ISSN 0377-2551
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ETO™ 2003
IÔ‡Ï ÈÔ˜ - ∞‡ÁÔ˘ÛÙ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 4
∞¡∞™∫O¶∏™∂π™ ∆ÚÔÊÈΤ˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË
REVIEW ARTICLES 239
ª. ÷Ù˙Ë„¿ÏÙË, ª. ∑‹‚·-¶ÂÙÚÔÔ‡ÏÔ˘
∞ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η ÛÙËÓ Î‡ËÛË Î·È Á·ÏÔ˘¯›·
M. Hatzipsalti, M. Ziva-Petropoulou 247
¶AI¢IATPIKH
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TOMO™ 66
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TEYXO™ 4
¡. ∫·Ì¿˜, ∂. ¶··‚·ÛÈÏ›Ԣ
∂ÈÏË„›· Î·È Î‡ËÛË
255
ORIGINAL ARTICLES 264
π. ªÔÛ¯·Ó‰Ú¤·, Ã. ÷Ù˙‹˜, π. ª·ÌÌ¿˜, °. ªÂÚÙÛÈ¿˜, ª. §ÈÓ·Ú‰¿Î˘, ª. ∫˘Úȷο΢, §. ÷Ù˙‹, ¡. ∫·Úη‚›ÙÛ·˜, ∞. ª·ÚÁȈڋ˜, ∞. ∫·Ê¿ÙÔ˜
Obesity indices and cardiovascular risk factors in rural dwelling Cretan children J. Moschandreas, C. Hatzis, Y. Mammas, G. Bertsias, M. Linardakis, M. Kiriakakis, L. Hatzi, N. Karkavitsas, A. Margioris, A. Kafatos
278
∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘, π. ∫·Ï¤ÁÈ·˜, ∞. °Ô‡Ó·Ú˘, ™. ™Â‚·ÛÙÈ¿‰Ô˘, ¡. ∞ÏÂ͛Ԣ, ∂. ∫ˆÛÙ·ÓÙ¤ÏÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜
∂Ê·ÚÌÔÁ‹ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ BFM-90 ÛÙËÓ ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·: ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·ÔÙÂϤÛÌ·Ù·
Epilepsy and pregnancy E. Hatzidaki, C. Giannakopoulou
Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
∂›Â‰· Á·ÛÙÚ›Ó˘, ÌÔÙÈÏ›Ó˘ Î·È ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ
Antipsychotic medications in pregnancy and lactation N. Kambas, E. Papavasiliou
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
¢Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ ·ÁÚÔÙÈ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘
Adverse reactions to foods The diagnostic approach
Gastrointestinal hormones in neonates of diabetic mothers Z. Hatzistamatiou, J. Kaleyias, A. Gounaris, S. Sevastiadou, N. Alexiou, E. Constantellou, C. Costalos
284
Application of the BFM-90 therapeutic protocol to childhood acute lymphoblastic leukaemia: prognostic factors and results
º. ∞ı·Ó·ÛÈ¿‰Ô˘, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡, ª. ∫Ô‡ÚÙË, ∞. ª¤ÓÔ˜, £. ¶··ÁˆÚÁ›Ô˘, ª. ™Ù¿ÌÔ˘, ¢. ∫·ÙÚÈÔ‡
F. Athanasiadou, M. Hatzistilianou, M. Kourti, A. Benos, T. Papageorgiou, M. Stamou, D. Catriu
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
July - ∞ugust 2003 . Volume 66 . No 4
IÔ‡Ï ÈÔ˜ - ∞‡ÁÔ˘ÛÙ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 4
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
°·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË: Û˘¯ÓfiÙËÙ·, ¤ÁηÈÚË ‰È¿ÁÓˆÛË
Continuation of table of contents
296
I. Xinias, C. Panteliadis, K. Spiroglou, N. Karatzas, V. Demertzidou, E. Karatza, G. Arsos
π. •˘ÓÈ¿˜, Ã. ¶·ÓÙÂÏÈ¿‰Ë˜, ∫. ™‡ÚÔÁÏÔ˘, ¡. ∫·Ú·Ù˙¿˜, µ. ¢ÂÌÂÚÙ˙›‰Ô˘, ∂. ∫·Ú·Ù˙¿, °. ÕÚÛÔ˜
H ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ ÛÙË ‰ÂηÂÙ›· 1990-1999
304
CASE REPORTS
EN¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ 311
Spontaneous resolution of cholelithiasis in a premature neonate A. A. Karatza, V. N. Pavlou, C. P. Kalogeropoulou, G. N. Markou, I. I. Tsota, S. P. Mantagos
∞. ∞. ∫·Ú·Ù˙¿, µ. ¡. ¶·‡ÏÔ˘, Ã. ¶. ∫·ÏÔÁÂÚÔÔ‡ÏÔ˘, °. N. ª¿ÚÎÔ˘, ∂. I. ∆ÛÒÙ·, ™. ¶. ª·ÓÙ·Áfi˜
º˘Ì·Ù›ˆÛË Û ·È‰È¿. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛÂˆÓ Ì ∆µ ·Û˘Ó‹ıÔ˘˜ ÂÓÙfiÈÛ˘ Î·È ÚÔ‚ÔÏ‹˜
Retinopathy of prematurity during the decade 1990-1999 E. Anastasiadou-Karageorgopoulou, A. Andreou, H. Basiakos, N. Manos, E. Koulali
∂. ∞Ó·ÛÙ·ÛÈ¿‰Ô˘-∫·Ú·ÁˆÚÁÔÔ‡ÏÔ˘, ∞. ∞Ó‰Ú¤Ô˘, Ã. ª·ÛÈ¿ÎÔ˜, ¡. ª¿ÓÔ˜, ∂. ∫ԇϷÏË
∞˘ÙfiÌ·ÙË ‰È¿Ï˘ÛË ¯ÔÏÔÏ›ıÔ˘ Û ÚfiˆÚÔ ÓÂÔÁÓfi
Gastroesophageal reflux in children with cerebral palsy: frequency, early diagnosis
316
Tuberculosis in children. Report of two cases with unusual location and presenting symptoms
Ã. §¿ÛηÚË, °. ∞Ó·ÛÙ·ÛÈ¿‰Ë˜, µ. ¶Ï·ÎԇϷ, ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜, °. ¶·Ó·ÁȈٷÎfiÔ˘ÏÔ˜, ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡
H. Laskari, G. Anastasiadis, V. Plakoula, D. Aggelopoulos, G. Panagiotakopoulos, K. Prountzou-Kassiou
™˘Ó¯›˙ÔÓÙ·È
Continued
J u l y - A u g u s t 2 0 0 3 .V o l u m e 6 6 . N o 4
πÔ‡Ï ÈÔ˜ - ∞‡ÁÔ˘ÛÙ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 4
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
321
NEWS FROM THE INTERNET
∂¶π™∆O§∏ ¶ƒO™ ∆∏ ™À¡∆∞•∏
325
LETTER TO THE EDITOR
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xi
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xiv
Abbreviations
July - August 2003 . Volume 66 . No 4
πÔ‡Ï ÈÔ˜ - ∞‡ÁÔ˘ÛÙ Ô˜ 2003
.
∆fiÌÔ˜ 66
. ∆‡¯Ô˜
4
¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜
Bimonthly Publication The Official Journal of the Hellenic Paediatric Society
EΉfiÙ˘ K. °ÚÈ‚¤·˜
Publisher K. Griveas
I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28
Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28
TËÏ.: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
Tel.: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ¢È¢ı˘ÓÙ‹˜ : ™. ÷˚‰¿˜ M¤ÏË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : °. µ·ÚÏ¿Ì˘ : ª. ∏Ï›· : π. ¶··‰¿ÙÔ˜ : ¡. ¶··‰fiÔ˘ÏÔ˜ : ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘ : ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ : ∫. ™ÙÂÊ·Ó›‰Ë˜ : ª. ∆ÛÔÏÈ¿ : ™. ºˆÙfiÔ˘ÏÔ˜
Scientific President Editor Members
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘
Manuscript Editing
EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘
English Editing S. Nakou
∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜
Publishing Coordinator
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SCIENTIFIC PUBLICATIONS Ltd P. Tsaldari 3, Marousi 151 22 Tel.: 210-61 41 360-5 Fax: 210-61 41 366
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Editorial Board : A. Constantopoulos : S. Haidas : F. Athanassiadou-Piperopoulou : G. Varlamis : M. Ilia : I. Papadatos : N. Papadopoulos : S. Polychronopoulou : K. Prountzou-Kassiou : C. Stefanidis : M. Tsolia : S. Fotopoulos
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J u l y - A u g u s t 2 0 0 3 .V o l u m e 6 6 .N o 4
πSSN 0377-2551 i
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜). 2. ∞Ó·ÛÎÔ‹ÛÂȘ. 3. µÚ·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. 4. ∂Ú¢ÓËÙÈΤ˜ ÌÂϤÙ˜. 5. ∂ÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ. 6. ∂›Î·ÈÚ· ı¤Ì·Ù·. 7. £¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜. 8. ∫ÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ. 9. ™‡ÓÙÔÌ· Ó¤·. 10. µÚ·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. 11. ∂ÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË. 12. ¶ÂÚÈÏ‹„ÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. 13. ∞Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘Ó‰ڛˆÓ Î·È ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 14. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ Î·ıÒ˜ Î·È ¿ÚıÚ· Ì ›ηÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·Ûı› ÛÙÔ ÂÙ‹ÛÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ·ÚÔ˘ÛÈ¿ÛÂˆÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì ›ηÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. µ. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚË-
Á›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ∫·ıÒ˜ Î·È fiÙÈ ÙËÚ‹ıËÎ·Ó ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). ™ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶·È‰È·ÙÚÈ΋” Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∏ ¶∞π¢π∞∆ƒπ∫∏ ÚÔÙ›ÓÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÈÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals) Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ JAMA 1997;277:927-934 http://jama.ama-assn.org/info/auinst_req.html OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Excel, ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ‰‡Ô (2) Ë̤Ú˜. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏÌ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜
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A4 (21x29.7 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È ÂÚÈıÒÚÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2,5 cm ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘. H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ·: ·. ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 2000-3000 ϤÍÂȘ. ‚. ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 1500-2500 ϤÍÂȘ. Á. ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ‰. ÙȘ ÂÈÛÙÔϤ˜ Û 250-500 ϤÍÂȘ. ™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ) ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·. ¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 200 ϤÍÂȘ, fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ∏ ÂÚ›ÏË„Ë ÙˆÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ Û ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο. T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ. K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·-
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Ô̤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ì ÏÂÙÔ̤ÚÂȘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜. TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ JAMA 1986;255:2329-2339. ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ. BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÛÙȘ ÂÈÛÙÔϤ˜. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JAMA 1997;277:927-934), http://jama.amaassn.org/info/auinst_req.html. OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus (List of Journals Indexed in Index Medicus, http://www.nlm.nih.gov).
¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”. T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279. Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: ÷ڷϷ̛‰Ë˜ π, ¶··‰fiÔ˘ÏÔ˜ ∞. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·ÈÌ›· [¶ÂÚ›ÏË„Ë]. 36Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1998 5-7 πÔ˘Ó›Ô˘; ¶¿ÊÔ˜, ∫‡ÚÔ˜; 1998. ÛÂÏ. 199. Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356. II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-
31; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã.. ∏ ıÂڷ›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡. [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. ¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, Î.Ï.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο. ¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. ∂ÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜. 2. ¢‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜. 3. 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜. 4. ™ÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂÚÈÏ·Ì‚¿ÓÂÈ: ·. Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜, ‚. fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›·, ‰. fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·. 5. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 6. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 7. ∫›ÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 8. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢). 9. µÈ‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 10. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó. 11. ∂ÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó. 12. ∆›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
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¶·È‰È·ÙÚÈ΋ 2003;66:239-246
∞¡∞™∫O¶∏™∏
Paediatriki 2003;66:239-246
REVIEW ARTICLE
∆ÚÔÊÈΤ˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ - ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ª. ÷Ù˙Ë„¿ÏÙË, ª. ∑‹‚· - ¶ÂÙÚÔÔ‡ÏÔ˘
Adverse reactions to foods - The diagnostic approach M. Hatzipsalti, M. Ziva - Petropoulou
¶ÂÚ›ÏË„Ë: OÈ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÚÔ‚¿ÏÏÔ˘Ó Ì ÔÈÎÈÏ›· Û˘Ìو̿وÓ, ΢ڛˆ˜ ·fi ÙÔ ‰¤ÚÌ·, ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ‹/Î·È ÙÔ Î˘ÎÏÔÊÔÚÈÎfi. ™˘¯Ó¿, Â›Ó·È ¯Ú‹ÛÈÌÔ˜ Ô ‰È·¯ˆÚÈÛÌfi˜ ·˘ÙÒÓ Û IgE Î·È ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ. ∞·Ú·›ÙËÙ· ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·˘ÙÒÓ Â›Ó·È ¤Ó· Ï‹Ú˜ ÈÛÙÔÚÈÎfi, Ì›· ÏÂÙÔÌÂÚ‹˜ Ê˘ÛÈ΋ ÂͤٷÛË Î·È ¤Ó·˜ ÂȉÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜. ŸÌˆ˜, Ë Gold standard ̤ıÔ‰Ô˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ·ÓÂÈı‡ÌËÙˆÓ ÙÚÔÊÈÎÒÓ ·ÓÙȉڿÛÂˆÓ Â›Ó·È Ë ‰ÈÏ‹ Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì ÂÈÎÔÓÈÎfi ÙÚfiÊÈÌÔ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (DBPCFC). ™ÙÔ ¿ÚıÚÔ ·˘Ùfi Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÔÚÈÛÌfi, ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ·ÏÏ¿ ΢ڛˆ˜ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ DBPCFC ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙ· ÙÚfiÊÈÌ·.
Abstract: Adverse reactions to foods may appear with a variety of symptoms expressed on the skin and in the respiratory, the digestive and/or the cardiovascular systems. It is often useful to distinguish between IgE and non-IgE mediated reactions. In order to diagnose food reactions a full history, a careful physical examination and specific tests are necessary. The gold standard method for confirmation is the double-blind placebo controlled food challenge (DBPCFC). This article reviews the literature regarding the definition and the clinical presentation of food allergy and in particular, the use of DBPCFC in its diagnosis.
§¤ÍÂȘ ÎÏÂȉȿ: ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·, ‰È¿ÁÓˆÛË, ÙÚÔÊÈ΋ ÚfiÎÏËÛË.
Key words: adverse reaction to foods, diagnosis, food challenge.
∂ÈÛ·ÁˆÁ‹ OÈ ·ÓÂÈı‡ÌËÙ˜ ·ÓÙȉڿÛÂȘ ÛÙ· ÙÚfiÊÈÌ· ›Ù ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ·ÏÏÂÚÁÈΤ˜, ›Ù fi¯È, ˘¿Ú¯Ô˘Ó ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ·ÓıÚÒÔ˘ ÛÙË ÁË, ÂÓÒ ÂÚÈÁڷʤ˜ ÙÔ˘˜ ¤¯Ô˘Ó Á›ÓÂÈ Î·È ·fi ÙÔÓ πÔÎÚ¿ÙË Î·È ÙÔÓ °·ÏËÓfi. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ ·ÈÒÓ· ÙÂÎÌËÚÈÒıËΠ·fi ÙÔÓ Hamburger ÁÈ· ÚÒÙË ÊÔÚ¿ ÂÚ›ÙˆÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜. ™ÙË ‰ÂηÂÙ›· ÙÔ˘ ’50, fï˜, ÂȯÂÈÚ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Èı·Ó‹˜ ·ÓÂÈı‡ÌËÙ˘ ·ÓÙ›‰Ú·Û˘ Û ¿Ì˘ÏÔ Î·Ï·ÌÔÎÈÔ‡ (1). ∞fi ÙfiÙÂ, ·Ú¿ ÙË Û˘ÛÛÒÚ¢ÛË ÁÓÒÛÂˆÓ ¿Óˆ Û ı¤Ì·Ù· ·ÏÏÂÚÁ›·˜ ÁÂÓÈο, ÔÏÏ¿ ·ÎfiÌ· ·ÔÙÂÏÔ‡Ó Â‰›Ô ‰ÈÂÚ‡ÓËÛ˘ Î·È ·Ú·Ì¤ÓÔ˘Ó ·‰È¢ÎÚ›-
ÓÈÛÙ· fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜. OÈ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙÚÔÊÈο ·ÈÙ›· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔ‚¿ÏÏÔ˘Ó Ì ÔÈÎÈÏ›· Û˘Ìو̿وÓ, ΢ڛˆ˜ ·fi ÙÔ ‰¤ÚÌ·, ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ‹/Î·È ÙÔ Î˘ÎÏÔÊÔÚÈÎfi. ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ‰¤ÚÌ· Î·È ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û˘Ó‰¤ÔÓÙ·È Ì IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ÂÓÒ ÌÂÌÔӈ̤ӷ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi ÚÔηÏÔ‡ÓÙ·È ·fi ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ. ∫·Ù¿ ÙËÓ ÂͤٷÛË ÙˆÓ Èı·ÓÒÓ ÙÚÔÊÈÎÒÓ ·ÏÏÂÚÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Â›Ó·È Û˘¯Ó¿ ¯Ú‹ÛÈÌÔ˜ Ô ‰È·¯ˆÚÈÛÌfi˜ Û IgE ‹ ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ. ∆Ô ·Ú¯ÈÎfi ÈÛÙÔÚÈÎfi Î·È Ë Ê˘ÛÈ΋ ÂͤٷÛË Â›Ó·È Ô˘ÛÈ·ÛÙÈο ·ÚfiÌÔÈ· Î·È ÛÙÔ˘˜ ‰‡Ô Ù‡Ô˘˜,
¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, ∞ı‹Ó·
Department of Paediatrics, “Asklipiion” General Hospital, Voula, Athens
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·ÏÏ¿ Ë ÂÚ·ÈÙ¤Úˆ ÂÎÙ›ÌËÛË ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο. °È· ÙË ÛˆÛÙ‹ ‰È¿ÁÓˆÛË ··ÈÙÂ›Ù·È Û˘¯Ó¿ ÂȉÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÚÔ˜ ·Ó›¯Ó¢ÛË ÂȉÈÎÒÓ ÙÚÔÊÈÎÒÓ IgE ·ÓÙÈۈ̿وÓ, ηıÒ˜ Î·È ·fi‰ÂÈÍË Ù˘ ˘ÔıÂÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ ̤ۈ ÂÚÈÔÚÈÛÙÈ΋˜ ‰›·ÈÙ·˜ Î·È ÙÚÔÊÈÎÒÓ ÚÔÎÏ‹ÛˆÓ. ∫ÏÈÓÈ΋ ·ÓÔ¯‹ Û ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· ·Ó·Ù‡ÛÛÂÙ·È Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ Û ÔÏÏÔ‡˜ ·ÛıÂÓ›˜, ÁÈ’ ·˘Ùfi ¯ÚÂÈ¿˙ÂÙ·È ·Ú·ÎÔÏÔ‡ıËÛË Û˘¯Ó¿ Î·È Ì ÙÚÔÊÈΤ˜ ÚÔÎÏ‹ÛÂȘ. ∏ ·Ó¿Ù˘ÍË Ó¤ˆÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÒÓ ÛÙÚ·ÙËÁÈÎÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÂͤÏÈÍË Èı·ÓÒ˜ Ó· ·ÔÙÂϤÛÂÈ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù· ÂfiÌÂÓ· ¯ÚfiÓÈ·. OÚÈÛÌÔ› ÂÓ ¯Ú‹ÛÂÈ ¶·Ú·Ù›ıÂÓÙ·È, ·Ú¯Èο, ÔÈ ÔÚÈÛÌÔ› ÂÓ ¯Ú‹ÛÂÈ ÁÈ· ÙȘ ÙÚÔÊÈΤ˜ ·ÓÂÈı‡ÌËÙ˜ ·ÓÙȉڿÛÂȘ Î·È Ë ÂÚÌËÓ›· ÙÔ˘˜ ‚¿ÛÂÈ ÙˆÓ ÚÔÙÂÈÓfiÌÂÓˆÓ ·fi ÙËÓ American Academy of Allergy and Immunology (2). ·) ∞ÓÂÈı‡ÌËÙ˜ ·ÓÙȉڿÛÂȘ (¢·ÈÛıËÛ›· Û οÔÈÔ ÙÚfiÊÈÌÔ): ∂›Ó·È ÁÂÓÈÎfi˜ fiÚÔ˜, ·Ó·ÊÂÚfiÌÂÓÔ˜ Û οı ÌË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ÙËÓ Î·Ù·Ó¿ÏˆÛË Î¿ÔÈÔ˘ ÙÚÔÊ›ÌÔ˘. ‚) ∆ÚÔÊÈ΋ ˘ÂÚ¢·ÈÛıËÛ›·: ¶ÚÔÛ‰ÈÔÚ›˙ÂÈ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÌÂÙ¿ ·fi ηٷӿψÛË ÙÚÔÊ›ÌÔ˘. ∂ÌÊ·Ó›˙ÂÙ·È Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ÙËÓ ÔÛfiÙËÙ· ‹ ÙËÓ „˘¯ÔÏÔÁÈ΋ ηٿÛÙ·ÛË. Á) ∆ÚÔÊÈ΋ ·Ó·Ê˘Ï·Í›·: ∫Ï·ÛÈ΋ ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Ù‡Ô˘ I, IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓË. ‰) ∆ÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·: ∂›Ó·È ÁÂÓÈÎfi˜ fiÚÔ˜ ‰È·Ù·Ú·¯‹˜ Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÌÂÙ¿ ·fi ηٷӿψÛË ÙÚÔÊ›ÌÔ˘, ¯ˆÚ›˜ Ó· Û˘Ó‰¤ÂÙ·È ·˘Ù‹ Ì ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi, ·ÏÏ¿ Ì ȉÈÔÛ˘ÁÎÚ·Ûȷο ·›ÙÈ· (ÙÔÍÈο, Ê·ÚÌ·ÎÔÏÔÁÈο, ÌÂÙ·‚ÔÏÈο). Â) ∆ÔÍÈÎfiÙ˘: ∂›Ó·È ‰Ú¿ÛË ÙÚÔÊ›ÌÔ˘ Ì ¿ÌÂÛÔ ÙÚfiÔ. ¶ÚÔηÏÂ›Ù·È ·fi ÙÔ͛Ә Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙÔ ›‰ÈÔ ÙÔ ÙÚfiÊÈÌÔ ‹ ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ ‹ ·Ú¿ÛÈÙ· Ô˘ ÂÈÌÔχÓÔ˘Ó ÙÔ ÙÚfiÊÈÌÔ. ÛÙ) ∆ÚÔÊÈ΋ ȉÈÔÛ˘ÁÎÚ·Ûȷ΋ ·ÓÙ›‰Ú·ÛË: ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÛÔÙÈ΋ ·ıÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË Û ÙÚÔÊ‹, ¯ˆÚ›˜ ˘ÔΛÌÂÓÔ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi. ˙) ∞Ó·Ê˘Ï·ÎÙÔÂȉ‹˜ ·ÓÙ›‰Ú·ÛË: ¶ÚÔÛÔÌÔÈ¿˙ÂÈ Ì ÙËÓ ·Ó·Ê˘Ï·ÎÙÈ΋, ·ÏÏ¿ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÌÂÛÔÏ·‚ËÙÒÓ ¯ˆÚ›˜ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi. Ë) º·ÚÌ·ÎÔÏÔÁÈ΋: ∞ÊÔÚ¿ Û ·ıÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË Û ÙÚfiÊÈÌÔ ÏfiÁˆ Ê˘ÛÈ΋˜ ‡·Ú͢ ‹ ÚÔÛı‹Î˘ Û ·˘Ùfi ¯ËÌÈ΋˜ Ô˘Û›·˜, Ë ÔÔ›· ÚÔηÏ› Ê·ÚÌ·ÎÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ·ÓÙ›‰Ú·ÛË. ı) ªÂÙ·‚ÔÏÈ΋ ·ÓÙ›‰Ú·ÛË: ∂›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÓÙ›‰Ú·Û˘ ÙÔ˘ ÙÚÔÊ›ÌÔ˘ ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ÍÂÓÈÛÙ‹.
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∞ÚÁfiÙÂÚ·, ÙÔ 1995 ‰ËÌÔÛȇıËÎÂ Ë ı¤ÛË Ù˘ ∂˘Úˆ·˚΋˜ ∞η‰ËÌ›·˜ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ (3), fiÔ˘ ÚÔÙ¿ıËΠӤ· Û˘ÓÙÔÌfiÙÂÚË Ù·ÍÈÓfiÌËÛË, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÔÈ ÙÚÔÊÈΤ˜ ·ÓÙȉڿÛÂȘ ‰È·ÎÚ›ÓÔÓÙ·È Û ÙÔÍÈΤ˜ Î·È ÌË ÙÔÍÈΤ˜. OÈ ÌË ÙÔÍÈΤ˜ ¤¯Ô˘Ó ‹ ‰ÂÓ ¤¯Ô˘Ó ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi. O fiÚÔ˜ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ·ÓÙȉڿÛÂȘ Ì ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi, ÂÓÒ ÁÈ· ÙȘ ˘fiÏÔȘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô fiÚÔ˜ ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·. ∏ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ‰È·ÎÚ›ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ, Û‡Ìʈӷ Ì ÙËÓ Î·Ù¿Ù·ÍË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·Ù¿ Coombs Î·È Gell, Û IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ‹ ÌË Ì ÙÔ˘˜ ÏÔÈÔ‡˜ ·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ù‡Ô˘˜. ∏ ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›· ‰È·ÎÚ›ÓÂÙ·È Û ʷÚÌ·ÎÔÏÔÁÈ΋, ÂÓ˙˘ÌÈ΋ Î·È ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜. ∆Ô 2001 ‰ËÌÔÛȇıËΠÛÙÔ Allergy ·fi ÂÈÙÚÔ‹ ÂȉÈÎÒÓ, ˘fi ÙËÓ ·ÈÁ›‰· ÙÔ˘ EAACI, ÙÚÔÔÔ›ËÛË Ù˘ ÂÓ ¯Ú‹ÛÂÈ ÔÚÔÏÔÁ›·˜, Ù· ΢ÚÈfiÙÂÚ· ÛËÌ›· Ù˘ ÔÔ›·˜ Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: O fiÚÔ˜ “˘ÂÚ¢·ÈÛıËÛ›·” ÚÔÙ›ÓÂÙ·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û·Ó fiÚÔ˜ “ÔÌڤϷ”, Ô ÔÔ›Ô˜ ηχÙÂÈ ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Ô˘ ‰‡Ó·ÓÙ·È Ó· ·Ó··Ú·¯ıÔ‡Ó ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ηıÔÚÈṲ̂ÓÔ ÂÚ¤ıÈÛÌ· Î·È Û ‰fiÛË ·ÓÂÎÙ‹ ·fi ˘ÁÈ‹ ¿ÙÔÌ·. O fiÚÔ˜ “·ÏÏÂÚÁ›·” ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜, ÛÙȘ Ôԛ˜ ÂÓ¤¯ÂÙ·È ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜. ∆¤ÏÔ˜, Ì ÙÔÓ fiÚÔ “·ÙÔ›·” ‰ËÏÒÓÂÙ·È ÔÈÎÔÁÂÓ‹˜ ‹ ·ÙÔÌÈ΋ ÚԉȿıÂÛË ÚÔ˜ ·Ú·ÁˆÁ‹ IgE ·ÓÙÈÛˆÌ¿ÙˆÓ ˆ˜ ·¿ÓÙËÛË Û ¯·ÌËϤ˜ ‰fiÛÂȘ ·ÏÏÂÚÁÈÔÁfiÓˆÓ Î·È Î˘Ú›ˆ˜ ÚˆÙÂ˚ÓÒÓ Î·È Ë ·Ó¿Ù˘ÍË Ù˘ÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ fiˆ˜ ¿ÛıÌ·, ÚÈÓÔÂÈÂÊ˘Î›Ùȉ· ‹ ¤Î˙ÂÌ·/‰ÂÚÌ·Ù›Ùȉ· (4). ™˘¯ÓfiÙËÙ· - ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ŸÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜, ‰ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· Î·È Ù· ·Ó·ÊÂÚfiÌÂÓ· ÔÛÔÛÙ¿ Î˘Ì·›ÓÔÓÙ·È Û ÌÂÁ¿ÏÔ Â‡ÚÔ˜. ∂Ó‰ÂÈÎÙÈο, ÁÈ· ÙËÓ ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ ·Ó·Ê¤ÚÔÓÙ·È ÔÛÔÛÙ¿ ·fi 0,3% ¤ˆ˜ 7,5%, ÂÓÒ Î·Ù’ ¿ÏÏÔ˘˜ ¤ˆ˜ 27% (5,6). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È Û ÌÂıÔ‰ÔÏÔÁÈο ·›ÙÈ· Î·È ÛÙÔ Â‡ÚÔ˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ô˘ οı ÊÔÚ¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙȘ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ. ¶¿ÓÙˆ˜, ÁÂÓÈο Ê·›ÓÂÙ·È fiÙÈ ÔÈ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ ηٷϷ̂¿ÓÔ˘Ó Âͤ¯Ô˘Û· ı¤ÛË ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛˆÓ. ™Â ÂÚÁ·Û›· ‰ËÌÔÛÈÂ˘Ì¤ÓË ÛÙÔ Lancet (7), ÔÈ Young Î·È Û˘Ó ·¤ÛÙÂÈÏ·Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û 20.000 ¿ÙÔÌ· ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ·ÓÙȉڿÛÂˆÓ Û 8 ÙÚfiÊÈÌ·. ∞fi ·˘ÙÔ‡˜ Ô˘ ·¿ÓÙËÛ·Ó, 18,5% ıˆÚÔ‡Û fiÙÈ Â›¯Â ‰˘Û·ÓÂÍ›· Û ·˘Ù¤˜ ÙȘ ÙÚÔʤ˜. ªÂÙ¿ ·fi ÚfiÎÏËÛË Ì ‰ÈÏ‹ Ù˘ÊÏ‹ ̤ıÔ‰Ô Û 93 ÂÍ
¶·È‰È·ÙÚÈ΋ 2003;66:239-246
·˘ÙÒÓ, ÌfiÓÔ ÙÔ 19% ‹Ù·Ó ıÂÙÈÎfi. ∆Ô ·ÔÙ¤ÏÂÛÌ· ‰›ÓÂÈ ¤Ó· ÔÛÔÛÙfi ›وÛ˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ 1,4% ÛÙ· 8 ‚·ÛÈο ÙÚfiÊÈÌ·. ™Â ¿ÏÏË ÂÚÁ·Û›· (8) ·fi ÙÔ˘˜ Bock Î·È Martin (1983), ÌÂÏÂÙ‹ıËÎ·Ó 500 ·È‰È¿ ·fi ÙË Á¤ÓÓËÛË Î·È ÁÈ· ‰È¿ÛÙËÌ· 3 ÂÙÒÓ, Ì ϋ„Ë ÈÛÙÔÚÈÎÔ‡, ÙÚÔÊÈ΋ ÚfiÎÏËÛË, ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Î·È RAST. ™ÙÔ Ù¤ÏÔ˜ ÙˆÓ 3 ÂÙÒÓ, 142 (20%) ·fi ·˘Ù¿ Ù· ·È‰È¿ ›¯·Ó ‡ÔÙ˜ ·ÓÙȉڿÛÂȘ Û ÙÚfiÊÈÌ· Î·È ÌfiÓÔ Û 27 ÂÚÈÙÒÛÂȘ (19%) ÂȂ‚·ÈÒıËΠ·˘Ùfi Ì ÚfiÎÏËÛË. ∏ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Ì ‰‡Ô ÙÚfiÔ˘˜: ·) ·ÛıÂÓ›˜ ÌÂ Û˘ÌÙÒÌ·Ù· ‹ Û˘Ó‰˘·ÛÌfi Û˘ÌÙˆÌ¿ÙˆÓ Ô˘ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÔÊ›ÏÔÓÙ·È Û ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· Î·È ‚) ·ÛıÂÓ›˜ Ì ÂÁηÙÂÛÙË̤ÓË ‰È¿ÁÓˆÛË ÓfiÛÔ˘, fiˆ˜ ¿ÛıÌ·, ÚÈÓ›Ùȉ·, ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Î·È ÎÓ›‰ˆÛË. ¶ÈÛÙ‡ÂÙ·È fiÙÈ ¤Ó· ÔÛÔÛÙfi ÂÍ ·˘ÙÒÓ ı· ¤¯ÂÈ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· Û·Ó ÚˆÙ·Ú¯ÈÎfi ‹ Û¯ÂÙÈ˙fiÌÂÓÔ ·›ÙÈÔ Ì ÙË ¯ÚfiÓÈ· ÓfiÛÔ ÙÔ˘. ™ÙȘ ·Ûı¤ÓÂȘ Ô˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·Ó·Ê˘Ï·Í›·, Ë ÎÓ›‰ˆÛË/ ÙÔ ·ÁÁÂÈÔÔ›‰ËÌ·, Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, Ë ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· Î·È ÂÈÂÊ˘Î›Ùȉ·, Ë ÔÚ҉˘ ̤ÛË ˆÙ›Ùȉ·, ÙÔ ¿ÛıÌ·, ÙÔ Û‡Ó‰ÚÔÌÔ Heiner, Ë Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·ÏÏÂÚÁÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ÔÈ ·ÈÌÔÚÚ·Á›Â˜ ·fi ÙÔ ÂÙÈÎfi, Ë ÂÏÎ҉˘ ÎÔÏ›Ùȉ·, ÔÈ ËÌÈÎڷӛ˜, Ù· „˘¯ÔÏÔÁÈο ÓÔÛ‹Ì·Ù· Î.¿. ¢È·ÁÓˆÛÙÈΤ˜ ̤ıÔ‰ÔÈ ∆· ‚·ÛÈο fiÚÁ·Ó·-ÛÙfi¯ÔÈ ÛÙËÓ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· Â›Ó·È ÙÔ ‰¤ÚÌ·, ÙÔ ÂÙÈÎfi, ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi. ∆Ô Û‡ÓÔÏÔ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ô˘ ÂΉËÏÒÓÔÓÙ·È ·fi ·˘Ù¿ Ù· fiÚÁ·Ó· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ Î·È ÌÔÚ› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ·ÏÏÂÚÁÈ΋˜ ‹ ÌË ·ÏÏÂÚÁÈ΋˜ ›‰Ú·Û˘. ∏ ·˘ÍË̤ÓË Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎÔÈÓÔ‡ ÛÙȘ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ Î·È Ë Ï·Óı·Ṳ̂ÓË Û˘¯Ó¿ ·fi‰ÔÛË ‰È·ÊfiÚˆÓ ·ı‹ÛÂˆÓ Û ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ÂÈ‚¿ÏÏÔ˘Ó ÙÔÓ ÛÎÂÙÈÎÈÛÌfi ÛÙËÓ ÂÎÙ›ÌËÛË Î·È ÙË ¯Ú‹ÛË ·ÓÙÈÎÂÈÌÂÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË. ∏ ˘ÂډȿÁÓˆÛË ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ Ô‰ËÁ› Û ‰È·ÙÚÔÊÈΤ˜ ‰È·Ù·Ú·¯¤˜, ˘ÔıÚ„›·, „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÂÓÒ Ë ˘Ô‰È¿ÁÓˆÛË ·Ê‹ÓÂÈ ÙÔÓ ·ÛıÂÓ‹ Ó· ˘ÔʤÚÂÈ Î·È ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÏÏÈ‹ ·Ó¿Ù˘ÍË Î·È Èı·Ó¿ Û ÌfiÓÈ̘ ‚Ï¿‚˜. ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Û ˘Ô„›· ÙÚÔÊÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ·ÓÙȉڿÛÂˆÓ ·Ú¯›˙ÂÈ Ì ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È Ê˘ÛÈ΋ ÂͤٷÛË. ™ÎÔfi˜ Â›Ó·È Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Â¿Ó Ú¿ÁÌ·ÙÈ Ô ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ·ÓÂÈı‡ÌËÙ˜ ·ÓÙȉڿÛÂȘ Û οÔÈÔ ÙÚfiÊÈÌÔ Î·È Â¿Ó ÛÙËÓ ·ÓÙ›‰Ú·ÛË ·˘Ù‹
Paediatriki 2003;66:239-246
ÂÌϤÎÂÙ·È ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜. ∂¿Ó ˘¿Ú¯ÂÈ Ù¤ÙÔÈ· ˘fiÓÔÈ·, Â›Ó·È ¯Ú‹ÛÈÌÔ Ó· Á›ÓÂÈ ÚÔÛ¿ıÂÈ· ¤ÓÙ·Í˘ Ù˘ ·ÓÙ›‰Ú·Û˘ Û IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓË ‹ fi¯È, ηıÒ˜ ı· Á›ÓÂÈ ‰È·ÊÔÚÂÙÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ÂÚ·ÈÙ¤Úˆ ÂϤÁ¯Ô˘. ∂›Û˘, ÛÎfiÈÌÔ Â›Ó·È Ó· Á›ÓÂÈ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·fi ¿ÏÏ· ·›ÙÈ·, Ù· ÔÔ›· ı· ÌÔÚÔ‡Û·Ó Ó· ÂΉËψıÔ‡Ó Ì ·ÚfiÌÔÈ· Û˘Ìو̷ÙÔÏÔÁ›·. ™ÙÔÓ ¶›Ó·Î· 1 ·Ó·Ê¤ÚÂÙ·È Ì›· ÛÂÈÚ¿ ¿ÏÏˆÓ ·ÈÙÈÒÓ Ô˘ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ, ÙˆÓ ÔÔ›ˆÓ Ù· Û˘ÌÙÒÌ·Ù· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ ÂÙÈÎfi. ™ÙÔÓ ¶›Ó·Î· 2 ·Ó·Ê¤ÚÔÓÙ·È Û˘ÌÙÒÌ·Ù· Ô˘ Û˘Ó‹ıˆ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ‰È¿ÊÔÚ· fiÚÁ·Ó·ÛÙfi¯Ô˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÚÔÊÈÎÒÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ (9). §‹„Ë ÈÛÙÔÚÈÎÔ‡ °ÂÓÈΤ˜ Ô‰ËÁ›Â˜ Ô˘ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ Î·Ù¿ ÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ªÂ ‚¿ÛË ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi, Ô ÁÈ·ÙÚfi˜ ı· ÚÔÛ·ı‹ÛÂÈ Ó· ÂÚ¢ӋÛÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ÙÚÔÊÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙËÚÈ˙fiÌÂÓÔ˜ ÛÙ· Û˘ÌÙÒÌ·Ù·, ÙÔÓ ¯ÚfiÓÔ Ù˘ ·ÓÙ›‰Ú·Û˘ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ ‡ÔÙÔ˘ ÙÚÔÊ›ÌÔ˘ ÁÈ· ÙËÓ ÚfiÎÏËÛË Ù˘ ·ÓÙ›‰Ú·Û˘. °È’ ·˘ÙfiÓ ÙÔÓ ÏfiÁÔ Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó Ù· ·ÎfiÏÔ˘ı·: ·) Ùo ›‰Ô˜ ÙÔ˘ ‡ÔÙÔ˘ ÙÚÔÊ›ÌÔ˘ Î·È Ë ÏËÊı›۷ ÔÛfiÙËÙ·, ‚) Ô ¯ÚfiÓÔ˜ Ô˘ ¤Ú·Û ·fi ÙË Ï‹„Ë ÙÔ˘ ÙÚÔÊ›ÌÔ˘ ¤ˆ˜ ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ Û˘Ìو̿وÓ, Á) Â¿Ó Ë Ï‹„Ë ÙÔ˘ ‡ÔÙÔ˘ ÙÚÔÊ›ÌÔ˘ ¤¯ÂÈ ÚÔηϤÛÂÈ ·ÚfiÌÔÈ· Û˘ÌÙÒÌ·Ù· Î·È ÛÙÔ ·ÚÂÏıfiÓ, ‰) Û˘Ó˘¿Ú¯ÔÓÙ˜ ·Ú¿ÁÔÓÙ˜ (¿ÛÎËÛË, ηٷӿψÛË ·ÏÎÔfiÏ) ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Â) ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ¤Ú·Û ·fi ÙËÓ ÙÂÏÂ˘Ù·›· ÊÔÚ¿ Ô˘ Û˘Ó¤‚Ë ÙÚÔÊÈ΋ ·ÓÙ›‰Ú·ÛË. ∂ÈϤÔÓ, Ï›Á· ÙÚfiÊÈÌ· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ ÔÛÔÛÙfi ÂÚ›Ô˘ 80-90% ÙˆÓ ‰È·ÈÛÙˆÌ¤ÓˆÓ ·ÓÙȉڿÛÂˆÓ (Ì ÂÍ·›ÚÂÛË ÙÔ ÛÙÔÌ·ÙÈÎfi ·ÏÏÂÚÁÈÎfi Û‡Ó‰ÚÔÌÔ), fiˆ˜ ÙÔ ·˘Áfi, ÙÔ Á¿Ï·, ÔÈ ÍËÚÔ› ηÚÔ›, Ë ÛfiÁÈ·, ÙÔ „¿ÚÈ Î·È Ù· ‰ËÌËÙÚȷο ÛÙ· ·È‰È¿, ÂÓÒ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÙÚÔʤ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ˘˜ ÍËÚÔ‡˜ ηÚÔ‡˜, ÙÔ „¿ÚÈ Î·È Ù· fiÛÙڷη. ∆Ô ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ¤¯ÂÈ Ùˆ¯‹ ÚÔÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Û ¯ÚfiÓÈ· ÚÔ‚Ï‹Ì·Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ (·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ¿ÛıÌ· Î·È ·ÏÏÂÚÁÈ΋ ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·), ÂÓÒ Û Ôͤ· ÚÔ‚Ï‹Ì·Ù· (·Ó·Ê˘Ï·Í›· Î·È ÎÓ›‰ˆÛË), ÌÂÙ¿ ÙË Ï‹„Ë ÂÓfi˜ ÙÚÔÊ›ÌÔ˘, Ë ÚÔÁÓˆÛÙÈ΋ ÙÔ˘ ·Í›· Â›Ó·È ˘„ËÏ‹ (10). ∂›Û˘, ηٿ ÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ı· Ú¤ÂÈ
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Ó· ·Ó·˙ËÙÔ‡ÓÙ·È Î·È ¿ÏÏ· ÙÚfiÊÈÌ· Ô˘ ηٷӷÏÒıËÎ·Ó ÙÔÓ ›‰ÈÔ ¯ÚfiÓÔ, ηıÒ˜ Î·È Èı·Ó¿ “ÂÈÌÔÏ˘Ṳ̂ӷ” ÙÚfiÊÈÌ· ·fi “Û˘ÁÎÂÎ·Ï˘Ì¤Ó· ˘ÏÈο” (9). º˘ÛÈ΋ ÂͤٷÛË ∏ ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ‰¤ÚÌ·, ÛÙÔ ÂÙÈÎfi Î·È ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi, ηıÒ˜ ›Û˘ ÛÙËÓ ·Ó›¯Ó¢ÛË ·ÙÔÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Ô˘ ΢ڛˆ˜ ·Ó¢ڛÛÎÔÓÙ·È Û ¿ÙÔÌ· Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ. ∂›Û˘, ÂÎÙÈÌ¿Ù·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ıÚ¤„˘ ÙÔ˘ ·ÙfiÌÔ˘ Î·È Ê˘ÛÈο ÛËÌ›· Ô˘ ˘Ô‰ËÏÒÓÔ˘Ó ÌË ·ÏÏÂÚÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ªÂ ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙË Ê˘ÛÈ΋ ÂͤٷÛË Ô ÁÈ·ÙÚfi˜ ı· Ú¤ÂÈ Ó· ·ÓÙÈÏËÊı› ·Ó Ù· Û˘ÌÙÒÌ·Ù· ˘ÔÎÚ‡ÙÔ˘Ó ÙÚÔÊÈ΋ ·ÏÏÂÚÁÈ΋ ‰È·Ù·Ú·¯‹ Î·È Ó· Èı·ÓÔÏÔÁ‹ÛÂÈ Â¿Ó Â›Ó·È IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓË ‹ fi¯È. OÚÈṲ̂Ó˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈ̘ Û IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ‰È·Ù·Ú·¯¤˜, ÂÓÒ Û ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂Ó˘ ÛËÌ·Û›·˜. ŒÙÛÈ, ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Î·È Ù· RAST ÛÙȘ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ‚ÔËıÔ‡Ó ÛÙËÓ ·Ó›¯Ó¢ÛË IgE ·ÓÙÈÛˆÌ¿ÙˆÓ Û ÂȉÈο ÙÚfiÊÈÌ·, ¯ˆÚ›˜ ·˘Ùfi Ó· ÛËÌ·›ÓÂÈ fiÙÈ Ù›ıÂÙ·È Ë ‰È¿ÁÓˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. OÈ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¯ÚËÛÈÌÂ‡Ô˘Ó ÛÙËÓ ·Ó›¯Ó¢ÛË ‡ÔÙˆÓ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓˆÓ ÙÚÔÊÈÎÒÓ ·ÏÏÂÚÁÈÒÓ. °ÂÓÈο, ¿ÓÙˆ˜, ÔÈ ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¤¯Ô˘Ó ÚÔÁÓˆÛÙÈ΋ ·Í›· ÌÈÎÚfiÙÂÚË ·fi 50% Û˘ÁÎÚÈÓfiÌÂÓ˜ Ì ٷ ·ÔÙÂϤ-
Paediatriki 2003;66:239-246
ÛÌ·Ù· ÌÂÙ¿ ·fi ÚfiÎÏËÛË. OÈ ·ÚÓËÙÈΤ˜ ··ÓÙ‹ÛÂȘ ۯ‰fiÓ ·ÔÎÏÂ›Ô˘Ó ÙȘ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ (ÚÔÁÓˆÛÙÈ΋ ·Í›· ≥95%). ∂Ô̤ӈ˜, ÂÓÒ ÔÈ ·ÚÓËÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ·ÔÎÏÂ›Ô˘Ó Û¯Â‰fiÓ ÙȘ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜, ÔÈ ıÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ı¤ÙÔ˘Ó ÌfiÓÔ ÙËÓ ˘fiÓÔÈ· Ù˘ ·ÚÔ˘Û›·˜ ·ÏÏÂÚÁ›·˜. ∂ÓÙÔ‡ÙÔȘ, Ì›· ıÂÙÈ΋ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· ÌÔÚ› Ó· ıˆÚËı› ‰È·ÁÓˆÛÙÈ΋ Û ·ÛıÂÓ›˜ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ÙËÓ Î·Ù·Ó¿ÏˆÛË Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÙÚÔÊ›ÌÔ˘ (9,10). ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ·ÚÓËÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ì ÂÌÔÚÈÎfi Âί‡ÏÈÛÌ·, ÂÊfiÛÔÓ ¤Ú¯ÂÙ·È Û ·ÓÙ›ıÂÛË Ì ۷ʤ˜ ÈÛÙÔÚÈÎfi, ı· Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÔÓÙ·È Ì ÊÚ¤ÛÎÔ ÙÚfiÊÈÌÔ ÚÈÓ ‚ÁÂÈ ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·. ∆· RAST, ›Û˘, ·ÓȯÓÂ‡Ô˘Ó ÂȉÈο IgE ÙÚÔÊÈο ·ÓÙÈÛÒÌ·Ù· ÛÙÔÓ ÔÚfi Î·È ¤¯Ô˘Ó ÙȘ ›‰È˜ ÂÊ·ÚÌÔÁ¤˜, ÂÓÒ ÚÔÙÈÌÒÓÙ·È Û ÔÚÈṲ̂Ó˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜: ·) Û ·ÛıÂÓ›˜ Ì ¤ÓÙÔÓÔ ‰ÂÚÌÔÁÚ·ÊÈÛÌfi, ‚) Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú¿ ‰ÂÚÌ·ÙÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, Á) Û ·ÛıÂÓ›˜ Ô˘ ‰˘ÛÎÔχÔÓÙ·È Ó· ‰È·Îfi„Ô˘Ó Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο Î·È ‰) Û ·ÛıÂÓ›˜ Ì ‡ÔÙ˜ ·ÔÎÏÂÈÛÙÈο ¢·ÈÛıËۛ˜ Û ÔÚÈṲ̂ӷ ÙÚfiÊÈÌ· (9). ¶ÚfiÛÊ·ÙË ÌÂϤÙË Ù˘ ÌÂıfi‰Ô˘ CAP-RAST FEIA Ù˘ Pharmacia Û ·È‰È¿ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ¤‰ÂÈÍ fiÙÈ Ô ÔÛÔÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÂȉÈÎÒÓ IgE ÙÚÔÊÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·Ú›¯Â ·˘ÍË̤ÓË ÚÔÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· ÁÈ· ÙÔ Á¿Ï·, ÙÔ ·˘Áfi, ÙÔ ÊÈÛÙ›ÎÈ Î·È ÙÔ „¿ÚÈ, Û ۯ¤ÛË Ì ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ (9).
¶›Ó·Î·˜ 1. ™ÂÈÚ¿ ·ÈÙÈÒÓ Ô˘ ı· Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘’ fi„ÈÓ Î·Ù¿ ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·ÏÏÂÚÁÈÎÒÓ ÙÚÔÊÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ñ ∞Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜: ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, ˘ÏˆÚÈ΋ ÛÙ¤ÓˆÛË, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ, Ó. Hirsprung ñ ∞Ó¿ÚÎÂȘ ÂÓ˙‡ÌˆÓ (ÚˆÙÔ·ı›˜, ‰Â˘ÙÂÚÔ·ı›˜): ·Ó¿ÚÎÂÈ· ‰È۷ί·Úȉ·ÛÒÓ, Á·Ï·ÎÙÔ˙·ÈÌ›·, Ê·ÈÓ˘ÏÔÎÂÙÔÓÔ˘Ú›· ñ ∫·ÎÔ‹ıÂȘ ñ ÕÏÏ·: ·ÁÎÚ·ÙÈ΋ ·Ó¿ÚÎÂÈ·, ¯ÔÏfiÏÈıÔ˜, Á·ÛÙÚÈÎfi ¤ÏÎÔ˜ ñ ¶ÚfiÛıÂÙ· ÙÚÔʛ̈Ó: Û˘ÓÙËÚËÙÈο Î·È ‚ÂÏÙȈÙÈο Á‡Û˘, ıÂÈÈο, ªSG-ÓÈÙÚÈο ñ ÃÚˆÛÙÈΤ˜: Tartazine Î·È ¿ÏϘ ·˙Ô¯ÚˆÛÙÈΤ˜ ñ ∆Ô͛Ә: ‚·ÎÙ‹ÚÈ·, ̇ÎËÙ˜ ñ £·Ï·ÛÛÈÓ¿ - „¿ÚÈ· ñ §ÔÈÌÒÍÂȘ: Û·ÏÌÔӤϷ, ÛÈÁΤÏÏ·, ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ, Yersinia, Campylobacter, ·Ú¿ÛÈÙ·, ÈÔ› ñ ∞ÓÙÈÁfiÓ· Ì˘Î‹ÙˆÓ ñ ∆˘¯·›Â˜ ÂÈÌÔχÓÛÂȘ: ̤ٷÏÏ·, ÂÓÙÔÌÔÎÙfiÓ·, ·ÓÙÈ‚ÈÔÙÈο ñ º·ÚÌ·ÎÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜: ηʽÓË, ıÂԂڈ̛ÓË, ÈÛÙ·Ì›ÓË, ÙÚ˘Ù·Ì›ÓË, ÛÂÚÔÙÔÓ›ÓË, Ù˘Ú·Ì›ÓË
¶›Ó·Î·˜ 2. ™˘ÌÙÒÌ·Ù· ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ∞fi ÙÔ ‰¤ÚÌ·: ∞fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi: ∞fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi: ∞fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi:
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∫Ó›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·, ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· - flushing, ÂÚ˘ıËÌ·Ù҉˜ ÎÓËÛÌ҉˜ ÂÍ¿ÓıËÌ·, ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ∫ÓËÛÌfi˜ Î·È Ô›‰ËÌ· ¯ÂÈϤˆÓ, ÁÏÒÛÛ·˜, ÛÙÔÌ·ÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, Ó·˘Ù›·, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ ‹ ΈÏÈÎfi˜, ¤ÌÂÙÔ˜ ‹ reflux, ‰È¿ÚÚÔÈ· ƒÈÓÈ΋ Û˘ÌÊfiÚËÛË, ÚÈÓfiÚÚÔÈ·, ÎÓËÛÌfi˜, Ù¤ÚÓÈÛÌ·, Ï·Ú˘ÁÁÈÎfi Ô›‰ËÌ·, ‚‹¯·˜, ‰˘Ûʈӛ·, Û˘ÚÈÁÌfi˜, ›ÌÔÓÔ˜ ‚‹¯·˜ ÀfiÙ·ÛË, ˙¿ÏË, shock
¶·È‰È·ÙÚÈ΋ 2003;66:239-246
Paediatriki 2003;66:239-246
¶›Ó·Î·˜ 3. ™ÙÔȯ›· Ô˘ Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘’ fi„ÈÓ Î·Ù¿ ÙË Ï‹„Ë ÈÛÙÔÚÈÎÔ‡ ñ ∆Ô ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Û˘¯Ó¿ ·Ó·ÎÚÈ‚¤˜ ñ ∏ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· Â›Ó·È ÈÔ Û˘¯Ó‹ ÛÙ· ÌÈÎÚ¿ ·È‰È¿ ΢ڛˆ˜ Ì ÙË ÌÔÚÊ‹ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ñ ™¯ÂÙÈο Ï›Á· ÙÚfiÊÈÌ· Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ñ ªÂ ÂÍ·›ÚÂÛË ÙËÓ ·ÏÏÂÚÁÈ΋ ˈÛÈÓÔÊÈÏÈ΋ ÔÈÛÔÊ·Á›Ùȉ· ‹ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, Â›Ó·È Û¿ÓÈÔ ¤Ó· ¿ÙÔÌÔ Ó· ·ÓÙȉڿ Û ÂÚÈÛÛfiÙÂÚ· ·fi 3 ÙÚfiÊÈÌ· ñ ŸÙ·Ó ¤Ó· ·È‰› Ì ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ·ÓÙȉڿ Û “Ó¤·” ‹ “ÔÏÏ·Ï¿” ÙÚfiÊÈÌ·, Â›Ó·È Èı·Ófi fiÙÈ Ï·Ì‚¿ÓÂÈ Ì “ÌË Ê·ÓÂÚfi” ÙÚfiÔ ÎÔÈÓ¿ ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· ñ ∂ÎÙfi˜ ·fi ÙȘ ·ÏÏÂÚÁ›Â˜ ÙÔ˘ ÂÙÈÎÔ‡, Ù· ÂÚÈÛÛfiÙÂÚ· ÙÚÔÊÈο ·ÏÏÂÚÁÈο Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È Û ϛÁ· ÏÂÙ¿ ¤ˆ˜ Ï›Á˜ ÒÚ˜ ·fi ÙË Ï‹„Ë ÙÔ˘ ÙÚÔÊÈÎÔ‡ ·ÏÏÂÚÁÈÔÁfiÓÔ˘ ñ OÈ ·ÏËı›˜ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ ÁÂÓÈο ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÎÏ·ÛÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ ‰¤ÚÌ·, ÙÔ ÂÙÈÎfi Î·È ÙÔ ·Ó·Ó¢ÛÙÈÎfi ñ ÀÔÎÂÈÌÂÓÈο ‹ Û˘ÌÙÒÌ·Ù· ‰È·Ù·Ú·¯ÒÓ Û˘ÌÂÚÈÊÔÚ¿˜ ˆ˜ ÌÔÓ·‰È΋ ÂΉ‹ÏˆÛË ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ Â›Ó·È Û¿ÓÈ· ñ ∞ÓÂÈı‡ÌËÙ˜ ·ÓÙȉڿÛÂȘ Û ¯ÚˆÛÙÈΤ˜ ‹ ÚfiÛıÂÙ· ÙÚÔÊÒÓ Â›Ó·È Û¯ÂÙÈο Û¿ÓȘ
Œ¯ÂÈ ·Ó·ÊÂÚı› Î·È Û ÂÏÏËÓÈΤ˜ ÌÂϤÙ˜ fiÙÈ Ë ›‰È· ̤ıÔ‰Ô˜ ÌÔÚ› Ó· ÚԂϤ„ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂȉÈÎÒÓ ÙÚÔÊÈÎÒÓ ÚÔÎÏ‹ÛÂˆÓ (ÁÈ· ÙÔ Á¿Ï· ·Ó·ÊÂÚfiÌÂÓË ÙÈÌ‹ >95% Û ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÚfiÎÏËÛ˘). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È ˆ˜ ¯Ú‹ÛÈÌË Ì¤ıÔ‰Ô˜ ÛÙË ‰È¿ÎÚÈÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ı· ·ÔÎÙ‹ÛÔ˘Ó ÎÏÈÓÈ΋ ·ÓÔ¯‹, Û ۯ¤ÛË Ì ·˘Ù¿ Ì ›ÌÔÓÔ Úfi‚ÏËÌ· (11). ∂›Û˘, ¿ÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο fiˆ˜ Ù· ˘„ËÏ¿ ‹ ·˘Í·ÓfiÌÂÓ· ›‰· ÂȉÈ΋˜ IgE, ηıÒ˜ Î·È ÈÛÙÔÚÈÎfi ·ÓÙ›‰Ú·Û˘ Û ÌÈÎÚ‹ ËÏÈΛ· Â›Ó·È ÂÈ‚·Ú˘ÓÙÈο fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÙÚÔÊÈÎÒÓ ÚÔÎÏ‹ÛˆÓ. ∆¤ÏÔ˜, Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ÂȉÈÎÒÓ IgE ÙÈÌÒÓ ¯ÚËÛÈ̇ÂÈ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·Ú·ÌÔÓ‹˜ ‹ ÌË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ (12). ª›· ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ¢›·ÈÙ· ·ÔÊ˘Á‹˜ - ¢ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘ ∂ÊfiÛÔÓ ÔÚÈṲ̂ӷ ÙÚfiÊÈÌ· ıˆÚËıÔ‡Ó ‡ÔÙ· ÁÈ· ¤ÎÏ˘ÛË ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘, ÂÊ·ÚÌfi˙ÂÙ·È ‰È·ÁÓˆÛÙÈο ‰›·ÈÙ· ·ÔÊ˘Á‹˜. °È· ÙËÓ ÂÈÙ˘¯›· ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜ ··ÈÙÂ›Ù·È Ë ·ÔÊ˘Á‹ ÙÔ˘ ÛˆÛÙÔ‡ ‹ ÙˆÓ ÛˆÛÙÒÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ. ∂›Û˘, ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë ÈηÓfiÙËÙ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ó· ‰È·ÙËÚ‹ÛÂÈ Ì›· ‰›·ÈÙ· ÂχıÂÚË ·fi fiϘ ÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ÌÔÚʤ˜ Ô˘ ÌÔÚ› Ó· ‚Ú›ÛÎÂÙ·È ÙÔ ‡ÔÙÔ ÙÚfiÊÈÌÔ, ηıÒ˜ Î·È Ë ·Ô˘Û›· ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂȉÂÈÓÒÛÔ˘Ó Ù· Û˘ÌÙÒÌ·Ù·, fiˆ˜ .¯. Ô Staph. aureus Û·Ó ÂÈÌfiÏ˘ÓÛË ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÔÈ ÈÒÛÂȘ ÛÙÔ ¿ÛıÌ· Î·È Ë ‰Â˘ÙÂÚÔ·ı‹˜ ·Ó¿ÚÎÂÈ· Ï·ÎÙ¿Û˘ Û ‚Ú¤ÊÔ˜ Ì ۇӉÚÔÌÔ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ (protein induced) (9). ∞Ó Ù· Û˘ÌÙÒÌ·Ù· ˘Ô¯ˆÚ‹ÛÔ˘Ó ÂÓÒ Ô ·ÛıÂÓ‹˜ Â›Ó·È Û ‰›·ÈÙ· ·ÔÊ˘Á‹˜, ··ÈÙÂ›Ù·È Î¿ÔÈÔ Â›‰Ô˜ ÙÚÔÊÈ΋˜ ÚfiÎÏËÛ˘ ÁÈ· Ó· ÂȂ‚·Èˆı› Ë ‰È¿ÁÓˆÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜, ÂȉÈο Û ¯ÚfiÓÈ· ÚÔ‚Ï‹Ì·Ù· fiˆ˜ Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Î·È ÙÔ ¿ÛıÌ·. OÈ ÙÚÔÊÈΤ˜ ÚÔÎÏ‹ÛÂȘ Â›Ó·È Ì¤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜, ηıÒ˜ Î·È ÁÈ· ÙËÓ Â·ÓÂÎÙ›ÌËÛË Ù˘ ÂÓÂÚÁfi-
ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ ÂÓÔ¯ÔÔÈËı¤ÓÙˆÓ ÙÚÔÊ›ÌˆÓ (12). OÈ ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘ ·fi ÙÔ ÛÙfiÌ· ‰È·ÎÚ›ÓÔÓÙ·È ÛÙȘ ·ÓÔÈÎÙ¤˜, fiÔ˘ Ô ÁÈ·ÙÚfi˜ Î·È Ô ·ÛıÂÓ‹˜ ÁÓˆÚ›˙Ô˘Ó ÙÔ ÙÚfiÊÈÌÔ, ÛÙȘ ·Ï¤˜ Ù˘ÊϤ˜, fiÔ˘ ÌfiÓÔ Ô ÁÈ·ÙÚfi˜ ÁÓˆÚ›˙ÂÈ Î·È ÛÙȘ ‰ÈϤ˜ Ù˘ÊϤ˜ ÂÏÂÁ¯fiÌÂÓ˜ Ì ÂÈÎÔÓÈÎfi ÙÚfiÊÈÌÔ, fiÔ˘ Ô‡ÙÂ Ô ÁÈ·ÙÚfi˜ Ô‡ÙÂ Ô ·ÛıÂÓ‹˜ ÁÓˆÚ›˙Ô˘Ó ÙËÓ Ô˘Û›·. ∂›Û˘, Ô ·ÛıÂÓ‹˜ ‹ ÔÈ ÁÔÓ›˜ ÙÔ˘ Ú¤ÂÈ Ó· Û˘ÌʈӋÛÔ˘Ó ÁÈ· ÙË ‰È·‰Èηۛ· Î·È ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜. ∞Ú¯Èο Û˘ÓÈÛÙ¿Ù·È ‰›·ÈÙ· ·ÔÊ˘Á‹˜ ÙˆÓ ‡ÔÙˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ ÁÈ· 7-14 Ë̤Ú˜, fiÙ·Ó ıˆÚÂ›Ù·È IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓË ·ÓÙ›‰Ú·ÛË Î·È ÁÈ· 2-3 Ì‹Ó˜ Û ¿ÏϘ ÂÚÈÙÒÛÂȘ, ȉ›ˆ˜ Û Á·ÛÙÚÂÓÙÂÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (13). °È· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ‰ÔÎÈÌ·Û›·˜ ÚfiÎÏËÛ˘, ·Ú¯Èο, Ô ·ÛıÂÓ‹˜ ‹ ÔÈ ÁÔÓ›˜ ÙÔ˘ Ú¤ÂÈ Ó· ÂÓËÌÂÚÒÓÔÓÙ·È ÁÈ· ÙË ‰È·‰Èηۛ· Î·È ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ (15). ∂›Û˘, ıˆÚÂ›Ù·È ·Ó·Áη›Ô Ó· ˘¿Ú¯Ô˘Ó Ê¿Ú̷η Î·È ÂÍÔÏÈÛÌfi˜ ηٿÏÏËÏ· ÁÈ· ÙËÓ ·Ó¿Ù·ÍË Ù˘¯fiÓ ·Ó·Ê˘Ï·Í›·˜, ÂÓÒ Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ¤ÙÔÈÌË ÚfiÛ‚·ÛË Û ÊϤ‚· Î·È Ë ‰ÔÎÈÌ·Û›· Ó· Á›ÓÂÙ·È Û ÓÔÛÔÎÔÌ›Ô. ∆¤ÏÔ˜, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· Â›Ó·È ˘fi È·ÙÚÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÂÎÙ›ÌËÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· Ê¿Ú̷η Ô˘ Ï·Ì‚¿ÓÂÈ Ô ·ÛıÂÓ‹˜ ÚÈÓ ÙËÓ ÚfiÎÏËÛË: ·) ÁÈ· ÙÔ ¿ÛıÌ·: Ù· ÂÈÛÓÂfiÌÂÓ·: - ‚2-‰ÈÂÁ¤ÚÙ˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Î·È ·ÓÙȯÔÏÈÓÂÚÁÈο Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È 1 Ë̤ڷ ÚÈÓ - ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È 48 ÒÚ˜ ÚÈÓ - ¯ÚˆÌÔÁÏ˘Î›Ó˜, ·ÓÙÈÈÛÙ·ÌÈÓÈο Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È 2-4 Ë̤Ú˜ ÚÈÓ - Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο Ì·ÎÚ¿˜ ‰Ú¿Û˘ Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜ ÚÈÓ - Ù· ÂÈÛÓÂfiÌÂÓ· Î·È Û˘ÛÙËÌ·ÙÈο ÛÙÂÚÔÂȉ‹ ÌÔÚ› Ó· Û˘Ó¯ÈÛÙÔ‡Ó Î·È ÁÈ· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Î·Ï‹˜ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜,
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‚) ÁÈ· ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·/ÎÓ›‰ˆÛË: Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο Î·È Ù· ÛÙÂÚÔÂȉ‹ ‹ Ó· ÌÂÈÒÓÂÙ·È Ë ‰fiÛË ÛÙ· ÙÂÏÂ˘Ù·›·, Á) ÁÈ· ÚÈÓ›Ùȉ· Î·È ¿ÛıÌ·: Ú¤ÂÈ Ó· ‰È·ÎfiÙÔÓÙ·È Ù· ·ÔÛ˘ÌÊÔÚËÙÈο, ÂÓÒ Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÌÔÚ› Ó· Û˘Ó¯›˙ÔÓÙ·È. ∏ ‰ÔÎÈÌ·Û›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÙÔ Úˆ›, ÌÂÙ¿ ·fi ÔÏÔÓ‡ÎÙÈ· ÓËÛÙ›·, ÍÂÎÈÓÒÓÙ·˜ Ì ‰fiÛË Ô˘ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ Û˘ÌÙÒÌ·Ù·. OÈ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ÙÚÔʤ˜ ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ: i) ·˘Ù¤˜ Ô˘ Â›Ó·È ÁÓˆÛÙ¤˜ fiÙÈ Û˘Ó‰¤ÔÓÙ·È Ì ·ıÔÏÔÁÈο ·ÔÙÂϤÛÌ·Ù· Î·È ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ, ii) ·˘Ù¤˜ Ì ÌË ÂȂ‚·ÈˆÌ¤Ó· ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ ÊÚÔ‡Ù· Î·È Ï·¯·ÓÈο Î·È iii) ·˘Ù¤˜ Ì ϛÁ· ‰Â‰Ô̤ӷ, ¯ˆÚ›˜ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ¿ÛÌ·ÙÔ˜ (.¯. ·ÏÎÔÔÏÔ‡¯· ÔÙ¿). ªÂÁ·Ï‡ÙÂÚË ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ÛÙËÓ ÚÒÙË Î·ÙËÁÔÚ›·, ¯ˆÚ›˜ ˘ÔÙ›ÌËÛË ÙˆÓ ¿ÏÏˆÓ ‰‡Ô. ∏ ·Ú·Û΢‹ Î·È Ë ÌÔÚÊ‹ Ù˘ ÙÚÔÊ‹˜, ȉ›ˆ˜ ÛÙËÓ Ù˘ÊÏ‹ ÚfiÎÏËÛË, ¤¯Ô˘Ó ȉȷ›ÙÂÚË ÛËÌ·Û›·, fiÔ˘ ÚÔÙÈÌ¿Ù·È Ë ÌÔÚÊ‹ ÎfiÓˆ˜. ∂‡ÎÔÏË ·Ú·Û΢‹ ÎfiÓˆ˜ Á›ÓÂÙ·È ·fi ÙÚÔʤ˜ ÍËÚ¤˜ ‹ ·Ê˘‰·ÙˆÌ¤Ó˜, fiˆ˜ ‰ËÌËÙÚȷο, ÍËÚÔ‡˜ ηÚÔ‡˜, ·Ê˘‰·ÙˆÌ¤ÓÔ Á¿Ï· ‹ ·˘Áfi, ÂÓÒ ÚÔ‚Ï‹Ì·Ù· ÚÔ·ÙÔ˘Ó Ì ٷ ÊÚÔ‡Ù·, Ù· Ï·¯·ÓÈο, Ù· ¯fiÚÙ·, Ù· „¿ÚÈ· Î·È Ù· fiÛÙڷη. ∂›Û˘, Û ÔÚÈṲ̂Ó˜ ÙÚÔʤ˜ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·Ú·Û΢‹˜ ‚ÈÔÌ˯·ÓÈο, ÛÂ Ï˘ÔÊÈÏÔÔÈË̤ÓË ÍËÚ¿ ÛÎfiÓË Î·È Û ‰È¿ÊÔÚ˜ ÔÛfiÙËÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· Û˘ÓÙËÚËıÔ‡Ó ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ. ∏ ÈÔ Û˘ÓËıÈṲ̂ÓË Û˘Û΢·Û›· Â›Ó·È Û ο„Ô˘Ï˜, ÁÈ·Ù› ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· Ó· Î·Ï˘Êı› ÌÂÁ¿ÏË ÔÛfiÙËÙ· ÙÚÔÊ‹˜, ÂÓÒ ÛÙ· ·È‰È¿ Ë Î¿Ï˘„Ë ÌÔÚ› Ó· Á›ÓÂÈ Û ·ÁˆÙ¿, Ûԇ˜, Îڤ̘ ÊÚÔ‡ÙˆÓ Î.Ï. ∞ÓÙ›ıÂÙ·, Ë Î¿Ï˘„Ë Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û ˘ÁÚfi ¤Î‰Ô¯Ô Û ‰‡Ô ÂÚÈÙÒÛÂȘ: ·) ÛÙÔ “oral allergy syndrome”, fiÔ˘ ÁÈ· Ó· ÂÎÏ˘ı› ÙÔ Û‡Ìو̷ Ú¤ÂÈ ÙÔ ·ÓÙÈÁfiÓÔ Ó· ¤ÚıÂÈ Û ·ʋ Ì ÙË ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈ΋ ÎÔÈÏfiÙËÙ· Î·È ‚) ÛÙË ‚·ÚÈ¿ ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË, ÁÈ·Ù› Ô ¤ÏÂÁ¯Ô˜ Ù˘ ·ÓÙ›‰Ú·Û˘ ¯ÚÔÓÈο Â›Ó·È ÂÓÙÔÓfiÙÂÚÔ˜, ÂÓÒ ÛÙËÓ Î¿„Ô˘Ï· Ú¤ÂÈ Ó· ÂÚÈ̤ÓÔ˘Ì ӷ ·ÔÚÚÔÊËı›. ™·Ó ÂÈÎÔÓÈ΋ ÙÚÔÊ‹ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ Ë ‰ÂÍÙÚfi˙Ë, Ô˘ ηχÙÂÙ·È Â‡ÎÔÏ· Û ο„Ô˘Ï˜ ‹ ¿ÏϘ Ù¯ÓÈΤ˜. ∏ ·Ú¯È΋ ‰fiÛË Â›Ó·È Î·ÙÒÙÂÚË ·fi ·˘Ù‹ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÚÔηϤÛÂÈ Û˘ÌÙÒÌ·Ù· Î·È ‰ÈÏ·ÛÈ¿˙ÂÙ·È ·Ó¿ 15-60 min, ·Ó¿ÏÔÁ· Ì ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙËÓ Ù¯ÓÈ΋ ¯ÔÚ‹ÁËÛ˘ (9,15,16). ∞ÓÔÈÎÙ‹ ÚfiÎÏËÛË: ÃÚËÛÈÌÔÔÈ›ٷÈ: ·) fiÙ·Ó Ë ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Â›Ó·È ·ÚÓËÙÈ΋ Î·È ÙÔ ÈÛÙÔÚÈÎfi ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÙÚÔÊ‹ ·ÌÊ›‚ÔÏÔ, ‚) fiÙ·Ó Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÙÚÔÊ‹ Ù· Û˘ÌÙÒÌ·Ù· ‰ÂÓ ·Ó·-
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§ÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi (+) (+) IgE/Th2 ÌÂÛÔÏ¿‚ËÛË ªË IgE/Th2 ÌÂÛÔÏ¿‚ËÛË ¢ÂÚÌ·ÙÈο tests - CAP-RAST ∂Ó‰ÔÛÎfiËÛË (+) (-) ¢›·ÈÙ· ·ÔÊ˘Á‹˜ (-) (-) (+) ∆ÚÔÊÈ΋ ÚfiÎÏËÛË + ∂ȉÈ΋ ‰›·ÈÙ· ∂ÈÎfiÓ· 1. ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜.
·Ú¿ÁÔÓÙ·È ÛÙ·ıÂÚ¿, ÒÛÙ ηÙËÁÔÚËÌ·ÙÈο Ó· ·ÔÌ·ÎÚ‡ÓÔ˘Ì ÙËÓ ‡ÔÙË ÙÚÔÊ‹ Î·È Á) ÁÈ· ÙË ‰È¢ÎÚ›ÓËÛË Ì›·˜ DBPCFC (16). ∞Ï‹ Ù˘ÊÏ‹ Ì ÂÈÎÔÓÈÎfi ¤ÏÂÁ¯Ô: ÃÚËÛÈÌÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ ÚÔ˜ ÂȂ‚·›ˆÛË Ù˘ ‰ÈÏ‹˜ Ù˘ÊÏ‹˜ Ì ÂÈÎÔÓÈÎfi ¤ÏÂÁ¯Ô. ¢ÈÏ‹ Ù˘ÊÏ‹ Ì ÂÈÎÔÓÈÎfi ¤ÏÂÁ¯Ô: ¶ÚÔÛ·ÚÌfi˙ÂÙ·È Û οı ·ÛıÂÓ‹ ·fi: ·) Ù· Û˘ÌÙÒÌ·Ù·, ‚) ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË Ï‹„Ë Ù˘ ÙÚÔÊ‹˜ ̤¯ÚÈ ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ Û˘Ìو̿وÓ, Á) ÙËÓ ÔÛfiÙËÙ· Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ Û˘Ìو̿وÓ, ‰) ÙÔ ÈÔ ÚfiÛÊ·ÙÔ ¤ÓÙÔÓÔ ÂÂÈÛfi‰ÈÔ Î·È Â) Â¿Ó ··ÈÙÔ‡ÓÙ·È Î·È ÂÈÚfiÛıÂÙÔÈ ·Ú¿ÁÔÓÙ˜ (.¯. ¿ÛÎËÛË). ∞Ú¯›˙Ô˘Ì Ì ÙÔ 1/10 Ù˘ ‰fiÛ˘ Ô˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·ÚÔ˘Û›·Û ·ÓÙ›‰Ú·ÛË Î·È ‰ÈÏ·ÛÈ¿˙Ô˘Ì Û 15-60 min ·Ó¿ÏÔÁ· Ì ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÌÊ¿ÓÈÛ˘ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ì¤¯ÚÈ Ô ·ÛıÂÓ‹˜ Ó· ÂÌÊ·Ó›ÛÂÈ Û˘ÌÙÒÌ·Ù· ‹ Ó· ¤¯ÂÈ Î·Ù·Ó·ÏÒÛÂÈ 8-10 g ÍËÚ¿˜ Ï˘ÔÊÈÏÔÔÈË̤Ó˘ ÙÚÔÊ‹˜ ‹ 60100 g ˘ÁÚ‹˜ (ÁÈ· 1 ‰fiÛË). ∞Ó Ë DBPCFC Â›Ó·È ·ÚÓËÙÈ΋, ÂϤÁ¯ÂÙ·È Ì ·ÓÔÈÎÙ‹ ÚfiÎÏËÛË. ∂›Ó·È ‰˘Ó·ÙfiÓ Ó· ¤¯Ô˘Ì ÂÚÈÙÒÛÂȘ Ì ·ÚÓËÙÈ΋ ‰ÈÏ‹ Ù˘ÊÏ‹ Î·È ıÂÙÈ΋ ·ÓÔÈÎÙ‹ ÚfiÎÏËÛË: ·) Â¿Ó ¯ÚËÛÈÌÔÔÈԇ̠ÌÈÎÚfiÙÂÚË ‰fiÛË ·fi ÙËÓ ··ÈÙÔ‡ÌÂÓË, ‚) Â¿Ó ÌÂÙ·‚ÏËı› Ë ·ÓÙÈÁÔÓÈÎfiÙËÙ· Ù˘ ÙÚÔÊ‹˜ ηٿ ÙËÓ ·Ú·Û΢‹ Î·È Á) ÁÈ· „˘¯ÔÏÔÁÈÎÔ‡˜ ÏfiÁÔ˘˜ Î·È Ù· Û˘ÌÙÒÌ·Ù·, Ù¤ÏÔ˜, Ó· Â›Ó·È ˘ÔÎÂÈÌÂÓÈο. ™Â ·ÓÙȉڿÛÂȘ ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜, ÔÈ ÚÔÎÏ‹ÛÂȘ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ‰fiÛÂȘ 0,3-0,6 g/kg Û 1-2 ¯ÔÚËÁ‹ÛÂȘ, ÂÓÒ Û ¿ÏϘ ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ Ô ·ÛıÂÓ‹˜ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ·ÚÎÂÙ¤˜ ‰fiÛÂȘ Û ̛· ÂÚ›Ô‰Ô 3 ËÌÂÚÒÓ Ì¤¯ÚÈ Ó· ÚÔ·„Ô˘Ó Û˘ÌÙÒÌ·Ù·. ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·Ù‹ÚËÛ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ Ù‡Ô Ù˘ ·ÓÙ›‰Ú·Û˘ (.¯. ÁÂÓÈο ¤ˆ˜ 2 ÒÚ˜ ÁÈ· ÙȘ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ, ¤ˆ˜ 4-8 ÒÚ˜ ÁÈ· ÙËÓ ÂÓÙÂÚÔÎÔÏ›Ùȉ· ·fi Á¿Ï· ·ÁÂÏ¿‰·˜, 24-48 ÒÚ˜ ÁÈ· ÙËÓ ÚˆÎÙÔÎÔÏ›Ùȉ· ηÈ, Ù¤ÏÔ˜, 3-4 Ë̤Ú˜ ÁÈ· ÙȘ ÔÏϷϤ˜ ·ÏÏÂÚÁ›Â˜ ÛÙËÓ ·ÏÏÂÚÁÈ΋ ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ IgEÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·ÓÙȉڿÛÂȘ, ÚÔÎÏ‹ÛÂȘ Ì Ӥ·
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ÙÚfiÊÈÌ· ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó Î¿ı 1-2 Ë̤Ú˜, ÂÓÒ ÁÈ· ÙȘ ÌË IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ÔÈ ÚÔÎÏ‹ÛÂȘ Ì Ӥ· ÙÚfiÊÈÌ· ¯ÚÂÈ¿˙ÂÙ·È Ó· ¤¯Ô˘Ó ÌÂÛԉȷÛÙ‹Ì·Ù· 3-5 ËÌÂÚÒÓ. ∞·Ú·›ÙËÙË ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Â›Ó·È Ë ¯Ú‹ÛË ·ÓÙÈÎÂÈÌÂÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Ù˘ ·ÓÙ›‰Ú·Û˘. ŒÙÛÈ, ÁÈ· ÙÔ ¿ÛıÌ· ıˆÚÂ›Ù·È ıÂÙÈ΋ Ë ÚfiÎÏËÛË ÌÂÙ¿ ·fi ÚÔηÏÔ‡ÌÂÓË ÙÒÛË Ù˘ ‚·ÛÈ΋˜ ÙÔ˘ FEV1 >20%. ™ÙËÓ ÎÓ›‰ˆÛË ÂÊ·ÚÌfi˙ÂÙ·È Ô Î·ÓfiÓ·˜ ÙˆÓ 9, ‰È·ÈÚÒÓÙ·˜ ÙÔ ‰¤ÚÌ· Û 9 ÂÚÈÔ¯¤˜, ÂÓÒ Î¿ı ÂÚÈÔ¯‹ ‚·ıÌÔÏÔÁÂ›Ù·È Ì Îϛ̷η ·fi 0 ¤ˆ˜ 4 ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÓÙ·ÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜. ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ¤¯ÂÈ ÂȉÈÎfi ÙÚfiÔ ‚·ıÌÔÏfiÁËÛ˘ ‰ÂÚÌ·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ (‰È¿ÁÓˆÛË Ì ٷ ÎÚÈÙ‹ÚÈ· ÙˆÓ Hanifin Î·È Rajka). °È· ÙË ÚÈÓ›Ùȉ· Á›ÓÂÙ·È ÚÈÓÔÌÂÙÚ›· Î·È ÎÏÈÓÈ΋ ÂͤٷÛË. ™ÙËÓ ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË ··ÈÙÂ›Ù·È Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÛʇÍÂˆÓ Î·È ∏∫°. ™Â ÈÛÙÔÚÈÎfi ‚·ÚÈ¿˜ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘, Ë ÚfiÎÏËÛË Á›ÓÂÙ·È Ì Ôχ ÚÔÛÔ¯‹ Î·È fiÙ·Ó Â›Ó·È ·Ó·ÚΛ˜ ÔÈ ÏÔȤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ (9,15). ¢ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì ÚfiÛıÂÙ·: ∏ ϤÔÓ ·ÍÈfiÈÛÙË Â›Ó·È Ë ‰ÈÏ‹ Ù˘ÊÏ‹ ÚfiÎÏËÛË ÂÏÂÁ¯fiÌÂÓË Ì ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ∏ Ô˘Û›· ¯ÔÚËÁÂ›Ù·È Û ο„Ô˘Ï˜ Ì ÚÔԉ¢ÙÈο ·˘Í·ÓfiÌÂÓ˜ ‰fiÛÂȘ, ÂÓÒ Î·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÂÙÔÈÌfiÙËÙ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Èı·ÓÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Ô˘ ÌÔÚ› Ó· ÚÔ·„Ô˘Ó. °ÂÓÈο, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÚfiÏÔ ÙˆÓ ÚfiÛıÂÙˆÓ ÙˆÓ ÙÚÔÊÒÓ Â›ÙÂ Û˘ÓÙËÚËÙÈÎÒÓ, ›Ù ‚ÂÏÙȈÙÈÎÒÓ Á‡Û˘, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ Û ˘„ËÏfi ÔÛÔÛÙfi ÛÙȘ ·ÓÂÈı‡ÌËÙ˜ ÙÚÔÊÈΤ˜ ·ÓÙȉڿÛÂȘ. ∂ÓÙÔ‡ÙÔȘ, Ë ‚ÈÔÌ˯·Ó›· ÙÚÔʛ̈Ó, ·ÓÙ·ÔÎÚÈÓfiÌÂÓË ÛÙÔÓ ¤ÓÙÔÓÔ ÚÔ‚ÏËÌ·ÙÈÛÌfi ÙÔ˘ ÎÔÈÓÔ‡ Û ·˘Ùfi ÙÔ ı¤Ì·, ¤¯ÂÈ ÌÂÈÒÛÂÈ ÙË ¯Ú‹ÛË ÙÔ˘˜ ÛÙÔ ÂÏ¿¯ÈÛÙÔ. ∂›Û˘, Ë ·Ó·ÁÚ·Ê‹ ÛÙË Û˘Û΢·Û›· Ù˘ ‡·Ú͢ ·˘ÙÒÓ ÙˆÓ Ô˘ÛÈÒÓ Â›Ó·È Ôχ ¯Ú‹ÛÈÌË ÁÈ· Ù· ¿ÙÔÌ· Ì ÁÓˆÛÙ‹ ¢·ÈÛıËÛ›·. ™˘ÌÂÚ¿ÛÌ·Ù· ™ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ·ÓÙȉڿÛˆÓ, ·ÏÏÂÚÁÈÎÒÓ ‹ ÌË, ÌÂÙ¿ ·fi Ï‹„Ë ÙÚÔÊ›ÌÔ˘, ÙÔ ÏÂÙÔÌÂÚ¤˜ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi, Ë Ê˘ÛÈ΋ ÂͤٷÛË, Ô ÂȉÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, ηıÒ˜ Î·È ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¤¯Ô˘Ó Û·Ê‹ ÚfiÏÔ. ∏ ‰ÈÏ‹ Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì ÂÈÎÔÓÈÎfi ÙÚfiÊÈÌÔ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Â›Ó·È Ë ÈÔ ·ÓÙÈÎÂÈÌÂÓÈ΋ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ̤ıÔ‰Ô˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ¯ÚfiÓÈˆÓ ‰È·Ù·Ú·¯ÒÓ (.¯. ¯ÚfiÓÈ· ÎÓ›‰ˆÛË, ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·) Î·È Î¿ı ·ÚÔ͇ÓÛˆ˜ ‰˘ÓËÙÈο Û˘Ó‰ÂfiÌÂÓ˘ Ì ·ÓÂÈı‡ÌËÙË ·ÓÙ›‰Ú·ÛË Û ϋ„Ë ÙÚÔÊ›ÌÔ˘. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi, ›Û˘, ÂϤÁ¯ÔÓÙ·È Û˘Ó˘¿Ú¯ÔÓÙ˜ ·Ú¿ÁÔÓÙ˜ Î·È „˘¯ÔÁÂÓ‹ ·›ÙÈ·. OÈ ÙÚÔÊÈΤ˜ ÚÔÎÏ‹ÛÂȘ ı· Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Û ȷÙÚÈÎfi ‹
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ÓÔÛÔÎÔÌÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ, ÂȉÈο ·Ó ˘¿Ú¯ÂÈ ˘Ô„›· IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ ‹ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜. ¢È·ÁÓˆÛÙÈο, Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë ‰È¿ÎÚÈÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ Ù·¯Â›·˜ ¤Ó·Ú͢ (Ù˘È΋ IgE-ÌÂÛÔÏ·‚Ô‡ÌÂÓË) ·fi Ù· Û‡Ó‰ÚÔÌ· ‚Ú·‰Â›·˜ ¤Ó·Ú͢, Ù· ÔÔ›· ΢ڛˆ˜ ÔÊ›ÏÔÓÙ·È Û ·ÓÙȉڿÛÂȘ ÌÂÛÔÏ·‚Ô‡ÌÂÓ˜ ·fi ∆-ÏÂÌÊÔ·ÙÙ·Ú·. ∞·ÈÙÂ›Ù·È ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÁÓÒÛÂˆÓ ÙÔ˘ È·ÙÚÈÎÔ‡ ÎfiÛÌÔ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ Î·È ÛÙË ‰È¢ÎÚ›ÓÈÛË Ù˘ ÙfiÛÔ ÂÓÙ˘ˆÛȷ΋˜ ‰È·ÊÔÚ¿˜ ÛÙ· Û˘ÌÙÒÌ·Ù· Î·È ÛÙ· fiÚÁ·Ó·-ÛÙfi¯Ô˘˜ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ·ÛıÂÓ›˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Loveless MH. Allergy for corn and its derivatives: experiments with a masked ingestion test for its diagnosis. J Allergy 1950;21:500-509. 2. Anderson JA, Sogn DD. Adverse reactions to foods: American Academy of Allergy and Immunology Committee on Adverse Reactions to Foods, National Institute of Allergy and Infectious Diseases, Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, July 1984, 84-2442. p. 4. 3. Bruijnzeel-Koomen C, Ortolani C, Aas K, Bindslev-Jensen C, Bjorksten B, Moneret-Vautrin D et al. Adverse reactions to food. European Academy of Allergology and Clinical Immunology Subcommittee. Allergy 1995;50:623-635. 4. Johansson SG, Hourihane JO, Bousquet J, BruijnzeelKoomen C, Dreborg S, Haahtela T et al. A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force. Allergy 2001;56:813-821. 5. Gerrard JW, MacKenzie JW, Goluboff N, Garson JZ, Maningas CS. Cow’s milk allergy: prevalence and manifestations in an unselected series of newborns. Acta Paediatr Scand 1973;234 (Suppl):S1-S21. 6. Kajosaari M. Food allergy in Finnish children aged 1 to 6 years. Acta Paediatr Scand 1982;71:815-819. 7. Young E, Stoneham MD, Petruckevitch A, Barton J, Rona R. A population study of food intolerance. Lancet 1994;343: 1127-1130. 8. Bock SA, Martin M. The incidence of adverse reactions to foods: a continuing study. J Allergy Clin Immunol 1983;71:98. 9. Sampson HA. Food allergy. Part 2: diagnosis and management. J Allergy Clin Immunol 1999;103:981-989. 10. Sampson HA. IgE-mediated food intolerance. J Allergy Clin Immunol 1988;81:495-504. 11. æ·ÚÚfi˜ º, •Â··‰¿ÎË ¶, ª·ÓÔ˘Û¿Î˘ ª, ∆·Ú·ÓÙ˙‹ §, ™˘Ú›ÁÔ˘ ∞, ¶··‰fiÔ˘ÏÔ˜ ¡ Î·È Û˘Ó. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ ÂȉÈ΋˜ IgE Î·È ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ÙˆÓ ÂȉÈÎÒÓ ÚÔÎÏ‹ÛÂˆÓ Û ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ (ÂÚ›ÏË„Ë). 4Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜. ∂ÏÏËÓÈ΋ ∞ÏÏÂÚÁÈÔÏÔÁÈ΋ Î·È ∫ÏÈÓÈ΋ ∞ÓÔÛÔÏÔÁ›·. ∞ı‹Ó·; 2001, ÙfiÌÔ˜ 8 (Suppl). ÛÂÏ. 4. 12. ¶··‰fiÔ˘ÏÔ˜ ¡, ∫·ÛÛ›ÌÔ˜ ¢, ™˘Ú›ÁÔ˘ ∞ Î·È Û˘Ó. ∞ÛÊ¿ÏÂÈ· ÙÚÔÊÈÎÒÓ ÚÔÎÏ‹ÛÂˆÓ Û ·È‰È¿ Ì ıÂÙÈÎfi ÈÛÙÔÚÈÎfi
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13. 14. 15.
