JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·1
¶·È‰È·ÙÚÈ΋ 2003;66:1
Paediatriki 2003;66:1
∂¶π™∆O§∏ ∞¶O ∆∏ ™À¡∆∞∫∆π∫∏ ∂¶π∆ƒO¶∏
∞Á·ËÙÔ› ™˘Ó¿‰ÂÏÊÔÈ, ªÂ ÙËÓ Â˘Î·ÈÚ›· ÙˆÓ ÂÔÚÙÒÓ ÙˆÓ ÃÚÈÛÙÔ˘Á¤ÓÓˆÓ Î·È ÙÔ˘ ·Ó·Ù¤ÏÏÔÓÙÔ˜ ¡¤Ô˘ ŒÙÔ˘˜, Ë ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ “¶∞π¢π∞∆ƒπ∫∏™” Î·È ÂÁÒ ÚÔÛˆÈο, Û·˜ ÛÙ¤ÏÏÔ˘Ì ÙȘ ıÂÚÌfiÙÂÚ˜ ¢¯¤˜ Ì·˜. ∂˘¯fiÌ·ÛÙ Û ۷˜ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ Û·˜ ˘Á›·, ÚÔÎÔ‹ Î·È Î¿ı ÂÈÙ˘¯›· ÛÙÔ˘˜ ÛÙfi¯Ô˘˜ Û·˜. ∏ Ó¤· ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ “¶∞π¢π∞∆ƒπ∫∏™” Ô˘ ·Ó¤Ï·‚ ·fi Ù· ̤۷ ÙÔ˘ ÙÚ¤¯ÔÓÙÔ˜ ¤ÙÔ˘˜, Û˘Ó¯›˙ÔÓÙ·˜ ÙÔ ‰ËÌÈÔ˘ÚÁÈÎfi ¤ÚÁÔ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘, οÓÂÈ Î¿ı ‰˘Ó·Ù‹ ÚÔÛ¿ıÂÈ· ÁÈ· ÙË Û˘Ó¯‹ ·ÓÔ‰È΋ ÔÚ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ì·˜ ÁÈ· ÙË ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È ÙËÓ ¤ÓÙ·Í‹ ÙÔ˘ ̤۷ ÛÙ· ‰ÈÂıÓ‹ È·ÙÚÈο ÂÚÈÔ‰Èο.
ªÂ Û˘Ó·‰ÂÏÊÈÎÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜ ÁÈ· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ O ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ™Ù·‡ÚÔ˜ ÷˚‰¿˜
1
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·2
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
∞¡∞™∫O¶∏™∏
Paediatriki 2003;66:2-11
REVIEW ARTICLE
¡Â˘ÚÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ª. ¡. ¶··‰ËÌËÙÚ›Ô˘
Neurological assessment of the newborn infants M. N. Papadimitriou
¶ÂÚ›ÏË„Ë: ™ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ ÛËÌÂÈÒıËΠÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÛÙË ÓÔÛËÏ›· ÙˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∞˘Ùfi Ô‰‹ÁËÛ Û ·˘ÍË̤ÓË ÂÈ‚›ˆÛË ÙˆÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∆·˘Ùfi¯ÚÔÓ· Ì ·˘Ù‹ ÙË ‚ÂÏÙ›ˆÛË, ¤ÁÈÓ ÂÊÈÎÙ‹ Ë ¯Ú‹ÛË ÂÚÈÛÛfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ Î·Ù¿ÏÏËÏˆÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ. ∏ ÚÔÛÔ¯‹ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ΢ڛˆ˜ ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È Doppler ÂÁÎÂÊ¿ÏÔ˘, ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÙËÓ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·Ê›· Î·È ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ. O ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ò˜ Ì›· ÔÏÔÎÏËڈ̤ÓË ÚÔÛ¤ÁÁÈÛË Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂÎÙ›ÌËÛ˘ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÚfiÁÓˆÛË Ù˘ ·ÒÙÂÚ˘ Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ÂͤÏÈ͢.
Abstract: During the last two decades there has been significant progress in the management of high-risk preterm infants resulting in an increased survival of low-birthweight infants. At the same time more techniques assessing the neurological well being of these infants have become available. Attention is mainly focused on brain ultrasound, Doppler, MRI, electroencephalography and various evoked potential modalities. The aim of this study is to illustrate how an integrated approach with the combined use of imaging and clinical evaluation can help in predicting neurodevelopmental outcomes.
§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÔÁÓfi, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘, ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο, Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘.
Key words: newborn infant, electroencephalography, brain ultrasound, evoked potentials, magne-tic resonance imaging.
∂ÈÛ·ÁˆÁ‹ ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ ·Ó·Ù˘¯ı› ·ÚÎÂÙfi ÂӉȷʤÚÔÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ó¢ÚÔÏÔÁ›· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘. ∞˘Ùfi ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Ì ÙËÓ ‡·ÚÍË ‚ÂÏÙÈÒÛÂˆÓ ÛÙË ÓÔÛËÏ›· ÙˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, ηıÒ˜ Î·È Ì ÙËÓ ·Ó·Î¿Ï˘„Ë Î·È ¯Ú‹ÛË Ó¤ˆÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘˜. ∏ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ Î·È Ë ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ Û ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (¶Ãµ°) (1,2).
∏ ÚÔÁÂÓÓËÙÈ΋ ¯Ú‹ÛË ÎÔÚÙÈÎÔÂȉÒÓ Á›ÓÂÙ·È Ì ·ÚÎÂÙ‹ ÂÚ›ÛÎÂ„Ë ÙÂÏÂ˘Ù·›·, ·ÊÔ‡ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ù· Ì·ÎÚ¿ (fi¯È fï˜ Î·È Ù· ‚Ú·¯¤· Î·È ÌÂÌÔӈ̤ӷ) Û¯‹Ì·Ù· ÚÔÁÂÓÓËÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯·ÌËÏfiÙÂÚÔ Ú˘ıÌfi ·Ó¿Ù˘Í˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ·ÏÏ¿ Î·È ÂÌÊ¿ÓÈÛË ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÂÓÒ Ù· Ì·ÎÚ¿ Û¯‹Ì·Ù· ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯ÂÈÚfiÙÂÚË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË (3,4). ™ÙËÓ ∂˘ÚÒË ÂÈ‚ÈÒÓÂÈ ÙÔ 50% ÙˆÓ ÓÂÔÁÓÒÓ Ì ∏∫ 25 ‚‰ÔÌ¿‰Â˜. ™ÙËÓ ∞ÁÁÏ›· Î·È ÙËÓ πÚÏ·Ó‰›· ¤ÁÈÓ ÙÔ 1995 Ë EPICure ÌÂϤÙË, Ë ÔÔ›· ¤‰ÂÈÍÂ
∆Ì‹Ì· ¡ÂÔÁ¤ÓÓËÙˆÓ, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
Department of Pediatrics, University of Athens “P. & A. Kyriakou” Children’s Hospital, Athens
2
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·3
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ 39% ÁÈ· ÓÂÔÁÓ¿ Ì ∏∫ <26 ‚‰ÔÌ¿‰Â˜. ∞fi Ù· ÓÂÔÁÓ¿ Ô˘ ÂÈ‚›ˆÛ·Ó, ÔÛÔÛÙfi 23% ·˘ÙÒÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Û ËÏÈΛ· 2,5 ÂÙÒÓ, ·ÚÔ˘Û›·˙ ٤ÙÔÈ· Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Ô˘ ¤‚·Ï·Ó ÙËÓ ÂÍ¿ÚÙËÛ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÁÈ· fiÏË ÙÔ˘˜ ÙË ˙ˆ‹ (5,6). ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (7) ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÙÔ 20% ·fi Ù· ·È‰È¿ Ô˘ ÂÈ‚›ˆÛ·Ó ÌÂÙ¿ ·fi ·ËÛË 32 ‚‰ÔÌ¿‰ˆÓ ‹ Ì µ° <1500 g ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈ΋ Âη›‰Â˘ÛË. ªÂϤÙ˜ ·fi ÙȘ ∏¶∞ ·Ó·Ê¤ÚÔ˘Ó ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÁÈ· ÓÂÔÁÓ¿ Ì µ° <1000 g, Ô˘ Êı¿ÓÔ˘Ó Ì¤¯ÚÈ ÙÔ 72% (8), ·ÏÏ¿ ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ Ì ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÚÔÏÔÁÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ (8,9). ∫ÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË OÈ ÚÒÙ˜ ÚÔÛ¿ıÂȘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ ¤ÁÈÓ·Ó ·fi ÙÔ˘˜ Andrè-Thomas Î·È Saint-Ann Dargassies (10-12) ÙÔ 1952, 1960 Î·È 1977. ø˜ ÛÙfi¯Ô ›¯·Ó ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ, ·ÏÏ¿ Î·È ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∞˘Ùfi˜ Ô ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ΢ڛˆ˜ ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Î·È ·Ú¯¤ÁÔÓˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Î·È ¤‰ÂȯÓ fiÙÈ Ë ÂͤÏÈÍ‹ ÙÔ˘˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ Î·È fi¯È ·fi ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ™¯Â‰fiÓ Ù·˘Ùfi¯ÚÔÓ· (1977) ÛÙËÓ OÏÏ·Ó‰›·, o Prechtl (13) ÂÊ¿ÚÌÔÛ ̛· ÂͤٷÛË ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈÎÂÓÙÚÒıËΠÛÙÔÓ Î·ıÔÚÈÛÌfi ‰È·ÊfiÚˆÓ “Û˘Ó‰ÚfïӔ (Û‡Ó‰ÚÔÌÔ ˘ÂÚ¢ÂÚÂıÈÛÙfiÙËÙ·˜, Û‡Ó‰ÚÔÌÔ ·¿ıÂÈ·˜, ËÌÈÛ‡Ó‰ÚÔÌÔ), ·ÏÏ¿ Î·È ‰È·ÊfiÚˆÓ ÛÙ·‰›ˆÓ ÂÁÚ‹ÁÔÚÛ˘, Ù· ÔÔ›· ηıÔÚ›˙Ô˘Ó ÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 1970, Ô Brazelton (14) ÂÛÙ›·Û ÙËÓ ÂͤٷÛË ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ·Ó¿ÌÂÛ· ÛÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ÙÔ ÂÍÂÙ·˙fiÌÂÓÔ ÓÂÔÁÓfi, Ì ÂÈΤÓÙÚˆÛË Û ÛËÌ›· Û˘ÌÂÚÈÊÔÚ¿˜, fiˆ˜ Ë ·¿ÓÙËÛË Û ·ÎÔ˘ÛÙÈο, ÔÙÈο, ·ÙÈο Î·È ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È Ë ÂÎÙ›ÌËÛË ÙfiÓÔ˘ Î·È Â˘ÂÚÂıÈÛÙfiÙËÙ·˜. ŸÏ˜ ÔÈ ÚÔËÁÔ‡ÌÂÓ˜ ̤ıÔ‰ÔÈ ··ÈÙÔ‡Û·Ó ÌÂÁ¿ÏË ÂÌÂÈÚ›· ·fi ÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ·ÚÎÂÙfi ¯ÚfiÓÔ ÁÈ· Ó· ÂÚ·ÙˆıÔ‡Ó. ∆Ô 1970, ÔÈ Dubowitz Î·È Û˘Ó (15) ·Ó¤Ù˘Í·Ó ¤Ó· Û‡ÛÙËÌ· ÂÎÙ›ÌËÛ˘ Ù˘ ËÏÈΛ·˜ ·ËÛ˘. ∞ÚÁfiÙÂÚ· (1981), ÔÈ ›‰ÈÔÈ ‰ËÌÈÔ‡ÚÁËÛ·Ó ¤Ó· Ó¤Ô Û‡ÛÙËÌ· Ó¢ÚÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ (16). O ÛÙfi¯Ô˜ ‹Ù·Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ¤Ó· Û‡ÛÙËÌ· ‡ÎÔÏÔ Î·È ÚÔÛÈÙfi Û ÏÈÁfiÙÂÚÔ ¤ÌÂÈÚÔ˘˜ ÁÈ·ÙÚÔ‡˜, ·Ó··Ú·ÁÒÁÈÌÔ Î·È Ì ηϋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÂÍÂÙ·ÛÙÒÓ. ¶ÂÚÈÂÏ¿Ì‚·Ó ÙËÓ ÂÎÙ›ÌËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÎÈÓËÙÈÎfiÙËÙ·˜, ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Û ۯ¤ÛË Ì ÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘, ηıÒ˜ Î·È ÙËÓ ÂÎÙ›ÌËÛË ÛËÌ›ˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË Û˘ÌÂÚÈÊÔÚ¿. ∞Ó Î·È Ë Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı›
Paediatriki 2003;66:2-11
ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÓÂÔÁÓÒÓ Î·È ÙË Û‡ÁÎÚÈÛË ÂÓfi˜ ÓÂÔÁÓÔ‡ Ì ¿ÏÏÔ, ÂÓÙÔ‡ÙÔȘ, Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ∂ÓÒ Ë ÛÙ·ıÂÚ¿ ·Ó¢ÚÈÛÎfiÌÂÓË Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, Ë ·ÚÔ˘Û›· Ó¢ÚÔÏÔÁÈÎÒÓ ·ÔÎÏ›ÛÂˆÓ Î·Ù¿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ ‰ÂÓ ÌÔÚ› ¿ÓÙÔÙ ӷ ÚÔ‰ÈοÛÂÈ ÙËÓ ·ÚÔ˘Û›·, ÙÔÓ Ù‡Ô ‹ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ (17). ∂ÓÙÔ‡ÙÔȘ, ÓÂfiÙÂÚË ÌÂϤÙË (18) ‰Â›¯ÓÂÈ fiÙÈ Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÓÂÔÁÓÔ‡ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, fiÙ·Ó Á›ÓÂÙ·È ÌÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜, Â›Ó·È ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ ¤Î‚·Û˘ ÁÈ· ·˘Ù¿ Ù· ÓÂÔÁÓ¿ Ì ηϋ Û˘Û¯¤ÙÈÛË ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÈÎfiÓ˜ ‚Ï¿‚˘ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘. ™¯Â‰fiÓ Ù·˘Ùfi¯ÚÔÓ·, Ë ÔÌ¿‰· ÙˆÓ Dubowitz ‰ËÌÔÛȇÂÈ Ì›· Ó¤· ÂΉԯ‹ Ó¢ÚÔÏÔÁÈ΋˜ ÂͤٷÛ˘ Ô˘ ‰›ÓÂÈ È‰È·›ÙÂÚË ¤ÌÊ·ÛË Û Ӥ· ı¤Ì·Ù·, fiˆ˜ ÔÈ ÁÂÓÈΤ˜ ÎÈÓ‹ÛÂȘ Î·È Ù· ÚfiÙ˘· ηٷÓÔÌ‹˜ ÙÔ˘ ÙfiÓÔ˘. ¶·Ú¿ÏÏËÏ·, ηıÔÚ›˙ÂÙ·È ¤Ó· ¢ÓÔ˚Îfi score (optimality score) ÚÔÎÂÈ̤ÓÔ˘ Ó· ηٷÛÙ‹ÛÂÈ ÙËÓ ÂÎÙ›ÌËÛË ÂÚÈÛÛfiÙÂÚÔ ÔÛÔÙÈ΋ Î·È Û˘ÁÎÚ›ÛÈÌË Û ‰È·‰Ô¯ÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ (19). ∏ ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ÙˆÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· Ó· ‰›‰ÂÙ·È ÌÈÎÚfiÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ ÎÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Î˘Ú›ˆ˜ ÙÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡. ∞˘Ùfi ÂÈ‚¿ÏÏÂÙ·È ˆ˜ ¤Ó· ‚·ıÌfi ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Û˘ÓÈÛÙ¿Ù·È Ë Ì›ˆÛË ÙˆÓ ¯ÂÈÚÈÛÌÒÓ ÛÙÔ ÂÏ¿¯ÈÛÙÔ, ηıÒ˜ ›Û˘ Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ›‰È˜ ÔÈ Û˘Óı‹Î˜ ÓÔÛËÏ›·˜ ÙÔ˘˜ (·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ‡·ÚÍË ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ Î.Ï.) ÂËÚ¿˙Ô˘Ó ÙËÓ ·˘ÙfiÌ·ÙË ÎÈÓËÙÈÎfiÙËÙ·. ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ·ÔÛ˘Ó‰ÂıÔ‡Ó ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È Â›Ó·È Û ÛÙ·ıÂÚ‹ ηٿÛÙ·ÛË, Ë ÎÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜. ¶Ôχ ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË Ù˘ ›‰È·˜ ÔÌ¿‰·˜ (20) ÚÔÙ›ÓÂÈ ÙËÓ Â¤ÎÙ·ÛË Ù˘ ¯Ú‹Û˘ ÙÔ˘ optimality score Û ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ fiÙ·Ó Êı¿ÓÔ˘Ó ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ÌËÓÒÓ, Ì ‰˘Ó·ÙfiÙËÙ· Ó· ‰›ÓÂÈ ÚfiÁÓˆÛË ÁÈ· ·ÒÙÂÚË ¤Î‚·ÛË. ∆ÂÏÂ˘Ù·›· ‰›‰ÂÙ·È ÌÂÁ¿ÏË ¤ÌÊ·ÛË ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ Ë ÔÈfiÙËÙ· ÙˆÓ ·˘ÙfiÌ·ÙˆÓ ÎÈÓ‹ÛÂˆÓ Û ۯ¤ÛË Ì ÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË (21-23). ™Ù· Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿, ÔÈ ·‰Ú¤˜ ÎÈÓ‹ÛÂȘ ¤¯Ô˘Ó ÚÔԉ¢ÙÈ΋ ¤Ó·ÚÍË Î·È ÂͤÏÈÍË Û ¤Ó· ̤ÁÈÛÙÔ Â›Â‰Ô ¤ÓÙ·Û˘ ηÈ, ·ÎÔÏÔ‡ıˆ˜, ÔÌ·Ï‹ Î·È ÛÙ·‰È·Î‹ Ì›ˆÛË. ∞ÓÙÈı¤Ùˆ˜, ÔÈ ÛÙÂÚÂfiÙ˘Â˜ ÎÈÓ‹ÛÂȘ Ô˘ ÍÂÎÈÓÔ‡Ó Î·È Î·Ù·Ï‹ÁÔ˘Ó ·fiÙÔÌ· Û˘ÓÔ‰Â‡Ô˘Ó ·ÓÒÌ·ÏË Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ·.
3
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·4
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ˘¿Ú¯ÂÈ ÏÔ‡ÛÈ· ‚È‚ÏÈÔÁÚ·Ê›· fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘Û¯¤ÙÈÛË ÙˆÓ ÏÂÁfiÌÂÓˆÓ ÁÂÓÈÎÒÓ ÎÈÓ‹ÛÂˆÓ (general movements) Ì ÙËÓ ·ÒÙÂÚË ¤Î‚·ÛË Û ηٷÛÙ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, .¯. ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· Ô˘ Û˘Óԉ‡ÂÈ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ‹ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· (22,23). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ¤ÏÂÁ¯Ô Ó¢ÚÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÚÔۋψÛË ‚ϤÌÌ·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 32 ‚‰ÔÌ¿‰ˆÓ (24). ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÔÙÈÎÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜, .¯. ÊÔ‡ÓÙ· ÎfiÎÎÈÓÔ˘ Ì·ÏÏÈÔ‡, ·Ú·ÙËÚÂ›Ù·È ·fi ÙȘ 34 ‚‰ÔÌ¿‰Â˜ Î·È ÌÂÙ¿, ÂÓÒ ÚÔۋψÛË ‚ϤÌÌ·ÙÔ˜ Î·È ·Ú·ÎÔÏÔ‡ıËÛË Û ÔÚÈ˙fiÓÙÈÔ Î·È Î¿ıÂÙÔ Â›Â‰Ô Â›Ó·È Î·Ï¿ ·ÓÂÙ˘Á̤ӷ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ Î·È ÌÂÙ¿. ∏ ·ÓÙ›‰Ú·ÛË ÛÙÔÓ ‹¯Ô Â›Ó·È ‹‰Ë ·ÚÔ‡Û· ·fi ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ Î·È ÂΉËÏÒÓÂÙ·È Ì ÙË ÌÂÙ·‚ÔÏ‹ Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ªÂÙ¿ ÙË Á¤ÓÓËÛË, Û·Ê‹˜ ·ÓÙ·fiÎÚÈÛË ÛÙÔÓ ‹¯Ô ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÛÙËÓ ËÏÈΛ· ÙˆÓ 28 ‚‰ÔÌ¿‰ˆÓ ÂÚ›Ô˘, fiÙ·Ó ÙÔ ÓÂÔÁÓfi ÌÔÚ› Ó· ·ÓÙȉڿÛÂÈ Ì ·ÓÔÈÁÔÎÏ›ÛÈÌÔ ÙˆÓ Ì·ÙÈÒÓ ‹ Í¿ÊÓÈ·ÛÌ· (12). ™Â ·Ô˘Û›· ·˘Ù‹˜ Ù˘ ·ÓÙ·fiÎÚÈÛ˘, ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜, fiˆ˜ ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο. ∏ ¯Ú‹ÛË ÙÔ˘ ÚÔÙ‡Ô˘ ÂͤٷÛ˘ Ù˘ ÔÌ¿‰·˜ Dubowitz (16) ÛÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜ Â›Ó·È ¯Ú‹ÛÈÌË Î·È Û¯ÂÙÈο ·Ï‹ ÁÈ· ‰È·‰Ô¯ÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÙˆÓ ÓÂÔÁÓÒÓ, ·ÎfiÌË Î·È ·fi ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÂÍÂÙ·ÛÙ¤˜. ∏ ÛÙ·ıÂÚ¿ ·Ó¢ÚÈÛÎfiÌÂÓË Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, ÂÊfiÛÔÓ Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÂÈÎfiÓ˜ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ Ù¯ÓÈΤ˜. ∏ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜ ıˆÚÂ›Ù·È ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Û¯ÂÙ›˙ÂÙ·È ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÈÎfiÓ˜ ‚Ï¿‚˘ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ Ù¯ÓÈΤ˜ Î·È Î˘Ú›ˆ˜ ÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ·Ó·Ï˘ÙÈο ηو٤ڈ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, Ê·›ÓÂÙ·È fiÙÈ Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÂÚ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙÔ˘ ÙÂÏÂÈfiÌËÓÔ˘ ‹ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÙÌ‹Ì· ÓÂÔÁ¤ÓÓËÙˆÓ ÌÔÚ› Ó· ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›·, Û ۯ¤ÛË ¿ÓÙÔÙ Ì ٷ Â˘Ú‹Ì·Ù· ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘ (·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ηو٤ڈ).
Paediatriki 2003;66:2-11
∞ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ÂÁÎÂÊ¿ÏÔ˘ ÀÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘ ∏ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÙÔ 1970 Î·È Î˘Ú›ˆ˜ Ë ¯Ú‹ÛË ÙˆÓ Ó¤ˆÓ ˘ÂÚ˯ÔÁÚ¿ÊˆÓ (sector scanners) ÙÔ 1980 η٤ÛÙËÛ·Ó ‰˘Ó·Ùfi ÙÔÓ Î·ıÔÚÈÛÌfi ÙfiÛÔ ÙÔ˘ Ù‡Ô˘ Î·È Ù˘ ı¤Û˘, fiÛÔ Î·È Ù˘ ›وÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ‚Ï·‚ÒÓ, Û ۯ¤ÛË ¿ÓÙÔÙ Ì ÙËÓ ËÏÈΛ· ·ËÛ˘. ∏ ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ ¤‰ˆÛ ڷÁÌ·ÙÈ΋ ÒıËÛË ÛÙË Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ, ‰ÈfiÙÈ Â›Ó·È Â‡ÎÔÏË, ·ÛÊ·Ï‹˜ Î·È ÊıËÓ‹ ̤ıÔ‰Ô˜, ÂÓÒ ÙÔ Ì˯¿ÓËÌ· Â›Ó·È ÊÔÚËÙfi Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ηٿÏÏËÏÔ ÁÈ· ¯Ú‹ÛË ÚÔ˘Ù›Ó·˜ ÛÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ªÂ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È Â‡ÎÔÏÔ Ó· ‰È·ÁÓˆÛÙ› fi¯È ÌfiÓÔ Ë ÂÚÈÎÔÈÏȷ΋-ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (¶∂∞), ·ÏÏ¿ Î·È Ë ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· (¶§), ÁÂÁÔÓfi˜ Ôχ ÛËÌ·ÓÙÈÎfi ·ÊÔ‡ Ë ÙÂÏÂ˘Ù·›· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¯ÂÈÚfiÙÂÚË ¤Î‚·ÛË. ŒÙÛÈ ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ‰Âȯı› fiÙÈ Ë ¶§ Û˘Ì‚·›ÓÂÈ Î˘Ú›ˆ˜ ÌÂٷ͇ 28 Î·È 32 ‚‰ÔÌ¿‰ˆÓ (25), ÂÓÒ Ë ˘ÔÊÏÔÈ҉˘ Ï¢ÎÔ̷ϷΛ· Â›Ó·È Û˘¯ÓfiÙÂÚË Û ÈÔ ÒÚÈÌ· ÓÂÔÁÓ¿. ™¯ÂÙÈο Ì ÙËÓ ¶∂∞, ÁÂÓÈο Â›Ó·È ·Ô‰ÂÎÙ‹ ÙÂÏÂ˘Ù·›· Ë Ù·ÍÈÓfiÌËÛË ÙÔ˘ Volpe (26) Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚÂȘ ‚·ıÌÔ‡˜ Î·È Í¯ˆÚÈÛÙ‹ ÂÚÈÁÚ·Ê‹ Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (¶›Ó·Î·˜ 1). º·›ÓÂÙ·È fiÙÈ Ë ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Ô˘ Û˘Óԉ‡ÂÈ ÂÙÂÚfiÏ¢ÚË ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· Û˘Ó‰¤ÂÙ·È, Û‹ÌÂÚ·, Ì ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ (26-28). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ·, Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙ‹ Ë Ù·ÍÈÓfiÌËÛË Ù˘ de Vries (29) (¶›Ó·Î·˜ 2). ∏ ¶∂∞ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ Ì ÙËÓ ¶§ Ô˘ Â›Ó·È Ì›· ηٿÛÙ·ÛË ·ÌÊÔÙÂÚfiÏ¢ÚË, ·Ó Î·È fi¯È ¿ÓÙÔÙÂ Û˘ÌÌÂÙÚÈ΋. ∏ ¶§ Û˘Ì‚·›ÓÂÈ Ì¤¯ÚÈ Î·È 11 ‚‰ÔÌ¿‰Â˜ ·fi ÙË Á¤ÓÓËÛË, ·ÎfiÌË Î·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë. ∂ÓÙÔ‡ÙÔȘ, ÔÈ ÌÂÙ·‚ÔϤ˜ Ù˘ ÂÚÈÎÔÈÏȷ΋˜ Ï¢΋˜ Ô˘Û›·˜ Û˘Ì‚·›ÓÔ˘Ó ·ÚÁfiÙÂÚ·. ∞˘ÍË̤ÓË ˘ÂÚ˯ÔÁ¤ÓÂÈ· Û ·˘Ù¤˜ ÙȘ ÂÚÈÔ¯¤˜ Â›Ó·È Û˘¯Ó‹ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜, Á›ÓÂÙ·È fï˜ ÂÓ‰ÂÈÎÙÈ΋ ¶§ ÌfiÓÔÓ fiÙ·Ó ÂÈ̤ÓÂÈ ÁÈ· ¿Óˆ ·fi 7-10 Ë̤Ú˜. OÈ Â·ÓÂÈÏËÌ̤Ó˜ ÂÍÂÙ¿ÛÂȘ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙȘ ÂfiÌÂÓ˜ 2-3 ‚‰ÔÌ¿‰Â˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰Â›ÍÔ˘Ó ÙËÓ ÂͤÏÈÍË Û ÏÈÁfiÙÂÚÔ ‹ ÂÚÈÛÛfiÙÂÚÔ ÂÎÙÂٷ̤Ó˜ ΢ÛÙÈΤ˜ ÌÂÙ·‚ÔϤ˜, οÔÈÔ˘ ‚·ıÌÔ‡ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‹ Î·È Î·Ì›· ÂÌÊ·Ó‹ ÌÂÙ·‚ÔÏ‹.
¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ÂÚÈÎÔÈÏȷ΋˜-ÂÓ‰ÔÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ µ·ıÌfi˜ 1. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ ¯ˆÚ›˜ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ‹ Ì ÌÈÎÚ‹ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· µ·ıÌfi˜ 2. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ + ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (10-50% Ù˘ Ï¿ÁÈ·˜ ÎÔÈÏ›·˜ Û ·Ú·Ô‚ÂÏÈ·›· ÙÔÌ‹) µ·ıÌfi˜ 3. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ + ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (>50% Ù˘ Ï¿ÁÈ·˜ ÎÔÈÏ›·˜ + ÔÍ›· ‰È¿Ù·ÛË) •Â¯ˆÚÈÛÙ‹ ÂÚÈÁÚ·Ê‹ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜
4
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·5
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
Paediatriki 2003;66:2-11
¶›Ó·Î·˜ 2. ∆·ÍÈÓfiÌËÛË ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ηٿ de Vries µ·ıÌfi˜ 1. µ·ıÌfi˜ 2. µ·ıÌfi˜ 3. µ·ıÌfi˜ 4.
¶·ÚÔ‰ÈΤ˜ ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÈ̤ÓÔ˘Û˜ ÁÈ· >7 Ë̤Ú˜ ¶ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÌÈÎÚ¤˜ ÂÓÙÔÈṲ̂Ó˜ ÌÂÙˆÔ‚ÚÂÁÌ·ÙÈΤ˜ ΢ÛÙÈΤ˜ ‚Ï¿‚˜ ¶ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÂÎÙÂٷ̤Ó˜ ÂÚÈÎÔÈÏȷΤ˜ ΢ÛÙÈΤ˜ ‚Ï¿‚˜ ÀÂÚ˯ÔÁ¤ÓÂȘ ÂÂÎÙÂÈÓfiÌÂÓ˜ ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ï¢΋ Ô˘Û›·, ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÂÎÙÂٷ̤Ó˜ ˘ÔÊÏÔÈÒ‰ÂȘ ΢ÛÙÈΤ˜ ‚Ï¿‚˜
∏ ·Ó·ÁÓÒÚÈÛË ÙˆÓ Î˘ÛÙÈÎÒÓ ‚Ï·‚ÒÓ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ ¯ÚfiÓÔ ÂͤٷÛ˘ Î·È ÙË ‰È·ÎÚÈÙÈ΋ ¢¯¤ÚÂÈ· ÙÔ˘ ˯ԂÔϤ·. ∂ÓÒ ÂÎÙÂٷ̤Ó˜ ‚Ï¿‚˜ Û˘Ó‹ıˆ˜ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Ì ÙË ¯Ú‹ÛË Ë¯Ô‚ÔϤ· 5 ª∏z, ÂÓÙÔÈṲ̂Ó˜ ·ÛÙÂȘ ··ÈÙÔ‡Ó Ë¯Ô‚ÔϤ· 7,5 MHz Î·È 10 MHz. ∏ ¢ÎÔÏ›· Ù˘ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ ‚Ï·‚ÒÓ ·˘ÙÒÓ Î·È Ù˘ ÂͤÏÈÍ‹˜ ÙÔ˘˜ ÂÈÙÚ¤ÂÈ ÙË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ù˘ ·Ú¯È΋˜ ÎÏÈÓÈ΋˜ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ Î·È Ù˘ ÂͤÏÈ͢ ÙˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ. ∂ÓÒ Ù· ÎÏÈÓÈο ÛËÌ›· ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È Ù˘ Ï¢ÎÔ̷ϷΛ·˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È Ôχ ‰È·ÊÔÚÂÙÈο, Û˘Ó‹ıˆ˜ ‰›ÓÔ˘Ó Ôχ ‰È·ÊÔÚÂÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë. ∏ ÂÈ̤ÓÔ˘Û·, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ˘ÔÙÔÓ›· (Ì ÌÂȈ̤ÓË fï˜ ÈÁÓ˘·Î‹ ÁˆÓ›·) Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ÂÚÈÎÔÈÏȷ΋-ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ¤¯ÂÈ Û˘Ó‹ıˆ˜ ηϋ ¤Î‚·ÛË. ∞ÓÙ›ıÂÙ·, Ô ·˘ÍË̤ÓÔ˜ ÙfiÓÔ˜ ÙˆÓ ÂÎÙÂÈÓfiÓÙˆÓ Ì˘ÒÓ, Ë Â˘ÂÚÂıÈÛÙfiÙËÙ· Î·È Ë ·ÓÒÌ·ÏË ı¤ÛË ÙˆÓ ‰·ÎÙ‡ÏˆÓ ÙˆÓ ¿Óˆ Î·È ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ ÙËÓ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· Â›Ó·È Û˘Ó‹ıˆ˜ ÚÔÁÓˆÛÙÈο η΋˜ ¤Î‚·Û˘ (30). ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂÍÂÙ¿ÛÂÈ ÙË Û˘Û¯¤ÙÈÛË ·Ó¿ÌÂÛ· ÛÙȘ ·ıÔÏÔÁÈΤ˜ ˘ÂÚ˯ÔÁÚ·ÊÈΤ˜ ÂÈÎfiÓ˜ Î·È ÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË. ªÈÎÚ‹ ‹ η̛· ‰È·ÊÔÚ¿ ¤¯ÂÈ ‚ÚÂı› ÛÙËÓ ¤Î‚·ÛË ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ¯ˆÚ›˜ ¶∂∞ ‹ Î·È Ì 1Ô˘ ‚·ıÌÔ‡ (¯ˆÚ›˜ ‰È¿Ù·ÛË ÎÔÈÏÈÒÓ) ·ÈÌÔÚÚ·Á›· (31). ¡ÂÔÁÓ¿ Ì ∏∫ ≤32 ‚‰ÔÌ¿‰ˆÓ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó ‰È¿Ù·ÛË ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÌÂÙ¿ ¶∂∞ Ì ‹ ¯ˆÚ›˜ ·ÚÂÁ¯˘Ì·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ÔÛÔÛÙfi 75% ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·È ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (32,33). O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ Ó¢ÚÔÏÔÁÈÎÒÓ Â·ÎfiÏÔ˘ıˆÓ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙË Û˘ÓÔ‰fi ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. µÚ¤ÊË Ô˘ ›¯·Ó ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· (ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ) ÌÔÚ› Ó· ¤¯Ô˘Ó ηϋ ¤Î‚·ÛË, ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ÓÔËÙÈ΋ ÂͤÏÈÍË (34). OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓٛϢÚË ËÌÈÏËÁ›· (22,34). ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ fiÙ·Ó ÔÈ ‚Ï¿‚˜ Â›Ó·È ÌÂÁ¿Ï˜ Î·È ÂÓÙÔ›˙ÔÓÙ·È Û ı¤ÛË ÚÔ˜ Ù· ›Ûˆ. ∏ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ÚÒÙÔ˘ ‚·ıÌÔ‡ ¶§
Â›Ó·È ÏÈÁfiÙÂÚÔ Â˘ÓÔ˚΋ ·fi Ù· ÓÂÔÁÓ¿ Ì ¶∂∞ 1Ô˘ Î·È 2Ô˘ ‚·ıÌÔ‡. ¶ÔÛÔÛÙfi ÂÚ›Ô˘ 10% ·Ó·Ù‡ÛÛÂÈ Û·ÛÙÈ΋ ‰ÈÏËÁ›· (35). O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ·˘Í¿ÓÂÈ ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ ‚·ıÌÔ‡˜ ¶§ ηٿ ÙËÓ de Vries. ∏ ı¤ÛË ÙˆÓ Î‡ÛÙÂˆÓ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Î·È Û˘Ó‹ıˆ˜ Ë ÂÓÙfiÈÛ‹ ÙÔ˘˜ ÛÙË ‚ÚÂÁÌ·ÙÔ˚Óȷ΋ ÂÚÈÎÔÈÏȷ΋ Ï¢΋ Ô˘Û›· Û˘Ó‰¤ÂÙ·È Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (‰ÈÏËÁ›·, ÙÂÙÚ·ÏËÁ›·) Ì ‹ ¯ˆÚ›˜ Ù‡ÊψÛË Î·È Û˘Ó‹ıˆ˜ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË (25,36-39). Ÿˆ˜ Â›Ó·È Ê·ÓÂÚfi, Ë ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶§ Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ·fi ÂΛÓË ÙˆÓ ÓÂÔÁÓÒÓ Ì ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ Ô˘ Û˘Óԉ‡ÂÈ ¶∂∞. ŒÙÛÈ, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÂÙ·È ‰È¿ÎÚÈÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ηٷÛÙ¿ÛÂˆÓ Ì ÙË ¯Ú‹ÛË Â·ÓÂÈÏËÌÌ¤ÓˆÓ ˘ÂÚ˯ÔÁÚ·ÊËÌ¿ÙˆÓ ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È (ÂÈÏÂÁ̤ӷ) Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ¤‰ˆÛ Ӥ· ÌÂÁ¿ÏË ÒıËÛË ÛÙË Ó¢ÚÔÏÔÁ›· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÙ›·˜. ∂›Ó·È ̤ıÔ‰Ô˜ ·ÎÚÈ‚‹, ··ÈÙ› ÌÂÙ·ÊÔÚ¿ Î·È ·Ú·ÌÔÓ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈ· ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÎÔÓÙ¿ ÛÙÔ Ì·ÁÓ‹ÙË, ¤¯ÂÈ fï˜ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Û ۯ¤ÛË Ì ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, fiÙÈ ÛÙÂÚÂ›Ù·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ù˘ ·ÎÙÈÓÔ‚ÔÏ›·˜. ∆ÂÏÂ˘Ù·›·, Ì ÙË ¯Ú‹ÛË ÓÂfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ ¤ÁÈÓ ‰˘Ó·Ù‹ Ë Ï‹„Ë ÂÈÎfiÓˆÓ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜, ·ÎfiÌË Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∏ ÈηÓfiÙËÙ· Ù˘ ·ÂÈÎfiÓÈÛ˘ Û ÙÔ̤˜ ÙÚÈÒÓ ÂȤ‰ˆÓ (ÛÙÂÊ·ÓÈ·›Â˜, Ô‚ÂÏÈ·›Â˜ Î·È ·ÍÔÓÈΤ˜) ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÛÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ÏÂÙÔÌÂÚÂÈÒÓ. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È Ë Î·Ï‡ÙÂÚË ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ·ÂÈÎfiÓÈÛ˘ Ù˘ ·Ó·ÙÔÌ›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È Ù˘ ÂͤÏÈ͢ Ù˘ Ì˘ÂϛӈÛ˘ in vivo. ŒÙÛÈ, ¤ÁÈÓ ‰˘Ó·Ù‹ Ë ÂÎÙ›ÌËÛË Ù˘ ›‰Ú·Û˘ ÙˆÓ ‰È·ÊfiÚˆÓ ‚Ï·‚ÒÓ ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÙË Ì˘ÂϛӈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (40,41). ∞˘Ùfi Ê·›ÓÂÙ·È Î·Ï¿ Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ ÙˆÓ Î˘ÛÙÈÎÒÓ ‚Ï·‚ÒÓ ‰È·ÊÔÚÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. º·›ÓÂÙ·È fiÙÈ ÔÈ Î‡ÛÙÂȘ Ô˘ ÚÔ·ÙÔ˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ Û˘Ó‹ıˆ˜ ηٷϋÁÔ˘Ó Û ‰È¿Ù·ÛË ÙˆÓ ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÁÏÔ›ˆÛË Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ Ì˘ÂϛӈÛ˘ ÛÙË ı¤ÛË ÙˆÓ Î‡ÛÙˆÓ. ∞ÓÙ›ıÂÙ·, ÛÙË ı¤ÛË ÙˆÓ ÔÚÂÁÎÂÊ·ÏÈÎÒÓ Î‡ÛÙÂˆÓ Ô˘ Â›Ó·È ‰Â˘ÙÂÚÔ·ı›˜
5
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·6
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ Ô˘ Û˘Óԉ‡ÂÈ ÂÚÈÎÔÈÏȷ΋ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›·, ·Ú·ÙËÚÂ›Ù·È “‰È¿ÛˆÛË” Ù˘ Ì˘ÂϛӈÛ˘. Œ¯Ô˘Ó Á›ÓÂÈ ·ÚÎÂÙ¤˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙË ¯Ú‹ÛË Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ˆ˜ ÚÔÁÓˆÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ¤Î‚·Û˘ (18,25,30,42-44). ŒÙÛÈ, ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ‰Âȯı› fiÙÈ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÔÈ ˘ÔÍÈΤ˜ ÈÛ¯·ÈÌÈΤ˜ ‚Ï¿‚˜ ÂÌÊ·Ó›˙Ô˘Ó ¤Ó· Ê¿ÛÌ· ‰È·ÊÔÚÂÙÈÎÒÓ ÂÈÎfiÓˆÓ, Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi ÂÈÎÚ¿ÙËÛË Ù˘ ‚Ï¿‚˘ ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· ̤¯ÚÈ ÙËÓ ÂÈÎÚ¿ÙËÛË Ù˘ ‚Ï¿‚˘ ÛÙË Ï¢΋ Ô˘Û›·. ¡ÂÔÁÓ¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë ÌÂÙ¿ ·fi Ô͇ ÂÚÈÁÂÓÓËÙÈÎfi Úfi‚ÏËÌ·, ÂΉËÏÒÓÔ˘Ó Î˘Ú›ˆ˜ ‚Ï¿‚Ë ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ·, ÂÓÒ ·˘Ù¿ Ô˘ ÂΉËÏÒÓÔ˘Ó ÙËÓ ›‰È· ÂÈÎfiÓ· ÌÂÙ¿ ·fi ›‰Ú·ÛË ÚÔÁÂÓÓËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, .¯. ·ÓÂÈÏËÌ̤ÓË ·ÈÌÔÚÚ·Á›· ‹ ÌÂȈ̤Ó˜ ÎÈÓ‹ÛÂȘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙Ô˘Ó ‚Ï¿‚Ë Ù˘ Ï¢΋˜ Ô˘Û›·˜. ∆· ÓÂÔÁÓ¿ Ì ‚Ï¿‚Ë ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚÔ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°), ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û·ÛÌÔ‡˜ ÌÂÙ¿ ·fi Ï›Á˜ Ë̤Ú˜ Ô˘ Â›Ó·È ·ÓıÂÎÙÈÎÔ› ÛÙËÓ ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÒ̷Ϙ ÎÈÓ‹ÛÂȘ ÙˆÓ ÔÊı·ÏÌÒÓ Î·È ‰˘ÛÎÔϛ˜ ÛÙÔ ıËÏ·ÛÌfi Î·È ÙËÓ Î·Ù¿ÔÛË. ∆· ÓÂÔÁÓ¿ ·˘Ù¿, ÌÂÙ¿ ·fi Ì›· ÌÈÎÚ‹ ÂÚ›Ô‰Ô ‡ÊÂÛ˘, ÂΉËÏÒÓÔ˘Ó ÂÈÎfiÓ· ‰˘ÛÙÔÓÈ΋˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÂÈÏË„›· (45). ™Ù· ÓÂÔÁÓ¿ Ì ‚Ï¿‚Ë Ù˘ Ï¢΋˜ Ô˘Û›·˜, ÙÔ ∏∂° Â›Ó·È ÏÈÁfiÙÂÚÔ ·Û˘Ó¯¤˜, ÔÈ Û·ÛÌÔ› ÂϤÁ¯ÔÓÙ·È Î·Ï‡ÙÂÚ·, ÂÓÒ Î·È Ù· ‰‡Ô (∏∂° Î·È Û·ÛÌÔ›) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚ÂÏÙ›ˆÛË. ∆· ÓÂÔÁÓ¿ ·˘Ù¿, ·Ú¿ ÙÔ fiÙÈ ·Ó·Ù‡ÛÛÔ˘Ó ÌÈÎÚÔÎÂÊ·Ï›·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì›· Ê˘ÛÈÔÏÔÁÈ΋ ·Ú¯Èο ÂÈÎfiÓ·. ™ËÌ›· ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Á›ÓÔÓÙ·È ÂÌÊ·Ó‹ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 46 ÌËÓÒÓ (45). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ Î·È ÙÔ ÚÒÈÌÔ ∏∂°, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Â›Ó·È Ôχ ‚ÔËıËÙÈο ÛÙËÓ ÚfiÁÓˆÛË ÁÈ· ÂΉ‹ÏˆÛË ËÌÈÏËÁ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÎfiÓ· ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘ (44,46). ª·ÁÓËÙÈ΋ Ê·ÛÌ·ÙÔÛÎÔ›· (Magnetic resonance spectroscopy) ∏ Ì·ÁÓËÙÈ΋ Ê·ÛÌ·ÙÔÛÎÔ›· Â›Ó·È Ì›· ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ‚ÈÔ¯ËÌ›·˜ ÙˆÓ ÈÛÙÒÓ Ì¤Ûˆ Ù˘ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ Ô˘ÛÈÒÓ ÛÙÔ˘˜ ÂÍÂÙ·˙fiÌÂÓÔ˘˜ ÈÛÙÔ‡˜. ∆ÂÏÂ˘Ù·›·, ÛÙȘ ÌÔÓ¿‰Â˜ Ô˘ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ Ù˘ ÌÂıfi‰Ô˘, ‰›ÓÂÙ·È ÌÂÁ¿ÏË ¤ÌÊ·ÛË ÒÛÙ ̤ۈ Ù˘ ¯Ú‹Û˘ Ù˘ Ó· ÂÎÙÈÌËı› Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ˆÚ›Ì·ÓÛ˘, ·ÏÏ¿ Î·È ÛÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰È·ÊfiÚˆÓ Û˘Ì‚·Ì¿ÙˆÓ Î·È Î˘Ú›ˆ˜
6
Paediatriki 2003;66:2-11
Ù˘ ·ÛÊ˘Í›·˜. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó ÛÙË Ê·ÛÌ·ÙÔÛÎÔ›· ÙÔ˘ ʈÛÊfiÚÔ˘ Î·È ÙÔ˘ ÚˆÙÔÓ›Ô˘. ªÂϤÙ˜ Û ÓÂÔÁÓ¿ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÏfiÁÔ˘ ʈÛÊÔÎÚ·ٛÓ˘ (Pcr) ÚÔ˜ ÙÔÓ ·ÓfiÚÁ·ÓÔ ÊˆÛÊfiÚÔ (Pi) ÌÂÙ¿ ·fi ·ÛÊ˘Í›·, Û ۯ¤ÛË Ì ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi Î·È ·˘Ùfi Û˘Óԉ‡ÂÙ·È Ì η΋ ¤Î‚·ÛË (47,48). OÈ ÌÂÙ·‚ÔϤ˜, fï˜, ·˘Ù¤˜ Ê·›ÓÔÓÙ·È ÌÂÙ¿ ÙȘ ÚÒÙ˜ 24 ÒÚ˜ ˙ˆ‹˜. ∞ÓÙ›ıÂÙ·, Ë Ê·ÛÌ·ÙÔÛÎÔ›· ÙÔ˘ ÚˆÙÔÓ›Ô˘ η٤ÛÙËÛ ‰˘Ó·Ù‹ ÙË Ï‹„Ë ÚˆÈÌfiÙÂÚˆÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ ÚÔ‰Èο˙Ô˘Ó Î·Î‹ ÚfiÁÓˆÛË. ∏ ·ÚÔ˘Û›· Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ (lactate) ÛÙÔ˘˜ ÈÛÙÔ‡˜ ÌÔÚ› Ó· ·ÓȯÓ¢ı› ·ÎfiÌË Î·È ÙȘ ÚÒÙ˜ 12-24 ÒÚ˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘¤ÛÙËÛ·Ó ·ÛÊ˘Í›·, ÁÂÁÔÓfi˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì η΋ ÚfiÁÓˆÛË (49-51). Doppler ÂÁÎÂÊ¿ÏÔ˘ ∏ ·ıÔÁ¤ÓÂÈ· ÔÏÏÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ ‚Ï·‚ÒÓ ÛÙÔ ÓÂÔÁÓÈÎfi ÂÁΤʷÏÔ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÂËÚ·Ṳ̂ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙ· ÂÁÎÂÊ·ÏÈο ·ÁÁ›·. ∞˘Ùfi ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· Î·È È‰È·ÈÙ¤Úˆ˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∏ ÚfiÛıÈ· ËÁ‹ ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ ¤¯ÂÈ ‰ÒÛÂÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ·, fi¯È ÌfiÓÔ ÛÙËÓ ·ÂÈÎfiÓÈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ÙË ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ, ·ÏÏ¿ Î·È ÛÙË Ì¤ÙÚËÛË Ù˘ Ù·¯‡ÙËÙ·˜ Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙȘ ÂÁÎÂÊ·ÏÈΤ˜ ·ÚÙËڛ˜ Ì ÙË ¯Ú‹ÛË Ù˘ Ù¯ÓÈ΋˜ Doppler. ªÂ ·˘Ù‹ ÙËÓ Ù¯ÓÈ΋ Á›ÓÂÙ·È Ì¤ÙÚËÛË Ù˘ Ù·¯‡ÙËÙ·˜ Î·È fi¯È Ù˘ ÚÔ‹˜, ηıÒ˜ Ë ‰È¿ÌÂÙÚÔ˜ ÙˆÓ ·ÁÁ›ˆÓ ‰ÂÓ ÌÔÚ› Ó· ÌÂÙÚËı› (ƒÔ‹ = Ù·¯‡ÙËÙ· x ÂÈÊ¿ÓÂÈ·). ™ÙȘ ÂÁÎÂÊ·ÏÈΤ˜ ·ÚÙËڛ˜, ÙÔ ‡„Ô˜ Ù˘ ̤ÁÈÛÙ˘ Û˘ÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ (Peak systolic velocity, PSV) Â›Ó·È ÂÚ›Ô˘ 3 ÊÔÚ¤˜ ÙÔ ‡„Ô˜ Ù˘ ÙÂÏԉȷÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ (End diastolic velocity, EDV). O ‰Â›ÎÙ˘ ÙÔ˘ Pourcelot (the resistance index of Pourcelot, PI) ˘ÔÏÔÁ›˙ÂÙ·È Ì ÙÔÓ ·ÎfiÏÔ˘ıÔ Ù‡Ô: PI =
PSV-EDV PSV
∆· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÙÔ˘ PI Î˘Ì·›ÓÔÓÙ·È ÌÂٷ͇ 0,65-0,90. ∆Ș ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜, Ù· Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfiÙÂÚË Ù·¯‡ÙËÙ· ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ·ÓÙ›ÛÙ·Û˘ ηٿ Pourcelot, Û ۯ¤ÛË Ì ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜. OÈ ÂӉ›ÍÂȘ ¯Ú‹Û˘ ÙÔ˘ Doppler ÛÙ· ÓÂÔÁ¤ÓÓËÙ· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·Ó·ÁÓÒÚÈÛË Ê˘ÛÈÔÏÔÁÈ΋˜ Î·È ÌË ·ÁÁÂȷ΋˜ ÚÔ‹˜ Û ·ÚÙËÚÈÔÊÏ‚ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÙËÓ ÙÔÈ΋ ‹ ÁÂÓÈÎÂ˘Ì¤ÓË Ì›ˆÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ÚÔ‹˜ Û ÂÁÎÂÊ·ÏÈο ¤ÌÊÚ·ÎÙ·, ÙËÓ “ÎÏÔ‹ ·›Ì·ÙÔ˜ ̤ۈ ÙÔ˘ ‚ÔÙ¿ÏÂÈÔ˘
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·7
¶·È‰È·ÙÚÈ΋ 2003;66:2-11
fiÚÔ˘” (Ì›ˆÛË Ù˘ ‰È·ÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ Ì ·ÎfiÏÔ˘ıË Î·Ù¿ÚÁËÛ‹ Ù˘ Î·È ÛÙÔ Ù¤ÏÔ˜ ·ÚÓËÙÈ΋ ‰È·ÛÙÔÏÈ΋ Ù·¯‡ÙËÙ· Ô˘ ·ÓÙ·Ó·ÎÏ¿ ÙË ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜ ·fi ÙËÓ ·ÔÚÙ‹ ÛÙËÓ Ó¢ÌÔÓÈ΋ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·ÛÙÔÏ‹˜) Î·È ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ (ηٿÚÁËÛË ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜) (52). ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ‰fiıËΠÌÂÁ¿ÏË ¤ÌÊ·ÛË ÛÙË ¯Ú‹ÛË ÙÔ˘ Doppler ÂÁÎÂÊ¿ÏÔ˘ Û ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. O Archer, ‹‰Ë ·fi ÙÔ 1986 (53), ¤‰ÂÈÍ fiÙÈ ¯·ÌËÏfi˜ ‰Â›ÎÙ˘ ·ÓÙ›ÛÙ·Û˘ ¤¯ÂÈ Â˘·ÈÛıËÛ›· 100% Î·È ÂȉÈÎfiÙËÙ· 81%, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË ÁÈ· ÊÙˆ¯‹ ¤Î‚·ÛË. O Levene (54), ÙÔ 1989, ¤‰ÂÈÍ fiÙÈ Ì›· ·ÓÒÌ·Ï· ·˘ÍË̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›· 93% Û ۇÁÎÚÈÛË Ì ÚÔÁÓˆÛÙÈ΋ ·Í›· 83% ÁÈ· ¯·ÌËÏfi ‰Â›ÎÙË ·ÓÙ›ÛÙ·Û˘. ∞˘Ù¤˜ ÔÈ ·ÏÏ·Á¤˜, ¿ÓÙˆ˜, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÓȯÓ¢ıÔ‡Ó ÌfiÓÔÓ ÌÂÙ¿ ÙȘ ÚÒÙ˜ 12-24 ÒÚ˜ Ù˘ ˙ˆ‹˜ ηÈ, ÂÔ̤ӈ˜, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈ̇ÛÔ˘Ó Û·Ó ÚÒÈÌÔÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÛÙȘ ÚÒÙ˜ 6 ÒÚ˜ Ù˘ ˙ˆ‹˜ (55). ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°) ∆Ô Û˘Ì‚·ÙÈÎfi ÔÏ˘Î¿Ó·ÏÔ (multichannel) ∏∂° Â›Ó·È ¤Ó· Ôχ ÛËÌ·ÓÙÈÎfi ÂÚÁ·ÏÂ›Ô ÛÙË Û˘ÓÔÏÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ. ∆Ô ∏∂° ‰ÂÓ ·ÔÙÂÏ› ÂͤٷÛË ÚÔ˘Ù›Ó·˜ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ™˘Ó‹ıˆ˜ Á›ÓÂÙ·È Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÌÂÙ¿ ·fi ·ÛÊ˘Í›· ‹ ÁÂÓÈο Û ۷ÛÌÔ‡˜, ÂÓÒ Á›ÓÂÙ·È Û¿ÓÈ· Û ÚfiˆÚ· ÓÂÔÁÓ¿ Î·È Î˘Ú›ˆ˜ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜. ∏ Ï‹„Ë ÂÓfi˜ Ù˘ÈÎÔ‡ ∏∂° Û ¤Ó· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚÔ ÓÂÔÁÓfi ÂÈ‚¿ÏÏÂÈ ·Ú·ÙÂٷ̤ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, ÂÓÒ Èı·Ófiٷٷ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È artifacts ̤ۈ ËÏÂÎÙÚÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ·fi ·ÚÎÂÙ¤˜ Û˘Û΢¤˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙȘ ÌÔÓ¿‰Â˜. ∂ÈϤÔÓ, Ë ÂÚÌËÓ›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È Ôχ ÈÔ ÔχÏÔÎË Û ۯ¤ÛË Ì ٷ ÙÂÏÂÈfiÌËÓ·, Ì ÌÂÁ¿Ï˜ ÌÂÙ·‚ÔϤ˜ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (background activity) Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË (56). ∏ ηٷÁÚ·Ê‹ ·fi ÔÏÏ·Ï¿ ËÏÂÎÙÚfi‰È· (4 ‹ 8 channels Ì ÙÔ Û‡ÛÙËÌ· Medilog) Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË Î·Ù·ÁÚ·Ê‹ Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚÔ‡Ó Ó· ·Ú¿Û¯Ô˘Ó ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙËÓ ÙÔÔÁÚ·ÊÈ΋ ηٷÓÔÌ‹ ÙˆÓ ·ÚÔ͢ÛÌÈÎÒÓ ÂÎÊÔÚÙ›ÛˆÓ, ÙȘ ·Û˘ÌÌÂÙڛ˜ ·Ó¿ÌÂÛ· ÛÙ· ËÌÈÛÊ·›ÚÈ· Î·È ÙȘ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ (57). ™Â ÔÏϤ˜ ÌÔÓ¿‰Â˜ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ ÊÔÚËÙÒÓ Û˘Û΢ÒÓ ∏∂° (Medilog System) ‹, ÈÔ ÚfiÛÊ·Ù·, ÌÈÎÚÒÓ Û˘ÛÙËÌ¿ÙˆÓ ‚·ÛÈÛÌ¤ÓˆÓ Û computer, Ù· ÔÔ›· ÂÈÙÚ¤Ô˘Ó ÙËÓ ·Ôı‹Î¢ÛË Û ‰ÈÛΤٷ ÙˆÓ Î·Ù·ÁÚ·ÊÒÓ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ¯ˆÚ›˜ Ó· ·ÚÂÌ‚·›ÓÔ˘Ó È‰È·›ÙÂÚ· ÛÙË
Paediatriki 2003;66:2-11
ÊÚÔÓÙ›‰· ÙˆÓ ÓÂÔÁÓÒÓ. À¿Ú¯ÂÈ, ›Û˘, Ë Ù¯ÓÈ΋ Cerebral Function Monitor (CFM, Lectromed), Ë ÔÔ›· ¤¯ÂÈ ·Ô‰Âȯı› ¯Ú‹ÛÈÌË ÛÙËÓ ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰· ÓÂÔÁÓÒÓ. ∏ ηٷÁÚ·Ê‹ Á›ÓÂÙ·È ÌfiÓÔ ·fi 2 ·ÌÊÈ‚ÚÂÁÌ·ÙÈο ËÏÂÎÙÚfi‰È·. ªÂ ÙÔ CFM ·Ú¤¯ÂÙ·È ¤Ó· Û˘Ì˘Îӈ̤ÓÔ, ÂÓÔÔÈË̤ÓÔ Û‹Ì· ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ‚·ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ì ÙË ¯Ú‹ÛË Ì›·˜ ÌÈÎÚ‹˜ Û˘Û΢‹˜ ‰›Ï· ÛÙË ıÂÚÌÔÎÔÈÙ›‰· ÙÔ˘ ÓÂÔÁÓÔ‡. OÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ë ·Ú·ÙÂٷ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Û·ÛÌÒÓ Â›Ó·È Ôχ ‡ÎÔÏÔ Ó· ‰È·ÈÛÙˆıÔ‡Ó ÛÙÔ CFM, ·ÎfiÌË Î·È ·fi ¿ÙÔÌ· Ì ÌÈÎÚ‹ ÂÌÂÈÚ›· ÛÙËÓ ·Ó¿ÁÓˆÛË Î·È ÂÚÌËÓ›· ÙÔ˘ Ù˘ÈÎÔ‡ ∏∂°. ŸÌˆ˜, ÔÈ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ Û·ÛÌÔ›, Ë ·ÚÔ‰È΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ηıÒ˜ Î·È Ë ·Û‡ÌÌÂÙÚË ‰Ú·ÛÙËÚÈfiÙËÙ· ÌÂٷ͇ ÙˆÓ 2 ËÌÈÛÊ·ÈÚ›ˆÓ ‰ÂÓ ·ÓȯÓ‡ÔÓÙ·È ÏfiÁˆ Ù˘ ¯Ú‹Û˘ 2 ÌfiÓÔ ËÏÂÎÙÚÔ‰›ˆÓ. ™Â Û˘ÁÎÂÎÚÈ̤ӷ ÙÌ‹Ì·Ù· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜ Ì ηϋ Û˘Û¯¤ÙÈÛË, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, Ì ÙÔ ÔÏ˘Î¿Ó·ÏÔ ∏∂° Ô˘ ÂÎÙÂÏÂ›Ù·È Ì ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙÔ ÙÌ‹Ì· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊËÌ¿ÙˆÓ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ. ™ÙȘ 27-28 ‚‰ÔÌ¿‰Â˜, Ë ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙÔ ∏∂° Â›Ó·È Î˘Ú›ˆ˜ ·Û˘Ó¯‹˜ (discontinu-ous), Ì ÁÚ‹ÁÔÚ˜ ÂÎÊÔÚÙ›ÛÂȘ (brief bursts) Ô˘ ‰È·ÎfiÙÔÓÙ·È ·fi Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ÂÚÈfi‰Ô˘˜ ¤ÏÏÂȄ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ªÂ ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ·ËÛ˘, ·˘Ù¤˜ ÔÈ ÂÚ›Ô‰ÔÈ ¤ÏÏÂȄ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÚÔԉ¢ÙÈο ÌÂÈÒÓÔÓÙ·È Û ‰È¿ÚÎÂÈ· Î·È ÛÙ· ÙÂÏÂÈfiÌËÓ· Ë ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È Î˘Ú›ˆ˜ Û˘Ó¯‹˜ (continuous). ∞Û˘Ó¯‹˜ ‰Ú·ÛÙËÚÈfiÙËÙ· ·Ú·ÙËÚÂ›Ù·È Ê˘ÛÈÔÏÔÁÈο ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ (58). ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ÙÂÏÂ˘Ù·›· ÂÈÎÂÓÙÚÒÓÔ˘Ó ÙÔ ÂӉȷʤÚÔÓ ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ¤Ó· “ÚÒÈÌÔ” ∏∂°, ‰ËÏ. fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ Û‡ÓÙÔÌ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË. OÈ Wertheim Î·È Û˘Ó (58), Ùo 1994, Ì ÙËÓ Î·Ù·ÁÚ·Ê‹ ∏∂° ÙȘ ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋-ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÚÒÈÌÔ ∏∂° ÌÔÚ› Ó· ‰ÒÛÂÈ ÚfiÁÓˆÛË Û ̷ÎÚÔÚfiıÂÛÌË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË. ∏ ÌÂϤÙË ·˘Ù‹ ¤‰ÂÈÍ fiÙÈ Ë Ê˘ÛÈÔÏÔÁÈ΋ ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, ÂÓÒ Ë ·Û‡ÌÌÂÙÚË Û˘Óԉ‡ÂÙ·È ·fi ËÌÈÏËÁ›·. ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ fiÔ˘ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË Î·Ù·ÛÙÔÏ‹ Ù˘ ‚·ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ‹ ÂÈÎfiÓ· status epilepticus, ˘¿Ú¯ÂÈ ÊÙˆ¯‹ ÚfiÁÓˆÛË. ÕÏϘ ÌÂϤÙ˜ (59-62) ¤‰ÂÈÍ·Ó ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÂÓÒ ·Ú¿ÏÏËÏ· Û˘Û¯¤ÙÈÛ·Ó ÙËÓ ‡·ÚÍË ÌË Ê˘ÛÈÔÏÔÁÈÎÒÓ Ú˘ıÌÒÓ ÛÙÔ ∏∂° Ì η΋ ¤Î‚·ÛË, ÂÓÒ ÙË ÁÚ‹ÁÔÚË Î·È Û·Ê‹ ‚ÂÏÙ›ˆÛË Û ‰È·‰Ô¯Èο
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¶·È‰È·ÙÚÈ΋ 2003;66:2-11
∏∂°, Ì ¢ÓÔ˚΋ ¤Î‚·ÛË. ∆ÂÏÂ˘Ù·›· ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ‰Â›¯ÓÔ˘Ó Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ ÚÒÈÌÔ˘ CFM ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (55,63,64) Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó CFM ̤۷ ÛÙȘ ÚÒÙ˜ 6 ÒÚ˜ Ù˘ ˙ˆ‹˜, ¤‰ÂÈÍ·Ó fiÙÈ ÛÙ·ıÂÚ¿ ·Û˘Ó¯¤˜ ‹ ¯·ÌËÏÔ‡ ‰˘Ó·ÌÈÎÔ‡ CFM Û˘Ó‰˘¿˙ÂÙ·È Ì η΋ ¤Î‚·ÛË, ÂÓÒ Ê˘ÛÈÔÏÔÁÈÎfi CFM Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·ÓÙÈÊ·ÙÈ΋. ª›· Û¯ÂÙÈο ÚfiÛÊ·ÙË ÌÂϤÙË (56) ¤‰ÂÈÍ fiÙÈ Ë ÂÈÌÔÓ‹ ·ÚÔ˘Û›·˜ ÛÙÔ ∏∂°, ÌÂÙ¿ ÙȘ 30-32 ‚‰ÔÌ¿‰Â˜, ÂÈÎfiÓ·˜ Ô˘ Ê˘ÛÈÔÏÔÁÈο ·Ú·ÙËÚÂ›Ù·È Û ∏∫ 28-30 ‚‰ÔÌ¿‰ˆÓ, Â›Ó·È ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÁÈ· η΋ ¤Î‚·ÛË. ∞˘Ùfi Èı·ÓÒ˜ ‰Â›¯ÓÂÈ fiÙÈ, ÂÎÙfi˜ ·fi ÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ˘¿Ú¯Ô˘Ó Î·È ¿ÏϘ ·Ú¿ÌÂÙÚÔÈ Ô˘ Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌÒÓÙ·È Î·Ù¿ ÙËÓ ÂÚÌËÓ›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ¢‡Ô Ôχ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (65,66) ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ CFM Â›Ó·È ÙÔ ›‰ÈÔ ·ÍÈfiÈÛÙÔ Ì ÙÔ ∏∂° fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔÁÓˆÛÙÈο ·Í›·. ∞˘Ùfi ηıÈÛÙ¿ ÙÔ CFM ÔχÙÈÌË Ù¯ÓÈ΋ ÛÙ· ¯¤ÚÈ· ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ. ¡Â˘ÚÔÊ˘ÛÈÔÏÔÁ›· ¶ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (∂voked potentials) ∆· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (ۈ̷ÙÔ·ÈÛıËÙÈο, ÔÙÈο Î·È ·ÎÔ˘ÛÙÈο) Â›Ó·È ËÏÂÎÙÚÈΤ˜ ··ÓÙ‹ÛÂȘ Û ·ÓÂÈÏËÌ̤ӷ Â͈ÙÂÚÈο ÂÚÂı›ÛÌ·Ù· Ô˘ ÌÔÚ› Ó· Â›Ó·È ÛˆÌ·ÙÔ·ÈÛıËÙÈο, ÔÙÈο ‹ ·ÎÔ˘ÛÙÈο. ∞ÔÙÂÏÔ‡Ó ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ÌÂıfi‰Ô˘˜ ÂÎÙ›ÌËÛ˘ Ù˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. Œ¯Ô˘Ó ÙÔ ÌÂÁ¿ÏÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ Â›Ó·È ÌË ÂÂÌ‚·ÙÈΤ˜ Î·È ÊıËÓ¤˜ ̤ıÔ‰ÔÈ, ·Ú¤¯Ô˘Ó Ì›· ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÛˆÌ·ÙÔ·ÈÛıËÙÈÎÒÓ, ·ÎÔ˘ÛÙÈÎÒÓ Î·È ÔÙÈÎÒÓ Ô‰ÒÓ, ¯ˆÚ›˜ ÙË Û˘ÓÂÚÁ·Û›· ÙÔ˘ ÓÂÔÁÓÔ‡. ∂ÓÙÔ‡ÙÔȘ, οÔȘ Â›Ó·È ¯ÚÔÓÔ‚fiÚ˜ Î·È Ì ‰˘ÛÎÔÏ›· ÛÙËÓ Î·Ù·ÁÚ·Ê‹, ÂÓÒ ÂÈϤÔÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ Ê˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ. ∆ÂÏÂ˘Ù·›·, Ë ‚ÂÏÙȈ̤ÓË ÌÂıÔ‰ÔÏÔÁ›· ¤¯ÂÈ ÂÈÙÚ¤„ÂÈ ÙË Û˘ÏÏÔÁ‹ ÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·fi ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. O Û˘Ó¯‹˜ ¤ÏÂÁ¯Ô˜ Ì ٷ ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ Î·È ÌË Ê˘ÛÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË ÙˆÓ ·ÈÛıËÙÈÎÒÓ Ô‰ÒÓ (sensory pathways). ∫¿ı ‰È·Ù·Ú·¯‹ Ô˘ ‰˘ÓËÙÈο ÂËÚ¿˙ÂÈ ÙȘ ·ÈÛıËÙÈΤ˜ Ô‰Ô‡˜, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÁÈ· ¯Ú‹ÛË ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ. ™ÙÂϯȷ›· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Auditory brainstem evoked responses) ∆· ÛÙÂϯȷ›· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο
8
Paediatriki 2003;66:2-11
Â›Ó·È È‰È·ÈÙ¤Úˆ˜ ¯Ú‹ÛÈÌ· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ ·ÒÏÂÈ·˜ ·ÎÔ‹˜ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, .¯. ÛÙ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿, ÙËÓ ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ÙȘ Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ∫¡™, ÙȘ ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÙË ÌËÓÈÁÁ›Ùȉ·, ÙËÓ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ÙÔ ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜. ∏ ηχÙÂÚË ËÏÈΛ· ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÎÔ‹˜ ÛÙ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È Ë ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë ‹ ÚÈÓ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÙÌ‹Ì·, ‰ÈfiÙÈ Ù· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÌÔÚ› Ó· Â›Ó·È ·ıÔÏÔÁÈο ÛÙ· ÚfiˆÚ· fiÙ·Ó Á›ÓÔÓÙ·È ÓˆÚ›˜ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ (ÚÈÓ ÙȘ 36 ‚‰ÔÌ¿‰Â˜), ÂÓÒ ·˘Ùfi Û˘Ó‹ıˆ˜ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û ϛÁ˜ ‚‰ÔÌ¿‰Â˜ (67). ∆· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ηÏfi Â›Ó·È Ó· ÂϤÁ¯ÔÓÙ·È ÚÈÓ ÙÔ˘˜ 3 Ì‹Ó˜, ‰ÈfiÙÈ ÌÂÙ¿ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ‰ÈÂÓÂÚÁËıÔ‡Ó ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÛÙË ‰È¿ÚÎÂÈ· Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡ÓÔ˘. ∆· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Â›Ó·È Ù· ÏÈÁfiÙÂÚÔ Î·Ù¿ÏÏËÏ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ΛӉ˘ÓÔ ÁÈ· ·Ó¿Ù˘ÍË Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ηı˘ÛÙ¤ÚËÛ˘ (68,69). OÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Visual evoked potentials, VEPs) £ÂˆÚÔ‡ÓÙ·È Â‡ÎÔÏ· ÛÙË ¯Ú‹ÛË ÙÔ˘˜ Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∂›Ó·È ¯Ú‹ÛÈÌ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ‹ ¯ˆÚ›˜ Úfi‚ÏËÌ· ÛÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÔÙÈÎÒÓ Ô‰ÒÓ. ™Â ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÂÚÈÎÔÈÏȷ΋ ΢ÛÙÈ΋ Ï¢ÎÔ̷ϷΛ·, ·ıÔÏÔÁÈο ÔÙÈο ‰˘Ó·ÌÈο ÚÔ‰Èο˙Ô˘Ó Î·Î‹ fiÚ·ÛË. ∂ÓÙÔ‡ÙÔȘ, ‰ÂÓ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ‰ÒÛÔ˘Ó ÚfiÁÓˆÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÒÙÂÚË ¤Î‚·ÛË (68). ™Ù· ÙÂÏÂÈfiÌËÓ· Á›ÓÔÓÙ·È Â˘¯ÂÚÒ˜ ·fi ÙË Á¤ÓÓËÛË Î·È ÌÂÙ¿. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ‰È·›ÛÙˆÛ·Ó fiÙÈ, ÂÎ ÙˆÓ ÙÚÈÒÓ, Ù· ÔÙÈο Î·È Ù· ۈ̷ÙÔ·ÈÛıËÙÈο Â›Ó·È ·ÍÈfiÈÛÙ·. ¢ÂÓ ÈÛ¯‡ÂÈ fï˜ ÙÔ ›‰ÈÔ Î·È ÁÈ· Ù· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (70-73). ™ˆÌ·ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Somatosensory evoked potentials, SEPs) ∂›Ó·È ¯ÚÔÓÔ‚fiÚ· ‰È·‰Èηۛ· (·fi ÙÔ Ì¤ÛÔ Î·È ÙÔ Ô›ÛıÈÔ ÎÓËÌÈ·›Ô Ó‡ÚÔ). £ÂˆÚÂ›Ù·È fiÙÈ ¤¯Ô˘Ó Ôχ ηϋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ·ÎfiÌË Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ (ȉȷ›ÙÂÚ· ·fi ÙÔ Ô›ÛıÈÔ ÎÓËÌÈ·›Ô Ó‡ÚÔ). ∞˘Ùfi ·Ô‰›‰ÂÙ·È Î·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÂÈÙÒÛÂȘ ÙˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ Ù· fi‰È· (.¯. ‰ÈÏËÁ›·) (74). ∞ÓÙ›ıÂÙ·, Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙÔ Ì¤ÛÔ Ó‡ÚÔ ‰ÂÓ Â›Ó·È ÙfiÛÔ ·ÍÈfiÈÛÙ· (75,76).
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™Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ù· Ê˘ÛÈÔÏÔÁÈο ۈ̷ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Û˘Ó‰˘¿˙ÔÓÙ·È Ì ηϋ ¤Î‚·ÛË, ÂÓÒ Ù· ·ıÔÏÔÁÈο Û˘Ó‰˘¿˙ÔÓÙ·È Ì η΋ (77). ™Ù· ›‰È· ÓÂÔÁÓ¿, ̤۷ ÛÙȘ 6 ÚÒÙ˜ ÒÚ˜ Ù˘ ˙ˆ‹˜, ÌÔÚÔ‡Ó (fiˆ˜ Î·È Ù· ÔÙÈο ‰˘Ó·ÌÈο) Ó· ‰ÒÛÔ˘Ó ·ÍÈfiÈÛÙË ÚfiÁÓˆÛË ÁÈ· η΋ ¤Î‚·ÛË (7173). ™ÙȘ 72 ÒÚ˜, Ë ÂȉÈÎfiÙËÙ· ·˘Í¿ÓÂÙ·È ÛÙÔ 93%. ªË Ê˘ÛÈÔÏÔÁÈο ·Ú¯Èο ۈ̷ÙÔ·ÈÛıËÙÈο ‰˘Ó·ÌÈο Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÔÓÙ·È, ‰ÈfiÙÈ fiÙ·Ó ÔÌ·ÏÔÔÈÔ‡ÓÙ·È Ì¤Û· ÛÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜, Â›Ó·È ·ÎfiÌË Èı·Ó‹ Ë Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË. §fiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó‡ÚÂÛ˘ Ó¢ÚÔÚÔÛٷ٢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ¤¯ÂÈ Ôχ ÌÂÁ¿ÏË ÛËÌ·Û›· Ë ·Ó·ÁÓÒÚÈÛË ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· η΋ ¤Î‚·ÛË, ‰ÈfiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› Ú¤ÂÈ Ó· ¯ÔÚËÁËıÔ‡Ó Ì¤Û· ÛÙȘ 6 ÚÒÙ˜ ÒÚ˜ Ù˘ ˙ˆ‹˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ·fi fiϘ ÙȘ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÙÔ ∏∂°, ÙÔ CFM Î·È Ù· SEPs ·Ú¤¯Ô˘Ó ÙȘ ϤÔÓ ·ÍÈfiÈÛÙ˜ ÏËÚÔÊÔڛ˜ Á‡Úˆ ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÔÚ›· Ù˘ ˘ÔÍÈ΋˜ ÈÛ¯·ÈÌÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Î·È Ù˘ ·ÎfiÏÔ˘ı˘ Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ÂͤÏÈ͢.
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Prognostic value of brainstem auditory evoked potentials in neonates. Arch Neurol 1983;40:360-365. Beverley DW, Smith IS, Beesley P, Jones J, Rhodes N. Relationship of cranial ultrasonography, visual and auditory evoked responses with neurodevelopmental outcome. Dev Med Child Neurol 1990;32:210-222. Guinard C, Fawer CL, Despland PA, Calame A. Auditory brainstem responses and ultrasound changes in a high-risk infants population. Helv Paediatr Acta 1989;43:377-388. de Vries LS, Eken P, Pierrat V, Daniels H, Casaer P. Prediction of neurodevelopmental outcome in the preterm infant: short latency cortical somatosensory evoked potentials compared with cranial ultrasound. Arch Dis Child 1992;67:1177-1181. Taylor MJ, Murphy WJ, Whyte HE. Prognostic reliability of somatosensory and visual evoked potentials of asphyxiated term infants. Dev Med Child Neurol 1992;34:507-515. Majnemer A, Rosenblatt B. Evoked potentials as predictors of outcome in neonatal intensive care unit survivors: review of the literature. Pediatr Neurol 1996;14:189-195. Scalais E, Francois-Adant A, Nuttin C, Bachy A, Guerit JM. Multimodality evoked potentials as a prognostic tool in term asphyxiated newborns. Electroencephalogr Clin Neurophysiol 1998;108:199-207. White CP, Cooke RW. Somatosensory evoked potentials following posterior tibial nerve stimulation predict later motor outcome. Dev Med Child Neurol 1994;36:34-40. Pierrat V, Eken P, Duquennoy C, Rousseau S, de Vries LS. Prognostic value of early SEP in neonates with cystic leukomalacia. Dev Med Child Neurol 1993;35:683-690. Ekert PG, Taylor MJ, Keenan NK, Boulton JE, Whyte HE. Early somatosensory evoked potentials in preterm infants: their prognostic utility. Biol Neonate 1997;71:83-91. de Vries LS, Pierrat V, Eken P, Minami T, Daniels H, Casaer P. Prognostic value of early somatosensory evoked potentials for adverse outcome in full-term infants with birth asphyxia. Brain Dev 1991;13:320-325.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-07-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 22-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª.¡. ¶··‰ËÌËÙÚ›Ô˘ ∞ÚÁÔÓ·˘ÙÒÓ 50, ∆.∫. 151 25, ª·ÚÔ‡ÛÈ
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∞¡∞™∫O¶∏™∏
Paediatriki 2003;66:12-19
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O ÚfiÏÔ˜ ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙË ‚ÚÂÊÈ΋ ‰È·ÙÚÔÊ‹ ª. ª·˘ÚfiΈÛÙ·, π. ÷ڈӛÙË, ∂. ∫fiÎÔÚË
Polyunsaturated fatty acids in infant nutrition M. Mavrocosta, I. Charoniti, E. Kokori
¶ÂÚ›ÏË„Ë: ∆· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (LC-PUFAs), ΢ڛˆ˜ ÙÔ ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (DHA) Î·È ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ (AA) Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ·ÓıÚÒÈÓÔ, ·ÏÏ¿ fi¯È ÛÙÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο Û˘ÛÙ·ÙÈο ÛÙÔȯ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÈÛ¯˘Ú¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ηıÒ˜ Î·È ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs ¤Ó·ÓÙÈ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜, Û¯ÂÙÈο Ì ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ‰È·ÓÔËÙÈ΋˜ Î·È ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜. ∆· Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ó·Ï˘ıÔ‡Ó, ÏfiÁˆ ÙˆÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÔÙÈ΋˜ Î·È ‰È·ÓÔËÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÛÙ· ·È‰È¿. ¶¿ÓÙˆ˜, ÔÈ Ì¤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs ÛÙËÓ ·Ó¿Ù˘ÍË, ȉȷ›ÙÂÚ· ÙˆÓ ÚfiˆÚˆÓ ‚ÚÂÊÒÓ. º˘ÛÈο ‰ÂÓ ÏÂ›Ô˘Ó Î·È ÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Û¯ÂÙÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· ÙˆÓ LC-PUFAs. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ¤¯ÂÈ Û¯¤ÛË Ì ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Û ÌÂÙÚ‹ÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ Ù˘ ˙ˆ‹˜ ‹ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÔÍÂȉˆÙÈΤ˜ ‚Ï¿‚˜. O ÚfiÏÔ˜ ÙˆÓ LC-PUFAs ÛÙËÓ ÂÌ‚Ú˘˚΋ Î·È ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·ÎfiÌË ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ȉ·ÓÈ΋˜ ·Ó·ÏÔÁ›·˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜. °È· ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜.
Abstract: LC-PUFAs, especially DHA and AA, are contained in breast milk but not in infant formulas. They are important components of the brain and retina. Many studies have demonstrated advantages of breastfeeding and of the supplemented with LCPUFAs milk versus the unsupplemented formulas on subsequent cognitive and visual function. The long term effects of the supplementation with LC-PUFAs can not be evaluated properly, because of the difficulty in assessing the visual and the cognitive function in children. Most of the studies however, demonstrate significant advantages of LC-PUFAs supplementation in infant growth, especially in premature infants. There are several concerns regarding the safety of LC-PUFAs supplements. The supplementation with LC-PUFAs may be related to reduced weight gain during the first year of life or increased risk for oxidant damage. The role of LCPUFAs in fetal and infant growth is not completely clarified; moreover there is no reliable method to evaluate the optimal proportions of DHA and AA to be taken. More studies are required so as to ascertain the role and the ideal intake of LC-PUFAs in infants’ diet.
§¤ÍÂȘ ÎÏÂȉȿ: ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘, ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇, ·Ú·¯È‰ÔÓÈÎfi Ô͇, ÏÈÓÔÏÂ˚Îfi Ô͇, ·-ÏÈÓÔÏÂÓÈÎfi Ô͇, ˆ-3 ÏÈ·Ú¿ Ôͤ·, ˆ6 ÏÈ·Ú¿ Ôͤ·.
Key words: long chain polyunsaturated fatty acids, linoleic acid, a-linolenic acid, docosahexaenoid acid, n-3 fatty acids, n-6 fatty acids.
