COVER MAY-JUNE02 24-04-02 14:33 ™ÂÏ›‰·1 ISSN 0377-2551
¶AI¢IATPIKH
●
TOMO™ 65
●
TEYXO™ 3
●
ETO™ 2002
ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3
∞ƒ£ƒO ™À¡∆∞•∏™ ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘
EDITORIAL 147
∞. ™Î·Ú‰Ô‡ÙÛÔ˘
A. Skardoutsou
∞¡∞™∫O¶∏™∂π™ π‰ÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙ· ·È‰È¿ (πº¡∂)
REVIEW ARTICLES 151
∂. ƒÒÌ·-°È·ÓÓ›ÎÔ˘
™‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ: ¶·ıÔÁ¤ÓÂÈ· Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘
160
ORIGINAL ARTICLES 167
∞. ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ 174
Comparison of high-frequency oscillatory ventilation with conventional mechanical ventilation in the treatment of respiratory distress syndrome in preterm infants V. Drossou-Agakidou, K. Sarafidis, P. Karagianni, E. Diamanti, N. Nikolaidis, G. Kremenopoulos
182
ª. ÷ڛÛË, ∂. °·Ï·Ó¿Î˘, ª. ∆˙Ô‡ÊË, ™. ™ÙÂÊ¿ÓÔ˘-§Â‚ÂȉÈÒÙÔ˘, ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
™˘ÌÂÚÈÊÔÚ¿, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹, ÙËÏÂı¤·ÛË Î·È ·È¯Ó›‰È Ì·ıËÙÒÓ ÛÙÔȯÂÈÒ‰Ô˘˜ Âη›‰Â˘Û˘ ÛÙËÓ ∫Ú‹ÙË
Botulinum toxin type A intramuscular injections in the treatment of spasticity in cerebral palsy A. Syrigou-Papavasiliou
µ. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, ∂. ¢È·Ì·ÓÙ‹, ¡. ¡ÈÎÔÏ·˝‰Ë˜, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜
∏ ÛÈÁΤÏψÛË ÛÙËÓ ◊ÂÈÚÔ Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985 - 1999
Increased capillary permeability syndrome (Leak syndrome): Pathogenesis and the newest evidence for its management M. Katsara, K. Papazoglou
Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙÔ˘ ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÓÂÔÁÓÒÓ
Inflammatory bowel disease (IBD) in children E. Roma-Giannikou
ª. ∫·ÙÛ¿Ú·, ∫. ¶·¿˙ÔÁÏÔ˘
∂Ó‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË
Botulinum toxin A for the treatment of cerebral palsy
Shigellosis in the region of Epirus during the 15year period from 1985 to 1999 M. Charisi, E. Galanakis, M. Tzoufi, S, Stephanou-Levidiotou, Z. Papadopoulou-Couloumbis
186
Nutritional habits, TV viewing, body health care and playing behavior of elementary school students in Crete, Greece
∫. ∞Ó˘Ê·ÓÙ¿Î˘, ª. ∞Ó˘Ê·ÓÙ¿ÎË, ∂. •˘ÏÔ‡ÚË, ∂. ™·Îο, Ã. §ÈÔÓ‹˜, ¡. ∞ÓÙˆÓ¿Î˘
K. Anyphantakis, M. Anyphantaki, I. Xylouri, I. Sakka, C. Lionis, N. Antonakis
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
May - June 2002 . Volume 65 . No 3
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·1
M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
CASE REPORTS
∂¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ À‰Ú·ÓÂÁÎÂÊ·Ï›· Û ÓÂÔÁ¤ÓÓËÙÔ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘
195
G. Baroutis, J. Kaleyias, C. Kacoulis, I. Paulidis, A. Gouliamos
°. ª·ÚÔ‡Ù˘, π. ∫·Ï¤ÁÈ·˜, ∫. ∫·ÎÔ˘ÏÏ‹˜, π. ¶·˘Ï›‰Ë˜, ∞. °Ô˘ÏÈ¿ÌÔ˜
™˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi
199
203
208
CURRENT ISSUES
∂¶π∫∞πƒ∞ £∂ª∞∆∞ 212
The assessment and management of pain in children G. Tsolas, G. Kafalidis, G. Triantafyllidis
°. ∆ÛfiÏ·˜, °. ∫·Ê·Ï›‰Ë˜, °. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜
LITERATURE ABSTRACTS
¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ ÕÛıÌ· Ô˘ “ÍÂÂÚ¿ÛÙËΔ ‰ÂÓ ÛËÌ·›ÓÂÈ ·Ô˘Û›· ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ
Rickettsial disease with clinical presentation mimicking Kawasaki disease M. Bitsori, E. Galanakis, D. Mamoulakis, E. Vasilaki, M. Antoniou, S. Sbyrakis
ª. ªÈÙÛÒÚË, ∂. °·Ï·Ó¿Î˘, ¢. ª·ÌÔ˘Ï¿Î˘, ∂. µ·ÛÈÏ¿ÎË, ª. ∞ÓÙˆÓ›Ô˘, ™. ™Ì˘Ú¿ÎȘ
∂ÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿
Congenital tuberculÔus lymphadenitis in a preterm infant Z. Hatzistamatiou, J. Kaleyias, U. Ikonomidou, E. Papathoma, E. Prifti, V. Petrocheilou-Paschou, Ch. Kostalos
∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘, π. ∫·Ï¤ÁÈ·˜, O. OÈÎÔÓÔÌ›‰Ô˘, ∂. ¶··ıˆÌ¿, ∂. ¶Ú›ÊÙË, µ. ¶ÂÙÚԯ›ÏÔ˘-¶¿Û¯Ô˘, Ã. ∫ÒÛÙ·ÏÔ˜
ƒÈÎÂÙÙÛÈÒÛÂȘ Ì ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓfiÛÔ˘ Kawasaki
Congenital chylothorax in a neonate G. Baroutis, M. Apostolou, J. Kaleyias, S. Sevastiadou, A. Antsaklis, C. Costalos
°. ª·ÚÔ‡Ù˘, ª. ∞ÔÛÙfiÏÔ˘, π. ∫·Ï¤ÁÈ·˜, ™. ™Â‚·ÛÙÈ¿‰Ô˘, ∞. ∞ÓÙ˙·ÎÏ‹˜, Ã. ∫ÒÛÙ·ÏÔ˜
™˘ÁÁÂÓ‹˜ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ÚfiˆÚÔ ÓÂÔÁÓfi
Hydranencephaly in a neonate. A case report
150
Outgrown asthma does not mean no airways inflammation
Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al Greek translation: M. Anthrakopoulos
™˘Ó¯›˙ÔÓÙ·È
Continued
May - June 2002 . Volume 65 . No 3
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·2
ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
ªÂϤÙË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ì·ÁÓËÛ›Ô˘ ÛÂ Û˘ÁÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT
Continuation of table of contents
166
Hoshino K, Ogawa K, Hishitani T, Kitazawa R ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.™. µ·ÚÏ¿Ì˘
ª›· ·Ï‹ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÚÔÛÒÔ˘
Hoshino K, Ogawa K, Hishitani T, Kitazawa R Greek translation: G.S, Varlamis 173
Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.™. µ·ÚÏ¿Ì˘
∏ ¯Ú‹ÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡
181
A 13C-urea breath test in children with Helicobacter pylori infection: assessment of eradication therapy and follow-up after treatment Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al Greek translation: G. Kafritsa
211
Kalliomaki M, Salminen S, Avrilomni H, Kero P, Koskinen P, Isolauri E ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. ∫·ÊÚ›ÙÛ·
™‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ Úfi‚Ï„˘ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÛÙ· ·È‰È¿
A simple method for evaluating abnormal lengthening of the QT interval during the face immersion test Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al Greek translation: G.S, Varlamis
Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. ∫·ÊÚ›ÙÛ·
∆· ÚÔ‚ÈÔÙÈο ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘
Studies of magnesium in congenital long QT syndrome
Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial Kalliomaki M, Salminen S, Avrilomni H, Kero P, Koskinen P, Isolauri E Greek translation: G. Kafritsa
218
Manczur TI, Greenough A, Pryor D, Rafferty GF ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∞. ÷Ù˙‹˜
Comparison of predictors of extubation from mechanical ventilation in children Manczur TI, Greenough A, Pryor D, Rafferty GF Greek translation: A. Hatzis
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xiii
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xvii
Abbreviations
May - June 2002 . Volume 65 . No 3
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·3
M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002
.
∆fiÌÔ˜ 65
. ∆‡¯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
TËÏ.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354
Tel.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354
EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∫. ª·Ï·Î¿ ¢È¢ı˘ÓÙ‹˜ : ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ M¤ÏË : ∂. ∞ÁÁÂÏ¿ÎË-°ÂˆÚÁ¿ÎË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ : °. µ·ÚÏ¿Ì˘ : ¶. ∫·ÊÚ›ÙÛ· : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ : £. ∆ÛÈÏÈÁÈ¿ÓÓ˘ : ∫. ∆ÛÔ˘Ì¿Î·˜ : ™. ºˆÙfiÔ˘ÏÔ˜ : A. ÷Ù˙‹˜
Scientific President Editor Members
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘
Manuscript Editing
∂È̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
English Editing Z. Papadopoulou-Couloumbis
∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: 010-7771 140 / 010-7771 663, Fax: 010-7758 354
Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 010-7771 140 / 010-7771 663, Fax: 010-7758 354
™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜
Publishing Coordinator
E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶. ∆۷ω¿ÚË 3, 151 22 M·ÚÔ‡ÛÈ TËÏ.: 010-61 41 360-5 Fax: 010-61 41 366
SCIENTIFIC PUBLICATIONS Ltd P. Tsaldari 3, Marousi 151 22 Tel.: 010-61 41 360-5 Fax: 010-61 41 366
EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹
29,35
Annual Subscription
EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜:
14,67
All foreign countries: US $ 30
Editorial Board : K. Malaka : Z. Papadopoulou-Couloumbis : E. Agelaki-Georgaki : F. Athanassiadou-Piperopoulou : M. Anthrakopoulos : G. Varlamis : P. Kafritsa : A. Konstadopoulos : Th. Tsiligiannis : K. Tsoumakas : S. Fotopoulos : ∞. Hatzis
Greek Editing I. Karavranou
M a y - J u n e 2 0 0 2 .V o l u m e 6 5 .N o 3
πSSN 0377-2551 i
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·5
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫H” 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∫H” ·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∫H”. ∂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∫H” 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· Excel 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 30 ËÌÂÚÒÓ 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 ‰‡Ô (2) 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˘.
v
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·6
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˘ ηÈ
vi
‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·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.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·7
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
vii
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·147
¶·È‰È·ÙÚÈ΋ 2002;65:147-150
∞ƒ£ƒO ™À¡∆∞•∏™
Paediatriki 2002;65:147-150
EDITORIAL
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ∞. ™Î·Ú‰Ô‡ÙÛÔ˘
Botulinum toxin A for the treatment of cerebral palsy A. Skardoutsou
¶ÂÚ›ÏË„Ë: ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·ÛÊ·Ï‹˜ Î·È Î·ÏÒ˜ ·ÓÂÎÙ‹ Û ¿Û¯ÔÓÙ˜ ·fi ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ·ÔÙÂÏ› Ë Î·Ù¿ÏÏËÏË ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ. ∆· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÂÈÙ˘Á¯¿ÓÔÓÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ÂÛÙȷ΋ Û·ÛÙÈÎfiÙËÙ· ÛÙÔ˘˜ Ì˘˜ ÌÈ·˜ ¿ÚıÚˆÛ˘ ‹ Û ÛÂÈÚ¿ ÁÂÈÙÔÓÈÎÒÓ Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Á΢ÏÒÛÂȘ, Ô‡Ù ÛËÌ·ÓÙÈ΋ Ì˘˚΋ ·‰˘Ó·Ì›·. ∏ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ ·ÔÙÂÏ› ıÂڷ¢ÙÈÎfi ÛÙfi¯Ô, ·ÏÏ¿ ÂȉÈÒÎÂÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÂÏÙȈı› Ë Î›ÓËÛË, Ë Ê˘ÛÈÔıÂڷ›·, Ó· ÚÔÏËÊıÔ‡Ó ÔÈ ·Á΢ÏÒÛÂȘ Î·È Ó· ÌÂÙ·ÙÂıÔ‡Ó ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ. OÈ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ Ú¤ÂÈ Ó· Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ÓÔÈ Î·È ÚÔÛ·ÚÌÔṲ̂ÓÔÈ ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ οı ·ÛıÂÓ‹.
Abstract: Botulinum toxin is a well tolerated, safe, and effective mode of therapy for the treatment of patients with spastic cerebral palsy. Appropriate patient selection is imperative. Best results are achieved in patients with focal spasticity, involving one or more neighboring joints, in the absence of fixed contractures or significant weakness of the injected muscles. Reduction of the spasticity is not necessarily the final therapeutic goal. The purpose of its administration is to control the spasticity and, in so doing, optimize patient function and comfort and prevent contractures. The expected goals of therapy should definitely be established and reviewed prior to therapy in order to develop an individualized plan that is appropriate for the needs of each patient.
§¤ÍÂȘ ÎÏÂȉȿ: ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, ·ÓÙÈÌÂÙÒÈÛË.
Key words: cerebral palsy, botulinum toxin, treatment.
∂ÈÛ·ÁˆÁ‹ ∏ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Â›Ó·È ÌË ÚÔԉ¢ÙÈ΋ ÎÏÈÓÈ΋ Û˘Ó‰ÚÔÌ‹, ÚÔηÏÂ›Ù·È ·fi ‚Ï¿‚˜ ÛÙËÓ ÎÈÓËÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ·ÓÒÚÈÌÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ì›· ÔÈÎÈÏ›· ·fi ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ™ÙË Û·ÛÙÈ΋ ÌÔÚÊ‹, Ë ÔÔ›· Û˘Ó·ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ·, ÂÛÙȷΤ˜ ÂÚÈÔ¯¤˜ Û·ÛÙÈÎfiÙËÙ·˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ·ÓÈÛÔÚÚÔ›· ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Âη٤ڈıÂÓ Ù˘ ¿ÚıÚˆÛ˘, Ë ÔÔ›· ÂÎÙfi˜ ·fi ÙËÓ ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Á΢ÏÒÛÂȘ, ·Ó·ÛÙÔÏ‹ Ù˘ ·‡ÍËÛ˘ ÙˆÓ ·ÁˆÓÈÛÙÒÓ Ì˘ÒÓ Î·È ÂÈÌ‹Î˘ÓÛË Î·È Ì˘˚΋ ·‰˘Ó·Ì›· ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ. °È· Ó· ·ÔηٷÛÙ·ı› Ë ÈÛÔÚÚÔ›· Ú¤ÂÈ Ó· ÌÂȈı› Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ ÙˆÓ ÈÔ ÂÓÂÚÁËÙÈÎÒÓ Ì˘ÒÓ Ù˘ ¿ÚıÚˆÛ˘. °È· ÙÔ ÛÎÔfi ·˘Ùfi ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ıÂڷ¢ÙÈο ̤ÙÚ· fiˆ˜ Ë Ê˘ÛÈÔıÂ-
ڷ›·, Ë ÂÎÏÂÎÙÈ΋ ÓˆÙÈ·›· ÚÈ˙ÔÙÔÌ‹, ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ Î·È Ê¿Ú̷η. ∆· ÙÂÏÂ˘Ù·›· ‰¤Î· ¯ÚfiÓÈ· ÚÔÛÙ¤ıËΠÛÙË ıÂڷ›· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È Ë ÙÔÈ΋ ¤Á¯˘ÛË ÛÙÔ˘˜ Ì˘˜ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ. º·ÚÌ·ÎÔÏÔÁ›· Î·È Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ·Ú¿ÁÂÙ·È ·fi ÙÔ Clostiridium Botulinum Î·È ÚÔηÏ› ·Ú¿Ï˘ÛË, ÂÂȉ‹ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ Ó¢ÚÔÌ˘˚ÎÔ‡ ‰È·‚È‚·ÛÙ‹ ·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË ·fi ÙȘ Ó¢ÚÈΤ˜ ·ÔÏ‹ÍÂȘ fiÙ·Ó ÂÓÂı› ÎÔÓÙ¿ ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë. ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÔÓ‡ڈÛË ÙÔ˘ Ì˘fi˜ Î·È Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌÔ. ∏ ÙÔÍ›ÓË ¤¯ÂÈ ÂÈϤÔÓ ÙËÓ ›‰È· ‰Ú¿ÛË ÛÙȘ ¯ÔÏÈÓÂÚÁÈΤ˜, ·Ú·Û˘Ì·ıËÙÈΤ˜ Î·È Û˘Ì·ıËÙÈΤ˜ ›Ó˜, Ì ·ÔÙ¤ÏÂÛÌ·
µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
2nd Pediatric Clinic of University of Athens Children’s Hospital “P. & A. Kyriakou”, Athens
147
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·148
¶·È‰È·ÙÚÈ΋ 2002;65:147-150
Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. Œ¯Ô˘Ó Ù·˘ÙÔÔÈËı› ÂÙ¿ ·ÓÙÈÁÔÓÈο ‰È·ÊÔÚÂÙÈÎÔ› ÔÚfiÙ˘ÔÈ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ, fiˆ˜ ÔÈ Ù‡ÔÈ A, B, C, D, E, F Î·È G. ™ÙÔ ÂÌfiÚÈÔ ‰È·Ù›ıÂÓÙ·È ‰‡Ô ·Ú·Û΢¿ÛÌ·Ù· ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ (BOTOX Î·È DYSPORT) Ù· ÔÔ›·, ·Ú¿ ÙÔ ÎÔÈÓfi Û‡ÛÙËÌ· ηÙËÁÔÚÈÔÔ›ËÛ˘, ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ÈÛ¯‡, ÂÓÒ ÂÈϤÔÓ ¤Ó· ·Ú·Û··ÛÌ· ÙÔ˘ Ù‡Ô˘ µ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÂÍÂÚÁ·Û›·˜. ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Â›Ó·È ÔÏ˘ÂÙ›‰ÈÔ ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi Ì›· ‚·Ú›· Î·È Ì›· ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ. ∏ ‚·Ú›· ¿Ï˘ÛÔ˜ Û˘Ó‰¤ÂÙ·È Ì¤Ûˆ ˘Ô‰Ô¯¤ˆÓ ˘„ËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ Ì ÙȘ Ó¢ÚÈΤ˜ ·ÔÏ‹ÍÂȘ Î·È Ë ÙÔÍ›ÓË ÂÈÛ¤Ú¯ÂÙ·È ÛÙÔ ÂÛˆÙÂÚÈÎfi Ù˘ ·fiÏË͢ Ì ÂÓ‰Ô·ÙÙˆÛË. ∂Λ, Ë ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ˜ ‰È·Û¿ ÂȉÈÎÔ‡˜ ‰ÂÛÌÔ‡˜ Ù˘ ÚˆÙ½Ó˘ Ô˘ ÚÔηÏ› ÙË Û‡ÓÙËÍË ÙˆÓ ¯ÔÏÈÓÂÚÁÈÎÒÓ Î˘ÛÙȉ›ˆÓ Ì ÙËÓ ÚÔÛ˘Ó·ÙÈ΋ ÌÂÌ‚Ú¿ÓË Î·È ÂÌÔ‰›˙ÂÈ ÙËÓ ÚÔÛ˘Ó·ÙÈ΋ ·ÂÏ¢ı¤ÚˆÛË Ù˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ (1). ∏ ·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË Ê˘ÛÈÔÏÔÁÈο ˘ÚÔ‰ÔÙ› ËÏÂÎÙÚÈο ‰˘Ó·ÌÈο Ù· ÔÔ›· ÚÔηÏÔ‡Ó ÙË Ì˘˚΋ Û‡Û·ÛË. ∏ ‰Ú¿ÛË Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙȘ ¯ÔÏÈÓÂÚÁÈΤ˜ Û˘Ó¿„ÂȘ Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Î·È ·Ó·ÛÙÚ¤„ÈÌË, ÂÂȉ‹ Ë ¯ÔÏÈÓÂÚÁÈ΋ ΢ÎÏÔÊÔÚ›· ·Ôηı›ÛÙ·Ù·È Î·È ÂÂȉ‹ ÛÙȘ ›‰È˜ ı¤ÛÂȘ Â΂ϷÛÙ¿ÓÔ˘Ó ÚÔÛˆÚÈÓ¿ Ӥ˜ Ó¢ÚÔÌ˘˚Τ˜ Û˘Ó¿„ÂȘ. ∏ Û·ÛÙÈÎfiÙËÙ· Â›Ó·È ¿ıÚÔÈÛÌ· ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ, fiˆ˜ ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ ÛÙËÓ ·ıËÙÈ΋ ‰È¿Ù·ÛË, ˘ÂÚÂÚÁÈο ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο Î·È ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ÎÈÓ‹ÛˆÓ. ∂›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ηٿÚÁËÛ˘ Ù˘ ·Ó·ÛÙÔÏ‹˜ Ô˘ ·ÛΛ ÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ¿Óˆ ÛÙ· ·-ÎÈÓËÙÈο ·ÙÙ·Ú· ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Ù· ÔÔ›· Á›ÓÔÓÙ·È ˘ÂÚ¢ÂÚ¤ıÈÛÙ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ÙfiÍÔ˘, ÌÂٷ͇ ·-ÎÈÓËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ì˘˚ÎÒÓ ·ÙÚ¿ÎÙˆÓ, ÙÔ ÔÔ›Ô Ú˘ıÌ›˙ÂÈ ÙÔ Ì˘˚Îfi ÙfiÓÔ. ™ÎÔfi˜ Ù˘ ıÂڷ›·˜ Ì ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Â›Ó·È Ë ÌÂÚÈ΋ ‹ Ï‹Ú˘ ·Ú¿Ï˘ÛË ÙÔ˘ ÂȉÈÎÔ‡ ÛÙfi¯Ô˘ (·ÁˆÓÈÛÙ¤˜ ̇˜) ¯ˆÚ›˜ Ó· ÂËÚ¿˙ÔÓÙ·È ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜. ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ΛÓËÛ˘ Î·È Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ̤ÏÔ˘˜, ÂÓÒ ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ̇˜ ÈÛ¯˘ÚÔÔÈÔ‡ÓÙ·È Ì ÙË Ê˘ÛÈÔıÂڷ›·. ∂ȉÈÒÎÂÙ·È Ë ‰È·Ù‹ÚËÛË Ù˘ ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÂϤÁ¯Ô˘ Ù˘ ΛÓËÛ˘ Î·È ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ‰Ú¿Û˘ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ. ∏ ÂÍ·Ê¿ÓÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ Ô‰ËÁ› ·Ó·ÁηÛÙÈο Û ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ Ì˘˚΋˜ ÔÌ¿‰·˜, ·ÏÏ¿ ·ÓÙ›ıÂÙ· ÌÔÚ› Ó· ·Ôηχ„ÂÈ Ù· ·ÚÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Ô˘ Â›Ó·È Ë Ì˘˚΋ ·‰˘Ó·Ì›· Î·È Ë ·ÒÏÂÈ· Ù˘ ÂȉÂÍÈfiÙËÙ·˜.
148
Paediatriki 2002;65:147-150
∂ÎÙ›ÌËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ per se ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Â›Ó·È ÙÔ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ·, Ë Ì¤ÙÚËÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ΛÓËÛ˘ ÛÙËÓ ¿ÚıÚˆÛË, Ù˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ Ì˘fi˜, Ù˘ Ì˘˚΋˜ ÈÛ¯‡Ô˜, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘fi˜, fiˆ˜ Á›ÓÂÙ·È Ì ÙȘ Îϛ̷Θ Ashworth (2) Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂȉÂÍÈfiÙËÙ·˜. ∏ ÂÎÙ›ÌËÛË Á›ÓÂÙ·È 1-3 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙȘ ÂÓ¤ÛÂȘ. ™ËÌ·ÓÙÈÎfi Â›Ó·È Ó· ·ÔÙÈÌËı› ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Û˘ÓÔÏÈ΋˜ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ (·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, Ê˘ÛÈÔıÂڷ›·, ÂÚÁÔıÂڷ›·, Á‡„ÈÓÔÈ Ó¿ÚıËΘ Î·È ÔÚıÒÛÂȘ). °È· ÙË Û˘ÓÔÏÈ΋ ·ÔÙ›ÌËÛË ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ̤ıÔ‰ÔÈ fiˆ˜ Â›Ó·È Ë ÎÈÓËÌ·ÙÈ΋ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘, Ë Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ Î·È ÔÈ ÌÂÙ·‚ÔϤ˜ ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Î›ÓËÛË, ηıÒ˜ Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Ì ‚¿ÛË ÔÚÈṲ̂Ó˜ Îϛ̷Θ. ∂›Û˘, ·ÔÙÈÌ¿Ù·È Î·È Ë ÚÔÛˆÈ΋ ÈηÓÔÔ›ËÛË ÙÔ˘ ÎˉÂÌfiÓ· Î·È ÙÔ˘ ¿Û¯ÔÓÙ·. °È· ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‚ÈÓÙÂÔÙ·Èӛ˜ Ù˘ ‚¿‰ÈÛ˘, Û‡ÛÙËÌ· ·Ó¿Ï˘Û˘ Ù˘ ΛÓËÛ˘ Û ‰‡Ô ‹ ÙÚÂȘ ‰È·ÛÙ¿ÛÂȘ (3) ‹ ËÏÂÎÙÚÔÁˆÓÈfiÌÂÙÚ· Ô˘ ÌÂÙÚÔ‡Ó ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ΛÓËÛ˘. OÈ ÌÂÙÚ‹ÛÂȘ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Ì Îϛ̷Θ, fiˆ˜ Â›Ó·È Ë Gross Motor Functional Measure Î·È Performance Measure (4) Î·È Ë Physician Rating Scales (5), ¤¯Ô˘Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ÂÊ·ÚÌÔÁ‹. ¢ÂÓ ··ÈÙÔ‡Ó ÂȉÈÎfi ÂÍÔÏÈÛÌfi, ·ÏÏ¿ ‚·Û›˙ÔÓÙ·È ÛÙËÓ ·Ú·Ù‹ÚËÛË ÔÚÈÛÌ¤ÓˆÓ ‰˘Ó·ÌÈÎÒÓ ÎÈÓ‹ÛÂˆÓ fiˆ˜ Â›Ó·È ÙÔ Î¿ıÈÛÌ· ÔÎÏ·‰fiÓ, Ë ÈÔÔ‰›·, Ë ÁˆÓ›· ÙÔ˘ ÁfiÓ·ÙÔ˜, Ë Ù·¯‡ÙËÙ· Ù˘ ‚¿‰ÈÛ˘ Î·È Ô Ù‡Ô˜ Ù˘ ‚¿‰ÈÛ˘, Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘ ‰›ÓÔ˘Ó ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· ÙˆÓ Ì˘ÒÓ-ÛÙfi¯ˆÓ Ô˘ ¤¯Ô˘Ó ÂÈÏÂÁ› Î·È ÙËÓ ·Ó¿ÁÎË Û˘ÌÏËڈ̷ÙÈ΋˜ ıÂڷ›·˜. OÈ Îϛ̷Θ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ¤¯Ô˘Ó ÂÈÎÚÈı› fiÙÈ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÓȯÓ‡ÛÔ˘Ó ÌÈÎÚ¤˜ ÌÂÙ·‚ÔϤ˜ Û ¿Û¯ÔÓÙ˜ Ì ̤ÙÚÈ· ·ÓÈηÓfiÙËÙ· Î·È fiÙÈ Û·Ó Ì¤Û· Ù˘ ¤Î‚·Û˘ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ͯˆÚ›ÛÔ˘Ó ÙË ‚ÂÏÙ›ˆÛË, ·fi ÂΛÓË Ô˘ ·Ó·Ì¤ÓÂÙ·È ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi ·ÚÎÂÙ¤˜ ·ÓÔÈÎÙ¤˜, ·ÏÏ¿ Î·È ‰ÈϤ˜ Ù˘ÊϤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÙÔ˘˜ Ì˘˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, ȉȷ›ÙÂÚ· ÙÔÓ Á·ÛÙÚÔÎÓ‹ÌÈÔ Î·È ÙÔ˘˜ ÚÔÛ·ÁˆÁÔ‡˜. ¢È·ÈÛÙÒıËΠÂÏ¿ÙÙˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ Á·ÛÙÚÔÎÓËÌ›Ô˘ Ì˘fi˜, ‚ÂÏÙ›ˆÛË Ù˘ ·ıËÙÈ΋˜ ·ÏÏ¿ Î·È Ù˘ ‰˘Ó·ÌÈ΋˜ Ú·¯È·›·˜ ¤ÎÙ·Û˘
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·149
¶·È‰È·ÙÚÈ΋ 2002;65:147-150
ÙÔ˘ ¿ÎÚÔ˘ Ô‰fi˜, ÙfiÛÔ Î·Ù¿ ÙËÓ fiÚıÈ· ÛÙ¿ÛË fiÛÔ Î·È Î·Ù¿ ÙË ‚¿‰ÈÛË (2,3,5-7). ∂›Û˘, ‚ÂÏÙ›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ‰Ú¿Û˘ ÙÔ˘ ÚfiÛıÈÔ˘ ÎÓËÌÈ·›Ô˘ Î·È ‚ÂÏÙ›ˆÛË ÙÔ˘ ‰È·ÛÎÂÏÈÛÌÔ‡ (6). ∏ ‚ÂÏÙ›ˆÛË ‰È·ÚΛ 3 ¤ˆ˜ 6 Ì‹Ó˜, ·ÏÏ¿ ÌÂÙ¿ ·fi ‰È·‰Ô¯ÈΤ˜ ÂÁ¯‡ÛÂȘ, ̤¯ÚÈ Î·È 2 ¯ÚfiÓÈ· (5), ‰È·›ÛÙˆÛË Ô˘ ‰È·ÌfiÚʈÛ ÙËÓ ˘fiıÂÛË fiÙÈ Ë · ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÌÔÚ› Ó· ÌÂÙ·ı¤ÛÂÈ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ÛÙÔ˘˜ ·¯›ÏÏÂÈÔ˘˜ Ù¤ÓÔÓÙ˜ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, fiÙ·Ó Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ˘ÔÙÚÔ¤˜ ÌÂÈÒÓÂÙ·È. ™ÙÔ ·ÓÒÙ·ÙÔ ¿ÎÚÔ, Û ̛· ÌÂϤÙË 14 ·È‰ÈÒÓ, Ë ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ·‡ÍËÛ ÛËÌ·ÓÙÈο ÙË Ì¤ÁÈÛÙË ÂÓÂÚÁËÙÈ΋ ¤ÎÙ·ÛË ÛÙÔÓ ·ÁÎÒÓ· Î·È ÙÔ ÌÂÁ¿ÏÔ ‰¿ÎÙ˘ÏÔ, fiˆ˜ Î·È ÙËÓ Î¿Ì„Ë Î·È ÙÔ ¿ÓÔÈÁÌ· Ù˘ ·Ï¿Ì˘, fï˜ Ë ÏÂÙ‹ ÎÈÓËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, fiˆ˜ ·˘Ù‹ ÂÎÙÈÌ‹ıËΠ̠ÙË Û‡ÏÏË„Ë ÓÔÌÈÛÌ¿ÙˆÓ, ‰ÂÓ ‚ÂÏÙÈÒıËÎÂ Î·È Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ˘Û›·Û ÚÔÛˆÚÈÓ‹ Âȉ›ӈÛË (8). OÈ ¶·ÓÙÂÏÈ¿‰Ë˜ Î·È Û˘Ó ÌÂϤÙËÛ·Ó 12 ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÛÙ· ÔÔ›· Ô ‚·ıÌfi˜ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÂÎÙÈÌ‹ıËΠ̠ÙËÓ ÙÚÔÔÔÈË̤ÓË Îϛ̷η Ashworth Î·È ÙË ¯Ú‹ÛË ÁˆÓÈfiÌÂÙÚÔ˘ (9). OÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ˘ÂÚÙÔÓ›·˜ Û fiÏÔ˘˜ ÙÔ˘˜ Ì˘˜ Ô˘ ÂÓ¤ıËÎ·Ó Î·È ·‡ÍËÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ·ıËÙÈÎÒÓ Î·È ÂÓÂÚÁËÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÛÙÔ ÈÛ¯›Ô, ÙÔ ÁfiÓ·ÙÔ, ÙË Ú·¯È·›· ¤ÎÙ·ÛË ÙÔ˘ ¿ÎÚÔ˘ Ô‰fi˜, fiˆ˜ Î·È ÙÔ˘ ηÚÔ‡. ∏ ·ӿÏË„Ë ÙˆÓ ›‰ÈˆÓ ‰fiÛÂˆÓ ÌÂÙ¿ 5-6 Ì‹Ó˜ ›¯Â ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù·. ™Â Ì›· ‰Â‡ÙÂÚË ÂÚÁ·Û›·, Ë ÔÔ›· ‰ËÌÔÛȇÂÙ·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜, ¯ÔÚËÁ‹ıËΠ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Û 67 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, Û 89 Û˘Ó‰ڛ˜, Ù· ÔÔ›· ÂÎÙÈÌ‹ıËÎ·Ó ÎÏÈÓÈο. ∏ Û˘ÁÁڷʤ·˜ ·Ó·Ê¤ÚÂÈ fiÙÈ ÙÔ 85% ÙˆÓ ·ÛıÂÓÒÓ ¤Ù˘¯Â Ï‹Úˆ˜ ‹ ÌÂÚÈÎÒ˜ ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ÛÙfi¯Ô Ô˘ ›¯Â ÙÂı› ÚÈÓ ÙËÓ ¤Á¯˘ÛË. ∂ÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ∏ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ ·ÔÙÂÏ› ıÂڷ¢ÙÈÎfi ÛÙfi¯Ô, ·ÏÏ¿ ÂȉÈÒÎÂÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÂÏÙȈı› Ë Î›ÓËÛË, Ó· ‰È¢ÎÔÏ˘Óı› ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ê˘ÛÈÎÔıÂڷ›·˜ Î·È Ë ÂÚÈÔ›ËÛË ÙÔ˘ ·ÛıÂÓ‹, Î·È Ó· ÚÔÏËÊıÔ‡Ó ÔÈ ·Á΢ÏÒÛÂȘ Î·È ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ¶ÚÈÓ ·Ú¯›ÛÂÈ Ë ıÂڷ›·, Ú¤ÂÈ Ó· ˘ÔÏÔÁÈÛÙ› ÙÔ ÎÏÈÓÈÎfi fiÊÂÏÔ˜ ÁÈ· ÙÔÓ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ÛıÂÓ‹ Î·È Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ¤Ó·˜ ÛÙfi¯Ô˜ Ì ÙË Û˘ÓÂÚÁ·Û›· ÔÌ¿‰·˜ ÁÈ·ÙÚÒÓ, ıÂڷ¢ÙÒÓ Î·È ÎˉÂÌfiÓˆÓ, ·ÊÔ‡ ÏËÊıÔ‡Ó ˘’ fi„ÈÓ fiÏ· Ù· ˘¿Ú¯ÔÓÙ· ηٿÏÏËÏ· ıÂڷ¢ÙÈο ̤۷ Ù· ÔÔ›· ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË. OÈ Û˘¯ÓfiÙÂÚÔÈ ÏÂÈÙÔ˘ÚÁÈÎÔ› ÛÙfi¯ÔÈ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ‚¿‰ÈÛ˘ Î·È Ù˘ ÛÙ¿Û˘. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È ÎÚ›ÛÈÌË ÁÈ· ÙËÓ ÂÈÙ˘¯›· Ù˘ ıÂڷ›·˜. ∆Ô ‚·ÛÈÎfi ÎÚÈÙ‹ÚÈÔ Â›Ó·È Ë ·ÚÔ˘Û›· ›ÌÔÓ˘
Paediatriki 2002;65:147-150
‹ ‰˘Ó·ÌÈ΋˜ ˘ÂÚÙÔÓ›·˜ Î·È Ë ·Ô˘Û›· ·Á΢ÏÒÛˆÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË ‹ ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ ·Ú¿Ï˘Û˘. ™ÙÔ˘˜ ÂÓÂı¤ÓÙ˜ Ì˘˜ ‰ÂÓ ı· Ú¤ÂÈ, ›Û˘, Ó· ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÂÏÂÁ¯fiÌÂÓË (·fi ÙË Û·ÛÙÈÎfiÙËÙ·) Ì˘˚΋ ·‰˘Ó·Ì›·, Ë ÔÔ›· ÌÔÚ› Ó· ·ÔÎ·Ï˘Êı› ÌÂÙ¿ ÙȘ ÂÓ¤ÛÂȘ. ∂Ӊ›ÍÂȘ ÁÈ· ÙË ıÂڷ›· ÛÙÔ ¿Óˆ ¿ÎÚÔ Â›Ó·È Ë Â›ÌÔÓË Î¿Ì„Ë ÙÔ˘ ·ÓÙ›¯ÂÈÚ·, Ë ÌfiÓÈÌË ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ̤۷ ÛÙËÓ ·Ï¿ÌË, Ë Î¿Ì„Ë ÙÔ˘ ηÚÔ‡ Ô˘ ÂÌÔ‰›˙ÂÈ ÙË ¯Ú‹ÛË ÙÔ˘ ¯ÂÚÈÔ‡, Ë ÌÂÁ¿ÏË Î¿Ì„Ë ÙÔ˘ ·ÁÎÒÓ·. ™ÙÔ Î¿Ùˆ ¿ÎÚÔ, ÔÈ ÂӉ›ÍÂȘ Â›Ó·È Ë ‰˘Ó·ÌÈ΋ ÈÔÔ‰›· Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ·ÎÏÔ˘ ‚¿‰ÈÛ˘, Ë ‰˘Ó·ÌÈ΋ Î¿Ì„Ë ÙÔ˘ ÁfiÓ·ÙÔ˜ Û ÁˆÓ›· 20Ô Û fiÏÔ ÙÔÓ Î‡ÎÏÔ Ù˘ ‚¿‰ÈÛ˘ Î·È Ë ÛËÌ·ÓÙÈ΋ ÂÊ›Â˘ÛË ÙˆÓ ÈÛ¯›ˆÓ. ∞ÊÔ‡ ·ÔÊ·ÛÈÛÙ› Ë ıÂڷ›·, ÂÊ·ÚÌfi˙ÂÙ·È ¤Ó· Û¯¤‰ÈÔ ‚¿ÛÂÈ ·ÏÁfiÚÈıÌˆÓ (10). ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ‰È·Ù›ıÂÙ·È Û·Ó Î·Ù„˘Á̤ÓË ÍËÚ‹ ÛÎfiÓË Û ÊÈ·Ï›‰È·, Ù· ÔÔ›· ‰È·ÙËÚÔ‡ÓÙ·È Û 4ÔC Î·È Ú¤ÂÈ Ó· ·Ó·Û˘ÓÙÂı› Ì ‰È¿Ï˘Ì· ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ 0,9%. ªÂ ÙÔ BOTOX, ÔÈ ÌÈÎÚÔ› ̇˜ ÂÓ›ÂÓÙ·È Ì ‰fiÛË 1-3 U/kg B.™. Î·È ÔÈ ÌÂÁ¿ÏÔÈ 3-6 U/kg B.™. ∏ ̤ÁÈÛÙË ‰fiÛË ÛÙË ı¤ÛË Î¿ı ¤ÓÂÛ˘ Â›Ó·È 50 U. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÔÏÔÎÏ‹ÚˆÛ˘ ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ Ì ÂÓ¤ÛÂȘ, Ë Û˘ÓÔÏÈ΋ ‰fiÛË ÙÔ˘ BOTOX ·Ó¤Ú¯ÂÙ·È Û 15 U/kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ∏ ¤ÓÂÛË Á›ÓÂÙ·È Ì ۇÚÈÁÁ· Mantoux Î·È ‚ÂÏfiÓ· ÌÂÁ¤ıÔ˘˜ 27 Î·È Ì‹ÎÔ˘˜ 4 cm. O Ì˘˜ ‰È·Ù›ÓÂÙ·È Î·È Ë ¤Á¯˘ÛË Á›ÓÂÙ·È ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ̤ÁÈÛÙ˘ Ì˘˚΋˜ Ì¿˙·˜. ¶ÚˆÙfiÎÔÏÏ· Ù· ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ÂÓ¤ÛÂˆÓ ÌÔÚ› Ó· ··ÈÙ‹ÛÔ˘Ó ÌfiÓÔ ÙÔÈÎfi ·Ó·ÈÛıËÙÈÎfi. °È· ÈÔ ÂÎÙÂٷ̤ӷ ÚˆÙfiÎÔÏÏ· ÌÔÚ› Ó· ··ÈÙËı› Ë Î·Ù·ÛÙÔÏ‹ Ù˘ Û˘Ó›‰ËÛ˘ Î·È ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›·. ™Â ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, ÔÈ ÂÓ¤ÛÂȘ ÌÔÚ› Ó· ·ӷÏËÊıÔ‡Ó. ∂¿Ó ‰ÂÓ ·Ú·ÙËÚËı› ·¿ÓÙËÛË ÛÙȘ ÂÓ¤ÛÂȘ, ·˘Ùfi ÌÔÚ› Ó· ÛËÌ·›ÓÂÈ ·ÔÙ˘¯›· ‹ ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ ÙÔ͛Ӣ, Ù· ÔÔ›· ·Ó·Ù‡ÛÛÔÓÙ·È Û ÔÛÔÛÙfi 7% ÙˆÓ ·Û¯fiÓÙˆÓ. OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ì ÙËÓ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ∞ Â›Ó·È Û¿ÓȘ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó fiÓÔ ÛÙË ı¤ÛË Ù˘ ¤ÓÂÛ˘, ·ÈÌÔÚÚ·Á›·, ·›ÛıËÌ· „‡¯Ô˘˜ ÛÙÔ˘˜ ÂÓÂı¤ÓÙ˜ Ì˘˜, ÂÍ¿ÓıËÌ·, ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË, Û˘ÌÙÒÌ·Ù· Áڛ˘, ˘ÂÚ‚ÔÏÈ΋ ·‰˘Ó·Ì›·, ‰˘ÛÎÔÈÏÈfiÙËÙ· Î·È ÎfiˆÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Brin MF. Botulinum toxin: Chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 1997;6:S146-S168. 2. Boyd RN, Pliatsios V, Starr R, Wolfe R, Graham HK. Biomechanical transformation of the gastrocnemius muscle with botulinum toxin A in children with cerebral palsy. Dev
149
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·150
¶·È‰È·ÙÚÈ΋ 2002;65:147-150
Paediatriki 2002;65:147-150
Med Child Neurol 2000;42:32-41. 3. Graham HK, Aoki KR, Autti-Ramo I, Boyd RN, Delgado MR, Gaebler-Spira DJ et al. Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture 2000;11:67-79. 4. Boyce W, Gowland C, Rosenbaum P, Lane M, Plews N, Goldsmith C et al. Gross motor performance measure for children with cerebral palsy: study design and preliminary findings. Can J Public Health 1992;83(Suppl 2):S34-S40. 5. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group. J Pediatr Orthop 2000;20:108-115. 6. Koman LA, Brashear A, Rosenfeld S, Chambers H, Russman B, Rang M et al. Botulinum toxin type A neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial. Pediatrics 2001;108:1062-1071. 7. Bakheit AM, Severa S, Cosgrove A, Morton R, Rousso SH,
Doderlein L et al. Safety profile and efficacy of botulinum toxin A (Dysport) in children with muscle spasticity. Dev Med Child Neurol 2001;43:234-238. 8. Corry IS, Cosgrove AP, Walsh EG, McClean D, Graham HK. Botulinum toxin A in the hemiplegic upper limb: a double-blind trial. Dev Med Child Neurol 1997;39:185-193. 9. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã, ª·Ï¿Ûη ∞, ∆˙ËÙËÚ›‰Ô˘ ª, ∫ÔÙ˙·ÂÚ›‰Ô˘ O, ∫·Ú·Ù˙¿-•ÈÊÏ›‰Ô˘ ∂. ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. ¶·È‰È·ÙÚÈ΋ 2000;63:412-417. 10. Edgar TS. Clinical utility of botulinum toxin in the treatment of cerebral palsy: Comprehensive Review. J Child Neurol 2001;16:37-46.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 16-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÁÁÂÏÈ΋ ™Î·Ú‰Ô‡ÙÛÔ˘ Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 54, ∆.∫. 115 28, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ÕÛıÌ· Ô˘ “ÍÂÂÚ¿ÛÙËΔ ‰ÂÓ ÛËÌ·›ÓÂÈ ·Ô˘Û›· ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ∆Ô 30-80% ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ô˘ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙË ÓfiÛÔ, ·ÓÂΉËÏÒÓÔ˘Ó ·ÛıÌ·ÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ·ÚÁfiÙÂÚ· ÛÙË ˙ˆ‹ ÙÔ˘˜. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÈ· Ù¤ÙÔÈ· ÂͤÏÈÍË Â›Ó·È ÂÓ ÔÏÏÔ›˜ ¿ÁÓˆÛÙÔÈ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂϤÁ¯ıËÎÂ Ë ‡·ÚÍË ˘ÔΛÌÂÓ˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÛÙ· ·È‰È¿ Ô˘ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙÔ ¿ÛıÌ· ÙÔ˘˜. ªÂ ÌË ‚ÚÔÁ¯ÔÛÎÔÈ΋ ̤ıÔ‰Ô ÂÏ‹ÊıË ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· ·fi Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ (n=35) Î·È ·fi ·È‰È¿ Ì ÈÛÙÔÚÈÎfi Û˘ÚÈÁÌÔ‡ (n=35). µÚ¤ıËΠ·‡ÍËÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÛÙÔ ¤ÎÏ˘Ì· ·ÙÔÈÎÒÓ ·È‰ÈÒÓ Ô˘ ÂıˆÚ›ÙÔ fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙÔ ¿ÛıÌ· ÙÔ˘˜ (̤ÛË ÙÈÌ‹ [‡ÚÔ˜ ÌÂÛ·›ˆÓ ÙÂÙ·ÚÙËÌÔÚ›ˆÓ] 0,36 [0,050,74] Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ 0,10 [0-018], p=0,002). ¢ÂÓ ·Ó¢ڤıË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‰È¿ÚÎÂÈ·˜
150
‡ÊÂÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙÔ˘ ‚·ıÌÔ‡ ˈÛÈÓÔÊÈÏ›·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ™˘ÌÂÚ·›ÓÔÓÙ·˜, ˘¿Ú¯ÂÈ ÂÈÌÔÓ‹ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Û ÌÂÚÈο ·È‰È¿ Ô˘ ¤¯Ô˘Ó "ÍÂÂÚ¿ÛÂÈ" ÙÔ ¿ÛıÌ· ÙÔ˘˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ›Ûˆ˜ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. 1
Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al Outgrown asthma does not mean no airways inflammation Eur Respir J 2002;19:284-287
ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·151
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
∞¡∞™∫O¶∏™∏
Paediatriki 2002;65:151-159
REVIEW ARTICLE
π‰ÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙ· ·È‰È¿ (πº¡∂) ∂. ƒÒÌ· - °È·ÓÓ›ÎÔ˘
Inflammatory bowel disease (IBD) in children E. Roma - Giannikou
¶ÂÚ›ÏË„Ë: ∏ ȉÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ¯ÚfiÓÈÔ ÓfiÛËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Û˘¯Ó¿ ‰Â ÚÔ‚ÏËÌ·Ù›˙ÂÈ ÛÙË ‰È¿ÁÓˆÛË Î·È Î·Ù’ ÂÍÔ¯‹Ó ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ¶ÂÚ›Ô˘ ÙÔ 20% ÙˆÓ ÂÓËÏ›ÎˆÓ ¤¯ÂÈ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, fiÔ˘ Û˘Ó‹ıˆ˜ ¤¯ÂÈ ‚·Ú‡ÙÂÚË ÔÚ›·. ™‹ÌÂÚ· Ë ÚfiÔ‰Ô˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤Ú¢ӷ ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ¤¯ÂÈ ‚ÔËı‹ÛÂÈ ÛÙËÓ ·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏˆÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÊÏÂÁÌÔÓ‹˜. °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙËÓ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹, ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË Î·È ÙË ıÂڷ›·.
Abstract: Inflammatory bowel disease (πµD) is an important chronic disease of childhood that often presents problems regarding the diagnosis and especially the therapeutic approach. Almost 20% of adult cases have their oncet in childhood. The progress noted during the recent years concerning the pathogenesis of the disease has contributed significantly to the discovery of appropriate drugs for the treatment of the inflammatory process. This review article gives the current data concerning the pathogenesis, clinical presentation, diagnostic approach and the treatment of this disease entity.
§¤ÍÂȘ ÎÏÂȉȿ: πº¡∂, ÂÏÎ҉˘ ÎÔÏ›ÙȘ, ÓfiÛÔ˜ Crohn, ·È‰È¿.
Key words: IBD, ulcerative colitis, Crohn’s disease, children.
∂ÈÛ·ÁˆÁ‹ O fiÚÔ˜ πº¡∂ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ÂÚÈÁÚ·Ê‹ Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn, ‰‡Ô ȉÈÔ·ıÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Î·È Í¯ˆÚ›˙Ô˘Ó ÌÂٷ͇ ÙÔ˘˜ ·fi ÙËÓ ÂÓÙfiÈÛË Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÊÏÂÁÌÔÓ‹˜ (1-3). ∞ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ·ÎfiÌ· Î·È ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, ·ÏÏ¿ ηْ ÂÍÔ¯‹Ó ÛÙËÓ ÂÊ˂›· (3,4). ∂ȉËÌÈÔÏÔÁ›· OÈ ÌÂϤÙ˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ·fiÎÏÈÛË ÌÂٷ͇ ÙÔ˘˜ (5,6). ¶·ÁÎÔÛÌ›ˆ˜ ˘ÔÏÔÁ›˙ÂÙ·È
fiÙÈ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚ›Ô˘ 20 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ηÙÔ›ÎÔ˘˜ ÙÔ ¯ÚfiÓÔ, ÂÓÒ ‰È·ÈÛÙÒÓÂÙ·È ÛÙ·ıÂÚ‹ ·‡ÍËÛË Ù˘ Ó. Crohn ÌÂÙ¿ ·fi ÙÔ 1950. ™ÙËÓ ∞ÌÂÚÈ΋, Ë Û˘¯ÓfiÙËÙ· Û ·È‰È¿ 10-19 ¯ÚÔÓÒÓ Â›Ó·È 2/100.000 ÁÈ· ÙËÓ ∂∫ Î·È 3,5/100.000 ÁÈ· ÙË Ó. Crohn, ÂÓÒ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÚÔԉ¢ÙÈο ÌÂÈÒÓÂÙ·È Ë ËÏÈΛ· ¤Ó·Ú͢. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÂÚ›Ô˘ Û ÔÛÔÛÙfi 20% ÙˆÓ ·ÛıÂÓÒÓ Ì πº¡∂, Ù· Û˘ÌÙÒÌ·Ù· ·Ú¯›˙Ô˘Ó ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·. ™ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ·ÎfiÌË Î·Ù·ÁÚ·Ê‹ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ô‡Ù ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ Ô‡Ù ÛÙ· ·È‰È¿ ÛÙÔ Û‡ÓÔÏÔ Ù˘ ¯ÒÚ·˜. ™Ù· Ï·›ÛÈ· ∂˘Úˆ·˚΋˜ ÌÂϤÙ˘, ÌÂÌÔӈ̤ӷ ÛÙËÓ ∫Ú‹ÙË ·fi ÙÔÓ ª·ÓÔ‡ÛÔ Î·È Û˘Ó ‚Ú¤ıËÎÂ Ë Û˘¯ÓfiÙËÙ· Ù˘ ∂∫ 16,6 Î·È Ù˘ Ó. Crohn 7,5 ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜ Î·È ÛÙ· πˆ¿ÓÓÈÓ· ·fi ÙÔ˘˜ ∆ÛÈ¿ÓÔ Î·È Û˘Ó
¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
Pediatric Gastroenterology 1st Pediatric Clinic of University of Athens
151
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·152
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
Paediatriki 2002;65:151-159
8,5 Î·È 1 ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜, ·ÓÙ›ÛÙÔȯ· (6). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· ÓÔÛËχıËÎ·Ó 320 ·È‰È¿ (236 Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È 69 Ì ÓfiÛÔ Crohn) (¶›Ó·Î·˜ 1). °ÂÁÔÓfi˜ Â›Ó·È fiÙÈ ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· Û ÔÛÔÛÙfi 15-25% Î·È Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË Ì ˘Â‡ı˘Ó· Û˘ÁÎÂÎÚÈ̤ӷ ÁÔÓ›‰È· (7,8). ∫ÏÈÓÈ΋ ÂÈÎfiÓ· À¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ÌÂٷ͇ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È ÓfiÛÔ˘ Crohn (1-4) (¶›Ó·Î·˜ 2). ™ÙËÓ ÏÂÈÔÓfiÙËÙ·, Ù· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ∂∫ ¤¯Ô˘Ó ‹È· Û˘ÌÙÒÌ·Ù·, fiˆ˜ ‰È·ÚÚÔ˚Τ˜ ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ Î·È ‹È· ÎÔÈÏȷο ¿ÏÁË Ô˘ Û˘Ó‹ıˆ˜ ÂÓÙÔ›˙ÔÓÙ·È ÛÙÔ ·ÚÈÛÙÂÚfi ÎfiÏÔÓ. ªfiÓÔ Û ÔÛÔÛÙfi 5% ÚÔ¤¯Ô˘Ó ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, ·ÚıÚÔ¿ıÂÈ·, ‰ÂÚÌ·ÙÈΤ˜ ‹ Ë·ÙÈΤ˜ ÂΉËÏÒÛÂȘ. °ÂÓÈο, Ë ‚·Ú‡ÙËÙ· ÙˆÓ ·Ú¯ÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ù˘ ∂∫ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ÂÓÙÂÚÈ΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ Ù˘ ÂÚ·ÈÙ¤Úˆ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘ (1). ∂ÓÒ Ë ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ÚÚÔÈ· Â›Ó·È ÙÔ Î‡ÚÈÔ Û‡Ìو̷ Û ÂÚÈÛÛfiÙÂÚÔ ·fi 90% ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, Ë ·Ú¯È΋ ÚÔ‚ÔÏ‹ Ù˘ ÓfiÛÔ˘ Crohn Â›Ó·È ÈÔ ·ıfiÚ˘‚Ë. ∏ ÎÏ·ÛÈ΋ ÂÈÎfiÓ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÔÈÏȷο ¿ÏÁË, ‰È¿ÚÚÔÈ·, ·ÓÔÚÂÍ›· Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜. ∂ÓÙÔ‡ÙÔȘ, Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ë ÚÔ‚ÔÏ‹ Â›Ó·È Ï·Óı¿ÓÔ˘Û· Ì ÚÔÂÍ¿Ú¯Ô˘Û˜ ÙȘ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ηı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ‹È· ÌË ÂȉÈο ÂÓÙÂÚÈο Û˘ÌÙÒÌ·Ù·, Ô˘ Ô‰ËÁÔ‡Ó ÙÂÏÈο Û ¶›Ó·Î·˜ 1. ¶·È‰È¿ Ì πº¡∂ ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ* ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ¡fiÛÔ˜ Crohn Indeterminate ÎÔÏ›ÙȘ ∞˘ÙÔ¿ÓÔÛË ™‡ÓÔÏÔ
236 69 8 7 320
* ÌË ‰ËÌÔÛÈÂ˘Ì¤Ó· ‰Â‰Ô̤ӷ
¶›Ó·Î·˜ 2. ∫ÏÈÓÈ΋ ÂÈÎfiÓ·
¢È¿ÚÚÔÈ· ∞ÈÌÔÚÚ·Á›· ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ∫·ı˘ÛÙ. ÛˆÌ. ·Ó¿Ù˘ÍË ¶ÚÔ¤¯Ô˘Ó
152
∂ÏÎ.ÎÔÏ›ÙȘ
Crohn
50% >90% 65% 10% ∆ÂÈÓÂÛÌfi˜
80% 50% 80% 35% ∞ÓÔÚÂÍ›·, ÎÔÈÏ. ¿ÏÁË, Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ
ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘. ¶Ú¿ÁÌ·ÙÈ, ·fi ÙË ÌÂϤÙË Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÛÙ· ·È‰È¿ Ì Crohn Ë ÓfiÛÔ˜ ‰È·ÁÓÒÛıËΠηٿ ̤ÛÔ fiÚÔ ÌÂÙ¿ 16 Ì‹Ó˜, ÂÓÒ Û ·˘Ù¿ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ÌÂÙ¿ 10 Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ™Ù· Ê·ÈÓÔÌÂÓÈο ·Û˘Ìو̷ÙÈο ·È‰È¿, ÌÂÏÂÙÒÓÙ·˜ ÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ ÙȘ η̇Ϙ ۈ̷ÙÈ΋˜ ÙÔ˘˜ ·Ó¿Ù˘Í˘, ‰È·ÈÛÙÒÓÂÙ·È Î·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·‡ÍËÛ˘ ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, Ô˘ ÛËÌ·›ÓÂÈ ˘ÔÎÏÈÓÈ΋ ÌÂÓ, ·ÏÏ¿ ÛËÌ·ÓÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÓfiÛÔ˘. ™Â ÔÏÏ¿ ·fi ·˘Ù¿ Ù· ·È‰È¿ ‰È·ÁÈÁÓÒÛÎÂÙ·È Ë ÓfiÛÔ˜ fiÙ·Ó ÂÌÊ·Ó›ÛÔ˘Ó ÎÔÈÏȷο Û˘ÌÙÒÌ·Ù· ‹ ·Ú·¤ÌÔÓÙ·È ·fi ÙÔÓ ÂÓ‰ÔÎÚÈÓÔÏfiÁÔ. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Ó. Crohn ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ Ô˘ Â›Ó·È Î·Ù’ ÂÍÔ¯‹Ó ÛÙÔÓ ÙÂÏÈÎfi ÂÈÏÂfi, ÂÓÒ Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi Û˘ÌÌÂÙ¤¯ÂÈ ÙÔ ·¯‡ ¤ÓÙÂÚÔ. ™Â ÔÛÔÛÙfi ̤¯ÚÈ 40% ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ (ÔÈÛÔÊ¿ÁÔ˘, ÛÙÔÌ¿¯Ô˘ ‹ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘) ÛÙ· ·È‰È¿ Î·È ÁÈ’ ·˘Ùfi Û˘Ó‰˘¿˙ÂÙ·È ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÓÒÙÂÚÔ˘ Î·È Î·ÙÒÙÂÚÔ˘ ÂÙÈÎÔ‡ Û˘Á¯ÚfiÓˆ˜ (1,2). ∞Ó·ÏfiÁˆ˜ Ù˘ ÂÓÙfiÈÛ˘, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› 3 Ù‡ÔÈ: ·) ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ì ӷ˘Ù›·, Â̤ÙÔ˘˜, ‰È¿ÚÚÔÈ·, ·ÓÔÚÂÍ›·, ÌÂÙ·ÁÂ˘Ì·ÙÈο ÎÔÏÈÎÔÂȉ‹ ¿ÏÁË Î·È Û˘ÌÙÒÌ·Ù· ‰˘Û„›·˜, ‚) ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ÌÂ Û˘ÌÙÒÌ·Ù· fiÌÔÈ· Ì ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÔfiÙÂ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· Á›ÓÂÈ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ·ÏÏ¿ ÛÙË Ó. Crohn ˘¿Ú¯ÂÈ Û˘¯Ó¿ ÂÚÈÚˆÎÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Î·È Á) Ì Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË. OÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ (Û˘¯ÓfiÙËÙ· ÂÚ›Ô˘ 25-36%) ÛÙËÓ πº¡∂ (1-4) Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∏ Û˘¯ÓfiÙÂÚË Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË Â›Ó·È Ë ·ÚıÚ›Ùȉ· (ÔÛÔÛÙfi 7-26%), Ô˘ Û˘¯Ó¿ ·Ú¯Èο ıˆÚÂ›Ù·È ÚÂ˘Ì·ÙÔÂȉ‹˜, ÂÓÒ Ë ÛÔÓ‰˘Ï›Ùȉ· ÂÌÊ·Ó›˙ÂÙ·È Ì ÔÛÔÛÙfi 2-6%. ∏ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜ Î·È ÙˆÓ ¯ÔÏËÊfiÚˆÓ ·ÔÙÂÏ› ›Û˘ Û˘¯Ó‹ Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË, ÙfiÛÔ Ù˘ πº¡∂ ÚˆÙÔ·ıÒ˜, fiÛÔ Î·È Û·Ó ·ÔÙ¤ÏÂÛÌ· Ù˘ ıÂڷ›·˜. ™Ù· ·È‰È¿ ÌÔÚ› Ó· ÚÔËÁÂ›Ù·È Ù˘ ÂΉ‹ÏˆÛ˘ Ù˘ πº¡∂ ‹ Ó· ÂÌÊ·Ó›˙ÂÙ·È ·ÎfiÌ· Î·È ÌÂÙ¿ ÔÏÈ΋ ÎÔÏÂÎÙÔÌ‹. ∏·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi 5-8% Î·È Ë ‚Ï¿‚Ë ÌÔÚ› Ó· Â›Ó·È ÂÓ‰ÔË·ÙÈ΋ (¯ÚfiÓÈ· ÂÓÂÚÁfi˜ Ë·Ù›ÙȘ, ΛÚÚˆÛË, ·Ì˘ÏÔ›‰ˆÛË, ÏÈ҉˜ ‹·Ú, ÂÚȯÔÏ·ÁÁÂÈ›ÙȘ), Â͈˷ÙÈ΋ (¯ÔÏÔÏÈı›·ÛË) ‹ ÌÈÎÙ‹ (ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›ÙȘ). ∏ ÙÂÏÂ˘Ù·›· ··ÓÙ¿Ù·È Û ÔÛÔÛÙfi 3,5% ÙˆÓ ·È‰ÈÒÓ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È 1% ÙˆÓ ·È‰ÈÒÓ Ì ÓfiÛÔ Crohn. ∏ ›ÌÔÓË ·Ú·ÌÔÓ‹ ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ¿Óˆ ·fi 6 Ì‹Ó˜ ·ÔÙÂÏ› ·fiÏ˘ÙË ¤Ó‰ÂÈÍË ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ë·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜. ÕÏÏÔÙ ¿ÏÈ Ù· ·ÚÈ· Û˘ÌÙÒÌ·Ù· ÌÔÚ› Ó· Â›Ó·È ÂÚÈÚˆÎÙÈ΋ ÓfiÛÔ˜, ÛÙÔÌ·Ù›Ùȉ·
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·153
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
¶›Ó·Î·˜ 3. ∂͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ ñ ∞ÚıÚ›Ùȉ· (7-26%), ÛÔÓ‰˘Ï›Ùȉ· (6%) ñ OÛÙÂÔÂÓ›·, ¿ÛËÙË Ó¤ÎÚˆÛË ñ O˙҉˜ ÂÚ‡ıËÌ· (5-10%), Á·ÁÁÚ·ÈÓ҉˜ ˘fi‰ÂÚÌ· ñ OÊı·ÏÌÈ΋ Û˘ÌÌÂÙÔ¯‹ (Ú·ÁÔÂȉ›Ùȉ·, ÂÈÛÎÏËÚ›Ùȉ·, ÎÂÚ·Ù›Ùȉ·) ñ ∞ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ıÚÔÌ‚ÒÛÂȘ, Ó¢Ì. ÂÌ‚ÔÏ‹) ñ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ (·Ó·ÈÌ›·, ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË) ñ ∏·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ (ÛÎÏËÚ. ¯ÔÏ·ÁÁ/ÙȘ, ¯Ú. Ë·Ù›ÙȘ, ΛÚÚˆÛË) ñ ¶·ÁÎÚ·ٛÙȘ ñ ¡ÂÊÚÔÏÈı›·ÛË, ˘‰ÚÔÓ¤ÊÚˆÛË, ÂÓÙÂÚÔ΢ÛÙÈο Û˘Ú›ÁÁÈ·, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›ÙȘ ñ ÀÔÛÈÙÈÛÌfi˜, ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, ÂÓ‹‚ˆÛË
‹ Ô˙҉˜ ÂÚ‡ıËÌ· (5-10%), ÂÓÒ Ë ÔÊı·ÏÌÈ΋ Û˘ÌÌÂÙÔ¯‹ Â›Ó·È ÂÚ›Ô˘ 4% (ÂÈÛÎÏËÚ›Ùȉ· Î·È Ú·ÁÔÂȉ›ÙȘ). OÈ ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ıÚfiÌ‚ˆÛË, Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹) Â›Ó·È Û¿ÓȘ, ·ÏÏ¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ∏ ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ πº¡∂ ıˆÚÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ˘ÂÚËÎÙÈÎfiÙËÙ· Ô˘ Û˘Ì‚·‰›˙ÂÈ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È ÂΉËÏÒÓÂÙ·È Ì ıÚÔÌ‚Ô·ÙÙˆÛË, ·‡ÍËÛË ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘, ÙÔ˘ ·Ú¿ÁÔÓÙ· V, VIππ Î·È Ì›ˆÛË Ù˘ ·ÓÙÈıÚÔÌ‚›Ó˘ IIπ. Œ¯ÂÈ ‰È·ÈÛÙˆı› ·ÓÙÔ¯‹ Ù˘ ·ÓÙÈËÎÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ÚˆÙ½Ó˘ C Î·È Ë ÌÔÚȷ΋ ‚Ï¿‚Ë Ô˘ Â›Ó·È ˘Â‡ı˘ÓË Â›Ó·È Ë ÌÂÙ¿ÏÏ·ÍË ÛÙÔ ÌfiÚÈÔ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (factor Leiden) (9). ∂›Û˘, ·Ú·ÙËÚÔ‡ÓÙ·È ·ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ fiˆ˜ ·Ó·ÈÌ›· (ÛȉËÚÔÂÓÈ΋, ÌÂÁ·ÏÔ‚Ï·ÛÙÈ΋, ¯ÚfiÓÈ·˜ ÓfiÛÔ˘, ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋) (10), ÂΉËÏÒÛÂȘ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi fiˆ˜ ÓÂÊÚÔÏÈı›·ÛË (5%), ˘‰ÚÔÓ¤ÊÚˆÛË, ÂÈÏÂÔ΢ÛÙÈο Û˘Ú›ÁÁÈ·, Ô˘ÚÔÏÔÈÌÒÍÂȘ Î·È ·Ì˘ÏÔ›‰ˆÛË. °ÂÓÈο, ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Û˘ÓÔ‰Â‡Ô˘Ó Û˘¯ÓfiÙÂÚ· ÙË ÓfiÛÔ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ÂÓÒ Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÂÓ‹‚ˆÛË ·ÔÙÂÏ› ÎÏ·ÛÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Crohn ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (1,2,4). ÀÔÛÈÙÈÛÌfi˜ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË O ˘ÔÛÈÙÈÛÌfi˜ ·ÔÙÂÏ› Ì›˙ÔÓ· ÂÈÏÔ΋ Ù˘ πº¡∂ Û fiϘ ÙȘ ËÏÈ˘ (˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ 85% ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ Ì ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ ˘ÔÛÈÙÈÛÌfi ÚˆÙ½Ó˘ Î·È ÂÓ¤ÚÁÂÈ·˜) Î·È Ô‰ËÁ› Û ηı˘ÛÙ¤ÚËÛË Ù˘ ÔÛÙÈ΋˜ ˆÚ›Ì·ÓÛ˘, Ù˘ ÂÌÌËÓ·Ú¯‹˜, ÂÓÒ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ÂÌÊ·Ó›˙ÂÈ ÙÂÏÈο ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (1-4). π‰È·›ÙÂÚ· ÛÙË Ó. Crohn ÂËÚ¿˙ÂÙ·È ÙÔ ·Ó¿ÛÙËÌ· Î·È ¤¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÙÂÏÈο ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÌfiÓÔ ÙÔ 12% ‰ÂÓ ı· ÂËÚ·ÛÙ› ·fi ÙË ÓfiÛÔ (3). ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ¤¯ÂÈ ÙÔ 65% ÛÙËÓ ∂∫ Î·È ÙÔ 85% ÛÙËÓ Crohn Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË 10% Î·È 30% ·ÓÙ›ÛÙÔȯ·. ∞˘Ùfi ÔÊ›ÏÂÙ·È
Paediatriki 2002;65:151-159
ÛÙË ÌÂȈ̤ÓË ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ, ÙË ‰˘Û·ÔÚÚfiÊËÛË, ÙËÓ ·‡ÍËÛË ÙˆÓ ·ˆÏÂÈÒÓ ·fi ÙÔ ¤ÓÙÂÚÔ, ÙËÓ Â›‰Ú·ÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙȘ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ. O ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈÎfi˜, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÎÔÚÙÈ˙fiÏË Î·È ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÌÔÚ› Ó· Â›Ó·È ÌÂȈ̤ÓË, ·ÏÏ¿ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ‰È¤ÁÂÚÛË, ηıÒ˜ ›Û˘ Ô insulin-like growth factor-1 Â›Ó·È ÌÂȈ̤ÓÔ˜ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó¿Ù˘ÍË, Â˘Ú‹Ì·Ù· Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙË ÌÂȈ̤ÓË ıÚ¤„Ë. ∂›Û˘, Ë ÛˆÌ·ÙỔ›ÓË-C Â›Ó·È ÌÂȈ̤ÓË Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ·ӤگÂÙ·È ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÌÂÙ¿ ·fi ÙË ‰È·ÈÙËÙÈ΋ ·Ú¤Ì‚·ÛË. ∞Ó Î·È Ù· ÛÙÂÚÔÂȉ‹ ÂÓ‰¤¯ÂÙ·È Ó· ÚÔηϤÛÔ˘Ó Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, Û˘Ó‹ıˆ˜ ÂÈÙÚ¤Ô˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË (1,2). ∂›Û˘, ·Ú·ÙËÚÂ›Ù·È ·Ó¿ÚÎÂÈ· Û ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›·, fiˆ˜ Ê˘ÏÏÈÎfi Î·È µ12, ∞DEK, Ûȉ‹ÚÔ˘ Î·È „¢‰·ÚÁ‡ÚÔ˘, ÛÂÏËÓ›Ô˘, ¯·ÏÎÔ‡, ÓÈÎÂÏ›Ô˘. ∞ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn Â›Ó·È ·ÎfiÌË ¿ÁÓˆÛÙË. ¶Èı·ÓfiÓ ˘ÂÈÛ¤Ú¯ÔÓÙ·È ÁÂÓÂÙÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (4,7,8). ∞Ó Î·È Ë ·ÎÚÈ‚‹˜ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ¯ÚfiÓÈ· ‰È¤ÁÂÚÛË ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙÔ ¤ÓÙÂÚÔ Û ÁÂÓÂÙÈο ¢¿ÏˆÙ· ¿ÙÔÌ·, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ¯ÚfiÓÈ· ‚ÏÂÓÓÔÁÔÓÈ΋ ‚Ï¿‚Ë (11). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ¤ÓÙÂÚÔ ‚Ú›ÛÎÂÙ·È Û ÌfiÓÈÌË ·ÓÔÛÔÏÔÁÈ΋ ‰È¤ÁÂÚÛË ·fi ÌÈÎÚԂȷο Î·È ÙÚÔÊÈο ·ÓÙÈÁfiÓ·. ™˘ÓÂÒ˜, ÙÔ ¤ÓÙÂÚÔ ‚Ú›ÛÎÂÙ·È Û ÌfiÓÈÌË “Ê˘ÛÈÔÏÔÁÈ΋ ÊÏÂÁÌÔÓ‹”, Ì ̤ÙÚÈÔ ·ÚÈıÌfi ·ÓÔÛÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ¯fiÚÈÔ (ÏÂÌÊÔ·ÙÙ·Ú·, Ì·ÎÚÔÊ¿Á·, Ï·ÛÌ·ÙÔ·ÙÙ·Ú·) (11). ¶ÈÛÙ‡ÂÙ·È fiÙÈ ·˘Ù‹ Ë ÈÛÔÚÚÔ›· ‰È·Ù·Ú¿ÛÛÂÙ·È ÛÙËÓ πº¡∂ Î·È ÚÔηÏÂ›Ù·È ·ıÔÏÔÁÈ΋ ÊÏÂÁÌÔÓ‹ Ì ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë. OÈ Î˘ÙÙ·ÚÔΛÓ˜ ·ÔÙÂÏÔ‡Ó ÙÔ ÎÏÂȉ› ÛÙËÓ ·ÓÔÛÔÚÚ‡ıÌÈÛË (4,12). ™ÙËÓ πº¡∂ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÈÛÔÚÚÔ›· ÌÂٷ͇ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î·È ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (IL-4, IL-10 Î·È TGF-‚). Œ¯Ô˘Ó, ‰ËÏ·‰‹, ‰È·ÈÛÙˆı› ·˘ÍË̤ӷ ›‰· ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (IL-1,6,8 Î·È TNF·) Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ·fi Ù· Ì·ÎÚÔÊ¿Á·, ÏÂÌÊÔ·ÙÙ·Ú· Î·È ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·. ∞˘Ùfi˜ Ô Î·Ù·ÚÚ¿ÎÙ˘ Ô‰ËÁ› ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÈÛÙÔ‡, Ô˘ ·ÓÙÈηı›ÛÙ·Ù·È ·fi ÈÓÒ‰Ë ÈÛÙfi. OÈ ›‰ÈÔÈ ·Ú¿ÁÔÓÙ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙËÓ ¤ÎÎÚÈÛË ËÏÂÎÙÚÔÏ˘ÙÒÓ Ô˘ ÂÈÙ›ÓÔ˘Ó ÙË ‰È¿ÚÚÔÈ·, ÂÓÒ ÛÙË ÓfiÛÔ ÙÔ˘ Crohn ÂÈϤÔÓ, ˘¿Ú¯ÂÈ ‰˘Û·ÔÚÚfiÊËÛË ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, ·ÒÏÂÈ· ¯ÔÏÈÎÒÓ ·Ï¿ÙˆÓ Î·È ˘ÂÚ·Ó¿Ù˘ÍË ÌÈÎÚÔ‚›ˆÓ. ∏ ÂÎÙÂٷ̤ÓË ‚Ï¿‚Ë ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Ô‰ËÁ› Û ·ÒÏÂÈ· ÏÂ˘ÎˆÌ¿ÙˆÓ Î·È ·ÈÌÔÚÚ·Á›· (4).
153
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·154
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
Paediatriki 2002;65:151-159
¢È¿ÁÓˆÛË ¢˘ÛÙ˘¯Ò˜ ‰ÂÓ ˘¿Ú¯ÂÈ Ì›· ÂȉÈ΋ ÂͤٷÛË ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ πº¡∂ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ÌËÓ ˘¿Ú¯Ô˘Ó ÙË ÛÙÈÁÌ‹ Ô˘ Á›ÓÂÙ·È Ô ¤ÏÂÁ¯Ô˜. ∏ ‰È¿ÁÓˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Ï‹ÚË ÂÎÙ›ÌËÛË ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛˆÓ, ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ, ÂÓ‰ÔÛÎÔÈÎÒÓ Î·È ÈÛÙÔÏÔÁÈÎÒÓ ‰Â‰Ô̤ӈÓ. ∏ ÂÓ‰ÔÛÎfiËÛË Ì ÔÏϷϤ˜ ‚ÈÔ„›Â˜ ÂÈÙÚ¤ÂÈ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÙËÓ ÈÛÙÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÔÙÂÏ› ÙËÓ ÈÔ ÂȉÈ΋ Î·È Â˘·›ÛıËÙË Ì¤ıÔ‰Ô. ∏ ÈÛÙÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË Ù˘ πº¡∂ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4 ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Ì ÚÔÂÍ¿Ú¯Ô˘Û· ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È Crohn. ∏ ÊÏÂÁÌÔÓ‹ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Â›Ó·È Î·Ù¿ Û˘Ó¤¯ÂÈ· ÈÛÙÔ‡ (¶›Ó·Î·˜ 5), ·Ú¯›˙ÂÈ ·fi ÙÔ ÔÚıfi Î·È Û˘Ó‹ıˆ˜ Ô ÙÂÏÈÎfi˜ ÂÈÏÂfi˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ÊÏÂÁÌÔÓ‹ ÛÙËÓ Crohn ÌÔÚ› Ó· Â›Ó·È ›‰È· Ì ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ·ÏÏ¿ Û˘Ó‹ıˆ˜ Â›Ó·È ÂÛÙȷ΋ ‹ ÙÌËÌ·ÙÈ΋, Û˘Ó‹ıˆ˜ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ÔÚıfi Î·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ· Û˘ÌÌÂÙ¤¯ÂÈ Ô ÙÂÏÈÎfi˜ ÂÈÏÂfi˜. ÷ڷÎÙËÚÈÛÙÈο Â›Ó·È Ù· ·ÊıÒ‰Ë ¤ÏÎË. πÛÙÔÏÔÁÈο ˘¿Ú¯Ô˘Ó Ù· ·ÔÛÙËÌ¿ÙÈ· ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È Ù· ÎÔÎÎÈÒÌ·Ù· ÛÙËÓ Crohn, Ô˘ fï˜ ·Ó¢ڛÛÎÔÓÙ·È Û ÌÈÎÚfi ÔÛÔÛÙfi. ™˘ÓÂÒ˜, ¿ÏÏÔÈ ‰Â›ÎÙ˜ fiˆ˜ Ë ÂÓ‰ÔÛÎÔÈ΋ ÂÈÎfiÓ· (fiÙ·Ó Â›Ó·È Ù˘È΋) Î·È Ë ÂÛÙȷ΋ ÊÏÂÁÌÔÓ‹ ÈÛÙÔÏÔÁÈο, Â›Ó·È ÂÓ‰ÂÈÎÙÈο Ù˘ Crohn. ∂‰Ò ı· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÂÎÙfi˜ ·fi ÙËÓ ÎÏ·ÛÈ΋ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ˘¿Ú-
¯ÂÈ Ë ·˘ÙÔ¿ÓÔÛË Î·È Ë ·ÚÔÛ‰ÈfiÚÈÛÙË (indeterminate) ÎÔÏ›ÙȘ, Ô˘ ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ÚfiÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË. ∏ ÙÂÏÂ˘Ù·›· ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi ̤¯ÚÈ 25% Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÓ‰ÔÛÎÔÈο Î·È ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ ı˘Ì›˙Ô˘Ó Î·È Ù· ‰‡Ô ÓÔÛ‹Ì·Ù·, ·ÏÏ¿ ÌÔÚ› ÌÂÏÏÔÓÙÈο Ó· Ï¿‚ÂÈ Ù˘È΋ ÂÈÎfiÓ· Crohn (13). ∏ ·˘ÙÔ¿ÓÔÛË Î·È È‰È·›ÙÂÚ· Ë ÌÈÎÚÔÛÎÔÈ΋ (ÎÔÏÏ·ÁÔÓÈ΋ Î·È ÏÂÌÊÔ΢ÙÙ·ÚÈ΋) ÎÔÏ›Ùȉ· Â›Ó·È Û¿ÓȘ ÛÙ· ·È‰È¿ Î·È ¤¯Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· (14). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (·ÈÌ·ÙÔÏÔÁÈÎfi˜, ‚ÈÔ¯ËÌÈÎfi˜) ‰ÂÓ ‚ÔËı¿ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ‰‡Ô ÓÔÛËÌ¿ÙˆÓ, ·ÏÏ¿ ‚ÔËı¿ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÓÂÚÁfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, Ù˘ ηٿÛÙ·Û˘ ‰È·ÙÚÔÊ‹˜ Î·È ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ÏÔÈÌÒ‰Ô˘˜ ·Ú¿ÁÔÓÙ·. ∂Ó‰ÂÈÎÙÈο ÂÓÂÚÁÔ‡ ÓfiÛÔ˘ Â›Ó·È Ë ·‡ÍËÛË Ù˘ ∆∫∂, ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ Î·È Ù· ¯·ÌËÏ¿ ›‰· ÏÂ˘ÎˆÌ·Ù›Ó˘. ∏ ·Ó‡ÚÂÛË ÙˆÓ pANCA ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È ÙˆÓ ASCA ÓfiÛÔ˘ Crohn (15). O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË, ÂÓÙÔ›˙ÂÈ ÙËÓ ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘, ‚ÔËı¿ ÛÙË ‰È·ÊÔÚԉȿÁÓˆÛË ÎÔÏ›Ùȉ·˜ Î·È Crohn Î·È ÂÓÙÔ›˙ÂÈ ÙȘ ÂÈÏÔΤ˜. ™ËÌ·ÓÙÈ΋ ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂÓÂÚÁfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Crohn (PCDAI) Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÈÛÙÔÚÈÎfi, ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, ÏÂ˘ÎˆÌ·Ù›ÓË, η̇Ϙ ·Ó¿Ù˘Í˘ (2).