16.
Î·È ÂȉÈ΋ IgE ÛÙÔ Á¿Ï· Î·È ÙÔ ·˘Áfi. ∂ÏÏËÓÈ΋ ∞ÏÏÂÚÁÈÔÏÔÁÈ΋ Î·È ∫ÏÈÓÈ΋ ∞ÓÔÛÔÏÔÁ›·. 8 (Suppl). ÛÂÏ. 5. Lessof MH. The diagnosis of food intolerance. Clin Exp Allergy 1995;25 (1 Suppl):S14-S15. Carter C. Dietary treatment of food allergy and intolerance. Clin Exp Allergy 1995;25 (1 Suppl):S34-S42. Bock SA, Sampson HA, Atkins FM, Zeiger RS, Lehrer S, Sachs M et al. Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual. J Allergy Clin Immunol 1988;82:986-997. Metcalfe DD, Sampson HA. Workshop on experimental methodology for clinical studies of adverse reactions to
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foods and food additives. J Allergy Clin Immunol 1990;86:421-442. 17. Lessof MH. Reactions to food additives. Clin Exp Allergy 1995;25 (1 Suppl):S27.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 01-10-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-04-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª. ÷Ù˙Ë„¿ÏÙË ª·ÎÚ˘ÁÈ¿ÓÓË 23-37, ∆.∫. 117 42, ª·ÎÚ˘ÁÈ¿ÓÓË, ∞ı‹Ó· E-mail: marach@internet.gr
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∞ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η ÛÙËÓ Î‡ËÛË Î·È Á·ÏÔ˘¯›· ¡. ∫·Ì¿˜1, ∂. ¶··‚·ÛÈÏ›Ԣ2
Antipsychotic medications in pregnancy and lactation N. Kambas1, E. Papavasiliou2
¶ÂÚ›ÏË„Ë: OÈ „˘¯ˆÛÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Û˘Ó‹ıÂȘ Û Á˘Ó·›Î˜ Ù˘ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜. ¶·Ú¿ ÙË ÓÔÛËÚfiÙËÙ¿ ÙÔ˘˜, ˘¿Ú¯ÂÈ Ù¿ÛË Ó· ·ÔʇÁÂÙ·È Î·Ù¿ ÙËÓ Î‡ËÛË Ë ¯ÔÚ‹ÁËÛË „˘¯ÔÊ·ÚÌ¿ÎˆÓ ÏfiÁˆ Èı·Ó‹˜ ÙÂÚ·ÙÔÁfiÓÔ˘ ‰Ú¿Û˘ ÛÙÔ ¤Ì‚Ú˘Ô. ∏ ·ËÛË, fï˜, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÚÔÊ˘Ï¿ÛÛÂÈ ÙË Á˘Ó·›Î· ·fi ÙËÓ ¤Ó·ÚÍË ‹ ÙËÓ ˘ÔÙÚÔ‹ ÙˆÓ „˘¯È·ÙÚÈÎÒÓ ·ı‹ÛˆÓ. OÈ Î›Ó‰˘ÓÔÈ ÁÈ· ÙË ÌËÙ¤Ú·, ÙÔ ¤Ì‚Ú˘Ô Î·È ÙÔ ıËÏ¿˙ÔÓ ÓÂÔÁÓfi ÌÔÚÔ‡Ó Ó· ÌÂȈıÔ‡Ó ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÌÔÓÔıÂڷ¢ÙÈο Û¯‹Ì·Ù· ÛÙË ¯·ÌËÏfiÙÂÚË ÈηӋ ‰ÔÛÔÏÔÁ›·, ΢ڛˆ˜ Ù˘ÈÎÒÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ, fiˆ˜ Ë ·ÏÔÂÚȉfiÏË. ™Â ·˘Ù‹ ÙËÓ ·Ó·ÛÎfiËÛË ÂÍÂÙ¿˙ÔÓÙ·È ÔÈ ÂÈÙÒÛÂȘ ÙˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Ô˘ÛÈÒÓ Î·Ù¿ ÙËÓ Î‡ËÛË Î·È ÙË Á·ÏÔ˘¯›·.
Abstract: Psychotic disorders are common in women of reproductive age. Despite their morbidity, there has been a tendency to avoid prescribing psychiatric medications to pregnant women because of possible teratogenic effects on the fetus. Published data suggest that pregnancy does not protect women from the onset or relapse of psychiatric disorders. The risks of psychotic disorder and its treatment to the mother, fetus and breast-feeding infant can be reduced with the use of monotherapy at the lowest effective dose, and especially the use of typical antipsychotic agents, such as haloperidol. In this review, the side effects of antipsychotic medication during pregnancy and lactation are examined.
§¤ÍÂȘ ÎÏÂȉȿ: Ê¿Ú̷η, ·ËÛË, ıËÏ·ÛÌfi˜, ·ÓÙÈ„˘¯ˆÛÈΤ˜ Ô˘Û›Â˜.
Key words: drugs, pregnancy, lactation, antipsychotic.
∂ÈÛ·ÁˆÁ‹ OÈ ÂÚÈÛÛfiÙÂÚ˜ „˘¯È·ÙÚÈΤ˜ ·ı‹ÛÂȘ ÛÙÔÓ Á˘Ó·ÈÎÂ›Ô ÏËı˘ÛÌfi ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙËÓ ·Ó··Ú·ÁˆÁÈ΋ ËÏÈΛ· Î·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. ¶ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 35% ÙˆÓ ÂÁ·ˆÓ ÛÙȘ ‰˘ÙÈΤ˜ ÎÔÈӈӛ˜ Ï·Ì‚¿ÓÂÈ „˘¯ÔÊ¿Ú̷η (1-3). ∞fi ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ ηٿ ÙȘ Ôԛ˜ ÙÔ ¤ÓÙÔÓÔ stress ÛÙËÓ ÂÚ›Ô‰Ô Ù˘ ÔÚÁ·ÓÔÁ¤ÓÂÛ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÚfiˆÚˆÓ Î·È ÏÈÔ‚·ÚÒÓ ÓÂÔÁÓÒÓ, ÌÈÎÚÔÎÂÊ·Ï›·, ¯·ÌËÏ‹ ‚·ıÌÔÏfiÁËÛË ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ·Ó¿Ù˘Í˘ ηÈ, ÙÔ ÛÔ˘‰·ÈfiÙÂÚÔ fiψÓ, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ΢ڛˆ˜ ÙˆÓ ÎÚ·ÓÈ·ÎÒÓ Ó¢ÚÈÎÒÓ Ù˘¯ÒÓ (4-6). ¡Â˘ÚÔÏËÙÈο ‹ ·ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η ∆· Ó¢ÚÔÏËÙÈο Ê¿Ú̷η (ÔÓÔÌ¿˙ÔÓÙ·È Î·È ·ÓÙÈÛ¯È˙ÔÊÚÂÓÈο, ·ÓÙÈ„˘¯ˆÛÈο ‹ Ì›˙ÔÓ· ËÚÂÌÈ-
ÛÙÈο) ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û¯È˙ÔÊÚ¤ÓÂÈ·˜, ηıÒ˜ ›Û˘ Û ‰È¿ÊÔÚÔ˘ Ù‡Ô˘ „˘¯Ô‰ÈÂÁÂÚÙÈΤ˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ Ë Ì·Ó›· Î·È Ù· ·Ú·ÏËÚ‹Ì·Ù·. ∆· Ó¢ÚÔÏËÙÈο Ê¿Ú̷η ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó, ‚¿ÛÂÈ Ù˘ ¯ËÌÈ΋˜ ÙÔ˘˜ ‰ÔÌ‹˜, Û ¤ÓÙ ·ÚȘ ηÙËÁÔڛ˜: ·) Ê·ÈÓÔıÂÈ·˙›Ó˜, ‚) ‚Ô˘Ù˘ÚÔÊ·ÈÓfiÓ˜, Á) ıÂÈÔÍ·Óı¤ÓÈ·, ‰) ‚ÂÓ˙·Ì›‰Â˜ Î·È Â) ‰È‚ÂÓ˙ÔÍ·˙›Ó˜. ∂ÎÙfi˜ ·fi ÙËÓ ·Ú·¿Óˆ Ù·ÍÈÓfiÌËÛË, Ë ÔÔ›· Ô˘ÛÈ·ÛÙÈο ‚·Û›˙ÂÙ·È ÛÙË ¯ËÌÈ΋ ‰ÔÌ‹ ÙÔ˘ ÌÔÚ›Ô˘, ÌÔÚ› Ó· Á›ÓÂÈ Î·È Ì›· ηٿٷÍË ÙˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Û‡Ìʈӷ Ì ÙË ‰Ú¿ÛË ÙÔ˘˜ ÛÙÔ˘˜ D2 ÓÙÔ·ÌÈÓÂÚÁÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜. ªÂ ÙËÓ Ù·ÍÈÓfiÌËÛË ·˘Ù‹ ¤¯Ô˘Ì ‰‡Ô ηÙËÁÔڛ˜: Ù· Ù˘Èο (Ê·ÈÓÔıÂÈ·˙›Ó˜, ‚Ô˘Ù˘ÚÔÊ·ÈÓfiÓ˜, ÈÌÔ˙›ÓË Î.Ï.) Î·È Ù· ¿Ù˘· ·ÓÙÈ„˘¯ˆÛÈο (ÎÏÔ˙·›ÓË, ÔÏ·Ó˙·›ÓË, ÚÈÛÂÚȉfiÓË). ™ÙËÓ Î‡ËÛË Î·È ÙË Á·ÏÔ˘¯›·, ÔÈ Ê·Ú̷΢ÙÈΤ˜
1 °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫ÔÚ›ÓıÔ˘, ª·ÈÂ˘Ù‹Ú-°˘Ó·ÈÎÔÏfiÁÔ˜ 2 °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫ÔÚ›ÓıÔ˘, ¶·È‰›·ÙÚÔ˜
1 General Hospital of Korinthos, Greece, Obstetrician 2 General Hospital of Korinthos, Greece, Paediatrician
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¶·È‰È·ÙÚÈ΋ 2003;66:247-254
Paediatriki 2003;66:247-254
Ô˘Û›Â˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û 5 ηÙËÁÔڛ˜ ÎÈÓ‰‡ÓÔ˘, Û‡Ìʈӷ Ì ÙËÓ Èı·Ó‹ ÙÔÍÈÎfiÙËÙ· ÙˆÓ Ô˘ÛÈÒÓ ÛÙÔ ¤Ì‚Ú˘Ô Î·È ÙÔ ÓÂÔÁÓfi, ·ÓÙ›ÛÙÔȯ· (¶›Ó·Î·˜ 1). ∫·Ù¿ ÙËÓ Î‡ËÛË, ·ÎÔÏÔ˘ıÂ›Ù·È Ë Ù·ÍÈÓfiÌËÛË ÙÔ˘ ∞ÌÂÚÈηÓÈÎÔ‡ OÚÁ·ÓÈÛÌÔ‡ ∆ÚÔÊ›ÌˆÓ (FDA). ™ÙËÓ Î·ÙËÁÔÚ›· ∞ ·Ó‹ÎÔ˘Ó Ô˘Û›Â˜ ·fiÏ˘Ù· ·ÛÊ·Ï›˜, ÛÙËÓ Î·ÙËÁÔÚ›· µ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·ÛÊ·Ï›˜ Ô˘Û›Â˜, ÛÙËÓ Î·ÙËÁÔÚ›· C ·Ó‹ÎÔ˘Ó Ô˘Û›Â˜ Û¯ÂÙÈο ·ÛÊ·Ï›˜, ÛÙËÓ Î·ÙËÁÔÚ›· D Èı·ÓfiÓ ÂÈ‚Ï·‚›˜ Ô˘Û›Â˜ ηÈ, Ù¤ÏÔ˜, ÛÙËÓ Î·ÙËÁÔÚ›· X ·Ó‹ÎÔ˘Ó ÔÈ Ô˘Û›Â˜ Ô˘ Â›Ó·È ·Ô‰Â‰ÂÈÁ̤ӷ ÂÈ‚Ï·‚›˜. ∫·Ù¿ ÙË Á·ÏÔ˘¯›·, Û‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜, ˘¿Ú¯Ô˘Ó - fiˆ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ‚È‚Ï›Ô ÙÔ˘ Bennett, 1996 (7) - ÔÈ ·ÎfiÏÔ˘ı˜ ηÙËÁÔڛ˜ ÎÈÓ‰‡ÓÔ˘: L1, L2, L3, L4 Î·È L5, ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÂ Ô˘Û›Â˜ ·fiÏ˘Ù· ·ÛÊ·Ï›˜ (L1), ·ÛÊ·Ï›˜ (L2), Û¯ÂÙÈο ·ÛÊ·Ï›˜ (L3), Èı·ÓfiÓ ÂÈ‚Ï·‚›˜ (L4) Î·È ÂÈ‚Ï·‚›˜ (L5), ·ÓÙ›ÛÙÔȯ·.
∞1. ∆À¶π∫∞ ∞¡∆πæÀÃø™π∫∞ º·ÈÓÔıÂÈ·˙›Ó˜ Î·È ıÂÈÔÍ·Óı›Ó˜ OÈ Ê·ÈÓÔıÂÈ·˙›Ó˜ Â›Ó·È ÔÈ Ô˘Û›Â˜ ÚÒÙ˘ ÂÎÏÔÁ‹˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ „˘¯ˆÛÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ù˘ ÂÁ·Ԣ. OÈ Ê·ÈÓÔıÂÈ·˙›Ó˜ ¤¯Ô˘Ó ·ÓÙÈ„˘¯ˆÛÈ΋, ·ÓÙÈÌÔ˘ÛηÚÈÓÈ΋ Î·È ·ÓÙÈÂÌÂÙÈ΋ ‰Ú¿ÛË. ∆· ÂÚÈÛÛfiÙÂÚ· Ó¢ÚÔÏËÙÈο Ê¿Ú̷η ¤¯Ô˘Ó ·ÓÙÈÂÌÂÙÈ΋ ‰Ú¿ÛË, Ì ÂÍ·›ÚÂÛË ÙË ıÂÈÔÚȉ·˙›ÓË. ∏ ÚÔÌÂı·˙›ÓË ‰ÂÓ Â›Ó·È Î·Ïfi ·ÓÙÈ„˘¯ˆÛÈÎfi Ê¿ÚÌ·ÎÔ, ¤¯ÂÈ fï˜ ·ÓÙÈÎÓËÛÌÒ‰Ë ‰Ú¿ÛË, ÏfiÁˆ ÙˆÓ ·ÓÙÈÛÙ·ÌÈÎÒÓ Ù˘ ȉÈÔًوÓ. º¿Ú̷η fiˆ˜ Ë ÚÔÌ·˙›ÓË, Ë Ï‚ÔÌÂÚÔÌ·˙›ÓË Î·È Ë ıÂÈÔÚȉ·˙›ÓË ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ì ۯÂÙÈ΋ ·ÛÊ¿ÏÂÈ· ηٿ ÙËÓ Î‡ËÛË. OÈ Ô˘Û›Â˜ ·˘Ù¤˜ ‰È·ÂÚÓÔ‡Ó Â‡ÎÔÏ· ÙÔÓ Ï·ÎÔ˘ÓÙÈ·Îfi ÊÚ·ÁÌfi. ∏ ηٷÓÔÌ‹ Î·È Î˘Ú›ˆ˜ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙÔ˘˜ ÛÙÔ ¤Ì‚Ú˘Ô Î·È ÙÔ ÓÂÔÁÓfi Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·ÚÁfi˜ Û ۯ¤ÛË Ì ·˘ÙfiÓ Ù˘ ÌËÙ¤Ú·˜, ·˘Í¿ÓÔÓÙ·˜ ¤ÙÛÈ ÙËÓ ÙÔÍÈÎfiÙËÙ¿ ÙÔ˘˜, ÏfiÁˆ
¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ÎÈÓ‰‡ÓÔ˘ - ÂÈÙÒÛÂȘ Ô˘ÛÈÒÓ Î·Ù¿ ÙËÓ Î‡ËÛË Î·È ÙË Á·ÏÔ˘¯›· O˘Û›·
∫·ÙËÁÔÚ›· ÎÈÓ‰‡ÓÔ˘ - ∂ÈÙÒÛÂȘ ∫‡ËÛË
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∞ÏÔÂÚȉfiÏË
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C - ¡ÂÔÁÓÈ΋ ηٷÛÙÔÏ‹ Î·È Î˘¿ÓˆÛË (14) - ™‡Ó‰ÚÔÌÔ ·fiÛ˘ÚÛ˘ (15) - ÀÔÙÔÓ›·, Ï‹ı·ÚÁÔ˜, ÈÎÙÂÚÈ΋ ¯ÚÔÈ¿ (16) ªÔÚ› Ó· ıˆÚËı› ·Ú¿ÁˆÓ ÚÒÙ˘ ÂÈÏÔÁ‹˜ ηٿ ÙËÓ Î‡ËÛË (17) C - ™Â ÂÈÚ·Ì·Ùfi˙ˆ·: ÌÈÎÚÔÌÂÏ›·,·ÓˆÌ·Ï›Â˜ ∫¡™ (20-22) ªÔÚ› Ó· ıˆÚËı› ·Ú¿ÁˆÓ Ì ¯·ÌËÏfi ÙÂÚ·ÙÔÁÂÓÂÙÈÎfi ΛӉ˘ÓÔ C - O˘‰ÂÙÂÚÔÂÓ›·, ·ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›· ∞ÓÙÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙËÓ Î‡ËÛË
C ∞ÓÙÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙËÓ Î‡ËÛË Î·È ÙË Á·ÏÔ˘¯›·, ÏfiÁˆ ·Ó·ÚÎÒÓ ÛÙÔȯ›ˆÓ ÛÙÔÓ ¿ÓıÚˆÔ C - ¢ÂÓ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ ÙÔ ÔÛÔÛÙfi ÙÂÚ·ÙÔÁ¤ÓÂÛ˘ (32) - ¢ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›·
°·ÏÔ˘¯›· L3 - ∫·Ù·ÛÙÔÏ‹ (19)
L2 - ¶ÓÂ˘Ì·ÙÈΤ˜ Î·È „˘¯ÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ (24) L3 - ∫·Ù·ÛÙÔÏ‹, Û·ÛÌÔ› - ∫·Ú‰È·ÁÁÂȷ΋ ·ÛÙ¿ıÂÈ· - ∞ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›· ∞ÓÙÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙÔÓ ıËÏ·ÛÌfi (25-27) L3 ∞Ó·Ú΋ ÛÙÔȯ›· L3 - ÿÎÙÂÚÔ˜, ˘ÓËÏ›·, ηډÈÔÌÂÁ·Ï›· (17) L2 - ¢ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ·ÚÂÓ¤ÚÁÂȘ (7)
¶·Ú·ÙËÚ‹ÛÂȘ › ÙˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ: ñ ¶·Ú¿ ÙËÓ Èı·Ó‹ ÂÌÊ¿ÓÈÛË Â͈˘Ú·ÌȉÈ΋˜ Û˘Ó‰ÚÔÌ‹˜ ÛÙÔ ÓÂÔÁÓfi (Ë ÔÔ›· Â›Ó·È ÂÍ¿ÏÏÔ˘ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜), ÊÚfiÓÈÌÔ ı· ‹Ù·Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ô˘Û›Â˜ Ù‡Ô˘ ·ÏÔÂÚȉfiÏ˘ Ì ÛÎÔfi Ó· ÂÚÈÔÚÈÛÙÔ‡Ó ÔÈ ·ÓÙȯÔÏÈÓÂÚÁÈΤ˜, ˘ÔÙ·ÛÈΤ˜ Î·È ·ÓÙÈÈÛÙ·ÌÈÓÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ ÛÙË ÌËÙ¤Ú· ñ °È· Ù· ¿Ù˘· ·ÓÙÈ„˘¯ˆÛÈο ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· ñ ¶Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È Ù· depo Û΢¿ÛÌ·Ù·, Ì ÛÎÔfi Ó· ÌÂȈı› Ë ÙÔÍÈ΋ ‰È¿ÚÎÂÈ¿ ÙÔ˘˜ ñ ∆Ô Û‡Ó‰ÚÔÌÔ ÛÙ¤ÚËÛ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÛÔ‚·Ú‹ ·ÚÂÓ¤ÚÁÂÈ· ·˘ÙÒÓ ÙˆÓ Ô˘ÛÈÒÓ
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Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ Û˘ÛÛÒÚ¢Û˘ ÛÙÔÓ ÂÌ‚Ú˘˚Îfi ÔÚÁ·ÓÈÛÌfi. ¶ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ ˘¿Ú¯Ô˘Ó ·fi ÙË ¯Ú‹ÛË ÙÔ˘˜ ηٿ ÙËÓ ˘ÂÚ¤ÌÂÛË Ù˘ ·ËÛ˘. ¢ÂÓ ÌÔÚÔ‡Ó, fï˜, Ó· ÂÍ·¯ıÔ‡Ó ·ÛÊ·Ï‹ Û˘ÌÂÚ¿ÛÌ·Ù·, ηı’ fiÙÈ ˆ˜ ·ÓÙÈÂÌÂÙÈο ÔÈ ‰ÔÛÔÏÔÁ›Â˜ ÙÔ˘˜ Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÙˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Û¯ËÌ¿ÙˆÓ. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ¯Ú‹ÛË ÙˆÓ Ê·ÈÓÔıÂÈ·˙ÈÓÒÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‰ÔÛÔÂÍ·ÚÙÒÌÂÓÔ Û‡Ó‰ÚÔÌÔ ·fiÛ˘ÚÛ˘ ‹ ·ÚÔ‰È΋ Â͈˘Ú·ÌȉÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙÔ ÓÂÔÁÓfi, Ë ÔÔ›· ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ ÁÈ· ÔÏÏÔ‡˜ Ì‹Ó˜ (8). ∫¿ı ÊÔÚ¿ Ô˘ ÔÈ Ô˘Û›Â˜ ·˘Ù¤˜ ¯ÔÚËÁÔ‡ÓÙ·È ÛÙËÓ ÂÁ΢ÌÔÓÔ‡Û·, Ú¤ÂÈ Ó· ‰›‰ÔÓÙ·È ÔÈ ¯·ÌËÏfiÙÂÚ˜ ‰ÔÛÔÏÔÁ›Â˜ Î·È ÁÈ· ÌÈÎÚ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ Â͈˘Ú·ÌȉÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙËÓ Î‡ËÛË, ÌÔÚ› Ó· ¯ÔÚËÁËı› ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÓÙÈ„˘¯ˆÛÈ΋ ·ÁˆÁ‹ ¤Ó·˜ ·ÓÙȯÔÏÈÓÂÚÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, fiˆ˜ Â›Ó·È Ë ‚ÈÂÚȉ¤ÓË. ∆Ô ÓÂÔÁÓfi Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÂÓ¿ ÁÈ· Ù˘¯fiÓ Â͈˘Ú·ÌȉÈΤ˜ ÂΉËÏÒÛÂȘ Î·È Û˘Ìو̷ÙÔÏÔÁ›· ·fiÛ˘ÚÛ˘. ∞Ó·ÊÔÚ¿ ÛÙË ¯ÏˆÚÔÚÔÌ·˙›ÓË ı· Á›ÓÂÈ ÂÓ Û˘Ó¯›· ·Ó·Ï˘ÙÈο, ηı’ fiÙÈ ˆ˜ ÚfiÙ˘Ô˜ Ê·ÈÓÔıÂÈ·˙›ÓË ˘¿Ú¯Ô˘Ó ÁÈ’·˘Ù‹Ó ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ. ÃψÚÔÚÔÌ·˙›ÓË (∫·ÙËÁÔÚ›· ·ËÛ˘ C Î·È Á·ÏÔ˘¯›·˜ L3 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Largactil, Zuledine Î.¿.) ∫‡ËÛË: OÈ Î‡ÚȘ ÂӉ›ÍÂȘ Ù˘ ˘‰ÚԯψÚÈ΋˜ ¯ÏˆÚÔÚÔÌ·˙›Ó˘ Â›Ó·È ÔÈ „˘¯ˆÛÈΤ˜ ηٷÛÙ¿ÛÂȘ. ¢È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·, fiˆ˜ Î·È ÔÈ ¿ÏϘ Ô˘Û›Â˜ Ù˘ ηÙËÁÔÚ›·˜ ·˘Ù‹˜. ™Ù· ÂÈÚ·Ì·Ùfi˙ˆ·, Ì ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚ· ·fi Ù· Û˘Ó‹ıË Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔ ¿ÓıÚˆÔ, ¤¯Ô˘Ó ηٷÁÚ·Ê› ÙÂÚ·ÙÔÁfiÓ˜ ÂÈÙÒÛÂȘ, fiˆ˜ Ï˘ÎfiÛÙÔÌ·, ·ÓˆÌ·Ï›Â˜ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ‰È·Ù·Ú·¯¤˜ ÔÚ¿Ûˆ˜, ηıÒ˜ ›Û˘ Î·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. Œ¯ÂÈ ·Ó·ÊÂÚı› ·ÎfiÌ· ÂÌ‚Ú˘ÔÙÔÍÈ΋ ‰Ú¿ÛË, ΢ڛˆ˜ ÛÙËÓ ÚÒÈÌË ÂÌ‚Ú˘˚΋ ÂÚ›Ô‰Ô, fiˆ˜ ÂÌ‚Ú˘˚Îfi˜ ı¿Ó·ÙÔ˜, ÌÂȈ̤ÓË ÁÔÓÈÌfiÙËÙ· Î·È ‚ȈÛÈÌfiÙËÙ· ÙˆÓ ÓÂÔÛÛÒÓ, ηıÒ˜ ›Û˘ ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ (9-11). ™ÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ˘¿Ú¯Ô˘Ó ηÏÒ˜ ÔÚÁ·ÓˆÌ¤Ó˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ Ó· ÂÍÂÙ¿˙Ô˘Ó ÙËÓ Ù˘¯fiÓ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¤ÎıÂÛ˘ ÛÙË ¯ÏˆÚÔÚÔÌ·˙›ÓË. OÈ ·Ó·ÊÔÚ¤˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÂÌÔӈ̤Ó˜ ηٷÁڷʤ˜ ‹ ·fi ÌÂϤÙ˜ Û ÌÈÎÚfi ·ÚÈıÌfi Á˘Ó·ÈÎÒÓ, ΢ڛˆ˜ ÌÂÙ¿ ·fi ¯Ú‹ÛË Ù˘ Ô˘Û›·˜ ˆ˜ ·ÓÙÈÂÌÂÙÈÎfi. º˘ÛÈο, ÔÈ ‰fiÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚ˜ ·fi ÙȘ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ÁÈ· ·ÓÙÈ„˘¯ˆÛÈ΋ ‰Ú¿ÛË. À¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ô˘ ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ
Paediatriki 2003;66:247-254
·ÛÊ¿ÏÂÈ· Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ¯ÏˆÚÔÚÔÌ·˙›Ó˘ fiÙ·Ó ¯ÔÚËÁËı› Û ¯·ÌËϤ˜ ‰fiÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ó·˘Ù›·˜ Î·È ÙˆÓ ÂÌÂÙÒÓ Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ™Ù· ›‰È· Û˘ÌÂÚ¿ÛÌ·Ù· ηٷϋÁÔ˘Ó Î·È ÔÈ ÌÂϤÙ˜ Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙÔ Ê¿ÚÌ·ÎÔ ÁÈ· ·Ó·ÏÁËÛ›·, ·ÌÓËÛ›· ‹ ηٷÛÙÔÏ‹ ηٿ ÙÔÓ ÙÔÎÂÙfi. Œ¯Ô˘Ó ηٷÁÚ·Ê› ÂÚÈÙÒÛÂȘ Ì ȉÈÔÛ˘ÁÎÚ·Ûȷ΋ ˘fiÙ·ÛË ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ Ô˘Û›·˜. º˘ÛÈο, Ë ·Ú·ÙÂÈÓfiÌÂÓË ˘ÔÙ·ÛÈ΋ ÎÚ›ÛË ÌÔÚ› Ó· Â›Ó·È ÂÈ‚Ï·‚‹˜ ÁÈ· ÙË ÌËÙ¤Ú· Î·È ÙÔ ¤Ì‚Ú˘Ô. ∆· ·Ú·¿Óˆ ÚÔ¤Ú¯ÔÓÙ·È ·fi ·Ï·È¤˜ ÌÂϤÙ˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’60, ÂÚ›Ô‰Ô˜ ηٿ ÙËÓ ÔÔ›· Ë Ô˘Û›· ›¯Â ÌÂÁ·Ï‡ÙÂÚË ¯Ú‹ÛË ·fi ÙË ÛËÌÂÚÈÓ‹ (12,13). ∞fi ÙË ÌÂϤÙË ÙÔ˘ Sobel (1961), Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÚÔÁÂÓÓËÙÈο Û ˘„ËϤ˜ ‰fiÛÂȘ (500-600 mg ËÌÂÚËÛ›ˆ˜) ÚÔοÏÂÛ ÓÂÔÁÓÈ΋ ηٷÛÙÔÏ‹ Î·È Î˘¿ÓˆÛË (14). Œ¯Ô˘Ó, ›Û˘, ·Ó·ÊÂÚı› Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ì Â͈˘Ú·ÌȉÈο ÎÈÓËÙÈο Û˘ÌÙÒÌ·Ù·, fiˆ˜ ˘ÂÚÙÔÓ›·, ÙÚfiÌÔ, ‰˘ÛÎÈÓËÛ›·, ‰È¤ÁÂÚÛË, ·‰˘Ó·Ì›· Î·È ÌÂȈ̤ÓË ‰È¿ıÂÛË ÁÈ· ıËÏ·ÛÌfi, ΢ڛˆ˜ fiÙ·Ó ÙÔ Ê¿ÚÌ·ÎÔ ¯ÔÚËÁËı› ÛÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ. ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ˘·ÁÔÚÂ‡Ô˘Ó ÙËÓ ‡·ÚÍË Û˘Ó‰ÚfiÌÔ˘ ·fiÛ˘ÚÛ˘. ∏ Û˘¯ÓfiÙËÙ· ·˘ÙÒÓ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Â›Ó·È ¯·ÌËÏ‹ Î·È ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜, ·Ó Î·È ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· Ô˘ ‰È‹ÚÎÂÛ ·ÚÎÂÙÔ‡˜ Ì‹Ó˜. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ·˘Ù¿ ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ Ì ˘„ËϤ˜ ‰fiÛÂȘ Î·È Û ÂÚ›Ô‰Ô ÎÔÓÙ¿ ÛÙÔÓ ÙÔÎÂÙfi (¿Óˆ ·fi 1200 mg ËÌÂÚËÛ›ˆ˜) (15). OÈ Hammond Î·È Û˘Ó, ÙÔ 1970, ÂÚȤÁÚ·„·Ó ÙËÓ ÂÚ›ÙˆÛË Ì›·˜ ·ÛıÂÓÔ‡˜ Ô˘ ηٷӿψÛÂ Û˘ÓÔÏÈο 8 g ¯ÏˆÚÔÚÔÌ·˙›Ó˘ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 10 Ë̤Ú˜ Ù˘ ·ËÛ˘. ∆Ô ÓÂÔÁÓfi Ô˘ ÁÂÓÓ‹ıËΠ‹Ù·Ó ˘ÔÙÔÓÈÎfi, ÏËı·ÚÁÈÎfi, Ì ÈÎÙÂÚÈ΋ ¯ÚÔÈ¿. ∆· ·Ú·¿Óˆ ·Ú¤ÌÂÈÓ·Ó ÁÈ· ÂÚ›Ô˘ ÙÚÂȘ ‚‰ÔÌ¿‰Â˜ (16). À¿Ú¯ÂÈ ÌfiÓÔ Ì›· ÌÂϤÙË Ô˘ Û˘Ó¤‰ÂÛ ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Ì ÙËÓ ÂÎÙÚˆÌÂÏ›·. ∫·È Û ·˘Ù‹, fï˜, Ë ¯ÏˆÚÔÚÔÌ·˙›ÓË ¯ÔÚËÁ‹ıËΠ̷˙› Ì ÙË ÌÂÎÏÔ˙›ÓË. ™ÙȘ Û˘Ó‹ıÂȘ ÌÈÎÚ¤˜ ‰fiÛÂȘ, ηıÒ˜ ›Û˘ Î·È Û ÌË Û˘ÛÙËÌ·ÙÈ΋ Ï‹„Ë, Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÛÊ·Ï‹˜ ÁÈ· ÙÔ ¤Ì‚Ú˘Ô. ª¿ÏÈÛÙ·, Û‡Ìʈӷ Ì ÙËÓ ·Ó·ÛÎfiËÛË ÙˆÓ Elia Î·È Û˘Ó (1987), ÈÛÙ‡ÂÙ·È fiÙÈ Ë ¯ÏˆÚÔÚÔÌ·˙›ÓË Ú¤ÂÈ Ó· Â›Ó·È Ô ıÂڷ¢ÙÈÎfi˜ ·Ú¿ÁˆÓ ÚÒÙ˘ ÂÎÏÔÁ‹˜, Â¿Ó ÂÈ‚¿ÏÏÂÙ·È ·ÓÙÈ„˘¯ˆÛÈ΋ ·ÁˆÁ‹ ηٿ ÙËÓ Î‡ËÛË (17). ¶·Ú¿ Ù·‡Ù·, Ë ¯Ú‹ÛË Ù˘ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È ÎÔÓÙ¿ ÛÙÔÓ ÙÔÎÂÙfi, ÏfiÁˆ Ù˘ ȉÈÔÛ˘ÁÎÚ·Ûȷ΋˜ ˘fiÙ·Û˘ Ô˘ ÂÈʤÚÂÈ ÛÙË ÌËÙ¤Ú· ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, Ù˘ ÂÌ‚Ú˘˚΋˜ ‰˘Û¯¤ÚÂÈ·˜.
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°·ÏÔ˘¯›·: ∏ ¯ÏˆÚÔÚÔÌ·˙›ÓË ·Ó‹ÎÂÈ ÛÙËÓ Î·ÙËÁÔÚ›· ÎÈÓ‰‡ÓÔ˘ L3 ηٿ ÙË Á·ÏÔ˘¯›·. ™˘ÓÂÒ˜, ıˆÚÂ›Ù·È “Û¯ÂÙÈο ·ÛÊ·Ï‹˜”. ∞ÂÎÎÚ›ÓÂÙ·È ÛÙÔ Á¿Ï· Û Ôχ ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜, ÔÈ Ôԛ˜ ‰ÂÓ ÍÂÂÚÓÔ‡Ó ÙÔ 3% Ù˘ ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘ Ù˘ ÌËÙ¤Ú·˜. ™˘ÓÈÛÙ¿Ù·È Ë ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈ· Ù˘¯fiÓ Î·Ù·ÛÙÔÏ‹ (18,19). µÔ˘Ù˘ÚÔÊ·ÈÓfiÓ˜ ∞ÏÔÂÚȉfiÏË (∫·ÙËÁÔÚ›· ·ËÛ˘ C Î·È Á·ÏÔ˘¯›·˜ L2 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Aloperidin, Sevium) ∫‡ËÛË: ∏ ·ÏÔÂÚȉfiÏË Â›Ó·È Ë Ï¤ÔÓ ÛËÌ·ÓÙÈ΋ Ô˘Û›· ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Ô˘ÛÈÒÓ. ¢È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ˘ÓÙÈ·Îfi ÊÚ·ÁÌfi ÙfiÛÔ ÛÙ· ÂÈÚ·Ì·Ùfi˙ˆ·, fiÛÔ Î·È ÛÙÔÓ ¿ÓıÚˆÔ. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ì ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚ· ·˘ÙÒÓ ÙÔ˘ ·ÓıÚÒÔ˘, ¤‰ÂÈÍ·Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÙÂÚ·ÙÔÁ¤ÓÂÛ˘, ηٷÁÚ¿ÊÔÓÙ·˜ ÂÚÈÙÒÛÂȘ ÌÂ Ï˘ÎfiÛÙÔÌ·, ÌÈÎÚÔÌÂÏ›·, ·ÓˆÌ·Ï›Â˜ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÎÚ·Ó›Ô˘ (20-22). ™Â ̇˜ Î·È Â›Ì˘Â˜ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› ÂÌ‚Ú˘ÔÙÔÍÈ΋ ‰Ú¿ÛË, fiˆ˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˜ ı¿Ó·ÙÔ˜, ÌÂȈ̤ÓË ·Ó¿Ù˘ÍË Î·Ù¿ ÙËÓ Î‡ËÛË Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó, ηıÒ˜ ›Û˘ ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ (21). ™ÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÒ˜ ÙÂÎÌËÚȈ̤Ó˜ ÌÂϤÙ˜. øÛÙfiÛÔ, Û‡Ìʈӷ Ì ·Ï·ÈfiÙÂÚË ÚÔÔÙÈ΋ ÌÂϤÙË ÙˆÓ van Waes Î·È Û˘Ó (1969), Ë ¯ÔÚ‹ÁËÛË ÌÈÎÚÒÓ ‰fiÛÂˆÓ Ù˘ ·ÏÔÂÚȉfiÏ˘, 0,6 mg ËÌÂÚËÛ›ˆ˜ ˆ˜ ·ÓÙÈÂÌÂÙÈÎfi ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, ‰ÂÓ ·‡ÍËÛ ÙÔ ÔÛÔÛÙfi ·ÓˆÌ·ÏÈÒÓ Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (23). ∞fi Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ Ì›· Û·Ê‹˜ Û¯¤ÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ Ï‹„˘ Ù˘ ·ÏÔÂÚȉfiÏ˘ Ì ÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ ·ÓˆÌ·Ï›Â˜. ∂Ô̤ӈ˜, Ô ÙÂÚ·ÙÔÁÂÓÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ·fi ÙË Ï‹„Ë Ù˘ Ô˘Û›·˜ Â›Ó·È ¯·ÌËÏfi˜. ∏ ÂÁ΢ÌÔÓÔ‡Û· ÌÔÚ› Ó· Ï¿‚ÂÈ ÙËÓ Ô˘Û›·, ÂÊfiÛÔÓ Ù· ıÂڷ¢ÙÈο Ù˘ ÏÂÔÓÂÎÙ‹Ì·Ù· ˘ÂÚ¤¯Ô˘Ó ÙÔ˘ Èı·ÓÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡. °·ÏÔ˘¯›·: ∞Ó Î·È Ë ·ÏÔÂÚȉfiÏË ·ÂÎÎÚ›ÓÂÙ·È Û ÛËÌ·ÓÙÈ΋ ÔÛfiÙËÙ· ÛÙÔ Á¿Ï· Ì ̛· ·Ó·ÏÔÁ›· Á¿Ï·:Ï¿ÛÌ· 0,6-0,7, ÂÓÙÔ‡ÙÔȘ ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛËÌ·ÓÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ. ™Â ÂÈÚ·Ì·ÙÈÎfi ÛÙ¿‰ÈÔ, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ˘ÓËÏ›· Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ı‹Ï·˙·Ó ·fi ÌËÙ¤Ú˜ ÛÙȘ Ôԛ˜ ¯ÔÚËÁ‹ıËÎÂ Ë ·ÏÔÂÚȉfiÏË. ∞fi Ù· ‰Â‰Ô̤ӷ ÙÔ˘ Yoshida (1998) ÚÔ·ÙÂÈ fiÙÈ Ô ıËÏ·ÛÌfi˜ ÙˆÓ ÓÂÔÁÓÒÓ ·fi ÌËÙ¤Ú˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó Ó¢ÚÔÏËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ì›ˆÛË Ù˘ ÓÂ˘Ì·ÙÈ΋˜ Î·È „˘¯ÔÎÈÓËÙÈ΋˜ ÈηÓfiÙËÙ¿˜ ÙÔ˘˜ (24).
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∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ıˆÚ› ÙËÓ ·ÏÔÂÚȉfiÏË Ô˘Û›· Ì ¿ÁÓˆÛÙË ‰Ú¿ÛË ÛÙÔ ÓÂÔÁÓfi, Ô˘ Èı·ÓfiÓ Ó· Â›Ó·È ÂÈ‚Ï·‚‹˜ (19). ∞2. ∞∆À¶∞ ∞¡∆πæÀÃø™π∫∞ ∫ÏÔ˙·›ÓË (∫·ÙËÁÔÚ›· ·ËÛ˘ C Î·È Á·ÏÔ˘¯›·˜ L3 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Leponex) ∫‡ËÛË: ∏ ÎÏÔ˙·›ÓË Â›Ó·È ÙÔ ·Ú¯·ÈfiÙÂÚÔ ¿Ù˘Ô ·ÓÙÈ„˘¯ˆÛÈÎfi, ÙÔ ÔÔ›Ô Â›Ó·È ‰È·ı¤ÛÈÌÔ Ì¤¯ÚÈ Û‹ÌÂÚ·. ø˜ ¿Ù˘Ô ·ÓÙÈ„˘¯ˆÛÈÎfi ÂÌÊ·Ó›˙ÂÈ ¯·ÌËÏ‹ ·ÓÙ·ÁˆÓÈÛÙÈ΋ Û˘ÁÁ¤ÓÂÈ· ÁÈ· ÙÔ˘˜ ˘Ô‰Ô¯Â›˜ D1 Î·È D2 Î·È ˘„ËÏ‹ ·ÓÙ·ÁˆÓÈÛÙÈ΋ Û˘ÁÁ¤ÓÂÈ· ÁÈ· ÙÔ˘˜ ÛÂÚÔÙÔÓÈÓÂÚÁÈÎÔ‡˜, ·-·‰ÚÂÓÂÚÁÈÎÔ‡˜ Î·È ÈÛÙ·ÌÈÓÂÚÁÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜. ∞fi ÙȘ ̤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ Ê·›ÓÂÙ·È fiÙÈ Ë ÎÏÔ˙·›ÓË Â›Ó·È ÂÍ›ÛÔ˘, ·Ó fi¯È ÂÚÈÛÛfiÙÂÚÔ, ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙË ¯ÏˆÚÔÚÔÌ·˙›ÓË Î·È ÙËÓ ·ÏÔÂÚȉfiÏË. ∞Ó·ÊÂÚfiÌÂÓ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË Ï‹„Ë ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Â›Ó·È Ë ÔÚıÔÛÙ·ÙÈ΋ ˘fiÙ·ÛË, Ë Ù·¯˘Î·Ú‰›·, ηıÒ˜ Î·È Ë ·ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›·, ÁÈ· ÙËÓ ÔÔ›· Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Û˘¯ÓÔ› ·ÈÌ·ÙÔÏÔÁÈÎÔ› ¤ÏÂÁ¯ÔÈ. §fiÁˆ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ù˘ ·ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›·˜ Î·È ÙÔ˘ ÎfiÛÙÔ˘˜ ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ÂÍÂÙ¿ÛˆÓ, Ë ÎÏÔ˙·›ÓË Î·ı›ÛÙ·Ù·È Ê¿ÚÌ·ÎÔ ‰Â‡ÙÂÚ˘ ÂÈÏÔÁ‹˜. ¶¿Ú· Ù·‡Ù·, ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ Û ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙ· ÎÏ·ÛÈο ·ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η. ∏ ÎÏÔ˙·›ÓË, ·ÓÙ›ıÂÙ· Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ ·ÓÙÈ„˘¯ˆÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰ÂÓ Î·Ù·ÛÙ¤ÏÏÂÈ ÙËÓ ¤ÎÎÚÈÛË Ù˘ ÚÔÏ·ÎÙ›Ó˘ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‰È·Ù·Ú¿ÛÛÂÈ ÙËÓ ˆÔÚÚËÍ›· Î·È ÙË ÁÔÓÈÌfiÙËÙ·. ™˘ÓÂÒ˜, Ë Á˘Ó·›Î· Ô˘ Ï·Ì‚¿ÓÂÈ ÙËÓ Ô˘Û›· ·˘Ù‹, Â›Ó·È Ôχ Èı·Ófi Ó· Ì›ÓÂÈ ¤ÁÎ˘Ô˜. ∏ ÎÏÔ˙·›ÓË ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ‰ÂÓ ¤‰ÂÈÍ·Ó ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙÂÚ·ÙÔÁÂÓ¤ÛÂˆÓ Î·È ÂÌ‚Ú˘ÔÙÔÍÈÎfiÙËÙ·˜, Û ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· 2-3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚ· ·fi ·˘Ù¿ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔÓ ¿ÓıÚˆÔ (25,26). ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ Ô˘ Ó· Û˘Ó‰¤Ô˘Ó ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¤ÎıÂÛË ÛÙËÓ ÎÏÔ˙·›ÓË ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜. Ÿˆ˜ ·Ó·Ê¤ÚıËÎÂ, Ë ¯Ú‹ÛË Ù˘ ÎÏÔ˙·›Ó˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ô˘‰ÂÙÂÚÔÂÓ›· ¤ˆ˜ Î·È ·ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›·, Û˘Ó‹ıˆ˜ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ Ù˘ ıÂڷ›·˜. ∏ ·ÚÂÓ¤ÚÁÂÈ· ·˘Ù‹, ÏfiÁˆ ηٷÛÙÔÏ‹˜ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ›Ù ·ÈÊÓȉ›ˆ˜, ›Ù ÛÙ·‰È·Î¿. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÂÈ‚¿ÏÏÂÙ·È Ô ·ÈÌ·ÙÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÂÁ·Ԣ ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, οı ‚‰ÔÌ¿‰· ÙȘ 18 ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ·ÁˆÁ‹˜ ηÈ, ηÙfiÈÓ ÙÔ‡ÙÔ˘, οı 15 Ë̤Ú˜ ÁÈ· ¤Ó·Ó ¯ÚfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹.
¶·È‰È·ÙÚÈ΋ 2003;66:247-254
OÈ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Û˘Ó¯›˙Ô˘Ó ÙË Ï‹„Ë ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó·Ó ¯ÚfiÓÔ, Ú¤ÂÈ Ó· ÂϤÁ¯Ô˘Ó οı ̋ӷ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Ì¤¯ÚÈ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜. ŸÙ·Ó ‰È·ÈÛÙˆı› Ë ‰È·Ù·Ú·¯‹, ÂÈ‚¿ÏÏÂÙ·È Ë ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. Ÿˆ˜ Î·È ÁÈ· ÙÔ˘˜ ÏÔÈÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Û˘ÓÈÛٿٷÈ, fiÔ˘ Â›Ó·È ÎÏÈÓÈο ÂÊÈÎÙfi, Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ΢ڛˆ˜ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ ‹ ÙȘ Ë̤Ú˜ Ô˘ ÚÔËÁÔ‡ÓÙ·È ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘ ÙÔÎÂÙÔ‡, Ì ÛÎÔfi Ó· ÚÔÏËÊı› Ë Î·Ù·ÛÙÔÏ‹ Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ·fiÛ˘ÚÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡. °·ÏÔ˘¯›·: ∏ ¯Ú‹ÛË Ù˘ ÎÏÔ˙·›Ó˘ ·ÓÙÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙÔÓ ıËÏ·ÛÌfi. ∏ ÎÏÔ˙·›ÓË ·ÂÎÎÚ›ÓÂÙ·È ÛÙÔ Á¿Ï·. ™ÙÔ ÓÂÔÁÓfi ÚÔηÏ› ηٷÛÙÔÏ‹, Ì›ˆÛË Ù˘ ıËÏ·ÛÙÈ΋˜ ÂÈı˘Ì›·˜, Û·ÛÌÔ‡˜ Î·È Î·Ú‰È·ÁÁÂȷ΋ ·ÛÙ¿ıÂÈ·. ª›· ·fi ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Â›Ó·È Ë ·ÎÔÎÈÔ΢ÙÙ·Ú·ÈÌ›·, Ë ÔÔ›· ÌÔÚ› Ó· ı¤ÛÂÈ Û ΛӉ˘ÓÔ ÙË ˙ˆ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÏfiÁˆ ¢ηÈÚÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ (25-27). ƒÈÛÂÚȉfiÓË (∫·ÙËÁÔÚ›· ·ËÛ˘ C Î·È Á·ÏÔ˘¯›·˜ L3 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Risperdal) ∏ ÚÈÛÂÚȉfiÓË ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙȘ ÛÔ‚·Ú¤˜ ·ÈÌ·ÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ÎÏÔ˙·›Ó˘. ÃËÌÈο, Ë Ô˘Û›· ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ٷ ˘fiÏÔÈ· ·ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η Î·È Ê·›ÓÂÙ·È Ó· Â›Ó·È ÈÛ¯˘Úfi˜ ·ÓÙ·ÁˆÓÈÛÙ‹˜ ÁÈ· ÙÔ˘˜ 5∏∆2·, 5∏∆7 ÛÂÚÔÙÔÓÈÓÂÚÁÈÎÔ‡˜, ·1, ·2-·‰ÚÂÓÂÚÁÈÎÔ‡˜, ∏1-ÈÛÙ·ÌÈÓÈÎÔ‡˜ Î·È ÙÔ˘˜ D2 ˘Ô‰Ô¯Â›˜. ∞ÓÙ›ıÂÙ·, ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·ÌËÏ‹ Û˘ÁÁ¤ÓÂÈ· ÁÈ· ÙÔ˘˜ ˘Ô‰Ô¯Â›˜ D1 Î·È D4 Ù˘ ÓÙÔ·Ì›Ó˘. OÈ Ï¤ÔÓ Û˘¯Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯Ú‹ÛË Ù˘ ÚÈÛÂÚȉfiÓ˘ Â›Ó·È ·¸Ó›·, ˙¿ÏË, ¿Á¯Ô˜, Ù·Ú·¯‹, ˘fiÙ·ÛË Î·È ÛÂÍÔ˘·ÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. º·›ÓÂÙ·È Ó· ·ÔÙÂÏ› ÙÔ Ê¿ÚÌ·ÎÔ ÚÒÙ˘ ÂÎÏÔÁ‹˜, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ì·ÓÈÔηٷıÏÈÙÈ΋˜ ‰È·Ù·Ú·¯‹˜, „˘¯ˆÛÈ΋˜ ηٿıÏȄ˘ Î.Ï. ∫‡ËÛË: ∂Î ÚÔÔÈÌ›Ô˘, Ú¤ÂÈ Ó· ÂÈÛËÌ¿ÓÔ˘Ì fiÙÈ Ë ¯Ú‹ÛË ÙˆÓ ÓÂfiÙÂÚˆÓ ¿Ù˘ˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ (fiˆ˜ Ë ÏÔÍ·›ÓË Î·È Ë ÔÏ·Ó˙·›ÓË) ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙËÓ Î‡ËÛË, ηıÒ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ. ∞fi Ù· ˘¿Ú¯ÔÓÙ· ‰Â‰Ô̤ӷ, Ë ÚÈÛÂÚȉfiÓË ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·. ™Ù· ÂÈÚ·Ì·Ùfi˙ˆ·, Â›Ì˘Â˜ Î·È ÎÔ˘Ó¤ÏÈ·, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË Û ‰fiÛÂȘ >2,5 mg/kg per os ÚÈÓ Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ÛÙ·‰›ˆÓ Ù˘ ·ËÛ˘ Î·È 10 mg/kg ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÔÚÁ·ÓÔÁ¤ÓÂÛ˘. ªÂ ÙË ‰Â‡ÙÂÚË ‰ÔÛÔÏÔÁ›· ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ‚¿ÚÔ˘˜ (28). °È· ÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔÈ-
Paediatriki 2003;66:247-254
¯Â›·. ∞fi ÚfiÛÊ·ÙË ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘, Ë ÚÔÁÂÓÓËÙÈ΋ ¯Ú‹ÛË Ù˘ Ô˘Û›·˜ ‰ÂÓ ‰ËÌÈÔ‡ÚÁËÛ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÛÙÔ ¤Ì‚Ú˘Ô Î·È ·ÚÁfiÙÂÚ· ÛÙÔ ıËÏ¿˙ÔÓ ÓÂÔÁÓfi (29). §·Ì‚¿ÓÔÓÙ·˜, fï˜, ˘’ fi„ÈÓ ÙËÓ ÂÌ‚Ú˘ÔÙÔÍÈ΋ ‰Ú¿ÛË ÛÙ· ÂÈÚ·Ì·Ùfi˙ˆ·, Û˘ÓÈÛÙ¿Ù·È Ë ¯Ú‹ÛË Ù˘ Ô˘Û›·˜ ÌfiÓÔ fiÔ˘ Ú·ÁÌ·ÙÈο ‰ÂÓ ˘¿Ú¯ÂÈ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ¢ÙÈ΋ χÛË. °·ÏÔ˘¯›·: ∏ ÚÈÛÂÚȉfiÓË Î·È ÙÔ ·Ú¿ÁˆÁÔ ·˘Ù‹˜, 9-O∏-ÚÈÛÂÚȉfiÓË, ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙÔ Á¿Ï· ÛÂ Û˘ÁÎÂÓÙÚÒÛÂȘ ÌÂÁ·Ï‡ÙÂÚ˜ ‹ ›Û˜ ·fi ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ Ô˘Û›·˜ ÛÙÔ Ï¿ÛÌ· (25). ª¤¯ÚÈ Û‹ÌÂÚ· ˘¿Ú¯ÂÈ ÌfiÓÔ Ì›· ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ÓÂÔÁÓÔ‡ Ô˘ ÂÎÙ¤ıËΠÛÙËÓ Ô˘Û›· ηٿ ÙË ‰È¿ÚÎÂÈ· ıËÏ·ÛÌÔ‡ ¯ˆÚ›˜ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (30). ∂Âȉ‹ Ù· ‰Â‰Ô̤ӷ Â›Ó·È ·Ó·Ú΋, ÂÊ’ fiÛÔÓ ¯ÔÚËÁÂ›Ù·È Ë Ô˘Û›· ÛÙË ıËÏ¿˙Ô˘Û· ÌËÙ¤Ú·, Û˘ÓÈÛÙ¿Ù·È Ë ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈ· Ù˘¯fiÓ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. OÏ·Ó˙·›ÓË (∫·ÙËÁÔÚ›· ·ËÛ˘ C Î·È Á·ÏÔ˘¯›·˜ L3 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Zyprexa) ∏ ÔÏ·Ó˙·›ÓË ·Ó‹ÎÂÈ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ¿Ù˘ˆÓ ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ¯ËÌÈ΋ Û˘ÁÁ¤ÓÂÈ· Ì ÙËÓ ÎÏÔ˙·›ÓË. Œ¯ÂÈ, ›Û˘, ÙÔÓ ›‰ÈÔ Ì˯·ÓÈÛÌfi ‰Ú¿Û˘. ∏ Ô˘Û›· ·˘Ù‹, Û ·ÓÙ›ıÂÛË Ì ٷ ·Ï·È¿ ·ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η, ‰ÂÓ ·˘Í¿ÓÂÈ Ù· ›‰· Ù˘ ÚÔÏ·ÎÙ›Ó˘ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙË ÁÔÓÈÌfiÙËÙ· ÙˆÓ Á˘Ó·ÈÎÒÓ ·˘ÙÒÓ ÏfiÁˆ Ù˘ ·Ú·ÙËÚÔ‡ÌÂÓ˘ ·Ú·ÈÔÌËÓfiÚÚÔÈ·˜. ¢ÂÓ ÂÌÊ·Ó›˙ÂÈ ÛËÌ·ÓÙÈΤ˜ Â͈˘Ú·ÌȉÈΤ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ∞fi ÙȘ ϤÔÓ Û˘¯Ó¤˜ ·Ó·ÊÂÚfiÌÂÓ˜ ·ÚÂÓ¤ÚÁÂȘ Â›Ó·È Ë ˘ÓËÏ›· Î·È Ë ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜. ∫‡ËÛË: ¢È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·. ™Ù· ÂÈÚ·Ì·Ùfi˙ˆ·, Û ‰fiÛÂȘ ˘„ËÏfiÙÂÚ˜ ·˘ÙÒÓ ÙÔ˘ ·ÓıÚÒÔ˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË. ¶·ÚÔ˘ÛÈ¿˙ÂÈ, fï˜, ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ÂÓ‰ÔÌ‹ÙÚÈˆÓ ı·Ó¿ÙˆÓ Î·È Ì›ˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ÂÌ‚Ú‡ˆÓ (26). ∞fi ÙË ÌÂϤÙË ÙˆÓ Schenker Î·È Û˘Ó (1999) Ê·›ÓÂÙ·È fiÙÈ ÙÔ 5-14% Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ÔÛfiÙËÙ·˜ ÂÚÓ¿ÂÈ Û ÂÓÂÚÁ‹ ÌÔÚÊ‹ ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ·, Û ‰È¿ÛÙËÌ· 4 ˆÚÒÓ (31). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ Goldstein Î·È Û˘Ó (2000), Û 23 ÚÔÔÙÈΤ˜ Î·È 9 ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ Ì ÚÔÁÂÓÓËÙÈ΋ ¯Ú‹ÛË Ù˘ Ô˘Û›·˜ ÂÍ‹¯ıËÛ·Ó Ù· ·ÎfiÏÔ˘ı· ÛÙÔȯ›·. ∏ ¤Î‚·ÛË ÙˆÓ 23 ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ ‹Ù·Ó ˆ˜ ÂÍ‹˜: ·˘ÙfiÌ·Ù˜ ·Ô‚ÔϤ˜ ÛËÌÂÈÒıËÎ·Ó Û ÙÚÂȘ ÂÁ·Ԣ˜ (ÔÛÔÛÙfi 13%) Î·È ÂÓ‰ÔÌ‹ÙÚÈÔ˜ ı¿Ó·ÙÔ˜ Û ̛· ¤Á΢Ô, ÌÂÙ¿ ·fi ·˘ÙfiÌ·ÙË Ú‹ÍË ÙˆÓ ˘Ì¤ÓˆÓ ÛÙȘ 37 ‚‰ÔÌ¿‰Â˜ (ÔÛÔÛÙfi 5%). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ÂÓ‰ÔÌ‹ÙÚÈÔ˘
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ı·Ó¿ÙÔ˘, Ë ÌËÙ¤Ú· ›¯Â ÂÈ‚·Ú˘Ì¤ÓÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi (۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ıÚÔÌ‚Ô΢ÙÔÂÓ›·, Ë·Ù›Ùȉ· Î·È ¯Ú‹ÛË ÔÏÏÒÓ Ê·Ú̿ΈÓ). ¢¤Î· ¤ÍÈ Á˘Ó·›Î˜ ›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi (ÔÛÔÛÙfi 80%), ÂÓÒ ¤ÁÈÓÂ Î·È Ì›· ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÛÙȘ 30 ‚‰ÔÌ¿‰Â˜, ÏfiÁˆ ÂÌ‚Ú˘˚΋˜ ‰˘Û¯¤ÚÂÈ·˜, Û ÌËÙ¤Ú· Ì ÈÛÙÔÚÈÎfi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È ÚÔÂÎÏ·Ì„›·. ¶·Ú¿Ù·ÛË Î˘‹Ûˆ˜ ÛËÌÂÈÒıËΠ۠‰‡Ô ÂÚÈÙÒÛÂȘ. ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ÙˆÓ 23 Á˘Ó·ÈÎÒÓ, Ë ¯Ú‹ÛË Ù˘ ÔÏ·Ó˙·›Ó˘ ‰ÂÓ ·‡ÍËÛ ٷ ÔÛÔÛÙ¿ ÙˆÓ ·Ô‚ÔÏÒÓ, ÙˆÓ ÂÓ‰ÔÌ‹ÙÚÈˆÓ ı·Ó¿ÙˆÓ, Ù˘ ÚÔˆÚfiÙËÙ·˜ ‹ ÌÂÈ˙fiÓˆÓ ·ÓˆÌ·ÏÈÒÓ Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (32). ∞fi ÙË ÌÂϤÙË ÙˆÓ Kirchheiner Î·È Û˘Ó (2000) ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ·ÚÂÓ¤ÚÁÂȘ ·fi ÙË Ï‹„Ë Ù˘ Ô˘Û›·˜ ηٿ ÙËÓ Î‡ËÛË (33). ∫·È ·fi Ù· ‰Â‰Ô̤ӷ ÙˆÓ Nagy Î·È Û˘Ó (2001) ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ÚÂÓ¤ÚÁÂȘ ·fi ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¤ÎıÂÛË ÛÙËÓ Ô˘Û›· ÙÔ˘ ÓÂÔÁÓÔ‡, Ë ÌËÙ¤Ú· ÙÔ˘ ÔÔ›Ô˘ ÂÏ¿Ì‚·Ó ÙËÓ ÔÏ·Ó˙·›ÓË ·fi ÙËÓ 25Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ Î·È Ì¤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ·˘Ù‹˜. ∆Ô Apgar score ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙÔ 1Ô ÏÂÙfi ‹Ù·Ó 7 Î·È ÛÙÔ 5Ô ÏÂÙfi ‹Ù·Ó 9 (34). °·ÏÔ˘¯›·: ∞fi Ù· ˘¿Ú¯ÔÓÙ· ÛÙÔȯ›· Û ÂÈÚ·Ì·Ùfi˙ˆ· Ê·›ÓÂÙ·È fiÙÈ Ë ÔÏ·Ó˙·›ÓË ·ÂÎÎÚ›ÓÂÙ·È ÛÙÔ Á¿Ï· ÙˆÓ Â›Ì˘ˆÓ. ™ÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· (32). OÈ Goldstein Î·È Û˘Ó (2000) ÂÚÈÁÚ¿ÊÔ˘Ó ‰‡Ô ÂÚÈÙÒÛÂȘ Ô˘ ÂÎÙ¤ıËÎ·Ó ÛÙËÓ ÔÏ·Ó˙·›ÓË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡ (32). ™ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË, Ë ÌËÙ¤Ú· Ô˘ ¤·Û¯Â ·fi ·Ú·ÓÔ˚΋ Û¯È˙ÔÊÚ¤ÓÈ·, ÂÏ¿Ì‚·Ó ÔÏ·Ó˙·›ÓË 10 mg Ì·˙› Ì ÙÚÈÊıÔÚÈÔÂÚ·˙›ÓË Î·È ·ÚÔÍÂÙ›ÓË fiÙ·Ó ÙÔ ÓÂÔÁÓfi Ù˘ ‹Ù·Ó 2 ÌËÓÒÓ. ™Â ·˘Ù‹ ÙËÓ ·Ó·ÊÔÚ¿ ‰ÂÓ ˘‹Ú¯·Ó ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ™ÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË, ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi ›ÎÙÂÚÔ, ˘ÓËÏ›· Î·È Î·Ú‰ÈÔÌÂÁ·Ï›·. ∏ ÌËÙ¤Ú· ÙÔ˘ ÂÏ¿Ì‚·Ó 5 mg ËÌÂÚËÛ›ˆ˜ ηٿ ÙÔ ÚÒÙÔ Î·È ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘. O ›ÎÙÂÚÔ˜ Î·È Ë ˘ÓËÏ›· ·Ú¤ÌÂÈÓ·Ó Î·È ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∂Ô̤ӈ˜, Ù· Û˘ÌÙÒÌ·Ù· ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ÛÙË Ï‹„Ë Ù˘ ÔÏ·Ó˙·›Ó˘ (17,32). º˘ÛÈο, ·fi ‰‡Ô ÌfiÓÔ ÂÚÈÙÒÛÂȘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ Ô˘Û›·˜ ηٿ ÙÔÓ ıËÏ·ÛÌfi. ª¤¯ÚÈ ÙË Û˘ÏÏÔÁ‹ ·ÚÎÒÓ ÛÙÔȯ›ˆÓ ÁÈ· ÙËÓ Ô˘Û›·, Û˘ÓÈÛÙ¿Ù·È Ó· ·ÔʇÁÂÙ·È Ô ıËÏ·ÛÌfi˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ·ÁˆÁ‹˜ Ì ÙËÓ ÔÏ·Ó˙·›ÓË Î·È, ÁÂÓÈο, Ù· ¿ÏÏ· ¿Ù˘· ·ÓÙÈ„˘¯ˆÛÈο Ê¿Ú̷η. ∞fi ÙËÓ ÚfiÛÊ·ÙË ÌÂϤÙË ÙˆÓ Koren Î·È Û˘Ó (2002) Ê·›ÓÂÙ·È fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ó¢ÚÈÎÔ‡ ۈϋӷ ÛÙ· ÓÂÔÁÓ¿ ÙˆÓ ·ÛıÂÓÒÓ Ì ۯÈ˙ÔÊÚ¤ÓÂÈ· ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÓÙÈ„˘¯ˆÛÈ΋ Ô˘Û›·, ·ÏÏ¿ ÛÙËÓ ¤ÏÏÂÈ„Ë Ê˘ÏÏÈÎÔ‡ Ôͤ-
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Ô˜ Î·È ÛÙËÓ ·¯˘Û·ÚΛ·. ∞˘ÙÔ› ÔÈ ‰‡Ô Û˘Ì·Ú¿ÁÔÓÙ˜ ‹Ù·Ó ·ÚÎÂÙ¿ Û˘¯ÓÔ› Û ·˘Ù‹ ÙËÓ ÏËı˘ÛÌȷ΋ ÔÌ¿‰· (35). ™Ô˘ÏÈÚ›‰Ë (∫·ÙËÁÔÚ›· Á·ÏÔ˘¯›·˜ L2 - ∂ÌÔÚÈο Û΢¿ÛÌ·Ù·: Dogmatyl, Nufarol, Darleton Î.¿.) ∞Ó·ÛÙ¤ÏÏÂÈ ÙÔ˘˜ D2 ÓÙÔ·ÌÈÓÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜, ÎÂÓÙÚÈÎÔ‡˜ Î·È ÂÚÈÊÂÚÈÎÔ‡˜. ™Â ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÚÔηÏ› ¤ÓÙÔÓË ˘ÂÚÚÔÏ·ÎÙÈÓ·ÈÌ›·. ∫‡ËÛË: ¢ÂÓ ˘¿Ú¯Ô˘Ó ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ. °·ÏÔ˘¯›·: ∏ ÛÔ˘ÏÈÚ›‰Ë Â›Ó·È ¤Ó·˜ ·ÓÙ·ÁˆÓÈÛÙ‹˜ Ù˘ ÓÙÔ·Ì›Ó˘ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ‰ÈÂÁ›ÚÔÓÙ·˜ ÙËÓ ¤ÎÎÚÈÛË Ù˘ ÚÔÏ·ÎÙ›Ó˘, ·˘Í¿ÓÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜. ™Â ‰‡Ô ÌÂϤÙ˜, ÔÈ ÌËÙ¤Ú˜ ÂÏ¿Ì‚·Ó·Ó 100 mg ÛÔ˘ÏÈÚ›‰Ë˜ ËÌÂÚËÛ›ˆ˜. OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ Ô˘Û›·˜ ÛÙÔ Á¿Ï· Î˘Ì¿ÓıËÎ·Ó ·fi 0,83 mg/l ¤ˆ˜ 1,97 mg/l. ™‡Ìʈӷ Ì ·˘Ù¤˜ ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ, ÙÔ ÓÂÔÁÓfi ı· Ï¿‚ÂÈ ·fi 8,7% ¤ˆ˜ Î·È 18% ÙˆÓ ‰fiÛÂˆÓ Ù˘ ÌËÙ¤Ú·˜. ™Â ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ÁÈ· Ù˘¯fiÓ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÛÙ· ÓÂÔÁÓ¿ (7). ∏ÏÂÎÙÚÔÛ·ÛÌÔıÂڷ›· (Electroconvulsive therapy - ECT) ¢ÂÓ Â›Ó·È Ï›Á˜ ÔÈ ÊÔÚ¤˜ Ô˘ Ë Ì·Óȷ΋ ‹ „˘¯ˆÛÈ΋ ¤ÁÎ˘Ô˜ ‰ÂÓ ‰¤¯ÂÙ·È Ó· Ï¿‚ÂÈ ÙË ıÂڷ¢ÙÈ΋ Ù˘ ·ÁˆÁ‹ ÏfiÁˆ Êfi‚Ô˘ Ù˘¯fiÓ ÙÂÚ·ÙÔÁ¤ÓÂÛ˘ ‹ ·Ú·ÓÔ˚ÎÒÓ Î·È ··ÙËÏÒÓ ÛΤ„ˆÓ, .¯. “ÙÔ Ê¿ÚÌ·ÎÔ Â›Ó·È ‰ËÏËÙ‹ÚÈÔ ÁÈ· ÙÔ ·È‰›”. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ˘¿ÚÍÔ˘Ó Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯Ú‹ÛË Ù˘ ECT. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ë ‰Ú¿ÛË Ù˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÛËÌ·ÓÙÈ΋˜ ÔÛfiÙËÙ·˜ Ó¢Úԉȷ‚È‚·ÛÙÒÓ, ÓÔÚ·‰ÚÂÓ·Ï›Ó˘, ÛÂÚÔÙÔÓ›Ó˘ Î·È ÓÙÔ·Ì›Ó˘, ‰È·Ì¤ÛÔ˘ ÙˆÓ ÚÔÎÏËı¤ÓÙˆÓ Û·ÛÌÒÓ. ∏ ECT ·ÔÙÂÏ› Ì›· ·ÛÊ·Ï‹ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË, Ë ÔÔ›· ÌÔÚ› Î·È Ó· Û˘Ó‰˘·ÛÙ› Ì ÙÔ˘˜ ·ÓÙÈ„˘¯ˆÛÈÎÔ‡˜ Î·È ·ÓÙÈηٷıÏÈÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ËÏÂÎÙÚÔÛ·ÛÌÔıÂڷ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÚÎÂÙ¤˜ ·ÚÂÓ¤ÚÁÂȘ ηٿ ÙËÓ Î‡ËÛË. OÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ˘ÔÍ›· Î·È ÙËÓ ˘fiÙ·ÛË, ÔÈ Ôԛ˜ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Î·Ù¿ ÙËÓ ÂÎÙ¤ÏÂÛË Ù˘ ÌÂıfi‰Ô˘. ∏ ̤ıÔ‰Ô˜ Ê·›ÓÂÙ·È, ›Û˘, Ó· ·ÂÏ¢ıÂÚÒÓÂÈ ˆÎ˘ÙÔΛÓË Î·È ¿ÏϘ ·ÁÁÂÈÔ‰Ú·ÛÙÈΤ˜ ÔÚÌfiÓ˜, fiÔ˘ Ë ÌÂÓ ÚÒÙË ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÚfiˆÚ˜ Û˘Û¿ÛÂȘ Ù˘ Ì‹ÙÚ·˜ Î·È ÔÈ ‰Â‡ÙÂÚ˜ ·ÈÌÔÚÚ·Á›Â˜ (36-39) (¶›Ó·Î·˜ 2). ™Â Ì›· ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÛÎfiËÛË ÙÔ˘ Miller (1994), ¤¯Ô˘Ó ηٷÁÚ·Ê› Û˘ÓÔÏÈο 28 ÂÈÏÔΤ˜ Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 300 ECT ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ™Â ·˘Ù¤˜ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÂÌ‚Ú˘˚΋ ηډȷ΋ ·ÚÚ˘ıÌ›·, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÛÙ·ÁÔÓÔÂȉ‹˜
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¶›Ó·Î·˜ 2. ∂ÈÙÒÛÂȘ Ù˘ ËÏÂÎÙÚÔÛ·ÛÌÔıÂڷ›·˜ ηٿ ÙËÓ Î‡ËÛË ñ ñ ñ ñ
∞˘ÙfiÌ·ÙË ·Ô‚ÔÏ‹ ¶ÚfiˆÚ˜ Û˘Û¿ÛÂȘ ∞ÔÎfiÏÏËÛË Ï·ÎÔ‡ÓÙ· ∂Ó‰ÔÌ‹ÙÚÈÔ˜ ı¿Ó·ÙÔ˜
ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ·, ÚfiˆÚ˜ Û˘Û¿ÛÂȘ Î·È ÚfiˆÚÔ˜ ÙÔÎÂÙfi˜, Ô ÔÔ›Ô˜ fï˜ ÔÊÂÈÏfiÙ·Ó Û ¿ÏÏË ·ÈÙ›·. ™Â 5 ÓÂÔÁÓ¿ ˘‹Ú¯Â οÔÈ·˜ ÌÔÚÊ‹˜ Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, η̛· fï˜ ‰ÂÓ Û¯ÂÙ›ÛÙËΠ̠ÙË Ì¤ıÔ‰Ô. ™ÙËÓ ·ÓˆÙ¤Úˆ ·Ó·ÛÎfiËÛË ·Ó·Ê¤ÚÔÓÙ·È ÙÚÂȘ ÂÚÈÙÒÛÂȘ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘ (40). ™Â ¿ÏϘ ‰‡Ô ÂÚÈÙÒÛÂȘ ηٷÁÚ¿ÊÂÙ·È Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡ ÌÂÙ¿ ·fi ECT. OÈ ÚfiˆÚ˜ Û˘Û¿ÛÂȘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÈÙ˘¯Ò˜ Ì ÙÔÎÔÏ˘ÙÈ΋ ·ÁˆÁ‹ (6,39). ∞ÓÙ›ıÂÙ·, Û ̛· ÂÚ›ÙˆÛË ·ÎÔÏÔ‡ıËÛ ·˘ÙfiÌ·ÙË ·Ô‚ÔÏ‹ ΢‹Ì·ÙÔ˜ 8 ‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙËÓ 3Ë Û˘Ó‰ڛ· (41). ∞fi Ù· ·Ú·¿Óˆ Ê·›ÓÂÙ·È fiÙÈ ÔÈ Ï¤ÔÓ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ECT ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ Â›Ó·È Ô ÚfiˆÚÔ˜ ÙÔÎÂÙfi˜, ÏfiÁˆ ·‡ÍËÛ˘ ÙˆÓ Û˘Û¿ÛÂˆÓ Ù˘ Ì‹ÙÚ·˜ Î·È Ë ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ·. Œ¯ÂÈ, ›Û˘, ·Ó·ÊÂÚı› ÚfiˆÚË ·ÔÎfiÏÏËÛË Ï·ÎÔ‡ÓÙ·. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÚ›ÙÔ˘ ÙÚÈÌ‹ÓÔ˘, ÚÈÓ ÙËÓ ¤Ó·ÚÍË ·˘Ù‹˜ Ù˘ ıÂڷ›·˜, Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ·ÓÙÈfiÍÈÓÔ ÁÈ· Ó· ÌÂÙÚÈ¿ÛÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ó¢ÌÔÓ›·˜ ·fi ÂÈÛÚfiÊËÛË. ∏ ·Ú΋˜ Ô͢ÁfiÓˆÛË Î·È Ô ˘ÂÚ·ÂÚÈÛÌfi˜ Ù˘ ÂÁ·Ԣ ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÎÙ¤ÏÂÛË Ù˘ ECT, Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙË Ì›ˆÛË Ù˘ ÂÌ‚Ú˘˚΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÏfiÁˆ ˘ÔÍ·ÈÌ›·˜ (40,42).
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 04-12-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 16-04-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¡›ÎÔ˜ ∫·Ì¿˜ ª. ∞ÔÛÙÔÏ›‰Ë 10, ∆.∫. 203 00, §Ô˘ÙÚ¿ÎÈ, ∫fiÚÈÓıÔ˜ E-mail: pyrghi@otenet.gr
¶·È‰È·ÙÚÈ΋ 2003;66:255-263
∞¡∞™∫O¶∏™∏
Paediatriki 2003;66:255-263
REVIEW ARTICLE
∂ÈÏË„›· Î·È Î‡ËÛË ∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
Epilepsy and pregnancy E. Hatzidaki, C. Giannakopoulou
¶ÂÚ›ÏË„Ë: ∏ ÂÈÏË„›· Â›Ó·È Ì›· Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ ·ÊÔÚ¿ ÛÙÔ 1% ÂÚ›Ô˘ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∂›Ó·È Ë Û˘¯ÓfiÙÂÚË Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ∆Ô 0,3-0,4% ÙˆÓ ÓÂÔÁÓÒÓ ÛÙȘ ̤Ú˜ Ì·˜ ÁÂÓÓÈ¤Ù·È ·fi ÂÈÏËÙÈΤ˜ ÌËÙ¤Ú˜. ∏ ÂÈÏË„›· Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÈÏÔÎÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÔÈ Ôԛ˜ ·ÂÈÏÔ‡Ó ÙË ˙ˆ‹ ÙfiÛÔ Ù˘ ÂÁ·Ԣ fiÛÔ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡ Ù˘. ∏ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ·˘Í¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙÔ ¤Ì‚Ú˘Ô. ™˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ Û΢¿ÛÌ·ÙÔ˜, ÛÙȘ ÌÈÎÚfiÙÂÚ˜ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ‰fiÛÂȘ, ·Ó¿ÏÔÁ· Ì ÙÔÓ Ù‡Ô ÂÈÏË„›·˜ Ô˘ ÂÌÊ·Ó›˙ÂÈ Ë ¤ÁÎ˘Ô˜ Î·È Ì ÙȘ ÏÈÁfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ÙfiÛÔ ÁÈ· ÙË Á˘Ó·›Î· fiÛÔ Î·È ÁÈ· ÙÔ ¤Ì‚Ú˘Ô. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ¤ÁÎ˘Â˜ Ì ÂÈÏË„›· ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË ¯ˆÚ›˜ Û˘Ì‚¿Ì·Ù·, ÙÔÎÂÙfi ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Î·È Á¤ÓÓËÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÓÂÔÁÓÔ‡. O ΛӉ˘ÓÔ˜ Á¤ÓÓËÛ˘ ·È‰ÈÔ‡ ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·ÓÙÈÏËÙfi˜ ÙfiÛÔ ·fi ÙËÓ ¤ÁÎ˘Ô fiÛÔ Î·È ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘. ∏ ÚÔÂÙÔÈÌ·Û›· Î·È Ô ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ Ù˘ ·ËÛ˘, ηıÒ˜ Î·È Ë ÂÈı·Ú¯Ë̤ÓË Î·È ÛˆÛÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÔÌ¿‰· ÂȉÈÎÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ¿ Ù˘, Â›Ó·È ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙËÓ ÔÌ·Ï‹ ÂͤÏÈÍË Ù˘ ·ËÛ˘ Î·È ÙÔ˘ ÙÔÎÂÙÔ‡ ¯ˆÚ›˜ ÂÈÏÔΤ˜ Î·È ÁÈ· ÙË Á¤ÓÓËÛË ÂÓfi˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÓÂÔÁÓÔ‡.
Abstract: Epilepsy is a functional neurological disease, which affects about 1% of the general population. It is the most common of the neurological disorders occurring during pregnancy. About 0.3% to 0.4% of babies nowadays are born to epileptic mothers. There is an association between epilepsy and an increased incidence of lifethreatening complications during the course of pregnancy, both to the pregnant woman and to her newborn infant. Anticonvulsant drugs can increase the incidence of congenital abnormalities in the fetus. Prescription of the most suitable medication, with the least side effects and in the lowest effective dosage, is recommended for the benefit of both the pregnant woman and the fetus. In the majority of cases, pregnancy in epileptic women follows a normal course terminating in a complication-free labour and delivery and resulting in the birth of a healthy newborn infant. However, the risk of congenital abnormalities in an infant born to an epileptic mother must be taken into consideration by the mother to be and her family. Careful planning and preparation for pregnancy and disciplined, accurate monitoring by specialized personnel during its course are vital prerequisites for its uneventful evolvement and the uncomplicated delivery of a healthy newborn.
§¤ÍÂȘ ÎÏÂȉȿ: ÂÈÏË„›·, ·ËÛË.
Key words: epilepsy, pregnancy.