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘
1st Pediatric Clinic, Venizelion Hospital of Heraklion, Crete
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™˘ÓÙÔÌÔÁڷʛ˜ LC-PUFAs LA ALA AA DHA §O ∫¡™
¶ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ §ÈÓÔÏÂ˚Îfi Ô͇ ·-ÏÈÓÔÏÂÓÈÎfi Ô͇ ∞Ú·¯È‰ÔÓÈÎfi Ô͇ ¡ÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ §È·Ú¿ Ôͤ· ∫ÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·
∂ÈÛ·ÁˆÁ‹ ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÚ¢ÓËÙÒÓ ¤¯ÂÈ ÂÛÙÈ·ÛÙ› ÛÙËÓ ÚÔÛı‹ÎË LC-PUFAs ÙˆÓ ÔÌ¿‰ˆÓ ˆ-3 Î·È ˆ-6 ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ·ÁÂÏ¿‰·˜. ∏ ·ÚÔ˘Û›· ÙˆÓ LC-PUFAs ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È fi¯È ÛÙ· ÙÚÔÔÔÈË̤ӷ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ Û Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·, ¤¯ÂÈ Û˘ÁÎÂÓÙÚÒÛÂÈ ÙËÓ ÚÔÛÔ¯‹ ÛÙË ÛËÌ·Û›· ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÔÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ∫¡™. °È· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi, Ù· ÏÈ›‰È· ·ÔÙÂÏÔ‡Ó ‚·ÛÈ΋ ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ Î·È Î‡ÚÈ· ‰ÔÌÈο Û˘ÛÙ·ÙÈο ÙˆÓ ÈÛÙÒÓ. ∆· ÏÈ·Ú¿ Ôͤ· ·ÔÙÂÏÔ‡ÓÙ·È ·fi ·ÓıÚ·ÎÈΤ˜ ·Ï˘Û›‰Â˜, Ù· ¿ÎÚ· ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ Â›Ó·È ¯ËÌÈÎÒ˜ fiÌÔÈ· ÌÂٷ͇ ÙÔ˘˜. ™ÙÔ ¤Ó· ¿ÎÚÔ Û˘Ó‰¤ÂÙ·È Ì›· ηڂÔ͢ÏÈ΋ ÔÌ¿‰· (-COOH), ÂÓÒ ÛÙÔ ¿ÏÏÔ ¿ÎÚÔ ¤Ó· ÌÂı‡ÏÈÔ (-CH3). ∆Ô ÙÂÏÂ˘Ù·›Ô ÔÓÔÌ¿˙ÂÙ·È ˆ¿ÎÚÔ. ¶ÔÏ˘·ÎfiÚÂÛÙ· ÔÓÔÌ¿˙ÔÓÙ·È ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ‰‡Ô ¤ˆ˜ ¤ÍÈ ‰ÈÏÔ‡˜ ‰ÂÛÌÔ‡˜. ∞Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚÒÙÔ˘ ‰ÈÏÔ‡ ‰ÂÛÌÔ‡ ˆ˜ ÚÔ˜ ÙÔ ˆ-¿ÎÚÔ, ‰È·ÎÚ›ÓÔÓÙ·È ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ÔÌ¿‰Â˜: ˆ-3, ˆ-6, ˆ9 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·. ª·ÎÚ¿˜ ·Ï‡ÛÔ˘ ϤÁÔÓÙ·È Ù· ÏÈ·Ú¿ Ôͤ· Ô˘ ¤¯Ô˘Ó ¿Ï˘ÛÔ Ì ¿Óˆ ·fi 18 ¿ÙÔÌ· ¿Óıڷη. ∆Ô ÏÈÓÔÏÂ˚Îfi (LA) (∂ÈÎfiÓ· 1) Î·È ÙÔ ·-ÏÈÓÔÏÂÓÈÎfi (ALA) (∂ÈÎfiÓ· 2) ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ·, ÁÈ·Ù› ‰ÂÓ Û˘ÓÙ›ıÂÓÙ·È ·fi ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi Î·È Ú¤ÂÈ
Paediatriki 2003;66:12-19
Ó· Ï·Ì‚¿ÓÔÓÙ·È ·fi ÙȘ ÙÚÔʤ˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÙÚ·Ô‡Ó Ì ̛· ÛÂÈÚ¿ ·ÓÙȉڿÛÂˆÓ Û ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘. ™˘ÓÂÒ˜, Ë Û‡ÓıÂÛË ÙˆÓ LCPUFAs ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ Úfi‰ÚÔÌˆÓ ÂÓÒÛÂˆÓ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∂›Û˘, Ë ·Ó·ÏÔÁ›· ÙÔ˘ ÏÈÓÔÏÂ˚ÎÔ‡ ÚÔ˜ ÙÔ ·-ÏÈÓÔÏÂÓÈÎfi Ô͇ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô ÁÈ· ÙËÓ ÈÛÔÚÚÔ›· ÙˆÓ LC-PUFAs ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∆· LC-PUFAs ·ÔÙÂÏÔ‡Ó ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· ÙÔÓ ÔÚÁ·ÓÈÛÌfi Î·È Úfi‰ÚÔ̘ ÂÓÒÛÂȘ ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ (ÚÔÛÙ·ÁÏ·Ó‰›Ó˜, ÚÔÛÙ·Î˘ÎϛӘ, ıÚÔÌ‚ÔÍ¿Ó˜ Î·È Ï¢ÎÔÙÚȤÓ˜). ∂ÈϤÔÓ, Ù· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎfi ‰ÔÌÈÎfi ÛÙÔÈ¯Â›Ô ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ, fiÔ˘ ˘¿Ú¯Ô˘Ó ΢ڛˆ˜ Û ÌÔÚÊ‹ ʈÛÊÔÏÈȉ›ˆÓ. ∂ȉÈÎfiÙÂÚ·, Ù· ʈÛÊÔÏÈ›‰È· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ·ÌÊÈ‚ÏÈÛÙÚÔÂȉԇ˜ ¯ÈÙÒÓ· Â›Ó·È È‰È·›ÙÂÚ· ÏÔ‡ÛÈ· Û ‰‡Ô LC-PUFAs, ÛÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ (AA, ˆ-6 ÔÏ˘·ÎfiÚÂÛÙÔ ÏÈ·Úfi Ô͇ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘) (∂ÈÎfiÓ· 3) Î·È ÛÙÔ ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (DHA, ˆ-3 ÔÏ˘·ÎfiÚÂÛÙÔ ÏÈ·Úfi Ô͇ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘) (∂ÈÎfiÓ· 4). ™ÙÔ˘˜ ÈÛÙÔ‡˜ ·˘ÙÔ‡˜, ÙÔ LA Î·È ∞LA ÂÚȤ¯ÔÓÙ·È Û ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜. ∆Ô DHA Â›Ó·È ÙÔ Î‡ÚÈÔ ˆ-3 ÏÈ·Úfi Ô͇ ÙÔ˘ Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ·ÔÙÂÏ› ÙÔ 40% ÙˆÓ ÔÏÈÎÒÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏÈÛÙÚÔÂȉԇ˜. ∆Ô ∞∞ Â›Ó·È ÙÔ Î‡ÚÈÔ ˆ-6 ÏÈ·Úfi Ô͇ ÙÔ˘ Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ·ÔÙÂÏ› Úfi‰ÚÔÌË ¤ÓˆÛË ÁÈ· ÙË Û‡ÓıÂÛË ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, Ï¢ÎÔÙÚÈÂÓ›ˆÓ Î·È ¿ÏÏˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ (1). ∆Ô ∞∞ ÌÔÚ› ‡ÎÔÏ· Ó· Û˘ÓÙÂı› ·fi LA. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ Û˘¯ÓfiÙÂÚ· ··ÓÙÒÌÂÓÔ LC-PUFA Ù˘ ‰È·ÙÚÔÊ‹˜. ∏ Û‡ÓıÂÛË ÙÔ˘ DHA ·fi ÙÔ ∞LA Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÈÔ ÂÚ›ÏÔΘ ·Ó·‚ÔÏÈΤ˜ ‰ÈÂÚÁ·Û›Â˜, Ë ·Ô‰ÔÙÈÎfiÙËÙ· ÙˆÓ ÔÔ›ˆÓ Â›Ó·È Ì¿ÏÏÔÓ ÌÂȈ̤ÓË Î·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ (2,3).
CH3-CH2-CH2-CH2-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-CH2-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 1. §ÈÓÔÏÂ˚Îfi Ô͇ (C 18:2 ˆ-6).
CH3-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-CH2-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 2. ·-§ÈÓÔÏÂÓÈÎfi Ô͇ (C 18:3 ˆ-3).
CH3-CH2-CH2-CH2-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 3. ∞Ú·¯È‰ÔÓÈÎfi Ô͇ (C 20:4 ˆ-6). CH3-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-COOH ∂ÈÎfiÓ· 4. ¡ÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (C 22:6 ˆ-3).
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¶·È‰È·ÙÚÈ΋ 2003;66:12-19
ª¤¯ÚÈ Û‹ÌÂÚ·, Ù· ÂÚÈÛÛfiÙÂÚ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·, Û ·ÓÙ›ıÂÛË Ì ÙÔ ÌËÙÚÈÎfi Á¿Ï·, ÂÚÈ›¯·Ó ÌfiÓÔ Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ·. ™‹ÌÂÚ·, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ LC-PUFAs ÛÙÔ Ï¿ÛÌ·, ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ ÂÚ˘ıÚÒÓ Î·È ÛÙÔ ÊÏÔÈfi ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÌÂȈ̤Ó˜ ÛÙ· ·È‰È¿ Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ¯ˆÚ›˜ ÚÔÛı‹ÎË LC-PUFAs, Û ۯ¤ÛË Ì ·˘Ù¤˜ Ô˘ ··ÓÙÒÓÙ·È ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ‹ ÛÙ· ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ÛÙ· ÔÔ›· ¤¯Ô˘Ó ÚÔÛÙÂı› LC-PUFAs (4). ∞Ó Î·È ÌÂϤÙ˜ Ì ÛÙ·ıÂÚ¿ ÈÛfiÙÔ· ‰Â›¯ÓÔ˘Ó fiÙÈ ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÙÚ¤„Ô˘Ó LA Û AA Î·È ALA Û DHA, Ù· ÂÓ˙˘ÌÈο Û˘ÛÙ‹Ì·Ù· (·ÔηڂÔÍ˘Ï¿ÛË Î·È ÚÔÛıÂÙ¿ÛË) Ô˘ ÌÂÙ·ÙÚ¤Ô˘Ó Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ· (§O) ÏÈÓÔÏÂ˚Îfi Î·È ÏÈÓÔÏÂÓÈÎfi Û LCPUFAs Â›Ó·È Ì¿ÏÏÔÓ ·Ó·Ú΋ ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ (5,6). ¢ÂÓ Â›Ó·È ÂȂ‚·ÈˆÌ¤ÓÔ ·Ó Ë Û¯ÂÙÈ΋ ·Ó¿ÚÎÂÈ· ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ÛÙ· ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ‚Ú¤ÊË, Û ̛· ÎÚ›ÛÈÌË ËÏÈΛ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÏÂÈÙÔ˘ÚÁÈΤ˜ Û˘Ó¤ÂȘ. ™˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ¤Ó·ÓÙÈ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· LCPUFAs, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰ÒÛÔ˘Ó ·ÎÚÈ‚¤˜ ·ÔÙ¤ÏÂÛÌ·, ÁÈ·Ù› ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÎÙfi˜ ÙˆÓ LC-PUFAs Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÔÙÈÎÔ‡ ÊÏÔÈÔ‡ Î·È ÙÔ˘ ∫¡™. ŒÙÛÈ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û˘ÁÎÚ›ÓÔ˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ‰È·ÙÚÔÊ‹˜ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Ì ‹ ¯ˆÚ›˜ ÙËÓ ÚÔÛı‹ÎË LC-PUFAs. ŸÏ˜ ÔÈ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙÔ ÂÚȯfiÌÂÓÔ ÙˆÓ §O ÛÙÔ Ï¿ÛÌ· ¤¯Ô˘Ó ‰Â›ÍÂÈ ˘„ËÏfiÙÂÚ· ›‰· LC-PUFAs ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË (7). ªÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË Û˘ÁΤÓÙÚˆÛË §O ÛÙÔ Ï¿ÛÌ· Î·È ÛÙ· ÏÈ›‰È· ÂÚ˘ıÚÒÓ Û ·È‰È¿ ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï·, Ì ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË LCPUFAs, ¤‰ÂÈÍ·Ó fiÙÈ Ù· ›‰¿ ÙÔ˘˜ Â›Ó·È ·ÓÙ›ÛÙÔȯ· Ù˘ ‰È·ÈÙËÙÈ΋˜ ÚfiÛÏ˄˘. ¶ÚÔÛı‹ÎË ÌfiÓÔ DHA ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘„ËÏfiÙÂÚ· ›‰· DHA ÛÙ· ÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÙˆÓ ÂÚ˘ıÚÒÓ Î·È Û˘Ó‹ıˆ˜ ¯·ÌËÏfiÙÂÚ· ›‰· ∞∞ Î·È ¿ÏÏˆÓ ˆ6 ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (8). ∏ ÚÔÛı‹ÎË AA Î·È DHA Ì·˙› ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘„ËÏ¿ ›‰· Î·È ÙˆÓ ‰‡Ô §O ÛÙÔ Ï¿ÛÌ·. ¶ËÁ¤˜ ÏÈ·ÚÒÓ ÔͤˆÓ ∆· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ LA, ∞LA, AA Î·È DHA ¤¯Ô˘Ó ȉȷ›ÙÂÚË ‰È·ÙÚÔÊÈ΋ ÛËÌ·Û›· ÁÈ· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi. ª›· ·ÚÈ· ËÁ‹ ÏÈ·ÚÒÓ ÔͤˆÓ Â›Ó·È ÙÔ È¯ı˘¤Ï·ÈÔ Ô˘ ÂÚȤ¯ÂÈ ÌÂÁ¿Ï· ÔÛ¿ ˆ-3, ·ÏÏ¿ ÂÏ¿¯ÈÛÙ· ÔÛ¿ ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘. ∆Ô LA Ô˘ ‚Ú›ÛÎÂÙ·È Î˘Ú›ˆ˜ Û ¤Ï·È·
14
Paediatriki 2003;66:12-19
Ï·¯·ÓÈÎÒÓ Î·È ¿ÏÏ· ÙÚfiÊÈÌ·, ıˆÚÂ›Ù·È ÙÔ ‚·ÛÈÎfi ··Ú·›ÙËÙÔ ÏÈ·Úfi Ô͇. ∆Ô ∞LA Î·È ÙÔ DHA ›ӷÈ, ›Û˘, ··Ú·›ÙËÙ·. ∆· ˆ-3 ÏÈ·Ú¿ Ôͤ· ˘¿Ú¯Ô˘Ó Û ‰È¿ÊÔÚ· ÙÚfiÊÈÌ·, fiˆ˜ ÛÙÔ ¤Ï·ÈÔ ÛfiÁÈ·˜, ÙÔ ÁÔÁÁ‡ÏÈ Î·È Ù· Ú¿ÛÈÓ· Ï·¯·ÓÈο. ∆Ô DHA ‚Ú›ÛÎÂÙ·È Î˘Ú›ˆ˜ ÛÙÔÓ ÎÚfiÎÔ ÙÔ˘ ·˘ÁÔ‡, ÛÙ· ÛÙÚ›‰È· Î·È Ù· „¿ÚÈ·. ∆· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ÌÔÚÔ‡Ó Ó· ÂÌÏÔ˘ÙÈÛÙÔ‡Ó Ì LC-PUFAs ·fi ȯı˘¤Ï·ÈÔ, ¤Ï·È· ·fi ÎÚfiÎÔ ·˘ÁÔ‡ ‹ ¤Ï·È· ·ÔÌÔӈ̤ӷ ·fi ÚÔ˚fiÓÙ· ˙‡ÌˆÛ˘ ÌÔÓÔ΢ÙÙ¿ÚÈˆÓ ÔÚÁ·ÓÈÛÌÒÓ (9). LC-PUFAs Î·È ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ∆· LC-PUFAs ‚Ú›ÛÎÔÓÙ·È ÛÙÔ Á¿Ï· fiÏˆÓ ÙˆÓ ıËÏ·˙Ô˘ÛÒÓ Á˘Ó·ÈÎÒÓ, ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ· Î·È Ù· DHA, ALA, ηıÒ˜ Î·È ¿ÏÏ· LCPUFAs (10). ∆Ô 50% Ù˘ ÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÚÔÛʤÚÂÙ·È ÛÙÔ ‚Ú¤ÊÔ˜ Ì ÙË ÌÔÚÊ‹ ÏÈȉ›ˆÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ÏÈ·Ú¿ Ôͤ· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· ÙÚÈÁÏ˘ÎÂÚ›‰È· (98-99%), ÂÓÒ ¤Ó· ÌÈÎÚfi ÔÛfi ˘¿Ú¯ÂÈ ÛÙ· ʈÛÊÔÏÈ›‰È·, ÌÔÓÔÁÏ˘ÎÂÚ›‰È· Î·È ‰ÈÁÏ˘ÎÂÚ›‰È·. ∆Ô ÔÏÈÎfi ÂÚȯfiÌÂÓÔ ÏÈȉ›ˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ Û˘Ó‹ıˆ˜ ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Á‡̷ÙÔ˜ Î·È Ì ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∂ËÚ¿˙ÂÙ·È, ›Û˘, ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ ÛÙË Á¤ÓÓËÛË, ÙȘ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔÓ ËÌÂÚ‹ÛÈÔ Ú˘ıÌfi (11,12). ∏ Û‡ÓıÂÛË ÙÔ˘ Ï›Ô˘˜ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂËÚ¿˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÙȘ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Ù˘ ÌËÙ¤Ú·˜. ŒÙÛÈ, fiÙ·Ó ÛÙȘ ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ¯ÔÚËÁËı› DHA, Ù· ›‰¿ ÙÔ˘ ÛÙÔ Á¿Ï· ·˘Í¿ÓÔÓÙ·È Ì ‰ÔÛÔÂÍ·ÚÙÒÌÂÓÔ Ú˘ıÌfi (13). µÚ¤ÊË Ù· ÔÔ›· Ï¿Ì‚·Ó·Ó DHA ̤ۈ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ›¯·Ó ˘„ËÏfiÙÂÚ· ›‰· ·˘ÙÔ‡ ÙÔ˘ ÌÔÚ›Ô˘ ÛÙȘ ‚·ÛÈΤ˜ ‰Ô̤˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (14). ∆· ˘„ËÏfiÙÂÚ· ›‰· LC-PUFAs (AA, DHA) ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ ‡·Ú Î·È ÌÂÙ¿ ·fi ¤Ó· Ì‹Ó· Í·ÊÓÈο ÌÂÈÒÓÔÓÙ·È, Û ›‰· Ô˘ ‰È·ÙËÚÔ‡ÓÙ·È Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ‚ÚÂÊÈ΋˜ ÂÚÈfi‰Ô˘. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó Û¯Â‰fiÓ ÛÙ·ıÂÚ¤˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ∞∞ Î·È D∏∞ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·, Û ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 12 ÌËÓÒÓ Ù˘ ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡. ∂Ô̤ӈ˜, LC-PUFAs ¯ÔÚËÁÔ‡ÓÙ·È ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË Î·È Î·Ù¿ ÙÔÓ ·Ú·ÙÂٷ̤ÓÔ ıËÏ·ÛÌfi. ∆Ô ·fiÏ˘ÙÔ ÂÚȯfiÌÂÓÔ ·Ó¿ dl ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚfi ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 12 ÌËÓÒÓ. ∏ ʇÛË ÙˆÓ ¯ËÌÈÎÒÓ ÂÓÒÛÂˆÓ ÛÙȘ Ôԛ˜ ÂÚȤ¯ÔÓÙ·È Ù· LC-PUFAs Î·È Î¿ÔȘ Ú˘ıÌÈÛÙÈΤ˜ ‰È·‰Èηۛ˜ ÛÙÔÓ Ì·˙ÈÎfi ·‰¤Ó·, ÌÔÚÔ‡Ó Ó· ÂÍËÁ‹ÛÔ˘Ó ·˘Ùfi ÙÔ ÚÔÊ·ÓÒ˜ ·Ú¿‰ÔÍÔ Ê·ÈÓfiÌÂÓÔ (12,15,16). LC-PUFAs Î·È ÚÔˆÚfiÙËÙ· Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ë ÈÔ ÁÚ‹ÁÔÚË ·‡ÍËÛË AA Î·È DHA ÛÙÔÓ ÂÁΤʷÏÔ Û˘Ì‚·›ÓÂÈ ÛÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, fiÙ·Ó Ù· LC-PUFAs
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·15
¶·È‰È·ÙÚÈ΋ 2003;66:12-19
·Ú¤¯ÔÓÙ·È ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ·. ∞fi ÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ ̤¯ÚÈ ÙÔ ‰Â‡ÙÂÚÔ ¤ÙÔ˜, Ô ÂÁΤʷÏÔ˜ ·˘Í¿ÓÂÙ·È Ì ÙË ÌÂÁ·Ï‡ÙÂÚ‹ ÙÔ˘ Ù·¯‡ÙËÙ· Î·È ÊÙ¿ÓÂÈ ÙÔ 70% ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘ ÂÓËÏ›ÎÔ˘. ∞ÔÙÂÏÂ›Ù·È Î˘Ú›ˆ˜ ·fi ‰ÔÌÈο ʈÛÊÔÏÈ›‰È· Î·È ÓÂÚfi. ∆· ʈÛÊÔÏÈ›‰È· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Â›Ó·È ÌÔÓ·‰Èο, ‰ÈfiÙÈ ¤¯Ô˘Ó Ì›· ·Û˘Ó‹ıÈÛÙ· ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË LCPUFAs, ΢ڛˆ˜ ∞∞ Î·È DHA, Ù· ÔÔ›· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ∫·Ù¿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹, Ù· ÏÈ·Ú¿ Ôͤ· ·Ú¤¯ÔÓÙ·È Ì¤Ûˆ ‰È·Ï·ÎÔ˘ÓÙȷ΋˜ ÌÂÙ·ÊÔÚ¿˜. ªÂÙ¿ ·fi ¤Ó· ÚfiˆÚÔ ÙÔÎÂÙfi, Ë ÌÂÙ·ÊÔÚ¿ ÏÈ·ÚÒÓ ÔͤˆÓ ‰È·ÎfiÙÂÙ·È, ÌÂÈÒÓÔÓÙ·˜ ¤ÙÛÈ ÙË Û˘ÁΤÓÙÚˆÛË ∞∞ Î·È DHA (17-19). Èڛ˜ Ì›· ‰È·ÈÙËÙÈ΋ ËÁ‹, Ù· ‚Ú¤ÊË Ú¤ÂÈ Ó· Û˘Óı¤ÙÔ˘Ó ÌÂÁ¿Ï· ÔÛ¿ DHA Î·È ∞∞ ÁÈ· Ó· ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ŒÙÛÈ, Ù· ÚfiˆÚ· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Â˘¿ÏˆÙ· Û ·Ó¿ÚÎÂÈ· DHA (20-22). ªÂÙ¿ ÙË Á¤ÓÓËÛË, ÙÔ ÌËÙÚÈÎfi Á¿Ï· ·Ú¤¯ÂÈ ÈηÓÔÔÈËÙÈο ÔÛ¿ ∞∞ Î·È DHA, Û ·ÓÙ›ıÂÛË Ì ٷ ÂÚÈÛÛfiÙÂÚ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ¶ÚfiˆÚ· ‚Ú¤ÊË Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·, fiÙ·Ó ÂÍÂÙ¿ÛÙËÎ·Ó Â›¯·Ó ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ηٿ ÙËÓ ËÏÈΛ· ÙˆÓ 7,5-8 ÂÙÒÓ, Û˘ÁÎÚÈÙÈο Ì ÚfiˆÚ· Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· (23). ªÂÙ¿ ÙËÓ ÚÔÛı‹ÎË LC-PUFAs ÛÙ· Á¿Ï·Ù· ÚfiˆÚˆÓ ‚ÚÂÊÒÓ, Ù· ‚Ú¤ÊË ¤‰ÂÈÍ·Ó ‚ÂÏÙȈ̤Ó˜ ·ÈÛıËÙËÚȷΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ (·ÓÙ·fiÎÚÈÛË ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ÛÙÔ Êˆ˜, ÔÙÈ΋ Ô͇ÙËÙ·), ÔÙÈ΋ ÚÔÛÔ¯‹ Î·È ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ Û ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜. ∂Âȉ‹ Ù· ÚfiˆÚ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ LC-PUFAs ÛÙË Á¤ÓÓËÛË ·’ fiÙÈ Ù· ÙÂÏÂÈfiÌËÓ·, ÌÔÚ› Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó‹ Ù· ÔʤÏË ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ LC-PUFAs ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (24). ŒÙÛÈ, ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÔÈ ··ÈÙ‹ÛÂȘ Û DHA Ú¤ÂÈ ÈηÓÔÔÈÔ‡ÓÙ·È, ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÂÙ·È Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÊÏÔÈÔ‡ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ™‹ÌÂÚ·, ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ÛÙÔȯ›· Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÙÔ AA Î·È ÙÔ DHA Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ó¿Ù˘Í˘. ™˘ÁÎÂÓÙÚÒÛÂȘ ∞∞ ÛÙÔ ·›Ì· Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ‚ÚÂÊÒÓ. ∂›Û˘, Ë ÛËÌ·Û›· ÙÔ˘ DHA ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂȉÈÎfiÙÂÚ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È Ï¤ÔÓ ÙÂÎÌËÚȈ̤ÓË (25). Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Û¯ÂÙ›˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ÙËÓ ÚfiÛÏË„Ë ··Ú·›ÙËÙˆÓ §O ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË, ·Ú¿ Ì ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (19,25,26). ∏ ¢ÂÚÁÂÙÈ΋ ‰Ú¿ÛË ÙˆÓ ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, ÙfiÛÔ ÛÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ fiÛÔ Î·È ÛÙȘ ÂÎ˙ÂÌ·ÙÔÂȉ›˜ ‰ÂÚÌ·Ù›Ùȉ˜ ÙˆÓ ‚ÚÂÊÒÓ, ¤¯ÂÈ ·Ú·-
Paediatriki 2003;66:12-19
ÙËÚËı› Â‰Ò Î·È ·ÚÎÂÙ¿ ¯ÚfiÓÈ·. º·›ÓÂÙ·È fiÙÈ Ë ¯ÔÚ‹ÁËÛË ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÚÔ¿ÁÂÈ ÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË Î·È ·ÚÂÌÔ‰›˙ÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ‚ÚÂÊÈÎÔ‡ ÂÎ˙¤Ì·ÙÔ˜ (27,28). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ¯·ÌËÏ‹ ÚfiÛÏË„Ë ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ηÈ, Û˘ÓÂÒ˜, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ (29). ŒÙÛÈ, ÁÈ· Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë ‚¤ÏÙÈÛÙË ÂÌ‚Ú˘˚΋ Î·È ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË, ÔÈ ¤ÁÎ˘Â˜ Î·È ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â·ÚΛ˜ ÔÛfiÙËÙ˜ ÙÚÔÊÒÓ ÏÔ‡ÛÈˆÓ Û LC-PUFAs ÛÙË ‰›·ÈÙ¿ ÙÔ˘˜, fiˆ˜ „¿ÚÈ Î·È ·˘Áfi, ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È·Ï·ÎÔ˘ÓÙȷ΋˜ ÌÂÙ·ÊÔÚ¿˜ ·˘ÙÒÓ ÙˆÓ §O Î·È ÁÈ· ÙËÓ ·‡ÍËÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘˜ ÛÙÔ Á¿Ï·. ∆· ‚ÚÂÊÈο Á¿Ï·Ù· Î·È ÂȉÈο ·˘Ù¿ Ô˘ ·Â˘ı‡ÓÔÓÙ·È Û ‚Ú¤ÊË Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Ú¤ÂÈ Ó· Â›Ó·È ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ·Ú΋ ÔÛ¿ LC-PUFAs, ÒÛÙ ӷ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙȘ ·Ó¿ÁΘ ÙˆÓ Ù·¯¤ˆ˜ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ ‚ÚÂÊÒÓ (9,30). LC-PUFAs Î·È ÔÙÈ΋ Ô͇ÙËÙ· ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÌÂÌ‚Ú¿Ó˜ ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ÛÙÔÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ ¤¯Ô˘Ó ÙȘ ˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ DHA ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi. ∆· ·ÙÙ·Ú· ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ˆÚÈÌ¿˙Ô˘Ó Ù·¯‡Ù·Ù· ÛÙÔ 3Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ Î·È ÛÙÔ˘˜ ÚÒÙÔ˘˜ 4-6 Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ‰È·ÈÙËÙÈ΋ ¿ÚÎÂÈ· DHA Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó Á›ÓÂÈ Û ‚Ú¤ÊË ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ıËÏ·ÛÌÔ‡ ‹ Ù˘ ÚÔÛı‹Î˘ LC-PUFAs ÛÙËÓ ÔÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (31-34). ∏ ÚÔÛı‹ÎË DHA ÛÙË ‰›·ÈÙ· ·Ú¿ÁÂÈ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, Ô˘ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó¤˜ ÛÙ· ÚfiˆÚ· ·Ú¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ª›· ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ÚfiˆÚ· ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Ì Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ȯı˘¤Ï·ÈÔ, ¤‰ÂÈÍ ‰È·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÛÙÔ˘˜ 2 Î·È ÛÙÔ˘˜ 4 Ì‹Ó˜ ˙ˆ‹˜ ÛÙ· ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÚÔÛı‹ÎË LC-PUFAs. ŸÌˆ˜, ÛÙȘ ËÏÈ˘ ÙˆÓ 6,5, 9 Î·È 12 ÌËÓÒÓ ‰ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (32). ªÔÚ› Ó· Â›Ó·È ‰˘ÛÎÔÏfiÙÂÚÔ Ó· ‚ÚÂıÔ‡Ó ‰È·ÊÔÚ¤˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘, ÁÈ·Ù› Ë ÔÙÈ΋ Ô͇ÙËÙ· ·ÏÏ¿˙ÂÈ Ù·¯‡Ù·Ù· ÙÔ˘˜ ÚÒÙÔ˘˜ ¤ÍÈ Ì‹Ó˜ Î·È ÌÂÙ¿ ÛÙ·ıÂÚÔÔÈ›ٷÈ. ™Â ¿ÏϘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË DHA, ·Ú·ÙËÚ‹ıËΠ˘„ËÏfiÙÂÚË ÔÙÈ΋ Ô͇ÙËÙ· Û ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ·ÎfiÏÔ˘ı˜ ËÏÈ˘: 1, 5, 2, 4, 7 Î·È 12 ÌËÓÒÓ (24,35). ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ Ù˘ ÂÌÏÔ˘ÙÈṲ̂Ó˘ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜ ηÈ
15
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·16
¶·È‰È·ÙÚÈ΋ 2003;66:12-19
·˘Ù‹ ¤Ó·ÓÙÈ Ù˘ ÌË ÂÌÏÔ˘ÙÈṲ̂Ó˘ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜, Û ÌÂÙÚ‹ÛÂȘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ (36-39). ª›· ÌÂÙ·-·Ó¿Ï˘ÛË Ô˘ Û˘ÁÎÚ›ÓÂÈ ÌËÙÚÈÎfi Á¿Ï·, ÎÔÈÓfi ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì LC-PUFAs ‰Â›¯ÓÂÈ ÏÂÔÓ¤ÎÙËÌ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‹ Ù˘ ÂÌÏÔ˘ÙÈṲ̂Ó˘ ‰È·ÙÚÔÊ‹˜ Û ÌÂÙÚ‹ÛÂȘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ Û ËÏÈΛ· 2 ÌËÓÒÓ Î·È Û ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂÙÚ‹ÛÂȘ Û ËÏÈΛ· 4 ÌËÓÒÓ. ¶¿ÓÙˆ˜, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û›ÙÈÛ˘ Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÙÂÎÌËÚȈ̤ӷ, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË. ™Ù· ÚfiˆÚ· ‚Ú¤ÊË, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ˘„ËÏfiÙÂÚË ÔÙÈ΋ Ô͇ÙËÙ· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‰È·ÈÙËÙÈÎÒÓ LC-PUFAs. ∆Ô ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Ô˘ ·Ú·ÙËÚÂ›Ù·È Î˘Ú›ˆ˜ ÛÙ· ÚfiˆÚ· ‚Ú¤ÊË, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙÔÓ Ù·¯‡ÙÂÚÔ ‚·ıÌfi ˆÚ›Ì·ÓÛ˘ ÙÔ˘ ÔÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÁÂÁÔÓfi˜ Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙ÂÈ ÙËÓ ÔÛfiÙËÙ· Î·È ÙËÓ ÔÈfiÙËÙ· ÙˆÓ ÚÒÈÌˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∂›Û˘, Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÌÔÚ› Ó· ÂËÚ¿˙ÂÈ ¿ÏÏÔ˘˜ ÙÔÌ›˜ Ù˘ ÔÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È fi¯È ÌfiÓÔ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· (40). LC-PUFAs Î·È ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ ªÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ‹ ¯ˆÚ›˜ ÂÌÏÔ˘ÙÈṲ̂ÓË ‰È·ÙÚÔÊ‹ Î·È Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ηٷϋÁÔ˘Ó Û οÔÈÔ ÔÚÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ª›· ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÔÈ Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ Û ‚Ú¤ÊË Ô˘ ‰È·ÙÚ¤ÊÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓË Ì LC-PUFAs Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ ‹Ù·Ó ıÂÙÈΤ˜ Û ËÏÈΛ· 4 ÌËÓÒÓ, ÂÓÒ ‰ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÛÙÔ˘˜ 12 Î·È 24 Ì‹Ó˜ ˙ˆ‹˜. Œ¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ·ÍÈÔÏfiÁËÛ˘ Ù˘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ Û ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË. ª›· ÌÂÙ·-·Ó¿Ï˘ÛË Û˘ÁÎÚ›ÓÂÈ ‚Ú¤ÊË Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‹ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È ÂÍÂÙ¿ÛÙËÎ·Ó Û ËÏÈ˘ 6-23 ÌËÓÒÓ, ·ÏÏ¿ Î·È ÛÔÚ·‰Èο ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· ̤¯ÚÈ 10-15 ÂÙÒÓ, Ì ‰ÔÎÈ̷ۛ˜ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘. ∆Ô ›‰ÈÔ ÙÂÛÙ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ÎÔÈÓfi ̤ÙÚÔ Û‡ÁÎÚÈÛ˘ ·fi fiϘ ÙȘ ÌÂϤÙ˜ Ô˘ ‹Ú·Ó ̤ÚÔ˜ ÛÙË ÌÂÙ·-·Ó¿Ï˘ÛË. ™Ù· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ·Ú·ÙËÚ‹ıËÎ·Ó ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÈ Ôԛ˜ Û˘Ó¯›ÛÙËÎ·Ó Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. Ÿˆ˜ Î·È Ì ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, ·Ú·ÙËÚ‹ıËΠÌÂÁ·Ï‡ÙÂÚÔ ÏÂÔÓ¤ÎÙËÌ· ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÌËÙÚÈÎfi Á¿Ï·, Û ۇÁÎÚÈÛË Ì ٷ ÙÂÏÂÈfiÌËÓ·. ∂›Û˘, ·Ú·ÙËÚ‹ıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ‰È¿Ú-
16
Paediatriki 2003;66:12-19
ÎÂÈ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ù˘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜, ÂÓÒ ‰ÂÓ ˘‹ÚÍ·Ó ·ÍÈfiÏÔÁ˜ ‰È·ÊÔÚ¤˜ Û ‚Ú¤ÊË fiÔ˘ Ë ‰È¿ÚÎÂÈ· ıËÏ·ÛÌÔ‡ ‹Ù·Ó 4-7 ‚‰ÔÌ¿‰Â˜. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÚÌËÓ¢ÙÔ‡Ó Â·ÎÚÈ‚Ò˜, ΢ڛˆ˜ ÏfiÁˆ Ù˘ ‡·Ú͢ Â͈ÁÂÓÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚ› Ó· Ù· ÂËÚ¿ÛÔ˘Ó, fiˆ˜ .¯. ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ, Ô ‰Â›ÎÙ˘ ÓÔËÌÔÛ‡Ó˘ ÙˆÓ ÁÔÓ¤ˆÓ, ÔÈ Û¯¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ηٿÛÙ·ÛË Ù˘ ÌËÙ¤Ú·˜ Î·È ¿ÏÏ· (41-44). ÕÏÏË ÌÂϤÙË Ô˘ Û‡ÁÎÚÈÓ ‚Ú¤ÊË ÛÈÙÈ˙fiÌÂÓ· Ì ‹ ¯ˆÚ›˜ ÂÌÏÔ˘ÙÈṲ̂ÓË ‰È·ÙÚÔÊ‹ Ì LC-PUFAs, ¤‰ÂÈÍ fiÙÈ ÔÈ Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ Û ·È‰È¿ Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· ‹Ù·Ó ıÂÙÈΤ˜ Û ËÏÈΛ· 4 ÌËÓÒÓ, ÂÓÒ ‰ÂÓ ˘‹Ú¯Â ÂÌÊ·Ó‹˜ ‰È·ÊÔÚ¿ ÛÙÔ˘˜ 12 Î·È 24 Ì‹Ó˜ ˙ˆ‹˜. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó ÌË ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È·ÓÔËÙÈ΋ Î·È „˘¯ÔÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ‚ÚÂÊÒÓ (40,45). ∏ ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË, Ô˘ ÂÎÙÈÌ‹ıËΠÛÙÔ˘˜ 10 Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ̤ۈ Ù˘ ÈηÓfiÙËÙ·˜ Â›Ï˘Û˘ οÔÈÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ (ÂÎÙ¤ÏÂÛË ÛÂÈÚ¿˜ ‚ËÌ¿ÙˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÈÙ¢¯ı› οÔÈÔ˜ ÛÙfi¯Ô˜), Ê¿ÓËΠӷ ˘ÂÚ¤¯ÂÈ Û ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Ì LC-PUFAs Á¿Ï·Ù· ·fi ÙË Á¤ÓÓËÛË Î·È ÁÈ· Ù¤ÛÛÂÚȘ Û˘Ó¯›˜ Ì‹Ó˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈÎfi, ÁÈ·Ù› ·˘ÍË̤Ó˜ ÂȉfiÛÂȘ Û ٤ÙÔÈÔ˘ ›‰Ô˘˜ ÈηÓfiÙËÙ· Â›Ï˘Û˘ ÚÔ‚ÏËÌ¿ÙˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶ÈÛÙ‡ÂÙ·È, ·ÎfiÌË, fiÙÈ Ù· LCPUFAs ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ıÂÙÈο Î·È ÙËÓ Ù·¯‡ÙËÙ· ÂÂÍÂÚÁ·Û›·˜ ÏËÚÔÊÔÚÈÒÓ, ηıÒ˜ Î·È ÙȘ ‰È·‰Èηۛ˜ ÂϤÁ¯Ô˘ Ù˘ ÚÔÛÔ¯‹˜. ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ Ù· ÔʤÏË Ù˘ Û›ÙÈÛ˘ Ì LC-PUFAs ÂÈ̤ÓÔ˘Ó ¤Ú· ·fi ÙËÓ ÂÚ›Ô‰Ô Î·Ù¿ ÙËÓ ÔÔ›· Ù· ‚Ú¤ÊË ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï·. ¶¿ÓÙˆ˜, ÚÔ˜ ÙÔ ·ÚfiÓ, ·Ó Î·È ·Ó·Ê¤ÚÔÓÙ·È ·ÚÎÂÙ¿ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· Ô˘ Ó· ÙÂÎÌËÚÈÒÓÔ˘Ó Ù· Ì·ÎÚÔÚfiıÂÛÌ· ÔʤÏË Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs Û¯ÂÙÈο Ì ÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ (46,47). ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ì Á¿Ï·Ù· ÂÌÏÔ˘ÙÈṲ̂ӷ Ì LC-PUFAs ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó ¤Ï·È· „·ÚÈÒÓ Ô˘ ÂÚȤ¯Ô˘Ó DHA Î·È ¿ÏÏ· ˆ-3 §O. ™Â Ì›· ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜, fiÔ˘ ¯ÔÚËÁ‹ıËÎ·Ó ÌfiÓÔ ˆ-3 ÏÈ·Ú¿ Ôͤ·, ÚfiˆÚ· ‚Ú¤ÊË ˙‡ÁÈ˙·Ó ÏÈÁfiÙÂÚÔ ‹ ›¯·Ó ÌÈÎÚfiÙÂÚÔ ‚¿ÚÔ˜ Û ۯ¤ÛË Ì ÙÔ ‡„Ô˜ Û ‰È¿ÊÔÚ˜ ÂÚÈfi‰Ô˘˜ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, ·fi fi,ÙÈ ‚Ú¤ÊË ÛÈÙÈ˙fiÌÂÓ· Ì ·Ï¿, ÌË ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù·. ™Â ¿ÏϘ ÌÂϤÙ˜ Ì ¯ÔÚ‹ÁËÛË LC-PUFAs
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·17
¶·È‰È·ÙÚÈ΋ 2003;66:12-19
·fi ȯı˘¤Ï·È· ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ‰È·ÊÔÚ¿. ∂›Û˘, ÙÔ ‚¿ÚÔ˜ ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ∞∞ ÛÙ· ʈÛÊÔÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (fiÛÔ ÌÂÁ·Ï‡ÙÂÚ· Â›Ó·È Ù· ÔÛ¿ ÙÔ˘ ∞A, ÙfiÛÔ ˘„ËÏfiÙÂÚÔ Â›Ó·È ÙÔ ‚¿ÚÔ˜ ÛÙÔ˘˜ 12 Ì‹Ó˜ ˙ˆ‹˜) (48). ¶¤Ú· ·fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ ȯı˘¤Ï·ÈÔ˘ Î·È ÙˆÓ ˆ-3 §O ÛÙËÓ ·Ó¿Ù˘ÍË, ÂÏ¿¯ÈÛÙ˜ Û˘Ó¤ÂȘ Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs ¤¯Ô˘Ó ·Ó·ÊÂÚı›. ŸÌˆ˜, ·ÚÎÂÙÔ› ıˆÚËÙÈÎÔ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ¤¯Ô˘Ó ÚÔ·„ÂÈ Û¯ÂÙÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· ÙˆÓ LC-PUFAs. ŒÓ·˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ·ÊÔÚ¿ ÛÙÔ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÔÏ˘·ÎfiÚÂÛÙˆÓ ÂÏ·›ˆÓ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë, ÁÈ·Ù› ÔÈ ÌÂÌ‚Ú¿Ó˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÎfiÚÂÛÙˆÓ §O Á›ÓÔÓÙ·È ÈÔ Â˘¿ÏˆÙ˜ Û ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë. ŒÙÛÈ, Ë ¯ÔÚ‹ÁËÛË LC-PUFAs ÌÔÚ› Ó· ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ÓfiÛÔ˘˜ ÓÂÔÁÓÒÓ Û¯ÂÙÈΤ˜ Ì ÔÍÂȉˆÙÈΤ˜ ‚Ï¿‚˜ ÌÂÌ‚Ú·ÓÒÓ, fiˆ˜ Â›Ó·È Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, Ë ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ ÙˆÓ ÓÂÔÁÓÒÓ, Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜. ∂›Û˘, ¯ÔÚ‹ÁËÛË ¯ˆÚ›˜ ηÏfi ÈÛÔ˙‡ÁÈÔ ÌÂٷ͇ ˆ-3 Î·È ˆ-6 LC-PUFAs ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·ÏÏÔ›ˆÛË ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÂÈÎÔÛ·ÓÔÂȉÒÓ. ŒÓ· ·ÎfiÌË ·ÚÓËÙÈÎfi ÛËÌÂ›Ô Â›Ó·È Ë Èı·Ó‹ ‰Ú¿ÛË ÙˆÓ ÂȉÈÎÒÓ LC-PUFAs ÛÙË ÌÂÙ·ÁÚ·Ê‹ ‰È·ÊfiÚˆÓ ÁÔÓȉ›ˆÓ (1). ŸÏÔÈ ÔÈ ·Ú·¿Óˆ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ‚ÈÔÏÔÁÈΤ˜ ‰Ú¿ÛÂȘ ÙˆÓ §O. ŸÌˆ˜, Ù· ÛÙÔȯ›· Ô˘ ÙÔ˘˜ ˘ÔÛÙËÚ›˙Ô˘Ó Â›Ó·È ÂÏ¿¯ÈÛÙ·. ™Â Ì›· ÌÂϤÙË Ô˘ ¤ÁÈÓ ۯÂÙÈο Ì ÙËÓ Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜, ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ Î·È ÛË„·ÈÌ›·˜, ‰ÂÓ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ì ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË LC-PUFAs. ¶¿ÓÙˆ˜, Ë Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ Î·È ÛË„·ÈÌ›·˜ ‹Ù·Ó ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚË ÛÙËÓ ÔÌ¿‰· Ô˘ ÛÈÙÈ˙fiÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· Ì LC-PUFAs. ™Â Ì›· ÚfiÛıÂÙË ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ Ë Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË Û ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· Ì ʈÛÊÔÏÈ›‰È· ·fi ÎÚfiÎÔ ·˘ÁÔ‡, ¤Ó·ÓÙÈ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌË ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· (49-51). ∂›Û˘, ¤¯Ô˘Ó ÚÔ·„ÂÈ ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ÂÓ Ì¤ÚÂÈ ·fi ÏÈ›‰È· ·˘ÁÔ‡. ∆Ô ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· ÂÚȤ¯ÂÈ ÔÏÏ·Ï¿ÛÈ· ÔÛ¿ ¯ÔÏËÛÙÂÚfiÏ˘ ·’ fiÙÈ ÙÔ ÎÔÈÓfi Á¿Ï·, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ ÚÔηϤÛÂÈ ·ÓËÛ˘¯›· Û¯ÂÙÈο Ì ÙȘ Èı·Ó¤˜ ÂÈÙÒÛÂȘ Ù˘ ÔÚ›·˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙËÓ ÚÒÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ·. ¶Ú¿ÁÌ·ÙÈ, ÛÂ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÌÂٷ͇ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Î·È ÎÔÈÓÔ‡ Á¿Ï·ÎÙÔ˜, ‚Ú¤ıËηÓ
Paediatriki 2003;66:12-19
·˘ÍË̤ӷ ›‰· ¯ÔÏËÛÙÂÚfiÏ˘, ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ (∞-π, ∞-ππ, µ) ÙËÓ 5Ë Î·È 30‹ Ë̤ڷ ¯ÔÚ‹ÁËÛ˘. ™ÙË Û˘Ó¤¯ÂÈ·, fï˜, ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙÔ˘ ÂÓfi˜ Ì‹Ó· ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û‡ÓıÂÛË Î·È ÙÔ ÂÚȯfiÌÂÓÔ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È Èı·Ófi Ó· ÂÍËÁÔ‡ÓÙ·È Ì Ì˯·ÓÈÛÌÔ‡˜ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ Û ۯ¤ÛË Ì ÙË ‰È·ÈÙËÙÈ΋ ÚfiÛÏË„Ë, Ú˘ıÌ›˙ÔÓÙ·˜ ·Ó¿ÏÔÁ· ÙËÓ ÂÓ‰ÔÁÂÓ‹ Û‡ÓıÂÛ‹ Ù˘ (52-56). ™˘ÌÂÚ¿ÛÌ·Ù· ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ÛÙÔȯ›· fiÙÈ ÙÔ ∞∞ Î·È ÙÔ DHA ÌÔÚ› Ó· Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ó¿Ù˘Í˘. ∂ȉÈÎfiÙÂÚ·, Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ DHA. ™˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔ ·›Ì· ÙˆÓ ∞∞ Î·È DHA Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ¤Ó·ÓÙÈ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜, ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÔÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÁÂÁÔÓfi˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· LC-PUFAs ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∆· ÔʤÏË ¯ÔÚ‹ÁËÛ˘ ÙˆÓ LC-PUFAs Â›Ó·È ÂÌÊ·Ó¤ÛÙÂÚ· ÛÙ· ÚfiˆÚ·, ·Ú¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË. ªÂϤÙ˜ Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· Ì LC-PUFAs ¤Ó·ÓÙÈ ÎÔÈÓÔ‡ Á¿Ï·ÎÙÔ˜, ‰Â›¯ÓÔ˘Ó ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘, Û fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÙˆÓ ÚfiˆÚˆÓ ΢ڛˆ˜ ‚ÚÂÊÒÓ, ÛÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÙÔ˘˜ ηٿÛÙ·ÛË, ηıÒ˜ Î·È ÛÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. §ÔÁÈο, ı· ÌÔÚÔ‡Û·Ì ӷ ˘Ôı¤ÛÔ˘Ì fiÙÈ ÔÈ ÂȉڿÛÂȘ ÙˆÓ LC-PUFAs ı· Â›Ó·È Î·È Ì·ÎÚÔÚfiıÂÛ̘, fï˜, ÚÔ˜ ÙÔ ·ÚfiÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· Ó· ÂȂ‚·ÈÒÓÔ˘Ó ·˘Ùfi ÙÔ Û˘Ì¤Ú·ÛÌ· (57,58). ¶¿ÓÙˆ˜, ı· ÌÔÚÔ‡Û·Ì ӷ ԇ̠̠ۯÂÙÈ΋ ·ÛÊ¿ÏÂÈ·, ÂÚÈÛÛfiÙÂÚÔ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÚfiˆÚ· ‚Ú¤ÊË, fiÙÈ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÂÓfi˜ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜ Ì LC-PUFAs ı· ›¯Â ÔÏÏ¿ Ó· ÚÔÛʤÚÂÈ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÙÚfiÔ ÂÌÏÔ˘ÙÈÛÌÔ‡ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ˘¿Ú¯ÂÈ ÛˆÛÙfi ÈÛÔ˙‡ÁÈÔ ÌÂٷ͇ ˆ-3 Î·È ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ. ∏ ÚÔÛı‹ÎË ÌfiÓÔ ˆ-3 LC-PUFAs ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ¯·ÌËÏfiÙÂÚË Û˘ÓÔÏÈ΋ ·Ó¿Ù˘ÍË, ¯·ÌËÏfiÙÂÚÔ ÏfiÁÔ ÙÔ˘ ‚¿ÚÔ˘˜ ÚÔ˜ ÙÔ ‡„Ô˜ Î·È ·Ó¿Ù˘ÍË ÔÌÈÏ›·˜ ÛÙÔ˘˜ 14 Ì‹Ó˜ ˙ˆ‹˜ Ô˘ ˘ÔÏ›ÂÙ·È. ∏ ȉ·ÓÈ΋ Û˘ÁΤÓÙÚˆÛË DHA Î·È Ë È‰·ÓÈ΋ ·Ó·ÏÔÁ›· ˆ-3 Î·È ˆ-6 LC-PUFAs ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙÔ˘ Ó¢ÚÈÎÔ‡ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÁÓˆÛÙ¤˜, ÁÂÁÔÓfi˜ Ô˘ ÚÔηÏ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ Û¯ÂÙÈο Ì ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜. ÃÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÔ˘Ó ·ÎfiÌË ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Ù· LC-PUFAs ‰ÚÔ˘Ó ÛÙË ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË.
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£ÂˆÚÂ›Ù·È ÛÎfiÈÌÔ Ó· ÚÔÛÙ›ıÂÓÙ·È Ù· ˆ-3 Î·È ˆ6 ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ÛÙȘ ·Ó·ÏÔÁ›Â˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∞˘Ù¤˜ Â›Ó·È 10:1 ÁÈ· Ù· LA Î·È ALA Î·È 2:1 ÁÈ· Ù· AA Î·È DHA (59). ŒÙÛÈ, Ì›· ÈÛÔÚÚÔË̤ÓË Î·È ÚÔÛÂÎÙÈ΋ ÚÔÛı‹ÎË LCPUFAs ı· ÌÔÚÔ‡Û ӷ ÈηÓÔÔÈ‹ÛÂÈ ÙËÓ ·Ó¿ÁÎË ÙˆÓ ‚ÚÂÊÒÓ Û ÏÈ·Ú¿ Ôͤ·, ȉȷ›ÙÂÚ· ÙˆÓ ÚÔÒÚˆÓ Î·È ·˘ÙÒÓ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. º˘ÛÈο, Ô ÚfiÏÔ˜ ÙˆÓ LC-PUFAs ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ï‹Úˆ˜. ∞·ÈÙÔ‡ÓÙ·È ÂÈϤÔÓ ¤Ú¢Ó˜ ÒÛÙ ӷ ÙÂÎÌËÚȈı› Ë Â˘ÂÚÁÂÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ÚfiˆÚˆÓ Î·È ÙÂÏÂÈfiÌËÓˆÓ ‚ÚÂÊÒÓ, ηıÒ˜ Î·È ÔÈ È‰·ÓÈΤ˜ ·Ó·ÏÔÁ›Â˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Heird WC. The role of polyunsaturated fatty acids in term and preterm infants and breastfeeding mothers. Pediatr Clin North Am 2001;48:173-185. 2. Giovannini M, Riva E, Agostoni C. Fatty acids in pediatric nutrition. Pediatr Clin North Am 1995;42:861-877. 3. Voss A, Reinhart M, Sankarappa S, Sprecher H. The metabolism of 7,10,13,16,19-docosapentaenoic acid to 4,7,10,13,16,19-docosahexaenoic acid in rat liver is independent of a 4-desaturase. J Biol Chem 1991;266: 19995-20000. 4. Makrides M, Neumann MA, Byard RW, Simmer K, Gibson RA. Fatty acid composition of brain, retina, and erythrocytes in breast- and formula-fed infants. Am J Clin Nutr 1994;60:189-194. 5. Crawford MA, Costeloe K, Ghebremeskel K, Phylactos A. The inadequacy of the essential fatty acid content of present preterm feeds. Eur J Pediatr 1998;157 (Suppl 1):S23-S27. 6. Innis SM. Plasma and red blood cell fatty acid values as indexes of essential fatty acids in the developing organs of infants fed with milk or formulas. J Pediatr 1992;120:S78-86. 7. Decsi T, Thiel I, Koletzko B. Essential fatty acids in full term infants fed breast milk or formula. Arch Dis Child Fetal Neonatal Ed 1995;72:F23-F28. 8. Maurage C, Guesnet P, Pinault M, Rochette de Lempdes JB, Galent A, Durand G et al. Plasma and erythrocyte phospholipid fatty acids of term infants fed breast milk or formulas supplemented with docosahexaenoic acid (DHA). J Pediatr Gastroenterol Nutr 1997;24:491. 9. Xiang ª, Zetterstrom R. Relation between polyunsaturated fatty acids and growth. Acta Paediatr 1999;88:78-82. 10. Agostoni C, Marangoni F, Bernardo L, Lammardo AM, Galli C, Riva E. Long-chain polyunsaturated fatty acids in human milk. Acta Paediatr 1999;88 (Suppl):68-71. 11. Jensen RG. The lipids in human milk. Prog Lipid Res 1996;35:53-92. 12. Hachey DL, Thomas MR, Emken EA, Garza C, Brown-Booth L, Adlof RO et al. Human lactation: maternal transfer of dietary triglycerides labeled with stable isotopes. J Lipid Res 1987;28:1185-1192. 13. Farquharson J, Cockburn F, Patrick WA, Jamieson EC, Logan RW. Infant cerebral cortex phospholipid fatty-acid composition and diet. Lancet 1992;340:810-813. 14. Agostoni C, Trojan S, Bellu R, Riva E, Bruzzese MG,
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-12-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆ¿ÓÓ· ÷ڈӛÙË ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú¿ÎÏÂÈÔ, ∫Ú‹ÙË
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Paediatriki 2003;66:20-28
ORIGINAL ARTICLE
T· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ˆ˜ ·ÈÙ›· ·È‰ÈÎÒÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ, ·ÏÏ¿ Û·Ó›ˆ˜ ÂÁη˘Ì¿ÙˆÓ ∂. ¶ÂÙÚ›‰Ô˘1,2, ¡. ª. ∞ϤÍÂ1, º. ¶··‰fiÔ˘ÏÔ˜1, ¢. ∆ÚȯfiÔ˘ÏÔ˜1,2
Central heating devices cause childhood injuries but rarely burns E. Petridou1,2, D. M. Alexe1, F. Papadopoulos1, D. Trichopoulos1,2
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· (ηÏÔÚÈʤÚ) Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ë ¤ÎÙ·ÛË Î·È Ê‡ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È Ë ÚfiÙ·ÛË ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰Â‰Ô̤ӷ ·fi ÙË ‚¿ÛË EDISS (Emergency Department Injury Surveillance System) Ô˘ ·ÊÔÚÔ‡Û·Ó Û ·Ù˘¯‹Ì·Ù· Ù˘ ÂÚÈfi‰Ô˘ 1996-1998, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Û ٤ÛÛÂÚ· ÌÂÁ¿Ï· ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· Ù˘ ¯ÒÚ·˜. ∏ ·ÚÔ‡Û· ÌÂϤÙË Û˘ÌÂÚȤϷ‚ ÂÚÈÛÙ·ÙÈο 533 ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 14 ÂÙÒÓ. ø˜ ÔÌ¿‰· ÂϤÁ¯Ô˘ ıˆڋıËÎ·Ó 21.865 ·È‰È¿ Ô˘ ˘¤ÛÙËÛ·Ó ¿ÏÏÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ. OÈ ·ÓÔȯ٤˜ ηÎÒÛÂȘ Ù˘ ÎÂÊ·Ï‹˜ ‹Ù·Ó Ô Û˘¯ÓfiÙÂÚÔ˜ Ù‡Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÂÓÒ ÌfiÓÔ 8 ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ˘¤ÛÙËÛ·Ó ¤Áη˘Ì· ·fi ·ʋ Ì ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·. ∆Ô 63% ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ·ÊÔÚÔ‡Û Û ·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ, ÂÓÒ ÙÔ 65% ·ÊÔÚÔ‡Û Û ·ÁfiÚÈ·. ¢‡Ô ‹Ù·Ó ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Ô˘ ÙÚ·˘Ì·Ù›˙ÔÓÙ·Ó ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·: Ë Ì›· ·ÊÔÚÔ‡Û Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (10-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ (΢ڛˆ˜ ηٿÁÌ·Ù·, ÂÍ·ÚıÚ‹Ì·Ù· Î·È ‰È·ÛÙÚ¤ÌÌ·Ù· ¿ÎÚˆÓ) Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ, ÂÓÒ Ë ‰Â‡ÙÂÚË Û˘ÌÂÚÈÏ¿Ì‚·Ó ·È‰È¿ οو ÙˆÓ 4 ÂÙÒÓ, Ù· ÔÔ›· ÙÚ·˘Ì·Ù›˙ÔÓÙ·Ó ÌÂÙ¿ ·fi ÙÒÛË ·fi ‡„Ô˜ ÛÙÔ ¯ÒÚÔ Ù˘ ÎÔ˘˙›Ó·˜ ‹ ÙÔ˘ ηıÈÛÙÈÎÔ‡, ·Ú’ fiÏÔ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ˘fi ÙËÓ ÂÈÙ‹ÚËÛË ÂÓËϛΈÓ. ∂Áη‡Ì·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ·ÔÎÏÂÈÛÙÈο ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰· ·È‰ÈÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Ô˘ ÔÊ›ÏÔÓÙ·È Û ıÂÚÌ·ÓÙÈο
Abstract: This research aimed to identify the magnitude, nature and risk factors of childhood injuries related to central heating devices in Greece and to propose preventive strategies. We used data recorded by the Emergency Department Injury Surveillance System (EDISS) over a three-year period (1996-1998) in four major pediatric hospitals across the country. The case group comprised of five hundred and thirty-three children less than 14 years-old, while 21865 children with other indoor injuries were used as controls. Open wounds of the head were the most common injuries and only eight children sustained burn injuries due to these devices. Sixty-three percent of central heating device related injuries were noted among children less than five years-old with a significant male preponderance (65%). Of the clusters identified, two are the most important: the first refers to older children (10-14 years old), who frequently sustain central heating device related injuries (mainly fractures, dislocations and strains of the limbs) in educational buildings. The second cluster includes children less than 4 years old who suffer injuries mainly falls from height - in the kitchen as well as the living room and bedroom despite recorded supervision. Burns were noted exclusively in this group. As a conclusion, injuries related to central heating devices represent a small, but not negligible, fraction of all indoor injuries. Prevention strategies pertain mainly to modifications of the product design or safer use of it and improvements in building design.
1 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ∆Ì‹Ì· ∂ȉËÌÈÔÏÔÁ›·˜, ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜, ¶·ÓÂÈÛÙ‹ÌÈÔ Harvard, ∏¶∞
1 Department of Hygiene and Epidemiology, University of Athens Medical School 2 Department of Epidemiology, Harvard School of Public Health, USA
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Paediatriki 2003;66:20-28
ÛÒÌ·Ù· ·ÔÙÂÏÔ‡Ó ÌÈÎÚfi, ·ÏÏ¿ fi¯È ·ÌÂÏËÙ¤Ô ÎÏ¿ÛÌ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. ∆· ̤ÙÚ· ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ Û˘Ó›ÛÙ·ÓÙ·È Î˘Ú›ˆ˜ Û ÙÚÔÔÔ›ËÛË ÙÔ˘ ۯ‰ȷÛÌÔ‡ ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ‹ Î·È ÙˆÓ ÎÙÈÚÈ·ÎÒÓ ˘Ô‰ÔÌÒÓ. §¤ÍÂȘ ÎÏÂȉȿ: ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ηÏÔÚÈʤÚ, ·Ù‡¯ËÌ·, ÙÚ·˘Ì·ÙÈÛÌfi˜, ·È‰›.
Key words: central heating device, childhood injury, safety modifications.
™˘ÓÙÔÌÔÁڷʛ˜
ÂÚÈÛÛfiÙÂÚ˜ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙ· ÂÁη‡Ì·Ù· Ô˘ ÌÔÚ› Ó· ÚÔÎÏËıÔ‡Ó ·fi ÙȘ ÂÁηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ (3-6). ∏ Û˘¯ÓfiÙËÙ·, Ë ‚·Ú‡ÙËÙ· Î·È Ë ¤Î‚·ÛË ¿ÏÏˆÓ Ù‡ˆÓ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·fi Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› ·ÚÎÒ˜. °È· Ó· ˘ÔÏÔÁÈÛÙ› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ·È‰È¿ Î·È Ó· ÌÂÏÂÙËıÔ‡Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ·˘ÙÒÓ, ¯ÚËÛÈÌÔÔÈ‹ıËΠ̛· ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ 300.000 ¿ÙÔÌ· Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó Û ÙÌ‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ ÂÓfi˜ ‰ÈÎÙ‡Ô˘ Û˘ÓÂÚÁ·˙fiÌÂÓˆÓ ÓÔÛÔÎÔÌ›ˆÓ, ¤¯ÔÓÙ·˜ ˘ÔÛÙ› ÙÚ·˘Ì·ÙÈÛÌfi.
EDISS ∫∂¶¶∞ EHLASS NOMESCO ICD9
Emergency Department Injury Surveillance System ∫¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ ∞Ù˘¯ËÌ¿ÙˆÓ The European Home and Leisure Accidents Surveillance System Nordic Medico - Statistical Committee International Classification of Diseases 9th rev.
∂ÈÛ·ÁˆÁ‹ O ۯ‰ȷÛÌfi˜ ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο ηٿ ÙÔÓ ÙÂÏÂ˘Ù·›Ô ·ÈÒÓ·, fiÛÔÓ ·ÊÔÚ¿ ÙfiÛÔ ÛÙËÓ ·ÛÊ¿ÏÂÈ· fiÛÔ Î·È ÛÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘˜. ∆· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ¤¯Ô˘Ó ϤÔÓ ·ÓÙÈηٷÛÙ‹ÛÂÈ ıÂÚÌ·ÓÙÈΤ˜ ËÁ¤˜ fiˆ˜ ÙÔ Ù˙¿ÎÈ Î·È Ë ÛfiÌ· ͇ÏÔ˘, ‚ÂÏÙÈÒÓÔÓÙ·˜ ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ÌÂÈÒÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ˘ÚηÁÈ¿˜. §fiÁˆ ÙÔ˘ ‡ÎÚ·ÙÔ˘ Îϛ̷ÙÔ˜ Ù˘ ¯ÒÚ·˜ Ì·˜, Ë ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ Â›Ó·È ·Ó·Áη›· ÌfiÓÔ ÁÈ· Ù¤ÛÛÂÚȘ Ì‹Ó˜ ÙÔ ¯ÚfiÓÔ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ‰È·ÌÂÚ›ÛÌ·Ù· Ù˘ ¯ÒÚ·˜. ∆· ÎÏ·ÛÈο Ù˙¿ÎÈ· ‰ÂÓ ·ÔÙÂÏÔ‡Û·Ó ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ˘ÚηÁÈ¿˜, ηıÒ˜ Ù· ÂÚÈÛÛfiÙÂÚ· Û›ÙÈ· ‹Ù·Ó ¯ÙÈṲ̂ӷ Ì ÌË Â‡ÊÏÂÎÙ· ˘ÏÈο, fiˆ˜ ¤ÙÚ˜ Î·È ÙÔ‡‚Ï·. ª¤¯ÚÈ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960, fï˜, ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ı·Ó·ÙËÊfiÚˆÓ ÂÚÈÙÒÛÂˆÓ ‰ËÏËÙËÚ›·Û˘ ·fi ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη ηٷÁÚ¿ÊÔÓÙ·Ó Î¿ı ¯ÚfiÓÔ. ™ÙȘ ̤Ú˜ Ì·˜, Ù· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÔÙÂÏÔ‡Ó ÙÔ Î‡ÚÈÔ Ì¤ÛÔ ı¤ÚÌ·ÓÛ˘, ÂÓÒ ÛÙ·‰È·Î¿ ÂÈÛ¿ÁÂÙ·È Î·È Ë ¯Ú‹ÛË ÎÂÓÙÚÈÎÒÓ ÎÏÈÌ·ÙÈÛÙÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ. ∞Ó Î·È Ù· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ıˆÚÔ‡ÓÙ·È ·ÚÎÂÙ¿ ·ÛÊ·Ï‹, ÌÂϤÙ˜ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 ¤‰ÂÈÍ·Ó fiÙÈ ÂÁη‡Ì·Ù· Î·È ¿ÏÏÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Û˘Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙË ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ (1,2). øÛÙfiÛÔ, Ï›Á˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂÎÔÓËı› Ì ÁÓÒÌÔÓ· ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·fi ÙË ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ÂÓÒ ÔÈ
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆Ô ∫¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ ∞Ù˘¯ËÌ¿ÙˆÓ (∫∂¶¶∞) ȉڇıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ ÛÙÔ ∆Ì‹Ì· ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ Ù˘ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË Î·È ÚfiÏË„Ë ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™Â Û˘ÓÂÚÁ·Û›· Ì ٤ÛÛÂÚ· ÌÂÁ¿Ï· ÓÔÛÔÎÔÌ›· Ù˘ ¯ÒÚ·˜, ¤¯ÂÈ ·Ó·Ù˘¯ı› Î·È ‰È·ÙËÚÂ›Ù·È ·fi ÙÔ ∫∂¶¶∞ Ì›· ÌÂÁ¿ÏË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ (Emergency Department Injury Surveillance System-EDISS), Ë ÔÔ›· ηχÙÂÈ fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÁÈ· fiϘ ÙȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜. ¢‡Ô ·fi Ù· Ù¤ÛÛÂÚ· ÓÔÛÔÎÔÌ›·, ÙÔ ¶·ÓÂÈÛÙËÌÈ·Îfi ¶·È‰È·ÙÚÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” Î·È ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ∞Ù˘¯ËÌ¿ÙˆÓ “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, ÂÓÙÔ›˙ÔÓÙ·È ÛÙËÓ Â˘Ú‡ÙÂÚË ÂÚÈÔ¯‹ ÙˆÓ ∞ıËÓÒÓ. ∆· ¿ÏÏ· ‰‡Ô ÓÔÛÔÎÔÌ›· ‚Ú›ÛÎÔÓÙ·È ÂÎÙfi˜ ∞ıËÓÒÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔ µfiÏÔ (“¡Ô̷گȷÎfi ¡ÔÛÔÎÔÌÂ›Ô ª·ÁÓËÛ›·˜”) Î·È ÛÙËÓ ∫¤Ú΢ڷ (“¡Ô̷گȷÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫¤Ú΢ڷ˜”). ∏ ‚¿ÛË Î·Ï‡ÙÂÈ fiÏ· Ù· ÂÚÈÛÙ·ÙÈο ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙˆÓ Û˘ÓÂÚÁ·˙fiÌÂÓˆÓ ÓÔÛÔÎÔÌ›ˆÓ ÙËÓ ÂÚ›Ô‰Ô 1996-1998. ∂ȉÈο ÂÎ·È‰Â˘Ì¤Ó˜ ÂÈÛΤÙÚȘ ˘Á›·˜ ‹Ú·Ó ÚÔÛˆÈο Û˘Ó¤ÓÙ¢ÍË ·fi ÙÔ ·È‰› Î·È ÙÔ Û˘ÓÔ‰fi ÙÔ˘, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ¤Ó· ÚÔ-Έ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, Û˘ÏϤÁÔÓÙ·˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÎÔÈÓˆÓÈο Î·È ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ÙȘ ÏÂÙÔ̤ÚÂȘ ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∏ ÂÈÏÔÁ‹ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ¤ÁÈÓ Ì ÎÚÈÙ‹ÚÈÔ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ıÂÚÌ·ÓÙÈÎÔ‡ ÛÒÌ·ÙÔ˜ ‹ ÙÔ˘ ۈϋӷ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ı¤ÚÌ·ÓÛ˘ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜. °È· ÙËÓ
21
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Paediatriki 2003;66:20-28
¶›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ 22.398 ·È‰ÈÒÓ (0-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ÛÙÔ EDISS, ÁÈ· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÙÚÈÒÓ ÂÙÒÓ (1996-1998) ˆ˜ ÚÔ˜ ÙȘ ‰È¿ÊÔÚ˜ ÌÂÙ·‚ÏËÙ¤˜ ªÂÙ·‚ÏËÙ‹
¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ∏ÏÈΛ· (¤ÙË) 0-4 5-9 10-14 º‡ÏÔ ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË °ÂˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ∞ı‹Ó· ∞ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ÷ڷÎÙËÚÈÛÙÈο ·Ù˘¯‹Ì·ÙÔ˜ ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∏̤ڷ ∫·ıËÌÂÚÈÓ‹ ™·‚‚·ÙÔ·ÚÈ·ÎÔ ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ªË¯·ÓÈÛÌfi˜ οΈÛ˘ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ·fi Û‡ÁÎÚÔ˘ÛË/ ÛÚÒÍÈÌÔ ·fi ÙÚ›ÙÔ ¿ÙÔÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ÷ڷÎÙËÚÈÛÙÈο Ù˘ οΈÛ˘ ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜ ∫·Ì›· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹
22
∞Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· No %
ÕÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ No %
∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘
0,001 335 144 54
62,9 27,0 10,1
12814 5575 3476
58,6 25,5 15,9
346 187
64,9 35,1
12549 9316
57,4 42,6
514 19
96,4 3,6
20834 1031
95,3 4,7
449 84
84,2 15,8
18473 3392
84,5 15,5
0,001
0,21
0,88
0,001 177 164 44 54 94
33,2 30,8 8,3 10,1 17,6
5664 6768 3539 3253 2641
25,9 30,9 16,2 14,9 12,1
439 94
82,4 17,6
18405 3460
84,2 15,8
387 146
72,6 27,4
15470 6395
70,7 29,3
0,26
0,35
0,001 191
35,8
9619
44,0
342
64,2
12246
56,0
109
20,5
5946
27,2
190
35,6
4659
21,3
66 145 8 15
12,4 27,2 1,5 2,8
1097 3513 1026 5624
5,0 16,1 4,7 25,7
374 159
70,2 29,8
14488 7377
66,3 33,7
412 78 11 3 7 8 0 14
77,3 14,6 2,1 0,6 1,3 1,5 0,0 2,6
7325 5581 1855 1972 583 1111 1542 1896
33,5 25,5 8,5 9,0 2,7 5,1 7,0 8,7
279
52,3
4523
20,7
0,001
0,06
0,001
0,001
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·23
¶·È‰È·ÙÚÈ΋ 2003;66:20-28
¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ∞ÚÈıÌfi˜ ηÎÒÛÂˆÓ ª›· ¶ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ŒÎ‚·ÛË ÃˆÚ›˜ ıÂڷ›· £Âڷ›· ¯ˆÚ›˜ ·Ú·ÎÔÏÔ‡ıËÛË £Âڷ›· Ì ·Ú·ÎÔÏÔ‡ıËÛË ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë £¿Ó·ÙÔ˜
Paediatriki 2003;66:20-28
186 58 10
34,9 10,9 1,9
6630 8270 2442
30,3 37,8 11,2
508 25
95,3 4,7
19625 2240
89,8 10,2
52 70 407 4 0
9,8 13,1 76,4 0,7 0,0
5017 5902 9205 1733 4
23,0 27,0 42,2 7,8 0,0
0,001
0,001
¿ÓÙÏËÛË ‰Â‰ÔÌ¤ÓˆÓ Û¯ÂÙÈÎÒÓ Ì ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÂÍ‹˜ ÎÒ‰ÈΘ: ·fi ÙË ‚¿ÛË EDISS 11-15, 38, 51, 53, 55, 60, 62 ÁÈ· ÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, 20220, 20230 ÁÈ· ÙÔ ÂÌÏÂÎfiÌÂÓÔ ·ÓÙÈΛÌÂÓÔ, ·fi ÙÔ ÂÁ¯ÂÈÚ›‰ÈÔ Îˆ‰ÈÎÔÔ›ËÛ˘ ÙÔ˘ European Home and Leisure Accidents Surveillance System (EHLASS-1986) (7) 1382, 2041 ÁÈ· ÙÔ ÂÌÏÂÎfiÌÂÓÔ ·ÓÙÈΛÌÂÓÔ, ·fi ÙËÓ ∆·ÍÈÓfiÌËÛË ∂͈ÙÂÚÈÎÒÓ ∞ÈÙ›ˆÓ ∆Ú·˘Ì·ÙÈÛÌÔ‡ Ù˘ NOMESCO (8) Î·È Ù¤ÏÔ˜, ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ÎÒ‰ÈΘ ÙÔ˘ ICD-9 (9). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ Ù˘ ÌÂϤÙ˘, ÛÙË ‚¿ÛË EDISS ηٷÁÚ¿ÊËÎ·Ó 22.398 ·È‰È¿ Ô˘ ›¯·Ó ·Ù˘¯‹Ì·Ù· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ. ∆· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ÂÓÂÏ¿ÎËÛ·Ó Û 533 ÂÚÈÙÒÛÂȘ. ∆· ÛÙÔȯ›· ·˘Ù¿ Â›Ó·È ÂÚÈÁÚ·ÊÈο Î·È ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È Û ηıÔÚÈṲ̂ӷ ÚfiÙ˘· ¯ÚÔÓÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜-¤ÎıÂÛ˘, ÌÔÚÔ‡Ó ˆÛÙfiÛÔ Ó· ·Ó·Ï˘ıÔ‡Ó ˆ˜ ÌÂϤÙË ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ. ∫·Ù¿ Û˘Ó¤ÂÈ·, ·ÛıÂÓ›˜ ıˆÚÔ‡ÓÙ·È Ù· ·È‰È¿ Ì ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Î·È Ì¿ÚÙ˘Ú˜ Ù· ˘fiÏÔÈ· 21.865 ·È‰È¿ Ì ¿ÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ (10). ∏ ·Ú¯È΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ·Ï¤˜ ÈÓ·ÎÔÔÈ‹ÛÂȘ ÙˆÓ ÛÙÔȯ›ˆÓ. ∞ÎÔÏÔ‡ıˆ˜, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜, ¤Ó· ·Ù‡¯ËÌ· Ó· ÔÊ›ÏÂÙ·È Û ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹ fi¯È ·Ó¿ÏÔÁ· ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÙÈ̤˜ ÙˆÓ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙÒÓ, ˘ÔÏÔÁ›ÛÙËΠ̠ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË. ∆Ô ÚÔÊ›Ï ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ηıÔÚ›ÛÙËΠÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ÛÙÔȯ›ˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÛÙ·ÙÈÛÙÈÎfi ÏÔÁÈÛÌÈÎfi SAS (11).
∞ÔÙÂϤÛÌ·Ù· ∆· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‚Ú¤ıËΠfiÙÈ Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÙÔ 2,4% fiÏˆÓ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. øÛÙfiÛÔ, ÌfiÏȘ 8 ·fi Ù· 533 ·È‰È¿ Ô˘ ÙÚ·˘Ì·Ù›ÛÙËÎ·Ó ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ˘¤ÛÙËÛ·Ó ¤Áη˘Ì·, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÔÈ Û˘Û΢¤˜ ·˘Ù¤˜ Û˘ÓÈÛÙÔ‡Ó Î›Ó‰˘ÓÔ ÁÈ· ·Ù˘¯‹Ì·Ù· ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ȉÈfiÙËÙ¤˜ ÙÔ˘˜ ˆ˜ ÛÒÌ·Ù· Ô˘ ηٷϷ̂¿ÓÔ˘Ó ¯ÒÚÔ Ì¤Û· ÛÙÔ Û›ÙÈ, ·Ú¿ ˆ˜ ·ÓÙÈΛÌÂÓ· Ô˘ ÂΤÌÔ˘Ó ıÂÚÌfiÙËÙ·. ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ Î·Ù·ÓÔ̤˜
ÙˆÓ ·È‰ÈÒÓ Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹Ù·Ó Ë ·ÈÙ›· ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ‹ fi¯È, Û ۯ¤ÛË Ì ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÛÙÔȯ›· ÙÔ˘ ÙfiÔ˘ Ô˘ ¤ÁÈÓ ÙÔ ·Ù‡¯ËÌ·, ·ÏÏ¿ Î·È Û ۯ¤ÛË Ì ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi. OÈ Û˘ÁÎÚ›ÛÂȘ ÛÙÔÓ ›Ó·Î· ·˘Ùfi ‚·Û›˙ÔÓÙ·È ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ηٷÓÔ̤˜ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Î·È Â͢ËÚÂÙÔ‡Ó ÙËÓ ÂÚÈÁÚ·Ê‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·Ú¿ ÙËÓ ·Ó¿Ï˘Û‹ ÙÔ˘˜, ηıÒ˜ ‰ÂÓ ¤¯Ô˘Ó ÏËÊı› ˘’ fi„ÈÓ ·ÌÔÈ‚·›ÔÈ Û˘Á¯˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ¶·Ú·ÙËÚÂ›Ù·È Ì›· ‰˘Û·Ó¿ÏÔÁË Û˘ÁΤÓÙÚˆÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, Û ۯ¤ÛË Ì ٷ ¿ÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘, ÛÙ· ·È‰È¿ Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜ Î·È ÛÙ· ·ÁfiÚÈ·, ÂÓÒ Ë ÂıÓÈÎfiÙËÙ· Î·È Ë ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ‰ÂÓ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙȘ Û˘Óı‹Î˜ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ‰ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË Ô‡Ù Ì ÙËÓ ÒÚ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Ô‡Ù Ì ÙËÓ Ë̤ڷ Ù˘ ‚‰ÔÌ¿‰·˜. ™¯Â‰fiÓ Ù· ‰‡Ô ÙÚ›Ù· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û˘Ó¤‚ËÛ·Ó ÛÙÔ Î·ıÈÛÙÈÎfi ÙÔ˘ ÛÈÙÈÔ‡ ‹ ÙËÓ ÎÚ‚·ÙÔο̷ڷ, ÂȉÈο ÛÙ· ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜ ·È‰È¿, ÂÓÒ Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ê·›ÓÂÙ·È fiÙÈ ˘Ê›ÛÙ·ÓÙ·È Ù· ·Ù˘¯‹Ì·Ù· ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ Û˘¯ÓfiÙÂÚ· Û ÂÎ·È‰Â˘ÙÈÎÔ‡˜ ¯ÒÚÔ˘˜. OÈ Û˘Û¯ÂÙ›ÛÂȘ ·˘Ù¤˜ ·ÓÙ·Ó·ÎÏÔ‡Ó Èı·ÓÒ˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ Ù‡Ô˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ∏ ›‰È· ˘fiıÂÛË ÌÔÚ› Ó· ‰È·Ù˘ˆı› Î·È ÁÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ ηٿ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘, fiÔ˘ ÔÈ Â͈ÙÂÚÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ·Ú·ÎˆÏ‡ÔÓÙ·È ·fi ÙȘ ηÈÚÈΤ˜ Û˘Óı‹Î˜. ª¿ÏÈÛÙ·, Ë Âԯȷ΋ ·˘Ù‹ ‰È·Î‡Ì·ÓÛË Â›Ó·È ÈÛ¯˘ÚfiÙÂÚË ÁÈ· Ù· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·. O ÈÔ Û˘¯Ófi˜ Ì˯·ÓÈÛÌfi˜ οΈÛ˘ ÛÙ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Â›Ó·È ÙÔ ·Ú·¿ÙËÌ· ‹ ÙÔ ÁÏ›ÛÙÚËÌ· Î·È Ë Â·ÎfiÏÔ˘ıË Û‡ÁÎÚÔ˘ÛË Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·. ª¿ÏÈÛÙ·, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ˘‹Ú¯Â ÂȂϤˆÓ ÂÓ‹ÏÈη˜ ÛÙÔ ¯ÒÚÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÔÈ ÂȂϤÔÓÙ˜ Â›Ó·È Ì¿ÏÏÔÓ ·Ó˘Ô„›·ÛÙÔÈ
23
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·24
¶·È‰È·ÙÚÈ΋ 2003;66:20-28
Paediatriki 2003;66:20-28
¶›Ó·Î·˜ 2. ™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™.∫.) Î·È 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O.∞.) ÁÈ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ۯ¤ÛË Ì ÙȘ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙ¤˜ ÌÂÙ¿ ·fi ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·ÏÁÔÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË ªÂÙ·‚ÏËÙ‹
∫·ÙËÁÔÚ›· ‹ ÚÔÛ·‡ÍËÛË
∏ÏÈΛ· º‡ÏÔ
5 ¤ÙË ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ªË¯·ÓÈÛÌfi˜ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ÌÂÙ¿ ·fi Û‡ÁÎÚÔ˘ÛË/ÛÚÒÍÈÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂Ó·ÏÏ·ÎÙÈ΋ ÚÔÛı‹ÎË ÌÂÙ·‚ÏËÙÒÓ ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜/η̛· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹ ¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë Ÿ¯È ¡·È
™.∫. 0,70 ¶.∞.* 0,79 ¶.∞.* 0,85 ¶.∞.* 1,23 ¶.∞.* 1,31 0,99 ¶.∞.* 0,62 0,72 1,20 ¶.∞.* 0,77 0,45 ¶.∞.* 1,51 1,08 0,23 0,07 3,77 ¶.∞.* 0,44 0,21 0,84 0,27 0,48
7,60 2,83 1,19 ¶.∞.* ¶.∞.* 0,19
95% O.∞.
∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘
0,61
0,80
0,001
0,66
0,95
0,01
0,53
1,35
0,49
0,98
1,55
0,08
1,09
1,58
0,003
0,80
1,24
0,97
0,44 0,52 0,91
0,88 0,98 1,60
0,008 0,04 0,19
0,64 0,35
0,94 0,57
0,01 0,0001
1,11 0,87 0,11 0,04
2,05 1,36 0,49 0,12
0,009 0,48 0,0001 0,0001
2,94
4,83
0,0001
0,23 0,07 0,38 0,004 0,27
0,84 0,69 1,84 20,26 0,86
0,01 0,01 0,66 0,55 0,01
3,94 1,46 0,60
14,68 5,49 2,35
0,0001 0,002 0,61
0,07
0,52
0,001
*¶.∞.: ¶ÏËı˘ÛÌfi˜ ·Ó·ÊÔÚ¿˜
Û¯ÂÙÈο Ì ÙÔÓ Î›Ó‰˘ÓÔ ·Ù˘¯‹Ì·ÙÔ˜ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Î·È ¤ÙÛÈ ‰ÂÓ ÂÛÙÈ¿˙Ô˘Ó ÙËÓ ÚÔÛÔ¯‹ ÙÔ˘˜ Û ·˘Ù¿. ™¯ÂÙÈο Ì ÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi, ‚Ú¤ıËΠfiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Â›Ó·È ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔ ÚfiÛˆÔ. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ (ÂÚ›Ô˘ 75%) ¯Ú‹˙ÂÈ ıÂڷ›·˜ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ Â›Ó·È ·ÚÎÂÙ¿ ÛÔ‚·Ú¿. ∂ÓÙÔ‡ÙÔȘ, Û˘Ó‹ıˆ˜ ‰ÂÓ ··ÈÙÔ‡Ó ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ‰ÂÓ Â›Ó·È ·ÂÈÏËÙÈο ÁÈ· ÙË ˙ˆ‹. ™ÙÔÓ ¶›Ó·Î· 2, ÌÂÙ¿ ·fi ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÏÔ-
24
Á·ÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË, ·Ú·Ù›ıÂÙ·È Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫) Î·È Ù· 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% O∞) ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ¤Ó· ·Ù‡¯ËÌ· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ Ó· ÚÔηÏÂ›Ù·È ·fi ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ÁÈ· οı ̛· ·fi ÙȘ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙ¤˜. ∆· ·ÔÙÂϤÛÌ·Ù· Û˘ÌʈÓÔ‡Ó ÁÂÓÈο Ì ÂΛӷ Ù˘ ÌÔÓÔ·Ú·ÁÔÓÙÈ΋˜ ·Ó¿Ï˘Û˘. OÈ ÌÂÁ·Ï‡ÙÂÚ˜ ·ÔÎÏ›ÛÂȘ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙË ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÔÊ›ÏÔÓÙ·È ÛÂ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Ó· ÔÊ›ÏÂÙ·È ¤Ó· ·Ù‡¯ËÌ· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ Û ıÂÚÌ·ÓÙÈÎfi ÛÒÌ· ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜, Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· Û ۯ¤ÛË Ì ٷ ·ÁfiÚÈ·,
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·25
¶·È‰È·ÙÚÈ΋ 2003;66:20-28
Paediatriki 2003;66:20-28
¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ ÙˆÓ 533 ·È‰ÈÒÓ (0-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ÛÙÔ EDISS, ÁÈ· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÙÚÈÒÓ ÂÙÒÓ (1996-1998), ˆ˜ ÚÔ˜ Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ηıÒ˜ Î·È ÂΛӷ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔ ·Ù‡¯ËÌ· Î·È ÙËÓ Î¿ÎˆÛË, Û ٤ÛÛÂÚȘ ÔÌ¿‰Â˜, ÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ ªÂÙ·‚ÏËÙ‹
™˘ÛÙ¿‰· 1Ë
∏ÏÈΛ· (¤ÙË) 0-4 5-9 10-14 º‡ÏÔ ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ªË¯·ÓÈÛÌfi˜ οΈÛ˘ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ÌÂÙ¿ ·fi Û‡ÁÎÚÔ˘ÛË/ÛÚÒÍÈÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜/η̛· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹ ¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë Ÿ¯È ¡·È
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15 23 16
4,5 16,0 29,6
189 13 11
56,4 9,0 20,4
2 79 18
0,6 54,9 33,3
129 29 9
38,5 20,1 16,7
30 24
8,7 12,8
145 68
41,9 36,3
70 29
20,2 15,5
101 66
29,2 35,3
53 1
10,3 5,2
204 9
39,7 47,4
93 6
18,1 31,6
164 3
31,9 15,8
16 13 1 9 15
9,0 7,9 2,3 16,7 16,0
70 81 28 20 14
39,6 49,4 63,6 37,0 14,9
31 13 4 4 47
17,5 7,9 9,1 7,4 50,0
60 57 11 21 18
33,9 34,8 25,0 38,9 19,1
47 7
10,7 7,4
176 37
40,1 39,4
84 15
19,1 16,0
132 35
30,1 37,2
27 27
14,1 7,9
95 118
49,7 34,5
29 70
15,2 20,5
40 127
21,0 37,1
6 7 3 30 0 8
5,5 3,7 4,6 20,7 0,0 53,3
66 82 15 38 8 4
60,6 43,2 22,7 26,2 100,0 26,7
20 27 38 14 0 0
18,3 14,2 57,6 9,7 0,0 0,0
17 74 10 63 0 3
15,6 38,9 15,1 43,4 0,0 20,0
31 23
8,3 14,5
157 56
42,0 35,2
60 39
16,0 24,5
126 41
33,7 25,8
9 32 9 2 0 0 2
2,2 41,0 81,8 66,7 0,0 0,0 14,3
160 28 1 1 6 8 9
38,8 35,9 9,1 33,3 85,7 100,0 64,3
90 5 0 0 1 0 3
21,9 6,4 0,0 0,0 14,3 0,0 21,4
153 13 1 0 0 0 0
37,1 16,7 9,1 0,0 0,0 0,0 0,0
4 1 45 4
1,4 0,5 77,6 40,0
180 19 9 5
64,5 10,2 15,5 50,0
89 9 0 1
31,9 4,9 0,0 10,0
6 157 4 0
2,2 84,4 6,9 0,0
53 1
10,0 25,0
211 2
39,9 50,0
98 1
18,5 25,0
167 0
31,6 0,0
˘„ËÏfiÙÂÚÔ˜ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘ Î·È ˘„ËÏfiÙÂÚÔ˜ fiÙ·Ó ˘¿Ú¯ÂÈ Â›‚ÏÂ„Ë ·fi ÂÓ‹ÏÈη. ∞ÓÙÈı¤Ùˆ˜, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ¯ÒÚÔ fiÔ˘ Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ·, Ì ÂÍ·›ÚÂÛË ÙË Ì¤ÙÚÈ· Ì›ˆÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ· ÛÙÔ ¯ÒÚÔ Ù˘ ÎÔ˘˙›Ó·˜. ŸÛÔÓ
·ÊÔÚ¿ ÛÙÔ Ì˯·ÓÈÛÌfi Ù˘ οΈÛ˘, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÙÔ ·Ù‡¯ËÌ· Ó· ÚÔÎÏ‹ıËΠ·fi ıÂÚÌ·ÓÙÈÎfi ÛÒÌ· Â›Ó·È ˘„ËÏfiÙÂÚÔ˜ fiÙ·Ó ˘‹Ú¯Â ·Ú·¿ÙËÌ· ‹ ÁÏ›ÛÙÚËÌ· Î·È Û‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ. ∏ ·Ó¿Ï˘ÛË Ù˘ ʇÛ˘ ÙˆÓ Î·ÎÒÛÂˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ηٷ‰ÂÈÎÓ‡ÂÈ Î˘Ú›ˆ˜ ·ÓÔȯٿ
25
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·26
¶·È‰È·ÙÚÈ΋ 2003;66:20-28
ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔ ÚfiÛˆÔ. O ¶›Ó·Î·˜ 3 ·ÚÔ˘ÛÈ¿˙ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù¤ÛÛÂÚȘ ·ÚȘ ÔÌ¿‰Â˜ Ì Êı›ÓÔ˘Û· ÛËÌ·Û›·: ∏ ÚÒÙË ÔÌ¿‰· ·Ó·Ê¤ÚÂÙ·È Û ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ·È‰È¿ (10-14 ¯ÚfiÓˆÓ), Ù· ÔÔ›· Û˘¯Ó¿ ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ Î·È ÙˆÓ ÔÔ›ˆÓ ÔÈ Î·ÎÒÛÂȘ Û˘Ó›ÛÙ·ÓÙ·È Û ηٿÁÌ·Ù·, ÂÍ·ÚıÚÒÛÂȘ Î·È ‰È·ÛÙÚ¤ÌÌ·Ù· ÙˆÓ ¿ÎÚˆÓ. ∏ ‰Â‡ÙÂÚË ÔÌ¿‰· ·ÊÔÚ¿ Û ·È‰È¿ Ôχ Ó·ڋ˜ ËÏÈΛ·˜ (0-4 ¯ÚfiÓˆÓ), Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ÙfiÛÔ ÛÙËÓ ÎÔ˘˙›Ó· fiÛÔ Î·È ÛÙÔ Î·ıÈÛÙÈÎfi Î·È ÙËÓ ÎÚ‚·ÙÔο̷ڷ, ·Ó Î·È ‚Ú›ÛÎÔÓÙ·È ˘fi ÂÈÙ‹ÚËÛË. O ·ÚÈÔ˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È Ë ÙÒÛË ·fi ‡„Ô˜. ∆· ÂÁη‡Ì·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ÔÌ¿‰· ·˘Ù‹. ªÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ‰È·Û›ÛÂˆÓ Î·È ÁÂÓÈÎfiÙÂÚ· ÙˆÓ Î·ÎÒÛÂˆÓ ÙÔ˘ ÎÚ·Ó›Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Â›Û˘ Û ·˘Ù‹ ÔÌ¿‰·. ∏ ÙÚ›ÙË ÔÌ¿‰· ·Ó·Ê¤ÚÂÙ·È Û ·È‰È¿ ÂӉȿÌÂÛ˘ ËÏÈΛ·˜ (5-9 ¯ÚfiÓˆÓ). ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Û Ôχ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·È‰È¿ ÌÂÙ·Ó·ÛÙÒÓ Ô˘ Û˘¯Ó¿ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ Î·È ‰ËÌfiÛÈ· ÎÙ›ÚÈ·, ˆ˜ ·ÔÙ¤ÏÂÛÌ· Û˘ÁÎÚÔ‡ÛÂˆÓ Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹ Ûڈ̷͛ÙÔ˜ ·fi ¿ÏÏ· ¿ÙÔÌ·. OÈ Î·ÎÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÌ¿‰·˜ ·˘Ù‹˜ Â›Ó·È Û˘¯Ó¿ Ù· ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ. ∏ ٤ٷÚÙË ÔÌ¿‰· ÌÔÈ¿˙ÂÈ Ì ÙË ‰Â‡ÙÂÚË ÛÙÔ fiÙÈ Î·Ï‡ÙÂÈ Î˘Ú›ˆ˜ ·È‰È¿ Ó·ڋ˜ ËÏÈΛ·˜, ·ÏÏ¿ Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË Ù· ·È‰È¿ Â›Ó·È Î˘Ú›ˆ˜ ÂÏÏËÓÈ΋˜ ÂıÓÈÎfiÙËÙ·˜, Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ „˘¯ÚÒÓ ÌËÓÒÓ ÙÔ˘ ¤ÙÔ˘˜ ηıÒ˜ Û˘ÁÎÚÔ‡ÔÓÙ·È Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·. OÈ Î·ÎÒÛÂȘ, ˆÛÙfiÛÔ, Â›Ó·È ÌÈÎÚfiÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÚfiÛˆÔ. ™˘˙‹ÙËÛË ∆· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰›ÎÙ˘· ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ·ÔÙÂÏÔ‡Ó ÙÔ Î‡ÚÈÔ Ì¤ÛÔ ı¤ÚÌ·ÓÛ˘ ÙˆÓ Î·ÙÔÈÎÈÒÓ Û ÔÏϤ˜ ¯ÒÚ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ∂ÏÏ¿‰·˜. ∏ ÛÙ·‰È·Î‹ ·‡ÍËÛË Ù˘ ¯Ú‹Û˘ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ·˘ÙÒÓ ¯·ÈÚÂÙ›ÛÙËΠˆ˜ ¤Ó· ÛËÌ·ÓÙÈÎfi ‚‹Ì· ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜, ·ÏÏ¿ Î·È Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ (12). ∫·Ù¿ ÙË ‰ÂηÂÙ›· 1990-2000, ÔÏÏÔ› Û˘ÁÁÚ·Ê›˜ ·fi ¯ÒÚ˜ Ù˘ µfiÚÂÈ·˜ ∂˘ÚÒ˘ Î·È Ù˘ ∞ÌÂÚÈ΋˜ ÂÓÙfiÈÛ·Ó ÎÈÓ‰‡ÓÔ˘˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ¯Ú‹ÛË ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ (3-6). OÈ Û˘ÁÁÚ·Ê›˜ ·˘ÙÔ› ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ Ï¤ÔÓ ÚÔÊ·Ó¤˜ Úfi‚ÏËÌ· Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ù· ÂÁη‡Ì·Ù·. ∞Ó Î·È Ë ‚È‚ÏÈÔÁÚ·Ê›· Á‡Úˆ ·fi ÙÔ ı¤Ì· Â›Ó·È ÂÚÈÔ-
26
Paediatriki 2003;66:20-28
ÚÈṲ̂ÓË, ÔÈ ÂÚ¢ÓËÙ¤˜ ÂÂÛ‹Ì·Ó·Ó fiÙÈ Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ı· ÌÔÚÔ‡Û·Ó Ó· ÂÌϤÎÔÓÙ·È Û ·Ù˘¯‹Ì·Ù· Ì Ì˯·ÓÈÛÌfi ‰È·ÊÔÚÂÙÈÎfi ·fi ·˘ÙfiÓ Ù˘ ÌÂÙ¿‰ÔÛ˘ ıÂÚÌfiÙËÙ·˜. ™‡Ìʈӷ Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ê·›ÓÂÙ·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ¯ÒÚ˜ Ì ‡ÎÚ·ÙÔ Îϛ̷, Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ Ì¤Ûˆ Ì˯·ÓÈÛÌÒÓ ÌÂÙ·ÊÔÚ¿˜ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (ÙÒÛË, Û‡ÁÎÚÔ˘ÛË Î·È ÁÏ›ÛÙÚËÌ·) Î·È fi¯È ıÂÚÌfiÙËÙ·˜ (¤Áη˘Ì·). ∏ ˘ÂÚÔ¯‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È ÙfiÛÔ ÛËÌ·ÓÙÈ΋, Ô˘ ıˆÚÂ›Ù·È Èı·Ófi Ù· ·Ù˘¯‹Ì·Ù· Ì Ì˯·ÓÈÛÌfi ÌÂÙ·ÊÔÚ¿˜ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Ó· ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ Û˘ÓÔÏÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÎfiÌ· Î·È Û ¯ÒÚ˜ Ì „˘¯ÚfiÙÂÚÔ Îϛ̷. O ¯·ÌËÏfi˜ ÂÈÔÏ·ÛÌfi˜ ÙˆÓ ÂÁη˘Ì¿ÙˆÓ ÛÙË ÌÂϤÙË ·˘Ù‹ ·ÓÙ·Ó·ÎÏ¿ Èı·ÓÒ˜ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÛÙËÓ ∂ÏÏ¿‰· ·ÔÙÂÏÔ‡Ó ·ÁˆÁÔ‡˜ ˙ÂÛÙÔ‡ ÓÂÚÔ‡, ÙÔ ÔÔ›Ô Û¿ÓÈ· ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 50ÔC, ıÂÚÌÔÎÚ·Û›· Ô˘ ‰ÂÓ ÚÔηÏ› ‡ÎÔÏ· ıÂÚÌÈΤ˜ ‚Ï¿‚˜. ∞ÓÙ›ıÂÙ·, Ë ıÂÚÌÔÎÚ·Û›· ÙˆÓ ·ÁˆÁÒÓ ·ÙÌÔ‡ Â›Ó·È Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚË, ˘ÂÚ‚·›ÓÔÓÙ·˜ Û˘¯Ó¿ ÙÔ˘˜ 90ÔC, ıÂÚÌÔÎÚ·Û›· Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ¿ÌÂÛ· ÛÔ‚·Ú¿ ÂÁη‡Ì·Ù· ÛÙÔ ‰¤ÚÌ· (6,13,14). ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘, Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÂÌϤÎÔÓÙ·È Û ÂÚ›Ô˘ 1/40 ·È‰Èο ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. O ·ÚÈıÌfi˜ ·˘Ùfi˜ ÌÔÚ› Ó· ÌËÓ Ê·›ÓÂÙ·È ÂÓÙ˘ˆÛÈ·Îfi˜, ·ÏÏ¿ Ë ÂÌÂÈÚ›· ¤¯ÂÈ Î·Ù·‰Â›ÍÂÈ fiÙÈ Ë ·Í›· Ù˘ ÚfiÏ˄˘ ¤ÁÎÂÈÙ·È ÛÙËÓ ÂÓ·Û¯fiÏËÛË ·ÎfiÌË Î·È Ì ÌÈÎÚ¿ Û¯ÂÙÈο ÚÔ‚Ï‹Ì·Ù·, ¤ÙÛÈ ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó ÙÂÏÈο ÌÂÁ¿Ï· ‚‹Ì·Ù· (15). ∏ ÚfiÏË„Ë ÛÙÔÓ ÙÔ̤· ·˘Ùfi ·ʛÂÙ·È ·Ú¯ÈÎÒ˜ ÛÙÔ˘˜ ÁÔÓ›˜ Î·È ÊÚÔÓÙÈÛÙ¤˜ ÙˆÓ ·È‰ÈÒÓ, ÔÈ ÔÔ›ÔÈ Ú¤ÂÈ Ó· ÂÓËÌÂÚˆıÔ‡Ó ·fi ÙÔ˘˜ ÁÂÓÈÎÔ‡˜ È·ÙÚÔ‡˜ Î·È ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜. ∆Ô ÁÂÓÈÎfiÙÂÚÔ ÚfiÙ˘Ô ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÊÔÚ¿ ΢ڛˆ˜ Û ÌÈÎÚfiÙÂÚ· ·È‰È¿ Î·È ÂȉÈÎfiÙÂÚ· ·ÁfiÚÈ·, Û˘Ó‹ıˆ˜ ηٿ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘, fiÙ·Ó Ù· ·È‰È¿ ÂÚÈÔÚ›˙Ô˘Ó ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘˜ ÛÙÔ ¯ÒÚÔ ÛÙÔ ÛÈÙÈÔ‡. ∏ Û˘Ó‹ı˘ ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ Â›Ó·È Â·Ú΋˜ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, Ù· ÔÔ›· Û˘Ì‚·›ÓÔ˘Ó Î˘Ú›ˆ˜ fiÙ·Ó Ù· ·È‰È¿ ·›˙Ô˘Ó Î·È ÛÚÒ¯ÓÔÓÙ·È Û ÂÚÈÔÚÈṲ̂ÓÔ ¯ÒÚÔ. §fiÁˆ Ù˘ ηٷÛ΢‹˜ ÙˆÓ ·Ï·ÈfiÙÂÚˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Ì ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜, Ù· ·Ù˘¯‹Ì·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Û˘¯Ó¿ ·ÊÔÚÔ‡Ó Û ·ÓÔȯ٤˜ ηÎÒÛÂȘ Ù˘ ÎÂÊ·Ï‹˜ Ô˘ ¯Ú‹˙Ô˘Ó È·ÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘.
JAN-FEB-03
14-05-03
14:37
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¶·È‰È·ÙÚÈ΋ 2003;66:20-28
™‡Ìʈӷ Ì ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Î·Ù¿ Û˘ÛÙ¿‰Â˜, ÔÈ ÚÔÛ¿ıÂȘ ÚfiÏ˄˘ ı· Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÔÓÙ·È Î˘Ú›ˆ˜ Û ÙÚÂȘ ÔÌ¿‰Â˜. ∏ ÚÒÙË ·ÊÔÚ¿ ÛÙ· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Î˘Ú›ˆ˜ ÛÙ· ·ÁfiÚÈ·, Ô˘ ˘Ê›ÛÙ·ÓÙ·È Ì¤Û· Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ ÛÔ‚·ÚÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜, fiˆ˜ ηٿÁÌ·Ù·, ›Ûˆ˜ ÏfiÁˆ Ù˘ ‰˘Ó·ÌÈÎfiÙËÙ·˜ Ô˘ Ù· ¯·Ú·ÎÙËÚ›˙ÂÈ Î·Ù¿ Ù· ÂÚÈ-ÂÊË‚Èο ¯ÚfiÓÈ·. ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·È‰È¿ Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜, Ù· ÔÔ›· ÚÔÛ·ıÒÓÙ·˜ Ó· ·Ó¤‚Ô˘Ó ¿Óˆ ÛÙ· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, ¤ÊÙÔ˘Ó ÛÙÔ ‰¿Â‰Ô Î·È ˘Ê›ÛÙ·ÓÙ·È Û˘¯Ó¿ ‰È¿ÛÂÈÛË ‹ Î·È Î·ÎÒÛÂȘ ÙÔ˘ ÎÚ·Ó›Ô˘. ∆¤ÏÔ˜, Ë ÙÚ›ÙË ÔÌ¿‰· ·ÊÔÚ¿ Û ·È‰È¿ ÌÂÙ·Ó·ÛÙÒÓ, ·ÏÏ¿ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ ηٷÛ΢·ÛÙÈο ÂÏ·ÙÙÒÌ·Ù· Ù˘ ˘Ô‰ÔÌ‹˜ ÙˆÓ Û¯ÔÏ›ˆÓ Û ˘Ô‚·ıÌÈṲ̂Ó˜ Û˘ÓÔÈ˘, ÛÙȘ Ôԛ˜ Û˘¯Ó¿ ηÙÔÈÎÔ‡Ó Ù· ·È‰È¿ ·˘Ù¿. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÓËÁÔÚÔ‡Ó Î·È ˘¤Ú ÔÏÏÒÓ Î·Ù¢ı˘ÓÙ‹ÚÈˆÓ Ô‰ËÁÈÒÓ Û¯ÂÙÈο Ì ÙËÓ Î·Ù·Û΢‹ ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘: ·) Ë ÂÈÊ¿ÓÂÈ· ÙˆÓ ÛˆÌ¿ÙˆÓ ı· Ú¤ÂÈ Ó· Â›Ó·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ Â›Â‰Ë, ÂÓÒ Ù· ÛÒÌ·Ù· ·Ï·ÈfiÙÂÚ˘ ηٷÛ΢‹˜ Ô˘ ¤¯Ô˘Ó ÔÏϷϤ˜ ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜ ı· Ú¤ÂÈ ÛÙ·‰È·Î¿ Ó· ·ÓÙÈηٷÛÙ·ıÔ‡Ó, ‚) Ù· ÛÒÌ·Ù· Ì ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜ Ô˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÔÛ˘ÚıÔ‡Ó ı· Ú¤ÂÈ Ó· ÂÚÈ‚ÏËıÔ‡Ó ·fi ¿ÏÏÔ, Â›Â‰Ô ˘ÏÈÎfi, Á) Ù· ÎÚ‚¿ÙÈ· ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ı· Ú¤ÂÈ Ó· Â›Ó·È ÙÔÔıÂÙË̤ӷ ÎÔÓÙ¿ ÛÙ· ÛÒÌ·Ù·, ηıÒ˜ Ù· ·È‰È¿ Û˘¯Ó¿ ÙÔÔıÂÙÔ‡Ó ÂΛ Ù· ¯¤ÚÈ· ÙÔ˘˜ ‹, ¤ÊÙÔÓÙ·˜ ·fi ÙÔ ÎÚ‚¿ÙÈ, ÂÁÎψ‚›˙ÔÓÙ·È ·Ó¿ÌÂÛ· Û ·˘Ùfi Î·È ÙÔ ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ‰) Ù· ÛÒÌ·Ù· ‰ÂÓ ı· Ú¤ÂÈ Ó· ÙÔÔıÂÙÔ‡ÓÙ·È Û ÁˆÓȤ˜ ÙÔ˘ ÛÈÙÈÔ‡ Ô˘ Â›Ó·È ÁÂÌ¿Ù˜ Ì ¤ÈÏ·, Â) Ù· ÛÒÌ·Ù· ı· Ú¤ÂÈ Ó· Â›Ó·È ¤ÙÛÈ ÙÔÔıÂÙË̤ӷ ÒÛÙ ӷ ÌËÓ ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ù· ·È‰È¿ Ó· ÏËÛÈ¿ÛÔ˘Ó ÂÓÒ ·›˙Ô˘Ó ÛÙÔ˘˜ ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜ ÙÔ˘ ÛÈÙÈÔ‡, ÛÙ) ÎÈÓËÙ¿ ·ÓÙÈΛÌÂÓ· ÌÂٷ͇ ÙÔ˘ ıÂÚÌ·ÓÙÈÎÔ‡ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ¯ÒÚÔ˘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Ù· ·È‰È¿ ÁÈ· Ó· ·›˙Ô˘Ó ı· Ú¤ÂÈ Ó· ·ÔÌ·ÎÚ‡ÓÔÓÙ·È, ˙) Ù· ÌÈÎÚ¿ ·È‰È¿ ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÈÙÚ¤ÂÙ·È Ó· ·Ó‚·›ÓÔ˘Ó ¿Óˆ ÛÙ· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· (·Ï¤˜ ÚÔÊ˘Ï¿ÍÂȘ, fiˆ˜ Ë ÙÔÔı¤ÙËÛË ÌÈ·˜ ηڤÎÏ·˜ ‹ ÂÓfi˜ ÙÚ·Â˙ÈÔ‡ ÌÚÔÛÙ¿ ·fi ÙÔ ÛÒÌ·, ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ Â›ÙˆÛË ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ) Î·È Ë) Û ۯÔÏ›· Î·È ‰ËÌfiÛÈ· ÎÙ›ÚÈ·, ηٿ ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘, Ë ·ÛÊ¿ÏÂÈ· ÙˆÓ ·È‰ÈÒÓ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› ¿ÌÂÛË ÚÔÙÂÚ·ÈfiÙËÙ·, ›Û˘ ‚·Ú‡ÙËÙ·˜ Ì ÙËÓ ÂÓÂÚÁÂȷ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜. O ¤ÏÂÁ¯Ô˜ Ù˘ ·ÛÊ·ÏÔ‡˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î·Ù·Û΢‹˜ ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÌÔÚ› Ó· Á›ÓÂÈ Ì ‚¿ÛË ÙȘ ÚԉȷÁڷʤ˜ Ô˘ ηıÔÚ›˙ÔÓÙ·È ·fi ÙÔÓ ∂ÏÏËÓÈÎfi OÚÁ·ÓÈÛÌfi ∆˘ÔÔ›ËÛ˘ (16).
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∏ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÚÔÎÏ‹ÛÂȘ ÛÙÔ ¯ÒÚÔ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Î·È Ù˘ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ ·ÁÎÔÛÌ›ˆ˜ (17). À¿Ú¯ÂÈ Ì›· Ù¿ÛË ·Ó·ÁÓÒÚÈÛ˘ Ù·˘ÙÔÔÈ‹ÛÈÌˆÓ ·ÈÙÈÒÓ ÁÈ· οı ·Ù‡¯ËÌ·, ÔÈ Ôԛ˜ ÌÔÚÔ‡Ó Ù·˘Ùfi¯ÚÔÓ· Ó· ÚÔ‚ÏÂÊıÔ‡Ó Î·È Ó· ÚÔÏËÊıÔ‡Ó (18). ∏ Ù¿ÛË ·˘Ù‹ ÌÔÚ› Ó· Ê·›ÓÂÙ·È ·ÎÚ·›·, ·ÏÏ¿ Â›Ó·È Û›ÁÔ˘Ú· ·ÍȤ·ÈÓË, ηı’ fiÙÈ ÚÔ¿ÁÂÈ ÙÔÓ ÂÓıÔ˘ÛÈ·ÛÌfi Î·È ÂÓÈÛ¯‡ÂÈ ÙËÓ ¤Ú¢ӷ Î·È ÙÔÓ ·ÎÙÈ‚ÈÛÌfi ÛÙÔ ¯ÒÚÔ Ù˘ ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™ÙÔ Ï·›ÛÈÔ ·˘Ùfi, Ë ÂÈÛ‹Ì·ÓÛË ÙÔ˘ ÚÔÊ›Ï ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜, ¤ÛÙˆ Î·È ÂÓfi˜ ÌÈÎÚÔ‡ ÔÛÔÛÙÔ‡ (2,4% Û ·˘Ù‹ ÙË ÌÂϤÙË) ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÌÔÚ› Ó· ıˆÚËı› ˆ˜ ¤Ó· ÌÈÎÚfi, ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi ‚‹Ì· ÛÙÔÓ ÙÔ̤· Ù˘ ÚfiÏ˄˘ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Home and Leisure Accident Research (HALAR). Fourteenth Annual Report of the Home Accident Surveillance System. London: Consumer Safety Unit, Department of Trade and Industry; 1990. 2. US Consumer Product Safety Commission. 1993 Product Summary Report. Washington; DC: National Electronic Injury Surveillance System; 1994. 3. Datubo-Brown DD, Gowar JP. Contact burns in children. Burns 1989;15:285-286. 4. Harper RD, Dickson WA. Domestic central heating radiators: a cause for concern in all age groups. Burns 1996;22:217-220. 5. Hurren JS, Dunn KW. Entrapment against radiators - an underestimated burn hazard to the elderly. Burns 1993;19:522-523. 6. Quinlan KP. Injury control in practice. Home radiator burns in inner-city children. Arch Pediatr Adolesc Med 1996;150:954-957. 7. EHLASS. European Home and Leisure Surveillance System Coding manual; 1986. 8. NOMESCO. Nordic Medico-Statistical Committee; May, 1994. 9. World Health Organization. International Classification of Diseases. 9th rev. Geneva, Switzerland: World Health Organization; 1980. 10. Miettinen OS. The “case-control” study: valid selection of subjects. J Chronic Dis 1985;38:543-548. 11. SAS/STAT User’s Guide, Version 6. 4th Edition; 1990. SAS Institute Inc. 12. Seretakis D, Lagiou P, Lipworth L, Signorello LB, Rothman KJ, Trichopoulos D. Changing seasonality of mortality from coronary heart disease. JAMA 1997;278:1012-1014. 13. Feldman KW, Schaller RT, Feldman JA, McMillon M. Tap water scald burns in children. Pediatrics 1978;62:1-7. 14. American Academy of Pediatrics Committee on Injury and Poison Prevention. Office-based counseling for injury prevention. Pediatrics 1991;88:1112-1118. 15. Petridou E. Injury prevention: an uphill battle (annotation). Inj Prev 1995;1:8.
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16. ∂ÏÏËÓÈÎfi˜ OÚÁ·ÓÈÛÌfi˜ ∆˘ÔÔ›ËÛ˘ (∂§O∆). www.elot.gr 17. Rivara FP, Aitken M. Prevention of injuries to children and adolescents. Adv Pediatr 1998;45:37-72. 18. Davis RM, Pless B. BMJ bans “accidents”. BMJ 2001;322:1320-1321.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ¶ÂÙÚ›‰Ô˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ª. ∞Û›·˜ 75, ∆.∫. 115 27, °Ô˘‰› E-mail: epetrid@med.uoa.gr
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂Ó‰ÔÓÔÛÔÎÔÌÂȷ΋ Û‹„Ë Û Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿: Ë ÂÌÂÈÚ›· ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘ - ¢›ÎÙ˘Ô ¤Ú¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜1 ™ÎÔfi˜: OÈ fi„ÈÌ· ÂÌÊ·ÓÈ˙fiÌÂÓ˜ ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ ‹, fiˆ˜ ÔÓÔÌ¿˙ÔÓÙ·È, ÂÓ‰ÔÓÔÛÔÎÔÌÂȷΤ˜ ÏÔÈÌÒÍÂȘ (∂¡§) Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î˘Ú›ˆ˜ ÌÂÙ¿ ÙËÓ ÙÚ›ÙË Ë̤ڷ ˙ˆ‹˜, ·ÔÙÂÏÔ‡Ó ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÁÈ· Ù· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ (¶Ãµ°) ÓÂÔÁÓ¿. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó Ù· ÔÛÔÛÙ¿ ÙˆÓ ∂¡§, ÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ë Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙËÓ ÔÚ›· ÙˆÓ ÓÂÔÁÓÒÓ Î·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∂ÎÙÈÌ‹ıËΠ̛· ÔÌ¿‰· 6956 ¶Ãµ° (µ°=401-1500 g) ÓÂÔÁÓÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙ· ÎÏÈÓÈο ΤÓÙÚ· ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘-¢›ÎÙ˘Ô ŒÚ¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜ ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1998-2000. ∆Ô ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘-¢›ÎÙ˘Ô ŒÚ¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜ ‰È·ÙËÚ› ¤Ó· Ï‹Ú˜ ·Ú¯Â›Ô ηٷÁÚ·Ê‹˜ fiÏˆÓ ÙˆÓ ÂÈÛ·ÁfiÌÂÓˆÓ ¶Ãµ° ÓÂÔÁÓÒÓ ÛÙ· Û˘ÌÌÂÙ¤¯ÔÓÙ· ÓÂÔÁÓÈο ΤÓÙÚ· ̤۷ Û ‰Âη٤ÛÛÂÚȘ Ë̤Ú˜ ·fi ÙË Á¤ÓÓËÛË. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 6215 ÓÂÔÁÓ¿ Ô˘ ¤˙ËÛ·Ó ¤Ú·Ó ÙˆÓ 3 ËÌÂÚÒÓ, Ù· 1313 (21%) ·ÚÔ˘Û›·Û·Ó ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È·, ÂȂ‚·ÈˆÌ¤Ó˘ Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, fi„ÈÌ˘ ÛË„·ÈÌ›·˜. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ (70%) ÔÊÂÈÏfiÙ·Ó Û Gram ıÂÙÈο ÌÈÎÚfi‚È·, Ì ÙÔ˘˜ ÎÔ·ÁÎÔ˘Ï¿ÛË ·ÚÓËÙÈÎÔ‡˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘˜ Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ 48% ÙˆÓ ∂¡§. ∆Ô ÔÛÔÛÙfi ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‹Ù·Ó ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁÔ ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È Ù˘ ËÏÈΛ·˜ ·ËÛ˘. OÈ ÂÈÏÔΤ˜ Ù˘ ÚÔˆÚfiÙËÙ·˜, fiˆ˜ Ô ·ÓÔÈÎÙfi˜ ‚ÔÙ¿ÏÂÈÔ˜ fiÚÔ˜, Ô ·Ú·ÙÂ-
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ٷ̤ÓÔ˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Ë ·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË ·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ, Ë ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· Î·È Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ‚Ú¤ıËΠӷ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ∂¡§. ∆· ÓÂÔÁÓ¿ Ô˘ ·ÚÔ˘Û›·Û·Ó ∂¡§ ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ (ηٿ ̤ÛÔ fiÚÔ 76 ¤Ó·ÓÙÈ 60 ËÌÂÚÒÓ). ∆· ·È‰È¿ Ì ∂¡§ ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· Âı¿ÓÔ˘Ó ·’ fiÙÈ ÂΛӷ ¯ˆÚ›˜ Ïԛ̈ÍË (18% ¤Ó·ÓÙÈ 7%). O ΛӉ˘ÓÔ˜ ÁÈ· ı¿Ó·ÙÔ ‹Ù·Ó ȉȷ›ÙÂÚ· ÌÂÁ¿ÏÔ˜ fiÙ·Ó Ë Ïԛ̈ÍË ÔÊÂÈÏfiÙ·Ó Û Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· (36%) ‹ Û ̇ÎËÙ˜ (32%). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ fi„ÈÌË Û‹„Ë ·ÔÙÂÏ› ¤Ó·Ó ÛËÌ·ÓÙÈÎfi ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ı·Ó¿ÙÔ˘ ÛÙ· ¶Ãµ° ÓÂÔÁÓ¿, ηıÒ˜ ›Û˘ Î·È ÛÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ ÙˆÓ ÂÈ˙ÒÓÙˆÓ. OÈ ÛÙÚ·ÙËÁÈΤ˜ Ì›ˆÛ˘ Ù˘ fi„ÈÌ˘ Û‹„˘ Î·È ÙˆÓ Û˘ÓÂÂÈÒÓ Ù˘ ÎÚ›ÓÔÓÙ·È ¿ÎÚˆ˜ ÂÈÙ·ÎÙÈΤ˜.
1 Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz R et al Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network Pediatrics 2002;110:285-291
™‡ÚÔ˜ ºˆÙfiÔ˘ÏÔ˜ ¶·È‰›·ÙÚÔ˜-¡ÂÔÁÓÔÏfiÁÔ˜ ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ µ’ ª∂¡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
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ORIGINAL ARTICLE
O fiÓÔ˜ ÛÙ· ÓÂÔÁÓ¿ µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜
Pain in neonates V. Drossou - Agakidou, K. Sarafidis, P. Karagianni, G. Kremenopoulos
¶ÂÚ›ÏË„Ë: ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (ª∂¡¡) Û¯ÂÙÈο Ì ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ, ηıÒ˜ Î·È ÙˆÓ Ù·ÎÙÈÎÒÓ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙȘ ª∂¡¡. ∞ÓÒÓ˘Ì· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÂÛÙ¿ÏËÛ·Ó ÛÙÔ È·ÙÚÈÎfi ÚÔÛˆÈÎfi Î·È ÛÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ 14 ª∂N¡ ‰ËÌfiÛÈˆÓ Î·È È‰ÈˆÙÈÎÒÓ ÓÔÛÔÎÔÌ›ˆÓ Û fiÏË ÙËÓ ∂ÏÏ¿‰·. ∞ÓÙ·ÔÎÚ›ıËÎ·Ó 106/117 ÁÈ·ÙÚÔ› (90,6%) ·fi 13 ª∂¡¡. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù·, fiÏÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ Ô˘ ¤¯ÂÈ Ô fiÓÔ˜ Û ·˘Ù¿. ∏ ·Ó·ÏÁËÛ›·-ηٷÛÙÔÏ‹ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÌË Â›ÁÔ˘Û·˜ ‰È·ÛˆÏ‹ÓˆÛ˘ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ·fi ÙÔ 81%, 60% Î·È 96% ÙˆÓ ÁÈ·ÙÚÒÓ, ·ÓÙ›ÛÙÔȯ·. øÛÙfiÛÔ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·Ó·ÏÁËÛ›· ÚÈÓ ·fi ÙȘ ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. ¶·Ú¿ÏÏËÏ·, Ë ÏÂÈÔ„ËÊ›· ÈÛÙ‡ÂÈ fiÙÈ ‰È¿ÊÔÚ· ÌË Ê·Ú̷΢ÙÈο ̤ÙÚ· ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙÔÓ fiÓÔ Î·È ÙË ‰˘ÛÊÔÚ›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. ™ÙÔ ÂȉÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÈ· ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÛÙȘ ÌÔÓ¿‰Â˜ ·¿ÓÙËÛ·Ó 12 ‰È¢ı˘ÓÙ¤˜. ªfiÓÔ Û 4/12 ª∂¡¡ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘. ∏ ·Ó·ÏÁËÛ›·-ηٷÛÙÔÏ‹ ÌÂÙÂÁ¯ÂÈÚËÙÈο ·ÔÙÂÏ› ¿ÁÈ· Ù·ÎÙÈ΋ Û fiϘ ÙȘ ª∂¡¡, ÂÓÒ ÌfiÓÔ Û 9 ¯ÔÚËÁÂ›Ù·È Û˘¯Ó¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È Û 1 ÚÈÓ ·fi ÙË ÌË Â›ÁÔ˘Û· ‰È·ÛˆÏ‹ÓˆÛË. ∆¤ÏÔ˜, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜
Abstract: The objective of the study was to identify views of Greek doctors as to pain perception by neonates and determine current practices regarding pain management in neonatal intensive care units (NICUs). Anonymous postal questionnaires were sent to 117 doctors working in 14 NICUs across Greece concerning their personal views and to 14 heads of NICUs concerning current practices. Overall, 106/117 (90.6 %) doctors working in 13 NICUs responded. All responders believe that neonates experience pain and are aware of the harmful effects pain and stress may have on them. Analgesia and sedation are regarded as necessary or important during mechanical ventilation, prior to non-emergency endotracheal intubation and postoperatively by 81%, 60% and 96% of the doctors, respectively. However, most doctors stated that analgesia is unnecessary during minor procedures, in all but chest tube placement. Most doctors stated that non-pharmacologic measures are effective in decreasing pain and discomfort during minor procedures. The questionnaires regarding NICUs’ practices were returned completed by 12 directors. Only in 4/12 NICUs there is a certain protocol for pain prevention and management. Analgesia-sedation administration postoperatively is a standard practice in all NICUs, whereas during mechanical ventilation it is often given in 9/12 NICUs and prior to nonemergency intubation in only one. Non-pharmacologic measures to reduce exposure to noxious stimuli and alleviate pain during minor procedures are used in most NICUs. Greek neonatologists believe that neonates experience pain and are aware
¡ÂÔÁÓÔÏÔÁÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ∞.¶.£ πÔÎÚ¿ÙÂÈÔ °¶¡ £ÂÛ/ӛ΢
Department of Neonatology, Aristotelion University of Thessaloniki, Ippokration General Hospital, Thessaloniki
29
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·30
¶·È‰È·ÙÚÈ΋ 2003;66:29-36
Paediatriki 2003;66:29-36
ª∂¡¡ ÂÊ·ÚÌfi˙ÔÓÙ·È ‰È¿ÊÔÚ· ÌË Ê·ÚÌ·ÎÔÏÔÁÈο ̤ÙÚ· ÁÈ· ÙË Ì›ˆÛË Ù˘ ¤ÎıÂÛ˘ Û ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. OÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȤ˜ ÙÔ˘ Û ·˘Ù¿. ∂ÓÒ Ô ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ fiÓÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Â·ÚÎÒ˜, ‰ÂÓ Û˘Ì‚·›ÓÂÈ ÙÔ ›‰ÈÔ Î·È Ì ÙÔÓ fiÓÔ Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÏϘ È·ÙÚÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ. OÈ ÌË Ê·Ú̷΢ÙÈÎÔ› ÙÚfiÔÈ Ì›ˆÛ˘ ÙÔ˘ fiÓÔ˘ Â›Ó·È Â˘Ú¤ˆ˜ ·Ú·‰ÂÎÙÔ› ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜.
of the harmful effects that pain and stress may have on them. Postoperative pain is treated adequately, whereas procedural pain is not. Nonpharmacologic measures are widely accepted.
§¤ÍÂȘ ÎÏÂȉȿ: fiÓÔ˜, ·Ó·ÏÁËÛ›·, ηٷÛÙÔÏ‹, ÓÂÔÁÓfi.
Key words: pain, analgesia, sedation, neonate.
∂ÈÛ·ÁˆÁ‹ ∏ ÂÓÙ·ÙÈ΋ ıÂڷ›· ÙˆÓ ÓÂÔÁÓÒÓ ÛÙȘ Û‡Á¯ÚÔÓ˜ ÌÔÓ¿‰Â˜ Û˘Óԉ‡ÂÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È ÂÒ‰˘ÓÔÈ ‹ ÚÔηÏÔ‡Ó ‰˘ÛÊÔÚ›· (1). øÛÙfiÛÔ, Ô fiÓÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ηÈ, ηٿ Û˘Ó¤ÂÈ·, οı ÙÚfiÔ˜ Ê·Ú̷΢ÙÈ΋˜ ‹ ÌË ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ Â›Ó·È Î¿ÙÈ Ô˘ ̤¯ÚÈ ÚfiÛÊ·Ù· ›¯Â ·ÁÓÔËı› ÂÛÊ·Ï̤ӷ, ηıÒ˜ ˘‹Ú¯Â Ë ·ÓÙ›ÏË„Ë fiÙÈ Ù· ÓÂÔÁÓ¿ Î·È È‰È·›ÙÂÚ· Ù· ÚfiˆÚ· ‰ÂÓ ÔÓÔ‡Ó. ∂›Ó·È ϤÔÓ Û·Ê¤˜ fiÙÈ Ù· ÓÂÔÁÓ¿ ‰È·ı¤ÙÔ˘Ó ÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ Î·È ·Ó·ÙÔÌÈ΋ ˆÚÈÌfiÙËÙ· Ô˘ Ù· ηıÈÛÙ¿ Èηӿ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ, ·ÎfiÌË Î·È ·Ó Â›Ó·È ÚfiˆÚ· (2). ª¿ÏÈÛÙ·, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÂÌÊ·Ó›˙Ô˘Ó ·ÚfiÌÔȘ ‹ ·˘ÍË̤Ó˜, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜, ÔÚÌÔÓÈΤ˜ Î·È ÌÂÙ·‚ÔÏÈΤ˜ ··ÓÙ‹ÛÂȘ (3). ∂ÈϤÔÓ, Ù· ÚfiˆÚ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ú·ÙÂٷ̤Ó˜ ÂÚÈfi‰Ô˘˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜, ·ÎfiÌË Î·È Û ÌË ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù·, ÏfiÁˆ ÂÏ·Ùو̤ÓÔ˘ Ô˘‰Ô‡ ÙÔ˘ fiÓÔ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÍË̤ÓË ‰ÈÂÁÂÚÛÈÌfiÙËÙ· ÙˆÓ Ô›ÛıÈˆÓ ÎÂÚ¿ÙˆÓ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡, ÁÂÁÔÓfi˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ “Ê·ÈÓfiÌÂÓÔ ¯ÔÚ‰›ÛÌ·ÙÔ˜” (4,5). ∆·˘Ùfi¯ÚÔÓ·, ÏËı·›ÓÔ˘Ó ÔÈ ÂӉ›ÍÂȘ fiÙÈ Ô fiÓÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ, ¿ÌÂÛ˜ ‹ ·ÒÙÂÚ˜ (3,6). ∏ ηٷÓfiËÛË Ù˘ ÛËÌ·Û›·˜ ÙÔ˘ fiÓÔ˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ó· ˘¿ÚÍÔ˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ηÙ¢ı‡ÓÛÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress ÛÙ· ÓÂÔÁÓ¿ ·fi ÊÔÚ›˜ fiˆ˜ Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ (American Academy of Pediatrics) Î·È Ë ∫·Ó·‰È΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· (Canadian Paediatric Society) (7). øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ‰ÈÂıÓÒ˜ ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·fi ÙȘ ‰È¿ÊÔÚ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (MENN), ·ÏÏ¿ Î·È ÛÙȘ ·fi„ÂȘ ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ Ô˘ ÂÚÁ¿-
˙ÔÓÙ·È Û ‰È·ÊÔÚÂÙÈο ‹ Î·È ÛÙÔ ›‰ÈÔ ÙÌ‹Ì·, ·Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ ÛÙ· ÓÂÔÁÓ¿ (8). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ª∂¡¡ ·Ó·ÊÔÚÈο Ì ÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È ÙËÓ ·Ó·ÁηÈfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘. ∂›Û˘, ηٷÁÚ¿ÊËÎ·Ó ÔÈ ÙÚ¤¯Ô˘Û˜ Ù·ÎÙÈΤ˜ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜, Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙ· ÙÚÈÙÔ‚¿ıÌÈ· ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Ù˘ ∂ÏÏ¿‰·˜.
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ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∂ȉÈο ·ÓÒÓ˘Ì· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÂÛÙ¿ÏËÛ·Ó Û 14 ‰ËÌfiÛȘ Î·È È‰ÈˆÙÈΤ˜ ª∂¡¡ Ù˘ ¯ÒÚ·˜, ·ÊÔ‡ ÚÔËÁ‹ıËΠÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›· ÂÓfi˜ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Ì ÙÔ ‰È¢ı˘ÓÙ‹ οı ÌÔÓ¿‰·˜. ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi Ì›· ÂÓfiÙËÙ· Ô˘ ·Â˘ı˘ÓfiÙ·Ó ÛÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Î·È ·ÊÔÚÔ‡Û ÙȘ ÚÔÛˆÈΤ˜ ÙÔ˘˜ ·fi„ÂȘ ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ï‹„˘ ̤ÙÚˆÓ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ Î·È ·fi Ì›· ¿ÏÏË ÂÓfiÙËÙ· Ô˘ ·Â˘ı˘ÓfiÙ·Ó ÛÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ Î·È ·ÊÔÚÔ‡Û ÙËÓ Ù·ÎÙÈ΋ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙË ª∂¡¡ Ô˘ ‰È¢ı‡ÓÔ˘Ó.
∞ÔÙÂϤÛÌ·Ù· ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ÂÈÛÙÚ¿ÊËÎ·Ó Û˘ÌÏËڈ̤ӷ ·fi 13 ª∂¡¡, 11 ‰ËÌfiÛȘ Î·È 2 ȉȈÙÈΤ˜. OÈ ÌÔÓ¿‰Â˜ Ô˘ ·¿ÓÙËÛ·Ó ÛÙÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ‹Ù·Ó ÔÈ ·ÎfiÏÔ˘ı˜: ∞’ ª∂¡¡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, µ’ ª∂¡¡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·ÙÚÒÓ “ÕÁÈÔ˜ ∞Ó‰Ú¤·˜”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∞ÏÂÍ¿Ó‰Ú·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∂. µÂÓÈ˙¤ÏÔ˘”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·31
¶·È‰È·ÙÚÈ΋ 2003;66:29-36
Paediatriki 2003;66:29-36
“π·ÛÒ”, ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “ªËÙ¤Ú·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¡›Î·È·˜ ¶ÂÈÚ·ÈÒ˜, ª∂¡¡ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ƒ›Ô˘ Î·È ¡ÂÔÁÓÔÏÔÁÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ πÔÎÚ¿ÙÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢. ∂ÚˆÙ‹ıËÎ·Ó Û˘ÓÔÏÈο 117 ÁÈ·ÙÚÔ› Î·È ·¿ÓÙËÛ·Ó 106 (90,6%). ∏ ηٷÓÔÌ‹ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ·Ó·ÏÔÁ›· ÂȉÈÎÒÓ ÓÂÔÁÓÔÏfiÁˆÓ, ÂȉÈÎÒÓ ·È‰È¿ÙÚˆÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Î·È ÂÍÂȉÈ΢fiÌÂÓˆÓ ÛÙË ¡ÂÔÁÓÔÏÔÁ›· Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™ÙÔ ÂȉÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÈ· ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ı› Ë ª∂¡¡ ·¿ÓÙËÛ·Ó 12/13 ‰È¢ı˘ÓÙ¤˜. ∞fi„ÂȘ ÙˆÓ ÁÈ·ÙÚÒÓ OÈ ÂÚˆÙËı¤ÓÙ˜ È·ÙÚÔ› ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿, ·ÎfiÌË Î·È Ù· ÚfiˆÚ·, ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘Û¿ÚÂÛÙ˜ Û˘Ó¤ÂȘ Ô˘ ¤¯ÂÈ Ô fiÓÔ˜ Î·È ÙÔ stress Û ·˘Ù¿. ™ÙÔÓ ¶›Ó·Î· 2 ηٷÁÚ¿ÊÔÓÙ·È ÔÈ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÛÙ· ‰È¿ÊÔÚ· fiÚÁ·Ó· Î·È Û˘ÛÙ‹Ì·Ù· Î·È Ë Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ·Ó·Ê¤ÚıËÎ·Ó ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› (81%) ıˆÚÔ‡Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Â›Ó·È ··Ú·›ÙËÙË (23%) ‹ ÛËÌ·ÓÙÈ΋ (58%). ¶·Ú¿ÏÏËÏ·, Ë ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˘ ÌË Â›ÁÔ˘Û·˜ ‰È·ÛˆÏ‹ÓˆÛ˘ ÎÚ›ÓÂÙ·È ˆ˜ ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋ ·fi ÙÔ 14% Î·È 46% ÙˆÓ ÂÚˆÙËı¤ÓÙˆÓ, ·ÓÙ›ÛÙÔȯ·. ™¯ÂÙÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ Û ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ fiˆ˜ ·˘Ù¤˜ Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ıˆÚÔ‡Ó ··Ú·›ÙËÙË ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. øÛÙfiÛÔ, ÙÔ 81% ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó ÛÙËÓ ÂÚÒÙËÛË ·˘Ù‹ ıˆÚ› ··Ú·›ÙËÙË ÙË ¯Ú‹ÛË ÙÔÈÎÒÓ ·Ó·ÈÛıËÙÈÎÒÓ ÚÈÓ ÙȘ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ. ∞Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο ÛÙ· ÓÂÔÁÓ¿, ÙÔ 96% ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÙË ¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ È·ÙÚÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË
™‡ÓÔÏÔ ¡ÂÔÁÓÔÏfiÁÔÈ ∂ÍÂȉÈ΢fiÌÂÓÔÈ ¶·È‰›·ÙÚÔÈ
ÕÓ‰Ú˜
°˘Ó·›Î˜
™‡ÓÔÏÔ
35 (33%) 30 2 3
71 (67%) 49 16 6
106 (100%) 79 (74,5%) 18 (17%) 9 (8,5%)
ıˆÚ› ··Ú·›ÙËÙË (78%) ‹ ÛËÌ·ÓÙÈ΋ (18%). ¶Ôχ ÌÈÎÚfi (4%) ‹Ù·Ó ÙÔ ÔÛÔÛÙfi ·˘ÙÒÓ Ô˘ ÈÛÙÂ‡Ô˘Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·Ó·ÏÁËÛ›· ÌÂÙÂÁ¯ÂÈÚËÙÈο. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÌË Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ Ì¤ÙÚˆÓ ÁÈ· ÙË Ì›ˆÛË Ù˘ ¤ÎıÂÛ˘ ÛÙ· ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛÂˆÓ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ·fi ÙÔ 95% ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó (¶›Ó·Î·˜ 4). ∆Ú¤¯Ô˘Û˜ Ù·ÎÙÈΤ˜ ÛÙȘ ª∂¡¡ ™‡Ìʈӷ Ì ÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ‰È¢ı˘ÓÙÒÓ, ÌfiÓÔ ÛÙÔ 33% ÙˆÓ ÌÔÓ¿‰ˆÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘. ™Â 9 ª∂¡¡ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯Ó¿ ηٷÛÙÔÏ‹ Î·È ·Ó·ÏÁËÛ›· ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, Û 2 ÌÔÓ¿‰Â˜ ÌfiÓÔ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ, fiˆ˜ fiÙ·Ó ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È Û 1 ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÔÙ¤. ™ÙÔÓ ¶›Ó·Î· 5 Ê·›ÓÔÓÙ·È Ù· ηٷÛÙ·ÏÙÈο-·Ó·ÏÁËÙÈο Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙȘ ‰È¿ÊÔÚ˜ ÌÔÓ¿‰Â˜. ™Â 4 ª∂¡¡ ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ Ë Û˘Ó¯‹˜ ÛÙ¿Á‰ËÓ ¯ÔÚ‹ÁËÛË ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î·È ·Ó·ÏÁËÙÈÎÒÓ Ê·Ú̿ΈÓ, ÂÓÒ Û 7 ¯ÔÚËÁÔ‡ÓÙ·È, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ÁÈ·ÙÚÔ‡, ÛÂ Û˘Ó¯‹ ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË (3 ª∂¡¡) ‹ Û ÚÔηıÔÚÈṲ̂ӷ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (4 ª∂¡¡). ª˘Ô¯¿Ï·ÛË ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯Ó¿ Û 2 ÌÔÓ¿‰Â˜, Û¿ÓÈ· Û 6, ÂÓÒ Û 4 ÌÔÓ¿‰Â˜ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÔÙ¤. ªÂÚÈΤ˜ ÌÔÓ¿‰Â˜ ¯ÚËÛÈÌÔÔÈÔ‡Ó 2 ›‰Ë Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ. ∆· Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Ì˘Ô¯·Ï·ÚˆÙÈο Â›Ó·È ÙÔ ‚ÚˆÌÈÔ‡¯Ô ·ÓÎÔ˘ÚfiÓÈÔ ¶›Ó·Î·˜ 2. ∞fi„ÂȘ ÙˆÓ È·ÙÚÒÓ: ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿ ™˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÀÔÍ›· - ÙÒÛË ÎÔÚÂÛÌÔ‡ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ªÂÙ·‚ÔÏ‹ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ªÂÙ·‚ÔÏ‹ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ªÂÙ·‚ÔÏ‹ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ∞ÓÙ·ÁˆÓÈÛÌfi˜ ·Ó·Ó¢ÛÙ‹Ú· ™‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· ∂ȉ›ӈÛË ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÕÓÔÈ· ∂˘ÂÚÂıÈÛÙfiÙËÙ·/stress ªÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ ∞ÒÙÂÚ˜ „˘¯ÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜
°È·ÙÚÔ› Ô˘ ·¿ÓÙËÛ·Ó (n=79) % 32
40,5
26
33
22
27,8
9 3 4 4
11,4 3,8 5 5
9 9 15 5
11,4 11,4 19 6,3
21
26,6
31
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·32
¶·È‰È·ÙÚÈ΋ 2003;66:29-36
Paediatriki 2003;66:29-36
¶›Ó·Î·˜ 3. ∞fi„ÂȘ ÙˆÓ È·ÙÚÒÓ: ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ Û ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÂÂÌ‚¿ÛÂȘ ∂›‰Ë ¤̂·Û˘ £ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË OÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ÀÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË ∆ÔÔı¤ÙËÛË ·ÚÙ. ÁÚ·ÌÌ‹˜ ∞Ó·ÚÚÔÊ‹ÛÂȘ ÙÚ·¯ÂÈÔۈϋӷ
∞·Ú·›ÙËÙË n (%)
™ËÌ·ÓÙÈ΋ n (%)
55 (51,8%) 10 (9,4%) 5 (4,7%) 11 (10,3%) 3 (2,8%)
37 (34,9%) 31 (29,2%) 20 (20,7%) 42 (39,6%) 16 (15%)
¶›Ó·Î·˜ 4. ¶ÚÔÙ›ÌËÛË ÙˆÓ È·ÙÚÒÓ Û¯ÂÙÈο Ì ÙÔ˘˜ ÌË Ê·Ú̷΢ÙÈÎÔ‡˜ ÙÚfiÔ˘˜ Ì›ˆÛ˘ ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜ ÛÙ· ÓÂÔÁÓ¿ °È·ÙÚÔ› (n=106) % ¶ÂÚÈÔÚÈÛÌfi˜ ¯ÂÈÚÈÛÌÒÓ ∂Ï¿ÙÙˆÛË ÊˆÙÈÛÌÔ‡ Î·È ıÔÚ‡‚Ô˘ ∞·Ï¿ ·ÙÈο ÂÚÂı›ÛÌ·Ù· (¯¿‰È) ºˆÏȤ˜ ªË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (țϷ) ÃÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ
93 85 82 60 70 33
87,7 80,2 77,3 50,6 66 31,1
¶›Ó·Î·˜ 5. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡ (n=11): ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ∫·Ù·ÛÙ·ÏÙÈο-·Ó·ÏÁËÙÈο Ê¿Ú̷η
ª∂¡¡ n (%)
ºÂÓÙ·Ó‡ÏË ªÔÚÊ›ÓË ¶Âıȉ›ÓË ªÈ‰·˙ÔÏ¿ÌË ªÔÚÊ›ÓË + ÊÂÓÙ·Ó‡ÏË ‹ ‰È·˙¿ÌË ºÂÓÙ·Ó‡ÏË + Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ‹/Î·È ¯ÏˆÚ¿ÏË ‹ ‚ÂÓ˙ԉȷ˙›ÓË
2 (18,3%) 2 (18,3%) 1 (9,1%) 1 (9,1%) 2 (18,3%) 4 (36,3%)
(Pavulon®) (5), ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ (Tracrium®) (3) Î·È ÙÔ cis-·ÙÚ·ÎÔ‡ÚÈÔ (Nimbex®) (2). ™Â 3 ÌÔÓ¿‰Â˜, Ù·˘Ùfi¯ÚÔÓ· Ì ٷ Ì˘Ô¯·Ï·ÚˆÙÈο ¯ÔÚËÁÂ›Ù·È Î·È Î¿ÔÈÔ Î·Ù·ÛÙ·ÏÙÈÎfi-·Ó·ÏÁËÙÈÎfi (Û 1 ÌÔÓ¿‰· ÊÂÓÙ·Ó‡ÏË, Û 1 ‰È·˙¿ÌË Î·È Û 1 ¤Ó˘‰ÚË ¯ÏˆÚ¿ÏË), ÂÓÒ Û 5 ÌÔÓ¿‰Â˜ ÂÈÎÚ·Ù› Ë ¿Ô„Ë fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·È ¿ÏÏÔ Ê¿ÚÌ·ÎÔ. ™Â η̛· ÌÔÓ¿‰· ‰ÂÓ ¯ÔÚËÁÂ›Ù·È Ì˘Ô¯¿Ï·ÛË ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ›ÁÔ˘Û·˜ ÌË ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˘ ‰È·ÛˆÏ‹ÓˆÛ˘. ∞Ó·ÊÔÚÈο Ì ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÛÙȘ ÌÔÓ¿‰Â˜ Û¯ÂÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Û 8 ÌÔÓ¿‰Â˜ ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ ·Ó·ÏÁËÙÈÎfi, Û˘ÛÙËÌ·ÙÈο ‹ ÙÔÈο. ™ÙÔÓ ¶›Ó·Î· 6 Ê·›ÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ‰È¿ÊÔÚ˜ ª∂¡¡ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÒ‰˘ÓˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. ∞ÓÂÍ¿ÚÙËÙ·, ¿ÓÙˆ˜, ·fi ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÚÔ˜ ÙÔ ·ÚfiÓ ÛÙÔ ÙÌ‹Ì· ÙÔ˘˜, 9 ‰È¢ı˘ÓÙ¤˜ ıˆÚÔ‡Ó ÙË
32
¢ÂÓ ¯ÚÂÈ¿˙ÂÙ·È n (%) 11 65 75 50 86
(10,3%) (61,3%) (70,7%) (47,1%) (81,1%)
¢ÂÓ ·¿ÓÙËÛ·Ó n (%) 3 (2,8%) 4 (3,7%) 3 (2,8%) 1 (0,9%)
¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ Î·È ·Ó·ÏÁËÛ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÒ‰˘ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋, 2 ÈÛÙÂ‡Ô˘Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È, ÂÓÒ Ô ‰È¢ı˘ÓÙ‹˜ Ì›·˜ ÌÔÓ¿‰·˜ ‰ÂÓ ·¿ÓÙËÛÂ. ªÂÙ¿ ·fi Ì›˙ÔÓ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ·Ó·ÏÁËÛ›· ¯ÔÚËÁÂ›Ù·È Û 11/12 ÌÔÓ¿‰Â˜ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË, ÂÓÒ 1 ÌÔÓ¿‰· ‰ÂÓ ÓÔÛËχÂÈ ¯ÂÈÚÔ˘ÚÁÈο ÂÚÈÛÙ·ÙÈο. ™ÙÔÓ ¶›Ó·Î· 7 Ê·›ÓÔÓÙ·È Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÂÙÂÁ¯ÂÈÚËÙÈο. ∆¤ÏÔ˜, Û fiϘ ÙȘ ÌÔÓ¿‰Â˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î¿ÔÈÔ Â›‰Ô˜ ÌË Ê·Ú̷΢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Â͈ÙÂÚÈÎÒÓ ‰ÈÂÁÂÚÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Î·È ÙË Ì›ˆÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ (¶›Ó·Î·˜ 8). ™˘˙‹ÙËÛË ™ÙË ÌÂϤÙË ·˘Ù‹ ¤ÁÈÓ ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· ÓÂÔÁÓÒÓ, ·Ó·ÊÔÚÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. §fiÁˆ Ù˘ ÌÂÁ¿Ï˘ ·ÓÙ·fiÎÚÈÛ˘ ÙˆÓ ÂÚˆÙËı¤ÓÙˆÓ, ıˆÚÂ›Ù·È fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó Â·ÚÎÒ˜ ÙËÓ ÂÏÏËÓÈ΋ Ú·ÁÌ·ÙÈÎfiÙËÙ· ÛÙÔ ı¤Ì· ·˘Ùfi. ∂›Ó·È Ôχ ÂÓı·ÚÚ˘ÓÙÈÎfi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‚Ï·ÙÈΤ˜ Û˘Ó¤ÂȤ˜ ÙÔ˘ Û ·˘Ù¿ Î·È È‰È·›ÙÂÚ· ÛÙÔ Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. øÛÙfiÛÔ, Û ÏÈÁfiÙÂÚ˜ ·fi ÙȘ ÌÈÛ¤˜ ª∂¡¡ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÒ‰˘ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜. ™ÙȘ ˘fiÏÔȘ ª∂¡¡, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÂÍ·ÚÙ¿Ù·È Ì¿ÏÏÔÓ ·fi ÙȘ ÚÔÛˆÈΤ˜ ·fi„ÂȘ Î·È ÚÔÙÈÌ‹ÛÂȘ ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡. ¶·ÚfiÌÔÈ· Â›Ó·È Ù· ‰Â‰Ô̤ӷ ·fi ÙÔ ‰ÈÂıÓ‹ ¯ÒÚÔ, fiÔ˘ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ôχ ÏÈÁfiÙÂÚÔ ÛÙȘ ÓÂÔÁÓÈΤ˜ ·’ fiÙÈ ÙȘ ·È‰È·ÙÚÈΤ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ (9). ŒÙÛÈ, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿ ·Ú·Ì¤ÓÂÈ ÌË ÈηÓÔÔÈËÙÈ΋, ·Ú¿ ÙËÓ ÈÛ¯˘Ú‹ ÂÔ›ıËÛË ÙˆÓ ÁÈ·ÙÚÒÓ fiÙÈ Ù· ÓÂÔÁÓ¿ ‚ÈÒÓÔ˘Ó ÂÒ‰˘Ó˜ ÂÌÂÈڛ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰È·ÊfiÚˆÓ ¯ÂÈÚÈÛÌÒÓ (10-12).
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·33
¶·È‰È·ÙÚÈ΋ 2003;66:29-36
Paediatriki 2003;66:29-36
¶›Ó·Î·˜ 6. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡: Û˘ÛÙËÌ·ÙÈ΋ ‹ ÙÔÈ΋ ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÚÈÓ ·fi ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ ª∂¡¡ £ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË OÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ∆ÔÔı¤ÙËÛË ·ÚÙËÚȷ΋˜ ÁÚ·ÌÌ‹˜ ∂ÎÏÂÎÙÈ΋ ‰È·ÛˆÏ‹ÓˆÛË ∞Ó·ÚÚfiÊËÛË ·fi ÙÚ·¯ÂÈÔۈϋӷ ÀÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË ÕÏÏ·
8 (66,7%) 3 (25%) 1 (8,3%) 2 (17%) 5 (41,7%)
¶›Ó·Î·˜ 7. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡ (n=11): ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÌÂÙÂÁ¯ÂÈÚËÙÈο ∞Ó·ÏÁËÙÈÎfi ªÔÚÊ›ÓË ªÔÚÊ›ÓË + ÊÂÓÙ·Ó‡ÏË ªÔÚÊ›ÓË + ·Ú·ÎÂÙ·ÌfiÏË ºÂÓÙ·Ó‡ÏË ºÂÓÙ·Ó‡ÏË + ·Ú·ÎÂÙ·ÌfiÏË ¶·Ú·ÎÂÙ·ÌfiÏË
º¿Ú̷η (·ÚÈıÌfi˜ ª∂¡¡) ºÂÓÙ·Ó‡ÏË (1), ÌÔÚÊ›ÓË (1), ÏȉÔη˝ÓË (4), EMLA (1) §È‰Ôη˝ÓË (2), EMLA (1) ºÂÓÙ·Ó‡ÏË EMLA (2) §È‰Ôη˝ÓË (4), EMLA (1) ¶›Ó·Î·˜ 8. ∆Ú¤¯Ô˘Û· Ú·ÎÙÈ΋ Û¯ÂÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÌË Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ÛÙȘ ª∂¡¡ ª∂¡¡ n (%)
ª∂¡¡ n (%) 1 (9,1%) 2 (18,2%) 1 (9,1%) 3 (27,2%) 2 (18,2%) 1 (9,1%)
∏ ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ÛÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÌÔÚ› ηٿ ¤Ó· ̤ÚÔ˜ Ó· ·Ô‰Ôı› ÛÙË ‰˘ÛÎÔÏ›· ÎÏÈÓÈ΋˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ fiÓÔ˘, ÛÙÔ Êfi‚Ô ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ Î·È È‰È·›ÙÂÚ· ÛÙÔÓ ÚÔ‚ÏËÌ·ÙÈÛÌfi Ô˘ ˘¿Ú¯ÂÈ Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÓÂÔÁÓÈÎfi ÂÁΤʷÏÔ (7). ∏ ‰È·ÛˆÏ‹ÓˆÛË Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ô˘ ÚÔηÏ› fiÓÔ Î·È ‰˘ÛÊÔÚ›· ÛÙ· ÓÂÔÁÓ¿. ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ‰ÂÓ ÓÔ›ٷÈ, ÂÎÙfi˜ ÂȉÈÎÒÓ ÂÚÈÙÒÛˆÓ, ‰È·ÛˆÏ‹ÓˆÛË ¯ˆÚ›˜ ·Ú΋ ηٷÛÙÔÏ‹, ÏfiÁˆ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ stress Ô˘ Û˘Ó¿ÁÂÙ·È. ∂›Û˘, Û ÌË Î·ÙÂÛÙ·Ï̤ӷ ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·ÛˆÏ‹ÓˆÛ˘ ÂÏ·ÙÙÒÓÂÙ·È Ë ÌÂÚÈ΋ ›ÂÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ (13) Î·È ·˘Í¿ÓÂÙ·È Ë ·ÚÙËÚȷ΋ Î·È ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË (14,15), ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜. øÛÙfiÛÔ, ‹Ù·Ó ηÈ, ÂÓ Ì¤ÚÂÈ, ·Ú·Ì¤ÓÂÈ ¿ÁÈ· ‰ÈÂıÓ‹˜ Ù·ÎÙÈ΋ ÛÙȘ ª∂¡¡ Ó· ‰È·ÛˆÏËÓÒÓÔÓÙ·È “Û ÂÁÚ‹ÁÔÚÛË” Ù· ÓÂÔÁÓ¿, ¯ˆÚ›˜ Ê·Ú̷΢ÙÈ΋ ηٷÛÙÔÏ‹, ·Ú¿ ÙȘ ÂӉ›ÍÂȘ fiÙÈ ÔÈ ·Ú·¿Óˆ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÚÈÓ ÙË ‰È·ÛˆÏ‹ÓˆÛË (16,17). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ÌÈÛÔ› ÁÈ·ÙÚÔ› Ô˘ ·¿ÓÙËÛ·Ó ıˆÚÔ‡Ó ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ Û ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·ÛˆÏ‹ÓˆÛË ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋. ∏ Ù·ÎÙÈ΋ ·˘Ù‹, fï˜, ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ Û 1 ÌÔÓ¿‰·. ™Â ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ ‚Ú¤ıËΠfiÙÈ ÛÙÔ 37% Î·È 69% ÙˆÓ ÓÂÔÁÓÈÎÒÓ ÌÔÓ¿‰ˆÓ ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· Î·È ∞˘ÛÙÚ·Ï›·, ·ÓÙ›ÛÙÔȯ·, ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ Î·Ù·ÛÙ·ÏÙÈÎfi ÚÈÓ ·fi ÙËÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·ÛˆÏ‹ÓˆÛË. ª¿ÏÈÛÙ·, Î·È ÛÙȘ ‰‡Ô ¯ÒÚ˜ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ Ê·ÚÌ¿-
¶ÂÚÈÔÚÈÛÌfi˜ ¯ÂÈÚÈÛÌÒÓ ∂Ï¿ÙÙˆÛË ÊˆÙÈÛÌÔ‡ Î·È ıÔÚ‡‚Ô˘ ∞·Ï¿ ·ÙÈο ÂÚÂı›ÛÌ·Ù· (¯¿‰È) ºˆÏȤ˜ ªË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (țϷ) ÃÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÕÏÏ·
10 (83,3%) 5 (42%) 8 (66,6%) 4 (33,3%) 10 (83,3%) 3 (25%) 1 (8,3%)
ÎˆÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙ· ÙÂÏÂÈfiÌËÓ·, ÚÔÊ·ÓÒ˜ ÏfiÁˆ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ‰˘ÛÎÔÏ›·˜ ÛÙË ‰È·ÛˆÏ‹ÓˆÛË ÙÔ˘ ÌÂÁ¿ÏÔ˘ Î·È ˙ˆËÚÔ‡ ÓÂÔÁÓÔ‡ (18,19). O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Ô˘ Û˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ÙË ‰È·ÛˆÏ‹ÓˆÛË, ·ÔÙÂÏ› ‰˘Û¿ÚÂÛÙÔ, ›Ûˆ˜ Î·È ÂÒ‰˘ÓÔ, ÂÚ¤ıÈÛÌ· ÁÈ· Ù· ÓÂÔÁÓ¿, ÙÔ ÔÔ›Ô ÚÔηÏ› ‰˘ÛÎÔÏ›· Û˘Á¯ÚÔÓÈÛÌÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú·, ÂÂÈÛfi‰È· ˘ÔÍ›·˜, Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· Î·È ÌÂÙ·‚ÔϤ˜ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ ÂÏ·ÙÙÒÓÔÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÔÈÔÂȉÒÓ (ÌÔÚÊ›ÓË ‹ ÊÂÓÙ·Ó‡ÏË) (20-22). ∞Ó Î·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ Â›Ó·È Ì›˙ÔÓ ËıÈÎfi ‰›ÏËÌÌ·, Ë ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ ‰ÂÓ ıˆÚÂ›Ù·È ˘Ô¯ÚˆÙÈ΋ Î·È ·ÔÙÂÏ› ‰›Ô ÎÏÈÓÈ΋˜ ¤Ú¢ӷ˜ (23). ™ÙËÓ ∂ÏÏ¿‰·, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÈÛÙ‡ÂÈ fiÙÈ Ù· ‰È·ÛˆÏËӈ̤ӷ ÓÂÔÁÓ¿ ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù·ÛÙÔÏ‹ Î·È Â›Ó·È È‰È·›ÙÂÚ· ÂÓı·ÚÚ˘ÓÙÈÎfi fiÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜ ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ ·Ó·ÏÁËÙÈÎfi ‹ ηٷÛÙ·ÏÙÈÎfi. ∏ ÔÈÎÈÏ›· ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ ‹ ηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ‰ÈÂıÓÒ˜ ÔÌÔʈӛ· Û¯ÂÙÈο Ì ÙÔ ÈÔ Î·Ù¿ÏÏËÏÔ Ê¿ÚÌ·ÎÔ ‹ Û˘Ó‰˘·ÛÌfi ÙÔ˘˜. ¶¿ÓÙˆ˜, Ù· ÔÈÔÂȉ‹, ȉȷ›ÙÂÚ· Ë ıÂÈÈ΋ ÌÔÚÊ›ÓË Î·È ÙÔ Û˘ÓıÂÙÈÎfi ÔÈÔÂȉ¤˜ ÊÂÓÙ·Ó‡ÏË, ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÈÔ Û˘¯Ó¿ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ˘˜ ·Ó·ÏÁËÙÈÎÔ‡˜ Î·È Î·Ù·ÛÙ·ÏÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÛÙ· ÓÂÔÁÓ¿, fiˆ˜ Î·È ÛÙȘ ª∂¡¡ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ∏ ¯Ú‹ÛË Î·È ÙˆÓ ‰‡Ô ıˆÚÂ›Ù·È ÁÂÓÈο ·ÛÊ·Ï‹˜ (24,25) Î·È ÚÔÛʤÚÂÈ ·ÚfiÌÔÈÔ ·Ó·ÏÁËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· (26). ∏ Ìȉ·˙ÔÏ¿ÌË, Ô˘ Â›Ó·È ‚Ú·¯Â›·˜ ‰Ú¿Û˘ ‚ÂÓ˙ԉȷ˙›ÓË, ÏfiÁˆ ÙˆÓ Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ Ù˘ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ Î·È Î˘Ú›ˆ˜ Ù˘
33
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·34
¶·È‰È·ÙÚÈ΋ 2003;66:29-36
¤ÏÏÂȄ˘ ÂÓÂÚÁÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ, ¤¯ÂÈ ÂÎÙÔ›ÛÂÈ ÙË ‰È·˙¿ÌË ·fi ÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ (7). øÛÙfiÛÔ, ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ı¤ÙÔ˘Ó ˘fi ·ÌÊÈÛ‚‹ÙËÛË ÙËÓ ·Ó·ÁηÈfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ¯Ú‹Û˘ Ù˘, ηı’ fiÛÔÓ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÓÂÔÁÓ¿ Ì ™∞¢ ‰ÂÓ ÌÂÙ¤‚·Ï ÙËÓ ÂͤÏÈÍË Î·È ÙȘ ÂÈÏÔΤ˜ Ù˘ ÓfiÛÔ˘ (27). ∂ÈϤÔÓ, Û˘Û¯ÂÙ›ÛÙËΠ̠ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (27,28) Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ÛËÌ·ÓÙÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ·fi ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· (Ì˘ÔÎÏÔӛ˜, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ‚·ıÌÔ‡ πππ-πV, ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· Î·È ı¿Ó·ÙÔÈ) (24,29). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë Ì˘Ô¯¿Ï·ÛË ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ÂÚÈÙÒÛÂȘ ·‰˘Ó·Ì›·˜ Û˘Á¯ÚÔÓÈÛÌÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ÌfiÓÔ Û 2 ª∂¡¡. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Û˘Ì‚·‰›˙ÂÈ Ì ÙË ÁÂÓÈÎfiÙÂÚË Ù¿ÛË Ì›ˆÛ˘ Ù˘ ¯Ú‹Û˘ Ù˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÏfiÁˆ ΢ڛˆ˜ ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ·fi Ù· Ì˘Ô¯·Ï·ÚˆÙÈο Î·È Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ Û˘Á¯ÚÔÓÈṲ̂ÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (30-33). ŒÙÛÈ, Ì ٷ ÛËÌÂÚÈÓ¿ ‰Â‰Ô̤ӷ, Ù· Ì˘Ô¯·Ï·ÚˆÙÈο ¤¯Ô˘Ó ı¤ÛË ÌfiÓÔ ÛÙËÓ ÂÚ›ÙˆÛË fiÔ˘ ÙÔ ÓÂÔÁÓfi ÂÍ·ÎÔÏÔ˘ı› Ó· “Ì¿¯ÂÙ·È” ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ·Ú¿ ÙËÓ Â·Ú΋ ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ Î·È ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ Û˘Á¯ÚÔÓÈṲ̂ÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (33). ŒÓ·˜ Û˘¯Ófi˜ ¯ÂÈÚÈÛÌfi˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Â›Ó·È Ë ·Ó·ÚÚfiÊËÛË Ì¤Ûˆ ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÔ›·˜ ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ Î·È ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Î·È ·ÚÔ‰È΋ ˘ÔÍ·ÈÌ›· (34,35). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ù· Ê·ÈÓfiÌÂÓ· ·˘Ù¿ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ (24,36). øÛÙfiÛÔ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÓÂÔÁÓÔÏfiÁÔ˘˜ Ô˘ ÂÚˆÙ‹ıËÎ·Ó Ê·›ÓÂÙ·È Ó· ·Ú·‚Ï¤Ô˘Ó ÙË ÛËÌ·Û›· ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ ·˘ÙÔ‡ ˆ˜ ËÁ‹˜ fiÓÔ˘ Î·È ‰˘ÛÊÔÚ›·˜ Î·È Ó· ıˆÚÔ‡Ó ÌË ··Ú·›ÙËÙË ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÚÈÓ ÙËÓ ·Ó·ÚÚfiÊËÛË Ù˘ ÙÚ·¯Â›·˜. ∫·Ù’ ¤ÎÙ·ÛË, Ë ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ηٷÛÙ·ÏÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÚÈÓ ÙËÓ ·Ó·ÚÚfiÊËÛË ‰ÂÓ ·ÔÙÂÏ› Ù·ÎÙÈ΋ ÙˆÓ ª∂¡¡ ÛÙËÓ ∂ÏÏ¿‰·. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰‹ÏˆÛ·Ó fiÙÈ Ô ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ fiÓÔ˜ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Â·ÚÎÒ˜. øÛÙfiÛÔ, ·ÎfiÌË Î·È ÙÔ ÌÈÎÚfi ÔÛÔÛÙfi (4%) Ô˘ ÈÛÙ‡ÂÈ ÙÔ ·ÓÙ›ıÂÙÔ, ıˆÚÂ›Ù·È fiÙÈ ‰ÂÓ Â›Ó·È ·Ô‰ÂÎÙfi. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜, Ô fiÓÔ˜ ÌÂÙ¿ ·fi Ì›˙ÔÓ˜ ÂÂÌ‚¿ÛÂȘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÈηÓÔÔÈËÙÈο, ΢ڛˆ˜ Ì ÔÈÔÂȉ‹. ∞ÓÙ›ıÂÙ·, Û ̛· ÌÔÓ¿‰· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ ·Ú·ÎÂÙ·ÌfiÏË, Ë ÔÔ›· fï˜ ‰ÂÓ ÚÔÛʤÚÂÈ ÈηÓÔÔÈËÙÈ΋ ·Ó·ÏÁËÛ›· ÌÂÙÂÁ¯ÂÈÚËÙÈο (37). ∞Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Û ÂÏ¿ÛÛÔÓ˜ ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÁÈ·ÙÚÒÓ ÈÛÙ‡ÂÈ fiÙÈ ‰ÂÓ ··ÈÙ›-
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Paediatriki 2003;66:29-36
Ù·È Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ÁÈ· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. ∞ÓÙ›ıÂÙ·, Ù· ÙÔÈο ·Ó·ÈÛıËÙÈο ıˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÁÈ· ÙȘ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ. øÛÙfiÛÔ, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ª∂¡¡ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. O ÂÒ‰˘ÓÔ˜ ¯ÂÈÚÈÛÌfi˜, ÁÈ· ÙÔÓ ÔÔ›Ô Û˘¯ÓfiÙÂÚ· ¯ÔÚËÁÂ›Ù·È Û˘ÛÙËÌ·ÙÈο ‹ ÙÔÈο ·Ó·ÏÁËÛ›·, Â›Ó·È Ë ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘ ηÈ, ÏÈÁfiÙÂÚÔ Û˘¯Ó¿, Ë ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË. ¶·ÚfiÌÔȘ Ù·ÎÙÈΤ˜ ·Ó·ÚÎÔ‡˜ ‹ ÂÏ¿¯ÈÛÙ˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛÂˆÓ ·Ú·ÙËÚÔ‡ÓÙ·È ‰ÈÂıÓÒ˜ (9-11,38). ∂Ӊ¯Ô̤ӈ˜, ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ Êfi‚Ô ÂÌÊ¿ÓÈÛ˘ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ Ë ÌÂı·ÈÌÔÛÊ·ÈÚÈÓ·ÈÌ›· Ô˘ ·Ú·ÙËÚÂ›Ù·È Ì ÙË ¯Ú‹ÛË Ù˘ ·ÏÔÈÊ‹˜ ÏȉÔη˝Ó˘/ÚÈÏÔη˝Ó˘ (EMLA) (39). OÈ ÌË Ê·Ú̷΢ÙÈÎÔ› ÙÚfiÔÈ ·Ó·ÏÁËÛ›·˜, fiˆ˜ Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ÂÒ‰˘ÓˆÓ ¯ÂÈÚÈÛÌÒÓ, Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ʈÙÈÛÌÔ‡ Î·È ÙÔ˘ ıÔÚ‡‚Ô˘, ÙÔ ¯¿‰È, Ë ÙÔÔı¤ÙËÛË ÙˆÓ ÓÂÔÁÓÒÓ Û ʈÏȤ˜ Î·È Ô ÌË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (țϷ) ‹ Ë ¯ÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, ·ÔÙÂÏÔ‡Ó ÂÓ·ÏÏ·ÎÙÈο ̤۷ Ì›ˆÛ˘ ÙÔ˘ stress Î·È ÙÔ˘ fiÓÔ˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙȘ ÂÏ¿ÛÛÔÓ˜ ÂÂÌ‚¿ÛÂȘ (40,41). OÈ Ì˯·ÓÈÛÌÔ› Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ¯ÂÈÚÈÛÌÔ› ·˘ÙÔ› ÚÔηÏÔ‡Ó ·Ó·ÏÁËÛ›·, ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›. ŒÙÛÈ, Ë ·Ó·ÏÁËÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌË ‰È·ÙÚÔÊÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÔÙÂÏ› ¤Ó· ΢ڛ·Ú¯Ô Î·È Â˘¯¿ÚÈÛÙÔ ÂÚ¤ıÈÛÌ· Ô˘ ·ÔÛ¿ ÙËÓ ÚÔÛÔ¯‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙÔÓ fiÓÔ, ÂÓÒ ·˘Ù‹ ÙˆÓ ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ·Ô‰›‰ÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÂÓ‰ÔÁÂÓÒÓ ÔÈÔÂȉÒÓ (42). ∞fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÚÔ·ÙÂÈ fiÙÈ ÔÈ ‰È¿ÊÔÚ˜ ÌË Ê·ÚÌ·ÎÔÏÔÁÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙ¤˜ ·fi ÙË ÌÂÁ¿ÏË ÏÂÈÔ„ËÊ›· ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚˆÙ‹ıËÎ·Ó Î·È fiÙÈ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ∆· ̤ÙÚ· Ô˘ Â›Ó·È ·Ô‰ÂÎÙ¿ ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ È·ÙÚÔ‡˜ Â›Ó·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÂÈÚÈÛÌÒÓ Î·È ÙˆÓ ¤ÓÙÔÓˆÓ Â͈ÙÂÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ (ʈÙÈÛÌfi˜, ıfiÚ˘‚Ô˜), ηıÒ˜ Î·È Ë ÂÊ·ÚÌÔÁ‹ ··ÏÒÓ ·ÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ (¯¿‰È). ∞ÓÙ›ıÂÙ·, ·fi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ Ù·ÎÙÈÎÒÓ ÙˆÓ ª∂¡¡, Ê·›ÓÂÙ·È fiÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÚÈÔÚÈÛÙ› ÙÔ Êˆ˜ Î·È Ô ıfiÚ˘‚Ô˜, ÂÓÒ Ù· ÌË Ê·Ú̷΢ÙÈο ̤ÙÚ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· Â›Ó·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÂÈÚÈÛÌÒÓ Î·È Ë È›Ï·. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÚÔ·ÙÂÈ fiÙÈ ÔÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ “ÔÓÔ‡Ó” ηÈ, ·Ú¿ÏÏËÏ·, ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress Û ·˘Ù¿. øÛÙfiÛÔ, Û ϛÁ˜ ª∂¡¡ ÂÊ·ÚÌfi˙ÂÙ·È Î¿ÔÈÔ Û˘ÁÎÂÎÚÈ̤ÓÔ
JAN-FEB-03
14-05-03
14:37
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¶·È‰È·ÙÚÈ΋ 2003;66:29-36
ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Ô˘ Û˘Óԉ‡ÂÈ ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, Ì ÂÍ·›ÚÂÛË ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÏÁËÛ›·. ∞·ÈÙÂ›Ù·È ÈÔ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ fiÓÔ˘ ÛÙȘ ÂÏÏËÓÈΤ˜ ª∂¡¡. ¶Èı·ÓÒ˜, ÂÈÛÙËÌÔÓÈÎÔ› ÊÔÚ›˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡, fiˆ˜ ÔÈ ¶·È‰È·ÙÚÈΤ˜ Î·È ¶ÂÚÈÁÂÓÓËÙÈΤ˜ ∂Ù·ÈÚ›˜, ı· ¤Ú ӷ ·Ó·Ù‡ÍÔ˘Ó ÔÌ¿‰· ÂÚÁ·Û›·˜ Ë ÔÔ›· ı· ÚÔÙ›ÓÂÈ Û˘ÁÎÂÎÚÈ̤Ó˜ Ô‰ËÁ›Â˜ Ê·ÚÌ·ÎÔÏÔÁÈ΋˜ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿. ∂˘¯·ÚÈÛٛ˜ OÈ Û˘ÁÁÚ·Ê›˜ ¢¯·ÚÈÛÙÔ‡Ó ıÂÚÌ¿ ÙÔ È·ÙÚÈÎfi ÚÔÛˆÈÎfi ÙˆÓ ª∂¡¡ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙË ÌÂϤÙË Î·ıÒ˜ Î·È ÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ ÙˆÓ ÌÔÓ¿‰ˆÓ: ∞Ó‰ÚfiÓÈÎÔ˘ ™, ¢ÂÏ·ÁÚ·ÌÌ¿ÙÈη ∏, º·ÚÚ‹-∫ˆÛÙÔÔ‡ÏÔ˘ §, °Ô‡Ó·ÚË ∞, ∫·ÏÔÁÈ¿ÓÓË ¡, ∫ˆÛÙ·ÓÙ›ÓÔ˘ °, ∫ÒÛÙ·ÏÔ Ã, ª·ÓÙ·Áfi ™, ¶ÂÙÌÂ˙¿ÎË ™, ™ÈÁ¿Ï· π, ™ÔÊ·Ù˙‹ π Î·È •¿ÓıÔ˘ ª.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Barker DP, Rutter ¡. Exposure to invasive procedures in neonatal intensive care unit admissions. Arch Dis Child Fetal Neonatal Ed 1995;72:F47-48. 2. Anand KJ, Carr DB. The neuroanatomy, neurophysiology, and neurochemistry of pain, stress, and analgesia in newborns and children. Pediatr Clin North Am 1989;36:795821. 3. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317:1321-1329. 4. Porter FL, Wolf CM, Miller JP. Procedural pain in newborn infants: the influence of intensity and development. Pediatrics 1999;104:e13. 5. Menon G, Anand KJ, McIntosh ¡. Practical approach to analgesia and sedation in the neonatal intensive care unit. Semin Perinatol 1998;22:417-424. 6. Porter FL, Grunau RE, Anand KJ. Long-term effects of pain in infants. J Dev Behav Pediatr 1999;20:253-261. 7. American Academy of Pediatrics and Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics 2000;105:454-461. 8. Kahn DJ, Richardson DK, Gray JE, Bednarek F, Rubin LP, Shah B et al. Variation among neonatal intensive care units in narcotic administration. Arch Pediatr Adolesc Med 1998;152:844-851. 9. Bauchner ∏, May ∞, Coates ∂. Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. J Pediatr 1992;121:647-649. 10. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics 1997;100:626-632. 11. Johnston CC, Collinge JM, Henderson SJ, Anand KJ. ∞ cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units. Clin J Pain 1997;13:308-312. 12. Heaton ƒ, Herd D. Neonatal pain relief [letter]. Arch Dis Child Fetal Neonatal Ed 2000;83:F77-78.