¶›Ó·Î·˜ 4. ∆‡ÔÈ πº¡∂
∞ÓÙÈÌÂÙÒÈÛË ™Ùfi¯ÔÈ Ù˘ Â›Ó·È Ë ‡ÊÂÛË Ù˘ ÓfiÛÔ˘, Ë ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ, Ë ‰ÈfiÚıˆÛË ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ, Ë Ê˘ÛÈÔÏÔÁÈ΋ ·‡ÍËÛË Î·È ·Ó¿Ù˘ÍË. ∏ ıÂڷ›· ‚·Û›˙ÂÙ·È Û 4 ÙÔÌ›˜: ·) Ê·Ú̷΢ÙÈ΋, ‚) ÛÈÙÈÛÙÈ΋, Á) ¯ÂÈÚÔ˘ÚÁÈ΋ Î·È ‰) „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË.
ñ ñ ñ ñ ñ ñ
∂ÏÎ҉˘ ÎÔÏ›ÙȘ ¡fiÛÔ˜ ÙÔ˘ Crohn Indeterminate colitis ∞˘ÙÔ¿ÓÔÛË ÎÔÏ›ÙȘ ∫ÔÏÏ·ÁÔÓÈ΋ §ÂÌÊÔ΢ÙÙ·ÚÈ΋
¶›Ó·Î·˜ 5. ™‡ÁÎÚÈÛË ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Crohn ÛÙ· ·È‰È¿ ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ™˘¯ÓfiÙËÙ· ŒÓ/ÍË ·È‰. ËÏÈÎ. ∂Ó‰ÔÛÎÔÈο
πÛÙÔÏÔÁÈο
∂ÈÏÔΤ˜
154
2/100.000 15-20% ™˘Ó¯fiÌÂÓË ÊÏÂÁÌÔÓ‹ 100% ÔÚıfi ‚Ï¿‚˜ ÛÂ: ¶¿Û¯ÔÓÙ· ‚ÏÂÓÓÔÁ. º˘ÛÈÔÏ. ÂÈÏÂfi˜ ∂Ï¿ÙÙˆÛË ‚ϤÓÓ˘ ∫Ú˘ÙÈο ·ÔÛÙ‹Ì·Ù· ∂ÓÙfiÈÛË ÛÙÔ ‚ÏÂÓ/ÓÔ ™˘Ó¯fiÌÂÓË ‚Ï¿‚Ë ¢È¿ÙÚËÛË ∆ÔÍ. ÌÂÁ¿ÎÔÏÔ Ca ·¯. ÂÓÙ¤ÚÔ˘
Crohn 3,5/100.000 20-25% ∂ÛÙȷ΋ ™˘Ó‹ıˆ˜ fi¯È ÔÚıfi º˘ÛÈÔÏÔÁÈÎfi ‚ÏÂÓÓÔÁ. ¶¿Û¯ˆÓ ÂÈÏÂfi˜ 50% ∂ÈıËÏ. ÎÔÎÎÈÒÌ·Ù· ¶ÂÚÈÎÚ˘Ù›Ùȉ· ∂¤ÎÙ·ÛË ˘Ô‚ÏÂÓ/ÓÈÔ ∆ÌËÌ·ÙÈ΋ ‚Ï¿‚Ë ∞fiÊÚ·ÍË, ·ÔÛÙ‹Ì·Ù· ™˘Ú›ÁÁÈ·, ÂÚÈÚˆÎÙ. ÓfiÛÔ˜ Ca ·¯. Î·È Ï. ÂÓÙ¤ÚÔ˘ ·Ó¿ÚÎÂÈ· µ12
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·155
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
∞. º·Ú̷΢ÙÈ΋: ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ··ÈÙÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Ô˘ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Î·È ÙËÓ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘. OÈ Î·ÙËÁÔڛ˜ Î·È Ô Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ∆· ·Ú·‰ÔÛȷο Ê¿Ú̷η, ·ÌÈÓÔÛ·ÏÈ΢ÏÈο Î·È ÎÔÚÙÈ˙fiÓË, ·ÔÙÂÏÔ‡Ó ÙÔÓ ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ. ∏ ÛÔ˘ÏÊ·Û·Ï·˙›ÓË Î·È 5-ASA ·Ú·Ì¤ÓÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‹È·˜ ¤ˆ˜ ̤ÙÚÈ·˜ ÓfiÛÔ˘ Î·È ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, ÂÓÒ Ù· ÎÔÚÙÈÎÔÂȉ‹ ·Ú·Ì¤ÓÔ˘Ó Ë ÚÒÙË ıÂڷ›· ÛÙË Ì¤ÙÚÈ· ¤ˆ˜ ‚·ÚÈ¿ ÓfiÛÔ Î·È ÂÈÙ˘Á¯¿ÓÔ˘Ó ‡ÊÂÛË Û ÔÛÔÛÙfi 70-80% ÂÚ›Ô˘. ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Î·È ÛÙ· ·È‰È¿ ¤Ó· ÓÂfiÙÂÚÔ ÎÔÚÙÈÎÔÂȉ¤˜, Ë ‚Ô˘‰Â˙ÔÓ›‰Ë (·fi ÙÔ ÛÙfiÌ· Î·È ·fi ÙÔ ÔÚıfi), Ô˘ ¤¯ÂÈ ÏÈÁfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ, ·ÏÏ¿ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ ˘ÔÏ›ÂÙ·È ·˘Ù‹˜ Ù˘ Ú‰ÓÈ˙fiÓ˘ (16). ∏ ÙÔÍÈÎfiÙËÙ· ηٿ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ¯Ú‹ÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Û·Ó ıÂڷ›· Û˘ÓÙ‹ÚËÛ˘ Ô‰‹ÁËÛ·Ó ÛÙË Û¯ÂÙÈο ÌÂÁ¿ÏË ¯Ú‹ÛË ÙˆÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÒÓ (∞zathioprine, 6-MP) ÁÈ· ÂÍ·ÚÙÒÌÂÓË ‹ ·ÓıÂÎÙÈ΋ ÛÙ· ÛÙÂÚÔÂȉ‹ ÓfiÛÔ (1719). O ÚfiÏÔ˜ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ‹ ·Ó·‚ÔÏ‹ Ù˘ ÎÔÏÂÎÙÔÌ‹˜ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·Ôı·ÚÚ˘ÓÙÈο ÛÙË Ó. Crohn. ™Â ÂÏ¿¯ÈÛÙ˜ ·ÂÏÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ Ó. Crohn Î·È ÎÔÏ›Ùȉ·˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È Û ¿ÏÏÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·, ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› ÙÔ FK (506) Tacrolimus Ô˘ Â›Ó·È Ì·ÎÚÔÏ›‰Ë, Ì ÂÚÈÛÛfiÙÂÚ˜ fï˜ ·ÚÂÓ¤ÚÁÂȘ Û˘ÁÎÚÈÙÈο Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË (1,17). ™Â ÂÚÈÙÒÛÂȘ Crohn Ì ·ÔÛÙ‹Ì·Ù· ‹ Û˘Ú›ÁÁÈ·, ÚÔÛÙ›ıÂÓÙ·È ÌÂÙÚÔÓȉ·˙fiÏË ‹ ciprofloxacin. Ÿˆ˜ ÂϤ¯ıË ‹‰Ë, Ô TNF-· ·ÔÙÂÏ› Ì›· ΢ÙÙ·ÚÔΛÓË ÎÏÂȉ› ÁÈ· ÙËÓ ÂÓÙÂÚÈ΋ ÊÏÂÁÌÔÓ‹ Î·È Û˘ÓÂÒ˜, Ë ‰¤ÛÌ¢ÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· ·˘ÙÔ‡ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÊÏÂÁÌÔÓ‹˜. ∆¤ÙÔÈÔ Û··ÛÌ· Â›Ó·È ÙÔ ÌÔÓÔÎψÓÈ-
Paediatriki 2002;65:151-159
Îfi ¯ÈÌ·ÈÚÈÎfi ·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ ÙÔ˘ fiÁÎÔ˘ · (·ÓÙÈ- TNF·), Ô˘ ·ÔÙÂÏ› ÚfiÛıÂÙÔ ıÂڷ¢ÙÈÎfi ̤ÛÔ ÁÈ· ÙË ¯ÚfiÓÈ· ÂÓÂÚÁfi ÓfiÛÔ Crohn ‹ ÌÂ Û˘Ú›ÁÁÈ· (20,21). ¶·Ú¿ Ù· Û¯ÂÙÈο ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂӉ›ÍÂȘ Û˘ÁÎÚÈÙÈο Ì ¿ÏÏÔ Ê¿ÚÌ·ÎÔ, ˘¿Ú¯ÂÈ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ÁÈ· ÙËÓ ·ÓÙÈÁÔÓÈÎfiÙËÙ¿ ÙÔ˘, ‰ÈfiÙÈ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÍÂÓÈÛÙ‹. ¢ÂÓ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ÂÌÂÈÚ›· Ì ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÚÈÔ‰È΋ ¯ÔÚ‹ÁËÛË (οı 2 Ì‹Ó˜). ¶¿ÓÙˆ˜, 3 ·fi ÙÔ˘˜ 37 ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó Ì·ÎÚÔ¯ÚfiÓÈ· ÙÔ Ê¿ÚÌ·ÎÔ ·ÚÔ˘Û›·Û·Ó ·ÓıÚÒÂÈ· ·ÓÙȯÈÌÂÚÈο ·ÓÙÈÛÒÌ·Ù· (20). ∞ӷʤÚÂÙ·È, ›Û˘, ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Crohn ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (22). £· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ë ÔÚ›· Â›Ó·È ‚·ÚÈ¿ ÛÙ· ·È‰È¿ Î·È ··ÈÙ› Û˘Ó‰˘·ÛÌfi Ê·ÚÌ¿ÎˆÓ ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ·. ∞fi Ù· 320 ·È‰È¿ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ (¶›Ó·Î·˜ 7), ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÌÈÛ¿ ¯ÚÂÈ¿ÛÙËÎ·Ó ÎÔÚÙÈÎÔÂȉ‹, ÂÓÒ Û ÌÂÚÈο ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› fiÏ· Ù· ÈÔ ¿Óˆ ıÂڷ¢ÙÈο Û¯‹Ì·Ù·. ŸÌˆ˜ Ù· Ú¿ÁÌ·Ù· ‰ÂÓ Â›Ó·È ÙfiÛÔ ·Ï¿. ŒÓ·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ·ÔÙÂÏ› ÙÚfiÊÈÌÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÁÈ· ÔÏÏÔ‡˜ Ì‹Ó˜ ‹ ÌÂ Û˘¯Ó¤˜ ÂÈÛ·ÁˆÁ¤˜, ÁÈ·Ù› ·Ú¿ ÙËÓ ¤ÓÙÔÓË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ‡ÊÂÛË. ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ Û˘Ó‹ıˆ˜ ·Ó‹ÎÔ˘Ó ·È‰È¿ Ì ‚·ÚÈ¿ ÓfiÛÔ ÙÔ˘ Crohn ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ·ÔÛÙ‹Ì·Ù· ‹ Û˘Ú›ÁÁÈ·, ‹ ·È‰È¿ Ì ·˘ÙÔ¿ÓÔÛË ÎÔÏ›Ùȉ·, Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÓ‰ÔÊϤ‚È· ıÂڷ›· Î·È ·ÚÂÓÙÂÚÈ΋ Û›ÙÈÛË. À¿Ú¯Ô˘Ó fï˜ Î·È ¿ÏÏ· Ê¿Ú̷η Ô˘ Â›Ó·È ˘fi ‰ÔÎÈÌ‹, fiˆ˜ Ë ı·ÏȉÔÌ›‰Ë, Ë ‚ÈÙ·Ì›ÓË ∂, Ù· ÏÈ·Ú¿ Ôͤ· ‚Ú·¯Â›·˜ ·Ï‡ÛÔ˘ Î·È Ë ÓÈÎÔÙ›ÓË (ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·), ÙÔ ‚ÈÛÌÔ‡ıÈÔ, ÙÔ ÎÂÙÔÙÈÊ·›ÓÈÔ, Ë Ë·Ú›ÓË, Ë ¯ÏˆÚÔΛÓË, Ë ÂÓ‰ÔÊϤ‚È· ÁÛÊ·ÈÚ›ÓË, Ë ÏÂ˘Î·Ê·›ÚÂÛË Î·È ÔÈ Ó¢ÚÔ·ÓÔÛÔÚÚ˘ıÌÈÛÙ¤˜ (Ù· Ó¢ÚÔÂÙ›‰È· Ô˘Û›·-ƒ, VIP Î·È Y)
¶›Ó·Î·˜ 6. º¿Ú̷η Î·È ÙÚfiÔ˜ ‰Ú¿Û˘ º¿Ú̷η ™Ô˘ÏÊ·Û·Ï·˙›ÓË, 5-ASA ∫ÔÚÙÈÎÔÂȉ‹
Azathioprine, 6-MP Methotrexate Cyclosporin Tacrolimus (FK506) Metronidazole πnfliximab
∆ÚfiÔ˜ ‰Ú¿Û˘
[ PG, Tromb/x, PAF, IL-1, Lym, Monoc., NF΂ [ cyclo- and lipooxygenase [ ¡F΂, IL-1, IL-2, Ê·Á/ÛË ÔÏ. [ ¯ËÌÂÈÔÙ. ÔÏ., ˈÛ., ÌÔÓ/Ó· + ·ÔÚÚfiÊËÛË Na, ‡‰·ÙÔ˜ [ natural killer, cytotoxic T-cells [ DNA, IL-1, + apoptosis [ IL-1, IL-3, IL-4, Á-IFN, TNF-· [ IL-2, IL-3, IL-4 ∞ÓÙÈÌÈÎÚԂȷ΋, ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋
[ TNF-·
155
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·156
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
Paediatriki 2002;65:151-159
¶›Ó·Î·˜ 7. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ 320 ·È‰ÈÒÓ Ì πº¡∂ ñ ñ ñ ñ ñ ñ
™Ô˘Ï/˙›ÓË ‹ 5-ASA ∫ÔÚÙÈÎÔÂȉ‹ Azathioprine Cyclosporine ÃÂÈÚ/΋ ¤̂·ÛË Anti-TNF
318 182 88 12 28 2
Î·È Ë ÛˆÌ·ÙÔÛÙ·Ù›ÓË (4). ∆¤ÏÔ˜, ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Ù· anti-sense ÔÏÈÁÔÓÔ˘ÎÏÂÔÙ›‰È· Ô˘ ‰ÂÛÌÂ‡Ô˘Ó ÙÔ m-RNA Ô˘ ¯ÚËÛÈ̇ÂÈ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ adhesion molecule 1 (ICAM-1). ∆Ô ı¤Ì· fï˜ Ù˘ ıÂڷ›·˜ Ì ·Ú¤Ì‚·ÛË ÛÙȘ ΢ÙÙ·ÚÔΛÓ˜ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌ· Ï˘ı›. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÙÔ Â‰›Ô Ù˘ Ê·ÚÌ·ÎÔÁÂÓÂÙÈ΋˜ Â›Ó·È Û ÂÌ‚Ú˘˚΋ ηٿÛÙ·ÛË. ∏ ÏËıÒÚ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙˆÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ ‰Â›¯ÓÂÈ ÍÂοı·Ú· ÙÔ ÛÔ‚·Úfi Úfi‚ÏËÌ· Ô˘ ˘¿Ú¯ÂÈ Û˘¯Ó¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ∆ÂÏÈο, Ë Û˘Ó¯‹˜ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Ù˘ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·˜ Ù˘ πº¡∂ ÚÔÊ·ÓÒ˜ ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó·Î¿Ï˘„Ë Ó¤ˆÓ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚˆÓ ÙÚfiˆÓ ıÂڷ›·˜. µ) ¢È·ÈÙËÙÈ΋: O ÚfiÏÔ˜ Ù˘ ‰È·ÈÙËÙÈ΋˜ ·Ú¤Ì‚·Û˘ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ‰Ú·Ì·ÙÈο ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· (23-25). ∏ Û›ÙÈÛË Û˘ÓÈÛÙ¿Ù·È Û ·È‰È¿ Ì πº¡∂ ÁÈ· Ó· ‰ÈÔÚıÒÛÂÈ Ù· ÂÏÏ›ÌÌ·Ù· (ÚfiÏË„Ë ‹ ·Ó¿Ù·ÍË ÙÔ˘ ˘ÔÛÈÙÈÛÌÔ‡ Î·È Ù˘ ¤ÏÏÂȄ˘ ȯÓÔÛÙÔȯ›ˆÓ), ·ÏÏ¿ Î·È Û·Ó ÚˆÙÔÁÂÓ‹˜ ıÂڷ›· Ù˘ ÂÓÂÚÁ‹˜ ÓfiÛÔ˘. ∏ ·ÚÔ˘Û›· Ù˘ ÙÚÔÊ‹˜ ÛÙÔ ¤ÓÙÂÚÔ ·ÛΛ ¿ÌÂÛË ÙÚÔÊÈ΋ ‰Ú¿ÛË ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ, ÚÔÛٷهÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Î·È ›Ûˆ˜ ÂÌÔ‰›˙ÂÈ ÙËÓ ·ıÔÁfiÓÔ ‰Ú¿ÛË ÙˆÓ ÌÈÎÚÔ‚›ˆÓ. ∂ÈϤÔÓ, ¤¯ÂÈ ÙËÓ È‰ÈfiÙËÙ· Ó· Ú˘ıÌ›˙ÂÈ ÙË ÊÏÂÁÌÔÓ‹ (1). ∆Ô ·È‰› Ì πº¡∂ Û˘Ó‹ıˆ˜ ˘ÔÏ›ÂÙ·È Û ·Ó¿Ù˘ÍË Î·È Ú·ÁÌ·ÙÈο ‰ÂÓ ÌÔÚ› Ó· ÂÈÙ¢¯ı› ‡ÊÂÛË ·Ó ‰ÂÓ ‰ÈÔÚıˆıÔ‡Ó Ù· ÂÏÏ›ÌÌ·Ù·. ∆· ‰È·ÈÙËÙÈο Û˘ÌÏËÚÒÌ·Ù· Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ· ‹ Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· fiÏÔ ÙÔ 24ˆÚÔ ‹ ÌfiÓÔ ÙÔ ‚Ú¿‰˘ ·ÔÙÂÏÔ‡Ó ÙÚfiÔ˘˜ ·Ó¿Ù·Í˘ ÙÔ˘ ¯ÚfiÓÈÔ˘ ˘ÔÛÈÙÈÛÌÔ‡ Î·È Ù˘ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘. ∆· ‰È·Ï‡Ì·Ù· ·˘Ù¿ Â›Ó·È ÔÏ˘ÌÂÚÈο, ËÌÈÛÙÔȯÂȷο Î·È ÛÙÔȯÂȷο. ∞Ú¯Èο ˘‹Ú¯Â ÚÔÙ›ÌËÛË ÛÙ· ÛÙÔȯÂȷο (ÁÈ·Ù› ¤¯Ô˘Ó ÌÂȈ̤ÓË ·ÓÙÈÁÔÓÈÎfiÙËÙ·), ·ÏÏ¿ ÙÂÏÂ˘Ù·›· Ù· ÔÏ˘ÌÂÚÈο ıˆÚÔ‡ÓÙ·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈο, ÂÎÙfi˜ Î·È ·Ó ‰ÂÓ Â›Ó·È ·ÓÂÎÙ¿ ·fi ÙÔ ¤ÓÙÂÚÔ ‹ ˘¿Ú¯ÂÈ Û‡Ó‰ÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ∏ ÏËıÒÚ· Ù¤ÙÔȈÓ, ÏÔ‡ÛÈˆÓ Û ıÂÚÌ›‰Â˜, ÂÓÙÂÚÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ¤¯ÂÈ ÌÂÈÒÛÂÈ ÙË ¯Ú‹ÛË Ù˘ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜, Ô˘ ÂÚÈÔÚ›˙ÂÙ·È Û·Ó ˘ÔÛÙËÚÈÎÙÈ΋ ıÂڷ›· ÛÙÔ ˘ÔÛÈÙÈṲ̂ÓÔ ·È‰› ÚÈÓ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË, ÌÂÙ¿ ·fi ÂÎÙÂٷ̤Ó˜ ÂÓÙÂÚÂÎÙÔ̤˜ Î·È Û‡Ó‰ÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ‹
156
Û ÌÂÁ¿ÏË ·ÈÌÔÚÚ·Á›·, ‰È¿ÙÚËÛË Î·È ÙÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ. O ÚfiÏÔ˜ Ù˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÛÙÂÓÒÛˆÓ, Û˘ÚÈÁÁ›ˆÓ ‹ ÂÚÈÚˆÎÙÈ΋˜ ÓfiÛÔ˘ ‰ÂÓ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ (1,24). °ÂÓÈο, Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË Ì ÛÙÔȯÂȷ΋ ‰›·ÈÙ· Â›Ó·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·ÛʷϤÛÙÂÚË Î·È ÊıËÓfiÙÂÚË Î·È ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂÈÏÔÁ‹ fiÙ·Ó ÙÔ ¤ÓÙÂÚÔ ÌÔÚ› Ó· ÙË ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ. ∆Ô Â›‰Ô˜ ·˘Ùfi Ù˘ ıÂڷ›·˜ ÌÔÚ› Ó· Â›Ó·È Ë ·ÔÎÏÂÈÛÙÈ΋ ıÂڷ›· ÛÙË Ó. Crohn Î·È ÌfiÓÔ Û˘ÌÏËڈ̷ÙÈ΋ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ ÌÂ Û˘ÁÎÚ›ÛÈÌ· ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ٷ ÎÔÚÙÈÎÔÂȉ‹ ÛÙË Ó. Crohn. ∏ ÌÂÙ·-·Ó¿Ï˘ÛË fï˜ ¤‰ÂÈÍ fiÙÈ ÛÙÔȯÂȷ΋ ‹ ÔÏ˘ÌÂÚÈ΋ ‰›·ÈÙ· Û·Ó ÌÔÓ·‰È΋ ÙÚÔÊ‹ ÁÈ· 2 Ì‹Ó˜ ÌÔÚ› Ó· ÂÈÙ‡¯ÂÈ ‡ÊÂÛË Ù˘ Crohn, ·ÏÏ¿ Ë ˘ÔÙÚÔ‹ Â›Ó·È Û˘¯Ó‹ (24,25). ™˘ÓÂÒ˜, ¤¯ÂÈ ·fiÏ˘ÙË ¤Ó‰ÂÈÍË Û·Ó Û˘ÌÏËڈ̷ÙÈ΋ ÛÙË Ê·Ú̷΢ÙÈ΋ ıÂڷ›· (1,24). ∞fi Ù· 320 ·È‰È¿ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ¯ÚÂÈ¿ÛÙËΠÂÓÙÂÚÈ΋ Û›ÙÈÛË Û·Ó Û˘ÌÏËڈ̷ÙÈ΋ ıÂڷ›· Ù˘ Ê·Ú̷΢ÙÈ΋˜, ÂÓÒ Û 2 ÌfiÓÔ ·È‰È¿ Ì ÓfiÛÔ Crohn ÌÂÙ¿ ·fi 6 ‚‰ÔÌ¿‰Â˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Û·Ó ·ÔÎÏÂÈÛÙÈ΋ ıÂڷ›·, ¯ÚÂÈ¿ÛÙËΠӷ ÚÔÛÙÂı› Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ÏfiÁˆ ÌË ·ÓÙ·ÔÎÚ›Ûˆ˜ Ù˘ ÓfiÛÔ˘ ÛÙÔ ¤Ó· ·È‰› Î·È Âȉ›ӈÛ˘ ÛÙÔ ¿ÏÏÔ. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Á›ÓÂÙ·È ÌÂÁ¿ÏË Û˘˙‹ÙËÛË ÁÈ· ÙÔ È¯ı˘¤Ï·ÈÔ (ˆ-3 ÏÈ·Ú¿ Ôͤ·) (26,27). Ÿˆ˜ ‹‰Ë ÂϤ¯ıË, ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹. ªÂٷ͇ ·˘ÙÒÓ Â›Ó·È Î·È Ë Ï¢ÎÔÙÚȤÓË µ4, Ù˘ ÔÔ›·˜ Ë ¤ÎÎÚÈÛ‹ ‰ÈÂÁ›ÚÂÙ·È ·fi ÙÔ ·Ú·¯È‰ÔÓÈÎfi, Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi Ù· ʈÛÊÔÏÈ›‰È· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∆· ˆ-3 ÏÈ·Ú¿ Ôͤ· ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ Î·È ÂÌÔ‰›˙Ô˘Ó ÙËÓ ·Ú·ÁˆÁ‹ Ï¢ÎÔÙÚȤÓ˘ µ4. ∏ ¯ÔÚ‹ÁËÛË Î·„Ô˘ÏÒÓ Ì ȯı˘¤Ï·ÈÔ Û ·ÛıÂÓ›˜ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ¤‰ÂÈÍ·Ó ÂÍ›ÛÔ˘ ηϿ ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ Ù· ÎÔÚÙÈÎÔÂȉ‹ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (26,27). ∆ÂÏÂ˘Ù·›·, Á›ÓÔÓÙ·È ÌÂϤÙ˜ ÁÈ· ÙË ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ LactÔbacillus GG Û ·È‰È¿ Ì Crohn (ÌfiÓÔ 4 ·È‰È¿), Ì ÙÔ ÛÎÂÙÈÎfi fiÙÈ Ë Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÚÔÛٷهÂÈ ÙËÓ ÚÔÛÎfiÏÏËÛË ÙˆÓ ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ (28,29). ™Ù· ·È‰È¿ ·˘Ù¿, Ô˘ ›¯·Ó ̤ÙÚÈ· ‚·Ú‡ÙËÙ· ÓfiÛÔ˘, ·Ú·ÙËÚ‹ıËΠ‚ÂÏÙ›ˆÛË. °) ÃÂÈÚÔ˘ÚÁÈ΋: OÈ ÛÙfi¯ÔÈ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂڷ›·˜ ‰È·Ê¤ÚÔ˘Ó ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È ÙËÓ Crohn, ·Ó Î·È ÔÈ ÂӉ›ÍÂȘ Û˘¯Ó¿ Â›Ó·È ÔÈ ›‰È˜ (30,31). ™ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Â›Ó·È ıÂڷ¢ÙÈ΋, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ‰ÂÓ Ê¤ÚÓÂÈ ÌfiÓÈÌÔ ·ÔÙ¤ÏÂÛÌ· (¶›Ó·Î·˜ 8). ∞ηٿۯÂÙË ·ÈÌÔÚÚ·Á›·, ‰È¿ÙÚËÛË, ·fiÊÚ·ÍË, ÙÔÍÈÎfiÙËÙ· ·fi ÙË Û˘Ó¤¯ÈÛË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ ‹ ·ÔÙ˘¯›· Ù˘ ıÂڷ¢ÙÈ΋˜
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·157
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
Paediatriki 2002;65:151-159
·ÁˆÁ‹˜ ·ÔÙÂÏÔ‡Ó ÎÔÈÓ¤˜ ÂӉ›ÍÂȘ Î·È ÁÈ· Ù· ‰‡Ô ÓÔÛ‹Ì·Ù·. ∂Ó›ÔÙÂ, ¤¯ÂÈ ¤Ó‰ÂÈÍË ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, ȉȷ›ÙÂÚ· fiÙ·Ó ‰È¢ÎÔχÓÂÈ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ. ∏ ÂÚÈÚˆÎÙÈ΋ ÓfiÛÔ˜ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ¯ÚÂÈ¿˙ÂÙ·È Â¤Ì‚·ÛË Î·È ‚¤‚·È· fiÙ·Ó ˘¿Ú¯ÂÈ Î·ÚΛÓÔ˜, Ô˘ ·ÔÙÂÏ› ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘. À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ˜ Ù¯ÓÈΤ˜, ·ÏÏ¿ ÚÔÙÈÌ¿Ù·È ÁÈ· ÙËÓ ∂∫ ÔÏÈ΋ ÎÔÏÂÎÙÔÌ‹ Î·È ÂÈÏÂÔÚˆÎÙÈ΋ ·Ó·ÛÙfïÛË Ì ‰ËÌÈÔ˘ÚÁ›· ı˘Ï¿ÎÔ˘ (30-32). ¶·Ú¿ ÙËÓ ÎÔÏÂÎÙÔÌ‹, ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ Ô˘ Êı¿ÓÂÈ ÙÔ 40% ÂÌÊ·Ó›˙ÂÈ ÛÙË Û˘Ó¤¯ÂÈ· ı˘Ï·Î›Ùȉ· (pouchitis) Î·È ¯ÚÂÈ¿˙ÂÙ·È ÙÔÈ΋ ıÂڷ›·. ∂ΛÓÔ fï˜ Ô˘ ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ·, ÙfiÛÔ ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ fiÛÔ ÛÙËÓ ·fiÊ·ÛË ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË, Â›Ó·È Ë ·˘ÙÔ¿ÓÔÛË Î·È Ë ·ÚÔÛ‰ÈfiÚÈÛÙË ÎÔÏ›Ùȉ· (Indeterminate colitis) Î·È ·˘Ùfi ÁÈ·Ù› Ë ·Ê·›ÚÂÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ‰ÂÓ ı· ·Ó·ÎÔ˘Ê›ÛÂÈ ·fi ÙÔ Úfi‚ÏËÌ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ڋ͢ ÙˆÓ ·Ó·ÛÙÔÌÒÛˆÓ, ÂÓÒ ÙÔ ÂÓ·ÔÌ›ÓÔÓ ¤ÓÙÂÚÔ ı· ÓÔÛ›. ∞˘Ùfi˜ Â›Ó·È Ô ÏfiÁÔ˜ Ô˘ ÂÈ‚¿ÏÏÂÙ·È Ó· ÙÂı› Ì ‚‚·ÈfiÙËÙ· Ë ‰È¿ÁÓˆÛË (33). ™ÙË Ó. Crohn Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ‰ÂÓ ÛËÌ·›ÓÂÈ ›·ÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Â›Ó·È Û˘¯Ó‹ Ë ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÛËÌÂ›Ô Ù˘ ¤̂·Û˘ Û ÔÛÔÛÙfi ̤¯ÚÈ 70%, ÂÓÒ ÛÙÔ ¯ÂÈÚÔ˘ÚÁfi Â›Ó·È ÁÓˆÛÙfi˜ Ô Î·ÓfiÓ·˜ fiÛÔ ÌÔÚ› Ó· ÌËÓ “·ÎÔ˘Ì‹ÛÂÈ” Ù· ¯¤ÚÈ· ÙÔ˘ ÛÙË Ó. Crohn. ∂ÓÙÔ‡ÙÔȘ, ÌÂÚÈΤ˜ ÊÔÚ¤˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÈ ÙÌËÌ·ÙÈ΋ ÂÓÙÂÚÈ΋ ·Ê·›ÚÂÛË, Û˘Ó‹ıˆ˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÂÈÏÂÔ‡ Î·È ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ∂ȉÈ΋ Ï·ÛÙÈ΋ (ÂÈÌ‹Î˘ ÙÔÌ‹ Î·È ÂÁοÚÛÈ· Ú·Ê‹ ÁÈ· Ó· ·˘ÍËı› Ô ·˘Ïfi˜) ÌÔÚ› Ó· Á›ÓÂÈ Û ÌÈÎÚ¿ ÙÌ‹Ì·Ù· ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ô˘ ¤¯Ô˘Ó οÓÂÈ ›ÓˆÛË Î·È ÛÙ¤ÓˆÛË, ·ÏÏ¿ ‰ÂÓ ¤¯Ô˘Ó ÂÓÂÚÁ‹ ÊÏÂÁÌÔÓ‹ (32). ¢) æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË: ∆· ‰‡Ô ·˘Ù¿ ÓÔÛ‹Ì·Ù· ÂıˆÚÔ‡ÓÙÔ Î¿ÔÙ „˘¯Ôۈ̷ÙÈο ÓÔÛ‹Ì·Ù·. ¶·Ú’ fiÏÔ Ô˘ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ „˘¯ÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ÂÓÙÔ‡ÙÔȘ Ë ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ „˘¯ÔÏÔÁ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙË ¯ÚfiÓÈ· ÓfiÛÔ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË (1-4). ∏ ¯ÚfiÓÈ· ¶›Ó·Î·˜ 8. ∂Ӊ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘ ÛÙËÓ πº¡∂ ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ñ ñ ñ ñ ñ ñ ñ ñ
∞ÈÌÔÚÚ·Á›· ¢È¿ÙÚËÛË ∆ÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ ∫ÂÚ·˘ÓÔ‚fiÏÔ˜ ÃÚfiÓÈ· ˘ÔÙÚ/˙Ô˘Û· ÓfiÛÔ˜ ÃÚ. ·ÓıÂÎÙÈ΋ ÓfiÛÔ˜ ™ˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË ¢È¿ÚÎÂÈ· >10 ¯Ú. Ì ‰˘ÛÏ·Û›·
Crohn ñ ñ ñ ñ
¢È¿ÙÚËÛË ∞fiÊÚ·ÍË ∞ηٿۯÂÙË ·ÈÌÔÚÚ·Á›· ™˘Ú›ÁÁÈ·, ·ÔÛÙ‹Ì·Ù· (·ÚÔ¯¤Ù¢ÛË) ñ ∫·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ (·Ê·›ÚÂÛË ¿Û¯ÔÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜)
¿ıËÛË, Ù· Ê¿Ú̷η Î·È ÔÈ Û˘¯Ó¤˜ ÓÔÛËÏ›˜ Û˘Ì›ÙÔ˘Ó Ì ÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ÂÊ˂›· fiÔ˘ Û˘Ì‚·›ÓÔ˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙËÓ ÚÔÛˆÈÎfiÙËÙ¿ ÙÔ˘ Î·È Ú·ÁÌ·ÙÈο Û˘¯Ó¿ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙË ¯ÔÚ‹ÁËÛË Ù˘ ıÂڷ›·˜. ∂›Ó·È ‡ÏÔÁÔ fiÙÈ ¯ÚÂÈ¿˙ÂÙ·È fi¯È ÌfiÓÔ ÙÔ ·È‰›, ·ÏÏ¿ Î·È fiÏË Ë ÔÈÎÔÁ¤ÓÂÈ· „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË. ∂ȉÈο ÔÈ ¤ÊË‚ÔÈ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ·fi ηı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÂÓ‹‚ˆÛË, ·fi ÙËÓ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜ ·fi ÙÔ ÚÔÛˆÂ›Ô Cushing Î·È ÙËÓ ·ÎÌ‹ ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹, ÂÓÒ ·ÔʇÁÔ˘Ó ÙȘ ·Ú¤Â˜ ÁÈ·Ù› ÔÓ¿Ó ‹ ¤¯Ô˘Ó ‰È¿ÚÚÔÈ·. ∞·ÈÙÂ›Ù·È ÛˆÛÙ‹ „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ¤ÁηÈÚË ‰È·›ÛÙˆÛË ÙˆÓ „˘¯ÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÁÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË. ∂ÈÏÔΤ˜ ·. ∂ÓÙÂÚÈΤ˜: OÈ Î‡ÚȘ ÂÈÏÔΤ˜ Â›Ó·È Ë Ì·˙È΋ ·ÈÌÔÚÚ·Á›· (1-3%), Ë ‰È¿ÙÚËÛË, ÙÔ ÙÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ (3-5%), ÂÓÒ ÂÈϤÔÓ ÛÙËÓ Crohn Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË (8%), Ù· ·ÔÛÙ‹Ì·Ù· Î·È Ù· Û˘Ú›ÁÁÈ·. MÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ·Ó¿Ù˘ÍË Î·ÚΛÓÔ˘ (34-36). ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ·Ó Ë ÓfiÛÔ˜ ·Ú¯›ÛÂÈ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, ·˘Í¿ÓÂÈ Ô Î›Ó‰˘ÓÔ˜ ÛÙËÓ ÂÊ˂›· Î·È Û˘ÓÂÒ˜ ¯ÚÂÈ¿˙ÂÙ·È ·ÊÂÓfi˜ ÌÂÓ screening, ·ÊÂÙ¤ÚÔ˘ ‰Â „˘¯ÔÏÔÁÈ΋ ÚÔÂÙÔÈÌ·Û›· ÁÈ· Ù˘¯fiÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. ™ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Ô Î›Ó‰˘ÓÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜, ·ÏÏ¿ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÂÚÈÙÒÛÂȘ ηÚΛÓÔ˘ Û ÓfiÛÔ ÙÔ˘ Crohn ÙfiÛÔ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ Ì Èı·ÓfiÙËÙ· 4 ¤ˆ˜ 20 ÊÔÚ¤˜, fiÛÔ Î·È ÛÙÔ ÏÂÙfi (ϤÌʈ̷) 50 ¤ˆ˜ 100 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· (3). ‚. ∂͈ÂÓÙÂÚÈΤ˜: OÛÙÂÔfiÚˆÛË ·fi ÙËÓ ÎÔÚÙÈ˙fiÓË ‹ ÙË ÓfiÛÔ ‰ÂÓ Â›Ó·È Û¿ÓÈ· (1,2,37,38). ∏ ıÚfiÌ‚ˆÛË Î·È ÔÈ ÂÌ‚ÔϤ˜ ·ÔÙÂÏÔ‡Ó ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ (9), ηıÒ˜ ›Û˘ Ë ÓÂÊÚÔÏÈı›·ÛË, Ë ˘‰ÚÔÓ¤ÊÚˆÛË, Ë ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· Ì ·ÓÔÛÔÏÔÁÈο Û˘ÌϤÁÌ·Ù· Î·È Ù· ÂÓÙÂÚÔ΢ÛÙÈο Û˘Ú›ÁÁÈ· Î·È ÔÊı·ÏÌÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜. ¶ÚfiÁÓˆÛË ∆˘Èο, Ë πº¡∂ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÚÈfi‰Ô˘˜ ÂÍ¿ÚÛÂˆÓ Î·È ˘Ê¤ÛˆÓ. (¶›Ó·Î·˜ 9). ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ∂∫ (70%) ÂÈÛ¤Ú¯ÔÓÙ·È Û ‡ÊÂÛË ÌÂÙ¿ ÙÔ˘˜ 3 ÚÒÙÔ˘˜ Ì‹Ó˜ Î·È ÂÚ›Ô˘ Ù· ÌÈÛ¿ Û˘ÓÔÏÈο ı· Ì›ÓÔ˘Ó Û ‡ÊÂÛË ÙÔÓ ÂfiÌÂÓÔ ¯ÚfiÓÔ (4). ∫ÔÏÂÎÙÔÌ‹ ı· ¯ÚÂÈ·ÛÙ› Û 26% ÙˆÓ ·È‰ÈÒÓ Ì ‚·ÚÈ¿ ÓfiÛÔ Î·È Û 10% Ì ‹È·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì πº¡∂ Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¤ÁÈÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ÎÔÏÂÎÙÔÌ‹ Û 28 ·È‰È¿ (9%). ªfiÓÔ ÙÔ 1% ÙˆÓ ·ÛıÂÓÒÓ Ì Crohn Ô˘ ¯ÂÈÚÔ˘ÚÁÔ‡ÓÙ·È ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ
157
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·158
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
Paediatriki 2002;65:151-159
¶›Ó·Î·˜ 9. ¶ÚfiÁÓˆÛË πº¡∂ ÛÙ· ·È‰È¿ ∂ÏÎ҉˘ ∫ÔÏ›ÙȘ
N. Crohn
⁄ÊÂÛË ÂÓÙfi˜ 3 ÌËÓÒÓ: 70%
1% ¯ˆÚ›˜ ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË
ÀÔÙÚÔ‹ ÂÓÙfi˜ 1 ¤ÙÔ˘˜: 50% ∫ÔÏÂÎÙÔÌ‹ ÂÓÙfi˜ 5 ÂÙÒÓ: 26%
∂ÈÏÂÔÎÔÏ›ÙȘ: ·ÓÙ·/ÛË, ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚. ¶ÂÚ›Ô˘ 70% ¯ÂÈÚÔ˘ÚÁÂ›Ô ÂÓÙfi˜ 10-20 ¯Ú.
¶ÚˆÎÙ›Ùȉ·: ¤Î/ÛË ÓfiÛÔ˘: 70% ∫›Ó‰˘ÓÔ˜ Ca ÌÂÙ¿ 10¯Ú.:
+
˘ÔÙÚÔ‹. ∆· ·È‰È¿ Ì ÂÈÏÂÔÎÔÏ›Ùȉ· ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚË ·ÓÙ·fiÎÚÈÛË ÛÙ· Ê¿Ú̷η Î·È ··ÈÙÂ›Ù·È Û˘¯ÓfiÙÂÚ· ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË, Û˘ÁÎÚÈÙÈο Ì ·˘Ù¿ Ô˘ ¿Û¯ÂÈ ÌfiÓÔ ÙÔ ÏÂÙfi ¤ÓÙÂÚÔ. ∆ÂÏÈο, Û ÔÛÔÛÙfi 70% ÛÙ· ÂfiÌÂÓ· 10-20 ¯ÚfiÓÈ· ·fi ÙË ‰È¿ÁÓˆÛË ı· ¯ÚÂÈ·ÛÙ› ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ÛÙËÓ Crohn. O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ ÛÙÔ ¿Û¯ÔÓ ¤ÓÙÂÚÔ Â›Ó·È ·˘ÍË̤ÓÔ˜ Î·È ÛÙ· ‰‡Ô ÓÔÛ‹Ì·Ù·. OÈ ·Ú¿ÁÔÓÙ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È Ë ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ (ÂȉÈο ¿Óˆ ·fi 10 ¯ÚfiÓÈ·, Ô Î›Ó‰˘ÓÔ˜ ÊÙ¿ÓÂÈ Û ÔÛÔÛÙfi 20%) Î·È Ë ¤ÎÙ·Û‹ Ù˘ (·ÓÎÔÏ›Ùȉ·), ηٷÛÙ¿ÛÂȘ ηْ ÂÍÔ¯‹Ó Û˘¯Ó¤˜ ÛÙ· ·È‰È¿, ηıÒ˜ ›Û˘ Î·È Ë ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ·. °È’ ·˘Ùfi, ÌÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ··ÈÙÂ›Ù·È Û˘ÛÙËÌ·ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÂÓ‰ÔÛÎfiËÛË Î·È ÔÏϷϤ˜ ‚ÈÔ„›Â˜ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ‰˘ÛÏ·Û›·˜, Ô˘ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÎÔÏÂÎÙÔÌ‹˜. ¢˘ÛÙ˘¯Ò˜, fï˜, ·˘Ù‹ Ë Ì¤ıÔ‰Ô˜ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ·ÛÊ·Ï‹˜, ÁÈ·Ù› ÂϤÁ¯ÂÙ·È ÂÏ¿¯ÈÛÙÔ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÈÛÙÔÏÔÁÈο Î·È ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ‰˘ÛÏ·Û›· Û ̷ÎÚÔÛÎÔÈο Ê˘ÛÈÔÏÔÁÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ÂÓÒ ÛÙÔ 40% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÌÊ·Ó›ÛıËΠηÚΛÓÔ˜ Î·È ¤Î·Ó·Ó ÎÔÏÂÎÙÔÌ‹ ‰ÂÓ ˘‹Ú¯Â ‰˘ÛÏ·Û›·. ∞fi Ì·ıËÌ·ÙÈο ÌÔÓ٤Ϸ ÁÈ· ÙÔ ÔÈ· Â›Ó·È Ë Î·Ï‡ÙÂÚË ÚfiÏË„Ë ‚Ú¤ıËΠfiÙÈ Ë ÔÏÈ΋ ÚÔÏËÙÈ΋ ÎÔÏÂÎÙÔÌ‹ ÌÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ·˘Í¿ÓÂÈ ÙËÓ ÂÈ‚›ˆÛË Î·Ù¿ 1,5 ¯ÚfiÓÔ, Û˘ÁÎÚÈÙÈο Ì ٷ ¿ÙÔÌ· Ô˘ ‰ÂÓ Á›ÓÂÙ·È Î·È Î·Ù¿ 10 Ì‹Ó˜ fiÙ·Ó Á›ÓÂÙ·È screening Ì ÂÓ‰ÔÛÎfiËÛË Î·È ‚ÈÔ„›Â˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ÂÓÙÂÚÈ΋˜ ‰˘ÛÏ·Û›·˜. ∆ÂÏÈο, Ë πº¡∂ ·ÔÙÂÏ› ¤Ó· ÛËÌ·ÓÙÈÎfi Î·È ‰‡ÛÎÔÏÔ ÓfiÛËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ÏËıÒÚ· ÙˆÓ Ê·Ú̷΢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ ‰ËÏÒÓÂÈ ÙËÓ ·‰˘Ó·Ì›· Ì·˜ Ó· ‰·Ì¿ÛÔ˘Ì ÙË ÓfiÛÔ Û ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ (39). ™Â Ì›· ÔÌ¿‰· ·È‰ÈÒÓ ··ÈÙÂ›Ù·È ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· ÁÈ· Ó· ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÓfiÛÔ˘. ™Ùfi¯Ô˜ Â›Ó·È fi¯È ÌfiÓÔ Ë ‡ÊÂÛË, ·ÏÏ¿ Î·È ÙÔ Ó· Â›Ó·È ÙÔ ·È‰› ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜ ˘ÁȤ˜ Î·È Ó· ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË. À¿Ú¯Ô˘Ó fï˜ ÛËÌ·ÓÙÈο ÂÚˆÙ‹Ì·Ù·: ª‹ˆ˜ fiÏ· ·˘Ù¿ Ù· Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈԇ̠ÁÈ· ÙË ¯ÚfiÓÈ· ·ÓÔÛÔηٷÛÙÔÏ‹ Á›ÓÔ˘Ó ·ÊÔÚÌ‹ Ó· ·Ó·Ù˘¯ı› ηÎÔ‹ıÂÈ· ·ÚÁfiÙÂÚ·; £· ˘¿ÚÍÂÈ ÈÔ ·ÍÈfiÈÛÙÔ˜ ÙÚfiÔ˜ ¤ÁηÈÚ˘ ÂÓÙfiÈÛ˘ Ù˘ ÂÓÙÂ-
158
[
+
[ ·Ó¿ÛÙËÌ· ÂÓ‹Ï. (·Ó ‰ÂÓ ÛÈÙÈÛÙÔ‡Ó ·È‰È¿) + ÂÚ›Ô˘ ›‰ÈÔ˜
ÚÈ΋˜ ‰˘ÛÏ·Û›·˜ Ô˘ ·ÔÙÂÏ› ÚÔηÚÎÈÓÈÎfi ÛÙ¿‰ÈÔ Î·È ··ÈÙ› ÎÔÏÂÎÙÔÌ‹; ◊ Ì‹ˆ˜ ¯ÚÂÈ¿˙ÂÙ·È ÚÔÏËÙÈ΋ ·ÎÚˆÙËÚÈ·ÛÙÈ΋ ¤̂·ÛË ÓˆÚ›ÙÂÚ·; ™Â ·˘Ù‹ ÙË ÚÈ˙È΋ χÛË Ë ·¿ÓÙËÛË Â›Ó·È ·ÚÓËÙÈ΋. ∫·È ·˘Ùfi ÁÈ·Ù› ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Î·ÚΛÓÔ fiÏ· Ù· ¿ÙÔÌ· Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÂÓÒ ÛÙËÓ Crohn Ô˘ Û˘Ó¤¯ÂÈ· ·˘Í¿ÓÂÈ ÛÂ Û˘¯ÓfiÙËÙ·, Ë ÂÁ¯Â›ÚËÛË ‰ÂÓ ·ÔÙÂÏ› ÚÈ˙È΋ χÛË. ∆Ô ·ÚÓËÙÈÎfi Â›Ó·È ˆ˜ fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· ·˘Í¿ÓÔÓÙ·È Ù· ·˘ÙÔ¿ÓÔÛ· Î·È Ì·˙› ÔÈ ·˘ÙÔ¿ÓÔÛ˜ ÎÔÏ›Ùȉ˜ Ô˘ ·ÔÙÂÏÔ‡Ó Ú·ÁÌ·ÙÈο ÛÔ‚·Úfi Úfi‚ÏËÌ·. ∆Ô È‰·ÓÈÎfi ı· ‹Ù·Ó Ë ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. ÿÛˆ˜ ÌÂÚÈο ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÔÈ ¤Ú¢Ó˜ ʤÚÔ˘Ó ÛÙÔ Êˆ˜ Ó¤· ÌÔÓÔ¿ÙÈ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Hofley P, Piccoli D. Inflammatory bowel disease in children. Med Clin N Am 1994;78:1281-1302. 2. Kirschner B. Ulcerative colitis and Crohn’s disease in children. Gastroenterol Clin N Am 1995;24:99-117. 3. Baldassano R, Piccoli D. Inflammatory bowel disease in pediatric and adolescent patients. Gastroenterol Clin N Am 1999;28:445-458. 4. Hyams J. Inflammatory bowel disease. Pediatr Rev 2000;21:291-295. 5. Adres P, Friedman L. Epidemiology and natural cource of inflammatory bowel disease. Gastroenterol Clin N Am 1999;28;255-282. 6. Shivananda S, Lennard-Jones J, Logan R, Fear N, Price A, Carpenter L. Incidence of inflammatory bowel disease across Europe: is there any difference between north and south? Results of a European collaborative study on inflammatory bowl disease (EC-IBD). Gut 1996;39:690-697. 7. Probert C, Jayanthi V, Hughes A, Thomson J, Wicks A, Mayberry J. Prevalence and family risk of ulcerative colitis and Crohn’s disease: an epidemiological study among Europeans and South Asians in Leicestershire. Gut 1993;34;1547-1551. 8. Pena S, Crusius B. Genetics of inflammatory bowel disease: Implications for the future. World J Surg 1998;22:390-393. 9. Liebman H, Kashani N, Sutherland D, McGehee, Kam L. The Factor Leiden mutation increases the risk of venous thrÔmbosis in patients with inflammatory bowel disease. Dis Colon Rectum 1997;40:437-439. 10. Gasche C, Reinisch W, Lochs H, Parsaei B, Bakos S,
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·159
¶·È‰È·ÙÚÈ΋ 2002;65:151-159
11.
12. 13.
14. 15.
16.
17. 18. 19.
20. 21.
22.
23.
24.
25.
26.
Wyatt J et al. Anemia in Crohn’s disease: Importance of inadequate erythropoietin production and iron deficiency. Dig Dis Sci 1994;39:1930-1934. Papadakis K, Targan S. Current theories on the causes of inflammatory bowel disease. Gastroenterol Clin N Am 1999;28:283-296. Rogler G, Andus T. Cytokines in inflammatory bowel disease. World J Surg 1998;22:382-389. Koltun W, Schoetz D, Roberts P, Murray J, Coller J, Malcolm C et al. Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis. Dis Colon Rectum 1991;34:857-860. Veress B, Lofberg R, Bergman L. Microscopic colitis syndrome. Gut 1995;36:880-886. Ruemmele F, Targan S, Levy G, Rubinski M, Braun J, Seidman E. Diagnostic accuracy of serological assays in pediatric inflammatory bowel disease. Gastroenterology 1998;115:822-829. Bar-Meir S, Chowers Y, Lavy A, Abramovitch D, Sternberg A, Leichtmann G et al. Budesonide versus prednisone in the treatment of active Crohns’ disease. Gastroenterology 1998;115:835-840. Choi P, Targan S. Immunomodulator therapy in inflammatory bowel disease. Dig Dis Sci 1994;39:1885-1892. Stein R, Hanauer S. Medical therapy for inflammatory bowel disease. Gastroenterol Clin N Am 1999;28:296-322. Kirschner B. Safety of azathioprine and 6-mercaptopurine in pediatric patients with inflammatory bowel disease. Gastroenterology 1998;115:813-821. Sands B. Novel therapies for inflammatory bowel disease. Gastroenterol Clin N Am 1999;28:323-352. Michetti P, Peppecorn M. Medical therapy of specific clinical presentations. Gastroenterol Clin N Am 1999;28:353-370. Lopez-Cubero S, Sullivan K, Mc Donald G. Course of Crohn’s disease after allogeneic marrow transplantation. Gastroenterology 1999;114:433-440. Kelly D, Fleming R. Nutritional considerations in inflammatory bowel diseases. Gastroenterol Clin N Am 1995;24:597-611. Han P, Burk A, Baldassano R, Rombeau J, Lichtenstein G. Nutrition and inflammatory bowel disease. Gastroenterol Clin N Am 1999;28:423-444. Heuschkel R, Menache C, Megerian T, Baird A. Enteral nutrition and corticosteroids in the treatment of acute Crohn’s disease in children. J Pediatr Gastroenterol Nutr 2000;31:8-15. Belluzzi A, Brignola C, Campieri M, Camporesi E, Gionchetti P,Rizzello F et al. Effects of fish oil derivative on
Paediatriki 2002;65:151-159
fatty acid phosholopid-membrane pattern in group of Crohn’s disease patients. Dig Dis Sci 1994;39:2589-2594. 27. Yang V. Eicosanoids and inflammatory bowel disease. Gastroenterol Clin N Am 1999;25:317-332. 28. Duffy L, Leavens A, Griffiths E, Dryja D. Perspectives on bifidobacteria as biotherapeutic agents in gastrointestinal health. Dig Dis Sci 1999;44:1499-1505. 29. Gupta P, Adrew H, Kirschner B, Guandalini S. Is Lactobacillus GG helpful in children with Crohn’s disease? Results of a preliminary, open-label study. J Pediatr Gastroenterol Nutr 2000;31:453-456. 30. Cohen Z. Surgical and research aspects of inflammatory bowel disease: Introduction. World J Surg 1998;22:333-334. 31. Hulten L. Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis. World J Surg 1998;22:335-341. 32. Becker J. Surgical therapy for ulcerative colitis and Crohn’s disease. Gastroenterol Clin N Am 1999;28:371-390. 33. Subramani K, Harpaz N, Bilotta J, Bodian C, Rubin P, Janowitz H et al. Refractory pouchitis: does it reflect underlying Crohn’s disease? Gut 1993;34:1539-1542. 34. Lewis J, Deren J, Lichtestein G. Cancer risk in patients with inflammatory bowel disease. Gastroenterol Clin N Am 1999;28:459-478. 35. Solomon M, Schnitzler M. Cancer and inflammatory bowel disease; Bias, epidemiology, surveillance, and treatment. World J Surg 1998;22:352-358. 36. Pohl C, Hombach A, Kruis W. Chronic inflammatory bowel disease and cancer. Hepatogastroenterol 2000;47:57-70. 37. Gokhale R, Favus M, Karrison T, Sutton M, Rich B, Kirschner BS. Bone mineral density assessment in children with inflammatory bowel disease. Gastroenterology 1998;114:902-911. 38. Cowan F, Warner J, Dunstan F, Evans W, Gregory J, Jenkins H. Inflammatory bowel disease and predisposition to osteopenia. Arch Dis Child 1997;76:325-329. 39. Casati J, Toner B, De Rooy E, Drossman D, Maunder R. Concerns of patients with inflammatory bowel disease. Dig Dis Sci 2000;45:26-31.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 31-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂. ƒÒÌ· - °È·ÓÓ›ÎÔ˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÂÛÙËÌ›Ô˘ ∞ıËÓÒÓ
159
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·160
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
∞¡∞™∫O¶∏™∏
Paediatriki 2002;65:160-166
REVIEW ARTICLE
™‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ: ¶·ıÔÁ¤ÓÂÈ· Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ª. ∫·ÙÛ¿Ú·, ∫. ¶·¿˙ÔÁÏÔ˘
Increased capillary permeability syndrome (Leak syndrome): Pathogenesis and the newest evidence for its management M. Katsara, K. Papazoglou
¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ··Û¯ÔÏ› Û˘¯Ó¿ Î·È ÚÔ‚ÏËÌ·Ù›˙ÂÈ ¤ÓÙÔÓ· ÙÔ˘˜ ÎÏÈÓÈÎÔ‡˜ ÁÈ·ÙÚÔ‡˜ fiÏˆÓ ÙˆÓ ÂȉÈÎÔًوÓ, fiÙ·Ó ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜. ∞Ó·ÛÎÔÔ‡ÓÙ·È Ë ·ÈÙÈÔÏÔÁ›·, Ë ·ıÔÁ¤ÓÂÈ·, Ë ıÂڷ¢ÙÈ΋ ÙÔ˘ ·ÓÙÈÌÂÙÒÈÛË Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ¯ÔÚ‹ÁËÛ˘ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÎÔÏÏÔÂȉÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÛÙËÓ ·Ó¿ÓË„Ë ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ÓÔÛ› ÛÔ‚·Ú¿.
Abstract: The increased capillary permeability syndrome (Leak syndrome) is a severe condition that challenges the clinicians who treat critically ill patients. This review discusses the etiology and the pathogenesis of the syndrome, the therapeutic approach as well as the newest data concerning the controversy regarding the administration of crystalloid-colloid solutions for the resuscitation of the critically ill patient.
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ, Û‡Ó‰ÚÔÌÔ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ, ‰È¿¯˘ÙË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË, ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ÎÔÏÏÔÂȉ‹, ·Ó¿ÓË„Ë Ì ˘ÁÚ¿.
Key words: capillary permeability, capillary leak, diffuse inflammatory response, crystalloids, colloids, fluid resuscitation.
∂ÈÛ·ÁˆÁ‹ ø˜ Û‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ÔÚ›˙ÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È¿¯˘ÙË ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ÙÚȯÔÂȉÈÎÒÓ ·ÁÁ›ˆÓ, Û˘ÛÙËÌ·ÙÈ΋ ‰È·Ê˘Á‹ Ï¿ÛÌ·ÙÔ˜ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È ·ÔÙÂÏ› ‰È·Ù·Ú·¯‹ Ù˘ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Û οÔÈÔ ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ· (1-3). ∏ ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ·Ú·ÙËÚÂ›Ù·È Û ‰È¿ÊÔÚ˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ: ÛÙË ÛË„·ÈÌ›·, ÙÔ ¤Áη˘Ì·, ÙÔ ÙÚ·‡Ì·, ÙȘ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ÙÔ ARDS, Û ηÚÎÈÓÔ·ı›˜ Î·È Û η¯ÂÎÙÈÎÔ‡˜ ·ÛıÂÓ›˜ (1,3-6). ∆· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‰˘ÛÌÂÓ‹ ÁÈ· ÙËÓ ¤Î‚·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ‰ÈfiÙÈ ÚÔηÏ› Ì›ˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, ·ÓıÂÎÙÈ΋ ˘fiÙ·ÛË ÛÙË ıÂڷ›· Ì ÂÓ‰ÔÊϤ‚È· ˘ÁÚ¿, Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·, ¯·ÌËÏ¿ ›‰· ·Ï‚Ô˘Ì›Ó˘ ÛÙÔ ·›Ì·, η΋ Ô͢ÁfiÓˆÛË ÙˆÓ ÈÛÙÒÓ, ÔÏ˘ÔÚÁ·-
ÓÈ΋ ·Ó¿ÚÎÂÈ· (2,5,7,8). ∏ ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÂΛÓÔ˘˜ Ô˘ ηٷϋÁÔ˘Ó, ·Ô‰›‰ÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ¤Ó· ̤ÚÔ˜, ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·˜ Ô˘ Ô‰ËÁ› ÛÙËÓ Î·Î‹ Ô͢ÁfiÓˆÛË ÙˆÓ ÈÛÙÒÓ.
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
Intensive Care Unit Children’s Hospital “P. & A. Kyriakou”, Athens
160
™ÙÔȯ›· ‚·ÛÈ΋˜ Ê˘ÛÈÔÏÔÁ›·˜ (9) ™Ù· ÙÚȯÔÂȉ‹ ·ÁÁ›· ÂÈÙÂÏÂ›Ù·È Ë ÛËÌ·ÓÙÈÎfiÙÂÚË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ‰ËÏ·‰‹ Ë ·ÓÙ·ÏÏ·Á‹ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ Î·È Î˘ÙÙ·ÚÈÎÒÓ ·Ô‚Ï‹ÙˆÓ ÌÂٷ͇ ÙˆÓ ÈÛÙÒÓ Î·È ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·›Ì·ÙÔ˜. À¿Ú¯Ô˘Ó ÂÚ›Ô˘ 10 ÂηÙÔÌ̇ÚÈ· ÙÚȯÔÂȉ‹ ÌÂ Û˘ÓÔÏÈ΋ ÂÈÊ¿ÓÂÈ· 500-700 m2 Ô˘ Â›Ó·È ˘Â‡ı˘Ó· ÁÈ’ ·˘Ù‹ ÙË ÏÂÈÙÔ˘ÚÁ›·. ∆Ô ÙÚȯÔÂȉÈÎfi ÙÔ›¯ˆÌ· ·ÔÙÂÏÂ›Ù·È ·fi ÌÔÓ‹ ÛÙÔÈ‚¿‰· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË (™¯‹Ì· 1). ™ÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË ˘¿Ú¯Ô˘Ó fiÚÔÈ Ô˘ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfiÙ·ÙÔ ÚfiÏÔ ÛÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·161
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
Paediatriki 2002;65:160-166
Ô˘ÛÈÒÓ ÌÂٷ͇ Ï¿ÛÌ·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡. ™ÙÔ˘˜ fiÚÔ˘˜ ·˘ÙÔ‡˜ ˘¿ÁÔÓÙ·È ÔÈ ÌÂÛÔ΢ÙÙ¿ÚȘ Û¯ÈṲ̂˜ ÌÂٷ͇ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ¤Ó· ¯·Ï·Úfi ϤÁÌ· ‰ÈÎÙ˘ˆÙÒÓ ÈÓȉ›ˆÓ ·fi ÚˆÙÂÔÁÏ˘Î¿Ó˜, ‰È·Ì¤ÛÔ˘ ÙˆÓ ÔÔ›ˆÓ ‰È·ÎÈÓÔ‡ÓÙ·È Ù· ÂÚÈÛÛfiÙÂÚ· ˘‰·ÙÔ‰È·Ï˘Ù¿ ÈfiÓÙ· Î·È ÌfiÚÈ·. ∂›Û˘, ÛÙÔ ÂÓ‰ÔıËÏÈ·Îfi ·ÙÙ·ÚÔ ˘¿Ú¯Ô˘Ó Ù· Ê·ÁÔ΢ÙÙ·ÚÈο ΢ÛÙ›‰È· Ô˘ ÌÂٷʤÚÔ˘Ó ÌÂÁ¿Ï· ÌfiÚÈ·, ·ÎfiÌË Î·È ÛÙÂÚ¿ ۈ̷ٛ‰È·, ·fi ÙË Ì›· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙËÓ ¿ÏÏË. ∏ ·ÓÙ·ÏÏ·Á‹ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÂٷ͇ ·›Ì·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ Á›ÓÂÙ·È Î˘Ú›ˆ˜ Ì ‰È¿¯˘ÛË. ∏ ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÙȘ ‰È¿ÊÔÚ˜ Ô˘Û›Â˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜, ÙÔ Û¯‹Ì· Î·È ÙÔ ËÏÂÎÙÚÈÎfi ÙÔ˘˜ ÊÔÚÙ›Ô (10). ∆· ÌfiÚÈ· ÙÔ˘ ÓÂÚÔ‡, Ô˘ Â›Ó·È Ù· ÌÈÎÚfiÙÂÚ·, ¤¯Ô˘Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ‰È·ÂÚ·ÙfiÙËÙ·. OÈ ÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È ÂÏ·ÊÚ¿ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙÔ˘˜ fiÚÔ˘˜, Ì ·ÔÙ¤ÏÂÛÌ· Ë ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË Ó· Â›Ó·È ·‰È·¤Ú·ÛÙË Û¯Â‰fiÓ ÛÙË ÏÂ˘ÎˆÌ·Ù›ÓË, ·Ó Î·È ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ ÚˆÙ½Ó˘ ÂÚÓÔ‡Ó ·fi ÙÔ Ï¿ÛÌ· ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ. ∆Ô ÈÓˆ‰ÔÁfiÓÔ Ô˘ ¤¯ÂÈ Ôχ ÌÂÁ·Ï‡ÙÂÚÔ ªµ ·fi ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÌÔÚ› Ó· ÂÚ¿ÛÂÈ ·fi ÙÔ˘˜ ÙÚȯÔÂȉÈÎÔ‡˜ fiÚÔ˘˜ Û ηٿÛÙ·ÛË ÊÏÂÁÌÔÓ‹˜, ÏfiÁˆ ÙÔ˘ Û¯‹Ì·Ùfi˜ ÙÔ˘ Ô˘ Â›Ó·È Û·Ó ‚ÂÏfiÓË (10). OÈ ÚˆÙ½Ó˜ ʤÚÔ˘Ó ·ÚÓËÙÈÎfi ËÏÂÎÙÚÈÎfi ÊÔÚÙ›Ô Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ̤۷ ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ, ηıÒ˜ ·ˆıÔ‡ÓÙ·È ·fi ÙȘ ÚˆÙÂÔÁÏ˘Î¿Ó˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Ô˘ Â›Ó·È ÎÈ ·˘Ù¤˜ ·ÚÓËÙÈο ÊÔÚÙÈṲ̂Ó˜), ÏfiÁˆ ÛÙ·ÙÈÎÔ‡ ËÏÂÎÙÚÈÛÌÔ‡ (11). O ‰È¿ÌÂÛÔ˜ ¯ÒÚÔ˜ (™¯‹Ì· 2) ·ÔÙÂÏÂ›Ù·È ·fi ÈÛ¯˘Ú¤˜ ›Ó˜ ÎÔÏÏ·ÁfiÓÔ˘ Ô˘ ÚÔÛ‰›‰Ô˘Ó ÙËÓ Ù¿ÛË Ô˘ Û˘ÁÎÚ·Ù› ÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ·fi ÏÂÙ¿ ÈÓ›‰È· ÚˆÙÂÔÁÏ˘Î¿Ó˘ Ô˘ Û˘Ó‰¤ÔÓÙ·È ¯·Ï·Ú¿ ÌÂٷ͇ ÙÔ˘˜ Û¯ËÌ·Ù›˙ÔÓÙ·˜ ¤Ó· ϤÁÌ·. ª¤Û· ÛÙÔ Ï¤ÁÌ· ·˘Ùfi ÂÁÎψ‚›˙ÂÙ·È ÙÔ ˘ÂډȋıËÌ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÙÔ “˙ÂϤ” ÙˆÓ ÈÛÙÒÓ. ∞Ó¿ÌÂÛ· Û ·˘Ùfi ÙÔ Ï¤ÁÌ· ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ
˘¿Ú¯Ô˘Ó Î·È Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜. ŸÙ·Ó fï˜ ·Ó·Ù‡ÛÛÂÙ·È ÈÛÙÈÎfi Ô›‰ËÌ·, ·˘Ù¤˜ ·ÎÚÈ‚Ò˜ ÔÈ ÂÚÈÔ¯¤˜ Ì ÙÔ ÂχıÂÚÔ ˘ÁÚfi ÂÎÙ‡ÛÛÔÓÙ·È ˘ÂÚ‚ÔÏÈο. À¿Ú¯Ô˘Ó 4 ‰˘Ó¿ÌÂȘ Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ Î›ÓËÛË ÙÔ˘ ÓÂÚÔ‡ ‰È·Ì¤ÛÔ˘ Ù˘ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi (™¯‹Ì· 3): ·) ∏ ̤ÛË ∆ÚȯÔÂȉÈ΋ ¶›ÂÛË (Pc) Ô˘ Ù›ÓÂÈ Ó· ÌÂÙ·ÎÈÓ› ÙÔ ÓÂÚfi ÚÔ˜ Ù· ¤Íˆ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÙÚȯÔÂȉԇ˜. ‚) ∏ ¶›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (Pif) Ô˘ Ù›ÓÂÈ Ó· ÌÂÙ·ÎÈÓ› ÙÔ ÓÂÚfi ÚÔ˜ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ (ÚÔ˜ Ù· ̤۷) fiÙ·Ó Â›Ó·È ıÂÙÈ΋, ·ÏÏ¿ ÚÔ˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (ÚÔ˜ Ù· ¤Íˆ) fiÙ·Ó Â›Ó·È ·ÚÓËÙÈ΋. Á) ∏ OÁÎÔÙÈ΋ ¶›ÂÛË (ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (¶p) Ô˘ Ù›ÓÂÈ Ó· ÚÔηÏ› fiÛ̈ÛË ÙÔ˘ ÓÂÚÔ‡ ÚÔ˜ Ù· ̤۷, ‰È·Ì¤ÛÔ˘ Ù˘ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ‰) ∏ ∫ÔÏÏÔÂȉÔÛ̈ÙÈ΋ ¶›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (¶if) Ô˘ Ù›ÓÂÈ Ó· ÚÔηÏ› fiÛ̈ÛË ÙÔ˘ ÓÂÚÔ‡ ÚÔ˜ Ù· ¤Íˆ ‰È·Ì¤ÛÔ˘ Ù˘ ÌÂÌ‚Ú¿Ó˘. ∏ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (Pif) Â›Ó·È ÂÏ·ÊÚ¿ ·ÚÓËÙÈ΋, Û ۯ¤ÛË Ì ÙËÓ ·ÙÌÔÛÊ·ÈÚÈ΋ ›ÂÛË Ô˘ ÂÍ·ÛÎÂ›Ù·È ÛÙÔ ‰¤ÚÌ· Ô˘ ıˆÚÂ›Ù·È ÌˉÂÓÈ΋. ∏ ·ÚÓËÙÈ΋ ·˘Ù‹ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ ·ÛΛ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ¤Ó·ÓÙÈ Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ Ôȉ‹Ì·ÙÔ˜ Î·È Â›Û˘ Û˘Ì‚¿ÏÏÂÈ ÛÙË Û˘ÓÂÎÙÈÎfiÙËÙ· ÙˆÓ ÈÛÙÒÓ, ηıÒ˜ ‰Ú· ˆ˜ ÎÂÓfi ·¤ÚÔ˜. ∏ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (¶p) ÚÔ¤Ú¯ÂÙ·È ·fi ÙȘ ‰È·Ï˘Ì¤Ó˜ ÚˆÙ½Ó˜ ÛÙÔ Ï¿ÛÌ·, ÂÓÒ Ë ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (¶if) ÂÍ·ÛÎÂ›Ù·È ·fi Ù· ÌfiÚÈ· ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ Â›Ó·È Û˘ÁÎÂÓÙڈ̤ӷ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (‰È‹ıËÛË Ì¤Ûˆ fiÚˆÓ, Ê·ÁÔ·وÛË). ™ÙËÓ Î·Ù·ÓÔÌ‹ ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ÓÂÚÔ‡ ÌÂٷ͇
Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡
Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡
ÂÓ‰ÔıËÏÈ·Îfi ·ÙÙ·ÚÔ ÙÚȯÔÂȉ¤˜ ÌÂÛÔ΢ÙÙ¿ÚÈ· Û¯ÈÛÌ‹
ÈÓ›‰È· ÚˆÙÂÔÁÏ˘Î¿Ó˘
Ê·ÁÔ΢ÙÙ·ÚÈο ΢ÛÙ›‰È·
›Ó˜ ÎÔÏÏ·ÁfiÓÔ˘ ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË
™¯‹Ì· 1
™¯‹Ì· 2
161
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·162
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
Paediatriki 2002;65:160-166
Ï¿ÛÌ·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡ ÈÛ¯‡ÂÈ Ô ÓfiÌÔ˜ ÙÔ˘ Starling, Ô˘ ÚÈÓ ·fi ¤Ó·Ó ·ÈÒÓ· ÂÚ›Ô˘ ‰È·Ù‡ˆÛ ÙËÓ ÈÛÔÚÚÔ›· Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË: Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Ô˘ ÊÈÏÙÚ¿ÚÂÙ·È ¤Íˆ ·fi ÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË ÛÙÔ ·ÚÙËÚÈ·Îfi ¿ÎÚÔ ÈÛÔ‰˘Ó·Ì› Ì ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Ô˘ ·ӷÚÚÔÊ¿Ù·È ·fi Ù· ÙÚȯÔÂȉ‹ ÛÙÔ ÊÏ‚ÈÎfi ¿ÎÚÔ. ¢ËÏ·‰‹, ÈÛ¯‡ÂÈ Ë Â͛ۈÛË: ¢È‹ıËÛË ˘ÁÚÔ‡ = ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ÌÂÌ‚Ú¿Ó˘ x ›ÂÛË ‰È‹ıËÛ˘ ¢È‹ıËÛË ˘ÁÚÔ‡ (Fluid flux): FF=Kfc[(Pc-Pif)6d(¶p-¶if)] Kfc = ÛÙ·ıÂÚ¿ ÙÚȯÔÂȉÈ΋˜ ‰È¿¯˘Û˘, 6d = ÛÙ·ıÂÚ¿ ·Ó¿ÎÏ·Û˘ ¶ÂÚ›Ô˘ ÙÔ 0,5% ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÊÈÏÙÚ¿ÚÂÙ·È ÂÎÙfi˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÙÔ ·ÚÙËÚÈ·Îfi ¿ÎÚÔ Î·È ‰È·¯¤ÂÙ·È ÚÔ˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ, ÁÈ· Ó· ·ӷÚÚÔÊËı› ۯ‰fiÓ fiÏÔ ·fi ÙÔ ÊÏ‚ÈÎfi ¿ÎÚÔ ÙˆÓ ÙÚȯÔÂȉÒÓ. ∆Ô 1/10 ÂÚ›Ô˘ Ù˘ ÔÛfiÙËÙ·˜ Ô˘ ÂÍ·ÁÁÂÈÒÓÂÙ·È ‰ÂÓ Â·Ó·ÚÚÔÊ¿Ù·È, ·ÏÏ¿ ÔÈ ÈÛÙÔ› ‰ÂÓ ÂÍÔȉԇÓÙ·È, ‰ÈfiÙÈ ·˘Ù‹ Ë ÂÈϤÔÓ ÔÛfiÙËÙ· ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ÏÂÌÊ·ÁÁÂÈ·Îfi ‰›ÎÙ˘Ô. ŸÙ·Ó ˘¿Ú¯ÂÈ ·ÓÈÛÔÚÚÔ›· ÛÙȘ ‰˘Ó¿ÌÂȘ Ô˘ ·ÛÎÔ‡ÓÙ·È Âη٤ڈıÂÓ Ù˘ ÌÂÌ‚Ú¿Ó˘, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Û˘Óı‹Î˜ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· Ôȉ‹Ì·ÙÔ˜. ŒÙÛÈ, Ô›‰ËÌ· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ÛÂ: ·) ·˘ÍË̤ÓË ›ÂÛË ÙˆÓ ÙÚȯÔÂȉÒÓ, ‚) ·ÒÏÂÈ· ÚˆÙÂ˚ÓÒÓ Ï¿ÛÌ·ÙÔ˜, Á) ·fiÊÚ·ÍË ÏÂÌÊ·ÁÁ›ˆÓ Î·È ‰) ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· ÙÚȯÔÂȉÒÓ (Leak syndrome). ∏ ‰ËÌÈÔ˘ÚÁ›· Ôȉ‹Ì·ÙÔ˜ ÚÔ‚ÏËÌ·Ù›˙ÂÈ Ôχ ÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi, ‰ÈfiÙÈ ÙÔ Ô›‰ËÌ· Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ (12): η΋ ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ ÛÙÔÓ Ó‡ÌÔÓ·, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì˘Ôηډ›Ô˘, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ηı˘ÛÙÂÚË̤ÓË ÂԇψÛË ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÙÚ·˘Ì¿ÙˆÓ, ÌÂȈ̤ÓË ‰È·ıÂÛÈÌfiÙËÙ· Ô͢ÁfiÓÔ˘ ÛÙÔ˘˜ ÈÛÙÔ‡˜, ¤ÏÎË Î·Ù¿ÎÏÈÛ˘.
ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ ¤¯ÂÈ ÌÂÏÂÙËı› ΢ڛˆ˜ ÛÙÔ ÛËÙÈÎfi shock. ∂ΛÓÔ Ô˘ ¿Û¯ÂÈ ÛÙÔ Leak syndrome Â›Ó·È Ë ÌÈÎÚÔ΢ÎÏÔÊÔÚ›· (13). ™ÙË ÛË„·ÈÌ›·, ÔÈ ÂÓ‰ÔÙÔ͛Ә ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ·ÏÏ¿ Î·È ¿ÏÏÔÈ ÂӉȿÌÂÛÔÈ ·Ú¿ÁÔÓÙ˜ ÊÏÂÁÌÔÓ‹˜ (TNF-·, IL-1, IL-2, IL-6, IL-8, ·Ú¿ÁÔÓÙ˜ C1, C3, C5 ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ·Ú¿ÁÔÓÙ˜ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, Ï¢ÎÔÙÚȤÓÈ·, ‚Ú·‰˘ÎÈÓ›ÓË, Ï·ÛÌ›ÓË, ÂÏ·ÛÙ¿ÛË Î.Ï.) ÂÓÂÚÁÔÔÈÔ‡Ó Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, Ù· ÔÔ›· Û˘ÁÎÔÏÏÒÓÙ·È Ì ٷ Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È ˘Ê›ÛÙ·ÓÙ·È Ù·¯Â›· ÌÂÙ·‚ÔÏ‹ Ù˘ ‰ÔÌ‹˜ Î·È ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜, Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Î·È ÙËÓ ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ¿˜ ÙÔ˘ (3,4,10,14,15). ∏ Û˘ÁÎfiÏÏËÛË ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ‚·ÛÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘ (SIRS). ªÂ ÙÔ Ì˯·ÓÈÛÌfi ·˘Ùfi ÚÔηÏÂ›Ù·È ·Â˘ı›·˜ ‚Ï¿‚Ë ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÂχıÂÚˆÓ ÚÈ˙ÒÓ O2, ˘‰ÚÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ηıÒ˜ Î·È Ì ÙËÓ ·fiÊÚ·ÍË ÙÔ˘ ·˘ÏÔ‡ ÙˆÓ ÙÚȯÔÂȉÒÓ ·fi Ù· Û˘ÛÛˆÚÂ˘Ì¤Ó· Ï¢ÎÔ·ÙÙ·Ú· (14). H ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÚÔ··ÈÙÂ›Ù·È ÁÈ· Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ Ë Û˘ÁÎfiÏÏËÛË Ì ٷ ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· (16). ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Û˘Ó‰¤Ô˘Ó ÙÔ ¡O Ì ÙËÓ ÚÔÒıËÛË Ù˘ Û˘ÁÎfiÏÏËÛ˘ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÛÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·. ∆Ô puzzle ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ÊÏÂÁÌÔÓ‹˜ ‰ÂÓ Â›Ó·È Ï‹Ú˜, ·ÏÏ¿ Ê·›ÓÂÙ·È fiÙÈ ÙÔ ¡O ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ, fi¯È ÌfiÓÔ Ú˘ıÌ›˙ÔÓÙ·˜ ÙÔÓ ÙfiÓÔ ÙˆÓ ·ÁÁ›ˆÓ, ·ÏÏ¿ Î·È ÂËÚ¿˙ÔÓÙ·˜ ÙË ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ Î·È ÙË ÊÏÂÁÌÔÓÒ‰Ë ·¿ÓÙËÛË (16). ∏ ‚Ï¿‚Ë Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜, Û˘Ó›ÛÙ·Ù·È Û ‰È·Ù·Ú·¯‹ ÙÔ˘ ‰ÈÎÙ‡Ô˘ ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ Ô˘ Û˘Óı¤ÙÔ˘Ó ÙȘ ÌÂÛÔ΢ÙÙ¿ÚȘ Û¯ÈṲ̂˜ (4), Ì ·ÔÙ¤ÏÂÛÌ· ÙË ¯·Ï¿ÚˆÛË ÙˆÓ ÛÙÂÓÒÓ Û˘Ó‰¤ÛÂˆÓ ÌÂٷ͇ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙË ‰È·Ê˘Á‹ ÚˆÙÂ˚ÓÒÓ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (3). º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÛÔ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ ÛÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ¶ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠÂÚÁ·Û›· (11) Ô˘ Û˘Û¯¤ÙÈÛ ÙÔ ÛËÙÈÎfi shock Ì ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÁÏ˘ÎÔ˙·ÌÈÓÔÁÏ˘Î·ÓÒÓ ÛÙÔ ·›Ì· Î·È ÛÙ· Ô‡Ú·, Ô˘ Èı·Ófiٷٷ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ÂÓ˙˘Ì·ÙÈο ·fi ÙÔ ÂÓ‰Ôı‹ÏÈÔ Î·È ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË. ∂›Û˘, ÚfiÛÊ·Ù· Ê¿ÓËÎÂ Ë Û˘Û¯¤ÙÈÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ Leak syndrome Î·È Ù˘ ·¤ÎÎÚÈÛ˘ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ ÛÙ· Ô‡Ú· (11).