∂ÈÛ·ÁˆÁ‹ O fiÚÔ˜ ÂÈÏË„›· ·Ó·Ê¤ÚÂÙ·È ÛÙË ¯ÚfiÓÈ· ‰È·Ù·Ú·¯‹ ηٿ ÙËÓ ÔÔ›· ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÂÚÂfiÙ˘· ·ӷϷ̂·ÓfiÌÂÓ· ÂÂÈÛfi‰È· ‰È·Ù·Ú·¯‹˜ Ù˘ Û˘Ó›‰ËÛ˘, Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, ÙÔ˘ Û˘Ó·ÈÛı‹Ì·ÙÔ˜, Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ‹ Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜. ∏ ÂÈÏË-
„›· Â›Ó·È Ì›· Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ ·ÊÔÚ¿ ÛÙÔ 1% ÂÚ›Ô˘ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ (1,2). ∂›Ó·È Ë Û˘¯ÓfiÙÂÚË Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ™‹ÌÂÚ·, ÙÔ 0,3-0,5% ÙˆÓ ÓÂÔÁÓÒÓ ÁÂÓÓÈ¤Ù·È ·fi ÂÈÏËÙÈΤ˜ ÌËÙ¤Ú˜ (3). ∏ ·ËÛË ÌÔÚ› Ó· ÂÈÙ›ÓÂÈ ÙË Û˘Ìو̷ÙÔÏÔÁ›· Ù˘
¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
Department of Neonatology of the University of Crete
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ÂÈÏËÙÈ΋˜ ÂÁ·Ԣ ‹ Ó· ·ӷ‰Ú·ÛÙËÚÈÔÔÈ‹ÛÂÈ ÙËÓ ÂÈÏËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (1). ∏ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ·˘Í¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙÔ ¤Ì‚Ú˘Ô (4-6). °È· ÙËÓ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÏËÚ¤ÛÙÂÚË È·ÙÚÈ΋ Î·È ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ·˘ÙÒÓ ÙˆÓ ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ Î·È ÙˆÓ ÓÂÔÁÓÒÓ ÙÔ˘˜, Ë Û˘ÁÎÚfiÙËÛË ÔÌ¿‰·˜ ·ÔÙÂÏÔ‡ÌÂÓ˘ ·fi Ì·ÈÂ˘Ù‹Ú·-Á˘Ó·ÈÎÔÏfiÁÔ, Ó¢ÚÔÏfiÁÔ, ÁÂÓÂÙÈÛÙ‹, ÓÂÔÁÓÔÏfiÁÔ Î·È ÂÎ·È‰Â˘Ì¤ÓÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ıˆÚÂ›Ù·È ··Ú·›ÙËÙË (7). ∂ȉڿÛÂȘ ÙˆÓ ÔÚÌÔÓÒÓ ÙÔ˘ ʇÏÔ˘ ÛÙËÓ ÂÈÏËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· OÈ ÛÙÂÚÔÂȉ›˜ ÔÚÌfiÓ˜ Ô˘ ·Ú¿ÁÔÓÙ·È ·fi Ù· ÂÈÓÂÊÚ›‰È· Î·È ÙȘ ÁÔÓ¿‰Â˜, ηıÒ˜ Î·È Ù· ÂÙ›‰È· Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙËÓ ˘fiÊ˘ÛË, Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó Ó¢ÚÔÁÂÓ‹ ‰Ú¿ÛË Î·È ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÂÈÏËÙÈ΋ ÎÚ›ÛË. ∆· ÔÈÛÙÚÔÁfiÓ·, ·ÎfiÌ· Î·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· ÛÙÔ ·›Ì·, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÚfiÎÏËÛË ÂÈÏËÙÈÎÒÓ ÎÚ›ÛˆÓ, ÂÓÒ Ë ¤ÏÏÂÈ„‹ ÙÔ˘˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË. ∏ ÚÔÁÂÛÙÂÚfiÓË Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Î·Ù·ÛÙ·ÏÙÈΤ˜ ȉÈfiÙËÙ˜ Î·È Ó· ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÂÈÏËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË Û¯¤ÛË ÔÈÛÙÚ·‰ÈfiÏ˘ ÚÔ˜ ÙËÓ ÚÔÁÂÛÙÂÚfiÓË, Ë ÔÔ›· ÔÈΛÏÏÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Á˘Ó·ÈΛԢ ·ÎÏÔ˘. ∏ Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ ÚÈÓ ÙËÓ ¤ÌÌËÓÔ Ú‡ÛË ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÙÒÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÚÔÁÂÛÙÂÚfiÓ˘, ÂÓÒ ÛÙË Ì¤ÛË ÙÔ˘ ·ÎÏÔ˘ Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ (1,8,9). ∂ÈÏË„›· Î·È ÂÊ˂›· ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, Ë ‰È¿ÁÓˆÛË Ù˘ ÂÈÏË„›·˜ Ù›ıÂÙ·È Ï·Óı·Ṳ̂ӷ Ì ۯÂÙÈ΋ ¢ÎÔÏ›·. ª¤¯ÚÈ Î·È ÙÔ 10% ÙˆÓ ÂÊ‹‚ˆÓ Ô˘ ıˆÚÂ›Ù·È fiÙÈ ¿Û¯Ô˘Ó ·fi ÂÈÏË„›·, ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· ¤¯ÂÈ ¿ÏÏË ÓfiÛÔ Ô˘ ÌÈÌÂ›Ù·È ÙËÓ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ù˘ (10,11). ∏ “ٷ̤Ϸ”, fï˜, ·˘Ù‹˜ Ù˘ ÓfiÛÔ˘ ÁÈ· οı ¿ÓıÚˆÔ Î·È È‰È·›ÙÂÚ· ÁÈ· ÙȘ Ó·ڤ˜ ¤Ê˂˜ ·ÔÙÂÏ› ¤Ó· ÛËÌ·ÓÙÈÎfi ÂÌfi‰ÈÔ, ÙfiÛÔ ÛÙËÓ ÚÔÛˆÈ΋ Î·È ÔÈÎÔÁÂÓÂȷ΋ ˙ˆ‹ fiÛÔ Î·È ÛÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ·ÔηٿÛÙ·ÛË. ª‹ˆ˜, ÏÔÈfiÓ, Â›Ó·È Î·ÈÚfi˜ ÁÈ· ·ÓÂÎÙ›ÌËÛË ·fi ÙÔ˘˜ ÂȉÈÎÔ‡˜ Î·È ÁÈ· Ì›· Ó¤· ÚÔÛ¿ıÂÈ· Â›Ï˘Û˘ ÙÔ˘ Ù˘¯fiÓ ‰È·ÁÓˆÛÙÈÎÔ‡ ÁÚ›ÊÔ˘; ∂›Ó·È fiÓÙˆ˜ ÂÈÏË„›· ‹ Ì‹ˆ˜ οÔÈ· ¿ÏÏË ÓfiÛÔ˜ Ô˘ ÌÈÌÂ›Ù·È ÙËÓ ÎÏÈÓÈ΋ Ù˘ ÚÔ‚ÔÏ‹; ∏ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Â›Ó·È ··Ú·›ÙËÙË ‹ ÌÔÚ› ‰˘ÓËÙÈο Ó· ‰È·ÎÔ› (10); ∏ ÂÈÏË„›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·¯˘Û·ÚΛ·, ¯·ÌËÏfiÙÂÚÔ ·Ó¿ÛÙËÌ· Î·È Î·ı˘ÛÙÂÚË̤ÓË ÂÌÌËÓ·Ú¯‹ (10). ∏ ÁÔÓÈÌfiÙËÙ· ÙˆÓ Á˘Ó·ÈÎÒÓ Ô˘ ¿Û¯Ô˘Ó ·fi ÂÈÏË„›· Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο. ∆fiÛÔ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÔÚÚËÎÙÈÎÒÓ Î‡ÎψÓ, fiÛÔ
256
Paediatriki 2003;66:255-263
Î·È Ë Â›ÙˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÔÏ˘Î˘ÛÙÈÎÒÓ ˆÔıËÎÒÓ Â›Ó·È ·˘ÍË̤Ó˜ Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (1,10,12,13). ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ·ÔÙ˘¯›·˜ Ù˘ ·ÓÙÈÛ˘ÏÏËÙÈ΋˜ ·ÁˆÁ‹˜, Ë ÔÔ›· ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ·fi ÙÔ ·ÓÙÈÂÈÏËÙÈÎfi Î·È ÛÙÔÓ ÂÓÈÛ¯˘Ì¤ÓÔ Î·Ù·‚ÔÏÈÛÌfi ÙˆÓ Â͈ÁÂÓÒÓ ÔÚÌÔÓÒÓ (5,7,14). ∏ ηڂ·Ì·˙›ÓË, Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ë Ê·ÈÓ˘ÙÔ˝ÓË Î·È Ë ÚÈÌȉfiÓË ¤¯Ô˘Ó Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ‰Ú¿ÛË. Œ¯ÔÓÙ·˜ ÌÈÎÚ‹ ‹ ηıfiÏÔ˘ ‰Ú¿ÛË ÛÙËÓ Â·ÁˆÁ‹ ÂÓ˙‡ÌˆÓ, ÙÔ ‚·ÏÚÔ˚Îfi Ô͇, ÔÈ ‚ÂÓ˙ԉȷ˙›Ó˜, Ë ‚Èη̷ÙÚ›ÓË Î·È Ë Ï·ÌÔÙÚÈÁ›ÓË ‰ÂÓ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ·ÔÙ˘¯›·˜ (5,7,14,15). ∞ÎfiÌ· Î·È ˘„ËϤ˜ ‰fiÛÂȘ ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi ‰ÂÓ ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÙËÓ ·ÓÙÈÛ˘ÏÏËÙÈ΋ ÚÔÛÙ·Û›·, ÂÓÒ Ë ÛˆÛÙ‹ ÂÓË̤ڈÛË Ù˘ ·ÛıÂÓÔ‡˜ ıˆÚÂ›Ù·È Ì›˙ÔÓÔ˜ ÛËÌ·Û›·˜ (15,16). ∂ȉڿÛÂȘ Ù˘ ·ËÛ˘ ÛÙËÓ ÂÈÏË„›· ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÎÚ›ÛÂˆÓ ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ÛÙȘ ÂÈÏËÙÈΤ˜ ¤ÁÎ˘Â˜. ∆· ÔÛÔÛÙ¿ ÔÈΛÏÏÔ˘Ó ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Î·È ·Ó·Ê¤ÚÔÓÙ·È ·fi 8% ¤ˆ˜ 46%. ™˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È Û ¿ÙÔÌ· Ì ·˘ÍË̤ÓË ÂÈÏËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È ·Ó·Ú΋ Ú‡ıÌÈÛË ÛÙËÓ ÚÔ Ù˘ ·ËÛ˘ ÂÚ›Ô‰Ô Ù˘ ˙ˆ‹˜ ÙÔ˘˜ (10,12). ∞˘Ù‹ Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÌÂȈ̤ÓË ·ÔÚÚfiÊËÛË ÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ÂÍ·ÈÙ›·˜ Ù˘ ˘ÂÚ¤ÌÂÛ˘, ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘, ÂӉ¯fiÌÂÓË Ì›ˆÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ‰fiÛÂˆÓ Î·È Û΢·ÛÌ¿ÙˆÓ Î·È Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ Ï¿ÛÌ· (10,17). ∏ ¤ÁÎ˘Ô˜ ‚Ú›ÛÎÂÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÂΉËÏÒÛÂÈ ÂÈÏËÙÈ΋ ÎÚ›ÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡ ÛÙÔ 1-2% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‹ ÛÙȘ ÂfiÌÂÓ˜ 24 ÒÚ˜ (›Û˘ Û ÔÛÔÛÙfi 1-2%). ∞ÓÙÈı¤Ùˆ˜, ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙÔ 50% ÙˆÓ ÂÁ·ˆÓ Ì ÂÈÏË„›· ·Ó·Ê¤ÚÔ˘Ó Î·Ï‡ÙÂÚË Ú‡ıÌÈÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, Ë ÔÔ›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÚÈÔÚÈṲ̂ÓË ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙȘ ÔÚÌÔÓÈΤ˜ ·ÏÏ·Á¤˜ Î·È ÁÂÓÈÎfiÙÂÚ· Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ÂÈı·Ú¯›· ÙÔ˘˜ (2,10,18). O ΛӉ˘ÓÔ˜ “status epilepticus” ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ ÙÔ˘ 1% (2,10). ™Â Ì›· Ù¤ÙÔÈ· ÂÚ›ÙˆÛË, Ô Î›Ó‰˘ÓÔ˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘ ÌÔÚ› Ó· ·Ó¤ÏıÂÈ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 50%, ÂÓÒ ·Ú¿ÏÏËÏ· ·˘Í¿ÓÂÙ·È ‰Ú·Ì·ÙÈο Ô Î›Ó‰˘ÓÔ˜ ÂÈÛÚfiÊËÛ˘ Ù˘ ÌËÙ¤Ú·˜ Î·È Ë ÌËÙÚÈ΋ ıÓËÙfiÙËÙ·. ™·Ó Èı·Ófi˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ¤¯ÂÈ ÚÔÙ·ı› Ë ÂÌ‚Ú˘˚΋ ·ÛÊ˘Í›·, Û·Ó Û˘Ó¤ÂÈ· Ù˘ ÔͤˆÛ˘ Î·È Ù˘ ˘ÔÍ›·˜ Ù˘ ÌËÙ¤Ú·˜, Ë ÌÂȈ̤ÓË ·ÈÌ·ÙÈ΋ ·ÚÔ¯‹ ÛÙËÓ ÂÌ‚Ú˘ÔÏ·ÎÔ˘ÓÙȷ΋ ÌÔÓ¿‰· Î·È Ë ·ÔÎfiÏÏËÛË ÙÔ˘
¶·È‰È·ÙÚÈ΋ 2003;66:255-263
Ï·ÎÔ‡ÓÙ· Ô˘ ÌÔÚ› Ó· Û˘Ì‚Â› ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ·Ú·ÙÂٷ̤ÓÔ˘ ÂÂÈÛÔ‰›Ô˘ Û·ÛÌÒÓ (7,19). ∂ȉڿÛÂȘ Ù˘ ÂÈÏË„›·˜ ÛÙËÓ Î‡ËÛË ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ¤ÁÎ˘Â˜ Ì ÂÈÏË„›· ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË ¯ˆÚ›˜ Û˘Ì‚¿Ì·Ù·, ÙÔÎÂÙfi ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Î·È Á¤ÓÓËÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÓÂÔÁÓÔ‡. ∂ÓÙÔ‡ÙÔȘ, Ë ÂÈÏË„›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Ì·È¢ÙÈÎÒÓ ÂÈÏÔÎÒÓ fiˆ˜ ÙÔÍÈÓ·ÈÌ›·, ÚÔÂÎÏ·Ì„›·, ÂÓ‰ÔÌ‹ÙÚÈÔ ı¿Ó·ÙÔ, ·ÔÎfiÏÏËÛË Ï·ÎÔ‡ÓÙ·, ÚfiˆÚÔ ÙÔÎÂÙfi, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘, ¯·ÌËÏfi Apgar score Î·È ·˘ÍË̤ÓË ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· (17,20). ∞fi ÙÔ˘˜ Nelson Î·È Û˘Ó ¤¯ÂÈ ·Ó·ÊÂÚı› ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘, ÌÈÎÚÔÎÂÊ·Ï›·˜ Î·È ‰È·ÓÔËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ ÛÙ· ·È‰È¿ ÙˆÓ ÌËÙ¤ÚˆÓ Ì ÂÈÏË„›· Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (21). O ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÈÏË„›·˜ ÛÙ· ·È‰È¿ ÙˆÓ ÌËÙ¤ÚˆÓ Ì ÂÈÏË„›· ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ‡·ÚÍË ˘ÔΛÌÂÓ˘ ·ıÔÏÔÁ›·˜, ·ÏÏ¿ Î·È ·fi ÙË ÌÔÚÊ‹ Ù˘. ™ÙȘ ÂÚÈÙÒÛÂȘ ȉÈÔ·ıÔ‡˜ ÁÂÓÈÎÂ˘Ì¤Ó˘ ÂÈÏË„›·˜, Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ÙÔ ·È‰› Ì ¤Ó·Ó ¿Û¯ÔÓÙ· Û˘ÁÁÂÓ‹ ·’ ‚·ıÌÔ‡ ·Ó¤Ú¯ÂÙ·È Û 5-20%, ÂÓÒ Â¿Ó ˘¿Ú¯ÂÈ Î·È ‰Â‡ÙÂÚÔ˜ ·’ ‚·ıÌÔ‡ Û˘ÁÁÂÓ‹˜ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 25%. ŒÙÛÈ, ÁÈ· Ì›· ÌËÙ¤Ú· Ì ȉÈÔ·ı‹ ÁÂÓÈÎÂ˘Ì¤ÓË ÂÈÏË„›·, Ô Î›Ó‰˘ÓÔ˜ Á¤ÓÓËÛ˘ ·È‰ÈÔ‡ Ì ÙËÓ ›‰È· ÓfiÛÔ Â›Ó·È 9-12% (22). Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Ù· ·È‰È¿ ÂÈÏËÙÈÎÒÓ ÌËÙ¤ÚˆÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ¯·ÌËÏfi ‰È·ÓÔËÙÈÎfi ËÏ›ÎÔ. ¢ÂÓ Â›Ó·È fï˜ ÍÂηı·ÚÈṲ̂ÓÔ Î·Ù¿ fiÛÔÓ ·˘Ùfi ÔÊ›ÏÂÙ·È ‹ fi¯È ÛÙËÓ Â›‰Ú·ÛË ÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ (23). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‹ ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÔÚÔ‡Ó Ó· ‰È·‰Ú·Ì·Ù›ÛÔ˘Ó ÈÛ¯˘ÚfiÙ·ÙÔ ÚfiÏÔ (23,24). ŒÓ· ·Ú·ÙÂٷ̤ÓÔ ·ÛÊ˘ÎÙÈÎfi ÂÂÈÛfi‰ÈÔ ÛÙ· Ï·›ÛÈ· ÂÈÏËÙÈ΋˜ ÎÚ›Û˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ÌÔÚ› Ó· ¤¯ÂÈ Î·Ù·ÛÙÚÔÊÈΤ˜ Û˘Ó¤ÂȘ ÁÈ· ÙÔÓ ÂÁΤʷÏÔ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ÌÔÚʈÙÈÎfi, ÙÔ ÎÔÈÓˆÓÈÎfi Î·È ÙÔ ÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÙˆÓ ·ÙfiÌˆÓ Ì ÂÈÏË„›· ÌÔÚ› Ó· Â›Ó·È ¯·ÌËÏfiÙÂÚÔ ·fi ·˘Ùfi ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∞˘Ù‹ Ë ‰È·ÊÔÚÔÔ›ËÛË ÌÔÚ› Ó· ·Ô‰Ôı› ·ÊÂÓfi˜ ÌÂÓ ÛÙËÓ ›‰È· ÙË ÓfiÛÔ Î·È ÛÙËÓ ÂӉ¯fiÌÂÓË ‡·ÚÍË Î¿ÔÈÔ˘ ‚·ıÌÔ‡ ÔÚÁ·ÓÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, ·ÊÂÙ¤ÚÔ˘ ‰Â ÛÙ· fiÚÈ· Ô˘ ı¤ÙÂÈ Ë ›‰È· Ë ÓfiÛÔ˜, Ë ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÎÔÈÓˆÓ›· ÁÂÓÈÎfiÙÂÚ· ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ¿ÙÔÌÔ. ¢ÂÓ Â›Ó·È Ï›Á˜ ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÂÈÏËÙÈο ¿ÙÔÌ· ·Ó·Áο˙ÔÓÙ·È ·fi ÙÔ ÎÔÈÓˆÓÈÎfi Û‡ÓÔÏÔ Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘˜. ¢˘ÛÎÔχÔÓÙ·È Ó· ÂÚÁ·ÛÙÔ‡Ó, Ó· Û˘Ó·Ó·ÛÙÚ·ÊÔ‡Ó ÙÔ˘˜ Û˘ÓÔÌËÏ›ÎÔ˘˜ ÙÔ˘˜, Ó· ·ÔÎÙ‹ÛÔ˘Ó ‰È΋ ÙÔ˘˜ ÔÈÎÔÁ¤ÓÂÈ· Î·È Ó· ˙‹ÛÔ˘Ó ÙËÓ Î·ıËÌÂÚÈÓfiÙËÙ· (26).
Paediatriki 2003;66:255-263
º·ÚÌ·ÎÔÎÈÓËÙÈ΋ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ ÛÙËÓ Î‡ËÛË ∏ ÌÂȈ̤ÓË Û˘ÁΤÓÙÚˆÛË ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ ÛÙÔ Ï¿ÛÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ·ÓÙ·Ó·ÎÏ¿ ÙË ÌÂȈ̤ÓË ·ÔÚÚfiÊËÛË, ÙËÓ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Ô˘ ÊÙ¿ÓÂÈ Ì¤¯ÚÈ ÙÔ 50%, ÙË ÌÂȈ̤ÓË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ÏÂ˘ÎˆÌ·ÙÈÓÒÓ Î·È ÙËÓ ·˘ÍË̤ÓË ·¤ÎÎÚÈÛË. ¢È·ÊÔÚÔÔÈÂ›Ù·È ÙfiÛÔ ÙÔ ‰ÂÛÌÂ˘Ì¤ÓÔ Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË, fiÛÔ Î·È ÙÔ ÂχıÂÚÔ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ·ÓÙÈÂÈÏËÙÈÎfi (5,27). O ÙfiÓÔ˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È Ë ÎÈÓËÙÈÎfiÙËÙ¿ ÙÔ˘ Â›Ó·È ÌÂȈ̤ӷ ηٿ ÙËÓ Î‡ËÛË, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË Î¤ÓˆÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘. ∏ Ó·˘Ù›· Î·È ÔÈ ¤ÌÂÙÔÈ Ô˘ Û˘Ì‚·›ÓÔ˘Ó È‰È·›ÙÂÚ· ÛÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ, ‰˘ÛÎÔÏÂ‡Ô˘Ó ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÙËÓ ÚfiÛÏË„Ë, ·ÏÏ¿ Î·È ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. O fiÁÎÔ˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·˘Í¿ÓÂÙ·È Î·Ù¿ 50%, ÂÓÒ ÙÔ ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ ηٿ 30%, ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÓÂÈÛʤÚÔ˘Ó ÛÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ ÛÙËÓ ¤Á΢Ô. ™Ù· ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ ·ËÛ˘, Ù· ›‰· Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÌÂÈÒÓÔÓÙ·È, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙÔ˘ ‰ÂÛÌÂ˘Ì¤ÓÔ˘ Î·È ÙËÓ ·‡ÍËÛË ÙÔ˘ ÂχıÂÚÔ˘ Î·È ‰È·ı¤ÛÈÌÔ˘ ÁÈ· ‚ÈÔÌÂÙ·Û¯ËÌ·ÙÈÛÌfi Î·È ·¤ÎÎÚÈÛË ÎÏ¿ÛÌ·ÙÔ˜ ÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡. ∏ ·ËÛË Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÂËÚ¿˙ÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Î·È ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ∏ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ΢ÎÏÔÊÔÚÔ‡Û·˜ ÚÔÁÂÛÙÂÚfiÓ˘ ¿ÁÂÈ Ù· Ë·ÙÈο ÌÈÎÚÔÛˆÌȷο ¤Ó˙˘Ì·, ÂÓÒ Ù· ÔÈÛÙÚÔÁfiÓ· ‰ÚÔ˘Ó ·Ó·ÛÙ·ÏÙÈο (5,27,28). °ÂÓÈο, Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ì›· ÙÒÛË ÙÔ˘ ÂȤ‰Ô˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi ÌÔÚ› Ó· ·ӷ‰Ú·ÛÙËÚÈÔÔÈ‹ÛÂÈ ÙËÓ ÂÈÏËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ó· ÚÔηϤÛÂÈ Û·ÛÌÔ‡˜. ∂ÓÙÔ‡ÙÔȘ, Ë ÙÒÛË ÙÔ˘ ÔÏÈÎÔ‡ ÂȤ‰Ô˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi ‰ÂÓ ÛËÌ·›ÓÂÈ ··Ú·›ÙËÙ· Î·È ÙÒÛË ÙÔ˘ ÂχıÂÚÔ˘ ÙÌ‹Ì·ÙÔ˜, Ô˘ Ô˘ÛÈ·ÛÙÈο Â›Ó·È Î·È ÙÔ ‰Ú·ÛÙÈÎfi (27,28). ∏ ηڂ·Ì·˙›ÓË ·ÔÚÚÔÊ¿Ù·È ·ÚÁ¿, ‰ÂÛ̇ÂÙ·È Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÛÙÔ 70-80% Î·È ÌÂÙ·‚ÔÏ›˙ÂÙ·È ÛÙÔ ‹·Ú (27,29). ∏ Ê·ÈÓ˘ÙÔ˝ÓË ‰ÂÛ̇ÂÙ·È Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÛÙÔ 90-93% Î·È ÌÂÙ·‚ÔÏ›˙ÂÙ·È, ›Û˘, ·fi ÙÔ ‹·Ú (27,30). ∆Ô ‚·ÏÚÔ˚Îfi ·ÔÚÚÔÊ¿Ù·È ÁÚ‹ÁÔÚ· Î·È ‰ÂÛ̇ÂÙ·È Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÛÙÔ 88-92% (27). ∏ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ‰ÂÓ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÚÒÙË ÁÚ·ÌÌ‹, ·ÊÔ‡ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ηٷÛÙÔÏ‹ Î·È Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜. Œ¯ÂÈ Î·Ï‹ ·ÔÚÚfiÊËÛË ·fi ÙÔ ÛÙfiÌ· Î·È ‰ÂÛ̇ÂÙ·È Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÛÙÔ 50%. ªÂÙ·‚ÔÏ›˙ÂÙ·È, ›Û˘, ·fi ÙÔ ‹·Ú. ∂¿ÁÂÈ Ù· ÌÈÎÚÔÛˆÌȷο Ë·ÙÈο ¤Ó˙˘Ì· Ì ÙÔÓ ›‰ÈÔ Ì˯·ÓÈÛÌfi fiˆ˜ Ë Ê·ÈÓ˘ÙÔ˝ÓË Î·È Ë Î·Ú‚·Ì·˙›ÓË, ÂËÚ¿˙ÔÓÙ·˜ ÙÔ ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ¿ÏÏˆÓ Ê·Ú̿ΈÓ. ¡ÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi ÌËÙ¤Ú˜ Ô˘ ¤·ÈÚÓ·Ó Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó Û‡Ó‰ÚÔÌÔ ÛÙ¤ÚËÛ˘. ¢Â‰Ô̤ÓÔ˘ ÙÔ˘
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Ì·ÎÚÔ‡ ¯ÚfiÓÔ˘ ËÌÈ˙ˆ‹˜ (̤¯ÚÈ Î·È 100 ÒÚ˜), Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙËÓ 7Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2-6 ‚‰ÔÌ¿‰Â˜ Â›Ó·È ··Ú·›ÙËÙË (5). ∆· Ó¤· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, fiˆ˜ Ë Ô͢ηڂ·Ì·˙›ÓË, Ë ÙÔÈÚ·Ì¿ÙË Î·È Ë ÊÂÏÌ·Ì¿ÙË ‰ÂÛ̇ÔÓÙ·È ·fi ÙË ÏÂ˘ÎˆÌ·Ù›ÓË Û ÌÈÎÚfiÙÂÚ˜ ÔÛfiÙËÙ˜, ÂÓÒ Ë ‚Èη̷ÙÚ›ÓË Î·È Ë Áη̷ÂÓÙ›ÓË ‰ÂÓ ‰ÂÛ̇ÔÓÙ·È Î·ıfiÏÔ˘. ∞ÂÎÎÚ›ÓÔÓÙ·È ·fi Ù· ÓÂÊÚ¿ Î·È ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ·Ú·ÁˆÁ‹ ÂӉȿÌÂÛˆÓ ÙÔÍÈÎÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ¶ÚÔÙ›ÓÔÓÙ·È Û·Ó ÌÔÓÔıÂڷ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ÈηÓÔÔÈËÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ Ô˘ Ó· ÂÁÁ˘¿Ù·È ÙËÓ ·ÛÊ·Ï‹ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ (5). ∆ÂÚ·ÙÔÁfiÓÔ˜ ‰Ú¿ÛË ·ÓÙÈÂÈÏËÙÈÎÒÓ ∏ ÂÈÏË„›· Ù˘ ÂÁ·Ԣ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ì ·˘ÍË̤ÓË Â›ÙˆÛË Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (10,31). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ 3% ÂÚ›Ô˘ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ™ÙȘ ÂÁ·Ԣ˜ Ì ÂÈÏË„›·, ·ÎfiÌ· Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ‰ÂÓ ‚Ú›ÛÎÔÓÙ·È Û ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹, Ô Î›Ó‰˘ÓÔ˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÔ‡ ÌÂ Û˘ÁÁÂÓ‹ ·ÓˆÌ·Ï›· Ê·›ÓÂÙ·È Ó· Â›Ó·È ·˘ÍË̤ÓÔ˜ (10). ∏ ÙÂÚ·ÙÔÁ¤ÓÂÛË ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È, ÙËÓ ËÏÈΛ· Ù˘ ·ËÛ˘, ÙË Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ Û΢¿ÛÌ·ÙÔ˜, ÂÓÒ ÌÂÚÈÎÔ› ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Û˘Ì‚·›ÓÂÈ Û ÁÂÓÂÙÈο ÚԉȷÙÂıÂÈ̤ӷ ¿ÙÔÌ· (10,32). ∏ ‚Ï·ÙÈ΋ ›‰Ú·ÛË Û˘Ì‚·›ÓÂÈ ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÛÙ· ·Ú¯Èο ÛÙ¿‰È·, fiÙ·Ó Ë Î‡ËÛË ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ·ÎfiÌ· ·ÓÙÈÏËÙ‹ ·fi ÙË Ì¤ÏÏÔ˘Û· ÌËÙ¤Ú· Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘. ∂›Ó·È, ÏÔÈfiÓ, ÚÔÊ·Ó¤˜ fiÙÈ Î¿ı ·Ú¤Ì‚·ÛË Ì ÙÚÔÔÔ›ËÛË ‹ ·ÎfiÌ· Î·È ‰È·ÎÔ‹ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜, Ë ÔÔ›· ı· Ú·ÁÌ·ÙÔÔÈËı› ¤ÛÙˆ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ÁÓˆÛÙÔÔ›ËÛË Ù˘ ·ËÛ˘, ‰ÂÓ ·Ú¤¯ÂÈ È‰È·›ÙÂÚË ÚÔÛÙ·Û›· ÁÈ· ÙÔ ¤Ì‚Ú˘Ô (10). ∏ ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙÔ ·ÓÙÈÂÈÏËÙÈÎfi Ê·Ú̷΢ÙÈÎfi Û··ÛÌ· ÙȘ ÚÒÙ˜ 7 ‚‰ÔÌ¿‰Â˜ Ù˘ ·ËÛ˘ ÚÔηÏ› Ì›˙ÔÓ˜ ÌÔÚÊÔÏÔÁÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÂÓÒ Û ÈÔ ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ ·ËÛ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÏ¿ÛÛÔÓ˜ ·ÓˆÌ·Ï›Â˜ (7). OÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙË ¯Ú‹ÛË ÔÏÏÒÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·Ú̿ΈÓ. ªÂ›˙ÔÓ˜ ·ÓˆÌ·Ï›Â˜ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ·fi ÙÔ Ó¢ÚÈÎfi (·ÓÂÁÎÂÊ·Ï›·, ÂÁÎÂÊ·ÏÔ΋ÏË, ÌËÓÈÁÁÔÌ˘ÂÏÔ΋ÏË, ‰Èۯȉ‹˜ Ú¿¯Ë) Î·È ÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ·, ηıÒ˜ Î·È ¯ÂÈÏÂÔÛ¯ÈÛٛ˜, ˘ÂÚˆ˚ÔÛ¯ÈÛٛ˜ Î·È Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. ∂ÎÙfi˜ fï˜ ·fi ÙȘ Ì›˙ÔÓ˜, ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ÂÏ¿ÛÛÔÓ˜ ·ÓˆÌ·Ï›Â˜ ÛÙ· ÓÂÔÁÓ¿ ·˘ÙÒÓ ÙˆÓ ÌËÙ¤ÚˆÓ, ΢ڛˆ˜
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·fi Ù· Ì¿ÙÈ· (˘ÂÚÙÂψÚÈÛÌfi˜), ÙÔ ÛÙfiÌ· (ÌÈÎÚÔÛÙÔÌ›·), Ù· ·˘ÙÈ¿ (¯·ÌËÏ‹ ÚfiÛÊ˘ÛË), ÙË Ì‡ÙË (ÌÈÎÚ‹ ̇ÙË, ηı›˙ËÛË Ù˘ ‚¿Û˘) Î·È Ù· ‰¿ÎÙ˘Ï· (˘ÔÏ·Û›· ÙˆÓ ¿ˆ Ê·Ï¿ÁÁˆÓ) (7,10,33). ∂ÏÏ›ÌÌ·Ù· Ó¢ÚÈÎÔ‡ ۈϋӷ Û˘Ì‚·›ÓÔ˘Ó fiÙ·Ó Ô ‚Ï·ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‰Ú¿ÛÂÈ ÌÂٷ͇ Ù˘ 21˘ Î·È 28˘ Ë̤ڷ˜ ·fi ÙËÓ ÚÒÙË Ë̤ڷ Ù˘ ÙÂÏÂ˘Ù·›·˜ ¤ÌÌËÓ˘ Ú‡Û˘, ¯ÂÈÏÂÔÛ¯ÈÛÙ›· fiÙ·Ó ‰Ú¿ÛÂÈ ÚÈÓ ÙËÓ 35Ë, ˘ÂÚˆ˚ÔÛ¯ÈÛÙ›· ÚÈÓ ÙËÓ 70‹, ÂÓÒ Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ· ÚÈÓ ÙËÓ 42Ë Ë̤ڷ (5). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ Ì˯·ÓÈÛÌfi ÚfiÎÏËÛ˘ ‚Ï¿‚˘, ‰ÂÓ Â›Ó·È Â·ÚÎÒ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. º·›ÓÂÙ·È, fï˜, Ó· ÚÔηÏÂ›Ù·È Ì¤Ûˆ ÂӉȿÌÂÛˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ Î·È fi¯È Ì ¿ÌÂÛË ‰Ú¿ÛË ÙÔ˘ Ê·Ú̷΢ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ ·Ú·ÁˆÁ‹ ÙÔÍÈÎÒÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘, fiˆ˜ ›Û˘ Î·È Ë ˘ÔÍ›· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË Ì›ˆÛË Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›. ∆Ô ¤Ó˙˘ÌÔ ˘‰ÚÔÏ¿ÛË ÙÔ˘ ÂÔÍÂȉ›Ô˘ ¤¯ÂÈ Û·Ó ÚfiÏÔ ÙÔ˘ ÙËÓ ÂÍÔ˘‰ÂÙ¤ÚˆÛË ÙˆÓ ÙÔÍÈÎÒÓ ÂӉȿÌÂÛˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡. ∏ ‰Ú·ÛÙËÚÈfiÙËÙ¿ ÙÔ˘ ÌÔÚ› Ó· ÌÂÙÚËı› ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡. º·›ÓÂÙ·È Ó· ÂϤÁ¯ÂÙ·È ·fi ‰‡Ô ·ÏÏËÏfiÌÔÚÊ· ÁÔÓ›‰È· Î·È ÂÎÊÚ¿˙ÂÙ·È Û ÙÚÂȘ Ê·ÈÓfiÙ˘Ô˘˜ Ì ¯·ÌËÏ‹, ̤ÙÚÈ· Î·È ˘„ËÏ‹ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ÕÙÔÌ· Ì ¯·ÌËÏ‹ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È ÔÌÔ˙˘ÁÒÙ˜ ÙÔ˘ ˘ÔÏÂÈfiÌÂÓÔ˘ ·ÏÏËÏ›Ô˘. ŒÌ‚Ú˘· Ì ¯·ÌËÏ‹ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ¤¯Ô˘Ó ÌÂȈ̤ÓË ÈηÓfiÙËÙ· οı·ÚÛ˘ ÙˆÓ ÙÔÍÈÎÒÓ ·˘ÙÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ Î·È ‚Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ (7,10,34). ∏ ·Ó¿ÚÎÂÈ· ÙÔ˘ Ê˘ÏÈÎÔ‡ ÔͤԘ ‰Ú· Û˘ÓÂÚÁÈο ÛÙËÓ ÙÂÚ·ÙÔÁ¤ÓÂÛË. ∆Ô Ê˘ÏÈÎfi Ô͇ Î·È Ë ‚ÈÙ·Ì›ÓË µ12 Â›Ó·È Û˘Ó¤Ó˙˘Ì· Ù˘ Û˘ÓıÂÙ¿Û˘ Ù˘ ÌÂıÂÈÔÓ›Ó˘, ¤Ó˙˘ÌÔ ÎÚÈÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙË ‚ÈÔÛ‡ÓıÂÛË ÙÔ˘ DNA. ÷ÌËÏ¿ ›‰· Ê˘ÏÈÎÔ‡ ÔͤԘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ (7,35). ∞ÓÙÈÂÈÏËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÙÔ ‚·ÏÚÔ˚Îfi Î·È Ë Ê·ÈÓ˘ÙÔ˝ÓË ¤¯ÂÈ ‚ÚÂı› fiÙÈ ‰È·Ù·Ú¿ÛÛÔ˘Ó ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ Ê˘ÏÈÎÔ‡ ÔͤԘ ÛÙÔ ¤Ì‚Ú˘Ô. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ê˘ÏÈÎÔ‡ ÔͤԘ ÌÂÈÒÓÔÓÙ·È Î·È Ë ıÂڷ›· Ì ·ÓÙÈÂÈÏËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÙÔ ‚·ÏÚÔ˚Îfi ‰Ú· ÂÓÈÛ¯˘ÙÈο Û ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ ÙË ‰È·Ù·Ú·¯‹ (7,36). À‰·ÓÙÔ˝Ó˜ ∏ ¯Ú‹ÛË ÙÔ˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓË Â›ÙˆÛË ¯ÂÈÏÂÔÛ¯ÈÛÙ›·˜ Î·È ˘ÂÚˆ˚ÔÛ¯ÈÛÙ›·˜, ·ÓˆÌ·Ï›Â˜ Ó˘¯ÈÒÓ, ˘ÔÏ·Û›· Ê·Ï¿ÁÁˆÓ Î·È ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ‰˘ÛϷۛ˜. ∏ ¯Ú‹ÛË ÙÔ˘˜ Û Á˘Ó·›Î˜ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ ı· Ú¤ÂÈ Ó· ·Ôı·ÚÚ‡ÓÂÙ·È, ÂÓÒ ·ÓÙÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ (10,37). ∏ ¯Ú‹ÛË Ù˘
¶·È‰È·ÙÚÈ΋ 2003;66:255-263
Ê·ÈÓ˘ÙÔ˝Ó˘ Û·Ó ÌÔÓÔıÂڷ›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÚfiÎÏËÛË ‰È·Ù·Ú·¯ÒÓ ÛÙÔ ¤Ì‚Ú˘Ô, ÔÈ Ôԛ˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û·Ó “Û‡Ó‰ÚÔÌÔ ˘‰·ÓÙÔ˝Ó˘”. ∆Ô Û‡Ó‰ÚÔÌÔ ·˘Ùfi ÂÚÈÏ·Ì‚¿ÓÂÈ Î·ı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ ÙfiÛÔ ÛÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ·, fiÛÔ Î·È ÛÙËÓ Â͈̋ÙÚÈ· ˙ˆ‹, ÌÈÎÚÔÎÂÊ·Ï›·, ‰È·ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ‰˘ÛϷۛ˜ ÌÂ Û˘¯ÓfiÙÂÚÔ ÙÔÓ ˘ÂÚÙÂψÚÈÛÌfi Î·È ˘ÔϷۛ˜ Ê·Ï¿ÁÁˆÓ Î·È Ó˘¯ÈÒÓ (10,38). µ·Ú‚ÈÙÔ˘ÚÈο (Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, ÚÈÌȉfiÓË) ∏ ¯Ú‹ÛË ÙÔ˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ÌÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, ‰˘ÛÌÔÚʛ˜ Î·È ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ‰˘ÛϷۛ˜ (10). µ·ÏÚÔ˚Îfi ∏ ¯Ú‹ÛË ÙÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‰˘ÛÌÔÚʛ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ‰È·ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. O ΛӉ˘ÓÔ˜ ‡·Ú͢ ÂÏÏÂÈÌÌ¿ÙˆÓ ÙÔ˘ Ó¢ÚÈÎÔ‡ ۈϋӷ ÂÌÊ·Ó›˙ÂÙ·È Ó· Â›Ó·È 1-2% Û ۯ¤ÛË Ì 0,2-0,5% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∂›Û˘, ¤¯ÂÈ ·Ó·ÊÂÚı› ·˘ÍË̤ÓË Â›ÙˆÛË Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ Î·È ·ÓˆÌ·ÏÈÒÓ ·fi ÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi. ∏ ¯Ú‹ÛË ÙÔ˘ ‚·ÏÚÔ˚ÎÔ‡ ·fi Á˘Ó·›Î˜ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ ı· Ú¤ÂÈ Ó· ·Ôı·ÚÚ‡ÓÂÙ·È, ÂÓÒ Ë ¯Ú‹ÛË ÙÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ·ÓÙÂӉ›ÎÓ˘Ù·È. ∂›Ó·È ›Ûˆ˜ ÙÔ ÌfiÓÔ ·ÓÙÈÂÈÏËÙÈÎfi ÁÈ· ÙÔ ÔÔ›Ô ¤¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ Ë ÙÂÚ·ÙÔÁfiÓÔ˜ ‰Ú¿ÛË Î·È ÔÈ ÁÂÓÈÎfiÙÂÚ˜ ÂÈÙÒÛÂȘ Ô˘ ¤¯ÂÈ ÛÙÔ Î‡ËÌ· Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓ˜ (10,12,33). ∫·Ú‚·Ì·˙›ÓË £ÂˆÚÂ›Ù·È ÙÔ ·ÓÙÈÂÈÏËÙÈÎfi Ê¿ÚÌ·ÎÔ Ì ÙË ÌÈÎÚfiÙÂÚÔ˘ ‚·ıÌÔ‡ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË. ∂ÓÙÔ‡ÙÔȘ, ÚfiÛÊ·Ù· ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜ ¤¯Ô˘Ó Û˘Û¯ÂÙ›ÛÂÈ ÙËÓ Î·Ú‚·Ì·˙›ÓË ÌÂ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi Ì ٷ ‚·Ú‚ÈÙÔ˘ÚÈο Î·È ÙË Ê·ÈÓ˘ÙÔ˝ÓË. OÈ ·Ó·ÊÔÚ¤˜, fï˜, Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÌÈÎÚfi˜. Œ¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ‡·Ú͢ ÂÏÏ›ÌÌ·ÙÔ˜ ÛÙÔ Ó¢ÚÈÎfi ۈϋӷ ÛÙÔ 0,9%, Ì Ì›ˆÛË Ù˘ ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜, ÙÔ˘ ‚¿ÚÔ˜ Î·È ÙÔ˘ Ì‹ÎÔ˘˜ ÛÒÌ·ÙÔ˜ ÛÙË Á¤ÓÓËÛË, Ì ‰˘ÛÌÔÚʛ˜, ˘ÔÛ·‰›·, ‚Ô˘‚ˆÓÔ΋ÏË Î·È ‰È·ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ÛÙÔ 20% ÙˆÓ ·È‰ÈÒÓ (10,12, 39). §·ÌÔÙÚÈÁ›ÓË, ‚Èη̷ÙÚ›ÓË, Áη̷ÂÓÙ›ÓË ™‡Ìʈӷ Ì ÌÂϤÙ˜ Û ˙Ò·, ‰ÂÓ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË. ∂ÓÙÔ‡ÙÔȘ, Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ¤¯ÂÈ Â·ÎÚÈ‚Ò˜ ‰ÈÂÚ¢ÓËı›, Ì ‚¿ÛË Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÂÚÈÛÛfiÙÂÚ· ÙÔ˘ ÂÓfi˜ Û΢¿ÛÌ·Ù·. ™‡Ìʈӷ Ì ÙËÓ ˘ËÚÂÛ›· ÙÚÔÊ›ÌˆÓ Î·È Ê·ÚÌ¿ÎˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜, ÔÈ Ô˘Û›Â˜ ·˘Ù¤˜ ‰ÂÓ ıˆÚÔ‡ÓÙ·È ·ıÒ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ηÈ
Paediatriki 2003;66:255-263
Ë ¯Ú‹ÛË ÙÔ˘˜ ÚÔÙ›ÓÂÙ·È ÌfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ÙÔ fiÊÂÏÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔÓ Î›Ó‰˘ÓÔ Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË ¯Ú‹ÛË ÙÔ˘˜ (7,10). ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ̤ÏÏÔ˘Û·˜ ÌËÙ¤Ú·˜ Ì ÂÈÏË„›· ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‰ÂÓ ·ÔÙÂÏ› ·ÈÙÈÔÏÔÁÈ΋, ·ÏÏ¿ ÌfiÓÔ Û˘Ìو̷ÙÈ΋ ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ™Ùfi¯Ô˜ Ù˘ Â›Ó·È Ë ÂÍ·ÛÊ¿ÏÈÛË ÛÙËÓ ·ÛıÂÓ‹ Ì›·˜ ˙ˆ‹˜ ¯ˆÚ›˜ ÂÂÈÛfi‰È· Û·ÛÌÒÓ ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì ÙËÓ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜. ™Â Ì›· ·ÛıÂÓ‹ Ô˘ Â›Ó·È ÂχıÂÚË ÂÂÈÛÔ‰›ˆÓ Ù· ÙÂÏÂ˘Ù·›· 2-5 ¯ÚfiÓÈ·, ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· Î·È Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË, Ë ‰È·ÎÔ‹ Ù˘ ·ÁˆÁ‹˜ ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È ÛÔ‚·Ú¿ (7,14). ∂¿Ó Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ ÎÚÈı› ··Ú·›ÙËÙË, Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ Û΢¿ÛÌ·ÙÔ˜ ·Ó¿ÏÔÁ· Ì ÙÔÓ Ù‡Ô ÂÈÏË„›·˜, Ì ÙȘ ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÏÈÁfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ÙfiÛÔ ÁÈ· ÙË Á˘Ó·›Î· fiÛÔ Î·È ÁÈ· ÙÔ ¤Ì‚Ú˘Ô, ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ÛÙȘ ¯·ÌËÏfiÙÂÚ˜ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ‰fiÛÂȘ. ∏ ¯Ú‹ÛË ÂÓfi˜ ÌfiÓÔ Û΢¿ÛÌ·ÙÔ˜, Â¿Ó Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, Â›Ó·È Û·ÊÒ˜ ·ÛʷϤÛÙÂÚË Î·È ÚÔÙÈÌfiÙÂÚË ·fi ÙË ¯Ú‹ÛË Ê·ÚÌ¿ÎˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi (7,31). ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÙÚ›ÌËÓÔ ÚÈÓ ÙË Û‡ÏÏË„Ë, ÂÓÒ Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË Ê˘ÏÈÎÔ‡ ıˆÚÂ›Ù·È Ì›˙ÔÓÔ˜ ÛËÌ·Û›·˜. ∏ Á˘Ó·›Î· ÂÓı·ÚÚ‡ÓÂÙ·È Ó· ‰È·Îfi„ÂÈ ÙÔ Î¿ÓÈÛÌ·, Ó· ¤¯ÂÈ ÈÛÔÚÚÔË̤ÓÔ ‰È·ÈÙÔÏfiÁÈÔ Î·È Ó· ÎÔÈÌ¿Ù·È ·ÚÎÂÙ¿. ∂¿Ó Ë ıÂڷ›· ‰ÂÓ ÌÔÚ› Ó· ‰È·ÎÔ›, ÚÔÙÈÌ¿Ù·È Ë ÌÔÓÔıÂڷ›· Ì ÙÔÓ ·Ú¿ÁÔÓÙ· Ô˘ ÂÌÊ·Ó›˙ÂÈ ÙËÓ ·ıˆfiÙÂÚË Û˘ÌÂÚÈÊÔÚ¿ ÛÙÔ ¤Ì‚Ú˘Ô. ÃÔÚËÁÂ›Ù·È ÛÙȘ ÌÈÎÚfiÙÂÚ˜ ·ÚΛ˜ ÁÈ· ¤ÏÂÁ¯Ô ‰fiÛÂȘ, ÙÌËÌ·ÙÈο ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· Ù˘ Ë̤ڷ˜, Ì ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÔÚÔ‡ ÛÙ· ¯·ÌËÏfiÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈο ÁÈ· ¤ÏÂÁ¯Ô ÙˆÓ ÎÚ›ÛÂˆÓ fiÚÈ·. ∂¿Ó Â›Ó·È ‰˘Ó·Ùfi, Ë ¯ÔÚ‹ÁËÛË ‚·ÏÚÔ˚ÎÔ‡ Î·È Î·Ú‚·Ì·˙›Ó˘ ÛÙȘ ¤ÁÎ˘Â˜ Ì ÈÛÙÔÚÈÎfi ÂÏÏÂÈÌÌ¿ÙˆÓ ÙÔ˘ Ó¢ÚÈÎÔ‡ ۈϋӷ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È. ∂¿Ó ¯ÔÚËÁÂ›Ù·È Ê·ÈÓ˘ÙÔ˝ÓË Î·È ‚·ÏÚÔ˚Îfi, Û˘ÓÈÛÙ¿Ù·È fiÔ˘ Â›Ó·È ‰˘Ó·Ù‹ Ë Ì¤ÙÚËÛË ÙÔ˘ ÂχıÂÚÔ˘ - Î·È fi¯È ÌfiÓÔ ÙÔ˘ ÔÏÈÎÔ‡ - Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi (5,7,10). ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¡Â˘ÚÔÏÔÁ›·˜ ÚÔÙ›ÓÂÈ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÚÈÓ ÙË Û‡ÏÏË„Ë, ÛÙËÓ ·Ú¯‹ οı ÙÚÈÌ‹ÓÔ˘ ·ËÛ˘, ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ Ì‹Ó· Ù˘ ·ËÛ˘, ηıÒ˜ Î·È ÙËÓ fiÁ‰ÔË Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi (16). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë Ó·˘Ù›· Î·È ÔÈ ¤ÌÂÙÔÈ Ù·Ï·ÈˆÚÔ‡Ó ÙÔ 50-90% ÙˆÓ ÂÁ·ˆÓ. ™ÙÔ 1,3% ÂÚ›Ô˘, Ë ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Â›Ó·È È‰È·›ÙÂÚ· ¤ÓÙÔÓË, Ì ˘ÂÚ¤ÌÂÛË, ÎÂÙÔÓÔ˘Ú›· Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜. ∏ ‰È·Ù·Ú·¯‹ ÛÙË
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¶·È‰È·ÙÚÈ΋ 2003;66:255-263
Ï‹„Ë Î·È ÙËÓ ·ÔÚÚfiÊËÛË ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ¤ÓÙ·ÛË Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ Î·È Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ÂÈʤÚÂÈ ·ÒÏÂÈ· ÙÔ˘ ÂϤÁ¯Ô˘ ÙˆÓ ÂÈÏËÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, Ì fiϘ ÙȘ ‰˘Û¿ÚÂÛÙ˜ Û˘Ó¤ÂȘ ÁÈ· ÙËÓ ¤ÁÎ˘Ô Î·È ÙÔ ¤Ì‚Ú˘Ô. Œ¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ‰È¿ÊÔÚÔÈ Ê·Ú̷΢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÌÂÙÔÎÏÔÚ·Ì›‰Ë, Ú·ÓÈÙȉ›ÓË, ‰ÈÊ·ÈÓ˘‰Ú·Ì›ÓË, ÚÔÌÂı·˙›ÓË Î·È ¿ÏÏÔÈ, Ì ¿ÏÏÔÙ ¿ÏÏ· ·ÔÙÂϤÛÌ·Ù·. ¶·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÙÒÛÂˆÓ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙ· ˆ˜ ¿Óˆ (7,40). ∏ ¤ÏÏÂÈ„Ë ÙÔ˘ Ê˘ÏÈÎÔ‡ ÔͤԘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ. ∏ Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ Û ÌË ÂÈÏËÙÈΤ˜ Á˘Ó·›Î˜ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Á¤ÓÓËÛ˘ ÓÂÔÁÓÔ‡ Ì ¤ÏÏÂÈÌÌ· ÛÙÔ Ó¢ÚÈÎfi ۈϋӷ ηٿ 60-100% (7,41). ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ Á˘Ó·›Î˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÎfiÌ· ·Ú΋˜ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ÙÂÎÌËÚ›ˆÛË (7). ∆Ô ∫¤ÓÙÚÔ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜ ÚÔÙ›ÓÂÈ ÙË Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË 0,4 mg/Ë̤ڷ Ê˘ÏÈÎÔ‡ ÔͤԘ Û οı Á˘Ó·›Î· ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜, Ì ÛÙfi¯Ô ÙË Ì›ˆÛË ÙÔ˘ ΛӉ˘ÓÔ˘ Á¤ÓÓËÛ˘ ÓÂÔÁÓÔ‡ Ì ÂÏÏ›ÌÌ·Ù· ÛÙÔ Ó¢ÚÈÎfi ۈϋӷ. ∞˘Ù‹ Ë ‰fiÛË Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÁÈ· ÚˆÙÔÁÂÓ‹ ÚfiÏË„Ë (42). ∆Ô 1996, ÙÔ ∞ÌÂÚÈηÓÈÎfi ∫ÔϤÁÈÔ ª·ÈÂ˘Ù‹ÚˆÓ °˘Ó·ÈÎÔÏfiÁˆÓ ÚfiÙÂÈÓ ÙË ¯ÔÚ‹ÁËÛË 4 mg ËÌÂÚËÛ›ˆ˜ Ê˘ÏÈÎÔ‡ ÔͤԘ ÙÚÂȘ Ì‹Ó˜ ÚÈÓ ·fi ÙË Û‡ÏÏË„Ë Î·È Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ÙÚÈÌ‹ÓÔ˘, Û οı Á˘Ó·›Î· Ô˘ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â Ì›· ·ËÛË ÂÌ‚Ú‡Ô˘ Ì ¤ÏÏÂÈÌÌ· ÛÙÔ Ó¢ÚÈÎfi ۈϋӷ Î·È ÂÈı˘Ì› Ó· Ì›ÓÂÈ ¤ÁÎ˘Ô˜, ÂÎÊÚ¿˙ÔÓÙ·˜ ÙËÓ ¿Ô„Ë fiÙÈ Ë ›‰È· ÚÔÏËÙÈ΋ ‰fiÛË Ê·›ÓÂÙ·È Ó· Â›Ó·È Ë ÂӉ‰ÂÈÁ̤ÓË Î·È ÁÈ· ÙȘ Á˘Ó·›Î˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ıÂڷ›· Ì ·ÓÙÈÂÈÏËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (19). ∞Ó¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ ∫ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ ˘fi ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ™˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ÙÔ ÚÒÙÔ 24ˆÚÔ Ù˘ ˙ˆ‹˜, ÌÔÚ› Ó· Â›Ó·È ÛÔ‚·Ú‹, ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙÔ ‰¤ÚÌ·, ÙÔÓ ÂÁΤʷÏÔ, ÙÔÓ ˘Â˙ˆÎfiÙ· Î·È ÙÔ ÂÚÈÙfiÓ·ÈÔ. ∏ ·‰Ú·ÓÔÔ›ËÛË Ù˘ ‚ÈÙ·Ì›Ó˘ ∫, ÂÍ·ÈÙ›·˜ Ù˘ ·ÁˆÁ‹˜ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ·fi Ù· ·ÓÙÈÂÈÏËÙÈο, ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ππ, VII, πÃ Î·È Ã Î·È ÙËÓ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ™˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË 1 mg ‚ÈÙ·Ì›Ó˘ ∫ ÛÙÔ ÓÂÔÁÓfi ÁÈ· ÚfiÏË„Ë ·ÈÌÔÚÚ·ÁÈ΋˜ ÓfiÛÔ˘, ÂÓÒ Â¿Ó ‰È·ÈÛÙˆı› ·Ó¿ÚÎÂÈ· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘, Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿ÛÌ·ÙÔ˜. ™˘ÌÏËڈ̷ÙÈ΋ ·fi ÙÔ ÛÙfiÌ· ¯ÔÚ‹ÁËÛË 20 mg ËÌÂÚË-
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Û›ˆ˜ ÛÙËÓ ¤ÁÎ˘Ô ÙÔÓ ÙÂÏÂ˘Ù·›Ô Ì‹Ó· Ù˘ ·ËÛ˘, Ê·›ÓÂÙ·È Ó· ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ·Ó¿ÚÎÂÈ· Ù˘ ‚ÈÙ·Ì›Ó˘ ∫ ÛÙÔ ÓÂÔÁÓfi, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ‰È¤Ú¯ÂÙ·È Â‡ÎÔÏ· ÙÔÓ Ï·ÎÔ‡ÓÙ· (7,10). ¶ÚÔÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ O ΛӉ˘ÓÔ˜ Á¤ÓÓËÛ˘ ·È‰ÈÔ‡ ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·ÓÙÈÏËÙfi˜ ÙfiÛÔ ·fi ÙËÓ ¤Á΢Ô, fiÛÔ Î·È ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘. ÀÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÙË 18Ë22Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ ı· ‰ÒÛÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÂӉ¯fiÌÂÓË ‡·ÚÍË Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙÔ ¤Ì‚Ú˘Ô. ∂ÈÚfiÛıÂÙ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ‡·ÚÍË ÂÏÏÂÈÌÌ¿ÙˆÓ ÙÔ˘ ÓˆÙÈ·›Ô˘ ۈϋӷ ı· ‰ÒÛÂÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ · ÂÌ‚Ú˘˚΋˜ ÚˆÙ½Ó˘ ÛÙÔÓ ÔÚfi Ù˘ ÌËÙ¤Ú·˜ ÙË 15Ë ¤ˆ˜ 22Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘. ¶ÚÔÙ›ÓÂÙ·È, ›Û˘, Ë ‰ÈÂÓ¤ÚÁÂÈ· ·ÌÓÈÔΤÓÙËÛ˘ ηٿ ÙËÓ 16Ë Â‚‰ÔÌ¿‰· ·ËÛ˘, Ì ÛÎÔfi ÙË Ì¤ÙÚËÛË Ù˘ · ÂÌ‚Ú˘˚΋˜ ÚˆÙ½Ó˘ ÛÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi, Ë ÔÔ›· ‚Ú›ÛÎÂÙ·È ·˘ÍË̤ÓË ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ¤¯Ô˘Ó ¤ÏÏÂÈÌÌ· ÙÔ˘ ÓˆÙÈ·›Ô˘ ۈϋӷ (17,19). ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘¯fiÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ·Ú¤¯ÂÈ ÛÙÔ˘˜ ÁÔÓ›˜ ÙËÓ ÂÈÏÔÁ‹ Ù˘ ‰È·ÎÔ‹˜ Ù˘ ·ËÛ˘ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰ÂÓ Âȉ¤¯ÔÓÙ·È ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË, ‰›ÓÂÈ ÂÚÈıÒÚÈ· ·Ô‰Ô¯‹˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Î·È ÂÈÙÚ¤ÂÈ ÙËÓ ÔÚÁ¿ÓˆÛË ÏËÚ¤ÛÙÂÚ˘ Î·È Î·Ù·ÏÏËÏfiÙÂÚ˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ÊÚÔÓÙ›‰·˜. ∂ÓÙÔ‡ÙÔȘ, Â›Ó·È ¯Ú‹ÛÈÌÔ Ó· ÂÓËÌÂÚÒÓÂÙ·È ÙfiÛÔ Ë ¤ÁÎ˘Ô˜, fiÛÔ Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘ ÁÈ· ÙȘ ·‰˘Ó·Ì›Â˜ ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ó›¯Ó¢ÛË fiÏˆÓ ÙˆÓ ÂӉ¯fiÌÂÓˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ, Ë ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË ÙˆÓ ÔÔ›ˆÓ ÌÔÚ› Ó· Á›ÓÂÈ ·ÓÙÈÏËÙ‹ ·ÚÁfiÙÂÚ·, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ‰È·ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË (1,17). ∆ÔÎÂÙfi˜ ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÈÏËÙÈÎÒÓ ÂÁ·ˆÓ ÔÏÔÎÏËÚÒÓÂÈ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË Ì ¤Ó·Ó ·ÛÊ·Ï‹ Î·È ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Î·È Û˘Ì‚¿Ì·Ù· ÎÔÏÈÎfi ÙÔÎÂÙfi. ŸÌˆ˜, ÔÛÔÛÙfi 1-2% ÙˆÓ ÂÈÏËÙÈÎÒÓ ÂÁ·ˆÓ ı· ‚ÈÒÛÂÈ ÙËÓ ÂÌÂÈÚ›· Ì›·˜ ÂÈÏËÙÈ΋˜ ÎÚ›Û˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡, ÂÓÒ 1-2%, ›Û˘, ı· ¤¯ÂÈ ·Ó¿ÏÔÁË ÂÌÂÈÚ›· ÙÔ 1Ô 24ˆÚÔ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi (2,10). °›ÓÂÙ·È, ÏÔÈfiÓ, ·ÓÙÈÏËÙfi fiÛÔ ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÙÂÏÈ΋ ¤Î‚·ÛË Â›Ó·È Ë Ï‹„Ë Ù˘ ·ÁˆÁ‹˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡, fiˆ˜ ›Û˘ Î·È Ë ‰È·Ù‹ÚËÛË ÙˆÓ ÂȤ‰ˆÓ Û ıÂڷ¢ÙÈο ›‰· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡, Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜ Û˘Ó¯›˙ÂÙ·È. ŸÏ· Ù· ·ÓÙÈÂÈÏËÙÈο Û΢¿ÛÌ·Ù· ÌÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó, ·Ó ÎÚÈı› ÛÎfiÈÌÔ, Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú·, ÂÓÒ Ë Ê·ÈÓ˘ÙÔ˝ÓË, ÙÔ ‚·ÏÚÔ˚Îfi Ô͇, Ë ‰È·˙¿ÌË, Ë ÎÏÔÓ·˙¿ÌË Î·È Ë
¶·È‰È·ÙÚÈ΋ 2003;66:255-263
Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÌÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó Î·È ·ÚÂÓÙÂÚÈο (2,10,19). ™ÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ›ÎÂÈÙ·È ÚfiˆÚÔ˜ ÙÔÎÂÙfi˜ Î·È ·ÔÊ·ÛÈÛÙ› Ë ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÙËÓ ¤ÁÎ˘Ô Ì ÛÙfi¯Ô ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ Ó¢ÌfiÓˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ηÏfi Â›Ó·È Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ¯ÔÚ‹ÁËÛË Ê·ÈÓ˘ÙÔ˝Ó˘, Ê·ÈÓÔ‚·Ú‚ÈÙ¿Ï˘, ηڂ·Ì·˙›Ó˘ Î·È ÚÈÌȉfiÓ˘, ¿ÁÔÓÙ·˜ Ù· Ë·ÙÈο ÌÈÎÚÔÛˆÌȷο ¤Ó˙˘Ì·, ηıÈÛÙ¿ ··Ú·›ÙËÙË ÙË ¯ÔÚ‹ÁËÛË ÌÂÁ·Ï‡ÙÂÚˆÓ ‰fiÛÂˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (10,43). ∏ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÏÔÚ·˙¿Ì˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Û·Ó ÔÍ›· ·ÓÙÈÌÂÙÒÈÛË ÂÈÏËÙÈ΋˜ ÎÚ›Û˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡. ∂¿Ó Ù· ÂÂÈÛfi‰È· Û·ÛÌÒÓ Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È ‹ Ë Â›ÙÔÎÔ˜ Â›Ó·È Û “status epilepticus”, Û˘ÓÈÛÙ¿Ù·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ›ÁÔ˘Û·˜ ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜. ∏ ÂÚÈÔ¯È΋ ÂÈÛÎÏËÚ›‰ÈÔ˜ ·Ó·ÈÛıËÛ›· ÚÔÙ›ÓÂÙ·È Ì ÛÎÔfi Ó· ÂÚÈÔÚÈÛÙ› ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÙÔ ÂÒ‰˘ÓÔ ÂÚ¤ıÈÛÌ·. ∏ ‰ÈÂÓ¤ÚÁÂÈ· ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜ Û·Ó Ù·ÎÙÈ΋ ÚÔ˘Ù›Ó·˜ Ì¿ÏÏÔÓ ‰ÂÓ ÚÔÙ›ÓÂÙ·È, ÂÓÒ ıˆÚÂ›Ù·È Â˘ÂÚÁÂÙÈ΋ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë Ú‡ıÌÈÛË Ù˘ ÂÈÏËÙÈ΋˜ ÂÁ·Ԣ ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋ Î·È ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÎÚ›ÛÂȘ ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‚‰ÔÌ¿‰· ÚÈÓ ÙÔÓ ÙÔÎÂÙfi. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÂÈÏËÙÈÎÒÓ ÛÙËÓ Â›ÙÔÎÔ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·Ù·ÛÙÔÏ‹ ÛÙÔ ¤Ì‚Ú˘Ô. ∏ ·ÚÔ˘Û›·, ÏÔÈfiÓ, ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡ È·ÙÚÔ‡ ÈηÓÔ‡ ÛÙËÓ ·Ó¿ÓË„Ë ÙÔ˘ ÓÂÔÁÓÔ‡, ıˆÚÂ›Ù·È ··Ú·›ÙËÙË. °È· ÏfiÁÔ˘˜ ·ÛÊ·Ï›·˜, Ë ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡ Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Û ÂÚÈÁÂÓÓËÙÈÎfi ΤÓÙÚÔ, ÙÔ ÔÔ›Ô Â›Ó·È ÈηÓfi Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙËÓ Â›ÙÔÎÔ, fiÛÔÓ ·ÊÔÚ¿ Û ÂӉ¯fiÌÂÓË ·Ó·ÁηÈfiÙËÙ· ›ÁÔ˘Û·˜ ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜, ηıÒ˜ Î·È ÙÔ ÓÂÔÁÓfi Ù˘ (2,10). £ËÏ·ÛÌfi˜ ∏ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ÛÙË ÌËÙ¤Ú· ‰ÂÓ ıˆÚÂ›Ù·È ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ŸÏ· ۯ‰fiÓ Ù· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η ·ÂÎÎÚ›ÓÔÓÙ·È ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∆Ô Û˘ÓÔÏÈÎfi ÔÛfi ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Ô˘ Ï·Ì‚¿ÓÂÈ ÙÔ ÓÂÔÁÓfi ‹ ÙÔ ‚Ú¤ÊÔ˜ Ì ÙÔ ıËÏ·ÛÌfi Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚÔ ·fi ·˘Ùfi Ô˘ ÌÂٷʤÚÂÙ·È Ì¤Ûˆ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ (7,10,17,44). ∂ÓÙÔ‡ÙÔȘ, ÂÂȉ‹ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È Ë ·¤ÎÎÚÈÛ‹ ÙÔ˘˜ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ Â›Ó·È ·Ó·Ú΋, Ë Â·Ó·Ï·Ì‚·ÓfiÌÂÓË ÚfiÛÏË„Ë ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÌÔÚ› ‰˘ÓËÙÈο Ó· ¤¯ÂÈ ·ıÚÔÈÛÙÈ΋ ‰Ú¿ÛË. ∆Ô Û˘ÓÔÏÈο ·ıÚÔÈ˙fiÌÂÓÔ ÔÛfi ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘¯ÓfiÙËÙ· Î·È ÙÔÓ Û˘ÓÔÏÈÎfi fiÁÎÔ ÙˆÓ ËÌÂÚ‹ÛÈˆÓ ÁÂ˘Ì¿ÙˆÓ, ÙËÓ ËÏÈΛ· ÙÔ˘ ‚Ú¤ÊÔ˘˜, ÙËÓ Î·Ù¿ÛÙ·ÛË Ù˘ ˘Á›·˜ ÙÔ˘ Î·È ·fi ÙË Ï‹„Ë ¿ÏÏˆÓ Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ Ù˘¯fiÓ ÂËÚ¿˙Ô˘Ó ÙËÓ
Paediatriki 2003;66:255-263
·ÔÚÚfiÊËÛË, ÙË ‚ÈԉȷıÂÛÈÌfiÙËÙ· ‹ ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Î·È ÙËÓ ·¤ÎÎÚÈÛ‹ ÙÔ˘ (10). OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘˜ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ÔÈΛÏÏÔ˘Ó ·fi 10% ¤ˆ˜ 100% ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘ ÛÙÔ ÌËÙÚÈÎfi Ï¿ÛÌ·. ªÂ ‰Â‰Ô̤ÓË ÙË ¯·ÌËÏfiÙÂÚË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ÙÔÓ Ì·ÎÚfiÙÂÚÔ ¯ÚfiÓÔ ËÌÈ˙ˆ‹˜ ÛÙÔ Ï¿ÛÌ· Û ۯ¤ÛË Ì ÙË ÌËÙ¤Ú· ÙÔ˘, Ë ‰Ú·ÛÙÈ΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÌÔÚ› Ó· Â›Ó·È ·˘ÍË̤ÓË (17). ŒÙÛÈ, ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ÌËÙ¤Ú· Ï·Ì‚¿ÓÂÈ ÚÈÌȉfiÓË, Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ‹ ‚ÂÓ˙ԉȷ˙›Ó˜, ÙÔ ÓÂÔÁÓfi ÌÔÚ› ‰˘ÓËÙÈο Ó· Â›Ó·È Û ηٷÛÙÔÏ‹ Î·È Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ‰˘ÛÎÔϛ˜ ÛÙË Û›ÙÈÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ Ù· ÛËÌ›· ηٷÛÙÔÏ‹˜ Â›Ó·È È‰È·›ÙÂÚ· ¤ÓÙÔÓ·, Û˘ÓÈÛÙ¿Ù·È Ë ‰È·ÎÔ‹ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∏ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È Ë ÚÈÌȉfiÓË ÚÔηÏÔ‡Ó ÛËÌ›· ηٷÛÙÔÏ‹˜ ÛÙÔ ‚Ú¤ÊÔ˜, ·ÊÔ‡ Ë ·¤ÎÎÚÈÛ‹ ÙÔ˘˜ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ÛËÌ·ÓÙÈ΋. ∏ Ù·ÎÙÈ΋ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÎÚ›ÓÔÓÙ·È ··Ú·›ÙËÙ· (2,17). ∏ Ê·ÈÓ˘ÙÔ˝ÓË ·ÂÎÎÚ›ÓÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Û ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜. ∆· ›‰· ÛÙÔÓ ÔÚfi ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·fi ÌËÙ¤Ú˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÌÔÓÔıÂڷ›· Ì ʷÈÓ˘ÙÔ˝ÓË Â›Ó·È ¯·ÌËÏ¿ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi (44). ∏ ıÂڷ›· Ù˘ ÌËÙ¤Ú·˜ Ì ηڂ·Ì·˙›ÓË ‹ ‚·ÏÚÔ˚Îfi Â›Ó·È ·ÛÊ·Ï‹˜ ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ Ô˘ ıËÏ¿˙ÂÈ. OÈ ÔÛfiÙËÙ˜ Ô˘ ÂÚÓÔ‡Ó ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ·ÔÚÚÔÊÔ‡ÓÙ·È ·fi ÙÔ ‚Ú¤ÊÔ˜ Â›Ó·È ÌÈÎÚ¤˜ Î·È Û˘Ó‹ıˆ˜ ·ÛÊ·Ï›˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· Ó¤· ·ÓÙÈÂÈÏËÙÈο ‚Èη̷ÙÚ›ÓË, Ï·ÌÔÙÚÈÁ›ÓË, Áη̷ÂÓÙ›ÓË Î·È ÊÂÏÌ·Ì¿ÙË, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ô˘ Ó· ÂÁÁ˘ÒÓÙ·È ÙËÓ ·ÛÊ·Ï‹ ¯Ú‹ÛË ÙÔ˘˜ ·fi ÙË ÌËÙ¤Ú· Ô˘ ıËÏ¿˙ÂÈ. ∏ ¯Ú‹ÛË Ù˘ ÊÂÏÌ·Ì¿Ù˘ Û˘ÓÈÛÙ¿Ù·È Ó· ·ÔʇÁÂÙ·È ·fi ÙË ıËÏ¿˙Ô˘Û· ÌËÙ¤Ú· ÂÍ·ÈÙ›·˜ ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘, ÔÈ Ôԛ˜ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙ· ¿ÌÂÛ· Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ٷ ›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ Ï¿ÛÌ· (10). ∏ ÂÈÏË„›· Â›Ó·È Ë Û˘¯ÓfiÙÂÚË Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ¢ÂÓ Â›Ó·È, fï˜, Ï›Á˜ ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô Ù˘ ÂÁ·Ԣ Ì ÂÈÏË„›· ‰ÂÓ Ù˘ ÂÈÙÚ¤ÂÈ Ó· ÁÓˆÛÙÔÔÈ‹ÛÂÈ ÙÔ Úfi‚ÏËÌ¿ Ù˘, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÙÔ ÂӉ¯fiÌÂÓÔ Ù˘ ÂÚÈıˆÚÈÔÔ›ËÛ˘ Ì ÙÚfiÌÔ. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi, fï˜, ÔÈ Û˘Ó¤ÂȘ ‰ÂÓ Â›Ó·È Ï›Á˜, Ô‡Ù ·Û‹Ì·ÓÙ˜ ÙfiÛÔ ÁÈ· ÙËÓ ›‰È· fiÛÔ Î·È ÁÈ· ÙÔ ÓÂÔÁÓfi Ù˘. ÃÚ¤Ô˜ Ù˘ ÎÔÈÓˆÓ›·˜ Â›Ó·È Ë ˘ÔÛÙ‹ÚÈÍË ·˘ÙÒÓ ÙˆÓ ·ÙfiÌˆÓ Û fiÏÔ˘˜ ÙÔ˘˜ ÙÔÌ›˜ Î·È Ë ‰È·Ù‹ÚËÛË ÙˆÓ ·Ú¯fiÌÂÓˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ Û ˘„ËÏfi ›‰Ô. ∏ ÚÔÂÙÔÈÌ·Û›· Î·È Ô ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ Ù˘ ·ËÛ˘, ηıÒ˜ Î·È Ë ÂÈı·Ú¯Ë̤ÓË Î·È ÛˆÛÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÔÌ¿‰·
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Paediatriki 2003;66:264-277
ORIGINAL ARTICLE
¢Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ ·ÁÚÔÙÈ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘ π. ªÔÛ¯·Ó‰Ú¤·, Ã. ÷Ù˙‹˜, π. ª·ÌÌ¿˜, °. ªÂÚÙÛÈ¿˜, ª. §ÈÓ·Ú‰¿Î˘, ª. ∫˘Úȷο΢, §. ÷Ù˙‹, ¡. ∫·Úη‚›ÙÛ·˜, ∞. ª·ÚÁȈڋ˜, ∞. ∫·Ê¿ÙÔ˜
Obesity indices and cardiovascular risk factors in rural dwelling Cretan children J. Moschandreas, C. Hatzis, Y. Mammas, G. Bertsias, M. Linardakis, M. Kiriakakis, L. Hatzi, N. Karkavitsas, A. Margioris, A. Kafatos
¶ÂÚ›ÏË„Ë: ∏ ¤ÁηÈÚË ·Ó‡ÚÂÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·fi ÙËÓ ·È‰È΋ ·ÎfiÌ· ËÏÈΛ· ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ™Ùfi¯ÔÈ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÚ¢ÓËı› Ë Û˘Û¯¤ÙÈÛË ‰È·ÊfiÚˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Ì ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁoÓÙ˜ ÁÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È Ó· ÂÎÙÈÌËı› Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜, Ù˘ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ Î·È Ù˘ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·˜. ™ˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ Î·È ‚ÈÔ¯ËÌÈΤ˜ ÌÂÙÚ‹ÛÂȘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Û 178 ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 201 ·È‰ÈÒÓ ÙÔ˘ ¢‹ÌÔ˘ ƒÔ‡‚· (99 ·ÁfiÚÈ·, 102 ÎÔÚ›ÙÛÈ·) ËÏÈΛ·˜ 415 ÂÙÒÓ. §‹„Ë ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ¤ÁÈÓ Û 111 ·È‰È¿. ∏ Û‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË Ù˘ ÔÏÏ·Ï‹˜ ÛÙ·ÙÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. ¶¤ÓÙ ÛÙÔ˘˜ 6 ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ·ÚÔ˘Û›·˙·Ó ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË Û˘ÁΤÓÙÚˆÛË ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ÙÔÓ ÏfiÁÔ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÚÔ˜ HDL-¯ÔÏËÛÙÂÚfiÏË. ∏ ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ (¶ª), ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ (™µ), Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™), ÙÔ ¿ıÚÔÈÛÌ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ (A¢¶) Î·È Ô ÏfiÁÔ˜ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ÚÔ˜ ‡„Ô˜ ÛÒÌ·ÙÔ˜ (¶ªÀ) Û˘Û¯ÂÙ›˙ÔÓÙ·Ó ıÂÙÈο Ì ٷ ›‰· Ù˘ ÈÓÛÔ˘Ï›Ó˘ (p<0,0005 ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ‰Â›ÎÙ˜). ¢ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÎÔÚÂṲ̂ÓÔ˘, ÌÔÓÔ·ÎfiÚÂÛÙÔ˘ ‹ ÔÏ˘·ÎfiÚÂÛÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ÙÔ˘˜ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ‰ÈÂıÓÒ˜ ηıÔÚÈṲ̂ӷ fiÚÈ·, ÙÔ 32% ÙˆÓ ·È‰ÈÒÓ ÎÚ›ıËΠ˘¤Ú‚·ÚÔ Î·È ÙÔ 9% ÙÔ˘ Û˘ÓfiÏÔ˘ ÎÚ›ıËΠ·¯‡Û·ÚÎÔ. ∆Ô 19% ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·˙ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· (TC >200 mg/dL), ÙÔ
Abstract: The risk of cardiovascular disease (CVD) is reduced by the early detection of predisposing factors. The aims of this study were to investigate the relationships between various obesity indices and cardiovascular disease risk factors and to estimate the prevalence of obesity, hypercholesteraemia and hyperinsulinaemia in a rural population of children. Complete anthropometric and biochemical measurements were obtained in 178 of the 201 children (99 boys, 102 girls) aged between 4 and 15 years living in a mountainous rural community in Crete. Adipose tissue samples were taken from 111 children. Using multiple regression techniques, five of the six obesity indices considered were found to be negatively related to HDL and positively related to triglyceride concentration and the total cholesterol (TC) to HDL ratio. Waist circumference, body weight, body mass index (BMI), the sum of four skinfolds and waist to height ratio were positively related to insulin concentration (p<0.0005 in all cases). No statistically significant relationship was found between the risk factors and the precentage of saturated, monounsaturated or polyunsaturated adipose fat. Using IOTF criteria, 32% of the children were overweight and 9% obese; 19% of the children had hypercholesteraemia (TC >200 mg/dL), 7% hyperinsulaemia (insulin >17 ÌIU/mol) and 32% increased arterial blood pressure (>95th percentile), while 29% had at least 2 risk factors. The findings of this study indicate an increased prevalence of obesity and other CVD risk factors in children living in rural Crete. Waist circumference appears to be as closely related as BMI to other risk
∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜ ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∆Ì‹Ì· π·ÙÚÈ΋˜ ™¯ÔÏ‹ ∂ÈÛÙËÌÒÓ ÀÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
Preventive Medicine and Nutrition Clinic Department of Social Medicine University of Crete Medical School, Heraklion, Crete
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¶·È‰È·ÙÚÈ΋ 2003;66:264-277
Paediatriki 2003;66:264-277
7% ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· (>17 ÌIU/mol), ÙÔ 32% ·˘ÍË̤ӷ ›‰· ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (>95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË), ÂÓÒ ÙÔ 29% ÙˆÓ Ì·ıËÙÒÓ Û˘ÁΤÓÙÚˆÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ∏ ÌÂϤÙË ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·¯˘Û·ÚΛ·˜ Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ Ù˘ ÔÚÂÈÓ‹˜ ∫Ú‹Ù˘. ∏ ̤ÙÚËÛË Ù˘ ¶ª ÂÌÊ·Ó›˙ÂÙ·È Ó· Â›Ó·È ÂÍ›ÛÔ˘ ÈÛ¯˘Úfi˜ ‰Â›ÎÙ˘ fiˆ˜ Ô ¢ª™, ÁÂÁÔÓfi˜ Ô˘ ηıÈÛÙ¿ ·Ó·Áη›· ÙËÓ Â¤ÎÙ·ÛË Ì›·˜ ÙfiÛÔ ·Ï‹˜ ̤ÙÚËÛ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË.
factors, a finding which supports the incorporation of this simple measurement in clinical practice.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ·¯˘Û·ÚΛ·, ÈÓÛÔ˘Ï›ÓË, ÏÈÔÚˆÙ½Ó˜, ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË HbA1c, ˘Ô‰fiÚÈÔ Ï›Ô˜, ‰Â›ÎÙ˜ HOMA.
Key words: risk factors, obesity, insulin, lipoproteins, glycosylated haemoglobin HbA1c, adipose fat, ∏Oª∞ indices.
™˘ÓÙÔÌÔÁڷʛ˜ ∞¢¶ ¢∂ ¢ª™ ª∆ ¶ª ¶ªÀ
ÕıÚÔÈÛÌ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ ¢È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ ¢Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ª¤ÛË ÙÈÌ‹ ¶ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ §fiÁÔ˜ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ÚÔ˜ ‡„Ô˜ ÛÒÌ·ÙÔ˜ ¶ªπ §fiÁÔ˜ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ÚÔ˜ ÂÚ›ÌÂÙÚÔ ÈÛ¯›ˆÓ ™µ ™ˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ∆∞ ∆˘È΋ ·fiÎÏÈÛË TG ∆ÚÈÁÏ˘ÎÂÚ›‰È· TC OÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË HDL-¯ÔÏËÛÙÂÚfiÏË §ÈÔÚˆÙ½ÓË ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ LDL-¯ÔÏËÛÙÂÚfiÏË §ÈÔÚˆÙ½ÓË ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ IRHOMA ¢Â›ÎÙ˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË SECRHOMA ¢Â›ÎÙ˘ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜
∂ÈÛ·ÁˆÁ‹ ™ÙË ÌÂϤÙË ÙˆÓ ∂Ù¿ ÈÚÒÓ Ô˘ ¿Ú¯ÈÛ ÙÔ 1960, Ô ·Ó‰ÚÈÎfi˜ ·ÁÚÔÙÈÎfi˜ ÏËı˘ÛÌfi˜ Ù˘ ∫Ú‹Ù˘ ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi ÙË ÌÈÎÚfiÙÂÚË 25ÂÙ‹ ıÓËÛÈÌfiÙËÙ· ·fi ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 15 ÏËı˘ÛÌÔ‡˜ Ù˘ ÌÂϤÙ˘ (1). ∏ ÔÌ·‰ÔÔÈË̤ÓË (pooled) ÂÈÎÈÓ‰˘ÓfiÙËÙ· ı·Ó¿ÙÔ˘ ·fi ηډȷÁÁÂÈ·Îfi ÓfiÛËÌ· Û¯ÂÙ›ÛÙËÎÂ, ÌÂٷ͇ ¿ÏψÓ, Ì ÙË Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË, ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ Î·È ÙË Û˘ÁΤÓÙÚˆÛË ¯ÔÏËÛÙÂÚfiÏ˘ ÔÚÔ‡ (2). O ¯·ÌËÏfi˜ ‰Â›ÎÙ˘ ıÓËÛÈÌfiÙËÙ·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ∫Ú‹Ù˘ Û¯ÂÙ›ÛÙËÎÂ, ›Û˘, Ì ÙËÓ ·Ú·‰ÔÛȷ΋ ÎÚËÙÈ΋ ‰›·ÈÙ·, Ô˘ ÂÚÈ›¯Â ¯·ÌËÏ‹ ÂÚÈÂÎÙÈÎfiÙËÙ· ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ˘„ËÏ‹ ÂÚÈÂÎÙÈÎfiÙËÙ· ÌÔÓÔ·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ (1). ™‹ÌÂÚ·, Ë Ù˘È΋ ‰›·ÈÙ· ÛÙËÓ ∫Ú‹ÙË ‰È·Ê¤ÚÂÈ ·ÚÎÂÙ¿ ·fi ·˘Ù‹Ó ÙÔ˘ 1960, ÌÂ
·˘ÍË̤ÓË ÚfiÛÏË„Ë ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÙfiÛÔ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, fiÛÔ Î·È ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ (3,4). ∏ ·˘ÍË̤ÓË ÚfiÛÏË„Ë ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙË ‰È·ÙÚÔÊ‹ (Î·È ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ·˘Ù¿ Ì 12-16 ¿ÙÔÌ· ¿Óıڷη) Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ ›‰· ¯ÔÏËÛÙÂÚfiÏ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ·˘ÍË̤ÓË Â›ÙˆÛË ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (5). ∏ ÚfiÛÏË„Ë Ï›Ô˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÂÁ¿ÏˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ ·ÓÙ·Ó·ÎÏ¿Ù·È ·fi ÙË Û‡ÛÙ·ÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ (6-8). ÕÏÏÔÈ ÛÔ‚·ÚÔ› ·Ú¿ÁÔÓÙ˜ ıÓËÛÈÌfiÙËÙ·˜ ·fi ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· Ô˘ ¤¯Ô˘Ó ‚ÚÂı› Û ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ Â›Ó·È Ë ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘, Ë ÌË-·ÓÔ¯‹ ÛÙË ÁÏ˘Îfi˙Ë Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 2 (9,10). ∆· ›‰· ÈÓÛÔ˘Ï›Ó˘ Ï¿ÛÌ·ÙÔ˜ ÌÂÙ¿ ·fi ÓËÛÙ›· ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘¯fiÓ ·ÓÙ›ÛÙ·Û˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ (11). ∏ ·¯˘Û·ÚΛ·, Ë ÔÔ›· ·ÔÙÂÏ› ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ˘fiÏÔÈˆÓ ÚԉȷıÂÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ (12). ¶ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ÌÂÁ¿Ï˘ ‰È¿ÚÎÂÈ·˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ·È‰È¿ Ì ηْ ÂÍ·ÎÔÏÔ‡ıËÛË ˘„ËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· Á›ÓÔ˘Ó ˘ÂÚÙ·ÛÈÎÔ› ˆ˜ ÂÓ‹ÏÈΘ Î·È fiÙÈ ¿Óˆ ·fi ÙÔ 80% ÙÔÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ·¯‡Û·ÚÎÔ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (13). ™Â Û¯¤ÛË Ì ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜, ÔÈ ¯ÒÚ˜ Ù˘ ÓfiÙÈ·˜ Î·È ·Ó·ÙÔÏÈ΋˜ ∂˘ÚÒ˘ ¤¯Ô˘Ó Ù· ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ (14). °È· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ‚·ıÌÔ‡ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÓ‹ÏÈΘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·Ù¿ ηÓfiÓ· Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™). π‰È·›ÙÂÚË ÛËÌ·Û›· ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Ô ˘ÔÏÔÁÈÛÌfi˜ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ fiˆ˜ Ë ÂÚ›ÌÂÙÚÔ˜ ̤Û˘, Ë ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ ÚÔ˜
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‡„Ô˜ ÛÒÌ·ÙÔ˜ Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ ÚÔ˜ ÂÚ›ÌÂÙÚÔ ÈÛ¯›ˆÓ, ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ÂÓ·fiıÂÛ˘ Ï›Ô˘˜ (ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ·), Ë ÔÔ›· Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ˘¤ÚÙ·Û˘ Î·È Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 2, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÂÚÈÊÂÚÈ΋ ·¯˘Û·ÚΛ· (15). °È· ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi, ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË Û˘˙‹ÙËÛË ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Û¯ÂÙÈο Ì ÙÔ ÔÈÔ˜ ‰Â›ÎÙ˘ ÚԂϤÂÈ Î·Ï‡ÙÂÚ· ÙËÓ ·ÚÔ˘Û›· ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· (16-18). ™Ùfi¯ÔÈ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ›ӷÈ: ·) Ó· ÂÚ¢ÓËı› Ë Û˘Û¯¤ÙÈÛË ‰È¿ÊÔÚˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Ì ÙȘ ÏÈÔÚˆÙ½Ó˜ ÙÔ˘ ÔÚÔ‡, ÙË ÁÏ˘Îfi˙Ë, ÙËÓ ÈÓÛÔ˘Ï›ÓË, ÙË ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË HbA1c Î·È ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ‚) Ó· ÂÎÙÈÌËı› Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜, Ù˘ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜, Ù˘ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·˜ Î·È Ù˘ ·˘ÍË̤Ó˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û ·È‰È¿ Ì›·˜ ıˆÚÔ‡ÌÂÓ˘ ·Ú·‰ÔÛȷ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¶ÏËı˘ÛÌfi˜ ∏ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠ÔÚÂÈÓ‹ ÂÚÈÔ¯‹ Ù˘ ÎÂÓÙÚÈ΋˜ ∫Ú‹Ù˘, ÛÙË ÓfiÙÈ· ÏÂ˘Ú¿ ÙÔ˘ æËÏÔÚ›ÙË. ™˘ÌÌÂÙ›¯·Ó fiÏ· Ù· ·È‰È¿ ÙÔ˘ ÓËÈ·ÁˆÁ›Ԣ (ËÏÈΛ·˜ 4-5 ÂÙÒÓ), ‰ËÌÔÙÈÎÔ‡ (6-11 ÂÙÒÓ) Î·È Á˘ÌÓ·Û›Ô˘ (12-15 ÂÙÒÓ) ÙÔ˘ ¢‹ÌÔ˘ ƒÔ‡‚·, ÂÓfi˜ ‰‹ÌÔ˘ ÌÂ Û˘ÓÔÏÈÎfi ÏËı˘ÛÌfi 2830 ·ÙfiÌˆÓ (ÛÙÔȯ›· ·ÔÁÚ·Ê‹˜ ÏËı˘ÛÌÔ‡ 1991). ∆Ô Û¯ÔÏÂ›Ô ‚Ú›ÛÎÂÙ·È ÛÙÔ ¯ˆÚÈfi °¤ÚÁÂÚË, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ƒÔ‡‚·, Ì ÏËı˘ÛÌfi 2110 ηÙԛΈÓ. ÕÏÏ· ¯ˆÚÈ¿ ÛÙËÓ ÂÚÈÔ¯‹ Â›Ó·È Ô ¶·Ó·ÛÛfi˜ (395 οÙÔÈÎÔÈ) Î·È Ë ¡‡‚ÚÈÙÔ˜ (325 οÙÔÈÎÔÈ). ∆· ÛÙÔȯ›· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·ÔÙÂÏÔ‡Ó Ì¤ÚÔ˜ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∞ÁˆÁ‹˜ ÀÁ›·˜ ÛÙËÓ ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ƒÔ‡‚·, Ô˘ ‰ÈÂÎÂÚ·ÈÒÓÂÙ·È ·fi ÙËÓ ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· Ù˘ ∫ÏÈÓÈ΋˜ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ∏ ÌÂıÔ‰ÔÏÔÁ›· Ù˘ ·Ú¤Ì‚·Û˘ Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹Ó Ô˘ ÂÊ·ÚÌfiÛÙËΠÛÙÔ ÙÚ¤¯ÔÓ ÚfiÁÚ·ÌÌ· Û ‰Â›ÁÌ· ÙˆÓ ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ Î·È Á˘ÌÓ·Û›ˆÓ Ù˘ ∫Ú‹Ù˘ (19). ∆· ÛÙÔȯ›· Ô˘ ·Ó·Ï‡ıËÎ·Ó ÁÈ· ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· Û˘ÏϤ¯ıËÎ·Ó ÛÙÔ ‰È¿ÛÙËÌ· ÌÂٷ͇ π·ÓÔ˘·Ú›Ô˘ Î·È ºÂ‚ÚÔ˘·Ú›Ô˘ 2001 Î·È ÔÈ ÌÂÙÚ‹ÛÂȘ Ï‹ÊıËÎ·Ó ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ú¤Ì‚·Û˘. ™ÙÔ Û¯ÔÏÂ›Ô Ù˘ ÂÚÈÔ¯‹˜ ÊÔÈÙÔ‡Û·Ó Û˘ÓÔÏÈο 201 Ì·ıËÙ¤˜ (86% ·fi ÙË °¤ÚÁÂÚË, 9% ·fi ÙË ¡‡‚ÚÈÙÔ Î·È 5% ·fi ÙÔÓ ¶·Ó·ÛÛfi). ∂ÓËÌÂÚˆÙÈο ÁÚ¿ÌÌ·Ù·-Û˘ÌʈÓËÙÈο Û˘ÁηٿıÂÛ˘ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË ‰fiıËÎ·Ó ÚÔ˜ ˘ÔÁÚ·Ê‹ ÛÙÔ˘˜ ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ. ∆ÂÏÈο, 192 ·È‰È¿ Û˘ÌÌÂÙ›¯·Ó ÛÙȘ ÂÍÂÙ¿ÛÂȘ (96% Û˘ÌÌÂÙÔ¯‹) Î·È ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙ· 178 ·È‰È¿, ÁÈ· Ù· ÔÔ›· ˘‹Ú¯·Ó Ï‹ÚË ÛˆÌ·ÙÔÌÂÙÚÈο Î·È ‚ÈÔ¯ËÌÈο ÛÙÔȯ›·. ∏ ËÏÈΛ· ÙˆÓ Ì·ıËÙÒÓ ‹Ù·Ó 4-15 ¤ÙË.