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13. Gibbons ƒ∞, Swedlow DB. Changes in oxygen saturation during elective tracheal intubation in infants. Anesth Analg 1987;66:860-862. 14. Raju ∆¡, Vidyasagar D, Torres C, Grundy D, Bennett EJ. Intracranial pressure during intubation and anesthesia in infants. J Pediatr 1980;96:860-862. 15. Friesen RH, Honda ∞∆, Thieme RE. Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg 1987;66:874-878. 16. Hickey PR, Hansen DD. Fentanyl- and sufentanil-oxygenpancuronium anesthesia for cardiac surgery in infants. Anesth Analg 1984;63:117-124. 17. Bhutada ∞, Sahni R, Rastogi S, Wung J∆. Randomized controlled trial of thiopental for intubation in neonates. Arch Dis Child Fetal Neonatal Ed 2000;82:F34-37. 18. Whyte S, Birrell G, Wyllie J. Premedication before intubation in UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-41. 19. Hancock S, Newell S, Brierley J, Berry ∞. Premedication for neonatal intubation: current practice in Australia and the United Kingdom [letter]. Arch Dis Child Fetal Neonatal Ed 2000;83:F77. 20. Dyke ªƒ, Kohan R, Evans S. Morphine increases synchronous ventilation in preterm infants. J Paediatr Child Health 1995;31:176-179. 21. Goldstein RF, µrazy JE. Narcotic sedation stabilizes arterial blood pressure fluctuations in sick premature infants. J Perinatol 1991;11:365-371. 22. Sabatino G, Quartulli L, Di Fabio S, Ramenghi LA. Hemodynamic effects of intravenous morphine infusion in ventilated preterm babies. Early Hum Dev 1997;47:263-270. 23. Kennedy KA, Tyson JE. Narcotic analgesia for ventilated newborns: are placebo-controlled trials ethical and necessary? J Pediatr 1999;134:127-129. 24. Anand KJ, Barton µ∞, McIntosh ¡, Lagercrantz ∏, Pelausa ∂, Young ∆∂ et al. Analgesia and sedation in preterm neonates who require ventilatory support: results from the ¡Oƒ∞π¡ trial. Neonatal Outcome and Prolonged Analgesia in Neonates. Arch Pediatr Adolesc Med 1999;153:331-338. 25. Quinn MW, Wild J, Dean HG, Hartley R, Rushforth JA, Puntis JW et al. Randomized double-blind controlled trial of effect of morphine Ôn catecholamine concentrations in ventilated preterm babies. Lancet 1993;342:324-327. 26. Lago ƒ, Benini F, Agosto C, Zacchello F. Randomized controlled trial of low dose fentanyl infusion in preterm infants with hyaline membrane disease. Arch Dis Child Fetal Neonatal Ed 1998;79:F194-197. 27. Jacqz-Aigrain ∂, Daoud ƒ, Burtin ƒ, Desplanques L, Beaufils F. Placebo-controlled trial of midazolam sedation in mechanically ventilated newborn babies. Lancet 1994;344:646-650. 28. Jacqz-Aigrain ∂, Daoud ƒ, Burtin ƒ, Maherzi S, Beaufils F. Pharmacokinetics of midazolam during continuous infusion in critically ill neonates. Eur J Clin Pharmacol 1992;42:329332. 29. Waisman D, Weintraub Z, Rotschild A, Bental Y. Myoclonic movements in very low birth weight premature infants associated with midazolam intravenous bolus administration. Pediatrics 1999;104:579.
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30. Cheung PY, Tyebkhan JM, Peliowski A, Ainsworth W, Robertson CM. Prolonged use of pancuronium bromide and sensorineural hearing loss in childhood survivors of congenital diaphragmatic hernia. J Pediatr 1999; 135:233239. 31. Fanconi S, Ensner S, Knecht B. Effects of paralysis with pancuronium bromide on joint mobility in premature infants. J Pediatr 1995;127:134-136. 32. McIntosh N. Hypotension associated with pancuronium use in the newborn. Lancet 1985;2:279. 33. Cools F, Offringa M. Neuromuscular paralysis for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2000;4:CD002773. 34. Shah AR, Kurth CD, Gwiazdowski SG, Chance µ, DelivoriaPapadopoulos ª. Fluctuations in cerebral oxygenation and blood volume during endotracheal suctioning in premature infants. J Pediatr 1992;120:769-774. 35. Kohlhauser C, Bernert G, Hermon ª, Popow C, Seidl R, Pollak ∞. Effects of endotracheal suctioning in highfrequency oscillatory and conventionally ventilated lÔw birth weight neonates on cerebral hemodynamics observed by near infrared spectroscopy (NIRS). Pediatr Pulmonol 2000;29:270-275. 36. Ninan ∞, O’Donnell ª, Hamilton ∫, ∆an L, Sankaran ∫. Physiologic changes induced by endotracheal instillation and suctioning in critically ill preterm infants with and without sedation. Am J Perinatol 1986;3:94-97.
37. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994;93:641-646. 38. Fernandez CV, Rees ∂ƒ. Pain management in Canadian level 3 neonatal intensive care units. CMAJ 1994;150:499504. 39. Brisman ª, Ljung µª, Otterbom π, Larsson LE, Andreasson SE. Methaemoglobin formation after the use of EMLA cream in term neonates. Acta Paediatr 1998;87:1191-1194. 40. Franck LS, Lawhon G. Environmental and behavioral strategies to prevent and manage neonatal pain. Semin Perinatol 1998;22:434-443. 41. Bucher HU, Baumgartner R, Bucher N, Seiler M, Fauchere JC. Artificial sweetener reduces nociceptive reaction in term newborn infants. Early Hum Dev 2000;59:51-60. 42. Carbajal R, Chauvet X, Couderc S, Olivier-Martin M. Randomized trial of analgesic effect of sucrose, glucose, and pacifiers in term neonates. BMJ 1999;319:1393-1397.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-05-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™·Ú·Ê›‰Ë˜ ∫ÔÛÌ¿˜ ∫‡Ì˘ 6µ, ∆.∫. 546 55, £ÂÛÛ·ÏÔÓ›ÎË E-mail: saraf@med.auth.gr
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· OÍ›· ÓÂÊÚÈ΋ ‚Ï¿‚Ë ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË Û ÓÂÔÁÓ¿1 ™ÎÔfi˜: ∏ Ô˘ÚÔÏԛ̈ÍË Â›Ó·È Ì›· ·fi ÙȘ ÈÔ Û˘ÓËıÈṲ̂Ó˜ ·Èٛ˜ ˘ÚÂÙÔ‡ ·‰È¢ÎÚ›ÓÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ ÛÙ· ÓÂÔÁÓ¿. ™Ùfi¯Ô˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰È·ÈÛÙˆı› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È Ë ÔÍ›· ÓÂÊÚÈ΋ ‚Ï¿‚Ë Û ÓÂÔÁÓ¿ ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 57 ÓÂÔÁÓ¿ (42 ·ÁfiÚÈ· Î·È 15 ÎÔÚ›ÙÛÈ·), ·ÊÔ‡ ·ÔÎÏ›ÛÙËÎ·Ó Ù· ÓÂÔÁÓ¿ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘. ∏ ̤ÛË ËÏÈΛ· ÛÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 32 Ë̤Ú˜ (5-60 Ë̤Ú˜). ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ÌÂÏÂÙ‹ıËÎ·Ó Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (99m)Tc-dimercaptosuccinic acid (DMSA). ∞ÔÙÂϤÛÌ·Ù·: ∞ӈ̷ϛ˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔ 35% ÙˆÓ ÓÂÔÁÓÒÓ. ∫˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ‰È·ÁÓÒÛıËΠ۠19 (33%) ÓÂÔÁÓ¿ (12 ·ÁfiÚÈ· Î·È 7 ÎÔÚ›ÙÛÈ·). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÔÍ›˜ ‚Ï¿‚˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÊÏÔÈÔ‡ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ DMSA Û 19 ÓÂÊÚÔ‡˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌË-
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ÛË Î·È Û 25 ÓÂÊÚÔ‡˜ ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ·ÏÈÓ‰ÚfiÌËÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÓÈÛٿٷÈ, ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË, Ó· ‰ÈÂÚ¢ÓÒÓÙ·È Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ DMSA fiÏ· Ù· ÓÂÔÁÓ¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 8 ‚‰ÔÌ¿‰ˆÓ.
1 Cascio S, Chertin B, Yoneda A, Rolle U, Kelleher J, Puri P Acute renal damage in infants after first urinary tract infection Pediatr Nephrol 2002;17:503-505
™ÙÂÊ·Ó›‰Ë˜ ∫. π. ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ ¡ÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
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ORIGINAL ARTICLE
∂͈ÓÔÛÔÎÔÌÂȷΤ˜ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ∞. ∆ÛÔ‡ÙÛÔ˘, ¢. °ÎÈÒÓ˘, ¶. ªfiÓÔ˘, §. ∆ÚÔ˘Ì¤Ù·˜, π. ¶··‰¿ÙÔ˜
Interhospital transport of critically ill children A. Tsoutsou, D. Gionis, P. Bonou, L. Troubetas, I. Papadatos
¶ÂÚ›ÏË„Ë: ∏ ÌÂÙ·ÊÔÚ¿ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ ¯ÚÂÈ¿˙ÂÙ·È ÛˆÛÙ‹ ÚÔÂÙÔÈÌ·Û›· Î·È ÛˆÛÙfi ۯ‰ȷÛÌfi, ÒÛÙ ӷ Â›Ó·È ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·fi ΤÓÙÚÔ ˘Á›·˜ ‹ ÓÔÛÔÎÔÌÂ›Ô Ù˘ ÂÚÈʤÚÂÈ·˜ Û ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌ›Ô. ªÂÏÂÙ‹ıËÎ·Ó ‚¿ÛÂÈ ÚˆÙÔÎfiÏÏÔ˘ 100 ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜ Ì›·˜ ‹ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ Î·È ÂÈÛ‹¯ıËÛ·Ó ·Â˘ı›·˜ ÛÙË ª∂£ (ÂÚ›Ô‰Ô˜ 1/1/1997 1/5/2000). ∆ÚÈ¿ÓÙ· ¤ÓÙ ·ÛıÂÓ›˜ ‹Ù·Ó ÎÔÚ›ÙÛÈ· Î·È 65 ·ÁfiÚÈ·, ËÏÈΛ·˜ ·fi 19 ËÌÂÚÒÓ Ì¤¯ÚÈ Î·È 14 ¯ÚfiÓˆÓ (̤ÛË ËÏÈΛ· 6,8 ¤ÙË). ™·Ú¿ÓÙ· ÔÎÙÒ Â›¯·Ó ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, 14 ‹Ù·Ó ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ Î·È 28 ·ÚÔ˘Û›·˙·Ó ·ıÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Ïԛ̈ÍË, Û·ÛÌÔ‡˜). ∂›ÎÔÛÈ ÙÚÂȘ ÌÂٷʤÚıËÎ·Ó ·fi ÓÔÛÔÎÔÌ›· Ù˘ ∞ÙÙÈ΋˜ Î·È 77 ·fi ÙËÓ ˘fiÏÔÈË ∂ÏÏ¿‰·. ∆Ô ∂∫∞µ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ 54 ·ÛıÂÓÒÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, 62 ·ÛıÂÓ›˜ ‹Ù·Ó Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ÁÈÓfiÙ·Ó Û 59 ·ÛıÂÓ›˜, ÂÓÒ Ï‹Ú˘ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÁÈÓfiÙ·Ó ÌfiÓÔ Û 10 ÂÚÈÙÒÛÂȘ. ∂Í‹ÓÙ· ¤ÍÈ ·ÛıÂÓ›˜ ‹Úı·Ó ¯ˆÚ›˜ ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È 30 ·ÛıÂÓ›˜ ¤Êı·Û·Ó ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ÂȉÔÔ›ËÛË. ∫·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∂£, 76 ·ÛıÂÓ›˜ ›¯·Ó ‚ÂÏÙȈı› Î·È 5 ·ÚÔ˘Û›·Û·Ó ˘ÔÏÂÈÌÌ·ÙÈ΋ Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹ (19 ·ÛıÂÓ›˜ ·Â‚›ˆÛ·Ó).
Abstract: Transfer of pediatric patients has to be well prepared and planned, in order to be safe and harmless. The purpose of this study is to estimate safety of transfer of critically ill children from health centers or regional hospital to a tertiary care center. We studied 100 patients who were transfered by transfer systems of 1 or 2 directions and were admitted directly in ICU between 1/1/1997 1/5/2000. Thirty five were girls and 65 were boys, aged from 19 days to 14 years (mean age 6.8 years). Forty eight had brain injury, 14 had multiple trauma, 28 presented medical problems (respiratory distress, infection, seizures). Twenty three were transfered from Attica hospitals and 77 from the rest of Greece. The National Emergency System transfered 54 patients. During transfer 62 patients were on mechanical ventilation. Fifty nine patients had saturation monitoring but only 10 had full monitoring of vital signs. Sixty six patients presented without any accompanying medical report and 30 patients presented without previous information. On discharge from ICU, 76 were improved and 5 had neurological sequellae (19 patients died).
§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÙ·ÊÔÚ¿ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, ÔÏ˘ÙÚ·˘Ì·Ù›·˜.
Key words: transport of critically ill children, traumatic brain injury, multiple trauma.
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
Intensive Care Unit, “P. & A. Kyriakou” Children’s Hospital
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∂ÈÛ·ÁˆÁ‹ ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ˘„ËÏ‹ È·ÙÚÈ΋ ÊÚÔÓÙ›‰· Ô˘ ·Ú¤¯Ô˘Ó ÔÈ ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£) Î·È Ë ·Ó¿Ù˘ÍË ÂȉÈÎÒÓ ÙÌËÌ¿ÙˆÓ (.¯. ÓÂÊÚÔÏÔÁÈÎfi, ÔÁÎÔÏÔÁÈÎfi, ηډÈÔ¯ÂÈÚÔ˘ÁÈÎfi) Ô‰‹ÁËÛ·Ó ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·fi ÛÔ‚·Ú¤˜ ·Ûı¤ÓÂȘ Î·È ÙÚ·˘Ì·ÙÈÛÌÔ‡˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ª∂£ ·È‰ÈÒÓ ÏÂÈÙÔ˘ÚÁÔ‡Ó Û˘Ó‹ıˆ˜ Û ÙÚÈÙÔ‚¿ıÌÈ· ÓÔÛÔÎÔÌ›·, οÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ·Ó¿ÁÎË Ù¤ÙÔÈ·˜ ÊÚÔÓÙ›‰·˜, ··Ú·›ÙËÙÔ ÎÚ›ÎÔ ÛÙË Û˘ÓÔÏÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ™ÙËÓ ∂ÏÏ¿‰·, ÙÔ ∂∫∞µ ·ÔÙÂÏ› “ÙÔÓ Â›ÛËÌÔ ÊÔÚ¤· ˘ËÚÂÛÈÒÓ Â›ÁÔ˘Û·˜ ÚÔÓÔÛÔÎÔÌÂȷ΋˜ È·ÙÚÈ΋˜” Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ, ÂÎÙfi˜ ·fi ÙËÓ ¿ÌÂÛË ·ÚÔ¯‹ È·ÙÚÈ΋˜ Î·È ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ Î·È ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÛÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ Î·È ÏËÛȤÛÙÂÚÔ ˘ÁÂÈÔÓÔÌÈÎfi Û¯ËÌ·ÙÈÛÌfi. ™ÙËÓ Ú¿ÍË, ÔÈ ÌÂÙ·ÊÔÚ¤˜ Á›ÓÔÓÙ·È ·fi ÚÔÛˆÈÎfi Ô˘ ·Ó‹ÎÂÈ Û ÂÚÈÊÂÚÂȷο ÓÔÛÔÎÔÌ›·, ΤÓÙÚ· ˘Á›·˜ (∫À) ‹ ·ÁÚÔÙÈο È·ÙÚ›· (∞π) Î·È ‰ÂÓ ¤¯ÂÈ ÙËÓ ··Ú·›ÙËÙË ÂÍÂȉ›Î¢ÛË ÛÙȘ ÌÂÙ·ÊÔÚ¤˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·fi ΤÓÙÚÔ ˘Á›·˜, ·ÁÚÔÙÈÎfi È·ÙÚÂ›Ô ‹ ÓÔ̷گȷÎfi ÓÔÛÔÎÔÌÂ›Ô Û ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌ›Ô. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆Ô ˘ÏÈÎfi ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜ Ì›·˜ ‹ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ·fi οÔÈÔ ¿ÏÏÔ ÓÔÛÔÎÔÌ›Ô, ∫À ‹ ∞π Î·È ÂÈÛ‹¯ıËÛ·Ó ·Â˘ı›·˜ ÛÙË ª∂£, ηٿ ÙËÓ ÂÚ›Ô‰Ô 1/1/1997 - 1/5/2000. OÈ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ Â›Ó·È ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ·fi Ù· ÓÔ̷گȷο ÓÔÛÔÎÔÌ›· (Ù· ΤÓÙÚ· ˘Á›·˜ ‹ Ù· ·ÁÚÔÙÈο È·ÙÚ›·), ÂÓÒ ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ Â›Ó·È ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ô˘ ÔÚÁ·ÓÒÓÔÓÙ·È ·fi ÙÔ ÂȉÈÎÂ˘Ì¤ÓÔ Î¤ÓÙÚÔ ÌÂÙ·ÊÔÚÒÓ. ∫·Ù¿ ÙËÓ Â›ÛÔ‰Ô ÙˆÓ ·ÛıÂÓÒÓ, Û˘ÌÏËÚÒıËΠÂÎÙÂٷ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ÂÚÈÏ¿Ì‚·Ó ÛÙÔȯ›· ÁÈ· ÙÔ ·Ù‡¯ËÌ· (‹ Û‡ÓÙÔÌÔ ÈÛÙÔÚÈÎfi, Â¿Ó ÂÚfiÎÂÈÙÔ ÁÈ· ·ıÔÏÔÁÈÎfi ÂÚÈÛÙ·ÙÈÎfi), ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË ÛÙ·ıÂÚÔÔ›ËÛË, ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ Ô˘ ¤ÁÈÓ ÛÙÔÓ ÚÒÙÔ ˘ÁÂÈÔÓÔÌÈÎfi ÛÙ·ıÌfi (∫À, ∞π), ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË ÛÙ·ıÂÚÔÔ›ËÛË ÛÙÔ ÓÔ̷گȷÎfi ÓÔÛÔÎÔÌ›Ô, ÙË ÌÂÙ·ÊÔÚ¿ ÚÔ˜ ÙÔ ÓÔÛÔÎÔÌÂ›Ô ˘Ô‰Ô¯‹˜, Ì ·Ó·ÊÔÚ¿ ÛÙÔ Ì¤ÛÔ Î·È ÙÔ ÊÔÚ¤· ÌÂÙ·ÊÔÚ¿˜, ÛÙË Û‡ÓıÂÛË Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚ¿˜, ÛÙÔÓ ÂÍÔÏÈÛÌfi ÌÂÙ·ÊÔÚ¿˜ Î·È ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹ ÁÈ· Ù˘¯fiÓ ÂÓ¤ÚÁÂȘ ηٿ ÙË ÌÂÙ·ÊÔÚ¿. ∏ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙËÓ Â›ÛÔ‰Ô ÛÙË ª∂£ ÂÎÙÈÌ‹ıËΠ·fi ÂȉÈÎÂ˘Ì¤ÓÔ È·ÙÚfi Î·È ·Ó·ÁÚ¿ÊËÎÂ Ë ¤Î‚·Û‹ ÙÔ˘ (‚ÂÏÙ›ˆÛË, Ó¢ÚÔÏÔÁÈο ˘ÔÏ›ÌÌ·Ù·, ı¿Ó·ÙÔ˜) ηٿ ÙËÓ ¤ÍÔ‰Ô. ∞ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜, ·ÏÏ¿ ‰ÂÓ ÂÈÛ‹¯ıËÛ·Ó ¿ÌÂÛ· ÛÙË ª∂£, ‰ÂÓ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË, ÂÂȉ‹ ‰ÂÓ ÌÔÚÔ‡Û·Ó Ó· Û˘ÏϯıÔ‡Ó fiϘ ·˘Ù¤˜ ÔÈ ÏËÚÔÊÔڛ˜.
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∞ÔÙÂϤÛÌ·Ù· ™Â ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô ÂÈÛ‹¯ıËÛ·Ó ÛÙË ª∂£ 678 ·È‰È¿. ∆Ô ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÔÙ¤ÏÂÛ·Ó 100 ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ÙÔ Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚÒÓ Î·È ÂÈÛ‹¯ıËÛ·Ó ¿ÌÂÛ· ÛÙË ª∂£. ∆· 65 ·È‰È¿ ‹Ù·Ó ·ÁfiÚÈ·, Ù· 35 ÎÔÚ›ÙÛÈ· Î·È Ë Ì¤ÛË ËÏÈΛ· ÙÔ˘˜ ‹Ù·Ó 6,9 ¯ÚfiÓÈ· (19 ËÌÂÚÒÓ ¤ˆ˜ 14 ¯ÚfiÓˆÓ). ¶ÂÚ›Ô˘ Ù· ÌÈÛ¿ ·fi Ù· ·È‰È¿ Ô˘ ÌÂٷʤÚıËÎ·Ó (48%) ›¯·Ó ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË (∫∂∫) Î·È 14% ‹Ù·Ó ÔÏ˘ÙÚ·˘Ì·Ù›Â˜. ∆· ˘fiÏÔÈ· ·È‰È¿ ÌÂٷʤÚıËÎ·Ó ÏfiÁˆ ÂÁη‡Ì·ÙÔ˜ (4%), ‚·ÚÈ¿˜ Ïԛ̈͢ (6%), ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (5%), Û·ÛÌÒÓ (5%), ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó·ÎÔ‹˜ (4%) Î·È ¿ÏÏˆÓ ·ÈÙ›ˆÓ (14%) (∂ÈÎfiÓ· 1). ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ·fiÛÙ·ÛË, ÙÔ 23% ÙˆÓ ·ÛıÂÓÒÓ ÌÂٷʤÚıËΠ·fi ÙËÓ ∞ÙÙÈ΋, ÙÔ 45% ·fi ÓÔÛÔÎÔÌ›· Ù˘ ™ÙÂÚ¿˜ ∂ÏÏ¿‰·˜ Î·È Ù˘ ¶ÂÏÔÔÓÓ‹ÛÔ˘ Î·È ÙÔ 32% ·fi ÙË ÓËÛȈÙÈ΋ ∂ÏÏ¿‰·. ∆Ô ∂∫∞µ ‹Ù·Ó Ô ÊÔÚ¤·˜ Ô˘ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ Û 54 ÂÚÈÙÒÛÂȘ. ∞fi ·˘Ù¤˜, ÔÈ 48 ÌÂÙ·ÊÔÚ¤˜ ‹Ù·Ó ηϿ ÔÚÁ·ÓˆÌ¤Ó˜ (ϋڈ̷ Ì ȷÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi/ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ÂÎ·È‰Â˘Ì¤ÓÔ ÛÙȘ ÌÂÙ·ÊÔÚ¤˜, ηٿÏÏËÏÔ˜ ÂÍÔÏÈÛÌfi˜), ÂÓÒ Û 6 ÂÚÈÙÒÛÂȘ ‰ÂÓ ˘‹Ú¯Â Û˘Óԉ›· È·ÙÚÔ‡. OÈ ˘fiÏÔȘ 46 ÌÂÙ·ÊÔÚ¤˜ ÔÚÁ·ÓÒıËÎ·Ó ·fi Ù· ηٿ ÙfiÔ˘˜ ÓÔÛÔÎÔÌ›·. ∞fi ·˘Ù¤˜, ÌfiÓÔ Û 11 ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡. ™˘ÓÔÏÈο, Û 59% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡, Û 31% ˘‹Ú¯Â È·ÙÚfi˜, ·ÏÏ¿ ¯ˆÚ›˜ ÙËÓ ··Ú·›ÙËÙË Âη›‰Â˘ÛË (ÂȉÈ΢fiÌÂÓÔ˜ ‹ ·ÁÚÔÙÈÎfi˜ È·ÙÚfi˜) Î·È Û 10% ÙˆÓ ÂÚÈÙÒÛˆÓ, Ô ‚·Ú¤ˆ˜ ¿Û¯ˆÓ ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ÌÂٷʤÚıËΠ¯ˆÚ›˜ Û˘Óԉ›· È·ÙÚÔ‡ (∂ÈÎfiÓ· 2). ªfiÓÔ ÙÔ 3% ÙˆÓ ÌÂÙ·ÊÔÚÒÓ ¤ÁÈÓ ÌÂ Û˘Óԉ›· ·È‰È¿ÙÚÔ˘, ¯ˆÚ›˜ fï˜ ÂÌÂÈÚ›· ÛÙȘ ÌÂÙ·ÊÔÚ¤˜. ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙ· ̤۷ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿, ›¯·Ì 34 ·ÂÚÔÌÂÙ·ÊÔÚ¤˜ (32 ·fi ÙÔ ∂∫∞µ), ÂÓÒ ÛÙȘ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ (66) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·ÛıÂÓÔÊfiÚ· Ô¯‹Ì·Ù·. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, 62 ·ÛıÂÓ›˜ ‹Ù·Ó ‰È·ÛˆÏËӈ̤ÓÔÈ Î·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ª∞), 33 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÌÂٷʤÚıËÎ·Ó ·fi ÙÔ ∂∫∞µ. ∂›ÎÔÛÈ ¤ÓÙ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Û ª∞ ·ÂÚ›˙ÔÓÙ·Ó Ì ·ÛÎfi (Û˘Û΢‹ Ambu). ∏ ·Ó·›Ì·ÎÙË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ¤ÁÈÓ Û 59 ·ÛıÂÓ›˜, ÂÓÒ Ï‹Ú˘ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ (ÛʇÍÂȘ, ·Ó·ÓÔ¤˜, ∞¶) Ì ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜ ¤ÁÈÓ ÌfiÓÔ Û 10 ÂÚÈÙÒÛÂȘ (ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ ∂∫∞µ ‰ÂÓ ¯ÚËÛÈÌÔÔÈ› ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜, ·Ú¿ ÌfiÓÔ ·Ó·›Ì·ÎÙË Ì¤ÙÚËÛË ÎÔÚÂÛÌÔ‡). ¢Âη٤ÛÛÂÚȘ ·ÛıÂÓ›˜ ‰ÂÓ ¤Ï·‚·Ó Ï‹ÚË Î·Ù·ÛÙÔÏ‹ Î·È Ì˘Ô¯¿Ï·ÛË, 13 ·ÛıÂÓ›˜ ÚÔÛ‹Ïı·Ó ¯ˆÚ›˜ IV ÁÚ·ÌÌ‹, 66 ·ÛıÂÓ›˜ ‰ÂÓ Û˘Óԉ‡ÔÓÙ·Ó ·fi ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È Û 30
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14
10 48
4 5 31
59
5
6 4 14 ∂ȉÈÎÂ˘Ì¤ÓÔ˜ ∫∂∫ ∂ȉÈ΢fiÌÂÓÔ˜/∞ÁÚÔÙÈÎfi˜ ¶ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ ∂Áη‡Ì·Ù·
Èڛ˜ È·ÙÚfi ∂ÈÎfiÓ· 2. ™˘Óԉ›· È·ÙÚÔ‡.
§Ô›ÌˆÍË ∞Ó·Ó. ‰˘Û¯¤ÚÂÈ· ™·ÛÌÔ› ∫∞∞ ÕÏÏ· ∂ÈÎfiÓ· 1. ∞Èٛ˜ ÌÂÙ·ÊÔÚ¿˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ.
ÂÚÈÙÒÛÂȘ ÌÂÙ·ÊÔÚÒÓ ‰ÂÓ ˘‹Ú¯Â ÂÓË̤ڈÛË ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ˘Ô‰Ô¯‹˜. ∫·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∂£, 76 ·ÛıÂÓ›˜ ›¯·Ó ‚ÂÏÙȈı› Î·È 5 ·ÚÔ˘Û›·˙·Ó ˘ÔÏÂÈÌÌ·ÙÈ΋ Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹. ¢ÂηÂÓÓ¤· ·ÛıÂÓ›˜ ·Â‚›ˆÛ·Ó. OÈ ı¿Ó·ÙÔÈ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔÈ ÛÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ ÙÔ˘ ∂∫∞µ (13/54 ¤Ó·ÓÙÈ 6/46). ™˘˙‹ÙËÛË OÈ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚÔ Úfi‚ÏËÌ· ÛÙËÓ ∂ÏÏ¿‰· ÏfiÁˆ Ù˘ ÁˆÁÚ·ÊÈ΋˜ ȉÈÔÌÔÚÊ›·˜ (˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·ÔÌÔӈ̤Ó˜ ÂÚÈÔ¯¤˜ Î·È ÓËÛÈ¿ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ˘ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·ÛıÂÓÒÓ) Î·È ÏfiÁˆ Ù˘ ·Ô˘Û›·˜ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ Û ·È‰È¿. ª¤¯ÚÈ ÚÈÓ 2 ¯ÚfiÓÈ· ‰ÂÓ ˘‹Ú¯·Ó ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ·È‰ÈÒÓ ÂÎÙfi˜ ∞ÙÙÈ΋˜. ªÂ ÙË ‰ËÌÈÔ˘ÚÁ›·, ·Ú¯Èο, Ù˘ ª∂£ ·È‰ÈÒÓ ÛÙË £ÂÛÛ·ÏÔÓ›ÎË Î·È ·ÚÁfiÙÂÚ· ÛÙÔ ∏Ú¿ÎÏÂÈÔ Ù˘ ∫Ú‹Ù˘ ¤¯ÂÈ ÌÂȈı› Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂٷʤÚÔÓÙ·È ÛÙËÓ ∞ı‹Ó·. ∏ ÌÂÏÏÔÓÙÈ΋ ‰ËÌÈÔ˘ÚÁ›· Î·È ¿ÏÏˆÓ ª∂£ ·È‰ÈÒÓ ı· ÂÚÈÔÚ›ÛÂÈ ÂÚÈÛÛfiÙÂÚÔ ·˘Ùfi ÙÔÓ ·ÚÈıÌfi. ¶·Ú’ fiÏ·
·˘Ù¿, Ë ·Ó¿ÁÎË ÁÈ· ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ı· Û˘Ó¯›˙ÂÈ Ó· ˘¿Ú¯ÂÈ (ÏfiÁˆ ·ÎÚÈ‚Ò˜ Ù˘ ÁˆÁÚ·ÊÈ΋˜ ȉÈÔÌÔÚÊ›·˜). ™ÙË ¯ÒÚ· Ì·˜, fiˆ˜ Î·È Û ¿ÏϘ ¯ÒÚ˜ (1), ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ÔÚÁ·ÓÒÓÔÓÙ·È Î·È Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÙfiÛÔ ·fi Ù· ›‰È· Ù· ÂÚÈÊÂÚÂȷο ÓÔÛÔÎÔÌ›· Ô˘ οÓÔ˘Ó ÙËÓ ·Ú·ÔÌ‹ (ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘), fiÛÔ Î·È ·fi ÙÔ ∂∫∞µ, ÙÔ ÔÔ›Ô ‰È·ı¤ÙÂÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚÒÓ ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛˆÓ) (2). °È· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ Ù˘ ·ÛÊ·ÏÔ‡˜ ÌÂÙ·ÊÔÚ¿˜, ÔÈ ˘ËÚÂۛ˜ ÙÔ˘ ∂∫∞µ ·Ó¿ ÂÚÈʤÚÂÈ· (˘¿Ú¯Ô˘Ó 12 ÂÚÈʤÚÂȘ) ÚÔ‚Ï¤Ô˘Ó (3): ·) ÂȯÂÈÚËÛÈ·Îfi ΤÓÙÚÔ ÂÈÎÔÈÓˆÓ›·˜ Î·È Û˘ÓÙÔÓÈÛÌÔ‡ Ô˘ ÛÙÂϯÒÓÂÙ·È ·fi È·ÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi ÚÔÛˆÈÎfi, ηıÒ˜ Î·È ÚÔÛˆÈÎfi ‰ÈÔÈ΋Ûˆ˜ Î·È Ù¯ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, Ô˘ ÂϤÁ¯ÂÈ Î·È Û˘ÓÙÔÓ›˙ÂÈ fiϘ ÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ Î·È ‚) ̤۷ ¿ÌÂÛ˘ ¤̂·Û˘ Î·È ÌÂÙ·ÊÔÚ¿˜ ·Û¯fiÓÙˆÓ Ô˘ ÛÙÂϯÒÓÔÓÙ·È ·fi È·ÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi ÚÔÛˆÈÎfi (·ÛıÂÓÔÊfiÚ· - ·Ï¿ Î·È ÎÈÓËÙ¤˜ ÌÔÓ¿‰Â˜ - Î·È ·ÛıÂÓÔÊfiÚ· ·ÂÚÔÛοÊË, ÂÏÈÎfiÙÂÚ· ‹ ·ÂÚÔÏ¿Ó·). §fiÁˆ ÙˆÓ Û˘ÓıËÎÒÓ Ô˘ ÂÈÎÚ·ÙÔ‡Ó ÛÙË ¯ÒÚ· Ì·˜, ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ıˆÚÔ‡ÓÙ·È fiÙÈ Â›Ó·È ·˘Ù¤˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ÙËÓ ··Ú·›ÙËÙË ÊÚÔÓÙ›‰· Î·È ·ÛÊ¿ÏÂÈ· ÛÙÔ˘˜ ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ Î·È ı· Ú¤ÂÈ Ó· ÚÔÙÈÌÒÓÙ·È, Û‡Ìʈӷ Ì ‰Â‰Ô̤ӷ ·fi ÙȘ ÌÂϤÙ˜ (1,2,4). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó ÙÔ ÌÔÓ·‰ÈÎfi ÙÚfiÔ ÌÂÙ·ÊÔÚ¿˜. Œ¯Ô˘Ó, fï˜, ÔÏÏ¿ ÌÂÈÔÓÂÎÙ‹Ì·Ù· (2). ∏ ÛËÌÂÚÈÓ‹ ‰È¿ÚıÚˆÛË ÙÔ˘ ∂∫∞µ ‰ÂÓ Î·Ï‡ÙÂÈ fiϘ ÙȘ ·Ó¿ÁΘ ÌÂÙ·ÊÔÚ¿˜ ‚·Ú¤ˆÓ ·Û¯fiÓÙˆÓ.
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™ÂÏ›‰·40
¶·È‰È·ÙÚÈ΋ 2003;66:37-41
∞fi ÙȘ ÌÂÙ·ÊÔÚ¤˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÙÔ ∂∫∞µ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ ÛÙÔ 54% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ ÔÈ ˘fiÏÔȘ ÌÂÙ·ÊÔÚ¤˜ ÔÚÁ·ÓÒıËÎ·Ó ·fi Ù· ηٿ ÙfiÔ˘˜ ÓÔÛÔÎÔÌ›·. ∆Ô ÚÔÛˆÈÎfi ·ÔÙÂÏ› ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÛÙÔÈ¯Â›Ô Î¿ıÂ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ (4,5). À¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û‡ÓıÂÛË Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚÒÓ, ·Ó¿ÏÔÁ· Ì ÙÔ Û‡ÛÙËÌ· Ô˘ ˘¿Ú¯ÂÈ Û οı ¯ÒÚ·. ™ÙËÓ ∞ÁÁÏ›· ÚÔÙ›ÓÂÙ·È, ÂÊfiÛÔÓ Ë ÙÔÈ΋ ª∂£ ·È‰ÈÒÓ ·Ó·Ï·Ì‚¿ÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ ·È‰ÈÒÓ, Ë ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ Ó· ·ÔÙÂÏÂ›Ù·È ·fi ÂȉÈÎÂ˘Ì¤ÓÔ È·ÙÚfi Î·È ÂÂÈڷ̤ÓË ÓÔÛËχÙÚÈ· (6). ∆· ̤ÏË Ù˘ ÔÌ¿‰·˜ Ú¤ÂÈ Ó· Â›Ó·È ÂÎ·È‰Â˘Ì¤Ó· Î·È ÁÓÒÛÙ˜ ¯ÂÈÚÈÛÌÒÓ fiˆ˜ Â›Ó·È Ë ‰È·ÛˆÏ‹ÓˆÛË, Ô ·ÂÚÈÛÌfi˜, Ë ÛÙ·ıÂÚÔÔ›ËÛË ·ÂÚ·ÁˆÁÔ‡, Ë ÙÔÔı¤ÙËÛË ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ (1,5). ∂›Û˘, ÙÔ ÚÔÛˆÈÎfi ÌÂÙ·ÊÔÚÒÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÍÔÈÎÂȈ̤ÓÔ Ì ÙÔ “ÂÚÈ‚¿ÏÏÔÓ” Ù˘ ÌÂÙ·ÊÔÚ¿˜ (·ÛıÂÓÔÊfiÚÔ, ÂÍÔÏÈÛÌfi˜) Î·È Ó· Â›Ó·È Û ı¤ÛË Ó· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÌÈÎÚ¿ Û˘Ì‚¿ÓÙ· (2). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÛÙÔ 59% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ Û ÌÂÙ·ÊÔÚ¤˜ È·ÙÚÔ‡ (·Ó·ÈÛıËÛÈÔÏfiÁÔ˜), ÛÙÔ 31% ˘‹Ú¯Â È·ÙÚfi˜ ¯ˆÚ›˜, fï˜, ÙȘ ÂȉÈΤ˜ ÁÓÒÛÂȘ (ÂȉÈ΢fiÌÂÓÔÈ Î·È ·ÁÚÔÙÈÎÔ› È·ÙÚÔ›) Î·È ÛÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ˘‹Ú¯Â Û˘Óԉ›· È·ÙÚÔ‡. ™˘ÁÎÚÈÙÈο, Û 48/54 ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ˘‹Ú¯Â Ï‹Ú˜ Î·È ÂÎ·È‰Â˘Ì¤ÓÔ Ï‹ÚˆÌ·, ÂÓÒ ÛÙȘ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ ÌfiÓÔ Û 11/46 ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡. ∞ÎfiÌ· Î·È ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ∂∫∞µ (È·ÙÚÈÎfi Î·È ÓÔÛËÏ¢ÙÈÎfi) ‰ÂÓ ¤¯ÂÈ ÙËÓ ··Ú·›ÙËÙË Âη›‰Â˘ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ, ·Ó Î·È ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜. ∏ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ÌÂÙ·ÊÔÚ¿˜ ηıÔÚ›˙ÂÙ·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ·fiÛÙ·ÛË ÌÂÙ·ÊÔÚ¿˜, Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ ¿ıËÛ˘, ÔÈ Î·ÈÚÈΤ˜ Û˘Óı‹Î˜ Î·È Ë ÙÔÈ΋ ÁˆÁÚ·Ê›·, Ë ·ÛÊ¿ÏÂÈ·, Ù· ‰È·ı¤ÛÈÌ· ̤۷ Î·È ÙÔ ÎfiÛÙÔ˜ (1,2). ∂ÎÙfi˜ ·fi ÙËÓ Ù·¯‡ÙËÙ·, οı ̤ıÔ‰Ô˜ ÌÂÙ·ÊÔÚ¿˜ (·ÛıÂÓÔÊfiÚÔ Â‰¿ÊÔ˘˜, ÂÏÈÎfiÙÂÚÔ, ·ÂÚÔÏ¿ÓÔ) ¤¯ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ô˘ ı· ·ÍÈÔÏÔÁËıÔ‡Ó ·Ó¿ÏÔÁ· Ì ÙȘ Û˘Óı‹Î˜ (2,4,6). ™ÙË ÌÂϤÙË ·˘Ù‹, ÂÚ›Ô˘ ÙÔ 1/3 (32%) ÙˆÓ ÌÂÙ·ÊÔÚÒÓ ÚÔÂÚ¯fiÙ·Ó ·fi Ù· ÓËÛÈ¿ Î·È ‹Ù·Ó ·ÂÚÔÌÂÙ·ÊÔÚ¤˜, Ì ÂÈϤÔÓ ‰˘ÛÎÔÏ›· Î·È ÎfiÛÙÔ˜. ∏ ηχÙÂÚË ÔÚÁ¿ÓˆÛË ÙˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ÓËÛÈ¿ Î·È Ë Ì¤ÚÈÌÓ· ÁÈ· ‰È·Û‡Ó‰ÂÛË Ì ٷ ÓÔÛÔÎÔÌ›· ÙˆÓ ÓËÛÈÒÓ ·˘ÙÒÓ ı· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË Ì›ˆÛË ÙˆÓ ·ÂÚÔÌÂÙ·ÊÔÚÒÓ. ª·˙› Ì ÙȘ ÚÔÛ¿ıÂȘ ÁÈ· ÙË Ì›ˆÛ‹ ÙÔ˘˜, fï˜, ı· Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈËı› ÂÓ›Û¯˘ÛË Î·È ‚ÂÏÙ›ˆÛ‹ ÙÔ˘˜, ÒÛÙ ӷ ÌÔÚÔ‡Ó Ó· Â͢ËÚÂÙ‹ÛÔ˘Ó ·Ó¿ ¿Û· ÛÙÈÁÌ‹ ›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ. ŸÏÔ ÙÔ Ê·Ú̷΢ÙÈÎfi ˘ÏÈÎfi Î·È Ô ··Ú·›ÙËÙÔ˜
40
Paediatriki 2003;66:37-41
ÂÍÔÏÈÛÌfi˜ ÁÈ· ÙË ÛÙ·ıÂÚÔÔ›ËÛË Î·È ÙË ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ Ó· ÌÂٷʤÚÂÙ·È ·fi ÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ (1,6). O ÂÍÔÏÈÛÌfi˜ ÌÂÙ·ÊÔÚÒÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÏ·ÊÚ‡˜ Î·È ÊÔÚËÙfi˜, Ó· Â›Ó·È ÚÔÛ·ÚÌÔṲ̂ÓÔ˜ ÛÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·È‰ÈÔ‡ (‰ËÏ·‰‹ Ó· ˘¿Ú¯Ô˘Ó fiÏ· Ù· ÌÂÁ¤ıË), Ó· ÏÂÈÙÔ˘ÚÁ› Î·È Ó· ÂÊ·ÚÌfi˙ÂÈ Û fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ÙˆÓ ·ÛıÂÓÔÊfiÚˆÓ (4). ∏ ‰È¿ÚÎÂÈ· Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÂÓۈ̷و̤Ó˘ ËÁ‹˜ ÂÓ¤ÚÁÂÈ·˜ Ú¤ÂÈ Ó· Â›Ó·È ‰ÈÏ¿ÛÈ· Ù˘ ·Ó·ÌÂÓfiÌÂÓ˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ·Ó·Ó¢ÛÙ‹Ú· ÌÂÙ·ÊÔÚ¿˜ (1,4). ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ (ÛʇÍÂȘ, ∞¶, ·Ó·ÓÔ¤˜, ÎÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ıÂÚÌÔÎÚ·Û›·) Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜, ηıÒ˜ Ë ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·ÛıÂÓÔÊfiÚÔ˘ ‰ÂÓ Â›Ó·È ·ÍÈfiÈÛÙË (1,2). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ 62% ÙˆÓ ·ÛıÂÓÒÓ ‚ÚÈÛÎfiÙ·Ó Û ª∞, ÂÓÒ 25/62 ·ÛıÂÓ›˜ ·ÂÚ›˙ÔÓÙ·Ó Ì ·ÛÎfi (Û˘Û΢‹ Ambu) Î·È fi¯È Ì ·Ó·Ó¢ÛÙ‹Ú· ÌÂÙ·ÊÔÚ¿˜ fiˆ˜ Û˘ÓÈÛٿٷÈ. ∏ ·Ó·›Ì·ÎÙË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ¤ÁÈÓ Û 59% ÙˆÓ ÂÚÈÙÒÛˆÓ, ·ÏÏ¿ ÌfiÓÔ Û 10% ¯ÚËÛÈÌÔÔÈ‹ıËΠÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜ Ì ϋÚË ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ. OÈ ·Èٛ˜ Ô˘ ηıÈÛÙÔ‡Ó ··Ú·›ÙËÙË ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ·ÛıÂÓ‹ Û ÙÚÈÙÔ‚¿ıÌÈÔ ÓÔÛÔÎÔÌÂ›Ô ‹ ª∂£ Â›Ó·È ÔÈΛϘ. ™ÙË ÌÂϤÙË ·˘Ù‹, ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·È‰ÈÒÓ ÌÂٷʤÚıËΠÏfiÁˆ ÙÚ·‡Ì·ÙÔ˜, ΢ڛˆ˜ ÏfiÁˆ ∫∂∫ (48%), ·ÏÏ¿ Î·È ÔÈÎ›ÏˆÓ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ (‚·ÚÈ¿ Ïԛ̈ÍË, ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ¤Áη˘Ì·, ∫∞∞, ‰ËÏËÙËÚÈ¿ÛÂȘ, ÓÈÁÌfi˜, ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î.¿.). ∂Ô̤ӈ˜, Ô È·ÙÚfi˜ Ô˘ ı· οÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ ·Ú¯Èο Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Î·È Ó· ÛÙ·ıÂÚÔÔÈ‹ÛÂÈ ÙÔ ¿ÚÚˆÛÙÔ ·È‰› Ô˘ ÌÂٷʤÚÂÙ·È Ì ‰È¿ÊÔÚ˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∏ ·Ú¯È΋ ·ÓÙÈÌÂÙÒÈÛË Î·È ÛÙ·ıÂÚÔÔ›ËÛË, Ô˘ Â›Ó·È ÙÔ ÚÒÙÔ ‚‹Ì· Ì›·˜ ÛˆÛÙ‹˜ ÌÂÙ·ÊÔÚ¿˜, ÛÎÔfi ¤¯ÂÈ ÙË ‰È·Ù‹ÚËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·, ¤ˆ˜ fiÙÔ˘ Ô ·ÛıÂÓ‹˜ Ó· ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ï‹Úˆ˜ ÛÙÔ ÙÚÈÙÔ‚¿ıÌÈÔ ÓÔÛÔÎÔÌÂ›Ô (7). ∂¿Ó ÎÚÈı› ··Ú·›ÙËÙË Ë ‰È·ÛˆÏ‹ÓˆÛË (·ÎfiÌ· Î·È Â› ·ÌÊÈ‚ÔÏ›·˜), ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ÙÔ Ù·¯‡ÙÂÚÔ ‰˘Ó·ÙfiÓ, ¯ˆÚ›˜ ·Ó·ÌÔÓ‹ Î·È ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË (1,2). ∏ ·ÁÁÂȷ΋ ÚÔۤϷÛË Î·È Ë ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ (‹ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ) ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ Î·È Ù˘ ∞¶ Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË. ∏ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· Î·È Ë ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ÙˆÓ ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ ‹ ηıÂÙ‹ÚˆÓ ·ÚÔ¯¤Ù¢Û˘ ·ÔÙÂÏÔ‡Ó ·Ï¿ ̤۷ ÚfiÏ˄˘ ·ÓÂÈı‡ÌËÙˆÓ ÂÈÏÔÎÒÓ Î·Ù¿ ÙË ÌÂÙ·ÊÔÚ¿. ∏ ¯ÔÚ‹ÁËÛË Î·Ù¿ÏÏËÏ˘ ηٷÛÙÔÏ‹˜ ‹ Î·È Ì˘Ô¯¿Ï·Û˘ ÌÂÈÒÓÂÈ ÙÔÓ
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·41
¶·È‰È·ÙÚÈ΋ 2003;66:37-41
ΛӉ˘ÓÔ Ù˘ Ù˘¯·›·˜ ·ÔۈϋӈÛ˘ ‹ ÌÂٷΛÓËÛ˘ ηıÂÙ‹ÚˆÓ, ·ÏÏ¿ Î·È ÙȘ Èı·ÓfiÙËÙ˜ ·‡ÍËÛ˘ Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Û ·È‰›· Ì ∫∂∫ (1). ™ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∫∂∫, ıÂÌÂÏÈÒ‰Ô˘˜ ÛËÌ·Û›·˜ Â›Ó·È Ë ÚfiÏË„Ë Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘ Ô˘ ÌÔÚ› Ó· ÚÔÎÏËı› ÏfiÁˆ Ù˘ ˘fiÙ·Û˘, Ù˘ ˘ÔÍ·ÈÌ›·˜ ‹ Ù˘ ÔͤˆÛ˘. ŸÙ·Ó Ë Îϛ̷η °Ï·ÛÎ҂˘ (GCS) Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 10, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‰È·ÛˆÏËÓÒÓÂÙ·È (ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ÛÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, Â¿Ó ‰ÂÓ ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ë Èı·ÓfiÙËÙ· ηÎÒÛÂˆÓ Ù˘ ∞ª™™) Î·È Ó· ÌÂٷʤÚÂÙ·È Û ϋÚË Î·Ù·ÛÙÔÏ‹ Î·È Ì˘Ô¯¿Ï·ÛË. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ı· ¤¯ÂÈ ÂȂ‚·ÈÒÛÂÈ ÙËÓ ÔÚı‹ ı¤ÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ. ∂›Û˘, Û ÂÈÁψÙÙ›Ùȉ· ‹ ‚·ÚÈ¿ Ï·Ú˘ÁÁ›Ùȉ·, Ë ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·ÊÔ‡ Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ‰È·ÛˆÏËÓˆı› Î·È Î·Ù·ÛÙ·Ï›. ™ÙÔ ¤Áη˘Ì·, ÂÎÙfi˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ˘ÁÚÒÓ ÁÈ· ÚfiÏË„Ë Ù˘ ˘ÔÔÁηÈÌÈ΋˜ ηٷÏËÍ›·˜, Â¿Ó ˘¿Ú¯Ô˘Ó ‚Ï¿‚˜ ÛÙÔ ÚfiÛˆÔ ‹ ÛÙÔȯ›· ÂÈÛÓ¢ÛÙÈÎÔ‡ ÂÁη‡Ì·ÙÔ˜, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‰È·ÛˆÏËÓÒÓÂÙ·È ¿ÌÂÛ· ‹ ¤ÁηÈÚ·, ‰ÈfiÙÈ ÛÙËÓ ÚÒÙË ÂÚ›ÙˆÛË ÙÔ Ô›‰ËÌ· Ô˘ ı· ‰ËÌÈÔ˘ÚÁËı› ÌÔÚ› Ó· ‰˘ÛÎÔϤ„ÂÈ ÙË ‰È·ÛˆÏ‹ÓˆÛË, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ·fi ÙȘ ‚Ï¿‚˜ ÛÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜. ™ÙË ÌÂϤÙË Ì·˜, ·Ó Î·È ÙÔ 62% ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ‰È·ÛˆÏËӈ̤ÓÔ, ÔÈ 29/62 Û˘Óԉ‡ÔÓÙ·Ó ·fi È·ÙÚfi ¯ˆÚ›˜ ÁÓÒÛÂȘ ‰È·ÛˆÏ‹ÓˆÛ˘. ∂ÈϤÔÓ, 14/62 ‰ÂÓ ¤Ï·‚·Ó ηٿÏÏËÏË Î·Ù·ÛÙÔÏ‹. ∏ ÁÚ‹ÁÔÚË Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÈÎÔÈÓˆÓ›· ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ÂÌÏÂÎfiÌÂÓÔ˘˜ ÛÙË ÌÂÙ·ÊÔÚ¿ ÊÔÚ›˜ (ÓÔÛÔÎÔÌÂ›Ô Ô˘ ·Ú·¤ÌÂÈ, ÓÔÛÔÎÔÌÂ›Ô ˘Ô‰Ô¯‹˜ Î·È Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜) Â›Ó·È ÂÍ›ÛÔ˘ ÛËÌ·ÓÙÈ΋ (1,2,4). ¢˘ÛÙ˘¯Ò˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÙÔ 66% ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ Û˘Óԉ¢fiÙ·Ó ·fi ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È ÛÙÔ 30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ˘‹Ú¯Â ÂÓË̤ڈÛË ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ˘Ô‰Ô¯‹˜. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· “·ÓÂÈı‡ÌËÙ· Û˘Ì‚¿ÓÙ·” ηٿ ÙË ÌÂÙ·ÊÔÚ¿ Â›Ó·È ÈÔ Û¿ÓÈ· fiÙ·Ó Ë ÌÂÙ·ÊÔÚ¿ Á›ÓÂÙ·È ·fi ÂȉÈÎÂ˘Ì¤ÓË ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ, Û ۯ¤ÛË Ì ÙȘ ÌÂÙ·ÊÔÚ¤˜ Ô˘ Á›ÓÔÓÙ·È ·fi ÌË ÂȉÈÎÂ˘Ì¤ÓË ÔÌ¿‰· (5). ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ¤Î‚·ÛË, ÛÙË ÌÂϤÙË ·˘Ù‹, ÔÈ ı¿Ó·ÙÔÈ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔÈ ÛÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ ÙÔ˘ ∂∫∞µ (13/54 ¤Ó·ÓÙÈ 6/46), ÂÓÒ Ë ·ÚÔ˘Û›· Ó¢ÚÔÏÔÁÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜ ‹Ù·Ó ·ÚfiÌÔÈ· ÛÙȘ 2 ÔÌ¿‰Â˜ (3/54 ¤Ó·ÓÙÈ 2/40). ŒÙÛÈ, Ë “ηχÙÂÚË” ÌÂÙ·ÊÔÚ¿ Ê·›ÓÂÙ·È Ó· ÌË Û˘Ó‰˘¿˙ÂÙ·È, Û ·˘Ù‹ ÙË ÌÂϤÙË, Ì ηχÙÂÚË ¤Î‚·ÛË. ŸÌˆ˜, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÚÔ-
Paediatriki 2003;66:37-41
ÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ¤Î‚·Û˘ ÔˆÛ‰‹ÔÙ Ϸ̂¿ÓÂÙ·È ˘’ fi„ÈÓ Ë ·Ú¯È΋ ‚·Ú‡ÙËÙ·, ÂÎÙ›ÌËÛË Ë ÔÔ›· ‰ÂÓ ¤ÁÈÓ ÛÙË ÌÂϤÙË Ì·˜. ∏ ÂÓÙ‡ˆÛ‹ Ì·˜ Â›Ó·È fiÙÈ Ù· ·È‰È¿ Ô˘ ÌÂٷʤÚıËÎ·Ó ·fi ÙÔ ∂∫∞µ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ·. ∂›Û˘, ‰ÂÓ ¤¯Ô˘Ó ηٷÁÚ·Ê› Ù· ÂÚÈÛÙ·ÙÈο Ô˘ η٤ÏËÍ·Ó Î·Ù¿ ÙË ÌÂÙ·ÊÔÚ¿. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂÙ·ÊÔÚ¿ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ Â›Ó·È ¤Ó· ÛËÌ·ÓÙÈÎfi ÎÔÌÌ¿ÙÈ ÛÙËÓ Â›ÁÔ˘Û· ·È‰È·ÙÚÈ΋ Ú¿ÍË. ∏ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ·˘ÙÒÓ ÛÙÔÓ ÚÒÙÔ ÛÙ·ıÌfi ÌÂÙ·ÊÔÚ¿˜, Ë ÛÙ·ıÂÚÔÔ›ËÛË Î·È Ë Î·Ï‹ ÔÚÁ¿ÓˆÛË Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÛÙÔ Î¤ÓÙÚÔ ÂΛÓÔ Ô˘ ı· ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ÔÏÔÎÏËڈ̤ÓË ÂÚ›ı·Ï„Ë Â›Ó·È ÎÂÊ·Ï·È҉˘. ∏ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Î·È Ë ÛÙ·ıÂÚÔÔ›ËÛ‹ ÙÔ˘˜ ı· Á›ÓÂÈ Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ÚÔÂÙÔÈÌ·Û›· Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚ¿˜, ·ÔÙÂÏÔ‡ÌÂÓË ·fi ÚÔÛˆÈÎfi ÂÎ·È‰Â˘Ì¤ÓÔ ÁÈ’ ·˘Ù‹. ªÂÙ·ÊÔÚ¤˜ Ô˘ Á›ÓÔÓÙ·È ·fi ÔÌ¿‰Â˜ ¯ˆÚ›˜ ÙËÓ ··ÈÙÔ‡ÌÂÓË ÂÌÂÈÚ›· ÌÔÚ› Ó· ¤¯Ô˘Ó ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÔÚ›· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ. ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ë ÂÓË̤ڈÛË ÙÔ˘ ΤÓÙÚÔ˘ ˘Ô‰Ô¯‹˜, Ë ÂÈÏÔÁ‹ ÙÔ˘ ÔÔ›Ô˘ ı· ‚·ÛÈÛÙ› ÛÙȘ ‰˘Ó·ÙfiÙËÙ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÂÚ›ÙˆÛ˘ (.¯. Â¿Ó ˘¿Ú¯ÂÈ Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÌ‹Ì·, ª∂£), ÒÛÙ ӷ ·ÔÊ¢¯ıÔ‡Ó ¿ÛÙԯ˜ ÌÂÙ·ÎÈÓ‹ÛÂȘ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Macrae DJ. Paediatric intensive care transport. Arch Dis Child 1994;71:175-178. 2. Pon S, Notterman DA. ∏ ÔÚÁ¿ÓˆÛË ÂÓfi˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ ÂÓÙ·ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÁÈ· ·È‰È¿. Pediatr Clin North Am 1993;40:325-3529 (ÌÂÙ·ÊÚ·Ṳ̂ÓÔ). 3. ªÈÏ¿Ï˘ ¢, ∫·Ú·Ì›Ó˘ ∞. ªÂÙ·Ù˘¯È·Î¿ ª·ı‹Ì·Ù· ∂›ÁÔ˘Û·˜ ¶ÚÔÓÔÛÔÎÔÌÂȷ΋˜ π·ÙÚÈ΋˜ 1995;134-163. 4. American Academy of Pediatrics. Guidelines for air and ground transportation of pediatric patients. Pediatrics 1986;78:943-950. 5. Edge WE, Kanter RK, Weigle CGM, Walsh RF. Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 1992;20:117-124. 6. British Paediatric Association. The care of critically ill children. Report of the multidisciplinary working party on paediatric intensive care. London: BPA; 1993. 7. Henning R. Emergency transport of critically ill children: stabilization before departure. Med J Aust 1992;156:117-124. ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢ËÌ‹ÙÚÈÔ˜ °ÎÈÒÓ˘ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ & §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
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¶·È‰È·ÙÚÈ΋ 2003;66:42-46
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2003;66:42-46
ORIGINAL ARTICLE
∞ÍÈÔÏfiÁËÛË Ù˘ ÎÂÊÚÔ˙›Ï˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜1, OÌ¿‰· ªÂϤÙ˘2
Evaluation of cefprozil in the treatment of streptococcal tonsillo-pharyngitis in children A. Constantopoulos1, Study Group2
¶ÂÚ›ÏË„Ë: §fiÁˆ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·ÔÙ˘¯›·˜ Ù˘ ıÂڷ›·˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Ì ÙËÓ ÂÓÈÎÈÏ›ÓË fiÛÔ Î·È ÙȘ Ì·ÎÚÔÏ›‰Â˜, ÔÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ÎÂÚ‰›˙Ô˘Ó Û˘Ó¯Ҙ ¤‰·ÊÔ˜ Û·Ó ıÂڷ›· ÂÎÏÔÁ‹˜ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË, Ì›· ÓÂfiÙÂÚË ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·, ¯ÔÚËÁ‹ıËΠ۠5175 ·ÛıÂÓ›˜ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜, ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ì ÂÍ·ÈÚÂÙÈο ·ÔÙÂϤÛÌ·Ù·. ∫ÏÈÓÈ΋ ›·ÛË ·Ú·ÙËÚ‹ıËΠ۠ÔÛÔÛÙfi 89,3% ÙˆÓ ·ÛıÂÓÒÓ, Ì ·Ú¿ÏÏËÏ· ˘„ËÏ¿ ÔÛÔÛÙ¿ Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂڷ›· (98,2%) Î·È ¯·ÌËÏ¿ ÔÛÔÛÙ¿ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ (4%) Î·È ·ÏÏ·Á‹˜ Ù˘ ıÂڷ›·˜ (2,6%). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Û˘ÌʈÓÔ‡Ó ·fiÏ˘Ù· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÌÂÏÂÙÒÓ ·fi ͤÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÎÂÊÚÔ˙›ÏË Â›Ó·È Ì›· ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ·ÛÊ·Ï‹˜ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜.
Abstract: Due to the increased incidence of clinical failure following oral penicillin and macrolides treatment, cephalosporins are continuously gaining ground as an alternative therapy of streptococcal tonsillo-pharyngitis. In the present study, cefprozil a novel oral cephalosporin, was administered to 5175 patients aged 3-18 years old, in several parts of Greece, with clinical evidence of streptococcal tonsillo-pharyngitis having excellent results. Cure based on clinical evidence was observed in 89.3% of patients, with concurrent high rates of compliance to the treatment (98.2%), low rates of adverse events (4%) and even lower rate of switch to other therapy (2.6%). These results are in full accordance with those of previous studies, indicating that cefprozil is an effective and safe choice for the treatment of streptococcal tonsillo-pharyngitis.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰›, ÛÙÚÂÙfiÎÔÎÎÔ˜, Ïԛ̈ÍË, ÎÂÊÚÔ˙›ÏË, ıÂڷ›·, ·Ì˘Á‰·Ï›Ùȉ·.
Key words: child, streptococcus, infection, cefprozil, treatment, tonsillitis.
∂ÈÛ·ÁˆÁ‹ ∏ ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· ÚÔηÏÂ›Ù·È ·fi ÙÔÓ ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘
ÔÌ¿‰·˜ ∞ (˘ÔÁfiÓÔ ÛÙÚÂÙfiÎÔÎÎÔ) Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·. ∂›Ó·È, fï˜, ȉȷ›ÙÂÚ· Û˘¯Ó‹ ÛÙ· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏
1 ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
1 Professor of Pediatrics, University of Athens
2 ª. ∞ÁÁÂÏ¿Î˘, ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜, ª. ∞ÚÁ˘Ú¿Î˘, ∂. ∞Ú¯ÈÙÂÎÙÔÓ›‰Ô˘, ª. ∞Ú¯ÔÓÙ›‰Ô˘, ™. ∞˘ÏˆÓ›Ù˘, ¢. µÈ‰¿Î˘, ∫. µÔ˘ÎÂÏ¿ÙÔ˘, °. µÚ˘ÒÓ˘, §. °·Ï¿Ó˘, ª. °È·ÓӷΛ‰Ô˘, ¡. °Î·Ì›Ï˘, ¶. °Ô˘Ú‰Ô˘¿Ú˘, ™. °Ú‡ÏÏ˘, ∫. ¢·ÓÂÏ¿ÙÔ˘, ∞. ¢È‰¿ÁÁÂÏÔ˜, °. ¢Ô‡‚Ú˘, ™. ¢ÚfiÛ˘, ∂. ∂Ï¢ıÂÚÈ¿‰Ô˘, °. ∑ÂÚ‚¿˜, Ã. ∑Ô˘Á·Ó¤ÏË, ∫. £ÂÚÌfi˜, Œ. π·Îˆ‚›‰Ô˘, ∞. ∫·ÎÔÁÈ¿ÓÓË, °. ∫·ÏÔÁÂÚfiÔ˘ÏÔ˜, °. ∫·ÂÙ·Ó¿Î˘, ¶. ∫·Ú·ÁÈ¿ÓÓ˘, ™. ∫·Ú·ÛÙ·Ì¿Ù˘, ∫. ∫ÔÚÒÓË-¶··ÓÙˆÓ›Ô˘, ¢. ∫·Û·¿Î˘, ¢. ∫·ÙÛÈοÚË, º. ∫·ÙÛÈԇϷ, ¢. ∫ψÛÙÔÔ‡ÏÔ˘, ∂. ∫fiÎÎÔÚË, ∞. ∫ÔÏÈÔ¿ÓÔ˘, ™. ∫fiÚÚ·, ∫. ∫ÔÙÛÈÒÓË, ∞. ∫Ô˘ÎfiÁÈ·, º. ∫Ô˘ÁÈ¿ÓÔ˜, ∫. ∫Ô‡ÚÙ˘, °. ∫ÚÔÎȉ¿˜, §. ∫˘Ú·ÓÔ‡‰Ë, ∂. ∫˘ÚÈ·ÎÔ‡, ∂. ∫˘Ú›ÙÛË, ∞. §ËÌÓ·›Ô˘, ∞. §˘ÎÔ˘Ú›ÓÔ˘, ∏. ª¿Ì·Ï˘, Ã. ª·ÓÙ¿, °. ª·ÚΤÙÔ˜, ª. ª·ÈÙ›ÓË, ∂. ª·ÙÛԇη-¶··ÓÈÎÔÏ¿Ô˘, °. ª·˘Ú¿Î˘, §. ªËÙÚfiÔ˘ÏÔ˜, π. ªÈ۷ϤÌ˘, §. ªÈÏ¿Ï˘, ∞. ªÔ˘Ú¿ÓÙ·-º·ÏÔ‡ÙÛÔ˘, ∞. ¡Èfi˙·, ∫. ¡Ù·Ïԇη˜, ƒ. ¡ÙÈÔ‡‰Ë-∞¯ÙÛfiÁÏÔ˘, ¶. ¡ÙÔ‡ÚÌ·, ª. ¶¿ÓÔ˘, ∂. ¶··‰ËÌËÙÚ›Ô˘, ∂. ¶··ı·Ó·Û›Ô˘, π. ¶··˚ˆ¿ÓÓÔ˘, ∞. ¶··ÓÙˆÓ›Ô˘, ¶. ¶›ÛÎÔÔ˜, π. ¶ÔÏ›ÙÛÔ˜, ∑. ¶ÔÏ˘¯ÚÔÓ›‰Ô˘, ¡. ¶Ô˘Ï·ÓÙ˙¿˜, ∫. ƒ¿Ù˘, ∞. ™·Î·Ï›‰Ô˘, ∂. ™·Ú·¿Ú˘, Ÿ. ™È‰ËÚÔÔ‡ÏÔ˘, ¢. ™ÔÏÔ‡ÎÔ˜, π. ™ÙÂÚÁ›‰Ë˜, ∞. ™Ù˘ÏÈ·Ó¿ÎË, ¢. ™˘Ìˆӛ‰Ë˜, ¢. ∆·Ï›‰Ë˜, ¢. ∆˙¿Ï·˜, °. ∆Û·Áη‰fiÔ˘ÏÔ˜, π. ∆Û·ÎÓ¿ÎË-ª·ÓˆÏ¿ÎË, ∫. ∆ÛÂÚÏÂÓÙ¿ÎË, °. ∆ÛÔÏ¿˜, °. ∆˘¯¿Ï·˜, ª. ÷ÈÚ¤Ù˘, ∫. ÷ω·ÈÔÔ‡ÏÔ˘-¶Ú¤ÓÙ˙·, ¶. ÷ÏÂÏ‹, º. ÷ÏÈÒÙ˘, π. ÷ڈӛÙË, ∂. ÷ÛÈÒÙÔ˘-∆Ô˘Ú›ÎË, ∂. ÷Ù˙Ë·ı·Ó·ÛÈ¿‰Ô˘, ∞. ÃÚËÛÙ¿ÎÔ˘, ¶. ÃÚ˘ÛfiÌ·ÏÏÔ˘
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¶·È‰È·ÙÚÈ΋ 2003;66:42-46
‰È¿ÁÓˆÛ‹ Ù˘ Ù›ıÂÙ·È Ì ·ÛÊ¿ÏÂÈ· Ì ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, ÂÓÒ ·ÍÈfiÈÛÙ· ·ÔÙÂϤÛÌ·Ù· ‰›ÓÂÈ Î·È Ë Ù·¯Â›· ̤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (1). ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË, ¿ÓÙˆ˜, Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ ÙË ‚Ô‹ıÂÈ· Ù¤ÙÔÈˆÓ Ù¯ÓÈÎÒÓ. ™ÙȘ Ï›ÛÙ˜ ÂÚÈÙÒÛÂȘ, Ë ‰È¿ÁÓˆÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ù›ıÂÙ·È ·fi ÛÙÔȯ›· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Î·È ÂȂ‚·ÈÒÓÂÙ·È Ì ηÏÏȤÚÁÂÈ· ÂȯڛÛÌ·ÙÔ˜, ÂÓÒ Ë ıÂڷ›· ¯ÔÚËÁÂ›Ù·È ÂÌÂÈÚÈο. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ì ·ÓÙÈ‚ÈÔÙÈο ·ÔÛÎÔ› ·ÊÂÓfi˜ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ˆ‰ÒÓ ÂÈÏÔÎÒÓ Ô˘ Â›Ó·È ‰˘ÓËÙÈο ÛÔ‚·Ú¤˜ (.¯. ÂÚÈ·Ì˘Á‰·ÏÈÎfi ·fiÛÙËÌ·), ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÌË ˘ˆ‰ÒÓ ÂÈÏÔÎÒÓ (.¯. ÚÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜) (2). ∏ 10‹ÌÂÚË ¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘ ·ÔÙÂÏ› ÙËÓ ÎÏ·ÛÈ΋ ıÂڷ›· ÁÈ· ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· (1). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· ·ÔÙ˘¯›· Ù˘ ÂÓÈÎÈÏ›Ó˘ Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ (1). ∏ ·ÔÙ˘¯›· ·˘Ù‹ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ·fi ÙÔÓ ÛÙÚÂÙfiÎÔÎÎÔ, ·ÏÏ¿ ·Ô‰›‰ÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ ÛÙËÓ ·ÚÔ˘Û›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ê¿Ú˘ÁÁ· ÌÈÎÚÔ‚›ˆÓ Ô˘, ¯ˆÚ›˜ Ó· Â›Ó·È ·ıÔÁfiÓ·, ·Ú¿ÁÔ˘Ó ¤Ó˙˘Ì· (‚-Ï·ÎÙ·Ì¿Û˜) Ô˘ ‰È·ÛÔ‡Ó Î·È ·‰Ú·ÓÔÔÈÔ‡Ó ÙËÓ ÂÓÈÎÈÏ›ÓË (Ê·ÈÓfiÌÂÓÔ ‚·ÎÙËÚȷ΋˜ ·ÚÂÌ‚ÔÏ‹˜) (1,3). ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ÂÓÈÎÈÏ›ÓË, ÔÈ Ì·ÎÚÔÏ›‰Â˜ Ô˘ ·Ó¤Î·ıÂÓ ·ÔÙÂÏÔ‡Û·Ó ÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË Û ÂÚ›ÙˆÛË ·ÏÏÂÚÁ›·˜ ÛÙȘ ‚-Ï·Îٿ̘, ¤¯Ô˘Ó Úfi‚ÏËÌ· ·ÓÙÔ¯‹˜ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, Ô˘ Û ÌÂÚÈΤ˜ ¯ÒÚ˜ Â›Ó·È Ôχ ÛÔ‚·Úfi. ∏ ·ÓÙÔ¯‹ ·˘Ù‹ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÛËÌ·ÓÙÈο ›‰· (38%) Î·È ÛÙËÓ ∂ÏÏ¿‰· Î·È ·ÊÔÚ¿ ÛÙȘ ·Ï·ÈfiÙÂÚ˜ (ÂÚ˘ıÚÔÌ˘Î›ÓË), ·ÏÏ¿ Î·È ÛÙȘ ÓÂfiÙÂÚ˜ Ì·ÎÚÔÏ›‰Â˜ (ÚÔÍÈıÚÔÌ˘Î›ÓË, ÎÏ·ÚÈıÚÔÌ˘Î›ÓË, ·˙ÈıÚÔÌ˘Î›ÓË) (4). OÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Â›Ó·È ÂÍ›ÛÔ˘ ‰Ú·ÛÙÈΤ˜ Ì ÙËÓ ÂÓÈÎÈÏ›ÓË ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, ¯ˆÚ›˜ fï˜ Ó· ‰È·ÛÒÓÙ·È ·fi ÙȘ Ï·ÎÙ·Ì¿Û˜ ÙˆÓ Û·ÚÔÊ‡ÙˆÓ ÙÔ˘ Ê¿Ú˘ÁÁ·. À¿Ú¯Ô˘Ó ÔÏϤ˜ ÌÂϤÙ˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ô˘ ‰Â›¯ÓÔ˘Ó ˘ÂÚÔ¯‹ ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ ¤Ó·ÓÙÈ Ù˘ ÂÓÈÎÈÏ›Ó˘ ÛÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· (1). ∏ ÎÂÊÚÔ˙›ÏË Â›Ó·È Ì›· Ó¤· ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·. Œ¯ÂÈ Â˘Ú‡ ·ÓÙÈÌÈÎÚÔ‚È·Îfi Ê¿ÛÌ· ηχÙÔÓÙ·˜ ÂÍ›ÛÔ˘ ηϿ Gram(+) Î·È Gram(-) ·ıÔÁfiÓ· Ù˘ ηıËÌÂÚÈÓ‹˜ ÎÏÈÓÈ΋˜ Ú¿Í˘. ∂ÌÊ·Ó›˙ÂÈ ÌÂÁ¿ÏË ‰Ú·ÛÙÈÎfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (MIC90 ≤0,032 mg/l) (4). ÃÔÚËÁÔ‡ÌÂÓË ·fi ÙÔ ÛÙfiÌ· ¤¯ÂÈ ÂÍ·ÈÚÂÙÈο Ê·Ú-
Paediatriki 2003;66:42-46
Ì·ÎÔÎÈÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο: ¿ÚÈÛÙË ‚ÈԉȷıÂÛÈÌfiÙËÙ· Î·È ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌÔÚ› Ó· ¯ÔÚËÁËı› Ì›· ‹ ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜, ÁÂÁÔÓfi˜ Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙË ıÂڷ›· (5,6). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó: ·) Ë ÂÎÙ›ÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÎÂÊÚÔ˙›Ï˘ Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, ‚) Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÎÂÊÚÔ˙›Ï˘ Î·È Á) Ë ÂÎÙ›ÌËÛË Ù˘ Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ ıÂڷ¢ÙÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË ÂÚÈÏ‹ÊıËÎ·Ó ·ÛıÂÓ›˜ ËÏÈΛ·˜ 3-18 ÂÙÒÓ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ı· ÌÔÚÔ‡Û ӷ ¯ÔÚËÁËı› ıÂڷ›· Â͈ÓÔÛÔÎÔÌÂȷο Ì ·ÓÙÈ‚ÈÔÙÈÎfi ·fi ÙÔ ÛÙfiÌ·. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ·ÛıÂÓÒÓ ·fi ÙË ÌÂϤÙË ·ÔÙ¤ÏÂÛ·Ó: ·) ÁÓˆÛÙ‹ ·ÏÏÂÚÁ›· ÛÙËÓ ÎÂÊÚÔ˙›ÏË Î·È ÁÂÓÈÎfiÙÂÚ· ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ‹ ÛÙȘ ÂÓÈÎÈϛӘ ÏfiÁˆ Èı·Ó‹˜ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÏÏÂÚÁ›·˜, ‚) Ë Ù·˘Ùfi¯ÚÔÓË Ï‹„Ë Î·È ¿ÏÏÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ‹ Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 7 Ë̤Ú˜ ÚÈÓ ÙË Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË Î·È Á) Ë ·ÚÔ˘Û›· ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÔÔÈ·Û‰‹ÔÙ ʇÛ˘ (Û˘ÁÁÂÓÔ‡˜, È·ÙÚÔÁÂÓÔ‡˜ ‹ ÔÊÂÈÏfiÌÂÓ˘ Û ˘ÔΛÌÂÓË ÓfiÛÔ). ™ÙËÓ ·Ú¯È΋ ›ÛÎÂ„Ë ÁÈÓfiÙ·Ó ·ÍÈÔÏfiÁËÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (¶›Ó·Î·˜ 1) Î·È ·ÔÊ·ÛÈ˙fiÙ·Ó Â¿Ó Ë fiÏË ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô ·ÛıÂÓ‹˜ ‹Ù·Ó ηٿÏÏËÏÔ˜ ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË, ÂÏ¿Ì‚·Ó ·ÁˆÁ‹ Ì ÎÂÊÚÔ˙›ÏË 30 mg/kg/24ˆÚÔ ÁÈ· 10 Ë̤Ú˜. ∏ Û˘ÓÔÏÈ΋ ËÌÂÚ‹ÛÈ· ‰ÔÛÔÏÔÁ›· ¯ÔÚËÁÔ‡ÓÙ·Ó Û ‰‡Ô ‰fiÛÂȘ (·Ó¿ 12ˆÚÔ), ›Ù ˘fi ÙË ÌÔÚÊ‹ ÂӷȈڋ̷ÙÔ˜ ›Ù ˘fi ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ÙˆÓ 500 mg. ∏ ̤ÁÈÛÙË ÂÈÙÚÂfiÌÂÓË ‰ÔÛÔÏÔÁ›· ‹Ù·Ó 1 g/24ˆÚÔ. ™Â ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·, 5-8 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, Ï·Ì‚¿ÓÔÓÙ·Ó ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÔÚ›· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙËÓ Ù˘¯fiÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Ù˘ ÓfiÛÔ˘ ‹ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ·fi ÙË ıÂڷ›·. ªÂ ‚¿ÛË Ù· ÛÙÔȯ›· ·fi ÙËÓ ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·, ‰ÈÓfiÙ·Ó Î·È Ô ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ ¤Î‚·Û˘ Ù˘ ıÂڷ›·˜: ·) ÿ·ÛË: Ï‹Ú˘ ·Ô‰ÚÔÌ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ Ù˘ Ïԛ̈͢, ‚) µÂÏÙ›ˆÛË: Ì›ˆÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ‹/Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ Î·È Á) ∞ÔÙ˘¯›·: ÔÚȷ΋ ·Ô‰ÚÔÌ‹, ÂÈÌÔÓ‹ ‹ Âȉ›ӈÛË ÙˆÓ Û˘Ìو̿وÓ. ¶·Ú¿ÏÏËÏ·, ηٿ ÙËÓ ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Ï·Ì‚¿ÓÔÓÙ·Ó ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙË Û˘ÌÌfiÚʈÛË ÛÙË ıÂڷ›·, ÙËÓ Èı·Ó‹ ·ÏÏ·Á‹ Ù˘ ıÂڷ›·˜, ηıÒ˜ Î·È ÙÔ˘˜ ÏfiÁÔ˘˜ Ô˘ ÙËÓ ˘·ÁfiÚÂ˘Û·Ó.
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¶·È‰È·ÙÚÈ΋ 2003;66:42-46
Paediatriki 2003;66:42-46
™ËÌÂÈÒÓÂÙ·È fiÙÈ fiÔ˘ ·Ó·Ê¤ÚÂÙ·È Ô fiÚÔ˜ Û˘ÌÌfiÚʈÛË ÛÙË ıÂڷ›·, ¤¯ÂÈ ÔÚÈÛÙ› ‰ÈÂıÓÒ˜ fiÙÈ Ô ¿ÚÚˆÛÙÔ˜ Ï·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 80% Ù˘ Û˘ÓÔÏÈ΋˜ ıÂڷ›·˜.
∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 89 ÂÚ¢ÓËÙ¤˜ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜, ÌÂ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi 5175 ·ÛıÂÓÒÓ. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 6,5±3,3 ¯ÚfiÓÈ· (‰È¿ÌÂÛË ËÏÈΛ·: 6 ¯ÚfiÓÈ·). ¶Ï‹Úˆ˜ ·ÍÈÔÏÔÁ‹ÛÈÌÔÈ ‹Ù·Ó 5087 ·ÛıÂÓ›˜. ™˘ÓÔÏÈο, ›·ÛË Ì ‚¿ÛË ÙȘ ÚԉȷÁڷʤ˜ Ù˘ ÌÂϤÙ˘ ÂÌÊ¿ÓÈÛ ÙÔ 89,3%, ‚ÂÏÙ›ˆÛË ÙÔ 9,2% Î·È ·ÔÙ˘¯›· ÙÔ 1,5% ÙˆÓ ·ÍÈÔÏÔÁ‹ÛÈÌˆÓ ·ÛıÂÓÒÓ (∂ÈÎfiÓ· 1). ∆Ô ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂڷ›· ‹Ù·Ó Ôχ ÌÈÎÚfi (1,8%), fï˜ Ë Â›ÙˆÛË Ù˘ ÌË Û˘ÌÌfiÚʈÛ˘ ÛÙËÓ ¤Î‚·ÛË Ù˘ ıÂڷ›·˜ ‹Ù·Ó Ôχ ÛËÌ·ÓÙÈ΋. OÈ ‰È·ÊÔÚ¤˜ Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ŒÙÛÈ, ÛÙËÓ ÂÚ›ÙˆÛË ÌË Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂڷ›· ÙÔ ÔÛÔÛÙfi ›·Û˘ ‹Ù·Ó ·ÚÎÂÙ¿ οو ·fi ÙÔ 50% Î·È Ô ˘ÔÏÔÁÈ˙fiÌÂÓÔ˜ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· “fi¯È Ï‹ÚË ›·ÛË” (‚ÂÏÙ›ˆÛË+·ÔÙ˘¯›·) ‹Ù·Ó 12,9 (95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘: 8,0-20,9). ∂Ô̤ӈ˜, Â¿Ó ÏË-
ÊıÔ‡Ó ˘’ fi„ÈÓ ÌfiÓÔ Ù· ¿ÙÔÌ· Ô˘ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂڷ›·, ÙÔ ÔÛÔÛÙfi Ù˘ ›·Û˘ ‹Ù·Ó ·ÎfiÌË ˘„ËÏfiÙÂÚÔ (90,2%). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ˘Ô¯ÒÚËÛÂ Ô ˘ÚÂÙfi˜, Ë Ì¤ÛË ÙÈÌ‹ ‹Ù·Ó 2,39±0,82 Ë̤Ú˜, ÂÓÒ ÙfiÛÔ Ë ‰È¿ÌÂÛË fiÛÔ Î·È Ë ÂÈÎÚ·ÙÔ‡Û· ÙÈÌ‹ ‹Ù·Ó Ë ‰Â‡ÙÂÚË Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (¶›Ó·Î·˜ 2). ∏ ·ÓÙ›ÛÙÔÈ¯Ë Ì¤ÛË ÙÈÌ‹ ÁÈ· ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ÏÔÈÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó 2,92±1,22, ÂÓÒ Ë ‰È¿ÌÂÛË ‹Ù·Ó Ë ÙÚ›ÙË Î·È Ë ÂÈÎÚ·ÙÔ‡Û· ÙÈÌ‹ ‹Ù·Ó Ë ‰Â‡ÙÂÚË Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (¶›Ó·Î·˜ 3). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Ù˘ ÏÔÈÌÒ͈˜ ‹Ù·Ó ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· (44 ·ÛıÂÓ›˜, ÔÛÔÛÙfi 0,86%). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Û˘Óԉ¢fiÙ·Ó, ¿ÓÙˆ˜, ·fi ·ÏÏ·Á‹ ÛÙË ıÂڷ›·. ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ıÂڷ›· ÂÌÊ·Ó›ÛÙËÎ·Ó Û 204 ·ÛıÂÓ›˜ (4%) Î·È ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ Û ‰È¿ÚÚÔÈ· Î·È Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi Û ¤ÌÂÙÔ. OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ‰ÂÓ ‹Ù·Ó Û˘Ó‹ıˆ˜ ÛÔ‚·Ú¤˜ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ÏÈÁfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÌÈÛÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó Î¿ÔÈ· ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ¿ÏÏ·Í·Ó ÙÂÏÈο
¶›Ó·Î·˜ 1. ™ÙÔȯ›· Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÙˆÓ ·ÛıÂÓÒÓ ™˘ÌÙÒÌ·Ù· ¶ÔÓfiÏ·ÈÌÔ˜ ¢˘ÛηٷÔÛ›· ¶ÔÓÔΤʷÏÔ˜ ƒ›ÁÔ˜ ∫ÔÈÏÈ·Îfi ¿ÏÁÔ˜ £ÂÚÌÔÎÚ·Û›· Ì·Û¯¿Ï˘
BÂÏÙ›ˆÛË 9,2%
™˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 82% 60,8% 48,1% 46,9% 32,5% Ô 38,9 C
∞ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË
¶ÔÛÔÛÙfi
°ÂÓÈ΋ ηٿÛÙ·ÛË ÂËÚ·Ṳ̂ÓË ¢‡ÛÙÚÔÔ ª¤ÁÂıÔ˜ ·Ì˘Á‰·ÏÒÓ ‰ÈÔÁΈ̤ÓÔ ∂›¯ÚÈÛÌ· ∂Ú˘ıÚfiÙ˘ ∂Í›‰ÚˆÌ· ∞˘ÙÈ¿-̇ÙË-Ï·ÈÌfi˜ Û˘Ì‚·Ù¿ Ì ·Ì˘Á‰·Ï›Ùȉ· (‰ÂÓ ˘‹Ú¯Â ‚‹¯·˜, ÚÈÓ›ÙȘ, ˆÙ›ÙȘ, ÂÈÂÊ˘Î›ÙȘ Î.¿.)