¶·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ∏ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ·Ú·Ì¤ÓÂÈ ·Û·Ê‹˜. ∏ ·˘ÍË̤ÓË ‰È·-
£Âڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∂›Ó·È ÁÓˆÛÙfi ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ ÂÈÎÔÛÙÔ‡ ·ÈÒÓ· fiÙÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ
ÙÚȯÔÂȉÈ΋ ›ÂÛË 17 mmHg (Pc)
ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ 28 mmHg (¶Ú)
›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ -5,3 mmHg (Pif) 6 mmHg (¶if) ™¯‹Ì· 3
162
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·163
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
·ÔηٿÛÙ·ÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È Ë ¤Á¯˘ÛË ÂÓ‰ÔÊϤ‚ÈˆÓ ˘ÁÚÒÓ (17). ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηχÙÂÚÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓË (17,18). ∞fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ˘Ê›ÛÙ·Ù·È Ë ·ÓÙÈ·Ú¿ıÂÛË: “ÎÚ˘ÛÙ·ÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹”; ∏ ȉ·ÓÈ΋ ηÙËÁÔÚ›· ˘ÁÚÒÓ Â›Ó·È ÂΛÓË Ô˘ ·ÔηıÈÛÙ¿ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi fiÁÎÔ, ·˘Í¿ÓÂÈ ÙËÓ ·fi‰ÔÛË ÙÔ˘ O2 ÛÙÔ˘˜ ÈÛÙÔ‡˜, ¯ˆÚ›˜ Ó· ÚÔηÏ› Ô›‰ËÌ· ÂÍ·ÈÙ›·˜ ‰È·Ê˘Á‹˜ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (24). ∆· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ·ÔÙÂÏÔ‡Ó Û˘Ó‹ıˆ˜ ÙËÓ ÚÒÙË ÂÎÏÔÁ‹, ‰ÈfiÙÈ Â›Ó·È Â˘Ú¤ˆ˜ ‰È·ı¤ÛÈÌ· Î·È ÏÈÁfiÙÂÚÔ ·ÎÚÈ‚¿ (8,19). ∂›Û˘, Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ·˘Í¿ÓÔ˘Ó ÙÔ Ú˘ıÌfi ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR), ·Ó·ÏËÚÒÓÔ˘Ó ÙÔ Û˘ÚÚÈÎӈ̤ÓÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ‚ÂÏÙȈ̤ÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. O fiÁÎÔ˜ ηٷÓÔÌ‹˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ Â›Ó·È Î˘Ú›ˆ˜ Ô ÂÍ·ÁÁÂÈ·Îfi˜ ¯ÒÚÔ˜ (12,19): οو ·fi ȉ·ÓÈΤ˜ Û˘Óı‹Î˜, ÙÔ 25% ÂÚ›Ô˘ ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ ·Ú·Ì¤ÓÂÈ ÂÓ‰·ÁÁÂȷο, ÂÓÒ ÙÔ ˘fiÏÔÈÔ ‰È·¯¤ÂÙ·È ÛÙÔÓ ÂÍ·ÁÁÂÈ·Îfi ¯ÒÚÔ (20). ŒÙÛÈ, 1 lit ÈÛfiÙÔÓÔ˘ ‰È·Ï‡Ì·ÙÔ˜ NaCl 0,9% ·Ó·Ì¤ÓÂÙ·È Ó· ·˘Í‹ÛÂÈ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ Î·Ù¿ ÂÚ›Ô˘ 100-300 ml. ∆· ·ÈÌÔ‰˘Ó·ÌÈο ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‚Ú·¯˘ÚfiıÂÛÌ· Î·È ··ÈÙÔ‡Ó 2-4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ fiÁÎÔ˘˜ Û ۯ¤ÛË Ì ٷ ÎÔÏÏÔÂȉ‹. O ÌÂÁ¿ÏÔ˜ fiÁÎÔ˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙÔ ÂÈı˘ÌËÙfi ·ÔÙ¤ÏÂÛÌ· (ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜) ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÏ¿ÙÙˆÛË Ù˘ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋˜ ›ÂÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ‰È¿ÌÂÛÔ˘ Ôȉ‹Ì·ÙÔ˜ ‹ ·ÎfiÌ· Î·È Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÛÙÔÓ ·ÛıÂÓ‹ (12,17). À¿Ú¯Ô˘Ó fï˜ Î·È Ù· ˘¤ÚÙÔÓ· ‰È·Ï‡Ì·Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ (NaCl 7,5%) Ô˘ ÂÍ·ÛÎÔ‡Ó ÔÛ̈ÙÈ΋ ›ÂÛË ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ Î˘ÙÙ¿ÚˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â·Ó·Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ˘ÁÚÔ‡ ÛÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ (17). ∆· ˘¤ÚÙÔÓ· ‰È·Ï‡Ì·Ù·, Û ·ÓÙ›ıÂÛË Ì ٷ ÈÛfiÙÔÓ·, ·ÔηıÈÛÙÔ‡Ó ÙÔÓ fiÁÎÔ Ï¿ÛÌ·ÙÔ˜, ‰È·ÙËÚÒÓÙ·˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ ÛÂ Û˘ÛÙÔÏ‹. £ÂˆÚËÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ˘¤ÚÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ Â›Ó·È ÔÈ ÌÈÎÚÔ› fiÁÎÔÈ Ô˘ ··ÈÙÔ‡ÓÙ·È Î·È Ë ·Â˘ı›·˜ ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË (21). ™Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù¿ ÙÔ˘˜ ˘¿ÁÂÙ·È Ë ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Î·È Ë ˘ÂگψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó. ∏ ¯Ú‹ÛË ÙÔ˘˜ Û ·ÈÌÔÚÚ·ÁÈÎfi shock ÌÂ Û˘Ó¯È˙fiÌÂÓË ·ÈÌÔÚÚ·Á›· ·ÌÊÈÛ‚ËÙ›ٷÈ, ηıÒ˜ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÔ˘Ó ÙËÓ ·ÈÌÔÚÚ·Á›· ÏfiÁˆ Ù˘ ·ÁÁÂÈԉȷÛÙÔÏ‹˜ Ô˘ ÚÔηÏÔ‡Ó (12). ¶·Ú’ fiÙÈ Ë ·Ó¿Ù·ÍË ÙÔ˘ shock ÁÂÓÈο ÍÂÎÈÓ¿ Ì ÎÚ˘ÛÙ·ÏÔÂȉ‹, Ù· ÎÔÏÏÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ÂÓ·ÏÏ·ÎÙÈ-
Paediatriki 2002;65:160-166
΋ χÛË Ô˘ ÚÔÙÈÌ¿Ù·È ·fi ÔÏÏÔ‡˜ (12). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ∞’ ¶·ÁÎÔÛÌ›Ô˘ ÔϤÌÔ˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ¤Ó· Ê˘ÙÈÎfi ÎÔÏÏÔÂȉ¤˜ ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ÎfiÌÌÈ Ù˘ ·Î·Î›·˜. ™ÙÔ µ’ ¶·ÁÎfiÛÌÈÔ fiÏÂÌÔ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·›Ì· Î·È Û˘ÛÙ·ÙÈο ·›Ì·ÙÔ˜ (12). ∆· ÎÔÏÏÔÂȉ‹ ıˆÚÔ‡ÓÙ·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο ˘ÁÚ¿ ·Ó¿Ó˄˘ Û ۯ¤ÛË Ì ٷ ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ (21,22), ‰ÈfiÙÈ Î·Ù¿ ÚÔÙÂÚ·ÈfiÙËÙ· ·˘Í¿ÓÔ˘Ó ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (‰È·Ù›ÓÔ˘Ó ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ), ÂÊ’ fiÛÔÓ Ë ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. ∫¿ı ÁÚ·ÌÌ¿ÚÈÔ ÎÔÏÏÔÂȉԇ˜ Û˘ÁÎÚ·Ù› ÂÚ›Ô˘ 20 ml ∏2O ÛÙËÓ Î˘ÎÏÔÊÔÚ›·. ∫·ıÒ˜ Ô fiÁÎÔ˜ ηٷÓÔÌ‹˜ ÙÔ˘˜ Â›Ó·È Î˘Ú›ˆ˜ Ô ÂÓ‰·ÁÁÂÈ·Îfi˜, Ù· ÎÔÏÏÔÂȉ‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ÂÍ‹˜ ÏÂÔÓÂÎÙ‹Ì·Ù· (20): ·) ∞·ÈÙÔ‡ÓÙ·È ÌÈÎÚfiÙÂÚÔÈ fiÁÎÔÈ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ fiÁÎÔ˘ Ï¿ÛÌ·ÙÔ˜, ‚) ÚÔηÏÔ‡Ó ÌÈÎÚfiÙÂÚÔ ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·, Á) ‰È·ÙËÚÔ‡Ó ÛÙ·ıÂÚ‹ ÙËÓ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË Ï¿ÛÌ·ÙÔ˜, ‰) Ù· ·ÈÌÔ‰˘Ó·ÌÈο ÙÔ˘˜ ·ÔÙÂϤÛÌ·Ù· ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÁÚËÁÔÚfiÙÂÚ· Î·È ‰È·ÚÎÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ Î·È Â) ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÌÂÙ·ÊÔÚ¿ O2, ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ÙÔÓ fiÁÎÔ ·ÏÌÔ‡. OÈ ˘ÔÛÙËÚÈÎÙ¤˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ·ÓÙÈ·Ú·ı¤ÙÔ˘Ó fiÙÈ (17,22): ·) ∆· ÎÔÏÏÔÂȉ‹ Â›Ó·È Ôχ ·ÎÚÈ‚fiÙÂÚ· ·fi Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ‚) ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤Ó˘ ÙÚȯÔÂȉÈ΋˜ ‰È·ÂÚ·ÙfiÙËÙ·˜, Ù· ÎÔÏÏÔÂȉ‹ ÂÚÓÔ‡Ó ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ, Û˘ÁÎÚ·ÙÒÓÙ·˜ ÓÂÚfi, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏÔ‡Ó ÂÓÙÔÓfiÙÂÚÔ Î·È ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ Ô›‰ËÌ·, ÙfiÛÔ Û˘ÛÙËÌ·ÙÈÎfi fiÛÔ Î·È Ó¢ÌÔÓÈÎfi, Á) Ù· Ê˘ÛÈο ÎÔÏÏÔÂȉ‹ ÌÔÚÔ‡Ó Ó· ÌÂÙ·‰ÒÛÔ˘Ó ÌÔÏ˘ÛÌ·ÙÈΤ˜ ·Ûı¤ÓÂȘ (HBV, HCV, HIV) ‹ ·ÎfiÌ· Ó· ÚÔηϤÛÔ˘Ó ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ Î·È ‰) fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ÌÂÁ¿ÏÔ˘˜ fiÁÎÔ˘˜ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ‹Í˘ (Ù· Ù¯ÓËÙ¿ ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù·). ∆· ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›Ó·È: ·) ¢È·Ï‡Ì·Ù· ·Ï‚Ô˘Ì›Ó˘ (5%, 20%). ∏ ·Ï‚Ô˘Ì›ÓË Â›Ó·È Î‡ÚÈ· ÚˆÙ½ÓË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ (ªµ 66.000 daltons) Î·È ·ÔÙÂÏ› ÙÔ 50% ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (12,23). ŒÁ¯˘ÛË 1 lit ∏∞ 5% ·˘Í¿ÓÂÈ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi fiÁÎÔ Î·Ù¿ 500-1000 ml. ∆Ô ‰È¿Ï˘Ì· ∏∞ 20% ÎÈÓËÙÔÔÈ› ˘ÁÚfi ·fi ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi Ì ·ÔÙ¤ÏÂÛÌ· ¤Á¯˘ÛË 100 ml Ó· ·˘Í¿ÓÂÈ ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ηٿ 400-500 ml Ì›· ÒÚ· ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË. ™Â ηٷÛÙ¿ÛÂȘ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜, fiˆ˜ ÛÙÔ ÛËÙÈÎfi ÛÔÎ, ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚ˜ ÔÛfiÙËÙ˜ ˘ÁÚÔ‡ ÌÔÚ› Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó (22). ∆· ‰È·Ï‡Ì·Ù· ·Ï‚Ô˘Ì›Ó˘ ‰ÂÓ ÂËÚ¿˙Ô˘Ó
163
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·164
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘ Î·È ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ. ¶·Ú¿ÁÔÓÙ·È ·fi Ï¿ÛÌ· ÔÏÏÒÓ ‰ÔÙÒÓ Î·È Ú·ÎÙÈο ‰ÂÓ ¤¯Ô˘Ó ΛӉ˘ÓÔ ÌÂÙ¿‰ÔÛ˘ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ, ηıÒ˜ ÂÂÍÂÚÁ¿˙ÔÓÙ·È Ì ıÂÚÌfiÙËÙ· Î·È ·ÔÛÙÂÈÚÒÓÔÓÙ·È Ì ˘ÂډȋıËÛË. ‚) ∆Ô ÚfiÛÊ·Ù· ηÙ„˘Á̤ÓÔ Ï¿ÛÌ· (FFP) (22,24) ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ˘¿Ú¯ÂÈ ‰È·Ù·Ú·¯‹ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ¶·Ú’ fiÙÈ ÙÔ Ï¿ÛÌ· ÚÔ¤Ú¯ÂÙ·È ·fi ÂıÂÏÔÓÙ¤˜ ·ÈÌÔ‰fiÙ˜ Î·È ¤¯ÂÈ ˘ÔÛÙ› ÚÔÛ¯ÙÈÎfi ¤ÏÂÁ¯Ô, ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ: ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ HCV 1/33.000ÌÔÓ¿‰Â˜, HBV 1/200.000 ÌÔÓ¿‰Â˜, HIV 1/225.000 ÌÔÓ¿‰Â˜. Á) ¢È·Ï‡Ì·Ù· ¢ÂÍÙÚ¿Ó˘ (40, 70) (12,22). ∂›Ó·È ÔÏ˘ÌÂÚ‹ ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘ Ì ̤ÛÔ ªµ 40.0000 Î·È 70.000 daltons, ·ÓÙ›ÛÙÔȯ·. £ÂˆÚÂ›Ù·È fiÙÈ Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û ‚·ÚÈ¿ ÓÔÛÔ‡ÓÙ˜ ·ÛıÂÓ›˜ ‚ÂÏÙÈÒÓÂÈ ÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·, ‰ÈfiÙÈ ÌÂÈÒÓÔ˘Ó ÙË ÁÏÔÈfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜, ·ÏÏ¿ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÛÙÔ 0,03% ÙˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, ÌÔÚ› Ó· ·ÚÂÌ‚ÏËıÔ‡Ó ÛÙȘ ·ÓÙȉڿÛÂȘ ‰È·ÛÙ·‡ÚˆÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜, ÂÓÒ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ‹Í˘. ‰) ∑ÂÏ·Ù›Ó˜ - Gelatins (Haemacel, Gelofusine) (12). ¶ÚÔ¤Ú¯ÔÓÙ·È ·fi ¯Ô›ÚÂÈÔ ÎÔÏÏ·ÁfiÓÔ. ∆Ô ªµ ÙÔ˘˜ Î˘Ì·›ÓÂÙ·È ·fi 24,5 K Da ¤ˆ˜ 22,6 K Da. Œ¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ·Ï·ÈfiÙÂÚ· ÛÙËÓ ∂˘ÚÒË. Œ¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ·Ú’ fiÏÔ Ô˘ Ô ÙÚfiÔ˜ ·Ú·Û΢‹˜ ÙÔ˘ Haemacel ¤¯ÂÈ ÙÚÔÔÔÈËı›. ∏ ¯Ú‹ÛË ÙÔ˘˜ ¤¯ÂÈ ÂÚÈÔÚÈÛÙ›, ηıÒ˜ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó ÌÈÎÚ‹ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. Â) À‰ÚÔ͢ÏȈ̤ÓÔ ‰È¿Ï˘Ì· ·Ì‡ÏÔ˘ (Hetastarch, ∏aessteril) (12,25). ∂›Ó·È ‰È·ı¤ÛÈÌÔ ˆ˜ ‰È¿Ï˘Ì· ˘‰ÚÔÏ˘Ì¤Ó˘ ·Ì˘ÏÔÂÎÙ›Ó˘ 6% ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi. ¶·Ú¿ÁÂÙ·È ·fi ηϷÌfiÎÈ ‹ ίڛ. ∆· ۈ̷ٛ‰È¿ ÙÔ˘ ¤¯Ô˘Ó ªµ Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 30.000 ¤ˆ˜ 2.400.000 daltons (22). ŒÓ· lit ‰È·Ï‡Ì·ÙÔ˜ ·Ì‡ÏÔ˘ ·˘Í¿ÓÂÈ ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ηٿ 700 ml-1 lit. ¶ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠ(10,25) fiÙÈ Ù· ‰È·Ï‡Ì·Ù· ·Ì‡ÏÔ˘ ÛÊÚ·Á›˙Ô˘Ó ÂÎÏÂÎÙÈο ÙÔ˘˜ fiÚÔ˘˜ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ÙÚȯÔÂȉÒÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÌÂÙ¿ ·fi οı ÏÔÁ‹˜ ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ·. À¿Ú¯Ô˘Ó ¤Ú¢Ó˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ù· ‰È·Ï‡Ì·Ù· ·˘Ù¿ ‚ÂÏÙÈÒÓÔ˘Ó ÙÔ Á·ÛÙÚÈÎfi pH (ÂÓ‰Ô‚ÏÂÓÓÔÁfiÓÈÔ) (25), ·Ó Î·È ·fi ¿ÏϘ ·ÌÊÈÛ‚ËÙÂ›Ù·È (26). ∆· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È fiÙÈ ÌÔÚ› Ó· ‰È·Ù·Ú¿ÍÔ˘Ó ÙËÓ ËÎÙÈÎfiÙËÙ·, Ó· ÚÔηϤÛÔ˘Ó ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‹ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ. ÛÙ) ∆· Û˘Ó‰˘·Ṳ̂ӷ ‰È·Ï‡Ì·Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ-ÎÔÏÏÔÂȉÒÓ (NaCl 7,5% + Dextran) (12) Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ¤Ú¢ӷ. ∆Ô ˘¤ÚÙÔÓÔ ÙÌ‹Ì· ÙˆÓ
164
Paediatriki 2002;65:160-166
‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ Ùp·‚¿ ÓÂÚfi ·fi ÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ ÁÈ· Ó· ·ÔηٷÛÙ‹ÛÂÈ Ù· ÌÂȈ̤ӷ ·Ôı¤Ì·Ù· ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ¯ÒÚÔ˘, ÂÓÒ ÙÔ ˘ÂÚÔÛ̈ÙÈÎfi ÙÌ‹Ì· ·ÚÔ‰Èο ·ÔÌÔÓÒÓÂÈ ÙÔ ˘ÁÚfi ·˘Ùfi ÂÓ‰·ÁÁÂȷο. Ë) ∆¤ÏÔ˜, ˘¿Ú¯Ô˘Ó Î·È Ù· ˘ÔηٿÛٷٷ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (12,21) Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÔÓ¿‰Â˜ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Ô˘ ¤¯Ô˘Ó Ï‹ÍÂÈ. ∆· ÏÂÔÓÂÎÙ‹Ì·Ù· Â›Ó·È ·Ó¿ÏÔÁ· ÙˆÓ ÌÂÙ·ÁÁ›ÛÂˆÓ ÌÂ Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿, ÂÓÒ ‰ÂÓ ÌÂÙ·‰›‰Ô˘Ó ÌÔÏ˘ÛÌ·ÙÈΤ˜ ·Ûı¤ÓÂȘ Î·È ‰ÂÓ ··ÈÙÔ‡Ó ‰È·ÛÙ·‡ÚˆÛË. ∞Ú¯ÈΤ˜, fï˜, ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ ÛÙ·Ì¿ÙËÛ·Ó, ‰ÈfiÙÈ ‰È·ÈÛÙÒıËΠ··ÁÔÚ¢ÙÈ΋ ÓÂÊÚÈ΋ ÙÔÍÈÎfiÙËÙ·. øÛÙfiÛÔ, Ӥ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È Ì ˘ÔηٿÛٷٷ ÔÏ˘ÌÂÚÈṲ̂Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, Ô˘ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó Ôχ ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ. ªÂϤÙ˜ ¶ÚÔ˜ Â›Ï˘ÛË Ù˘ ·ÓÙÈ·Ú¿ıÂÛ˘ “ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹;” ¤¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÌÂϤÙ˜, ¯ˆÚ›˜ fï˜ Ó· ‰Â›¯ÓÔ˘Ó Û·Ê‹ ˘ÂÚÔ¯‹ Ù˘ Ì›·˜ ‹ Ù˘ ¿ÏÏ˘ ηÙËÁÔÚ›·˜. OÈ ÌÂϤÙ˜ ·˘Ù¤˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˘ ·Í›·˜ ÂÍ·ÈÙ›·˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÂÚȤϷ‚·Ó, ·ÏÏ¿ Î·È ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ-ÎÚÈÙËÚ›ˆÓ Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó. °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, ·fi ‰ÂηÂÙ›·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ¿Ú¯ÈÛ ӷ ÂÊ·ÚÌfi˙ÂÙ·È Ë ÌÂÙ·-·Ó¿Ï˘ÛË, Ì ÙË Û˘ÁΤÓÙÚˆÛË ÛÙÔȯ›ˆÓ ·fi ·ÚfiÌÔÈ· ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ (27) ÁÈ· ÙË ‰ÈÂÍ·ÁˆÁ‹ ÈÔ ·ÍÈfiÈÛÙˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ. ŒÙÛÈ, Ô Velanovich ·fi ÙËÓ ∫·ÏÈÊfiÚÓÈ· ‰ËÌÔÛ›Â˘Û ÙÔ 1989 ÌÂϤÙË (27), fiÔ˘ ¯ÚËÛÈÌÔÔ›ËÛ ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ÁÈ· Ó· ÂÎÙÈÌ‹ÛÂÈ ·Ó ˘‹Ú¯Â ‰È·ÊÔÚ¿ ıÓËÙfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹ ˆ˜ ˘ÁÚ¿ ·Ó¿Ó˄˘. ™˘Ó¤ÏÂÍ ÛÙÔȯ›· ·fi 8 ÚÔÁÂÓ¤ÛÙÂÚ· ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜, ·ÚfiÌÔÈ· ۯ‰ȷṲ̂Ó˜, fiÔ˘ ·Ó·ÊÂÚfiÙ·Ó Î·È Ë ıÓËÙfiÙËÙ· Î·È Î·Ù¤ÏËÍ fiÙÈ ˘‹Ú¯Â Û¯ÂÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ· ηٿ 5,7% ˘¤Ú ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ. ¢‡Ô ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ë π·ÙÚÈ΋ ™¯ÔÏ‹ Ù˘ OÎÏ·¯fiÌ· ‰ËÌÔÛ›Â˘Û ¿ÏÏË ÌÂÙ·-·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ (28), Ì ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ‰ÂÓ ˘‹Ú¯Â Û·Ê‹˜ ‰È·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ· Û ·ÛıÂÓ›˜ Ô˘ ‰È·¯ˆÚ›ÛÙËÎ·Ó Û 3 ηÙËÁÔڛ˜: ˘Ô‚ÔÏ·ÈÌ›·, ¯ÂÈÚÔ˘ÚÁÈÎfi ÛÙÚ˜ Î·È ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·. øÛÙfiÛÔ, ÂΛÓÔ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ ‰‡Ô ηÙËÁÔڛ˜ ‹Ù·Ó ÙÔ ÎfiÛÙÔ˜: Ë ·Ó¿ÓË„Ë Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ÎfiÛÙÈ˙ 45,13 ‰ÔÏ¿ÚÈ·, ÂÓÒ Ô Î¿ı ‰È·Ûˆı›˜ Ì ÎÔÏÏÔÂȉ‹ ·ÛıÂÓ‹˜ ÎfiÛÙÈ˙ 1493,6 ‰ÔÏ¿ÚÈ·! ŒÙÛÈ, ÔÈ ÂÚ¢ÓËÙ¤˜ ÚfiÙÂÈÓ·Ó Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ˆ˜ ˘ÁÚ¿ ÚÒÙ˘ ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·Ó¿Ù·ÍË ÙÔ˘ shock.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·165
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
∆Ô 1998 ·ÎÔÏÔ‡ıËÛ·Ó ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ ÂÚÈÔ‰ÈÎfi British Medical Journal Î·È ÍÂÛ‹ÎˆÛ·Ó Û¿ÏÔ Û˘˙ËÙ‹ÛÂˆÓ Î·È ·ÓÙÈ·Ú·ı¤ÛÂˆÓ ÛÙÔ˘˜ È·ÙÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. ∏ ÈÔ ÁÓˆÛÙ‹ ·fi ·˘Ù¤˜ (29) Û˘Ó¤ÏÂÍ ‰Â‰Ô̤ӷ ·fi 30 ÚÔËÁÔ‡ÌÂÓ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Î·È ÂÚȤϷ‚ 1419 ·ÛıÂÓ›˜. ∂ϤÁ¯ıËÎÂ Ë ıÓËÙfiÙËÙ· ·fi οı ·ÈÙ›·, fiˆ˜ ηٷÁÚ¿ÊËΠÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ follow up Ù˘ οı ÌÂϤÙ˘. ∆Ô ·ÔÙ¤ÏÂÛÌ· ‹Ù·Ó fiÙÈ, ÁÈ· fiϘ ÙȘ ηÙËÁÔڛ˜ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó, Ô Î›Ó‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙËÓ ÔÌ¿‰· Ô˘ ÂÏ¿Ì‚·Ó ·Ï‚Ô˘Ì›ÓË Î·Ù¿ 6%, ‰ËÏ·‰‹ ÁÈ· οı 17 ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ·Ï‚Ô˘Ì›ÓË, ˘‹Ú¯Â ¤Ó·˜ ÂÈϤÔÓ ı¿Ó·ÙÔ˜! OÈ Û˘ÁÁÚ·Ê›˜ ÚfiÙÂÈÓ·Ó Ó· ·ÓÂÎÙÈÌËı› ÂÂÈÁfiÓÙˆ˜ Ë ¯Ú‹ÛË Ù˘ ·Ï‚Ô˘Ì›Ó˘ ÛÙËÓ ·Ó¿ÓË„Ë ÙˆÓ ·ÛıÂÓÒÓ Î·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ Û ÚÔÛÂÎÙÈο ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜. ¡ÂfiÙÂÚË ÌÂÙ·-·Ó¿Ï˘ÛË (17) ·fi ÙÔÓ ∫·Ó·‰¿ ÌÂϤÙËÛ 105 ¿ÚıÚ· Î·È Û˘Ó¤ÏÂÍ 17 ÚˆÙÔÁÂÓ›˜ ÌÂϤÙ˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó·Ó Û˘ÓÔÏÈο 814 ·ÛıÂÓ›˜. ∂ϤÁ¯ıËÎÂ Ë ıÓËÙfiÙËÙ·, Ë ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È Ë ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜. ∆Ô ÙÂÏÈÎfi Û˘Ì¤Ú·ÛÌ· ‹Ù·Ó fiÙÈ ‰ÂÓ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Î·È ÛÙȘ ÙÚÂȘ ÂÍÂÙ·˙fiÌÂÓ˜ ·Ú·Ì¤ÙÚÔ˘˜ ·Ó¿ÌÂÛ· ÛÙȘ ÔÌ¿‰Â˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ Î·È Û ÂΛӘ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÔÏÏÔÂȉ‹. ∫·È ¿ÏÈ ÚÔÙ¿ıËÎ·Ó ÌÂÁ·Ï‡ÙÂÚ˜, ηϿ ۯ‰ȷṲ̂Ó˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, ÒÛÙ ӷ ηٷÛÙ› ‰˘Ó·Ùfi Ó· ·Ó·‰ÂȯıÔ‡Ó ÌÈÎÚ¤˜ ‰È·ÊÔÚ¤˜ ÛÙ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰‡Ô ıÂÚ·ÂÈÒÓ, ·Ó Ú·ÁÌ·ÙÈο ˘¿Ú¯Ô˘Ó. ∆· ‰Â‰Ô̤ӷ ÙˆÓ ÌÂÙ·-·Ó·Ï‡ÛˆÓ, fiÙ·Ó ÂÚÌËÓ¢ÙÔ‡Ó ÚÔÛÂÎÙÈο, ‰ÂÓ ‰Â›¯ÓÔ˘Ó Û·Ê‹ ˘ÂÚ›Û¯˘ÛË ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÙˆÓ ÎÔÏÏÔÂȉÒÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ·. ∆Ô Â›‰Ô˜ ÙˆÓ ˘ÁÚÒÓ ·Ó¿Ó˄˘ ‰ÂÓ ‚Ú¤ıËΠӷ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ıÓËÙfiÙËÙ·˜ ÛÙÔ˘˜ ‚·ÚÈ¿ ·ÛıÂÓ›˜, Ô‡Ù ÌÔÚÔ‡Ó Ó· ˘ÔÛÙËÚȯıÔ‡Ó ·ÏÏ·Á¤˜ ÛÙËÓ ÙÚ¤¯Ô˘Û· Ú·ÎÙÈ΋ (30). ∂ΛÓÔ Ô˘ ÚÔÙ›ÓÂÙ·È Â›Ó·È Î·Ï¿ ۯ‰ȷṲ̂Ó˜, ÌÂÁ¿Ï˜ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ı· ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ ÙÚ¤¯Ô˘Û· È·ÙÚÈ΋ Ú·ÎÙÈ΋ Î·È ı· ÌÔÚ¤ÛÔ˘Ó Ó· Ú›ÍÔ˘Ó Êˆ˜ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ Î·È Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ÔÚıÔÏÔÁÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ™ÙÔ ÌÂٷ͇, Ë ¯ÔÚ‹ÁËÛË ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÎÔÏÏÔÂȉÒÓ ı· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È Û οı ·ÛıÂÓ‹ Ì ‚¿ÛË Ù· ·ıÔÊ˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ, ÙËÓ ÎÏÈÓÈ΋ ÂÌÂÈÚ›·, ÙÔ ÎfiÛÙÔ˜ Î·È ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜ ÙÔ˘ ™˘ÛÙ‹Ì·ÙÔ˜ ¶·ÚÔ¯‹˜ ÀËÚÂÛÈÒÓ ÀÁ›·˜ (17,30).
Paediatriki 2002;65:160-166
µÈ‚ÏÈÔÁÚ·Ê›· 1. Kim PK, Deutschman CS. Inflammatory responses and mediators. Surg Clin North Am 2000;80:885-894. 2. Thijs LG, Schneider AJ, Groeneveld AB. The haemodynamics of septic shock. Int Care Med 1990;16(Suppl 3):S182-S186. 3. Schexnayder SM. Pediatric septic shock. Pediatr Rev 1999;20:303-308. 4. Zimmerman JJ, Shelhamer JH, Parrillo JE. Quantitative analysis of polymorphonuclear leucocyte superoxide anion generation in critically ill children. Crit Care Med 1985;13:143-149. 5. Fleck A, Raines G, Hawker F, Trotter J, Wallace PI, Ledingham IM et al. Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury. Lancet 1985;1:781-783. 6. Bascom JU, Gosling P, Zikria BA. Hypoalbuminemia, Surgical leak and clinical capillary leak sndrome. Arch Surg 2000;135:95-98. 7. Gibbs J, Gull W, Henderson W, Daley J, Kwan H, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity. Arch Surg 1999;134:36-42. 8. Journal article. Practice parameters for hemodynamic support of sepsis in adult patient sepsis. Crit Care Med 1999;27:639-660. 9. Guyton AC. Capillary dynamics and exchange of fluid between the blood and interstitial fluid. In: Guyton AC. Textbook of medical physiology. 7th ed. Saunders International; 1986. p. 348-360. 10. Zikria BA, King TG, Stanford JM, Freeman HP. A biophysical approach to capillary permeability. Surg 1989;105:625-631. 11. Oragui E, Nadel S, Kyd P, Levin M. Increased excretion of urinary glycosaminoglycans in meningococcal septicemia and their relationship to proteinuria. Crit Care Med 2000;28:3002-3008. 12. ªcCunn M, Karlin A. Non blood fluid resuscitation-More questions than answers. Anesth Clin North Am 1999;17:107-123. 13. Hinshaw LB. Sepsis/septic shock: Participation of the microcirculation: An abbreviated review. Crit Care Med 1996;24:1072-1089. 14. De Kleijn ED, Hazelzet JA, Kornelisse RF. Pathophysiology of meningococcal sepsis in children. Eur J Pediatr 1998;157:869-880. 15. Radke A, Mottaghy K, Goldman C, Khorram-Sefat R. C1 inhibitor prevents capillary leakage after thermal trauma. Crit Care Med 2000;28:3224-3232. 16. Anning PB, Evans TW. Leucocytes in sepsis: Do they just keep rolling along? Crit Care Med 2000;28:3108-3109. 17. Choi PT, Yip G, Quinonez LG, Cook D. Crystalloids vs colloids in fluid resuscitation: systematic review. Crit Care Med 1999;27:200-210. 18. Astiz ME, Rackow EC. Crystalloid-colloid controversy revisited. Crit Care Med 1999;27:34-35. 19. Jindal N, Hollenberg SM, Dellinger RP. Sepsis and septic shock-Pharmacologic issues in the management of septic shock. Crit Care Clin 2000;16:233-249.
165
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·166
¶·È‰È·ÙÚÈ΋ 2002;65:160-166
20. Weil MH. Crystalloids, colloids and fluid compartments. Crit Care Med 1999;27:3-5. 21. Henry S, Scalea TM. Trauma care in the new millenniumResuscitation in the new millennium. Surg Clin North Am 1999;79:1259-1267. 22. Prough DS. Practical solutions for difficult problems. Anesth Clin North Am 1996;14:341-360. 23. Quinlan GJ, Margarson MP, Mumby S, Evans TW. Administration of albumin to patients with sepsis syndrome: a possible beneficial role in plasma thiol repletion. Clin Sci 1998;95:459-465. 24. Ernest D, Belzberg AS, Dodek PM. Distribution of normal saline and 5% albumin infusions in septic patients. Crit Care Med 1999;27:46-50. 25. Marik J, Iglesias J. Would the colloid detractors please sit down! Crit Care Med 2000;28:2652-2654. 26. Forrest DM, Baigorri F, Chittock DR, Spinelli JJ, Russell JA. Volume expansion using pentastarch does not change gastric-arterial CO2 gradient or gastric intramucosal pH in patients who have sepsis syndrome. Crit Care Med 2000;28:2254-2258. 27. Velanovich V. Crystalloid versus colloid fluid resuscitation: A meta-analysis of mortality. Surgery 1989;105:65-71. 28. Bisonni RS. Colloids versus crystalloids in fluid
Paediatriki 2002;65:160-166
resuscitation: an analysis of randomized controlled trials. J Fam Pract 1991;32:387-390. 29. Cochrane Injuries Group, Department of Epidemiology and Public Health, Institute of Child Health, London: Human albumin administration in critically ill patients: a systematic review of randomized controlled trials. Cochrane Albumin Reviewers. BJM 1998;317:23-40. 30. Webb R. The appropriate role of colloids in managing fluid imbalance: a critical review of recent meta-analytic findings. Crit Care Med 2000;4(Suppl 2):S26-32.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 24-09-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ∫·ÙÛ¿Ú· ¢ÈÛÙfiÌÔ˘ 9, ¡. ∑ˆÁÚ¿ÊÔ˘ ∆.∫. 157 72, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ªÂϤÙË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ì·ÁÓËÛ›Ô˘ ÛÂ Û˘ÁÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT1 ∆Ô Î·ÙÈfiÓ Ì·ÁÓ‹ÛÈÔ Î·Ù·Ï‡ÂÈ ‹ ÂÓÂÚÁÔÔÈ› ÂÚÈÛÛfiÙÂÚ· ·fi 300 ¤Ó˙˘Ì· Î·È Ô ÚfiÏÔ˜ ÙÔ˘ ¤¯ÂÈ ÌÂÏÂÙËı› ȉȷ›ÙÂÚ· ÛÙÔ Û‡Ó‰ÚÔÌÔ ÙÔ˘ Ì·ÎÚÔ‡ QT (Û. QT), ·ÏÏ¿ fi¯È ÙfiÛÔ Ôχ ÛÙË Û˘ÁÁÂÓ‹ ÌÔÚÊ‹ ÙÔ˘. OÈ Û˘ÁÁÚ·Ê›˜ ÂÍÂÙ¿˙Ô˘Ó ÙÔ ÚfiÏÔ ÙÔ˘ Mg ÛÙÔ Û˘ÁÁÂÓ¤˜ Û. QT Î·È ÂÎÙÈÌÔ‡Ó ÙË Û¯¤ÛË ÙÔ˘ Ì ¯·Ú·ÎÙËÚÈÛÙÈο ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. ™˘˙ËÙÔ‡Ó, ›Û˘, ÙËÓ Èı·ÓfiÙËÙ· Û˘ÌÏËڈ̷ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ Mg ˆ˜ ıÂڷ›· ˘ÔÙÚÔÒÓ Û˘ÁÎÔÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Û ÂÚÈÙÒÛÂȘ ¤ÏÏÂÈ„‹˜ ÙÔ˘. ∏ ÌÂϤÙË ÂÚÈÂÏ¿Ì‚·Ó 22 ·ÛıÂÓ›˜, 14 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Ì ıÂÙÈÎfi Î·È 8 Ì ·ÚÓËÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi, ηıÒ˜ Î·È 30 Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∏ ̤ÛË ËÏÈΛ· ‹Ù·Ó ≈12,5 ¯ÚfiÓˆÓ Î·È Ë Ì¤ÛË ÙÈÌ‹ QTc ≈519 ms. ™Ù· ¿ÙÔÌ· ·˘Ù¿ ÌÂÙÚ‹ıËÎ·Ó Ù· ›‰· ÙÔ˘ Mg ÙÔ˘ ÔÚÔ‡ (SMg) Î·È ÙÔ˘ ηٷÎÚ·ÙÔ‡ÌÂÓÔ˘ Mg (MgR). O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÁÈÓfiÙ·Ó ÌÂ Ù‡Ô Ô˘ ‚·ÛÈ˙fiÙ·Ó ÛÙȘ ÙÈ̤˜ SMg, Mg ÙˆÓ Ô‡ÚˆÓ Î·È ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÚÈÓ Î·È ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Mg ÂÓ‰ÔÊϤ‚È·. ∆· ˘„ËÏ¿ ›‰· ηٷÎÚ·ÙÔ‡ÌÂÓÔ˘ Mg ıˆڋıËÎ·Ó ˆ˜ ¤ÏÏÂÈ„Ë Mg. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Û. QT ‚Ú¤ıËÎ·Ó ¯·ÌËÏ¿ ›‰· SMg Î·È ˘„ËÏ¿ MgR. ∏ ¯ÔÚ‹ÁËÛË Mg ‰ÂÓ ‚Ú¿¯˘Ó ÙÔ QT, Ô‡Ù ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ Mg Î·È ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QTc. ∞ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi Û˘ÁÎÔÈÎÒÓ ÎÚ›ÛÂˆÓ Â›¯·Ó ˘„ËÏfiÙÂÚ· ›-
166
‰· MgR Û ۯ¤ÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ Î·È Ë ¯ÔÚ‹ÁËÛË Mg ‚ÂÏÙ›ˆÛ ÙËÓ ¤ÏÏÂÈ„‹ ÙÔ˘. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË fiÙÈ ÌÂÚÈÎÔ› ·ÛıÂÓ›˜ Ì Û. QT ¤¯Ô˘Ó ¤ÏÏÂÈ„Ë Mg Î·È fiÙÈ ·˘Ù‹ Û˘Óԉ‡ÂÙ·È ·fi Û˘ÁÎÔÈΤ˜ ÚÔÛ‚ÔϤ˜, ÔÈ Ôԛ˜ ÂȉÈο Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÌÔÚÔ‡Ó Ó· ÚÔÏ·Ì‚¿ÓÔÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Mg. ∂Âȉ‹, fï˜, ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ù‡ÔÈ Û. QT Ì ‰È·ÊÔÚÂÙÈÎfi ÁÔÓȉȷÎfi ¯·Ú·ÎÙ‹Ú·, Ë ¤ÏÏÂÈ„Ë Mg Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Û·Ó ÚfiÛıÂÙÔ˜ ·Ú¿ÁˆÓ Û ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘.
1 Hoshino K, Ogawa K, Hishitani T, Kitazawa R Studies of magnesium in congenital long QT syndrome Pediatr Cardiol 2002;23:41-48
µ·ÚÏ¿Ì˘ °.™. ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ∞.¶.£.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·167
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2002;65:167-173
ORIGINAL ARTICLE
∂Ó‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ∞. ™˘Ú›ÁÔ˘ - ¶··‚·ÛÈÏ›Ԣ
Botulinum toxin type A intramuscular injections in the treatment of spasticity in cerebral palsy A. Syrigou - Papavasiliou
¶ÂÚ›ÏË„Ë: ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Û ÂÓ‰ÔÌ˘˚΋ ¤Á¯˘ÛË ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ÙËÓ ÂÌÂÈÚ›· Ì·˜ Û 67 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ̤Û˘ ËÏÈΛ·˜ 5,3 ÂÙÒÓ (2-13,5 ÂÙÒÓ), Ù· ÔÔ›· ¤Ï·‚·Ó ÙËÓ ÙÔÍ›ÓË Û 89 Û˘Ó‰ڛ˜. ∏ ·ÍÈÔÏfiÁËÛË Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ¤ÁÈÓ Ì ‚¿ÛË ÚˆÙfiÎÔÏÏÔ Î·È Ë Û˘ÏÏÔÁ‹ ÙˆÓ ÛÙÔȯ›ˆÓ ¤ÁÈÓ ÚÔ‰ÚÔÌÈο. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔȯ›· ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘, fiˆ˜ ·˘Ù‹ ÎÚ›ÓÂÙ·È Ì ÙËÓ Â›Ù¢ÍË ÚÔ·ÔÊ·ÛÈṲ̂ÓÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘. ∏ ̤ıÔ‰Ô˜ ˘‹ÚÍ ·ÛÊ·Ï‹˜, ηıÒ˜ ‹È˜ Î·È Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„È̘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Û˘Ó¤‚ËÛ·Ó Û 3 ·fi ÙȘ 89 Û˘Ó‰ڛ˜ (3,3%). ∂›Û˘, ˘‹ÚÍ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ηıÒ˜ 57 ·fi ÙÔ˘˜ 67 ·ÛıÂÓ›˜ (85%) Â¤Ù˘¯·Ó Ï‹Úˆ˜ ‹ ÌÂÚÈÎÒ˜ ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ÛÙfi¯Ô Ô˘ ›¯Â ÙÂı› ÚÔ ÙˆÓ ÂÁ¯‡ÛˆÓ. ∆· ÈηÓÔÔÈËÙÈο ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·ÏÏ¿ Î·È ÛÙËÓ ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ, ÙˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÚÔ˜ ¤Á¯˘ÛË, Î·È ÛÙÔÓ Î·ıÔÚÈÛÌfi ηٿ ÙËÓ ·Ú¯È΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙˆÓ Ú·ÏÈÛÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÛÙfi¯ˆÓ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÈÙ¢¯ıÔ‡Ó.
Abstract: Botulinum toxin type A intramuscular injections have been utilized for the management of spasticity in patients with cerebral palsy. We present our experience with 67 children and adolescents with cerebral palsy, mean age 5.3 years (range 213.5 years), who received the toxin in 89 sessions. The evaluation and management of our patient population was performed according to a specific protocol, and the data collection was done prospectively. In this study we present data regarding the safety and efficacy of the method as this was evaluated through the attainment of predetermined functional goals. The method was safe since mild and fully reversible side effects occurred in 3 out of 89 sessions (3.3%). In addition it was effective, since 57 out of 67 patients (85%) demonstrated full or partial functional goal attainment. These satisfactory results are attributed to the therapeutic efficacy of the drug, but also to the careful selection of the patients, the muscle groups to be injected as well as to the designation, during the initial patient evaluation, of the realistic functional goals expected to be achieved.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, Û·ÛÙÈÎfiÙËÙ·, ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË.
Key words: botulinum toxin, spasticity, cerebral palsy.
ø˜ Û·ÛÙÈÎfiÙËÙ· ÔÚ›˙ÂÙ·È Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÈÛıËÙÈÎÔ-ÎÈÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·‡ÍËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ Ù·¯‡ÙËÙ· Ù˘ ΛÓËÛ˘ Î·È Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ӷ ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο. ∞ÔÙÂÏ› Ì›· ·fi ÙȘ ÂΉËÏÒÛÂȘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ·, Ì·˙› Ì ÙËÓ ·‰˘Ó·-
Ì›·, ÙË ÌÂȈ̤ÓË ÂȉÂÍÈfiÙËÙ· ÛÙȘ ÎÈÓ‹ÛÂȘ ηÈ, Û ‚·Ú‡ÙÂÚË ÚÔÛ‚ÔÏ‹, ÙËÓ ¿ÚÂÛË Î·È ÙȘ Û˘Áο̄ÂȘ. O ·ÓÒÙÂÚÔ˜ ÎÈÓËÙÈÎfi˜ Ó¢ÚÒÓ·˜ ÌÔÚ› Ó· ‚Ï·ÊÙ› ·fi ÔÈΛϷ ·›ÙÈ· Î·È Û ‰È¿ÊÔÚ· ›‰·. ∏ ‚Ï¿‚Ë ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ÓˆÚ›˜ ÛÙË ˙ˆ‹, ·fi ·›ÙÈ· ÚÔÁÂÓÓËÙÈο, ÂÚÈÁÂÓÓËÙÈο ‹
¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·
Neurology Clinic, Children’s Hospital of Penteli, Athens
167
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·168
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
ÌÂÙ·ÁÂÓÓËÙÈο, Ô‰ËÁ› ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (∂¶). ªÂ ÙÔÓ fiÚÔ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ·Ó·ÊÂÚfiÌ·ÛÙ Û ̛· ÔÌ¿‰· Û˘Ó‰ÚfiÌˆÓ ÂÙÂÚÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ô˘ ÔÊ›ÏÂÙ·È Û ÛÙ·ÙÈ΋ ‚Ï¿‚Ë ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∂ΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ Ì ÎÈÓËÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ·ÏÏ¿ ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó‹ıˆ˜ Î·È ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ÏËÓ Ù˘ ÎÈÓËÙÈ΋˜. ∏ ∂¶ Ù·ÍÈÓÔÌÂ›Ù·È Û ۷ÛÙÈ΋, ‰˘ÛÎÈÓËÙÈ΋, ·Ù·ÍÈ΋ Î·È ÌÈÎÙ‹ ÌÔÚÊ‹. ∏ Û·ÛÙÈ΋ ÌÔÚÊ‹ Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ Î·È ÂÚ·ÈÙ¤Úˆ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙÔ˘˜ ηو٤ڈ Ù‡Ô˘˜: Û·ÛÙÈ΋ ËÌÈÏËÁ›·, Ô˘ Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ ÌÔÚÊ‹, Û·ÛÙÈ΋ ‰ÈÏËÁ›·, Ô˘ ·Ó¢ڛÛÎÂÙ·È Î·Ù’ ÂÍÔ¯‹Ó Û ÚfiˆÚ· ·È‰È¿, Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, Ô˘ Â›Ó·È Ë ‚·Ú‡ÙÂÚË ÌÔÚÊ‹ Ô˘ Û˘¯Ó¿ Û˘Ó‰˘¿˙ÂÙ·È Ì ¿ÏϘ ‚·ÚȤ˜ ·Ó·Ëڛ˜ Î·È Ù¤ÏÔ˜, Û·ÛÙÈ΋ ÌÔÓÔÏËÁ›·, Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È ·ÙÂÏ‹˜ ËÌÈÏËÁ›·. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜, ȉȷ›ÙÂÚ· fiÙ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏϘ ‚·ÚȤ˜ ·Ó·Ëڛ˜, fiˆ˜ .¯. ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÂÊ’ fiÛÔÓ Ë Ì˘˚΋ ÈÛ¯‡˜ ÙÔ˘ Û·ÛÙÈÎÔ‡ ̤ÏÔ˘˜ (‹ Û·ÛÙÈÎÒÓ ÌÂÏÒÓ) Â›Ó·È Â·Ú΋˜, ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜, ‰ËÏ·‰‹ Ó· ‚ÔËı‹ÛÂÈ ÙÔ ·È‰› Ó· ηı‹ÛÂÈ, Ó· ÔÚıÔÛٷًÛÂÈ Î·È Ó· ‚·‰›ÛÂÈ. OÈ ÛÙfi¯ÔÈ Ù˘ ıÂڷ›·˜ Ù˘ ∂¶ Â›Ó·È Ó· ÌÂÁÈÛÙÔÔÈ‹ÛÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·, Ó· ÂÏ·¯ÈÛÙÔÔÈ‹ÛÂÈ ÙȘ Û˘Áο̄ÂȘ Î·È ¿ÏϘ ÂÈÏÔΤ˜ Î·È Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ÙȘ ÔÚıÔ‰ÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ¤ÙÛÈ ÒÛÙ ӷ Á›ÓÔ˘Ó Û ·È‰› ÌÂÁ·Ï‡ÙÂÚÔ ‹ ÈÔ ÒÚÈÌÔ, Ì ٷ ηχÙÂÚ· ‰˘Ó·Ù¿ ·ÔÙÂϤÛÌ·Ù·. ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ (∞∆-∞) Â›Ó·È Ì›· ·fi ÙȘ 7 Ó¢ÚÔÙÔ͛Ә (Ô˘ ÔÓÔÌ¿˙ÔÓÙ·È ∞-G), ÔÈ Ôԛ˜ ·Ú¿ÁÔÓÙ·È ·fi ‰È¿ÊÔÚ· ÛÙÂϤ¯Ë ÙÔ˘ ∫ψÛÙËÚȉ›Ô˘ Ù˘ ·ÏÏ·ÓÙ›·Û˘ (Clostridium botulinum). ∂›Ó·È Ë ÈÔ ÌÂÏÂÙË̤ÓË ·fi ÙÔ˘˜ 7 Ù‡Ô˘˜ Î·È ¤¯ÂÈ Â›ÛËÌË ¤ÁÎÚÈÛË ÁÈ· ¯Ú‹ÛË Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ· (1,2). ªÂÈÒÓÂÈ ÂÎÏÂÎÙÈο ÙËÓ ˘ÂÚ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Ì˘fi˜ Î·È ÂÈϤÔÓ, ÂÂȉ‹ ÂÓ›ÂÙ·È ÙÔÈο, ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ ˙¿ÏË, ·ÒÏÂÈ· ÌÓ‹Ì˘, ÎfiˆÛË Î.¿. Ô˘ ÚÔηÏÔ‡Ó Ù· ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ê¿Ú̷η (3). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ë ·Ó·ÊÔÚ¿ ÛÙËÓ ÂÌÂÈÚ›· Ì·˜ Ì ÂÓ‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ¤ÙÛÈ ÒÛÙ ӷ ·Ó·‰ÂȯıÔ‡Ó ÔÈ ÂӉ›ÍÂȘ, Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· Ù˘ ÌÂıfi‰Ô˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ÌÂϤÙË ÂÚÈÂÏ¿Ì‚·Ó 67 ·È‰È¿ Ì ∂¶ Ô˘ ¤Ï·‚·Ó ∞∆∞ Û 89 ‰È·‰Ô¯ÈΤ˜ Û˘Ó‰ڛ˜ ∂.ª. ÂÁ¯‡ÛˆÓ. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó 5,3 ¤ÙË (2-13,5 ¤ÙË) Î·È Ù· 20 ›¯·Ó Û·-
168
Paediatriki 2002;65:167-173
ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›· ¯ˆÚ›˜ ‰˘Ó·ÙfiÙËÙ· ·ÓÂÍ¿ÚÙËÙÔ˘ ηı›ÛÌ·ÙÔ˜, Ù· 28 Û·ÛÙÈ΋ ‰ÈÏËÁ›·, Ì ‰˘Ó·ÙfiÙËÙ· ·ÓÂÍ¿ÚÙËÙ˘ fiÚıÈ·˜ ÛÙ¿Û˘ Î·È ¯ˆÚ›˜ ·ÓÂÍ¿ÚÙËÙË ‚¿‰ÈÛË, Ù· 14 Û·ÛÙÈ΋ ËÌÈÈÏËÁ›·, fiÏ· Ì ·ÓÂÍ¿ÚÙËÙË ‚¿‰ÈÛË Î·È Ù· 5 ÌÈÎÙ‹ Û·ÛÙÈ΋ ‰˘ÛÙÔÓÈ΋ ÌÔÚÊ‹ ∂¶, ¯ˆÚ›˜ ·ÓÂÍ¿ÚÙËÙÔ Î¿ıÈÛÌ·. ∆Ô ÚˆÙfiÎÔÏÏÔ ·ÍÈÔÏfiÁËÛ˘ ·È‰ÈÒÓ Ì ∂¶ ÁÈ· Èı·Ó‹ ¯Ú‹ÛË ∞-∆ ÂÊ·ÚÌfiÛÙËΠÂÍ·Ú¯‹˜ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Î·È Î·ÏÔ‡Û ÁÈ· Ù· ÂÍ‹˜: ·) ∞ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ Ù·˘Ùfi¯ÚÔÓ· ·fi Ó¢ÚÔÏfiÁÔ, ÔÚıÔ‰ÈÎfi Î·È Ê˘ÛÈÔıÂÚ·Â˘Ù‹, Ì ÛÙfi¯Ô ÙË Û‡ÌʈÓË ÁÓÒÌË ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ ‰˘Ó·ÌÈÎfi ÙÔ˘ ÚÔ˜ ‚ÂÏÙ›ˆÛË. ‚) ∫·ıÔÚÈÛÌfi ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÛÙfi¯ˆÓ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÈÙ¢¯ıÔ‡Ó Ì ÙË ¯Ú‹ÛË ∞∆-∞. Á) ™˘˙‹ÙËÛË ÁÈ· ÂÓ·ÏÏ·ÎÙÈΤ˜ ‹ ÚfiÛıÂÙ˜ ıÂڷ›˜, fiˆ˜ Á˘„ÒÛÂȘ, Ê¿Ú̷η, ÔÚıÔ‰ÈÎfi ¯ÂÈÚÔ˘ÚÁ›Ô. ‰) ∂ÓË̤ڈÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Û˘Ìʈӛ· ÁÈ· ÙËÓ ÂÎÙ¤ÏÂÛË ÙˆÓ ÂÁ¯‡ÛˆÓ. Â) ¶ÂÚ·ÈÙ¤Úˆ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙËÓ ÔÌ¿‰· Ì Îϛ̷Θ Î·È ‚ÈÓÙÂÔÛÎfiËÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙˆı› ·ÓÙÈÎÂÈÌÂÓÈο Ë ÌÂÙ·‚ÔÏ‹ Ù˘ ηٿÛÙ·Û˘ ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ. °È· ·˘ÙfiÓ ÙÔ ÛÎÔfi ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, ·ÏÏ¿ ‰ÂÓ ı· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Û ·˘Ù‹ ÙË ÌÂϤÙË, Î·È ÁˆÓÈÔÌÂÙÚ›·, Îϛ̷η Ashworth ÁÈ· ÙË Ì¤ÙÚËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘, Îϛ̷η Gross Motor Function Measure (GMFM) ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È ‚ÈÓÙÂÔÛÎfiËÛË Û‡Ìʈӷ Ì ηıÔÚÈṲ̂Ó˜ Ô‰ËÁ›Â˜ ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ı¤ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡. ÛÙ) ∂›ÛÔ‰Ô ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ¤Ó· Úˆ›. ÃÚ‹ÛË ·Ó·ÈÛıËÙÈ΋˜ Îڤ̷˜ ÛÙ· ÛËÌ›· Ô˘ ÂÈϤÁÔÓÙ·È ÁÈ· ¤Á¯˘ÛË. ÃÔÚ‹ÁËÛË ËÚÂÌÈÛÙÈÎÔ‡ Î·È ·Ó·ÏÁËÙÈÎÔ‡ ·fi ÙÔ˘ ÔÚıÔ‡ (ªÈ‰·˙ÔÏ¿ÌË 0,2-0,3 mg/kg, ¶Âıȉ›ÓË 1 mg/kg). AÎÔÏÔ‡ıËÛ·Ó ÂÁ¯‡ÛÂȘ ∞∆-∞ ÛÙÔ˘˜ ÂÈÏÂÁ̤ÓÔ˘˜ Ì˘˜. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó Î·È Ù· 2 Û΢¿ÛÌ·Ù· Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙËÓ ∂ÏÏ¿‰·. ∆Ô ·Ï·ÈfiÙÂÚÔ, Botox, Û ̤ÁÈÛÙË ‰ÔÛÔÏÔÁ›· 13 U/kg/Û˘Ó‰ڛ· Î·È ÙÔ ÓÂfiÙÂÚÔ, Dysport, Û ‰ÔÛÔÏÔÁ›· 40 U/kg/Û˘Ó‰ڛ·. ∆Ô Ê¿ÚÌ·ÎÔ ÂÁ¯‡ıËΠÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ̇˜ Û‡Ìʈӷ Ì ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ·fi ÙȘ Ê·Ú̷΢ÙÈΤ˜ ÂÙ·ÈÚ›˜ ‰ÔÛÔÏÔÁ›· ·Ó¿ Ì˘. ˙) ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· 2-3 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Î·È ¤ÍÔ‰Ô˜ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. Ë) ∂·Ó·ÍÈÔÏfiÁËÛË Û 1, 3 Î·È 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË. ŒÁÈÓ ÚÔÛ¿ıÂÈ· ÂÊ·ÚÌÔÁ‹˜ ÙˆÓ ÚÔ·Ó·ÊÂÚıÂÈÛÒÓ ÎÏÈ̿ΈÓ, Ë ÔÔ›· ‹Ù·Ó ÌÂÚÈÎÒ˜ ÂÈÙ˘¯‹˜, ‰ÈfiÙÈ ÔÈ ·ÍÈÔÏÔÁ‹ÛÂȘ ÙˆÓ È·ÙÚÒÓ Î·È ÙˆÓ Ê˘ÛÈÔıÂڷ¢ÙÒÓ ‰ÂÓ Û˘Ó¤ÂÛ·Ó ¯ÚÔÓÈο ‹ ‰ÂÓ ¤ÁÈÓ·Ó ·fi Ù· ›‰È· ¿ÙÔÌ· ÛÙÔ˘˜ ·ÎÚÈ‚Ò˜ ÚÔηıÔÚÈṲ̂ÓÔ˘˜ ¯ÚfiÓÔ˘˜. ø˜ ·ÔÙ¤ÏÂÛÌ·, ˘¿Ú¯ÂÈ ·Ó·ÁηÈfiÙËÙ· ÁÈ· ÂÚ·ÈÙ¤Úˆ Û˘ÏÏÔÁ‹ Î·È ÂÂÍÂÚÁ·Û›· ·˘ÙÒÓ ÙˆÓ ‰Â‰Ô̤ӈÓ. ™Ù·ıÂÚ¿ Î·È ·fi ÙÔÓ ›‰ÈÔ È·ÙÚfi ÂÎÙÈÌ‹ıËΠÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È Ë Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ ·ÍÈÔÏÔÁ‹ıËΠˆ˜ ÂÍ‹˜: i) ¶Ôχ ηϋ, fiÙ·Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ÂÂÙ‡¯ıË Ï‹Úˆ˜ (.¯. Â¿Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ‹Ù·Ó ÙÔ ·È‰› Ó· ηı›ÛÂÈ ·ÓÂÍ¿ÚÙËÙ·, ·˘Ùfi˜ ı· fiÊÂÈÏ ӷ ÂÈÙ¢¯ı› Ï‹Úˆ˜), ii) ∫·Ï‹, fiÙ·Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ÂÂÙ‡¯ıË ÌÂÚÈÎÒ˜, iii) ªÈÎÚ‹, fiÙ·Ó Â‹Ïı ÌfiÓÔ Ì›ˆÛË ÙÔ˘
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·169
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ¯ˆÚ›˜ ›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Î·È iv) O˘‰ÂÌ›·, › ·Ô˘Û›·˜ οı ÌÂÙ·‚ÔÏ‹˜. ı) ∂·ÓÂÁ¯‡ÛÂȘ ¤ÁÈÓ·Ó Û 22 ·È‰È¿ Ì ÙËÓ ›‰È· ·ÎÚÈ‚Ò˜ ÌÂıÔ‰ÔÏÔÁ›·. ∏ ·fiÊ·ÛË ÁÈ· ·ӤÁ¯˘ÛË ‹Ù·Ó ÚÔ˚fiÓ Ù˘ ›‰È·˜ ‰È·‰Èηۛ·˜ Ì ÙËÓ ·Ú¯È΋ ¤Á¯˘ÛË. ¢ËÏ·‰‹, Ë ÔÌ¿‰· ·ÓÂͤٷ˙ ÙÔ˘˜ ıÂڷ¢ÙÈÎÔ‡˜ ÛÙfi¯Ô˘˜, ·ÍÈÔÏÔÁÔ‡Û ηٿ fiÛÔ Ë Û·ÛÙÈÎfiÙËÙ· οÔÈˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ·ÔÙÂÏÔ‡Û ÂÌfi‰ÈÔ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Âͤٷ˙ ÙËÓ Èı·ÓfiÙËÙ· ÁÈ· ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂڷ›˜ (ÔÚıÒÛÂȘ, Á˘„ÒÛÂȘ, ¯ÂÈÚÔ˘ÚÁ›Ô). ¶ÚÔÊ·ÓÒ˜, Ë ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ¤Á¯˘ÛË ¤·È˙ ηıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·fiÊ·ÛË. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ÔÊı·ÏÌÔÊ·Ó‹˜ Ë ·Ó¿ÁÎË ÁÈ· ·ӤÁ¯˘ÛË, ηıÒ˜ Ë Û·ÛÙÈÎfiÙËÙ· ·ÓÂÁηı›ÛÙ·ÙÔ Ì ÙËÓ ¿ÚÔ‰Ô ÙˆÓ ÌËÓÒÓ. ÕÏÏÔÙ ¿ÏÈ, Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ê˘ÛÈÔıÂڷ›·˜ Î·È ÙˆÓ ÔÚıÒÛˆÓ, Ë Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û οÔȘ Ì˘˚Τ˜ ÔÌ¿‰Â˜ ıˆÚÔ‡ÓÙ·Ó Â·Ú΋˜ Î·È ÙÂÏÈο ÚÔ¯ˆÚÔ‡Û·Ì Û ÂÁ¯‡ÛÂȘ ¿ÏÏˆÓ Ì˘ÒÓ. ø˜ ÂÏ¿¯ÈÛÙÔ˜ ¯ÚfiÓÔ˜ ÁÈ· ·ӤÁ¯˘ÛË Â›¯Â ·ÔÊ·ÛÈÛÙ› ÙÔ ÙÂÙÚ¿ÌËÓÔ.
∞ÔÙÂϤÛÌ·Ù· ∞) ∂Á¯‡ÛÂȘ ∞∆-∞ ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·Ó·ÊÂÚfiÌ·ÛÙ Û ÂÁ¯‡ÛÂȘ Ì˘ÒÓ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ. ŒÁ¯˘ÛË ¤ÁÈÓ ÛÙÔ˘˜ ÂÍ‹˜ Ì˘˜: ¶ÚÔÛ·ÁˆÁÔ‡˜, Ô›ÛıÈÔ˘˜ ÌËÚÈ·›Ô˘˜, Á·ÛÙÚÔÎÓ‹ÌÈÔ˘˜, ˘ÔÎÓËÌ›‰ÈÔ˘˜, ÚfiÛıÈÔ˘˜ Î·È Ô›ÛıÈÔ˘˜ ÎÓËÌÈ·›Ô˘˜. ŒÁÈÓ·Ó ·Ó¿ Û˘Ó‰ڛ· 2-11 ÂÁ¯‡ÛÂȘ Ì ‰ÔÛÔÏÔÁ›· Ô˘ Î˘Ì¿ÓıËΠ·fi 3,5-13 U/kg ÁÈ· ÙÔ Botox, Î·È ·fi 10-40 U/kg ÁÈ· ÙÔ Dysport. ª¤ÁÈÛÙË ‰fiÛË ·Ó¿ ÛËÌÂ›Ô ¤Á¯˘Û˘ ÁÈ· ÙÔ Botox ‹Ù·Ó 50 U Î·È ÁÈ· ÙÔ Dysport 150 U. µ) ¶ÚÔ‚Ï‹Ì·Ù· ηٿ ÙȘ ÂÁ¯‡ÛÂȘ Î·È ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ∞∆-∞ ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ·Ó¤¯ıËÎ·Ó ÙȘ ÂÁ¯‡ÛÂȘ ηϿ. ŒÓ· ·È‰› ÂÌÊ¿ÓÈÛ ˘ÓËÏ›· Î·È ·ÚÔ‰ÈÎfi ˘Ô-·ÂÚÈÛÌfi Î·È Ù¤ıËΠ۠·Ú·ÎÔÏÔ‡ıËÛË Ì Ô͢ÌÂÙÚ›·. O ÎÔÚÂÛÌfi˜ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ¤Êı·Û ÛÙÔ 92% Î·È ÌÂÙ¿ Ï›Á˜ ÒÚ˜ ÙÔ ·È‰› ‹Ù·Ó ÙÂÏ›ˆ˜ ηϿ. ∆Ô Û‡Ì‚·Ì· ·Ô‰fiıËΠÛÙ· Ê¿Ú̷η Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó PR ˆ˜ ËÚÂÌÈÛÙÈÎfi Î·È ·Ó·ÏÁËÙÈÎfi. ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ∞∆-∞ ÂÌÊ·Ó›ÛÙËÎ·Ó Û 3 ·È‰È¿ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ 89 Û˘Ó‰ÚÈÒÓ. ◊Ù·Ó fiϘ ÂÏ¿ÛÛÔÓ˜ Î·È ‹Ù·Ó ÔÈ ÂÍ‹˜: ·ÚÔ‰È΋ ÂÓÔ‡ÚËÛË (1), ÙÔÈÎfi˜ ÂÚÂıÈÛÌfi˜ (1), ·ÚÔ‰È΋ Ì˘˚΋ ·‰˘Ó·Ì›· (1). ∏ ‰È¿ÚÎÂÈ· ÙˆÓ ·ÓˆÙ¤Úˆ ‹Ù·Ó ·fi Ï›Á˜ ÒÚ˜ ¤ˆ˜ Ï›Á˜ Ë̤Ú˜ Î·È Ù· Ê·ÈÓfiÌÂÓ· ‹Ù·Ó Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„ÈÌ·. °) ∂›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ ™Â 29 ·fi 67 ·È‰È¿ (43,3%) ÂÂÙ‡¯ıË Ï‹Úˆ˜ Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜, Û 28 (41,8%) ÂÂÙ‡¯ıË ÌÂÚÈÎÒ˜ Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ Î·È Û 7 ˘‹ÚÍ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜, ¯ˆÚ›˜ ·ÍÈfiÏÔ-
Paediatriki 2002;65:167-173
ÁÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· (™¯‹Ì· 1). µÂÏÙ›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ·Ú·ÙËÚ‹ıËΠηٿ ÙËÓ 1Ë Â·ÓÂͤٷÛË (1Ô˜ Ì‹Ó·˜) Û 64 ·ÛıÂÓ›˜. ∏ ›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘, Ï‹Ú˘ ‹ ÌÂÚÈ΋, ηٷÁÚ¿ÊËΠÛÙËÓ ÂͤٷÛË ÙÔ˘ ÙÚÈÌ‹ÓÔ˘ Î·È Â›¯Â ·Ú·ÙËÚËı› ·Ó¿ÌÂÛ· ÛÙÔÓ 1Ô Î·È ÙÔÓ 3Ô Ì‹Ó· ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ ÛÙÔ˘˜ 57 ·ÛıÂÓ›˜. ¢) ∂·ÓÂÁ¯‡ÛÂȘ ∞˘Ù¤˜ ¤ÁÈÓ·Ó ÌÂÙ¿ ̤ÛÔ ‰È¿ÛÙËÌ· 6,2 ÌËÓÒÓ (38 Ì‹Ó˜) Î·È Â›¯·Ó fiϘ Ôχ ηÏfi ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ·, ‰ËÏ·‰‹ Ï‹ÚË ‹ ÌÂÚÈ΋ ›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘. ŒÁÈÓ·Ó fiϘ Û ·È‰È¿ Ô˘ ›¯·Ó ·ÓÙ·ÔÎÚÈı› ¿ÚÈÛÙ· ÛÙË ÚÔËÁÔ‡ÌÂÓË ¤Á¯˘ÛË Î·È ·ÊÔÚÔ‡Û·Ó Â›Ù ÙȘ ›‰È˜ Ì˘˚Τ˜ ÔÌ¿‰Â˜ ‹ ¿ÏϘ. ªfiÓÔ Û ¤Ó·Ó ·ÛıÂÓ‹ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ·Ú¤Ï¢ÛË ÙÚÈÌ‹ÓÔ˘ Î·È fi¯È ÙÂÙÚ·Ì‹ÓÔ˘, fiˆ˜ ›¯Â ·Ú¯Èο ·ÔÊ·ÛÈÛÙ›. O ÏfiÁÔ˜ ‹Ù·Ó fiÙÈ ÙÔ ·È‰› ·˘Ùfi, ÙÔ ÔÔ›Ô ¤·Û¯Â ·fi ÙÂÙÚ·ÏËÁ›· Î·È Â›¯Â ÂÈÙ‡¯ÂÈ Ó· ηı›ÛÂÈ ÌÂÙ¿ ÙËÓ ÚÒÙË ¤Á¯˘ÛË, ¤¯·Ó ÙË ‰˘Ó·ÙfiÙËÙ· ·˘Ù‹ ÌÂÙ¿ ·fi ÙËÓ ·Ú¤Ï¢ÛË ÙÚÈÌ‹ÓÔ˘ ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙÔ˘˜ Ô›ÛıÈÔ˘˜ ÌËÚÈ·›Ô˘˜ Î·È ÚÔÛ·ÁˆÁÔ‡˜ ÔÈ ÔÔ›ÔÈ Â›¯·Ó ÂÁ¯˘ı›. ™˘˙‹ÙËÛË OÈ ÂΉËÏÒÛÂȘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ÂÓÙfiÈÛË, ÙËÓ ¤ÎÙ·ÛË Î·È ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ ‚Ï¿‚˘ ÛÙÔÓ ÂÁΤʷÏÔ ‹ ÛÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi. ªÔÚ› Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜, Ù˘ ·ÓÙ›Ï˄˘, ηıÒ˜ Î·È ÚÔ‚Ï‹Ì·Ù· ÁÓˆÛÙÈο Î·È ÎÈÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ ÎÈÓËÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂΉËψı› Ì ۷ÛÙÈÎfiÙËÙ·, Ì˘˚ÎÔ‡˜ Û·ÛÌÔ‡˜ Û ο̄Ë, ·‰˘Ó·Ì›· Î·È ·ÒÏÂÈ· ÙÔ˘ ÎÈÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ÏÂÙÒÓ ÎÈÓ‹ÛˆÓ. ∞Ó·ÏfiÁˆ˜ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ‚Ï¿‚˘ Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ¶Ï‹Ú˘ ›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘: 29 ·È‰È¿ (43,3%)
10/28 8/20 ÙÂÙÚ·ÏËÁ›Â˜ ‰ÈÏËÁ›Â˜
9/14 2/4 ‰˘ÛÙÔÓÈΤ˜ ËÌÈÏËÁ›Â˜ ÌÔÚʤ˜ ∂.¶.
ªÂÚÈ΋ ›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘: 28 ·È‰È¿ (41,8%)
4/14 1/4 ‰˘ÛÙÔÓÈΤ˜ 14/28 9/20 ÙÂÙÚ·ÏËÁ›Â˜ ‰ÈÏËÁ›Â˜ ËÌÈÏËÁ›Â˜ ÌÔÚʤ˜ ∂.¶. ªÂ›ˆÛË Û·ÛÙÈÎfiÙËÙ·˜ ¯ˆÚ›˜ ·ÍÈfiÏÔÁÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ·: 7 ·È‰È¿ (10,4%) ™¯‹Ì· 1. §ÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ÂÁ¯‡ÛÂˆÓ ∞∆-∞.