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™ˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ OÈ ¤ÍÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‹Ù·Ó Ë ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ (¶ª), ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ (™µ), Ô ¢ª™, Ô ÏfiÁÔ˜ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ÚÔ˜ ‡„Ô˜ ÛÒÌ·ÙÔ˜ (¶ªÀ), Ô ÏfiÁÔ˜ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ÚÔ˜ ÂÚ›ÌÂÙÚÔ ÈÛ¯›ˆÓ (¶ªπ) Î·È ÙÔ ¿ıÚÔÈÛÌ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ (∞¢¶). OÈ ÂÚ›ÌÂÙÚÔÈ Ì¤Û˘ Î·È ÈÛ¯›ˆÓ ÌÂÙÚ‹ıËÎ·Ó Ì ϷÛÙÈ΋ Ù·ÈÓ›· ÚÔ˜ ÙÔ ÏËÛȤÛÙÂÚÔ ¯ÈÏÈÔÛÙfiÌÂÙÚÔ. ∆Ô ™µ ÌÂÙÚ‹ıËΠ̠ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˙˘ÁÔ‡ ‰¿ÊÔ˘˜ (Seca alpha) Ì ·ÎÚ›‚ÂÈ· 100 g. ∏ ̤ÙÚËÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ¯ˆÚ›˜ ˘Ô‰‹Ì·Ù· Î·È Ì ÂÏ·ÊÚ‡ ÚÔ˘¯ÈÛÌfi. ™Â ·È‰È¿ ËÏÈΛ·˜ 6 ÂÙÒÓ Î·È ¿Óˆ, Ë Ì¤ÙÚËÛË ÙÔ˘ ‡„Ô˘˜ ÛÒÌ·ÙÔ˜ ¤ÁÈÓ Û fiÚıÈ· ÛÙ¿ÛË, ¯ˆÚ›˜ ˘Ô‰‹Ì·Ù·, Ì ÙÔ˘˜ ÒÌÔ˘˜ Û ı¤ÛË ·Ó¿·˘Û˘ Î·È Ù· ¿Óˆ ¿ÎÚ· Ó· ·ÈˆÚÔ‡ÓÙ·È ÂχıÂÚ·. °È· ÙÔ ÛÎÔfi ·˘Ùfi ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ó·ÛÙËÌfiÌÂÙÚÔ, ÚÔÛ·ÚÌÔṲ̂ÓÔ Û ›ÛÈÔ ÙÔ›¯Ô, ÙÔ ÔÔ›Ô Û¯ËÌ¿ÙÈ˙ ÔÚı‹ ÁˆÓ›· Ì ÙÔ ¿ÙˆÌ·. O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ‡„Ô˘˜ ¤ÁÈÓ ÛÙÔ ÏËÛȤÛÙÂÚÔ 0,5 cm. ™Â ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 6 ÂÙÒÓ, ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÌÂÙÚ‹ıËΠ۠‡ÙÈ· ı¤ÛË, ¿Óˆ Û ۷ӛ‰È ÂȉÈ΋˜ ηٷÛ΢‹˜. O ¢ª™ ˘ÔÏÔÁ›ÛÙËΠ‰È·ÈÚÒÓÙ·˜ ÙÔ ™µ (kg) Ì ÙÔ ÙÂÙÚ¿ÁˆÓÔ ÙÔ˘ ‡„Ô˘˜ ÛÒÌ·ÙÔ˜ (m2). ∆Ô ¿¯Ô˜ ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÙÚÈΤʷÏÔ˘, ‰ÈΤʷÏÔ˘, Ù˘ ˆÌÔÏ¿Ù˘ Î·È ÙÔ˘ Ï·ÁÔÓ›Ô˘ ÌÂÙÚ‹ıËΠ̠Lange Skinfold Caliper, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ fiÙÈ Ô ÂÍÂÙ·˙fiÌÂÓÔ˜ ‹Ù·Ó Û fiÚıÈ· ÛÙ¿ÛË Ì ٷ ¿Óˆ ¿ÎÚ· Û ı¤ÛË ·Ó¿·˘Û˘ ÛÙ· Ï¿ÁÈ· ÙÔ˘ ÎÔÚÌÔ‡. ª¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ∏ ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̠ÙÔÓ ÂÍÂÙ·˙fiÌÂÓÔ Î·ıÈÛÙfi Î·È ÌÂÙ¿ ·fi ·Ó¿·˘ÛË 5-10 min. ÃÚËÛÈÌÔÔÈ‹ıËΠ˘‰Ú·ÚÁ˘ÚÈÎfi ÛÊ˘ÁÌÔÌ·ÓfiÌÂÙÚÔ Ì ηٿÏÏËÏÔ Ì¤ÁÂıÔ˜ ÂÚȯÂÈÚ›‰·˜, ÒÛÙ ӷ ηχÙÂÈ ÙÔ 5075% Ù˘ ÂÚÈ̤ÙÚÔ˘ ÙÔ˘ ‰ÂÍÈÔ‡ ‚Ú·¯›ÔÓ·. ∫·Ù·ÁÚ¿ÊËÎÂ Ë Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË Î·È Ë ‰È·ÛÙÔÏÈ΋ ηٿ ÙËÓ ¤ÌÙË Ê¿ÛË. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ÌÂÙÚ‹ıËΠÙÚÂȘ ÊÔÚ¤˜ Î·È ˘ÔÏÔÁ›ÛÙËÎÂ Ô Ì¤ÛÔ˜ fiÚÔ˜ (ÚˆÙfiÎÔÏÏÔ MONICA study). ¢Â›ÁÌ·Ù· ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ ¢Â›ÁÌ·Ù· ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ÂÏ‹ÊıËÛ·Ó ·fi ÙÔ ¿Óˆ ¤Íˆ ÙÂÙ·ÚÙËÌfiÚÈÔ ÙÔ˘ ÁÏÔ˘ÙÔ‡, Ì ‚ÂÏfiÓ· Û˘Ó‰Â‰Â̤ÓË Û ۈÏËÓ¿ÚÈÔ ÎÂÓÔ‡ ÙˆÓ 10 ml. ∏ ÂÚÈÔ¯‹ Ï‹„˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ›¯Â ÚÔËÁÔ˘Ì¤Óˆ˜ ·ÔÏ˘Ì·Óı› Ì ÔÈÓfiÓÂ˘Ì· Î·È ¤ÂÈÙ· ›¯Â „ÂηÛÙ› Ì ÙÔÈÎfi ·Ó·ÈÛıËÙÈÎfi (¯ÏˆÚÈÔ‡¯Ô ·Èı‡ÏÈÔ). OÈ ‰È·‰Èηۛ˜ Ï‹„˘ Î·È ·Ó¿Ï˘Û˘ ‹Ù·Ó ·˘Ù¤˜ ÙˆÓ Beynen Î·È Katan (20). ∆· ‰Â›ÁÌ·Ù· ·ÔıË·ÙËηÓ, ¤ˆ˜ fiÙÔ˘ ·Ó·Ï˘ıÔ‡Ó, Û ıÂÚÌÔÎÚ·Û›· -80ÔC. ¶ÔÛfiÙËÙ· 3-10 mg ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ÌÂٷʤÚıËΠ۠‰ÔÎÈÌ·ÛÙÈÎfi ۈϋӷ borosilicate 12 ml Î·È ·Ì¤Ûˆ˜ ÚÔÛÙ¤ıËΠ1 ml ÌÂı·ÓÔÏÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ¡·O∏ 1¡. ∆Ô ‰È¿Ï˘Ì· ıÂÚÌ¿ÓıËΠ۠˘‰·ÙfiÏÔ˘ÙÚÔ ÛÙÔ˘˜ 80ÔC ÁÈ· 10 min, „‡¯ıËÎÂ Î·È Î·ÙfiÈÓ ÚÔÛÙ¤ıËÎ·Ó 2 ml ÌÂı·ÓÔÏÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ÙÚÈÊıÔÚÈÔ‡¯Ô˘ ‚ÚˆÌ›Ô˘ 14% (BF3 14% methanol). ∞ÎÔÏÔ‡ıËÛ ı¤ÚÌ·ÓÛË Û ˘‰·ÙfiÏÔ˘ÙÚÔ ÁÈ· 4 min, „‡ÍË Î·È ÚÔÛı‹ÎË 3 ml ÎÔÚÂṲ̂ÓÔ˘ ˘‰·ÙÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ¡·Cl Î·È 1 ml ÂÍ·Ó›Ô˘ (C6H14). ∆Ô Ì›ÁÌ· Ô˘ ÚԤ΢„ ·Ó·ÎÈÓ‹ıËΠÈÛ¯˘Ú¿ ÁÈ· 2-3 min Î·È Ë ÔÚÁ·ÓÈ΋ Ê¿ÛË (Ô˘ ÂÚȤ¯ÂÈ ÙÔ˘
¶·È‰È·ÙÚÈ΋ 2003;66:264-277
ÌÂı˘ÏÂÛÙ¤Ú˜ FAME) ÌÂٷʤÚıËΠ۠ÊÈ·Ï›‰ÈÔ ÁÈ· ·Ó¿Ï˘ÛË Û ·¤ÚÈÔ ¯ÚˆÌ·ÙÔÁÚ¿ÊÔ (SHIMADZU GC-17A), Ô˘ Â›Ó·È ÂÍÔÏÈṲ̂ÓÔ˜ Ì ÎÔÏÒÓ· ÙÚȯÔÂȉԇ˜ SP-2560 Ì‹ÎÔ˘˜ 100 m x 0,25 Ìm x 0,2 Ìm film thickness (SUPELCO). °È· ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ·Ó·ÏˆÌ¤ÓˆÓ Ô˘ÛÈÒÓ (FAME), ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ˘¿Ú¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›· ·fi ÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ SUPELCO Î·È ‰È¿Ï˘Ì· ÚfiÙ˘ˆÓ FAME (SUPELCO). ∞fi ÙȘ ÔÛfiÙËÙ˜ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Ô˘ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó (ÎÔÚÂṲ̂ӷ, ÌÔÓÔ·ÎfiÚÂÛÙ·, ÔÏ˘·ÎfiÚÂÛÙ·, trans, ˆÌ¤Á·-3 Î·È ˆÌ¤Á·-6 ÏÈ·Ú¿ Ôͤ·), ˘ÔÏÔÁ›ÛÙËÎ·Ó Ù· ÔÛÔÛÙ¿ ÁÈ· οı ¤Ó· ͯˆÚÈÛÙ¿ ˆ˜ ÚÔ˜ ÙÔ Û‡ÓÔÏÔ ÙˆÓ 39 ÏÈ·ÚÒÓ ÔͤˆÓ. §‹„Ë ·›Ì·ÙÔ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ·Ó·Ï‡ÛÂȘ °È· ÙȘ ‚ÈÔ¯ËÌÈΤ˜ ·Ó·Ï‡ÛÂȘ, ¤ÁÈÓ ϋ„Ë 10 ml ÊÏ‚ÈÎÔ‡ ·›Ì·ÙÔ˜ ÌÂÙ¿ ·fi ÔÏÔÓ‡¯ÙÈ· 12ˆÚË ÓËÛÙ›·. ∆· ‰Â›ÁÌ·Ù· ÌÂٷʤÚıËÎ·Ó Û 3,5-4 ÒÚ˜ ·fi ÙËÓ ·Ú¯‹ Ù˘ Ï‹„˘ ÛÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ ¢È·ÙÚÔÊ‹˜ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ Ì ÊÔÚËÙfi „˘ÁÂ›Ô Ì ·ÁÔ·ÛÙÂȘ, ÒÛÙ ӷ Ô ‰È·ÙËÚËıÔ‡Ó Û ıÂÚÌÔÎÚ·Û›· 3-4 C. ∆Ô ·›Ì· Ê˘ÁÔÎÂÓÙÚ‹ıËΠ۠4000 rpm ÁÈ· 15 min Î·È Ô ÔÚfi˜ ηٷÓÂÌfiÙ·Ó Û ϷÛÙÈο ÛˆÏËÓ¿ÚÈ· Eppendorf. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ (TG), Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (TC), Ù˘ ÏÈÔÚˆÙ½Ó˘ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ (HDL-¯ÔÏËÛÙÂÚfiÏË) Î·È Ù˘ ÏÈÔÚˆÙ½Ó˘ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ (LDL-¯ÔÏËÛÙÂÚfiÏË) ¤ÁÈÓ ÙËÓ ›‰È· Ë̤ڷ Ì ÙË Û˘ÏÏÔÁ‹ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ, Ì ÌÂıfi‰Ô˘˜ Ô˘ ‹‰Ë ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› (19). ÀÔÏÔÁ›ÛÙËÎÂ Ô ÏfiÁÔ˜ TC ÚÔ˜ HDL-¯ÔÏËÛÙÂÚfiÏË (TC/HDL). ∆ËÓ ›‰È· Ë̤ڷ, ›Û˘, ¯ÚËÛÈÌÔÔÈ‹ıËΠÔÚfi˜ ·fi ÙÔ ·›Ì· ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂȤ‰ˆÓ ÁÏ˘Îfi˙˘ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ÂÍÔÎ˘Ó¿Û˘ Ì ÂȉÈÎfi ·˘ÙÔ-·Ó·Ï˘Ù‹ AU-640 (Olympus Instruments) Î·È Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜ ÙÈÌÒÓ 70-115 mg/dL. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰Â›ÁÌ·Ù· ÔÏÈÎÔ‡ ·›Ì·ÙÔ˜ Ì ·ÓÙÈËÎÙÈÎfi (EDTA) ÁÈ· ÙË Ì¤ÙÚËÛË Ù˘ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c). O ÔÛÔÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ¤ÁÈÓ Ì ˘ÁÚ‹ ¯ÚˆÌ·ÙÔÁÚ·Ê›· ˘„ËÏ‹˜ ·fi‰ÔÛ˘ (HPLC, HiAUTOAIC HA 8140, Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜ ÙÈÌÒÓ HbA1c: 3-6%). ∏ ÈÓÛÔ˘Ï›ÓË ÚÔÛ‰ÈÔÚ›ÛÙËΠÔÛÔÙÈο Ì ÙË Ì¤ıÔ‰Ô RIA (Insulin Immunoradiometric assay kit Diasorin s.r.l.), ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜ 3-17 ÌIU/ml. ∂ÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÔÓ¤ˆÓ ∑ËÙ‹ıËΠ·fi ÙÔ˘˜ ÁÔÓ›˜ Ó· Û˘ÌÏËÚÒÛÔ˘Ó ¤Ó· Û‡ÓÙÔÌÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙÔ ™µ Î·È ÙÔ ‡„Ô˜ ÙÔ˘ οı ÁÔÓ¤·, ηıÒ˜ Î·È ÁÈ· ÙËÓ ·ÚÔ˘Û›· ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ‹ ‰È·‚‹ÙË Î‡ËÛ˘. ∞ÎfiÌ·, ÚˆÙ‹ıËÎ·Ó ÔÈ ÁÔÓ›˜ ÁÈ· Ù˘¯fiÓ ÂÂÈÛfi‰ÈÔ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηٿ ÙÔ ·ÚÂÏıfiÓ. O ¢ª™ ÙÔ˘ οı ÁÔÓ¤· ˘ÔÏÔÁ›ÛÙËΠ̠ÙË ‰È·›ÚÂÛË ÙÔ˘ ·Ó·ÊÂÚfiÌÂÓÔ˘ ‚¿ÚÔ˘˜ Ì ÙÔ ÙÂÙÚ¿ÁˆÓÔ ÙÔ˘ ·Ó·ÊÂÚfiÌÂÓÔ˘ ‡„Ô˘˜. ™Ù·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ O ‚·ıÌfi˜ Û˘Û¯¤ÙÈÛ˘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ Ì ÙÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ÌÂÏÂÙ‹ıËΠ̠ÙÔ˘˜ Û˘ÓÙÂÏÂÛÙ¤˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ Pearson. ∆È̤˜ p<0,05 ıˆڋıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ÛÙȘ Û˘Û¯ÂÙ›ÛÂȘ ÌÂÙ·‚ÏËÙÒÓ. ∂Ê·ÚÌfiÛÙËÎ·Ó Ù¯ÓÈΤ˜ ÔÏÏ·Ï‹˜ ·-
Paediatriki 2003;66:264-277
ÏÈÓ‰ÚfiÌËÛ˘ (multiple regression), ÒÛÙ ӷ ÂÎÙÈÌËı› Ô ‚·ıÌfi˜ ÛÙÔÓ ÔÔ›Ô ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ˘˜ ÂÍÂÙ·˙fiÌÂÓÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÙˆÓ Ì·ıËÙÒÓ. OÈ Î·Ù·ÓÔ̤˜ ÙÈÌÒÓ Ù˘ ÈÓÛÔ˘Ï›Ó˘, ÙÔ˘ ™µ, Ù˘ ¶ª, ÙÔ˘ ∞¢¶, ÙÔ ¶ªÀ, ÙˆÓ ÂȤ‰ˆÓ TG Î·È ÙÔ˘ ÏfiÁÔ˘ TC ÚÔ˜ HDL-¯ÔÏËÛÙÂÚfiÏË ÂÌÊ¿ÓÈÛ·Ó ıÂÙÈ΋ ÏÔÍfiÙËÙ· ηÈ, ¤ÙÛÈ, ÙÚÔÔÔÈ‹ıËÎ·Ó Û ÏÔÁ·ÚÈıÌÈ΋ Îϛ̷η ÚÈÓ ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÛÙȘ ·Ó·Ï‡ÛÂȘ. ∂ÎÙÈÌ‹ÛÂȘ Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ˘ÔÏÔÁ›ÛÙËÎ·Ó Ì ÙȘ ÂÍÈÛÒÛÂȘ ∏Oª∞ (¤¯ÔÓÙ·˜ ÚÒÙ· ÌÂÙ·ÙÚ¤„ÂÈ ÙȘ ÌÂÙÚ‹ÛÂȘ Ù˘ ÁÏ˘Îfi˙˘ Û mmol/l): IRHOMA = (ÈÓÛÔ˘Ï›ÓË Â› ÁÏ˘Îfi˙Ë) ‰È¿ 22,5 Î·È SECRHOMA = (ÈÓÛÔ˘Ï›ÓË Â› 20) ‰È¿ (ÁÏ˘Îfi˙Ë Ì›ÔÓ 3,5), ·ÓÙÈÛÙÔ›¯ˆ˜ (21). ∫·È ÔÈ ‰‡Ô ‰Â›ÎÙ˜ ¯ÚÂÈ¿ÛÙËÎ·Ó ÁÈ· ÙȘ ·Ó·Ï‡ÛÂȘ ÌÂÙ·ÙÚÔ‹ Û ÏÔÁ·ÚÈıÌÈ΋ Îϛ̷η.
∞ÔÙÂϤÛÌ·Ù· ÷ڷÎÙËÚÈÛÙÈο ÙÔ˘ ÏËı˘ÛÌÔ‡ ÌÂϤÙ˘ ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ Î·È ‚ÈÔ¯ËÌÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ ÁÈ· Ù· ·ÁfiÚÈ· Î·È Ù· ÎÔÚ›ÙÛÈ· Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ¢ª™ ÙˆÓ ·ÁÔÚÈÒÓ ‹Ù·Ó 18,5 kg/m2 [Ù˘È΋ ·fiÎÏÈÛË (∆∞) 3,5], Û¯ÂÙÈο ÌÈÎÚfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ô˘ ‹Ù·Ó 19,7 kg/m2 (∆∞ 3,9, p<0,05). ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ¢ª™ ÛÙ· ·ÁfiÚÈ· ËÏÈΛ·˜ <10 ÂÙÒÓ (fiÔ˘ Ù· 10 ¤ÙË ‹Ù·Ó Ë ‰È¿ÌÂÛË ËÏÈΛ· ÛÙÔ ‰Â›ÁÌ· ÌÂϤÙ˘) ‹Ù·Ó 17,4 kg/m2 (∆∞ 3,2), ÂÓÒ Û ·˘Ù¿ ËÏÈΛ·˜ ≥10 ÂÙÒÓ ‹Ù·Ó 19,4 kg/m2 (∆∞ 3,5). OÈ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÛÙ· ÎÔÚ›ÙÛÈ· ‹Ù·Ó 18,1 kg/m2 (∆∞ 3,0) Î·È 20,9 kg/m2 (∆∞ 4,1). ™ËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˘‹Ú¯Â ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ÛÙÔ ∞¢¶ (̤Û˜ ÙÈ̤˜ Û ·ÁfiÚÈ· 37,1 mm, ∆∞ 23,9 Î·È Û ÎÔÚ›ÙÛÈ· 50,6 mm, ∆∞ 34,5, p<0,0001) Î·È ÙÔ ¶ªπ, fiÔ˘ ÁÈ· ÙÔ ¶ªπ ÔÈ ÙÈ̤˜ ÛÙ· ÎÔÚ›ÙÛÈ· ‹Ù·Ó ÌÈÎÚfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÙˆÓ ·ÁÔÚÈÒÓ. ™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ÂÓÙÔ›ÛÙËÎ·Ó Î·È Û ¿ÏϘ ÌÂÙ·‚ÏËÙ¤˜ fiˆ˜ ÈÓÛÔ˘Ï›ÓË, HDL-¯ÔÏËÛÙÂÚfiÏË, TC/HDL, TG, Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË, ÁÏ˘Îfi˙Ë, πRHOMA Î·È SECRHOMA (¶›Ó·Î·˜ 1). ™Â ‰‡Ô ÎÔÚ›ÙÛÈ· ˘‹ÚÍ·Ó ·ÎÚ·›Â˜ ÙÈ̤˜ (extreme values) Ù˘ SECRHOMA (2016 Î·È 3402), ÔÈ Ôԛ˜ ·Ê·ÈÚ¤ıËÎ·Ó ÚÈÓ Á›ÓÂÈ Ë ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›·. ŸÏ· Ù· ·È‰È¿ ›¯·Ó ›‰· ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ, ÂÓÒ ÌfiÓÔ 1 ›¯Â ›‰· ÁÏ˘Îfi˙˘ (ÔÚȷο) ¿Óˆ ·fi ÙÔ ·ÓÒÙÂÚÔ Ê˘ÛÈÔÏÔÁÈÎfi, Ì ÙÈÌ‹ 117 mg/dL (·ÏÏ¿ Ë Û˘ÁΤÓÙÚˆÛË Ù˘ HbA1c ÛÙÔ ·›Ì· Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÂÙ¿¯ÚÔÓ˘ Ì·ı‹ÙÚÈ·˜ ‹Ù·Ó 4,6%, ‰ËÏ·‰‹ ÂÚ›Ô˘ ÛÙË ‰È¿ÌÂÛÔ ÙˆÓ ¿ÏÏˆÓ ÙÈÌÒÓ). ∆¤ÛÛÂÚ· ·È‰È¿ ›¯·Ó ›‰· ÁÏ˘Îfi˙˘ ¯·ÌËÏfiÙÂÚ· ·fi ÙÔ Î·ÙÒÙÂÚÔ fiÚÈÔ ÙˆÓ 70 mg/dL (Ì ÙÈ̤˜ ÌÂٷ͇ 60
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Paediatriki 2003;66:264-277
¶›Ó·Î·˜ 1. ™ˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ, ÏÈÔÚˆÙ½Ó˜ ÔÚÔ‡ Î·È ‚ÈÔ¯ËÌÈΤ˜ ·Ó·Ï‡ÛÂȘ Û 178 Ì·ıËÙ¤˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘ Ì ‚¿ÛË ÙÔ Ê‡ÏÔ ∞ÁfiÚÈ· (n=87) ª∆ (∆∞) ¢È¿ÌÂÛÔ˜ ∏ÏÈΛ· (¤ÙË) B¿ÚÔ˜ (kg) ⁄„Ô˜ (cm) 2 ¢ª™* (kg/m ) ∞¢¶** (mm) ¶ª (cm) ¶ªπ** ™˘ÛÙÔÏÈ΋ ∞¶* (mmHg) ¢È·ÛÙÔÏÈ΋ ∞¶ (mmHg) HbA1c (%) TC (mg/dL) HDL-¯ÔÏËÛÙÂÚfiÏË*** (mg/dL) LDL-¯ÔÏËÛÙÂÚfiÏË (mg/dL) TC/HDL*** TG***(mg/dL) πÓÛÔ˘Ï›ÓË** (ÌIU/ml) °Ï˘Îfi˙Ë* (mg/dL) §ÂÈÙÔ˘ÚÁ›· ‚-΢ÙÙ¿ÚˆÓ (SECR∏Oª∞)** ∞ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË (IR∏Oª∞)****
∫ÔÚ›ÙÛÈ· (n=91) ª∆ (∆∞) ¢È¿ÌÂÛÔ˜
™‡ÓÔÏÔ (n=178) ª∆ (∆∞) ¢È¿ÌÂÛÔ˜
10 (3,1) 36,6 (13,9) 138 (17,7) 18,5 (3,5) 37,1 (23,9) 63,2 (9,5) 0,9 (0,05) 111,4 (9,0) 67,3 (7,3) 4,5 (0,3) 174,7 (27,8)
10 33,6 139 17,7 28,0 61,0 0,9 110,0 67,3 4,5 175,0
10 (2,9) 40,2 (15,5) 140 (16,6) 19,7 (3,9) 50,6 (24,5) 63,9 (10,0) 0,8 (0,05) 114,3 (10,3) 68,4 (7,4) 4,5 (0,1) 178,4 (28,6)
10 38,0 140 18,9 46,0 63,0 0,8 112,3 68,0 4,5 178,0
10 (3,0) 38,4 (14,8) 139 (17,1) 19,1 (3,8) 44,0 (25,1) 63,6 (9,9) 0,8 (0,1) 112,9 (9,8) 67,9 (7,4) 4,5 (0,3) 176,6 (28,2)
10 35,9 139 18,2 34,5 61,8 0,8 110,7 68,0 4,5 177,5
58,2 (13,8)
56,0
52,8 (13,1)
51,0
55,5 (13,7)
54,0
104,3 (24,0) 3,1 (0,8) 61,8 (26,0) 7,0 (3,2) 85,0 (7,2)
104,0 2,9 58,0 7,7 85,0
111,3 (25,4) 3,5 (0,9) 72,0 (29,0) 10,9 (9,1) 82,1 (8,1)
105,0 3,3 66,0 6,1 82,0
107,9 (24,9) 3,3 (0,9) 66,8 (28,0) 9,0 (5,2) 83,5 (7,8)
104,0 3,2 62,0 7,8 83,0
127,1 (72,2)
109
214,0 (159,4)
162,0
172,2 (132,4)
132,0
1,5 (0,7)
1,3
2,1 (1,3)
1,8
1,8 (1,1)
1,6
ª.∆.: ª¤ÛË ÙÈÌ‹ ∆.∞.: ∆˘È΋ ·fiÎÏÈÛË * p<0,05 ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ʇψÓ, Mann-Whitney test ** p<0,0001 ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ʇψÓ, Mann-Whitney test *** p<0,01 ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ʇψÓ, Mann-Whitney test **** p<0,001 ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ʇψÓ, Mann-Whitney test
Î·È 70 mg/dL). ¢ÂηÙÚ›· ÎÔÚ›ÙÛÈ· ·fi Ù· 178 ·È‰È¿ ›¯·Ó ›‰· ÈÓÛÔ˘Ï›Ó˘ >17 ÌIU/ml. ™Â 4 ·È‰È¿, Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ ‹Ù·Ó <3 ÌIU/ml. ∆Ô 55% (¡=98) ÙˆÓ ·È‰ÈÒÓ Â›¯Â ›‰· TC >170 mg/dL Î·È 34 ·fi ·˘Ù¿ (35%, 19% Û˘ÓfiÏÔ˘ ‰Â›ÁÌ·ÙÔ˜) ›¯·Ó ÙÈ̤˜ >200 mg/dL (ÔÚȷο ·˘ÍË̤ӷ Î·È ·˘ÍË̤ӷ ›‰·: 22, 23 ·ÓÙÈÛÙÔ›¯ˆ˜). ∂ÈϤÔÓ, 35 ·È‰È¿ (20%) ›¯·Ó ÙÈ̤˜ LDL-¯ÔÏËÛÙÂÚfiÏ˘ >130 mg/dL (·˘ÍË̤ӷ ›‰·, 22). ¶ÂÓ‹ÓÙ· ¤ÍÈ ·È‰È¿ (32%) ›¯·Ó ÙÈ̤˜ Û˘ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ¿Óˆ ·fi ÙËÓ 95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ÙÈÌÒÓ Û ·È‰È¿ ÛÙȘ ∏.¶.∞. ‚¿ÛÂÈ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘, ÂÓÒ 17 ·È‰È¿ (10%) ›¯·Ó ÙÈ̤˜ ‰È·ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ¿Óˆ ·fi Ù· ·ÓÙ›ÛÙÔȯ· fiÚÈ· (24). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Ù·˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ·¯˘Û·ÚΛ·˜, ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·˜ (>17 ÌIU/ml), ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ (>200 mg/dL) Î·È ·˘ÍË̤Ó˘ Û˘ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (>95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË), 51 ·fi Ù· 178 ·È‰È¿ ›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ·fi ÙÔ˘˜ 4 ·Ú¿ÁÔÓÙ˜, 7 ·È‰È¿ (5 ·ÁfiÚÈ·, 2 ÎÔÚ›ÙÛÈ·) ›¯·Ó 3 Î·È 2 ·È‰È¿ (ÎÔÚ›ÙÛÈ·) ›¯·Ó Î·È ÙÔ˘˜ 4 ·Ú¿ÁÔ-
268
ÓÙ˜ ÎÈÓ‰‡ÓÔ˘. O ·ÚÈıÌfi˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘, Û ۯ¤ÛË Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÁÔÚÈÒÓ (34 ÎÔÚ›ÙÛÈ· ·ÓÙ› ÙÔ˘ ÚÔ‚ÏÂfiÌÂÓÔ˘ 26, ¯2=6,91, df=1, p=0,009). ™ÙÔÓ ¶›Ó·Î· 2 ·Ó·ÁÚ¿ÊÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ó¿Ï˘Û˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ηٿ ʇÏÔ. À‹Ú¯Â Ì›· ÌÈÎÚ‹, ·ÏÏ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ·ÚÔ˘Û›· ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ (‰È¿ÌÂÛ˜ ÙÈ̤˜: 23,2% ÁÈ· Ù· ·ÁfiÚÈ·, 22,0% ÁÈ· Ù· ÎÔÚ›ÙÛÈ·, p<0,05), ·ÏÏ¿ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ¿ÏÏË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ Ê‡ÏˆÓ ÛÙË Û‡ÛÙ·ÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜. ∆· ÛÙÔȯ›· ·fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi Î·È Ù· ·Ó·ÊÂÚfiÌÂÓ· ·ÓıÚˆÔÌÂÙÚÈο ‰Â‰Ô̤ӷ ÙˆÓ ÁÔÓ¤ˆÓ ÙˆÓ Ì·ıËÙÒÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. OÈ ·Ù¤Ú˜ ÙˆÓ Ì·ıËÙÒÓ ÂÌÊ·Ó›ÛÙËÎ·Ó ˘¤Ú‚·ÚÔÈ (25<¢ª™<30 kg/m2) ηٿ 56% Î·È ·¯‡Û·ÚÎÔÈ (¢ª™ ≥30 kg/m2) ηٿ 20%. ∆· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ÛÙȘ ÌËÙ¤Ú˜ ‹Ù·Ó 36% Î·È 17%. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ‰ÈÂıÓÒ˜ ηıÔÚÈṲ̂ӷ fiÚÈ· ÙÔ˘ ¢ª™
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¶ª r=0,30, fiÏ· p<0,0005 Î·È ™µ r=-0,19, p=0,01). ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ‰Â›ÎÙ˜ ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ٷ ›‰· TC. OÈ ‰Â›ÎÙ˜ ¶ªÀ Î·È ∞¢¶ ÂÌÊ¿ÓÈÛ·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ LDL-¯ÔÏËÛÙÂÚfiÏË (r=0,21, p=0,006 Î·È r=0,19, p=0,013, ·ÓÙ›ÛÙÔȯ·). OÈ Û¯¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ÙˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ ÛÙȘ ÌÔÓÔÌÂÙ·‚ÏËÙ¤˜ Û˘Û¯ÂÙ›ÛÂȘ ÂȂ‚·ÈÒıËÎ·Ó Î·È ÛÙȘ ·Ó·Ï‡ÛÂȘ ÔÏÏ·Ï‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘, Ì ·Ú¿ÏÏËÏÔ ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (¶›Ó·Î·˜ 4). ∫·È ÔÈ 6 ‰Â›ÎÙ˜ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË, ·Ú’ fiÏÔ Ô˘ ÙÔ 89-93% Ù˘ ‰È·Î‡Ì·ÓÛ˘ ÙˆÓ ÙÈÌÒÓ Ù˘ ‰ÂÓ ÌÔÚÔ‡Û ӷ ÚÔ‚ÏÂÊı›. OÈ ‰Â›ÎÙ˜ ¶ª, ™µ, ¢ª™ Î·È ∞¢¶ ÂÌÊ¿ÓÈÛ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË (r=0,51, 0,58, 0,50, 0,40, ·ÓÙ›ÛÙÔȯ·, p<0,0005 Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ) ηÈ, ›Û˘, Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi, Ì ÙË ‰È·ÛÙÔÏÈ΋ ›ÂÛË (r=0,32 Ì p<0,0005, 0,37 Ì p<0,0005, r=0,29 Ì p<0,0005 Î·È 0,19 Ì p=0,012, ·ÓÙ›ÛÙÔȯ·). ∏
ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ ·Ó¿ ËÏÈΛ· (ÌÈÛ¿ ¤ÙË) Î·È Ê‡ÏÔ, 58 ·È‰È¿ (33% ÙˆÓ 178 ·È‰ÈÒÓ Ì ϋÚÂȘ ÌÂÙÚ‹ÛÂȘ) ÎÚ›ıËÎ·Ó ˘¤Ú‚·Ú· ηÈ, ·fi ·˘Ù¿ Ù· ·È‰È¿, Ù· 16 (9% ÙÔ˘ Û˘ÓfiÏÔ˘) ÎÚ›ıËÎ·Ó ·¯‡Û·Úη (25). OÈ 58 ˘¤Ú‚·ÚÔÈ Î·È ·¯‡Û·ÚÎÔÈ Ì·ıËÙ¤˜ ›¯·Ó ÛÙ·ÙÈÛÙÈο ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, LDL-¯ÔÏËÛÙÂÚfiÏ˘, ÏfiÁÔ˘ TC/HDL, TG Î·È ÈÓÛÔ˘Ï›Ó˘ Û ۯ¤ÛË Ì ÙÔ˘˜ Ì·ıËÙ¤˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜. ™˘Û¯ÂÙ›ÛÂȘ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Ì ÏÈÔÚˆÙ½Ó˜ ÔÚÔ‡, ·ÚÙËÚȷ΋ ›ÂÛË, Û˘ÁΤÓÙÚˆÛË ÈÓÛÔ˘Ï›Ó˘, ›‰· ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ Î·È ÙÈ̤˜ HbA1c ¶¤ÓÙ ·fi ÙÔ˘˜ 6 ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙȘ ÙÈ̤˜ HDL-¯ÔÏËÛÙÂÚfiÏ˘ (¢ª™ r=-0,27, p<0,0005, ¶ªÀ r=-0,28, p<0,0005, ∞¢¶ r=-0,25, p=0,001, ¶ª r=-0,24, p=0,001, ™µ r=-0,17, p=0,023) Î·È ıÂÙÈ΋ Û¯¤ÛË Ì ÙÔ ÏfiÁÔ TC/HDL (¢ª™ r=0,34, ¶ªÀ r=0,36, ∞¢¶ r=0,35,
¶›Ó·Î·˜ 2. ™‡ÓıÂÛË ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Û ÏÈ·Ú¿ Ôͤ· Û 111 Ì·ıËÙ¤˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘ ηٿ ʇÏÔ* ∫·ÙËÁÔÚ›· ÏÈ·ÚÒÓ ÔͤˆÓ**
∫ÔÚÂṲ̂ӷ *** ªÔÓÔ·ÎfiÚÂÛÙ· ¶ÔÏ˘·ÎfiÚÂÛÙ· Trans ø̤Á·-3 ø̤Á·-6
∞ÁfiÚÈ· (n=46)
∫ÔÚ›ÙÛÈ· (n=65)
™‡ÓÔÏÔ (n=111)
ª¤ÛË ÙÈÌ‹ % (∆∞)
¢È¿ÌÂÛÔ˜ %
ª¤ÛË ÙÈÌ‹ % (∆∞)
¢È¿ÌÂÛÔ˜ %
ª¤ÛË ÙÈÌ‹ % (∆∞)
¢È¿ÌÂÛÔ˜ %
23,6 (3,5) 60,2 (3,9) 13,4 (0,9) 1,6 (0,4) 0,80 (0,13) 12,5 (0,9)
23,2 60,6 13,4 1,6 0,79 12,6
22,1 (2,5) 61,7 (2,5) 13,6 (1,0) 1,5 (0,3) 0,77 (0,12) 12,7 (1,0)
22,0 61,8 13,5 1,5 0,74 12,7
22,7 (3,0) 61,1 (3,2) 13,5 (1,0) 1,5 (0,3) 0,78 (0,12) 12,6 (0,9)
22,8 61,1 13,5 1,5 0,78 12,6
* ∞fi Ù· 178 ·È‰È¿ Ì ϋÚË ‰Â‰Ô̤ӷ ÛÙȘ ۈ̷ÙÔÌÂÙÚÈΤ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ÌÂÙÚ‹ÛÂȘ, 111 Û˘ÌÊÒÓËÛ·Ó Ó· Ú·ÁÌ·ÙÔÔÈËı› Ï‹„Ë ‰Â›ÁÌ·ÙÔ˜ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ** % ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ *** p<0,05 ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ʇψÓ, Mann-Whitney test ¶›Ó·Î·˜ 3. ∞·ÓÙ‹ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ÙˆÓ Ì·ıËÙÒÓ ÛÙÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ˘Á›·˜ (n=86*)
Œ¯ÂÈ ˘¤ÚÙ·ÛË Œ¯ÂÈ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË ∂›¯Â ‰È·‚‹ÙË Î‡ËÛ˘ Œ¯ÂÈ ˘ÔÛÙ› ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ À¤Ú‚·ÚÔ˜** ¶·¯‡Û·ÚÎÔ˜***
ªËÙ¤Ú· n (%)
¶·Ù¤Ú·˜ n (%)
3 (4) 1 (1) 2 (2) 0 31 (36) 15 (17)
5 (6) 0 1 (1) 48 (56) 17 (20) ª¤ÛË ÙÈÌ‹ (∆∞)
µ¿ÚÔ˜ (kg) ⁄„Ô˜ (cm) 2 ¢ª™ (kg/m )
68,4 (10,7) 161,9 (6,6) 26,2 (4,1)
81,8 (12,0) 172,7 (7,1) 27,4 (3,6)
* ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Û˘ÌÏËÚÒıËÎ·Ó ·fi 86 ÁÔÓ›˜ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û 157 ·È‰È¿ 2 ** 25<¢ª™<30 kg/m 2 *** ¢ª™ >30 kg/m
269
¶·È‰È·ÙÚÈ΋ 2003;66:264-277
¶ªÀ ‰ÂÓ ·ÚÔ˘Û›·ÛÂ Û˘Û¯¤ÙÈÛË Ì ÙË Û˘ÛÙÔÏÈ΋ ‹ ÙË ‰È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË, ÂÓÒ Ë ¶ªπ ÂÌÊ¿ÓÈÛ ·ÚÓËÙÈ΋ Û¯¤ÛË ÌfiÓÔ Ì ÙË Û˘ÛÙÔÏÈ΋ ›ÂÛË (r=-0,28, p<0,0005). OÈ ‰Â›ÎÙ˜ ¶ª, ™µ, ¢ª™, ∞¢¶ Î·È ¶ªÀ ÂÌÊ¿ÓÈÛ·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ ›‰· ÈÓÛÔ˘Ï›Ó˘ ÓËÛÙ›·˜ (r=0,59, 0,65, 0,63, 0,57 Î·È 0,21, ·ÓÙ›ÛÙÔȯ·, p<0,0005 ÁÈ· ÙȘ ÚÒÙ˜ 4 ÌÂÙ·‚ÏËÙ¤˜ Î·È p=0,005 ÁÈ· ÙËÓ ¶ªÀ). ∞ÓÙ›ıÂÙ·, Ë ¶ªπ ÂÌÊ¿ÓÈÛ ·ÚÓËÙÈ΋ Û¯¤ÛË Ì ÙȘ ÙÈ̤˜ ÈÓÛÔ˘Ï›Ó˘ (r=-0,36, p<0,0005). OÈ 5 ‰Â›ÎÙ˜ Ì ÙË ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÚÔ˜ Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘, ‰È·Ù‹ÚËÛ·Ó ÙË Û¯¤ÛË ·˘Ù‹ Î·È ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ËÏÈΛ· Î·È Ê‡ÏÔ (Û fiÏ· Ù· 5 ÌÔÓ٤Ϸ ·ÏÈÓ‰ÚfiÌËÛ˘ ›¯·Ó ÚÔ‚ÏÂÙÈ΋ ‰‡Ó·ÌË ÂÚ›Ô˘ ÛÙÔ 50%, ¶›Ó·Î·˜ 4). ∞ÓÙ›ıÂÙ·, Ë Û¯¤ÛË Ù˘ ¶ªπ Ì ÙȘ ÙÈ̤˜ ÈÓÛÔ˘Ï›Ó˘ ¯¿ıËΠÌÂÙ¿ ·fi ÙÔÓ ¤ÏÂÁ¯Ô ÁÈ· ËÏÈΛ· Î·È Ê‡ÏÔ. OÈ ‰Â›ÎÙ˜ ¶ª, ™µ, ∞¢¶ Î·È ¢ª™ ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ·ÚÓËÙÈ΋ Û¯¤ÛË Ì ٷ ›‰· ÁÏ˘Îfi˙˘ (r=-0,24 Ì p=0,002, r=-0,22 Ì p=0,004, r=-0,21 Ì p=0,005 Î·È r=-0,19 Ì p=0,01, ·ÓÙ›ÛÙÔȯ·). ∆Ô ∞¢¶, Ë ¶ª Î·È Ë ¶ªÀ ÂÌÊ¿ÓÈÛ·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ HbA1c (r=0,18, 0,15 Î·È 0,14, Î·È ÛÙȘ ÙÚÂȘ ÂÚÈÙÒÛÂȘ 0,01<p≤0,05). ªÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ, ηӤӷ˜ ·fi ÙÔ˘˜ ‰Â›ÎÙ˜ ‰ÂÓ Â›¯Â Û˘Û¯¤ÙÈÛË Ì ÙË ÁÏ˘Îfi˙Ë Î·È ÌfiÓÔ ÙÔ ∞¢¶ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ ÙÈ̤˜ HbA1c (·Ú¿ÁÔÓÙ·˜ ·ÏÈÓ‰ÚfiÌËÛ˘ 0,13 Î·È 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ 0,03-0,23, p=0,011) (¶›Ó·Î·˜ 4). OÈ ‰Â›ÎÙ˜ ¶ª, ™µ, ¢ª™, ∞¢¶ Î·È ¶ªÀ ÂÌÊ¿ÓÈÛ·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Î·È Ì ÙËÓ ÂÎÙÈÌÒÌÂÓË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ SECRHOMA (r=0,62, 0,67, 0,63, 0,58 Î·È 0,20, ·ÓÙ›ÛÙÔȯ·, p<0,0005 ÁÈ· ÙȘ ÚÒÙ˜ 4 ÌÂÙ·‚ÏËÙ¤˜ Î·È p=0,004 ÁÈ· ÙËÓ ¶ªÀ) Î·È Ì ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË πRHOMA (r=0,56, 0,62, 0,60, 0,54 Î·È 0,18, ·ÓÙ›ÛÙÔȯ·, p<0,0005 ÁÈ· ÙȘ ÚÒÙ˜ 4 ÌÂÙ·‚ÏËÙ¤˜ Î·È p=0,006 ÁÈ· ÙË ¶ªÀ). ∞ÓÙ›ıÂÙ·, Ë ¶ªπ ÂÌÊ¿ÓÈÛ ·ÚÓËÙÈ΋ Û¯¤ÛË Î·È Ì ÙÔ˘˜ ‰‡Ô ‰Â›ÎÙ˜ (SECRHOMA r=-0,37, p<0,0005 Î·È IRHOMA r=-0,35, p<0,0005). OÈ 5 ‰Â›ÎÙ˜ Ì ÙË ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÚÔ˜ Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘, ‰È·Ù‹ÚËÛ·Ó ÙË Û¯¤ÛË ·˘Ù‹ Î·È ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ËÏÈΛ· Î·È Ê‡ÏÔ (Ë ‰‡Ó·ÌË Ù˘ Úfi‚Ï„˘ ‹Ù·Ó ÌÂٷ͇ 33% Î·È 45% ÛÙ· ÌÔÓ٤Ϸ IRHOMA Î·È 48% Ì 55% ÛÙ· ÌÔÓ٤Ϸ SECRHOMA, ¶›Ó·Î·˜ 4). ∞ÓÙ›ıÂÙ·, Ë Û¯¤ÛË Ù˘ ¶ªπ Ì ÙȘ ÙÈ̤˜ ÈÓÛÔ˘Ï›Ó˘ ¯¿ıËΠÌÂÙ¿ ·fi ÙÔÓ ¤ÏÂÁ¯Ô ÁÈ· ËÏÈΛ· Î·È Ê‡ÏÔ. ™˘Û¯ÂÙ›ÛÂȘ Û‡ÛÙ·Û˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· OÈ Û¯¤ÛÂȘ ÌÂٷ͇ ÏÈ·ÚÒÓ ÔͤˆÓ ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ Î·È ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ·¤‚ËÛ·Ó ÛÂ
270
Paediatriki 2003;66:264-277
ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ÌË-ÈÛ¯˘Ú¤˜. ∆Ô ÔÛÔÛÙfi ÙˆÓ trans ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔÓ ÏÈÒ‰Ë ÈÛÙfi ÂÌÊ¿ÓÈÛ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È ·ÚÓËÙÈ΋ Ì ٷ ›‰· TG (r=0,19, p=0,039 Î·È r=0,286, p=0,004, ·ÓÙ›ÛÙÔȯ·). ¶·Ú¿ÏÏËÏ·, ˘‹ÚÍ ̛· ıÂÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ÔÛÔÛÙÔ‡ ÌÔÓÔ·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ TG (r=0,199, p=0,033). ∆Ô ÔÛÔÛÙfi ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ ˘Ô‰fiÚÈÔ Ï›Ô˜ Û¯ÂÙÈ˙fiÙ·Ó ıÂÙÈο Ì ÙË Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË (r=0,20, p=0,031) Î·È ÈÔ ÂȉÈο, Ù· ˆÌ¤Á·-3 ÂÌÊ¿ÓÈÛ·Ó ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË Ì ÙË Û˘ÛÙÔÏÈ΋ (r=0,24, p=0,009) Î·È ÙË ‰È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË (r=0,21, p=0,025). ∏ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ Û ÎÔÚÂṲ̂ӷ ÏÈ·Ú¿ Ôͤ· ÂÌÊ¿ÓÈÛ ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û¯¤ÛË Ì ٷ ›‰· ÈÓÛÔ˘Ï›Ó˘ (r=-0,338, p<0,001) Î·È Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ (r=0,35, p<0,0001), ÂÓÒ Ù· ÌÔÓÔ·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· ·ÚÔ˘Û›·Û·Ó ıÂÙÈ΋ Û¯¤ÛË Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË (r=0,286, p=0,002). ∂ÈÚfiÛıÂÙ·, ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ˘‹Ú¯Â Î·È ÌÂٷ͇ ÙˆÓ ˆÌ¤Á·-3 ÏÈ·ÚÒÓ ÔͤˆÓ ηÈ: ·) Ù˘ ÈÓÛÔ˘Ï›Ó˘ (r=0,206, p=0,002), ‚) Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ (r=0,21, p=0,014) Î·È Á) Ù˘ Û¯ÂÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË (r=0,20, p=0,018). ∫·Ì›· ̤ÙÚËÛË ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ ÂÎ ‰È·ÙÚÔÊ‹˜ ‹ ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ HbA1c. ∏ ·Ó¿Ï˘ÛË Ì ÔÏÏ·Ï‹ ·ÏÈÓ‰ÚfiÌËÛË ¤‰ÂÈÍ ˆ˜ ÙÔ ÔÛÔÛÙfi ÙˆÓ ˆÌ¤Á·-3 ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ ÏÈÒ‰Ë ÈÛÙfi ÂÚÌ‹ÓÂ˘Â Ì¤ÚÔ˜ Ù˘ ‰È·Î‡Ì·ÓÛ˘ ÛÙȘ ÙÈ̤˜ ÙˆÓ LDL-¯ÔÏËÛÙÂÚfiÏË Î·È TC/HDL, ÂÓÒ Ù· trans ÏÈ·Ú¿ Ôͤ· ÚÔ¤‚ÏÂ·Ó Ì¤ÚÔ˜ ·fi ÙË ‰È·Î‡Ì·ÓÛË ÙˆÓ ÂȤ‰ˆÓ TG (¶›Ó·Î·˜ 5). ∞fi ÙȘ ÂÊ·ÚÌÔÁ¤˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ‰ÂÓ ÚԤ΢„·Ó ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ÎÔÚÂṲ̂ӈÓ, ÌÔÓÔ·ÎfiÚÂÛÙˆÓ Î·È ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ÙˆÓ ÎÏ·ÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ™˘˙‹ÙËÛË ∏ ÌÂϤÙË ·˘Ù‹ ·ÔÙÂÏ› Ì›· ÚÔÛ¿ıÂÈ· Û˘Û¯¤ÙÈÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Ì ÙÔ Û‡ÓÔÏÔ ÙˆÓ Î‡ÚÈˆÓ ÚԉȷıÂÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· ·Ó¿Ù˘ÍË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. OÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ‚Ú¤ıËÎ·Ó Ó· ÂÚÌËÓÂ‡Ô˘Ó ÙË ‰È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÈÓÛÔ˘Ï›Ó˘ (4050%) Î·È Û˘ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (¤ˆ˜ 35%) ÂÚÈÛÛfiÙÂÚÔ ·fi ·˘Ù¤˜ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ (7-11%). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ηٷϋÁÔ˘Ó ÛÙÔ fiÙÈ Ë ¶ªπ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È ÙfiÛÔ ÛÙÂÓ¿ Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·, fiÛÔ ÔÈ ¿ÏÏÔÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜. ∏ ¶ªπ Â›Ó·È Ô ÌfiÓÔ˜ ‰Â›ÎÙ˘ Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È ÌÂ
¶·È‰È·ÙÚÈ΋ 2003;66:264-277
Paediatriki 2003;66:264-277
¶›Ó·Î·˜ 4. ∞ÔÙÂϤÛÌ·Ù· Ù˘ ·Ó¿Ï˘Û˘ ÔÏÏ·Ï‹˜ ÛÙ·ÙÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÁÈ· ÙË Û¯¤ÛË ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Ì ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·* ∂Í·ÚÙÒÌÂÓË ÌÂÙ·‚ÏËÙ‹
∞ÓÂÍ¿ÚÙËÙË ÌÂÙ·‚ÏËÙ‹**
R**
™˘ÓÙÂÏÂÛÙ‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘)
t ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË
p-value
πÓÛÔ˘Ï›ÓË***
™µ*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶***
0,52 0,46 0,50 0,40 0,48
1,25 (0,98 ¤ˆ˜ 1,52) 1,93 (1,40 ¤ˆ˜ 2,46) 0,08 (0,06 ¤ˆ˜ 0,09) 1,71 (1,09 ¤ˆ˜ 2,34) 0,49 (0,37 ¤ˆ˜ 0,61)
9,08 7,22 8,45 5,04 7,89
<0,0005 <0,0005 <0,0005 <0,0005 <0,0005
™µ*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶***
0,55 0,53 0,54 0,48 0,54
1,30 (1,00 ¤ˆ˜ 1,59) 2,21 (1,65 ¤ˆ˜ 2,77) 0,08 (0,06 ¤ˆ˜ 0,10) 2,04 (1,38 ¤ˆ˜ 2,71) 0,53 (0,40 ¤ˆ˜ 0,66)
8,69 7,82 8,24 6,04 7,99
<0,0005 <0,0005 <0,0005 <0,0005 <0,0005
™µ*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶*** ∞¢¶*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶*** ™µ*** ¶ª*** ¢ª™ ¶ªπ ¶ªÀ*** ∞¢¶*** ™µ*** ¶ª*** ¢ª™ ¶ªπ ¶ªÀ*** ∞¢¶*** ™µ*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶*** ™µ*** ¶ª*** ¢ª™ ¶ªÀ*** ∞¢¶*** ™µ*** ¶ª*** ¢ª™
0,45 0,38 0,42 0,33 0,41 0,04 0,06 0,05 0,06 0,05 0,07 0,10 0,10 0,08 0,11 0,07 0,14 0,19 0,18 0,12 0,20 0,15 0,19 0,21 0,17 0,17 0,20 0,35 0,29 0,30 0,23 0,27 0,15 0,11 0,11
1,22 (0,92 ¤ˆ˜ 1,52) 1,83 (1,25 ¤ˆ˜ 2,41) 0,07 (0,05 ¤ˆ˜ 0,92) 1,58 (0,91 ¤ˆ˜ 2,26) 0,47 (0,34 ¤ˆ˜ 0,60) 0,13 (0,03 ¤ˆ˜ 0,23) 41,1 (9,9 ¤ˆ˜ 72,4) 1,27 (0,19 ¤ˆ˜ 2,35) 47,3 (12,6 ¤ˆ˜ 82,1) 8,3 (0,8 ¤ˆ˜ 15,8) -11,9 (-20,8 ¤ˆ˜ -3,0) -30,2 (-46,5 ¤ˆ˜ -13,9) -1,01 (-1,57 ¤ˆ˜ -0,44) -68,2 (-111,9 ¤ˆ˜ -24,5) -36,9 (-54,9 ¤ˆ˜ -18,4) -4,9 (-8,8 ¤ˆ˜ -0,9) 0,34 (0,18 ¤ˆ˜ 0,51) 0,78 (0,49 ¤ˆ˜ 1,07) 0,03 (0,02 ¤ˆ˜ 0,04) 1,34 (0,58 ¤ˆ˜ 2,20) 0,89 (0,57 ¤ˆ˜ 1,21) 0,15 (0,08 ¤ˆ˜ 0,22) 0,64 (0,39 ¤ˆ˜ 0,90) 1,24 (0,79 ¤ˆ˜ 1,69) 0,04 (0,02 ¤ˆ˜ 0,05) 1,19 (0,68 ¤ˆ˜ 1,70) 0,29 (0,18 ¤ˆ˜ 0,40) 19,10 (13,45 ¤ˆ˜ 24,74) 27,28 (16,62 ¤ˆ˜ 37,95) 1,00 (0,64 ¤ˆ˜ 1,36) 19,59 (7,23 ¤ˆ˜ 31,94) 5,94 (3,37 ¤ˆ˜ 8,51) 10,15 (5,27 ¤ˆ˜ 15,03) 13,18 (4,18 ¤ˆ˜ 22,19) 0,42 (0,11 ¤ˆ˜ 0,73)
8,10 6,25 7,46 4,61 6,90 2,58 2,60 2,31 2,69 2,19 -2,63 -3,65 -3,52 -3,08 -3,96 -2,43 4,08 5,34 4,90 3,38 5,51 4,14 5,03 5,43 4,53 4,58 5,33 6,68 5,05 5,41 3,13 4,57 4,11 2,89 2,66
<0,0005 <0,0005 <0,0005 <0,0005 <0,0005 0,011 0,010 0,022 0,008 0,030 0,009 <0,0005 0,001 0,002 <0,0005 0,016 <0,0005 <0,0005 <0,0005 0,001 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 <0,0005 0,002 <0,0005 <0,0005 0,004 0,008
§ÂÈÙÔ˘ÚÁ›· ‚-΢ÙÙ¿ÚˆÓ (SECR∏Oª∞)***
∞ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË (πR∏Oª∞)***
HbA1c LDL-¯ÔÏËÛÙÂÚfiÏË
HDL-¯ÔÏËÛÙÂÚfiÏË
TC/HDL
TG
™˘ÛÙÔÏÈ΋ ∞¶
¢È·ÛÙÔÏÈ΋ ∞¶
* n=178. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÌfiÓÔ ÔÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ì ÙËÓ ÂÍ·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹. ¢ÂÓ ˘‹Ú¯·Ó Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ Î·È Ù˘ ÁÏ˘Îfi˙˘ ‹ Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ** ¶¤Ú·Ó ÙÔ˘ ‰Â›ÎÙË ·¯˘Û·ÚΛ·˜, ÙÔ Ê‡ÏÔ Î·È Ë ËÏÈΛ· ÂÚÈÂÏ‹ÊıËÛ·Ó Û οı ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘ *** ™Â Îϛ̷η Ê˘ÛÈÎÔ‡ ÏÔÁ¿ÚÈıÌÔ˘
271
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Paediatriki 2003;66:264-277
ÙËÓ ÈÓÛÔ˘Ï›ÓË (ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÛÙËÓ ÔÏ˘ÌÂÙ·‚ÏËÙ‹ ·Ó¿Ï˘ÛË). ∏ ¶ª, Ë ¶ªÀ Î·È Ô ¢ª™ ·ÚÔ˘Û›·˙·Ó ÙËÓ ÈÛ¯˘ÚfiÙÂÚË Û˘Û¯¤ÙÈÛË Ì ٷ ›‰· ÏÈÔÚˆÙÂ˚ÓÒÓ. ∆Ô ™µ ›¯Â ÛÙÂÓfiÙÂÚË Û¯¤ÛË Ì ÙË Û˘ÛÙÔÏÈ΋ Î·È ‰È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ·fi ÙÔ˘˜ ¿ÏÏÔ˘˜ ‰Â›ÎÙ˜. ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ¤¯Ô˘Ó ›Û˘ ‰Â›ÍÂÈ ÙË ıÂÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜ Î·È ÂȤ‰ˆÓ TC, TG, LDL-¯ÔÏËÛÙÂÚfiÏË, ηıÒ˜ Î·È ÙËÓ ·ÚÓËÙÈ΋ Û¯¤ÛË Ì ÙȘ ÙÈ̤˜ HDL-¯ÔÏËÛÙÂÚfiÏ˘ (26,27). ∏ ÌÂϤÙË Bogalusa Heart Study ÛÙȘ ∏.¶.∞. (Ì 2996 ·È‰È¿ ËÏÈΛ·˜ 517 ÂÙÒÓ) Î·È ¿ÏϘ ÂÚÁ·Û›Â˜ ηٷϋÁÔ˘Ó ÛÙÔ ›‰ÈÔ Û˘Ì¤Ú·ÛÌ· Ì ÙËÓ ·ÚÔ‡Û·, ‰ËÏ·‰‹ fiÙÈ ›Ûˆ˜ Ë ¶ª ·ÔÙÂÏ› ÙÔÓ Î·Ï‡ÙÂÚÔ ‰Â›ÎÙË Î·Ù·ÓÔÌ‹˜ Ï›Ô˘˜ ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÙˆÓ ·È‰ÈÒÓ Ì ‰˘ÛÌÂÓ‹ Û˘ÁΤÓÙÚˆÛË ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ÈÓÛÔ˘Ï›Ó˘ Î·È ÙËÓ ˘¤ÚÙ·ÛË (16,18,28). ªÂ ‚¿ÛË ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ·ÁfiÚÈ· ‹Ù·Ó 23,6% (95% ¢∂: 22,6-24,6%). ™Â ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠·ÁfiÚÈ· ËÏÈΛ·˜ 8-16 ÂÙÒÓ Û ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ù˘ ∫Ú‹Ù˘ ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980, ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ‹Ù·Ó 20,3% (95% ¢∂: 19,321,3%) (29). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ·ÏÏ·Á‹ ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ Ô˘ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÛÙËÓ ∫Ú‹ÙË ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ (4). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Û‡ÛÙ·ÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ‚Ú¤ıËΠfiÙÈ ‰ÂÓ ·ÔÙÂÏ› ÈÛ¯˘Úfi ‰Â›ÎÙË ÁÈ· Ù· ›‰· ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Û˘ÌʈÓ› Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚfiÛÊ·Ù˘ ÌÂϤÙ˘ Û ·È‰È¿ ËÏÈΛ·˜ 12 ÂÙÒÓ ·fi ÙËÓ ∫Ú‹ÙË, Ë ÔÔ›· ¤‰ÂÈÍ ˆ˜ ÔÈ ‰Â›ÎÙ˜
·¯˘Û·ÚΛ·˜ ·ÔÙÂÏÔ‡Ó ÈÛ¯˘ÚfiÙÂÚÔ˘˜ ‰Â›ÎÙ˜ ÁÈ· Ù· ›‰· ÏÈÔÚˆÙÂ˚ÓÒÓ Û ۯ¤ÛË Ì ÙË Û‡ÛÙ·ÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ·fi ÙË ÁÏÔ˘ÙÈ·›· ÂÚÈÔ¯‹ (30). ∆Ô ˘Ô‰fiÚÈÔ Ï›Ô˜ Ù˘ ÂÚÈÔ¯‹˜ ·˘Ù‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ÏÈfiÏ˘Û˘ Û ۯ¤ÛË Ì ·˘Ùfi Ù˘ ÎÔÈÏȷ΋˜ ¯ÒÚ·˜ (31), fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ·fi ÙÔ˘˜ Mamalakis Î·È Û˘Ó (32). ∏ ÏÈfiÏ˘ÛË ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ Ë·ÙÈ΋˜ Û‡ÓıÂÛ˘ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ÙËÓ ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ‹˜ ÙÔ˘˜ ÛÙÔ Ï¿ÛÌ·. ªÂϤÙË Û ·È‰È¿ ËÏÈΛ·˜ 11-18 ÂÙÒÓ ¤‰ÂÈÍ fiÙÈ Ë Û‡ÛÙ·ÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ù˘ ÎÔÈÏȷ΋˜ ÂÚÈÔ¯‹˜ ·ÔÙÂÏ› ηχÙÂÚÔ ‰Â›ÎÙË ÁÈ· Ù· ›‰· ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·’ fi,ÙÈ ·˘Ù‹ Ù˘ ÁÏÔ˘ÙÈ·›·˜ ÂÚÈÔ¯‹˜ (32). ∏ ›‰Ú·ÛË Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ ÛÙ· ÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ÚÔÛ‰ÈÔÚÈÛÙ› ·ÎfiÌ· (33), ÂÓÒ ÔÈ Û¯ÂÙÈΤ˜ ÌÂϤÙ˜ Â›Ó·È Û¿ÓȘ. °È· ·È‰ÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜, ÂÎÙfi˜ ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ ÌÂÏÂÙÒÓ, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯Ô˘Ó ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÌÂϤÙ˜ Û˘Û¯¤ÙÈÛ˘ Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ٷ ›‰· ÏÈÔÚˆÙÂ˚ÓÒÓ. ∆· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ÌÂϤÙ˘ Û ·¯‡Û·Úη ÂÓ‹ÏÈη ¿ÙÔÌ· ÛÙËÓ πÛ·Ó›· ¤‰ÂÈÍ·Ó fiÙÈ ‰ÂÓ ˘‹Ú¯Â Û˘Û¯¤ÙÈÛË ÎÔÚÂÛÌ¤ÓˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Ì ٷ ÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, ÂÓÒ ˘‹Ú¯Â ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ˆÌ¤Á·-3 ÏÈ·ÚÒÓ ÔͤˆÓ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ٷ ÙÚÈÁÏ˘ÎÂÚ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ HDL, ÁÂÁÔÓfi˜ Ô˘ ÔÈ Û˘ÁÁÚ·Ê›˜ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ˆ˜ ·ÚfiÌÔÈÔ Â‡ÚËÌ· Ì ·˘Ùfi ¿ÏÏˆÓ ÂȉËÌÈÔÏÔÁÈÎÒÓ ÌÂÏÂÙÒÓ ÛÙË ™ÎˆÙ›·, ºÈÓÏ·Ó‰›· Î·È πÙ·Ï›· (33). À¿Ú¯ÂÈ, Û ÌÂÁ¿ÏÔ ‚·ıÌfi, ·ÏÏËÏÔÂÈÎ¿Ï˘„Ë ÌÂٷ͇ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ Î·È ·˘ÙÒÓ ÁÈ· ‰È·‚‹ÙË Ù‡Ô˘ 2 (34). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· ÂÓÔ¯ÔÔÈ›ٷÈ
¶›Ó·Î·˜ 5. ∞ÔÙÂϤÛÌ·Ù· ·Ó¿Ï˘Û˘ ÔÏÏ·Ï‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÁÈ· ÙË Û¯¤ÛË Û‡ÓıÂÛ˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·* ∂Í·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹
§ÂÈÙÔ˘ÚÁ›· ‚-΢ÙÙ¿ÚˆÓ (SECR∏Oª∞)*** ∞ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË (πR∏Oª∞)*** LDL-¯ÔÏËÛÙÂÚfiÏË TC/HDL TG
∞ÓÂÍ¿ÚÙËÙË ÌÂÙ·‚ÏËÙ‹ (ÏÈ·Ú¿ Ôͤ·)**
R**
™˘ÓÙÂÏÂÛÙ‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘)
t ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË
p-value
∫ÔÚÂṲ̂ӷ ø̤Á·-3*** ø̤Á·-3*** ø̤Á·-3*** ø̤Á·-3*** Trans***
0,31 0,31 0,27 0,08 0,08 0,11
-0,86 (-1,65 ¤ˆ˜ -0,08) 0,70 (0,08 ¤ˆ˜ 1,33) 0,65 (0,03 ¤ˆ˜ 1,26) 33,7 (0,0 ¤ˆ˜ 67,4) 0,33 (0,01 ¤ˆ˜ 0,65) -0,46 (-0,81 ¤ˆ˜ -0,12)
-2,18 2,22 2,08 1,98 2,02 -2,66
0,031 0,028 0,040 0,050 0,046 0,009
* n=117. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÌfiÓÔ ÔÈ ÔÌ¿‰Â˜ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÁÈ· ÙȘ Ôԛ˜ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ì ÙËÓ ÂÍ·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹. ¢ÂÓ ˘‹Ú¯·Ó Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ÙËÓ HbA1c, ÙË ÁÏ˘Îfi˙Ë, ÙËÓ ÈÓÛÔ˘Ï›ÓË, ÙËÓ ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË, ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË, ÙË Û˘ÛÙÔÏÈ΋ ‹ ÙË ‰È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ** ∂ÎÙfi˜ ·fi ÙËÓ Î·ÙËÁÔÚ›· ÏÈ·ÚÒÓ ÔͤˆÓ, ÙÔ Ê‡ÏÔ Î·È Ë ËÏÈΛ· ÂÚÈÂÏ‹ÊıËÛ·Ó Û οı ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘ *** ™Â Îϛ̷η Ê˘ÛÈÎÔ‡ ÏÔÁ¿ÚÈıÌÔ˘
272
¶·È‰È·ÙÚÈ΋ 2003;66:264-277
fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· ÁÈ· ÙËÓ ÚfiÎÏËÛË ÛÔ‚·ÚÒÓ ·ÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ ÏfiÁˆ ·ıËÚÔÛÎÏ‹Ú˘ÓÛ˘. ªÂÁ¿Ï˜ ÚÔÔÙÈΤ˜ ÏËı˘ÛÌȷΤ˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ˆ˜ Ë ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (35). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, fiÏÔÈ ÔÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜, ÂÎÙfi˜ ·fi ÙËÓ ¶ªπ, ·ÚÔ˘Û›·Û·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ ›‰· ÈÓÛÔ˘Ï›Ó˘ ÛÙÔ Ï¿ÛÌ·. ªÂ ‚¿ÛË ·˘Ùfi ÙÔ ÛÙÔÈ¯Â›Ô Î·È ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì¤¯ÚÈ ÛÙÈÁÌ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë Ì¤ÙÚËÛË ÈÓÛÔ˘Ï›Ó˘ Ï¿ÛÌ·ÙÔ˜ ÛÙ· Ï·›ÛÈ· Ù˘ ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ·Ó·‰ÂÈÎÓ‡ÂÙ·È Ë ÛËÌ·Û›· ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ‰ÂÈÎÙÒÓ ÛÙÔÓ ÂÓÙÔÈÛÌfi ·È‰ÈÒÓ Ì ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·. ™Â ·¯‡Û·Úη ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜, ¤Ó·˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ‰È·Ù·Ú·¯‹ ÛÙËÓ Î·Ì‡ÏË ·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ Â›Ó·È Ë ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· ÌÂÙ¿ ·fi ÓËÛÙ›· (35). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·fi ÙȘ 13 Ì·ı‹ÙÚȘ Ì ·˘ÍË̤ӷ ›‰· ÈÓÛÔ˘Ï›Ó˘ (ËÏÈΛ·˜ 7-14 ÂÙÒÓ), ÔÈ 10 Ù·ÍÈÓÔÌ‹ıËÎ·Ó ˆ˜ ˘¤Ú‚·Ú˜ ‚¿ÛÂÈ ÙˆÓ ÙÈÌÒÓ Ù˘ International Obesity Task Force (πOTF, 25) Î·È 3 ·fi ·˘Ù¤˜ ÎÚ›ıËÎ·Ó ·¯‡Û·ÚΘ. ∫·Ì‡ÏË ·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ ¤ÁÈÓ Û 7 ÎÔÚ›ÙÛÈ·, ·ÏÏ¿ ‰ÂÓ ÚԤ΢„·Ó ÂӉ›ÍÂȘ ÁÈ· ÌË-·ÓÔ¯‹ ÛÙË ÁÏ˘Îfi˙Ë (fiÏ· Ù· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ). OÈ ÂÎÙÈÌ‹ÛÂȘ Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ (∏Oª∞) ›¯·Ó ÛÙÂÓ‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Î·È ÂȉÈο Ì ÙÔ ™µ, ÙÔÓ ¢ª™ Î·È ÙËÓ ¶ª. OÈ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ‰ÂÈÎÙÒÓ ∏Oª∞ Î·È ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÙÔ˘ ¢ª™ ¤¯Ô˘Ó ‚ÚÂı› Î·È Û ÌÂϤÙ˜ Û ·È‰È¿ Ù˘ πÓ‰›·˜, Ù˘ ∞ÌÂÚÈ΋˜ Î·È Ù˘ ¡fiÙÈ·˜ ∞ÊÚÈ΋˜ Î·È Û¯ÂÙ›˙ÔÓÙ·È Â›Û˘ Ì ÙÔÓ Ú˘ıÌfi ÌÂÙ·‚ÔÏ‹˜ ÙÔ˘ ‚¿ÚÔ˘˜ (weight velocity), fiÔ˘ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ¤¯ÂÈ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ‰Â›ÎÙË πRHOMA (36-38). ∆Ô Û˘Ì¤Ú·ÛÌ· Ì›·˜ ÌÂϤÙ˘ Û ·È‰È¿ Ù˘ ∞ÁÁÏ›·˜ ËÏÈΛ·˜ 10-11 ÂÙÒÓ ‹Ù·Ó fiÙÈ Ë ·¯˘Û·ÚΛ· Â›Ó·È ÈÔ Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙÔ Â›Â‰Ô Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË ·’ fi,ÙÈ ÙÔ Ì¤ÁÂıÔ˜ ηٿ ÙË Á¤ÓÓËÛË (39). ∏ ÂÏ¿ÙÙˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ Ì ·‡ÍËÛË Ù˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ Î·È Ë ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ ÌÔÚÔ‡Ó Ó· ηı˘ÛÙÂÚ‹ÛÔ˘Ó ‹ ·ÎfiÌ· Ó· ÛÙ·Ì·Ù‹ÛÔ˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 2 (35). OÈ ÙÈ̤˜ Ù˘ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ HbA1c ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó Ù· ›‰· ÁÏ˘Îfi˙˘ ÛÙÔ ·›Ì· ÁÈ· ÌÂÁ·Ï‡ÙÂÚË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Û ۯ¤ÛË Ì ÙȘ ÙÈ̤˜ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜. O ÌfiÓÔ˜ ‰Â›ÎÙ˘ ·¯˘Û·ÚΛ·˜ Ô˘ Û˘Û¯ÂÙ›ÛÙËΠ̠ٷ ›‰· ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ‹Ù·Ó ÙÔ ∞¢¶. ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ‚Ú¤ıËÎ·Ó Û ÌÂϤÙË Û 1610 ·È‰È¿ ËÏÈΛ·˜ 6-16 ÂÙÒÓ ÛÙËÓ ∆˙·Ì¿Èη, fiÔ˘ Ë
Paediatriki 2003;66:264-277
‰ÂÚÌ·ÙÈ΋ Ù˘¯‹ ÙÚÈΤʷÏÔ˘ ‹Ù·Ó Ô ÌfiÓÔ˜ ‰Â›ÎÙ˘ ·¯˘Û·ÚΛ·˜ (¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Î·È ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ Î·È ÙÔ ‚·ÚÔ˜/‡„Ô˜3 ˆ˜ ‰Â›ÎÙ˜, ponderal index) Ô˘ Û˘Û¯ÂÙ›ÛÙËΠ̠ٷ ›‰· ·ÈÌÔÛÊ·ÈÚ›Ó˘ HbA1c (40). øÛÙfiÛÔ, Ë Û¯ÂÙÈ΋ ·Ô˘Û›· ‰Â‰ÔÌ¤ÓˆÓ Û¯ÂÙÈο Ì ÙË ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË ÛÙ· ·È‰È¿ Î·È ÙË Û¯¤ÛË Ù˘ Ì ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·, ηıÈÛÙ¿ ·Ó·Áη›· ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛË ·ÓÙ›ÛÙÔȯˆÓ ÌÂÏÂÙÒÓ ÛÙÔ Ì¤ÏÏÔÓ. O Û‡Á¯ÚÔÓÔ˜ ÙÚfiÔ˜ ˙ˆ‹˜, Ë ÂÚÈÔÚÈṲ̂ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ë ÛÙ¿ÛË ÙˆÓ ÁÔÓ¤ˆÓ Û ı¤Ì·Ù· ‰È·ÙÚÔÊ‹˜ ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‰È·ÌfiÚʈÛ˘ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙˆÓ ·È‰ÈÒÓ Á‡Úˆ ·fi Û˘Ó‹ıÂȘ ˘Á›·˜. π‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi˜ ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Ê·›ÓÂÙ·È Ô ÙÚfiÔ˜ ‰È·ÙÚÔÊ‹˜ Î·È ÔÈ Û˘Ó‹ıÂȘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (41). øÛÙfiÛÔ, Ì›· ÛÂÈÚ¿ ·fi ÌÂϤÙ˜ Û ‰›‰˘ÌÔ˘˜ Î·È ˘ÈÔıÂÙË̤ӷ ·È‰È¿ ¤¯Ô˘Ó ·Ô‰ÒÛÂÈ ÙË Û˘Û¯¤ÙÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÙˆÓ ÁÔÓ¤ˆÓ Ì ÂΛÓË ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ Î·È Û ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (42,43), fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ·fi ÙÔ˘˜ Mamalakis Î·È Û˘Ó (17). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ˘‹ÚÍ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ¢ª™ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ˘ ·Ù¤Ú· Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi Ù˘ ÌËÙ¤Ú·˜, ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÙÔ˘ ·È‰ÈÔ‡ (r=0,24, p=0,004 ÁÈ· ÙÔÓ ·Ù¤Ú·, r=0,20, p=0,016 ÁÈ· ÙË ÌËÙ¤Ú·). ∏ ∂ÈÎfiÓ· 1 ·ÂÈÎÔÓ›˙ÂÈ ÙË Û¯¤ÛË ÌÂٷ͇ Ù˘ ·¯˘Û·ÚΛ·˜ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ·Ù¤ÚˆÓ ÙÔ˘˜. πÛ¯˘Ú‹ ÛÙ·ÙÈÛÙÈο Û˘Û¯¤ÙÈÛË ·ÚÔ˘ÛÈ¿ÛÙËÎÂ Î·È ÌÂٷ͇ ¶ªÀ ÙÔ˘ ·È‰ÈÔ‡ Î·È ¢ª™ ÙÔ˘ ·Ù¤Ú· (r=0,40, p<0,0001), ÌÂٷ͇ ∞¢¶ Î·È ¢ª™ ÙÔ˘ ·Ù¤Ú· (r=0,25, p=0,002) Î·È ÌÂٷ͇ ¶ªπ Î·È ¢ª™ ÙÔ˘ ·Ù¤Ú· (r=0,23, p=0,006). O ÌÔÓ·‰ÈÎfi˜ ‰Â›ÎÙ˘ ·¯˘Û·ÚΛ·˜ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙÔÓ ‰ËÏÔ‡ÌÂÓÔ ¢ª™ Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó ÙÔ ™µ ÙÔ˘ ·È‰ÈÔ‡ (r=0,18, p=0,03). ª›· ÛÂÈÚ¿ ·fi ÌÂϤÙ˜ Û ‰È¿ÊÔÚÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÂÓËÏ›ÎˆÓ ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ Ë ¯Ú‹ÛË ·˘ÙÔ-·Ó·ÊÂÚfiÌÂÓˆÓ (self-reported) ÙÈÌÒÓ ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÙÔ˘ ‡„Ô˘˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ˘ÔÂÎÙ›ÌËÛË ÙÔ˘ ¢ª™ Î·È ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ·¯˘Û·ÚΛ·˜. ∞˘Ù‹ Ë ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙÔ˘ ¢ª™ Ô˘ ¤¯ÂÈ ˘ÔÏÔÁÈÛÙ› ·fi ÌÂÙÚ‹ÛÂȘ Î·È ÙÔ˘ ¢ª™ Ô˘ ¤¯ÂÈ ÂÎÙÈÌËı› ·fi ·Ó·ÊÂÚfiÌÂÓ˜ ÙÈ̤˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙȘ Á˘Ó·›Î˜ ·’ fi,ÙÈ ÛÙÔ˘˜ ¿Ó‰Ú˜ (44-46). ∂Ô̤ӈ˜, ˘¿Ú¯ÂÈ ÂÚ›ÙˆÛË ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· Ó· ¤¯Ô˘Ó ˘ÔÂÎÙÈÌËı› ÔÈ Ú·ÁÌ·ÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Î·È ÂȉÈο ·˘Ù¤˜ ÌÂٷ͇ ÙÔ˘ ¢ª™ ÌËÙ¤Ú·˜ Î·È ÙˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜. ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi ‡ÚËÌ· Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ Â›Ó·È fiÙÈ ÛÙÔÓ ÏËı˘ÛÌfi Ô˘ ÌÂÏÂÙ‹ıËÎÂ, ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi˜ ÙˆÓ ·È‰ÈÎÒÓ ÏËı˘ÛÌÒÓ ÛÂ
273
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274
100 90 80 70 ¶ÔÛÔÛÙfi (%)
·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ∫Ú‹Ù˘, ˘¿Ú¯ÂÈ ˘„ËÏfi ÔÛÔÛÙfi ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ. ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ÛÙËÓ ∂ÏÏ¿‰· Î·È Û ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ù· ›‰· Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Â›Ó·È ˘„ËÏfiÙÂÚ· ÛÙȘ ·ÁÚÔÙÈΤ˜ Û ۯ¤ÛË Ì ÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË 90.997 ·È‰ÈÒÓ ËÏÈΛ·˜ 6-7 ÂÙÒÓ Î·È 106.284 ÂÊ‹‚ˆÓ ËÏÈΛ·˜ 13-14 ÂÙÒÓ ÛÙËÓ πÛ·Ó›·, ‚Ú¤ıËΠfiÙÈ Ë Èı·ÓfiÙËÙ· Ó· Â›Ó·È ¤Ó· ·È‰› ˘¤Ú‚·ÚÔ ‹Ù·Ó ˘„ËÏfiÙÂÚË ÛÙȘ ·ÁÚÔÙÈΤ˜ ·Ú¿ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ (47). To 33% ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó ˘¤Ú‚·ÚÔ Î·È Û˘ÓÔÏÈο ˘‹Ú¯Â ÔÛÔÛÙfi 9% ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ, ÂÓÒ Û ̛· ÚfiÛÊ·ÙË ÌÂϤÙË ÛÙËÓ fiÏË Ù˘ £ÂÛÛ·ÏÔӛ΢ Û 2458 ·È‰È¿ ËÏÈΛ·˜ 6-17 ÂÙÒÓ ‚Ú¤ıËΠÔÛÔÛÙfi 22% Î·È 4% ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ, ·ÓÙ›ÛÙÔȯ· (¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ù· ›‰È· IOTF ÎÚÈÙ‹ÚÈ· ÙÔ˘ ¢ª™) (48). ™ÙËÓ ÚÔ·Ó·ÊÂÚfiÌÂÓË ÌÂϤÙË, Ì¿ÏÈÛÙ·, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙËÓ ∂ÏÏ¿‰· ˘¿Ú¯ÂÈ ·‡ÍËÛË ÛÙÔÓ ÂÈÔÏ·ÛÌfi ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ 29% ÙˆÓ Ì·ıËÙÒÓ Â›¯Â ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ·fi ÙÔ˘˜ 4 ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· (·¯˘Û·ÚΛ·, ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·, ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È Û˘ÛÙÔÏÈ΋ ˘¤ÚÙ·ÛË). ª¿ÏÈÛÙ·, Ù· ÎÔÚ›ÙÛÈ· ÂÌÊ·Ó›ÛÙËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ÂÈÚÚ‹ ÛÙËÓ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Û ۯ¤ÛË Ì ٷ ·ÁfiÚÈ· (¯2-·Ó¿Ï˘ÛË, p=0,009). ™Â ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠7054 ·È‰È¿ ËÏÈΛ·˜ 11-12 ÂÙÒÓ ÛÙËÓ ∫‡ÚÔ, ÙÔ 18% ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÙÔ 15% ÙˆÓ ÎÔÚÈÙÛÈÒÓ (p<0,001) Û˘ÁΤÓÙÚˆÓ 2 ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (ÂÎ ÙˆÓ 4: Û˘ÛÙÔÏÈ΋ ˘¤ÚÙ·ÛË, ·¯˘Û·ÚΛ·, ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È ÌÂȈ̤ÓË Ê˘ÛÈ΋ ηٿÛÙ·ÛË), ÂÓÒ 5,3% Î·È 3,2% ·ÓÙ›ÛÙÔȯ· ›¯Â ¿Óˆ ·fi 3 ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (49). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ÛÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜ Ù˘ ·ÁÚÔÙÈ΋˜ ÂÚÈÔ¯‹˜ ÙÔ˘ ÿڷη, ÛÙÔÓ ÓÔÌfi ∏Ú·ÎÏ›Ԣ, 150 ·È‰ÈÒÓ ËÏÈΛ·˜ 12-13 ¯ÚÔÓÒÓ, ÙÔ 14% ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÙÔ 20% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·ÚÔ˘Û›·ÛÂ Û˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ 120 mmHg Î·È 15% ÙˆÓ ·È‰ÈÒÓ ÎÚ›ıËΠ˘¤Ú‚·ÚÔ (ηÈ/‹ ·¯‡Û·ÚÎÔ, fiÔ˘ ÔÈ Û˘ÁÁÚ·Ê›˜ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ˆ˜ ÎÚÈÙ‹ÚÈÔ ÙÔÓ ¢ª™ >21 kg/m2) (50). À‹Ú¯·Ó οÔÈÔÈ ÂÚÈÔÚÈÛÌÔ› ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ª›· ·‰˘Ó·Ì›· ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ Û¯ÂÙ›˙ÔÓÙ·Ó Û οÔÈÔ ‚·ıÌfi ÁÂÓÂÙÈο ÌÂٷ͇ ÙÔ˘˜. ªfiÓÔ 40 ·fi Ù· 178 ·È‰È¿ ‰ÂÓ Â›¯·Ó οÔÈÔÓ ·‰ÂÚÊfi ‹ ·‰ÂÚÊ‹ Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙÔ ÚfiÁÚ·ÌÌ·. £· ‹Ù·Ó ȉȷ›ÙÂÚ· ÂӉȷʤÚÔÓ Ó· ÂÎÙÈÌ‹ÛÂÈ Î·Ó›˜ Û ÁÂÓÂÙÈÎfi Â›Â‰Ô ÙËÓ Â›‰Ú·ÛË ÁÓˆÛÙÒÓ ÁÔÓȉ›ˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ηډȷÁÁÂÈ·Îfi ΛӉ˘ÓÔ (.¯. ÁÔÓfiÙ˘Ô˜ ApoE). ¶·Ú¿ÏÏËÏ·, Ô
Paediatriki 2003;66:264-277
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EÈÎfiÓ· 1. ∏ ηٷÓÔÌ‹ ÙÔ˘ ¢ª™ ÙˆÓ ·Ù¤ÚˆÓ ·Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ·¯˘Û·ÚΛ·˜ ÙˆÓ ·È‰ÈÒÓ.
·ÚÈıÌfi˜ ÙˆÓ Ì·ıËÙÒÓ ‹Ù·Ó Û¯ÂÙÈο ÌÈÎÚfi˜ Î·È ÙÔ ËÏÈÎÈ·Îfi ‡ÚÔ˜ ÌÂÁ¿ÏÔ. ∏ ËÏÈΛ· ‚Ú¤ıËΠӷ ·ÚÔ˘ÛÈ¿˙ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË, ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Î·È ÙÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ (ÂÓÒ ‰ÂÓ ˘‹Ú¯Â Û˘Û¯¤ÙÈÛË Ì ÙȘ ÏÈÔÚˆÙ½Ó˜, ÙË ÁÏ˘Îfi˙Ë Î·È ÙËÓ HbA1c), ·ÏÏ¿ ÛÙ· ÌÔÓ٤Ϸ ·ÏÈÓ‰ÚfiÌËÛ˘ ›¯Â ÏËÊı› ˘’ fi„ÈÓ Ë ËÏÈΛ· (ˆ˜ Û˘ÌÌÂÙ·‚ÏËÙ‹). ∂·Ó·Ï‹ÊıËηÓ, fï˜, ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ Û ‰‡Ô ÔÌ¿‰Â˜ Ì·ıËÙÒÓ (οو ·fi ÙË ‰È¿ÌÂÛË ËÏÈΛ· ÙˆÓ 10 ÂÙÒÓ Î·È ¿Óˆ ·fi ·˘Ù‹ ÙËÓ ËÏÈΛ·) Î·È ‰ÂÓ ÂÓÙÔ›ÛÙËÎ·Ó ‰È·ÊÔÚ¤˜ ÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∂›Û˘, Ì ‚¿ÛË ÙÔÓ ÌÈÎÚfi ·ÚÈıÌfi ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, ·Ôʇ¯ıËÎÂ Ë ¯ÚËÛÈÌÔÔ›ËÛË ÔÚ›ˆÓ Ì ‚¿ÛË ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ (ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜), ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› Ë ·ÚÔ˘Û›· ·¯˘Û·ÚΛ·˜. ŒÓ·˜ ¿ÏÏÔ˜ ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó fiÙÈ ‰ÂÓ ÂÎÙÈÌ‹ıËΠÙÔ ÛÙ¿‰ÈÔ ÁÂÓÓËÙÈ΋˜ ·Ó¿Ù˘Í˘ ηٿ Tanner ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∂›Û˘, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÙÔÌ‹˜ ‰ÂÓ ˘‹Ú¯·Ó ÌÂÙÚ‹ÛÂȘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ‹ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÈ· ÙË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ οı ·È‰ÈÔ‡. O ¢ª™ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÁÈ· Ó· ÂÓÙÔÈÛÙÔ‡Ó Ù· ˘¤Ú‚·Ú· Î·È ·¯‡Û·Úη ·È‰È¿, ‰ÈfiÙÈ Â›Ó·È ¤Ó·˜ ‰Â›ÎÙ˘ ÁÈ· ÙÔÓ ÔÔ›Ô ˘¿Ú¯Ô˘Ó ‰ÈÂıÓ‹ ÎÚÈÙ‹ÚÈ· Î·È ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯Ó¿ Û ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜. ¢ÂÓ ˘¿Ú¯ÂÈ, fï˜, οÔÈÔ˜ ÔÚÈÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, Ô ÔÔ›Ô˜ Ó· Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙfi˜ (51), fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ·fi ÙÔ˘˜ Mamalakis Î·È Û˘Ó (30). øÛÙfiÛÔ, Ô ÔÚÈÛÌfi˜ Ú¤ÂÈ Ó· ¤¯ÂÈ Û¯¤ÛË Ì ÙÔ˘˜ ‰Â›ÎÙ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ (52), ÔÈ ÔÔ›ÔÈ Û˘Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ·Ú·ÁfiÓÙˆÓ
¶·È‰È·ÙÚÈ΋ 2003;66:264-277
ÎÈÓ‰‡ÓÔ˘ Ô˘ ÂÚ¢ӋıËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ª›· ÂÍ‹ÁËÛË ÁÈ· ÙËÓ Èı·Ó‹ ·‰˘Ó·Ì›· ÙÔ˘ ¢ª™ Â›Ó·È fiÙÈ ·È‰È¿ Ì ÙÔÓ ›‰ÈÔ ¢ª™ ÌÔÚ› Ó· ¤¯Ô˘Ó ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ ÛÙÔ Û˘ÓÔÏÈÎfi ϛԘ ÛÒÌ·ÙÔ˜. ∞Ó·¿ÓÙËÙÔ ·Ú·Ì¤ÓÂÈ ÙÔ ÂÚÒÙËÌ· ·Ó Ë ¶ª Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙfiÛÔ Î·Ïfi˜ ‰Â›ÎÙ˘ fiÛÔ Ô ¢ª™ ÁÈ· ÙËÓ ÂÓÙfiÈÛË Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ·¯˘Û·ÚΛ·˜. Ÿˆ˜ ‰È·ÈÛÙÒıËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ¶ª Â›Ó·È ¤Ó·˜ ‰Â›ÎÙ˘ Ì ÂÍ›ÛÔ˘ ÛÙÂÓ‹ Û¯¤ÛË Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÛÙ· ·È‰È¿, fiˆ˜ Ô ¢ª™, ÂÓÒ Â›Ó·È Û¯ÂÙÈο ‡ÎÔÏÔ Ó· ÌÂÙÚËı› Ë ¶ª Ì ·ÎÚ›‚ÂÈ·. ™˘ÓÔ„›˙ÔÓÙ·˜, Ë ÂÓ‰ÔÎÔÈÏȷ΋ ÂÓ·fiıÂÛË Ï›Ô˘˜ (fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙËÓ ¶ª) ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi Û¯ÂÙ›˙ÂÙ·È Ì ‰˘ÛÌÂÓ‹ ÂÈÎfiÓ·, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ. ∏ ·Ï‹ ̤ÙÚËÛË Ù˘ ¶ª ‹Ù·Ó ÂÍ›ÛÔ˘ ÈÛ¯˘Ú‹ ˆ˜ ‰Â›ÎÙ˘, fiˆ˜ Ô ¢ª™, ÁÂÁÔÓfi˜ Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ ı· ÌÔÚÔ‡Û ӷ ÂÂÎÙ·ı› ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. O ÏËı˘ÛÌfi˜ Ô˘ ÌÂÏÂÙ‹ıËÎÂ, ·Ú¿ ÙÔÓ ÌÈÎÚfi ·ÚÈıÌfi ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, ıˆÚÂ›Ù·È ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi˜ ÙÔ˘ ·È‰ÈÎÔ‡ ·ÁÚÔÙÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ù˘ ∫Ú‹Ù˘. ∏ ÌÂϤÙË ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·¯˘Û·ÚΛ·˜, ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ Î·È ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·˜ ÛÙ· ·È‰È¿ Ù˘ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ ÙÔ˘ ƒÔ‡‚·, Ô˘ ˘ÔÙ›ıÂÙ·È fiÙÈ ‰È·ÙËÚ› ÙÔÓ ·Ú·‰ÔÛÈ·Îfi ÙÚfiÔ ˙ˆ‹˜ Î·È ‰È·ÙÚÔÊ‹˜. ∆· ÛÙÔȯ›· Ù˘ ÌÂϤÙ˘ ηıÈÛÙÔ‡Ó ·Ó·Áη›· ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ÙˆÓ ‚·ÛÈÎÒÓ ·˘ÙÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ¯ÚfiÓˆÓ ˙ˆ‹˜. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙÔÓ ¢‹ÌÔ ƒÔ‡‚· ÁÈ· ÙË ¯ÚËÌ·ÙÔ‰fiÙËÛË Ù˘ ÌÂϤÙ˘. ∂˘¯·ÚÈÛÙÔ‡ÌÂ, ›Û˘, ÙȘ ÂÚ¢ӋÙÚȘ Î. ∫·ÙÂÚ›Ó· ™·ÚÚ‹ Î·È Î. πÁÓ·ÓÙ›· ∫ˆÊˆÔ‡ÏÔ˘, ÙËÓ ·È‰›·ÙÚÔ Î. ª·Ú›· ªÈÙÛÒÚË Î·È ÙË ÁÚ·ÌÌ·Ù¤· Î. ™ÔÊ›· ºÏÔ˘Ú‹. ¶ÔÏϤ˜ ¢¯·ÚÈÛٛ˜ Î·È ÛÙÔ˘˜ ‰·ÛοÏÔ˘˜ Î·È Î·ıËÁËÙ¤˜ ÙÔ˘ Û¯ÔÏ›Ԣ ÛÙÔ ƒÔ‡‚·, ÙËÓ Î. °ÂˆÚÁ›· ∫·„¿ÏË ÛÙÔ ¢‹ÌÔ ÙÔ˘ ƒÔ‡‚· Î·È ‚‚·›ˆ˜ fiÏÔ˘˜ ÙÔ˘˜ Ì·ıËÙ¤˜ Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜ ÁÈ· ÙËÓ ¤ÓıÂÚÌË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙË ÌÂϤÙË.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Kromhout D, Menotti A, Bloemberg B, Aravanis C, Blackburn H, Buzina R et al. Dietary saturated and trans fatty acids and cholesterol and 25-year mortality from coronary heart disease: the Seven Countries Study. Prev Med 1995;24:308-315. 2. Menotti A, Blackburn H, Kromhout D, Nissinen A, Adachi H, Lanti M. Cardiovascular risk factors as determinants of 25year all-cause mortality in the seven countries study. Eur J Epidemiol 2001;17:337-346. 3. Moschandreas J, Kafatos A. Food and nutrient intakes of Greek (Cretan) adults. Recent data for food-based dietary guidelines in Greece. Br J Nutr 1999;81 (2 Suppl):S71-S76.