∞ÔÙ˘¯›· 1,5%
32,3% 20,1% 71,1% 76,8% 97,4% 53,7%
92,2%
100% ∞ÔÙ˘¯›· 80% 60% BÂÏÙ›ˆÛË 40% 20%
ÿ·ÛË 89,3% ∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ·ÁˆÁ‹˜.
44
ÿ·ÛË
0% ™˘ÌÌfiÚʈÛË
ªË Û˘ÌÌfiÚʈÛË
∂ÈÎfiÓ· 2. ÷ڷÎÙËÚÈÛÌfi˜ ·ÁˆÁ‹˜ ·Ó¿ÏÔÁ· Ì ÙË Û˘ÌÌfiÚʈÛË ÛÙË Ï‹„Ë ÙÔ˘ Ê·ÚÌ¿ÎÔ˘.
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·45
¶·È‰È·ÙÚÈ΋ 2003;66:42-46
Paediatriki 2003;66:42-46
¶›Ó·Î·˜ 2. ÃÚÔÓÈ΋ ÛÙÈÁÌ‹ ÙÒÛ˘ ÙÔ˘ ˘ÚÂÙÔ‡
∏̤ڷ ÙÒÛ˘ ˘ÚÂÙÔ‡
1 2 3 4 5 6+
™‡ÓÔÏÔ ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ ™‡ÓÔÏÔ ÌË ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ °ÂÓÈÎfi Û‡ÓÔÏÔ
™˘¯ÓfiÙËÙ·
¶ÔÛÔÛÙfi › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ··ÓÙËı¤ÓÙˆÓ (%)
496 2118 1638 310 26 11
10,8% 46,1% 35,6% 6,7% 0,6% 0,2%
4599 576 5175
100%
¶›Ó·Î·˜ 3. ÃÚÔÓÈ΋ ÛÙÈÁÌ‹ ˘Ô¯ÒÚËÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ™˘¯ÓfiÙËÙ·
¶ÔÛÔÛÙfi › ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ··ÓÙËı¤ÓÙˆÓ (%)
∏̤ڷ ˘Ô¯ÒÚËÛ˘ 1 ÙˆÓ ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ 2 3 4 5 6 7 8
353 1491 1474 679 340 93 30 15
7,9% 33,3% 32,9% 15,2% 7,6% 2,1% 0,7% 0,3%
™‡ÓÔÏÔ ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ ™‡ÓÔÏÔ ÌË ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ °ÂÓÈÎfi Û‡ÓÔÏÔ
4475 700 5175
100%
ÙË ıÂڷ›· ÂÍ·ÈÙ›·˜ ·˘Ù‹˜. ™˘ÓÔÏÈο, ·ÏÏ·Á‹ ıÂڷ›·˜ ÁÈ· fiϘ ÙȘ ·Èٛ˜ ¤ÁÈÓ Û 130 ·ÛıÂÓ›˜ (2,6%). ∞Ó Î·È ‰ÂÓ ¤ÁÈÓ·Ó Î·ÏÏȤÚÁÂȘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, Ù· Â˘Ú‹Ì·Ù· ÛÙËÓ ∂ÈÎfiÓ· 2 ‰Â›¯ÓÔ˘Ó fiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ·Ì˘Á‰·Ï›Ùȉ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ¢È·ÊÔÚÂÙÈο, Â¿Ó ÂÚfiÎÂÈÙÔ ÁÈ· ÈÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜, ‰ÂÓ ı· ‰È·ÈÛÙˆÓfiÙ·Ó ‰È·ÊÔÚ¿ Û ·ÛıÂÓ›˜ Ì η΋ Û˘ÌÌfiÚʈÛË. ™˘˙‹ÙËÛË ∏ ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· Â›Ó·È Ì›· Û˘¯Ó‹ ¿ıËÛË Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏ ·Ú·‰ÔÛȷ΋ ıÂڷ›· Ì ÂÓÈÎÈÏ›ÓË ¤¯ÂÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÔÙ˘¯›·˜ Î·È ˘ÔÙÚÔÒÓ, ·Ú¿ ÙË ‰Ú·ÛÙÈÎfiÙËÙ¿ Ù˘ ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (1). ∂ÈϤÔÓ, ÔÈ Ì·ÎÚÔÏ›‰Â˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ›·, ¤¯Ô˘Ó ÛÔ‚·Úfi Úfi‚ÏËÌ· ·ÓÙÔ¯‹˜ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, Ô˘ ·ÊÔÚ¿ ÙfiÛÔ ÛÙ· ·Ï·ÈfiÙÂÚ· fiÛÔ Î·È ÛÙ· ÓÂfiÙÂÚ· ̤ÏË ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ·ÓÙÈ‚ÈÔÙÈÎÒÓ (4). ∞ÓÙ›ıÂÙ·, ÔÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Â›Ó·È ‰Ú·ÛÙÈΤ˜ ¤Ó·ÓÙÈ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ fiˆ˜ Î·È Ë ÂÓÈÎÈÏ›ÓË, ÂÓÒ ÛÙÂÚÔ‡ÓÙ·È ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·˘Ù‹ ÂÌÊ·Ó›˙ÂÈ (‰È¿Û·ÛË ·fi ‚-Ï·ÎÙ·Ì¿Û˜, η΋ Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋). π‰È·›ÙÂÚ· Ë ÎÂÊÚÔ˙›ÏË, Ì›· ÓÂfiÙÂÚË ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·, ¤¯ÂÈ ÌÂÁ¿ÏË ‰Ú·ÛÙÈ-
ÎfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘. ™Â ÌÂϤÙ˜ Û˘ÁÎÚÈÙÈΤ˜ Î·È ÌË ¤‰ÂÈÍ ÂÍ·ÈÚÂÙÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Û ÔÈÎÈÏ›· ÏÔÈÌÒ͈Ó, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ (5,6). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Û ‰ÔÛÔÏÔÁ›· 30 mg/kg/24ˆÚÔ Û ·ÛıÂÓ›˜ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, ¤Ù˘¯Â ˘„ËÏfi ÔÛÔÛÙfi ÎÏÈÓÈ΋˜ ›·Û˘ (89,3%). ™ËÌÂÈÒÓÂÙ·È, ›Û˘, fiÙÈ Ô ¯ÚfiÓÔ˜ ̤¯ÚÈ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡ Î·È ÙˆÓ ÏÔÈÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó ÌÈÎÚfi˜, Ì ÙÔ Ï›ÛÙÔ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ó· ˘Ô¯ˆÚ› ‹‰Ë ·fi ÙË ‰Â‡ÙÂÚË Ë̤ڷ Ù˘ ıÂڷ›·˜, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ Ù·¯Â›· ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›·. ∆Ô ÔÛÔÛÙfi ·˘Ùfi (89,3%) ‹Ù·Ó ·ÎfiÌË ˘„ËÏfiÙÂÚÔ (90,2%) ·Ó Ï·Ì‚¿ÓÔÓÙ·Ó ˘’ fi„ÈÓ ÌfiÓÔ ÔÈ ·ÛıÂÓ›˜ Ô˘ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂڷ›·. To ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂڷ›· Ô˘ ·Ú·ÙËÚ‹ıËΠ̠ÙËÓ ÎÂÊÚÔ˙›ÏË ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Î·È Ô˘ ·ÔÙÂÏ› Ô˘ÛÈ·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÎÏÈÓÈ΋ ÂÈÙ˘¯›· Ù˘ ıÂڷ›·˜, Ú¤ÂÈ Ó· ·Ô‰Ôı› ·ÊÂÓfi˜ ÛÙÔ ·Ïfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Ù˘ ÎÂÊÚÔ˙›Ï˘, ·ÊÂÙ¤ÚÔ˘ ÛÙÔ ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ô˘ ·Ú·ÙËÚ‹ıËηÓ. ∞Í›˙ÂÈ Ó· ÙÔÓÈÛÙ› ÙÔ È‰È·›ÙÂÚ· ¯·ÌËÏfi ÔÛÔÛÙfi ·ÏÏ·Á‹˜ Ù˘ ıÂڷ›·˜ Ô˘ ηٷÁÚ¿ÊËΠÛÙËÓ ·ÚÔ‡Û·
45
JAN-FEB-03
14-05-03
14:37
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¶·È‰È·ÙÚÈ΋ 2003;66:42-46
ÌÂϤÙË, Ô˘ ‹Ù·Ó Û˘Ó¿ÚÙËÛË ÙfiÛÔ Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ fiÛÔ Î·È Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ıÂڷ›·˜, fiˆ˜ ·˘Ù‹ ÂÎÊÚ¿ÛÙËΠ̠ÙÔ ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· Ù˘ ÎÂÊÚÔ˙›Ï˘ Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› Û ÔÏϤ˜ ÌÂϤÙ˜, Û˘ÁÎÚÈÙÈΤ˜ Î·È ÌË. ŒÙÛÈ, .¯. ÔÈ µrook Î·È Û˘Ó (7) Û ̛· Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË Ì ÂÚ˘ıÚÔÌ˘Î›ÓË ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙfi ›·Û˘ 90% Ì ÙËÓ ÎÂÊÚÔ˙›ÏË, ÂÓÒ ÙÔ ÔÛÔÛÙfi ‚·ÎÙËÚÈÔÏÔÁÈ΋˜ ÂÎÚ›˙ˆÛ˘ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ ÛÙËÓ ›‰È· ÌÂϤÙË ¤Êı·Û ÙÔ 95% ¤Ó·ÓÙÈ ÌfiÏȘ 74% Ì ÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË. ™Â Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË, ›Û˘, ÙˆÓ Milatovic Î·È Û˘Ó, Ë ÎÂÊÚÔ˙›ÏË ‹Ù·Ó ·ÓÒÙÂÚË Ù˘ ÂÓÈÎÈÏ›Ó˘ ÙfiÛÔ Û ÎÏÈÓÈÎfi fiÛÔ Î·È Û ‚·ÎÙËÚÈÔÏÔÁÈÎfi Â›Â‰Ô (8). ™Â Ì›· ¿ÏÏË ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ ›¯Â Ù· ›‰È· ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ÎÂÊ·ÎÏfiÚË Ô˘ ¯ÔÚËÁ‹ıËΠ3 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Î·È ÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË Ô˘ ¯ÔÚËÁ‹ıËΠ4 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ (9). ∏ ·ÓÒÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ÎÂÊÚÔ˙›Ï˘, Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, Ô‰‹ÁËÛ ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ Ó· Û˘˙ËÙÔ‡Ó ÙÔ ÂӉ¯fiÌÂÓÔ ·Ó·ıÂÒÚËÛ˘ Ù˘ ıÂڷ›·˜ ÂÎÏÔÁ‹˜ ÁÈ· ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·. ™ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÙÔ Î‡ÚÈÔ Âȯ›ÚËÌ· ˘¤Ú Ù˘ ÂÓÈÎÈÏ›Ó˘ Â›Ó·È ÙÔ ¯·ÌËÏfi ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜. ∂¿Ó, fï˜, ÏËÊı› ˘’ fi„ÈÓ ÙÔ “ÎÚ˘Êfi” ÎfiÛÙÔ˜ Ô˘ ÂÚÈÎÏ›ÂÈ Ì›· ·ÔÙ˘¯›· Ù˘ ıÂڷ›·˜ (Ó¤· È·ÙÚÈ΋ ›Û΄Ë, Ó¤Ô ·ÓÙÈ‚ÈÔÙÈÎfi, ÙÚÒÛË ÙÔ˘ ·ÚÔ˘˜ ÙÔ˘ È·ÙÚÔ‡, ·Ô˘Û›· ·fi Û¯ÔÏ›Ô-‰Ô˘ÏÂÈ¿ Î.Ï.), ηıÒ˜ Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÌÂÁ¿ÏË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ì ÙË ¯Ú‹ÛË ‚Ú·¯¤ˆÓ (5 ÌÂÚÒÓ) Û¯ËÌ¿ÙˆÓ, Ë “Ï¿ÛÙÈÁÁ· ›Ûˆ˜ Á›ÚÂÈ ÙÂÏÈο ÚÔ˜ ÙÔ Ì¤ÚÔ˜ ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ” (10). ∏ ·ÚÔ‡Û· ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Û ·È‰È¿ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ÂÌÊ·Ó›˙ÂÈ ÌÂÁ¿ÏË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ô˘ Û˘Ó‰˘¿˙ÂÙ·È Ì ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Î·È ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. ªÂ ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿, Ë ÎÂÊÚÔ˙›ÏË Ú¤ÂÈ
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Ó· ıˆÚÂ›Ù·È Û·Ó Ì›· ·ÍÈfiÈÛÙË Î·È ·ÛÊ·Ï‹˜ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Pichichero ME, Casey JR, Mayes T, Francis AB, Marsocci SM, Murphy AM et al. Penicillin failure in streptococcal tonsillopharyngitis: causes and remedies. Pediatr Infect Dis J 2000;19:917-923. 2. Kaplan EL. The resurgence of group A streptococcal infections and their sequelae. Eur J Clin Microbiol Infect Dis 1991;10:55-57. 3. Brook I. ∆he role of beta-lactamase producing bacteria and bacterial interference in streptococcal tonsillitis. Int J Antimicrob Agents 2001;17:439-442. 4. Syrogiannopoulos GA, Grivea IN, Fitoussi F, Doit C, Katopodis GD, Bingen E et al. High prevalence of erythromycin resistance of Streptococcus pyogenes in Greek children. Pediatr Infect Dis J 2001;20:863-868. 5. Barriere SL. Review of in vitro activity, pharmacokinetic characteristics, safety, and clinical efficacy of cefprozil, a new oral cephalosporin. Ann Pharmacother 1993;27: 1082-1089. 6. Wiseman LR, Benfield P. Cefprozil. A review of its antibacterial activity, pharmacokinetic properties, and therapeutic potential. Drugs 1993;45:295-317. 7. Brook I, Aronovitz GH, Pichichero ME. Open-label, parallel-group, multicenter, randomized study of cefprozil versus erythromycin in children with group A streptococcal pharyngitis/tonsillitis. Clin Ther 2001;23: 1889-1900. 8. Milatovic D, Adam D, Hamilton H, Materman E. Cefprozil versus penicillin V in the treatment of streptococcal tonsillopharyngitis. Antimicrob Agents Chemother 1993; 37:1620-1623. 9. Aronovitz G. Treatment of upper and lower respiratory tract infections: Clinical trials with cefprozil. Pediatr Infect Dis J 1998;17 (8 Suppl):S83-S88. 10. ∞dam D, Scholz H, Helmerking M. Short-course antibiotic treatment of 4782 culture-proven cases of group A streptococcal tonsillopharyngitis and incidence of poststreptococcal sequelae. J Infect Dis 2000;182:509-516. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-11-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-12-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
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CASE REPORT
ÀÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Û ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I °. ∆Ú›Ì˘1, ª. ªÔÛ¯fi‚Ë1, ∏. ∫·Ú·Ó›Î·˜2, ª. ∫·Ó¿ÚÈÔ˘3, ∞. ƒ·ÊÙÔÔ‡ÏÔ˘4, º. ∆˙ˆÚÙ˙¿ÙÔ˘ - ™Ù·ıÔÔ‡ÏÔ˘1
Subacute vertebral osteomyelitis in a child with type I diabetes mellitus G. Trimis1, M. Moschovi1, I. Karanikas2, M. Kanariou3, A. Raftopoulou4, F. Tzortzatou - Stathopoulou1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ 14 ÂÙÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I Î·È Â›ÌÔÓÔ ¿ÏÁÔ˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ·fi ÌËÓfi˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÂÚÈÔ¯‹ ¤ıÂÛ ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜. ¢È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ¤ıÂÛ ÙË ‰È¿ÁÓˆÛË ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ˘ÏÈÎÔ‡ Ù˘ ‚ÈÔ„›·˜ ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. OÈ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ ˘Ô¯ÒÚËÛ·Ó ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹. ∆Ô ÂӉȷʤÚÔÓ ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙË Û¿ÓÈ· ÂΉ‹ÏˆÛË ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Û ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË Ù˘ ÂÚ›ÙˆÛ˘.
Abstract: A case of a 14 year-old boy with type I diabetes mellitus and persistent pain in the spine of one month’s duration is described. A magnetic resonance imaging of vertebral column was performed and the patient was initially considered to have lymphoma. The diagnosis of twelfth thoracic vertebrae osteomyelitis was established by transcutaneous biopsy. Staphylococcus aureus was isolated from the culture of the biopsy material. The manifestations of the disease resolved after antibiotic treatment. Subacute vertebral osteomyelitis is a rare condition, even in a child with diabetes mellitus, and the diagnosis is often overlooked initially.
§¤ÍÂȘ ÎÏÂȉȿ: ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, ÔÛÙÂÔÌ˘ÂÏ›ÙȘ, ۷ί·Ú҉˘ ‰È·‚‹Ù˘.
Key words: spine, osteomyelitis, diabetes mellitus.
∂ÈÛ·ÁˆÁ‹ ∏ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ˘ÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Û˘Á¯¤ÂÙ·È ÔÏϤ˜ ÊÔÚ¤˜ Ì ·˘Ù‹ ÙˆÓ Î·ÎÔ‹ıˆÓ fiÁΈÓ, fiˆ˜ ÙÔ Ï¤Ìʈ̷, ÙÔ ÔÛÙÂÔÛ¿ÚΈ̷, ÙÔ Û¿ÚΈ̷ Ewing’s, ÙÔ ËˆÛÈÓfiÊÈÏÔ ÎÔÎΛˆÌ· Î·È ·ÓÙ›ÛÙÚÔÊ· (1). ∏ ÈÔ Â˘·›ÛıËÙË ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Â›Ó·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) Ì ¢·ÈÛıËÛ›· 98%, fï˜ Ë ÂȉÈÎfiÙËÙ¿ Ù˘ ‰ÂÓ Â›Ó·È ·ÓÙ›ÛÙÔÈ¯Ë Î·È ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 75% (2). °È· ÙËÓ Â‰Ú·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ··ÈÙÂ›Ù·È ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ ‹, › ·ÔÙ˘¯›·˜, ·ÓÔȯً ‚ÈÔ„›· (3). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ 14 ÂÙÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I Ô˘ ·ÚÔ˘Û›·Û ›-
ÌÔÓÔ ¿ÏÁÔ˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ·fi ÌËÓfi˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÂÚÈÔ¯‹˜ ¤ıÂÛ ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜. ªÂ ÙË ‚Ô‹ıÂÈ· ‰È·‰ÂÚÌÈ΋˜ ‚ÈÔ„›·˜ ‰È·ÁÓÒÛıËΠÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ˘ÏÈÎÔ‡ Ù˘ ‚ÈÔ„›·˜ ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. OÈ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ ˘Ô¯ÒÚËÛ·Ó ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹.
¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 1 ªÔÓ¿‰· ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜, A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 µ’ OÚıÔ‰È΋ ∫ÏÈÓÈ΋ 3 ∞ÓÔÛÔÏÔÁÈÎfi ∆Ì‹Ì· 4 ∆Ì‹Ì· ∫ÏÈÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜
“Agia Sophia” Children’s Hospital, Athens 1 Hematology-Oncology Unit, 1st Pediatric Clinic of University of Athens 2 2nd Orthopedic Clinic 3 Department of Immunology 4 Department of Clinical Microbiology
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 14 ÂÙÒÓ ·Ú·¤ÌÊıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜ ÛÙÔ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ. ∏ Èı·Ó‹ ·˘Ù‹ ‰È¿ÁÓˆÛË Ù¤ıËΠ·fi ÙËÓ MRI Ù˘ ıˆÚ·ÎÔ-ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ÛÙËÓ ÔÔ›· ˘Ô‚Ï‹ıËÎÂ
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Ô ·ÛıÂÓ‹˜ ÁÈ·Ù› ·ÚÔ˘Û›·˙ ›ÌÔÓÔ ¿ÏÁÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ ·fi ÌËÓfi˜. O ·ÛıÂÓ‹˜ Â›Ó·È ÙÔ ‰Â‡ÙÂÚÔ ·È‰› ÙÂÙÚ·ÌÂÏÔ‡˜ ÔÈÎÔÁ¤ÓÂÈ·˜ Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÂÙ·È ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ I ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 7 ÂÙÒÓ, Ô ÔÔ›Ô˜ Ú˘ıÌ›˙ÂÙ·È ÌÂÙÚ›ˆ˜ Ì ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ ÈÓÛÔ˘Ï›Ó˘ Î·È ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹ (ÙÈ̤˜ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜: 200-350 mg/dl, ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË HbA1c: 9,5-11%, ÙÂÏÂ˘Ù·›· ÙÈÌ‹: 9,6%). OÈ ÂÓԯϋÛÂȘ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ÍÂΛÓËÛ·Ó ÚÔ ÌËÓfi˜, ÌÂÙ¿ ·fi ¤ÓÙÔÓË ¿ÛÎËÛË. O ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·ÛÂ, ›Û˘, ˘„ËÏfi ˘ÚÂÙfi ̤¯ÚÈ 40ÔC Ù· ÙÚ›· ÚÒÙ· 24ˆÚ·, Ô˘ ·Ô‰fiıËΠ۠ÈÔÁÂÓ‹ Ïԛ̈ÍË. §fiÁˆ ÚÔԉ¢ÙÈ΋˜ Âȉ›ӈÛ˘ ÙÔ˘ ¿ÏÁÔ˘˜, ¤ÁÈÓ ÔÚıÔ‰È΋ ÂÎÙ›ÌËÛË ÙËÓ ¤ÌÙË Ë̤ڷ Ù˘ ÓfiÛÔ˘. ∏ ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË Î·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜, fiÔ˘ Ë ÌÔÚÊÔÏÔÁ›· ÙˆÓ ÛÔÓ‰‡ÏˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋, ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ıÏ¿Û˘ Ì˘ÒÓ. ™˘ÛÙ‹ıËΠ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ Î·È ·˘ÛÙËÚ‹ ηٿÎÏÈÛË Û ·ÓÙ·ÏÁÈ΋ ı¤ÛË ÁÈ· 15 Ë̤Ú˜. ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ÙÔ ¿ÏÁÔ˜ ·ÚÔ˘Û›·Û ۯÂÙÈ΋ ‡ÊÂÛË. ™ÙË Û˘Ó¤¯ÂÈ·, fï˜, ·ÚÔ˘ÛÈ¿ÛÙËΠ‰Ú·Ì·ÙÈ΋ Âȉ›ӈÛË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÂÌÔ‰›˙ÔÓÙ·È ÔÈ ·Ï¤˜ ÎÈÓ‹ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡. ŒÁÈÓ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Ì MRI Î·È ‰È·ÈÛÙÒıËΠÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ì ·ÓÒÌ·ÏÔ ÂÚ›ÁÚ·ÌÌ· Ù˘ ÚfiÛıÈ·˜ Î·È Î¿Ùˆ ·Ú˘Ê‹˜ ·˘ÙÔ‡, Ë ÔÔ›· ‰ËÌÈÔ˘ÚÁÔ‡Û ÙËÓ ÂÓÙ‡ˆÛË ‰È·‚ÚÒÛÂˆÓ Î·È ÏÈÁfiÙÂÚÔ Û˘ÌÈÂÛÙÈÎÔ‡ ηٿÁÌ·ÙÔ˜. ∆·˘Ùfi¯ÚÔÓ·, ·ÂÈÎÔÓÈ˙fiÙ·Ó Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ¤ÚÈÍ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘, Ë ÔÔ›· ·ÚÔ˘Û›·˙ ÌÈÎÚ‹ ¤ÎÙ·ÛË ÚÔ˜ Ù· οو ¤ÌÚÔÛıÂÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘ (∂ÈÎfiÓ· 1). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ¤ıÂÙ·Ó ÙËÓ ˘fiÓÔÈ· ‰ÈËıËÙÈ΋˜ ÂÍÂÚÁ·Û›·˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘, Ë ÔÔ›· ÂӉ¯Ô̤ӈ˜ ÔÊÂÈÏfiÙ·Ó Û ϤÌʈ̷. O ·ÛıÂÓ‹˜ ·Ú·¤ÌÊıËΠÛÙËÓ ÎÏÈÓÈ΋ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Èı·Ó‹˜ ηÎÔ‹ıÂÈ·˜. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ¤ÓÙÔÓË Â˘·ÈÛıËÛ›· ÛÙËÓ Î·ÙÒÙÂÚË ıˆÚ·ÎÈ΋ Î·È ·ÓÒÙÂÚË ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÂ Û˘ÓÔ‰fi Ì˘˚Îfi Û·ÛÌfi. ∆Ô ¿ÏÁÔ˜ ÂÈÙÂÈÓfiÙ·Ó Î·Ù¿ ÙȘ ÎÈÓ‹ÛÂȘ ο̄˘ Î·È ¤ÎÙ·Û˘ ÙÔ˘ ÎÔÚÌÔ‡. ∆Ô ÛËÌÂ›Ô Laseque ‹Ù·Ó ÂÓÙfiÓˆ˜ ıÂÙÈÎfi ¿Ìʈ. ∞fi ÙËÓ ÂͤٷÛË ÙˆÓ ˘fiÏÔÈˆÓ Û˘ÛÙËÌ¿ÙˆÓ ‰ÂÓ ÂÓÙÔ›ÛÙËÎ·Ó ¿ÏÏ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ·˘ÍË̤ÓÔÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂: 85 mm, CRP: 50 mg/L, ÊÂÚÚÈÙ›ÓË:
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Paediatriki 2003;66:47-51
196 ng/ml, LDH: 497 IU/L, Cu: 150 Ìg/dl), ÂÓÒ Ë ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (Ht: 42,9%, Hb: 14,2 g/dl, WBC: 8200/Ìl, PLT: 268.000/Ìl) Î·È Ô ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ¤ÏÂÁ¯Ô˜ ÁÈ· Ê˘Ì·Ù›ˆÛË Î·È ‚ÚԢΤÏψÛË ·¤‚Ë ·ÚÓËÙÈÎfi˜. ™ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· Ù˘ ÂÚÈÔ¯‹˜ ·ÂÈÎÔÓ›ÛÙËÎÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ì χÛË Î·Ù¿ ÙÔ ÚfiÛıÈÔ Î¿Ùˆ ¯Â›ÏÔ˜ ·˘ÙÔ‡. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ Ì Ù¯ӋÙÈÔ ¤‰ÂÈÍ ·˘ÍË̤ÓË Î·ı‹ÏˆÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔÓ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ. ∏ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙÂı› ‰È¿ÁÓˆÛË, ÚÔÁÚ·ÌÌ·Ù›ÛÙËΠ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÛÔÓ‰‡ÏÔ˘ ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ. ∆Ô ·È‰› Ù¤ıËΠ۠·˘ÛÙËÚ‹ ηٿÎÏÈÛË, Û ·ÓÙ·ÏÁÈ΋ ı¤ÛË Î·È ÙÔ˘ ¯ÔÚËÁ‹ıËΠÈÛ¯˘Ú‹ ·Ó·ÏÁËÙÈ΋ ·ÁˆÁ‹. ¶·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË, fï˜ ÙËÓ Ù¤Ù·ÚÙË Ë̤ڷ ÓÔÛËÏ›·˜ ÂÌÊ¿ÓÈÛ ˘ÚÂÙfi ̤¯ÚÈ 39oC Ì ڛÁÔ˜, ¯ˆÚ›˜ Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ Ô˘ ÂÏ‹ÊıË ·ÔÌÔÓÒıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÙÂ˚ÎÔÏ·Ó›ÓË 800 mg/24ˆÚÔ:2 (̤ÁÈÛÙË ‰fiÛË), ÎÂÊÔÙ·Í›ÌË 150 mg/kg/24ˆÚÔ:3 Î·È ·ÌÈηۛÓË 15 mg/kg/24ˆÚÔ:2 ÂÓ‰ÔÊÏ‚›ˆ˜. O ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛ ÂÓÙfi˜ 36
∂ÈÎfiÓ· 1. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ù˘ ıˆÚ·ÎÔ-ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ¢È·ÎÚ›ÓÂÙ·È Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Î·È Ë ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙·, Ë ÔÔ›· ·ÚÔ˘ÛÈ¿˙ÂÈ Â¤ÎÙ·ÛË ÚÔ˜ Ù· οو ¤ÌÚÔÛıÂÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘.
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·49
¶·È‰È·ÙÚÈ΋ 2003;66:47-51
ˆÚÒÓ Î·È ÙËÓ ÂfiÌÂÓË Ë̤ڷ ¤ÁÈÓÂ Ë ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ÙÔ˘ ÚÔۂ‚ÏË̤ÓÔ˘ ÛÔÓ‰‡ÏÔ˘. ∞fi ÙËÓ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË ÙÔ˘ ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ ‰È·ÈÛÙÒıËΠÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· (ÂÈÎfiÓ· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜), ÛÙÔ ¿ÌÂÛÔ ·Ú·Û··ÛÌ· ‹Ù·Ó ÔÚ·ÙÔ› Gram(+) ÎfiÎÎÔÈ Û ۈÚÔ‡˜, ÂÓÒ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ‰Â›ÁÌ·ÙÔ˜ ·fi ÙÔ ›‰ÈÔ ˘ÏÈÎfi ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ô˘ ·ÚÔ˘Û›·˙ ÙËÓ ›‰È· ¢·ÈÛıËÛ›· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô Û٤ϯԘ Ô˘ ·ÔÌÔÓÒıËΠÛÙÔ ·›Ì·. ™˘ÁÎÂÎÚÈ̤ӷ, ÙÔ Û٤ϯԘ ‹Ù·Ó ·ÓıÂÎÙÈÎfi ÛÙËÓ ÔÍ·ÎÈÏÏ›ÓË, ÙËÓ ÎÂÊ·ÏÂÍ›ÓË Î·È ÙËÓ ÎÂÊÔ˘ÚÔÍ›ÌË, ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙÔ ÛÙË ÁÂÓÙ·ÌÈΛÓË Î·È ÙËÓ ·ÌÈηۛÓË Î·È Â˘·›ÛıËÙÔ ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË, ÙÔ ÊÔ˘ÛȉÈÎfi Ô͇, ÙËÓ ÎÏÈÓ‰·Ì˘Î›ÓË, ÙËÓ ÙÂ˚ÎÔÏ·Ó›ÓË Î·È ÙË ‚·ÓÎÔÌ˘Î›ÓË. ™‡Ìʈӷ Ì ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù·, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Î·È ·ÔÊ·Û›ÛÙËÎÂ Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ Ì ÙÂ˚ÎÔÏ·Ó›ÓË Î·È ·ÌÈηۛÓË. ∆Ô ¿ÏÁÔ˜ ˘Ô¯ÒÚËÛ ı·̷ÙÈο ÂÓÙfi˜ 5 ËÌÂÚÒÓ Î·È ÙÔ ·È‰› ¿Ú¯ÈÛ ӷ ÎÈÓËÙÔÔÈÂ›Ù·È Ì ÙË ‚Ô‹ıÂÈ· ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ·. ™˘Á¯ÚfiÓˆ˜, ˘‹ÚÍ ‚ÂÏÙ›ˆÛË ÛÙÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂: 30 mm, CRP: 4 mg/L, ÊÂÚÚÈÙ›ÓË: 60 ng/ml, LDH: 240 IU/L, Cu: 50 Ìg/dl). ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÔÏÔÎÏËÚˆı› Ô ¤ÏÂÁ¯Ô˜, ¤ÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÂÚÈÔ¯‹, fiÔ˘ ÂȂ‚·ÈÒıËÎÂ Ë ÔÛÙÂÔÏ˘ÙÈ΋ ÂÍÂÚÁ·Û›· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Î·È Ë ·Ô˘Û›· ‚Ï¿‚˘ ÙˆÓ ·ÔʇÛÂˆÓ Î·È ÙÔ˘ Ì˘ÂÏÈÎÔ‡ ۈϋӷ, ÂÓÒ ¿ÏϘ ÂÛٛ˜ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ·ÔÎÏ›ÛÙËÎ·Ó Ì ÔÏfiÛˆÌÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Á¿ÏÏÈÔ. §fiÁˆ Ù˘ ÌÈÎÚÔ‚È·ÈÌ›·˜, ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ fiÔ˘ ‰ÂÓ ·ÓȯÓ‡ıËÎ·Ó Â΂ϷÛÙ‹ÛÂȘ. ∆· ·ÓÙÈÛÒÌ·Ù· ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈο, ÔÈ ÙÈ̤˜ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÛÙÔÓ ÔÚfi ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜, ÂÓÒ ÔÈ ˘ÔÔÌ¿‰Â˜ Ig3 Î·È Ig4 ‹Ù·Ó ¯·ÌËϤ˜: Ig3: 20 mg/dl (º∆: 28-141 mg/dl) Î·È Ig4: 25 mg/dl (º∆: 40-184 mg/dl). ∏ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, fiˆ˜ Î·È Ë ‰ÔÎÈÌ·Û›· DHR (dihydrorhodamine 123 fluorescence test) Ì ‰È¤ÁÂÚÛË ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ, Ë ÔÔ›· ÂϤÁ¯ÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÂÓ˙‡ÌˆÓ ÙÔ˘˜ Ô˘ ·ÛÎÔ‡Ó ÌÈÎÚÔ‚ÈÔÎÙfiÓÔ ‰Ú¿ÛË, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. O ·ÛıÂÓ‹˜ ÂÍ‹Ïı ·ÊÔ‡ Û˘ÌÏ‹ÚˆÛ 28 Ë̤Ú˜ ÂÓ‰ÔÊϤ‚È·˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ Î·È ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜. ¢ÂÓ ·ÚÔ˘Û›·˙ η̛· ÂÓfi¯ÏËÛË ÛÙËÓ ¿Û¯Ô˘Û· ÂÚÈÔ¯‹ Î·È Â›¯Â ·Ó·Ù‡ÍÂÈ ÈηÓÔÔÈËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ·. ™˘ÓÂÛÙ‹ıË Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ì ÊÔ˘ÛȉÈÎfi Ô͇ 20 mg/kg/24ˆÚÔ:3 Î·È ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË 10 mg/kg/ 24ˆÚÔ:2 ÁÈ· ¿ÏϘ 8 ‚‰ÔÌ¿‰Â˜ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙË-
Paediatriki 2003;66:47-51
Úȷο. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ¤ÁÈÓ Ӥ· MRI ÛÙË ıˆÚ·ÎÔ-ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, fiÔ˘ ·Ú·ÙËÚ‹ıËΠÂÍ¿ÏÂÈ„Ë Ù˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜, ·ÏÏ¿ ·Ú·ÌÔÓ‹ ÙˆÓ ‰È·‚ÚÒÛÂˆÓ ÛÙÔÓ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ, ÛÙ¤ÓˆÛË ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ÌÂÛ·ÚıÚ›Ô˘ ‰È·ÛÙ‹Ì·ÙÔ˜, ηٷÛÙÚÔÊ‹ ÙÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ Î·È Â¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙËÓ ¿Óˆ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘, fiÔ˘ ·Ú·ÙËÚ‹ıËÎ·Ó Â›Û˘ ‰È·‚ÚÒÛÂȘ (∂ÈÎfiÓ· 2). OÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ ·Ú¤ÌÂÓ·Ó ¯·ÌËÏÔ› (∆∫∂: 22 mm, CRP: <3,4 mg/L). ™˘ÓÂÛÙ‹ıË Ù·ÎÙÈ΋ ÔÚıÔ‰È΋ Î·È Ó¢ÚÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÙËÓ ÚfiÏË„Ë ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. ™˘˙‹ÙËÛË ∏ ÔÛÙÂÔÌ˘ÂÏ›ÙȘ, ÂȉÈο ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, Â›Ó·È Û¿ÓÈ· Î·È Ë ‰È¿ÁÓˆÛ‹ Ù˘ - ÛÙÔ ‹ÌÈÛ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ - ηı˘ÛÙÂÚ› ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó· Ì‹Ó·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηı˘ÛÙÂÚ› Ë ¤Ó·ÚÍË ·ÁˆÁ‹˜ Î·È Ó· ÂÈ‚·Ú‡ÓÂÙ·È Ë ÚfiÁÓˆÛË (4). ¶·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ Û ¿ÙÔÌ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 50 ÂÙÒÓ, Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ¿ÚÚÂÓÔ˜ ʇÏÔ˘, Ì οÔÈÔ ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· fiˆ˜ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, ¯ÚfiÓÈ· Ï‹„Ë ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ηÎÔ‹ıÂÈ·, ·ÏÎÔÔÏÈÛÌfi, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ‹ ÚÔËÁËı›۷ ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË (4,5). ∆Ô Â›ÌÔÓÔ
∂ÈÎfiÓ· 2. ¡¤· Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ›‰È· ÂÚÈÔ¯‹ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÂÙ¿ ·fi 2 Ì‹Ó˜. ¢È·ÈÛÙÒÓÂÙ·È ·Ú·ÌÔÓ‹ ÙˆÓ ‰È·‚ÚÒÛÂˆÓ ÛÙÔ ÛÒÌ· ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘, ·Ú·ÙËÚÂ›Ù·È fï˜ ηٷÛÙÚÔÊ‹ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ Î·È ‰È¿‚ÚˆÛË Ù˘ ¿Óˆ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ∏ ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙· ¤¯ÂÈ ÂÍ·ÏÂÈÊı›.
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¶·È‰È·ÙÚÈ΋ 2003;66:47-51
¿ÏÁÔ˜ Î·È Ë Â˘·ÈÛıËÛ›· Û ÂÓÙÔÈṲ̂ÓÔ ÛËÌÂ›Ô Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, fiÙ·Ó Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂, CRP), ı¤ÙÔ˘Ó ˆ˜ Èı·ÓfiÙÂÚË ‰È¿ÁÓˆÛË ÙËÓ ÔÍ›· ‹ ˘ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·. O ˘ÚÂÙfi˜ Î·È Ë Ï¢ÎÔ΢ÙÙ¿ÚˆÛË fiÙ·Ó Û˘Ó˘¿Ú¯Ô˘Ó ˘ÔÛÙËÚ›˙Ô˘Ó ÙË ‰È¿ÁÓˆÛË, fï˜ Ë ·Ô˘Û›· ÙÔ˘˜ ‰ÂÓ ÙËÓ ·ÔÎÏ›ÂÈ. ∂› ·‰˘Ó·Ì›·˜ ‰È¿ÎÚÈÛ˘ ÌÂٷ͇ ÊÏÂÁÌÔÓ‹˜ Î·È Î·ÎÔ‹ıÂÈ·˜ Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ MRI ÛÙËÓ ÂÚÈÔ¯‹, ··ÈÙÂ›Ù·È ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· Ù˘ ÔÛÙÈ΋˜ ‚Ï¿‚˘ ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ, ÂÓÒ Â› ·ÔÙ˘¯›·˜ Á›ÓÂÙ·È ·ÓÔȯً ‚ÈÔ„›· (3,5). ∏ Û˘ÓËı¤ÛÙÂÚË ÂÓÙfiÈÛË ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË Â›Ó·È Ë ÔÛÊ˘Ô˚ÂÚ‹ ÌÔ›Ú· (60%) Î·È ·ÎÔÏÔ˘ı› Ë ıˆÚ·ÎÈ΋ (33%) Î·È Ë ·˘¯ÂÓÈ΋ (7%) (5). OÈ ˘Â‡ı˘ÓÔÈ ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ›ӷÈ, ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, Ô ÂȉÂÚÌÈÎfi˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘, Ô ‚-·ÈÌÔÏ˘ÙÈÎfi˜ ÛÙÚÂÙfiÎÔÎÎÔ˜ Ù˘ ÔÌ¿‰·˜ µ, Ô ÛÙÚÂÙfiÎÔÎÎÔ˜ viridans Î·È ÙÔ ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ. ª˘ÎËÙÈ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ˆ˜ Û˘ÓÔ‰fi ·›ÙÈÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Â›Ó·È Û·ÓÈfiÙ·ÙÔÈ (4,6). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Û˘ÓÙËÚËÙÈ΋ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ (75-85%), Ì ÂÓ‰ÔÊϤ‚È· ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÁÈ· 4-6 ‚‰ÔÌ¿‰Â˜ ηÈ, ·ÎÔÏÔ‡ıˆ˜, ·ÁˆÁ‹ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ¢ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· ÙË ‰È¿ÚÎÂÈ· Ù˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÁˆÁ‹˜ (2 ˆ˜ 8 ‚‰ÔÌ¿‰Â˜) (6,7). ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ¿Û¯Ô˘Û·˜ ÂÚÈÔ¯‹˜ Ì ÙË ‚Ô‹ıÂÈ· ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ó¢ÚÔÏÔÁÈ΋˜ Û˘Ó‰ÚÔÌ‹˜ (6). ø˜ ÎÚÈÙ‹ÚÈÔ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ıÂڷ›· ıˆÚÂ›Ù·È Ë ·ÔηٿÛÙ·ÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÛÙÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ Â›Ó·È Ë ∆∫∂ Î·È Ë CRP. ™Â ÔÚÈṲ̂ӷ ΤÓÙÚ·, ÔÈ ·ÚÓËÙÈΤ˜ ÙÈ̤˜ ·˘ÙÒÓ ÙˆÓ ‰ÂÈÎÙÒÓ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ (7). ∂› ·ÔÙ˘¯›·˜ ÙˆÓ ·ÓˆÙ¤Úˆ ıÂڷ¢ÙÈÎÒÓ Ì¤ÙÚˆÓ, ·ÎÔÏÔ˘ı› ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ Ù˘ ÚÔۂ‚ÏË̤Ó˘ ÂÚÈÔ¯‹˜ (3,6). ∏ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·Ó·Ì¤ÓÂÙ·È Û 3-6 Ì‹Ó˜ (8). ∏ ËÏÈΛ· οو ÙˆÓ 40 ÂÙÒÓ, Ë ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÛˆÛÙ‹ ·ÎÈÓËÙÔÔ›ËÛË, Ë ¤ÁηÈÚË ¤Ó·ÚÍË ·ÁˆÁ‹˜ Î·È Ë ÁÚ‹ÁÔÚË ÙÒÛË ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÔÊ˘Á‹ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ (4,5). ∏ ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Â›Ó·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·, ·ÎfiÌ· Î·È Û ¿ÙÔÌ· Ì ·˘ÍË̤ÓÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Â›Ó·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘. ™˘Ó‹ıˆ˜, ¯ÚÂÈ¿˙ÔÓÙ·È ·ÚÎÂÙ¤˜ ‰ÂηÂٛ˜ ̤¯ÚÈ Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ÔÈ ÚÔ¸Ôı¤ÛÂȘ ÂÁηٿÛÙ·Û˘ Ì›·˜ ÙfiÛÔ ÛÔ‚·Ú‹˜
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Ïԛ̈͢ Û ‰È·‚ËÙÈο ¿ÙÔÌ·. ∆¤ÙÔÈÔÈ ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·, Ë ÂÚÈÊÂÚÈ΋ Ó¢ÚÔ¿ıÂÈ· Î·È ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ˘ÂÚÏ·Û›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È Ë ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ·ÁÁ›ˆÓ ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜, Ì ·ÎfiÏÔ˘ıÔ ÙË ‰ËÌÈÔ˘ÚÁ›· ÌÈÎÚÔıÚfiÌ‚ˆÓ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË ÌÈÎÚÔ‚›ˆÓ (9). ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ¢ԉÒÓÂÙ·È Û ÈÛÙÔ‡˜ Ì ÊÙˆ¯‹ ·ÁÁ›ˆÛË, fiˆ˜ Â›Ó·È Ù· ÔÛÙ¿. OÈ Û˘¯ÓfiÙÂÚ˜ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ··ÓÙÒÓÙ·È ÛÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Â›Ó·È Ë ·Ó·ÛÙÔÏ‹ Ù˘ ÌÈÎÚÔ‚ÈÔÎÙfiÓÔ˘ ‰Ú¿Û˘ ÙˆÓ ÂÓ˙‡ÌˆÓ ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Î·È Ë ‰È·Ù·Ú·¯‹ Ù˘ ÈηÓfiÙËÙ¿˜ ÙÔ˘˜ ÁÈ· Ê·ÁÔ΢ÙÙ¿ÚˆÛË (10). ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ›Û˘, ¤¯ÂÈ ·Ú·ÙËÚËı› ÙÒÛË Ù˘ IgG ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ‹ ¯·ÌËϤ˜ ÙÈ̤˜ ÔÚÈÛÌ¤ÓˆÓ ˘ÔÔÌ¿‰ˆÓ Ù˘ Î·È ·‡ÍËÛË Ù˘ IgA Î·È Ù˘ IgM ÛÙÔÓ ÔÚfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ·ÓÔÛ›·, ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Ì›ˆÛË ÙÔ˘ ÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÙˆÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û ÔÚÈṲ̂ÓÔ˘˜ Ì·ÎÚÔ¯ÚfiÓÈÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ (11). ∏ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÔÚ› Ó· ÚÔÎÏËı› ·ÈÌ·ÙÔÁÂÓÒ˜, Ô˘ Â›Ó·È Î·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ, ·fi ‰È·ÙÈÙÚ·›ÓÔÓ ÙÚ·‡Ì· ‹ ηٿ Û˘Ó¤¯ÂÈ· ÈÛÙÔ‡. O Û˘ÓËı¤ÛÙÂÚÔ˜ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ Ô‰fi ÌÂÙ¿‰ÔÛ˘, Â›Ó·È Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, fï˜, ¤¯ÂÈ ·Ú·ÙËÚËı› ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚÈÓÈ΋˜ ÊÔÚ›·˜ Î·È ÌÈÎÚÔ‚È·ÈÌ›·˜ ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·Ú¿ÁÔÓÙ·. ∏ Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ ÙÔ˘ ÚÈÓÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ·ÛıÂÓ›˜ Ì ÌË ÈηÓÔÔÈËÙÈ΋ Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘, fiˆ˜ ·˘Ù‹ ·ÔÙ˘ÒÓÂÙ·È Û ÙÈ̤˜ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ Î·È ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c) (12). º·›ÓÂÙ·È fiÙÈ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÈηÓfiÙËÙ· ÙˆÓ ÂÓ˙‡ÌˆÓ ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Ó· ηٷÛÙÚ¤ÊÔ˘Ó ÂÓ‰Ô΢ÙÙ¿ÚÈ· Ù· ÛÙÂϤ¯Ë ÙÔ˘ ‚·ÎÙËÚȉ›Ô˘. ∂›Û˘, Ù· ÏÂÌÊÔ·ÙÙ·Ú¿ ÙÔ˘˜ ‰ÂÓ ‰ÈÂÁ›ÚÔÓÙ·È Â·ÚÎÒ˜ in vitro ·fi ÙÔ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎfi ·ÓÙÈÁfiÓÔ (11,12). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·ÛıÂÓ‹ Ì·˜, Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ ¤ÁÈÓ ·ÈÌ·ÙÔÁÂÓÒ˜. ∏ ÂӉ¯fiÌÂÓË Î¿ÎˆÛË ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË Î·Ù¿ ÙËÓ ¿ÛÎËÛË, Ì ÙȘ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÁÁ›ˆÛË, ÙË Ó¤ÎÚˆÛË ÙÔ˘ ÔÛÙÔ‡ Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÔÎÈÓÒÓ Ô˘ ÚÔοÏÂÛÂ, ¢fi‰ˆÛ ÙËÓ ÂÛÙȷ΋ ÚfiÎÏËÛË ÌÈÎÚԂȷ΋˜ ÊÏÂÁÌÔÓ‹˜. ∞ÎÔÏÔ‡ıˆ˜, ÂÍÂÏ›¯ıËÎÂ Ë Ïԛ̈ÍË ÛÙÔÓ ÛfiÓ‰˘ÏÔ, Ë ÔÔ›· ÏfiÁˆ Ù˘ ·˘ÛÙËÚ‹˜ ηٿÎÏÈÛ˘ Î·È Ù˘ ÈÛ¯˘Ú‹˜ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ ‰È¤‰Ú·Ì ˘ÔÎÏÈÓÈο ÙÔ ÚÒÙÔ 20‹ÌÂÚÔ. ¶ÚÔԉ¢ÙÈο, Ë ÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· ÚÔοÏÂÛ ‰È‹ıËÛË ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ̤ÚÔ˘˜ ÙÔ˘
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ÛÔÓ‰˘ÏÈÎÔ‡ ÛÒÌ·ÙÔ˜ Î·È ‰ËÌÈÔ˘ÚÁ›· ·ÔÛÙËÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ ·Ú·ÛÔÓ‰˘ÏÈο. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ‡·ÚÍË ·ÚÙËÚÈÔÊÏ‚ˆ‰ÒÓ ÎfiÏˆÓ Ì ‚Ú·‰Â›· ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙË ÌÂÙ¿Ê˘ÛË ÙÔ˘ ÛÔÓ‰‡ÏÔ˘, ÏËÛ›ÔÓ Ù˘ ÂÈÊ˘Ûȷ΋˜ Ͽη˜, ÌÂÈÒÓÂÈ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ·fi Ù· Ï¢ÎÔ·ÙÙ·Ú·, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ·ÔÛÙËÌ¿ÙˆÓ (13). ∏ ¤ÍÔ‰Ô˜ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· ÚÔοÏÂÛ ÙÔ ‰Â‡ÙÂÚÔ Â̇ÚÂÙÔ ÂÂÈÛfi‰ÈÔ. ªÂÙ·ÁÂÓ¤ÛÙÂÚ·, Ë ÊÏÂÁÌÔÓ‹ ÂÂÎÙ¿ıËΠ̤ۈ ÙÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ ÛÙÔÓ Î·ÙÒÙÂÚÔ ÛfiÓ‰˘ÏÔ, ÁÈ’ ·˘Ùfi ÛÙË ‰Â‡ÙÂÚË MRI ·ÂÈÎÔÓ›˙ÂÙ·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜, ÏËÓ ÙÔ˘ ÎÏÂÈÛÙÔ‡ ÙÚ·‡Ì·ÙÔ˜, Ô˘ Û˘Ó¤‚·Ï·Ó ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ‹Ù·Ó Ë Ì¤ÙÚÈ· Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ ÛÙÔÓ ÔÚfi, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙȘ ÙÈ̤˜ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c) Î·È ÔÈ ¯·ÌËϤ˜ ÙÈ̤˜ ÙˆÓ ˘ÔÙ¿ÍÂˆÓ Ig3 Î·È Ig4. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ë ‰ÈËıËÙÈ΋ ÂÍÂÚÁ·Û›· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÚÔηÏ› ¤ÓÙÔÓÔ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· ÌÂٷ͇ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Î·È Î·ÎÔ‹ıÔ˘˜ ÓÔÛ‹Ì·ÙÔ˜. ∏ ˘ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Û ·È‰È¿ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ·Ó Î·È Â›Ó·È Û¿ÓÈ·, Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë. ∏ Û˘ÓÂÎÙ›ÌËÛË ÙÔ˘ ·ÙÔÌÈÎÔ‡ ·Ó·ÌÓËÛÙÈÎÔ‡ Î·È ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Ù˘ ·ÚÔ‡Û·˜ ÓfiÛÔ˘ Î·È Î˘Ú›ˆ˜ Ë ‰ÈÂÓ¤ÚÁÂÈ· ‰È·‰ÂÚÌÈ΋˜ ‹ ·ÓÔȯً˜ ‚ÈÔ„›·˜ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· Ó· ÙÂÎÌËÚȈı› Ë ‰È¿ÁÓˆÛË. ŒÙÛÈ ı· ÏËÊıÔ‡Ó Ù· ·Ó·Áη›· ıÂڷ¢ÙÈο ̤ÙÚ· Ì ÙË ÌÈÎÚfiÙÂÚË ‰˘Ó·Ù‹ ηı˘ÛÙ¤ÚËÛË, ¯ˆÚ›˜ Ó· ÚÔηÏÂ›Ù·È ·‰ÈηÈÔÏfiÁËÙË ·ÓËÛ˘¯›· ÛÙÔÓ ·ÛıÂÓ‹ Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ Î·È Ó· ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ¿ÛÎÔ˜ ÔÏ˘‰¿·Ó˜ ÂÍÂÙ¿ÛÂȘ.
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of diagnosis with MR imaging. Radiology 1991;180:533539. Mader JT, Ortiz M, Calhoun JH. Update on the diagnosis and management of osteomyelitis. Clin Podiatr Med Surg 1996;13:701-724. Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997;79:874-880. Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis 2001;33: 527-532. Carek PJ, Dickerson LM, Sack JL. Diagnosis and management of osteomyelitis. Am Fam Physician 2001; 63:2413-2420. Song KM, Sloboda JF. Acute hematogenous osteo myelitis in children. J Am Acad Orthop Surg 2001;9:166-175. Rasool MN. Primary subacute haematogenous osteomyelitis in children. J Bone Joint Surg Br 2001;83:93-98. DeFeo WT, Jay RM. Osteomyelitis associated with peripheral vascular disease secondary to diabetes mellitus. J Foot Surg 1976;15:159-165. Dziatkowiak H, Kowalska M, Denys A. Phagocytic and bactericidal activity of granulocytes in diabetic children. Diabetes 1982;31:1041-1043. Gorus FK, Vandewalle CL, Winnock F, Lebleu F, Keymeulen B, Van der Auwera B et al. Increased prevalence of abnormal immunoglobulin M, G, and A concentrations at clinical onset of insulin-dependent diabetes mellitus: a registry-based study. The Belgian Diabetes Registry. Pancreas 1998;16:50-59. Tuazon CU, Perez A, Kishaba T, Sheagren JN. Staphylococcus aureus among insulin-injecting diabetic patients. An increased carrier rate. JAMA 1975;231:1272. Whalen JL, Parke WW, Mazur JM, Stauffer ES. The intrinsic vasculature of developing vertebral end plates and its nutritive significance to the intervertebral discs. J Pediatr Orthop 1985;5:403-410.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Cottias P, Tomeno B, Anract P, Vinh TS, Forest M. Subacute osteomyelitis presenting as a bone tumour. A review of 21 cases. Int Orthop 1997;21:243-248. 2. Erdman WA, Tamburro F, Jayson HT, Weatherall PT, Ferry KB, Peshock RM. Osteomyelitis: characteristics and pitfalls
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÈÒÚÁÔ˜ ∆Ú›Ì˘ ∏Ï›· ∑ÂÚ‚Ô‡ 72, ∆.∫. 111 44, ∞ı‹Ó·
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CASE REPORT
™˘Ó‡·ÚÍË ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Î·È ÓfiÛÔ˘ Gilbert: ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. OÈÎÔÓfiÌÔ˘, π. ∆Û¿ÙÚ·, ª. ∞ı·Ó·Û›Ô˘ - ªÂÙ·Í¿
Co-existence of hereditary spherocytosis and Gilbert’s syndrome: a case report M. Economou, I. Tsatra, M. Athanassiou - Metaxa
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË Ó·ڋ˜ ·ÛıÂÓÔ‡˜ Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Î·È ÓfiÛÔ˘ Gilbert. ∏ ÓfiÛÔ˜ Gilbert, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ·fi ÂÂÈÛfi‰È· ηÏÔ‹ıÔ˘˜ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚ‹ ÎÏÈÓÈ΋ ÛËÌ·Û›· ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·. øÛÙfiÛÔ, Û ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ ÚÔηÏ› ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÊÔÚÙ›Ô˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ÂÈÙ›ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ Û¯ËÌ·ÙÈÛÌÔ‡ ¯ÔÏÔÏ›ıˆÓ Î·È Ô‰ËÁ› Û ‰È·ÊÔÚԉȷÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ·ÛıÂÓÔ‡˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È.
Abstract: A case of hereditary spherocytosis and Gilbert’s syndrome co-existence in a young girl is described. Gilbert’s syndrome, characterized by episodes of mild unconjugated hyperbilirubinaemia, is of limited importance in normal individuals. In cases of chronic hemolysis, however, co-existence of the syndrome may lead to a combined effect in producing high levels of bilirubin and increase the risk of gallstone formation. Additionally, it may result in diagnostic problems, as in the case described below.
§¤ÍÂȘ ÎÏÂȉȿ: ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ÓfiÛÔ˜ Gilbert, ¤ÌÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ¯ÚfiÓÈ· ·ÈÌfiÏ˘ÛË, ¯ÔÏÔÏÈı›·ÛË.
Key words: hereditary spherocytosis, Gilbert’s syndrome, unconjugated hyperbilirubinaemia, chronic haemolysis, gallstones.
∂ÈÛ·ÁˆÁ‹ ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ¤ÌÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ÔÊ›ÏÂÙ·È Â›Ù Û ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ ·Û‡Ó‰ÂÙ˘ (¤ÌÌÂÛ˘) ¯ÔÏÂÚ˘ıÚ›Ó˘, ›Ù Û ÌÂȈ̤ÓË Ë·ÙÈ΋ ÚfiÛÏË„Ë ‹ Û‡Ó‰ÂÛË ·˘Ù‹˜ (1). ∏ ·ÈÌfiÏ˘ÛË Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· ˘ÂÚ·Ú·ÁˆÁ‹˜ Ù˘ ¤ÌÌÂÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ì›· ·fi ÙȘ Û˘ÓËı¤ÛÙÂÚ· ··ÓÙÒÌÂÓ˜ Û˘ÁÁÂÓ›˜ ·ÈÌÔÏ˘ÙÈΤ˜ ·Ó·È̛˜ Â›Ó·È Ë ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË (hereditary spherocytosis, HS). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ÌÂȈ̤ÓË Û‡Ó‰ÂÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, Ë ÓfiÛÔ˜ Gilbert ıˆÚÂ›Ù·È Ë ˘Â‡ı˘ÓË ‰È·Ù·Ú·¯‹ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ (2,3). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ì ÙËÓ ÂÍ·›ÚÂÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘, ‰È·Ê¤ÚÂÈ ÛÙȘ ‰‡Ô ÚÔ·Ó·ÊÂÚı›Û˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, Ë Û˘Ó‡·ÚÍË ·˘ÙÒÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ‰È·ÊÔÚԉȷÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù· (4-6), fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ Ó·ڋ˜ ·ÛıÂÓÔ‡˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 12 ÂÙÒÓ Ì ÁÓˆÛÙ‹ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Ô˘ ‰È·ÁÓÒÛÙËΠÛÙ· Ï·›ÛÈ· ‰ÈÂÚ‡ÓËÛ˘ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜ Û ËÏÈΛ· 4 ÂÙÒÓ. ∏ ‰È¿ÁÓˆÛË Â›¯Â ÙfiÙ ÙÂı› Ì ‚¿ÛË ÙËÓ ·Ó‡ÚÂÛË ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, ÙÔÓ ·˘ÍË̤ÓÔ ·ÚÈıÌfi ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Î·È ÙËÓ ÂÏ·Ùو̤ÓË ˆÛ̈ÙÈ΋ ·ÓÙ›ÛÙ·ÛË ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ. ◊‰Ë ·fi ÙÔÓ ·Ú¯ÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ›¯Â ‰È·ÈÛÙˆı› ˘ÂÚ˯ÔÁÚ·ÊÈο Ë ·ÚÔ˘Û›· ¯ÔÏÔÏ›ıˆÓ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË. ∆Ô ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi Ù˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂχıÂÚÔ. ∫·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÙÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘, Ë ·ÛıÂÓ‹˜ ‹Ù·Ó Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÌfiÓÔÓ ‹È· ÛÏËÓÔÌÂÁ·Ï›· (ÂÚ›Ô˘ 2 cm) Î·È ÈÎÙÂÚÈ΋ ¯ÚÔÈ¿ ‰¤ÚÌ·ÙÔ˜ Î·È ÂÈÂÊ˘ÎfiÙˆÓ. ¢È·ÙËÚÔ‡Û ÈηÓÔÔÈËÙÈο ›‰· ·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È ·ÈÌ·ÙÔÎÚ›ÙË (Hb ~13,2 g/dl, Ht ~40%) Ì ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, °¶¡ πÔÎÚ¿ÙÂÈÔ, £ÂÛÛ·ÏÔÓ›ÎË
1st Pediatric Clinic of Aristotelion University, “Ippokration” General Hospital, Thessaloniki
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(ÂÚ›Ô˘ 3%) Î·È Ì¤ÙÚÈ· ·‡ÍËÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ (6,5 mg/dl), ¤ÌÌÂÛ˘ ηٿ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (5,5 mg/dl). ™Â ËÏÈΛ· 11 ÂÙÒÓ, ÏfiÁˆ ÂΉ‹ÏˆÛ˘ ¤ÓÙÔÓˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ¯ÔÏÔÏÈı›·Û˘ (ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜, ‰˘Û„›·˜, Ó·˘Ù›·˜, ÂÌ¤ÙˆÓ Î·È ·ÒÏÂÈ·˜ ‚¿ÚÔ˘˜), ·ÔÊ·Û›ÛÙËÎÂ Ë ‰ÈÂÓ¤ÚÁÂÈ· ¯ÔÏÔ΢ÛÙÂÎÙÔÌ‹˜ Ì ٷ˘Ùfi¯ÚÔÓË ÛÏËÓÂÎÙÔÌ‹. øÛÙfiÛÔ, Ë ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ‰ÂÓ ·ÔηٷÛÙ¿ıËΠÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÛÏ‹Ó· (ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË 4,3 mg/dl, ¤ÌÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË 3,45 mg/dl). ™Ù· Ï·›ÛÈ· Ù˘ ÂÎ Ó¤Ô˘ ‰ÈÂÚ‡ÓËÛ˘ Ù˘ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ·ÔÎÏ›ÛÙËÎÂ Ë Èı·ÓfiÙËÙ· Ê·ÚÌ·ÎÔÁÂÓÔ‡˜ ·Ó·ÛÙÔÏ‹˜ Û‡Ó‰ÂÛ˘ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ηıÒ˜ Î·È Ë ·ÚÔ˘Û›· ÂÈÎÔ˘ÚÈÎÔ‡ ÛÏ‹Ó· Ô˘ ı· ÌÔÚÔ‡Û ӷ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·ÓÙÈÚÚÔÔ‡ÌÂÓË ‹È· ·ÈÌfiÏ˘ÛË. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (SGOT, SGPT, ÁGT, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÔÏÈο Ï¢ÎÒÌ·Ù·, ÏÂ˘ÎˆÌ·Ù›Ó˜ Î·È ÛÊ·ÈÚ›Ó˜) ‹Ù·Ó, ›Û˘, Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÓËÛÙ›·˜ Î·È ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÙÚÔÊ‹˜ ¤‰ÂÈÍ ÙÈ̤˜ ¤ÌÌÂÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ 3,5 Î·È 2,3 mg/dl, ·ÓÙ›ÛÙÔȯ·. ªÂ ÙËÓ ÈÛ¯˘Ú‹, ϤÔÓ, ˘Ô„›· Ù˘ ÓfiÛÔ˘ Gilbert, ˙ËÙ‹ıËÎÂ Ë Ú·ÁÌ·ÙÔÔ›ËÛË ·Ó¿Ï˘Û˘ DNA Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR) ÛÙËÓ π·ÙÚÈ΋ ™¯ÔÏ‹ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, fiÔ˘ Î·È ·ÓȯÓ‡ıËΠ۠ÔÌÔ˙˘ÁˆÙ›· Ë ‰È·ÌfiÚʈÛË ∞(∆∞)7∆∞∞, Ë ÔÔ›· ÂÓ¤¯ÂÙ·È ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ŒÎÙÔÙÂ, Ë ·ÛıÂÓ‹˜, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÛˆÛÙ‹ ‰È·ÙÚÔÊÈ΋ ·ÁˆÁ‹, ·Ú·Ì¤ÓÂÈ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÌfiÓÔ ÂÚÈÛÙ·Ûȷο ˘›ÎÙÂÚÔ. ™˘˙‹ÙËÛË ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Â›Ó·È Ë Û˘¯ÓfiÙÂÚË Û˘ÁÁÂÓ‹˜ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· ÔÊÂÈÏfiÌÂÓË Û ‰È·Ù·Ú·¯‹ Ù˘ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÌÂ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 1:2000 ÛÙË µÔÚÂÈÔ‰˘ÙÈ΋ ∂˘ÚÒË Î·È ÙË µfiÚÂÈ· ∞ÌÂÚÈ΋ (7). ∏ ‚ÈÔ¯ËÌÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ Û˘Ó›ÛÙ·Ù·È Û ·ÏÏ·Á‹ Ù˘ ‰ÔÌ‹˜ ÙÔ˘ ΢ÙÙ·ÚÔÛÎÂÏÂÙÔ‡ Ù˘ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÏfiÁˆ ‚Ï¿‚˘ ‰ÔÌÈÎÒÓ ÚˆÙÂ˚ÓÒÓ fiˆ˜ Â›Ó·È Ë ÛÂÎÙÚ›ÓË, Ë ·Ó΢ڛÓË ‹, Û·ÓÈfiÙÂÚ·, Ë ÚˆÙ½ÓË 4.2 (1,8). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ Â›Ó·È Ë ·ÒÏÂÈ· ÙÔ˘ Û¯‹Ì·ÙÔ˜ ÙÔ˘ ÂÚ˘ıÚÔ΢ÙÙ¿ÚÔ˘, Ì ÌÂÙ·ÙÚÔ‹ ·˘ÙÔ‡ ·fi ·ÌÊ›ÎÔÈÏÔ ‰›ÛÎÔ Û ÛÊ·ÈÚÔ·ÙÙ·ÚÔ Î·È ·ÎfiÏÔ˘ıË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÛÙÔ ÛÏ‹Ó·. ∏ HS ÎÏËÚÔÓÔÌÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ÂÓÒ Ë ÌÂÙ·‚›‚·ÛË Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Â›Ó·È Û·ÓÈfiÙÂÚË (9).
Paediatriki 2003;66:52-54
∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ·: ·fi ÙËÓ ·Û˘Ìو̷ÙÈ΋ ÊÔÚ›· ̤¯ÚÈ ÙËÓ ÂΉ‹ÏˆÛË ‚·ÚÈ¿˜ ·Ó·ÈÌ›·˜ ÂÍ·ÚÙÒÌÂÓ˘ ·fi ÌÂÙ·ÁÁ›ÛÂȘ Î·È Û˘Óԉ¢fiÌÂÓ˘ ·fi ÛÏËÓÔÌÂÁ·Ï›· Î·È ›ÎÙÂÚÔ. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·˙ ‹È· HS, Ì ·ÓÙÈÚÚÔÔ‡ÌÂÓË ·ÈÌfiÏ˘ÛË ¯ˆÚ›˜ Û˘ÓÔ‰fi ·Ó·ÈÌ›·. ∏ ‰ËÌÈÔ˘ÚÁ›· ¯ÔÏÔÏ›ıˆÓ, Ô˘ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘, ‹Ù·Ó ‹‰Ë ·ÚÔ‡Û· ÛÙË ÌÈÎÚ‹ ·ÛıÂÓ‹ ηٿ ÙÔ ¯ÚfiÓÔ ‰È¿ÁÓˆÛ˘ Ù˘ HS. ∏ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È ›Ûˆ˜ Ë ÌfiÓË ¤Ó‰ÂÈÍË ÁÈ· ‰ÈÂÓ¤ÚÁÂÈ· ÛÏËÓÂÎÙÔÌ‹˜ Û ·ÛıÂÓ›˜ Ì HS ‹È·˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜, ÌÂÙ¿ ÙËÓ ÔÔ›· ·Ó·Ê¤ÚÂÙ·È ÎÏÈÓÈ΋ ›·ÛË, ‰ËÏ·‰‹ ˘Ô¯ÒÚËÛË Ù˘ ·Ó·ÈÌ›·˜ Î·È ÙÔ˘ ÈÎÙ¤ÚÔ˘ Û ÔÛÔÛÙfi 100% (9). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ˆÛÙfiÛÔ, Ë ·Ó·ÌÂÓfiÌÂÓË ›·ÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∞ÊÔ‡ ·ÔÎÏ›ÛÙËÎ·Ó Ù· ˘fiÏÔÈ· Èı·Ó¿ ·›ÙÈ· ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, Ù¤ıËÎÂ Ë ˘Ô„›· Û˘Ó‡·Ú͢ Ù˘ ÓfiÛÔ˘ Gilbert Î·È ·ÔÊ·Û›ÛÙËÎÂ Ë Ú·ÁÌ·ÙÔÔ›ËÛË Ù˘ ÂÌÂÈÚÈ΋˜ ‰ÔÎÈÌ·Û›·˜ ̤ÙÚËÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÌÂÙ¿ ·fi ÓËÛÙ›· Î·È ·fi ¯ÔÚ‹ÁËÛË ÙÚÔÊ‹˜ (9), ÂÓÒ Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù¤ıËΠÙÂÏÈο Ì ÙË Ì¤ıÔ‰Ô ·Ó¿Ï˘Û˘ DNA. H ÓfiÛÔ˜ Gilbert ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ UDP-ÁÏ˘ÎÔ˘ÚÔÓ˘Ï-ÙÚ·ÓÛÊÂÚ¿Û˘ 1 ÛÙÔ ¯ÚˆÌfiۈ̷ 2q37 (ÂÍfiÓÈ· 1-5 ‹ ÂÎÎÈÓËÙ‹˜ TATAAbox), Ì ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ô˘ÚȉÈÓÔ-‰ÈʈÛÊÔÓÈ΋ ÁÏ˘ÎÔ˘ÚÔÓÈ΋ ÙÚ·ÓÛÊÂÚ¿ÛË Î·È ·ÎfiÏÔ˘ıË ·Ó·ÛÙÔÏ‹ Û‡Ó‰ÂÛ˘ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ (9). ∏ Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ ÔÈΛÏÏÂÈ Û ‰È¿ÊÔÚ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ·fi 3-36%, ·Ó¿ÏÔÁ· Ì ÙË Ê˘Ï‹ Î·È ÙÔ Ê‡ÏÔ (2,3,11-13). O ÙÚfiÔ˜ ÎÏËÚÔÓÔÌÈ΋˜ ÌÂÙ·‚›‚·Û˘ Â›Ó·È Ô ·˘ÙÔۈ̷ÙÈÎfi˜ ÂÈÎÚ·ÙÒÓ, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ˜ ·fi ·ÙÂÏ‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ·. ∏ ÓfiÛÔ˜ Gilbert ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏ› Ê˘ÛÈÔÏÔÁÈ΋ ·Ú·ÏÏ·Á‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ÎÏÈÓÈο ·fi ÂÂÈÛfi‰È· ηÏÔ‹ıÔ˘˜ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ΢ڛˆ˜ Û ηٷÛÙ¿ÛÂȘ ÓËÛÙ›·˜. ∂ÓÒ ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Ë ÎÏÈÓÈ΋ ÛËÌ·Û›· Ù˘ ÓfiÛÔ˘ Â›Ó·È ÌÈÎÚ‹, Û ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ ÚÔηÏ› ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÊÔÚÙ›Ô˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ÂÈÙ›ÓÔÓÙ·˜ ¤ÙÛÈ ÙÔÓ Î›Ó‰˘ÓÔ Û¯ËÌ·ÙÈÛÌÔ‡ ¯ÔÏÔÏ›ıˆÓ (7,14). ∏ ÂÈ‚¿Ú˘ÓÛË ·˘Ù‹ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› fi¯È ÌfiÓÔ ÛÂ Û˘Ó‡·ÚÍË Ù˘ ÓfiÛÔ˘ Ì ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ·ÏÏ¿ Î·È Ì ¿ÏϘ ÌÔÚʤ˜ ÎÏËÚÔÓÔÌÈ΋˜ (‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ¤ÏÏÂÈ„Ë G6PD) ‹ ›ÎÙËÙ˘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ (·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·) (7,15). ™Â οı ÂÚ›ÙˆÛË, Ô ·È‰›·ÙÚÔ˜ Ô˘ ·Ú·ÎÔÏÔ˘ı› ¤Ó·Ó ·ÛıÂÓ‹ Ì ¯ÚfiÓÈ· ·ÈÌfiÏ˘ÛË, ·ÏÏ¿ Î·È ·˘Ùfi˜ Ô˘ ‰ÈÂÚÂ˘Ó¿ ¤Ó·Ó ·ÛıÂÓ‹ Ì ¯ÔÏÔÏÈı›·ÛË,
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ı· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ηٿ ÓÔ˘ ÙËÓ Èı·ÓfiÙËÙ· Û˘Ó‡·Ú͢ Î·È ·ÏÏËÏ›‰Ú·Û˘ Ù˘ ¯ÚfiÓÈ·˜ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ Ì ÙË ÓfiÛÔ Gilbert. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿ ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ∂ÚÁ·ÛÙËÚ›Ô˘ Ù˘ ∞’ ¶·ıÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÁÈ· ÙË ÌÔÚȷ΋ ÂȂ‚·›ˆÛË Ù˘ ÓfiÛÔ˘ Gilbert.
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µÈ‚ÏÈÔÁÚ·Ê›· 1. Becker P, Lux S. Disorders of the red cell membrane. In: Nathan DG, Oski FA, editors. Hematology of infancy and childhood. 4th ed. Philadelphia: W.B. Saunders Company; 1993. p. 529-633. 2. Borlak J, Thum T, Landt O, Erb K, Hermann R. Molecular diagnosis of a familial nonhemolytic hyperbilirubinemia (Gilbert’s syndrome) in healthy subjects. Hepatology 2000;32:792-795. 3. Burchell B, Hume R. Molecular genetic basis of Gilbert’s syndrome. J Gastroenterol Hepatol 1999;14:960-966. 4. Berk PD, Blaschke TF. Detection of Gilbert’s syndrome in patients with hemolysis. Ann Intern Med 1972;77:527-531. 5. Katz ME, Weinstein IM. Extreme hyperbilirubinemia in a patient with hereditary spherocytosis, Gilbert’s syndrome, and obstructive jaundice. Am J Med Sci 1978;275:373-379. 6. Sharma S, Vukelja SJ, Kadakia S. Gilbert’s syndrome coexisting with and masking hereditary spherocytosis. Ann Hematol 1997;74:287-289. 7. del Giudice EM, Perrotta S, Nobili B, Specchia C, d’Urzo G, Iolascon A. Coinheritance of Gilbert syndrome increases the risk for developing gallstones in patients with hereditary spherocytosis. Blood 1999;94:2259-2262. 8. Palek J, Jarolim P. Clinical expression and laboratory detection of red blood cell membrane protein mutations. Semin Hematol 1993;30:249-283. 9. Palek J, Jarolim P. Red cell membrane disorders. In:
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Hoffman R, Benz EJ, Shattil SJ, Furil B, Cohen HJ, Silberstein LE, editors. Hematology. Basic Principles and Practice. 2nd ed. Churchill Livingstone Inc; 1995. p. 667709. Monaghan G, Ryan M, Seddon R, Hume R, Burchell B. Genetic variation in bilirubin UDP-glucurononyltransferase gene promoter and Gilbert’s syndrome. Lancet 1996;347:578-581. Rudenski AS, Halsall DJ. Genetic testing for Gilbert’s syndrome: how useful is it in determining the cause of jaundice? Clin Chem 1998;44:1604-1609. Beutler E, Gelbart T, Demina A. Racial variability in the UDPglucuronosyltransferase 1 (UGT1A1) promoter: a balanced polymorphism for regulation of bilirubin metabolism? Proc Natl Acad Sci USA 1998;95:8170-8174. ∆Û¤˙Ô˘ ∞, ∆˙¤ÙË ª, ∫›ÙÛÈÔ˘ ™, °·ÏÏ¿ ∞, ∫·‚·˙·Ú¿Î˘ ∂, ÷Ù˙ˉËÌԇϷ ∞ Î·È Û˘Ó. ™‡Ó‰ÚÔÌÔ Gilbert: ÁÔÓÔÙ˘È΋ ·Ó¿Ï˘ÛË Î·È Û˘Û¯¤ÙÈÛË Ì ÙÔ Ê·ÈÓfiÙ˘Ô Û ·È‰ÈÎfi ÏËı˘ÛÌfi. ¶·È‰È·ÙÚÈ΋ 2000;63:21-26. Berk PD, Berman MD, Blitzer BL, Chretien P, Martin JF, Scharschmidt BF et al. Effect of splenectomy on hepatic bilirubin clearance in patients with herediatry spherocytosis: implications for the diagnosis of Gilbert’s syndrome. J Lab Clin Med 1981;98:37-45. Sampietro M, Lupica L, Perrero L, Comino A, Martinez di Montemuros F, Cappellini MD et al. The expression of UDPglucuronosyltransferase gene is a major determinant of bilirubin level in heterozygous beta-thalassaemia and in G6PD deficiency. Br J Haematol 1997;99:437-439.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 22-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÈÚ¿ÓÙ· ∞ı·Ó·Û›Ô˘ ∞Á. ™ÔÊ›·˜ 30, ∆.∫. 546 22, £ÂÛÛ·ÏÔÓ›ÎË E-mail: marina@med.auth.gr
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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2003;66:55-57
CASE REPORT
¶·ÚÔ˘Û›· ·ÚÔ‰ÈÎÔ‡ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ Û ·È‰› Ì ÓfiÛÔ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ª. §ÈıÔÍÔÔ‡ÏÔ˘, ª. ∞ı·Ó·Û›Ô˘, Ã. ∆۷ηϛ‰Ë˜, µ. ∞˚‚¿˙˘
Presentation of lupus anticoagulant in a child caused by cat scratch disease: a case report M. Lithoxopoulou, M. Athanasiou, C. Tsakalidis, V. Aivazis
¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ·ÔÙÂÏ› Ì›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÏÔÈÌÒ‰Ë ÓfiÛÔ Ô˘ ¤¯ÂÈ ˆ˜ ·›ÙÈÔ ÙË Bartonella henselae Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ô›‰ËÌ· Î·È ¿ÏÁÔ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ. ¶ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ·È‰È¿ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ. ™˘Ó‹ıˆ˜ ÚÔηÏ› ÏÂÌÊ·‰ÂÓ›Ùȉ· Ô˘ Â›Ó·È ¯ÚfiÓÈ· Î·È ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ô˘ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ηÈ, ˆ˜ Û˘ÓÔ‰fi Û‡Ìو̷ Ù˘ Ïԛ̈͋˜ ÙÔ˘, Ù˘¯·›· ·Ó‡ÚÂÛË ·Ú¿Ù·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·ƒTT) ÏfiÁˆ ·ÚÔ˘Û›·˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ (LA) ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·.
Abstract: Cat scratch disease is a self-limited infectious disease characterized by edema and pain in the lymph nodes caused by Bartonella henselae. Most patients are children and young adults. Usual symptoms are chronic or regional lymphadenopathy, malaise, anorexia and fever. We describe a patient with regional lymphadenopathy and transient prolonged activated partial thromboplastine time associated with lupus anticoagulant caused by cat scratch disease. This was found during the preoperative tests.
§¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜, bartonella henselae, ÏÂÌÊ·‰ÂÓ›Ùȉ·, ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘, ¯ÚfiÓÔ˜ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘.
Key words: cat scratch disease, bartonella henselae, chronic lymphadenopathy, lupus anticoagulant, activated partial thromboplastine time.
∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ·ÔÙÂÏ› Ì›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÏÔÈÌÒ‰Ë ÓfiÛÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ô›‰ËÌ· Î·È ¿ÏÁÔ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (ÂÚÈÔ¯È΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÏÂÌÊ·‰ÂÓ›Ùȉ·) Î·È ÔÈÎÈÏ›· ÎÔÈÓÒÓ Û˘ÓÔ‰ÒÓ Û˘ÌÙˆÌ¿ÙˆÓ fiˆ˜ ηÎÔ˘¯›·, ÎfiˆÛË, ·ÓÔÚÂÍ›·, Â̤ÙÔ˘˜, ÎÂÊ·Ï·ÏÁ›·, Ê·Ú˘ÁÁ›Ùȉ·, ˘ÚÂÙfi ‹ Î·È ÛÔ‚·ÚfiÙÂÚˆÓ fiˆ˜ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ÛÏËÓÔÌÂÁ·Ï›·, ηıÒ˜ Î·È ·ÚÔ‰ÈÎfi ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ÙÔ˘ ÎÔÚÌÔ‡ Î·È ¿ÏÏ· (1-4). ™˘Ó‹ıˆ˜ ÚÔηÏ› ÏÂÌÊ·‰ÂÓ›Ùȉ· Ô˘ Â›Ó·È ¯ÚfiÓÈ· Î·È ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. ÕÙ˘· Â˘Ú‹Ì·Ù· Â›Ó·È Ë ÂÈÂÊ˘Î›Ùȉ·, Ë ÚÔˆÙÈ·›· ·‰ÂÓ›Ùȉ·, Ë ÂÁÎÂÊ·Ï›Ùȉ·, Ë ¿ÚÂÛË ÎÚ·ÓÈ·ÎÒÓ Ó‡ڈÓ, Ë ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ, Ë ÔÛÙÂ-
ÔÌ˘ÂÏ›Ùȉ·, Ë Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ·, ÙÔ ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· Î·È Ë Ó¢ÌÔÓ›· (2,5). ∏ ÚÒÙË ·Ó·ÊÔÚ¿ Î·È ÂÚÈÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘ ¤ÁÈÓ ·fi ÙÔÓ Henri Parinaud ÙÔ 1889, ÂÓÒ Ô Robert Debre ÙÔ 1931 ·Ó·ÁÓÒÚÈÛ fiÙÈ Ë Á¿Ù· ·ÔÙÂÏ› ÙÔÓ ÂӉȿÌÂÛÔ ÍÂÓÈÛÙ‹ Î·È ¤‰ˆÛ ÙËÓ ÔÓÔÌ·Û›· ÛÙË ÓfiÛÔ. ∏ Bartonella henselae ˆ˜ ·›ÙÈÔ Ù˘ ÓfiÛÔ˘, Ô˘ ÌÂÙ·‰›‰ÂÙ·È ·fi ¤ÓÙÔÌÔ ÛÙË Á¿Ù·, Ë ÔÔ›· Î·È ·ÔÙÂÏ› ÙË ‰ÂÍ·ÌÂÓ‹ Ù˘ ÓfiÛÔ˘, ·Ó·ÁÓˆÚ›ÛÙËΠÙÔ 1993 (4,5). ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë ÂÌÊ¿ÓÈÛË ·Ú·ÙÂٷ̤ÓÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·ƒ∆∆) ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ (LA) Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·fi ÏÔÈÌÒÍÂȘ, ÈÔÁÂÓ›˜, ÚˆÙÔ˙ˆÈΤ˜, Ê˘Ì·Ù›ˆÛË
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ °.¶.¡. “πÔÎÚ¿ÙÂÈÔ”, £ÂÛÛ·ÏÔÓ›ÎË
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(3-5), ÓfiÛÔ ÙÔ˘ Lyme, ηÎÔ‹ıÂȘ, (ÌÔÓ‹ÚË fiÁÎÔ, Ï¢¯·È̛˜, ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù·), Ï‹„Ë Ê·ÚÌ¿ÎˆÓ (Ê·ÈÓÔıÂÈ·˙›Ó˜, ÚÔη˚Ó·Ì›‰Ë, ¯ÏˆÚÔıÂÈ·˙›Ó˜, ·ÓÙÈÛ˘ÏÏËÙÈο), ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· (™∂§, ƒ∞, Û‡Ó‰ÚÔÌÔ Sjogren, ‰ÂÚÌ·ÙÔÌ˘ÔÛ›Ùȉ·/ÔÏ˘Ì˘ÔÛ›Ùȉ·, „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, ·ÁÎ˘ÏˆÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·) ‹ Ó· ·ÔÙÂÏ› Ù˘¯·›Ô ‡ÚËÌ· ÛÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ (6-8). ∆Ô ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ (LA) ·ÔÙÂÏ› ¤Ó·Ó ›ÎÙËÙÔ ·Ó·ÛÙÔϤ· ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ‹Í˘. ∞Ó‹ÎÂÈ Ì·˙› Ì ٷ ·ÓÙÈηډÈÔÏÈÈÓÈο ·ÓÙÈÛÒÌ·Ù· Î·È Ù· ÂȉÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ Ô˘‰¤ÙÂÚˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ, ÛÙ· ·ÓÙÈʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù· (9-12), in vitro ‰Â, ÚÔηÏÔ‡Ó ·Ú¿Ù·ÛË Û˘Ó‹ıˆ˜ ÙÔ˘ ·PTT. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ô˘ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi ÓfiÛÔ ·Ì˘¯‹˜ Ó˘¯ÈÒÓ Á¿Ù·˜ Î·È Ù˘¯·›· ·Ó‡ÚÂÛË ·Ú·ÙÂٷ̤ÓÔ˘ ·ƒTT ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 9 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÏfiÁˆ ÙÚ·¯ËÏÈ΋˜ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜, ȉ›ˆ˜ ·ÚÈÛÙÂÚ¿. ∏ ÓfiÛÔ˜ ÂÌÊ·Ó›ÛÙËΠ̠˘ÚÂÙfi Î·È ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ (block) ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÙÚ·¯ËÏÈ΋ ¯ÒÚ·, ¯ˆÚ›˜ ¿ÏÏ· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: Hb: 12,3 g/dl, Ht: 38%, ÏÂ˘Î¿: 8900/mm3 (¶: 64%, §: 28%, ª: 7%), ·ÈÌÔÂÙ¿ÏÈ·: 368.000/mm3, ∆∫∂: 45 mm ÙËÓ 1Ë ÒÚ· Î·È CRP: 33,4 mg/dl. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Û˘Ó‹ıˆÓ ÈÒÓ, fiˆ˜ ÙÔ˘ Epstein Barr, Cytomegalovirus, Herpes simple, Parvo B19, Coxsackie B1-B5, ηıÒ˜ Î·È ÁÈ· ÙÔÍfiÏ·ÛÌ· ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∆¤ÏÔ˜, Ë mantoux ‹Ù·Ó ·ÚÓËÙÈ΋. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. O ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜ ¿Ìʈ ¤‰ÂÈÍ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÙÚ·¯ËÏÈ΋ ¯ÒÚ· Û˘ÚÚ¤ÔÓÙ˜ ÏÂÌÊ·‰¤Ó˜ Ì ÂÏ·Ùو̤ÓË Ë¯ÔÁ¤ÓÂÈ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ‚Ú›ÛÎÔÓÙ·Ó Û ًÍË. ¶·ÚfiÌÔÈ·˜ ˘Ê‹˜ ÏÂÌÊ·‰¤Ó˜ ˘‹Ú¯·Ó ÛÙËÓ ·ÚˆÙȉÈ΋ Î·È ÛÙË ‰ÂÍÈ¿ Ï¿ÁÈ· ÙÚ·¯ËÏÈ΋ ¯ÒÚ·. ∆Ô Ì˘ÂÏfiÁÚ·ÌÌ· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. §ÂÙÔÌÂÚ¤ÛÙÂÚË Ï‹„Ë ÈÛÙÔÚÈÎÔ‡ ·ÔÎ¿Ï˘„ ÙËÓ ‡·ÚÍË Á¿Ù·˜ ÛÙÔ Û›ÙÈ ÙÔ˘ ·ÛıÂÓ‹. ¢‹ÁÌ·Ù· ‹ ·Ì˘¯¤˜ ÛÙ· ¿ÎÚ· ÙÔ˘ ·ÛıÂÓ‹ ‰ÂÓ ·Ú·ÙËÚ‹ıËηÓ. ªÂ ÙËÓ ˘fiÓÔÈ· Ù˘ ÓfiÛÔ˘ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ¤ÁÈÓ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Bartonella henselae, Ô ÔÔ›Ô˜ ¤‰ÂÈÍ IgM ·ÓÙÈÛÒÌ·Ù· ıÂÙÈο 1:20 Î·È IgG >1:256. O Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó Ô ›‰ÈÔ˜ ηÈ
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ÌÂÙ¿ ·fi 15 Ë̤Ú˜. O ·ÛıÂÓ‹˜ Ù¤ıËΠ۠ıÂڷ›· Ì ·ÌÔÍÈÎÈÏÏ›ÓË Û ‰fiÛË 80 mg/kg ·fi ÙÔ ÛÙfiÌ· ÁÈ· 10 Ë̤Ú˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÎÂÊÙÚÈ·ÍfiÓË 100 mg/kg ÂÓ‰ÔÊÏ‚›ˆ˜ ÁÈ· 10 Ë̤Ú˜, ¯ˆÚ›˜ ‚ÂÏÙ›ˆÛË, Ì Ӥ· ‰ÈfiÁΈÛË ÏÂÌÊ·‰¤ÓˆÓ Ù˘ Ì·Û¯·ÏÈ·›·˜ ¯ÒÚ·˜ Î·È ÌË ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡. ∞ÔÊ·Û›ÛÙËÎÂ Ë ·Ê·›ÚÂÛË Î·È Ë ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·, ‚Ú¤ıËΠÌÂÁ¿ÏË ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·PTT) 31”/59” (‡ÚÔ˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÁÈ· ·ƒTT: 30”-37”), ÂÓÒ Ô ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ Î·È Ù· ·ÈÌÔÂÙ¿ÏÈ· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆· ›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ππ, VIII, IX, XI, XII ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ ‚Ú¤ıËΠ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ (LA) ıÂÙÈÎfi, Ë ·ÚÔ˘Û›· ÙÔ˘ ÔÔ›Ô˘ ÂȂ‚·ÈÒıËΠ̠ÙË ‰ÔÎÈÌ·Û›· dRVVT (dilute Russell’s viper venom time) 35”/70”. ∆· ·ÓÙÈηډÈÔÏÈÈÓÈο ·ÓÙÈÛÒÌ·Ù· (APC) ‚Ú¤ıËÎ·Ó ·ÚÓËÙÈο. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍ ϋڈ˜ ηٷÚÁË̤ÓË ·Ú¯ÈÙÂÎÙÔÓÈ΋ ·fi ÙËÓ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ÂÈıËÏÈÔÂȉÒÓ ÎÔÎÎÈˆÌ¿ÙˆÓ Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË, ÂÓÒ Á‡Úˆ ·fi ÙË Ó¤ÎÚˆÛË ·Ú·ÙËÚ‹ıËÎ·Ó ÂÈıËÏÈÔÂȉ‹ ÈÛÙÈÔ·ÙÙ·Ú·, ηıÒ˜ Î·È ÔÏ˘‡ÚËÓ· ÁÈÁ·ÓÙÔ·ÙÙ·Ú·. OÈ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ¯ÚÒÛÂȘ ÁÈ· ̇ÎËÙ˜ Î·È Ì˘ÎÔ‚·ÎÙËÚ›‰È· ‹Ù·Ó ·ÚÓËÙÈΤ˜. ∏ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÈÛÙÔÚÈÎfi, ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÓfiÛÔ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡ ‚ÂÏÙÈÒıËΠÌÂÙ¿ ·fi ‰¤Î· Ë̤Ú˜, ÂÓÒ Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· (·PTT: 31”/31,5” Î·È LA(-) ·ÚÓËÙÈÎfi) ·ÔηٷÛÙ¿ıËÎ·Ó ÌÂÙ¿ ·fi 2 Ì‹Ó˜, ¯ˆÚ›˜ Ô ·ÛıÂÓ‹˜ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÔÔÈÔ‰‹ÔÙ ۇÌو̷ ‹ Ó· Ï¿‚ÂÈ ÂȉÈ΋ ıÂڷ›·. ™˘˙‹ÙËÛË Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ë ÂÌÊ¿ÓÈÛË ·Ú¿Ù·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ ·ƒTT ÛÙ· ·È‰È¿ ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ LA Â›Ó·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ‰È΋ Î·È Î·ÏÔ‹ı˘ Î·È Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ·fi ÏÔÈÌÒÍÂȘ ‹ Ó· ·ÔÙÂÏ› Ù˘¯·›Ô ‡ÚËÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ (6-8). ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜, Ë ·Ó‡ÚÂÛË Ù˘ ·Ú¿Ù·Û˘ ÙÔ˘ ·ƒ∆∆ ‹Ù·Ó Ù˘¯·›·, ÛÙ· Ï·›ÛÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ‰ÈÔÁΈ̤ÓÔ˘ ÏÂÌÊ·‰¤Ó·, ÏfiÁˆ Ù˘ ÓfiÛÔ˘ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜, Ë ÔÔ›· ÂȂ‚·ÈÒıËΠ̠ÙËÓ ·Ó‡ÚÂÛË ÛÙÔÓ ÔÚfi ÙÔ˘ ·ÛıÂÓÔ‡˜
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IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Bartonella henselae. ∏ ·ÓˆÙ¤Úˆ ‰È¿ÁÓˆÛË Ù¤ıËΠÌÂÙ¿ ·fi ÙÔÓ ÏÂÙÔÌÂÚ‹ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ô ÔÔ›Ô˜ ·¤ÎÏÂÈÛ ÙËÓ Î·ÎÔ‹ıË ‰ÈfiÁΈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ Î·È Î˘Ú›ˆ˜ ·fi ÙË ÏÂÙÔÌÂÚ‹ Ï‹„Ë ÈÛÙÔÚÈÎÔ‡, Ë ÔÔ›· ·ÔÎ¿Ï˘„ ÙËÓ ‡·ÚÍË Î·ÙÔÈΛ‰ÈÔ˘ ˙ÒÔ˘ (Á¿Ù·˜) ÛÙÔ Û›ÙÈ ÙÔ˘ ·ÛıÂÓ‹. ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË. ∆Ô 30% ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÂÌÊ·‰¤Ó˜ Û ÔÏϷϤ˜ ı¤ÛÂȘ. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂӉ›ÎÓ˘Ù·È Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜, ÂÓÒ ¿ÏÏÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÓÈÛÙÔ‡Ó ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Û ÂÚ›ÙˆÛË ·Ú·ÙÂÈÓfiÌÂÓÔ˘ ˘ÚÂÙÔ‡ (2,3,13). ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ ¯ÔÚËÁ‹ıËΠʷÚ̷΢ÙÈ΋ ·ÁˆÁ‹ ÏfiÁˆ ÙÔ˘ ·Ú·ÙÂÈÓfiÌÂÓÔ˘ ˘ÚÂÙÔ‡ Î·È Ù˘ Ó¤·˜ ÂÌÊ¿ÓÈÛ˘ ‰ÈÔÁΈ̤ÓÔ˘ ÏÂÌÊ·‰¤Ó· (ÛÙË Ì·Û¯·ÏÈ·›· ¯ÒÚ·). ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍÂ Â˘Ú‹Ì·Ù· ÌË ÂȉÈÎÒÓ ·ÏÏÔÈÒÛˆÓ, ηıÒ˜ Î·È ÔÏÏ·Ï¿ ÂÈıËÏÈÔÂȉ‹ ÎÔÎÎÈÒÌ·Ù· Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË, fiˆ˜ ¿ÏψÛÙ ·Ó·ÌÂÓfiÙ·Ó (1,2,14). ∏ Ù˘¯·›· ·Ó‡ÚÂÛË ÙÔ˘ ·Ú·ÙÂٷ̤ÓÔ˘ ·ƒ∆∆ ÛÙÔÓ ÚÔÂÁ¯ÂÈÚËÙÈÎfi ¤ÏÂÁ¯Ô ÌÂÙ¿ ·fi ÏÂÙÔÌÂÚ‹ ‰ÈÂÚ‡ÓËÛË ‚Ú¤ıËΠfiÙÈ ÔÊÂÈÏfiÙ·Ó ÛÙËÓ ‡·ÚÍË Î˘ÎÏÔÊÔÚÔ‡ÓÙÔ˜ LA. £ÂˆÚ‹Û·Ì fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ LA Û ¤Ó· ·È‰› Ô˘ ‰ÂÓ ÂÌÊ¿ÓÈ˙ ·ÈÌÔÚÚ·ÁÈΤ˜ ÂΉËÏÒÛÂȘ ‹ ıÚÔÌ‚ÒÛÂȘ, ‹Ù·Ó ·ÚÔ‰È΋ Î·È Î·ÏÔ‹ı˘, ÔÊÂÈÏfiÌÂÓË ÛÙË Ïԛ̈ÍË ÙÔ˘ ·ÛıÂÓ‹ ·fi ÙË Bartonella henselae. ™ÙËÚÈ˙fiÌÂÓÔÈ ÛÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ (4,6,8,11,12), ÚÔ¯ˆÚ‹Û·Ì ÛÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó· ·Ú¿ ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ·ƒ∆∆, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚËı› ·ÈÌÔÚÚ·Á›· ‹ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ÂԇψÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ·È‰È¿ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› ·Ú¿Ù·ÛË ÙÔ˘ ·ƒ∆∆, Ë ÔÔ›· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË, ·ÏÏ¿ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‡·Ú͢ LA (6,8,11,12). ∆Ô LA, o ›ÎÙËÙÔ˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ‹Í˘, Â›Ó·È Û˘Ó‹ıˆ˜ ·ÚÔ‰ÈÎfi Ì ηÏÔ‹ıË ÔÚ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Joseph R Lex. Catscratch disease. Medicine Journal 2001;2:8. 2. Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to “Rochalimaea henselae” antigen in suspected
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cat-scratch disease. Lancet 1992;339:1443-1445. 3. Margileth AM. Antibiotic therapy for catscratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J 1992;11:474-478. 4. Eckart P, Tournade G, Amiour M, Guillot M, Courtheoux P, Rousselot P. Maladie des griffes du chat de presentation pseudotumorale. Arch Pediatr 2001;8:393-396. 5. Carithers HA. Cat-scratch disease. An overview based on a study of 1200 patients. Am J Dis Child 1985;139:1124-1133. 6. OÈÎÔÓfiÌÔ˘ ª, ∫Ô‡ÛË ∞, ∆Û¿ÙÚ· π, °·Ú˘›‰Ô˘ µ, ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ ª. ¶·ÚÔ‰ÈÎfi ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·: ÂÚÈÁÚ·Ê‹ ÙÂÛÛ¿ÚˆÓ ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ 2002;65:77-80. 7. ªale C, Lechner K, Eichinger S, Kyrle PA, Kapiotis S, Wank H et al. Clinical significance of lupus anticoagulants in children. J Pediatr 1999;134:199-205. 8. Lee MT, Nardi MA, Hadzi-Nesic J, Karpatkin M. Transient hemorrhagic diathesis associated with an inhibitor of prothrombin with lupus anticoagulant in a 1ó year-old girl: report of a case and review of literature. Am J Hematol 1996;51:307-314. 9. Hoffman R, Benz EJ, Shattil SJ, Furil B, Cohen HJ, eds. Inhibitors of blood coagulation. In: Hematology. Basic Principles and Practice. 2nd ed. Churchill Livingstone Inc; 1995. p. 1746-1755. 10. Seaman DE, Londino AV Jr, Kwoh CK, Medsger TA Jr, Manzi S. Antiphospholipid antibodies in pediatric systemic lupus erythematosus. Pediatrics 1995;96:1040-1045. 11. Manco-Johnson MJ, Nuss R, Key N, Moertel C, Jacobson L, Meech S et al. Lupus anticoagulant and protein S deficiency in children with postvaricella purpura fulminans or thrombosis. J Pediatr 1996;128:319-323. 12. Manco-Johnson MJ. Antiphospholipid antibodies in children. Semin Thromb Hemost 1998;24:591-598. 13. Adal KA, Cockerell CJ, Petri WA Jr. Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea. N Engl J Med 1994;330:1509-1515. 14. Infectious Diseases and Immunization Committee, Canadian Pediatric Society. CPS: Cat scratch disease: diagnosis and management. Paediatr Child Health 1997;2:275-278.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-08-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª. §ÈıÔÍÔÔ‡ÏÔ˘ µ·Û. °ÂˆÚÁ›Ô˘ 24, ∆.∫. 546 40, £ÂÛÛ·ÏÔÓ›ÎË
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∂¶π∫∞πƒ∞ £∂ª∞∆∞
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CURRENT ISSUES
ŒÎ‚·ÛË ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∞. ª·ÓÔ˘Ú¿, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
Outcome of newborns conceived by in vitro fertilization A. Manoura, C. Giannakopoulou
¶ÂÚ›ÏË„Ë: ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÂÚ›Ô˘ ÂÓ‹ÓÙ· ¯ÈÏÈ¿‰Â˜ ·È‰È¿ ÁÂÓÓÈÔ‡ÓÙ·È Î¿ı ¯ÚfiÓÔ Ì ÙË Ì¤ıÔ‰Ô Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘. ∂›ÎÔÛÈ ¯ÚfiÓÈ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ÚÒÙÔ˘ “·È‰ÈÔ‡ ÙÔ˘ ۈϋӷ” ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ÂÚˆÙËÌ·ÙÈο ˆ˜ ÚÔ˜ ÙËÓ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ù¯ÓÔÏÔÁ›·˜. ∆· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ Á¤ÓÓËÛ˘ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹, ÚÔˆÚfiÙËÙ·˜, ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, Ô˘ ÊÙ¿ÓÂÈ ÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ Î˘‹ÛÂˆÓ Ô˘ ¤¯Ô˘Ó ÚÔ¤ÏıÂÈ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË. ¢È·ÊÔÚ¤˜ ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌËÙ¤ÚˆÓ Û˘Ì‚¿ÏÏÔ˘Ó, ›Û˘, ÛÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ¤Î‚·ÛË. ∆· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÂȉÈο ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È Â›Û˘ ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘Í‹ ÙÔ˘˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋, ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜. ∏ ·ӷÙÔÔı¤ÙËÛË ÛÙË Ì‹ÙÚ· ‰‡Ô, ÙÔ ·ÓÒÙÂÚÔ, ÂÌ‚Ú‡ˆÓ, Ì ÚÔÔÙÈ΋ ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ÙËÓ ÙÔÔı¤ÙËÛË ÂÓfi˜ ÌfiÓÔ “ηϋ˜ ÔÈfiÙËÙ·˜” ‚ÈÒÛÈÌÔ˘ ÂÌ‚Ú‡Ô˘, ı· ‚ÂÏÙÈÒÛÂÈ Î·Ù¿ Ôχ ÙËÓ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘.
Abstract: During the last years, almost fifty thousand children are born every year after in vitro fertilization. Twenty years after the birth of the first baby conceived by in vitro fertilization, many questions concerning the outcome of these children remain unanswered. Pregnancies achieved after in vitro fertilization bear an increased risk for prematurity, low birth weight, perinatal mortality and delivery by cesarean section compared with pregnancies after spontaneous conception. Adverse outcome is mainly due to the high frequency of multiple pregnancies, which reach one third of in vitro fertilization pregnancies. Differences in maternal characteristics also contribute to this adverse outcome. Children conceived by in vitro fertilization are at higher risk of neurological sequelae, especially cerebral palsy, which is also mainly due to the high frequency of multiple gestations. Physical growth is within normal range while congenital malformations do not seem to be higher. Two-embryo transfer policy and, in the near future, the effective selection and transfer of one viable embryo will improve the outcome of children born after in vitro fertilization.
§¤ÍÂȘ ÎÏÂȉȿ: Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ôχ‰˘ÌË Î‡ËÛË.
Key words: in vitro fertilization, multiple pregnancy.
∂ÈÛ·ÁˆÁ‹ ¶ÂÚÈÛÛfiÙÂÚ· ·fi ›ÎÔÛÈ ¯ÚfiÓÈ· ¤¯Ô˘Ó ÂÚ¿ÛÂÈ ·fi ÙË Á¤ÓÓËÛË ÙÔ˘ ÚÒÙÔ˘ “̈ÚÔ‡ ÙÔ˘ ۈϋӷ” (1). ∞fi ÙfiÙÂ, ÔÈ Ì¤ıÔ‰ÔÈ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··-
Ú·ÁˆÁ‹˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ, ¤¯Ô˘Ó ‰ÒÛÂÈ ÙË ¯·Ú¿ Ù˘ ·fiÎÙËÛ˘ ÂÓfi˜ ·È‰ÈÔ‡ Û ÔÏÏ¿ ˙¢Á¿ÚÈ· Ì ÚÔ‚Ï‹Ì·Ù· ˘ÔÁÔÓÈÌfiÙËÙ·˜. ¶·Ú¿ÏÏËÏ·, fï˜, ¤¯Ô˘Ó ÂÁ›ÚÂÈ Î·È
¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
Department of Neonatology of University of Crete
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¶·È‰È·ÙÚÈ΋ 2003;66:58-64
ÔÏÏÔ‡˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË Î·È ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ù¯ÓÔÏÔÁ›·˜. ªÂ ÙËÓ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ·ÚÎÂÙ¿ ÛÙ¿‰È· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ˘ÂÚˉԇÓÙ·È, ·ÊÔ‡ Ë ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË Á›ÓÂÙ·È ·Ú¯Èο in vitro. ∆· ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙȘ Èı·Ó¤˜ ÂȉڿÛÂȘ ÛÙÔ ¤Ì‚Ú˘Ô, ·˘Ù‹˜ Ù˘ ·Ú¤Ì‚·Û˘ ÛÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ‰È·‰Èηۛ˜ Ù˘ ÁÔÓÈÌÔÔ›ËÛ˘, ‰ÂÓ ¤¯Ô˘Ó ··ÓÙËı› ·ÎfiÌ·. ∏ ·Ó·ÛÎfiËÛË ·˘Ù‹ ÛÎÔfi ¤¯ÂÈ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ù· ¿ÌÂÛ· ÂÚÈÁÂÓÓËÙÈο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î·È Ó· Û˘ÓÔ„›ÛÂÈ ÙÔ˘˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ Ô˘ ˘¿Ú¯Ô˘Ó Û‹ÌÂÚ· Û¯ÂÙÈο Ì ÙËÓ ·ÒÙÂÚË ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ∆¯ÓÔÏÔÁ›· ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ ∏ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ÛÙËÚ›˙ÂÙ·È ÛÙË Û˘ÏÏÔÁ‹ ˆ·Ú›ˆÓ Î·È ÛÙËÓ ÙÔÔı¤ÙËÛ‹ ÙÔ˘˜, Ì·˙› Ì ηٿÏÏËÏ· ÂÂÍÂÚÁ·Ṳ̂ÓÔ Û¤ÚÌ·, Û ‰ÔÎÈÌ·ÛÙÈÎfi ۈϋӷ ‹ ÙÚ˘‚Ï›· Ì ηٿÏÏËÏÔ ıÚÂÙÈÎfi ˘ÏÈÎfi, ÒÛÙ ӷ Á›ÓÂÈ Ë ÁÔÓÈÌÔÔ›ËÛË. ™ÙË Û˘Ó¤¯ÂÈ·, ·ÎÔÏÔ˘ı› ÂÌʇÙ¢ÛË ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ ÛÙË Ì‹ÙÚ· (2). ∞Ú¯Èο, ‰ÂÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ê¿Ú̷η ÚfiÎÏËÛ˘ ˆÔÚÚËÍ›·˜, ‰È·ÈÛÙÒıËΠfï˜ fiÙÈ Ë Ì¤ıÔ‰Ô˜ Ì ϋ„Ë ˆ·Ú›Ô˘ ·fi Á˘Ó·›Î· ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÁÂÓÓËÙÈÎfi ·ÎÏÔ ·ÚÔ˘Û›·˙ ÔÏÏ¿ Ú·ÎÙÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÌÈÎÚfi ÔÛÔÛÙfi ÂÈÙ˘¯›·˜. ™‹ÌÂÚ·, ÁÈ· ÙË Ï‹„Ë ˆ·Ú›ˆÓ, Á›ÓÂÙ·È Î·Ù¿ ηÓfiÓ· Ê·Ú̷΢ÙÈ΋ ‰È¤ÁÂÚÛË ÙˆÓ ˆÔıËÎÒÓ. ∂ͤÏÈÍË Ù˘ ÎÏ·ÛÈ΋˜ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ·ÔÙÂÏ› Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ÌfiÓÔ ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘ ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ· ÙÔ˘ ˆ·Ú›Ô˘ (ICSH) ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ·ÛıÂÓÔÛÂÚÌ›·˜. ∏ ηٿ„˘ÍË ÂÌ‚Ú‡ˆÓ Û ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÁÔÓÈÌÔÔ›ËÛ˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÁÈ· ʇϷÍË ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ (2). ∏ ¯ÚËÛÈÌÔÔ›ËÛË ‰È·ÊfiÚˆÓ ÔÚÌÔÓÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ÁÈ· ÙËÓ ÚfiÎÏËÛË ˆÔÚÚËÍ›·˜, Ë Èı·ÓfiÙËÙ· ‚Ï¿‚˘ ÙÔ˘ ˆ·Ú›Ô˘ ηٿ ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ï‹„˘ ÙÔ˘ ‹ ηٿ ÙËÓ Â·Ó·ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ÛÙË Ì‹ÙÚ·, Ë ¯Ú‹ÛË Î·ÏÏÈÂÚÁËÙÈÎÒÓ ˘ÏÈÎÒÓ Ô˘ Èı·ÓfiÓ ¤¯Ô˘Ó οÔÈ· ›‰Ú·ÛË ÛÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ¤Ì‚Ú˘Ô, ηıÒ˜ Î·È Ë Î·Ù¿„˘ÍË ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ÂÌ‚Ú‡ˆÓ ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ·ÓËÛ˘¯›Â˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ·˘Ù¤˜ ÙȘ ÌÂıfi‰Ô˘˜ (3,4). ¶·Ú¿ÏÏËÏ·, Ë ÚÔÛ¿ıÂÈ· ·‡ÍËÛ˘ ÙˆÓ ÔÛÔÛÙÒÓ Â›Ù¢Í˘ ÂÁ΢ÌÔÛ‡Ó˘ ÌÂÙ¿ ·fi ¤Ó· ·ÎÏÔ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ Â·Ó·ÙÔÔı¤ÙËÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ÂÌ‚Ú‡ˆÓ ÛÙË Ì‹ÙÚ·. ∏ Ú·ÎÙÈ΋ ·˘Ù‹ ›¯Â Û·Ó
Paediatriki 2003;66:58-64
·ÔÙ¤ÏÂÛÌ· ÙË ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Ì ·ÚÓËÙÈΤ˜ Û˘Ó¤ÂȘ ÛÙËÓ ÚfiÁÓˆÛË ÙˆÓ ÓÂÔÁÓÒÓ. ¶Ôχ‰˘Ì˜ ΢‹ÛÂȘ ∆· Ôχ‰˘Ì· ÓÂÔÁÓ¿ ÛÙÔÓ ¿ÓıÚˆÔ ·ÔÙÂÏÔ‡Ó Ê˘ÛÈÔÏÔÁÈο ÙÔ 2-3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (5). ∏ Û˘¯ÓfiÙËÙ· ‰›‰˘Ì˘ ·ËÛ˘ ·Ó·Ê¤ÚÂÙ·È 1/80, ÙÚ›‰˘Ì˘ 1/6400, ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˘ Ù¿Í˘ Ôχ‰˘Ì˜ ΢‹ÛÂȘ, Ë Û˘¯ÓfiÙËÙ· ÌÂÈÒÓÂÙ·È ÂÎıÂÙÈο. ∏ Ôχ‰˘ÌË Î‡ËÛË Â›Ó·È Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· ÁÔÓÈÌÔÔ›ËÛ˘ ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ˆ·Ú›ˆÓ (‰ÈˆÔÁÂÓ‹ ‰›‰˘Ì·) (6). ∏ ‰È·›ÚÂÛË ÂÓfi˜ ÁÔÓÈÌÔÔÈË̤ÓÔ˘ ˆ·Ú›Ô˘ Û ‰‡Ô ·ÓÔÌÔÈfiÙ˘· ¤Ì‚Ú˘· (ÌÔÓÔˆÔÁÂÓ‹) ·ÔÙÂÏ› ¤Ó·Ó ¿ÏÏÔ Ì˯·ÓÈÛÌfi ‰ËÌÈÔ˘ÚÁ›·˜ ‰È‰‡ÌˆÓ. ∏ Û˘¯ÓfiÙËÙ· ÌÔÓÔˆÔÁÂÓÔ‡˜ ‰›‰˘Ì˘ ·ËÛ˘ Â›Ó·È 3,5 ÛÙȘ 1000 ÁÂÓÓ‹ÛÂȘ Î·È Â›Ó·È Û¯ÂÙÈο ÛÙ·ıÂÚ‹ ·ÁÎfiÛÌÈ· (7). ∞ÓÙ›ıÂÙ·, Ë Û˘¯ÓfiÙËÙ· ‰ÈˆÔÁÂÓÔ‡˜ ‰›‰˘Ì˘ ·ËÛ˘ Î˘Ì·›ÓÂÙ·È ·fi 4 ¤ˆ˜ 50 ÛÙȘ 1000 ÁÂÓÓ‹ÛÂȘ Î·È ÂËÚ¿˙ÂÙ·È ·fi ÙË Ê˘Ï‹, ·fi Ì›· ÔÈÎÔÁÂÓÂȷ΋ ÚԉȿıÂÛË Ô˘ ÌÂٷʤÚÂÙ·È ·fi ÙË ÌËÙ¤Ú·, ·fi ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, ÙÔÓ ÙfiÎÔ, ÙË ‰È·ÙÚÔÊ‹ ‹ ÙËÓ ÂÔ¯‹ ÙÔ˘ ¯ÚfiÓÔ˘. OÈ ÔχÙÔΘ ÌËÙ¤Ú˜ ¤¯Ô˘Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ‰›‰˘ÌË Î‡ËÛË, ηıÒ˜ Î·È ÔÈ Á˘Ó·›Î˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Ì ÙË Ì¤ÁÈÛÙË Û˘¯ÓfiÙËÙ· ÛÙ· 37 ¯ÚfiÓÈ· (7). ∆· ÌÔÓÔˆÔÁÂÓ‹ ‰›‰˘Ì· ·ÔÙÂÏÔ‡Ó ÙÔ 10-18% ÙˆÓ ˙ÒÓÙˆÓ ‰È‰‡ÌˆÓ (8). ∏ ÂÚÈÁÂÓÓËÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤Ó˜ Î·È Ë Èı·ÓfiÙËÙ· ÂÚÈÁÂÓÓËÙÈÎÔ‡ ı·Ó¿ÙÔ˘ Â›Ó·È 2,5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ·fi Ù· ‰ÈˆÔÁÂÓ‹ (9). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ì›· ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∏ ·‡ÍËÛË ·˘Ù‹ ·Ô‰›‰ÂÙ·È Î·Ù¿ ÙÔ ¤Ó· ÙÚ›ÙÔ ÂÚ›Ô˘ ÛÙËÓ ÚÔ˜ Ù· ¿Óˆ ÌÂÙ·ÙfiÈÛË Ù˘ ̤Û˘ ËÏÈΛ·˜ ÙˆÓ ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ Î·È Î·Ù¿ Ù· ‰‡Ô ÙÚ›Ù· ÛÙËÓ Â˘Ú›· ¯Ú‹ÛË ÙˆÓ ÌÂıfi‰ˆÓ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ (5). ∏ ıÂڷ›· ·ÓˆÔÚÚËÎÙÈÎÒÓ Á˘Ó·ÈÎÒÓ Ì ʷÚ̷΢ÙÈο Û΢¿ÛÌ·Ù· ·ÁˆÁ‹˜ ˆÔÚÚËÍ›·˜ Û¯ÂÙ›˙ÂÙ·È Ì ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ Ôχ‰˘Ì˘ ·ËÛ˘ Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ê¿ÚÌ·ÎÔ Î·È ÙË ‰fiÛË. ∏ ÎÈÙÚÈ΋ ÎÏÔÌÈÊ·›ÓË Î·È ¿ÏÏ· ·ÓÙÈ-ÔÈÛÙÚÔÁfiÓ· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ‰›‰˘Ì˘ ·ËÛ˘ Û 10% Î·È ÙÚ›‰˘Ì˘ ·ËÛ˘ Û 1%, ÂÓÒ Û ıÂڷ›· ÌÂ Û˘Ì‚·ÙÈο Û¯‹Ì·Ù· ÁÔÓ·‰ÔÙÚÔÈÓÒÓ, Ô Î›Ó‰˘ÓÔ˜ Ôχ‰˘Ì˘ ·ËÛ˘ Â›Ó·È ÂÚ›Ô˘ 25% (3). ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘, Ô Î›Ó‰˘ÓÔ˜ Ôχ‰˘Ì˘ ·ËÛ˘ ·˘Í¿ÓÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ Ô˘ ·ӷÙÔÔıÂÙÔ‡ÓÙ·È ÛÙË Ì‹ÙÚ·. OÚÈṲ̂ӷ ΤÓÙÚ· ıˆÚÔ‡Ó fiÙÈ Ë ÂÌʇÙ¢ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ
59
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·60
¶·È‰È·ÙÚÈ΋ 2003;66:58-64
·˘Í¿ÓÂÈ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ Ù˘ ÌÂıfi‰Ô˘. øÛÙfiÛÔ, ¤¯ÂÈ ‰Âȯı› fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ˆ·Ú›ˆÓ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Î·È fiÙÈ Ë ÂÌʇÙ¢ÛË ÙÚÈÒÓ ·ÓÙ› ‰‡Ô ˆ·Ú›ˆÓ ‰ÂÓ ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÔÛÔÛÙfi ÙˆÓ Î˘‹ÛÂˆÓ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È (3). ∏ Û˘¯ÓfiÙËÙ· Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Û ÂÚÈÙÒÛÂȘ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ Â›Ó·È 2030%, ÂÓÒ ÙÔ 30-40% ÙˆÓ ÌˆÚÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÂÙ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ÚÔ¤Ú¯ÔÓÙ·È ·fi Ôχ‰˘Ì˜ ΢‹ÛÂȘ (5). OÈ ‰›‰˘Ì˜ ΢‹ÛÂȘ ¤¯Ô˘Ó ·˘ÍËı› ÛÙȘ ∏¶∞ ·fi 1,8% ÙÔ 1971 Û 2,7% ÙÔ 1997 (8). ¶ÂÚÈÛÛfiÙÂÚÔ ÂÓÙ˘ˆÛȷ΋ Â›Ó·È Ë ·‡ÍËÛË ÙˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ Ù¿Í˘ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∆· ÙÚ›‰˘Ì· ÓÂÔÁÓ¿, ·fi 296 ·Ó¿ 1 ÂηÙÔÌ̇ÚÈÔ ˙ÒÓÙˆÓ ÁÂÓÓ‹ÛÂˆÓ ÙÔ 1971, ¤ÊÙ·Û·Ó ÙȘ 1584 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1997, Ù· ÙÂÙÚ¿‰˘Ì· ·fi 13 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1971 ¤ÊÙ·Û·Ó ÙȘ 144 ÙÔ 1996, ÂÓÒ Ù· ÂÓÙ¿‰˘Ì· ·fi 3,8 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1971 ¤ÊÙ·Û·Ó ÙȘ 20,8 ÙÔ 1996 (8). ¶ÚfiÁÓˆÛË ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∆· ÓÂÔÁÓ¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó, ÁÂÓÈο, ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ Á¤ÓÓËÛ˘ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹, ÚÔˆÚfiÙËÙ·˜, ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (3,5,10,11). ™Â ÌÂϤÙË Ô˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ 4298 ΢‹ÛÂȘ Î·È 5539 ÓÂÔÁÓ¿ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ ‚Ú¤ıËΠfiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ‹Ù·Ó 31,9%, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÚÈÁÂÓÓËÙÈÎÒÓ ı·Ó¿ÙˆÓ ‹Ù·Ó 1,8% Î·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ Ì ËÏÈΛ· ·ËÛ˘ ÌÈÎÚfiÙÂÚË ÙˆÓ 33 ‚‰ÔÌ¿‰ˆÓ ‹Ù·Ó 4,8%, Û ·ÓÙ›ıÂÛË Ì 13,2%, 0,8% Î·È 1,1% ·ÓÙ›ÛÙÔȯ· ÁÈ· Ù· ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (11). ™Â ¿ÏÏË ÌÂÁ¿ÏË ÌÂϤÙË ·fi ÙË ™Ô˘Ë‰›·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ ‚Ú¤ıËΠ30,3% ÛÙȘ ΢‹ÛÂȘ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Û ·ÓÙ›ıÂÛË Ì ÙÔ 6,3% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ÷ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‰È·ÈÛÙÒıËΠÛÙÔ 27,4%, Û ۯ¤ÛË Ì ÙÔ 6,3% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5). ¶Èı·Ófi ›ӷÈ, ˆÛÙfiÛÔ, fiÙÈ ÛÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ Û˘Ì‚¿ÏÏÂÈ Î·È ÙÔ ¿Á¯Ô˜, ÙfiÛÔ ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔ Î·È ÙˆÓ ÁÈ·ÙÚÒÓ, ÁÈ· ÂÈÙ˘¯‹ ¤Î‚·ÛË Ù˘ ·ËÛ˘ fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ô˘ Ô‰ËÁ› Û ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Ì ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË Î·ÈÛ·ÚÈ΋ ÙÔÌ‹ ÛÙȘ 36 Ì 37 ‚‰ÔÌ¿‰Â˜ (3,10). ™ËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ‚Ú¤ıËÎ·Ó Î·È ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· Ô˘ ‹Ù·Ó 8,2ò, ÂÓÒ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ‹Ù·Ó 6,6ò (5). ∏ ‰˘ÛÌÂÓ¤ÛÙÂÚË ·˘Ù‹ ¤Î‚·ÛË ¤¯ÂÈ ·Ô‰Ôı› Û ÌÂ-
60
Paediatriki 2003;66:58-64
Á¿ÏÔ ‚·ıÌfi ÛÙÔ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Ì ٷ ·˘ÍË̤ӷ ÚÔ‚Ï‹Ì·Ù· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (5,12). øÛÙfiÛÔ, Ê·›ÓÂÙ·È fiÙÈ Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Û˘ÓÙÂÏÔ‡Ó ÛÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ·˘Ù‹ ¤Î‚·ÛË, ·ÊÔ‡ ‰È·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË ¤¯ÂÈ ‚ÚÂı› Î·È Û ÓÂÔÁÓ¿ ·fi ·Ï¤˜ ΢‹ÛÂȘ (3,13,14). ·. ¶ÚfiÁÓˆÛË ÓÂÔÁÓÒÓ ·fi ·Ï¤˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ·Ó··Ú·ÁˆÁ‹˜ ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó Û˘ÁÎÚ›ÓÂÈ ÙËÓ ¤Î‚·ÛË ÓÂÔÁÓÒÓ ·fi ·Ï¤˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ·Ó··Ú·ÁˆÁ‹˜ Ì ÂΛÓË ÓÂÔÁÓÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÌʈÓÔ‡Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ‰È·ÙÚ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· ÚfiˆÚÔ ÙÔÎÂÙfi Î·È ÁÈ· ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (4,5,10,15). ¶·Ú’ fiÏÔ Ô˘ ¤Ó· ̤ÚÔ˜ ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ·Ô‰›‰ÂÙ·È ÛÙ· ‰È·ÊÔÚÂÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ Á˘Ó·ÈÎÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, ÚˆÙÔÙfiΘ), ·ÎfiÌ· Î·È fiÙ·Ó Á›ÓÂÈ ÂÍÔÌÔ›ˆÛË ÙˆÓ ÔÌ¿‰ˆÓ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙÔÓ ÙfiÎÔ Ù˘ ÌËÙ¤Ú·˜, Ë ‰È·ÊÔÚ¿ ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ Û ۯ¤ÛË Ì ÂΛӷ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë ·Ú·Ì¤ÓÂÈ (4,5,15-17). ∂›Ó·È Èı·Ófi fiÙÈ Ë ˘ÔΛÌÂÓË ·ÈÙ›· Ù˘ ˘ÔÁÔÓÈÌfiÙËÙ·˜ Î·È Ë Ê·Ú̷΢ÙÈ΋ ‰È¤ÁÂÚÛË ÙˆÓ ˆÔıËÎÒÓ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Î‚·ÛË (3,4,18). ∂ÓÈÛ¯˘ÙÈÎfi Ù˘ ¿Ô„˘ ·˘Ù‹˜ Â›Ó·È fiÙÈ Û ΢‹ÛÂȘ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÌÂÙ¿ ·fi ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÙÔÔı¤ÙËÛË ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘, fiÔ˘ ˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ ·Ó‰ÚÈ΋ ÛÙÂÈÚfiÙËÙ· ÂÓÒ ÔÈ Á˘Ó·›Î˜ Â›Ó·È ˘ÁÈ›˜, Ô Î›Ó‰˘ÓÔ˜ ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡, ηıÒ˜ Î·È ÙÔ Ì¤ÛÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Â›Ó·È ·ÚfiÌÔÈ· Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4,19,20). ‚. ¶ÚfiÁÓˆÛË Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ÙÚfiÔ Û‡ÏÏ˄˘, Û˘Óԉ‡ÔÓÙ·È ·fi ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Ù˘ ÌËÙ¤Ú·˜ Î·È ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ. OÈ ÂÈÏÔΤ˜ ·fi ÏÂ˘Ú¿˜ Ù˘ ÂÁ·Ԣ ÂÌÊ·Ó›˙ÔÓÙ·È 3-7 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· Û ÂÚ›ÙˆÛË Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ ·’ fi,ÙÈ ÛÙȘ ÌÔÓ‹ÚÂȘ ΢‹ÛÂȘ (6). ∆Ô ÔÛÔÛÙfi ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ Â›Ó·È ·˘ÍË̤ÓÔ (6). ∏ ÚÔˆÚfiÙËÙ· Î·È ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ·ÔÙÂÏÔ‡Ó ÙȘ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ ÙˆÓ ÓÂÔÁÓÒÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ¶ÚfiˆÚÔ˜ ÙÔÎÂÙfi˜ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ 20-50% ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, ÂÓÒ ÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ‰È‰‡ÌˆÓ Î·È ¿Óˆ ·fi ÙÔ 90% ÙˆÓ ÙÚ›‰˘ÌˆÓ Î·È ÙÂÙÚ¿‰˘ÌˆÓ ÁÂÓÓÈ¤Ù·È Ì ‚¿ÚÔ˜
JAN-FEB-03
14-05-03
14:37
™ÂÏ›‰·61
¶·È‰È·ÙÚÈ΋ 2003;66:58-64
ÌÈÎÚfiÙÂÚÔ ÙˆÓ 2500 g (7,8). O ΛӉ˘ÓÔ˜ Á¤ÓÓËÛ˘ Ôχ ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ ÓÂÔÁÓÔ‡ (<1500 g) Â›Ó·È 68% ÁÈ· Ù· ‰›‰˘Ì·, ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Î›Ó‰˘ÓÔ ÛÙȘ ÌÔÓ‹ÚÂȘ ΢‹ÛÂȘ (0,71,6%) (6,8). ∏ ÓÔÛËÚfiÙËÙ· ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ôχ‰˘ÌˆÓ Î·È ·ÏÒÓ Î˘‹ÛˆÓ, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡ (6,7,21). O ΛӉ˘ÓÔ˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ‚Ú¤ıËΠ0,2%, 1,3% Î·È 7,6% Û ·Ï¤˜, ‰›‰˘Ì˜ Î·È ÙÚ›‰˘Ì˜ ΢‹ÛÂȘ, ·ÓÙ›ÛÙÔȯ· (21,22). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ·˘ÍË̤ÓË Î˘Ú›ˆ˜ ÛÙ· ÌÔÓÔˆÔÁÂÓ‹ ‰›‰˘Ì· (7). ∏ ıÓËÛÈÌfiÙËÙ· Â›Ó·È Ôχ ·˘ÍË̤ÓË ÛÙ· ÓÂÔÁÓ¿ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ™Ù· ‰›‰˘Ì· ÓÂÔÁÓ¿, Ë ıÓËÛÈÌfiÙËÙ· Â›Ó·È Ù¤ÛÛÂÚȘ Ì ¤ÓÙ ÊÔÚ¤˜ ·˘ÍË̤ÓË Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·ÏÒÓ Î˘‹ÛˆÓ, ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÚ›‰˘Ì· ÓÂÔÁÓ¿, Ë ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· ÂÙ·Ï·ÛÈ¿˙ÂÙ·È (7,22). ™ÙËÓ ·‡ÍËÛË ·˘Ù‹ Û˘ÓÙÂÏÔ‡Ó Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡, ÚÔÂÎÏ·Ì„›·˜, ÚfiÙˆÛ˘ ÔÌÊ·Ï›‰·˜ Î·È ¿ÏÏˆÓ ÂÈÏÔÎÒÓ. ¶¤Ú· ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ·˘Ù¿ Ô˘ ·ÊÔÚÔ‡Ó ÛÙ· ÓÂÔÁÓ¿ Ôχ‰˘Ì˘ ·ËÛ˘ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ÙÚfiÔ Û‡ÏÏ˄˘, ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó Ë ‰È·‰Èηۛ· ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ ÂÈ‚·Ú‡ÓÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ ÚfiÁÓˆÛË. ™Â Û‡ÁÎÚÈÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë, Ù· ÓÂÔÁÓ¿ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ ÁÂÓÓÈÔ‡ÓÙ·È ·fi ÌËÙ¤Ú˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È ÚˆÙÔÙfiΘ, ·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ì·È¢ÙÈÎÒÓ ÂÈÏÔÎÒÓ (23). øÛÙfiÛÔ, ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÌʇÙ¢ÛË ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÌ‚Ú‡ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ÌÔÓÔˆÔÁÂÓÒÓ ‰È‰‡ÌˆÓ Ô˘ ¤¯Ô˘Ó Î·È ÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË. ªÂ ‚¿ÛË ÙÔ ÛÎÂÙÈÎfi ·˘Ùfi, ı· ÂÚ›ÌÂÓ ›Ûˆ˜ ηÓ›˜ ‚ÂÏÙȈ̤ÓË ¤Î‚·ÛË ÙˆÓ ‰È‰‡ÌˆÓ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ Û ۯ¤ÛË Ì ·˘Ù¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ª›· ÚfiÛÊ·ÙË ÌÂϤÙË ‰Â›¯ÓÂÈ ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (24). OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ, ηıÒ˜ Î·È ÓÂÔÁÓÒÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÛÙËÓ ÔÌ¿‰· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (25,26). OÈ ÂÚÈÛÛfiÙÂÚÔÈ, fï˜, Û˘ÌʈÓÔ‡Ó fiÙÈ Ë ÓÂÔÁÓÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÁÈ· Ù· ÓÂÔÁÓ¿ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Û ۯ¤ÛË Ì ·˘Ù¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (5,11,27).
Paediatriki 2003;66:58-64
™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ∏ ›وÛË ÙˆÓ Û˘ÁÁÂÓÒÓ Î·È ¯ÚˆÌÔÛˆÌÈ·ÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÌÂÙ¿ ·fi ÙËÓ ÎÏ·ÛÈ΋ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î˘Ì·›ÓÂÙ·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÌÂٷ͇ 2% Î·È 2,5%, ÔÛÔÛÙ¿ Ô˘ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ·˘Ù¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÁÈ· ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (4,10,28,29). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË, ˆÛÙfiÛÔ, ·Ó·Ê¤ÚÂÙ·È ‰ÈÏ¿ÛÈÔ˜ ΛӉ˘ÓÔ˜ ÌÂÈ˙fiÓˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ (30). OÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜, ÂÍ¿ÏÏÔ˘, ·Ó·Ê¤ÚÔ˘Ó Ì›· ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÌÂÙ¿ıÂÛ˘ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, ·ÙÚËÛ›·˜ ÔÈÛÔÊ¿ÁÔ˘ Î·È ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ ·˘Ù¿ (3,5,31,32). µ¤‚·È·, Ú¤ÂÈ Ó· Ï¿‚ÂÈ Î·Ó›˜ ˘’ fi„ÈÓ ÙÔ˘ fiÙÈ ˘¿Ú¯ÂÈ Î·Ï‡ÙÂÚË ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ·˘ÍË̤ÓË ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ‰È·ÎÔ‹˜ ·˘ÙÒÓ ÙˆÓ Î˘‹ÛÂˆÓ Û ÂÚ›ÙˆÛË ‰È·›ÛÙˆÛ˘ οÔÈ·˜ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜, ηıÒ˜ Î·È ·˘ÍË̤ÓÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. øÛÙfiÛÔ, Ë ·Ó‡ÚÂÛË - Û ÚfiÛÊ·ÙË ÌÂϤÙË - ‰ÈÏ¿ÛÈ·˜ Û˘¯ÓfiÙËÙ·˜ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔÈËÛ˘, ·ÎfiÌ· Î·È fiÙ·Ó ÌÂÏÂÙÒÓÙ·È ·È‰È¿ ÌfiÓÔ ·fi ·Ï¤˜ ΢‹ÛÂȘ Î·È Á›ÓÂÈ ÂÍÔÌÔ›ˆÛË ÙˆÓ ÔÌ¿‰ˆÓ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ Î·È ¿ÏÏÔ˘˜ Èı·ÓÔ‡˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰È·ÙËÚ› ÙËÓ ·ÓËÛ˘¯›· Ô˘ ˘¿Ú¯ÂÈ ˆ˜ ÚÔ˜ ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ‰ËÌÈÔ˘ÚÁ› ÙËÓ ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˘ (30). ∞Ó¿ÏÔÁ· ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ÎÏ·ÛÈ΋ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·Ó·Ê¤ÚÔÓÙ·È Î·È ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ηٿ„˘Í˘ ÂÌ‚Ú‡ˆÓ (3,4,33). ªÂÁ·Ï‡ÙÂÚ˜ ·ÓËÛ˘¯›Â˜ ÂÁ›ÚÔ˘Ó ÔÈ ÓÂfiÙÂÚ˜, ÂÚÈÛÛfiÙÂÚÔ ÂÂÌ‚·ÙÈΤ˜ Ù¯ÓÈΤ˜ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ë ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ¤Á¯˘ÛË ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘. ™ÙË Ì¤ıÔ‰Ô ·˘Ù‹, ÔÈ Ì˯·ÓÈÛÌÔ› ÂÈÏÔÁ‹˜ ηٿ ·ÓÒÌ·ÏˆÓ ÛÂÚÌ·ÙÔ˙ˆ·Ú›ˆÓ Î·È ˆ·Ú›ˆÓ ˘ÂÚˉԇÓÙ·È, ÔÈ ·˘ÍË̤ÓÔÈ ¯ÂÈÚÈÛÌÔ› ÌÔÚ› Ó· ÂÈʤÚÔ˘Ó Ì˯·ÓÈ΋ ‹ ¯ËÌÈ΋ ‚Ï¿‚Ë ÛÙÔ ˆ¿ÚÈÔ Ì ·ÔÙ¤ÏÂÛÌ· ‰È·Ù·Ú·¯‹ ÛÙË Ì›ˆÛË Î·È ÙË Ì›ÙˆÛË, ÂÓÒ Ë ¤ÎıÂÛË Û ÔÈΛÏÔ˘˜ ¯ËÌÈÎÔ‡˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ (4,34,35). ¶·Ú’ fiÏÔ Ô˘ Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ÁÂÓÓËı› Ì ·˘Ù‹ ÙË Ì¤ıÔ‰Ô Â›Ó·È Û¯ÂÙÈο ÌÈÎÚfi˜, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ̤¯ÚÈ ÙÒÚ· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ (4,19,35,36). ∫·È ÛÙË Ì¤ıÔ‰Ô ·˘Ù‹, fï˜, ˘¿Ú¯Ô˘Ó ÂÚ¢ÓËÙ¤˜ Ô˘ ·Ó·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (30). ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜, Ê·›ÓÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ, ÙfiÛÔ ÙˆÓ ÛˆÌ·ÙÈÎÒÓ
61
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14:37
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fiÛÔ Î·È ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ʇÏÔ˘, Â›Ó·È ·˘ÍË̤ÓË Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (0,83% ¤Ó·ÓÙÈ 0,19-0,23% ÁÈ· ÙȘ ·ÓˆÌ·Ï›Â˜ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ʇÏÔ˘, 0,36% ¤Ó·ÓÙÈ 0,07% ÁÈ· ÙȘ ·ÓˆÌ·Ï›Â˜ ·˘ÙfiÛˆÌˆÓ ¯ÚˆÌÔۈ̿وÓ) (4,20,37). O ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Èı·Ó¿ Û¯ÂÙ›˙ÂÙ·È Ì ·˘Ù‹ ηı·˘Ù‹ ÙË ‰È·‰Èηۛ· ÁÔÓÈÌÔÔ›ËÛ˘, ¯ˆÚ›˜ Ó· ·ÔÎÏ›ÂÙ·È Ì›· ·˘ÍË̤ÓË Â›ÙˆÛË ¯ÚˆÌÔÛˆÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ· ·ÓÙÚÒÓ Ì Úfi‚ÏËÌ· ÁÔÓÈÌfiÙËÙ·˜ (4,20). æ˘¯Ôۈ̷ÙÈ΋ ÂͤÏÈÍË - ∞ÒÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ‚Ú¤ıËΠ·Ó¿ÏÔÁË Ì ·˘Ù‹ ÙˆÓ ·È‰ÈÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4). ŸÙ·Ó ÌÂÏÂÙÒÓÙ·È Û·Ó ÂÓÈ·›· ÔÌ¿‰·, Ù· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÂÌÊ·Ó›˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÂȉÈο ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (38). øÛÙfiÛÔ, ÙÔ Â‡ÚËÌ· ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, ÂÓÒ Ù· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ·Ï¤˜ ΢‹ÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÏ·ÊÚ¿ ·˘ÍË̤ÓÔ, ·ÏÏ¿ fi¯È ÛËÌ·ÓÙÈÎfi ÛÙ·ÙÈÛÙÈο, ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ (38). ∂Ô̤ӈ˜, Ê·›ÓÂÙ·È fiÙÈ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ „˘¯Ôۈ̷ÙÈ΋ ÙÔ˘˜ ÂͤÏÈÍË, Ù· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Â›Ó·È Ì¤Û· ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ· (3,4). ∞Ó¿ÏÔÁË Â›Ó·È Î·È Ë ·Ó¿Ù˘ÍË Î·È Ë „˘¯oۈ̷ÙÈ΋ ÂͤÏÈÍË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÂÚÈÛÛfiÙÂÚÔ ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô Ù˘ ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋˜ ÙÔÔı¤ÙËÛ˘ ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘ (ISCI) (35). ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¤Ì‚Ú˘· Ô˘ ηٷ„‡¯ıËÎ·Ó Î·È Û˘ÓÙËÚ‹ıËηÓ, ‰ÂÓ ¤¯Ô˘Ó ‚ÚÂı› ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙËÓ „˘¯Ôۈ̷ÙÈ΋ ÂͤÏÈÍË Û ۯ¤ÛË Ì ·È‰È¿ Ê˘ÛÈÔÏÔÁÈ΋˜ Û‡ÏÏ˄˘ ‹ ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË “ÊÚ¤ÛΈӔ ÂÌ‚Ú‡ˆÓ (39). ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ, ηıÒ˜ Î·È Ë Û¯¤ÛË ÁÔÓ¤ˆÓ-·È‰ÈÒÓ ¤¯ÂÈ ÌÂÏÂÙËı› Î·È Û˘ÁÎÚÈı› Ì ·È‰È¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ∏ ÔÈfiÙËÙ· Ù˘ ÁÔÓÈ΋˜ ÊÚÔÓÙ›‰·˜ Î·È Ë ·ÏÏËÏ›‰Ú·ÛË ÁÔÓ¤ˆÓ-·È‰ÈÔ‡ ‚Ú¤ıËΠ·ÓÒÙÂÚË ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (3,4). OÈ ÌËÙ¤Ú˜ ÙˆÓ ·È‰ÈÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘Ó·ÈÛıËÌ·ÙÈο ‰Â̤Ó˜ Ì ٷ ·È‰È¿ ÙÔ˘˜, ÔÈ ·Ù¤Ú˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÛÙËÓ ·Ó·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ Î·È ÔÈ Û¯¤ÛÂȘ ÁÔÓ¤ˆÓ-·È‰ÈÒÓ Â›Ó·È ·ÓÒÙÂÚ˜ Û ۇÁÎÚÈÛË Ì ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› ˘ÈÔıÂÙË̤ÓÔ ‹ ·È‰› ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4,40). ™Â ·Ï·ÈfiÙÂÚË ÌÂϤÙË Â›¯Â ·Ó·ÊÂÚı› ·˘ÍË̤ÓÔ ÔÛÔÛÙfi Ó¢ÚÔÂÎÙÔ‰ÂÚÌÈÎÒÓ fiÁÎˆÓ Û ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (41). ¡ÂfiÙÂÚ˜ ÌÂϤ-
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Ù˜, ˆÛÙfiÛÔ, ‰ÂÓ ¤‰ÂÈÍ·Ó ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó¿Ù˘Í˘ ηÎÔ‹ıÂÈ·˜ Û ·˘Ù¿ Ù· ·È‰È¿, Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5,42). øÛÙfiÛÔ, ÂÂȉ‹ Ô Î·ÚΛÓÔ˜ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈÔ˜, ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ÙÂÎÌËÚÈˆÌ¤ÓˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜, ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·È‰ÈÒÓ (5,42). ™˘ÌÂÚ¿ÛÌ·Ù· ∂›ÎÔÛÈ ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÚÒÙË ÂÈÙ˘¯Ë̤ÓË Î‡ËÛË ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Î·È ·ÓËÛ˘¯›Â˜ ÁÈ· ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ÎÚ‡‚ÂÈ Ë ˘ÂÚΤڷÛË ÔÏÏÒÓ ÛÙ·‰›ˆÓ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘. ∫¿ı ¯ÚfiÓÔ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹ 50.000 ·È‰È¿ (37). ∞fi ·˘Ù¿, ¤Ó· Û¯ÂÙÈο ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (ÂÚ›Ô˘ 30%) ÁÂÓÓÈÔ‡ÓÙ·È ÚfiˆÚ· ‹ Ì ÌÈÎÚfi ‚¿ÚÔ˜ (ÂÚ›Ô˘ 27%) Û ۯ¤ÛË Ì 6,3% Î·È 4,6% ·ÓÙ›ÛÙÔȯ·, ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5). ∏ ÔÏÔ¤Ó· ¢ڇÙÂÚË ÂÊ·ÚÌÔÁ‹ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤¯ÂÈ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·‡ÍËÛË ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ÙˆÓ ÓÂÔÁÓÒÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘. ¶ÚfiÛÊ·ÙË ÌÂϤÙË ·Ô‰›‰ÂÈ ÙÔ 45% Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ οو ·fi 1250 g Î·È ÙÔ 50% Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Û ËÏÈΛ· ·ËÛ˘ οو ÙˆÓ 35 ‚‰ÔÌ¿‰ˆÓ ÛÙ· ÓÂÔÁÓ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (43). ∆Ô Î‡ÚÈÔ ·›ÙÈÔ ÁÈ· Ù· ‰˘ÛÌÂÓ¤ÛÙÂÚ· ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ Ô˘ ÊÙ¿ÓÔ˘Ó ÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (5,44). ¢È·ÊÔÚ¤˜ ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌËÙ¤ÚˆÓ Û˘Ì‚¿ÏÏÔ˘Ó, ›Û˘, ÛÙ· ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÚÔˆÚfiÙËÙ·˜ Î·È ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ (5). ∏ ·‡ÍËÛË ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Â›Ó·È È·ÙÚÔÁÂÓ‹˜ Î·È ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÛÙË ıÂڷ›· Ì ʷÚ̷΢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÚfiÎÏËÛ˘ ˆÔÚÚËÍ›·˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Â·Ó·ÙÔÔı¤ÙËÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ÂÌ‚Ú‡ˆÓ ÛÙË Ì‹ÙÚ·, Û ̛· ÚÔÛ¿ıÂÈ· ·‡ÍËÛ˘ ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈÙ˘¯›·˜ Ù˘ ÌÂıfi‰Ô˘. øÛÙfiÛÔ, ÔÏϤ˜ ÂÚÁ·Û›Â˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÂÌʇÙ¢ÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ‰‡Ô ÂÌ‚Ú‡ˆÓ ‰ÂÓ ·˘Í¿ÓÂÈ Ù· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜, ÂÓÒ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÙÚ›‰˘Ì˘ ·ËÛ˘ (22,45,46). ∞Ó¿Ï˘ÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi 44.000 ·ÎÏˆÓ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤‰ÂÈÍ fiÙÈ Ë ÌÂÙ·ÊÔÚ¿ ‰‡Ô ·ÓÙ› ÙÚÈÒÓ ÂÌ‚Ú‡ˆÓ ÌÂÈÒÓÂÈ ÙÔ ÔÛÔÛÙfi ÙÚ›‰˘Ì˘ ·ËÛ˘ ·fi 6% Û 0,4%, ¯ˆÚ›˜ ‰È·ÊÔÚ¿ ÛÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·ËÛ˘ (5). ªÂ ‚¿ÛË ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ ˘ÔÏÔÁ›ÛÙËΠfiÙÈ Ë ÛÙÚ·ÙËÁÈ΋ ÌÂÙ·ÊÔÚ¿˜ ‰‡Ô ÂÌ‚Ú‡ˆÓ ı· Ì›ˆÓ ÙËÓ Â›ÙˆÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ·fi 1,69% Û 0,89% (22,47). ™Â ÔÏϤ˜ ¯ÒÚ˜, Û‹ÌÂÚ·, ·ÊÔ‡ ¤ÁÈÓ·Ó Î·Ù·ÓÔËÙ¤˜ ÔÈ Û˘Ó¤ÂȘ Ù˘ ·‡ÍËÛ˘ ÙˆÓ
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Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Î·È ¤ÁÈÓ ·ÓÙÈÏËÙfi fiÙÈ Ë ÂÈÙ˘¯›· Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ‰ÂÓ ÎÚ›ÓÂÙ·È ÌfiÓÔ ·fi Ù· ÔÛÔÛÙ¿ ÂÈÙ˘¯Ô‡˜ ÂÁ΢ÌÔÛ‡Ó˘, ·ÏÏ¿ ΢ڛˆ˜ ·fi ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Ú¯ÔÓÙ·È ÛÙÔÓ ÎfiÛÌÔ, Û˘ÓÈÛÙ¿Ù·È Ë ÂÌ‚Ú˘ÔÌÂÙ·ÊÔÚ¿ ‰‡Ô ÙÔ Ôχ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ (5,44). ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ ÌÂıfi‰ˆÓ ηٿ„˘Í˘ Î·È Ê‡Ï·Í˘ ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ Î·È Ë Â›Ù¢ÍË ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ÙÚfiˆÓ ÂÈÏÔÁ‹˜ “ηϋ˜ ÔÈfiÙËÙ·˜” ‚ÈÒÛÈÌˆÓ ÂÌ‚Ú‡ˆÓ ı· ÂÈÙÚ¤„Ô˘Ó ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ÙËÓ Î·ıȤڈÛË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ·ӷÙÔÔı¤ÙËÛ˘ ÂÓfi˜ ÌfiÓÔ ÂÌ‚Ú‡Ô˘, Ô˘ ¯ˆÚ›˜ Ó· ÂËÚ¿ÛÂÈ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯Ô‡˜ ÂÁ΢ÌÔÛ‡Ó˘, ı· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (44). µÈ‚ÏÈÔÁÚ·Ê›· 1. Steptoe PC, Edwards RG. Birth after reimplantation of a human embryo [letter]. Lancet 1978;2:366. 2. ª·ÓÙ˙·‚›ÓÔ˜ £, ∫·Ó¿Î·˜ ¡. ∂͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î·È ÓÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹. ∂ÊË‚ °˘Ó ∞Ó· ∂ÌÌËÓ 1998;10:106-116. 3. Buitendijk SE. Children after in vitro fertilization. An overview of the literature. Int J Technol ∞ssess Health Care 1999;15:52-65. 4. Tarlatzis BC, Grimbizis G. Pregnancy and child outcome after assisted reproduction techniques. Hum Reprod 1999;14 (1 Suppl):231-244. 5. Bergh T, Ericson A, Hillensjo T, Nygren KG, Wennerholm UB. Deliveries and children born after in vitro fertilisation in Sweden 1982-95: a retrospective cohort study. Lancet 1999;354:1579-1582. 6. The ESHRE Capri Workshop Group. Multiple gestation and pregnancy. Hum Reprod 2000;15:1856-1864. 7. Revenis ME, Johnson LA. Multiple gestations. In: Avery GB, Fletcher MA, MacDonald MG, editors. Neonatology: Patholophysiology and Management of the Newborn. 4th ed. Philadelphia: JB Lippincott Co; 1994. p. 417-426. 8. Warner µB, Kiely JL, Donovan EF. Multiple births and outcome. Clin Perinatol 2000;27:347-361. 9. Kochenour NK. Obstetric management of multiple gestation. In: Fanaroff AA, Martin RJ, editors. NeonatalPerinatal Medicine: Diseases of the fetus and infant. 6th ed. St. Louis: Mosby-Year book Inc; 1997. p. 289-294. 10. D’Souza SW, Rivlin E, Cadman J, Richards B, Buck P, Lieberman BA. Children conceived by in vitro fertilization after fresh embryo transfer. Arch Dis Child 1997;76:F70F74. 11. Dhont M, De Sutter P, Ruyssinck G, Martens G, Bekaert A. Perinatal outcome of pregnancies after assisted reproduction: a case-control study. Am J Obstet Gynecol 1999;181:688-695. 12. Lancaster B, on behalf of Australian in vitro fertilization collaborative group. High incidence of preterm deliveries and early losses in pregnancy after in vitro fertilization. BMJ 1985;291:1160-1163. 13. Doyle P, Beral V, Maconochie N. Preterm delivery, low birth
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Hamberger L, Niklasson A, Nilsson L et al. Postnatal growth and health in children born after cryopreservation as embryos. Lancet 1998;351:1085-1090. Golombok S, Brewaeys A, Cook R, Giavazzi MT, Guerra D, Mantovani A et al. The European study of assisted reproduction families: family functioning and child development. Hum Reprod 1996:11:2324-2331. White L, Giri N, Vowels MR, Lancaster PA. Neuroectodermal tumours in children born after assisted conception. Lancet 1990;336:1577. Doyle P, Bunch KJ, Beral V, Draper GJ. Cancer incidence in children conceived with assisted reproduction technology. Lancet 1998;352:452-453. Tough SC, Greene CA, Svenson LW, Belik J. Effects of in vitro fertilization on low birth weight, preterm delivery, and multiple birth. J Pediatr 2000;136:618-622. Hazekamp J, Bergh C, Wennerholm UB, Hovatta O, Karlstrom PO, Selbing A. Avoiding multiple pregnancies in ART: consideration of new strategies. Hum Reprod 2000;15:1217-1219. Staessen C, Janssenswillen C, Van den Abbeel E, Devroey P, Van Steirteghem AC. Avoidance of triplet pregnancies by elective transfer of two good quality embryos. Hum Reprod 1993;8:1650-1653. Vauthier-Brouzes D, Lefebvre G, Lesourd S, Gonzales J, Darbois Y. How many embryos should be transferred in in vitro fertilization? A prospective randomized study. Fertil Steril 1994;62:339-342. Blickstein I, Weissman A. Estimating the risk of cerebral palsy after assisted conceptions. N Engl J Med 1999;341:1313-1314.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-04-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-09-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37, ∆.∫. 713 05, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
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AWARD-WINNING ARTICLE
ªÂϤÙË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (Multi Drug Resistance, MDR) ‰È¿ ÙÔ˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ÔÍ›· Ï¢¯·ÈÌ›· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜* ¶. ∆˙ÒÚÙ˙Ë1, ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘ - ∞Ó‰ÚÔ˘Ï·Î¿ÎË1, π. ¶. ¶·Ó·ÁÈÒÙÔ˘1, ∫. ∆Û›ÙÛÈη˜1, K. ™ÙÂÊ·Ó¿ÎË2, ™. ÷˚‰¿˜1
Evaluation of the immunocytochemical expression of P-170 in acute leukemias of childhood* P. Tzortzi1, S. Polychronopoulou - Androulakaki1, J. P. Panagiotou1, K. Tsitsikas1, K. Stefanaki2, S. Haidas1
¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂڷ›· ·ÔÙÂÏ› Ì›· ·fi ÙȘ ΢ÚÈfiÙÂÚ˜ ·Èٛ˜ ıÂڷ¢ÙÈ΋˜ ·ÔÙ˘¯›·˜ ÛÙ· ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ. ¶ÔÏÏÔ› Ì˯·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜, ·ÏÏ¿ Ô ÈÔ ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi˜ Î·È Î·Ï¿ ÌÂÏÂÙË̤ÓÔ˜ Â›Ó·È ·˘Ùfi˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘. ∆Ô ÁÔÓ›‰ÈÔ ·˘Ùfi Έ‰ÈÎÔÔÈ› Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÙËÓ ƒ-170, Ô˘ ‰Ú· ˆ˜ ·ÓÙÏ›·, ÌÂٷʤÚÔÓÙ·˜ ÙÔÓ Î¿ı ʷÚ̷΢ÙÈÎfi, ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ, ηٷÚÁÒÓÙ·˜ ¤ÙÛÈ ÙË ‚Ï·ÙÈ΋ ›‰Ú·ÛË Ù˘ ¯ËÌÂÈÔıÂڷ¢ÙÈ΋˜ Ô˘Û›·˜ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ. ∆ËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ ·ÎÔÏÔ‡ıËÛ·Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜, ΢ڛˆ˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ·Ó·˙ËÙ‹ıËΠηْ ÂÍÔ¯‹Ó ÛÙËÓ ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÂÓÒ Ôχ Ï›Á˜ ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ô˘ Â›Ó·È Î·È Ë ÂÈÎÚ·Ù¤ÛÙÂÚË ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶Ôχ ÏÈÁfiÙÂÚ˜ ·Ó·Ê¤ÚÔÓÙ·È Î·È ÛÙÔ˘˜ ‰‡Ô Ù‡Ô˘˜ Ï¢¯·ÈÌ›·˜ Û ‰È·ÊÔÚÂÙÈΤ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ (.¯. ‰È¿ÁÓˆÛË Î·È ˘ÔÙÚÔ‹). ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë ·ÔÙ‡ˆÛË Ù˘ ·ÚÔ˘Û›·˜ ‹ ÌË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô ∞ƒ∞∞ƒ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Î·È Ù˘ ÔÍ›·˜ ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ë ÚÔÁÓˆÛÙÈ΋ Ù˘ ı¤ÛË ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. ªÂÏÂÙ‹ıËηÓ
Abstract: The multidrug resistant (MDR) phenotype has been suggested as a major cause of treatment failure in hematologic malignancies. However, there is a complexity of MDR mechanisms. Perhaps the best understood mechanism of multidrug resistance involves that of the P-170 glycoprotein (P-gp), one membrane transporter protein which is responsible for transporting chemotoxic agents out of the malignant cells. Encoded by the MDR-1 gene, P-gp acts as an efflux pump, excreting chemotherapeutic agents from cells, before they can exert their cytotoxic effect. Several prospective studies have attempted to evaluate the clinical relevance of P-170 in childhood acute leukemia. In our study, P-170 expression was evaluated in 57 children with acute lymphoblastic leukemia (ALL) (49 on diagnosis and 8 on relapse) and in 13 children with acute non lymphoblastic leukemia (ANLL) (8 on diagnosis and 5 on relapse), diagnosed between 1 January 1996 and 31 July 1999. Bone marrow was examined immunocyto-chemically (APAAP technique) with three monoclonal antibodies of P-170 (JSB-1, C219 and MRK16). P-170 positive expression (P-170+) was found in 18/49 patients with ALL at initial diagnosis (36.7%) and in 5/8 patients at relapse (62.5%), while in patients with ANLL, P-170 positive expression was found in 5/8 at diagnosis (62.5%) and 2/5 at relapse (40%). In the ALL group with P170 positive at diagnosis complete remission (CR) was achieved in 16/18 (88.9%) patients, and 2/18 (11.1%) died, while in the ALL group with P-170
¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 1 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ 2 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ
“Agia Sophia” Children’s Hospital, Athens 1 Department of Pediatric Hematology-Oncology 2 Laboratory of Clinical Pathology
* µ’ ÈڤÌÂÈÔ Œ·ıÏÔ 38Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 2000
* 2nd “Choremeio” Award 38th Panhellenic Pediatric Meeting, 2000
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ÚÔÔÙÈο 57 ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Î·È 13 Ì ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (OM§§), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó ÛÙo ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1/1/1996 ¤ˆ˜ 31/7/1999 Î·È ÛÙ· ÔÔ›· ·ÎÔÏÔ˘ı‹ıËΠÔÌÔÈÔÁÂÓÒ˜ ÙÔ ·Ó¿ÏÔÁÔ Ì ÙÔ ÓfiÛËÌ· ıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ (ALL-BFM ’95 Î·È AML-BFM ’93) ÁÈ· ÙËÓ O§§ Î·È ÙËÓ Oª§§, ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ (57), ÔÈ 49 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË. ∞fi ·˘ÙÔ‡˜, 3 ˘ÔÙÚÔ›·Û·Ó Î·È Ì·˙› Ì ¿ÏÏÔ˘˜ 5 ·Ï·ÈfiÙÂÚÔ˘˜ ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ì O§§ Û ˘ÔÙÚÔ‹ (Û‡ÓÔÏÔ 8). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ì Oª§§ (13), 8 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË. ∞fi ·˘ÙÔ‡˜, 2 ˘ÔÙÚÔ›·Û·Ó Î·È Ì·˙› Ì ¿ÏÏÔ˘˜ 3 ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ì Oª§§ Û ˘ÔÙÚÔ‹ (Û‡ÓÔÏÔ 5). OÈ ‰È¿ÌÂÛÔÈ ¯ÚfiÓÔÈ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 24 Ì‹Ó˜ Î·È 18 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÁÈ· ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙËÓ ˘ÔÙÚÔ‹ ‹Ù·Ó 28,5 Ì‹Ó˜ Î·È 26 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ∂ȯڛÛÌ·Ù· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂÏÂÙ‹ıËÎ·Ó ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο (∞ƒ∞∞ƒ Ù¯ÓÈ΋) Ì ÙË ¯Ú‹ÛË ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ƒ-170 (JSB-1, C219 Î·È MRK16). ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÌÔÓ·‰È΋ ‚È‚ÏÈÔÁÚ·ÊÈο Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú·, Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÌË ·Ó›¯Ó¢Û˘ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ¯2 ÙÂÛÙ. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ, ıÂÙÈ΋ ¤ÎÊÚ·ÛË ÛÙËÓ ƒ-170 ·ÓȯÓ‡ıËΠ۠ÔÛÔÛÙfi 52,6%. ∂ÓÓ¤· ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ıÂÙÈÎfiÙËÙ· Î·È ÛÙ· ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·. ∆· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 86,6% ÁÈ· ÙÔ JSB1, 80% ÁÈ· ÙÔ C219 Î·È 63,3% ÁÈ· ÙÔ MRK16. ∂ȉÈÎfiÙÂÚ·, ÁÈ· ÙȘ ÂÈ̤ÚÔ˘˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ: ™Â 18/49 ·ÛıÂÓ›˜ (36,7%) Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Û 5/8 ·ÛıÂÓ›˜ (62,5%) ηٿ ÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ‚Ú¤ıËΠ۠5/8 (62,5%), ÂÓÒ ÛÙËÓ ˘ÔÙÚÔ‹ Û 2/5 (40%). ™Â Û¯¤ÛË Ì ÙËÓ ÔÚ›· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ: ·) ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ170 ηٿ ÙË ‰È¿ÁÓˆÛË (18), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠16/18 ·ÛıÂÓ›˜ (88,9%), ÂÓÒ 2/18 (11,1%) η٤ÏËÍ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹). ∞ÓÙ›ıÂÙ·, ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (31), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠27/31 ·ÛıÂÓ›˜ (87,1%), 1/31 (3,2%) ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹, ÂÓÒ 3/31 (9,7%) η٤ÏËÍ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô). ‚) ™ÙËÓ
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negative at diagnosis complete remission (CR) was achieved in 27/31 (87.1%) patients, 1/31 relapsed and 3/31 (9.7%) died. In the ALL group with P-170 positive at relapse complete remission (CR) was achieved in 2/5 (40%) patients, 1/5 (20%) relapsed and 2/5 (40%) died, while in the ALL group with P170 negative at relapse, complete remission (CR) was achieved in 3/3 (100%) patients. In the ANLL group with P-170 positive expression at diagnosis, complete remission was achieved in 3/5 (60%) patients, while 2/5 (40%) died, due to uncontrolled disease. In the ANLL group with P-170 negative at diagnosis 2/3 (66.6%) patients relapsed, and 1/3 (3.3%) died during the induction phase. In the ANLL group with P-170 positive expression at relapse complete remission was achieved in 2/2 (100%) patients, while in the ANLL group with P-170 negative at relapse 3/3 (100%) patients entered into complete remission. In the total population of our study, 30 out of 67 patients (52.6%) expressed the MDR protein. We found 26 (86.6%) cases positive for JSB-1, 24 (80%) for C219 and 19 (63.3%) for MRK16. Increased P-170 expression was more frequently found in patients with ALL at relapse than at initial diagnosis, while in patients with ANLL increased P-170 expression was found on both diagnosis and relapse. In the ALL group, P-170(+) at relapse was associated with a shorter remission rate (40%) and shorter median survival (40%) compared with P-170(-) expression (the percentages were 100% and 0% respectively). In the ANLL group, P-170 positive at diagnosis was associated with a shorter median survival (40%) compared with P-170 negative expression (33.3%). In our study the correlation between P-170 expression and age, WBC count, karyotype, sex and FAB morphology in childhood acute leukemia was not found statistically significant, perhaps due to the relatively small number of patients and the limited follow-up period. P-170 expression seems insufficient so far, to fully explain all patterns of resistance. However, determination of the P-gp status in the leukaemic blasts at diagnosis and relapse may be used as an additional prognostic factor.
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ÔÌ¿‰· Ù˘ Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (5), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠3/5 ·ÛıÂÓ›˜ (60%), ÂÓÒ ı¿Ó·ÙÔ˜ ‹Ïı Û 2/5 (40%) (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹). ™ÙËÓ ÔÌ¿‰· Ù˘ Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (3), 2/3 (66,6%) ·ÚÔ˘Û›·Û·Ó ˘ÔÙÚÔ‹, ÂÓÒ 1/3 (33,3%) η٤ÏËÍ (ÛÙËÓ ¤ÊÔ‰Ô). Á) ™ÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (5), 2/5 ·ÛıÂÓ›˜ (40%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· ‰È¿ÌÂÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜ 15 Ì‹Ó˜, 1/5 (20%) ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹, ÂÓÒ 2/5 ·ÛıÂÓ›˜ (40%) ·Â‚›ˆÛ·Ó. ∞ÓÙ›ıÂÙ·, ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (3), 3/3 (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 26, 30 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· Î·È Ù¤ÏÔ˜, ‰) ÛÙËÓ ÔÌ¿‰· Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (2), 2/2 ·ÛıÂÓ›˜ (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 20 Î·È 25 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ÔÌ¿‰· Ù˘ Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (3), 3/3 (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 20, 26 Î·È 38 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ™˘ÌÂÚ·ÛÌ·ÙÈο: ·) ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÂÊfiÛÔÓ Ù· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ¤Ó· ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷, ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈΤ˜ ·ÔÎÏ›ÛÂȘ ηٿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Û ıÂÙÈο ‰Â›ÁÌ·Ù·. ™ÙÔ ˘fi ÌÂϤÙË ˘ÏÈÎfi ‚Ú¤ıËΠfiÙÈ ÙÔ JSB-1 ¤¯ÂÈ Û¯ÂÙÈ΋ ‹ ·fiÏ˘ÙË ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ηı’ fiÛÔÓ ÙÔ ÔÛÔÛÙfi ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘ ‹Ù·Ó 86,6% ¤Ó·ÓÙÈ 80% ÙÔ˘ C219 Î·È 63,3% ÙÔ˘ MRK16. ‚) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Û ÔÛÔÛÙfi 36,7%, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËΠۯ‰fiÓ ‰ÈÏ¿ÛÈÔ (62,5%). Á) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ·Ú·ÙËÚ‹ıËΠ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Û ۯ¤ÛË Ì ÙËÓ O§§ (62,5%). ∫·Ù¿ ÙËÓ ˘ÔÙÚÔ‹, ·Ú·ÙËÚ‹ıËΠ›Û˘ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (40%). ‰) OÈ ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%). Â) OÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË (40%) Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜
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Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·). ¶·Ú’ fiÙÈ ‰È·Ê·›ÓÂÙ·È ÂÎ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÂϤÙ˘ Ë ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈ΋ ÛËÌ·Û›· Ô˘ ÂÓ¤¯ÂÈ Ë ·ÚÔ˘Û›· Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ O§§ Î·È Oª§§ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Èı·ÓfiÓ ÏfiÁˆ ÙÔ˘ ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜, ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô, ÙÔ Ê‡ÏÔ, ÙËÓ Î·Ù¿ FAB ÌÔÚÊÔÏÔÁ›·, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙÔÓ Î·Ú˘fiÙ˘Ô. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú· ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹, ·Ó Î·È ‰ÂÓ Â›Ó·È ÈηÓfi˜ Ó· ÂÚÌËÓ‡ÛÂÈ fiÏÔ˘˜ ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·ÚÌ·ÎÔ·ÓÙÔ¯‹˜, ˆÛÙfiÛÔ, ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ÂÈϤÔÓ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË Ù˘ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘. §¤ÍÂȘ ÎÏÂȉȿ: ÔÏÏ·Ï‹ Ê·ÚÌ·ÎÔ·ÓÙÔ¯‹, ƒ-ÁÏ˘ÎÔÚˆÙ½ÓË, ÔÍ›· Ï¢¯·ÈÌ›·, ·È‰È΋ ËÏÈΛ·, ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·, ∞ƒ∞∞ƒ.
Key words: MDR, P-glycoprotein, childhood, ALL, ANLL, immunocytochemistry, APAAP.