169
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·170
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
ÙˆÓ ÂΉËÏÒÛˆÓ, Ë ÎÈÓËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÚÈÔÚ›˙ÂÙ·È Î·È ÚÔ·ÙÂÈ ·Ó·ËÚ›·. ∏ Û·ÛÙÈÎfiÙËÙ· ÔÊ›ÏÂÙ·È Û ˘ÂÚ‰ÈÂÁÂÚÛÈÌfiÙËÙ· ÙÔ˘ Ì˘ÔÙ·ÙÈÎÔ‡ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ Î·È ˆ˜ Û‡Ìو̷ ÌÔÚ› Ó· ÂÚÈÔÚ›ÛÂÈ ÛËÌ·ÓÙÈο ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ·ÙfiÌÔ˘ ÛÙËÓ ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹, ηıÒ˜ ·fi ÌfiÓË Ù˘ Ô‰ËÁ› Û ηٷӿψÛË ·˘ÍË̤Ó˘ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· ÙËÓ Î›ÓËÛË, Ó· ÚÔηϤÛÂÈ Û˘Áο̄ÂȘ Î·È fiÓÔ Î·È Ó· ÂÚÈÔÚ›ÛÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÔÚıÒÛÂˆÓ (4). ŒÓ·˜ ·fi ÙÔ˘˜ ·ÚÈÔ˘˜ ÛÙfi¯Ô˘˜ Ì›ˆÛ˘ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÂȤ‰Ô˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ¢ËÏ·‰‹, Â¿Ó Ë ‚Ï¿‚Ë ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Ù¤ÙÔÈ· ¤ÙÛÈ ÒÛÙ Ì Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Ô ·ÛıÂÓ‹˜ Ó· ÌÔÚ¤ÛÂÈ Ó· ‚·‰›ÛÂÈ, Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ¤Ó·˜ ηÏfi˜ ÛÙfi¯Ô˜ Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ·ÔÊ¿ÛÂȘ Ì·˜ Û¯ÂÙÈο Ì ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ı· Û˘˙ËÙËıÔ‡Ó ÂÚ·ÈÙ¤Úˆ. ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ηıÔÚ›˙ÂÈ ÙÔÓ ÙÚfiÔ ıÂڷ¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘. º˘ÛÈÔıÂڷ›· Î·È ÔÚıˆÙÈÎÔ‡ Ù‡Ô˘ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÚΛ˜ ÁÈ· ÙËÓ ÂÏ·ÊÚ¿ Û·ÛÙÈÎfiÙËÙ·. ∏ ̤ÙÚÈ· Î·È ÛÔ‚·Ú‹ Û·ÛÙÈÎfiÙËÙ·, fï˜, Û˘Ó‹ıˆ˜ ··ÈÙÔ‡Ó ÂÈÚfiÛıÂÙË Î·È ÈÔ ÂÈıÂÙÈ΋ ıÂڷ›·. ¶·Ï·ÈfiÙÂÚ·, ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ ‹Ù·Ó Ô Î·Ù’ ÂÍÔ¯‹Ó ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÌË ‚ÂÏÙÈÔ‡ÌÂÓ˘ Ì ¿ÏϘ ÌÂıfi‰Ô˘˜ Û·ÛÙÈÎfiÙËÙ·˜. ∆· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÔÈΛϷ Î·È ¿ÓÙÔÙ ÂÍ·ÚÙÒÌÂÓ· ·fi ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ Î·È ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ÛˆÛÙÔ‡ ¯ÚfiÓÔ˘ ÁÈ· ÙËÓ Â¤Ì‚·ÛË Î·ıÒ˜ Î·È ÙˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÛÙȘ Ôԛ˜ Ô ¯ÂÈÚÔ˘ÚÁfi˜ ¤ÏÂÁ ӷ ¤̂ÂÈ. OÈ ÔÚıÔ‰ÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Û˘Ó¯›˙Ô˘Ó Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ˆ˜ Ë ÔÚÈÛÙÈ΋ χÛË. ¡Â˘ÚÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÙÔ˘ Ù‡Ô˘ ÙˆÓ Ô›ÛıÈˆÓ ÂÎÏÂÎÙÈÎÒÓ ÚÈ˙ÔÙÔÌÒÓ ‰ÔÎÈÌ¿ÛÙËÎ·Ó Û ·ÚÎÂÙÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ÔÈ ÂӉ›ÍÂȘ ‹Ù·Ó ÂÚÈÔÚÈṲ̂Ó˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· fi¯È ¿ÓÙ· Ù· ·Ó·ÌÂÓfiÌÂÓ·. ø˜ ·ÔÙ¤ÏÂÛÌ·, Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ ‰ÂÓ ‚ڋΠ¢Ú›· ÂÊ·ÚÌÔÁ‹ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·È ÂÚÈÔÚ›ÛÙËΠÛÙ· ·È‰È¿ Ì ۷ÛÙÈ΋ ‰ÈÏËÁ›·, ηϋ ÓÔËÌÔÛ‡ÓË, ηÏfi ÎÔÚÌfi Î·È ¯¤ÚÈ·. ∆Ô Â‰›Ô ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ¿ÏÏˆÓ ÌÔÚÊÒÓ Ì¤ÙÚÈ·˜ Î·È ÛÔ‚·Ú‹˜ Û·ÛÙÈÎfiÙËÙ·˜ ¤ÌÂÈÓÂ Î·È ¿ÏÈ ·ÓÔÈÎÙfi. ∏ ηٷÓÔÌ‹ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ηıÔÚ›˙ÂÈ Â¿Ó Ô ·ÛıÂÓ‹˜ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì “ÙÔÈΤ˜” ·ÚÂÌ‚¿ÛÂȘ ‹ fi¯È. ∂¿Ó Ë Û·ÛÙÈÎfiÙËÙ· Â›Ó·È Î·ıÔÏÈ΋ ‹ ‚·Ú›·, ÔÈ ÂÈÏÔÁ¤˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜, ¤¯Ô˘Ó ·Ó·ÎÔ˘ÊÈÛÙÈÎfi ¯·Ú·ÎÙ‹Ú· Î·È fi¯È ÛÙfi¯Ô ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó·‚¿ıÌÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì·˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û˘¯Ó¿ ηıÔÚ›˙ÂÈ ÙȘ
170
Paediatriki 2002;65:167-173
‰˘Ó·ÙfiÙËÙ˜ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, ΢ڛˆ˜ Û ÂÚÈÙÒÛÂȘ fiÔ˘ ÔÈ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ Î·È Ë Û·ÛÙÈÎfiÙËÙ· ÛÔ‚·Ú‹. π‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ fiÔ˘ ÙÔ ÛÙ¿‰ÈÔ ÂͤÏÈ͢ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁΤʷÏÔ˘ Û·ÊÒ˜ ηıÔÚ›˙ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÙfiÓÔ˘, ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó¿‰˘Û˘ Ù˘ ˘ÂÚÙÔÓ›·˜ Î·È ÙÔ Ú˘ıÌfi Ù˘ Âȉ›ӈۋ˜ Ù˘, Ë ÂÈÏÔÁ‹ ÙÔ˘ ÛˆÛÙÔ‡ ¯ÚfiÓÔ˘ ·Ú¤Ì‚·Û˘ Â›Ó·È Ô˘ÛÈ·ÛÙÈ΋. O ÂÓÙÔÈÛÌfi˜ ÙÔ˘ ÂȤ‰Ô˘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ¤¯ÂÈ Â›Û˘ ÛËÌ·Û›· ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ ıÂڷ›·˜, ηıÒ˜ Ë Û·ÛÙÈÎfiÙËÙ· ÛÙ· οو ¿ÎÚ· Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÓˆÙÈ·›· ‚Ï¿‚Ë ÌÔÚ› Ó· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ‰È·ÊÔÚÂÙÈο ·fi ·˘Ù‹Ó Ô˘ ÔÊ›ÏÂÙ·È Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∆¤ÏÔ˜, Ë ÂÈÏÔÁ‹ Ù˘ ·Ú¤Ì‚·Û˘ ÔÊ›ÏÂÈ Ó· Ï·Ì‚¿ÓÂÈ ˘’ fi„ÈÓ ÙË Û˘ÓÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·È‰ÈÔ‡, ‰ËÏ·‰‹ ÙË ÓÔËÌÔÛ‡ÓË ÙÔ˘, ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘, ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÚfiÁÓˆÛË Ì ‚¿ÛË ÙË Ê‡ÛË Î·È ÙÔÓ ÂÓÙÔÈÛÌfi Ù˘ ‚Ï¿‚˘ Î·È ÙÔ ·Ó·Ù˘ÍÈ·Îfi ÛÙ¿‰ÈÔ ÛÙÔ ÔÔ›Ô ‚Ú›ÛÎÂÙ·È. ¶fiÛË ÛËÌ·Û›· ÛÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Â›Â‰Ô ÌÔÚ› Ó· ¤¯ÂÈ Ë ÂÏ¿ÙÙˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÂÓfi˜ ̤ÏÔ˘˜, Â¿Ó ÙÔ ·È‰› ·‰˘Ó·Ù› Ó· ÂÊ·ÚÌfiÛÂÈ ÂÎÔ‡ÛÈÔ ¤ÏÂÁ¯Ô ÛÙËÓ Î›ÓËÛ‹ ÙÔ˘; ∏ ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË, ÔÈ Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ÈÛÔÚÚԛ˜, ÙÔ ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈÎfi ›‰Ô, fiÏ· ηıÔÚ›˙Ô˘Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ó· ·ÓÙ¤ÍÂÈ ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Î·È Ó· ÂÊ·ÚÌfiÛÂÈ ·˘Ù¿ Ô˘ ÂÌ›˜ Û˘ÓÈÛÙԇ̠(6). ∏ ∞∆-∞ ¯ÚËÛÈÌÔÔÈ‹ıËΠıÂڷ¢ÙÈο ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 Î·È ·Ô‰Â›¯ÙËΠ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·Ú¯Èο ÛÙË ıÂڷ›· Ù˘ ‰˘ÛÙÔÓ›·˜ Î·È Î·ÙfiÈÓ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ (7,8). ªÂÙ¿ ÙËÓ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË, Ë ∞∆-∞ Û˘Ó‰¤ÂÙ·È Ì ¯ÔÏÈÓÂÚÁÈΤ˜ ÚÔÛ˘Ó·ÙÈΤ˜ ÌÂÌ‚Ú¿Ó˜ ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë. ªÂ ÙÔ Ì˯·ÓÈÛÌfi Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚˆÛ˘, ÙÔ ÌfiÚÈÔ ÂÈÛ¤Ú¯ÂÙ·È ÛÙ· ÂÓ‰Ô΢ÙÙ·ÚÈο ΢ÛÙ›‰È·, ‰È·¯ˆÚ›˙ÂÙ·È ÛÙËÓ ÂÏ·ÊÚ¿ Î·È ‚·Ú›· ¿Ï˘ÛÔ Ô˘ ÙÔ ·ÔÙÂÏÔ‡Ó Î·È Ë ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ˜ ·ÂÏ¢ıÂÚÒÓÂÙ·È ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·. ∂Λ, Ì ÂÓ˙˘ÌÈÎfi Ì˯·ÓÈÛÌfi ÚÔηÏ› ÙÂÏÈο ·Ó·ÛÙÔÏ‹ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ ÛÙË Û‡Ó·„Ë, ÌÏÔοÚÔÓÙ·˜ ¤ÙÛÈ ÙË Ó¢Úԉȷ‚›‚·ÛË (1). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ·Ó·Ù‡ÛÛÔÓÙ·È ·ÓÙÈÛÒÌ·Ù· ÂÓ·ÓÙ›ÔÓ Ù˘ ∞∆-∞, ·Ó Î·È ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi fiÛÔ Û˘¯Ó¿ Û˘Ì‚·›ÓÂÈ ·˘Ùfi. ∏ ·Ó¿Ù˘ÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÍÔ˘‰ÂÙÂÚÒÓÂÈ ÙËÓ Â˘ÂÚÁÂÙÈ΋ ‰Ú¿ÛË Ù˘ ∞∆-∞ Î·È Û ·ÛıÂÓ›˜ Ô˘ ·Ú¯Èο ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο Û ·˘Ù‹ ÙË ÌÔÚÊ‹ ıÂڷ›·˜ Â›Ó·È Â˘ÓfiËÙÔ fiÙÈ Ô‰ËÁ› Û ·ÒÏÂÈ· Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ÂfiÌÂÓ˜ ÂÁ¯‡ÛÂȘ. ∂›Ó·È, ÂÔ̤ӈ˜, ÏÔÁÈÎfi Ó· Ï·Ì‚¿ÓÂÙ·È ÚfiÓÔÈ· ¤ÙÛÈ ÒÛÙ ӷ ÌÂȈı› Ô Î›Ó‰˘ÓÔ˜ Û¯ËÌ·ÙÈÛÌÔ‡ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ. OÈ ·Ú¿ÁÔÓÙ˜
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·171
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
Ô˘ ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙÔ Û¯ËÌ·ÙÈÛÌfi ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È Ù· ÁÂÓÂÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ë Û˘ÓÔÏÈ΋ ¤ÎıÂÛ‹ ÙÔ˘ ÛÙÔ Û‡ÌÏÂÁÌ· Ó¢ÚÔÙÔ͛Ӣ-ÚˆÙ½Ó˘, Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÛfiÙËÙ· ÚˆÙ½Ó˘ ·Ó¿ ÂÁ¯˘fiÌÂÓË ‰fiÛË ∞∆-∞, ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÁ¯‡ÛÂˆÓ Î·È ÙË ¯ÔÚËÁÔ‡ÌÂÓË ‰ÔÛÔÏÔÁ›· ·Ó¿ ¤Á¯˘ÛË (9). °È· Ó· ÂÏ·¯ÈÛÙÔÔÈËı› ÂÔ̤ӈ˜ Ô Î›Ó‰˘ÓÔ˜ Û¯ËÌ·ÙÈÛÌÔ‡ ·ÓÙÈۈ̿وÓ, Â›Ó·È ·Ó·Áη›Ô Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë ‰fiÛË ÛÙ· ¯·ÌËÏfiÙÂÚ· ‰˘Ó·Ù¿ ıÂڷ¢ÙÈο ›‰· Î·È Ó· ÌÂÁÂı‡ÓÔÓÙ·È Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ¯ÔÚ‹ÁËÛ˘ Ù˘ ∞∆-∞ ÛÙÔ Ì¤ÁÈÛÙÔ ‰˘Ó·Ùfi (10). O ηıÔÚÈÛÌfi˜ Ù˘ ‰fiÛ˘ Á›ÓÂÙ·È Ì ‚¿ÛË ÙÔ˘˜ ›Ó·Î˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ‰ÔÛÔÏÔÁÈÎfi ‡ÚÔ˜ ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÙ· ·È‰È¿ Î·È ·Ó¿ÏÔÁ· Ì ÙÔ Ì˘ Ô˘ ÂÁ¯‡ÂÙ·È. ∏ ÂÌÂÈÚ›· ÙÔ˘ È·ÙÚÔ‡ ÛÙË Û˘Ó¤¯ÂÈ· ηıÔÚ›˙ÂÈ Â¿Ó Ë ‰fiÛË Ô˘ ı· ÂÁ¯˘ı› Â›Ó·È ÛÙÔ Î·ÙÒÙÂÚÔ ¿ÎÚÔ ÙÔ˘ ‰ÔÛÔÏÔÁÈÎÔ‡ ‡ÚÔ˜ ‹ ÛÙÔ ·ÓÒÙÂÚÔ. ∏ ̤ÙÚËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ÛÙË ıÂڷ›· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ıˆÚÂ›Ù·È ·Ó·Áη›·, ·Ó Î·È ÔÈ ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ Î·È Îϛ̷Θ ¤¯Ô˘Ó Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ Â˘Ú›·˜ ÎÚÈÙÈ΋˜. ∏ ›ÂÛË ÁÈ· ·ÓÙÈÎÂÈÌÂÓÈΤ˜ Îϛ̷Θ ̤ÙÚËÛ˘ ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ì›·˜ ıÂڷ›·˜ ¤¯ÂÈ ˘·ÁÔÚ¢ı› ·ÊÂÓfi˜ ·fi ÙÔ˘˜ ·ÛÊ·ÏÈÛÙÈÎÔ‡˜ ÊÔÚ›˜ Î·È ·ÊÂÙ¤ÚÔ˘ ·fi ÙËÓ ·Ó·ÁηÈfiÙËÙ· ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ, fiˆ˜ ·˘Ù‹ ÚÔ·ÙÂÈ ·fi ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ̤ıÔ‰Ô Î·È ÙËÓ ·Î·‰ËÌ·˚΋ È·ÙÚÈ΋. ∂ȉÈο ÁÈ· ÙË Û·ÛÙÈÎfiÙËÙ·, ηı›ÛÙ·Ù·È ‰˘Û¯ÂÚ‹˜ Ë ÔÛÔÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜, Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ¿ÏÁÔ˘˜ (11). ŸÌˆ˜, ÙÂÏÈο, ·Ó·Ù‡¯ıËÎ·Ó Ì¤ıÔ‰ÔÈ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ıÂڷ¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ ÛÙË Û·ÛÙÈÎfiÙËÙ·, ÌÔÏÔÓfiÙÈ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÌÂÙÚËıÔ‡Ó ÔÚÈṲ̂ӷ Ê·ÈÓfiÌÂÓ·, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ô fiÓÔ˜ Û ÌÔÓ¿‰Â˜, fiˆ˜ ÌÂÙÚ¿Ù·È Ë ·ÈÌÔÛÊ·ÈÚ›ÓË. ∞fi ÙËÓ ·ÍÈÔÏfiÁËÛË ÚÈÓ Î·È ÌÂÙ¿ ÙË ıÂڷ›· ÌÔÚ› Ó· ÚÔ·„ÂÈ ÙÔ ÔÛÔÛÙfi Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì·˜. ∆· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ·Ú¤Ì‚·Û˘ ·ÍÈÔÏÔÁÔ‡ÓÙ·È ˆ˜ ÏÂÈÙÔ˘ÚÁÈο ‹ Ù¯ÓÈο, ÂÓÒ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Î·Ù¤¯ÂÈ Ô ‚·ıÌfi˜ ÈηÓÔÔ›ËÛ˘ ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÏÏ¿ Î·È Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Û ۯ¤ÛË Ì ÙÔ ÎfiÛÙÔ˜. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Â›Ó·È ÛÎfiÈÌÔ Ó· Û˘˙ËÙËıÔ‡Ó ÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Î·È Ë ÎÚÈÙÈ΋ Á‡Úˆ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ηıÒ˜ Î·È Ë ÙÔÔı¤ÙËÛË Â›ÛËÌˆÓ ÔÚÁ·ÓÈÛÌÒÓ (U.K. Botulinum toxin and Cerebral Palsy Working Party) Û¯ÂÙÈο Ì ÙËÓ ∞∆-∞ Û ·È‰È¿ Ì ∂¶ (12). ∏ ¯Ú‹ÛË Ù˘ ∞∆-∞ ¤¯ÂÈ ‰Â›ÍÂÈ Â˘ÓÔ˚ο ‚Ú·¯˘ÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È Ù˘ ‰˘ÛÙÔÓ›·˜ ÛÙËÓ ∂¶. £¤Ì· ÚÔ˜ Û˘˙‹ÙËÛË ·ÔÙÂÏ› Ë ‰ÔÛÔÏÔÁ›· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·Ó¿ Ì˘, Ë ÔÔ›· ¤¯ÂÈ Î·ıÔÚÈ-
Paediatriki 2002;65:167-173
ÛÙ› Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ Ì˘fi˜, ·ÏÏ¿ Ì ÌÂÁ¿ÏË ·fiÎÏÈÛË ·fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ¯Ú‹Û˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ™ÙËÓ ·ÚÔ‡Û· Ê¿ÛË ÔÈ ·fi„ÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ Û˘ÁÎÏ›ÓÔ˘Û˜ Î·È ÔÈ ÚÔÙÂÈÓfiÌÂÓ˜ ‰fiÛÂȘ Â›Ó·È Û˘Ó‹ıˆ˜ ·˘Ù¤˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙÔ ‰ÈÎfi Ì·˜ ˘ÏÈÎfi, ‰ËÏ·‰‹ 13 U/kg Botox Î·È 40 U/kg Dysport. ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Ôχ ÛËÌ·ÓÙÈο, ηıÒ˜ ·ÎfiÌË ‰ÂÓ ¤¯ÂÈ ·Ôχو˜ ‰È¢ÎÚÈÓÈÛÙ› ÔÈÔÈ Â›Ó·È ÔÈ Î·Ï‡ÙÂÚÔÈ ˘Ô„‹ÊÈÔÈ ÁÈ· ·˘Ù‹ ÙË ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ∆Ô Î‡ÚÈÔ ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ Â›Ó·È Ë ˘ÂÚÙÔÓ›· ¯ˆÚ›˜ Û‡Áη̄Ë, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ ∂¶. ¶ÂÚÈÛÛfiÙÂÚÔ Û·Ê¤˜ Â›Ó·È Û ÔÈÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È Ë ·ÁˆÁ‹ Î·È ·˘ÙÔ› Â›Ó·È ÔÈ ÂÍ‹˜: ·) ∞ÛıÂÓ›˜ Ì ÌfiÓÈÌË ÈÔÔ‰›· (ÁˆÓ›· οو ÙˆÓ 90 ÌÔÈÚÒÓ Ì ÙÔ ÁfiÓ˘ ÛÂ Î¿Ì„Ë Î·È ¤ÓÙÔÓË ·ÓÙ›ÛÙ·ÛË). ‚) ÀÔÙÔÓÈ΋ ÌÔÚÊ‹ ∂¶ Ì ¤ÓÙÔÓË Ì˘˚΋ ·‰˘Ó·Ì›·. Á) ªË Û˘ÓÂÚÁ¿ÛÈÌË ÔÈÎÔÁ¤ÓÂÈ· ‹ ıÂÚ·Â˘Ù¤˜. ‰) ∂Ӊ›ÍÂȘ ·Ú·ÁˆÁ‹˜ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ ÙÔ͛Ӣ. ∞ÎfiÌË ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó Ì·ÎÚÔÚfiıÂÛÌ· Ë ¯Ú‹ÛË Ù˘ ∞∆-∞ ı· ·Ô‰Âȯı› ÎÏÈÓÈο ˆÊÂÏ‹˜ Î·È - ·fi ÔÈÎÔÓÔÌÈ΋ ¿Ô„Ë - ˆ˜ ηϋ ¤Ӊ˘ÛË ÚÔ˜ fiÊÂÏÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜. ¶¿ÓÙˆ˜, Ë ‰˘Ó·ÙfiÙËÙ· Ù˘ ∞∆-∞ Ó· ÌÂÈÒÛÂÈ ÙË Û·ÛÙÈÎfiÙËÙ· Î·È Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∂¶ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi ·ÚÎÂÙ¤˜ ‰ÈϤ˜ Ù˘ÊϤ˜ ‹ ·ÓÔÈÎÙ¤˜ ÌÂϤÙ˜ (13-20). OÈ ·Ú¯ÈΤ˜ ÌÂϤÙ˜ Âͤٷ˙·Ó ÙË ‚Ú·¯˘ÚfiıÂÛÌË ˆÊ¤ÏÂÈ· (21), fï˜ ÔÈ ÈÔ ÚfiÛÊ·Ù˜ ÂÍÂÙ¿˙Ô˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·Ú¤Ì‚·Û˘ ÂÚÈÛÛfiÙÂÚÔ Ì·ÎÚÔÚfiıÂÛÌ· (22). ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·Ó·ÊÂÚı‹Î·Ì ÛÙËÓ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Ô˘ Ë ıÂڷ¢ÙÈ΋ ÔÌ¿‰· ¤ıÂÛ ηٿ ÙËÓ ·Ú¯È΋ ·ÍÈÔÏfiÁËÛË, ÂÓÒ Û ·ÒÙÂÚÔ ¯ÚfiÓÔ ı· ·ÍÈÔÏÔÁËıÔ‡Ó ÔÈ ÏÔȤ˜ Îϛ̷Θ ÔÈ Ôԛ˜ Û˘ÏϤÁÔÓÙ·È. Ÿˆ˜ ÚԷӷʤÚıËÎÂ, Ë Û˘ÏÏÔÁ‹ ÙˆÓ ÛÙÔȯ›ˆÓ ·˘ÙÒÓ ÛÙ· ÛˆÛÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· Î·È Ì Ù¯ÓÈΤ˜ ·ÍÈfiÈÛÙ˜ ¤¯ÂÈ ·Ô‰Âȯı› ȉȷ›ÙÂÚ· ‰˘Û¯ÂÚ‹˜ Î·È Â›ÔÓË Î·È ıˆÚԇ̠fiÙÈ Ù· ̤¯ÚÈ ÛÙÈÁÌ‹˜ Û˘Ïϯı¤ÓÙ· ‰Â‰Ô̤ӷ, ·Ó Î·È ÔÏÏ¿ Î·È Û ÔÈΛÏÔ˘˜ ÙÔÌ›˜, ‰ÂÓ Â›Ó·È ·ÎfiÌË Û˘ÓÔÏÈο ·ÍÈÔÏÔÁ‹ÛÈÌ·. £· Ú¤ÂÈ ÛÙÔ ÛËÌÂ›Ô ·˘Ùfi Ó· ÛËÌÂȈı› fiÙÈ Ë ¯Ú‹ÛË ·ÓÙÈÎÂÈÌÂÓÈÎÒÓ ÌÂıfi‰ˆÓ ·ÍÈÔÏfiÁËÛ˘ Û ÌÈÎÚ¿ ΢ڛˆ˜ ·È‰È¿ Â›Ó·È Úfi‚ÏËÌ·, ηıÒ˜ ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ˆ˜ ÚÔ˜ ÙË ‰È·ıÂÛÈÌfiÙËÙ· ÙˆÓ ÌÂıfi‰ˆÓ ·ÏÏ¿ Î·È ˆ˜ ÚÔ˜ ÙËÓ ·ÍÈÔÈÛÙ›· ÙÔ˘˜ (23). ∆Ô Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘ ÌÂÙÚ¿Ù·È ·ıËÙÈο, ÂÓÒ ÙÔ Â‡ÚÔ˜
171
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·172
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
Ù˘ ÂÓÂÚÁËÙÈ΋˜ ΛÓËÛ˘ ‰ÂÓ ÌÔÚ› Ó· ÌÂÙÚËı› Û ÌÈÎÚ¤˜ ËÏÈ˘. OÈ ÌÂÙ·‚ÔϤ˜ ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ‰‡ÛÎÔÏ· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Û ·È‰È¿, ÂÓÒ Ë ÎÚÈÙÈ΋ ÁÈ· ÙȘ ˘¿Ú¯Ô˘Û˜ ÌÂıfi‰Ô˘˜, .¯. Ashworth, Â›Ó·È fiÙÈ ¤¯Ô˘Ó ηٷÛ΢·ÛÙ› ÁÈ· ÂÓ‹ÏÈΘ. OÈ ‰˘ÛÎÔϛ˜ ÛÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ Îϛ̷Θ, fiˆ˜ Ë GMFM, Â›Ó·È ÔÏϤ˜, ηıÒ˜ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ Û˘¯Ó¿ ‰ÂÓ Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· ÂÂȉ‹ ‰ÈÂÎÂÚ·ÈÒÓÔÓÙ·È ·fi ıÂÚ·Â˘Ù¤˜ Ì ‹ ¯ˆÚ›˜ Û¯ÂÙÈ΋ Âη›‰Â˘ÛË Î·È Â›Ó·È ¯ÚÔÓÔ‚fiÚ˜. ∏ Û˘ÁÎÂÎÚÈ̤ÓË ¿ÓÙˆ˜ ̤ıÔ‰Ô˜ ¤¯ÂÈ ÂȉÈο ·Ó·Ù˘¯ı› ÁÈ· ·È‰È¿ Ì ∂¶ Î·È ‰›ÓÂÈ ·ÎÚȂ›˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ‰ÂÍÈfiÙËÙ˜ Ô˘ ¤¯ÂÈ ÙÔ ·È‰› ˆ˜ ÚÔ˜ ÙËÓ ·‰Ú‹ ÎÈÓËÙÈÎfiÙËÙ·. ∏ ÔÈfiÙËÙ· ÙˆÓ ÎÈÓ‹ÛÂˆÓ ‰ÂÓ ÂÍÂÙ¿˙ÂÙ·È (24). ™ËÌ·Û›· ¤¯ÂÈ fiÙÈ ·ÎfiÌË Î·È ¤Ó· ˘ÁȤ˜ ·È‰› 5 ÂÙÒÓ ÌÔÚ› Ó· ÂÎÙÂϤÛÂÈ ÙË Îϛ̷η. O Ê˘ÛÈÔıÂÚ·Â˘Ù‹˜ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ›Ô˘ 60 min ·fi ÙÔ ¯ÚfiÓÔ ÙÔ˘ Î·È ÚÔËÁÔ‡ÌÂÓË Âη›‰Â˘ÛË. ∆¤ÏÔ˜, Ë ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘ ‰ÂÓ Â›Ó·È Â˘Ú¤ˆ˜ ‰È·ı¤ÛÈÌË Î·È Â›Ó·È ‰‡ÛÎÔÏË fiÙ·Ó ÙÔ ·È‰› Â›Ó·È ÌÈÎÚfi Î·È ÌË Û˘ÓÂÚÁ¿ÛÈÌÔ. ∆Ô Ì‹Ó˘Ì· ÙÔ ÔÔ›Ô ÂÈı˘Ìԇ̠ӷ ÌÂٷʤÚÔ˘Ì Ì ÙË ÌÂϤÙË ·˘Ù‹ Â›Ó·È fiÙÈ ÔÈ ÂÁ¯‡ÛÂȘ ∞∆-∞ Â›Ó·È Ì¤ıÔ‰Ô˜ ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∏ Ï‹Ú˘ ‹ ÌÂÚÈ΋ ›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Û 57 ·fi Ù· 67 ·È‰È¿ (85%) ıˆÚÂ›Ù·È ˆ˜ ¿ÎÚˆ˜ ÈηÓÔÔÈËÙÈ΋, ȉȷ›ÙÂÚ· Â¿Ó ÏËÊı› ˘’ fi„ÈÓ Ô Ôχ ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÂÏ·ÊÚÒÓ Î·È Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„ÈÌˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ. £ÂˆÚԇ̠fiÙÈ ÙÔ Î·Ïfi ·˘Ùfi ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹ ˘Ô„‹ÊÈˆÓ ·ÛıÂÓÒÓ Î·È Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÁÈ· ¤Á¯˘ÛË, ·ÏÏ¿ Î·È ÛÙÔ˘˜ Ú·ÏÈÛÙÈÎÔ‡˜ ıÂڷ¢ÙÈÎÔ‡˜ ÛÙfi¯Ô˘˜ Ô˘ ı¤Û·ÌÂ. ∂ÈϤÔÓ, ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Î·È Ë Û˘ÌÌfiÚʈÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ˆ˜ ÚÔ˜ ÙÔ ··Ú·›ÙËÙÔ Ê˘ÛÈÔıÂڷ¢ÙÈÎfi ÚfiÁÚ·ÌÌ· ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ. ∆· ·ÓÙ›ıÂÙ·, ‰ËÏ·‰‹ Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÂÁ¯‡ÛÂˆÓ Û ̇˜ Ì ÌfiÓÈÌË Û‡ÁÎ·Ì„Ë Ô˘ ÌfiÓÔÓ ¤Ó· ¯ÂÈÚÔ˘ÚÁÂ›Ô ÌÔÚ› Ó· ·Ó·Ù¿ÍÂÈ, Ë ˘ÂÚ‚ÔÏÈ΋ ‰ÔÛÔÏÔÁ›·, ÔÈ ˘„ËÏÔ›, ÌË Ú·ÁÌ·ÙÔÔÈ‹ÛÈÌÔÈ ÏÂÈÙÔ˘ÚÁÈÎÔ› ÛÙfi¯ÔÈ Ô˘ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ˘’ fi„ÈÓ ÙË Û˘ÓÔÏÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙȘ ÏÔȤ˜ ·Ó·Ëڛ˜ ÙÔ˘, ı· Ô‰ËÁÔ‡Û·Ó Û ÌË ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· Î·È ÛÙËÓ ·‰ÈηÈÔÏfiÁËÙË Û·Ù¿ÏË ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ (Ê¿Ú̷η Ì ˘„ËÏfi ÎfiÛÙÔ˜, ¯ÚfiÓÔ˜ È·ÙÚÈÎÔ‡ Î·È ·Ú·˚·ÙÚÈÎÔ‡ ÚÔÛˆÈÎÔ‡). ∆¤ÏÔ˜, ÙÔÓ›˙ÂÙ·È Ë ·Ó·ÁηÈfiÙËÙ· Ù˘ ÛÙÂÓ‹˜ Û˘ÓÂÚÁ·Û›·˜ Ù˘ ÔÌ¿‰·˜ (ÔÚıÔ‰ÈÎfi˜, Ê˘ÛÈÔıÂÚ·Â˘Ù‹˜, Ó¢ÚÔÏfiÁÔ˜) ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ ÚÈÓ Î·È ÌÂÙ¿ ·fi ÙȘ ÂÁ¯‡ÛÂȘ. ∏ ·fiÙÔÌË Ì›ˆÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Ô˘ ¤گÂÙ·È Ì ÙË ¯Ú‹ÛË Ù˘ ∞∆-∞, ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÛÙÔ˘˜ ıÂÚ·Â˘Ù¤˜ Ó· ÂÛÙÈ¿ÛÔ˘Ó Û ÏÂÈÙÔ˘ÚÁÈ-
172
Paediatriki 2002;65:167-173
ÎÔ‡˜ ÛÙfi¯Ô˘˜ Î·È ÛÙËÓ ÔÌ¿‰· ·ÓÙÈÌÂÙÒÈÛ˘ Ó· ÂÊ·ÚÌfiÛÂÈ ·ÚÂÌ‚¿ÛÂȘ ÁÚ‹ÁÔÚ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο. µÈ‚ÏÈÔÁÚ·Ê›· 1. Dolly JO. Therapeutic and research exploitation of botulinum neurotoxins. Eur J Neurol 1997;4(Suppl 2):S5-S10. 2. Boyd R, Graham HK. Botulinum toxin A in the management of children with cerebral palsy: indications and outcome. Eur J Neurol 1997;(Suppl 2):S15-S22. 3. Davidoff RA. Antispasticity drugs: mechanisms of action. Ann Neurol 1985;17:107-116. 4. Mayer NH. Clinicophysiologic concepts of spasticity and motor dysfunction in adults with an upper motor neuron lesion. Muscle Nerve 1997;20(Suppl 6):S1-S13. 5. Peacock WJ, Staudt LA. Selective posterior rhizotomy: evolution of theory and practice. Pediatr Neurosurg 199192;17:128-134. 6. Russman BS, Tilton A, Gormley ME. Cerebral palsy: A rational approach to a treatment protocol, and the role of Botulinum toxin in treatment. Muscle Nerve 1997;20(Suppl 6):S181-S193. 7. Comella Cl, Jankovic J, Brin MF. Use of botulinum toxin type A in the treatment of cervical dystonia. Neurology 2000;55(Suppl 5):S15-S21. 8. Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology: Assessment: the clinical usefulness of botulinum toxin-A in treating neurologic disorders. Neurology 1990;40:1332-1336. 9. Jankovic J, Schwartz K. Response and immunoresistance to botulinum toxin injections. Neurology 1995;45:1743-1746. 10. Greene P, Fahn S, Diamond B. Development of resistance to botulinum toxin type A in patients with torticollis. Mov Disord 1994;9:213-217. 11. Pierson SH. Outcome measures in spasticity management. Muscle Nerve 1997;20(Suppl 6):S36-S60. 12. Carr LJ, Cosgrove AP, Gringras P, Neville BGR (on behalf of the UK Botulinum Toxin and Cerebral Palsy Working Party). Position paper on the use of botulinum toxin in cerebral palsy. Arch Dis Child 1998;3:271-273. 13. Sutherland DH, Kaufman KR, Wyatt MP, Chambers HG. Injection of botulinum A toxin into the gastrocnemius muscle of patients with cerebral palsy: a 3-dimensional motion analysis study. Gait Posture 1996;4:269-279. 14. Calderone-Gonzalez R, Calderon-Sepuvelda R, RinconReyes M, Garcia-Ramirez J, Mino-Arango E. Botulinum toxin A in management of cerebral palsy. Pediatr Neurol 1994;4:284-288. 15. Cosgrove AP, Corry IS, Graham HK. Botulinum toxin in the management of the lower limb in cerebral palsy. Dev Med Child Neurol 1994;36:386-396. 16. Koman LA, Mooney JF III, Smith BP, Gooman A, Mulvaney T. Management of spasticity in cerebral palsy with botulinum-A toxin: report of a preliminary, randomized, double-blind trial. J Pediatr Orthop 1994;14:299-303. 17. Zelnik N, Giladi N, Goikhman I, Keren G, Moris R, Honigman S. The role of botulinum toxin in the treatment of lower limb spasticity in children with cerebral palsy - a pilot study. Isr J Med Sci 1997;33:129-133.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·173
¶·È‰È·ÙÚÈ΋ 2002;65:167-173
Paediatriki 2002;65:167-173
18. Corry IS, Cosgrove AP, Duffy CM, McNeill S, Taylor TC, Graham HK. Botulinum toxin a compared with stretching casts in the treatment of spastic equinus: a randomized prospective trial. J Pediatr Orthop 1998;18:304-311. 19. Wong V. Use of botulinum toxin injection in 17 children with spastic cerebral palsy. Pediatr Neurol 1998;18:124-131. 20. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã, ª·Ï¿Ûη ∞, ∆˙ËÙËÚ›‰Ô˘ ª, ∫ÔÙ˙·ÂÚ›‰Ô˘ O, ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘. ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. ¶·È‰È·ÙÚÈ΋ 2000;63:412-417. 21. Koman LA, Mooney JF III, Smith BP, Walker F, Leon JM. Botulinum toxin type a neuromuscular blockade in the treatment of lower limb spasticity in cerebral palsy: I. A randomized, double-blind, placebo-controlled trial. J Pediatr Orthop 2000;20:108-115. 22. Koman LA, Brashear A, Rosenfeld S, Chambers H, Russman B, Rang M et al. Botulinum toxin type A neuromuscular blockade in the treatment of equinus foot
deformity in cerebral palsy: A multicenter, open-label clinical trial. Pediatrics 2001;108:1062-1071. 23. Arens LJ, Goldschmidt RB, Leary PM. Botulinum toxin treatment in cerebral palsy: intervention with poor evaluation? Develop Med Child Neurol 1998;40:785-786. 24. Russel D, Rosenbaum P, Gowland C, Hardy S, Lane M, Plews N et al. In: The Gross Motor Function Measure. 2nd ed. Toronto Canada: Hugh McMillan Rehabilitation Centre, McMaster University; 1993.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-02 2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÈÁfiÓË ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ ª·Ó‰ËÏ·Ú¿ 8, ∆.∫. 146 71, ¡¤· ∂Ú˘ıÚ·›·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ª›· ·Ï‹ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÚÔÛÒÔ˘*1 ∆Ô Û¿ÓÈÔ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT (Û. QT) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÈÌ‹Î˘ÓÛË Ù˘ ÎÔÈÏȷ΋˜ ÂÓ·fiψÛ˘ Î·È ·fi ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘. ™Â ÔÏÏÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È ÎÏËÚÔÓÔÌÈÎfi. Œ¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› ÌÂÙ·ÏÏ¿ÍÂȘ ÔÏÏÒÓ ÁfiÓˆÓ, Ô˘ Ô Î·ı¤Ó·˜ Έ‰ÈÎÔÔÈ› Ì›· ‰›Ô‰Ô ÈfiÓÙˆÓ. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ ÛÙËÓ ÎÔχ̂ËÛË Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿, ÌÔÚ› Ó· Û˘Ì‚Â› ÂȉÈ΋ ÂÓÂÚÁÔÔ›ËÛË Î·È Û˘¯Ó¿ ¤گÂÙ·È Û˘ÁÎÔÈ΋ ÎÚ›ÛË, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Ì¤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ ·˘ÙÔ‡ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ¶ÚfiÛÊ·Ù· ·Ó·Ê¤ÚıËÎÂ Ë ‰ÔÎÈÌ·Û›· ÂÌ‚¿ÙÈÛ˘ Û ÎÚ‡Ô ÓÂÚfi (10ÔC) Û ıÂÚÌÔÎÚ·Û›· ÂÚÈ‚¿ÏÏÔÓÙÔ˜ 20ÔC, ÌÂÙ¿ ·fi ‚·ıÈ¿ ÂÈÛÓÔ‹. ŸÙ·Ó ÙÔ Ì·ÎÚfi QT ‰ÂÓ Â›Ó·È ÔÈÎÔÁÂÓÔ‡˜ ÌÔÚÊ‹˜, ›¯Â ‚ÚÂı› fiÙÈ Ë Û¯¤ÛË QT/HR (‰È¿ÚÎÂÈ· QT/ηډȷ΋ Û˘¯ÓfiÙËÙ·) Ô˘ ˘ÔÏÔÁÈ˙fiÙ·Ó ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÚÈÓ Î·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÈÔ ¿Óˆ ‰ÔÎÈÌ·Û›·˜, ·ÚÔ˘Û›·˙ ̛· ‰È·ÊÔÚ¿ (ÎÏ›ÛË) Ô˘ Â›Ó·È ¯Ú‹ÛÈÌÔ˜ ‰Â›ÎÙ˘ Úfi‚Ï„˘ ÁÈ· ·ÓÒÌ·ÏË ÂÈÌ‹Î˘ÓÛË ÙÔ˘ QT***. OÈ Û˘ÁÁÚ·Ê›˜ (ı¤ÏÔÓÙ·˜ ÚÔÊ·ÓÒ˜ Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË Ì¤ıÔ‰fi ÙÔ˘˜) ÌÂϤÙËÛ·Ó 19 ·È‰È¿ Ì Û. QT Î·È 54 ˆ˜ ÔÌ¿‰· ÂϤÁ¯Ô˘. ∏ ÎÏ›ÛË Ô˘ ÌÂÙÚ‹ıËΠ·fi ÙÔ˘Ï¿¯ÈÛÙÔÓ 4 ÂÈÏÂÁ̤ӷ ‰Â‰Ô̤ӷ ÛËÌ›· ÚÈÓ Î·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ‹Ù·Ó Û‡ÌʈÓË Ì ÙËÓ ÎÏ›ÛË Ô˘ ÌÂÙÚ‹ıËΠ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰Ô̤ӈÓ. ∂›Û˘, Ë Û¯¤ÛË ÌÂٷ͇ ÎÏ›Û˘ Î·È ÙÈÌ‹˜ QTc** ÛÙËÓ ÂÏ¿¯ÈÛÙË Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· ‹Ù·Ó Ôχ ıÂÙÈ΋. ™˘ÌÂÚ·›ÓÂÙ·È, ÂÔ̤ӈ˜, fiÙÈ Â›Ó·È ‰˘Ó·Ùfi ·ÓÙ› Ó· ˘ÔÏÔÁ›˙ÂÙ·È Ë ÈÔ ¿Óˆ Û¯¤ÛË ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰Ô̤ӈÓ, Ó· ˘ÔÏÔÁ›˙ÂÙ·È Ì ٷ ‰Â‰Ô̤ӷ ·fi 4 ÌfiÓÔ ÂÈÏÂÁ̤ӷ ÛË-
Ì›· Î·È fiÙÈ ÌÔÚԇ̠ӷ ·ÓÙÈηٷÛÙ‹ÛÔ˘Ì ÙÔÓ ˘ÔÏÔÁÈÛÌfi ·˘Ù‹˜ Ù˘ ‰È·ÊÔÚ¿˜ (ÎÏ›Û˘) ·Â˘ı›·˜ Ì ÙËÓ ÙÈÌ‹ QTc ÛÙËÓ ÂÏ¿¯ÈÛÙË Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ Ù˘ ÎÂÊ·Ï‹˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Èı·ÓfiÙËÙ· ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ QT ηٿ ÙËÓ ÎÔχ̂ËÛË ÌÔÚ› Ó· ÂϤÁ¯ÂÙ·È Ì ÙË ‰ÔÎÈÌ·Û›· ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÎÂÊ·ÏÈÔ‡ Î·È Ó· ˘ÔÏÔÁ›˙ÂÙ·È ·Â˘ı›·˜ ÙÔ QTc. *¢ÔÎÈÌ·Û›· ·Ó¿ÏÔÁË Ì ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ηٿ‰˘Û˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi Ù˘ ·ÁÔ·ÛÙ˘ **QTc=QT/√RR ***Yoshinaga M, Kamimura J, Fukushige T, Kusubae R, Shimago A, Nishi J et al. Face immersion in cold water induces prolongation of the QT interval and T-wave changes in children with nonfamilial long QT syndrome. Am J Cardiol 1999;83:1494-1497
1 Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al A simple method for evaluating abnormal lengthening of the QT interval during the face immersion test Pediatr Cardiol 2002;23:122-126
µ·ÚÏ¿Ì˘ °.™. ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ∞.¶.£.
173
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·174
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2002;65:174-181
ORIGINAL ARTICLE
™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙÔ˘ ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÓÂÔÁÓÒÓ µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, ∂. ¢È·Ì·ÓÙ‹, ¡. ¡ÈÎÔÏ·˝‰Ë˜, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜
Comparison of high-frequency oscillatory ventilation with conventional mechanical ventilation in the treatment of respiratory distress syndrome in preterm infants V. Drossou - Agakidou, K. Sarafidis, P. Karagianni, E. Diamanti, N. Nikolaidis, G. Kremenopoulos
¶ÂÚ›ÏË„Ë: O ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ (High Frequency Oscillatory Ventilation, HFOV) ÂÊ·ÚÌfi˙ÂÙ·È Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (™∞¢), ·ÏÏ¿ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·ÎfiÌË ·Ó Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ·fi ÙÔ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi (™∞) Î·È ·Ó ÌÂÈÒÓÂÈ ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ HFOV Î·È ÙÔ˘ ™∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ Î·È ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘. ¶ÚfiˆÚ· ÓÂÔÁÓ¿ (µ° <1250 g) Ì ™∞¢ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Ù˘¯·›· Û ‰‡Ô ÔÌ¿‰Â˜, ÙËÓ ÔÌ¿‰· ™∞, ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ™∞, Î·È ÙËÓ ÔÌ¿‰· HFOV/™∞, ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ™∞¢ Î·È ·ÎÔÏÔ‡ıËÛ ™∞ ηٿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi. ∆· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ™∞ (n=20) ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌ· Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ HFOV/™∞ (n=10) ˆ˜ ÚÔ˜ Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÙÔ˘˜ ÂÚÈÁÂÓÓËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÙË ‚·Ú‡ÙËÙ· ™∞¢. ∫·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË, ÔÈ ‰˘Ô ÔÌ¿‰Â˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙËÓ Î˘„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ (AaDO2) Î·È ÙÔ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ (¢O) ÙȘ ÚÒÙ˜ 48 ÒÚ˜ ıÂڷ›·˜ ηıÒ˜ Î·È ÛÙË Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∂›Û˘, ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ IIIÔ˘ Î·È IVÔ˘ ‚·ıÌÔ‡, ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ ÚÔˆÚfiÙËÙ·˜ (∞Ù¶) ≥3+, ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘, ÙËÓ ÂÈ‚›ˆÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜. øÛÙfiÛÔ, Ô ™∞ ·¤Ù˘¯Â Û 7/20 ÓÂÔÁÓ¿. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ À∞ Ì ٷϷÓÙÒÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ
Abstract: High-frequency oscillatory ventilation (HFOV) is used for the treatment of respiratory distress syndrome (RDS) in preterm neonates. It has not been clarified yet whether HFOV is more effective than conventional mechanical ventilation (CMV) in improving oxygenation and ventilation and decreasing the incidence of complications of RDS. The aim of this study was to compare the effect of HFOV and CMV on oxygenation and ventilation of very low birth weight neonates with RDS, and on the incidence of its complications. Premature neonates (BW <1250 g) were randomly divided into two groups, the CMV group treated with CMV, and the HFOV/CMV group treated with HFOV during the acute stage of RDS followed by CMV during weaning. It was found that the CMV group (n=20) was comparable to the HFOV/CMV group (n=10) with regard to demographic characteristics, perinatal factors and severity of RDS. On follow up, the two groups did not differ significantly regarding the arterial-alveolar oxygen difference, the oxygenation index in the first 48 hours of treatment and the duration of mechanical ventilation. The incidence of complications (air leak syndromes, intra-periventricular hemorrhage of grade III-IV, chronic lung disease and retinopathy of prematurity of at least 3+ degree), as well as the survival and duration of hospitalization did not differ significantly between the two groups. However, CMV failed in 7/20 neonates. We conclude that the use of HFOV, as initial treatment of RDS in very premature neonates, is effective in improving oxygenation and ventilation. The rate of successful treatment of RDS is higher with the use of HFOV, although it
¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. πÔÎÚ¿ÙÂÈÔ °¶¡ £ÂÛÛ·ÏÔӛ΢
Department of Neonatology, Aristotelion University of Thessaloniki, “Ippokration” General Hospital, Thessaloniki
174
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·175
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
Paediatriki 2002;65:174-181
Ô͢ÁfiÓˆÛË Î·È ÙÔÓ ·ÂÚÈÛÌfi ÙˆÓ Ó¢ÌfiÓˆÓ. OÈ Èı·ÓfiÙËÙ˜ ÂÈÙ˘¯Ô‡˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ™∞¢ Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ Ì ÙÔÓ À∞, ·Ó Î·È ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ˘ÂÚÔ¯‹ ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞.
has not been found to have a significant advantage regarding the effectiveness and the incidence of complications as compared to CMV.
§¤ÍÂȘ ÎÏÂȉȿ: ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜, Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜, Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ÚfiˆÚ· ÓÂÔÁÓ¿.
Key words: high-frequency oscillatory ventilation, conventional mechanical ventilation, respiratory distress syndrome, premature neonates.
™˘ÓÙÔÌÔÁڷʛ˜
Ê·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ À∞ (6). øÛÙfiÛÔ, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó ‹Ù·Ó ÈÔ ÂÏȉÔÊfiÚ·, ηıÒ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ À∞ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ™∞¢ Î·È ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ö¡, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (7-10). ∆· ‰È·ÊÔÚÂÙÈο ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· ·Ô‰fiıËÎ·Ó ÛÙË ‰È·ÊÔÚÂÙÈ΋ ÛÙÚ·ÙËÁÈ΋ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ À∞. ¶ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË Î·Ù·Ï‹ÁÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ·fi ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ˘¿Ú¯Ô˘Ó ‰ÂÓ ‰È¢ÎÚÈÓ›˙ÂÙ·È ·Ó Ô À∞ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ·fi ÙÔ ™∞ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ Î·È ·Ó ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ¿ÌÂÛˆÓ ‹ Ì·ÎÚÔÚfiıÂÛÌˆÓ ÂÈÏÔÎÒÓ (11). ™ÙËÓ ∂ÏÏ¿‰·, ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ À∞ ˘¿Ú¯ÂÈ Û ÂÏ¿¯ÈÛÙ· ÓÂÔÁÓÈο ÙÌ‹Ì·Ù· ηÈ, Û˘ÓÂÒ˜, Ë ÂÌÂÈÚ›· ‰ÂÓ Â›Ó·È ÌÂÁ¿ÏË. ™ÙÔ ÙÌ‹Ì· Ì·˜ ·ÔÊ·Û›ÛÙËÎÂ Ë ÌÂϤÙË ·˘Ù‹ ÌÂÙ¿ ·fi ÙËÓ ·fiÎÙËÛË 5ÂÙÔ‡˜ ÂÌÂÈÚ›·˜ ·fi ÙË ¯Ú‹ÛË ÙÔ˘, ΢ڛˆ˜ ˆ˜ ıÂڷ›·˜ ‰È¿ÛˆÛ˘. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË ‰‡Ô ÙÚfiˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÙÔ˘ À∞ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ ™∞, ˆ˜ ÚÔ˜ ÙËÓ Ô͢ÁfiÓˆÛË Î·È ·ÂÚÈÛÌfi ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ™∞¢ Î·È ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ.
∞Ù¶ ¢O ¢P FiO2 AaDO2 PaO2 ™∞ ™∞¢ À∞ HFOV ö¡
∞ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· ÚÔˆÚfiÙËÙ·˜ ¢Â›ÎÙ˘ Ô͢ÁfiÓˆÛ˘ ∂‡ÚÔ˜ Ù·Ï¿ÓÙˆÛ˘ ∫Ï¿ÛÌ· ÂÈÛÓÂfiÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ ∫˘„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ ªÂÚÈ΋ ›ÂÛË Ô͢ÁfiÓÔ˘ ÛÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· ™˘Ì‚·ÙÈÎfi˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ™‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ ÃÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜
∂ÈÛ·ÁˆÁ‹ OÈ ÛËÌ·ÓÙÈÎfiٷ٘ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ ÚÔÒÚˆÓ, Î·È È‰È·›ÙÂÚ· Ë ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ù¯ÓÈ΋˜ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ™∞, Û˘Ó¤‚·Ï·Ó ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ™ÙËÓ ÚÔÛ¿ıÂÈ· ÂÚ·ÈÙ¤Úˆ Ì›ˆÛ˘ ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, fiˆ˜ Â›Ó·È Ù· Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· Î·È Ë Ã¶¡, ·Ó·˙ËÙ‹ıËÎ·Ó ÂÓ·ÏÏ·ÎÙÈÎÔ› ÙÚfiÔÈ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ì ÛÙfi¯Ô ÙË Ì›ˆÛË ÙÔ˘ ‚·ÚÔ(ÔÁÎÔ)ÙÚ·‡Ì·ÙÔ˜. ŒÓ·˜ Ù¤ÙÔÈÔ˜ ÙÚfiÔ˜ Â›Ó·È Î·È Ô À∞ Ô˘ ıˆÚÂ›Ù·È ÏÈÁfiÙÂÚÔ “ÙÚ·˘Ì·ÙÈÎfi˜”, ηıÒ˜ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È ÔÈ Î˘ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ¤ÎÙ˘Í˘ ÙˆÓ Î˘„ÂÏ›‰ˆÓ (1). À¿Ú¯Ô˘Ó 3 ›‰Ë À∞: Ô À∞ Ì ٷϷÓÙÒÛÂȘ (high frequency oscillatory ventilation, HFOV), Ô À∞ Ì ·ÂÚÈÒıËÛË (high frequency jet ventilation) Î·È Ô À∞ Ì ‰È·ÎÔ‹ ÚÔ‹˜ (high frequency flow interrupter) (2). ∞Ú¯Èο, ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô À∞ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ Î·È ÙÔ˘ ·ÂÚÈÛÌÔ‡ ÓÂÔÁÓÒÓ Ì ™∞¢, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ·¤Ù˘¯Â Ô ™∞, ¯ˆÚ›˜ Ó· ÚÔηÏ› ‚·ÚfiÙÚ·˘Ì· (3-5). ™ÙËÓ ÚÒÙË, fï˜, ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠÌÂÁ·Ï‡ÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ À∞ Û ÓÂÔÁÓ¿ Ì ™∞¢ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, ÂÓÒ ˘‹Ú¯·Ó ÂӉ›ÍÂȘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂ-
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó ÚÔÁÚ·ÌÌ·ÙÈṲ̂ӷ ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÛÔ‚·Úfi ™∞¢ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ Û ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜ (π·ÓÔ˘¿ÚÈÔ˜-¢ÂΤ̂ÚÈÔ˜ 2000), Ù· ÔÔ›· ¯ÚÂÈ¿ÛÙËÎ·Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÔ‚·Ú‹˜ ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ∫ÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ ÛÙË ÌÂϤÙË ‹Ù·Ó Ù· ÂÍ‹˜: ·) ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ≤1250 g Î·È ‰È¿ÚÎÂÈ· ·ËÛ˘ 26-32 ‚‰ÔÌ¿‰Â˜, ‚) ·ÚÔ˘Û›· ™∞¢ ≥2Ô˘ ‚·ıÌÔ‡ ·ÎÙÈÓÔÏÔÁÈο Î·È Á) ·Ó¿ÁÎË ÂÊ·ÚÌÔÁ‹˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ̤۷ ÛÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ ·fi ÙË Á¤ÓÓËÛË. ∞fi ÙË ÌÂϤÙË ·ÔÎÏ›ÛÙËÎ·Ó ÓÂÔÁÓ¿ Ì Ì›˙ÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· IVÔ˘ ‚·ıÌÔ‡ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÓÂÔÁÓ¿ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË. ∆· ÓÂÔÁÓ¿ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Ù˘¯·›·, Û‡Ìʈӷ Ì ÙË
175
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·176
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
ÛÂÈÚ¿ ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÙÌ‹Ì·, Û ‰‡Ô ÔÌ¿‰Â˜, ÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ Î·È ÙËÓ ÔÌ¿‰· ÙÔ˘ HFOV/™∞. ∏ ηٷÓÔÌ‹ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ¤ÁÈÓ Ì ·Ó·ÏÔÁ›· 2:1 ÁÈ· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜. ™ÙËÓ ÔÌ¿‰· ™∞ ÂÊ·ÚÌfiÛÙËΠÂÏÂÁ¯fiÌÂÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ·Ó·Ó¢ÛÙ‹Ú· ›ÂÛ˘ (SLE 2000). OÈ ·Ú¯ÈΤ˜ Ú˘ıÌ›ÛÂȘ ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ‹Ù·Ó: ·) ̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (PIP) 18-25 cm H2O, ‚) ¯ÚfiÓÔ˜ ÂÈÛÓÔ‹˜ (π∆) 0,36-0,40 sec, Á) ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË (PEEP) 4-5 cm H2O Î·È ‰) Û˘¯ÓfiÙËÙ· ·Ó·ÓÔÒÓ 60/min. ™ÙËÓ ÔÌ¿‰· HFOV/™∞ ÂÊ·ÚÌfiÛÙËΠHFOV Ì ·Ó·Ó¢ÛÙ‹Ú· Sensormedics 3100A, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ™∞, Ô ÔÔ›Ô˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ ˙ˆ‹˜, ‰ËÏ·‰‹ ηٿ ÙË Ê¿ÛË ÛÙ·ıÂÚÔÔ›ËÛ˘ ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV, ηıÒ˜ Î·È Î·Ù¿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·fi ÙÔÓ HFOV. ∫·Ù¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù·ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ (12-15). ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ ·Ú¯ÈΤ˜ Ú˘ıÌ›ÛÂȘ ÛÙÔÓ HFOV ‹Ù·Ó: ·) ·Ú¯È΋ ̤ÛË ›ÂÛË ·ÂÚÔÊfiÚˆÓ (Paw) ηٿ 2-4 cm H2O ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ™∞, ‚) ‡ÚÔ˜ Ù·Ï¿ÓÙˆÛ˘ (¢P) ÙfiÛÔ, ÒÛÙ ӷ ÚÔηÏÔ‡ÓÙ·È ÔÚ·Ù¤˜ ‰ÔÓ‹ÛÂȘ ÙÔ˘ ıÒڷη, Á) FiO2 ›‰ÈÔ Ì ·˘Ùfi Ô˘ ··ÈÙÔ‡ÓÙ·Ó ÛÙÔ ™∞ ηٿ ÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ Ù˘ ÛÙ·ıÂÚÔÔ›ËÛ˘, ‰) Û˘¯ÓfiÙËÙ· Ù·Ï¿ÓÙˆÛ˘ (Frequency) 10 Hz Î·È Â) I:∂ ratio=1:2. OÈ ·Ú¿ÌÂÙÚÔÈ ·˘Ù¤˜ ÙÚÔÔÔÈÔ‡ÓÙ·Ó ·Ó¿ÏÔÁ· Ì ٷ ·¤ÚÈ· ·›Ì·ÙÔ˜ Î·È ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∏ ¤ÎÙ˘ÍË ÙÔ˘ ıÒڷη ıˆÚÔ‡ÓÙ·Ó ÈηÓÔÔÈËÙÈ΋ fiÙ·Ó ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÙÔ ‰ÂÍÈfi ‰È¿ÊÚ·ÁÌ· ‚ÚÈÛÎfiÙ·Ó ÛÙÔ ‡„Ô˜ Ù˘ 8˘-9˘ ÏÂ˘Ú¿˜ ηٿ Ì‹ÎÔ˜ Ù˘ ÌÂÛÔÎÏÂȉÈ΋˜ ÁÚ·ÌÌ‹˜. ∏ ·Ó¿Ù˘ÍË ·Ó·Ó¢ÛÙÈ΋˜ ·ÏοψÛ˘ ·ÓÙÈÌÂÙˆÈ˙fiÙ·Ó Ì Ì›ˆÛË Ù˘ ¢ƒ. ∆· ÎÚÈÙ‹ÚÈ· ·ÔÁ·Ï·ÎÙÈÛÌÔ‡ ·fi ÙÔÓ HFOV Î·È ÌÂÙ·ÊÔÚ¿˜ Û ™∞ ‹Ù·Ó Paw <8 cm H2O Î·È FiO2 <0,3. ∫ÚÈÙ‹ÚÈÔ ·ÔÙ˘¯›·˜ ÙÔ˘ ™∞ ‹Ù·Ó Ë ·‰˘Ó·Ì›· ‰È·Ù‹ÚËÛ˘ PaO2 >50 mmHg Ì PIP >25 cm H2O Î·È FiO2 ≥0,8, ÂÓÒ ÎÚÈÙ‹ÚÈÔ ·ÔÙ˘¯›·˜ ÙÔ˘ HFOV ‹Ù·Ó Ë ·‰˘Ó·Ì›· ‰È·Ù‹ÚËÛ˘ PaO2 >50 mmHg, ·Ú¿ ÙËÓ ÈηÓÔÔÈËÙÈ΋ ¤ÎÙ˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ÙËÓ ·Ô˘Û›· ˘fiÙ·Û˘. ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‚fiÂÈ·˜ ÚÔ¤Ï¢Û˘ (Survanta® Abbott Laboratories USA, Ross). ∏ ÚÒÙË ‰fiÛË ¯ÔÚËÁ‹ıËΠ30-60 min ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÛÙ· ÚfiˆÚ· Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÛÙ· ÌÂÙ·ÊÂÚfiÌÂÓ· ·fi ¿ÏϘ ÎÏÈÓÈΤ˜ Î·È ÓÔÛÔÎÔÌ›·. ∏ ¯ÔÚ‹ÁËÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Ì¤¯ÚÈ 3 ÊÔÚ¤˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· Î·È ÙȘ ·Ó¿ÁΘ Û Ô͢ÁfiÓÔ. ∫·Ù·ÁÚ¿ÊËÎ·Ó Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÂÔÁÓÒÓ (‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ‰È¿ÚÎÂÈ· ·ËÛ˘ Î·È Ê‡ÏÔ), Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ, Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi 24 ÒÚ˜, Ë ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÔÈ ÂÈÏÔΤ˜ (Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· IIIÔ˘ - IVÔ˘ ‚·ıÌÔ‡), Ë Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ô͢ÁfiÓÔ˘, Ë ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È Ë ÂÈ‚›ˆÛË. ∏ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· ÂÎÙÈÌ‹ıËΠ̠‚¿ÛË ÙȘ
176
Paediatriki 2002;65:174-181
ÌÂÙ·‚ÔϤ˜ Ù˘ ̤Û˘ ›ÂÛ˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, Ù˘ ΢„ÂÏȉԷÚÙËÚȷ΋˜ ‰È·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘ [AaDO2= (716xFiO2)(PaCO2/0,8)-PaO2] Î·È ÙÔ˘ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ [¢O= (MAPÃFiO2)/PaO2] ÛÙȘ 2 ÒÚ˜ (Î·È ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·Ó Ì ™∞) Î·È Î·ÙfiÈÓ ÛÙȘ 6, 24 Î·È 48 ÒÚ˜ ˙ˆ‹˜. ∆· ÓÂÔÁÓ¿ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó ÁÈ· ÂÌÊ¿ÓÈÛË Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, ö¡ Î·È ∞Ù¶. °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Á›ÓÔÓÙ·Ó ‰È·‰Ô¯Èο ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ÂÁÎÂÊ¿ÏÔ˘ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙËÓ 3Ë Î·È 10Ë Ë̤ڷ ÓÔÛËÏ›·˜. OÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ÁÈÓfiÙ·Ó ÙËÓ 32Ë-34Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë Î·È Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Î¿ı 2-4 ‚‰ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ٷ Â˘Ú‹Ì·Ù·. ø˜ ö¡ ÔÚ›ÛÙËÎÂ Ë ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ·fi ÙË Û‡ÏÏË„Ë. ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ̤Û˜ ÙÈ̤˜ Î·È ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ. °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· t ÙÔ˘ student (unpaired student’s t-test), ÂÓÒ ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÔÛÔÛÙÈ·›ˆÓ ·Ó·ÏÔÁÈÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ·ÎÚÈ‚‹˜ ‰ÔÎÈÌ·Û›· ÙÔ˘ Fischer (Fischer’s exact test).
∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó 30 ÓÂÔÁÓ¿, 20 ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ Î·È 10 ÛÙËÓ ÔÌ¿‰· HFOV/™∞. OÈ ‰‡Ô ÔÌ¿‰Â˜ ÓÂÔÁÓÒÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘, ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ÙËÓ ·Ó·ÏÔÁ›· ·ÁÔÚÈÒÓ / ÎÔÚÈÙÛÈÒÓ, ÙÔÓ ÙÚfiÔ ÙÔÎÂÙÔ‡ Î·È ÙÔ Apgar score ÛÙÔ 1Ô Î·È 5Ô min (¶›Ó·Î·˜ 1). ∂›Û˘, ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó Û˘ÁÎÚ›ÛÈ̘ ˆ˜ ÚÔ˜ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ™∞¢ Î·È ÙÔ˘˜ ÚÔÁÂÓÓËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ¿ ÙÔ˘, fiˆ˜ Â›Ó·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÁÈ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 24 ÒÚ˜ Î·È Ë ÚÔÁÂÓÓËÙÈ΋ Ï‹„Ë ÛÙÂÚÔÂȉÒÓ (¶›Ó·Î·˜ 1). ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Î·È Ô Ì¤ÛÔ˜ ·ÚÈıÌfi˜ ‰fiÛÂˆÓ ·Ó¿ ÓÂÔÁÓfi ‹Ù·Ó ·ÚfiÌÔÈÔ˜ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 2). ∫·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË, Ë Ì¤ÛË ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· HFOV/™∞ ÛÙȘ 2, 6, 24 Î·È 48 ÒÚ˜ ˙ˆ‹˜, ·’ fiÙÈ ÛÙËÓ ÔÌ¿‰· ™∞, ÏfiÁˆ ÙÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÌÂϤÙ˘, ‰ËÏ·‰‹ Ù˘ Ù·ÎÙÈ΋˜ ÙÔ˘ “ηχÙÂÚÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ” (∂ÈÎfiÓ· 1). ¢ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ AaDO2 Î·È ÙÔ ¢O ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÛÙ· ·ÓÙ›ÛÙÔȯ· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (∂ÈÎfiÓ· 2). ∆· ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ·Ú¤ÌÂÈÓ·Ó ÛÙÔÓ À∞ ÁÈ· 3,65±2,45 Ë̤Ú˜. OÈ ‰‡Ô ÔÌ¿‰Â˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ÌfiÓÔ ™∞ ‹ HFOV+™∞). ™Â ¤ÓÙ ÓÂÔÁÓ¿ ·fi οı ÔÌ¿‰· ÂÊ·ÚÌfiÛÙËΠÚÈÓÈÎfi CPAP ÌÂÙ¿ ÙËÓ ·ÔۈϋӈÛË. ∂›Û˘, ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·177
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
Paediatriki 2002;65:174-181
¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ
µ° (g) (x ± SD) ¢∫ (‚‰.) (x ± SD) ™∞¢ 2Ô˘/ ™∞¢ 3Ô˘-4Ô˘ ‚·ıÌÔ‡ (n) KoÏÈÎfis ÙÔÎÂÙfi˜/ηÈÛ·ÚÈ΋ ÙÔÌ‹ (n) ∞ÁfiÚÈ·/ÎÔÚ›ÙÛÈ· (n) ƒ∂À >24 ÒÚ˜ (n) ™ÙÂÚÔÂȉ‹ ÚÔÁÂÓÓËÙÈο (n) APGAR score: 1Ô min (x ± SD) 5Ô ÏÂÙfi (x± SD)
™∞ (n=20)
HFOV/™∞ (n=10)
P
996 ± 196 27,5 ± 1,8 7/13 10/10 12/8 5 13 4,0 ± 1,8 7,2 ± 1
1019 ± 244 27,2 ± 1,1 4/6 7/3 3/7 3 7 3,3 ± 2,7 6,1 ± 2,5
0,78 0,69 1 0,44 0,24 1 1 0,41 0,15
ƒ∂À: Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ
¶›Ó·Î·˜ 2. ¢È¿ÚÎÂÈ· Î·È ¿ÌÂÛ˜ ÂÈÏÔΤ˜ ÙˆÓ ‰‡Ô Ù‡ˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ OÌ¿‰· ™∞ (n=20) ¢È¿ÚÎÂÈ· HFOV (ËÌ., x ± SD) ™˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· Û ª∞ (ËÌ., x ± SD) 17,9 ± 11 ∞ÔÙ˘¯›· ª∞ (n) 7* ∂¶ (‰fiÛÂȘ/ÓÂÔÁÓfi, x ± SD) 2,2 ± 0,8 ™‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú·: ¶Ó¢ÌÔıÒڷη˜ (n) 5 ∂ӉȿÌÂÛÔ Ó¢ÌÔÓÈÎfi ÂÌʇÛËÌ· (n) 1 ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ‚·ıÌÔ‡ IIπ-IV (n) 5
OÌ¿‰· HFOV/™∞ (n=10)
P
3,65 ± 2,45 17 ± 12,4 2,4 ± 1,3 1 3 3
0,87 0,06 0,19 0,63 0,09 1
HFOV: ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ ™∞: Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜ ª∞: Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ∂¶: ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ * ™Ù· 7 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ·¤Ù˘¯Â Ô Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜, ÂÊ·ÚÌfiÛÙËΠHFOV ˆ˜ ıÂڷ›· ‰È¿ÛˆÛ˘
ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· Ó¢ÌÔıÒڷη, ÂӉȿÌÂÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÂÌÊ˘Û‹Ì·ÙÔ˜ Î·È ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ πIπÔ˘ Î·È IVÔ˘ ‚·ıÌÔ‡ (¶›Ó·Î·˜ 2). ™ÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ ¤˙ËÛ·Ó 12/20 (65%) Î·È ÛÙËÓ ÔÌ¿‰· ÙÔ˘ HFOV 7/10 (70%) ÓÂÔÁÓ¿, ¯ˆÚ›˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (¶›Ó·Î·˜ 3). øÛÙfiÛÔ, Û 7 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ÙÔ˘ ™∞ ·¤Ù˘¯Â Ô ™∞ Î·È ¯ÚÂÈ¿ÛÙËΠӷ ÂÊ·ÚÌÔÛÙ› HFOV ˆ˜ ıÂڷ›· ‰È¿ÛˆÛ˘. ∆· 7 ·˘Ù¿ ÓÂÔÁÓ¿ ¤˙ËÛ·Ó. ∏ Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Ô˘ ¤˙ËÛ·Ó ‰ÂÓ ¤‰ÂÈÍ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙȘ ·Ó¿ÁΘ Û O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ·fi ÙË Û‡ÏÏË„Ë, ÛÙË Û˘¯ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ∞Ù¶ Î·È ÛÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (¶›Ó·Î·˜ 3). ™˘˙‹ÙËÛË ¶·Ú¿ ÙËÓ 20ÂÙ‹ ¤Ú¢ӷ, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ‰È¢ÎÚÈÓÈÛÙ› ·Ó Ô À∞ ˘ÂÚ¤¯ÂÈ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞ Ì ıÂÙÈΤ˜ ȤÛÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢, ηıÒ˜ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ì HFOV Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. OÈ ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ ¤¯Ô˘Ó ·Ô‰Ôı› ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ Ù·ÎÙÈΤ˜ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ À∞. ™ÙË ÌÂϤÙË Ì·˜ ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù·-
ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ, ηٿ ÙËÓ ÔÔ›· ÂȉÈÒÎÂÙ·È Ô Î·Ï‡ÙÂÚÔ˜ fiÁÎÔ˜ Ó¢ÌfiÓˆÓ (optimal lung volume), Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤Û˘ ›ÂÛ˘ ·ÂÚÔÊfiÚˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ ·fi ·˘Ù‹ ÛÙÔ ™∞ (12-14). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë Ì¤ÛË ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ HFOV ‰È·ÙËÚ‹ıËΠÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ·’ fiÙÈ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ™∞, Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ ÙÔ˘ ™∞¢. ªÂ ÙËÓ Ù·ÎÙÈ΋ ·˘Ù‹ ‚ÂÏÙÈÒÓÂÙ·È Ë Ô͢ÁfiÓˆÛË, ηıÒ˜ ‰È·ÓÔ›ÁÔÓÙ·È ÔÈ ·ÛÙ·ı›˜ ·ÙÂÏÂÎÙ·ÛÈΤ˜ ΢„ÂÏ›‰Â˜ Î·È ·˘Í¿ÓÂÈ Ë ÏÂÈÙÔ˘ÚÁÈ΋ ˘ÔÏÂÈfiÌÂÓË ¯ˆÚËÙÈÎfiÙËÙ· ÙˆÓ Ó¢ÌfiÓˆÓ (16). ∂ÈÚfiÛıÂÙ·, Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ηχÙÂÚÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ HFOV ‰Ú· ÚÔÏËÙÈο ÛÙËÓ ÚfiÎÏËÛË Ó¢ÌÔÓÈ΋˜ ‚Ï¿‚˘, ÛÙËÓ ÔÔ›· Û˘Ì‚¿ÏÏÔ˘Ó ÔÈ ÌÂÁ¿Ï˜ ΢ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ›ÂÛ˘ Î·È ÙÔ˘ fiÁÎÔ˘ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (17). O ·Ú¯ÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó Ó· ÂÎÙÈÌËı› ·Ó Ô HFOV ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ Ì ™∞¢ Ù·¯‡ÙÂÚ· ·fi ÙÔ ™∞. ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô HFOV ‰ÂÓ ˘ÂÚÙÂÚ› Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, ηıÒ˜ ‰ÂÓ ‰È·ÈÛÙÒÛ·Ì ٷ¯‡ÙÂÚË ‚ÂÏÙ›ˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ HFOV, fiˆ˜ ·˘Ù‹ ηٷÁÚ¿ÊËΠÛÙȘ
177
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·178
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
HFOV ™∞
20 *
*
15
Mean PAW
Paediatriki 2002;65:174-181
* *
10 5
0
2
6
24
48
flÚ˜ ˙ˆ‹˜ ∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ÙÈÌÒÓ (x ± SD) Ù˘ ̤Û˘ ›ÂÛ˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ (mean, PAW) ÛÙȘ ÔÌ¿‰Â˜ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (™∞) Î·È ÙÔ˘ ˘„›Û˘¯ÓÔ˘/Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (HFOV), *P<0,05.
ÌÂÙ·‚ÔϤ˜ Ù˘ AaDO2 Î·È ÙÔ˘ ¢O ÛÙȘ ÚÒÙ˜ 48 ÒÚ˜ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘. ¶·ÚfiÌÔÈ· ‹Ù·Ó Ù· Â˘Ú‹Ì·Ù· ¿ÏÏˆÓ Û˘ÁÁڷʤˆÓ, ÔÈ ÔÔ›ÔÈ ÂÊ·ÚÌfi˙ÔÓÙ·˜ ·ÚfiÌÔÈ· ÛÙÚ·ÙËÁÈ΋ À∞ ‰ÂÓ ‰È·›ÛÙˆÛ·Ó ‰È·ÊÔÚ¿ ÛÙËÓ Ô͢ÁfiÓˆÛË ÓÂÔÁÓÒÓ Ì ™∞¢ ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠHFOV, Û˘ÁÎÚÈÙÈο Ì ÂΛӷ ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠ™∞ (9,18,19). ∞ÓÙ›ıÂÙ·, Û ¿ÏϘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ÓÂÔÁÓ¿ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì HFOV ›¯·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË AaDO2 ÙȘ ÚÒÙ˜ 12 ÒÚ˜ ÙÔ˘ ª∞ Î·È ¯ÚÂÈ¿ÛÙËÎ·Ó ÏÈÁfiÙÂÚ˜ ‰fiÛÂȘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (10,20,21). ∆Ô ÙÂÏÂ˘Ù·›Ô ‡ÚËÌ·, ·Ó Î·È ‰ÂÓ ÂȂ‚·ÈÒıËΠÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, ·Ô‰›‰ÂÙ·È ÛÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ·Ó¿Ù˘Í˘ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È Ù˘ ÂÍfi‰Ô˘ ÚˆÙÂ˚ÓÒÓ ÛÙȘ ΢„ÂÏ›‰Â˜ ηÈ, ÙÂÏÈο, ÛÙËÓ ·Ú¿Ù·ÛË Ù˘ ‰Ú¿Û˘ ÙÔ˘ Â͈ÁÂÓÔ‡˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (22,23). ¢Â‡ÙÂÚÔ˜ ÛÙfi¯Ô˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ ›‰Ú·Û˘ ÙÔ˘ HFOV ÛÙȘ ¿ÌÂÛ˜ Î·È ·ÒÙÂÚ˜ ÂÈÏÔΤ˜, ηıÒ˜ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ™∞¢. ∞fi ÙȘ ¿ÌÂÛ˜ ÂÈÏÔΤ˜, ÌÂÏÂÙ‹ıËÎÂ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú· Î·È ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜. OÈ ÌÂÁ·Ï‡ÙÂÚ˜ ̤Û˜ ȤÛÂȘ ·ÂÚÔÊfiÚˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔ HFOV Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, οÓÔ˘Ó Èı·Ó‹ ÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·. øÛÙfiÛÔ, ·fi ÙË ÌÂϤÙË Ì·˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·‡ÍËÛË ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú· Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘. Ÿˆ˜ ÂȂ‚·ÈÒÓÔ˘Ó Î·È ¿ÏϘ ÌÂϤÙ˜, Ì ÙÔ HFOV, fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛˆÛÙ¿, ‰ÂÓ ·˘Í¿ÓÂÙ·È (8,10,18-20), ‹ Î·È ÂÏ·ÙÙÒÓÂÙ·È, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·. ∞˘Ùfi ·Ô‰›‰ÂÙ·È
178
ÛÙÔ ÌÈÎÚfiÙÂÚÔ ‡„Ô˜ Î·È ‰È·Î˘Ì¿ÓÛÂȘ (swings) Ù˘ ›ÂÛ˘ Ô˘ ·ÛÎÂ›Ù·È Ì ÙÔÓ À∞ ÛÙÔ Â›Â‰Ô ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ·Ú¿ ÙË ÌÂÁ·Ï‡ÙÂÚË Ì¤ÛË ›ÂÛË Ô˘ ÌÂÙÚ¿Ù·È ÛÙÔ Î‡Îψ̷ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· (24). ∆Ô ÂӉȷʤÚÔÓ fï˜ ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÂÈÎÂÓÙÚÒÓÂÙ·È ÂÍ›ÛÔ˘ ÛÙË Û¯¤ÛË ÙÔ˘ HFOV Ì ÙËÓ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë. OÈ Û˘ÁÁÚ·Ê›˜ Ù˘ HiFi ÌÂϤÙ˘ (6) ‚Ú‹Î·Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘, Ô˘ ÙËÓ ·¤‰ˆÛ·Ó ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ Û˘Ó¯ԇ˜ ›ÂÛ˘ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜ ÂÏ·ÙÙÒÓÂÈ ÙË ÊÏ‚È΋ ·ӷÊÔÚ¿ Î·È ÚÔηÏ› ÊÏ‚È΋ Û˘ÌÊfiÚËÛË ÂÓ‰ÔÎÚ·Óȷο (6). ™ÙË ÌÂϤÙË Ì·˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜, fiˆ˜ ¿ÏψÛÙÂ Î·È Û ¿ÏϘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ì HFOV, ÛÙȘ Ôԛ˜ ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù·ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ (8,10,18-20). ∞Ó Î·È ÛÙȘ ÌÂÙ·-·Ó·Ï‡ÛÂȘ Ê·›ÓÂÙ·È fiÙÈ Ô HFOV ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜, ÛËÌÂÈÒÓÂÙ·È ·’ fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ fiÙÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ·˘Ù¿ ÂËÚ¿˙ÔÓÙ·È ¤ÓÙÔÓ· ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ HiFi ÌÂϤÙ˘ (25,26). µ·ÛÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Ó¤ˆÓ ÙÚfiˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÚÔÒÚˆÓ Ì ™∞¢ Â›Ó·È Ë ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ö¡. OÈ ÂÏ›‰Â˜ ÁÈ· ÂÏ¿ÙÙˆÛË Ù˘ ö¡ ‚·Û›ÛÙËÎ·Ó ÛÙËÓ ÂÔ›ıËÛË fiÙÈ Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ‰È·ÊÔÚÂÙÈÎÔ‡ ÙÚfiÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ı· ‹Ù·Ó ‰˘Ó·Ù‹ Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·Ó¿Ù˘Í‹ Ù˘. ™ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ Ô͢ÁfiÓÔ˘, ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ë ·Ó¿Ù˘ÍË ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, ηıÒ˜ Î·È ÔÈ ÌÂÁ¿Ï˜ ΢ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ›ÂÛ˘ Î·È ÙÔ˘ fiÁÎÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ™∞ (27). ªÂ ÙÔ HFOV ÌÔÚ› Ó· ÂÏ·ÙÙˆı› Ô ¯ÚfiÓÔ˜ ¤ÎıÂÛ˘ ÛÙÔ Ô͢ÁfiÓÔ, ηıÒ˜ ‚ÂÏÙÈÒÓÂÙ·È Ù·¯‡ÙÂÚ· Ë Ô͢ÁfiÓˆÛË. ∂ÈϤÔÓ, fiˆ˜ ¤¯ÂÈ ÚÔ·Ó·ÊÂÚı›, ÔÈ È¤ÛÂȘ Ô˘ ·ÛÎÔ‡ÓÙ·È ÛÙÔ Â›Â‰Ô ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ·ÏÏ¿ Î·È ÔÈ ‰È·Î˘Ì¿ÓÛÂȘ (swings) ÙÔ˘˜, Â›Ó·È ÌÈÎÚfiÙÂÚ˜ (24). ∞Ó·ÊÔÚÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ HFOV ÛÙËÓ ·Ó¿Ù˘ÍË ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜, ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ Û ˙Ò· ¤‰ÂÈÍ·Ó fiÙÈ Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÌÂÈÒÓÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË ‰È·ÊfiÚˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜ (28,29). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, fï˜, ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·fi ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Û ÓÂÔÁÓ¿ Ì ™∞¢ (1). ∞fi ÎÏÈÓÈ΋ ¿Ô„Ë, Ù· ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù· Ù˘ HiFi ÌÂϤÙ˘, Ô˘ ‹Ù·Ó Ë ÚÒÙË ÌÂÁ¿ÏË ÌÂϤÙË, ‹Ù·Ó ·ÔÁÔËÙ¢ÙÈο ˆ˜ ÚÔ˜ ÙËÓ Â›‰Ú·Û‹
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·179
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
35
HFOV ™∞
30
¢√
Paediatriki 2002;65:174-181
25
600
20
500
AaDO2
15 10 5 0
HFOV ™∞
700
400 300 200 100
2
6
24
48
0 2
6
24
flÚ˜ ˙ˆ‹˜
flÚ˜ ˙ˆ‹˜
∂ÈÎfiÓ· 2. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ÙÈÌÒÓ (x ± SD) ÙÔ˘ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ (¢O) Î·È Ù˘ ΢„ÂÏȉԷÚÙËÚȷ΋˜ ‰È·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘ (AaDO2) ÛÙȘ ÔÌ¿‰Â˜ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (™∞) Î·È ÙÔ˘ ˘„›Û˘¯ÓÔ˘/Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (HFOV). ¶›Ó·Î·˜ 3. ∂ͤÏÈÍË ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ¤˙ËÛ·Ó
∂È‚›ˆÛË (n,%) ∏̤Ú˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (x ± SD) ÃÔÚ‹ÁËÛË O2 (ËÌ., x ± SD) O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ (n) O2 ÙËÓ 36Ë Â‚‰. ÌÂÙ¿ ÙË Û‡ÏÏË„Ë (n) ∞Ù¶ ≥3+
OÌ¿‰· ™∞
OÌ¿‰· HFOV/™∞
P
12 (65)* 73 ± 21 34,9 ± 19 7 0 3
7 (70) 68,1 ± 19,8 34,3 ± 16 4 1 1
1 0,63 0,94 1 0,33 1
∞Ù¶: ∞ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ * ™˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È 7 ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ˆ˜ ıÂڷ›· ‰È¿ÛˆÛ˘
ÙÔ˘ HFOV ÛÙË Ã¶¡ (6). ™ÙË ÌÂϤÙË ·˘Ù‹, fï˜, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÌÈÎÚ¤˜ ȤÛÂȘ, Ì ÛÎÔfi Ó· ÂÏ·ÙÙˆı› ÙÔ ‚·ÚfiÙÚ·˘Ì· ÙÔ˘ Ó‡ÌÔÓ·, ÂÓÒ ÙËÓ ÂÔ¯‹ ÂΛÓË ‰ÂÓ ‹Ù·Ó ‰È·ı¤ÛÈÌÔ˜ Ô ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÎÏÈÓÈ΋ ¯Ú‹ÛË (6,25). ∞fi ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó, ÛÙȘ Ôԛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘, ÔÚÈṲ̂Ó˜ ¤‰ÂÈÍ·Ó ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ö¡ (4,5,9,10,15), ÂÓÒ Û ¿ÏϘ ‰ÂÓ ÂËÚ¿ÛÙËΠÛËÌ·ÓÙÈο (8,21). øÛÙfiÛÔ, ‰‡Ô ÚfiÛÊ·Ù˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ÙˆÓ ÌÂÏÂÙÒÓ Û‡ÁÎÚÈÛ˘ ÙÔ˘ HFOV Ì ÙÔ ™∞ Û ÓÂÔÁÓ¿ Ì ™∞¢, ‰Â›¯ÓÔ˘Ó Ù¿ÛË ÂÏ¿ÙÙˆÛ˘ Ù˘ ö¡ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô HFOV (11,25). ™ÙË ÌÂϤÙË Ì·˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È ÛÙȘ ·Ó¿ÁΘ Û O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë. ¶ÈÛÙ‡ԢÌ fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂËÚ¿ÛÙËÎ·Ó ‰˘ÛÌÂÓÒ˜ ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙËÓ ÔÌ¿‰· HFOV/™∞ ‰ÂÓ ÂÊ·ÚÌfiÛÙËΠ·ÔÎÏÂÈÛÙÈο HFOV Û fiÏÔ ÙÔ ‰È¿ÛÙËÌ· Ô˘ ¯ÚÂÈ·˙fiÙ·Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ·ÏÏ¿ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Î·È ™∞, ÙfiÛÔ Î·Ù¿ ÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ Ù˘ ÛÙ·ıÂÚÔÔ›ËÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ fiÛÔ Î·È Î·Ù¿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·fi ÙÔÓ HFOV. ÕÏψÛÙÂ, ÌÂϤÙ˜ Û ˙Ò· ¤‰ÂÈÍ·Ó fiÙÈ ·Îfi-
Ì· Î·È ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ¯ÔÚ‹ÁËÛË ıÂÙÈÎÒÓ È¤ÛÂˆÓ Ô‰ËÁ› Û ÂÈıËÏȷ΋ ‚Ï¿‚Ë, ¤ÍÔ‰Ô ÚˆÙÂ˚ÓÒÓ ÛÙȘ ΢„ÂÏ›‰Â˜ Î·È Â˘Ú‹Ì·Ù· ˘·ÏÔÂȉԇ˜ ÌÂÌ‚Ú¿Ó˘ (30). ∂ÈϤÔÓ, ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¿ÌÂÛË ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ HFOV, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ Ì ™∞¢ Î·È Ë ·ÔÎÏÂÈÛÙÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ̤¯ÚÈ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·Â˘ı›·˜ Û CPAP ‹ οÛη Ô͢ÁfiÓÔ˘ (Head box), ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Ã¶¡ (15,16,26). ∆¤ÏÔ˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÛÔ‚·Ú‹˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜, ÙË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È ÙËÓ ÂÈ‚›ˆÛË, fiˆ˜ Î·È Û ¿ÏϘ ÌÂϤÙ˜ (8,10,19,20). ¶Ú¤ÂÈ, fï˜, Ó· ÂÈÛËÌ¿ÓÔ˘Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜ ·¤Ù˘¯Â Û 7 ÓÂÔÁÓ¿, ·ÓÙ›ıÂÙ· Ì ÙÔÓ HFOV Ô˘ ‰ÂÓ ·¤Ù˘¯Â Û ηӤӷ ·fi Ù· ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËÎÂ. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ HFOV ˆ˜ ıÂڷ›·˜ ‰È¿ÛˆÛ˘ ÛÙ· 7 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ·¤Ù˘¯Â Ô ™∞ Èı·ÓÒ˜ ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ (31). ™˘ÌÂÚ·ÛÌ·ÙÈο, ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ Ê·›ÓÂÙ·È fiÙÈ Ë ÚÒÈÌË ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÛÙ· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ‚ÂÏÙÈÒÓÂÈ ÙËÓ
179
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·180
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
Ô͢ÁfiÓˆÛË Î·È ÙÔÓ ·ÂÚÈÛÌfi ÙˆÓ Ó¢ÌfiÓˆÓ ¯ˆÚ›˜, fï˜, Û·Ê‹ ˘ÂÚÔ¯‹ ·¤Ó·ÓÙÈ ÛÙÔ ™∞. ∂›Û˘, ‰ÂÓ ·˘Í¿ÓÂÈ ÙËÓ ÂÈ‚›ˆÛË, ·Ó Î·È Ë Èı·ÓfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ™∞¢ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Ì ÙÔÓ À∞ ·’ fiÙÈ Ì ÙÔ ™∞. ∆¤ÏÔ˜, ‰ÂÓ ÂÏ·ÙÙÒÓÂÈ ÙȘ ¿ÌÂÛ˜ Î·È Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∂Ӊ¯Ô̤ӈ˜, Ë ¯Ú‹ÛË ÙÔ˘ HFOV ˆ˜ ·ÔÎÏÂÈÛÙÈÎÔ‡ ÙÚfiÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÓÂÔÁÓÒÓ Ì ™∞¢ Ó· ‚ÂÏÙÈÒÛÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘. ¶¿ÓÙˆ˜, ·fi ÙËÓ 6ÂÙ‹ ÂÌÂÈÚ›· Ì·˜ ÛÙË ¯Ú‹ÛË ÙÔ˘ HFOV ıˆÚԇ̠fiÙÈ ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ··ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÂÍÔÈΛˆÛË Î·È Âη›‰Â˘ÛË, ηıÒ˜ ÌÔÚ› Ó· Á›ÓÂÈ ÂÈΛӉ˘ÓÔ˜, ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ Â·Ú΋˜ ÂÌÂÈÚ›· ÛÙË ¯Ú‹ÛË ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Sugiura M, McCulloch PR, Wren S, Dawson RH, Froese AB. Ventilator pattern influences neutrophil influx and activation in atelectasis - prone rabbit lung. J Appl Physiol 1994;77:1355-1365. 2. Eichenwald EC, Stark A. High-frequency ventilation: Current status. Pediatr Rev 1999;20:e127-e133. 3. deLemos RA, Coalson JJ, Gerstmann DR, Null DM Jr, Ackerman NB, Escobedo MB et al. Ventilatory management of infant baboons with hyaline membrane disease: the use of high frequency ventilation. Pediatr Res 1987;21:594-602. 4. deLemos RA, Coalson JJ, Meredith KS, Gestmann DR, Null DM Jr. A comparison of ventilation strategies for the use of high-frequency oscillatory ventilation in the treatment of hyaline membrane disease. Acta Anaesthesiol Scand 1989;90[Suppl]:102-107. 5. Gerstman DR, deLemos RA, Coalson JJ, Clark RH, Wiswell TE, Winter DC et al. Influence of ventilatory technique on pulmonary varo-injury in baboons with hyaline membrane disease. Pediatr Pulmonol 1988;5:82-91. 6. HIFI Study Group. High-frequency oscillatory ventilation compared with conventional mechanical ventilation in the treatment of respiratory failure in preterm infants. N Engl J Med 1989;320:88-93. 7. HIFO Study Group. Randomized study of high-frequency oscillatory ventilation in infants with severe respiratory distress syndrome. J Pediatr 1993;122:609-612. 8. Ogawa Y, Miyasaka K, Kawano T, Imura S, Inukai K, Okuyama K et al. A multi-center trial of high frequency oscillatory ventilation as compared with conventional mechanical ventilation in preterm infants with respiratory failure. Early Hum Dev 1993;32:1-10. 9. Clark RH, Gerstman DR, Null DM, deLemos RA. Prospective randomized comparison of high-frequency oscillatory and conventional ventilation in respiratory distress syndrome. Pediatrics 1992;89:5-12. 10. Plavka R, Kopecky P, Serbon V, Svilhovec P, Zlatohlavkova B, Janus V. A prospective randomized comparison of conventional mechanical ventilation and
180
Paediatriki 2002;65:174-181
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
high-frequency oscillatory ventilation in treatment of respiratory distress syndrome in extremely premature newborns. Int Care Med 1999;25:68-75. Cools F, Offinga M. Meta-analysis of elective highfrequency ventilation in preterm infants with respiratory distress syndrome. Arch Dis Child (Fetal Neonatal Ed) 1999;80:F15-F20. Boynton BR, Villanueva D, Hammond MD, Vreeland PN, Buckley B, Frantz ID 3rd. Effect of mean airway pressure on gas exchange during high-frequency oscillatory ventilation. J Appl Physiol 1991;70:701-707. Chan V, Greenough A. Determinants of oxygenation during high frequency oscillation. Eur J Pediatr 1993;152:350-353. Dimitriou G, Greenouph A. Measurement of lung volume and optimal oxygenation during high frequency oscillation. Arch Dis Child (Fetal Neonatal Ed) 1995;72:F180-173. Rimensberger PC, Beghetti M, Hanquinet S, Berner M. First intention high-frequency oscillation with early lung volume optimization improves pulmonary outcome in very low birth weight infants with respiratory distress syndrome. Pediatrics 2000;105:1202-1208. Kolton M, Cattran CB, Kent G, Volgyesi G, Froese AB, Bryan AC. Oxygenation during high-frequency ventilation compared with conventional mechanical ventilation in two models of lung injury. Anesth Analg 1982;61:323-332. McCulloch PR, Forkert PG, Froese AB. Lung volume maintenance prevents lung injury during high frequency oscillatory ventilation in surfactant - deficient rabbits. Am Rev Respir Dis 1998;137:1185-1192. Rettwitz-Volk W, Veldman A, Roth B, Vierzig A, Kachel W, Varnholt V et al. A prospective, randomized, multicenter trial of high-frequency oscillatory ventilation compared with conventional ventilation in preterm infants with respiratory distress syndrome receiving surfactant. J Pediatr 1998;132:200-202. Thome U, Gotze-Speer B, Speer CP, Pohlandt F. Comparison of pulmonary inflammatory mediators in preterm infants treated with intermittent positive pressure ventilation or high frequency oscillatory ventilation. Pediatr Res 1998;44:330-337. Gerstman DR, Minton SD, Stoddard RA, Meredith KS, Monaco F, Bertand JM et al. The Provo multi-center high frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome. Pediatrics 1996;98:1196-1197. Moriete G, Paris-Llado J, Walti H, Escande B, Magny JF, Cambonie G et al. Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome. Pediatrics 2001;107:363-372. Jackson JC, Truog WE, Standaert TA, Juul SE, Murphy JH, Chi EY et al. Effect of high-frequency ventilation on the development of alveolar edema in premature monkeys at risk for hyaline membrane disease. Am Rev Respir Dis 1991;143:865-871. Jackson JC, Truog WE, Standaert TA, Murphy JH, Juul SE, Chi EY et al. Reduction in lung injury after combined
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·181
¶·È‰È·ÙÚÈ΋ 2002;65:174-181
24.
