÏÔÛÔÚ›ÓË ¤¯ÂÈ Â˘ÓÔ˚Îfi ·ÔÙ¤ÏÂÛÌ·. ∏ Ì·ÎÚfi¯ÚÔÓË, ÂÓÙÔ‡ÙÔȘ, ¯ÔÚ‹ÁËÛ‹ Ù˘ (¤Ú·Ó ÙˆÓ ‰‡Ô ÂÙÒÓ) Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂÚ›ÛÎÂ„Ë Î·È ÂÎÙfi˜ ·fi ÙÔ Û˘¯Ófi ¤ÏÂÁ¯Ô ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ÓÂÊÚÈ΋ ‚ÈÔ„›· ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘. ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· ·fi 38 ·ÛıÂÓ›˜ fiÔ˘ ÙÔ Ê¿ÚÌ·ÎÔ ¯ÔÚËÁ‹ıËΠ·fi 2 Ì‹Ó˜ ¤ˆ˜ 7,5 ¯ÚfiÓÈ· ¤‰ÂÈÍ ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· 31 ·fi ·˘Ù¿, ÔÛÔÛÙfi 81,5%, Ë ‰Â ·ӷÏËÙÈ΋ ÓÂÊÚÈ΋ ‚ÈÔ„›· Ô˘ ¤ÁÈÓ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÂÎ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Û ¤ÍÈ ÂÚÈÙÒÛÂȘ ÂÍ ·˘ÙÒÓ ‰ÂÓ ¤‰ˆÛÂ
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¶·È‰È·ÙÚÈ΋ 2001;64:247-254
·ÔÙÂϤÛÌ·Ù· ÂÓ‰ÂÈÎÙÈο ÙÔÍÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi (18). ªÂÙ¿ ¿ÚÔ‰Ô ¯ÚfiÓÔ˘, ¤Ó· ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, Ô˘ Û ÔÛÔÛÙfi ·Ó¤Ú¯ÂÙ·È Û ÂÚ›Ô˘ 20% Î·È Ô˘ ÈÛÙÔÏÔÁÈο ·Ó‹ÎÂÈ ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ı· Û˘Ó¯›ÛÂÈ Ó· ˘ÔÙÚÔÈ¿˙ÂÈ. ∏ ·ӷÏËÙÈ΋ ‚ÈÔ„›· ÓÂÊÚÔ‡ Ô˘ Û˘¯Ó¿ ‰ÈÂÓÂÚÁÂ›Ù·È ÛÙ· ¿ÙÔÌ· ·˘Ù¿ ·ÔηχÙÂÈ Û ÔÛÔÛÙfi 45%-75% ÂͤÏÈÍË ÙÔ˘ ÈÛÙÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Û ÂΛÓÔ Ù˘ ∂ÛÙȷ΋˜ ∆ÌËÌ·ÙÈ΋˜ ™ÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ (∂∆™). ∂¿Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ÚÔÛÙÂı› Î·È ¤Ó·˜ ·Ú¯ÈÎfi˜ ·ÚÈıÌfi˜ ÂÎ ÙˆÓ ·È‰ÈÒÓ Ô˘ Ô˘‰¤ÔÙ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙËÓ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È Ô˘ ·ÔÙÂÏ› ÂÚ›Ô˘ ÙÔ 15% › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Á›ÓÂÙ·È ·ÓÙÈÏËÙfi fiÙÈ ¤Ó·˜ fi¯È ·Û‹Ì·ÓÙÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ı· Êı¿ÛÂÈ ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· ‹ ı· ÂÓËÏÈÎȈı› Ì ÙË ÓfiÛÔ ·˘Ù‹. ∆Ô ÁÂÁÔÓfi˜ ÏÔÈfiÓ fiÙÈ ·ÚÎÂÙ¿ ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓ ¡™ ı· ÂÍÂÏȯıÔ‡Ó, fiˆ˜ ÚԷӷʤÚıËÎÂ, Û ∂∆™ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÈÛ¯‡Ô˘Û· ·Ú·Ù‹ÚËÛË fiÙÈ 20%-25% ÙˆÓ ÚˆÙÔ·ıÒÓ ÂÚÈÙÒÛÂˆÓ ∂∆™ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙËÓ ·Ú¯È΋ ıÂڷ¢ÙÈ΋ ÙÔ˘˜ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹, ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÛÙËÓ ¿Ô„Ë fiÙÈ Ë ÓfiÛÔ˜ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È Ë ∂∆™ ¤¯Ô˘Ó ÎÔÈÓ‹ ·ıÔÁ¤ÓÂÈ·. Œˆ˜ ÙÔ 1974, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·Ó ·ıÔÁÔÓÂÙÈο οÔÈ· ÚˆÙÔ·ı‹˜ ‚Ï¿‚Ë ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÁÂÓÈο. ∞ÚÁfiÙÂÚ· ·Â‰Â›¯ıË Ì ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔȯ›· fiÙÈ ˘¿Ú¯Ô˘Ó ·˘ÍË̤ӷ ›‰· ÎÈÙÔÎÈÓÒÓ ÛÙÔ ·›Ì· Î·È È‰È·›ÙÂÚ· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 1 Î·È 8 Ù· ÔÔ›· ıˆڋıËÎ·Ó ˘Â‡ı˘Ó· ÁÈ· ÙËÓ ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜. ∏ ϤÔÓ ÚfiÛÊ·ÙË, ÂÓÙÔ‡ÙÔȘ, ¿Ô„Ë ˆ˜ ÚÔ˜ ÙËÓ ÎÔÈÓ‹ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ ÂÛÙÈ¿˙ÂÈ ÙÔ ÂӉȷʤÚÔÓ ÛÙÔ ÌÂÙ·ÙÚÂÙÈÎfi ·˘ÍËÙÈÎfi ·Ú¿ÁÔÓÙ· TGF-8, Ë ÁÔÓȉȷ΋ ¤ÎÊÚ·ÛË ÙÔ˘ ÔÔ›Ô˘ ÌÂÏÂÙ‹ıËΠ۠‚ÈÔ„È·Îfi ˘ÏÈÎfi 53 ·È‰ÈÒÓ Ì ¡™ Î·È ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ÙÔ˘ Û 2 ·fi 14 ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, Û 18 ·fi 20 Ì ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô Î·È Û 33 ·fi 39 ·È‰È¿ Ì ∂∆™. ∞fi ÙË ÁÂÓÂÙÈ΋ ·˘Ù‹ ÌÂϤÙË ÚÔ·ÙÂÈ fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÔÚ› Ó· ıˆÚËı› ‰Â›ÎÙ˘ ÚÒÈÌ˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ Ô˘ ¿ÏÏÔÙ ı· ÂÍÂÏȯı› Û ∂∆™. °ÂÓÂÙÈο, Ù¤ÏÔ˜, ‰Â‰Ô̤ӷ ·fi ÌÂϤÙË Ô˘ ¤¯ÂÈ ¤ˆ˜ ÙÒÚ· ‰ÈÂÓÂÚÁËı› Û ¤ÓÙ ÔÈÎÔÁ¤ÓÂȘ Ì ÔÈÎÔÁÂÓ¤˜ ¡™ ¤‰ÂÈÍ·Ó ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú· ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÛÙȘ ÙÚÂȘ Î·È ˘ÔÏÂÈfiÌÂÓÔ ÛÙȘ ‰‡Ô, Ë ‰Â ¯·ÚÙÔÁÚ¿ÊËÛË ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ÁÈ· ÙË ÓfiÛÔ ÁÔÓȉÈÒÌ·ÙÔ˜ ¤¯ÂÈ
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ÂÓÙÔÈÛÙ› ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· 19q, 13,11q, q21q22, Iq25-q31, Iq (19). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ∂∆™ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·˘Í·ÓfiÌÂÓË Î·Ù¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÚÈÓ ÙÔ 1990 ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 20% ÁÈ· ÙË Ï¢΋ Ê˘Ï‹, 38% ÁÈ· ÙË Ì·‡ÚË Î·È 8% ÁÈ· ÙËÓ ¤Á¯ÚˆÌË ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÌÂÙ¿ ÙÔ 1990 Ù· ÔÛÔÛÙ¿ ·˘Ù¿ ·Ó¤Ú¯ÔÓÙ·È ÁÈ· ÙȘ ·ÓÙ›ÛÙÔȯ˜ Ê˘Ï¤˜ Û 45%, 69% Î·È 33% › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™ (24). ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∂∆™ ·ÎÔÏÔ˘ı›, ηٿ ÙË Ê¿ÛË Ù˘ ÚÒÙ˘ ‰È¿ÁÓˆÛ˘, Ù· ›‰È· ıÂڷ¢ÙÈο ÛÙ¿‰È· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ·Ó·ÛÔηٷÛÙ·ÏÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ÚԷӷʤÚıËηÓ. ¶ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó 378 ·ÛıÂÓ›˜ Ì ∂∆™ ¤‰ÂÈÍ fiÙÈ ÔÛÔÛÙfi 25% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ı` ·ÓÙ·ÔÎÚÈı› ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Ï‹Úˆ˜, 3% ı· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÂÚÈ΋ ·ÓÙ·fiÎÚÈÛË Î·È ÙÔ ˘fiÏÔÈÔ 72% ı· Â›Ó·È ·ÓıÂÎÙÈÎfi ÛÙ· ‰È¿ÊÔÚ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· (20,21). OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÚ¢ÓËÙ¤˜ Û˘ÌʈÓÔ‡Ó ÛÙËÓ ¿Ô„Ë fiÙÈ Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë ‰ÂÓ ¤¯ÂÈ ıÂÙÈÎfi ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û ·ÓÙ›ıÂÛË Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ÁÈ· ÙËÓ ÔÔ›· Ù· ÔÛÔÛÙ¿ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ Î˘Ì·›ÓÔÓÙ·È Â˘Ú‡Ù·Ù· ·fi 20%-80%. ∏ ‰Ú¿ÛË Ù˘ ¿ÓÙˆ˜ Â›Ó·È Î·Ï‡ÙÂÚË fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÌÈÎÚ‹ ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ (21). ŒÓ· ¿ÏÏÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ô˘ ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ Ì ∂∆™ Â›Ó·È ÙÔ ÚˆÙfiÎÔÏÏÔ Mendoza, ÙÔ ÔÔ›Ô ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ¤Á¯˘ÛË IV Methylprednisolone 30 mg/kg (Solu-Medrol) ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (30 Û˘ÓÔÏÈΤ˜ ‰fiÛÂȘ Û 20 Ì‹Ó˜). ™ÙËÓ ÂÚÁ·Û›· ·˘Ù‹, ÔÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û 66% ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘˜, ÌfiÓÈÌË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È Ì›ˆÛË Ù˘ GFR Û ÔÛÔÛÙfi 9%, á∞ ÌË ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ 16% Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ 9% (22). ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· › Ì›· ‰ÂηÂÓÙ·ÂÙ›· ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË 23 ·È‰ÈÒÓ Ì ∂∆™ ¤‰ÂÈÍ ̷ÎÚfi¯ÚÔÓË ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ÔÛÔÛÙfi 66,6%, Ù· ıÂڷ¢ÙÈο ‰Â Û¯‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó fiÌÔÈ· Ì ٷ ÚÔ·Ó·ÊÂÚı¤ÓÙ· (23). ŒÓ· ¿ÏÏÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ôχ Ï›ÁÔ ‰ÔÎÈÌ·Ṳ̂ÓÔ, ·ÊÔÚ¿ ÛÙË ¯ÔÚ‹ÁËÛË µÈÓÎÚÈÛÙ›Ó˘ πV, ¿·Í ‚‰ÔÌ·‰È·›ˆ˜ Û ‰fiÛË 1,5 mg/m2 › ÔÎÙÒ Â‚‰ÔÌ¿‰Â˜. ∆· ·ÔÙÂϤÛÌ·Ù· ·fi ÚÒÙË ÂÎÙ›ÌËÛË ÎÚ›ÓÔÓÙ·È ÂÓı·ÚÚ˘ÓÙÈο (24). ∞fi ¿ÏÏË ÔÌ¿‰· ÂÚ¢ÓËÙÒÓ ÛÙȘ ∏.¶.∞. ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Ë Ê·Ú̷΢ÙÈ΋ Ô˘Û›· Tacrolimus (FK 508) Û ‰fiÛË 0,15 mg/kg Û ‰‡Ô ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ. ∆Ô Ê¿ÚÌ·ÎÔ ¯ÔÚËÁ‹ıËΠ۠20 ·È‰È¿ Ì ∂∆™ Î·È Ù· ÚÔηٷÚÙÈο ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó Ï‹ÚË ‡ÊÂÛË ÛÙÔ 40% Î·È ÌÂÚÈ΋ ÛÙÔ 25% ÙˆÓ ·Û¯fiÓÙˆÓ.
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∏ Ê·Ú̷΢ÙÈ΋ ‰Ú¿ÛË Ù˘ Ô˘Û›·˜ ·˘Ù‹˜, fiˆ˜ Î·È ÔÈ ·ÚÂÓ¤ÚÁÂȘ, ÂÚÈÁÚ¿ÊÔÓÙ·È fiÌÔȘ Ì ÂΛӘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ Èı·Ó‹˜ ÙÔÍÈÎfiÙËÙ·˜ Ú¤ÂÈ Ó· ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ù· ›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ·›Ì· (25). ø˜ ÚÔ˜ ÙËÓ ÂÊ·ÚÌÔÁ‹, Ù¤ÏÔ˜, ¿ÏÏˆÓ Ù¯ÓÈÎÒÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∂∆™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ˘¿Ú¯Ô˘Ó ÌÂÌÔӈ̤ӷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ¯Ú‹ÛË Ù˘ ÏÈȉԷʷ›ÚÂÛ˘ (26), Ù˘ Ï·ÛÌ·Ê·›ÚÂÛ˘ (27), fiˆ˜ ›Û˘ Î·È Ù˘ πV ¯Ú‹Û˘ Ù˘ ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜ Û ̛· ÂÊ¿·Í ‰fiÛË ÙˆÓ 50 mg/m2 ÌËÓÈ·›ˆ˜ › 6 Ì‹Ó˜. ∂¿Ó Ô ·ÛıÂÓ‹˜ ηٷϋÍÂÈ Û ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÌÔÚ› Ó· ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Enfants Malades ÙÔ˘ ¶·ÚÈÛÈÔ‡, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙÔ 35% › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·È‰ÈÒÓ ÌÂٷ͇ 1973-1996. ∞Ù˘¯Ò˜, Ë ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ·Ú¯È΋ ÚÔÛ‚ÔÏ‹ ÂÍ ·˘Ù‹˜ ·ÊÔÚ¿ Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 6 ¯ÚfiÓˆÓ, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·Ó¤Ú¯ÂÙ·È ÛÙËÓ ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ÙÔ˘ 54% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ∂∆™. ∞fi ÙÔ ›‰ÈÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ·Ó·Ê¤ÚÂÙ·È ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÔÛÔÛÙ¿ Ù˘ ٿ͈˜ ÙÔ˘ 60% Û˘Ó›· Ù˘ ÚÔ·Ó·ÊÂÚı›۷˜ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·. ∞fi ÙȘ ıÂڷ¢ÙÈΤ˜ ÚÔÙ¿ÛÂȘ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ı¤Ì· ·˘Ùfi, ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ‰›‰ÂÙ·È ÛÙËÓ Ï·ÛÌ·Ê·›ÚÂÛË (28).
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9.
10.
11.
12.
13.
14.
15.
16.
17. 18.
µÈ‚ÏÈoÁÚ·Ê›· 1. Schiesinger ER, Sulz HA, Mosher WE et al. The Nephrotic syndrome: Its incidence and implications for the community. Am J Dis Child 1968;116:623. 2. A report of the International Study of Kidney Disease in Children. The primary nephrotic syndrome in children: Identification of patients with minimal change nephrotic syndorme from initial response to prednisolone. J Paediatr 1981;98:561. 3. Kher KK, Swect M, Makker S. Nephrotic Syndrome in children. Curr Probl Pediatr 1988;18:199. 4. International Study of Kidney Disease in Children. Prospective, controlled trial of cyclophosphamide therapy in children with nephrotic syndrome. Lancet 1974;2:423-425. 5. Grupe WE, Makker SP, Ingelfinger J. Chlorambucil treatment of frequently relapsing nephrotic syndrome. N Engl J Med 1976;295:746. 6. Ueda N, Chihara M, Kawaguchi S et al. Intermittent versus long term tapering prednisolone for initial therapy in children with idiopathic nephrotic syndrome. J Pediatr 1988;112:122-126. 7. Reid CJD, Mursh MJ, Murdoch SM, Clark C. Nephrotic syndrome in childhood complicated by life threatening pulmonary oedema. BMJ 1996;312:36-38. 8. Tarshish P, Tobin JN, Bernstein J, Edelman CM Jr.
19.
20.
21.
22.
23.
Prognostic significance of the early course of minimal changes nephrotic syndrome: Report of the International Study of Kidney Disease in children. J Am Soc Nephrol 1997;8:769. Cameron JS, Chantler C et al. Long term stability of remission in nephrotic syndrome, after treatment with Cyclophosphamide. BMJ 1974;4:7. Guesry P, Lenoir G, Broyer M. Gonadal effects of chlorambucil given to prepubertal and pubertal boys for nephrotic syndrome. J Pediatr 1978;92:299. Watson AR, Rance CP, Bain J. Long-term effects of cyclophosphamide on testicular function. BMJ 1985;291:1457. Trompeter RS. Immunosuppressive therapy in the nephrotic syndrome in children. Pediatr Nephrol 1989;3:194. Konrad M, Mytilineos J, Ruder H et al. HLA-DR7 predicts the response to alkylating agents in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 1997;11:16. Niaudet P, Drachman R, Gagnadoux MF, Broyer M. Treatment of idiopathic nephrotic syndrome with levamisole. Acta Paediatric Scand 1984;73:637. British Association for Paediatric Nephrology. Levamisole for conticosteroid - dependent nephrotic syndrome in childhood. Lancet 1991;337:1555. °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË E, ªfiÙ˘ ¶, ∫ÔÙÛÒÓ˘ ∫, ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞. ∏ §È‚·ÌÈ˙fiÏË ˆ˜ ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙÔ È‰ÈÔ·ı¤˜ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ (¡™). (¶ÂÚ›ÏË„Ë). 10Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¡ÂÊÚÔÏÔÁ›·˜. ∫·‚¿Ï·; 24-27 ª·˝Ô˘ 1998. ÛÂÏ. 28. Niaudet P, Habib R. Cyclosporine in the treatment of idiopathic nephrosis. J Am Soc Nephrol 1994;5:1049. °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË ∂, ¢ÚÔÛ¿ÙÔ˘-∞Ú‚·Ó›ÙË ¶, ¡·ÎÔÔ‡ÏÔ˘ §, ™fiÙÛÈÔ˘ º, ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞. ∏ ‰È· ‚ÈÔ„›·˜ ÓÂÊÚÔ‡ ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÂÎ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ (CY-A) ÌÂÙ¿ Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ·È‰È¿ Ì ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ (¡™). (¶ÂÚ›ÏË„Ë). 35Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. ∞Á›· ¶ÂÏ·Á›·: ∫Ú‹ÙË; 13-15 πÔ˘Ó›Ô˘ 1997. ÛÂÏ. 376. Fuchshuber A, Jean G, Gribouval O et al. Mapping a gene (SNR1) to chromosome 1q25-q31 in idiopathic neprotic syndrome confirms a distinct entity of autosomal recessive nephrosis. Hum Mol Genet 1995;4:2155. Ingulli E, Singh A, Baqi A et al. Aggressive long-term cyclosporine therapy for steroid-resistant focal segmental glomerulosclerosis. J Am Soc Nephrol 1995;5:1820. Niaudet P, for the French Society of Pediatric Nephrology. Treatment of childhood steroid resistant idiopathic nephrosis with a combination of cyclosporine and prednisone. J Pediatr 1994;125:981. Tune BM, Kirpekar R, Sibley RF et al. Intravenous methylprednisolone and oral alkylating agent therapy of prednisolone-resistant pediatric focal glomerulosclerosis: A long-term follow up. Clin Neprhol 1995;43:84. °ÂˆÚÁ¿ÎË ∂, ™fiÙÛÈÔ˘ º, ¡·ÎÔÔ‡ÏÔ˘ §, ∫·ÔÁÈ¿ÓÓ˘ ∞, ÷ÚÔÎfiÔ˜ ∂, ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞. ∏ ÚfiÁÓˆÛË Ù˘ ÂÛÙȷ΋˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ (∂™∫) ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ∂ÌÂÈÚ›· ÌÈ·˜ 15ÂÙ›·˜. (¶ÂÚ›ÏË„Ë). 37Ô
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24.
25.
26.
27.
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¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. £ÂÛÛ·ÏÔÓ›ÎË; 2830 ª·˝Ô˘ 1999. ÛÂÏ. 129. Goonasekera L, Koziell A, Hullton S, Dillon M. Vincristine and focal segmental sclerosis; Do we need a multicenter trial? Pediatr Nephrol 1998;12:284. McCauley J, Shapiro R, Ellis D et al. Pilot trial of FK 506 for the management of steroid-resistant nephrotic syndrome. Nephrol Dial Tranplant 1993;8:1286. Yokoyama K, Sakai S, Yamaguchi Y, Susuki Y. Complete remission of the Nephrotic syndrome due to focal glomerular slcerosis achieved with low density lipoprotein absorption alone. Nephron 1996;72:316. Ginsburg DS, Dau P. Plasmapheresis in the treatment of
steroid-resistant focal segmental glomerulosclerosis. Clin Nephrol 1997;48:282. 28. Niaudet P. Treatment of idiopathic Nephrotic syndrome in children. April 22, 2000; Up to Date www .uptodate. com (800)998-6374.(781)237-4788.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ¡. °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ŸÙ·Ó Ô “Û˘ÚÈÁÌfi˜” ‰ÂÓ Â›Ó·È Û˘ÚÈÁÌfi˜: ·ÎÔ˘ÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ ÛÙ· ‚Ú¤ÊË1 ∂ÈÛ·ÁˆÁ‹: OÈ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ “Û˘ÚÈÁÌÔ‡” (“wheeze”) Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏfi˜ ηٿ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜. ∂ÓÙÔ‡ÙÔȘ, ¤¯ÂÈ Á›ÓÂÈ Ê·ÓÂÚfi fiÙÈ ÙfiÛÔ ÔÈ ÁÔÓ›˜, fiÛÔ Î·È ÔÈ ÁÈ·ÙÚÔ› ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔÓ fiÚÔ “Û˘ÚÈÁÌfi˜” ÁÈ· Ì›· ÔÈÎÈÏ›· ·ÎÔ˘ÛÙÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ. OÈ Û˘¯ÓfiÙÂÚÔÈ ·ÎÔ˘ÛÙÔ› ‹¯ÔÈ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ˘˜ ηÙÒÙÂÚÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È “ÚfiÁ¯ÔÈ” (“ruttles”), ÔÈ ÔÔ›ÔÈ ‰È·Ê¤ÚÔ˘Ó ·fi ÙÔÓ ÎÏ·ÛÈÎfi Û˘ÚÈÁÌfi ‰ÈfiÙÈ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi Ôχ ¯·ÌËÏfiÙÂÚ˜ Û˘¯ÓfiÙËÙ˜, Û˘Ó¯fiÌÂÓÔ “ÎÚÔÙ¿ÏÈÛÌ·” Î·È ÛÙÂÚÔ‡ÓÙ·È ÌÔ˘ÛÈÎfiÙËÙ·˜. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó, Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ·ÎÔ˘ÛÙÈ΋˜ ·Ó¿Ï˘Û˘, Ó· Á›ÓÂÈ Û·Ê‹˜ ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘ Û˘ÚÈÁÌÔ‡ ·fi ÙÔ˘˜ “ÚfiÁ¯Ô˘˜”. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ¤Ó· ÌÈÎÚfi ¢·›ÛıËÙÔ ÈÂ˙ÔËÏÂÎÙÚÈÎfi ·ÈÛıËÙ‹Ú· ÂÈÙ¿¯˘ÓÛ˘ (piezoelectric accelerometer) ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ó¢ÌÔÓÈÎÒÓ ‹¯ˆÓ Û 15 ‚Ú¤ÊË, ÂÙ¿ ÌÂ Û˘ÚÈÁÌfi Î·È ÔÎÙÒ Ì “ÚfiÁ¯Ô˘˜”. ¶ÏËÚÔÊÔڛ˜ Û¯ÂÙÈΤ˜ Ì ÙÔÓ Î‡ÎÏÔ Ù˘ ·Ó·ÓÔ‹˜ ÂÏ‹ÊıËÛ·Ó Ì ÙË ¯Ú‹ÛË Â·ÁˆÁÈ΋˜ ÏËı˘ÛÌÔÁÚ·Ê›·˜. ∆· ·ÎÔ˘ÛÙÈο Û‹Ì·Ù· ·Ó·Ï‡ıËÎ·Ó Ì ÙË ‚Ô‹ıÂÈ· Ù·¯Â›·˜ ηٿ Fourier ÌÂÙ·ÙÚÔ‹˜ (Respiratory Acoustics Laboratory Environment programme). ∞ÔÙÂϤÛÌ·Ù·: ¢Â›¯ıËΠfiÙÈ ÔÈ ·ÎÔ˘ÛÙÈΤ˜ ȉÈfiÙËÙ˜ ÙˆÓ ‰‡Ô ‹¯ˆÓ ‹Ù·Ó ÂÓÙÂÏÒ˜ ‰È·ÎÚÈÙ¤˜. O ÎÏ·ÛÈÎfi˜ Û˘ÚÈÁÌfi˜
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¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi Î˘Ì·ÙÔÂȉ‹ ÌÔÚÊÔÏÔÁ›· Ù˘ η̇Ï˘, Ì ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ ‰È·ÎÚÈÙ¤˜ ÎÔÚ˘Ê¤˜ ÛÙË ‰È¿Ù·ÍË Ê·ÛÌ·ÙÈ΋˜ ÈÛ¯‡Ô˜, ÂÓÒ ÔÈ “ÚfiÁ¯ÔÈ” ·ÓÙÈÚÔۈ‡ÔÓÙ·Ó ·fi Ì›· ·Î·ÓfiÓÈÛÙË, ÌË Î˘Ì·ÙÔÂȉ‹ η̇ÏË, Ì ‰È¿¯˘Ù˜ ÎÔÚ˘Ê¤˜ ÛÙË Ê·ÛÌ·ÙÈ΋ ÈÛ¯‡ Î·È Ì ·˘ÍË̤ÓË ¤ÓÙ·ÛË ÙÔ˘ ‹¯Ô˘ ÛÙȘ Û˘¯ÓfiÙËÙ˜ <600 Hz. ™˘ÌÂÚ¿ÛÌ·Ù·: ∂›Ó·È ÛËÌ·ÓÙÈ΋ Ë ‰È¿ÎÚÈÛË, ÙfiÛÔ ÁÈ· ÙÔ˘˜ ÎÏÈÓÈÎÔ‡˜ ÁÈ·ÙÚÔ‡˜, fiÛÔ Î·È ÁÈ· ÙÔ˘˜ ÂȉËÌÈÔÏfiÁÔ˘˜, ÙˆÓ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ·ÎÔ˘ÛÙÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ, Ì ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ·ÎÔ˘ÛÙÈΤ˜ ȉÈfiÙËÙ˜, ηٿ Ù· ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜.
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Elphick HE, Ritson S, Rogers H, Everard ML When a “wheeze” is not a wheeze: acoustic analysis of breath sounds in infants Eur Respir J 2000;16:593-597 ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·255
¶·È‰È·ÙÚÈ΋ 2001;64:255-260
¡∂ºƒ√§√°π∞
Paediatriki 2001;64:255-260
NEPHROLOGY
π‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÛÙ· ·È‰È¿ ∫. π. ™ÙÂÊ·Ó›‰Ë˜
Idiopathic hypercalciuria C. J. Stefanidis
¶ÂÚ›ÏË„Ë: ∏ ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ·, ·ÊÔ‡ ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ 7% ÙÔ˘ ÏËı˘ÛÌÔ‡. ∞ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘ Î·È Û˘¯Ó¿ ‰È·ÈÛÙÒÓÂÙ·È Û ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Û˘¯ÓÔ˘Ú›·˜‰˘ÛÔ˘Ú›·˜. ∂›Û˘, ¤¯ÂÈ ·ÈÙÈÔÏÔÁÈο Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÔÛÙÂÔfiÚˆÛ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· ·È‰È¿ Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 3,5 mg/kg/24ˆÚÔ, ÂÓÒ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ‰È·ÈÛÙÒÓÔÓÙ·È Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË. ™Ù· ·È‰È¿ ıˆÚÂ›Ù·È ·˘ÍË̤ÓÔ ÙÔ ËÏ›ÎÔ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË ÂÓfi˜ Ù˘¯·›Ô˘ ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ, fiÙ·Ó Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi 0,2 mg/mg ‹ 0,5 mmol/mmol. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ πÀ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. ¶ÚfiÛÊ·Ù· ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Ù· ÁÔÓ›‰È· ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D, Ù˘ 1· ˘‰ÚÔÍ˘Ï¿Û˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D Î·È ÙˆÓ ‰È·‡ÏˆÓ ¯ÏˆÚ›Ô˘ ˆ˜ ˘Â‡ı˘Ó· ÁÈ· ÙËÓ πÀ. ™‡ÓÙÔÌ· ·Ó·Ì¤ÓÂÙ·È Î·È ¿ÏÏ· ÁÔÓ›‰È· Ó· Ù·˘ÙÔÔÈËıÔ‡Ó. ∏ Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË Ù˘ Àπ ÂÍ·ÚÙ¿Ù·È Î·È ·fi ‰È·ÙÚÔÊÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, fiˆ˜ Â›Ó·È Ë ÚfiÛÏË„Ë ÙÔ˘ Ó·ÙÚ›Ô˘, ÙÔ˘ Î·Ï›Ô˘ Î·È ÙˆÓ ÚˆÙÂ˚ÓÒÓ. ¢ÂÓ Û˘ÓÈÛÙ¿Ù·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ πÀ, ÁÈ·Ù› Ì·ÎÚfi¯ÚÔÓÈ· ÚÔηÏ› ÂÏ¿ÙÙˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜. OÈ ·ÛıÂÓ›˜ Ì πÀ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ÂÚÈÔÚÈÛÌfi ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È Ì ·˘ÍË̤ÓË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ. ∂›Û˘, Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ˘‰ÚԯψÚÔıÂÈ·˙›‰Ë Û ·È‰È¿ Ì πÀ Î·È ˘ÔÙÚÔÈ¿˙Ô˘Û· Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ‹ ÓÂÊÚÔÏÈı›·ÛË.
Abstract: Idiopathic hypercalciuria (IH) is a common disorder affecting about 7% of the population. IH is the main cause of renal stone disease and it is frequently diagnosed in children with hematuria and the frequency-dysuria syndrome. Its role in the development of osteoporosis in adults is also documented. Normal calcium excretion rate in children is defined as being lower than 3.5 mg/kg per day, while significantly higher values are observed in infants. In children a urinary calcium/creatinine ratio, obtained in a single voided morning specimen, that is greater than 0.2 mg/mg or 0.5 mmol/mmol is regarded as elevated. Recent studies indicate a multifactorial etiology of IH. Some candidate genes responsible for idiopathic hypercalciuria include those of the vitamin D receptor, the 1 alphahydroxylase of vitamin D and chloride channels, but others remain to be identified. The phenotypic expression of IH depends on many nutritional factors, such as the intake of sodium, potassium and proteins. Dietary calcium restriction can no longer be recommended for the treatment of IH, because on a long-term basis it may cause decreased bone mineral density. Patients with IH should be kept on a dietary sodium restriction and high fluid intake. Hydrochlorothiazide should be prescribed when IH is associated with recurrent episodes of macroscopic hematuria or stone disease.
§¤ÍÂȘ ÎÏÂȉȿ: ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ÓÂÊÚÔÏÈı›·ÛË, ·ÈÌ·ÙÔ˘Ú›·, ˘‰ÚԯψÚÔıÂÈ·˙›‰Ë.
Key words: idiopathic hypercalciuria, renal stone disease, hematuria, hydrochlorothiazide.
∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ NÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ AıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
∞ssociate Director Division of Nephrology “A. & P. Kyriakou” Children’s Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:255-260
∏ ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ·, ·ÊÔ‡ ÂÌÊ·Ó›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 7% ÙÔ˘ ÏËı˘ÛÌÔ‡, Ì ÙËÓ ›‰È· Û˘¯ÓfiÙËÙ· ÙfiÛÔ ÛÙ· ·È‰È¿, fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (1). O fiÚÔ˜ πÀ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Albright Î·È Henneman Ùo 1953 Û ·ÛıÂÓ›˜ Ì ·Û‚ÂÛÙÈÔ˘Ú›· Î·È ÓÂÊÚÔÏÈı›·ÛË Ì ϛıÔ˘˜ ·fi ·Û‚¤ÛÙÈÔ, ÔÈ ÔÔ›ÔÈ Â›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ·Û‚¤ÛÙÈÔ Î·È ÊˆÛÊfiÚÔ ÔÚÔ‡ Î·È Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÎÙÈÓÔÁڷʛ˜ ÔÛÙÒÓ (2). ŒÙÛÈ, ÁÈ· Ó· ‰È·ÁÓˆÛÙ› πÀ Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó fiϘ ÔÈ ¿ÏϘ ·Èٛ˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (¶›Ó·Î·˜ 1). ø˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÔÚ›˙ÂÙ·È Ë ËÌÂÚ‹ÛÈ· ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Û ÔÛfiÙËÙ· ÌÂÁ·Ï‡ÙÂÚË ·fi 3,5 mg/kg (‹ 0,18 mmol/kg). ™Â ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, ÙfiÛÔ Û ÂÓ‹ÏÈΘ fiÛÔ Î·È Û ·È‰È¿ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë ¿Ô„Ë fiÙÈ Ë ‰È¿ÁÓˆÛË Â›Ó·È Ôχ Èı·Ó‹ fiÙ·Ó ÙÔ ËÏ›ÎÔ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË ÂÓfi˜ Ù˘¯·›Ô˘ ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ (Ca/Cr Ô‡ÚˆÓ) Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi 0,2 mg/mg ‹ 0,5 mmol/mmol (3,4). OÚȷΤ˜ ÙÈ̤˜ ÙÔ˘ ËÏ›ÎÔ˘ Ca/Cr Ô‡ÚˆÓ ÌÂٷ͇ 0,15 mg/mg Î·È 0,20 mg/mg Ú¤ÂÈ Ó· ‚¿˙Ô˘Ó ÙËÓ ˘Ô„›· ÁÈ· Èı·Ó‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ·ÊÔ‡ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ı· ‰È·ÁÓˆÛÙ› ÙÂÏÈο ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ 65% ÙˆÓ ·È‰ÈÒÓ Ì ÙȘ ÙÈ̤˜ ·˘Ù¤˜ (3). ™Ù· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ÌËÓÒÓ ‰ÂÓ ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÂ›Ù·È Ë ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·fi ÙÔ ËÏ›ÎÔ Ca/Cr Ô‡ÚˆÓ, ·ÏÏ¿ ÌfiÓÔ ·fi Û˘ÏÏÔÁ¤˜ Ô‡ÚˆÓ 24ÒÚÔ˘. ™ÙËÓ ËÏÈΛ· ·˘Ù‹, ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ Ô‡ÚˆÓ 24ÒÚÔ˘ Û ÔÛfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 3,5 mg/kg (‹ 0,18 mmol/kg) ıˆÚÔ‡ÓÙ·È ·ıÔÁÓˆÌÔÓÈΤ˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (3). ¶ÚfiÛÊ·Ù·, ÂÎÙfi˜ ·Ô ÙË ÓÂÊÚÔÏÈı›·ÛË, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ πÀ Î·È ·ÚÎÂÙ¿ ¿ÏÏ· ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù·. ∂›Û˘, ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ë ·ÈÙÈÔÏÔÁ›· Ù˘ Î·È ¤¯Ô˘Ó ·Ó·ıˆÚËı› ÔÏϤ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘.
Paediatriki 2001;64:255-260
∫ÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ È‰ÈÔ·ı‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ∏ πY Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘, ·ÊÔ‡ ÂÚ›Ô˘ ÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔÏÈı›·ÛË Ì ϛıÔ˘˜ ·fi ·Û‚¤ÛÙÈÔ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔ Úfi‚ÏËÌ· ·˘Ùfi (4). ∂›Û˘, ¤¯ÂÈ ÙÂÎÌËÚȈı› Ì ÔÏϤ˜ ÌÂϤÙ˜ fiÙÈ ÔÈ Ï›ıÔÈ Ì ·Û‚¤ÛÙÈÔ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘. ∏ ‰È¢ÎÚ›ÓÈÛË Ù˘ ÔÈÎÔÁÂÓÔ‡˜ ÚԉȿıÂÛ˘ ÁÈ· ÓÂÊÚÔÏÈı›·ÛË Û ·ÛıÂÓ›˜ Ì πÀ Â›Ó·È ‰˘Û¯ÂÚ‹˜, ÁÈ·Ù› Ë πÀ ·ÔÙÂÏ› ¤Ó· ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓÂÊÚÔÏÈı›·Û˘. ŒÙÛÈ, ÔÈ ·ÛıÂÓ›˜ Ì ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·fi ·˘ÍË̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ ÌÔÚ› Ó· ÌËÓ ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÔÙ¤ πÀ, ·Ó Ë ÚfiÛÏË„Ë ·Û‚ÂÛÙ›Ô˘ ‹/Î·È Ó·ÙÚ›Ô˘ Â›Ó·È ¯·ÌËÏ‹ (5). ∞ÎfiÌ·, Ë ÂÌÊ¿ÓÈÛË ÓÂÊÚÔÏÈı›·Û˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Û˘Ó‡·Ú͢ ‰È·ÊfiÚˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ŒÙÛÈ, ÛÙ· ·È‰È¿ Ì ÓÂÊÚÔÏÈı›·ÛË Û˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó Ì ÙËÓ πÀ Î·È ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù· (6), fiˆ˜ Ë ·‡ÍËÛË Ô˘ÚÈÎÔ‡ ÔͤԘ Ô‡ÚˆÓ (ÛÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ), Ë ˘ÂÚÔÍ·ÏÔ˘Ú›· (ÛÙÔ 30 ˆ˜ 40%) Î·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÎÈÙÚÈÎÒÓ ÙˆÓ Ô‡ÚˆÓ (ÛÙÔ 25%) (5). ∆¤ÏÔ˜, Ë ÔÈÎÔÁÂÓ‹˜ ÂÈ‚¿Ú˘ÓÛË Ê·›ÓÂÙ·È fiÙÈ Û˘Ó‹ıˆ˜ ‰ÂÓ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ ÂÓfi˜ ÁÔÓȉ›Ô˘, ·ÏÏ¿ Û ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÔÏÏ·ÏÒÓ ÁÔÓȉ›ˆÓ Ì ‰È·ÊÔÚÂÙÈ΋ Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË ÛÙ· ‰È¿ÊÔÚ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (4). ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë πÀ Â›Ó·È Ì›· Û˘¯Ó‹ ·ÈÙ›· ·ÈÌ·ÙÔ˘Ú›·˜ (7-10). ŒÙÛÈ, Ôχ Û˘¯Ó¿ Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ πÀ Á›ÓÂÙ·È ·fi ÙËÓ ·ÈÙÈÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Ë Û˘Û¯¤ÙÈÛË Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Ì ÙËÓ πÀ ¤ÁÈÓ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1981 ·fi ÙÔÓ Moore (10) Î·È ÛÙȘ ÂfiÌÂÓ˜ ‰‡Ô ‰ÂηÂٛ˜ ÂȂ‚·ÈÒıËΠ̠·ÚÎÂÙ¤˜ ÌÂϤÙ˜. ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Î˘Ì·›ÓÂÙ·È ·fi ÙÔ 9% ¤ˆ˜ ÙÔ 35% ÙˆÓ ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔ˘Ú›· (79,11). ∂›Û˘, ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Ë πÀ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Î·È Û ÂÓ‹ÏÈΘ
¶›Ó·Î·˜ 1. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ ÔÚÔ‡ (3) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
π‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) ∫ÏËÚÔÓÔÌÈ΋ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ì ˘ÔʈÛÊ·Ù·ÈÌÈ΋ Ú·¯›Ùȉ· (¡fiÛÔ˜ ÙÔ˘ Dent) ªÂÙ¿ÏÏ·ÍË ÙÔ˘ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘ CLCN5 ™·ÚÎÔ›‰ˆÛË ™‡Ó‰ÚÔÌÔ Bartter NÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË ª·ÎÚfi¯ÚÔÓË ·ÎÈÓËÙÔÔ›ËÛË A˘ÍË̤ÓË ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘, ‚ÈÙ·Ì›Ó˘ D ‹ ·Û‚ÂÛÙ›Ô˘ £Âڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÊÔ˘ÚÔÛÂÌ›‰Ë ‹ ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂ ™‡Ó‰ÚÔÌÔ Seyberth (˘ÂÚÚÔÛÙ·ÁÏ·Ó‰ÈÓ·ÈÌ›· ∂) £˘ÚÂÔÙÔ͛ΈÛË
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¶·È‰È·ÙÚÈ΋ 2001;64:255-260
(15). ∆· ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì πÀ Û˘Ó‹ıˆ˜ Â›Ó·È ·ÁfiÚÈ· Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÓÂÊÚÔÏÈı›·Û˘, Ì ÎÚ˘ÛÙ¿ÏÏÔ˘˜ ÔÍ·ÏÈÎÔ‡ ·Û‚ÂÛÙ›Ô˘ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Ô‡ÚˆÓ Î·È ·ÚÔ˘Û›·˙·Ó ÈÔ Û˘¯Ó¿ Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· (11). ∂›Û˘, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜ ·ÚÔ˘Û›·Û·Ó ÓÂÊÚÔÏÈı›·ÛË Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·fi fiÙÈ Ù· ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ (17). ŒÙÛÈ Ê·›ÓÂÙ·È fiÙÈ Ë ‰È·›ÛÙˆÛË πÀ Û ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ÓÂÊÚÔÏÈı›·ÛË Î·È Ì ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ πÀ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÏËÊıÔ‡Ó ÛËÌ·ÓÙÈο ÌÂÏÏÔÓÙÈο ÚÔ‚Ï‹Ì·Ù·. ∂ÎÙfi˜ ·fi ÙËÓ ·ÈÌ·ÙÔ˘Ú›·, Ë πÀ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ٷ ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ Î·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË Â›Ó·È Ë ‰È·›ÛÙˆÛË ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ˘ÂÚ˯ÔÁÂÓÒÓ ÎËÏ›‰ˆÓ ÛÙȘ Î¿Ï˘Î˜. ∞fi Ù· 196 ·È‰È¿ ËÏÈΛ·˜ 0,9 ¤ˆ˜ 15,9 ÂÙÒÓ ÛÙ· ÔÔ›· ‰È·ÈÛÙÒıËΠÙÔ Úfi‚ÏËÌ· ·˘Ùfi, ÛÙÔ 70% ˘‹Ú¯Â ÈÛÙÔÚÈÎfi ÓÂÊÚÔÏÈı›·Û˘ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ¤Ó· Û˘ÁÁÂÓ‹ ÚÒÙÔ˘ ‹ ‰Â˘Ù¤ÚÔ˘ ‚·ıÌÔ‡. ∆· ·È‰È¿ ·˘Ù¿ ›¯·Ó ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÈÌ·ÙÔ˘Ú›· Û ÔÛÔÛÙfi 41%, ÎÔÈÏȷο ¿ÏÁË ‹/Î·È Î˘ÛÙÈο ÂÓԯϋ̷ٷ. ™ÙÔ 33% ÙˆÓ ·ÛıÂÓÒÓ ‰È·ÈÛÙÒıËΠ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ÂÓÒ ÛÙÔ 20% ·‡ÍËÛË ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÙˆÓ Ô‡ÚˆÓ. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÙÔ 33% ÙˆÓ 29 ·È‰ÈÒÓ ·ÚÔ˘Û›·Û ÓÂÊÚÔÏÈı›·ÛË ÌÂÙ¿ ·fi 2-9 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ (16). ∏ Î·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË ÌÔÚ› Ó· Â›Ó·È ¤Ó· ·Ú¯ÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÔÏÈı›·Û˘ Î·È Èı·ÓÒ˜ ÂÍËÁ› ÔÏÏ¿ ·fi Ù· Û˘ÌÙÒÌ·Ù· Î·È Â˘Ú‹Ì·Ù· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (16). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ¤¯ÂÈ Á›ÓÂÈ
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ÈÔ Û˘¯Ó‹ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ (18,19). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ·fi Ù· 16 ·È‰È¿ Ì ÙÔ Úfi‚ÏËÌ· ·˘Ùfi, ÌfiÓÔ Ù· ‰‡Ô ›¯·Ó ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ (19). ™˘¯Ó¿, ÙÔ ÌfiÓÔ Â‡ÚËÌ· ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È ÔÈ ˘ÂÚ˯ÔÁÂÓ›˜ ÓÂÊÚÈΤ˜ ˘Ú·Ì›‰Â˜. AÈÙÈÔÏÔÁ›· ∏ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌÔÚ› Ó· ÚÔÎÏËı› ·fi ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ‰È·ÊfiÚˆÓ ÁÂÓÂÙÈÎÒÓ ‹ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (¶›Ó·Î·˜ 3). ∏ πÀ Ê·›ÓÂÙ·È fiÙÈ ÌÂÙ·‚È‚¿˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· Ù‡Ô ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ (21). ŸÌˆ˜, Ë ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌÔÚ› Ó· ÌÂÙ·‚È‚¿˙ÂÙ·È Î·È Ì ˘ÔÏÂÈfiÌÂÓÔ Ê˘ÏÔÛ‡Ó‰ÂÙÔ Ù‡Ô ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÂÙ·ÏÏ¿ÍÂȘ Û ÁÔÓ›‰È· Ù· ÔÔ›· ÂϤÁ¯Ô˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÂÓfi˜ ÓÂÊÚÈÎÔ‡ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘, Ô˘ ¤¯ÂÈ ÚfiÛÊ·Ù· ÂÚÈÁÚ·Ê› (22). To ›‰ÈÔ Úfi‚ÏËÌ· ÌÔÚ› Ó· ¤¯ÂÈ Î·È ÔÈÎÔÁÂÓ‹ ¯·Ú·ÎÙ‹Ú·, fï˜ ·ÎfiÌË ‰ÂÓ ¤¯ÂÈ Ù·˘ÙÔÔÈËı› Ë ÁÔÓȉȷ΋ ‚Ï¿‚Ë (3). OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘ ¤¯Ô˘Ó ÌÂÁ¿ÏË ÔÈÎÈÏ›· Ê·ÈÓÔÙ˘È΋˜ ¤ÎÊÚ·Û˘. ŒÙÛÈ, ÔÈ ·ÛıÂÓ›˜ Ì ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÙË ÓfiÛÔ ÙÔ˘ Dent, Ô˘ ÂΉËÏÒÓÂÙ·È Û· Û‡Ó‰ÚÔÌÔ Fanconi Ì ڷ¯›Ùȉ· Î·È Û˘¯Ó¿ Û˘Ó˘¿Ú¯ÂÈ Î·È ÌÈÎÚÔÌÔÚȷ΋ ÚˆÙÂ˚ÓÔ˘Ú›· ÛˆÏËÓ·Úȷ΋˜ ÚÔ¤Ï¢Û˘ (23-25). OÚÈṲ̂ÓÔÈ, ¿ÏÈ, ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‹È· ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÊÚÔÏÈı›·Û˘ ‹ ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ŸÌˆ˜, ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ ηÈ
¶›Ó·Î·˜ 2. ∫ÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ È‰ÈÔ·ı‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· 1. 2. 3. 4. 5. 6. 7. 8. 9.
∫ÔÈÏȷο ¿ÏÁË (3) ∂ÓÔ‡ÚËÛË (12) ∫˘ÛÙÈο ÂÓԯϋ̷ٷ (‰˘ÛÔ˘Ú›·, Û˘¯ÓÔ˘Ú›·) (13,14) ¢˘ÛÂÍ‹ÁËÙË ˘Ô˘Ú›· (3) ™˘¯Ó¤˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ (19) ªÈÎÚÔÛÎÔÈ΋ Î·È Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· (7-10,15) ∫·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË (16) ¡ÂÊÚÔÏÈı›·ÛË ¡ÂÊÚ·Û‚¤ÛÙˆÛË (18,19)
¶›Ó·Î·˜ 3. ¶·Ú¿ÁÔÓÙ˜, Ô˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ °ÂÓÂÙÈ΋ ÚԉȿıÂÛË
¶·Ú¿ÁÔÓÙ˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜
ñOÈÎÔÁÂÓ‹˜ ÂÈ‚¿Ú˘ÓÛË ñ¢È·Ù·Ú·¯¤˜ ΢ÙÙ·ÚÈ΋˜ ÌÂÙ·ÊÔÚ¿˜ ·Û‚ÂÛÙ›Ô˘, ¯ÏˆÚ›Ô˘ Î·È Ó·ÙÚ›Ô˘ ñ¢È·Ù·Ú·¯¤˜ ΢ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ ·Û‚ÂÛÙ›Ô˘ ñ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ‚ÈÙ·Ì›Ó˘ D
ñ¶ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘ Î·È Î·Ï›Ô˘ ñ¶ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë ñ¢ÈÔ˘ÚËÙÈο
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ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (26). ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠ۠ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ· fiÙÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‰È·‡ÏÔ˘ ·Û‚ÂÛÙ›Ô˘ (ECaC) ÌÔÚ› Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì οÔȘ ÌÔÚʤ˜ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜. O ‰›·˘ÏÔ˜ ·˘Ùfi˜ ¤¯ÂÈ ·ÔÌÔÓˆı› ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ, ÛÙÔÓ ÂÈÏÂfi Î·È ÛÙÔ ÓÂÊÚfi Î·È ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ 1,25 DHVD ÂÍ·Úو̤ÓË Î·ÏÌÈÓ‰›ÓË (calbindin) D28k (27). ∂›Û˘, ¤¯ÂÈ ÂÚÈÁÚ·Ê› ¤Ó· ÔÈÎÔÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ·Û‚ÂÛÙ›Ô˘ (28). ∆¤ÏÔ˜, ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ÔÈÎÔÁ¤ÓÂȘ °·ÏÏÔηӷ‰ÒÓ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·fi ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÁÔÓȉ›Ô˘, Ô˘ ÂϤÁ¯ÂÈ ÙÔ˘˜ ˘Ô‰Ô¯Â›˜ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÛÙÔ ¯ÚˆÌfiۈ̷ 12q 12-14 (29). ™Â ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë ¿Ô„Ë fiÙÈ Ë πÀ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ˙˘ÌÈ΋˜ ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘. ŒÙÛÈ, Ë Ca/ªg ATP¿ÛË ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ·ÛıÂÓÒÓ Ì πÀ ‚Ú¤ıËΠ·˘ÍË̤ÓË, ÂÓÒ ‰ÂÓ ‚Ú¤ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ Ù˘ Na/K ATP-¿Û˘ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì πÀ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∂›Ó·È Èı·Ófi Ë ‰È·Ù·Ú·¯‹ ÛÙË Ca/ªg ATP¿ÛË ÙˆÓ ·ÛıÂÓÒÓ Ó· ·ÔÙÂÏ› Ì›· ÎÏËÚÔÓÔÌÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ·Û‚ÂÛÙ›Ô˘ Î·È Ó· Û˘Û¯ÂÙ›˙ÂÙ·È ·ÈÙÈÔÏÔÁÈο Ì ÙËÓ πÀ (30). ∂›Û˘, ‰È·ÈÛÙÒıËΠÂÏ¿ÙÙˆÛË Ù˘ Na/K ATP-¿Û˘ Î·È ÂÏ¿ÙÙˆÛË Ù˘ Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿˜ Û ·È‰È¿ Ì πÀ. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ·ÔηٷÛÙ¿ıËÎ·Ó ÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ (31). ™Â ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ ÁÈÓfiÙ·Ó ‰È¿ÎÚÈÛË Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Û ÂÓÙÂÚÈÎfi Ù‡Ô, Ô˘ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ Î·È Û ÓÂÊÚÈÎfi Ù‡Ô, Ô˘ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ÛˆÏËÓ·Úȷ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ∏ ‰È¿ÎÚÈÛË ÙˆÓ Ù‡ˆÓ ·˘ÙÒÓ ÁÈÓfiÙ·Ó ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·˘ÍË̤Ó˘ ÔÛfiÙËÙ·˜ ·Û‚ÂÛÙ›Ô˘ Î·È ÌÂÙ¿ ·fi ÂÚÈÔÚÈÛÌfi Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘ (3). ™‹ÌÂÚ· Â›Ó·È ·Ô‰ÂÎÙfi ˆ˜ ÔÈ ‰‡Ô ·˘Ù¤˜ ÌÔÚʤ˜ ·ÔÙÂÏÔ‡Ó ·ÎÚ·›Â˜ ÌÔÚʤ˜ Ù˘ ›‰È·˜ ÓÔÛÔÏÔÁÈ΋˜ ÔÓÙfiÙËÙ·˜. ŒÙÛÈ, Û ̛· ÚfiÛÊ·ÙË ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ Û 16 ·fi Ù· 30 ·È‰È¿ Ë πÀ ‹Ù·Ó ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ Î·È Û 14 ÓÂÊÚÈÎÔ‡ Ù‡Ô˘. ŸÙ·Ó, fï˜, Ù· 16 ·È‰È¿ Ì ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ πÀ ·ÓÂÎÙÈÌ‹ıËÎ·Ó ÌÂÙ¿ ·fi 3-7 ¯ÚfiÓÈ·, ÌfiÓÔ Ù· 7 Û˘Ó¤¯È˙·Ó Ó· ¤¯Ô˘Ó ÙÔ˘ ›‰ÈÔ˘ Ù‡Ô˘ πÀ, Ù· 6 ›¯·Ó ÓÂÊÚÈÎÔ‡ Ù‡Ô˘ πÀ Î·È Ù· 3 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ∂ÓÒ, ·fi Ù· 14 ·È‰È¿ Ì ÓÂÊÚÈÎÔ‡ Ù‡Ô˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌfiÓÔ Ù· 6 Û˘Ó¤¯È˙·Ó Ó· ¤¯Ô˘Ó πÀ ÙÔ˘ ›‰ÈÔ˘ Ù‡Ô˘, Ù· 4 ›¯·Ó ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ πÀ Î·È Ù· 4 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ (32). O ÌfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ›¯Â ›‰Ú·ÛË ÛÙËÓ ·¤ÎÎÚÈÛË
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·Û‚ÂÛÙ›Ô˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‹Ù·Ó Ë ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘. ÕÏψÛÙÂ, ¤¯Ô˘Ó ‰È·ÈÛÙˆı› ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÛÙ· ̤ÏË ÔÈÎÔÁÂÓ›ˆÓ Ì πÀ (33). ∏ ÛËÌ·Û›· Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘ ÛÙËÓ ÚfiÎÏËÛË ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÙÔÓ›˙ÂÙ·È Î·È Û ̛· ¿ÏÏË ÌÂϤÙË, fiÔ˘ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ËÏ›ÎÔ˘ Ca/ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ Ì ÙÔ ËÏ›ÎÔ Na/K Ô‡ÚˆÓ (34). ∞˘Ùfi ‰Â›¯ÓÂÈ ÙËÓ ·ÓÙ›ÛÙÚÔÊË ÛËÌ·Û›· ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È ÙÔ˘ Î·Ï›Ô˘ ÛÙËÓ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ™ÙËÓ ›‰È· ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË Î·Ï›Ô˘ ›¯Â ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÚÔηÏÒÓÙ·˜ ÂÏ¿ÙÙˆÛË ÙÔ˘ ËÏ›ÎÔ˘ Na/K Ô‡ÚˆÓ (34). Œ¯ÂÈ ¿ÏψÛÙ ‰È·ÈÛÙˆı› Û ÂÓ‹ÏÈΘ fiÙÈ ÙÔ Ó¿ÙÚÈÔ ÙˆÓ Ô‡ÚˆÓ Ô˘ ·ÓÙ·Ó·ÎÏ¿ ÙËÓ ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘, Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË Û˘¯ÓfiÙËÙ· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ (35). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÚfiÛÊ·Ù· ÂÈÚ·Ì·ÙÈο ÛÙÔȯ›· ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ¿Ô„Ë fiÙÈ Ë Ì·ÎÚfi¯ÚÔÓË ˘ÂÚ‚ÔÏÈ΋ ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÎϤÛÂÈ ·‡ÍËÛË Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘. ŒÙÛÈ, ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÚÔÎÏ‹ıËΠ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Û ¤Ó·Ó ·ÚÈıÌfi ÂÈÚ·Ì·Ùfi˙ˆˆÓ Ì ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÌÂÙ¿ ·fi Ì·ÎÚfi¯ÚÔÓË ˘ÂÚ‚ÔÏÈ΋ ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë, Ô˘ ÔÊÂÈÏfiÙ·Ó Û ·‡ÍËÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ Ì¿˙·˜ Î·È ˘ÂÚ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘ (36). ∞ÓÙÈÌÂÙÒÈÛË ∏ ıÂڷ›· Ù˘ πÀ ·ÔÛÎÔ› ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·Ô‚ÔÏ‹˜ ·Û‚ÂÛÙ›Ô˘ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·. ¶Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘, ÂÂȉ‹ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÙËÓ ÔÛÙÂÔÂÓ›·, Ë ÔÔ›· Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó‹ ÛÙËÓ πÀ (3). ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘. ∞Ó Ô ÂÚÈÔÚÈÛÌfi˜ ·˘Ùfi˜ ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ‰›·ÈÙ· ÏÔ‡ÛÈ· Û οÏÈÔ ‹/Î·È ÎÈÙÚÈÎfi οÏÈÔ. ∂¿Ó Ë ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹ ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ¤¯ÂÈ ‰È·ÈÛÙˆı› ÓÂÊÚÔÏÈı›·ÛË, Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ‰ÈÔ˘ÚËÙÈο Ù˘ ÔÌ¿‰·˜ ÙˆÓ ıÂÈ·˙ȉÒÓ Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙË ÛˆÏËÓ·Úȷ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙÔ ·ÓÈfiÓ ÛΤÏÔ˜ Ù˘ ·Á·Ï˘ ÙÔ˘ Henle (3). Œ¯ÂÈ ‰È·ÈÛÙˆı› ÂÏ¿ÙÙˆÛË Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ ÙˆÓ ·È‰ÈÒÓ Ì πÀ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ (31). ™ÙËÓ ›‰È· ÌÂϤÙË ·˘Í‹ıËΠÛËÌ·ÓÙÈο Ë Na/K ATP-¿ÛË Î·È ÂÏ·ÙÙÒıËÎÂ Ë Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ Û ·È‰È¿ Ì πÀ. ∏ ·ÔηٿÛÙ·ÛË Ù˘ Na/K ATP-
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¿Û˘ Î·È ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿˜ ÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË Ù˘ ¢ÂÚÁÂÙÈ΋˜ ÙÔ˘˜ ›‰Ú·Û˘ ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÛˆÏËÓ·Úȷ΋˜ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ·ÛıÂÓÒÓ Ì πÀ (31). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó οÔȘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙË Ì·ÎÚfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÙˆÓ ıÂÈ·˙ȉÒÓ, ÁÈ·Ù› ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈȉ›ˆÓ (37). ∞fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ Û ·ÛıÂÓ›˜ Ì πÀ Ì ÈÛÙÔÚÈÎfi Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ (3). ÿÛˆ˜, fï˜, Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ıÂÈ·˙›‰Â˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓÂÊÚÔÏÈı›·Û˘, ·ÊÔ‡ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ·È‰È¿ Ì πÀ Î·È Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ·ÚÔ˘Û›·Û·Ó Û˘¯ÓfiÙÂÚ· ÓÂÊÚÔÏÈı›·ÛË Û ۯ¤ÛË Ì ·È‰È¿ Ì πÀ ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ (17). H ıÂڷ›· Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·Ú·Ì¤ÓÂÈ ÂÌÂÈÚÈ΋ Î·È Û˘¯Ó¿ ‚·Û›˙ÂÙ·È Û ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Î·È fi¯È Û ·ÚΛ˜ Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜. ª¤¯ÚÈ Ó· ˘¿ÚÍÔ˘Ó ÛÙÔȯ›· ·fi Ù¤ÙÔȘ ÌÂϤÙ˜ Â›Ó·È ÛÎfiÈÌÔ Ó· ÂÚÈÔÚÈÛÙ› Ë ·ÏfiÁÈÛÙË ¯Ú‹ÛË ÙˆÓ ıÂÈ·˙ȉÒÓ, Ô˘ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÌfiÓÔ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÔÈ Î·Ù¿ÏÏËϘ ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ. ∂›Û˘, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ˘ÂÚ‚ÔÏÈ΋˜ ÚfiÛÏ˄˘ ÚˆÙÂ˚ÓÒÓ, Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘ Î·È Ë ·‡ÍËÛË Ù˘ ÚfiÛÏ˄˘ Î·Ï›Ô˘ Ê·›ÓÂÙ·È fiÙÈ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÏ¿ÙÙˆÛË Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜, ÂÓÒ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (3).
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9.
10. 11.
12.
13.
14. 15.
16.
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18.
19.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Houillier P, Paillard M. Pathophysiology of idiopathic hypercalciuria: recent advances. Adv Nephrol 1998; 28:137-161. 2. Albright F, Henneman B, Benedict PH. Idiopathic hypercalciuria: A preleminary report. Proc R Spc Med Lond1953;46:1077. 3. Langman CB. Disorders of Phosphorus, calcium and vitamin D. Pediatric Nephrology. In: Barrat TM, Avner ED, Harmon WE, editors. Lippincot-William-Wilkins; 1999. p. 529-544. 4. Coe FL. Treated and untreated recurrent nephrolithiasis in patients with idiopathic hypercalciuria, hyperuricosuria, or no metabolic disorder. Ann Intern Med 1977;87:404-410. 5. Vosburg E, Peters TJ. Pathogenesis of idiopathic hypercalciuria: a review. J R Soc Med 1987. 6. Perrone HC, dos Santos DR, Santos MV, Pinheiro ME, Toporovski J, Ramos OL et al. Urolithiasis in childhood: metabolic evaluation. Pediatr Nephrol 1992;6:54-56. 7. Stapleton FB. Idiopathic hypercalciuria: association with isolated hematuria and risk for urolithiasis in children. The Southwest Pediatric Nephrology Study Group. Kidney Int 1990;37:807-811. 8. Perrone HC, Ajzen H, Toporovski J, Schor N. Metabolic
20.
21. 22.
23.
24.
25.
disturbance as a cause of recurrent hematuria in children. Kidney Int 1991;39:707-710. Turi S, Visy M, Vissy A, Jaszai V, Czirbesz Z, Haszon I et al. Long-term follow-up of patients with persistent /recurrent, isolated haematuria: a Hungarian multicentre study. Pediatr Nephrol 1989;3:235-239. Moore ES. Hypercalciuria in children. Contrib Nephrol 1981;27:20. Stark H, Tieder M, Eisenstein B, Davidovits M, Litwin A. Hypercalciuria as a cause of persistent or recurrent haematuria. Arch Dis Child 1988;63:312-313. Pace G, Aceto G, Cormio L, Traficante A, Tempesta A, Lospalluti ML et al. Nocturnal enuresis can be caused by absorptive hypercalciuria. Scand J Urol Nephrol 1999;33:111-114. Alon U, Warady BA, Hellerstein S. Hypercalciuria in the frequency-dysuria syndrome of childhood. J Pediatr 1990;116:103-105. Fivush B. Irritability and dysuria in infants with idiopathic hypercalciuria. Pediatr Nephrol 1990;4:262-263. Levy FL, Kemp RD, Breyer JA. Macroscopic hematuria secondary to hypercalciuria and hyperuricosuria. Am J Kidney Dis 1994;24:515-518. La Manna A, Polito C, Cioce F, De Maria G, Capacchione A, Rocco CE et al. Calyceal microlithiasis in children: report on 196 cases. Pediatr Nephrol 1998;12:214-217. A report of the Southwest Pediatric Nephrology study group. Idiopathic hypercalciuria: association with isolated hematuria and risk for nephrolithiasis in children. Kidney Int 1990;37:807-811. Shultz PK, Strife JL, Strife CF, McDaniel JD. Hyperechoic renal medullary pyramids in infants and children. Radiology 1991;181:163-167. Sorino P, Giordano M, Puteo F, Palumbo F, Rossiello P, Caringella DA. Hyperechogenicity of the renal medulla in children: clinico-echographic correlations. Arch Ital Urol Androl 1996;68(5 Suppl):117-123. Lopez MM, Castillo LA, Chavez JB, Ramones C. Hypercalciuria and recurrent urinary tract infection in Venezuelan children. Pediatr Nephrol 1999;13:433-437. Coe FL, Parks JH, Moore ES. Familiar idiopathic hypercalciuria. N Engl J Med 1979;300:337-341. Lloyd SE, Pearse SH, Fisher SE. A common molecular basis for three inherited kidney stone diseases. Nature 1996;379:445-449. Wrong OM, Norden AG, Feest TG. Dent's disease; a familial proximal renal tubular syndrome with lowmolecular-weight proteinuria, hypercalciuria, nephrocalcinosis, metabolic bone disease, progressive renal failure and a marked male predominance. QJM 1994;87:473-493. Pook MA, Wrong O, Wooding C, Norden AG, Feest TG, Thakker RV. Dent's disease, a renal Fanconi syndrome with nephrocalcinosis and kidney stones, is associated with a microdeletion involving DXS255 and maps to Xp11.22. Hum Mol Genet 1993;2:2129-2134. Fisher SE, van Bakel I, Lloyd SE, Pearce SH, Thakker RV, Craig IW. Cloning and characterization of CLCN5, the human kidney chloride channel gene implicated in Dent
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26.
27. 28.
29.
30.
31.
32.
disease (an X-linked hereditary nephrolithiasis). Genomics 1995;29:598-606. Frymoyer PA, Scheinman SJ, Dunham PB. X-linked recessive nephrolithiasis with renal failure. N Engl J Med 1991;325:681-686. Hoedentrop JGJ. Hypercalciuria. A defect on enteric calicium channel? Biological Chemistry 1999;274:857-878. Pearce SH, Williamson C, Kifor O, Bai M, Coulthard MG, Davies M et al. A familial syndrome of hypocalcemia with hypercalciuria due to mutations in the calcium-sensing receptor. N Engl J Med 1996;335:1115-1122. Scott P, Ouimet D, Valiquette L, Guay G, Proulx Y, Trouve ML et al. Suggestive evidence for a susceptibility gene near the vitamin D receptor locus in idiopathic calcium stone formation. J Am Soc Nephrol 1999;10:1007-1013. Bianchi G, Vezzoli G, Cusi D, Cova T, Elli A, Soldati L et al. Abnormal red-cell calcium pump in patients with idiopathic hypercalciuria. N Engl J Med 1988;319:897901. Reusz GS, Dobos M, Vasarhelyi B, Sallay P, Szabo A, Horvath C et al. Sodium transport and bone mineral density in hypercalciuria with thiazide treatment. Pediatr Nephrol 1998;12:30-34. Aladjem M, Barr J, Lahat E, Bistritzer. Renal and absorptive hypercalciuria: a metabolic disturbance with
Paediatriki 2001;64:255-260
33. 34.
35.
36.
37.
varying and interchanging modes of expression. Pediatrics 1996;97:216-219. Pak CYC, McGuire J, Peterson R. Familiar absorptive hypercalciuria in a large kindred. J Urol 1981;126:717-719. Osorio AV, Alon US. The relationship between urinary calcium, sodium, and potassium excretion and the role of potassium in treating idiopathic hypercalciuria. Pediatrics 1997;100:675-681. Cirillo M, Ciacci C, Laurenzi M, Mellone M, Mazzacca G, De Santo NG. Salt intake, urinary sodium, and hypercalciuria. Miner Electrolyte Metab 1997;23:265-268. Hess B, Ackermann D, Essig M, Takkinen R, Jaeger P. Renal mass and serum calcitriol in male idiopathic calcium renal stone formers: role of protein intake. J Clin Endocrinol Metab 1995;80:1916-1921. Reusz GS, Dobos M, Tulassay T. Hydrochlorothiazide treatment of children with hypercalciuria: effects and side effects. Pediatr Nephrol 1993;6:699-702.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ π. ™ÙÂÊ·Ó›‰Ë˜ ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· H ›‰Ú·ÛË Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË Û ·È‰È¿ Ì ¿ÛıÌ·1 ∂ÈÛ·ÁˆÁ‹: ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÌÔÚ› ‚Ú·¯˘ÚfiıÂÛÌ· Ó· ÂËÚ¿ÛÔ˘Ó ‰˘ÛÌÂÓÒ˜ ÙËÓ ·Ó¿Ù˘ÍË ·È‰ÈÒÓ Ì ¿ÛıÌ·. øÛÙfiÛÔ, Ù· ·ÒÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÁˆÁ‹˜ ·˘Ù‹˜ ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̛· ÚÔÔÙÈ΋ ÌÂϤÙË Û ·È‰È¿ Ì ¿ÛıÌ· ÁÈ· Ó· ÂÍÂÙ·ÛÙ› ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ıÂڷ›·˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ˆ˜ ÚÔ˜ ÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛ‹ ÙÔ˘˜. ªÂÏÂÙ‹ıËÎ·Ó 211 ·È‰È¿ Ô˘ ¤Êı·Û·Ó Û ·Ó¿ÛÙËÌ· ÂÓËÏ›ÎÔ˘: 142 ·È‰È¿ Ì ¿ÛıÌ· Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë, 18 Ì¿ÚÙ˘Ú˜, ÔÈ ÔÔ›ÔÈ ‹Ù·Ó ·È‰È¿ Ì ¿ÛıÌ· Ô˘ ‰ÂÓ Â›¯·Ó Ï¿‚ÂÈ ÔÙ¤ ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ Î·È 51 ˘ÁÈ‹ ·‰¤ÚÊÈ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë Î·È Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, ›Û˘, ˆ˜ Ì¿ÚÙ˘Ú˜. ∞ÔÙÂϤÛÌ·Ù·: ∆· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ Ù˘ ‚Ô˘‰ÂÛÔÓ›‰Ë˜ ¤Êı·Û·Ó Û ·Ó¿ÛÙËÌ· ÂÓËÏ›ÎÔ˘ ÌÂÙ¿ ·fi ̤ÛË ‰È¿ÚÎÂÈ· Ï‹„˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ 9,2 ÂÙÒÓ (‡ÚÔ˜ 3 - 13) Î·È Ì¤ÛË ËÌÂÚ‹ÛÈ· ‰fiÛË 412 Ìg (‡ÚÔ˜ 110 - 877). ∏ Û˘ÓÔÏÈ΋ ̤ÛË ‰fiÛË Ù˘ ‚Ô˘‰ÂÛÔÓ›‰Ë˜ ‹Ù·Ó 1,35 g (‡ÚÔ˜ 0,41 – 3,99). ∏ ̤ÛË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÌÂÙÚËı¤ÓÙÔ˜ Î·È ÚÔ‚ÏÂfiÌÂÓÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÂÓËÏ›ÎÔ˘ ‹Ù·Ó +0,3 cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, 0,6 ¤ˆ˜ +1,2) ÁÈ· Ù· ·È‰È¿ Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë, -
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0,2cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, -2,4 ¤ˆ˜ +2,1) ÁÈ· ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ì ¿ÛıÌ· Î·È +0,9cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, -0,4 ¤ˆ˜ +2,2) ÁÈ· Ù· ˘ÁÈ‹ ·‰¤ÚÊÈ·. ∆Ô ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ÂÍ·ÚÙ‹ıËΠÛËÌ·ÓÙÈο (p<0,001) ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ıÂڷ›·˜ Ì ‚Ô˘‰ÂÛÔÓ›‰Ë. ¶·Ú¿ ÙÔ fiÙÈ Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ÂÙÒÓ ıÂڷ›·˜ Ì ‚Ô˘‰ÂÛÔÓ›‰Ë, ÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ‰ÂÓ ÂËÚ¿ÛÙËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·È‰È¿ Ì ¿ÛıÌ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó Ì·ÎÚÔ¯ÚfiÓÈ· ‚Ô˘‰ÂÛÔÓ›‰Ë ÊÙ¿ÓÔ˘Ó ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË.
1Agertoft L, Pedersen S Effect of long-term treatment with inhaled budesonide on adult height in children with asthma N Engl J Med 2000;343:1064-1069
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Paediatriki 2001;64:261-267
EMERGENCY AND INTENSIVE CARE PEDIATRICS
∞Ù˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ∫. ∆ÛÔ˘Ì¿Î·˜
Accidents in childhood and adolescence C. Tsoumakas
¶ÂÚ›ÏË„Ë: ∆· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Ó ÛÔ‚·ÚfiÙ·ÙÔ Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜, ·ÊÔ‡ Â›Ó·È Ë ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ Î·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó. ŸÛÔÓ ·ÊÔÚ¿ ·È‰È¿ οو ÙˆÓ 5 ¯ÚfiÓˆÓ, Ù· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘˜ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Û fiÏÔ ÙÔÓ ÎfiÛÌÔ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙËÓ ÂÊ˂›· Î·È ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi Á›ÓÂÙ·È ·ÎfiÌË ¯ÂÈÚfiÙÂÚÔ ·Ó ˘ÔÏÔÁÈÛÙ› Î·È ÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ÂÈ˙ÒÓÙˆÓ Ô˘ ̤ÓÔ˘Ó ·Ó¿ËÚÔÈ. ∆· ·Ù˘¯‹Ì·Ù· ·Ó·„˘¯‹˜ ηıÒ˜ Î·È Ù· ·ÁÁÂÏÌ·ÙÈο ÌÔÚÔ‡Ó Ó· ÂÚÈÔÚÈÛÙÔ‡Ó ÛËÌ·ÓÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ‚·ÛÈÎÒÓ Î·ÓfiÓˆÓ ·ÛÊ·Ï›·˜, ÂÓÒ ÁÈ· Ù· ÂÚÈ‚·ÏÏÔÓÙÈο Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÔÚÁ·ÓˆÌ¤ÓË ·ÓÙÈÌÂÙÒÈÛË ·fi ÙËÓ ÔÏÈÙ›·. OÈ ·È‰›·ÙÚÔÈ ¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ‰˘Ó·ÌÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·.