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4. Kafatos A, Verhagen H, Moschandreas J, Apostolaki I, Van Westerop JJ. Mediterranean diet of Crete: foods and nutrient content. J Am Diet Assoc 2000;100:1487-1493. 5. Kromhout D. Epidemiology of cardiovascular diseases in Europe. Public Health Nutr 2001;4:441-457. 6. Wolk A, Furuheim M, Vessby B. Fatty acid composition of adipose tissue and serum lipids are valid biological markers of dairy fat intake in men. J Nutr 2001;131:828-833. 7. Garland M, Sacks FM, Colditz GA, Rimm EB, Sampson LA, Willett WC et al. The relation between dietary intake and adipose tissue composition of selected fatty acids in US women. Am J Clin Nutr 1998;67:25-30. 8. Tjonneland A, Overvad K, Thorling E, Ewertz M. Adipose tissue fatty acids as biomarkers of dietary exposure in Danish men and women. Am J Clin Nutr 1993;57:629-633. 9. Whincup PH, Cook DG, Adshead F, Taylor S, Papacosta O, Walker M et al. Cardiovascular risk factors in British children from towns with widely differing adult cardiovascular mortality. BMJ 1996;313:79-84. 10. Rao G. Insulin resistance syndrome. Am Fam Physician 2001;63:1159-1163. 11. Valdez R. Epidemiology. Nutr Rev 2000;58:S4-S6. 12. British Nutrition Foundation. The nature and risks of obesity. London: British Nutrition Foundation; 1992. 13. Rabbia F, Veglio F, Pinna G, Oliva S, Surgo V, Rolando B et al. Cardiovascular risk factors in adolescence: prevalence and familial aggregation. Prev Med 1994;23:809-815. 14. Livingstone B. Epidemiology of childhood obesity in Europe. Eur J Pediatr 2000;159 (1 Suppl):S14-S34. 15. Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994;73:460-468. 16. Maffeis C, Pietrobelli A, Grezzani A, Provera S, Tato L. Waist circumference and cardiovascular risk factors in prepubertal children. Obes Res 2001;9:179-187. 17. Mamalakis G, Kafatos A, Manios Y, Anagnostopoulou T, Apostolaki I. Obesity indices in a cohort of primary school children in Crete: a six year prospective study. Int J Obes Relat Metab Disord 2000;24:765-771. 18. Savva SC, Tornaritis M, Savva ME, Kourides Y, Panagi A, Silikiotou N et al. Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord 2000;24:1453-1458. 19. ∫·Ê¿ÙÔ˜ ∞, ª·ÓÈfi˜ °, ÷Ù˙‹˜ Ã, ªÔÛ¯·Ó‰Ú¤· π, ª·ÏˆÌÂÓ¿ÎË ∂, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢ Î·È Û˘Ó. ∞ÍÈÔÏfiÁËÛË ÚÔÁÚ¿ÌÌ·ÙÔ˜ “∞ÁˆÁ‹ ÀÁ›·˜” ÌÂÙ¿ ·fi ÙÚ›· ¯ÚfiÓÈ· ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙ· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ∫Ú‹Ù˘. ¶·È‰È·ÙÚÈ΋ 1998;61:483-497. 20. Beynen AC, Katan MB. Rapid sampling and long-term storage of subcutaneous adipose-tissue biopsies for determination of fatty acid composition. Am J Clin Nutr 1985;42:317-322. 21. Cervenakova Z, Ksinantova L, Koska J. Effect of body composition on indices of insulin sensitivity and beta-cell
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-07-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-04-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÒÓ˘ ∫·Ê¿ÙÔ˜ ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜ ™¯ÔÏ‹ ∂ÈÛÙËÌÒÓ ÀÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ ∆. £. 2208, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: kafatos@med.uoc.gr
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ORIGINAL ARTICLE
∂›Â‰· Á·ÛÙÚ›Ó˘, ÌÔÙÈÏ›Ó˘ Î·È ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ ∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘1, π. ∫·Ï¤ÁÈ·˜1, ∞. °Ô‡Ó·Ú˘2, ™. ™Â‚·ÛÙÈ¿‰Ô˘1, ¡. ∞ÏÂ͛Ԣ2, ∂. ∫ˆÛÙ·ÓÙ¤ÏÏÔ˘3, Ã. ∫ÒÛÙ·ÏÔ˜1
Gastrointestinal hormones in neonates of diabetic mothers Z. Hatzistamatiou1, J. Kaleyias1, A. Gounaris2, S. Sevastiadou1, N. Alexiou2, E. Constantellou3, C. Costalos1
¶ÂÚ›ÏË„Ë: OÈ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜ Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (¡¢ª) ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı›. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚ›ÛÂÈ ÙȘ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜ Û ·˘Ù¿ Ù· ÓÂÔÁÓ¿. ¶ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘, Ù˘ ÌÔÙÈÏ›Ó˘ Î·È ÙÔ˘ ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ Ì ¢·›ÛıËÙ˜ Ú·‰ÈÔ·ÓÔÛÔÂÓ˙˘ÌÈΤ˜ ÌÂıfi‰Ô˘˜ ÛÂ: ·) 22 ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ Î·È ‚) 20 ˘ÁÈ‹ ÓÂÔÁÓ¿ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È ÌÂÙ¿ ·fi ÙÚÂȘ Ë̤Ú˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ÚÔÁÂ˘Ì·ÙÈο. ∆· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ (pg/ml) ÛÙÔ Ï¿ÛÌ· ÛÙË Á¤ÓÓËÛË ‹Ù·Ó 69±25 ÛÙ· ¡¢ª Î·È 78±21 ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (p=ns) Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË 82±21 Î·È 96±28, ·ÓÙ›ÛÙÔȯ· (p=ns). ∆· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ (pmol/l) ‹Ù·Ó 72±15 ÛÙ· ¡¢ª Î·È 57±24 ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (p<0,05) Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË 90±33 Î·È 60±30, ·ÓÙ›ÛÙÔȯ· (p<0,05). ∆· ›‰· ÙÔ˘ ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ (pg/ml) ‹Ù·Ó 12±5 ÛÙ· ¡¢ª Î·È 12±7 ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (p=ns) Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË 10±6 Î·È 9±6, ·ÓÙ›ÛÙÔȯ· (p=ns). ∆· ¡¢ª ›¯·Ó ˘„ËÏfiÙÂÚ· ›‰· ÌÔÙÈÏ›Ó˘ ÛÙË Á¤ÓÓËÛË Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó ÙË ‚¿ÛË ÁÈ· ÂÚ·ÈÙ¤Úˆ ·ÍÈÔÏfiÁËÛË ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ Û ¡¢ª.
Abstract: There is no information on gastrointestinal hormones in infants of diabetic mothers (IDMs). The objective of the study was to measure gastrointestinal hormones in IDMs. Using sensitive radioimmunoassays plasma concentrations of gastrin, motilin and VIP have been measured and compared in: a) 22 neonates of diabetic mothers and b) 20 healthy neonates at birth and prepradially after three days of enteral feeding. Plasma concentrations of gastrin (pg/ml) at birth were 69±25 in IDMs and 78±21 in controls (p=ns) and after enteral feeding were 82±21 and 96±28 respectively (p=ns). Plasma concentrations of motilin (pmol/l) at birth were 72±15 in IDMs and 57±24 in controls (p<0.05) and after enteral feeding were 90±33 and 60±30 respectively (p<0.05). Plasma concentrations of VIP (pg/ml) at birth were 12±5 in IDMs and 12±7 in controls (p=ns) and after enteral feeding were 10±6 and 9±6 respectively (p=ns). These findings suggest that IDM have higher concentration of motilin at birth and after enteral feeding compared to healthy neonates while, the levels of gastrin and VIP are similar to controls. These findings form a basis for further assessment of gastrointestinal peptides in IDM.
§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ, Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜, Á·ÛÙÚ›ÓË, ÌÔÙÈÏ›ÓË, ·ÁÁÂÈÔÂÓÂÚÁfi ÂÓÙÂÚÈÎfi ÂÙ›‰ÈÔ.
Key words: gastrointestinal hormones, infants of diabetic mothers, gastrin, motilin, VIP.
1 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 2 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ, ¶ÂÈÚ·È¿˜ 3 ∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ, ¶ÂÈÚ·È¿˜
1 NICU, General District Hospital “Alexandra”, Athens 2 NICU, General District Hospital “Agios Panteleimon”, Piraeus 3 Laboratory of Endocrinology, General District Hospital “Agios Panteleimon”, Piraeus
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™˘ÓÙÔÌÔÁڷʛ˜ ¡¢ª VIP
¡ÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ Vassoactive intestinal peptide (·ÁÁÂÈÔÂÓÂÚÁfi ÂÓÙÂÚÈÎfi ÂÙ›‰ÈÔ)
∂ÈÛ·ÁˆÁ‹
OÈ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜ Â›Ó·È ÂÙ›‰È· Ô˘ ·Ú¿ÁÔÓÙ·È ÛÙÔÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ Î·È ÛÙÔ ¿ÁÎÚ·˜ Î·È ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆· ›‰· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› Û ÙÂÏÂÈfiÌËÓ· Î·È ÚfiˆÚ· ÓÂÔÁÓ¿ (1-3). ∞ÍÈÔÛËÌ›ˆÙ˜ ·ÏÏ·Á¤˜ ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ Û˘Ì‚·›ÓÔ˘Ó ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘. OÈ Lucas Î·È Û˘Ó (1) ÌÂϤÙËÛ·Ó Ù· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘, Ù˘ Á·ÛÙÚ›Ó˘ Î·È ÙÔ˘ ÂÓÙÂÚÔÁÏ˘Î·ÁfiÓÔ˘ Û ÓÂÔÁ¤ÓÓËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 24 ÚÒÙˆÓ ËÌÂÚÒÓ ˙ˆ‹˜ Î·È Î·Ù¤ÏËÍ·Ó fiÙÈ Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË ˘ÚÔ‰ÔÙ› ÙËÓ ¤ÎÎÚÈÛË ÙˆÓ ÔÚÌÔÓÒÓ ·˘ÙÒÓ. ∆· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Â›Ó·È ÂÓÙ·Ï¿ÛÈ· ·fi ÂΛӷ ÙˆÓ ÂÓËÏ›ÎˆÓ Î·È ·˘Í¿ÓÔÓÙ·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÌÂÙ¿ ÙÔ ÚÒÙÔ Á‡̷ (1,4). ∆· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Â›Ó·È ¯·ÌËÏ¿, ·ÏÏ¿ ·˘Í¿ÓÔÓÙ·È ÛËÌ·ÓÙÈο ÙË 2Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜ (1). ∆· ›‰· ÙÔ˘ ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ (VIP) Â›Ó·È ·˘ÍË̤ӷ ηٿ ÙË Á¤ÓÓËÛË Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÙˆÙÈ΋ ÔÚ›· (5,6). ∆· ›‰· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› Û ÓÂÔÁÓ¿ ̠ίڈṲ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi (7), ÛÙÔ˘˜ ÎÔÏÈÎÔ‡˜ ÙÔ˘ 1Ô˘ ÙÚÈÌ‹ÓÔ˘ (8), Û ¿Û¯ÔÓÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÂÏ¿¯ÈÛÙË ÂÓÙÂÚÈ΋ Û›ÙÈÛË (minimal enteric feeding) (9), Û ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ ˘fi ʈÙÔıÂڷ›· (10) Î·È Û ÚfiˆÚ· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ô˘ ¤Ï·‚·Ó ÚÔÁÂÓÓËÙÈο ÎÔÚÙÈÎÔÂȉ‹ (11). ∆· ›‰· ÙˆÓ ÔÚÌÔÓÒÓ ·˘ÙÒÓ ‰ÂÓ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ÌÂÏÂÙËı› Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ. OÈ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Û˘Ó‹ıÂȘ Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (12). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ˘ÂÚÁÏ˘Î·ÈÌ›· ÂËÚ¿˙ÂÈ ÙË Á·ÛÙÚÈ΋ ΤӈÛË Î·È ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Û ¿Û¯ÔÓÙ˜ ·fi ‰È·‚‹ÙË, ·ÏÏ¿ Î·È Û ˘ÁÈ›˜ (12,13). ™Â ÂÈÚ·Ì·ÙÈÎfi ÌÔÓÙ¤ÏÔ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›·˜, Ù· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈο ÌÂȈ̤ӷ (13). ∆Ô 53% ÙˆÓ ÂÓËÏ›ÎˆÓ Ì ™¢ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·ı˘ÛÙ¤ÚËÛË Ù˘ Á·ÛÙÚÈ΋˜ ΤӈÛ˘ ηٿ ÙËÓ ˘ÂÚÁÏ˘Î·ÈÌ›·, ÂÓÒ ·ÓÙ›ıÂÙ· ÂÈÙ·¯‡ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˘ÔÁÏ˘Î·ÈÌ›·˜. OÈ Lam Î·È Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ Ë ÔÍ›· ˘ÂÚÁÏ˘Î·ÈÌ›· ÌÂÈÒÓÂÈ ÙËÓ ¤ÎÎÚÈÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÔͤԘ Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÔÏ˘ÂÙȉ›Ô˘ (14). OÈ µ·˙·›Ô˘ Î·È Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ Ù· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ Î·È Ù˘ Ó¢ÚÔÙÂÓÛ›Ó˘ ÛÙ· ‰È·‚ËÙÈο ·È‰È¿ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ· Û ۯ¤ÛË Ì ÙÔ˘˜ ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜, ÂÓÒ Ù·
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›‰· ÁÏ˘Î·ÁfiÓ˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ· (15). ∏ Á·ÛÙÚ›ÓË ·Ú¿ÁÂÙ·È ·fi Ù· G-·ÙÙ·Ú· ÙÔ˘ ¿ÓÙÚÔ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘. ¢ÈÂÁ›ÚÂÈ ÙËÓ ¤ÎÎÚÈÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ·fi Ù· Î·Ï˘Ù‹ÚÈ· ·ÙÙ·Ú· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ¤¯ÂÈ ÙÚÔÊÈ΋ ‰Ú¿ÛË ÛÙÔÓ Á·ÛÙÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ (16). ∫·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· Û ۯ¤ÛË Ì ·˘Ù¿ ÙˆÓ ÂÓËÏ›ÎˆÓ (17). OÈ Lucas Î·È Û˘Ó (1) ¤‰ÂÈÍ·Ó fiÙÈ ÙȘ ÚÒÙ˜ 3-6 ÒÚ˜ ˙ˆ‹˜ Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ ÌÂÈÒÓÔÓÙ·È Û ÂΛӷ ÙˆÓ ÂÓËϛΈÓ, fï˜, ÌÂÙ¿ ÙÔ ÚÒÙÔ Á‡̷ ÛËÌÂÈÒÓÂÙ·È ˘ÂÚÁ·ÛÙÚÈÓ·ÈÌ›·, Ë ÔÔ›· ‰È·ÙËÚÂ›Ù·È Û fiÏË ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (18). ∏ ÌÔÙÈÏ›ÓË ·Ú¿ÁÂÙ·È ·fi ÂÓ‰ÔÎÚÈÓÈο ·ÙÙ·Ú· ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Î·È Ù˘ Ó‹ÛÙȉ·˜ Î·È ·˘Í¿ÓÂÈ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÂÓÒ ÂÓÂÚÁÔÔÈ› Î·È ÙËÓ ·˘ÙfiÌ·ÙË ÎÈÓËÙÈÎfiÙËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÌÂÛ˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ÂÚÈfi‰Ô˘ (1,19). ∆· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Â›Ó·È ˘„ËÏ¿ Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔÁÂ˘Ì·ÙÈ΋ ·‡ÍËÛË (1,20). ∆Ô ·ÁÁÂÈÔÂÓÂÚÁfi ÂÓÙÂÚÈÎfi ÂÙ›‰ÈÔ ·Ú¿ÁÂÙ·È ÛÙȘ Ó¢ÚÈΤ˜ ·ÔÏ‹ÍÂȘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ۈϋӷ Î·È ÂËÚ¿˙ÂÈ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ (5). ∆· ›‰· ÙÔ˘ VIP Â›Ó·È ˘„ËÏ¿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙˆÙÈ΋ ÔÚ›· (5,6). §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ fiÙÈ Ë ˘ÂÚÁÏ˘Î·ÈÌ›· ÂËÚ¿˙ÂÈ Ù· ›‰· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ, ηıÒ˜ ›Û˘ fiÙÈ Ù· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ ‚Ú›ÛÎÔÓÙ·È Û ÂÚÈfi‰Ô˘˜ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ‰ÈÂÚ¢ӋıËÎÂ Ë Èı·Ó‹ ›‰Ú·ÛË ÙÔ˘ ‰È·‚‹ÙË Î‡ËÛ˘ ÛÙ· ›‰· ÙÚÈÒÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ (Á·ÛÙÚ›Ó˘, ÌÔÙÈÏ›Ó˘ Î·È VIP) ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î‡ËÛ˘ ‹ Ù‡Ô˘ π Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ “∞ÏÂÍ¿Ó‰Ú·” Î·È ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ ·fi ÙÔÓ ª¿ÈÔ 1999 ̤¯ÚÈ Î·È ÙÔÓ ¢ÂΤ̂ÚÈÔ 1999. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ·fi ÙË ÌÂϤÙË ‹Ù·Ó ÔÈ Û˘ÁÁÂÓ›˜ ‹ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È ÚˆÙÔ·ı‹ ÓÔÛ‹Ì·Ù· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÛÙ· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ÓÔÛÔÎÔÌ›·, ÔÈ ÌËÙ¤Ú˜ ÙˆÓ ÔÔ›ˆÓ ›¯·Ó Ù·ÎÙÈ΋ Ì·È¢ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ‰ÂÓ Â›¯·Ó ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ∏ ÌÂϤÙË ‹Ù·Ó ÚÔ‰ÚÔÌÈ΋. ∞fi οı ÓÂÔÁÓfi ‰È·‚ËÙÈ΋˜ ÌËÙ¤Ú·˜ Î·È ·fi ÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Ì¿ÚÙ˘Ú· Ï·Ì‚·ÓfiÙ·Ó 1 ml ·›Ì·ÙÔ˜ ·fi ÂÚÈÊÂÚÈ΋ ÊϤ‚· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Ê¿ÛË π) Î·È ÌÂÙ¿ ·fi 3 Ë̤Ú˜ Ï‹ÚÔ˘˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ÚÔÁÂ˘Ì·ÙÈο (Ê¿ÛË ππ). O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÂȤ‰ˆÓ Á·ÛÙÚ›Ó˘, ÌÔÙÈÏ›Ó˘ ηÈ
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VIP ¤ÁÈÓ Ì ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô (RIA) ÛÙȘ Ê¿ÛÂȘ π Î·È ππ. ∆· ·ÓÙȉڷÛÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ Á·ÛÙÚ›Ó˘, Ù˘ ÌÔÙÈÏ›Ó˘ Î·È ÙÔ˘ VIP ‹Ù·Ó ·ÓÙ›ÛÙÔȯ·: ·) Diagnostic Products Corporation, Los Angeles, USA, ‚) EuroDiagnostica AB, Sweden Î·È Á) Inc Star Science Technology and Research Inc Star MN, USA. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙË ‰ÔÎÈÌ·Û›· t-test. ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.
∞ÔÙÂϤÛÌ·Ù· ÷ڷÎÙËÚÈÛÙÈο ÓÂÔÁÓÒÓ ∂›ÎÔÛÈ ‰‡Ô ÓÂÔÁÓ¿ (ÔÌ¿‰· ∞) ÌËÙ¤ÚˆÓ Ì ‰È·‚‹ÙË (17/22 Ì ‰È·‚‹ÙË Î‡ËÛ˘ Î·È 5/22 Ì ™¢ Ù‡Ô˘ π) Î·È 20 ÓÂÔÁÓ¿ ÌË ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (ÔÌ¿‰· µ) Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÛÙË ÌÂϤÙË. ∆Ô Ì¤ÛÔ µ° (±SD) ÙˆÓ ÓÂÔÁÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ ‹Ù·Ó 2790 g (±900 g) Î·È Ù˘ ÔÌ¿‰·˜ B 3150 g (±500 g) (p=ns). ∏ ̤ÛË ¢∫ (±SD) ÙˆÓ ÓÂÔÁÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ ‹Ù·Ó 36 (±2,1) ‚‰ÔÌ¿‰Â˜ Î·È Ù˘ ÔÌ¿‰·˜ µ 38,5 (±1,6) ‚‰ÔÌ¿‰Â˜ (p=ns). ∂›Â‰· Á·ÛÙÚ›Ó˘ - ÌÔÙÈÏ›Ó˘ - VIP ∆· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ (pg/ml), Ù˘ ÌÔÙÈÏ›Ó˘ (pmol/l) Î·È ÙÔ˘ VIP (pg/ml) ÛÙ· ¡¢ª Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Î·È ÛÙȘ ‰‡Ô Ê¿ÛÂȘ Ù˘ ÌÂϤÙ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ·) °·ÛÙÚ›ÓË (∂ÈÎfiÓ· 1) º¿ÛË π: ∆· ›‰· Á·ÛÙÚ›Ó˘ (±SD) (pg/ml) ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‹Ù·Ó ¯·ÌËÏfiÙÂÚ· ÛÙËÓ
ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ [69 (±25) pg/ml] Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ [78 (±21) pg/ml], ¯ˆÚ›˜ fï˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p=ns). º¿ÛË ππ: ∆· ›‰· Á·ÛÙÚ›Ó˘ (±SD) (pg/ml) ÌÂÙ¿ ·fi 3 Ë̤Ú˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ‹Ù·Ó 82 pg/ml (±21) ÛÙËÓ ÔÌ¿‰· ∞ Î·È 96 pg/ml (±28) ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (p=ns). ∆· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó ˘„ËÏfiÙÂÚ· ÛÙË Ê¿ÛË ππ, ¯ˆÚ›˜ fï˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ‚) ªÔÙÈÏ›ÓË (∂ÈÎfiÓ· 2) º¿ÛË π: ∆· ›‰· ÌÔÙÈÏ›Ó˘ (±SD) (pmol/l) ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‹Ù·Ó ˘„ËÏfiÙÂÚ· ÛÙËÓ ¶›Ó·Î·˜ 1. ∂›Â‰· Á·ÛÙÚ›Ó˘, ÌÔÙÈÏ›Ó˘ Î·È VIP Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (ÔÌ¿‰· ∞) Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (ÔÌ¿‰· µ) OÚÌfiÓË
¡ÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ ¡=22
°·ÛÙÚ›ÓË (pg/ml) (̤ÛË ÙÈÌ‹±SD) º¿ÛË π 69±25 º¿ÛË ππ 82±21 ªÔÙÈÏ›ÓË (pmol/l)(̤ÛË ÙÈÌ‹±SD) º¿ÛË π 72±15 º¿ÛË ππ 90±33 VIP (pg/ml) (̤ÛË ÙÈÌ‹±SD) º¿ÛË π 12±5 º¿ÛË ππ 10±6
ª¿ÚÙ˘Ú˜
p-value
N=20 78±21 96±28
ns ns
57±24 60±30
<0,05 <0,05
12±7 9±6
ns ns
140 120
pg/ml
100 80 60 40
69
82
78
96
20 0 OÌ¿‰· ∞ - º¿ÛË π OÌ¿‰· ∞ - º¿ÛË ππ OÌ¿‰· µ - º¿ÛË π OÌ¿‰· µ - º¿ÛË ππ ∂ÈÎfiÓ· 1. ∂›Â‰· Á·ÛÙÚ›Ó˘ (pg/ml) ÛÙ· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (ÔÌ¿‰· ∞) Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (ÔÌ¿‰· µ) ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Ê¿ÛË π) Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË (Ê¿ÛË ππ).
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140 120 100
pmol/l
80 60 40 20
72
90
57
60
0 OÌ¿‰· ∞ - º¿ÛË π OÌ¿‰· ∞ - º¿ÛË ππ OÌ¿‰· µ - º¿ÛË π OÌ¿‰· µ - º¿ÛË ππ ∂ÈÎfiÓ· 2. ∂›Â‰· ÌÔÙÈÏ›Ó˘ (pmol/l) ÛÙ· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (ÔÌ¿‰· ∞) Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (ÔÌ¿‰· µ) ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Ê¿ÛË π) Î·È ÌÂÙ¿ ·fi ÂÓÙÂÚÈ΋ Û›ÙÈÛË (Ê¿ÛË ππ).
ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ [72 (±15) pmol/l] Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ [57 (±24) pmol/l ] Î·È Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,05). º¿ÛË ππ: ∆· ›‰· ÌÔÙÈÏ›Ó˘ (±SD) (pmol/l) ÌÂÙ¿ ·fi 3 Ë̤Ú˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙËÓ ÔÌ¿‰· ∞ [90 (±33) pmol/l] Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ [60 (±30) pmol/l] (p<0,05). ∆· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ·˘Í‹ıËÎ·Ó ÛËÌ·ÓÙÈο ÛÙËÓ ÔÌ¿‰· ∞ ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË (p<0,05), ÂÓÒ ÛÙËÓ ÔÌ¿‰· µ ‰ÂÓ ÛËÌÂÈÒıËΠÙÚÔÔÔ›ËÛË (p=ns). Á) VIP (∂ÈÎfiÓ· 3) º¿ÛË π: ∆· ›‰· ÙÔ˘ VIP (±SD) (pg/ml) ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‹Ù·Ó ·ÚfiÌÔÈ· Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ [12 (±5) pg/ml ÛÙËÓ ÔÌ¿‰· ∞ Î·È 12 (±7) pg/ml ÛÙËÓ ÔÌ¿‰· B] (p=ns). º¿ÛË ππ: ∆· ›‰· ÙÔ˘ VIP (±SD) (pg/ml) ÌÂÙ¿ ·fi 3 Ë̤Ú˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ‹Ù·Ó ·ÚfiÌÔÈ· Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ [10 (±6) pg/ml ÛÙËÓ ÔÌ¿‰· ∞ Î·È 9 (±6) pg/ml ÛÙËÓ ÔÌ¿‰· µ] (p=ns). ∆· ›‰· ÙÔ˘ VIP ‰ÂÓ ÙÚÔÔÔÈ‹ıËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË Û η̛· ·fi ÙȘ ‰‡Ô ÔÌ¿‰Â˜. ™˘˙‹ÙËÛË ªÂÏÂÙ‹ıËÎ·Ó Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘, Ù˘ ÌÔÙÈÏ›Ó˘ Î·È ÙÔ˘ ·ÁÁÂÈÔÂÓÂÚÁÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ Î·È Û ̿ÚÙ˘Ú˜,
·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È ÌÂÙ¿ ·fi 3 Ë̤Ú˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘. ∆· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ Â›¯·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ›‰· ÌÔÙÈÏ›Ó˘, ¯·ÌËÏfiÙÂÚ· ›‰· Á·ÛÙÚ›Ó˘ Î·È ›‰È· ›‰· VIP ÛÙË Á¤ÓÓËÛË, Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ªÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘, Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ ·ÚÔ˘Û›·Û·Ó ¿ÓÔ‰Ô Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜, Ù· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ·˘Í‹ıËÎ·Ó ÛËÌ·ÓÙÈο ÛÙ· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ, ÂÓÒ Ù· ›‰· ÙÔ˘ VIP ‰ÂÓ ÙÚÔÔÔÈ‹ıËηÓ. ∆· ›‰· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Â›Ó·È ˘„ËÏfiÙÂÚ· Û ۯ¤ÛË Ì ·˘Ù¿ ÙˆÓ ÂÓËϛΈÓ. ¶Èı·Ó¤˜ ·Èٛ˜ ÁÈ· Ù· ˘„ËÏfiÙÂÚ· ›‰· ÙˆÓ ÔÚÌÔÓÒÓ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Â›Ó·È ÙÔ Û¯ÂÙÈο ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ù· ÌÈÎÚ¿ ÌÂÛԉȷÛÙ‹Ì·Ù· Ô˘ ÌÂÛÔÏ·‚Ô‡Ó ·Ó¿ÌÂÛ· ÛÙ· Á‡̷ٷ Î·È Ô ÌÂÁ¿ÏÔ˜ fiÁÎÔ˜ ÚÔÛÏ·Ì‚·ÓfiÌÂÓˆÓ ˘ÁÚÒÓ (Ë Î·Ù·Ó¿ÏˆÛË Á¿Ï·ÎÙÔ˜ ·fi ¤Ó· ÓÂÔÁÓfi 2 ‚‰ÔÌ¿‰ˆÓ ·ÓÙÈÛÙÔȯ› Û 10-20 l ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜) (1). ∏ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ˘ÚÔ‰ÔÙ› ÙËÓ ¤ÎÎÚÈÛË ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ, ÔÈ Ôԛ˜ ̤ۈ ÂÓ‰ÔÎÚÈÓÈ΋˜, ·Ú·ÎÚÈÓÈ΋˜ Î·È Ó¢ÚÔÂÎÎÚÈÙÈ΋˜ ‰Ú¿Û˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ (1-3). OÈ Bjornsson Î·È Û˘Ó ÌÂϤÙËÛ·Ó ÙËÓ Â›‰Ú·ÛË Ù˘ ÔÍ›·˜ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ ÛÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È Î·Ù¤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ˘ÂÚÁÏ˘Î·ÈÌ›· ÌÂÈÒÓÂÈ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Î·È Ù˘ Ó‹ÛÙȉ·˜ (12). OÈ
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20 18 16 14
mg/dl
12 10 8 6 4 2
12
10
12
9
0 OÌ¿‰· ∞ - º¿ÛË π OÌ¿‰· ∞ - º¿ÛË ππ OÌ¿‰· µ - º¿ÛË π OÌ¿‰· µ - º¿ÛË ππ ∂ÈÎfiÓ· 3. ∂›Â‰· VIP (mg/dl) ÛÙ· ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ (ÔÌ¿‰· ∞) Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (ÔÌ¿‰· µ) ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Ê¿ÛË π) Î·È ÌÂÙ¿ ·fi ÂÓÙÂÚÈ΋ Û›ÙÈÛË (Ê¿ÛË ππ).
Barnett Î·È Owyang ¤‰ÂÈÍ·Ó fiÙÈ Ë ˘ÂÚÁÏ˘Î·ÈÌ›· ηٷÛÙ¤ÏÏÂÈ Ù· ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (21). OÈ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜ ¤¯Ô˘Ó ÂÎÙÂÓÒ˜ ÌÂÏÂÙËı› ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ÙfiÛÔ ÛÂ Ê˘ÛÈÔÏÔÁÈο ÙÂÏÂÈfiÌËÓ· Î·È ÚfiˆÚ· ÓÂÔÁÓ¿ (1-3,5,6), fiÛÔ Î·È Û ¿ÏϘ ηٷÛÙ¿ÛÂȘ (4,7-11). ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÚÒÙË ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Ô˘ ÌÂϤÙËÛ ٷ ›‰· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ Û ÓÂÔÁÓ¿ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ. ∆· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ ‹Ù·Ó ÂÏ·ÊÚ¿ ¯·ÌËÏfiÙÂÚ· ÛÙ· ¡¢ª Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜, ¯ˆÚ›˜ fï˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ªÂÙ¿ ·fi ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ Ù· ›‰· Ù˘ Á·ÛÙÚ›Ó˘ ·˘Í‹ıËηÓ. ∏ ˘ÂÚÁ·ÛÙÚÈÓ·ÈÌ›· Ù˘ ÓÂÔÁÓÈ΋˜ ËÏÈΛ·˜ Î·È Ë Â›Ù·ÛË ·˘Ù‹˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Â›Ó·È ÛÙ·ıÂÚfi ‡ÚËÌ· Û fiϘ ÙȘ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙȘ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ÷ÌËÏ¿ ›‰· Á·ÛÙÚ›Ó˘ ‰È·›ÛÙˆÛ·Ó ÔÈ Shulman Î·È Kanarek Û ÓÂÔÁÓ¿ ÂÍ·ÈÚÂÙÈο ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Ô˘ ‰ÂÓ ÛÈÙ›˙ÔÓÙ·Ó ÂÓÙÂÚÈο (4). ∏ Á·ÛÙÚ›ÓË ¤¯ÂÈ ÙÚÔÊÈ΋ ‰Ú¿ÛË ÛÙÔ ¤ÓÙÂÚÔ Î·È Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ë ¤ÁηÈÚË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆· ¡¢ª ›¯·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ›‰· ÌÔÙÈÏ›Ó˘ Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Î·È Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ‰È·ÙËÚ‹ıËÎÂ Î·È ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË.
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À„ËÏ¿ ›‰· ÌÔÙÈÏ›Ó˘ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ÓÂÔÁÓ¿ ̠ίڈṲ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi Î·È Û ‚Ú¤ÊË Ì ÎÔÏÈÎÔ‡˜ ÚÒÙÔ˘ ÙÚÈÌ‹ÓÔ˘ (7,8). ∆· ˘„ËÏ¿ ›‰· Ù˘ ÌÔÙÈÏ›Ó˘ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ‰È·Ù·Ú·¯¤˜ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· ÙˆÓ ÌÂÏÂÙËı¤ÓÙˆÓ ÓÂÔÁÓÒÓ. ∆· ›‰· ÙÔ˘ VIP ‹Ù·Ó ·ÚfiÌÔÈ· Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ Î·È ‰ÂÓ ÙÚÔÔÔÈ‹ıËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË. ∆· ›‰· ÙÔ˘ VIP Â›Ó·È ·˘ÍË̤ӷ ÛÙË Á¤ÓÓËÛË Î·È ·˘Í¿ÓÔÓÙ·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘, Ì ÎÔڇʈÛË ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ (5). OÈ °Ô‡Ó·Ú˘ Î·È Û˘Ó ‰È·›ÛÙˆÛ·Ó ·˘ÍË̤ӷ ›‰· ÙÔ˘ VIP Û ÓÂÔÁÓ¿ Ì ›ÎÙÂÚÔ ˘fi ʈÙÔıÂڷ›· (10). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÔÙÂϤÛÔ˘Ó ÙË ‚¿ÛË ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÙˆÓ ÓÂÔÁÓÒÓ ‰È·‚ËÙÈÎÒÓ ÌËÙ¤ÚˆÓ Û ۯ¤ÛË Ì ÙȘ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ÔÚÌfiÓ˜. ∞·ÈÙ›ٷÈ, fï˜, ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È¢ÎÚÈÓÈÛÙ› Ë ÎÏÈÓÈ΋ ÛËÌ·Û›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Lucas A, Adrian TE, Christofides N, Bloom SR, AynsleyGreen A. Plasma motilin, gastrin, and enteroglucagon and feeding in the human newborn. Arch Dis Child 1980;55:673-677. 2. Lucas A, Bloom SR, Aynsley-Green A. Development of gut
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 12-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ Õıˆ 31 & OÚˆÔ‡, ∆.∫. 262 26, ¶¿ÙÚ· E-mail: Kaleyias@hotmail.com
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ORIGINAL ARTICLE
∂Ê·ÚÌÔÁ‹ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ BFM-90 ÛÙËÓ ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·: ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·ÔÙÂϤÛÌ·Ù· º. ∞ı·Ó·ÛÈ¿‰Ô˘1, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡1, ª. ∫Ô‡ÚÙË1, ∞. ª¤ÓÔ˜2, £. ¶··ÁˆÚÁ›Ô˘1, ª. ™Ù¿ÌÔ˘1, ¢. ∫·ÙÚÈÔ‡1
Application of the BFM-90 therapeutic protocol to childhood acute lymphoblastic leukaemia: prognostic factors and results F. Athanasiadou1, M. Hatzistilianou1, M. Kourti1, A. Benos2, T. Papageorgiou1, M. Stamou1, D. Catriu1
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ Â›Ó·È Ë ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ù˘ ÂÈ‚›ˆÛ˘ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ô˘ ¤Ï·‚·Ó ıÂڷ›· Ì ‚¿ÛË ÙÔ ÚˆÙfiÎÔÏÏÔ BFM-90 Î·È Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÚfiÏÔ˘ ηıÈÂÚˆÌ¤ÓˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙÔ Ï·›ÛÈÔ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ·ÓˆÙ¤Úˆ ÚˆÙÔÎfiÏÏÔ˘. ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 70 ·È‰È¿ (39 ·ÁfiÚÈ· Î·È 31 ÎÔÚ›ÙÛÈ·) Ì ‰È¿ÌÂÛË ËÏÈΛ· Ù· 4,6 ¤ÙË (‡ÚÔ˜: 3 Ì‹Ó˜-15 ¤ÙË), Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙË µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ∞Ã∂¶∞ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· π·ÓÔ˘·Ú›Ô˘ 1993-¢ÂÎÂÌ‚Ú›Ô˘ 1999. O ‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜ ·Ú·Ù‹ÚËÛ˘ ‹Ù·Ó 53 Ì‹Ó˜ (‡ÚÔ˜: 14 Ë̤Ú˜-97 Ì‹Ó˜) Î·È Ë Èı·ÓfiÙËÙ· ÂχıÂÚ˘ ÓfiÛÔ˘ ÂÈ‚›ˆÛ˘ Û ÚÒÙË ‡ÊÂÛË (eventfree survival - EFS) ‹Ù·Ó 77,46% (CI: 70-86%). ∏ Èı·ÓfiÙËÙ· Û˘ÓÔÏÈ΋˜ ÂÈ‚›ˆÛ˘ (overall survival OS) ‹Ù·Ó 82,61% (CI: 74-90%). ™Â Û˘Ó¯È˙fiÌÂÓË Ï‹ÚË ‡ÊÂÛË ‚Ú›ÛÎÔÓÙ·È 58 ·ÛıÂÓ›˜, ÂÓÒ 12 η٤ÏËÍ·Ó. ÀÔÙÚÔ‹ ·ÚÔ˘Û›·Û·Ó 8 ·ÛıÂÓ›˜, 6 ÛÙÔÓ Ì˘ÂÏfi Î·È 2 ÛÙÔ˘˜ fiÚ¯ÂȘ, ÂÓÒ Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË Â˘Ú›ÛÎÔÓÙ·È 3 ·ÛıÂÓ›˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 14 Ì‹Ó˜, ‡ÚÔ˜: 6-23 Ì‹Ó˜). ¢˘ÛÌÂÓ‹ ›‰Ú·ÛË ÛÙËÓ Èı·ÓfiÙËÙ· EFS Ì ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p log-rank ≤0,05) ›¯·Ó: Ë ËÏÈΛ· ≤3 ¤ÙË, Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (WBC ≥50x109/L), Ë ÙÈÌ‹ Ù˘ LDH (≥1000 IU/L), Ë Ë·ÙÔÌÂÁ·Ï›· (≥3 cm), Ë ÛÏËÓÔÌÂÁ·Ï›· (≥3 cm) Î·È Ë Î·Ù¿Ù·ÍË Î·Ù¿ NCI (National Cancer Institute, US) ÛÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∏ Cox-regression ·Ó¿Ï˘ÛË ·ÔÎ¿Ï˘„ fiÙÈ ÈÛ¯˘ÚfiÙÂÚÔ˜ ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (WBC ≥50x109/L). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÎÚ›ÓÔÓÙ·È Ôχ
Abstract: The aim of this study is to perform a retrospective analysis of survival of children with newly diagnosed acute lymphoblastic leukaemia (ALL) who were treated according to the BFM-90 protocol in the 2nd University Department of Pediatrics at AHEPA General Hospital and to analyze the value of established prognostic factors. Seventy children (39 male and 31 female) with a median age of 4.6 years (range: 3 months-15years) were included in this study. The median observation time was 53 months (range: 14 days-97 months) and the estimate of probability of event-free survival, pEFS, was 77.46% (CI: 70-86%), and that of overall survival, pOS, was 82.61% (CI: 74-90%). At the time of collecting the data, 58 patients were in continuous complete remission and 12 patients had died. Relapse occurred in 8 patients, 6 in the bone marrow and 2 in the testes, and 3 patients achieved second remission for a median time of 14 months (range: 6-23 months). The following variables were adversely associated with EFS: age ≤3 years, WBC count ≥50x109/L, LDH value ≥1000 IU/L, hepatomegaly, splenomegaly, and NCI (National Cancer Institute, US) classification in the high-risk group. In the Cox regression analysis, WBC count ≥50x109/L emerged as the most significant adverse prognostic factor. The results of this study appear to be in concordance with other reports from international study groups. This can be attributed to the high compliance to standardized protocolbased treatment.
1 µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ∞.¶.£., £ÂÛÛ·ÏÔÓ›ÎË 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜, ∆Ì‹Ì· π·ÙÚÈ΋˜ ∞.¶.£., £ÂÛÛ·ÏÔÓ›ÎË
1 2nd Paediatric Clinic of Aristotelion University, Thessaloniki 2 Department of Hygiene, Aristotelion University of Thessaloniki
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¶·È‰È·ÙÚÈ΋ 2003;66:284-295
Paediatriki 2003;66:284-295
ÈηÓÔÔÈËÙÈο Î·È Â›Ó·È Û ϋÚË ·ÓÙÈÛÙÔȯ›· Ì ٷ ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ. ∞˘Ùfi ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Î·È Ù‹ÚËÛË Î·ıÈÂÚˆÌ¤ÓˆÓ ‰ÈÂıÓÒÓ ÚˆÙÔÎfiÏψÓ. §¤ÍÂȘ ÎÏÂȉȿ: ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÚˆÙfiÎÔÏÏÔ BFM-90, ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜.
Key words: childhood acute lymphoblastic leukaemia, BFM-90 protocol, prognostic factors.
∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË Î·ÎÔ‹ı˘ ÓÂÔÏ·ÛÌ·ÙÈ΋ ÓfiÛÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∞ÔÙÂÏ› ÙÔ 25-30% fiÏˆÓ ÙˆÓ ·È‰ÈÎÒÓ ÓÂÔÏ·ÛÈÒÓ, ÌÂ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 3-4 ÂÚÈÙÒÛÂȘ ÂÙËÛ›ˆ˜ ·Ó¿ 100.000 ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 15 ÂÙÒÓ (1,2). ∂›Ó·È ÓfiÛËÌ· Ì ¢ڇ Î·È ÂÙÂÚÔÁÂÓ¤˜ Ê¿ÛÌ· ÙfiÛÔ ˆ˜ ÚÔ˜ ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi, fiÛÔ Î·È ˆ˜ ÚÔ˜ ÙÔÓ ÎÏÈÓÈÎfi Ê·ÈÓfiÙ˘Ô. ∂ÈϤÔÓ, Û‹ÌÂÚ· Ù· ÔÛÔÛÙ¿ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì O§§ ÍÂÂÚÓÔ‡Ó ÙÔ 70% (20). ∆Ô Â›Ù¢ÁÌ· ·˘Ùfi ÌÔÚ› Ó· ·Ô‰Ôı›: ·) ÛÙËÓ ÚÔʇϷÍË ÙÔ˘ ∫¡™, ‚) ÛÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Á) ÛÙËÓ Î·Ù¿Ù·ÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ Ì ‚¿ÛË ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ‰) ÛÙËÓ ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ıÂڷ›·˜ Ì ‚¿ÛË ÙÔÓ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È Ë ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì O§§ Î·È Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÚfiÏÔ˘ ηıÈÂÚˆÌ¤ÓˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙÔ Ï·›ÛÈÔ Ù˘ ÂÊ·ÚÌÔÁ‹˜ Û‡Á¯ÚÔÓˆÓ ÂÓÙ·ÙÈÎÒÓ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ.
‹Ù·Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Ë ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ë ÙÈÌ‹ Ù˘ LDH. ∂ÈϤÔÓ, Û˘ÌÏËÚˆÓfiÙ·Ó Ë ÌÔÚÊÔÏÔÁÈ΋ Î·È ·ÓÔÛÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜, ηıÒ˜ ›Û˘ Î·È ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, fiˆ˜ Ë Ù˘¯fiÓ ˘ÔÙÚÔ‹, Ô ¯ÚfiÓÔ˜ Î·È Ë ı¤ÛË ÂÌÊ¿ÓÈÛ‹˜ Ù˘, Ô ı¿Ó·ÙÔ˜, Ô ¯ÚfiÓÔ˜ Î·È Ë ·ÈÙ›· ı·Ó¿ÙÔ˘, Ô ¯ÚfiÓÔ˜ ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ Î·È Ë ÙÂÏÂ˘Ù·›· ›ÛÎÂ„Ë ÁÈ· ·ӤÏÂÁ¯Ô. OÈ ·ÛıÂÓ›˜, ÛÙË Û˘Ó¤¯ÂÈ·, Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ‰È¿ÊÔÚ˜ ηÙËÁÔڛ˜ ·Ó¿ÏÔÁ· Ì ٷ ÂÚÁ·ÛÙËÚȷο Î·È ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹. ¶ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ›¯Â ÚÔËÁËı› Ë Î·Ù¿Ù·Í‹ ÙÔ˘˜ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ BFM-90 (6): ·) ÔÌ¿‰· ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (SR): BFM-RF <0,8 Î·È ‚Ï¿ÛÙ˜ <1.000/ÌL ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÙËÓ 8Ë Ë̤ڷ Î·È fi¯È ∆-O§§ Î·È ÌË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ∫¡™, ‚) ÔÌ¿‰· ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (MR): ‚Ï¿ÛÙ˜ <1.000/ÌL ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÙËÓ 8Ë Ë̤ڷ Î·È BFM-RF ≥0,8 ‹ BFM-RF <0,8 Î·È Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ∫¡™ ‹ ∆-O§§ Î·È Á) ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (HR): ‚Ï¿ÛÙ˜ ≥1.000/ÌL ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÙËÓ 8Ë Ë̤ڷ ‹ ‚Ï¿ÛÙ˜ <1.000/ÌL ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÙËÓ 8Ë Ë̤ڷ, ·ÏÏ¿ ≥5% ‚Ï¿ÛÙ˜ ÛÙÔÓ Ì˘ÂÏfi ÙËÓ 33Ë Ë̤ڷ. [BFM-RF (Risk-factor) = 0,2 x log (·ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ/ ÌL+1) + 0,06 x ‹·Ú (cm ˘fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ) + 0,04 x ÛÏ‹Ó·˜ (cm ˘fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ)] (6). ∂ÈϤÔÓ, ÁÈ· ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ¤ÁÈÓ ηٿٷÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ηٿ NCI (18): ·) ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘: WBC <50x109/L Î·È ËÏÈΛ· 1 ¤ˆ˜ <10 ¤ÙË Î·È ‚) ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘: WBC ≥50x109/L ‹ ËÏÈΛ· ≥10 ÂÙÒÓ. ¢È¿ÁÓˆÛË ∏ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ ¤ÁÈÓ Ì ΢ÙÙ·ÚÔÌÔÚÊÔÏÔÁÈ΋ Î·È ÈÛÙÔ¯ËÌÈ΋ ÂͤٷÛË ÂȯÚÈÛÌ¿ÙˆÓ ·›Ì·ÙÔ˜ Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. °È· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ ‹Ù·Ó ··Ú·›ÙËÙË Ë ‡·ÚÍË ≥25% ‚Ï·ÛÙÒÓ ÛÙÔÓ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ. ∏ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÔÚ›ÛÙËΠˆ˜ Ë ‡·ÚÍË ≥5 ‚Ï¿ÛÙ˜/ÌL ÌË ·ÈÌ·ÙËÚÔ‡ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ ‹ Ë Ï¢¯·ÈÌÈ΋ ‰È‹ıËÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÌÂÙ¿ ·fi ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÁÈÓfiÙ·Ó ÔÊı·ÏÌÔÏÔÁÈÎfi˜ Î·È Ë¯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜. OÈ ·ÓÔÛÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ıˆÚÔ‡ÓÙ·Ó ıÂÙÈÎÔ› ÂÊfiÛÔÓ ÂÎÊÚ¿˙ÔÓÙ·Ó Û ≥20% ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ù·ÍÈÓÔÌ‹ıËΠ۠ÚÔ-ÚÔ-µ ÂÊfiÛÔÓ ‹Ù·Ó TdT+, HLA-DR+, CD19+, Û ÚÔ-µ ÂÊfiÛÔÓ ‹Ù·Ó TdT+/-, HLA-DR+/-
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο ÔÈ Ê¿ÎÂÏÔÈ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ∞Ã∂¶∞ Î·È ¤Ï·‚·Ó ıÂڷ›· Ì ‚¿ÛË ÙÔ ÚˆÙfiÎÔÏÏÔ BFM90 (Berlin-Frankfurt-Münster), ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· π·ÓÔ˘·Ú›Ô˘ 1993-¢ÂÎÂÌ‚Ú›Ô˘ 1999 (¶›Ó·Î·˜ 1) (∂ÈÎfiÓ· 1). ∞fi ÙË ÌÂϤÙË ÂÍ·ÈÚ¤ıËÎ·Ó 1 ·ÛıÂÓ‹˜ Ì ÒÚÈÌË B-O§§ Î·È 1 ·ÛıÂÓ‹˜ Ô˘ ÚÔÛ‹Ïı Ì ˘ÔÙÚÔ‹ O§§. °È· οı ·È‰› Û˘ÌÏËÚˆÓfiÙ·Ó ÂȉÈÎfi ÚˆÙfiÎÔÏÏÔ, ÛÙÔ ÔÔ›Ô ˘‹Ú¯·Ó ‰ËÌÔÁÚ·ÊÈο ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ÛÙÔȯ›· ηٿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∆· ‰ËÌÔÁÚ·ÊÈο Î·È ÎÏÈÓÈο ÛÙÔȯ›· ÂÚÈÂÏ¿Ì‚·Ó·Ó ÙÔ ÔÓÔÌ·ÙÂÒÓ˘ÌÔ ÙÔ˘ ·È‰ÈÔ‡, ÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜ ÙÔ˘, ÙÔ Ê‡ÏÔ, ÙËÓ ËÌÂÚÔÌËÓ›· Á¤ÓÓËÛ˘, ÙËÓ ËÌÂÚÔÌËÓ›· ÂÈÛ·ÁˆÁ‹˜ ÛÙË ÎÏÈÓÈ΋, ÙËÓ ËÌÂÚÔÌËÓ›· ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜, Ù· ÎÏÈÓÈο ÛËÌ›· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙËÓ Ù˘¯fiÓ ‡·ÚÍË Ë·ÙÔÌÂÁ·Ï›·˜, ÛÏËÓÔÌÂÁ·Ï›·˜, ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·˜, ÙË Û˘ÌÌÂÙÔ¯‹ ‹ ÌË ÙˆÓ fiÚ¯ÂˆÓ Î·È ÙË ‰È‹ıËÛË ‹ ÌË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘
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¶·È‰È·ÙÚÈ΋ 2003;66:284-295
Paediatriki 2003;66:284-295
¶›Ó·Î·˜ 1. ¶ÚˆÙfiÎÔÏÏÔ BFM-90 º¿ÚÌ·ÎÔ º¿ÛË ÂÊfi‰Ô˘ ¶ÚˆÙfiÎÔÏÏÔ π ¶Ú‰ÓÈ˙fiÓË (per os) µÈÓÎÚÈÛÙ›ÓË (IV) ¢·Ô˘ÓÔÚÔ˘‚ÈΛÓË (IV) L-∞Û·Ú·ÁÈÓ¿ÛË (IV) ªÂıÔÙÚÂÍ¿ÙË (IT) ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (IV) ∫˘Ù·Ú·‚›ÓË (IV) 6-ªÂÚηÙÔÔ˘Ú›ÓË ªÂıÔÙÚÂÍ¿ÙË (IT) º¿ÛË Â‰Ú·›ˆÛ˘ (Û SRG & MRG) ¶ÚˆÙfiÎÔÏÏÔ M 6-ªÂÚηÙÔÔ˘Ú›ÓË ªÂıÔÙÚÂÍ¿ÙË MÂıÔÙÚÂÍ¿ÙË (IT) ¶ÚˆÙfiÎÔÏÏÔ M-A L-∞Û·Ú·ÁÈÓ¿ÛË (IM) º¿ÛË Â·ÓÂÊfi‰Ô˘ (Û SRG & MRG) ¶ÚˆÙfiÎÔÏÏÔ II ¢ÂÍ·ÌÂı·˙fiÓË (per os) µÈÓÎÚÈÛÙ›ÓË (IV) ¢ÔÍÔÚÔ˘‚ÈΛÓË (IV) L-AÛ·Ú·ÁÈÓ¿ÛË (IV) ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (IV) ∫˘Ù·Ú·‚›ÓË (IV) 6-£ÈÔÁÔ˘·Ó›ÓË (orally) ªÂıÔÙÚÂÍ¿ÙË (IT) ∂ÓÙ·ÙÈ΋ ·Ó‰ڷ›ˆÛË (HRG ÌfiÓÔ) ™ÙÔÈ¯Â›Ô HR-1 ¢ÂÍ·ÌÂı·˙fiÓË (per os) 6-MÂÚηÙÔÔ˘Ú›ÓË µÈÓÎÚÈÛÙ›ÓË (IV) ªÂıÔÙÚÂÍ¿ÙË ∫˘Ù·Ú·‚›ÓË L-AÛ·Ú·ÁÈÓ¿ÛË (IM) ªÂıÔÙÚÂÍ¿ÙË/Î˘Ù·Ú·‚›ÓË/Ú‰ÓÈ˙fiÓË (IT) ™ÙÔÈ¯Â›Ô HR-2 ¢ÂÍ·ÌÂı·˙fiÓË (per os) £ÈÔÁÔ˘·Ó›ÓË (per os) µÈÓ‰ÂÛ›ÓË (IV) ªÂıÔÙÚÂÍ¿ÙË πÊÔÛÊ·Ì›‰Ë ¢·Ô˘ÓÔÚÔ˘‚ÈΛÓË L-∞Û·Ú·ÁÈÓ¿ÛË (IM) MÂıÔÙÚÂÍ¿ÙË/Î˘Ù·Ú·‚›ÓË/Ú‰ÓÈ˙fiÓË (IT) ™ÙÔÈ¯Â›Ô HR-3 ¢ÂÍ·ÌÂı·˙fiÓË ∫˘Ù·Ú·‚›ÓË ∂ÙÔÔÛ›‰Ë L-AÛ·Ú·ÁÈÓ¿ÛË (IM) ªÂıÔÙÚÂÍ¿ÙË/Î˘Ù·Ú·‚›ÓË/Ú‰ÓÈ˙fiÓË (IT)
¢fiÛË (/m2)
∏̤Ú˜
60 mg 1,5 mg 30 mg 10.000 IU 12 mg 1000 mg 75 mg 60 mg 12 mg
1-28 8, 15, 22, 29 8, 15, 22, 29 12, 15, 18, 21, 24, 27, 30, 33 1, 15, 29 36, 64 38-41, 45-48, 52-55, 59-62 36-64 45, 59
25 mg 5 g/m2 12 mg
1-56 8, 22, 36, 50 8, 22, 36, 50
25.000 IU
10, 24, 38, 52
10 mg 1,5 mg 30 mg 10.000 IU 1000 mg 75 mg 60 mg 12 mg
1-21 8, 15, 22, 29 8, 15, 22, 29 8, 11, 15, 18 36 38-41, 45-48 36-49 38, 45
20 mg 100 mg 1,5 mg 5g 2g 25.000 IU 12 mg/30 mg/10 mg
1-5 1-5 1, 5 1 5 6 1
20 mg 100 mg 3 mg 5g 400 mg 50 mg 25.000 IU 12 mg/30 mg/10 mg
1-5 1-5 1 1 1-5 5 6 1
20 mg 2g 150 mg 25.000 IU 12 mg/30 mg/10 mg
1-5 1, 2 3-5 6 5
CD10+, CD19+ Î·È cyIg+ (΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋), Û ÒÚÈÌË µO§§ ÂÊfiÛÔÓ ‹Ù·Ó TdT+, HLA-DR+, CD19+, CD22+, cyIg+ Î·È sIg+ (ÂÈÊ·ÓÂȷ΋), Û ∆-O§§ ÂÊfiÛÔÓ ‹Ù·Ó TdT+, CD2+, cyCD3+, CD7+ Î·È Û ‰ÈÊ·ÈÓÔÙ˘È΋ O§§ ÂÊfiÛÔÓ ˘‹Ú¯Â Ù·˘Ùfi¯ÚÔÓË ¤ÎÊÚ·ÛË Û ÙÔ˘Ï¿¯ÈÛÙÔÓ 20% ÙˆÓ ÏÂÌÊÔ‚Ï·ÛÙÒÓ ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·ÓÙÈÁfiÓˆÓ Ù˘ Ì˘ÂÏÈ΋˜ ÛÂÈÚ¿˜ (CD13, CD33, CD65s).
286
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË OÈ ‰È·ÊÔÚ¤˜ ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ·Ó¿ÌÂÛ· ÛÙȘ ˘ÔηÙËÁÔڛ˜ ÙˆÓ ·ÛıÂÓÒÓ ÌÂÏÂÙ‹ıË2 Î·Ó Ì ÙË ‰ÔÎÈÌ·Û›· ¯ Î·È ÙÔ Mann Whitney U test. ∏ ÂÎÙ›ÌËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ÂÈ‚›ˆÛ˘ (overall survival - OS) Î·È Ù˘ ÂÈ‚›ˆÛ˘ ¯ˆÚ›˜ ÓfiÛÔ Û ÚÒÙË ‡ÊÂÛË (event-free survival - EFS) ¤ÁÈÓ Ì ÙË Ì¤ıÔ‰Ô Kaplan-Meier, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ùo˘
¶·È‰È·ÙÚÈ΋ 2003;66:284-295
OÌ¿‰· ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘
Paediatriki 2003;66:284-295
º¿ÛË ÂÊfi‰Ô˘
º¿ÛË Â‰Ú·›ˆÛ˘
º¿ÛË Â·ÓÂÊfi‰Ô˘
I
M
II
12 Gy*
M OÌ¿‰· ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘
I
º¿ÛË Û˘ÓÙ‹ÚËÛ˘
II
R M-A
OÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘
H R 1
IA
H R 2
H R 3
H R 1
H R 2
H R 3
H R 1
12 Gy* H R 3
H R 2
∂‚‰ÔÌ¿‰Â˜ 0
5
11
21
28
30
104
∂ÈÎfiÓ· 1. º¿ÛÂȘ ıÂڷ›·˜ ÚˆÙÔÎfiÏÏÔ˘ BFM-90.
Ù˘ÈÎÔ‡ ÛÊ¿ÏÌ·ÙÔ˜ (standard error - SE) Î·È 95% ‰È·ÛÙ‹Ì·ÙÔ˜ ·ÍÈÔÈÛÙ›·˜ (confidence interval - CI) (3). ∏ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ˘ÔÏÔÁ›ÛÙËΠ·fi ÙËÓ ËÌÂÚÔÌËÓ›· ‰È¿ÁÓˆÛ˘ ¤ˆ˜ ÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ›Û΄˘ ÁÈ· ·ӤÏÂÁ¯Ô ‹ ÙËÓ ËÌÂÚÔÌËÓ›· ı·Ó¿ÙÔ˘. ∏ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Û ÚÒÙË ‡ÊÂÛË ˘ÔÏÔÁ›ÛÙËΠ·fi ÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ‰È¿ÁÓˆÛ˘ ̤¯ÚÈ ÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ›Û΄˘ ÁÈ· ¤ÏÂÁ¯Ô ‹ ̤¯ÚÈ ÙËÓ ËÌÂÚÔÌËÓ›· Ô˘ ˘‹Ú¯Â Û˘Ì‚¿Ó. ø˜ Û˘Ì‚¿Ó ÔÚ›ÛÙËÎÂ Ë ·ÔÙ˘¯›· ›Ù¢Í˘ Ï‹ÚÔ˘˜ ‡ÊÂÛ˘ (ÚfiˆÚÔ˜ ı¿Ó·ÙÔ˜ ‹ ·ÓıÂÎÙÈ΋ Ï¢¯·ÈÌ›·), Ë ˘ÔÙÚÔ‹ Î·È Ô ı¿Ó·ÙÔ˜ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ Ï‹ÚÔ˘˜ ‡ÊÂÛ˘. OÈ ·ÛıÂÓ›˜ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ‰È¿ÊÔÚ˜ ÔÌ¿‰Â˜ ·Ó¿ÏÔÁ· Ì ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂͤÊÚ·˙·Ó ηٿ ÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ‰È¿ÁÓˆÛ˘, ÔÈ ÔÔ›ÔÈ ‹Ù·Ó: ËÏÈΛ· (<1 ¤ÙÔ˘˜, 1-6 ÂÙÒÓ, ≥6 ÂÙÒÓ Î·È ≤3/>3 ÂÙÒÓ), ʇÏÔ, Ë·ÙÔÌÂÁ·Ï›· Î·È ÛÏËÓÔÌÂÁ·Ï›· (</≥3 cm ˘fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ), Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ, ÙÔ˘ ∫¡™, ÙˆÓ fiگˆÓ, o ·ÚÈıÌfi˜ ÙˆÓ 9 9 Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (WBC <10x10 /L, 10-25x10 /L, 259 9 9 50x10 /L 50-100x10 /L, >100x10 /L), Ë ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (Hb </≥10 g/dl), o ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ 3 (</≥100.000/mm ), Ë ÙÈÌ‹ Ù˘ LDH (</≥1000 IU/L), Ô ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ (ÚÔ-ÚÔ-B, ÚÔ-B, T-O§§, ‰ÈÊ·ÈÓÔÙ˘È΋ O§§, ·‰È·ÊÔÚÔÔ›ËÙË O§§) Î·È Ë Ù·ÍÈÓfiÌËÛË Î·Ù¿ NCI. OÈ ‰È·ÊÔÚ¤˜ ÛÙ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ Î·ÙËÁÔÚÈÒÓ ÙˆÓ ·ÛıÂÓÒÓ ÂÎÙÈÌ‹ıËÎ·Ó Ì ÙÔ 2-sided log-rank test (4). ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÌÂÙ·‚ÏËÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ·ÍÈÔÏÔÁ‹ıËΠ̠ÙËÓ ·Ó¿Ï˘ÛË Cox-regression (5). °È· ÙËÓ ·Ó¿Ï˘ÛË ·˘Ù‹ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÌfiÓÔ ÔÈ ·Ú¿ÌÂÙÚÔÈ Ô˘ ›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙËÓ EFS (p log-rank <0,05). ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙÔ ·Î¤ÙÔ “SPSS for windows” (version 10.0).
∞ÔÙÂϤÛÌ·Ù· ∫ÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ¯·Ú·ÎÙËÚÈÛÙÈο ∞fi ÙÔ˘˜ 70 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘, 39 (55,7%) ‹Ù·Ó ·ÁfiÚÈ· Î·È 31 (44,2%) ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 3 ÌËÓÒÓ ¤ˆ˜ Î·È 15 ÂÙÒÓ. ŒÓ·˜ ÂÎ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ‚Ú¤ÊÔ˜, 46 ›¯·Ó ËÏÈΛ· 1-<6 ÂÙÒÓ Î·È 23 ≥6 ÂÙÒÓ, Ì ‰È¿ÌÂÛË ËÏÈΛ· Ù· 4,5 ¤ÙË. O ‰È¿ÌÂÛÔ˜ ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‹Ù·Ó 11,7x109/L (‡ÚÔ˜: ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ 0,13x109/L-185,8x109/L), 49.000/mm3 (‡ÚÔ˜: 8000/mm3-480.000/mm3), Ù˘ ÙÈÌ‹˜ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ 7,3 g/dl (‡ÚÔ˜: 3,5 g/dl16,9 g/dl) Î·È Ù˘ ÙÈÌ‹˜ Ù˘ LDH 827 IU/L (‡ÚÔ˜: 62 IU/L-5210 IU/L). ªÂ ‚¿ÛË ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· Ô˘ ÔÚ›˙ÂÈ ÙÔ ÚˆÙfiÎÔÏÏÔ BFM-90, 36 (51,4%) ·ÛıÂÓ›˜ ·Ó‹Î·Ó ÛÙËÓ ÔÌ¿‰· ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (standard-risk) Î·È 34 (48,6%) ÛÙËÓ ÔÌ¿‰· ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (medium-risk). ªÂ ‚¿ÛË ÙËÓ Î·Ù¿Ù·ÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· NCI, 41 (58,6%) ·ÛıÂÓ›˜ ÂÎÏ‹ÚˆÓ·Ó Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ÔÌ¿‰·˜ ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È 29 (41,4%) Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∫·Ó¤Ó·˜ ·ÛıÂÓ‹˜ ηٿ ÙË ‰È¿ÁÓˆÛË ‰ÂÓ Â›¯Â ‰È‹ıËÛË ÙÔ˘ ∫¡™ ‹ ÙˆÓ fiگˆÓ. ∏ ηٿٷ͋ ÙÔ˘˜ Û ‰È¿ÊÔÚ˜ ÔÌ¿‰Â˜ Û ۯ¤ÛË Ì ٷ ÂÚÁ·ÛÙËÚȷο Î·È ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙÔ˘˜ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ™ÙËÓ ∂ÈÎfiÓ· 2 Ê·›ÓÔÓÙ·È ÔÈ ÔÛÔÛÙÈ·›Â˜ ·Ó·ÏÔÁ›Â˜ ÙˆÓ Î˘Ú›·Ú¯ˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜. ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ˘„ËÏfi
287
¶·È‰È·ÙÚÈ΋ 2003;66:284-295
Paediatriki 2003;66:284-295
·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ WBC ≥50x109/L ·ÚÔ˘Û›·˙·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÙÈÌ‹ Ù˘ LDH (≥1000 IU/L) (∂ÈÎfiÓ· 3) Î·È ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÛÏËÓÔÌÂÁ·Ï›·˜ (p<0,05). ∞ÔÙÂϤÛÌ·Ù· ıÂڷ›·˜ O ‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜ ·Ú·Ù‹ÚËÛ˘ ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 53 Ì‹Ó˜ (‡ÚÔ˜: 14 Ë̤Ú˜97 Ì‹Ó˜). H Èı·ÓfiÙËÙ· EFS ‹Ù·Ó 77,14% (CI: 6986%) Î·È Ë Èı·ÓfiÙËÙ· OS ‹Ù·Ó 82,35% (CI: 7490%) (∂ÈÎfiÓ˜ 4 Î·È 5). ∆· ıÂڷ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ŒÓ·˜ ·ÛıÂÓ‹˜ ›¯Â ÚfiˆÚÔ ı¿Ó·ÙÔ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ıÂڷ›·˜, ÂÓÒ Û˘ÓÔÏÈο 3 ·ÛıÂÓ›˜ η٤ÏËÍ·Ó ÛÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 5 ‚‰ÔÌ¿‰ˆÓ Ù˘ ıÂڷ›·˜ ÂÊfi‰Ô˘. ∞ÈÙ›· ı·Ó¿ÙÔ˘, fiˆ˜ ·˘Ù‹ ηٷÁÚ·ÊfiÙ·Ó ÛÙ· ÈÛÙÔÔÈËÙÈο ı·Ó¿ÙÔ˘, ‹Ù·Ó Ë ·ÈÌÔÚÚ·Á›·. ªÂÙ¿, fï˜, ·fi ÏÂÙÔÌÂÚ‹ ·Ó¿Ï˘ÛË ÙˆÓ Ê‡ÏÏˆÓ ÓÔÛËÏ›·˜ ‰È·ÈÛÙÒıËΠfiÙÈ ·˘Ù‹ ‹Ù·Ó ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ‚·ÚÈ¿˜ Ì˘ÂÏÈ΋˜ ·Ï·Û›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·Ú·ÙÂٷ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›· Î·È Û˘Ó˘¿Ú¯Ô˘Û· Ïԛ̈ÍË.
ÀÔÙÚÔ‹ ·ÚÔ˘Û›·Û·Ó 8 ·ÛıÂÓ›˜, 6 ÛÙÔÓ Ì˘ÂÏfi Î·È 2 ÛÙÔ˘˜ fiÚ¯ÂȘ. ¢ÂÓ ˘‹Ú¯·Ó ‰È·ÊÔÚ¤˜ Û ۯ¤ÛË Ì ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ˘ÔÙÚÔ‹˜, ηıÒ˜ 4 ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ˘ÔÙÚÔ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Î·È 4 ̤۷ ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙËÓ ÔÏÔÎÏ‹ÚˆÛ‹ Ù˘. ∆ÚÂȘ ·ÛıÂÓ›˜ ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 6 ¤ˆ˜ 23 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 14 Ì‹Ó˜), ÂÓÒ 5 ·ÛıÂÓ›˜ η٤ÏËÍ·Ó (Û ‰È¿ÛÙËÌ· ·fi 2 ¤ˆ˜ 6 Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜).
∞ÓÔÚÂÍ›·Î·Ù·‚ÔÏ‹ 18,3%
¶˘ÚÂÙfi˜ 31%
¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ (%) ÙˆÓ ·ÛıÂÓÒÓ Û‡Ìʈӷ Ì ٷ ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÂÈÛ·ÁˆÁ‹˜ ªÂÙ·‚ÏËÙ‹
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ
¶ÔÛÔÛÙfi ·ÛıÂÓÒÓ (%)
32/70 14/70 8/70 8/70 8/70
45,8 20 11,4 11,4 11,4
57/70 13/70
81,4 18,6
57/70 13/70
81,4 18,6
40/66 26/66
60,6 39,4
44/70 26/70
62,6 37,4
42/70 28/70
60 40
28/68 40/68
41,2 58,8
7/70 60/70 1/70 1/70 1/70
10 85,8 1,4 1,4 1,4
∫·Ù·‚ÔÏ‹ 31%
∞Ó·ÈÌ›· 36,6%
∂ί˘ÌÒÛÂȘ ÂÙ¤¯ÂȘ 21,1%
∞ÚıÚ·ÏÁ›· 22,5%
∂ÈÎfiÓ· 2. ∫·Ù·ÓÔÌ‹ (%) ÙˆÓ ·ÛıÂÓÒÓ Û‡Ìʈӷ Ì ٷ ΢ڛ·Ú¯· Û˘ÌÙÒÌ·Ù· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹.
9
288
6000
5000 p<0,05 4000 LDH (IU/L)
ñ ∞ÚÈıÌfi˜ Ï¢ÎÒÓ (x10 /L) <10 10-25 25-50 50-100 ≥100 ñ ∞ÈÌÔÛÊ·ÈÚ›ÓË (g/dl) ≤10 >10 3 ñ ∞ÈÌÔÂÙ¿ÏÈ· (/mm ) <100.000 ≥100.000 ñ LDH <1.000 ≥1.000 ñ ∏·ÙÔÌÂÁ·Ï›· <3 cm (˘fi Ï¢ÚÈÎfi ÙfiÍÔ) ≥3 cm ñ ™ÏËÓÔÌÂÁ·Ï›· <3 cm (˘fi Ï¢ÚÈÎfi ÙfiÍÔ) ≥3 cm ñ §ÂÌÊ·‰ÂÓÈ΋ ‰ÈfiÁΈÛË ∞Ô˘Û›· ¶·ÚÔ˘Û›· ñ ∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ¶ÚÔ-ÚÔ-µ ¶ÚÔ-µ ∆-O§§ ¢ÈÊ·ÈÓÔÙ˘È΋ O§§ ∞‰È·ÊÔÚÔÔ›ËÙË O§§
3000
2000
1000
0 50.000
100.000
150.000
200.000
WBC ∂ÈÎfiÓ· 3. ¢È¿ÁÚ·ÌÌ· ‰È·ÛÔÚ¿˜ ÙˆÓ ÙÈÌÒÓ Ù˘ LDH Û ۯ¤ÛË Ì ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ.
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1,0
0,8
0,8
0,6
0,6
p OS
p EFS
1,0
0,4
0,4
0,2
0,2
0
0 0
20
40
60
80
100
0
ª‹Ó˜ ∂ÈÎfiÓ· 4. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ OS ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ.
¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ™ÙÔÓ ¶›Ó·Î· 4 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ıÂڷ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· Î·È Ë Èı·ÓfiÙËÙ· EFS Û ۯ¤ÛË Ì ÙȘ ÎÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·Ì¤ÙÚÔ˘˜. Ÿˆ˜ ÚÔ·ÙÂÈ, ‰˘ÛÌÂÓ‹ ›‰Ú·ÛË ÛÙËÓ Èı·ÓfiÙËÙ· EFS Ì ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p logrank ≤0,05) ›¯·Ó: Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ WBC ≥50x109/L, Ë ÙÈÌ‹ Ù˘ LDH ≥1000 IU/L, Ë ËÏÈΛ· (≤3 ÂÙÒÓ), Ë Ë·ÙÔÌÂÁ·Ï›· (≥3 cm), Ë ÛÏËÓÔÌÂÁ·Ï›· (≥3 cm) Î·È Ë Ù·ÍÈÓfiÌËÛË Î·Ù¿ NCI ÛÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (∂ÈÎfiÓ˜ 6-11). OÈ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ‚Ú¤ıËΠfiÙÈ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙË Èı·ÓfiÙËÙ· EFS (p log-rank <0,05), Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÛÙËÓ ·Ó¿Ï˘ÛË Cox regression. ∞˘Ù‹ ·ÔÎ¿Ï˘„ fiÙÈ ÈÛ¯˘ÚfiÙÂÚÔ˜ ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, WBC ≥50x109/L (¶›Ó·Î·˜ 5). ™˘˙‹ÙËÛË ªÂ Ù· Û‡Á¯ÚÔÓ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ·, Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ·È‰È΋ O§§ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÂχıÂÚÔÈ ÓfiÛÔ˘ (pEFS) Î˘Ì·›ÓÔÓÙ·È ·fi 63% ¤ˆ˜ 83% (6-16). °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÙÔ ÔÛÔÛÙfi EFS ‹Ù·Ó 77,14% (CI: 69-86%) Î·È ÙÔ ÔÛÔÛÙfi OS ‹Ù·Ó 82,35% (CI: 74-90%). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È Û ·fiÏ˘ÙË ·ÓÙÈÛÙÔȯ›· Ì ٷ ‰ËÌÔÛÈÂ˘Ì¤Ó· ·Ô-
20
40
60 ª‹Ó˜
80
100
∂ÈÎfiÓ· 5. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ. ¶›Ó·Î·˜ 3. ∞ÔÙÂϤÛÌ·Ù· ıÂڷ›·˜ ∞ÔÙÂϤÛÌ·Ù· ñ ÀÔÙÚÔ‹ ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ ªÂÙ¿ ÙÔ ¤Ú·˜ Ù˘ ıÂڷ›·˜ ª˘ÂÏfi˜ ŸÚ¯ÂȘ ™‡ÓÔÏÔ ñ £¿Ó·ÙÔÈ ¶ÚfiˆÚÔ˜ ı¿Ó·ÙÔ˜ ™ÙË Ê¿ÛË ÂÊfi‰Ô˘ ™ÙË Ê¿ÛË Â·ÓÂÊfi‰Ô˘ ªÂÙ¿ ·fi ˘ÔÙÚÔ‹ ™‡ÓÔÏÔ ñ ™˘Ó¯È˙fiÌÂÓË Ï‹Ú˘ ‡ÊÂÛË
¡ (/70) 4 4 6 2 8 1 4 2 5 12 58
ÙÂϤÛÌ·Ù· ·fi ÙËÓ ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ÙÔ˘ BFM-90 Ô˘ ‹Ù·Ó 78,1±1% Î·È 85±1%, ·ÓÙ›ÛÙÔȯ· (6). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÎÚ›ÓÔÓÙ·È Ôχ ÈηÓÔÔÈËÙÈο Î·È Â›Ó·È Û ϋÚË ·ÓÙÈÛÙÔȯ›· Ì ٷ ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ. ∞˘Ùfi ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÈÛÙ‹ ÂÊ·ÚÌÔÁ‹ Î·È Ù‹ÚËÛË Î·ıÈÂÚˆÌ¤ÓˆÓ ‰ÈÂıÓÒÓ ÚˆÙÔÎfiÏψÓ. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë O§§ ıˆÚÂ›Ù·È ÙÔ ÚfiÙ˘Ô ÓfiÛËÌ· ÂÊ·ÚÌÔÁ‹˜ ÂÈÙ˘¯ËÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ ·ÚÂÌ‚¿ÛˆÓ, ̤ۈ ¢ڤˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ÛÙË
289
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¶›Ó·Î·˜ 4. ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Èı·ÓfiÙËÙ· ÂχıÂÚ˘ ÓfiÛÔ˘ ÂÈ‚›ˆÛ˘ (EFS) ªÂÙ·‚ÏËÙ‹ ñ ™‡ÓÔÏÔ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ñ ∏ÏÈΛ· (¤ÙË) ≤3 >3 ñ NCI ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ µ·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ñ ∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ¶ÚÔ-ÚÔ-µ ¶ÚÔ-µ ÕÏÏÔ* 9 ñ ∞ÚÈıÌfi˜ Ï¢ÎÒÓ (x10 /L) <50 ≥50 ñ ∞ÈÌÔÛÊ·ÈÚ›ÓË (g/dl) ≤10 >10 ñ ∞ÈÌÔÂÙ¿ÏÈ· (/mm3) <100.000 ≥100.000 ñ LDH (IU/L) <1000 ≥1000 ñ ∏·ÙÔÌÂÁ·Ï›· <3 cm ≥3 cm ñ ™ÏËÓÔÌÂÁ·Ï›· <3 cm ≥3 cm ñ §ÂÌÊ·‰ÂÓÈ΋ ‰ÈfiÁΈÛË ∞Ô˘Û›· ¶·ÚÔ˘Û›·
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ (%)
∂FS (SE)
P (log-rank)
70 39/70 (55,7) 31/70 (44,3)
77,14% (4) 76,92% (6) 77,42% (6)
0,97
18/70 52/70
61,11% (9) 82,69% (4)
0,04
41/70 (58,6) 29/70 (41,4)
85,37% (5) 65,52% (7)
0,05
7/70 (10) 60/70 (85,7) 3/70 (4,3)
71,43% (7) 81,67% (4) 0
0,0000
54/70 (77,1) 16/70 (22,9)
85,19% (4) 50% (13)
0,002
57/70 (81,4) 13/70 (18,6)
80,7% (5) 61,54% (11)
0,14
57/70 (81,4) 13/70 (18,6)
75,44% (13) 84,62% (9)
0,45
40/66 (60,6) 26/66 (39,4)
82,5% (5) 65,38% (7)
0,05
44/70 (62,6) 26/70 (37,4)
84,09% (5) 65,38% (8)
0,05
42/70 (60) 28/70 (40)
88,1% (4) 60,7% (7)
0,01
28/68 (41,2) 40/68 (58,9)
82,14% (6) 75% (5)
0,5
* T-O§§, ‰ÈÊ·ÈÓÔÙ˘È΋ O§§, ·‰È·ÊÔÚÔÔ›ËÙË O§§
¯ÒÚ· Ì·˜, Ë ÔÔ›· ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·ÛıÂÓÒÓ ‰ÂÓ ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙÔÓ Û¯Â‰È·ÛÌfi Ó¤ˆÓ ıÂڷ¢ÙÈÎÒÓ ÛÙÚ·ÙËÁÈÎÒÓ, Ó· ˘ÈÔıÂÙÔ‡ÓÙ·È ‰ÈÂıÓ‹ ÚˆÙfiÎÔÏÏ· Ì ·Ô‰Â‰ÂÈÁ̤ÓË ˘„ËÏ‹ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ¯·ÌËÏ‹ ÙÔÍÈÎfiÙËÙ·. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ‰È·ÊfiÚˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ıÂڷ›·˜ ¤¯ÂÈ ·Ó·ÌÊ›‚ÔÏ· Û˘Ì‚¿ÏÂÈ ÛÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. ™ËÌ·ÓÙÈΤ˜ ÚÔÛ¿ıÂȘ ¤¯Ô˘Ó Á›ÓÂÈ ÁÈ· ÙË ı¤ÛÈÛË ÔÌfiʈӷ ·Ô‰ÂÎÙÒÓ ÚÔÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙËÓ ·È‰È΋ O§§. ∞˘Ù¿ Ù· ÎÚÈÙ‹ÚÈ· Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ‰È·ÊfiÚˆÓ ıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ ·fi ‰È·ÊÔÚÂÙÈΤ˜ ÔÌ¿‰Â˜ ÌÂϤÙ˘. ™ÙË ƒÒÌË, ÙÔ 1985, ¤ÁÈÓÂ Ë ÚÒÙË ÛÔ‚·Ú‹ ÚÔÛ¿ıÂÈ· Ì ÙË ÌÔÚÊ‹ Û˘ÛÙ¿ÛÂˆÓ ÁÈ· ÙËÓ Î·ÙËÁÔÚÈÔÔ›ËÛË Ù˘ ·È‰È΋˜ O§§ Û 2 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘, ÙËÓ ÔÌ¿‰· ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (standard risk - SR)
290
Î·È ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (high risk - HR), Û‡Ìʈӷ Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÙËÓ ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË (17). ∞ÚÁfiÙÂÚ·, ÙÔ 1993, ÙÔ NCI Û˘ÌÊÒÓËÛ Ì ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ƒÒÌ˘ Î·È ıÂÛ›ÛÙËÎ·Ó Ù· ÎÔÈÓ¿ ÎÚÈÙ‹ÚÈ· NCπ (18). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ô˘ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ηٿ NCI ›¯·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË Èı·ÓfiÙËÙ· ∂FS Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘, Ì Èı·ÓfiÙËÙ· EFS 65,52±7% Î·È 85,37±5%, ·ÓÙ›ÛÙÔȯ·. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÌÔÚÔ‡Ó Ó· Û˘ÁÎÚÈıÔ‡Ó Î·È Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ, fiˆ˜ ·˘Ù¿ ÙÔ˘ BFM-90 Û‡Ìʈӷ Ì ٷ ÔÔ›· ÁÈ· ÙËÓ ÔÌ¿‰· ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ë Èı·ÓfiÙËÙ· EFS ‹Ù·Ó 86±1% (6) Î·È Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ·ÛıÂÓÒÓ Ì µ-O§§ Ô˘ ¤Ï·‚·Ó ıÂڷ›· Ì ٷ ÚˆÙfiÎÔÏÏ· POG (Alinc-14) (Pediatric Oncology Group) ‹ CCG (Children’s Cancer Group) (CCG 100 Î·È CCG-
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1,0
1,0 WBC<50.000/ÌL
NCI, ‚·ÛÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘
0,8
0,8 NCI, ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘
0,6
0,6 p EFS
p EFS
WBC≥50.000/ÌL
0,4
0,4
0,2
p=0,05
0,2
p=0,002
0
0 0
20
40
60 ª‹Ó˜
80
100
0
20
40
60 ª‹Ó˜
80
100
∂ÈÎfiÓ· 6. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ.
∂ÈÎfiÓ· 7. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ٷ ÎÚÈÙ‹ÚÈ· NCI.
1800) Ô˘ ›¯·Ó 80,3% Èı·ÓfiÙËÙ· ÙÂÙÚ·ÂÙÔ‡˜ EFS (18). ∞ÓÙÈÛÙÔ›¯ˆ˜, Û˘ÁÎÚ›ÛÈÌ· Â›Ó·È Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÁÈ· ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·fi ÙÔ BFM-90 Î·È CCG/POG Ô˘ ‹Ù·Ó 64±2% Î·È 63,9%, ·ÓÙ›ÛÙÔȯ· (6,18). O ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Â›Ó·È ¤Ó·˜ ·Ó·ÁÓˆÚÈṲ̂ÓÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÔÈ ·ÛıÂÓ›˜ Ì ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ WBC ≥50x109/L ›¯·Ó ÛÙ·ÙÈÛÙÈο ‰˘ÛÌÂÓ¤ÛÙÂÚË ¤Î‚·ÛË Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì WBC <50x109/L Ì Èı·ÓfiÙËÙ· EFS 85,19±4% Î·È 50±13%, ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ Cox regression ·Ó¿Ï˘ÛË, Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ WBC ≥50x109/L ·Ó·‰Â›¯ÙËΠˆ˜ Ô ÈÔ ÛËÌ·ÓÙÈÎfi˜ ‰˘ÛÌÂÓ‹˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË Î·È Ê¿ÓËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì WBC ≥50x109/L ›¯·Ó 2,78 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· ˘ÔÙÚÔ‹ ‹ ı¿Ó·ÙÔ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 2,78, 95% CI: 1,12-8,2) Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì WBC <50x109/L. ¢ÂÓ ˘¿Ú¯ÂÈ ·fiÏ˘ÙË ÔÌÔʈӛ· ÌÂٷ͇ ÙˆÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÎÚ›ÛÈÌÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÁÈ· ÙËÓ Î·Ù¿Ù·ÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÔÚÈṲ̂Ó˜ ÔÌ¿‰Â˜, fiˆ˜ Ë ÔÌ¿‰· ÙÔ˘ St Jude’s Research Hospital (SJCRH) (13), Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ù· ·È‰È¿ Ì ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ≥25x109/L ÛÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ÕÏϘ
ÔÌ¿‰Â˜, fiˆ˜ Ë ÔÌ¿‰· ÙÔ˘ Nordic Society of Pediatric Hematology and Oncology (NOPHO) (16) Î·È Ë ÔÌ¿‰· ÙÔ˘ CCG (8), ηٷٿÛÛÔ˘Ó Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ù· ·È‰È¿ Ì ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ≥50x109/L, ÂÓÒ ÔÈ ÔÌ¿‰Â˜ POG (12) Î·È DFCI (Dana Farber Cancer Institute) (15) ¯ÚËÛÈÌÔÔÈÔ‡Ó ˆ˜ ÎÚÈÙ‹ÚÈÔ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ≥100x109/L ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·È‰ÈÒÓ Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÙË ıÂڷ›· ÙÔ˘˜ Ì ÈÔ ÂÓÙ·ÙÈο Î·È ÂÈıÂÙÈο Û¯‹Ì·Ù· ıÂڷ›·˜. ∆Ô ˘„ËÏfi ÊÔÚÙ›Ô ÙÔ˘ fiÁÎÔ˘ Û˘Û¯ÂÙ›˙ÂÙ·È ÎÏÈÓÈο Ì ÙËÓ Ë·ÙÔÌÂÁ·Ï›·, ÙË ÛÏËÓÔÌÂÁ·Ï›· Î·È ÙË ÏÂÌÊ·‰ÂÓÈ΋ ‰ÈfiÁΈÛË. ∏ ‡·ÚÍË Ë·ÙÔÌÂÁ·Ï›·˜ ‹ ÛÏËÓÔÌÂÁ·Ï›·˜ Â›Ó·È ‰‡Ô ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Â›Ó·È ÂÓۈ̷و̤ÓÔÈ Û ·ÚÎÂÙ¿ ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· Ì ÙË ÌÔÚÊ‹ ÙÔ˘ BFM-RF, fiˆ˜ ÈÛ¯‡ÂÈ ÁÈ· ÙȘ ÔÌ¿‰Â˜ BFM (6), AIEOP (Italian Association of Pediatric Hematology and Oncology) (7) Î·È DCLSG (Dutch Childhood Leukemia Study Group) (10). ÕÏϘ ÔÌ¿‰Â˜, fiˆ˜ Ë NOPHO (16), Ë DFCI (15), Ë CCG (8) Î·È Ë POG (12), ›Û˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ì ˷ÙÔÌÂÁ·Ï›· ‹ ÛÏËÓÔÌÂÁ·Ï›· (≥3 cm ˘fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ) ›¯·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ EFS Ì ÙÈ̤˜ 65,38±8% Î·È 60,7±7%, ·ÓÙ›ÛÙÔȯ·, Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ ¯ˆÚ›˜ Ë·ÙÔÌÂÁ·Ï›·
291
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1,0
1,0 ◊·Ú <3 cm
™Ï‹Ó·˜ <3 cm
0,8
0,8 ◊·Ú ≥3 cm ™Ï‹Ó·˜ ≥3 cm p EFS
0,6
p EFS
0,6
0,4
0,4
p=0,01
p=0,05 0,2
0,2
0
0 0
20
40
60
80
100
ª‹Ó˜
0
20
40
60
80
100
ª‹Ó˜
∂ÈÎfiÓ· 8. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ÙËÓ Ë·ÙÔÌÂÁ·Ï›·.