25.
26.
27. 28.
29.
surfactant and high-frequency ventilation. Am J Respir Crit Care Med 1994;150:534-539. Frantz ID 3rd, Close RH. Alveolar pressure swings during high-frequency ventilation in rabbits. Pediatr Res 1985;19:162-166. Henderson-Smart DJ, Bhuta T, Cools F, Offringa M. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2000;2:CD000104. Clark RH, Dykes FD, Bachman TE, Ashurst JT. Intraventricular hemorrhage and high-frequency ventilation: a meta-analysis of prospective clinical trials. Pediatrics 1996;98:1058-1061. Speer CP. Inflammatory mechanisms in neonatal chronic lung disease. Eur J Pediatr 1999;158:S18-22. Imai Y, Kawano T, Miyasaka K, Takata M, Omai T, Okyama K. Inflammatory chemical mediators during conventional ventilation and during high frequency oscillatory ventilation. Am Rev Respir Crit Care Med 1994;150:2114-2115. Yoder BA, Siler-Khodr T, Winter VT, Coalson JJ. Highfrequency oscillatory ventilation: effects on lung function,
Paediatriki 2002;65:174-181
mechanics, and airway cytokines in the immature baboon model for neonatal chronic lung disease. Am J Respir Crit Care Med 2000;162:1867-1876. 30. Dreyfuss D, Basset G, Soler P, Saumon G. Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis 1985;132:880-884. 31. Bhuta T, Henderson-Smart DJ. Rescue high frequency oscillatory ventilation versus conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2000;2:CD000438.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-09-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ µ·ÛÈÏÈ΋ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E-mail: agaki@med.auth.gr
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∏ ¯Ú‹ÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› Ë ¯ÚËÛÈÌfiÙËÙ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ (H. pylori), ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂڷ›·˜ ÂÎÚ›˙ˆÛ˘ Î·È ÙË ÌÂÙ¤ÂÈÙ· ·Ú·ÎÔÏÔ‡ıËÛË. ∞ÛıÂÓ›˜ Î·È Ì¤ıÔ‰ÔÈ: 72 ·È‰È¿ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ ˘Ô‚Ï‹ıËÎ·Ó Û Á·ÛÙÚÔÛÎfiËÛË Î·È Ï‹„Ë ‚ÈÔ„ÈÒÓ ÁÈ· ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË, ηÏÏȤÚÁÂÈ· Î·È Ù·¯Â›· ̤ıÔ‰Ô Ô˘Ú¿Û˘ (CLO-test). ¶·Ú¿ÏÏËÏ·, ¤ÁÈÓ ̤ÙÚËÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi Î·È fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C. ∞ÔÙÂϤÛÌ·Ù·: 47 ·fi ÙÔ˘˜ 72 ·ÛıÂÓ›˜ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó Ïԛ̈ÍË ·fi H. pylori Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ‚ÈÔ„›·˜. ∏ ¢·ÈÛıËÛ›· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÁÈ· ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi H. pylori ‹Ù·Ó 95% ÛÙ·ÙÈÛÙÈο Û˘ÁÎÚ›ÛÈÌË Ì ·˘Ù‹ Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘ (94%), Ù˘ Ù·¯Â›·˜ ÌÂıfi‰Ô˘ Ô˘Ú¿Û˘ (96%) Î·È Ù˘ ÔÚÔÏÔÁÈ΋˜ ÌÂıfi‰Ô˘ (91%) Î·È ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ Ù˘ ηÏÏȤÚÁÂÈ·˜ (79%). ∏ ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ‚Ú¤ıËΠӷ Â›Ó·È 100%, Û˘ÁÎÚ›ÛÈÌË Ì ·˘Ù‹ ÙˆÓ ¿ÏÏˆÓ ‰ÔÎÈÌ·ÛÈÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂڷ›·˜ ÂÎÙÈÌ‹ıËΠ̠Á·ÛÙÚÔÛÎfiËÛË Î·È ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÙÔ˘˜ 24 H. pylori ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜. °È· ÙÔ ÛÎÔfi ·˘Ùfi, Ë Â˘·ÈÛıËÛ›· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Î·È Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘
‹Ù·Ó 100%, ÂÓÒ Ù˘ ηÏÏȤÚÁÂÈ·˜ Î·È Ù˘ Ù·¯Â›·˜ ÌÂıfi‰Ô˘ Ô˘Ú¿Û˘ ‹Ù·Ó 88%. 11 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û Á·ÛÙÚÔÛÎfiËÛË Î·È ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜. ¢ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· Î·È Ù˘ ‚ÈÔ„›·˜ ÛÂ Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ ·ÛıÂÓ›˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ Ïԛ̈͢ ·fi H. pylori Û ·È‰È¿ ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·ÓÒÙÂÚÔ ÂÙÈÎfi, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂڷ›·˜ ÂÎÚ›˙ˆÛ˘ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ıÂڷ›·.
1 Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al A 13C-urea breath test in children with Helicobacter pylori infection: assessment of eradication therapy and follow-up after treatment J Gastroenterol 2001;36:606-611
°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
181
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·182
¶·È‰È·ÙÚÈ΋ 2002;65:182-185
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2002;65:182-185
ORIGINAL ARTICLE
∏ ÛÈÁΤÏψÛË ÛÙËÓ ◊ÂÈÚÔ Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985 - 1999 ª. ÷ڛÛË1, ∂. °·Ï·Ó¿Î˘1, ª. ∆˙Ô‡ÊË1, ™. ™ÙÂÊ¿ÓÔ˘ - §Â‚ÂȉÈÒÙÔ˘2, ∑. ¶··‰ÔÔ‡ÏÔ˘ - ∫Ô˘ÏÔ˘Ì‹1
Shigellosis in the region of Epirus during the 15year period from 1985 to 1999 M. Charisi1, E. Galanakis1, M. Tzoufi1, S. Stephanou - Levidiotou2, Z. Papadopoulou - Couloumbis1
¶ÂÚ›ÏË„Ë: ∏ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂȤ‰Ô˘ ˘ÁÈÂÈÓ‹˜ ¤¯ÂÈ ÂÈʤÚÂÈ Ô˘ÛÈÒ‰Ë Ì›ˆÛË ÛÙË ÓÔÛËÚfiÙËÙ· Ù˘ ÛÈÁΤÏψÛ˘ ÛÙË ¯ÒÚ· Ì·˜. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ÛÙË 15ÂÙ›· 1985-1999. ∫·Ù·ÁÚ¿ÊËÎ·Ó fiϘ ÔÈ ÂÚÈÙÒÛÂȘ ÛÈÁΤÏψÛ˘ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ÂÚ›Ô‰Ô 1985-1999, ηıÒ˜ Î·È fiÏ· Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÈfi‰Ô˘ ÌÂϤÙ˘ ÓÔÛËχÙËÎ·Ó 46 ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ (27 ·ÁfiÚÈ· Î·È 19 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 3 ÌËÓÒÓ-13 ÂÙÒÓ). ∏ ̤ÛË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ˘ÔÏÔÁ›ÛÙËΠ۠5 ÂÈÛ·ÁˆÁ¤˜/100.000 ·È‰È¿/¤ÙÔ˜, ¯ˆÚ›˜ ÛËÌ·ÓÙÈΤ˜ ÂÙ‹ÛȘ ‰È·Î˘Ì¿ÓÛÂȘ. ™ËÌÂÈÒıËΠfï˜ Û·Ê‹˜ ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù¿ ÙÔÓ Ì‹Ó· ∞‡ÁÔ˘ÛÙÔ (39% ÙÔ˘ Û˘ÓfiÏÔ˘, p<0,001). ∞fi Ù· 46 ·È‰È¿, Ù· 7 (15%) ÂÌÊ¿ÓÈÛ·Ó ˘ÚÂÙÈÎÔ‡˜ Û·ÛÌÔ‡˜, 2 ›¯·Ó ÂÈÎfiÓ· ‚·ÚÈ¿˜ ·Ê˘‰¿ÙˆÛ˘ Î·È 1 ·Ú·Ï˘ÙÈÎfi ÂÈÏÂfi. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÎÔÚ¿ÓˆÓ ·Ó·Ù‡¯ıËÎ·Ó S. flexneri (67%), S. boydii (13%), S. sonnei (13%) Î·È S. dysenteriae (7%). ™ËÌ·ÓÙÈ΋ ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∏ ÂȉËÌÈ΋ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ ÛËÌÂÈÒıËΠ۠ΈÌfiÔÏË ÙÔ˘ ÓÔÌÔ‡ πˆ·ÓÓ›ÓˆÓ Î·È ·ÊÔÚÔ‡Û 84 ·È‰È¿, ·fi Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó Ù· 26 (14 ·ÁfiÚÈ· Î·È 12 ÎÔÚ›ÙÛÈ·). ∞Ô‰fiıËΠÛÙË ÌfiÏ˘ÓÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ‡‰Ú¢Û˘ ·fi Shigella sonnei. ™ÙËÓ ÔÌ¿‰· ·˘Ù‹ ‰ÂÓ ˘‹ÚÍ·Ó ÂÈÏÔΤ˜. ŸÏ· Ù· ·È‰È¿ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ¤Î‚·ÛË.
Abstract: The improvement of hygiene standards in Greece has resulted in a substantial decrease in the incidence of shigellosis. The aim of the present study was to record the number of children with shigellosis in the region of Epirus, during the 15year period from 1985 to 1999. All shigella cases that were hospitalized from 1985 to 1999 were recorded, as well as the disease cases in children during a local outbreak in October 1996. During the study period, 46 sporadic cases of shigellosis (27 boys and 19 girls, aged 3 months to 13 years), were admitted to the hospital. The mean incidence of the disease was estimated to be 5 hospital admissions per 100000 children per year, without any significant annual fluctuations. However an increased prominence of the disease was noted during the month of August (39% in total, p<0.001). Seven of the 46 hospitalized children (15%) had febrile seizures, two had serious dehydration and one had paralytic ileus. The stool cultures were positive for S. flexneri (67%), S. boydii (13%), S. sonnei (13%) and S. dysenteriae (7%). No significant resistance to antibiotics was observed. The epidemic outbreak occurred in a small town near the city of Ioannina and involved 84 children, 26 of whom (14 boys and 12 girls) were hospitalized. This localised epidemic was associated with the infection of the water supply by S. sonnei. There were no complications. All children in the study had an excellent outcome.
§¤ÍÂȘ ÎÏÂȉȿ: ÛÈÁΤÏψÛË, ·È‰È¿, ÂȉËÌÈÔÏÔÁ›·, ◊ÂÈÚÔ˜.
Key words: shigellosis, children, epidemiology, Epirus.
1 ∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ 2 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¶.¶.°.¡. πˆ·ÓÓ›ÓˆÓ
1 Department of Child Health University of Ioannina Medical School 2 Laboratory of Microbiology, General University Hospital of Ioannina
182
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·183
¶·È‰È·ÙÚÈ΋ 2002;65:182-185
∂ÈÛ·ÁˆÁ‹ ∏ ÛÈÁΤÏψÛË Â›Ó·È ÓfiÛÔ˜ Ì ·ÁÎfiÛÌÈ· ηٷÓÔÌ‹ Î·È ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÁÈ· ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ (1). ™ÙË ¯ÒÚ· Ì·˜, Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂȤ‰Ô˘ ˘ÁÈÂÈÓ‹˜ ¤¯ÂÈ ÌÂÈÒÛÂÈ Ô˘ÛȈ‰Ò˜ ÙË ÓÔÛËÚfiÙËÙ· Ù˘ ÛÈÁΤÏψÛ˘. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ∂ȉÈÎÔ‡ ∫¤ÓÙÚÔ˘ ∂ȉËÌÈÔÏÔÁÈ΋˜ ¶·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ¶·Ú¤Ì‚·Û˘, ηٿ ÙÔ ¤ÙÔ˜ 1999 ‰ËÏÒıËÎ·Ó Û˘ÓÔÏÈο 80 Ó¤· ÎÚÔ‡ÛÌ·Ù· ·ÓÂÏÏËÓ›ˆ˜ (2). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ηٿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999. ÀÏÈÎfi Î·È Ì¤ıÔ‰Ô˜ ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÏ‹ÊıËÛ·Ó fiϘ ÔÈ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ÛÈÁΤÏψÛ˘ Û 46 ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ÛÙÔ ‰È¿ÛÙËÌ· 1985-1999, ηıÒ˜ Î·È Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ Û 84 ·È‰È¿ ÛÙË ‰È¿ÚÎÂÈ· Ì›·˜ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996. ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο Ù· ÈÛÙÔÚÈο ÙˆÓ ·ÛıÂÓÒÓ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó Ù· ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘, Ù· ÛÙÂϤ¯Ë ÛÈÁΤÏÏ·˜ Ô˘ ·ÔÌÔÓÒıËÎ·Ó Î·È Ë Â˘·ÈÛıËÛ›· ÙÔ˘˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ Î·È Ù¤ÏÔ˜, Ë ·ÁˆÁ‹ Î·È Ë ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ. ŸÏ· Ù· ‰Â›ÁÌ·Ù· ÎÔÚ¿ÓˆÓ Î·ÏÏÈÂÚÁ‹ıËÎ·Ó Û Mac Conkey ¿Á·Ú Î·È Salmonella-Shigella ¿Á·Ú. ∏ Ù·˘ÙÔÔ›ËÛË Î·È Ë ‰ÔÎÈÌ·Û›· ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ¤ÁÈÓ·Ó Ì ÙÔ Û‡ÛÙËÌ· Pasco MIC/ID Î·È ·ÓÙÈÔÚÔ‡˜ ÙÔ˘ Ô›ÎÔ˘ Wellcome.
AÔÙÂϤÛÌ·Ù· 1. ™ÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ™ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999 ÓÔÛËχÙËÎ·Ó Û˘ÓÔÏÈο 46 ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· ÛÈÁΤÏψÛ˘, 27 ·ÁfiÚÈ· Î·È 19 ÎÔÚ›ÙÛÈ·. ∏ ËÏÈΛ· ÙÔ˘˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 3 ÌËÓÒÓ ¤ˆ˜ 13 ÂÙÒÓ (̤ÛË ËÏÈΛ· Ù· 5 ¤ÙË). MÈÎÚfiÙÂÚ· ÙˆÓ 24 ÌËÓÒÓ ‹Ù·Ó 13 ·È‰È¿ (28%). ªÂ ‚¿ÛË ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi Ù˘ ∏›ÚÔ˘, Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ˘ÔÏÔÁ›ÛÙËΠ۠5 ÂÈÛ·ÁˆÁ¤˜ ·Ó¿ 100.000 ·È‰È¿ ·Ó¿ ¤ÙÔ˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·Î˘Ì¿ÓÛÂȘ ·fi ¤ÙÔ˜ Û ¤ÙÔ˜. ∏ ÌËÓÈ·›· ηٷÓÔÌ‹ ·ÚÔ˘Û›·Û ۷ʋ ¤Í·ÚÛË Î·Ù¿ ÙÔÓ ∞‡ÁÔ˘ÛÙÔ, Ô ÔÔ›Ô˜ Û˘ÁΤÓÙÚˆÓ ÙÔ 39% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ (p<0,001) (™¯‹Ì· 1). K·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, ÔÈ ·ÛıÂÓ›˜ ÂÌÊ¿ÓÈ˙·Ó ˘ÚÂÙfi >38,5ÔC ۯ‰fiÓ ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ (97%) Î·È ‹ÈÔ˘ ‹ ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ·Ê˘‰¿ÙˆÛË Û ÔÛÔÛÙfi 30%. ™Ô‚·Ú‹ ·Ê˘‰¿ÙˆÛË (>10%) ·Ú·ÙËÚ‹ıËΠ۠‰‡Ô ·È‰È¿ (ÔÛÔÛÙfi 4%). §Â˘ÎÔ΢ÙÙ¿ÚˆÛË (>10.000/Ìl, ·ÓÒÙÂÚË ÙÈÌ‹ 26.200/Ìl) ÂÌÊ¿ÓÈÛ ÙÔ 58% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‹Ù·Ó ·˘ÍË̤ÓË ÛÙÔ˘˜ 19 ·fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ fiÔ˘ ÌÂÙÚ‹ıËΠ(‡ÚÔ˜ 10-326 mg/dl).
Paediatriki 2002;65:182-185
20 18 16 14 12 10 8 6 4 2 0
Ú. Ú. ÈÔ˜ Ó. Ï. Á. Ù. Ù. ¤Ì. ÂÎ. . ‚. ¢ I·Ó ºÂ M¿ A M¿ IÔ‡ IÔ‡ A‡ ™Â OÎ NÔ
™¯‹Ì· 1. ªËÓÈ·›· ηٷÓÔÌ‹ ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÛÈÁΤÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999.
ÀÔÓ·ÙÚÈ·ÈÌ›· ÂÌÊ¿ÓÈÛ·Ó ÌfiÓÔ ‰‡Ô Ó‹È· ËÏÈΛ·˜ 3 ÂÙÒÓ (¤Ó· ·ÁfiÚÈ Î·È ¤Ó· ÎÔÚ›ÙÛÈ), ÂÓÒ ¤Ó· ·ÁfiÚÈ 6 ÂÙÒÓ ÚÔÛ‹Ïı Ì ˘·Û‚ÂÛÙÈ·ÈÌ›· (6,5 mg/dl). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘ ·ÔÌÔÓÒıËÎ·Ó Î·È Ù· 4 ÛÙÂϤ¯Ë ÛÈÁΤÏÏ·˜ Ì ÙËÓ ·ÎfiÏÔ˘ıË Û˘¯ÓfiÙËÙ·: Shigella flexneri 67%, Shigella sonnei 13%, Shigella boydii 13% Î·È Shigella dysenteriae 7%. AÓıÂÎÙÈο ÛÙÂϤ¯Ë ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1994 Î·È ·ÊÔÚÔ‡Û·Ó ·ÔÎÏÂÈÛÙÈο ÙË Shigella flexneri: ·ÓÙÔ¯‹ ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË 63% Î·È ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË 25%. AÓıÂÎÙÈÎfiÙËÙ· ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Î·È ÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∏ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‹Ù·Ó ıÂÙÈ΋ ÌfiÓÔ Û ̛· ÂÚ›ÙˆÛË Ïԛ̈͢ ·fi Shigella flexneri. ∆¤ÏÔ˜, ηٿ ÙË ‰È·‰ÚÔÌ‹ Ù˘ ÓfiÛÔ˘, 2 ·ÛıÂÓ›˜ ËÏÈΛ·˜ 2 ÂÙÒÓ Î·È 6 ÂÙÒÓ ÂÌÊ¿ÓÈÛ·Ó Ô˘ÚÔÏԛ̈ÍË ·fi Escherichia coli Î·È Klebsiella oxytoca ·ÓÙ›ÛÙÔȯ·. 2. ∫ÚÔ‡ÛÌ·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂȉËÌÈ΋ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ, ·˘Ù‹ ÛËÌÂÈÒıËΠÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996 Û ̛· ΈÌfiÔÏË-ÚÔ¿ÛÙÈÔ Ù˘ fiÏ˘ ÙˆÓ πˆ·ÓÓ›ÓˆÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ¿ Ù˘ ÓfiÛËÛ·Ó 84 ·È‰È¿. ∏ ËÏÈΛ· ÙÔ˘˜ Î˘Ì¿ÓıËΠ·fi 1-14 ¤ÙË, Ì ̤ÛË ËÏÈΛ· Ù· 9 ¤ÙË. ∞fi Ù· 84 ·È‰È¿ Ô˘ ÓfiÛËÛ·Ó, ·Ó¿ÁÎË ÓÔÛËÏ›·˜ ›¯·Ó Ù· 26 (ÔÛÔÛÙfi 31%). ∏ ÂȉËÌÈ΋ ·˘Ù‹ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ ·Ô‰fiıËΠÛÙË ÌfiÏ˘ÓÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ‡‰Ú¢Û˘ Ù˘ ÂÚÈÔ¯‹˜ ·fi χ̷ٷ. ∆Ô Û٤ϯԘ Ô˘ ·ÔÌÔÓÒıËΠ‹Ù·Ó Shigella sonnei ·ÓıÂÎÙÈ΋ Û ·ÌÈÎÈÏÏ›ÓË, ·ÌÔ͢ÎÈÏÏ›ÓË-ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇, ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË Î·È ÙÂÙڷ΢ÎϛӘ, ÂÓÒ ‹Ù·Ó ¢·›ÛıËÙÔ Û ÎÂÊ·ÏÔÛÔÚ›Ó˜, ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Î·È ÎÈÓÔÏfiÓ˜. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÓÙÔÈṲ̂ÓË ÂȉËÌ›· ÓfiÛËÛ·Ó Î·È 76 ÂÓ‹ÏÈΘ, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÓÔÛËχÙËÎ·Ó ÔÈ 24, ÔÛÔÛÙfi 32%, ›‰ÈÔ Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÙˆÓ ·È‰ÈÒÓ (3).
183
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·184
¶·È‰È·ÙÚÈ΋ 2002;65:182-185
3. ∂ÈÏÔΤ˜ ∂ÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÌfiÓÔ ÛÙ· ·È‰È¿ Ì ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, ·fi Ù· 46 ·È‰È¿, Ù· 7 (15%) ÂÌÊ¿ÓÈÛ·Ó Û·ÛÌÔ‡˜ Ì ˘ÚÂÙfi, Ù· 2 (4%) ÂÈÎfiÓ· ‚·ÚÈ¿˜ ·Ê˘‰¿ÙˆÛ˘ Ì ·Ú·ÙÂٷ̤ÓË ÓfiÛËÛË Î·È 1 ı‹Ï˘ ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 7 ÌËÓÒÓ ·Ú·Ï˘ÙÈÎfi ÂÈÏÂfi Ì ‹È· ÛÏËÓÔÌÂÁ·Ï›· Î·È ÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÙÔÓ›·. ∏ ÙÈÌ‹ ÙÔ˘ Î·Ï›Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ (5,1 mEq/l) Î·È Ô ÂÈÏÂfi˜ ˘Ô¯ÒÚËÛ ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ (¶›Ó·Î·˜ 1). ∞fi Ù· 7 ·È‰È¿ (4 ·ÁfiÚÈ·, 3 ÎÔÚ›ÙÛÈ·) Ô˘ ÂÌÊ¿ÓÈÛ·Ó Û·ÛÌÔ‡˜, Ù· 3 ›¯·Ó ıÂÙÈÎfi ·ÙÔÌÈÎfi ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ Î·È 1 ›¯Â ˘ÔΛÌÂÓÔ Ó¢ÚÔÏÔÁÈÎfi ÓfiÛËÌ· (Û‡Ó‰ÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 6 Î·È ·˘ÙÈÛÌfi). ∞fi Ù· ˘fiÏÔÈ· 3, ÛÙÔ 1 Û˘Ó˘‹Ú¯Â ˘·Û‚ÂÛÙÈ·ÈÌ›· ηٿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Û·ÛÌÒÓ Î·È Û 1 ÏÂÈÔ·ÙÙˆÛË ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (15 ·ÙÙ·Ú·/mm3). OÈ Û·ÛÌÔ› ·Ú·ÙËÚ‹ıËÎ·Ó ÙȘ ÚÒÙ˜ 24 ÒÚ˜ Ù˘ ÓfiÛÔ˘, Ì ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· 38,5Ô40,0ÔC (̤ÛË 39,3ÔC), ‹Ù·Ó ÁÂÓÈÎÂ˘Ì¤ÓÔÈ ÙÔÓÈÎÔÎÏÔÓÈÎÔ›, Ì ‰È¿ÚÎÂÈ· Ï›ÁˆÓ ÏÂÙÒÓ. ∂Í·›ÚÂÛË ·ÔÙ¤ÏÂÛ·Ó 2 ·ÛıÂÓ›˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ Û·ÛÌÔ› ‰È‹ÚÎÂÛ·Ó ¿Óˆ ·fi 30 ÏÂÙ¿. ÀÔÙÚÔ‹ ·ÚÔ˘Û›·Û 1 ·È‰›, ÙÔ ÔÔ›Ô Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ›‰È·˜ ÓÔÛËÏ›·˜, ÂΉ‹ÏˆÛÂ Î·È ÂÛÙÈ·ÎÔ‡˜ Û·ÛÌÔ‡˜. ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ Û 3 ·ÛıÂÓ›˜ Î·È ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ™Â ηӤӷ ·È‰› ‰ÂÓ ··ÈÙ‹ıËΠ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹. ∫·È ÔÈ 7 ·ÛıÂÓ›˜ ·Ó‹Î·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÛÈÁΤÏψÛ˘. ŸÏÔÈ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÚfiÁÓˆÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ηٿ ̤ÛÔÓ fiÚÔ 10ÂÙÔ‡˜ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜, Ì ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË ÙÔ ·È‰› Ì ÙÔÓ ·˘ÙÈÛÌfi, Ô˘ Û˘Ó¤¯ÈÛ ӷ ÂÌÊ·Ó›˙ÂÈ Û‡ÓıÂÙ˜ ÂÛÙȷΤ˜ ÎÚ›ÛÂȘ Î·È ¤Ï·‚ ̷ÎÚÔ¯ÚÔÓ›ˆ˜ ‰ÈÏ‹ ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹. ™˘˙‹ÙËÛË ™ÙËÓ ÂÚÈÔ¯‹ Ì·˜, Ë ÛÈÁΤÏψÛË ÛÙ· ·È‰È¿ ÂÈ̤ÓÂÈ Ì ¯·ÌËÏ‹ ›وÛË Î·È Ì ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜ (80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù¿ ÙÔ ‰È¿ÛÙËÌ· πÔ‡ÏÈÔ˜-OÎÙÒ‚ÚÈÔ˜). ∆Ô Û٤ϯԘ Ô˘ ÂÈÎÚ·Ù› Â›Ó·È Ë Shigella flexneri, Ë ÔÔ›· ¢ı‡ÓÂÙ·È ÁÈ· Ù· ‰‡Ô ÙÚ›Ù· ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘. ∆Ô ·ÔÙ¤ÏÂÛÌ· ·˘Ùfi Â›Ó·È ÛÂ Û˘Ìʈӛ· Ì ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÛÙË µfiÚÂÈÔ ∂ÏÏ¿‰· ηٿ ÙËÓ ›‰È· ÂÚ›Ô‰Ô Î·È ÛÙËÓ ÔÔ›· Ë Shigella flexneri ·ÔÌÔÓÒıËΠÛÙÔ 55% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (4). ∞ÓÙ›ıÂÙ·, ÙÔ Û٤ϯԘ Ô˘ ÂÈÎÚ·Ù› Û ¿ÏϘ ‰˘ÙÈΤ˜ ¯ÒÚ˜ Â›Ó·È Ë Shigella sonnei (1,5), ÂÓÒ ÛÙȘ ¯ÒÚ˜ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘ Â›Ó·È ·ÎfiÌË ˘„ËÏ‹ Ë Â›ÙˆÛË Ù˘ Shigella dysenteriae, ÙfiÛÔ Û ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· fiÛÔ
184
Paediatriki 2002;65:182-185
¶›Ó·Î·˜ 1. ∂ΉËÏÒÛÂȘ Ù˘ ÛÈÁΤÏψÛ˘ Û 72 ·È‰È¿ ·fi ÙËÓ ◊ÂÈÚÔ Ô˘ ÓÔÛËχÙËÎ·Ó Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999. ∂Ή‹ÏˆÛË
¡
%
¶˘ÚÂÙfi˜ ¢È¿ÚÚÔȘ ◊È·-̤ÙÚÈ· ·Ê˘‰¿ÙˆÛË ™·ÛÌÔ› ™Ô‚·Ú‹ ·Ê˘‰¿ÙˆÛË ¶·Ú·Ï˘ÙÈÎfi˜ ÂÈÏÂfi˜
71 72 28 7 2 1
98,6 100 39 9,7 2,8 1,4
Î·È Û ÂȉË̛˜ (6,7). ∏ ‰È·‰ÚÔÌ‹ Ù˘ ÛÈÁΤÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ηٿ ηÓfiÓ· ‹È·. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 72 ·È‰ÈÒÓ Ô˘ ÓÔÛËχıËηÓ, ÌfiÓÔ ‰‡Ô ‚Ú¤ÊË ËÏÈΛ·˜ <12 ÌËÓÒÓ ÂÌÊ¿ÓÈÛ·Ó ·Ú·ÙÂٷ̤ÓÔ Â̇ÚÂÙÔ Î·È ‰È¿ÚÚÔȘ Ì ·ÎfiÏÔ˘ıË ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ ËÎÙÈÎfiÙËÙ·˜. ∏ ÙÂÏÈ΋ ¤Î‚·ÛË ‹Ù·Ó ¿ÚÈÛÙË Û fiÏ· Ù· ·È‰È¿. ∏ ÈÔ Û˘¯Ó‹ Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË ‹Ù·Ó ÔÈ Û·ÛÌÔ› (5,3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Î·È 9,7% ÙˆÓ ·È‰ÈÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÓÔÛÔÎÔÌÂȷ΋ ·ÁˆÁ‹), ÔÛÔÛÙfi Û·ÊÒ˜ ÌÈÎÚfiÙÂÚÔ ·fi ·˘Ùfi Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ¿ÏϘ ÌÂϤÙ˜, fiÔ˘ Ù· ÔÛÔÛÙ¿ ·Ó¤Ú¯ÔÓÙ·È ¤ˆ˜ Î·È ¿Óˆ ·fi 45% (4,8,9). ŸÌˆ˜, Û ÌÂϤÙ˜ fiÔ˘ ·Ó·Ê¤ÚÂÙ·È ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Û·ÛÌÒÓ Ê·›ÓÂÙ·È fiÙÈ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·È‰È¿ Ì Ôχ ÛÔ‚·Ú¤˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ (4,9), ÂÓÒ Û ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ú·ÙËÚÂ›Ù·È ·ÚfiÌÔÈ· Ì ÙË ‰È΋ Ì·˜, ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· Û·ÛÌÒÓ, ÙfiÛÔ Û Â͈ÙÂÚÈÎÔ‡˜ fiÛÔ Î·È Û ÓÔÛËÏ¢fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ (5,7% Î·È 1,7% ·ÓÙ›ÛÙÔȯ·) (8). ¶Èı·ÓfiÓ Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ Û·ÛÌÒÓ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÓfiÛÔ˘ Î·È fi¯È ÛÙËÓ ÙÔÍ›ÓË Ù˘ ÛÈÁΤÏÏ·˜, ηıÒ˜ ˆ˜ ·ıÔÁÂÓÂÙÈο ·›ÙÈ· ıˆÚÔ‡ÓÙ·È Û‹ÌÂÚ· Ô ˘ÚÂÙfi˜ Î·È ÔÈ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ (8,10). ™Â ·˘Ùfi Û˘ÓËÁÔÚÔ‡Ó Î·È Ù· ‰Èο Ì·˜ ‰Â‰Ô̤ӷ, ηıÒ˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Û·ÛÌÔ› Û ηӤӷ ·fi Ù· 84 ·È‰È¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜, ÛÙ· ÔÔ›· ›¯Â ·Ú·Û¯Âı› Ôχ ¤ÁηÈÚ· È·ÙÚÈ΋ ÊÚÔÓÙ›‰·. ™Â ·È‰È¿ Ì ۷ÛÌÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÛÈÁΤÏψÛ˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔÈ·˙fiÓÙˆÓ ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘˜ (11,12), ‡ÚËÌ· Û‡ÌʈÓÔ Î·È Ì ٷ ‰Èο Ì·˜ ‰Â‰Ô̤ӷ, ·ÊÔ‡ Ù· 3 ·fi Ù· 7 ·È‰È¿ Ì ۷ÛÌÔ‡˜ ›¯·Ó ıÂÙÈÎfi ·ÙÔÌÈÎfi ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ. ∞fi Ù· Â˘Ú‹Ì·Ù¿ Ì·˜ ÚÔ·ÙÂÈ fiÙÈ ÔÈ Û·ÛÌÔ› ÛÙË ÛÈÁΤÏψÛË Â›Ó·È Ì¿ÏÏÔÓ Ì›· ·Û˘Ó‹ı˘ ÂÈÏÔ΋, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ÓfiÛÔ˜ ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ·. ∫·Ù¿ ηÓfiÓ· ÚfiÎÂÈÙ·È ÁÈ· ηÏÔ‹ıÂȘ Û·ÛÌÔ‡˜, Ô˘ ‰ÂÓ ˘ÔÙÚÔÈ¿˙Ô˘Ó Î·È ¤¯Ô˘Ó ¿ÚÈÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÚfiÁÓˆÛË, ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈο ηٿÏÔÈ· (1,4,8,11).
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·185
¶·È‰È·ÙÚÈ΋ 2002;65:182-185
∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·Ú·ÎÔÏÔ‡ıËÛ˘, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÚfiÁÓˆÛË. ∏ Û‡Á¯ÚÔÓË Ù¿ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ó· ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙÈ‚ÈÔÙÈο Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ‰È·ÈÛو̤Ó˘ ÛÈÁΤÏψÛ˘, ηıÒ˜ ·ÊÂÓfi˜ ÌÂÓ ÌÂÈÒÓÂÙ·È Ë ‰È¿ÚÎÂÈ· Ù˘ ‰È¿ÚÚÔÈ·˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÂÍ·Ï›ÊÂÙ·È Ù·¯‡ÙÂÚ· Ë ÛÈÁΤÏÏ· ·fi Ù· ÎfiÚ·Ó· Î·È ÌÂÈÒÓÂÙ·È Ë ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Ù˘ ÓfiÛÔ˘ (5). ∞·ÈÙÂ›Ù·È ‚‚·›ˆ˜ ‡ÏÔÁË ¯Ú‹ÛË ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. °È· ÙËÓ ÙÂÏÈ΋ ·fiÊ·ÛË ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Ú¤ÂÈ ÂÈÈϤÔÓ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·È ÔÈ Û˘Óı‹Î˜ οı ¯ÒÚ·˜. ™ÙË ÌÂϤÙË Ì·˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÔÛÔÛÙ¿ ·ÓıÂÎÙÈÎfiÙËÙ·˜ ·Ó¿ÏÔÁ· Ì ·˘Ù¿ ¿ÏÏˆÓ Â˘Úˆ·˚ÎÒÓ ¯ˆÚÒÓ Î·È Û·ÊÒ˜ ¯·ÌËÏfiÙÂÚ· ·fi Ù· ·ÓÙ›ÛÙÔȯ· ÙˆÓ ¯ˆÚÒÓ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘, fiÔ˘ Ë ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË ·ÁÁ›˙ÂÈ ÙÔ 97% Î·È ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË ÙÔ 93% (6,13). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ÂÌÊ·Ó›˙ÂÈ Î·È Ë ÁÂÈÙÔÓÈ΋ ¯ÒÚ· Ù˘ ∞Ï‚·Ó›·˜, Ì ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË 87% Î·È ÛÙËÓ TMP-SMZ 48,5% (14). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ, ·Ú¿ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘, Ô Î›Ó‰˘ÓÔ˜ ÂÓÙÔÈÛÌ¤ÓˆÓ ÂȉËÌÈÒÓ Â›Ó·È ¿ÓÙ· ˘·ÚÎÙfi˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·fiÙÔÌË ¤Í·ÚÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜, ÙfiÛÔ Û ·È‰È¿ fiÛÔ Î·È Û ÂÓ‹ÏÈΘ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘, Ë ÛÈÁΤÏψÛË ÂÌÊ·Ó›˙ÂÙ·È Ì ÛÔÚ·‰Èο Û˘Ó‹ıˆ˜ ÎÚÔ‡ÛÌ·Ù·. ªÂ ÙËÓ ¤ÁηÈÚË ÂÓ˘‰¿ÙˆÛË, Ë ¤Î‚·ÛË Â›Ó·È ¿ÚÈÛÙË. °È· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ȉȷ›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ Ë ˘ÁÈÂÈÓ‹ ÙˆÓ ÎÂÓÙÚÈÎÒÓ ‰ÈÎÙ‡ˆÓ ‡‰Ú¢Û˘, ηıÒ˜ Î·È ÔÈ ·˘ÛÙËÚÔ› ηÓfiÓ˜ ·ÙÔÌÈ΋˜ ˘ÁÈÂÈÓ‹˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gomez HF, Cleary TG. Shigella. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 4th ed. Philadelphia: WB Saunders; 1998. p. 1307-1317. 2. ∂ȉËÌÈÔÏÔÁÈÎfi ¢ÂÏÙ›Ô §ÔÈ̈‰ÒÓ ¡ÔÛËÌ¿ÙˆÓ ∂ÏÏ¿‰Ô˜. ªËÓÈ·›· ¤Î‰ÔÛË ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ ∂ȉÈÎÒÓ §ÔÈÌÒ͈Ó, π·ÓÔ˘¿ÚÈÔ˜ 2000. 3. Tsiara St, Famelias J, Christou L, Bourantas KL, Tsianos E. A shigellosis Ôutbreak in an urban area. 2nd European Congress of Chemotherapy and 7th Biennial Conference of Antiinfective Agents and Chemotherapy. Hamburg, May 1998, Abstract Book M 325. 4. Kavaliotis J, Karyda S, Konstantoula T, Kansouzidou A, Tsagaropoulou H. Shigellosis of childhood in northern
Paediatriki 2002;65:182-185
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Greece: epidemiological, clinical and laboratory data of hospitalized patients during the period 1971-96. Scand J Infect Dis 2000;32:207-211. American Academy of Pediatrics. Shigella infections. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk. Grove Village, IL: American Academy of Pediatrics; 2000. p. 510-512. Khalil K, Khan SR, Mazhar K, Kaijser B, Lindblom GB. Occurrence and susceptibility to antibiotics of Shigella species in stools of hospitalized children with bloody diarrhea in Pakistan. Am J Trop Med Hyg 1998;58:800-803. Bhimma R, Rollins NC, Cooradia HM, Adhikan M. Postdysenteric hemolytic uremic syndrome in children during an epidemic of Shigella dysentery in Kwazulu/Natal. Pediatr Nephrol 1997;11:560-564. Khan WA, Dhar U, Salam MA, Griffiths JK, Rand W, Bennish ML. Central nervous system manifestations of childhood shigellosis. Prevalence, risk factors and outcome. Pediatrics 1999;103:E18. Ozturk MK, Caksen H, Sumerkan B. Convulsions in childhood shigellosis and antimicrobial resistance patterns of shigella isolates. Turk J Pediatr 1996;38:183-188. Askenazi S, Cleary KR, Pickering LK, Murray BE, Cleary TG. The association of Shiga toxin and other cytotoxins with the neurologic manifestations of shigellosis. J Infect Dis 1990;161:961-965. Zvulunov A, Lerman M, Ashkenazi S, Weitz R, Nitzan M, Dinari G. The prognosis of convulsions during childhood shigellosis. Eur J Pediatr 1990;149:293-294. Lahat E, Katz Y, Bistritzer T, Eshel G, Aladjem M. Recurrent seizures in children with Shigella-associated convulsions. Ann Neurol 1990;28:393-395. Navia MM, Capitano L, Ruiz J, Vargas M, Urassa H, Schellemberg D et al. Typing and characterization of mechanisms of resistance of Shigella spp. isolated from feces of children under 5 years of age from Ifakara, Tanzania. J Clin Microbiol 1999;37:3113-3117. Lito Cj, Zaho I, Saraci Sh, Foto E, Venecka E, Grimci L et al. Treatment of shigellosis in paediatric patients. Europaediatrics 2000, Rome March 2002, Abstract book p. 164.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 08-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 08-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∆˙Ô‡ÊË ªÂÚfiË ∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ T.£. 1186, ∆.∫. 451 10, πˆ¿ÓÓÈÓ·
185
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·186
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2002;65:186-194
ORIGINAL ARTICLE
™˘ÌÂÚÈÊÔÚ¿, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹, ÙËÏÂı¤·ÛË Î·È ·È¯Ó›‰È Ì·ıËÙÒÓ ÛÙÔȯÂÈÒ‰Ô˘˜ Âη›‰Â˘Û˘ ÛÙËÓ ∫Ú‹ÙË ∫. ∞Ó˘Ê·ÓÙ¿Î˘1, ª. ∞Ó˘Ê·ÓÙ¿ÎË1, ∂. •˘ÏÔ‡ÚË 1, ∂. ™·Îο1, Ã. §ÈÔÓ‹˜2, ¡. ∞ÓÙˆÓ¿Î˘1,2
Nutritional habits, TV viewing, body health care and playing behavior of elementary school students in Crete, Greece K. Anyphantakis1, M. Anyphantaki1, I. Xylouri1, I. Sakka1, C. Lionis2, N. Antonakis1,2
¶ÂÚ›ÏË„Ë: ¢ÈÂÚ¢ÓÒÓÙ·È Ù˘¯fiÓ ‰È·ÊÔÚ¤˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È·ÙÚÔÊ‹, ÙÔ ·È¯Ó›‰È, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ Î·È ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ ÌÂٷ͇ Ì·ıËÙÒÓ ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ∫Ú‹Ù˘ Î·È Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ÂÓÙÔÈÛÙÔ‡Ó Ï¿ıË Î·È Ó· ÚÔÙ·ıÔ‡Ó Ï‡ÛÂȘ. ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 284 ·È‰È¿, 6 ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ Ù˘ ∫Ú‹Ù˘. ∆· 4 ‚Ú›ÛÎÔÓÙ·Ó ÛÙËÓ ‡·ÈıÚÔ, ÂÓÒ Ù· 2 Û ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ∏ ÏËÚÔÊÔÚ›· Û˘ÏϤ¯ıËΠ̠ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ Û˘ÌÏËÚˆÓfiÙ·Ó ÛÙÔ Û¯ÔÏ›Ô, ·ÚÔ˘Û›· ‰·ÛÎ¿ÏˆÓ Î·È ÂÚ¢ÓËÙÒÓ. ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÎfiÎÎÈÓÔ Î·È ¿ÛÚÔ ÎÚ¤·˜ (p<0,02), ÂÓÒ Ë Î·Ù·Ó¿ÏˆÛË Ù˘ÔÔÈËÌ¤ÓˆÓ ÙÚÔÊÒÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚË Û ·È‰È¿ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (p<0,001). ∆· ·È‰È¿ Ù˘ ˘·›ıÚÔ˘ ›¯·Ó Û˘¯ÓfiÙÂÚ· ÙÂÚˉÔÓÈṲ̂ӷ ‰fiÓÙÈ· (p<0,0005). ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤‚ÏÂ·Ó ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË (p<0,03), ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÙËÓ ÒÚ· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË (p<0,0005). ∆· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤·È˙·Ó Û˘¯ÓfiÙÂÚ· ̤۷ ÛÙÔ Û›ÙÈ (p<0,0001), ÂÚ·ÙÔ‡Û·Ó ÏÈÁfiÙÂÚÔ (p<0,001) Î·È ¤·È˙·Ó Û˘¯ÓfiÙÂÚ· ηıÈÛÙÈο ·È¯Ó›‰È· (p<0,0001). ∏ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ·È¯ÓȉÈÔ‡ Î·È ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘. ∫·Ù·ÁÚ¿ÊËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË, Ô˘ Èı·ÓfiÓ ÔÊ›ÏÔÓÙ·Ó ÛÙÔÓ ÙÚfiÔ ˙ˆ‹˜ Ô˘ ‰È·Ê¤ÚÂÈ ÌÂٷ͇ ˘·›ıÚÔ˘ Î·È fiÏ˘, ·ÏÏ¿ Î·È ÛÙȘ ÔÏÂÔ‰ÔÌÈΤ˜ Û˘Óı‹Î˜ Ù˘ fiÏ˘. ∆· ·È‰È¿ ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi Ù· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· Î·È ÛÙÚ¤ÊÔÓÙ·È ÛÙËÓ
Abstract: The behavior of elementary school students associated with nutrition, TV viewing, playing and body health care, was investigated in a rural and an urban area of Crete, Greece. This study attempts to examine wrong behaviors and to suggest possible solutions. A questionnaire was used to register these behaviors in 6 elementary schools (2 in urban and 4 in rural areas). The questionnaires were completed with the assistance of the teachers and the investigators. 284 children (142 males, 142 females) comprised the population of the study. Children from rural areas, as compared to children from urban areas, were eating more red and white meat (p<0.02), while children from urban areas were eating larger amounts of conserved foods (p<0.001). Children from rural areas demonstrated more dental caries (p<0.0005), and were spending more time watching TV (p<0.03), Children from urban areas most often consumed food while watching TV (p<0.0005). Children from urban areas were spending more time playing in the house (p<0.0001), walked less (p<0.001) and often played table games (p<0.0001). The age and the gender were correlated with playing behavior and exercise. The differences observed between rural and urban areas were possibly the result of the different life style especially in the urban areas which tend to be overcrowded. In the urban areas the children cannot play traditional games outside the home and therefore they spend more time playing in the house. Better health education, housing improvement in the cities and development
1 ∫¤ÓÙÚÔ ÀÁ›·˜ ∞ÓˆÁ›ˆÓ, ∫Ú‹ÙË 2 ∫ÏÈÓÈ΋ ∫ÔÈÓˆÓÈ΋˜ Î·È OÈÎÔÁÂÓÂȷ΋˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
1 Anogia Health Center, Crete 2 Clinic of Social and Family Medicine of University of Crete
186
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·187
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
ÙËÏÂfiÚ·ÛË Î·È ÛÙ· ηıÈÛÙÈο ·È¯Ó›‰È·. ∏ ·ÁˆÁ‹ ˘Á›·˜, Ë ‚ÂÏÙ›ˆÛË Ù˘ ¯ˆÚÔÙ·Í›·˜ ÙˆÓ fiÏÂˆÓ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÚfiÏ˄˘ ÛÙËÓ ‡·ÈıÚÔ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ‰ÈÂÚÂ˘Ó‹Û·ÌÂ.
of prevention programs in the rural areas are possible solutions for these problems.
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÙÚÔÊ‹, ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹, ÙËÏÂfiÚ·ÛË, ·È¯Ó›‰È, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹.
Key words: nutrition, TV viewing, playing, body health care, rural areas.
™˘ÓÙÔÌÔÁڷʛ˜
Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿ ¤¯ÂÈ Â›Û˘ Û˘Û¯ÂÙÈÛÙ› Ì η΋ ·fi‰ÔÛË ÛÙÔ Û¯ÔÏÂ›Ô (20), ‚›·ÈË Û˘ÌÂÚÈÊÔÚ¿ (17,21), Ì›ˆÛË ÙˆÓ Â˘Î·ÈÚÈÒÓ ÁÈ· Û˘˙‹ÙËÛË Ì ٷ ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (22) Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ (23). ∆Ô ·È¯Ó›‰È Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ Î·È ÓÂ˘Ì·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Î·È ıˆÚÂ›Ù·È Ì¤ÛÔ ÎÔÈÓˆÓÈÎÔÔ›ËÛ˘, ·ÁˆÁ‹˜ Î·È Ì¿ıËÛ˘ (24). ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ô ÙÚfiÔ˜ Ô˘ ·›˙Ô˘Ó Ù· ·È‰È¿ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ Î·È Ù· ËÏÂÎÙÚÔÓÈο ·È¯Ó›‰È· ¤¯Ô˘Ó ÂÈÛ‚¿ÏÂÈ ÛÙ· Û›ÙÈ· Î·È ··Û¯ÔÏÔ‡Ó ÔÏϤ˜ ÒÚ˜ Ù· ·È‰È¿ (4). ∆· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· ·ÓÔÈÎÙÔ‡ ¯ÒÚÔ˘ ‰ÂÓ Â›Ó·È Û‹ÌÂÚ· ÛÙȘ ÚÒÙ˜ ÚÔÙÈÌ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ·˘Ù¿ Ó· ÎÈÓÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ (4). ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ·ÎfiÌË ·Ú¿ÌÂÙÚÔ Ô˘ Û˘Ó‰¤ÂÙ·È Î·È Ì ÙËÓ ·¯˘Û·ÚΛ· Î·È Ì ÙËÓ Î·Î‹ ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘ Î·È ¤¯ÂÈ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·¯˘Û·ÚΛ·˜, η΋˜ ¯Ú‹Û˘ Ù˘ ÙËÏÂfiÚ·Û˘ Î·È ·ÏÏ·Á‹˜ ÛÙ· ·È¯Ó›‰È· Ô˘ ·›˙Ô˘Ó Ù· ·È‰È¿ Û‹ÌÂÚ·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ‰ÈÂÚ¢ӋÛÂÈ ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Ì·ıËÙÒÓ ‚·ÛÈ΋˜ Âη›‰Â˘Û˘, ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ, Û ۯ¤ÛË Ì ÙË ‰È·ÙÚÔÊ‹, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙÔ ·È¯Ó›‰È Î·È ÙË ÊÚÔÓÙ›‰· Ù˘ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, Ó· ÂÓÙÔ›ÛÂÈ Ù˘¯fiÓ Ï·Óı·Ṳ̂Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ Î·È Ó· ÚÔÙ›ÓÂÈ Ï‡ÛÂȘ.
∏.¶.∞. MS SPSS TV SD p df
∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ∞ÌÂÚÈ΋˜ Microsoft Statistical Package for Social Sciences Television Standard Deviation ™˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜
∂ÈÛ·ÁˆÁ‹ ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙȘ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ Û˘Ó‹ıÂȘ, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ·ÏÏ¿ Î·È ÙÔ ·È¯Ó›‰È ÂËÚ¿˙ÂÈ ¿ÌÂÛ· Î·È Ì·ÎÚÔÚfiıÂÛÌ· ÙË ÛˆÌ·ÙÈ΋ Î·È ÙËÓ „˘¯È΋ ÙÔ˘˜ ˘Á›· (1-4). OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚԷӷʤÚıËÎ·Ó Û¯ÂÙ›˙ÔÓÙ·È ÌÂٷ͇ ÙÔ˘˜ (2) Î·È Û‹ÌÂÚ· ÂÈÎÚ·Ù› Ë ·ÓÙ›ÏË„Ë fiÙÈ Ë ÚfiÏË„Ë Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·fi Ôχ ÌÈÎÚ‹ ËÏÈΛ· (5), ÂÓÒ ÂÎ·È‰Â˘ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (6). ™‹ÌÂÚ·, Ë ·¯˘Û·ÚΛ· ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈÎfiÙ·ÙË ¯ÚfiÓÈ· ÓfiÛÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ë ·‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ·ÚÔÌÔÈ¿˙ÂÙ·È Ì ÙËÓ ·Ê‡ÓÈÛË ÎÔÈÌÒÌÂÓÔ˘ Á›Á·ÓÙ· (1,7). ∏ Û˘Û¯¤ÙÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ì ÙË ÌÂÏÏÔÓÙÈ΋ ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ·fi ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· ¤¯ÂÈ ÙÔÓÈÛÙ› ·fi ÔÏÏÔ‡˜ Û˘ÁÁÚ·Ê›˜ (8,9). ∂›Û˘, Ë ·¯˘Û·ÚΛ· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÔÏϤ˜ ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ Ë ˘¤ÚÙ·ÛË, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È ÔÈ Î·ÎÒÛÂȘ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (9-13). OÈ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ·¯˘Û·ÚΛ·˜, fiˆ˜ Ë ÌÂȈ̤ÓË ·˘ÙÔÂÎÙ›ÌËÛË, Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó ›Û˘ ÙÔÓÈÛÙ› (14). ∏ ÙËÏÂfiÚ·ÛË ·Ó·ÌÊÈÛ‚‹ÙËÙ· ¤¯ÂÈ ÂÈÛ‚¿ÏÂÈ ‰˘Ó·ÌÈο ÛÙË ˙ˆ‹ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ·È‰ÈÒÓ (15,16) Î·È ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ù· ·È‰È¿ ÛÙȘ ∏.¶.∞. ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÙfiÛ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË fiÛ˜ Î·È Ì¿ıËÌ· ÛÙÔ Û¯ÔÏÂ›Ô (17). ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ıÂÙÈο Ì ÙËÓ ·¯˘Û·ÚΛ·, ·ÊÂÓfi˜ ÌÂÓ ÁÈ·Ù› ÌÂÈÒÓÂÙ·È Ë Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡ Î·È ·ÊÂÙ¤ÚÔ˘ ÁÈ·Ù› Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ÙÚÒÓ ¤ÙÔÈ̘ (Û˘Û΢·Ṳ̂Ó˜) ÙÚÔʤ˜ fiÙ·Ó ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÙËÏÂfiÚ·ÛË (2,18,19). ∏ ˘ÂÚ‚ÔÏÈ΋ Î·È ¯ˆÚ›˜ ÂÈÏÔÁ‹ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·-
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó fiÏ· Ù· ·È‰È¿ ÙˆÓ ÙÂÛÛ¿ÚˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ Ù¿ÍÂˆÓ ÙÔ˘ ‰ËÌÔÙÈÎÔ‡, Û ¤ÍÈ ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ∫Ú‹Ù˘. ∆· Ù¤ÛÛÂÚ· ‰ËÌÔÙÈο Û¯ÔÏ›· (∞ÍÔ‡, µÂÓ›Ô˘, ∑ˆÓÈ·ÓÒÓ, ∞ÓˆÁ›ˆÓ) ‚Ú›ÛÎÔÓÙ·È Û ÔÚÂÈÓ‹ ·ÁÚÔÙÔÎÙËÓÔÙÚÔÊÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ÓÔÌÔ‡ ƒÂı‡ÌÓ˘. ∆· ˘fiÏÔÈ· ‰‡Ô ‚Ú›ÛÎÔÓÙ·È Û ˘ÎÓÔηÙÔÈÎË̤Ó˜ ÂÚÈÔ¯¤˜ Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ (13Ô Î·È 42Ô ‰ËÌÔÙÈο Û¯ÔÏ›· ∏Ú·ÎÏ›Ԣ). ∆· ·È‰È¿ Û˘ÌÏ‹ÚˆÛ·Ó ·ÓÒÓ˘ÌÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ¯ˆÚÈ˙fiÙ·Ó Û ¤ÓÙ ÂÓfiÙËÙ˜: ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙÔ˘ ·È‰ÈÔ‡, Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜, Û˘Ó‹ıÂȘ Û¯ÂÙÈΤ˜ Ì ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹, Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ Î·È Ì ÙÔ ·È¯Ó›‰È. OÈ ÂÚˆÙ‹ÛÂȘ ‹Ù·Ó ·Ï¤˜ Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ÔÏÏ·Ï‹˜ ÂÈÏÔÁ‹˜. ∏ Û˘ÌÏ‹ÚˆÛË ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ ¤ÁÈÓ ηٿ ÙÔ˘˜ Ì‹Ó˜ ™Â٤̂ÚÈÔ Î·È OÎÙÒ‚ÚÈÔ ÙÔ˘ ¤ÙÔ˘˜ 2000, ·ÚÔ˘Û›· ÙˆÓ ÂÚ¢ÓËÙÒÓ Î·È ÙˆÓ ‰·ÛοψÓ, ̤۷ ÛÙËÓ Ù¿ÍË. ¶ÚÈÓ ·fi ÙË
187
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·188
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
Û˘ÌÏ‹ÚˆÛË ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ, Ô ÂÚ¢ÓËÙ‹˜ ÂÍËÁÔ‡Û ÛÙ· ·È‰È¿ ÙÔ ÛÎÔfi Î·È ÙÔÓ ÙÚfiÔ Û˘ÌÏ‹ÚˆÛ˘ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ Î·È Ù· ηıÔ‰ËÁÔ‡Û Ì ÛÙÂÚÂfiÙ˘Â˜ Ô‰ËÁ›Â˜ ÛÙË Û˘ÌÏ‹ÚˆÛ‹ ÙÔ˘. ∆· ‰Â‰Ô̤ӷ Ô˘ Û˘ÁÎÂÓÙÚÒıËÎ·Ó Î·Ù·¯ˆÚ‹ıËÎ·Ó Û ËÏÂÎÙÚÔÓÈ΋ ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ηٷÛ΢¿ÛÙËΠÁÈ· ÙȘ ·Ó¿ÁΘ Ù˘ ÌÂϤÙ˘ Î·È Ë ÂÂÍÂÚÁ·Û›· ¤ÁÈÓ Ì ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ù· ÚÔÁÚ¿ÌÌ·Ù· MS Access 2000, MS Excel 2000 Î·È SPSS 10.1. OÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó ÙÔ t test ÁÈ· ÙË Û‡ÁÎÚÈÛË Ì¤ÛˆÓ ÙÈÌÒÓ, ÙÔ ¯2 test ÁÈ· ÙË Û‡ÁÎÚÈÛË ÔÛÔÛÙÒÓ, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ·Ú·ÌÂÙÚÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ÌË ·Ú·ÌÂÙÚÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ Î·È Ë Logistic Regression ·Ó¿Ï˘ÛË ÁÈ· Û˘Û¯ÂÙ›ÛÂȘ ÛÙȘ Ôԛ˜ ÂÌϤÎÔÓÙ·Ó ‰ÈˆÓ˘ÌÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜.