∂ÈÛ·ÁˆÁ‹ O ηÚΛÓÔ˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi, ·Ó Î·È Û¯ÂÙÈο Û¿ÓÈÔ ÓfiÛËÌ·, ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ·ÈÙ›· ı·Ó¿ÙÔ˘ ÌÂÙ¿ ·fi Ù· ·Ù˘¯‹Ì·Ù· (1). ∏ ÂÙ‹ÛÈ· ›وÛË ÙÔ˘ ηÚΛÓÔ˘ ÛÙȘ ËÏÈ˘ ¤ˆ˜ 5 ÂÙÒÓ ·Ó·Ê¤ÚÂÙ·È Û 150 Ӥ˜ ÂÚÈÙÒÛÂȘ, ÂÓÒ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (5-14 ÂÙÒÓ) Â›Ó·È 90-100 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 1.000.000 ·È‰È¿, ·ÓÙÈÛÙÔ›¯ˆ˜. ∞fi ÙÔ Û‡ÓÔÏÔ ·˘Ùfi, ÙÔ ¤Ó· ÙÚ›ÙÔ ÂÚ›Ô˘ ·ÊÔÚ¿ ÛÙȘ ÔÍ›˜ Ï¢¯·È̛˜ Î·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ÔÍ›˜ ÏÂÌÊÔ‚Ï·ÛÙÈΤ˜ (1-4). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÔÈ Ó¤Â˜ ÂÈÙ‡ÍÂȘ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛÔÏÔÁ›·˜, Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ù˘ ÁÂÓÂÙÈ΋˜ ‚Ô‹ıËÛ·Ó ·ÊÂÓfi˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ηÚÎÈÓÔÁ¤ÓÂÛ˘, ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Î·Ï‡ÙÂÚË Ù·ÍÈÓfiÌËÛË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·ÎÔËıÂÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (1). ™ËÌ·ÓÙÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÂÓfi˜ ηÎÔ‹ıÔ˘˜ ΢ÙÙ¿ÚÔ˘, Ô˘ ηٿ οÔÈÔ ÙÚfiÔ ÌÔÚÔ‡Ó Ó· ÚÔ‰ÈοÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘, ‰ËÏ·‰‹ ÙËÓ Èı·ÓfiÙËÙ· ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ó· ·ÓÙ·ÔÎÚÈı› ÈηÓÔÔÈËÙÈο ÛÙË ıÂڷ›· Î·È Ó· ·Ú·Ì›ÓÂÈ ÛÂ Û˘Ó¯‹ Ï‹ÚË ‡ÊÂÛË ‹ fi¯È, ›ӷÈ: ·) Ô Ú˘ıÌfi˜ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘, ‚) Ë ‰˘Ó·ÙfiÙËÙ· Î·È Ë Ù·¯‡ÙËÙ· ‰È·ÛÔÚ¿˜ ÙÔ˘, Á) Ë ·˘ÍË̤ÓË ‹ ÂÏ·Ùو̤ÓË ·Ú¯È΋ ·ÓÙ·fiÎÚÈÛ‹ ÙÔ˘ ÛÙ· ¯ÔÚËÁÔ‡ÌÂÓ· ¯ËÌÂÈÔıÂڷ¢ÙÈο Î·È ‰) Ë ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÛÙ· Ê¿Ú̷η ·˘Ù¿ ηٿ ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ (5). ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·È‰ÈÒÓ Ì ηÚΛÓÔ
¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ·. OÈ Ï¢¯·È̛˜, ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Î·È ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋, ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 ·fi ÂÈ‚›ˆÛË Ù˘ Ù¿Í˘ ÙÔ˘ 70% Î·È 50% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÚÈÓ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ÔÈ ÙÈ̤˜ ·˘Ù¤˜ ‹Ù·Ó ÛÙ·ıÂÚ¿ οو ÙÔ˘ 10% (2). ™‹ÌÂÚ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ 2 ÛÙ· 3 ·È‰È¿ Ì ηÎfiËı˜ ÓÂfiÏ·ÛÌ· ı· Ù‡¯Ô˘Ó Ì·ÎÚ¿˜ ÂÈ‚›ˆÛ˘ ÂχıÂÚ˘ ÓfiÛÔ˘, ÂÓÒ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÌÈÛ¿ ı· ıÂڷ¢ıÔ‡Ó. £ÂˆÚÂ›Ù·È fiÙÈ ÙÔÓ 21Ô ·ÈÒÓ· ÌÂٷ͇ ÙˆÓ ÂÓËÏ›ÎˆÓ ËÏÈΛ·˜ 20-29 ÂÙÒÓ, 1/1000 ı· ¤¯ÂÈ ıÂڷ¢ı› ·fi οÔÈ· ηÎÔ‹ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (4). ¶·Ú¿ ÙË ÌÂÁ¿ÏË ÚfiÔ‰Ô fï˜ Ô˘ ¤¯ÂÈ ÛËÌÂȈı› ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙË ıÂڷ›· ÙˆÓ ·È‰ÈÒÓ Ì Ï¢¯·ÈÌ›·, ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·˘ÙÒÓ Û˘Ó¯›˙ÂÈ Ó· ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ·fi ÙËÓ ·Ú¯È΋ ÂÈÛ·ÁˆÁ‹ Û ‡ÊÂÛË. ∞˘Ùfi Û ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·Ô‰›‰ÂÙ·È ÛÙËÓ ÂÁÁÂÓ‹ ‹ ›ÎÙËÙË ·ÓÙÔ¯‹ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú· ÛÙÔ˘˜ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ·ÎfiÌ· Î·È ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜, ÔfiÙ ¤¯Ô˘Ì ÎÏÈÓÈ΋ ÂÍ·Ê¿ÓÈÛË Ù˘ ÓfiÛÔ˘, ıˆÚËÙÈο, ·Ú·Ì¤ÓÂÈ ¤Ó·˜ ·ÚÈıÌfi˜ ηÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ, Ô˘ ·ÔÙÂÏ› ÙËÓ ÂÔÓÔÌ·˙fiÌÂÓË ÂÏ¿¯ÈÛÙË ˘ÔÏÂÈÌÌ·ÙÈ΋ ÓfiÛÔ (minimal residual disease, MRD), Ù· ÔÔ›· ÏfiÁˆ ·ÓÙÔ¯‹˜ ÛÙË ıÂڷ›·, ÂÈ‚ÈÒÓÔ˘Ó Î·È Â˘ı‡ÓÔÓÙ·È ÙÂÏÈο ÁÈ· ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (5). ∏ ·Ó¿Ù˘ÍË Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ‰ÚÔ˘Ó ÌÂÌÔӈ̤ӷ
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‹ ÛÂ Û˘Ó‰˘·ÛÌfi (1). ∂ÓÔ¯ÔÔÈËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ıˆÚÔ‡ÓÙ·È: ·) Ë ‰˘Ó·ÙfiÙËÙ· in vivo “·fiÎÚ˘„˘” ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ÂÚÈÔ¯¤˜-“ÎÚËÛʇÁÂÙ·” ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ·fi fiÔ˘ ‰È·Ê‡ÁÔ˘Ó ÙˆÓ ˘„ËÏÒÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÙˆÓ ¯ÔÚËÁÔ˘Ì¤ÓˆÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (.¯. Ô ÂÁΤʷÏÔ˜ Î·È Ô ÓˆÙÈ·›Ô˜ Ì˘ÂÏfi˜ Ì ÙȘ ÂÚÈ‚¿ÏÏÔ˘Û˜ Ì‹ÓÈÁÁ˜ ·ÔÙÂÏÔ‡Ó ÎÏ·ÛÈο ·Ú·‰Â›ÁÌ·Ù· “Î·Ù·Ê˘Á›Ô˘” ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÏfiÁˆ ÙÔ˘ ˘¿Ú¯ÔÓÙÔ˜ ·ÈÌ·ÙÔÂÁÎÂÊ·ÏÈÎÔ‡ ÊÚ·ÁÌÔ‡, ÙÔÓ ÔÔ›Ô ‰È·ÂÚÓÔ‡Ó Ù· ¯ËÌÂÈÔıÂڷ¢ÙÈο Ê¿Ú̷η ÌfiÓÔ Û Ôχ ˘„ËϤ˜ ‰fiÛÂȘ). ‚) ÙÔ Ì¤ÁÂıÔ˜ Ù˘ Ï¢¯·ÈÌÈ΋˜ Ì¿˙·˜ (ÌÂÁ¿ÏË Ï¢¯·ÈÌÈ΋ Ì¿˙· ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ›ÎÙËÙ˘ ·Ó¿Ù˘Í˘ ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜). Á) Ë ·ÚÔ˘Û›· ÂÓ‰ÔÁÂÓÔ‡˜ ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (multi drug resistance, MDR). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÔÈ ÌÂÁ¿Ï˜ Ï¢¯·ÈÌÈΤ˜ Ì¿˙˜ ÂÚȤ¯Ô˘Ó ·ÙÙ·Ú· ‹‰Ë ·ÓıÂÎÙÈο Û ÔÌ¿‰Â˜ ΢ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ì¿ÏÈÛÙ· ÛÂ Û˘¯ÓfiÙËÙ· 1/1.000.000 ·ÙÙ·Ú· (de novo Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹, ıˆڛ· ÙˆÓ Goldie-Goldman). ‰) Ë ·Ó¿Ù˘ÍË ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ οو ·fi ÙËÓ ›ÂÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Î˘ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ (›ÎÙËÙË Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹), ÁÂÁÔÓfi˜ Ô˘ ηıÔÚ›˙ÂÙ·È Î·È ·fi ȉÈÔÛ˘ÛÙ·ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ (6). ∆· ηÎÔ‹ıË Î‡ÙÙ·Ú· ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ó· ·Ó·Ù‡ÛÛÔ˘Ó Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ·Ú·Î¿ÌÙÔ˘Ó ÙËÓ ÙÔÍÈ΋ ÁÈ· ·˘Ù¿ ‰Ú¿ÛË Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ ̤ۈ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ‹ ÙÚÔÔÔ›ËÛ˘ Ù˘ ‰Ú¿Û˘ Ì›·˜ ÛÂÈÚ¿˜ ÁÔÓȉ›ˆÓ (6-9). OÈ ÈÔ ÁÓˆÛÙ¤˜ Ô‰Ô› ·Ó¿Ù˘Í˘ ·fi Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú· Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙ· ¯ËÌÂÈÔıÂڷ¢ÙÈο ›ӷÈ: ·) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘, Ô˘ Ô‰ËÁ› ÛÙËÓ ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ì›·˜ ÁÏ˘ÎÔÚˆÙ½Ó˘, Ù˘ ƒ-170, Ô˘ ‰ÚÒÓÙ·˜ ˆ˜ ·ÓÙÏ›· ÌÂٷʤÚÂÈ ÙÔ Ê¿ÚÌ·ÎÔ ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηٷÚÁÂ›Ù·È Ë ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ. ‚) OÈ ÌÂÙ·‚ÔϤ˜ ÛÙËÓ ·fiÙˆÛË, ‰ËÏ·‰‹ ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ Î˘ÙÙ·ÚÈÎfi ı¿Ó·ÙÔ (˘ÂÚ¤ÎÊÚ·ÛË ‹ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ƒ-53 ‹ ÙÔ˘ µcl-2 ÁÔÓȉ›Ô˘). Á) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ‹ Ë ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ MRP ÁÔÓȉ›Ô˘, Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ 10q24 ¯ÚˆÌfiۈ̷, Ì ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ MRP ÚˆÙ½Ó˘ (multidrug resistance associated protein), Ë ÔÔ›· ÌÂٷʤÚÂÈ Ì›· ÌÂÁ¿ÏË ÔÈÎÈÏ›· ÚÔ˚fiÓÙˆÓ, fiˆ˜ ÏÈÔÊÈÏÈο ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈο Ê¿Ú̷η Ô˘ ‰ÚÔ˘Ó Ì¤Ûˆ ATP-ÂÍ·ÚÙÒÌÂÓˆÓ Ì˯·ÓÈÛÌÒÓ.
Paediatriki 2003;66:65-81
‰) OÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘-S-ÙÚ·ÓÛÊÂÚ¿Û˘, ΢ڛˆ˜ ˘fi ÙËÓ ¤ÓÓÔÈ· Ù˘ ·‡ÍËÛ˘ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ¿˜ Ù˘. ∆· ·˘ÍË̤ӷ ΢ÙÙ·ÚÈο ›‰· ÁÏÔ˘Ù·ıÂÈfiÓ˘ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ·Ô‰fiÌËÛË ÙˆÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ·fi Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú·. Â) ∏ ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÙÔÔ˚ÛÔÌÂÚ¿Û˘ ππ, Ì ·ÔÙ¤ÏÂÛÌ· ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÛÙfi¯ˆÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔÓ ˘Ú‹Ó·. ÛÙ) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ LRP ÁÔÓȉ›Ô˘, Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ 16p42 ¯ÚˆÌfiۈ̷, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ LRP ÚˆÙ½Ó˘ (LRP - lung resistance related protein), Ë ÔÔ›· ‚Ú›ÛÎÂÙ·È ÛÙÔ˘˜ fiÚÔ˘˜ Ù˘ ˘ÚËÓÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È ÂËÚ¿˙ÂÈ ÙËÓ ˘ÚËÓÈ΋ Û˘ÁΤÓÙÚˆÛË ÙˆÓ Ê·Ú̿ΈÓ. ∂ȉÈÎfiÙÂÚ·, Ë ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (MDR-1) Â›Ó·È Ô ÈÔ ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi˜ Î·È ÈÔ Î·Ï¿ ÌÂÏÂÙË̤ÓÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (MDR). ∆Ô MDR-1 ÁÔÓ›‰ÈÔ ‚Ú›ÛÎÂÙ·È ÛÙÔ Ì·ÎÚ‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 7. ∞ӷχÛÂȘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÙÔ˘ ·ÓıÚÒÔ˘ ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô ÁÔÓ›‰È·, Ù· MDR-1 Î·È MDR-2, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÛÙÂÓ¿ Î·È Îˆ‰ÈÎÔÔÈÔ‡Ó ÔÌfiÏÔÁ˜ ÌÂÌ‚Ú·ÓÈΤ˜ ÚˆÙ½Ó˜. ∞Ó Î·È Ù· ‰‡Ô ÔÓÔÌ¿˙ÔÓÙ·È MDR ÁÔÓ›‰È· ÏfiÁˆ ÙˆÓ ‰ÔÌÈÎÒÓ ÙÔ˘˜ ÔÌÔÈÔًوÓ, ˆÛÙfiÛÔ, ÌfiÓÔ ÙÔ MDR-1 ¤¯ÂÈ Û˘Ó‰Âı› ̤¯ÚÈ Û‹ÌÂÚ· Ì ÙËÓ ÔÏÏ·Ï‹ Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹. ∏ ‰Ú¿ÛË Ù˘ ÚˆÙ½Ó˘ ÙÔ˘ MDR2 ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, fï˜ ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ MDR (6,7,10). ∆Ô MDR-1 ÁÔÓ›‰ÈÔ Îˆ‰ÈÎÔÔÈ›, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, ÙËÓ ƒ-170, Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 170.000 dalton, Ô˘ ÂÚÈÁÚ¿ÊËΠÙÔ 1976 ·fi ÙÔ˘˜ Juliano Î·È Ling (6,7). ∆Ô ·Ú¯ÈÎfi ƒ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ·ÁÁÏÈ΋ ϤÍË permeability, Ô˘ ÛËÌ·›ÓÂÈ ‰È·ÂÚ·ÙfiÙËÙ·, ÁÈ·Ù› Ë ƒ-170 ‰Ú· ˆ˜ ·ÓÙÏ›·, ÌÂٷʤÚÔÓÙ·˜ ÙÔ Ê¿ÚÌ·ÎÔ ‹ ÔÔÈÔÓ‰‹ÔÙ ¿ÏÏÔ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ. OÈ FÔgÔ Î·È Û˘Ó (6) ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÁÔÓ›‰ÈÔ MDR1 ÂÎÊÚ¿˙ÂÙ·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ·ÙÙ·Ú· ÂÈÓÂÊÚȉ›ˆÓ, ÓÂÊÚÒÓ, ‹·ÙÔ˜, ¯ÔÏËÊfiÚˆÓ ·ÁÁ›ˆÓ, ÂÓÙ¤ÚÔ˘, Ï·ÎÔ‡ÓÙ·, ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ·ÈÌÔÔÈËÙÈÎÒÓ ·Ú¯¤ÁÔÓˆÓ Î˘ÙÙ¿ÚˆÓ. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ Û ÔÏÏ¿ ¿ÏÏ· fiÚÁ·Ó· Â›Ó·È ¯·ÌËÏfiÙÂÚË ‹ ·Ó‡·ÚÎÙË. ∏ ƒ-170 ‚Ú›ÛÎÂÙ·È ÛÙË ÌÂÌ‚Ú¿ÓË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÏÂÈÙÔ˘ÚÁ› Û·Ó ·ÓÙÏ›·, Ô˘ ÚÔÛٷهÂÈ Ù· ·ÙÙ·Ú· ·fi ‰È¿ÊÔÚ˜ ÙÔÍÈΤ˜ Ô˘Û›Â˜, .¯. Ê¿Ú̷η, ÚÔ˚fiÓÙ· ·ÏηÏÔÂȉÒÓ Î.¿. ™Ù· Ê˘ÛÈÔÏÔÁÈο ÂÈÓÂÊÚ›‰È· ‚Ú›ÛÎÂÙ·È ÛÙȘ ΢ÙÙ·ÚÈΤ˜
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ÌÂÌ‚Ú¿Ó˜ Î·È ‰Ú· Û·Ó ÂÓ‰Ô΢ÙÙ·ÚÈÎfi˜ ÌÂÙ·ÊÔÚ¤·˜ ÁÈ· ÂȉÈο ÚÔ˚fiÓÙ·, .¯. ÛÙÂÚÔÂȉ‹. ∂›Û˘, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË MDR ÁÔÓȉ›ˆÓ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÁ΢ÌÔÛ‡ÓË. O Ê˘ÛÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ Ù˘ ÁÏ˘ÎÔÚˆÙ½Ó˘ ƒ-170 ÂÓÙ›ÓÂÙ·È Û ·ÙÙ·Ú· ÔÚÁ¿ÓˆÓ Ì ÂÓ‰ÔÎÚÈÓ‹ Î·È Â͈ÎÚÈÓ‹ ÌÔ›Ú·, .¯. ¯ÔÏ‹, ÂÁÁ‡˜ ÛˆÏËÓ¿ÚÈ· ÓÂÊÚÒÓ, ÂÈÓÂÊÚ›‰È· Î.¿. ∆¤ÏÔ˜, ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ ƒ-170 ·ÓȯÓ‡ÔÓÙ·È ÛÙ· 2/3 ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (µ Î·È ∆) Î·È ÌÔÓÔ΢ÙÙ¿ÚˆÓ Î·È ÂÚ›Ô˘ ÛÙÔ 1/3 ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (10). ™Â ÌÂÙ·ÏÏ¿ÍÂȘ ‹ Û ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ, Ë ·Ú·ÁˆÁ‹ Ù˘ ƒ-170 ÚˆÙ½Ó˘ ·˘Í¿ÓÂÙ·È. ∂Ô̤ӈ˜, ÛÙȘ ÂÚÈÙÒÛÂȘ ηÎÔËıÂÈÒÓ, Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ170 Èı·Ó¿ ÈÛ¯˘ÚÔÔÈ› Ù· ·ÙÙ·Ú· ¤Ó·ÓÙÈ Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ (ê£), ÚÔÛ‰›‰ÂÈ ÌÂÁ·Ï‡ÙÂÚË ·ÓÙÔ¯‹ ÛÙ· ¯ËÌÂÈÔıÂڷ¢ÙÈο Ê¿Ú̷η Î·È ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ ·Ú·ÙËÚÂ›Ù·È fi¯È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ʿÚ̷η Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜, ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ÌË Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÂÙÚ·¯ÏˆÚ›‰ÈÔ ÙÔ˘ ¿Óıڷη, ÌÂÙ¿ ·fi
Paediatriki 2003;66:65-81
ËÏÂÎÙÚÔÛfiÎ ‹ ›‰Ú·ÛË ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡ stress (10-13). ∞fi ÔÏϤ˜ ‰ÈÂıÓ›˜ ÌÂϤÙ˜ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Ë ·Ó¿Ù˘ÍË, ̤ۈ ‚ÈÔ¯ËÌÈÎÒÓ Ì˯·ÓÈÛÌÒÓ, ·ÓÙ›ÛÙ·Û˘ ‹ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›ÛÙ·Û˘ ÙˆÓ Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ΢ÙÙ·ÚÔÛÙ·ÙÈο Ê¿Ú̷η, fiˆ˜ .¯. ÛÙ· ·ÏηÏÔÂȉ‹ ·Ú¿ÁˆÁ· Ù˘ Vinca Rosea ‹ ÛÙ· ·Ú¿ÁˆÁ· Ù˘ ÂÈÔ‰ÔÊ˘ÏÏÔÙÔ͛Ӣ. ∆· ΢ÙÙ·ÚÔÛÙ·ÙÈο ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÌÂٷ͇ ÙˆÓ ‚·ÛÈÎÒÓ ·ÓÙÈÏ¢¯·ÈÌÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ë ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÚÔ˜ ·˘Ù¿ ıˆÚÂ›Ù·È ˆ˜ ‚·ÛÈ΋ ·ÈÙ›· ˘ÔÙÚÔ‹˜, ÂȉÈÎfiÙÂÚ· ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ Î·ÎÔËıÂÈÒÓ (13,14). ªÂ ‚¿ÛË ÏÔÈfiÓ ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ MDR, Ù· ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈο Ê¿Ú̷η ¤¯Ô˘Ó ¯ˆÚÈÛÙ› Û ‰‡Ô ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Û¯ÂÙ›˙ÔÓÙ·È ‹ fi¯È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜. ™˘ÁÎÂÎÚÈ̤ӷ: ·) ™Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Ê¿Ú̷η (˘‰ÚfiÊÔ‚·) ÂÓÙ¿ÛÛÔÓÙ·È ÔÈ ·Óıڷ΢ÎϛӘ, Ù· ·ÏηÏÔÂȉ‹ Ù˘ Vinca, ÔÈ ÂÈÔ‰ÔÊ˘ÏÏÔÙÔ͛Ә Î·È ÔÈ Ù·Í¿Ó˜. ‚) ™Ù· ÌË Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Ê¿Ú̷η (˘‰ÚfiÊÈÏ·) ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜,
∂ÈÎfiÓ· 1·. ∞ÏÁfiÚÈıÌÔ˜ 49 ·ÛıÂÓÒÓ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È 8 ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹.
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ÔÈ ·ÓÙÈÌÂÙ·‚Ôϛ٘, Ù· ·Ú¿ÁˆÁ· Ï·Ù›Ó·˜ Î·È Ë ÚÔηڂ·˙›ÓË (14). ∏ ¤Ú¢ӷ Û‹ÌÂÚ·, ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο, Û˘Ó¯›˙ÂÙ·È ÂÓÙ·ÙÈο, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌ‹ÛÂÈ ÙȘ Û˘Ó¤ÂȘ ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ Ù˘ ƒ-170 Û ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ηÎÔ‹ıˆÓ ÓÔÛËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÓËϛΈÓ. °È· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ, ÔÈ Ôԛ˜ ÌÂÙÚÔ‡Ó Â›Ù ÙËÓ ¤ÎÊÚ·ÛË ÙˆÓ ÁÔÓȉ›ˆÓ MDR (ÔÈÔÙÈÎfi˜ ¤ÏÂÁ¯Ô˜) ‹ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ (ÔÛÔÙÈÎfi˜ ¤ÏÂÁ¯Ô˜) (9,11,13, 14). ∆¤ÙÔȘ ̤ıÔ‰ÔÈ Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜: i) ∏ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ ÁÔÓȉ›ˆÓ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÂ Â›Â‰Ô RNA (Northern blot, RT-PCR) Î·È Ô In situ ˘‚ÚȉÈÛÌfi˜. OÈ Ì¤ıÔ‰ÔÈ ·˘Ù¤˜, ·Ú’ fiÙÈ Â›Ó·È Â˘·›ÛıËÙ˜, ‰ÂÓ ·ÓȯÓÂ‡Ô˘Ó ÙË ‰˘ÓËÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ›Ûˆ˜ ÂËÚ¿˙ÔÓÙ·È ·fi ·Ó¿ÌÂÈÍË ÌË Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ ÛÙÔÓ ˘fi ¤ÏÂÁ¯Ô Ï¢¯·ÈÌÈÎfi ÏËı˘ÛÌfi. ii) §ÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜. OÈ ‰ÔÎÈ̷ۛ˜ ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙË Ì¤ÙÚËÛË Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‹ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÔÚÈÛÌ¤ÓˆÓ ÂÓ˙‡ÌˆÓ ‹, Ù¤ÏÔ˜, ÛÙË ‰Ú¿ÛË ÔÚÈÛÌ¤ÓˆÓ Ô˘ÛÈÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÙÚÔÔÔÈËÙ¤˜ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜. ∂›Û˘, Ë Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Ì ÙË ¯Ú‹ÛË ÊıÔÚȈ̤Ó˘ ¯ÚˆÛÙÈ΋˜ (dye rhodamine 123) ¯ÚË-
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ÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·Ú·ÁfiÓÙˆÓ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ( ƒ-170, MRP). £· Ú¤ÂÈ Â‰Ò Ó· ÙÔÓÈÛÙ› fiÙÈ ÔÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Û˘¯Ó¿ ÌÂÙÚÔ‡Ó ÙÔ ·ÔÙ¤ÏÂÛÌ· ÔÏÏ·ÏÒÓ Ì˯·ÓÈÛÌÒÓ ·Ó¿Ù˘Í˘ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ MDR ÙˆÓ Î˘ÙÙ¿ÚˆÓ (.¯. Ë rhodamine 123 ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ÌÂÙ·ÊÂÚfiÌÂÓË ·fi ‰‡Ô ÚˆÙ½Ó˜, ÙËÓ ƒ-170 Î·È ÙËÓ MRP) Î·È fi¯È ÌÂÌÔӈ̤ӷ. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË, ·ÓÙ›ıÂÙ·, ÔÈ Ì¤ıÔ‰ÔÈ ·Ó›¯Ó¢Û˘ ÚˆÙÂ˚ÓÒÓ Ì¤Ûˆ Ù˘ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜ Â›Ó·È ·ÏÔ‡ÛÙÂÚ˜, ¢ÎÔÏfiÙÂÚ˜ Î·È Ù·¯‡ÙÂÚ˜. °È’ ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂÈϤ¯ıËÎÂ Ë ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›· ˆ˜ ̤ıÔ‰Ô˜ ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË Ù˘ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙ· Ï¢¯·ÈÌÈο ·ÙÙ·Ú·. iii) ∏ ·Ó›¯Ó¢ÛË ÙˆÓ ·Ú·ÁfiÌÂÓˆÓ ÚˆÙÂ˚ÓÒÓ Û ÌÔÚÈ·Îfi Â›Â‰Ô (Western blot). °È· ÙȘ ÌÂıfi‰Ô˘˜ ·˘Ù¤˜ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Ìʈӛ· ÁÈ· ÙÔ ÔÈÔ Â›Â‰Ô ıÂÙÈÎfiÙËÙ·˜ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ MDR Ê·ÈÓfiÙ˘Ô˘. ™Â Â›Â‰Ô ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜, Ù· ·ÔÙÂϤÛÌ·Ù· ÂÍ·ÚÙÒÓÙ·È ·fi: ·) ÙÔ Â›‰Ô˜ ÙÔ˘ ·ÓÙÈÛÒÌ·ÙÔ˜, ‚) ÙË ‰È·‰Èηۛ· ÌÔÓÈÌÔÔ›ËÛ˘ Î·È Á) Ù· ›‰· ıÂÙÈ΋˜ ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ. ™‹ÌÂÚ·, ¤¯Ô˘Ì ÛÙË ‰È¿ıÂÛ‹ Ì·˜ ‰È¿ÊÔÚ· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÚˆÙÂ˚ÓÒÓ Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜. ∂ȉÈÎfiÙÂÚ· ÁÈ· ÙËÓ Ï¤ÔÓ ÁÓˆÛÙ‹ ÚˆÙ½ÓË, ÙËÓ ƒ-170, ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ÂÈ̤ÚÔ˘˜ ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·
∂ÈÎfiÓ· 1‚. ∞ÏÁfiÚÈıÌÔ˜ 8 ·ÛıÂÓÒÓ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È 5 ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹.
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¶›Ó·Î·˜ 1. ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂϤÁ¯ıËÎ·Ó Û ·È‰È¿ Ì O§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘
º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÛÙÔ ·›Ì· ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB
∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË
ŒÎÊÚ·ÛË Ù˘ P-170
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË ≤100 x 109/L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ / (Common) T-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ∞¤Ù˘¯·Ó ¢ÂÓ ¤ÁÈÓ £ÂÙÈ΋ ∞ÚÓËÙÈ΋
Ô˘ ÙËÓ ·ÓȯÓ‡ԢÓ. ∞fi ·˘Ù¿, ¿ÏÏ· ·ÓȯÓÂ‡Ô˘Ó ÂÈÊ·ÓÂÈ·ÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘, fiˆ˜ Ù· ªR∫16, ªR∫-17, VIC2, 4E2 (Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· ¤¯Ô˘Ó ÌÂÁ¿ÏË ÂȉÈÎfiÙËÙ·), ÂÓÒ ¿ÏÏ· ·ÓȯÓÂ‡Ô˘Ó Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘, fiˆ˜ ÙÔ JSB-1 (¤¯ÂÈ ÌÂÁ¿ÏË ÂȉÈÎfiÙËÙ·), ÙÔ C219 Î·È ÙÔ C494 (12,15). °È· ÙËÓ ·‡ÍËÛË Ù˘ ¢·ÈÛıËÛ›·˜ Î·È Ù˘ ÂȉÈÎfiÙËÙ·˜ Ù˘ ÌÂıfi‰Ô˘ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·ÓÙÈÛÒÌ·Ù· Ô˘ ·Ó·ÁÓˆÚ›˙Ô˘Ó ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘ ƒ-170 ÚˆÙ½Ó˘. ∆· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· JSB-1, C219 Î·È MPK16 Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂٷ͇ ÙˆÓ ÂÈÎÚ·Ù¤ÛÙÂÚˆÓ ÁÈ· ÙËÓ ·Ó›¯ÓÂ˘Û‹ Ù˘ (16-18). ∆Ô ÚÒÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ô˘ ÌÂÏÂÙ‹ıËΠ‹Ù·Ó ÙÔ C219, ¤Ó· IgG-2a ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ Î˘ÙÙ¿ÚˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙË doxorubicine, ‚ÈÓÎÚÈÛÙ›ÓË Î.¿. ∞Ó·ÁÓˆÚ›˙ÂÈ ¤Ó· ÌÈÎÚfi ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Â›ÙÔÔ ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∞ÓÙȉڿ Î·È Ì ٷ ‰‡Ô ÚˆÙÂ˚ÓÈο ·Ú¿ÁˆÁ· MDR-1 Î·È MDR-2, ¯ˆÚ›˜ Ó· Â›Ó·È ÂȉÈÎfi ÁÈ· οÔÈÔ ·fi Ù· ‰‡Ô. ∆Ô ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ JSB-1 Â›Ó·È ¤Ó· IgG-1 ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ ·ÓıÂÎÙÈÎÒÓ ÛÙËÓ ÎÔϯÈΛÓË Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·ÁÓˆÚ›˙ÂÈ ¤Ó· ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Â›ÙÔÔ Ù˘ ƒ-170, ÙfiÛÔ Û ·ÓıÚÒÈÓ· ·ÙÙ·Ú·, fiÛÔ Î·È Û ηÎÔ‹ıË Î‡ÙÙ·Ú· ÂÈÚ·Ì·Ùfi˙ˆˆÓ. OÈ Tsuruo Î·È Û˘Ó ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÛÙË ÌÂϤÙË ÙÔ˘˜ ÙÔ ªP∫16, ·ÓıÚÒÈÓÔ ÂȉÈÎfi ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ì ÌÂÁ¿ÏË ¯ËÌÈ΋ Û˘ÁÁ¤ÓÂÈ· ÁÈ· ÙÔ MDR1 (16). ∂›Ó·È ¤Ó· ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·-
72
O§§ ‰È¿ÁÓˆÛË
O§§ ˘ÔÙÚÔ‹
29 (59,1%) 20 (40,8%) 31 (63,3%) 18 (36,7%) 37 (75,5%) 12 (24,5%) 46 (93,8%) 3 (6,2%) 44 (89,8%) 5 (10,2%) 35 (71,4%) 12 (24,5%) 2 (4,1%) 44 (89,8%) / (35) (71,5%) 5 (10,2%) 18 (36,7%) 4 (8,1%) 3 (6,2%) 9 (18,4%) 15 (30,6%) 18 (36,7%) 39 (63,3%)
6 (75%) 2 (25%) 0 (0%) 8 (100%) 6 (75%) 2 (25%) 8 (100%) 0 (0%) 7 (87,5%) 1 (12,5%) 6 (75%) 2 (25%) 0 (0%) 7 (87,5%) / (6) (75%) 1 (12,5%) 2 (25%) 2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 5 (62,5%) 3 (37,5%)
ÓÙÈ ·ÓıÂÎÙÈÎÒÓ Û doxorubicine ·ÓıÚÒÈÓˆÓ Ï¢¯·ÈÌÈÎÒÓ Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·ÁÓˆÚ›˙ÂÈ ¤Ó·Ó Â͈ÙÂÚÈÎfi ÂÈÊ·ÓÂÈ·Îfi ›ÙÔÔ. ∞ÓÙ›ıÂÙ· Ì ÙÔ C219, ‰ÂÓ ·ÓÙȉڿ Ì ÙÔ ÚˆÙÂ˚ÓÈÎfi ·Ú¿ÁˆÁÔ ÙÔ˘ MDR-2. ™ÎÔfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ: ·) Ë ·Ó·˙‹ÙËÛË Ù˘¯fiÓ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂڷ›·, ̤ۈ Ù˘ ·Ó‡ÚÂÛ˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ÚˆÙ½Ó˘ ƒ-170 Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜ Û ÛÂÈÚ¿ Ó¤ˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙË Ê¿ÛË Ù˘ ·Ú¯È΋˜ ‰È¿ÁÓˆÛ˘ ‹ Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ Î·È ‚) Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÛÙË ¯ËÌÂÈÔıÂڷ›· Î·È ÙËÓ ¤Î‚·ÛË ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ÚÔÔÙÈ΋˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 67 ·ÛıÂÓ›˜ Ì ÔÍ›· Ï¢¯·ÈÌ›·, 38 ·ÁfiÚÈ· Î·È 29 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 14 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 6 ¤ÙË), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÛÙÔ ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1/1/1996 ¤ˆ˜ 31/7/1999. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÌÂÏÂÙ‹ıËÎ·Ó 57 ·ÛıÂÓ›˜ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Î·È 13 Ì ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (Oª§§). ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§, 49 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË Î·È 8 ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔ›·Û·Ó, 3 ·Ó‹Î·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ 49 ·ÛıÂÓÒÓ, ÂÓÒ 5 ·Ï·ÈfiÙÂÚÔÈ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘, ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (Û‡ÓÔÏÔ ·ÛıÂÓÒÓ ÔÌ¿‰·˜ O§§ Û ˘ÔÙÚÔ‹: 8). OÈ ‰‡Ô ÔÌ¿‰Â˜
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¶›Ó·Î·˜ 2. ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂϤÁ¯ıËÎ·Ó Û ·È‰È¿ Ì OM§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘
º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ FAB
∫·Ú˘fiÙ˘Ô˜
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· MR HR M1 M2 M3 M5 M7 º˘ÛÈÔÏÔÁÈÎfi˜ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ¢ÂÓ ¤ÁÈÓÂ
ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ (‰È¿ÁÓˆÛ˘-˘ÔÙÚÔ‹˜), Ë ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1·. ∞ÓÙ›ÛÙÔȯ·, ·ÛıÂÓ›˜ Ì OM§§, 8 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ ÛÙËÓ ÔÌ¿‰· Ù˘ ˘ÔÙÚÔ‹˜ ÂÚÈÏ‹ÊıËÛ·Ó 2/8 Ô˘ ˘ÔÙÚÔ›·Û·Ó Î·È ÔÈ 3 ·Ï·ÈfiÙÂÚÔÈ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (Û‡ÓÔÏÔ ·ÛıÂÓÒÓ ÔÌ¿‰·˜ OM§§ Û ˘ÔÙÚÔ‹: 5). OÈ ‰‡Ô ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ (‰È¿ÁÓˆÛ˘-˘ÔÙÚÔ‹˜), Ë ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1‚. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÚ›¯ıËΠÛÙÔÓ ÌÔÚÊÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ÙˆÓ Ì˘ÂÏÈÎÒÓ ÂȯÚÈÛÌ¿ÙˆÓ, ÙËÓ Î·Ù¿ FAB Ù·ÍÈÓfiÌËÛË Î·È ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ Î·È Î˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. OÈ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Î·È OM§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2, ·ÓÙ›ÛÙÔȯ·. OÈ ·ÛıÂÓ›˜ Ì O§§ ¤Ï·‚·Ó ÔÌÔÈÔÁÂÓÒ˜ ÙÔ °ÂÚÌ·ÓÈÎfi ™˘ÓÂÚÁ·ÙÈÎfi £Âڷ¢ÙÈÎfi ¶ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95 Î·È ‰È·¯ˆÚ›ÛÙËÎ·Ó Û ÔÌ¿‰Â˜: ·) ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (MR) (31) Î·È ‚) ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (HR) (25). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ÂÊ·ÚÌfiÛÙËΠÔÌÔÈÔÁÂÓÒ˜ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ™˘ÓÂÚÁ·ÙÈÎfi °ÂÚÌ·ÓÈÎfi £Âڷ¢ÙÈÎfi ¶ÚˆÙfiÎÔÏÏÔ AML-BFM ’93. O ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ·fi ÙË ‰È¿ÁÓˆÛË Î˘Ì·›ÓÂÙ·È ·fi 6 Ì‹Ó˜ ¤ˆ˜ 3,5 ¯ÚfiÓÈ· (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 24 Ì‹Ó˜), ÂÓÒ ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ ·fi 5 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 18 Ì‹Ó˜). O ‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜ ˘ÔÙÚÔ‹˜ ·fi ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 19 Ì‹Ó˜ ÁÈ· ÙËÓ ÔÌ¿‰· Ù˘ O§§ Î·È 26 Ì‹Ó˜ ÁÈ· ÙËÓ ÔÌ¿‰· Ù˘ OM§§. O ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ˘ÔÙÚÔ‹ Î˘Ì·›ÓÂÙ·È ·fi 2 ¤ˆ˜ 27 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 28,5 Ì‹Ó˜) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Î·È ·fi 11 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì OM§§. ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 13 ·È‰È¿ Ì ¿ÏÏ· ηÏÔ‹ıË ‹ ÌË ·ÈÌ·ÙÔÏÔÁÈο ηÎÔ‹ıË ÓÔÛ‹Ì·Ù·, ÛÙ· ÔÔ›· ˘‹Ú¯Â ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (ªO). ∞Ó·Ï˘ÙÈÎfiÙÂ-
OM§§ ‰È¿ÁÓˆÛË
OM§§ ˘ÔÙÚÔ‹
4 (50%) 4 (50%) 3 (37,5%) 5 (62,5%) 2 (25%) 3 (37,5%) 1 (12,5%) 1 (12,5%) 1 (12,5%) 2 (25%) 1 (12,5%) 1 (12,5%) 4 (50%)
5 (100%) 0 (0%) 0 (0%) 5 (100%) 2 (40%) 2 (40%) 1 (20%) 0 (0%) 0 (0%) 2 (40%) 1 (20%) 1 (20%) 1 (20%)
Ú·, 3 ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È Ì˘ÂÏÈ΋ ‰È‹ıËÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ıÂÙÈÎÔ› Ì¿ÚÙ˘Ú˜, ÂÓÒ 3 ·ÛıÂÓ›˜ Ì ˘ÔÏ·ÛÙÈ΋ ·Ó·ÈÌ›·, 2 Ì ·Ó·ÈÌ›· Fanconi, 2 Ì ȉÈÔ·ı‹ ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ Î·È 3 Ì Ԣ‰ÂÙÂÚÔÂÓ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ·ÚÓËÙÈÎÔ› Ì¿ÚÙ˘Ú˜. ∂ÈϤÔÓ, ˆ˜ ıÂÙÈο ‰Â›ÁÌ·Ù· ·Ó·ÊÔÚ¿˜ (controls) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Î˘ÙÙ·ÚÈο ÂȯڛÛÌ·Ù· ·fi Ê˘ÛÈÔÏÔÁÈÎfi ‹·Ú, ÂÓÒ ˆ˜ ·ÚÓËÙÈο ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰Â›ÁÌ·Ù· Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·ÛıÂÓÒÓ, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ∞ƒ∞∞ƒ: ·) ¯ˆÚ›˜ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ·Óٛۈ̷ ‹ ‚) Ì ·Óٛۈ̷ ÌË ‰È·ÛÙ·˘ÚÔ‡ÌÂÓÔ Ì ÙË Ï¢΋ ÛÂÈÚ¿ (·Óٛۈ̷ ¤Ó·ÓÙÈ Ù˘ ΢ÙÙ·ÚÔÎÂÚ·Ù›Ó˘ Î·È Ù˘ ‰ÂÛÌ›Ó˘). ∏ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÌÂÏÂÙ‹ıËΠ̠ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘-·ÓÙÈ-·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (∞ƒ∞∞ƒ) (16,18) Û ΢ÙÙ·ÚÈο ÂȯڛÛÌ·Ù· (cytospins) ·fi Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ, ̤ۈ ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ: JSB-1, (YLEM, code: MCF 404), C219 (Centocor WH29) Î·È MRK16 (KAMIYA BIOMEDICAL, MC-012). ∞fi οı ·ÛıÂÓ‹ ÌÂÏÂÙ‹ıËÎ·Ó 3 ‰Â›ÁÌ·Ù· ÁÈ· οı ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷, ·Ó¿ Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÁÓˆÛË-˘ÔÙÚÔ‹). ∏ Ù¯ÓÈ΋ ·˘Ù‹ Â›Ó·È ·ÍÈfiÈÛÙË, Ù·¯Â›· Î·È ÔÈÎÔÓÔÌÈ΋ ˆ˜ ̤ıÔ‰Ô˜ ÚÔ˘Ù›Ó·˜ ÁÈ· ¤Ó· ·ÈÌ·ÙÔÏÔÁÈÎfi ÂÚÁ·ÛÙ‹ÚÈÔ. µÈ‚ÏÈÔÁÚ·ÊÈο ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË ÁÈ· ‰Â›ÁÌ·Ù· Ì ÌÈÎÚfi Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ΢ÙÙ¿ÚˆÓ (<105), Ù· ÔÔ›· Â›Ó·È ‰‡ÛÎÔÏÔ ‹ ·‰‡Ó·ÙÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó Ì ¿ÏϘ ÌÂıfi‰Ô˘˜. ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ Â›Ó·È fiÙÈ ÌÔÚ› Ó· ‰È·ÎÚ›ÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û ÌÂÌÔӈ̤ÓÔ˘˜ ¢‰È¿ÎÚÈÙÔ˘˜ ÌÔÚÊÔÏÔÁÈο ÏËı˘ÛÌÔ‡˜. ¶·Ú¿ÏÏËÏ·, Ù· ÂȯڛÛÌ·Ù· ÌÂÏÂÙ‹ıËÎ·Ó Î·È Ì ¯ÚÒÛË Giemsa. ∏ ̤ıÔ‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ ÛÙ¿‰È·: i) ™Â ‰Â›ÁÌ· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Á›ÓÂÙ·È ‰È·¯ˆÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì Ficoll-Hypaque (density 1.077, Seromed), Ê˘ÁÔΤÓÙÚËÛË Û 1800 ÛÙÚÔʤ˜ ÁÈ· 20 ÏÂÙ¿, Ì ÛÎÔfi ÙÂÏÈ΋ Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÌÔÓÔ‡ÚËÓˆÓ Î˘ÙÙ¿ÚˆÓ 10x106 ·ÙÙ·Ú·/ÌL. ii) ª¤ÚÔ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ Ê˘ÁÔÎÂÓÙÚÂ›Ù·È ÂÎ Ó¤Ô˘ ÛÙË Ê˘ÁfiÎÂÓÙÚÔ Cytospin (Shandon) Û 400 ÛÙÚÔʤ˜ ÁÈ· 3 ÏÂÙ¿, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ΢ÙÙ·ÚÈÎÒÓ ÂȯÚÈÛÌ¿ÙˆÓ
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∂È‚›ˆÛË
JAN-FEB-03
∂ÈÎfiÓ· 2. £ÂÙÈ΋ ÂÈÊ·ÓÂȷ΋ ¤ÎÊÚ·ÛË Ù˘ P-170.
¶·Ú·ÎÔÏÔ‡ıËÛË (Ì‹Ó˜) ∂ÈÎfiÓ· 4. ∫·Ì‡ÏË ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ì O§§.
∂ÈÎfiÓ· 3. πÛ¯˘Ú¿ ıÂÙÈ΋ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÌÂÌ‚Ú·ÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ P-170. Ì ÙË ÌÔÚÊ‹ cytospin, Ù· ÔÔ›· ·ÔÍËÚ·›ÓÔÓÙ·È ÛÙÔÓ ·ÙÌÔÛÊ·ÈÚÈÎfi ·¤Ú· ÁÈ· 3 ÒÚ˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÌÔÓÈÌÔÔÈÔ‡ÓÙ·È Û Ì›ÁÌ· ·ÎÂÙfiÓ˘-ÌÂı·ÓfiÏ˘ 1:1 ÁÈ· 90’’ Û ıÂÚÌÔÎÚ·Û›· ‰ˆÌ·Ù›Ô˘. ∫·ÙfiÈÓ, ÌÂٷʤÚÔÓÙ·È Û buffer TBS (tris-buffersaline), Ô˘ Â›Ó·È 1/10 ‰È·Ï‡Ì·ÙÔ˜ 0.5 ª Tris -HCL Ì p∏ 6 Û 0.15 ª Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ÁÈ· 5 ÚÒÙ· ÏÂÙ¿. iii) ™ÙË Û˘Ó¤¯ÂÈ·, Ù· ‰Â›ÁÌ·Ù· ÙÔÔıÂÙÔ‡ÓÙ·È ÛÙÔ˘˜ Ï·ÛÙÈÎÔ‡˜ ı·Ï·ÌÔ‡˜-coverplates ÙÔ˘ Ì˯·Ó‹Ì·ÙÔ˜ Sequenza Ù˘ ÂÙ·ÈÚ›·˜ Shandon Î·È Âˆ¿˙ÔÓÙ·È Ì 0,20 ml ‰È·Ï‡Ì·ÙÔ˜ ÚˆÙÔÁÂÓÔ‡˜ ·ÓÙÈÛÒÌ·ÙÔ˜ anti-P glycoprotein 170 Ì buffer TBS Û ·Ú·›ˆÛË 1:30, Û ˘ÁÚfi ı¿Ï·ÌÔ ÁÈ· 30 ÚÒÙ· ÏÂÙ¿. iv) ∆· ‰Â›ÁÌ·Ù· ÍÂϤÓÔÓÙ·È ÙÚÂȘ ÊÔÚ¤˜ (6 ÏÂÙ¿) Ì buffer TBS Î·È ÛÙË Û˘Ó¤¯ÂÈ· ˆ¿˙ÔÓÙ·È Ì 0,20 ml ¤ÙÔÈÌÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ÔÏ˘‰‡Ó·ÌÔ˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ·ÓÙÈÛÒÌ·ÙÔ˜ goat anti-mouse ÁÈ· 10 ÚÒÙ· ÏÂÙ¿. v) ªÂÙ¿ ·fi Ó¤Ô Í¤Ï˘Ì·, ˆ¿˙ÔÓÙ·È Ì 0,20 ml ·ÓÔÛÔÛ˘ÌϤÁÌ·ÙÔ˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ÁÈ· 10 ÚÒÙ· ÏÂÙ¿. vi) ∞ÊÔ‡ ÍÂÏ˘ıÔ‡Ó ÂÎ Ó¤Ô˘ ÁÈ· 6 ÚÒÙ· ÏÂÙ¿, ˆ¿˙ÔÓÙ·È Ì 0,25 ml ¯ÚˆÌÔÁfiÓÔ˘ ÁÈ· 20 ÏÂÙ¿. vii) •ÂϤÓÔÓÙ·È ¿ÏÈ ÁÈ· 6 ÚÒÙ· ÏÂÙ¿ Î·È ÂÓ Û˘Ó¯›·
74
Ù· ‰Â›ÁÌ·Ù· ‚¿ÊÔÓÙ·È Ì 0,25 ml ·ÈÌ·ÙÔÍ˘Ï›Ó˘ Mayer’s (LIPSHAW IMMUNON, No 407050). viii) ∆¤ÏÔ˜, ·ÊÔ‡ ÍÂÏ˘ıÔ‡Ó Ì ·oÛÙ·Á̤Óo ÓÂÚfi, ÙÔÔıÂÙÂ›Ù·È Â› ÙÔ˘ ˘ÏÈÎÔ‡ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÂÈÎ·Ï˘ÙÚ›‰·, Ô˘ Û˘ÁÎÔÏÏ¿Ù·È Ì ‰È·Ê·Ó¤˜ ˘ÏÈÎfi. ∆· ‰Â›ÁÌ·Ù· ÌÂÏÂÙ‹ıËÎ·Ó Û ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ ·fi ‰‡Ô ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÌÂÏÂÙËÙ¤˜, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ÁÓÒÚÈ˙·Ó ÙË Ê¿ÛË ÂϤÁ¯Ô˘ Ù˘ ÓfiÛÔ˘. ™Â οı ‰Â›ÁÌ· ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ë ·Ó·ÏÔÁ›· ÙˆÓ ıÂÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ë ¤ÓÙ·ÛË Ù˘ ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘˜, ηıÒ˜ Î·È Ë ÌÔÚÊÔÏÔÁ›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì ¯ÚÒÛË Giemsa. ø˜ ıÂÙÈο ÛÙËÓ P-170 ÚˆÙ½ÓË Î‡ÙÙ·Ú· ıˆڋıËÎ·Ó ÂΛӷ Ô˘ ‚¿ÊÙËÎ·Ó ¤ÓÙÔÓ· ÎfiÎÎÈÓ· (∂ÈÎfiÓ· 2), ÂÓÒ ·ÚÓËÙÈο ÂΛӷ Ô˘ ‰ÂÓ ‚¿ÊÙËηÓ. ø˜ ıÂÙÈο ıˆڋıËÎ·Ó Ù· ‰Â›ÁÌ·Ù· ÛÙ· ÔÔ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ 1% ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÚÔÛÏ¿Ì‚·Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷. ™Â οıÂ Ì˘ÂÏÈÎfi ›¯ÚÈÛÌ· ÂϤÁ¯ÔÓÙ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 1000 ·ÙÙ·Ú· ·fi ‰‡Ô ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·Ú·ÙËÚËÙ¤˜. 2 ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ¯ ÙÂÛÙ. ªÂÏÂÙ‹ıËÎÂ Ë Û˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ MDR Ê·ÈÓÔ̤ÓÔ˘ ̤ۈ Ù˘ ·Ó›¯Ó¢Û˘ Ù˘ ƒ-170 Ì ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ Î·È ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Ï¢¯·ÈÌ›· (ËÏÈΛ·, ʇÏÔ, ·ÚÈıÌfi˜ Ï¢ÎÒÓ, ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜, ηڢfiÙ˘Ô˜, ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘).
∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 49 ·È‰È¿ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, 3 ˘ÔÙÚÔ›·Û·Ó (Û ‰È¿ÛÙËÌ· 4, 17 Î·È 23 ÌËÓÒÓ ·fi ÙË ‰È¿ÁÓˆÛË, ·ÓÙ›ÛÙÔȯ·), 3 η٤ÏËÍ·Ó (2 ÚÒÈÌÔÈ ı¿Ó·ÙÔÈ) Î·È Ù· ˘fiÏÔÈ· 43 ‚Ú›ÛÎÔÓÙ·È Û ϋÚË ÚÒÙË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 5 ¤ˆ˜ 46 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜
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¶›Ó·Î·˜ 3. ∞ÔÙÂϤÛÌ·Ù· ¤ÎÊÚ·Û˘ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹
O§§ ‰È¿ÁÓˆÛË O§§ ˘ÔÙÚÔ‹
JSB-1+
JSB-1-
C219+
C219-
MPK16+
MPK16-
15/49 30,6% 4/8 50%
34/49 69,4% 4/8 50%
12/49 24,5% 5/8 62,5%
37/49 75,5% 3/8 37,5%
11/49 22,5% 2/8 25%
38/49 77,5% 6/8 75%
¶›Ó·Î·˜ 4. ∞ÔÙÂϤÛÌ·Ù· ¤ÎÊÚ·Û˘ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹
Oª§§ ‰È¿ÁÓˆÛË Oª§§ ˘ÔÙÚÔ‹
JSB-1+
JSB-1-
C219+
C219-
MPK16+
MPK16-
5/8 62,5% 2/5 40%
3/8 37,5% 3/5 60%
5/8 62,5% 2/5 40%
3/8 37,5% 3/5 60%
4/8 50% 2/5 40%
4/8 50% 3/5 60%
¶›Ó·Î·˜ 5. ŒÎÊÚ·ÛË Ù˘ MDR ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜
O§§ ‰È¿ÁÓˆÛË O§§ ˘ÔÙÚÔ‹ Oª§§ ‰È¿ÁÓˆÛË Oª§§ ˘ÔÙÚÔ‹
MDR+
MDR-
18/49 (36,7%) 5/8 (62,5%)
31/49 (63,9%) 3/8 (37,5%)
5/8 (62,5%) 2/5 (40%)
3/8 (37,5%) 3/5 (60%)
¯ÚfiÓÔ˜: 26 Ì‹Ó˜). ∞fi Ù· 3 Ô˘ ˘ÔÙÚÔ›·Û·Ó, 2 η٤ÏËÍ·Ó Û 2 Î·È 3 Ì‹Ó˜ ·fi ÙËÓ ˘ÔÙÚÔ‹ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÙÔ ÙÚ›ÙÔ ·Ú·Ì¤ÓÂÈ Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 10 Ì‹Ó˜ (∂ÈÎfiÓ· 1·). ∞fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ ÛÙËÓ ˘ÔÙÚÔ‹, 3 η٤ÏËÍ·Ó (1 ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜), ÂÓÒ ÔÈ ¿ÏÏÔÈ 2 ‚Ú›ÛÎÔÓÙ·È Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 19 ¤ˆ˜ 38 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 27 Ì‹Ó˜). ∏ η̇ÏË ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 4 (Kaplan-Meier cumulative event-free survival). ∞fi ÙÔ˘˜ 8 ·ÛıÂÓ›˜ Ì OM§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, 2 ˘ÔÙÚÔ›·Û·Ó (Û ‰È¿ÛÙËÌ· 12 Î·È 26 ÌËÓÒÓ ·fi ÙË ‰È¿ÁÓˆÛË, ·ÓÙ›ÛÙÔȯ·), 3 η٤ÏËÍ·Ó (2 ÚÒÈÌÔÈ ı¿Ó·ÙÔÈ) Î·È ÔÈ ˘fiÏÔÈÔÈ 3 ‚Ú›ÛÎÔÓÙ·È Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 16 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜). OÈ 2 ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔ›·Û·Ó ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 16 Î·È 20 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ∆¤ÏÔ˜, Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘, ‚Ú›ÛÎÔÓÙ·È Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 20 ¤ˆ˜ 36 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜) (∂ÈÎfiÓ· 1‚). ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 210 ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ, ˘‹Ú¯·Ó Û˘ÓÔÏÈο 110 ıÂÙÈο ‰Â›ÁÌ·Ù· (52,3%).
∂ÓÓ¤· ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ıÂÙÈÎfiÙËÙ· Î·È ÛÙ· ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·. ∂› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ, Ù· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó 86,6% ÁÈ· ÙÔ JSB-1, 80% ÁÈ· ÙÔ C219 Î·È 63,3% ÁÈ· ÙÔ MRK16. ∆Ô ÔÛÔÛÙfi ıÂÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙ· ‰Â›ÁÌ·Ù¿ Ì·˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 11% ¤ˆ˜ 82%. ∏ ¤ÓÙ·ÛË Ù˘ ıÂÙÈÎfiÙËÙ·˜ ‰È·ÎÚ›ıËΠ۠‹È·, ̤ÙÚÈ· Î·È ¤ÓÙÔÓË. ∂›¯·Ì ¤ÓÙÔÓË ÂÚ˘ıÚ‹ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÌÂÌ‚Ú·ÓÈ΋ ·ÓÙ›‰Ú·ÛË (∂ÈÎfiÓ· 3) Ì ٷ JSB-1 Î·È C219, ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· Ô˘, fiˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, ·ÓȯÓÂ‡Ô˘Ó Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘ ƒ-170 Î·È ¤ÓÙÔÓË ÂÚ˘ıÚ‹ ÂÈÊ·ÓÂȷ΋ ÌÂÌ‚Ú·ÓÈ΋ ·ÓÙ›‰Ú·ÛË Ì ªR∫16 ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ô˘, fiˆ˜ ›Û˘ ¤¯ÂÈ ·Ó·ÊÂÚı›, ·ÓȯÓ‡ÂÈ ÂÈÊ·ÓÂÈ·Îfi ›ÙÔÔ Ù˘ ƒ-170. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤ÎÊÚ·Û˘ οı ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Î·È Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 3 Î·È 4, ·ÓÙ›ÛÙÔȯ·. ™Â 18/49 (36,7%) ·ÛıÂÓ›˜ Ì O§§ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ Û 5/8 (62,5%) ÛÙËÓ ˘ÔÙÚÔ‹ (¶›Ó·Î·˜ 5). ™Â 5/8 (62,5%) ·ÛıÂÓ›˜ Ì Oª§§ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ Û 2/5 (40%) ÛÙËÓ ˘ÔÙÚÔ‹ (¶›Ó·Î·˜ 5). ™ÙË ‰È¿ÁÓˆÛË: ·) ·fi ÙÔ˘˜ 18 ·ÛıÂÓ›˜ Ì O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (11,1%) ·Â‚›ˆÛ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹), ÂÓÒ 16 (88,9%) ÂÈÛ‹¯ıËÛ·Ó Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË, ‚) ·fi ÙÔ˘˜ 31 ·ÛıÂÓ›˜ Ì O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 1 (3,6%) ˘ÔÙÚÔ›·ÛÂ, 3 (9,7%) η٤ÏËÍ·Ó (1 ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜) Î·È 27 (87,1%) ÂÈÛ‹¯ıËÛ·Ó Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË, Á) ·fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (40%) ·Â‚›ˆÛ·Ó (1 ÛÙËÓ
75
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14:38
™ÂÏ›‰·76
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Paediatriki 2003;66:65-81
¶›Ó·Î·˜ 6. ™˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR Ì ÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘
ñ O§§ ‰È¿ÁÓˆÛË (49) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ ÀÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ ñ O§§ ˘ÔÙÚÔ‹ (8) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ 2Ë ˘ÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ
MDR+
%
MDR-
%
18/49 16/18 1/18 0/18 2/18
36,7% 88,9% 5,5% 0% 11,1%
31/49 27/31 1/31 1/31 3/31
63,9% 87,1% 3,2% 3,2% 9,7%
5/8 2/5 0/5 1/5 2/5
62,5% 40% 0% 20% 40%
3/8 3/3 0/3 0/3 0/3
37,5% 100% 0% 0% 0%
¶›Ó·Î·˜ 7. ™˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR Ì ÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘
ñ OM§§ ‰È¿ÁÓˆÛË (8) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ ÀÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ ñ OM§§ ˘ÔÙÚÔ‹ (5) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ 2Ë ˘ÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ
MDR+
%
MDR-
%
5/8 3/5 1/5 0/5 2/5
62,5% 60% 20% 0% 40%
3/8 0/3 1/3 2/3 1/3
37,5% 0% 33,3% 66,6% 33,3%
2/5 2/2 0/2 0/2 0/2
40% 100% 0% 0% 0%
3/5 3/3 0/3 0/3 0/3
60% 100% 0% 0% 0%
¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹), ÂÓÒ 3 (60%) ÂÌÊ¿ÓÈÛ·Ó Ï‹ÚË ‡ÊÂÛË Î·È ‰) ·fi ÙÔ˘˜ 3 ·ÛıÂÓ›˜ Ì Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ170, 2 (66,6%) ˘ÔÙÚÔ›·Û·Ó Î·È 1 η٤ÏËÍ (ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜) (¶›Ó·Î·˜ 6 Î·È 7). ™ÙËÓ ˘ÔÙÚÔ‹: ·) ·fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (40%) ·Â‚›ˆÛ·Ó, 1 (20%) ˘ÔÙÚÔ›·Û ÂÎ Ó¤Ô˘, ÂÓÒ 2 (40%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 19 Î·È 27 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·, ‚) Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì O§§ (100%) Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 26, 30 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·, Á) Î·È ÔÈ 2 ·ÛıÂÓ›˜ Ì Oª§§ (100%) Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 20 Î·È 26 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· Î·È ‰) Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì Oª§§ (100%) Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 20, 26 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· (¶›Ó·Î·˜ 6 Î·È 7). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 8 Î·È 9, ·ÓÙ›ÛÙÔȯ·.
76
∆· ÔÛÔÛÙ¿ fiÏˆÓ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËÎ·Ó ·˘ÍË̤ӷ, ۯ‰fiÓ ‰ÈÏ¿ÛÈ·, Û˘ÁÎÚÈÙÈο Ì ÂΛӷ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170. ¶·Ú’ fiÏ· ·˘Ù¿, ÏfiÁˆ ÙÔ˘ Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰ËÏ·‰‹ ÙÔ Ê‡ÏÔ, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÙÔÓ Î·Ú˘fiÙ˘Ô, ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô Î·È ÙËÓ ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 8 Î·È 9). ™˘˙‹ÙËÛË ∏ ÂͤÏÈÍË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Û˘ÓÙÂϤÛÙËΠ̤۷ ·fi Ì›· ‰È·‰ÚÔÌ‹ ÔÏÏÒÓ ‰ÂηÂÙÈÒÓ. ∆Ô 1945 ·Ó·ÁÓˆÚ›ÛÙËÎÂ Ë ÓfiÛÔ˜ ˆ˜ È·ÙÚÈÎfi Úfi‚ÏËÌ· Î·È ÌfiÏȘ ÙÔ 1975 ¿Ú¯ÈÛ ӷ ‰È·Ê·›ÓÂÙ·È Ë Èı·ÓfiÙËÙ· Ú·ÁÌ·ÙÈ΋˜ ›·Û˘ Ì ÙËÓ ·Ó¿Ù˘ÍË ÈÔ ÂÈıÂÙÈÎÒÓ Î·È ÂÓÙ·ÙÈÎÔÔÈËÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ (2,4,6). ∂ÈϤÔÓ, ÔÈ Ó¤Â˜ ÂÈÙ‡ÍÂȘ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛÔÏÔÁ›·˜, Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ù˘ ÁÂÓÂÙÈ΋˜
JAN-FEB-03
14-05-03
14:38
™ÂÏ›‰·77
¶·È‰È·ÙÚÈ΋ 2003;66:65-81
Paediatriki 2003;66:65-81
¶›Ó·Î·˜ 8. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÌÂٷ͇ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ¤ÎÊÚ·Û˘ Ù˘ MDR ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘
º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB
∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË
ŒÎÊÚ·ÛË Ù˘ ƒ-170
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË 9 ≤100 x 10 /L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ (Common) T-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ∞¤Ù˘¯·Ó ¢ÂÓ ¤ÁÈÓÂ
MDR+
MDR-
P
11 (22,5%) 7 (14,3%) 10 (20,4%) 8 (16,3%) 14 (28,5%) 4 (8,2%) 18 (36,7%) 0 (0%) 17 (34,7%) 1 (2%) 10 (20,4%) 6 (12,4%) 2 (4,1%) 16 (10) (32,6%) 2 (4,1%) 10 (20,4%) 0 (0%) 2 (4,1%) 2 (4,1%) 4 (8,2%) 18 (36,7%)
18 (36,7%) 13 (26,5%) 21 (42,9%) 10 (20,4%) 23 (46,8%) 8 (16,3%) 28 (57,1%) 3 (6,2%) 27 (55,1%) 4 (8,2%) 25 (50,7%) 6 (12,4%) 0 (0%) 29 (24) (59,2%) 2 (4,1%) 8 (16,3%) 4 (8,2%) 1 (2%) 7 (14,3%) 11 (22,4%) 31 (63,3%)
0,075
Ô˘ ‚Ô‹ıËÛ·Ó ·ÊÂÓfi˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ηÚÎÈÓÔÁ¤ÓÂÛ˘, ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Î·Ï‡ÙÂÚË Ù·ÍÈÓfiÌËÛË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·ÎÔËıÂÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, fi¯È ÌfiÓÔ Û ÂÌÂÈÚÈ΋ ·ÏÏ¿ Î·È Û ·ÈÙÈÔÏÔÁË̤ÓË ‚¿ÛË, Û˘ÓÙ¤ÏÂÛ·Ó ÙÂÏÈο ÛÙË ÛËÌÂÚÈÓ‹ ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÓÙ·ÂÙÔ‡˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Ï¢¯·ÈÌ›·. ¶·Ú¿ Ù·‡Ù·, ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·ÙËÚÂ›Ù·È ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ ·ÎfiÌ· Î·È ÛÙȘ Ï¢¯·È̛˜ Ô˘ ηıÔÚ›˙ÔÓÙ·È ˆ˜ ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (ÂÚ›Ô˘ 20%), ÂÓÒ Ôχ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∂ÈϤÔÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, ·Ú¿ ÙËÓ ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ ‹‰Ë Û˘ÓÙÂÏÂÛÙ›, Ù· ÙÚ¤¯ÔÓÙ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÈ‚›ˆÛË Ù˘ ٿ͈˜ ÙÔ˘ 40% ¤ˆ˜ 60%. ™˘ÓÂÒ˜, Â›Ó·È Ê˘ÛÈÎfi Ó· ÂÁ›ÚÔÓÙ·È ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ˆ˜ ÚÔ˜ Ù· ·›ÙÈ· ·ÔÙ˘¯›·˜ Ù˘ ıÂڷ›·˜ (1,2,13,19,20). ¶ÔÏ˘¿ÚÈı̘ ÌÂϤÙ˜ ۯ‰ȿÛÙËÎ·Ó Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÔÙ˘¯›·˜ Î·È ÙËÓ ·Ó·˙‹ÙËÛË Ó¤ˆÓ ·Ú·ÁfiÓÙˆÓ ‹ ·Ú·Ì¤ÙÚˆÓ Ô˘, ÂÚÈÏ·Ì‚·ÓfiÌÂÓÔÈ ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ı· ¤ÚÈ¯Ó·Ó Êˆ˜ Û ˘Â‡ı˘ÓÔ˘˜ ÁÈ· ÙË Ê·Ú̷΢ÙÈ΋ ·ÔÙ˘¯›· Ì˯·ÓÈÛÌÔ‡˜ (‚ÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ¿Ì˘Ó·˜ ÙˆÓ Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ) (17,18,20,21). ªÂٷ͇ ÙˆÓ ÔÈÎ›ÏˆÓ ·Ú·ÁfiÓÙˆÓ, Ù· ÙÂÏ¢-
0,255 0,063 0,063 0,062 0,099
0,277 0,031
0,168
Ù·›· ¯ÚfiÓÈ· ȉȷ›ÙÂÚ· ¤¯ÂÈ ÌÂÏÂÙËı› ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ·Ó¿Ù˘Í˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÂ Â›Â‰Ô Î˘Ú›ˆ˜ ÂÚÁ·ÛÙËÚÈ·Îfi. ø˜ ΢ÚÈfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ ıˆÚÂ›Ù·È Ë ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘, Ô˘ ·ÓȯÓ‡ÂÙ·È Ì¤Ûˆ Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÁÏ˘ÎÔÚˆÙ½Ó˘, Ë ÔÔ›· ›Ûˆ˜ Â›Ó·È ·ÚÔ‡Û· ÛÙËÓ ·Ú¯‹ Î·È ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ ‹ ÛÙȘ ˘ÔÙÚÔ¤˜ Ù˘ ÓfiÛÔ˘ (12,19,20,22-24). ∆Ô 1990, ÔÈ Kuwazuru Î·È Û˘Ó ‰ËÌÔÛ›Â˘Û·Ó 3 ÌÂϤÙ˜ Û ÂÓ‹ÏÈÎÔ˘˜ ·ÛıÂÓ›˜ Ì O§§, 11 Ì ¯ÚfiÓÈ· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Î·È 25 Ì ∆-O§§, fiÔ˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ C219 ÁÈ· ÙËÓ Ù˘¯fiÓ ·Ó›¯Ó¢ÛË Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜. OÈ ÂÓ ÏfiÁˆ ÂÚ¢ÓËÙ¤˜ ·¤‰ÂÈÍ·Ó Û˘Û¯¤ÙÈÛË Ù˘ ·ÚÔ˘Û›·˜ ƒ-170 Î·È Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘, Ô˘ ÂΉËÏÒÓÂÙ·È Â›Ù ˆ˜ ÌË ·Ú¯È΋ ·¿ÓÙËÛË ÛÙË ıÂڷ›· (·ÓıÂÎÙÈ΋ ÓfiÛÔ˜), ›Ù Ì ˘ÔÙÚÔ‹. ªÂ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ÂÈÛËÌ·›ÓÔ˘Ó ÙËÓ ÎÏÈÓÈ΋ ÛËÌ·Û›· ÙÔ˘ ªDR Ê·ÈÓÔ̤ÓÔ˘ (25-27). ™ÙË Û˘Ó¤¯ÂÈ·, ÌÂϤÙ˜ Û ·È‰È¿ Ì O§§ Ô˘ ÚÔÛ‰ÈfiÚÈ˙·Ó ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Ì ÌÔÚȷΤ˜ ÌÂıfi‰Ô˘˜ Û ‰È¿ÊÔÚ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘, ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯ÂÈ ·Ó·ÏÔÁÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ·˘ÍË̤ӷ ÔÛ¿ ƒ170 Î·È Ù˘ ·˘ÍË̤Ó˘ ·ÓÙÔ¯‹˜ ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙË Ãª£, ÙfiÛÔ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, fiÛÔ Î·È ÛÙËÓ ‡ÊÂÛË, ÛÙËÓ ˘ÔÙÚÔ‹ Î·È ÛÙË
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¶·È‰È·ÙÚÈ΋ 2003;66:65-81
Paediatriki 2003;66:65-81
¶›Ó·Î·˜ 9. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÌÂٷ͇ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙËÓ ˘ÔÙÚÔ‹
º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB
∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË 9 ≤100 x 10 /L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ (Common) ∆-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ¢ÂÓ ¤ÁÈÓÂ
ŒÎÊÚ·ÛË Ù˘ ƒ-170
‰Â‡ÙÂÚË ‡ÊÂÛË (11,19,28). ∞ÎÔÏÔ‡ıËÛ·Ó, fï˜, ‰‡Ô ÌÂϤÙ˜ Ô˘ ‰ÂÓ ¤‰ÂÈÍ·Ó ÎÏÈÓÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙËÓ ÎÏÈÓÈ΋ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ (30,31). ™ÙËÓ ÚÒÙË ¯ÚËÛÈÌÔÔÈ‹ıËΠÌfiÓÔ ÙÔ MPK16 ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Û 19 ·ÛıÂÓ›˜ ̠Ϣ¯·ÈÌ›·, ÂÎ ÙˆÓ ÔÔ›ˆÓ 5 ›¯·Ó O§§, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÌÂÏÂÙ‹ıËÎÂ Ë ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û 141 ·ÛıÂÓ›˜ Ì O§§ Î·È Û 27 Ì Oª§§ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜. ªÂ ÛÎÔfi ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ›‰Ú·Û˘ Ù˘ MDR ÛÙËÓ ÚfiÁÓˆÛË Ù˘ O§§ Î·È Ù˘ Oª§§ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Û ‰È·ÊÔÚÂÙÈΤ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ (‰È¿ÁÓˆÛË-˘ÔÙÚÔ‹), ÌÂÏÂÙ‹Û·Ì ÚÔÔÙÈο ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Ì ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô ∞ƒ∞∞ƒ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· (JSB-1, MRK16, C219) Û 57 ·ÛıÂÓ›˜ Ì O§§ (49 ÛÙË ‰È¿ÁÓˆÛË Î·È 8 Û ˘ÔÙÚÔ‹) Î·È Û 13 ·ÛıÂÓ›˜ Ì Oª§§ (8 ÛÙË ‰È¿ÁÓˆÛË Î·È 5 Û ˘ÔÙÚÔ‹), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Î·È ıÂڷ‡ÙËÎ·Ó Ì ·Ó¿ÏÔÁ· (ALL-BFM ’95 Î·È AML-BFM ’93) ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· ÛÙÔ ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. µÚ¤ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ170 (ۯ‰fiÓ ‰ÈÏ¿ÛÈÔ) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ÛÙËÓ ˘ÔÙÚÔ‹ (62,5%), ÂÓÒ ‰ÂÓ ıˆڋıËÎÂ Â˘Î·Ù·ÊÚfiÓËÙÔ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈÎfiÙËÙ·˜ Ù˘ ƒ170 ηٿ ÙË ‰È¿ÁÓˆÛË (36,7%) (de novo MDR). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÙfiÛÔ ÛÙËÓ ˘ÔÙÚÔ‹ (40%), fiÛÔ Î·È ÛÙË ‰È¿ÁÓˆÛË (62,5%), ¢-
78
MDR+
MDR-
P
4 (50%) 1 (12,5%) 0 (0%) 5 (62,5%) 4 (50%) 1 (12,5%) 5 (62,5%) 0 (0%) 4 (50%) 1 (12,5%) 4 (50%) 1 (12,5%) 0 (0%) 4 (50%) 1 (12,5%) 2 (25%) 2 (25%) 0 (0%) 1 (12,5%) 5 (62,5%)
2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 2 (25%) 1 (12,5%) 3 (37,5%) 0 (0%) 3 (37,5%) 0 (0%) 2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 0 (0%) 0 (0%) 0 (0%) 1 (12,5%) 2 (25%) 3 (37,5%)
0,48 0,5 0,157 0,993 0,157 0,147
0,48 0,034
0,48
Ú‹Ì·Ù· Ô˘ Û˘ÌʈÓÔ‡Ó Ì ÂΛӷ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ (29-35). OÈ Herweijer Î·È Û˘Ó ·Ó›¯ÓÂ˘Û·Ó ˘„ËÏfiÙÂÚË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û 5 ·fi ÙÔ˘˜ 9 ·ÛıÂÓ›˜ Ì ∆O§§ Î·È Û 2 Ì µ-O§§ Î·È Î·Ù¤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÌÔÚ› Ó· ‚ÚÂı› Û fiÏÔ˘˜ ÙÔ˘˜ ˘ÔÙ‡Ô˘˜ ÙˆÓ Ï¢¯·ÈÌÈÒÓ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ‚Ú¤ıËΠ۠20/52 ·ÛıÂÓ›˜ Ì µ-O§§ Î·È Û 3/5 ·ÛıÂÓ›˜ Ì ∆-O§§ (17). ∂ӉȷʤÚÔ˘Û˜ Â›Ó·È ÔÈ ÌÂϤÙ˜ ÙˆÓ Pirker Î·È Û˘Ó Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ MDR1 ÁÔÓȉ›Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ‚Ú·¯‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ‡ÊÂÛË, ÂÈ‚›ˆÛË ÂχıÂÚË ÓfiÛÔ˘ Î·È ÙÂÏÈ΋ ÂÈ‚›ˆÛË (32), ηıÒ˜ Î·È ÙˆÓ Goasguen JE Î·È Û˘Ó, ÔÈ ÔÔ›ÔÈ ‚Ú‹Î·Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ (73%) ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó (32%) (30). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi (40%) ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·). ∂›Û˘, ÔÈ ·ÛıÂÓ›˜ Ì Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (40%) ıÓËÙfiÙËÙ·˜, Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%) (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿).
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¶ÈÛÙ‡ÂÔ˘Ì fiÙÈ ÏfiÁˆ ÙÔ˘ Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ ƒ-170 Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô, ÙÔ Ê‡ÏÔ, ÙËÓ Î·Ù¿ FAB ÌÔÚÊÔÏÔÁ›·, ÙÔÓ Î·Ú˘fiÙ˘Ô, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘, ÁÂÁÔÓfi˜ Ô˘ ÂÈÛËÌ·›ÓÂÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ (33,35,36). ∂›Û˘, Èı·Ó¿ ÁÈ· ÙÔÓ ›‰ÈÔ ÏfiÁÔ, ·Ú’ fiÙÈ ‰È·Ê·›ÓÂÙ·È Ë ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈ΋ ›‰Ú·ÛË Ù˘ ·ÚÔ˘Û›·˜ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Ì O§§ Î·È Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹, ÙÔ‡ÙÔ ‰ÂÓ ‰È·ÈÛÙÒıËΠ̠ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· (¶›Ó·Î·˜ 8 Î·È 9). ∆¤ÏÔ˜, ·ÓÙ›ıÂÙ· Ì ÙÔ˘˜ Filipits Î·È Û˘Ó (1997) Î·È den Boer Î·È Û˘Ó (1997), ÔÈ ÔÔ›ÔÈ ·Ó·Ê¤ÚıËÎ·Ó Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙȘ ‰˘ÛÎÔϛ˜ ÙˆÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈÎÒÓ ÌÂıfi‰ˆÓ ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÔÛÔÛÙÔ‡ ·ӷÏË„ÈÌfiÙËÙ·˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·˘Í‹ıËÎÂ Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ ∞ƒ∞∞ƒ Ù¯ÓÈ΋˜: ·) Ì ÙË ¯Ú‹ÛË ‰ÂÈÁÌ¿ÙˆÓ ·Ó·ÊÔÚ¿˜ οı ÊÔÚ¿ Ô˘ ÚÔÛ‰ÈÔÚÈ˙fiÙ·Ó Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û οÔÈÔÓ ·ÛıÂÓ‹, ÒÛÙ ӷ ÌËÓ ˘¿Ú¯Ô˘Ó „¢‰Ò˜ ıÂÙÈο ‹ „¢‰Ò˜ ·ÚÓËÙÈο ‰Â›ÁÌ·Ù·, ηıÒ˜ Î·È ‚) Ì ÙË Û˘Ìʈӛ· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌÂٷ͇ ÙˆÓ ·ÓÂÍ¿ÚÙËÙˆÓ ·Ú·ÙËÚËÙÒÓ. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙË ¯Ú‹ÛË ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘ ÂÓfi˜ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ. ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÌÔÓ·‰È΋ Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú·. ™ÙÔ ˘fi ÌÂϤÙË ˘ÏÈÎfi ‚Ú¤ıËΠfiÙÈ ÙÔ JSB-1 ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170. ∆Ô ÔÛÔÛÙfi ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘ ‹Ù·Ó 86,6%, ¤Ó·ÓÙÈ 80% ÙÔ˘ C219 Î·È 63,3% ÙÔ˘ MRK16. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ170 ÛÙËÓ ˘ÔÙÚÔ‹ (62,5%) Û ۯ¤ÛË Ì ÙË ‰È¿ÁÓˆÛË, ÂÓÒ ‰ÂÓ ıˆÚÂ›Ù·È Î·ıfiÏÔ˘ Â˘Î·Ù·ÊÚfiÓËÙÔ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈÎfiÙËÙ·˜ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (36,7%) (de novo MDR). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ‚Ú¤ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÙfiÛÔ ÛÙË ‰È¿ÁÓˆÛË (62,5%), fiÛÔ Î·È ÛÙËÓ ˘ÔÙÚÔ‹ (40%). OÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi (40%) ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%) Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·).
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OÈ ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%) Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%) (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿). ∞fi ÙȘ ̤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ηıÒ˜ Î·È ·Ô ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÂÈÛËÌ·›ÓÂÙ·È fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηÈ, ̤ۈ ·˘Ù‹˜, Ù˘ MDR ÛÙ· Ï¢¯·ÈÌÈο ·ÙÙ·Ú· ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈηÚÎÈÓÈÎÒÓ Ê·Ú̿ΈÓ, ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ·ÎfiÌË ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∏ ÌÂϤÙË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙË ¯Ú‹ÛË ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ, fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Â›Ó·È Û¯ÂÙÈο ÚÔÛÈÙ‹, ·Ú·ÁÒÁÈÌË Î·È ·ÍÈfiÈÛÙË ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ MDR. ∂›Ó·È ‚¤‚·È· ÁÓˆÛÙfi fiÙÈ Ë ·ÚÔ˘Û›· Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂڷ›· Â›Ó·È ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi Ê·ÈÓfiÌÂÓÔ. ªÂϤÙ˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Ì ÙË ¯Ú‹ÛË Î·Ù¿ÏÏËÏˆÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂڷ›·, Â›Ó·È ·Ó¿ÁÎË Ó· ÚÔÁÚ·ÌÌ·ÙÈÛÙÔ‡Ó ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ Ì¤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ·ÊÔÚÔ‡Ó Û ÌÈÎÚÔ‡˜ ·ÚÈıÌÔ‡˜ ·ÛıÂÓÒÓ, ıˆÚԇ̠fiÙÈ Ë ÌÂÙ·-·Ó¿Ï˘ÛË ÛÙËÓ ÔÔ›· ı· Û˘ÌÂÚÈÏËÊıÔ‡Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ı· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ì¤¯ÚÈ Û‹ÌÂÚ· ¢ÚËÌ¿ÙˆÓ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (Multi Drug Resistance, MDR) ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¤Ó·ÓÙÈ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∆· Û˘ÌÂÚ¿ÛÌ·Ù· Ì›·˜ Ù¤ÙÔÈ·˜ ÌÂϤÙ˘, ÌÂÙ·ÊÂÚfiÌÂÓ· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË, ı· ¤¯Ô˘Ó ÌÂÙ¿ ‚‚·ÈfiÙËÙ·˜ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ ̠Ϣ¯·ÈÌ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Ditter L, Li FP. Epidemiology of cancer in childhood. In: Nathan DG, Oski FA. Hematology of infancy and childhood. 5th ed. Philadelphia: W.B. Saunders Company; 1998. p. 1071-1091. 2. Niemeyer CM, Sally SE. Acute lymphoblastic leukemia. In: Nathan DG, Oski FA. Hematalogy of infancy and childhood. 5th ed. Philadelphia: W.B. Saunders Company; 1998. p. 1245-1285. 3. Grier ∏E, Sivin πC. Myeloid leukemia, myelodysplasia and myeloproliferative diseases in children. In: Nathan DG, Oski FA. Hematology of infancy and childhood. 5th ed. Philadelphia: W.B. Saunders Company; 1998. p. 12861321.
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1997;34 (5 Suppl):25-33. 36. Dhooge C, Moerloose B, Laureys G, Kint J, Ferster A, De Bacquer D et al. P-glycoprotein is an independent prognostic factor predicting relapse in childhood acute lymphoblastic leukaemia: results of a 6-year prospective study. Br J Haematol 1999;105:676-683.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶·Ó·ÁÈÒÙ· ∆˙ÒÚÙ˙Ë ¶Ï·Ù·ÈÒÓ 7, ÷˚‰¿ÚÈ, ∆.∫. 124 61, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂›Â‰· ÙÔ˘ ·Ó·ÛÙÔϤ· ·1-ÚˆÙÂ˚Ó¿ÛË Ù˘ ÂÏ·ÛÙ¿Û˘ ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú· ÓÂÔÁ¤ÓÓËÙˆÓ Ì ԢÚÔÏԛ̈ÍË1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÚ¢ÓËı› ·Ó Ô ·Ó·ÛÙÔϤ·˜ ·1-ÚˆÙÂ˚Ó¿ÛË Ù˘ ÂÏ·ÛÙ¿Û˘ (∂-·1-PI) ÛÙÔÓ ÔÚfi Î·È Ù· Ô‡Ú· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Û·Ó ¤Ó·˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÛÙ· ÓÂÔÁÓ¿. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÙÚ‹ıËÎ·Ó Ì ·ÓÔÛÔÚÔÛ‰ÈÔÚÈÛÌfi Ù· ›‰· ∂-·1-PI ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú·: ·) Û 23 ÓÂÔÁÓ¿ Ì ԢÚÔÏԛ̈ÍË, ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È 72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ‚) Û 10 “Ê˘ÛÈÔÏÔÁÈο” ÓÂÔÁÓ¿, Ì ‹È· ÚÔ‚Ï‹Ì·Ù·, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Û·Ó Ì¿ÚÙ˘Ú˜ Î·È Á) Û 15 ÓÂÔÁÓ¿ Ì ÂȂ‚·ÈˆÌ¤ÓË Û‹„Ë. ∞ÔÙÂϤÛÌ·Ù·: ∆· ›‰· Ï¿ÛÌ·ÙÔ˜ ÙÔ˘ ∂-·1-PI ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ì ԢÚÔÏԛ̈ÍË Î·È ÙˆÓ “Ê˘ÛÈÔÏÔÁÈÎÒÓ”. ∆· ›‰· fï˜ Ù˘ ∂-·1-PI ÛÙ· Ô‡Ú· ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙ· ÓÂÔÁÓ¿ Ì ԢÚÔÏԛ̈ÍË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ. ª›· ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ∂-·1-PI ÛÙ· Ô‡Ú· ·Ú·ÙËÚ‹ıËΠ72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ۯ‰fiÓ Û fiÏ· Ù· ÓÂÔÁÓ¿, ÂÎÙfi˜ ·fi 2 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· Ë Ïԛ̈ÍË ‹Ù·Ó ›ÌÔÓË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ∂-·1-PI ÛÙ· Ô‡Ú· ÛÙÔ Â›Â‰Ô ·ÔÎÔ‹˜ (cutoff
level) ÙˆÓ 48 Ìg/l ›¯Â ¢·ÈÛıËÛ›· 83%, ÂȉÈÎfiÙËÙ· 90%, ıÂÙÈ΋ ÚÔ‚ÏÂÙÈ΋ ·Í›· 95% Î·È Ì›· ·ÚÓËÙÈ΋ ÚÔ‚ÏÂÙÈ΋ ·Í›· 69% ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÛÙ· ÓÂÔÁÓ¿. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·˘ÍË̤ӷ ›‰· ÛÙ· Ô‡Ú· ÙÔ˘ ∂-·1-PI Ê·›ÓÂÙ·È Ó· Â›Ó·È ¤Ó· ¯Ú‹ÛÈÌÔ ‰È·ÁÓˆÛÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙȘ ÓÂÔÁÓÈΤ˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ, ·ÎfiÌË Î·È ÛÙ· ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó ·ÓÙÈ‚›ˆÛË Î·È Èı·Ó¿ ¤Ó·˜ ÔχÙÈÌÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ·ÔÙ˘¯›· Ù˘ ıÂڷ›·˜.
1 Bakakos P, Messaritaki A, Mandyla H, Nicolaidou P, Anagnostakis D Plasma and urine elastase alpha-1-proteinase inhibitor levels in neonatal urinary tract infection Biol Neonate 2002;81:109-112
™‡ÚÔ˜ ºˆÙfiÔ˘ÏÔ˜ ¶·È‰›·ÙÚÔ˜-¡ÂÔÁÓÔÏfiÁÔ˜ ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ µ’ ª∂¡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
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∂π¢π∫O ∞ƒ£ƒO
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SPECIAL ARTICLE
¢ËÌfiÛÈ· ˘Á›·: Á¤Ê˘Ú· ÂÈÚ‹Ó˘* ¶. ¢. §··ÙÛ¿Ó˘
Public health: a bridge for peace* P. D. Lapatsanis
¶ÂÚ›ÏË„Ë: “∫·› â› Áɘ ÂåÚ‹ÓË” ‰È·ÎËÚ‡ÛÛÂÙ·È ÛÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ. OÈ “ÌÂÁ¿ÏÔÈ” Ù˘ Á˘ ·Û¿˙ÔÓÙ·È ÙÔ ÙÚÔ¿ÚÈÔ: “∫·› â› Áɘ fiÏÂÌÔ˜”. ∏ ÙÚÔÌÔÎÚ·Ù›· ¤¯ÂÈ ÛËÌÂÈÒÛÂÈ Ú·Á‰·›· ·‡ÍËÛË Î·È Â˘ÓÔÂ›Ù·È Ë ·Ó¿Ù˘Í‹ Ù˘ ÛÙȘ ¯ÒÚ˜ Ô˘ ˘¿Ú¯ÂÈ ÔÏÈÙÈ΋ ·ÛÙ¿ıÂÈ· Î·È ¿ÓÈÛË Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂıÓÈÎÔ‡ ÏÔ‡ÙÔ˘. O ÛÎÔfi˜ ÙÔ˘ ÙÚÔÌÔÎÚ·ÙÈÎÔ‡ ÎÙ˘‹Ì·ÙÔ˜ Â›Ó·È Ó· ÚÔηϤÛÂÈ ıÏ›„Ë, ·ÓÈÎfi Î·È Û‡Á¯˘ÛË ÛÙËÓ ÎÔÈÓˆÓ›·. ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ¤Ó· Úfi‚ÏËÌ· ‰˘ÛÂ›Ï˘ÙÔ, ‰ÈfiÙÈ ÔÈ ÙÚÔÌÔÎÚ¿Ù˜ ¤¯Ô˘Ó ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÛÙfi¯Ô. O ÛÙÚ·ÙËÁfi˜ Col. Powell ÚÔÊËÙÈο ·Ó¤ÊÂÚ ÛÙÔ ∫ÔÁÎÚ¤ÛÔ ÙˆÓ ∏¶∞ (ª¿ÈÔ˜ 2001): “∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ÙÔ ÛÎÔÙÂÈÓfi ÎÔÌÌ¿ÙÈ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘. ∂›Ó·È Ï˘ËÚfi, ·ÏÏ¿ ¤ÙÛÈ Â›Ó·È. ŒÓ· ̤ÚÔ˜ ÙÔ˘ ÎfiÛÌÔ˘ ·Û¯ÔÏÂ›Ù·È Ì ÙËÓ ÙÚÔÌÔÎÚ·Ù›·”. ∂›¯·Ó ·Ú¤ÏıÂÈ ÌfiÓÔ ÙÚÂȘ Ì‹Ó˜ ·fi ÙËÓ ÔÌÈÏ›· ÙÔ˘ Col. Powell, fiÙ·Ó Â‹Ïı ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÛÙË ¡. ÀfiÚÎË. ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È Ì›· ηٿÛÙ·ÛË Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È, ·ÏÏ¿ ‰ÂÓ ÂÍÔ˘‰ÂÙÂÚÒÓÂÙ·È. ∏ ‰ËÌfiÛÈ· ˘Á›· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó· ·fi Ù· Ô˘ÛÈÒ‰Ë Ì¤ÙÚ· ηٿ Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜. ∏ ÈÛÙÔÚ›· ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ‰Â›¯ÓÂÈ Ò˜ ·Ó·Ù‡¯ıËÎÂ Ë ÙÚÔÌÔÎÚ·Ù›·. ∏ ¯ÒÚ· ·˘Ù‹ › 200 ¯ÚfiÓÈ· ›¯Â ÛÙÚ·ÙËÁÈ΋ ÛËÌ·Û›· ÁÈ· ÙȘ ·˘ÙÔÎÚ·ÙÔڛ˜. ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó, ÙÔ 1970, ¤ÁÈÓ ÙÔ Ì‹ÏÔ Ù˘ ¤ÚȉԘ ÌÂٷ͇ ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. OÈ ÎÔÌÌÔ˘ÓÈÛÙ¤˜ ÂÎıÚfiÓÈÛ·Ó ÙÔ ‚·ÛÈϤ· ™·¯ ÙÔ 1973 Î·È ÙÔ 1978 ‰ËÌÈÔ˘ÚÁ‹ıËΠÎÔÌÌÔ˘ÓÈÛÙÈ΋ ‰ÈÎÙ·ÙÔÚ›· Ô˘ Ô‰‹ÁËÛ Û ̷˙ÈΤ˜ ÂÎÙÂϤÛÂȘ ÙÔ˘ ·ÊÁ·ÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. OÈ ∏¶∞, ÔÈ Ôԛ˜ ˘ÔÛÙ‹ÚÈ˙·Ó ÙÔ ¶·ÎÈÛÙ¿Ó, ‰ËÌÈÔ‡ÚÁËÛ·Ó ·ÓÙ›ÛÙ·ÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó. ∆Ô 1989, Ô Úfi‰ÚÔ˜ °ÎÔÚÌ·ÙÛfiÊ ·Ó·ÁοÛÙËΠӷ ÙÂÏÂÈÒÛÂÈ ·˘ÙfiÓ ÙÔÓ ¯ÚfiÓÈÔ fiÏÂÌÔ.
Abstract: The last decades the hymn of the church “a peace over the land” is not praised but the hymn “a war over the land” is embraced. Terrorism thrives in countries with varying degrees of state failure. The purpose of the terroristic hit is to produce panic, confusion, and grief in the society. The terrorists will not be easy to eradicate from the society because such is the nature of terrorism. The General Colin Powell reported in the US senate in May 2001 that “Terrorism is part of the dark side of globalisation. However, sadly, it is part of doing business in the world”. His words were to prove prophetic because on Tuesday September 11, 2001, terrorism raised a threat on human life. Public health could be one of the important measures against terrorism. The history of Afghanistan reveals how the terrorism has been developed. For almost 200 years the country was a strategic spot for empires. The Russian-Iranian axis with US were against the Taliban (2001). Afghanistan people could be a little cynical to western politicians who promised peace to the Afghans. Afghanistan and Pakistan are both at the lowest level of child health care. Life-expectancy for men is 45.3 and women 47.2 (1999). Infant mortality rate per 1000 live births is 165; mortality rate in under 5 year-old is 257ò; adult illiteracy 74%, malnutrition 70% while use of betterment water service is 13%. Concerning the Middle East crisis it is obvious that both communities will support revenge as a normal and acceptable strategy. C. Bellamy noted that “Israelis and Palestinians teach their children to use terrorism increasing their acceptance of violence as a method
OÌ. ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ, πˆ¿ÓÓÈÓ·
Em. Professor of Pediatrics University of Ioannina Medical School, Ioannina
* ∞Ó·ÎÔÈÓÒıËΠÛÙË 12Ë ∂ÈÛÙËÌÔÓÈ΋ ∂Ή‹ÏˆÛË ¶·È‰È·ÙÚÈ΋˜, ™Â٤̂ÚÈÔ˜ 2002, πˆ¿ÓÓÈÓ·
* It was presented in the 12th Pediatric Scientific Conference, September 2002, Ioannina
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∆· ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ Ù˘ ¢‡Û˘ ·Ó¤ÊÂÚ·Ó ÂÏ¿¯ÈÛÙ· ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ì ·ÔÙ¤ÏÂÛÌ· Ë ¯ÒÚ· Ó· ÂÁηٷÏÂÈÊı› ÛÙÔÓ fiÏÂıÚÔ. OÈ ∆·ÏÈÌ¿Ó, ˘ÔÛÙËÚÈ˙fiÌÂÓÔÈ ·fi ÙÔ ¶·ÎÈÛÙ¿Ó, η٤Ϸ‚·Ó ÙËÓ ÂÍÔ˘Û›· Î·È ·ÓÙÈη٤ÛÙËÛ·Ó ÙÔ 1995 ÙÔ ÎÔÌÌÔ˘ÓÈÛÙÈÎfi ηıÂÛÙÒ˜ Ì ¤Ó·Ó ÚÔÈÎÈṲ̂ÓÔ, ·ÏÏ¿ ÂÍÙÚÂÌÈÛÙ‹ ÈÛÏ·ÌÈÛÙ‹ (Wahhabism). O ¿ÍÔÓ·˜ ƒˆÛ›·˜-πÚ¿Ó Ì·˙› Ì ÙȘ ∏¶∞ ‹Ù·Ó ÂÓ·ÓÙ›ÔÓ ÙˆÓ ∆·ÏÈÌ¿Ó. OÈ ˘ÔÛ¯¤ÛÂȘ ÙˆÓ ÔÏÈÙÈÎÒÓ ÙÔ˘ ‰˘ÙÈÎÔ‡ ÎfiÛÌÔ˘ ÁÈ· ÂÈÚ‹Ó¢ÛË ÛÙËÓ ÂÚÈÔ¯‹ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ΢ÓÈÛÌfi ·fi ÙÔ˘˜ ∞ÊÁ·ÓÔ‡˜. O ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘ ηٿ ÙÔ ¤ÙÔ˜ 1999 ÁÈ· ÙÔ˘˜ ¿Ó‰Ú˜ ‹Ù·Ó 45,3 ¯ÚfiÓÈ· Î·È ÁÈ· ÙȘ Á˘Ó·›Î˜ 47,2. ∏ ÓÂÔÁÓÈ΋ ıÓËÛÈÌfiÙËÙ· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 165ò, ÂÓÒ ÛÙȘ ∏¶∞ ÛÙÔ 7ò. ∆Ô ÔÛÔÛÙfi ÙˆÓ ·Ó·ÏÊ¿‚ËÙˆÓ ÛÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ·Ó¤Ú¯ÂÙ·È ÛÙÔ 64% Î·È ÛÙȘ ∏¶∞ ÛÙÔ 1%. O ˘ÔÛÈÙÈÛÌfi˜ ÛÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ ·Ó¤Ú¯ÂÙ·È Û 70% ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È 0% ÛÙËÓ ∞ÌÂÚÈ΋. ∫·ı·Úfi, fiÛÈÌÔ ÓÂÚfi Â›Ó·È ‰È·ı¤ÛÈÌÔ ÛÙÔ 13% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ 100% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ∞ÌÂÚÈ΋˜. ™Â ¤Ó· ÙÌ‹Ì· Ù˘ ∆¯ÂÚ¿Ó˘, Ë ·ÚÔ¯‹ ÓÂÚÔ‡ ‰È·ÎfiÙÂÙ·È 12 ÒÚ˜ ÙËÓ Â‚‰ÔÌ¿‰·. ∞ÍȈ̷ÙÔ‡¯ÔÈ ÙÔ˘ ¶·ÎÈÛÙ¿Ó ·Ó¤ÊÂÚ·Ó fiÙÈ ÏfiÁˆ ÍËÚ·Û›·˜ ˘‹ÚÍ·Ó ·ÒÏÂȘ 1,2 ‰ÈÛÂηÙÔÌÌ˘Ú›ˆÓ ‰ÔÏ·Ú›ˆÓ ∞ÌÂÚÈ΋˜ ÂÎ ÙˆÓ ·ÁÚÔÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ. ™¯Â‰fiÓ ÌÈÛfi ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ÛÙÔÓ Ï·Ó‹ÙË Ì·˜ ‰ÂÓ ¤¯Ô˘Ó ¿ÚÎÂÈ· ·ÚÔ¯‹˜ ÓÂÚÔ‡ Î·È ·Ó ‰ÂÓ ÏËÊıÔ‡Ó Ì¤ÙÚ·, ÙÔ 2025 ÙÔ 35% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ ı· ¤¯ÂÈ Ï›·Ó ÌÂȈ̤ÓË ·ÚÔ¯‹ ÓÂÚÔ‡ (ۯ‰fiÓ 2,8 ‰ÈÛÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ). ∏ ÌÂȈ̤ÓË ·ÚÔ¯‹ ÓÂÚÔ‡ ‰ËÌÈÔ˘ÚÁ› ÎÔÈÓˆÓÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ Âڋ̈ÛË Î·È Èı·ÓÒ˜ “ÌÂÙ·Ó¿ÛÙ˜ ‡‰·ÙÔ˜”. ∆Ô 1998, Ë ¤ÎıÂÛË ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ OÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜ ·Ó·Ê¤ÚÂÈ fiÙÈ ··ÈÙÔ‡ÓÙ·È 10 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÙÔ ¯ÚfiÓÔ ÁÈ· Ó· ÂÊԉȷÛÙ› fiÏÔ˜ Ô ÏËı˘ÛÌfi˜ Ù˘ Á˘ Ì ηı·Úfi ÓÂÚfi. ∞˘Ùfi ÙÔ ÎfiÛÙÔ˜ ÈÛÔ‰˘Ó·Ì› Ì ÙÔ 1/10 ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ÍÔ‰Â‡Ô˘Ó ÔÈ ∂˘Úˆ·›ÔÈ ÁÈ· ·ÏÎÔÔÏÔ‡¯· ÔÙ¿ ‹ Ì ÙÔ ‹ÌÈÛ˘ ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ηٷӷÏÒÓÔ˘Ó ∞ÌÂÚÈηÓÔ› Î·È ∂˘Úˆ·›ÔÈ Î¿ı ¯ÚfiÓÔ ÁÈ· ˙ˆÔÙÚÔʤ˜ ÙˆÓ Î·ÙÔÈΛ‰ÈˆÓ ˙ÒˆÓ ÙÔ˘˜. ∞fi ÙËÓ ÎÚ›ÛË ÛÙË ª¤ÛË ∞Ó·ÙÔÏ‹ Ê·›ÓÂÙ·È fiÙÈ ÙfiÛÔ ÔÈ πÛÚ·ËÏÈÓÔ› fiÛÔ Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ıˆÚÔ‡Ó ÙËÓ Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·Ùfi˜ ÙÔ˘˜ ÂÊÈÎÙ‹ Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ú¿ÍÂˆÓ ÂΉ›ÎËÛ˘ Î·È ‚›·˜. O ‰È¢ı˘ÓÙ‹˜ Ù˘ UNICEF C. Bellamy ·Ó¤ÊÂÚ fiÙÈ ÔÈ πÛÚ·ËÏÈÓÔ› Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ‰È‰¿ÛÎÔ˘Ó ÛÙ· ·È‰È¿ ÙÔ˘˜ ÙËÓ ÙÚÔÌÔÎÚ·Ù›· ˆ˜ ̤ıÔ‰Ô Â›Ï˘Û˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘˜. OÈ Î˘‚ÂÚÓ‹ÛÂȘ Ù˘ ∂Ó. ∂˘ÚÒ˘ Î·È ÙˆÓ ∏¶∞ Ô˘ ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ Â›Ó·È ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÂÈÚ‹Ó˘ ÛÙÔÓ ÎfiÛÌÔ, Ú¤ÂÈ Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó ÒÛÙ ÌÂÙ¿ ÙËÓ Î·Ù¿·˘ÛË ÙˆÓ Â¯ıÚÔÚ·ÍÈÒÓ Ó· ÂÈÌÂÏËıÔ‡Ó ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜, ‰ÈfiÙÈ Ô ¿Ì·¯Ô˜ ÏËı˘ÛÌfi˜
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for resolving problems”. In old days there was one Herod but nowadays there are many. Christ will not be born again but he continues to suffer in the Middle East on behalf of innocent civilian victims who die in the street, bus, school or their houses.
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¶·È‰È·ÙÚÈ΋ 2003;66:82-88
Paediatriki 2003;66:82-88
Â›Ó·È Ù·Ï·ÈˆÚË̤ÓÔ˜, ηÎÔÔÈË̤ÓÔ˜ Î·È ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜. O Benjamin Disraeli ·Ó·Ê¤ÚÂÈ ÙÔ 1877 fiÙÈ “Ë ˘Á›· ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È Ë Ú·ÁÌ·ÙÈ΋ ıÂÌÂÏ›ˆÛ˘ Ù˘ Â˘Ù˘¯›·˜ Î·È Ù˘ ‰‡Ó·Ì˘ ÁÈ· Ì›· ·ÓÂÍ¿ÚÙËÙË ÔÏÈÙ›·”. ∆ËÓ ÂÔ¯‹ Ô˘ ÁÂÓÓ‹ıËÎÂ Ô ÃÚÈÛÙfi˜ ˘‹Ú¯Â ¤Ó·˜ ∏Ú҉˘. ™‹ÌÂÚ·, Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ô˘ ˘ÈÔıÂÙÔ‡Ó ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ Î·È ÌÂıÔ‡Ó ·fi ÙÔ ·›Ì· ÙˆÓ ÛÊ·ÁÒÓ Î·È ÙȘ ÊÔÓÈΤ˜ ÂÎÚ‹ÍÂȘ. O ÃÚÈÛÙfi˜ ›Ûˆ˜ ‰ÂÓ ı· Í·Ó·ÁÂÓÓËı›, ·ÏÏ¿ ÂÍ·ÎÔÏÔ˘ı› Ó· ÛÙ·˘ÚÒÓÂÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ ÔϤÌÔ˘, ÛÙÔ ÚfiÛˆÔ ·ıÒˆÓ ı˘Ì¿ÙˆÓ Ô˘ ·Ê‹ÓÔ˘Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÓÔ‹ ÙÔ˘˜ ÛÙÔ ‰ÚfiÌÔ, ÛÙÔ ÏˆÊÔÚ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô ‹ οو ·fi ÙË ‚ÔÌ‚·Ú‰ÈṲ̂ÓË ÛÙ¤ÁË ÙÔ˘ ÛÈÙÈÔ‡ ÙÔ˘˜. §¤ÍÂȘ ÎÏÂȉȿ: ‰ËÌfiÛÈ· ˘Á›·, ÂÈÚ‹ÓË, ÙÚÔÌÔÎÚ·Ù›·.
Key words: public health, peace, terrorism.
“∫·› â› Áɘ ÂåÚ‹ÓË” ‰È·ÎËÚ‡ÛÛÂÙ·È ÛÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ Ù˘ °¤ÓÓËÛ˘ ÙÔ˘ £Â·ÓıÚÒÔ˘. OÈ “ÌÂÁ¿ÏÔÈ” fï˜ Ù˘ Á˘ ·Û¿˙ÔÓÙ·È ÙÔ ÙÚÔ¿ÚÈÔ “∫·› â› Áɘ fiÏÂÌÔ˜” (1). ∆· ÎÚÔ‡ÛÌ·Ù· ÙˆÓ ÙÚÔÌÔÎÚ·ÙÈÎÒÓ ÎÙ˘ËÌ¿ÙˆÓ ¤¯Ô˘Ó ·˘ÍËı› Û ¯ÒÚ˜ Ì ÔÏÈÙÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ ·ÛÙ¿ıÂÈ· fiˆ˜ Ë ∞ÏÁÂÚ›·, ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë µfiÚÂÈ· πÚÏ·Ó‰›·, ÙÔ πÚ¿Î, Ë ∫ÔÏÔÌ‚›·, Ë ¶·Ï·ÈÛÙ›ÓË Î·È ÙÔ ™Ô˘‰¿Ó. ∞˘Ù¤˜ ÔÈ ¯ÒÚ˜ ‰È·ÎÚ›ÓÔÓÙ·È Î·È ÁÈ· ÙËÓ ¿ÓÈÛË Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂıÓÈÎÔ‡ ÏÔ‡ÙÔ˘. O Pillar, ·Ú¯ËÁfi˜ Ù˘ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈ΋˜ ÔÚÁ¿ÓˆÛ˘ ÙˆÓ ∏¶∞, Ô ÔÔ›Ô˜ ‹Ù·Ó ·Ú¯ËÁfi˜ Ù˘ CIA (Central Intelligence Agency), ÛÙÔ ‚È‚Ï›Ô “∏ ÙÚÔÌÔÎÚ·Ù›· Î·È Ë Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Ù˘ ∞ÌÂÚÈ΋˜” ÈÛ¯˘Ú›˙ÂÙ·È fiÙÈ Ë ÙÚÔÌÔÎÚ·Ù›· ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Î·È fi¯È Ì ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈο ̤ÙÚ· fiˆ˜ ‰Èψ̷ٛ·, ·Ú·ÓÔÌ›·, ÛÙÚ·ÙȈÙÈ΋ ‚›· Î·È ÔÈÎÔÓÔÌÈÎfi ÂÌ¿ÚÁÎÔ (2). ∞˘Ù¿ ÎÚ›ÓÔÓÙ·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈο Î·È ‰ÂÓ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ‡ÊÂÛË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜. ¢ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È ‰Èı‡Ú·Ì‚ÔÈ Î·È Ê·ÓÊ·ÚÔÓÈÛÌÔ›. O ÛÙÚ·ÙËÁfi˜ Col. Powell ÚÔÊËÙÈο ·Ó¤ÊÂÚ ÛÙËÓ ÔÌÈÏ›· ÙÔ˘ ÙÔÓ ª¿ÈÔ ÙÔ˘ 2001 ÛÙÔ ∫ÔÁÎÚ¤ÛÔ: “∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ÙÔ ÛÎÔÙÂÈÓfi ÎÔÌÌ¿ÙÈ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘. ∂›Ó·È Ï˘ËÚfi, ·ÏÏ¿ ¤ÙÛÈ Â›Ó·È. ŒÓ· ̤ÚÔ˜ ÙÔ˘ ÎfiÛÌÔ˘ ·Û¯ÔÏÂ›Ù·È Ì ÙËÓ ÙÚÔÌÔÎÚ·Ù›·”. ∏ ÙÚÔÌÔÎÚ·Ù›· ·ÔÙÂÏ› ‰˘ÛÂ›Ï˘ÙÔ Úfi‚ÏËÌ·, ηıÒ˜ ÔÈ ÙÚÔÌÔÎÚ¿Ù˜ ‰È·ı¤ÙÔ˘Ó ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÛÙfi¯Ô Î·È ÂÓÂÚÁÔ‡Ó Ì ÚÔÛÂÎÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜. ∂›Û˘, Ô ¯ÚfiÓÔ˜ Î·È Ô ÙfiÔ˜ Ì›·˜ ÙÚÔÌÔÎÚ·ÙÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ηıÔÚ›˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ·fi ÙÔ˘˜ ‰Ú¿ÛÙ˜. ŒÙÛÈ, ÔÔÈÔ‰‹ÔÙ ̤ÙÚÔ ·ÛÊ¿ÏÂÈ·˜ Û ·ÂÚÔÏ¿Ó· ‹ ·ÂÚÔ‰ÚfiÌÈ·, fiˆ˜ ÛÙÚ·ÙȈÙÈΤ˜ ‰˘Ó¿ÌÂȘ, Â›Ó·È ·Ó·ÚΤ˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÙÚÔÌÔÎÚ·ÙÒÓ. ∆Ô ÙÚÔÌÔÎÚ·ÙÈÎfi ÎÙ‡ËÌ· ÚÔηÏ› „˘¯ÔÏÔÁÈ-
ο ÙÚ·‡Ì·Ù·, ıÏ›„Ë, ·ÓÈÎfi Î·È Û‡Á¯˘ÛË (3). ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÈÙÈ΋˜ Î·È ÎÔÈÓˆÓÈ΋˜ ·ÏÏ·Á‹˜. ªÂÙ¿ ÙÔ ıÏÈ‚ÂÚfi ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ 2001 ÛÙË ¡. ÀfiÚÎË, Ë Â͈ÙÂÚÈ΋ ·ÌÂÚÈηÓÈ΋ ÔÏÈÙÈ΋ ÛÙËÚ›¯ÙËΠÛÙË ÛÙÚ·ÙȈÙÈ΋ ÈÛ¯‡ Î·È ¯ÚËÛÈÌÔÔ›ËÛ ÙË ÁÏÒÛÛ· Ù˘ ·ÓÙÂΉ›ÎËÛ˘. O ªÔ˘˜ ˙‹ÙËÛ ·fi fiÏ· Ù· ÔÏÈÙÈṲ̂ӷ ÎÚ¿ÙË Ó· Û˘ÓÂÚÁ·ÛÙÔ‡Ó ÁÈ· Ó· ÂΉÈÒÍÔ˘Ó ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÙÔ˘˜ ∆·ÏÈÌ¿Ó, ÔÈ ÔÔ›ÔÈ ›Ûˆ˜ ¤¯Ô˘Ó ÚÔηϤÛÂÈ ÎfiˆÛË ÛÙÔ Ï·fi ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. ∏ Ù·ÎÙÈ΋ ·˘Ù‹ ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ ÌË ÔÚı‹. OÈ ∞ÌÂÚÈηÓÔ› ÏËÛÌfiÓËÛ·Ó ÙËÓ È·ÙÚÈ΋ Î·È ÙË ‰ËÌfiÛÈ· ˘Á›·, ÔÈ Ôԛ˜ ·›˙Ô˘Ó ¤Ó·Ó ¤ÌÌÂÛÔ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÂÈÚ‹Ó˘ Î·È ÙË ÛÙ·ıÂÚfiÙËÙ· Û ¯ÒÚ˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ‰È¿Ï˘ÛË Î·È Î·Ù¿ÙˆÛË. ∏ ‰ËÌfiÛÈ· ˘Á›· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÙÔ Î·Ï‡ÙÂÚÔ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈÎfi ̤ÙÚÔ Ô˘ ·ÎfiÌË, fï˜, ‰ÂÓ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı›. ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó ‰ÂÓ Â›Ó·È ÔÌÔÈÔÁÂÓ¤˜ ÎÚ¿ÙÔ˜. Œ¯ÂÈ 22 ÂηÙÔÌ̇ÚÈ· ÏËı˘ÛÌfi Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ∆·˙›ÎÔ˘˜, O˘˙̤ÎÔ˘˜ Î·È ¶·ÛÙÔ‡Ó˜. OÈ ∆·ÏÈÌ¿Ó ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ˘˜ ¶·ÛÙÔ‡Ó˜. ∏ ÚfiÛÊ·ÙË ÈÛÙÔÚ›· ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ‰Â›¯ÓÂÈ fiÙÈ ‹Ù·Ó Ì›· ¯ÒÚ· ÂÈÚÚ‹˜ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜, ‰ÈfiÙÈ Â› ‰‡Ô ·ÈÒÓ˜ ‹Ù·Ó ÛÙÚ·ÙËÁÈ΋ ı¤ÛË ÁÈ· ·˘ÙÔÎÚ·ÙÔڛ˜ Û ·ÎÌ‹ ‹ ·Ú·ÎÌ‹. ∆Ô 1970, ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ¤ÁÈÓ ÙÔ Ì‹ÏÔ Ù˘ ¤ÚȉԘ ÌÂٷ͇ ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ∆Ô 1973, ÔÈ ÎÔÌÌÔ˘ÓÈÛÙ¤˜ ÂÎıÚfiÓÈÛ·Ó ÙÔ ‚·ÛÈϤ· ™·¯. ∆Ô 1978 ¤ÁÈÓ ÎÔÌÌÔ˘ÓÈÛÙÈ΋ ‰ÈÎÙ·ÙÔÚ›·, Ë ÔÔ›· Ô‰‹ÁËÛ Û ̷˙ÈΤ˜ ÂÎÙÂϤÛÂȘ ÙÔ˘ ·ÊÁ·ÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. OÈ ∏¶∞ Ô˘ ˘ÔÛÙ‹ÚÈ˙·Ó ÙÔ ¶·ÎÈÛÙ¿Ó ‰ËÌÈÔ‡ÚÁËÛ·Ó ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ·ÓÙ›ÛÙ·ÛË. ∞˘Ù‹ Ë ¯ÚfiÓÈ· Û‡ÚÚ·ÍË ·Ó¿ÁηÛ ÙÔ 1989 ÙÔÓ Úfi‰ÚÔ °ÎÔÚÌ·ÙÛfiÊ Ó· ÙÂÚÌ·Ù›ÛÂÈ ÙÔÓ fiÏÂÌÔ. ∆·
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¶·È‰È·ÙÚÈ΋ 2003;66:82-88
̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ Ù˘ ¢‡Û˘ ·Ó¤ÊÂÚ·Ó ÂÏ¿¯ÈÛÙ· ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, ÌÂ Û˘Ó¤ÂÈ· Ë ¯ÒÚ· Ó· ÂÁηٷÏÂÈÊı› ÛÙÔÓ fiÏÂıÚÔ. ™ÎÔÙÒıËÎ·Ó 1,5 ÂηÙÔÌ̇ÚÈÔ Ôϛ٘, ÂÓÒ 6 ÂηÙÔÌ̇ÚÈ· ‹Ú·Ó ÙÔ ‰ÚfiÌÔ Ù˘ ÚÔÛÊ˘ÁÈ¿˜ ÚÔ˜ ÙÔ πÚ¿Ó Î·È ÙÔ ¶·ÎÈÛÙ¿Ó. ŒÓ·˜ ÙÚÔÌÂÚfi˜ ÂÌʇÏÈÔ˜ fiÏÂÌÔ˜ ·Ó·Ù‡¯ıËΠÛÙËÓ ÂÚÈÔ¯‹ ·fi ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ∆Ô 1995, ÔÈ ∆·ÏÈÌ¿Ó ˘ÔÛÙËÚÈ˙fiÌÂÓÔÈ ·fi ÙÔ ¶·ÎÈÛÙ¿Ó, ‹Ú·Ó ÙËÓ ÂÍÔ˘Û›· Î·È ·ÓÙÈη٤ÛÙËÛ·Ó ÙÔ ÎÔÌÌÔ˘ÓÈÛÙÈÎfi ηıÂÛÙÒ˜ ·fi ¤Ó·Ó ÚÔÈÎÈṲ̂ÓÔ, ·ÏÏ¿ ÂÍÙÚÂÌÈÛÙ‹ πÛÏ·ÌÈÛÙ‹ (Wahhabism). ∆Ô 2001, ÔÈ ∏¶∞ ˘ÔÛÙËÚÈ˙fiÌÂÓ˜ ·fi ÙË ƒˆÛ›· Î·È ÙÔ πÚ¿Ó, ‰ËÌÈÔ‡ÚÁËÛ·Ó ¤Ó·Ó ¿ÍÔÓ· ηٿ ÙˆÓ ∆·ÏÈÌ¿Ó. ∂·Ó¤ÊÂÚ·Ó ÙÔÓ ‚·ÛÈÏÈ¿ ™·¯ Û ËÏÈΛ· 86 ÂÙÒÓ. OÈ ÔÏÈÙÈÎÔ› Ù˘ ¢‡Û˘ ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÎÏ‹ÛÛÔÓÙ·È fiÙ·Ó Ô ÏËı˘ÛÌfi˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È Î˘ÓÈÎfi˜ ÁÈ· ÙËÓ ÂÈÚ‹ÓË Ô˘ ÙÔ˘˜ ÂÁÁ˘‹ıËηÓ. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ OÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜, Ë ¯ÒÚ· ·˘Ù‹ ¤¯ÂÈ Ôχ ¯·ÌËÏfi Â›Â‰Ô ÊÚÔÓÙ›‰·˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜, η٤¯ÔÓÙ·˜ ÙËÓ 173Ë ı¤ÛË Û ۇÓÔÏÔ 191 ¯ˆÚÒÓ. ™ÙÔ ¶·ÎÈÛÙ¿Ó Î·È ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, ÙÔ Â›Â‰Ô ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ ‚Ú›ÛÎÂÙ·È ÛÙÔ Î·ÙÒÙ·ÙÔ Â›Â‰Ô, ‰ËÏ·‰‹ ·ÎfiÌË ¯·ÌËÏfiÙÂÚ· Î·È ·fi ÙË ™·¯¿Ú· Ù˘ ∞ÊÚÈ΋˜. ∆Ô 1999, Ô ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘ ÁÈ· ÙÔ˘˜ ¿Ó‰Ú˜ ‹Ù·Ó Ù· 45,3 ¯ÚfiÓÈ· Î·È ÁÈ· ÙȘ Á˘Ó·›Î˜ Ù· 47,2. ™ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, 165/1000 ·È‰È¿ Âı·›ÓÔ˘Ó Î·Ù¿ ÙË Á¤ÓÓËÛË, ÂÓÒ ÛÙËÓ ∞ÌÂÚÈ΋ 7/1000. ™Ù· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ, Âı·›ÓÔ˘Ó 257/1000 Î·È 8/1000 ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙȘ ∏¶∞, ·ÓÙ›ÛÙÔȯ·. ™ÙȘ ËÏÈ˘ ¿Óˆ ÙˆÓ 15 ÂÙÒÓ, ÙÔ 64% ÙˆÓ ∞ÊÁ·ÓÒÓ Â›Ó·È ·Ó·ÏÊ¿‚ËÙÔÈ, ÂÓÒ ÛÙȘ ∏¶∞ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ·Ó¤Ú¯ÂÙ·È ÌfiÏȘ Û 1%. O ˘ÔÛÈÙÈÛÌfi˜ ÛÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È 70% Î·È 0% ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙËÓ ∞ÌÂÚÈ΋, ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Î·ı·Úfi Î·È fiÛÈÌÔ ÓÂÚfi ·Ú¤¯ÂÙ·È ÛÙÔ 13% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ 100% ÙˆÓ ∞ÌÂÚÈηÓÒÓ (3). ∆Ô Û‡ÛÙËÌ· ˘Á›·˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Û¯Â‰fiÓ Î·Ù¤ÚÚ¢Û ٷ ÙÂÏÂ˘Ù·›· ‰‡Ô ¯ÚfiÓÈ·. ∏ ÍËÚ·Û›· Î·È Ô fiÏÂÌÔ˜ ÚÔοÏÂÛ·Ó ÌÂÙ·Ó¿ÛÙ¢ÛË ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó Î·È ÙÔ πÚ¿Ó. ¢‡Ô ÂηÙÔÌ̇ÚÈ· ∞ÊÁ·ÓÔ› ÎÈÓ‹ıËÎ·Ó ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó Î·È 1.500.000 ÛÙÔ πÚ¿Ó. ªÂ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ‚ÔÌ‚·Ú‰ÈÛÌÒÓ, ¯ÈÏÈ¿‰Â˜ ¿ÓıÚˆÔÈ ¤Ê˘Á·Ó ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó, ÙÔ πÚ¿Ó Î·È ¿ÏϘ ÁÂÈÙÔÓÈΤ˜ ¯ÒÚ˜. ∆Ô ÌÂÙ·Ó·ÛÙ¢ÙÈÎfi ·̷ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙ· ÔÎÙÒ ÂηÙÔÌ̇ÚÈ·. O ÏÈÌfi˜ ‹‰Ë Ì·ÛÙ›˙ÂÈ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙÔ˘ ÏËı˘ÛÌÔ‡. ∫¿Ùˆ ·fi ·˘Ù¤˜ ÙȘ Û˘Óı‹Î˜, ηӤӷ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈÎfi ̤ÙÚÔ ‰ÂÓ ÚfiÎÂÈÙ·È Ó· ·Ô‰ÒÛÂÈ. ¶Ú¤ÂÈ Ó· ‚ÚÂıÔ‡Ó ÙÚfiÔÈ
Paediatriki 2003;66:82-88
‚Ô‹ıÂÈ·˜ ÙˆÓ ÏËı˘ÛÌÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ΛӉ˘ÓÔ (populations at risk), ·Ú¿ ̤ıÔ‰ÔÈ ÙÈ̈ڛ·˜. O Lafeet Afridi, ·ÍȈ̷ÙÔ‡¯Ô˜ ÙÔ˘ ¶·ÎÈÛÙ¿Ó, ·Ó¤ÊÂÚ fiÙÈ Ë ¢‡ÛË Ú¤ÂÈ Ó· ÎÙ›ÛÂÈ Û¯ÔÏ›· Î·È ÓÔÛÔÎÔÌ›· ÙÔ Ù·¯‡ÙÂÚÔ, ‰ÈfiÙÈ ÔÈ Û˘Ì·ıÔ‡ÓÙ˜ ÚÔ˜ ÙÔ˘˜ ∆·ÏÈÌ¿Ó ı· Ï¿‚Ô˘Ó Ì¤ÚÔ˜ ÛÙÔÓ fiÏÂÌÔ Î·È ı· Á›ÓÔ˘Ó ÂÈÚ·Ù¤˜ (3). ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È ÙÔ ı‡Ì· ÙˆÓ Î˘‚ÂÚÓ‹ÛÂˆÓ Ô˘ ı¤ÏÔ˘Ó Ó· ηٷÔÏÂÌ‹ÛÔ˘Ó ÙËÓ ÙÚÔÌÔÎÚ·Ù›·. ∏ ÔÏÈÙÈ΋ ÙˆÓ ‰˘ÙÈÎÒÓ ‰˘Ó¿ÌÂˆÓ Ú¤ÂÈ Ó· Â›Ó·È Ì·ÎÚÔ¯ÚfiÓÈ· Î·È Ó· ¤¯ÂÈ ÙÚÈÏ‹ ηÙ‡ı˘ÓÛË: ˘Á›·, ·Ó¿Ù˘ÍË Î·È ·ÓıÚÒÈÓ· ‰ÈηÈÒÌ·Ù·. ∞˘Ù¿ Ú¤ÂÈ Ó· ·ÔÙÂÏÔ‡Ó ÙÔ ÛÙÚ·ÙËÁÈÎfi ÎÏÂȉ› Ù˘ ¢‡Û˘. ∏ Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Â›Ó·È Û˘Ó‹ıˆ˜ ‚Ú·¯˘ÚfiıÂÛÌË Î·È ÂÛÙÈ¿˙ÂÙ·È ÛÙȘ ¿ÌÂÛ˜ ÔÏÈÙÈΤ˜ Î·È ÛÙÚ·ÙȈÙÈΤ˜ ÂȉÈÒÍÂȘ. ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó, Ù· ∏ӈ̤ӷ ŒıÓË ¤ÛÙÚ„·Ó fiÏË ÙËÓ ÚÔÛÔ¯‹ Û ¤Ó· ÚfiÛˆÔ Î·È ›ÂÛ·Ó ÙÔ˘˜ ∆·ÏÈÌ¿Ó Ó· ·Ú·‰ÒÛÔ˘Ó ÙÔÓ Osama Bin Laden. ∞ÁÓfiËÛ·Ó ÙȘ ÂȉڿÛÂȘ ÛÙËÓ ˘Á›· Î·È ·¤Ù˘¯·Ó ÛÙËÓ ¿Ù·ÍË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜. OÈ ‰˘ÙÈΤ˜ ‰˘Ó¿ÌÂȘ Ú¤ÂÈ Ó· ȤÛÔ˘Ó ÙÔ˘˜ ¢ÈÂıÓ›˜ OÚÁ·ÓÈÛÌÔ‡˜ Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔÓ ¿Û¯ÔÓÙ· ÏËı˘ÛÌfi. ¶·Ú¿ÏÏËÏ·, Ú¤ÂÈ Ó· ÌÂÚÈÌÓ‹ÛÔ˘Ó ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ (¿ÚÎÂÈ· fiÛÈÌÔ˘ ÓÂÚÔ‡, ·ÔÊ˘Á‹ ÍËÚ·Û›·˜ Î.Ï.). O ¶·ÁÎfiÛÌÈÔ˜ OÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ (¶OÀ) ¤ÛÙÂÈÏ 10.000 ÙfiÓÔ˘˜ ÛÈÙ¿ÚÈ ÁÈ· ÙÔ˘˜ ÌÂÙ·Ó¿ÛÙ˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· ∆Ú¿Â˙·, ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ 2001 ÛÙȘ ∏¶∞ ı· ¤¯ÂÈ ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÔÈÎÔÓÔÌ›· ÙˆÓ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ ¯ˆÚÒÓ. ∫·Ù¿ ÙÔÓ Devaragan, ı· Âı¿ÓÔ˘Ó 20.000-40.000 ÂÚÈÛÛfiÙÂÚ· ·È‰È¿, ÂÓÒ ÂÚ›Ô˘ 10 ÂηÙÔÌ̇ÚÈ· ÂÈϤÔÓ ¿ÓıÚˆÔÈ ı· ˙‹ÛÔ˘Ó Ì ¤Ó· ‰ÔÏ¿ÚÈÔ ÙËÓ Ë̤ڷ. OÈ ˘Ô·Ó¿Ù˘ÎÙ˜ ¯ÒÚ˜ ı· ÂÚÈÔÚ›ÛÔ˘Ó ÙȘ ‰·¿Ó˜ ÁÈ· ÙË ‰ËÌfiÛÈ· ˘Á›·, ‰ËÏ·‰‹ ÙË ‰·¿ÓË ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· Aids, Ê˘Ì·Ù›ˆÛË, ÂÏÔÓÔÛ›· Î·È ÌËÙÚÈ΋ ˘Á›·. ∂Ô̤ӈ˜, ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÚÔοÏÂÛ ÌÂÁ·Ï‡ÙÂÚË ÔÈÎÔÓÔÌÈ΋ ‰˘ÛÙ˘¯›· ÛÙȘ ÊÙˆ¯¤˜ ·’ fiÙÈ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜. O ¶OÀ ˘ÔÏÔÁ›˙ÂÈ fiÙÈ ÙÔ 2005 ı· ¤¯ÂÈ ÂÍ·Ê·ÓÈÛÙ› Ë ÔÏÈÔÌ˘ÂÏ›Ùȉ· ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ ¶·ÎÈÛÙ¿Ó. ∫·È ÔÈ ‰‡Ô ¯ÒÚ˜ ÛËÌ›ˆÛ·Ó ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô ÛÙË Ì›ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜. ªÂÙ¿ ÙËÓ Â›ıÂÛË Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÛÙË ¡. ÀfiÚÎË ÙˆÓ ∏¶∞, 1,5 ÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÌÂÙ·Ó¿ÛÙÂ˘Û·Ó ÛÙ· Û‡ÓÔÚ· ÙÔ˘ ¶·ÎÈÛÙ¿Ó, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÙÔ 20% ‹Ù·Ó ·È‰È¿. §fiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÌË ÂÌ‚ÔÏÈ·ÛÌ¤ÓˆÓ ·È‰ÈÒÓ, ·Ó·Ì¤ÓÂÙ·È ÂȉËÌ›· ÈÏ·Ú¿˜ Î·È ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙÔ ¶·ÎÈÛÙ¿Ó.
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¶·È‰È·ÙÚÈ΋ 2003;66:82-88
∆Ô ™Â٤̂ÚÈÔ ÙÔ˘ 2001 ›¯Â ÚÔÁÚ·ÌÌ·ÙÈÛÙ› Ì·˙ÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙ· ·È‰È¿ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó, Ô ·ÚÈıÌfi˜ ÙˆÓ ÔÔ›ˆÓ ÛÙËÓ ËÏÈΛ· οو ÙˆÓ 5 ÂÙÒÓ ·Ó¤Ú¯ÂÙ·È Û 5 ÂηÙÔÌ̇ÚÈ·. §fiÁˆ ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ‚ÔÌ‚·Ú‰ÈÛÌÒÓ, Ù· ·È‰È¿ ÌÂÙ·ÎÈÓ‹ıËÎ·Ó ·fi Ù· ·ÛÙÈο ΤÓÙÚ· ÚÔ˜ ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜. ŒÙÛÈ ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÓÙÔÈÛÙÔ‡Ó Î·È Ó· ÂÌ‚ÔÏÈ·ÛÙÔ‡Ó. ª¤¯ÚÈ ÙÔ ™Â٤̂ÚÈÔ ÙÔ˘ 2000, ·Ó·Ê¤ÚıËÎ·Ó 9 ÂÚÈÙÒÛÂȘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È 50 ÛÙÔ ¶·ÎÈÛÙ¿Ó. ¡¤· ÂıÓÈ΋ Ë̤ڷ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÚÔÁÚ·ÌÌ·Ù›ÛÙËÎÂ Ë 8Ë ¡ÔÂÌ‚Ú›Ô˘ 2001, ȉȷ›ÙÂÚ· ÁÈ· Ù· ·È‰È¿ ÙˆÓ ÌÂÙ·Ó·ÛÙÒÓ Ô˘ ‹Ù·Ó ÛÙ· Û‡ÓÔÚ· Ì ÙÔ ¶·ÎÈÛÙ¿Ó. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ OÎÙˆ‚Ú›Ô˘ 2001 ‰È·Ù¤ıËÎ·Ó ·fi ÙË UNICEF 35 ÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó. O ¶OÀ ·Ó¤ÊÂÚ fiÙÈ Ù· ÔÈÎÔÓÔÌÈο ÎÂÊ¿Ï·È· ‹Ù·Ó ÌÈÎÚ¿ ÁÈ· Ó· ηχ„Ô˘Ó ÙȘ ·Ó¿ÁΘ ˘Á›·˜ Î·È ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ. O Kofi Annan ÂÂÛ‹Ì·Ó fiÙÈ ¯ÚÂÈ¿˙ÔÓÙ·È 854 ÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÁÈ· Ó· ‚ÔËı‹ÛÔ˘Ó 7,5 ÂηÙÔÌ̇ÚÈ· ∞ÊÁ·ÓÔ‡˜ ÁÈ· 6 Ì‹Ó˜ (4). ∆· ∏ӈ̤ӷ ŒıÓË ‰È·›ÛÙˆÛ·Ó fiÙÈ ÌÂÙ¿ ·fi 23 ¯ÚfiÓÈ· ÂÌfiÏÂÌ˘ ηٿÛÙ·Û˘ Î·È 3 ¯ÚfiÓÈ· ÌÂÁ¿Ï˘ ÍËÚ·Û›·˜, ÔÈ Û˘Óı‹Î˜ ˙ˆ‹˜ ¤¯Ô˘Ó ÂȉÂÈÓˆı› ÛÙËÓ ÂÚÈÔ¯‹. ªÂÙ¿ ·fi ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘, ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÙÔ˘ OÎÙˆ‚Ú›Ô˘ 2001, ¤Êı·Ó·Ó ÛÙË ∫·ÌÔ‡Ï 218 ÙfiÓÔÈ ÛÈÙ·ÚÈÔ‡. ∏ ÌÂÁ¿ÏË ÍËÚ·Û›· ÚÔοÏÂÛ ·Ûı¤ÓÂÈ· ÙÔ˘ ‹·ÙÔ˜, Ë ÔÔ›· ‹Ù·Ó ı·Ó·ÙËÊfiÚÔ˜. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ¶OÀ, ÙÔ 1999 ÂηÙfi ¿ÙÔÌ· ¤ı·Ó·Ó ·fi ·˘Ù‹ ÙË ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ Î·È 400 ·ÎfiÌ· ÚÔÛ‚ϋıËÛ·Ó. ∫·Ù¿ ÙËÓ ÍËÚ·Û›· ÙÔ˘ 1970 ·Ó·Ê¤ÚıËΠfiÙÈ Ë ÓfiÛÔ˜ ÚÔηÏ› ·fiÊÚ·ÍË ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ Î·Ù·Ó¿ÏˆÛË „ˆÌÈÔ‡ ÙÔ ÔÔ›Ô ¤¯ÂÈ ·Ó·ÌÂȯı› Ì ÛfiÚÔ˘˜ ËÏÈÔÙÚÔ›Ô˘. ∞˘Ùfi ÙÔ Â›‰Ô˜ „ˆÌÈÔ‡ ηٷӷÏÒÓÂÙ·È ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Û ÂÚ›Ô‰Ô ÍËÚ·Û›·˜. ∆Ô ËÏÈÔÙÚfiÈÔ, Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÍËÚ·Û›·˜, ÂÚȤ¯ÂÈ ˘ÚÔÏȉ›ÓË Ô˘ Â›Ó·È ·ÏηÏÔÂȉ¤˜ Î·È ‚Ú›ÛÎÂÙ·È Î·È ÛÙÔ Á¿Ï· ÙˆÓ ·ÁÂÏ¿‰ˆÓ, ÙˆÓ ÚÔ‚¿ÙˆÓ Î.Ï., ·ÊÔ‡ ·˘Ùfi ·ÔÙÂÏ› ‚·ÛÈ΋ ÙÚÔÊ‹ ÙˆÓ ˙ÒˆÓ Î·Ù¿ ÙËÓ ÍËÚ·Û›·. ∆Ô 1975, ¿ÏÈ ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÚÔÛ‚ϋıËÛ·Ó ·fi ÙË ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ “Charmac” 7.200 οÙÔÈÎÔÈ Ì¤Û· Û 2 ¯ÚfiÓÈ·. ∏ ¤ÏÏÂÈ„Ë ÁÓÒÛ˘ ·˘Ù‹˜ Ù˘ ·ÈÙ›·˜ ÚÔηÏ› ˘„ËÏ‹ ıÓËÛÈÌfiÙËÙ· Î·È ‰˘ÛÙÚÔÊ›·, fiˆ˜ ÙÔ Kwashorkor. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÙÚÔÊ‹˜ Î·È Ë ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÛfiÚˆÓ ÙÔ˘ ËÏÈÔÙÚÔ›Ô˘ ·fi ÙÔ „ˆÌ› Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓfiÛÔ˘. º˘ÛÈο, fiϘ ÔÈ ÂÓ¤ÚÁÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ¤ÁηÈÚ·. ∆ÔÓ OÎÙÒ‚ÚÈÔ 2001, ‚ÈÔÏfiÁÔÈ ‹Á·Ó ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó
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Paediatriki 2003;66:82-88
Ó· ÂϤÁÍÔ˘Ó ÙÔ „ˆÌ› ÙˆÓ ·ÓıÚÒˆÓ Î·È ÙÔ Á¿Ï· ÙˆÓ ·ÁÂÏ¿‰ˆÓ (4). ∏ ¤ÏÏÂÈ„Ë ÙÔ˘ ÓÂÚÔ‡ ÛÙË ÁË Ì·˜ Â›Ó·È Î·Ù·ÛÙÚÔÊÈ΋ Î·È Á›ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ¤Î‰ËÏË Û ÂÚÈfi‰Ô˘˜ ÍËÚ·Û›·˜. À¿Ú¯Ô˘Ó ÔÏϤ˜ ¯ÒÚ˜ Ô˘ ˘ÔʤÚÔ˘Ó ·fi ÍËÚ·Û›· fiˆ˜ ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë µfiÚÂÈ· ∞ÊÚÈ΋, Ë µfiÚÂÈ· ∫›Ó·, Ë πÓ‰›·, ÙÔ πÚ¿Ó, Ë ∫ÂÓÙÚÈ΋ ∞ÌÂÚÈ΋, Ë ª¤ÛË ∞Ó·ÙÔÏ‹, Ë ¡fiÙÈ· ∫ÔÚ¤·, ÙÔ ¶·ÎÈÛÙ¿Ó Î·È Ë ™·¯¿Ú·. ™Â ¤Ó· ÙÌ‹Ì· Ù˘ ∆¯ÂÚ¿Ó˘, Ë ·ÚÔ¯‹ ÓÂÚÔ‡ ‰È·ÎfiÙÂÙ·È Ì›· Ë̤ڷ ÙËÓ Â‚‰ÔÌ¿‰· ÁÈ· 12 ÒÚ˜. ∞ÍȈ̷ÙÔ‡¯ÔÈ ÙÔ˘ ¶·ÎÈÛÙ¿Ó ·Ó¤ÊÂÚ·Ó fiÙÈ ÏfiÁˆ Ù˘ ÍËÚ·Û›·˜ ηٷÁÚ¿ÊËÎ·Ó ·ÒÏÂȘ 1,2 ‰ÈÛÂηÙÔÌÌ˘Ú›ˆÓ ‰ÔÏ·Ú›ˆÓ ·fi ÙȘ ·ÁÚÔÙÈΤ˜ ηÏÏȤÚÁÂȘ. ™ÙÔ ªÂÍÈÎfi Î·È ÙÔ ¡fiÙÈÔ ∆¤Í·˜, Ù· ·Ôı¤Ì·Ù· ÓÂÚÔ‡ Â›Ó·È ¯·ÌËÏ¿ ÌÂ Û˘Ó¤ÂÈ· ÔÈ ·ÁÚfiÙ˜ Ó· ¤¯Ô˘Ó Úfi‚ÏËÌ· ·Ú‰Â‡Ûˆ˜ ÙˆÓ ÎÙËÌ¿ÙˆÓ ÙÔ˘˜, ÔfiÙ ‰·Ó›˙ÔÓÙ·È ÓÂÚfi ·fi ÙÔ ∆¤Í·˜. ∞ÎfiÌË Î·È ÔÈ fiÏÂȘ ÙÔ˘ ªÂÍÈÎÔ‡ Ô˘ Û˘ÓÔÚÂ‡Ô˘Ó Ì ÙÔ ∆¤Í·˜ ¤¯Ô˘Ó Úfi‚ÏËÌ· ÏÂÈ„˘‰Ú›·˜. ŒÓ· ÍËÚfi ηÏÔη›ÚÈ ÛÙËÓ ∫ÂÓÙÚÈ΋ ∞ÌÂÚÈ΋ ÚÔοÏÂÛ ÙËÓ ·ÒÏÂÈ· ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÈÛÔ‰ËÌ¿ÙˆÓ Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 50% Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 700.000 ·ÁÚÔÙÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ. ™ÙȘ ·Ú·¿Óˆ 10 ¯ÒÚ˜, ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÌÈÛfi ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ˘ÔʤÚÔ˘Ó ·fi ·Ó¿ÚÎÂÈ· ·ÚÔ¯‹˜ ÓÂÚÔ‡. ∞Ó ‰ÂÓ ÏËÊıÔ‡Ó Î·Ù¿ÏÏËÏ· ̤ÙÚ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ ¤ÙÔ˜ 2025 ÙÔ 35% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ (ÂÚ›Ô˘ 2,8 ‰ÈÛÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ) ı· ·ÓÙÈÌÂÙˆ›˙ÂÈ Úfi‚ÏËÌ· ÏÂÈ„˘‰Ú›·˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÎÔÈÓˆÓÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ Âڋ̈ÛË ÙˆÓ ÂÚÈÔ¯ÒÓ Ô˘ Ï‹ÙÙÔÓÙ·È ·fi ÙËÓ ÍËÚ·Û›· Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·̷ÙÔ˜ “ÌÂÙ·Ó·ÛÙÒÓ ‡‰·ÙÔ˜”. ªfiÓÔ ÙÔ 3% ÙÔ˘ ÓÂÚÔ‡ Ù˘ Á˘ Â›Ó·È ÊÚ¤ÛÎÔ, ÂÓÒ ÙÔ ÂÚÈÛÛfiÙÂÚÔ ‰ÂÓ Â›Ó·È ‰È·ı¤ÛÈÌÔ ÂÂȉ‹ Â›Ó·È ÂÁÎψ‚ÈṲ̂ÓÔ Û ˘‰·ÙÔı‹Î˜ ÙˆÓ ¿ÁˆÓ. ∏ ·Ó·ÏÔÁ›· ÊÚ¤ÛÎÔ˘ ÓÂÚÔ‡ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙË ÁË ·ÓÙÈÛÙÔȯ› Û ó ÎÔ˘Ù·Ï¿ÎÈ ÙÔ˘ ÁÏ˘ÎÔ‡ ·Ó¿ 100 L ÓÂÚÔ‡ (5). ∞˘Ùfi ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÏÈÙÈΤ˜ ·ÓÙÈ·Ú·ı¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ÎÚ·ÙÒÓ ÁÈ· ÙÔ ÓÂÚfi ÙˆÓ ÔÙ·ÌÒÓ Î·È ÙˆÓ ˘‰¿ÙÈÓˆÓ ·ÔıËÎÒÓ. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈ·Ú¿ıÂÛË ÌÂٷ͇ ÙˆÓ fiÏÂˆÓ ÙˆÓ πÓ‰ÈÒÓ ·Ó¿ÁηÛ ÙËÓ Î˘‚¤ÚÓËÛË Ó· ηıÈÂÚÒÛÂÈ ‰ÈηÛÙ‹ÚÈ· ÓÂÚÔ‡ ÁÈ· Ó· Ú˘ıÌ›˙ÔÓÙ·È ÔÈ ‰È·ÊÔÚ¤˜ ÙÔ˘˜. ™ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë ÏÂÈ„˘‰Ú›· Î·È Ë ÍËÚ·Û›· ÚÔοÏÂÛ·Ó ÙË ı·Ó·ÙËÊfiÚÔ ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜. ∏ Ì›ˆÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ ÓÂÚÔ‡ ÚÔÎÏ‹ıËΠ·fi ÔÏϤ˜ ·Èٛ˜, fiˆ˜ Ë Ù·¯Â›· ·‡ÍËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ȉ›ˆ˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë ˘ÂÚ‚ÔÏÈ΋ ¿ÓÙÏËÛË ÙˆÓ ·ÔıËÎÒÓ ÓÂÚÔ‡, ÔÈ Î·Ù·Û΢¤˜ ˘‰·ÙÔÊÚ·ÎÙÒÓ Î·È ·ÔıËÎÒÓ ÓÂÚÔ‡, Ë ˘ÂÚ‚ÔÏÈ΋ ηٷӿψÛË ÙÔ˘ ÓÂÚÔ‡ Î·È ÔÈ ·ÏÏ·Á¤˜ ÙÔ˘ Îϛ̷ÙÔ˜.
JAN-FEB-03
14-05-03
17:18
™ÂÏ›‰·87
¶·È‰È·ÙÚÈ΋ 2003;66:82-88
∂ÎÙfi˜ ·fi ÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÓÂÚÔ‡, ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ·ÔÙÂÏ› Î·È Ë ‰È·Ù‹ÚËÛË Ù˘ ÔÈfiÙËÙ¿˜ ÙÔ˘. ∆Ô ‰È·ı¤ÛÈÌÔ ÓÂÚfi ÌÔÚ› Ó· ÂÈÌÔχÓÂÙ·È Ì ·ÓıÚÒÈÓ· ÎfiÚ·Ó·, Ô‡Ú·, ·ıÔÁfiÓÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜, ‚ÈÔÌ˯·ÓÈο ·fi‚ÏËÙ·, È·ÙÚÈο Î·È ÎÙËÓÈ·ÙÚÈο Ê¿Ú̷η Î·È Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙˆÓ ÏÔÈÌÒÓ, fiˆ˜ ÂÓÙÔÌÔÎÙfiÓ·, Ê¿Ú̷η ÁÈ· ·ÚÔ˘Ú·›Ô˘˜, ÔÓÙÈÎÔ‡˜ Î.Ï. ™ÙÔ ª·ÁÎÏ·ÓÙ¤˜, ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 1/3 Ù˘ ¯ÒÚ·˜ ·ÓÙÈÌÂÙˆ›˙ÂÈ ÛÔ‚·Úfi Úfi‚ÏËÌ· ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÓÂÚÔ‡ ·fi ·ÚÛÂÓÈÎfi. ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ·ÚÛÂÓÈÎfi Ô˘ ÂÚȤ¯ÂÙ·È ÛÙÔ ÓÂÚfi ÚÔÊ˘Ï¿ÛÛÂÈ ÌÂÓ ÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ·fi ÓÔÛ‹Ì·Ù· Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È ·fi ÙÔ ÓÂÚfi, fiˆ˜ .¯. ¯ÔϤڷ, Ù‡ÊÔ Î·È Ë·Ù›Ùȉ· ∞, ÛÎÔÙÒÓÂÈ ‰Â 500 ¯ÈÏÈ¿‰Â˜ ηÙÔ›ÎÔ˘˜ Ù˘ ¯ÒÚ·˜ οı ¯ÚfiÓÔ (5). ¢È¿ÊÔÚ˜ χÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÏÂÈ„˘‰Ú›·˜ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÈfiÙËÙ·˜ ÙÔ˘ ÓÂÚÔ‡ Ú¤ÂÈ Ó· ÚÔÙ·ıÔ‡Ó. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÔÙ·ÌÔ› ÂϤÁ¯ÔÓÙ·È ·fi ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ¯ÒÚ˜. ŒÙÛÈ Â›Ó·È ˙ˆÙÈÎfi, Ì ÂıÓÈΤ˜ Û˘Ìʈӛ˜ Î·È ‰ÈÂıÓ›˜ Û˘Ì‚¿ÛÂȘ, Ó· ηٷÓÂÌËı› ÙÔ ÓÂÚfi ÌÂٷ͇ ÙˆÓ ÂӉȷÊÂÚfiÌÂÓˆÓ ¯ˆÚÒÓ. ∆Ô 1998, Ë ¤ÎıÂÛË ÙÔ˘ ¶OÀ ·Ó¤ÊÂÚ fiÙÈ ··ÈÙÔ‡ÓÙ·È 10 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÙÔ ¯ÚfiÓÔ ÁÈ· Ó· ÂÊԉȷÛÙ› fiÏÔ˜ Ô ÏËı˘ÛÌfi˜ Ù˘ Á˘ Ì ˘ÁÈÂÈÓfi Î·È Î·ı·Úfi ÓÂÚfi. ∆Ô ÎfiÛÙÔ˜ ·˘Ùfi ÈÛÔ‰˘Ó·Ì› Ì ÙÔ 1/10 ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ÍÔ‰Â‡Ô˘Ó ÔÈ ∂˘Úˆ·›ÔÈ ÁÈ· ·ÏÎÔÔÏÔ‡¯· ÔÙ¿, Ì ÙÔ ÔÛfi Ô˘ ÍÔ‰Â‡Ô˘Ó ÁÈ· ·ÁˆÙ¿ ‹ Ì ÙÔ ‹ÌÈÛ˘ ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ‰··ÓÔ‡Ó ∞ÌÂÚÈηÓÔ› Î·È ∂˘Úˆ·›ÔÈ Î¿ı ¯ÚfiÓÔ ÁÈ· ÙÚÔʤ˜ ÙˆÓ Î·ÙÔÈΛ‰ÈˆÓ ˙ÒˆÓ ÙÔ˘˜. ∏ Ó¤· Ù¿ÍË Ú·ÁÌ¿ÙˆÓ Ê·›ÓÂÙ·È fiÙÈ Ô‰‹ÁËÛ ÙÔÓ ¿ÓıÚˆÔ Ó· Á›ÓÂÈ ÂÚÈÛÛfiÙÂÚÔ ˙ˆfiÊÈÏÔ˜ Î·È ÏÈÁfiÙÂÚÔ ÊÈÏ¿ÓıÚˆÔ˜. ∆Ô ÌÈÎÚfi ÎfiÛÙÔ˜ ¯ÚËÌ¿ÙˆÓ ÌÔÚ› Ó· Â›Ó·È Ë ÚÒÙË ÂÓ¤ÚÁÂÈ· ÁÈ· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Î·ı·ÚÔ‡ Î·È ˘ÁÈÂÈÓÔ‡ ÓÂÚÔ‡ ÛÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ Ï·Ó‹ÙË Ì·˜. ∆· ∂ӈ̤ӷ ŒıÓË ÔÚÁ·ÓÒÓÔ˘Ó ÙÔ 2003 ÙÔ “¢ÈÂıÓ¤˜ ŒÙÔ˜ ºÚ¤ÛÎÔ˘ ¡ÂÚÔ‡”. ∂›Ó·È ÛËÌ·ÓÙÈÎfi, ÔÈ Î˘‚ÂÚÓ‹ÛÂȘ ÙˆÓ ÎÚ·ÙÒÓ, Ó· ÌËÓ ÂÚÈÔÚÈÛÙÔ‡Ó Û ÔÚ¿Ì·Ù· Î·È ıˆÚËÙÈο Ï¿Ó· ÁÈ· ηı·Úfi ÓÂÚfi, ·ÏÏ¿ Ó· ÂÊ·ÚÌfiÛÔ˘Ó Ì¤ÙÚ· Ú·ÎÙÈο Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ÁÈ· ÙËÓ Â›Ù¢ÍË ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ (5). ™‡Ìʈӷ Ì ‰ËÌÔÛÎfiËÛË ÙÔ˘ CNN (∞Ú›ÏÈÔ˜ 2002), ÔÈ ∞ÌÂÚÈηÓÔ›, ‰˘ÛÙ˘¯Ò˜, ÈÛÙÂ‡Ô˘Ó fiÙÈ Ë ∞ÌÂÚÈ΋ Â›Ó·È ÈÛ¯˘ÚfiÙÂÚË ÌÂÙ¿ ÙËÓ 11Ë ™ÂÙÂÌ‚Ú›Ô˘, ÂÓÒ ÙÔ 90% ‰¤¯ÂÙ·È fiÙÈ ¿ÏÏ·Í·Ó “Ù· ¿ÓÙ· ÁÈ· ¿ÓÙ·”. ∆Ô 60% Ù¿ÛÛÂÙ·È ˘¤Ú ÙÔ˘ ÔϤÌÔ˘ Î·È ÙÔ 75% ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ÔÈ ∏¶∞ Ú¤ÂÈ Ó· ÛÙ›ÏÔ˘Ó ÛÙÚ·Ù‡̷ٷ ÂÓ·ÓÙ›ÔÓ ÙÔ˘ πÚ¿Î ÁÈ· Ó· ·Ó·ÙÚ¤„Ô˘Ó ÙÔÓ ™·ÓÙ¿Ì ÃÔ˘ÛÂ˝Ó (6). ∞fi ÙËÓ ÎÚ›ÛË ÛÙË ª¤ÛË ∞Ó·ÙÔÏ‹ Ê·›ÓÂÙ·È fiÙÈ ÙfiÛÔ ÔÈ πÛÚ·Ëϛ٘ fiÛÔ Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ıˆ-
Paediatriki 2003;66:82-88
ÚÔ‡Ó ÙËÓ Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·Ùfi˜ ÙÔ˘˜ ÂÊÈÎÙ‹ Ì ÙËÓ ÂΉ›ÎËÛË Î·È ÙË ‚›· (7). ™‡Ìʈӷ Ì ÙËÓ ¿Ô„Ë ÙˆÓ È·ÙÚÒÓ ÁÈ· Ù· ·ÓıÚÒÈÓ· ‰ÈηÈÒÌ·Ù·, ÔÈ ‰‡Ô ÎÔÈӈӛ˜ ¤¯Ô˘Ó ÂÈÛ¤ÏıÂÈ Û ¤Ó·Ó ·ÎÏÔ ·ÏÏËÏÔÂÍfiÓÙˆÛ˘. ¶ÏËÚÔÊÔڛ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÓÔÛÔÎÔÌÂȷο ·˘ÙÔΛÓËÙ· ÙˆÓ ¶·Ï·ÈÛÙÈÓ›ˆÓ Ô˘ ›¯·Ó ÂÏÂÁ¯ı› ·fi ÙȘ ŒÓÔϘ ¢˘Ó¿ÌÂȘ ÙÔ˘ πÛÚ·‹Ï ˘ÚÔ‚ÔÏ‹ıËÎ·Ó Î·È ÙÔ Ï‹ÚˆÌ¿ ÙÔ˘˜ ÊÔÓ‡ıËÎÂ. ∂ÈÛÙÔϤ˜ ·fi È·ÙÚÔ‡˜ ÙˆÓ ∏¶∞, ÙÔ˘ Eӈ̤ÓÔ˘ µ·ÛÈÏ›Ԣ Î·È ÙÔ˘ πÛÚ·‹Ï ÚÔ˜ ÙÔ ÂÚÈÔ‰ÈÎfi Lancet, Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÛÙÔ ¿ÚıÚÔ Ì ٛÙÏÔ “Failure to address the health toll of Middle East crisis”, ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ ÓÔÛÔÎÔÌÂȷο ·˘ÙÔΛÓËÙ· ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·fi ÙÔ˘˜ ¶·Ï·ÈÛÙ›ÓÈÔ˘˜ ˆ˜ ·˘ÙÔΛÓËÙ· ·˘ÙÔÎÙÔÓ›·˜ Ô˘ ¤ÊÂÚ·Ó ¿ÚÚˆÛÙ· ·È‰È¿ ‹ ÓÂÎÚÔ‡˜ ÙÔÔıÂÙË̤ÓÔ˘˜ Û ÂÎÚËÎÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜, Ì ÛÎÔfi Ó· ·Ú·Ï·Ó‹ÛÔ˘Ó ÙȘ ŒÓÔϘ ¢˘Ó¿ÌÂȘ ÙÔ˘ πÛÚ·‹Ï ÁÈ· Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ηÌÈο˙È ÂÓ·ÓÙ›ÔÓ πÛÚ·ËÏÈÓÒÓ ÔÏÈÙÒÓ (7). ¶·Ï·ÈÛÙÈÓÈ·Îfi ·ÛıÂÓÔÊfiÚÔ Ì ÂÎÚËÎÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Î·È ‚fî˜ ·ÔÂÈÚ¿ıËΠӷ ·ÂÈÏ‹ÛÂÈ ÙË ˙ˆ‹ ÙÔ˘ Colin Powell ÙÔ ‚Ú¿‰˘ Ù˘ ·Ê›ÍÂÒ˜ ÙÔ˘ ÛÙÔ πÛÚ·‹Ï Û‡Ìʈӷ Ì ÙË Ì·ÚÙ˘Ú›· ÙÔ˘ Ô‰ËÁÔ‡ ÙÔ˘ ·ÛıÂÓÔÊfiÚÔ˘, fiˆ˜ ÂÈÛËÌ·›ÓÂÈ ÛÙËÓ ÂÈÛÙÔÏ‹ ÙÔ˘ Ô ª. Lauer ·fi ÙÔ Cleveland ÙˆÓ ∏¶∞ (8). À¿Ú¯Ô˘Ó Û·Ê›˜ ÂӉ›ÍÂȘ fiÙÈ ˘‹Ú¯Â ¤ÏÏÂÈ„Ë ÙÚÔʛ̈Ó, ÓÂÚÔ‡ Î·È ËÏÂÎÙÚÈÎÔ‡ Ú‡̷ÙÔ˜ Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ ÛÙË ‰ËÌfiÛÈ· ˘Á›·. OÈ ËÏÂÎÙÚÈΤ˜ ÂÁηٷÛÙ¿ÛÂȘ Ô˘ ηٷÛ΢¿ÛÙËÎ·Ó ÛÙË ÏˆÚ›‰· Ù˘ °¿˙·˜ ÙÔ 1993 ÛÙÔ›¯ÈÛ·Ó 4,5 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ∞ÌÂÚÈ΋˜ Î·È ¤¯Ô˘Ó ˘ÔÛÙ› ÙÂÚ¿ÛÙȘ ˙ËÌȤ˜. O Carrol Bellamy, ‰È¢ı˘ÓÙ‹˜ Ù˘ Unicef, ·Ó¤ÊÂÚ fiÙÈ ÔÈ πÛÚ·ËÏÈÓÔ› Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ‰È‰¿ÛÎÔ˘Ó ÛÙ· ·È‰È¿ ÙÔ˘˜ ÙËÓ ÙÚÔÌÔÎÚ·Ù›· ˆ˜ ̤ıÔ‰Ô Â›Ï˘Û˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘˜. OÈ Î˘‚ÂÚÓ‹ÛÂȘ Ù˘ ∂Ó. ∂˘ÚÒ˘ Î·È ÙˆÓ ∏¶∞, ÔÈ Ôԛ˜ ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ Â›Ó·È ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÂÈÚ‹Ó˘ ÛÙÔÓ ÎfiÛÌÔ, Ú¤ÂÈ Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó, ÒÛÙ ÌÂÙ¿ ÙËÓ Î·Ù¿·˘ÛË ÙˆÓ Â¯ıÚÔÚ·ÍÈÒÓ Ó· ÂÈÌÂÏËıÔ‡Ó ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Ô˘ ‰ÂÓ Â›Ó·È ÔÏ˘Ù¤ÏÂÈ·, ·ÏÏ¿ ÂÈ‚¿ÏÏÂÙ·È ‰ÈfiÙÈ Ô ¿Ì·¯Ô˜ ÏËı˘ÛÌfi˜ Â›Ó·È Ù·Ï·ÈˆÚË̤ÓÔ˜, ηÎÔÔÈË̤ÓÔ˜ Î·È ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜. O Benjamin Disraeli ÙÔ 1877 ·Ó¤ÊÂÚ fiÙÈ “∏ ˘Á›· ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È Ë Ú·ÁÌ·ÙÈ΋ ıÂÌÂÏ›ˆÛ˘ Ù˘ Â˘Ù˘¯›·˜ Î·È Ù˘ ‰‡Ó·Ì˘ ÁÈ· Ì›· ·ÓÂÍ¿ÚÙËÙË ÔÏÈÙ›·”. ∆ËÓ ÂÔ¯‹ Ô˘ ÁÂÓÓ‹ıËÎÂ Ô ÃÚÈÛÙfi˜ ˘‹Ú¯Â ÌfiÓÔ ¤Ó·˜ ∏Ú҉˘. ™‹ÌÂÚ· Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ô˘ Û˘ÌÂÚÈʤÚÔÓÙ·È Û·Ó Ó· ¤¯Ô˘Ó ̤۷ ÙÔ˘˜ ÙÔÓ ∏ÚÒ‰Ë Î·È ÌÂıÔ‡Ó ·fi ÙÔ ·›Ì· ÙˆÓ ÛÊ·ÁÒÓ Î·È ·fi ÙÔ ıfiÚ˘‚Ô ÙˆÓ ÊÔÓÈÎÒÓ ÂÎڋ͈Ó. O ÃÚÈÛÙfi˜ ›Ûˆ˜ Ó· ÌËÓ Í·Ó·ÁÂÓÓËı›,
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·ÏÏ¿ ÂÍ·ÎÔÏÔ˘ı› Ó· ÛÙ·˘ÚÒÓÂÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ ÔϤÌÔ˘, ÛÙÔ ÚfiÛˆÔ ÙˆÓ ·ıÒˆÓ ı˘Ì¿ÙˆÓ Ô˘ ·Ê‹ÓÔ˘Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÓÔ‹ ÛÙÔ ‰ÚfiÌÔ, ÛÙÔ ÏˆÊÔÚ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô ‹ οو ·fi ÙË ‚ÔÌ‚·Ú‰ÈṲ̂ÓË ÛÙ¤ÁË ÙÔ˘ ÛÈÙÈÔ‡ ÙÔ˘˜ (1). O ¶OÀ, ÔÈ ÌË ÎÚ·ÙÈΤ˜ ÔÚÁ·ÓÒÛÂȘ, Ë ∂ӈ̤ÓË ∂˘ÚÒË Î·È Ë ¢ÈÂıÓ‹˜ ∆Ú¿Â˙· Ú¤ÂÈ Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·Ó·Û˘ÁÎÚfiÙËÛË Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ¿ÓıÚˆÔÈ Âı·›ÓÔ˘Ó ÂÚ›Ô˘ Û ËÏÈΛ· 47 ÂÙÒÓ, ÂÓÒ ¤Ó· ÛÙ· Ù¤ÛÛÂÚ· ·È‰È¿ Âı·›ÓÂÈ ÛÙ· ¤ÓÙ ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘. ∆ÚÂȘ ¯ÈÏÈ¿‰Â˜ ¿ÓıÚˆÔÈ ÛÎÔÙÒıËÎ·Ó Û ¤Ó· ¯ÚfiÓÔ ·fi ÙȘ Ó¿ÚΘ Î·È ·ÚÎÂÙÔ› ¤ÌÂÈÓ·Ó ·Ó¿ËÚÔÈ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ηıÂÛÙÒÙÔ˜ ÙˆÓ ∆·ÏÈÌ¿Ó, ‰ÂÓ ·Ú¯fiÙ·Ó È·ÙÚÈ΋ ÊÚÔÓÙ›‰· ÛÙȘ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ Î·È ¤ÙÛÈ ÛËÌÂÈÒıËΠ˘„ËÏ‹ ÌËÙÚÈ΋ ıÓËÛÈÌfiÙËÙ·. ™ËÌ·ÓÙÈ΋ ÚÔÙÂÚ·ÈfiÙËÙ· ·ÔÙÂÏ›, ›Û˘, Ë È·ÙÚÈ΋ ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ Î·È Ì ̤ÙÚ· ÚfiÏ˄˘ ·fi Ù· ÌÂÙ·‰È‰fiÌÂÓ· ÓÔÛ‹Ì·Ù·. ∏ ·Ó·‚¿ıÌÈÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ı· ¯ÚÂÈ·ÛÙ› 5-10 ¯ÚfiÓÈ·. ∂›Ó·È ÁÓˆÛÙfi ·fi ÚÔËÁÔ‡ÌÂÓ˜ Û˘ÁÎÚÔ‡ÛÂȘ fiˆ˜ Ù˘ ªÔ˙·Ì‚›Î˘, ÙÔ˘ ∫ÔÛfi‚Ô˘ Î.Ï. fiÙÈ Ë ÊıËÓ‹ ¤Ӊ˘ÛË ˘Á›·˜ Â›Ó·È ÛÊ¿ÏÌ·. ŒÓ· ·ÈÛÈfi‰ÔÍÔ Ì‹Ó˘Ì· ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È fiÙÈ Î·ı‹ÎÔÓÙ· ÀÔ˘ÚÁÔ‡ ÀÁ›·˜ ·Ó¤Ï·‚Â Ë Suhaila Seddiqui ¯ÂÈÚÔ˘ÚÁfi˜ ·fi ÙËÓ ∫·ÌÔ‡Ï. ∏ ‰È¿ÛˆÛË ·ÓıÚÒˆÓ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Â›Ó·È ËıÈ΋ Î·È ÂÈÙ·ÎÙÈ΋ ·Ó¿ÁÎË ÁÈ· fiÏÔ ÙÔÓ ÎfiÛÌÔ. ∏ ¤Ӊ˘ÛË ÛÙËÓ ˘Á›· ›Ûˆ˜ ·Ô‰Âȯı› fiÙÈ Â›Ó·È Ë ·ÛʷϤÛÙÂÚË Â¤Ó‰˘ÛË ÁÈ· ÙËÓ ÂÈÚ‹ÓË. ∫·Ù¿ ÙÔÓ °ÂÚÌ·Ófi Obermann “Don’t try to be God, just work hard to be Human”, ‰ËÏ·‰‹ “ÌËÓ ÚÔÛ·ı›˜ Ó· Á›ÓÂȘ £Âfi˜, ÂÚÁ¿ÛÔ˘ ÛÎÏËÚ¿ Ó· Â›Û·È ºÈÏ¿ÓıÚˆÔ˜” (9). ∏ ‰ËÌfiÛÈ· ˘Á›· Â›Ó·È ¤Ó· Ó¤Ô ÂÚÁ·ÏÂ›Ô ÁÈ· ÙËÓ Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Î·È ÁÈ· Ù· ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈο ̤ÙÚ·. ∂ÍÔ˘‰ÂÙÂÚÒÓÔÓÙ·˜ ÙËÓ Â›Ó·, ÙÔ ÏÈÌfi, ÙȘ ·ÚÚÒÛÙȘ, ÙË ÊÙÒ¯ÂÈ· Î·È ÙËÓ ÎÔÈÓˆÓÈ΋ ·ÔÌfiÓˆÛË ÌÔÚ› Ó· ÂÈÙ¢¯ı› ηχÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· ·fi ÙȘ ‚fî˜, Ù· ·ÂÚÔÏ¿Ó·, ÙȘ ÂȉÈΤ˜ ‰˘Ó¿ÌÂȘ Î·È ÙËÓ ·ÔÌfiÓˆÛË. ∏ ·ÛÊ¿ÏÂÈ· Ù˘ Á˘ ı· ÂÈÙ¢¯ı› ηχÙÂÚ· Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÛÙ·ıÂÚÒÓ Î·È ÈÛ¯˘ÚÒÓ ÎÔÈÓˆÓÈÒÓ. ∏
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‰ËÌfiÛÈ· ˘Á›·, ÙÔÓ 21Ô ·ÈÒÓ·, Â›Ó·È Ì¤ÚÔ˜ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘ ηٿ ÙËÓ ÂχıÂÚË ·ÁÔÚ¿ ‹ ¤¯ÂÈ ·ÁÎÔÛÌÈfiÙËÙ·, ‰ËÏ·‰‹ ÔÈÎÔ˘ÌÂÓÈÎfiÙËÙ·, ηٿ ÙË ¯ÚÈÛÙÈ·ÓÈ΋ ¿Ô„Ë. ∞˘Ù‹ Ë ·Ó¿ÁÎË Ù˘ ·ÁÎÔÛÌÈfiÙËÙ·˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ ‰ÂÓ Â›¯Â ÂÈÛËÌ·Óı› Ì ÙfiÛË ¤ÌÊ·ÛË Û ηӤӷ ÚÔËÁÔ‡ÌÂÓÔ ·ÈÒÓ·. ÃÚÂÈ¿˙ÂÙ·È fï˜ ÂÍÂȉ›Î¢ÛË, Û˘Ì·Ú¿ÛÙ·ÛË Î·È ‰Ú¿ÛË Â› Ù˘ ÎÔÈÓˆÓÈ΋˜ Î·È ÔÏÈÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÁÈ· Ó· ‚ÂÏÙȈı› Ë ‰ËÌfiÛÈ· ˘Á›· Û fiÏÔ ÙÔÓ ÏËı˘ÛÌfi Ù˘ Á˘. ∏ ∂ӈ̤ÓË ∂˘ÚÒË, Û‡Ìʈӷ Ì ÙÔ ÚfiÁÚ·ÌÌ· Ô˘ ı· ÂÊ·ÚÌfiÛÂÈ ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 2003, ¤Î·Ó ÙÔ ÚÒÙÔ ‚‹Ì· ÁÈ· Ó· ‚ÂÏÙȈı› Ë ‰ËÌfiÛÈ· ˘Á›· Û fiÏÔ ÙÔÓ ÎfiÛÌÔ. §Â›ÂÈ, fï˜, Ô ÂÛÙÈ·ÛÌfi˜, Ë Û˘ÁÎÂÎÚÈ̤ÓË ‚Ô‹ıÂÈ· Î·È Ë ÔÏÈÙÈ΋ ‚Ô‡ÏËÛË. ∏ ‰ËÌfiÛÈ· ˘Á›· Â›Ó·È ¤Ó· ̤ÙÚÔ Ô˘ ˘ÔÙÈÌ‹ıËΠ·fi ÙËÓ ·ÁÎÔÛÌÈÔÔÈË̤ÓË ·ÛÊ¿ÏÂÈ· ÙÔ˘ Ï·Ó‹ÙË Ì·˜. ∏ ·ÚÔ¯‹ ηϋ˜ ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÁÈ· fiÏÔ ÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ Ï·Ó‹ÙË Ú¤ÂÈ Ó· Á›ÓÂÈ Ë µ›‚ÏÔ˜ ÙÔ˘ 21Ô˘ ·ÈÒÓ·, Â¿Ó ı¤ÏÔ˘Ì ӷ Ú·ÁÌ·ÙÔÔÈËı› ÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ (10) “∫·› â› Áɘ ÂåÚ‹ÓË”. µÈ‚ÏÈÔÁÚ·Ê›· 1. ™ÙÂÊ·ÓÔÔ‡ÏÔ˘ ∞. ∫·È › Á˘ fiÏÂÌÔ˜. ∂ÛÙ›·; 2001, 24 ¢ÂÎÂÌ‚Ú›Ô˘. 2. Pillar PR. Terrorism and US foreign policy Washington: Brookings Institution; 2001. 3. Horton R. Public health: a neglected counter terrorist measure. Lancet 2001;358:1112-1113. 4. Ahmad K. Health and safety of Afghans hangs in the balance. Lancet 2001;358:1069-1070. 5. Nor any drop to drink [Editorial]. Lancet 2001;358:1025. 6. ÕÏÏ·Í·Ó “Ù· ¿ÓÙ· ÁÈ· ¿ÓÙ·” ÈÛÙÂ‡Ô˘Ó ÔÈ ∞ÌÂÚÈηÓÔ›. ∂ÛÙ›·; 2002, 2 ∞ÚÈÏ›Ô˘. 7. Failure to address the health toll of the Middle East crisis [Editorial]. Lancet 2002;359:1261. 8. Lauer MS. Health toll of the Middle East crisis. Lancet 2002;359:1860-1861. 9. Obermann K. More life for Lifeline. Lancet 2001;358:2174. 10. ∫·ÈÓ‹ ¢È·ı‹ÎË: ∫·Ù¿ §Ô˘Î¿Ó ∂˘·ÁÁ¤ÏÈÔ (2,14). HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 23-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶¤ÙÚÔ˜ §··ÙÛ¿Ó˘ ∞ÛÎÏËÈÔ‡ 44, ∆.∫. 114 71, ∞ı‹Ó·