∂ÈÎfiÓ· 9. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ÙË ÛÏËÓÔÌÂÁ·Ï›·.
‹ ÛÏËÓÔÌÂÁ·Ï›· Ì EFS 84,09±5% Î·È 88,1±4%, ·ÓÙ›ÛÙÔȯ·. ∞Ó Î·È ÔÈ ·ÛıÂÓ›˜ Ì ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ›¯·Ó ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· EFS (ÙÈÌ‹: 75±5%) Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ ¯ˆÚ›˜ ÏÂÌÊ·‰ÂÓÈ΋ Û˘ÌÌÂÙÔ¯‹ (ÙÈÌ‹: 82,14±6%), Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÌË ÛËÌ·ÓÙÈ΋. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ÔÌ¿‰· BFM90 Û ۯ¤ÛË Ì ÙËÓ ‡·ÚÍË Ë·ÙÔÌÂÁ·Ï›·˜ ‹ ÛÏËÓÔÌÂÁ·Ï›·˜ Ô˘ ‹Ù·Ó 71±1% Î·È 68±2% (6). ∏ ÙÈÌ‹ Ù˘ LDH ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Â›¯Â ÛËÌ·ÓÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ. OÈ ·ÛıÂÓ›˜ Ì ÙÈÌ‹ LDH ≥1000 IU/L ›¯·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi EFS Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÙÈÌ‹ LDH <1000 IU/L, Ì Èı·ÓfiÙËÙ· EFS 65,38±7% Î·È 84,09±5%, ·ÓÙ›ÛÙÔȯ·. ∂ÈϤÔÓ, ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÙÈÌ‹˜ Ù˘ LDH Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ. ∞˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÛÂ Û˘Ìʈӛ· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Pui Î·È Û˘Ó, ÛÙË ÌÂϤÙË ÙˆÓ ÔÔ›ˆÓ Ë LDH ›¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ‰˘ÛÌÂÓ‹ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÁÈ· ÙËÓ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË (19). O ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ë ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ‰ÂÓ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙËÓ Èı·ÓfiÙËÙ· EFS. ∞˘Ùfi Â›Ó·È ÛÂ Û˘Ìʈӛ· Ì ÙȘ Û‡Á¯ÚÔÓ˜ ÌÂϤÙ˜, ÛÙȘ Ôԛ˜ ÙfiÛÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, fiÛÔ Î·È Ë ÙÈÌ‹ Ù˘ ·È-
ÌÔÛÊ·ÈÚ›Ó˘ ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ (20). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ Ê‡ÏÔ, Ù· ÔÛÔÛÙ¿ Ù˘ ÂχıÂÚ˘ ÓfiÛÔ˘ ÂÈ‚›ˆÛ˘ ‰ÂÓ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ·Ó¿ÌÂÛ· ÛÙ· ·ÁfiÚÈ· Î·È Ù· ÎÔÚ›ÙÛÈ·, Ì ÙÈ̤˜ 76,92±6% Î·È 78,13±6%, ·ÓÙ›ÛÙÔȯ·. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÌʈÓÔ‡Ó Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Steinherz Î·È Û˘Ó (21) Î·È Gustafsson Î·È Û˘Ó (22) ·fi ÙȘ ÔÌ¿‰Â˜ CCG Î·È NOPHO ·ÓÙ›ÛÙÔȯ·, ÛÙȘ Ôԛ˜ ‰ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË Û ۯ¤ÛË Ì ÙÔ Ê‡ÏÔ. ∞ÓÙ›ıÂÙ·, fï˜, Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÌ¿‰·˜ BFM-90, Ù· ·ÁfiÚÈ· ›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ‰˘ÛÌÂÓ¤ÛÙÂÚË ¤Î‚·ÛË Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (6). ™‡Ìʈӷ Ì ٷ ‰ËÌÔÛÈÂ˘Ì¤Ó· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ BFM-90, ·ÓÂÍ¿ÚÙËÙÔ˜ ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ë ËÏÈΛ· <1 ¤ÙÔ˘˜ ‹ >6 ÂÙÒÓ (6). °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ Èı·ÓfiÙËÙ· EFS Ì ‚¿ÛË ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ∂ÈϤÔÓ, Û ·ÓÙ›ıÂÛË Ì ÙȘ Û‡Á¯ÚÔÓ˜ ÌÂϤÙ˜ fiÔ˘ Ë ‚ÚÂÊÈ΋ O§§ ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ͯˆÚÈÛÙ‹ ‚ÈÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ì ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË (23), ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ˘‹Ú¯Â 1 ‚Ú¤ÊÔ˜ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ó¯È˙fiÌÂÓË Ï‹ÚË ‡ÊÂÛË. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ô ·ÚÈıÌfi˜ ·˘Ùfi˜ ‰ÂÓ ÂÈÙÚ¤ÂÈ Û˘ÁÎÚ›ÛÂȘ Î·È ‰ÂÓ ‚ÔËı¿ ÛÙËÓ ÂÍ·ÁˆÁ‹ ·ÛÊ·ÏÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ.
292
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1,0
1,0 LDH<1000 IU/L
∏ÏÈΛ· >3 ÂÙÒÓ 0,8
0,8 LDH≥1000 IU/L
0,6
0,6
p EFS
p EFS
∏ÏÈΛ· ≤3 ÂÙÒÓ
0,4
0,4
p log-rank=0,04
p=0,05 0,2
0 0
0,2
20
40
60
80
100
0 0
20
ª‹Ó˜
40
60
80
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∂ÈÎfiÓ· 10. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ÙËÓ ÙÈÌ‹ Ù˘ LDH.
∂ÈÎfiÓ· 11. Kaplan-Meier ÂÎÙ›ÌËÛË Ù˘ EFS Û ۯ¤ÛË Ì ÙËÓ ËÏÈΛ·.
∞ӷχÔÓÙ·˜, fï˜, ÙËÓ Èı·ÓfiÙËÙ· ∂FS Ì ‚¿ÛË ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ ËÏÈΛ·˜ ≤3 ÂÙÒÓ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· EFS (61,11±9%) Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ ËÏÈΛ·˜ >3 ÂÙÒÓ (Èı·ÓfiÙËÙ· EFS 82,69±4%). ∆Ô ÔÛÔÛÙfi ÚfiˆÚ˘ ıÓËÙfiÙËÙ·˜ (early mortality rate) ÚÈÓ ÙËÓ 33Ë Ë̤ڷ ıÂڷ›·˜ ‹Ù·Ó 4,2% (4/70), ÙÔ ÔÔ›Ô Â›Ó·È ·ÚÎÂÙ¿ ˘„ËÏfi Û ۯ¤ÛË Ì ¿ÏϘ Û‡Á¯ÚÔÓ˜ ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ Î˘Ì·›ÓÂÙ·È ·fi 1% ¤ˆ˜ 2,5% (6,24,25). Ÿˆ˜ ÚԤ΢„ ÌÂÙ¿ ·fi ÏÂÙÔÌÂÚ‹ ·Ó¿Ï˘ÛË ÙˆÓ Ê‡ÏÏˆÓ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ, Ë ·ÈÌÔÚÚ·Á›· Ô˘ ηٷÁÚ¿ÊÂÙ·È ˆ˜ Ë Î‡ÚÈ· ·ÈÙ›· ı·Ó¿ÙÔ˘, ‹Ù·Ó Ë Û˘Ó¤ÂÈ· ‚·ÚÈ¿˜ Ì˘ÂÏÈ΋˜ ·Ï·Û›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·Ú·ÙÂٷ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›· ÌÂÙ¿ ·fi ¯ËÌÂÈÔıÂڷ›· Î·È Û˘Ó˘¿Ú¯Ô˘Û· Ïԛ̈ÍË. ∆Ô Â‡ÚËÌ· ·˘Ùfi ÂÊÈÛÙ¿ ÙËÓ ÚÔÛÔ¯‹ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ·Ú¯fiÌÂÓ˘ ˘ÔÛÙËÚÈÎÙÈ΋˜ ıÂڷ›·˜, ȉȷ›ÙÂÚ· ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ıÚÔÌ‚ÔÂÓ›·˜ ÌÂÙ¿ ·fi ¯ËÌÂÈÔıÂڷ›·, Ì ¤ÁηÈÚË ·Ú¤Ì‚·ÛË ÁÈ· ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ. ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ı·Ó¿ÙˆÓ Ô˘ ÛËÌÂÈÒıËÎ·Ó ‹Ù·Ó ηٿ ÙË Ê¿ÛË ÂÊfi‰Ô˘ ‹ ·ÓÂÊfi‰Ô˘. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ·˘ÙÒÓ ÙˆÓ Ê¿ÛÂˆÓ ıÂڷ›·˜ Ù· Û¯‹Ì·Ù· Â›Ó·È ·ÚÎÂÙ¿ ÂÓÙ·ÙÈο ηÈ, ηٿ Û˘Ó¤ÂÈ·, ·ÚÎÂÙ¿ ÙÔÍÈο. ∞˘Ùfi ʤÚÓÂÈ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔÓ Û‡Á¯ÚÔÓÔ ÚÔ-
¶›Ó·Î·˜ 5. ∞ÔÙÂϤÛÌ·Ù· Cox-regression ·Ó¿Ï˘Û˘ ªÂÙ·‚ÏËÙ‹ ñ ∏ÏÈΛ· (<3 ÂÙÒÓ) ñ ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 9 (≥50x10 /L) ñ ™ÏËÓÔÌÂÁ·Ï›· (≥3 cm)
95% CI
™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜
p
0,53-4,56
1,56
0,4
1,12-8,2 0,92-8,1
2,78 2,68
0,04 0,06
‚ÏËÌ·ÙÈÛÌfi ÙˆÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÙËÓ ·Ó·Î¿Ï˘„Ë Ó¤ˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ı· ÂÓۈ̷وıÔ‡Ó ÛÙ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ·, ÒÛÙÂ Ë ·‡ÍËÛË ÙÔ˘ ÚÔÛ‰fiÎÈÌÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì O§§ Ó· Û˘Ó‰˘¿˙ÂÙ·È Î·È Ì Ì›ˆÛË Ù˘ ¿ÌÂÛ˘ ‹ ·ÒÙÂÚ˘ ÙÔÍÈÎfiÙËÙ·˜ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÁˆÁ‹˜. ◊‰Ë ÛÙȘ Û‡Á¯ÚÔÓ˜ ÌÂϤÙ˜ ·ÍÈÔÏÔÁÂ›Ù·È Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ·Ó›¯Ó¢Û˘ Î·È ÔÛÔÙÈÎÔÔ›ËÛ˘ Ù˘ ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈÌÌ·ÙÈ΋˜ ÓfiÛÔ˘. Ÿˆ˜ ÚÔ·ÙÂÈ, Ë ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ Î·È ÌÔÚȷ΋ ÂÎÙ›ÌËÛË Ù˘ ÔÚ›·˜ Ù˘ ˘ÔÌÈÎÚÔÛÎÔÈ΋˜ ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈÌÌ·ÙÈ΋˜ ÓfiÛÔ˘ Ê·ÓÂÚÒÓÂÈ fiÙÈ Ë ·ÚÁ‹ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Â›Ó·È ÛËÌÂ›Ô ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (26,27). ∂ÈϤÔÓ, Ë ÌÂϤÙË ÙˆÓ ÁÂÓÂÙÈÎÒÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ÂÓ˙‡ÌˆÓ ı· ÚÔÛʤÚÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÂÍ·ÙƠ̂΢ÛË ÙˆÓ
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Ê·Ú̷΢ÙÈÎÒÓ ‰fiÛÂˆÓ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Ê·ÚÌ¿ÎˆÓ (28). ªÂ ÙËÓ ·ÏÌ·ÙÒ‰Ë ÚfiÔ‰Ô Ô˘ ·Ú·ÙËÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙÔÓ ÙÔ̤· Ù˘ ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜ Ì ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ÁÔÓȉȷÎÔ‡ ¯¿ÚÙË Ù˘ ÓfiÛÔ˘ οı ·ÛıÂÓ‹ Ì ÙȘ ÌÂıfi‰Ô˘˜ ÙˆÓ DNA ÌÈÎÚÔÛ˘ÛÙÔȯÈÒÓ (DNA microarrays), ı· Â›Ó·È ÂÊÈÎÙfi Ó· ηÙ¢ı‡ÓÂÙ·È Ë ıÂڷ›· ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÁÂÓÂÙÈÎÔ‡˜ ˘ÔÙ‡Ô˘˜ Ù˘ Ï¢¯·ÈÌ›·˜ Î·È Ó· ÚÔÛ·ÚÌfi˙ÂÙ·È Ë ‰È¿ÚÎÂÈ¿ Ù˘ ÛÙÔ ÁÂÓÂÙÈÎfi ÔÚÙÚ¤ÙÔ ÙÔ˘ οı ·ÛıÂÓ‹ (29,30).
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residual disease in childhood acute lymphoblastic leukemia. N Engl J Med 1998;339:591-598. 28. Evans WE, Relling MV, Rodman JH, Crom WR, Boyett JM, Pui CH. Conventional compared with individualized chemotherapy for childhood acute lymphoblastic leukemia. N Engl J Med 1998;338:499-505. 29. Golub TR, Slonim DK, Tamayo P, Huard C, Gaasenbeek M, Mesirov JP et al. Molecular classification of cancer: class discovery and class prediction by gene expression monitoring. Science 1999;286:531-537. 30. Evans WE, Relling MV. Pharmacogenomics: translating functional genomics into rational therapeutics. Science 1999;286:487-491.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-11-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 12-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: º·Ó‹ ∞ı·Ó·ÛÈ¿‰Ô˘ ªËÙÚÔfiψ˜ 55, ∆.∫. 546 23, £ÂÛÛ·ÏÔÓ›ÎË E-mail: nontas@topo.auth.gr
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ORIGINAL ARTICLE
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Gastroesophageal reflux in children with cerebral palsy: frequency, early diagnosis I. Xinias1, C. Panteliadis1, K. Spiroglou1, N. Karatzas2, V. Demertzidou1, E. Karatza1, G. Arsos2
¶ÂÚ›ÏË„Ë: ∏ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ·Ó·Ê¤ÚÂÙ·È Û˘¯Ó¿ Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (∂¶). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜, Ù˘ ‚·Ú‡ÙËÙ·˜ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ °O¶ Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ, ηıÒ˜ Î·È Ë ·Ó·˙‹ÙËÛË Ù˘ Û¯¤Û˘ Ù˘ °O¶ ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÌÔÚʤ˜ ∂¶. ŒÓ·˜ ÂÈϤÔÓ ÛÙfi¯Ô˜ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ ·Ó·ÁηÈfiÙËÙ·˜ Î·È Ù˘ ·ÍÈÔÈÛÙ›·˜ ÂÓfi˜ ÌË ÂÂÌ‚·ÙÈÎÔ‡ screening test ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÏËı˘ÛÌȷ΋ ÔÌ¿‰·. ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 52 ·È‰È¿ Ì ∂¶, Ù· ÔÔ›· ‰ÈÂÚ¢ӋıËÎ·Ó ÁÈ· °O¶ Ì 24ˆÚË pH-ÌÂÙÚ›·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘-ÔÈÛÔÊ¿ÁÔ˘. O ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ·ÎfiÌË ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°) Î·È ·ÈÌ·ÙÔÏÔÁÈÎfi Î·È ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô. ∞fi Ù· ·È‰È¿ Ù˘ ÌÂϤÙ˘, ÙÔ 44,2% (23/52) ›¯Â °O¶ ‰È·ÁÓˆṲ̂ÓË Ì pH-ÌÂÙÚ›·. ¢ÂÓ ‚Ú¤ıËΠۯ¤ÛË ÌÂٷ͇ Ù˘ ÂÌÊ¿ÓÈÛ˘ °O¶ Î·È ÙˆÓ Û·ÛÙÈÎÒÓ ‹ ÌË Û·ÛÙÈÎÒÓ ÌÔÚÊÒÓ Ù˘ ∂¶, fiˆ˜ ›Û˘ ‰ÂÓ ‚Ú¤ıËΠۯ¤ÛË ÌÂٷ͇ °O¶ Î·È Ê‡ÏÔ˘. ™Ô‚·ÚÔ‡ ‚·ıÌÔ‡ °O¶ ‰È·ÈÛÙÒıËΠÛÙÔ 52,2% (12/23 ·È‰È¿) Î·È Ì¤ÙÚÈÔ˘ ‚·ıÌÔ‡ ÛÙÔ ˘fiÏÔÈÔ 47,8% (11/23 ·È‰È¿). OÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ Ù˘ °O¶ ‹Ù·Ó Ë ÛȉËÚÔÂÓ›· (56,5%), Ë ·Ó·ÈÌ›· (47,8%), Ë Î·Î‹ ıÚ¤„Ë (34,8%), ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (26%) Î·È ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (26%). ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜ ‹Ù·Ó ıÂÙÈÎfi ÁÈ· °O¶ ÛÙÔ 53,8% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (28/52 ·È‰È¿). ™Â Û¯¤ÛË Ì ÙËÓ pH-ÌÂÙÚ›·, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ‹Ù·Ó 82,1% ηÈ
Abstract: The aims of this study were to investigate the frequency, severity and complications of gastroesophageal reflux (GOR) in children under 5 years with cerebral palsy (CP), to evaluate the need for a reliable, non-invasive GOR-screening test in this population group, in which GOR is common, and to investigate a possible relationship between GOR and CP type. Fifty-two children with CP were investigated for GOR by 24-hour pH monitoring, ultrasonography (U/S) and scintigraphy. The examination also included chest X-ray, CT or MRI of the brain, EEG and various blood tests. GOR was pH-metrically diagnosed in 23/52 patients (44.2%) and was rated severe in 12/23 (52.2%) and moderate in 11/23 (47.8%). GOR occurrence did not differ significantly between spastic and nonspastic forms of CP or between males and females. The most frequent complications of GOR were iron deficiency (56.5%), anaemia (47.8%), malnutrition (34.8%), low body weight (26%) and recurrent lower respiratory tract infections (26%). U/S findings were consistent with GOR in 28/52 patients (53.8%). Compared to pH-metry, U/S sensitivity and specificity were 82.1% and 68.96%, respectively. Scintigraphy performed in 19 pH-metry- and U/SGOR positive patients was positive in only 9/19 (47.4%). The study confirms that moderate or severe GOR is common in children with CP, frequently leading to complications, but not influenced by sex or CP type. U/S may be used as a screening test, first at age 12-16 months and then six-monthly, to ensure timely diagnosis of GOR in children with CP. Confirmatory investigation by 24-hour pH monitoring
∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢, π·ÙÚÈ΋ ™¯ÔÏ‹, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ¶˘ÚËÓÈ΋˜ π·ÙÚÈ΋˜
Aristotelion University of Thessaloniki, Medical School, Ippokration Hospital, Thessaloniki 1 3rd Paediatric Clinic 2 Laboratory of Nuclear Medicine
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68,96%, ·ÓÙ›ÛÙÔȯ·. ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘ÔÈÛÔÊ¿ÁÔ˘ ¤ÁÈÓ Û 19 ·È‰È¿ Ô˘ ›¯·Ó Ù·˘Ùfi¯ÚÔÓ· ıÂÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È pH-ÌÂÙÚ›· Î·È ‚Ú¤ıËΠıÂÙÈÎfi ÌfiÓÔ ÛÙÔ 47,4% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (9/19 ·È‰È¿). ∏ °O¶ Û ·È‰È¿ Ì ∂¶ Â›Ó·È Û˘¯Ó‹ Î·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â›Ó·È Ì¤ÙÚÈ· ‹ ‚·ÚÈ¿, ÌÂ Û˘Ó¤ÂÈ· ÙË Û˘¯Ó‹ ÂÌÊ¿ÓÈÛË ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ. ¢ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ Û¯¤ÛË Ù˘ °O¶ ÌÂ Û˘ÁÎÂÎÚÈ̤ÓË ÌÔÚÊ‹ ∂¶ ‹ Ì ÙÔ Ê‡ÏÔ. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜ Â›Ó·È ·ÍÈfiÈÛÙÔ Î·È ıˆÚÂ›Ù·È ·Ó·Áη›Ô Û·Ó screening test. £· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È Û ·È‰È¿ Ì ∂¶, ·Ú¯Èο ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-16 ÌËÓÒÓ Î·È ·ÚÁfiÙÂÚ· ÂÚÈÔ‰Èο οı 6 Ì‹Ó˜ ÁÈ· ¤ÁηÈÚË ·ÔÎ¿Ï˘„Ë Ù˘ °O¶. ™Â ıÂÙÈΤ˜ ÂÚÈÙÒÛÂȘ, Ë ‰È¿ÁÓˆÛË ı· Ú¤ÂÈ Ó· ÂȂ‚·ÈÒÓÂÙ·È Ì 24ˆÚË pH-ÌÂÙÚ›·. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘-ÔÈÛÔÊ¿ÁÔ˘ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ °O¶ ÛÙËÓ ∂¶.
should be applied in U/S-positive cases. Scintigraphy is not indicated for screening GOR in CP patients.
§¤ÍÂȘ ÎÏÂȉȿ: ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, screening (ÚÔÛ˘Ìو̷ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜).
Key words: cerebral palsy, gastroesophageal reflux, screening.
∂ÈÛ·ÁˆÁ‹ ∏ Û¯¤ÛË ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ (∂¶) Î·È Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (°O¶) ·Ó·Ê¤ÚıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Abrahams Î·È Burkitt ÙÔ 1970, ÔÈ ÔÔ›ÔÈ ‚Ú‹Î·Ó ·ÏÈÓ‰ÚfiÌËÛË Ì 24ˆÚË pH-ÌÂÙÚ›· ÛÙÔ 75% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂϤÙËÛ·Ó (1). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂȂ‚·ÈÒıËÎ·Ó ·ÚÁfiÙÂÚ· Î·È ·fi ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜, ÔÈ ÔÔ›ÔÈ ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· °O¶ Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Û ÔÛÔÛÙfi 26-91% (2-6), ¤Ó·ÓÙÈ 25% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (7). ∏ °O¶ Û ·È‰È¿ Ì ∂¶ Â›Ó·È Â›ÎÙËÙË, ·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ˙ˆ‹˜ (8) Î·È ¤¯ÂÈ ·Ô‰Ôı› Û ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ‰ÚÔ˘Ó ·˘ÙfiÓÔÌ· ‹ Û˘ÓÂÚÁÈο (9). OÈ Î˘ÚÈfiÙÂÚ˜ ̤ıÔ‰ÔÈ Ô˘ ˘¿Ú¯Ô˘Ó ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ °O¶ Â›Ó·È ÙÔ ÔÈÛÔÊ·ÁÔÁÚ¿ÊËÌ·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ·, Ë ÔÈÛÔÊ·ÁÔÛÎfiËÛË, Ë Ì·ÓÔÌÂÙÚ›· Î·È Ë 24ˆÚË pH-ÌÂÙÚ›· (10). OÈ ·Ú·¿Óˆ ̤ıÔ‰ÔÈ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ∏ ¢·ÈÛıËÛ›· Î·È Ë ÂÍÂȉ›Î¢ÛË Ù˘ οı ÌÂıfi‰Ô˘ ‰È·Ê¤ÚÂÈ, ·ÏÏ¿ ¯ˆÚ›˜ ·ÌÊÈÛ‚‹ÙËÛË ÙÔ “¯Ú˘Ûfi ÚfiÙ˘Ô” Â›Ó·È Ë pH-ÌÂÙÚ›·, Ë ÔÔ›· ·ÔÙÂÏ› ÂͤٷÛË ·Ó·ÊÔÚ¿˜ (10,11). ¶·Ú’ fiÏ· ·˘Ù¿, Ë ·Ó·ÁηÈfiÙËÙ· Î·È Ë ·ÍÈÔÈÛÙ›· Ì›·˜ ÌË ÂÂÌ‚·ÙÈ΋˜ ÂͤٷÛ˘ ‰È·ÏÔÁ‹˜ ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› ̤¯ÚÈ Û‹ÌÂÚ·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ÌÂÏÂÙËı› Ë Û˘¯ÓfiÙËÙ· Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ °O¶ Û ·È‰È¿ Ì ∂¶ ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ Î·È Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó Ë ·Ó·-
ÁηÈfiÙËÙ· Î·È Ë ·ÍÈÔÈÛÙ›· Ì›·˜ ÌË ÂÂÌ‚·ÙÈ΋˜ ÂͤٷÛ˘ ‰È·ÏÔÁ‹˜ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÏËı˘ÛÌȷ΋ ÔÌ¿‰·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 52 ·È‰È¿ (32 ·ÁfiÚÈ· Î·È 20 ÎÔÚ›ÙÛÈ·) ËÏÈΛ·˜ 1-5 ÂÙÒÓ Ì ‰È¿ÁÓˆÛË ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ (¶›Ó·Î·˜ 1). ŸÏ· Ù· ·È‰È¿ ·ÚÔ˘Û›·˙·Ó ‰È¿ÊÔÚ· ¿Ù˘· Û˘ÌÙÒÌ·Ù·, ‡ÔÙ· ÁÈ· ÓfiÛÔ ·fi °O¶ (°O¶¡), fiˆ˜ Â̤ÙÔ˘˜, ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÏÔÈÌÒÍÂȘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î.Ï. ¶·È‰È¿ οو ÙˆÓ 12 ÌËÓÒÓ ‰ÂÓ ÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË, ‰ÈfiÙÈ ÚÈÓ ·fi ÙËÓ ËÏÈΛ· ·˘Ù‹ ‰ÂÓ Â›Ó·È Û·Ê‹˜ Ë ÌÔÚÊ‹ Ù˘ ∂¶ Î·È ÂÂȉ‹ Ë °O¶ Â›Ó·È Â›ÎÙËÙË Î·È ÂÌÊ·Ó›˙ÂÙ·È ·ÚÁfiÙÂÚ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Èı·ÓfiÙÂÚ· ÌÂÙ¿ ÙÔ 1Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜ (8). ∂·ÓÂÎÙ›ÌËÛË ÙÔ˘ Ù‡Ô˘ Ù˘ ∂¶ ÛÙ· 52 ·È‰È¿ ¤ÁÈÓ ÌÂÙ¿ ·fi 2 ¯ÚfiÓÈ·. ™Â οı ·ÛıÂÓ‹ Ï‹ÊıËΠϋÚ˜ ÈÛÙÔÚÈÎfi (·ÙÔÌÈÎfi, ÔÈÎÔÁÂÓÂÈ·Îfi, ·ËÛ˘, ÂÚÈÁÂÓÓËÙÈÎfi, ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜), Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÂ Û˘ÌÙÒÌ·Ù· Î·È ÂÈÏÔΤ˜ Èı·Ó‹˜ °O¶¡. ŒÁÈÓ ÎÏÈÓÈ΋ Î·È Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÌÔÚÊ‹˜ Ù˘ ∂¶, Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ Î·È ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ™Â fiÏ· Ù· ·È‰È¿ ¤ÁÈÓ 24ˆÚË pH-ÌÂÙÚ›·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°), ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ (CT/MRI), ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Î·È ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, Ûȉ‹ÚÔ˘, ÊÂÚÚÈÙ›Ó˘ Î·È ÏÂ˘ÎˆÌ¿ÙˆÓ ÔÚÔ‡. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ô ·ÛıÂÓ‹˜ Ï¿Ì‚·Ó οÔÈ· Ê¿Ú̷η, ¤ÁÈÓ ÚÔÛˆÚÈÓ‹ ‰È·ÎÔ‹ ·˘ÙÒÓ, ÒÛÙ ӷ ÌËÓ ÂËÚ·ÛÙ› Ô ÙfiÓÔ˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÛÊÈÁÎÙ‹Ú· (∫O™). °È· ÙËÓ pH-ÌÂÙÚ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠÊÔÚËÙ‹ Û˘Û΢‹ ηٷÁÚ·Ê‹˜ Ù˘ ÂÙ·ÈÚ›·˜ Synectics Medical
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(Digitrapper Mk III) Ì ‰ÈοӷÏÔ ËÏÂÎÙÚfi‰ÈÔ Î·Ù·ÁÚ·Ê‹˜. ∏ ÙÔÔı¤ÙËÛË ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘ ÁÈÓfiÙ·Ó ‰È¿ Ù˘ ÚÈÓÈ΋˜ Ô‰Ô‡ Î·È Ë ·fiÛÙ·ÛË ÚÈÓfi˜-∫O™ (L) ˘ÔÏÔÁ›ÛÙËΠۇÌʈӷ Ì ÙÔÓ Î·ÓfiÓ· ÙÔ˘ Strobel (11-13): L (cm) = [(0,252 x ‡„Ô˜) +5] x 0,87. ∂Ȃ‚·›ˆÛË Ù˘ ÛˆÛÙ‹˜ ı¤Û˘ ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘, ÂÚ›Ô˘ 3-4 cm ¿Óˆ ·fi ÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ Û˘Ì‚ÔÏ‹, ÁÈÓfiÙ·Ó pH-ÌÂÙÚÈο Î·È ÌfiÓÔ Â› ·ÌÊÈ‚ÔÏÈÒÓ ·ÎÙÈÓÔÛÎÔÈο. ∏ ‰È¿ÚÎÂÈ· Ù˘ ηٷÁÚ·Ê‹˜ ‹Ù·Ó 24 ÒÚ˜, ¯ˆÚ›˜ Ó· Á›ÓÂÈ ·ÏÏ·Á‹ ÛÙȘ Û˘Ó‹ıÂȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÙÔ˘ ·ÛıÂÓ‹. OÈ ÙÈ̤˜ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH ·ÔıË·ÔÓÙ·Ó ÛÙË ÌÓ‹ÌË Î¿ı 6 sec, ÂÓÒ ÂÂÈÛfi‰È· ·ÏÈÓ‰ÚfiÌËÛ˘ ıˆÚÔ‡ÓÙ·Ó ·˘Ù¿ Ì ‰È¿ÚÎÂÈ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 15 sec (14). ŸÍÈÓË ·ÏÈÓ‰ÚfiÌËÛË ıˆÚÔ‡ÓÙ·Ó Ë ÙÈÌ‹ ÙÔ˘ pH ≤4, ÂÓÒ ·ÏηÏÈ΋ fiÙ·Ó ‹Ù·Ó ≥8. ∆· ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (8,15). ∞ÎÔÏÔ‡ıËÛ Doppler Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜ Ì ·ÛÚfiÌ·˘ÚË Û˘Û΢‹ ˘ÂÚ‹¯ˆÓ. ∆· ÂÂÈÛfi‰È· °O¶ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ıˆڋıËÎ·Ó ·ıÔÏÔÁÈο Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ÎÚÈÙ‹ÚÈ·, ·Ó¿ÏÔÁ· Ì ÙÔÓ fiÁÎÔ Î·È ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ (16). ™Ù· ·È‰È¿ Ô˘ ·ÚÔ˘Û›·˙·Ó °O¶ ·Ô‰Â‰ÂÈÁ̤ÓË Ì 24ˆÚË pH-ÌÂÙÚ›· Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜, ÁÈÓfiÙ·Ó Ú·‰ÈÔ˚ÛÔÙÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘-ÔÈÛÔÊ¿ÁÔ˘. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÁÈÓfiÙ·Ó Ì ڷ‰ÈÔÂÈÛËÌ·Ṳ̂ÓÔ Á¿Ï· ÛÙ·ıÂÚ‹˜ Û‡ÓıÂÛ˘ ÌÂÙ¿ ·fi 8-12 ÒÚ˜ ÓËÛÙ›·˜. ∆Ô 99m Á¿Ï· ÂÈÛËÌ·ÈÓfiÙ·Ó Ì ÎÔÏÏÔÂȉ¤˜ ÙÔ˘ Ù¯ÓËÙ›Ô˘ 99 ( Tc colloid) Î·È Ë ÔÛfiÙËÙ· ˘ÔÏÔÁÈ˙fiÙ·Ó Û‡Ìʈӷ Î·È Ì ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ÛÙ· 300 ml/1,73 m2 (13). ™ÙËÓ Ú¿ÍË, Ë ÌÈÛ‹ Ù˘ ˘ÔÏÔÁÈÛı›۷˜ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜ ÂÈÛËÌ·ÈÓfiÙ·Ó Ì ÙÔ Ú·‰ÈÔ˚ÛfiÙÔÔ, ÂÓÒ Ë ˘fiÏÔÈË ÌÈÛ‹ ÔÛfiÙËÙ· ‰ÂÓ ÂÈÛËÌ·ÈÓfiÙ·Ó. ∆Ô ÂÈÛËÌ·Ṳ̂ÓÔ Á¿Ï· ¯ÔÚËÁÔ‡ÓÙ·Ó ÛÙÔ ·È‰› ·fi ÙÔ ÛÙfiÌ· ‹ Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú·. ∞ÎÔÏÔ‡ıˆ˜, ¯ÔÚËÁÔ‡ÓÙ·Ó Ë ÌË ÂÈÛËÌ·Ṳ̂ÓË ÔÛfiÙËÙ· Á¿Ï·ÎÙÔ˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÍÂÏ˘ı› ÙÔ ÛÙfiÌ·, Ô Ê¿Ú˘ÁÁ·˜ Î·È Ô ÔÈÛÔÊ¿ÁÔ˜ ·fi Ù· ˘ÔÏ›ÌÌ·Ù· ÙÔ˘ Ú·‰ÈÔ˚ÛÔÙfiÔ˘. ∆Ô ·È‰› ·ÎÈÓËÙÔÔÈÔ‡ÓÙ·Ó Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜ (Û¿ÎÔÈ ¿ÌÌÔ˘, ÈÌ¿ÓÙ˜) Î·È ·ÎÔÏÔ˘ıÔ‡Û·Ó Ï‹„ÂȘ Ì ÙË Á-οÌÂÚ· Û ·ÚÈÛÙÂÚ‹ ÚfiÛıÈ· ÏÔÍ‹ ı¤ÛË (LAO). ∏ ‰È¿ÚÎÂÈ· Ù˘ Ï‹„˘ ‹Ù·Ó 1 ÒÚ·. O ‰Â›ÎÙ˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ˘ÔÏÔÁÈ˙fiÙ·Ó ·fi ÙÔÓ Ù‡Ô (17): RI (%) = [(Eso)-(Bgr) / (SÔ)] x 100 (So: Á·ÛÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙËÓ ·Ú¯‹ Ù˘ ÌÂϤÙ˘, Eso: ÔÈÛÔÊ·ÁÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Bgr: ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙÔ Background). ™Â ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ¯ˆÚ›˜ ·ÏÈÓ‰ÚfiÌËÛË, ÔÈ ÙÈ̤˜ ÙÔ˘ RI Î˘Ì·›ÓÔÓÙ·È ·fi 0,1-5,0% (17-19). ∏ ÔÈÔÙÈ΋ ÂÎÙ›ÌËÛË ÁÈÓfiÙ·Ó ·Ú·ÎÔÏÔ˘ıÒÓÙ·˜ Û cine mode ÙÔ Û‡ÓÔÏÔ Ù˘ ÌÂϤÙ˘ Î·È Î·ıÔÚ›˙ÔÓÙ·˜ ÙÔÓ ·ÚÈıÌfi, ÙÔ ‡„Ô˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÏÈÓ‰ÚfiÌËÛ˘ (Â¿Ó Ë °O¶ ¤Êı·Ó ÛÙÔÓ ·ÓÒÙÂÚÔ ÔÈÛÔÊ¿ÁÔ) Î·È ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË Î¿ı·ÚÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ·fi ÙÔÓ ÔÈÛÔÊ¿ÁÔ (20). ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹, ÛÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Û‡ÛÙËÌ· Windows 98 Î·È Ì ÙÔ
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ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ ÕÚÚÂÓ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘ £‹Ï˘
Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È Ÿ¯È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È ¡·È
ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· GraphPad InStat. ¶ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· Û˘ÁÎÚ›ÛÂȘ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÔÌ¿‰ˆÓ, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· x2. °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ËÏÈÎÈÒÓ ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÔÚÊÒÓ ∂¶ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌË ·Ú·ÌÂÙÚÈ΋ ̤ıÔ‰Ô˜ Mann-Whitney. ™Ù·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· ÁÈÓfiÙ·Ó ‰ÂÎÙ‹ ÁÈ· ÙÈ̤˜ p<0,05.
¶·È‰È·ÙÚÈ΋ 2003;66:296-303
Paediatriki 2003;66:296-303
∞ÔÙÂϤÛÌ·Ù· ∞fi ÙÔ˘˜ 52 ·ÛıÂÓ›˜ Ì ∂¶, ÔÈ 32 (61,5%) ›¯·Ó Û·ÛÙÈ΋ ÌÔÚÊ‹ Î·È Û˘ÁÎÂÎÚÈ̤ӷ 18 ›¯·Ó Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, 8 Û·ÛÙÈ΋ ËÌÈÏËÁ›· Î·È 6 Û·ÛÙÈ΋ ‰ÈÏËÁ›·. OÈ ˘fiÏÔÈÔÈ 20 ·ÛıÂÓ›˜ (38,5%) ›¯·Ó ÌË Û·ÛÙÈ΋ ÌÔÚÊ‹ ∂¶, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ 12 ›¯·Ó ÌÈÎÙ‹, 6 ·Ù·ÍÈ΋ Î·È 2 ‰˘ÛÎÈÓËÙÈ΋-Â͈˘Ú·ÌȉÈ΋ ÌÔÚÊ‹. ™ÙÔ 19,2% ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ˘‹Ú¯Â ÈÛÙÔÚÈÎfi ÚÔˆÚfiÙËÙ·˜ Ì ‰È¿ÚÎÂÈ· ·ËÛ˘ <38 ‚‰ÔÌ¿‰Â˜ Î·È ÙÔ ˘fiÏÔÈÔ 80,8% ‹Ù·Ó ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ∏ ηٷÓÔÌ‹ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÔÚÊÒÓ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘, Ë Û˘¯ÓfiÙËÙ· Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ °O¶ Ì pH-ÌÂÙÚ›· Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Ì 24ˆÚË pH-ÌÂÙÚ›· ‰È·ÈÛÙÒıËΠ۠ÔÛÔÛÙfi 44,2% (23/52 ·È‰È¿), ÂÓÒ Ì ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ ÔÛÔÛÙfi ·˘Ùfi ·ÓÂÚ¯fiÙ·Ó Û 53,8% (28/52). °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ÂȂ‚·ÈˆÌ¤ÓË Î·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ ‰È·ÈÛÙÒıËΠ۠19 ·È‰È¿ (36,5%). ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Û ۯ¤ÛË Ì ÙËÓ pH-ÌÂÙÚ›· ›¯Â ¢·ÈÛıËÛ›· 82,1%, ÂÓÒ Ë ÂȉÈÎfiÙËÙ· ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 68,96% (¶›Ó·Î·˜ 4). ∏ ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (PPV), Ë ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (NPV) Î·È Ë ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· (accuracy) Ê·›ÓÔÓÙ·È, ›Û˘, ÛÙÔÓ ¶›Ó·Î· 4.
™‡Ìʈӷ Ì ÌÂϤÙ˜ (5,11), Ô ‚·ıÌfi˜ (‚·Ú‡ÙËÙ·) Ù˘ °O¶ ηıÔÚ›˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ‰Â›ÎÙË ·ÏÈÓ‰ÚfiÌËÛ˘ (¢¶), Ô ÔÔ›Ô˜ Â›Ó·È ÙÔ ÔÛÔÛÙfi ÙÔ˘ ¯ÚfiÓÔ˘ ηٷÁÚ·Ê‹˜ Ô˘ ÙÔ pH ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Â›Ó·È ÌÈÎÚfiÙÂÚÔ ·fi 4. ∏ °O¶ ıˆÚÂ›Ù·È ‹È· fiÙ·Ó Ô ¢¶ Â›Ó·È 5-10% (ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ¯ÚfiÓÔ˘ ηٷÁÚ·Ê‹˜), ̤ÙÚÈ· fiÙ·Ó Â›Ó·È 10-20%, ÂÓÒ ÛÔ‚·Ú‹ ıˆÚÂ›Ù·È fiÙ·Ó Ô ¢¶ Â›Ó·È >20%. ∞fi Ù· 23 ·È‰È¿ Ì ıÂÙÈ΋ pH-ÌÂÙÚ›·, ÛÔ‚·Ú‹ °O¶ ›¯Â ÙÔ 52,1% (12/23 ·È‰È¿), ̤ÙÚÈ· ÙÔ 47,8% (11/23), ÂÓÒ ‹È· °O¶ ‰ÂÓ ‰È·ÈÛÙÒıËΠ۠ηӤӷ ·È‰› Ù˘ ÌÂϤÙ˘ (¶›Ó·Î·˜ 3). ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘-ÔÈÛÔÊ¿ÁÔ˘ ¤ÁÈÓ Û 19 ·ÛıÂÓ›˜ Ô˘ ›¯·Ó Ù·˘Ùfi¯ÚÔÓ· ıÂÙÈ΋ pHÌÂÙÚ›· Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ∞fi ·˘ÙÔ‡˜, ÙÔ 47,4% (9/19) ›¯Â Â˘Ú‹Ì·Ù· ·ıÔÏÔÁÈ΋˜ °O¶ Î·È ÛÙÔÓ Ú·‰ÈÔ˚ÛÔÙÔÈÎfi ¤ÏÂÁ¯Ô. ¶ÔÛÔÛÙfi 36,8% (7/19) ›¯Â ·ÏÈÓ‰ÚÔÌ‹ÛÂȘ ηٿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜, ·ÏÏ¿ Ô ‰Â›ÎÙ˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (Reflux Index) ‰ÂÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ 5% ÁÈ· Ó· ıˆÚËıÔ‡Ó ·ıÔÏÔÁÈΤ˜. ∆¤ÏÔ˜, ÙÔ 15,8% (3/19 ·È‰È¿) ‰ÂÓ Â›¯Â ·ÏÈÓ‰ÚÔÌ‹ÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÛÈÓıËÚÔÁÚ·ÊÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ Û˘¯ÓfiÙËÙ· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (·Ô‰Â‰ÂÈÁ̤ÓË Ì pH-ÌÂÙÚ›·) ÛÙ· ‰‡Ô ʇϷ ‹Ù·Ó 43,8% (14/32) ÁÈ· Ù· ·ÁfiÚÈ· Î·È 45%
¶›Ó·Î·˜ 2. ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ °O¶ ηٿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· 24ˆÚ˘ pH-ÌÂÙÚ›·˜* (8,15) ñ ¢Â›ÎÙ˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (¢¶): ¶ÔÛÔÛÙfi Û˘ÓÔÏÈÎÔ‡ ¯ÚfiÓÔ˘ Ô˘ ÙÔ pH ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Â›Ó·È ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 4 (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ̤¯ÚÈ 5% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ¯ÚfiÓÔ˘ ηٷÁÚ·Ê‹˜**) ñ ∞ÚÈıÌfi˜ ÂÂÈÛÔ‰›ˆÓ Ì ‰È¿ÚÎÂÈ· ÌÂÁ·Ï‡ÙÂÚË ·fi 5 ÏÂÙ¿ (·ıÔÏÔÁÈÎfi˜ fiÙ·Ó ÛËÌÂÈÒÓÔÓÙ·È >7 ÂÂÈÛfi‰È·/24ˆÚÔ) ñ ∫¿ı·ÚÛË ÔͤԘ. ø˜ οı·ÚÛË ÔͤԘ ÔÚ›˙ÂÙ·È ÙÔ ËÏ›ÎÔ Ù˘ Û˘ÓÔÏÈ΋˜ ‰È¿ÚÎÂÈ·˜ (Û ÏÂÙ¿) ÙˆÓ ÂÂÈÛÔ‰›ˆÓ °O¶ Ì pH ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 4 ‰È¿ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ °O¶ (·ıÔÏÔÁÈ΋ ıˆÚÂ›Ù·È fiÙ·Ó Â›Ó·È >4 ÏÂÙ¿) ñ ªÂÁ·Ï‡ÙÂÚÔ Û ‰È¿ÚÎÂÈ· ÂÂÈÛfi‰ÈÔ (·ıÔÏÔÁÈÎfi fiÙ·Ó Â›Ó·È >20 ÏÂÙ¿) ñ ¶ÔÛÔÛÙfi ÂÂÈÛÔ‰›ˆÓ >5 ÏÂÙ¿ (·ıÔÏÔÁÈÎfi fiÙ·Ó Â›Ó·È >12%) ñ ™˘¯ÓfiÙËÙ· ·ÏÈÓ‰ÚÔÌ‹ÛÂˆÓ (·ıÔÏÔÁÈÎfi fiÙ·Ó Â›Ó·È >1,5 ÂÂÈÛfi‰ÈÔ/ÒÚ·) * ∆· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· ÈÛ¯‡Ô˘Ó ÁÈ· ÌÂÙÚ‹ÛÂȘ ¿Óˆ ·fi 16 ÒÚ˜. °È· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË °O¶, Ú¤ÂÈ Ó· Â›Ó·È ·ıÔÏÔÁÈο ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ·fi Ù· ÎÚÈÙ‹ÚÈ· ** ◊È· ıˆÚÂ›Ù·È Ë °O¶ fiÙ·Ó Ô ¢¶ Â›Ó·È 5-10% (ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ¯ÚfiÓÔ˘ ηٷÁÚ·Ê‹˜), ̤ÙÚÈ· ÌÂٷ͇ 10-20%, ÂÓÒ ÛÔ‚·Ú‹ ıˆÚÂ›Ù·È fiÙ·Ó Ô ¢¶ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ 20% ¶›Ó·Î·˜ 3. µ·Ú‡ÙËÙ· °O¶ ÛÙȘ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ∂¶ ηٿ ÙËÓ 24ˆÚË pH-ÌÂÙÚ›· Û ۇÁÎÚÈÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ∆‡Ô˜ ∂¶ (n) ™·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›· (18) ™·ÛÙÈ΋ ‰ÈÏËÁ›· (6) ™·ÛÙÈ΋ ËÌÈÏËÁ›· (8) ∂͈˘Ú·ÌȉÈ΋ (2) ∞Ù·ÍÈ΋ (6) ªÈÎÙ‹ (12) ™‡ÓÔÏÔ (52)
◊ÈÔ˜
µ·ıÌfi˜ °O¶ ª¤ÙÚÈÔ˜
™Ô‚·Úfi˜
0 0 0 0 0 0 0
3 2 2 1 1 2 11
5 1 2 0 2 2 12
£ÂÙÈο Â˘Ú‹Ì·Ù· pH-ÌÂÙÚ›· ÀÂÚ˯ÔÁÚ¿ÊËÌ· 8 3 4 1 3 4 23
7 4 5 1 4 7 28
n: ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ °O¶: Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ∂¶: ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË O ‚·ıÌfi˜ Ù˘ °O¶ ηıÔÚ›ÛÙËΠۇÌʈӷ Ì ٷ ‰ÈÂıÓ‹ ÎÚÈÙ‹ÚÈ· Ô˘ ÈÛ¯‡Ô˘Ó ÁÈ· ÙËÓ 24ˆÚË pH-ÌÂÙÚ›·
299
¶·È‰È·ÙÚÈ΋ 2003;66:296-303
Paediatriki 2003;66:296-303
¶›Ó·Î·˜ 4. ∞ÍÈÔÏfiÁËÛË ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ (Û ۯ¤ÛË Ì ÙËÓ pH-ÌÂÙÚ›·) ÛÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ Û ·È‰È¿ Ì ∂¶ TP (19)
FP (9)
TN (20)
FN (4)
Se 82,1% (23/28)
Sp 68,96% (20/29)
Ac 75,0% (39/52)
PPV 67,86% (19/28)
NPV 83,3% (20/24)
TP (true positive): ÔÚıÒ˜ ıÂÙÈο FP (false positive): „¢‰Ò˜ ıÂÙÈο TN (true negative): ÔÚıÒ˜ ·ÚÓËÙÈο FN (false negative): „¢‰Ò˜ ·ÚÓËÙÈο Se (sensitivity): ¢·ÈÛıËÛ›· Sp (specificity): ÂȉÈÎfiÙËÙ· Ac (accuracy): ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· PPV (positive predictive value): ıÂÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ NPV (negative predictive value): ·ÚÓËÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ™ÙȘ ·ÚÂÓı¤ÛÂȘ ·Ó·Ê¤ÚÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ
(9/20) ÁÈ· Ù· ÎÔÚ›ÙÛÈ· (p=0,59). ∏ Û˘¯ÓfiÙËÙ· Ù˘ °O¶ ÛÙȘ Û·ÛÙÈΤ˜ ÌÔÚʤ˜ ‹Ù·Ó 46,9% (15/32) Î·È ÛÙȘ ÌË Û·ÛÙÈΤ˜ ÌÔÚʤ˜ 40% (8/20), ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÌË ÛËÌ·ÓÙÈ΋ (p=0,59). ∏ ËÏÈΛ· ÌÂٷ͇ Û·ÛÙÈÎÒÓ Î·È ÌË Û·ÛÙÈÎÒÓ ÌÔÚÊÒÓ ∂¶ ‰ÂÓ ‰È¤ÊÂÚÂ, ›Û˘, ÛËÌ·ÓÙÈο (p=0,698). OÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ ÛÙ· 23 ·È‰È¿ Ô˘ ›¯·Ó °O¶ ÛÙËÓ pH-ÌÂÙÚ›· ‹Ù·Ó Ë ÛȉËÚÔÂÓ›· (56,5%), Ë Î·Î‹ ıÚ¤„Ë (34,8%), Ë ·Ó·ÈÌ›· (47,8%), ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (26%) Î·È Ë ÛÙ·ÛÈÌfiÙËÙ· ÙÔ˘ ‚¿ÚÔ˘˜ (26%) (¶›Ó·Î·˜ 5). §ÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ ‹Ù·Ó Ë ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·, Ë ÛÙ·ÛÈÌfiÙËÙ· ÙÔ˘ ‡„Ô˘˜ Î·È Ë ·ıÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Ì ‚ÚÔÁ¯ÂÎٷۛ˜ Î·È ÂÈÎfiÓ· Ó¢ÌÔÓÈ΋˜ ›ÓˆÛ˘. ∞ÓÙ›ıÂÙ·, ·È‰È¿ ¯ˆÚ›˜ °O¶ (n=33) ›¯·Ó ÂΉËÏÒÛÂȘ Ô˘ ·Ú·¤ÌÔ˘Ó Û °O¶ ÂÈÏÔΤ˜ Û ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ (¶›Ó·Î·˜ 5). ™˘˙‹ÙËÛË ™‡Ìʈӷ Î·È Ì ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (35,21,22), Ë Û˘¯ÓfiÙËÙ· Ù˘ °O¶ ÛÙËÓ ∂¶ ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›˜ ‰È·Î˘Ì¿ÓÛÂȘ (25-91%), ÂÓÒ ·Ó·Ê¤ÚÂÙ·È ¯·ÌËÏfiÙÂÚË (8%) ÛÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· (23). OÈ Bohmer Î·È Û˘Ó (24) Û ÚfiÛÊ·ÙË ÌÂϤÙË ÙÔ˘˜ ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· °O¶ 55,3% Û ÓÔËÙÈο ηı˘ÛÙÂÚË̤ӷ ·È‰È¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ȉڇ̷ٷ, ÂÓÒ ÔÈ Del Giudice Î·È Û˘Ó (1999) ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· Ù˘ °O¶ Û ·È‰È¿ Ì ∂¶ 91% (6). OÈ Ravelli Î·È Milla (5) ‰ÈÂÓÂÚÁÒÓÙ·˜ 24ˆÚË pH-ÌÂÙÚ›· Û 50 ·ÛıÂÓ›˜ Ì Â̤ÙÔ˘˜ Î·È ‚Ï¿‚Ë ÙÔ˘ ∫¡™, ‰È¤ÁÓˆÛ·Ó °O¶ Û ÔÛÔÛÙfi 58%. ™ÙË ÌÂϤÙË ÙˆÓ Reyes Î·È Û˘Ó (4), ÔÈ ÔÔ›ÔÈ Â›Û˘ ÂÊ¿ÚÌÔÛ·Ó 24ˆÚË pH-ÌÂÙÚ›· Û ·È‰È¿ Ì ∂¶, Ë Û˘¯ÓfiÙËÙ· ·ÓÂÚ¯fiÙ·Ó Û 70% Î·È Ë °O¶ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ· (43%) Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (22%), ¯ˆÚ›˜ Ó· ÌÔÚ› Ó· ‰Ôı› οÔÈ· ÂÍ‹ÁËÛË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Û˘¯ÓfiÙËÙ· Ù˘ °O¶ (·Ô‰Â‰ÂÈÁ̤ÓË Ì 24ˆÚË pH-ÌÂÙÚ›·) ‹Ù·Ó 44,2%. ¢È·ÊÔÚ¿ Û˘¯ÓfiÙËÙ·˜ Ù˘ °O¶ ÌÂٷ͇ ·ÁÔÚÈÒÓ (43,8%) Î·È ÎÔÚÈÙÛÈÒÓ
300
(45%) ‰ÂÓ ‰È·ÈÛÙÒıËΠ(p>0,05). ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ·fi ·˘Ù¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î·È ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ °O¶ ÛÙ· ·È‰È¿ Ì ∂¶ Â›Ó·È ·˘ÍË̤ÓË. ∆· ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ¤Ó·ÓÙÈ ÙˆÓ ˘„ËÏfiÙÂÚˆÓ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ (¤ˆ˜ 90%), ›Ûˆ˜ Ó· ÔÊ›ÏÔÓÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ˘ÏÈÎfi Ù˘ ÚÒÙ˘ ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi ·È‰È¿ ËÏÈΛ·˜ ¤ˆ˜ 5 ¯ÚfiÓˆÓ Î·È ÚÔÊ·ÓÒ˜ ‰ÂÓ Â›¯Â ÂΉËψı› ·ÎfiÌË Ë °O¶. ∏ ¢·ÈÛıËÛ›· ÙˆÓ ÌÂıfi‰ˆÓ ‰È¿ÁÓˆÛ˘ Ù˘ °O¶ ·Ó·Ê¤ÚÂÙ·È Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜. §·Ì‚¿ÓÔÓÙ·˜ ˆ˜ ÂͤٷÛË ·Ó·ÊÔÚ¿˜ ÙËÓ pH-ÌÂÙÚ›·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·Ó·Ê¤ÚÂÙ·È Ó· ¤¯ÂÈ Â˘·ÈÛıËÛ›· ¤ˆ˜ 87% (16,25,26). ¶ÚfiÛÊ·Ù· (1997), ÔÈ Hirsch Î·È Û˘Ó (25) ÂÊ·ÚÌfi˙ÔÓÙ·˜ ¤Á¯ÚˆÌÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Û 84 ·È‰È¿, ‰È·›ÛÙˆÛ·Ó ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ÙˆÓ ˘ÂÚ‹¯ˆÓ ÁÈ· ÙËÓ ·ÔÎ¿Ï˘„Ë °O¶ (94%). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹Ù·Ó ıÂÙÈÎfi Û ÔÛÔÛÙfi 53,8% ÙˆÓ ·ÛıÂÓÒÓ. §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ Û·Ó “¯Ú˘Ûfi ÚfiÙ˘Ô” ÙËÓ pH-ÌÂÙÚ›·, Ë Â˘·ÈÛıËÛ›· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ‹Ù·Ó 82,1% (19/23 ·È‰È¿ Ì ıÂÙÈ΋ pH-ÌÂÙÚ›· ›¯·Ó Î·È ıÂÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·). ∏ ÂȉÈÎfiÙËÙ· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ Û ۯ¤ÛË Ì ÙËÓ pH-ÌÂÙÚ›· ‹Ù·Ó 68,96%. ™‡Ìʈӷ Î·È Ì ¿ÏϘ ÌÂϤÙ˜, Ë ÂȉÈÎfiÙËÙ· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ Û ۯ¤ÛË Ì ÙËÓ pH-ÌÂÙÚ›· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 58% Î·È ÌÔÚ› Ó· ·˘ÍËı› ÛËÌ·ÓÙÈο fiÙ·Ó, Û ¿ÙÔÌ· ¯ˆÚ›˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, ÔÈ ‰È·ÈÛو̤Ó˜ ·ÏÈÓ‰ÚÔÌ‹ÛÂȘ ıˆÚËıÔ‡Ó Û·ÊÒ˜ ·ıÔÏÔÁÈΤ˜ (16). ∏ ¢·ÈÛıËÛ›· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË °O¶ ÔÈΛÏÏÂÈ ·Ó¿ÌÂÛ· ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Î·È Î˘Ì·›ÓÂÙ·È ·fi 14-90% (27). ™‡Ìʈӷ Ì ¿ÏÏÔ˘˜ ÌÂÏÂÙËÙ¤˜, Ë Â˘·ÈÛıËÛ›· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ Û ۇÁÎÚÈÛË Ì ÙËÓ pH-ÌÂÙÚ›· Î˘Ì·›ÓÂÙ·È ·fi 75% ¤ˆ˜ 100%, ÂÓÒ Ë ÂȉÈÎfiÙËÙ· ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 90% (20,28,29). OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ Â˘·ÈÛıËÛ›· Â›Ó·È Ô fiÁÎÔ˜ Î·È Ë Û‡ÓıÂÛË ÙÔ˘ Á‡̷ÙÔ˜, Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘
¶·È‰È·ÙÚÈ΋ 2003;66:296-303
Paediatriki 2003;66:296-303
Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘, Ë Â˘·ÈÛıËÛ›· Ù˘ Á-camera, Ë ÂÍ·Ûı¤ÓËÛË Ù˘ ·ÎÙÈÓÔ‚ÔÏ›·˜, Ô fiÁÎÔ˜ Î·È Ë ‰È¿ÚÎÂÈ· Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·È‰È¿ Ì ıÂÙÈ΋ pH-ÌÂÙÚ›· Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (n=19) ›¯·Ó ıÂÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Û ÔÛÔÛÙfi 47,4% (9/19 ·È‰È¿), ÂÓÒ ÙÔ 36,8% (7/19 ·È‰È¿) ›¯Â ·ÏÈÓ‰ÚfiÌËÛË, ·ÏÏ¿ ÛÙ· fiÚÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ (RI <5%). O ‚·ıÌfi˜ (‚·Ú‡ÙËÙ·) Ù˘ °O¶ ÛÙ· ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ÔÈΛÏÏÂÈ. OÈ Gustafsson Î·È Tibbling ‚Ú‹Î·Ó Ì¤ÙÚÈÔ˘ Î·È ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ °O¶ ÛÙÔ 61% ÙˆÓ ·È‰ÈÒÓ Ì ·ÏÈÓ‰ÚfiÌËÛË (ÛÔ‚·Ú‹ ÌÔÚÊ‹ ÛÙÔ 22% Î·È Ì¤ÙÚÈ· ÛÙÔ 39%) (30). ¶·ÚfiÌÔÈ· ÔÛÔÛÙ¿ ·Ó·Ê¤ÚÔ˘Ó Î·È ÔÈ Ravelli Î·È Milla, ÔÈ ÔÔ›ÔÈ ‚Ú‹Î·Ó Ì¤ÙÚÈ· Î·È ÛÔ‚·Ú‹ ÌÔÚÊ‹ °O¶ ÛÙÔ 68% ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÈÓ‰ÚfiÌËÛË (5). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ̤ÙÚÈÔ˘ Î·È ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ °O¶ ‚Ú¤ıËΠÛÙÔ 100% ÙˆÓ ·È‰ÈÒÓ Ì ·ÏÈÓ‰ÚfiÌËÛË (̤ÙÚÈ· ÛÙÔ 47,8%, ÛÔ‚·Ú‹ ÛÙÔ 52,2%, ÂÓÒ ‰ÂÓ ‚Ú¤ıËΠ‹È·), ¤Ó·ÓÙÈ 61% Î·È 68% ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ ÌÂÏÂÙÒÓ. °È· ÙË ‰È·ÊÔÚ¿ ·˘Ù‹ ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ùfi Ó· ‰Ôı› Û·Ê‹˜ ÂÍ‹ÁËÛË. ÿÛˆ˜ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ¯ÚËÛÈÌÔÔÈ‹ıËΠ‰ÈοӷÏÔ ËÏÂÎÙÚfi‰ÈÔ Î·Ù·ÁÚ·Ê‹˜, ÙÔ ÔÔ›Ô ·˘Í¿ÓÂÈ ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ pH-ÌÂÙÚ›·˜. ¢È·ÊÔÚ¤˜, fï˜, ˘¿Ú¯Ô˘Ó Î·È ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ °O¶ ÛÙȘ Ù¤ÛÛÂÚȘ ÌÔÚʤ˜ ∂¶. OÈ Reyes Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ‰ÂÓ ‚Ú‹Î·Ó Î·Ì›· Û¯¤ÛË ÌÂٷ͇ °O¶ Î·È Î¿ÔÈ·˜ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÔÚÊ‹˜ ∂¶ (Û ·È‰È¿ ËÏÈΛ·˜ 0,6-11,8 ÂÙÒÓ), Ô‡Ù ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ·Ó·ËÚ›·˜ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ °O¶ (4). ∞ÓÙ›ıÂÙ·, ¿ÏϘ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Ù˘ °O¶ ÛÙȘ Û·ÛÙÈΤ˜ ÌÔÚʤ˜ ∂¶. OÈ Sondheimer Î·È Û˘Ó (3), Û 15 ·È‰È¿ Ì ‚Ï¿‚Ë ÙÔ˘ ∫¡™ Î·È °O¶ (ËÏÈΛ·˜ 14±0,9 ÂÙÒÓ), ‚Ú‹Î·Ó fiÙÈ ÙÔ 75% Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ·Ú·ÙËÚ‹ıËΠÛÙȘ Û·ÛÙÈΤ˜ ÌÔÚʤ˜, ÂÓÒ ÔÈ Ravelli Î·È Milla (5) Ô˘ ÌÂϤÙËÛ·Ó 50 ·È‰È¿ Ì ∂¶ (ËÏÈΛ·˜ 4 ÌËÓÒÓ-15,5 ÂÙÒÓ), ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· °O¶ ÛÙȘ Û·ÛÙÈΤ˜ ÌÔÚʤ˜ Û ÔÛÔÛÙfi 46%. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë
Û˘¯ÓfiÙËÙ· Ù˘ °O¶ (Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ pH-ÌÂÙÚ›·˜) ÛÙȘ Û·ÛÙÈΤ˜ ÌÔÚʤ˜ ·ÓÂÚ¯fiÙ·Ó Û ÔÛÔÛÙfi 46,9% (15/32 ·È‰È¿), ÂÓÒ ÛÙȘ ÌË Û·ÛÙÈΤ˜ Û 40% (8/20 ·È‰È¿). OÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ Ù˘ °O¶ Û ·È‰È¿ Ì ∂¶ Â›Ó·È ÛÙÂÓÒÛÂȘ ÙÔ˘ ÂÙÈÎÔ‡, ÔÈÛÔÊ¿ÁÔ˜ Ù‡Ô˘ Barett, Ô˘ ıˆÚÂ›Ù·È ÚÔηÚÎÈӈ̷Ù҉˘ ηٿÛÙ·ÛË, ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·, ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Î·È Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË (3,6,21,22). OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ‰˘ÛÎÔϛ˜ ηٿÔÛ˘ Ô˘ ˘¿Ú¯Ô˘Ó, Ô‰ËÁÔ‡Ó Û ηı˘ÛÙÂÚË̤ÓË ·Ó¿Ù˘ÍË Î·È ıÚ¤„Ë Î·È ÂËÚ¿˙Ô˘Ó ·ÚÓËÙÈο Ù· ÔÏÏ·Ï¿ ıÂڷ¢ÙÈο ̤ÙÚ·. OÈ ÂÈÏÔΤ˜ Ù˘ °O¶ ÛÙËÓ ∂¶ ‰ÂÓ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÂÓ¿ ̤¯ÚÈ Û‹ÌÂÚ·, ›Ûˆ˜ ÂÍ·ÈÙ›·˜ Î·È ÙˆÓ ¿ÏÏˆÓ ÛÔ‚·ÚÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ¤¯Ô˘Ó Ù· ·È‰È¿ Ì ∂¶. ™ÙË ÌÂϤÙË ÙˆÓ Drvaric Î·È Û˘Ó Û 52 ·ÛıÂÓ›˜ Ì ∂¶, ·Ó·Ê¤ÚÂÙ·È Û˘¯ÓfiÙËÙ· °O¶ 62%, ÙÔ 79% ÙÔ˘ ÔÔ›Ô˘ (41/52 ·È‰È¿) ‹Ù·Ó οو ·fi ÙËÓ 3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (∂£) ˆ˜ ÚÔ˜ ÙÔ ‚¿ÚÔ˜, ÙÔ 32% ›¯Â ¯·ÌËÏfiÙÂÚË ÏÂ˘ÎˆÌ·Ù›ÓË ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (<3,8 g/dl), ÂÓÒ ˘ÔÚˆÙÂ˚Ó·ÈÌ›· ·Ú·ÙËÚ‹ıËΠÛÙÔ 8% (31). øÛÙfiÛÔ, Û ·˘Ù‹ ÙË ÌÂϤÙË ‰ÂÓ ¤ÁÈÓÂ Û˘Û¯¤ÙÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ·˘ÙÒÓ Ì ÙËÓ ·ÚÔ˘Û›· ‹ ÌË °O¶. OÈ Reyes Î·È Û˘Ó, Û 23 ·È‰È¿ Ì ∂¶, ‚Ú‹Î·Ó ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ‰È·ÙÚÔÊ‹˜ (‰˘ÛÎÔϛ˜ Ì¿ÛËÛ˘, ‰˘ÛηٷÔÛ›· Î·È Â̤ÙÔ˘˜) ÛÙÔ 70%, ÛÙ·ÛÈÌfiÙËÙ· ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ÛÙÔ 52% Î·È ·Ó·ÈÌ›· ÛÙÔ 31% ÙˆÓ ·È‰ÈÒÓ (4). ™ÙËÓ ›‰È· ÂÚÁ·Û›·, ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·Ó·Ê¤ÚÔÓÙ·Ó ÛÙÔ 31%, ÂÓÒ °O¶ ·Ô‰Â‰ÂÈÁ̤ÓË Ì 24ˆÚË pH-ÌÂÙÚ›· ‚Ú¤ıËΠÛÙÔ 70% ÙˆÓ ·ÛıÂÓÒÓ. ∆· ÚÔ‚Ï‹Ì·Ù· ‰È·ÙÚÔÊ‹˜ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ‰ÂÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ì °O¶ Û ۇÁÎÚÈÛË Ì ·˘Ù¿ ¯ˆÚ›˜ °O¶. ∞˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ô‰‹ÁËÛ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë Î·Î‹ ıÚ¤„Ë ·fi ÌfiÓË Ù˘ ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó ··Ú·›ÙËÙ· Ì °O¶, ·ÏÏ¿ ÔÊÂÈÏfiÙ·Ó Î·È Û ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜. ∞ÓÙ›ıÂÙ·, ÔÈ Ravelli Î·È Milla ·Ó·Ê¤ÚÔ˘Ó Ôχ
¶›Ó·Î·˜ 5. ∂ÈÏÔΤ˜ °O¶ Û ·È‰È¿ Ì ∂¶ Î·È ·Ô‰Â‰ÂÈÁ̤ÓË ·ÏÈÓ‰ÚfiÌËÛË (n=23) Î·È Û ·È‰È¿ ¯ˆÚ›˜ °O¶ (n=33) ∂ÈÏÔ΋ ∫·Î‹ ıÚ¤„Ë* ÀÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜ ∞Ó·ÈÌ›· ™È‰ËÚÔÂÓ›· ÀÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· µ¿ÚÔ˜ ÛÒÌ·ÙÔ˜ <3Ë ∂£ ⁄„Ô˜ ÛÒÌ·ÙÔ˜ <3Ë ∂£ ¶·ıÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη
∞ÛıÂÓ›˜ Ì °O¶ n (%) 8 (34,8) 6 (26) 11 (47,8) 13 (56,5) 4 (17,3) 6 (26) 4 (17,3) 5 (21,7)
∞ÛıÂÓ›˜ ¯ˆÚ›˜ °O¶ n (%) 4 5 7 4 8 6
2 (6) (12,1) (15,1) (21,2) (12,1) (24,2) (18,1) 3 (9)
n: ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ * ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ <10Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (∂£) Î·È ÏÂ˘ÎˆÌ·Ù›ÓË ÔÚÔ‡ <2,5 g/l ‹ ·Ó·ÈÌ›·
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˘„ËÏ¿ ÔÛÔÛÙ¿ (92%) ÛÙ·ÛÈÌfiÙËÙ·˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Û ·È‰È¿ Ì ∂¶ Î·È °O¶ (5). ™Â ÌÂϤÙË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó 32 ·È‰È¿ Ì ∂¶ Î·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ÙÔ 80% ·ÚÔ˘Û›·˙ °O¶ ·Ô‰Â‰ÂÈÁ̤ÓË Ì 24ˆÚË pH-ÌÂÙÚ›·, ÙÔ 47% ÙÔ˘ ÔÔ›Ô˘ (13/32) ›¯Â ÛȉËÚÔÂÓ›· Î·È ÙÔ 16% (5/32) ·Ó·ÈÌ›· (30). ∆Ô 9% (3/32) ·ÚÔ˘Û›·˙ Ó¢ÌÔÓÈΤ˜ ÂÛٛ˜ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ÂÓÒ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜ ·Ó·Ê¤ÚÔÓÙ·Ó Û 3 ·È‰È¿ (9%). ™Â ·ÓÙ›ıÂÛË Ì ¿ÏϘ ÌÂϤÙ˜, ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ÌÂÏÂÙ‹ıËÎ·Ó ÔÈ ÂÈÏÔΤ˜ Ù˘ °O¶ Û ۯ¤ÛË Ì ÙËÓ ·ÚÔ˘Û›· ·Ô‰Â‰ÂÈÁ̤Ó˘ ·ÏÈÓ‰ÚfiÌËÛ˘. ŒÙÛÈ, ÛÙ· ·È‰È¿ Ì °O¶ (n=23) η΋ ıÚ¤„Ë ·Ú·ÙËÚ‹ıËΠ۠ÔÛÔÛÙfi 34,8%, ÛȉËÚÔÂÓ›· ÛÙÔ 56,5%, ·Ó·ÈÌ›· ÛÙÔ 47,8%, ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙÔ 26% Î·È ÛÙ·ÛÈÌfiÙËÙ· ‚¿ÚÔ˘˜ ÛÙÔ 26%. §ÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ ‹Ù·Ó Ë ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·, Ë ÛÙ·ÛÈÌfiÙËÙ· ‡„Ô˘˜ Î·È Ë ·ıÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Ì ‚ÚÔÁ¯ÂÎٷۛ˜ Î·È ÂÈÎfiÓ· Ó¢ÌÔÓÈ΋˜ ›ÓˆÛ˘ (¶›Ó·Î·˜ 5). ∞ÓÙ›ıÂÙ·, Ù· ·È‰È¿ ¯ˆÚ›˜ °O¶ ›¯·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÂΉËÏÒÛÂȘ Ô˘ ·Ú·¤ÌÔ˘Ó Û °O¶¡. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û˘¯ÓfiÙËÙ· Ù˘ °O¶ ÛÙ· ·È‰È¿ Ì ∂¶ Â›Ó·È ·˘ÍË̤ÓË Î·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì¤ÙÚÈÔ˘ ¤ˆ˜ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏ› Û˘¯Ó¿ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜. ŒÙÛÈ, Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË Û fiÏ· Ù· ·È‰È¿ Ì ∂¶. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Û οı ·È‰› Ì ∂¶ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÁÈ· °O¶ (screening test) Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ·Ú¯Èο ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-16 ÌËÓÒÓ Î·È ÌÂÙ¿ ÂÚÈÔ‰Èο οı 6 Ì‹Ó˜ Î·È Ì¤¯ÚÈ ÙË Û¯ÔÏÈ΋ ËÏÈΛ·. ∏ ¢·ÈÛıËÛ›· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ Â›Ó·È ˘„ËÏ‹ (>80%) Î·È ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙÔÓ ÌË ÂÂÌ‚·ÙÈÎfi Ù˘ ¯·Ú·ÎÙ‹Ú·, ·ÏÏ¿ Î·È ÙËÓ ·Ô˘Û›· ·ÎÙÈÓÔ‚ÔÏ›·˜, ηı›ÛÙ·Ù·È ·Ú¯Èο ̤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ÛÙÔ screening ÙˆÓ ·È‰ÈÒÓ Ì ∂¶. ∏ pH-ÌÂÙÚ›·, ÏfiÁˆ ÙÔ˘ ÂÂÌ‚·ÙÈÎÔ‡ Ù˘ ¯·Ú·ÎÙ‹Ú·, ·ÏÏ¿ Î·È ÙÔ˘ ˘„ËÏfiÙÂÚÔ˘ ÎfiÛÙÔ˘˜, ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ Ì ıÂÙÈο ˘ÂÚ˯ÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù·. ∞ÓÙ›ıÂÙ·, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÌ¿¯Ô˘-ÔÈÛÔÊ¿ÁÔ˘ ¤¯ÂÈ ÌÈÎÚfiÙÂÚË Â˘·ÈÛıËÛ›· ÛÙËÓ ·ÔÎ¿Ï˘„Ë °O¶ (~50%), ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ ÎfiÛÙÔ˜, ··ÈÙ› ·ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÂÎı¤ÙÂÈ Û ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·. °È· ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ °O¶ Û ·È‰È¿ Ì ∂¶. µÈ‚ÏÈÔÁÚ·Ê›· 1. Abrahams P, Burkitt BF. Hiatus hernia and gastroesophageal reflux in children and adolescents with cerebral
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 09-05-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘ °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 46, ∆.∫. 546 42, £ÂÛÛ·ÏÔÓ›ÎË E-mail: klspirog@med.auth.gr
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2003;66:304-310
ORIGINAL ARTICLE
H ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ ÛÙË ‰ÂηÂÙ›· 1990-1999 ∂. ∞Ó·ÛÙ·ÛÈ¿‰Ô˘ - ∫·Ú·ÁˆÚÁÔÔ‡ÏÔ˘1, ∞. ∞Ó‰Ú¤Ô˘1, Ã. ª·ÛÈ¿ÎÔ˜2, ¡. ª¿ÓÔ˜1, ∂. ∫ԇϷÏË2
Retinopathy of prematurity during the decade 1990-1999 E. Anastasiadou - Karageorgopoulou1, A. Andreou1, H. Basiakos2, N. Manos1, E. Koulali2
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ó· ηٷÁÚ·Ê› Ë Û˘¯ÓfiÙËÙ·, Ë ·ÓÙÈÌÂÙÒÈÛË Î·È Ë ¤Î‚·ÛË Ù˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ (∞Ù¶) Û fiÏ· Ù· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (µ°) <1500 g, Ô˘ ÓÔÛËχıËÎ·Ó Î·È Â¤˙ËÛ·Ó, ÛÙÔ ¡ÂÔÁÓÔÏÔÁÈÎfi ÙÌ‹Ì· ÙÔ˘ ∂™À ÙÔ˘ πÔÎÚ¿ÙÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢ ηٿ ÙË ‰ÂηÂÙ›· 19901999. ∏ ‰ÂηÂÙ›· ‰È·ÈÚ¤ıËΠ۠‰‡Ô ÂÚÈfi‰Ô˘˜: ∞ (1990-1994) Î·È µ (1995-1999). ∆· ÓÂÔÁÓ¿, ›Û˘, ¯ˆÚ›ÛÙËÎ·Ó Û ‰‡Ô ηÙËÁÔڛ˜ ·Ó¿ÏÔÁ· Ì ÙÔ µ° (501-1000 g Î·È 1001-1500 g), ÔÈ Ôԛ˜ Û˘ÁÎÚ›ıËÎ·Ó ÌÂٷ͇ ÙÔ˘˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶. ∫·Ù¿ ÙËÓ ∞ ÂÚ›Ô‰Ô, ∞Ù¶ ·ÚÔ˘Û›·Û·Ó 24 (37,5%) ·fi Ù· 64 ÓÂÔÁÓ¿ Ì µ° 5011000 g Ô˘ ¤˙ËÛ·Ó Î·È 22 (8,5%) ·fi Ù· 258 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g (p<0,0001). ∆Ô Ì¤ÛÔ µ° Ù˘ ÚÒÙ˘ ηÙËÁÔÚ›·˜ ‹Ù·Ó 865±93 g (‰È·Î‡Ì·ÓÛË 670-1000) Î·È Ë ‰È¿ÚÎÂÈ· ·ËÛ˘ (¢∫) ‹Ù·Ó 26,7±1,3 (‰È·Î‡Ì·ÓÛË 25-29 ‚‰ÔÌ¿‰Â˜). ∆Ô Ì¤ÛÔ µ° Ù˘ ‰Â‡ÙÂÚ˘ ηÙËÁÔÚ›·˜ ‹Ù·Ó 1348±230 g (‰È·Î‡Ì·ÓÛË 1001-1500 g) Î·È Ë ¢∫ ‹Ù·Ó 30±2,3 (‰È·Î‡Ì·ÓÛË 26-32 ‚‰ÔÌ¿‰Â˜). ∞Ù¶ I-II ÛÙ·‰›Ô˘ ›¯·Ó 15 (23,5%) ÓÂÔÁÓ¿ Ì µ° 501-1000 g Î·È 19 (7,3%) Ì µ° 1001-1500 g (p<0,0001), ÂÓÒ ∞Ù¶ IIIV ÛÙ·‰›Ô˘ ›¯·Ó 9 (14%) Î·È 3 (1,2%) ÓÂÔÁÓ¿, ·ÓÙ›ÛÙÔȯ· (p<0,0001). ∫·Ù¿ ÙË µ ÂÚ›Ô‰Ô, ∞Ù¶ ·ÚÔ˘Û›·Û·Ó 42 (37,8%) ·fi Ù· 111 ÓÂÔÁÓ¿ Ì µ° 501-1000 g Î·È 24 (6,5%) ·fi Ù· 364 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g (p<0,001). ∆Ô Ì¤ÛÔ µ° Ù˘ ÚÒÙ˘ ηÙËÁÔÚ›·˜ ‹Ù·Ó 853,7±95,8 g (‰È·Î‡Ì·ÓÛË 615-1000 g) Î·È Ë ¢∫ ‹Ù·Ó 26,7±1,6 (‰È·Î‡Ì·ÓÛË 24-30 ‚‰ÔÌ¿‰Â˜). ∆Ô Ì¤ÛÔ µ° Ù˘ ‰Â‡ÙÂÚ˘ ηÙËÁÔÚ›·˜ ‹Ù·Ó 1260±210 g (‰È·Î‡Ì·ÓÛË 1020-1450 g) Î·È Ë ¢∫ ‹Ù·Ó 28,5±2,6 (‰È·Î‡Ì·ÓÛË 26-34 ‚‰ÔÌ¿‰Â˜). AÙ¶ π-ππ ÛÙ·‰›Ô˘ ·ÚÔ˘Û›·Û·Ó 30 (27%) ÓÂÔÁÓ¿ ÌÂ
Abstract: The aim of the study was to record the incidence, the treatment and the outcome of retinopathy of prematurity (ROP) during the decade 1990-1999, in the Neonatal Department of Ippokration General Hospital of Thessaloniki. All the neonates with birth weight (BW) ≤1500 g, who were admitted and survived in the department during the decade 1990-1999 were included. The decade was divided in 2 periods: period A (1990-1994) and period B (1995-1999) and the infants were also divided in 2 groups according to the BW (501-1000 g and 10011500 g), which were compared between each other. During the period A 24 (37.5%) infants developed ROP from 64 infants with BW 501-1000 g who survived and 22 (8.52%) from 258 infants with BW 1001-1500 g (p<0.0001). For the first group, the mean BW of the affected infants was 865±93 g (range 670-1000 g) and mean gestational age (GA) 26.7±1.3 (range 25-29 weeks). For the second group, the mean BW of the affected infants was 1348±230 g (range 1060-1500 g) and mean GA 30±2.3 (range 26-32 weeks). Fifteen (23.5%) infants, with BW 501-1000 g, and 19 (7.3%), with BW 10011500 g, had ROP stages I and II (p<0.0001), while 9 (14%) and 3 (1.2%) from the corresponding groups had severe ROP stages III-V, with or without plus disease (p<0.0001). During the period B 42 (37.8%) infants developed ROP from 111 with BW 501-1000 g who survived and 24 (6.59%) from 364 infants with BW 1001-1500 g (p<0.001). For the first group the mean BW of the affected infants was 853.7±95.8 g (range 615-1000 g) and the GA 24-30 weeks (x=26.7±1.5). For the second group, the mean BW of the affected infants was 1260±210 g (range 10201450 g) and the GA 28.5±2.6 (range 26-34 weeks).
1 ª∂¡¡ ∂™À πÔÎÚ¿ÙÂÈÔ °¶¡£, £ÂÛÛ·ÏÔÓ›ÎË 2 OÊı·ÏÌÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ πÔÎÚ¿ÙÂÈÔ˘ °¶¡£, £ÂÛÛ·ÏÔÓ›ÎË
1 Division of Neonatology, Ippokration General Hospital, Thessaloniki 2 Ophthalmologic Clinic, Ippokration General Hospital, Thessaloniki
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¶·È‰È·ÙÚÈ΋ 2003;66:304-310
Paediatriki 2003;66:304-310
µ° 501-1000 g Î·È 20 (5,5%) ÓÂÔÁÓ¿ Ì µ° 10011500 g (p<0,0001), ÂÓÒ ∞Ù¶ πππ-V ÛÙ·‰›Ô˘ ·ÚÔ˘Û›·Û·Ó 12 (10,8%) Î·È 4 (1,1%) ÓÂÔÁÓ¿, ·ÓÙ›ÛÙÔȯ· (p<0,0001). ∏ Û‡ÁÎÚÈÛË ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ ÛÙȘ ‰‡Ô ηÙËÁÔڛ˜ µ°, ¤‰ÂÈÍ ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p>0,01).
Thirty (27%) infants with BW 501-1000 g and 20 (5.5%) with BW 1001-1500 g had ROP stages I and II while 12 (10.8%) and 4 (1.1%) from the corresponding groups had severe ROP stages III-V, with or without plus disease (p<0.0001). The comparison between the two periods didn’t show statistically significant differences (p>0.01) between the periods A and B for the neonates with BW <1000 g, 1001-1500 g totally and for the two categories (stages I and II, stage ≥III).
§¤ÍÂȘ ÎÏÂȉȿ: ∞Ù¶, Û˘¯ÓfiÙËÙ·, ·ÓÙÈÌÂÙÒÈÛË.
Key words: ROP, incidence, treatment.
∂ÈÛ·ÁˆÁ‹ ∏ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ (∞Ù¶), ÁÓˆÛÙ‹ ·fi ÙÔ 1942 Ì ÙÔ fiÓÔÌ· ÔÈÛıÔÊ·ÎÈ΋ ÈÓÔÏ·Û›·, Â›Ó·È Ì›· ÂÍÂÏÈÎÙÈ΋ ¿ıËÛË Ô˘ ·ÊÔÚ¿ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÓÒÌ·ÏË ·Ó¿Ù˘ÍË ÙˆÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÈÎÒÓ ·ÁÁ›ˆÓ (1,2). ∆˘Èο, ÚÔÛ‚¿ÏÏÂÈ ÚfiˆÚ·, Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÔ͢ÁfiÓÔ Î·È, Û¿ÓÈ·, ÙÂÏÂÈfiÌËÓ·, Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜ ÓÂÔÁÓ¿, Ô˘ ‰ÂÓ ÂÎÙ¤ıËÎ·Ó Û ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘. ∞ÚÎÂÙÔ› ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó Û˘Ó‰Âı› Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ (2,3). ∏ ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ∞Ù¶ ¤ÁÈÓ ۇÌʈӷ Ì ÙË ‰ÈÂıÓ‹ Ù·ÍÈÓfiÌËÛË, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÓÙfiÈÛË, ÙËÓ ¤ÎÙ·ÛË Î·È ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ‚Ï·‚ÒÓ (2). ∏ ÂÓÙfiÈÛË ÙˆÓ ‚Ï·‚ÒÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ˙ÒÓË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ÛÙËÓ ÔÔ›· ÂÓÙÔ›˙ÔÓÙ·È. ∫·ıÔÚ›ÛÙËÎ·Ó ÙÚÂȘ ˙ÒÓ˜ ΢ÎÏÈΤ˜, ÔÌfiÎÂÓÙÚ˜ Ì ΤÓÙÚÔ ÙË ıËÏ‹. ∏ ¤ÎÙ·ÛË ÙˆÓ ‚Ï·‚ÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ˆÚÒÓ ÛÙȘ Ôԛ˜ ÂÎÙ›ÓÔÓÙ·È. ∫¿ı ÒÚ· Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ‰Ò‰Âη ΢ÎÏÈÎÔ‡˜ ÙÔÌ›˜, ÙfiÍÔ˘ 30 ÌÔÈÚÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÈÚÂ›Ù·È Ô ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜. ∏ ÂÓÙfiÈÛË Î·È Ë ¤ÎÙ·ÛË ÙˆÓ ‚Ï·‚ÒÓ Î·ıÔÚ›˙Ô˘Ó ÙË ‚·Ú‡ÙËÙ· Ù˘ ¿ıËÛ˘, Ë ÔÔ›· ‰È·ÎÚ›ÓÂÙ·È Û ¤ÓÙ ÛÙ¿‰È·. ∆· ÛÙ¿‰È· πππ-V ıˆÚÔ‡ÓÙ·È ‚·ÚÈ¿˜ ÌÔÚÊ‹˜ ∞Ù¶. ∏ ·ÔÎfiÏÏËÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ¯·Ú·ÎÙËÚ›˙ÂÈ Ù· ÛÙ¿‰È· IV Î·È V. ∏ ‰È¿Ù·ÛË Î·È Ë ÔÊÈÔÂȉ‹˜ ÔÚ›· ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÓfi˜ ÙÂÙ·ÚÙËÌÔÚ›Ô˘ ÙÔ˘ Ô›ÛıÈÔ˘ fiÏÔ˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙÔ ÛÙ¿‰ÈÔ Ì ÙÔ ÚfiıÂÌ· Û˘Ó (+) (plus (+) disease). ∞˘Ù‹ ‰È¢ÎÚÈÓ›˙ÂÈ ÂÚ·ÈÙ¤Úˆ ÙË ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ ‰ÈfiÙÈ, ηٿ ηÓfiÓ·, ÚÔËÁÂ›Ù·È Ù˘ ·ÔÎfiÏÏËÛ˘ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ∆Ô ÛÙ¿‰ÈÔ III plus, ÛÙÔ ÔÔ›Ô ÔÈ ‚Ï¿‚˜ ˘ÂÚ‚·›ÓÔ˘Ó Û ¤ÎÙ·ÛË ¤ÓÙÂ Û˘Ó¯›˜ ‹ ÔÎÙÒ ·Û˘Ó¯›˜ ÒÚ˜ Î·È ÂÓÙÔ›˙ÔÓÙ·È ÛÙË ˙ÒÓË 1 ‹ 2, ηıÔÚ›˙ÂÙ·È Û·Ó Ô˘‰fi˜ (threshold) ∞Ù¶ Î·È ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÁÈ· ¿ÌÂÛË ÂÊ·ÚÌÔÁ‹ ÎÚ˘ÔËÍ›·˜ ‹ ʈÙÔËÍ›·˜ (4). ∆Ô ÚÔËÁÔ‡ÌÂÓÔ ÛÙ¿‰ÈÔ, ÙÔ ÚÔ-Ô˘‰ÈÎfi
(pre-threshold), Â›Ó·È ÏÈÁfiÙÂÚÔ ÛÔ‚·Úfi. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶ ÁÈ· ÓÂÔÁÓ¿ ‚¿ÚÔ˘˜ <1,5 kg, Î˘Ì·›ÓÂÙ·È ·fi 12% ¤ˆ˜ 78% (5,6). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞Ù¶ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ ÛÙÔ ÔÔ›Ô ‚Ú›ÛÎÂÙ·È Ë ¿ıËÛË. ™Ù· ÚÒÙ· 2 ÛÙ¿‰È· ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Î·Ì›· ·Ú¤Ì‚·ÛË, ‰ÈfiÙÈ ÔÈ Èı·ÓfiÙËÙ˜ ·˘ÙfiÌ·Ù˘ ˘ÔÛÙÚÔÊ‹˜ Â›Ó·È Î·Ï¤˜ (5,7,8). ™ÙÔ ÔÚÈ·Îfi 3+ ÛÙ¿‰ÈÔ Î·È ÂÊfiÛÔÓ ÔÈ ‚Ï¿‚˜ ˘ÂÚ‚·›ÓÔ˘Ó Û ¤ÎÙ·ÛË ÙȘ 5 Û˘Ó¯›˜ ÒÚ˜ ‹ ÙȘ 8 ·Û˘Ó¯›˜ ÛÙË ˙ÒÓË π ‹ ππ, Û˘ÓÈÛÙ¿Ù·È Ë ¿ÌÂÛË (ÂÓÙfi˜ 72 ˆÚÒÓ) ÎÚ˘ÔËÍ›· ‹ ʈÙÔËÍ›· Ù˘ ·Ó¿ÁÁÂÈ·˜ ÂÚÈÔ¯‹˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ (7). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂÚÈÁÚ¿ÊÔÓÙ·È Ë Û˘¯ÓfiÙËÙ· Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞Ù¶ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ·Ó·Ê¤ÚÔÓÙ·È Ù· ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ·˘Ù‹ ÙËÓ ¿ıËÛË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ·ÚÔ‡Û· ÌÂϤÙË ·ÊÔÚ¿ ÛÙË ‰ÂηÂÙ›· 1990-1999 Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ fiÏ· Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì µ° ≤1500 g Ô˘ ÓÔÛËχıËÎ·Ó ÛÙÔ ¡ÂÔÁÓÔÏÔÁÈÎfi ÙÌ‹Ì· Î·È ÂÈ‚›ˆÛ·Ó. ∆· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì µ° >1500 g Î·È Ù· ÙÂÏÂÈfiÌËÓ· ÂÍÂÙ¿˙ÔÓÙ·Ó ÔÊı·ÏÌÔÏÔÁÈο ÁÈ· ∞Ù¶ ÌfiÓÔÓ fiÙ·Ó ˘‹Ú¯·Ó ÁÓˆÛÙÔ›, ÂÈ‚·Ú˘ÓÙÈÎÔ› ÁÈ· ∞Ù¶, ·Ú¿ÁÔÓÙ˜. ∏ ‰ÂηÂÙ›· ‰È·ÈÚ¤ıËΠ۠‰‡Ô ÂÚÈfi‰Ô˘˜: ÙËÓ ∞ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ¤ÙË 1990-1994 Î·È ÙË µ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ¤ÙË 1995-1999. ™Â οı ÂÚ›Ô‰Ô ‰È·ÎÚ›Ó·Ì ‰‡Ô ηÙËÁÔڛ˜ ÓÂÔÁÓÒÓ: Ì›· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ fiÏ· Ù· ÓÂÔÁÓ¿ Ì µ° 501-1000 g Î·È Ì›· ¿ÏÏË Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ fiÏ· Ù· ÓÂÔÁÓ¿ Ì µ° 1001-1500 g. ™Â οı ÂÚ›Ô‰Ô ¯ˆÚÈÛÙ¿, ÔÈ ‰‡Ô ηÙËÁÔڛ˜ µ° Û˘ÁÎÚ›ıËÎ·Ó ÌÂٷ͇ ÙÔ˘˜ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶. ŒÁÈÓÂ, ›Û˘, Û‡ÁÎÚÈÛË ÙˆÓ ‰‡Ô ηÙËÁÔÚÈÒÓ µ° ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ, ˆ˜ ÚÔ˜ ÙÔ˘˜ ›‰ÈÔ˘˜ ·Ú¿ÁÔÓÙ˜. ∂ÎÙfi˜ ·fi ÙËÓ ÚÔˆÚfiÙËÙ·, ¿ÏÏÔÈ ÁÓˆÛÙÔ›, ÂÈ‚·Ú˘ÓÙÈÎÔ› ÁÈ· ∞Ù¶, ·Ú¿ÁÔÓÙ˜ Ô˘ ˘‹Ú¯·Ó ÛÙ· ÓÂÔÁÓ¿, ‰ÂÓ ÂϤÁ¯ıËÎ·Ó ÛÙ·ÙÈÛÙÈο. ™‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ÎÏÈÓÈ΋˜, fiÏ· Ù· ÓÂÔÁÓ¿ Ô˘ ¤˙ËÛ·Ó, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ¢∫, ÂÍÂÙ¿ÛÙËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜ ‹ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· Ì ¤ÌÌÂÛË ÔÊı·ÏÌÔÛÎfiËÛË ÁÈ· ÚÒÙË ÊÔÚ¿ Û ËÏÈΛ· ηٿ ̤ÛÔ
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¶·È‰È·ÙÚÈ΋ 2003;66:304-310
Paediatriki 2003;66:304-310
fiÚÔ 4-5 ‚‰ÔÌ¿‰ˆÓ ˙ˆ‹˜. ∆· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ¢∫ ≤25 ‚‰ÔÌ¿‰Â˜ ÂÍÂÙ¿˙ÔÓÙ·Ó ÁÈ· ÚÒÙË ÊÔÚ¿ Û ÌÂÙ·-ÂÌÌËÓÔÚÚÔ˚΋ ËÏÈΛ· 31-32 ‚‰ÔÌ¿‰ˆÓ, ÂÓÒ Ù· ÚfiˆÚ· Ì ¢∫ 31-32 ‚‰ÔÌ¿‰Â˜ ÂÍÂÙ¿˙ÔÓÙ·Ó Û ËÏÈΛ· 34-35 ‚‰ÔÌ¿‰ˆÓ. OÈ ÂfiÌÂÓ˜ ÔÊı·ÏÌÔÛÎÔ‹ÛÂȘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·Ó ·Ó¿ÏÔÁ· Ì ٷ ·Ú¯Èο Â˘Ú‹Ì·Ù·. ŸÙ·Ó ‰ÂÓ ˘‹Ú¯Â ∞Ù¶ Î·È Ë ·ÁÁ›ˆÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ‰ÂÓ ‹Ù·Ó Ï‹Ú˘, Ë ÔÊı·ÏÌÔÛÎfiËÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Î¿ı 1-2 ‚‰ÔÌ¿‰Â˜, ̤¯ÚÈ Ï‹ÚÔ˘˜ ·ÁÁ›ˆÛ˘. ∏ ÂͤٷÛË ÙÔ˘ ‚˘ıÔ‡ ÙˆÓ ÓÂÔÁÓÒÓ ÁÈÓfiÙ·Ó ·fi ÔÊı·ÏÌ›·ÙÚÔ ÂÍÔÈÎÂȈ̤ÓÔ ÛÙË ¯Ú‹ÛË ÙÔ˘ ¤ÌÌÂÛÔ˘ ÔÊı·ÏÌÔÛÎÔ›Ô˘ Î·È ¤ÌÂÈÚÔ ÛÙȘ ȉȷÈÙÂÚfiÙËÙ˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ÙˆÓ ÚÔÒÚˆÓ. ÃÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ‰ÈfiÊı·ÏÌ˘ ¤ÌÌÂÛ˘ ÔÊı·ÏÌÔÛÎfiËÛ˘ ÌÂÙ¿ ·fi Ï‹ÚË Ì˘‰Ú›·ÛË, ‰ÈfiÙÈ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ·Ú·Ù‹ÚËÛ˘ Ù˘ ·ÒÙÂÚ˘ ÂÚÈʤÚÂÈ·˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, fiÔ˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÔÈ ÂΉËÏÒÛÂȘ Ù˘ ¿ıËÛ˘. °È· ÙË Ì˘‰Ú›·ÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÎÔÏχÚÈ· Ê·ÈÓ˘ÏÂÊÚ›Ó˘ 2,5%, ΢ÎÏÔÂÓÙÔÏ¿Ù˘ 0,2% Î·È ÙÚÔÈη̛‰Ë˜ 1%, Û ‰È¿ÊÔÚ˜ ·Ó·ÏÔÁ›Â˜, Ô˘ ÂÓÛÙ·Ï¿˙ÔÓÙ·Ó ÙÚÂȘ ÊÔÚ¤˜ ·Ó¿ 10 ÏÂÙ¿ Î·È ·ÎÔÏÔ˘ıÔ‡ÛÂ Ë ÂͤٷÛË ÌÂÙ¿ ·fi 30 ÏÂÙ¿. ∏ ÂͤٷÛË ÁÈÓfiÙ·Ó ÌÂ Û˘Ó·›ÛıËÛË fiÙÈ ·ÔÙÂÏ› Ì›· ٷϷȈڛ· ÁÈ· Ù· ÓÂÔÁÓ¿ Î·È fiÙÈ ‰ÂÓ Â›Ó·È ¿ÌÔÈÚË Û˘Ì‚·Ì¿ÙˆÓ. ◊Ù·Ó Û‡ÓÙÔÌË (<1,5 min) Î·È fiÔ˘ ‹Ù·Ó ‰˘Ó·Ùfi ÁÈÓfiÙ·Ó ¯ˆÚ›˜ ¯Ú‹ÛË ÂÚÁ·Ï›ˆÓ, .¯. ‚ÏÂÊ·ÚԉȷÛÙÔϤ· ‹ ÛÎÏËÚÈÎÔ‡ ÂÓÙ˘ˆÙ‹. ŸÏ· Ù· ÓÂÔÁÓ¿ ÓÔÛËχıËÎ·Ó Û ÂÚÈ‚¿ÏÏÔÓ ÌÂ Û˘ÓËıÈṲ̂ÓÔ ËÏÈ·Îfi ʈ˜ ÙËÓ Ë̤ڷ Î·È Û¯ÂÙÈο ¤ÓÙÔÓÔ, ÊıÔÚ›˙ÔÓ Êˆ˜ ÙÔ ‚Ú¿‰˘, Ì ÂÓ·ÏÏ·ÛÛfiÌÂÓ˜ ÂÚÈfi‰Ô˘˜ ¯·ÌËÏÔ‡ ʈÙÈÛÌÔ‡. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ʈÙÔıÂڷ›·˜, Ù· Ì¿ÙÈ· ‹Ù·Ó ¿ÓÙÔÙÂ Î·Ï˘Ì̤ӷ. °ÈÓfiÙ·Ó ÚÔÛ¿ıÂÈ· ÒÛÙÂ Ô ÎÔÚÂÛÌfi˜ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ Û Ô͢ÁfiÓÔ Ó· ‰È·ÙËÚÂ›Ù·È Î¿Ùˆ ·fi 92-95%. ™Â ηӤӷ ÓÂÔÁÓfi ‰ÂÓ ¯ÔÚËÁ‹ıËΠ‚ÈÙ·Ì›ÓË ∂ ÚÔÊ˘Ï·ÎÙÈο ‹ ıÂڷ¢ÙÈο. ∏ ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ∞Ù¶ ¤ÁÈÓ ۇÌ-
ʈӷ Ì ÙË ‰ÈÂıÓ‹ Ù·ÍÈÓfiÌËÛË (2). O ¯ÚfiÓÔ˜ ·ÓÂͤٷÛ˘ ηıÔÚÈ˙fiÙ·Ó ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ÙÂÏÂ˘Ù·›·˜ ÂͤٷÛ˘. ∂¿Ó ˘‹Ú¯Â ·ÓˆÚÈÌfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ, ·ÏÏ¿ fi¯È ∞Ù¶, Ë Â·ÓÂͤٷÛË ÁÈÓfiÙ·Ó ÌÂÙ¿ ·fi 4 ‚‰ÔÌ¿‰Â˜. ∂¿Ó Ë ∞Ù¶ ·ÊÔÚÔ‡Û ÛÙȘ ˙ÒÓ˜ π ‹ ππ Î·È ‹Ù·Ó ÛÙ·‰›Ô˘ 2+ ‹ 3, Ë ÂͤٷÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó ÌÂÙ¿ ·fi 1 ‚‰ÔÌ¿‰·. ¡ÂÔÁÓ¿ Ì ·Ô‰Ú·ÌÔ‡Û· ∞Ù¶ ·ÓÂÍÂÙ¿˙ÔÓÙ·Ó ÌÂÙ¿ ·fi 3 Ì‹Ó˜. °È· ÙË Û‡ÁÎÚÈÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÙ·ÙÈÛÙÈ΋ ̤ıÔ‰Ô˜ ¯2 Î·È Ë ‰ÔÎÈÌ·Û›· Fisher’s exact.
∞ÔÙÂϤÛÌ·Ù· ∆ËÓ ÂÚ›Ô‰Ô ∞ ÓÔÛËχıËÎ·Ó 173 ÓÂÔÁÓ¿ Ì µ° ≤1000 g Î·È Â¤˙ËÛ·Ó 64 (37%), Ô˘ ›¯·Ó µ° 6701000 g (¯=865±93) Î·È ¢∫ 25-29 ‚‰ÔÌ¿‰Â˜ (¯=26,7±1,3). ∆ËÓ ›‰È· ÂÚ›Ô‰Ô ÓÔÛËχıËÎ·Ó Î·È 348 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g Î·È Â¤˙ËÛ·Ó 258 (74,1%), Ì µ° 1060-1500 g (x=1348±230) Î·È ¢∫ 26-32 ‚‰ÔÌ¿‰Â˜ (¯=30±2,3) (¶›Ó·Î·˜ 1). ∞fi Ù· 64 ÓÂÔÁÓ¿ Ì µ° ≤1000 g Ô˘ ¤˙ËÛ·Ó, 24 (37,5%) ·ÚÔ˘Û›·Û·Ó ∞Ù¶. ∞fi ·˘Ù¿, 15 (23,5%) ›¯·Ó ∞Ù¶ π-ππ ÛÙ·‰›Ô˘ Î·È 9 (14%) ›¯·Ó ‚·ÚÈ¿ ∞Ù¶ πππ-V ÛÙ·‰›Ô˘, Ì ‹ ¯ˆÚ›˜ plus disease. ∞fi Ù· 9 ÓÂÔÁÓ¿ Ì ‚·ÚÈ¿ ∞Ù¶, 3 ›¯·Ó ∞Ù¶ III ÛÙ·‰›Ô˘ Î·È 6 ›¯·Ó ∞Ù¶ ≥πππ+. ∞fi Ù· 258 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g Ô˘ ¤˙ËÛ·Ó, 22 (8,5%) ·ÚÔ˘Û›·Û·Ó ∞Ù¶. ∞fi ·˘Ù¿, 19 (7,5%) ›¯·Ó ∞Ù¶ I-II ÛÙ·‰›Ô˘ Î·È 3 (1,2%) ›¯·Ó ‚·ÚÈ¿ ∞Ù¶ πππ-V ÛÙ·‰›Ô˘ Ì ‹ ¯ˆÚ›˜ plus disease. ∞fi Ù· 3 ÓÂÔÁÓ¿ Ì ‚·ÚÈ¿ ∞Ù¶, 1 ›¯Â ∞Ù¶ πππ ÛÙ·‰›Ô˘ Î·È 2 ›¯·Ó ∞Ù¶ ≥πππ+. ŸÏ· Ù· ÓÂÔÁÓ¿ Ì ∞Ù¶ π-ππ ÛÙ·‰›Ô˘, ηıÒ˜ Î·È Ù· 4 ÓÂÔÁÓ¿ Ì ∞Ù¶ III ÛÙ·‰›Ô˘ ›¯·Ó ·˘ÙfiÌ·ÙË ˘ÔÛÙÚÔÊ‹ Ù˘ ∞Ù¶ Ì ηϋ ÌÂÙ¤ÂÈÙ· ·Ó¿Ù˘ÍË Ù˘ fiÚ·Û˘. ∞fi
¶›Ó·Î·˜ 1. ¡ÂÔÁÓ¿ Ì ∞Ù¶ ·Ó¿ÏÔÁ· Ì ÙÔ µ° Î·È ÙË ¢∫ ¶ÂÚ›Ô‰Ô˜ ∞: 1990-1994 π &ππ ÛÙ¿‰ÈÔ ¡Ô (%)**
µ° (g)±SD
¢∫ (‚‰.)
∞Ù¶* (%)
≤1000 865±93
26,7±1,3
24/64 (37,5)
1001-1500 1348±230
30±2,3
22/258 (8,5)***
µ° (g)±SD
¢∫ (‚‰.)
∞Ù¶* (%)
≤1000 853,7±95,8
26,7±1,5
42/111 (37,8)#
1001-1500 1260±210
28,5±2,6
24/364 (6,6)***#
µ·ÚÈ¿ ≥πππ ÛÙ¿‰ÈÔ ¡Ô (%)**
£Âڷ›·
15 (23,5)
9 (14)
2 ÎÚ˘ÔËÍ›·/1 Laser
19 (7,5)***
3 (1,2)***
¶ÂÚ›Ô‰Ô˜ µ: 1995-1999 π &ππ ÛÙ¿‰ÈÔ ¡Ô (%)
µ·ÚÈ¿ ≥πππ ÛÙ¿‰ÈÔ ¡Ô (%)
£Âڷ›·
30 (27)#
12 (10,8)#
8 ÎÚ˘ÔËÍ›·
20 (5,5)***#
4 (1,1)***#
3 ÎÚ˘ÔËÍ›·
* ™˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÓÂÔÁÓÒÓ Ì ∞Ù¶/·ÚÈıÌfi˜ ÓÂÔÁÓÒÓ Ô˘ ¤˙ËÛ·Ó ** AÚÈıÌfi˜ ÓÂÔÁÓÒÓ Ì ∞Ù¶ (% ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó) *** p<0,0001 ÌÂٷ͇ Ù˘ Ì›·˜ ηÙËÁÔÚ›·˜ µ° (≤1000 g) ¤Ó·ÓÙÈ Ù˘ ¿ÏÏ˘ (1001-1500 g) Ù˘ ›‰È·˜ ÂÚÈfi‰Ô˘ ÁÈ· ÙÔ Û‡ÓÔÏÔ Ù˘ ∞Ù¶ Î·È Ù· ‰‡Ô ÛÙ¿‰È¿ Ù˘ # p>0,1 ÌÂٷ͇ οı ηÙËÁÔÚ›·˜ µ° (≤1000 g, 1001-1500 g) Ù˘ ÂÚÈfi‰Ô˘ ∞ ÚÔ˜ ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Ù˘ ÂÚÈfi‰Ô˘ µ ÁÈ· ÙÔ Û‡ÓÔÏÔ Ù˘ ∞Ù¶ Î·È Ù· ‰‡Ô ÛÙ¿‰È·
306
¶·È‰È·ÙÚÈ΋ 2003;66:304-310
Ù· 6 ÓÂÔÁÓ¿ Ì ∞Ù¶ ≥πππ+ Î·È µ° ≤1000 g, 3 ÂϤÁ¯ıËÎ·Ó Ì ηı˘ÛÙ¤ÚËÛË ÏfiÁˆ ‚·ÚÈ¿˜ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘, ›¯·Ó ∞Ù¶ V ÛÙ·‰›Ô˘ ¿Ìʈ Î·È ·Ó¤Ù˘Í·Ó ¿ÚÈÛÙË fiÚ·ÛË ·fi ÙÔÓ ¤Ó· ÔÊı·ÏÌfi Î·È ÌÂȈ̤ÓË ·fi ÙÔÓ ¿ÏÏÔ. ∞fi Ù· 2 ÓÂÔÁÓ¿ Ì ∞Ù¶ ≥πππ+ Î·È µ° 1001-1500 g, ÛÙÔ ¤Ó· ‰ÂÓ ‹Ù·Ó ÂÊÈÎÙfi˜ Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ‚˘ıÔ‡ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÏfiÁˆ ·ÈÌÔÚÚ·ÁÈÒÓ ÛÙÔ ˘·ÏÔÂȉ¤˜ Î·È fiÙ·Ó ·˘Ùfi η٤ÛÙË ‰˘Ó·Ùfi, Ë ÚfiÁÓˆÛË ÁÈ· ÙËÓ fiÚ·ÛË ‹Ù·Ó Ùˆ¯‹. ∆Ô ¿ÏÏÔ ÂϤÁ¯ıËΠ̠ηı˘ÛÙ¤ÚËÛË ÏfiÁˆ ‚·ÚÈ¿˜ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘, ·ÏÏ¿ ·Ó¤Ù˘Í ÈηÓÔÔÈËÙÈ΋ fiÚ·ÛË. ™Â 2 ÓÂÔÁÓ¿ Ì µ° ≤1000 g ¤ÁÈÓ ÎÚ˘ÔËÍ›· Î·È ¤Ó· Ù˘ ›‰È·˜ ηÙËÁÔÚ›·˜ ıÂڷ‡ıËΠ̠Laser. ∞fi Ù· 2 ÓÂÔÁÓ¿ Ô˘ ˘Â‚Ï‹ıËÛ·Ó Û ÎÚ˘ÔËÍ›·, 1 η٤ÏËÍ ·fi ·›ÙÈ· Ô˘ ‰ÂÓ Â›¯·Ó Û¯¤ÛË Ì ÙËÓ ¿ıËÛË Î·È 1 ·ÚÔ˘Û›·Û ˘ÔÛÙÚÔÊ‹ Ù˘ ∞Ù¶ Ì ηϋ ÌÂÙ¤ÂÈÙ· ·Ó¿Ù˘ÍË Ù˘ fiÚ·Û˘. ∆Ô ÓÂÔÁÓfi Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠Laser ·Ú¤ÌÂÈÓÂ Ù˘ÊÏfi. ™˘ÓÔÏÈο, ˘‹ÚÍ ¤Ó· Ù˘ÊÏfi ÓÂÔÁÓfi Ì µ° ≤1000 g (ÔÛÔÛÙfi 1,55% › ÙˆÓ ÂȂȈۿÓÙˆÓ Ì ‚·ÚÈ¿ ∞Ù¶). ∆ËÓ µ ÂÚ›Ô‰Ô ÓÔÛËχıËÎ·Ó 196 ÓÂÔÁÓ¿ Ì µ° 501-1000 g Î·È Â¤˙ËÛ·Ó 111 (56,5%), Ô˘ ›¯·Ó µ° 615-1000 g (¯=853,7±95,8) Î·È ¢∫ 24-30 ‚‰ÔÌ¿‰Â˜ (¯=26,7±1,5). ∆ËÓ ›‰È· ÂÚ›Ô‰Ô ÓÔÛËχıËÎ·Ó Î·È 415 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g Î·È Â¤˙ËÛ·Ó 364 (87,7%), Ô˘ ›¯·Ó µ° 1020-1450 g (¯=1260±210) Î·È ¢∫ 26-34 ‚‰ÔÌ¿‰Â˜ (¯=28,5±2,6) (¶›Ó·Î·˜ 1). ∞fi Ù· 111 ÓÂÔÁÓ¿ Ì µ° ≤1000 g Ô˘ ¤˙ËÛ·Ó, 42 (37,8%) ·ÚÔ˘Û›·Û·Ó ∞Ù¶. ∞fi ·˘Ù¿, 30 (27%) ›¯·Ó ∞Ù¶ π-ππ ÛÙ·‰›Ô˘ Î·È 12 (10,8%) ›¯·Ó ‚·ÚÈ¿ ∞Ù¶ πππ-V ÛÙ·‰›Ô˘ Ì ‹ ¯ˆÚ›˜ plus disease. ∞fi Ù· 12 ÓÂÔÁÓ¿ Ì ‚·ÚÈ¿ ∞Ù¶, 3 ›¯·Ó ∞Ù¶ πππ ÛÙ·‰›Ô˘ Î·È ˘ÔÛÙÚÔÊ‹ Ù˘ ∞Ù¶ Î·È 9 ›¯·Ó ∞Ù¶ ≥πππ+. ∞fi Ù· 9 ÓÂÔÁÓ¿ Ì ∞Ù¶ ≥πππ+ Î·È µ° <1001 g, 1 ›¯Â ˘ÔÛÙÚÔÊ‹ Ù˘ ∞Ù¶ ·fi ÙÔÓ ¤Ó· ÔÊı·ÏÌfi Ì ηϋ ·Ó¿Ù˘ÍË Ù˘ fiÚ·Û˘ Û‡ÛÙÔȯ· Î·È Ù· ˘fiÏÔÈ· 8 ¯ÂÈÚÔ˘ÚÁ‹ıËηÓ. ∞fi Ù· 364 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g Ô˘ ¤˙ËÛ·Ó, 24 (6,6%) ·ÚÔ˘Û›·Û·Ó ∞Ù¶. ∞fi ·˘Ù¿, 20 (5,5%) ›¯·Ó ∞Ù¶ I-II ÛÙ·‰›Ô˘ Î·È 4 (1,1%) ›¯·Ó ‚·ÚÈ¿ ∞Ù¶ III-V ÛÙ·‰›Ô˘ Ì ‹ ¯ˆÚ›˜ plus disease. ™Â ÎÚ˘ÔËÍ›· ˘Â‚Ï‹ıËÛ·Ó 8 ·fi Ù· 12 ÓÂÔÁÓ¿ Ì ‚·ÚÈ¿ ∞Ù¶ Î·È µ° ≤1000 g Î·È 3 ·fi Ù· 4 ÓÂÔÁÓ¿ Ì ‚·ÚÈ¿ ∞Ù¶ Î·È µ° 1001-1500 g. ªÂÙ¿ ÙËÓ ÎÚ˘ÔËÍ›·, 1 ·fi Ù· 8 ÓÂÔÁÓ¿ Ì µ° ≤1000 g η٤ÏËÍ ·fi ·›ÙÈ· Ô˘ ‰ÂÓ Â›¯·Ó Û¯¤ÛË Ì ÙËÓ ¿ıËÛË, 2 ›¯·Ó η΋ ÚfiÁÓˆÛË, 1 ›¯Â ·Û‹Ì·ÓÙË ‚ÂÏÙ›ˆÛË, ÂÓÒ Ù· ˘fiÏÔÈ· 4 ·ÚÔ˘Û›·Û·Ó ˘ÔÛÙÚÔÊ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ∞Ù¶. ∞fi Ù· 3 ÓÂÔÁÓ¿ Ì µ° 1001-1500 g Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÎÚ˘ÔËÍ›·, ˘ÔÛÙÚÔÊ‹ ·Ú·ÙËÚ‹ıËΠÛÙ· 2 Î·È ·ÔÎfiÏÏËÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Û 1. ŒÓ· ÓÂÔÁÓfi Ù˘ ›‰È·˜ ηÙËÁÔÚ›·˜ ‚¿ÚÔ˘˜ ›¯Â ∞Ù¶ ππ
Paediatriki 2003;66:304-310
ÛÙ·‰›Ô˘ ÛÙÔÓ ¤Ó· ÔÊı·ÏÌfi Î·È πππ ÛÙ·‰›Ô˘ ÛÙÔÓ ¿ÏÏÔ Ô˘ ÂÍÂÏ›¯ıËΠ۠ÂÚÈÊÂÚÈ΋ ·ÔÎfiÏÏËÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ÏfiÁˆ ÌË Ù‹ÚËÛ˘ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ·ÓÂϤÁ¯Ô˘ ·fi ÙÔ˘˜ ÁÔÓ›˜. ∏ fiÚ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ·Ó·Ù‡¯ıËΠ¿ÚÈÛÙ·. ™˘ÓÔÏÈο, ˘‹ÚÍ·Ó 3 Ù˘ÊÏ¿ ÓÂÔÁÓ¿ Ì µ° ≤1000 g (ÔÛÔÛÙfi 2,7% › ÙˆÓ ÂȂȈۿÓÙˆÓ Ì ‚·ÚÈ¿ ∞Ù¶). ∞ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ ÛÙË ˙ÒÓË 1 ‹ plus disease ›¯·Ó 2 ÓÂÔÁÓ¿ Ì µ° ≤1000 g ÙËÓ ∞ ÂÚ›Ô‰Ô Î·È 2 ÙËÓ µ ÂÚ›Ô‰Ô Î·È 1 ÓÂÔÁÓfi Ì µ° 1001-1500 g ÙËÓ ∞ Î·È 2 ÓÂÔÁÓ¿ ÙËÓ µ ÂÚ›Ô‰Ô. ∞Ù¶ Ì ¤ÎÙ·ÛË ÂÚÈÛÛfiÙÂÚË ·fi 6 ÒÚ˜ ›¯·Ó ÙËÓ ∞ ÂÚ›Ô‰Ô 10 ÓÂÔÁÓ¿ Ì µ° ≤1000 g Î·È 1 Ì µ° 1001-1500 g Î·È ÙË µ ÂÚ›Ô‰Ô 15 ÓÂÔÁÓ¿ Ì µ° ≤1000 g Î·È 6 Ì µ° 1001-1500 g. ™Â οı ÂÚ›Ô‰Ô, Ù· ÓÂÔÁÓ¿ Ì µ° ≤1000 g, Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ Ì µ° 1001-1500 g, ›¯·Ó ÛÙ·ÙÈÛÙÈο ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· (p<0,0001) ÛÙÔ Û‡ÓÔÏÔ Ù˘ ∞Ù¶ Î·È ÛÙȘ ηÙËÁÔڛ˜ ÛÙ·‰›ˆÓ Ù˘ (¶›Ó·Î·˜ 1). ªÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ ‰ÂÓ ˘‹Ú¯·Ó ÛËÌ·ÓÙÈΤ˜ (p>0,1) ‰È·ÊÔÚ¤˜ ÛÙË Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ (ÔÏÈ΋ Î·È ·Ó¿ ÛÙ¿‰È·) ηٿ ÙË Û‡ÁÎÚÈÛË ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ηÙËÁÔÚÈÒÓ µ°. ™ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ÓÂÔÁÓÒÓ Ì µ° >1500 g Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÔÊı·ÏÌÔÛÎÔÈο, ‚Ú¤ıËÎ·Ó ÌfiÓÔ 7 ÓÂÔÁÓ¿ Ì ∞Ù¶, ÛÙ·‰›Ô˘ π Î·È ππ, ÂÓÒ ÛÙË Î·ÙËÁÔÚ›· ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ ‰ÂÓ ‚Ú¤ıËΠηӤӷ Ì ∞Ù¶. ∏ ¢∫ ÙˆÓ 7 ÓÂÔÁÓÒÓ Î˘Ì·ÈÓfiÙ·Ó ·fi 32 ¤ˆ˜ 36 ‚‰ÔÌ¿‰Â˜. ™˘˙‹ÙËÛË ∏ ∞Ù¶ ··ÓÙ¿ Û ÓÂÔÁÓ¿ Ì µ° <1500 g Î·È Î˘Ú›ˆ˜ Û ÓÂÔÁÓ¿ Ì µ° <1000 g. O ÌÔÓ·‰ÈÎfi˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ∞Ù¶ ·Ú·Ì¤ÓÂÈ Ë ÌÂÁ¿ÏË ·ÓˆÚÈÌfiÙËÙ· (5). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÛÔ‚·Ú‹ ∞Ù¶ ·ÚÔ˘ÛÈ¿ÛÙËΠÌfiÓÔ Û ÓÂÔÁÓ¿ Ì µ° <1500 g Î·È ‹Ù·Ó ÛËÌ·ÓÙÈο Û˘¯ÓfiÙÂÚË ÛÙ· ÌÈÎÚfiÙÂÚ· Î·È ÈÔ ·ÓÒÚÈÌ· ÓÂÔÁÓ¿. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶ Û ÓÂÔÁÓ¿ Ì µ° <1,5 kg Î˘Ì·›ÓÂÙ·È ·fi 12% ¤ˆ˜ 78% (5,6). ∏ Û˘¯ÓfiÙËÙ· Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ ÛÙ· ÂÚÈÛÙ·ÙÈο Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Î·È ÁÈ· ÙȘ ‰‡Ô ηÙËÁÔڛ˜ µ° Â›Ó·È ·ÚfiÌÔȘ Ì ·˘Ù¤˜ ÂÚÁ·ÛÈÒÓ ·fi ÚÔËÁ̤Ó˜ ˘ÁÂÈÔÓÔÌÈο ¯ÒÚ˜ (2,3,6,9,10). ∏ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì µ° <1500 g ÙË µ ÂÚ›Ô‰Ô Â›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· Î·È ÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÓÂÔÁÓÒÓ Ì ∞Ù¶. ∏ ÔÛÔÛÙÈ·›· ·Ó·ÏÔÁ›·, fï˜, ·Ú¤ÌÂÈÓÂ Ë ›‰È·. ªÂÚÈΤ˜ ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ µ° ÂÏ·ÙÙÒÓÂÙ·È, ·Ó Î·È ‰ÂÓ Â›Ó·È Î·Ï¿ ηٷÓÔËÙfi ÁÈ·Ù› Û˘Ì‚·›ÓÂÈ ·˘Ùfi (11). ¶·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó Û˘Ó‰Âı› Ì ∞Ù¶ ÛÙ· Ôχ ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È Ë ·Ú·ÙÂٷ̤ÓË,
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·ÓÂͤÏÂÁÎÙË ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ Î·È Ë ·ÛÙ·ı‹˜ ÓÂÔÁÓÈ΋ ÔÚ›·, Ô˘ ˘Ô‰ËÏÒÓÂÙ·È ·fi ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÙËÓ Ó¢ÌÔÓÈ΋ ‰È·Ê˘Á‹ ·¤Ú·, ÙËÓ ÂÓ‰ÔÎÔÈÏȷ΋ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ÙË Û‹„Ë, ÙÔ shock Î.¿. OÈ ·ÓˆÙ¤Úˆ ·Ú¿ÁÔÓÙ˜ ˘‹Ú¯·Ó ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ·ÏÏ¿ ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ù‹ Ë ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘˜ ÂÂÍÂÚÁ·Û›·. ∆· ÓÂÔÁÓ¿ Ì ∞Ù¶ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ÛÔ‚·Ú¤˜ ˘ÔÏÂÈÌÌ·ÙÈΤ˜ ‚Ï¿‚˜, fiˆ˜ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·È „˘¯ÔÎÈÓËÙÈ΋ ˘ÛÙ¤ÚËÛË (12,13). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ Â›Ó·È Ë ÈÔ Û˘Ó‹˜ ·ÓÂÍ¿ÚÙËÙË È·ÙÚÈ΋ ·Ú¿ÌÂÙÚÔ˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ∞Ù¶. ∏ ÂÏÂÁ¯fiÌÂÓË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ ÂÚÈfiÚÈÛ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· Ù˘ ¿ıËÛ˘ ÌÂÙ¿ ÙÔ 1953 (7), ·ÏÏ¿ Ë ∞Ù¶ ·ÓÂÌÊ·Ó›ÛÙËΠηٿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970, fiÙ·Ó Ë ÂÈ‚›ˆÛË ÙˆÓ ·Ú¿ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ ÓÂÔÁÓÒÓ ¿Ú¯ÈÛ ӷ ·˘Í¿ÓÂÙ·È (14). ∏ ·‡ÍËÛË ·˘Ù‹ Û˘Ó¯›ÛÙËΠ̤¯ÚÈ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÊ·ÚÌÔÁ‹ Ù˘ ÎÚ˘ÔıÂڷ›·˜ (4). ¶ÚfiÛÊ·ÙË ÌÂϤÙË ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ Û ÓÂÔÁÓ¿ Ì ¢∫ <28 ‚‰ÔÌ¿‰Â˜, Ë ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ÙȘ ÚÒÙ˜ 8 ‚‰ÔÌ¿‰Â˜ ˙ˆ‹˜, Û ÔÛfiÙËÙ· ·ÚÎÂÙ‹ Ó· ‰È·ÙËÚ‹ÛÂÈ ‰È·‰ÂÚÌÈÎfi ÎÔÚÂÛÌfi Ô͢ÁfiÓÔ˘ 88-98%, Û˘Óԉ‡ÙËΠ̠ÛÔ‚·Ú‹ ∞Ù¶ Ô˘ ¯ÚÂÈ·˙fiÙ·Ó ÎÚ˘ÔıÂڷ›· 4 ÊÔÚ¤˜ ÈÔ Û˘¯Ó¿ Û ۇÁÎÚÈÛË Ì ÓÂÔÁÓ¿ Ô˘ ¤Ï·‚·Ó Ô͢ÁfiÓÔ ·ÚÎÂÙfi ÁÈ· ‰È·Ù‹ÚËÛË ‰È·‰ÂÚÌÈÎÔ‡ ÎÔÚÂÛÌÔ‡ 70-90% (15). ∏ ‰È·Ù‹ÚËÛË ¯·ÌËÏfiÙÂÚÔ˘ ÎÔÚÂÛÌÔ‡ ‰ÂÓ Û˘Óԉ¢fiÙ·Ó ·fi ·‡ÍËÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ‹ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. O Û˘Ó¯‹˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ Î·È Ë ‰ÈfiÚıˆÛË Ù˘ ˘ÂÚÔÍ›·˜ Û ۯ¤ÛË Ì ÙÔÓ ÂÚÈÔ‰ÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ ¤‰ÂÈÍ ӷ ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶ (16). ∏ ¯ÔÚ‹ÁËÛË ˘„ËÏfiÙÂÚˆÓ ˘ÎÓÔÙ‹ÙˆÓ Ô͢ÁfiÓÔ˘ (ÎÔÚÂÛÌfi˜ Ô͢ÁfiÓÔ˘ >94%), fiÙ·Ó Ë ∞Ù¶ ¤¯ÂÈ Êı¿ÛÂÈ ÛÙÔ ÚÔ-Ô˘‰ÈÎfi ÛÙ¿‰ÈÔ, ‰ÂÓ ÂȉÂÈÓÒÓÂÈ ÙȘ ‚Ï¿‚˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Î·È ÌÔÚ› Ó· ¤¯ÂÈ ·Ó·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÛÙËÓ ÂͤÏÈÍË ÚÔ˜ ÙÔ Ô˘‰ÈÎfi ÛÙ¿‰ÈÔ (17,18). ∏ ¯ÔÚ‹ÁËÛË, fï˜, ˘„ËÏfiÙÂÚˆÓ ˘ÎÓÔÙ‹ÙˆÓ Ô͢ÁfiÓÔ˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÏfiÁˆ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ‚Ï¿‚˘ ÙˆÓ Ó¢ÌfiÓˆÓ (17). ™ÙË ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ Ê·›ÓÂÙ·È fiÙÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙ÂÈ Î·È Ë Ê˘Ï‹. ¡ÂÔÁÓ¿ ∞ÊÚÔ·ÌÂÚÈηÓÒÓ Â›Ó·È ÏÈÁfiÙÂÚÔ Èı·Ófi Ó· ·Ó·Ù‡ÍÔ˘Ó ‚·ÚÈ¿ ∞Ù¶ (19). ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ‚·ÚÈ¿˜ ∞Ù¶ Ô˘ ‰ÂÓ ‰ÈηÈÔÏÔÁÔ‡ÓÙ·Ó ·fi ÙË ¢∫, ‚Ú¤ıËΠfiÙÈ ˘‹Ú¯Â ÁÂÓÂÙÈ΋ ‚Ï¿‚Ë (7). ∏ Û‹„Ë ·fi Candida ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Û·Ó ¤Ó·˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ‚·ÚÈ¿˜ ∞Ù¶ (19,20), ¯ˆÚ›˜ ·˘Ùfi Ó· ¤¯ÂÈ ÂȂ‚·Èˆı› ·fi ¿ÏϘ ÂÚÁ·Û›Â˜ (21). ∞ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢-
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ı› Î·È fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÙËÓ ·Ó¿Ù˘ÍË ‹ ÚÔʇϷÍË ·fi ‚·ÚÈ¿ ∞Ù¶, fiÙ·Ó ·˘Ù¿ ¯ÔÚËÁÔ‡ÓÙ·È ÚÔÁÂÓÓËÙÈο ‹ ÌÂÙ·ÁÂÓÓËÙÈο ÁÈ· ÙË ıÂڷ›· Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (19-22). ¶ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ¤‰ÂÈÍ fiÙÈ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÌÂÙ·ÁÂÓÓËÙÈο ‰ÂÓ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙË Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· Ù˘ ∞Ù¶ (23). ¢ÂÓ ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ·Ô‰Â‰ÂÈÁ̤ÓÔ˜ ÙÚfiÔ˜ ÚÔʇϷ͢ ÙˆÓ ÓÂÔÁÓÒÓ ·fi ÙËÓ ÚÔÛ‚ÔÏ‹ ·fi ∞Ù¶. ∏ Û¯¤ÛË ÌÂٷ͇ ¢∫ Î·È Û˘¯ÓfiÙËÙ·˜ ∞Ù¶ ηıÈÛÙ¿ ۷ʤ˜ fiÙÈ Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜ ÚfiÏ˄˘ Ù˘ ·ÒÏÂÈ·˜ fiÚ·Û˘ ·fi ∞Ù¶ Â›Ó·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÚfiˆÚˆÓ ÁÂÓÓ‹ÛˆÓ. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ Î·È Ú·ÎÙÈÎÒÓ Ô˘ ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÛÙ·ıÂÚ‹ Î·È ÌË ÂÂÈÛԉȷ΋ ÔÚ›· ÛÙ· ÓÂÔÁÓ¿, ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ó· ÂÚÈÔÚ›˙ÂÙ·È Ë ÂÌÊ¿ÓÈÛË Ù˘ ∞Ù¶ ÛÙ· ÈÔ ÌÈÎÚ¿ Î·È ·ÓÒÚÈÌ· ÓÂÔÁÓ¿ (11,24). ∆¤ÙÔȘ Ú·ÎÙÈΤ˜ Â›Ó·È Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈ˙fiÓ˘, Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Î·È ÈÓ‰ÔÌÂı·Î›Ó˘ Î·È ¿ÏϘ ÌÈÎÚfiÙÂÚ˜ ·ÚÂÌ‚¿ÛÂȘ. ∏ Ê·ÚÌ·ÎÔÏÔÁÈ΋ ÚÔʇϷÍË ÁÈ· ∞Ù¶ ‚·Û›˙ÂÙ·È ÛÙËÓ ˘fiıÂÛË fiÙÈ Ë ÙÚ·˘Ì·ÙÈ΋ ‚Ï¿‚Ë ÙˆÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÈÎÒÓ ÙÚȯÔÂȉÈÎÒÓ ·ÁÁ›ˆÓ Â›Ó·È ÚˆÙÔÁÂÓÒ˜ ÔÍÂȉˆÙÈ΋. ∞fi ÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ, ȉȷ›ÙÂÚ· ¤¯ÂÈ ÌÂÏÂÙËı› Ë ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ ∂ ·fi ÔÏÏ¿ ΤÓÙÚ·, ¯ˆÚ›˜ Ó· ·Ô‰Âȯı› fiÙÈ ¤¯ÂÈ Î¿ÔÈ· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· (7). §›Á˜ ÂÚÁ·Û›Â˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÈÓÔÛÈÙfiÏË Î·È Ë D ÂÓÈÎÈÏÏ·Ì›ÓË ÂÏ·ÙÙÒÓÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶, ·ÏÏ¿ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ Î·È ÈÔ Ï‹ÚÂȘ ÌÂϤÙ˜ ÁÈ· Ó· ÂȂ‚·ÈˆıÔ‡Ó ·˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· (25,26). ∏ ÚÔʇϷÍË ·fi ÙÔ Êˆ˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› fiÙÈ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë ÙˆÓ ÙÚȯÔÂȉÒÓ, ‰ÂÓ ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ∞Ù¶ (27). ∏ ∞Ù¶ Êı¿ÓÂÈ ÙÔ ÚÔ-Ô˘‰ÈÎfi ÛÙ¿‰ÈÔ Î·Ù¿ ̤ÛÔ fiÚÔ Û ÌÂÙ·-ÂÌÌËÓÔÚÚÔ˚΋ ËÏÈΛ· ·ËÛ˘ 36 ‚‰ÔÌ¿‰ˆÓ Î·È ÔÙ¤ ÚÈÓ ÙËÓ 31Ë Â‚‰ÔÌ¿‰·. O Ô˘‰fi˜ Ù˘ ∞Ù¶ ¤¯ÂÈ ¤Ó·ÚÍË ÂÚ›Ô˘ 1 ‚‰ÔÌ¿‰· ·ÚÁfiÙÂÚ· Î·È Ì¤ÛË ËÏÈΛ· 37 ‚‰ÔÌ¿‰Â˜ Î·È ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÚÈÓ ÙȘ 32 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË Û‡ÏÏË„Ë (28). ∏ ¤Ó·ÚÍË Î·È Ù· ÁÂÁÔÓfiÙ· Ù˘ ∞Ù¶ Û˘Ì‚·›ÓÔ˘Ó Û ¯ÚÔÓÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ÌÂÙ·-ÂÌÌËÓÔÚÚÔ˚΋ ËÏÈΛ· Î·È fi¯È Ì ÙË ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ·. ∞˘Ùfi Û˘Ó¿ÁÂÙ·È fiÙÈ Ë ∞Ù¶ ÂÓÂÚÁÔÔÈÂ›Ù·È fiÙ·Ó Ô ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜ Êı¿ÛÂÈ ¤Ó·Ó ÔÚÈṲ̂ÓÔ ‚·ıÌfi ˆÚÈÌfiÙËÙ·˜ Î·È fi¯È fiÙ·Ó ÂÚ¿ÛÂÈ ¤Ó·˜ ÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ËÌÂÚÒÓ ‹ ‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙË ‚Ï¿‚Ë ÛÙ· ·Ó·Ù˘ÛÛfiÌÂÓ· ·ÁÁ›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞Ù¶ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ ÛÙÔ ÔÔ›Ô ‚Ú›ÛÎÂÙ·È Ë ¿ıËÛË. ™Ù· ÚÒÙ· 2
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ÛÙ¿‰È· ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Î·Ì›· ·Ú¤Ì‚·ÛË, ‰ÈfiÙÈ ÔÈ Èı·ÓfiÙËÙ˜ ·˘ÙfiÌ·Ù˘ ˘ÔÛÙÚÔÊ‹˜ Â›Ó·È Î·Ï¤˜ (5,7,8), fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙ· ÂÚÈÛÙ·ÙÈο Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ™ÙÔ ÔÚÈ·Îfi 3+ ÛÙ¿‰ÈÔ Î·È ÂÊfiÛÔÓ ÔÈ ‚Ï¿‚˜ ˘ÂÚ‚·›ÓÔ˘Ó Û ¤ÎÙ·ÛË ÙȘ 5 Û˘Ó¯›˜ ÒÚ˜ ‹ 8 ·Û˘Ó¯›˜ ÛÙË ˙ÒÓË π ‹ ππ, Û˘ÓÈÛÙ¿Ù·È Ë ¿ÌÂÛË (ÂÓÙfi˜ 72 ˆÚÒÓ) ÎÚ˘ÔËÍ›· ‹ ʈÙÔËÍ›· Ù˘ ·Ó¿ÁÁÂÈ·˜ ÂÚÈÔ¯‹˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ (7). ∏ ÎÚ˘ÔıÂڷ›· ÂÏ·ÙÙÒÓÂÈ ÙËÓ Ùˆ¯‹ ¤Î‚·ÛË ·fi 51,4% Û 31,1%. ∞Ó ‰ÂÓ Á›ÓÂÈ ıÂڷ›·, Û˘Ì‚·›ÓÂÈ ·ÔÎfiÏÏËÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Û ÂÚ›Ô˘ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (7,10). µ·ÚÈ¿ ∞Ù¶ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È ıÂڷ›· Â›Ó·È Ôχ ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ ÛÙ· ÓÂÔÁÓ¿ Ì ¢∫ >29 ‚‰ÔÌ¿‰Â˜, Ì ·ÔÙ¤ÏÂÛÌ· ÛÙȘ ∏¶∞ ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ˘Ô¯ÚˆÙÈÎfi ÔÊı·ÏÌÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ó· ·ÊÔÚÔ‡Ó ÌfiÓÔ Û ÓÂÔÁÓ¿ Ì ¢∫ <28 ‚‰ÔÌ¿‰Â˜ ‹ µ° <1500 g. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ˘‹ÚÍ·Ó ÌfiÓÔ 2 ÓÂÔÁÓ¿ Ì ¢∫ >29 ‚‰ÔÌ¿‰Â˜ Î·È ‚·ÚÈ¿ ∞Ù¶ Ô˘ ¯ÚÂÈ¿ÛÙËΠıÂڷ›· ηٿ ÙË µ ÂÚ›Ô‰Ô. °È· Ù· ÚfiˆÚ· Ì ¢∫ >28 ‚‰ÔÌ¿‰Â˜, ÔÊı·ÏÌÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Á›ÓÂÙ·È fiÙ·Ó ˘¿Ú¯Ô˘Ó ˘Ô„›Â˜ fiÙÈ ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ∞Ù¶ ηٿ ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÓÂÔÁÓÔÏfiÁÔ˘ (7). ∏ ·Ú·Ù‹ÚËÛË fiÙÈ ·Ú¿ ÙËÓ ¤ÁηÈÚË Â¤Ì‚·ÛË ÛÙÔ Ô˘‰ÈÎfi ÛÙ¿‰ÈÔ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÓÂÔÁÓÒÓ ı· ·Ú·Ì›ÓÔ˘Ó Ù˘ÊÏ¿, ¤¯ÂÈ ÚÔηϤÛÂÈ ÙËÓ ¤Ó·ÚÍË Ì›·˜ ÔÏ˘ÎÂÓÙÚÈ΋˜ ÌÂϤÙ˘, fiÔ˘ Ë ıÂڷ›· ·Ú¯›˙ÂÈ ÛÙÔ ÚÔ-Ô˘‰ÈÎfi ·ÓÙ› ÛÙÔ Ô˘‰ÈÎfi ÛÙ¿‰ÈÔ. OÈ ÚÔÛ¿ıÂȘ ‰È¿ÛˆÛ˘ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ ÌÂÙ¿ ÙËÓ ·ÔÎfiÏÏËÛË Â›Ó·È Û˘¯Ó¿ ·ÔÁÔËÙ¢ÙÈΤ˜ (7). ™ÙË ÌÂϤÙË Ì·˜, ÙËÓ ÂÚ›Ô‰Ô 1990-1994 ÙÔ 25% ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚·ÚÈ¿ ∞Ù¶ III-V ÛÙ·‰›Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÎÚ˘ÔËÍ›· ‹ Laser ¤Ó·ÓÙÈ ÙÔ˘ 68% Ù˘ ÂÚÈfi‰Ô˘ 1995-1999. ∏ ‰È·ÊÔÚ¿ ÛÙ· ÔÛÔÛÙ¿ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÛÙÔ fiÙÈ ÙËÓ ÚÒÙË ÂÚ›Ô‰Ô ÙÔ 30% ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚·ÚÈ¿ ∞Ù¶ ÂϤÁ¯ıËΠ̠ηı˘ÛÙ¤ÚËÛË, ·ÊÂÙ¤ÚÔ˘ ÙË ‰Â‡ÙÂÚË ÂÚ›Ô‰Ô ÂÚÈÛÛfiÙÂÚ· ÓÂÔÁÓ¿ ›¯·Ó ∞Ù¶ III+. µ·ÚÈ¿ ∞Ù¶ Ô˘ ÚÔηÏ› Ù‡ÊψÛË ··ÓÙ¿ Û ÔÛÔÛÙfi 2-11% ÙˆÓ ÂȂȈۿÓÙˆÓ ÓÂÔÁÓÒÓ Ì µ° <1000 g. ¶ÔÛÔÛÙfi 50% ÙˆÓ ÂȂȈۿÓÙˆÓ ·fi ‚·ÚÈ¿ ∞Ù¶ Ì هÊψÛË ¤¯ÂÈ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË (8). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ˘‹ÚÍ 1 Ù˘ÊÏfi ·È‰› Ì µ° ≤1000 g ηٿ ÙËÓ ÂÚ›Ô‰Ô ∞ (1,55% › ÙˆÓ ÂȂȈۿÓÙˆÓ) Î·È 3 Ì µ° ≤1000 g ηٿ ÙË µ ÂÚ›Ô‰Ô (2,7% › ÙˆÓ ÂȂȈۿÓÙˆÓ). ∫·È Ù· 3 Ù˘ÊÏ¿ ·È‰È¿ Ù˘ µ ÂÚÈfi‰Ô˘ ¤¯Ô˘Ó ‚·ÚÈ¿ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ÔÊÂÈÏfiÌÂÓË Û ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· ‹ ÂÁÎÂÊ·ÏÈ΋ ·ÙÚÔÊ›·. O ÔÊı·ÏÌÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·È‰ÈÒÓ Ì ∞Ù¶ Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È ÂÚÈÔ‰Èο ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË
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·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ, fiˆ˜ Ë ·ÔÎfiÏÏËÛË ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Ë ˘„ËÏ‹ Ì˘ˆ›·, Ô ÛÙÚ·‚ÈÛÌfi˜, Ë ·Ì‚Ï˘ˆ›· Î.¿. (7). ¶·Ú¿ ÙȘ ÌÂÁ¿Ï˜ ÚÔfi‰Ô˘˜ Ô˘ ¤¯Ô˘Ó ÛËÌÂȈı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Î·È ıÂڷ›· Ù˘ ∞Ù¶, ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ÔÏÏ¿ Ô˘ Ú¤ÂÈ Ó· ÌÂÏÂÙËıÔ‡Ó. µÈ‚ÏÈÔÁÚ·Ê›· 1. Terry T. Extreme prematurity and fibroblastic overgrowth of persistent vascular sheath behind each crystalline lens. Am J Ophthalmol 1942;25:203-204. 2. Committee for the Classification of Retinopathy of Prematurity. An international classification of retinopathy of prematurity. Arch Ophthalmol 1984;102:1130-1134. 3. Phelps DL. Retinopathy of prematurity. Pediatr Rev 1995;16:50-56. 4. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity. Preliminary results. Arch Ophthalmol 1988;106:471-479. 5. Hussain N, Clive J, Bhandari V. Current incidence of retinopathy of prematurity, 1989-1997. Pediatrics 1999; 104:e26. 6. Valentine PH, Jackson JC, Kalina RE, Woodrum DE. Increased survival of low birth weight infants: impact on the incidence of retinopathy of prematurity. Pediatrics 1989;84:442-445. 7. Phelps DL. Using new information in retinopathy of prematurity. In: Hansen T, McIntosh N, eds. Current topics in neonatology. 3rd ed. WB Saunders; 1999. p. 174-199. 8. Phelps DL. Retinopathy of prematurity. Pediatr Clin North Am 1993;40:705-714. 9. Cryotherapy for Retinopathy of Prematurity Cooperative Group: Multicenter trial of cryotherapy for retinopathy of prematurity 3ó year out-come-structure and function. Arch Ophthalmol 1993;111:339-344. 10. Bullard SR, Donahue SP, Feman SS, Sinatra RB, Walsh WF. The decreasing incidence and severity of retinopathy of prematurity. J AAPOS 1999;3:46-49. 11. Gehrs KM, Barnes GH, Rosenthal WN, Lee S. The infant with threshold retinopathy of prematurity in the 1990s. Invest Ophthalmol Vis Sci 1997;38:S746. 12. Takahashi A, Majima A, Suzuki C. The association between retinopathy of prematurity and chronic general complications. Clin Ophthalmol 1995;49:935-938. 13. Fledelius HC. Central nervous system damage and retinopathy of prematurity - an ophthalmic follow-up of prematures born in 1982-84. Acta Paediatr 1996;85:1186-1191. 14. Gibson DL, Sheps SB, Uh SH, Schechter MT, McCormick AQ. Retinopathy of prematurity-induced blindness: birth weight-specific survival and the new epidemic. Pediatrics 1990;86:405-412. 15. Tin W, Milligan DW, Pennefather P, Hey E. Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation. Arch Dis Child Fetal Neonatal Ed 2001;84:F106-110. 16. Bancalari E, Flynn J, Goldberg RN, Bawol R, Cassady J,
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∞˘ÙfiÌ·ÙË ‰È¿Ï˘ÛË ¯ÔÏÔÏ›ıÔ˘ Û ÚfiˆÚÔ ÓÂÔÁÓfi ∞. ∞. ∫·Ú·Ù˙¿1, µ. ¡. ¶·‡ÏÔ˘1, Ã. ¶. ∫·ÏÔÁÂÚÔÔ‡ÏÔ˘2, °. N. ª¿ÚÎÔ˘1, ∂. I. ∆ÛÒÙ·2, ™. ¶. ª·ÓÙ·Áfi˜1
Spontaneous resolution of cholelithiasis in a premature neonate A. A. Karatza1, V. N. Pavlou1, C. P. Kalogeropoulou2, G. N. Markou1, I. I. Tsota2, S. P. Mantagos1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡ 28 ‚‰ÔÌ¿‰ˆÓ Ì ÏÈı›·ÛË ¯ÔÏˉfi¯Ô˘ ·ÛÙ˘. ∆Ô ÓÂÔÁÓfi ÂÌÊ¿ÓÈÛ ·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· ÛË„·ÈÌ›·˜ Î·È ÁÂÓÈÎÂ˘Ì¤Ó˘ Ì˘ÎËÙ›·Û˘ ·fi Candida albicans. ÃÚÂÈ¿ÛÙËΠÌ˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ ÁÈ· 40 Ë̤Ú˜ Î·È ¤Ï·‚ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ÙÔ ›‰ÈÔ ‰È¿ÛÙËÌ·. ∆Ô 11Ô 24ˆÚÔ ÂÌÊ¿ÓÈÛ ·ÔÊÚ·ÎÙÈÎfi ›ÎÙÂÚÔ Î·È ÙÔ 18Ô 24ˆÚÔ ·‡ÍËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Ì ̤ÁÈÛÙ˜ ÙÈ̤˜ ÙÔ 29Ô 24ˆÚÔ ˙ˆ‹˜, Ô˘ Û˘Ì›ÙÂÈ Ì ÙËÓ ¤Ó·ÚÍË Û›ÙÈÛ˘. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ ÎÔÈÏ›·˜, ¤Ó·Ó Ì‹Ó· ·ÚÁfiÙÂÚ·, ·Ó¤‰ÂÈÍ ˘ÂÚ˯ÔÁÂÓ¤˜ ÌfiÚʈ̷ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË (¯ÔÏfiÏÈıÔ˜), ¯ˆÚ›˜ Â˘Ú‹Ì·Ù· ·fi Ù· ÏÔÈ¿ fiÚÁ·Ó·. ∆Ô ÓÂÔÁÓfi ·Ú¤ÌÂÈÓ ·Û˘Ìو̷ÙÈÎfi Î·È ÂÍ‹Ïı ·fi ÙË ÌÔÓ¿‰· ÙÔ 100fi 24ˆÚÔ ˙ˆ‹˜, Ì ‹È· ·˘ÍË̤Ó˜ ÙÈ̤˜ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È ¯ÔÏÂÚ˘ıÚ›Ó˘. O ‚‰ÔÌ·‰È·›Ô˜ ·ӤÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈÎfi Ë·ÙÈÎfi ·Ú¤Á¯˘Ì· Î·È ·Ô˘Û›· Ï›ıÔ˘ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË ‹ ÛÙ· ¯ÔÏËÊfiÚ· ÙÔ 108Ô 24ˆÚÔ ˙ˆ‹˜. ∂Âȉ‹ ÔÈ ÓÂÔÁÓÈÎÔ› ¯ÔÏfiÏÈıÔÈ ¤¯Ô˘Ó ηÏÔ‹ıË ÔÚ›· Î·È Û˘¯Ó¿ ‰È·Ï‡ÔÓÙ·È ·˘ÙfiÌ·Ù·, ÛÙ· ÓÂÔÁÓ¿ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ·Û˘Ìو̷ÙÈο Û˘ÓÈÛÙ¿Ù·È Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È Ù·ÎÙÈ΋ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË.
Abstract: The case is presented of a neonate born prematurely at 28 weeks of gestation with cholelithiasis. The infant had repeated episodes of sepsis and generalized infection due to Candida albicans and required mechanical ventilation and parenteral nutrition for 40 consecutive days. Cholestasis was noted on day 11 and elevation of the hepatic enzymes on day 18, with maximum concentrations on day 29 when oral feeds were initiated. Ultrasonography of the upper abdomen showed an echodense mass within the gallbladder (gallstone) one month later, with no pathological findings in any other organs. The neonate remained asymptomatic and was discharged on day 100 with slightly increased serum levels hepatic enzymes and bilirubin. Weekly follow-up showed normal appearance of the liver with no stones in the gallbladder or biliary tree at 108 days of life. As neonatal gallstones follow a benign course and often dissolve spontaneously, conservative management with periodic ultrasonographic followup of asymptomatic neonates is suggested.
§¤ÍÂȘ ÎÏÂȉȿ: ¯ÔÏÔÏÈı›·ÛË, ÓÂÔÁÓfi, ÚÔˆÚfiÙËÙ·.
Key words: cholelithiasis, neonate, prematurity.
∂ÈÛ·ÁˆÁ‹ ∏ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È Û¿ÓÈÔ Â‡ÚËÌ· ÛÙ· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ıˆÚÔ‡ÓÙ·È Ë ÚÔˆÚfiÙËÙ·, Ë Û‹„Ë, Ë ·ÈÌfiÏ˘ÛË, Ë ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ÙÔ˘ ÂÈÏÂÔ‡ Î·È Ë ¯ÚfiÓÈ· ıÂڷ›· Ì ‰ÈÔ˘ÚËÙÈο. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·Û˘Ìو̷ÙÈÎÔ‡ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡ Ì ÏÈı›·ÛË ¯ÔÏˉfi¯Ô˘ ·ÛÙ˘, ÛÙÔ ÔÔ›Ô
·Ú·ÙËÚ‹ıËΠ·˘ÙfiÌ·ÙË ‰È¿Ï˘ÛË ÙÔ˘ ¯ÔÏÔÏ›ıÔ˘ Î·È ·Ô˘Û›· ÙÔ˘ ÛÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ·ӤÏÂÁ¯Ô ÛÙÔÓ 3Ô Ì‹Ó· Ù˘ ˙ˆ‹˜.
1 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ 2 ∫ÏÈÓÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÎÙÈÓÔÏÔÁ›·˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ¶·ÙÚÒÓ
1 Department of Paediatrics, Neonatal Intensive Care Unit, University of Patras 2 Department of Radiology, University of Patras
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¡ÂÔÁÓfi ı‹Ï˘, ËÏÈΛ·˜ ·ËÛ˘ 28 ‚‰ÔÌ¿‰ˆÓ, Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 1020 g, ÁÂÓÓ‹ıËΠ·fi ÌËÙ¤Ú· ÚˆÙÔÙfiÎÔ ËÏÈΛ·˜ 19 ÂÙÒÓ, ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi
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Î·È ·˘ÙfiÌ·ÙË Ú‹ÍË ˘Ì¤ÓˆÓ ‰È¿ÚÎÂÈ·˜ 2 ˆÚÒÓ. ∏ ÌËÙ¤Ú· ÂÌÊ¿ÓÈÛÂ Û˘Û¿ÛÂȘ 5 Ë̤Ú˜ ÚÈÓ ÙÔÓ ÙÔÎÂÙfi. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ù˘ ¯ÔÚËÁ‹ıËΠÙÔÎfiÏ˘ÛË Ì ÈÛÔÍÔ˘Ú›ÓË, 2 ‰fiÛÂȘ Betamethasone Î·È Cefuroxime acetil ÏfiÁˆ Ï¢ÎÔ΢ÙÙ¿ÚˆÛ˘ Î·È ıÂÙÈ΋˜ CRP. ∆Ô ·ÌÓÈ·Îfi ˘ÁÚfi ‹Ù·Ó ÂÏ·ÊÚ¿ ίڈṲ̂ÓÔ Î·È ÙÔ Apgar score ‹Ù·Ó 8 ÛÙÔ 1Ô Î·È 5Ô ÏÂÙfi. ∞̤ۈ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙË ª∂¡, ¯ÚÂÈ¿ÛÙËΠÌ˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Î·È ¯ÔÚËÁ‹ıËÎ·Ó 2 ‰fiÛÂȘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∆¤ıËΠ۠·ÁˆÁ‹ Ì Ampicilline Î·È Tobramycin. ∂Âȉ‹ ÙÔ 3Ô 24ˆÚÔ ·ÚÔ˘Û›·Û ‰È·Ù·Ú·¯¤˜ ÛÙË ıÂÚÌÔÚÚ‡ıÌÈÛË, ˘ÂÚÁÏ˘Î·ÈÌ›· Î·È ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, Ë ·ÁˆÁ‹ ÙÚÔÔÔÈ‹ıËΠ۠Aztreonam, Piperacillin-Tazobactam Î·È Clindamycin. ∆Ô 5Ô 24ˆÚÔ ‰È·ÈÛÙÒıËΠÔÊı·ÏÌ›· Î·È ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÂÎÎڛ̷ÙÔ˜ ·Ó·Ù‡¯ıËΠCandida albicans. ∆Ô 9Ô 24ˆÚÔ ÂÌÊ¿ÓÈÛ ˘fiÛÎÏËÚË ÎÔÈÏ›· Ì ‰È·ÁÚ·Ê‹ ÂÓÙÂÚÈÎÒÓ ÂϛΈÓ. ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ïԛ̈͢ Î·È Ë ·ÁˆÁ‹ ÙÚÔÔÔÈ‹ıËΠ۠Meropenem Î·È Teicoplanin. ∆Ô 11Ô 24ˆÚÔ ÂÌÊ¿ÓÈÛ ·ÔÊÚ·ÎÙÈÎfi ›ÎÙÂÚÔ (¯ÔÏÂÚ˘ıÚ›ÓË ÔÏÈ΋ 11,4 mg/dl Î·È ¿ÌÂÛË 6,1 mg/dl). øÛÙfiÛÔ, ÂÂȉ‹ ÛÙËÓ ˘ÂÚË‚È΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ Î·È ÙÚ·¯ÂÈÔۈϋӷ ·ÔÌÔÓÒıËΠCandida albicans, ÂÓÒ Ë Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‹Ù·Ó ÛÙ›ڷ, ÛÙËÓ ·ÁˆÁ‹ ÚÔÛÙ¤ıËΠÏÈÔÛˆÌÈ΋ ·ÌÊÔÙÂÚÈΛÓË µ. ¢‡Ô Ë̤Ú˜ ·ÚÁfiÙÂÚ· ·ÔÌÔÓÒıËΠCandida albicans, ÙfiÛÔ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ fiÛÔ Î·È ÛÙËÓ ˘ÂÚË‚È΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, ÔfiÙ ÚÔÛÙ¤ıËÎÂ Î·È Fluconazole. ∏ ‰ÈÏ‹ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁ‹ıËΠÁÈ· 30 Ë̤Ú˜. O ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ 10Ô 24ˆÚÔ ˙ˆ‹˜ ·Ó¤‰ÂÈÍ ˘ÔÂÂÓ‰˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· 1Ô˘ ‚·ıÌÔ‡ ·ÚÈÛÙÂÚ¿. ∂·Ó·ÏËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ 18Ô 24ˆÚÔ ¤‰ÂÈÍ ˘ÔÂÂÓ‰˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· 2Ô˘ ‚·ıÌÔ‡ ¿Ìʈ, fiˆ˜ Î·È ‰‡Ô ˘fi˘ÎÓÔ˘˜ Û¯ËÌ·ÙÈÛÌÔ‡˜ Ì ˯ÔÁÂÓ‹ ¿Ïˆ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ı·Ï¿ÌÔ˘ (Èı·Ó¿ Ì˘ÎËÙÈ·ÛÈο ·ÔÛÙËÌ¿ÙÈ·). ∂›Û˘, ·fi ÙËÓ ›‰È· Ë̤ڷ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, Ì ̤ÁÈÛÙ˜ ÙÈ̤˜ ÙÔ 29Ô 24ˆÚÔ ˙ˆ‹˜ (SGOT: 760 U/L, SGPT: 472 U/L, LDH: 664 U/L), ÔfiÙ ¿Ú¯ÈÛÂ Î·È Ë Û›ÙÈÛË. ∆Ô 1Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜-‹·ÙÔ˜, ÙÔ ÔÔ›Ô ¤ÁÈÓ ÙË 18Ë Ë̤ڷ ˙ˆ‹˜, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. ¢ÂÓ ˘‹Ú¯Â ·ÛÎËÙÈÎfi ˘ÁÚfi, “Ï¿ÛË” ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË ‹ ‰È¿Ù·ÛË ·˘Ù‹˜. ∆Ô 24Ô 24ˆÚÔ ˙ˆ‹˜ ÂÌÊ¿ÓÈÛ ÂÎ Ó¤Ô˘ ˆ¯ÚÔÁ·È҉˜ ¯ÚÒÌ·, ‰È¿Ù·ÛË ÎÔÈÏ›·˜ Ì ‰È·ÁÚ·Ê‹ ÂÓÙÂÚÈÎÒÓ ÂÏ›ÎˆÓ Î·È ·‡ÍËÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ·Ó·ÁÎÒÓ. ŒÙÛÈ, ÛÙÔ ‰ÈÏfi ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎfi Û¯‹Ì· ÚÔÛÙ¤ıËÎ·Ó Vancomycin Î·È Netilmicin. ÃÚÂÈ¿ÛÙËΠ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÁÈ· 40
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Ë̤Ú˜, ‰È¿ÛÙËÌ· ηٿ ÙÔ ÔÔ›Ô ¤Ï·‚ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹, ηıÒ˜ Î·È ÔÏϷϤ˜ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ (13 Û˘ÓÔÏÈο). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ¯ÔÏfiÛÙ·Û˘ ÂÚȤϷ‚Â Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÈÔÁÂÓ›˜ Ë·Ù›Ùȉ˜, ·ÌÈÓÔÍÂfiÁÚ·ÌÌ· ÔÚÔ‡ Î·È Ô‡ÚˆÓ, ·1-·ÓÙÈıÚ˘„›ÓË, ÙÂÛ٠ȉÚÒÙ·, ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Î·È mantoux, Ù· ÔÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. O ¤ÏÂÁ¯Ô˜ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‹Ù·Ó Û˘Ì‚·Ùfi˜ Ì ˘Ôı˘ÚÂÔÂȉÈÛÌfi (∆4: 6,6 Ìg/dl, ∆3: 0,90 ng/ml, TSH: 0,80 mIU/ml), Ô ÔÔ›Ô˜ ·Ô‰fiıËΠÛÙËÓ ÚÔˆÚfiÙËÙ·, ÛÙË Ïԛ̈ÍË Î·È ÙË ÁÂÓÈÎfiÙÂÚ· ÂËÚ·Ṳ̂ÓË Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ÙÔ 72Ô 24ˆÚÔ ·Ó¤‰ÂÈÍ ˘ÂÚ˯ÔÁÂÓ¤˜ ÌfiÚʈ̷ ÂÓÙfi˜ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ‰È·ÛÙ¿ÛÂˆÓ 1,0 x 0,5 cm, ¯ˆÚ›˜ Â˘Ú‹Ì·Ù· ·fi Ù· ÏÔÈ¿ fiÚÁ·Ó· Ù˘ ¿Óˆ ÎÔÈÏ›·˜ (∂ÈÎfiÓ· 1). ¢ÂÓ Û˘Ó˘‹Ú¯Â ÓÂÊÚÔÏÈı›·ÛË Î·È Ô Ï›ıÔ˜ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ‰ÂÓ ‹Ù·Ó ÔÚ·Ùfi˜ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜. ∂·Ó·ÏËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ 92Ô 24ˆÚÔ ¤‰ÂÈÍ ‰È¿Ù·ÛË ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ, ¯ˆÚ›˜ Ó· ÌÔÚ› Ó· ·Ó·‰Âȯı› ÎÒÏ˘Ì· ÛÙÔÓ ¯ÔÏˉfi¯Ô fiÚÔ (∂ÈÎfiÓ· 2). ∂·ÓÂϤÁ¯ıËÎÂ Ô ¯ÔÏfiÏÈıÔ˜, fiˆ˜ Î·È Ë ˘ÎÓ‹ ¯ÔÏ‹ ÂÓÙfi˜ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜. ∏ Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· (HIDA) ·Ó¤‰ÂÈÍ ÈηÓÔÔÈËÙÈ΋ ÚfiÛÏË„Ë ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ·fi ÙÔ ‹·Ú Î·È Î·ı˘ÛÙÂÚË̤ÓË ·¤ÎÎÚÈÛ‹ ÙÔ˘ ÛÙÔ ¤ÓÙÂÚÔ, ÂÓÒ Ë ¯ÔÏˉfi¯Ô˜ ·ÛÙË ‰ÂÓ ·ÂÈÎÔÓ›ÛÙËΠ·ÎfiÌ· Î·È ÛÙȘ ηı˘ÛÙÂÚË̤Ó˜ Ï‹„ÂȘ (ÌÂÙ¿ ·fi 8 ÒÚ˜) (∂ÈÎfiÓ· 3). ∆Ô ÓÂÔÁÓfi ·Ú¤ÌÂÈÓ ·Û˘Ìو̷ÙÈÎfi Î·È ÂÍ‹Ïı ·fi ÙË ÌÔÓ¿‰· ÙÔ 100fi 24ˆÚÔ ˙ˆ‹˜, Ì ÂÏ·ÊÚ¿ ·˘ÍË̤Ó˜ ÙÈ̤˜ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ (SGOT: 220 U/L, SGPT: 132 U/L, ÁGT: 104 U/L, ALP: 1077 U/L), ¯ÔÏÂÚ˘ıÚ›Ó˘ (ÔÏÈ΋: 6,31 mg/dl Î·È ¿ÌÂÛË: 3,32 mg/dl) Î·È Ê˘ÛÈÔÏÔÁÈ΋ ËÎÙÈÎfiÙËÙ· (P∆: 14,4’’, PTT: 40,1’’). O ·ӤÏÂÁ¯Ô˜, Ì›· ‚‰ÔÌ¿‰· ·ÚÁfiÙÂÚ·, ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈÎfi Ë·ÙÈÎfi ·Ú¤Á¯˘Ì·, ·Ô˘Û›· Ï›ıÔ˘ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË ‹ ÛÙ· ¯ÔÏËÊfiÚ·, ÂÓÒ ÔÈ ÙÈ̤˜ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ‰È·ÙËÚ‹ıËÎ·Ó Û ·ÚfiÌÔÈ· ›‰· Ì ÂΛӷ Ù˘ ÂÍfi‰Ô˘ ·fi ÙË ÌÔÓ¿‰· (∂ÈÎfiÓ· 4). OÈ ÁÔÓ›˜ ·ÚÓ‹ıËÎ·Ó ‰È·ÁÓˆÛÙÈ΋ ‚ÈÔ„›· ‹·ÙÔ˜. ™˘˙‹ÙËÛË ™˘ÁÎÂÎÚÈ̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÔÏÔÏÈı›·Û˘ ÛÙ· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË (1,2). ÃÔÏfiÏÈıÔÈ ·Ú·ÙËÚÔ‡ÓÙ·È Û˘ÓËı¤ÛÙÂÚ· ÛÙ· ¿ÚÚˆÛÙ·, ÚfiˆÚ· ÓÂÔÁÓ¿ Ô˘ ‰È·Ó‡Ô˘Ó ÂÚÈfi‰Ô˘˜ ·Ú·ÙÂٷ̤Ó˘ ÓËÛÙ›·˜, Ì ·ÔÙ¤ÏÂÛÌ· ·ÊÂÓfi˜ ÌÂÓ Ó· ÌËÓ ‰ÈÂÁ›ÚÂÙ·È Ë Û˘ÛÙ·ÏÙÈÎfiÙËÙ· Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙ˘ ÏfiÁˆ ¤ÏÏÂȄ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È ·ÊÂÙ¤ÚÔ˘ Ó· ˘ÔÛÙËÚ›˙ÔÓÙ·È ÌÂ
¶·È‰È·ÙÚÈ΋ 2003;66:311-315
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∂ÈÎfiÓ· 1 (·, ‚). ÀÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ ÎÔÈÏ›·˜ (72Ô 24ˆÚÔ). ∂ÈÌ‹Î˘ ÙÔÌ‹ ÛÙÔ Â›Â‰Ô Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜. ∞Ó·ÁÓˆÚ›˙ÂÙ·È ˘ÂÚ˯ÔÁÂÓ‹˜ ¯ÔÏfiÏÈıÔ˜ (‚¤ÏÔ˜) ÂÈÌ‹ÎÔ˘˜ ‰È·Ì¤ÙÚÔ˘ 1 cm Ô˘ ‰ËÌÈÔ˘ÚÁ› ·ÎÔ˘ÛÙÈ΋ ÛÎÈ¿.
∂ÈÎfiÓ· 2. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ ÎÔÈÏ›·˜ (92Ô 24ˆÚÔ). §›ıÔ˜ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË Î·È ‰È¿Ù·ÛË ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ (‚¤ÏÔ˜).
ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ÁÈ· ÌÂÁ¿Ï· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ ¯ÔÏfiÛÙ·Û˘ Ô˘ ÔÊ›ÏÂÙ·È Û ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Â›Ó·È ¿ÁÓˆÛÙË, Èı·Ófiٷٷ fï˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. Œ¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Ë ·ÓˆÚÈÌfiÙËÙ· Ù˘ ÂÓÙÂÚÔË·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ ÙˆÓ ÚÔÒÚˆÓ, Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÚÌÔÓÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ô˘ Û˘Ó¿ÁÂÙ·È Ë ·Ú·ÙÂٷ̤ÓË ÓËÛÙ›·, Ô Èı·Ófi˜ ÙÔÍÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ÙˆÓ ·ÌÈÓÔͤˆÓ Î·È Ë ¤ÏÏÂÈ„Ë Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ··Ú·›ÙËÙˆÓ Û˘ÛÙ·ÙÈÎÒÓ ·fi ÙËÓ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ (1). ™˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‹·ÙÔ˜, fiˆ˜ ·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· Û‹„˘, ¤ÎıÂÛË Û ÙÔÍÈο Ê¿Ú̷η Î·È ÂÂÈÛfi‰È· ˘fiÙ·Û˘ ‹ shock (2). ∂ÓÙÔ‡ÙÔȘ, Ë ¯ÔÏfiÛÙ·ÛË ·fi ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ·Ú·Ì¤ÓÂÈ ‰È¿ÁÓˆÛË ÂÍ ·ÔÎÏÂÈÛÌÔ‡ Î·È Ù· ÚÔۂ‚ÏË̤ӷ ÓÂÔÁÓ¿ Ú¤ÂÈ Ó· ‰ÈÂÚ¢ÓÒÓÙ·È ÁÈ· Ù˘¯fiÓ ‡·ÚÍË
ıÂڷ‡ÛÈÌˆÓ ·ÈÙ›ˆÓ ¯ÔÏfiÛÙ·Û˘. OÈ Û˘¯Ó¤˜ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜, ÔÈ Ôԛ˜ Û˘Ó¿ÁÔÓÙ·È ·˘ÍË̤ÓÔ ÊÔÚÙ›Ô ¯ÔÏÂÚ˘ıÚ›Ó˘ (3), ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ·ı‹ÛÂȘ ÙÔ˘ ÂÈÏÂÔ‡ (2,4), Ë Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ›· Ì ÊÔ˘ÚÔÛÂÌ›‰Ë (5), fiˆ˜ Î·È Ë ·Ê˘‰¿ÙˆÛË Î·È Ë Û˘Ó‡·ÚÍË Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙˆÓ ¯ÔÏËÊfiÚˆÓ (4), ¤¯Ô˘Ó Û˘Ó‰˘·ÛÙ› ›Û˘ Ì ·˘ÍË̤ÓË Â›ÙˆÛË ÓÂÔÁÓÈ΋˜ ¯ÔÏfiÛÙ·Û˘ Î·È ¯ÔÏÔÏÈı›·Û˘. ∏ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È Û˘ÓËı¤ÛÙÂÚË ÛÙ· ¿ÚÚÂÓ· Û ۯ¤ÛË Ì ٷ ı‹Ï· ÓÂÔÁÓ¿ Î·È Û˘¯Ó¿ ÌÔÚ› Ó· ÌË Û˘Óԉ‡ÂÙ·È ·fi οÔÈÔÓ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ (4). ∆Ô ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ÂÌÊ¿ÓÈÛ ·ÚÎÂÙÔ‡˜ ·fi ÙÔ˘˜ ÚÔ·Ó·ÊÂÚı¤ÓÙ˜ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ·Ó¿Ù˘ÍË ¯ÔÏfiÛÙ·Û˘, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ıÂڷ›·˜ Ì ·ÌÊÔÙÂÚÈΛÓË µ, Ë ÔÔ›· ¤¯ÂÈ ‰˘ÓËÙÈο ÙÔÍÈ΋ ‰Ú¿ÛË ÛÙËÓ ÂÎÎÚÈÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‹·ÙÔ˜ (6). Œ¯Ô˘Ó ÂÚÈÁÚ·Ê› Û¿ÓȘ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ ÌÂ Ì˘ÎËÙ›·ÛË ·fi Candida Î·È ·ÔÊÚ·ÎÙÈÎfi ›ÎÙÂÚÔ, ÔÊÂÈÏfiÌÂÓÔ Û ·fiÊÚ·ÍË ÙˆÓ ¯ÔÏËÊfiÚˆÓ ·fi Ì˘Î‹ÏÈ· (7). ∞˘Ùfi ‰ÂÓ ÈÛ¯‡ÂÈ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ‰ÂÓ ·Ó¤‰ÂÈÍ ·ıÔÏÔÁ›· ·fi ÙÔ ‹·Ú ‹ Ù· ¯ÔÏËÊfiÚ· ÛÙË Ê¿ÛË Ù˘ ÂÓÂÚÁ‹˜ ηÓÙÈÓÙ›·Û˘. ∏ ÓÂÔÁÓÈ΋ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È Û¿ÓÈÔ ÓfiÛËÌ·. ∂ÓÙÔ‡ÙÔȘ, Ë ÁÂӛ΢ÛË Ù˘ ¯Ú‹Û˘ ÙˆÓ ˘ÂÚ‹¯ˆÓ ¤¯ÂÈ ·˘Í‹ÛÂÈ ÙËÓ ·Ó›¯ÓÂ˘Û‹ Ù˘, ·ÎfiÌ· Î·È Û ·Û˘Ìو̷ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ (8). OÈ Ï›ıÔÈ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ˆ˜ Ù˘¯·›Ô ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ‡ÚËÌ· Û ·ÓıÚÒÈÓ· ¤Ì‚Ú˘· Î·È Û˘Ó‹ıˆ˜ ÂÍ·Ê·Ó›˙ÔÓÙ·È ¯ˆÚ›˜ ıÂڷ›· (9). ¶·ÚfiÌÔÈ· Â›Ó·È Ë Ê˘ÛÈ΋ ÈÛÙÔÚ›· Î·È ÙˆÓ ÓÂÔÁÓÈÎÒÓ ¯ÔÏÔÏ›ıˆÓ, ÔÈ ÔÔ›ÔÈ ÁÂÓÈο ¤¯Ô˘Ó ηÏÔ‹ıË ÔÚ›· Î·È Û˘¯Ó¿ ‰È·Ï‡ÔÓÙ·È ·˘ÙfiÌ·Ù· (4,10,11). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ù· ÓÂÔÁÓ¿ ·Ú·Ì¤ÓÔ˘Ó
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∂ÈÎfiÓ· 3 (·, ‚). ƒ·‰ÈÔ˚ÛÔÙÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· Ì Tc-99m Mebrofenin. ·) ∫·Ù¿ Ù· ÚÒÙ· 30 ÏÂÙ¿ ·Ú·ÙËÚÂ›Ù·È ÈηÓÔÔÈËÙÈ΋ ÚfiÛÏË„Ë ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ·fi ÙÔ ‹·Ú. ‚) §‹„ÂȘ 75 ÏÂÙ¿, 4 Î·È 8 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË. ™ËÌÂÈÒıËΠηı˘ÛÙÂÚË̤ÓË ·¤ÎÎÚÈÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Ì ·Ó›¯Ó¢ÛË Ú·‰ÈÔÛËÌ·Ṳ̂Ó˘ ¯ÔÏ‹˜ ÛÙȘ ÂÓÙÂÚÈΤ˜ ¤ÏÈΘ 4 ÒÚ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË (οو ·ÚÈÛÙÂÚ¿). ∏ ¯ÔÏˉfi¯Ô˜ ·ÛÙË ‰ÂÓ ·ÂÈÎÔÓ›ÛÙËΠÛÙȘ ηı˘ÛÙÂÚË̤Ó˜ Ï‹„ÂȘ ÌÂÙ¿ ·fi 8 ÒÚ˜ (οو ‰ÂÍÈ¿).
∂ÈÎfiÓ· 4. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ ÎÔÈÏ›·˜ (108Ô 24ˆÚÔ). ∏ ¯ÔÏˉfi¯Ô˜ ·ÛÙË (‚¤ÏÔ˜) ÂϤÁ¯ÂÙ·È ÎÂÓ‹ Ï›ıÔ˘.
·Û˘Ìو̷ÙÈο, Û˘ÓÈÛÙ¿Ù·È Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È Ù·ÎÙÈÎfi˜ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ (11). ¶·Ú’ fiÏ· ·˘Ù¿, ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÂÓ¿ ÁÈ· ÂΉ‹ÏˆÛË Ïԛ̈͢, Ï‹ÚÔ˘˜ ·fiÊڷ͢ ‹ ÚÔԉ¢ÙÈ΋˜ Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. À¿Ú¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÂÌÂÈÚ›· fiÛÔÓ ·ÊÔÚ¿ ÛÙË ¯Ú‹ÛË ÙÔ˘ Ô˘ÚÛÔ‰ÂÔ͢¯ÔÏÈÎÔ‡ ÔͤԘ ÛÙ· ÓÂÔÁÓ¿, ÂÓÒ o ÚfiÏÔ˜ ÙÔ˘ ÛÙË ÓÂÔÁÓÈ΋ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È ·ÌÊ›‚ÔÏÔ˜ (12,13). OÈ Û˘Ìو̷ÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¯ÔÏÔÏÈı›·Û˘ Î·È ¯ÔÏˉԯÔÏÈı›·Û˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÌÂıfi‰Ô˘˜ ‹ Ì ÌÂıfi‰Ô˘˜ ÂÂÌ‚·ÙÈ΋˜ ·ÎÙÈÓÔÏÔÁ›·˜ (4,10,14,15). µÈ‚ÏÈÔÁÚ·Ê›· 1. Farrell MK, Balistreri WF. Parenteral nutrition and hepatobiliary dysfunction. Clin Perinatol 1986;13:197-212.
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2. McEvoy CF, Suchy FJ. Biliary tract disease in children. Pediatr Clin North Am 1996;43:75-98. 3. Jeffrey I, Lund RJ, Whitelaw A. Cholelithiasis in a preterm infant. Pediatr Pathol 1984;2:207-213. 4. St-Vil D, Yazbeck S, Luks FI, Hancock BJ, Filiatrault D, Youssef S. Cholelithiasis in newborns and infants. J Pediatr Surg 1992;27:1305-1307. 5. Blickman JG, Herrin JT, Cleveland RH, Jaramillo D. Coexisting nephrolithiasis and cholelithiasis in premature infants. Pediatr Radiol 1991;21:363-364. 6. Gaeta GB, Utili R, Adinolfi LE, Tripodi MF, Esposito V. Effects of amphotericin B on the excretory function and the colloid clearance capacity of the perfused rat liver. J Hepatol 1989;8:344-350. 7. Carstensen H, Nilsson KO, Nettelblad SC, Cederlund CG, Hildell J. Common bile duct obstruction due to an intraluminal mass of candidiasis in a previously healthy child. Pediatrics 1986;77:858-861. 8. Citak EC, Ergenekon E, Alpaslan HG, Atalay Y, Koc E, Zengin A. Asymptomatic neonatal cholelithiasis. Indian J Pediatr 2001;68:91-93. 9. Stringer MD, Lim P, Cave M, Martinez D, Lilford RJ. Fetal gallstones. J Pediatr Surg 1996;31:1589-1591. 10. Debray D, Pariente D, Gauthier F, Myara A, Bernard O. Cholelithiasis in infancy: a study of 40 cases. J Pediatr 1993;122:385-391. 11. Haddad S, Hage G, Sukkarieh A, Ghorayeb Z, Atallah N. Spontaneous resolution of cholelithiasis in an infant. J Med Liban 1996;44:230-232. 12. Levine A, Maayan A, Shamir R, Dinari G, Sulkes J, Sirotta L. Parenteral nutrition-associated cholestasis in preterm neonates: evaluation of ursodeoxycholic acid treatment. J Pediatr Endocrinol Metab 1999;12:549-553. 13. Maruyama K, Koizumi T. Choledocholithiasis in an infant of extremely low birthweight. J Paediatr Child Health 2002;38:204-205.
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14. Ishitani MB, Shaul DB, Padua EA, McAlpin CA. Choledocholithiasis in a premature neonate. J Pediatr 1996;128:853-855. 15. Asabe K, Handa N. Infant cholelithiasis: report of a case. Surg Today 1997;27:71-75.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-12-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-05-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù¤Ê·ÓÔ˜ ¶. ª·ÓÙ·Áfi˜ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ ∆.∫. 265 04, ƒ›Ô, ¶¿ÙÚ· E-mail: smantagos@med.upatras.gr
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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2003;66:316-320
CASE REPORT
º˘Ì·Ù›ˆÛË Û ·È‰È¿. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛÂˆÓ Ì ∆µ ·Û˘Ó‹ıÔ˘˜ ÂÓÙfiÈÛ˘ Î·È ÚÔ‚ÔÏ‹˜ Ã. §¿ÛηÚË, °. ∞Ó·ÛÙ·ÛÈ¿‰Ë˜, µ. ¶Ï·ÎԇϷ, ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜, °. ¶·Ó·ÁȈٷÎfiÔ˘ÏÔ˜, ∫. ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡
Tuberculosis in children. Report of two cases with unusual location and presenting symptoms H. Laskari, G. Anastasiadis, V. Plakoula, D. Aggelopoulos, G. Panagiotakopoulos, K. Prountzou - Kassiou
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ ÌÂ Ê˘Ì·Ù›ˆÛË ·Û˘Ó‹ıÔ˘˜ ÂÓÙfiÈÛ˘ Î·È ÚÔ‚ÔÏ‹˜. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi ˘‹Ú¯·Ó ‰È·ÁÓˆÛÙÈΤ˜ ‰˘ÛÎÔϛ˜. ∏ ÚÒÙË ÂÚ›ÙˆÛË (·ÁfiÚÈ 11 ÂÙÒÓ) ‹Ù·Ó Ê˘Ì·Ù›ˆÛË Ì ÂÈÓ¤ÌËÛË Î·È ÙÔ˘ ÂÙÈÎÔ‡, Ô˘ ÂÌÊ¿ÓÈ˙Â Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Û‡ÛÙËÌ·. ∞˘Ùfi Û˘ÓÂÙ¤ÏÂÛ ӷ ÓÔÛËÏ¢Ù› Ô ·ÛıÂÓ‹˜ Û·Ó ÂÚÈÛÙ·ÙÈÎfi Â̇ÚÂÙ˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ηٿ ÙËÓ ÚÒÙË ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Û ÓÔÛÔÎÔÌ›Ô, ¯ˆÚ›˜ Ó· ÙÂı› ·Ú¯Èο ÛÙÔ˘˜ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎÔ‡˜ Û˘ÏÏÔÁÈÛÌÔ‡˜ Ë Èı·Ó‹ ‰È¿ÁÓˆÛË Ù˘ ∆µ ÂÓÙÂÚ›Ùȉ·˜. O ·ÛıÂÓ‹˜ Ù˘ ‰Â‡ÙÂÚ˘ ÂÚ›ÙˆÛ˘ (ÎÔÚ›ÙÛÈ 10 ÂÙÒÓ) ›¯Â ÈÛÙÔÚÈÎfi, Û˘Ìو̷ÙÔÏÔÁ›·, ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È ¯ÂÈÚÔ˘ÚÁÈο Â˘Ú‹Ì·Ù· Ô˘ ·Ú¤ÂÌ·Ó Û ‡·ÚÍË Â¯ÈÓfiÎÔÎÎÔ˘ ·ÛÙˆ˜ Ó‡ÌÔÓ·. ªÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÂϤÁ¯Ô˘ Ê¿ÓËΠfiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ê˘Ì·Ù›ˆÛË Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ. OÈ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ηıÒ˜ Ë Ê˘Ì·Ù›ˆÛË ÂÍ·ÎÔÏÔ˘ı› Ó· ˘¿Ú¯ÂÈ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ì ·Ó·ÊÂÚfiÌÂÓË ·‡ÍËÛË Ù˘ ›وۋ˜ Ù˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™Ùfi¯Ô˜ Â›Ó·È Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ÓfiÛÔ˜ ·Ó¢ڛÛÎÂÙ·È Î·È Û ÌË Ù˘ÈΤ˜ ÌÔÚʤ˜ Î·È fiÙÈ Â›Ó·È ÛÎfiÈÌÔ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ Û˘ÏÏÔÁÈÛÙÈ΋, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛ‹ Ù˘.
Abstract: Two cases of tuberculosis (TB) in children are reported. The location of the disease and the presenting symptoms were unusual for their age, causing diagnostic difficulties. The first case was that of an eleven year-old boy who had TB with involvement of the abdomen and the gastrointestinal system. The presenting symptoms from the gastrointestinal system resulted in a diagnosis after his first hospital admission of “acute gastroenteritis”, with no reference to TB in the differential diagnosis. The second case was that of a ten year-old girl whose history, symptoms and laboratory results referred to “echinococcosis of the lung”. Following completion of the investigation it became obvious that both were cases of TB. TB continues to be observed in children, with an increasing incidence in recent years. These cases are reported in order to emphasize that the disease may present atypically and a high index of suspicion is required to make an early diagnosis.
§¤ÍÂȘ ÎÏÂȉȿ: Ê˘Ì·Ù›ˆÛË, ·È‰È¿, ÂÓ‰ÔÎÔÈÏȷ΋, Ù‡Ô˘ ÂÓËÏ›ÎÔ˘.
Key words: tuberculosis, children, intraabdominal, adult type.
∂ÈÛ·ÁˆÁ‹ OÈ ËÏÈ˘ 5-14 ÂÙÒÓ Û˘¯Ó¿ ·ÔηÏÔ‡ÓÙ·È “¢ÓÔÔ‡ÌÂÓË ËÏÈΛ· Ù˘ Ê˘Ì·Ù›ˆÛ˘”, ÁÈ·Ù› Â›Ó·È Ë ËÏÈÎȷ΋ ÔÌ¿‰· Ì ÙË ÌÈÎÚfiÙÂÚË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ‰ÈÂıÓÒ˜. ∂ÈϤÔÓ, Ë Ê˘Ì·Ù›ˆÛË ÛÙ· ·È‰È¿ ÂÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· Û·Ó ÚˆÙÔ·ı‹˜ Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË Ì ‰ÈÔÁΈ̤ÓÔ˘˜ ÙÔ˘˜ ÂȯÒÚÈÔ˘˜ ÏÂÌ-
Ê·‰¤Ó˜ Î·È ›Ûˆ˜ οÔÈÔ˘ ‚·ıÌÔ‡ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë. ∏ Â͈Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË ÛÙ· ·È‰È¿ ‰ÂÓ Â›Ó·È Û˘¯Ó‹. ¶ÈÔ Û˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ηı˘ÛÙÂÚ› Î·È ··ÓÙ¿Ù·È ÌÂ Û˘Ó‡·ÚÍË ‹ fi¯È Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘. OÈ ‰‡Ô ÂÚÈÙÒÛÂȘ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·ÊÔÚÔ‡Ó
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
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1st Paediatric Clinic, “Aghia Sophia” Children’s Hospital, Athens
¶·È‰È·ÙÚÈ΋ 2003;66:316-320
Û ·È‰È¿ ËÏÈΛ·˜ 11 Î·È 10 ÂÙÒÓ. ™ÙËÓ ÚÒÙË ˘‹Ú¯Â Î·È Â͈Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË (Ê˘Ì·Ù›ˆÛË ÂÙÈÎÔ‡ Î·È Ê˘Ì·ÙÈ҉˘ ÂÚÈÙÔÓ›Ùȉ·). ∆Ô ‰Â‡ÙÂÚÔ ·È‰› ›¯Â Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË, ·ÏÏ¿ Ì ÂÓÙfiÈÛË ÛÙÔ ‰ÂÍÈfi οو Ó¢ÌÔÓÈÎfi ÏÔ‚fi Î·È Û¯ËÌ·ÙÈÛÌfi ÛËÏ·›Ô˘ ÛÙËÓ ›‰È· ÂÚÈÔ¯‹, ÂÓÙfiÈÛË Î·È ‚Ï¿‚Ë ·Û˘Ó‹ıÈÛÙË Û ·È‰È΋ ËÏÈΛ·. ∏ Û·ÓÈfiÙËÙ· ·˘ÙÒÓ ÙˆÓ ‰‡Ô ÂÚÈÙÒÛˆÓ, ÔÈ ‰È·ÊÔÚԉȷÁÓˆÛÙÈΤ˜ ‰˘ÛÎÔϛ˜ Ô˘ ·ÚÔ˘Û›·˙·Ó Î·È Ë ÎÔÈÓˆÓÈ΋ ‰È¿ÛÙ·ÛË Ù˘ ‰Â‡ÙÂÚ˘ (›¯Â ÌÔÏ˘Óı› ÌÂ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÂÓfi˜ ÌÈÎÚÔ‡ ÓËÛÈÔ‡) ·ÔÙ¤ÏÂÛ·Ó ÙȘ ·Èٛ˜ ÂÚÈÁÚ·Ê‹˜ ÙÔ˘˜. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË ÚÒÙË ∞ÁfiÚÈ ËÏÈΛ·˜ 11 ÂÙÒÓ ÚÔÛ‹Ïı Û ·گȷÎfi ÓÔÛÔÎÔÌÂ›Ô Ì ˘ÚÂÙfi, Â̤ÙÔ˘˜ Î·È ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ. ¡ÔÛËχÙËÎÂ Û·Ó ÂÚÈÛÙ·ÙÈÎfi ÌÈÎÚԂȷ΋˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ì Èı·Ó‹ ·ÈÙ›· ÙË Û·ÏÌÔӤϷ (‰ÂÓ ·ÔÌÔÓÒıËΠÙÔ ÌÈÎÚfi‚ÈÔ ÛÙȘ ηÏÏȤÚÁÂȘ) Î·È ¯ÔÚËÁ‹ıËΠ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË. ŒÌÂÈÓ ·‡ÚÂÙÔ Î·È ÂÍ‹ÏıÂ, ·ÏÏ¿ ÌÂÙ¿ ·fi 6 Ë̤Ú˜ Ô ˘ÚÂÙfi˜ ˘ÔÙÚÔ›·ÛÂ Î·È ¤ÁÈÓ ·ÓÂÈÛ·ÁˆÁ‹ ÙÔ˘. ™ÙÔÓ ¤ÏÂÁ¯Ô Ô˘ ·ÎÔÏÔ‡ıËÛ ‰È·ÈÛÙÒıËΠÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‡·ÚÍË Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ·ÚÈÛÙÂÚ¿ Î·È Û CT ÎÔÈÏ›·˜ ·ÛÎÈÙÈÎfi ˘ÁÚfi, ‰ÈfiÁΈÛË ·ÁÎÚ¤·ÙÔ˜ Î·È Ô›‰ËÌ· ÂÓÙÂÚÈÎÒÓ ÂϛΈÓ. ∏ Mantoux ¤‰ÂÈÍ ‰È‹ıËÛË ‰È·Ì¤ÙÚÔ˘ 5 mm Î·È Ë ÂͤٷÛË ÙÔ˘ ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡ 800 Ï¢ÎÔ·ÙÙ·Ú· ·Ó¿ ÙÂÙÚ·ÁˆÓÈÎfi ¯ÈÏÈÔÛÙfi Ì ÏÂÌÊÔ·ÙÙ·Ú· 95% Î·È Ï‡Έ̷ 3 g%. ∏ ΢ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ηÎÔ‹ıË Î‡ÙÙ·Ú·. ªÂ Èı·Ó‹ ÙË ‰È¿ÁÓˆÛË Ê˘Ì·ÙÈÒ‰Ô˘˜ Ïԛ̈͢ ¯ÔÚËÁ‹ıËΠπ¡∏ Î·È RIF. ªÂÙ¿ ·fi Ì›· ‚‰ÔÌ¿‰·, ÂÂȉ‹ Ô ˘ÚÂÙfi˜ Û˘Ó¯È˙fiÙ·Ó, ¤ÁÈÓ ‰È·ÎÔ‹ Ù˘ ·ÓÙ›-∆µ ·ÁˆÁ‹˜ Î·È ·Ú·ÔÌ‹ ÙÔ˘ ·ÛıÂÓ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋, ÙÔ ·È‰› ¤·Û¯Â Î·È ‹Ù·Ó ˆ¯Úfi, ›¯Â ‰È·ÙÂٷ̤ÓË ÎÔÈÏÈ¿ Î·È ıÂÚÌÔÎÚ·Û›· 38oC. ∆Ô ‹·Ú ‹Ù·Ó „ËÏ·ÊËÙfi 2 cm, Ô ÛÏ‹Ó·˜ 1 cm Î·È Ë ·ÚÙËÚȷ΋ ›ÂÛË ‹Ù·Ó 100/70 mmHg. ¢ÂÓ ‰È·ÈÛÙÒıËÎ·Ó Ôȉ‹Ì·Ù· ‹ „ËÏ·ÊËÙÔ› ÏÂÌÊ·‰¤Ó˜. ∆Ô ·ÙÔÌÈÎfi Î·È ÎÏËÚÔÓÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ‹Ù·Ó ÂχıÂÚ·. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ·ÈÌÔÛÊ·ÈÚ›ÓË 11 g/dL, ·ÈÌ·ÙÔÎÚ›ÙË 33%, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 18.000/mm3 Ì ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 76%, ÏÂÌÊÔ·ÙÙ·Ú· 17% Î·È ÌÔÓÔ‡ÚËÓ· 4%. ∏ TKE ‹Ù·Ó 11 mm ÙËÓ 1Ë ÒÚ·. OÈ ËÏÂÎÙÚÔχÙ˜ ÔÚÔ‡, Ë Ô˘Ú›·, Ë ÎÚ·ÙÈÓ›ÓË, Ë ·Ì˘Ï¿ÛË ÔÚÔ‡ Î·È Ô‡ÚˆÓ, Ù· ÔÏÈο Ï¢ÎÒÌ·Ù·, ÔÈ ÏÂ˘ÎˆÌ·Ù›Ó˜ Î·È Ë ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο.
Paediatriki 2003;66:316-320
∏ Mayer ÎÔÚ¿ÓˆÓ ‹Ù·Ó ·ÚÓËÙÈ΋, Ë ÁÏ˘Îfi˙Ë 108 mg/dl, Ë SGOT 38 U/L, Ë SGPT 65 U/L, Ë ÁGT 73 U/L Î·È Ë ¯ÔÏÂÚ˘ıÚ›ÓË Î·È ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. OÈ ÔÚÔ·ÓÙȉڿÛÂȘ Widal Î·È Wright ‹Ù·Ó ·ÚÓËÙÈΤ˜. O ¤ÏÂÁ¯Ô˜ ÁÈ· Ë·Ù›Ùȉ· Î·È HIV Ïԛ̈ÍË ‹Ù·Ó ·ÚÓËÙÈÎfi˜, Ë ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ¤‰ÂÈÍ ¿ÏÈ ‰È‹ıËÛË 5 mm Î·È Ë Î·Ì‡ÏË ·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ ‹Ù·Ó ·ıÔÏÔÁÈ΋. ∏ CT ıÒڷη Î·È ÎÔÈÏ›·˜ (∂ÈÎfiÓ· 1) ¤‰ÂÈÍ ‰È¿Ù·ÛË ˘ÏÒÓ, Ï¢ÚÈÙÈÎfi ˘ÁÚfi ·ÚÈÛÙÂÚ¿ Î·È ·ÙÂÏÂÎÙ·Û›· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ οو ÏÔ‚Ô‡ ÙÔ˘ Ó‡ÌÔÓ·. À‹Ú¯Â Ì›ˆÛË Ù˘ ÔÛfiÙËÙ·˜ ÙÔ˘ ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡ Î·È Ì›ˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Î·È ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÙˆÓ ÂÓÙÂÚÈÎÒÓ ÂÏ›ÎˆÓ Û˘ÁÎÚÈÙÈο Ì ÙËÓ 1Ë CT. O ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ¤‰ÂÈÍ 720 ÏÂ˘Î¿/mm2 Ì 97% ÏÂÌÊÔ·ÙÙ·Ú·, Ï›Á· ÂÚ˘ıÚ¿, ÂÓÒ ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ‚·Î›ÏÔ˘˜ Koch. ªÂ Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ ÙËÓ ∆µ Ïԛ̈ÍË, ¿ÏÏË ¯ÚÔÓ›˙Ô˘Û· ÊÏÂÁÌÔÓ‹ ‹ ηÎÔ‹ıÂÈ·, ÍÂΛÓËÛ ·ÓÙ›-∆µ ·ÁˆÁ‹ (2 Ë̤Ú˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘) Ì INH, RIF Î·È ˘Ú·˙ÈÓ·Ì›‰Ë. °Ú‹ÁÔÚ·, Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓ‹ ‚ÂÏÙÈÒıËÎÂ, ¤ÌÂÈÓ ·‡ÚÂÙÔ˜ ÌÂÙ¿ ·fi Ì›· ‚‰ÔÌ¿‰· ıÂڷ›·˜ Î·È Ë ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜ ˘Ô¯ÒÚËÛÂ. ™ÙÔÓ Â·Ó¤ÏÂÁ¯Ô Ì ·/· ıÒÚ·ÎÔ˜ Î·È U/S ÎÔÈÏ›·˜ ÌÂÙ¿ ·fi 20 Ë̤Ú˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Ï¢ÚÈÙÈÎfi ‹ ·ÛÎÈÙÈÎfi ˘ÁÚfi, ÂÓÒ Ë ‰ÈfiÁΈÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ›¯Â ÂÚ·ÈÙ¤Úˆ ˘Ô¯ÒÚËÛË. ∏ ÁÏ˘Îfi˙Ë Î·È Ù· Ë·ÙÈο ¤Ó˙˘Ì· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, Ë ÁGT ·Ú¤ÌÂÓ ÔÚȷο ·˘ÍË̤ÓË, ÂÓÒ ˘‹Ú¯Â Ë ‰È¿Ù·ÛË ÙˆÓ ˘ÏÒÓ Î·È Ë ·ÙÂÏÂÎÙ·Û›· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ Ó‡ÌÔÓ·. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿, Ë ‰È¿Ù·ÛË ÙˆÓ ˘ÏÒÓ Î·È Ë ·ÙÂÏÂÎÙ·Û›· ¤ÌÂÓ·Ó. ªÂÙ¿ ·fi Û˘ÓÔÏÈ΋ ·ÓÙ›-∆µ ·ÁˆÁ‹ 18 ÌËÓÒÓ (ÙÔ˘˜ ÚÒÙÔ˘˜ 2 Ì‹Ó˜ Ù· ÙÚ›· ÚÔ·Ó·ÊÂÚı¤ÓÙ· Ê¿Ú̷η Î·È ÛÙË Û˘Ó¤¯ÂÈ· π¡∏ Î·È RIF), ÙÔ ·È‰› ›¯Â ·Ó·ÚÚÒÛÂÈ Ï‹Úˆ˜. ∏ ÂÛÙ›· ÌÂÙ¿‰ÔÛ˘ Ù˘ Ïԛ̈͢ ‰ÂÓ ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ÂÓÙÔÈÛÙ›. ·
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∂ÈÎfiÓ· 1. CT ÎÔÈÏÈ¿˜ Î·È ıÒڷη: ·) ·ÙÂÏÂÎÙ·Û›· ·ÚÈÛÙÂÚÔ‡ οو ÏÔ‚Ô‡, ‚) ·ÛÎÈÙÈÎfi ˘ÁÚfi, Á) ‰ÈfiÁΈÛË ·ÁÎÚ¤·ÙÔ˜ Î·È ‰) Ô›‰ËÌ· ÂÓÙÂÚÈÎÒÓ ÂϛΈÓ.
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¶·È‰È·ÙÚÈ΋ 2003;66:316-320
¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 10 ÂÙÒÓ ÚÔÛ‹Ïı ÛÙËÓ ÎÏÈÓÈ΋ Ì ˘ÚÂÙfi, ‚‹¯· Î·È ÂÈÁ·ÛÙÚ·ÏÁ›· ·fi ÙÚÈË̤ÚÔ˘, ÂÓÒ 36 ÒÚ˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ·ÚÔ˘Û›·Û ÂÂÈÛfi‰ÈÔ Ô˘ ¤ÌÔÈ·˙ Ì “˘‰·Ù¤ÌÂÛË”. ◊Ù·Ó ÙÔ 2Ô ·È‰› ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Î·È ÙÔ ·ÙÔÌÈÎfi Î·È ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi Ù˘ ‹Ù·Ó ÂχıÂÚ·. ∏ ÔÈÎÔÁ¤ÓÂÈ· ηÙÔÈÎÔ‡Û Û ÌÈÎÚfi ÓËÛ› Î·È Ë ÌÂÙ·ÊÔÚ¿ Ù˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤ÁÈÓ ÌÂÙ¿ ·fi Û‡ÛÙ·ÛË ÙÔ˘ ·ÁÚÔÙÈÎÔ‡ ÁÈ·ÙÚÔ‡. ∏ ÁÂÓÈ΋ ηٿÛÙ·ÛË ‹Ù·Ó ηϋ. ™ÙËÓ ·ÎÚfi·ÛË ÙˆÓ Ó¢ÌfiÓˆÓ ‚Ú¤ıËÎ·Ó ‰È¿¯˘ÙÔÈ Ú˘Á¯¿˙ÔÓÙ˜, ·¯Â›˜ Î·È ÏÂÙÔ› ˘ÁÚÔ› ÚfiÁ¯ÔÈ ÛÙÔÓ ‰ÂÍÈfi Ó‡ÌÔÓ·, ÂÓÒ ·fi Ù· ¿ÏÏ· Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ˘‹Ú¯·Ó ·ıÔÏÔÁÈο ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ Hb 11,6 g/dl, ÏÂ˘Î¿ 12.270/mm3 Ì ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 65%, ÏÂÌÊÔ·ÙÙ·Ú· 22%, ÌÔÓÔ‡ÚËÓ· 2%, ˈÛÈÓfiÊÈÏ· 2%, ·ÈÌÔÂÙ¿ÏÈ· 541.000/mm3, TKE 27 mm Î·È CRP 12 g/l. O ·‰Úfi˜ ‚ÈÔ¯ËÌÈÎfi˜, Ë·ÙÈÎfi˜ Î·È Ô ¤ÏÂÁ¯Ô˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ›. ™ÙËÓ ·/· ıÒڷη (∂ÈÎfiÓ· 2) ‰È·ÈÛÙÒıËΠ‡ÎÓˆÛË Î·Ù¿ ÙÔ ¤Íˆ ÙÌ‹Ì· ÙÔ˘ ‰ÂÍÈÔ‡ ̤ÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÏÔ‚Ô‡, ÂÓÙfi˜ Ù˘ ÔÔ›·˜ ÚÔ‚·ÏÏfiÙ·Ó ÛÙÚÔÁÁ˘Ïfi ÌfiÚʈ̷ Ì ۷ʋ fiÚÈ· ˘Âډȷ‡Á·Û˘. ∏ ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ڷÁ›۷ Î·È ÂÈÌÔÏ˘Óı›۷ ·ÛÙË Ó‡ÌÔÓ·. ™‡Ìʈӷ Ì ÙÔÓ ˘fiÏÔÈÔ ¤ÏÂÁ¯Ô, ÙÔ U/S ÎÔÈÏ›·˜ Î·È ÓÂÊÚÒÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi, Ù· Ù‡ÂÏ· Î·È ÙÔ ‚ÚÔÁ¯ÈÎfi ¤ÎÎÚÈÌ· ‹Ù·Ó ·ÚÓËÙÈÎfi ÁÈ· ‚Koch, Ù· ·ÓÙȯÈÓÔÎÔÎÎÈο ·ÓÙÈÛÒÌ·Ù· ıÂÙÈο Û ¤Ó· ÂÚÁ·ÛÙ‹ÚÈÔ, ÂÓÒ ‚Ú¤ıËÎ·Ó ·ÚÓËÙÈο Û ‰‡Ô ¿ÏÏ·, Ë CT ıÒڷη ‹Ù·Ó ¯ˆÚ›˜ ‰ÈÔÁΈ̤ÓÔ˘˜ ÏÂÌÊ·‰¤Ó˜, Ë ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ¤‰ÂÈÍ ‰È‹ıËÛË 14 mm (›¯Â ÚÔËÁËı› BCG ÚÔ ÙÚÈÂÙ›·˜). ∆Ô ·È‰› ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠·ÓÙÈÂÏÌÈÓıÈ΋ Î·È ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ (·Ï‚ÂÓ‰·˙fiÏË Î·È ÎÂÊÔ˘ÚÔÍ›ÌË). O ˘ÚÂÙfi˜ ·Ú¯Èο ˘Ô¯ÒÚËÛÂ, ÛÙË Û˘Ó¤¯ÂÈ· fï˜ ˘ÔÙÚÔ›·ÛÂ, Ì ٷ˘Ùfi¯ÚÔÓË Âȉ›ӈÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ Î·È ·‡ÍËÛË ÙˆÓ ‰ÂÈÎÙÒÓ Ïԛ̈͢. ªÂ Û˘Ó¯È˙fiÌÂÓË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ (ÎÂÊÔÙ·Í›ÌË, ÎÏÈÓ‰·Ì˘Î›ÓË Î·È ·Ï‚ÂÓ‰·˙fiÏË), ·Ú·ÙËÚ‹ıËΠӤ· ‚ÂÏÙ›ˆÛË Î·È ·ÚÁfiÙÂÚ· ÂÎ Ó¤Ô˘ ˘ÔÙÚÔ‹. ™Â ηÈÓÔ‡ÚÈ· ·/· ıÒڷη ‰È·ÈÛÙÒıËΠ“˘‰Ú·ÂÚÈÎfi Â›Â‰Ô ÛÙËÓ Î‡ÛÙË ÙÔ˘ ‰ÂÍÈÔ‡ οو ÏÔ‚Ô‡” Î·È ÙÔ ·È‰› ¯ÂÈÚÔ˘ÚÁ‹ıËΠ̠ÛÎÔfi ÙËÓ ÂÎÙÔÌ‹ Ù˘ ·ÛÙˆ˜. ™ÙËÓ Â¤Ì‚·ÛË ‚Ú¤ıËΠ“ÊÏÂÁÌ·›ÓÔ˘Û· ·Ú·ÛÈÙÈ΋ ·ÛÙË ÛÙËÓ ÎÔÚ˘Ê‹ ÙÔ˘ ‰ÂÍÈÔ‡ οو ÏÔ‚Ô‡” Î·È ¤ÁÈÓ ÂÎÙÔÌ‹ Ù˘. ∆Ô ·È‰› Û˘Ó¤¯ÈÛ ӷ Â›Ó·È Â̇ÚÂÙÔ Î·È ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÙÂÌ·¯›Ô˘ ÙÔ˘ Ó‡ÌÔÓ· Ô˘ ÂÍ·ÈÚ¤ıËΠ¤‰ˆÛÂ Â˘Ú‹Ì·Ù· “Û˘Ì‚·Ù¿ Ì ÎÔÎΛˆÌ· Ê˘Ì·Ù›ˆÛ˘”. ªÂÙ¿ Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ¯ÔÚËÁ‹ıËΠÛÙË ÌÈÎÚ‹ ·ÛıÂÓ‹ ·ÓÙ›-∆µ ·ÁˆÁ‹ (Ì π¡∏, RIF ηÈ
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˘Ú·˙ÈÓ·Ì›‰Ë), ÛÙËÓ ÔÔ›· ·ÓÙ·ÔÎÚ›ıËΠ̠ÚÔԉ¢ÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ Ù˘ ηٿÛÙ·Û˘ Î·È ·˘ÚÂÍ›·. ∏ ËÁ‹ ÌfiÏ˘ÓÛ˘ ‹Ù·Ó ̤ÏÔ˜ Ù˘ ¢ڇÙÂÚ˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ·ÙÂÏÒ˜ ıÂÚ·Â˘Ì¤ÓÔ, Ì ÁÓˆÛÙ‹ ÙË ÓfiÛÔ. ∆Ô ÁÂÁÔÓfi˜ ‰ÂÓ Â›¯Â ÁÓˆÛÙÔÔÈËı› ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ÁÈ· ÏfiÁÔ˘˜ ÎÔÈÓˆÓÈÎÔ‡˜, ·Ú¿ ÙȘ ÂÚˆÙ‹ÛÂȘ ηٿ ÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ·ÛıÂÓ‹˜ ÂÍ‹Ïı ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô Ì ԉËÁ›Â˜ ÁÈ· Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ Î·È ÂÚÈÔ‰ÈÎÔ‡˜ ·ӤÏÂÁ¯Ô˘˜. ªÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË 2 ÌËÓÒÓ ıÂڷ›·˜, Ë ˘Ú·˙ÈÓ·Ì›‰Ë ‰ÈÂÎfiË. ∞fi ÙÔÓ 5Ô Ì‹Ó· ·ÓÙ›∆µ ·ÁˆÁ‹˜, ÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· ¿ÏÏ·Í ÏfiÁˆ ÂÌÊ¿ÓÈÛ˘ ÛËÌ·ÓÙÈ΋˜ Ë·ÙÔÙÔÍÈÎfiÙËÙ·˜, ÌË ‚ÂÏÙÈÔ‡ÌÂÓ˘ ÌÂÙ¿ ·fi Ì›ˆÛË Ù˘ ‰fiÛ˘ Ù˘ RIF. ∏ ·ÁˆÁ‹ Û˘Ó¯›ÛÙËΠ̠∂ªµ Î·È π¡∏ ÁÈ· ¿ÏÏÔ˘˜ 14 Ì‹Ó˜. ªÂÙ¿ ·fi Û˘ÓÔÏÈ΋ ·ÁˆÁ‹ 19 ÌËÓÒÓ Î·È Û˘Ó¤¯ÈÛË Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· ¿ÏÏÔ˘˜ 18 Ì‹Ó˜ ‰ÂÓ ˘‹Ú¯·Ó ÚÔ‚Ï‹Ì·Ù· ÎÏÈÓÈο ‹ ÂÚÁ·ÛÙËÚȷο. ™ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ ıÂڷ›·˜ Î·È Ù˘ ÌÂÙ¤ÂÈÙ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÓÔÛÔÎÔÌ›· ÂÓËϛΈÓ, ÂϤÁ¯ıËΠÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘ ·ÛıÂÓÔ‡˜ ·ÏÏ¿ Î·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ Î·ÙÔ›ÎˆÓ ÙÔ˘ ÌÈÎÚÔ‡ ÓËÛÈÔ‡. ∂ÓÙÔ›ÛÙËÎ·Ó Î·È ¿ÏÏÔÈ ¿Û¯ÔÓÙ˜ ·fi ∆µ Î·È ÚÔÁÚ·ÌÌ·Ù›ÛÙËÎÂ Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ™˘˙‹ÙËÛË ∏ ›وÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÁÂÓÈο, ·ÏÏ¿ Î·È ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÂȉÈÎfiÙÂÚ·, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·˘Í¿ÓÂÙ·È ‰ÈÂıÓÒ˜ (1,2). ∞˘Ùfi Á›ÓÂÙ·È È‰È·›ÙÂÚ· ·ÓÙÈÏËÙfi Û ÏËı˘ÛÌÔ‡˜ ÌÂÙ·Ó·ÛÙÒÓ, ·ÙfiÌˆÓ Ì ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο ÚÔ‚Ï‹Ì·Ù· Î·È Û ·ÛıÂÓ›˜ Ì HIV Ïԛ̈ÍË. £ÂˆÚÂ›Ù·È fiÙÈ Ù· ¿ÙÔÌ· ‚ÚÂÊÈ΋˜ ‹ ÌÂÙ·-ÂÊË‚È΋˜ ËÏÈΛ·˜ ‰È·ÙÚ¤¯Ô˘Ó ÙÔÓ ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ (1). OÈ ‰‡Ô ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·Ó Û ·˘Ù¤˜ ÙȘ ÔÌ¿‰Â˜. ∏ ·ıÔÁ¤ÓÂÛË Ù˘ Â͈Ó¢ÌÔÓÈ΋˜, Î·È ‰Ë ÎÔÈÏȷ΋˜,
∂ÈÎfiÓ· 2. ¶‡ÎÓˆÛË ‰ÂÍÈÔ‡ ̤ÛÔ˘ ÏÔ‚Ô‡ ηÈ, ÂÓÙfi˜ ·˘Ù‹˜, ÛÙÚÔÁÁ˘Ïfi ÌfiÚʈ̷ Ì ۷ʋ fiÚÈ· ˘Âډȷ‡Á·Û˘.
¶·È‰È·ÙÚÈ΋ 2003;66:316-320
Ê˘Ì·Ù›ˆÛ˘ Ô˘ ›¯·Ì ÛÙËÓ 1Ë ÂÚ›ÙˆÛË Â›Ó·È ÔÈΛÏË. ∏ Ê˘Ì·ÙÈ҉˘ ÂÚÈÙÔÓ›Ùȉ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È Û¿ÓÈ· Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ‰Â˘ÙÂÚÔ·ıÒ˜ ÏfiÁˆ ·ÈÌ·ÙÔÁÂÓÔ‡˜ ‰È·ÛÔÚ¿˜ ·fi ÂÓÂÚÁ‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ ‹ ίÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË. ∂›Û˘, ÌÔÚ› Ó· ÂΉËψı› Â¿Ó ˘¿ÚÍÂÈ Â·ÓÂÓÂÚÁÔÔ›ËÛË ·ÏÈ¿˜ Ê˘Ì·ÙÈÒ‰Ô˘˜ ÂÛÙ›·˜ ÛÙÔ ÂÚÈÙfiÓ·ÈÔ ‹ ¿ÏÏË ÂÓ‰ÔÎÔÈÏȷ΋ ÂÛÙ›· (1,3-5,10). ∏ Ê˘Ì·ÙÈ҉˘ ÂÓÙÂÚ›Ùȉ·, Ô˘ ÚÔÊ·ÓÒ˜ ÂÍ·ÈÙ›·˜ Ù˘ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ÚÔÛ‹Ïı ÛÙÔ ÚÒÙÔ ÓÔÛÔÎÔÌ›Ô, Û˘Ó·ÓÙ¿Ù·È Â›Û˘ Û ·ÈÌ·ÙÔÁÂÓ‹ ‰È·ÛÔÚ¿ ‹ ηٿÔÛË ÊÏÂÁÌÔÓˆ‰ÒÓ ÂÎÎÚ›ÛÂˆÓ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ÛÙË Ê¿ÛË Ù˘ ÚˆÙÔ·ıÔ‡˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘. ∫ÏÈÓÈο, Ë ÂÓ‰ÔÎÔÈÏȷ΋ Ê˘Ì·Ù›ˆÛË ÌÔÚ› Ó· ÌÈÌËı› Î·È ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, ÂÓÒ Û οÔȘ ·fi ·˘Ù¤˜ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Â˘Ú‹Ì·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (5). ∫¿ÔÈ· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·, Â¿Ó ˘¿Ú¯Ô˘Ó, ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ Ê˘Ì·Ù›ˆÛ˘, fiˆ˜ Ë ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÂÓÙÂÚÈÎÒÓ ÂÏ›ÎˆÓ ÛÙËÓ ÂÈÏÂÔÙ˘ÊÏÈ΋ ‚·Ï‚›‰· ‹ Ë ·Ó‡ÚÂÛË ÂÏÎÒÓ ÛÙÔÓ ÂÓÙÂÚÈÎfi ۈϋӷ (6,9). ∏ ·Ó‡ÚÂÛË ·ÛΛÙË ‹ ‰ÈfiÁΈÛ˘ ÌÂÛÂÓÙ¤ÚÈˆÓ ÏÂÌÊ·‰¤ÓˆÓ ÛÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Û˘ÓËÁÔÚ›, ›Û˘, ˘¤Ú Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ‰È¿ÁÓˆÛ˘. O ¤ÏÂÁ¯Ô˜ ÙÔ˘ ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡ ‚ÔËı¿ÂÈ ‰È·ÁÓˆÛÙÈο, ·ÏÏ¿ ¯ÚÂÈ¿˙ÔÓÙ·È Î·È ÈÔ ÂȉÈÎÔ› ¯ÂÈÚÈÛÌÔ›, fiˆ˜ ÂÓ‰ÔÛÎfiËÛË Î·È Ï‹„Ë ‚ÈÔ„›·˜ ÂÓÙ¤ÚÔ˘ ‹ ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· (2,5). ∫·Ù¿ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰‡Ô Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÚÈÙÒÛˆÓ, Ë Û˘Ì‚·Ù‹ Î·È Ì ∆µ Û˘Ó‡·ÚÍË Â˘ÚËÌ¿ÙˆÓ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Î·È Ë ˘¿Ú¯Ô˘Û· ÎÏÈÓÈ΋ Î·È ·ÂÈÎÔÓÈÛÙÈ΋ ÂÈÎfiÓ· Ù˘ ÎÔÈÏ›·˜ ÈÛ¯˘ÚÔÔÈÔ‡Û·Ó ÙËÓ Èı·ÓfiÙËÙ· ‰Â˘ÙÂÚÔ·ıÔ‡˜ ∆µ Ïԛ̈͢ ·fi ÚˆÙÔ·ı‹ ÂÛÙ›· ÛÙÔÓ Ó‡ÌÔÓ· ‹ ÂÓ‰ÔÎÔÈÏȷο. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux, Ô˘ Î·È ÛÙËÓ Â·Ó¿ÏË„Ë ¤‰ÂÈÍ ‰È‹ıËÛË ÌfiÓÔ 5 mm, ‰ÂÓ ıˆڋıËΠÌË Û˘Ì‚·Ù‹ Ì ÙË ‰È¿ÁÓˆÛË Ù˘ ∆µ Ïԛ̈͢. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ 10% ÙˆÓ ·È‰ÈÒÓ Ì ·Ô‰Â‰ÂÈÁ̤ÓË (Ì ηÏÏȤÚÁÂÈ·) ∆µ Ïԛ̈ÍË Î·È ÌË ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ‰ÂÓ ·ÓÙȉڿ ¿ÌÂÛ· ÛÙË ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux (5TU ·fi PPD). ¶·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë Ó·ڋ ËÏÈΛ· ÙÔ˘ ÂÏÂÁ¯fiÌÂÓÔ˘ ·ÙfiÌÔ˘, Ë Î·Î‹ ıÚ¤„Ë, ¿ÏϘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (ÂȉÈο ÈÏ·Ú¿, ·ÓÂÌÔ‚ÏÔÁÈ¿ Î·È ÁÚ›Ë) Î·È Ë ‚·ÚÈ¿ ÂÎÙÂٷ̤ÓË Ê˘Ì·ÙÈ҉˘ Ïԛ̈ÍË, ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÛÙÔ ‰ÂÚÌ·ÙÈÎfi test ÌÂ Ê˘Ì·Ù›ÓË. £ÂˆÚ‹ıËΠfiÙÈ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ÂÓ¤ÈÙ ÛÙËÓ ÙÂÏÂ˘Ù·›· ηÙËÁÔÚ›· ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ. ŒÙÛÈ, ·ӷ¯ÔÚËÁ‹ıËΠٷ¯‡Ù·Ù· ·ÓÙ›-∆µ ·ÁˆÁ‹ ÌÂ
Paediatriki 2003;66:316-320
ÙÚ›· Ê¿Ú̷η (π¡∏, RIF, ˘Ú·˙ÈÓ·Ì›‰Ë), ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· Û˘Ó¯È˙fiÙ·Ó Ô ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ (3,6,7,9,10). ∏ 2Ë ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û Û ÎÔÚ›ÙÛÈ Ì Ó¢ÌÔÓÈ΋ ∆µ. ¶·Ú’ fiÙÈ ÙÔ ·È‰› ‹Ù·Ó 10 ÂÙÒÓ, ÙÔ ÂÚÈÛÙ·ÙÈÎfi ·ÊÔÚÔ‡Û ÛÂ Ê˘Ì·Ù›ˆÛË Ù‡Ô˘ ÂÓËÏ›ÎÔ˘. ∆Ô ÈÛÙÔÚÈÎfi, Ë ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ·, Ô ÙfiÔ˜ Î·È ÔÈ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘ Û˘ÓËÁÔÚÔ‡Û·Ó ÁÈ· ‡·ÚÍË Â¯ÈÓfiÎÔÎÎÔ˘ ·ÛÙˆ˜ ÛÙÔÓ Ó‡ÌÔÓ·. ∂ÈϤÔÓ, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì µCG Ô˘ ›¯Â ÚÔËÁËı› ÌÔÚÔ‡Û ӷ ‰ÈηÈÔÏÔÁ‹ÛÂÈ ÙËÓ ‡·ÚÍË ıÂÙÈ΋˜ Mantoux Ì ‰È¿ÌÂÙÚÔ 1,4 cm (10). ∆¤ÏÔ˜, ÔÈ ÁÔÓ›˜ ·¤ÎÚ˘„·Ó fiÙÈ ˘‹Ú¯·Ó ÛÙËÓ Â˘Ú‡ÙÂÚË ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ·fi Ê˘Ì·Ù›ˆÛË (ı›Ԙ, ÁÈ·ÁÈ¿) - Î·È Ì¿ÏÈÛÙ· ·ÙÂÏÒ˜ ıÂÚ·Â˘Ì¤ÓÔÈ. ¢ÂÓ ‹ıÂÏ·Ó, fiˆ˜ ›·Ó, Ó· Á›ÓÂÈ ÁÓˆÛÙfi ÛÙË ÌÈÎÚ‹ ·گȷ΋ ÎÔÈÓˆÓ›· Ô˘ ˙Ô‡Û·Ó. ŸÏ· Ù· ·Ú·¿Óˆ Û˘ÓÂÙ¤ÏÂÛ·Ó ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘. O ¤ÏÂÁ¯Ô˜ ·ÓÙȯÈÓÔÎÔÎÎÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‰ÂÓ ‚Ô‹ıËÛÂ, ηıÒ˜ ÌÂÙ¿ ÙËÓ ·Ó‡ÚÂÛË ıÂÙÈÎÒÓ ·Ú¯Èο Î·È ÙËÓ Ù·˘Ùfi¯ÚÔÓË ·ÚÓËÙÈ΋ ·¿ÓÙËÛË ·fi ¿ÏÏÔ ÂÚÁ·ÛÙ‹ÚÈÔ, ÂÛÙ¿ÏË Û 3Ô ÂÚÁ·ÛÙ‹ÚÈÔ ·›Ì· ÁÈ· ·ӿÏË„Ë Ù˘ ÂͤٷÛ˘, Ë ÔÔ›· ‹Ù·Ó ·ÚÓËÙÈ΋. O ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÓÙȯÈÓÔÎÔÎÎÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÛÙ· ÙÚ›· ÂÚÁ·ÛÙ‹ÚÈ· ¤ÁÈÓ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ¤ÌÌÂÛ˘ ·ÈÌÔÛ˘ÁÎfiÏÏËÛ˘, Ë ÔÔ›· ¤¯ÂÈ Èı·ÓfiÙËÙ˜ „¢‰Ò˜ ıÂÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜. ∆ÂÏÈο, Ë ÂͤÏÈÍË ÙÔ˘ ·È‰ÈÔ‡ Ô‰‹ÁËÛ Û ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Î·È ÂÍ·›ÚÂÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍ ÎÔÎΛˆÌ· Ê˘Ì·Ù›ˆÛ˘. ∆Ô ·È‰› ·ÓÙ·ÔÎÚ›ıËΠÛÙËÓ ·ÁˆÁ‹ Î·È ÛÙËÓ ÙÂÏÂ˘Ù·›· ·ÓÂͤٷۋ ÙÔ˘, 18 Ì‹Ó˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜, ‹Ù·Ó ÂχıÂÚÔ ÓfiÛÔ˘ Î·È Û ηϋ ηٿÛÙ·ÛË. O ÂÓÙÔÈÛÌfi˜ Ù˘ ËÁ‹˜ ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ ‹Ù·Ó Ë ·ÈÙ›· Ó· ÂÏÂÁ¯ıÔ‡Ó ÔÈ Î¿ÙÔÈÎÔÈ ÙÔ˘ ÓËÛÈÔ‡ Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ıÂڷ¢ÙÈο ÔÈ ¿Û¯ÔÓÙ˜ ·fi ∆µ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Starke JR, Munoz G. Tuberculosis. In: Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders Company; 2000. p. 885-897. 2. Starke JR, Jacobs RF, Jereb J. Resurgence of tuberculosis in children. J Pediatr 1992;120:839-855. 3. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol 1993;88:989-999. 4. Lingenfelser T, Zak J, Marks IN, Steyn E, Halkett J, Price SK. Abdominal tuberculosis: still a potentially lethal disease. Am J Gastroenterol 1993;88:744-750. 5. Paul CR, Rabah R, Rao RB. Unusual presentation of intraabdominal tuberculosis. Clin Pediatr 1996;35:597-599. 6. Singh MM, Bhargava AN, Jain KP. Tuberculous peritonitis. An evaluation of pathogenetic mechanisms, diagnostic procedures and therapeutic measures. N Engl J Med
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1969;281:1091-1094. 7. ¢ÂÏËÁÈÒÚÁ˘ ¢, °ÎÈÔ‡Ú‰· ∞. º˘Ì·ÙÈ҉˘ ÂÚÈÙÔÓ›ÙȘ Û ·ÁfiÚÈ ËÏÈΛ·˜ 10 ÂÙÒÓ. ¢ÂÏÙ ∞’ ¶·È‰ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1981;28:246-252. 8. ºÔ˘Û¤ÎË-÷Ù˙ËÁˆÚÁ›Ô˘ ∞, £ÂÔ‰ˆÚ›‰Ô˘-¶··ÁÚËÁÔÚ›Ô˘ ª, ª·ÚÎfiÛÔÁÏÔ˘ ¢, §È¿Ë-∞‰·Ì›‰Ô˘ ∂, ¶··ÓÈÎÔÏ¿Ô˘ ∞, ∑Ô˘ÌÔ˘Ï¿Î˘ ¢. º˘Ì·ÙÈ҉˘ ÂÓÙÂÚ›ÙȘ Û ·È‰› Ì ¯ÚfiÓÈ· ÎÔÎÎȈ̷ÙÒ‰Ë ÓfiÛÔ. ¶·È‰È·ÙÚÈ΋ 1994;57:617-621. 9. Leder RA, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995;33:691-705. 10. Hussey G, Chisholm T, Kibel M. Miliary tuberculosis in children: a review of 94 cases. Pediatr Infect Dis J 1991;10:832-836. 11. Starke JR, Correa AG. Management of mycobacterial infection and disease in children. Pediatr Infect Dis J 1995;14:455-469.
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12. O’Brien RJ, Long MW, Cross FS, Lyle MA, Snider DE Jr. Hepatotoxicity from isoniazid and rifampin among children treated for tuberculosis. Pediatrics 1983;72:491-499. 13. Golditz GA, Brewer TF, Berkey CS, Wilson ME, Burdick E, Fineberg HV et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. JAMA 1994;271:698-702.
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¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
¡∂∞ ∫ÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ¤Î‚·ÛË ÙÔ˘ ™Ô‚·ÚÔ‡ OͤԘ ∞Ó·Ó¢ÛÙÈÎÔ‡ ™˘Ó‰ÚfiÌÔ˘ (™O∞™ ‹ SARS) ÛÙ· ·È‰È¿ ∫ÔÚ›Ó· ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡, ¶·È‰›·ÙÚÔ˜
¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ·Ó·ÊÔÚ¿ ÁÈ·ÙÚÒÓ ·fi ÙÔ Hong Kong Ô˘ ‰ËÌÔÛȇÙËΠÛÙÔ ‰È·‰›ÎÙ˘Ô ÛÙÔ Lancet ÛÙȘ 29 ∞ÚÈÏ›Ô˘ 2003 Î·È ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙˆÓ ·È‰ÈÒÓ ˆ˜ ·ÛıÂÓÒÓ Ì SARS, ÛÙË ıÂڷ›· Î·È ÙËÓ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ Û 10 ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙ· ÓÔÛÔÎÔÌ›· Prince of Wales Î·È Princess Margaret ÙÔ˘ Hong Kong ·fi 13 ¤ˆ˜ 28 ª·ÚÙ›Ô˘ 2003. ¢¤Î· ·È‰È¿ ËÏÈΛ·˜ ·fi 1,5 ¤ˆ˜ 16,5 ÂÙÒÓ ÂÈÛ‹¯ıËÛ·Ó Ì ˘Ô„›· SARS. ¶·Ú·ÙËÚ‹ıËÎ·Ó ‰‡Ô ͯˆÚÈÛÙ¤˜ ÎÏÈÓÈΤ˜ ÂÈÎfiÓ˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. OÈ ¤ÊË‚ÔÈ ÂÌÊ¿ÓÈÛ·Ó ˘ÚÂÙfi, ‚‹¯·, ηÎÔ˘¯›·, Ì˘·ÏÁ›Â˜, ÊÚ›ÎÈ· Î·È Ú›ÁÔ˜ (Û·Ó ·˘Ù¿ ÙˆÓ ÂÓËϛΈÓ), ÂÓÒ Ù· ÌÈÎÚfiÙÂÚ· ·È‰È¿ ÂÌÊ¿ÓÈÛ·Ó Î˘Ú›ˆ˜ ‚‹¯·, ÚÈÓÈ΋ ηٷÚÚÔ‹, ˘ÚÂÙfi Î·È ‚‹¯·. ŸÏ· Ù· ·È‰È¿ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ WHO ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ SARS Î·È fiÏ· ›¯·Ó ¤ÚıÂÈ Û ·ʋ Ì ¿Û¯ÔÓÙ˜ ÂÓ‹ÏÈΘ. ∂ÓÓ¤· ·fi Ù· 10 ·È‰È¿ ›¯·Ó ·ıÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ÛÙËÓ ÂÈÛ·ÁˆÁ‹. ∆Ô Î‡ÚÈÔ Â‡ÚËÌ· ÛÙȘ ·ÎÙÈÓÔÁڷʛ˜ ıÒÚ·ÎÔ˜ ‹Ù·Ó ‰È¿Û·ÚÙ˜ ıÔÏÂÚfiÙËÙ˜, ÂÓÒ 4 ·fi Ù· 5 ÌÈÎÚfiÙÂÚ· ·È‰È¿ ›¯·Ó ÙÌËÌ·ÙÈ΋ ‡ÎÓˆÛË Î·È 2 ÌÂÁ·Ï‡ÙÂÚ· (¤ÊË‚ÔÈ) ›¯·Ó ·ÌÊÔÙÂÚfiÏ¢ÚË ıÔÏÂÚfiÙËÙ· ÙˆÓ Î¿Ùˆ ÏÔ‚ÒÓ. ™Â ¤Ó·Ó ·ÛıÂÓ‹, Ë ‡ÎÓˆÛË ‰È·ÁÓÒÛÙËΠÌfiÓÔ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜. §ÂÌÊÔÂÓ›· (0,3-3,0 x 10 G/L) ›¯·Ó fiÏÔÈ ÔÈ ·ÛıÂÓ›˜, ΢ڛˆ˜ ÌÂٷ͇ Ù˘ 3˘ Î·È 7˘ Ë̤ڷ˜ Ù˘ ÓfiÛÔ˘. ™Â Î·Ó¤Ó·Ó ·ÛıÂÓ‹ ‰ÂÓ ‚Ú¤ıËÎ·Ó ¿ÏÏ· ·ıÔÁfiÓ·, ÈÔ› ‹ ̇ÎËÙ˜. ÕÏÏ· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÂÚÈÂÏ¿Ì‚·Ó·Ó ÌÂÙÚ›ˆ˜ ¯·ÌËÏ¿ ·ÈÌÔÂÙ¿ÏÈ·, ˘„ËÏ‹ LDH Î·È ˘„ËÏ‹ ALT (alanine aminotransferase). O ÎÔÚˆÓÔ˚fi˜ ·ÔÌÔÓÒıËΠ۠ηÏÏȤÚÁÂÈ· Û 2 ·ÛıÂÓ›˜ Î·È Ë PCR η٤‰ÂÈÍ ÙÔÓ Èfi Û 4 ·fi Ù· 6 ·È‰È¿ Ô˘ ÂϤÁ¯ıËηÓ. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ¯ÔÚËÁ‹ıËÎ·Ó ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ·ÓÙÈ-ÈÈο Ê¿Ú̷η Î·È ·ÓÙÈ‚ÈÔÙÈο. ™˘ÁÎÂÎÚÈ̤ӷ, ¯ÔÚËÁ‹ıËÎ·Ó ÂÓ‰ÔÊϤ‚È· ÎÂÊÔ˘ÚÔÍ›ÌË, ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÎÏ·ÚÈıÚÔÌ˘Î›ÓË, ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÚÈÌ·‚ÈÚ›ÓË Û ‰fiÛË 40 mg/kg/Ë̤ڷ ‰È·ÈÚÂ̤ÓË Û 2 ‹ 3 ‰fiÛÂȘ. ∂¿Ó Ô ˘ÚÂÙfi˜ ¤ÌÂÓ ÌÂÙ¿ 48 ÒÚ˜, ÛÙËÓ ·ÁˆÁ‹ Û˘ÌÂÚÈÏ·Ì‚·ÓfiÙ·Ó Ú‰ÓÈ˙ÔÏfiÓË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ∂Ó‰ÔÊϤ‚È· ÚÈÌ·‚ÈÚ›ÓË, Û ‰fiÛË 20 mg/kg/Ë̤ڷ, ¯ÔÚËÁ‹ıËΠ۠·ÛıÂÓ›˜ Ì ̤ÙÚÈ· Û˘ÌÙÒÌ·Ù· Î·È Ôχ ˘„ËÏfi ˘ÚÂÙfi Ì·˙› Ì ˘‰ÚÔÎÔÚÙÈ˙fiÓË 2 mg/kg/6 ÒÚ˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜. ™Â ·ÛıÂÓ›˜ Ì ›ÌÔÓÔ ˘ÚÂÙfi Î·È ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË, ÎÏÈÓÈ΋ ‹ ·ÎÙÈÓÔÏÔÁÈ΋, ¯ÔÚËÁ‹ıËΠıÂڷ›· Ì ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (10-20 mg/kg) Û ÒÛÂȘ. ∏ ıÂڷ›· ·˘Ù‹ ¯ÔÚËÁ‹ıËΠ۠1 ÌÈÎÚfi ·È‰› Î·È 4 ÂÊ‹‚Ô˘˜. ™Â ‰‡Ô Ë̤Ú˜, Ô ˘ÚÂÙfi˜ ›¯Â ˘Ô¯ˆÚ‹ÛÂÈ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜, ÂÎÙfi˜ ·fi ¤Ó·Ó. ªfiÓÔ 3 ·ÛıÂÓ›˜ ¯ÚÂÈ¿ÛÙËÎ·Ó ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Ì Ô͢ÁfiÓÔ (maxim 50%), Ì¿Ûη, BiPAP ‹ IPPV. ª¤¯ÚÈ ·˘Ù‹ ÙËÓ ·Ó·ÊÔÚ¿ ηӤӷ ·È‰› ‰ÂÓ Î·Ù¤ÏËÍÂ. OÈ Û˘ÁÁÚ·Ê›˜ Û˘ÌÂÚ·›ÓÔ˘Ó, Û‡Ìʈӷ Ì ٷ ̤¯ÚÈ ÙÒÚ· ÛÙÔȯ›·, fiÙÈ Ù· ·È‰È¿ ·Ó·Ù‡ÛÛÔ˘Ó Ì›· ËÈfiÙÂÚË ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Î·È ÏÈÁfiÙÂÚÔ ÂÈıÂÙÈ΋ ÎÏÈÓÈ΋ ÔÚ›· Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÙÔ˘˜ ÂÓ‹ÏÈΘ. Lancet 2003;361:1701-1703
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¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
∞ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË: Ӥ˜ Èı·Ó¤˜ ËÁ¤˜ ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
∏ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ·ÔÙÂÏ› Û˘¯Ófi Úfi‚ÏËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÂÓÒ ÔÏϤ˜ ÊÔÚ¤˜ Û¯ÂÙ›˙ÂÙ·È Ì ¤ÓÙÔÓ˜ ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ. OÈ Û˘Óı‹Î˜ ¤ÎıÂÛ˘ ÛÙȘ ÙÚÔʤ˜ Ô˘ Ô‰ËÁÔ‡Ó Û ·ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË Â›Ó·È ·ÎfiÌË ·ÙÂÏÒ˜ ηٷÓÔËÙ¤˜. ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË ‰ËÌÔÛÈÂ˘Ì¤ÓË ÛÙÔ New England Journal of Medicine, Ë ÔÌ¿‰· ÙÔ˘ Gideon Lack ÂÓÙfiÈÛ ̤۷ ·fi Ì›· ÔÌ¿‰· 14.000 ·È‰ÈÒÓ, 50 ÂÚ›Ô˘ ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ ÊÈÛÙ›ÎÈ, Ë ÔÔ›· ˆ˜ ÁÓˆÛÙfiÓ Â›Ó·È Û˘¯Ó‹ ÛÙȘ ·ÁÁÏÔÛ·ÍÔÓÈΤ˜ ¯ÒÚ˜ Î·È ÌÔÚ› Ó· ·Ô‚› ÌÔÈÚ·›·. ∆· ·È‰È¿ ·˘Ù¿ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ¤·Û¯·Ó Î·È ·fi ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·. ™˘ÁÎÚ›ÓÔÓÙ·˜ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ¤ÎıÂÛ˘ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ì ·È‰È¿ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ¯ˆÚ›˜ ·ÏÏÂÚÁ›· ÛÙÔ ÊÈÛÙ›ÎÈ Î·È Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, ‰È·›ÛÙˆÛ fiÙÈ Ë ‰È·ÙÚÔÊ‹ Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ ·ÔÙÂÏ› ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ·, fiˆ˜ ÂıˆÚ›ÙÔ ·Ï·ÈfiÙÂÚ·. ∞ÓÙ›ıÂÙ·, fiÏ· ۯ‰fiÓ Ù· ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ ÊÈÛÙ›ÎÈ Â›¯·Ó ÂÎÙÂı› Û ‚ÚÂÊÈ΋ ËÏÈΛ· Û ηÏÏ˘ÓÙÈΤ˜ Îڤ̘ Ô˘ ÂÚÈ›¯·Ó ·Ú·¯È‰¤Ï·ÈÔ (ÊÈÛÙÈΤϷÈÔ). £ÂÙÈ΋, ›Û˘, Û˘Û¯¤ÙÈÛË ˘‹Ú¯Â Î·È Ì ÙË ¯Ú‹ÛË Á¿Ï·ÎÙÔ˜ ÛfiÁÈ·˜ Ù· 2 ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜. ∆Ô Û˘Ì¤Ú·ÛÌ· Â›Ó·È fiÙÈ Ë ¤ÎıÂÛË Û ·ÏÏÂÚÁÈÔÁÔÓÈΤ˜ ÚˆÙ½Ó˜ ̤ۈ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Û ·È‰È¿ Ì ÊÏÂÁÌ·›ÓÔÓ ‰¤ÚÌ·, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË Î·È ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·. ∂›Û˘, ÛÙËÓ ·ÏÏÂÚÁ›· ·˘Ù‹ ÌÔÚ› ›Ûˆ˜ Ó· Ô‰ËÁËı› ηÓ›˜ ̤ۈ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ Ì ÙË ÛfiÁÈ·, ·Ó Î·È ·˘Ùfi ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. ∏ ¯Ú‹ÛË Î·ÏÏ˘ÓÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ϋÚË Î·È ÏÂÙÔÌÂÚ‹ ηٷÓfiËÛË Ù˘ Û‡ÛÙ·Û‹˜ ÙÔ˘˜, ÂÓÒ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ ηÏfi ı· ‹Ù·Ó Ó· ·ÔʇÁÂÙ·È Ë ¯Ú‹ÛË Û΢·ÛÌ¿ÙˆÓ Ô˘ ÂÚȤ¯Ô˘Ó Âί˘Ï›ÛÌ·Ù· Èı·Ó¿ ·ÏÏÂÚÁÈÔÁfiÓˆÓ ÚˆÙÂ˚ÓÒÓ. New Engl J Med 2003;348:977-985
∏ ·¯˘Û·ÚΛ· Ù˘ ÌËÙ¤Ú·˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÛÙÔ ¤Ì‚Ú˘Ô ∫ÔÚ›Ó· ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡, ¶·È‰›·ÙÚÔ˜
OÈ Watkins ML Î·È Û˘Ó ‰ËÌÔÛÈÂ‡Ô˘Ó ÛÙÔ Pediatrics ÙÔ˘ ª·˝Ô˘ Ì›· ÌÂϤÙË Ù˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ Ù˘ ÌËÙ¤Ú·˜ Î·È ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙÔ ¤Ì‚Ú˘Ô. À¿Ú¯Ô˘Ó ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ı¤Ì· Î·È Î˘Ú›ˆ˜ ÛÙË Û˘Û¯¤ÙÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ Ù˘ ÌËÙ¤Ú·˜ Ì ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÓˆÙÈ·›Ô˘ ۈϋӷ. ™Â ·˘Ù‹ ÙË ÌÂϤÙË, Ô ‰Â›ÎÙ˘ ۈ̷ÙÈ΋˜ Ì¿˙·˜ (µªπ) ÚÈÓ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ÂÏ‹ÊıË ˘’ fi„ÈÓ Û ÌËÙ¤Ú˜ ÓÂÔÁÓÒÓ ÌÂ Î·È ¯ˆÚ›˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 1993 ¤ˆ˜ ÙÔÓ ∞‡ÁÔ˘ÛÙÔ 1997. OÈ ÌËÙ¤Ú˜ ¯ˆÚ›ÛÙËÎ·Ó Û 3 ÔÌ¿‰Â˜: ·) Ì ÛÔ‚·Ú‹ ·¯˘Û·ÚΛ· (µªπ >35), ‚) Ì ̤ÙÚÈ· ·¯˘Û·ÚΛ· (µªπ=25-29,9) Î·È Á) Ì ηÓÔÓÈÎfi ‚¿ÚÔ˜ (µªπ=18,5-24,9). ™˘ÁÎÚÈÙÈο, Ù· ÓÂÔÁ¤ÓÓËÙ· ÙˆÓ ·¯‡Û·ÚÎˆÓ ÌËÙ¤ÚˆÓ Â›¯·Ó 3,5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¤¯Ô˘Ó ·ÓˆÌ·Ï›Â˜ ÓˆÙÈ·›Ô˘ ۈϋӷ, 3,3 ÊÔÚ¤˜ Ó· ¤¯Ô˘Ó ÔÌÊ·ÏÔ΋ÏË, 2 ÊÔÚ¤˜ Ó· ¤¯Ô˘Ó ·ÓˆÌ·Ï›· ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Î·È 2 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¤¯Ô˘Ó ÔÏϷϤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜. ŸÛÔ ÛÔ‚·ÚfiÙÂÚË ‹Ù·Ó Ë ·¯˘Û·ÚΛ· ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ˜ ‹Ù·Ó Ô Î›Ó‰˘ÓÔ˜ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ.
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ø˜ Èı·ÓÔ› Ì˯·ÓÈÛÌÔ› ÚfiÎÏËÛ˘ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ·Ó·Ê¤ÚÔÓÙ·È: ·) ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜, fiˆ˜ ˘ÂÚÁÏ˘Î·ÈÌ›·, ˘ÂÚÈÓÛÔ˘ÏÈÓÈÛÌfi˜ Î·È ·˘ÍË̤ӷ ›‰· ÔÈÛÙÚÔÁfiÓˆÓ (ÂȉÈο Ô ˘ÂÚÈÓÛÔ˘ÏÈÓÈÛÌfi˜ Â›Ó·È ÁÓˆÛÙfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÓˆÙÈ·›Ô˘ ۈϋӷ) Î·È ‚) ÔÈ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ ÙˆÓ ·¯‡Û·ÚÎˆÓ ÌËÙ¤ÚˆÓ Û ÔÚÈṲ̂ӷ ȯÓÔÛÙÔȯ›· Î·È ‚Èٷ̛Ә, fiˆ˜ .¯. ÙÔ Ê˘ÏÏÈÎfi Ô͇, ÁÓˆÛÙfi ÁÈ· ÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ ÙÔ˘ ‰Ú¿ÛË ÛÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÓˆÙÈ·›Ô˘ ۈϋӷ. ∏ Ú·ÎÙÈ΋ ·Í›· ·˘Ù‹˜ Ù˘ ·Ú·Ù‹ÚËÛ˘ ÁÈ· ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Û˘Ó›ÛÙ·Ù·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ·È‰È¿ Ô˘ Ù· ‚Ï¤Ô˘Ó Ì·˙› Ì ÙȘ ÌËÙ¤Ú˜ ÙÔ˘˜, ÔÈ Ôԛ˜ Èı·ÓfiÓ ı· ·ÔÎÙ‹ÛÔ˘Ó Î·È ¿ÏÏ· ·È‰È¿. ™˘ÓÂÒ˜, ¤¯Ô˘Ó ÙËÓ Â˘Î·ÈÚ›· Ó· ÂÓËÌÂÚÒÛÔ˘Ó ÙȘ ÌËÙ¤Ú˜ ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ‰È·ÙÚ¤¯ÂÈ ÙÔ ÌÂÏÏÔÓÙÈÎfi ¤Ì‚Ú˘fi ÙÔ˘˜ ·fi ÙËÓ ·¯˘Û·ÚΛ· ÙÔ˘˜ Î·È Ó· ÙȘ ÂÓı·ÚÚ‡ÓÔ˘Ó Ó· ¯¿ÛÔ˘Ó ‚¿ÚÔ˜ ÚÈÓ ÙËÓ ÂfiÌÂÓË ÂÁ΢ÌÔÛ‡ÓË ÙÔ˘˜. Pediatrics 2003;111:1152
Human metapneumovirus: ¤Ó·˜ Ó¤Ô˜ Èfi˜, Û˘¯Ófi ·›ÙÈÔ ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿ ∂ÈÚ‹ÓË ∫ÔÓÙÔfi‰Ë, ¶·È‰›·ÙÚÔ˜
OÈ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·ÔÙÂÏÔ‡Ó ·ÁÎfiÛÌÈ· ÙË 2Ë ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ. ∞Ó Î·È Ô RSV Î·È ÔÈ ÈÔ› Ù˘ Áڛ˘ Î·È ·Ú·Áڛ˘ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (‚ÚÔÁ¯ÈÔÏ›Ùȉ·, Ó¢ÌÔÓ›·), Ë ·ÈÙÈÔÏÔÁ›· ÛÙÔ 15-34% ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·˘ÙÒÓ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË. ¶ÚfiÛÊ·Ù·, ÛÙȘ ∫¿Ùˆ ÃÒÚ˜, Ù·˘ÙÔÔÈ‹ıËΠ¤Ó·˜ ¿ÁÓˆÛÙÔ˜ ÏÔÈÌÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ›¯Â ·ÔÌÔÓˆı› Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· ·fi 28 ‚Ú¤ÊË Î·È ·È‰È¿ Ì Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ÚÒÙÔ ·ıÔÁfiÓÔ ÁÈ· ÙÔ˘˜ ·ÓıÚÒÔ˘˜ Û٤ϯԘ ÈÔ‡ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÙˆÓ metapneumovirus. O Èfi˜ ·˘Ùfi˜, Ô ÔÔ›Ô˜ ÔÓÔÌ¿ÛÙËΠHuman metapneumovirus (hMPV), ·ÓȯÓ‡ıËΠÛÙË Û˘Ó¤¯ÂÈ· ÛÙËÓ ∞˘ÛÙÚ·Ï›·, ÛÙÔÓ ∫·Ó·‰¿ Î·È ÛÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ. ∆Ô˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ ÙˆÓ ÂÙÒÓ 2001-2002, ÂÎÔÓ‹ıËΠÛÙÔ Connecticut ÙˆÓ ∏.¶.∞. ÌÂϤÙË Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÚÔ‚ÔÏ‹˜ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Èfi ·˘Ùfi ÛÙ· ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ Û ·˘Ù‹ ÙËÓ ÂÚÈÔ¯‹. O Èfi˜ ·Ó·˙ËÙ‹ıËΠ̠ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ (PCR) ÛÙ· ·Ó·Ó¢ÛÙÈο ÂÎÎڛ̷ٷ ·È‰ÈÒÓ Ô˘ ·ÚÔ˘Û›·˙·Ó Û˘ÌÙÒÌ·Ù· ·Ó·Ó¢ÛÙÈ΋˜ Ïԛ̈͢ Î·È ÛÙ· ÔÔ›· ‰ÂÓ ·ÓȯÓ‡ÔÓÙ·Ó Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ Ù· ·ÓÙÈÁfiÓ· ÙˆÓ ÈÒÓ RSV, Áڛ˘, ·Ú·Áڛ˘ Î·È ·‰ÂÓÔ˚ÒÓ. ™ÙË ÌÂϤÙË ·˘Ù‹ ‰È·ÈÛÙÒıËΠfiÙÈ Ë hMPV ·ÔÙÂÏ› Û˘¯Ófi ·›ÙÈÔ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Î·È Î·ÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (6,4% ÙˆÓ ÂÚÈÙÒÛˆÓ, fiÔ˘ ‰ÂÓ ·ÓȯÓ‡ÂÙ·È ¿ÏÏÔ ·›ÙÈÔ). ¢È·ÈÛÙÒıËÎÂ, ›Û˘, fiÙÈ ÔÈ ÌÈÛÔ› ÂÚ›Ô˘ ·ÛıÂÓ›˜ ·fi ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ·fi Ïԛ̈ÍË ·fi ÙÔÓ hMPV, ÂÌÊ¿ÓÈ˙·Ó Û˘ÌÙÒÌ·Ù· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ Î·È ·ÚÎÂÙÔ› ·fi ·˘ÙÔ‡˜ (>30%) ·ÚÔ˘Û›·˙·Ó ˘ÔÍ·ÈÌ›·. OÈ Û˘ÁÁÚ·Ê›˜ ÂÈÛËÌ·›ÓÔ˘Ó ÙÔÓ Èı·Ó¿ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÙÔ˘ ÈÔ‡ ·˘ÙÔ‡ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜. Pediatrics 2003;111:1407-1410
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¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
∏§∂∫∆ƒO¡π∫∂™ ¢π∂À£À¡™∂π™ ∏ ¡ÂÔÁÓÔÏÔÁ›· ÛÙÔ ÚÔÛ΋ÓÈÔ Neonatology on the web - www.neonatology.org ŸÙ·Ó ·Ó·˙ËÙ› ηÓ›˜ Û˘ÁÎÂÓÙڈ̤Ó˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙË ÓÂÔÁÓÔÏÔÁ›·, ÙÔ neonatology.org Â›Ó·È Ì›· ·fi ÙȘ ÏËÚ¤ÛÙÂÚ˜ ËÁ¤˜. ¢ËÌÈÔ˘ÚÁ‹ıËΠ·fi ÙËÓ È·ÙÚÈ΋ ÔÌ¿‰· ÙÔ˘ Cedars-Sinai Medical Center ÛÙÔ Los Angeles Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÂÁ¿ÏÔ ·ÚÈıÌfi ¿ÚıÚˆÓ, ·˘ÙÔÌ·ÙÔÔÈËÌ¤ÓˆÓ ·ÏÁÔÚ›ıÌˆÓ Î·È ·Ó·ÊÔÚÒÓ Ô˘ ÍÂÎÈÓÔ‡Ó ·fi ÙËÓ ÈÛÙÔÚ›· Ù˘ ¡ÂÔÁÓÔÏÔÁ›·˜ Î·È ÊÙ¿ÓÔ˘Ó Ì¤¯ÚÈ ÚfiÛÊ·Ù· ÚÔÁÚ¿ÌÌ·Ù· ÁÈ· PDAs. ∏ ·ÈÛıËÙÈ΋ Î·È Ô ‰ÔÌÈÎfi˜ ۯ‰ȷÛÌfi˜ Ù˘ ÛÂÏ›‰·˜ ‰ÂÓ ¤¯Ô˘Ó Ó· Âȉ›ÍÔ˘Ó Î¿ÙÈ È‰È·›ÙÂÚÔ Î·È Ì¿ÏÏÔÓ ı· ÌÔÚÔ‡Û·Ó Ó· ¯·Ú·ÎÙËÚÈÛÙÔ‡Ó ˆ˜ “·Ï·È¿˜ Ìfi‰·˜”, ·ÏÏ¿ ·˘Ùfi ηıfiÏÔ˘ ‰ÂÓ ÂÌÔ‰›˙ÂÈ ÙËÓ ÚÔÛ¤ÁÁÈÛË ÛÙËÓ ÏËÚÔÊÔÚ›·. ∂ӉȷʤÚÔÓ ¤¯ÂÈ, ›Û˘, ÙÔ virtual tour, Ì›· ÙÚÈۉȿÛÙ·ÙË ÂÚÈ‹ÁËÛË Û ̛· ÂÈÎÔÓÈ΋ ÌÔÓ¿‰· ÓÂÔÁÓÒÓ. ∏ ·Ó·Ó¤ˆÛË ÙˆÓ ÛÂÏ›‰ˆÓ Â›Ó·È Ù·ÎÙÈ΋ Î·È ¤ÙÛÈ ÌÔÚ› Ó· Â›Ó·È Î·Ó›˜ ‚¤‚·ÈÔ˜ fiÙÈ ÔÈ ÏËÚÔÊÔڛ˜ Ô˘ ı· Ï¿‚ÂÈ ·fi ÙÔ ËÏÂÎÙÚÔÓÈÎfi ·˘Ùfi Û‡ÁÁÚ·ÌÌ· ·Ó·ÊÔÚ¿˜ ı· Â›Ó·È ·ÎÚȂ›˜ Î·È Â›Î·ÈÚ˜.
∞ÏÔÔÈË̤ÓË ÂÈÛÙ‹ÌË ChildHealthMonitor - www.childhealthmonitor.org ¶ÚÔÛ·ıÒÓÙ·˜ Ó· ÈÛÔÚÚÔ‹ÛÂÈ ÌÂٷ͇ Ù˘ ˘ÂÚ‚ÔÏ‹˜ Î·È Ù˘ ·ÏÔ˚ÎfiÙËÙ·˜ ÙˆÓ Î·Ù·Ó·ÏˆÙÈÎÒÓ ÂÓÙ‡ˆÓ Î·È Ù˘ ÂÍÂȉ›Î¢Û˘ Î·È ÛÙ·ÙÈÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ÙˆÓ ÂÈÛÙËÌÔÓÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ, Ë ÔÌ¿‰· ÙÔ˘ ChildHealthMonitor ·Ú·ÎÔÏÔ˘ı› Î·È ·Ó·Ê¤ÚÂÈ ÙËÓ ·È‰È·ÙÚÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· Ì ·ÏÔÔÈË̤ÓÔ ÙÚfiÔ, ÒÛÙ ӷ Á›ÓÂÙ·È Î·Ù·ÓÔËÙ‹ Î·È ·fi ÌË ÂȉÈÎÔ‡˜. ¶ÂÚȤ¯ÂÈ, ›Û˘, Û˘ÏÏÔÁ¤˜ ¿ÚıÚˆÓ Û¯ÂÙÈÎÒÓ Ì ÙȘ Û˘¯ÓfiÙÂÚ˜ ·È‰È·ÙÚÈΤ˜ ÔÓÙfiÙËÙ˜. ∂›Ó·È ¤Ó· ηÏfi ·Ú¿‰ÂÈÁÌ· ÂÌÔÚÈÎÔ‡ ÙfiÔ˘, fiÔ˘ - ¯ˆÚ›˜ ȉȷ›ÙÂÚ˜ ˘ÂÚ‚ÔϤ˜ - ·Ú¤¯ÔÓÙ·È ÂÂÍÂÚÁ·Ṳ̂Ó˜ ÏËÚÔÊÔڛ˜ Û ÌÔÚÊ‹ Ô˘ ı· ÌÔÚÔ‡Û ηÓ›˜ Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ ÁÈ· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘.
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∂¶π™∆O§∏ ¶ƒO™ ∆∏ ™À¡∆∞•∏
Paediatriki 2003;66:325-326
LETTER TO THE EDITOR
∞ÍÈfiÙÈÌ ·ÚÈ ¶Úfi‰ÚÂ, £· ‹ıÂÏ· Ó· Û˘Á¯·ÚÒ ÂÛ¿˜ ÚÔÛˆÈο Î·È fiÏ· Ù· ̤ÏË ÙÔ˘ ¢.™. Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ÁÈ· ÙËÓ Î·Ù¿ ÁÂÓÈ΋ ÔÌÔÏÔÁ›· ÂÈÙ˘¯›· ÙÔ˘ 41Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ. £· ‹ıÂÏ·, ›Û˘, Ó· Û·˜ ‰ËÏÒÛˆ ÙËÓ ·ÒÏÂÈ· ÙÔ˘ Poster ÌÔ˘ Ì ·ÚÈıÌfi P140 Î·È Ù›ÙÏÔ: “°ÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË Û ÚÔ‚Ï‹Ì·Ù· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ΢ÙÙ·ÚÔÁÂÓÂÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Ì ·ÌÓÈÔΤÓÙËÛË”, ÌÂ Û˘ÁÁÚ·Ê›˜ ÙÔ˘˜ Î.Î. Ã. ÷Ù˙ËÛ‚·ÛÙÔ‡-§Ô˘Î›‰Ô˘ Î·È ∫. ª·ÏÙ˙‹ (∂ÚÁ·ÛÙ‹ÚÈÔ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋˜ Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ∞.¶.£., °¶¡ πÔÎÚ¿ÙÂÈÔ £ÂÛÛ·ÏÔӛ΢) Î·È §. ºÏˆÚÂÓÙ›Ó-∞Ú¿Ú (Alfa Lab, ∫¤ÓÙÚÔ ªÔÚȷ΋˜ µÈÔÏÔÁ›·˜ Î·È ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋˜ ¢È¿ÁÓˆÛ˘, ∞ı‹Ó·). ™˘ÁÎÂÎÚÈ̤ӷ, ÙËÓ ∫˘Úȷ΋ 19-06-2003 Î·È ÒÚ· 19:00 ·Ú¤Ï·‚· ·fi ÙÔÓ ¯ÒÚÔ ÙˆÓ ·Ó·ÚÙËÌ¤ÓˆÓ ·Ó·ÎÔÈÓÒÛÂˆÓ ÙÔ ¤Ó· ·fi Ù· Poster ÌÔ˘ Ì ·ÚÈıÌfi PO67, ‰ÂÓ ˘‹Ú¯Â fï˜ ÙÔ Poster Ì ·ÚÈıÌfi P140, ÙÔ ÔÔ›Ô ÂÚÈÂÏ¿Ì‚·Ó ÂÈÎfiÓ· Û¿ÓÈÔ˘ ηڢfiÙ˘Ô˘ Î·È ÊˆÙÔÁڷʛ˜ ‰‡Ô Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ Û Á˘·ÏÈÛÙÂÚfi ʈÙÔÁÚ·ÊÈÎfi ¯·ÚÙ› Î·È Û ‰È·ÛÙ¿ÛÂȘ ¯·ÚÙÈÔ‡ ∞4 (‚Ï. ηو٤ڈ). £· ‹ıÂÏ· Ó· Û·˜ ·Ú·Î·Ï¤Ûˆ Ó· ‰ËÌÔÛȇÛÂÙ ÙËÓ ÂÚ›ÙˆÛË Ì ÙÔÓ Î·Ú˘fiÙ˘Ô ˆ˜ ·ÂÈÎÔÓÈÛÙÈ΋ ÁÈ· Ó· ηÙÔ¯˘ÚÒÛˆ ÙÔ ¤ÚÁÔ ÌÔ˘. ∂›Û˘, ·Ó Û˘ÌʈÓ›ÙÂ, Ó· ‰ËÌÔÛȇÛÂÙ ÙËÓ ÂÈÛÙÔÏ‹ ÌÔ˘ ÚÔ˜ ·ÔÊ˘Á‹Ó ·ÚfiÌÔÈˆÓ ÂÂÈÛÔ‰›ˆÓ ÛÙÔ Ì¤ÏÏÔÓ. ™·˜ ¢¯·ÚÈÛÙÒ Î·È ÂÏ›˙ˆ ÛÙËÓ ·Ô‰Ô¯‹ Ù˘ ÚfiÙ·Û‹˜ ÌÔ˘. £ÂÛÛ·ÏÔÓ›ÎË, 02-07-2003 ªÂ ÙÈÌ‹ Ã. ÷Ù˙ËÛ‚·ÛÙÔ‡-§Ô˘Î›‰Ô˘
°ÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË Û ÚÔ‚Ï‹Ì·Ù· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ΢ÙÙ·ÚÔÁÂÓÂÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Ì ·ÌÓÈÔΤÓÙËÛË
∂ÈÎfiÓ· 1. º˘ÛÈÔÏÔÁÈÎfi ·ÁfiÚÈ 2,5 ÂÙÒÓ. O ηڢfiÙ˘fi˜ ÙÔ˘ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ·ÌÓÈ·Îo‡ ˘ÁÚÔ‡ ÙÔ˘ ‹Ù·Ó: 46,ÃÀ/47,ÃÀ, +20 Û ·Ó·ÏÔÁ›· 27/12 (¶ÂÚ›ÙˆÛË ·/· 1).
∂ÈÎfiÓ· 2. º˘ÛÈÔÏÔÁÈÎfi ı‹Ï˘ 1 ¤ÙÔ˘˜. O ηڢfiÙ˘fi˜ ÙÔ˘ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ÙÔ˘ ‹Ù·Ó: 45,ÃÃ,der(14;21)(q10;q10) de novo (¶ÂÚ›ÙˆÛË ·/· 3).
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∂ÈÎfiÓ· 3. ∫·Ú˘fiÙ˘Ô˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘: 47,ÃÀ,+mar de novo. ŒÁÈÓ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ Ì Ù¯ÓÈ΋ FISH ÚÔÎÂÈ̤ÓÔ˘ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ¯ÚˆÌÔÛˆÌÈ΋ ÚԤϢÛË ÙÔ˘ ‰Â›ÎÙË ·˘ÙÔ‡ (mar). À‚ÚȉÈÛÌfi˜ Ì ·ÓȯÓÂ˘Ù¤˜ Ù˘ ÂÚÈÔ¯‹˜ alpha satellite ÁÈ· Ù· ¯ÚˆÌÔÛÒÌ·Ù· 13/21, 14/22 Î·È 15 ·Ó·ÁÓÒÚÈÛ·Ó ÙÔ ¯ÚˆÌÔÛˆÌÈÎfi ‰Â›ÎÙË Ô˘ ¤¯ÂÈ ·ÓȯÓ¢Ù› ÛÙÔÓ Î·Ú˘fiÙ˘Ô ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·˘ÙÔ‡ ˆ˜ ÚÔÂÚ¯fiÌÂÓÔ ·fi Ù· ¯ÚˆÌÔÛÒÌ·Ù· 13 ‹ 21. OÈ ÁÔÓ›˜ ¤ÏÂÍ·Ó ÙË Û˘Ó¤¯ÈÛË Ù˘ ·ËÛ˘ Î·È ÁÂÓÓ‹ıËΠ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi ·ÁfiÚÈ (¶ÂÚ›ÙˆÛË ·/· 8).
∫·Ù¿ ·Ú¤ÎÎÏÈÛË ÙˆÓ ·Ú¯ÒÓ ÙÔ˘ ¶ÂÚÈÔ‰ÈÎÔ‡, ‰ËÌÔÛȇÔÓÙ·È ÔÈ ˆ˜ ¿Óˆ ʈÙÔÁڷʛ˜ ÏfiÁˆ ÙÔ˘ ·Ù˘¯Ô‡˜ Û˘Ì‚¿ÓÙÔ˜ Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ Poster.
O ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫·ıËÁËÙ‹˜ ™Ù·‡ÚÔ˜ ÷˚‰¿˜
326
¶PO™EXH ™YNE¢PIA
12-13 ™ÂÙÂÌ‚Ú›Ô˘ 2003
Erasmus Workshop on Molecular Therapeutics in Acute Leukemia ¶ÏËÚÔÊÔڛ˜: Erasmus Workshop Leukemia Tel.: +31 (0)10 4087669 Fax: +31 (0)10 4089462 E-mail: info@emco.fgg.eur.nl Website: www.eur.nl/fgg/emco
Rotterdam, The Netherlands
18-21 ™ÂÙÂÌ‚Ú›Ô˘ 2003
28th UMEMPS Congress Secretariat: Dr S. Afif - Pr. M. Oumlil Tel. & Fax: +212 22 22 6386 E-mail: smpcasa@wanadoo.net.ma
Marrakech, Morocco
1-4 OÎÙˆ‚Ú›Ô˘ 2003
TRANSMED 2003: 11th European Mediterranean Obstetrics, Perinatology & Paediatrics Meeting ¶ÏËÚÔÊÔڛ˜: Kamel BARGAOUI Tel.: +33 607 686 118 Fax: +33 743 839 985 E-mail: kamel.bargaoui@wanadoo.fr
Lisboa, Portugal
5-7 OÎÙˆ‚Ú›Ô˘ 2003
2nd International Symposium on Perinatal and Developmental Medicine ¶ÏËÚÔÊÔڛ˜: Milos Cerny M.D. Tel.: 42 0 257 272 350 Fax: 42 0 257 214 550 E-mail: milos.cerny@lfmotol.cuni.cz
Prague, Czech Republic
10-12 OÎÙˆ‚Ú›Ô˘ 2003
4th International Pediatric Cardiovascular Symposium: Heart Failure in Pediatrics ¶ÏËÚÔÊÔڛ˜: Jane Darrish Tel.: 404 929 8645 Fax: 404 315 2885 E-mail: jane.darrish@choa.org
Atlanta, GA, United States
xi
¶PO™EXH ™YNE¢PIA
19-22 OÎÙˆ‚Ú›Ô˘ 2003
Europaediatrics 2003 ¶ÏËÚÔÊÔڛ˜: Kenes International Tel.: +41 22 908 0488 Fax: +41 22 732 2850 E-mail: europaediatrics2003@kenes.com Website: www.kenes.com/europaediatrics2003
Prague, Czech Republic
20-23 ¡ÔÂÌ‚Ú›Ô˘ 2003
14th European Congress on Pediatric and Neonatal Intensive Care Astir Palace Hotel ¶ÏËÚÔÊÔڛ˜: ZITA Congress E-mail: grasimosk@zita-congress.gr
∞ı‹Ó·
9-12 ºÂ‚ÚÔ˘·Ú›Ô˘ 2004
15th International Congress on anti-Cancer Treatment ¶ÏËÚÔÊÔڛ˜: T.C.O. Tel.: (33-1) 42 94 87 32 Fax: (33-1) 42 94 87 33 Website: www.icact.com E-mail: info@icact.com
Paris, France
10-13 πÔ˘Ó›Ô˘ 2004
9th Congress of the European Hematology Association ¶ÏËÚÔÊÔڛ˜: Eurocongres Conference Management Tel.: +31 20 679 3411 Fax: +31 20 673 7306 E-mail: eha2004@eurocongres.com Website: www.eurocongres.com/eha2004
Geneva, Switzerland
xii
™YNTOMO°PAºIE™
ABBREVIATIONS
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
AIDS
Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜
AMP, ADP, ATP
ÌÔÓÔ-, ‰È-, ÙÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË
ATPase cal CSF ‹ ENY CNS ‹ ∫¡™ cm CoA cmÑ cm2 cAMP ÆC CRP DNA ECG ‹ ∏∫° EEG ‹ ∏∂° ELISA ESR ‹ ∆∫∂ EDTA g Hct Hb HLA
ÙÚÈʈÛÊ·Ù¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ ıÂÚÌ›‰· ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂηÙÔÛÙfi Û˘Ó¤Ó˙˘ÌÔ ∞ ΢‚ÈÎfi ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢ÎÏÈÎfi AMP ‚·ıÌfi˜ KÂÏÛ›Ô˘ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‰ÂÔ͢ÚÈ‚Ô˙ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤Ó˙˘ÌÔ-Û˘Ó‰¤Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù·¯‡ÙËÙ· ηıÈ˙‹Ûˆ˜ ÂÚ˘ıÚÒÓ Âı˘ÏÂÓԉȷÌÈÓÔÙÂÙÚ·ÔÍÂ˚Îfi Ô͇ ÁÚ·ÌÌ¿ÚÈo ·ÈÌ·ÙÔÎÚ›Ù˘ ·ÈÌÔÛÊ·ÈÚ›ÓË ·ÓÙÈÁfiÓÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜
Ig ICU ‹ ª∂£ IU i.m. ‹ ∂.ª. i.p. ‹ ∂.¶. i.v. ‹ ∂.º. L log mol ªW ‹ MB MCH MCV mRNA m min n N NS ‹ ª™ Ôsm % PCR pH PCO2 PO2 p
·ÓÔÛÔÛÊ·ÈÚ›ÓË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚ο ÂÓ‰ÔÊϤ‚È· Ï›ÙÚÔ(·) ÏÔÁ¿ÚÈıÌÔ˜ ÁÚ·ÌÌÔÌfiÚÈÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ̤ÛË ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÚ˘ıÚÒÓ Ì¤ÛÔ˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ ·ÁÁÂÏÈÔÊfiÚÔ˜ RNA ̤ÙÚÔ ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÙÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·
acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability
xiv
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·
by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9
6
3
2
1
-1
-2
-3
-6
-9
-12
-15
-18
Combining prefixes T G M k h da d c m Ì n p f a
xv