∞ÔÙÂϤÛÌ·Ù· O Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Ï·‚·Ó ̤ÚÔ˜ ÛÙË ÌÂϤÙË ‹Ù·Ó 284 (142 ·ÁfiÚÈ· Î·È 142 ÎÔÚ›ÙÛÈ·). ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Ô˘ Û˘ÌÏËÚÒıËÎ·Ó ‹Ù·Ó ›Û˘ 284, ÂÓÒ ˘‹Ú¯·Ó 8 Û˘ÓÔÏÈο ·Ó·¿ÓÙËÙ˜ ÂÚˆÙ‹ÛÂȘ Û 8 ‰È·ÊÔÚÂÙÈο ÂÚˆÙËÌ·ÙÔÏfiÁÈ· (ÔÛÔÛÙfi ·Ó·¿ÓÙËÙˆÓ ÂÚˆÙ‹ÛÂˆÓ 0,07%). ∞fi Ù· 284 ·È‰È¿, Ù· 133 (70 ·ÁfiÚÈ·, 63 ÎÔÚ›ÙÛÈ·) ÚÔ¤Ú¯ÔÓÙ·Ó ·fi Ù· Ù¤ÛÛÂÚ· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ˘·›ıÚÔ˘ Î·È Ù· ˘fiÏÔÈ· 151 (72 ·ÁfiÚÈ·, 79 ÎÔÚ›ÙÛÈ·) ·fi Ù· ‰‡Ô ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ. ∏ ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ËÏÈΛ· Î·È Ê‡ÏÔ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜: ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (n=151, ÔÛÔÛÙfi 51,2%) ·¿ÓÙËÛ·Ó fiÙÈ ¤ÙÚˆÁ·Ó 5 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, 88 ·È‰È¿ (31%) ¤ÙÚˆÁ·Ó 4 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, 43 (15,1%) 3 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ Î·È ÌfiÓÔ 2 ·È‰È¿ (0,7%) 2 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ. ¢ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ··ÓÙ‹ÛÂˆÓ ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ Î·È ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ ÁÂ˘Ì¿ÙˆÓ ·Ó¿ Ë̤ڷ (t value=1,93, df=282, p>0,05). ™ÙÔÓ ¶›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ··ÓÙ‹ÛÂˆÓ ÛÙȘ ÂÚˆÙ‹ÛÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ·È‰ÈÒÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (59,6%) ·¿ÓÙËÛ·Ó fiÙÈ ¤ÙÚˆÁ·Ó ÁÈ· ÚˆÈÓfi ¤ÙÔȶ›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ηٿ ËÏÈΛ· Î·È Ê‡ÏÔ
8 ÂÙÒÓ (3Ë Ù¿ÍË) 9 ÂÙÒÓ (4Ë Ù¿ÍË) 10 ÂÙÒÓ (5Ë Ù¿ÍË) 11 ÂÙÒÓ (6Ë Ù¿ÍË) ™‡ÓÔÏÔ
188
∞ÁfiÚÈ
∫ÔÚ›ÙÛÈ
™‡ÓÔÏÔ
23 41 33 45 142
38 38 31 35 142
61 79 64 80 284
Ì· Ù˘ÔÔÈË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ÂÓÒ Ù¤ÙÔÈ· ÙÚfiÊÈÌ· ¤ÙÚˆÁ·Ó Ôχ Ï›Á· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (3,8%). ∏ ‰È·ÊÔÚ¿ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∞Ó¿ÏÔÁ· ·ÔÙÂϤÛÌ·Ù· ¤‰ˆÛÂ Î·È Ë ·Ó¿Ï˘ÛË ÙˆÓ ··ÓÙ‹ÛÂˆÓ Û¯ÂÙÈο Ì ÙÔ ·ÔÁÂ˘Ì·ÙÈÓfi Ê·ÁËÙfi. ∆Ô 34,5% ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤ÙÚˆÁ·Ó ÁÈ· ÚˆÈÓfi Ù˘ÔÔÈË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ¤ÙÚˆÁ ÙÔÓ ›‰ÈÔ Ù‡Ô ÙÚÔÊ›ÌˆÓ Î·È ÙÔ ·fiÁÂ˘Ì·. ∂›Û˘, Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ú¤ıËΠfiÙÈ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÎfiÎÎÈÓÔ, ·ÏÏ¿ Î·È ¿ÛÚÔ, ÎÚ¤·˜ Û ۯ¤ÛË Ì ٷ ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). µÚ¤ıËÎÂ, Ù¤ÏÔ˜, fiÙÈ ˘‹Ú¯Â ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ ÙˆÓ ·È‰ÈÒÓ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ Ì ÙËÓ ÔÔ›· ¤ÙÚˆÁ·Ó ¯fiÚÙ· (Rs=0,240, p<0,001). ™ˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹: OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ ‰ÔÓÙÈÒÓ ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∆Ô 10,5% ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ‰ÂÓ ‚Ô‡ÚÙÛÈ˙ ηıfiÏÔ˘ Ù· ‰fiÓÙÈ· ÙÔ˘, ¤Ó·ÓÙÈ ÙÔ˘ 1,3% ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿). ∂›Û˘, ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ô‡ÚÙÛÈ˙·Ó Û˘¯ÓfiÙÂÚ· Ù· ‰fiÓÙÈ· ÙÔ˘˜ Î·È Â›¯·Ó ÏÈÁfiÙÂÚ· ¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ›¯Â ÛÊÚ·Á›ÛÌ·Ù· ‰ÂÓ ‰È¤ÊÂÚ ÛÙȘ ‰‡Ô ÂÚÈÔ¯¤˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙËÓ Î·ı·ÚÈfiÙËÙ· ÙÔ˘ ÛÒÌ·ÙÔ˜ (¶›Ó·Î·˜ 4), Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ï¤ÓÔÓÙ·Ó Û˘¯ÓfiÙÂÚ·, ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÂÚÈÔÈÔ‡ÓÙ·Ó Û˘¯ÓfiÙÂÚ· Ù· Ó‡¯È· ÙÔ˘˜. ŸÏ˜ ÔÈ ·Ú·¿Óˆ ‰È·ÊÔÚ¤˜ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. ¶·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘: ™ÙÔÓ ¶›Ó·Î· 5 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘. ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË ÙȘ ηıËÌÂÚÈÓ¤˜ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿), ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÙËÓ ÒÚ· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË Î·È Ì¿ÏÈÛÙ· ¤ÙÚˆÁ·Ó Ù˘ÔÔÈË̤ӷ - Û˘ÓÙËÚË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ·ÏÏ¿ Î·È Ì·ÁÂÈÚÂ̤ÓÔ ÛÙÔ Û›ÙÈ Ê·ÁËÙfi (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). ∆Ô 80,1% ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ ÂÓÒ ¤‚Ï ÙËÏÂfiÚ·ÛË. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Û¯ÂÙÈο Ì ÙËÓ ÒÚ· Ô˘ ÛÙ·Ì·ÙÔ‡Û·Ó Ó· ‚Ï¤Ô˘Ó ÙËÏÂfiÚ·ÛË ÙÔ ‚Ú¿‰˘ Î·È Û¯ÂÙÈο Ì ÙÔ ÔÈÔ˜ ¤ÏÂÁ ٷ ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ·È‰È¿. ™Â ÔÛÔÛÙfi 38% Ù· ·È‰È¿ ·ÔÊ¿ÛÈ˙·Ó ÌfiÓ· ÙÔ˘˜ ÁÈ· ÙÔ ÚfiÁÚ·ÌÌ· Ô˘ ı· ·Ú·ÎÔÏÔ˘ı‹ÛÔ˘Ó Î·È Û ÔÛÔÛÙfi 27,5% ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ÚÔ‚¿ÏÏÔÓÙ·Ó ÌÂÙ¿ ÙȘ 9:00 ÌÌ.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·189
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
¶›Ó·Î·˜ 2. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ÂÚˆÙ‹ÛÂȘ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜. ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙÚˆ˜ οı Ë̤ڷ; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ÎfiÎÎÈÓÔ ÎÚ¤·˜; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ¿ÛÚÔ ÎÚ¤·˜; (fi¯È „¿ÚÈ) ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ¯fiÚÙ·; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ „¿ÚÈ;
ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p
4,46 ± 0,7
4,28 ± 0,8
1,93
282
ª™**
2,27 ± 1,5
1,81 ± 1,6
2,42
282
<0,02
1,83 ± 1,2
1,45 ± 1
2,72
282
<0,01
4,16 ± 2,4
4,59 ± 2,6
-1,46
282
ª™
1,63 ± 1,2
1,87 ± 1,3
-1,54
282
ª™
∂ÚÒÙËÛË
ñ ∆È ÙÚˆ˜ ÙÔ Úˆ›; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÛÙÔ Û¯ÔÏ›Ô; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ÌÂÛË̤ÚÈ; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ·fiÁÂ˘Ì·; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ‚Ú¿‰˘; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·;
£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test
n1
%
n2
%
¯2
5 111 17
3,76 83,46 12,78
90 37 23
59,60 24,50 15,23
96,39 96,15 0,18
1 <0,0001 1 <0,0001 1 ª™
43 85 5
32,33 63,91 3,76
50 92 9
33,11 60,93 5,96
0,00 1,15 0,32
1 1 1
ª™ ª™ ª™
1 129 2
0,75 96,99 1,50
2 147 1
1,32 97,35 0,66
1,01 0,03 0,01
1 1 1
ª™ ª™ ª™
27 67 38
20,30 50,38 28,57
58 36 56
38,41 23,84 37,09
10,21 20,41 1,94
1 <0,002 1 <0,0005 1 ª™
2 119 11
1,50 89,47 8,27
12 122 16
7,95 80,79 10,60
4,97 3,49 0,21
1 1 1
df
p
<0,05 ª™ ª™
* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
¶›Ó·Î·˜ 3. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ Î·Ù¿ÛÙ·ÛË Î·È ÙËÓ ˘ÁÈÂÈÓ‹ ÙˆÓ ‰ÔÓÙÈÒÓ ÙÔ˘˜
∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‚Ô˘ÚÙÛ›˙ÂȘ Ù· ‰fiÓÙÈ· ÛÔ˘; ∂ÚÒÙËÛË
ñ Œ¯ÂȘ ¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·; ñ Œ¯ÂȘ ÛÊÚ·Á›ÛÌ·Ù·; ñ µÔ˘ÚÙÛ›˙ÂȘ Ù· ‰fiÓÙÈ· ÛÔ˘;
ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜ 2,17 ± 1,1
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df** p
2,64 ± 1,3
-3,26
£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜ n1 75 54 119
% 56,39 40,60 89,47
n2 39 64 149
% 25,83 42,38 98,68
282
<0,001
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test ¯2 26,22 0,03 9,61
df* 1 1 1
p <0,0005 ª™** <0,005
* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
189
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·190
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
¶›Ó·Î·˜ 4. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· οÓÂȘ ÔÏfiÛˆÌÔ Ì¿ÓÈÔ; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÏÔ‡˙ÂȘ ÙÔ ÎÂÊ¿ÏÈ ÛÔ˘; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙÔ Ì‹Ó· Îfi‚ÂȘ Ù· Ó‡¯È· ÛÔ˘;
ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
t-value
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË df*
p
2,86 ± 1,5
3,38 ± 2,3
-4,14
282
<0,0001
2,59 ± 1,7
3,24 ± 2,7
-2,40
282
<0,02
6,43 ± 3,7
5,1 ± 3,2
3,29
282
<0,001
* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ¶›Ó·Î·˜ 5. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘
∂ÚÒÙËÛË ñ ¶fiÛ˜ ÒÚ˜ ÙËÓ Ë̤ڷ ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ∂ÚÒÙËÛË
ñ ∆È ÙÚˆ˜ fiÙ·Ó ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ¶ÔÈÔ˜ ÂÈϤÁÂÈ Ù· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ‚ϤÂȘ ÛÙËÓ ÙËÏÂfiÚ·ÛË; ∂Û‡; OÈ ÁÔÓ›˜ ÛÔ˘; ∂Û‡ Î·È ÔÈ ÁÔÓ›˜ ÛÔ˘;
ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p
2,48 ± 1,7 3,89 ± 2,4
2,04 ± 1,6 3,57 ± 2,4
2,23 1,13
282 282
<0,03 ª™**
17,95 ± 6,0 17,99 ± 6,0
17,77 ± 6,0 17,73 ± 5,1
0,25 0,39
282 280
ª™ ª™
£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test
n1
%
n2
%
¯2
df
p
23 36 74
17,29 27,07 55,64
43 78 34
28,48 51,66 22,52
4,36 16,78 31,57
1 1 1
<0,05 <0,0005 <0,0005
50 23 60
37,59 17,29 45,11
57 27 68
37,75 17,88 45,03
0,00 0,00 0,01
1 1 1
ª™ ª™ ª™
* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
¶·È¯Ó›‰È: ∞fi ÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙÔ ·È¯Ó›‰È (¶›Ó·Î·˜ 6) ‚Ú¤ıËΠfiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ Ô˘ ‰È¤ıÂÙ·Ó Ù· ·È‰È¿ ÛÙȘ ·ÛÙÈΤ˜ Î·È ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ÁÈ· ·È¯Ó›‰È, ‚Ú¤ıËÎ·Ó fï˜ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙÔ Ò˜ ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó ÙÔ ¯ÚfiÓÔ ·˘Ùfi. ∂ÎÙfi˜ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6, ‚Ú¤ıËÎ·Ó ıÂÙÈΤ˜ Î·È ·ÚÓËÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ù˘ ËÏÈΛ·˜ Î·È ÙÔ˘ ʇÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ·È¯Ó›‰È, ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ (¶›Ó·Î·˜ 7). ¶·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘, ·ÏÏ¿ Î·È ÙÔ˘ ·È¯ÓȉÈÔ‡ ¤Íˆ ·fi ÙÔ Û›ÙÈ, Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜. ∆· ·ÁfiÚÈ· ‰··ÓÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ·fi Ù· ÎÔÚ›ÙÛÈ· ÁÈ· ·È¯Ó›‰È Î·È Ô ÂÈϤÔÓ ·˘Ùfi˜ ¯ÚfiÓÔ˜
190
·ÊÈÂÚˆÓfiÙ·Ó Û ·È¯Ó›‰È· ¤Íˆ ·fi ÙÔ Û›ÙÈ. ∆· ·È‰È¿ Ô˘ ‰‹ÏˆÛ·Ó fiÙÈ ¤·È˙·Ó ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ (n=216) ¤‚ÏÂ·Ó ÏÈÁfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ¤·È˙·Ó ηıÈÛÙÈο ·È¯Ó›‰È· (n=68) ÙȘ ηıËÌÂÚÈÓ¤˜ (t value=2,89, df=282, p<0,005), ·ÏÏ¿ Î·È Ù· ™·‚‚·ÙÔ·Úȷη (t value=3,33, df=282, p<0,001). ™˘˙‹ÙËÛË OÈ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÛÙȘ Û˘Ó‹ıÂȘ ÙˆÓ ·È‰ÈÒÓ ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÛÙË ÌÂϤÙË ·˘Ù‹ ‹Ù·Ó ÔÏϤ˜ Î·È ÂÓÙ˘ˆÛȷΤ˜. ∞Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Ë ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ô˘ ÂÈϤͷÌ ·¤¯ÂÈ ÂÚ›Ô˘ 40 ¯ÈÏÈfiÌÂÙÚ· ·fi ÙËÓ fiÏË ÙÔ˘ ∏Ú·ÎÏ›Ԣ Î·È 50 ¯ÈÏÈfiÌÂÙÚ· ·fi ÙËÓ fiÏË ÙÔ˘ ƒÂı‡ÌÓÔ˘. À¿Ú¯ÂÈ Û˘ÁÎÔÈÓˆÓ›· Ì ÙȘ fiÏÂȘ ·˘Ù¤˜ ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ Î·È ÔÈ Â-
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·191
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
¶›Ó·Î·˜ 6. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÒÚ˜ ÂÚ›Ô˘ ·›˙ÂȘ οı ̤ڷ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛ˜ ÒÚ˜ ·›˙ÂȘ ̤۷ ÛÙÔ Û›ÙÈ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛ˜ ÒÚ˜ ·›˙ÂȘ ¤Íˆ ·fi ÙÔ Û›ÙÈ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛË ÒÚ˜ ÂÚ·Ù¿˜ ÙËÓ Ë̤ڷ (Û ÏÂÙ¿); ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ∂ÚÒÙËÛË
ñ ∆È Â›‰Ô˘˜ ·È¯Ó›‰È· ·›˙ÂȘ; ∫·ıÈÛÙÈο ·È¯Ó›‰È· ¶·È¯Ó›‰È· Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ÙÚ¤ÍÂȘ
ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p
3,24 ± 1,9 5,26 ± 2,6
3,1 ± 1,9 5,46 ± 2,9
0,583 -0,59
282 282
ª™** ª™
1,07 ± 0,8 1,83 ± 1,4
1,53 ± 1,3 2,70 ± 2,1
-3,63 -4,03
281 281
<0,0001 <0,0001
2,18 ± 1,5 3,47 ± 1,9
1,57 ± 1,3 2,82 ± 2,0
3,68 2,51
281 282
<0,0001 <0,02
62,62 ± 57,2 87,91 ± 93,6
41,63 ± 51,2 50,83 ± 65,2
3,24 3,90
281 280
<0,001 <0,0001
£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test
n1
%
n2
%
¯2
df**
p
28 103
21,05 77,44
113 113
74,83 74,83
79,68 0,14
1 1
<0,0001 ª™
* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
ÚÈÛÛfiÙÂÚÔÈ Î¿ÙÔÈÎÔÈ ¤¯Ô˘Ó ȉȈÙÈ΋˜ ¯Ú‹Û˘ ·˘ÙÔΛÓËÙÔ. ∏ ËÏÂÎÙÚÔ‰fiÙËÛË ÙˆÓ ¯ˆÚÈÒÓ Ù˘ ÂÚÈÔ¯‹˜ Ô˘ ÂÈϤͷÌ ¤¯ÂÈ Á›ÓÂÈ ÚÈÓ ÙÔ 1970 Î·È Û¯Â‰fiÓ fiÏ· Ù· Û›ÙÈ· ‰È·ı¤ÙÔ˘Ó „ËÊȷΤ˜ ÙËÏÂʈÓÈΤ˜ ÁÚ·Ì̤˜. OÈ ÂÚÈÔ¯¤˜ Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ Ô˘ ÂÈϤͷÌÂ Â›Ó·È ˘ÎÓÔηÙÔÈÎË̤Ó˜, Ì ΢ÎÏÔÊÔÚÈ·Îfi Úfi‚ÏËÌ·, ¯ˆÚ›˜ ÔÏÏÔ‡˜ ·ÓÔÈÎÙÔ‡˜ ¯ÒÚÔ˘˜ Î·È Ì ·ÚÎÂÙ¿ ÔÈÎÔ‰ÔÌ‹Ì·Ù· ¯ˆÚ›˜ ÓfiÌÈÌË ¿‰ÂÈ·. ∏ Û˘Û¯¤ÙÈÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÙËÓ ÏÔ‡ÛÈ· Û ˙ˆÈο Ï›Ë ‰È·ÙÚÔÊ‹ (13) ¤¯ÂÈ ·Ó·ÁοÛÂÈ ÙÔ˘˜ ÁÔÓ›˜ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¿ÊıÔÓ· Ê˘ÙÈο ÙÚfiÊÈÌ· ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜, ÁÂÁÔÓfi˜ Ô˘ οÔȘ ÊÔÚ¤˜ ÊÙ¿ÓÂÈ ÛÙËÓ ˘ÂÚ‚ÔÏ‹ Î·È ‰ËÌÈÔ˘ÚÁ› ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ (25,26). ™ÙË ÌÂϤÙË Ì·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó ηٿ ̤ÛÔÓ fiÚÔ 1,8 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È 4,6 ÊÔÚ¤˜ ¯fiÚÙ· (¶›Ó·Î·˜ 2). ™ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ‹Ù·Ó ÌÈÎÚfiÙÂÚË (2,3 ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È 4,2 ¯fiÚÙ·). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ú¿ÁÌ·ÙÈ ˘¿Ú¯ÂÈ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ÁÔÓ¤ˆÓ ÛÙÔ ı¤Ì· Ù˘ ‰È·ÙÚÔÊ‹˜ Ì ÎÚ¤·˜, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÎfiÌË Û˘ÓÔÏÈο Ë ‰È·ÙÚÔÊ‹ Ì ˙ˆÈο ÙÚfiÊÈÌ· (ÎfiÎÎÈÓÔ ÎÚ¤·˜, ¿ÛÚÔ ÎÚ¤·˜, „¿ÚÈ) Â›Ó·È Û˘¯ÓfiÙÂÚË ·˘Ù‹˜
ÌÂ Ê˘ÙÈο (¶›Ó·Î·˜ 2). ™ÙË ÌÂϤÙË Ì·˜, ›Û˘, ‰È·ÈÛÙÒÛ·Ì fiÙÈ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ÙÔ˘ ·È‰ÈÔ‡ ÌÂȈÓfiÙ·Ó Ë Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ¤ÙÚˆÁ·Ó ¯fiÚÙ· (ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË) Î·È ·˘Ùfi ›Ûˆ˜ ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÙÚÔÊÒÓ ·fi Ù· ›‰È· Ù· ·È‰È¿ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ Î·È ÛÙËÓ Î·Î‹ ‰È··È‰·ÁÒÁËÛË ÙˆÓ ·È‰ÈÒÓ. ∆Ô Â‡ÚËÌ· fiÙÈ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù· ·È‰È¿ ¤ÙÚˆÁ·Ó ηٿ ̤ÛÔ fiÚÔ 2,5 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ¯fiÚÙ· ·fi fiÙÈ ÎfiÎÎÈÓÔ ÎÚ¤·˜ (¶›Ó·Î·˜ 2), ‰Â›¯ÓÂÈ fiÙÈ Èı·ÓfiÓ Î¿ÔȘ ÔÈÎÔÁ¤ÓÂȘ ÂÚÈfiÚÈ˙·Ó ˘ÂÚ‚ÔÏÈο ÙËÓ ÔÛfiÙËÙ· ˙ˆÈÎÒÓ ÙÚÔÊÒÓ ·fi ÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ (12 ·È‰È¿ ‰ÂÓ ¤ÙÚˆÁ·Ó ηıfiÏÔ˘ ÎfiÎÎÈÓÔ ÎÚ¤·˜, ÂÓÒ ‰‡Ô ·fi ·˘Ù¿ ‰ÂÓ ¤ÙÚˆÁ·Ó Ô‡Ù ¿ÛÚÔ ÎÚ¤·˜). ¶ÈÛÙ‡ԢÌ ÏÔÈfiÓ, fiÙÈ Û‹ÌÂÚ·, Ë ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Ú¤ÂÈ Ó· Â›Ó·È Î·È ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË ÙÔ˘ ÂÚÈÔÚÈÛÌÔ‡ ÙˆÓ ˙ˆÈÎÒÓ ÙÚÔÊÒÓ, ·ÏÏ¿ Î·È ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ ·ÚÎÔ‡˜ ÚfiÛÏ˄˘ ÙˆÓ ··Ú·›ÙËÙˆÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ô˘ÛÈÒÓ, ÛÙËÓ ÔÔ›· Ù· ˙ˆÈο ÙÚfiÊÈÌ· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ (25,26). ∏ ηٷӿψÛË ¤ÙÔÈÌˆÓ Ù˘ÔÔÈËÌ¤ÓˆÓ ÙÚÔÊÒÓ ÙÔ˘ ÂÌÔÚ›Ô˘ (snacks) ‚Ú¤ıËΠӷ Â›Ó·È Û˘¯Ó‹, ΢ڛˆ˜ ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (¶›Ó·Î·˜ 2). ∆· ÙÚfiÊÈÌ· ·˘Ù¿ Â›Ó·È Â‡Á¢ÛÙ· ηÈ
191
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·192
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Û˘¯Ó¿ ˆÏÔ‡ÓÙ·È Ì ÌÈÎÚ¿ “‰ÒÚ·” ̤۷ ÛÙË Û˘Û΢·Û›·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ù· ˙ËÙÔ‡Ó Â›ÌÔÓ· Ù· ·È‰È¿, ÂÓÒ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·ÔÙÂÏÔ‡Ó Â‡ÎÔÏË Ï‡ÛË. ∏ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙˆÓ ÙÚÔÊÒÓ ·˘ÙÒÓ Û ˙ˆÈο Ï›Ë Î·È Ë ·fi‰ÔÛ‹ ÙÔ˘˜ Û ıÂÚÌ›‰Â˜ Â›Ó·È ÌÂÁ¿ÏË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏÔ‡Ó ·¯˘Û·ÚΛ· Î·È Ó· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘, ÂÓÒ ¤¯Ô˘Ó ηÙËÁÔÚËı› fiÙÈ ÚÔηÏÔ‡Ó Ï‹ıÔ˜ ¿ÏÏˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ (1). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Â›¯·Ó ÛˆÛÙfiÙÂÚ˜ Û˘Ó‹ıÂȘ (¶›Ó·Î·˜ 2). ∏ ÙÂÏÂ˘Ù·›· ·˘Ù‹ ‰È·ÊÔÚ¿ Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Î·Ù·Ó·ÏÒÓÔ˘Ó, ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ Î‡ÚÈˆÓ ÁÂ˘Ì¿ÙˆÓ, ÙÚfiÊÈÌ· Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙȘ ·ÁÚÔÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘˜ Î·È ¤ÙÛÈ ·ÔʇÁÔ˘Ó Ù· ¤ÙÔÈÌ· ÙÚfiÊÈÌ·. ∆Ô ı¤Ì· ·˘Ùfi ··ÈÙ› ÂÚÈÛÛfiÙÂÚË ‰ÈÂÚ‡ÓËÛË. ∆Ô Â‡ÚËÌ· fiÙÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Î·È ÛÙȘ ·ÁÚÔÙÈΤ˜ Î·È ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ÙÚÒÓ ڈÈÓfi (¶›Ó·Î·˜ 2) ÛËÌ·›ÓÂÈ fiÙÈ ÔÈ ÁÔÓ›˜, ·ÏÏ¿ Î·È Ù· ›‰È· Ù· ·È‰È¿, Ú¤ÂÈ Ó· ÂÓËÌÂÚˆıÔ‡Ó ÁÈ· ÙË ÛËÌ·Û›· Ù˘ Ï‹„˘ ÚˆÈÓÔ‡. ¶¿ÓÙˆ˜, ·Ó¿ÏÔÁ· ÔÛÔÛÙ¿ ·Ú¿ÏÂȄ˘ ÙÔ˘ ÚˆÈÓÔ‡ Ê·ÁËÙÔ‡ ·Ó·Ê¤ÚÔÓÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ ·fi ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ (27). ∆Ô ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó¤ÊÂÚ·Ó Ô‰ÔÓÙÈ·ÙÚÈο ÚÔ‚Ï‹Ì·Ù· ÛÙȘ ‰‡Ô ÂÚÈÔ¯¤˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ÂÚ›Ô˘ ÙÔ ›‰ÈÔ Î·È ÂÚ›Ô˘ ›ÛÔ Ì ·˘Ùfi Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ¿ÏϘ ÌÂϤÙ˜ (28-29). OÈ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿„·Ì ۯÂÙÈο Ì ÙË ÛÙÔÌ·ÙÈ΋ ˘Á›· ÙˆÓ Ì·ıËÙÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈΤ˜ (¶›Ó·Î·˜ 3). ∆Ô ÔÛÔÛÙfi ÙˆÓ Ì·ıËÙÒÓ Ô˘ ·Ó¤ÊÂÚ·Ó fiÙÈ Â›¯·Ó “¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·”, ‰ËÏ·‰‹ ‰fiÓÙÈ· Ô˘ ›¯·Ó ÌË ıÂÚ·Â˘Ì¤ÓË ÙÂÚˉfiÓ·, ‹Ù·Ó ˘ÂÚ‰ÈÏ¿ÛÈÔ ÛÙȘ ·ÁÚÔÙÈΤ˜ ·fi fiÙÈ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ∂›Û˘, ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ô‡ÚÙÛÈ˙ ٷ ‰fiÓÙÈ· ÙÔ˘, Û ۯ¤ÛË Ì ٷ ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ, ·ÏÏ¿ Î·È Ù· ‚Ô‡ÚÙÛÈ˙·Ó ÏÈÁfiÙÂÚ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÌÔÚ› Ó· ·Ô‰ÔıÔ‡Ó ÛÙÔ ¯·ÌËÏfiÙÂÚÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (28), ·ÏÏ¿ Î·È ÛÙË ‰˘ÛÎÔÏfiÙÂÚË ÚfiÛ‚·Û‹ ÙÔ˘˜ Û ԉÔÓÙÈ·ÙÚÈΤ˜ ˘ËÚÂۛ˜. ™ÙËÓ ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ô˘ ÌÂÏÂÙ‹Û·Ì ‰ÂÓ ˘¿Ú¯ÂÈ Ô‰ÔÓÙ›·ÙÚÔ˜ Î·È ¤ÙÛÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ˘ËÚÂۛ˜ Ô‰ÔÓÙÈ·ÙÚÈ΋˜ ÚfiÏ˄˘, ·ÁˆÁ‹˜ ˘Á›·˜ Î·È ıÂڷ›·˜. ¶·Ú¿ ÙȘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿ÊËÎ·Ó Û¯ÂÙÈο Ì ÙËÓ ·ÙÔÌÈ΋ ˘ÁÈÂÈÓ‹ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ˘fi ÌÂϤÙË ÂÚÈÔ¯¤˜ (¶›Ó·Î·˜ 4), Ë ÂÓ·Û¯fiÏËÛ‹ ÙÔ˘˜ Ì ÙËÓ Î·ı·ÚÈfiÙËÙ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈ΋ Î·È ÁÈ· ÙȘ ‰‡Ô ÂÚÈÔ¯¤˜. ™ÙÔÓ ÙÔ̤· ·˘Ùfi, Ë ·ÁˆÁ‹ ˘Á›·˜ ı· ›¯Â Ï›-
192
Paediatriki 2002;65:186-194
Á· Ó· ÚÔÛʤÚÂÈ, ÙÔ˘Ï¿¯ÈÛÙÔÓ ˆ˜ ÚÔ˜ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÚˆÙ‹ıËÎ·Ó Ù· ·È‰È¿. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘, Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÏÈÁfiÙÂÚ˜ ÒÚ˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙËÏÂfiÚ·ÛË ·fi fiÙÈ Û ·ÓÙ›ÛÙÔÈ¯Ë ÌÂϤÙË ÙˆÓ ∏.¶.∞. (17). ™ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚË ÒÚ· ÙËÏÂfiÚ·ÛË, Û ۯ¤ÛË Ì ÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙȘ ηıËÌÂÚÈÓ¤˜ (¶›Ó·Î·˜ 5), Û ·ÓÙ›ıÂÛË Ì ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙËÓ πÛ·Ó›· (30), fiÔ˘ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‰··ÓÔ‡Û·Ó ÏÈÁfiÙÂÚË ÒÚ· ÛÙËÓ ÙËÏÂfiÚ·ÛË ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ. ∆Ô Â‡ÚËÌ· fiÙÈ Û¯Â‰fiÓ ÙÔ 38% ÙˆÓ ·È‰ÈÒÓ ‚ϤÂÈ ·ÓÂͤÏÂÁÎÙ· fi,ÙÈ ÚfiÁÚ·ÌÌ· ı¤ÏÂÈ Î·È ÙÔ Â‡ÚËÌ· fiÙÈ ÔÏÏ¿ ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ÚfiÁÚ·ÌÌ·Ù· Ô˘ ÚÔ‚¿ÏÏÔÓÙ·Ó ÌÂÙ¿ ÙȘ 9:00 ÌÌ, ˘Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ÂÏÏÈ‹ ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Û ı¤Ì·Ù· ÛˆÛÙ‹˜ ı¤·Û˘ Ù˘ ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿. ∞Ó¿ÏÔÁÔ Úfi‚ÏËÌ· ÂÓÙÔ›ÛÙËÎÂ Î·È ÛÙË ÌÂϤÙË Ô˘ ÚԷӷʤڷÌ (30). ∏ ηٷӿψÛË Û˘ÓÙËÚËÌ¤ÓˆÓ ÙÚÔÊ›ÌˆÓ ÙÔ˘ ÂÌÔÚ›Ô˘, ·ÏÏ¿ Î·È Ê·ÁËÙÔ‡ Ô˘ ·Ú·Û΢·˙fiÙ·Ó ÛÙÔ Û›ÙÈ, ηٿ ÙËÓ ÒÚ· Ô˘ Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ (¶›Ó·Î·˜ 5). ∞˘Ùfi ·ÔÙÂÏ› ÌÈ· ·ÎfiÌË ÂÈ‚Ï·‚‹ Û˘Ó‹ıÂÈ· ÁÈ· ÙËÓ ˘Á›·, ·ÊÔ‡ ıˆÚÂ›Ù·È ·fi ÔÏÏÔ‡˜ Û˘ÁÁÚ·Ê›˜ Û·Ó Ì›· ·fi ÙȘ ·Èٛ˜ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ (2,30). ∏ ÙÚÔÊ‹ Ô˘ ηٷӷÏÒÓÂÙ·È Î·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ Û˘Ó‹ıˆ˜ Ï·Ì‚¿ÓÂÙ·È ÂÈϤÔÓ ·fi ·˘Ù‹ Ô˘ Ú·ÁÌ·ÙÈο ¯ÚÂÈ¿˙ÂÙ·È ÙÔ ·È‰› (30). OÈ ·Èٛ˜ Ù˘ Û˘¯ÓfiÙÂÚ˘ ηٷӿψÛ˘ ÙÚÔÊ‹˜ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÈϤÔÓ ‰ÈÂÚ‡ÓËÛË. ™Â ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Ù¤ÙÔȘ ‰È·ÊÔÚ¤˜ (30). OÈ ıÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ˆÚÒÓ Ô˘ ‚Ï¤Ô˘Ó ÙËÏÂfiÚ·ÛË (¶›Ó·Î·˜ 7) ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ·Ó·ÌÂÓfiÌÂÓ˜ (·˘ÙÔÓfiÌËÛË ÙÔ˘ ·È‰ÈÔ‡), ·Ó Î·È ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì· (23). ∞ÓÙÈı¤Ùˆ˜, ¤¯ÂÈ Î·Ù·ÁÚ·Ê› ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË (23), ÂÓÒ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠ٤ÙÔÈ· ‰È·ÊÔÚ¿. ∆· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ¯ÚfiÓÔ˜ Ô˘ ‰È¤ıÂÙ·Ó Ù· ·È‰È¿ ÁÈ· ·È¯Ó›‰È ÛÙȘ ·ÛÙÈΤ˜ Î·È ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ‹Ù·Ó Ô ›‰ÈÔ˜ (¶›Ó·Î·˜ 6). ∞˘Ùfi Èı·Ófiٷٷ ÔÊÂÈÏfiÙ·Ó ÛÙ· ÂÓÈ·›· ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÙˆÓ ·È‰ÈÒÓ Û fiϘ ÙȘ ÂÚÈÔ¯¤˜ Ù˘ ∂ÏÏ¿‰·˜, Ô˘ ·ÔÚÚÔÊÔ‡Û·Ó ›‰ÈÔ
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·193
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
Paediatriki 2002;65:186-194
¶›Ó·Î·˜ 7. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ Î·È ÙÔ˘ ʇÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ Û˘ÓËıÂÈÒÓ Û¯ÂÙÈο Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ™˘Û¯ÂÙ›ÛÂȘ ∏ÏÈΛ· / flÚ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / flÚ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂÈ ÙËÏÂfiÚ·ÛË ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂÈ ÙËÏÂfiÚ·ÛË Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛË ÒÚ· ÂÚ·Ù¿ οı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛË ÒÚ· ÂÚ·Ù¿ οı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ∞Ó ·›˙ÂÈ Î·ıÈÛÙÈο ·È¯Ó›‰È·** ∏ÏÈΛ· / ∞Ó ·›˙ÂÈ ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη** ¶fiÛ˜ ÒÚ˜ ÂÚ·Ù¿ (ηı.) / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ (ηı.)*** ¶fiÛ˜ ÒÚ˜ ÂÚ·Ù¿ (™∫) / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ (™∫)***
™˘ÓÙÂÏÂÛÙ‹˜ Rs = 0,153 Rs = -0,036 Rs = 0,077 Rs = 0,172 Rs = 0,076 Rs = 0,073 Rs = -0,59 Rs = -0,64 Rs = 0,190 Rs = 0,209 Rs = 0,340 Rs = 0,394 B = -0,595 B = 0,285 µ = 0,197 µ = 0,155 µ = -0,108 µ = -0,032 µ = 0,438 µ = 0,408 Rp = -0,165 Rp = -0,202
p <0,01 ª™**** ª™ <0,005 ª™ ª™ ª™ ª™ <0,001 <0,0001 <0,0001 <0,0001 <0,0001 <0,03 <0,005 <0,001 ª™ ª™ <0,0001 <0,0001 <0,01 <0,001
* YÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman (Rs) ** Logistic Regression *** YÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson (Rp) **** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
¯ÚfiÓÔ ·fi ÙËÓ Ë̤ڷ ÙˆÓ ·È‰ÈÒÓ. ∏ ¤ÏÏÂÈ„Ë fï˜ ˘·›ıÚÈˆÓ ¯ÒÚˆÓ Î·È ÔÈ Î›Ó‰˘ÓÔÈ Ô˘ ˘¿Ú¯Ô˘Ó ¤Íˆ ·fi ÙÔ Û›ÙÈ ÁÈ· Ù· ·È‰È¿ Ù˘ fiÏ˘, ·Ó¿Áη˙·Ó Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ÌÂϤÙ˘ Ì·˜ Ó· ·›˙Ô˘Ó Ì¤Û· ÛÙÔ Û›ÙÈ, Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·fi Ù· ·È‰È¿ ÙˆÓ ¯ˆÚÈÒÓ (¶›Ó·Î·˜ 6). ∞˘Ùfi Ù· ÛÙÚ¤ÊÂÈ ÂÚÈÛÛfiÙÂÚÔ ÛÙ· ηıÈÛÙÈο ·È¯Ó›‰È· Î·È Î˘Ú›ˆ˜ ÛÙ· Û‡Á¯ÚÔÓ· ËÏÂÎÙÚÔÓÈο ·È¯Ó›‰È· (video-games Î·È ·È¯Ó›‰È· ËÏÂÎÙÚÔÓÈÎÒÓ ˘ÔÏÔÁÈÛÙÒÓ) Ô˘ ÔÏϤ˜ ÊÔÚ¤˜ (fi¯È fï˜ ¿ÓÙ·) ¤¯Ô˘Ó ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÁÈ· ÙËÓ ˘Á›· ÙÔ˘˜ (4,31-33). ∆· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ¤·È˙·Ó ÂÚÈÛÛfiÙÂÚÔ Û ·ÓÔÈÎÙÔ‡˜ ¯ÒÚÔ˘˜ Î·È Ù· ·ÁfiÚÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi Ù· ÎÔÚ›ÙÛÈ· (¶›Ó·Î·˜ 7). ∆Ô ·È¯Ó›‰È Û ·ÓÔȯÙÔ‡˜ ¯ÒÚÔ˘˜ ʤÚÓÂÈ Ù· ·È‰È¿ ÎÔÓÙ¿ ÛÙ· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ Î·È ¤ÓÙÔÓË Ì˘˚΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (4). ∆· ·È¯Ó›‰È· ·˘Ù¿ ÂÌÔ‰›˙Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ Î·È ·Ó·Ù‡ÛÛÔ˘Ó ÙÔ Ó‡̷ Û˘ÓÂÚÁ·Û›·˜ Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÔÌ¿‰ˆÓ (24). ∆· ÛÙÔȯ›· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ Î·È ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ÌÂϤÙ˘, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È·ÙÚÔÊ‹, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ Î·È ÙÔ ·È¯Ó›‰È, ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο. ∆Ô Â›Â‰Ô Ù˘ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ (΢ڛˆ˜ Ù˘ ˘ÁÈÂÈÓ‹˜ ÙˆÓ ‰ÔÓÙÈÒÓ) ‹Ù·Ó ˘„ËÏfiÙÂÚÔ ÛÙȘ fiÏÂȘ, ·ÏÏ¿ Ë ‰È·ÙÚÔÊ‹ Î·È Ë
ۈ̷ÙÈ΋ ¿ÛÎËÛË ‹Ù·Ó ÛˆÛÙfiÙÂÚ˜ ÛÙËÓ ‡·ÈıÚÔ. O Û‡Á¯ÚÔÓÔ˜ ÙÚfiÔ˜ ˙ˆ‹˜ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÁ΢ÌÔÓ› ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· ÙË ÛˆÌ·ÙÈ΋ Î·È ÙËÓ „˘¯È΋ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. ∆· ÛÙÔȯ›· Ì·˜, ›Û˘, ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ÙËÏÂfiÚ·ÛË Â›Ó·È ¤Ó· ̤ÛÔ Ô˘ ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛˆÛÙ¿ ·fi Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ Î·È Ë Î·Î‹ ·˘Ù‹ ¯Ú‹ÛË ÂÁ΢ÌÔÓ› ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. ∏ ·ÁˆÁ‹ ˘Á›·˜, ÛÂ Â›Â‰Ô ·È‰ÈÒÓ Î·È ÁÔÓ¤ˆÓ Î·È Ë ÚÔÛ¿ıÂÈ· ÂÍ·ÛÊ¿ÏÈÛ˘ ÛˆÛÙfiÙÂÚÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ÌÔÚÔ‡Ó Ó· ÚÔÏ¿‚Ô˘Ó ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ·ÂÈÏÔ‡Ó ÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÌÂÏÂÙ‹Û·ÌÂ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Sokol RJ. The chronic disease of childhood obesity: The sleeping giant has awakened. J Pediatr 2000;136:711-713. 2. Robinson TN. Reducing children’s television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282:1561-1567. 3. Ekblom B, Astrand PO. Role of physical activity on health in children and adolescents. Acta Paediatr 2000;89:762-774. 4. ∫·Ú‰·Ú¿˜ ¶, ™ÎÂÓÙ¤Ú˘ ¡, °È·ÓÓ·ÎÔ‡ ∞, ∆ÛÂÚÌÂÓ›‰Ë˜ π, ¢ÔÁ¿Ó˘ °. ¶Ò˜ ·›˙Ô˘Ó Ù· ·È‰È¿ Û‹ÌÂÚ·. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1994;6:161-175. 5. Kleinman R. Towards a “new beginning” dietary fat restrictions in infancy? Acta Paediatr 2000;89:2-4. 6. §ÈÔÓ‹˜ Ã, ∫·Ê¿ÙÔ˜ ∞, µÏ·¯ÔÓÈÎÔÏ‹˜ π. ∂Î·È‰Â˘ÙÈ΋
193
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·194
¶·È‰È·ÙÚÈ΋ 2002;65:186-194
7. 8.
9.
10. 11.
12.
13.
14.
15.
16. 17.
18.
19.
20.
·Ú¤Ì‚·ÛË Û ̷ıËÙ¤˜ Á˘ÌÓ·Û›ˆÓ ÛÙËÓ ∫Ú‹ÙË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ. ∏ ›‰Ú·ÛË ÛÙȘ ÁÓÒÛÂȘ ˘Á›·˜. ¶·È‰È·ÙÚÈ΋ 1992;55:339-351. Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obesity 1996;20:488-492. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992;327:1350-1355. DiPietro L, Mossberg HO, Stunkard AJ. A 40-year history of overweight children in Stockholm: life-time overweight, morbidity and mortality. Int J Obes Relat Metab Disord 1994;18:585-590. Dietz WH. Childhood obesity: susceptibility, cause and management. J Pediatr 1983;103:676-686. Sullivan M, Karlson J, Sjostrom L, Backman L, Bengtsson C, Bouchard C et al. Swedish obese subjects (SOS) - an intervention study of obesity. Baseline evaluation of health and psychological functioning in the first 1743 subjects examined. Int J Obes 1993;17:503-512. Zannolli R, Rebeggiani A, Chiarelli F, Morgese G. Hyperinsulinism as a marker of obese children. Am J Dis Child 1993;147:837-841. ∂˘ı˘ÌÈ¿‰Ë˜ ∞, §Â˘Îfi˜ ¡, ¶··‰fiÔ˘ÏÔ˜ π, ∫·˙ÈÓ¿Î˘ °, ∆Û¿·˜ ∞, ∂˘ı˘ÌÈ¿‰Ë˜ π Î·È Û˘Ó. ∂›ÙˆÛË ·Ú·ÁfiÓÙˆÓ ·ıËڈ̿وÛ˘ Û ·È‰È¿ Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1997;9:184-189. von Almen TK, Figueroa-Colon R, Suskind RM. Psychological considerations in the treatment of childhood obesity. In: Giorgi PL, Suskind RM, Catassi C, eds. The obese child. Basel: Karger; 1992. p. 162-171. Bernard-Bonnin AC, Gilbert S, Rousseau E, Masson P, Maheux B. Television and the 3- to 10-years-old child. Pediatrics 1991;88:48-53. Fosarelli P. Television and children: a review. J Dev Behav Pediatr 1984;5:30-36. American Academy of Pediatrics, Committee on Communications children, adolescents and television. Pediatrics 1990;85:1119-1120. Durant RH. The relationship among television watching, physical activity and body composition of young children. Pediatrics 1994;94:441-455. §˘‰¿ÎË ∂, ∫·Ê¿ÙÔ˜ ∞, ∫Ô˘Ó¿ÏË ¢, ∞ÔÛÙÔÏ¿ÎË π. ¢È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ, Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È ÏÈ›‰È· ÔÚÔ‡ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 12-14 ¯ÚfiÓˆÓ. ¶·È‰È·ÙÚÈ΋ 1994;57:330-347. Gupta RK, Saini DP, Achariya U. Impact of television on children. Indian J Pediatr 1994;61:153-159.
194
Paediatriki 2002;65:186-194
21. Gadow KD, Sprafkin J. Field experiments of television violence with children: evidence for an environmental hazard? Pediatrics 1989;83:399-405. 22. Robinson JP. Television's impact on everyday life: some cross-national evidence. In: Rubinstein EA, Comstock GA, Murray JP, eds. Television and Social Behavior. Television in day-to-day life: Patterns of Use. Washington, DC: Government Printing Office; 1972. p. 410-431. 23. Owens J, Maxim R, McGuinn M, Nobile C, Msall M, Alario A. Television-viewing habits and sleep disturbance in school children. ∏ÏÂÎÙÚÔÓÈÎfi ¿ÚıÚÔ: Pediatrics 1999;104:e27. 24. Mitchel N, Manson O. The theories of play. New York: AS Barnes and Co; 1982. 25. ∫·ÙÚÈÔ‡-¡ÈÎÔϷοÎË ¢. ¶ÔÈ· Ë ı¤ÛË Ù˘ Ê˘ÙÔÊ·Á›·˜ ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ; ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1997;9:53-56. 26. Sandres TAB, Manning J. The growth and development of vegan children. J ∏um Nutr Diet 1992;5:11-21. 27. Wolfe WS, Campbell CC. Food pattern, diet quality and related characteristics of schoolchildren in New York State. J Am Diet Assoc 1993;11:1280-1284. 28. πrigoyen ME, Maupome G, Mejia AM. Caries experience and treatment needs in a 6- to 12-years-old urban population in relation to socio-economic status. Community Dent Health 1999;16:245-249. 29. §Ô˘ÏÔ˘‰È¿‰Ë˜ ∫. ∆ÂÚˉÔÓÈ΋ ÂÌÂÈÚ›· ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∆Ô ™ÙfiÌ· 1994;22:137-146. 30. Moran-Vazquez JO, Alatorre-Montoya LE, Garcia-Perez J, Guillen-Baumgarten N, Novoa-Menchaca A. Children and their television watching habits. A comparative study in rural and urban environments. Considerations on the effects. Bol Med Hosp Infant Mex 1990;47:332-335. 31. Griffiths MD. Amusement machine playing in childhood and adolescence: a comparative analysis of video games and fruit machines. J Adolesc 1990;40:53-73. 32. Segal K, Dietz W. Physiologic responses to playing a video game. Am J Dis Child 1990;145:1034-1035. 33. Goosens JA, Andermamm F, Remilland GM. Reflex seizures induced by calculation, card or board games and spatial tasks. Neurology 1990;40:1171-1176. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙˆÓ¿Î˘ ¡›ÎÔ˜ ™ÂÚÚÒÓ 3, ∆.∫. 713 07, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: antonakisnikos@yahoo.gr
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·195
¶·È‰È·ÙÚÈ΋ 2002;65:195-198
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2002;65:195-198
CASE REPORT
À‰Ú·ÓÂÁÎÂÊ·Ï›· Û ÓÂÔÁ¤ÓÓËÙÔ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ °. ª·ÚÔ‡Ù˘1, π. ∫·Ï¤ÁÈ·˜1, ∫. ∫·ÎÔ˘ÏÏ‹˜2, π. ¶·˘Ï›‰Ë˜2, ∞. °Ô˘ÏÈ¿ÌÔ˜3
Hydranencephaly in a neonate. A case report G. Baroutis1, J. Kaleyias1, C. Kacoulis2, I. Paulidis2, A. Gouliamos3
¶ÂÚ›ÏË„Ë: ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È Ì›· Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÏÏÂÈ„Ë ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Î·È ·ÓÙÈηٿÛÙ·Û‹ ÙÔ˘˜ ·fi ·ÛÙÂȘ Ï‹ÚÂȘ Ì ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi. ∆Ô ÓÂÔÁÓfi Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ÌÔÚ› Ó· Ê·›ÓÂÙ·È Ê˘ÛÈÔÏÔÁÈÎfi Î·È Ë ‰È¿ÁÓˆÛË Ó· ÌË Á›ÓÂÈ ·ÓÙÈÏËÙ‹ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜. ∏ ÙÂÏÈ΋ ¤Î‚·ÛË Â›Ó·È ‰˘ÛÌÂÓ‹˜ Î·È Ô ı¿Ó·ÙÔ˜ ¤گÂÙ·È Î·Ù¿ ηÓfiÓ· ÚÈÓ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ˙ˆ‹˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Ô˘ ‰È·ÁÓÒÛÙËΠÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘.
Abstract: Hydranencephaly is a rare central nervous system malformation in which the brain’s cerebral hemispheres are absent and replaced by sacs with cerebrospinal fluid. An infant with hydranencephaly may appear normal at birth. Diagnosis may be delayed for several months because early behavior appears to be relatively normal. The outlook for children with hydranencephaly is poor. Death generally occurs before the age of one year. This is a case report of an infant with hydranencephaly who was diagnosed on the first day of life using ultrasound of the brain.
§¤ÍÂȘ ÎÏÂȉȿ: ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ÓÂÔÁ¤ÓÓËÙÔ.
Key words: hydranencephaly, neonate.
∂ÈÛ·ÁˆÁ‹ OÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™) ÂÌÊ·Ó›˙ÔÓÙ·È Û ÔÛÔÛÙfi 0,2% ÙˆÓ ÁÂÓÓËı¤ÓÙˆÓ ˙ˆÓÙ·ÓÒÓ ÓÂÔÁÓÒÓ. ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ∫¡™. O Tang (1) ÌÂϤÙËÛ ·Ó·‰ÚÔÌÈο ÙȘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ∫¡™ ÁÈ· Ì›· ‰ÂηÂÙ›· Î·È ‰È·›ÛÙˆÛ 79 ÂÚÈÛÙ·ÙÈο › Û˘ÓfiÏÔ˘ 59392 ÓÂÔÁÓÒÓ (0,13%). À‰Ú·ÓÂÁÎÂÊ·Ï›· ›¯·Ó Ù· 4 ·fi Ù· 79 ÓÂÔÁÓ¿, ‰ËÏ·‰‹ ÌfiÏȘ ÙÔ 5% › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ∫¡™. ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ï‹ÚË ¤ÏÏÂÈ„Ë Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ Ô˘Û›·˜ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ ·fi Ú¢ÛÙ‹ Ô˘Û›· ‹ ˘ÁÚfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ, ·˘Ù‹ ÌÔÚ› Ó· Â›Ó·È Ï‹Ú˘ ‹ ÌÂÚÈ΋, ¯ˆÚ›˜ Û˘Ó‹ıˆ˜ Ó· ÂËÚ¿˙ÔÓÙ·È ÙÔ Û٤ϯԘ ÙÔ˘
ÂÁÎÂÊ¿ÏÔ˘ Î·È Ô ÚÔÌ‚ÔÂȉ‹˜ ÂÁΤʷÏÔ˜ (2). ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Ô˘ ‰È·ÈÛÙÒıËΠÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ ˘ÂÚ˯ÔÙÔÌÔÁÚ·ÊÈο, ÏfiÁˆ Û¯ÂÙÈο ÌÂÁ¿Ï˘ ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜.
1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶.°.¡.∞. “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 2 ∞’ ª·È¢ÙÈ΋-°˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶.°.¡.∞. “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 3 ∆Ì‹Ì· ∞ÍÔÓÈ΋˜ Î·È ª·ÁÓËÙÈ΋˜ ∆ÔÌÔÁÚ·Ê›·˜ ¶.°.¡.∞. “∞ÚÂÙ·›ÂÈÔ”, ∞ı‹Ó·
1 Neonatal Department, General District Hospital of Athens “Alexandra”, Athens 2 1st Obstetric-Gynecology Clinics of University of Athens General District Hospital of Athens “Alexandra”, Athens 3 Department of CT and MRI General District Hospital of Athens “Areteio”, Athens
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÙÂÏÂÈfiÌËÓÔ ÓÂÔÁ¤ÓÓËÙÔ ·ÁfiÚÈ, ÙÔ ÚÒÙÔ ·È‰› ¿Á·Ì˘ Á˘Ó·›Î·˜ 17 ÂÙÒÓ, Ë ÔÔ›· ‰ÂÓ ¤Ù˘¯Â Ì·È¢ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. O ·Ù¤Ú·˜ ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ Â›¯Â Û˘ÁÁÂÓÈ΋ Û¯¤ÛË Ì ÙË ÌËÙ¤Ú·. ∏ ÌËÙ¤Ú· ‰ÂÓ ‹Ù·Ó ηӛÛÙÚÈ·. ∆Ô ÓÂÔÁÓfi ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi, ¤ÎÏ·„ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘ Î·È ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠ·Ó¿ÓË„Ë (Apgar score ÛÙÔ 1Ô Î·È 5Ô min=9). ∆· ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο Î·È Ë
195
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·196
¶·È‰È·ÙÚÈ΋ 2002;65:195-198
ÂͤٷÛË ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÙÔ˘ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆· ÓÂÔÁÓÈο ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÂÎχÔÓÙ·Ó Ê˘ÛÈÔÏÔÁÈο Î·È Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ ‹Ù·Ó ›Û˘ Ê˘ÛÈÔÏÔÁÈÎfi˜. ∆· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó: µ¿ÚÔ˜ Á¤ÓÓËÛ˘: 3200 g, (∂£=50Ë), Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜: 53 cm (∂£=90Ë), ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜: 38,5 cm (∂£>90˘). ∏ ÚfiÛıÈ· Î·È Ô›ÛıÈ· ËÁ‹ ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Î·È ‰ÂÓ Â›¯Â ‰È¿ÛÙ·ÛË Ú·ÊÒÓ. ∏ ÌÔÓ·‰È΋ ¤Ó‰ÂÈÍË Ô˘ Ô‰‹ÁËÛ ÛÙËÓ ÂÎÙ¤ÏÂÛË ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÂÁÎÂÊ¿ÏÔ˘ (Real-time, 5 MHz) ‹Ù·Ó Ë ÌÂÁ¿ÏË ÂÚ›ÌÂÙÚÔ˜ Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜: ¢ÌÂÁ¤ı˘ ·ÛÙË Ì ‰È·˘Á¤˜ ˘ÁÚfi Ô˘ ηٷϷ̂¿ÓÂÈ ÙÔÓ ˘ÂÚÛÎËÓ›‰ÈÔ ¯ÒÚÔ. OÈ ı¿Ï·ÌÔÈ, ÙÔ ‰Ú¤·ÓÔ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ë ·ÚÂÁÎÂÊ·Ï›‰· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· ‰ÂÓ ·ÂÈÎÔÓ›ÛÙËÎ·Ó (¶›Ó·Î·˜ 1) (∂ÈÎfiÓ˜ 1-3). O ¤ÏÂÁ¯Ô˜ Û˘ÌÏËÚÒıËΠ̠˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· (∂ÈÎfiÓ˜ 4 Î·È 5). ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È Î·Ú‰È¿˜ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ‚˘ıÔÛÎfiËÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (TORCH) ‹Ù·Ó ·ÚÓËÙÈÎfi˜. O ηڢfiÙ˘Ô˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ (46ÃÀ). ∆Ô ÓÂÔÁÓfi ·Â‚›ˆÛ ÙË 15Ë Ë̤ڷ ˙ˆ‹˜. ¢ÂÓ ‰ÈÂÓÂÚÁ‹ıËΠÓÂÎÚÔÙÔÌÈÎfi˜ ¤ÏÂÁ¯Ô˜. ™˘˙‹ÙËÛË ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È Ì›· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÛÙËÓ ÔÔ›· ˘¿Ú¯ÂÈ Ï‹Ú˘ ¤ÏÏÂÈ„Ë ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Ì ·Ó¤·ÊÔ ÙÔ ıfiÏÔ ÙÔ˘ ÎÚ·Ó›Ô˘ Î·È ÙȘ Ì‹ÓÈÁÁ˜. ∏ ·ÚÂÁÎÂÊ·Ï›‰·, Ô ÌÂÛÂÁΤʷÏÔ˜, ÔÈ ı¿Ï·ÌÔÈ Î·È Ù· ‚·ÛÈο Á¿ÁÁÏÈ· Â›Ó·È Ê˘ÛÈÔÏÔÁÈο (3). ∞Ó Î·È Ë ·ÎÚÈ‚‹˜ ·ÈÙÈÔÏÔÁ›· Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Â›Ó·È ¿ÁÓˆÛÙË, Ë Ï¤ÔÓ ÂÈÎÚ·ÙÔ‡Û· ˘fiıÂÛË Â›Ó·È fiÙÈ ÚÔηÏÂ›Ù·È ·fi ¤ÌÊÚ·ÎÙÔ, ÚÔÂÚ¯fiÌÂÓÔ ·fi ·ÌÊÔÙÂÚfiÏ¢ÚË ‹ ÂÙÂÚfiÏ¢ÚË ·fiÊÚ·ÍË ÙˆÓ ¤Ûˆ ηڈٛ‰ˆÓ ‹ ÙˆÓ ¤Ûˆ ÛÊ·Á›ÙȉˆÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∞˘Ùfi Ô‰ËÁ› Û ӤÎÚˆÛË Î·È ·ÔÚÚfiÊËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÈÛÙÔ‡, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË Ì›·˜ ÎÔÈÏfiÙËÙ·˜ Ï‹ÚÔ˘˜ ˘ÁÚÔ‡ Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi Ì‹ÓÈÁÁ˜. O ·ıÔÁÂÓÂÙÈÎfi˜ ·˘Ùfi˜ Ì˯·ÓÈÛÌfi˜ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙË ‰È·›ÛÙˆÛË Ù˘ ·Ó¿Ù˘Í˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜
Paediatriki 2002;65:195-198
Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ Èı‹ÎˆÓ Î·È ÚÔ‚¿ÙˆÓ (4), ηıÒ˜ Î·È ÙË ÛÙ·‰È·Î‹ ÂÁηٿÛÙ·ÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Û ·ÓıÚÒÈÓ· ¤Ì‚Ú˘·, Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÛÂ Û˘Ó¯‹ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÛÙ· Ï·›ÛÈ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ (5). ÕÏÏÔÈ Èı·ÓÔ› ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ›, Ô˘ ÌÔÚ› Ó· Â›Ó·È ·fi ̤ÚÔ˘˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘, Â›Ó·È Ë ·-
∂ÈÎfiÓ· 1. ™ÙÂÊ·ÓÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘). ∞ÂÈÎÔÓ›˙ÂÙ·È Ë Â˘ÌÂÁ¤ı˘ ·ÛÙË Ô˘ ·ÓÙÈηıÈÛÙ¿ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· Î·È ÙÔ ·Î¤Ú·ÈÔ ‰Ú¤·ÓÔ.
∂ÈÎfiÓ· 2. ™ÙÂÊ·ÓÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ·). ∞ÂÈÎÔÓ›˙ÂÙ·È Ë Â˘ÌÂÁ¤ı˘ ·ÛÙË Ô˘ ·ÓÙÈηıÈÛÙ¿ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· Î·È ÔÈ Âӈ̤ÓÔÈ ı¿Ï·ÌÔÈ.
¶›Ó·Î·˜ 1. ÀÂÚ˯ÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ñ ¶Ï‹Ú˘ ·Ô˘Û›· ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ ñ ª›· ÌÂÁ¿ÏË, ÁÂÌ¿ÙË ˘ÁÚfi, ÎÔÈÏfiÙËÙ· ÂÓÙfi˜ ÙÔ˘ ıfiÏÔ˘ ÙÔ˘ ÎÚ·Ó›Ô˘ ηٷϷ̂¿ÓÔ˘Û· ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ ñ º˘ÛÈÔÏÔÁÈÎÔ› ı¿Ï·ÌÔÈ Î·È ËÌÈÛÊ·ÈÚ›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ ñ ∞Ó¤·ÊÔ ÙÔ ‰Ú¤·ÓÔ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘
196
∂ÈÎfiÓ· 3. ¶·Ú·Ô‚ÂÏÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ·). ∞ÂÈÎÔÓ›˙ÂÙ·È Ô ı¿Ï·ÌÔ˜ Î·È Ô ÛÎÒÏËη˜.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·197
¶·È‰È·ÙÚÈ΋ 2002;65:195-198
Paediatriki 2002;65:195-198
∂ÈÎfiÓ· 4 Î·È 5. ÀÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘. ∂Ȃ‚·ÈÒÓÂÙ·È Ë Ï‹Ú˘ ˘ÔηٿÛÙ·ÛË ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Ì ∂¡À (·ÚÈÛÙÂÚ¿), Ë ¤ÓˆÛË ÙˆÓ ı·Ï¿ÌˆÓ Î·È Ë ·ÚÔ˘Û›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ Î·È ÙÔ˘ ‰Ú¿ÓÔ˘ (‰ÂÍÈ¿).
Ú·ÙÂٷ̤ÓË ÂÌ‚Ú˘˚΋ ˘ÔÍ›· ηÈ, ·fi ̤ÚÔ˘˜ Ù˘ ÂÁ·Ԣ, Ë ÂÌÊ¿ÓÈÛË ˘ÔÙ·ÛÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, Ù· ÔÔ›· ÂӉ¯Ô̤ӈ˜ Ó· ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÈÊÓ›‰È· ‰È·ÛÙÔÏ‹ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ, ÌÂ Û˘Ó¤ÂÈ· ÙË Ú‹ÍË Â‡ıÚ·˘ÛÙˆÓ ·ÁÁ›ˆÓ Î·È ÙË Ì·˙È΋ ·ÈÌÔÚÚ·Á›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (6). OÚÈṲ̂ÓÔÈ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ (ÙÔÍfiÏ·ÛÌ· Î·È Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜) Ô˘ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÔ˘Ó ÙÔ ¤Ì‚Ú˘Ô Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜, ˆ˜ Û˘Ó¤ÂÈ· ÓÂÎÚˆÙÈ΋˜ ·ÁÁÂÈ›Ùȉ·˜ ‹ ÙÔÈ΋˜ ηٷÛÙÚÔÊ‹˜ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ Ô˘Û›·˜. O ¤ÏÂÁ¯Ô˜ Û˘ÁÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‹Ù·Ó ·ÚÓËÙÈÎfi˜ Î·È Ë ‚˘ıÔÛÎfiËÛË ‰ÂÓ Î·Ù¤‰ÂÈÍ ¯ÔÚÈÔ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ· ‹ ¿ÏϘ ‚Ï¿‚˜. ∞ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ˘ÔÏ·Û›· ÙˆÓ ˘ÂÚÎÏÈÓÔÂȉÒÓ ÙÌËÌ¿ÙˆÓ ÙˆÓ ¤Ûˆ ηڈٛ‰ˆÓ Î·È Ê˘ÛÈÔÏÔÁÈΤ˜ ÙË ‚·ÛÈ΋, ÙȘ Ô›ÛıȘ ÂÁÎÂÊ·ÏÈΤ˜ Î·È ÙȘ ÛÔÓ‰˘ÏÈΤ˜ ·ÚÙËڛ˜ (5). OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛÔÚ·‰ÈΤ˜, ÂÓÙÔ‡ÙÔȘ ˘¿Ú¯Ô˘Ó ÌÂÚÈΤ˜ ·Ó·ÎÔÈÓÒÛÂȘ ÔÈÎÔÁÂÓÒÓ ˘‰Ú·ÓÂÁÎÂÊ·ÏÈÒÓ. OÈ Hamby Î·È Û˘Ó (2) ‰ËÌÔÛ›Â˘Û·Ó ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ‰›‰˘ÌˆÓ, ·ÁfiÚÈ Î·È ÎÔÚ›ÙÛÈ, Ù· ÔÔ›· ›¯·Ó ˘‰Ú·ÓÂÁÎÂÊ·Ï›·. ™ÙÔ ·ÁfiÚÈ ‰È·ÈÛÙÒıËΠÂÈϤÔÓ ·ÁÂÓÂÛ›· Ù˘ ÎÓ‹Ì˘ Î·È ÛÙÔ ÎÔÚ›ÙÛÈ ÂÎÛÙÚÔÊ‹ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È ·ÁÂÓÂÛ›· ÙˆÓ ÓÂÊÚÒÓ. OÈ Foweler Î·È Û˘Ó (7) ÂÚȤÁÚ·„·Ó ÂÓÙ¿‰˘Ì· ÎÔÚ›ÙÛÈ·, Ù· ÔÔ›· ›¯·Ó ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ˘‰ÚÔΤʷÏÔ Î·È ·ÚıÚÔÁÚ‡ˆÛË. OÈ ÓÂÎÚÔÙÔÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ¤‰ÂÈÍ·Ó ·ÓÒÌ·ÏË ·ÁÁ›ˆÛË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. O Siber (8) ·ÚÔ˘Û›·Û ¤Ó· Û‡Ó‰ÚÔÌÔ, Èı·ÓÒ˜ ÎÏËÚÔÓÔÌÔ‡ÌÂÓÔ ÌÂ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ¯·Ú·ÎÙ‹Ú·, ÙÔ˘ ÔÔ›Ô˘ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ·ÔÙÂÏÔ‡Ó Ë ÌÈÎÚÔÎÂÊ·Ï›·, Ë ÌÈÎÚÔÊı·ÏÌ›·, Ë ıÔÏÂÚfiÙËÙ· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜, Ë Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, o ˘ÔÛ·‰›·˜, Ë ÎÚ˘„ÔÚ¯›· Î·È Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· (10). ∏ ÁÔÓȉȷ΋ ÌÂϤÙË Ì›·˜ ÌÂÁ¿Ï˘ ·ÈÌÔÌÈÎÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜ ÂÓÙfiÈÛ ‡ÔÙÔ ÁÔÓȉ›ˆÌ· ÛÙÔ
‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16 (1613.3-12) (9). ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÂÚ›ÙˆÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Û ·È‰› Ô˘ ·Â‚›ˆÛ Û ËÏÈΛ· 4 ÂÙÒÓ, ÛÙÔ ÔÔ›Ô ‰È·ÁÓÒÛÙËΠÂÈϤÔÓ Î·È ‰È·Ù·Ú·¯‹ ÛÙË ÌÈÙÔ¯ÔÓ‰Úȷ΋ ·Ó·Ó¢ÛÙÈ΋ ·Ï˘Û›‰· (10). ∏ Û·ÓÈfiÙËÙ· ÙˆÓ ÔÈÎÔÁÂÓÒÓ ÂÚÈÙÒÛÂˆÓ Î·È Ë ÂÓÙ˘ˆÛȷ΋ ·fi‰ÂÈÍË Ù˘ ‡·Ú͢ Ì›·˜ ηٷÛÙÚÔÊÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ‰ÂÓ Â›Ó·È ÁÂÓÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ (6). Œ¯ÂÈ ·Ó·ÊÂÚı› Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ÌÈÎÚ‹˜ ËÏÈΛ·˜ Ù˘ ÌËÙ¤Ú·˜ (<18 ÂÙÒÓ) Î·È Î·Ó›ÛÌ·ÙÔ˜ Ù˘ ÂÁ·Ԣ (11). ∏ ÌËÙ¤Ú· ÙÔ˘ ÓÂÔÁÓÔ‡ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‹Ù·Ó ÌÈÎÚ‹˜ ËÏÈΛ·˜ (17 ÂÙÒÓ), ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È Î·Ó›ÛÙÚÈ·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ˙ÒÓÙ· ÓÂÔÁÓ¿, Ú¤ÂÈ Ó· ÙÂı› ·fi ÙË ‚·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜ Î·È ÙËÓ ·ÏÔ‚Ò‰Ë ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·, Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (¶›Ó·Î·˜ 2) (12). ™ÙȘ ÂÚÈÙÒÛÂȘ Ì ‚·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ‰˘Û¯ÂÚ‹˜. ∏ ·ÚÔ˘Û›· Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÌÊÈ‚ÚÂÁÌ·ÙÈ΋˜ ‰È·Ì¤ÙÚÔ˘, Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ ÙËÓ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÂÈ ˆ˜ ̤ÛÔ ‰È·ÎÚ›Ûˆ˜ ÙˆÓ ‰‡Ô ·˘ÙÒÓ ·ıÔÏÔÁÈÎÒÓ ÔÓÙÔÙ‹ÙˆÓ (3). ∂ÓÙÔ‡ÙÔȘ, Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È Â›Û˘ Ì ÌÂÁ¿ÏË ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜, fiˆ˜ Î·È ÛÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ™ÙËÓ ˘‰ÚÔÎÂÊ·Ï›·, ÌÔÚ› ÌÂÚÈΤ˜ ÊÔÚ¤˜ Ó· Ê·Ó› ˘ÂÚ˯ÔÁÚ·ÊÈο ¤Ó· ÏÂÙfi ¯Â›ÏÔ˜ Ï¢΋˜ Ô˘Û›·˜ Î·È ÊÏÔÈÔ‡ Á‡Úˆ ·fi ÙȘ ÎÔÈϛ˜ Û ‡·ÚÍË ÛÔ‚·ÚÔ‡ ˘‰ÚÔÎÂÊ¿ÏÔ˘, ÂÓÒ Û ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ‰ÂÓ ˘¿Ú¯ÂÈ Î·ıfiÏÔ˘ ÂÚÈÊÂÚÈÎfi˜ ÈÛÙfi˜. ™Â ·ÌÊÈ‚ÔÏ›·, ‰ÈÂÓÂÚÁÂ›Ù·È ˘ÔÏÔÁÈÛÙÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, Ô˘ Â›Ó·È Î·Ï‡ÙÂÚ˜ Ù¯ÓÈΤ˜ ÛÙËÓ ·ÂÈÎfiÓÈÛË Ù˘ ÂÚÈʤÚÂÈ·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ ‰È¿ÎÚÈÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ˘‰ÚÔÎÂÊ¿ÏÔ˘ Â›Ó·È Ô˘ÛÈ҉˘ ÁÈ·Ù› ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÚfiÎÂÈÙ·È ÁÈ· ˘‰ÚÔΤʷÏÔ, ÌÔÚ› Ë ÔÚ›· ÙÔ˘ ÓÂÔÁÓÔ‡ Ó· Â›Ó·È Î·Ï‹ Ì ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘
197
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·198
¶·È‰È·ÙÚÈ΋ 2002;65:195-198
Paediatriki 2002;65:195-198
¶›Ó·Î·˜ 2. ÀÂÚ˯ÔÁÚ·ÊÈ΋ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ∞ӈ̷ϛ· ∫¡™
∞Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο
µ·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜
ñ ¶·ÚÔ˘Û›· ‰Ú¿ÓÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ñ ¶·ÚÔ˘Û›· ‰È¿Û·ÚÙˆÓ ÙÌËÌ¿ÙˆÓ ÙÔ˘ ÊÏÔÈÔ‡ ñ ¶·ÓÙÂÏ‹˜ ¤ÏÏÂÈ„Ë ÙÔ˘ ‰Ú¿ÓÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ñ ⁄·ÚÍË ÚfiÛıÈÔ˘ ÊÏÔÈÔ‡, ËÌÈÛÂÏËÓÔÂȉԇ˜ Û¯‹Ì·ÙÔ˜ ñ ªÔÓfi¯ˆÚË ÎÔÈÏ›·, Û¯‹Ì·ÙÔ˜ ¤ÏÌ·ÙÔ˜ ·ÏfiÁÔ˘ ñ ™˘Ó¤ÓˆÛË ı·Ï¿ÌˆÓ ÛÙË Ì¤ÛË ÁÚ·ÌÌ‹ ñ ∞Ô˘Û›· 3˘ ÎÔÈÏ›·˜ Î·È Ó¢ÚÔ¸ÔʇÛˆ˜ ñ ™Ô‚·Ú¤˜ ·ÓˆÌ·Ï›Â˜ ÛÙË Ì¤ÛË ÁÚ·ÌÌ‹ ÙÔ˘ ÚÔÛÒÔ˘, fiˆ˜ ΢Îψ›·, ËıÌÔÎÂÊ·Ï›·, ‡·ÚÍË “ÚÔ‚ÔÛΛ‰·˜”, Ï·ÁÒ¯ÂÈÏÔ, ·Ô˘Û›· ÔÊı·ÏÌÈÎÒÓ ÎfiÁ¯ˆÓ Î·È Ì‡Ù˘, ˘ÔÙÂÏÔÚÈÛÌfi˜
∞ÏԂ҉˘ ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·
∂¡À Â¿Ó ·˘Ù‹ Á›ÓÂÈ ¤ÁηÈÚ·, ÂÓÒ Û ÂÚ›ÙˆÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜, Ë ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ∂¡À ‰ÂÓ ı· ‚ÂÏÙÈÒÛÂÈ Î·ıfiÏÔ˘ ÙËÓ ¤Î‚·ÛË (13). ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ¤¯ÂÈ ÂÍ·ÈÚÂÙÈο ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÂÚÈÛÙ·ÙÈο Ô˘ ¤˙ËÛ·Ó Â› Ì·ÎÚfiÓ (14). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ ÙÔ˘˜ ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÂÌÊ·Ó›˙Ô˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙȘ Ó¢ÚÔÏÔÁÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÚÔۋψÛ˘ Î·È ·Ó·˙‹ÙËÛ˘ ÙˆÓ Ì·ÙÈÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ˘ÂÚ˯ÔÁÚ·Ê›· ·ÔÙÂÏ› Ì›· ·Ï‹ Î·È ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô ‰È¿ÁÓˆÛ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ë ÔÔ›· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ¤ÁηÈÚ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÒÛÙ ·ÚfiÌÔȘ ÂÚÈÙÒÛÂȘ ÂÌ‚Ú‡ˆÓ ÌË Û˘Ì‚·ÙÒÓ Ì ÙË ˙ˆ‹ Ó· ·ÓȯÓ‡ÔÓÙ·È ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ì ÛÙfi¯Ô ÙË ‰È·ÎÔ‹ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·˜ Ì ‚¿ÛË Ù· ˘ÂÚ˯ÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÔÓÙÔÙ‹ÙˆÓ Â›Ó·È ‰˘Û¯ÂÚ‹˜, fï˜ ¯ˆÚ›˜ ȉȷ›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌ·Û›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Î·È ÔÈ ‰‡Ô ηٷÛÙ¿ÛÂȘ Â›Ó·È ·Û‡Ì‚·Ù˜ Ì ÙË ˙ˆ‹ Î·È Ë Ì·È¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ›‰È·. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ·ÓÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ôχ ÌÈÎÚfi˜ fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·Ó¿ÏÔÁÔ ÚÔËÁÔ‡ÌÂÓÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ™‹ÌÂÚ·, Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û ÓÂÔÁÓ¿, ÏfiÁˆ Ù˘ Û¯ÔÏ·ÛÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ·ËÛ˘. ∂ÓÙÔ‡ÙÔȘ, Û ÂÁ·Ԣ˜ Ì ·Ó·Ú΋ Ì·È¢ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, Ë Èı·ÓfiÙËÙ· ‰È¿ÁÓˆÛ˘ ÛÙÔ ÓÂÔÁÓfi Â›Ó·È ˘·ÚÎÙ‹ Î·È ÁÈ’ ·˘Ùfi Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Tang MH. The association between maternal smoking and fetal hydranencephaly. J Obstet Gynecol Res 1999;25:39-42. 2. Hamby WB, Krauss RF, Beswick WF. Hydranencephaly: clinical diagnosis. Presentation of seven cases. Pediatrics 1950;6:371-383. 3. Pretorius D. Diagnosis of brain neuropathology in utero. In: Naidich TP, Quencer R, editors. Clinical neurosono-
198
4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
14.
graphy ultrasound of the central nervous system. 1st ed. Berlin: Springer-Verlag Berlin; 1987. p. 15. Myers RE. Brain pathology following fetal vascular occlusion: An experimental study. Invest Opthalmol 1969;8:41-50. Edmondson SR, Hallak M, Carpenter RG, Cotton DB. Evolution of hydranencephaly following intracerebral hemorrage. Obstet Gynecol 1992;79:573-575. Bondurant S, Boehm FH, Fleischer AC, Machin JE. Antepartum diagnosis of fetal intracranial hemorrhage by ultrasound. Obstet Gynecol 1984;63(Suppl):7S-25S. Foweler M, Dow R, White TA, Green CH. Congenital hydrocephalus-hydrancephaly in five siblings, with autopsy studies: a new disease. Dev Med Child Neurol 1972;14:173-188. Siber M. X-linked recessive microencephaly, microphthalmia with corneal opacities, spastic quadriplegia, hypospadias and cryptorchidism. Clin Genetics 1984; 26:453-456. Kavaslar GN, Onengut S, Derman O, Kaya A, Tolun A. The novel genetic disorder microhydranencephaly maps to chromosome 16p13.3-12.1. Am J Hum Genet 2000;66:1705-1709. Castro-Gago M, Alonso A, Pintos-Martinez E, Beiras-Iglesias A, Campos Y, Arenas J et al. Congenital hydranencephalichydrocephalic syndrome associated with mitochodrial dysfunction. J Child Neurol 1999;14:131-135. Lubinsky MS, Adkins W, Kaveggia EG. Decreased maternal age with hydranencephaly. Am J Med Genet 1997;69:232-234. Fiske CE, Fill RA. Ultrasound of the normal and abnormal neural axis. Radiol Clin N Am 1982;20:285-296. Dublin AB, French BN. Diagnostic image evaluation of hydranencephaly and pictorially similar entities, with emphasis on computed tomography. Radiology 1980;137:81-90. Mc Abee GN, Chan A, Erde EL. Prolonged survival with hydranencephaly: report of two patients and literature review. Pediatr Neurol 2000;23:80-84.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ Õıˆ 31 Î·È øÚÔÔ‡, ∆.∫. 262 26, ¶¿ÙÚ· E-mail: kaleyias@hotmail.com
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·199
¶·È‰È·ÙÚÈ΋ 2002;65:199-202
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2002;65:199-202
CASE REPORT
™˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi °. ª·ÚÔ‡Ù˘1, ª. ∞ÔÛÙfiÏÔ˘1, π. ∫·Ï¤ÁÈ·˜1, ™. ™Â‚·ÛÙÈ¿‰Ô˘1, ∞. ∞ÓÙ˙·ÎÏ‹˜2, Ã. ∫ÒÛÙ·ÏÔ˜1
Congenital chylothorax in a neonate G. Baroutis1, M. Apostolou1, J. Kaleyias1, S. Sevastiadou1, A. Antsaklis2, C. Costalos1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ‰›‰˘ÌÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÌÂ Û˘ÁÁÂÓ‹ ¯˘ÏÔıÒڷη. ø˜ ¯˘ÏÔıÒڷη˜ ÔÚ›˙ÂÙ·È Ë Û˘ÏÏÔÁ‹ ÏÂÌÊÈÎÔ‡ ˘ÁÚÔ‡ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. ™ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Ô Û˘ÁÁÂÓ‹˜, fiÛÔ Î·È Ô ÙÚ·˘Ì·ÙÈÎfi˜ ¯˘ÏÔıÒڷη˜. ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È ÛËÌ·ÓÙÈ΋, ÂÂȉ‹ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ¤ÁηÈÚ˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ Î‡ÚÈˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘, Ô˘ Â›Ó·È Ë ·ÛÊ˘Í›· Î·È Ë ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·. ∏ ıÂڷ›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ ϤÌÊÔ˘ ·fi ÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ì ·ÔηٿÛÙ·ÛË ÙˆÓ ˘ÁÚÒÓ-ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ¯¿ÓÔÓÙ·È, ÛÙË ¯Ú‹ÛË Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÛÙËÓ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹. ∏ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ·Ú¯›˙ÂÈ ÌfiÓÔ fiÙ·Ó ÛÙ·Ì·Ù‹ÛÂÈ Ë ‰È·Ê˘Á‹ ϤÌÊÔ˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· Î·È Û˘Ó›ÛÙ·Ù·È Û ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È·. ¶Ôχ Û¿ÓÈ· ¯ÚÂÈ¿˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË.
Abstract: This is a case report of a twin premature newborn with congenital chylothorax. Chylothorax is defined as the effusion of lymph in the pleural cavity. In the neonatal period, both congenital and traumatic forms of chylothorax exist with equal frequency. Major symptoms at birth include asphyxia and respiratory distress, therefore the antenatal diagnosis, by the use of ultrasound, is essential in order to initiate appropriate therapeutic intervention soon after birth. Treatment consists of mechanical ventilation, drainage of chyle, replacement of fluid-electrolyte and protein losses, and parenteral nutrition. Introduction of oral feeding should be initiated only after the chyle effusion in the pleural cavity is successfully terminated, and consists of feeding with a medium-chain triglyceride containing formula. In a minority of cases surgical intervention may be necessary.
§¤ÍÂȘ ÎÏÂȉȿ: ¯˘ÏÔıÒڷη˜, ÓÂÔÁ¤ÓÓËÙÔ.
Key words: chylothorax, newborn.
∂ÈÛ·ÁˆÁ‹ O ¯˘ÏÔıÒڷη˜ Â›Ó·È Û¿ÓÈ· ·ÈÙ›· ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Û ÓÂÔÁÓfi Î·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ˘ÁÚÔ‡ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (1). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙÔ˘ ¯˘ÏÔıÒڷη Î·È Ë ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË (1,2). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Ú¤ÂÈ Ó· Èı·ÓÔÏÔÁÂ›Ù·È fiÙ·Ó Û ÚÔÁÂÓÓËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·Ú·ÙËÚÂ›Ù·È ¿ıÚÔÈÛË ˘ÁÚÔ‡ ÛÙÔ ıÒڷη ÂÙÂÚfiÏ¢ڷ ‹ ·ÌÊÔÙÂÚfiÏ¢ڷ, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ÂÌ‚Ú˘˚Îfi˜ ‡‰Úˆ-
·˜, ·ÛΛÙ˘ ‹ Ô›‰ËÌ·, ÂÓÒ Â›Ó·È ·Ó¤·ÊÔ ÙÔ ‰È¿ÊÚ·ÁÌ· Î·È ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ë Î·Ú‰ÈÔ¿ıÂÈ· (3).
1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·” 2 ∞’ ª·È¢ÙÈ΋-°˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·”
1 Neonatology Department, General District Hospital of Athens “Alexandra” 2 1st Department of Obstetric-Gynecology, General District Hospital of Athens “Alexandra”
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¢›‰˘ÌË Î‡ËÛË, ηٿ ÙËÓ 32Ë Â‚‰ÔÌ¿‰·, ·ÚÔ˘Û›·Û ˘‰Ú¿ÌÓÈÔ Î·È Û ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠϢÚÈÙÈ΋ Û˘ÏÏÔÁ‹ ÛÙÔ ¤Ó· ¤Ì‚Ú˘Ô. ∆Ô ¿ÏÏÔ ¤Ì‚Ú˘Ô ‹Ù·Ó Î·È ·Ú¤ÌÂÈÓÂ Ê˘ÛÈÔÏÔÁÈÎfi. §fiÁˆ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ·˘ÙÒÓ Ô ÙÔÎÂÙfi˜ ¤ÁÈÓ Ì ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ∫∆ ÛÙËÓ 32Ë Â‚‰ÔÌ¿‰· ÂÁ΢ÌÔÛ‡Ó˘. ∞̤ۈ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ÙÔ
199
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·200
¶·È‰È·ÙÚÈ΋ 2002;65:199-202
¿Û¯ÔÓ ÓÂÔÁÓfi, ¿ÚÚÂÓ Ì µ°=2560 g, ª™=48 cm, ¶∫=32 cm ¯ÚÂÈ¿ÛÙËΠ·Ó¿ÓË„Ë Ì ¯ÔÚ‹ÁËÛË O2 Ì ·ÛÎfi. ∆Ô Apgar score ÛÙÔ 1Ô Î·È 5Ô min ‹Ù·Ó 5 Î·È 7 ·ÓÙ›ÛÙÔȯ·. ™ÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘Û›·Û ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÚÔԉ¢ÙÈο ÂȉÂÈÓÔ‡ÌÂÓË, ÔfiÙ ٤ıËΠ۠Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ÛÙÔÓ ÔÔ›Ô ·Ú¤ÌÂÈÓ ÁÈ· 5 ÂÈÎÔÛÈÙÂÙÚ¿ˆÚ·. ∆Ô ÓÂÔÁÓfi ‰ÂÓ ·ÚÔ˘Û›·˙ ÛËÌ›· ‡‰Úˆ· ‹ ÏÂÌÊÔ›‰ËÌ·. ∏ ·/· ıÒڷη ¤‰ÂÈÍ ÂÎÙÂٷ̤ÓË Ï¢ÚÈÙÈ΋ Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ‰ÂÍÈ¿, ¯ˆÚ›˜ Û˘ÓÔ‰fi ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë (∂ÈÎfiÓ· 1). ™·Ó Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ Û˘ÏÏÔÁ‹˜ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Û˘ÁÁÂÓÒ˜ Ù¤ıËÎ·Ó Ô ¯˘ÏÔıÒڷη˜, ÙÔ Â̇ËÌ· Î·È Ë ·ÈÌÔÚÚ·Á›·. ŒÁÈÓ·Ó ‰‡Ô ÂÎÎÂÓˆÙÈΤ˜ ·Ú·ÎÂÓÙ‹ÛÂȘ ıÒڷη (1Ë Î·È 2Ë ·ÓÙ›ÛÙÔȯ·: pH: 7,4 Î·È 7, ·ÙÙ·Ú·: 2440 Î·È 12.000/ml, ÏÂÌÊÔ·ÙÙ·Ú·: 80 Î·È 80%, χΈ̷: 4,3 Î·È 3,6 g/dl, ۿί·ÚÔ: 126 Î·È 82 mg/dl, LDH: 176 Î·È 316 IU/L, Î/˜: ÛÙ›Ú˜) Î·È ·Ú¤ÌÂÈÓÂ Û˘Ó¯‹˜ ·ÚÔ¯¤Ù¢ÛË ÁÈ· 3 Ë̤Ú˜. ∆Ô ˘ÁÚfi Ù˘ ·ÚÔ¯¤Ù¢Û˘ ‹Ù·Ó ·¯‡ÚÚ¢ÛÙÔ, ‰È·˘Á¤˜, ÎÈÙÚÈÓfi¯ÚÔ˘Ó. ∏ ËÏÂÎÙÚÔÊfiÚËÛË ÏÈȉ›ˆÓ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ¤‰ÂÈÍ ÙÚÈÁÏ˘ÎÂÚ›‰È· 752 mg/dl, ÔÏÈο ÏÈ›‰È· 1047 mg/dl Î·È ¯ÔÏËÛÙÂÚfiÏË 30 mg/dl. ∞fi ÙÔÓ ˘fiÏÔÈÔ ¤ÏÂÁ¯Ô ÛËÌÂÈÒÓÔÓÙ·È Ù· Ï¢ÎÒÌ·Ù· ÔÚÔ‡ (5,1 g/dl, ·Ï‚Ô˘Ì›ÓË 3,3 g/dl), ÔÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÔÚÔ‡ [IgG=230 mg/dl (ÊÙ. 600-1200), IgA=6,5 mg/dl (ÊÙ. 3-13), IgM=15,2 (ÊÙ. 15-59)]. O ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (TORCH) ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∫·Ú˘fiÙ˘Ô˜ ›¯Â Á›ÓÂÈ ÚÔÁÂÓÓËÙÈο Î·È ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ ¿ÚÚÂÓÔ˜. ªÂ ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÙÔ˘ ÂÈÎfiÓ· ÂȂ‚·ÈÒıËÎÂ Ë Èı·ÓÔÏÔÁÔ‡ÌÂÓË ‰È¿ÁÓˆÛË ÙÔ˘ ¯˘ÏÔıÒڷη. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ ·ÚÔ˘Û›·Û Ó¢ÌÔıÒڷη Î·È ÛË„·ÈÌ›· ·fi staphylococcus epidermidis, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ·ÚÔ¯¤Ù¢ÛË Î·È ·ÓÙÈ‚›ˆÛË, ·ÓÙ›ÛÙÔȯ·.
∂ÈÎfiÓ· 1. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÓÂÔÁÓÔ‡ ÌÂ Û˘ÁÁÂÓ‹ ÂÙÂÚfiÏ¢ÚÔ ¯˘ÏÔıÒڷη (ÔÌÔÈÔÁÂÓ‹˜ ıÔÏÂÚfiÙËÙ· ‰ÂÍÈÔ‡ ËÌÈıˆÚ·Î›Ô˘).