Abstract: Accidents in childhood and adolescence are regarded as a very serious problem of public health, since they constitute the first cause of death and can be prevented to a great extent. For children under the age of 5 years, accidents at home and in the surrounding area comprise 60% of the total number of accidents, and their type has a direct relationship with the age of the children. Road accidents are regarded all over the world as the first cause of death in adolescence and this is even worse if we add the great percentage of the survivors who become handicapped. Accidents which result from both pleasure and business trips can be constrained to a great extent by adaptating basic safety measures, while for environmental accidents there must be an organized confrontation by the society. Pediatricians have significant opportunities for dynamic intervention in order to prevent most accidents in childhood and adolescence.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ù˘¯‹Ì·Ù·, ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, ÔÈÎȷο ·Ù˘¯‹Ì·Ù·, ÚfiÏË„Ë.
Key words: accidents, road accidents, home accidents, prevention.
¶ÚÈÓ ÌÂÚÈο ¯ÚfiÓÈ· Ë π·ÙÚÈ΋ Î·È Ë ¶ÔÏÈÙ›· ·ÓÙÈÌÂÙÒÈ˙·Ó Ù· ·Ù˘¯‹Ì·Ù· ¯ˆÚ›˜ Û˘ÓÙÔÓÈÛÌfi Î·È ÚfiÁÚ·ÌÌ·. ™‹ÌÂÚ·, fï˜, Ù· ·Ù˘¯‹Ì·Ù· Î·È Ô ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ Ù˘ ÚfiÏË„‹˜ ÙÔ˘˜ ·ÔÙÂÏÔ‡Ó ÚÒÙÈÛÙË ÊÚÔÓÙ›‰· ÙˆÓ ˘ËÚÂÛÈÒÓ ÀÁ›·˜ fiÏˆÓ ÙˆÓ ÚÔËÁÌ¤ÓˆÓ ¯ˆÚÒÓ Î·È ·ÓÙÈΛÌÂÓÔ ‰È‰·Ûηϛ·˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ™‹ÌÂÚ· Á›ÓÔÓÙ·È ÌÂÁ¿Ï˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ÏËÚ¤ÛÙÂÚË ÌÂϤÙË ÙˆÓ ·ÈÙ›ˆÓ, Ù˘ ÂȉËÌÈÔÏÔÁ›·˜, Ù˘ ·ÓÙÈÌÂÙÒÈ-
Û˘ Î·È Ù˘ ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁËı› ΤÓÙÚ· ‰ËÏËÙËÚÈ¿ÛˆÓ, ÙÚ·˘Ì·ÙÈÔÏÔÁÈο ΤÓÙÚ·, ΤÓÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÂÁη˘Ì¿ÙˆÓ Î.Ï., fiÔ˘ ÙÔ ı‡Ì· ·Ù˘¯‹Ì·ÙÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Û˘ÓÙÔÓÈṲ̂ӷ ·fi ÔÌ¿‰· ÂȉÈÎÒÓ. O fiÚÔ˜ ·Ù‡¯ËÌ· ÛËÌ·›ÓÂÈ ÙÔ Û˘Ì‚¿Ó Ô˘ ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë Ù‡¯Ë˜. ∏ ·ÓÙ›ÏË„Ë ·˘Ù‹ ·ÔÙÂÏÔ‡Û ÛÙÔ ·ÚÂÏıfiÓ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÊÚ·ÁÌfi ÁÈ· ÙËÓ ÚfiÔ‰Ô ÛÙÔÓ ¤ÏÂÁ¯Ô Î·È ÙËÓ
¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ∫.∞.∆. ∞ÙÙÈ΋˜
Director of Pediatric Division K.A.T. Hospital of Attica, Athens
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ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™‹ÌÂÚ· ÈÛÙ‡ԢÌ ˆ˜ 9 ÛÙȘ 10 ÊÔÚ¤˜ ÙÔ ·Ù‡¯ËÌ· ÔÊ›ÏÂÙ·È Û ·ÓıÚÒÈÓÔ Ï¿ıÔ˜, Û ·Ì¤ÏÂÈ·, Û ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ∂ȉÈÎfiÙÂÚ·, fiÛÔÓ ·ÊÔÚ¿ Ù· ·Ù˘¯‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ ÚÔÛÙ›ıÂÙ·È Î·È Ô ·Ú¿ÁÔÓÙ·˜ ¿ÁÓÔÈ·˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È fiÏˆÓ fiÛˆÓ ¤¯Ô˘Ó ÂÈ̤ÏÂÈ· ·È‰ÈÒÓ. ∆· ·Ù˘¯‹Ì·Ù·, ÂÔ̤ӈ˜, ‰ÂÓ Â›Ó·È Î·ÎÔÙ˘¯›· ·ÏÏ¿ ÓfiÛÔ˜ Î·È ÂȉËÌ›·, ÂÓ·ÓÙ›ÔÓ Ù˘ ÔÔ›·˜ ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· ÂÌ‚fiÏÈÔ Î·È ‰ÂÓ ÌÔÚ› Ó· ˘¿ÚÍÂÈ ·ÓÔÛ›·. ∏ ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÛÈÌfiÙËÙ· ·fi Ù· ·Ù˘¯‹Ì·Ù· Â›Ó·È ·˘ÍË̤ÓË Û 3 ȉȷ›ÙÂÚ· ¢·ı›˜ ÔÌ¿‰Â˜ ÏËı˘ÛÌÔ‡: ÛÙ· ·È‰È¿, ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ Î·È Ù· ¿ÙÔÌ· Ô˘ ÌÂÈÔÓÂÎÙÔ‡Ó ÛˆÌ·ÙÈο, ÓÂ˘Ì·ÙÈο Î·È ÎÔÈÓˆÓÈο. ∆· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÁÈ· Ù· ·È‰È¿ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ (50%), Ì ‰Â‡ÙÂÚË ÙȘ ηÎÔ‹ıÂȘ (15%) Î·È ÙÚ›ÙË ÙȘ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ (8%). OÈ ÏfiÁÔÈ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ·È‰È¿ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚ· ¢·ı‹ ÔÌ¿‰· Â›Ó·È ÔÈ ÂÍ‹˜: ·) ¤¯Ô˘Ó ·˘ÍË̤ÓË ÂÚȤÚÁÂÈ· Î·È Ù¿ÛË ÁÈ· ÂÍÂÚ‡ÓËÛË, ‚) ÌÂÈÔÓÂÎÙÔ‡Ó ÛÙÔ Û˘ÓÙÔÓÈÛÌfi ÙˆÓ ÎÈÓ‹ÛˆÓ, Á) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔԉ¢ÙÈ΋ ·Ó¿Ù˘ÍË Ù˘ ·‰Ú‹˜ ÎÈÓËÙÈÎfiÙËÙ·˜, ‰) ·Ú¯›˙Ô˘Ó Ó· Û˘ÓÂȉËÙÔÔÈÔ‡Ó ÙË Û¯¤ÛË ·ÈÙ›Ô˘-·ÔÙÂϤÛÌ·ÙÔ˜, Â) ‰ÂÓ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È Â‡ÎÔÏ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜, ÛÙ) ÂΉËÏÒÓÔ˘Ó ·ÚÓËÙÈÛÌfi ‹ Î·È Â¯ıÚfiÙËÙ· ÛÙȘ Û˘Ì‚Ô˘Ï¤˜ ÙˆÓ ÁÔÓ¤ˆÓ, ˙) Ô ‰‡ÛÙÚÔÔ˜ ¯·Ú·ÎÙ‹Ú·˜ ÔÚÈÛÌ¤ÓˆÓ ‰Ú· ¢ÓÔ˚ο ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ, Ë) ¤¯Ô˘Ó ·ÓÒÚÈÌË Î·È ÂÁˆÎÂÓÙÚÈ΋ ÛΤ„Ë (ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·), ı) ÂӉȷʤÚÔÓÙ·È Ó· Â›Ó·È ·Ô‰ÂÎÙ¿ ·fi ÙÔ˘˜ Û˘ÓÔÌ‹ÏÈÎÔ‡˜ ÙÔ˘˜ (Û¯ÔÏÈ΋ ËÏÈΛ·), È) ¤ÏÎÔÓÙ·È ·fi ÙË ÁÔËÙ›· Ù˘ ÂÚȤÙÂÈ·˜ (ÚÔÂÊË‚È΋ ËÏÈΛ·). ∫¿ı ËÏÈΛ· ¤¯ÂÈ ÙÔ˘˜ ‰ÈÎÔ‡˜ Ù˘ ȉȷ›ÙÂÚÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜: i) ™ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: OÈ ÙÒÛÂȘ ¤Ú¯ÔÓÙ·È ÚÒÙ˜ ÛÂ Û˘¯ÓfiÙËÙ· Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ë ·ÛÊ˘Í›· ·fi ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Î·È Ù· ÂÁη‡Ì·Ù·. ii) ™ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·: ∆Ș ÙÒÛÂȘ ·ÎÔÏÔ˘ıÔ‡Ó Ô ÓÈÁÌfi˜, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ, Ù· ÂÁη‡Ì·Ù·, ÂÓÒ Ù· ÙÚÔ¯·›· ˘ÔÏ›ÔÓÙ·È ÚÔ˜ ÙÔ ·ÚfiÓ. iii) ™ÙË Û¯ÔÏÈ΋ ËÏÈΛ·: ¶ÚÒÙË ı¤ÛË ¤¯Ô˘Ó Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Ì ÙÔ ·È‰› Â˙fi, ÂÈ‚¿ÙË ‹ Ô‰ËÏ¿ÙË Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ô ÓÈÁÌfi˜ Î·È Ù· ÂÁη‡Ì·Ù·, ÂÓÒ ÌÂÈÒÓÔÓÙ·È ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ. iv) ™ÙËÓ ÂÊË‚È΋ ËÏÈΛ·: ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÎÚ·ÙÔ‡Ó ÙËÓ ÚÒÙË ı¤ÛË Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ·Ù˘¯‹Ì·Ù· ·fi ·ıÏ‹Ì·Ù·, Ô ÓÈÁÌfi˜, Ù· ÂÁη‡Ì·Ù·, Ù· ·Ù˘¯‹Ì·Ù· ·fi ¯Ú‹ÛË ·ÏÎÔfiÏ Î·È Ó·ÚΈÙÈÎÒÓ Î·È ÔÈ ·fiÂÈÚ˜ ·˘ÙÔÎÙÔÓ›·˜. °È· ‰È‰·ÎÙÈÎÔ‡˜ ΢ڛˆ˜ ÏfiÁÔ˘˜ Ù· ·Ù˘¯‹Ì·Ù· ÛÙ· ·È‰È¿ ı· ÌÔÚÔ‡Û·Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û ÔÚÈṲ̂Ó˜ ηÙËÁÔڛ˜, ·Ó Î·È Ù· fiÚÈ· οı ηÙË-
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ÁÔÚ›·˜ Â›Ó·È ·Û·Ê‹: - √ÈÎȷο (ÛÙÔ Û›ÙÈ) - ∞ıÏËÙÈο Î·È ·Ó·„˘¯‹˜ (ÛÙË Ê‡ÛË) - ∆ÚÔ¯·›· (ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜) - ∂·ÁÁÂÏÌ·ÙÈο (ÛÙËÓ ÂÚÁ·Û›·) - ¶ÂÚÈ‚·ÏÏÔÓÙÈο (˘ÚËÓÈο, ˘ÚηÁȤ˜, ÛÂÈÛÌÔ›, ıÂÔÌËӛ˜) Ô˘ ÂËÚ¿˙Ô˘Ó ÌÂÁ¿ÏÔ˘˜ ÏËı˘ÛÌÔ‡˜. OÈÎȷο ·Ù˘¯‹Ì·Ù· ∆· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ¯ÚfiÓˆÓ. ∆Ô Â›‰Ô˜ ÙÔ˘˜ ‚¤‚·È· ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ·) OÈ ÙÒÛÂȘ Â›Ó·È ·fi Ù· ÈÔ Û˘ÓËıÈṲ̂ӷ ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ. ∆· ‚Ú¤ÊË ¤ÊÙÔ˘Ó 2 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·fi Ù· ÌÈÎÚ¿ ·È‰È¿ Î·È 10 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ·. ∏ ÙÒÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÌÔÚ› Ó· Á›ÓÂÈ ·fi ÙËÓ ÎÔ‡ÓÈ·, ÙÔ ÎÚ‚·Ù¿ÎÈ ÙÔ˘, ÙÔ baby relax, ÙȘ ·ÚÔÛٿ٢٘ ÛοϘ, ÙÔ Á˘·ÏÈṲ̂ÓÔ ¿ÙˆÌ· Î·È ÙË ÛÙÚ¿Ù·. ‚) ∏ ÂÈÛÚfiÊËÛË Í¤ÓˆÓ ÛˆÌ¿ÙˆÓ (ÍËÚÔ› ηÚÔ›, ηÚÊ›ÙÛ˜, ÛÙ·˘ÚÔ˘‰¿ÎÈ· Î.Ï. ÌÔÚ› Ó· Á›ÓÂÈ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Ô˘ ÙÔ ‚Ú¤ÊÔ˜ ÌÔÚ› Ó· ‚¿ÏÂÈ ÛÙÔ ÛÙfiÌ· ÙÔ˘ fi,ÙÈ ÎÚ·Ù¿ÂÈ ÛÙÔ ¯¤ÚÈ ÙÔ˘. Á) ∆· ·Ù˘¯‹Ì·Ù· ·fi ÓÈÁÌfi Â›Ó·È 5 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚ· ÛÙ· ·È‰È¿ 2-4 ¯ÚfiÓˆÓ ·’ fiÙÈ ÛÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜ Î·È 2 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·o fiÙÈ ÛÙ· ·È‰È¿ 6-12 ¯ÚfiÓˆÓ. ‰) ∆· ÂÁη‡Ì·Ù· Â›Ó·È Ù· Û˘¯ÓfiÙÂÚ· Î·È ÛÔ‚·ÚfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ ÁÈ· ·È‰È¿ 2-5 ¯ÚfiÓˆÓ Î·È ·Ú·ÙËÚÔ‡ÓÙ·È 3 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚÔ ·’ fiÙÈ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘. ∆Ô 80% ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ ·Ù˘¯ËÌ¿ÙˆÓ Û˘Ì‚·›ÓÂÈ ÛÙËÓ ÎÔ˘˙›Ó· ÙÔ˘ ÛÈÙÈÔ‡ Î·È ÏÈÁfiÙÂÚÔ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ Î·È ÙÔ ÏÔ˘ÙÚfi. ∆Ô 90% ÚÔηÏÂ›Ù·È ·fi ˘ÁÚ‹ Î·È ÙÔ 10% ·fi ÍËÚ‹ ıÂÚÌfiÙËÙ·. ∂›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·ÁfiÚÈ·, ÛÙ· ÚˆÙfiÙÔη ·È‰È¿, Û ‰È·ÌÂÚ›ÛÌ·Ù·, ÂÍ·ÚÙÒÌÂÓ· ¿ÓÙ· ·fi ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∂˘Ù˘¯Ò˜, ÔÈ ËÏÂÎÙÚÔÏË͛˜ ¤¯Ô˘Ó ÂÚÈÔÚÈÛÙ› ÁÈ·Ù› Û ÔÏÏ¿ Û›ÙÈ· ÙÔÔıÂÙÔ‡ÓÙ·È È· ·˘ÙfiÌ·ÙÔÈ ‰È·ÎfiÙ˜. Â) OÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Â›Ó·È Û˘¯Ó‹ ÌÔÚÊ‹ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿, ·ÏÏ¿ Û¿ÓÈ· ı·Ó·ÙËÊfiÚ˜. OÈ Û˘¯ÓfiÙÂÚÔÈ ÙÚfiÔÈ ‰ËÏËÙËÚ›·Û˘ ÛÙ· ·È‰È¿ Â›Ó·È Ë Î·Ù¿ÔÛË Î·È Û·ÓÈfiÙÂÚ· Ë ÂÈÛÓÔ‹ ‹ Ë ·ÔÚÚfiÊËÛË ·fi ÙÔ ‰¤ÚÌ·. ∞fi ¤Ú¢ӷ ÛÙËÓ ∞¶∫¶∞, ÙÔ 80% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó ÂÍ·ÈÙ›·˜ ‰ËÏËÙËÚÈ¿ÛˆÓ, Â›Ó·È Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ. ∆Ô Â›‰Ô˜ Ì ÙÔ ÔÔ›Ô ‰ËÏËÙËÚÈ¿˙ÔÓÙ·È Ù· ·È‰È¿ ¤¯ÂÈ Û¯¤ÛË: i) ªÂ ÙÔ ÂıÓÈÎfi Î·È ‚ÈÔÙÈÎfi Â›Â‰Ô (.¯. ÛÙȘ ˘fi ·Ó¿Ù˘ÍË ¯ÒÚ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ʈÙÈÛÙÈÎfi Î·È ıÂÚÌ·ÓÙÈÎfi ÙÔ ÂÙڤϷÈÔ, ÙÔ 40% ÙˆÓ
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‰ËÏËÙËÚÈ¿ÛÂˆÓ ÔÊ›ÏÔÓÙ·È Û’·˘Ùfi). ii) ªÂ ÙȘ Û˘Ó‹ıÂȘ Ù˘ ˙ˆ‹˜ ÙÔ˘ Ï·Ô‡. ™ÙȘ ¯ÒÚ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ Áο˙È, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Ì CO η٤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË. iii) ªÂ ÙË Û‡ÓıÂÛË ÙÔ˘ ÏËı˘ÛÌÔ‡: ·È‰È¿ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‰ËÏËÙËÚÈ¿˙ÔÓÙ·È Â˘ÎÔÏfiÙÂÚ· ÌÂ Ê˘ÙÔÊ¿Ú̷η Î·È ÂÓÙÔÌÔÎÙfiÓ·. iv) ªÂ ÙÔ Ú‡̷ Ù˘ Û‡Á¯ÚÔÓ˘ Û˘ÓÙ·ÁÔÁÚ·Ê›·˜. ÛÙ) ∆· ·Ù˘¯‹Ì·Ù· ÏfiÁˆ ¯Ú‹Û˘ ÂÚÁ·Ï›ˆÓ (Ì·¯·›ÚÈ·, „·Ï›‰È·), Ì˯·ÓËÌ¿ÙˆÓ (ÙÚ˘¿ÓÈ·) Î·È fiÏˆÓ Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ ·È‰ÈÒÓ ·fi Â΢ÚÛÔÎÚfiÙËÛË ÁÂÌ¿ÙÔ˘ ˘ÚÔ‚fiÏÔ˘ fiÏÔ˘ Â›Ó·È ÙÔ ¯ÂÈÚfiÙÂÚÔ ·Ú¿‰ÂÈÁÌ· ÁÔÓÂ˚΋˜ ·Ì¤ÏÂÈ·˜). ∆· ̤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ˘Ô¯ÚÂÒÛÂȘ ÙfiÛÔ Ù˘ ÔÏÈÙ›·˜ fiÛÔ Î·È Ù˘ ›‰È·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ÔÏÈÙ›· Ú¤ÂÈ: ·) Ó· ÂÓËÌÂÚÒÓÂÈ Ì ÂȉÈο ÛÂÌÈÓ¿ÚÈ·, fiˆ˜ Î·È ÂȉÈΤ˜ ÂÎÔ̤˜ ÛÙ· ªª∂, ·È‰È¿, ÁÔÓ›˜ Î·È ‰·ÛοÏÔ˘˜ ÁÈ· ÙÔ˘˜ ÙÚfiÔ˘˜ ·ÔÊ˘Á‹˜ Î·È ÚÔÛÙ·Û›·˜ ·fi Ù· ·Ù˘¯‹Ì·Ù·, ‚) Ó· ÂÓÈÛ¯‡ÂÈ Ù· ΤÓÙÚ· ‰ËÏËÙËÚÈ¿ÛÂˆÓ ‹ ¿ÏÏ· ÂȉÈο ΤÓÙÚ· Ô˘ ¤¯Ô˘Ó ÁÈ· ¤ÚÁÔ ÙÔ˘˜ ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, Á) Ó· ˘Ô¯ÚÂÒÓÂÈ ÙȘ Ê·ÚÌ·ÎÔ‚ÈÔÌ˯·Ó›Â˜, ‚ÈÔÌ˯·Ó›Â˜ ·È¯ÓȉÈÒÓ Î.Ï. Ó· ÂÊ·ÚÌfi˙Ô˘Ó ÂȉÈÎÔ‡˜ ηÓfiÓ˜ ·ÛÊ·Ï›·˜. ∏ ÔÈÎÔÁ¤ÓÂÈ· Ú¤ÂÈ Ó· ÂÈÎÂÓÙÚÒÓÂÈ ÙÔ ÂӉȷʤÚÔÓ Ù˘: ·) ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ Û¯Â‰›ˆÓ ηٷÛ΢‹˜ ÙÔ˘ ÛÈÙÈÔ‡ Î·È Û fi,ÙÈ ˘¿Ú¯ÂÈ Û ·˘Ùfi, ‚) ÛÙËÓ ·Ó·ÁÓÒÚÈÛË, ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Î·È ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÎÈÓ‰‡ÓˆÓ, ·Ú¿ÏÏËÏ· Ì ÙËÓ ·˘ÛÙËÚfi-
Paediatriki 2001;64:261-267
ÙÂÚË ÂÈÙ‹ÚËÛË. ™ÙÔÓ ¶›Ó·Î· 1 ·Ó·Ê¤ÚÔÓÙ·È ÂÈÁÚ·ÌÌ·ÙÈο Ù¤ÙÔȘ Ô‰ËÁ›Â˜. ∞Ù˘¯‹Ì·Ù· ·Ó·„˘¯‹˜ Î·È ·ıÏËÙÈο ∞ÊÔÚÔ‡Ó ÌÂÌÔӈ̤ӷ ¿ÙÔÌ· ‹ Î·È ÔÌ¿‰Â˜. ∆· ·ıÏ‹Ì·Ù· Î·È „˘¯·ÁˆÁÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ô˘ ÚÔηÏÔ‡Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·Ù˘¯ËÌ¿ÙˆÓ, Û˘¯Ó¿ ÛÔ‚·ÚÒÓ, Â›Ó·È Ë ÎÔχ̂ËÛË, Ë È·Û›·, ÙÔ „¿ÚÂÌ·, ÙÔ ÛÎÈ (ÛÙÔ ‚Ô˘Ófi Î·È ÙË ı¿Ï·ÛÛ·), Ë ¿ÏË, ÂÓÒ Û˘¯Ó¿ Â›Ó·È Ù· ·Ù˘¯‹Ì·Ù· Î·È ÛÙËÓ ·È‰È΋ ¯·Ú¿. ∂ȉÈÎfiÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÎÔχ̂ËÛË, ·Ó Î·È Ë ∂ÏÏ¿‰· Â›Ó·È ¯ÒÚ· Ô˘ ‚Ú¤¯ÂÙ·È ·fi ı¿Ï·ÛÛ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ¿ÓıÚˆÔÈ ‰ÂÓ Í¤ÚÔ˘Ó ÎÔχÌÈ. ŒÙÛÈ, Ô ÓÈÁÌfi˜ ·ÔÙÂÏ› ÛÔ‚·Ú‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ (ÙË ‰Â‡ÙÂÚË) ÛÙËÓ ÂÊË‚›·. ∞˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ‰È·ÙÚ¤¯Ô˘Ó fiÛÔÈ ‚Ú›ÛÎÔÓÙ·È ˘fi ÙËÓ Â‹ÚÂÈ· ·ÏÎÔfiÏ˘ Î·È Ó·ÚΈÙÈÎÒÓ ‹ Â›Ó·È ÂÈÏËÙÈÎÔ›. º˘ÛÈο, ‰È·Ê¤ÚÂÈ Ô ÓÈÁÌfi˜ ÛÙË ı¿Ï·ÛÛ· ·’ fiÙÈ ÛÙËÓ ÈÛ›Ó·, fiÔ˘ ÏfiÁˆ ˘ÂÚˆÛ̈ÙÈÎfiÙËÙ·˜ ÚÔηÏ› ÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. ∏ ÂÊ·ÚÌÔÁ‹ ηÓfiÓˆÓ ·ÛÊ·Ï›·˜ Â›Ó·È Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ÚfiÏ˄˘ ·fi Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿: ∆¤ÙÔÈÔÈ Î·ÓfiÓ˜ ›ӷÈ: ·) OÈ ·È‰fiÙÔÔÈ ‰ÂÓ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È ‰›Ï· Û ‰ÚfiÌÔ˘˜, Ó· Â›Ó·È ·Ê‡Ï·ÎÙ˜ ‹ ¯ˆÚ›˜ ÂÚ›ÊÚ·ÍË. ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· ËÁ·›ÓÔ˘Ó ÂΛ ÌfiÓ· ÙÔ˘˜. ‚) ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· ËÁ·›ÓÔ˘Ó ÁÈ· ÎÔχ̂ËÛË ¯ˆÚ›˜ ÛˆÛ›‚ÈÔ. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË. ∏ ·ÁÚ‡ÓËÛË ÛÙȘ ‰ËÌfiÛȘ ÈÛ›Ó˜ Î·È ÛÙȘ ·ÎÙ¤˜ Ì ÂȉÈΤ˜ ÔÌ¿‰Â˜ ÂÏ·ÙÙÒÓÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÈÁÌÒÓ. ™ÙȘ ȉȈÙÈΤ˜ ÈÛ›Ó˜ ÂÈ‚¿ÏÏÂÙ·È
¶›Ó·Î·˜ 1. O‰ËÁ›Â˜ ÁÈ· ÙËÓ ÚfiÏË„Ë ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ 1. ºÚÔÓÙ›ÛÙ ÒÛÙ ÛÙÔ ‰È·Ì¤ÚÈÛÌ· ‹ ÛÙÔ Û›ÙÈ Û·˜ Î·È ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ Ó· ˘¿Ú¯Ô˘Ó ÚԉȷÁڷʤ˜ ·ÛÊ¿ÏÂÈ·˜. O ηٿÏÏËÏÔ˜ ʈÙÈÛÌfi˜ ̤۷ Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ Â›Ó·È ··Ú·›ÙËÙÔ ÛÙÔȯ›Ô. 2. ªËÓ ÂÁηٷÏ›ÂÙ ÔÙ¤ ÙÔ ·È‰› Û·˜ ÌfiÓÔ ÛÙÔ Û›ÙÈ ‹ Û ÂÈΛӉ˘Ó· ÛËÌ›· ̤۷ Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÓ‹ÏÈÎÔ˘. 3. ∞ÔÌ·ÎÚ‡ÓÂÙ ٷ ÂÈΛӉ˘Ó· ·È¯Ó›‰È· ·fi ÙÔ Û›ÙÈ Î·È ÌËÓ ·Ê‹ÓÂÙ ÔÙ¤ ÂÈΛӉ˘Ó· Ú¿ÁÌ·Ù· ÛÙ· ¯¤ÚÈ· ÙˆÓ ·È‰ÈÒÓ. 4. ªËÓ ·Ê‹ÓÂÙ ÛËÌ·ÓÙÈ΋ ÔÛfiÙËÙ· ÓÂÚÔ‡ Û ÌÂÁ¿Ï· ‰Ô¯Â›· ‹ ÛÙÔ Ì¿ÓÈÔ Î·È ·ÛÊ·Ï›ÛÙ ηϿ ËÁ¿‰È·, ÛÙ¤ÚÓ˜ ‹ ¿ÏÏÔ˘˜ ¯ÒÚÔ˘˜ Û˘ÏÏÔÁ‹˜ ÓÂÚÔ‡. 5. ªËÓ Î˘ÎÏÔÊÔÚ›Ù Ì ÊÏÈÙ˙¿ÓÈ· ˙ÂÛÙÒÓ ÚÔÊËÌ¿ÙˆÓ ·ÚfiÛÂÎÙÔÈ Î·È ·‰ÂÈ¿ÛÙ fiÏ· Ù· ÔÙ‹ÚÈ· ÌÂ Ù˘¯fiÓ ˘ÔÏ›ÌÌ·Ù· ÔÙÒÓ. 6. ÷ÌËÏÒÛÙ ÙÔ ıÂÚÌÔÛÙ¿ÙË ÙÔ˘ ıÂÚÌÔۛʈӷ, ‰È·ÙËÚ›ÛÙ ۂËṲ̂Ó˜ ÙȘ ÂÛٛ˜ Ù˘ ÎÔ˘˙›Ó·˜ fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·È Î·Ï‡ÙÂÙ ¿ÓÙÔÙ ÙȘ ËÏÂÎÙÚÈΤ˜ Ú›˙˜. 7. µÂ‚·Èˆı›Ù fiÙÈ ‚Ú›ÛÎÔÓÙ·È Û ·ÛÊ·Ï‹ ÛËÌ›· ÙÔ ÛȉÂÚˆÙ‹ÚÈÔ Î·È Ù· ʈÙÈÛÙÈο Î·È ÊÚÔÓÙ›ÛÙ ӷ ˘¿Ú¯ÂÈ Û‡ÛÙËÌ· ·ÛÊ·Ï›·˜ ÛÙÔÓ ›Ó·Î· ÙÔ˘ ËÏÂÎÙÚÈÎÔ‡. 8. ∆ÔÔıÂÙ›ÛÙ Û ·Î›Ó‰˘ÓË ı¤ÛË ¤ÈÏ· Ì ·È¯ÌËÚ¿ ¿ÎÚ· Î·È ·ÔʇÁÂÙ ÙȘ fiÚÙ˜ Ì Ù˙¿ÌÈ· Î·È ·˘Ù¤˜ Ô˘ ÎÏ›ÓÔ˘Ó ÌfiÓ˜ ÙÔ˘˜. 9. ∂Í·ÛÊ·Ï›ÛÙ fiÙÈ ÔÈ ÛοϘ ‰ÂÓ Â›Ó·È ·fiÙÔ̘ Î·È Á˘·ÏÈÛÙÂÚ¤˜, fiˆ˜ Î·È Ù· ·ÙÒÌ·Ù· ÙÔ˘ ÛÈÙÈÔ‡. 10. ™˘ÓËı›ÛÙ ӷ ÎÏ›ÓÂÙ ÙÔ Î¿Ï˘ÌÌ· Ù˘ ÙÔ˘·Ï¤Ù·˜, ÌËÓ ·Ê‹ÓÂÙ ӷ ÎÚ¤ÌÂÙ·È ÙÔ ÎÔÚ‰fiÓÈ ·fi ÙȘ ÂÚÛ›‰Â˜ Î·È ·ÔÌ·ÎÚ‡ÓÂÙ ηڤÎϘ ‹ ÙÚ·¤˙È· ·fi Ù· ·Ú¿ı˘Ú· ÙÔ˘ ÛÈÙÈÔ‡. 11. ™Ù·Ì·Ù›ÛÙ ӷ ¯ÚËÛÈÌÔÔț٠ϷÛÙÈΤ˜ Û·ÎԇϘ Î·È ÂÍ·ÛÊ·Ï›ÛÙ fiÙÈ Ô ÛÎÔ˘È‰ÔÙÂÓÂΤ˜ ʤÚÂÈ Î¿Ï˘ÌÌ· Ô˘ ·ÓÔ›ÁÂÈ ‰‡ÛÎÔÏ· Î·È ‚Ú›ÛÎÂÙ·È Û ·ÛʷϤ˜ ÛËÌ›Ô. 12. ∂Í·Ê·Ó›ÛÙ ٷ Ê˘Ù¿ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ‰ËÏËÙËÚ›·ÛË. 13. ™Ô‚·Ú¢Ù›ÙÂ Î·È Ê˘Ï¿ÍÙ ÙÔ Î˘ÓËÁÂÙÈÎfi ‹ ÙÔ ˘ËÚÂÛÈ·Îfi Û·˜ fiÏÔ Û ۛÁÔ˘ÚÔ ÛËÌ›Ô, ¿‰ÂÈÔ Î·È ·ÛÊ·ÏÈṲ̂ÓÔ. º˘Ï¿ÍÙ ÛÊ·›Ú˜, ÛοÁÈ· Î·È Ì·ÚÔ‡ÙÈ Û ¿ÏÏÔ ÛËÌ›Ô, Û›ÁÔ˘ÚÔ Î·È ·ÛʷϤ˜. 14. ªËÓ ·Ê‹ÓÂÙ ʿÚ̷η Î·È ÙÛÈÁ¿Ú· Û ÚÔÛÈÙ¿ ÛËÌ›· Î·È ÎÏ›ÛÙ ηϿ Ù· ÓÙÔ˘Ï¿È·.
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¶·È‰È·ÙÚÈ΋ 2001;64:261-267
ÂÚ›ÊÚ·ÍË. ŸÔ˘ ‰ÂÓ ˘¿Ú¯ÂÈ, ÔÈ ÓÈÁÌÔ› Â›Ó·È 10Ï¿ÛÈÔÈ. ∞Ó¿ÏÔÁ· ̤ÙÚ· Ú¤ÂÈ Ó· ÙËÚÔ‡ÓÙ·È Û fiÏ· Ù· ·ıÏ‹Ì·Ù·. ∆ÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙËÓ ÂÊ˂›·. ™Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ÛȉËÚÔ‰ÚÔÌÈο Î·È Ù· ·ÂÚÔÔÚÈο, Ù· ÔÔ›· ·Ó Î·È Û˘Ì‚·›ÓÔ˘Ó Û·ÓÈfiÙÂÚ·, Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÛÔ‚·Ú¿. ™ÙËÓ ∂˘ÚÒË, Ë ∂ÏÏ¿‰·, Ë ¶ÔÚÙÔÁ·Ï›· Î·È Ë πÛ·Ó›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔ˘˜ ÈÔ ·˘ÍË̤ÓÔ˘˜ ‰Â›ÎÙ˜ Ô‰È΋˜ ıÓËÛÈÌfiÙËÙ·˜. ∏ ∂ÏÏ¿‰· ‰Â, η٤¯ÂÈ ÙËÓ ÚÒÙË ı¤ÛË ÛÙËÓ Â› ÙÔȘ ÂηÙfi ·Ó·ÏÔÁ›· ‰È¿ıÂÛ˘ ÙÔ˘ ∞∂¶ (2,5% ÂÚ›Ô˘) ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÂÓÒ Ù· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ÛÙȘ ∏¶∞ Â›Ó·È 1,5% Î·È ÛÙË ™Ô˘Ë‰›· 0,85%. ¶·Ú’ fiÏ· ·˘Ù¿, ÛÙËÓ ∂ÏÏ¿‰· ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈÔÈ ·’ fiÙÈ ·ÁÎÔÛÌ›ˆ˜, Û ۯ¤ÛË Ì ÙÔÓ ÏËı˘ÛÌfi Ù˘. ™ÙËÓ ∂ÏÏ¿‰· ¤¯Ô˘Ì ÂÙËÛ›ˆ˜ 2.000 ı·Ó¿ÙÔ˘˜, 4.000 ÛÔ‚·ÚÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ Î·È 30.000 ÂÏ·ÊÚ‡ÙÂÚÔ˘˜. ™ÙËÓ ∂˘ÚÒË, ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ·ÚÈıÌÔ› Â›Ó·È 70.000 ı¿Ó·ÙÔÈ Î·È 2.000.000 ÙÚ·˘Ì·Ù›Â˜, ÂÓÒ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ ÛËÌÂÈÒÓÔÓÙ·È 300.000 ı¿Ó·ÙÔÈ Î·È 8.000.000 ÙÚ·˘Ì·Ù›Â˜. ªÂ ÙÔ˘˜ Ú˘ıÌÔ‡˜ ·˘ÙÔ‡˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ 1:3 E˘Úˆ·›Ô˘˜ ·ı·›ÓÂÈ ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Î·È 1:100 ¯¿ÓÂÈ ÙË ˙ˆ‹ ÙÔ˘. ∆Ô 1/3 ÙˆÓ ÓÂÎÚÒÓ Î·È ÙˆÓ ÙÚ·˘Ì·ÙÈÒÓ Â›Ó·È ·È‰È¿. ∆Ô ÙÚ·ÁÈÎfi ·˘Ùfi ÁÂÁÔÓfi˜ Á›ÓÂÙ·È ¯ÂÈÚfiÙÂÚÔ ·Ó ˘ÔÏÔÁ›ÛÂÈ Î·Ó›˜ fiÙÈ ÂÎÙfi˜ ·fi ÙÔ˘˜ ı·-
Paediatriki 2001;64:261-267
Ó¿ÙÔ˘˜, ÔÏÏÔ› ·fi ÙÔ˘˜ ÙÚ·˘Ì·Ù›Â˜ ̤ÓÔ˘Ó ·Ó¿ËÚÔÈ Î·È fiÙÈ Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ˘ÁÈ‹ Î·È Ó·ڿ ¿ÙÔÌ·. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÎÏËÛË Ô‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ Ê·›ÓÂÙ·È ˆ˜ ¤¯Ô˘Ó Û¯¤ÛË: ·) Ì ÙÔ ›‰ÈÔ ÙÔ ·È‰›, ÙËÓ ËÏÈΛ· ÙÔ˘ Î·È ÙȘ Ê˘ÛÈΤ˜ ·‰˘Ó·Ì›Â˜ Ô˘ ÔÊ›ÏÔÓÙ·È Û ·˘Ù‹, ‚) Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘, ÙÔ˘˜ ÁÔÓ›˜ Î·È ÙÔ˘˜ ‰·ÛοÏÔ˘˜ ÙÔ˘, ÙËÓ Âη›‰Â˘ÛË Î·È ÙËÓ ÂÓË̤ڈÛË Ô˘ ÙÔ˘ ·Ú¤¯Ô˘Ó, Á) Ì ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô‰ÈÎÔ‡ ‰ÈÎÙ‡Ô˘ Î·È ‰) Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Ô‰ËÁÒÓ (¶›Ó·Î·˜ 2). OÈ ÛÔ‚·ÚfiÙÂÚ˜ ·Ú·‚¿ÛÂȘ ·fi ÙÔ˘˜ Ô‰ËÁÔ‡˜, Ô˘ ηٿ ηÓfiÓ· Ô‰ËÁÔ‡Ó Û ı·Ó·ÙËÊfiÚ· ‹ ÛÔ‚·Ú¿ ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∞fi ÛÙÔȯ›· Ù˘ ÙÚÔ¯·›·˜ Ê·›ÓÂÙ·È ˆ˜ ÙÔ ™·‚‚·ÙÔ·ÚÈ·ÎÔ Á›ÓÔÓÙ·È Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Î·È ˆ˜ ÙȘ Ó˘¯ÙÂÚÈÓ¤˜ ÒÚ˜, ·Ó Î·È Î˘ÎÏÔÊÔÚ› ÙÔ 1/10 ÙˆÓ Ô¯ËÌ¿ÙˆÓ, Û˘Ì‚·›ÓÂÈ ÙÔ 1/3 ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™ÙËÓ ∞ı‹Ó· Ê·›ÓÂÙ·È ˆ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ô Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤¯ÂÈ ÌÂȈı›, ¤¯Ô˘Ó fï˜ ·˘ÍËı› Ù· ı·Ó·ÙËÊfiÚ· ·Ù˘¯‹Ì·Ù·. ∆Ô ·˘ÙÔΛÓËÙÔ ¤¯ÂÈ ‚ÚÂı› ˆ˜ Â›Ó·È 45 ÊÔÚ¤˜ ÂÈÛʷϤÛÙÂÚÔ Û ۯ¤ÛË Ì ÙÔ ·ÂÚÔÏ¿ÓÔ Î·È ÙÔ ÛȉËÚfi‰ÚÔÌÔ. ∆Ô ·È‰›, ‚¤‚·È·, ÌÔÚ› Ó· ‚ÚÂı› ˆ˜ ı‡Ì· ÙÚÔ¯·›Ô˘ ›Ù ˆ˜ Â˙fi˜, ›Ù ˆ˜ ÂÈ‚¿Ù˘ ‹ Ô‰ËÏ¿Ù˘ ‹ Î·È ˆ˜ Ô‰ËÁfi˜, ·ÚÁfiÙÂÚ·, Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·. ∆Ô ·È‰› ˆ˜ Â˙fi˜ ∆Ô 30% ÙˆÓ ÓÂÎÚÒÓ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È Â˙Ô› Î·È Î˘Ú›ˆ˜ ·È‰È¿ ηÈ
¶›Ó·Î·˜ 2. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÎÏËÛË Ô‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ ∞) ∏ ÌÈÎÚ‹ ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ì ÙȘ ·‰˘Ó·Ì›Â˜ Ù˘ - ÙÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È ÙÔ ÌÈÎÚfiÙÂÚÔ ÔÙÈÎfi ‰›Ô - Ë ·ÈÛıËÙËÚȷ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·ÓˆÚÈÌfiÙËÙ· - Ë ·‰˘Ó·Ì›· ÁÓÒÛ˘ ÙˆÓ ÛËÌ¿ÙˆÓ - Ë ÔÚÌËÙÈÎfiÙËÙ· Î·È ·ÚÔÚÌËÙÈÎfiÙËÙ· - Ë ÁÔËÙ›· Ô˘ ÚÔηÏ› Ô Î›Ó‰˘ÓÔ˜ - Ë ËÏÈΛ·, ÙÔ Ê‡ÏÔ, Ë ÎÔÈÓˆÓÈ΋ Ù¿ÍË, Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜, Ô ¯ÚfiÓÔ˜ Û˘Ì‚¿ÓÙÔ˜ µ) ∆Ô ·ÓıÚÒÈÓÔ ÂÚÈ‚¿ÏÏÔÓ (ÁÔÓ›˜, ÎˉÂÌfiÓ˜ Î.Ï.) - ·ÁÓÔÔ‡Ó ÙÔ˘˜ ÛÙ·ıÌÔ‡˜ ÂͤÏÈ͢ Î·È ˆÚ›Ì·ÓÛ˘ ÙˆÓ ·È‰ÈÒÓ - ˘ÂÚÂÎÙÈÌÔ‡Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙˆÓ ·È‰ÈÒÓ - Á›ÓÔÓÙ·È ÔÈ ›‰ÈÔÈ Î·Î¿ ·Ú·‰Â›ÁÌ·Ù· - ‰ÂÓ ‰›ÓÔ˘Ó ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙËÓ Âη›‰Â˘ÛË Î·È ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ - ‰ÂÓ ÂӉȷʤÚÔÓÙ·È È‰È·›ÙÂÚ· ÁÈ· ÙËÓ Î˘ÎÏÔÊÔÚȷ΋ ·ÁˆÁ‹ ÙˆÓ ·È‰ÈÒÓ °) O ¯ˆÚÔÙ·ÍÈÎfi˜ Î·È Î˘ÎÏÔÊÔÚÈ·Îfi˜ ÂÚ›Á˘ÚÔ˜ - Ô Û¯Â‰È·ÛÌfi˜ ÙˆÓ ‰ÚfiÌˆÓ (ÌÔÓfi‰ÚÔÌÔÈ, ‰È·‚¿ÛÂȘ, ÛËÌ·ÙÔ‰fiÙËÛË) - Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ΢ÎÏÔÊÔÚ›·˜ (ÙÚÔ¯ÔÊfiÚ·, Ù·¯‡ÙËÙ˜ Î.Ï.) - ¿ÏÏÔÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (‰fiÌËÛË ÁÂÈÙÔÓÈ¿˜, ·È‰fiÙÔÔÈ, Û¯ÔÏ›·, ηٷÛÙ‹Ì·Ù· Î.Ï.) ¢) OÈ ·‰˘Ó·Ì›Â˜ ÙˆÓ Ô‰ËÁÒÓ - η΋ Û˘ÓÙ‹ÚËÛË Ô¯ËÌ¿ÙˆÓ - ÂÈÔÏ·ÈfiÙËÙ·, ¤ÏÏÂÈ„Ë Âη›‰Â˘Û˘ - ÌË Ù‹ÚËÛË Î·ÓfiÓˆÓ Î.Ô.Î.
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¶·È‰È·ÙÚÈ΋ 2001;64:261-267
¤ÊË‚ÔÈ, ÂÓÒ ÛÙËÓ ∂˘ÚÒË ÙÔ ÔÛÔÛÙfi η٤گÂÙ·È ÛÙÔ 20% Î·È ÛÙȘ ∏¶∞ ÛÙÔ 16%. ∆Ô ·È‰› ˆ˜ Â˙fi˜ ÌÂÈÔÓÂÎÙ› ÛËÌ·ÓÙÈο ÁÈ· ÙÔ˘˜ ÏfiÁÔ˘˜ Ô˘ ‹‰Ë ·Ó·Ê¤ÚıËÎ·Ó ÎÈ ¤ÙÛÈ ¯ÚÂÈ¿˙ÂÙ·È ÂÈÙ‹ÚËÛË Î·È Âη›‰Â˘ÛË: ·) ·È‰È¿ <5 ¯ÚfiÓˆÓ ¤¯Ô˘Ó ·Ó¿ÁÎË ·fi Û˘Ó¯‹ Î·È ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË fiÙ·Ó Â›Ó·È ÛÙÔ ‰ÚfiÌÔ, ‚) ·È‰È¿ <7 ¯ÚfiÓˆÓ Â›Ó·È ·ÓÒÚÈÌ· Î·È ·ÚÔÚÌËÙÈο Î·È Â‡ÎÔÏ· ·ÎÔÏÔ˘ıÔ‡Ó ÙËÓ ·Ú¤·, Á) ·È‰È¿ <9 ¯ÚfiÓˆÓ ÌÔÚÔ‡Ó Ó· ‰È·Û¯›ÛÔ˘Ó ÙÔ ‰ÚfiÌÔ ¯ˆÚ›˜ ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ·ÊÔ‡ ÂÎ·È‰Â˘ÙÔ‡Ó, ÂÓÒ, ‰) ·È‰È¿ >12 ¯ÚfiÓˆÓ ÌÔÚÔ‡Ó Ó· Û˘ÌÂÚÈʤÚÔÓÙ·È ÛˆÛÙ¿ Û·Ó Â˙Ô› ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜. ™ÙËÓ Î˘ÎÏÔÊÔÚȷ΋ ·ÁˆÁ‹ ¤Ú·Ó ÙˆÓ ÁÓˆÛÙÒÓ ‚·ÛÈÎÒÓ ÂÓÓÔÈÒÓ (Ë ÛËÌ·ÙÔ‰fiÙËÛË ˆ˜ ·Ú¿‰ÂÈÁÌ·) Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë Î·Ù·ÓfiËÛË ÙˆÓ fiÚˆÓ: ‹¯Ô˜ ·fiÛÙ·ÛË, Ù·¯‡ÙËÙ·. ∆Ô ·È‰› ˆ˜ ÂÈ‚¿Ù˘ °È· ÙËÓ ·ÛÊ·Ï‹ ÌÂÙ·ÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂ÓÔÈ ‚·ÛÈÎÔ› ηÓfiÓ˜ Ô˘ ÔÈΛÏÔ˘Ó ·fi ¯ÒÚ· Û ¯ÒÚ· (¶›Ó·Î·˜ 4): ·) ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· οıÔÓÙ·È ÁÈ· ηӤӷ ÏfiÁÔ ÛÙÔ ÌÚÔÛÙÈÓfi οıÈÛÌ· ·ÏÏ¿ ¿ÓÙÔÙ ÛÙÔ ›Ûˆ. ∂›Û˘, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÛÙÔ fiÚÙÌÂ̤, ÛÙ· ÁfiÓ·Ù· ‹ ÛÙËÓ ·ÁηÏÈ¿ οÔÈÔ˘. ™Â ÂӉ¯fiÌÂÓË -·ÎfiÌË Î·È ÂÏ·ÊÚÈ¿- Û‡ÁÎÚÔ˘ÛË ‹ Û ·fiÙÔÌÔ ÊÚÂÓ¿ÚÈÛÌ· ÙÔ ·È‰› ÎÈÓ‰˘Ó‡ÂÈ Ó· ÎÙ˘‹ÛÂÈ ÛÙÔ Ù·ÌÏfi ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘. Œ¯ÂÈ ‚ÚÂı› ˆ˜ ÙÔ 90% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Î·È ÛÒıËηÓ, ÔÈ ÔÔ›ÔÈ ÎÚ·ÙÔ‡Û·Ó ·È‰È¿ ÛÙËÓ ·ÁηÏÈ¿ ÙÔ˘˜, ÛÒıËÎ·Ó ÂÂȉ‹ ÙÔ ·È‰› ÙÔ˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ·Û›‰·. ‚) ∆Ô ·È‰› Ú¤ÂÈ ¿ÓÙÔÙ ӷ οıÂÙ·È ÛÙÔ ÂȉÈÎfi οıÈÛÌ· ·ÛÊ·Ï›·˜, Ì ÙËÓ ÂȉÈ΋ ˙ÒÓË ·ÛÊ·Ï›·˜. ¶ÔÙ¤ ‰ÂÓ Ú¤ÂÈ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È 2 ·È‰È¿ Ì·˙› Û ÌÈ›· ˙ÒÓË. ªÂ ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ·È‰ÈÎÒÓ Î·ıÈÛÌ¿ÙˆÓ, ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂȈıÔ‡Ó Î·Ù¿ 70% Î·È ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› ηٿ 67%. ∞fi ÙÔ˘˜ ÁÔÓ›˜, fï˜, Ô˘ ̤ÓÔ˘Ó ÛÙËÓ ∞ı‹Ó· Î·È ¤¯Ô˘Ó ·˘ÙÔΛÓËÙÔ, ÌfiÓÔ ÙÔ 58% ·ÁÔÚ¿˙ÂÈ ·È‰Èο ηı›ÛÌ·Ù· ·˘ÙÔ¶›Ó·Î·˜ 3. ¶Ô‡ ÔÊ›ÏÔÓÙ·È Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·; 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
¶·Ú·‚È¿ÛÂȘ ÛËÌ·ÙÔ‰fiÙË ¶·Ú·‚È¿ÛÂȘ ÚÔÙÂÚ·ÈfiÙËÙ·˜ ªË Ù‹ÚËÛË ·fiÛÙ·Û˘ ·ÛÊ·Ï›·˜ ÀÂÚ‚ÔÏÈ΋ Ù·¯‡ÙËÙ· ∫›ÓËÛË ÛÙÔ ·ÓÙ›ıÂÙÔ Ú‡̷ ∞ÓÙÈηÓÔÓÈ΋ ·ÏÏ·Á‹ ψڛ‰·˜ ΢ÎÏÔÊÔÚ›·˜ O‰‹ÁËÛË ˘fi ÙËÓ Â‹ÚÂÈ· „˘¯ÔÙÚfiˆÓ Ô˘ÛÈÒÓ ÕÁÓÔÈ· ÛˆÛÙ‹˜ Ô‰‹ÁËÛ˘ ∫Ô‡Ú·ÛË ÙÔ˘ Ô‰ËÁÔ‡, ·fiÛ·ÛË ÚÔÛÔ¯‹˜ ÃÚ‹ÛË ÂÎÙ˘ÊψÙÈÎÒÓ ÊÒÙˆÓ ∫·Î‹ ηٿÛÙ·ÛË ÙÚÔ¯ÔÊfiÚÔ˘
Paediatriki 2001;64:261-267
ÎÈÓ‹ÙÔ˘ ÂÓÒ ÛÙËÓ Â·Ú¯›· ÙÔ 32%. ∏ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÁÔÚ¿. ∫·È Ê˘ÛÈο ÌfiÓÔ ÙÔ 0,51% ·ÁÔÚ¿˙ÂÈ ÙÔ ÙÂÏÂ˘Ù·›·˜ Ù¯ÓÔÏÔÁ›·˜ οıÈÛÌ· ·ÛÊ·Ï›·˜ Ô˘ Â›Ó·È ÂȉÈÎfi ÁÈ· ÙÔ ‚¿ÚÔ˜, ÙËÓ ËÏÈΛ·, ÙÔ ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ·Ú¤¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÚÔÛÙ·Û›·. ∏ ˙ÒÓË ·ÛÊ·Ï›·˜ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÛÙ· ›Ûˆ ηı›ÛÌ·Ù·, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÂÈ ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ηٿ 22% Î·È ÙÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ 50%. ∆ÔÓ›˙ÂÙ·È, ‚¤‚·È·, ˆ˜ Ë ˙ÒÓË ·ÛÊ·Ï›·˜ ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË fiÙ·Ó ÙÔ ‰È·ÁÒÓÈÔ ÙÌ‹Ì· Ù˘ ÂÚÓ¿ ·fi ÙÔ Ì¤ÛÔ ÂÚ›Ô˘ Ù˘ ·fiÛÙ·Û˘ ÌÂٷ͇ ÙÔ˘ ¿ÎÚÔ˘ ÙÔ˘ ÒÌÔ˘ Î·È ÙÔ˘ Ï·ÈÌÔ‡. Á) ¶ÔÙ¤ Ù· ·È‰È¿ ÛÙÔ ·˘ÙÔΛÓËÙÔ Ì ÎÚ·ÙÒÓÙ·˜ ÂÈΛӉ˘Ó· ·È¯Ó›‰È·. ‰) OÈ fiÚÙ˜ ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ú¤ÂÈ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È ·fi ÙËÓ ¤Íˆ ÏÂ˘Ú¿. ¶ÔÏÏ¿ ·È‰È¿ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È ‹ Î·È ÛÎÔÙÒÓÔÓÙ·È ¤ÊÙÔÓÙ·˜ ¤Íˆ ·fi ÙËÓ fiÚÙ· ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ô˘ ·ÓÔ›ÁÂÈ ·fiÙÔÌ· Û ÛÙÚÔÊ‹ ‹ fiÙ·Ó ·›˙Ô˘Ó Ì ÙËÓ fiÚÙ· ¯ˆÚ›˜ Ó· ÊÔÚÔ‡Ó ˙ÒÓË. ∆Ô ·È‰› ˆ˜ Ô‰ËÁfi˜ ∆Ô ·È‰› ÌÔÚ› Ó· Â›Ó·È Ô‰ËÁfi˜ Ô‰ËÏ¿ÙÔ˘, ÌÔÙÔÛ˘ÎϤٷ˜ ‹, ˆ˜ ¤ÊË‚Ô˜, ·˘ÙÔÎÈÓ‹ÙÔ˘. ∫·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ·È‰› Ô˘ ·›˙ÂÈ Î·È ÙÔ ÚfiÏÔ ÙÔ˘ Ô‰ËÁÔ‡, ÙËÓ ˆÚÈÌfiÙËÙ·, ÙËÓ Âη›‰Â˘ÛË, ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô¯‹Ì·ÙÔ˜, ÙËÓ ·˘ÛÙËÚ‹ Ù‹ÚËÛË ÙÔ˘ ÎÒ‰Èη Ô‰È΋˜ ΢ÎÏÔÊÔÚ›·˜ Û ۯ¤ÛË ¿ÓÙ· Ì ÙÔ ¯ˆÚÔÙ·ÍÈÎfi ÂÚ›Á˘ÚÔ. OÈ ŒÏÏËÓ˜ Û˘ÁÎÔÈÓˆÓÈÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó ˆ˜ Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô‰ÈÎÔ‡ ‰ÈÎÙ‡Ô˘ Ù˘ ¯ÒÚ·˜ ¢ı‡ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi fiÏÔ˘˜ ÙÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ. ª¤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ∆· ÚÔÛ¯‹ ¯ÚfiÓÈ· ·Ó·Ì¤ÓÂÙ·È Ó· ·˘ÍËı› Ë ıÓËÙfiÙËÙ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·fi Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, Û·Ó ·ÔÙ¤ÏÂÛÌ· Ù˘ ·‡ÍËÛ˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Ù·ÍȉÈÒÓ Ì ·˘ÙÔΛÓËÙÔ (ÂÚÈÛÛfiÙÂÚ˜ ÔÈÎÔÁ¤ÓÂȘ ·ÔÎÙÔ‡Ó ·˘ÙÔΛÓËÙÔ Î·È ¶›Ó·Î·˜ 4. ¶Ò˜ Ú¤ÂÈ Ó· Ù·ÍÈ‰Â‡Ô˘Ó Ù· ·È‰È¿; ·) ¶ÔÙ¤ ÛÙÔ ÌÚÔÛÙÈÓfi, ·ÏÏ¿ ¿ÓÙ· ÛÙÔ ›Ûˆ οıÈÛÌ· ‚) ¶ÔÙ¤ ÛÙÔ ÔÚÙ-ÌÂ̤, ÛÙ· ÁfiÓ·Ù· ‹ ÙËÓ ·ÁηÏÈ¿ οÔÈÔ˘ Á) ¡· ÌËÓ ÎÚ·ÙÔ‡Ó ÂÈΛӉ˘Ó· ·È¯Ó›‰È· ‰) ¶¿ÓÙ· ÛÙÔ ÂȉÈÎfi οıÈÛÌ· ·ÛÊ·Ï›·˜ Ì ÙËÓ ÂȉÈ΋ ˙ÒÓË Â) ¶ÔÙ¤ ‰‡Ô ·È‰È¿ Û ̛· ˙ÒÓË ·ÛÊ·Ï›·˜ ÛÙ) OÈ fiÚÙ˜ ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È ·’ ¤Íˆ.
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ÂÍÔ¯È΋ ηÙÔÈΛ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ù·ÍÈ‰Â‡Ô˘Ó Û˘¯ÓfiÙÂÚ·, ÂÓÒ ÌÂÁ·Ï‡ÙÂÚÔ˜ Â›Ó·È Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÙ·ÎÈÓÂ›Ù·È Ì ·˘ÙÔΛÓËÙÔ ÛÙÔ˘˜ ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜ Î·È Ù· Û¯ÔÏ›·). °È· ÙÔ ÏfiÁÔ ·˘Ùfi ¯ÚÂÈ¿˙ÂÙ·È È‰È·›ÙÂÚË ÚÔÛ¿ıÂÈ· Î·È Î·Ù¿ÏÏËÏÔ˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ ÚfiÏ˄˘, ÒÛÙ ӷ ‚ÂÏÙȈıÔ‡Ó ÔÈ ‰Â›ÎÙ˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ó· ˘¿ÚÍÂÈ Ì›ˆÛË ·Ó·ËÚÈÒÓ Î·È ı·Ó¿ÙˆÓ. ∆¤ÙÔÈ· ÚÔÁÚ¿ÌÌ·Ù· ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Û ÔÏϤ˜ ¯ÒÚ˜ Î·È ·¤‰ˆÛ·Ó. ™ÙËÓ ∂ÏÏ¿‰· ¯ÚÂÈ¿˙ÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ÚÔÛ¿ıÂÈ·. ∆· ηχÙÂÚ· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ‰ÈÂıÓÒ˜ Ê·›ÓÂÙ·È Ó· ·Ô‰›‰Ô˘Ó ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: 1) ÃÚ‹ÛË Î·Ù¿ÏÏËÏ˘ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ Î·È ÂȉÈÎÔ‡ ηı›ÛÌ·ÙÔ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÛÙ· ‚Ú¤ÊË, Ù· ÌÈÎÚfiÙÂÚ· Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∏ ¯Ú‹ÛË ÎÚ¿ÓÔ˘˜ ·fi ÙÔ˘˜ ÌÔÙÔÛ˘ÎÏÂÙÈÛÙ¤˜ Î·È ÙÔ˘˜ Ô‰ËÏ¿Ù˜ Ê·›ÓÂÙ·È ˆ˜ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÛÙÔ ÎÂÊ¿ÏÈ Î·Ù¿ 85%, 2) ·˘ÛÙËÚfiÙÂÚË ·ÛÙ˘ÓfiÌ¢ÛË ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ∫.O.∫., 3) ·˘ÛÙËÚfiÙÂÚÔ ¤ÏÂÁ¯Ô ·Ó›¯Ó¢Û˘ ·ÏÎÔfiÏ˘ ÛÙÔ ·›Ì· ηٿ ÙËÓ Ô‰‹ÁËÛË, 4) ηχÙÂÚË Âη›‰Â˘ÛË Î·È ·˘ÛÙËÚfiÙÂÚË ÂͤٷÛË ÁÈ· ÙË Ï‹„Ë ¿‰ÂÈ·˜ Ô‰‹ÁËÛ˘, 5) ÛˆÛÙ‹ Û˘ÓÙ‹ÚËÛË ÙˆÓ Ô¯ËÌ¿ÙˆÓ Î·ıÒ˜ Î·È ·˘ÛÙËÚfi˜ Î·È Ù·ÎÙÈÎfi˜ ¤ÏÂÁ¯fi˜ ÙÔ˘˜, 6) ‚ÂÏÙ›ˆÛË ÙˆÓ Ô‰ÈÎÒÓ ‰ÈÎÙ‡ˆÓ, ÛˆÛÙ‹ Û‹Ì·ÓÛË, ηχÙÂÚË ÔÚ·ÙfiÙËÙ·, ηχÙÂÚË ‰fiÌËÛË. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ ÛËÌÂÚÈÓfi Ô‰ÈÎfi ‰›ÎÙ˘Ô Ù˘ ¯ÒÚ·˜ Ì·˜ ‰ÂÓ ¤¯ÂÈ ÚÔ¸Ôı¤ÛÂȘ ·ÛÊ·Ï›·˜ ÂÓÒ ÌfiÓÔ ÛÙÔ 10% ÙˆÓ Ô‰ÒÓ ÌÔÚÔ‡Ó Ó· ·Ó·Ù˘¯ıÔ‡Ó Ù·¯‡ÙËÙ˜ Ô˘ Ó· ÍÂÂÚÓÔ‡Ó Ù· 80 ¯ÈÏ./ÒÚ·. ∂·ÁÁÂÏÌ·ÙÈο ·Ù˘¯‹Ì·Ù· ∂·ÁÁÂÏÌ·ÙÈο Â›Ó·È Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÁ·Û›·˜. ¢˘ÛÙ˘¯Ò˜ Î·È Û‹ÌÂÚ·, ÛÙÔÓ 21Ô ·ÈÒÓ·, Ù¤ÙÔÈ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó ÂÎÙfi˜ ·fi ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Û ÌÈÎÚfiÙÂÚ· ·È‰È¿, ·ÊÔ‡ Ë ÂÚÁ·Û›· ÁÈ· ÔÏÏ¿ ·È‰È¿ Â›Ó·È ÙÔ ÌÔÓ·‰ÈÎfi ̤ÛÔ ÂÈ‚›ˆÛ˘. ¢ÈÂıÓÒ˜, Ë ıÓËÛÈÌfiÙËÙ· ·fi ·ÁÁÂÏÌ·ÙÈο ·Ù˘¯‹Ì·Ù· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ÂÚÁ·˙fiÌÂÓÔ˘˜ Û ÔÚ˘¯Â›·, Ï·ÙÔÌ›·, ÔÈÎÔ‰Ô̤˜, ÁˆÚÁÈÎÔ‡˜ ¯ÒÚÔ˘˜, ηıÒ˜ Î·È ÛÙÔ Û˘ÁÎÔÈÓˆÓÈ·Îfi ÙÔ̤·, ÙȘ ÌÂÙ·ÊÔÚ¤˜, ÙË ‚ÈÔÌ˯·Ó›· Î·È Ù· Ó·˘ÙÈο ·ÁÁ¤ÏÌ·Ù·. ø˜ Û˘¯ÓfiÙÂÚÔÈ ÙÚfiÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·Ó·Ê¤ÚÔÓÙ·È: ·) ÔÈ ¯ÂÈÚÈÛÌÔ› ¯ÂÈÚˆÓ·ÎÙÈÎÒÓ ÂÚÁ·Ï›ˆÓ ‹ Ì˯·ÓËÌ¿ÙˆÓ Î·È Ë ÙÒÛË ÙÔ˘ ·ÙfiÌÔ˘ ‹ ·ÓÙÈÎÂÈ̤ӈÓ, ‚) Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, Ô ÔÔ›Ô˜ Â›Ó·È Ô ¯ÂÈÚfiÙÂÚÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜. ∞ÎÔÏÔ˘ıÔ‡Ó ÙÔ ÎÂÊ¿ÏÈ, Ù· Ì¿ÙÈ· Î·È Ù· ‰¿ÎÙ˘Ï· ÙˆÓ ¯ÂÚÈÒÓ. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Â·ÁÁÂÏÌ·ÙÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ Â›‰Ô˜ Ù˘ ÂÚÁ·Û›·˜, ηıÒ˜ Î·È ÙËÓ ÂÌÂÈÚ›·, ÙËÓ ¤ÓÙ·ÛË, ÙËÓ ÂÍ¿ÓÙÏËÛË, ÙËÓ ÚÔÛˆÈÎfiÙËÙ·
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ÙÔ˘ ÂÚÁ·˙fiÌÂÓÔ˘ Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜. ∆Ô 95% ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜ ı· ÌÔÚÔ‡Û·Ó Ó· ÚÔÏËÊıÔ‡Ó ·Ó ÂÊ·ÚÌfi˙ÔÓÙ·Ó Ù· ÂÓ‰ÂÈÎÓ˘fiÌÂÓ· ̤ÙÚ· ÚfiÏ˄˘. ¶ÂÚÈ‚·ÏÏÔÓÙÈο ·Ù˘¯‹Ì·Ù· ™Ù· ÂÚÈ‚·ÏÏÔÓÙÈο ·Ù˘¯‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ˘ÚËÓÈο, Ù· ¯ËÌÈο, ÔÈ ˘ÚηÁȤ˜, ÔÈ ıÂÔÌËӛ˜ (ÛÂÈÛÌÔ›, ÏËÌ̇Ú˜, Ù˘ÊÒÓ˜), Ù· ÔÔ›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂËÚ¿ÛÔ˘Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÙÔ˘ ÏËı˘ÛÌÔ‡. °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ Û˘ÓÂÂÈÒÓ ·˘ÙÒÓ ÙˆÓ Î·Ù·ÛÙÚÔÊÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÔÚÁ·ÓˆÌ¤ÓË Ì¤ıÔ‰Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ ·fi ÙËÓ ÔÏÈÙ›· Î·È Ï‹Ú˘ ÂÓË̤ڈÛË fiÏÔ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È ÙˆÓ ·È‰ÈÒÓ ÁÈ· ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ∏ ÔÚ›· ÙˆÓ ı˘Ì¿ÙˆÓ ·Ù˘¯‹Ì·ÙÔ˜ ∆Ô ·È‰›, ÌÂÙ¿ ÙÔ ·Ù‡¯ËÌ·, ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜, ÒÛÙ ӷ ·Ú·Û¯Âı› Ë Î·Ù·ÏÏËÏfiÙÂÚË Î·È Ë Ï¤ÔÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‚Ô‹ıÂÈ·. ™ÙÔ ™¯‹Ì· 1 ·ÂÈÎÔÓ›˙ÂÙ·È Ë ÔÚ›· ÙÔ˘ ı‡Ì·ÙÔ˜ ·fi ·Ù‡¯ËÌ·. ¶ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ∆· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÛÔ‚·ÚfiÙ·ÙÔ Úfi‚ÏËÌ· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ fiÏˆÓ ÙˆÓ ¯ˆÚÒÓ Î·È ·˘Ùfi ÂÂȉ‹ ΢ڛˆ˜ ·ÊÔÚÔ‡Ó ÙÔ Ó·ÓÈÎfi Î·È ˘ÁÈ‹ ÏËı˘ÛÌfi, ¿ÏÏ· Î·È ‰ÈfiÙÈ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó. ∆· ·Ù˘¯‹Ì·Ù· ‰ÂÓ ÚÔηÏÔ‡ÓÙ·È ·fi “ηÎÔÙ˘¯›·”. E›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÙÔ ·ÓıÚÒÈÓÔ Ï¿ıÔ˜, Ë ·Ê¤ÏÂÈ·, Ë ·ÂÚÈÛ΄›·, Ë ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, Ë ¿ÁÓÔÈ·. A˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ì ˘Ô¯Ú¤ˆÛË Ó· ÚÔÏ¿‚Ô˘ÌÂ. ∏ ÂÊ·ÚÌÔÁ‹ ÔÏÔÎÏËÚˆÌ¤ÓˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ ÚÔ¸Ôı¤ÙÂÈ ÌÂϤÙË ·fi Û·Ê‹ ÂȉËÌÈÔÏÔÁÈ΋ ¿Ô„Ë Î·È ·Ó¿Ï˘ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË Û˘¯ÓfiÙËÙ·, ÙË ‚·Ú‡ÙËÙ·, ÙÔ ÎfiÛÙÔ˜ Î·È ÁÂÓÈο ÙȘ Û˘Ó¤ÂȘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÚÒÙ· ÁÈ· Ù· ı‡Ì·Ù· Î·È ‡ÛÙÂÚ· ÁÈ· ÙËÓ ∂ıÓÈ΋ OÈÎÔÓÔÌ›·. ∏ ™˘ÓÔÌÔÛÔÓ‰›· ∂˘Úˆ·˚ÎÒÓ ∂ȉÈÎÔÙ‹ÙˆÓ ÛÙËÓ ¶·È‰È·ÙÚÈ΋, ·fi ÙË Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ Ô˘ ¤Î·Ó ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, η٤ÏËÍ ÛÙÔ Û˘Ì¤Ú·ÛÌ· ˆ˜ Ë ‰ËÌÈÔ˘ÚÁ›· ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Â›Ó·È ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Ì¤ÙÚÔ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿, ÂÓÒ Ë Âη›‰Â˘ÛË ¤ÂÙ·È ÛÙË ÛÂÈÚ¿. ™ÙËÓ ∂ÏÏ¿‰·, Ôχ Ï›Á· ̤ÙÚ· ÚfiÏ˄˘ Â›Ó·È ˘Ô¯ÚˆÙÈο Ì ÓfiÌÔ˘˜, ·ÏÏ¿ Î·È fiÛ· ¤¯Ô˘Ó ıÂÛÈÛÙ› ‰ÂÓ ÙËÚÔ‡ÓÙ·È, ·Ú’ fiÏÔ Ô˘ Ë Î·Ù¿ÛÙ·ÛË ÛÙÔ ¯ÒÚÔ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Â›Ó·È ·fi ÙÚ·ÁÈ΋ ¤ˆ˜ ‰Ú·Ì·ÙÈ΋. OÈ ·È‰›·ÙÚÔÈ Î·Ù¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË, Ë ÔÔ›· ÙÔ˘˜ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·Ú¤Ì‚Ô˘Ó ‰˘Ó·ÌÈο ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ
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·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. ªÔÚÔ‡Ó Ó· ›ÛÔ˘Ó ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ·˘ÍË̤ÓË Â·ÁÚ‡ÓËÛË Î·È ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ ÁÈ· ·ÔÊ˘Á‹ ·Ù˘¯ËÌ¿ÙˆÓ, Û˘Ì‚Ô˘Ï‡ÔÓÙ¿˜ ÙÔ˘˜ ÌËÓ ˘ÂÚÂÎÙÈÌÔ‡Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙˆÓ ·È‰ÈÒÓ Î·È Ó· ÌËÓ ÂÚÈÊÚÔÓÔ‡Ó ÙÔÓ Î›Ó‰˘ÓÔ. ∂›Û˘, ÌÔÚÔ‡Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙÔ Ó· ÏËÊıÔ‡Ó Ì¤ÙÚ· ÁÈ· ÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÒÛÙ ӷ ‰ËÌÈÔ˘ÚÁËı› ·ÛʷϤ˜ ÂÚÈ‚¿ÏÏÔÓ ÛÙÔ Û›ÙÈ, ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜, ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ·Ó·„˘¯‹˜. OÈ ·È‰›·ÙÚÔÈ ÌÔÚÔ‡Ó Ó· ··ÈÙ‹ÛÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·ÛÊ·ÏÒÓ ÚÔ˚fiÓÙˆÓ, fiˆ˜ ·È¯Ó›‰È· Î·È Û˘Û΢·Û›Â˜ Ê·ÚÌ¿ÎˆÓ ÂÊ·ÚÌfi˙ÔÓÙ·˜ ÓÔÌÔıÂÙÈΤ˜ ·ÏÏ·Á¤˜. ™ËÌ·ÓÙÈ΋, ›Û˘, Â›Ó·È Ë ·Ú¤Ì‚·Û‹ ÙÔ˘˜ ÛÙËÓ Âη›‰Â˘ÛË, ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ÛÙÔ È·ÙÚ›Ô, ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÛÙ· ªª∂. ∆Ô ·Ú¯·›Ô ÚËÙfi “ηχÙÂÚ· Ó· ÚÔÏ·Ì‚¿ÓÂȘ ·Ú¿ Ó· ıÂڷ‡ÂȘ” ÈÛ¯‡ÂÈ Î·ÙÂÍÔ¯‹Ó ÛÙÔÓ ÙÔ̤· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ.
7.
8. 9.
10.
11. 12.
13.
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∞Ó·ÛÙ·Û¤·-µÏ¿¯Ô˘ ∫. ∞Ù˘¯‹Ì·Ù· ÛÙËÓ ∂Ê˂›·. ¢ÂÏÙ. ∞’ ¶·È‰È·ÙÚ. ∫ÏÈÓ. ¶·ÓÂ. ∞ıËÓÒÓ 1997;44:138-141. 2. Agran P, Castillo D, Winn D. Childhood motor vehicle occupant injuries. Am J Dis Child 1990;144:653-662. 3. Agran P. Childhood motor vehicle occupant injuries. Am J Dis Child 1990;144:641-642. 4. µ·ÙÔ‡ ∂. ¶·È‰È¿ ¯ˆÚ›˜ “ÔÌڤϷ” ÚÔÛÙ·Û›·˜. ∂Ï¢ıÂÚÔÙ˘›·; 2000, 22 ª·ÚÙ›Ô˘. 5. Christoffer K, Scheidt P, Agran P. Standard definition for childhood injury research: excerpts from a conference report. Pediatrics 1992;89:1027-1034. 6. Chorba T, Klein T. Increases in crash involvement and
14. 15.
16.
fatalities among motor vehicle occupants younger than 5 years old. Pediatrics 1993;91:847-901. ¢ËÌfiÔ˘ÏÔ˜ ¡. ∫·ÎÒÛÂȘ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. Focus. (™‡Á¯ÚÔÓË π·ÙÚÈ΋ ∂ÓË̤ڈÛË) 1996;76:36-43. ¢ËÌfiÔ˘ÏÔ˜ ¡. ∆ÚÔ¯·›· ·Ù˘¯‹Ì·Ù·. ¶ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË. ∂ÈıÂÒÚËÛË ÀÁ›·˜ 1996;41:97-98. Eichelberger M, Gotschall C, Feely H, Harstad P, Bowman L. Parental attitudes and knowledge of child safety. Am J Dis Child 1990;144:714-720. Johnston C, Hivara F, Soderberg R. Children in car crashes. Analysis of data for injury and use of restraints. Pediatrics 1994;93:960-965. ∫ÙÂÓ¿˜ ∂. O‰Èο ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ∂ÏÏ¿‰·. π·ÙÚÈ΋ 1994;65:181-183. ∫ˆÛÙ·Ú›‰Ô˘ ™, ∞Ó·ÛÙ·Û¤·-µÏ¿¯Ô˘ ¶, ™ˆÙËÚÔÔ‡ÏÔ˘ º, ¶·Ó·ÁÔÔ‡ÏÔ˘ ª, ¶·Ó·ÁÔÔ‡ÏÔ˘ °, ∑·¯·ÚÈ¿‰Ë ∞ Î·È Û˘Ó. ¶ÚfiÏË„Ë ÙÚÔ¯·›ˆÓ ηÎÒÛˆÓ: ™˘Óı‹Î˜ ÌÂÙ·ÊÔÚ¿˜ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÙÔ ·˘ÙÔΛÓËÙÔ. ¶·È‰È·ÙÚÈ΋ 1996;59:325-333. Rivara F, Thompson D, Thompson R. The seattle children’s bicycle helmet campaign, changes in helmet use and head injury admissions. Pediatrics 1994;93:567-569. Rosenberg M, Rodriguez J, Chorba T. Childhood injuries, where we are. Pediatrics 1990;89(Suppl):1084-1091. Sosin D, Sacks J, Holmgreen P. Head injuryassociated deaths from motorcycle crashes. JAMA 1990;264:2395-2399. ™ÙÔȯ›· ÛÔÎ ÁÈ· ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ÙÚÔ¯·›·. ∆· ¡¤·; 2000, 23 ª·ÚÙ›Ô˘.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: KˆÓÛÙ·ÓÙ›ÓÔ˜ ∆ÛÔ˘Ì¿Î·˜ ¢. ªfiÛ¯· 8, ª·ÚÔ‡ÛÈ, 151 24 ∞ı‹Ó·
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Paediatriki 2001;64:268-271
EMERGENCY AND INTENSIVE CARE PEDIATRICS
AÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ∫. ¶·¿˙ÔÁÏÔ˘
Management of the child with multiple trauma K. Papazoglou
¶ÂÚ›ÏË„Ë: ∆Ô ·È‰ÈÎfi ÙÚ·‡Ì· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfiÙ·ÙÔ Úfi‚ÏËÌ· ÂÂȉ‹ Ù· ·È‰È¿, ›Ù ˆ˜ Â˙Ô› ›Ù ˆ˜ Ô‰ËÏ¿Ù˜, ˘fiÎÂÈÓÙ·È Û 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ··ÈÙ› ¿ÌÂÛË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È ·ÍÈÔÏfiÁËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ù˘ ΢ÎÏÔÊÔÚ›·˜ Î·È Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘ Î·È ÂÓ Û˘Ó¯›· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ÂÓÂÚÁÂÈÒÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó¿ÓË„Ë Î·È ÛÙ·ıÂÚÔÔ›ËÛË ÙˆÓ ÙÚÈÒÓ ·˘ÙÒÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. ∏ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ¿ÌÂÛË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì¤Û· ÛÙËÓ ÚÒÙË ÒÚ· - ÙË ÏÂÁfiÌÂÓË “¯Ú˘Û‹ ÒÚ·” - Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË fiÛÔ Î·È ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ‹ ÙÔ˘ ·È‰ÈÔ‡ Ì ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË.
Abstract: Pediatric trauma remains a significant problem because children as pedestrians or bicyclists have a threefold danger as compared to adults. Successful resuscitation of the injured child begins with the recognition of the critical nature of the airway. Children could tolerate hypotension, but they are exquisitely sensitive to cerebral hypoxia. The early assessment and the rapid and prompt resuscitation and treatment of the respiratory, circulatory and nervous systems during the first “golden hour” remains the cornerstone not only for the survival, but also for the good prognosis and outcome of the severely injured children.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ÙÚ·‡Ì·, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË ÛÙ· ·È‰È¿, ÂÎÙ›ÌËÛË, ·ÓÙÈÌÂÙÒÈÛË, “¯Ú˘Û‹ ÒÚ·”.
Key words: pediatric trauma, initial assessment, treatment, “golden hour”.
™ÙȘ Û‡Á¯ÚÔÓ˜ ÎÔÈӈӛ˜, Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·, ÙÔ ÙÚ·‡Ì· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ˘Á›·˜. ™ÙËÓ EÏÏ¿‰· ¤¯ÂÈ Ï¿‚ÂÈ Û¯Â‰fiÓ ‰È·ÛÙ¿ÛÂȘ ÂȉËÌÈ΋˜ ÓfiÛÔ˘ ÏfiÁˆ ÙˆÓ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. TÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ, ηıÒ˜ Ù· ·È‰È¿ - Û·Ó Â˙Ô› ‹ Ô‰ËÏ¿Ù˜ - ‰È·ÙÚ¤¯Ô˘Ó 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·’ fiÙÈ ÔÈ ÂÓ‹ÏÈΘ. ™ÙȘ H¶A, 8.000 ·È‰È¿ ¤ı·Ó·Ó Û’ ¤Ó· ¯ÚfiÓÔ ÏfiÁˆ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ÂÚ›Ô˘ 2.000.000 ÓÔÛËχıËÎ·Ó Î·È 100.000 ·Ú¤ÌÂÈÓ·Ó Ì ÌfiÓÈÌ· Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·.
∆· ‰Â‰Ô̤ӷ ÛÙËÓ EÏÏ¿‰· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·fi Ù· ·ÎfiÏÔ˘ı· ÛÙÔȯ›·: ™Â ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜ (1996) 230 ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 15 ÂÙÒÓ ÚÔÛ‹Ïı·Ó ÛÙÔ NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡” Ì ÙÚ·‡Ì·Ù· ÏfiÁˆ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ηٿ ÙÔ ÔÔ›Ô ‹Ù·Ó ÂÈ‚¿Ù˜ ·˘ÙÔÎÈÓ‹ÙÔ˘. ™ÙÔ˘˜ 12 Ì‹Ó˜ ÙÔ˘ 1998, 612 ·È‰È¿ - ÙÚ·˘Ì·Ù›Â˜ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ÂÈ‚¿Ù˜ Î·È Â˙Ô›, ÚÔÛ‹Ïı·Ó ÛÙ· E͈ÙÂÚÈο I·ÙÚ›· ÙÔ˘ ·ÓˆÙ¤Úˆ NÔÛÔÎÔÌ›Ԣ. T· ÛÙÔȯ›· ·˘Ù¿ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ K¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ AÙ˘¯ËÌ¿ÙˆÓ, Ù˘ Œ‰Ú·˜ YÁÈÂÈÓ‹˜ Î·È EȉËÌÈÔÏÔÁ›·˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ.
¶·È‰›·ÙÚÔ˜ - EÓÙ·ÙÈÎÔÏfiÁÔ˜ AÓ·ÏËÚÒÙÚÈ· ¢È¢ı‡ÓÙÚÈ· Ù˘ M.E.£. NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
Pediatric Intensive Care Specialist Associate Director of PICU Children’s Hospital “P. & A. Kyriakou”, Athens
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™ÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜ ÙÔ˘ NÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡” ÂÈÛ¿ÁÔÓÙ·È ÂÙËÛ›ˆ˜ 26-30 ·È‰È¿ Ì ‚·Ú‡ ÙÚ·˘Ì·ÙÈÛÌfi, ÏfiÁˆ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ¢ÂÓ Â›Ó·È ·ÎÚÈ‚‹˜, ›Û˘, Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ô˘ ηٷϋÁÔ˘Ó ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Û fiÏË ÙËÓ EÏÏ¿‰·. OÈ ı¿Ó·ÙÔÈ ÛÙ· ·È‰È¿ ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ ÂÈÛ˘Ì‚·›ÓÔ˘Ó Û 2 ¯ÚfiÓÔ˘˜: ¿ÌÂÛ· Î·È Ì¤Û· ÛÙȘ ÚÒÙ˜ ÒÚ˜ ‹ ÌÂÙ¿ ·fi ÂÚ›Ô˘ 4 Ë̤Ú˜. A˘Ùfi Â›Ó·È È‰È·›ÙÂÚ˘ ÛËÌ·Û›·˜, ÁÈ·Ù› Ë Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ¿ÌÂÛË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì¤Û· ÛÙËÓ ÚÒÙË ÒÚ· ·fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi - ÙË “¯Ú˘Û‹ ÒÚ·” - Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË, fiÛÔ Î·È ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡. A˘Ùfi˜ Ô ¯ÚfiÓÔ˜ Ù˘ ÚÒÙ˘ “¯Ú˘Û‹˜” ÒÚ·˜ ¯ˆÚ›˙ÂÙ·È Û 2 ÛÙ¿‰È·: ̤۷ ÛÙ· ÚÒÙ· 30 min ı· Ú¤ÂÈ Ó· Á›ÓÂÈ Ù·˘Ùfi¯ÚÔÓ· Ë ÚÒÙË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ·È‰ÈÔ‡ ÔÏ˘ÙÚ·˘Ì·Ù›· Î·È Ë ·Ó¿ÓË„Ë ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ (primary survey). ŒÂÈÙ·, ÛÙÔ 2Ô ÛÙ¿‰ÈÔ, ·ÎÔÏÔ˘ı› Ì›· ‰Â‡ÙÂÚË - ÈÔ ÏÂÙÔÌÂÚÂȷ΋ - ÎÏÈÓÈ΋ ÂͤٷÛË, Ë ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ Î·È Ô ‰È·ÁÓˆÛÙÈÎfi˜ Î·È ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (second survey). EÂȉ‹ ̤۷ ÛÙÔÓ fiÚÔ “·ÓÙÈÌÂÙÒÈÛË” ÂÌÂÚȤ¯ÂÙ·È, ÂȉÈο fiÛÔÓ ·ÊÔÚ¿ οÔÈ· ›ÁÔ˘Û· ηٿÛÙ·ÛË, Ë ‚·ÛÈÎfiÙ·ÙË ¤ÓÓÔÈ· Ù˘ ·ÍÈÔÏfiÁËÛ˘, ÙÔ Ï·›ÛÈÔ ÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ‹ ÙÔ˘ È·ÙÚÔ‡ Ô˘ ı· ‚ÚÂı› ÙËÓ ÚÒÙË ÒÚ· ÎÔÓÙ¿ ÛÙÔ ·È‰› Ú¤ÂÈ Ó· Â›Ó·È ÙÔ ÂÍ‹˜: Ë ÚÒÙË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ÁÚ‹ÁÔÚ· - Û 1 min Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·˜ ·ÍÈÔÏfiÁËÛË: ·) Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ‚) Ù˘ ΢ÎÏÔÊÔÚ›·˜ Î·È Á) Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘. T· ·È‰È¿ Ì ÛÔ‚·Ú‹ οΈÛË ‰È·ÎÚ›ÓÔÓÙ·È Û¯ÂÙÈο ‡ÎÔÏ· ·fi ÙËÓ ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ ÛÙËÓ ·Ó·ÓÔ‹, ÙËÓ ‡·ÚÍË ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ηٷÏËÍ›·˜ Î·È ·fi ÙË Ì›ˆÛË ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘. E› ˘¿Ú͈˜ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó·ÎÔ‹˜ ÂÊ·ÚÌfi˙ÂÙ·È ¿ÌÂÛ· Ë B·ÛÈ΋ AÓ¿ÓË„Ë (∂ÈÎfiÓ· 1). ¢È·ÊÔÚÂÙÈο, ÔÈ ÂÓ¤ÚÁÂȘ Ô˘ ··ÈÙÔ‡ÓÙ·È
Airway (·ÂÚ·ÁˆÁÔ›)
ηٿ ÛÂÈÚ¿ ÚÔÙÂÚ·ÈfiÙËÙ·˜ Â›Ó·È ÔÈ ÂÍ‹˜: ∏ ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô˘ ı· Á›ÓÂÈ Ì ÙËÓ ·Ú·Ù‹ÚËÛË Ù˘ Û˘ÌÌÂÙÚÈ΋˜ ‹ ÌË ¤ÎÙ˘Í˘ ÙÔ˘ ıÒڷη, Ù˘ ‡·Ú͢ Ù·¯‡ÓÔÈ·˜ ‹ ÂÚÁÒ‰Ô˘˜ ·Ó·ÓÔ‹˜ ‹ ˘fiÓÔÈ·˜, ‹ ·Ú¿‰Ô͢ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜. ∆·˘Ùfi¯ÚÔÓ·, Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁËı› ÙÔ ¯ÚÒÌ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ. H ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, Ë ÔÔ›· Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË Î·È Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË O2 100% Ì ̿Ûη ‹ Ì ̿Ûη Î·È ambu, ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÂÈÛÚfiÊËÛ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ·È‰ÈÔ‡ Û ηٿÏÏËÏË ı¤ÛË, ÙËÓ ÂÓ‰ÔÙÚ·¯Âȷ΋ ‰È·ÛˆÏ‹ÓˆÛË Î·È ÂÓ ·Ó¿ÁÎË ÙËÓ ÎÚÈÎÔı˘ÚÂÔÂȉÔÙÔÌ‹ ‰È¿ ‚ÂÏfiÓ˘ (Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· Û ÓÔÛÔÎÔÌÂ›Ô ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÍÂȉÈÎÂ˘Ì¤Ó˘ ÌÂÙ·ÊÔÚ¿˜). OÈ ÙÚÂȘ ÛÔ‚·ÚfiÙÂÚ˜ ηÎÒÛÂȘ ÙÔ˘ ıÒڷη ›ӷÈ: ·) Ô Ó¢ÌÔÓÔıÒڷη˜ ˘fi Ù¿ÛË, Ô˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο ›ÁÔÓ Úfi‚ÏËÌ· Î·È ··ÈÙ› ¿ÌÂÛË ·Ú·Î¤ÓÙËÛË ‰È¿ ‚ÂÏfiÓ˘ ÛÙÔ 2Ô ÌÂÛÔχÚÈÔ ‰È¿ÛÙËÌ·, ÛÙË ÌÂÛÔÎÏÂȉÈ΋ ÁÚ·ÌÌ‹ Î·È ÂÓ Û˘Ó¯›· ÙÔÔı¤ÙËÛË Büllau, ‚) Ô ·ÓÔÈÎÙfi˜ Ó¢ÌÔÓÔıÒڷη˜, Ô˘ ··ÈÙ› ÂȈ̷ÙÈÛÌfi Ì Á¿˙˜ Î·È ÙÔÔı¤ÙËÛË Büllau Û ¿ÏÏÔ ÛËÌÂ›Ô ÙÔ˘ ıÒڷη Î·È Á) Ù· ‰ÈÏ¿ ηٿÁÌ·Ù· ÂÚÈÛÛfiÙÂÚˆÓ ÙˆÓ 2 Ï¢ÚÒÓ, Ô˘ ÂÂȉ‹ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÙËÓ ·Ó·ÓÔ‹, ··ÈÙÔ‡Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ŒÓ· ¿ÏÏÔ ÛËÌÂ›Ô ˘„›ÛÙ˘ ÛËÌ·Û›·˜ ÂΛÓË ÙËÓ ÚÒÙË ‰‡ÛÎÔÏË, ·ÏÏ¿ ÎÚ›ÛÈÌË, ÒÚ· Â›Ó·È fiÙÈ Ë ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ‚·ÙfiÙËÙ·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È Ë Ô͢ÁfiÓˆÛË ÙÔ˘ ·È‰ÈÔ‡ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ٷ˘Ùfi¯ÚÔÓË ÚÔÛÙ·Û›· Ù˘ ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (∞ª™™). K¿ı ·È‰› ÔÏ˘ÙÚ·˘Ì·Ù›·˜ ı· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ Î¿ÎˆÛË Ù˘ ∞ª™™, ̤¯ÚȘ ·Ô‰Â›Íˆ˜ ÙÔ˘ ÂÓ·ÓÙ›Ô˘. £· Ú¤ÂÈ, ÏÔÈfiÓ, Ó· ·ÔʇÁÔÓÙ·È ÔÈ ‚›·ÈÔÈ ¯ÂÈÚÈÛÌÔ› (fi¯È ¤ÎÙ·ÛË ‹ ¤ÓÙÔÓË Î¿Ì„Ë ÙÔ˘ ·˘¯¤Ó·), ÙÔ ÎÂÊ¿ÏÈ ı· Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È Û Ԣ‰¤ÙÂÚË ı¤ÛË, “ÛÙÂÚˆ̤ÓÔ” Û ·˘Ù‹
Breathing (·Ó·ÓÔ‹)
Circulation (΢ÎÏÔÊÔÚ›·)
EÈÎfiÓ· 1. µ·ÛÈ΋ ·Ó¿ÓË„Ë.
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ÙË ı¤ÛË Ì ÙË ‚Ô‹ıÂÈ· Ù·ÈÓ›·˜ Ï¢ÎÔÏ¿ÛÙË ‹ ‚·Ú¤ˆÓ ·ÓÙÈÎÂÈÌ¤ÓˆÓ ÙÔÔıÂÙËÌ¤ÓˆÓ Âη٤ڈıÂÓ Ù˘ ÎÂÊ·Ï‹˜ (ÛÙÔ ‡„Ô˜ ÙˆÓ ·˘ÙÈÒÓ). E¿Ó ˘¿Ú¯ÂÈ, ÙÔÔıÂÙÂ›Ù·È ·˘¯ÂÓÈÎfi ÎÔÏ¿ÚÔ. EÊfiÛÔÓ ·ÔηٷÛÙ·ı› ηı·Úfi˜ Î·È ·ÓÔÈÎÙfi˜ ·ÂÚ·ÁˆÁfi˜, ·Ú΋˜ ·ÂÚÈÛÌfi˜ Î·È Ô͢ÁfiÓˆÛË, ÂfiÌÂÓË ÚÔÙÂÚ·ÈfiÙËÙ· Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ·È‰ÈÔ‡. ∆· ÛÔ˘‰·ÈfiÙÂÚ· ÎÏÈÓÈο ÛËÌ›· ÂÎÙ›ÌËÛ˘ ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ ›ӷÈ: ·) ∏ ηډȷ΋ Û˘¯ÓfiÙËÙ·, Ô˘ Â›Ó·È ÁÈ· Ù· ·È‰È¿ Ô Ï¤ÔÓ Â˘·›ÛıËÙÔ˜ ‰Â›ÎÙ˘ Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∆· ·È‰È¿ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ·ÓÙÈÚÚÔÔ‡Ó Ì ·ÁÁÂÈÔÛ‡Û·ÛË Î·È ‰È·ÙËÚÔ‡Ó ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Ì ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Û ÔÛÔÛÙfi ̤¯ÚÈ Î·È 25% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ fiÁÎÔ˘. ‚) H ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ·. ∂¿Ó ˘¿Ú¯ÂÈ Ù·¯‡ÓÔÈ· Â›Ó·È ‰Â›ÎÙ˘ Á·Ï·ÎÙÈ΋˜ ÔͤˆÛ˘ ÔÊÂÈÏfiÌÂÓ˘ Û ÈÛÙÈ΋ ˘ÔÍ›· - ÌË Î·Ï‹ ¿Ú‰Â˘ÛË ÙˆÓ ÈÛÙÒÓ. Á) H ÙÚȯÔÂȉÈ΋ ΢ÎÏÔÊÔÚ›·, Ô˘ ÂϤÁ¯ÂÙ·È Ì ÙËÓ ›ÂÛË Ù˘ ÎÔ›Ù˘ ÙÔ˘ fiÓ˘¯Ô˜. E¿Ó Ë ÙÚȯÔÂȉÈ΋ ·ӷÊÔÚ¿ Â›Ó·È >2 sec, ‰ËÏÒÓÂÙ·È Î˘ÎÏÔÊÔÚÈ΋ ·Ó¿ÚÎÂÈ·. ‰) H ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∆Ô „˘¯Úfi Î·È ÎÔÏÏ҉˜ ‰¤ÚÌ· Â›Ó·È ‰Â›ÎÙ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡. Â) H Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ·. ∂¿Ó ˘¿Ú¯ÂÈ Û‡Á¯˘ÛË ‹/Î·È ÎÒÌ·, ›Ûˆ˜ ‰ËÏÒÓÂÙ·È Î·Î‹ ·ÈÌ¿ÙˆÛË ÙÔ˘ K.N.™. H ΢ÎÏÔÊÔÚÈ΋ ·Ó¿ÚÎÂÈ· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ·ÒÏÂÈ· ·›Ì·ÙÔ˜, ÓˆÙÈ·›Ô Shock (ÔÊÂÈÏfiÌÂÓÔ Û ·ÒÏÂÈ· ÙÔ˘ ÙfiÓÔ˘ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ˘fiÙ·ÛË, ‚Ú·‰˘Î·Ú‰›· Î·È ˘ÔıÂÚÌ›·) Î·È Û Ó¢ÌÔıÒڷη ˘fi Ù¿ÛË. H ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ: i) ÙËÓ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛ‹ Ù˘, ii) ÙË ¯ÔÚ‹ÁËÛË O2 100%, iii) ÙËÓ ¿ÛÎËÛË ›ÂÛ˘ ÛÙË ı¤ÛË Ù˘ ÂÓÂÚÁÔ‡ ·ÈÌÔÚÚ·Á›·˜, iv) ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË ÊÏ‚È΋˜ Ô‰Ô‡ (ÌÂÙ¿ ·fi ÚÔÛ¿ıÂÈ· 1-2 min, Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÂÓ‰ÔÔÛÙÈ΋ ‚ÂÏfiÓË) Î·È v) ÙËÓ ÂÈıÂÙÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, ÚÈÓ ÂÁηٷÛÙ·ı› ˘fiÙ·ÛË. T· ¯ÔÚËÁÔ‡ÌÂÓ· ‰È·Ï‡Ì·Ù· Û shock Â›Ó·È Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹: Ringer’s Lactate, Nacl 0,9% Î·È Ù· ÎÔÏÏÔÂȉ‹: ·ÓıÚÒÈÓË ÏÂ˘ÎˆÌ·Ù›ÓË, Hea- maccel, HAES-steril 10%. XÔÚËÁÔ‡ÓÙ·È Û ‰fiÛË 20 ml/kg*, Û 10-15 min ‹ Ì ۇÚÈÁÁ· push. E› ÌË ·Ó·Ù¿Íˆ˜ ÙÔ˘ shock, ¯ÔÚËÁÔ‡ÓÙ·È ÂÎ Ó¤Ô˘ Ì 20 ml/kg* Î·È ÛÙË Û˘Ó¤¯ÂÈ· ¯ÔÚËÁÔ‡ÓÙ·È Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿ 10 ml/kg*.
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E¿Ó, ·Ú¿ ÙËÓ ·ÓˆÙ¤Úˆ ·ÁˆÁ‹, ‰ÂÓ ˘¿Ú¯ÂÈ ‚ÂÏÙ›ˆÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜, ÙfiÙÂ Ë Èı·ÓfiÙËÙ· ÂÛˆÙÂÚÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ÎÔÈÏ›·˜ ‹ ıÒÚ·ÎÔ˜ Î·È Î·Ù·ÁÌ¿ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ Â›Ó·È ÌÂÁ¿ÏË. MÂÙ¿ ÙËÓ ÂÎÙ›ÌËÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ù˘¯fiÓ Î˘ÎÏÔÊÔÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ·ÎÔÏÔ˘ı› Ë ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡. H Ù·¯Â›· Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ “ÛËÌ›·-ÎÏÂȉȿ”: ·) ̤ÁÂıÔ˜ Î·È ·ÓÙ›‰Ú·ÛË Ù˘ ÎfiÚ˘ ÙˆÓ ÔÊı·ÏÌÒÓ ÛÙÔ Êˆ˜, ‚) ‡·ÚÍË ·ÓÈÛÔÎÔÚ›·˜ ‹ fi¯È, Á) Â›Â‰Ô Û˘Ó›‰ËÛ˘ Î·È ‰) Ù‡Ô˜ ·Ó·ÓÔ‹˜ (·ıÔÏÔÁÈ΋ ‹ ¿ÚÚ˘ıÌË). OÈ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ (KEK) ·ÔÙÂÏÔ‡Ó ÙÔ Û˘¯ÓfiÙÂÚÔ ÙÚ·˘Ì·ÙÈÛÌfi ÌÂÙ¿ ·fi ¤Ó· ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· ‹ ÙÒÛË ‹ ¿ÏÏÔ˘ ›‰Ô˘˜ ·Ù‡¯ËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ™Ù· ·È‰È¿, ÔÈ ÂÚÈÔ¯¤˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ô˘ ˘Ê›ÛÙ·ÓÙ·È Î¿ÎˆÛË, ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Â›Ó·È ÔÈ ÂÍ‹˜: ÎÂÊ·Ï‹ 51%, ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚ· 38,8%, ıÒڷη˜ 4,5%, ÎÔÈÏ›· 4,5%. TÔ 75% ÙˆÓ ·È‰ÈÒÓ Ì ÔÏÏ·Ï¿ ÙÚ·‡Ì·Ù· ¤¯ÂÈ K∂K Î·È ÙÔ 80% ÙˆÓ ı·Ó¿ÙˆÓ ÔÏ˘ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ·È‰ÈÒÓ ¤¯ÂÈ Û¯¤ÛË Ì ‚·ÚÈ¿ KEK. ø˜ ·ÈÙ›· ·˘ÙÒÓ ·Ó·Ê¤ÚÂÙ·È ÙÔ ÌÂÁ¿ÏÔ ÎÂÊ¿ÏÈ ÙˆÓ ·È‰ÈÒÓ Û ۯ¤ÛË Ì ÙÔ ˘fiÏÔÈÔ ÛÒÌ·, Ë ¯·Ï·Ú‹ Ì˘ÔÛÎÂÏÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ÙÚ·¯‹ÏÔ˘, Ë ˙ÂÏ·ÙÈÓ҉˘ Û‡ÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘˜ (ÌË Ì˘ÂÏÈÓÔÔ›ËÛË) ηıÒ˜ Î·È ¿ÏÏÔÈ ·Ó·ÙÔÌÈÎÔ› ÂÓ‰ÔÎÚ·ÓÈ·ÎÔ› ÏfiÁÔÈ. H ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û KEK ‰È·ÎÚ›ÓÂÙ·È Û ڈÙÔ·ı‹, Ô˘ ÂÈÛ˘Ì‚·›ÓÂÈ ·ÎÚÈ‚Ò˜ ÙËÓ ÒÚ· ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ (ηٿÁÌ·Ù· ÎÚ·Ó›Ô˘, ˘fiÂÈÛÎÏËÚ›‰ÈÔ ·È̿و̷, ˘·Ú·¯ÓÔÂȉ‹˜ ·ÈÌÔÚÚ·Á›·, ·ÈÌÔÚÚ·ÁÈΤ˜ ıÏ¿ÛÂȘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘) Î·È Û ‰Â˘ÙÂÚÔ·ı‹, Ô˘ ¯Ú‹˙ÂÈ È‰È·›ÙÂÚ˘ ÚÔÛÔ¯‹˜. H ‰Â˘ÙÂÚÔ·ı‹˜ ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë O2 ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. H ·Ï‹ Â͛ۈÛË Ô˘ ‰›ÓÂÈ ÙËÓ ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û·Ó ÙË ‰È·ÊÔÚ¿ Ù˘ M¤Û˘ AÚÙËÚȷ΋˜ ¶›ÂÛ˘ Î·È Ù˘ EÓ‰ÔÎÚ¿ÓÈ·˜ ¶›ÂÛ˘, ‰›ÓÂÈ Î·È ÙË ‰È¿ÛÙ·ÛË ÙˆÓ ‰‡Ô ·˘ÙÒÓ ‚·ÛÈÎfiÙ·ÙˆÓ ·Ú·Ì¤ÙÚˆÓ (¶›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÂÁÎÂÊ¿ÏÔ˘ = AÚÙËÚȷ΋ ›ÂÛË - EÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË). H ̤ÛË A¶ Ú¤ÂÈ, ÏÔÈfiÓ, Ó· ‰È·ÙËÚËı› ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÁÈ· Ó· ÂÈÙ¢¯ı› ÊÚÔÓÙ›‰· ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Î·È Ë ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË Ó· ·Ú·Ì›ÓÂÈ ≤ 20 mmHg, ¤ÙÛÈ ÒÛÙ ӷ ·ÓÙÈÌÂÙˆÈÛÙ› ÙÔ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ·. H ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ı· Ú¤ÂÈ Ó· Â›Ó·È ÛÙ·ıÂÚ‹ >50 mmHg. H ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì KEK ı· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·fi ÙË ÛÙÈÁÌ‹ ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÁÈ· ÙËÓ ÚfiÏË„Ë, ΢ڛˆ˜, ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ‚Ï·‚ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ·) ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ‚·ÙfiÙËÙ·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ‚) ÙËÓ
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¿ÌÂÛË ¯ÔÚ‹ÁËÛË O2, Á) ÙËÓ ·ÎÈÓËÙÔÔ›ËÛË Ù˘ AM™™, ‰) ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ (¿ÚÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜), Â) ÙËÓ Î·Ù¿ÏÏËÏË ı¤ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÛÙ) ÙË ¯ÔÚ‹ÁËÛË Ì·ÓÈÙfiÏ˘ 20% (‰fiÛË: 0,25-0,5 mg/kg* IV) › ÂӉ›ÍÂˆÓ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. MÂÙ¿ ÙË ÛÙ·ıÂÚÔÔ›ËÛË Î·È ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Î˘ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙËÓ ·ÍÈÔÏfiÁËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ KN™, ·ÎÔÏÔ˘ı› Ì›· ÁÚ‹ÁÔÚË ÎÏÈÓÈ΋ ÂͤٷÛË. T· ·Ú¯Èο A, B, C, D, E, ‰ÈÂıÓÒ˜ Û‹ÌÂÚ·, Û˘ÌÏ‹ÚˆÛ·Ó Ï¤ÔÓ ÙËÓ Îϛ̷η Ù˘ ÂÎÙ›ÌËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·Ù›·, ÛËÌ·ÙÔ‰ÔÙÒÓÙ·˜ Î·È ÙË ÛÂÈÚ¿ ÚÔÙÂÚ·ÈÔًوÓ. A: Airway AÂÚ·ÁˆÁÔ› B: Breathing AÓ·ÓÔ‹ C: Circulation K˘ÎÏÔÊÔÚ›· D: Disability N¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ E: Exposure ŒÎıÂÛË-ÂͤٷÛË fiÏÔ˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ TÔ ÙÂÏÂ˘Ù·›Ô, Ë ÁÚ‹ÁÔÚË ‰ËÏ·‰‹ ¤ÎıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È Ë ÎÏÈÓÈ΋ Ì ٷ ¯¤ÚÈ· ÂͤٷÛË Û 1 min, ÌÔÚ› Ó· ·Ó·Î·Ï‡„ÂÈ ÛËÌ›· - ÎÏÂȉȿ ÁÈ· ÙË Û˘ÓÔÏÈ΋ ÂÊ·ÚÌÔÁ‹ ·Ó¿Ó˄˘. ŒÌÊ·ÛË ‰›ÓÂÙ·È Î·È ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÌÂٷ͇ 36-37ÔC, Û·Ó ·Ú¿ÁÔÓÙ· ÌË ·ÔÛÙ·ıÂÚÔÔ›ËÛ˘ fiÏˆÓ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. T· fiÛ· ·Ó·Ê¤ÚıËÎ·Ó Ì¤¯ÚÈ ÙÒÚ· ·ÊÔÚÔ‡Ó Î·È Ú¤ÂÈ Ó· ·ÊÔÚÔ‡Ó Ù· ÚÒÙ· ÏÂÙ¿ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ̤۷ ÛÙÔ ·ÛıÂÓÔÊfiÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ Î·È Î·Ù¿ ÙËÓ ÚÒÙË ÒÚ· ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ̤۷ ÛÙË M.E.£. H ‰Â‡ÙÂÚË ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ ÔÏ˘ÙÚ·˘Ì·Ù›· (secondary survey) ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙÔ NÔÛÔÎÔÌÂ›Ô È· - ÌÈ· ÈÔ ÏÂÙÔÌÂÚ‹ ÎÏÈÓÈ΋ ÂͤٷÛË fiÏˆÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È Î·ÎÒÛˆÓ, ÙÔÓ ·Ó·Áη›Ô ·ÎÙÈÓÔÏÔÁÈÎfi Î·È ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È ÙËÓ ¤Ó‰ÂÈÍË - ‹ fi¯È - ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘. H ÏÔÈ‹ ÎÏÈÓÈ΋ ÂͤٷÛË ı· ÂÚÈÏ¿‚ÂÈ Ù· ÂÍ‹˜: ÙÔ ıfiÏÔ ÙÔ˘ ÎÚ·Ó›Ô˘ Î·È ÙÔ ÙÚȯˆÙfi Ù˘ ÎÂÊ·Ï‹˜ ÁÈ· Ù˘¯fiÓ Î·Ù¿ÁÌ·Ù·, ÎÂÊ·Ï·È̿و̷, ÂÎÚÔ‹ ENY ‹ ·›Ì·ÙÔ˜ - ÛËÌ›· ηٿÁÌ·ÙÔ˜ Ù˘ ‚¿Û˘ ÙÔ˘ ÎÚ·Ó›Ô˘. £· ÂϯıÔ‡Ó ÛËÌ›· ‚Ï¿‚˘ Ù˘ AM™™, fiˆ˜ ¯·Ï·Ú‹ ·Ú¿Ï˘ÛË (ÙÂÙÚ·ÏËÁ›·, ·Ú·ÏËÁ›·), ·Ó·ÈÛıËÛ›· οو ·fi ÙȘ ÎÏ›‰Â˜, ·ÓÂÍ‹ÁËÙË ˘fiÙ·ÛË ‹ ˘ÔıÂÚÌ›· Î·È ‰È·ÊÚ·ÁÌ·ÙÈ΋ ·Ó·ÓÔ‹. T· Ì·ÎÚ¿ ÔÛÙ¿ ÂϤÁ¯ÔÓÙ·È ÁÈ· ÙËÓ ‡·ÚÍË ·Ú·ÌfiÚʈÛ˘, Ôȉ‹Ì·ÙÔ˜ ‹ ¢·ÈÛıËÛ›·˜. H ÔÚıÔ‰È΋ οΈÛË ‰ÂÓ ÚÔηÏ› ·ÂÈÏËÙÈο ÁÈ· ÙË ˙ˆ‹ ÚÔ‚Ï‹Ì·Ù·, ·ÏÏ¿ Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜. H ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ı· ·ÎÔÏÔ˘ı‹ÛÂÈ ÌÂÙ¿ ÙȘ ·Ó¿ÏÔÁ˜ ÂӉ›ÍÂȘ. OÈ ·Ôχو˜ ·Ó·Áη›Â˜ ·ÎÙÈÓÔÁڷʛ˜ Û ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı‹ ·ÛıÂÓ‹ ›ӷÈ
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·˘Ù¤˜ ÙÔ˘ ıÒڷη, Ë Ï¿ÁÈ· AM™™ Î·È ÙˆÓ ÔÛÙÒÓ ÏÂοÓ˘. H ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÂͤٷÛË ÂÎÏÔÁ‹˜ Û ·È‰› Ì KEK, ÂÊfiÛÔÓ Î·È fiÙ·Ó ÛÙ·ıÂÚÔÔÈËı›. ¶ÙÒÛË ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ ·ÔÙÂÏ› ¿ÌÂÛË ¤Ó‰ÂÈÍË ÁÈ· CT ÂÁÎÂÊ¿ÏÔ˘. TÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú‡Ù·Ù· ÏfiÁˆ Ù˘ ¢ÎÔÏ›·˜ Ù˘ ÂͤٷÛ˘. H ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È Ë ÂͤٷÛË ÂÎÏÔÁ‹˜ Û ÛÙ·ıÂÚÔÔÈË̤ÓÔ ·ÛıÂÓ‹ ÁÈ· ÙȘ ηÎÒÛÂȘ Ù˘ ÎÔÈÏ›·˜. ŸÌˆ˜, ÛËÌ·ÓÙÈÎfiÙ·ÙË Â›Ó·È Ë ‚Ô‹ıÂÈ· Ù˘ ÂÚÈÙÔÓ·˚΋˜ χÛ˘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ·ÈÌÔÚÚ·Á›·˜ Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ‹·ÙÔ˜ Î·È ÛÏËÓfi˜ - Û ·ÛÙ·ı‹ ·ÛıÂÓ‹. ÕÌÂÛ˜ ÂӉ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘ ·ÔÙÂÏÔ‡Ó Ë ·ÓÈÛÔÎÔÚ›· Ì ÂÙÂÚfiÏ¢ÚË ËÌÈ¿ÚÂÛË (= ˘fi ‹ ÂÈÛÎÏËÚ›‰ÈÔ ·È̿و̷ - ΛӉ˘ÓÔ˜ ÂÁÎÔÏ·ÛÌÔ‡ ÛÙÂϤ¯Ô˘˜) Î·È ·ÛıÂÓ‹˜ Ì ÌË ·Ó·Ù·ÛÛfiÌÂÓË Î˘ÎÏÔÊÔÚÈ΋ ηٷÏËÍ›·, ·Ú¿ ÙË Û˘Ó¯‹ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ·›Ì·ÙÔ˜ Î·È ¯ˆÚ›˜ ÂÌÊ·Ó‹ ·ÈÌÔÚÚ·ÁÈ΋ ÂÛÙ›·. ™˘ÓÔ„›˙ÔÓÙ·˜, ˆ˜ ‚·ÛÈο ÛËÌ›· Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÂÈÛËÌ·›ÓÔÓÙ·È Ù· ÂÍ‹˜: ·) ™ÙÔ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ ·È‰›, fiˆ˜ Î·È Û οı Â›ÁÔÓ ÂÚÈÛÙ·ÙÈÎfi, Ë ·ÍÈÔÏfiÁËÛË, Ë ‰È¿ÁÓˆÛË Î·È Ë ıÂڷ›· Â›Ó·È Ù·˘Ùfi¯ÚÔÓË ÙËÓ ÚÒÙË ¯Ú˘Û‹ ÒÚ·, ‚) T· ·È‰È¿ Ì ÛÔ‚·Úfi ÙÚ·‡Ì· ͯˆÚ›˙Ô˘Ó ·fi ÙËÓ ·ÚÔ˘Û›· ÎÒÌ·ÙÔ˜, ‰È·Ù·Ú·¯ÒÓ Ù˘ ·Ó·ÓÔ‹˜ Î·È ÛËÌ›ˆÓ ηٷÏËÍ›·˜, Á) H Îϛ̷η ÚÔÙÂÚ·ÈÔÙ‹ÙˆÓ ·ÓÙÈÌÂÙÒÈÛ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ABCDE Î·È ‰) H Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ Î·È Ë ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi: i) ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ‰˘Ó·ÙÔÙ‹ÙˆÓ ·Ó¿Ó˄˘ ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ii) ÙËÓ ÔÚÁ·ÓˆÌ¤ÓË, Ù·¯Â›· Î·È ·ÛÊ·Ï‹ ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹ Û ÔÚÁ·ÓˆÌ¤ÓÔ Î¤ÓÙÚÔ. BÈ‚ÏÈÔÁÚ·Ê›· 1. Kochanek P. Ischemic and traumatic brain injury. Pathobiology and cellular mechanisms. Crit Care Med 1993;21:333-335. 2. Evaluation, stabilization and initial management after multiple trauma. In: Zimmerman J, editor. Pediatric Critical Care. Mosby Year Book; 1992. p. 1158-1164. 3. Multiple trauma in the pediatric patient. In: Rogers M, editor. Pediatric Intensive Care. Third edition; 1996. p. 1467-1503. 4. Head and spinal cord injury. In: Rogers M, editor. Pediatric Intensive care. Third edition. 1996. p. 836-847. 5. Julie I, Sanchez MD, Charles N, Paidas MD. Trauma care in the new millenium. Childhood trauma. Surg Clin N Am 1999;79:1503-1528. ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔÓ›ÎË ¶·¿˙ÔÁÏÔ˘ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
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INFECTIONS
§ÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜: ·fi ÙÔÓ 20Ô ÛÙÔÓ 21Ô ·ÈÒÓ· ∂. ƒÔËÏ›‰Ë˜
Infections in immunosuppressed patients: from the 20th to the 21st century E. Roilides
¶ÂÚ›ÏË„Ë: OÈ ·ÓÔÛÔÏÔÁÈΤ˜ ·Ó¿ÚÎÂȘ ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜. ∆· ·›ÙÈ· ·‡ÍËÛ˘ ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÒÓ ·ÛıÂÓÒÓ ÛÙȘ Ë̤Ú˜ Ì·˜ Â›Ó·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋˜ ıÂڷ›·˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (AIDS), Ë ÌÂÁ¿ÏË ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ë ÂÓÙ·ÙÈ΋ ÓÔÛËÏ›· Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ¿ÏÏˆÓ ·ÛıÂÓÒÓ. ∞Ó¿ÏÔÁ· Ì ÙÔ ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, Ô ·ÛıÂÓ‹˜ Â›Ó·È ¿ÏÏÔÙ ¢·›ÛıËÙÔ˜ Û ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. π‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎÔ› Â›Ó·È ÔÈ ÈÔ› ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ô Èfi˜ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÔÈ ÂÈÔÏ‹˜ Î·È ÂÓ Ùˆ ‚¿ıÂÈ Ì˘ÎËÙÈ¿ÛÂȘ. ∏ ηχÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ÈÔ ÌÂÁ¿ÏË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â¤ÊÂÚ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ.
Abstract: Immunodeficiencies can be either congenital or acquired. Causes of the recent increase of immunodeficient patients are the intensification of antineoplastic therapy, tissue and organ transplantation, acquired immunodeficiency syndrome (AIDS), the frequent use of immunosuppressive drugs and the intense treatment of very-low-birth neonates and of other patients. Depending on the immune defect, patients may at times be susceptible to different organisms. Particularly significant are respiratory viruses, varicella virus and superficial or invasive mycoses. Better management of infections and longer survival of these patients has led to a significant improvement of patients’ quality of life.
§¤ÍÂȘ ÎÏÂȉȿ: ÏÔÈÌÒÍÂȘ, ·ÓÔÛÔηٷÛÙÔÏ‹.
Key words: infections, immunosuppression.
OÈ ·ÓÔÛÔÏÔÁÈΤ˜ ·Ó¿ÚÎÂȘ ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜, ηıÒ˜ ›Û˘ Û ڈÙÔ·ı›˜ Î·È ‰Â˘ÙÂÚÔ·ı›˜. OÈ Î˘ÚÈfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞Ó¿ÏÔÁ· Ì ÙÔ ÂÈÎÚ·ÙÔ‡Ó ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, Ô ·ÛıÂÓ‹˜ Â›Ó·È Â˘·›ÛıËÙÔ˜ Û ¿ÏÏÔÙ ¿ÏÏÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ¶·Ú·‰Â›ÁÌ·Ù· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Â˘·›ÛıËÙÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÂÏÏ›ÌÌ·Ù· ÛÙËÓ ∆ ΢ÙÙ·ÚÈ΋ ‹ ÛÙË µ ΢ÙÙ·ÚÈ΋ (¯˘ÌÈ΋) ‹ ÛÙË Ê·ÁÔ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. O ·ÚÈıÌfi˜ ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÒÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ·˘ÍËı› ¿Ú· Ôχ ÛÙȘ Ë̤Ú˜ Ì·˜. ∆· ·›ÙÈ·
Ù˘ ·‡ÍËÛ˘ ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÒÓ ·ÛıÂÓÒÓ, ȉȷ›ÙÂÚ· ÛÙËÓ ¶·È‰È·ÙÚÈ΋, Â›Ó·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋˜ ıÂڷ›·˜, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (AIDS), Ë ÌÂÁ¿ÏË ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ë ÂÓÙ·ÙÈ΋ ÓÔÛËÏ›· Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ¿ÏÏˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, Ë Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Ë Ì·ÎÚfiÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ ‹ ›ÎÙËÙË ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Û˘Ó¤‚·Ï ÛÙË ÌÂÁ¿ÏË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙÔ˘˜ ÛÙȘ Ë̤Ú˜ Ì·˜. ∂ȉÈÎfiÙÂÚ·, Ë ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋ ıÂڷ›·, ΢ÙÙ·ÚÔÙÔÍÈ΋ ¯ËÌÂÈÔıÂڷ›· ‹ ·ÎÙÈÓÔıÂڷ›·,
3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢
3rd Department of Pediatrics Aristotelion University of Thessaloniki
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¶·È‰È·ÙÚÈ΋ 2001;64:272-275
Paediatriki 2001;64:272-275
¶›Ó·Î·˜ 1. ™˘¯ÓfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ
¶›Ó·Î·˜ 2. ¶·Ú·‰Â›ÁÌ·Ù· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Â˘·›ÛıËÙÔÈ ·ÛıÂÓ›˜ Ì ·ÓÔÛÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù·
™˘ÁÁÂÓ›˜ - ™˘ÁÁÂÓ‹˜ Ô˘‰ÂÙÂÚÔÂÓ›· - ÃÚfiÓÈ· ÎÔÎÎȈ̷Ù҉˘ ÓfiÛÔ˜ - ÀÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·È̛˜ - ∫ÔÈÓ‹ ÌÂÙ·‚ÏËÙ‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· - ÕÏϘ ·Ó¿ÚÎÂȘ Ù˘ ∆ Î·È µ ΢ÙÙ·ÚÈ΋˜ ÛÂÈÚ¿˜ ∂›ÎÙËÙ˜ - ¡ÂÔϷۛ˜ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ (Ï¢¯·È̛˜, ÓfiÛÔ˜ Hodgkin, ¿ÏÏ· ÏÂÌÊÒÌ·Ù·) - ∞Ï·ÛÙÈ΋ ·Ó·ÈÌ›· - ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· - HIV Ïԛ̈ÍË - ªÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ - ÈÛÙÒÓ
ñ T ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· - πÔ› (΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜) - ¶ÚˆÙfi˙ˆ· (ÙÔÍfiÏ·ÛÌ·) - ª‡ÎËÙ˜ (Ó¢ÌÔÓÔ·ÛÙË carinii, ÎÚ˘ÙfiÎÔÎÎÔ˜ Î·È Î¿ÓÙÈÓÙ·) ñ B ΢ÙÙ·ÚÈ΋ ‹ ¯˘ÌÈ΋ ·ÓÔÛ›· - ¶˘ÔÁfiÓ· Î·È ¿ÏÏ· ÌÈÎÚfi‚È· ñ º·ÁÔ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· – ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, Ì·ÎÚÔÊ¿Á· - ¶·ıÔÁfiÓ· Î·È ÌË ·ıÔÁfiÓ· ÌÈÎÚfi‚È· - ª‡ÎËÙ˜ (οÓÙÈÓÙ·, ·Û¤ÚÁÈÏÏÔ˜)
¯ÔÚËÁÂ›Ù·È Ì ÈÔ ÂÈıÂÙÈÎfi ÙÚfiÔ. OÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÂÁ·‰fiÛÂȘ Ê·ÚÌ¿ÎˆÓ ˘Ô‚ÔËıÔ‡ÌÂÓ˜ ·fi ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ·˘ÙfiÏÔÁË ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. µ·ıÈ¿ Î·È ·Ú·ÙÂٷ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Û‡ÓËı˜ Ê·ÈÓfiÌÂÓÔ, ηıÒ˜ ›Û˘ Î·È Ì›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ∆ ‚ÔËıËÙÈÎÒÓ (Th) ΢ÙÙ¿ÚˆÓ. ∆· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Â›Ó·È Â›Ù ÌË ÂȉÈο, fiˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ë ·˙·ıÂÈÔÚ›ÓË, ›Ù ÂȉÈο, fiˆ˜ Ë Î˘ÎÏÔÛÔÚ›ÓË A Î·È Ù· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ ∆ ‚ÔËıËÙÈÎÔ‡ ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘. H ¯Ú‹ÛË ·˘ÙÒÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Ì¤ÓÂÙ·È Ó· ·˘ÍËı› Ôχ ÛÙÔ Ì¤ÏÏÔÓ ÏfiÁˆ Ù˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ, ·ÏÏ¿ ı· Á›ÓÔ˘Ó ÈÔ ÂÎÏÂÎÙÈο Î·È Ì ÏÈÁfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·ÓÔÛÔηٷÛÙÔÏ‹ ΢ڛˆ˜ Ù˘ T ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜, ηıÒ˜ ›Û˘ Î·È Ù˘ Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜. ∏ ¯˘ÌÈ΋ ·ÓÔÛ›· ÂËÚ¿˙ÂÙ·È ÎÈ ·˘Ù‹ ¤ÌÌÂÛ·. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÙˆÓ ·ÛıÂÓÒÓ Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο Û ÌÂÁ¿Ï˜ ‰fiÛÂȘ (>2 mg/kg ËÌÂÚ‹ÛÈ·) Î·È ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (>15 Ë̤Ú˜). OÈ ÌÈÎÚ¤˜ ‰fiÛÂȘ, Ë ÙÔÈ΋ ¯Ú‹ÛË (.¯. ‰ÂÚÌ·ÙÔÏÔÁÈ΋) ηıÒ˜ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û ÂÈÛÓÔ¤˜ ÁÈ· ÙÔÈ΋ ‰Ú¿ÛË ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜, Û˘Ó‹ıˆ˜ ‰ÂÓ ÚÔηÏÔ‡Ó ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∆Ô AIDS ˘‹ÚÍÂ Ë ·ÈÙ›· Ó· ·˘ÍËı› ÛËÌ·ÓÙÈο Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÏÏ¿ Î·È ÔÈΛϷ ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· Û ÙÂÚ¿ÛÙȘ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ Ï·Ó‹ÙË Ì·˜ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·. ∂ÓÙÔ‡ÙÔȘ, Ë ÚfiÔ‰Ô˜ Ù˘ Ôχ ‰Ú·ÛÙÈ΋˜ ·ÓÙÈÚÂÙÚÔ˚È΋˜ ıÂڷ›·˜ Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÓÔ˘ÎÏÂÔÛȉÈÎÒÓ ·Ó·ÏfiÁˆÓ Î·È ·Ó·ÛÙÔϤˆÓ Ù˘ ÚˆÙ¿Û˘, ηıÒ˜ ›Û˘ Î·È Ë Î·Ï‡ÙÂÚË ÚfiÏË„Ë
¤¯Ô˘Ó ÚÔηϤÛÂÈ ÂÓÙ˘ˆÛȷ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì AIDS ÛÙȘ ‰˘ÙÈΤ˜ ¯ÒÚ˜. ∞ÓÙ›ıÂÙ·, Ê·›ÓÂÙ·È Ì›· ÌÂÁ¿ÏË ·‡ÍËÛË ÛÙȘ ¯ÒÚ˜ Ù˘ AÊÚÈ΋˜ Î·È Ù˘ AÛ›·˜, fiÔ˘ Ë ÂȉËÌ›· Û˘Ó¯›˙ÂÈ Ó· ÂÂÎÙ›ÓÂÙ·È ÏfiÁˆ ¤ÏÏÂȄ˘ Ê·ÚÌ¿ÎˆÓ ‹ ÏfiÁˆ ÎÔÈÓˆÓÈÎÒÓ ‰ÔÌÒÓ ÛÙȘ ¯ÒÚ˜ ·˘Ù¤˜. H Ù¿ÛË Ô˘ ı· ·ÎÔÏÔ˘ı‹ÛÂÈ Ë ›‰È· Ë ÓfiÛÔ˜ ı· ηıÔÚ›ÛÂÈ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ù‹. OÈ ÏÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÚÔηÏÔ‡ÓÙ·È ·fi ÎÔÈÓ¿ ‹ ¢ηÈÚȷο ·ıÔÁfiÓ·. OÚÈṲ̂ӷ ·Ú·‰Â›ÁÌ·Ù· Ù¤ÙÔÈˆÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È Ù· ÂÍ‹˜: ·) O˘‰ÂÙÂÚÔÂÓ›· Î·È ÂÏÏ›ÌÌ·Ù· Ù˘ Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜. OÈ Î·Ù·ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÛË„·ÈÌ›· ·fi ÎÔÈÓ¿ ÌÈÎÚfi‚È·, Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÏÔÈÌÒÍÂȘ ‰¤ÚÌ·ÙÔ˜ Î·È Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, Ó¢ÌÔӛ˜ Î·È ¿ÏϘ Û˘Ó‹ıÂȘ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ. ∂›Û˘, ÛÙ· ·È‰È¿ ·˘Ù¿ fiˆ˜ Î·È ÛÙÔÓ ˘fiÏÔÈÔ ·È‰ÈÎfi ÏËı˘ÛÌfi Â›Ó·È Û˘Ó‹ıÂȘ ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. OÈ ÏÔÈÌÒÍÂȘ Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ͤӷ ÛÒÌ·Ù· Î·È Î˘Ú›ˆ˜ ÂÓ‰ÔÊϤ‚ÈÔ˘˜ ηıÂÙ‹Ú˜ Â›Ó·È Ôχ Û˘¯Ó¤˜. OÈ ÂÓ‰ÔÊϤ‚ÈÔÈ Î·ıÂÙ‹Ú˜ Ì ÙËÓ ÈÓÈ΋ Ô˘ ÂÓ·ÔÙ›ıÂÙ·È ÛÙÔ ¿ÎÚÔ ÙÔ˘˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·ÔÈÎÈÛÌÔ‡ ÙÔ˘˜ Î·È Ïԛ̈͢ ÛÙ· ·È‰È¿ ·˘Ù¿. ‚) HIV Ïԛ̈ÍË. OÈ ·ÛıÂÓ›˜ Ì AIDS ·ı·›ÓÔ˘Ó ÏÔÈÌÒÍÂȘ Î·È ·fi ÎÔÈÓ¿ ·ıÔÁfiÓ· ·ÏÏ¿ Î·È ·fi ¢ηÈÚÈ·ÎÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ ¶Ó¢ÌÔÓÔ·ÛÙË carinii, TÔÍfiÏ·ÛÌ· gondii, ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·. ∂›Û˘, ·ı·›ÓÔ˘Ó Û˘¯Ó¿ ηÓÙÈÓÙÈ·ÛÈ΋ ÛÙÔÌ·Ù›Ùȉ·, ÂÎı‡ÛÂȘ ¤ÚËÙ· Î·È ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. Á) §ÔÈÌÒÍÂȘ ·ÛıÂÓÒÓ Ì ·Ó¿ÚÎÂÈ· Ù˘ ¯˘ÌÈ΋˜ ·ÓÔÛ›·˜. ∆· ·È‰È¿ Ì ·Ó·Ú΋ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ·ı·›ÓÔ˘Ó Û˘¯Ó¿ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·fi ÂÏ˘ÙÚÔÊfiÚ· ÌÈÎÚfi‚È·, .¯. Ó¢ÌÔӛ˜, ˆÙ›Ùȉ˜ Î·È ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ˜.
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¶·È‰È·ÙÚÈ΋ 2001;64:272-275
Paediatriki 2001;64:272-275
¢‡Ô ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈΤ˜ ηÙËÁÔڛ˜ ÈÒÓ ÁÈ· Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Â›Ó·È ÔÈ ÈÔ› ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Î˘Ú›ˆ˜ Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜ (RSV), ÔÈ ÈÔ› Ù˘ Áڛ˘ ∞ Î·È µ, Ù˘ ·Ú·Áڛ˘ 1 Î·È 3 Î·È ÔÈ ·‰ÂÓÔ˚Ô›. OÈ ÈÔ› ·˘ÙÔ› ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ‚·ÚÈ¿ Ó¢ÌÔÓ›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜, Ô˘ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÌÔÚ› Ó· Â›Ó·È ı·Ó·ÙËÊfiÚ·. ∂›Û˘, ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ¯ÚfiÓÈ· ÊÔÚ›· Î·È ‰È·ÛÔÚ¿ ÙÔ˘˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. O Èfi˜ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÚÔηÏ› ÈÔ ‚·ÚÈ¿ Ïԛ̈ÍË ÛÙ· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Ô˘ ÌÔÚ› Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙȘ ÎÏÈÓÈΤ˜ Ù˘ ÂΉËÏÒÛÂȘ Ó¢ÌÔÓ›· Î·È ˘ÎÓfi, ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·. ∏ ¤ÎıÂÛË ÛÙÔÓ Èfi Á›ÓÂÙ·È ÔÏϤ˜ ÊÔÚ¤˜ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›·, fiÔ˘ ·ÚΛ ÎÔÈÓfi ·È¯Ó›‰È ÁÈ· ÌÂÚÈο ÏÂÙ¿ ‹ ·Ú·ÌÔÓ‹ ÛÙÔ ¯ÒÚÔ ÁÈ· 1 ÒÚ· ÁÈ· Ó· ÌÂÙ·‰Ôı›. ∏ ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÙˆÓ Â›ÓÔÛˆÓ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ Á›ÓÂÙ·È Ì ˘ÂÚ¿ÓÔÛË Á-ÛÊ·ÈÚ›ÓË ÙȘ ÚÒÙ˜ 72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË. ∏ ÂÓÂÚÁËÙÈ΋ ·ÓÔÛÔÔ›ËÛË Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚·ÚÈ¿˜ ·˘Ù‹˜ ÂÈÏÔ΋˜. ª›· ¿ÏÏË, Ôχ ÛËÌ·ÓÙÈ΋ ηÙËÁÔÚ›· ÏÔÈÌÒÍÂˆÓ ÛÙÔ˘˜ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È ÔÈ ÂÈÔÏ‹˜ Î·È ÂÓ Ùˆ ‚¿ıÂÈ Ì˘ÎËÙÈ¿ÛÂȘ. ∆¤ÙÔȘ Â›Ó·È Ë Î·ÓÙÈÓÙ›·ÛË ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È Ù˘ ÂÚÈÔ¯‹˜ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ, ÔÈ ‰ÂÚÌ·ÙÔÊ˘ÙÈ¿ÛÂȘ, ÔÈ ÂÓ‰ËÌÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ, Ë Ì˘ÎËı·ÈÌ›·, ÂÓÙÔÈṲ̂Ó˜ ÂÓ Ùˆ ‚¿ıÂÈ ÏÔÈÌÒÍÂȘ Î·È Ë ÓÂÔÁÓÈ΋ Û˘ÛÙËÌ·ÙÈ΋ ηÓÙÈÓÙ›·ÛË. ™Â Ì›· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË fiÏˆÓ ÙˆÓ ÓÂÎÚÔÙÔÌÒÓ Ô˘ ¤ÁÈÓ·Ó Û ÌÂÁ¿ÏÔ E˘Úˆ·˚Îfi ÓÔÛÔÎÔÌÂ›Ô ·fi ÙÔ 1978 ̤¯ÚÈ ÙÔ 1982 (1) ‚Ú¤ıËΠfiÙÈ ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ ›¯·Ó ˘ÂÚÙÚÈÏ·ÛÈ·ÛÙ› ηٿ ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi (™¯‹Ì· 1).
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Έτος ™¯‹Ì· 1. ∂ÈÔÏ·ÛÌfi˜ Û˘ÛÙËÌ·ÙÈÎÒÓ Ì˘ÎËÙÈ¿ÛÂˆÓ Û ÓÂÎÚÔÙÔ̤˜ (1).
274
∆Ë ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ Ì˘ÎËÙÈ¿ÛÂˆÓ ‰Â›¯ÓÂÈ Î·È Ë ·ÏÌ·Ù҉˘ ·Ó¿Ù˘ÍË ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ Ê·Ú̿ΈÓ. ∂Ó‰ÂÈÎÙÈÎfi Ù˘ ÛÔ˘‰·ÈfiÙËÙ·˜ Ô˘ ¤¯Ô˘Ó ÚÔÛÏ¿‚ÂÈ ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ ÛÙË Û‡Á¯ÚÔÓË È·ÙÚÈ΋ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ì¤¯ÚÈ Ù· Ù¤ÏË Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’70 ˘‹Ú¯·Ó ÌfiÓÔ ÂÏ¿¯ÈÛÙ· ·ÓÙÈÌ˘ÎËÙÈ·ÛÈο Ê¿Ú̷η, ÁÈ· Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ¤Ó·˜ ηٷÈÁÈÛÌfi˜ Ê·ÚÌ¿ÎˆÓ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· (™¯‹Ì· 2) (2). OÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ, Û‹ÌÂÚ·, Â›Ó·È ¤Ó· ˘·ÚÎÙfi Î·È ÔÏÔ¤Ó· ÌÂÁ·Ï‡ÙÂÚÔ Úfi‚ÏËÌ· ÛÙËÓ ¶·È‰È·ÙÚÈ΋. £ÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ÁÈ· ̇ÎËÙ˜ ‰ÂÓ Â›Ó·È “ÂÈÌÔχÓÛÂȘ” Î·È Ú¤ÂÈ ¿ÓÙ· Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Ì ÔÏÏ‹ ÚÔÛÔ¯‹. À¿Ú¯Ô˘Ó ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Û˘ÛÙËÌ·ÙÈ΋ Ì˘ÎËÙ›·ÛË Î·È Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË Î·È Î·ı˘ÛÙÂÚ›. ¶·Ú’ fiÏÔ Ô˘ ÙÔ ·ÓÙÈÌ˘ÎËÙfiÁÚ·ÌÌ· ¤¯ÂÈ È· ÚÔÙ˘ÔÔÈËı› ÁÈ· ÙÔ˘˜ ‚Ï·ÛÙÔ̇ÎËÙ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ Candida, ÁÈ· ÙÔ˘˜ ˘ÊÔ̇ÎËÙ˜ (∞Û¤ÚÁÈÏÏÔÈ Î·È ¿ÏÏÔÈ), ·Ú·Ì¤ÓÂÈ ·ÎfiÌË Î·ı·Ú¿ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜ ¯ˆÚ›˜ η̛· ÚÔÙ˘ÔÔ›ËÛË ‹ Û˘Û¯ÂÙÈÛÌfi ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ÎÏÈÓÈ΋˜ ·¿ÓÙËÛ˘. ∏ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ ‰‡ÛÎÔÏË Î·È Ë ÚfiÁÓˆÛË Û˘Ó¯›˙ÂÈ Ó· Â›Ó·È Ôχ ‚·ÚÈ¿. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ··ÈÙ› Î·È ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ηٷÛÙÔÏ‹˜ ÙÔ˘ ·Ì˘ÓÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞˘Ù‹ Û˘Ó›ÛÙ·Ù·È Û ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‹/Î·È ¿ÏÏˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ, ·ӷÊÔÚ¿ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ·›Ì·, ¯ÔÚ‹ÁËÛË ·ÈÌÔÔÈËÙÈÎÒÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÌÂÙ·ÁÁ›ÛÂȘ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ì·˙› Ì ‹ ¯ˆÚ›˜ ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘ÙÙ·ÚÔΛÓ˜. OÈ ÙÂÏÂ˘Ù·›Â˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ·ÏÏ¿ Î·È ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ. ŒÓ· ı¤Ì· Ôχ ÛËÌ·ÓÙÈÎfi Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÂÌ˘Ú¤ÙÔ˘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ ·ÛıÂÓ‹. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ‚ÚÂı› fiÙÈ fiÏÔÈ ÔÈ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ¤¯Ô˘Ó ÙÔÓ ›‰ÈÔ Î›Ó‰˘ÓÔ ÁÈ· ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. ŒÙÛÈ, Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‚·ıÌÔ‡ ÎÈÓ‰‡ÓÔ˘ Û ÌÈÎÚfi, ̤ÙÚÈÔ Î·È ÌÂÁ¿ÏÔ Â›Ó·È ÚˆÙ·Ú¯È΋˜ ÛËÌ·Û›·˜. ∆Ô ÈÔ ÛÔ˘‰·›Ô Â›Ó·È Ë ¿ÌÂÛË ÂÌÂÈÚÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ì¤¯ÚÈ ÙË ÁÓˆÛÙÔÔ›ËÛË ÙˆÓ ÌÈÎÚÔ‚ÈÔÏÔÁÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ªÂ ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ô ·ÛıÂÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹ ÛÙÔ Û›ÙÈ. ∆fiÛÔ ÛÙË Ì›· fiÛÔ Î·È ÛÙËÓ ¿ÏÏË ÂÚ›ÙˆÛË, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Ï‹„Ë fiÏˆÓ ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·È Î·ÏÏÈÂÚÁÂÈÒÓ. ∞ÓÂÍ¿ÚÙËÙ· ·fi ÙË ÓÔÛËÏ›· ÙÔ˘ ·È‰ÈÔ‡ ·Ú¯›˙ÂÈ ÂÌÂÈÚÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ Â˘Ú¤Ô˜ Ê¿ÛÌ·ÙÔ˜ ·fi ÙÔ ÛÙfiÌ· ‹ ·ÚÂÓÙÂÚÈο Î·È Â·Ó·ÚÔÛ‰ÈÔÚ›˙ÂÙ·È
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·275
¶·È‰È·ÙÚÈ΋ 2001;64:272-275
Paediatriki 2001;64:272-275
Echinocandin, pneumocandin, pradimidin, nikkomyicin, voricinazole, SCH56592, Nyotran, KY-62 AmBisome Amphocil
lipid AmB’s
Abelcet intraconazole fluconazole
oral solution
ketoconazole terbinafine
Amphotericin B
miconazole 5-flucytosine
Nystatin Griseofulvin 1950
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™¯‹Ì· 2. ∞ÏÌ·Ù҉˘ ·‡ÍËÛË ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ Ê·Ú̿ΈÓ.
Ô ‚·ıÌfi˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Û ‹È·, ̤ÙÚÈ· ‹ ‚·ÚÈ¿. ªÂ ÙËÓ ÂÈÏÂÎÙÈ΋ ·˘Ù‹ ÔÏÈÙÈ΋ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌÂÁ¿ÏË ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. ¶ÚfiÏË„Ë ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ∏ ÚfiÏË„Ë ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Â›Ó·È ·) ÂÓÂÚÁËÙÈ΋, Ì ٷ ÂÌ‚fiÏÈ· Î·È ‚) ·ıËÙÈ΋, Ì ·ÓÔÛÔÛÊ·ÈÚ›Ó˜. °ÂÓÈ΋ ·Ú¯‹ ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ Â›Ó·È fiÙÈ Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ ‰ÂÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ˙ˆÓÙ·ÓÔ‡˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜. OÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ٷ Û˘Ó‹ıË ÂÌ‚fiÏÈ· Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÔÓÙ·È. T· ·È‰È¿ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· Ì‹Ó· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÂÈÛ¢Ṳ̂ÓÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏ›ˆÓ Î·È ‰ÂÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ˙ˆÓÙ·ÓÔ‡˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. O ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi˜, ȉȷ›ÙÂÚ· Û ·È‰È¿ ̠Ϣ¯·ÈÌ›·. E›Û˘, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ηٿ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Î·È Ù˘ Áڛ˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎÔ› Î·È Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È. T· ·È‰È¿ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÎÔÚÙÈÎÔıÂڷ›· Û ‰fiÛË >2 mg/kg ‰ÂÓ Ú¤ÂÈ Ó· ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Î·Ù¿ ÙË ıÂڷ›· Î·È ÁÈ· 1-2 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹
Ù˘, ȉȷ›ÙÂÚ· Ì ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜. T· ·‰¤ÏÊÈ· ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·È‰ÈÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ÂÌ‚fiÏÈÔ Sabin ÁÈ·Ù› ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÈÔ‡˜ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ (3). H ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÂȉÈÎÒÓ ‹ ÌË ÂȉÈÎÒÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ. MËÓÈ·›Â˜ ÂÓ‰ÔÊϤ‚Ș ÂÁ¯‡ÛÂȘ ÌË ÂȉÈ΋˜ ÁÛÊ·ÈÚ›Ó˘ (IVIG) ¯ÔÚËÁÔ‡ÓÙ·È Û ¯˘ÌÈ΋ ·Ó¿ÚÎÂÈ·. ∂ȉÈΤ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜, .¯. ηٿ ÙÔ˘ ÈÔ‡ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Î·È ÙÔ˘ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô‡ (VZV Î·È CMV), ¯ÔÚËÁÔ‡ÓÙ·È ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ÏÔÈÌÒÍÂȘ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ÏÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ·˘ÍËı› ¿Ú· Ôχ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™’ ·˘Ùfi ÂËÚ¤·ÛÂ Ë ÌÂÁ¿ÏË Â›Ù¢ÍË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·È Ù˘ ·ÓÙÈ·ÔÚÚÈÙÈ΋˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È. EÓÙÔ‡ÙÔȘ, ηχÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ÈÔ ÌÂÁ¿ÏË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â¤ÊÂÚ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. H ÚfiÔ‰Ô˜ ·˘Ù‹ ·ÔÙ¤ÏÂÛ ÛÙ·ıÌfi ÛÙËÓ ÂͤÏÈÍË Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ Î·È ·ÊÂÙËÚ›· ÁÈ· ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜ ÛÙ· ÂfiÌÂÓ· ¯ÚfiÓÈ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Groll AH, Shah PM, Mentzel C, Schneider M, JustNuebling G, Huebner K. Trends in the postmortem epidemiology of invasive fungal infections at a University Hospital. J Infect 1996;33:23-32. 2. Edwards JE Jr, Bodey GP, Bowden RA, Buchner T, de Pauw BE, Filler SG, et al. International Conference for the Development of a Consensus on the Management and Prevention of Severe Candida Infections. Clin Infect Dis 1997;25:43-59. 3. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡-™È‰ËÚÔÔ‡ÏÔ˘ M. ∂Ì‚ÔÏÈ·ÛÌÔ› ·ÛıÂÓÒÓ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡. ¢ÂÏÙ ∞’¶·È‰·ÙÚ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1996; 43:101-105.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ÌÌ·ÓÔ˘‹Ï ƒÔËÏ›‰Ë˜ 3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49, 546 42, £ÂÛÛ·ÏÔÓ›ÎË e-mail: roilides@med.auth.gr
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∞πª∞∆O§O°π∞ - O°∫O§O°π∞
Paediatriki 2001;64:276-279
HEMATOLOGY - ONCOLOGY
∞ÓÙÈÌÂÙÒÈÛË ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ™. °Ú·Ê¿ÎÔ˜
Haematopoietic stem cell transplantation for the treatment of haematological, malignant, and genetic diseases S. Graphakos
¶ÂÚ›ÏË„Ë: ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª∞∫) ·ÔÙÂÏ› ηıÈÂڈ̤ÓË ıÂڷ›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÚÈÛÌ¤ÓˆÓ ÛÔ‚·ÚÒÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. O ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο. ™ÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 250 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÂÙËÛ›ˆ˜. ∆· ÌÔۯ‡̷ٷ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì·. °È· Ó· ıˆÚËı› ÔÛÔÙÈο ·ÚΤ˜ ÙÔ ÌfiÛ¯Â˘Ì· Ú¤ÂÈ ÙÔ Ì˘ÂÏÈÎfi Ó· ÂÚȤ¯ÂÈ >3x108 Â̇ÚËÓ· ·ÙÙ·Ú·/Kgr µ™ ÙÔ˘ ‰¤ÎÙË, ÙÔ ÂÚÈÊÂÚÈÎfi >5x106 CD34+/Kgr µ™ Î·È ÙÔ ÔÌÊ·ÏÈÎfi >5x107 ÌÔÓÔ˘ÚËÓÈο ·ÙÙ·Ú·/Kgr µ™. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÏÏÔÁÂÓÂÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÌÔۯ‡̷ٷ ·fi ÂıÂÏÔÓÙ¤˜ ‰fiÙ˜ ÌË Û˘ÁÁÂÓÈÎÔ‡˜ ÚÔ˜ ÙÔÓ ¿Û¯ÔÓÙ· (Volunteer Unrelated Donor). À¿Ú¯Ô˘Ó ÔÚÈṲ̂Ó˜ ‚·ÛÈΤ˜ ÚÔ¸Ôı¤ÛÂȘ, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ˘ÔΛÌÂÓÔ ÓfiÛËÌ·, ÙËÓ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔÓ Ù‡Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ™ÙȘ ÔÍ›˜ Ï¢¯·È̛˜, Ë ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Î˘Ì·›ÓÂÙ·È ·fi 55-75%, ÛÙË ‚·ÚÈ¿ ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ˘ÂÚ‚·›ÓÂÈ ÙÔ 80%, ÂÓÒ ÛÙË ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Ë Ï‹Ú˘ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Ôχ ˘„ËÏ‹. ™ÙË ÌÔÓ¿‰· Ì·˜ Û˘ÁÎÂÎÚÈ̤ӷ, ÙÔ ÔÛÔÛÙfi ›·Û˘ Û ۇÓÔÏÔ 47 ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 92%.
Abstract: Haematopoietic stem cell transplantation is an established therapeutic method for the treatment of various haematological, malignant, and genetic diseases. The source of haematopoietic graft could be either bone marrow or peripheral blood or cord blood. The number of allogeneic transplants performed from volunteer unrelated donors has substantially increased during the last few years with satisfactory results. The nature of the underlying disease, the patient’s clinical condition and the type of transplantation are the main factors that influence the outcome. In acute leukemia the five year survival after transplantation free of disease is estimated to be between 55-75%, while in severe aplastic anaemia it exceeds 80%. Excellent results have been achieved in patients with thalassaemia, and currently in our unit, disease free survival in 47 transplanted thalassaemic children is 92%.
§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÔÌÊ·ÏÈÎfi ·›Ì·.
Key words: haematopoietic stem cell transplantation, cord blood.
ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
Division of Bone Marrow Transplantation “St. Sophia” Children’s Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:276-279
∏ ªÂÙ·ÌfiÛ¯Â˘ÛË ª˘ÂÏÔ‡ ÙˆÓ √ÛÙÒÓ ‹ fiˆ˜ Ú¤ÂÈ ÔÚıfiÙÂÚ· Ó· ·ÔηÏÂ›Ù·È ªÂÙ·ÌfiÛ¯Â˘ÛË ∞Ú¯¤ÁÔÓˆÓ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ (ª∞∫), ·ÔÙÂÏ› ηıÈÂڈ̤ÓË ıÂڷ›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÚÈÛÌ¤ÓˆÓ ÛÔ‚·ÚÒÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (1). ∏ ª∞∫ ‰È·ÎÚ›ÓÂÙ·È Û ·˘ÙfiÏÔÁË, fiÔ˘ ‰fiÙ˘ Î·È Ï‹Ù˘ Â›Ó·È ÙÔ ›‰ÈÔ ¿ÙÔÌÔ, Û˘ÁÁÂÓÂÙÈ΋ fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ÁÂÓÂÙÈο Ù·˘ÙfiÛËÌÔ˜ Ì ÙÔÓ ¿Û¯ÔÓÙ· (ÌÔÓÔˆ˚ÎÔ› ‰›‰˘ÌÔÈ) Î·È ·ÏÏÔÁÂÓÂÙÈ΋, fiÔ˘ ‰fiÙ˘ Î·È Ï‹Ù˘ ‰È·Ê¤ÚÔ˘Ó ÁÂÓÂÙÈο. ™ÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË, Ô ‰fiÙ˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÈÛÙÔÛ˘Ì‚·Ùfi˜ ·‰ÂÏÊfi˜ ÙÔ˘ ¿Û¯ÔÓÙ·, ÌÔÚ› fï˜ Ó· Â›Ó·È Î·È ÌË ·fiÏ˘Ù· Û˘Ì‚·Ùfi˜ Û˘ÁÁÂÓ‹˜ ›Ù ÂıÂÏÔÓÙ‹˜, Ô ÔÔ›Ô˜ ‰ÂÓ ¤¯ÂÈ Û˘ÁÁ¤ÓÂÈ· Ì ÙÔÓ ¿Û¯ÔÓÙ· Î·È ÂÌÊ·Ó›˙ÂÈ ÌÂÚÈ΋ ‹ Î·È Ï‹ÚË ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· Ì ·˘ÙfiÓ. O ·ÚÈıÌfi˜ ÙˆÓ ª∞∫ ¤¯ÂÈ ·˘ÍËı› Ú·Á‰·›· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È ÙÔ 1999 ηٷÁÚ¿ÊËÎ·Ó ·fi ÙËÓ ∂˘Úˆ·˚΋ ÔÌ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ (∂µª∆) 6441 ·ÏÏÔÁÂÓÂÙÈΤ˜ Î·È 14989 ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ÂÓÒ ÛÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙË ¯ÚÔÓÈ¿ ·˘Ù‹ 200 ªÂÙ·ÌÔۯ‡ÛÂȘ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ. ∆· ·ÈÌÔÔÈËÙÈο ÌÔۯ‡̷ٷ (2) ÚÔ¤Ú¯ÔÓÙ·È: ·) ·fi Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, Ô ÔÔ›Ô˜ ·Ú·Ì¤ÓÂÈ Ë Î‡ÚÈ· ËÁ‹ ΢ÙÙ¿ÚˆÓ ÁÈ· ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ‚) ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Ô˘ ηÙÂÍÔ¯‹Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ (ÛÙÔÓ ·ÛıÂÓ‹ ¯ÔÚËÁÂ›Ù·È ·˘ÍËÙÈÎfi˜ ·ÈÌÔÔÈËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (G-CSF), Ù· ·Ú¯¤ÁÔÓ· ·ÈÌÔÔÈËÙÈο ·ÙÙ·Ú· ÎÈÓËÙÔÔÈÔ‡ÓÙ·È ·fi ÙÔ Ì˘ÂÏfi ÛÙËÓ ÂÚÈʤÚÂÈ· Î·È Î·ÙfiÈÓ Û˘ÏϤÁÔÓÙ·È Ì Ì˯·Ó‹Ì·Ù· ΢ÙÙ·ÚÔ·Ê·›ÚÂÛ˘ Û 2-3 Û˘Ó‰ڛ˜), Á) ·fi ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· (O¶∞), ÙÔ ÔÔ›Ô ÂÚȤ¯ÂÈ ÈηÓfi ·ÚÈıÌfi ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÌÔÚ› Ó· Á›ÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ¿ÙÔÌ· ‚¿ÚÔ˘˜ <40 kgr. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì O¶∞ Á›ÓÔÓÙ·È Î˘Ú›ˆ˜ Û ·È‰È¿. ¶ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ °È· ÙËÓ ÂÈÙ˘¯›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂Ó˜ ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ: 1) ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ‰fiÙË. ¶Ú¤ÂÈ Ó· Â›Ó·È ÈÛÙÔÛ˘Ì‚·Ùfi˜ Ì ÙÔÓ ¿Û¯ÔÓÙ·. ∏ Èı·ÓfiÙËÙ· Ó· ‚ÚÂı› Û˘Ì‚·Ùfi ̤ÏÔ˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ÂÚ›Ô˘ 30%. ™Â ÂÚ›ÙˆÛË ·‰˘Ó·Ì›·˜ ·Ó‡ÚÂÛ˘ Á›ÓÂÙ·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÂÓ·ÏÏ·ÎÙÈÎÔ‡˜ ‰fiÙ˜, fiˆ˜ Â›Ó·È Ô ÌË ·fiÏ˘Ù· Û˘Ì‚·Ùfi˜ Û˘ÁÁÂÓ‹˜, Ô ÂıÂÏÔÓÙ‹˜ ‰fiÙ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ô˘ ·Ó¢ڛÛÎÂÙ·È ·fi ÙȘ ‰ÈÂıÓ›˜ ÙÚ¿Â˙˜ ‰ÔÙÒÓ ‹ ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· Ô˘ ·Ó·˙ËÙ›ٷÈ
Paediatriki 2001;64:276-279
·fi ·ÓÙ›ÛÙÔȯ˜ ‰ÈÂıÓ›˜ ÙÚ¿Â˙˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·ÓÔÛÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ, Û˘Ó‹ıˆ˜ Á›ÓÂÙ·È ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ∆ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙÔ ÌfiÛ¯Â˘Ì·. O ϤÔÓ ‰È·‰Â‰Ô̤ÓÔ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜ Â›Ó·È Ë ıÂÙÈ΋ ÂÈÏÔÁ‹ ÙˆÓ CD34+ ΢ÙÙ¿ÚˆÓ Ì ·ÓÔÛÔÌ·ÁÓËÙÈΤ˜ ÌÂıfi‰Ô˘˜. 2) ∏ ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∂¿Ó ˘¿Ú¯ÂÈ ÓÂÔÏ·ÛÌ·ÙÈÎfi ÓfiÛËÌ·, ηٿÏÏËÏÔ˜ ¯ÚfiÓÔ˜ Â›Ó·È fiÙ·Ó ¤¯ÂÈ ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÓfiÛÔ˘. ™Â ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ‹ ÁÂÓÂÙÈÎfi ÓfiÛËÌ·, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· Á›ÓÂÈ ÛÙÔ Û˘ÓÙÔÌfiÙÂÚÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË. 3) ∏ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∫·Ù¿ ÙË ÛÙÈÁÌ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ô ·ÛıÂÓ‹˜ ‰ÂÓ Ú¤ÂÈ Ó· ¤¯ÂÈ ÂÓÂÚÁfi Ïԛ̈ÍË Î·È Ù· fiÚÁ·Ó· ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ (ηډȿ, ÓÂÊÚÔ›, Ó‡ÌÔÓ˜, ‹·Ú) ‰ÂÓ Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜. 4) ∏ “ÚÔÂÙÔÈÌ·Û›·” ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. °›ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Î˘ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Û Ôχ ˘„ËϤ˜ ‰fiÛÂȘ Ô˘ ÌÔÚ› Ó· Û˘Ó‰˘·ÛÙÔ‡Ó Î·È Ì ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›·. ™ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, Ù· ϤÔÓ Û˘Ó‹ıË ÚˆÙfiÎÔÏÏ· Â›Ó·È ·˘Ù¿ Ô˘ Û˘Ó‰˘¿˙Ô˘Ó Î˘ÎÏÔʈÛÊ·Ì›‰Ë Ì ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· ‹ ΢ÎÏÔʈÛÊ·Ì›‰Ë Ì ‚Ô˘ÛÔ˘ÏÊ¿ÓË. ™Ù· ·È‰È¿, Ë ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÂÊ·ÚÌÔÁ‹ ÏfiÁˆ ÙˆÓ ÛÔ‚·ÚÒÓ ¿ÌÂÛˆÓ Î·È ·ÒÙÂÚˆÓ ·ÚÂÓÂÚÁÂÈÒÓ Ô˘ ÂÌÊ·Ó›˙ÂÈ. ∏ “ÚÔÂÙÔÈÌ·Û›·” ·˘Ù‹ ¤¯ÂÈ ¤Ó·Ó ÙÚÈÏfi ÛÙfi¯Ô: ·) ÙË ‰ËÌÈÔ˘ÚÁ›· “¯ÒÚÔ˘” ÛÙË Ì˘ÂÏÈ΋ ÎÔÈÏfiÙËÙ· ÁÈ· Ó· ÌÔÚ¤ÛÂÈ Ó· ÂÁηٷÛÙ·ı› Î·È Ó· ·Ó·Ù˘¯ı› ÙÔ ÌfiÛ¯Â˘Ì·, ‚) ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· Ó· ÌËÓ ·Ó·ÁÓˆÚ›ÛÂÈ ˆ˜ ͤÓÔ ÙÔ ÌfiÛ¯Â˘Ì· Î·È ÙÔ ·ÔÚÚ›„ÂÈ Î·È Á) ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ˘ÔÏÂÈfiÌÂÓˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ÛÙÔ ÛÒÌ·, ÁÈ· Ó· ·ÔÊ¢¯ı› Ô Î›Ó‰˘ÓÔ˜ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘. 5) ∏ ¤ÓÙÔÓË Î·È Û˘Ó¯‹˜ ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘ Î·È Ô˘‰ÂÙÂÚÔÂÓÈÎÔ‡ ·ÛıÂÓÔ‡˜ ̤¯ÚÈ ÙËÓ Ï‹ÚË ·ÈÌÔÔÈËÙÈ΋ Î·È ÏÂÌÊÈ΋ ·ÔηٿÛÙ·Û‹ ÙÔ˘. °È· ÙËÓ ÚÔʇϷÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·fi ÙË ÓfiÛÔ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹ (GVHD), ¯ÔÚËÁÂ›Ù·È Î˘ÎÏÔÛÔÚ›ÓË ∞, ÁÈ· ‰È¿ÛÙËÌ· 3-12 ÌËÓÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‚Ú·¯Â›· ¯ÔÚ‹ÁËÛË ÌÂıÔÙÚÂÍ¿Ù˘. ∞ÈÌÔÔÈËÙÈο ÌÔۯ‡̷ٷ ∆Ô Ì˘ÂÏÈÎfi ÌfiÛ¯Â˘Ì· ÁÈ· Ó· ıˆÚËı› ·ÚΤ˜ Ú¤ÂÈ Ó· ÂÚȤ¯ÂÈ >3x108 Â̇ÚËÓ· ·ÙÙ·Ú·/kgr µ™ ÙÔ˘ ‰¤ÎÙË Î·È Ô fiÁÎÔ˜ Ô˘ ÙÔ ÂÚȤ¯ÂÈ Â›Ó·È 10-20 ml/kg µ™ ‰¤ÎÙË. ™Â ·Û‡Ì‚·Ù˜ Î·È Û ÌË Û˘ÁÁÂÓÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ηıÒ˜ ›Û˘ ÛÂ
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ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, Ô ·ÚÈıÌfi˜ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜. ŸÙ·Ó ¯ÚËÛÈÌÔÔÈԇ̠ÂÚÈÊÂÚÈÎfi ·›Ì·, Ô ·ÚÈıÌfi˜ 3,5-5,0 106/kg µ™ CD34+ ΢ÙÙ¿ÚˆÓ ıˆÚÂ›Ù·È Ôχ ÈηÓÔÔÈËÙÈÎfi˜ ÁÈ· ÙËÓ Ù·¯Â›· ·Ó·Á¤ÓÓËÛË Ù˘ ·ÈÌÔÔ›ËÛ˘, ÂÓÒ Ì ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì·, Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÔÓÔ˘ÚËÓÈÎÒÓ Î·È CD34+ ΢ÙÙ¿ÚˆÓ Ô˘ Ú¤ÂÈ Ó· Ï¿‚ÂÈ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· Â›Ó·È Ù˘ Ù¿Í˘ ÙˆÓ 5x107/kg Î·È 0,5x106/kg, ·ÓÙ›ÛÙÔȯ·. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·ÈÌÔÔÈËÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Á›ÓÂÙ·È ÛÙÔÓ ·ÛıÂÓ‹ ÂÓ‰ÔÊϤ‚È· ̤ۈ ηıÂÙ‹Ú· Ù‡Ô˘ Hickman Î·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·fi 15-20 Ë̤Ú˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· >500 Ô˘‰ÂÙÂÚfiÊÈÏ·/ί, ÂÓÒ ·ÈÌÔÂÙ¿ÏÈ· >20000/ί ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ÙËÓ 21Ë-25Ë Ë̤ڷ. ∂ÈÏÔΤ˜ ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÚÔÛʤÚÂÈ ÙËÓ ›·ÛË Û ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ·ÛıÂÓÒÓ, ·ÏÏ¿ ‰ËÌÈÔ˘ÚÁ› ÔÏÏ·Ï¿ ÚÔ‚Ï‹Ì·Ù· Î·È ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Û ÔÚÈṲ̂ÓÔ˘˜. ™˘ÓËıÈṲ̂Ó˜ ÚÒÈ̘ ÂÈÏÔΤ˜ Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ, Ë Ó¢ÌÔÓ›Ùȉ·, Ë ÊÏ‚ԷÔÊÚ·ÎÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜ (3), ÔÈ ‚Ï¿‚˜ ÙÔ˘ ÂÙÈÎÔ‡, Ë ÔÍ›· Î·È ¯ÚfiÓÈ· ÓfiÛÔ˜ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹ (GVHD) (4). ∏ ıÓËÙfiÙËÙ· ·fi ÙËÓ ÙÔÍÈÎfiÙËÙ· Ù˘ ıÂڷ›·˜ ·Ó¤Ú¯ÂÙ·È Û 3-5% ÁÈ· ÙȘ ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È 5-10% ÁÈ· ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜. ŸÙ·Ó ·˘Ù¤˜ Á›ÓÔÓÙ·È Ì ÌË Û˘Ì‚·Ùfi ‹ ÌË Û˘ÁÁÂÓÈÎfi ‰fiÙË, ÙÔ ÔÛÔÛÙfi ˘ÂÚ‚·›ÓÂÈ ÔÏϤ˜ ÊÔÚ¤˜ ÙÔ 25%. ∞ÔÙÂϤÛÌ·Ù· ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ª∞∫ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ˘ÔΛÌÂÓÔ ÓfiÛËÌ· Î·È ÙÔ ÛÙ¿‰Èfi ÙÔ˘, ÙÔÓ Ù‡Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙËÓ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. °ÂÓÈο, Â›Ó·È Î·Ï‡ÙÂÚ· ÛÙ· ·È‰È¿ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, fiˆ˜ ›Û˘ Î·È ÛÙ· ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù·, ÂÓÒ ÛÙȘ ÓÂÔÏ·ÛÌ·ÙÈΤ˜ ·ı‹ÛÂȘ, fiÙ·Ó ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û ϋÚË ‡ÊÂÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ ‚·ÚÈ¿ ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· Û ·È‰È¿ Ô˘ ¤¯Ô˘Ó ÈÛÙÔÛ˘Ì‚·Ùfi Û˘ÁÁÂÓÈÎfi ‰fiÙË Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¿ÌÂÛ· Ì ª∞∫, ¯ˆÚ›˜ Ó· ÂȯÂÈÚÂ›Ù·È ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÂÈÙ˘Á¯¿ÓÂÙ·È ›·ÛË ÛÙÔ 90% ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙˆÓ ·ÛıÂÓÒÓ (5). ∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Â›Ó·È ÓfiÛËÌ· ÙÔ ÔÔ›Ô Û‹ÌÂÚ· ıÂڷ‡ÂÙ·È ÂÈÙ˘¯Ò˜ ÌÂ Û˘Ì‚·ÙÈ΋ ¯ËÌÂÈÔıÂڷ›·. ŒÙÛÈ, ª∞∫ Á›ÓÂÙ·È ÌfiÓÔ Û ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔÈ¿˙Ô˘Ó Î·È ÛÙËÓ 1Ë ‡ÊÂÛË, ÌfiÓÔ Û ۿÓȘ ÌÔÚʤ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. OÌÔ›ˆ˜, Ë ÔÍ›· Ì˘ÂÏÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· ¤·„ ӷ ¤¯ÂÈ ÙË ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË Ô˘ ›¯Â
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ÚÔ 10ÂÙ›·˜ Î·È ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ ıÂڷ‡ÂÙ·È Û‹ÌÂÚ· Ì ¤ÓÙÔÓË ¯ËÌÂÈÔıÂڷ›·. ª∞∫ Î·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Á›ÓÂÙ·È ÛÙȘ Ï›Á˜ ÌÔÚʤ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÛÙȘ ˘ÔÙÚÔ¤˜ (6). ∏ Èı·ÓfiÙËÙ· ›·Û˘ Ù˘ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ Ì ª∞∫ Î˘Ì·›ÓÂÙ·È ·fi 55-75%, ÂÓÒ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÁÈ· ÙÔ˘˜ 32 ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÌÂÙ·ÌÔÛ¯Â˘ı› ÛÙË ÌÔÓ¿‰· Ì·˜ Â›Ó·È 63%. °È· Ù· Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈο Û‡Ó‰ÚÔÌ· Î·È ÙË ¯ÚfiÓÈ· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, Ë ª∞∫ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ıÂڷ›· Î·È Ù· ¿Û¯ÔÓÙ· ·È‰È¿ Ú¤ÂÈ Û‡ÓÙÔÌ· Ó· ÚÔˆıÔ‡ÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi Û˘Ì‚·Ùfi ‹ ÌË Û˘ÁÁÂÓÈÎfi ‰fiÙË. ∆· ˘ÔÙÚÔÈ¿˙ÔÓÙ· Î·È ·ÓıÂÎÙÈο ÛÙË ıÂڷ›· ÏÂÌÊÒÌ·Ù· Hodgkin Î·È ÌË Hodgkin ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·˘ÙfiÏÔÁË ª∞∫, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÈ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙ· ·È‰È¿. ∞ÛıÂÓ›˜ Ù˘ ÌÔÓ¿‰·˜ Ì·˜ ÂÌÊ·Ó›˙Ô˘Ó 5ÂÙ‹ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ (Ô˘ Ú·ÎÙÈο ÈÛÔ‰˘Ó·Ì› Ì ϋÚË ›·ÛË) Ô˘ ·Ó¤Ú¯ÂÙ·È Û 65% ÛÙ· ÌË Hodgkin Î·È 77% ÛÙ· Hodgkin ÏÂÌÊÒÌ·Ù·. ¶ÔÏÏÔ› Û˘Ì·Á›˜ fiÁÎÔÈ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·˘ÙfiÏÔÁË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŸÌˆ˜, ÁÈ· ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ·˘ÙÔ‡˜ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÊÙˆ¯¿, ‰ÈfiÙÈ Û˘Ó‹ıˆ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌfiÓÔ ·Ú¿Ù·ÛË Ù˘ ‡ÊÂÛ˘ Î·È Ë ÓfiÛÔ˜ ˘ÔÙÚÔÈ¿˙ÂÈ ·ÚÁfiÙÂÚ·. ∞Ó Î·È Ù· ¿Û¯ÔÓÙ· ·È‰È¿ ·Ó¤¯ÔÓÙ·È Î·Ï¿ ˘„ËϤ˜ ‰fiÛÂȘ ¯ËÌÂÈÔıÂڷ›·˜ (ÌÂÁ·ıÂڷ›·) Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·È‰ÈÎÔ› fiÁÎÔÈ Â›Ó·È ¯ËÌÂÈÔ¢·›ÛıËÙÔÈ, ̤¯ÚÈ Û‹ÌÂÚ· ۯ‰fiÓ Î·Ó¤Ó·˜ Û˘Ì·Á‹˜ fiÁÎÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰ÂÓ ·ÔÙÂÏ› ·fiÏ˘ÙË ¤Ó‰ÂÈÍË ÁÈ· ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË. ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ ÛÙ·‰›Ô˘ 4 ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÂÈÙ˘¯Ò˜ ÛÙÔ 15% ÙˆÓ ·ÛıÂÓÒÓ Ì ÙË Û˘Ì‚·ÙÈ΋ ıÂڷ›· (¯ËÌÂÈÔıÂڷ›· ·ÎÙÈÓÔ‚ÔÏ›·, ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË). ªÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ (›·ÛË) Î˘Ì·›ÓÂÙ·È ÛÙÔ 35% (7). ∞fi Ù· ‰È¿ÊÔÚ· ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ª∞∫, ‰‡Ô Â›Ó·È ·˘Ù¿ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂӉȷʤÚÔÓ Î·È ÂȉÂÈÎÓ‡Ô˘Ó Î·Ï¿ ·ÔÙÂϤÛÌ·Ù·: ÔÈ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ (΢ڛˆ˜ Ë ‚·ÚÈ¿ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ· - SCID) Î·È Ë ªÂÛÔÁÂȷ΋ ∞Ó·ÈÌ›·. OÈ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¤ÁηÈÚ·, ÚÈÓ Ô ·ÛıÂÓ‹˜ ÂÈ‚·Ú˘Óı› Ì ÏÔÈÌÒÍÂȘ. ∂¿Ó Ô ‰fiÙ˘ Â›Ó·È Û˘Ì‚·Ùfi˜ ·‰ÂÏÊfi˜, Ë ÂÈÙ˘¯‹˜ ‰ÈfiÚıˆÛË Ù˘ ÁÂÓÂÙÈ΋˜ ·˘Ù‹˜ ‚Ï¿‚˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ 80% ÙˆÓ ·È‰ÈÒÓ. ŸÙ·Ó Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Á›ÓÂÈ ·fi ÌÂÚÈÎÒ˜ Û˘Ì‚·Ùfi (·ÏÔÙ·˘ÙfiÛËÌÔ) ÁÔÓ¤·, ÙfiÙ ٷ ÔÛÔÛÙ¿ ›·Û˘ Î˘Ì·›ÓÔÓÙ·È ÛÙÔ 60%. ∏ ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Â›Ó·È ÙÔ ÈÔ Û˘¯Ófi ÁÂÓÂÙÈÎfi ÓfiÛËÌ· Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Î·È ¤¯ÂÈ
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ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙË ¯ÒÚ· Ì·˜ ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Û¯fiÓÙˆÓ. ™‹ÌÂÚ·, ÔÈ ¿Û¯ÔÓÙ˜ ·fi ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ÔÈ ÔÔ›ÔÈ ˘Ô‚¿ÏÏÔÓÙ·È Û ٷÎÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ Î·È ÛˆÛÙ‹ ·ÔÛȉ‹ÚˆÛË, ÂÈÙ˘Á¯¿ÓÔ˘Ó ÈηÓÔÔÈËÙÈ΋ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ¤¯Ô˘Ó ÚÔÛ‰fiÎÈÌÔ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÂÈ‚›ˆÛ˘. ¶·Ú’ fiÏ· ·˘Ù¿ Ë ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Â›Ó·È ¤Ó· Ôχ ÛÔ‚·Úfi ÓfiÛËÌ· Ô˘ ˘Ô‚¿ÏÏÂÈ ÙÔÓ ·ÛıÂÓ‹ Û ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ (ÏÔÈÌÒÍÂȘ, ·ÈÌÔÛȉ‹ÚˆÛË Î.Ï.), ÂÓÒ ÚÈ˙È΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Á›ÓÂÙ·È ÌfiÓÔ Ì ª∞∫. OÈ ı·Ï·ÛÛ·ÈÌÈÎÔ› ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘, (I) ¯·ÌËÏÔ‡, (II) ÂӉȷ̤ÛÔ˘ Î·È (III) ˘„ËÏÔ‡, Ì 3 ÎÚÈÙ‹ÚÈ· Ù· ÔÔ›· ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ÔÌ¿‰· Pesaro Ù˘ πÙ·Ï›·˜. ∞˘Ù¿ ›ӷÈ: Ë Ë·ÙÔÌÂÁ·Ï›· ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô ‚·ıÌfi˜ ·ÔÛȉ‹ÚˆÛ˘ Î·È Ë ‡·ÚÍË Ë·ÙÈ΋˜ ›ÓˆÛ˘. ∏ ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È ÂÍ·ÈÚÂÙÈ΋, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ˘Ô‰Â¤ÛÙÂÚ· ÛÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜. ™Â Û‡ÓÔÏÔ 850 ·ÛıÂÓÒÓ ÙÔ˘ Pesaro, Ë ‰ÈfiÚıˆÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜ ÂÂÙ‡¯ıË ÛÙÔ 86% Ù˘ ÔÌ¿‰Ô˜ I, ÛÙÔ 74% Ù˘ ÔÌ¿‰Ô˜ II Î·È ÛÙÔ 53% Ù˘ ÔÌ¿‰Ô˜ III, ÂÓÒ Ë ıÓËÙfiÙËÙ· ·ÓÙ›ÛÙÔȯ· ‹Ù·Ó 5%, 16% Î·È 33%. ™ÙË ªÔÓ¿‰· ªªO ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ·›‰ˆÓ “∞Á›· ™ÔÊ›·” ¤¯Ô˘Ó ÌÂÙ·ÌÔÛ¯Â˘ı› 46 ı·Ï·ÛÛ·ÈÌÈο ·È‰È¿. ∞fi ·˘Ù¿, ÙÔ ¤Ó· ¤¯ÂÈ ·ÔÚÚ›„ÂÈ ÙÔ ÌfiÛ¯Â˘Ì·, ÙÚ›· ¤¯Ô˘Ó ηٷϋÍÂÈ Î·È Ù· ˘fiÏÔÈ· 42 Â›Ó·È ıÂÚ·Â˘Ì¤Ó·, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÌÔÔ›ËÛË ÙÔ˘ ‰fiÙË ÙÔ˘˜, ‰ËÏ·‰‹ Ë ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Ì ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 26 Ì‹Ó˜ (5-64 Ì‹Ó˜) ·Ó¤Ú¯ÂÙ·È ÛÙÔ fi¯È Â˘Î·Ù·ÊÚfiÓËÙÔ ÔÛÔÛÙfi ÙÔ˘ 92% (8). ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÛÙÔ ‰È¿ÛÙËÌ· ÙˆÓ 30 ¯ÚfiÓˆÓ Ô˘ ¤Ú·Û·Ó ·fi ÙfiÙ Ԣ ÁÈ· ÚÒÙË ÊÔÚ¿ ÂÊ·ÚÌfiÛÙËΠ۠·È‰› Ô˘ ¤·Û¯Â ·fi SCID, ·Ô‰Â›¯ıËΠ·fiÏ˘Ù· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ÁÈ· ¯ÈÏÈ¿‰Â˜ ·ÛıÂÓ›˜. ªÂ ÙËÓ Î·Ï‡ÙÂÚË ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ·ÛıÂÓÒÓ, ÙË
Paediatriki 2001;64:276-279
¯Ú‹ÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙËÓ ·‡ÍËÛË ÙˆÓ ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ Î·È ÙËÓ Î·Ï‡ÙÂÚË ÂÈÏÔÁ‹ ÙÔ˘˜ Ì Ù¯ÓÈΤ˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜, Â›Ó·È ‚¤‚·ÈÔ fiÙÈ fi¯È ÌfiÓÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ı· ·˘ÍËı›, ·ÏÏ¿ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Û˘Ó¯Ҙ ı· ‚ÂÏÙÈÒÓÔÓÙ·È. µÈ‚ÏÈÔÁÚ·Ê›· 1. Goldman JM, Schmitz N, Niethammer D, Gratwohl A. Indications for stem cell transplantation. In: Apperley J, Gluckman E, Gratwohl A, editors. Blood and Marrow Transplantation. The EBMT Handbook; 1998. p. 59-70. 2. Gluckman E. Sources of haematopoietic stem cells for allogeneic transplantation. In: Apperley J, Gluckman E, Gratwohl A, editors. Blood and Marrow Transplantation. The EBMT Handbook; 1998. p. 59-70. 3. Bearman SI. The syndrome of hepatic VOD after marrow transplantation. Blood 1995;85:3005-3020. 4. Storb R, Deeg J. Methotrexate and cyclosporine compared with cyclosporine alone for prophylaxis of acute graft versus host disease after BMT for leukemia. N Engl J Med 1986;314:729-735. 5. Kojima S, Horibe K, Inaba J, Yoshimi A, Takahashi Y, Kudo K et al. Long-term outcome of acquired aplastic anaemia in children: comparison between immunosuppressive therapy and bone marrow transplantation. Brit J Haem 2000;111:321-328. 6. Gorin NC. Stem cell transplantation in acute leukemia. Annals N York Acad Sciences 1995;770:262-287. 7. Camani NR. Autotransplants for neuroblastoma. Bone Marrow Transplant 1996;17:301-304. 8. Peristeri J, Kitra V, Goussetis E, Petropoulos D, Theodosaki M, Kattamis A et al. Haematopoietic stem cell transplantation for the management of haemoglobinopathies in Greek patients. Transf Science 2000;23:263-264.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù¤ÏÈÔ˜ °Ú·Ê¿ÎÔ˜ MÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, 115 27, ∞ı‹Ó·
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∞πª∞∆O§O°π∞ - O°∫O§O°π∞
Paediatriki 2001;64:280-284
HEMATOLOGY - ONCOLOGY
ªÂÙÂη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· ª. ∫·ÏÌ·ÓÙ‹
Training in Pediatric Hematology - Oncology M. Kalmanti MD
¶ÂÚ›ÏË„Ë: ∞ӷχÔÓÙ·È Ù· ÎÚ·ÙÔ‡ÓÙ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Âη›‰Â˘ÛË ÛÙËÓ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ¶ÚÔÙ›ÓÔÓÙ·È ÙÚfiÔÈ, ¯ÒÚÔÈ Î·È ·ÓÙÈΛÌÂÓ· Âη›‰Â˘Û˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ıˆÚÂ›Ù·È ÔÏÔÎÏËڈ̤ÓË ˘ÔÂȉÈÎfiÙËÙ· Î·È ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ.
Abstract: The recent data regarding training requirements in the subspecialty of Pediatric Hematology - Oncology are analyzed. The criteria for training programs, hospital settings and fields of training are suggested in order for it to succeed in becoming an accepted subspecialty in Greece.
§¤ÍÂȘ ÎÏÂȉȿ: ˘ÔÂȉÈÎfiÙËÙ·, ·È‰È·ÙÚÈ΋ ·ÈÌ·ÙÔÏÔÁ›· - ÔÁÎÔÏÔÁ›·.
Key words: subspecialty, pediatric hematology oncology.
πÛÙÔÚÈ΋ ·Ó·‰ÚÔÌ‹ ™·Ó ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜, Ë ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· Â›Ó·È ÙfiÛÔ ·ÏÈ¿ fiÛÔ Î·È Ë ¤Ú¢ӷ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. OÈ ‚·ÛÈΤ˜ ·Ú¯¤˜ Ù˘ Â›Ó·È fiÌÔȘ Ì ·˘Ù¤˜ Ù˘ ¶·ıÔÏÔÁ›·˜ - ∞ÈÌ·ÙÔÏÔÁ›·˜ Î·È ÔÈ ÚÒÙ˜ ÛËÌ·ÓÙÈΤ˜ ÂÚÁ·Û›Â˜ Î·È ·Ú·ÙËÚ‹ÛÂȘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔÓ ÙÔ̤· ÙˆÓ µ·ÛÈÎÒÓ ∂ÈÛÙËÌÒÓ. ∂›Ó·È ··Ú·›ÙËÙÔ Ó· ·Ó·Ê¤ÚÔ˘Ì ÔÓfiÌ·Ù· Ô˘ Û˘Ó¤ÙÂÈÓ·Ó ÛÙËÓ ·Ó¿Ù˘ÍË ·˘ÙÔ‡ ÙÔ˘ ‰›Ô˘, fiˆ˜ ÙˆÓ Ehrlich, Metchnikoff, Landsteiner, Chauffard, Downey, Minot, Castle, Whipple, Wintrobe, Jaksch, Lederer, Cooley, Blackfan, Fanconi (1). ™ËÌ·ÓÙÈÎfi ÛÙ·ıÌfi ÛÙËÓ ·Ó·Î¿Ï˘„Ë ‰È·ÊÔÚÒÓ ÌÂٷ͇ ·ÈÌ·ÙÔÏÔÁ›·˜ ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ ·ÔÙ¤ÏÂÛÂ Ë ÌÂϤÙË Ù˘ ÂÈÎfiÓ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙÔÓ Hayem ÙÔ 1889, Ë ·Ú·Ù‹ÚËÛË ÙÔ 1909 ·fi ÙÔÓ Flesh fiÙÈ ÔÈ ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ·Ó¿ÏÔÁ· Ì ÙȘ ËÏÈ˘ ÙˆÓ ·È‰ÈÒÓ, Â›Ó·È ÙfiÛÔ ÛËÌ·ÓÙÈΤ˜ Ô˘ ηÓ›˜ ‰ÂÓ Â›Ó·È Û ı¤ÛË Ó· ‰ÒÛÂÈ ÔÚÈÛÙÈο Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜, Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ù· ÓÂÔÁÓ¿ ÂÌÊ·Ó›˙Ô˘Ó ·ÚÔ‰È΋
ÂÚ˘ıÚÔ‚Ï¿ÛÙˆÛË ·fi ÙÔÓ Lippman ÙÔ 1924 Î·È ·ÚÎÂÙ¿ ·ÚÁfiÙÂÚ· Ë ÂÚÈÁÚ·Ê‹ Ù˘ ¿ÁÓˆÛÙ˘ ̤¯ÚÈ ÙfiÙ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ÙÔ 1944, ·fi ÙÔÓ Halbrech (2). ∆· ÚÒÙ· ¿ÚıÚ· Ô˘ ·Ó·Ê¤ÚıËÎ·Ó Û ÛËÌ·ÓÙÈΤ˜ ÎÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·ÙËÚ‹ÛÂȘ ÁÈ· Ê˘ÛÈÔÏÔÁÈΤ˜ ‹ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙ· ·È‰È¿, ‰ËÌÔÛȇÙËÎ·Ó ÙÔ 1925 ÛÙÔ American Journal of Diseases of Children, ÛÙÔ ÔÔ›Ô ·Ó·Ê¤ÚıËΠfiÙÈ Ë ·‡ÍËÛË ÙˆÓ ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Â›Ó·È ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚËÌ· ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ ÙÔÓ ›‰ÈÔ ¯ÚfiÓÔ ÛÙËÓ πÙ·Ï›· Î·È 3 ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÛÙË °ÂÚÌ·Ó›·, ‰ËÌÔÛȇÙËÎ·Ó ·Ú·ÙËÚ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙÔÓ fiÁÎÔ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÂÚ˘ıÚÒÓ ÛÂ Ê˘ÛÈÔÏÔÁÈΤ˜ Î·È ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÛÙ· ·È‰È¿ (3-5). ∏ Û˘Ì‚ÔÏ‹ ÙÔ˘ Thomas B. Cooley ·fi ÙÔ Detroit, Ô˘ ¯ÒÚÈÛ ÙËÓ ÔÓÙfiÙËÙ· “ı·Ï·ÛÛ·ÈÌ›·” ·fi ÙËÓ ·Ú¯È΋ Ù˘ ÂÚÈÁÚ·Ê‹ Û·Ó ÂÚ˘ıÚÔ‚Ï·ÛÙÈ΋ ·Ó·ÈÌ›·, ÛËÌ·ÙÔ‰fiÙËÛ ÙË ÌÂϤÙË ÙˆÓ ·ÈÌÔÛÊ·ÈÚÈÓÔ·ıÂÈÒÓ, ·Ó Î·È Ê˘ÛÈο ÙfiÙ ‰ÂÓ ‹Ù·Ó ÁÓˆÛÙfi fiÙÈ Ë ÙÂÏÈ΋ ‰È·Ù·Ú·¯‹ ÂÛÙÈ·˙fiÙ·Ó ÛÙËÓ
¢È¢ı‡ÓÙÚÈ· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ Î·È MÔÓ¿‰·˜ ªÂÙ·ÌÔÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, ∫Ú‹ÙË
Head of the Department of Pediatric Hematology-Oncology and the Division of Bone Marrow Transplantation University Hospital of Heraklion, Crete
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·ÈÌÔÛÊ·ÈÚ›ÓË. ¶·Ú’ fiÏ· ·˘Ù¿, ‹Ù·Ó ·˘Ùfi˜ Ô˘ ÚÒÙÔ˜ Û˘Ó¤Ï·‚ ÙËÓ È‰¤· fiÙÈ ·˘Ù¤˜ ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÌÔÔ›ËÛ˘ ‹Ù·Ó ÁÂÓÂÙÈο ηıÔÚÈṲ̂Ó˜ (6-7). ™Ù· ÌÂÙ¤ÂÈÙ· ¯ÚfiÓÈ·, ¿Ú¯ÈÛ ӷ ·Ó·Ù‡ÛÛÂÙ·È Ë ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· ÛÙËÓ ∂˘ÚÒË, Ì ڈÙÔfiÚÔ˘˜ ÙÔÓ Guido Fanconi, ÙÔÓ Conrad Gasser, ÙÔÓ Zuelzer, ÙÔÓ Kostmann, ÙÔÓ Clanzmann Î·È Ì ÙÔ˘˜ ÚˆÙÔfiÚÔ˘˜ ·fi ÙËÓ ∞ÌÂÚÈ΋ ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Ù˘ µÔÛÙÒÓ˘ Blackfan Î·È Diamond. OÈ ÙÂÏÂ˘Ù·›ÔÈ ¤ıÂÛ·Ó ÙË ‚¿ÛË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ∞ÌÂÚÈ΋. ∞˘ÙÔ› ÔÈ ‰‡Ô Âͤ‰ˆÛ·Ó ÙÔÓ ÚÒÙÔ ¿ÙÏ·ÓÙ· ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ÓfiÛˆÓ ÛÙ· ·È‰È¿ ÙÔ 1944 (8-10). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁ›·, Ë ÚˆÙÔÔÚ›· ·Ú¯›˙ÂÈ Ì ‰È¿ÛËÌÔ˘˜ ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˘˜ ÂΛӢ Ù˘ ÂÔ¯‹˜, fiˆ˜ Ô Wardrop Ô˘ ¤Î·Ó ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÚÂÙÈÓÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ÙÔ 1809, ÙÔ 1814 Ô Rance Ì ÂÚÈÁÚ·Ê‹ fiÁÎˆÓ ÓÂÊÚÒÓ, Î·È fiÁÎˆÓ ÎÔÈÏ›·˜ ÙÔ 1814 ·fi ÙÔÓ Gairdner. ∆Ô 1828 ·fi ÙÔÓ Hodgkin, Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÙˆÓ 7 ÚÒÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÔÌÒÓ˘Ì˘ ÓfiÛÔ˘ Î·È ÙÔ 1832 Ô Jessop ÂÚÈÁÚ¿ÊÂÈ ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÓÂÊÚÂÎÙÔÌ‹ Û ·È‰›. ¶ÂÚ·ÈÙ¤Úˆ ÛÙ·ıÌÔ‡˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁ›· ·ÔÙ¤ÏÂÛ·Ó Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ 7 ÂÚÈÙÒÛÂˆÓ ÓÂÊÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁfi Wilms ÙÔ 1877, Ë ÚÒÙË Ï‹„Ë ÊˆÙÔÁÚ·Ê›·˜ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ ÙÔ 1864 ·fi ÙÔÓ Damon, Ë ÚÒÙË ÂȯÔÚ‹ÁËÛË ¤Ú¢ӷ˜ ÛÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· ÛÙÔÓ Farber ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Ù˘ µÔÛÙÒÓ˘ ÁÈ· ÙȘ ÌÂϤÙ˜ ÙÔ˘ ÛÙË ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÙÂÚ›Ó˘ ÙÔ 1947, Î·È Ë ÚÒÙË Û˘ÁÎÚfiÙËÛË Û ÔÌ¿‰· ÌÂϤÙ˘ Î·È ıÂڷ›·˜ ÔÏÏÒÓ Î¤ÓÙÚˆÓ ÛÙËÓ ∞ÌÂÚÈ΋ ÙÔ 1952 (Children’s Cancer study group), ÛÙÔ ÔÔ›Ô ¿Ú¯ÈÛ·Ó Ó· ÌÂÏÂÙÒÓÙ·È 200-250 ·È‰È¿ ÙÔ ¯ÚfiÓÔ Ì ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ηÎÔ‹ıÂÈ·˜. ™ÙËÓ ∂ÏÏ¿‰·, ÔÈ ÚÒÙÔÈ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ı¤Ì·Ù· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ ‹Ù·Ó ÔÈ Î.Î ∫. ÈڤÌ˘, §. ∑¿ÓÓÔ˘ Î·È Ã. ∫·ÙÙ¿Ì˘ Ì ÛËÌ·ÓÙÈΤ˜ ÌÂϤÙ˜ ÛÙȘ ÂÓ˙˘ÌÔ¿ıÂȘ, ·ÈÌÔÏ˘ÙÈÎfi ›ÎÙÂÚÔ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ. µ·ÛÈο ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· ™‡Ìʈӷ Ì ÙȘ ‰ÈÂıÓ›˜ ÛÙ·ÙÈÛÙÈΤ˜ Ô˘ ÈÛ¯‡Ô˘Ó Î·È ÁÈ· ÙË ¯ÒÚ· Ì·˜, ÙÔ 1972 Ô Î·ÚΛÓÔ˜ ÛÙ· ·È‰È¿ ›¯Â ›وÛË 12 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿, ÂÓÒ ÙÔ 1990 14 ·Ó¿ 100.000 ·È‰È¿. ªÂ ÙË ÛËÌÂÚÈÓ‹ ÂÈÙ˘¯Ë̤ÓË ıÂڷ›·, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ÁÓÒÛË ªÔÚȷ΋˜ µÈÔÏÔÁ›·˜ Î·È ·Ó¿Ù˘ÍË ÔÏÏ·ÏÒÓ ÂȉÈÎÔÙ‹ÙˆÓ Î·ıÒ˜ Î·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ÚfiÁÓˆÛË Ô˘ ¤¯Ô˘Ó Ù· ·È‰È¿
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·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ, Ù· ‰ÈÂıÓ‹ ÛÙ·ÙÈÛÙÈο ‰Â‰Ô̤ӷ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ 65% Û˘ÓÔÏÈο ÙˆÓ ·È‰ÈÒÓ Ì ηÚΛÓÔ ıÂڷ‡ÂÙ·È Ï‹Úˆ˜, ÙÔ 90% ‚ÂÏÙÈÒÓÂÙ·È, ÂÓÒ ¤Ó·˜ ÛÙÔ˘˜ 900 ÂÓ‹ÏÈΘ ÛÙȘ ∏¶∞ ËÏÈΛ·˜ 18-44 ÂÙÒÓ ¤¯ÂÈ ÂÈ‚ÈÒÛÂÈ ·fi οÔÈ· ÌÔÚÊ‹ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ Î·È ˙ÂÈ Ì›· Ê˘ÛÈÔÏÔÁÈ΋ ÂÈÙ˘¯‹ ˙ˆ‹ (11). ™ÙȘ ηÏÔ‹ıÂȘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ ÛÙ· ·È‰È¿, ‰ËÏ·‰‹ ÛÙÔÓ ÎÏ¿‰Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) ÔÈ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ‰È·Ù·Ú·¯¤˜ (ÂÚ˘ıÚÒÓ, ‹Í˘), ‚) ÔÈ ·Ï·ÛÙÈΤ˜ ·Ó·È̛˜, Ô˘‰ÂÙÂÚÔÂӛ˜, ÔÈÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ Î·È Á) ÔÈ ıÚÔÌ‚ÔÂӛ˜ (·ÈÌÔÚÚÔÊÈÏ›·, ıÚÔÌ‚ˆÙÈΤ˜ ‰È·Ù·Ú·¯¤˜). ™ÙÔȯ›· ÁÈ· ÙËÓ ˘ÔÂȉÈÎfiÙËÙ· (∏.¶.∞., ∂˘ÚÒË) §fiÁˆ Ù˘ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓ˘ ÁÓÒÛ˘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›·, ¤ÁÈÓ ۷ʋ˜ Ë ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ Âη›‰Â˘Û˘ ÛÙÔÓ ÎÏ¿‰Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜. ∏ ÚÒÙË ¯ÒÚ· Ô˘ ÙÔ Âȯ›ÚËÛ ‹Ù·Ó Ë ∞ÌÂÚÈ΋ Ì 3 ¯ÚfiÓÈ· Âη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È 3 ¯ÚfiÓÈ· Âη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. ∞ÎÔÏÔ‡ıËÛÂ Ë ∂˘ÚÒË, ¯ˆÚ›˜ ›ÛËÌÔ Ù›ÙÏÔ ÂȉÈÎfiÙËÙ·˜ fiˆ˜ ÔÈ ∏¶∞, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ù˘ ÔÔ›·˜ ÚÔÙ›ÓÔÓÙ·È 5 ¯ÚfiÓÈ· ¶·È‰È·ÙÚÈ΋˜ Î·È 3 ¯ÚfiÓÈ· Âη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· – OÁÎÔÏÔÁ›·. ™ÙËÓ ∂ÏÏ¿‰·, ·ÎfiÌË ‰ÂÓ Â›Ó·È Î·ıÔÚÈṲ̂ÓÔ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÛÙÔ ÔÔ›Ô ÌÔÚ› Ó· ıˆÚËı› ¤Ó·˜ ÁÂÓÈÎfi˜ ¶·È‰›·ÙÚÔ˜ ÈηÓfi˜ Ó· ÂÍ·Û΋ÛÂÈ ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ·ÊÔ‡ Ë ÂȉÈÎfiÙËÙ· ÛÙË °ÂÓÈ΋ ¶·È‰È·ÙÚÈ΋ ·ÎfiÌË Â›Ó·È 4 ¯ÚfiÓÈ·. ªÂ ·˘Ùfi ÙÔ ‰Â‰Ô̤ÓÔ, Ù· ÙÚ›· ÂÈϤÔÓ ¯ÚfiÓÈ· ˘ÔÂȉÈÎfiÙËÙ·˜ ıˆÚÔ‡ÓÙ·È ¿ÎÚˆ˜ ··Ú·›ÙËÙ·. ™‡Ìʈӷ Ì ÙËÓ American Society of Pediatric Hematology-Oncology (ASPHO), ÛÙȘ ∏¶∞ ·˘Ù‹ ÙË ÛÙÈÁÌ‹ ˘¿Ú¯Ô˘Ó 65 ΤÓÙÚ· Ô˘ ¯ÔÚËÁÔ‡Ó ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ÂÓÒ ÛÙÔÓ ∫·Ó·‰¿ ÌfiÓÔÓ 6. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· Ù˘ ·Ú·¿Óˆ ÂÙ·ÈÚ›·˜, ·fi ÙÔ 1974-1998 ηٷÁÚ¿ÊËÎ·Ó 1.348 ¶·È‰›·ÙÚÔÈ ∞ÈÌ·ÙÔÏfiÁÔÈ - OÁÎÔÏfiÁÔÈ ÛÙȘ ∏¶∞, 1.1001.200 ÂÍ·ÛÎÔ‡Ó ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ÂÓÒ 50-60 ·Ô¯ˆÚÔ‡Ó Î¿ı ¯ÚfiÓÔ. ªÂ ‚¿ÛË ·˘Ù¿, Ë ·Ó¿ÁÎË ÁÈ· Ó¤Ô˘˜ ¶·È‰È¿ÙÚÔ˘˜ ∞ÈÌ·ÙÔÏfiÁÔ˘˜ - √ÁÎÔÏfiÁÔ˘˜ ÙÔÔıÂÙÂ›Ù·È Û 80-100 ÂÙËÛ›ˆ˜ (12). ™‡Ìʈӷ Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· Ù˘ ∞ÌÂÚÈ΋˜, Ù· ··Ú·›ÙËÙ· ÛÙÔȯ›· Ô˘ Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ¤Ó· ∫¤ÓÙÚÔ ÁÈ· Ó· Âηȉ‡ÂÈ ¶·È‰È¿ÙÚÔ˘˜ ∞ÈÌ·ÙÔÏfiÁÔ˘˜ - OÁÎÔÏfiÁÔ˘˜ ›ӷÈ: ·) ÂÎ·È‰Â˘Ì¤Ó˜ ÓÔÛËχÙÚȘ, ‚) ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ·È‰ÈÒÓ, Á) ¶·È‰Ô·ÎÙÈÓԉȷÁÓˆÛÙÈ΋ ÌÔÓ¿‰·, ‰) ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ÌÔÓ¿‰·/ÎÏÈÓÈ΋, Â) ¯ÂÈÚÔ˘ÚÁÔ‡˜ Ì ÂÌÂÈÚ›· ÛÙË Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈ΋,
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Ô˘ÚÔÏÔÁ›·, ÔÚıÔ‰È΋ ·›‰ˆÓ, ÛÙ) „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË, ˙) ÂÚÁ·ÛÙ‹ÚÈ· ∞ÈÌ·ÙÔÏÔÁÈο-∫˘ÙÙ·ÚÔÏÔÁÈο, Ë) ÂÚÁ·ÛÙ‹ÚÈ· ÎÏÈÓÈ΋˜ ¯ËÌ›·˜ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÂȤ‰ˆÓ Ê·Ú̿ΈÓ, ı) ÙÚ¿Â˙· ·›Ì·ÙÔ˜, È) Ê·ÚÌ·ÎÂ›Ô (ÁÈ· ·Ú·Û΢‹ Î·È ‰È¿ıÂÛË ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ), È·) ‰˘Ó·ÙfiÙËÙ· ·ÔÌfiÓˆÛ˘ ·ÛıÂÓÒÓ ·fi ÌÈÎÚfi‚È· Ô˘ ÙÔ˘˜ ÌÔχÓÔ˘Ó ‰È· ÙÔ˘ ·¤ÚÔ˜, È‚) OÁÎÔÏÔÁÈÎfi ¶·È‰È·ÙÚÈÎfi Û˘Ì‚Ô‡ÏÈÔ Û ٷÎÙ¿ ‰È·ÛÙ‹Ì·Ù·, ÈÁ) Û˘ÌÌÂÙÔ¯‹ Û ÎÔÈÓ¿ ÚˆÙfiÎÔÏÏ· ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (15). ™ÙÔȯ›· ÁÈ· ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜ ·fi ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ ™ÙËÓ ∂ÏÏ¿‰· ÏÂÈÙÔ˘ÚÁÔ‡Ó Ù· ηو٤ڈ ÙÌ‹Ì·Ù·: ™ÙËÓ ∞ı‹Ó·: ∞) ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1 ∫ÏÈÓÈ΋ (¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁÈ΋/OÁÎÔÏÔÁÈ΋) (∂™À), 1 ªÔÓ¿‰· (∞ÈÌ·ÙÔÏÔÁÈ΋/OÁÎÔÏÔÁÈ΋, ¶·ÓÂÈÛÙËÌȷ΋), 2 ªÔÓ¿‰Â˜ ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ (Ì›· ∂™À, Ì›· ¶·ÓÂÈÛÙËÌȷ΋), 1 ªÔÓ¿‰· ∞ÈÌÔÚÚ·ÁÈÎÒÓ ¢È·ı¤ÛÂˆÓ (∂™À), 1 ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ (∂™À). µ) ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡”, Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1 ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ (∂™À) ™ÙË £ÂÛÛ·ÏÔÓ›ÎË: ∞) 1 ∫ÏÈÓÈ΋ ∂™À (OÁÎÔÏÔÁÈ΋) πÔÎÚ¿ÙÂÈÔ, µ) 1 ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ (¶·ÓÂÈÛÙËÌȷ΋) πÔÎÚ¿ÙÂÈÔ, °) 1 ªÔÓ¿‰· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜/OÁÎÔÏÔÁ›·˜ (¶·ÓÂÈÛÙËÌȷ΋) ∞Ã∂¶∞, ¢) 1 ªÔÓ¿‰· ªªO ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ ∂™À, °. ¶··ÓÈÎÔÏ¿Ô˘. ™ÙËÓ ∫Ú‹ÙË: ∞) 1 ∫ÏÈÓÈ΋ (¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁÈ΋/√ÁÎÔÏÔÁÈ΋ Î·È ªªO) (¶·ÓÂÈÛÙËÌȷ΋). ªÂ ‚¿ÛË Ù· ÛÙÔȯ›· ·fi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁÈ΋˜/OÁÎÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜, ÛÙËÓ ∂ÏÏ¿‰· οı ¯ÚfiÓÔ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È 150 ÂÚÈÙÒÛÂȘ Û˘Ì·ÁÒÓ fiÁÎˆÓ Î·È 100 Ï¢¯·ÈÌ›·˜, Ô˘ ÓÔÛËχÔÓÙ·È Î·Ù¿ 95% ÛÙ· ·Ú·¿Óˆ ÙÌ‹Ì·Ù· ÌÂ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÎÏÈÓÒÓ ÁÈ· ÙËÓ ∞ı‹Ó· 65 Î·È 6 ÁÈ· ÙË ªªO, ÁÈ· ÙË £ÂÛÛ·ÏÔÓ›ÎË 40 Î·È 2 ÁÈ· ÙË ªªO Î·È ÁÈ· ÙËÓ ∫Ú‹ÙË 20 Î·È 2 ÁÈ· ÙË ªªO, ¯ˆÚ›˜ ‚¤‚·È· Ó· ˘¿Ú¯ÂÈ ·ÎfiÌË Â›ÛËÌË ÛÙ·ÙÈÛÙÈ΋. ™Ù· ·Ú·¿Óˆ ˘¿Ú¯ÔÓÙ· ∆Ì‹Ì·Ù· ÙÔ˘ ∂ÏÏËÓÈÎÔ‡ ¯ÒÚÔ˘, ¿‰ÂÈ· ¯ÔÚ‹ÁËÛ˘ ÂȉÈÎfiÙËÙ·˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ ¤¯ÂÈ ‰Ôı› Û ÙÚ›·, ·fi Ù· ÔÔ›· Û ‰‡Ô Ï‹Ú˘ (3,5 ¯ÚfiÓÈ·) Î·È Û ¤Ó· ÌÂÚÈ΋ (1,5 ¯ÚfiÓÔ˜). OÈ ÁÈ·ÙÚÔ› Ô˘ ·ÛÎÔ‡Ó ÙËÓ ÂȉÈÎfiÙËÙ· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ¶·È‰›·ÙÚÔÈ, ¶·È‰›·ÙÚÔÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ (∂ÏÏ¿‰·, ∂˘ÚÒË, ∏.¶.∞.) Î·È ∞ÈÌ·ÙÔÏfiÁÔÈ (Ì Âȉ›Î¢ÛË Û ¶·È‰È·ÙÚÈο ∞ÈÌ·ÙÔÏÔÁÈο - OÁÎÔÏÔÁÈο ∫¤ÓÙÚ·). ∏ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ -
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OÁÎÔÏÔÁ›·˜ ȉڇıËΠÙÔ 1986 Î·È ·ÚÈıÌ› ÂÚ› Ù· 70 ÂÚ›Ô˘ ̤ÏË. ∞˘Ù¿, ·Ó¿ ÂȉÈÎfiÙËÙ˜, ›ӷÈ: 44 ¶·È‰›·ÙÚÔÈ, 6 ∞ÈÌ·ÙÔÏfiÁÔÈ, 7 ¶·È‰›·ÙÚÔÈ Ì ¿‰ÂÈ· ·Û΋Ûˆ˜ ·ÁÁ¤ÏÌ·ÙÔ˜ ÛÙȘ ∏¶∞ Î·È 13 ÂÈÛÙ‹ÌÔÓ˜ ¿ÏÏˆÓ ÂȉÈÎÔًوÓ. ∂η›‰Â˘ÛË ∞·Ú·›ÙËÙ· ÎÚÈÙ‹ÚÈ· ÁÈ· Âη›‰Â˘ÛË Â›Ó·È Ë ¿ÚÈÛÙË ÁÓÒÛË Ù˘ ∫ÏÈÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ (ÂÏ¿¯ÈÛÙÔ 3 ¯ÚfiÓÈ·), ÂÓÒ ÁÈ· ÁÈ·ÙÚÔ‡˜ Ì ÂȉÈÎfiÙËÙ· ∞ÈÌ·ÙÔÏÔÁ›·˜, Ë Âη›‰Â˘ÛË Ù˘ ˘Ô¯ÚˆÙÈ΋˜ ‰ÈÂÙ›·˜ Û ¶·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· ‹ ÙÌ‹Ì·Ù· Ô˘ ‰È·ı¤ÙÔ˘Ó ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô Âη›‰Â˘Û˘, ÛÙfi¯Ô˜ Â›Ó·È Ë ·fiÎÙËÛË ÂÌÂÈÚ›·˜ ÛÙËÓ ∫ÏÈÓÈ΋ Î·È Ù· Â͈ÙÂÚÈο È·ÙÚ›·, Ë ÁÓÒÛË ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, ·ÈÌfiÛÙ·Û˘ Î·È ‹Í˘ ·Ú¿ÏÏËÏ· Ì ÙË ÁÓÒÛË ÂȉËÌÈÔÏÔÁ›·˜/·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÓÔÛËÌ¿ÙˆÓ ·›Ì·ÙÔ˜ (ηÏÔ‹ıˆÓ Î·È Î·ÎÔ‹ıˆÓ ·fi ÙË ÓÂÔÁÓÈ΋ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 10 ¯ÚfiÓˆÓ) ηıÒ˜ Î·È Î·ÎÔ‹ıˆÓ fiÁΈÓ. π‰È·›ÙÂÚË ‚·Ú‡ÙËÙ· ·ÔÎÙ¿ Î·È Ë Âη›‰Â˘ÛË ÛÙËÓ ÎÏÈÓÈ΋ ¤Ú¢ӷ (·Ó¿Ï˘ÛË ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ, ÂȉËÌÈÔÏÔÁ›·, ÚˆÙfiÎÔÏÏ·), ηıÒ˜ Î·È ÛÙ· ÂÚÁ·ÛÙ‹ÚÈ· (·ÈÌ·ÙÔÏÔÁÈÎfi, ·ÓÔÛÔÏÔÁÈÎfi, ‹Í˘, ·ÈÌÔ‰ÔÛ›·˜, ÈÛÙÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi, ΢ÙÙ·ÚÔÁÂÓÂÙÈÎfi). °È· Ó· ıˆÚËı› ¤Ó· ÙÌ‹Ì· ηٿÏÏËÏÔ Ó· Âηȉ‡ÂÈ ¶·È‰È¿ÙÚÔ˘˜ ÛÙËÓ ∞ÈÌ·ÙÔÏÔÁ›·, ı· Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ÔÌ¿‰· ·ÙfiÌˆÓ ·Û¯ÔÏÔ‡ÌÂÓˆÓ Ì ÙÔ ·ÓÙÈΛÌÂÓÔ, Ó· ¤¯ÂÈ Û˘ÓÂÚÁ·Û›· Ì ÂıÓÈÎÔ‡˜ Î·È ‰ÈÂıÓ›˜ ÔÚÁ·ÓÈÛÌÔ‡˜, Ó· ÌÔÚ› Ó· ÂÈÙÂÏ› ÛˆÛÙ‹ ηٷÁÚ·Ê‹ Î·È Ó· ¤¯ÂÈ Û˘ÌÌÂÙÔ¯‹ Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Î·È ÚˆÙfiÎÔÏÏ· (13). ™Ù· Ï·›ÛÈ· Ù˘ ··Ú·›ÙËÙ˘ Âη›‰Â˘Û˘ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) Ë ·˘Ù¿ÚÎÂÈ· ÛÙË ‰È¿ÁÓˆÛË Î·ÏÔ‹ıˆÓ Î·È Î·ÎÔ‹ıˆÓ ÓÔÛËÌ¿ÙˆÓ ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, Ì˘ÂÏfi, ÔÛÙÂÔÌ˘ÂÏÈ΋ ‚ÈÔ„›·, ‚ÈÔÏÔÁÈο ˘ÁÚ¿, ‚) Ë ·˘Ù¿ÚÎÂÈ· ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Î·È ‰˘Ó·ÙfiÙËÙ· ÂÈÎÔÈÓˆÓ›·˜ Ì ¿ÏÏ· ΤÓÙÚ· (ÂÛˆÙÂÚÈÎÔ‡ Î·È ‰ÈÂıÓ‹), Á) Ë ·˘Ù¿ÚÎÂÈ· ÛÙÔÓ Ï‹ÚË ÚÔÁÚ·ÌÌ·ÙÈÛÌfi ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ηÏfiËı˜ ‹ ηÎfiËı˜ ÓfiÛËÌ· (14). ∂Èı˘ÌËÙ‹ Âη›‰Â˘ÛË, ÙËÓ ÔÔ›· ‰‡Ó·ÓÙ·È Ó· ·Ú¤¯Ô˘Ó ÌÂÚÈο ΤÓÙÚ·, Â›Ó·È Ë ÁÓÒÛË ÂÎÙ¤ÏÂÛ˘ ·ÏÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ·ÈÌÔ‰ÔÛ›·˜, ‹Í˘ Î·È ÂÚÁ·ÛÙËÚȷ΋˜ ·ÈÌ·ÙÔÏÔÁ›·˜ (Âη›‰Â˘ÛË Î˘ÎÏÔÙÂÚÒ˜ ÛÙ· ·ÓÙ›ÛÙÔȯ· ÂÚÁ·ÛÙ‹ÚÈ·), Ë ·‰Ú‹ ÁÓÒÛË ÂÎÙ›ÌËÛ˘ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ (CAT SCAN, NMR, ™ÈÓıËÚÔÁÚ·Ê‹Ì·Ù·), ‚·ÛÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È ÂÚÌËÓ›·˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ë ·‰Ú‹ ÁÓÒÛË Î˘ÙÙ·Ú·Ê·›ÚÂÛ˘, Ï·ÛÌ·Ê·›ÚÂÛ˘, ·ÈÌÔÂÙ·ÏÈÔ·Ê·›ÚÂÛ˘.
MAY- JUNE '01 TELIKO
30-05-03
18:55
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¶·È‰È·ÙÚÈ΋ 2001;64:280-284
ŒÓ· ÚÔÙÂÈÓfiÌÂÓÔ Û¯‹Ì· ÁÈ· 3ÂÙ‹ Âη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›·/OÁÎÔÏÔÁ›· ÂÚÈÏ·Ì‚¿ÓÂÈ: I) ∫ÏÈÓÈ΋ ∂η›‰Â˘ÛË: 21 Ì‹Ó˜, II) ¢È·Ù·Ú·¯¤˜ ‹Í˘-·ÈÌfiÛÙ·Û˘: 3 Ì‹Ó˜, III) ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘: 3 Ì‹Ó˜, IV) ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜: 3 Ì‹Ó˜, V) ∂ÚÁ·ÛÙËÚȷ΋ ∞ÈÌ·ÙÔÏÔÁ›·: 3 Ì‹Ó˜, VI) ∞ÈÌÔ‰ÔÛ›·: 3 Ì‹Ó˜. ŸÛÔÓ ·ÊÔÚ¿ Ù· ·Ú·¿Óˆ, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÛÙÔ˘˜ 21 Ì‹Ó˜ Âη›‰Â˘Û˘ ÛÙËÓ ∫ÏÈÓÈ΋ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÂÚÈÛÙ·ÙÈο Ô˘ ·ÊÔÚÔ‡Ó fiϘ ÙȘ ÂÈ̤ÚÔ˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Î·È ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ Î·È ¤¯Ô˘Ó ηıÔÚÈÛÙ› Û ÙÚ›ÌËÓË Âη›‰Â˘ÛË, ‰ËÏ. ‰È·Ù·Ú·¯¤˜ ‹Í˘ - ·ÈÌfiÛÙ·Û˘, ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ, ¿ÚÚˆÛÙÔÈ Î·È ·È‰È¿ Ì ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ηÙÔ¯˘Úˆı› Ë ÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜, Â›Ó·È ··Ú·›ÙËÙÔ Ó· ·˘ÍËı› Ô ·ÚÈıÌfi˜ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ¤¯Ô˘Ó Âη›‰Â˘ÛË ÛÙÔ ·ÓÙÈΛÌÂÓÔ. ∂ÈϤÔÓ, ÙÔ Ì¿ıËÌ· ÛÙ· ¶·ÓÂÈÛÙ‹ÌÈ· Ú¤ÂÈ Ó· Á›ÓÂÈ ·˘ÙÔÙÂϤ˜, Ú¤ÂÈ Ó· ÂÎÔÓÔ‡ÓÙ·È ‰È‰·ÎÙÔÚÈΤ˜ ‰È·ÙÚÈ‚¤˜ Ì ı¤Ì·Ù· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ OÁÎÔÏÔÁ›·˜, Ó· Á›ÓÔÓÙ·È ‰ËÌÔÛȇÛÂȘ Û ‰ÈÂıÓ‹ ÂÚÈÔ‰Èο Ì ۇÛÙËÌ· ÎÚÈÙÒÓ,ηıÒ˜ Î·È Ó· ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÛÙȘ ‰ÈÂıÓ›˜ ÔÚÁ·ÓÒÛÂȘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ (International Society of Pediatric Oncology [SIOP], American Society of Pediatric Hematology/Oncology [ASPHO], European Society of Pediatric Hematology & Immunology [ESPHI], European Group for Blood & Marrow Transplantation [EBMT]). ∆· ∫¤ÓÙÚ· Ô˘ ıˆÚÔ‡ÓÙ·È Î·Ù¿ÏÏËÏ· ÁÈ· ¯ÔÚ‹ÁËÛË ÂȉÈÎfiÙËÙ·˜ Ú¤ÂÈ Ó· Â›Ó·È ¶·ÓÂÈÛÙËÌȷΤ˜ ∫ÏÈÓÈΤ˜ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ OÁÎÔÏÔÁ›·˜ ·˘ÙÔÙÂÏ›˜ ‹ ¶·È‰È·ÙÚÈΤ˜ Ì ·ÓÙ›ÛÙÔȯ˜ ÌÔÓ¿‰Â˜, ∫ÏÈÓÈΤ˜ ÙÔ˘ ∂™À Ì ¶·È‰È·ÙÚÈΤ˜ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ - OÁÎÔÏÔÁÈΤ˜ ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜, ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜ Ì ÁÈ·ÙÚÔ‡˜ Ô˘ ‰È·ı¤ÙÔ˘Ó Â›ÛËÌ· ·Ô‰Â‰ÂÈÁ̤ÓË Âη›‰Â˘ÛË Û ·Ó·ÁÓˆÚÈṲ̂ӷ ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ (ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 ¯ÚfiÓÈ·) ‹ Û ΤÓÙÚ· Ù˘ ∂ÏÏ¿‰·˜ (ÙÔ˘Ï¿¯ÈÛÙÔÓ 6 ¯ÚfiÓÈ·). ™Ù· ∫¤ÓÙÚ· Âη›‰Â˘Û˘ ÛÙËÓ ∂ÏÏ¿‰·, ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ ηıÔÚ›˙ÔÓÙ·È ÁÈ·: ∞) ∞ÈÌ·ÙÔÏÔÁÈο - OÁÎÔÏÔÁÈο ∆Ì‹Ì·Ù·, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÎÏÈÓÒÓ (15), ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù’ ¤ÙÔ˜ (20 ·ÛıÂÓ›˜), ÙÔÓ ·ÚÈıÌfi ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ Î·Ù’ ¤ÙÔ˜ (100 ·ÛıÂÓ›˜), ÙˆÓ ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (500 ·ÛıÂÓ›˜), Î·È ˆ˜ ÚÔ˜ ÙÔ ÚÔÛˆÈÎfi (¶·È‰›·ÙÚÔÈ ∞ÈÌ·ÙÔÏfiÁÔÈ-OÁÎÔÏfiÁÔÈ, ¤ÌÂÈÚ˜ ÓÔÛËχÙÚȘ, „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË).
Paediatriki 2001;64:280-284
µ) ªÔÓ¿‰Â˜ ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÎÏÈÓÒÓ (10), ÙÔÓ ·ÚÈıÌfi ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ ·È‰ÈÒÓ (100), ÙË Û˘ÓÂÚÁ·Û›·/Û‡Ó‰ÂÛË ÌÔÓ¿‰·˜ Ì ÂȉÈο ÙÌ‹Ì·Ù· (ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi, ηډÈÔÏÔÁÈÎfi Î.Ï.), Î·È ˆ˜ ÚÔ˜ ÙË Û˘ÓÂÚÁ·Û›· Ì ÂÚÁ·ÛÙ‹ÚÈÔ fiÔ˘ ı· Á›ÓÂÙ·È ‰È¿ÁÓˆÛË Î·È ¤ÏÂÁ¯Ô˜ ·ÈÌÔÛÊ·ÈÚÈÓÔ·ıÂÈÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ Î·È ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜. °) ªÔÓ¿‰Â˜ ∞ÈÌfiÛÙ·Û˘-∞ÈÌÔÚÚÔÊÈÏ›·˜, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù’ ¤ÙÔ˜ (50), ÙÔÓ ·ÚÈıÌfi ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (1000 ·ÛıÂÓ›˜), ˆ˜ ÚÔ˜ ÙÔ ÚÔÛˆÈÎfi (3 ¶·È‰›·ÙÚÔÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ, ‚ÈÔÏfiÁÔÈ ‹ ‚ÈÔ¯ËÌÈÎÔ›, Ê˘ÛÈÔıÂÚ·Â˘Ù¤˜, ÎÔÈÓˆÓÈ΋ ÏÂÈÙÔ˘ÚÁfi˜, „˘¯ÔÏfiÁÔ˜), Î·È ˆ˜ ÚÔ˜ ÙË Û˘ÓÂÚÁ·Û›·Û‡Ó‰ÂÛË Ì ÔÚıÔ‰ÈÎfi Î·È Ô‰ÔÓÙÈ·ÙÚÈÎfi ÙÌ‹Ì· Î·È ÂÚÁ·ÛÙ‹ÚÈÔ ÛÙÔ ÔÔ›Ô ÂÈÙÂÏÂ›Ù·È Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜, ıÚÔÌ‚ÔÊÈÏ›·˜, ›ÎÙËÙˆÓ ·Ó·ÛÙ·ÏÙÒÓ Î·È ÚÔÁÂÓÂÙÈ΋˜ ‰È¿ÁÓˆÛ˘ ·ÈÌÔÚÚÔÊÈÏ›·˜. ¢) °È· ÙȘ ªÔÓ¿‰Â˜ ªÂÙ·ÌfiÛ¯Â˘Û˘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ, ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È Î˘ÙÙ¿ÚˆÓ ·›Ì·ÙÔ˜ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘) ηıÔÚ›˙ÂÙ·È Ô ·ÚÈıÌfi˜ ÎÏÈÓÒÓ (2-4), Ô ·ÚÈıÌfi˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÂÙËÛ›ˆ˜ (15, ÂÎ ÙˆÓ ÔÔ›ˆÓ 5 ·ÏÏÔÁÂÓÂÙÈΤ˜), Ô ·ÚÈıÌfi˜ ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (150 ·ÛıÂÓ›˜), ÙÔ ÚÔÛˆÈÎfi (3 ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ ¶·È‰›·ÙÚÔÈ ‹ ∞ÈÌ·ÙÔÏfiÁÔÈ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· OÁÎÔÏÔÁ›·, ‚ÈÔÏfiÁÔ˜, ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÓÔÛËχÙÚȘ, „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË) ηıÒ˜ Î·È ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÂÂÍÂÚÁ·Û›·˜ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™Â ·˘Ùfi ÂÈÙÂÏÂ›Ù·È ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË Î·Ù¿„˘ÍË/ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÂÂÍÂÚÁ·Û›· Î·È Î¿ı·ÚÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ, ¤ÏÂÁ¯Ô˜ ¯ÈÌ·ÈÚÈ΋˜ ηٿÛÙ·Û˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ Î·È Î·ÏÏȤÚÁÂȘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ªÂ ‚¿ÛË ÙȘ ·ÓˆÙ¤Úˆ ÚÔÙ¿ÛÂȘ Î·È Ì ÙË Û˘Ì‚ÔÏ‹, ÂÎÙfi˜ ·fi ÙËÓ ∂Ù·ÈÚ›· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜, Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ·ÏÏ¿ Î·È fiÏˆÓ ÙˆÓ ¶·ÓÂÈÛÙËÌ›ˆÓ Ù˘ ¯ÒÚ·˜, Â›Ó·È ÂÊÈÎÙ‹ Ë ¿ÚÈÛÙË Âη›‰Â˘ÛË - ÌÂÙÂη›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Flesch H, quoted by Baar H, Stransky E. Die Klinische Hamatologie des Kindesalters; Leipzig: Franz Deuticke; 1928. 2. Halbrecht I. Role of hemo-agglutinins anti-A and anti-B in pathogenesis of the newborn (icterus neonatorum praecox). Am J Dis Child 1964;45:1. 3. Lippman HS. A morphologic and quantitative study of the
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blood corpuscles in the new-born period. Am J Dis Child 1924;27:473. Friedlander A, Wiedemer C, quoted by Baar H, Stransky E. Die Klinische Hamatologie des Kindesalters; Leipzig: Franz Deuticke; 1928. Zibordi F. Ematologia Infantile Normale e Patologica. Milano: Instituto Editoriale Scientifico; 1925. Cooley TB, Lee P. Series of cases of splenomegaly in children with anemia and peculiar bone changes. Trans Am Pediatr Soc 1925;37:29. Valentine WN, Neel JV. Hematologic and genetic study of the transmission of thalassemia (Cooley’s anemia: Mediterranean anemia). Arch Intern Med 1944;74:185. Blackfan KD, Diamond LK. Atlas of the Blood in Children. New York: The Commonwealth Fund; 1944. Fanconi G. Die primaren Anamien und Erythroblastosen im Kindesalter. Monatsschr Kinderhilkd 1937;68:129. Zuelzer WW, Bajoghli M. Chronic granulocytopenia in childhood. Blood 1964;23:359. American Academy of Pediatrics Section Statement: Guidelines for the Pediatric Cancer Center and Role of Such Centers in Diagnosis and Treatment. Pediatrics 1997;99:139.
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12. Arceci RJ, Reaman GH, Cohen AR, Lampkin BC. Position statement for the need to define Pediatric Hematology/Oncology programs: A model of subspecialty care for chronic childhood diseases. J Pediatr Hematol/Oncol 1998;20:98. 13. ∫·ÏÌ·ÓÙ‹ ª. ∂η›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ∂ÈÛ‹ÁËÛË ÛÙÔ ECTS Erasmus Program. 1997. 14. Voute PA. Personal communication; 17/3/2000. 15. American Board of Pediatrics. Program Requirements for Residency Education in Pediatric Hematology/Oncology, Accreditation Council for Graduate Medical Education 2000 (ACGME). www.Abp.org.
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Ù·Ó›· Î·È ÙËÓ OÏÏ·Ó‰›·. OÈ ÓÔÛËχÙÚȘ, ÂÓÒ ‚Ú›ÛÎÂÙ·È ÙÔ ÓÂÔÁÓfi ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡, ÚÔÙÈÌÔ‡Ó Ó· ¿ÚÔ˘Ó ÙËÓ ÁÓÒÌË ÙˆÓ ÁÔÓÈÒÓ ÁÈ· ÙȘ ÂÚ·ÈÙ¤Úˆ ÂÈÏÔÁ¤˜ ıÂڷ›·˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ŒÓ· ÂÍ·ÈÚÂÙÈο ÚfiˆÚÔ ÓÂÔÁÓfi ıˆÚÂ›Ù·È ‚ÈÒÛÈÌÔ ·fi ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÁÈ·ÙÚÒÓ, ÂÓÒ ÌÂÙ¿ ·fi οÔÈ· Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ηٿÛÙ·Û˘, Ë ·fiÊ·ÛË ÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ∆· ÛÙÔȯ›· ·˘Ù¿ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÛËÌ·Û›· ÁÈ· Ù· ËıÈο ‰ÈÏ‹ÌÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Î·Ù¿ ÙË ıÂڷ›· ÓÂÔÁÓÒÓ Ô˘ Â›Ó·È ÔÚȷο ‚ÈÒÛÈÌ· Î·È ÁÈ· ÙËÓ ÂÚÌËÓ›· Î·È ÙË Û‡ÁÎÚÈÛË ÙˆÓ ‰ÈÂıÓÒÓ ÛÙ·ÙÈÛÙÈÎÒÓ.
1de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al. Treatment choices for extremely preterm infants: an international perspective J Pediatr 2000;137:608-615
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∞πª∞∆O§O°π∞ - O°∫O§O°π∞
Paediatriki 2001;64:285-289
HEMATOLOGY - ONCOLOGY
™‡Á¯ÚÔÓË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. µ·ÛÈΤ˜ ·Ú¯¤˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· µ. ∞. §·‰‹˜
Modern treatment of thalassaemia. Principles and effectiveness V. A. Ladis
¶ÂÚ›ÏË„Ë: O ÎÏÈÓÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ Ù˘ ªÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜ (ª∞) Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ‚·ıÌfi Ù˘ ·Ó¿ÚÎÂÈ·˜ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ÔÏ˘ÂÙȉÈÎÒÓ ·Ï˘Û›‰ˆÓ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ï‹ÚË ·‰˘Ó·Ì›· (‚0) ‹ ÙË ÛÔ‚·Ú‹ ·Ó¿ÚÎÂÈ· (‚+) ·Ú·ÁˆÁ‹˜ ‚-·Ï˘Û›‰ˆÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ªÂ›˙ÔÓ· ‚-ª∞, ÂÓÒ ·˘Ù¤˜ Ô˘ Ô‰ËÁÔ‡Ó Û ̤ÙÚÈ· (‚++) ‹ ÂÏ·ÊÚ¿ ·Ó¿ÚÎÂÈ· (‚+++), Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂӉȿÌÂÛË ÌÔÚÊ‹ Ù˘ ‚-ª∞. ŒÙÛÈ Û‹ÌÂÚ·, ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÔÚÈÛÙ› Ë Î·Ù¿ÏÏËÏË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË, ıˆÚÂ›Ù·È ··Ú·›ÙËÙÔ˜ Î·È Ô ÁÔÓÔÙ˘ÈÎfi˜ ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘. §·Óı·Ṳ̂ÓË ÂÈÏÔÁ‹ Î·È Î˘Ú›ˆ˜ ·‰˘Ó·Ì›· Û˘ÌÌfiÚʈÛ˘ ÚÔ˜ ÙËÓ ÂÓ‰ÂÈÎÓ˘fiÌÂÓË ıÂڷ›·, ÂȉÂÈÓÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË, Ì ·ÚÈÔ ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÙËÓ ·ÈÌÔÛȉ‹ÚˆÛË. To ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 25 ÂÙÒÓ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ì ÂÏ·ÊÚÔ‡ ‚·ıÌÔ‡ ·ÈÌÔÛȉ‹ÚˆÛË (n: 53, ÊÂÚÚÈÙ›ÓË <2000 Ìg/L) ˘ÂÚ‚·›ÓÂÈ ÙÔ 98%, Ì ̤ÙÚÈ· ·ÔÛȉ‹ÚˆÛË (n: 60, ÊÂÚÚÈÙ›ÓË 20004000 Ìg/L) ÂÚ›Ô˘ 94%, ÂÓÒ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ì ‚·ÚÈ¿ ·ÈÌÔÛȉ‹ÚˆÛË (n: 29, >4000 Ìg/L) ÌÂÈÒÓÂÙ·È ÛÙÔ 69%. °È· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·Û¯fiÓÙˆÓ (n: 594), ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 92% ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ, 72% ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 30 ÂÙÒÓ, ÂÓÒ ÙÔ 68,5% ˘ÂÚ‚·›ÓÂÈ ÙËÓ ËÏÈΛ· ÙˆÓ 40 ÂÙÒÓ. ∏ ÔÚÁ·ÓˆÌ¤ÓË ·Ú·ÎÔÏÔ‡ıËÛË Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÔÛȉ‹ÚˆÛË ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÂÊ·ÚÌfiÛÙËΠÌÂÙ¿ ÙÔ 1975, ‚ÂÏÙÈÒÓÂÈ ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ (93%) Û ۯ¤ÛË Ì ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ù˘ ›‰È·˜ ËÏÈΛ·˜ (24 ÂÙÒÓ) Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ·fi ÙÔ 1975 (81%). ∏ ·‡ÍËÛË Ù˘ ̤Û˘ ËÏÈΛ·˜ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·Ó¿ ‰ÂηÂÙ›·,
Abstract: The clinical severity of thalassaemia syndromes is closely related to the degree of suppression of globin chain synthesis, which is depended on the type of ‚ gene mutation. As a rule, mutations leading to total (‚0) or severe suppression (‚+) of ‚-chain production are related to ‚-thalassaemia major, while those with moderate (‚++) or mild (‚+++) suppression are related to ‚-thalassaemia intermedia. Thus, precise molecular characterization on diagnosis predicts the prognosis and determines the early application of transfusions in patients with thalassaemia major, or the restriction of unnecessary transfusions in thalassaemia intermedia. Failure in therapeutic options or poor compliance with conventional treatment, worsen the morbidity and reduce the survival due to iron toxicity. In a series of selected patients aged 21-25 yrs, we found that the expected survival by the age of 25 years was related to compliance of chelation. Specifically, the expected survival of well-chelated patients (n: 53, ferritin <2000 Ìg/L) was over 98%, in moderately chelated patients (n: 60, ferritin 2000-4000 Ìg/L) 94%, and only 69% in nonchelated patients (n: 29, ferritin >4000 Ìg/L). The overall survival for a cohort of 594 patients was estimated to be 92% up to the age of 20 years, 72% up to the age of 30 while 68.5% of the patients live over the age of 40 yrs. Close followup and intensive chelation of patients followed in our clinic since 1975 improved survival to 93% as compared to a survival of 81% of patients of the same age (24 years old) born before 1975 and not closely followed. The effectiveness of modern conventional treatment is demonstrated by the
ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
Division of Mediterranean Anemia A’ Pediatric Clinic of University of Athens “Agia Sophia” Children’s Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:285-289
Paediatriki 2001;64:285-289
·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Û‡Á¯ÚÔÓ˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (1980: 7,6 ÂÙÒÓ, 1990: 15 ÂÙÒÓ, 2000: 23 ÂÙÒÓ), Ë ‰Â Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ, ·fi 100 ÂÚ›Ô˘ ÙÔ 1980, Û 15 ÙÔ 1990 Î·È Û ÏÈÁfiÙÂÚ· ·fi 5 ÙÔ 2000, ·Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ÂÈÙ˘¯›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚfiÏ˄˘. ªÂٷ͇ ÙˆÓ ÓÂfiÙÂÚˆÓ ıÂڷ¢ÙÈÎÒÓ ÚÔÛÂÁÁ›ÛˆÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¤¯ÂÈ ·Ô‰ÒÛÂÈ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ÂÓÒ Ë ¯Ú‹ÛË Ó¤ˆÓ ¯ËÏÈÎÒÓ Ô˘ÛÈÒÓ ·fi ÙÔ ÛÙfiÌ· Î·È Ê·ÚÌ¿ÎˆÓ Ô˘ ÚÔ¿ÁÔ˘Ó ÙË ‚ÈÔÛ‡ÓıÂÛË ÙˆÓ Á-·Ï˘Û›‰ˆÓ, ·Ó·Ì¤ÓÂÙ·È Ó· ‚ÂÏÙÈÒÛo˘Ó ÙËÓ ÂÈ‚›ˆÛË Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·Û¯fiÓÙˆÓ.
increase of the mean age of our patient cohort at ten year intervals (1980: mean age 7.6 y., 1990: mean age 15 y., 2000: mean age 23y.), while the progressive reduction of new cases demonstrates the effectiveness of the prevention programs. The number of patients below 5 yrs was nearly 100 in 1980, 15 in 1990 and less than 5 in 2000. Among the new therapeutic approaches, transplantation of hematopoietic cells has given positive results, while the use of new oral chelators and substances inducing Á-chain synthesis are expected to improve the survival and quality of life.
§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ıÂڷ›·, ÚfiÏË„Ë, ÂÈ‚›ˆÛË.
Key words: thalassaemia, treatment, prevention, survival.
∆· Û‡Ó‰ÚÔÌ· Ù˘ ª∞ Î·È ÁÂÓÈÎfiÙÂÚ· ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ Û‡ÓıÂÛ˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ÔÌ¿‰· ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙËÓ ∂ÏÏ¿‰·. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÏ˘ÂÙȉÈ΋ ·Ï˘Û›‰· ÛÙË ‰ÔÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ù˘ ÔÔ›·˜ Ë Û‡ÓıÂÛË ÂËÚ¿˙ÂÙ·È, Ù· Û‡Ó‰ÚÔÌ· Ù˘ ª∞ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È Û ·, ‚, Á, ‰ ÌÔÚʤ˜ ‹ Î·È Û˘Ó‰˘·ÛÌÔ‡˜ ·˘ÙÒÓ. ∞fi fiϘ ·˘Ù¤˜, ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ ¤¯Ô˘Ó ÔÈ ·, ‚ Î·È ‰‚ ÌÔÚʤ˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ë ‚-ª∞ ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ Î·È ÈÔ ‚·ÚÈ¿ ÌÔÚÊ‹ ÛÙË ¯ÒÚ· Ì·˜, fiˆ˜ Î·È ÛÙȘ ˘fiÏÔȘ ªÂÛÔÁÂȷΤ˜ ¯ÒÚ˜ (1,2). ∏ ÎÏÈÓÈ΋ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ÂÎÊÚ¿˙ÂÙ·È Ì ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ·, Ë ÔÔ›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙË ÌÔÚȷ΋ ‚Ï¿‚Ë Ô˘ ÚÔηÏ› ÙË ‰È·Ù·Ú·¯‹. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚ›Ô˘ 200 ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ÎÒ‰Èη Ô˘ ·ÊÔÚÔ‡Ó ÙË Û‡ÓıÂÛË ÙˆÓ ‚-·Ï˘Û›‰ˆÓ. ∞Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ·Ó·ÛÙÔÏ‹˜ Ù˘ Û‡ÓıÂÛ˘ Ô˘ ÚÔηÏÔ‡Ó Î·È ¿Ú· ÙËÓ ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ ·ÚÎÔ‡˜ ÔÛfiÙËÙ·˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ∞, Ê·›ÓÂÙ·È ˆ˜ ‰È·ÌÔÚÊÒÓÂÙ·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· (3). ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ï‹ÚË ·‰˘Ó·Ì›· (‚Ô) ‹ ÙË ÛËÌ·ÓÙÈ΋ ·Ó·ÛÙÔÏ‹ (‚+) Ù˘ ·Ú·ÁˆÁ‹˜ ÙˆÓ ‚·Ï˘Û›‰ˆÓ, Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÁÓˆÛÙ‹ Ì·˜ ÎÏ·ÛÈ΋ ªÂ›˙ÔÓ· ª∞, ÂÓÒ ÌÂÙ·ÏÏ¿ÍÂȘ Ì ÈÔ ‹È· (‚++) ‹ Ôχ ÂÏ·ÊÚ¿ (‚+++) ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ ‚·Ï˘Û›‰ˆÓ, Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÔηÏÔ‡ÌÂÓË ∂ӉȿÌÂÛË ÌÔÚÊ‹ ª∞. ™‹ÌÂÚ· ˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ ÂӉȷʤÚÔÓ ÛÙË ÌÂϤÙË Ù˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÁfiÓÔ˘ (ÁÔÓfiÙ˘Ô˘), Ì ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi Î·È ÎÏÈÓÈÎfi Ê·ÈÓfiÙ˘Ô. ∞fi ÌÂϤÙ˜ Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÁÈ· ÙÔ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ÌÔÚȷ΋˜ ‰È·Ù·Ú·¯‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Ì ªÂ›˙ÔÓ· ηÈ
∂ӉȿÌÂÛË ‚-ª∞, ÂÓÙÔ›ÛÙËÎ·Ó ¿Óˆ ·fi 25 ÌÂÙ·ÏÏ¿ÍÂȘ Ù˘ ‰ÔÌ‹˜ ÙˆÓ ‚-·Ï˘Û›‰ˆÓ, Ô˘ ›¯·Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂΉ‹ÏˆÛË ‚·Ú¤Ô˜, ‹ ‹ÈÔ˘ ÎÏÈÓÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·Ú‡ ÎÏÈÓÈÎfi Ê·ÈÓfiÙ˘Ô Ì›˙ÔÓÔ˜ ª∞, ÔÈ Û˘¯ÓfiÙÂÚ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ·ÊÔÚÔ‡Û·Ó ÙÔ˘˜ Ù‡Ô˘˜ codon 39 (17%), IVS1-1 (13%) Î·È Ì ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÙÔÓ Ù‡Ô IVS1-110 (45,5%). OÈ ÌÂÙ·ÏÏ¿ÍÂȘ ·˘Ù¤˜ Ô‰ËÁÔ‡Ó Û ‚Ô ‹ ‚+ ÌÔÚʤ˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂӉȿÌÂÛË ÌÔÚÊ‹ ª∞, ÔÈ Û˘¯ÓfiÙÂÚ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ·ÊÔÚÔ‡Û·Ó ÙÔ˘˜ Ù‡Ô˘˜ IVS1-6, -87 Î·È -101 Ô˘ Ô‰ËÁÔ‡Ó Û ‚++ ‹ ‚+++ ÌÔÚʤ˜ (4,5) (¶›Ó·Î·˜ 1). ∞Ó Î·È Ë ÌÔÚÊ‹ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘ ÛÙÔÓ ‚ÁfiÓÔ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÎÏÈÓÈ΋˜ ‚·Ú‡ÙËÙ·˜, ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÎÏÈÓÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘. µÂÏÙ›ˆÛË .¯. Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ·ıÔÏÔÁÈÎfi˜ ÁfiÓÔ˜ ·-ª∞ ‹ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ Á-ÁfiÓÔ˘ Ô˘ ÂÓÂÚÁÔÔÈ› ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ÂÌ‚Ú˘˚΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ÂÓÒ Âȉ›ӈÛË ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ÙÚÈÏ·ÛÈ·Ṳ̂ÓÔ˜ ·ıÔÏÔÁÈÎfi˜ ·-ÁfiÓÔ˜ (6,7). ∏ ÛÙÂÓ‹ ·˘Ù‹ Û˘Û¯¤ÙÈÛË ÁÔÓfiÙ˘Ô˘-Ê·ÈÓfiÙ˘Ô˘ ÂÓÈÛ¯‡ÂÈ ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÙÔ˘ ¯·Ú·ÎÙËÚÈÛÌÔ‡ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘, Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ
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¶›Ó·Î·˜ 1. ∞‰Ú‹ Û˘Û¯¤ÙÈÛË ÎÏÈÓÈÎÔ‡ Î·È ·ÈÌ·ÙÔÏÔÁÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘ Ì ÁÔÓfiÙ˘Ô ·ÛıÂÓÒÓ Ì ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· º·ÈÓfiÙ˘Ô˜ π. ª∂π∑ø¡ ª.∞. ππ. ∂¡¢π∞ª∂™∏ ª.∞. 1. µ·Ú‡˜ Ù‡Ô˜ ( ‚++) 1. µ·Ú‡˜ Ù‡Ô˜ ( ‚Ô ) 2. ◊ÈÔ˜ Ù‡Ô˜ ( ‚+++) 2. ◊ÈÔ˜ Ù‡Ô˜ ( ‚+ ) °ÔÓfiÙ˘Ô˜ cd-39, IVSI-1, IVSI-110 IVSI-6, -87, -101
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·ÈÌ·ÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË, Ì ÛÙfi¯Ô ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÚfiÁÓˆÛ˘, ÙÔ Û¯Â‰È·ÛÌfi Ù˘ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Î·È ÙË ‰È·ÌfiÚʈÛË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Î·È ÁÂÓÂÙÈ΋˜ ηıÔ‰‹ÁËÛ˘ (8).
Paediatriki 2001;64:285-289
£Âڷ¢ÙÈΤ˜ ·Ú¯¤˜ ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË Ì¿˜ ÂÈÙÚ¤ÂÈ ÙËÓ ¤ÁηÈÚË Î·È ¯ˆÚ›˜ ÂÈ‚Ï·‚›˜ ηı˘ÛÙÂÚ‹ÛÂȘ ¤Ó·ÚÍË ıÂڷ›·˜ Ì ÌÂÙ·ÁÁ›ÛÂȘ, fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ªÂ›˙ÔÓ· ÌÔÚÊ‹, ‹ ÙËÓ ·ÔÊ˘Á‹ ¿ÛÎÔˆÓ ÌÂÙ·ÁÁ›ÛˆÓ, fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ∂ӉȿÌÂÛË ÌÔÚÊ‹. ∏ ÁÓÒÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ - ‹ ÌË - ·Ú·ÁˆÁ‹˜ ·ÚÎÔ‡˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ∞, ·ÔÙÂÏ› Û‹ÌÂÚ· ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛˆÓ. OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ Î·È Ë ÂÓÙ·ÙÈ΋ ·ÔÛȉ‹ÚˆÛË ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÎÚÔÁˆÓÈ·›Ô˘˜ Ï›ıÔ˘˜ Ù˘ Û˘Ì‚·ÙÈ΋˜ ıÂڷ›·˜ Ù˘ ª∞ (9). Œ¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ Ë ª∞ ÌÔÚ› Ó· ıˆÚËı› È¿ÛÈÌË ÓfiÛÔ˜, Ì ÙËÓ ÚÔ¸fiıÂÛË ÂÍ·ÛÊ¿ÏÈÛ˘ ·ÚÎÒÓ Î·È ·ÛÊ·ÏÒÓ ÌÂÙ·ÁÁ›ÛÂˆÓ Î·È ÙË ‰È· ‚›Ô˘, ÌÂ Û˘Ó¤ÂÈ·, Ï‹ÚË Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· ÂÓÙ·ÙÈ΋˜ ·ÔÛȉ‹ÚˆÛ˘. ŸÌˆ˜, ÛËÌ·ÓÙÈο Ú·ÎÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Â›Ù Ì ÙË ‰È·‰Èηۛ· ÙˆÓ ÌÂÙ·ÁÁ›ÛˆÓ, ›Ù Ì ÙËÓ ·‰˘Ó·Ì›· Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·Û¯fiÓÙˆÓ ÛÙË ıÂڷ›· ·ÔÛȉ‹ÚˆÛ˘, ηıÔÚ›˙Ô˘Ó ÙËÓ Ú·ÁÌ·ÙÈ΋ ηٿÛÙ·ÛË, fiˆ˜ ·˘Ù‹ ‰È·ÌÔÚÊÒÓÂÙ·È Ì ÙËÓ ·ÔÙ‡ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ÙÂÏÈο ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘.
92%, ÛÙËÓ ËÏÈΛ· ÙˆÓ 30 ÂÙÒÓ ¤ÊÙÂÈ ÛÙÔ 72%, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ¤ÊÙÂÈ Ì Ôχ ÌÈÎÚfiÙÂÚÔ Ú˘ıÌfi, ̤¯ÚÈ 68,4% ÁÈ· ÙȘ ËÏÈ˘ ÌÂÙ¿ Ù· 40 ¯ÚfiÓÈ· (™¯‹Ì· 2). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ÎÏÈÓÈ΋ Ì·˜ ·Ú·Ù‹ÚËÛË, fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ı¿Ó·ÙÔÈ Û˘Ì‚·›ÓÔ˘Ó Û ̛· ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô ÌÂٷ͇ ÙˆÓ ËÏÈÎÈÒÓ ÙˆÓ 20 Î·È 30 ÂÙÒÓ, Ô˘ ·Ú·ÙËÚÂ›Ù·È Î·È Ë ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· (10). ∏ ÂÈÛ·ÁˆÁ‹ Ù˘ ¢ÂÛÊÂÚÈÔÍ·Ì›Ó˘ ÁÈ· ÙË ıÂڷ›· ·ÔÛȉ‹ÚˆÛ˘ ÙÔÔıÂÙÂ›Ù·È ¯ÚÔÓÈο ÛÙËÓ ·Ú¯‹ Ù˘ 10ÂÙ›·˜ ÙÔ˘ ’70, ÂÓÒ Ú·ÎÙÈο ÛÙË ¯ÒÚ· Ì·˜ ÁÂÓÈ·ÂÙ·È ÙÔ 1975 Ì ÙËÓ ÔÚÁ¿ÓˆÛË Î·È ÏÂÈÙÔ˘ÚÁ›· ÂȉÈÎÒÓ ÌÔÓ¿‰ˆÓ ·Ú·ÎÔÏÔ‡ıËÛ˘ ·Û¯fiÓÙˆÓ Ì ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ (11). ªÂ ÎÚÈÙ‹ÚÈÔ ÙËÓ ÂÈ‚›ˆÛË, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ıÂڷ›·˜ ¿Ú¯ÈÛ·Ó Ó· Ê·›ÓÔÓÙ·È 25 ¯ÚfiÓÈ· ÌÂÙ¿. ∆Ô ÚÔÛ‰fiÎÈÌÔ Ù˘ ÂÈ‚›ˆÛ˘ ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1975 Î·È ‹Ù·Ó οو ·fi ÙËÓ Â›‰Ú·ÛË Ù˘ ÓÂfiÙÂÚ˘ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, Û˘ÁÎÚ›ÓÂÙ·È Ì ÙËÓ ÂÈ‚›ˆÛË Ù˘ ÔÌ¿‰·˜ ·ÙfiÌˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ·fi ÙÔ 1975 Î·È ¿Ú· ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ›¯·Ó ˘ÔÛÙ› ÙȘ ‚Ï·ÙÈΤ˜ ÂȉڿÛÂȘ Ù˘ ˘ÔÍ›·˜ Î·È Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ûȉ‹ÚÔ˘ (™¯‹Ì· 3). ∏ η̇ÏË ÂÈ‚›ˆÛ˘ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ÙÔ ’75 Â›Ó·È ¯ÂÈÚfiÙÂÚË Û˘ÁÎÚÈÙÈο Ì ÙË Û˘ÓÔÏÈ΋ η̇ÏË (64,7% ¤Ó·ÓÙÈ 68,4%), fiˆ˜ ›Û˘ Î·È ·fi ÙËÓ Î·Ì‡ÏË Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1975 (81% ¤Ó·ÓÙÈ 93%) , ËÏÈΛ·˜ Û‹ÌÂÚ· 24-25 ÂÙÒÓ.
∞ÈÌÔÛȉ‹ÚˆÛË Î·È ÂÈ‚›ˆÛË ∂ÎÙfi˜ ·fi ÙÔ˘˜ ÁÓˆÛÙÔ‡˜ ‹ ¿ÁÓˆÛÙÔ˘˜ ÚÔÏ‹„ÈÌÔ˘˜ - ‹ fi¯È - ÎÈÓ‰‡ÓÔ˘˜, fiˆ˜ Ù· ·ÈÌ·ÙÔÁÂÓÒ˜ ÌÂÙ·‚È‚·˙fiÌÂÓ· ÈÔÁÂÓ‹ ÓÔÛ‹Ì·Ù·, Ô Î‡ÚÈÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¿˙ÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È Ë ·ÈÌÔÛȉ‹ÚˆÛË ÙˆÓ ÔÚÁ¿ÓˆÓ. ™Â ÙÚÂȘ ÔÌ¿‰Â˜ ·Û¯fiÓÙˆÓ Ì ª∞ (n: 142) Ù˘ ÎÏÈÓÈ΋˜ Ì·˜, ËÏÈΛ·˜ 21-25 ÂÙÒÓ, Ì ÂÏ·ÊÚ¿, ̤ÙÚÈ· Î·È ‚·ÚÈ¿ ·ÈÌÔÛȉ‹ÚˆÛË, Û˘ÁÎÚ›ıËÎÂ Ë Â›ÙˆÛË Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ûȉ‹ÚÔ˘ Û ۯ¤ÛË Ì ÙËÓ ÂÈ‚›ˆÛË. ™ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 53) Ì ̤ÛË ÙÈÌ‹ ÊÂÚÚÈÙ›Ó˘ οو ·fi 2000 ng/dl Ù· ÙÂÏÂ˘Ù·›· ¤ÓÙ ¯ÚfiÓÈ·, ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÁÈ· Ù· 25 ÙÔ˘˜ ¯ÚfiÓÈ· Â›Ó·È ¿Óˆ ·fi 98%, ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 60) Ì ›‰· ÊÂÚÚÈÙ›Ó˘ ÌÂٷ͇ 20004000 ÂÚ›Ô˘ 94%, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο ÛÙÔ 69% ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 29) Ì ÊÂÚÚÈÙ›ÓË ¿Óˆ ·fi 4000 ng/dl (™¯‹Ì· 1). ™Â Û‡ÓÔÏÔ 594 ·Û¯fiÓÙˆÓ, ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ Êı¿ÓÂÈ ÛÙÔ
∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ıÂڷ›·˜ Î·È ÚfiÏ˄˘ ™ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ª∞ ÛÙË ¯ÒÚ· Ì·˜, ÂÎÙfi˜ ·fi ÙËÓ Â›‰Ú·ÛË Ù˘ Û‡Á¯ÚÔÓ˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘, Û˘Ó¤‚·ÏÂ Î·È Ë ÂÈÙ˘¯›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚfiÏ˄˘ (12). ¢ÂÓ ı· ·Ó·Ï˘ı› Ë ÌÂıÔ‰ÔÏÔÁ›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ, Ô‡Ù ı· ÂÎÙÈÌËı› Ô ‚·ıÌfi˜ ÚÔÛ¤ÁÁÈÛ˘ ÙˆÓ ÛÙfi¯ˆÓ Ô˘ ¤¯Ô˘Ó ÙÂı› ·ÓÂÏÏ·‰Èο. £· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙËÓ ÂͤÏÈÍË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ËÏÈÎÈÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ Ù˘ ÌÔÓ¿‰·˜ Ì·˜ ηٿ ÙÔ ‰È¿ÛÙËÌ· ÙˆÓ 25 ÂÙÒÓ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘, Ô˘ ·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙfiÛÔ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂڷ›·˜, fiÛÔ Î·È ÙËÓ ÂÈÙ˘¯›· Ù˘ ÚfiÏ˄˘. ∫·Ù¿ ÙÔ ¤ÙÔ˜ 1980, Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈÒÓ 441 ·Û¯fiÓÙˆÓ Ô˘ ›¯·Ó Û˘ÁÎÂÓÙÚˆı› ·fi ÙÔ 1975 Î·È ÓÔÛËχÔÓÙ·Ó ÛÙË ÌÔÓ¿‰· Ì·˜, Ê·›ÓÂÙ·È ÛÙÔ ™¯‹Ì· 4. O ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È ËÏÈΛ·˜ ̤¯ÚÈ 10 ÂÙÒÓ, Ë Ì¤ÛË ËÏÈΛ· 7,6 ¤ÙË, ÂÓÒ Ù· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ ‹Ù·Ó ÂÚ›Ô˘ 100.
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¿Óˆ ÙˆÓ 15 ÂÙÒÓ. ¶·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ, Â›Ó·È ÏÈÁfiÙÂÚ· ·fi 5 (™¯‹Ì· 6). ¢Â‰Ô̤ÓÔ˘ fiÙÈ, ÛÙÔÓ ÂÏ¿¯ÈÛÙÔ ·ÚÈıÌfi ÙˆÓ ·Û¯fiÓÙˆÓ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÂÈÛ·ÁfiÌÂÓÔÈ ·ÛıÂÓ›˜, ΢ڛˆ˜ ÂÍ ∞Ï‚·Ó›·˜, ‡ÎÔÏ· ÌÔÚԇ̠ӷ ‰È·ÈÛÙÒÛÔ˘Ì ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÂÈÙ˘¯›·˜ Ù˘ ÚfiÏ˄˘.
™¯‹Ì· 1
™¯‹Ì· 2
™¯‹Ì· 3
∆Ô 1990, Ë Î·Ì‡ÏË Î·Ù·ÓÔÌ‹˜ ÙˆÓ ËÏÈÎÈÒÓ 554 ·Û¯fiÓÙˆÓ ÌÂÙ·ÎÈÓÂ›Ù·È ÚÔ˜ ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘, Ì ̤ÛË ËÏÈΛ· Ù· 15 ¯ÚfiÓÈ·. ¶·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, Â›Ó·È ÂÚ›Ô˘ 15 (™¯‹Ì· 5). ∆Ô ¤ÙÔ˜ 2000, Ë Ì¤ÛË ËÏÈΛ· ·˘Í¿ÓÂÈ ÛÙ· 23 ¯ÚfiÓÈ·, ÂÓÒ ÙÔ 85% ÙˆÓ 555 ·Û¯fiÓÙˆÓ Â›Ó·È ËÏÈΛ·˜
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¡ÂfiÙÂÚ˜ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ∆ÔÓ ·Ú¯ÈÎfi ÛÙfi¯Ô Ù˘ ÔÛÔÙÈ΋˜, ˆ˜ ÚÔ˜ ÙËÓ ÂÈ‚›ˆÛË, ÂÈÙ˘¯›·˜ ·ÎÔÏÔ‡ıËÛÂ Ë ÚÔÛ¿ıÂÈ· ‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ Ù˘ ˙ˆ‹˜ Ì ÚÔÔÙÈ΋ ÙËÓ Ï‹ÚË ¤ÓÙ·ÍË ÙˆÓ ·Û¯fiÓÙˆÓ ÛÙËÓ ÎÔÈÓˆÓ›· (13). ™ËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· ÁÈ· ÙËÓ ÂÈÙ˘¯›· ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ Â›Ó·È Ë ÚfiÛÊ·ÙË Î˘ÎÏÔÊÔÚ›· ÓÂfiÙÂÚˆÓ ¯ËÏÈÎÒÓ Ô˘ÛÈÒÓ ·fi ÙÔ ÛÙfiÌ·, Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË Û˘ÌÌfiÚʈÛË ÛÙË ıÂڷ›· ·ÔÛȉ‹ÚˆÛ˘ (14). ¶·Ú¿ÏÏËÏ· Ì ÙË ÌÂÚÈ΋ ‹ Ï‹ÚË ·ÓÙÈηٿÛÙ·ÛË Ù˘ ·ÚÂÓÙÂÚÈ΋˜ ıÂڷ›·˜ Ì ¯¿È·, ·Ó·Ì¤ÓÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜, Ë Ì›ˆÛË Î·È ÙˆÓ ·Ó·ÁÎÒÓ ÁÈ· ÌÂÙ·ÁÁ›ÛÂȘ Ì ÙË ¯Ú‹ÛË Ê·Ú̿ΈÓ, fiˆ˜ Ë ˘‰ÚÔ͢Ԣڛ· Î·È ÔÈ ÂÓÒÛÂȘ ÙÔ˘ ‚Ô˘Ù˘ÚÈÎÔ‡ Ôͤˆ˜, Ô˘ ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ Á-·Ï˘Û›‰ˆÓ, ·˘Í¿ÓÔ˘Ó Ù· ›‰· Ù˘ ÂÌ‚Ú˘˚΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÌË ·Ô‰ÔÙÈ΋ ÂÚ˘ıÚÔÔ›ËÛË (15). ¶·Ú¿ ÙË ÌÂÁ¿ÏË ÚfiÔ‰Ô Ù˘ ÁÔÓȉȷ΋˜ ıÂڷ›·˜ Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠ӷ ÂȯÂÈÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ÚÔÔÙÈ΋ ÂÊ·ÚÌÔÁ‹˜ Ù˘ ÛÙË ª∞ Ê·›ÓÂÙ·È ·ÎfiÌ· ·ÔÌ·ÎÚ˘Ṳ̂ÓË (16). ∂ÓÙÔ‡ÙÔȘ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÂΛ Ô˘ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË, Û‹ÌÂÚ· ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÌÂ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÔÌ¿‰· ÙˆÓ ÚÒËÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ, fiˆ˜ ·ÔηÏÔ‡ÓÙ·È ‰ÈÂıÓÒ˜ (ex-thalassaemics), ÔÈ ÔÔ›ÔÈ ·Ó Î·È ‰ÂÓ ¤¯Ô˘Ó ··ÏÏ·Á› ·fi ÙÔ ÁÂÓÂÙÈÎfi ÙÔ˘˜ ÓfiÛËÌ·, ¤¯Ô˘Ó ·Ô‰ÂÛÌ¢Ù› ÙÂÏ›ˆ˜ ·fi ÙËÓ ·Ó¿ÁÎË ÙˆÓ ÌÂÙ·ÁÁ›ÛÂˆÓ (17). ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ô˘ ÚÔ·ÙÂÈ ÙÂÏÈο ·fi ÙËÓ ÚÔÛ¿ıÂÈ· ·˘Ù‹, Â›Ó·È Ë ÙÚÔÔÔ›ËÛË Ù˘ ª∞ ·fi ¤Ó· ı·Ó·ÙËÊfiÚÔ ÓfiÛËÌ· Ù˘ ÚÒÙ˘ ·È‰È΋˜ ËÏÈΛ·˜ Û ¯ÚfiÓÈÔ ÓfiÛËÌ·, Ì ÚÔ‚Ï‹Ì·Ù· ΢ڛˆ˜ ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ, ·ÏÏ¿ Î·È ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÚÔÔÙÈΤ˜ Ì·ÎÚ¿˜ ÂÈ‚›ˆÛ˘ Î·È ·Ô‰ÂÎÙ‹˜ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ (18). µÈ‚ÏÈÔÁÚ·Ê›· 1. Kattamis C, Metaxotou-Mavromati A, Wood WG, Nash JR, Weatherall DJ. The heterogeneity of normal HbA2 ‚thalassemia in Greece. Br J Haematol 1979;42:109. 2. Kattamis C, Metaxotou-Mavromati A, Ladis V, Tsiarta H, Laskari S, Kanavakis E. The clinical phenotype of ‚ and ‰‚ thalassemia in Greece. Eur J Pediatr 1982;139:135-138. 3. Baysal E, Carver MFH. The ‚- and ‰- thalassemia repository. Hemoglobin 1995;19:213-236.
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™¯‹Ì· 6 4. Kattamis C, Hu H, Cheng G, Reese AL, GonzalezRedondo JM, Kutlar A et al. Molecular characterization of ‚-thalassaemia in 174 Greek patients with thalassaemia major. Br J Haematol 1990;74:342-346.
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5. Kanavakis E, Traeger-Synodinos J, Tzetis M, MetaxotouMavromati A, Ladis V, Kattamis C. Molecular characterization of homozygous (high HbA2) ‚thalassemia intermedia in Greece. Pediatr Hematol Oncol 1995;12:37-45. 6. Ho PJ, Hall GW, Luo LY, Weatherall DJ, Thein SL. Betathalassaemia intermedia; is it possible consistently to predict phenotype from genotype? Br J Haematol 1998;100:70-78. 7. Traeger-Synodinos J, Kanavakis E, Vrettou C, Maragoudaki E, Michael T, Metaxotou-Mavromati A et al. The triplicated a-globin gene locus in ‚-thalassemia heterozygotes: clinical, haematological, biosynthetic, and molecular studies. Br J Haematol 1996;95:467-471. 8. Kattamis C. Genotypes and clinical and hematological phenotypes of ‚ and ‰‚ thalassemias. In: Bartsokas C, Loukopoulos D, eds. Genetics of Hematological Disorders. New York: Hemisphere; 1992. p. 65-77. 9. Kattamis C, Ladis V. Conventional treatment of ‚Thalassemia syndromes. (A personal experience). Int J Pediatr Hematol Oncol 1997;4:513-522. 10. Ladis V, Berdousi H, Palamidou F, Agrafioti C, Papadopoulou A, Anagnostopoulos G et al. Morbidity and mortality of iron intoxication in adult patients with thalassemia major, and effectiveness of chelation. Transfusion Science 2000;23:255-256. 11. ∫·ÙÙ¿Ì˘ Ã, §·‰‹˜ µ, ªÂٷ͈ÙÔ‡-ª·˘ÚÔÌÌ¿ÙË ∞, ÷Ù˙ËÛ˘ÌÂÒÓ ª, ª·ÎÚ˘ÁÈ¿ÓÓ˘ ∫, ª·ÙÛ·ÓÈÒÙ˘ ¡. OÚÁ¿ÓˆÛË Î·È ÏÂÈÙÔ˘ÚÁ›· ÌÔÓ¿‰·˜ ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ Î·È ıÂڷ›·˜ Â͈ÙÂÚÈÎÒÓ ·ÛıÂÓÒÓ Ì ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. π·ÙÚÈ΋ ∂ÈıÂÒÚËÛË ∂ÓfiÏˆÓ ¢˘Ó¿ÌÂˆÓ 1997;11:379-383. 12. Loukopoulos D. Prenatal diagnosis of thalassemia and the hemoglobinopathies; a review. In: Sirchia G, Zanella A, editors. Milano: Centro Transfusionale Ospedale Maggiore Policlinico di Milano. Thalassemia Today. The Mediterranean Experience; 1987. p. 177-182. 13. Kattamis C. Psychological development, education, employment and social integration of thalassemic patients. In: Gross K, Aumiller J, Gelzer J. editors. Desferrioxamine history, clinical value and perspectives. Munich: MMV Medizin Verlag; 1992. p. 53-68. 14. Hoffbrand AV. Oral iron chelators. Semin Hematol 1996;33:1-8. 15. Oliviery NF. Reactivation of fetal hemoglobin in patients with beta-thalassemia. Semin Hematol 1996;33:24-42. 16. Smith AE. Gene therapy where we go? Molecular Medicine. Lancet 1999;354:S11-S13. 17. Lucarelli G, Galiberti M, Giardini G, Polchi P, Angelucci E, Boronciani D et al. Bone Marrow Transplantation in Thalassemia. In: Cohen A, editor. Cooley’s Anemia. 7th Symposium. New York: The New York Academy of Sciences; 1998. p. 270-275. 18. Rund D, Rachmilewitz E. Thalassemia Major 1995: Older patients, new therapies. Blood Rev 1995;9:25-32.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ. ∞. §·‰‹˜ MoÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
289
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Paediatriki 2001;64:290-292
GASTROENTEROLOGY-HEPATOLOGY-NUTRITION
∂ÍÂÏ›ÍÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ Á·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ™. ¡Ô‡ÛÈ· - ∞Ú‚·ÓÈÙ¿ÎË
Recent developments in pediatric gastroenterology S. Nousia - Arvanitakis
¶ÂÚ›ÏË„Ë: ∏ Ú·Á‰·›· ÂͤÏÈÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜. ∏ ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË Î·ıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË Î·È Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘. ∏ ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË ÂÈÙÚ¤ÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ ¯ÂÈÚÈÛÌÒÓ, fiˆ˜ ÙËÓ ·Ê·›ÚÂÛË Í¤ÓˆÓ ÛˆÌ¿ÙˆÓ, ÙËÓ ÔÏ˘ÂÎÙÔÌ‹ Î·È ÙË ÛÎÏËÚÔıÂڷ›·. ∏ ÌÔÚȷ΋ ‚ÈÔÏÔÁ›· Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÔÏÏÒÓ ÓfiÛˆÓ, Ô‰‹ÁËÛ Û ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, Û Ӥ˜ ıÂڷ¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ Î·È Û ÚÔÔÙÈΤ˜ ÁÔÓȉȷ΋˜ ıÂڷ›·˜.
Abstract: The rapid development of Pediatric Gastroenterology is due primarily to the application of endoscopy of the gastrointestinal tract in pediatric patients and the application of molecular biology. Diagnostic endoscopy allows direct observation of the upper and lower gastrointestinal tract mucosa and the performance of biopsies. Therapeutic endoscopy allows, among others, the removal of foreign bodies, polypectomy and sclerotherapy. Molecular biology has contributed to the understanding of many gastrointestinal diseases of childhood, and has led to the application of specialized diagnostic methods, new therapeutic approaches and the prospect of gene therapy.
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË, ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË, ÌÔÚȷ΋ ‚ÈÔÏÔÁ›·.
Key words: diagnostic endoscopy, therapeutic endoscopy, molecular biology.
∏ ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ÍÂΛÓËÛ ˆ˜ ˘ÈÔıÂÙË̤ÓÔ ·È‰› Ù˘ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÙˆÓ ÂÓËϛΈÓ, ηٿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960. ¶·È‰›·ÙÚÔÈ Ì ÂӉȷʤÚÔÓ ÛÙË °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·, Ì·ıËÙ‡۷Ì Û ΤÓÙÚ· °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÙˆÓ ÂÓËϛΈÓ. ∆Ô ¤ÙÔ˜ 1991, Ë ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ·Ó·ÁÓˆÚ›ÛÙËΠˆ˜ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙȘ ∏¶∞ Î·È ıÂÛ›ÛÙËÎ·Ó ÂÍÂÙ¿ÛÂȘ ÁÈ· ÙËÓ ·fiÎÙËÛË ‰ÈÏÒÌ·ÙÔ˜. ∆Ô ¤ÙÔ˜ 1999, Ë ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ·Ó·ÁÓˆÚ›ÛÙËΠÛÙËÓ ∂˘ÚÒË. ¶ÚÈÓ ·ÎfiÌË ·Ó·ÁÓˆÚÈÛÙ› Ë ÂȉÈÎfiÙËÙ· ›ÛËÌ·, ÂÙ·ÈÚ›˜ ·È‰È¿ÙÚˆÓ Ì ÂӉȷʤÚÔÓ ÛÙË °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ›¯·Ó È‰Ú˘ı› ÛÙȘ ∏¶∞ ÙÔ ¤ÙÔ˜ 1972, ·ÏÏ¿ Î·È ÛÙËÓ ∂˘ÚÒË, §·ÙÈÓÈ΋ ∞ÌÂÚÈ΋ Î·È ∞Û›·. ∆Ô 1999, ȉڇıËÎÂ Ë ∂ÏÏË-
ÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜.
∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ·, ¶·È‰È·ÙÚÈ΋˜-°·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢
Associate Professor of Pediatrics-Gastroenterology Aristotelion University of Thessaloniki
290
∂ÍÂÏ›ÍÂȘ ÛÙËÓ Ù¯ÓÔÏÔÁ›· ÙˆÓ ÂÓ‰ÔÛÎÔ›ˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤¯ÂÈ ÌÂÙ·ÌÔÚÊÒÛÂÈ ÙÔ Â‰›Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜. ¶·Ï·ÈfiÙÂÚ·, Ë ‰È·ÁÓˆÛÙÈ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ Á·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ‚·ÛÈ˙fiÙ·Ó ÛÙËÓ ÎÏÈÓÈ΋ ·Ú·Ù‹ÚËÛË, ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙËÓ ·Ó¿Ï˘ÛË ‚ÈÔÏÔÁÈÎÒÓ ˘ÁÚÒÓ Î·È ÛÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∏ ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ ηıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË Î·È ÙË Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘, ¯ˆÚ›˜
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¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. O ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤¯ÂÈ ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ ۈϋӷ. OÈ ÂÍÂÏ›ÍÂȘ ÛÙËÓ Ù¯ÓÔÏÔÁ›· ÙˆÓ ÂÓ‰ÔÛÎÔ›ˆÓ ¤‰ˆÛ ÒıËÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·. ∆Ô 1971 ηٷÛ΢¿ÛÙËΠÙÔ ÚÒÙÔ Â‡Î·ÌÙÔ Á·ÛÙÚÔÛÎfiÈÔ ÁÈ· ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∆Ë ‰ÂηÂÙ›· ÙÔ˘ 1980 ·Ó·Ù‡¯ıËÎÂ Ë ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË Î·È ÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 Ì ÙËÓ ·Ú·ÁˆÁ‹ Î·È ÙËÓ Â˘Ú›· ‰È¿ıÂÛË ÂÓ‰ÔÛÎÔ›ˆÓ ÌÈÎÚ‹˜ ‰È·Ì¤ÙÚÔ˘, ·Ó·Ù‡¯ıËÎÂ Ë ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË. ∏ ÂÓ‰ÔÛÎfiËÛË ı· ÂȂ‚·ÈÒÛÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÈÛÔÊ·Á›Ùȉ·˜ Ì ÂÌ‚¤ÏÂÈ· Î·È Û·Ê‹ÓÂÈ· Î·È ·Ú¿ÏÏËÏ· ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ù˘ ¿ÌÂÛ˘ ·Ó·ÁÓÒÚÈÛ˘ Ù˘ ÌÔÓÈÏÈ·ÛÈ΋˜ ÔÈÛÔÊ·Á›Ùȉ·˜ Î·È Ù˘ ¿ÌÂÛ˘ ÂÈÛÎfiËÛ˘ Î·È ÌÂϤÙ˘ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ Á·ÛÙÚÈÎÒÓ ÂÏÎÒÓ. ∏ ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Ô‰‹ÁËÛ ÛÙËÓ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘ ÙÔ˘ ˘ÏˆÚÔ‡ ·fi ÙÔ˘˜ Warren Î·È Marshal. ∏ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ·, Ë ÔÔ›· ‰Â›¯ÓÂÈ ¿¯˘ÓÛË ÙˆÓ Á·ÛÙÚÈÎÒÓ Ù˘¯ÒÓ ·ÏÏ¿ Î·È Ë ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙˆÓ ÙÚÈÒÓ ÂȤ‰ˆÓ ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ‰›ÓÔ˘Ó ÌfiÓÔ ˘Ô„›· Á·ÛÙÚ›Ùȉ·˜. O ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔηχÙÂÈ ÙËÓ ÂÈÎfiÓ· Ù˘ Á·ÛÙÚ›Ùȉ·˜ ÙÔ˘ ¿ÓÙÚÔ˘, ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ï‹„˘ ‰ÂÈÁÌ¿ÙˆÓ ÁÈ· ÙËÓ Ù·¯Â›· ‰ÔÎÈÌ·Û›· Ù˘ Ô˘Ú¿Û˘ Î·È ÁÈ· ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË (1). ¶·Ï·ÈfiÙÂÚ·, Ë ·Ê·›ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ‹Ù·Ó ÚÔ‚ÏËÌ·ÙÈ΋. ªÂ ÙËÓ ÂÓ‰ÔÛÎfiËÛË Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ê·›ÚÂÛË Ù˘ Ô‰ÔÓÙÔÁÏ˘Ê›‰·˜, Ë ÔÔ›· ¤¯ÂÈ ÛÊËÓˆı› ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ. ∂›Ó·È ‰˘Ó·Ù‹ Ë ÂÎÙÔÌ‹ ÌÈÛ¯ˆÙÔ‡ Ôχԉ· ÙÔ˘ ÛÈÁÌÔÂȉԇ˜. ÕÏÏË ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÂÌ‚·ÙÈ΋˜ ÂÓ‰ÔÛÎfiËÛ˘ ·ÔÙÂÏ› Ë ÛÎÏËÚÔıÂڷ›· ÙˆÓ ÎÈÚÛÒÓ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. ∏ ÂÊ·ÚÌÔÁ‹ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Î·È ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÓfiÛˆÓ ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ÂÍÂÏ›ÍÂȘ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ô‰‹ÁËÛ·Ó Û ÂÈÎfiÓ˜ ·›ÛÙ¢Ù˘ Û·Ê‹ÓÂÈ·˜. ∂ÍÂÏ›ÍÂȘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›· OÈ ÂÍÂÏ›ÍÂȘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›· Û˘Ó¤‚·Ï·Ó ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÔÏÏÒÓ ÓfiÛˆÓ, Ô‰‹ÁËÛ·Ó Û ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ì ‚¿ÛË ÙËÓ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘, Û Ӥ˜ ıÂڷ¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ Ì ‚¿ÛË ÙËÓ ·Ó·Û‡ÓıÂÛË ÙÔ˘ DNA Î·È Û ÚÔÔÙÈΤ˜ ÁÔÓȉȷ΋˜ ıÂڷ›·˜. ∫Ï·ÛÈÎfi ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› Ë Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ÁÔÓ›‰ÈÔ˘ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ ÛÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌ·ÙÔÛÒÌ·ÙÔ˜ 7 ÙÔ ¤ÙÔ˜ 1989 (2). ∏ ÁÓÒÛË Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘, Ë ÔÔ›· Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙË ‰È·Ù·Ú·¯‹ ÛÙË ÌÂÙ·ÊÔÚ¿ ÈfiÓÙˆÓ ‰È·-
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̤ÛÔ˘ ÂÓ‰Ô·˘ÏÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ, Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ Ù˘ ÓfiÛÔ˘. ø˜ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› 750 ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘. ∞fi ·˘Ù¤˜, Ë ÌÂÙ¿ÏÏ·ÍË ¢F508 ÚÔÛ‚¿ÏÏÂÈ ÙÔ 70% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì ∫π. ∏ ÚˆÙ½ÓË Ë ÔÔ›· Έ‰ÈÎÔÔÈÂ›Ù·È ·fi ÙÔ ÁÔÓ›‰ÈÔ Ù˘ ∫π, ·ÔÙÂÏ› ‰›·˘ÏÔ ¯ÏˆÚ›Ô˘, Ô ÔÔ›Ô˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Î˘ÎÏÈÎfi AMP Î·È ¤¯ÂÈ Ù·˘ÙÔÔÈËı› Û ÔÏÏ¿ ÎÔÚ˘Ê·›· ÂÈı‹ÏÈ·: ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘, ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ fiÚÔ˘, ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘. ∞˘Ùfi ÂÍËÁ› ÙËÓ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ, Ù· ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· fiÚˆÓ. ∏ ÚˆÙ½ÓË CFTR Û˘ÓÙ›ıÂÙ·È ÛÙÔ ÂÓ‰ÔÏ·ÛÌ·ÙÈÎfi ‰›ÎÙ˘Ô, ·Ó·‰ÈÏÒÓÂÙ·È ÛÙË Û˘Û΢‹ Golgi Î·È ÌÂٷʤÚÂÙ·È ÛÙËÓ ÎÔÚ˘Ê·›· ÌÂÌ‚Ú¿ÓË ˆ˜ ‰›·˘ÏÔ˜ ¯ÏˆÚ›Ô˘ (3). ∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‰È·‡ÏÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ∫π. OÈ ÌÂÙ·ÏÏ¿ÍÂȘ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û 5 ‚·ÛÈΤ˜ Ù¿ÍÂȘ. ™ÙËÓ ÚÒÙË Ù¿ÍË π, Ë ÚˆÙ½ÓË ‰ÂÓ ·Ú¿ÁÂÙ·È Î·ıfiÏÔ˘. ∂‰Ò ·Ó‹ÎÂÈ Ë Û¯ÂÙÈο Û˘¯Ó‹ ·ÓÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË G542X. ™ÙË ‰Â‡ÙÂÚË Ù¿ÍË ππ, Ë ÚˆÙ½ÓË ·Ú¿ÁÂÙ·È ÛÙÔ ÂÓ‰ÔÏ·ÛÌ·ÙÈÎfi ‰›ÎÙ˘Ô, ·ÏÏ¿ ˘¿Ú¯ÂÈ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó·‰›ÏˆÛË Î·È ÌÂÙ·ÊÔÚ¿ Ù˘ ÛÙËÓ ÎÔÚ˘Ê·›· ÂÈÊ¿ÓÂÈ·. ∂‰Ò ·Ó‹ÎÂÈ Ë ÈÔ Û˘¯Ó‹ ÌÂÙ¿ÏÏ·ÍË ¢F508. ™ÙËÓ ÙÚ›ÙË Ù¿ÍË πππ, Ë ÚˆÙ½ÓË ‰ÂÓ ··ÓÙ¿ ÛÙÔ Î˘ÎÏÈÎfi AMP. ∂‰Ò ·Ó‹ÎÂÈ Ë Û¯ÂÙÈο Û˘¯Ó‹ ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË G551D. ∞˘Ù¤˜ ÔÈ ÙÚÂȘ Ù¿ÍÂȘ ·ÊÔÚÔ‡Ó ‚·ÚȤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ, ÔÈ Ôԛ˜ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÛÙÔÓ Ï‹ÚË Ê·ÈÓfiÙ˘Ô Ù˘ ∫π. OÈ ÂfiÌÂÓ˜ ‰‡Ô Ù¿ÍÂȘ ·ÊÔÚÔ‡Ó ‹È˜ ÌÂÙ·ÏÏ¿ÍÂȘ. ™ÙËÓ Ù¤Ù·ÚÙË Ù¿ÍË πV, Ë ÚˆÙ½ÓË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂȈ̤ÓË ·ÁˆÁÈÌfiÙËÙ·. ∂‰Ò ·Ó‹ÎÂÈ Ë ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË R117H, Ë ÔÔ›· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È ÛÙËÓ ÎÏËÚÔÓÔÌÈ΋ ·ÁÎÚ·ٛÙȉ·. ∆¤ÏÔ˜, ÛÙËÓ ¤ÌÙË Ù¿ÍË V, Ë Û‡ÓıÂÛË Ù˘ ÚˆÙ½Ó˘ Â›Ó·È ÌÂȈ̤ÓË ‹ ˘¿Ú¯ÂÈ ÂÏ·ÊÚ¿ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó·‰›ÏˆÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘. ∂‰Ò ·Ó‹ÎÂÈ Ë ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË ∞455∂. À¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÚˆÙ½Ó˘ CFTR Î·È Ù˘ ‚Ï¿‚˘ ÙˆÓ ÔÚÁ¿ÓˆÓ. ŸÙ·Ó Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÚˆÙ½Ó˘ ·ÔÙÂÏ› ÙÔ 1% Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜, Ô Ê·ÈÓfiÙ˘Ô˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÎÏ·ÛÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ∫π. ÀÔÏÂÈfiÌÂÓË ÏÂÈÙÔ˘ÚÁ›· 5% ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ·ÁÎÚ·ÙÈ΋ ¿ÚÎÂÈ·, ÂÓÒ 10% ÙË Û˘ÁÁÂÓ‹ ·ÙÚËÛ›· ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘. ∏ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ηÙÈÔÓÈÎÔ‡ ıÚ˘„ÈÓÔÁfiÓÔ˘ ·fi ÙÔÓ Whitcomb ÙÔ 1996
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Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ Ù˘ ÎÏËÚÔÓÔÌÈ΋˜ ·ÁÎÚ·ٛÙȉ·˜, Ë ÔÔ›· ÂÍËÁÂ›Ù·È Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÌÂÙ·ÏÏ·Á̤Ó˘ ıÚ˘„›Ó˘ ÛÂ Û˘ÁΤÓÙÚˆÛË Ë ÔÔ›· ˘ÂÚ‚·›ÓÂÈ ÙË ‰Ú¿ÛË ÙÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ıÚ˘„›Ó˘ Î·È Ô‰ËÁ› Û ·˘ÙÔ„›· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ (4). ∏ ·Ó‡ÚÂÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Ù˘ ÚˆÙ½Ó˘ CFTR Û ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ ¯ÚfiÓÈ· ·ÁÎÚ·ٛÙȉ· ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ˘ÔÔÌ¿‰· Ì ·ıÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ CFTR Ë ÔÔ›· ·ÊÔÚ¿ ÂȉÈο ÙÔ ¿ÁÎÚ·˜ (5). ∂Ê·ÚÌÔÁ‹ Ù˘ ÚˆÙ½Ó˘ CFTR ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·ÔÙÂÏ› Ë ÁÔÓÔÙ˘È΋ ÂȂ‚·›ˆÛË Ù˘ ∫π Î·È Ë ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË. ∏ ÁÓÒÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ CFTR ‚Ô‹ıËÛ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ÎÏ·ÛÈ΋˜ ‰ÔÎÈÌ·Û›·˜ ȉÚÒÙ·. ∆¤ÏÔ˜, Ë ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ÛÙȘ ÚÔÔÙÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·ÁÎÚ·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÚÔÛ¿ıÂÈ· ηٷÛ΢‹˜ Û΢·ÛÌ¿ÙˆÓ ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ÏÈ¿Û˘ ÌÈÎÚÔ‚›ˆÓ ‹ Ì˘Î‹ÙˆÓ, ÛÙË Û‡ÓıÂÛË ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ÁψÛÛÈ΋˜ ÏÈ¿Û˘ Î·È ÛÙË ÁÔÓȉȷ΋ ıÂڷ›·, Ë ÔÔ›· Û˘Ó›ÛÙ·Ù·È ÛÙË ÌÂÙ·ÊÔÚ¿ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ÁÔÓ›‰ÈÔ˘ Ù˘ ÏÈ¿Û˘ ‹ ¿ÏÏˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔ Ë·ÙÔ¯ÔÏÈÎfi Û‡ÛÙËÌ· ‹ ÛÙÔ ¤ÓÙÂÚÔ, ÒÛÙÂ Ô ·ÛıÂÓ‹˜ Ó· ·Ô¯Ù‹ÛÂÈ ÙË ‰˘-
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Ó·ÙfiÙËÙ· Ó· ·Ú¿ÁÂÈ ‰Èο ÙÔ˘ ¤Ó˙˘Ì·. ∞˘Ùfi Â›Ó·È ¤Ó· ÌfiÓÔ ·Ú¿‰ÂÈÁÌ· ÙˆÓ ı·˘Ì·ÛÙÒÓ ÂÍÂÏ›ÍÂˆÓ Î·È ÚÔÔÙÈÎÒÓ ÛÙÔ Â‰›Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Nousia-Arvanitakis S, Theoharides A, Zaramboukas T, Malaka-Lambrellis E, Pavlitou K, Polydorou F et al. Helicobacter pylori associated gastro-duodenal disease in Northern Greek children with recurrent abdominal pain. Hell J Gastroenterol 1996;9:242-245. 2. Nousia-Arvanitakis S. Cystic fibrosis and the pancreas: recent scientific advances. J Clin Gastroenterol 1999;29:138-142. 3. Taylor CJ. Chronic pancreatitis and mutations of the cystic fibrosis gene. Gut 1999;44:8-9. 4. Whitcomb DC. Hereditary pancreatitis: new insights into acute and chronic pancreatitis. Gut 1999;45:317-322. 5. Sharer N, Schwartz M, Malone G. Mutations of the cystic fibrosis gene in chronic pancreatitis. N Engl J Med 1998;339:6456-52.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™¿ÓÙ· ¡Ô‡ÛÈ·-∞Ú‚·ÓÈÙ¿ÎË ∆£ 322, £¤ÚÌË, 570 01, £ÂÛÛ·ÏÔÓ›ÎË e-mail: sarvanit@med.auth.gr
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Paediatriki 2001;64:293-299
GASTROENTEROLOGY-HEPATOLOGY-NUTRITION
ÃÔÏfiÛÙ·ÛË ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË K. ™‡ÚÔÁÏÔ˘
Cholestasis of infancy: diagnosis and treatment K. Spiroglou
¶ÂÚ›ÏË„Ë: ∏ ¯ÔÏfiÛÙ·ÛË ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ·ÔÙÂÏ› ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· Î·È Û˘¯Ó¿ ··ÈÙ› ¿ÌÂÛË ‰È·ÊÔÚԉȿÁÓˆÛË ÌÂٷ͇ ·ÙÚËÛ›·˜ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ Î·È ÓÂÔÁÓÈ΋˜ Ë·Ù›Ùȉ·˜. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ‰›ÓÂÙ·È ¤ÌÊ·ÛË ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¯ÔÏfiÛÙ·Û˘ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· fiÔ˘ Â›Ó·È Û˘¯ÓfiÙÂÚË Î·È ÙÔÓ›˙ÂÙ·È Î˘Ú›ˆ˜ Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ì ٷ ˘¿Ú¯ÔÓÙ· ÂÚÁ·ÛÙËÚȷο ̤۷. ∂›Û˘, ·Ó·Ï‡ÂÙ·È Ë ·ÓÙÈÌÂÙÒÈÛË, ÙfiÛÔ ÁÂÓÈο fiÛÔ Î·È ·ÈÙÈÔÏÔÁÈο.
Abstract: Cholestasis in infancy is an important diagnostic problem, which in the neonatal period needs prompt evaluation and exclusion of extrahepatic biliary atresia from other causes of neonatal hepatitis. This discussion emphasizes the evaluation of cholestasis in infancy, especially in the neonatal period where it represents a small but important group of disorders. It also describes the clinical and laboratory diagnostic evaluation as well as the therapeutic approach based on general principles as well as on etiology.
§¤ÍÂȘ ÎÏÂȉȿ: ¯ÔÏfiÛÙ·ÛË, ›ÎÙÂÚÔ˜, ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·.
Key words: cholestasis, jaundice, neonatal hepatitis.
ø˜ ¯ÔÏfiÛÙ·ÛË ıˆÚÂ›Ù·È Ë ‰È·Ù·Ú·¯‹ ·Ú·ÁˆÁ‹˜ - ·ÚÔ¯¤Ù¢Û˘ Ù˘ ¯ÔÏ‹˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÎÚ¿ÙËÛË Ô˘ÛÈÒÓ ÛÙÔ ·›Ì· Î·È ÙÔ˘˜ ÈÛÙÔ‡˜, ÔÈ Ôԛ˜ Ê˘ÛÈÔÏÔÁÈο ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙË ¯ÔÏ‹. ∫ÏÈÓÈο ηıÔÚ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÈÎÙ¤ÚÔ˘, ÛÎÔÙÂÈÓfi¯ÚÔˆÓ Ô‡ÚˆÓ, ÎÓËÛÌÔ‡ Î·È Í·ÓıÂÏ·ÛÌ¿ÙˆÓ (1-5). I‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÔÎÙ¿ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·. ™ÙȘ ËÏÈ˘ ·˘Ù¤˜ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÁÓˆÛÙ‹ Î·È Û·Ó ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·, ·Ú·ÙÂٷ̤ÓÔ˜ ÓÂÔÁÓÈÎfi˜ ·ÔÊÚ·ÎÙÈÎfi˜ ›ÎÙÂÚÔ˜ ‹ ÓÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË (4). ∞ÔÙÂÏ› ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ì ÔÏϤ˜ ÔÌÔÈfiÙËÙ˜ ·ÏÏ¿ Î·È ‰È·ÊÔÚ¤˜ (4,6,7). O ¯ÔÏÔÛÙ·ÙÈÎfi˜ ›ÎÙÂÚÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ÂÌÊ·Ó›˙ÂÙ·È ÌÂ Û˘¯ÓfiÙËÙ· 1:2500 ¤ˆ˜ 1:5000 ˙ÒÓÙ· ÓÂÔÁ¤ÓÓËÙ· (1) Î·È ÂÚ›Ô˘ ÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∆· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó
¯ÔÏfiÛÙ·ÛË ÛÙ· ·È‰È¿ Â›Ó·È ÔÏ˘¿ÚÈıÌ· (¶›Ó·Î·˜ 1). ™Â ·‰Ú¤˜ ÁÚ·Ì̤˜, Ù· ÓÂÔÁÓ¿ Ì ¯ÔÏfiÛÙ·ÛË ¯ˆÚ›˙ÔÓÙ·È Û 2 ηÙËÁÔڛ˜: ·) ·˘Ù¿ Ì ÂÓ‰ÔË·ÙÈ΋ ÓfiÛÔ Î·È ‚) ·˘Ù¿ Ì Â͈˷ÙÈ΋ (™¯‹Ì· 1). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÔÏÏÒÓ ÂÚÁ·ÛÈÒÓ Ê·›ÓÂÙ·È fiÙÈ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌ›ÙÂÈ ‚·ÛÈο Û 2 ηÙËÁÔڛ˜: ÙËÓ ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (∞∂ö) Ì ̛· Û˘¯ÓfiÙËÙ· 1:8000 ¤ˆ˜ 1:12000 ˙ÒÓÙ· ÓÂÔÁÓ¿ (8,9) Î·È ÙËÓ È‰ÈÔ·ı‹ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· (π¡∏) Ì ̛· Û˘¯ÓfiÙËÙ· 1:4800 ¤ˆ˜ 1:9000 ˙ÒÓÙ· ÓÂÔÁÓ¿ (1). OÈ ‰‡Ô ·˘Ù¤˜ ηٷÛÙ¿ÛÂȘ ·ÔÙÂÏÔ‡Ó ÙÔ 70-80 % ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¯ÔÏfiÛÙ·Û˘ Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, ÂÓÒ Ï›Á· ¯ÚfiÓÈ· ÚÈÓ, ÂÍ›ÛÔ˘ Û˘¯Ó‹ ‹Ù·Ó Î·È Ë ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· ·fi ÏÔÈÌÒÍÂȘ. ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ¯ÔÏfiÛÙ·Û˘ ÔÊ›ÏÔÓÙ·È Û ÔÍ›· ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· (4).
°’ ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔÓ›ÎË
3rd Pediatric Department of the Aristotelion University Ippokration General Hospital, Thessaloniki
293
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18:55
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¶·È‰È·ÙÚÈ΋ 2001;64:293-299
¶›Ó·Î·˜ 1. ∞›ÙÈ· ¯ÔÏfiÛÙ·Û˘ ÛÙ· ·È‰È¿ π. ∂͈˷ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·. ¯ÔÏÈ΋ ·ÙÚËÛ›· ‚. ¯ÔÏÈ΋ ˘ÔÏ·Û›· Á. ÛÙ¤ÓˆÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‰. ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ Â. ÓÂÔÏ·Û›·, ¯ÔÏfiÏÈıÔÈ ππ. ∂Ó‰ÔË·ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·. π‰ÈÔ·ı‹ 1. π‰ÈÔ·ı‹˜ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· 2. ∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË, ›ÌÔÓË ·. ·ÚÙËÚÈÔË·ÙÈ΋ ‰˘ÛÏ·Û›· (Û‡Ó‰ÚÔÌÔ Alagille) ‚. ÓfiÛÔ˜ ÙÔ˘ Byler Á. ÙÚȸ‰ÚÔÎÔÚ·ÛÙ·ÓÔ˚΋ Ô͢·ÈÌ›· ‰. Û‡Ó‰ÚÔÌÔ Zellweger (ÂÁÎÂÊ·ÏÔ-Ë·ÙÔ-ÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ) Â. ÌË Û˘Ó‰ÚÔÌÈ΋ Ì›ˆÛË ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‚. ∞Ó·ÙÔÌÈο ·›ÙÈ· 1. ™˘ÁÁÂÓ‹˜ Ë·ÙÈ΋ ›ÓˆÛË ‹ Ó·ÓÈ΋ ÔÏ˘Î˘ÛÙÈ΋ ÓfiÛÔ˜ ÓÂÊÚÒÓ–‹·ÙÔ˜) 2. ¡fiÛÔ˜ Caroli Á. ªÂÙ·‚ÔÏÈο ·›ÙÈ· ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·ÌÈÓÔͤˆÓ ñ ∆˘ÚÔÛÈÓ·ÈÌ›·. ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÏÈȉ›ˆÓ ñ ¡fiÛÔ˜ ÙÔ˘ Wolman ñ ¡fiÛÔ˜ Niemann-Pick ñ ¡fiÛÔ˜Gaucher ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ˘‰·Ù·ÓıÚ¿ÎˆÓ ñ °·Ï·ÎÙÔ˙·ÈÌ›· ñ ºÚÔ˘ÎÙÔ˙·ÈÌ›· ñ °Ï˘ÎÔÁÔÓ›·ÛË ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ¯ÔÏÈÎÒÓ ÔͤˆÓ ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· ¯ˆÚ›˜ ÁÓˆÛÙfi ¤ÏÏÂÈÌÌ· ·Ó¿ÚÎÂÈ· ·1 ·ÓÙÈıÚ˘„›Ó˘ ΢ÛÙÈ΋ ›ÓˆÛË È‰ÈÔ·ı‹˜ ˘Ô¸ÔÊ˘ÛÈÛÌfi˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ‰. ∏·Ù›Ùȉ˜ 1. §ÔÈÌÒ‰Ë ·›ÙÈ· ñ ªÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ ñ ∏·Ù›Ùȉ· µ ñ πÔ› Reo, Coxsackie, Echo Î.Ï. ñ ∆ÔÍÔÏ¿Û̈ÛË ñ ™‡ÊÈÏȘ ñ º˘Ì·Ù›ˆÛË 2. ∆ÔÍÈο ·›ÙÈ· ñ ¶·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ñ ™Ë„·ÈÌ›· Â. °ÂÓÂÙÈο ‹ ¯ÚˆÌÔۈ̷ÙÈο ñ ÙÚÈۈ̛· ∂ ñ Û‡Ó‰ÚÔÌÔ Down ñ ÏÂÚÂÎÔÓÈÛÌfi˜ (Û‡Ó‰ÚÔÌÔ Donahue’s) ÛÙ. ¢È¿ÊÔÚ· πÛÙÈÔ·ÙÙˆÛË Ã ∂ÓÙÂÚÈ΋ ·fiÊÚ·ÍË ™‡Ó‰ÚÔÌÔ ÔÏ˘ÛÏËÓ›·˜
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∞) ¡ÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË ∞ÓÙÈÌÂÙˆ›˙ÔÓÙ·˜ ¤Ó· ÓÂÔÁÓfi Ì ¯ÔÏfiÛÙ·ÛË, ·˘ÙfiÌ·Ù· ÚÔ·ÙÔ˘Ó Ù¤ÛÛÂÚ· ÂÚˆÙËÌ·ÙÈο: ·) À¿Ú¯Ô˘Ó ¿ÌÂÛ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÂÈÏÔ‡Ó ÙË ˙ˆ‹; ‚) ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ ‰ÂÓ Â›Ó·È ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ; Á) ª‹ˆ˜ ¤¯ÂÈ Î¿ÔÈ· Ë·Ù›Ùȉ· ÁÈ· ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È ıÂڷ›· ‹ ÁÂÓÂÙÈΤ˜ Û˘Ì‚Ô˘Ï¤˜; ‰) ¶Ò˜ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ıÚ¤„˘; °ÂÓÈο, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ¯ÔÏÔÛÙ·ÙÈÎÔ‡ ·È‰ÈÔ‡ ·Ú·Ì¤ÓÂÈ ¤Ó· ‰‡ÛÎÔÏÔ ¤ÚÁÔ Ô˘ ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÛÙËÓ ·ÓÔÌÔÈÔÁ¤ÓÂÈ· ÙˆÓ ¯ÔÏÔÛÙ·ÙÈÎÒÓ Û˘Ó‰ÚfiÌˆÓ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙË ÛÎÔÙÂÈÓ‹ ·ıÔÁ¤ÓÂÈ· ÔÏÏÒÓ ·fi ÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ (10). ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË Î·È ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ‰È·Ù·Ú·¯ÒÓ Ô˘ ˘fiÎÂÈÓÙ·È Û ÂȉÈ΋ ıÂڷ›· (.¯. Á·Ï·ÎÙÔ˙·ÈÌ›·) ‹ ÚÒÈÌË ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË, fiˆ˜ Ë ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∞ÎfiÌË ÎÈ ·Ó Ë ıÂڷ›· ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹, ·È‰È¿ Ì ¯ÚfiÓÈ· ÂÍÂÏÈÛÛfiÌÂÓË Ë·ÙÔ¿ıÂÈ· ÌÔÚÔ‡Ó Ó· ˆÊÂÏËıÔ‡Ó ·fi ÙȘ ÚÔÛ¿ıÂȘ ÁÈ· ηχÙÂÚË ıÚÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ‹ Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ (1). πÛÙÔÚÈÎfi Î·È Ê˘ÛÈ΋ ÂͤٷÛË: ¶ÚˆÙ·Ú¯ÈÎfi˜ ÛÎÔfi˜ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÓÂÔÁÓÈ΋˜ ¯ÔÏfiÛÙ·Û˘ Â›Ó·È o ‰È·¯ˆÚÈÛÌfi˜ Ù˘ ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ ·fi ÙËÓ Â͈˷ÙÈ΋ ‚Ï¿‚Ë, Ë ·Ó·˙‹ÙËÛË ÓfiÛˆÓ Ô˘ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Î·È Ë ·Ó·ÁÓÒÚÈÛË ÎÏÈÓÈÎÒÓ ÂÈÏÔÎÒÓ, ÁÈ· ÙȘ Ôԛ˜ Ë ÁÂÓÈ΋ ıÂڷ›· ÌÔÚ› Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∆· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο (¶›Ó·Î·˜ 2) ÔÔÈ·Û‰‹ÔÙ ·ÈÙ›·˜ Ô˘ ÚÔηÏ› ¯ÔÏfiÛÙ·ÛË Â›Ó·È Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ fiÌÔÈ· (1). ∆Ô Î‡ÚÈÔ Û‡Ìو̷ Â›Ó·È Ô ›ÎÙÂÚÔ˜, Ô ÔÔ›Ô˜ Á›ÓÂÙ·È ÂÌÊ·Ó‹˜ fiÙ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ˘Âڂ› Ù· 2-3 mg/dl, ÙÔ ÓÂÔÁÓfi fï˜ ÌÔÚ› Ó· ÌË Ê·›ÓÂÙ·È ÈÎÙÂÚÈÎfi ̤¯ÚÈ Ë ¯ÔÏÂÚ˘ıÚ›ÓË Ó· ÊÙ¿ÛÂÈ Ù· 7 mg/dl (1,11). ∂ÌÊ·Ó›˙ÂÙ·È ·Ú¯Èο ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÚÔԉ¢ÙÈο ¶›Ó·Î·˜ 2. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓÂÔÁÓÈ΋˜ Ë·Ù›Ùȉ·˜ ñ ñ ñ ñ ñ
ÿÎÙÂÚÔ˜ ∞ԯڈ̷ÙÈÛÌfi˜ ÎÔÚ¿ÓˆÓ (ηıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË) À¤Ú¯ÚˆÛË Ô‡ÚˆÓ ¢ÈfiÁΈÛË ‹·ÙÔ˜ Ì ‹ ¯ˆÚ›˜ ‰ÈfiÁΈÛË ÛÏ‹Ó· °ÂÓÈο Û˘ÌÙÒÌ·Ù·: ˆ¯ÚfiÙËÙ·, Ô›‰ËÌ·, ÚÔˆÚfiÙËÙ·, ‰˘ÛˆÚÈÌfiÙËÙ· ñ ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·: ÂÌÂÙÔ›, ·ÓÔÚÂÍ›·, ¿ÚÓËÛË ıËÏ·ÛÌÔ‡ (ÌÔÚ› Ó· ÚÔËÁÔ‡ÓÙ·È ÙÔ˘ ÈÎÙ¤ÚÔ˘) ñ ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ∫¡™: ˘ÔÙÔÓ›·, ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·Ú¯¤ÁÔÓˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ (Moro, ıËÏ·ÛÌÔ‡, ηٿÔÛ˘)
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¶·È‰È·ÙÚÈ΋ 2001;64:293-299
Paediatriki 2001;64:293-299
¡ÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË
Â͈˷ÙÈ΋
Â͈˷ÙÈ΋ ·ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ
ÂÓ‰ÔË·ÙÈ΋
Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë
‚Ï¿‚Ë ¯ÔÏËÊfiÚˆÓ fiÚˆÓ
ÂÓ‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· ‹ Ì›ˆÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ÌÂÙ·‚ÔÏÈ΋ ÓfiÛÔ˜
ȉÈÔ·ı‹ ·›ÙÈ· ÈÔÁÂÓ‹˜ ÓfiÛÔ˜ Û˘Ó‰ÚÔÌÈÎfi˜ Ù‡Ô˜
ÌË Û˘Ó‰ÚÔÌÈÎfi˜ Ù‡Ô˜
™¯‹Ì· 1. ∫‡ÚȘ ηÙËÁÔڛ˜ ¯ÔÏfiÛÙ·Û˘
ÂÂÎÙ›ÓÂÙ·È ÚÔ˜ ÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·, ηıÒ˜ Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·˘Í¿ÓÂÈ (11). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ fiÛÔ ÓˆÚ›ÙÂÚ· ·ÓÙÈÌÂÙˆÈÛÙ› Ë Â͈˷ÙÈ΋ ·ÙÚËÛ›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ÙfiÛÔ Î·Ï‡ÙÂÚ· Â›Ó·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ·fi„ˆ˜ ÚÔ‹˜ ¯ÔÏ‹˜. £· Ú¤ÂÈ ÏÔÈfiÓ, ·Ó Ô ›ÎÙÂÚÔ˜ ·Ú·Ù›ÓÂÙ·È ÌÂÙ¿ ÙË 14Ë Ë̤ڷ Ù˘ ˙ˆ‹˜, Ó· Á›ÓÂÈ ‰ÈÂÚ‡ÓËÛË ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Â͈˷ÙÈ΋˜ ·ÙÚËÛ›·˜ (12). ÕÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ¯ÔÏfiÛÙ·Û˘ Ô˘ ı· Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó Â›Ó·È Ô ·Ô¯ÚˆÌ·ÙÈÛÌfi˜ ÙˆÓ ÎÔÚ¿ÓˆÓ Î·È Ë ˘¤Ú¯ÚˆÛË ÙˆÓ Ô‡ÚˆÓ. ¢ÈfiÁΈÛË ‹·ÙÔ˜ Î·È ÛÏËÓfi˜, ·ÛΛÙ˘, Ô›‰ËÌ·, Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ·ÚÁfiÙÂÚ· (1,3). ∞ӷʤÚÂÙ·È fiÙÈ ÔÚÈṲ̂ӷ ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ Î·È Â͈˷ÙÈ΋˜ ‚Ï¿‚˘ (3) (¶›Ó·Î·˜ 3). ∆· ÎÏÈÓÈο ·˘Ù¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÌÔÚÔ‡Ó Ó· ı¤ÛÔ˘Ó ‰È¿ÁÓˆÛË Û ÔÛÔÛÙfi 82% ÙˆÓ ÂÚÈÙÒÛˆÓ. øÛÙfiÛÔ, Ë ÚÔÛı‹ÎË Î·È ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·˘Í¿ÓÂÈ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· ÌfiÓÔ Î·Ù¿ 3% (‰ËÏ. 85%). ∏ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Û˘Ìو̿وÓ, fiˆ˜ Ë Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ë ÌÂȈ̤ÓË ıÚ¤„Ë, Ë ·ÓÔÚÂÍ›· ‹ ÔÈ ÂÌÂÙÔ› Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ÌÂÙ·‚ÔÏÈ΋˜ ‰È·Ù·Ú·¯‹˜, fiˆ˜ Ë Á·Ï·ÎÙÔ˙·ÈÌ›· ‹ Ù˘ÚÔÛÈÓ·ÈÌ›·, ÂÓÒ Â˘Ú‹Ì·Ù· fiˆ˜ ÙÔ ÂÌ‚Ú˘fiÙÔÍÔ, ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÔÓ‰‡ÏˆÓ ‹ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· ÛÙËÓ ÂÛÙ›· ·ÎÚfi·Û˘ Ù˘ Ó¢ÌÔÓÈ΋˜, ı¤ÙÔ˘Ó ÙËÓ ¤Ó‰ÂÈÍË ¤Ó‰ÂÈ·˜ ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ÁÓˆÛÙ‹ Î·È ˆ˜ ·ÚÙËÚÈÔ-Ë·ÙÈ΋ ‰˘ÛÏ·Û›· (Û‡Ó‰ÚÔÌÔ Alagille) (3,13,14). ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜: O ÂÚÁ·ÛÙËÚÈ·Îfi˜
¤ÏÂÁ¯Ô˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â›Ó·È ·ÚÎÂÙ¿ ÔχÏÔÎÔ˜ Î·È Û˘¯Ó¿ ··ÈÙ› ÔÏϤ˜ Î·È Â·ÓÂÈÏËÌ̤Ó˜ ÂÍÂÙ¿ÛÂȘ (¶›Ó·Î·˜ 4). µ·ÛÈÎfi˜ ÛÎÔfi˜ ÂÓfi˜ ·Ú¯ÈÎÔ‡ ÂϤÁ¯Ô˘ Â›Ó·È Ó· ÂȂ‚·Èˆı› Ë ·ÚÔ˘Û›· ¯ÔÏfiÛÙ·Û˘, Ó· ηıÔÚÈÛÙ› Ë ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Î·È Ó· ‰È·ÁÓˆÛÙÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ, ÔÈ Ôԛ˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Â‡ÎÔÏ· Î·È ÁÚ‹ÁÔÚ·. °È· ÙÔ ÛÎÔfi ·˘Ùfi, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÏ˘¿ÚÈı̘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ. øÛÙfiÛÔ ‰ÂÓ ˘¿Ú¯ÂÈ Î¿ÔÈÔ ‰È·ÁÓˆÛÙÈÎfi test Ô˘ Ó· ‚ÔËı‹ÛÂÈ ÛÙÔ ‰È·¯ˆÚÈÛÌfi ÂÓ‰Ô-Ë·ÙÈ΋˜ Î·È Â͈-Ë·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ÙË ‚ÈÔ„›· ‹·ÙÔ˜. OÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ì›· ÏËıÒÚ· ÂÍÂÙ¿ÛˆÓ. ∞Ú¯Èο ÂϤÁ¯ÂÙ·È Ë Ë·ÙÈ΋ Î·È ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙÔ ·ÈÌÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Î·È Ô ËÎÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜, ÂÍÂÙ¿ÛÂȘ ÁÂÓÈΤ˜ Ô˘ ı· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ‚¤‚·È· Î·È ÙÔ˘ ‹·ÙÔ˜ (3,10). ™ÙË Û˘Ó¤¯ÂÈ·, Ô ¤ÏÂÁ¯Ô˜ ÔÏÔÎÏËÚÒÓÂÙ·È Ì ÂȉÈÎfiÙÂÚ˜ ÂÍÂÙ¿ÛÂȘ fiˆ˜ Ô ¤ÏÂÁ¯Ô˜ ·Ó·˙‹ÙËÛ˘ ÏÔÈÌÒ͈Ó, ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÂÓ‰ÔÎÚÈÓÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ‹ ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛˆÓ. OÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, ÁÓˆÛÙÔ‡˜ Ì ÙÔ ·ÎÚˆÓ‡ÌÈÔ TORCH (ÙÔÍfiÏ·ÛÌ·, Ô˘ÚÔÏԛ̈ÍË, ÂÚ˘ıÚ¿, CMV, ¤Ú˘), SLAVE (Û‡ÊÈÏË, ÏÈÛÙ¤ÚÈ·, Ë·Ù›Ùȉ· µ, ·ÓÂÌ¢ÏÔÁÈ¿, ÏÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË) ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÙfiÛÔ ÛÙÔ ÓÂÔÁÓfi fiÛÔ Î·È ÛÙË ÌËÙ¤Ú· (1,3). ∞ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜: O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ ÛÙÔÓ ÛÈÓıËÚÔÁÚ·ÊÈÎfi Î·È Û ÂΛÓÔÓ Ì ˘ÂÚ‹¯Ô˘˜. ∏ real-time
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¶·È‰È·ÙÚÈ΋ 2001;64:293-299
Paediatriki 2001;64:293-299
¶›Ó·Î·˜ 3. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓ‰Ô- Î·È Â͈- Ë·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ ÷ڷÎÙËÚÈÛÙÈο
∂͈˷ÙÈ΋ ¯ÔÏfiÛÙ·ÛË
∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË
3200
2700
79
26
16 87
30 53
94 86 63
47 30 1
µ¿ÚÔ˜ Á¤ÓÓËÛ˘ Û g ÃÚÒÌ· ÎÔÚ¿ÓˆÓ ÂÓÙfi˜ 10 ËÌÂÚÒÓ ·fi ÂÈÛ·ÁˆÁ‹ (% ·¯ÔÏÈο) ∏ÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ·¯ÔÏÈÎÒÓ ÎÔÚ¿ÓˆÓ Û Ë̤Ú˜ ∏·ÙÔÌÂÁ·Ï›· ‹ ·ıÔÏÔÁÈ΋ Û‡ÛÙ·ÛË (%) µÈÔ„›· ‹·ÙÔ˜ ñ ¶˘Ï·›· ›ÓˆÛË (% ıÂÙÈ΋) ñ ¶ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (% ıÂÙÈ΋) ñ µ‡ÛÌ·Ù· ¯ÔÏ‹˜
¶›Ó·Î·˜ 4. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË (ÈÛÙÔÚÈÎfi, Ê˘ÛÈ΋ ÂͤٷÛË, ¯ÚÒÌ· ÎÔÚ¿ÓˆÓ) 2. µÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ñ ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (ÔÏÈ΋-¿ÌÂÛË) ñ ∞ÌÈÓÔÙÚ·ÓÛÊÂÚ¿Û˜ (SGOT, SGPT) ñ ŒÏÂÁ¯Ô˜ Û˘ÓıÂÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ‹·ÙÔ˜ (Ï¢ÎÒÌ·Ù· ÔÚÔ‡, ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘) ñ ∫·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ñ OÚÔÏÔÁÈ΋ ·Ó›¯Ó¢ÛË ÈÒÓ (HbsAG, HIV Î.Ï.) ñ º·ÈÓfiÙ˘Ô˜ ·1 ·ÓÙÈıÚ˘„›Ó˘ ñ ∆4 Î·È TSH ñ ÃψÚÈÔ‡¯· ȉÚÒÙ· ñ ŒÏÂÁ¯Ô˜ ÌÂÙ·‚ÔÏÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (·ÌÈÓfiÁÚ·ÌÌ· ÔÚÔ‡ Î·È Ô‡ÚˆÓ, ·Ó·ÁˆÁÈΤ˜ Ô˘Û›Â˜) ÊÂÚÚÈÙ›ÓË ÔÚÔ‡ 3. ∞ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ñ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ñ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ñ ‰È·‰ÂÚÌÈ΋ ‰ÈË·ÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ñ ·Ï›Ó‰ÚÔÌË ÂÓ‰ÔÛÎÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· 4. µÈÔ„›· ‹·ÙÔ˜
˘ÂÚ˯ÔÁÚ·Ê›· ÌÔÚ› Ó· ‰ÒÛÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙË Û‡ÛÙ·ÛË ÙÔ˘ ‹·ÙÔ˜ Î·È Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜, Ó· ‰Â›ÍÂÈ ÙËÓ ·ÚÔ˘Û›· ¯ÔÏfiÏÈıˆÓ, ·ÛΛÙË ‹ ΢ÛÙÈÎÒÓ ‰È·Ù¿ÛÂˆÓ ÙÔ˘ ¯ÔÏÈÎÔ‡ ‰¤Ó‰ÚÔ˘ (15,16). O ÛÈÓıËÚÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì Ù¯ӋÙÈÔ Û˘Ó‰Â‰Â̤ÓÔ Ì ·Ú¿ÁˆÁÔ IDA (ÈÌÈÓԉȷÎÂÙÈÎfi Ô͇) ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â͈˷ÙÈ΋˜ ·ÙÚËÛ›·˜ ·fi ÌË ·ÔÊÚ·ÎÙÈ΋ ¯ÔÏfiÛÙ·ÛË (17-19). ÕÏϘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Â›Ó·È Ë ‰È·‰ÂÚÌÈ΋ ‰ÈË·ÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· Î·È Ë ·Ï›Ó‰ÚÔÌË ÂÓ‰ÔÛÎÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›·. ¶ÚÔ¸Ôı¤ÙÔ˘Ó, fï˜, ÔÚÁ·ÓˆÌ¤Ó˜ ÌÔÓ¿‰Â˜ Ì ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi. ∆¤ÏÔ˜, Ë ‚ÈÔ„›· ‹·ÙÔ˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ Ë ÈÔ ··Ú·›ÙËÙË Î·È Î·ıÔÚÈÛÙÈ΋ ÂͤٷÛË ÛÙËÓ ÂÎÙ›ÌËÛË ‚Ú¤ÊÔ˘˜ Ì ›ÌÔÓË ˘ÂÚ¯ÔÏÂÚ˘-
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ıÚÈÓ·ÈÌ›·. ∏ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (ductular proliferation), ‚˘ÛÌ¿ÙˆÓ ¯ÔÏ‹˜, ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ˘Ï·›Ô˘ ‰È·ÛÙ‹Ì·ÙÔ˜ Î·È ·Ú¯fiÌÂÓ˘ ›ÓˆÛ˘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ·ÙÚËÛ›·˜ ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (20,21). ∞Ó ·Ú’ fiÏ· ·˘Ù¿, ÂÍ·ÎÔÏÔ˘ı› Ó· ˘¿Ú¯ÂÈ Úfi‚ÏËÌ·, ÙÔ ÂfiÌÂÓÔ ‚‹Ì· Â›Ó·È Ë ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· Ì ٷ˘Ùfi¯ÚÔÓË ‚ÈÔ„›· Î·È ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›·. ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ¯ÔÏfiÛÙ·Û˘ (¶›Ó·Î·˜ 5) ™Â ÓÂÔÁÓ¿-‚Ú¤ÊË Ô˘ Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Ë ‚ÈÔ„›· ‹·ÙÔ˜ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ·fiÊڷ͢ ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ‰ÈÂÓÂÚÁÂ›Ù·È ‰ÈÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· Î·È ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ÒÛÙ ӷ ηıÔÚÈÛÙ› Ë ı¤ÛË Î·È Ë ¤ÎÙ·ÛË Ù˘ ·fiÊڷ͢ Î·È ÙÔ Â›‰Ô˜ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‰ÈfiÚıˆÛ˘ Ù˘ ‚Ï¿‚˘ (.¯. ÂÁ¯Â›ÚËÛË Kasai). ™Â ‚Ú¤ÊË Ì ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË ‹ ‚Ú¤ÊË Ì Â͈-Ë·ÙÈ΋ ·ÙÚËÛ›· ¯ÂÈÚÔ˘ÚÁË̤ӷ, Ô˘ ‰ÂÓ Î·ÙÔÚıÒıËΠ·Ú΋˜ ÚÔ‹ Ù˘ ¯ÔÏ‹˜, Ë ·ÓÙÈÌÂÙÒÈÛË Î·ıÔÚ›˙ÂÙ·È ·fi ÙȘ ÎÏÈÓÈΤ˜ Û˘Ó¤ÂȘ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ¯ÔÏfiÛÙ·Û˘ (3,4). OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· Ì ÙË ÌÂȈ̤ÓË ÚÔ‹ Ù˘ ¯ÔÏ‹˜ Î·È ÔÊ›ÏÔÓÙ·È ÛÂ: 1) ηٷÎÚ¿ÙËÛË ·fi ÙÔ ‹·Ú Ô˘ÛÈÒÓ Ô˘ Ê˘ÛÈÔÏÔÁÈο ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙË ¯ÔÏ‹ (¯ÔÏÂÚ˘ıÚ›ÓË, ȯÓÔÛÙÔȯ›·, ¯ÔÏÈο Ôͤ·, ¯ÔÏÂÛÙÂÚ›ÓË), 2) ÌÂȈ̤ÓË ·¤ÎÎÚÈÛË ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ (Ì›ˆÛË ˘ÎÓÔÙ‹ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ ÛÙÔ ¤ÓÙÂÚÔ Ì ·ÔÙ¤ÏÂÛÌ· ‰˘Û·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ) Î·È 3) Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë ÂÍÂÏÈÛÛfiÌÂÓË Û ΛÚÚˆÛË, ˘Ï·›· ˘¤ÚÙ·ÛË Î·È Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· (™¯‹Ì· 2). °ÂÓÈο, η̛· ıÂڷ›· ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ‹ ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘, ÁÈ’ ·˘Ùfi Î·È ·ÔÛÎÔ› ÛÙÔ Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Î·È Ó· ÌÂÈÒÛÂÈ ÙȘ ÂÈÏÔΤ˜ (22). ª›· ·fi ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ Î·È ÈÔ ¿ÌÂÛ˜ ÂÈÏÔΤ˜ Ù˘ ¯ÚfiÓÈ·˜ ¯ÔÏfiÛÙ·Û˘ Â›Ó·È Ë ÌÂȈ̤ÓË
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¶·È‰È·ÙÚÈ΋ 2001;64:293-299
¶›Ó·Î·˜ 5. ∞ÓÙÈÌÂÙÒÈÛË ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË 1. ¢È·ÙÚÔÊ‹ °¿Ï· Û‡Ìʈӷ Ì ÙȘ ıÂÚÌȉÈΤ˜ ÙÔ˘ ·Ó¿ÁΘ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ MCT (OÈÏ – ÊfiÚÌÔ˘Ï·) 2. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙË ÚÔ‹ Ù˘ ¯ÔÏ‹˜ º·ÈÓÔ‚·Ú‚ÈÙ¿ÏË 5 mg/kg, H ÃÔÏÂÛÙ˘Ú·Ì›ÓË 4 - 16 g/H ∆ÂÚÊÂÓ·‰›ÓË 1 - 3 mg/kg, H 3. π¯ÓÔÛÙÔȯ›· ·Û‚¤ÛÙÈÔ 25 - 100 mg/kg, H (ÛÙÔȯÂÈÒ‰ÂȘ ·Ó¿ÁΘ) ʈÛÊfiÚÔ˜ 25 - 50 mg/kg, H „¢‰¿ÚÁ˘ÚÔ˜ 1 mg/kg, H 4. µÈٷ̛Ә ·) ˘‰·ÙÔ‰È·Ï˘Ù¤˜ Û ‰‡Ô ‰fiÛÂȘ ‚) ÏÈÔ‰È·Ï˘Ù¤˜ ∞ 10000 - 15000 iu/H D 1200 - 5000 iu/H E 100 - 400 iu/H K 5 - 10 mg/ ·Ó¿ 3 - 5 Ë̤Ú˜ 5. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛΛÙË ™ÂÈÚÔÓÔÏ·ÎÙfiÓË 3 - 5 mg/kg, H ºÔ˘ÚÔÛÂÌ›‰Ë 1 - 2 mg/kg Ë̤ڷ ·Ú’ Ë̤ڷ, ¤ˆ˜ ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ ¶ÂÚÈÔÚÈÛÌfi˜ Na: ¤ˆ˜ 1 mg/kg, H
·¤ÎÎÚÈÛË ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ. ∏ ÌÂȈ̤ÓË ·˘Ù‹ ·¤ÎÎÚÈÛË Ù˘ ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ηٷÎÚ¿ÙËÛË Û˘ÛÙ·ÙÈÎÒÓ Ù˘ ¯ÔÏ‹˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÎÓËÛÌÔ‡, Í·ÓıˆÌ¿ÙˆÓ, ÈÎÙ¤ÚÔ˘, ηıÒ˜ Î·È Î·Ù·ÎÚ¿ÙËÛË ¯ÔÏÈÎÒÓ ÔͤˆÓ Î·È ÌÂÙ·ÏÏÈÎÒÓ ÈfiÓÙˆÓ (Cu, Mg, Al) Ô˘ ‰ÚÔ˘Ó ÙÔÍÈο ÛÙÔ ‹·Ú (3,4). ∂›Û˘, Ë ÌÂȈ̤ÓË ˘ÎÓfiÙËÙ· ¯ÔÏÈÎÒÓ ÔͤˆÓ ÛÙÔ ¤ÓÙÂÚÔ Ô‰ËÁ› Û η΋ ıÚ¤„Ë ÏfiÁˆ ·ÔÚÚfiÊËÛ˘ ÙÔ˘ Ï›Ô˘˜, ÙˆÓ ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ Î·È ‰È¿ÚÚÔȘ. ¶¤Ú·, fï˜, ·fi ÙȘ ÏÈÔ‰È·Ï˘Ù¤˜ ‚Èٷ̛Ә ··ÈÙÂ›Ù·È Ú‡ıÌÈÛË ÙˆÓ ıÚÂÙÈÎÒÓ ·Ó·ÁÎÒÓ. ∂Âȉ‹ Ô ‚·ıÌfi˜ Ù˘ ‰˘Û·ÔÚÚfiÊËÛ˘ ÙˆÓ ÏÈÒÓ ÌÔÚ› Ó· Â›Ó·È Ôχ ÌÂÁ¿ÏÔ˜ ·Ó Ë ÚÔ‹ Ù˘ ¯ÔÏ‹˜ ¤¯ÂÈ ÌÂȈı› ÛËÌ·ÓÙÈο, Ë Î¿Ï˘„Ë ÙˆÓ ıÂÚÌȉÈÎÒÓ ·Ó·ÁÎÒÓ (19) Ô˘ ·Ú¤¯ÔÓÙ·È Ì ÙȘ ÙÚÔʤ˜ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 125% ¤ˆ˜ 150%. ∏ η΋ ·ÔÚÚfiÊËÛË ÙÔ˘ Ï›Ô˘˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ÏÈ·ÚÒÓ ·Ï‡ÛÂˆÓ (MC∆ formula-oil), ÂÓÒ ÔÈ ·Ó¿ÁΘ Û ÏÈÔ‰È·Ï˘Ù¤˜ ‚Èٷ̛Ә ·ÓÙÈÌÂÙˆ›˙oÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ‚ÈÙ·ÌÈÓÒÓ Û ‰fiÛÂȘ 2-4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ (3,16). ∏ ·ÚÔ˘Û›· Í·ÓıˆÌ¿ÙˆÓ Î·È ÎÓËÛÌÔ‡ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ Û˘Ó‹ıˆ˜ ÙËÓ Î·Ù·ÎÚ¿ÙËÛË Î·È ·‡ÍËÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÙÔ˘ ÔÚÔ‡ Î·È ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ, ·ÓÙ›ÛÙÔȯ·. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηٿÛÙ·Û˘ ·˘Ù‹˜ ¯ÔÚËÁÔ‡ÓÙ·È ¯ËÏÈΤ˜ Ô˘Û›Â˜ (.¯. ¯ÔÏÂÛÙ˘Ú·Ì›ÓË), ÔÈ Ôԛ˜ ·˘Í¿ÓÔ˘Ó ÙËÓ ¤ÎÎÚÈÛË (ÚÔ‹) Ù˘ ¯ÔÏ‹˜, ÌÂÈÒÓÔÓÙ·˜ ÙÔÓ ÂÓÙÂÚÔË·ÙÈÎfi ·ÎÏÔ Î·È Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ë ÔÔ›· ‰ÈÂÁ›-
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ÚÂÈ ÙË ÚÔ‹ ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ (23). ∏ ¯ÔÏfiÛÙ·ÛË, Û·Ó ¯ÚfiÓÈ· ÂÍÂÏÈÛÛfiÌÂÓË ÓfiÛÔ˜, Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·Ó¿Ù˘ÍË ›ÓˆÛ˘, Ë ÔÔ›· ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË Î›ÚÚˆÛ˘ Î·È Ù· ·ÎfiÏÔ˘ı¿ Ù˘, ÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË (˘ÂÚÛÏËÓÈÛÌfi˜, ·ÛΛÙ˘, ·ÈÌÔÚÚ·Á›· ·fi ÎÈÚÛÔ‡˜ ÔÈÛÔÊ¿ÁÔ˘) Î·È ÙËÓ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· (1,3). ªÔÚ›, fï˜, Ë ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ Ó· ÔÊ›ÏÂÙ·È Û Á·ÛÙÚ›Ùȉ· ‹ ÂÙÈÎfi ¤ÏÎÔ˜. ∂Âȉ‹ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ‰È·ÊÔÚÂÙÈ΋, Â›Ó·È ··Ú·›ÙËÙË Ë ÂÓ‰ÔÛÎfiËÛË ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (4). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛΛÙË ˘·ÁÔÚ‡ÂÙ·È ·fi ÙËÓ ·Ó·ÎÔ‡ÊÈÛË Ù˘ ‰˘ÛÊÔÚ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔÓ Î›Ó‰˘ÓÔ ÂÚÈÙÔÓ·˚΋˜ ÌfiÏ˘ÓÛ˘. ™Â ‹ÈÔ ·ÛΛÙË, ·Ú¯Èο Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ Ó·ÙÚ›Ô˘. ∏ ÚfiÛÏË„‹ ÙÔ˘ ÂÚÈÔÚ›˙ÂÙ·È ÛÙÔ 0,5 g ËÌÂÚËÛ›ˆ˜ (ÂÚ›Ô˘ 1-2 mEq/kg/24ˆÚÔ). ∞Ó Ë ÓÂÊÚÈ΋ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ÈηÓÔÔÈËÙÈ΋, ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ˜ Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÔÚËÁÔ˘Ì¤ÓˆÓ ˘ÁÚÒÓ. ∏ ‰ÈÔ‡ÚËÛË Û˘¯Ó¿ Ú˘ıÌ›˙ÂÙ·È Ì ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ fiˆ˜ Ë ÊÔ˘ÚÔÛÂÌ›‰Ë, ÌfiÓË ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÛÂÈÚÔÓÔÏ·ÎÙfiÓË, Ù· ÔÔ›· ·Ó·ÎÔ˘Ê›˙Ô˘Ó ÙÔÓ ·ÛıÂÓ‹ ÂÚÈÔÚ›˙ÔÓÙ·˜ ÙË Û˘ÛÛÒÚ¢ÛË ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡ ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ·. ™Â ·ÓıÂÎÙÈÎfi ·ÛΛÙË ‹ ·ÛΛÙË Ì ÌÂÁ¿ÏË ÔÛfiÙËÙ· ˘ÁÚÔ‡, Ë ÂÎÎÂÓˆÙÈ΋ ·Ú·Î¤ÓÙËÛË Î·È Ù·˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÏÂ˘ÎˆÌ·Ù›Ó˘ Î·È ÊÔ˘ÚÔÛÂÌ›‰Ë˜ ÌÔÚ› Ó· ·Ó·ÎÔ˘Ê›ÛÂÈ ÙÔÓ ·ÛıÂÓ‹ (24). OÈ ÎÈÚÛÔ› ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Î·È ÙÔ˘ ıfiÏÔ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ·ÔÙÂÏÔ‡Ó Ì›· ÛÔ‚·Ú‹ ÂÈÏÔ΋ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Ô˘ ÌÔÚ› Ó· ·ÂÈÏ‹ÛÂÈ ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∫·Ù¿ ηÈÚÔ‡˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ̤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÎÈÚÛÒÓ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, fiˆ˜ Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ‚·ÛÔÚÂÛ›Ó˘, ‚ ·‰ÚÂÓÂÚÁÈÎÔ› ·Ó·ÛÙÔÏ›˜ (b blocking agents) fiˆ˜ Ë ÚÔÚ·ÓÔÏfiÏË (3,4) ‹ ‰È¿ÊÔÚ· ·Ó·ÛÙÔ̈ÙÈο ΢ÎÏÒÌ·Ù·. ™Â ‚·ÚȤ˜ ·ÈÌÔÚÚ·Á›Â˜ Ô˘ ÂÈ̤ÓÔ˘Ó, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ Ì·ÏfiÓÈ Sengstaken - Blakemore (25). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â˘Ú¤ˆ˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÈÌÔÚÚ·Á›·˜ Ë ÛÎÏËÚÔıÂڷ›· Î·È Ù· ÂÏ·ÛÙÈο ‰·ÎÙ˘Ï›‰È· (rubber rings). ∏ ·Ó¿Ù˘ÍË ÈÓÒ‰Ô˘˜ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ‰È¿ÊÔÚ· Ê¿Ú̷η, fiˆ˜ Ë ÎÔϯÈΛÓË, Ë D-ÂÓÈÎÈÏÏ·Ì›ÓË Î·È Ù· ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉ‹. ŸÌˆ˜, Ù· ÂÚÈÛÙ·ÙÈο Â›Ó·È Ï›Á· Î·È ¯ÚÂÈ¿˙ÔÓÙ·È Î·È ¿ÏϘ ÌÂϤÙ˜ ÁÈ· Ó· ÂȂ‚·Èˆı› Ë ˆÊ¤ÏÂÈ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ (26,27). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ Ï‹„˘, Û˘ÓÙ‹ÚËÛ˘ Î·È ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜
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ÃÔÏfiÛÙ·ÛË ∫·Ù·ÎÚ¿ÙËÛË ÃÔÏÈο Ôͤ· : ÎÓËÛÌfi˜ ∏·ÙÔÙÔÍÈÎfiÙËÙ·
ªÂȈ̤ÓË ¤ÎÎÚÈÛË ¯ÔÏÈÎÒÓ ÔͤˆÓ ‰˘Û·ÔÚÚfiÊËÛË Ï›Ô˜ : η΋ ıÚ¤„Ë, ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘
ÃÔÏÂÚ˘ıÚ›ÓË : ›ÎÙÂÚÔ˜ ÃÔÏÂÛÙÂÚfiÏË : ˘ÂÚ¯ÔÏÂÛÙÂÚÔÏ·ÈÌ›· •·ÓıˆÌ¿ÙˆÛË π¯ÓÔÛÙÔȯ›·
ÏÈÔ‰È·Ï˘Ù¤˜ ‚Èٷ̛Ә ∞ : ÏÂÙfi ‰¤ÚÌ· D : ÔÛÙÂÔÂÓ›· E : Ó¢ÚÔÌ˘˚΋ ÂÎʇÏÈÛË ∫ : ˘ÔÚÔıÚÔÌ‚ÈÓ·ÈÌ›· ¢È¿ÚÚÔÈ· / ÛÙ·ÙfiÚÚÔÈ·
¶ÚÔԉ¢ÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜ ¶˘Ï·›· ˘¤ÚÙ·ÛË
˘ÂÚÛÏËÓÈÛÌfi˜
·ÛΛÙ˘
Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·
ÎÈÚÛÔ› (·ÈÌÔÚÚ·Á›·)
™¯‹Ì· 2. ∫ÏÈÓÈο ·ÎfiÏÔ˘ı· ¯ÚfiÓÈ·˜ ¯ÔÏfiÛÙ·Û˘
Î·È Ë ¯Ú‹ÛË ÙˆÓ ÓÂfiÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ë ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ó· ·ÔÙÂÏ› Û‹ÌÂÚ· ηıÈÂڈ̤ÓË Î·È ÁÂÓÈÎÒ˜ ·Ô‰ÂÎÙ‹ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË, fiÙ·Ó ˘¿Ú¯Ô˘Ó ÔÈ ·Ó¿ÏÔÁ˜ ÂӉ›ÍÂȘ. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ·È‰ÈÒÓ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (28) ·Ó¤Ú¯ÂÙ·È Û‹ÌÂÚ· ÛÙÔ 80% - 90%. ∆¤ÏÔ˜, ηٿ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ¯ÔÏÔÛÙ·ÙÈÎÔ‡ ·È‰ÈÔ‡ ı· Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó Î¿ÔÈ· ÁÂÓÈο ̤ÙÚ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÚÔ‚ÏËÌ¿ÙˆÓ, fiˆ˜ Ë ·Ó¿Ù˘ÍË, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ›, Ë ˘ÁÈÂÈÓ‹ ÙˆÓ ‰ÔÓÙÈÒÓ Î·È Ë „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. µ) ÃÔÏfiÛÙ·ÛË Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ¯ÔÏfiÛÙ·Û˘ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÔÊ›ÏÔÓÙ·È Û ÏÔÈÌÒÍÂȘ Ô˘ ÚÔηÏÔ‡ÓÙ·È ÌÂÙ¿ ÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·. ∂›Û˘, ÔÏϤ˜ ·fi ÙȘ ηٷÛÙ¿ÛÂȘ Ô˘ ÚÔηÏÔ‡Ó ¯ÔÏfiÛÙ·ÛË ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ·ÚÁfiÙÂÚ· Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∆· Û˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ¯ÔÏfiÛÙ·ÛË ÛÙ· ·È‰È¿ ·˘Ù¿ Î·È ı· Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó, Â›Ó·È Ë ¯ÚfiÓÈ· Ë·Ù›Ùȉ· (ÈÔÁÂÓ‹˜, ·˘ÙÔ¿ÓÔÛË ‹ Ê·Ú̷΢ÙÈ΋), ·Ó¿ÚÎÂÈ· Ù˘ ·1 ·ÓÙÈıÚ˘„›Ó˘, ÓfiÛÔ˜ Wilson, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Û‡Ó‰ÚÔÌ· ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘, ¯ÔÏÔÏÈı›·ÛË, fiÁÎÔÈ Î.Ï.
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∏ ‰ÈÂÚ‡ÓËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ ‰È·Ê¤ÚÂÈ Ô˘ÛÈ·ÛÙÈο ·fi ÂΛÓË ÙˆÓ ÓÂÔÁÓÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Sucky FJ. Approach to the infant with cholestasis. Chapter 20. In: Sucky FJ, editor. Liver Disease in Children. London: Mosby; 1994. p. 349-355. 2. Reichen J. Pharmacologic treatment of cholestasis. Sem Liv Dis 1993;13:302-315. 3. Moyer MS, Balistreri WF. Prolonged neonatal obstructive jaundice. In: Walker WA, Durie PR, Hamilton JR, WalkerSmith JA, Watkins JB, eds. Pediatric Gastrointestinal Disease-Pathophysiology-diagnosis-management. Philadelphia: Dc Decker Inc; 1991. p. 835-848. 4. Balistreri WF. Cholestasis in Behrman: Nelson Textbook of Pediatrics. 15th ed. W.B. Saunders Co; 1996. 5. Craig JM, Landing BH. Form of hepatitis in the neonatal period simulating biliary atresia. Arch Pathol 1952;54:321-333. 6. ∑ˆÁÚ¿ÊÔ˜ Ã, ™‡ÚÔÁÏÔ˘ ∫, §ÂΛ‰Ô˘ O. ÃÔÏÔÛÙ·ÙÈÎfi˜ ›ÎÙÂÚÔ˜ ÛÙ· ‚Ú¤ÊË: ¶·Ú·ÎÔÏÔ‡ıËÛË 49 ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ 1989;52:356-363. 7. ™‡ÚÔÁÏÔ˘ K, º·ÚÛ¿ÚË M, ∫·Ú·ÁÎÈfi˙ÔÁÏÔ˘-§·ÌÔ‡‰Ë £, ∑ˆÁÚ¿ÊÔ˜ Ã. π‰ÈÔ·ı‹˜ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·: ÔÚ›· Î·È ÚfiÁÓˆÛË. ¶·È‰È·ÙÚÈ΋ µ∂ 1995;7:269-272. 8. Mieli-Vergani G, Howard ER, Mowat A. Liver disease in infancy: a 20 year perspective. Gut 1991;32(Suppl): S123-S128. 9. Psacharopoulos HT, Howard ER, Portmann B et al. Extahepatic biliary atresia: preoperative assessment and surgical results in 47 consecutive cases. Arch Dis Child 1980;55:851.
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10. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child 1969;188:454-458. 11. Matthew PM, Wharton BA. Investigation and management of neonatal jaundice: a problem-orientated case record. Arch Dis Child 1981;56:949-953. 12. DeBelle RC, Vaupshas V, Vitullo BB et al. Intestinal absorption of bile salts: immature development in the neonate. J Pediatr 1979;94:472-476. 13. Franken EA, Smith WL, Siddiqui A. Noninvasive evaluations of liver disease in pediatrtics. Radiol Clin N Am 1980;18:239-252. 14. ª·Ï¿Ûη ∞, •˘ÓÈ¿˜ π, ¶··¯Ú‹ÛÙÔ˘ º, ¡Ù·Ú›Ï˘ ∂, ™‡ÚÔÁÏÔ˘ ∫. ™‡Ó‰ÚÔÌÔ Alagille. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ µ∂ 1999;11:125-129. 14·. Krishnamurthy S, Krishnamurthy GT. Technetium-99m iminodiacetic acid organic anions: review of biokinetcs and clinical application in hepatology. Hepatology 1989;9:139-153. 15. Huller JO. Sonography of the biliary tract in infants and children. Am J Roentgenol 1991;157:1051-1058. 16. Weinberger E, Blumhagen JD, Odell JM. Gallbladder contraction in biliary atresia. Am J Roentgenol 1987;149:401-402. 17. Miller JH, Sinatra FR, Thomas DW. Biliary excretion disorders in infants: evaluation using 99mTc-PIPIDA. AM J Radiol 1980;135:47-52. 18. Majd M, Reba RC, Altman RP. Hepatobiliary scintigraphy with 99mTc-PIPIDA in the evaluation of neonatal jaundice. Pediatrics 1981;67:140-145. 19. Sokol RJ. Medical management of the infant or child with chronic liver disease. Semin Liver Dis 1987;7:155-167.
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20. Ferry DG, Selby ML, Udall J et al. Guide to early diagnosis of biliary obstruction in infancy. Review of 143 cases. Clin Pediatr 1985;24:305-311. 21. Brough AJ, Bernstein J. Conjugated hyperbilirubinaemia in early infancy. Human Pathol 1974;5:507-514. 22. Bloomer JR, Boyer JL. Phenobarbital effects in cholestatic liver disease. Ann Intern Med 1985;82:310-317. 23. Gines P, Tito L, Arroyo V et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493-1502. 24. Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices: a decadal progress report. Dig Dis Sci 1980;25:267-272. 25. Starzl TE, Iwatsuki S, VanThiel DH et al. Evolution of liver transplantation. Hepatology 1982;2:614-636. 26. Lee H, Vacanti JP. Liver transplantation and its long term management in children. Pediatr Clin N Am 1996;43:99-124. 27. Zifroni A, Schaffner F. Long term follow-up of patients with PBC on colchicine therapy. Hepatology 1991;14:990-993. 28. Ramirez RO, Sokol RJ. Medical management of cholestasis. In: Sucky F, ed. Liver disease in children. London: Mosby; 1994. p. 356-388.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, 546 42, £ÂÛÛ·ÏÔÓ›ÎË e-mail: klspirog@med.auth.gr
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Paediatriki 2001;64:300-303
GASTROENTEROLOGY-HEPATOLOGY-NUTRITION
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÛÙËÓ ∂ÏÏ¿‰·. ∆È ¤¯ÂÈ Á›ÓÂÈ - ªÂÏÏÔÓÙÈΤ˜ ÚˆÙÔ‚Ô˘Ï›Â˜ £. ∑¿¯Ô˘
Breastfeeding in Greece. What has been done - Targets for the future T. Zachou
¶ÂÚ›ÏË„Ë: ∏ ¶·ÁÎfiÛÌÈ· ∞genda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË ·fi ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ›ӷÈ: 1981, ı¤ÛÈÛË ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. 1989, ηıÔÚÈÛÌfi˜ ÙˆÓ “¢¤Î· µËÌ¿ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. 1990, “¢È·Î‹Ú˘ÍË Innocenti”, ÁÈ· ÙËÓ ¶ÚÔÛÙ·Û›·, ÀÔÛÙ‹ÚÈÍË Î·È ¶ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. 1992-1993, ¶ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԕ, “ºÈÏÈÎfi ÃÒÚÔ ∂ÚÁ·Û›·˜ Ù˘ ªËÙ¤Ú·˜” Î·È ı¤ÛÈÛË Ù˘ “¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”. 2000, ÛÙfi¯Ô˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌÔ‡ ÀÁ›·˜ ÙˆÓ ∏.¶.∞, ÒÛÙ ٷ ÔÛÔÛÙ¿ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ó· ÊÙ¿ÛÔ˘Ó ÙÔ 75%. ™ÙË ¯ÒÚ· Ì·˜ ·Ú·ÙËÚÂ›Ù·È ÛÙ·ıÂÚ¿ ·˘Í·ÓfiÌÂÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ·fi ÙËÓ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ· Î·È ÙËÓ ¶ÔÏÈÙ›·. ∆Ô 1979-81 Ú·ÁÌ·ÙÔÔÈ‹ıËΠη̿ÓÈ· “∂ÈÛÙÚÔÊ‹ ÛÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. ∆Ô 1983 ˘ÈÔıÂÙ‹ıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ÂÓ·ÚÌÔÓ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ∆Ô 1985 ȉڇıËΠÛÙÔ ª·ÈÂ˘Ù‹ÚÈÔ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘” ªÔÓ¿‰· ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ∆Ô 1993 Û˘ÛÙ‹ıËΠ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ∆Ô 1995 ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÛÙ· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µËÌ¿ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. ∆Ô 1996 ıÂÛ›ÛÙËÎÂ Ë “¶·ÁÎfiÛÌÈ· ∂‚‰ÔÌ¿‰· ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”. ∆Ô 1997 ηıÈÂÚÒıËÎ·Ó ÛÂÌÈÓ¿ÚÈ· 40 ˆÚÒÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ÁÈ· ·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜. ∆Ô 1999 Ë ÁÔÓÈ΋ ¿‰ÂÈ· ¤ÁÈÓ ÂÙ‹ÛÈ· Ì ϋÚÂȘ ·Ô‰Ô¯¤˜ Ù˘ ÂÚÁ·˙fiÌÂÓ˘ ÌËÙ¤Ú·˜. ¢Â‰Ô̤ÓÔ˘ fiÙÈ
Abstract: The World Breastfeeding Agenda is full of dates for breastfeeding promotion. The most important are the following: 1981, “International Code of Marketing of Breast Milk Substitutes”. 1989, Statement of WHO and UNICEF for the “Ten Steps to Successful Breastfeeding”. 1990, “Innocenti Declaration on Protecting, Supporting and Promoting Breastfeeding”. 1992-3, “BabyFriendly Hospital Initiative”, “Mother-Friendly Work Place Initiative” and establishment of the “World Breastfeeding Week”. 2000, The National Health Promotion and Disease Prevention objectives of U.S.A. targets to increase to 75% the percentage of breastfeeding mothers. In our country, there is an increasing interest in breastfeeding among health professionals and the Government. 197981, campaign “Return to Breastfeeding”. 1983, the Greek Government adopted the “International Code of marketing of Breast Milk Substitutes”. 1985, a Breastfeeding Promotion Unit was established at “Helena Venizelou” Maternity Hospital in Athens. 1993, a National Breastfeeding Committee was established. 1995, the Ministry of Health sent a circular to all Maternity Hospitals requesting the implementation of the “Ten Steps to Successful Breastfeeding”. Since 1996, the “World Breastfeeding Week” is celebrated in Greece. Since 1997, a 40-hour Breastfeeding seminar has been established for health professionals. In 1999, maternity leave was increased to one year, with the mother being granted full salary. In Greece, there has been no recent data concerning national breastfeeding
¶·È‰›·ÙÚÔ˜ - ¡ÂÔÁÓÔÏfiÁÔ˜ ∆¤ˆ˜ ¢È¢ı‡ÓÙÚÈ· Ù˘ ªÔÓ¿‰·˜ º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁ¤ÓÓËÙˆÓ - ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ∆Ú¿Â˙·˜ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜ ÙÔ˘ ¡ÂÔÁÓÔÏÔÁÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ¶.°.¡. ª·È¢ÙËÚ›Ô˘ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘”
Pediatrician - Neonatologist Former Director of the Unit of Normal Newborns Promotion of Breast Feeding - Maternal Milk Bank, Neonatology Division of the General Maternity Hospital “Elena Venizelou”, Athens
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Paediatriki 2001;64:300-303
ÛÙË ¯ÒÚ· Ì·˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚfiÛÊ·Ù· ÔÛÔÛÙ¿ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi ›‰Ô, ÚˆÙ·Ú¯ÈÎfi ̤ÏËÌ· ı· ‹Ù·Ó Ì›· ·ÓÂÏÏ‹ÓÈ· ¤Ú¢ӷ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘˜ Î·È ÌÂÙ¿, ÁÓˆÚ›˙ÔÓÙ·˜ ÙËÓ Ù˘¯fiÓ ·Ó¿ÚÎÂÈ·, Ì ·fiÏ˘ÙË ÁÓÒÛË Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Î·Ù¿ÏÏËϘ Û˘Óı‹Î˜ ÒÛÙÂ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Ó· Á›ÓÂÈ Ë ÂÈÎÚ·Ù¤ÛÙÂÚË ‰È·ÙÚÔÊ‹.
rates, and therefore there is a great need for a national census the results of which will help to create the appropriate conditions for making breastfeeding the predominant feeding modality.
§¤ÍÂȘ ÎÏÂȉȿ: ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÔÏÈÙÈ΋, ÚÔ·ÁˆÁ‹, ˘ÔÛÙ‹ÚÈÍË.
Key words: breastfeeding, policy, promotion, support.
∏ ÂÔ¯‹ Ì·˜ Â›Ó·È ÂÔ¯‹ ¤ÎÚË͢ ÁÓÒÛÂˆÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È Ô ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ Í·Ó·ÎÂÚ‰›˙ÂÈ ÙË ¯·Ì¤ÓË ÙÔ˘ ı¤ÛË Û·Ó ÙË ÌÔÓ·‰È΋ Î·È ·Ó·ÓÙÈηٿÛÙ·ÙË ÙÚÔÊ‹ ÁÈ· ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Î·È ÙÔ ‚Ú¤ÊÔ˜. ∆·˘Ùfi¯ÚÔÓ· ÚÔ‚¿ÏÏÔÓÙ·È Î·È Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· ÙÔ ·È‰›, ÙË ÌËÙ¤Ú·, ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÙËÓ ÎÔÈÓˆÓ›·, ÙËÓ ÔÏÈÙ›·, ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù· ÔÔ›· Â›Ó·È ·Ó·ÌÊÈÛ‚‹ÙËÙ·. ∏ ¶·ÁÎfiÛÌÈ· ∞genda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË ·fi ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘. ¶ÚÈÓ ‰Ô‡Ì ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙË ¯ÒÚ· Ì·˜, ı· ·Ó·ÊÂÚıԇ̠۠ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜, ÁÈ·Ù› fiÔÈÔ˜ ÂӉȷʤÚÂÙ·È ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‰ÂÓ ı· ¤Ú ӷ ÙȘ ·ÁÓÔ›. ŒÙÛÈ, ÙÔ 1981 ÛÙËÓ ¶·ÁÎfiÛÌÈ· ™˘Ó¿ÓÙËÛË ÀÁ›·˜ ıÂÛ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” ÁÈ· ÙË ÛˆÛÙ‹ ¯Ú‹ÛË ÙÔ˘˜, ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Ì ȷÙÚÈ΋ Û˘ÓÙ·Á‹ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓÂͤÏÂÁÎÙ˘ ‰È·Ê‹ÌÈÛ‹˜ ÙÔ˘˜ (1). ∞ÔÙ¤ÏÂÛÌ· ·˘ÙÒÓ ˘‹ÚÍÂ Ë ÚÔÛÙ·Û›· ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. O ∫Ò‰Èη˜ ÈÛ¯‡ÂÈ ‰ÈÂıÓÒ˜ ·fi ÙÔ 1983. ∆Ô 1989 ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ Î·È ÙËÓ UNICEF, ÙÔÓ›ÛÙËÎÂ Ô ÂȉÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ ÚÔÛˆÈÎÔ‡ ÙˆÓ ª·È¢ÙËÚ›ˆÓ ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚÈÍË, ÙËÓ ÚÔ¿ÛÈÛË Î·È ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Î·È ÔÚ›ÛÙËÎ·Ó Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ÂÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” (2). £· ·Ó·ÊÂÚıԇ̠ÌÂ Û˘ÓÙÔÌ›· Û ·˘Ù¿. ¶Ú¤ÂÈ: 1) ¡· ˘¿Ú¯ÂÈ ÁÚ·Ù‹ ÔÏÈÙÈ΋ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Î·È Ë ÔÏÈÙÈ΋ ·˘Ù‹ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ª·È¢ÙËÚ›Ô˘, Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘. 2) ∆Ô ÚÔÛˆÈÎfi Ó· Âηȉ‡ÂÙ·È, ÒÛÙ ӷ Â›Ó·È ÈηÓfi Ó· ÂÊ·ÚÌfiÛÂÈ ÙËÓ ÔÏÈÙÈ΋ ·˘Ù‹. 3) ¡· ÂÓËÌÂÚÒÓÔÓÙ·È fiϘ ÔÈ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ ÁÈ· Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ó· Âηȉ‡ÔÓÙ·È. 4) ¡· ‰›‰ÂÙ·È ‚Ô‹ıÂÈ· ÛÙȘ Ӥ˜ ÌËÙ¤Ú˜ Ó· ÍÂÎÈÓ‹ÛÔ˘Ó ÙÔ ıËÏ·ÛÌfi ̤۷ ÛÙÔ ÚÒÙÔ ËÌ›ˆÚÔ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. 5) OÈ ÌËÙ¤Ú˜ Ó· ÍÂÎÈÓ‹ÛÔ˘Ó ÛˆÛÙ¿ ÙÔ ªËÙÚÈÎfi ıËÏ·ÛÌfi, ÁÈ·Ù› Ë ÛˆÛÙ‹ ÙÔÔı¤ÙËÛË ÙÔ˘
·È‰ÈÔ‡ ÛÙÔ ÛÙ‹ıÔ˜ Ù˘ ÌËÙ¤Ú·˜ Â›Ó·È ÙÔ ∞ Î·È ÙÔ ø Ù˘ ÂÈÙ˘¯›·˜ ÙÔ˘. ∞ÎfiÌË, Ú¤ÂÈ Ó· Âηȉ‡ÔÓÙ·È ÒÛÙ ӷ ‰È·ÙËÚÔ‡Ó ÙË Á·ÏÔ˘¯›· Û ÂÚ›ÙˆÛË Ô˘ Ù˘¯fiÓ ı· ·Ô¯ˆÚÈÛÙÔ‡Ó Ù· ·È‰È¿ ÙÔ˘˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ¤Ó· ÚfiˆÚÔ ÙÔÎÂÙfi ‹ ÛÙË Á¤ÓÓËÛË ÂÓfi˜ ÚÔ‚ÏËÌ·ÙÈÎÔ‡ ·È‰ÈÔ‡. 6) ™ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Ó· ‰›ÓÂÙ·È ÌfiÓÔ ÌËÙÚÈÎfi Á¿Ï·, Ô‡Ù ˘ÁÚ¿, Ô‡ÙÂ Û˘Ìϋڈ̷ ͤÓÔ˘ Á¿Ï·ÎÙÔ˜, ÂÎÙfi˜ Â¿Ó ˘¿Ú¯ÂÈ ÂȉÈÎfi˜ È·ÙÚÈÎfi˜ ÏfiÁÔ˜. 7) ¡· ÂÊ·ÚÌfi˙ÂÙ·È ÙÔ Û‡ÛÙËÌ· “rooming in”, Ô˘ ÛËÌ·›ÓÂÈ ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Ó· Â›Ó·È ‰›Ï· ÛÙË ÌËÙ¤Ú· ÙÔ˘ 24 ÒÚ˜ ÙÔ 24ˆÚÔ. 8) ¡· ÂÓı·ÚÚ‡ÓÂÙ·È Ô Î·Ù¿ ‚Ô‡ÏËÛË ıËÏ·ÛÌfi˜. ∆Ô ·È‰› Ó· ÙÚÒÂÈ fiÔÙ ı¤ÏÂÈ, fiÛÔ ı¤ÏÂÈ ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙË Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ÙˆÓ ÁÂ˘Ì¿ÙˆÓ. 9) ¡· ÌËÓ ‰›ÓÔÓÙ·È È›Ï˜ ÛÙ· ·È‰È¿ Ô˘ ıËÏ¿˙Ô˘Ó. 10) ¡· È‰Ú˘ıÔ‡Ó ÔÌ¿‰Â˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙȘ Ôԛ˜ Ó· ÌÂÙ¤¯Ô˘Ó ÌËÙ¤Ú˜, ÁÈ· ÙË Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ª·ÈÂ˘Ù‹ÚÈÔ. ∆Ô 1990, ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜, ÙËÓ UNICEF Î·È ¿ÏÏÔ˘˜ ¢ÈÂıÓ›˜ OÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ÀÁ›· Î·È ¢È·ÙÚÔÊ‹ ÙÔ˘ ¶·È‰ÈÔ‡ ·Ó·ÎÔÈÓÒıËÎÂ Ë “¢È·Î‹Ú˘ÍË Innocenti” (1) Û‡Ìʈӷ Ì ÙËÓ ÔÔ›·: i) ŸÏ˜ ÔÈ Î˘‚ÂÚÓ‹ÛÂȘ ̤¯ÚÈ ÙÔ 1995 ı· Ú¤ÂÈ Ó· ÔÚ›ÛÔ˘Ó ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ii) ¶Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Û fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. O ·ÔÎÏÂÈÛÙÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È Ì¤¯ÚÈ Î·È ÙÔÓ 6Ô Ì‹Ó· Î·È Ô ÌÂÚÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ (‰ËÏ·‰‹ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ¿ÏϘ ÙÚÔʤ˜) Ó· Û˘Ó¯›˙ÂÙ·È Î·È ¤Ú· ·fi Ù· 2 ¯ÚfiÓÈ·. iii) ¶Ú¤ÂÈ Ó· ÙËÚÔ‡ÓÙ·È Ù· ¿ÚıÚ· ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. iv) ¶Ú¤ÂÈ Ó· ıÂÛÈÛÙ› ¢ÂÚÁÂÙÈ΋ ÓÔÌÔıÂÛ›· ÁÈ· ÙȘ ÌËÙ¤Ú˜ Ô˘ ıËÏ¿˙Ô˘Ó Î·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Û˘Óı‹Î˜, ÒÛÙÂ Ë ÓÔÌÔıÂÛ›· Ó· ÂÊ·ÚÌfi˙ÂÙ·È. ∆Ô 1992 ·Ó·ÎÔÈÓÒıËΠ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ Î·È ÙËÓ UNICEF Ë ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌÂ›Ô - Baby Friendly Hospital Initiative”. O ·ÎÚÔÁˆÓÈ·›Ô˜ Ï›ıÔ˜ ÙÔ˘ “ºÈÏÈÎÔ‡ ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԣ” Â›Ó·È Ë
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¶·È‰È·ÙÚÈ΋ 2001;64:300-303
ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µ‹Ì·ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Î·È Ë Ù‹ÚËÛË ÙˆÓ ¿ÚıÚˆÓ ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ™‹ÌÂÚ·, Ô ·ÚÈıÌfi˜ ÙÔ˘˜ ÍÂÂÚÓ¿ ÙȘ 15.000 Û 128 ¯ÒÚ˜. ∆· 6000 ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ∫›Ó·. ŸÏ˜ ÔÈ ∂˘Úˆ·˚Τ˜ ¯ÒÚ˜ ¤¯Ô˘Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ “ºÈÏÈÎfi ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԕ. ∏ °ÂÚÌ·Ó›· ¤¯ÂÈ 11. ∏ ∞ÁÁÏ›· ¤¯ÂÈ 23. ™ÙË ™Î·Ó‰ÈÓ·‚›· fiÏ· Ù· ¡ÔÛÔÎÔÌ›· Â›Ó·È ºÈÏÈο ÁÈ· ÙÔ ‚Ú¤ÊÔ˜. ŸÏ˜ ÔÈ ¯ÒÚ˜ Ù˘ µ·ÏηÓÈ΋˜ ¤¯Ô˘Ó ·fi ¤Ó·. ∏ ∞Ï‚·Ó›· ·¤ÎÙËÛ ÚfiÛÊ·Ù· ÙÔ ‰Â‡ÙÂÚÔ. ∏ ∆Ô˘ÚΛ· ¤¯ÂÈ ¿Óˆ ·fi 70. ∏ ∞›Á˘ÙÔ˜ ¤¯ÂÈ 117, ÂÓÒ Ë ∂ÏÏ¿‰· ηӤӷ. ∂›Û˘, ÙÔ ›‰ÈÔ ¤ÙÔ˜ ηıÈÂÚÒıËÎÂ Ë “¶·ÁÎfiÛÌÈ· ∂‚‰ÔÌ¿‰· ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ 1-7 ∞˘ÁÔ‡ÛÙÔ˘” ·fi ÙËÓ W.A.B.A. (World Alliance for Breastfeeding Action). ∫¿ı ¯ÚfiÓÔ, ÁÈ· ÙÔÓ ÂÔÚÙ·ÛÌfi Ù˘ ÔÚ›˙ÂÙ·È ¤Ó· ı¤Ì·. °È· ·˘Ùfi ÙÔ ¤ÙÔ˜ ÙÔ ı¤Ì· ›ӷÈ: “ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ - ¢Èη›ˆÌ· ÛÔ˘”. ∆Ô 1993 ·Ó·ÎÔÈÓÒıËΠ·fi ÙËÓ W.A.B.A. Î·È ˘ÔÛÙËÚ›¯ÙËΠ·fi ÙËÓ ¶.O.À. Î·È UNICEF, Ë ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÃÒÚÔ ∂ÚÁ·Û›·˜ Ù˘ ªËÙ¤Ú·˜ - Mother-Friendly Work Place Initiative”, Ô˘ ¤¯ÂÈ ÛÙfi¯Ô Ó· ‰›‰ÂÙ·È ‰˘Ó·ÙfiÙËÙ· ÛÙË ÌËÙ¤Ú· Ó· ıËÏ¿˙ÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÁ·Û›·˜ Ù˘ Ì ÂȉÈο ‰È·Ï›ÌÌ·Ù· Î·È Û ÂȉÈÎfi ¯ÒÚÔ (4). ªÂ fiÏ· ·˘Ù¿ Ù· ̤ÙÚ·, ÙȘ ÚˆÙÔ‚Ô˘Ï›Â˜, ÙÔ˘˜ ıÂÛÌÔ‡˜ Î·È ÔÏÏ¿ ¿ÏÏ· (·ÊÔ‡, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ë Agenda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË Ì ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘) Û fiÏÔ ÙÔÓ ÎfiÛÌÔ, Û˘Ó¯Ҙ Ù· ÔÛÔÛÙ¿ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·˘Í¿ÓÔ˘Ó. ∫·È ¿ÏÈ, Ù· ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿, Ô˘ ÍÂÂÚÓÔ‡Ó ÙÔ 95%, η٤¯Ô˘Ó ÔÈ ™Î·Ó‰ÈÓ·‚ÈΤ˜ ¯ÒÚ˜. O ∂ıÓÈÎfi˜ ¶ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ ÀÁ›·˜ ÙˆÓ ∏.¶.∞. ¤¯ÂÈ ÛÙfi¯Ô ηٿ ÙÔ ¤ÙÔ˜ 2000, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ıËÏ¿˙Ô˘Ó Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ Ó· Êı¿ÛÂÈ ÙÔ 75%, ÂÓÒ Î·Ù¿ ÙÔÓ ¤ÎÙÔ Ì‹Ó· ÙÔ 50% (5). O ÙfiÔ˜ Ì·˜ ıˆÚÂ›Ù·È Ë ¯ÒÚ· Ì ٷ ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·fi fiϘ ÙȘ ¯ÒÚ˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘. ∂›Ó·È fï˜ ‚¤‚·ÈÔ, fiÙÈ ·Ú·ÙËÚÂ›Ù·È ÛÙ·ıÂÚ¿ ·˘Í·ÓfiÌÂÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi ΢ڛˆ˜ ·fi ÙÔ˘˜ Ó¤Ô˘˜ ÁÈ·ÙÚÔ‡˜, ·È‰›·ÙÚÔ˘˜ ·ÎfiÌË Î·È Ì·ÈÂ˘Ù‹Ú˜, Ì·›Â˜ ·ÏÏ¿ Ôχ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙȘ ÌËÙ¤Ú˜. ∂ÍÂÙ¿˙ÔÓÙ·˜ ÙÈ ¤ÁÈÓ ÛÙÔÓ ÙfiÔ Ì·˜ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi, ·Ú¯›˙Ô˘Ì ·fi ÙÔ 1979-1981 Ì ÙËÓ Î·Ì¿ÓÈ· : “∂ÈÛÙÚÔÊ‹ ÛÙÔÓ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Ù˘ ∞’ ¶·ÓÂÈÛÙËÌȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∂› ‰‡Ô ¯ÚfiÓÈ· ·Ú·ÙËÚ‹ıËΠÌÈ· ·‡ÍËÛË ÙˆÓ ÔÛÔÛÙÒÓ. ªÂÙ¿, fï˜, ·fi ·˘Ùfi ‹ÏıÂ Î·È ¿ÏÈ ÙÔ Ù¤ÏÌ·. ∆Ô 1983 ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ-
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·˜, ˘ÈÔıÂÙ‹ıËÎÂ Î·È ÂÓ·ÚÌÔÓ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” (6). ∞fi ÙÔ 1985 ÛÙÔ ª·ÈÂ˘Ù‹ÚÈÔ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘” ÏÂÈÙÔ˘ÚÁ› ÂȉÈ΋ ªÔÓ¿‰· º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁ¤ÓÓËÙˆÓ - ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ∆Ú¿Â˙· ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜, Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÔÔ›·˜ ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi ÙÔ 1947 (7). ∏ ªÔÓ¿‰·, ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Ù˘, Ì ÂȉÈο ÚÔÁÚ¿ÌÌ·Ù· Âηȉ‡ÂÈ ÂȉÈ΢fiÌÂÓÔ˘˜ ·È‰›·ÙÚÔ˘˜, ÊÔÈÙËÙ¤˜ ª·È¢ÙÈÎÒÓ Î·È ¡ÔÛËÏ¢ÙÈÎÒÓ ™¯ÔÏÒÓ Î·ıÒ˜ Î·È Ì¤ÏÏÔÓÙ˜ Î·È Ó¤Ô˘˜ ÁÔÓ›˜. ∆Ô 1993 Û˘ÛÙ‹ıËÎÂ Ë ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ (8). ∆Ô 1995 ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜ ÚÔ˜ fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· Ô˘ ¤¯Ô˘Ó Ì·È¢ÙÈο Î·È ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Ì ÛÎÔfi Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È, Û‡Ìʈӷ Ì ÙË “¢È·Î‹Ú˘ÍË Innocenti”, Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Ô˘ ıÂÛ›ÛÙËÎ·Ó ·fi ÙËÓ ¶.O.À. Î·È ÙËÓ UNICEF (9). ∆Ô 1996 ηıÈÂÚÒıËÎÂ Î·È ÂÓ·ÚÌÔÓ›ÛÙËΠ̠ÙȘ Û˘Óı‹Î˜ Ù˘ ¯ÒÚ·˜ Ì·˜ Ô ÂÔÚÙ·ÛÌfi˜ Ù˘ “¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”, ·fi 1-7 ¡ÔÂÌ‚Ú›Ô˘ οı ¯ÚfiÓÔ, ÁÈ· ÂÓË̤ڈÛË Î·È Â˘·ÈÛıËÙÔÔ›ËÛË, ÙfiÛÔ ÙˆÓ ˘Â‡ı˘ÓˆÓ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘, fiÛÔ Î·È Ù˘ ÎÔÈÓˆÓ›·˜ ÁÂÓÈÎfiÙÂÚ· (10). ∆Ô 1997 ηıÈÂÚÒıËÎ·Ó ÛÂÌÈÓ¿ÚÈ· 40 ˆÚÒÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi, 2 ÊÔÚ¤˜ ÙÔ ¯ÚfiÓÔ ÁÈ· ·È‰›·ÙÚÔ˘˜, Ì·›Â˜ Î·È ¿ÏÏÔ˘˜ ·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜ Ô˘ ˘ËÚÂÙÔ‡Ó Û ‰ËÌfiÛÈ· ȉڇ̷ٷ, ÒÛÙ ӷ Á›ÓÔ˘Ó ˘Ú‹Ó˜ Âη›‰Â˘Û˘ ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ÂÚÁ·Û›·˜ ÙÔ˘˜ (11). ∂›Û˘, ηıÈÂÚÒıËΠÂÙ‹ÛÈ· ËÌÂÚ›‰· ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Ì ¢ÈÂıÓ‹ ™˘ÌÌÂÙÔ¯‹ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ∂·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜. ∞ÎfiÌË, Â›Ó·È ÁÓˆÛÙfi fiÙÈ Û οı ÂÈÛÙËÌÔÓÈ΋ ·È‰È·ÙÚÈ΋ Û˘Ó¿ÓÙËÛË Î·È Û˘Ó¤‰ÚÈÔ Á›ÓÔÓÙ·È ·Ó·ÎÔÈÓÒÛÂȘ Î·È ·Ó·ÊÔÚ¤˜ ÛÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi. ∆Ô 1998 ¤ÁÈÓ ÂÚÒÙËÛË ÛÙËÓ µÔ˘Ï‹ ·) ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ÏËÚÔÊfiÚËÛ˘ Î·È Âη›‰Â˘Û˘ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi ·fi ÙÔ ÓËÈ·ÁˆÁÂ›Ô ˆ˜ ÙËÓ ∞ÓÒÙ·ÙË ∂η›‰Â˘ÛË, ‚) ÁÈ· ‰˘Ó·ÙfiÙËÙ· ı¤ÛÈÛ˘ ¢ÂÚÁÂÙÈ΋˜ ÓÔÌÔıÂÛ›·˜ ÁÈ· ÙËÓ ÂÚÁ·˙fiÌÂÓË ÌËÙ¤Ú· Ô˘ ıËÏ¿˙ÂÈ Î·È Á) ÁÈ· ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎÔÈÓÔ‡ Ì ٷ ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘. ∆Ô 1999 ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÚÔ˜ fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· Ó· ÙËÚÂ›Ù·È Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ∆ÔÓ ›‰ÈÔ ¯ÚfiÓÔ Â›Û˘, „ËÊ›ÛÙËΠÓfiÌÔ˜ Û‡Ìʈӷ Ì ÙÔÓ ÔÔ›Ô Ë ÁÔÓÈ΋ ¿‰ÂÈ· ¤ÁÈÓ ¤Ó·˜ ¯ÚfiÓÔ˜, Ì ϋÚÂȘ ·Ô‰Ô¯¤˜ Ù˘ ÂÚÁ·˙fiÌÂÓ˘ ÌËÙ¤Ú·˜. ∏ ·Í›· ·˘ÙÒÓ fï˜, ı· ‹Ù·Ó ÛËÌ·ÓÙÈ΋ ¿Ó
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fiÏ· ·˘Ù¿ ÂÊ·ÚÌfi˙ÔÓÙ·Ó. ŸÏÔÈ Í¤ÚÔ˘Ì fiÙÈ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” Û˘Ó¯Ҙ ·Ú·‚È¿˙ÂÙ·È Â›ÛËÌ· Î·È ·Ó›ÛËÌ·. ∆Ô ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜ ¤ÛÙÂÈÏ ÙËÓ ÂÁ·ÎÏÈÔ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µ‹Ì·ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” ÙÔ 1995. ™‹ÌÂÚ·, ¤ÓÙ ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ù· ª·ÈÂ˘Ù‹ÚÈ· Ô˘ ÂÊ·ÚÌfi˙Ô˘Ó ¤ÛÙˆ Î·È ÌÂÚÈο ·fi Ù· ‚‹Ì·Ù· Â›Ó·È ÂÏ¿¯ÈÛÙ·. ∏ ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ‰ÂÓ Â›Ó·È ı¤Ì· ·Ïfi. ÃÚÂÈ¿˙ÂÙ·È ÛˆÛÙ‹ ÂÓË̤ڈÛË, Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ ÊÔÚ¤ˆÓ, ·ÓȉÈÔÙ¤ÏÂÈ·, ·ÓıÚÒÈÓË Â·Ê‹ Î·È Î˘Ú›ˆ˜ ·Ó·ÁÓÒÚÈÛË Ù˘ ÛÔ˘‰·ÈfiÙËÙ¿˜ ÙÔ˘ ÁÈ· ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. ∞fi‰ÂÈÍË Ù˘ ·Ó·ÁÓÒÚÈÛ˘ Ù˘ ÛÔ˘‰·ÈfiÙËÙ·˜ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È Î·È Ë ·ÔÓÔÌ‹ ÙÔ 1998, ·ÚÂÌÊÂÚÔ‡˜ ‚Ú·‚›Ԣ Nobel, (Ô˘ ηıÈÂÚÒıËΠÁÈ· ÙË ‚Ú¿‚¢ÛË ·ÙfiÌˆÓ ‹ ÔÚÁ·ÓÈÛÌÒÓ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó Ì ÙÔ ¤ÚÁÔ ÙÔ˘˜ ÛÙÔ Î·Ïfi Ù˘ ·ÓıÚˆfiÙËÙ·˜), Û ÌË ∫˘‚ÂÚÓËÙÈÎfi OÚÁ·ÓÈÛÌfi, ÛÙÔ International Baby Food Action Network (¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô µÚÂÊÈÎÒÓ ∆ÚÔÊÒÓ), ÁÈ·Ù› › 15 ¯ÚfiÓÈ· Ì¿¯ÂÙ·È ÁÈ· ÙËÓ Ù‹ÚËÛË ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” (12). °ÓˆÚ›˙ÔÓÙ·˜ ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙÔÓ ÙfiÔ Ì·˜ Î·È ¤¯ÔÓÙ·˜ Ù· ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·Ó¿ÌÂÛ· Û ¿ÏϘ ¯ÒÚ˜, ı· ¤Ú ӷ ÁÓˆÚ›˙Ô˘Ì Û ÙÈ ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ·˘Ù‹ Ë ı¤ÛË. ¶·Ú’ fiÏ· ·˘Ù¿, ÚfiÛÊ·Ù· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi Â›Â‰Ô ÛÙÔÓ ÙfiÔ Ì·˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó. ∆· ÙÂÏÂ˘Ù·›· Â›Ó·È ÙÔ˘ 1990. ∂Ô̤ӈ˜, ÚˆÙ·Ú¯ÈÎfi Ì·˜ ̤ÏËÌ· ı· ‹Ù·Ó Ó· ÍÂÎÈÓ‹ÛÂÈ ÌÈ· ¶·ÓÂÏÏ‹ÓÈ· ŒÚ¢ӷ ÁÈ· Ù· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi ›‰Ô. ŒÂÈÙ·, Û˘ÓÂȉËÙÔÔÈÒÓÙ·˜ ÙËÓ Ù˘¯fiÓ ·Ó¿ÚÎÂÈ¿ Ì·˜, ÌÔÚԇ̠ӷ ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ì ηٿÏÏËϘ Û˘Óı‹Î˜ ÚÔ·ÁˆÁ‹˜ ÙÔ˘ Ì ·fiÏ˘ÙË ÁÓÒÛË ÙˆÓ È‰ÈÔÙ‹ÙˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ·Ú·ÁˆÁ‹˜ ÙÔ˘, ÙˆÓ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡, ÙˆÓ ÎÈÓ‰‡ÓˆÓ Ù˘ Ù¯ÓÈ΋˜ ‰È·ÙÚÔÊ‹˜ Î·È Ù˘ ÛˆÛÙ‹˜ ÔÏÈÙÈ΋˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ªfiÓÔ ÙfiÙÂ, ÔÈ ÌËÙ¤Ú˜ ı· ÌÔÚ¤ÛÔ˘Ó Ì ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Ó· ıÂÌÂÏÈÒÛÔ˘Ó ÙË ÛˆÌ·ÙÈ΋, ÓÂ˘Ì·ÙÈ΋ Î·È „˘¯È΋ ˘Á›· ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜.
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µÈ‚ÏÈÔÁÚ·Ê›· 1. International Code of Marketing of Breast Milk Substitutes. W.H.O. & UNICEF World Health Assembly; 1981. 2. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Statement W.H.O. & UNICEF, Geneva; 1989. 3. Innocenti Declaration on Protecting, Promoting and Supporting Breastfeeding. W.H.O., UNICEF, S.I.D.A, A.I.D USA, Florence; 1990. 4. Baby-Friendly Hospital Initiative. W.H.O. & UNICEF; 1992. World Breastfeeding Week. W.A.B.A. (World Alliance for Breastfeeding Action); 1992. Mother-Friendly Work Place Initiative. W.H.O. & UNICEF; 1993. 5. Healthy People 2000. National and Human Services, U.S Department of Health and Human Services, Public Health Services Publication. No (PHS) 91-50213. 6. ∂Ê·ÚÌÔÁ‹ ¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ÀÁÈÂÈÓ‹˜, °Ú·ÊÂ›Ô ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜. ∞¶. 23630 9/11/1983. 7. OÚÁ·ÓÈÛÌfi˜ ¡ÔÛÔÎÔÌ›Ԣ ª·È¢ÙËÚ›Ô˘ Ô˘ ȉڇıËΠ̠ÙÔ .‰/ÁÌ· 321/85 ∞Ú. ∞3‚. ∂ÊËÌÂÚ›‰· Ù˘ ∫˘‚ÂÚÓ‹Ûˆ˜ Ù˘ ∂ÏÏËÓÈ΋˜ ¢ËÌÔÎÚ·Ù›·˜. ∞Ú. Ê˘Ï. 47; 29/1/1990. 8. ™‡ÛÙ·ÛË ∂ıÓÈ΋˜ ∂ÈÙÚÔ‹˜ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 5311; 20/7/1993. 9. ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ - ·Ó·Ê·›ÚÂÙÔ ‰Èη›ˆÌ· οı ÓÂÔÁ¤ÓÓËÙÔ˘. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 3618; 9/10/1995. 10. ∫·ıȤڈÛË ÂÔÚÙ·ÛÌÔ‡ ¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ÛÙË ¯ÒÚ· Ì·˜. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 3756; 28/8/1996. 11. ∂Î·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi: 1-7 ¡ÔÂÌ‚Ú›Ô˘ 1997. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 5019; 8/9/1997. 12. Breastfeeding N.G.O wins alternative Nobel Prize. B.F.H.I. Newsletter; 9/12/1998.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: £¤ÌȘ ∑¿¯Ô˘ §ÂˆÊ. ∞ÏÂÍ¿Ó‰Ú·˜ 201, 115 23, ∞ı‹Ó·
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Paediatriki 2001;64:304-307
ASSOCIATED SUBSPECIALTIES
∆Ú·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ‰ÔÓÙÈÒÓ §. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë
Dental injuries L. Papagiannouli - Laskaridi
¶ÂÚ›ÏË„Ë: ∏ ÂÚÁ·Û›· ·˘Ù‹ Ú·ÁÌ·Ù‡ÂÙ·È ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ ‰ÔÓÙÈÒÓ Î·È ÙˆÓ ÂÚÈÔ‰ÔÓÙÈÎÒÓ ÈÛÙÒÓ. ∂ȉÈÎfiÙÂÚ· ÂÚÈÁÚ¿ÊÂÈ Ù· ›‰Ë ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ‰ÔÓÙÈÒÓ Î·È ÙˆÓ ÂÚÈÔ‰ÔÓÙÈÎÒÓ ÈÛÙÒÓ, ÙÔÓ›˙ÂÈ ÙËÓ ¿ÌÂÛË ÂͤٷÛË Î·È ıÂڷ›· ÙÔ˘ ·ÛıÂÓ‹ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ›· ÁÈ· οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∆¤ÏÔ˜, ·Ó·Ê¤ÚÔÓÙ·È Ù· ÚÔÏËÙÈο ̤ÙÚ· ÁÈ· ÙË Ì›ˆÛË ‹ ÂÍ¿ÏÂÈ„Ë ÙÔ˘ Ô‰ÔÓÙÈÎÔ‡ ÙÚ·˘Ì·ÙÈÛÌÔ‡.
Abstract: This paper deals with the injuries of the teeth as well as the periodontal tissue injuries. More specifically, the paper describes each type of injury, emphasizes the need for immediate examination and treatment of the patient and presents the appropriate treatment for each type of injury. Finally, it reports the preventive measures to reduce or eliminate dental trauma (in children and adolescents).
§¤ÍÂȘ ÎÏÂȉȿ: Ô‰ÔÓÙÈÎfi˜ ÙÚ·˘Ì·ÙÈÛÌfi˜, ıÂڷ›·, ÚfiÏË„Ë.
Key words: dental injuries, treatment, prevention.
Ÿˆ˜ Û οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ¤ÙÛÈ Î·È ÛÙÔ Ô‰ÔÓÙÈÎfi ÙÚ·‡Ì· ¤Ó· Û¯ÔÏ·ÛÙÈÎfi ÈÛÙÔÚÈÎfi Â›Ó·È ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË Ì›·˜ ÛˆÛÙ‹˜ ‰È¿ÁÓˆÛ˘ Î·È ıÂڷ›·˜ (1,2). ∏ ·ÍÈÔÏfiÁËÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡ Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ë ‰È¿ÁÓˆÛË ¿ÏÏˆÓ Èı·ÓÒÓ Î·ÎÒÛˆÓ, ȉȷ›ÙÂÚ· ·˘ÙÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ∫¡™ (ÂÁÎÂÊ·ÏÈ΋ ‰È¿ÛÂÈÛË, ˘ÔÛÎÏËÚ›‰ÈÔ ·È̿و̷, ·ÈÌÔÚÚ·Á›·), ÚÔËÁÔ‡ÓÙ·È Î¿ı ¿ÏÏ˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. O ÎÏÈÓÈÎfi˜ Ú¤ÂÈ Ó· ¤¯ÂÈ ˘„ËÏfi ‚·ıÌfi ˘Ô„›·˜ ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ Ó· ÔÊ›ÏÂÙ·È Û ηÎÔÔ›ËÛË ÙÔ˘ ·È‰ÈÔ‡. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô ÁÈ· Èı·Ó¿ ηٿÁÌ·Ù· ÛÙ· ÔÛÙ¿ Ù˘ ÎÂÊ·Ï‹˜ Î·È ÙÔ˘ ÙÚ·¯‹ÏÔ˘, ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ Ì·Ï·ÎÒÓ ÈÛÙÒÓ ÙÔ˘ ÚÔÛÒÔ˘, ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È ÙˆÓ ·ÚıÚÒÛˆÓ. ™ÙËÓ ÂÓ‰ÔÛÙÔÌ·ÙÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È, ÏËÓ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ‰ÔÓÙÈÔ‡ Î·È ÔÈ ¤ÚÈÍ ÈÛÙÔ› ÁÈ· Èı·ÓfiÙËÙ· ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡. O ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È ··Ú·›ÙËÙÔ˜ Û οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ (1-3).
∞ÓÙÈÌÂÙÒÈÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÌfiÓÈÌˆÓ ‰ÔÓÙÈÒÓ 1. ∆Ú·˘Ì·ÙÈÛÌfi˜ ÛÎÏËÚÒÓ ÈÛÙÒÓ ‰ÔÓÙÈÔ‡-ÔÏÊÔ‡ ™Â ÂÚ›ÙˆÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ Ù˘ ̇Ï˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ (·‰·Ì·ÓÙ›Ó˘-Ô‰ÔÓÙ›Ó˘), ··Ú·›ÙËÙË Â›Ó·È Ë ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ì ڈٷگÈÎfi ÛÎÔfi ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÔÏÊÔ‡. Œ¯ÂÈ ‚ÚÂı› ˆ˜ Ë ¤ÎıÂÛË 1 mm Ô‰ÔÓÙ›Ó˘ ¤¯ÂÈ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÔÎ¿Ï˘„Ë 20.000-45.000 Ô‰ÔÓÙÈÓÔÛˆÏËÓ·Ú›ˆÓ ̤ۈ ÙˆÓ ÔÔ›ˆÓ ÌÈÎÚfi‚È· Î·È ÂÚÂı›ÛÌ·Ù· ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ıÂÚÌÈο, ¯ËÌÈο ÌÂٷʤÚÔÓÙ·È ÛÙÔÓ ÔÏÊfi, Ì ·ÔÙ¤ÏÂÛÌ· Ë ˘Á›· ÙÔ˘ ÔÏÊÔ‡ Ó· Ù›ıÂÙ·È Û ΛӉ˘ÓÔ (1). ∞Ó ÙÔ ÙÌ‹Ì· ÙÔ˘ ‰ÔÓÙÈÔ‡ Ô˘ ·ÔÛ¿ÛÙËΠ‰ÂÓ ·ÔηٷÛÙ·ı› ¿ÌÂÛ·, ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ÊÏÂÁÌÔÓ‹˜ ‹ Î·È Ó¤ÎÚˆÛ˘ ÙÔ˘ ÔÏÊÔ‡. ™‹ÌÂÚ· Ì ٷ ˘ÏÈο ·ÈÛıËÙÈÎÒÓ ·ÔηٷÛÙ¿ÛÂˆÓ Ô˘ ‰È·ı¤ÙÂÈ Ô Ô‰ÔÓÙ›·ÙÚÔ˜, Â›Ó·È ‰˘Ó·Ù‹ Ë ·fi‰ÔÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Î·È Ù˘ ·ÈÛıËÙÈ΋˜ ÙˆÓ ‰ÔÓÙÈÒÓ Û ̛· ÌfiÓÔ Â›Û΄Ë. ∏ ·Ó·ÁηÈfiÙËÙ· Ù˘ ¿ÌÂÛ˘ ·ÔηٿÛÙ·Û˘ ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ‰ÔÓÙÈÒÓ ˘·ÁÔÚ‡ÂÙ·È Î·È ·fi „˘¯ÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘, ÁÈ· ¢ÓfiËÙÔ˘˜ ÏfiÁÔ˘˜, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊË‚È΋˜
√‰ÔÓÙÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¢È¢ı‡ÓÙÚÈ· ∂ÚÁ·ÛÙËÚ›Ô˘ ¶·È‰Ô‰ÔÓÙÈ·ÙÚÈ΋˜
Athen’s University Dental School Director of Pediatric Dentistry Laboratory
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¶·È‰È·ÙÚÈ΋ 2001;64:304-307
ËÏÈΛ·˜ Â›Ó·È ÈÔ ÛËÌ·ÓÙÈÎÔ›. ™Â ÂÚ›ÙˆÛË Î·Ù¿ÁÌ·ÙÔ˜ Ù˘ ̇Ï˘, Ôχ ÛËÌ·ÓÙÈÎfi Â›Ó·È Ó· ‚ÚÂı› Î·È Ó· Ê˘Ï·¯Ù› Û ÓÂÚfi ÙÔ Û·Ṳ̂ÓÔ ÎÔÌÌ¿ÙÈ ÙÔ˘ ‰ÔÓÙÈÔ‡. ªÂ Ù· Û‡Á¯ÚÔÓ· Û˘ÁÎÔÏÏËÙÈο ˘ÏÈο Â›Ó·È ‰˘Ó·Ù‹, Ê˘ÛÈο οو ·fi ÔÚÈṲ̂Ó˜ ÚÔ¸Ôı¤ÛÂȘ, Ë Â·Ó·Û˘ÁÎfiÏÏËÛË ÙÔ˘ Û·Ṳ̂ÓÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (2). ™Â ÂÚÈÙÒÛÂȘ ηٷÁÌ¿ÙˆÓ ‰ÔÓÙÈÒÓ Î·È Ù·˘Ùfi¯ÚÔÓÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÙÔ˘ ÚÔÛÒÔ˘, ı· Ú¤ÂÈ, ·Ó ‰ÂÓ ‚ÚÂı› ÙÔ Û·Ṳ̂ÓÔ ÎÔÌÌ¿ÙÈ ÙÔ˘ ‰ÔÓÙÈÔ‡, Ó· Á›ÓÂÙ·È ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Î·È ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÁÈ· Ù˘¯fiÓ ÂÓÛÊ‹ÓˆÛ‹ ÙÔ˘ ÛÙÔ˘˜ Ì·Ï·ÎÔ‡˜ ÈÛÙÔ‡˜. ™Â ÂÚÈÙÒÛÂȘ ηٿÁÌ·ÙÔ˜ Ù˘ ̇Ï˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙÔÓ ÔÏÊfi, ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ÔÎ¿Ï˘„˘ Î·È ÙÔ ¯ÚfiÓÔ Ô˘ ÌÂÛÔÏ¿‚ËÛ ̤¯ÚÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, Ë ıÂڷ›· ÔÈΛÏÏÂÈ ·fi ·Ï‹ Î¿Ï˘„Ë ÙÔ˘ ÔÏÊÔ‡ ̤¯ÚÈ Î·È ÂÓ‰Ô‰ÔÓÙÈ΋ ıÂڷ›· (·ÔÓ‡ڈÛË). ¢fiÓÙÈ· Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ¤ÁηÈÚ· ÌÔÚ› Ó· ÓÂÎÚˆıÔ‡Ó, Ì ÌÔÓ·‰ÈÎfi Û‡Ìو̷ ÔÏϤ˜ ÊÔÚ¤˜ ÙËÓ ·ÏÏ·Á‹ ÙÔ˘ ¯ÚÒÌ·ÙÔ˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (1-3). ™‹ÌÂÚ·, ÂÎÙÂٷ̤ӷ ηٿÁÌ·Ù· Ù˘ ̇Ï˘ ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Û˘ÓÙËÚËÙÈο, Ì ˘ÏÈο Ô˘ ·Ô‰›‰Ô˘Ó ÈηÓÔÔÈËÙÈο ÙÔ ¯ÚÒÌ· Î·È ÙÔ Û¯‹Ì· ÙÔ˘ ‰ÔÓÙÈÔ‡. ∂ÓÙÔ‡ÙÔȘ, ÌÂÚÈΤ˜ ÊÔÚ¤˜ ··ÈÙÂ›Ù·È ÚÔÛıÂÙÈ΋ ·ÔηٿÛÙ·ÛË, ‰ËÏ. ÔÏÈ΋ Î¿Ï˘„Ë Ù˘ ̇Ï˘ Ì ̛· ÛÙÂÊ¿ÓË ÎÂÚ·ÌÈ΋ ‹ ÌÂÙ·ÏÏÔÎÂÚ·ÌÈ΋ (ÔÚÛÂÏ¿ÓË). O ÈÔ ÛÔ‚·Úfi˜ Î·È ÂÈΛӉ˘ÓÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ ÙˆÓ ‰ÔÓÙÈÒÓ Â›Ó·È Ù· ηٿÁÌ·Ù· Ù˘ Ú›˙·˜, ȉȷ›ÙÂÚ· ·Ó ‰ÂÓ ‰È·ÁÓˆÛÙÔ‡Ó ¤ÁηÈÚ· Î·È ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛıÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈο (2). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù¤ÙÔÈˆÓ Î·Ù·ÁÌ¿ÙˆÓ Û˘Ó›ÛÙ·Ù·È Û ·ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ‰ÔÓÙÈÒÓ ÁÈ· 2-3 Ì‹Ó˜ Ì ÂȉÈÎfi Ó¿ÚıËη. ™Â Ù¤ÙÔȘ ÂÚÈÙÒÛÂȘ, Ë ÚfiÁÓˆÛË Ù˘ ‰È·Ù‹ÚËÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ı¤ÛË ÙÔ˘ ηٿÁÌ·ÙÔ˜, ·fi ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È ÙÔ ‚·ıÌfi ÂÎÙfiÈÛ˘ ÙˆÓ Î·Ù·ÁfiÙˆÓ ÙÌËÌ¿ÙˆÓ, ·fi ÙÔ ÛÙ¿‰ÈÔ ‰È¿Ï·Û˘ Ù˘ Ú›˙·˜ Î·È ·fi ÙËÓ ÔÈfiÙËÙ· Ù˘ ıÂڷ›·˜. 2. ∆Ú·˘Ì·ÙÈÛÌfi˜ ‰ÔÓÙÈÔ‡ ÌÂ Û˘ÌÌÂÙÔ¯‹ Î·È ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘ O ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ·ÎfiÏÔ˘ı˜ ÂÚÈÙÒÛÂȘ: ·) ¢È¿ÛÂÈÛË ‹ ÙÚ¿ÓÙ·ÁÌ· ¯ˆÚ›˜ ÙËÓ ‡·ÚÍË ÎÈÓËÙÈÎfiÙËÙ·˜ ‹ ÂÎÙfiÈÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ Ê·ÙÓ›Ô. ‚) ∫ÈÓËÙÈÎfiÙËÙ· ¯ˆÚ›˜ ÌÂÙ·ÙfiÈÛË ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ™ÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ Û˘ÓÈÛÙ¿Ù·È Ì·Ï·Î‹ ‰È·ÙÚÔÊ‹ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡. ™Â ÂÚ›ÙˆÛË Ô˘ ηٿ ÙË Û‡ÁÎÏÂÈÛË Ì ٷ ‰fiÓÙÈ· ÙÔ˘ ·ÓÙ›ıÂÙÔ˘ ÊÚ·ÁÌÔ‡ (·ÓÙ·ÁˆÓÈÛÙ¤˜) ˘¿Ú¯ÂÈ
Paediatriki 2001;64:304-307
›ÂÛË ÛÙ· ÙÚ·˘Ì·ÙÈṲ̂ӷ ‰fiÓÙÈ·, Á›ÓÂÙ·È ÂÎÏÂÎÙÈÎfi˜ ÙÚÔ¯ÈÛÌfi˜ ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ. Á) ¶Ï¿ÁÈ· ÌÂÙ·ÙfiÈÛË Î·È ÂÎÙfiÈÛË ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ÂÈ‚¿ÏÏÂÙ·È Ë Â·Ó·ÙÔÔı¤ÙËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË Ô˘ ›¯Â ÛÙÔ Ê·ÙÓ›Ô ÚÈÓ ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi Î·È Ë ·ÎÈÓËÙÔÔ›ËÛ‹ ÙÔ˘ Ì ÂȉÈÎfi Ó¿ÚıËη. ‰) ∂Ì‚‡ıÈÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ̤۷ ÛÙÔ Ê·ÙÓ›Ô. O ÙÚ·˘Ì·ÙÈÛÌfi˜ ·˘Ùfi˜ Û˘Óԉ‡ÂÙ·È ·fi Û‡ÓıÏÈ„Ë ‹ οٷÁÌ· ÙÔ˘ Ê·ÙÓ›Ô˘. ∏ ÂÌ‚‡ıÈÛË ÌÔÚ› Ó· Â›Ó·È ÌÂÚÈ΋ ‹ ÔÏÈ΋. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Á›ÓÂÙ·È Ë ÚÔԉ¢ÙÈ΋ Î·È ÂÏÂÁ¯fiÌÂÓË Â·Ó·ÊÔÚ¿ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË ÙÔ˘ ÛÙÔ ÊÚ·ÁÌfi Ì ÔÚıÔ‰ÔÓÙÈΤ˜ ‰˘Ó¿ÌÂȘ. OÈ ÈÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙËÓ ÂÌ‚‡ıÈÛË Â›Ó·È Ë Ó¤ÎÚˆÛË ÙÔ˘ ÔÏÊÔ‡ Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ·ÔÚÚfiÊËÛË Ù˘ Ú›˙·˜ (Â͈ÙÂÚÈ΋ ‹ ÂÛˆÙÂÚÈ΋), ÂÓ·Û‚ÂÛÙ›ˆÛË ÙÔ˘ ÔÏÊÔ‡, ·ÎfiÌ· Î·È ·ÒÏÂÈ· Ù˘ ÛÙ‹ÚÈ͢ ÙÔ˘ ‰ÔÓÙÈÔ‡ (Ê·ÙÓÈÔÏ˘Û›·). Â) ªÂÚÈ΋ ÂÎÁfiÌʈÛË ·fi ÙÔ Ê·ÙÓ›Ô. ∏ ÂÚ›ÙˆÛË ·˘Ù‹ ÙÚ·˘Ì·ÙÈÛÌÔ‡ Â›Ó·È Ë ·ÓÙ›ıÂÙË ·fi ÙËÓ ÚÔËÁÔ‡ÌÂÓË, ‰ËÏ. Ë ÌÂÚÈ΋ ¤ÍÔ‰Ô˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ Ê·ÙÓ›Ô Î·È ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙËÓ ¿ÌÂÛË Â·Ó·ÊÔÚ¿ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË ÙÔ˘ ÂÓÙfi˜ ÙÔ˘ Ê·ÙÓ›Ô˘ Î·È ÙËÓ ·ÎÈÓËÙÔÔ›ËÛ‹ ÙÔ˘ Ì ӿÚıËη. ™Â ÔÚÈṲ̂Ó˜ fï˜ ÂÚÈÙÒÛÂȘ, fiÙ·Ó ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ Â·Ó·ÊÔÚ¿ ‹ fiÙ·Ó Ë ·ÓÙÈÌÂÙÒÈÛË Á›ÓÂÈ ÌÂÙ¿ ¿ÚÔ‰Ô ÔÏÏÒÓ ˆÚÒÓ ‹ ËÌÂÚÒÓ, ÂӉ›ÎÓ˘Ù·È Ë Â·Ó·ÊÔÚ¿ Ì ÔÚıÔ‰ÔÓÙÈΤ˜ ‰˘Ó¿ÌÂȘ. ∫·È Û’·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ˘Ê›ÛÙ·Ù·È Ô Î›Ó‰˘ÓÔ˜ ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÚԷӷʤÚıËηÓ. ÛÙ) OÏÈ΋ ÂÎÁfiÌʈÛË. ∆Ô ÈÔ ‰Ú·Ì·ÙÈÎfi ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ Â›Ó·È Ë ÔÏÈ΋ ÂÎÁfiÌʈÛË, ‰ËÏ. Ë ÔÏÈ΋ ¤ÍÔ‰Ô˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÔÏÈ΋˜ ÂÎÁfiÌʈÛ˘ ·ÔÙÂÏ› ÂÚ›Ô˘ ÙÔ 3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜, Â›Ó·È ‰Â Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Û˘ÌÏÔÎÒÓ, ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ‹ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù¿ ÙȘ ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ (1-3). ™˘¯ÓfiÙÂÚ· ·ÊÔÚ¿ ¤Ó· ‰fiÓÙÈ, ˘¿Ú¯Ô˘Ó fï˜ ÂÚÈÙÒÛÂȘ ÂÌÏÔ΋˜ Î·È ÂÚÈÛÛÔÙ¤ÚˆÓ ‰ÔÓÙÈÒÓ. ™˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-10 ¯ÚfiÓˆÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· ‰ËÏ. Ù˘ ·Ó·ÙÔÏ‹˜ ÙˆÓ ÙÔ̤ˆÓ ‰ÔÓÙÈÒÓ Î·È ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ (ÂÚÈÔ‰fiÓÙÈÔ) ‰ÂÓ ¤¯ÂÈ ÔÚÁ·Óˆı›, Ì ·ÔÙ¤ÏÂÛÌ· Ë ‰ÔÌ‹ ÙÔ˘ Ó· Â›Ó·È ¯·Ï·Ú‹. ∆· ‰fiÓÙÈ· Ô˘ ÈÔ Û˘¯Ó¿ ÂÎÁÔÌÊÒÓÔÓÙ·È Â›Ó·È ÔÈ ÎÂÓÙÚÈÎÔ› ÙÔÌ›˜ Ù˘ ¿Óˆ ÁÓ¿ıÔ˘. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÎÁfiÌʈÛ˘ Â›Ó·È Ë ¿ÌÂÛË Â·Ó·ÙÔÔı¤ÙËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙÔ Ê·ÙÓ›Ô (·ÓÂÌʇÙ¢ÛË). ∆Ô ÎÏÂȉ› Ù˘ ÂÈÙ˘¯›·˜ Ù˘ ·ÓÂÌʇÙ¢Û˘ Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ù˘ ˙ˆÙÈÎfiÙËÙ·˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘. O
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¯ÚfiÓÔ˜ Ô˘ ·Ú·Ì¤ÓÂÈ ÙÔ ‰fiÓÙÈ ÂÎÙfi˜ Ê·ÙÓ›Ô˘ Î·È Ô ÙÚfiÔ˜ ‰È·Ù‹ÚËÛ‹˜ ÙÔ˘ Â›Ó·È ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ Û˘ÓÙÂÏÂÛÙ¤˜ ÂÈÙ˘¯›·˜ Ù˘ ·ÓÂÌʇÙ¢Û˘. ∆Ô È‰·ÓÈÎfiÙÂÚÔ Â›Ó·È ÙÔ ‰fiÓÙÈ Ó· ÙÔÔıÂÙËı› Í·Ó¿ ÛÙË ı¤ÛË ÙÔ˘ ̤۷ ÛÙÔ Ê·ÙÓ›Ô ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÎÁfiÌʈÛË ·fi ÙÔÓ ÙÚ·˘Ì·Ù›· ‹ οÔÈÔ ¿ÏÏÔ ¿ÙÔÌÔ Î·È Ó· Û˘ÁÎÚ·ÙÂ›Ù·È ÛÙË ı¤ÛË ÙÔ˘ Ì ̛· Á¿˙· ‹ Ì·ÓÙ‹ÏÈ. ∆Ô Ê·ÙÓ›Ô Â›Ó·È ÙÔ Î·Ï‡ÙÂÚÔ Ì¤ÛÔ ÌÂÙ·ÊÔÚ¿˜ ̤¯ÚÈ Ó· Êı¿ÛÂÈ Ô ·ÛıÂÓ‹˜ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚ›Ô. ¢˘ÛÙ˘¯Ò˜ fï˜ ·˘Ùfi Û˘Ì‚·›ÓÂÈ Û¿ÓÈ·. ™˘Ó‹ıˆ˜ Ô ÙÚ·˘Ì·Ù›·˜ ÔÓ¿, ‰ÂÓ Â›Ó·È Û˘ÓÂÚÁ¿ÛÈÌÔ˜ Î·È Ô‡Ù ·˘Ùfi˜ Ô‡Ù ηÓ›˜ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ (ÁÔÓ›˜, ‰¿ÛηÏÔ˜, ÚÔÔÓËÙ‹˜ Û ·ıÏԷȉȤ˜) ÙÔÏÌ¿ Ó· οÓÔ˘Ó ÙËÓ Â·ÓÂÌʇÙ¢ÛË. ∂ÈϤÔÓ, Û˘¯Ó¿ ÊÔ‚Ô‡ÓÙ·È ÙÔ ·›Ì·, ÌË Ù˘¯fiÓ ÎÔÏÏ‹ÛÔ˘Ó Î¿ÔÈ· ÌÂÙ·‰ÔÙÈ΋ ·Ûı¤ÓÂÈ·, ‹ ÌËÓ ÚÔηϤÛÔ˘Ó ÂÈϤÔÓ ÙÚ·˘Ì·ÙÈÛÌfi. ™Â ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ Á›ÓÂÙ·È ¿ÌÂÛË Â·ÓÂÌʇÙ¢ÛË, ÙÔ ‰fiÓÙÈ Ú¤ÂÈ Ó· ‰È·ÙËÚËı› ̤¯ÚÈ ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚ›Ô, ¤ÙÛÈ ÒÛÙ ӷ ÚÔÎÏËı› Ô ÌÈÎÚfiÙÂÚÔ˜ ‰˘Ó·Ùfi˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘. ™˘ÁÎÂÎÚÈ̤ӷ, Ú¤ÂÈ Ó· Û˘ÁÎÚ·ÙÂ›Ù·È ·fi ÙË Ì‡ÏË Ì ÚÔÛÔ¯‹ Ó· ÌËÓ ÂÈÚ·¯ı› Ë Ú›˙· Î·È Ó· ηı·ÚÈÛÙ›, Ì ÓÂÚfi ¯ˆÚ›˜ ÈÛ¯˘Ú‹ ›ÂÛË, Ó· ÙÔÔıÂÙËı› Û ¤Ó· ÌÈÎÚfi ‰Ô¯Â›Ô Ì Á¿Ï· ‹ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ‹ Û¿ÏÈÔ. ∆· ηχÙÂÚ· ˘ÁÚ¿ ÌÂÙ·ÊÔÚ¿˜ ıˆÚÔ‡ÓÙ·È ÙÔ ‰È¿Ï˘Ì· Hank (Hank’s solution) Î·È ÙÔ Á¿Ï· (1,2). ŸÙ·Ó ÊÙ¿ÛÂÈ Ô ·ÛıÂÓ‹˜ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚÂ›Ô Î·È ·ÊÔ‡ ÂÍ·ÎÚÈ‚ˆı› Ì ÙÔ ÈÛÙÔÚÈÎfi Î·È Ì›· ηϋ ÎÏÈÓÈ΋ Î·È ·ÎÙÈÓÔÁÚ·ÊÈ΋ ÂͤٷÛË fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÏÏÔ˜ ÛÔ‚·ÚfiÙÂÚÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ Ù˘ ÎÂÊ·Ï‹˜ ‹ ÙÔ˘ ·˘¯¤Ó·, Ô Ô‰ÔÓÙ›·ÙÚÔ˜ ÙÔ Â·Ó·ÙÔÔıÂÙ› Î·È ÙÔ ·ÎÈÓËÙÔÔÈ› Ì ÂȉÈÎfi Ó¿ÚıËη ÁÈ· 7-10 Ë̤Ú˜ ÂÚ›Ô˘. À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ›‰Ë Ó¿ÚıËη ÁÈ· ·ÎÈÓËÙÔÔ›ËÛË ‰ÔÓÙÈÔ‡. ¶ÚÔÙÈÌÒÓÙ·È ÔÈ Ó¿ÚıËΘ Ô˘ Â›Ó·È ÛÙ·ıÂÚÔ›, ·ÏÏ¿ Û˘Á¯ÚfiÓˆ˜ ÂÍ·ÛÊ·Ï›˙Ô˘Ó Ì›· ÌÈÎÚ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ÛÙÔ ‰fiÓÙÈ. OÈ Ó¿ÚıËΘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·fi ÙÔ˘˜ ÁÓ·ıÔ¯ÂÈÚÔ˘ÚÁÔ‡˜ ÁÈ· ·ÎÈÓËÙÔÔ›ËÛË ‰ÔÓÙÈÒÓ Û ÂÚ›ÙˆÛË Î·Ù·ÁÌ¿ÙˆÓ ÙˆÓ ÁÓ¿ıˆÓ ·ÓÙÂӉ›ÎÓ˘ÓÙ·È. ∆¤ÙÔÈÔÈ ¿Î·ÌÙÔÈ Ó¿ÚıËΘ Ô˘ Û˘Ó‹ıˆ˜ ÙÔÔıÂÙÔ‡ÓÙ·È ÁÈ· ÌÂÁ¿Ï· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÚÔηÏÔ‡Ó ·Á·ψÛË Î·È ·ÔÚÚfiÊËÛË Ù˘ Ú›˙·˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (2,3). ∏ ÚfiÁÓˆÛË Ù˘ ‰È·Ù‹ÚËÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ Â›Ó·È Û˘Ó¿ÚÙËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÌÔÓ‹˜ ÂÎÙfi˜ Ê·ÙÓ›Ô˘, ÙÔ˘ ̤ÛÔ˘ ‰È·Ù‹ÚËÛ˘ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ÌÂÛÔÏ¿‚ËÛ ·fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ̤¯ÚÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË. ∏ ÚfiÁÓˆÛË Â›Ó·È ·ÚÎÂÙ¿ ηϋ ·Ó ÙÔ ‰fiÓÙÈ Â¯ÂÈ ‰È·ÙËÚËı› Û ˘ÁÚfi ÂÚÈ‚¿ÏÏÔÓ Î·È Â·ÓÂÌÊ˘Ù¢ı› ̤۷ Û 30 min. ªÂÙ¿ ÙËÓ ¿ÚÔ‰Ô 2 ˆÚÒÓ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ ÌÂÈÒÓÂÙ·È Î·Ù·ÎfiÚ˘Ê· (1,2).
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°È· ÙË Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÌfiÏ˘ÓÛ˘ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ô˘ Û˘Ó¿ÁÂÙ·È Î·È ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·ÔÚÚfiÊËÛ˘ Ù˘ Ú›˙·˜, Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÁÈ· Ù¤ÛÛÂÚȘ Ë̤Ú˜ (ÂÓÈÎÈÏ›ÓË, 1.000.000 IU ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi Î·È ÛÙË Û˘Ó¤¯ÂÈ· 2.000.000 4.000.000 IU ÁÈ· 4 Ë̤Ú˜) (1). ª›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ Â·ÓÂÌʇÙ¢ÛË Û˘ÓÈÛÙ¿Ù·È ÂÓ‰Ô‰ÔÓÙÈ΋ ıÂڷ›· ÙÔ˘ ·ÓÂÌÊ˘Ù¢ı¤ÓÙÔ˜ ‰ÔÓÙÈÔ‡, ÂÂȉ‹ Û˘Ó‹ıˆ˜ Ô ÔÏÊfi˜ ÓÂÎÚÒÓÂÙ·È Î·Ù¿ ÙËÓ ÂÎÁfiÌʈÛË. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÙÚ·‡Ì·ÙÔ˜, ·ÏÏ¿ ȉȷ›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘, Û˘ÓÈÛÙ¿Ù·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Û¯ÔÏ·ÛÙÈ΋ ÛÙÔÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ Î·È ¯Ú‹ÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ, .¯. ‰È·Ï‡Ì·ÙÔ˜ ¯ÏˆÚÂÍȉ›Ó˘, ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ Û¯ËÌ·ÙÈÛÌÔ‡ Ù˘ Ô‰ÔÓÙÈ΋˜ ÌÈÎÚԂȷ΋˜ Ͽη˜. ∏ Û˘Ì‚Ô˘Ï‹ ·È‰È¿ÙÚÔ˘ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÙÂÙ·ÓÈÎÔ‡ ÔÚÔ‡ Â›Ó·È ··Ú·›ÙËÙË. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ ÙÔ˘ ‰ÔÓÙÈÔ‡ Î·È ÙÔ˘ ÔÏÊÔ‡, ηıÒ˜ Î·È Û ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘, Ë Û˘ÛÙËÌ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË - ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË Î·Ù¿ ÂÚ›ÙˆÛË ÙÚ·‡Ì·ÙÔ˜ Î·È ·ÛıÂÓÔ‡˜ - Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È ÙËÓ ÚfiÏË„Ë ÂÈÏÔÎÒÓ. ∞ÓÙÈÌÂÙÒÈÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ OÈ ÈÔ Û˘¯ÓÔ› ÙÚ·˘Ì·ÙÈÛÌÔ› ÛÙ· ÓÂÔÁÈÏ¿ ‰fiÓÙÈ· Â›Ó·È ÂÌ‚‡ıÈÛË, ÌÂÙ·ÙfiÈÛË, ÂÎÁfiÌʈÛË Î·È Î¿Ù·ÁÌ· Ù˘ ̇Ï˘ (1,2). O ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Â›Ó·È Ô ›‰ÈÔ˜ Ì ٷ ÌfiÓÈÌ·, Ì ÂÍ·›ÚÂÛË ÙȘ ÂÚÈÙÒÛÂȘ ÔÏÈ΋˜ ÂÎÁfiÌʈÛ˘, ÌÂÚÈ΋˜ ÌÂÙ·ÙfiÈÛ˘ Î·È ÂÓÛÊ‹ÓˆÛ˘. ∏ ·ÓÂÌʇÙ¢ÛË ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ ·ÓÙÂӉ›ÎÓ˘Ù·È ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘ ‚Ï¿‚˘ ÛÙÔ Û¤ÚÌ· ÙÔ˘ ÌfiÓÈÌÔ˘ ‰ÔÓÙÈÔ‡. ∏ ‰È·Ù‹ÚËÛË ÙÔ˘ ¯ÒÚÔ˘ Ô˘ ηÙ›¯Â ÙÔ ‰fiÓÙÈ ÌÂÙ¿ ÙËÓ ÂÎÁfiÌʈۋ ÙÔ˘ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ ÚÔÛı›ˆÓ Ù˘ ¿Óˆ ÁÓ¿ıÔ˘. ™Â ÂÚÈÙÒÛÂȘ ÌÂÚÈ΋˜ ÌÂÙ·ÙfiÈÛ˘ ‹ ÂÌ‚‡ıÈÛ˘, Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ÓÂÔÁÈÏÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·Ó Ù›ıÂÙ·È Û ΛӉ˘ÓÔ ÙÔ ‰È¿‰Ô¯Ô ÌfiÓÈÌÔ. °È· ·Ú¿‰ÂÈÁÌ·, Û ÂÚÈÙÒÛÂȘ ÂÌ‚‡ıÈÛ˘ ÓÂÔÁÈÏÔ‡ ‰ÔÓÙÈÔ‡ ÔÏϤ˜ ÊÔÚ¤˜ Ë ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ·Ó·ÌÔÓ‹ ·ÓÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡, ÌÔÚ› fï˜ Ó· ÎÚÈı› ·Ó·Áη›· Ë ¿ÌÂÛË ÂÍ·ÁˆÁ‹ ÙÔ˘, ·Ó ·ÎÙÈÓÔÁÚ·ÊÈο ‰È·ÈÛÙˆı› ÛÙÂÓ‹ ·ʋ ÙÔ˘ Ì ÙÔ ÌfiÓÈÌÔ Ô‰ÔÓÙÈÎfi Û¤ÚÌ·. ∏ ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ Â›Ó·È ··Ú·›ÙËÙË ÁÈ·Ù› ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÔÏϤ˜ ‚Ï·ÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔ˘˜ ‰È·‰fi¯Ô˘˜ ÌfiÓÈÌÔ˘˜, fiˆ˜ ·Ô¯ÚˆÌ·ÙÈÛÌfi˜ ·‰·Ì·ÓÙ›Ó˘, ˘ÔÏ·Û›· ·‰·Ì·ÓÙ›Ó˘, ·Ú·ÌfiÚʈÛË Ù˘ ̇Ï˘, Ô‰fiÓو̷, ‰ÈÏ·ÛÈ·ÛÌfi˜
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Ù˘ Ú›˙·˜, ÌÂÚÈ΋ ‹ ÔÏÈ΋ ‰È·ÎÔ‹ Ù˘ ‰È¿Ï·Û˘ Ù˘ Ú›˙·˜, ‰È·Ù·Ú·¯‹ Ù˘ ·Ó·ÙÔÏ‹˜ (1,2). ¶ÚfiÏË„Ë °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ÂÈ‚¿ÏÏÔÓÙ·È Ù· ·ÎfiÏÔ˘ı·: ·) ™ÙÂÓ‹ ›‚ÏÂ„Ë ÙˆÓ ÓË›ˆÓ fiÙ·Ó ·Ú¯›˙Ô˘Ó Ó· ÂÚ·ÙÔ‡Ó, ‚) ¢È·ÌfiÚʈÛË ·ÛÊ·ÏÒÓ ¯ÒÚˆÓ Ô˘ ÎÈÓÔ‡ÓÙ·È Î·È ·›˙Ô˘Ó Ù· ÌÈÎÚ¿ ·È‰È¿, Á) ∂Ê·ÚÌÔÁ‹ ÙˆÓ ‰ÈÂıÓÒÓ Î·ÓfiÓˆÓ Î˘ÎÏÔÊÔÚ›·˜ Ì ÙÚÔ¯ÔÊfiÚ· (˙ÒÓË ·ÛÊ·Ï›·˜, ÎÚ¿ÓË), ‰) OÚÁ¿ÓˆÛË ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ÚfiÙ˘·, Â) ÃÚ‹ÛË ÚÔÛٷ٢ÙÈÎÒÓ Ó·Úı‹ÎˆÓ ÙˆÓ ‰ÔÓÙÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ·ıÏËÌ¿ÙˆÓ (.¯. basket, Ô‰fiÛÊ·ÈÚÔ) Î·È ÛÙ) OÚıÔ‰ÔÓÙÈ΋ ıÂڷ›· Û ÂÚÈÙÒÛÂȘ ·˘ÍË̤Ó˘ ÔÚÈ˙fiÓÙÈ·˜ ÚfiÙ·Í˘ ÙˆÓ ¿Óˆ ‰ÔÓÙÈÒÓ. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ÚÔÛٷ٢ÙÈÎÔ‡˜ Ó¿ÚıËΘ ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ·˘ÙÔ› Â›Ó·È ÂÍ·ÈÚÂÙÈο ¯Ú‹ÛÈÌÔÈ Î·È ¤¯Ô˘Ó ηıÈÂÚˆı› Û ·ÁÁÂÏ̷ٛ˜ ·›ÎÙ˜ ÙÔ˘ basket Î·È ÙÔ˘ Ô‰ÔÛÊ·›ÚÔ˘ ÁÈ·Ù› ÌÂÈÒÓÔ˘Ó ÙËÓ Èı·ÓfiÙËÙ·: i) ηٿÁÌ·ÙÔ˜ Ù˘ ̇Ï˘ ·fi ÙÚ·˘Ì·ÙÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÁÚÔıÈ¿, ·ÁΈÓȤ˜ Î.Ï., ii) ‚›·È˘ ÂÎÙfiÈÛ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ˘˜ ›‰ÈÔ˘˜ ·Ú¿ÁÔÓÙ˜, iii) ‚›·È˘ ·ʋ˜ ÙˆÓ ¿Óˆ Î·È Î¿Ùˆ ‰ÔÓÙÈÒÓ Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î¿Ù·ÁÌ· ‹ ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ ÈÛÙÒÓ Ô˘ ÛÙËÚ›˙Ô˘Ó Ù· ‰fiÓÙÈ·, iv) ÂÁÎÂÊ·ÏÈ΋˜ ‰È¿ÛÂÈÛ˘, ·ÈÌÔÚÚ·-
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Á›·˜ Î·È v) ÂÎÙfiÈÛ˘ ÙÔ˘ ÎÔÓ‰‡ÏÔ˘ Ù˘ οو ÁÓ¿ıÔ˘ ÚÔ˜ Ù· ›Ûˆ Î·È ¿Óˆ. À¿Ú¯Ô˘Ó ÚÔηٷÛ΢·Ṳ̂ÓÔÈ Î·È ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓÔÈ Ó¿ÚıËΘ. ¶ÚÔÙÈÌfiÙÂÚÔÈ Â›Ó·È ÔÈ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓÔÈ. ∏ ‰È·‰Èηۛ· ··ÈÙ› ÙË Ï‹„Ë ÂÓfi˜ ·ÔÙ˘ÒÌ·ÙÔ˜ ÙˆÓ ‰ÔÓÙÈÒÓ, ·fi ÙÔ ÔÔ›Ô ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÙÔ ÂÎÌ·ÁÂ›Ô ÙÔ˘˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· - Ì ÙË ‚Ô‹ıÂÈ· ÂȉÈ΋˜ Û˘Û΢‹˜ - Á›ÓÂÙ·È Ë Î·Ù·Û΢‹ ÙÔ˘ Ó¿ÚıËη ·fi Ï·ÛÙÈÎfi ‰È·Ê·Ó¤˜ ˘ÏÈÎfi (1,2). µÈ‚ÏÈÔÁÚ·Ê›· 1. Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Munksgaard, Copenhagen: Mosby; 1994. 2. µ·Ó‰¤Ú·˜ ∞. ∆Ô ∆Ú·‡Ì· ÛÙ· ‰fiÓÙÈ·. 1Ë ÂΉ. ∞ı‹Ó·: ∞ÚÁ˘ÚÈ¿‰Ë˜; 1991. 3. American Academy of Pediatric Dentistry and P and G Oral Health Products: Smiles For Tomorrow. A Program designed for the pediatric physicians. 1995.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: §. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë ∂ÚÁ·ÛÙ‹ÚÈÔ ¶·È‰Ô‰ÔÓÙÈ·ÙÚÈ΋˜ √‰ÔÓÙÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
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O ·È‰›·ÙÚÔ˜ Î·È ÙÔ ·È‰› Ì ÙËÓ ÈÓÔ΢ÛÙÈ΋ ™. ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘
The pediatrician and the patient with cystic fibrosis S. Doudounakis
¶ÂÚ›ÏË„Ë: ∆· ·È‰È¿ Ì ÈÓÔ΢ÛÙÈ΋, ÂÎÙfi˜ ·fi Ù·ÎÙÈ΋ ÂÚÈÔ‰È΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ ÙÔ˘ ÂȉÈÎÔ‡ ΤÓÙÚÔ˘, Û˘Ó¯›˙Ô˘Ó Ó· ÂÈÛΤÙÔÓÙ·È ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ Ô˘ ˙Ô˘Ó Ì·ÎÚÈ¿ ·fi ÙÔ Î¤ÓÙÚÔ ÈÓÔ΢ÛÙÈ΋˜. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· Â›Ó·È Û ı¤ÛË Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Ù· ÚÒÈÌ· Û˘ÌÙÒÌ·Ù· Ù˘ ÓfiÛÔ˘ ηıÒ˜ Î·È ÂΛӘ ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙËÓ ÂͤÏÈÍ‹ Ù˘. ™ÎÔfi˜ Ù˘ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ˘ÔÁÚ·ÌÌÈÛÙÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù· ηıÒ˜ Î·È Ù· ‰È·ÁÓˆÛÙÈο Î·È ıÂڷ¢ÙÈο ÚÔ‚Ï‹Ì·Ù· Ù˘ ÈÓÔ΢ÛÙÈ΋˜, ¤ÙÛÈ ÒÛÙ ӷ ÂÓÈÛ¯˘ı› Ô ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘.
Abstract: Children with cystic fibrosis, apart from the frequent visits to a cystic fibrosis center, are simultaneously followed by a pediatrician. The role of the pediatrician is particularly significant for those patients who live far from the cystic fibrosis center and their visits are not as regular as required. It is therefore essential that every pediatrician should be familiar with the most common diagnostic and therapeutic problems in cystic fibrosis. More specifically, pediatricians should be able to recognize the early symptoms as well as those clinical signs that are associated with the progress of the disease. The aim of this review is to highlight these issues in order to strengthen the role of pediatricians in the treatment of cystic fibrosis.
§¤ÍÂȘ ÎÏÂȉȿ: ÈÓÔ΢ÛÙÈ΋, ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë.
Key words: cystic fibrosis, primary care.
∏ ÈÓÔ΢ÛÙÈ΋ (π¡∫) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ÎÏËÚÔÓÔÌÈ΋ ÓfiÛÔ˜ ÛÙËÓ ∂˘ÚÒË. ∏ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ Ù·ÎÙÈ΋˜ Î·È Â›ÌÔÓ˘ Ê˘ÛÈÔıÂڷ›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÈıÂÙÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫. ŒÙÛÈ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ù· ·È‰È¿ ÛÙ· ÔÔ›· ¤ÁÈÓÂ Ë ‰È¿ÁÓˆÛË ÌÂÙ¿ ÙÔ ¤ÙÔ˜ 1990, ı· ¤¯Ô˘Ó ̤ÛÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ 40 ¯ÚfiÓÈ·, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ù· ›‰È· ıÂڷ¢ÙÈο ̤۷ Ô˘ ¤¯Ô˘Ì ۋÌÂÚ· (1). OÈ ·ÛıÂÓ›˜ Ì π¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ÂȉÈο ΤÓÙÚ· ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÛÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ·˘Ù¿ (2).
∞fi ÙËÓ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÈÓÔ΢ÛÙÈ΋˜ ÛÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 7 ÙÔ 1989, ‚Ú¤ıËΠfiÙÈ ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ÙÔ ÁÔÓ›‰ÈÔ ·˘Ùfi Έ‰ÈÎÔÔÈ› Ì›· ÚˆÙ½ÓË, Ë ÔÔ›· ·ÔÙÂÏÂ›Ù·È ·fi 1480 ·ÌÈÓÔͤ· Î·È ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Â͈ÎÚÈÓÒÓ ·‰¤ÓˆÓ. ∏ ÚˆÙ½ÓË ·˘Ù‹ ÏÂÈÙÔ˘ÚÁ› Û·Ó ·ÓÙÏ›· CI (3). ™Â ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋, Ë ÚˆÙ½ÓË Ù˘ π¡∫ ·) ‰ÂÓ ·Ú¿ÁÂÙ·È ‹ ‚) ·Ú¿ÁÂÙ·È Î·È Î·Ù·ÛÙÚ¤ÊÂÙ·È ÂÓ‰Ô΢ÙÙ¿ÚÈ· ‹ Á) ·Ú¿ÁÂÙ·È Û Ôχ ÌÈÎÚ‹ ÔÛfiÙËÙ· ‹ ‰) ·˘Ù‹ Ô˘ ·Ú¿ÁÂÙ·È ‰˘ÛÏÂÈÙÔ˘ÚÁ› (4). OÈ ÁÓÒÛÂȘ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯Ô˘Ó Û˘Ó‰Ú¿ÌÂÈ ÛÙË ıÂڷ›· Ù˘ π¡∫
¢È¢ı˘ÓÙ‹˜ ∆Ì‹Ì·ÙÔ˜ πÓÔ΢ÛÙÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
Director, Division of Cystic Fibrosis Children’s Hospital “St. Sophia”, Athens
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MAY- JUNE '01 TELIKO
30-05-03
18:55
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¶·È‰È·ÙÚÈ΋ 2001;64:308-311
˘¤Ú ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ™ÙË ‰ÂηÂÙ›· Ô˘ ¿Ú¯ÈÛ ·Ó·Ì¤ÓÂÙ·È ÂÓÙÔÓfiÙÂÚË Î·È Û˘ÛÙËÌ·ÙÈÎfiÙÂÚË ÚÔÛ¿ıÂÈ· ÁÈ· Ó· ÂÈÙ¢¯ı›, ›Ù ‰È· Ù˘ ·ÔηٿÛÙ·Û˘ Ù˘ ·Ú·ÁˆÁ‹˜ ‹ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÚˆÙ½Ó˘, ‹ Ù˘ ÁÔÓȉȷ΋˜ ıÂڷ›·˜ ÔÈ Ôԛ˜ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË. O ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ÈÓÔ΢ÛÙÈ΋ Î·È Ó· Û˘ÌÌÂÙ¤¯ÂÈ: ·) ÛÙË ‰È¿ÁÓˆÛË, ‚) ÛÙËÓ ÚfiÏË„Ë, Á) ÛÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË Î·È ‰) ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë. ·) ¢È¿ÁÓˆÛË: ∏ ÈÓÔ΢ÛÙÈ΋, ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ, ÚÔ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi, ÂÓÒ ÌÂÙ¿ Ù· 6 ¯ÚfiÓÈ· ÚÔ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ª¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ ¤¯Ô˘Ó ‰È·ÁÓˆÛÙ› Ù· 2/3 ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ Ù˘ πÓÔ΢ÛÙÈ΋˜ Ù˘ ∞ı‹Ó·˜. ‚) ¶ÚfiÏË„Ë: °È· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ Â›Ó·È ··Ú·›ÙËÙË Ë ÚÔÙÚÔ‹ ÙˆÓ ÛÙÂÓÒÓ Û˘ÁÁÂÓÒÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÁÂÓÂÙÈÎfi ¤ÏÂÁ¯Ô. Á) æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË: ∆Ô ¯ÚfiÓÈÔ ÓfiÛËÌ· Ì ÙËÓ Î·Î‹ ÚfiÁÓˆÛË, Ë ÂÓÂÚÁ‹ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ Î·ıËÌÂÚÈÓ‹ Ê˘ÛÈÔıÂڷ›· ηıÒ˜ Î·È ÔÈ Û˘¯Ó¤˜ ÓÔÛËÏ›˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÎÔ˘Ú¿˙Ô˘Ó ÙÔ˘˜ ÁÔÓ›˜. O ·È‰›·ÙÚÔ˜, Ì ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ Ê›ÏÔ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ηÏÂ›Ù·È Ó· ÙËÓ ˘ÔÛÙËÚ›ÍÂÈ. ‰) ¶ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë: O ·È‰›·ÙÚÔ˜ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ÚÔÛ¿ıÂÈ· ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫, ·Ó·Ï·Ì‚¿ÓÔÓÙ·˜ ÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Ì π¡∫. ∏ ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È Ë Î·Ï‹ Û˘ÓÂÚÁ·Û›· Ì ÙÔ Î¤ÓÙÚÔ ÈÓÔ΢ÛÙÈ΋˜ ‚ÔËıÔ‡Ó ÛÙËÓ ¤ÁηÈÚË Î·È ÂÈÙ˘¯‹ Â›Ï˘ÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Ì π¡∫, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ıÂÙÈ΋ ›‰Ú·ÛË fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÈÌ‹Î˘ÓÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. £Âڷ›· Ù˘ ÈÓÔ΢ÛÙÈ΋˜ ∏ ıÂڷ›· Ù˘ π¡∫ Û‹ÌÂÚ· Â›Ó·È Û˘Ìو̷ÙÈ΋ Î·È Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ÂÙÈÎÔ‡ Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ηıÒ˜ Î·È ÛÙËÓ ÚfiÏË„Ë Ù˘ ·Ê˘‰¿ÙˆÛ˘. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ÂÙÈÎÔ‡: ∆Ô 85% ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫ ¤¯ÂÈ ·ÁÎÚ·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È Â›Ó·È ··Ú·›ÙËÙË Ë ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì·. ∏ ‰ÔÛÔÏÔÁ›· ÂÍ·ÙÔÌÈ·ÂÙ·È Î·È ÔÈΛÏÏÂÈ Â˘Ú¤ˆ˜. ƒ˘ıÌ›˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÛfiÙËÙ· Î·È ÙÔ Â›‰Ô˜ Ù˘ ‰È·ÙÚÔÊ‹˜ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ph ‹ ÙËÓ Î¤ÓˆÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ¿ÏÏ·. ¶fiÛ· ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· Ú¤ÂÈ Ó· ‰ÒÛÔ˘ÌÂ
Paediatriki 2001;64:308-311
Û ¤Ó· ·ÛıÂÓ‹ Ì π¡∫; ∆· ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· ¯ÔÚËÁÔ‡ÓÙ·È, ¤ÙÛÈ ÒÛÙ ӷ ¤¯Ô˘Ì 1-2 ÎÂÓÒÛÂȘ ηϋ˜ Û‡ÛÙ·Û˘ Î·È Ó· ÂÈÙ‡¯Ô˘Ì ηϋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË. ª›· Û˘Ó‹ı˘ ‰fiÛË Â›Ó·È 500-1500 IU/ÏÈ¿ÛË/kg/Á‡̷ (6). ∏ ¯ÔÚ‹ÁËÛË ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ ∞, D, ∂ Â›Ó·È ··Ú·›ÙËÙË Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÁÎÚ·ÙÈ΋ ·Ó¿ÚÎÂÈ·. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÁÈ· ÙȘ ‚Èٷ̛Ә ∞ Î·È D Â›Ó·È Ë ‰ÈÏ¿ÛÈ· ÙˆÓ ËÌÂÚ‹ÛÈˆÓ ·Ó·ÁÎÒÓ ÁÈ· Ù· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∏ ‚ÈÙ·Ì›ÓË ∂ ¯ÔÚËÁÂ›Ù·È ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·: Ë ‰fiÛË ÛÙ· ‚Ú¤ÊË Â›Ó·È 25-50 mg/24ˆÚÔ, ÛÙ· ·È‰È¿ 100 mg/24ˆÚÔ Î·È ÛÙÔ˘˜ ¤ÊË‚Ô˘˜ 100-200 mg/24ˆÚÔ (6). ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡: 1. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ È͈‰ÒÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ. ∏ Ê˘ÛÈÔıÂڷ›· ·ÔÙÂÏ› ÙÔÓ Î˘ÚÈfiÙÂÚÔ ÙÚfiÔ ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚÈÌ¿ÙˆÓ Î·È Â›Ó·È ÙÔ ‚·ÛÈÎfiÙÂÚÔ ÙÌ‹Ì· Ù˘ ıÂڷ›·˜. O ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÂÈ Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ Î·È Ó· ÙÔ˘˜ ÚÔÙÚ¤ÂÈ ÛÙËÓ Î·Ù‡ı˘ÓÛË ·˘Ù‹. ÕÏÏÔÈ ÙÚfiÔÈ Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛÂˆÓ Â›Ó·È Ë ÂÓ˘‰¿ÙˆÛË, Ù· ‚ÏÂÓÓÔÏ˘ÙÈο Î·È rhDNA (Pulmozyme), ÙÔ ˘¤ÚÙÔÓÔ NaCl. 2. ∏ ·ÓÙÈÌÂÙÒÈÛË Î·È ÚfiÏË„Ë ÙˆÓ ÏÔÈÌÒ͈Ó. ∏ π¡∫ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ¯ÚfiÓÈ· ÂÓ‰Ô‚ÚÔÁ¯È΋ Ïԛ̈ÍË, fiÔ˘ Û˘Ó‹ıˆ˜ ·Ó·Ù‡ÛÛÔÓÙ·È St.aureus, H.Influenzae, Ps.Aeruginosa. OÈ ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ∏ ηı˘ÛÙ¤ÚËÛË ‹ Ë Î·Î‹ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÔÚ› Ó· ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ÌfiÓÈÌË Ì›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. OÈ Â·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ, Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, ÂÈʤÚÔ˘Ó ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÂÁηٿÛÙ·ÛË ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ™ÙȘ ·ÚÔ͇ÓÛÂȘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ¯ÔÚËÁԇ̠·ÓÙÈ‚›ˆÛË Â›Ù ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ›Ù ∂º, ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÛÙȘ ηÏÏȤÚÁÂȘ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ. ∆· Û˘ÌÙÒÌ·Ù· Ô˘ Ô‰ËÁÔ‡Ó ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚›ˆÛ˘ Û ·ÛıÂÓ›˜ Ì π¡∫ ‰ÂÓ Â›Ó·È ÌfiÓÔ ·˘Ù¿ Ù˘ ÔÍ›·˜ Ïԛ̈͢ (Ô ˘ÚÂÙfi˜ Ì ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù· ηٿ ÙËÓ ·ÎÚfi·ÛË ÙÔ˘ ıÒڷη), ·ÏÏ¿ Ô‰ËÁԇ̷ÛÙ ÂΛ, ‰ËÏ·‰‹ ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÒÛˆ˜, Î·È fiÙ·Ó ˘¿Ú¯ÂÈ ·Úfi͢ÓÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ Ô˘
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¶·È‰È·ÙÚÈ΋ 2001;64:308-311
Paediatriki 2001;64:308-311
¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ Î·È ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù·. ¢‡Ô ˘ÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ Î·È ‰‡Ô ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù· Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ‰È·ÈÛÙÒÛÔ˘Ì fiÙÈ ¤Ó·˜ ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (7) (¶›Ó·Î·˜ 1). ŒÓ· ·È‰› Ì π¡∫, ÙÔ ÔÔ›Ô ·ÚÔ˘ÛÈ¿˙ÂÈ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜, ı· Ú¤ÂÈ Ó· ·›ÚÓÂÈ ·ÓÙÈ‚›ˆÛË. ∏ ·ÓÔÛ›·, ÙfiÛÔ Ë ¯˘ÌÈ΋ fiÛÔ Î·È Ë Î˘ÙÙ·ÚÈ΋, fiÛÔ ÌÔÚÔ‡Ó Ó· ÂÏÂÁ¯ıÔ‡Ó, Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì π¡∫. ∞fi‰ÂÈÍË ·˘ÙÔ‡ ·ÔÙÂÏ› ÙÔ fiÙÈ Ù· ·È‰È¿ Ì π¡∫ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÂÈÙ˘¯Ò˜ ÙȘ ÏÔÈÌÒÍÂȘ Ô˘ ‰ÂÓ ·ÊÔÚÔ‡Ó ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ∆ÔÈο, fï˜, ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Â˘·›ÛıËÙÔ. ŒÙÛÈ, ‰È¿ÊÔÚ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜) ÚÔηÏÔ‡Ó ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ∆¤ÙÔȘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Ô˘ Û˘¯Ó¿ ÚÔηÏÔ‡Ó ·Úfi͢ÓÛË Â›Ó·È ÏÔÈÌÒÍÂȘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi, ·‰ÂÓÔ˚Ô‡˜, ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘, Áڛ˘ Î·È ·Ú·Áڛ˘, ·ÓÂÌÔ‚ÏÔÁÈ¿˜, ÂÚ˘ıÚ¿˜, ÈÏ·Ú¿˜, ηıÒ˜ ›Û˘ ÏÔÈÌÒÍÂȘ ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ Â›Ó·È ÎÔÎ·Ù˘, ¯Ï·Ì‡‰È·, Ì˘ÎfiÏ·ÛÌ·, Ì˘ÎÔ‚·ÎÙËÚ›‰È·, ÏÂÁȈӤϷ (8). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÈ ÏÔÈÌÒÍÂȘ ·˘Ù¤˜ ı· Ú¤ÂÈ Ó· ÚÔÏ·Ì‚¿ÓÔÓÙ·È, fiÙ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Ì ÂÌ‚ÔÏÈ·ÛÌÔ‡˜. ∆· ÂÌ‚fiÏÈ· Ô˘ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· Ù· ·È‰È¿ Ì ÙËÓ π¡∫ Â›Ó·È Ù· ›‰È· Ô˘ Á›ÓÔÓÙ·È Î·È ÛÙ· ¿ÏÏ· ·È‰È¿, ‰ËÏ·‰‹ DTP, MMR, ·ÈÌÔÊ›ÏÔ˘, Ê˘Ì·Ù›ˆÛ˘. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÌ‚fiÏÈÔ Áڛ˘ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Ì ‰‡Ô ÌÈÛ¤˜ ‰fiÛÂȘ (0,25 ml x 2) ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ÂÓÒ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 3-12 ÂÙÒÓ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì 2 ÔÏfiÎÏËÚ˜ ‰fiÛÂȘ (0,5 ml x 2) ÂÊ’ fiÛÔÓ Â›Ó·È Ô ÚÒÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜. ∆Ô ÂÌ‚fiÏÈÔ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ̛· ÔÏfiÎÏËÚË ‰fiÛË (0,5 ml x 1) οı ¯ÚfiÓÔ, ÂÊ’ fiÛÔÓ ÚfiÎÂÈÙ·È ÁÈ· ·ÓÂÌ‚ÔÏÈ·ÛÌfi. Œˆ˜ fiÙÔ˘ ΢ÎÏÔÊÔÚ‹ÛÂÈ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜, ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È acyclovir (1530 mg/kg/24ˆÚÔ) ÁÈ· 5 Ë̤Ú˜, Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÚÒÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜. ∂›Û˘, Ô ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ο-
ÓÂÈ Ù· ÂÌ‚fiÏÈ· Ù˘ Ë·Ù›Ùȉ·˜ µ Î·È Ë·Ù›Ùȉ·˜ ∞, ÏfiÁˆ Ù˘ ¯ÚfiÓÈ·˜ Ë·ÙÔ¿ıÂÈ·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÓfiÛÔ˜. ™˘Ó‹ıË Û˘ÌÙÒÌ·Ù· ·ÛıÂÓÒÓ Ì ÈÓÔ΢ÛÙÈ΋ Ô˘ ηÏÂ›Ù·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Ô ·È‰›·ÙÚÔ˜ (5) µ‹¯·˜: O ‚‹¯·˜ Â›Ó·È ¤Ó·˜ Ê˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜, Ô ÔÔ›Ô˜ ÚÔÛٷهÂÈ ÙÔ˘˜ Ó‡ÌÔÓ˜ ·fi ÙËÓ ÂÈÛÓÔ‹ Í¤ÓˆÓ ÛˆÌ·Ùȉ›ˆÓ. ∂›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ Û‡Ìو̷ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ™ÙÔ ·È‰› Ì ÈÓÔ΢ÛÙÈ΋ ·ÔÙÂÏ› Ì˯·ÓÈÛÌfi ·Ô‚ÔÏ‹˜ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ, ÔÈ Ôԛ˜ ·‰˘Ó·ÙÔ‡Ó Ó· ‚ÁÔ˘Ó ÏfiÁˆ ÌÂÈÔÓÂÎÙÈ΋˜ ‚ÏÂÓÓÔÎÚÔÛÛˆÙ‹˜ οı·ÚÛ˘. ∆Ô ·È‰› Ì ÈÓÔ΢ÛÙÈ΋ ‚‹¯ÂÈ ÁÈ·Ù› Ú¤ÂÈ Ó· ‚Á¿ÏÂÈ ÙȘ ‚ÚÔÁ¯ÈΤ˜ ÂÎÎÚ›ÛÂȘ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ Ô˘ ‚Ú›ÛÎÂÙ·È ÙÔ ·È‰›, ‰ÂÓ Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÈ ÙÔ ‚‹¯· ÙÔ˘ Î·È ‰ÂÓ Ú¤ÂÈ Ó· ÙÔ˘ ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙȂ˯Èο. ∏ ·‡ÍËÛË ÙÔ˘ ‚‹¯· Î·È ÙˆÓ Ù˘¤ÏˆÓ, fiˆ˜ ·Ó·Ê¤Ú·ÌÂ, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ·Úfi͢ÓÛ˘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ¶fiÓÔ˜ ÛÙÔ ıÒڷη: O ·ÈÊÓ›‰ÈÔ˜, Ô͇˜ ÂÙÂÚfiÏ¢ÚÔ˜ fiÓÔ˜ ÛÙÔ ıÒڷη ÌÔÚ› Ó· Â›Ó·È Ó¢ÌÔıÒڷη˜ Î·È ÂȉÈÎfiÙÂÚ· Â¿Ó Û˘Óԉ‡ÂÙ·È Ì ‰‡ÛÓÔÈ·. ∏ ‡·ÚÍ‹ ÙÔ˘ ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∞ÌÊÔÙÂÚfiÏ¢ÚÔ˜ fiÓÔ˜ ÛÙÔ ıÒڷη Èı·Ófiٷٷ ‰ÂÓ Â›Ó·È Ó¢ÌÔıÒڷη˜, ·ÏÏ¿ Â›Ó·È Û˘Ó‹ıˆ˜ Ì˘˚΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∞ÈÌfiÙ˘ÛË: ∞Ó¿ÏÔÁ· Ù˘ ÔÛfiÙËÙ¿˜ Ù˘ ‰È·ÎÚ›ÓÂÙ·È Û ÌÈÎÚ‹, ÌÂÛ·›· Î·È ÌÂÁ¿ÏË. ŸÙ·Ó Ë ·ÚÔ˘Û›· ·›Ì·ÙÔ˜ ÛÙ· Ù‡ÂÏ· Â›Ó·È ÁÚ·ÌÌÔÂȉ‹˜ ‹ ·Ó¿ÌÈÎÙË, Û˘¯Ó¿, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ıÂڷ›·. ªÈÎÚ‹, fï˜, Î·È Â›ÌÔÓË ·ÚÔ˘Û›· Ù˘ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ·Úfi͢ÓÛ˘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ Î·È Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Ó¿ÁÎË ıÂڷ›·˜. ∆·˘Ùfi¯ÚÔÓ·, Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë ·Ó·˙‹ÙËÛË ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·ÈÌÔÚÚ·Á›·, .¯. Û·Ï˘ÎÈÏÈο, ÎÈÚÛÔ› ÔÈÛÔÊ¿ÁÔ˘. ¶fiÓÔ˜ ÛÙËÓ ÎÔÈÏÈ¿: ∏ η΋ ¤„Ë ÛÙÔ ¤ÓÙÂÚÔ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ÔÁÎÒ‰ÂȘ ÏÈ·Ú¤˜ ÎÂÓÒÛÂȘ, Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÙÔ “ÈÛÔ‰‡Ó·ÌÔ ÂÈÏÂÔ‡ ·fi Ì˘ÎÒÓÈÔ” Ô˘ ÂΉËÏÒÓÂÙ·È Ì fiÓÔ ÛÙËÓ ÎÔÈÏÈ¿ Î·È ÌË ·Ô‚ÔÏ‹ ÎÔÚ¿ÓˆÓ Ï¤ÔÓ ÙÔ˘ 24ÒÚÔ˘.
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ÀÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ
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¡¤Â˜ ‰ÈËı‹ÛÂȘ ÛÙËÓ ·/Ê›· ıÒڷη ªÂ›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ∂Ï¿ÙÙˆÛË ‚¿ÚÔ˘˜ ∂Ï¿ÙÙˆÛË Sat O2 ∞‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ·Ó·ÓÔÒÓ ªÂÙ·‚ÔϤ˜ ÛÙË Ê˘ÛÈ΋ ÂͤٷÛË
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™˘ÌÂÚ·›ÓÔ˘Ì fiÙÈ Ë ÈÓÔ΢ÛÙÈ΋ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÛÔ‚·Ú¿ ˘fi„Ë Î·È Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ¤ÓÙÔÓË ˘·ÎÙÈ΋ ·ÁˆÁ‹, ·ÊÔ‡ ‚¤‚·È· ·ÔÎÏÂÈÛÙ› Ë ‡·ÚÍË ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜, fiˆ˜ Ë ÛΈÏËÎÔÂȉ›ÙȘ ‹ Ô ÂÁÎÔÏ·ÛÌfi˜.
Paediatriki 2001;64:308-311
5. 6. 7.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Elborn J, Shale D, Britton JD. Cystic fibrosis: Current survival and population estimates to the year 2000. Thorax 1991;46:881-885. 2. Welsh J, Phenan R, Hey E. Cystic fibrosis mortality in England and Wales and Victoria Australia. Arc Dis Child 1984;59:71-83. 3. Riordan J, Rommens J, Kerem BJ et al. Identification of the cystic fibrosis gene: Cloning and characterisation of complementary DNA. Science 1989;245:1066-1073. 4. Welsh J, Smith E. Molecular mechanisms of CFTR
8.
chloride channel dysfunction in cystic fibrosis. Cell 1993;73:1251-1254. Stern R. The primary care physician and the patient with cystic fibrosis. J Pediatr 1989;114:31-36. On the team. The general practitioner and cystic fibrosis. Gardiner-Caldwell; 1994. Orenstein D, Pattishal E, Noyes B, Kurland G, Harkigan E, Lu V. Safety of Ciprofloxacin in children with cystic fibrosis. Clin Pediatr 1993;504-506. Ramsey B, Gore E, Smith A, Cooney M, Redding G, Foy H. The effect of respiratory viral infections on patients with cystic fibrosis. Am J Dis Child 1989;143:662-668.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù·‡ÚÔ˜ ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘ ¢/ÓÙ‹˜ ∆Ì‹Ì·ÙÔ˜ πÓÔ΢ÛÙÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¢ÂÓ ˘¿Ú¯ÂÈ ·ÓÙÈÎÂÈÌÂÓÈο ÌÂÙÚ‹ÛÈÌÔ fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Ì ·ÂÚÔı¿Ï·ÌÔ Û ‚Ú¤ÊË Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·1 ™ÎÔfi˜: ¢ÈÂÓÂÚÁ‹ıËΠ̛· ‰ÈÏ‹-Ù˘ÊÏ‹, ÂÏÂÁ¯fiÌÂÓË Ì placebo, Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË, ÁÈ· Ó· ‰ÈÂÚ¢ÓËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ, fiÙ·Ó ·˘Ù¿ ¯ÔÚËÁÔ‡ÓÙ·Ó Â› ÙÚ›ÌËÓÔ Ì ·ÂÚÔı¿Ï·ÌÔ Î·È Ì¿Ûη ÚÔÛÒÔ˘ Û ‚Ú¤ÊË Ô˘ ·Ó¤ÚÚˆÓ·Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™·Ú¿ÓÙ· ÔÎÙÒ, ˘ÁÈ‹ ηٿ Ù· ¿ÏÏ·, ‚Ú¤ÊË Ô˘ ·Ó¤ÚÚˆÓ·Ó ·fi ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜, Ù˘¯·ÈÔÔÈ‹ıËηÓ, ÒÛÙ ӷ Ï¿‚Ô˘Ó 150 Ìg ÚÔÈÔÓÈ΋˜ ÊÏÔ˘ÙÈη˙fiÓ˘ (FP) ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‹ placebo Ì ·ÂÚÔı¿Ï·ÌÔ Babyhaler. ∆· ‚Ú¤ÊË ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Ì·ÎÚÔÚfiıÂÛÌ·, Ú·ÁÌ·ÙÔÔÈÒÓÙ·˜ ÂÙ¿ ÂÎÙÈÌ‹ÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜, Ì ÙË ‚Ô‹ıÂÈ· ËÌÂÚÔÏÔÁ›ˆÓ Û˘Ìو̿وÓ, ‚È‚ÏÈ·Ú›ˆÓ ˘Á›·˜, ÎÏÈÓÈ΋˜ ÂͤٷÛ˘, ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ηٷÁÚ·Ê‹˜ Ó˘ÎÙÂÚÈÓÔ‡ ‚‹¯· Î·È ÙÈÌÒÓ ÎÔÚÂÛÌÔ‡ Ô͢ÁfiÓÔ˘. ∏ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÂÙÚ‹ıËΠ6 Ì‹Ó˜ ÌÂÙ¿ ÙÔ ÂÍÈÙ‹ÚÈÔ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ™·Ú¿ÓÙ· ÙÚ›· ‚Ú¤ÊË ÔÏÔÎÏ‹ÚˆÛ·Ó ÙË ÌÂϤÙË (FP 21, placebo 22). ∞ÔÙÂϤÛÌ·Ù·: ¢ÂÓ Â˘Ú¤ıËÛ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÚÂȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÌÂÙÚ‹ıËηÓ, ‰ËÏ·‰‹ ÙÔ Ó˘ÎÙÂÚÈÓfi ‚‹¯·, ÙÔÓ ÎÔÚÂÛÌfi Ô͢ÁfiÓÔ˘ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ. ∏ ‚·ıÌÔÏÔÁ›· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó ¯·ÌËÏ‹ ÙfiÛÔ ÛÙËÓ ÔÌ¿‰· Ô˘ ¤Ï·‚ FP, fiÛÔ Î·È Û ÂΛÓË Ô˘ ¤Ï·‚ placebo, Ì ·Ô˘Û›· (0) Û˘-
ÌÙˆÌ¿ÙˆÓ ‹ ‹È· (1) Û˘ÌÙÒÌ·Ù· Û ≥90% ÙˆÓ ËÌÂÚÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘. ¢ÂÓ Â˘Ú¤ıËÛ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ìو̿وÓ, ÛÙË ¯Ú‹ÛË Î·Ù’ ›ÎÏËÛÈÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‹ ÛÙȘ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ıÂڷ›·˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÌÂϤÙ˘ ‹ ηٿ ÙËÓ ÂÓ Û˘Ó¯›· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ‰ÂÓ Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿Ù·È Ë ¯Ú‹ÛË ÂÈÛÓÂfiÌÂÓ˘ ÊÏÔ˘ÙÈη˙fiÓ˘ Û ·È‰È¿ Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·.
1 Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H No objective benefit from steroids inhaled via a spacer in infants recovering from bronchiolitis Eur Respir J 2000;15:388-394
ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
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¶·È‰È·ÙÚÈ΋ 2001;64:312-314
™À¡∂ƒ°∞∑Oª∂¡∂™ ∂π¢π∫O∆∏∆∂™
Paediatriki 2001;64:312-314
ASSOCIATED SUBSPECIALTIES
ÀÔÛ·‰›·˜ ¢. ∫ÂÚ·Ì›‰·˜
Hypospadias D. Keramidas
¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë Â›Ú· Ì·˜ ·fi 441 ÂÚÈÙÒÛÂȘ ˘ÔÛ·‰›· Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ 1986 - 1999. ∏ ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÎÂÓÙÚÈÎÒ˜ Ù˘ ‚·Ï¿ÓÔ˘ Û ‰È¿ÊÔÚ˜ ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ ·fi ÙË ‚¿ÛË Ù˘ ‚·Ï¿ÓÔ˘ ¤ˆ˜ ÙÔ ÂÚ›ÓÂÔ, Û˘Ó‰˘·˙fiÙ·Ó Ì ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ¤ÏÏÂÈÌÌ· ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ̤ÚÔ˘˜ Ù˘ ·ÎÚÔÔÛı›·˜ Î·È Ì ·ÚÔ˘Û›· ¯ÔÚ‰‹˜ ÂÚÈÊÂÚÈο Ù˘ Ô˘Ú‹ıÚ·˜ ÚÔηÏÔ‡Û·˜ Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜. OÈ ˆ˜ ¿Óˆ ·ÓˆÌ·Ï›Â˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ Ì ÛÙfi¯Ô ÙÔÓ Â˘ıÂÈ·ÛÌfi ÙÔ˘ ¤Ô˘˜ Î·È ÙËÓ Â΂ÔÏ‹ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘. ∏ ËÏÈΛ· ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ÂÁ¯Â›ÚËÛË Î˘Ì·ÈÓfiÙ·Ó ·fi 20 ÌËÓÒÓ Ì¤¯ÚÈ 3 ÂÙÒÓ. ∏ ·ÓÒÌ·ÏË Â΂ÔÏ‹ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙË ‚¿Ï·ÓÔ Î·È ˘fi ÙË ÛÙÂÊ¿ÓË, ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 50,3% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ Ù¯ÓÈ΋ Ì·˜ Ù˘ ÌÂÙ·ÙfiÈÛ˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈ΋ ı¤ÛË ÛÙË ‚¿Ï·ÓÔ ¯ÚËÛÈÌÔÔÈ‹ıËΠ̠ηÏfi ÏÂÈÙÔ˘ÚÁÈÎfi Î·È ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. O ÚfiÛıÈÔ˜ Â˚Îfi˜ ˘ÔÛ·‰›·˜ ·ÓÙÈÚÔۈ‡ÂÈ 40,5% ÙˆÓ ÂÚÈÙÒÛˆÓ. ÃÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù¯ÓÈ΋ Ù˘ Ô˘ÚËıÚÔÏ·ÛÙÈ΋˜ ηٿ ªathieu. °È· ÙȘ ‰ÈÔÚıÒÛÂȘ ÙˆÓ ˘fiÏÔÈˆÓ ÌÔÚÊÒÓ ˘ÔÛ·‰›·, Ô Â˘ıÂÈ·ÛÌfi˜ Û˘Ó‰˘¿ÛÙËΠ̠ԢÚËıÚÔÏ·ÛÙÈ΋ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÂÁοÚÛÈÔ ÛˆÏËÓˆÙfi ÎÚËÌÓfi Ì ·ÁÁÂÈ·Îfi Ì›Û¯Ô ·fi ÙÔ ¤Ûˆ ¤Ù·ÏÔ Ù˘ ·ÎÚÔÔÛı›·˜. ∫˘ÚÈfiÙÂÚË ÂÈÏÔ΋ ÙˆÓ ˆ˜ ¿Óˆ ÂÁ¯ÂÈÚËÙÈÎÒÓ ÌÂıfi‰ˆÓ ‹Ù·Ó ÙÔ Û˘Ú›ÁÁÈÔ Ù˘ Ô˘Ú‹ıÚ·˜. ¶·ÚÔ˘ÛÈ¿ÛÙËΠ۠13,4% ÙˆÓ ¯ÂÈÚÔ˘ÚÁËı¤ÓÙˆÓ Î·È ·ÓÙÈÌÂÙˆ›ÛÙËΠÂÈÙ˘¯Ò˜ Ì ÂÁ¯Â›ÚËÛË ‹ ·ÓÂÁ¯Â›ÚËÛË Û‡ÁÎÏÂÈÛ˘ ÙÔ˘ Û˘ÚÈÁÁ›Ô˘.
Abstract: Our experience with 441 cases of hypospadias operated upon during a 13-year period is presented. The anatomical abnormality of termination of the urethral orifice proximally to the normal site was associated with ventral deficiency of the prepuce and ventral flexion of the shaft due to chordee situated distal to the orifice. One-stage repair for shaft straitening and urethroplasty was used in all forms of hypospadias. In the majority of patients the age at time of operation varied from 20 months to 3 years. Distal hypospadias was the most common lesion. The glandular and subcoronal meatus accounted for 50.3% of cases. Our technique of urethra advancement, combined with glanuloplasty and prepuceoplasty, was used with very good cosmetic and functional results. Penile hypospadias with urethra orifice on the distal shaft accounted for 40.5% of cases. The perimeatal - based flap (Mathieu procedure) was used. All other forms of hypospadias were surgically corrected using transverse preputial island flap. Main postoperative complication was fistula formation needing surgical repair in 13.4% of the cases.
§¤ÍÂȘ ÎÏÂȉȿ: ˘ÔÛ·‰›·˜, ÎÔÈÏÈ·Îfi ÛÙfiÌÈÔ Ô˘Ú‹ıÚ·˜, Î¿Ì„Ë ¤Ô˘˜, ¤Ó·˜ ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ¯ÚfiÓÔ˜.
Key words: hypospadias, ventral urethral orifice, chordee, one-stage operation.
¢È¢ı˘ÓÙ‹˜ ÙÔ˘ µ’ ÃÂÈÚÔ˘ÚÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”
Director, 2nd Department of Pediatric Surgery “Aghia Sophia” Children’s Hospital, Athens
312
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·313
¶·È‰È·ÙÚÈ΋ 2001;64:312-314
O ˘ÔÛ·‰›·˜ Â›Ó·È Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, Ù˘ ÔÔ›·˜ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÁÓˆÚÈÛÌ· Â›Ó·È Ë Â΂ÔÏ‹ ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÙÔ˘ ¿ÚÚÂÓ· Û ¿Ù˘Â˜ ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ ÎÂÓÙÚÈÎfiÙÂÚ· Ù˘ ÎÔÚ˘Ê‹˜ Ù˘ ‚·Ï¿ÓÔ˘. OÈ ı¤ÛÂȘ ·˘Ù¤˜ ÔÈΛÏÏÔ˘Ó ·fi ÙËÓ ›‰È· ÙË ‚¿Ï·ÓÔ ¤ˆ˜ ÙÔ ÂÚ›ÓÂÔ. ™ÎÔfi˜ Ù˘ ÔÌÈÏ›·˜ ·˘Ù‹˜ ÂÈÓ·È Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÔÈ Û‡Á¯ÚÔÓ˜ ·fi„ÂȘ fiˆ˜ ·˘Ù¤˜ ÂÊ·ÚÌfi˙ÔÓÙ·È, ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÙË ‰ÈfiÚıˆÛË Ù˘ ·ÓˆÌ·Ï›·˜ ÛÙË µ' ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”. ∆· ·Ó·ÙÔÌÈο ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ˘ÔÛ·‰›· ‰È·ÎÚ›ÓÔÓÙ·È Û ڈÙ‡ÔÓÙ· Î·È Û˘Ó˘¿Ú¯ÔÓÙ·. ¶ÚˆÙ‡ÔÓ ÁÓÒÚÈÛÌ· Â›Ó·È Ë ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜, ‚¿ÛÂÈ Ù˘ ÔÔ›·˜ Ô ˘ÔÛ·‰›·˜ Ù·ÍÈÓÔÌÂ›Ù·È Î·Ù¿ Duckett Û ÙÚÂȘ ·ÚȘ ÔÌ¿‰Â˜: ÙÔÓ ÚfiÛıÈÔ, ÙÔ Ì¤ÛÔ Î·È ÙÔÓ Ô›ÛıÈÔ. ™ÙÔÓ ÚfiÛıÈÔ ˘ÔÛ·‰›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ‚·Ï·ÓÈÎfi˜, Ô ÛÙÂÊ·ÓÈ·›Ô˜ Î·È Ô ˘Ô‚·Ï·ÓÈÎfi˜. ∏ ÔÌ¿‰· ·˘Ù‹ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ Ù‡Ô, ·ÓÙÈÚÔۈ‡ÔÓÙ·˜ 50% ÙÔ˘ Û˘ÓfiÏÔ˘. ™ÙÔÓ Ô›ÛıÈÔ ˘ÔÛ·‰›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ÔÛ¯ÂÔÂ˚Îfi˜, Ô ÔÛ¯Â˚Îfi˜ Î·È Ô ÂÚÈÓÂ˚Îfi˜. OÈ Ù‡ÔÈ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ÙÔ 20% ÙÔ˘ Û˘ÓfiÏÔ˘. ∆¤ÏÔ˜, Ô Ì¤ÛÔ˜ ˘ÔÛ·‰›·˜ (ÂÚÈÊÂÚÈÎfi˜, ÌÂÛÔÂ˚Îfi˜, ÎÂÓÙÚÈÎfi˜) ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 30% ÙÔ˘ Û˘ÓfiÏÔ˘. ™˘Ó˘¿Ú¯ÔÓÙ· ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ˘ÔÛ·‰›· Â›Ó·È ÙÔ ¤ÏÏÂÈÌÌ· Ù˘ ·ÎÚÔÚÔÛı›·˜ Î·È Ë Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜. OÈ ·ÓˆÌ·Ï›Â˜ ·˘Ù¤˜ ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó Ì ÙÔÓ ˘ÔÛ·‰›· ηÙ' ·fiÏ˘ÙË ¤ÓÓÔÈ·. ∂ȉÈÎfiÙÂÚ·, ÙÔ ¤ÏÏÂÈÌÌ· Ù˘ ·ÎÚÔÚÔÛı›·˜ ·ÊÔÚ¿ ÙÔ ÎÔÈÏÈ·Îfi ·˘Ù‹˜ ̤ÚÔ˜, ÂÓÒ Ë Î¿Ì„Ë ·ÊÔÚ¿ ÙÔ Ì¤ÚÔ˜ ÙÔ˘ ¤Ô˘˜ Ô˘ Â›Ó·È ÂÚÈÊÂÚÈο ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜. O ‚·ıÌfi˜ ο̄˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙÔ˘˜ Ù‡Ô˘˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ˘ÔÛ·‰›·, ÌÈÎÚfiÙÂÚÔ˜ ‰Â ÛÙÔ˘˜ Ù‡Ô˘˜ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ˘ÔÛ·‰›·. ∆Ô Ì¤ÁÂıÔ˜ Ù˘ ο̄˘ Ú¤ÂÈ Ó· ·Ó·˙ËÙÂ›Ù·È Î·Ù¿ ÙË Ê˘ÛÈ΋ ÂͤٷÛË. ∏ Î¿Ì„Ë ·Ó·‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔÓ ÂÍÂÙ¿˙ÔÓÙ· Ì ¤ÏÍË Ù˘ fiÛı˘ ÚÔ˜ ÙË ‚¿ÛË ÙÔ˘ ¤Ô˘˜. ™Ù· Û˘Ó˘¿Ú¯ÔÓÙ· ÁÓˆÚ›ÛÌ·Ù· ÌÔÚÔ‡Ó Ó· ÂÚÈÏËÊıÔ‡Ó Î·È ·ÓˆÌ·Ï›Â˜ ÙˆÓ fiÚ¯ÂˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙËÓ ·Ó·ÙÔÌÈ΋ ÙÔ˘˜ ı¤ÛË. ∞ӈ̷ϛ˜ ÙˆÓ fiÚ¯ÂˆÓ ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó Û˘¯Ó¿ Ì ÙÔÓ ˘ÔÛ·‰›·. ™ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ÔÈ fiÚ¯ÂȘ Â›Ó·È ·„ËÏ¿ÊËÙÔÈ ‹ ˘ÔÏ·ÛÙÈÎÔ› Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÂÍÂÙ¿ÛÂȘ ηıÔÚÈÛÌÔ‡ ÙÔ˘ ʇÏÔ˘. ∏ ̤ÛË Û˘¯ÓfiÙËÙ· ÙÔ˘ ˘ÔÛ·‰›· Â›Ó·È 1:300 ÁÂÓÓ‹ÛÂȘ. ™˘¯ÓfiÙÂÚÔÈ Â›Ó·È ÔÈ ‚·Ï·ÓÈÎfi˜ Î·È ˘Ô‚·Ï·ÓÈÎfi˜ ˘ÔÛ·‰›·˜ Ì ·Ó·ÏÔÁ›· 1:140 ÁÂÓÓ‹ÛÂȘ, ·ÎÔÏÔ˘ı› Ô Â˚Îfi˜ ˘ÔÛ·‰›·˜ Ì ·Ó·ÏÔÁ›· 1:1250 ÁÂÓÓ‹ÛÂȘ Î·È ¤ÂÙ·È Ô ÔÛ¯Â˚Îfi˜ Î·È Ô ÂÚÈÓÂ˚Îfi˜ ˘ÔÛ·‰›·˜, ÔÈ ÔÔ›ÔÈ ··ÓÙÒÓÙ·È Ì›·
Paediatriki 2001;64:312-314
ÊÔÚ¿ Û οı 3.330 ÁÂÓÓ‹ÛÂȘ. O ˘ÔÛ·‰›·˜ ÚÔηÏ› ÛÔ‚·Ú¿ ÏÂÈÙÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù·. ∞˘Ù¿ ·ÊÔÚÔ‡Ó ÙË ÊÔÚ¿ Ù˘ ·ÎÙ›Ó·˜ ÙˆÓ Ô‡ÚˆÓ Î·È ÙË Û˘ÓÔ˘Û›·. ∞ÓÙ›ıÂÙ·, Ë ÁÔÓÈÌfiÙËÙ· ‰ÂÓ ÂËÚ¿˙ÂÙ·È ‰ÈfiÙÈ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ Û¤ÚÌ·ÙÔ˜. ∏ ·ÎÙ›Ó· ÙˆÓ Ô‡ÚˆÓ ¤¯ÂÈ ÊÔÚ¿ ۯ‰fiÓ Î¿ıÂÙË ÛÙÔ ‚·Ï·ÓÈÎfi ˘ÔÛ·‰›·, οıÂÙË ÛÙÔ ÛÙÂÊ·ÓÈ·›Ô Î·È ÌÂÛÔÂ˚Îfi ˘ÔÛ·‰›·, ÂÓÒ ÛÙÔÓ ÔÛ¯Â˚Îfi Ë Ô‡ÚËÛË Á›ÓÂÙ·È Û ηıÈÛÙ‹ ı¤ÛË. ∫·Ù¿ ÙË Û˘ÓÔ˘Û›·, Ë Â›ÛÔ‰Ô˜ ÙÔ˘ ¤Ô˘˜ ÛÙÔÓ ÎfiÏÔ ÌÔÚ› Ó· Â›Ó·È ÂÒ‰˘ÓË ·Ó Ë Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜ Â›Ó·È ÌÈÎÚ‹ Î·È ·‰‡Ó·ÙË ·Ó Ë Î¿Ì„Ë Â›Ó·È ÌÂÁ¿ÏË. ∏ ÂÎÛÂÚÌ¿ÙÈÛË Á›ÓÂÙ·È ÂÎÙfi˜ ÙÔ˘ ÎfiÏÔ˘ ·Ó Ô ˘ÔÛ·‰›·˜ Â›Ó·È ÎÂÓÙÚÈÎfi˜ (ÔÛ¯ÂÔÂ˚Îfi˜, ÔÛ¯Â˚Îfi˜, ÂÚÈÓÂ˚Îfi˜). OÈ Ô‰ËÁ›Â˜ ·fi ÙÔÓ ·È‰›·ÙÚÔ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ Ú¤ÂÈ Ó· ‰›‰ÔÓÙ·È Ì ÌÂÁ¿ÏË ÂÚ›Û΄Ë. ∏ ÏËÚÔÊÔÚ›· ÁÈ· ÙÔ ‚·Ï·ÓÈÎfi ‹ ÙÔ ÛÙÂÊ·ÓÈ·›Ô ˘ÔÛ·‰›· fiÙÈ “Â›Ó·È ·Ïfi Úfi‚ÏËÌ·” Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È. ∂›Û˘, Ë ÏËÚÔÊÔÚ›· fiÙÈ Ë ÂÚÈÛÛÂ‡Ô˘Û· Ú·¯È·›· ·ÎÚÔÔÛı›· ÌÔÚ› Ó· ·Ê·ÈÚÂ›Ù·È ÁÈ· ÏfiÁÔ˘˜ ÎÔÛÌËÙÈÎÔ‡˜ Â›Ó·È Ï¿ıÔ˜. ∆Ô Ì¤ÚÔ˜ ·˘Ùfi Ù˘ ·ÎÚÔÔÛı›·˜ Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È Ì¤¯ÚÈ Ó· ÔÏÔÎÏËÚˆı› Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Ù˘ ·ÓˆÌ·Ï›·˜. ∞ÔÙÂÏ› ··Ú·›ÙËÙÔ ÈÛÙfi ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÓÂÔÔ˘Ú‹ıÚ·˜, ̤ۈ ÌÈÛ¯ˆÙÔ‡ ÎÚËÌÓÔ‡, ÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡, ΢ڛˆ˜ ˘ÔÛ·‰›· ·ÏÏ¿ Î·È ÁÈ· ·ÓÂÁ¯Â›ÚËÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ¿ÏÏˆÓ ·Ï·ÈfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ. ∏ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ˘ÔÛ·‰›· ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÁÓˆÛÙ‹. ¶·ÚÔ˘ÛÈ¿˙ÂÈ ÔÈÎÔÁÂÓ‹ ›وÛË (10% 28%). °ÓˆÚ›˙Ô˘Ì fï˜ Ù· ÂÌ‚Ú˘˚ο ÛÙ¿‰È· ÂͤÏÈ͢ ÛÙË ‰È¿Ï·ÛË ÙˆÓ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ Î·È Ù˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ ÂͤÏÈ͢ ÌÂ Û˘Ó¤ÂÈ· ÙË Û˘ÁÁÂÓ‹ ·ÓˆÌ·Ï›·. ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ ÙËÓ 6Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰· ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÁÂÓÓËÙÈÎfi ʇ̷ ÂÚÈÊÂÚÈο ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ fiÚÔ˘. ∆ËÓ 7Ë Â‚‰ÔÌ¿‰· ÂÌÊ·Ó›˙ÔÓÙ·È 2 ̤Û˜ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ Ú·¯È·›ˆ˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ ʇ̷ÙÔ˜ Î·È 2 Ï¿ÁȘ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜. ∞fi ÙÔ ÁÂÓÓËÙÈÎfi ʇ̷ ‰È·Ï¿ÛÛÔÓÙ·È Ë ‚¿Ï·ÓÔ˜ Î·È Ë ‚·Ï·ÓÈ΋ ÌÔ›Ú· Ù˘ Ô˘Ú‹ıÚ·˜. ∞fi ÙȘ ̤Û˜ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ ‰È·Ï¿ÛÛÂÙ·È Ë Ô˘Ú‹ıÚ· ÏËÓ Ù˘ ‚·Ï·ÓÈ΋˜. ∞fi ÙȘ Ï¿ÁȘ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ ‰È·Ï¿ÛÛÔÓÙ·È ÙÔ ‰¤ÚÌ· ÙÔ˘ ¤Ô˘˜ (fiÛıË) Î·È ÙÔ fiÛ¯ÂÔ. ∆¤ÏÔ˜, ·fi ÙÔ ÌÂÛfi‰ÂÚÌ· ÚÔ¤Ú¯ÔÓÙ·È Ù· ÛËÚ·ÁÁÒ‰Ë ÛÒÌ·Ù·, Ô ‰·ÚÙfi˜ ¯ÈÙÒÓ·˜ Î·È Ë ÂÚÈÙÔÓ›·. ™˘Ó˘¿Ú¯Ô˘Û˜ ·ÓˆÌ·Ï›Â˜ Ì ÙÔÓ ˘ÔÛ·‰›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÊÔÚÔ‡Ó ÙÔ˘˜ fiÚ¯ÂȘ Î·È ÂȉÈÎfiÙÂÚ· ÙË ı¤ÛË ÙˆÓ fiگˆÓ. ∫Ú˘„ÔÚ¯›· Û˘Ó˘¿Ú¯ÂÈ Û ÔÛÔÛÙfi 10% - 20%. ∂›Ó·È Èı·Ófi Ë Û˘Ó‡·ÚÍË Ù˘ ÎÚ˘„ÔÚ¯›·˜ Ó· ÔÊ›ÏÂÙ·È Û ·Ó·Ú΋ ·Ú·ÁˆÁ‹ ·Ó‰ÚÔÁfiÓˆÓ Î·Ù¿ ÙËÓ Î‡ËÛË. ÕÏϘ Û˘Ó˘¿Ú¯Ô˘Û˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Ë ·ÙÚÔÊ›· ÙˆÓ
313
MAY- JUNE '01 TELIKO
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18:55
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¶·È‰È·ÙÚÈ΋ 2001;64:312-314
fiگˆÓ, Ë ÎÈÚÛÔ΋ÏË Î·È Ë ÛÂÚÌ·ÙÔ΋ÏË. ™ÙÔÓ ¿ÚÚÂÓ· „¢‰ÂÚÌ·ÊÚÔ‰ÈÙÈÛÌfi Ì ÂÚÈÓÂ˚Îfi ˘ÔÛ·‰›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂϤÙË Ì ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÂͤٷÛË Î·ıÔÚÈÛÌÔ‡ ÙÔ˘ ʇÏÔ˘. ∞ӈ̷ϛ˜ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi fiˆ˜ Ô ÌÔÓ‹Ú˘ ÓÂÊÚfi˜, ÔÈ ‰ÈÏÔ› Ô˘ÚËÙ‹Ú˜ Î·È ¿ÏϘ, ··ÓÙÔ‡Ó ÌÂ Û˘¯ÓfiÙËÙ· 4%, Û ·ÓÙ›ıÂÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi fiÔ˘ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ·˘ÙÒÓ Â›Ó·È Î¿Ùˆ ÙÔ˘ 2%. ∆¤ÏÔ˜, Ô ˘ÔÛ·‰›·˜ ÌÔÚ› Ó· ·ÔÙÂÏ› ̤ÚÔ˜ Û¿ÓÈˆÓ Û˘Ó‰ÚfïÓ. ™Ùfi¯ÔÈ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‰ÈfiÚıˆÛ˘ ÙÔ˘ ˘ÔÛ·‰›· ›ӷÈ: ·) Ô Â˘ıÂÈ·ÛÌfi˜ ÙÔ˘ ¤Ô˘˜, ‚) Ë ÙÔÔı¤ÙËÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ó¤ÔÔ˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘. OÈ ÛÙfi¯ÔÈ ·˘ÙÔ› Ú¤ÂÈ Ó· ÂÈÙ˘Á¯¿ÓÔÓÙ·È Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ Î·È Ó· ÂÍ·ÛÊ·Ï›˙Ô˘Ó Î·Ïfi ÏÂÈÙÔ˘ÚÁÈÎfi Î·È ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ∆Ô Ë̤ÙÂÚÔ ˘ÏÈÎfi ·ÔÙÂÏÔ‡Ó 441 ÂÚÈÙÒÛÂȘ Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ 1986-1999. ∏ ËÏÈΛ· ÙˆÓ “·ÛıÂÓÒÓ” ·˘ÙÒÓ Î˘Ì·›ÓÂÙ·È ·fi 20 ÌËÓÒÓ Ì¤¯ÚÈ 3 ÂÙÒÓ. À¿Ú¯Ô˘Ó fï˜ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ·ÙfiÌˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ̤¯ÚÈ 16 ÂÙÒÓ. OÈ Ù‡ÔÈ ˘ÔÛ·‰›· Ô˘ ¯ÂÈÚÔ˘ÚÁ‹Û·Ì ÛÙË µ' ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” ‹Ù·Ó Ì ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ ÔÈ ·ÎfiÏÔ˘ıÔÈ: 1) ÚfiÛıÈÔÈ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ì ÙÔ ‚·Ï·ÓÈÎfi, ÙÔ ÛÙÂÊ·ÓÈ·›Ô Î·È ÙÔÓ ˘Ô‚·Ï·ÓÈÎfi, 2) ÎÂÓÙÚÈÎÔ›, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ì ÙÔÓ ÔÛ¯ÂÔÂ˚Îfi, ÙÔÓ ÔÛ¯Â˚Îfi Î·È ÙÔÓ ÂÚÈÓÂ˚Îfi Î·È 3) ̤ÛÔÈ ˘ÔÛ·‰›Â˜. OÈ ÂÁ¯ÂÈÚËÙÈΤ˜ Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹Û·Ì ‹Ù·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ÙÚÂȘ: ·) ¶ÚÔÒıËÛË Ù˘ Ô˘Ú‹ıÚ·˜ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋. ¶ÚfiÎÂÈÙ·È ÁÈ· ËÌÂÙ¤Ú· Ù¯ÓÈ΋ Ì ÂӉ›ÍÂȘ ÙÔ ‚·Ï·ÓÈÎfi Î·È ÙÔ ÛÙÂÊ·ÓÈ·›Ô ˘ÔÛ·‰›· (1). ‚) ∞ÓÂÛÙÚ·Ì̤ÓÔ˜ Î·È Ï¿ÁÈÔÈ ÎÚËÌÓÔ› ηٿ Mathieu (2). ∏ Ù¯ÓÈ΋ ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ˘Ô‚·Ï·ÓÈÎÔ‡ Î·È ÙÔ˘ ÌÂÛÔÂ˚ÎÔ‡ ˘ÔÛ·‰›·. Á) ªÈÛ¯ˆÙfi˜ ÎÚËÌÓfi˜ (island flap) ·fi ÙËÓ ·ÎÚÔÔÛı›· ηٿ Duckett (3). ÃÚËÛÈÌÔÔÈ‹ıËΠ(·fi ÙÔ ¤ÙÔ˜ 1996) ÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ÔÛ¯ÂÔÂ˚ÎÔ‡, ÔÛ¯Â˚ÎÔ‡ Î·È ÂÚÈÓÂ˚ÎÔ‡ ˘ÔÛ·‰›·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 441 ÂÁ¯ÂÈÚ‹ÛˆÓ, Ë ÚÒÙË (ÚÔÒıËÛË Ô˘Ú‹ıÚ·˜ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋) ¤ÁÈÓ Û 222 “·ÛıÂÓ›˜”, Ë ÂÁ¯Â›ÚËÛË ªathieu ¤ÁÈÓ Û 179 “·ÛıÂÓ›˜”, ÂÓÒ ÂÁ¯Â›ÚËÛË Ì ÌÈÛ¯ˆÙfi ÎÚËÌÓfi ·ÎÚÔÔÛı›·˜ ¤ÁÈÓ Û 40 “·ÛıÂÓ›˜”. OÈ ‰ÈÔÚıÒÛÂȘ fiÏˆÓ ÙˆÓ ÌÔÚ-
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ÊÒÓ ˘ÔÛ·‰›·, ‰ËÏ·‰‹ ¢ıÂÈ·ÛÌfi˜ ÙÔ˘ ¤Ô˘˜ Î·È ÙÔÔı¤ÙËÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘ ¤ÁÈÓ·Ó Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ. ªÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜ ÙÔ˘ ˘ÔÛ·‰›· ›ӷÈ: 1) ÙÔ Û˘Ú›ÁÁÈÔ (‹ Û˘Ú›ÁÁÈ·) Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜, ÙÔ ÔÔ›Ô ·ÚÔ˘Û›·Û·Ó 59 ÂÚÈÙÒÛÂȘ ÛÙÔ ˘ÏÈÎfi Ì·˜ (13,4%), 2) Ë ˘Ô¯ÒÚËÛË Ù˘ Ô˘Ú‹ıÚ·˜ ÌÂÙ¿ ÂÁ¯Â›ÚËÛË ÚÔÒıËÛ˘ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋ Û 4 ÂÚÈÙÒÛÂȘ (1,8%). ∞˘Ù¤˜ ÔÈ 4 ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Ó ÙȘ ÚÒÙ˜ ÂÁ¯ÂÈÚ‹ÛÂȘ Ù˘ ÛÂÈÚ¿˜ ÙˆÓ 222 ‚·Ï·ÓÈÎÒÓ Î·È ÛÙÂÊ·ÓÈ·›ˆÓ ˘ÔÛ·‰›ˆÓ Ô˘ ‰ÈÔÚıÒÛ·Ì Ì ÙËÓ Ù¯ÓÈ΋ Ì·˜. ∏ ˘Ô¯ÒÚËÛË Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠·ÓÂÁ¯Â›ÚËÛË Î·Ù¿ Mathieu, ÂÓÒ Ù· Û˘Ú›ÁÁÈ· Ù˘ Ô˘Ú‹ıÚ·˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙË ÁÓˆÛÙ‹ ÎÏ·ÛÈ΋ Ù¯ÓÈ΋, Ô˘ Û˘Ó›ÛÙ·Ù·È Û Ó·ÚÔÔ›ËÛË ÙˆÓ ÈÛÙÒÓ ÙÔ˘ Û˘ÚÈÁÁ›Ô˘ Î·È Û˘ÚÚ·Ê‹ Û ÛÙÚÒÌ·Ù· Ì ·ÚÈÔ Ì¤ÏËÌ· ÙËÓ ·ÔÊ˘Á‹ ·ʋ˜ ÙˆÓ Ú·ÌÌ¿ÙˆÓ ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ÛÙÚÒÌ·ÙÔ˜ Ì ٷ Ú¿ÌÌ·Ù· ÙÔ˘ ˘ÂÚΛÌÂÓÔ˘. ™˘ÌÂÚ¿ÛÌ·Ù· ∞fi ÙÔ ˘ÏÈÎfi ·˘Ùfi Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ô ˘ÔÛ·‰›·˜ ·) Â›Ó·È ÌÈ· Û˘Ó‹ı˘ Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ‚) ÚÔηÏ› ÛÔ‚·Ú¿ ÏÂÈÙÔ˘ÚÁÈο Î·È Î·Ù' ¤ÎÙ·ÛË „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, Á) ÌÔÚ› Ó· ‰ÈÔÚıˆı› Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ, Ô ÔÔ›Ô˜ ÛÙԯ‡ÂÈ ÛÙÔÓ Â˘ıÂÈ·ÛÌfi ÙÔ˘ ¤Ô˘˜ Î·È ÛÙËÓ ÙÔÔı¤ÙËÛË Ù˘ Ô˘Ú‹ıÚ·˜ ‹ Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ ÛÙË ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘, ‰) ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÏÔ΋, Ë ÔÔ›· Â›Ó·È Û˘ÚÚ›ÁÈÔ Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ Û ÔÛÔÛÙfi 13,4%. µÈ‚ÏÈÔÁÚ·Ê›· 1. Keramidas D, Soutis M. Urethra advancement, granduloplasty and preputioplasty in distal hypospadias. Eur J Peditr Surg 1995;5:348-351. 2. Mathieu P. Traitement en un temps de l’ hypospadias balanique et juxta-balanique. J Chir 1932;39:481-484. 3. Duckett JW. The island flap techique for hypospadias repair. Urol Clin N ∞m1981;8:503-511.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢. ∫ÂÚ·Ì›‰·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” 115 27, °Ô˘‰›, ∞ı‹Ó·
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Paediatriki 2001;64:315-317
ASSOCIATED SUBSPECIALTIES
∫ÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË
Criteria for referral of children to the ophthalmologist A. Koidou-Tsiligianni
¶ÂÚ›ÏË„Ë: O ·È‰›·ÙÚÔ˜ Â›Ó·È Ô ÚÒÙÔ˜ ÁÈ·ÙÚfi˜ Ô ÔÔ›Ô˜ ı· ‰È·ÈÛÙÒÛÂÈ ÙËÓ ‡·ÚÍË ÔÊı·ÏÌÔÏÔÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔ ·È‰›, ›Ù ÛÙ· Ï·›ÛÈ· Ù˘ ÂÚÈÔ‰È΋˜ ÂͤٷÛ˘, ›Ù ÁÈ·Ù› Û ·˘ÙfiÓ Û˘Ó‹ıˆ˜ ·Â˘ı‡ÓÔÓÙ·È ÚˆÙ·Ú¯Èο ÔÈ ÁÔÓ›˜ fiÙ·Ó ‰È·ÈÛÙÒÛÔ˘Ó Î¿ÔÈÔ ·Ó¿ÏÔÁÔ Úfi‚ÏËÌ·. ∆· ÎÚÈÙ‹ÚÈ· Ì ٷ ÔÔ›· ı· ·Ú·ÂÌÊı› ÙÔ ·È‰› ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ·ÊÔÚÔ‡Ó Ù· ·È‰È¿ ÌÂ Ù˘¯·›· ‰È·›ÛÙˆÛË ÔÊı·ÏÌÔÏÔÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ Û ÂͤٷÛË ÚÔ˘Ù›Ó·˜ (.¯. Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ‰È·Ù·Ú·¯‹ fiÚ·Û˘), Ì ¿ıËÛË ÙˆÓ ÔÊı·ÏÌÒÓ Ô˘ ··ÈÙ› ÂȉÈ΋ ÂͤٷÛË Î·È ıÂڷ›· ·fi ÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ (.¯. ÊÏÂÁÌÔÓ‹, Ïԛ̈ÍË, ÙÚ·‡Ì·), ‹ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ¿ıËÛË Ô˘ ¤¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ‹ ÂÈÏÔΤ˜ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜.
Abstract: The general pediatrician is the first doctor who will ascertain the presence of an eye disorder in the child, either during a routine physical examination (well child physical examination), or because of the parents’ concern when they notice a relevant disorder. The criteria for referring a child to the pediatric ophthalmologist include the incidental finding of an eye disorder during a routine physical examination (i.e. congenital anomaly, vision disorder), the presence of an ophthalmological condition that requires specific examination and treatment by an ophthalmologist (i.e. inflammation, infection, trauma), or the existence of a systemic disorder associated with eye pathology or complications from the eyes.
§¤ÍÂȘ ÎÏÂȉȿ: ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, ·Ú·ÔÌ‹ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ.
Key words: ophthalmological disorder, referral to the ophthalmologist.
O ·È‰›·ÙÚÔ˜, fiÓÙ·˜ ÂÍ ÔÚÈÛÌÔ‡ Ô ÁÈ·ÙÚfi˜ ÙÔ˘ ·È‰ÈÔ‡, Â›Ó·È ·˘Ùfi˜ Ô˘ ı· ÂÍÂÙ¿ÛÂÈ ÚÒÙÔ˜ Ù· Ì¿ÙÈ· Î·È ÙËÓ fiÚ·Û‹ ÙÔ˘ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ı· ÁÂÓÓËı›. °È· ÔÏÏ¿ ¯ÚfiÓÈ· Â›Ó·È ·˘Ùfi˜ ÛÙÔÓ ÔÔ›Ô ı· ·Â˘ı˘ÓıÔ‡Ó ÔÈ ÁÔÓ›˜ fiÙ·Ó ‰È·ÈÛÙÒÛÔ˘Ó Î¿ÔÈÔ ÔÊı·ÏÌÔÏÔÁÈÎfi Úfi‚ÏËÌ· (1). £· ·Ú·ı¤ÛÔ˘ÌÂ Û˘ÓÔÙÈο Ù· ÎÚÈÙ‹ÚÈ· Ì ٷ ÔÔ›· Ô ·È‰›·ÙÚÔ˜ ı· ·Ú·¤Ì„ÂÈ ÙÔ ·È‰› ÁÈ· ÂͤٷÛË Î·È ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ÛÙÔÓ ÂȉÈÎfi ÔÊı·ÏÌ›·ÙÚÔ. °È· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ¯ˆÚ›˙Ô˘Ì ٷ ·È‰È¿ o˘ ¯Ú‹˙Ô˘Ó ·Ú·ÔÌ‹˜ Û ÙÚÂȘ ηÙËÁÔڛ˜: ·) Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, ‚) ·È‰È¿ Ì ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, Á) ·È‰È¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ.
¶·Ú·ÔÌ‹ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ ¶ÚfiÎÂÈÙ·È ÁÈ· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, Ô˘ ηٿ ÙËÓ ÂÚÈÔ‰È΋ ÂͤٷÛË ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜ ‰È·ÈÛÙÒÓÂÙ·È ÔÊı·ÏÌÔÏÔÁÈÎfi Úfi‚ÏËÌ·. ∫·ÙˆÙ¤Úˆ ·Ú·ı¤ÙÔ˘Ì ÙËÓ ÚÔÙÂÈÓfiÌÂÓË ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘, ηıÒ˜ Î·È Ù· ÎÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ (2,3). 1. ¡ÂÔÁÓ¿: ∂ÍÂÙ¿˙ÂÙ·È ÚˆÙ›ÛÙˆ˜ Ë ·ÎÂÚ·ÈfiÙËÙ· ÙˆÓ ÔÊı·ÏÌÒÓ, Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÎfiÁ¯Ô˘ Î·È Ë ·ÚÔ˘Û›· ‹ ÌË ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ì ·Ïfi Ê·Îfi ¯ÂÈÚfi˜ (ÂÈÛÎfiËÛË) Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂϤÁ¯ÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘ Ì ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÙÔ˘ ʈÙfi˜.
OÊı·ÏÌÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
Division of Ophthalmology “P. & A. Kyriakou” Children’s Hospital of Athens
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ªÂ ÙÔ ÔÊı·ÏÌÔÛÎfiÈÔ Û ·fiÛÙ·ÛË 30 ÂηÙÔÛÙÒÓ ÂϤÁ¯ÂÙ·È Ë ÚÔ‰›ÓË ·ÓÙ·‡ÁÂÈ· ÙÔ˘ ‚˘ıÔ‡. ¶·Ú·¤ÌÔÓÙ·È Ù· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ‰È·ÈÛÙÒÓÂÙ·È ÔÔÈ·‰‹ÔÙÂ Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ·‰˘Ó·Ì›· ¤ÎÏ˘Û˘ ÙÔ˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ÙÔ˘ ʈÙfi˜, Ô˘ Ê˘ÛÈÔÏÔÁÈο ÂÎχÂÙ·È ÌÂÙ¿ ÙËÓ 32Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘, ‹ ÛÎÔÙÂÈÓfi, ‹ Ï¢Îfi ¤ÏÏÂÈÌÌ· ÛÙË ÚÔ‰›ÓË ·ÓÙ·‡ÁÂÈ· ÙÔ˘ ‚˘ıÔ‡. 2. µÚ¤ÊË 6 - 8 ÌËÓÒÓ: ™ÙËÓ ËÏÈΛ· ·˘Ù‹ ÂÍÂÙ¿˙ÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘, ÂϤÁ¯ÔÓÙ·˜ Ò˜ ÚÔÛËÏÒÓÂÈ Î·È Ò˜ ·Ú·ÎÔÏÔ˘ı› ¤Ó· ʈÙÂÈÓfi ÛÙfi¯Ô ‹ ¤Ó· ·ÓÙÈΛÌÂÓÔ Î¿ı ̿ÙÈ ¯ˆÚÈÛÙ¿. ∂ÍÂÙ¿˙ÂÙ·È Â›Û˘, Ô Û˘Á¯ÚÔÓÈÛÌfi˜ ÙˆÓ ÎÈÓ‹ÛÂˆÓ ÙˆÓ ‚ÔÏ‚ÒÓ Î·È Ë ‡·ÚÍË - ‹ ÌË - ÛÙÚ·‚ÈÛÌÔ‡ Ì ÙȘ ·ÓÙ·Ó·ÎÏ¿ÛÂȘ ÙÔ˘ ʈÙfi˜ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ Î·È ÙË ‰ÔÎÈÌ·Û›· Î¿Ï˘„˘. ∂ÊfiÛÔÓ ‰È·ÈÛÙˆı› ÛÙÚ·‚ÈÛÌfi˜, ¿ÚÓËÛË ÛÙËÓ Î¿Ï˘„Ë ÙÔ˘ ÂÓfi˜ ÔÊı·ÏÌÔ‡ Î·È ·‰˘Ó·Ì›· ÚÔۋψÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ÛÙfi¯Ô˘, ÙfiÙ ÙÔ ‚Ú¤ÊÔ˜ ·Ú·¤ÌÂÙ·È ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ÁÈ· ¤ÏÂÁ¯Ô Ù˘ ·ÈÙ›·˜ ηْ ·Ú¯¿˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÁÈ· ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ Î·È Ù˘ ÌÂȈ̤Ó˘ fiÚ·Û˘. ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ÚÔ‰›Ó˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ ‚˘ıÔ‡ Ì ÙÔ ÔÊı·ÏÌÔÛÎfiÈÔ. 3. ¡‹È· 3 - 5 ÂÙÒÓ: ∏ ËÏÈΛ· ·˘Ù‹ Â›Ó·È Ë Î·Ù¿ÏÏËÏË ÁÈ· Ó· Á›ÓÂÈ Î·È Ë ÔÛÔÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ fiÚ·Û˘. ™ÙÔÓ ÔÈÎÂ›Ô ¯ÒÚÔ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ È·ÙÚ›Ԣ, ÙÔ ·È‰› ÂÍÂÙ¿˙ÂÙ·È Û ÂȉÈÎÔ‡˜ ›Ó·Î˜ ÂϤÁ¯Ô˘ Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÁÈ· Ù· Ó‹È·. ¶·Ú·¤ÌÔÓÙ·È Ù· ·È‰È¿, ÛÙ· ÔÔ›· ‰È·ÈÛÙÒÓÂÙ·È ÔÙÈ΋ Ô͇ÙËÙ· ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜, ÌÈÎÚfiÙÂÚË ‹ ›ÛË ·fi 5/10. ∂›Û˘, ÂϤÁ¯ÂÙ·È Ë ÔÊı·ÏÌÔÎÈÓËÙÈÎfiÙËÙ· Î·È Ë ‡·ÚÍË - ‹ ÌË ÛÙÚ·‚ÈÛÌÔ‡. ∂ÎÙfi˜ ·fi ÙÔ Û˘ÁÁÂÓ‹ ÛÙÚ·‚ÈÛÌfi, ÛÙËÓ ËÏÈΛ· ·˘Ù‹ ·Ú·ÙËÚÂ›Ù·È Î·È Ô ÚÔÛ·ÚÌÔÛÙÈÎfi˜ ÛÙÚ·‚ÈÛÌfi˜, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È ·Ó·Áη›Ô Ó· Á›ÓÂÈ ¤ÁηÈÚ· Ì ٷ ηٿÏÏËÏ· ‰ÈoÚıˆÙÈο Á˘·ÏÈ¿. ∏ ·Ó·Î¿Ï˘„Ë Ù˘ ·Ì‚Ï˘ˆ›·˜ Î·È ÙÔ˘ ·ÈÙ›Ô˘ Ô˘ ÙËÓ ÚÔοÏÂÛÂ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÈ, ÙÔ ·ÚÁfiÙÂÚÔ, ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· (4). 4. ¶·È‰È¿ >5 ÂÙÒÓ: ™ÙÔ˘˜ ›Ó·Î˜ ÙÔ˘ Snellen ÂÍÂÙ¿˙ÂÙ·È Î¿ı ¯ÚfiÓÔ Ë ÔÙÈ΋ Ô͇ÙËÙ· Î·È ÙÔ ·È‰› ·Ú·¤ÌÂÙ·È fiÙ·Ó ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜ ¤¯ÂÈ fiÚ·ÛË Î¿Ùˆ ·fi 7/10. O ¤ÏÂÁ¯Ô˜ Ù˘ ÔÊı·ÏÌÔÎÈÓËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ‚˘ıÔ‡ Û˘ÌÏËÚÒÓÔ˘Ó ÙËÓ ÂͤٷÛË. ¶·Ú·ÔÌ‹ ·È‰ÈÒÓ Ì ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ· ¶ÚfiÎÂÈÙ·È ÁÈ· ·È‰È¿ Ô˘ ÚˆÙÔÂÌÊ·Ó›˙Ô˘Ó ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, ·ÏÏ¿ ·Ú¯Èο ·Â˘ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÚÒÙË ÂͤٷÛË ÛÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜. OÈ Û˘ÓËı¤ÛÙÂÚ˜ ·Èٛ˜ ›ӷÈ:
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1. ∆Ô “∫fiÎÎÈÓÔ Ì¿ÙÈ” ¶¿Óˆ ·fi 20 Èı·Ó¤˜ ·Èٛ˜ ÚÔηÏÔ‡Ó ÂÚ˘ıÚfiÙËÙ· ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÚfiÎÂÈÙ·È ÁÈ· ·Ï¤˜ ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜ ÂÈÂÊ˘Î›Ùȉ˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·Ï¿ ·ÓÙÈ‚ÈÔÙÈο ÎÔÏχÚÈ· ·fi ÙÔÓ ·È‰›·ÙÚÔ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Û˘Ó‹ıˆ˜, Ë ÂÚ˘ıÚfiÙËÙ· Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚË, ˘¿Ú¯Ô˘Ó ˘‰·Ú›˜ ‹ ˘Ò‰ÂȘ ÂÎÎÚ›ÛÂȘ, ÈÛÙÔÚÈÎfi ÚfiÛÊ·Ù˘ ›ˆÛ˘ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÊÔ›ÙËÛË Û ·È‰ÈÎfi ÛÙ·ıÌfi Î.Ï. ∆Ô ·È‰› ‰ÂÓ ˘ÔʤÚÂÈ, Ô‡Ù ÔÓ¿ÂÈ. ¶ÂÚÈÛÛfiÙÂÚÔ, ÔÈ ÁÔÓ›˜ ÂÓÔ¯ÏÔ‡ÓÙ·È ·fi ÙË ı¤· ÙˆÓ ÎfiÎÎÈÓˆÓ Ì·ÙÈÒÓ. OÈ Û˘¯ÓfiÙÂÚ˜ ηÙËÁÔڛ˜ ÓfiÛˆÓ Ô˘ ÂΉËÏÒÓÔÓÙ·È Ì “ÎfiÎÎÈÓÔ Ì¿ÙÈ” (5,6) ›ӷÈ: ∞) ºÏÂÁÌÔÓ¤˜ ¶ÚfiÛıÈÔ˘ ∏ÌÈÌÔÚ›Ô˘, fiˆ˜ i) ¡ÂÔÁÓÈ΋ ÔÊı·ÏÌ›·, ii) ∂ÈÂÊ˘Î›Ùȉ· (ªÈÎÚԂȷ΋, πÔÁÂÓ‹˜, ∞ÏÏÂÚÁÈ΋), iii) ∫ÂÚ·Ù›Ùȉ· (∂ÚËÙÈ΋, ŒÏÎÔ˜ ÎÂÚ·ÙÔÂȉԇ˜), iv) πÚȉÔ΢ÎÏ›Ùȉ· (π‰ÈÔ·ı‹˜, Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘). µ) ∆Ú·‡Ì·Ù·, fiˆ˜ i) ÀfiÛÊ·ÁÌ·, ii) ∆Ú·˘Ì·ÙÈ΋ ·fiÙˆÛË ÂÈıËÏ›Ô˘ ÎÂÚ·ÙÔÂȉԇ˜, iii) •¤ÓÔ ÛÒÌ· ÎÂÚ·ÙÔÂȉԇ˜, iv) ¢È·ÌÂÚ¤˜ ÙÚ·‡Ì· ‚ÔÏ‚Ô‡. °) ŒÁη˘Ì·. ¢) °Ï·‡ÎˆÌ·, i) ¶ÚˆÙÔ·ı¤˜-™˘ÁÁÂÓ¤˜, ii) ¢Â˘ÙÂÚÔ·ı¤˜ (ÚÂÙÈÓÔ‚Ï¿Ûو̷). ∆· ÎÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ı· Â›Ó·È Ë ‰·ÎÚ‡ÚÚÔÈ·, Ô fiÓÔ˜, Ë ıfiψÛË ÎÂÚ·ÙÔÂȉԇ˜, ÙÔ ÈÛÙÔÚÈÎfi ÚfiÛÊ·ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÙÔ ÂÚËÙÈÎfi ÂÍ¿ÓıËÌ· ‚ÏÂÊ¿ÚˆÓ ‹ ÙÔ ÈÛÙÔÚÈÎfi Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘. 2. ªÂȈ̤ÓË fiÚ·ÛË ÕÏÏÔ Û‡Ìو̷ ÔÊı·ÏÌÔÏÔÁÈ΋˜ ÓfiÛÔ˘ Â›Ó·È Ë ‰È·›ÛÙˆÛË, ·fi Ù· ›‰È· Ù· ·È‰È¿ ‹ ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ÌÂȈ̤Ó˘ fiÚ·Û˘ ÛÙÔÓ ¤Ó· ‹ Î·È ÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜. ø˜ ·›ÙÈ· ÌÂȈ̤Ó˘ fiÚ·Û˘ ·Ó·Ê¤ÚÔÓÙ·È: i) ÔÈ ·Ó·ÙÔÌÈΤ˜ ‚Ï¿‚˜ ÔÙÈ΋˜ Ô‰Ô‡, ii) ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, iii) Ô ÛÙÚ·‚ÈÛÌfi˜ ·Ì‚Ï˘ˆ›·, iv) ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, v) Ë ËÌÈÎÚ·Ó›· Î·È vi) Ë ˘ÛÙÂÚÈ΋ Ù‡ÊψÛË. ∏ ÌÂȈ̤ÓË fiÚ·ÛË Â›Ó·È ·fi ÌfiÓË Ù˘ ÎÚÈÙ‹ÚÈÔ ·Ú·ÔÌ‹˜. ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›Ó·È ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ŸÙ·Ó, fï˜, Û˘Ì‚·›ÓÂÈ ·ÈÊÓ›‰È· ‹ Û ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÙfiÙ ڤÂÈ Ó· ·ÔÎÏÂÈÛıÔ‡Ó ¿ÏϘ ÛÔ‚·Ú¤˜ ·Èٛ˜. O ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÂϤÁÍÂÈ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, fiÙ·Ó ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi, ÛÙ· ·È‰È¿ Ô˘ Û˘ÓÂÚÁ¿˙ÔÓÙ·È, ‹ ÙËÓ ÈηÓfiÙËÙ· ÚÔۋψÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓfi˜ ÛÙfi¯Ô˘ ÛÙ· ‚Ú¤ÊË, Û οı ̿ÙÈ ¯ˆÚÈÛÙ¿. ∂¿Ó ‰È·ÈÛÙˆı› Ì›ˆÛË Ù˘ fiÚ·Û˘, ÙÔ ·È‰› ı· Ú¤ÂÈ Ó· ·Ú·ÂÌÊı› ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ. 3. ¡ÔÛ‹Ì·Ù· ÙÔ˘ ÎfiÁ¯Ô˘ ª›· ÂȉÈ΋ ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ ÁÈ· Ù· ÔÔ›·
MAY- JUNE '01 TELIKO
30-05-03
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¶·È‰È·ÙÚÈ΋ 2001;64:315-317
·Â˘ı‡ÓÔÓÙ·È ·Ú¯Èο ÛÙÔÓ ·È‰›·ÙÚÔ, Â›Ó·È Ù· ÓÔÛ‹Ì·Ù· ÙÔ˘ ÎfiÁ¯Ô˘. OÈ Î˘ÚÈfiÙÂÚ˜ ·ı‹ÛÂȘ ÙÔ˘ ÎfiÁ¯Ô˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È Ë ÂÚÈÎÔÁ¯È΋ ÎÔÁ¯È΋ ΢ÙÙ·Ú›ÙȘ, ÔÈ ·ÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜, Ë ı˘ÚÂÔÂȉÈ΋ ÔÊı·ÏÌÔ¿ıÂÈ·, ÔÈ fiÁÎÔÈ (ηÏÔ‹ıÂȘ, ηÎÔ‹ıÂȘ), Ù· ÙÚ·‡Ì·Ù· (·È̿و̷, οٷÁÌ·). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÚfiÎÂÈÙ·È ÁÈ· ÊÏÂÁÌÔÓ¤˜ Ù˘ ÂÚÈÎÔÁ¯È΋˜ ÂÚÈÔ¯‹˜ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÁÈ· ÛÔ‚·Ú¤˜ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ÎÔÁ¯ÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ∆· ÛËÌ›· Ù˘ ÊÏÂÁÌÔÓ‹˜, ÙÔ Ô›‰ËÌ· ÙˆÓ ‚ÏÂÊ¿ÚˆÓ, Ë ˘ÂÚ·ÈÌ›·, Ô fiÓÔ˜, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ‚ÔÏ‚Ô‡, Ë ‰Èψ›· Â›Ó·È Û˘Ó‹ıˆ˜ ÚÔÂÍ¿Ú¯ÔÓÙ· Î·È ·ÔÙÂÏÔ‡Ó ·ÈÙ›· ¿ÌÂÛ˘ ÂͤٷÛ˘ ·fi ÔÊı·ÏÌ›·ÙÚÔ. ∂ÎÙfi˜ fï˜ ·fi ·˘Ù¿, Ë ‰È·›ÛÙˆÛË, Û οı ÂÚ›ÛÙ·ÛË, ÂÍfiÊı·ÏÌÔ˘ Ô˘ - ‹ ¯ˆÚ›˜ Ó· - Û˘Óԉ‡ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÛÙËÓ fiÚ·ÛË, ·ÔÙÂÏ› ÛÔ‚·Úfi ÏfiÁÔ ·Ú·ÔÌ‹˜ (6). ¶·Ú·ÔÌ‹ ·È‰ÈÒÓ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ ¶·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ·fi Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ ÛÙËÓ ÔÔ›· ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯ÂÈ ‹ Ó· ÚÔÛ‚¿ÏÂÙ·È Ô ÔÊı·ÏÌfi˜, Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÁÈ· ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË, Ô˘ ¿ÏÏÔÙ ¯ÚËÛÈ̇ÂÈ ÛÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ¿ÏÏÔÙ ÚÔÏ·Ì‚¿ÓÂÈ ÙȘ ÂÈÙÒÛÂȘ Ù˘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ (7). OÈ Î˘ÚÈfiÙÂÚ˜ ÔÌ¿‰Â˜ Ù¤ÙÔÈˆÓ ÓÔÛËÌ¿ÙˆÓ Â›Ó·È: ∞) ¡ÔÛ‹Ì·Ù· Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡: Û˘ÁÁÂÓ‹ (‚ÏÂÓÓÔÔÏ˘Û·Î¯·ÚȉÒÛÂȘ), ÎÔÏÏ·ÁÔÓÒÛÂȘ (ÚÂ˘Ì·ÙÔÂȉ‹˜ ·ÚıÚ›ÙȘ, ‰ÂÚÌ·ÙÔÌ˘ÔÛ›ÙȘ, ÛÎÏËÚÔ‰ÂÚÌ›· Î.Ï.), ¿ÏÏ· ÓÔÛ‹Ì·Ù· (Û‡Ó‰ÚÔÌÔ Marfan). µ) ™˘ÁÁÂÓ›˜ ‹ ›ÎÙËÙ˜ Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ: ÈÔÁÂÓ›˜ (ÂÚËÙÈΤ˜ ÏoÈÌÒÍÂȘ, AIDS), ÌÈÎÚԂȷΤ˜ (ÛË„·ÈÌ›·, ‚·ÎÙËÚȷ΋ ÂÓ‰Ôηډ›Ùȉ·), Ì˘ÎËÙÈ·ÛÈΤ˜ (ÈÛÙÔÏ¿Û̈ÛË, ηÓÙÈÓÙ›·ÛË), ·Ú·ÛÈÙÈΤ˜ (ÙÔÍÔÏ¿Û̈ÛË, ÏÂ˚ÛÌ·Ó›·ÛË). °) ∞ÏÏÂÚÁÈΤ˜ Î·È ¿ÏϘ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜. ¢) ∂Ó‰ÔÎÚÈÓÔÏÔÁÈο ÓÔÛ‹Ì·Ù·: ÓÔÛ‹Ì·Ù· ı˘ÚÂÔÂȉԇ˜, ÓÔÛ‹Ì·Ù· ·Ú·ı˘ÚÂÔÂȉÒÓ, ۷ί·Ú҉˘ ‰È·‚‹Ù˘. ∂) ¶·ı‹ÛÂȘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜: ˘‰ÚÔΤʷÏÔ˜, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, Û˘ÁÁÂÓ›˜ ÏÔÈÌÒ-
Paediatriki 2001;64:315-317
ÍÂȘ, ʷΈ̷ÙÒÛÂȘ, ÂÎÊ˘ÏÈÛÙÈο ÓÔÛ‹Ì·Ù· (™∫¶), fiÁÎÔÈ. ™Ù) ∫ÂÊ·Ï·ÏÁ›·, Ë ÔÔ›· ·ÔÙÂÏ› ¤Ó· ηıËÌÂÚÈÓfi Úfi‚ÏËÌ· Ô˘ ··Û¯ÔÏ› ÙÔÓ ·È‰›·ÙÚÔ. ¶Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ Â¿Ó Î·È fiÙ ı· ·Ú·¤Ì„ÂÈ ¤Ó· ·È‰› Ô˘ ·Ú·ÔÓÂ›Ù·È ÁÈ· ÎÂÊ·Ï·ÏÁ›·, ·fi ÙË ÛÙÈÁÌ‹ Ô˘ Â›Ó·È ¤Ó· Û˘¯Ófi Û‡Ìو̷, ÙÔ ÔÔ›Ô Ô‰ËÁ› Ù· ·È‰È¿ ÛÙÔÓ ·È‰›·ÙÚÔ. ¢‡Ô Â›Ó·È ÔÈ ÏfiÁÔÈ Ô˘ ı· ˙ËÙËı› ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ÛÙ· Ï·›ÛÈ· ÂϤÁ¯Ô˘ Ù˘ ÎÂÊ·Ï·ÏÁ›·˜ Î·È ‰È¤Ô˘Ó ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë: Ë ÂͤٷÛË ÙÔ˘ ‚˘ıÔ‡ ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ë ‰È·›ÛÙˆÛË Ù˘¯fiÓ ‰È·ıÏ·ÛÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ô˘ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÎÂÊ·Ï·ÏÁ›·. ∞Ó¿ÏÔÁ· Ì ÙÔ ÈÛÙÔÚÈÎfi, ÙÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘, ÙË Û˘ÓÔ‰fi - ‹ ÌË - Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î.Ï., Ë ·Ú·ÔÌ‹ ı· Á›ÓÂÈ ÂÂÈÁfiÓÙˆ˜ ‹ ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÂͤٷÛË. ™Â ÔÔÈ·‰‹ÔÙ ÂÚ›ÙˆÛË, Ë ·Á·ÛÙ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰È¿ÙÚÔ˘ Ì ÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ı· Â›Ó·È ÚÔ˜ fiÊÂÏÔ˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓ‹. µÈ‚ÏÈÔÁÚ·Ê›· 1. Bacal DA, Rousta ST, Herte RW. Why early vision screening matters. Contemp Pediatr 1999;16:155-167. 2. American Academy of Pediatrics. Eye examination and vision screening in infants, children and young adults. Pediatrics 1996;98:53-55. 3. American Academy of Ophthalmology. Policy statement: Vision screening for infants and children; 1996. 4. Bacal DA, Herte RV. Don’t be lazy about looking for amblyopia. Contemp Pediatr 1998;15:99-107. 5. Grin TR, Nelson NB, Jeffers JB. Eye injuries in Childhood. Pediatrics 1987;80:13-18. 6. Robinson H. Diseases of the Orbit. In: Harley RB, ed. Pediatric Ophthalmology. 2nd ed. Philadelphia: W.B.Saunders Company; 1983. p. 349. 7. Day S. Uveal Manifastations (noninflammatory) of Systemic Disease. In: Taylor D, ed. Pediatric √phthalmology. 1st ed. Boston: Blackwell Scientific Publications; 1990. p. 287.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË OÊı·ÏÌÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “ ¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
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¶·È‰È·ÙÚÈ΋ 2001;64:318
Paediatriki 2001;64:318
¶∞ƒOƒ∞ª∞ / ∂RRATUM ™ÙËÓ ÂÚÁ·Û›· Ì ٛÙÏÔ “∆ÔÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Ï·Ú˘ÁÁÔÙÚ·¯ÂÈÔ‚ÚÔÁ¯›Ùȉ·˜” Ë ÔÔ›· ‰ËÌÔÛȇıËΠÛÙÔÓ ∆fiÌÔ 64, ÛÂÏ. 59-64 ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫∏”, ·Ó·ÁÚ¿ÊËÎÂ Ô ÂÈÛÙËÌÔÓÈÎfi˜ Ù›ÙÏÔ˜ Ù˘ Î. ª·Ú›·˜ ∂ÌÔÚÈ¿‰Ô˘ ˆ˜ “∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ·” ·ÓÙ› ÁÈ· “∂›ÎÔ˘ÚË ∫·ıËÁ‹ÙÚÈ·”. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫∏”, ηıÒ˜ Î·È Ô ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡, Ô˘‰fiψ˜ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ ·Ú·¿Óˆ Ï¿ıÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤ÙÛÈ ‹Ù·Ó ‰È·Ù˘ˆÌ¤ÓÔ˜ Ô ÂÈÛÙËÌÔÓÈÎfi˜ Ù›ÙÏÔ˜ Ù˘ Î. ∂ÌÔÚÈ¿‰Ô˘ ÛÙËÓ ÚˆÙfiÙ˘Ë ÂÚÁ·Û›· Ô˘ ˘Ô‚Ï‹ıËΠÁÈ· ÎÚ›ÛË, ÙËÓ ÔÔ›· ›¯·Ó ˘ÔÁÚ¿„ÂÈ fiÏÔÈ ÔÈ Û˘ÁÁÚ·Ê›˜. ∂ÈϤÔÓ, ‰ÂÓ ¤ÁÈÓ η̛· ·ÏÏ·Á‹ ÙÔ˘ ÂÈÛÙËÌÔÓÈÎÔ‡ Ù›ÙÏÔ˘ Ù˘ Î. ∂ÌÔÚÈ¿‰Ô˘ ÛÙÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ Ô˘ ÂÛÙ¿ÏË ÛÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÁÈ· Ù˘¯fiÓ ‰ÈÔÚıÒÛÂȘ ÚÈÓ ÙËÓ ÙÂÏÈ΋ ‰ËÌÔÛ›Â˘ÛË. ªÂÙ¿ ÙË ‰ËÌÔÛ›Â˘ÛË Ù˘ ·Ú·¿Óˆ ÂÚÁ·Û›·˜ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫∏”, Ë Î. ª. ∂ÌÔÚÈ¿‰Ô˘ ˙‹ÙËÛ ÂÁÁڿʈ˜ Ó· ‰ÈÔÚıˆı› ÙÔ Ï¿ıÔ˜ Ô˘ ¤ÁÈÓ ÂÎ ·Ú·‰ÚÔÌ‹˜ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û¯ÂÙÈο Ì ÙÔÓ ÂÈÛÙËÌÔÓÈÎfi Ù˘ Ù›ÙÏÔ.
∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹
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10Ë ¢ÈËÌÂÚ›‰· ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛÂˆÓ ¶ÏËÚÔÊÔڛ˜: ∫ÒÛÙ·˜ ¶Ú›ÊÙ˘ ∆ËÏ.: 8036 472 Fax: 6131 173
∞ı‹Ó·
8-12 ª·˝Ô˘
27Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ ª·È¿Ó‰ÚÔ˘ 23 ∆ËÏ.: 7211 845 & 7243 161 Fax: 7215 082 e-mail: iea@mednet.gr
∞ı‹Ó·
10-12 ª·˝Ô˘
¢ÈÂıÓ¤˜ ™˘Ó¤‰ÚÈÔ Ì ı¤Ì·: "The Consequences in adult age of endocrine diseases in childhood" ¶ÏËÚÔÊÔڛ˜: µ·ÛÈÏÈ΋ ª¿‰Ô˘ ∆ËÏ.: 031-447 444 Fax: 031-282 476 e-mail: Krassas@the.forthnet.gr
£ÂÛÛ·ÏÔÓ›ÎË
18-20 ª·˝Ô˘
2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¶·È‰Ô„˘¯È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ∂ÏÏ¿‰Ô˜ "æ˘¯Ôۈ̷ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ – £ÂˆÚËÙÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ" ¶ÏËÚÔÊÔڛ˜: Easy Travel ∆ËÏ.: 3615 201 & 3609 442 Fax: 3125 572 e-mail: easytravel@fol.gr
∞ı‹Ó·
1-3 πÔ˘Ó›Ô˘
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
17-20 πÔ˘Ó›Ô˘
European Society for Paediatric Hematology and Oncology (ESPHI)
Lucerne, ∂Ï‚ÂÙ›·
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2Ô ¶·ÁÎfiÛÌÈÔ ™˘Ó¤‰ÚÈÔ §Â˚ÛÌ·Ó›·Û˘ ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∆ËÏ.: 7499 312 ¤ˆ˜ 317 Fax: 7705 752
∫Ú‹ÙË
5-8 ∞˘ÁÔ‡ÛÙÔ˘
European Society for Pediatric Research Congreszon Ltd/ESPR Itälahdenkatu 22A 00210 Helsinki, Finland Fax: +358 9 5840 9555
∂ÏÛ›ÓÎÈ, ºÈÏ·Ó‰›·
2-4 ™ÂÙÂÌ‚Ú›Ô˘
The fetus as a patient: International course ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∫· ¶¤ÓË Ã·Ù˙ËÁˆÚÁ›Ô˘ ∆ËÏ.: 01 7499 312 ¤ˆ˜ 317 Fax: 01 7705 752
πˆ¿ÓÓÈÓ·
9-14 ™ÂÙÂÌ‚Ú›Ô˘
11th International Clinical Genetics Seminar "The Genetics of Diabetes Mellitus" ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∆ËÏ.: 01 7499 300 Fax: 01 7713 795 e-mail: congress@triaenatours.gr
∏Ú¿ÎÏÂÈÔ
9-14 ™ÂÙÂÌ‚Ú›Ô˘
23rd International Congress of Pediatrics ¶ÏËÚÔÊÔڛ˜: Chinese Medical Association 42 Dongsi Xidajie, Beijing 100710, China ∆ËÏ.: 86-10-6527 8804 / 6527 8803 Fax: 86-10-65-123-754 e-mail: 231CP@chinamed.com.cn.
Beijing, ∫›Ó·
23-27 ™ÂÙÂÌ‚Ú›Ô˘
World Congress of Perinatal Medicine ¶ÏËÚÔÊÔڛ˜: Santiago Dexeus Font Foundation Paeso Bonanova 67, 08017 Barcelona ∆ËÏ.: +34 (93) 227 4709 Fax: +34 (93) 418 78 32 e-mail: Fundacio@indexus.uab.es
µ·ÚÎÂÏÒÓË, πÛ·Ó›·
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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˘ÁΤÓÙÚˆÛË 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
xxi
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·326
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·
by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) 9 giga- (10 ) 6 mega-(10 ) 3 kilo- (10 ) 2 hecto(10 ) 1 deca (10 ) -1 deci (10 ) -2 centi- (10 ) -3 milli(10 ) -6 micro (10 ) -9 nano (10 ) -12 pico (10 ) -15 femto (10 ) -18 atto (10 )
xxii
Combining prefixes T G M k h da d c m Ì n p f a
MAY- JUNE '01 TELIKO
30-05-03
18:55
™ÂÏ›‰·327
Συνταγογραφικές Πληροφορίες ∆ιαφηµιζόµενων Προϊόντων
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 %