200
Paediatriki 2002;65:199-202
∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÚÈ·˜ ÓfiÛÔ˘ ÙÔ˘, Ô˘ ‹Ù·Ó Ô ¯˘ÏÔıÒڷη˜, ¤ÁÈÓ Ì ·ÔÊ˘Á‹ Û›ÙÈÛ‹˜ ÙÔ˘ Ì Á¿Ï· ̤¯ÚÈ ÙÔ 10Ô 24ˆÚÔ ˙ˆ‹˜, ÔfiÙ ¿Ú¯ÈÛÂ Ë ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÁÈ· 7 Ë̤Ú˜. ¢È·ÎfiËΠfï˜ ÏfiÁˆ ˘ÔÙÚÔ‹˜ ÙÔ˘ ¯˘ÏÔıÒڷη. ∏ ·ӷۛÙÈÛË ¤ÁÈÓ ÌÂÙ¿ ·fi 15 Ë̤Ú˜ (32Ô 24ˆÚÔ ˙ˆ‹˜) Ì ÂȉÈÎfi Á¿Ï· Ô˘ ÂÚÈ›¯Â ÏÈ·Ú¿ Ôͤ· ̤Û˘ ·Ï‡ÛÔ˘ (MCT). ∆Ô ÂȉÈÎfi Á¿Ï· ¯ÔÚËÁ‹ıËÎÂ Û˘ÓÔÏÈο ÁÈ· 3 Ì‹Ó˜ ÂÚ›Ô˘ Î·È ·ÎÔÏÔ‡ıˆ˜ ÙÔ ‚Ú¤ÊÔ˜ ÛÈÙ›ÛÙËΠ̠ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ¯ˆÚ›˜ Ó· ÛËÌÂȈı› ˘ÔÙÚÔ‹ ÙÔ˘ ¯˘ÏÔıÒڷη (∂ÈÎfiÓ· 2). ∆Ô ‚Ú¤ÊÔ˜ Û‹ÌÂÚ· Â›Ó·È 15 ÌËÓÒÓ Î·È Â›Ó·È ·Ôχو˜ Ê˘ÛÈÔÏÔÁÈÎfi. ™˘˙‹ÙËÛË O ¯˘ÏÔıÒڷη˜ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ˘ÁÚÔ‡ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, ·ÏÏ¿ ·ÔÙÂÏ› ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Î·È Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ·Ó¤Ú¯ÂÙ·È Û 1/10000 ÙÔÎÂÙÔ‡˜ Î·È 1/2000 ÂÈÛ·ÁˆÁ¤˜ ÓÂÔÁ¤ÓÓËÙˆÓ. ∏ Û¯¤ÛË ·ÁÔÚÈÒÓ:ÎÔÚÈÙÛÈÒÓ Â›Ó·È 2:1 (4). ∏ ÂÙÂÚfiÏ¢ÚË ÌÔÚÊ‹, ΢ڛˆ˜ ‰ÂÍÈ¿, Â›Ó·È Ë Ï¤ÔÓ Û˘Ó‹ı˘, fiˆ˜ Î·È Ë ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ∞˘Ùfi Èı·ÓÒ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó·ÙÔÌ›· ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘. ™¯ÂÙÈο Ì ÙËÓ ÂÍ‹ÁËÛË ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη ˘¿Ú¯Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ. ªÈ· Èı·Ó‹ ÂÍ‹ÁËÛË ı· ÌÔÚÔ‡Û ӷ Â›Ó·È Ë Â˘¿ÏˆÙË ‰È·‰ÚÔÌ‹ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘. ªÔÚ› ‰ËÏ·‰‹ Ó· ÚÔÎÏËı› ¯˘ÏÔıÒڷη˜ ·fi ÙË Ú‹ÍË ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘ ÏfiÁˆ ˘ÂÚ¤ÎÙ·Û˘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Î·È ÏfiÁˆ ·˘ÍË̤Ó˘ ÊÏ‚È΋˜ ›ÂÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡. ∏ ·ÈÙ›· ·˘Ù‹ fï˜ Û·Ó›ˆ˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο. ™˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ÏÂÌÊÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙÔ Â›Â‰Ô ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘ ¿ÓˆıÂÓ ‹ οوıÂÓ ÙÔ˘ ¤ÌÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ô‰ËÁ› Û ‰ÂÍÈfi ‹
∂ÈÎfiÓ· 2. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ¯˘ÏÔıÒڷη.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·201
¶·È‰È·ÙÚÈ΋ 2002;65:199-202
·ÚÈÛÙÂÚfi ¯˘ÏÔıÒڷη ·ÓÙ›ÛÙÔȯ· (4). ™ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Â›Ó·È ÂÌÊ·Ó‹ ÛÙË Á¤ÓÓËÛË Î·È ÛÙȘ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜ (4). ∂›Ó·È Èı·ÓfiÓ Ô Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Û‡Ó‰ÚÔÌÔ Turner, ÙÔ Û‡Ó‰ÚÔÌÔ Noonan, ÙÔ Û‡Ó‰ÚÔÌÔ Down ‹ ÙÔÓ ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· (5). ∞ÎfiÌË ¤¯ÂÈ ·Ó·ÊÂÚı› Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi Ì ı˘ÚÂÔÙÔ͛ΈÛË ‰Â˘ÙÂÚÔ·ıÒ˜ ÚÔ˜ ÙË ÓfiÛÔ Grave Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ (6) Î·È ÔÏϤ˜ ÊÔÚ¤˜ Û˘Ó‰˘¿˙ÂÙ·È Ì ÔÏ˘¸‰Ú¿ÌÓÈÔ. O ¯˘ÏÔıÒڷη˜ ÂΉËÏÒÓÂÙ·È Ì ÛËÌ›· ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ì ÂÏ¿ÙÙˆÛË Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ıÒڷη Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜ ηٿ ÙËÓ ·ÎÚfi·ÛË, ÂÓÒ Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Â›Ó·È ÔÌÔÈÔÁÂÓ‹˜ ıÔÏÂÚfiÙËÙ· ÂÙÂÚfiÏ¢ڷ ‹ ·ÌÊÔÙÂÚfiÏ¢ڷ, Ì ‹ ¯ˆÚ›˜ ÌÂÙ·ÙfiÈÛË ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÚÔ˜ ÙËÓ ˘ÁÈ‹ ÏÂ˘Ú¿ (∂ÈÎfiÓ· 1). ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Û fiÚıÈ· ı¤ÛË ‰Â›¯ÓÂÈ Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ÛÙË ‚¿ÛË Ù˘ ˘Â˙ˆÎÔÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜. ∏ ·ÎÙÈÓÔÁÚ·ÊÈ΋ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÌËÓ Â›Ó·È Â‡ÎÔÏË ÏfiÁˆ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ Ù˘ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ Ì ÛÔ‚·Ú‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ, fiˆ˜ ›Û˘ Ë Ù˘È΋ ÂÈÎfiÓ· Ù˘ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÂÌÊ·Ó‹˜. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ, Ô ¤ÏÂÁ¯Ô˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ˘ ıÒڷη Â›Ó·È ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ ‹ÈˆÓ Û˘ÏÏÔÁÒÓ. ∏ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÂȂ‚·Èˆı› Ì ÙËÓ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη Î·È ÙË ‰È·›ÛÙˆÛË Ù˘ Ù˘È΋˜ Û‡ÓıÂÛ˘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ˘ÁÚÔ‡. ∏ ϤÌÊÔ˜ Â›Ó·È Î›ÙÚÈÓË, ‰È·˘Á‹˜, Á›ÓÂÙ·È Á·Ï·ÎÙ҉˘ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È Ï·Óı·Ṳ̂ӷ ÂÎÏ·Ì‚¿ÓÂÙ·È ˆ˜ ‡ÔÓ. ªÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙË ¯ÔÚ‹ÁËÛË Ì¤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ, Ë Ï¤ÌÊÔ˜ Á›ÓÂÙ·È ‰È·˘Á‹˜ Î·È Î›ÙÚÈÓË Í·Ó¿ (7). ∆· ‚ÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ϤÌÊÔ˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (1). ¶·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Â›Ó·È ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Î˘Ú›ˆ˜ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ¶›Ó·Î·˜ 1. µÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Û ¯˘ÏÔıÒڷη ñ ¢È·˘Á¤˜ Î·È Î›ÙÚÈÓÔ (ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË Á·Ï·ÎÙ҉˜) ñ ™Ù›ÚÔ ÌÈÎÚÔ‚›ˆÓ ñ ÕÔÛÌÔ ñ Â.‚.: 1.012-1.025 ñ ÷ڷÎÙËÚÈÛÙÈο ÚˆÙÂ˚ÓÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ, fiˆ˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ñ À„ËÏ¿ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ñ ÷ÌËÏ¿ ›‰· ¯ÔÏËÛÙÂÚ›Ó˘ ñ §Â˘ÎÔ·ÙÙ·Ú·: 6,0-8,0 x 109/l ñ §ÂÌÊÔ·ÙÙ·Ú· >80%, ΢ڛˆ˜ ∆ ÏÂÌÊÔ·ÙÙ·Ú·
Paediatriki 2002;65:199-202
O ¯˘ÏÔıÒڷη˜ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È Ì ÌË·ÓÔÛÔÏÔÁÈÎfi ÂÌ‚Ú˘˚Îfi ‡‰Úˆ·, Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙËÓ ·Ú·ÎÒÏ˘ÛË Ù˘ ·ӷÊÔÚ¿˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙËÓ Î·Ú‰È¿ Ȥ˙ÔÓÙ·˜ ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÊϤ‚˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙË Ì·˙È΋ ·ÒÏÂÈ· ÚˆÙÂ˚ÓÒÓ ÛÙÔÓ Ï¢ÚԉȷÊÚ·ÁÌ·ÙÈÎfi ¯ÒÚÔ, Ë ÔÔ›· Ô‰ËÁ› Û ÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÚˆÙÂ˚Ó·ÈÌ›· Î·È Ô›‰ËÌ·. O Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ ÌÔÚ› Ó· Â›Ó·È Ë ·ÈÙ›· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡. ∆· ÁÂÓÈο ̤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¯˘ÏÔıÒڷη ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ ϤÌÊÔ˘, ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜, ÙËÓ ·Ó·Ï‹ÚˆÛË ÙˆÓ ·ÔÏÂÛı¤ÓÙˆÓ ˘ÁÚÒÓ Î·È ÙËÓ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ (7,8). ™ÙȘ ÂÚÈÙÒÛÂȘ ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ Ë ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ÒÛÙ ӷ ‰ÈÂÓÂÚÁËı› ¤ÁηÈÚ· ∫∆ Î·È Ó· ·ÔÊ¢¯ı› Ë ÂÚ·ÈÙ¤Úˆ ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘Û¯¤ÚÂÈ· (3,9). O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ۯ‰fiÓ ¿ÓÙÔÙÂ Â›Ó·È ··Ú·›ÙËÙÔ˜, ÂÂȉ‹ ˘¿Ú¯ÂÈ ·Ó·Ú΋˜ ¤ÎÙ˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ, ÂÌ̤ÓÔ˘Û· ÂÌ‚Ú˘˚΋ ΢ÎÏÔÊÔÚ›· ‹ Î·È ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ. ∂Ó‰ÔÌ‹ÙÚÈ· ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη ¤¯ÂÈ ÂÊ·ÚÌÔÛÙ› ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› Ë ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ Î·È Ë ·ÛÊ˘Í›· ηٿ ÙË Á¤ÓÓËÛË, Ì ΛӉ˘ÓÔ fï˜ ÙËÓ ˘Ô-ÔÁηÈÌ›· ÙÔ˘ ÂÌ‚Ú‡Ô˘. ªÂÙ¿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ¯˘ÏÔıÒڷη, Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ Û˘Ó¯›˙ÂÙ·È Û ‚¿ÚÔ˜ ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ (‰È·Ê˘Á‹ ÛÙÔÓ ÙÚ›ÙÔ ¯ÒÚÔ), ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈηٿÛÙ·Û˘ ÙˆÓ ·ÔÏÂÛı¤ÓÙˆÓ ˘ÁÚÒÓ (fiˆ˜ Á›ÓÂÙ·È Â͈ÌËÙÚ›ˆ˜) (10). ŸÌˆ˜, Ë ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ·Ú·Î¤ÓÙËÛ˘ ÙÔ˘ ıÒڷη, Â›Ó·È Ì›· ηϋ ÂÓ·ÏÏ·ÎÙÈ΋ Ù·ÎÙÈ΋ (3,10). ™ÙȘ ÂÚÈÙÒÛÂȘ ÛÔ‚·ÚÔ‡ ¯˘ÏÔıÒڷη Ô˘ ÚÔηÏ› ÌË ·ÓÔÛÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· ÌÔÚ› Ó· ÂȯÂÈÚËı› Ë ÚÔÁÂÓÓËÙÈ΋ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη (11) ‹ Ë Û˘Ó¯‹˜ Ï¢ÚÔ-·ÌÓȷ΋ ·ÚÔ¯¤Ù¢ÛË (pleuro-amniotic shunt) ϤÌÊÔ˘ (12). ∞Ó Á›ÓÂÈ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, Û˘Ì‚·›ÓÂÈ ÁÚ‹ÁÔÚË ˘ÔÙÚÔ‹ Î·È ÙfiÙ ڤÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È Û˘Ó¯‹˜ ·ÚÔ¯¤Ù¢ÛË ·Ú¿ÏÏËÏ· Ì ÌÈÎÚ‹ ›ÂÛË ·Ó·ÚÚfiÊËÛ˘. ∞˘Ù‹ Ë Ù·ÎÙÈ΋ ıˆÚÂ›Ù·È ÚÔÙÈÌfiÙÂÚË ·fi ÙȘ ·ӷϷ̂·ÓfiÌÂÓ˜ ·Ï¤˜ ·Ú·ÎÂÓÙ‹ÛÂȘ. ªÂÚÈΤ˜ ÊÔÚ¤˜, Ë ËÌÂÚ‹ÛÈ· ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi ÙÔÓ Î˘ÎÏÔÊÔÚÔ‡ÌÂÓÔ fiÁÎÔ ˘ÁÚÒÓ, Ô‰ËÁÒÓÙ·˜ Û ˘Ô-ÔÁηÈÌ›·, ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·, ˘ÔÓ·ÙÚÈ·ÈÌ›·, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Î·È ‰È·Ù·Ú·¯‹ ÛÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· (12). ∞˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ıˆÚÔ‡ÓÙ·È ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔÈ ÂÂȉ‹ ¯¿ÓÔ˘Ó Ù· ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· ·ÓÙÈÛÒÌ·Ù·. ∏ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Â›Ó·È ·ÚÔ‰È΋ Î·È ‰È·ÚΛ fiÛÔ Î·È Ë ·ÒÏÂÈ· ϤÌÊÔ˘ (13). ∂Ô̤ӈ˜, ·ÛıÂÓ›˜ Ì ¯˘ÏÔıÒڷη
201
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·202
¶·È‰È·ÙÚÈ΋ 2002;65:199-202
Ú¤ÂÈ Ó· ·ÔÌÔÓÒÓÔÓÙ·È ·fi ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ÈÔÁÂÓ‹ Ïԛ̈ÍË Î·È Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÂÌ‚ÔÏ›ˆÓ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Û ËÏÈ˘ Ô˘ ·˘Ù¿ ÂӉ›ÎÓ˘ÓÙ·È (13). °È· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ϤÌÊÔ˘ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ›ÛÔÈ fiÁÎÔÈ ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿ÛÌ·ÙÔ˜. OÈ Kosloke Î·È Û˘Ó (8) ·Ú·Ù‹ÚËÛ·Ó ÂÏ¿ÙÙˆÛË ÛÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ fiÙ·Ó ¯ÔÚËÁÂ›Ù·È Á¿Ï· Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È·, Û ۇÁÎÚÈÛË Ì ÙÔ Î·ÓÔÓÈÎfi Á¿Ï·. ŸÌˆ˜, Ë Ù·ÎÙÈ΋ ·˘Ù‹ ·ÌÊÈÛ‚ËÙÂ›Ù·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∞ÊÔ‡ ·ÎfiÌË Î·È Ë fiÛË ‡‰·ÙÔ˜ ÚÔηÏ› ·‡ÍËÛË ÛÙËÓ Î˘ÎÏÔÊÔÚ›· Ù˘ ϤÌÊÔ˘, Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ÂÚÈÙÒÛÂȘ ˘ÂÚ·Ú·ÁˆÁ‹˜ ϤÌÊÔ˘ (5). ™Â ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÛÙȘ ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη, Û˘ÁÎÚ›ıËÎÂ Ë ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ì ÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË Ì¤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰ÈˆÓ Î·È ÙÔ Û˘Ì¤Ú·ÛÌ· Â›Ó·È fiÙÈ Ë ÚÒÙË Ì¤ıÔ‰Ô˜ ˘ÂÚÙÂÚ› Ù˘ ‰Â‡ÙÂÚ˘ ÏfiÁˆ Ù˘ ÛËÌ·ÓÙÈ΋˜ Ì›ˆÛ˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ (10 Ë̤Ú˜ ¤Ó·ÓÙÈ 23, ·ÓÙ›ÛÙÔȯ·) (8). ™Â ÈÔ ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Ì›·˜ ‰ˆ‰ÂηÂÙ›·˜, ÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÓÈÛÙÔ‡Ó Ó· ·Ú¯›˙ÂÈ Ë Û›ÙÈÛË Ì ÌËÙÚÈÎfi ‹ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Û ·ÔÙ˘¯›· Ó· ¯ÔÚËÁÂ›Ù·È Á¿Ï· Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È· (14). °ÂÓÈο, Ë ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ Á¿Ï·ÎÙÔ˜ ·Ú¯›˙ÂÈ ·ÊÔ‡ Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ ¤¯ÂÈ ÛÙ·Ì·Ù‹ÛÂÈ ÁÈ· Ì›· ‚‰ÔÌ¿‰·, ÂÎÙfi˜ ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‹È˜ ÌÔÚʤ˜ ¯˘ÏÔıÒڷη. ™Â ÂÚÈÙÒÛÂȘ ÂÎÙÂٷ̤ÓÔ˘ Î·È ÛÔ‚·ÚÔ‡ ¯˘ÏÔıÒڷη Ô˘ ηٷϋÁÂÈ Û ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ Î·È ÂÓÒ Ë Û˘ÓÙËÚËÙÈ΋ ıÂڷ›· ¤¯ÂÈ ·ÔÙ‡¯ÂÈ, Ë ÂÚ¢ÓËÙÈ΋ ıˆÚ·ÎÔÙÔÌ‹ Â›Ó·È ÙÔ ÂfiÌÂÓÔ ‚‹Ì·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÂÓÒ Ë ıÓËÛÈÌfiÙËÙ· ÙÔ˘ ÂÙÂÚfiÏ¢ÚÔ˘ ¯˘ÏÔıÒڷη Â›Ó·È ¯·ÌËÏ‹, ÙÔ˘ ·ÌÊÔÙÂÚfiÏ¢ÚÔ˘ Â›Ó·È Ôχ ˘„ËÏ‹ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 60% (9). ∆ÔÓ›˙ÂÙ·È fiÙÈ Ë ¤ÁηÈÚË Î·È Î·Ù¿ÏÏËÏË Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ Â›Ó·È Û¯Â‰fiÓ ¿ÓÙ· ÂÈÙ˘¯‹˜ Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Û¿ÓÈ· ¯ÚÂÈ¿˙ÂÙ·È, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ ‰È·ÚΛ Ôχ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Straaten van HLM, Gerards LJ, Krediet TG. Chylothorax in the neonatal period. Eur J Pediatr 1993;152:2-5. 2. Vade A, Kramer L. Extralobar pulmonary sequestration
202
Paediatriki 2002;65:199-202
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
presenting as intractable pleural effusion. Pediatr Radiol 1989;19:333-334. Meizner I, Carmi R, Bar-Ziv J. Congenital chylothorax. Prenatal ultrasonic diagnosis and successful postpartum management. Prenat Diagn 1986;6:217-221. Van Aerde J, Campell AN, Smyth JA, Lyoyd D, Bryan MH. Spontaneous chylothorax in newborns. Am J Dis Child 1984;138:961-964. Puddy V, Lam BC, Tang M, Wong KY, Lam YH, Wong K et al. Variable levels of mosaicism for trisomy 21 in a nonimmune hydropic infant with chylothorax. Prenat Diagn 1999;19:764-766. Ibrahim H, Asamoah A, Krouskop RW, Lewis D, Webster P, Pramanik AK. Congenital chylothorax in neonatal thyrotoxicosis. J Perinatol 1999;19:68-71. Femandez Alvarez JR, Kalache KD, Grauel EL. Management of spontaneous congenital chylothorax: oral medium-chain triglycerides versus total parenteral nutrition. Am J Perinatol 1999;16:415-420. Kosloke AM, Martin LW, Schubert WK. Management of chylothorax in children by thoracocentesis and MCTfeedings. J Pediatr Surg 1974;9:365-371. Carmant L, Le Guennec JC. Congenital chylothotax and persistent pulmonary hypertension of the neonate. Acta Paediatr Scan 1989;78:789-792. Petres RE, Redwine FO, Schneider K. Chylothorax in a twin pregnancy of 34 weeks, sonographically diagnosed. Eur J Obstet Reprod Biol 1983;16:205-211. Petres RE, Redwine FO, Cruikshank DP. Congenital bilateral chylothorax: antepartum diagnosis and successful intrauterine surgical management. J Am Med Assoc 1982;248:1360-1365. Booth P, Nicolaides KH, Greenough A, Gamsu HR. Pleuroamniotic shunting for fetal chylothorax. Early Hum Dev 1987;15:365-367. Mc Williams BC, Fan LL, Murphy SA. Transient T-cell depression in postoperative chylothorax. J Pediatr 1981;99:595-596. AI Tawil K, Ahmed G, Al-Hathal M, AI Jarallah Y, Campell N. Congenital chylothorax. Am J Perinatol 2000;17:121-126.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-08-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ª·ÚÔ‡Ù˘ ∞Á›·˜ ∂ϤÓ˘ 2, ∆.∫. 157 72, ∑ˆÁÚ¿ÊÔ˘
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·203
¶·È‰È·ÙÚÈ΋ 2002;65:203-207
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2002;65:203-207
CASE REPORT
™˘ÁÁÂÓ‹˜ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ÚfiˆÚÔ ÓÂÔÁÓfi ∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘1, π. ∫·Ï¤ÁÈ·˜1, O. OÈÎÔÓÔÌ›‰Ô˘1, ∂. ¶··ıˆÌ¿1, ∂. ¶Ú›ÊÙË2, µ. ¶ÂÙÚԯ›ÏÔ˘ - ¶¿Û¯Ô˘2, Ã. ∫ÒÛÙ·ÏÔ˜1
Congenital tuberculÔus lymphadenitis in a preterm infant Z. Hatzistamatiou1, J. Kaleyias1, U. Ikonomidou1, E. Papathoma1, E. Prifti2, V. Petrocheilou - Paschou2, Ch. Kostalos1
¶ÂÚ›ÏË„Ë: ∏ Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È Ì›· Û¿ÓÈ· ÓfiÛÔ˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡, ÙÔ ÔÔ›Ô ·ÚÔ˘Û›·ÛÂ Ê˘Ì·ÙÈÒ‰Ë ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ËÏÈΛ· 2 ‚‰ÔÌ¿‰ˆÓ. ∏ ÌËÙ¤Ú· ÙÔ˘ ÓÂÔÁÓÔ‡, 20 Ë̤Ú˜ ÚÈÓ ÙÔÓ ÙÔÎÂÙfi, ÓfiÛËÛ ·fi ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È ÌËÓÈÁÁ›Ùȉ·. ∏ ÌË ÂȉÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÚÔ‚ÔÏ‹˜ Ù˘ ÓfiÛÔ˘ Î·È Ë ˘„ËÏ‹ ıÓËÙfiÙËÙ· ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂڷ›· Ù˘ ÓfiÛÔ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·.
Abstract: Congenital tuberculosis is a rare disease. This is a case report of a two week-old premature infant with tuberculÔus lymphadenitis. His mother, twenty days prior to labour, presented miliary tuberculosis and meningitis. The nonspecific nature of presenting signs and symptoms and the high mortality rate in the absence of early therapy, signify the importance of early diagnosis and treatment during the neonatal period and infancy.
§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË, ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÓÂÔÁ¤ÓÓËÙÔ.
Key words: congenital tuberculosis, lymphadenitis, newborn.
∂ÈÛ·ÁˆÁ‹ ∏ ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È ˘„ËÏfiÙÂÚË Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ÂÚÈfi‰Ô˘˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ· ·Ô‰›‰ÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙË Û˘¯ÓfiÙÂÚË Â›ÙˆÛË Ù˘ ÎÂÁ¯ÚÔÂȉԇ˜ Ê˘Ì·Ù›ˆÛ˘ Î·È Ù˘ Ê˘Ì·ÙÈÒ‰Ô˘˜ ÌËÓÈÁÁ›Ùȉ·˜, ·ÊÂÙ¤ÚÔ˘ ‰Â Û ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ ÏfiÁˆ Û˘¯Ó¿ ¿Ù˘ˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (1,2). OÈ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ÓfiÛÔ˘ Î·È Ë ÂͿψÛË ÙÔ˘ AIDS Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ïԛ̈͢ Û Á˘Ó·›Î˜ Ù˘ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ (3,4). ø˜ ·ÎfiÏÔ˘ıÔ, ÂΉ‹ÏˆÛË Ê˘Ì·Ù›ˆÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Ô‰ËÁ› Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi Û˘ÁÁÂÓ‹ Ê˘Ì·Ù›ˆÛË. ¶ÂÚÈÁÚ¿ÊÂÙ·È Û¿ÓÈ· ÂÚ›ÙˆÛË ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡, ÌËÙ¤Ú·˜ Ô˘ ÓfiÛËÛ Ì ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È Ê˘Ì·ÙÈÒ‰Ë ÌËÓÈÁÁ›Ùȉ·, 20 Ë̤Ú˜ ÚÈÓ
ÙÔÓ ÙÔÎÂÙfi. ∆Ô ÓÂÔÁÓfi ·ÚÔ˘Û›·ÛÂ Ê˘Ì·ÙÈÒ‰Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· ÙË ‰¤Î·ÙË ¤ÌÙË Ë̤ڷ Ù˘ ˙ˆ‹˜ ÙÔ˘.
¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∫ÏÈÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiˆÚÔ ¿ÚÚÂÓ ÓÂÔÁÓfi 29 ‚‰ÔÌ¿‰ˆÓ, ÙÔ ‰Â‡ÙÂÚÔ ‰›‰˘Ì˘ ·ËÛ˘, ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. ∆Ô ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó 1150 g (50Ë ∂£) Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ 26,5 cm. (50Ë ∂£).∆Ô Apgar score ÛÙÔ ÚÒÙÔ Î·È ÙÔ ¤ÌÙÔ ÏÂÙfi ‹Ù·Ó 8 Î·È 9, ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔ ÈÛÙÔÚÈÎfi Ù˘ ÌËÙ¤Ú·˜, Ë ÔÔ›· ‹Ù·Ó ∂ÏÏËÓ›‰·, ÚˆÙ¤ÁÎ˘Ô˜ Î·È ÚˆÙÔÙfiÎÔ˜, ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÙËÓ 26Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ ÓfiÛËÛ ·fi ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È Ê˘Ì·ÙÈÒ‰Ë ÌËÓÈÁÁ›Ùȉ·, ÔfiÙ ¤ÁÈÓ ÂÈÛ·ÁˆÁ‹ Ù˘ Û ÓÔÛÔÎÔÌÂ›Ô Î·È ¿Ú¯ÈÛ ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹. ∆ËÓ 29Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ ÌÂٷʤÚıËΠ̷۠È¢ÙÈ΋ ÎÏÈÓÈ΋ Î·È ˘Ô‚Ï‹ıËΠ۠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚfiˆÚ˘ ¤Ó·Ú͢ ˆ‰›ÓˆÓ. ∏ ÌËÙ¤Ú· ‹Ù·Ó ¯ÚfiÓÈÔ˜ General District Hospital “Alexandra”, Athens 1 Neonatal Department 2 Microbiology Department
203
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·204
¶·È‰È·ÙÚÈ΋ 2002;65:203-207
Paediatriki 2002;65:203-207
ÊÔÚ¤·˜ Ë·Ù›Ùȉ·˜ µ, ÂÓÒ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∆Ô ÓÂÔÁÓfi ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ·fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰ÂÓ ˘‹Ú¯·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ë ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È Ù· Ë·ÙÈο ¤Ó˙˘Ì· ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Î·È Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‹Ù·Ó ·ÚÓËÙÈ΋. ™ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÂÛÙ¿ÏËÛ·Ó ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÁÈ· ηÏÏȤÚÁÂÈ·, ∂¡À ÁÈ· ÁÂÓÈ΋ ÂͤٷÛË Î·È Î·ÏÏȤÚÁÂÈ·, ηıÒ˜ Î·È ÙÚ›· ‰Â›ÁÌ·Ù· Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ÁÈ· ·Ó·˙‹ÙËÛË Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. H ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ‹Ù·Ó ·ÚÓËÙÈ΋. ªÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘, ÙÔ ÓÂÔÁÓfi ‰ÂÓ ‹Ïı ϤÔÓ Û ·ʋ Ì ÙË ÌËÙ¤Ú· ÙÔ˘. ¡ÔÛËχıËΠ۠ÎÏÂÈÛÙ‹ ıÂÚÌÔÎÔÈÙ›‰· ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ÏfiÁˆ ÚÔˆÚfiÙËÙ·˜ Î·È ¤Ï·‚ ¯ËÌÂÈÔÚÔʇϷÍË Ì ÈÛÔÓÈ·˙›‰Ë (10 mg/k/Ë̤ڷ) ÏfiÁˆ Ù˘ ÎÂÁ¯ÚÔÂȉԇ˜ Ê˘Ì·Ù›ˆÛ˘ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘. ∆Ô ÓÂÔÁÓfi, ÙË 12Ë Ë̤ڷ ˙ˆ‹˜, ·ÚÔ˘Û›·Û ÛË„·ÈÌ›· ·fi Klebsiella pneumoniae, ÁÈ· ÙËÓ ÔÔ›· ¤Ï·‚ ·ÓÙÈÛË„·ÈÌÈ΋ ·ÁˆÁ‹ (Amoxycillinclavulanic acid Î·È Netromycin). O Ó¤Ô˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, ÂÎÙfi˜ ·fi ÙË ıÂÙÈ΋ ηÏÏȤÚÁÈ· ·›Ì·ÙÔ˜, ¤‰ÂÈÍ ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 9200/Ìl (¶ 60%, § 35%, ª 5%), ·ÈÌÔÂÙ·Ï›ˆÓ 80.000/Ìl Î·È Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË Â›¯Â ıÂÙÈÎÔÔÈËı› (13,5 mg/dl). H ÁÂÓÈ΋ ÙÔ˘ ∂¡À ¤‰ÂÈÍ ·ÙÙ·Ú· 30/Ìl (ÏÂÌÊÔ·ÙÙ·Ú·), ۿί·ÚÔ 67 mg/dl (Ì ۿί·ÚÔ ·›Ì·ÙÔ˜ 90 mg/dl), χΈ̷ 40mg/dl. ÕÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù· ∂¡À ¯ÚˆÌ·ÙÈṲ̂ӷ ηٿ Gram, ‹Ù·Ó ·ÚÓËÙÈο ÁÈ· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Î·È Ë Î·ÏÏȤÚÁÂÈ· ÛÙ›ڷ ÁÈ· ÎÔÈÓ¿ ÌÈÎÚfi‚È·. ∆Ë 15Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÂÓÒ ÙÔ ÓÂÔÁÓfi ‹Ù·Ó ˘fi ·ÓÙÈÛË„·ÈÌÈ΋ ·ÁˆÁ‹, ·ÚÔ˘Û›·Û ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Î·È Ë·ÙÔÛÏËÓÈ΋ ‰ÈfiÁΈÛË
(‹·Ú 4 cm, ÛÏ‹Ó·˜ 3 cm). ∞Ú¯Èο, ›¯Â ÙÚÂȘ ÌÈÎÚÔ‡˜ ÙÚ·¯ËÏÈÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜ ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘, ÌË Â˘Î›ÓËÙÔ˘˜, ÌÂÁ¤ıÔ˘˜ ÂÚ›Ô˘ 0,5 cm. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰¤Ó˜ ÛÙËÓ ˘ÈÓȷ΋ ¯ÒÚ·, ÂÓÒ ÔÈ ÙÚ·¯ËÏÈÎÔ› ÏÂÌÊ·‰¤Ó˜ ‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó Û ̤ÁÂıÔ˜ (1 cm) (∂ÈÎfiÓ· 1 Î·È 2). §fiÁˆ Ù˘ Âȉ›ӈÛ˘ Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ Î·È ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Ù˘ ÌËÙ¤Ú·˜, ÎÚ›ıËΠÛÎfiÈÌÔ Ó· ÏËÊı› ˘ÏÈÎfi ·fi ÙÔ˘˜ ÏÂÌÊ·‰¤Ó˜ ÁÈ· ‚ÈÔ„›· Î·È ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ÂͤٷÛË. ∂›Û˘, ÂÏ‹ÊıËÛ·Ó ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ÂÛÙ¿ÏËÛ·Ó ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÁÈ· ·Ó·˙‹ÙËÛË M. tuberculosis. ∂ÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË: ∞fi ÙÔ ˘ÏÈÎfi ·Ú·Î¤ÓÙËÛ˘ ÙÔ˘ ÏÂÌÊ·‰¤Ó· ¤ÁÈÓ·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ: ∞) ÕÌÂÛ· ÌÈÎÚÔÛÎÔÈο ·Ú·Û΢¿ÛÌ·Ù·, Ù· ÔÔ›· ¯ÚˆÌ·Ù›ÛÙËηÓ: i) ηٿ Gram Î·È ii) Ì ¯ÚÒÛË Zielh-Neelsen (∑-¡). ∫·Ù¿ ÙË ÌÈÎÚÔÛÎfiËÛË ‰ÂÓ ·Ó¢ڤıËÛ·Ó Ì ÙË ¯ÚÒÛË Gram ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, ÂÓÒ ÛÙ· ·Ú·Û΢¿ÛÌ·Ù· Ì ¯ÚÒÛË ∑-¡ ·Ú·ÙËÚ‹ıËÎ·Ó ¿ÊıÔÓ· ÏÂÙ¿, ÂÏ·ÊÚ¿ Î·Ì˘ÏˆÙ¿, Ô͢¿ÓÙÔ¯· ‚·ÎÙËÚ›‰È·, Ù· ÔÔ›· ‰È·Ù¿ÛÛÔÓÙ·Ó Î·Ù¿ ÌÈÎÚÔ‡˜ ÛˆÚÔ‡˜ ‹ ÌÂÌÔӈ̤ӷ ˙‡ÁË. ∏ ÌÔÚÊÔÏÔÁ›· ·˘Ù‹ ‹Ù·Ó Ù˘È΋ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ. µ) °È· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ›‰Ô˘˜ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù·, ÂÊ·ÚÌfiÛÙËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ıÂÚÌÔ·ÓıÂÎÙÈ΋˜ ÔÏ˘ÌÂÚ¿Û˘ (PCR) Û ˘ÏÈÎfi ÏÂÌÊ·‰ÂÓÈÎÔ‡ ÈÛÙÔ‡ (5). °È· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙÔ˘ DNA ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ, Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹, ÙÔ ‰È·ÁÓˆÛÙÈÎfi Û‡ÛÙËÌ· PCR-Amlicor MTB (Roche Diagnostic Systems Inc. Branchburg N.J. U.S.A.) Ô˘ ÂÓÈÛ¯‡ÂÈ ÙÔ DNA ÛÙfi¯Ô (ÌÂÁ¤ıÔ˘˜ 584 ÓÔ˘ÎÏÂÔÙȉ›ˆÓ), Ô ÔÔ›Ô˜ Έ‰ÈÎÔÔÈ› ÙÔ 16S RNA ÙÔ˘ M. Tuberculosis complex.
∂ÈÎfiÓ· 1. ∆Ú·¯ËÏÈ΋ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·.
∂ÈÎfiÓ· 2. ÀÈÓȷ΋ Î·È ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·.
204
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·205
¶·È‰È·ÙÚÈ΋ 2002;65:203-207
∆Ô ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂͤٷÛ˘ ‹Ù·Ó Û˘Ì‚·Ùfi Ì ÙËÓ ·ÚÔ˘Û›· ÛÙÔÓ ÈÛÙfi M. tuberculosis. °) ∫·ÏÏȤÚÁÂÈ·: ∞fi ÙÔ ˘ÏÈÎfi ÙÔ˘ ÏÂÌÊ·‰¤Ó· ¤ÁÈÓ ηÏÏȤÚÁÂÈ·, ÙfiÛÔ ÁÈ· ÎÔÈÓ¿ ÌÈÎÚfi‚È· Û ·ÈÌ·ÙÔ‡¯Ô ¿Á·Ú, fiÛÔ Î·È ÁÈ· Ì˘ÎÔ‚·ÎÙËÚ›‰È· Û ÂȉÈÎfi ıÚÂÙÈÎfi ˘ÏÈÎfi Lowenstein-Jensen. ™ÙÔ ·ÈÌ·ÙÔ‡¯Ô, ÌÂÙ¿ ·fi ÂÒ·ÛË ·ÂÚÔ‚›ˆ˜ Û ·ÙÌfiÛÊ·ÈÚ· CO2 Î·È ·Ó·ÂÚÔ‚›ˆ˜, ‰ÂÓ ·Ó·Ù‡¯ıËÎ·Ó ·ÔÈ˘ ÌÈÎÚÔ‚›ˆÓ. ™ÙÔ ˘ÏÈÎfi Lowenstein-Jensen, ÌÂÙ¿ ·fi ÂÒ·ÛË ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ ·Ó·Ù‡¯ıËÎ·Ó ·ÔÈ˘ Ô͢¿ÓÙÔ¯Ô˘ ‚·ÎÙËÚȉ›Ô˘ Ô˘ ‹Ù·Ó ÍËÚ¤˜, ‡ıÚ˘Ù˜, ΛÙÚÈÓÔ˘ ¯ÚÒÌ·ÙÔ˜. ∆Ô ‚·ÎÙËÚ›‰ÈÔ ·˘Ùfi Ù·˘ÙÔÔÈ‹ıËΠˆ˜ ª. tuberculosis. ¢) ∂˘·ÈÛıËÛ›· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο: ∆Ô M. tuberculosis Ô˘ ·ÔÌÔÓÒıËΠ·fi ÙÔÓ ÏÂÌÊ·‰¤Ó· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ¢·›ÛıËÙÔ Û fiÏ· Ù· ÚˆÙ‡ÔÓÙ· ·ÓÙÈÊ˘Ì·ÙÈο Ê¿Ú̷η (ÈÛÔÓÈ·˙›‰Ë, ÚÈÊ·ÌÈΛÓË, ÛÙÚÂÙÔÌ˘Î›ÓË, ˘Ú·˙›Ó·Ì›‰Ë Î·È Âı·Ì‚Ô˘ÙfiÏË). OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÁÈ· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ‹Ù·Ó ·ÚÓËÙÈΤ˜. O ÏÔÈfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 9100/Ìl (¶ 37%, § 48%, ª 15%), ∆∫∂ 12 mm/1Ë ÒÚ·, SGOT 33 IU/L, SGPT 11 IU/L, ÁGt 231 IU/L. ¡¤· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó Î·È ¿ÏÈ Ê˘ÛÈÔÏÔÁÈ΋. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ·Ú¤ÌÂÈÓ ·ÚÓËÙÈ΋ Î·È ıÂÙÈÎÔÔÈ‹ıËΠ·ÚÁfiÙÂÚ· Û ËÏÈΛ· 4 ÌËÓÒÓ (7 mm). O ¤ÏÂÁ¯Ô˜ ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∏ ‚˘ıÔÛÎfiËÛË ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. §fiÁˆ ÌË Âȉ›ӈÛ˘ Ù˘ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜, ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Ë·ÙÈÎÔ‡ ÂϤÁ¯Ô˘, Ù˘ ÛÙ·ıÂÚ‹˜ ηٿÛÙ·Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ù˘ ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ÓfiÛÔ˘ ·fi ˘ÏÈÎfi ÂÚÈÊÂÚÈÎÔ‡ ÏÂÌÊ·‰¤Ó·, ‰ÂÓ ÎÚ›ıËΠÛÎfiÈÌÔ Ó· ÂÏÂÁ¯ı› ÂÚ·ÈÙ¤Úˆ Ë Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Ì ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô ‹ ‚ÈÔ„›·. ™ÙÔ ÓÂÔÁÓfi ¯ÔÚËÁ‹ıËΠ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ (ÈÛÔÓÈ·˙›‰Ë 10 mg/k/Ë̤ڷ, ÚÈÊ·ÌÈΛÓË 15 mg/k/Ë̤ڷ, ˘Ú·˙ÈÓ·Ì›‰Ë 30 mg/k/Ë̤ڷ Î·È ÛÙÚÂÙÔÌ˘Î›ÓË 30 mg/k/Ë̤ڷ). ∏ ÛÙÚÂÙÔÌ˘Î›ÓË ¯ÔÚËÁ‹ıËΠÙÔ˘˜ ‰‡Ô ÚÒÙÔ˘˜ Ì‹Ó˜ Î·È Ë ÏÔÈ‹ ·ÁˆÁ‹ ÁÈ· 9 Ì‹Ó˜ Û˘ÓÔÏÈο. ∏ ÔÚ›· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ÔÌ·Ï‹, Ì ÛÙ·‰È·Î‹ ˘Ô¯ÒÚËÛË ¤ˆ˜ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (∂ÈÎfiÓ· 3) Î·È Â¿ÓÔ‰Ô ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ‹·ÙÔ˜ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. ™Â Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÁÈÓfiÙ·Ó ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Î·È ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, ÔÈ Ôԛ˜ ‹Ù·Ó ¿ÓÙ· ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ∆Ô ¿ÏÏÔ ÓÂÔÁÓfi ‰ÂÓ ÂÌÊ¿ÓÈÛ ÎÏÈÓÈο ÛËÌ›· Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ Î·È fiϘ ÔÈ Î·ÏÏȤÚÁÂȘ Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡, ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ‹Ù·Ó ·ÚÓËÙÈΤ˜ ÛÙËÓ ·Ó·˙‹ÙËÛË Ì˘ÎÔ‚·-
Paediatriki 2002;65:203-207
∂ÈÎfiÓ· 3. ∆Ú·¯ËÏÈ΋ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ·Ô‰ÚÔÌ‹ ÌÂÙ¿ ·fi ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹.
ÎÙËÚȉ›ˆÓ. ¶·Ú¤ÌÂÈÓ ÛÙÔ ÙÌ‹Ì· ÏfiÁˆ ÚÔˆÚfiÙËÙ·˜ Î·È ÙÔ˘ ¯ÔÚËÁ‹ıËΠÚÔʇϷÍË Ì ÈÛÔÓÈ·˙›‰Ë. ™Â ËÏÈΛ· 3 ÌËÓÒÓ Ë ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ·Ú¤ÌÂÈÓ ·ÚÓËÙÈ΋, ÔfiÙÂ Î·È ÂÌ‚ÔÏÈ¿ÛÙËΠ̠BCG. ∫·È Ù· ‰‡Ô ÓÂÔÁÓ¿ ÂÍ‹Ïı·Ó ·fi ÙÔ ÙÌ‹Ì· Û ËÏÈΛ· 4 ÌËÓÒÓ Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™Â ËÏÈΛ· 6 ÌËÓÒÓ Î·È ÛÙ· ‰‡Ô ÓÂÔÁÓ¿ ¤ÁÈÓ·Ó ÚÔÎÏËÙ¿ ·ÎÔ˘ÛÙÈο ‰˘Ó·ÌÈο (ABR) Ù· ÔÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆· ‚Ú¤ÊË ‹Ù·Ó Û ٷÎÙÈ΋ ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ Î·È Â›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË, ¯ˆÚ›˜ ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·. ™˘˙‹ÙËÛË ª¤¯ÚÈ ÙÔ 19Ô ·ÈÒÓ·, Ë ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë ÁÈ· ÙË Û¯¤ÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ Ì ÙËÓ Î‡ËÛË ‹Ù·Ó ·˘Ù‹ Ô˘ ›¯Â ‰È·Ù˘ÒÛÂÈ Ô πÔÎÚ¿Ù˘, fiÙÈ ‰ËÏ·‰‹ Ë Î‡ËÛË Â›¯Â ¢ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÔÚ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘ (6). ™‹ÌÂÚ·, fï˜, Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ë Î‡ËÛË ÂÈ‚·Ú‡ÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÔÚ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘. ∏ Á¤ÓÓËÛË ÂÓfi˜ ÓÂÔÁÓÔ‡ ÌÂ Ê˘Ì·Ù›ˆÛË Ô˘ ÌÔχÓıËΠηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ‹ ηٿ ÙÔÓ ÙÔÎÂÙfi ·ÔÙÂÏ› Û¿ÓÈ· ÂÚ›ÙˆÛË (3,7). ∏ ‚·ÎÙËÚÈ·ÈÌ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Ù˘ ÌËÙ¤Ú·˜ Î·È Ó· ÚÔηϤÛÂÈ ÌfiÏ˘ÓÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ (8). ∏ ÌÂÙ¿‰ÔÛË Ù˘ Ïԛ̈͢ ÛÙÔ ÓÂÔÁÓfi ÌÔÚ› Ó· Á›ÓÂÈ Ì ÙÚÂȘ ÙÚfiÔ˘˜ (9): ·) ∞ÈÌ·ÙÔÁÂÓ‹˜ ‰È·ÛÔÚ¿: ∆· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ÌÔÚ› Ó· ‰È·Û·ÚÔ‡Ó ·ÈÌ·ÙÔÁÂÓÒ˜, ‰È·Ì¤ÛÔ˘ Ù˘ ÔÌÊ·ÏÈ΋˜ ÊϤ‚·˜ fiÙ·Ó ˘¿Ú¯Ô˘Ó Ê˘Ì·ÙÈÒ‰ÂȘ ·ÔÈ˘ ÛÙÔÓ Ï·ÎÔ‡ÓÙ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Û¯ËÌ·Ù›˙ÂÙ·È ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔ ‹·Ú ‹ ÔÏϷϤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜,
205
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·206
¶·È‰È·ÙÚÈ΋ 2002;65:203-207
Paediatriki 2002;65:203-207
fiÙ·Ó Ù· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ·Ú·Î¿Ì„Ô˘Ó ÙÔ ‹·Ú ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÊÏÂ‚Ò‰Ô˘˜ fiÚÔ˘. ‚) ªÂ ηٿÔÛË: ∞ÌÓÈ·Îfi ˘ÁÚfi ÌÔÏ˘Ṳ̂ÓÔ Â›Ù ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ· ›Ù ·fi ÙÔ ÂÓ‰ÔÌ‹ÙÚÈÔ (Û ÂÚ›ÙˆÛË Ê˘Ì·ÙÈÒ‰Ô˘˜ ÂÓ‰ÔÌËÙÚ›ÙȉԘ), ÌÔÚ› Ó· ηٷÔı› ·fi ÙÔ ¤Ì‚Ú˘Ô Î·È Ó· Û¯ËÌ·ÙÈÛÙ› ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔÓ ÂÓÙÂÚÈÎfi ۈϋӷ. Á) ªÂ ÂÈÛÚfiÊËÛË: ªÔÏ˘Ṳ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi ÌÔÚ› Ó· ÂÈÛÚÔÊËı› Î·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ‰È¿Û·ÚÙ˜ ÂÛٛ˜ ÛÙÔ˘˜ Ó‡ÌÔÓ˜. ∏ Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÏÈÁfiÙÂÚ˜ ·fi 300 ÂÚÈÙÒÛÂȘ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (10) Î·È 3 ÛÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÂÏÏËÓÈ΋ (7,11). ∏ ̤ÛË ËÏÈΛ· ÎÏÈÓÈ΋˜ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È 24 Ë̤Ú˜ (‡ÚÔ˜ ·fi 1 ̤¯ÚÈ 84 Ë̤Ú˜). ∏ Û¯¤ÛË ·ÁÔÚÈÒÓ/ÎÔÚÈÙÛÈÒÓ Â›Ó·È 2/1. OÈ Ï¤ÔÓ Û˘¯Ó¤˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (9). ∏ Â͈Ó¢ÌÔÓÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Ô˘ ·ÚÔ˘Û›·Û ÙÔ ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Â›Ó·È ·Û˘Ó‹ı˘ ÂΉ‹ÏˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ (8%). ∆· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ ¤¯Ô˘Ó ÙÂı› ‹‰Ë ·fi ÙÔ 1935 ·fi ÙÔÓ Beitzke (4,9,12). OÈ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ‹ Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Î·È Ó· ÙÂÎÌËÚÈÒÓÂÙ·È Ë Ê˘Ì·ÙÈ҉˘ ʇÛË ÙÔ˘˜. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔ ‹·Ú ‹ Ó· ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ì ‚‚·ÈfiÙËÙ· Ë Èı·ÓfiÙËÙ· Â͈ÌËÙÚ›Ô˘ ÌfiÏ˘ÓÛ˘ Ì ÙËÓ ¿ÌÂÛË ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË ÌËÙ¤Ú· ‹ ·fi ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÁ‹ ÌfiÏ˘ÓÛ˘. ∆Ô ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ ‹Úı Û ·ʋ Ì ÙË ÌËÙ¤Ú· ÙÔ˘ ·fi ÙËÓ Ë̤ڷ Á¤ÓÓËÛ˘, Ô‡Ù ÂÎÙ¤ıËΠ¿ÌÂÛ· Û ¿ÏÏÔ ¿ÙÔÌÔ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ·ÊÔ‡ ÓÔÛËÏ¢fiÙ·Ó Û ¶›Ó·Î·˜ 1. ∫ÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘* ™˘ÌÙÒÌ·Ù· ‹ ÛËÌ›·
™˘¯ÓfiÙËÙ· (%)
ñ ∏·ÙÔÛÏËÓÔÌÂÁ·Ï›· ñ ∞Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ñ ¶˘ÚÂÙfi˜ ñ §ÂÌÊ·‰ÂÓÔ¿ıÂÈ· ñ ∫ÔÈÏȷ΋ ‰È¿Ù·ÛË ñ §‹ı·ÚÁÔ˜ ‹ ¢ÂÚÂıÈÛÙfiÙËÙ· ñ øÙ›ÙȘ ñ µÏ·Ùȉ҉˘ ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë ñ ŒÌÂÙÔ˜, ¿ÓÔÈ·, ΢¿ÓˆÛË, ·Ú·ÙÂÈÓfiÌÂÓÔ˜ ›ÎÙÂÚÔ˜, Û·ÛÌÔ›, ÂÙ¤¯ÂȘ
76 72 48 38 24 21 17 14 <10
* Cantwell M, Sheab Z, Costello A, Sands L, Green W, Ewing S et al. Congenital tuberculosis. NEJM 1994; 330:1051-1054
206
ÎÏÂÈÛÙ‹ ıÂÚÌÔÎÔÈÙ›‰· ÛÙË ÌÔÓ¿‰· ÙÔ˘ ÙÌ‹Ì·ÙÔ˜. ¶ÚfiÛÊ·Ù·, ¤¯Ô˘Ó ÚÔÙ·ı› Ó¤· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ·ÛÊ·Ï‹ ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ (4). ªÂ ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ÙÔ ÓÂÔÁÓfi Ú¤ÂÈ Ó· ¤¯ÂÈ Ê˘Ì·ÙÈÒ‰Ë ÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ·fi Ù· ·ÎfiÏÔ˘ı·: ·) Ë ÔÚÁ·ÓÈ΋ Ê˘Ì·ÙÈ҉˘ ‚Ï¿‚Ë Ó· ¤¯ÂÈ ‰È·ÈÛÙˆı› ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜, ‚) ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi Û‡ÌÏÂÁÌ· ‹ Ë·ÙÈÎfi ÎÔÎΛˆÌ·, Á) Ê˘Ì·ÙÈ҉˘ ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ÌËÙ¤Ú·˜ Î·È ‰) ·ÔÎÏÂÈÛÌfi˜ Ù˘ Èı·ÓfiÙËÙ·˜ ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Â͈ÌËÙÚ›ˆ˜, Ì ÂϤÁ¯Ô ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙfi˜ ÙÔ˘. ∞fi Ù· ‰È¿ÊÔÚ· fiÚÁ·Ó·, ÔÈ Ó‡ÌÔÓ˜ Î·È ÙÔ ‹·Ú Â›Ó·È ÂΛӷ ÛÙ· ÔÔ›· ÂÓÙÔ›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· Ù· Ì˘ÎÔ‚·ÎÙËÚ›‰È· (13). ÕÏϘ ÂÓÙÔ›ÛÂȘ Â›Ó·È ÙÔ ∫¡™ (50%), Ô Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ, ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, Ô ÛÏ‹Ó·˜, ÔÈ ÓÂÊÚÔ›, Ô ÏÂÌÊÈÎfi˜ ÈÛÙfi˜, ÙÔ ‰¤ÚÌ·, ÙÔ Ì¤ÛÔ Ô˘˜ (Û˘Ó‹ıˆ˜ ‰ÂÍÈ¿ Ô˘ ÔÊ›ÏÂÙ·È Û ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ì·ÛÙÔÂȉԇ˜ ÔÛÙÔ‡) (14). °È· ÙËÓ ÙÂÎÌËÚ›ˆÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ Ë·ÙÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ ··ÈÙÂ›Ù·È ·ÓÔÈÎÙ‹ ‚ÈÔ„›· ‹ ·˘ÙÔ„›· (12). ¶ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi Û‡ÌÏÂÁÌ· ÙÂÎÌËÚÈÒÓÂÙ·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË (2 ÂÚÈÙÒÛÂȘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÌÂÙ¿ ÙÔ 1980 ÌÂÙ¿ ·fi ÓÂÎÚÔÙÔÌ‹). ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ ‰ÈÂÓÂÚÁ‹ıËΠ‚Ô„›· ‹·ÙÔ˜, ÂÂȉ‹ Ë ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒıËΠ·fi ‰Â›ÁÌ· ÂÚÈÊÂÚÈÎÔ‡ ÏÂÌÊ·‰¤Ó·, Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ú¤ÌÂÈÓÂ Ê˘ÛÈÔÏÔÁÈ΋, Ë ‰ÈfiÁΈÛË ÙÔ˘ ‹·ÙÔ˜ ‰ÂÓ ÂȉÂÈÓÒıËÎÂ Î·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ÛÙ·ıÂÚ‹. ∏ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙËÚ›˙ÂÙ·È Û ÌÂıfi‰Ô˘˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔ‚Ï‹Ì·Ù·, ·ÊÂÓfi˜ ÌÂÓ Â˘·ÈÛıËÛ›·˜ Î·È ÂȉÈÎfiÙËÙ·˜, fiˆ˜ Ë ·Ó·˙‹ÙËÛË ÙˆÓ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ ÛÙ· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù·, ·ÊÂÙ¤ÚÔ˘ ‰Â ··ÈÙÔ‡Ó ÌÂÁ¿ÏÔ ¯ÚfiÓÔ ÂÒ·Û˘ (8 ‚‰ÔÌ¿‰Â˜), fiˆ˜ ÔÈ Î·ÏÏȤÚÁÂȘ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË Ù· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù· ‹Ù·Ó ıÂÙÈο Î·È ·fi ÙÔ ÈÛÙÔÚÈÎfi Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó ‰˘Ó·ÙfiÓ Ô ÎÏÈÓÈÎfi˜ È·ÙÚfi˜ Ó· ı¤ÛÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ÌÂıfi‰Ô˘ (PCR) ¤‰ˆÛ ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ›‰Ô˘˜ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Ù·¯‡Ù·Ù·, ÂÓÒ ‰È·ÊÔÚÂÙÈο ı· ¯ÚÂÈ·˙fiÙ·Ó ·Ó·ÌÔÓ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ (5). µÂ‚·›ˆ˜, Ë Î·ÏÏȤÚÁÂÈ· Â›Ó·È ·ÎfiÌË ··Ú·›ÙËÙË ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¢·ÈÛıËÛ›·˜ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘, ·ÏÏ¿ Â›Ó·È ÛËÌ·ÓÙÈÎfi Î·È ÎÚ›ÛÈÌÔ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ıÂڷ›· ÌÔÚ› Ó· ·Ú¯›ÛÂÈ ·Ì¤Ûˆ˜ Ì ٷ ηٿ ÙÂÎÌ‹ÚÈÔ Î·Ù¿ÏÏËÏ· Ê¿Ú̷η ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Â›‰Ô˜ ÌÈÎÚÔ‚›Ô˘. ∏ ıÓËÙfiÙËÙ· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ ›ӷÈ
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·207
¶·È‰È·ÙÚÈ΋ 2002;65:203-207
Paediatriki 2002;65:203-207
¶›Ó·Î·˜ 2. º¿Ú̷η Î·È ‰fiÛÂȘ ÁÈ· ÙË ıÂڷ›· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘* º¿Ú̷η
πÛÔÓÈ·˙›‰Ë ƒÈÊ·ÌÈΛÓË ¶˘Ú·˙ÈÓ·Ì›‰Ë ™ÙÚÂÙÔÌ˘Î›ÓË ∂ı·Ì‚Ô˘ÙfiÏË
∫·ıËÌÂÚÈÓ‹ ‰fiÛË (mg/k/Ë̤ڷ)
¢‡Ô ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· (mg/k/‰fiÛË)
10-15 10-20 20-40 20-40 10-25
20-30 10-20 50 20-40 50
* Starke SR. Tuberculosis. Clin Perinatol 1997;24:107-126
˘„ËÏ‹ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÍ·ÈÙ›·˜ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ‰È¿ÁÓˆÛ˘, Ë ÔÔ›· ÔÏϤ˜ ÊÔÚ¤˜ ‰˘ÛÙ˘¯Ò˜ Ù›ıÂÙ·È ÓÂÎÚÔÙÔÌÈο (15). ∆· Ê¿Ú̷η Î·È ÔÈ ‰fiÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ıÂڷ›· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (9). ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ Ù· ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó ÈÛÔÓÈ·˙›‰Ë Ú¤ÂÈ Ó· ·›ÚÓÔ˘Ó Î·È ˘ÚȉÔÍ›ÓË. ∏ ¯ÔÚ‹ÁËÛË Ù˘ ˘ÚȉÔ͛Ӣ ÚÔÏ·Ì‚¿ÓÂÈ ÙË Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, ÛÙËÓ ÔÔ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Ë ÂÚÈÔÚÈṲ̂ÓË ÈηÓfiÙËÙ· ·ÎÂÙ˘Ï›ˆÛ˘ Ù˘ ÈÛÔÓÈ·˙›‰Ë˜ ·fi ÙÔ ‹·Ú, ¯ˆÚ›˜ Ó· ·ÚÂÌÔ‰›˙ÂÙ·È Ë ·ÓÙÈÊ˘Ì·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÌÔÚ› Ó· ÂÈ‚Ú·‰‡ÓÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Û·Ê‹˜ ÂÚÌËÓ›· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ (16). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜. ŸÌˆ˜, ÔÈ ÚfiÛÊ·Ù˜ ÌÂÙ·‚ÔϤ˜ ÛÙ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Ì ÙË ÌÂÁ¿ÏË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌÂÙ¿ ÙÔ 1985, ÂÍ·ÈÙ›·˜ ÙÔ˘ AIDS, Ù˘ ÌÂÙ·Ó¿ÛÙ¢Û˘ ·ÙfiÌˆÓ ·fi ¯ÒÚ˜ ÂÓ‰ËÌÈΤ˜ Î·È Ù˘ ‰È·ÛÔÚ¿˜ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ, ·˘Í¿ÓÔ˘Ó ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂڷ›· Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜ Ê˘Ì·Ù›ˆÛ˘ Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ÚfiÁÓˆÛË ÁÈ· ÙË ÌËÙ¤Ú· Î·È ÙÔ ÓÂÔÁÓfi.
3. Adhikari M, Pillay T, Pillay DS. Tuberculosis in the newborn: an emerging disease. Pediatr Infect Dis J 1997;16:1108-1112. 4. Cantwell M, Sheab Z, Costello A, Sands L, Green W, Ewing S et al. Congenital tuberculosis. NEJM 1994; 330:1051-1054. 5. ∑¤Ú‚· §. ªÔÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘. π·ÙÚÈ΋ 2001;79:226-228. 6. Snider DE Jr. Pregnancy and tuberculosis. Chest 1984;86:115-121. 7. ∫Ô˘ÙÛÔ˘ÏȤÚ˘ ∏, ∫·˙Ï·Ú‹˜ ∂. ™˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË. π·ÙÚÈ΋ 1970;17:419-423. 8. ™ÔψÌfi˜ °, ∫Ô˘ÙÛÔ˘ÏȤÚ˘ ∏. ∂Á΢ÌÔÛ‡ÓË Î·È Ê˘Ì·Ù›ˆÛË: ÎÏÈÓÈ΋ Î·È ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁ·Ԣ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡. ¶·È‰È·ÙÚÈ΋ 1990;53:193-202. 9. Starke SR. Tuberculosis. Clin Perinatol 1997;24:107-126. 10. Nemir RL, O’ Haze D. Congenital tuberculosis review and diagnostic guidelines. Am J Dis Child 1985;139:284-287. 11. ∆Û›ÙÛÈη ∞, æ‡¯Ô˘ º, ™˘ÚÈÔÔ‡ÏÔ˘ µ, ∫Ú›ÎÔ˜ •, ¡ÈÎÔÏ·˝‰Ô˘ ¶. ™˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË. ¶Ú·ÎÙÈο 38Ô˘ ¶·ÓÂÏÏËÓ›Ô˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; ∫ˆ˜. πÔ‡ÓÈÔ˜ 16-18 2000; ÛÂÏ. 112. 12. Beitzke H. Uber die angeborene tuberkulose infektion. Ergeb Gesamten Tuberculose Forsch 1935;7:1-30. 13. Schaat HS, Nel ED. Tuberculosis presenting as cholestatic jaundice in early infancy. J Pediatr Gastroenterol Nutr 1992;15:437-439. 14. Ng PC, Hiu J, Fok TF, Nelson EA, Cheung KL, Wong W. Isolated congenital tuberculosis otitis in a preterm infant. Acta Paediatr 1995;84:955-956. 15. Pillet P, Crill J, Rakotonirina G, Holvoet-Vermant L, Auregen G, Guyon P. Congenital tuberculosis: difficulties in early diagnosis. Arch Pediatr 1999;6:635-639. 16. Mazade MA, Evans EM, Starke SR, Corree AG. Congenital tuberculosis presenting as sepsis syndrome: case report and review of the literature. Pediatr Infect Dis J 2001;20:439-442.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Snider DE, Bloch AB. Congenital tuberculosis. Tubercle 1984;65:81-82. 2. Hageman J, Shulman S, Schreiber M, Luck S, Yogev R. Congenital tuberculosis: critical reappraisal of clinical findings and diagnostic procedures. Pediatrics 1980;66:980-984.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∑ˆ‹ ÷Ù˙ËÛÙ·Ì·Ù›Ô˘ ™ÔψÌÔ‡ 2, ∆.∫. 185 47, ¡. º¿ÏËÚÔ E-mail: kaleyias@hotmail.com
207
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·208
¶·È‰È·ÙÚÈ΋ 2002;65:208-211
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2002;65:208-211
CASE REPORT
ƒÈÎÂÙÙÛÈÒÛÂȘ Ì ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓfiÛÔ˘ Kawasaki ª. ªÈÙÛÒÚË1, ∂. °·Ï·Ó¿Î˘1, ¢. ª·ÌÔ˘Ï¿Î˘1, ∂. µ·ÛÈÏ¿ÎË1, ª. ∞ÓÙˆÓ›Ô˘2, ™. ™Ì˘Ú¿ÎȘ1
Rickettsial disease with clinical presentation mimicking Kawasaki disease M. Bitsori1, E. Galanakis1, D. Mamoulakis1, E. Vasilaki1, M. Antoniou2, S. Sbyrakis1
¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÂÚÈÙÒÛÂȘ ‰‡Ô ·È‰ÈÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ÓfiÛÔ Kawasaki, Ô˘ ·Ô‰Â›¯ÙËΠÙÂÏÈο fiÙÈ Â›¯·Ó ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ. ∆Ô ÚÒÙÔ ·È‰› ‹Ù·Ó ÎÔÚ›ÙÛÈ 4 ÂÙÒÓ Ì Ïԛ̈ÍË ·fi Rickettsia typhi (ÂÓ‰ËÌÈÎfi˜ Ù‡ÊÔ˜) Î·È ÙÔ ‰Â‡ÙÂÚÔ ‹Ù·Ó ·ÁfiÚÈ 18 ÌËÓÒÓ Ì Ïԛ̈ÍË ·fi Coxiella burnetii (˘ÚÂÙfi˜ Q). ∏ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ¤ÁÈÓ Ì ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∫·È Ù· ‰‡Ô ·È‰È¿ ›¯·Ó ÈÛÙÔÚÈÎfi ·ʋ˜ Ì ˙Ò·. ™˘˙ËÙÔ‡ÓÙ·È ÔÈ ÔÌÔÈfiÙËÙ˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ Kawasaki Ì ÙȘ ÚÈÎÂÙÙÛÈÒÛÂȘ Î·È Ù· ‰È·ÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜.
Abstract: We report two children with a clinical presentation resembling Kawasaki disease. The first patient was a 4-year-old girl with Rickettsia typhi infection (murine typhus), and the second an 18-month-old boy with Coxiella burnetii infection (Q fever). The diagnosis was confirmed with positive serology. Both children had a history of animal contact. The similarity of manifestations of Kawasaki disease to rickettsial infections and the diagnostic pitfalls in such cases are discussed.
§¤ÍÂȘ ÎÏÂȉȿ: ÚÈÎÂÙÙÛÈÒÛÂȘ, ÓfiÛÔ˜ Kawasaki.
Key words: rickettsioses, Kawasaki disease.
∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ÔÍ›· Â̇ÚÂÙË ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ‚Ú¤ÊË Î·È Ó‹È·. ∞ÚÎÂÙÔ› ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, fiˆ˜ ›‰Ë Rickettsiae Î·È Yersinia, ÙÔ Propionibacterium acnes, Ô Èfi˜ Epstein-Barr, ÔÈ ÂÚËÙÔ˚Ô› 6 Î·È 7, ÚÂÙÚÔ˚Ô› Î·È Ô Èfi˜ Parvo, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙË ÓfiÛÔ, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· ¤¯ÂÈ ÔÙ¤ ·Ô‰ÂȯÙ› ÔÔÈ·‰‹ÔÙ ۷ʋ˜ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË (1). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki Á›ÓÂÙ·È Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË Ô˘ Ó· ÙËÓ ÂȂ‚·ÈÒÓÂÈ. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÂÚÈÙÒÛÂȘ ‰‡Ô ·È‰ÈÒÓ Ì Èı·Ó‹ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË ÓfiÛÔ˘ Kawasaki, Ô˘ ÙÂÏÈο ‰È·ÁÓÒÛÙËÎ·Ó ˆ˜ ÚÈÎÂÙÙÛÈÒÛÂȘ. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË 1Ë ∫ÔÚ›ÙÛÈ 4 ÂÙÒÓ, Ì ÂχıÂÚÔ ÚÔËÁÔ‡ÌÂÓÔ
ÈÛÙÔÚÈÎfi, ÂÈÛ‹¯ıË Ì ˘ÚÂÙfi ¤ˆ˜ 40ÔC ·fi 8Ë̤ÚÔ˘, Ì ڛÁÔ˜, Ì˘·ÏÁ›Â˜, η΋ ‰È¿ıÂÛË Î·È ÂÍ¿ÓıËÌ· Ô˘ ÂÌÊ·Ó›ÛÙËΠ‰‡Ô Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ Ù˘. ™ÙÔ ·È‰› ›¯Â ¯ÔÚËÁËı› ÎÂÊÔ˘ÚÔÍ›ÌË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ÂͤڢıÚ· ·Ú›ÛıÌÈ·, ·ÌÊÔÙÂÚfiÏ¢ÚË ÔÚ҉˘ ÂÈÂÊ˘Î›Ùȉ·, ·ÌÊÔÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ ̤ÁÈÛÙ˘ ‰È·Ì¤ÙÚÔ˘ 2 cm, ÂÎÛÂÛËÌ·Ṳ̂ÓË ÂÚ˘ıÚfiÙËÙ· ¯ÂÈϤˆÓ Ì ڷÁ¿‰Â˜ Î·È ÁÂÓÈÎÂ˘Ì¤ÓÔ ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·Ï·ÌÒÓ Î·È ÙˆÓ ÂÏÌ¿ÙˆÓ. ∆Ô ‹·Ú Î·È Ô ÛÏ‹Ó·˜ ‹Û·Ó „ËÏ·ÊËÙ¿, 2 cm Î·È 6 cm ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó Ï¢ÎÔÂÓ›· Ì ·fiÏ˘ÙÔ ·ÚÈıÌfi Ï¢ÎÒÓ 3,5x109/L, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ 2,6x109/L, ·ÈÌÔÛÊ·ÈÚ›ÓË 11 g/dL, ıÚÔÌ‚ÔÂÓ›· Ì ·fiÏ˘ÙÔ ·ÚÈıÌfi ·ÈÌÔÂÙ·Ï›ˆÓ 103x109/L, ÌÈÎÚ‹ ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 62 U/L Î·È SGPT 85 U/L) Î·È Ù·-
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ 2 ∆Ì‹Ì· µ·ÎÙËÚÈÔÏÔÁ›·˜-¶·Ú·ÛÈÙÔÏÔÁ›·˜-∑ˆÔÓfiÛˆÓ Î·È °ÂˆÁÚ·ÊÈ΋˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
1 Department of Pediatrics, University of Crete 2 Department of Bacteriology-Parasitology-Zoonoses and Geographical Medicine, University of Crete
208
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·209
¶·È‰È·ÙÚÈ΋ 2002;65:208-211
¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (∆∫∂) 41 mm/h. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜. ™ÙÔ Ù¤Ù·ÚÙÔ 24ˆÚÔ ÓÔÛËÏ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÈÛÙÒıËΠ·˘¯ÂÓÈ΋ ‰˘Ûη̄›· Î·È Ô›‰ËÌ· ÂÏÌ¿ÙˆÓ. ∏ ÁÂÓÈ΋ ÂͤٷÛË ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ (∂¡À) ¤‰ÂÈÍ 22 ÏÂ˘Î¿/mm3 (18 ÏÂÌÊÔ·ÙÙ·Ú· Î·È 4 Ô˘‰ÂÙÂÚfiÊÈÏ·), ÌÂ Ê˘ÛÈÔÏÔÁÈο ›‰· ÁÏ˘Îfi˙˘ Î·È ÚˆÙ½Ó˘. ªÂ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki, ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· Á-ÛÊ·ÈÚ›ÓË Û ̛· ‰fiÛË ÙˆÓ 2 g/kg Î·È ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘ (5 mg/kg/24ˆÚÔ) ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ŒÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Èfi Epstein-Barr, ÂÚËÙÔ˚Ô‡˜ 1 Î·È 2, ·‰ÂÓÔ˚fi, Borrelia burgdoferi Î·È Leishmania donovani ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ÔÍ›· Ïԛ̈ÍË. OÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· Rickettsia typhi, Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡, ÙËÓ ÚÒÙË Î·È ÙËÓ Ù¤Ù·ÚÙË Ë̤ڷ ÓÔÛËÏ›·˜ ‹Ù·Ó IgM 1:400 Î·È 1:25.600 Î·È IgG 1:30.720 Î·È 1:61.440 ·ÓÙ›ÛÙÔȯ·, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÓ‰ËÌÈÎÔ‡ Ù‡ÊÔ˘. ™Â ÂÚÒÙËÛË ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· Èı·Ó‹ ·ʋ Ì ˙Ò·, ¤ÁÈÓ ÁÓˆÛÙfi ÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ fiÙÈ ÙÔ ·È‰› ‚Ú¤ıËΠӷ ·›˙ÂÈ Ì ÓÂÎÚ¿ ÔÓÙ›ÎÈ· ÛÙÔ ˘fiÁÂÈÔ Ù˘ ηÙÔÈΛ·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ï›Á˜ Ë̤Ú˜ ÚÈÓ ÂÌÊ·ÓÈÛÙÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù¿ ÙÔ˘. ™ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜, Ù· Û˘ÌÙÒÌ·Ù· ˘Ô¯ÒÚËÛ·Ó ÛÙ·‰È·Î¿ ¯ˆÚ›˜ οÔÈ· ÂÈϤÔÓ ·ÁˆÁ‹. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·ÔϤÈÛË. ∆Ô ·È‰› ÂÍ‹Ïı ÌÂÙ¿ ·fi ÓÔÛËÏ›· ‰¤Î· ËÌÂÚÒÓ. ™Â ·ӷÏËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ‰‡Ô ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹. ™Â ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 16 ÌËÓÒÓ ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÚÔ‚Ï‹Ì·Ù·. ¶ÂÚ›ÙˆÛË 2Ë ∞ÁfiÚÈ 18 ÌËÓÒÓ ÂÈÛ‹¯ıË Ì ˘ÚÂÙfi Î·È ‚‹¯· ·fi 8Ë̤ÚÔ˘. ∞ӷʤÚıËÎÂ, ›Û˘, fiÙÈ ·ÚÔ˘Û›·Û ÂÍ¿ÓıËÌ· ÛÙÔÓ ÎÔÚÌfi ¤ÓÙ Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘, Ô˘ ˘Ô¯ÒÚËÛ Û ÙÚÂȘ Ë̤Ú˜. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ·ÌÊÔÙÂÚfiÏ¢ÚË ˘Ò‰Ë˜ ÂÈÂÊ˘Î›Ùȉ·, ÂͤڢıÚ· ÊÏÂÁÌ·›ÓÔÓÙ· ·Ú›ÛıÌÈ· Î·È ¿Êı˜ ÛÙÔ ÛÙÔ-
Paediatriki 2002;65:208-211
Ì·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ·ÌÊÔÙÂÚfiÏ¢ÚÔÈ ˘ÁÚÔ› ÚfiÁ¯ÔÈ Î·È ‹ÈÔ Ô›‰ËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ. ∆Ô ‹·Ú Î·È Ô ÛÏ‹Ó·˜ ‹Ù·Ó „ËÏ·ÊËÙ¿, 5 cm Î·È 2 cm οو ·fi Ù· ·ÓÙ›ÛÙÔȯ· Ï¢ÚÈο ÙfiÍ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ï¢ÎÒÓ 13,3x109/L, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ 6,9x109/L, ·ÈÌÔÛÊ·ÈÚ›ÓË 9,2 g/dL, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ 903x109/L, ÌÈÎÚ‹ ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 45 U/L Î·È SGPT 60 U/L) Î·È ∆∫∂ 85 mm/h. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜ Î·È Ë Î·ÏÏȤÚÁÂÈ· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·Ó¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù¤ıËΠ˘fiÓÔÈ· ÓfiÛÔ˘ Kawasaki, ÙÔ ·È‰› ‰ÂÓ ‹Ú ÙËÓ ÂӉ‰ÂÈÁ̤ÓË ·ÁˆÁ‹, ηıÒ˜ ‰ÂÓ ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ÃÔÚËÁ‹ıËΠÌfiÓÔ ÎÏ·ÚÈıÚÔÌ˘Î›ÓË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÈÔ‡˜ Áڛ˘, ·Ú·Áڛ˘ Î·È Coxsackie, ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi, ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi, Èfi Epstein-Barr Î·È Mycoplasma pneumoniae ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ÔÍ›· Ïԛ̈ÍË. OÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Ù˘ Ê¿Û˘ ππ Ù˘ Coxiella burnetii Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ‹Ù·Ó IgM 1:100 Î·È IgG 1:400. O ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛ ÛÙȘ ÂfiÌÂÓ˜ ‰‡Ô Ë̤Ú˜ Î·È Ù· ÏÔÈ¿ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ‚ÂÏÙÈÒıËÎ·Ó ÛÙ·‰È·Î¿. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·ÔϤÈÛË ÛÙȘ ·Ï¿Ì˜ Î·È Ù· ¤ÏÌ·Ù·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Ô˘ ¤ÁÈÓ ÙËÓ ¤ÌÙË Ë̤ڷ ÓÔÛËÏ›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. ª›· ‚‰ÔÌ¿‰· ·ÚÁfiÙÂÚ·, ÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· Coxiella burnetii ‹Ù·Ó IgM 1:400 Î·È IgG 1:1920. ŒÙÛÈ ÂȂ‚·ÈÒıËÎÂ Ë ‰È¿ÁÓˆÛË ˘ÚÂÙÔ‡ Q. Ÿˆ˜ ‰È¢ÎÚÈÓ›ÛÙËΠ·fi ÙÔ ÈÛÙÔÚÈÎfi, ÙÔ ·È‰› ‰ÂÓ Â›¯Â ¿ÏÏË Â·Ê‹ Ì ˙Ò·, ÂÎÙfi˜ ·fi ÙÔ˘˜ ÙÚÂȘ Û·ÏÔ˘˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™Â ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 3 ÂÙÒÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·. ™˘˙‹ÙËÛË O ÂÓ‰ËÌÈÎfi˜ Ù‡ÊÔ˜ (Rickettsia typhi) Î·È Ô ˘ÚÂÙfi˜ Q (Coxiella burnetii) Â›Ó·È ÂÓ‰ËÌÈΤ˜ ÏÔÈÌÒÍÂȘ ÛÙȘ ªÂÛÔÁÂȷΤ˜ ¯ÒÚ˜ Î·È ÛÙÔ ÓËÛ› Ù˘
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÓfiÛÔ˘ Kawasaki Û ‰‡Ô ·È‰È¿ Ì Ïԛ̈ÍË ·fi R. typhi Î·È C. Burnetii ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÓfiÛÔ˘ Kawasaki
¶ÂÚ›ÙˆÛË 1Ë
¶ÂÚ›ÙˆÛË 2Ë
ñ ¶˘ÚÂÙfi˜ ‰È¿ÚÎÂÈ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ 5 ËÌÂÚÒÓ ñ ¶·ÚÔ˘Û›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ·ÎfiÏÔ˘ı· ¤ÓÙ ÛËÌ›· ∞ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ·, Û˘Ó‹ıˆ˜ ÌË ˘Ò‰Ë˜ ∞ÏÏÔÈÒÛÂȘ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∞ÏÏÔÈÒÛÂȘ ¿ÎÚˆÓ ¯ÂÈÚÒÓ-Ô‰ÒÓ ∂Í¿ÓıËÌ·, ΢ڛˆ˜ ÎÔÚÌÔ‡, ÔχÌÔÚÊÔ ·ÏÏ¿ ÌË Ê˘Û·Ïȉ҉˜ ∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· >1,5 cm, Û˘Ó‹ıˆ˜ ÂÙÂÚfiÏ¢ÚË
¡·È (13 Ë̤Ú˜)
¡·È (10 Ë̤Ú˜)
¡·È ¡·È ¡·È ¡·È ¡·È, ·ÌÊÔÙÂÚfiÏ¢ÚË
¡·È, ˘Ò‰Ë˜ ¡·È ¡·È ¡·È Ÿ¯È
209
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·210
¶·È‰È·ÙÚÈ΋ 2002;65:208-211
∫Ú‹Ù˘ (2,3). ∏ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ Ïԛ̈͢ Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ (IFAT, bioMérieux) ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÂȉÈÎÒÓ IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Û ٛÙÏÔ˘˜ >1:40 ‹/Î·È ÙÂÙÚ·Ï·ÛÈ·ÛÌfi ÙÔ˘ Ù›ÙÏÔ˘ Û ·ӷÏËÙÈÎfi ‰Â›ÁÌ· 2-3 ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ·. ™ÙÔ ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜, Ë Ì¤ıÔ‰Ô˜ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ¤Ó·ÚÍË ÙËÓ ·Ú·›ˆÛË 1:25 ÁÈ· Ù· πgª ·ÓÙÈÛÒÌ·Ù· Î·È ÙËÓ ·Ú·›ˆÛË 1:60 ÁÈ· Ù· IgG. ∏ ÓfiÛÔ˜ Kawasaki Û˘Ó‰¤ıËΠ̠ÙȘ ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ ’70, fiÙ·Ó ‰È·ÈÛÙÒıËÎ·Ó ÛˆÌ·Ù›‰È· Ì ÌÂÁ¿ÏË ÔÌÔÈfiÙËÙ· Ì ÚÈΤÙÙÛȘ Û ˘ÏÈÎfi ‚ÈÔ„›·˜ ÛÏ‹Ó· ·ÛıÂÓÒÓ Ì ÓfiÛÔ Kawasaki (4). ™ÙË Û˘Ó¤¯ÂÈ·, ÂÚÈÁÚ¿ÊËÎ·Ó ·ÛıÂÓ›˜ ÌÂ Û˘ÌÙÒÌ·Ù· ÂÓ‰ÂÈÎÙÈο ÓfiÛÔ˘ Kawasaki Î·È ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Û˘Ì‚·Ùfi Ì ÔÍ›· Ïԛ̈ÍË ·fi C. burnetii (5). MÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ÙË Û˘Û¯¤ÙÈÛË (6), ˆÛÙfiÛÔ Ù· ÎÔÈÓ¿ ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·fi ÚÈΤÙÙÛȘ Î·È Ù˘ ÓfiÛÔ˘ Kawasaki, fiˆ˜ ·Ú·ÙÂÈÓfiÌÂÓÔ˜ ˘ÚÂÙfi˜, ÂÍ¿ÓıËÌ· Î·È Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Î·È ÙÔ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· Ô˘ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó, ¤¯Ô˘Ó ‹‰Ë ÂÈÛËÌ·Óı› ÁÈ· ÙÔ ªÂÛÔÁÂÈ·Îfi ÎËÏÈ‰Ò‰Ë ˘ÚÂÙfi (R. conorii) (7,8). ∏ ·ÛıÂÓ‹˜ Ì·˜ Ì Ïԛ̈ÍË ·fi R. typhi ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki (¶›Ó·Î·˜ 1). ∏ ÏÂÈÔ·ÙÙˆÛË ÙÔ˘ ∂¡À, Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÓfiÛÔ˘ Kawasaki, ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ›˜ Ì ÂÓ‰ËÌÈÎfi Ù‡ÊÔ (9). ∏ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹ Ô˘ ‰È·ÈÛÙÒıËΠÛÙËÓ ·ÛıÂÓ‹ Ì·˜ ‰ÂÓ ¤¯ÂÈ, ·’ fiÛÔ ÁÓˆÚ›˙Ô˘ÌÂ, ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ‹ Ì Ïԛ̈ÍË ·fi R. typhi, ı· ÌÔÚÔ‡Û fï˜ Ó· Â›Ó·È Û˘Ì‚·Ù‹ Ì ÓfiÛÔ Kawasaki. ∆Ô ·È‰› ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠Á-ÛÊ·ÈÚ›ÓË ÚÈÓ Á›ÓÔ˘Ó ÁÓˆÛÙ¿ Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÔÚÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘. OÈ ˘„ËÏÔ› Ù›ÙÏÔÈ IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ R. typhi ÙËÓ fiÁ‰ÔË Î·È ‰ˆ‰¤Î·ÙË Ë̤ڷ Ù˘ ÓfiÛÔ˘ Î·È Ô ÙÂÙÚ·Ï·ÛÈ·ÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgM ·ÓÙÈÛˆÌ¿ÙˆÓ ÂȂ‚·›ˆÛ·Ó ÙËÓ ÔÍ›· Ïԛ̈ÍË. O Ù›ÙÏÔ˜ ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔ Â·Ó·ÏËÙÈÎfi ‰Â›ÁÌ· ‹Ù·Ó ÌfiÓÔ ‰ÈÏ¿ÛÈÔ˜ ÙÔ˘ ·Ú¯ÈÎÔ‡, fï˜ Ù· ‰‡Ô ‰Â›ÁÌ·Ù· ÂÏ‹ÊıËÛ·Ó Ì ÌÈÎÚ‹ ¯ÚÔÓÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙÔ˘˜, ÏfiÁˆ Ù˘ ÂÈΛÌÂÓ˘ ¯ÔÚ‹ÁËÛ˘ Ù˘ Á-ÛÊ·ÈÚ›Ó˘. §fiÁˆ Ù˘ Ï‹„˘ Ù˘ Á-ÛÊ·ÈÚ›Ó˘, ÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ‰ÂÓ Â·Ó·Ï‹ÊıËÎ·Ó ÛÙË Ê¿ÛË ·Ó¿ÚÚˆÛ˘. ∆· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·È‰ÈÔ‡ ˘Ô¯ÒÚËÛ·Ó ¯ˆÚ›˜ ÂȉÈ΋ ıÂڷ›· Î·È ‰ÂÓ ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹. Ÿˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÂÓ‰ËÌÈÎÔ‡ Ù‡ÊÔ˘ ÛÙ· ·È‰È¿ Ë ÓfiÛÔ˜ ¤¯ÂÈ ‹È· ÔÚ›· Î·È ˘Ô-
210
Paediatriki 2002;65:208-211
¯ˆÚ› ·ÎfiÌË Î·È ¯ˆÚ›˜ ÂȉÈ΋ ·ÁˆÁ‹ (3). O ˘ÚÂÙfi˜ Q ıˆÚÂ›Ù·È ·Û˘Ó‹ı˘ ÛÙ· ·È‰È¿ Î·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ Â›Ó·È ÏÈÁfiÙÂÚÔ Î·Ï¿ ÁÓˆÛÙ‹ ÛÙËÓ ËÏÈΛ· ·˘Ù‹. ∞Ó Î·È ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ˆ˜ Ó¢ÌÔÓ›Ùȉ·, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ Ïԛ̈ÍË Ì ¢ڇ Ê¿ÛÌ· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (10). ∂Í¿ÓıËÌ· ¤¯ÂÈ ·Ó·ÊÂÚı› Û¿ÓÈ· (10). O ·ÛıÂÓ‹˜ Ì·˜ ›¯Â Û˘ÌÙÒÌ·Ù· Û˘Ì‚·Ù¿ Ì ÓfiÛÔ Kawasaki, fï˜ Ë ‰È¿ÁÓˆÛË ‰ÂÓ ÙÂÎÌËÚÈÒıËÎÂ, ηıÒ˜ ‰ÂÓ ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ∆Ô ·È‰› ‰ÂÓ ¤Ï·‚ ·ÁˆÁ‹ Ì Á-ÛÊ·ÈÚ›ÓË, ÂϤÁ¯ıËΠfï˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Î·È ·Ú·ÎÔÏÔ˘ı‹ıËΠÌÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘. O ÙÂÙÚ·Ï·ÛÈ·ÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgM ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Ë ·‡ÍËÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgG ÂȂ‚·›ˆÛ·Ó ÙË ‰È¿ÁÓˆÛË ÔÍ›·˜ Ïԛ̈͢ ·fi Coxiella burnetii. ∏ ÂÓÂÚÁÔÔ›ËÛË ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ˘ÂÚ·ÓÙÈÁfiÓ· ¤¯ÂÈ ıˆÚËı› ˆ˜ Èı·Ófi˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ÓfiÛÔ˘ Kawasaki Î·È ÂÓ‰¤¯ÂÙ·È Û ¤Ó· ÔÛÔÛÙfi ÂÚÈÙÒÛÂˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› fiˆ˜ ÔÈ ÚÈΤÙÙÛȘ Ó· ÌÔÚÔ‡Ó Ó· ‰Ú¿ÛÔ˘Ó Ì ·˘Ùfi ÙÔÓ ÙÚfiÔ (13). ªÔÏÔÓfiÙÈ Ë Ì¤¯ÚÈ ÙÒÚ· ¤Ú¢ӷ ‰ÂÓ ¤¯ÂÈ ·Ô‰Â›ÍÂÈ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË ÙˆÓ ÚÈÎÂÙÙÛÈÒÓ Ì ÙË ÓfiÛÔ Kawasaki, ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki Û ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜. O Û˘Ó‹ı˘ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ Â›Ó·È ÂȉÈÎfi˜ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ Ì¤ıÔ‰Ô˜ Ô˘ Ó· ÌÔÚ› Ó· ÙÂÎÌËÚÈÒÛÂÈ ÓˆÚ›˜ ÙË ‰È¿ÁÓˆÛË. ŸÌˆ˜, ·ÊÔ‡ Ë ÓfiÛÔ˜ Kawasaki ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙ›, Ë Î·Ù¿ÏÏËÏË ·ÁˆÁ‹ ‰ÂÓ ı· Ú¤ÂÈ Ó· ηı˘ÛÙÂÚ› Û ÂÚÈÙÒÛÂȘ Ô˘ ÏËÚÔ‡ÓÙ·È Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki, ·ÎfiÌË Î·È ·Ó Ù›ıÂÙ·È ˘fiÓÔÈ· ÚÈÎÂÙÙÛ›ˆÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Melish ME. Kawasaki syndrome. Pediatr Rev 1996; 17:153-162. 2. Antoniou M, Tselentis Y, Gikas A, Stratigakis N, Vlachonikolis I, Kafatos A et al. The seroprevalence of ten zoonoses in two villages in Crete, Greece. Eur J Epidemiol 1995;11:415-423. 3. ™Ù·˘Ú¿Î˘ π, ¶··ÁˆÚÁ›Ô˘ Ã, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢, ª·ÏˆÌÂÓ¿ÎË ∂. §Ô›ÌˆÍË ·fi Rickettsia typhi - Ì˘˚Îfi˜ ÂÍ·ÓıËÌ·ÙÈÎfi˜ Ù‡ÊÔ˜ - Û ·È‰È¿. ¶·È‰È·ÙÚÈ΋ 1996; 59:194-200. 4. Carter RF, Haynes ME, Morton J. Rickettsia like bodies and splenitis in Kawasaki disease. Lancet 1976;ii: 1254-1255. 5. Swaby ED, Fisher-Hoch S, Lambert HP, Stern H. Is Kawasaki disease a variant of Q fever? Lancet 1980;2:146. 6. Kafetzis DA, Maltezou HC, Constantopoulou I, Antonaki G,
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·211
¶·È‰È·ÙÚÈ΋ 2002;65:208-211
7.
8.
9.
10.
Paediatriki 2002;65:208-211
Liapi G, Mathioudakis I. Lack of association between Kawasaki syndrome and infection with Rickettsia conorii, Rickettsia typhi, Coxiella burnetii or Ehrlichia phagocytophila group. Pediatr Infect Dis J 2001;20:703-706. Parha S, Garoufi A, Yiallouros P, Theodoridis CH, Karpathios TH. Carbamazepine hypersensitivity and rickettsiosis mimicking Kawasaki disease. Eur J Pediatr 1993;52:1040-1041. Jenkins Dr, Rees JC, Pollitt C, Cant A, Craft AW. Mediterranean spotted fever mimicking Kawasaki disease. BMJ 1997;314:655-666. Dumler JS, Taylor JP, Walker DH. Clinical and laboratory features of murine typhus in south Texas, 1980 though 1987. JAMA 1991;266:1365-1370. Tselentis Y, Gikas A, Kofteridis D, Kyriakakis E, Lydataki N,
Bouros D et al. Q fever in the Greek island of Crete: epidemiological, clinical and therapeutic data from 98 cases. Clin Infect Dis 1995;20:1311-1316. 11. Meissner HC, Leung DYM. Superantigens, conventional antigens and the etiology of Kawasaki syndrome. Pediatr Infect Dis J 2000;19:91-94.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-11-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ªÈÙÛÒÚË ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶∂¶∞°¡∏ ∆.£. 1352, ∆.∫. 711 10, ∏Ú¿ÎÏÂÈÔ E-mail: bitmar@hol.gr
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∆· ÚÔ‚ÈÔÙÈο ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘1 ∂ÈÛ·ÁˆÁ‹: ∏ Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ ı· ‹Ù·Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ›Ù¢ÁÌ· ÁÈ· ÙË ‰ËÌfiÛÈ· ˘Á›·, ȉ›ˆ˜ ÙˆÓ ‰˘ÙÈÎÒÓ ÎÔÈÓˆÓÈÒÓ. ™‡Ìʈӷ Ì ÙËÓ ˘ÁÈÂÈÓÈÛÙÈ΋ ˘fiıÂÛË, Ë ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ ·Ô‰›‰ÂÙ·È ÛÙË ÌÂȈ̤ÓË ÌÈÎÚԂȷ΋ ¤ÎıÂÛË ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ∆· ÚÔ‚ÈÔÙÈο Â›Ó·È Î·ÏÏȤÚÁÂȘ ‰˘ÓËÙÈο “¢ÂÚÁÂÙÈÎÒÓ” ÌÈÎÚÔ‚›ˆÓ, Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó ÛÙË ¯ÏˆÚ›‰· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÂÓÙ¤ÚÔ˘. ™ÎÔfi˜: ∫‡ÚÈÔ ÛÎÔfi ·ÔÙ¤ÏÂÛÂ Ë ÌÂϤÙË Ù˘ ›‰Ú·Û˘ ÛÙËÓ ·ÙÔÈ΋ ÓfiÛÔ ÙÔ˘ Ï·ÎÙÔ‚¿ÎÈÏÏÔ˘ GG (Ë ¯Ú‹ÛË ÙÔ˘ ¤¯ÂÈ ·Ô‰Âȯı› ·ÛÊ·Ï‹˜ ÛÙË ÌÈÎÚ‹ ËÏÈΛ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË ıÂڷ›· Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™Â ‰ÈÏ‹ Ù˘ÊÏ‹ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ‰fiıËΠϷÎÙÔ‚¿ÎÈÏÏÔ˜ GG ÚÈÓ ÙÔÓ ÙÔÎÂÙfi Û ÌËÙ¤Ú˜ Ô˘ ›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·Ó ÚÒÙ˘ ‚·ıÌ›‰·˜ Û˘ÁÁÂÓ‹ (‹ Û‡ÓÙÚÔÊÔ) Ì ·ÙÔÈÎfi ¤Î˙ÂÌ·, ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‹ ¿ÛıÌ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÁÈ· 6 Ì‹Ó˜ ÛÙ· ‚Ú¤ÊË ÙÔ˘˜. ∆Ô ¯ÚfiÓÈÔ ˘ÔÙÚÔÈ¿˙ÔÓ ·ÙÔÈÎfi ¤Î˙ÂÌ· Ô˘ Â›Ó·È Ë Î˘ÚÈfiÙÂÚË ÂΉ‹ÏˆÛË ·ÏÏÂÚÁ›·˜ Ù· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ‹Ù·Ó Ë Î‡ÚÈ· ·Ú¿ÌÂÙÚÔ˜ ÌÂϤÙ˘. ∞ÔÙÂϤÛÌ·Ù·: ∞ÙÔÈÎfi ¤Î˙ÂÌ· ‰È·ÁÓÒÛÙËΠ۠46 ·fi Ù· 132 ·È‰È¿ (35%) ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ. ÕÛıÌ· ‰È·ÁÓÒÛÙËΠ۠6 Î·È ·ÏÏÂÚÁÈ΋ ÚÈÓ›ÙȘ Û ¤Ó·. ∏ Û˘¯ÓfiÙËÙ· ÂÎ˙¤Ì·ÙÔ˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ô˘ ‹Ú ÚÔ‚ÈÔÙÈο ‹Ù·Ó
ηٿ ÙÔ ‹ÌÈÛ˘ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ ÔÌ¿‰· placebo (15/64 [23%] vs 31/68 [46%], Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ 0,51 [95% CI 0,320,84]). ™˘ÌÂÚ¿ÛÌ·Ù·: O Ï·ÎÙÔ‚¿ÎÈÏÏÔ˜ GG ‚ÔËı¿ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÚÒÈÌ˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ Û ·È‰È¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. º·›ÓÂÙ·È fiÙÈ Ë ¯ÏˆÚ›‰· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ËÁ‹ Ê˘ÛÈÎÒÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÒÓ Î·È ÚÔ‚ÈÔÙÈÎÒÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘.
1 Kalliomaki M, Salminen S, Arvilomni H, Kero P, Koskinen P, Isolauri E Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial Lancet 2001;357:1076-1079
°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
211
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·212
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
E¶π∫∞πƒ∞ £∂ªA∆∞
Paediatriki 2002;65:212-218
CURRENT ISSUES
∂ÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ °. ∆ÛfiÏ·˜, °. ∫·Ê·Ï›‰Ë˜, °. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜
The assessment and management of pain in children G. Tsolas, G. Kafalidis, G. Triantafyllidis
¶ÂÚ›ÏË„Ë: O Ô͇˜ fiÓÔ˜ ·ÔÙÂÏ› ÙÔ Û˘ÓËı¤ÛÙÂÚÔ, ·ÏÏ¿ Î·È ÙÔ Ï¤ÔÓ ÂÓÔ¯ÏËÙÈÎfi ˘ÔÎÂÈÌÂÓÈÎfi Û‡Ìو̷ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤Ó· ·È‰› ÛÙÔ Ï·›ÛÈÔ ÙÚ·˘Ì·ÙÈÛÌÒÓ, ÓÔÛËÌ¿ÙˆÓ ‹ Î·È ·Ó·Áη›ˆÓ È·ÙÚÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ Î·È ÙÔ ÔÔ›Ô Û¯Â‰fiÓ ¿ÓÙ· Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ Â›Â‰Ô ·ÓËÛ˘¯›·˜ Î·È Â·ÁÚ‡ÓËÛ˘ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶·Ú¿ ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÂÈÙÒÛÂˆÓ Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ÙÔ ·›ÛıËÌ· ÙÔ˘ fiÓÔ˘ ÛÙÔ ·È‰› , Û˘¯Ó¿ ˘ÔÂÎÙÈÌ¿Ù·È Î·È ˘ÔıÂڷ‡ÂÙ·È ÂÍ·ÈÙ›·˜ ÂÛÊ·ÏÌ¤ÓˆÓ ·ÓÙÈÏ‹„ˆÓ, fiˆ˜ .¯. fiÙÈ Ù· ·È‰È¿ ‰ÂÓ ·ÈÛı¿ÓÔÓÙ·È ÙÔÓ fiÓÔ fiˆ˜ ÔÈ ÂÓ‹ÏÈΘ ‹ fiÙÈ “Ô fiÓÔ˜ ‰È·ÌÔÚÊÒÓÂÈ ¯·Ú·ÎÙ‹Ú·”, ηıÒ˜ Î·È ÏfiÁˆ ÙÔ˘ Êfi‚Ô˘ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ Ê·Ú̿ΈÓ. OÈ ·ÓÙÈÏ‹„ÂȘ ·˘Ù¤˜, ηıÒ˜ Î·È ÔÈ ·Ó·ÚΛ˜ ÁÓÒÛÂȘ ÙˆÓ ·È‰È¿ÙÚˆÓ Á‡Úˆ ·fi ÙÔ ı¤Ì· ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘, ·ÚÂÌ‚·›ÓÔ˘Ó ·Ó·ÛÙ·ÏÙÈο ÛÙË ‰È·‰Èηۛ· ·Ó·ÁÓÒÚÈÛ˘, ÛˆÛÙ‹˜ ÂÎÙ›ÌËÛ˘ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ıÂڷ›·˜ ÙÔ˘. ∏ ÂΉ‹ÏˆÛË ÙÔ˘ fiÓÔ˘ ·ÔÙÂÏ› ÙË Û˘ÓÈÛٷ̤ÓË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ, „˘¯ÔÏÔÁÈÎÒÓ Î·È Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ηıÒ˜ Î·È ¿ÏÏˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹, ÂÓÒ Ì¤Ûˆ ·˘ÙÔ‡ ÙÔ ·È‰› ÂÎÊÚ¿˙ÂÈ ÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯È΋ ‰˘Û·Ú¤ÛÎÂÈ· Ô˘ ·ÈÛı¿ÓÂÙ·È ÌÂÙ¿ ·fi Ú·ÁÌ·ÙÈ΋ ‹ ‰˘ÓËÙÈ΋ ‚Ï¿‚Ë ÙˆÓ ÈÛÙÒÓ. O fiÓÔ˜ Â›Ó·È ÌÈ· ÂÓ‰ÔÁÂÓ‹˜ ˘ÔÎÂÈÌÂÓÈ΋ Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÂÌÂÈÚ›· Î·È ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÂ›Ù·È Î·È Ó· ıÂڷ‡ÂÙ·È ˆ˜ Ù¤ÙÔÈ·. ŸÙ·Ó ÏÔÈfiÓ ÙÔ ÂÈ‚¿ÏÏÔ˘Ó ÔÈ ÂÚÈÛÙ¿ÛÂȘ, ÔÈ ·È‰›·ÙÚÔÈ ı· Ú¤ÂÈ Ó· Â›Ó·È ˘Â‡ı˘ÓÔÈ ÁÈ· ÙË Ì¤ÚÈÌÓ· ˆ˜ ÚÔ˜ ÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙÔ˘˜. ∏ ›Ù¢ÍË ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ÁÓÒÛÂÒÓ ÙÔ˘˜ Á‡Úˆ ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì·,
¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ ¡›Î·È·˜, ¶ÂÈÚ·È¿˜
212
Abstract: Acute pain is one of the most common and most disturbing subjective symptoms experienced by children as a result of injury or illness, and during necessary medical procedures. The sensation of pain is the result of a variety of sensory, emotional, cognitive and behavioral components that go well beyond that of a simple sensory experience. It is associated with increased anxiety, withdrawal, somatic symptoms, and increased parental distress. Despite of the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. Numerous myths such as the idea that children and especially infants do not feel pain the way adults do, insufficient knowledge among caregivers, fears about side effects of pain medications, and the belief by some health care workers “that pain builds character in children”, contribute to the lack of effective management. Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatricians are responsible for eliminating or relieving pain and suffering in children when possible. To accomplish this, pediatricians need to expand their knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly, use a multimodal as well as a multidisciplinary approach to pain when possible by involving the family and advocating for the use of effective analgesic treatment in children.
Pediatric Clinic of Peripheral General Hospital “Ag. Panteleimon”, Nikea, Piraeus
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·213
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
Paediatriki 2002;65:212-218
ÙË ÛˆÛÙ‹ Ú·ÎÙÈ΋ ÙÔ˘˜ ÛÙÔ˘˜ ÂοÛÙÔÙ ¯ÂÈÚÈÛÌÔ‡˜, ÙËÓ Úfi‚Ï„‹ ÙÔ˘˜ ÁÈ· ÙÔ Èı·Ófi ÂӉ¯fiÌÂÓÔ Ó· ÚÔÎÏËı› ¿ÏÁÔ˜ ÛÙÔ ·È‰› ÛÙ· Ï·›ÛÈ· ÓfiÛÔ˘ ‹ ÏfiÁˆ È·ÙÚÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ ‹ ÂÂÌ‚¿ÛˆÓ, ÙËÓ Î·Ù¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÔ‡ ηÈ, Ù¤ÏÔ˜, ÙË ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘˜ Ì ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙËÓ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙÔÓ fiÓÔ. ∏ ·Ó·ÎÔ‡ÊÈÛË ·fi ÙÔÓ fiÓÔ Ô˘ Û˘Óԉ‡ÂÈ Ì›· ·ÚÚÒÛÙÈ· ‹ Ô˘ ÚÔηÏÂ›Ù·È È·ÙÚÔÁÂÓÒ˜ ·fi ‰È·ÁÓˆÛÙÈÎÔ‡˜ ‹ ıÂڷ¢ÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, ·ÔÙÂÏ› ‚·ÛÈ΋ ·Ú¯‹ Ù˘ È·ÙÚÈ΋˜ Î·È Î‡ÚÈ· ˘Ô¯Ú¤ˆÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘, Ë ÔÔ›· ‰ÂÓ Ú¤ÂÈ ÔÙ¤ Ó· ˘ÔÙÈÌ¿Ù·È ‹ Ó· ·Ú·ÁÓˆÚ›˙ÂÙ·È. §¤ÍÂȘ ÎÏÂȉȿ: fiÓÔ˜ (¿ÏÁÔ˜), ·Ó·ÏÁËÙÈο Ê¿Ú̷η, ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘.
Key words: pain, analgesics, pain treatment.
∂ÈÛ·ÁˆÁ‹ ∞ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ¢ı‡ÓË Î·È ˘Ô¯Ú¤ˆÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Ë ÚÔÛ¿ıÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘, Ì ÛÎÔfi ÙËÓ ÂÍ¿ÏÂÈ„‹ ÙÔ˘ ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙË ÌÂÚÈ΋ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·È‰ÈÔ‡, ÂÊfiÛÔÓ ‚‚·›ˆ˜ ÙÔ‡ÙÔ Â›Ó·È ÂÊÈÎÙfi. ¶·Ú¿ Ù·‡Ù·, Â›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ ˘ÔıÂڷ‡ÂÙ·È (1). O Û˘ÓËı¤ÛÙÂÚÔ˜ Ù‡Ô˜ fiÓÔ˘ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤Ó· ·È‰› Â›Ó·È Ô Ô͇˜ fiÓÔ˜ Ô˘ ·ÎÔÏÔ˘ı› ÙÚ·˘Ì·ÙÈÛÌÔ‡˜, ÓÔÛ‹Ì·Ù·, ηıÒ˜ Î·È È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜. ∂ÓÒ ˘¿Ú¯ÂÈ ÂÎÙÂٷ̤ÓË ‚È‚ÏÈÔÁÚ·Ê›·, Ë ÔÔ›· ·Ú¤¯ÂÈ ÁÓÒÛÂȘ ˆ˜ ÚÔ˜ ÙËÓ ·ÍÈÔÏfiÁËÛË Î·È ÙË ıÂڷ›· ÙÔ˘ ÔͤԘ fiÓÔ˘ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ¢ڤˆ˜ ‰È·ı¤ÛÈ̘, ¯·ÌËÏÔ‡ ÎfiÛÙÔ˘˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ÌÂıfi‰Ô˘˜, ÔÈ ÁÓÒÛÂȘ ·˘Ù¤˜ Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛˆÛÙ¿. ∞Ó Î·È Ë ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÈÎÂÓÙÚÒÓÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔͤԘ fiÓÔ˘, ˘Ô¯Ú¤ˆÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ·ÏÏ¿ Î·È ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ ·ÔÙÂÏ› Ë ·Ó·ÁÓÒÚÈÛË fiÏˆÓ ÙˆÓ Ù‡ˆÓ ·˘ÙÔ‡, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ·˘ÙÒÓ ÙÔ˘ ¯ÚfiÓÈÔ˘ fiÓÔ˘, ÙÔ˘ ‰È·Ï›ÔÓÙÔ˜ fiÓÔ˘, ÙÔ˘ fiÓÔ˘ ÙÔ˘ Û¯ÂÙÈ˙fiÌÂÓÔ˘ Ì ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ‹ Ì ηٷÏËÎÙÈ΋ ÓfiÛÔ (2). ºÚ·ÁÌÔ‡˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ ·ÔÙÂÏÔ‡Ó: ·) Ô Ì‡ıÔ˜ fiÙÈ Ù· ·È‰È¿ Î·È ÂȉÈο Ù· ‚Ú¤ÊË ‰ÂÓ ·ÈÛı¿ÓÔÓÙ·È ÙÔÓ fiÓÔ fiˆ˜ ÔÈ ÂÓ‹ÏÈΘ ‹ Î·È ·Ó ÙÔÓ ·ÈÛı¿ÓÔÓÙ·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÓÂÈı‡ÌËÙ˜ Û˘Ó¤ÂȘ ·fi ·˘ÙfiÓ, ‚) Ë ·Ô˘Û›· ·ÍÈÔÏfiÁËÛ˘ Î·È Â·Ó·ÍÈÔÏfiÁËÛ˘ ˆ˜ ÚÔ˜ ÙËÓ ‡·ÚÍË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡, Á) Ë ¤ÏÏÂÈ„Ë ÈηÓfiÙËÙ·˜ Û‡ÏÏ˄˘ Î·È ÔÛÔÙÈÎÔÔ›ËÛ˘ ÌÈ·˜ ηٿ Ù· ¿ÏÏ· ˘ÔÎÂÈÌÂÓÈ΋˜ ÂÌÂÈÚ›·˜, ‰) Ë ¤ÏÏÂÈ„Ë Â·ÚÎÔ‡˜ ÁÓÒÛ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘, Â) Ë È‰¤· fiÙÈ Ë ÂÓ·Û¯fiÏËÛË Ì ÙÔÓ fiÓÔ ÛÙ· ·È‰È¿ ··ÈÙ› ¯ÚfiÓÔ
Î·È ÚÔÛ¿ıÂÈ· Î·È ÛÙ) Ô Êfi‚Ô˜ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘ ·Ó·ÏÁËÙÈ΋˜ ıÂڷ›·˜, fiˆ˜ Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ΤÓÙÚÔ˘ Î·È Ô ÂıÈÛÌfi˜. ∆¤ÏÔ˜, ÚÔÛˆÈΤ˜ ·ÓÙÈÏ‹„ÂȘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚÌËÓ›· Î·È ÙÔ ÚfiÏÔ ÙÔ˘ ¿ÏÁÔ˘˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÂÓfi˜ ·È‰ÈÔ‡ (fiˆ˜ Ï.¯. Ë ·ÓÙ›ÏË„Ë fiÙÈ “Ô fiÓÔ˜ ‰È·ÌÔÚÊÒÓÂÈ ¯·Ú·ÎÙ‹Ú·”) Ê·›ÓÂÙ·È ‰˘ÛÙ˘¯Ò˜ ˆ˜ ·ÚÂÌ‚·›ÓÔ˘Ó ·Ó·ÛÙ·ÏÙÈο ÛÙË ‰È·‰Èηۛ· Ù˘ ·Ó·ÁÓÒÚÈÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Û fiÏ· Ù· ·È‰È¿ (3). ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ (AAP) ˘ÔÛÙËÚ›˙ÂÈ ÙÔ ËıÈÎfi ¯Ú¤Ô˜ Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈÌÂÙÒÈÛ˘ fiÏˆÓ ÙˆÓ ÂȉÒÓ ÙÔ˘ fiÓÔ˘ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔͤԘ fiÓÔ˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÌÔÚÔ‡Ó Û‹ÌÂÚ· Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ÂÈÙ˘¯›·, Ú¤ÂÈ fï˜ Ó· ÂÈÛËÌ·Óı› fiÙÈ ÙfiÛÔ ÔÈ ·ÓËÛ˘¯›Â˜ ÙˆÓ ·È‰ÈÒÓ fiÛÔ Î·È Ù˘¯fiÓ ¿ÏÏ· Û˘Ó˘¿Ú¯ÔÓÙ· Û˘ÌÙÒÌ·Ù· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·Ù¿ ÙË ‰È·‰Èηۛ· ÂÈÏÔÁ‹˜ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·È‰ÈÔ‡. ∂ÎÙ›ÌËÛË Î·È ·ÍÈÔÏfiÁËÛË ÙÔ˘ fiÓÔ˘ OÈ Â·ÁÁÂÏ̷ٛ˜ ÛÙÔ ¯ÒÚÔ Ù˘ ˘Á›·˜ ı· Ú¤ÂÈ Ó· ÚÔ‚Ï¤Ô˘Ó ÂÈΛÌÂÓ˜ ÂÒ‰˘Ó˜ ÂÌÂÈڛ˜, ÚÔ‚·›ÓÔÓÙ·˜ ÛÙȘ ·Ó·Áη›Â˜ ηٿÏÏËϘ Ú˘ıÌ›ÛÂȘ Î·È ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÂΛ Ô˘ Ú¤ÂÈ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÚÔ¸Ôı¤ÙÂÈ ÙË ÛˆÛÙ‹ ÂÎÙ›ÌËÛË Î·È Û˘Ó¯‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ ¯·Ú·ÎÙ‹ÚˆÓ Î·È Ù˘ ¤ÓÙ·Û‹˜ ÙÔ˘, ηıÒ˜ Î·È ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ÛÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, Ú¿ÁÌ· ·Ôχو˜ ÂÊÈÎÙfi Û fiϘ ÙȘ ËÏÈ˘, ·fi ÙË ÓÂÔÁÓÈ΋ ¤ˆ˜ Î·È ÙËÓ ÂÊ˂›· (4). ™ÙÔ ¯ÒÚÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ, Ô fiÓÔ˜, Ë ·ÓÙ·fiÎÚÈÛ‹ ÙÔ˘ ÛÙË ıÂڷ›·, ·ÏÏ¿ Î·È ÔÈ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ
213
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·214
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
Ê·ÚÌ¿ÎˆÓ ı· Ú¤ÂÈ Ó· ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔ ‰È¿ÁÚ·ÌÌ· ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÒÛÙ ӷ ˘Ô‚ÔËıÂ›Ù·È Î·Ù’ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ Ë ÂÈÎÔÈÓˆÓ›· ÌÂٷ͇ ÙˆÓ ıÂÚ·fiÓÙˆÓ È·ÙÚÒÓ. O fiÓÔ˜ ÌÔÚ› Ó· ·ÍÈÔÏÔÁËı› Ì ÙËÓ ·Ó·˙‹ÙËÛË ÏËÚÔÊÔÚÈÒÓ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹, ÙËÓ ·Ú·Ù‹ÚËÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ ÚÔÛÒÔ˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ηÈ, Ù¤ÏÔ˜, Ì ÙËÓ ÂÎÙ›ÌËÛË ÛÙÔȯ›ˆÓ Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ¯·Ú·ÎÙ‹Ú· ÙÔ˘, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÂÈÎÔÈÓˆÓ›·˜ Ô˘ ‰È·ı¤ÙÂÈ. ∏ ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ÙÔ˘ fiÓÔ˘ ÚÔ¸Ôı¤ÙÂÈ ÛˆÛÙ‹ ÂÎÙ›ÌËÛË Ù˘ ÔÏ˘ÏÔÎfiÙËÙ·˜ ̤ۈ Ù˘ ÔÔ›·˜ ÙÔ ·È‰› ·ÈÛı¿ÓÂÙ·È ÙËÓ ÂÒ‰˘ÓË ÂÌÂÈÚ›·, ηıÒ˜ Î·È Ù˘ ›‰Ú·Û˘ „˘¯ÔÏÔÁÈÎÒÓ Î·È ·Ó·Ù˘ÍÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∂Âȉ‹ Ô fiÓÔ˜ ·ÔÙÂÏ› Ì›· ˘ÔÎÂÈÌÂÓÈ΋ ÂÌÂÈÚ›·, Ë ÂÚÈÁÚ·Ê‹ Ù˘ ‰È·Ê¤ÚÂÈ ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ (5). ŸÌˆ˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ‚‚·Èˆı› ηÓ›˜ fiÙÈ Ù· ·È‰È¿, ȉȷ›ÙÂÚ· Ù˘ ËÏÈΛ·˜ ÙˆÓ 3-7 ÂÙÒÓ, Â›Ó·È Û ı¤ÛË Ó· ‰ÒÛÔ˘Ó ÏËÚÔÊÔڛ˜, ÚÈÓ Î¿ı ÂÚÈÁÚ·Ê‹ ÁÈ· ÙË ı¤ÛË, ÙËÓ ÔÈfiÙËÙ·, ÙËÓ ¤ÓÙ·ÛË Î·È ÙËÓ ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ fiÓÔ˘ Á›ÓÂÈ ·Ô‰ÂÎÙ‹. ∏ ·Ú·Ù‹ÚËÛË ÙÔ˘ ÙÚfiÔ˘ ·ÓÙ›‰Ú·Û‹˜ ÙÔ˘˜ ÛÙÔ ÂÒ‰˘ÓÔ ÂÚ¤ıÈÛÌ· ı· Ú¤ÂÈ Ó· Û˘ÌÏËÚÒÓÂÈ ÙËÓ ˘ÔÎÂÈÌÂÓÈ΋ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ·È‰ÈÔ‡, ¤ÙÛÈ ÒÛÙ ӷ ·ÔÙÂÏ› ÌÈ· ·ÍÈfiÈÛÙË ÂÓ·ÏÏ·ÎÙÈ΋ χÛË fiÙ·Ó Ë ÙÂÏÂ˘Ù·›· ‰ÂÓ ÌÔÚ› Ó· ÏËÊı› ‹ fiÙ·Ó ‰ÂÓ ıˆÚÂ›Ù·È ·ÚÎÔ‡ÓÙˆ˜ ·ÍÈfiÈÛÙË. ŸÙ·Ó Ë ÂÈÎÔÈÓˆÓ›· ηı›ÛÙ·Ù·È ‰˘Û¯ÂÚ‹˜, Ë ÛËÌ·Û›· Ô˘ ¤¯ÂÈ Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ ·¤Ó·ÓÙÈ ÛÙÔ ÂÚ¤ıÈÛÌ· ı· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È Û¯ÔÏ·ÛÙÈο. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ fiÓÔ ·ÓÙ·Ó·ÎÏ¿ ÙË Ê˘ÛÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÔ˘ ηٿÛÙ·ÛË, ÙÔ fiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈο ÙÔÓ ·ÓÙÈÌÂÙˆ›˙ÂÈ, ηıÒ˜ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ Î·È Î·Ù’ ¤ÎÙ·ÛË ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. °È· ·Ú¿‰ÂÈÁÌ·, ¤Ó· ÛÙˆÈÎfi ‹ ηٷıÏÈÙÈÎfi ·È‰› Ì ÈÛ¯˘Úfi fiÓÔ ÌÔÚ› Ó· ÌËÓ ÙÔÓ ÂÚÈÁÚ¿„ÂÈ fiÙ·Ó ÚˆÙËı› Î·È Ó· ÌËÓ ÂÌÊ·Ó›˙ÂÈ Ù· ·Ó·ÌÂÓfiÌÂÓ· ÁÈ· ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ÛÙÔȯ›· ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘. ∆Ô ¿ÏÁÔ˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·È‰È¿ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ, ηıÒ˜ Î·È Ì ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏÔ Ó· ÂÎÙÈÌËı› ÛˆÛÙ¿. ¶ÔÏÈÙÈÛÙÈΤ˜ Î·È ÁψÛÛÈΤ˜ ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ÙÔÓ ÂÍÂÙ·˙fiÌÂÓÔ Î·ıÈÛÙÔ‡Ó, ÌÂÚÈΤ˜ ÊÔÚ¤˜, ÚÔ‚ÏËÌ·ÙÈ΋ ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ fiÓÔ˘. ∂ÊfiÛÔÓ, ÏÔÈfiÓ, ˘¿Ú¯Ô˘Ó Ù¤ÙÔÈ· ÚÔ‚Ï‹Ì·Ù·, ·ÍÈfiÈÛÙË ÌÔÚ› Ó· Â›Ó·È Ë Ì·ÚÙ˘Ú›· ÙÔ˘ ÁÔÓ¤· ‹ οÔÈÔ˘ ¿ÏÏÔ˘ ·ÙfiÌÔ˘ Ô˘ ÁÓˆÚ›˙ÂÈ Î·Ï¿ ÙÔ ·È‰›, ·Ó Î·È Â‰Ò ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÌÈ· Ù¿ÛË ˘ÔÂÎÙ›ÌËÛ˘ ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜.
214
Paediatriki 2002;65:212-218
¶fiÓÔ˜ ÔÊÂÈÏfiÌÂÓÔ˜ Û ȷÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ ∏ ÚÔÛ¤ÁÁÈÛË ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ ¿ÏÁÔ˘˜ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ¤ÓÙ·ÛË Î·È ‰È¿ÚÎÂÈ¿ ÙÔ˘, ÙÔ ¿Á¯Ô˜ Ô˘ ÂӉ¯Ô̤ӈ˜ ˘¿Ú¯ÂÈ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹, ·ÏÏ¿ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ È·ÙÚÈÎÔ‡ ¯ÂÈÚÈÛÌÔ‡ ‹ Ù˘ ¤̂·Û˘ (6,7). OÈ È·ÙÚÈÎÔ› ¯ÂÈÚÈÛÌÔ› ı· Ú¤ÂÈ Ó· ÂÎÙÂÏÔ‡ÓÙ·È ·fi ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi, ¤ÙÛÈ ÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë ¤ÓÙ·ÛË ·˘Ù‹˜ Ù˘ ÂÒ‰˘Ó˘ ÁÈ· ÙÔ ·È‰› ‰È·‰Èηۛ·˜. ∞Ó¿ÏÔÁ· Ì ÙË Ê‡ÛË Ù˘ ¤̂·Û˘ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰ÈÔ‡, ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ fiÓÔ˘ ÌÔÚ› Ó· ÂÈÙ¢¯ı› Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÌÂıfi‰ˆÓ ‚·ıÈ¿˜ ηٷÛÙÔÏ‹˜ ‹ Î·È ·Ó·ÈÛıËÛ›·˜ ¤ˆ˜ ÙËÓ ˘ÈÔı¤ÙËÛË ÛÙÚ·ÙËÁÈÎÒÓ Û˘ÌÂÚÈÊÔÚ¿˜, ÔÈ Ôԛ˜ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ ÂÓ›Û¯˘ÛË Ù˘ ·˘ÙÔÂÔ›ıËÛ˘ ÙÔ˘ ·È‰ÈÔ‡, ·Ú¿ÏÏËÏ· ‹ fi¯È Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (8). ∏ ÂÊ·ÚÌÔÁ‹ ÙÔÈÎÒÓ ·Ó·ÈÛıËÙÈÎÒÓ, fiˆ˜ .¯. ÙÔ ÁÓˆÛÙfi Ì›ÁÌ· ·Ó·ÈÛıËÙÈÎÒÓ EMLA, ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› Ú·ÎÙÈ΋ ÚÔ˘Ù›Ó·˜ ·ÎfiÌË Î·È Û ·ÏÔ‡˜ È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, fiˆ˜ Â›Ó·È ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ·ÈÌÔÏË„›·. ∆Ô ¿ÏÁÔ˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÌÂÚÈΤ˜ ÌÈÎÚ¤˜, ·ÏÏ¿ ·ÚÎÂÙ¿ ÂÒ‰˘Ó˜, È·ÙÚÈΤ˜ ÂÂÌ‚¿ÛÂȘ fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ÂÚÈÙÔÌ‹, ‰ÂÓ ¤¯ÂÈ Ï¿‚ÂÈ ÙË ‰¤Ô˘Û· ÚÔÛÔ¯‹ ¤ÙÛÈ ÒÛÙ ӷ ·Ó·ÎÔ˘Ê›˙ÂÙ·È Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÚÔ·Ó·ÊÂÚı›۷ ¤̂·ÛË fi¯È ÌfiÓÔ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· fiÓÔ˘, ·ÏÏ¿ Û˘Ó‰¤ÂÙ·È Â›Û˘ Ì ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ‰˘ÛÎÔϛ˜ ÛÙËÓ Ô‡ÚËÛË ÁÈ· ·ÚÎÂÙ¤˜ Ë̤Ú˜ ·ÚÁfiÙÂÚ·. ∏ ıÂڷ¢ÙÈ΋ ÏÔÈfiÓ ·Ú¤Ì‚·ÛË Â›Ó·È ÂȂ‚ÏË̤ÓË ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ·, ·ÏÏ¿ Î·È ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ™ÙËÓ ÂÚ›ÙˆÛË ÂÂÌ‚¿ÛÂˆÓ Î·Ù¿ ÙȘ Ôԛ˜ Ô fiÓÔ˜ ÚԂϤÂÙ·È Ó· Â›Ó·È È‰È·›ÙÂÚ· Ô͇˜, fiˆ˜ ·˘Ùfi˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙË ‚ÈÔ„›· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ıÂڷ›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔÈ΋˜ ·Ó·ÈÛıËÛ›·˜ (9-11). ∏ ¯Ú‹ÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ˆ˜ ÌÔÓÔıÂڷ›· fi¯È ÌfiÓÔ ‰ÂÓ ÚÔηÏ› ·Ó·ÏÁËÛ›·, ·ÏÏ¿ ÂÈÚÔÛı¤Ùˆ˜ ηıÈÛÙ¿ ‰‡ÛÎÔÏË ÙËÓ ÂÈÎÔÈÓˆÓ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙÔ ÁÈ·ÙÚfi (12-17). ∏ ∞∞ƒ Û˘ÓÈÛÙ¿ ÙË ¯Ú‹ÛË Î·Ù·ÛÙÔÏ‹˜ Î·È ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÒ‰˘Ó˜ ÂÂÌ‚¿ÛÂȘ Û‡Ìʈӷ ÌÂ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ (18,19). ¶fiÓÔ˜ Û¯ÂÙÈ˙fiÌÂÓÔ˜ Ì ÂÁ¯ÂÈÚ‹ÛÂȘ Î·È ÙÚ·‡Ì·Ù· ∏ ÌÂϤÙË ÙÔ˘ ‰ÈÂÁ¯ÂÈÚËÙÈÎÔ‡ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ fiÓÔ˘ ¤¯ÂÈ Û˘ÓÂÈÛʤÚÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ÂÎÙ›ÌËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ (7). ªÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙË
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·215
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
ıˆڛ· fiÙÈ Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ Î·È ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ÌÔÚÔ‡Ó Ó· ÌÂȈıÔ‡Ó ÛËÌ·ÓÙÈο ¯¿ÚË ÛÙËÓ ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ (20). ∞Ó Î·È ÛËÌ·ÓÙÈΤ˜ ̤ıÔ‰ÔÈ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ fiÓÔ˘ ·ÔÙÂÏÔ‡Ó Ë ÂÈÛÎÏËÚ›‰ÈÔ˜ ·Ó·ÈÛıËÛ›· Î·È Ë ÂÏÂÁ¯fiÌÂÓË ·fi ÙÔÓ ·ÛıÂÓ‹ ·Ó·ÏÁËÛ›·, Ù· ÂÚÈÛÛfiÙÂÚ· ÂÚÈÛÙ·ÙÈο ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ÙÔÓ ·È‰›·ÙÚÔ ¯ˆÚ›˜ ÙËÓ ˘ÈÔı¤ÙËÛË ÔχÏÔÎˆÓ Ù¯ÓÈÎÒÓ. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÂÏÂÁ¯fiÌÂÓË ·fi ÙÔÓ ·ÛıÂÓ‹ ·Ó·ÏÁËÛ›· (PCA-Patient Controlled Analgesia) ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 6 ÂÙÒÓ (2125). ∆Ô ı¤Ì· Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ·Ó·ÏÁËÛ›·˜ ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È Ì ÙÔ˘˜ ÁÔÓ›˜ ÚÈÓ ÙËÓ Â¤Ì‚·ÛË (7). µ·ÛÈο ÛÙÔȯ›· Ù˘ Ê·ÚÌ·ÎÔÏÔÁÈ΋˜ ıÂڷ›·˜ ·ÔÙÂÏÔ‡Ó ÙÔ Â›‰Ô˜ ÙÔ˘ ·Ó·ÏÁËÙÈÎÔ‡, Ë ‰fiÛË ÙÔ˘, Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· Î·È Ë Ô‰fi˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ Ê·Ú̿ΈÓ, fiˆ˜ Ù· ÔÈÔÂȉ‹, ηıÒ˜ Î·È Ù· ÌË ÔÈÔÂȉ‹ ·Ó·ÏÁËÙÈο Î·È ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η. OÈÔÂȉ‹ fiˆ˜ Ë ÎÈÙÚÈ΋ Ê·ÈÓÙ·Ó‡ÏË, Ë ıÂÈÈ΋ ÌÔÚÊ›ÓË Î·È Ë ˘‰ÚԯψÚÈ΋ ˘‰ÚÔÌÔÚÊfiÓË ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ì¤ÙÚÈ·˜ ¤ˆ˜ Î·È ÛÔ‚·Ú‹˜ ÂÓÙ¿Ûˆ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ ¿ÏÁÔ˘˜. ∏ Ê·ÈÓÙ·Ó‡ÏË, ÏfiÁˆ Ù˘ ÈÛ¯˘Ú‹˜ ηٷÛÙÔÏ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔÓ ÎÔÈÓfi ı¿Ï·ÌÔ, ·Ú¿ ÌfiÓÔ ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ‹ Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜. ∏ ˘‰ÚԯψÚÈ΋ ÌÂÂÚȉ›ÓË (Âıȉ›ÓË) ‰ÂÓ ·ÔÙÂÏ› ÔÈÔÂȉ¤˜ ÂÎÏÔÁ‹˜, ÏfiÁˆ Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ Ù˘ ÚÔ˚fiÓÙˆÓ Î·È ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘ (7,26). ∏ ¯Ú‹ÛË Ù˘ ·Ú·ÎÂÙ·ÌfiÏ˘ Î·È ÙˆÓ ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ÔÈÔÂȉ‹, ÌÔÚ› Ó· ÂÏ·ÙÙÒÛÂÈ ÙË ‰fiÛË ÙÔ˘ ÔÈÔÂȉԇ˜ Ô˘ ı· ¯ÚÂÈ·ÛÙ› ÁÈ· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ›‰ÈÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜. ªÔÚ›, ›Û˘, Ó· ¯ÔÚËÁËı› Î·È Ë Ó·Ï‚Ô˘ÚÊ›ÓË (nubaine), Ë ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ÂÂÌ‚¿ÛÂȘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘fiıÂÙ· ·Ú·ÎÂÙ·ÌfiÏ˘ ·Ó¿ ÂÍ¿ˆÚÔ Ì ¿ÚÈÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∂Âȉ‹ ÛËÌ·ÓÙÈÎfi ÛÙfi¯Ô ·ÔÙÂÏ› Ë fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘, Ë ‰fiÛË ¤Ó·Ú͢ ı· Ú¤ÂÈ Ó· Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹, ÂÓÒ ÔÈ ÂfiÌÂÓ˜ ı· Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (7). ∏ ¯ÔÚ‹ÁËÛË ÔÏÏ·ÏÒÓ, ÌÈÎÚÒÓ Î·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ‰fiÛÂˆÓ ·Ó·ÏÁËÙÈÎÒÓ ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ fiÓÔ˘, ÙËÓ Â›Ù·ÛË Ù˘ ·ÓËÛ˘¯›·˜, ηıÒ˜ Î·È ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ fiˆ˜ Â›Ó·È ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ΤÓÙÚÔ˘. ∏ Ù·¯Â›· Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Â›Ó·È ·ÛʷϤÛÙÂÚË ·fi ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË
Paediatriki 2002;65:212-218
¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ÂÂȉ‹ Ô‰ËÁ› Û ÁÚ‹ÁÔÚË ·Ó·ÎÔ‡ÊÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË ÌÈÎÚfiÙÂÚË Û˘ÓÔÏÈ΋ ‰fiÛË ÙÔ˘ ÂοÛÙÔÙ ÂÈÏÂÁfiÌÂÓÔ˘ ·Ó·ÏÁËÙÈÎÔ‡. ∂ÎÙfi˜ ÌÂÌÔÓˆÌ¤ÓˆÓ ÂÚÈÙÒÛˆÓ, Ù· ·Ó·ÏÁËÙÈο ‰ÂÓ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÂÓ‰ÔÌ˘˚ÎÒ˜, ÏfiÁˆ ÙÔ˘ ÙÔÈÎÔ‡ ¿ÏÁÔ˘˜ ·ÏÏ¿ Î·È Ù˘ ·ÛÙ·ıÔ‡˜ ·ÔÚÚfiÊËÛ‹˜ ÙÔ˘˜ ηْ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ. ∏ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË ÚÔÙÈÌ¿Ù·È ÁÈ· fiÓÔ ‹ÈÔ ‹ ̤ÙÚÈ·˜ ¤ÓÙ·Û˘. ŸÙ·Ó fï˜ ÙÔ ·È‰› ¯ÚÂÈ¿˙ÂÙ·È ¿ÌÂÛË ·Ó·ÎÔ‡ÊÈÛË ·fi ÙÔÓ fiÓÔ, ÂӉ›ÎÓ˘Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜. °È· ̤ÙÚÈ·˜ ·ÏÏ¿ Î·È ÛÔ‚·Ú‹˜ ÂÓÙ¿Ûˆ˜ fiÓÔ Ô˘ ÂÈ̤ÓÂÈ, ÂӉ›ÎÓ˘Ù·È 24ˆÚË Û˘Ó¯‹˜ ¯ÔÚ‹ÁËÛË ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ÌÂÛԉȷÛÙ‹Ì·Ù·. ∏ ‰ÔÛÔÏÔÁ›· Î·È Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ÚÔÛ·ÚÌfi˙ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂÈÛËÌ·›ÓÔÓÙ·È ÛÙÔ˘˜ ÁÔÓ›˜ ÔÈ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ÔÈÔÂȉÒÓ, fiˆ˜ Ë Ó·˘Ù›·, Ô ¤ÌÂÙÔ˜ Î·È Ô ÎÓËÛÌfi˜, ¤ÙÛÈ ÒÛÙ ӷ ÂÏ·ÙÙÒÓÂÙ·È Ë ·ÓËÛ˘¯›· ÙÔ˘˜ Î·È Ó· ·ÔʇÁÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ·˘ı·›ÚÂÙ˘ ‰È·ÎÔ‹˜ Ù˘ ·Ó·ÏÁËÙÈ΋˜ ·ÁˆÁ‹˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ¿‰ÈÎË Ù·Ï·ÈˆÚ›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜. ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙËÓ ·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË ÔÈÔÂȉÒÓ (.¯. ‰˘ÛÎÔÈÏÈfiÙËÙ·) Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Î·Ù¿ÏÏËÏ·. ∏ Èı·Ó‹ ·ıÚÔÈÛÙÈ΋ Û˘Ó¤ÚÁÂÈ· ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ, ·Á¯ÔÏ˘ÙÈÎÒÓ, ·ÓÙÈÂÌÂÙÈÎÒÓ Î·È ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÂÈ‚¿ÏÏÂÈ ÙËÓ ·‰È¿ÏÂÈÙË ·ÍÈÔÏfiÁËÛË ÙfiÛÔ Ù˘ ÚÔÎÏËı›۷˜ ·Ó·ÏÁËÛ›·˜, fiÛÔ Î·È ÙÔ˘ ÂȤ‰Ô˘ ηٷÛÙÔÏ‹˜. ªÂÙ¿ ÙËÓ ·Ó¿ÓË„Ë ·fi Ì›· ÂÒ‰˘ÓË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË, Ë ·Ó·ÏÁËÙÈ΋ ·ÁˆÁ‹ ÌÔÚ› Ó· ÌÂÙ·‚ÏËı› ·Ó·ÏfiÁˆ˜ ÙˆÓ ·Ó·ÁÎÒÓ, ÔÙ¤ fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ‰È·ÎÔ› ·fiÙÔÌ·. ∞Ó Î·È ˘¿Ú¯ÂÈ Ï¤ÔÓ ·˘ÍË̤ÓË Ù¿ÛË ÁÈ· “ÂÁ¯ÂÈÚ‹ÛÂȘ Ù˘ Ì›·˜ Ë̤ڷ˜” ‹ ÁÈ· ÁÚ‹ÁÔÚË ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂÙ¿ ·fi ¤Ó· “·Ïfi ¯ÂÈÚÔ˘ÚÁ›Ԕ (.¯. ·Ì˘Á‰·ÏÂÎÙÔÌ‹ ‹ ·Ê·›ÚÂÛË ·‰ÂÓÔÂȉÒÓ Â΂ϷÛÙ‹ÛˆÓ), ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Î·È ÂÌÂÈÚ›· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÏÁÔ˘˜ Ô˘ ÙȘ Û˘Óԉ‡ÂÈ, ¤ÙÛÈ ÒÛÙ ӷ ÙÂÎÌËÚÈÒÓÂÙ·È Ë ÔÚıfiÙËÙ· Ù˘ ÂÈÏÔÁ‹˜ Ù˘ ‚Ú·¯Â›·˜ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ¶¿ÓÙˆ˜, ÛÙȘ ÂÂÌ‚¿ÛÂȘ ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜, ÙÔ ˘fiıÂÙÔ Ù˘ ·Ú·ÎÂÙ·ÌfiÏ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙÔ ›‰ÈÔ Ê¿ÚÌ·ÎÔ ·fi ÙÔ ÛÙfiÌ· Ê·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ¿ÚÈÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Ô˘ ÔÊ›ÏÂÙ·È Û ÛÔ‚·Úfi ÙÚ·˘Ì·ÙÈÛÌfi, Ô ÔÔ›Ô˜ ÂÈ‚¿ÏÏÂÈ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÙÚ·˘Ì·Ù›· Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜, ÌÔÚ› Ó· ˘ÔÙÈÌËı› ÏfiÁˆ Ù˘ ÚÔÙÂÚ·ÈfiÙËÙ·˜ Ô˘ ¤¯Ô˘Ó ¯ÂÈÚÈÛÌÔ› ‰È¿ÛˆÛ˘ Ù˘ ˙ˆ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ì ÛËÌ·ÓÙÈÎfiٷ٘ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔÓ ¿ÚÚˆÛÙÔ. ŒÙÛÈ, ÏÔÈfiÓ,
215
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·216
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÌÂÙ¿ ·fi ÛÔ‚·Úfi ÙÚ·˘Ì·ÙÈÛÌfi ηı›ÛÙ·Ù·È ·Ó·Áη›· Ë ¿ÌÂÛË Î·È ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘, fiÛÔ ÎÈ ·Ó ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ‰Â˘ÙÂÚÂ‡Ô˘Û·˜ ÛËÌ·Û›·˜. O fiÓÔ˜ ·˘Ùfi˜ ÌÔÚ› Ó· ·Ô‰Ôı› Û ÔÈΛϷ ·›ÙÈ· fiˆ˜ Â›Ó·È ÙÔ ›‰ÈÔ ÙÔ ÙÚ·‡Ì·, ÔÈ ¯ÂÈÚÔ˘ÚÁÈÎÔ› ¯ÂÈÚÈÛÌÔ›, Ù˘¯fiÓ ˘ÔΛÌÂÓË ÓfiÛÔ˜ ‹ Î·È ÙÔ Û‡ÓÔÏÔ Ù˘ ‰È·‰Èηۛ·˜ ÙÔÔıÂÙ‹Ûˆ˜ ÊÏ‚ÈÎÒÓ Ô‰ÒÓ Î·È ·ÚÔ¯ÂÙ‡ÛÂˆÓ (27). ∏ ÂÈÏÔÁ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, Ù˘ ‰ÔÛÔÏÔÁ›·˜, Ù˘ Ô‰Ô‡ ·ÏÏ¿ Î·È ÙÔ˘ ÙÚfiÔ˘ ¯ÔÚ‹ÁËÛ˘ (Û˘Ó¯‹˜ ‹ ‰È·ÏÂ›Ô˘Û·) Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÛıÂÓ‹. π‰È·›ÙÂÚË Ì¤ÚÈÌÓ· ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÁÈ· ÙËÓ ÔÌ·Ï‹ ÂÓ·ÏÏ·Á‹ ÙˆÓ Î‡ÎÏˆÓ ‡ÓÔ˘-·Ê‡ÓÈÛ˘ ÎÈ ·˘Ùfi ÂÂȉ‹ Ë ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÙÔ˘ ÛÙ·‰›Ô˘ ÙÔ˘ ‡ÓÔ˘, ‚ÔËı¿ ÙÔÓ ·ÛıÂÓ‹ Ó· ·ÓÙÂÂͤÏıÂÈ Î·Ï‡ÙÂÚ· ÛÙËÓ „˘¯ÔÊıfiÚÔ ÂÒ‰˘ÓË ÂÌÂÈÚ›· ÙÔ˘. ∏ ·Ú¿Ù·ÛË ÙÔ˘ fiÓÔ˘ ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ ÙËÓ ·Ú¿ÏÏËÏË ·Ú¿Ù·ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ÔÈÔÂȉÒÓ (28). OÈ ‰fiÛÂȘ ı· Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Î·Ï¿ ·ÓÂÎÙ¤˜, ÂÓÒ ÂÈ‚¿ÏÏÂÙ·È Ë ÛÙ·‰È·Î‹ Î·È ·ÚÁ‹ ‰È·ÎÔ‹ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ ÚÔ˜ ·ÔÊ˘Á‹ ÛÙÂÚËÙÈÎÒÓ Ê·ÈÓÔÌ¤ÓˆÓ (29). ¶fiÓÔ˜ ÛÙ· Ï·›ÛÈ· ÔÍ›·˜ ÓfiÛÔ˘ O fiÓÔ˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÔÍ›· ÓfiÛÔ, fiˆ˜ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, Ê·Ú˘ÁÁ›Ùȉ·, ÌËÓÈÁÁ›Ùȉ· (ÎÂÊ·Ï·ÏÁ›·) Î·È ÊÏÂÁÌÔÓÒ‰Ë ÓÔÛ‹Ì·Ù· Ù˘ ˘¤ÏÔ˘ (˘ÂÏÈÎfi˜ fiÓÔ˜), ı· Ú¤ÂÈ Â›Û˘ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È. ∏ Ê·Ú̷΢ÙÈ΋ ·Ú¤Ì‚·ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯Ú‹ÛË ·Ú·ÎÂÙ·ÌfiÏ˘, ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ô˘ÛÈÒÓ Î·È Û·ÓÈfiÙÂÚ· ÔÈÔÂȉÒÓ Î·È ÙÔÈÎÒÓ ·Ó·ÏÁËÙÈÎÒÓ. ∆¤ÏÔ˜, ÌË Ê·ÚÌ·ÎÔÏÔÁÈΤ˜ ıÂڷ¢ÙÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Ë ¯·Ï¿ÚˆÛË Î·È Ë „˘¯ÔıÂڷ›· ÌÔÚÔ‡Ó Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Ì ÂÈÙ˘¯›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜. º¿Ú̷η ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ∆· Ê¿Ú̷η Ô˘ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ‰È·ÎÚ›ÓÔÓÙ·È Û ÌË ÔÈÔ‡¯·, ÔÈÔ‡¯· Î·È Û ¿ÏÏ· Ê¿Ú̷η Ù· ÔÔ›· Û˘ÌÏËÚÒÓÔ˘Ó ÙË ‰Ú¿ÛË ÙˆÓ ·Ú·¿Óˆ (30). ™ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ÌË ÔÈÔ‡¯ˆÓ ·Ó·ÏÁËÙÈÎÒÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·ÛÈÚ›ÓË (‰fiÛË: 10-15 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÔÔ›· fï˜ ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ï¤ÔÓ ·Ú¿ ÌfiÓÔ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ (fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÛÙȘ ÚÂ˘Ì·ÙÈΤ˜ ·ı‹ÛÂȘ, Kawasaki Î.Ï.), Ë ·Ú·ÎÂÙ·ÌfiÏË (‰fiÛË: 10-15 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÚÔ·Ú·ÎÂÙ·ÌfiÏ˘ (‰fiÛË: 20 mg/kg/6 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜) Î·È Ù· ÌË ÛÙÂÚÈÓÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë, fiˆ˜ ÙÔ ÌÂÊÂÓ·ÌÈÎfi Ô͇
216
Paediatriki 2002;65:212-218
(‰fiÛË: 5-6 mg/kg/6 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë Ó·ÚÔͤÓË (‰fiÛË: 5-7 mg/kg/8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÙÔÏÌÂÙ›ÓË (‰fiÛË: 5-7 mg/kg/6-8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë È‚Ô˘ÚÔÊ·›ÓË (‰fiÛË: 4-10 mg/kg/6-8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·) Î·È Ë ÈÓ‰ÔÌÂı·Î›ÓË (‰fiÛË: 0,5-2 mg/kg/8-12 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·). ™Ù· ·Ó·ÏÁËÙÈο Ù˘ ηÙËÁÔÚ›·˜ ·˘Ù‹˜ ‰ÂÓ ·Ó·Ù‡ÛÛÂÙ·È Ê˘ÛÈ΋ ÂÍ¿ÚÙËÛË ‹ ·ÓÔ¯‹. ∆· ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο ·ÔÙÂÏÔ‡Ó Ù· ·ÚÈ· Ê¿Ú̷η ÁÈ· ÛÔ‚·Úfi fiÓÔ (.¯. Û ıÚÔÌ‚ˆÙÈΤ˜ ÎÚ›ÛÂȘ ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜ ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ Ì ηÚΛÓÔ ‹ Î·È ÂÓ›ÔÙ ÛÙÔÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi fiÓÔ) Î·È ‰ÚÔ˘Ó ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ·ÓÙÔ¯‹ ÛÙ· ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù·, ¯ˆÚ›˜ Ó· ηٷÚÁÔ‡Ó ÙËÓ ·›ÛıËÛË ÙÔ˘ fiÓÔ˘. ÃÔÚËÁÔ‡ÓÙ·È Ì ÔÈΛÏÔ˘˜ ÙÚfiÔ˘˜ [·fi ÙÔ ÛÙfiÌ·, ÂÓ‰ÔÌ˘˚ÎÒ˜, ˘Ô‰ÔÚ›ˆ˜, ÂÓ‰Ô‰ÂÚÌÈÎÒ˜, ‰È·‚ÏÂÓÓÔÁÔÓ›ˆ˜ (̇ÙË, ÔÚıfi), ηıÒ˜ Î·È ÛÙÔÓ ÂÈÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ] Î·È ¤¯Ô˘Ó ÔÈΛÏË ‰È¿ÚÎÂÈ· ‰Ú¿Ûˆ˜ (·fi 30 ÏÂÙ¿ - 2 ÒÚ˜ ÁÈ· ÙË Ê·ÈÓÙ·Ó‡ÏË ¤ˆ˜ 3-8 ÒÚ˜ ÁÈ· ÙË ÌÔÚÊ›ÓË, ÙËÓ ˘‰ÚÔÌÔÚÊfiÓË, ÙË ÌÂı·‰fiÓË Î·È ÙË Ó·Ï‚Ô˘ÚÊ›ÓË). ∆· Ê¿Ú̷η ·˘Ù¿ ÚÔηÏÔ‡Ó ·ÓÔ¯‹ (ÂÏ¿ÙÙˆÛË Ù˘ ÚÔηÏÔ‡ÌÂÓ˘ ·Ó·ÏÁËÛ›·˜ ÌÂÙ¿ ·fi ·ӷϷ̂·ÓfiÌÂÓË ¯ÔÚ‹ÁËÛË), Ê˘ÛÈ΋ ÂÍ¿ÚÙËÛË Î·È Û·Ó›ˆ˜ ÂıÈÛÌfi. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› Ë ‰Ú¿ÛË ÙˆÓ ÔÈÔ‡¯ˆÓ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi ΤÓÙÚÔ Î·È ÛÙ· ·ÁÁ›· Ù˘ ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ΢ÎÏÔÊÔÚ›·˜, ÌÂ Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ ·›Ì·ÙÔ˜. ™Â ÂÚ›ÙˆÛË ˘ÂÚ‰ÔÛÔÏÔÁ›·˜ ÙˆÓ ÔÈÔ‡¯ˆÓ Ê·ÚÌ¿ÎˆÓ ÂÌÊ·Ó›˙ÂÙ·È ÎÒÌ·, ·ÚÁ‹ ÂÈfiÏ·ÈË ·Ó·ÓÔ‹ Î·È Ì‡ÛË. ∂ȉÈÎfi ·ÓÙ›‰ÔÙÔ Û ÂÚÈÙÒÛÂȘ ‰ËÏËÙËÚÈ¿Ûˆ˜ Ì ÔÈÔ‡¯· Â›Ó·È Ë Ó·ÏÔÍfiÓË Û ‰fiÛË 0,002 mg/kg. ∆· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο Â›Ó·È Ë ÌÔÚÊ›ÓË (‰fiÛË: 0,1 mg/kg/2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜ ‹ 0,1-0,15 mg/kg/3-4 ÒÚ˜ ÂÓ‰ÔÌ˘˚ÎÒ˜ ‹ 0,05-0,06 mg/kg/1 ÒÚ· ÛÂ Û˘Ó¯‹ ¤Á¯˘ÛË ‹ 0,3-0,6 mg/kg/8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ· ˘fi ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ‚Ú·‰Â›·˜ ·Ô‰ÂÛ̇ۈ˜), Ë Âıȉ›ÓË (‰fiÛË: 0,8-1 mg/kg/2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜ ‹ 0,8-1,3 mg/kg/3-4 ÒÚ˜ ÂÓ‰ÔÌ˘˚ÎÒ˜ ‹ ˘Ô‰ÔÚ›ˆ˜), Ë Îˆ‰Â˝ÓË (‰fiÛË: 0,5-1 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÌÂı·‰fiÓË (‰fiÛË: 0,1 mg/kg/4 ÒÚ˜ ·Ú¯Èο, ÛÙË Û˘Ó¤¯ÂÈ· ·Ó¿ 6-12 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜), Ë Ê·ÈÓÙ·Ó‡ÏË (‰fiÛË: 1-2 Ìg/kg/1-2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜) Î·È Ë ˘‰ÚÔÌÔÚÊfiÓË (‰fiÛË: 0,05-0,1 mg/kg/6ÒÚ˜, ¤ˆ˜ Î·È 5 mg/‰fiÛË ·fi ÙÔ ÛÙfiÌ·). ŸÏ· Ù· ·Ú·¿Óˆ ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο Ê¿Ú̷η ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ‹ Û ªÔÓ¿‰Â˜ ∞˘ÍË̤Ó˘ ºÚÔÓÙ›‰·˜ Ì Ôχ ηϋ ηٷÁÚ·Ê‹ ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ (monitoring) Î·È Ì ·Ú¿ÏÏËÏË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘.
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·217
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
∆¤ÏÔ˜, Ê¿Ú̷η ÌÂ Û˘ÌÏËڈ̷ÙÈ΋ ‰Ú¿ÛË Â›Ó·È Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο, Ù· ËÚÂÌÈÛÙÈο-˘ÓˆÙÈο, Ù· ÙÔÈο ·Ó·ÈÛıËÙÈο, Ë Î·Ú‚·Ì·˙›ÓË ·fi Ù· ·ÓÙÈÂÈÏËÙÈο, Ë ÔÔ›· ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ÂÚÈÙÒÛÂȘ ËÌÈÎÚ·Ó›·˜ Î·È Ó¢ڷÏÁ›·˜, ηıÒ˜ Î·È ÔÚÈṲ̂ÓÔÈ ·Ó·ÛÙÔÏ›˜ ÙˆÓ ‚-˘Ô‰Ô¯¤ˆÓ ‹ Ù˘ ·ÓÙ·ÏÏ·Á‹˜ ÙˆÓ ÈfiÓÙˆÓ ·Û‚ÂÛÙ›Ô˘ Ô˘ ¤¯Ô˘Ó ›Û˘ ¯ÚËÛÈÌÔÔÈËı› ÛÙËÓ ËÌÈÎÚ·Ó›·. ™Ù· Ê¿Ú̷η ·˘Ù¿ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ·Ó‹ÎÔ˘Ó Î·È Ù· ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹, Ù· ÔÔ›· ‰ÚÔ˘Ó ·Ó·ÏÁËÙÈο, ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÛÙÔ Ô›‰ËÌ· Î·È ÙË ÊÏÂÁÌÔÓ‹, .¯. Û fiÁÎÔ˘˜ ÂÁÎÂÊ¿ÏÔ˘, ÔÛÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Î·È ÛÙȘ ·ÚıÚ·ÏÁ›Â˜ ÙˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ™˘ÌÂÚ¿ÛÌ·Ù· ∞ÔÙÂÏ› ‚·ÛÈÎfi ηı‹ÎÔÓ ÙˆÓ ·È‰È¿ÙÚˆÓ ·ÏÏ¿ Î·È fiÏˆÓ fiÛˆÓ ‰Ú·ÛÙËÚÈÔÔÈÔ‡ÓÙ·È ÛÙÔ ¯ÒÚÔ Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡, Ó· ÂȉÂÈÎÓ‡Ô˘Ó ÙËÓ ··ÈÙÔ‡ÌÂÓË ÚÔÛÔ¯‹ ˆ˜ ÚÔ˜ ÙËÓ ÚfiÏË„Ë Î·È ÙË ÛˆÛÙ‹ ÂÓ Á¤ÓÂÈ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜ Î·È ·ÈÙÈÔÏÔÁ›·˜. ∂›Ó·È ·Ôχو˜ ÂÛÊ·Ï̤ÓË Ë ·ÓÙ›ÏË„Ë fiÙÈ Ù· ·È‰È¿ ‰ÂÓ ÔÓÔ‡Ó fiÛÔ ÔÈ ÂÓ‹ÏÈΘ. ∂›Û˘, Ë ıÂÒÚËÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ ˆ˜ ·Ó·Áη›Ô˘ ·Ú¿ÁÔÓÙ· ÁÈ· ÙË ‰È·ÌfiÚʈÛË ÈÛ¯˘ÚÔ‡ ¯·Ú·ÎÙ‹Ú· ‹ Î·È ˆ˜ ı¤Ì·ÙÔ˜ ‹ÛÛÔÓÔ˜ ÛËÌ·Û›·˜ Â›Ó·È ·Ó›ÙÚÂÙË Î·È Ú¤ÂÈ Ó· ·Ó‹ÎÂÈ ÔÚÈÛÙÈο ÛÙÔ ·ÚÂÏıfiÓ. µÂ‚·›ˆ˜, ··ÈÙÂ›Ù·È Ó· ¤¯Ô˘Ó fiÏÔÈ ÔÈ ·È‰›·ÙÚÔÈ ÙȘ ·Ó·Áη›Â˜ ÁÓÒÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ fiÓÔ˘ ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË Î·È Ó· ÚÔ‚·›ÓÔ˘Ó ÛÙËÓ Î·Ù¿ÏÏËÏË, οı ÊÔÚ¿, ·ÓÙÈÌÂÙÒÈÛË. ¶ÚÔ·ÓÙfi˜, fï˜, Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÓ Ú¤Ô˘Û· ÛÙ¿ÛË Î·È Â˘·ÈÛıËÛ›·, ÊÚÔÓÙ›˙ÔÓÙ·˜ Ó· ÂÊ·ÚÌfi˙Ô˘Ó ÚÔÏËÙÈ΋ ·Ó·ÏÁËÛ›· ÂÓ fi„ÂÈ ‰˘ÓËÙÈο ÂÒ‰˘ÓˆÓ ¯ÂÈÚÈÛÌÒÓ, Ó· ·ÍÈÔÏÔÁÔ‡Ó ÛˆÛÙ¿ ÙÔÓ fiÓÔ ÙÔ˘ ·È‰ÈÔ‡ Û˘Ó˘ÔÏÔÁ›˙ÔÓÙ·˜ ÙË ‚ÈÔÏÔÁÈ΋, ÓÔËÙÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÔ˘ ˆÚ›Ì·ÓÛË Î·ıÒ˜ Î·È ÙÔ˘˜ ÎÔÈÓˆÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÛˆÛÙ¿ Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η Î·È Ó· ˘ÔÛÙËÚ›˙Ô˘Ó „˘¯ÔÏÔÁÈο ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Schechter NL, Berde CB, Vaster M. Pain in infants, children, and adolescents: an overview. In: Schechter NL, Berde CB, Vaster M, eds. Pain in infants, children, and adolescents. Baltimore, MD: Williams & Wilkins; 1993. p. 3-9. 2. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982;306:639-645. 3. Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm: the ethics of pain control in infants and children. N Engl J Med 1994;331:541-544. 4. McGrath PA. Pain in children: Nature, assessment, and treatment. New York, NY: Guilford Press; 1990. 5. McGrath PA, Brigham MC. The assessment of pain in children and adolescents. In: Turk DC, Melzack R, eds.
Paediatriki 2002;65:212-218
6.
7.
8.
9. 10.
11.
12.
13.
14. 15.
16.
17. 18.
19.
20.
21.
Handbook of Pain Assessment. New York, NY: Guilford Press; 1992. p. 295-314. Jay SM, Elliot CH. A stress inoculation program for parents whose children are undergoing painful medical procedures. J Consult Clin Psychol 1990;58:799-804. Carr DB, Jacox AK, Chapman CR. Acute pain management in infants, children, and adolescents: Operative and medical procedures: Quick Reference Guide for clinicians. Rockville, MD: Agency for Health Care Policy and Research; 1992. AHCPR Publication No. 920020. Available at: http://www.ahcpr.gov/gils/00000052.htm. Accessed June 4, 2001. Zeltzer LK, Altaian A, Cohen D, LeBaron S, Munuksela L, Schechter NL. American Academy of Pediatrics. Report of the Subcommittee on the Management of pain associated with procedures in children with cancer. Pediatrics 1990;86:826-831. Wiswell TE. Circumcision: an update. Curr Probl Pediatr 1992;22:424-431. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984;5:246-250. Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision II: effects upon mother-infant interaction. Early Hum Dev 1982;7:367-374. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997;278:2157-2162. Stang HJ, Snellman LW, Condon LM, Conroy MM, Liebo R, Brodersen L et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics 1997;100:E3. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991;87:215-218. Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997;336:1197-1201. Kurtis PS, DeSilva HM, Bernstein BA, Malakh l, Schechter NL. A comparison of Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics 1999; 103:E23. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr 1991;30:429-432. American Academy of Pediatrics, Committee on Drugs and Section on Anesthesiology. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 1985;76:317-321. American Academy of Pediatrics, Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89:1110-1115. Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and post-operative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9. Wolf AR, Valley RD, Fear DW, Roy WL, Lerman J. Bupivacaine for caudal analgesia in infants and children:
217
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·218
¶·È‰È·ÙÚÈ΋ 2002;65:212-218
22.
23. 24.
25.
26.
the optimal effective concentration. Anesthesiology 1988;69:102-106. Wood CE, Goresky GV, Klassen KA, Kuwahara B, Neil SG. Complications of continuous infusions for postoperative analgesia in children. Can J Anaesth 1994;41:613-620. Berde C. Epidural analgesia in children. Can J Anaesth 1994;41:555-560. Berde CB, Lehn BM, Yee JD, Sethna NF, Russo D. Patient controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia. J Pediatr 1991;18:460-466. Doyle E, Mottart KJ, Marshall C, Morton NS. Comparison of different bolus doses of morphine for patient-controlled analgesia in children. Br J Anaesth 1994;72:160-163. Morisy L, Platt D. Hazards of high dose meperidine. JAMA 1986;255:467-468.
Paediatriki 2002;65:212-218
27. Brill JE. Control of pain. Progr Pediatr Crit Care 1992;8:203-218. 28. Tobias JD, Rassmussen GE. Pain management and sedation in the pediatric intensive care unit. Pediatr Clin N Am 1994;41:1269-1292. 29. Anand KJ, Arnold JH. Opioid tolerance and dependence in infants and children. Crit Care Med 1994;22:334-342. 30. ∆·Ú·ÓÙ˙‹-¶ÔÙ·ÌÈ¿ÓÔ˘ ¶, ºÚÂÙ˙¿ÁÈ·˜ ∞. O fiÓÔ˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ¶·È‰È·ÙÚÈ΋˜, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 1989;9:109-130. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 27-11-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ ¶¿ÚÓËıÔ˜ 32, ∆.∫. 190 13, ™·ÚˆÓ›‰· ∞ÙÙÈ΋˜
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ™‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ Úfi‚Ï„˘ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÛÙ· ·È‰È¿1 ™ÎÔfi˜: ∏ ·ÔÙ˘¯›· Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·È‰ÈÒÓ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ª∞) Û˘Óԉ‡ÂÙ·È ·fi ·‡ÍËÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ Î·È Ù˘ ÓÔÛËÚfiÙËÙ·˜. °È’ ·˘Ùfi Î·È Â›Ó·È ÂÈı˘ÌËÙ‹ Ë Â͇ÚÂÛË ÂÓfi˜ ‰Â›ÎÙË ÂÈÙ˘¯Ô‡˜ ·ÔÛ‡Ó‰ÂÛ˘ ·fi ÙÔ ª∞. ∏ ÌÂϤÙË ·˘Ù‹ ¤ÁÈÓ Ì ÛÎÔfi Ó· ‰Â›ÍÂÈ ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·ÏÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÌÂÙÚ‹ÛˆÓ, ÂȉÈÎfiÙÂÚ· ÔÈ ·Ó·ÊÂÚfiÌÂÓÔÈ ˆ˜ Û˘Ó‰˘·Ṳ̂ÓÔÈ ‰Â›ÎÙ˜ ·ÔۈϋӈÛ˘, ‹Ù·Ó ÈÔ ·ÍÈfiÈÛÙÔÈ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Úfi‚ÏÂ„Ë Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·È‰ÈÒÓ ·fi ÙÔ ª∞, ·’ fiÙÈ Ù· ·Ó¿ÏÔÁ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. ™¯Â‰È·ÛÌfi˜: ¶ÚÔÔÙÈ΋ ÌÂϤÙË ·Ú·Ù‹ÚËÛ˘. ÃÒÚÔ˜: ∆ÚÈÙÔ‚¿ıÌÈ· ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¶·È‰ÈÒÓ (ª∂£¶). ∞ÛıÂÓ›˜: ŸÏ· Ù· ·È‰È¿ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ª∞ ÁÈ· >24 ÒÚ˜ Û ‰È¿ÛÙËÌ· 12 ÌËÓÒÓ, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÁÔÓ›˜ ›¯·Ó ‰ÒÛÂÈ ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË. ŒÏÂÁ¯Ô˜: OÈ ·Ó·Ó¢ÛÙÈΤ˜ ÌÂÙÚ‹ÛÂȘ Á›ÓÔÓÙ·Ó Î·Ù¿ ̤ÛÔ fiÚÔ 7 ÒÚ˜ (‡ÚÔ˜ 0,2-25 ÒÚ˜) ÚÈÓ ÙËÓ ·ÔۈϋӈÛË. ∞¤ÚÈ· ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ Ï·Ì‚¿ÓÔÓÙ·Ó ·ÎÚÈ‚Ò˜ ÚÈÓ ÙËÓ ·ÔۈϋӈÛË. OÈ ÙÈ̤˜ fiÏˆÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ·Ó·Ï‡ÔÓÙ·Ó ˆ˜ ÚÔ˜ ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙËÓ ÂȉÈÎfiÙËÙ· Î·È Û˘ÁÎÚ›ÓÔÓÙ·Ó ÔÈ ÂÚÈÔ¯¤˜ οو ·fi ÙȘ η̇Ϙ, Ì ÛÙfi¯Ô Ó· ‚ÚÂı› Ô Ï¤ÔÓ ·ÎÚÈ‚‹˜ ‰Â›ÎÙ˘ Úfi‚Ï„˘ Ù˘ ÂÈÙ˘¯Ô‡˜ ·ÔۈϋӈÛ˘. ªÂÙÚ‹ÛÂȘ Î·È Î˘ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù·: ™˘ÓÔÏÈο ÌÂÏÂÙ‹ıËÎ·Ó 47 ·È‰È¿ (̤Û˘ ËÏÈΛ·˜ 3,9 ¤ÙË, ‡ÚÔ˜ 0,1-17,3 ¤ÙË). ∏ ·ÔۈϋӈÛË ·¤Ù˘¯Â Û 7. O ÌÈÎÚfi˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ (<7,5 ml/kg) Î·È Ô ¯·ÌËÏfi˜ ηٿ ÏÂÙfi ·ÂÚÈÛÌfi˜ (<250 ml/kg) ›¯·Ó ÙË ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· (86% Î·È 71%
218
·ÓÙ›ÛÙÔȯ·) Î·È ÂȉÈÎfiÙËÙ· (61% Î·È 71% ·ÓÙ›ÛÙÔȯ·) Û ۯ¤ÛË Ì ÙËÓ Úfi‚ÏÂ„Ë Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·ÔۈϋӈÛ˘. ∏ ΢„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ (AaDO2) ‹Ù·Ó ÏÈÁfiÙÂÚÔ ·ÍÈfiÈÛÙË ˆ˜ ÚÔ˜ ÙËÓ Úfi‚ÏÂ„Ë Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·ÔۈϋӈÛ˘ (ÂÚÈÔ¯‹ οو ·fi ÙËÓ Î·Ì‡ÏË 0,51). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ̤ÙÚËÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ fiÁÎˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ª∞ ÛÙ· ·È‰È¿, ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÂÈÙ˘¯‹ ·Ôۈϋӈۋ ÙÔ˘˜.
™˘Ó‰˘·Ṳ̂ÓÔÈ ‰Â›ÎÙ˜ ·ÔۈϋӈÛ˘: - ‰˘Ó·ÌÈ΋ ÂÓ‰ÔÙÈÎfiÙËÙ· x ΢„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ x ̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË / ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ· - (̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË - ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË) x (·˘ıfiÚÌËÙÔ˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ : Ì˯·ÓÈÎfi˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜) - ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ· / ·˘ıfiÚÌËÙÔ˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜
1 Manczur TI, Greenough A, Pryor D, Rafferty GF Comparison of predictors of extubation from mechanical ventilation in children Pediatr Crit Care Med 2000;1:28-32
÷Ù˙‹˜ ∞Ó·ÛÙ¿ÛÈÔ˜
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·219
¶PO™EXH ™YNE¢PIA
23-25 ª·˝Ô˘ 2002
14Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ¶ÏËÚÔÊÔڛ˜: FORUM International Congress Organizers ∆ËÏ.: 0310 - 257 128 & 0310 - 243 588 Fax: 0310 - 231 849 E-mail: forup@otenet.gr
£ÂÛÛ·ÏÔÓ›ÎË
25-26 ª·˝Ô˘ 2002
11Ë ¢ÈËÌÂÚ›‰· ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛÂˆÓ ¶ÏËÚÔÊÔڛ˜: Î. ¶Ú›ÊÙ˘ °. ¡. ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ ∆ËÏ.: 010 - 80 36 484 Fax: 010 - 61 31 173 E-mail: kpriftis@otenet.gr
∞ı‹Ó·
13-15 πÔ˘Ó›Ô˘ 2002
13th Annual Congress of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) Tel./Fax: ++ 386 (0) 1 430 17 14 E-mail: ivan.vidmar@kclj.si
Ljubljana, Slovenia
21-23 πÔ˘Ó›Ô˘ 2002
40Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: C&C International A.E. Conventions & Congresses ∆ËÏ.: 010 - 68 89 100 Fax: 010 - 68 44 777 E-mail: congress@cnc.gr
£ÂÛÛ·ÏÔÓ›ÎË
4-7 πÔ˘Ï›Ô˘ 2002
12th International Conference on oral chelation in the treatment of thalassemia and other diseases ¶ÏËÚÔÊÔڛ˜: ERA E¶E ∆ËÏ.: 010 - 36 34 944 Fax: 010 - 36 31 690 E-mail: info@era.gr
™·ÓÙÔÚ›ÓË
14-15 ™ÂÙÂÌ‚Ú›Ô˘ 2002
2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ¶ÏËÚÔÊÔڛ˜: C&C International A.E. Conventions & Congresses ∆ËÏ.: 010 - 68 89 100 Fax: 010 - 68 44 777 E-mail: congress@cnc.gr
∞ı‹Ó·
xiii
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·220
¶PO™EXH ™YNE¢PIA
19-21 ™ÂÙÂÌ‚Ú›Ô˘ 2002
27 UMEMPS Congress Congress Secretariat: Viajes Pacifico, S.L. c/ Maria Cubi, 4 entlo Tel.: +34 93 238 8777 Fax: +34 93 238 7488 E-mail: pg@pacif-meetings.com
Alicante, Spain
20-25 ™ÂÙÂÌ‚Ú›Ô˘ 2002
9th International Child Neurology Congress and the 7th Asian and Oceanian Congress of Child Neurology ¶ÏËÚÔÊÔڛ˜: Dr. Yu-Wu Jiang, Xin-Hua Bao E-mail: icnc@public3.bta.net.cn Website: http://www.ciccs-t.org.cn/icnc2002
Beijing, China
27-29 ™ÂÙÂÌ‚Ú›Ô˘ 2002
6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ Ì ¢ÈÂıÓ‹ ™˘ÌÌÂÙÔ¯‹ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ÁÈ· ÙË ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜
£ÂÛÛ·ÏÔÓ›ÎË
28 ™ÂÙÂÌ‚Ú›Ô˘ 2002
∏ÌÂÚ›‰· Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎÒÓ Û˘Ó‰ÚfiÌˆÓ ∂ÏÏËÓÈ΋˜ ∞ÈÌ·ÙÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ ¶ÏËÚÔÊÔڛ˜: ∂æπ§O¡ ∆ËÏ.: 010 - 72 54 360-2 Fax: 010 - 72 54 363 E-mail: epsilon@hol.gr
¡·‡ÏÈÔ
xiv
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·221
™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
xv
MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·222
™˘ÓÙÔÌÔÁڷʛ˜
·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¿‰·
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9
6
3
2
1
-1
-2
-3
-6
-9
-12
-15
-18
xvi
EÏÏËÓÈÎÔ› fiÚÔÈ
Combining prefixes T G M k h da d c m Ì n p f a
AÁÁÏÈÎÔ› fiÚÔÈ by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit