ISSN 0377-2551
¶AI¢IATPIKH
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TOMO™ 66
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TEYXO™ 5
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ETO™ 2003
™ÂÙ¤Ì‚Ú ÈÔ˜ - √ÎÙÒ‚ÚÈ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 5
∞¡∞™∫O¶∏™∂π™ Henoch-Schonlein ÔÚʇڷ
REVIEW ARTICLES 327
™. ºÂÛÛ¿ÙÔ˘
™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1: ÁÂÓÂÙÈ΋ Î·È ·ÓÔÛÔÏÔÁÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘
S. Fessatou 334
∂. ¶··‰ÔÔ‡ÏÔ˘, ¢. ª·ÌÔ˘Ï¿Î˘, ™. ™ËÊ¿Î˘
ORIGINAL ARTICLES 344
π. ∫·Ï¤ÁÈ·˜, ∂. ¶··ıˆÌ¿, ™. °·‚Ú›ÏË, O. OÈÎÔÓÔÌ›‰Ô˘, ∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘, Ã. ¶ÂÙÚÔÔ‡ÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜
O ÚfiÏÔ˜ ÙÔ˘ power Doppler ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ÛÙ· ·È‰È¿
352
The role of power Doppler ultrasonography in the diagnosis of acute pyelonephritis in children N. Tsourounakis, S. Megremis, A. Schinaki, T. Tsekoura, S. Stefanaki, A. Tsilimigaki
357
∞. ∆Û·Ì·ÚÏ‹-∫ÈÙÛ·Ú¿, ∫. ∫Ô˘ÓÂÓÔ‡
¶ÂÚÈÁÚ·ÊÈ΋ ÂȉËÌÈÔÏÔÁ›· ·Ù˘¯ËÌ¿ÙˆÓ Û ¿ÙÔÌ· οو ÙˆÓ 24 ÂÙÒÓ Û ÁˆÁÚ·ÊÈο ÔÚÈÔıÂÙË̤ÓË ËÌÈ·ÛÙÈ΋ ÂÚÈÔ¯‹ Ù˘ £ÂÛÛ·Ï›·˜
Longitudinal study of bronchopulmonary dysplasia in very low birth weight infants J. Kaleyias, E. Papathoma, S. Gavrili, O. Ikonomidou, Z. Hatzistamatiou, C. Petropoulou, C. Costalos
¡. ∆ÛÔ˘ÚÔ˘Ó¿Î˘, ™. ªÂÁÚ¤Ì˘, ∞. ™¯ÔÈÓ¿ÎË, £. ∆ÛÂÎÔ˘Ú¿, ™. ™ÙÂÊ·Ó¿ÎË, ∞. ∆ÛÈÏÈÌÈÁοÎË
OÈ ÔÈÎÔÁÂÓÂȷΤ˜ Û¯¤ÛÂȘ ˆ˜ ·Ú¿ÁÔÓÙ·˜ Ú‡ıÌÈÛ˘ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 1
Type 1 diabetes mellitus: the genetic and immunological basis of the disease E. Papadopoulou, D. Mamoulakis, S. Sifakis
Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ ¢È·¯ÚÔÓÈ΋ ÌÂϤÙË Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ Û ÓÂÔÁÓ¿ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘
Henoch-Schonlein purpura
Family relationships as a factor in the control of type 1 diabetes mellitus A. Tsambarli-Kitsara, K. Kounenou
364
Descriptive epidemiology of accidents in people aged under 24 years in a semi-urban area of Thessaly
∞. ∞Ó·ÛÙ·Û›Ô˘, £. º·Ú̷ο΢, ¡. ¢ÂÛ‡Ú˘, ∫. ∫·ÙÛÈ·Ú‰¿Ó˘, •. ∑·‚ÈÙÛ¿ÓÔ˜
A. Anastasiou, T. Farmakakis, N. Dessypris, K. Katsiardanis, X. Zavitsanos
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
September - October 2003 . Volume 66 . No 5
™ÂÙ¤Ì‚Ú ÈÔ˜ - √ÎÙÒ‚ÚÈ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 5
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
CASE REPORTS
EN¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ ∞ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘
381
A. Kourtesis, G. Kalavrouziotis, C. Paphitis, G. Papadopoulos, E. Basta, P. Azariadis
∞. ∫Ô˘ÚÙ¤Û˘, °. ∫·Ï·‚ÚÔ˘˙ÈÒÙ˘, Ã. ¶·Ê›Ù˘, °. ¶··‰fiÔ˘ÏÔ˜, ∂. ª¿ÛÙ·, ¶. ∞˙·ÚÈ¿‰Ë˜
µ·ÚÈ¿ Û˘Ìو̷ÙÔÏÔÁ›· ıÚfiÌ‚ˆÛ˘ Û ‚Ú¤ÊÔ˜
387
Severe symptomatology of thrombosis in a baby G. Sideri, K. Papazoglou, M. Tsolia, K. Voudris, A. Skardoutsou, S. Aroni, I. Papadatos
°. ™È‰ÂÚ‹, ∫. ¶·¿˙ÔÁÏÔ˘, ª. ∆ÛÔÏÈ¿, ∫. µÔ‡‰Ú˘, ∞. ™Î·Ú‰Ô‡ÙÛÔ˘, ™. ∞ÚÒÓË, π. ¶··‰¿ÙÔ˜
NfiÛÔ˜ Kawasaki. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È Ó¤· ‰Â‰Ô̤ӷ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘
Anomalous origin of the right pulmonary artery from the ascending aorta. A case report
392
Kawasaki disease. A case report and new aspects of the pathogenesis of the disease ª. Polichronaki, V. Aggelakou, I. Charoniti
ª. ¶ÔÏ˘¯ÚÔÓ¿ÎË, µ. ∞ÁÁÂÏ¿ÎÔ˘, π. ÷ڈӛÙË
N∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
397
NEWS FROM THE INTERNET
∞¡∞∫OI¡ø™∏
401
ANNOUNCEMENT
™˘Ó¯›˙ÔÓÙ·È
Continued
S e p t e m b e r - O c t o b e r 2 0 0 3 .V o l u m e 6 6 . N o 5
™ÂÙ¤Ì‚Ú ÈÔ˜ - √ÎÙÒ‚ÚÈ Ô˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 5
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
∞¡OIKTH ∂¶π™∆O§∏
321
OPEN LETTER
∂¶π™∆O§∏ ¶ƒO™ ∆∏ ™À¡∆∞•∏
325
LETTER TO THE EDITOR
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xi
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xiv
Abbreviations
September - October 2003 . Volume 66 . No 5
™ÂÙ¤Ì‚Ú ÈÔ˜ - √ÎÙÒ‚ÚÈ Ô˜ 2003
.
∆fiÌÔ˜ 66
. ∆‡¯Ô˜
5
¢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
E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶. ∆۷ω¿ÚË 3, 151 22 M·ÚÔ‡ÛÈ TËÏ.: 210-61 41 360-5 Fax: 210-61 41 366
SCIENTIFIC PUBLICATIONS Ltd P. Tsaldari 3, Marousi 151 22 Tel.: 210-61 41 360-5 Fax: 210-61 41 366
EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹
40
EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜:
20
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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
Greek Editing I. Karavranou
Annual Subscription All foreign countries: US $ 50
September-October 2003 .Volume 66 . No 5
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;66:327-333
∞¡∞™∫O¶∏™∏
Paediatriki 2003;66:327-333
REVIEW ARTICLE
Henoch - Schonlein ÔÚʇڷ ™. ºÂÛÛ¿ÙÔ˘
Henoch - Schonlein purpura S. Fessatou
¶ÂÚ›ÏË„Ë: ∏ Henoch-Schonlein (HSP) Â›Ó·È Ì›· ·˘ÙÔ¿ÓÔÛË, ̤ۈ IgA Û˘ÌÏÂÁÌ¿ÙˆÓ, ·ÁÁÂÈ›Ùȉ· Ù˘ ·È‰È΋˜ ΢ڛˆ˜ ËÏÈΛ·˜, Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÙÚÈ¿‰· Û˘Ìو̿وÓ: ÔÚÊ˘ÚÈÎfi ÂÍ¿ÓıËÌ· ΢ڛˆ˜ ÛÙ· οو ¿ÎÚ·, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÓÂÊÚÈ΋ ÚÔÛ‚ÔÏ‹ ‹/Î·È ·ÚıÚ›Ùȉ·. ªÂÚÈΤ˜ ÊÔÚ¤˜, οÔÈÔ Û‡Ìو̷ Ù˘ ÙÚÈ¿‰·˜ ÌÔÚ› Ó· ·Ô˘ÛÈ¿˙ÂÈ Î·È ·˘Ùfi Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÔÚÔÛ·Ó·ÙÔÏÈÛÌfi ·fi ÙË ‰È¿ÁÓˆÛË. ∞Ó Î·È Ë ·ÈÙ›· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË, Û˘¯Ó¿ ¤¯ÂÈ ·Ú·ÙËÚËı› Û˘Û¯¤ÙÈÛË Ì ÏÔÈÌÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ Ô ÛÙÚÂÙfiÎÔÎÎÔ˜ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÙÔ Ì˘ÎfiÏ·ÛÌ·, Ê¿Ú̷η, ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ·, ‰‹ÁÌ·Ù· ÂÓÙfïÓ, ¤ÎıÂÛË ÛÙÔ ÎÚ‡Ô Î.Ï. ∏ ıÂڷ›· Â›Ó·È ˘ÔÛÙËÚÈÎÙÈ΋ Î·È ÔÈ ·ÛıÂÓ›˜ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘¯Ó‹ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜.
Abstract: Henoch-Schonlein purpura (HSP) is an IgA-mediated, autoimmune vasculitis of childhood with a triad of symptoms, comprising a purpuric rash occurring on the lower extremities, abdominal pain and/or renal involvement and arthritis. However, any feature of the triad may be absent, leading to confusion in diagnosis of the condition. Although the cause is unknown, HSP is often associated with infectious agents such as group A streptococci and Mycoplasma, or with drug allergies, food reactions, insect bites, exposure to cold, etc. Treatment is supportive and close followup of the renal status is indicated for children affected by this disorder.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏÂÚÁÈ΋ ÔÚʇڷ, HenochSchonlein ÔÚʇڷ, ·ÁÁÂÈ›Ùȉ·.
Key words: allergic purpura, Henoch-Schonlein purpura, vasculitis.
∂ÈÛ·ÁˆÁ‹ ∏ Henoch-Schonlein ÔÚʇڷ (HSP) Â›Ó·È Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· Î·È ·Ó·Ê¤ÚıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ Heberden ÙÔ 1806 (1). ∏ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÔÚÊ˘ÚÈÎÔ‡ ÂÍ·Óı‹Ì·ÙÔ˜ Ì ÙËÓ ·ÚıÚ·ÏÁ›· ÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ Johann Schonlein ÙÔ 1837 Î·È ÔÓÔÌ¿ÛÙËΠ“ÚÂ˘Ì·ÙÈ΋ ÂÏ›ˆÛË” (peliosis rheumatica) (2). ∆Ô 1874, Ô Eduard Henoch ÚfiÛıÂÛ ÙËÓ ÂÚÈÁÚ·Ê‹ 4 ·È‰ÈÒÓ Ì ‰ÂÚÌ·ÙÈ΋ ÔÚʇڷ Ô˘ Û˘Ó‰˘·˙fiÙ·Ó Ì ΈÏÈÎÔÂȉ‹ ÎÔÈÏȷο ¿ÏÁË, ·ÈÌÔÚÚ·Á›· ÙÔ˘ ÂÙÈÎÔ‡ Î·È ·ÚıÚ·ÏÁ›Â˜, ÂÓÒ ÙÔ 1899 ÂÈÛ‹Ì·Ó ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÓÂÊÚÒÓ ÛÙË ÓfiÛÔ (3,4). O fiÚÔ˜ “·Ó·Ê˘Ï·ÎÙÔÂȉ‹˜ ÔÚʇڷ” ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ Frank Î·È Î·ıÈÂÚÒıËΠÙÔ 1920 ·fi ÙÔÓ Glansmann (5,6). O Gairdner, ÙÔ 1946, ‹Ù·Ó ·˘Ùfi˜ Ô˘ ıÂÌÂÏ›ˆÛ ÙË
ʇÛË Ù˘ ·ÏÏÂÚÁÈ΋˜ ÔÚʇڷ˜, fiÙÈ ‰ËÏ·‰‹ ‰ÂÓ ÂÓ¤¯ÂÙ·È ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ Ë ·Ó·Ê˘Ï·Í›·, ·ÏÏ¿ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ·ÁÁÂÈ›Ùȉ· (7).
µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
2nd Paediatric Clinic, “P. & A. Kyriakou” Children’s Hospital, Athens
∂ȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· ∏ HSP Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÁÁÂÈ›Ùȉ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (8). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ ·Ó¤Ú¯ÂÙ·È ÂÚ›Ô˘ Û 10-14 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ÙÔ ¯ÚfiÓÔ (9). ∞Ó Î·È ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ›˜ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 86 ÂÙÒÓ, ÙÔ 75% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·ÊÔÚ¿ Û ·È‰È¿ ËÏÈΛ·˜ 2-10 ÂÙÒÓ, Ì ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Û ·È‰È¿ ËÏÈΛ·˜ 5 ÂÙÒÓ (10-12). ∞ӷʤÚÂÙ·È ÌÈÎÚ‹ ˘ÂÚÔ¯‹ ÙˆÓ ·ÁÔÚÈÒÓ Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·, fiˆ˜ Î·È Âԯȷ΋ ηٷÓÔÌ‹, Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÌÂٷ͇ ÊıÈÓÔÒÚÔ˘ Î·È ¿ÓÔÈ͢ (8,10,11,13).
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∞ÈÙÈÔÏÔÁ›· ∏ ·ÈÙ›· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË, ·Ó Î·È Ôχ Û˘¯Ó¿ ÚÔËÁÂ›Ù·È Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙÔ ¯ÂÈÌÒÓ· Î·È ÙËÓ ¿ÓÔÈÍË ˘ÔÛÙËÚ›˙ÂÈ ÙË ıˆڛ· fiÙÈ Î¿ÔÈÔ˜ ÏÔÈÌÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ˘ÚÔ‰ÔÙ› ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ Û ¢·›ÛıËÙ· ¿ÙÔÌ·. ¶ÔÏÏÔ› ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ HSP, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÛÙÚÂÙfiÎÔÎÎÔÈ Ù˘ ÔÌ¿‰·˜ ∞, ÙÔ Ì˘ÎfiÏ·ÛÌ·, ·‰ÂÓÔ˚Ô›, Ô Èfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·, ÙÔ ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡, Ë ˘ÂÚÛ›ÓÈ·, Ë ÛÈÁΤÏÏ·, Ë ÏÂÁÈÔÓ¤ÏÏ·, ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘, ÔÈ ÈÔ› coxsackie B, ÈÏ·Ú¿˜, ÂÚ˘ıÚ¿˜, Epstein-Barr, Ë·Ù›Ùȉ·˜ µ, HIV Î·È ·Ú‚Ô˚fi˜ B19 Î·È Ë Toxocara canis (8,14). ∞fi fiÏÔ˘˜ ÙÔ˘˜ ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË HSP, Ô ‚-·ÈÌÔÏ˘ÙÈÎfi˜ ÛÙÚÂÙfiÎÔÎÎÔ˜ ¤¯ÂÈ ÌÂÏÂÙËı› ÂÚÈÛÛfiÙÂÚÔ (9-11,13). ∂›Û˘, ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Ê¿Ú̷η (ÎÂÊÔ˘ÚÔÍ›ÌË, ‚·ÓÎÔÌ˘Î›ÓË), ηÎÔ‹ıÂȘ (Ï¢¯·ÈÌ›·, ϤÌʈ̷), ÂÌ‚fiÏÈ· (ÈÏ·Ú¿˜, ¯ÔϤڷ˜), ‰‹ÁÌ·Ù· ÂÓÙfïÓ, ˘ÂÚ¢·ÈÛıËÛ›· Û ÙÚÔʤ˜ Î·È ¤ÎıÂÛË ÛÙÔ ÎÚ‡Ô (14). ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ∏ ‰È¿ÁÓˆÛË Ù˘ HSP ‚·Û›˙ÂÙ·È Û ÎÏÈÓÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Î·È Ù›ıÂÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ¤Îı˘ÛË ÙÔ˘ ÎÏ·ÛÈÎÔ‡ ÂÍ·Óı‹Ì·ÙÔ˜. ∆Ô 1990, ÙÔ ∞ÌÂÚÈηÓÈÎfi ∫ÔϤÁÈÔ ƒÂ˘Ì·ÙÔÏÔÁ›·˜ ı¤ÛÈÛ 4 ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ HSP: ·) „ËÏ·ÊËÙfi ÔÚÊ˘ÚÈÎfi ÂÍ¿ÓıËÌ·, ‚) ËÏÈΛ· ≤20 ÂÙÒÓ, Á) Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ (‰È¿¯˘Ù· ÎÔÈÏȷο ¿ÏÁË ‹ ÈÛ¯·ÈÌ›· ÂÓÙ¤ÚÔ˘, Û˘Ó‹ıˆ˜ Ì ·ÈÌÔÚÚ·ÁÈΤ˜ ‰È¿ÚÚÔȘ) Î·È ‰) ·Ó‡ÚÂÛË ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ ‹ ÙˆÓ ÊÏ‚ȉ›ˆÓ Û ‚ÈÔ„›· ‰¤ÚÌ·ÙÔ˜ (ÂÈÎfiÓ· Ï¢ÎÔ΢ÙÙ·ÚÔÎÏ·ÛÙÈ΋˜ ·ÁÁÂÈ›Ùȉ·˜). °È· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ··ÈÙÔ‡ÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·fi Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· (15). ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ∏ ÓfiÛÔ˜ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÂÙ·È ˆ˜ Ì›· ÙÚÈ¿‰· Û˘Ìو̿وÓ, Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÚÔ˘Û›· „ËÏ·ÊËÙ‹˜ ÔÚʇڷ˜ ÛÙ· οو ¿ÎÚ·, ÎÔÈÏȷο ¿ÏÁË, ÓÂÊÚÈ΋ ÚÔÛ‚ÔÏ‹ ‹ Î·È ·ÚıÚ›Ùȉ·. ·) ∂Í¿ÓıËÌ·: ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÂÍ¿ÓıËÌ· Â›Ó·È „ËÏ·ÊËÙfi ÔÚÊ˘ÚÈÎfi, ‰È·Ì¤ÙÚÔ˘ 2-10 mm Î·È ·Ó¢ڛÛÎÂÙ·È ÛÙÔ 100% ÙˆÓ ·ÛıÂÓÒÓ. ™˘Ó‹ıˆ˜ Û˘ÚÚ¤ÂÈ ÛÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜ Î·È Ù· οو ¿ÎÚ·, ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ÛÙ· ¿Óˆ ¿ÎÚ·, ÙÔ ÚfiÛˆÔ Î·È Ù· ˆÙÈο ÙÂÚ‡ÁÈ· (ȉ›ˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ), ÂÓÒ ÔÈ ÂÎı‡ÛÂȘ ÛÙÔÓ ÎÔÚÌfi Â›Ó·È Û¿ÓȘ (11,16). ªÂÚÈΤ˜ ÊÔÚ¤˜, ÔÈ ÂÎı‡ÛÂȘ ÎËÏȉԂϷÙÈ‰Ò‰Ô˘˜ ÎÓȉˆÙÈÎÔ‡ ÂÍ·Óı‹Ì·ÙÔ˜ ÚÔËÁÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ ·fi 24 ÒÚ˜ ÙˆÓ ÔÚÊ˘ÚÈÎÒÓ ‚Ï·‚ÒÓ (7).
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‚) ∞ÚıÚ›Ùȉ·: ∏ ·ÚıÚ›Ùȉ· Â›Ó·È Ë ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ∂ÌÊ·Ó›˙ÂÙ·È Û 60-85% ÙˆÓ ·ÛıÂÓÒÓ Î·È Â›Ó·È ÙÔ ÚÒÙÔ Û‡Ìو̷ Ù˘ ÓfiÛÔ˘ Û 25% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (8,13). ™˘¯ÓfiÙÂÚ· ÚÔÛ‚¿ÏÏÔÓÙ·È ÔÈ Î·Ù¿ ÁfiÓ˘ Î·È Ô‰ÔÎÓËÌÈΤ˜ ·ÚıÚÒÛÂȘ ηÈ, Û·ÓÈfiÙÂÚ·, ÔÈ ·ÚıÚÒÛÂȘ ÙˆÓ ¿Óˆ ¿ÎÚˆÓ (·ÁÎÒÓ˜, ηÚÔ›) (8,11,14). ¢ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› Â¿Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÏËıÈÓ‹ ÊÏÂÁÌÔÓ‹ ÙÔ˘ ·ÚıÚÈÎÔ‡ ˘Ì¤Ó·, ·ÊÔ‡ Ï›ÁÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ·Ó¿Ï˘ÛË ·ÚıÚÈÎÔ‡ ˘ÁÚÔ‡ ‹ ‚ÈÔ„›·. ∂›Ó·È ۯ‰fiÓ Û›ÁÔ˘ÚÔ fiÙÈ ÙÔ ÂÚÈ·ÚıÚÈÎfi Ô›‰ËÌ· ÙˆÓ Ì·Ï·ÎÒÓ ÈÛÙÒÓ Û˘Ì‚¿ÏÏÂÈ ÛÙË Û˘Ìو̷ÙÔÏÔÁ›· fiÛÔ Î·È Ë ÂÓ‰Ô·ÚıÚÈ΋ ·ıÔÏÔÁ›·. ∏ ·ÚıÚ›Ùȉ· Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË Î·È ‰ÂÓ Î·Ù·Ï›ÂÈ ·Ú·ÌÔÚÊÒÛÂȘ. Ÿˆ˜ Î·È ÙÔ ÔÚÊ˘ÚÈÎfi ÂÍ¿ÓıËÌ·, Ë ·ÚıÚ›Ùȉ· ‚ÂÏÙÈÒÓÂÙ·È Ì ÙÔÓ ÎÏÈÓÔÛÙ·ÙÈÛÌfi Î·È ÂȉÂÈÓÒÓÂÙ·È Ì ÙËÓ ÎÈÓËÙÔÔ›ËÛË (8,10,14). Á) °·ÛÙÚÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ: ™˘ÌÌÂÙÔ¯‹ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û 50-75% ÙˆÓ ·ÛıÂÓÒÓ (10,11,17). ™˘Ó‹ıÂȘ ÂΉËÏÒÛÂȘ ·ÔÙÂÏÔ‡Ó Ù· ÎÔÈÏȷο ¿ÏÁË, ÂÓÒ Û 14-36% ÙˆÓ ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÚÔËÁÔ‡ÓÙ·È ÙˆÓ ÂÎı‡ÛÂˆÓ ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ (18). ∆· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ÔÊ›ÏÔÓÙ·È ÛÙÔ Ô›‰ËÌ· ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·fi ÙËÓ ·ÁÁÂÈ›Ùȉ·. ™Â ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÎÔÈÏ›·˜ ·Ú·ÙËÚÔ‡ÓÙ·È ÔÏ˘ÂÛÙȷΤ˜ ÂÚÈÔ¯¤˜ ¿¯˘ÓÛ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ô›‰ËÌ· ÙÔ˘ ÌÂÛÂÓÙÂÚ›Ô˘, ·ÁÁÂȷ΋ Û˘ÌÊfiÚËÛË Î·È ÌË ÂȉÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· (19). OÈ Î‡ÚȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ·fi ÙË Á·ÛÙÚÂÓÙÂÚÈ΋ Ô‰fi ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â̤ÙÔ˘˜, ‰È¿ÚÚÔȘ, ÂÚÈÔÌÊ·ÏÈο ÎÔÈÏȷο ¿ÏÁË Ô˘ ÌÈÌÔ‡ÓÙ·È ÛΈÏËÎÔÂȉ›Ùȉ· Î·È ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ. ª·˙È΋ ·ÈÌÔÚÚ·Á›· ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÂÚ›Ô˘ 2% ÙˆÓ ·ÛıÂÓÒÓ (15). ªÔÚ› ·ÎfiÌË Ó· Û˘Ì‚Â› ·fiÊÚ·ÍË ÂÓÙ¤ÚÔ˘ ‹/Î·È ‰È¿ÙÚËÛË. ∞Ó Î·È ÌÔÚ› Ó· ÚÔÛ‚ÏËı› ÔÔÈÔ‰‹ÔÙ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘, Û˘¯ÓfiÙÂÚ· ¿Û¯Ô˘Ó ÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ Î·È Ô ÂÈÏÂfi˜ (8). ª›· Ôχ ÛÔ‚·Ú‹ ÂÈÏÔ΋ Â›Ó·È Ô ÂÁÎÔÏ·ÛÌfi˜, Ô˘ Û˘Ì‚·›ÓÂÈ Û 1-5% ÙˆÓ ·ÛıÂÓÒÓ (10,11,13,14). °È· ÙË ‰È¿ÁÓˆÛË ‹ ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘, ÂͤٷÛË ÂÎÏÔÁ‹˜ ·ÔÙÂÏ› ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ (20). ‰) ¡ÂÊÚÈ΋ ÚÔÛ‚ÔÏ‹: ∏ ÈÔ ÛÔ‚·Ú‹ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÓÂÊÚÒÓ. ∆Ô ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÚÔÛ‚¿ÏÏÂÙ·È ·fi ÓÂÊÚ›Ùȉ· Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 20-50% (·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ: ~25%, ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿: ~50%) (10,11,21). ∆· ÔÛÔÛÙ¿ ·˘Ù¿ ÌÔÚ› Ó· Â›Ó·È ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚ·, ·ÊÔ‡ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ·ÛıÂÓ›˜ ÌfiÓÔ Ì ˘¤ÚÙ·ÛË, ¯ˆÚ›˜ ÂΉËÏÒÛÂȘ ·ÈÌ·ÙÔ˘Ú›·˜ ‹ ÚˆÙÂ˚ÓÔ˘Ú›·˜ (22). ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ·ÚıÚ›Ùȉ· Î·È ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Ë ÓÂÊÚ›Ùȉ· Ôχ Û¿ÓÈ· ÚÔËÁÂ›Ù·È Ù˘ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ (10).
¶·È‰È·ÙÚÈ΋ 2003;66:327-333
∆Ô 80% ÙˆÓ ·ÛıÂÓÒÓ ÂΉËÏÒÓÂÈ ÙË ÓÂÊÚ›Ùȉ· Û ‰È¿ÛÙËÌ· 4 ‚‰ÔÌ¿‰ˆÓ Î·È ÙÔ 95% Û ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (23,24). ∞Ó Î·È Ë ÂÌÊ¿ÓÈÛË Ù˘ ÓÂÊÚ›Ùȉ·˜ ÌÂÙ¿ ÙÔ˘˜ 3 Ì‹Ó˜ Â›Ó·È Û¿ÓÈ·, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Ì¤¯ÚÈ Î·È 5 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (23,24). ∏ ·ÚÈ· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓÂÊÚ›Ùȉ·˜ Â›Ó·È Ë ·ÈÌ·ÙÔ˘Ú›·. ™¯Â‰fiÓ ÛÙ·ıÂÚfi ‡ÚËÌ· Ù˘ ÓÂÊÚÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ ·ÔÙÂÏ› Ë ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›·, ÂÓÒ ÂÚ›Ô˘ 40% ÙˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›·. ¶ÚˆÙÂ˚ÓÔ˘Ú›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÈÌ·ÙÔ˘Ú›· ·Ú·ÙËÚÂ›Ù·È ÛÙ· 2/3 ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ ÚˆÙÂ˚ÓÔ˘Ú›· ¯ˆÚ›˜ ·ÈÌ·ÙÔ˘Ú›· Û˘Ì‚·›ÓÂÈ Ôχ Û¿ÓÈ· (10,11,23,24). ∏ ÓÂÊÚ›Ùȉ· Â›Ó·È Ë ÌfiÓË ÂΉ‹ÏˆÛË Ù˘ HSP Ô˘ ÌÔÚ› Ó· ÂÍÂÏȯı› Û ¯ÚfiÓÈ· ÓfiÛÔ. ∞Ó Î·È ÔÛÔÛÙfi 30-50% ÙˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ÂÈ̤ÓÔ˘Û˜ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ÂͤٷÛË Ô‡ÚˆÓ, Û ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË, ÌfiÓÔ ÙÔ 1% ·fi ·˘ÙÔ‡˜ ÂÍÂÏ›ÛÛÔÓÙ·È Û ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ÓfiÛÔ (21,25). ¶ÔÏÏÔ› ÌÂÏÂÙËÙ¤˜ ¤¯Ô˘Ó ÚÔÛ·ı‹ÛÂÈ Ó· Û˘Û¯ÂÙ›ÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ Ù˘ HSP Ì ÙËÓ ÎÏÈÓÈ΋ ‚·Ú‡ÙËÙ· Î·È ÙË ÓÂÊÚÈ΋ ÈÛÙÔ·ıÔÏÔÁ›·. Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ˘„ËÏÔ› Ù›ÙÏÔÈ IgA ·ÓÙÈÂÓ‰ÔıËÏÈ·ÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ˘„ËÏ¿ ›‰· ıÚÔÌ‚ÔÌÔÓÙÔ˘Ï›Ó˘ ÛÙÔÓ ÔÚfi ÌÔÚ› Ó· ·ÔÙÂÏÔ‡Ó ÎÏÈÓÈο ¯Ú‹ÛÈÌÔ˘˜ ‰Â›ÎÙ˜ ÓÂÊÚÈ΋˜ ÚÔÛ‚ÔÏ‹˜ (26). °ÂÓÈο, ÔÈ ·ÛıÂÓ›˜ Ì ÌÂÌÔӈ̤ÓË ·ÈÌ·ÙÔ˘Ú›·, Ì ‹ ¯ˆÚ›˜ ÌÈÎÚ‹ ÚˆÙÂ˚ÓÔ˘Ú›·, ¤¯Ô˘Ó ηϋ ÚfiÁÓˆÛË. ∞ÓÙ›ıÂÙ·, ÔÛÔÛÙfi ÂÚ›Ô˘ 50% ÙˆÓ ·È‰ÈÒÓ Ì ÓÂÊÚ›Ùȉ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÌÂÙ¿ ·fi 10 ¯ÚfiÓÈ· (21,23-25). ∏ ‚·Ú‡ÙËÙ· Ù˘ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ Î·È Ë ÙÂÏÈ΋ ¤Î‚·ÛË Û¯ÂÙ›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ٷ ÈÛÙÔ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜. ∏ η΋ ÚfiÁÓˆÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÌËÓÔÂȉÒÓ Û¯ËÌ·ÙÈÛÌÒÓ Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 50% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ (21,23,25). ∞ÓÂÍ¿ÚÙËÙ·, fï˜, ·fi ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ‹ Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÓÂÊÚ›Ùȉ· ¯ÚÂÈ¿˙ÔÓÙ·È Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· Û˘Ì‚Â› ÔÏÏ¿ ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· (27). OÈ Goldstein Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ 16 ·fi 44 (36%) ÂÁ΢ÌÔÛ‡Ó˜ 24 Á˘Ó·ÈÎÒÓ Ô˘ ›¯·Ó HSP ÛÙËÓ ·È‰È΋ ÙÔ˘˜ ËÏÈΛ·, ÂÈϤ¯ıËÎ·Ó Ì ڈÙÂ˚ÓÔ˘Ú›· ‹ Ì ˘¤ÚÙ·ÛË (28). ™‡Ìʈӷ Ì ¤Ó·Ó ·ÏÁfiÚÈıÌÔ ¯ÂÈÚÈÛÌÔ‡ Ù˘ ÓÂÊÚ›Ùȉ·˜ Ô˘ ÚÔÙ›ÓÂÙ·È, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Ì ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ, ÎÚ·ÙÈÓ›Ó˘ ·›Ì·ÙÔ˜ Î·È Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ηٿ ÙÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘. ∏ ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÂÙ·È ÙÔ˘Ï¿¯È-
Paediatriki 2003;66:327-333
ÛÙÔÓ Î¿ı 7 Ë̤Ú˜, fiÛÔ Ë ÓfiÛÔ˜ Â›Ó·È ÂÓÂÚÁ‹. ∂¿Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂΉËÏÒÛÂȘ ÓÂÊÚ›Ùȉ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘Ù‹˜ Ù˘ ÂÚÈfi‰Ô˘, ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Ì ÁÂÓÈ΋ Ô‡ÚˆÓ Ì›· ÊÔÚ¿ οı ̋ӷ, ÁÈ· 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÂÍ¿ÏÂÈ„Ë fiÏˆÓ ÙˆÓ ÂΉËÏÒÛˆÓ. ∏ ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û οı ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. OÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÓÂÊÚ›Ùȉ· Û ÔÔÈ·‰‹ÔÙ ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹, Ú¤ÂÈ Ó· ÌÂÙÚÔ‡Ó Û˘¯Ó¿ ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Î·È ÙËÓ ÎÚ·ÙÈÓ›ÓË ·›Ì·ÙÔ˜, ¤ˆ˜ fiÙÔ˘ Ë ÓÂÊÚ›Ùȉ· ·ÚÔ˘ÛÈ¿ÛÂÈ ‡ÊÂÛË. ∞ÎfiÌ·, ÔÈ Á˘Ó·›Î˜ Ì ÈÛÙÔÚÈÎfi ÓÂÊÚ›Ùȉ·˜ ·fi HSP ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Ú¤ÂÈ Ó· οÓÔ˘Ó Û˘¯Ó¿ ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ï¢ÎÒÌ·ÙÔ˜ Î·È Ó· ÌÂÙÚÔ‡Ó ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. ¡ÂÊÚÈ΋ ‚ÈÔ„›· ÂӉ›ÎÓ˘Ù·È Û ·ÛıÂÓ›˜ Ì ÓÂÊÚ›Ùȉ· Ô˘ ¤¯ÂÈ ÂÈϷΛ Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ˘¤ÚÙ·ÛË ‹ οÔÈÔ˘ ‚·ıÌÔ‡ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÒÛÙ ӷ ÌÔÚ› Ó· Á›ÓÂÈ ÈÔ ÛˆÛÙ‹ ÚfiÁÓˆÛË (8). Â) ÕÏϘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ: ÕÏϘ Û¿ÓȘ Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ HSP Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ¶ÔÚ›· Ù˘ ÓfiÛÔ˘ ªÂ ÂÍ·›ÚÂÛË ÙË ÓÂÊÚ›Ùȉ·, Ë HSP Â›Ó·È Ì›· ÔÍ›· ÓfiÛÔ˜ Ô˘ ‰È·ÚΛ ·fi ÌÂÚÈΤ˜ Ë̤Ú˜ ¤ˆ˜ ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜. ∫·Ù¿ ̤ÛÔ fiÚÔ, Ë ‰È¿ÚÎÂÈ¿ Ù˘ Â›Ó·È 4 ‚‰ÔÌ¿‰Â˜, Ì ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 3 ‚‰ÔÌ¿‰Â˜ ¤ˆ˜ 2 ¯ÚfiÓÈ·, ÂÓÒ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ ·Ó·ÚÚÒÓÂÈ Û 6-8 ‚‰ÔÌ¿‰Â˜ (8,10,11). ¶ÔÛÔÛÙfi ÂÚ›Ô˘ 30-40% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙ÂÈ Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ˘ÔÙÚÔ¤˜ ÙˆÓ Û˘Ìو̿وÓ, ÂÓÒ ÙÔ 94% ·fi ·˘ÙÔ‡˜ ÙȘ ÂÌÊ·Ó›˙ÂÈ Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ 4 Ì‹Ó˜. OÈ ˘ÔÙÚÔ¤˜ Â›Ó·È ÈÔ Û˘¯Ó¤˜ Û ·ÛıÂÓ›˜ Ì ÓÂÊÚ›Ùȉ· (8,10,11). ∂ÚÁ·ÛÙËÚȷο Î·È ÈÛÙÔ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∏ ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈ΋ ‹ ‰Â›¯ÓÂÈ ‹È· Ï¢ÎÔ΢ÙÙ¿ÚˆÛË. O ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜, ÂÓÒ ÌÔÚ› Ó· Â›Ó·È ·˘ÍË̤ÓÔ˜ Û ·ÛıÂÓ›˜ Ì ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ ‹ ·ÈÌÔÚÚ·Á›· ÂÙÈÎÔ‡ (8,15). O Ê˘ÛÈÔÏÔÁÈÎfi˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ ‰È·ÊÔÚÔÔÈ› ÙËÓ HSP ·fi ÙËÓ È‰ÈÔ·ı‹ ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ. ∞Ó Î·È Ë ·ÈÌÔÚÚ·Á›· Â›Ó·È Ë Î‡ÚÈ· ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘, Ô ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ Î·È Ô ¯ÚfiÓÔ˜ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎÔ›. ªÂÚÈΤ˜ ÊÔÚ¤˜, ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ¤¯Ô˘Ó ÂÏ·Ùو̤ӷ ›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· Ãπππ (29). ™Â ÌÂÚÈΤ˜ ÌÂϤÙ˜, Ù· ¯·ÌËÏ¿ ›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· Ãπππ Û˘Ó‰¤ÔÓÙ·È Ì ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi (30).
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Paediatriki 2003;66:327-333
¶›Ó·Î·˜ 1. ™¿ÓȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ HSP ¡Â˘ÚÈÎfi Û‡ÛÙËÌ·
¢¤ÚÌ· ª˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ· O˘ÚÔÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· °·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·
∞Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ∫˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ· OÊı·ÏÌÔ› ÕÏÏ·
∫ÂÊ·Ï·ÏÁ›·, ¢ÂÚÂıÈÛÙfiÙËÙ·, Û·ÛÌÔ›, ˘·ÈÛıËÛ›·, ·Ê·Û›·, ¿ÚÂÛË, ¯ÔÚ›·, ·Ù·Í›·, ÊÏÔÈ҉˘ Ù‡ÊψÛË, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, Ó¢ÚÔ¿ıÂÈ· ÎÚ·ÓÈ·ÎÒÓ Ó‡ڈÓ, ÂÚÈÊÂÚÈ΋ ÌÔÓÔÓ¢ÚÔ¿ıÂÈ·, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈΤ˜ ·ÓˆÌ·Ï›Â˜, ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜, Guillain-Barre º˘ÛÛ·Ïȉ҉ÂȘ ‚Ï¿‚˜ ª˘ÔÛ›Ùȉ·, ·ÈÌÔÚÚ·Á›· ÛÙÔ˘˜ Ì˘˜ OÚ¯›Ùȉ·, ·ÈÌÔÚÚ·ÁÈ΋ ΢ÛÙ›Ùȉ·, ·fiÊÚ·ÍË Ô˘ÚËÙ‹ÚˆÓ ∂ÓÙÂÚÔ¿ıÂÈ· Ì ·ÒÏÂÈ· ÚˆÙ½Ó˘, ·ÁÎÚ·ٛÙȉ·, ¯ÔÏÔ΢ÛÙ›Ùȉ·, ÈÛ¯·ÈÌÈ΋ ¯ÔÏ·ÁÁÂÈÔ¿ıÂÈ·, ‡‰Úˆ·˜ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜, ·ÙÂÏ‹˜ ·fiÊÚ·ÍË ÂÓÙ¤ÚÔ˘, ‰È¿ÙÚËÛË ÂÓÙ¤ÚÔ˘, ÛÙ¤ÓˆÛË ÔÈÛÔÊ¿ÁÔ˘ ‹/Î·È ÂÓÙ¤ÚÔ˘, ·fiÊÚ·ÍË ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘, „¢‰ÔÌÂÌ‚Ú·Ó҉˘ ÎÔÏ›Ùȉ· ¶Ó¢ÌÔÓÈ΋ ·ÈÌÔÚÚ·Á›· ∫·Ú‰›Ùȉ· ¶ÚfiÛıÈ· Ú·ÁÔÂȉ›Ùȉ· ∞ÓÙÈʈÛÊÔÏÈȉÈÎfi Û‡Ó‰ÚÔÌÔ
∏ IgA Â›Ó·È Ë ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ô˘ ·›˙ÂÈ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ HSP. ¶ÂÚ›Ô˘ 60% ÙˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ·˘ÍË̤ӷ ›‰· IgA ÛÙÔ ·›Ì· (31). À¿Ú¯Ô˘Ó ‰‡Ô ˘ÔÙ‡ÔÈ IgA: Ë IgA1 Î·È Ë IgA2. Œ¯ÂÈ ‚ÚÂı› fiÙÈ Ë HSP Û¯ÂÙ›˙ÂÙ·È Ì ·ÓˆÌ·Ï›Â˜ Ô˘ ·ÊÔÚÔ‡Ó ÌfiÓÔ ÛÙËÓ IgA1 Î·È fi¯È ÛÙËÓ IgA2. ∏ ·ÈÙ›· ÁÈ· ÙËÓ ·ÔÎÏÂÈÛÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Ù˘ IgA1 ÛÙËÓ ·ÓÔÛÔ·ıÔÁ¤ÓÂÈ· Ù˘ HSP ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË (32-34). ∏ HSP Â›Ó·È Ì›· Ï¢ÎÔ΢ÙÙ·ÚÔÎÏ·ÛÙÈ΋ ·ÁÁÂÈ›Ùȉ·, Ë ÔÔ›· ·ÊÔÚ¿ ÛÙ· ÌÈÎÚ¿ ·ÁÁ›· (·ÚÙËÚÈfiÏÈ· Î·È ÊÏ‚›‰È·). ∆· ¯·Ú·ÎÙËÚÈÛÙÈο ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰ÈËı‹ÛÂȘ ·fi Ô˘‰ÂÙÂÚfiÊÈÏ·, ̤۷ Î·È Á‡Úˆ ·fi Ù· ‰ÂÚÌ·ÙÈο ·ÁÁ›· (7,32). ªÂϤÙ˜ Ì ·ÓÔÛÔÊıÔÚÈÛÌfi ·ÔÎ¿Ï˘„·Ó ÂÓ·Ôı¤ÛÂȘ ÎÔÎΛˆÓ IgA Î·È ÏÈÁfiÙÂÚ˜ ÂÓ·Ôı¤ÛÂȘ ·fi Û˘Ìϋڈ̷ C3 Î·È ÈÓÈ΋ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ·ÁÁ›ˆÓ (32). ∆· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ ÔÈΛÏÔ˘Ó ·fi ÂÏ¿¯ÈÛÙ˜ ·ÏÏÔÈÒÛÂȘ ̤¯ÚÈ ÂÛÙȷ΋ ‹ ‰È¿¯˘ÙË ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›·, Ë ÔÔ›· ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ÛÂÈÚ·Ì·ÙÈÎÔ‡˜ ÌËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ‡˜ (23-25). ∆· ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ·fi ÙÔÓ ·ÓÔÛÔÊıÔÚÈÛÌfi Â›Ó·È ‰È¿¯˘Ù˜ ÌÂÛ·ÁÁÂȷΤ˜ ÂÓ·Ôı¤ÛÂȘ ·fi IgA (23,32). ™Â ÌÂÚÈο ‰Â›ÁÌ·Ù· ‚ÈÔ„›·˜ ÌÔÚ› Ó· ˘¿Ú¯Ô˘Ó ÂÓ·Ôı¤ÛÂȘ C3 Î·È ÚÔÂÚ‰›Ó˘ (23). ∏ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Â›Ó·È fiÌÔÈ· Ì ·˘Ù‹ Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÔÚʇڷ˜. ŸÌˆ˜, Ù· Â˘Ú‹Ì·Ù· ÁÈ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ·fi ÙÔ˘˜ ÔÚÔÏÔÁÈÎÔ‡˜ ÂϤÁ¯Ô˘˜ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (35). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÚÔÛ·ıÔ‡Ó Ó· ηıÔÚ›ÛÔ˘Ó ÙÔÓ ÚfiÏÔ Ù˘ ÂÓ‰ÔıËÏ›Ó˘-1 Î·È ¿ÏÏˆÓ Î˘ÙÔÎÈÓÒÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ HSP (36,37). ªÂÏÂÙËÙ¤˜ ¤¯Ô˘Ó ‰È·ÈÛÙÒÛÂÈ Û˘Û¯¤ÙÈÛË Ù˘
330
HSP Ì ٷ HLA B18, B35 Î·È DR4, ηıÒ˜ Î·È ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ DRB1*01 Î·È DRB1*11 Û ·ÛıÂÓ›˜ Ì HSP (38,39). ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ∏ HSP ¤¯ÂÈ ÔÏϤ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, ÔÈ Ôԛ˜ Â›Ó·È ÎÔÈÓ¤˜ Ì ¿ÏϘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂÈ›Ùȉ˜, ȉȷ›ÙÂÚ· Ì ÙË Wegener Î·È ÙË ÌÈÎÚÔÛÎÔÈ΋ ÔÏ˘·ÁÁÂÈ›Ùȉ· (microscopic polyvasculitis). ∆· IgG ΢ÙÔÏ·ÛÌÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ (cANCA) ˘¿Ú¯Ô˘Ó Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ÎÔÎÎȈ̿وÛË Wegener, ÂÓÒ Ù· ÂÚÈ˘ÚËÓÈο ·ÓÙÈÛÒÌ·Ù· (pANCA) Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÔÏ˘·ÁÁÂÈ›Ùȉ· (40). ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ·ÔÙ‡¯ÂÈ Ó· ‚ÚÔ˘Ó IgG ANCA Û ·ÛıÂÓ›˜ Ì HSP, ÂÓÒ ÎÏ·ÛÈΤ˜ ̤ıÔ‰ÔÈ Ì ·ÓÔÛÔÊıÔÚÈÛÌfi ÁÈ· ·Ó›¯Ó¢ÛË IgG ANCA ‚Ô‹ıËÛ·Ó ÛÙÔÓ ‰È·¯ˆÚÈÛÌfi Ù˘ HSP ·fi Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂÈ›Ùȉ˜, fiˆ˜ Ë Wegener Î·È Ë ÌÈÎÚÔÛÎÔÈ΋ ÔÏ˘·ÁÁÂÈ›Ùȉ· (41,42). £Âڷ›· ¢ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ıÂڷ›·. ∏ ·ÁˆÁ‹ Â›Ó·È Î˘Ú›ˆ˜ ˘ÔÛÙËÚÈÎÙÈ΋ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÏÈÓÔÛÙ·ÙÈÛÌfi Î·È Â·Ú΋ ÂÓ˘‰¿ÙˆÛË. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÛÙË ıÂڷ›· Ù˘ HSP ·fi ÙÔ 1950, ÂÓÒ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û·Ê‹ ‰Â‰Ô̤ӷ fiÙÈ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙÔ ÔÚÊ˘ÚÈÎfi ÂÍ¿ÓıËÌ·, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ ‹ ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ˘ÔÙÚÔÒÓ (8). ™Â ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÌÔÚ› Ó· ÂÈÙ·¯‡ÓÔ˘Ó ÙËÓ ‡ÊÂÛË Ù˘ ·ÚıÚ›Ùȉ·˜ Î·È ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ (8,43). ∆· ‰Â‰Ô̤ӷ Â›Ó·È Ï›Á· fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÂÙÈ΋ ‰Ú¿ÛË ÙÔ˘˜, fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È ÛÙȘ Û˘ÓËıÈṲ̂Ó˜ ‰fiÛÂȘ, ÛÙË ıÂڷ›· ÂÁηÙÂÛÙË̤Ó˘ ÓÂÊÚ›Ùȉ·˜ (25,44). ™˘Ó‹ıˆ˜, ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û ·È‰È¿ Ì ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Î·È ‹ÈÔ˘ ‚·ıÌÔ‡
¶·È‰È·ÙÚÈ΋ 2003;66:327-333
ÓÂÊÚ›Ùȉ·. ŸÌˆ˜, Ë ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ (30 mg/kg/24ˆÚÔ ÁÈ· 3 Ë̤Ú˜) ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ ÂÓ‰ÔÊÏ‚›ˆ˜, ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜ ·fi ÙÔ ÛÙfiÌ·, ÌfiÓÔ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˙·ıÈÔÚ›ÓË ‹ ΢ÎÏÔʈÛÊ·Ì›‰Ë, ÌÔÚ› Ó· ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ ‰Ú¿ÛË Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ÓÂÊÚ›Ùȉ· (·ÈÌ·ÙÔ˘Ú›·, ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ÂÏ·Ùو̤ÓË GFR, ‡·ÚÍË ÛÙË ‚ÈÔ„›· >50% ÌËÓÔÂȉÒÓ Û¯ËÌ·ÙÈÛÌÒÓ) (8,45-48). ∏ ÚÔʇϷÍË ·fi ÙËÓ fi„ÈÌË ÂÌÊ¿ÓÈÛË ÓÂÊÚ›Ùȉ·˜ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ï‹ ÙÂÏÈ΋ ÚfiÁÓˆÛË Ù˘ HSP. ªÂÚÈΤ˜ ÌÂϤÙ˜ ÚÔÛ·ıÔ‡Ó Ó· ··ÓÙ‹ÛÔ˘Ó ÛÙÔ ÂÚÒÙËÌ· Â¿Ó Ë ÚÒÈÌË ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔÊ˘Ï¿ÛÛÂÈ ·fi ÙËÓ fi„ÈÌË ÂÌÊ¿ÓÈÛË ÓÂÊÚ›Ùȉ·˜, Ì ·ÓÙÈÊ·ÙÈο fï˜ ·ÔÙÂϤÛÌ·Ù· (49,50). ∏ ‰·„fiÓË Ê·›ÓÂÙ·È Ó· Âȉڿ ıÂÙÈο ÛÙÔ ÂÍ¿ÓıËÌ· Î·È Èı·ÓfiÓ ‚Ú·¯‡ÓÂÈ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘. ∂›Ó·È Èı·Ófi fiÙÈ ‰Ú· ̤ۈ ·Ó·ÛÙÔÏ‹˜ Ù˘ ·ÏÏËÏ›‰Ú·Û˘ IgA Î·È Ô˘‰ÂÙÂÚfiÊÈÏˆÓ (51). ÃÚÂÈ¿˙ÔÓÙ·È ÔÏϤ˜ ÌÂϤÙ˜ ·ÎfiÌ· ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ›‰Ú·Û‹˜ Ù˘ ÛÙËÓ HSP. OÚÈṲ̂ÓÔÈ ÌÂÏÂÙËÙ¤˜ ÚÔÙ›ÓÔ˘Ó ÙË ¯ÔÚ‹ÁËÛË ·Ú¿ÁÔÓÙ· Ãπππ ÁÈ· ÙË ıÂڷ›· ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ Î·È Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (29,52). ∏ Ï·ÛÌ·Ê·›ÚÂÛË ¤¯ÂÈ ÂÊ·ÚÌÔÛÙ› Ì ÂÈÙ˘¯›· Û ϛÁÔ˘˜ ·ÛıÂÓ›˜ Ì ٷ¯¤ˆ˜ ÂÍÂÏÈÛÛfiÌÂÓË ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·. ™Â ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤¯ÂÈ ¯ÔÚËÁËı› ÂÓ‰ÔÊϤ‚È· ‹ ÂÓ‰ÔÌ˘˚ο Á-ÛÊ·ÈÚ›ÓË (53-55). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ HSP Â›Ó·È Ì›· ÔÍ›· Ï¢ÎÔ΢ÙÔÎÏ·ÛÙÈ΋ ·ÁÁÂÈ›Ùȉ· Ô˘ ΢ڛˆ˜ ·ÊÔÚ¿ Û ·È‰È¿. OÈ Î‡ÚȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Â›Ó·È ÙÔ ÔÚÊ˘ÚÈÎfi ÂÍ¿ÓıËÌ·, Ë ·ÚıÚ›Ùȉ·, ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Ë ·ÈÌÔÚÚ·Á›· ÂÙÈÎÔ‡ Î·È Ë ÓÂÊÚ›Ùȉ·. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË, fï˜ Â›Ó·È ·Ô‰Â‰ÂÈÁ̤ÓÔ fiÙÈ Ë IgA ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÓÔÛÔ·ıÔÁ¤ÓÂÈ·, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛ‹ Ù˘ ÛÙÔÓ ÔÚfi, Ù· ΢ÎÏÔÊÔÚÔ‡ÓÙ· IgA ·ÓÔÛÔÛ˘ÌϤÁÌ·Ù· Î·È ÙËÓ ÂÓ·fiıÂÛ‹ Ù˘ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ·ÁÁ›ˆÓ Î·È ÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙˆÓ ÓÂÊÚÒÓ. ∏ HSP Û¯ÂÙ›˙ÂÙ·È Ì ·ÓˆÌ·Ï›Â˜ Ô˘ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο ÛÙËÓ IgA1 Î·È fi¯È ÛÙËÓ IgA2. ∞Ó Î·È ÔÏÏ¿ Â˘Ú‹Ì·Ù· Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÛÙËÓ HSP, Ë Î‡ÚÈ· ‚¿ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ IgA ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË. ∞Ó Î·È Ë HSP Â›Ó·È ÔÍ›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÓfiÛÔ˜, ÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ ·ÛıÂÓÒÓ ı· ¤¯ÂÈ Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ˘ÔÙÚÔ¤˜ ÙˆÓ Û˘Ìو̿وÓ. ∏ ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÌÔÚ› Ó· ÂÈÙ·¯‡ÓÂÈ ÙËÓ ‡ÊÂÛË Ù˘ ·ÚıÚ›Ùȉ·˜ Î·È ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜, fï˜ ‰ÂÓ ÚÔÊ˘Ï¿ÛÛÂÈ ·fi ÙȘ ˘ÔÙÚÔ¤˜. ™‹ÌÂÚ·, ηӤӷ ıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ‰ÂÓ Ê·›-
Paediatriki 2003;66:327-333
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REVIEW ARTICLE
™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1: ÁÂÓÂÙÈ΋ Î·È ·ÓÔÛÔÏÔÁÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ ∂. ¶··‰ÔÔ‡ÏÔ˘1, ¢. ª·ÌÔ˘Ï¿Î˘1, ™. ™ËÊ¿Î˘2
Type 1 diabetes mellitus: the genetic and immunological basis of the disease E. Papadopoulou1, D. Mamoulakis1, S. Sifakis2
¶ÂÚ›ÏË„Ë: ™ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1 (∆1™¢) Û˘ÌÌÂÙ¤¯Ô˘Ó ÁÂÓÂÙÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∏ ÁÂÓÂÙÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È È‰È·›ÙÂÚ· Û‡ÓıÂÙË, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ‰Â ·fi ÙË Ì›˙ÔÓ· ›‰Ú·ÛË ÁÔÓȉ›ˆÓ Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· Î·È ¯·ÚÙÔÁÚ·ÊÔ‡ÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (HLA). £ÂˆÚÂ›Ù·È fiÙÈ Û˘ÁÎÂÎÚÈ̤ÓÔÈ ·ÏfiÙ˘ÔÈ HLA ηıÔÚ›˙Ô˘Ó ÙËÓ Â˘·ÈÛıËÛ›·/ÚԉȿıÂÛË ÛÙË ÓfiÛÔ ‹ ·ÓÙ›ıÂÙ· ÚÔÛʤÚÔ˘Ó ÛËÌ·ÓÙÈ΋ ÚÔÛÙ·Û›· ·fi ·˘Ù‹Ó. ∏ ÁÂÓÂÙÈ΋ ÂÈ‚¿Ú˘ÓÛË Ù˘ ÓfiÛÔ˘ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÁÔÓ›‰ÈÔ IDDM1 (ÂÚÈÔ¯‹ 6p21.3). ∏ ·ÚÔ˘Û›· ÙÔ˘ ·Û·Ú·ÁÈÓÈÎÔ‡ ÔͤԘ ÛÙË ı¤ÛË 57 (Asp 57) Ù˘ DQ ‚-·Ï‡ÛÔ˘ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È ·fi ÙÔ IDDM1, ÚÔÛʤÚÂÈ ÚÔÛÙ·Û›· ·¤Ó·ÓÙÈ ÛÙË ÓfiÛÔ. ∆· ÔÌfi˙˘Á· non-Asp 57 ¿ÙÔÌ· ¤¯Ô˘Ó ۯ‰fiÓ ÂηÙÔÓÙ·Ï¿ÛÈÔ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ Ó· ÓÔÛ‹ÛÔ˘Ó. ∏ Ù·˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· Arg 52 ÛÙËÓ DQ ·-¿Ï˘ÛÔ ·˘Í¿ÓÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ Èı·ÓfiÙËÙ· ÓfiÛËÛ˘. ∂›ÎÔÛÈ ÂÚ›Ô˘ ÌËHLA ÁÂÓÂÙÈÎÔ› ÙfiÔÈ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ ·ÚÎÒ˜ ÙÂÎÌËÚȈ̤ÓË Â›Ó·È Ë Û˘ÌÌÂÙÔ¯‹ ÌfiÓÔ ÙˆÓ ÁÔÓȉ›ˆÓ IDDM2 (11p15.5) Î·È IDDM12 (2q33). O Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ·ÓÙÈÓËÛȉȷÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (ICA), ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ÚˆÙ½Ó˘ IA-2, ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ·ÔηڂÔÍ˘Ï¿Û˘ ÙÔ˘ ÁÏÔ˘Ù·ÌÈÓÈÎÔ‡ ÔͤԘ (GAD∞) Î·È ÙˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ÈÓÛÔ˘Ï›Ó˘ (IAA) Ê·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›· Û ·È‰È¿ Ì ·˘ÍË̤ÓË ÁÂÓÂÙÈ΋ ÂÈ‚¿Ú˘ÓÛË ÁÈ· ™¢ Î·È ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ ÓfiÛÔ˘. ∞Ó¿ÌÂÛ· Û ¿ÏÏÔ˘˜ “·ÁÎÚ·ÙÔÙÚfiÔ˘˜” ÈÔ‡˜ ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Ô Èfi˜ Coxsackie B4, ÏfiÁˆ Ù˘ ÔÌfiÏÔÁ˘ ·ÏÏËÏÔ˘¯›·˜ ÌÂٷ͇ Ù˘ ÌË ‰ÔÌÈ΋˜ ÚˆÙ½Ó˘ ÙÔ˘ 2C Î·È ÙÔ˘ Ì›˙ÔÓÔ˜ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ‰È·‚‹ÙË
Abstract: Genetic and environmental factors are involved in the development of type 1 diabetes mellitus (T1DM). The complex genetic basis of the disease is characterized by the major influence of genes regulating the immune system. Certain HLA haplotypes are related to T1DM susceptibility or protection. The main susceptibility locus resides within the major histocompatibility complex (MHC) on chromosome 6p21. Aspartic acid at position 57 (Asp 57) of the DQ ‚-chain protects against the disease. The homozygous absence of Asp 57, confers a 100-fold relative risk for diabetes. Arginine presence at position 52 (Arg 52) of the DQ ·-chain also confers a higher risk for T1DM. The combination of homozygous absence of Asp 57 with concomitant presence of Arg 52 appears to have an additive effect. About twenty non-HLA loci contributing to disease susceptibility have already been identified, but the specific function of only two (IDDM2 in 11p15.5 and IDDM12 in 2q33) is known. The combination of the levels of islet cell antibodies (ICA), insulin autoantibodies (IAA), antibodies to GAD and antibodies to protein IA-2 permits prediction of the appearance of clinical diabetes in high-risk individuals. Certain viral infections, especially those caused by Coxsackie B viruses and related enteroviruses, have been associated with the development of T1DM. The sequence homology between the Coxsackie B virus nonstructural protein 2C (CVB4 p2C) and the major diabetes autoantigen glutamic acid decarboxylase (GAD65) supports the hypothesis of “molecular mimicry”, a phenomenon which may also explain those cases following early exposure to bovine serum albumin, with responsibility of the ABBOS milk component. Increased understanding
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘, ∏Ú¿ÎÏÂÈÔ 2 ª·È¢ÙÈ΋-°˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘, ∏Ú¿ÎÏÂÈÔ
1 Paediatric Clinic of the University of Crete, Heraklion 2 Obstetrics-Gynaecology Clinic of the University of Crete, Heraklion
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Paediatriki 2003;66:334-343
GAD65. ∞˘Ù‹ Ë ıˆڛ· Ù˘ “ÌÔÚȷ΋˜ ·ÔÌ›ÌËÛ˘” ˘ÔÛÙËÚ›˙ÂÈ ÙÔÓ ÚfiÏÔ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ Î·È ÂȉÈÎfiÙÂÚ· ÙÔ˘ ÂÙȉ›Ô˘ ABBOS ˆ˜ ‰˘ÓËÙÈÎfi ·Ú¿ÁÔÓÙ· ¤Ó·Ú͢ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·¿ÓÙËÛ˘ Û ¿ÙÔÌ· Ô˘ Â›Ó·È ÁÂÓÂÙÈο ÚԉȷÙÂıÂÈ̤ӷ. ∏ ¯·ÚÙÔÁÚ¿ÊËÛË ÙˆÓ ˘Â‡ı˘ÓˆÓ ÁÔÓȉ›ˆÓ Î·È Ë Ï‹Ú˘ ηٷÓfiËÛË ÙˆÓ ˘Â‡ı˘ÓˆÓ ÁÂÓÂÙÈÎÒÓ Î·È ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ı· Û˘Ì‚¿ÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË, ηıÒ˜ Î·È ÛÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘.
of the genetic and immunological mechanisms will contribute to improved diagnostic and therapeutic approach to the disease.
§¤ÍÂȘ ÎÏÂȉȿ: ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1, ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ 1 (IDDM1), IDDM2, IDDM12.
Key words: type 1 diabetes mellitus, insulindependent diabetes mellitus 1 (IDDM1), IDDM2, IDDM12.
∂ÈÛ·ÁˆÁ‹ O ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1 (∆1™¢) ·ÔÙÂÏ› ÌÂÙ·‚ÔÏÈ΋ ‰È·Ù·Ú·¯‹ ÔÌÔÈfiÛÙ·Û˘ Ù˘ ÁÏ˘Îfi˙˘, ÛÙËÓ ÔÔ›· ‚·ÛÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi Â›Ó·È Ë ‰ËÌÈÔ˘ÚÁ›· ÎÂÙÔͤˆÛ˘ Ô˘ Û˘Ì‚·›ÓÂÈ fiÙ·Ó ‰ÂÓ ¯ÔÚËÁËı› Â͈ÁÂÓÒ˜ ÈÓÛÔ˘Ï›ÓË. ¶ÚfiÎÂÈÙ·È ÁÈ· ÁÂÓÂÙÈο ÂÙÂÚÔÁÂÓ‹, ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ, Ë ÔÔ›· ÚÔÛ‚¿ÏÏÂÈ ÙÔ 0,3% Ù˘ Ï¢΋˜ Ê˘Ï‹˜ (1). ∏ ·˘ÙÔ¿ÓÔÛË Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ÛÙ· ÓËÛ›‰È· Langerhans ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ÚÔηÏ› ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ ÙË ÌÂÚÈ΋ Î·È ÙÂÏÈο ÙËÓ Ï‹ÚË ·Ó·ÛÙÔÏ‹ Ù˘ ·Ú·ÁˆÁ‹˜ ÈÓÛÔ˘Ï›Ó˘, Ë ÔÔ›· Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· Ì›· ·Ï˘Û›‰· ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ˘‰·Ù·ÓıڿΈÓ, ÙˆÓ ÚˆÙÂ˚ÓÒÓ, ÙˆÓ ÏÈÒÓ, ÙˆÓ ˘ÁÚÒÓ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ (2-5). ∂ȉÈÎfiÙÂÚ·, Ë ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ÂÌÊ·Ó›˙ÂÙ·È fiÙ·Ó Ù· ·Ôı¤Ì·Ù· Ù˘ ÈÓÛÔ˘Ï›Ó˘ ÌÂȈıÔ‡Ó Î¿Ùˆ ·fi 10-15% ÙˆÓ ÂȤ‰ˆÓ ÂÎÂ›ÓˆÓ Ô˘ ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ¿ÙÔÌÔ ıˆÚÔ‡ÓÙ·È Ê˘ÛÈÔÏÔÁÈο. ÀÔÛÙËÚ›˙ÂÙ·È, ›Û˘, fiÙÈ Ù· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È fiÙ·Ó ÙÔ 80% ÂÚ›Ô˘ ÙˆÓ ÓËÛȉ›ˆÓ ÂÚȤ¯ÂÈ Î‡ÙÙ·Ú· Ô˘ ‰ÂÓ ÂÎÎÚ›ÓÔ˘Ó ÈÓÛÔ˘Ï›ÓË (6). O ÎÏ·ÛÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ Ù˘ ÓfiÛÔ˘ ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ ÔÏ˘‰È„›·, ÔÏ˘Ê·Á›·, ÔÏ˘Ô˘Ú›· Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜ (5). ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ˆÛ̈ÙÈ΋˜ ‰ÈÔ‡ÚËÛ˘, Ë ÔÔ›· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ˘ÂÚÁÏ˘Î·ÈÌ›·. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ Ô‰ËÁÔ‡Ó ÚÔԉ¢ÙÈο Û ÂÈÏÔΤ˜ ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ (ۯ‰fiÓ ÛÙÔ 20% ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ·ÙfïÓ), ÙÔÓ Ó¢ÚÈÎfi ÈÛÙfi, ÙÔÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ Î·È Ù· ·ÈÌÔÊfiÚ· ·ÁÁ›· (7).
·Ú¿ ÙËÓ ÂÈÎfiÓ· Ù˘ ·ÈÊÓ›‰È·˜ ¤Ó·Ú͢ Ô˘ ··ÙËÏ¿ ‰›‰ÂÈ, ·ÔÙÂÏ› ÛÙËÓ Ô˘Û›· ·ÔÙ¤ÏÂÛÌ· ÚÔԉ¢ÙÈ΋˜ ÂͤÏÈ͢ ηٿ ÙË ‰È¿ÚÎÂÈ· Ì›·˜ ÂÚÈfi‰Ô˘ ÌËÓÒÓ ¤ˆ˜ ÂÙÒÓ. ¶Èı·Ó¿ ·˘Ùfi Ó· ·ÔÙÂÏ› ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ›‰Ú·Û˘ ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ¿Óˆ Û ¤Ó· ÁÂÓÂÙÈο ÂÈ‚·Ú˘Ì¤ÓÔ ¿ÙÔÌÔ (2-5,8). ∞fi ·ÚÎÂÙÔ‡˜ ÂÚ¢ÓËÙ¤˜ ¤¯ÂÈ Á›ÓÂÈ ÚÔÛ¿ıÂÈ· Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ‚·ÛÈÎÔ› ‰Â›ÎÙ˜, Ô Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ÔÔ›ˆÓ ı· ÂÈÙÚ¤ÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, ÚÈÓ ·˘Ù‹ ÂΉËψı› ÎÏÈÓÈο. ™ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜, Ù· ·ÔÙÂϤÛÌ·Ù· ¿ÏÏÔÙ ÂÓı·ÚÚ˘ÓÙÈο Î·È ¿ÏÏÔÙ fi¯È - ·Ó·‰ÂÈÎÓ‡Ô˘Ó ·Ú·Ì¤ÙÚÔ˘˜ Ì ‰˘Ó·ÙfiÙËÙ· Úfi‚Ï„˘ Ù˘ ÓfiÛÔ˘. ∞ӷʤÚÔÓÙ·È ÂÈÏÂÎÙÈο Ù· ·ÓÙÈÁfiÓ· ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC ‹ HLA - Major Histocompatibility Complex ‹ Human Leukocyte Antigen), ÂÓÂÚÁÔÔÈË̤ÓÔÈ ÏËı˘ÛÌÔ› ∆΢ÙÙ¿ÚˆÓ, Ù›ÙÏÔÈ ‰È·ÊfiÚˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ·ÓÙÈۈ̿وÓ, ηıÒ˜ Î·È Ë ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÈÓÛÔ˘Ï›Ó˘ (2-5). ∏ ÁÂÓÂÙÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È È‰È·›ÙÂÚ· Û‡ÓıÂÙË Î·È ‰ÂÓ ÌÔÚ› Ó· Ù·ÍÈÓÔÌËı› Ì ‚¿ÛË Ù· ÎÏ·ÛÈο ÚfiÙ˘· ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂÍËÁ› ÙÔÓ ÏfiÁÔ Ô˘ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â ·Ô‰Ôı› ÛÙË ÓfiÛÔ Ô Ù›ÙÏÔ˜ “ÂÊÈ¿ÏÙ˘ ÙˆÓ ÁÂÓÂÙÈÛÙÒÓ” (9). §›Á· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, fiÙ·Ó ÙÔ ÙÔ›Ô ¿Ú¯ÈÛ ӷ Á›ÓÂÙ·È ÈÔ ÍÂοı·ÚÔ, ¯·Ú·ÎÙËÚ›ÛÙËΠ·Ï¿ ˆ˜ “ÔÓÔΤʷÏÔ˜” Û ۯ¤ÛË Ì ÙË ÁÂÓÂÙÈ΋ ÙÔ˘ ÂÚÌËÓ›· (10). ™ÙË Û˘Ó¤¯ÂÈ·, ˘ÔÛÙËÚ›¯ıËΠfiÙÈ ÚfiÎÂÈÙ·È Û·ÊÒ˜ ÁÈ· ÎÏËÚÔÓÔÌÈÎfiÙËÙ· ÔÏ˘ÁÔÓȉȷÎÔ‡ Ù‡Ô˘ ‹ - Ì ‰È·ÊÔÚÂÙÈ΋ ‰È·Ù‡ˆÛË - ÁÈ· “Û‡ÓıÂÙÔ ÁfiÓÔ”, ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÔÔ›Ô˘ Û ·ÚÎÂÙ¿ ÁÔÓ›‰È· Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÓfiÛÔ (11). ¶·Ú¿ÏÏËÏ·, ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Î·È ÔÈ ·ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› η٤¯Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ∞˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È Ì ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Û ÚfiÛÊ·Ù· ‰È·ÁÓˆṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜, fiÔ˘ ·Ô‰ÂÈÎÓ‡ÂÙ·È
∂ÈÛ·ÁˆÁ‹ ÛÙË ÁÂÓÂÙÈ΋ Î·È ·ÓÔÛÔÏÔÁÈ΋ ‚¿ÛË ÙÔ˘ ∆1™¢ ŒÓ·˜ Û˘Ó‰˘·ÛÌfi˜ ÁÂÓÂÙÈÎÒÓ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ™‹ÌÂÚ·, ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ ÎÂÚ‰›˙ÂÈ ¤‰·ÊÔ˜ Ë ¿Ô„Ë fiÙÈ Ë ÓfiÛÔ˜,
335
¶·È‰È·ÙÚÈ΋ 2003;66:334-343
∂ȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ∏ ›وÛË Ù˘ ÓfiÛÔ˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Â›Ó·È 1 ·Ó¿ 2500 ·È‰È¿ ÛÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ Î·È ÊÙ¿ÓÂÈ ¤ˆ˜ 1 ·Ó¿ 300 ·È‰È¿ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ (16). ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ∆1™¢ ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜ ÙÔ˘ ÎfiÛÌÔ˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿Ï˜ ‰È·Î˘Ì¿ÓÛÂȘ, Ì ÔÛÔÛÙ¿ Ô˘ ¿ÏÏÔÙ ÊÙ¿ÓÔ˘Ó ÛÙ· ˘„ËÏ¿ ›‰· ÙˆÓ 40-50 ÂÚÈÙÒÛÂˆÓ ·Ó¿ 100.000 ·È‰È¿ ·Ó¿ ¤ÙÔ˜, fiˆ˜ ÛÙË ºÈÓÏ·Ó‰›· Î·È 30-35 ÛÙË ™·Ú‰ËÓ›· Î·È ¿ÏÏÔÙ ¤ÊÙÔ˘Ó ¯·ÌËÏ¿ ÛÙȘ 0,1 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ·Ó¿ ¤ÙÔ˜ ‹ ÏÈÁfiÙÂÚÔ, fiˆ˜ Û ÂÚÈÔ¯¤˜ Ù˘ ∫›Ó·˜ (17-20). ∏ Û˘¯ÓfiÙËÙ· ·˘Ù‹ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Û fiÏÔ˘˜ ۯ‰fiÓ ÙÔ˘˜ ÏËı˘ÛÌÔ‡˜, ΢ڛˆ˜ fï˜ Û ·˘ÙÔ‡˜ Ô˘ ·ÚÔ˘Û›·˙·Ó ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ı· Â›Ó·È 40% ˘„ËÏfiÙÂÚË ÙÔ 2010 Û ۯ¤ÛË Ì ÙÔ 1997 (19). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È, ›Û˘, ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÛÙ·ÙÈÛÙÈο ‰Â‰Ô̤ӷ ˘Ô‰ÂÈÎÓ‡Ô˘Ó Â›Ù·ÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Û ڈÈÌfiÙÂÚË ËÏÈΛ·, ηıÒ˜ Î·È ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Û˘ÁÎÚÈÙÈο Ì ÙȘ ÏÈÁfiÙÂÚÔ ·ÓÂÙ˘Á̤Ó˜ ‹ ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ (7,20). ∂ȉÈÎfiÙÂÚ· ÛÙËÓ ∂ÏÏ¿‰·, Ô ∆1™¢ - ÌÂ Û˘¯ÓfiÙËÙ· ÂÚ›Ô˘ 9 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ·Ó¿ ¤ÙÔ˜ - ·ÚÔ˘ÛÈ¿˙ÂÈ Ì›· ȉȷ›ÙÂÚË Î·Ù·ÓÔÌ‹ Ì ÌÂÁ·Ï‡ÙÂÚË ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ÓfiÙÈÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙÔ ‚fiÚÂÈÔ ÙÌ‹Ì· Ù˘ ¯ÒÚ·˜ (21,22). ∏ ÔÈÎÈÏfiÌÔÚÊË Î·Ù·ÓÔÌ‹ Ù˘ ÓfiÛÔ˘ ·Ó¿ ÙÔÓ ÎfiÛÌÔ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÁÂÓÂÙÈ΋ Î·È ÌÔÚȷ΋ ‚¿ÛË Ù˘ (23). ∆ËÓ ·Ú·¿Óˆ ‰È·›ÛÙˆÛË ÂȂ‚·ÈÒÓÂÈ Ë ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË Ô˘ Û˘Ó‰¤ÂÈ ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ∆1™¢ Û ‰È·ÊÔÚÂÙÈΤ˜ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜ Î·È ÏËı˘ÛÌÔ‡˜ Ì ÙËÓ ˘ÔÏÔÁÈṲ̂ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÔÌfi˙˘Á˘ ·Ô˘Û›·˜ ·Û·Ú·ÁÈÓÈÎÔ‡ ÔͤԘ ÛÙË ı¤ÛË 57 Ù˘ DQ ‚-·Ï‡ÛÔ˘ (∂ÈÎfiÓ· 1), ÁÈ· ÙÔ ÔÔ›Ô ı· Á›ÓÂÈ ÏfiÁÔ˜ ·Ó·Ï˘ÙÈÎfiÙÂÚ· ÛÙË Û˘Ó¤¯ÂÈ·. ™ÙÔ ·ÚÂÏıfiÓ, Ô ∆1™¢ ‰È·ÎÚÈÓfiÙ·Ó ·fi ÙÔÓ Ù‡Ô˘ 2 ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (∆2™¢) ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ˜ ˆ˜ “Ó·ÓÈÎfi˜” Î·È Ì ·Ó·ÌÂÓfiÌÂÓË ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ. ™‹ÌÂÚ·,
336
Ù· ·Ú·¿Óˆ ‰ÂÓ ÈÛ¯‡Ô˘Ó, ÂÊfiÛÔÓ ÛÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ë ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Û˘Ì‚·›ÓÂÈ ÌÂÙ¿ Ù· 20 ¤ÙË. OÈ ÂÓ‹ÏÈÎÔÈ, fï˜, ·ÛıÂÓ›˜ Ì ∆1™¢ ÂÌÊ·Ó›˙Ô˘Ó ·ÚÎÂÙ¿ ‰È·ÊÔÚÂÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ Û ۯ¤ÛË Ì ٷ ·È‰È¿-·ÛıÂÓ›˜. ∂ȉÈÎfiÙÂÚ·, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ·ÚÓËÙÈÎÔ› ÁÈ· ·ÓÙÈÁfiÓ· ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÛÙ‹Ì·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (HLA), Ù· ÔÔ›· Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙË ÓfiÛÔ ÛÙ· ·È‰È¿. ∂›Û˘, ηٿ ÙË ‰È¿ÁÓˆÛË ·ÓȯÓ‡ÔÓÙ·È ÛÙÔÓ ÔÚfi ÙÔ˘˜ Û ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ·ÓÙÈÓËÛȉȷο ·ÓÙÈÛÒÌ·Ù· (islet cell antibodies - ICA), ÂÓÒ Ë ·Ó¿ÚÎÂÈ· Ù˘ ÈÓÛÔ˘Ï›Ó˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÛËÌ·ÓÙÈο ËÈfiÙÂÚË. ∆· ÛÙÔȯ›· ·˘Ù¿ Èı·Ó¿ ˘Ô‰ÂÈÎÓ‡Ô˘Ó Ì›· ȉȷ›ÙÂÚË ˘ÔÔÌ¿‰· Ù˘ ÓfiÛÔ˘, Ì ·Ó·ÌÂÓfiÌÂÓË ·‡ÍËÛË Ì ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜, fiˆ˜ ›Û˘ ˘ÔÁÚ·ÌÌ›˙Ô˘Ó ÙË ÁÂÓÂÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (24). ∏ ÁÂÓÂÙÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ - ™˘Û¯¤ÙÈÛË Ì ÙÔ Û‡ÛÙËÌ· HLA ∏ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÛÙÔÓ ∆1™¢ ·ÔÙÂÏ› ·Ó·ÌÊÈÛ‚‹ÙËÙÔ ÁÂÁÔÓfi˜, ȉȷ›ÙÂÚ· fiˆ˜ ÚÔ·ÙÂÈ ÌÂÙ¿ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÛÙÔȯ›ˆÓ ÂÎÙÂÙ·Ì¤ÓˆÓ ÂÚ¢ÓÒÓ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÙfiÛÔ Û ˙‡ÁË ‰È‰‡ÌˆÓ, fiÛÔ Î·È Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÔÈÎÔÁÂÓÂÈÒÓ Ì ¿Û¯ÔÓÙ· ̤ÏË (25-28). ∂›Û˘, Ë ‰È·›ÛÙˆÛË ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÙ·È Î·È ·fi ÙÔ fiÙÈ ¤Ó·˜ ·ÚÈıÌfi˜ ÓÔÛËÌ¿ÙˆÓ ÎÏËÚÔÓÔÌÔ‡ÌÂÓˆÓ Ì ÙÔ˘˜ ÓfiÌÔ˘˜ ÙÔ˘ Mendel ÂÌÊ·Ó›˙ÂÈ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ™¢ (¶›Ó·Î·˜ 1). ∏ ›وÛË Ù˘ ÓfiÛÔ˘ Û ÌÔÓÔ˙˘ÁˆÙÈÎÔ‡˜ ‰›‰˘ÌÔ˘˜ Â›Ó·È 30-50% (1), ˘Ô‰ÂÈÎÓ‡ÔÓÙ·˜ ¤ÙÛÈ fiÙÈ ÂÎÙfi˜ ·fi ÙË Û·Ê‹ Û˘Ì‚ÔÏ‹ ÁÔÓȉ›ˆÓ, ÔÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Û˘ÌÌÂÙ¤¯Ô˘Ó Û ÛËÌ·ÓÙÈÎfi 30
™˘¯ÓfiÙËÙ·/100.000
ÂÎÙÂٷ̤ÓË ‰È‹ıËÛË ÙˆÓ ÓËÛȉ›ˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ·fi ∆-ÏÂÌÊÔ·ÙÙ·Ú· (Ì ˘ÂÚÔ¯‹ ÙˆÓ CD8+ ¤Ó·ÓÙÈ ÙˆÓ CD4+ ΢ÙÙ¿ÚˆÓ), µ-ÏÂÌÊÔ·ÙÙ·Ú·, ÌÔÓÔ·ÙÙ·Ú· Î·È Ï·ÛÌ·ÙÔ·ÙÙ·Ú· (12-13). ∆· ·ÙÙ·Ú· ·˘Ù¿ ¿ÁÔ˘Ó in vitro ÙËÓ ¤ÎÏ˘ÛË Î˘ÙÙ·ÚÔÎÈÓÒÓ, fiˆ˜ ÈÓÙÂÚÏ¢ΛÓ˜ 1 Î·È 6, ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ ÙÔ˘ fiÁÎÔ˘-· (TNF-·), ηıÒ˜ Î·È ÈÓÙÂÚÊÂÚfiÓË-Á. OÈ Ô˘Û›Â˜ ·˘Ù¤˜ ıˆÚÂ›Ù·È fiÙÈ ·˘Í¿ÓÔ˘Ó ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ (14). ™ÙÔÓ ¿ÓıÚˆÔ, Ë Î˘ÙÙ·ÚÔΛÓË Ô˘ Ê·›ÓÂÙ·È Ó· ÂÎÊÚ¿˙ÂÙ·È ÛÙ·ıÂÚ¿ ÛÙ· ·ÙÙ·Ú· ÙˆÓ ÓËÛȉ›ˆÓ Ô˘ ¤¯Ô˘Ó ‰ÈËıËı› (Î·È Èı·ÓfiÙÂÚ· ÛÙ· ‚-·ÙÙ·Ú·), Â›Ó·È Ë ÈÓÙÂÚÊÂÚfiÓË-· (15).
Paediatriki 2003;66:334-343
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20
NÔÚ‚ËÁ›· ∏.¶.∞.- §Â˘ÎÔ› ∏.¶.∞.- ¡¤ÁÚÔÈ
10
À = -1,412 + 39,930 x R = 1,00 ∫›Ó· 0 0
0,2
0,4
0,6
0,8
1,0
™˘¯ÓfiÙËÙ· ÁÔÓȉ›Ô˘ Non-Asp-57 ∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂÙ‹ÛÈ·˜ Û˘¯ÓfiÙËÙ·˜ ∆1™¢ (ÚÔÛ·ÚÌÔṲ̂Ó˘ ·Ó¿ ËÏÈΛ·) Î·È ÁÔÓȉȷ΋˜ Û˘¯ÓfiÙËÙ·˜ “nonAsp-57”.
¶·È‰È·ÙÚÈ΋ 2003;66:334-343
Paediatriki 2003;66:334-343
›Û˘ ‚·ıÌfi ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘. ¢È¿ÊÔÚÔÈ ÂÚ¢ÓËÙ¤˜ ‰È·Ù‡ˆÛ·Ó ıˆڛ˜ Û ۯ¤ÛË Ì ÙÔÓ Ù‡Ô ÌÂÙ·‚›‚·Û˘ ÙÔ˘ ∆1™¢, ¯ˆÚ›˜ fï˜ Ó· ·Ú·ı¤ÙÔ˘Ó Â·Ú΋ ÛÙÔȯ›· ÂȂ‚·›ˆÛ˘. OÈ ˘Ôı¤ÛÂȘ ·˘Ù¤˜ ·ÊÔÚÔ‡Û·Ó Û ˘ÔÏÂÈfiÌÂÓÔ, ΢ڛ·Ú¯Ô ‹ ÔÏ˘·Ú·ÁÔÓÙÈÎfi ÚfiÙ˘Ô ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜, ÂÓÒ ·Ó·Ù‡¯ıËΠ›Û˘ Ë ıˆڛ· Ù˘ ÚԉȿıÂÛ˘ (susceptibility) ·¤Ó·ÓÙÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ (10,29). ¶·Ú·ÎÔÏÔ˘ıÒÓÙ·˜ ÙËÓ ÂͤÏÈÍË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÛÙÔ Â‰›Ô ·˘Ùfi, ηıÒ˜ Î·È ÙË ‰˘ÛÎÔÏ›· Ô˘ ÔÏϤ˜ ÊÔÚ¤˜ ÚÔ·ÙÂÈ ÛÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ, ·Ó·Î‡ÙÂÈ Ë ·Ó¿ÁÎË Û‡ÁÎÚÈÛ˘ Ì ·ÓÙ›ÛÙÔȯ· ‰Â‰Ô̤ӷ ÛÙÔÓ ∆2™¢. ¶ÚÔηÏ› ¤ÎÏËÍË ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÓÒ Û˘Ó‹ıˆ˜ ÛÙ· ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù· ·˘Ùfi Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙË ‚·Ú‡ÙÂÚË ÎÏÈÓÈ΋ ÌÔÚÊ‹ Â›Ó·È Î·È ·˘Ùfi Ô˘ ¤¯ÂÈ ÙË Û·Ê¤ÛÙÂÚË ÁÂÓÂÙÈ΋ ‚¿ÛË, ÛÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË Û˘Ì‚·›ÓÂÈ ÙÔ ·ÓÙ›ÛÙÚÔÊÔ. ŒÙÛÈ, ÌÂϤÙ˜ ÌÔÓÔ˙˘ÁˆÙÈÎÒÓ ‰È‰‡ÌˆÓ Ì ∆2™¢ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Û ÔÛÔÛÙfi ۯ‰fiÓ 100% ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ Ë ·Ú¯È΋ ÂΉ‹ÏˆÛ‹ Ù˘ ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔÓ ¤Ó· ·fi ÙÔ˘˜ ‰‡Ô ‰È‰‡ÌÔ˘˜ Û ËÏÈΛ· ÌÂÙ¿ Ù· 45 ¤ÙË, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÂÏ·ÙÙÒÓÂÙ·È ÛÙÔ 50% ÁÈ· ‰È‰‡ÌÔ˘˜ Ì ∆2™¢ fiÔ˘ Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ ¤Ó· ·fi Ù· ‰‡Ô ̤ÏË ¯ÚÔÓÔÏÔÁÈο ÚˆÈÌfiÙÂÚ· (30). ª›· ηχÙÂÚË ÚÔÛ¤ÁÁÈÛË ÙˆÓ ÔÈÎÔÁÂÓÒÓ ÂÚÈÙÒÛÂˆÓ ∆1™¢ ·ÔηχÙÂÈ ÙË Ì›˙ÔÓ· ›‰Ú·ÛË ·fi ÁÔÓ›‰È· Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· Î·È Û˘ÁÎÂÎÚÈ̤ӷ ·fi ·˘Ù¿ Ô˘ ¯·ÚÙÔÁÚ·ÊÔ‡ÓÙ·È ÛÙËÓ ∏L∞ ÂÚÈÔ¯‹ (31). ™ÙÔ ›‰ÈÔ Û˘Ì¤Ú·ÛÌ· η٤ÏËÍ·Ó ·Ú·ÙËÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Û ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, fiˆ˜ Ë ‚·ÚÈ¿ Ì˘·Ûı¤ÓÂÈ·, Ë ı˘ÚÂÔÂȉ›Ùȉ· Hashimoto, Ë Î·ÎÔ‹ı˘ ·Ó·ÈÌ›· Î·È ÔÚÈṲ̂ÓÔÈ Ù‡ÔÈ Ù˘ ÓfiÛÔ˘ ÙÔ˘ Addison, Ù· ÔÔ›· Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ∆1™¢ (31). ∆Ô Ì›˙ÔÓ Û‡ÌÏÂÁÌ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (HLA) Â›Ó·È ¤Ó· ÂÍ·ÈÚÂÙÈο ÔÏ˘ÌÔÚÊÈÎfi Û‡ÌÏÂÁÌ· ÁÔÓȉ›ˆÓ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌ·ÙÔÛÒÌ·ÙÔ˜ 6 Î·È Â›Ó·È ˘Â‡ı˘ÓÔ ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘. ◊‰Ë ·fi ÙÔ 1987, ÔÈ Todd Î·È ÔÈ Û˘Ó ‰È·›ÛÙˆÛ·Ó fiÙÈ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 50% Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÛÙÔ ∆1™¢ ¯·ÚÙÔÁÚ·ÊÂ›Ù·È ÛÙËÓ ÂÚÈÔ¯‹ ·˘Ù‹ Î·È Û˘ÁÎÂÎÚÈ̤ӷ Û ·˘Ù‹ ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ù¿Í˘ II, Ì›·˜ ·fi ÙȘ ÙÚÂȘ Ù¿ÍÂȘ ÛÙȘ Ôԛ˜ ˘Ô‰È·ÈÚÂ›Ù·È ÙÔ Û‡ÌÏÔÎÔ ·˘Ùfi Î·È Ô˘ Ù˘Èο ÔÚ›˙ÂÙ·È ˆ˜ IDDM1 (Insulin
Dependent Diabetes Mellitus 1) (32,33) (∂ÈÎfiÓ· 2). ∆· ÁÔÓ›‰È· Ù˘ Ù¿Í˘ II (ÔÈ ÙÚÂȘ ΢ÚÈfiÙÂÚ˜ ÂÎÊÚ·˙fiÌÂÓ˜ ı¤ÛÂȘ Ù˘ ÔÔ›·˜ Â›Ó·È DR, DQ Î·È DP) ·Ú¿ÁÔ˘Ó ‰ÈÌÂÚ›˜ ÁÏ˘ÎÔÚˆÙ½Ó˜ (·ÔÙÂÏÔ‡ÌÂÓ˜ ·fi · Î·È ‚ ·Ï˘Û›‰Â˜) Î·È ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·ıÒ˜ Î·È ÙˆÓ Î˘ÙÙ¿ÚˆÓ ·ÚÔ˘Û›·Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ (antigen-presenting cells), fiˆ˜ Ù· Ì·ÎÚÔÊ¿Á·. ªÂÙ¿ ÙË Û‡Ó‰ÂÛË Ì ·˘Ù¤˜ ÙȘ ÁÏ˘ÎÔÚˆÙ½Ó˜, ÙÔ ·ÓÙÈÁfiÓÔ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙ· ‚ÔËıËÙÈο ∆-ÏÂÌÊÔ·ÙÙ·Ú· Î·È ‰ËÌÈÔ˘ÚÁÂ›Ù·È Ë ¯˘ÌÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË. ∏ ·Ó¿Ù˘ÍË Ù¯ÓÈÎÒÓ ·Ó¿Ï˘Û˘ ÙÔ˘ DNA (RFLPs, ·Ó¿Ï˘ÛË ·ÏÏËÏÔ˘¯›·˜ DNA, ÁÔÓȉȷÎÔ› ·ÓȯÓÂ˘Ù¤˜) η٤ÛÙËÛ ‰˘Ó·Ù‹ ÙËÓ ÂÚ·ÈÙ¤Úˆ Ù˘ÔÔ›ËÛË ÙˆÓ HLA ·ÓÙÈÁÔÓÈÎÒÓ Ê·ÈÓÔÙ‡ˆÓ Û ˘ÔηÙËÁÔڛ˜. ∏ ÛÙÂÓ‹ Û‡Ó‰ÂÛË ÙˆÓ ÁÔÓȉȷÎÒÓ ı¤ÛÂˆÓ ÙÔ‡˜ ‰›ÓÂÈ ÙËÓ È‰ÈfiÙËÙ· Ó· ÎÏËÚÔÓÔÌÔ‡ÓÙ·È ˆ˜ Û‡ÓÔÏÔ, ‰ËÏ·‰‹ Û·Ó ¤Ó·˜ ·ÏfiÙ˘Ô˜. £ÂˆÚËÙÈο, Ë Û˘¯ÓfiÙËÙ· ‰‡Ô ·ÓÙÈÁfiÓˆÓ Û ¤Ó·Ó ·ÏfiÙ˘Ô ı· ¤Ú ӷ Â›Ó·È ›ÛË Ì ÙÔ ÔÏÏ·Ï¿ÛÈÔ ÙˆÓ Û˘¯ÓÔÙ‹ÙˆÓ ÙÔ˘ οı ·ÓÙÈÁfiÓÔ˘. øÛÙfiÛÔ, ÔÚÈṲ̂ÓÔÈ Û˘Ó‰˘·ÛÌÔ› ÙÔ˘˜ ··ÓÙÔ‡Ó Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË. ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ηÏÂ›Ù·È “·ÓÈÛÔÚÚÔ›· Û‡Ó‰ÂÛ˘” (linkage disequilibrium) (34). OÈ Thomson Î·È Û˘Ó (1988) ·Ó¤Ï˘Û·Ó Ù· ·ÔÙÂϤÛÌ·Ù· 11 Û˘ÓÔÏÈο ÌÂÏÂÙÒÓ Ô˘ ·ÊÔÚÔ‡Û·Ó Û 1792 ¿ÙÔÌ· Ï¢΋˜ Ê˘Ï‹˜ Ô˘ ¤·Û¯·Ó ·fi ∆1™¢ (35). ªÂ ‰Â‰Ô̤ÓÔ fiÙÈ Ô Û˘ÓÔÏÈÎfi˜ ΛӉ˘ÓÔ˜ ÓfiÛËÛ˘ ÁÈ· Ù· ·‰¤ÚÊÈ· ¿Û¯ÔÓÙ· Â›Ó·È Ù˘ Ù¿Í˘ ÙÔ˘ 6%, ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ë Èı·ÓfiÙËÙ· ÓfiÛËÛ˘ ÁÈ· Ù· ·‰¤ÚÊÈ· Ô˘ ÌÔÈÚ¿˙ÔÓÙ·È ‰‡Ô, ¤Ó·Ó ‹ ηӤӷ ·ÏfiÙ˘Ô HLA. ∞˘Ù‹ ‚Ú¤ıËΠӷ Â›Ó·È 12,9%, 4,5% Î·È 1,8%, ·ÓÙ›ÛÙÔȯ·. ∆Ô ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÎÈÓ‰‡ÓÔ˘ ÓfiÛËÛ˘ ‹Ù·Ó 19,2% ÁÈ· Ù· ·‰¤ÚÊÈ· Ô˘ ÌÔÈÚ¿˙ÔÓÙ·È Î·È ÙÔ˘˜ ‰‡Ô ·ÏfiÙ˘Ô˘˜ Ì DR3/DR4 ¿Û¯ÔÓÙ·. ∆Ô ÛÙÔÈ¯Â›Ô ÂΛÓÔ Ô˘ ÚÔÛ‰›‰ÂÈ ÌÔÓ·‰ÈÎfiÙËÙ· ÛÙÔÓ ∆1™¢ ¤Ó·ÓÙÈ ¿ÏÏˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ Â›Ó·È fiÙÈ Û˘ÁÎÂÎÚÈ̤ÓÔÈ HLA ·ÏfiÙ˘ÔÈ, ÂÎÙfi˜ ·fi ¢·ÈÛıËÛ›· ‹ ÚԉȿıÂÛË ÛÙË ÓfiÛÔ, ÚÔÛʤÚÔ˘Ó Î·È ÛËÌ·ÓÙÈ΋ ÚÔÛÙ·Û›· ·fi ÙË ÓfiÛÔ, Ì ΢ڛ·Ú¯Ô ¯·Ú·ÎÙ‹Ú· › Ù˘ ¢·ÈÛıËÛ›·˜ (36) (¶›Ó·Î·˜ 2). OÈ ÚÒÙ˜ Û˘Û¯ÂÙ›ÛÂȘ ∆1™¢ Î·È HLA ·ÊÔÚÔ‡Û·Ó ÛÙ· Ù¿Í˘ I ·ÓÙÈÁfiÓ· µ8 Î·È µ15, ÛÙËÓ ·ÚÔ˘Û›· ÙˆÓ ÔÔ›ˆÓ ·Ô‰fiıËΠ·˘ÍË̤ÓË ÚԉȿıÂÛË ÛÙË ÓfiÛÔ (37). ∞ÚÁfiÙÂÚ·, Ë Û¯¤ÛË ·˘Ù‹ ·Ô‰fiıËΠ۠·ÓÈÛÔÚÚÔ›· Û‡Ó‰ÂÛ˘ Ì ٷ ·ÓÙÈÁfiÓ· DR3
¶›Ó·Î·˜ 1. °ÂÓÂÙÈο ÓÔÛ‹Ì·Ù· ÌÂÙ·‚È‚·˙fiÌÂÓ· Ì ÙÔ˘˜ ÓfiÌÔ˘˜ ÙÔ˘ Mendel, Ù· ÔÔ›· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË ñ ¶ÔÏÏ·Ï‹ ÓÂÔÏ·Û›· ÂÓ‰ÔÎÚÈÓÒÓ Ù‡Ô˘ I (131100) ñ ª˘ÔÙÔÓÈ΋ ‰˘ÛÙÚÔÊ›· (160900) ñ ™‡Ó‰ÚÔÌÔ Bardet-Biedl (209900) ñ ™‡Ó‰ÚÔÌÔ Donahue (246200)
ŸÁÎÔÈ ˘fiÊ˘Û˘, ·Ú·ı˘ÚÂÔÂȉÒÓ Î·È ·ÁÎÚ¤·ÙÔ˜, ÂÙÈÎfi ¤ÏÎÔ˜ ∫·Ù·ÚÚ¿ÎÙ˘, Ì˘ÔÙÔÓ›·, Ì˘Ô·ıËÙÈÎfi ÚÔÛˆÂ›Ô ¶·¯˘Û·ÚΛ·, ˘ÔÁÔÓ·‰ÈÛÌfi˜, ÔÏ˘‰·ÎÙ˘Ï›· ¡·ÓÈÛÌfi˜, ÏÈÔ‰˘ÛÙÚÔÊ›·, ÌÂÁ·Ï·ÎÚ›·, ¢ÌÂÁ¤ıË ÁÂÓÓËÙÈο fiÚÁ·Ó·
O Έ‰ÈÎfi˜ ÛÙËÓ ·Ú¤ÓıÂÛË ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ Î·Ù¿ McKusick ηٿٷÍË ÙˆÓ ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ
337
¶·È‰È·ÙÚÈ΋ 2003;66:334-343
Paediatriki 2003;66:334-343
Î·È DR4 Ù¿Í˘ II, Ë Ù·˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ÙˆÓ ÔÔ›ˆÓ ·Ó·Ê¤ÚÂÙ·È ˆ˜ ‰ÂηϷÛÈ¿˙ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÓfiÛËÛ˘ Û˘ÁÎÚÈÙÈο Ì ·ÚÓËÙÈÎÔ‡˜ ÁÈ· ·˘Ù¿ Ì¿ÚÙ˘Ú˜. (2-5). ∏ ‚·ı‡ÙÂÚË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ô‰‹ÁËÛ Û ̛· ÂÎ Ó¤Ô˘ ·Ó·ÙÚÔ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·˘ÙÒÓ, ·ÊÔ‡ Ë Û‡Ó‰ÂÛË Ì ٷ HLA-DR ·ÏÏ‹ÏÈ· ÂÚÌËÓ‡ÙËÎÂ Î·È ·˘Ù‹ Ì ÙË ÛÂÈÚ¿ Ù˘ Û ·ÓÈÛÔÚÚÔ›· Û‡Ó‰ÂÛ˘ Ì ٷ ·ÓÙÈÁfiÓ· Ù˘ HLA-DQ ÂÚÈÔ¯‹˜ (32,38,39). ∏ Û·Ê‹˜ ÁÂÓÂÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÁÔÓȉ›ˆÓ DQ ÂȂ‚·ÈÒıËΠÌÂÙ¿ ·fi ÌÂϤÙ˜ Û ÔÈÎÔÁ¤ÓÂȘ, ÛÙȘ Ôԛ˜ ÔÈ ¿Û¯ÔÓÙ˜ ·fiÁÔÓÔÈ ·ÚÔ˘Û›·˙·Ó Ù· DQ ·- Î·È ‚-‰ÈÌÂÚ‹ ̤ۈ ·ÓÙ›ÛÙÔȯ˘ Û˘ÌÏËڈ̷ÙÈÎfiÙËÙ·˜ (trans-complementation), ¯ˆÚ›˜ ÔÈ ÁÔÓ›˜ ÙÔ˘˜ Ó· ÂÎÊÚ¿˙Ô˘Ó Û ڈÙÂ˚ÓÈÎfi Â›Â‰Ô Î¿ÔÈÔ ·fi Ù· DQ ·ÏÏ‹ÏÈ· Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È (40). ∏ ·Ó¿Ï˘ÛË Û‡Ó‰ÂÛ˘ ÙˆÓ Herr Î·È Û˘Ó (2000) Ì ÙË ¯Ú‹ÛË ÔÏ˘ÌÔÚÊÈÎÒÓ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈÎÒÓ ‰ÂÈÎÙÒÓ Û 385 ÔÈÎÔÁ¤ÓÂȘ Ì ˙‡ÁË ·‰ÂÚÊÒÓ Ô˘ ÓÔÛÔ‡Û·Ó, ·¤‰ÂÈÍ fiÙÈ ÙÔ Ì¤ÁÈÛÙÔ Ù˘ ÁÂÓÂÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÁÈ· ÙË ÓfiÛÔ ‚Ú›ÛÎÂÙ·È ÛÙÔÓ ÁÂÓÂÙÈÎfi ÙfiÔ D6S2444, 85 Kb ÎÂÓÙÚÔÌÂÚÈο ÙÔ˘ HLADQµ1 (41). ∏ ¯Ú‹ÛË ·ÓȯÓÂ˘Ù‹ DQ ÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË ·ÏÏËÏÔ˘¯›·˜ ·ÌÈÓÔͤˆÓ ÛÙË ‚-DQ ¿Ï˘ÛÔ, ¤‰ÂÈÍ fiÙÈ Ë ÔÌfi˙˘ÁË ·ÚÔ˘Û›· ÙÔ˘ ·Û·Ú·ÁÈÓÈÎÔ‡ ÔͤԘ ÛÙË HLA ÂÚÈÔ¯‹ Xڈ̷Ùfiۈ̷ 6 ∆¿ÍË πππ
∆¿ÍË ππ
∆¿ÍË π
DP DQ DR 21 C4 Bf C2 TNF· TNF‚ µ
C
A
∆AP I ∆AP 2
DPB2 DPA2 DPB1 DPA1
DMA
DP-˘ÔÂÚÈÔ¯‹
DOB
DQB2 DQA2 DQB1 DQA1
DQ-˘ÔÂÚÈÔ¯‹
DRB1 DRB2 DRB3 DRB9 DRA1
DR-˘ÔÂÚÈÔ¯‹
∂ÈÎfiÓ· 2. ∏ ÂÚÈÔ¯‹ HLA ÛÙÔ ¯ÚˆÌ·Ùfiۈ̷ 6.
ı¤ÛË 57 (∞sp 57) ÚÔÛʤÚÂÈ ·fiÏ˘ÙË ÚÔÛÙ·Û›· ·¤Ó·ÓÙÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ π™¢ (39). ∂ӉȷʤÚÔÓ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÎfiÌË Î·È Ë ÂÙÂÚfi˙˘ÁË ·ÚÔ˘Û›· ÙÔ˘ ∞sp 57 ÛÙË ‚-DQ ¿Ï˘ÛÔ Ê·›ÓÂÙ·È Ó· ÏÂÈÙÔ˘ÚÁ› Û οÔÈÔ ‚·ıÌfi ÚÔÛٷ٢ÙÈο. ∞ÓÙÈı¤Ùˆ˜, Ë ÔÌfi˙˘ÁË ·Ô˘Û›· ÙÔ˘ ·Û·Ú·ÁÈÓÈÎÔ‡ ÔͤԘ ÛÙË ı¤ÛË 57 (non-Asp 57) ÚÔÛ‰›‰ÂÈ Ì›· ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘, ·ÓÂÍ·Úًو˜ Â¿Ó ÛÙË ı¤ÛË ·˘Ù‹ ‚Ú›ÛÎÂÙ·È ÙÔ ·ÌÈÓÔ͇ ÛÂÚ›ÓË, ‚·Ï›ÓË ‹ ·Ï·Ó›ÓË. ∂ȉÈÎfiÙÂÚ·, ÙÔ 96% ÙˆÓ ‰È·‚ËÙÈÎÒÓ Ù‡Ô˘ 1 Â›Ó·È ÔÌfi˙˘ÁÔ non-Asp 57 (¡∞/¡∞), ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi Û ˘ÁÈ‹ ¿ÙÔÌ· Â›Ó·È ÌfiÓÔ 19,5%. ∆Ô ·Ú·¿Óˆ ·ÓÙÈÚÔۈ‡ÂÈ ¤Ó·Ó 100Ï¿ÛÈÔ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ ·Ó·ÊÔÚÈο Ì ÙË ÓfiÛÔ ÁÈ· Ù· ¡∞/¡∞ ¿ÙÔÌ·, ÔÛÔÛÙfi Ô˘ ˘ÂÚ¤¯ÂÈ ·ÚÈıÌËÙÈο Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ·ÓÙ›ÛÙÔȯ· Ô˘ ‰›ÓÔ˘Ó ÔÚÔÏÔÁÈο ÚÔÛ‰ÈÔÚÈ˙fiÌÂÓÔÈ DR Ê·ÈÓfiÙ˘ÔÈ (39). ™Ù· ·Ú·¿Óˆ ÚÔÛÙ¤ıËÎÂ Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ë ·ÚÔ˘Û›· Ù˘ ·ÚÁÈÓ›Ó˘ ÛÙË ı¤ÛË 52 (Arg 52) Ù˘ DQ ·-·Ï‡ÛÔ˘ Û˘ÓÙÂÏ› Î·È ·˘Ù‹ ÛÙËÓ ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘, ηıÒ˜ Î·È fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ÔÌÔ˙˘ÁÒÙË non-Asp 57 Ù˘ DQ ‚ ·Ï‡ÛÔ˘ Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· Arg 52 Ù˘ DQ ·-·Ï‡ÛÔ˘ ‰Ú· Ì ·ıÚÔÈÛÙÈÎfi ÙÚfiÔ ÂÈ‚·Ú˘ÓÙÈο ÁÈ· ÙË ÓfiÛÔ (42). ª›· ÚfiÙ·ÛË Èı·Ó‹˜ ÂÚÌËÓ›·˜ ÙˆÓ ·Ú·¿Óˆ Â›Ó·È ·˘Ù‹ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙËÓ Asp 57 Î·È ÙË non-Arg 52, ÛÙË ‚ Î·È · ¿Ï˘ÛÔ ·ÓÙ›ÛÙÔȯ·, Ó· ‰ËÌÈÔ˘ÚÁÔ‡Ó ÌË Â˘ÓÔ˚Τ˜ ÚÔ¸Ôı¤ÛÂȘ ˘Ô‰Ô¯‹˜ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ (∂ÈÎfiÓ˜ 3· Î·È 3‚). ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ, ‰ÂÓ Á›ÓÂÙ·È ÛˆÛÙ¿ Ë “·ÚÔ˘Û›·ÛË” ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÛÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘. ∞˘Ù‹ Ë ·Ô˘Û›· “ÂÊ·ÚÌÔÁ‹˜” ˘Ô‰Ô¯¤·-·ÓÙÈÁfiÓÔ˘ Â›Ó·È Ô˘ ÚÔÊ˘Ï¿ÛÛÂÈ ·fi ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ∆-΢ÙÙ¿ÚÔ˘, ηıÒ˜ Î·È ·fi fiÏ· Ù· ·ÓÔÛÔÏÔÁÈο ·ÚÂfiÌÂÓ¿ Ù˘. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, Ë ·Ô˘Û›· Asp 57 Î·È Ë ·ÚÔ˘Û›· Arg 52 ÂÈÙÚ¤ÂÈ ÙËÓ ˘Ô‰Ô¯‹ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Î·È ÙËÓ Â·ÎfiÏÔ˘ıË ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘ ·fi ÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘, Ô ÔÔ›Ô˜ ÛÙË Û˘Ó¤¯ÂÈ· ÂÓÂÚÁÔÔÈÂ›Ù·È (42,43).
¶›Ó·Î·˜ 2. O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ Ù‡Ô˘ 1 ‰È·‚‹ÙË Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ˘˜ HLA-DR Î·È HLA-DQ ·ÏfiÙ˘Ô˘˜ ∫›Ó‰˘ÓÔ˜ HLA DRB1 À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ª¤ÙÚÈÔ˘ ÎÈÓ‰‡ÓÔ˘
ª¤ÙÚÈ· ÚÔÛÙ·Û›·
πÛ¯˘Ú‹ ÚÔÛÙ·Û›·
338
0401, 0402, 0405 0301 0801 0101 0901 0401 0403 0701 1101 1501 1401 0701
HLA HLA DQA1
HLA DQB1
0301 0501 0401 0101 0301 0301 0301 0201 0501 0102 0101 0201
0302 0201 0402 0501 0303 0301 0302 0201 0301 0602 0503 0303
¶·È‰È·ÙÚÈ΋ 2003;66:334-343
Paediatriki 2003;66:334-343
°ÔÓ›‰È· ÂÎÙfi˜ Ù˘ HLA ÂÚÈÔ¯‹˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ∆1™¢ ∂Ú¢ÓËÙÈο ÚÔÁÚ¿ÌÌ·Ù· ¯·ÚÙÔÁÚ¿ÊËÛ˘ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ Û ÔÈÎÔÁ¤ÓÂȘ Ì ÚÔۂ‚ÏË̤ӷ ˙‡ÁË ·‰ÂÚÊÒÓ ·fi ∆1™¢, ·Ó·‰ÂÈÎÓ‡Ô˘Ó - ÂÎÙfi˜ ·fi ÙÔ Î‡ÚÈÔ ˘Â‡ı˘ÓÔ ÁÔÓ›‰ÈÔ 6p21.3 - ¿ÏÏÔ˘˜ 20 ÂÚ›Ô˘ ÌË HLA ÁÂÓÂÙÈÎÔ‡˜ ÙfiÔ˘˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Û ¿ÏÏÔÙ ¿ÏÏÔ ‚·ıÌfi Ì ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (44). ™‹ÌÂÚ·, ˆÛÙfiÛÔ, ıˆÚÂ›Ù·È fiÙÈ ‰‡Ô ÌË-HLA ÁÂÓÂÙÈÎÔ› ÙfiÔÈ Â˘ı‡ÓÔÓÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙË ÁÂÓÂÙÈ΋ ÂÈ‚¿Ú˘ÓÛË ÚÔ˜ ÙË ÓfiÛÔ. ∆Ô ÁÔÓ›‰ÈÔ IDDM2 ‰ڿ˙ÂÙ·È ÛÙËÓ ÂÚÈÔ¯‹ p15.5 ÙÔ˘ ¯ÚˆÌ·ÙÔÛÒÌ·ÙÔ˜ 11 Î·È Û˘Ì‚¿ÏÏÂÈ Î·Ù¿ 10% ÂÚ›Ô˘ ÛÙËÓ ÚԉȿıÂÛË ÁÈ· ÙË ÓfiÛÔ (8,33,45). ∏ ÁÂÓÂÙÈ΋ ·˘Ù‹ ÂÚÈÔ¯‹ Â›Ó·È ÔÏ˘ÌÔÚÊÈ΋, ηı’ fiÛÔÓ Û ·˘Ù‹ ¯·ÚÙÔÁÚ·ÊÂ›Ù·È ÔÈΛÏÔ˜ ·ÚÈıÌfi˜ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈÎÒÓ Â·Ó·Ï‹„ÂˆÓ ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉ›ˆÓ (Variable number of tandem repeats - VNTR). ∂ȉÈÎfiÙÂÚ·, Ë ‚Ú·¯Â›· Ù¿ÍË I VNTR ·ÏÏËÏ›ˆÓ Úԉȷı¤ÙÂÈ ÛÙË ÓfiÛÔ, ÂÓÒ ·ÓÙ›ıÂÙ· Ë Ì·ÎÚ‡ÙÂÚË Ù¿ÍË II ·ÏÏËÏ›ˆÓ ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· (36). ŒÓ·˜ ¿ÏÏÔ˜ ÁÂÓÂÙÈÎfi˜ ÙfiÔ˜ Û¯ÂÙÈ˙fiÌÂÓÔ˜ Ì ÙÔ ‰È·‚‹ÙË Ù‡Ô˘ I Â›Ó·È Ô IDDM12 ÛÙÔ ¯ÚˆÌ·Ùfiۈ̷ 2q33. ™ÙÔ Â›Â‰Ô ·˘Ùfi Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÂÌÊ·Ó‹˜ ›‰Ú·ÛË ¿Óˆ ÛÙËÓ Î˘ÙÙ·ÚÔÙÔÍÈ΋ ∆-ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ÚˆÙ½ÓË 4 (Cytotoxic T-lymphocyte-associated protein 4 - CTLA-4). ∏ ÚˆÙ½ÓË ·˘Ù‹ Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ (46). øÛÙfiA‡Ï·Î·˜ ÙÔ˘ Bjorkman
ÛÔ, Ë ÁÂÓÂÙÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ηχÙÂÙ·È ÌfiÓÔ ·fi ÙÔ˘˜ ÙÚÂȘ ÁÂÓÂÙÈÎÔ‡˜ ÙfiÔ˘˜ Ô˘ ÚԷӷʤÚıËηÓ. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚfiÛÊ·Ù· ‰ËÌÔÛÈÂ˘Ì¤Ó˘ Û˘ÁÎÂÓÙÚˆÙÈ΋˜ ·Ó¿Ï˘Û˘ ‰Â‰ÔÌ¤ÓˆÓ Î·È ·fi ÙȘ ÙÚÂȘ ·ÓȯÓ¢ÙÈΤ˜ ¤Ú¢Ó˜ ÛÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· (genome scans) Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Ì¤¯ÚÈ ÙÒÚ·, ˘¿Ú¯ÂÈ Û˘Ìʈӛ· ÛÙÔ fiÙÈ ÂÙ¿ ÁÂÓÂÙÈÎÔ› ÙfiÔÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ÂӉ›ÍÂȘ Û‡Ó‰ÂÛ˘ (linkage) Ì ÙÔÓ ∆1™¢. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ·˘ÙÔ› Â›Ó·È ÔÈ: 6p21 (IDDM1), 11p15 (IDDM2), 16q22-q24 Î·È Ì ÏÈÁfiÙÂÚ˜ ÂӉ›ÍÂȘ Û˘Û¯¤ÙÈÛ˘ ÔÈ 10p11 (IDDM10), 2q31 (IDDM7, IDDM12, IDDM13), 6q21 (IDDM15) Î·È 1q42 (47). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÒÓ ÙˆÓ ÌÂÏÂÙÒÓ Ê¤ÚÓÔ˘Ó ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙËÓ ·Ó¿ÁÎË ‰ËÌÈÔ˘ÚÁ›·˜ Î·È ¿ÏÏˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÌÂÏÏÔÓÙÈÎÒÓ ‰ÈÂıÓÒÓ ÂÈÛÙËÌÔÓÈÎÒÓ Û˘ÓÂÚÁ·ÛÈÒÓ, ÒÛÙ ӷ Û˘ÁÎÂÓÙÚˆıÔ‡Ó Î·È Ó· ·Ó·Ï˘ıÔ‡Ó ·ÎfiÌË ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›·, Ù· ÔÔ›· ı· ‰È¢ÎÔχÓÔ˘Ó ÙË ¯·ÚÙÔÁÚ¿ÊËÛË ÙˆÓ ˘Â‡ı˘ÓˆÓ ÁÔÓȉ›ˆÓ Ù˘ ÓfiÛÔ˘. ¢Â›ÎÙ˜ Úfi‚Ï„˘ Ù˘ ÓfiÛÔ˘ Û ·È‰È¿ Ì ·˘ÍË̤ÓË ÁÂÓÂÙÈ΋ ÂÈ‚¿Ú˘ÓÛË ™ÙÔÓ ÔÚfi ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ù‡Ô˘ I ·Ó¢ڛÛÎÔÓÙ·È ‰È·ÊÔÚÂÙÈο ·ÓÙÈÛÒÌ·Ù·, Ë ·ÚÔ˘Û›· ÙˆÓ ÔÔ›ˆÓ ÌÔÚ› Ó· ÚÔËÁÂ›Ù·È Ì‹Ó˜ ‹ ¯ÚfiÓÈ· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (2-5,36,48-56). ∫ÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Ô˘ ¿Ú¯ÈÛ·Ó ÚÈÓ A‡Ï·Î·˜ ÙÔ˘ Bjorkman Arg 52
·-∞Ï˘Û›‰·
·-∞Ï˘Û›‰·
∞ÓÙÈÁfiÓÔ ∞ÓÙÈÁfiÓÔ ‚-∞Ï˘Û›‰· ÀÔ‰Ô¯¤·˜ ∆-΢ÙÙ¿ÚÔ˘
‚-∞Ï˘Û›‰· ÀÔ‰Ô¯¤·˜ ∆-΢ÙÙ¿ÚÔ˘
∂ÈÎfiÓ· 3·. ∏ ·ÓÙ›‰Ú·ÛË Î·Ù¿ ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ·fi ÙÔ˘˜ ÂȉÈÎÔ‡˜ HLA DQ ˘ÔÙ‡Ô˘˜ ÛÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘ ∆΢ÙÙ¿ÚÔ˘. ∏ ·ÚÔ˘Û›· ÙÔ˘ ·Û·ÚÙÈÎÔ‡ ÔͤԘ ÛÙË ı¤ÛË 57 Ù˘ DQ ‚-·Ï‡ÛÔ˘ Î·È Ë ·Ô˘Û›· Ù˘ ·ÚÁÈÓ›Ó˘ ÛÙË ı¤ÛË 52 Ù˘ ·-·Ï‡ÛÔ˘ ·ÔÙÚ¤ÂÈ ÙË Û‡Ó‰ÂÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÛÙËÓ ·‡Ï·Î· ÙÔ˘ Bjorkman (43).
∂ÈÎfiÓ· 3‚. ∏ ¤ÏÏÂÈ„Ë ÙÔ˘ ·Û·ÚÙÈÎÔ‡ ÔͤԘ ÛÙË ı¤ÛË 57 Ù˘ DQ ‚-·Ï‡ÛÔ˘ Î·È Ë ·ÚÔ˘Û›· ·ÚÁÈÓ›Ó˘ ÛÙË ı¤ÛË 52 Ù˘ ··Ï‡ÛÔ˘ ÂÈÙÚ¤Ô˘Ó ÛÙÔ ·ÓÙÈÁfiÓÔ Ó· Û˘Ó‰Âı› ÛÙËÓ ·‡Ï·Î· ÙÔ˘ Bjorkman Î·È Ó· ·Ó·ÁÓˆÚÈÛÙ› ·fi ÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘ ∆΢ÙÙ¿ÚÔ˘, Ô ÔÔ›Ô˜ ÂÓÂÚÁÔÔÈÂ›Ù·È (43).
339
¶·È‰È·ÙÚÈ΋ 2003;66:334-343
·fi 25 ÂÚ›Ô˘ ¯ÚfiÓÈ·, ·ÔÎ¿Ï˘„·Ó ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ·ÓÙÈÓËÛȉȷÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (islet cell antibodies - ICA) ÛÙÔÓ ÔÚfi ÂÚÈÛÛfiÙÂÚˆÓ ·fi 80% ÚˆÙԉȷÁÓˆÛÌ¤ÓˆÓ ·ÛıÂÓÒÓ (57). ¶ÚfiÎÂÈÙ·È ÁÈ· ·ÓÙÈÛÒÌ·Ù· Ô˘ ÛÙÚ¤ÊÔÓÙ·È Î·Ù¿ ΢ÙÙ¿ÚˆÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ‹ ÙÔ˘ ΢ÙÙ·ÚÔÏ¿ÛÌ·ÙÔ˜ ÙˆÓ ÓËÛȉ›ˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, ¯ˆÚ›˜ Ó· Â›Ó·È ÂȉÈο ÁÈ· Ù· ÈÓÛÔ˘ÏÈÓÔ·Ú·ÁˆÁ¿ ‚-·ÙÙ·Ú· (48). ª›· Ó¤· ‰È¿ÛÙ·ÛË ¤‰ˆÛÂ Ë ·Ó·Î¿Ï˘„Ë fiÙÈ ¿ÙÔÌ· Ù· ÔÔ›· ‰ÂÓ Â›¯·Ó ÚÔËÁÔ‡ÌÂÓË ¤ÎıÂÛË Û Â͈ÁÂÓ‹ ÈÓÛÔ˘Ï›ÓË, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ÈÓÛÔ˘Ï›Ó˘ (insulin autoantibodies - IAA) (51). ∏ ÚÔÛ¿ıÂÈ· ·Ó›¯Ó¢Û˘ ·ÓÙÈÁfiÓˆÓ “ÛÙfi¯ˆÓ” ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ˘‹ÚÍ ̷ÎÚfi¯ÚÔÓË Î·È Â›ÔÓË Î·È ÙÂÏÈο ·¤‰ˆÛ ÂÓ Ì¤ÚÂÈ Ì ÙËÓ ·Ó·ÁÓÒÚÈÛË ÂÓfi˜ ÂȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ 64-kD, ÙÔ ÔÔ›Ô ‚Ú¤ıËΠÛÙÔÓ ÔÚfi ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, ·ÏÏ¿ fi¯È Û ÔÌ¿‰· ÂϤÁ¯Ô˘ (49). ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ·ÔηڂÔÍ˘Ï¿ÛË ÙÔ˘ ÁÏÔ˘Ù·ÌÈÓÈÎÔ‡ ÔͤԘ (glutamic acid decarboxylase - GAD), ÚˆÙ½ÓË Ô˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Î·È Ì ÙÔÓ ∆1™¢ Û ÔÏÏ¿ ÚfiÙ˘· ÂÈÚ·Ì·Ùfi˙ˆˆÓ, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ÌË ·¯‡Û·ÚÎÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ÔÓÙÈÎÔ‡˜ (non-obese diabetic NOD) (51,54). ∆· ·ÓÙÈÛÒÌ·Ù· GAD∞ (GADantibodies) Ê·›ÓÂÙ·È Ó· ˘ÂÚ¤¯Ô˘Ó ¤Ó·ÓÙÈ ÙˆÓ IAA, ηıÒ˜ Ë ·ÚÔ˘Û›· ÙÔ˘˜ Â›Ó·È ÂÈÎÚ·Ù¤ÛÙÂÚË ÚÈÓ ÙËÓ ¤Ó·ÚÍË ‹ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (51,54). ∂›Û˘, ıÂÙÈο GAD∞ ·Ó¢ڛÛÎÔÓÙ·È Û ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi - Û ۯ¤ÛË Ì ٷ ICA - Û ÚÒÙÔ˘ ‚·ıÌÔ‡ Û˘ÁÁÂÓ›˜ ·ÛıÂÓÒÓ Ì ™¢ Ù‡Ô˘ I (58). ¡¤Â˜ ‰˘Ó·ÙfiÙËÙ˜ ÚԤ΢„·Ó Ì ÙËÓ ·Ó·Î¿Ï˘„Ë ‰‡Ô ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÒÓ ·ÓÙÈÁÔÓÈÎÒÓ ÙÌËÌ¿ÙˆÓ 40-kD Î·È 37-kD, ÛÙ· ÔÔ›· ‰fiıËÎÂ Ë ÔÓÔÌ·Û›· IA-2 Î·È IA-2c (phogrin), ·ÓÙ›ÛÙÔȯ· (59,60). ∆Ô 1998, ÔÈ Kulmala Î·È Û˘Ó, ÌÂÏÂÙÒÓÙ·˜ Ù˘¯·›Ô ÏËı˘ÛÌfi ·fi 755 ·‰¤ÚÊÈ· ·È‰ÈÒÓ Ô˘ ¤·Û¯·Ó ·fi ∆1™¢, ÂÎÙ›ÌËÛ·Ó ÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÂÛÛ¿ÚˆÓ ÔÌ¿‰ˆÓ ·ÓÙÈۈ̿وÓ, ‰ËÏ·‰‹ ÙˆÓ ICA, ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ÚˆÙ½Ó˘ IA-2, ÙˆÓ GAD∞ Î·È ÙˆÓ IAA. ∏ ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÂÎÙÈÌ‹ıËΠ۠43%, 55%, 42% Î·È 29% Î·È Ë Â˘·ÈÛıËÛ›· Û 81%, 69%, 69% Î·È 25%, ·ÓÙ›ÛÙÔȯ· (61). ™ÙËÓ ›‰È· ÌÂϤÙË, Ë ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÂÌÊ¿ÓÈÛ˘ ∆1™¢ ÛÂ Û˘ÁÁÂÓ›˜ ·ÛıÂÓÒÓ Ô˘ ›¯·Ó ¤Ó· ‹ Û˘Ó‰˘·ÛÌfi ‰‡Ô ‹ ÙÚÈÒÓ Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙË ÓfiÛÔ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó 2%, 25% Î·È 70%, ÂÓÒ Û ¿ÏÏË ·ÚfiÌÔÈ· ÌÂϤÙË ‹Ù·Ó 15%, 44% Î·È 100%, ·ÓÙ›ÛÙÔȯ· (62). ∆¤ÏÔ˜, ÔÈ Kimpimaki Î·È Û˘Ó (2000), Û ̛· ·Ó¿ÏÔÁË ÌÂϤÙË Î·Ù·Ï‹ÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ù· ·ÓÙÈÛÒÌ·Ù· ·˘Ù¿ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÔÙÂϤÛÔ˘Ó Î·Ù¿ οÔÈÔ ÙÚfiÔ “ÙÔÔÙËÚËÙ¤˜” ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Û ·È‰È¿ Ì ·˘ÍË̤ÓÔ ÁÂÓÂÙÈÎfi ΛӉ˘ÓÔ (63).
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¶·Ú¿ÁÔÓÙ˜ Ô˘ ‰˘ÓËÙÈο ·ÔÙÂÏÔ‡Ó ¤Ó·˘ÛÌ· ÁÈ· ÙË ÓfiÛÔ ∂›Ó·È ϤÔÓ Û¯Â‰fiÓ ‚¤‚·ÈË Ë Û˘ÌÌÂÙÔ¯‹ ÔÚÈÛÌ¤ÓˆÓ ÈÒÓ ˆ˜ ·Ú·ÁfiÓÙˆÓ ¤Ó·Ú͢ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ‰È·‰Èηۛ·˜ Ô˘ Ô‰ËÁ› ÙÂÏÈο ÛÙË ÓfiÛÔ (64). ∏ Û˘ÁÁÂÓ‹˜ ÂÚ˘ıÚ¿ ·ÔÙÂÏ› ÎÏ·ÛÈÎfi ·Ú¿‰ÂÈÁÌ· ÁÈ· ÙÔ fiÙÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ™ÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ Ì ۇӉÚÔÌÔ Û˘ÁÁÂÓÔ‡˜ ÂÚ˘ıÚ¿˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ‰È·‚‹Ù˘, Ì ϷÓı¿ÓÔ˘Û· ÂÚ›Ô‰Ô ÔÏÏÒÓ ÂÙÒÓ Î·È Ì¤ÛË ËÏÈΛ· ¤Ó·Ú͢ Ù· 13 ¤ÙË (65). ∂›Ó·È Èı·Ófi fiÙÈ Î·È ¿ÏϘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ·ÔÙÂÏÔ‡Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ∆π™¢. ™˘ÁÎÂÎÚÈ̤ӷ, ·Ú·ÙËÚ‹ıËΠfiÙÈ Î·Ù¿ ÙËÓ Î‡ËÛË Ù· ›‰· IgG Î·È IgM ·ÓÙÈÛˆÌ¿ÙˆÓ ÂȉÈÎÒÓ ÔÌ¿‰ˆÓ ÂÓÙÂÚÔ˚ÒÓ ‹Ù·Ó ˘„ËÏfiÙÂÚ· Û 57 ÌËÙ¤Ú˜ ·È‰ÈÒÓ Ô˘ ·Ó¤Ù˘Í·Ó ÌÂÙ¤ÂÈÙ· ∆π™¢, Û˘ÁÎÚÈÙÈο Ì 203 ÌËÙ¤Ú˜ ·ÓÙ›ÛÙÔȯˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ (66). ™˘ÁÎÂÎÚÈ̤ÓÔÈ ÈÔ› ¤¯Ô˘Ó ·Ó·ÊÂÚı› ˆ˜ “·ÁÎÚ·ÙÔÙÚfiÔÈ”, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Ô Èfi˜ Ù˘ ·ÚˆÙ›Ùȉ·˜, Ô Coxsackie B4 (CVB4), ηıÒ˜ Î·È ¿ÏÏÔÈ ÂÓÙÂÚÔ˚Ô› (67,68). ªÈÎÚ¤˜ “ÂȉË̛˜” ‰È·‚‹ÙË ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÌÂÙ¿ ·fi ÂȉËÌ›· ÈÒÛˆÓ, ÌÂÚÈΤ˜ ·fi ÙȘ Ôԛ˜ Ì¿ÏÈÛÙ· Ì ̛· ΢ÎÏÈ΋ Û˘¯ÓfiÙËÙ· ÙÂÛÛ¿ÚˆÓ ¤ˆ˜ ¤ÓÙ ÂÙÒÓ (67). ª›· ·Ó¿ÏÔÁË ıˆڛ· ·Ó·Ù‡¯ıËΠÁÈ· ÙËÓ ·ÚˆÙ›Ùȉ·, ¯ˆÚ›˜ fï˜ ÙÂÏÈο Ó· ÛÙÔȯÂÈÔıÂÙËı› (67). π‰È·›ÙÂÚÔ˜ ÏfiÁÔ˜ ¤¯ÂÈ Á›ÓÂÈ ÁÈ· ÙÔÓ CVB4, ηı’ fiÙÈ Ë ÔÌfiÏÔÁË ·ÏÏËÏÔ˘¯›· ÌÂٷ͇ Ù˘ ÌË ‰ÔÌÈ΋˜ ÚˆÙ½Ó˘ ÙÔ˘ 2C (CVB4 p2C) Î·È ÙÔ˘ Ì›˙ÔÓÔ˜ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ‰È·‚‹ÙË GAD65 ·ÔÙÂÏ› ÙË ‚¿ÛË Ù˘ ˘fiıÂÛ˘ Ù˘ “ÌÔÚȷ΋˜ ·ÔÌ›ÌËÛ˘” (molecular mimicry). ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ·ÓÙÈÛÒÌ·Ù· Ô˘ ·Ú¿ÁÔÓÙ·È ˆ˜ ·¿ÓÙËÛË Û Ïԛ̈ÍË ·fi Èfi Coxsackie ÌÔÚÔ‡Ó Ó· ·ÓÙȉÚÔ‡Ó Ì ÙÔ ·ÓÙÈÁfiÓÔ GAD ÙˆÓ ‚΢ÙÙ¿ÚˆÓ, Û˘ÌÌÂÙ¤¯ÔÓÙ·˜ Ì ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ÛÙËÓ ·˘ÙÔ¿ÓÔÛË Î·Ù·ÛÙÚÔÊ‹ ·˘ÙÒÓ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (68). øÛÙfiÛÔ, Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ì›· ·ÓÙÈۈ̷ÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ CBV4 p2C ‰ÂÓ ÂÈÛ¿ÁÂÈ ·Ó·Áη›· ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÛÙÔ GAD65 (69). ŒÓ· ‰Â‡ÙÂÚÔ ·Ú¿‰ÂÈÁÌ· “ÌÔÚȷ΋˜ ·ÔÌ›ÌËÛ˘” Ô˘ ÚÔÙ¿ıËΠÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∆1™¢ Î·È Ô˘ ‚·Û›˙ÂÙ·È Î˘Ú›ˆ˜ Û ÚfiÙ˘· ÂÈÚ·Ì·Ùfi˙ˆˆÓ, ·ÊÔÚ¿ ÛÙËÓ ¤ÎıÂÛË ÛÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÙÔ˘ Á¿Ï·ÎÙÔ˜ Ù˘ ·ÁÂÏ¿‰·˜ ηٿ ÙË Û›ÙÈÛË ÛÙËÓ ÚÒÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (70). ™Â ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ·Ú·ÙËÚ‹ıËΠ‚Ú·¯‡ÙÂÚË ÂÚ›Ô‰Ô˜ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· Ù· ‰È·‚ËÙÈο ·È‰È¿, Û˘ÁÎÚÈÙÈο Ì ÌË ÚÔۂ‚ÏË̤ӷ ·‰¤ÚÊÈ· ‹ Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (71). ™˘ÓÂÒ˜, ÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ ÂÌϤÎÂÙ·È Û·Ó ¤Ó·˜ ‰˘ÓËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¤Ó·Ú͢ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·¿ÓÙËÛ˘ Û ¿ÙÔÌ· Ô˘ Â›Ó·È ÁÂÓÂÙÈο
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ÚԉȷÙÂıÂÈ̤ӷ. ∂ȉÈÎfiÙÂÚ·, ÙÔ ÂÙ›‰ÈÔ ABBOS ·ÔÙÂÏ› ÙÔ Û˘ÛÙ·ÙÈÎfi ÂΛÓÔ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÁÈ· ÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠÌÂÙ·‚ÔÏ‹ ‹ ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û˘ Á-ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÈÓÙÂÚÏ¢ΛÓ˘-4 ÛÙ· ÏÂÌÊÔ·ÙÙ·Ú· ·È‰ÈÒÓ Ì ÚfiÛÊ·ÙË ¤Ó·ÚÍË ™¢ Ù‡Ô˘ I (72), ηıÒ˜ Î·È ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÓÙÈۈ̷ÙÈ΋ ·ÓÙ›‰Ú·ÛË ÌÂٷ͇ ÙÔ˘ ÂÙȉ›Ô˘ ·˘ÙÔ‡ Î·È ÚˆÙÂ˚ÓÒÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ (ÚˆÙ½ÓË 69, p69). ¶·Ú¿ ÙÔ fiÙÈ Ë ıˆڛ· ·˘Ù‹ ˘ÔÛÙËÚ›¯ıËΠ·fi ·ÚÎÂÙ¤˜ ÌÂϤÙ˜, ‰ÂÓ ¤ÁÈÓ ηıÔÏÈο ·Ô‰ÂÎÙ‹ ÂÍ·ÈÙ›·˜ ÂÚ¢ÓÒÓ Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ·Ó›¯Ó¢ÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÙÔ˘ ·ÁÂÏ·‰ÈÓÔ‡ Á¿Ï·ÎÙÔ˜ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È Û˘ÓËı¤ÛÙÂÚ· Û ڈÙԉȷÁÓˆṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ∆1™¢, Û˘ÁÎÚÈÙÈο ÌÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ‹ ·ÛıÂÓ›˜ Ô˘ ¿Û¯Ô˘Ó ·fi ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (73). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÚfiÔ‰Ô˜ Û ÔÏÏ¿ ‰›·, ηıÒ˜ Î·È Ë ‰˘Ó·ÙfiÙËÙ· ÌÂϤÙ˘ ÙÔ˘ ∆1™¢ Û ÂÈÚ·Ì·Ùfi˙ˆ·, Ô‰‹ÁËÛ·Ó ÛÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË Ù˘ ÁÂÓÂÙÈ΋˜ ‚¿Û˘ ÙÔ˘. OÈ Î˘Ú›·Ú¯ÔÈ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· Ù· HLA-DQ ·ÏÏ‹ÏÈ·, ÂÓÒ ·Ú¿ÏÏËÏ·, Ë Û˘Ó¤¯ÈÛË Ù˘ ¤Ú¢ӷ˜ ÛÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· ·Ó·‰ÂÈÎÓ‡ÂÈ Î·È ¿ÏÏÔ˘˜ Û˘Ó˘Â‡ı˘ÓÔ˘˜ ÁÂÓÂÙÈÎÔ‡˜ ÙfiÔ˘˜. ∆ÂÏÈÎfi˜ ÛÙfi¯Ô˜ fiÏˆÓ ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ, ·ÓÔÛÔÏÔÁÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÌÂÏÂÙÒÓ Ú¤ÂÈ Ó· Â›Ó·È Ë ‰ËÌÈÔ˘ÚÁ›· ÌÂıfi‰ˆÓ Úfi‚Ï„˘ Î·È ıÂڷ›·˜ Ù˘ ÓfiÛÔ˘ Ì ·ÓÔÛÔıÂڷ›· Î·È ÁÂÓÂÙÈ΋ ·Ú¤Ì‚·ÛË. ∂˘¯·ÚÈÛٛ˜ OÈ Û˘ÁÁÚ·Ê›˜ ı· ‹ıÂÏ·Ó Ó· ÂÎÊÚ¿ÛÔ˘Ó ÙȘ ¢¯·ÚÈÛٛ˜ ÙÔ˘˜ ÛÙÔÓ ∫·ıËÁËÙ‹ ¶·È‰È·ÙÚÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ Î. ™Ù¤ÏÈÔ ™Ì˘Ú¿ÎÈ ÁÈ· ÙËÓ ÎÚÈÙÈ΋ ·Ó¿ÁÓˆÛË ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÙȘ Ôχ ¯Ú‹ÛÈ̘ ·Ú·ÙËÚ‹ÛÂȘ.
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66. Dahlquist GG, Ivarsson S, Lindberg B, Forsgren M. Maternal enteroviral infection during pregnancy as a risk factor for childhood IDDM. A population-based case-control study. Diabetes 1995;44:408-413. 67. Prince GA, Jenson AB, Billups LC, Notkins AL. Infection of human pancreatic beta cell cultures with mumps virus. Nature 1978;271:158-161. 68. Kaufman DL, Erlander MG, Clare-Salzler M, Atkinson MA, Maclaren NK, Tobin AJ. Autoimmunity to two forms of glutamate decarboxylase in insulin-dependent diabetes mellitus. J Clin Invest 1992;89:283-292. 69. Vreugdenhil GR, Batstra MR, Aanstoot HJ, Melchers WJ, Galama JM. Analysis of antibody responses against coxsackie virus B4 protein 2C and the diabetes autoantigen GAD(65). J Med Virol 1999;59:256-261. 70. Schrezenmeir J, Jagla A. Milk and diabetes. J Am Coll Nutr 2000;19 (2 Suppl):S176-S190. 71. Borch-Johnsen K, Joner G, Mandrup-Poulsen T, Christy M, Zachau-Christiansen B, Kastrup K et al. Relation between breast-feeding and incidence rates of insulin-dependent diabetes mellitus. A hypothesis. Lancet 1984;2:1083-1086. 72. Karlsson MG, Ludvigsson J. The ABBOS-peptide from bovine serum albumin causes an IFN-gamma and IL-4 mRNA response in lymphocytes from children with recent onset of type 1 diabetes. Diabetes Res Clin Pract 2000;47:199-207. 73. Atkinson MA, Bowman MA, Kao KJ, Campbell L, Dush PJ, Shah SC et al. Lack of immune responsiveness to bovine serum albumin in insulin-dependent diabetes. N Engl J Med 1993;329:1853-1858. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 06-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-05-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂Ï¢ıÂÚ›· ¶··‰ÔÔ‡ÏÔ˘ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ (¶∞°¡∏) ∆.∫. 712 01, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: bm-pjhkka@otenet.gr
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ORIGINAL ARTICLE
¢È·¯ÚÔÓÈ΋ ÌÂϤÙË Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ Û ÓÂÔÁÓ¿ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ π. ∫·Ï¤ÁÈ·˜, ∂. ¶··ıˆÌ¿, ™. °·‚Ú›ÏË, O. OÈÎÔÓÔÌ›‰Ô˘, ∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘, Ã. ¶ÂÙÚÔÔ‡ÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜
Longitudinal study of bronchopulmonary dysplasia in very low birth weight infants J. Kaleyias, E. Papathoma, S. Gavrili, O. Ikonomidou, Z. Hatzistamatiou, C. Petropoulou, C. Costalos
¶ÂÚ›ÏË„Ë: ™ÎÔfi Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ ·ÔÙ¤ÏÂÛÂ Ë ‰È·¯ÚÔÓÈ΋ ÌÂϤÙË Ù˘ ›وÛ˘ Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ (µ¶¢) Û Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ (¶Ãµ°¡) Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÓfiÛÔ. ¶ÚfiÎÂÈÙ·È ÁÈ· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË, ÛÙËÓ ÔÔ›· Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 380 ¶Ãµ°¡ (µ° ≤1500 g) Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ ›‰ÈÔ ÂÚÈÁÂÓÓËÙÈÎfi ΤÓÙÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÚÈÒÓ ÂÚÈfi‰ˆÓ: 1989-1990 (ÂÚ›Ô‰Ô˜ π), 1994-1995 (ÂÚ›Ô‰Ô˜ ππ) Î·È 1999-2000 (ÂÚ›Ô‰Ô˜ πππ). ø˜ µ¶¢ ÔÚ›ÛÙËÎÂ Ë Ô͢ÁÔÓÔÂÍ¿ÚÙËÛË ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜, Ì ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Û˘Ì‚·Ù‹ Ì ÙË ÓfiÛÔ. ∞ÍÈÔÏÔÁ‹ıËÎ·Ó ‰È·¯ÚÔÓÈο ÔÈ ÚÔÁÂÓÓËÙÈÎÔ› Î·È ÂÚÈÁÂÓÓËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∂Ê·ÚÌfiÛÙËΠÌÔÓÔ·Ú·ÁÔÓÙÈ΋ Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó ÔÈ Èı·ÓÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË µ¶¢. ™ÙȘ ÂÚÈfi‰Ô˘˜ π, ππ Î·È πππ ·ÚÔ˘Û›·Û ™∞¢ ÙÔ 60%, 66% Î·È 58% ÙˆÓ ÓÂÔÁÓÒÓ (p=ns), ·Â‚›ˆÛ ÙÔ 23%, 20% Î·È 22% (p=ns) Î·È µ¶¢ ·Ó¤Ù˘Í ÙÔ 13,3%, 10,7% Î·È 11,2% (p=ns), ·ÓÙ›ÛÙÔȯ·. ∆· 149/232 (64%) ÓÂÔÁÓ¿ Ì ™∞¢ ÂÈ‚›ˆÛ·Ó ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ (∏∑), 44 (29%) ·fi Ù· ÔÔ›· ·Ó¤Ù˘Í·Ó µ¶¢. OÈ ÚÔÁÂÓÓËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙËÓ ·Ó¿Ù˘ÍË µ¶¢. ∏ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢. OÈ ÓÂÔÁÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙËÓ ·Ó¿Ù˘ÍË µ¶¢ ‹Ù·Ó ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (µ° <1000 g) (OR=3,1), Ë ‰È¿ÚÎÂÈ· ·ËÛ˘ (¢∫ <29 ‚‰ÔÌ¿‰Â˜) (OR=3,4), ÙÔ ¯·ÌËÏfi Apgar score (≤4) ÙÔ 1Ô Î·È ÙÔ 5Ô ÏÂÙfi (OR=2,1 Î·È 3, ·ÓÙ›ÛÙÔȯ·), Ô ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ (∞∞¶) (OR=3,5), Ô Ó¢ÌÔıÒڷη˜ (OR=6,1), Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· (¡∂∫) (OR=2,1) Î·È Ë ÛË„·ÈÌ›· (OR=4,4). ∏ ¯ÔÚ‹ÁËÛË
Abstract: The objective of this study was the longitudinal assessment of the incidence of and the risk factors for bronchopulmonary dysplasia (BPD) in very low birth weight neonates (VLBWN). This retrospective study reviewed 380 neonates with birth weight ≤1500 g born in the same perinatal centre during three time periods: 1989-1990 (period I), 1994-1995 (period II) and 1999-2000 (period III). BPD was defined as oxygen dependency on the 28th day of life along with chest X-ray appearance consistent with the diagnosis. Univariate and multivariate analyses were used to identify the risk factors related to the development of BPD. Three hundred and eighty VLBWN were born during the study periods. During periods I, II and III, respectively 60%, 66% and 58% of the neonates developed RDS (p=ns), the mortality rate was 23%, 20% and 22% (p=ns) and the incidence of BPD was 13.3%, 10.75% and 11.2% (p=ns). One hundred and forty nine of 232 neonates with RDS (64%) survived on the 28th day of life. Among the survivors, 44/149 (29%) developed BPD. No correlation was found between the antenatal factors and BPD development, and specifically antenatal steroid therapy was not correlated with a lower incidence. The neonatal factors that increased the risk of BPD were the following: low birth weight (<1000 g) (OR=3.1), low gestational age (<29 weeks) (OR=3.4), low Apgar score (≤4) at 1 min and 5 min (OR=2.1 and 3 respectively), patent ductus arteriosus (PDA) (OR=3.5), pneumothorax (OR=6.1), necrotizing enterocolitis (NEC) (OR=2.1) and sepsis (OR=4.4). The absence of association between surfactant replacement and BPD in this population suggests that surfactant therapy could
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó·
Neonatal Intensive Care Unit, General District Hospital of Athens “Alexandra”, Athens
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Paediatriki 2003;66:344-351
ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û ÓÂÔÁÓ¿ Ì ™∞¢ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢. ∏ ›وÛË Ù˘ µ¶¢ ÛÙ· ¶Ãµ°¡ ‹Ù·Ó ÛÙ·ıÂÚ‹ ·fi ÙÔ 1989 ̤¯ÚÈ ÙÔ 2000 ÛÙÔ ›‰ÈÔ ÂÚÈÁÂÓÓËÙÈÎfi ΤÓÙÚÔ. OÈ ÚÔÁÂÓÓËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢. OÈ ÓÂÔÁÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢ ‹Ù·Ó Ë ∏∫ (<29 ‚‰ÔÌ¿‰Â˜), ÙÔ µ° (<1000 g), ÙÔ ¯·ÌËÏfi Apgar score (≤4), o ∞∞¶, Ô Ó¢ÌÔıÒڷη˜, Ë ¡∂∫ Î·È Ë ÛË„·ÈÌ›·.
not prevent RDS from developing into BPD. In conclusion, the incidence of BPD in VLBWN remained constant from 1989 through 2000 in the same perinatal centre. No antenatal factors were associated with BPD, but neonatal factors increasing the risk were low birth weight (<1000 g), low GA (<29 weeks), low Apgar score (≤4), PDA, pneumothorax, NEC and sepsis.
§¤ÍÂȘ ÎÏÂȉȿ: ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿.
Key words: bronchopulmonary dysplasia, risk factors, very low birth weight neonates.
™˘ÓÙÔÌÔÁڷʛ˜
Ó· ·Ó·Ù‡ÍÔ˘Ó µ¶¢. ∂ÈÚfiÛıÂÙ·, ¤¯ÂÈ ÛËÌÂȈı› ·ÏÏ·Á‹ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Î·È ÙËÓ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ù˘ µ¶¢. ∂ÓÒ Ë “ÎÏ·ÛÈ΋” µ¶¢ ‹Ù·Ó ΢ڛˆ˜ Û˘Ó¤ÂÈ· ÙÔ˘ ‚·ÚÔÙÚ·‡Ì·ÙÔ˜-ÔÁÎÔÙÚ·‡Ì·ÙÔ˜ (‚Ï¿‚Ë ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÏfiÁˆ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ì ˘„ËϤ˜ ȤÛÂȘ/fiÁÎÔ˘˜) Î·È Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ô͢ÁfiÓÔ˘, Ë “Ó¤·” µ¶¢ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÙËÓ ÂÔ¯‹ ÙÔ˘ ∂¶ ıˆÚÂ›Ù·È Û˘Ó¤ÂÈ· Ù˘ ·ÏÏËÏ›‰Ú·Û˘ ÔÈÎ›ÏˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Ô‰ËÁÔ‡Ó ÛÙÔÓ ·Ú·ÙÂٷ̤ÓÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Î·È ÙÔÓ ·ÔÈÎÈÛÌfi ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Ì ·ıÔÁfiÓ·, Ù· ÔÔ›· ˘ÚÔ‰ÔÙÔ‡Ó ÙË ÊÏÂÁÌÔÓÒ‰Ë ÂÍÂÚÁ·Û›· (6). ∏ ›وÛË Ù˘ µ¶¢ ÔÈΛÏÏÂÈ ·fi 4,6% ̤¯ÚÈ 72% (7). ∏ ¢Ú›· ‰È·Î‡Ì·ÓÛË Ù˘ ›وÛ˘ Ù˘ µ¶¢ ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÙÂÚÔÁ¤ÓÂÈ· ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ÌÂÏÂٿٷÈ, ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ Î·È ÙˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ ÔÚÈÛÌÒÓ Ù˘ ÓfiÛÔ˘. ∏ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ʇÛË Ù˘ µ¶¢ Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙ‹ (2,8). ¶ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙË µ¶¢, fiˆ˜ Ë ˘ÂÚÔÍ›· (9), ÙÔ ‚·ÚÔÙÚ·‡Ì· (10), Ë ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (11,12), Ô ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ (13), Ë ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ (14) Î·È ÔÈ ÏÔÈÌÒÍÂȘ (15). ∏ ·ÚÔ‡Û· ÌÂϤÙË Û¯Â‰È¿ÛÙËΠÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂÏÂÙËıÔ‡Ó ÔÈ Èı·ÓÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ÓÂÔÁÓ¿ ∂õ° Û ÙÚÂȘ ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈfi‰Ô˘˜. ∏ ÚÒÙË ÂÚ›Ô‰Ô˜ ‹Ù·Ó ÚÈÓ ÙË ¯Ú‹ÛË ÙÔ˘ ∂¶ Î·È ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ (19891990), Ë ‰Â‡ÙÂÚË ‹Ù·Ó Ë ·Ú¯È΋ ÂÚ›Ô‰Ô˜ ·fiÎÙËÛ˘ ÂÌÂÈÚ›·˜ (1994-1995) Î·È Ë ÙÚ›ÙË ‹Ù·Ó Ë ÂÚ›Ô‰Ô˜ ÌÂÙ¿ ·fi ÙËÓ ·fiÎÙËÛË ÂÌÂÈÚ›·˜ Î·È ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·ÓˆÙ¤Úˆ (1999-2000).
∞∞¶ µ° µ¶¢ ¢∫ ∂¶ ∏∑ ¡∂∫ ¶Ãµ°¡ ¶Ã∫
∞ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· ¢È¿ÚÎÂÈ· ·ËÛ˘ ∂ÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ∏̤ڷ ˙ˆ‹˜ ¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· ¶Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ¶ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ
∂ÈÛ·ÁˆÁ‹ ∏ ÛËÌ·ÓÙÈ΋ Ù¯ÓÔÏÔÁÈ΋ ÚfiÔ‰Ô˜ Ô˘ ¤¯ÂÈ ÛËÌÂȈı› ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· 20ÂÙ›·, Û˘Ó¤‚·Ï ÛËÌ·ÓÙÈο ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÂÍ·ÈÚÂÙÈο ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ¡¤Â˜ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Ì›ˆÛ·Ó ÙË ıÓËÙfiÙËÙ·, ·ÏÏ¿ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ÛÙË Ì›ˆÛË Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ (µ¶¢) ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË (1). ∏ µ¶¢ Â›Ó·È Ì›· ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ¿ıËÛË ÙˆÓ ÓÂÔÁÓÒÓ, Ë ÔÔ›· ÂÌÊ·Ó›ÛÙËΠ̠ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙË ıÂڷ›· Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ·fi ÙÔ ™∞¢ Î·È ·ÔÙÂÏ› Û‹ÌÂÚ· ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ Û ·˘Ù‹Ó ÙËÓ ËÏÈΛ· (2). ∏ µ¶¢ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1967 ·fi ÙÔ˘˜ Northway Î·È Û˘Ó (3). ∆Ô 1979, ÔÈ Bancalari Î·È Û˘Ó (4) ÚfiÙÂÈÓ·Ó Ó¤· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·. ∆Ô 1988, ÔÈ Shennan Î·È Û˘Ó (5) fiÚÈÛ·Ó ˆ˜ ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ ÙËÓ Ô͢ÁÔÓÔÂÍ¿ÚÙËÛË Î·Ù¿ ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë. ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (∂¶) Ì›ˆÛ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ™∞¢ Î·È Î·Ù’ ¤ÎÙ·ÛË ÙËÓ ·Ó¿ÁÎË ÁÈ· “ÂÈıÂÙÈÎfi” Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Î·È ·Ú·ÙÂٷ̤ÓË Ô͢ÁÔÓÔıÂڷ›·. ¶·Ú’ fiÏ· ·˘Ù¿, Ë Â›ÙˆÛË Ù˘ µ¶¢ ‰ÂÓ ¤¯ÂÈ ÌÂȈı› Î·È ›Ûˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ·˘ÍËÙÈ΋ ÔÚ›· (6). ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÙÔ˘ ∂¶ Î·È Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ ‚ÂÏÙ›ˆÛ·Ó ÛËÌ·ÓÙÈο ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÂÍ·ÈÚÂÙÈο ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·È ÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¶ÚfiÎÂÈÙ·È ÁÈ· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÙˆÓ È·ÙÚÈÎÒÓ ·Ú¯Â›ˆÓ ÙˆÓ ¶Ãµ°¡ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÔ·Ó·ÊÂÚıÂÈÛÒÓ ÂÚÈfi‰ˆÓ I, II Î·È πππ. ∂ÈϤ¯ıËÎ·Ó ÔÈ ÙÚÂȘ ·˘Ù¤˜
345
¶·È‰È·ÙÚÈ΋ 2003;66:344-351
Paediatriki 2003;66:344-351
ÂÚ›Ô‰ÔÈ ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÍÈÔÏÔÁËıÔ‡Ó ‰È·¯ÚÔÓÈο ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (µ¶¢), Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ‰‡Ô ÛËÌ·ÓÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÓÔÛËÏ›·: ÙËÓ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Î·È ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ. ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó Ù· ¶Ãµ°¡ (µ° ≤1500 g) Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ ›‰ÈÔ ÂÚÈÁÂÓÓËÙÈÎfi ΤÓÙÚÔ (ª·ÈÂ˘Ù‹ÚÈÔ “∞ÏÂÍ¿Ó‰Ú·”) Î·È ÓÔÛËχıËÎ·Ó ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ÙÔ˘ ›‰ÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÚÈÒÓ ÂÚÈfi‰ˆÓ: ÂÚ›Ô‰Ô˜ π (1989-1990), ÂÚ›Ô‰Ô˜ ππ (1994-1995), ÂÚ›Ô‰Ô˜ πππ (1999-2000). ∆· ıÓËÛÈÁÂÓ‹ ÓÂÔÁÓ¿ Î·È Ù· ÓÂÔÁÓ¿ Ì ·Û‡Ì‚·Ù˜ Ì ÙË ˙ˆ‹ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ·ÔÎÏ›ÛÙËÎ·Ó ·fi ÙË ÌÂϤÙË. ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠ‰È·¯ÚÔÓÈ΋ ·ÍÈÔÏfiÁËÛË: ·) ÙˆÓ ÓÂÔÁÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ‰È¿ÚÎÂÈ· ·ËÛ˘, ʇÏÔ, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, Apgar score), ‚) ÙˆÓ Ì·È¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (›‰Ô˜ ÙÔÎÂÙÔ‡, Ôχ‰˘ÌË Î‡ËÛË, Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ı˘Ï·Î›Ô˘, ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·, ÚÔÂÎÏ·Ì„›·, ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ), Á) Ù˘ ÓÔÛËÚfiÙËÙ·˜ (™∞¢, Ó¢ÌÔıÒڷη˜, ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜, ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ÛË„·ÈÌ›·, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜, ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·) Î·È ‰) Ù˘ ıÓËÙfiÙËÙ·˜. ∆· ÓÂÔÁÓ¿ Ì ™∞¢ Ô˘ ÂÈ‚›ˆÛ·Ó ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ ¯ˆÚ›ÛÙËÎ·Ó Û 2 ÔÌ¿‰Â˜: ·) ÓÂÔÁÓ¿ Ì ™∞¢ Ô˘ ÂÈ‚›ˆÛ·Ó ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Ì µ¶¢ Î·È ‚) ÓÂÔÁÓ¿ Ì ™∞¢ Ô˘ ÂÈ-
‚›ˆÛ·Ó ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ ¯ˆÚ›˜ µ¶¢. ∆· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË µ¶¢ ‹Ù·Ó Ù· ÚÔÙÂÈÓfiÌÂÓ· ·fi ÙÔ˘˜ Bancalari Î·È Û˘Ó (4). ¢ÈÂÚ¢ӋıËÎÂ Ë Èı·Ó‹ Û˘Û¯¤ÙÈÛË Ù˘ µ¶¢ Ì ÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ Ì·È¢ÙÈÎÔ‡˜ Î·È ÓÂÔÁÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∂Ê·ÚÌfiÛÙËΠÌÔÓÔ·Ú·ÁÔÓÙÈ΋ (x2, student t-test, Mann-Whitney U test) Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË (multiple logistic regression analysis-backward), ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS.
∞ÔÙÂϤÛÌ·Ù· ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ Ô˘ ÌÂÏÂÙ‹ıËΠÁÂÓÓ‹ıËÎ·Ó 380 ¶Ãµ°¡ [180/380 ‹Ù·Ó ·ÁfiÚÈ· (47,4%) Î·È 200/380 ‹Ù·Ó ÎÔÚ›ÙÛÈ· (52,6%)]. ∏ ̤ÛË ÙÈÌ‹ (± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË) ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 1115 (±250) g [25Ë ∂™: 900 g Î·È 75Ë ∂™: 1330 g, ‡ÚÔ˜: 440-1500 g] Î·È Ë Ì¤ÛË ÙÈÌ‹ (± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË) Ù˘ ‰È¿ÚÎÂÈ·˜ ·ËÛ˘ ‹Ù·Ó 29,6 (±2,8) ‚‰ÔÌ¿‰Â˜ [25Ë ∂™: 27,2 Î·È 75Ë ∂™: 32 ‚‰ÔÌ¿‰Â˜, ‡ÚÔ˜: 22-36 ‚‰ÔÌ¿‰Â˜]. OÈ ÓÂÔÁÓÈÎÔ› Î·È ÔÈ Ì·È¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ ıÓËÙfiÙËÙ· ÙȘ ÚÒÙ˜ 28 Ë̤Ú˜ ˙ˆ‹˜, Ë ÂÈ‚›ˆÛË ¯ˆÚ›˜ µ¶¢ Î·È Ë ÂÈ‚›ˆÛË Ì µ¶¢ ÛÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Û ۯ¤ÛË Ì ÙËÓ ËÏÈΛ· ·ËÛ˘ Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1.
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο Î·È ÓÔÛËÚfiÙËÙ· ÙˆÓ ¶Ãµ°¡ ÛÙȘ ÙÚÂȘ ÂÚÈfi‰Ô˘˜ ¶·Ú¿ÁÔÓÙ·˜ I ¡ µ° (̤ÛË ÙÈÌ‹±SD) (g) ¢∫ (̤ÛË ÙÈÌ‹±SD) (‚‰.) ™∞¢ £ÓËÙfiÙËÙ· ÙËÓ 28Ë ∏∑ £ÓËÙfiÙËÙ· >28Ë ∏∑ ™˘ÓÔÏÈ΋ ıÓËÙfiÙËÙ· µ¶¢ £ÓËÙfiÙËÙ· Û µ¶¢ ∞ÁfiÚÈ·/ÎÔÚ›ÙÛÈ· IUGR ∫·ÈÛ·ÚÈ΋ ÙÔÌ‹ ∂Ó‰ÔÎÔÏÈ΋ ÁÔÓÈÌÔÔ›ËÛË ¶Ôχ‰˘ÌË Î‡ËÛË ¶Ã∫ ¶ƒ£ ÃÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· ¶ÚÔÂÎÏ·Ì„›· Apgar score ÛÙÔ 5Ô ÏÂÙfi ¶Ó¢ÌÔıÒڷη˜ ∞∞¶ ¡∂∫ ™Ë„·ÈÌ›· ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ∞ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·
346
135 1116±242 29,7±2,9 80/135 (60%) 31/135 (23%) 7/135 (5%) 38/135 (28%) 18/135 (13,3) 6/18 (33%) 64/71 54/135 (40%) 60/135 (44%) 15/135 (11%) 13/135 (9,6%) 13/135 (9,6%) 13/135 (9,6%) 7,2±1,6 25/135 (18%) 16/135 (12%) 8/125 (6,5%) 42/135 (31%)
¶ÂÚ›Ô‰Ô˜ II
III
121 1119±245 29,5±2,7 80/121 (66%) 25/121 (20%) 6/121 (5%) 31/121 (25%) 13/121 (10,7%) 5/13 (38%) 52/69 41/121 (52%) 63/121 (52%) 18/121 (15%) 35/121 (29%) 14/121(11,5%) 15/121 (12%) 12/121 (10%) 14/121 (11%) 7,2±2,1 5/121 (4%) 22/121 (18%) 9/121 (7%) 34/121 (28%) 10/121 (8%) 18/121 (15%)
124 1108±262 29,6±2,9 72/124 (58%) 27/124 (22%) 3/124 (2,5%) 30/124 (24%) 14/124 (11,2%) 3/14 (21%) 64/60 38/124 (30%) 89/124 (70%) 30/124 (24%) 41/124 (33%) 40/124 (32%) 14/124 (12%) 15/124 (12%) 18/124 (14%) 7,7±1,6 8/124 (6,5%) 13/124 (10%) 23/124 (18%) 33/124 (26%) 15/124 (12%) 16/124 (13%)
I/II 0,7 0,5 0,1 0,7 0,6 0,7 0,6 0,6 0,4 0,3 0,2 0,001 0,47 0,4 0,61 0,8 0,001 0,11 0,54 0,59
p-value II/III 0,7 0,8 0,1 0,6 0,7 0,6 0,8 0,3 0,2 0,6 0,001 0,05 0,48 0,01 0,78 0,61 0,49 0,01 0,39 0,85 0,01 0,8
I/III 0,79 0,61 0,84 0,39 0,4 0,3 0,46 0,53 0,11 0,49 0,001 0,001 0,69 0,7 0,22 0,01 0,006 0,1 0,001 0,55 0,2 0,21
¶·È‰È·ÙÚÈ΋ 2003;66:344-351
Paediatriki 2003;66:344-351
4
46
54 79
88
% 50
30
11 16
4 8
10
£¿Ó·ÙÔ˜ ∂È‚›ˆÛË Ì µ¶¢ ∂È‚›ˆÛË ¯ˆÚ›˜ µ¶¢ ∂ÈÎfiÓ· 1. £ÓËÙfiÙËÙ· Î·È µ¶¢ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· ·ËÛ˘.
¶›Ó·Î·˜ 2. ¶·Ú¿ÌÂÙÚÔÈ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Î·È ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ÙˆÓ ¶Ãµ°¡ ÛÙȘ ÙÚÂȘ ÂÚÈfi‰Ô˘˜ I ñ ª¤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (̤ÛË ÙÈÌ‹) ± SD 23,9±8 ñ ª¤ÁÈÛÙË ˘ÎÓfiÙËÙ· ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ (̤ÛË ÙÈÌ‹) ± SD 72±25 ñ ∏̤Ú˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (‰È¿ÌÂÛË ÙÈÌ‹) ± SEM (‡ÚÔ˜) 6±1,7 (1-70) ñ ∏̤Ú˜ Ô͢ÁÔÓÔıÂڷ›·˜ (‰È¿ÌÂÛË ÙÈÌ‹) ± SEM (‡ÚÔ˜) 6±2,3 (1-150) ñ ∏̤Ú˜ ÓÔÛËÏ›·˜ (‰È¿ÌÂÛË ÙÈÌ‹) ± SEM (‡ÚÔ˜) 63,4±3,14 (17-210)
™‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ·ÚÔ˘Û›·Û·Ó 232/380 ÓÂÔÁÓ¿ (61%). ™ÙÔÓ ¶›Ó·Î· 2 ηٷÁÚ¿ÊÔÓÙ·È ÔÈ ·Ú¿ÌÂÙÚÔÈ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ (̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË, ̤ÁÈÛÙË ˘ÎÓfiÙËÙ· ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘), Ë ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ë ‰È¿ÚÎÂÈ· Ô͢ÁÔÓÔıÂڷ›·˜ Î·È Ë ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ÛÙȘ ÙÚÂȘ ÂÚÈfi‰Ô˘˜. ∆ËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ ÂÈ‚›ˆÛ·Ó Ù· 149/232 ÓÂÔÁÓ¿ (64%) Ì ™∞¢. ∆· 44/149 (29%) ÂÈ‚›ˆÛ·Ó Ì µ¶¢ Î·È Ù· ˘fiÏÔÈ· 124/149 (71%) ¯ˆÚ›˜ µ¶¢. ∆Ô Ì¤ÛÔ µ° (±SD) (g) ÙˆÓ ÓÂÔÁÓÒÓ Ì µ¶¢ ‹Ù·Ó 950 (±192) g, ÂÓÒ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó ¯ˆÚ›˜ µ¶¢ ‹Ù·Ó 1158 (±220) g (p<0,001). ∏ ̤ÛË ¢∫ (±SD) ÙˆÓ ÓÂÔÁÓÒÓ Ì µ¶¢ ‹Ù·Ó 27,7 (±1,8) ‚‰Ô-
¶ÂÚ›Ô‰Ô˜ II
III
I/II
20,9±4,8
20,1±3,5
0,04
0,48
0,001
50±26
56±22
0,001
0,93
0,001
5±1,4 (1-63)
4±1,8 (1-95)
0,04
0,84
0,06
5,3±1,4 (1-70)
5,2±1,4 (1-120)
0,46
0,46
0,4
0,64
0,15
0,3
59±2,9 (16-142) 54,5±2,7 (15-130)
p-value II/III
I/III
Ì¿‰Â˜, ÂÓÒ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó ¯ˆÚ›˜ µ¶¢ ‹Ù·Ó 29,5 (±2,3) ‚‰ÔÌ¿‰Â˜ (p<0,001). ∏ Û˘Û¯¤ÙÈÛË ÙˆÓ Ì·È¢ÙÈÎÒÓ Î·È ÙˆÓ ÓÂÔÁÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì ÙË µ¶¢ ηٷÁÚ¿ÊÂÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 3 Î·È 4, ·ÓÙ›ÛÙÔȯ·. OÈ ·Ú¿ÌÂÙÚÔÈ Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, ÔÈ ‰fiÛÂȘ ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë ‰È¿ÚÎÂÈ· Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, Ù˘ Ô͢ÁÔÓÔıÂڷ›·˜ Î·È Ù˘ ÓÔÛËÏ›·˜ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 5. §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ʇÛË Ù˘ µ¶¢, ‰ÈÂÓÂÚÁ‹ıËΠÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÔ›·˜ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6.
347
¶·È‰È·ÙÚÈ΋ 2003;66:344-351
Paediatriki 2003;66:344-351
¶›Ó·Î·˜ 3. ™˘Û¯¤ÙÈÛË Ì·È¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì ÙË µ¶¢ (ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË) ¶·Ú¿ÁÔÓÙ·˜
µ¶¢ (+)
∆ÔÎÂÙfi˜ º˘ÛÈÔÏÔÁÈÎfi˜ 21/62 (34%) ∫·ÈÛ·ÚÈ΋ ÙÔÌ‹ 23/87 (26%) ∂Ó‰ÔÎÔÏÈ΋ ÁÔÓÈÌÔÔ›ËÛË (+) 7/25 (28%) (-) 37/125 (29%) ¶Ôχ‰˘ÌË Î‡ËÛË ∞Ï‹ 34/108 (31%) ¶Ôχ‰˘ÌË 10/41 (24%) ¶ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ (+) 8/28 (28%) (-) 36/121 (29%) ¶ÚÔÂÎÏ·Ì„›· (+) 2/17 (11%) (-) 42/132 (31%) ÃÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· (+) 5/21 (24%) (-) 39/128 (30%) ¶·Ú·ÙÂٷ̤ÓË Ú‹ÍË ı˘Ï·Î›Ô˘ (+) 11/41 (27%) (-) 33/108 (30%)
p-value 0,48
0,8
0,78
0,73
0,24
0,84
0,9
™˘˙‹ÙËÛË ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ ¤¯ÂÈ ÂÎÔÓËı› ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ÓËı› Ë Â›ÙˆÛË Ù˘ µ¶¢ Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ù‹. OÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ Â›Ó·È ·Ó·‰ÚÔÌÈΤ˜ (7,9,17-20). ™Â ÚfiÛÊ·Ù· ‰ËÌÔÛÈÂ˘Ì¤ÓË ÚÔ‰ÚÔÌÈ΋ ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, Ë Â›ÙˆÛË Ù˘ µ¶¢ ·Ó¤Ú¯ÂÙ·È Û 25% (8). ∏ ›وÛË Ù˘ µ¶¢ ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›· ‰È·Î‡Ì·ÓÛË Î·È ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔÓ ÔÚÈÛÌfi Ù˘ ÓfiÛÔ˘ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÙÔÓ ÏËı˘ÛÌfi Ô˘ ÌÂÏÂٿٷÈ. ™Â ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜, Ë Â›ÙˆÛË ‰È·Ê¤ÚÂÈ ·fi ΤÓÙÚÔ Û ΤÓÙÚÔ. ™Â ÚfiÛÊ·Ù· ‰ËÌÔÛÈÂ˘Ì¤ÓË ÌÂϤÙË Ô˘ ÂÎÔÓ‹ıËΠÛÙȘ ∏¶∞, Ë Â›ÙˆÛË Ù˘ µ¶¢ Î˘Ì·ÈÓfiÙ·Ó ·fi 4% ¤ˆ˜ 21% (16). ™Â ÔÏ˘ÎÂÓÙÚÈ΋ ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÛÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ, Ë Â›ÙˆÛË Ù˘ µ¶¢ ‹Ù·Ó 12-16% (17), ÂÓÒ Û ÌÂϤÙË ÛÙË ºÈÓÏ·Ó‰›· ¤ÊÙ·Ó ÙÔ 30% (9). ∏ ›وÛË Ù˘ µ¶¢ ÛÙËÓ ·ÚÔ‡Û· ÔÌ¿‰· ¶Ãµ°¡ ‹Ù·Ó 14%. ¶ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË (6 ÓÂÔÁÓÔÏÔÁÈΤ˜ ÌÔÓ¿‰Â˜) ÛÙÔÓ ¡ÔÌfi ∞ÙÙÈ΋˜ ηٿ ÙÔ ¤ÙÔ˜ 1993, ¤‰ÂÈÍ fiÙÈ Ë Û˘ÓÔÏÈ΋ ›وÛË Ù˘ µ¶¢ Î˘Ì·ÈÓfiÙ·Ó ·fi 3,8% ¤ˆ˜ 15,3% (18).
¶›Ó·Î·˜ 4. ™˘Û¯¤ÙÈÛË ÓÂÔÁÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì ÙË µ¶¢ (ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË) ¶·Ú¿ÁÔÓÙ·˜ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ <1000 g ≥1000 g ¢È¿ÚÎÂÈ· ·ËÛ˘ ≤28 ‚‰ÔÌ¿‰Â˜ >28 ‚‰ÔÌ¿‰Â˜ º‡ÏÔ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂Ó‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ (+) (-) Apgar score ÙÔ 1Ô ÏÂÙfi ≤4 >4 Apgar score ÙÔ 5Ô ÏÂÙfi ≤4 >4 ÃÔÚ‹ÁËÛË ∂¶ (+) (-) ∞∞¶ (+) (-) ¶Ó¢ÌÔıÒڷη˜ (+) (-) ¡∂∫ (+) (-) ™Ë„·ÈÌ›· (+) (-)
348
µ¶¢ (+)
p-value
OR
0,03
3,1 (1,8-5,3)
<0,001
3,4 (2-5,6)
28/60 (46%) 16/89 (17%) 26/50 (52%) 18/99 (18%) 0,28 26/78 (33%) 18/71 (25%) 0,77 11/45 (24%) 33/104 (31%) 0,01
2,1 (1,3-3,9)
0,001
3 (1,5-4,5)
10/24 (41%) 32/125 (25%) 3/12 (25%) 41/137 (19%) 0,25 31/100 (31%) 13/49 (28%) 0,001
3,5 (1,6-7,6)
0,001
6,2 (2,3-8,2)
0,05
2,1 (1,2-4,9)
0,001
4,4 (2-9,7)
17/36 (47%) 27/113 (24%) 16/24 (66%) 8/125 (7%) 12/29 (41%) 32/120 (26%) 31/44 (70%) 40/115 (34%)
¶·È‰È·ÙÚÈ΋ 2003;66:344-351
Paediatriki 2003;66:344-351
¶›Ó·Î·˜ 5. ™˘Û¯¤ÙÈÛË ·Ú·Ì¤ÙÚˆÓ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Î·È ‰È¿ÚÎÂÈ·˜ ÓÔÛËÏ›·˜ Ì ÙË µ¶¢
ª¤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (±SD) ª¤ÁÈÛÙË ˘ÎÓfiÙËÙ· ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ (±SD) ¢È¿ÚÎÂÈ· Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ (±SD) ¢È¿ÚÎÂÈ· Ô͢ÁÔÓÔıÂڷ›·˜ (±SD) ¢fiÛÂȘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (±SD) ¢È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ (Ë̤Ú˜) ¶›Ó·Î·˜ 6. ™˘Û¯¤ÙÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ (ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË) ¶·Ú¿ÁÔÓÙ·˜ ¢∫ (≤28 ‚‰ÔÌ¿‰Â˜) B° (<1000 g) º‡ÏÔ ∆ÔÎÂÙfi˜ ∂Ó‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ¶XK ∂Ó‰ÔÎÔÏÈ΋ ÁÔÓÈÌÔÔ›ËÛË ¶Ôχ‰˘ÌË Î‡ËÛË ÃÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· Apgar score ÙÔ 1Ô ÏÂÙfi (≤4) Apgar score ÙÔ 5Ô ÏÂÙfi (≤4) ∞Ó¿ÓË„Ë ÛÙËÓ ·›ıÔ˘Û· ÃÔÚ‹ÁËÛË ∂¶ ¶Ó¢ÌÔıÒڷη˜ ∞∞¶ ¡∂∫ ™Ë„·ÈÌ›·
p-value 0,001 0,01 0,13 0,4 0,1 0,26 0,45 0,41 0,65 0,003 0,001 0,001 0,25 0,01 0,001 0,01 0,01
∏ ‰È·¯ÚÔÓÈ΋ ÂͤÏÈÍË Ù˘ ›وÛ˘ Ù˘ µ¶¢ ‹Ù·Ó ÛÙ·ıÂÚ‹ Î·È ÛÙȘ 3 ÂÚÈfi‰Ô˘˜. ™Ù·ıÂÚ‹ ›وÛË Ù˘ µ¶¢ ‰È·›ÛÙˆÛ·Ó Î·È ÔÈ Manktelow Î·È Û˘Ó (19), ÔÈ ÔÔ›ÔÈ ÌÂϤÙËÛ·Ó Ù˘ ›وÛË Ù˘ ÓfiÛÔ˘ Û 3 ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈfi‰Ô˘˜ (1987, 1992 Î·È 1997). OÈ Fenton Î·È Û˘Ó (20) ÌÂϤÙËÛ·Ó ÙËÓ Â›ÙˆÛË Ù˘ µ¶¢ ÙËÓ ÂÔ¯‹ ÚÔ-∂¶ Î·È ÌÂÙ¿-∂¶ Î·È Î·Ù¤ÏËÍ·Ó fiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ¶Ãµ°¡ ‚ÂÏÙÈÒıËÎÂ, Ì ·‡ÍËÛË fï˜ Ù˘ ÂÈ‚›ˆÛ˘ Ì µ¶¢. ∏ ÌÈÎÚ‹ ËÏÈΛ· ·ËÛ˘ Î·È ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ·ÔÙÂÏÔ‡Ó ÎÔÈÓ¿ ·Ô‰ÂÎÙÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ (7,8,22,23). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ô ‚·ıÌfi˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ ‹Ù·Ó Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Ù· ÓÂÔÁÓ¿ ËÏÈΛ·˜ ·ËÛ˘ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 29 ‚‰ÔÌ¿‰ˆÓ ›¯·Ó ÙÚÈÏ¿ÛÈÔ Î›Ó‰˘ÓÔ (OR=3,4) ÁÈ· µ¶¢ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ Ì ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ·ËÛ˘. ¶·ÚfiÌÔÈ·, Ù· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 1000 g ›¯·Ó ÙÚÈÏ¿ÛÈÔ Î›Ó‰˘ÓÔ (OR=3,1) Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 1000-1500 g. O ÌÂÁ¿ÏÔ˜ ‚·ıÌfi˜ ÚÔˆÚfiÙËÙ·˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÔÚÊÔÏÔÁÈ΋ Î·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÓˆÚÈÌfiÙËÙ· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ·ÔÙÂÏ› ¤Ó·Ó ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ Û ¶Ãµ°¡. OÈ Palta ηÈ
µ¶¢ (+)
µ¶¢ (-)
p-value
23,2±5,7 0,7±0,19 31±20 49±14 2,4±0,8 89±40
20±5,6 0,53±0,23 6±5 7±5 1,4±0,9 65±22
0,05 <0,001 <0,001 <0,001 <0,01 <0,001
Û˘Ó (21) η٤ÏËÍ·Ó fiÙÈ Ô Î›Ó‰˘ÓÔ˜ µ¶¢ ·˘Í¿ÓÂÙ·È Î·Ù¿ 1,4 ·Ó¿ 100 g Ì›ˆÛ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È Î·Ù¿ 2,4 ·Ó¿ ‚‰ÔÌ¿‰· Ì›ˆÛ˘ Ù˘ ‰È¿ÚÎÂÈ·˜ ·ËÛ˘ (.¯. Ù· ÓÂÔÁÓ¿ Ì µ° 601-700 g ›¯·Ó ۯ‰fiÓ ÌÈ¿ÌÈÛË ÊÔÚ¿ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó µ¶¢ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ Ì µ° 701-800 g Î·È Ù· ÓÂÔÁÓ¿ Ì ‰È¿ÚÎÂÈ· ·ËÛ˘ 26 ‚‰ÔÌ¿‰Â˜ ›¯·Ó ‰˘fiÌÈÛÈ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó µ¶¢ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ Ì ¢∫ 27 ‚‰ÔÌ¿‰Â˜). ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘Û¯¤ÙÈÛË ÙÔ˘ ʇÏÔ˘ Ì ÙË µ¶¢, Â›Ó·È ·ÓÙÈÊ·ÙÈο. OÈ Palta Î·È Û˘Ó (21), ÔÈ Kraybill Î·È Û˘Ó (23) Î·È ÔÈ Krohonen Î·È Û˘Ó (9) ηٷϋÁÔ˘Ó fiÙÈ Ù· ·ÁfiÚÈ· ¤¯Ô˘Ó ‰ÈÏ¿ÛÈÔ Î›Ó‰˘ÓÔ (OR=1,9) ÁÈ· µ¶¢. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, fiˆ˜ Î·È ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ, ηٷϋÁÔ˘Ó fiÙÈ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È ÙÔ Ê‡ÏÔ Ì ÙË µ¶¢ (8,13,22). ∆Ô ¯·ÌËÏfi Apgar score (≤5) ÙÔ 1Ô Î·È ÙÔ 5Ô ÏÂÙfi Û˘Û¯ÂÙ›ÛÙËΠÈÛ¯˘Ú¿ Ì ÙË µ¶¢. ∏ Û˘Û¯¤ÙÈÛË ·˘Ù‹ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔ ÈÛ¯˘Ú‹ Ì ÙË ‚·ıÌÔÏÔÁ›· ÛÙÔ 5Ô ÏÂÙfi. ∆· ÓÂÔÁÓ¿ Ô˘ ›¯·Ó Apgar score ÙÔ 5Ô ÏÂÙfi ÌÈÎÚfiÙÂÚÔ ‹ ›ÛÔ ÙÔ˘ 4, ›¯·Ó ÙÚÈÏ¿ÛÈÔ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ›¯·Ó >4 (OR=3). ªÂ ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù· Û˘ÌʈÓÔ‡Ó ÙfiÛÔ ÔÈ Palta Î·È Û˘Ó (OR=2,2) (21) fiÛÔ Î·È ÔÈ Sinkin Î·È Û˘Ó (24). ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̠ÙË µ¶¢. OÈ Egreteau Î·È Û˘Ó (8), Û ·ÓÙ›ıÂÛË Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, η٤ÏËÍ·Ó fiÙÈ Ë ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘. ™Â ·˘Ù‹ ÙË ÌÂϤÙË, fï˜, Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÓÂÔÁÓ¿ ∏∫ <31 ‚‰ÔÌ¿‰ˆÓ, ÂÓÒ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÎÚÈÙ‹ÚÈÔ ÂÈÛfi‰Ô˘ ‹Ù·Ó ÙÔ µ° <1500 g. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÓÂÔÁÓ¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ·ËÛ˘. ∏ ¯ÔÚ‹ÁËÛË ∂¶ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢, ‡ÚËÌ· Ì ÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (25). ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ∂¶, fiˆ˜ Ë ¤ÏÏÂÈ„Ë Ù˘ ʈÛÊ·Ùȉ˘Ï¯ÔÏ›Ó˘ Î·È Ù˘ ÚˆÙ½Ó˘, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì µ¶¢. ∂ÈÚfiÛıÂÙ·, ÁÏ˘ÎÔÏÈ›‰È· Î·È ÚˆÙ½Ó˜, ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ∂¶, ¤¯Ô˘Ó ‚ÚÂı› Û ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· ÓÂÔÁÓÒÓ Ì µ¶¢. ¶·Ú’ fiÏ· ·˘Ù¿, ‰ÂÓ ¤¯ÂÈ
349
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‰È¢ÎÚÈÓÈÛÙ› Â¿Ó Ë Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ∂¶ Û˘Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ (26). ¢‡Ô ÚfiÛÊ·Ù˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ηٷϋÁÔ˘Ó Û ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·. O Halliday (1) η٤ÏËÍ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ∂¶, ¿Û¯ÂÙ· ·fi ÙÔÓ Ù‡Ô ‹ ÙÔÓ ÙÚfiÔ ¯ÔÚ‹ÁËÛ˘, ‰ÂÓ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢, ÂÓÒ ·ÓÙ›ıÂÙ· ÔÈ Kresch Î·È Clive (27) ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ∂¶ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢ (ÔÈ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ·˘Ù¤˜ ÛÙËÚ›¯ıËÎ·Ó Û ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜). ¶ÚfiÛÊ·ÙË ÚÔ‰ÚÔÌÈ΋ ÌÂϤÙË Î·Ù¤ÏËÍ fiÙÈ Ô ∂¶ ‰ÂÓ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢ (8). O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ì ˘„ËϤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Û˘Û¯ÂÙ›ÛÙËÎÂ, fiˆ˜ ·Ó·ÌÂÓfiÙ·Ó, Ì ÙË µ¶¢, ‡ÚËÌ· Ì ÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó ÔÈ Marshall Î·È Û˘Ó (28), ÔÈ Watson Î·È Û˘Ó (22), Ô Cooke (7), ÔÈ Palta Î·È Û˘Ó (21) Î·È ÔÈ van Marter Î·È Û˘Ó (29). O Ó¢ÌÔıÒڷη˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ (OR=6,2), ‡ÚËÌ· Ì ÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (30). O ∞∞¶ (OR=3,5), Ë ¡∂∫ (OR=2,1) Î·È Ë ÛË„·ÈÌ›· (OR=4,4) ‹Ù·Ó ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢, Â˘Ú‹Ì·Ù· Ì ٷ ÔÔ›· Û˘ÌʈÓÔ‡Ó Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (7,13,16,21). OÈ Rojas Î·È Û˘Ó (13) ¤‰ÂÈÍ·Ó fiÙÈ Ô ∞∞¶ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ (OR=6,2) ηÈ, Ì¿ÏÈÛÙ·, Ë Û˘Ó‡·ÚÍË ÛË„·ÈÌ›·˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÛËÌ·ÓÙÈο (OR=48,3). OÈ Palta Î·È Û˘Ó (21) ¤‰ÂÈÍ·Ó fiÙÈ Ô ∞∞¶ ‰ÈÏ·ÛÈ¿˙ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢. OÈ Yeo Î·È Û˘Ó (31) ÌÂϤÙËÛ·Ó 265 ¶Ãµ°¡ ·Ó·‰ÚÔÌÈο (1989-1992) Î·È Î·Ù¤ÏËÍ·Ó fiÙÈ Ë ÛË„·ÈÌ›· (OR=5), Ë ¡∂∫ (OR=11) Î·È Ô ∞∞¶ (OR=4,4) ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ∆Ô Â›‰Ô˜ ÙÔ˘ ÙÔÎÂÙÔ‡, Ë Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ë Ôχ‰˘ÌË Î‡ËÛË, Ë ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· Î·È Ë ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ı˘Ï·Î›Ô˘ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙËÓ ·Ó¿Ù˘ÍË µ¶¢. O Cooke (7) ¤‰ÂÈÍ fiÙÈ Ô Ê˘ÛÈÔÏÔÁÈÎfi˜ ÙÔÎÂÙfi˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· µ¶¢ (OR=2). ¶·ÚfiÌÔȘ ÌÂϤÙ˜ ‰ÂÓ Î·Ù¤ÏËÍ·Ó ÛÂ Û˘Û¯¤ÙÈÛË Ù˘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ ‹ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ڋ͢ ı˘Ï·Î›Ô˘ Ì ÙË µ¶¢, ·Ó Î·È Ë ÓfiÛÔ˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÊÏÂÁÌÔÓ‹ (8). OÈ Watson Î·È Û˘Ó (22) ‰ÂÓ ‰È·›ÛÙˆÛ·Ó ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ Û ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ì ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·. ∏ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢, ‡ÚËÌ· Ì ÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (8,22,28). ¶ÚfiÛÊ·ÙË ÚÔ‰ÚÔÌÈ΋ ÌÂϤÙË, ηٿ ÙËÓ ÔÔ›· ¯ÔÚËÁ‹ıËÎ·Ó ÚÔÁÂÓÓËÙÈο ÎÔÚÙÈÎÔÂȉ‹ ÛÙÔ 51% ÙˆÓ Î˘‹ÛˆÓ, ‰ÂÓ ¤‰ÂÈÍ Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· µ¶¢ (8). OÈ ÂÚ¢ÓËÙ¤˜ ηٷϋÁÔ˘Ó fiÙÈ Ë Â˘ÂÚÁÂÙÈ΋ ‰Ú¿ÛË ÙˆÓ ÚÔÁÂÓÓËÙÈÎÒÓ ÎÔÚÙÈÎÔÂȉÒÓ ÛÙË µ¶¢ ›Ûˆ˜ Ó· ‰È·Ê·ÈÓfiÙ·Ó Â¿Ó ÙÔ ÔÛÔÛÙfi ¯ÔÚ‹ÁËÛ˘ ‹Ù·Ó ˘„ËÏfiÙÂÚÔ, Î·È ‰Ë ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ô˘ ÙÔ ÔÛÔÛÙfi ‹Ù·Ó ·ÎfiÌ· ÈÔ ¯·ÌËÏfi
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(10% Î·È 35% ÛÙȘ ÂÚÈfi‰Ô˘˜ ππ Î·È πππ, ·ÓÙ›ÛÙÔȯ·). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë µ¶¢ ·ÔÙÂÏ› ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÓfiÛÔ. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ·˘Ù‹ ‹Ù·Ó Ë ÂÍ·ÈÚÂÙÈ΋ ÚÔˆÚfiÙËÙ· (µ° <1000 g, ¢∫ <29 ‚‰ÔÌ¿‰Â˜), ÙÔ ¯·ÌËÏfi Apgar score ÙÔ 1Ô Î·È ÙÔ 5Ô ÏÂÙfi, Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ì ˘„ËϤ˜ ·Ú·Ì¤ÙÚÔ˘˜, Ô ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜, Ô Ó¢ÌÔıÒڷη˜, Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· Î·È Ë ÛË„·ÈÌ›·. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙË µ¶¢ ‹Ù·Ó ÙÔ Ê‡ÏÔ, ÙÔ Â›‰Ô˜ ÙÔÎÂÙÔ‡, Ë Ôχ‰˘ÌË Î‡ËÛË, Ë Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ë ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·, Ë ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ı˘Ï·Î›Ô˘, Ë ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Î·È Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Halliday HL. Clinical trials of surfactant replacement in Europe. Biol Neonate 1997;71 (Suppl 1):S8-S12. 2. ∫ÒÛÙ·ÏÔ˜ Ã∞. µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·. ª›· ÓÂÔÁÓÈ΋ ¿ıËÛË Û ·Ó·˙‹ÙËÛË Ó¤·˜ Ù·˘ÙfiÙËÙ·˜; ¶·È‰È·ÙÚÈ΋ 1996;59:29-32. 3. Northway WH Jr, Rosan RC, Porter DY. Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia. N Engl J Med 1967;276:357-368. 4. Bancalari E, Abdenour GE, Feller R, Gannon J. Bronchopulmonary dysplasia: clinical presentation. J Pediatr 1979;95:819-823. 5. Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics 1988;82:527-532. 6. Bancalari E, del Moral T. Bronchopulmonary dysplasia and surfactant. Biol Neonate 2001;80 (Suppl 1):S7-S13. 7. Cooke RW. Factors associated with chronic lung disease in preterm infants. Arch Dis Child 1991;66:776-779. 8. Egreteau L, Pauchard JY, Semama DS, Matis J, Liska A, Romeo B et al. Chronic oxygen dependency in infants born at less than 32 weeks’ gestation: incidence and risk factors. Pediatrics 2001;108:e26. 9. Korhonen P, Tammela O, Koivisto AM, Laippala P, Ikonen S. Frequency and risk factors in bronchopulmonary dysplasia in a cohort of very low birth weight infants. Early Hum Dev 1999;54:245-258. 10. Gorenflo M, Vogel M, Herbst L, Bassir C, Kattner E, Obladen M. Influence of clinical and ventilatory parameters on morphology of bronchopulmonary dysplasia. Pediatr Pulmonol 1995;19:214-220. 11. Konishi M, Fujiwara T, Chida S, Maeta H, Shimada S, Kasai T et al. A prospective, randomized trial of early versus late administration of a single dose of surfactant-TA. Early Hum Dev 1992;29:275-282. 12. ∞Ó‰Ú¤Ô˘ ∞. ¶Ó¢ÌÔÓÈ΋ ‚Ï¿‚Ë ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ: ·ıÔÊ˘ÛÈÔÏÔÁ›·, ÚfiÏË„Ë, ıÂڷ›·. ¶·È‰È·ÙÚÈ΋ 1996;59:377-384. 13. Rojas MA, Gonzalez A, Bancalari E, Claure N, Poole C,
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-01-2003 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-05-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ Õıˆ 31 Î·È øÚˆÔ‡, ∆.∫. 262 26, ¶¿ÙÚ· E-mail: Kaleyias@hotmail.com
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Paediatriki 2003;66:352-356
ORIGINAL ARTICLE
O ÚfiÏÔ˜ ÙÔ˘ power Doppler ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ÛÙ· ·È‰È¿ ¡. ∆ÛÔ˘ÚÔ˘Ó¿Î˘, ™. ªÂÁÚ¤Ì˘, ∞. ™¯ÔÈÓ¿ÎË, £. ∆ÛÂÎÔ˘Ú¿, ™. ™ÙÂÊ·Ó¿ÎË, ∞. ∆ÛÈÏÈÌÈÁοÎË
The role of power Doppler ultrasonography in the diagnosis of acute pyelonephritis in children N. Tsourounakis, S. Megremis, A. Schinaki, T. Tsekoura, S. Stefanaki, A. Tsilimigaki
¶ÂÚ›ÏË„Ë: ¢È¿ÊÔÚ˜ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì Tc-99m dimercaptosuccinic acid (DMSA) Ô˘ ıˆÚÂ›Ù·È ÂͤٷÛË ·Ó·ÊÔÚ¿˜. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ Ë ÂͤٷÛË ÙˆÓ ÓÂÊÚÒÓ Ì ÙÔ power Doppler ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (PDU) ÌÔÚ›, ›Û˘, Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ∫·Ù¿ ÙË ‰ÈÂÙ›· 2000-2001 ÌÂÏÂÙ‹ıËÎ·Ó 110 ·È‰È¿, Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙÔ ·È‰È·ÙÚÈÎfi ÙÌ‹Ì· Ì ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ¶Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ Û 74 ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËηÓ, ÌÂٷ͇ ¿ÏψÓ, Û PDU Î·È DMSA. ∞fi ÙË ÌÂϤÙË ÂÍ·ÈÚ¤ıËÎ·Ó ‚Ú¤ÊË ËÏÈΛ·˜ οو ÙˆÓ 3 ÌËÓÒÓ Î·È ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ô˘ÚÔÏԛ̈͢ ‹ ÓÂÊÚÈ΋ ·ÓˆÌ·Ï›·. ∞ÌÊfiÙÂÚ˜ ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ¤‰ÂÈÍ·Ó Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û 20 ·ÛıÂÓ›˜. ∆Ô DMSA Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠˆ˜ ̤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ¤‰ÂÈÍ ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ ‚Ï¿‚˜ Û 54 ·ÛıÂÓ›˜, ÛÙÔ˘˜ 32 ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ ‚Ï¿‚˜ ‹Ù·Ó ÌÔÓÔÂÛÙȷΤ˜, ÂÓÒ ÛÙÔ˘˜ 22 ‹Ù·Ó ÔÏ˘ÂÛÙȷΤ˜. ∆Ô PDU ·Ó·ÁÓÒÚÈÛ 25 ·fi Ù· 54 ·È‰È¿ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·, Ù· 15 ÂÎ ÙˆÓ ÔÔ›ˆÓ ›¯·Ó ÌÔÓÔÂÛÙȷΤ˜ ‚Ï¿‚˜ Î·È Ù· ˘fiÏÔÈ· 10 ›¯·Ó ÔÏ˘ÂÛÙȷΤ˜. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ê¿ÓËΠfiÙÈ ÙÔ power Doppler ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Â›¯Â ÔÏÈ΋ ¢·ÈÛıËÛ›· 46% Î·È ÂȉÈÎfiÙËÙ· 100% ÛÙËÓ ÂÎÙ›ÌËÛË ·È‰ÈÒÓ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·, Ì ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· 100% Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· 41%.
Abstract: Many imaging techniques have been used for the diagnosis of acute pyelonephritis, including renal scintigraphy with Tc-99m dimercaptosuccinic acid (DMSA) and more recently power Doppler ultrasonography (PDU), with DMSA as the reference method. A study was made of 110 children hospitalised with a clinical diagnosis of acute pyelonephritis during the years 2000-2001. Seventy four of these patients underwent full investigation including PDU and DMSA. Infants aged less than 3 months and patients with recurrent urinary tract infections or renal abnormalities were excluded from the study. Both imaging techniques revealed normal findings in 20 patients. DMSA revealed acute pyelonephritis in 54 patients, with multifocal lesions in 22 and simple focal lesions in 32 patients. PDU identified 25 of the 54 children with acute pyelonephritis, 15 with simple focal and 10 with multifocal lesions. In this study PDU had a sensitivity of 46% and specificity of 100% in the investigation of patients with acute pyelonephritis, with a positive predictive value of 100% and negative predictive value of 41%.
§¤ÍÂȘ ÎÏÂȉȿ: power Doppler, Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·.
Key words: power Doppler, urinary tract infection, acute pyelonephritis.
µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, ∫Ú‹ÙË
2nd Paediatric Clinic, Venizelio General Hospital of Heraklion, Crete
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¶·È‰È·ÙÚÈ΋ 2003;66:352-356
∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· Â›Ó·È Ì›· Û˘¯Ó‹ Ïԛ̈ÍË Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÌË ·Ó·ÛÙÚ¤„ÈÌË ÓÂÊÚÈ΋ Ô˘ÏÔÔ›ËÛË, Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ̷ÎÚÔÚfiıÂÛ̘ ÂÈÏÔΤ˜ fiˆ˜ ˘¤ÚÙ·ÛË, ÙÔÍÈÓ·ÈÌ›·, ÂÏ·Ùو̤ÓË ÛÂÈÚ·Ì·ÙÈ΋ ‰È‹ıËÛË Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (1,2). ™Â ·ÛıÂÓ›˜ Ì ÓÂÊÚÈΤ˜ Ô˘Ï¤˜ ¤¯ÂÈ ·Ó·ÊÂÚı› ˘¤ÚÙ·ÛË Û ÔÛÔÛÙfi 10-18% ÙˆÓ ÂÊ‹‚ˆÓ Î·È Ó·ÚÒÓ ÂÓËÏ›ÎˆÓ (3). O˘ÏÔÔ›ËÛË Û·Ó ÂÈÏÔ΋ Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Û˘Ì‚·›ÓÂÈ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 51-64% ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÓÂÊÚÒÓ (2,4). ∏ ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÛÙȘ Ô˘ÚÔÏÔÈÌÒÍÂȘ Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. °È· ·ÚÎÂÙ¿ ¯ÚfiÓÈ·, Ë ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ›¯Â ‚·ÛÈÛÙ› ΢ڛˆ˜ Û ÌË ÂȉÈΤ˜ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, fiˆ˜ ˘ÚÂÙfi˜ >38ÔC, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ ‹ fiÓÔ˜ ÛÙËÓ ÔÛÊ˘˚΋ ¯ÒÚ·, ˘Ô˘Ú›·, ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, ·˘ÍË̤ÓË ∆∫∂ Î·È CRP (2,3,5,6). ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË, fï˜, Ì ÙË ¯Ú‹ÛË ·˘ÙÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Â›Ó·È ‰‡ÛÎÔÏË, ȉȷ›ÙÂÚ· ÛÙ· ÌÈÎÚ¿ ·È‰È¿. ∫·Ì›· ·fi ·˘Ù¤˜ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ‰ÂÓ ·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘ ÛÙËÓ ÔÍ›· Ïԛ̈ÍË (3,5,6). ∞ÚÎÂÙ¤˜ ·ÂÈÎÔÓÈÛÙÈΤ˜ Ù¯ÓÈΤ˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ̤ÛÔ ÁÈ· ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ·fi ÙË Ïԛ̈ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, Ì ¢·ÈÛıËÛ›· Ô˘ Î˘Ì·›ÓÂÙ·È Û ÔÛÔÛÙfi 11-69%, ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ̤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ‹ Ù˘ ·ÎfiÏÔ˘ı˘ ÓÂÊÚÈ΋˜ Ô˘ÏÔÔ›ËÛ˘ (7,8). ªÈÎÚ‹ ¢·ÈÛıËÛ›· ¤¯ÂÈ, ›Û˘, Ë ÂÓ‰ÔÊϤ‚È· Ô˘ÚÔÁÚ·Ê›· (3,9). ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È ¤Ó· ¢·›ÛıËÙÔ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÂÚÁ·ÏÂ›Ô Ì ˘„ËÏ‹ ÂȉÈÎfiÙËÙ·, ˆÛÙfiÛÔ ‰ÂÓ Â›Ó·È Ú·ÎÙÈ΋ Ë ¯Ú‹ÛË Ù˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÛÙ· ·È‰È¿ (3,6,10-12). ∆Ô DMSA ¤¯ÂÈ Î·ıÈÂÚˆı› ˆ˜ ̤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜, Ì ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· Ô˘ ÊÙ¿ÓÔ˘Ó ¤ˆ˜ 92,1% Î·È 99% ·ÓÙ›ÛÙÔȯ·, fiˆ˜ ¤¯ÂÈ ·Ô‰Âȯı› ·fi ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ (10,14). £ÂˆÚ›ٷÈ, ›Û˘, ̤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚÈ΋˜ Ô˘ÏÔÔ›ËÛ˘ (2-6,8-14). ∆Ô power Doppler ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È Ì›· Ó¤· ˘ÂÚ˯ÔÁÚ·ÊÈ΋ Ù¯ÓÈ΋ Ô˘ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1993 ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ Michigan (15). ∏ ‚·ÛÈ΋ ·Ú¯‹ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÌÂıfi‰Ô˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ Îˆ‰ÈÎÔÔ›ËÛË Ù˘ ¤ÓÙ·Û˘ ÙÔ˘ Û‹Ì·ÙÔ˜ ÙÔ˘ Doppler Û ¯ÚÒÌ·. ∏ ¤ÓÙ·ÛË
Paediatriki 2003;66:352-356
ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÛfiÙËÙ· Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Î·È fi¯È ·fi ÙËÓ Ù·¯‡ÙËÙ· ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ ÚÔ‹˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙÔ ¤Á¯ÚˆÌÔ Doppler (16-18). ∆Ô PDU Û˘ÓÈÛÙ¿ Ì›· ·Ó·‚¿ıÌÈÛË ÛÙÔ software ÙÔ˘ ·ÚfiÓÙÔ˜ ¤Á¯ÚˆÌÔ˘ Doppler, ¯ˆÚ›˜ Ó· ··ÈÙ› ÂÈÚfiÛıÂÙÔ ÂÍÔÏÈÛÌfi (15,19). Œ¯ÂÈ 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ·fi ÙÔ Û˘Ì‚·ÙÈÎfi ¤Á¯ÚˆÌÔ Doppler ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÚÔ‹˜, ÂÓÒ Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌÔ ÁÈ· ÌÈÎÚ¿ ·ÁÁ›· - Î·È ·˘Ù¿ Ì ÌÈÎÚ‹ Ù·¯‡ÙËÙ· ÚÔ‹˜ fiˆ˜ Ù· ·ÚÂÁ¯˘Ì·ÙÈο ·ÁÁ›· ÙÔ˘ ÓÂÊÚÔ‡ (1519,20). ™ÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi ÓÂÊÚÈÎfi ÊÏÔÈfi, Ë ·ÂÈÎfiÓÈÛË Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ÚÔ‹˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÁÁ›ˆÛË ÙÔ˘ ÈÛÙÔ‡, Ë ÔÔ›· ·ÔÙÂÏÂ›Ù·È ·fi ÔÏ˘¿ÚÈıÌ· ÌÈÎÚ¿ ·ÁÁ›· Ô˘ ·ıÚÔ›˙ÔÓÙ·È Î·È ‰ËÌÈÔ˘ÚÁÔ‡Ó Ì›· ‰È¿¯˘ÙË ¯ÚÒÛË (17,18,20). ™ÙËÓ ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·, ÙÔ PDU ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·ÂÈÎÔÓ›ÛÂÈ ÂÚÈÔ¯¤˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ (11,12,17,19,21,22). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ PDU ÛÙËÓ ·Ó›¯Ó¢ÛË ˘ÂÏÔÓÂÊÚÈÙȉÈÎÒÓ ‚Ï·‚ÒÓ Û ·È‰È¿ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È Ë Û‡ÁÎÚÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì ·˘Ù¿ ÙÔ˘ DMSA. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∞fi Ù· 110 ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ·fi 1/1/2000 ¤ˆ˜ 31/12/2001 Ì ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο Ïԛ̈͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÔ ÙÈÎÔ‡, fiˆ˜ ˘ÚÂÙfi˜ >38,5 C, ¿ÏÁÔ˜ ÛÙËÓ ÔÛʇ, ıÂÙÈο ÓÈÙÚÒ‰Ë, ÌÈÎÚÔ‚ÈÔ˘Ú›·, ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, ·˘ÍË̤ÓË ∆∫∂ Î·È CRP, Ë ÌÂϤÙË Û˘ÌÂÚȤϷ‚ 74 ·È‰È¿, ÛÙ· ÔÔ›· ¤ÁÈÓ ϋÚ˘ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜. ™Â ·˘Ù¿ Ù· ·È‰È¿ ¤ÁÈÓÂ Û˘ÌÏËڈ̷ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì Ԣڛ·, ÎÚ·ÙÈÓ›ÓË, ËÏÂÎÙÚÔχÙ˜ Î·È Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ™ÙË ÌÂϤÙË ‰ÂÓ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ‚Ú¤ÊË ÌÈÎÚfiÙÂÚ· ÙˆÓ 3 ÌËÓÒÓ, ηıÒ˜ Î·È ·È‰È¿ Ì ÁÓˆÛÙfi ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ Ô˘ÚÔÏԛ̈͢, ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ ‹ ÓÂÊÚÈ΋˜ ·ÓˆÌ·Ï›·˜. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜ ˘Ô‚Ï‹ıËÎ·Ó ·Ú¯Èο Û ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, Ô˘ÚËÙ‹ÚˆÓ Î·È Î‡ÛÙˆ˜, ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ‰È·Ù¿ÛÂˆÓ ‹ ¿ÏÏˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ηıÒ˜ Î·È Û power Doppler ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ̤۷ ÛÙȘ 5 ÚÒÙ˜ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ∆Ô PDU ¤ÁÈÓ ·fi ¤ÌÂÈÚÔ ·ÎÙÈÓÔÏfiÁÔ, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ˘ÂÚ˯ÔÙÔÌÔÁÚ¿ÊÔ ATL 5000 HDI. ∫·ÙfiÈÓ, ˘Ô‚Ï‹ıËÎ·Ó Û ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì Á-οÌÂÚ·, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Tc-99m DMSA, ÙÔ ÔÔ›Ô ¤ÁÈÓ Û 67 ·È‰È¿ ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ‰ÂηË̤ÚÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Î·È Û 7 ·È‰È¿ ÙËÓ 3Ë ‹ 4Ë Â‚‰ÔÌ¿‰·. ∂›Û˘, ηٿ ÙË ÓÔÛËÏ›· ÙÔ˘˜ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÓÈÔ‡Û· ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. ∏ ÌÂϤÙË Ì ÙÔ PDU ÂÚÌËÓ‡ÙËΠˆ˜ Ê˘ÛÈÔÏÔÁÈ΋ ÛÙËÓ
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¶·È‰È·ÙÚÈ΋ 2003;66:352-356
ÂÚ›ÙˆÛË Ô˘ ·Ú·ÙËÚ‹ıËΠÔÌÔÈfiÌÔÚÊË ÂÈÎfiÓ· ·ÈÌ¿ÙˆÛ˘ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì· ÛÂ Û˘ÁÎÚÈÓfiÌÂÓ· ‚¿ıË, Û ϋ„ÂȘ ηٿ ÙÔÓ ÂÈÌ‹ÎË Î·È ÂÁοÚÛÈÔ ¿ÍÔÓ·. ∏ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Ù¤ıËΠ̠ÙËÓ ·ÂÈÎfiÓÈÛË Ì›·˜ ÂÚÈÔ¯‹˜ Ì ÌÂȈ̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙÔ ÊÏÔÈfi ÙÔ˘ ÓÂÊÚÔ‡, Û ۯ¤ÛË Ì ٷ ¿ÏÏ· ÙÌ‹Ì·Ù· ÙÔ˘ ›‰ÈÔ˘ ÓÂÊÚÔ‡ ÛÙÔ ›‰ÈÔ ‚¿ıÔ˜ (9,11,21) (∂ÈÎfiÓ· 1·). ø˜ ̤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ ÛÙË ÌÂϤÙË ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ DMSA, Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ÙÔ PDU ÁÈ· ÙËÓ ·ÚÔ˘Û›· ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ∏ ÂͤٷÛË Ì ÙÔ DMSA ÂÚÌËÓ‡ÂÙ·È ·ıÔÏÔÁÈ΋ fiÙ·Ó ·Ó¢ڛÛÎÔÓÙ·È ÂÛÙȷΤ˜ ‹ ‰È¿¯˘Ù˜ ÂÚÈÔ¯¤˜ ÂÏ·Ùو̤Ó˘ ÚfiÛÏ˄˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙË ÊÏÔÈÒ‰Ë ÌÔ›Ú· ÙÔ˘ ÓÂÊÚÔ‡, ʈÙÔÂÓÈΤ˜, ¯ˆÚ›˜ ·ÒÏÂÈ· fiÁÎÔ˘ ‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÂÚÈÁÚ¿ÌÌ·ÙÔ˜ (3,21) (∂ÈÎfiÓ· 1‚).
∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 74 ·È‰È¿ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜, Ù· 52 ‹Ù·Ó ÎÔÚ›ÙÛÈ· (70%) Î·È Ù· 22 ‹Ù·Ó ·ÁfiÚÈ· (30%). ∏ ËÏÈΛ· ÙÔ˘˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 3 Ì‹Ó˜ ¤ˆ˜ 14 ¤ÙË (‰È¿ÌÂÛË ËÏÈΛ·: 2,5 ¤ÙË). ™·Ú¿ÓÙ· ‰‡Ô ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ (57%) ‹Ù·Ó ‚Ú¤ÊË, 13 ·ÛıÂÓ›˜ (18%) ‹Ù·Ó 1-4 ÂÙÒÓ Î·È 19 ·ÛıÂÓ›˜ (25%) ‹Ù·Ó 5-14 ÂÙÒÓ. ∆Ô DMSA ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi Û 20 ·ÛıÂÓ›˜ (27%). ∆Ô PDU ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi Û fiÏÔ˘˜ ·˘ÙÔ‡˜ ÙÔ˘˜ 20 ·ÛıÂÓ›˜. ∂Ô̤ӈ˜, Ë ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ‹Ù·Ó 100%. ™ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 54 ·ÛıÂÓ›˜ (73%) ·Ú·ÙËÚ‹ıËÎ·Ó ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ ‚Ï¿‚˜ ÛÙÔ DMSA. ∆Ô PDU ·Ó·ÁÓÒÚÈÛ 25 ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ 54 ·ÛıÂÓ›˜, Ì ¢·ÈÛıËÛ›· 46%, ÂÓÒ 29 ·È‰È¿ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi PDU. ∏ ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È 100%, ÂÓÒ Ë ·ÚÓËÙÈ΋ 41% (¶›Ó·Î·˜ 1).
1·
Paediatriki 2003;66:352-356
∞fi ÙÔ˘˜ 54 ·ÛıÂÓ›˜ Ì ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ ‚Ï¿‚˜ ÛÙÔ DMSA ÓÂÊÚÒÓ, ÛÙÔ˘˜ 32 ÔÈ ‚Ï¿‚˜ ‹Ù·Ó ÌÔÓÔÂÛÙȷΤ˜ Î·È ÛÙÔ˘˜ 22 ÔÏ˘ÂÛÙȷΤ˜. ¢Âη¤ÓÙ ·fi ÙÔ˘˜ 32 ·ÛıÂÓ›˜ Ì ÙȘ ÌÔÓÔÂÛÙȷΤ˜ ‚Ï¿‚˜ ›¯·Ó ›Û˘ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ PDU. ªÂ ÙÔ PDU ‰ÂÓ ·ÔηχÊıËÎ·Ó ÔÈ ‚Ï¿‚˜ Û 12 ·ÛıÂÓ›˜ Ì ̛· ÌÈÎÚ‹ ‚Ï¿‚Ë ÛÙÔÓ ¿Óˆ fiÏÔ ÙÔ˘ ÓÂÊÚÔ‡, Û 3 ·ÛıÂÓ›˜ Ì ̛· ÌÈÎÚ‹ ‚Ï¿‚Ë ÛÙÔÓ Î¿Ùˆ fiÏÔ Î·È Û 2 ·¯‡Û·ÚÎÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ‚Ï¿‚Ë ÛÙË ÌÂÛfiÙËÙ· ÙˆÓ ÓÂÊÚÒÓ. ™Â 10 ·fi ÙÔ˘˜ 22 ·ÛıÂÓ›˜ Ì ÙȘ ÔÏ˘ÂÛÙȷΤ˜ ‚Ï¿‚˜ ÛÙÔ DMSA ÓÂÊÚÒÓ, ‚Ú¤ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ÛÙÔ PDU. OÈ ‚Ï¿‚˜ Ô˘ ‰ÂÓ ·ÔηχÊıËÎ·Ó ‹Ù·Ó Û 5 ·ÛıÂÓ›˜ ÛÙÔÓ ¿Óˆ Î·È Î¿Ùˆ fiÏÔ ÙÔ˘ ÓÂÊÚÔ‡, Û 2 ·ÛıÂÓ›˜ ÛÙÔÓ ¿Óˆ fiÏÔ Î·È ÛÙÔ ¤Ûˆ ¯Â›ÏÔ˜ ÙÔ˘ ÓÂÊÚÔ‡ Î·È Û 5 ·ÛıÂÓ›˜ ÛÙÔ ¤Ûˆ Î·È ¤Íˆ ¯Â›ÏÔ˜ ÙÔ˘ ÓÂÊÚÔ‡. ∫˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ·ÓȯÓ‡ÙËΠ۠22 ·È‰È¿ (30%). ∞fi ÙÔ˘˜ 54 ·ÛıÂÓ›˜ Ì ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ ‚Ï¿‚˜ ÛÙÔ DMSA, ÔÈ 23 (42%) ‹Ù·Ó ‚Ú¤ÊË, ÂÓÒ ÔÈ ˘fiÏÔÈÔÈ 31 (58%) ‹Ù·Ó ·È‰È¿ ËÏÈΛ·˜ 1-14 ÂÙÒÓ. ∞fi Ù· 25 ·È‰È¿ Ì ·ıÔÏÔÁÈÎfi PDU, ÌfiÓÔ Ù· 5 (20%) ‹Ù·Ó ‚Ú¤ÊË. ∆· ˘fiÏÔÈ· 20 ·È‰È¿ (80%) ›¯·Ó ËÏÈΛ· >1 ¤ÙÔ˘˜. ™‡Ìʈӷ Ì ٷ ·Ú·¿Óˆ, ·fi Ù· 31 ·È‰È¿ 1-14 ÂÙÒÓ Ì ·ıÔÏÔÁÈÎfi DMSA, Ù· 20 (65%) ›¯·Ó ·ıÔÏÔÁÈÎfi Î·È ÙÔ PDU. ™˘˙‹ÙËÛË ªÂϤÙ˜ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙÒÓ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÔÍ›· ‚·ÎÙËÚȉȷ΋ Ïԛ̈ÍË ÙÔ˘ ÓÂÊÚÔ‡ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·fiÊÚ·ÍË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÚÙËÚÈÔÏ›ˆÓ Î·È ÙËÓ ÂÏ·Ùو̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙ· ÚÔۂ‚ÏË̤ӷ ÙÌ‹Ì·Ù·, Ù· ÔÔ›· ÌÔÚ› Ó·
1‚
∂ÈÎfiÓ· 1. ∞ÂÈÎfiÓÈÛË Ù˘ ˘ÂÏÔÓÂÊÚÈÙȉÈ΋˜ ‚Ï¿‚˘ ÛÙÔ PDU Ì ÂÚÈÔ¯‹ ÌÂȈ̤Ó˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì· (1·) Î·È ÂÚÈÔ¯‹ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔÓ ¤ÏÂÁ¯Ô Ì DMSA (1‚).
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Paediatriki 2003;66:352-356
¶›Ó·Î·˜ 1. ∏ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ PDU Û ۇÁÎÚÈÛË Ì ÙÔ DMSA Û 74 ·È‰È¿ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ∂ÍÂÙ·˙fiÌÂÓË Ì¤ıÔ‰Ô˜ PDU (+) PDU (-) ™‡ÓÔÏÔ ·È‰ÈÒÓ
ª¤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜ DMSA (+) DMSA (-) 25 29 54
0 20 20
™‡ÓÔÏÔ ·È‰ÈÒÓ
25 49 74
∂˘·ÈÛıËÛ›·: 46% (25/54) ∂ȉÈÎfiÙËÙ·: 100% (20/20) £ÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·: 100% (25/25) ∞ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·: 41% (20/49)
·Ó·ÁÓˆÚÈÛÙÔ‡Ó Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ PDU (11,21). ªÂ ÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ·, ÙÔ Ú·‰ÈÔÊ¿ÚÌ·ÎÔ ÚÔÛÏ·Ì‚¿ÓÂÙ·È Ê˘ÛÈÔÏÔÁÈο ·fi Ù· ÂÁÁ‡˜ ÛˆÏËÓ·Úȷο ·ÙÙ·Ú· ÙÔ˘ ÓÂÊÚÔ‡ (9). ∏ ÚfiÛÏË„‹ ÙÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙÔ ÓÂÊÚÈÎfi ÊÏÔÈfi Î·È ·fi ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ ÙˆÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ (3,14). ∂Ï·Ùو̤ÓË ÚfiÛÏË„Ë ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙȘ ÂÚÈÔ¯¤˜ ÔÍ›·˜ ÊÏÂÁÌÔÓ‹˜ Û˘Ì‚·›ÓÂÈ ÚÒÈÌ· Î·È ÔÊ›ÏÂÙ·È ÛÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÛÙËÓ ÙÔÈ΋ ÈÛ¯·ÈÌ›· (3). ∞Ó¿ÏÔÁ· Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÚÔۂ‚ÏË̤ÓÔ˘ ÓÂÊÚÔ‡ ÛÙÔ DMSA, ÔÈ ‚Ï¿‚˜ ‰È·ÎÚ›ÓÔÓÙ·È Û ÂÛÙȷΤ˜, ÔÏ˘ÂÛÙȷΤ˜ Î·È ‰È¿¯˘Ù˜ (11,21,23). OÈ ÓÂÊÚÈΤ˜ Ô˘Ï¤˜ Û˘Ì‚·›ÓÔ˘Ó ÌfiÓÔ ÛÙȘ ı¤ÛÂȘ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ÚÔËÁÔ‡ÌÂÓ˜ ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ ‚Ï¿‚˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ïԛ̈͢ (3). OÈ ÔÍ›˜ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ‚Ï¿‚˜ Â›Ó·È ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„È̘ Î·È ‰ÂÓ Ô‰ËÁÔ‡Ó ¿ÓÙ· Û ÓÂÊÚÈ΋ Ô˘ÏÔÔ›ËÛË. ∫ÏÈÓÈΤ˜ Î·È ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ·Ô‰Â›ÍÂÈ fiÙÈ Ë ÓÂÊÚÈ΋ Ô˘ÏÔÔ›ËÛË ÌÔÚ› Ó· ÚÔÏËÊı› ‹ Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ì ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Î·È ÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ›· Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ (3). ŒÓ·˜ ÌÂıÔ‰ÔÏÔÁÈÎfi˜ ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ ‰ÂÓ Â›Ó·È ¿ÓÙ· ¢¯ÂÚ‹˜ Ë ‰È¿ÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÔͤˆÓ ·ÚÂÁ¯˘Ì·ÙÈÎÒÓ ‚Ï·‚ÒÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È ÙˆÓ ÓÂÊÚÈÎÒÓ Ô˘ÏÒÓ ‹ ÙˆÓ Û˘ÁÁÂÓÒÓ ‰˘ÛÏ·ÛÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ‚Ï·‚ÒÓ Ô˘ ÚÔ¸‹Ú¯·Ó. ∞˘Ùfi˜ Ô ÂÚÈÔÚÈÛÌfi˜ ·ÊÔÚ¿ Û fiϘ ÙȘ ÌÂϤÙ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔ DMSA ˆ˜ ̤ıÔ‰Ô ·Ó·ÊÔÚ¿˜. ÕÏψÛÙÂ, Ô ÏËı˘ÛÌfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÂÈϤ¯ıËΠ̠‚¿ÛË ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ÎÚÈÙ‹ÚÈ· ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ∆· ‰Â‰Ô̤ӷ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÂȂ‚·ÈÒÓÔ˘Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·Ó¿ÌÂÛ· ÛÙ· ·È‰È¿ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· (2). ∂›Û˘, ÛÙ· ‚Ú¤ÊË ËÏÈΛ·˜ ¤ˆ˜ 12 ÌËÓÒÓ ‰È·ÈÛÙÒıËΠÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ˘ÂÏÔÓÂÊÚÈÙȉÈÎÒÓ ‚Ï·‚ÒÓ Û ۯ¤ÛË Ì ÙȘ ˘fiÏÔȘ ËÏÈ˘. ŒÓ· ÁÚ‹ÁÔÚÔ Î·È ·ÍÈfiÈÛÙÔ ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô ı· ‹Ù·Ó ¯Ú‹ÛÈÌÔ ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ
Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· Ô˘ ··ÈÙÔ‡Ó ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ (2). ŒÙÛÈ, ı· ÌÔÚÔ‡Û ӷ ÌÂȈı› Ë Â›ÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ Ô˘ÏÔÔ›ËÛ˘ Î·È ÙˆÓ Ì·ÎÚÔÚfiıÂÛÌˆÓ ÂÈÏÔÎÒÓ Ù˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, fiˆ˜ Ê·›ÓÂÙ·È ÛÙ· ·ÔÙÂϤÛÌ·Ù·, ÙÔ PDU ·Ó·ÁÓÒÚÈÛ ۈÛÙ¿ fiÏ· Ù· ·È‰È¿ ¯ˆÚ›˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·, ÂÓÒ ·Ó·ÁÓÒÚÈÛ ÌfiÓÔ ÙÔ 46% ÙˆÓ ·È‰ÈÒÓ Ì ˘ÂÏÔÓÂÊÚ›Ùȉ·. ∂›Û˘, fiÏ· Ù· ·È‰È¿ Ì ıÂÙÈÎfi PDU ›¯·Ó ÙË ÓfiÛÔ, ÂÓÒ Ë ¯·ÌËÏ‹ ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ÙÔ˘ ·Í›· ‰Â›¯ÓÂÈ fiÙÈ ¤Ó· ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ ·Ô˘Û›· ˘ÂÏÔÓÂÊÚÈÙȉÈ΋˜ ‚Ï¿‚˘. ™Â ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È ·ÚfiÌÔÈ· ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ Î·È Â˘·ÈÛıËÛ›· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 75% ¤ˆ˜ 88% (11,12,21). ¶·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¤·Û ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‹Ù·Ó Ë ‰˘ÛÎÔÏ›· ÛÙË Û˘ÓÂÚÁ·Û›· Ì ÙÔ˘˜ ÌÈÎÚÔ‡˜ ·ÛıÂÓ›˜. OÈ ÎÈÓ‹ÛÂȘ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È Ù˘ ·Ó·ÓÔ‹˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ·Ú¿ÛÈÙ· ÛÙËÓ Î·Ù·ÁÚ·Ê‹, ȉ›ˆ˜ ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ (11,19,21,24). ∞˘Ùfi Ê·›ÓÂÙ·È ·fi ÙÔ ¯·ÌËÏfi ÔÛÔÛÙfi ıÂÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙÔ PDU ÛÙ· ‚Ú¤ÊË Û ۯ¤ÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ (57%) ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ó‹ÎÂÈ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ™Â ‰‡Ô ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜, fiÔ˘ Ë Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ‹Ù·Ó 80% Î·È 88%, Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 5 Î·È 18,5 ¤ÙË, ·ÓÙ›ÛÙÔȯ· (2,11). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Â˘·ÈÛıËÛ›· ÙÔ˘ PDU ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 114 ÂÙÒÓ ‹Ù·Ó 65%. ∂›Û˘, Ë ·Û·ÊÔÔ›ËÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÓÂÊÚÔ‡ ·fi ÁÂÈÙÔÓÈÎfi ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ‹ ·fi ÂÈηχÙÔ˘Û· ÏÂ˘Ú¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙË ÌË ·Ó·ÁÓÒÚÈÛË ÌÈÎÚÒÓ ÂÛÙÈÒÓ ‚Ï¿‚˘, ȉ›ˆ˜ ÛÙÔÓ ¿Óˆ fiÏÔ ÙÔ˘ ÓÂÊÚÔ‡ (21), fiˆ˜ Û˘Ó¤‚Ë Û 12 ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘. ÕÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÚ› Ó· ÂËÚ¤·Û ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ‹Ù·Ó Ë ·¯˘Û·ÚΛ· (11,19). ¢‡Ô ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ·¯‡Û·ÚÎÔÈ. OÈ ·ÓˆÙ¤Úˆ ·Ú¿ÁÔÓÙ˜, ÌÂÌÔӈ̤ÓÔÈ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi, ηıÒ˜ ›Û˘ Î·È Ë ·‰˘Ó·Ì›· ÂÎÙ¤ÏÂÛ˘ Ù˘ ÂͤٷÛ˘ ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ 24ÒÚÔ˘ ·fi ÙËÓ ÚÔۤϢÛË ÙˆÓ ·ÛıÂÓÒÓ, ÌÔÚ› Ó· ıˆÚËı› fiÙÈ
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Û˘Ó¤‚·Ï·Ó ÛÙË ÌË ·ÔÎ¿Ï˘„Ë ˘ÂÏÔÓÂÊÚÈÙȉÈÎÒÓ ‚Ï·‚ÒÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™Â ‰‡Ô ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜, ÔÈ ·ÛıÂÓ›˜ Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· ÂÍÂÙ¿ÛÙËÎ·Ó Ì ÙÔ PDU ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ 24ÒÚÔ˘ ·fi ÙËÓ ÚÔÛ¤ÏÂ˘Û‹ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (11,12). ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ PDU, ·˘Ùfi ·ÔÙÂÏ› Ì›· ÁÚ‹ÁÔÚË Ì¤ıÔ‰Ô, ÌË ÂÂÌ‚·ÙÈ΋, ¯·ÌËÏÔ‡ ÎfiÛÙÔ˘˜, ¯ˆÚ›˜ Ó· ··ÈÙ› ÂÈÚfiÛıÂÙÔ ÂÍÔÏÈÛÌfi, ÛÙÂÚÂ›Ù·È ÈÔÓ›˙Ô˘Û·˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ Î·È ‰ÂÓ ··ÈÙ› ÙË ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÊϤ‚ÈÔ˘ ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ̤ÛÔ˘ (11,21,24). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÙÔ power Doppler ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Â›Ó·È Ì¤ıÔ‰Ô˜ Ì ˘„ËÏ‹ ÂȉÈÎfiÙËÙ· (100%). ŸÌˆ˜, ·Ó Î·È ¤¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ ÌÈÎÚfiÙÂÚË Â˘·ÈÛıËÛ›· ·fi ÙÔ DMSA ÓÂÊÚÒÓ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ ÛÙ· ·È‰È¿, Â›Ó·È ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË ‰È·ÁÓˆÛÙÈ΋ ̤ıÔ‰Ô˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÏfiÁˆ ÙˆÓ ÛËÌ·ÓÙÈÎÒÓ Ù˘ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Jacobson SH, Eklof O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. BMJ 1989;299:703-706. 2. Hitzel A, Liard A, Vera P, Manrique A, Menard JF, Dacher JN. Color and power Doppler sonography versus DMSA scintigraphy in acute pyelonephritis and in prediction of renal scarring. J Nucl Med 2002;43:27-32. 3. Majd M, Rushton HG. Renal cortical scintigraphy in the diagnosis of acute pyelonephritis. Semin Nucl Med 1992;22:98-111. 4. Benador D, Benador N, Slosman DO, Nussle D, Mermillod B, Girardin E. Cortical scintigraphy in the evaluation of renal parenchymal changes in children with pyelonephritis. J Pediatr 1994;124:17-20. 5. Morin D, Veyrac C, Kotzki PO, Lopez C, Dalla Vale F, Durand MF et al. Comparison of ultrasound and dimercaptosuccinic acid scintigraphy changes in acute pyelonephritis. Pediatr Nephrol 1999;13:219-222. 6. Talner LB, Davidson AJ, Lebowitz RL, Dalla Palma L, Goldman SM. Acute pyelonephritis: can we agree on terminology? Radiology 1994;192:297-305. 7. Dacher JN, Avni F, Francois A, Rypens F, Monroc M, Eurin D et al. Renal sinus hyperechogenicity in acute pyelonephritis: description and pathological correlation. Pediatr Radiol 1999;29:179-182. 8. Barry BP, Hall N, Cornford E, Broderick NJ, Somers JM, Rose DH. Improved ultrasound detection of renal scarring in children following urinary tract infection. Clin Radiol 1998;53:747-751. 9. Rosenberg AR, Rossleigh MA, Brydon MP, Bass SJ, Leighton DM, Farnsworth RH. Evaluation of acute urinary tract infection in children by dimercaptosuccinic acid scintigraphy: a prospective study. J Urol 1992;148:1746-1749.
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10. Majd M, Nussbaum Blask AR, Markle BM, Shalaby-Rana E, Pohl HG, Park JS et al. Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology 2001;218:101-108. 11. Sakarya ME, Arslan H, Erkoc R, Bozkurt M, Atilla MK. The role of power Doppler ultrasonography in the diagnosis of acute pyelonephritis. Br J Urol 1998;81:360-363. 12. Dacher JN, Pfister C, Monroc M, Eurin D, LeDosseur P. Power Doppler sonographic pattern of acute pyelonephritis in children: comparison with CT. Am J Roentgenol 1996;166:1451-1455. 13. Verboven M, Ingels M, Delree M, Piepsz A. 99mTc-DMSA scintigraphy in acute urinary tract infection in children. Pediatr Radiol 1990;20:540-542. 14. Rushton HG, Majd M. Dimercaptosuccinic acid renal scintigraphy for the evaluation of pyelonephritis and scarring: a review of experimental and clinical studies. J Urol 1992;148:1726-1732. 15. Rubin JM, Adler RS. Power Doppler expands standard color capability. Diagn Imaging 1993;15:66-69. 16. Hamper UM, DeJong MR, Caskey CI, Sheth S. Power Doppler imaging: clinical experience and correlation with color Doppler US and other imaging modalities. Radiographics 1997;17:499-513. 17. Martinoli C, Pretolesi F, Crespi G, Bianchi S, Gandolfo N, Valle M et al. Power Doppler sonography: clinical applications. Eur J Radiol 1998;27 (Suppl 2):S133-S140. 18. Bude RO, Rubin JM. Power Doppler sonography. Radiology 1996;200:21-23. 19. Babcock DS, Patriquin H, LaFortune M, Dauzat M. Power Doppler sonography: basic principles and clinical applications in children. Pediatr Radiol 1996;26:109-115. 20. Bude RO, Rubin JM, Adler RS. Power versus conventional color Doppler sonography: comparison in the depiction of normal intrarenal vasculature. Radiology 1994;192:777-780. 21. Winters WD. Power Doppler sonographic evaluation of acute pyelonephritis in children. J Ultrasound Med 1996;15:91-96. 22. Clautice-Engle T, Jeffrey RB Jr. Renal hypoperfusion: value of power Doppler imaging. Am J Roentgenol 1997;168:1227-1231. 23. Svanborg C, de Man P, Sandberg T. Renal involvement in urinary tract infection. Kidney Int 1991;39:541-549. 24. Dacher JN. Contribution of vascular ultrasonic studies for the study of kidney diseases in children. Arch Pediatr 1997;4:1255-1258.
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ORIGINAL ARTICLE
OÈ ÔÈÎÔÁÂÓÂȷΤ˜ Û¯¤ÛÂȘ ˆ˜ ·Ú¿ÁÔÓÙ·˜ Ú‡ıÌÈÛ˘ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 1 ∞. ∆Û·Ì·ÚÏ‹ - ∫ÈÙÛ·Ú¿, ∫. ∫Ô˘ÓÂÓÔ‡
Family relationships as a factor in the control of type 1 diabetes mellitus A. Tsambarli - Kitsara, K. Kounenou
¶ÂÚ›ÏË„Ë: OÈ Û¯¤ÛÂȘ Ô˘ ·Ó·Ù‡ÛÛÂÈ ÙÔ ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1 ÂÓÙfi˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ·ÔÙÂÏÔ‡Ó ¤Ó·Ó Ôχ ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÛÙËÓ ÔÚ›· ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘ Ù˘ ÓfiÛÔ˘. ∏ ·ÚÔ‡Û· ÌÂϤÙË ÂÈÎÂÓÙÚÒÓÂÙ·È Î˘Ú›ˆ˜ ÛÙË Û¯¤ÛË ÁÔÓ¤ˆÓ-·È‰ÈÔ‡ Ì ‰È·‚‹ÙË. ∂ÎÙÂٷ̤ÓË ÌÂϤÙË ‰ÈÂÚ‡ÓËÛ Ì ÔÈÔÙÈΤ˜ ÌÂıfi‰Ô˘˜ (·Ú·Ù‹ÚËÛË, ÂȘ ‚¿ıÔ˜ Û˘Ó¤ÓÙ¢ÍË) Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ “ÎÏÈÓÈÎÔ‡ ˘Ô‰Â›ÁÌ·ÙÔ˜ ÌÂϤÙ˘ Ù˘ „˘¯Ôۈ̷ÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜”, Û ‰Â›ÁÌ· ÂÏÏËÓÈÎÒÓ ÔÈÎÔÁÂÓÂÈÒÓ Ì ‰˘ÛÎÔϛ˜ ÛÙË Ú‡ıÌÈÛË ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË. ∏ ÌÂϤÙË ·Ó¤‰ÂÈÍÂ Û˘ÁÎÂÎÚÈ̤ÓË Ù˘ÔÏÔÁ›· ÙˆÓ Û¯¤ÛÂˆÓ ÛÙÔ Ï·›ÛÈÔ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ·˘ÙÒÓ. OÈ ÔÈÎÔÁ¤ÓÂȘ ÂÌÊ·Ó›˙Ô˘Ó ‰È¿Û·ÛË Ù˘ ÁÔÓÈÎfiÙËÙ·˜, ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿, ¤ÏÏÂÈ„Ë ÔÚ›ˆÓ ÛÙȘ Û¯¤ÛÂȘ ÙˆÓ ÌÂÏÒÓ, ÂÌÏÔ΋ ÙÔ˘ Û˘Ìو̷ÙÈÎÔ‡ ·È‰ÈÔ‡ ÛÙË Û˘˙˘ÁÈ΋ Û‡ÁÎÚÔ˘ÛË, ·Ô˘Û›· ÂÍ·ÙÔÌ›Î¢Û˘, ·Ó¿ıÂÛË ÁÔÓÈÎÔ‡ ÚfiÏÔ˘ ÛÙÔ ÌË-Û˘Ìو̷ÙÈÎfi ·È‰›, ηıÒ˜ Î·È ·Û¿ÊÂÈ· ÚfiÏˆÓ Î·È Î·ÓfiÓˆÓ ÛÙȘ Û¯¤ÛÂȘ. ∆· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÌÔÚ› Ó· ÂȉڿÛÔ˘Ó ÙfiÛÔ ÛÙËÓ ÔÚ›· ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘ fiÛÔ Î·È ÛÙËÓ ÔÈfiÙËÙ· Ù˘ ηıËÌÂÚÈÓ‹˜ ˙ˆ‹˜ ÔÏfiÎÏËÚ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜.
Abstract: The parent-child relationship plays a crucial role in the course of metabolic control in childhood diabetes type 1. This study attempted to clarify the characteristics of the parent-child relationship in families with a child with diabetes. The study used qualitative research methods (observation, in-depth interview) to investigate the criteria of the model of the “psychosomatic family”, in a sample of Greek families facing problems with the metabolic control of a child’s diabetes. The research revealed a typology of parental attitude and behaviour characterized by: parental disruption, overprotectiveness, absence of limits, involvement of the child in a marital crisis, assignment of the parental role to a nonsymptomatic child, ambiguity of roles and rules. The characteristics observed may have an impact not only on the course of metabolic control, but also on the quality of everyday life for the whole family.
§¤ÍÂȘ ÎÏÂȉȿ: ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1, “„˘¯Ôۈ̷ÙÈ΋ ÔÈÎÔÁ¤ÓÂÈ·”, ÁÔÓÈÎfiÙËÙ·.
Key words: diabetes mellitus type 1, “psychosomatic family”, parenthood.
∂ÈÛ·ÁˆÁ‹ O ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1 Â›Ó·È ¤Ó· ¯ÚfiÓÈÔ ·˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ· (1) Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜. ∏ ÓfiÛÔ˜ ··ÈÙ› Ú·ÎÙÈΤ˜ Ú‡ıÌÈÛ‹˜ Ù˘, fiˆ˜ ¯ÔÚ‹ÁËÛË ÂÓ¤ÛÈÌ˘ ÈÓÛÔ˘Ï›Ó˘ (2-3 ‰fiÛÂȘ ËÌÂÚËÛ›ˆ˜), ̤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÁÏ˘Îfi˙˘ ÛÙÔ ·›Ì· (>3-4 ÊÔÚ¤˜), ÂÈ-
‰È΋ ‰È·ÙÚÔÊÈ΋ ·ÁˆÁ‹ Î·È ¿ÛÎËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ™Ùfi¯Ô˜ Ù˘ Ú‡ıÌÈÛ˘ Â›Ó·È Ë ÚfiÏË„Ë ÙˆÓ ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ÂÚ›ÙˆÛË ¯ÚfiÓÈ·˜ ·Ó·ÚÎÔ‡˜ Ú‡ıÌÈÛ˘ (2). Ÿˆ˜ Û οı ¯ÚfiÓÈ· ·Ûı¤ÓÂÈ·, Ë ‰È¿ÁÓˆÛË ÙÔ˘ ‰È·‚‹ÙË ÛÙÔ ·È‰›-̤ÏÔ˜ Ì›·˜ ÔÈÎÔÁ¤ÓÂÈ·˜ ÚÔηÏ› ¤ÓÙÔÓÔ ¿Á¯Ô˜ ÛÙÔ˘˜ ÁÔÓ›˜. ∏ ÔÈÎÔÁ¤ÓÂÈ·
¶·È‰·ÁˆÁÈÎfi ∆Ì‹Ì· ¢ËÌÔÙÈ΋˜ ∂η›‰Â˘Û˘, ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ÈÁ·›Ô˘ ™˘Ì‚Ô˘Ï¢ÙÈÎfi ∫¤ÓÙÚÔ, ¶·ÓÂÈÛÙ‹ÌÈÔ ¶ÂÈÚ·ÈÒ˜
Faculty of Primary Education, University of the Aegean Counseling Center, University of Piraeus
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¶·È‰È·ÙÚÈ΋ 2003;66:357-363
ÂÈÛ¿ÁÂÙ·È Û ̛· “ÎÚ›ÛË”, Ë Â›Ï˘ÛË Ù˘ ÔÔ›·˜ ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ì˯·ÓÈÛÌÒÓ ÚÔÛ·ÚÌÔÁ‹˜. ∏ ˙ˆ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÂËÚ¿˙ÂÙ·È ÏfiÁˆ ÙˆÓ ·ÏÏ·ÁÒÓ Ô˘ ÂÈ‚¿ÏÏÂÈ Ë ¿ıËÛË ÙÔ˘ ‰È·‚‹ÙË. ∞Ú¯Èο, ˘ÚÔ‰ÔÙÔ‡ÓÙ·È ¤ÓÙÔÓ· Û˘Ó·ÈÛı‹Ì·Ù· Ô˘ ÔÈ ÁÔÓ›˜ ÔÊ›ÏÔ˘Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó: Êfi‚Ô˜ ·ÒÏÂÈ·˜ ÙÔ˘ ·È‰ÈÔ‡ ·fi Ì›· Èı·Ó‹ ˘ÔÁÏ˘Î·ÈÌÈ΋ ÎÚ›ÛË (3,4) ‹ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ (5), ¿Á¯Ô˜ ÁÈ· ÙÔ Ì¤ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, ¤ÓıÔ˜ ÁÈ· ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ˘ÁÈÔ‡˜ ·È‰ÈÔ‡, ·˘ÙÔ-ηÙËÁÔڛ˜ Î·È ÂÓÔ¯‹ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÔÚ›· Ù˘ ·Ûı¤ÓÂÈ·˜. ∂ÈϤÔÓ, ÂÈÛ¿ÁÔÓÙ·È Ó¤Â˜ Ú·ÎÙÈΤ˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ˙ˆ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (ÂÚÈÔÚÈÛÌÔ› Ô˘ ÂÈ‚¿ÏÏÔÓÙ·È ·fi ÙÔ ÚfiÁÚ·ÌÌ· Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘). ∆¤ÏÔ˜, ··ÈÙÂ›Ù·È ·Ó·ÚÔÛ·ÚÌÔÁ‹ ÙˆÓ ÚfiψÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ù· ·˘ÍË̤ӷ ›‰· ÊÚÔÓÙ›‰·˜ Î·È Â˘ı‡Ó˘. ™˘ÓÂÒ˜, Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰È·‚‹ÙË ‰ÂÓ Û˘ÓÈÛÙ¿ ÌfiÓÔ ¤Ó· ÓÔÛÔÏÔÁÈÎfi Û˘Ì‚¿Ó, ·ÏÏ¿ Î·È Ì›· „˘¯ÔÎÔÈÓˆÓÈ΋ ηٿÛÙ·ÛË, Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ‡·ÚÍË Â·ÚÎÔ‡˜ “¢ÂÏÈÍ›·˜” ·fi ÙËÓ ÏÂ˘Ú¿ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ŒÓ·˜ Ôχ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙË Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ÂÈÙ˘¯‹˜ „˘¯ÔÎÔÈÓˆÓÈ΋ ÚÔÛ·ÚÌÔÁ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È È‰È·›ÙÂÚ· ÙˆÓ ÁÔÓ¤ˆÓ - ÂÊfiÛÔÓ ÂΛÓÔÈ ·Ó·Ï·Ì‚¿ÓÔ˘Ó ·Ú¯Èο ÙËÓ Â˘ı‡ÓË Ù˘ Ú‡ıÌÈÛ˘ - ÛÙ· ηÈÓÔ‡ÚÈ· ‰Â‰Ô̤ӷ Ô˘ ÂÈ‚¿ÏÏÂÈ Ë ·ÚÔ˘Û›· Ù˘ ÓfiÛÔ˘ (3). £· ÌÔÚÔ‡Û ηÓ›˜ Ó· ˘Ôı¤ÛÂÈ fiÙÈ ÙÔ ÂÈÙ˘¯¤˜ ͤڷÛÌ· Ù˘ ÎÚ›Û˘, ÛÙËÓ ÔÔ›· ÂÈÛ¤Ú¯ÂÙ·È Ë ÔÈÎÔÁ¤ÓÂÈ·, Û˘ÓÈÛÙ¿ ÙËÓ ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÂÈÙ˘¯‹ Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘. ∆Ô ‰ÔÌÈÎfi ˘fi‰ÂÈÁÌ· ÚÔÛÂÁÁ›˙ÂÈ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ˆ˜ ¤Ó· Û‡ÛÙËÌ· Ô˘ ηıÔÚ›˙ÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì ‚¿ÛË ÙË ‰ÔÌ‹ ÙÔ˘ (.¯. ÌÔÓÔÁÔÓÂ˚Τ˜, ˘ÚËÓÈΤ˜, ÂÎÙÂٷ̤Ó˜) Î·È Ù· fiÚÈ· (Û·Ê‹, ¿Î·ÌÙ·, ËÌÈ-‰È·ÂÚ·Ù¿) ÌÂٷ͇ ÙˆÓ ˘ÔÛ˘ÛÙËÌ¿ÙˆÓ ÙÔ˘ (ÁÔÓ›˜, ·È‰È¿) (6). ™‡Ìʈӷ Ì ÙÔ ‰ÔÌÈÎfi ˘fi‰ÂÈÁÌ·, Ì›· ˘ÁÈ‹˜ ÔÈÎÔÁ¤ÓÂÈ· Ú¤ÂÈ Ó· ÂÌÊ·Ó›˙ÂÈ Û·Ê›˜ ηÓfiÓ˜ Ô˘ Ó· ‰È¤Ô˘Ó ÙȘ Û¯¤ÛÂȘ ÙˆÓ ÌÂÏÒÓ, ‰È·-ÁÂÓ·΋ ÈÂÚ·Ú¯›· (ÁÔÓ›˜ ˆ˜ ηıÔ‰ËÁËÙ¤˜), ÂÈÙ˘¯‹ Â›Ï˘ÛË ÙˆÓ Û˘ÁÎÚÔ‡ÛÂˆÓ Î·È ·Ô‰ÂÎÙ‹ - ·fi Ù· ̤ÏË Ù˘ - ηٷÓÔÌ‹ ÙˆÓ ÚfiψÓ. ªÂ ‚¿ÛË ÙÔ ·Ú·¿Óˆ ˘fi‰ÂÈÁÌ·, ÔÈ Minuchin Î·È Û˘Ó ‰È·Ù‡ˆÛ·Ó ¤Ó· ÎÏÈÓÈÎfi ˘fi‰ÂÈÁÌ· ÌÂϤÙ˘ ÙˆÓ “„˘¯Ôۈ̷ÙÈÎÒÓ ÔÈÎÔÁÂÓÂÈÒÓ” (7). ∆Ô ˘fi‰ÂÈÁÌ· ·˘Ùfi ÚԤ΢„ ̤۷ ·fi ÙËÓ ÎÏÈÓÈ΋ ÂÚÁ·Û›· Ì Ó·ڤ˜ ·ÛıÂÓ›˜ Ô˘ ˘¤ÊÂÚ·Ó ·fi Û˘Ó¯›˜ ÎÚ›ÛÂȘ ÎÂÙÔͤˆÛ˘ Î·È Ô‰ËÁÔ‡ÓÙ·Ó Û ·ÓÂÈÏËÌ̤Ó˜ ÂÈÛ·ÁˆÁ¤˜ Û ÎÏÈÓÈΤ˜. ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ô‰‹ÁËÛ ÛÙËÓ ¿ÚÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Û¯¤ÛÂˆÓ ÁÔÓ¤ˆÓ-·È‰ÈÔ‡ Î·È Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÚ›ÛÂˆÓ ÎÂÙÔͤˆÛ˘. ∏ ·Ú·ÎÔÏÔ‡ıËÛË (follow-up) ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ·Ó¤ÊÂÚ Ӥ˜ ÂÈÛ·ÁˆÁ¤˜, ÁÂÁÔÓfi˜ Ô˘ ·ÔÙ¤-
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Paediatriki 2003;66:357-363
ÏÂÛ ¤Ó‰ÂÈÍË fiÙÈ Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘ ›¯Â ‰È¿ÚÎÂÈ·. ™‡Ìʈӷ Ì ÙÔ˘˜ Minuchin Î·È Û˘Ó, Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ‰È¤Ô˘Ó ÙȘ Û¯¤ÛÂȘ ÛÙȘ “„˘¯Ôۈ̷ÙÈΤ˜” ÔÈÎÔÁ¤ÓÂȘ, ÛÙȘ Ôԛ˜ ˘‹Ú¯Â ·Ó·Ú΋˜ Ú‡ıÌÈÛË, Â›Ó·È Ù· ÂÍ‹˜ (7): ·) ÷Ϸڿ fiÚÈ· ÌÂٷ͇ ÙˆÓ ˘ÔÛ˘ÛÙËÌ¿ÙˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (ÁÔÓ›˜, ·È‰È¿), Ù· ̤ÏË Ù˘ ÔÔ›·˜ Ô‰ËÁÔ‡ÓÙ·È Û ¯·ÌËÏfi ‚·ıÌfi ·˘ÙÔÓÔÌ›·˜ ÏfiÁˆ ˘ÂÚ‚ÔÏÈ΋˜ ÂÌÏÔ΋˜ ÛÙȘ Û¯¤ÛÂȘ (enmeshment). OÈ Î·ÓfiÓ˜ Ô˘ ÔÚ›˙Ô˘Ó Ù· ‰ÈηÈÒÌ·Ù· Î·È ÙȘ ˘Ô¯ÚÂÒÛÂȘ ÙˆÓ ÌÂÏÒÓ ‰ÂÓ Â›Ó·È Û·Ê›˜ Î·È ÛÙ·ıÂÚÔ› ‹ ηٷÛÙÚ·ÙËÁÔ‡ÓÙ·È. O ȉȈÙÈÎfi˜ ˙ˆÙÈÎfi˜ ¯ÒÚÔ˜ ÙˆÓ ·ÙfiÌˆÓ Â›Ó·È ÂÏ¿¯ÈÛÙÔ˜ ηÈ, ·ÓÙ›ÛÙÔȯ·, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë ‰˘Ó·ÙfiÙËÙ· ÚˆÙÔ‚Ô˘Ï›·˜ Î·È ·Ó¿Ï˄˘ ¢ı‡Ó˘. ∏ ··Ú·›ÙËÙË ÈÂÚ¿Ú¯ËÛË ÛÙË Û¯¤ÛË ÁÔÓ¤ˆÓ-·È‰ÈÒÓ ‰ÂÓ ÙËÚÂ›Ù·È Î·È Ë ÁÔÓÈ΋ ·˘ıÂÓÙ›· ηٷÚÚ¤ÂÈ. ∫·Ù¿ Û˘Ó¤ÂÈ·, “ÙÔ ¿ÙÔÌÔ ¯¿ÓÂÙ·È Ì¤Û· ÛÙÔ Û‡ÛÙËÌ·”, ‰ËÏ·‰‹ ·‰˘Ó·Ù› Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÂÈ ·˘ÙfiÓÔÌ· Î·È Ó· ·Ó·Ï¿‚ÂÈ ÙȘ ¢ı‡Ó˜ ÙÔ˘ (7). ‚) ∆· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Î·È ˘¤ÚÌÂÙÚË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·ÓÙ›‰Ú·ÛË Û οı ËÁ‹ ¤ÓÙ·Û˘. Á) O ·ÛıÂÓ‹˜ ·ÈÛı¿ÓÂÙ·È Â˘ı‡ÓË Ó· ÚÔÛٷهÂÈ ÙËÓ ÂÓfiÙËÙ· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, “¯ÚËÛÈÌÔÔÈÒÓÙ·˜” Ù· Û˘ÌÙÒÌ·Ù¿ ÙÔ˘. ∏ “ÊÚÔÓÙ›‰·” ÙÔ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓ›Û¯˘ÛË Ù˘ ÂÁÁ‡ÙËÙ·˜ ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ. ∞˘Ùfi˜ Ô ¯ÂÈÚÈÛÌfi˜ Ù˘ ·Ûı¤ÓÂÈ·˜ ·ÔÙÂÏ› ÂÓÈÛ¯˘ÙÈÎfi ·Ú¿ÁÔÓÙ·. ‰) ∏ ÔÈÎÔÁ¤ÓÂÈ· ÂȉÂÈÎÓ‡ÂÈ ·Î·Ì„›· (rigidity) ÛÙÔÓ ÙÚfiÔ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘. ∂›Ó·È ‰Â‰Ô̤ÓÔ fiÙÈ Ì›· ÔÈÎÔÁ¤ÓÂÈ· ÛÙÔÓ Î‡ÎÏÔ Ù˘ ˙ˆ‹˜ Ù˘ ÂÚÓ¿ ·fi Ê¿ÛÂȘ ·Ó¿Ù˘Í˘ (Á¤ÓÓËÛË ·È‰ÈÔ‡, ÂÊ˂›·), ηٿ ÙȘ Ôԛ˜ ÔÈ ·Ó¿ÁΘ (·˘ÙÔÓÔÌ›·˜ Î·È ÛÙ‹ÚÈ͢) ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È. OÈ „˘¯Ôۈ̷ÙÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ ‰˘ÛÎÔχÔÓÙ·È Ó· ·Ú·ÎÔÏÔ˘ı‹ÛÔ˘Ó ÙȘ ·Ó·Ù˘ÍȷΤ˜ ·Ó¿ÁΘ ÙˆÓ ÌÂÏÒÓ, ‰È·ÙËÚÒÓÙ·˜ ÙÔ˘˜ ›‰ÈÔ˘˜ ÔÚÈÛÌÔ‡˜ Û¯¤ÛÂˆÓ (¤Ó· ·È‰› Â›Ó·È ¿ÓÙ· ¤Ó· ·È‰› Ô˘ Ú¤ÂÈ Ó· ˘ÔÛÙËÚ›˙ÂÙ·È ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi), Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·Ú·Ì¤ÓÂÈ ·Ó·Ú΋˜ Ë ·˘ÙÔÓÔÌ›· ÙˆÓ ÌÂÏÒÓ. Â) ∞ÔÊ˘Á‹ Â›Ï˘Û˘ Ù˘ Û‡ÁÎÚÔ˘Û˘, Ë ÔÔ›· ÔÊ›ÏÂÙ·È ÛÙÔ ¯·ÌËÏfi ‚·ıÌfi ‰È·ÊÔÚÔÔ›ËÛ˘ Ù˘ Ù·˘ÙfiÙËÙ·˜ ÙˆÓ ÌÂÏÒÓ. ∏ Û‡ÁÎÚÔ˘ÛË ‚ÈÒÓÂÙ·È ·fi Ù· ̤ÏË ˆ˜ ΛӉ˘ÓÔ˜ Ô˘ Ú¤ÂÈ Ó· ·ÔÊ¢¯ı›. ™˘¯Ó¿, Ë ÛÙ¿ÛË ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi ıÚËÛ΢ÙÈΤ˜ ÂÔÈı‹ÛÂȘ ‹ ¿Î·ÌÙÔ˘˜ ËıÈÎÔ‡˜ ηÓfiÓ˜: “™ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ Ì·˜ ¿ÓÙ· Û˘ÌʈÓԇ̔ ‹ “¢ÂÓ Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜”. ÛÙ) ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi Û‡ÛÙËÌ· ÏÂÈÙÔ˘ÚÁ› Ì ٤ÙÔÈÔ ÙÚfiÔ, ÒÛÙ ӷ ÎÚ·Ù¿ ÂÓÂÚÁfi ÙÔ Û‡Ìو̷. ∏ ‰È·Ù‹ÚËÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ Â›Ó·È ·fiÚÚÔÈ· Ù˘ ·Ó¿ÌÂÈ͢ ÙÔ˘ ·È‰ÈÔ‡ ÛÙË Û˘˙˘ÁÈ΋ Û‡ÁÎÚÔ˘ÛË.
¶·È‰È·ÙÚÈ΋ 2003;66:357-363
OÈ ÁÔÓ›˜ ··Û¯ÔÏÔ‡ÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi Ì ÙÔ ·È‰› Î·È Ë Û˘˙˘ÁÈ΋ Û‡ÁÎÚÔ˘ÛË ÌÂٷʤÚÂÙ·È ÛÙÔ Â‰›Ô Ù˘ ÁÔÓÈÎfiÙËÙ·˜. ∆Ô ÌÔÓÙ¤ÏÔ ·˘Ùfi ÂÊ·ÚÌfiÛÙËÎÂ Î·È Û ¿ÏϘ ·Ûı¤ÓÂȘ, fiˆ˜ ÙÔ ¿ÛıÌ·, Ë Ó¢ÚÈ΋ ·ÓÔÚÂÍ›· (7), Ë ·Ûı¤ÓÂÈ· ÙÔ˘ Crohn, Ë ÂÏÎ҉˘ ÎÔÏ›Ùȉ· (8), ηıÒ˜ Î·È Û ÚÔ‚Ï‹Ì·Ù· ‰È·ÙÚÔÊ‹˜ (9). ∏ ·ÚÔ‡Û· ÌÂϤÙË ÂȯÂÈÚ› Ó· ÂÚÈÁÚ¿„ÂÈ, Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ı¤ÙÂÈ ÙÔ ÎÏÈÓÈÎfi ÌÔÓÙ¤ÏÔ Ù˘ “„˘¯Ôۈ̷ÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜”, ÙË ÁÔÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Î·È ÙË Û¯¤ÛË ÁÔÓ¤·-·È‰ÈÔ‡ Û ÂÏÏËÓÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1, Ô ÌÂÙ·‚ÔÏÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È ·Ó·Ú΋˜. OÈ ÁÔÓ›˜ ‰˘ÛÎÔχÔÓÙ·È Ó· ¯ÂÈÚÈÛÙÔ‡Ó ˙ËÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙË Ú‡ıÌÈÛË ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Î·È Ó· ÍÂÂÚ¿ÛÔ˘Ó ÙÔ ¿Á¯Ô˜ Ô˘ ·ÈÛı¿ÓÔÓÙ·È, ·ÎfiÌË Î·È ·Ó ¤¯Ô˘Ó ÂÚ¿ÛÂÈ 4 ¤ÙË (ª.O.) ·ÊfiÙÔ˘ ¤ÁÈÓÂ Ë ‰È¿ÁÓˆÛË. Œ¯ÂÈ ÏËÊı› ˘’ fi„ÈÓ fiÙÈ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÚÔÛ·ÚÌÔÁ‹˜ ÛÙËÓ ·Ûı¤ÓÂÈ· ηٿ ̤ÛÔ fiÚÔ Â›Ó·È 1 ¤ÙÔ˜ (10,11). ∆Ô Î‡ÚÈÔ ÂÚ¢ÓËÙÈÎfi ÂÚÒÙËÌ· Â›Ó·È Â¿Ó ÔÈ ÔÈÎÔÁ¤ÓÂȘ ·˘Ù¤˜, ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ‰˘ÛÏÂÈÙÔ˘ÚÁÔ‡Ó Û ¤Ó· „˘¯ÔÏÔÁÈÎfi ›‰Ô, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο (ÛÙË ‰ÔÌ‹ Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜) ÙˆÓ “„˘¯Ôۈ̷ÙÈÎÒÓ ÔÈÎÔÁÂÓÂÈÒÓ”, fiˆ˜ ·˘Ù¿ ÔÚ›ÛÙËÎ·Ó ·fi ÙËÓ ÎÏÈÓÈ΋ ÔÌ¿‰· ÙÔ˘ Minuchin (7). ∆Ô ÂÚÒÙËÌ· ·˘Ùfi Ù›ıÂÙ·È ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ÔÈ ÔÈÎÔÁ¤ÓÂȘ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ¤Ú¢ӷ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¤ÓÙÔÓÔ ¿Á¯Ô˜, ·Ú’ fiÏÔ Ô˘ Ë ‰È¿ÚÎÂÈ· Ù˘ ·Ûı¤ÓÂÈ·˜ Â›Ó·È Î·Ù¿ ̤ÛÔ fiÚÔ 4 ¤ÙË Î·È ·Ó·˙ËÙÔ‡Ó ‚Ô‹ıÂÈ· ÁÈ· Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ÙËÓ Î·Ù¿ÛÙ·ÛË, ÙfiÙ ÌÔÚ› Ó· Á›ÓÂÈ ÏfiÁÔ˜ ÁÈ· ¯ÚfiÓÈ· „˘¯ÔÏÔÁÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÂÓ ÏfiÁˆ ÔÈÎÔÁÂÓÂÈÒÓ. ∞Ó Î·È ÔÈ ÔÈÎÔÁ¤ÓÂȘ ·˘Ù¤˜ ‰˘ÛÎÔχÔÓÙ·È ÛÙË Ú‡ıÌÈÛË, Û‡Ìʈӷ Ì ÙȘ ÙÈ̤˜ Ù˘ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (7,7-8,5), ÙÔ ÂӉȷʤÚÔÓ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ÂÛÙÈ¿˙ÂÙ·È ÛÙËÓ ÔÚ›· Ù˘ „˘¯ÔÎÔÈÓˆÓÈ΋˜ Ú‡ıÌÈÛ˘ ÙÔ˘ ‰È·‚‹ÙË. ™‡Ìʈӷ Ì ¤Ó· ¿ÚıÚÔ ·Ó·ÛÎfiËÛ˘ (12), ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÚ¢ÓÒÓ ÛÙÔ Â‰›Ô Ù˘ Û¯¤Û˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÙÔ ·È‰›-̤ÏÔ˜ ·˘Ù‹˜ ÂÛÙÈ¿˙ÂÈ ÛÙ· ·ÔÙÂϤÛÌ·Ù· Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘, ÂÓÒ ÂÏ¿¯ÈÛÙ˜ (13) ÂÈÎÂÓÙÚÒÓÔÓÙ·È ÛÙ· „˘¯ÔÎÔÈÓˆÓÈο Î·È Ù· ÚÔ‚Ï‹Ì·Ù· Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜. O ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ó· ·Ó·‰Â›ÍÂÈ ÙËÓ ÔÚÁ¿ÓˆÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈ·ÎÒÓ Û¯¤ÛÂˆÓ ˆ˜ ·Ú¿ÁÔÓÙ· ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û „˘¯ÔÏÔÁÈÎfi ›‰Ô. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÂÚ¢ÓÒÓÙ·È Ë ‰ÔÌ‹, Ë ÈÂÚ·Ú¯›·, Ù· fiÚÈ· ÌÂٷ͇ ÙˆÓ ˘ÔÛ˘ÛÙËÌ¿ÙˆÓ, ÔÈ Î·ÓfiÓ˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÔÈ ÚfiÏÔÈ ÙˆÓ ÌÂÏÒÓ Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘˜, ηıÒ˜ Î·È Ô ÙÚfiÔ˜ Ô˘ ·˘Ù¿ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÂȉÚÔ‡Ó ÛÙË ‰˘ÛÎÔÏ›· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ó· ‰È·¯ÂÈÚÈÛÙ› ÙËÓ ·Ûı¤ÓÂÈ· Î·È Ó· ÂÈÙ‡¯ÂÈ ÙËÓ ÔÌ·Ï‹ ÚÔÛ·ÚÌÔÁ‹ Ù˘ Û ·˘Ù‹.
Paediatriki 2003;66:357-363
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙËÓ ¤Ú¢ӷ Û˘ÌÌÂÙ›¯·Ó 30 ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› ÚÔÛ¯ÔÏÈ΋˜ ‹ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1, ÌÂÙ¿ ·fi ·Ú·ÔÌ‹ ÙÔ˘˜ ·fi ÙÔÓ ·ÚÌfi‰ÈÔ È·ÙÚfi. ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙÔ˘˜ ‹Ù·Ó: ·) ÁÔÓÈÎfi ¿Á¯Ô˜ ÁÈ· ÙË Ú‡ıÌÈÛË, ‚) ·‰˘Ó·Ì›· ÚÔÛ·ÚÌÔÁ‹˜ ÛÙȘ ··ÈÙ‹ÛÂȘ Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘, Á) ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 1 ¤ÙÔ˘˜ Î·È ‰) Ë ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ (ÚÔÛ¯ÔÏÈ΋, Û¯ÔÏÈ΋). ŸÏ˜ ÔÈ ÔÈÎÔÁ¤ÓÂȘ ·ÔÙÂÏÔ‡ÓÙ·Ó Î·È ·fi ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜. ¢Âη¤ÓÙ ÔÈÎÔÁ¤ÓÂȘ ›¯·Ó ‰‡Ô ·È‰È¿, 5 ›¯·Ó ÙÚ›· Î·È 10 ›¯·Ó ¤Ó· ·È‰›. ∆Ô ÂÎ·È‰Â˘ÙÈÎfi Â›Â‰Ô ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó ÙÔ ÂÍ‹˜: 20 ÁÔÓ›˜ ‹Ù·Ó ·fiÊÔÈÙÔÈ ·ÓÂÈÛÙËÌ›Ô˘, 10 ·fiÊÔÈÙÔÈ ÎÔÏÂÁ›Ô˘, 6 ·fiÊÔÈÙÔÈ Ù¯ÓÈÎÒÓ Û¯ÔÏÒÓ, 18 ·fiÊÔÈÙÔÈ ‰Â˘ÙÂÚÔ‚¿ıÌÈ·˜ Âη›‰Â˘Û˘ Î·È 6 ‰È¤ÎÔ„·Ó ÙË ÊÔ›ÙËÛË ÚÈÓ ÔÏÔÎÏËÚÒÛÔ˘Ó ÙË Á˘ÌÓ·Ûȷ΋ Âη›‰Â˘ÛË. ŸÏÔÈ ÔÈ ·Ù¤Ú˜ ÂÚÁ¿˙ÔÓÙ·Ó, ÂÓÒ 6 ÌËÙ¤Ú˜ ÂÚÁ¿˙ÔÓÙ·Ó, 6 ‰È¤ÎÔ„·Ó ÙËÓ ÂÚÁ·Û›· ÙÔ˘˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Î·È 18 ›Ù ‰ÂÓ ÂÚÁ¿ÛÙËÎ·Ó ÔÙ¤ ›Ù ‰È¤ÎÔ„·Ó ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ Á¿ÌÔ ÙÔ˘˜. OÈ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ‰È¤ÌÂÓ·Ó Û ÚÔ¿ÛÙÈ· ÙˆÓ ∞ıËÓÒÓ Î·È Â›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ̤ÏÔ˜ Ù˘ ÂÎÙÂٷ̤Ó˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ô˘ ˙Ô‡Û Ôχ ÎÔÓÙ¿. OÈ ÔÈÎÔÁ¤ÓÂȘ ÂϤÁ¯ıËÎ·Ó Ó· Ù·ÈÚÈ¿˙Ô˘Ó ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ì ‰È·‚‹ÙË (5-11 ÂÙÒÓ), ÙÔ Ê‡ÏÔ ÙÔ˘˜ (13 ·ÁfiÚÈ· Î·È 17 ÎÔÚ›ÙÛÈ·), ÙËÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ (ÌÂÛ·›·) ηÈ, Ù¤ÏÔ˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ûı¤ÓÂÈ·˜ (̤ÛÔ˜ fiÚÔ˜: 4 ¤ÙË). ∏ ÚÒÙË Â·Ê‹ Ì ÙÔ˘˜ ÁÔÓ›˜ Î·È Ù· ·È‰È¿ ¤ÁÈÓ ÛÙÔ ¢È·‚ËÙÔÏÔÁÈÎfi ∫¤ÓÙÚÔ, ÙÔ ÔÔ›Ô ÂÈÛΤÙÔÓÙ·È ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘. O ·ÚÌfi‰ÈÔ˜ È·ÙÚfi˜ ÙÔ‡˜ ·Ú·¤ÌÂÈ Û ‚Ô‹ıÂÈ·, ·Ó ÎÚ›ÓÂÈ fiÙÈ Â›Ó·È ··Ú·›ÙËÙË ‹ ·Ó ÙË ˙ËÙ‹ÛÔ˘Ó. ∫·Ù¿ ÙËÓ ÚÒÙË Â·Ê‹, ˙ËÙ‹ıËΠ·fi ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙËÓ ¤Ú¢ӷ, Û˘˙ËÙ‹ıËÎÂ Ô ÙÚfiÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜ Ù˘ Î·È ÔÚ›ÛÙËÎÂ Ë ÚÒÙË ÂÚ¢ÓËÙÈ΋ Û˘Ó¿ÓÙËÛË. OÈ Û˘Ó·ÓÙ‹ÛÂȘ ¤Ï·‚·Ó ¯ÒÚ· ÛÙÔ Û›ÙÈ Ù˘ οı ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È ‰È‹ÚÎÂÛ·Ó ¤ˆ˜ fiÙÔ˘ ÂÈÙ¢¯ı› Ì›· Ï‹Ú˘ ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘. ∏ ̤ÛË ‰È¿ÚÎÂÈ· Ù˘ οıÂ Û˘Ó¿ÓÙËÛ˘ ‹Ù·Ó 2 ÒÚ˜. O ̤ÛÔ˜ ·ÚÈıÌfi˜ Û˘Ó·ÓÙ‹ÛÂˆÓ ÁÈ· ÙËÓ Î¿ı ÔÈÎÔÁ¤ÓÂÈ· ‹Ù·Ó 10 Î·È ÂÚÈÂÏ¿Ì‚·Ó·Ó ·ÙÔÌÈΤ˜ ‚‰ÔÌ·‰È·›Â˜ Û˘Ó‰ڛ˜ Ì ÙÔ Î¿ı ̤ÏÔ˜ ¯ˆÚÈÛÙ¿, Ì ÙÔ ˙¢Á¿ÚÈ Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ∞Ú¯Èο, Ô ÛÙfi¯Ô˜ ‹Ù·Ó Ó· ÂÈÙ¢¯ıÔ‡Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 Û˘Ó·ÓÙ‹ÛÂȘ Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, 2 Û˘Ó·ÓÙ‹ÛÂȘ Ì ÙÔ ˙‡ÁÔ˜ Î·È 2 Ì ÙÔ Î¿ı ̤ÏÔ˜ ¯ˆÚÈÛÙ¿. ∆Ș ÌÂÁ·Ï‡ÙÂÚ˜ ·ÓÙÈÚÚ‹ÛÂȘ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ¤ÊÂÚ·Ó ÔÈ ·Ù¤Ú˜, ηıÒ˜ 4 ·ÚÓ‹ıËÎ·Ó Ì¤¯ÚÈ Ù¤ÏÔ˘˜ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ (Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, ÔÈ ÂÎÙÈÌ‹ÛÂȘ ÁÈ· ÙÔ ÚfiÏÔ ÙÔ˘ ·Ù¤Ú· ‚·Û›ÛÙËÎ·Ó ÛÙË ‰È·ÛÙ·‡ÚˆÛË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ ÙˆÓ ¿ÏÏˆÓ ÌÂÏÒÓ) Î·È 15 ıÂÒÚËÛ·Ó fiÙÈ Ì›· ÚÒÙË Û˘Ó¿ÓÙËÛË ‹Ù·Ó ·ÚÎÂÙ‹. ∆ÂÏÈο, 14 ·fi ·˘ÙÔ‡˜ Û˘ÌÊÒÓËÛ·Ó Ó· Û˘Ó¯›ÛÔ˘Ó Ì¤¯ÚÈ Ù¤ÏÔ˘˜, ηٷÓÔÒÓÙ·˜ ÙË ÛËÌ·ÓÙÈÎfiÙËÙ· ÙÔ˘ ÚfiÏÔ˘ ÙÔ˘˜. O ۯ‰ȷÛÌfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‚·Û›ÛÙËΠ۠ÔÈÔÙÈΤ˜ ÌÂıfi‰Ô˘˜ „˘¯ÔÏÔÁÈ΋˜ ¤Ú¢ӷ˜. ∏ ÔÈÔÙÈ΋ ¤Ú¢ӷ ÂÈϤ¯ıËΠÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÂÈ Û·Ê‹˜ Ë ÔÏ˘ÏÔÎfiÙËÙ· ÙˆÓ Û¯¤ÛÂˆÓ ÁÔÓ¤ˆÓ-·È‰ÈÒÓ (14) Î·È Ó· ·Ó·‰˘ıÔ‡Ó ¤ÓÓÔȘ Î·È Û¯¤ÛÂȘ, ÔÈ Ôԛ˜ ı· ‰ÈÂÚ¢ÓÒÓÙ·Ó ÁÈ· ÚÒÙË ÊÔÚ¿ Û ÂÏÏËÓÈÎfi ‰Â›ÁÌ·. ¶·Ú¿‰ÂÈÁÌ· Ì›·˜ Ù¤ÙÔÈ·˜ Û¯¤Û˘ ·ÔÙÂÏ›
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¶·È‰È·ÙÚÈ΋ 2003;66:357-363
Ë ÁÔÓÈ΋ ÛÙ¿ÛË Î·È Û˘ÌÂÚÈÊÔÚ¿ ·¤Ó·ÓÙÈ ÛÙÔ ·È‰› Ô˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Úfi‚ÏËÌ· ˘Á›·˜. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰‡Ô ÔÈÔÙÈΤ˜ ̤ıÔ‰ÔÈ: ∞) ∏ ·Ú·Ù‹ÚËÛË ÛÙÔ Ê˘ÛÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ (ÔÈ˘), Ë ÔÔ›· ÂÈÙÚ¤ÂÈ ÙË Û‡ÏÏË„Ë Î·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ‰ÈÂÚÁ·ÛÈÒÓ Ô˘ ‰È¤Ô˘Ó ÙȘ Û¯¤ÛÂȘ ÙˆÓ ÌÂÏÒÓ, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Û˘ÌÌÂÙÔ¯‹˜ ÛÙËÓ ¤Ú¢ӷ Î·È ·È‰ÈÒÓ Ôχ Ó·ڋ˜ ËÏÈΛ·˜ (15), Ù· ÔÔ›· ‰ÂÓ Â›Ó·È Û ı¤ÛË Ó· ··ÓÙ‹ÛÔ˘Ó Ù· ›‰È· Û ÂÚˆÙËÌ·ÙÔÏfiÁÈ·. ∫·Ù¿ ÙËÓ ·Ú·Ù‹ÚËÛË, ‰ÈÂÚ¢ӋıËηÓ: ·) Ô ÙÚfiÔ˜ ·ÏÏËÏ›‰Ú·Û˘ ÙˆÓ ÌÂÏÒÓ (Û˘ÌÌ·¯›Â˜, Û˘ÁÎÚÔ‡ÛÂȘ, ·ÔÛÙ·ÛÈÔÔ›ËÛË, ‚·ıÌfi˜ ‰È·ÊÔÚÔÔ›ËÛ˘ ÙˆÓ Û¯¤ÛˆÓ, ÈÂÚ·Ú¯›·, ¤ÓÙ·ÛË), ‚) Ë Û¯¤ÛË ·ÏÏËÏ›‰Ú·Û˘ Î·È ÂÚȯÔ̤ÓÔ˘ ÙÔ˘ ÏfiÁÔ˘ Î·È Á) Ô ÙÚfiÔ˜ ·ÏÏËÏ›‰Ú·Û˘ Û ۯ¤ÛË Ì ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ¤ÎÊÚ·ÛË. µ) ∏ ÂȘ ‚¿ıÔ˜ Û˘Ó¤ÓÙ¢ÍË (in-depth interviewing), Ë ÔÔ›· ˆ˜ ·ÓÔȯً ËÌȉÔÌË̤ÓË Û˘Ó¤ÓÙ¢ÍË ·ÔÙÂÏ› ηٿÏÏËÏÔ Ì¤ÛÔ ÁÈ· ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ¤Ú¢ӷ Ù˘ π·ÙÚÈ΋˜ Ù˘ OÈÎÔÁ¤ÓÂÈ·˜ (16). ∫·Ù¿ ÙË ‰ÈÂÍ·ÁˆÁ‹ Î·È ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙˆÓ Û˘ÓÂÓÙ‡ÍÂˆÓ ÂÚ¢ӋıËηÓ: ·) ÔÈ ÛΤ„ÂȘ Î·È Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ ÌÂÏÒÓ, ηıÒ˜ Î·È Ô ÙÚfiÔ˜ Ô˘ ÔÚÁ·ÓÒÓÔ˘Ó ÛÂ Â›Â‰Ô ÛΤ„˘ fiÛ· ÙÔ˘˜ ÂÚÈ‚¿ÏÏÔ˘Ó, Ì ÛÙfi¯Ô ÙËÓ ·ÔÎ¿Ï˘„Ë ÎÚ˘ÊÒÓ ÓÔËÌ¿ÙˆÓ, ‚) Ë Û‡Ó‰ÂÛË ÓÔ‹Ì·ÙÔ˜ Î·È ·ÏÏËÏ›‰Ú·Û˘ ›Ù Ì ¿ÌÂÛË ÂÚÒÙËÛË ÁÈ· ÙÔ Ò˜ ÔÈ ›‰ÈÔÈ ‚Ï¤Ô˘Ó ÙË ÛÙ¿ÛË ÙÔ˘˜ Û ۯ¤ÛË Ì ÙËÓ ˘fi ÌÂϤÙË Û˘ÌÂÚÈÊÔÚ¿, ›Ù Ì ÙË Û˘Û¯¤ÙÈÛË Ù˘ ÛÙ¿Û˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ηٿ ÙËÓ ·Ó¿Ï˘ÛË Î·È Á) Ë ÂÚÌËÓ›· ÙÔ˘ ÓÔ‹Ì·ÙÔ˜ Û‡Ìʈӷ Ì ÙÔ ˘fi‰ÂÈÁÌ· Ù˘ “„˘¯Ôۈ̷ÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜” (7). OÈ Û˘ÓÂÓÙ‡ÍÂȘ Ì·ÁÓËÙÔʈӋıËηÓ, ηÙfiÈÓ ·‰Â›·˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ∆Ô ˘ÏÈÎfi ·Ó·Ï‡ıËΠÛÂ Û˘ÓÂÚÁ·Û›· Ì ÔÈÎÔÁÂÓÂȷ΋ ıÂڷ‡ÙÚÈ· ÁÈ· ÙËÓ ·‡ÍËÛË Ù˘ ·ÓÙÈÎÂÈÌÂÓÈÎfiÙËÙ·˜ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ¤·ÈÚÓ ÙË Û˘Ó¤ÓÙ¢ÍË. ∏ ·Ó¿Ï˘ÛË ÙÔ˘ ˘ÏÈÎÔ‡ ·fi ÙËÓ ÔÈÎÔÁÂÓÂȷ΋ ıÂڷ‡ÙÚÈ· ·Ó¤‰ÂÈÍ ÙÔ ÚfiÏÔ ÙÔ˘ ·ÙfiÌÔ˘ ·˘ÙÔ‡: ·fi ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ (26) ¤ÁÈÓ ‰ÂÎÙfi˜ ˆ˜ Ô “ÂȉÈÎfi˜” Ô˘ ı· ÌÔÚÔ‡Û ӷ ÙÔ˘˜ ηıÔ‰ËÁ‹ÛÂÈ ÛÙËÓ Â›Ï˘ÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘˜. OÈ ˘fiÏÔȘ ÔÈÎÔÁ¤ÓÂȘ ¤‰ˆÛ·Ó ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜ ı· ÌÔÚÔ‡Û·Ó Ó· ‚ÔËı‹ÛÔ˘Ó Î·È ¿ÏϘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› Ì ‰È·‚‹ÙË. ∞Ó Î·È ÛÙÔ Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·Ó·Ì¤ÓÂÙ·È fiÙÈ Ë ·ÚÔ˘Û›· ÂÓfi˜ ÙÚ›ÙÔ˘ ÚÔÛÒÔ˘ ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ Ù· ˘fi ·Ú·Ù‹ÚËÛË Ê·ÈÓfiÌÂÓ·, ÔÈ ¿ÓıÚˆÔÈ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÏÏ¿ÍÔ˘Ó ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘˜ Û ‚¿ıÔ˜ (17). ∏ Ì›ˆÛË ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ·ÏÏÔ›ˆÛ˘ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ ÂÈÙ‡¯ıËΠ·ÊÂÓfi˜ Ì ÙË ‰È·ÛÙ·‡ÚˆÛË ÙˆÓ ÛÙÔȯ›ˆÓ ̤ۈ Ù˘ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ ÏfiÁÔ˘ Î·È Ù˘ ·ÏÏËÏ›‰Ú·Û˘ Ô˘ ·Ú·ÙËÚ‹ıËÎÂ Î·È ·ÊÂÙ¤ÚÔ˘ Ì ÙËÓ ÂÚÌËÓ›· ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙËÓ ÔÈÎÔÁÂÓÂȷ΋ ıÂڷ‡ÙÚÈ·.
∞ÔÙÂϤÛÌ·Ù· ∆· ·ÔÙÂϤÛÌ·Ù· ‚·Û›ÛÙËÎ·Ó ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÔÈÓÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ fiÏˆÓ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Î·È Â›Ó·È Ù· ÂÍ‹˜: ·) OÈ Û¯¤ÛÂȘ ÙˆÓ ÌÂÏÒÓ ÌÂٷ͇ ÙÔ˘˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ¯·ÌËÏfi ‚·ıÌfi ‰È·ÊÔÚÔÔ›ËÛ˘ ÙˆÓ ·ÙfiÌˆÓ (enmeshed). OÈ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Á›ÓÔÓÙ·È
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·fi ÎÔÈÓÔ‡ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ È‰ÈˆÙÈÎfi˜ ¯ÒÚÔ˜ ÁÈ· ηӤӷ. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ÁÔÓ›˜ ϤÓÂ: “¢ÂÓ ¿ˆ ÔÙ¤ Î¿Ô˘ ÌfiÓË ÌÔ˘, Â›Ì·È fiÏË ÙËÓ Ë̤ڷ Ì·˙› ÙÔ˘” ‹ “ŸÔ˘ ¿ÌÂ, ı· ¿Ì fiÏÔÈ Ì·˙›”. ∂Ȃ‚·›ˆÛË ·˘ÙÔ‡ ÙÔ˘ Â˘Ú‹Ì·ÙÔ˜ ·ÔÙÂÏ› Ë Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÌÂÏÒÓ, ηıÒ˜ ˘‹ÚÍ ̛· Ù¿ÛË ·ÔÊ˘Á‹˜ ÙˆÓ ·ÙÔÌÈÎÒÓ Û˘Ó·ÓÙ‹ÛˆÓ, ·ÔηχÙÔÓÙ·˜ ÙË ‰˘ÛÎÔÏ›· ÙÔ˘˜ Ó· ηٷÓÔ‹ÛÔ˘Ó ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ ÚÔÛˆÈÎÔ‡ ¯ÒÚÔ˘ Î·È ¯ÚfiÓÔ˘. ∆· ·È‰È¿ ·ÚÂÓ¤‚·ÈÓ·Ó ÛÙȘ ·ÙÔÌÈΤ˜ Û˘Ó·ÓÙ‹ÛÂȘ Î·È ÙȘ Û˘Ó·ÓÙ‹ÛÂȘ ÙÔ˘ ˙‡ÁÔ˘˜, ÂÓÒ Û˘¯Ó¿ ·˘Ù¤˜ ‰È·ÎfiÙÔÓÙ·Ó ÚÔÎÂÈ̤ÓÔ˘ ÔÈ ÁÔÓ›˜ Ó· ‰È·ÛÊ·Ï›ÛÔ˘Ó fiÙÈ ÙÔ ·È‰› Ì ‰È·‚‹ÙË Â›Ó·È Î·Ï¿. O ¯·ÌËÏfi˜ ‚·ıÌfi˜ ‰È·ÊÔÚÔÔ›ËÛ˘ Â›Ó·È ÂÌÊ·Ó‹˜ Î·È ÛÙ· ÏfiÁÈ· ÙÔ˘˜, Ù· ÔÔ›· ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Ú‡ıÌÈÛË Ù˘ ·Ûı¤ÓÂÈ·˜ ·ÔÙÂÏ› ÛËÌÂ›Ô Î·ıÔÚÈÛÙÈÎfi Ù˘ ηıËÌÂÚÈÓfiÙËÙ·˜ ÁÔÓ¤ˆÓ Î·È ·È‰ÈÔ‡. OÈ ÁÔÓ›˜, ·Ó Î·È ·Ó·Ê¤ÚÔÓÙ·Ó ÛÙÔ ÙÈ ¤Î·Ó ÙÔ ·È‰›, ¤ÏÂÁ·Ó: “º¿Á·Ì ÙÔ Ê·ÁËÙfi Ì·˜… ∫¿Ó·Ì ÙË Ì¤ÙÚËÛ‹ Ì·˜… ¢ÂÓ ‚Á·›ÓÔ˘Ì fiÙ·Ó Â›Ó·È Ë ÒÚ· ÁÈ· ÙË Ì¤ÙÚËÛ‹ Ì·˜… O ÁÈ·ÙÚfi˜ Ì¿˜ ‚ڋΠϛÁÔ ·Ó‚·Ṳ̂ÓÔ˘˜”. ‚) O ¯·ÌËÏfi˜ ‚·ıÌfi˜ ‰È·ÊÔÚÔÔ›ËÛ˘ ÛÙȘ Û¯¤ÛÂȘ Ô‰ËÁ› ÛÙËÓ ·Ô˘Û›· ÔÚ›ˆÓ ·Ó¿ÌÂÛ· ÛÙ· ˘ÔÛ˘ÛÙ‹Ì·Ù· ÁÔÓ¤ˆÓ Î·È ·È‰ÈÒÓ. ∏ ÈÂÚ·Ú¯›· (ÁÔÓ›˜-·È‰È¿) ηٷÛÙÚ·ÙËÁ›ٷÈ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ô‰˘Ó¿ÌˆÛË Ù˘ ·˘ıÂÓÙ›·˜ Ô˘ ·ÔÓ¤Ô˘Ó ÔÈ ÁÔÓÈΤ˜ ÌÔÚʤ˜, Ë ÔÔ›· ¤¯ÂÈ ˆ˜ ·ÎfiÏÔ˘ıÔ ÙË ‰ËÌÈÔ˘ÚÁ›· Û˘Ó·ÈÛıËÌ¿ÙˆÓ ¿Á¯Ô˘˜, ·Ó·ÛÊ¿ÏÂÈ·˜ Î·È ı˘ÌÔ‡ ÛÙÔ Û˘Ìو̷ÙÈÎfi ·È‰›. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ÁÔÓ›˜ ϤÓÂ: “∂‰Ò ̤۷ ÎÔ˘Ì¿ÓÙÔ Î¿ÓÂÈ Ô ‰È·‚‹Ù˘. ∂Ì›˜ οÓÔ˘Ì fi,ÙÈ ı¤ÏÂÈ ·˘Ùfi˜. ∞ÎÔÏÔ˘ıԇ̠fiÏÔÈ ÙÔ ÚfiÁÚ·ÌÌ· ÙÔ˘ ‰È·‚‹ÙË… ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ Î·ÓfiÓ˜. ¶Ò˜ Ó· ‚¿ÏÂȘ fiÚÈ· ÛÙÔ ·È‰›, Ò˜ Ó· ÙÔ˘ ÂȘ ÙÈ Ó· οÓÂÈ fiÙ·Ó Â›Ó·È ¤ÙÛÈ ÎÈ ·ÏÏÈÒ˜ ÙfiÛÔ Ôχ ÂÚÈÔÚÈṲ̂ÓÔ… ÊÔ‚¿Ì·È fiÙÈ ı· ¿ıÂÈ Î¿ÙÈ ·fi ÙÔÓ ÙfiÛÔ ÂÚÈÔÚÈÛÌfi” ‹ “¢ÂÓ ÌÔÚԇ̠ӷ ÙÔ˘ ԇ̠ٛÔÙ·, ÁÈ·Ù› Á›ÓÔÓÙ·È ¯ÂÈÚfiÙÂÚ· Ù· Ú¿ÁÌ·Ù·... ÛÙÂÓÔ¯ˆÚÈ¤Ù·È Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ¯ÂÈÚfiÙÂÚ·”. Á) ∏ ·Ô˘Û›· ÔÚ›ˆÓ (·ÔÛÙ¿ÛˆÓ) ·Ó¿ÌÂÛ· ÛÙ· ˘ÔÛ˘ÛÙ‹Ì·Ù· (ÁÔÓ¤ˆÓ-·ÛıÂÓÔ‡˜) Á›ÓÂÙ·È ÈÔ ÂÌÊ·Ó‹˜ ̤۷ ·fi ÙËÓ ·ÚÔ˘Û›· Ù˘ ÎÚ˘Ê‹˜ “Û˘ÌÌ·¯›·˜” (coalition) Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ·Ó¿ÌÂÛ· ÛÙÔ ·È‰› Î·È ÙË ÌËÙ¤Ú·. OÈ ÁÔÓ›˜ ‰ÂÓ ·ÔÙÂÏÔ‡Ó - Û‡Ìʈӷ Ì ÙÔ ‰ÔÌÈÎfi ˘fi‰ÂÈÁÌ· ÔÌ·Ï‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (6) - ¤Ó· ͯˆÚÈÛÙfi ˘ÔÛ‡ÛÙËÌ· Ô˘ ¤¯ÂÈ ÙÔ ÚfiÏÔ ÙÔ˘ ηıÔ‰ËÁËÙ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∞ÓÙ›ıÂÙ·, ‰ËÌÈÔ˘ÚÁÂ›Ù·È ¤Ó· Ó¤Ô ˘ÔÛ‡ÛÙËÌ· Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ÙÔÓ ·ÛıÂÓ‹ Î·È ÙË ÌËÙ¤Ú· ÙÔ˘. ∏ ÌËÙ¤Ú·, ηٿ ·ÚÈÔ ÏfiÁÔ, ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ÁÔÓÈÎfi Ù˘ ÚfiÏÔ: “∆Ô ÌfiÓÔ Ô˘ Ì ··Û¯ÔÏ› Â›Ó·È ÙÈ ı· οӈ Ì ÙÔ ·È‰› ÌÔ˘”, “∂Ì›˜ È· ‰ÂÓ ¤¯Ô˘Ì ¿ÏÏË ˙ˆ‹”. ∏ “Û˘ÌÌ·¯›·” ·˘Ù‹ ÂÓÈÛ¯‡ÂÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÌËÙ¤Ú· Â›Ó·È ÂΛÓË Ô˘ ÊÚÔÓÙ›˙ÂÈ ÙÔ ·È‰› Ì ‰È·‚‹ÙË Î·È ‚Ú›ÛÎÂÙ·È Û˘Ó¯Ҙ
¶·È‰È·ÙÚÈ΋ 2003;66:357-363
ÎÔÓÙ¿ ÙÔ˘, Û˘Óԉ‡ÔÓÙ¿˜ ÙÔ Û fiϘ ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜. ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ, Ë ÌËÙ¤Ú· ÂÚÓ¿ÂÈ ÙË Ó‡¯Ù· ‹ ÙÌ‹Ì· ·˘Ù‹˜ Ì ÙÔÓ ·ÛıÂÓ‹, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÛÊ·Ï›ÛÂÈ fiÙÈ “fiÏ· ı· ¿Ó ηϿ”. ∏ Ú·ÎÙÈ΋ ·˘Ù‹ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚÔÛÎfiÏÏËÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙË ÌËÙ¤Ú· ÙÔ˘. ‰) ∏ ·ÙÚÈ΋ Û˘ÌÌÂÙÔ¯‹ Î·È ÂÌÏÔ΋ Û ˙ËÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ·È‰› Ì ‰È·‚‹ÙË ·Ô˘ÛÈ¿˙ÂÈ. OÈ ·Ù¤Ú˜ ·ÔʇÁÔ˘Ó ÙËÓ ÂÌÏÔ΋ ÙÔ˘˜ ÛÙË Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘ ‹ ÙËÓ Ú·ÎÙÈ΋ Ù˘ ̤ÙÚËÛ˘ Î·È Ù˘ ¤ÓÂÛ˘, ηıÒ˜ ‰ÂÓ ·ÈÛı¿ÓÔÓÙ·È fiÙÈ ÌÔÚÔ‡Ó Ó· ÙÔ Î¿ÓÔ˘Ó: “∏ Á˘Ó·›Î· ÌÔ˘ ͤÚÂÈ Î·Ï‡ÙÂÚ·. ∂ÁÒ ‰ÂÓ ÓÔÌ›˙ˆ fiÙÈ ÌÔÚÒ”, “∏ Á˘Ó·›Î· ÌÔ˘ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Ì·˙› ÙÔ˘, ÔfiÙ ·˘Ù‹ ͤÚÂÈ Î·Ï‡ÙÂÚ·”, “∞fi ÙËÓ ·Ú¯‹ ÙÔ ÍÂÎÈÓ‹Û·Ì ¤ÙÛÈ Î·È ÙÒÚ· ı¤ÏÂÈ ÌfiÓÔ ÙË ÌËÙ¤Ú· ÙÔ˘”. ∞Ó Î·È ÔÈ ‰‡Ô ÁÔÓ›˜ ‚ÈÒÓÔ˘Ó ÙËÓ ¤ÓÂÛË Î·È ÙË Ì¤ÙÚËÛË ˆ˜ Ôχ ÂÒ‰˘Ó˜ ‰È·‰Èηۛ˜, Ô ·Ù¤Ú·˜ ·‰˘Ó·Ù› Ó· ÂÌϷΛ Û ·˘Ù‹ ÙË ‰È·‰Èηۛ·: “¢ÂÓ ·ÓÙ¤¯ˆ Ó· ÙÚ˘¿ˆ ÙÔ ·È‰› ÌÔ˘” ‹ “∂ÁÒ ‰ÂÓ ·ÓÙ¤¯ˆ Ó· ÙÔ Î¿Óˆ ÛÙÔÓ Â·˘Ùfi ÌÔ˘, Ò˜ Ó· ÙÔ Î¿Óˆ ÛÙÔ ·È‰› ÌÔ˘;”. ∏ ¤ÏÏÂÈ„Ë Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ·Ù¤Ú· ·Ó·Ê¤ÚÂÙ·È ·fi fiÏ· Ù· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Á›ÓÂÙ·È ·ÓÙÈÏËÙ‹ ˆ˜ Ì›· ·ÔÛÙ·ÛÈÔÔ›ËÛ‹ ÙÔ˘: “O Ì·Ì¿˜ fiÏÔ Ï›ÂÈ”, “∂, ‰ÂÓ Î¿ÓÂÈ Î·È Ù›ÔÙ· Ó· ‚ÔËı‹ÛÂÈ”, “∫·È fiÙ·Ó Â›Ó·È Â‰Ò, Â›Ó·È ÛÙÔ ÁÚ·ÊÂ›Ô ÙÔ˘”. ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ Ë Î·ıËÌÂÚÈÓfiÙËÙ· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜, Ë ÌË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·Ù¤Ú· Á›ÓÂÙ·È ·ÓÙÈÏËÙ‹ ˆ˜ ·Ô˘Û›· Î·È ·fi ÙËÓ ›‰È· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ∞ÓÙ›ıÂÙ·, fiÛÔ ÈÔ Ôχ ÂÌϤÎÂÙ·È Ô ·Ù¤Ú·˜ ÛÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, ΢ڛˆ˜ ÛÙÔ ı¤Ì· Ù˘ ‰È·ÙÚÔÊ‹˜ Î·È Ù˘ Ù‹ÚËÛ˘ ÙÔ˘ ˆÚ·Ú›Ô˘ (4 ÂÚÈÙÒÛÂȘ), ÙfiÛÔ ÈÔ Ôχ ‚ÈÒÓÂÙ·È ·fi Ù· ̤ÏË ˆ˜ ·ÚÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. Â) ¶·Ú·ÙËÚÂ›Ù·È ¤ÓÙÔÓË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÂÌÏÔ΋ ÙˆÓ ÌÂÏÒÓ, Ë ÔÔ›· ÂÎÊÚ¿˙ÂÙ·È Ì¤Û· ·fi Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ‰È·Î˘Ì¿ÓÛÂȘ, ·ÓÙ›ÛÙÔȯ˜ ÙˆÓ ‰È·Î˘Ì¿ÓÛÂˆÓ Ù˘ ÁÏ˘Îfi˙˘. °È· ·Ú¿‰ÂÈÁÌ·, ϤÓÂ: “∆ÚÂÏ·›ÓÔÌ·È fiÙ·Ó Ù· Ú¿ÁÌ·Ù· ‰ÂÓ ¿Ó ηϿ” ‹ “¶Â˜ Ì·˜, ·È‰› ÌÔ˘, fiÛÔ ¤¯ÂȘ Ó· ËÚÂÌ‹ÛÔ˘Ì”. ÛÙ) ∏ ¤ÓÙÔÓË ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÁÔÓ¤ˆÓ ·¤Ó·ÓÙÈ ÛÙÔÓ ·ÛıÂÓ‹ Ô‰ËÁ› Ù· ·È‰È¿ Î·È ÙÔ˘˜ ›‰ÈÔ˘˜ Û ¯·ÌËÏfi ‚·ıÌfi ·˘ÙÔÓÔÌ›·˜, ·Î·Ì„›· ÛÙË Û˘ÌÂÚÈÊÔÚ¿ Î·È ·ÚÂÌfi‰ÈÛË Ù˘ ·Ó·Ù˘Íȷ΋˜ ÔÚ›·˜ ÙÔ˘ ·È‰ÈÔ‡. OÈ ÁÔÓ›˜ Î·È Î˘Ú›ˆ˜ Ë ÌËÙ¤Ú·, ¤¯ÔÓÙ·˜ ÙËÓ Ï‹ÚË Â˘ı‡ÓË ÙfiÛÔ ÁÈ· ÙË Ú‡ıÌÈÛË fiÛÔ Î·È ÁÈ· ÙË Û˘ÓÔÏÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ Î·È ·ÛÎÒÓÙ·˜ Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ¤ÏÂÁ¯Ô, ·ÚÂÌÔ‰›˙Ô˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÚˆÙÔ‚Ô˘ÏÈÒÓ ÙÔ˘ Î·È Ù˘ ÁÂÓÈÎfiÙÂÚ˘ ·˘ÙÔÓfiÌËÛ‹˜ ÙÔ˘. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ÌËÙ¤Ú˜ ·Ó·Ê¤ÚÔ˘Ó: “∆ÒÚ· Ù· Ú¿ÁÌ·Ù· Â›Ó·È ˘fi ¤ÏÂÁ¯Ô. ∆È ı· Á›ÓÂÈ fï˜ ÛÙËÓ ÂÊ˂›·;”, “ªÂ ·ÓÈÎÔ‚¿ÏÂÈ Ë È‰¤· fiÙÈ
Paediatriki 2003;66:357-363
ı· ¿ÂÈ Û¯ÔÏ›Ԕ, “…Î·È ÛÙÔ ÊÚÔÓÙÈÛÙ‹ÚÈÔ ÙËÓ ÂÚÈ̤ӈ Ó· ÙÂÏÂÈÒÛÂÈ, Ì‹ˆ˜ Î·È Û˘Ì‚Â› οÙÈ”. ˙) ∆Ô ·È‰› Ì ‰È·‚‹ÙË Ê·›ÓÂÙ·È Ó· ÏÂÈÙÔ˘ÚÁ› ˆ˜ “‰È·ÌÂÛÔÏ·‚ËÙ‹˜” ÛÙȘ Û¯¤ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ. ∞˘Ùfi Á›ÓÂÙ·È Ì ‰‡Ô ÙÚfiÔ˘˜: i) ∏ Û˘ÌÌ·¯›· ÌËÙ¤Ú·˜-·ÛıÂÓÔ‡˜ ÂÎÙÔ›˙ÂÈ ÙÔÓ ·Ù¤Ú·, Ô ÔÔ›Ô˜ ·Ô‰¤¯ÂÙ·È ·˘Ù‹ ÙËÓ ·fiÛÙ·ÛË, ηıÒ˜ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÂÂͤÏıÂÈ ÛÙÔ ‚¿ÚÔ˜ Ù˘ ¢ı‡Ó˘ Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘. °È· ·Ú¿‰ÂÈÁÌ·, ϤÓÂ: “O Ì·Ì¿˜ fiÏÔ Ï›ÂÈ” ‹ “¢ÂÓ Î¿ÓÂÈ Î·È Ù›ÔÙ· ÁÈ· Ó· ‚ÔËı‹ÛÂÈ”. ii) ∏ Û˘˙˘ÁÈ΋ Û‡ÁÎÚÔ˘ÛË ÌÂÙ·ÙÚ¤ÂÙ·È Û ÁÔÓÈ΋ Î·È ÂÎÊÚ¿˙ÂÙ·È Ì¤Û· ·fi ÙȘ ‰È·ÊˆÓ›Â˜ ÁÈ· ÙËÓ ·Ó·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ Ì ‰È·‚‹ÙË. ™˘Ó‹ıÂȘ ‰È·ÊˆÓ›Â˜ ›ӷÈ: “¢ÂÓ ÙÔÓ ÚfiÛÂ͘ Î·È ·Ó¤‚ËΔ ‹ “¢ÂÓ ÙËÓ ·Ê‹ÓÂȘ Î·È Ï›ÁÔ ÌfiÓË Ù˘”. Ë) ∏ ÁÔÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÓÙÔÓË ‰È·ÊˆÓ›·, ηıÒ˜ fiÙ·Ó Ô ¤Ó·˜ ÁÔÓ¤·˜ Ù· ÂÈÙÚ¤ÂÈ fiÏ· ÛÙÔ ·È‰› Ì ‰È·‚‹ÙË, Ô ¿ÏÏÔ˜ Á›ÓÂÙ·È ·˘ÛÙËÚfi˜ Î·È ·ÓÙ›ÛÙÚÔÊ·. ∏ ‰È·ÊˆÓ›· ÂÓÈÛ¯‡ÂÙ·È ·fi ÙÔ Êfi‚Ô ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÂÌÊ¿ÓÈÛË ˘ÔÁÏ˘Î·ÈÌÈÎÒÓ ÎÚ›ÛˆÓ, Ô ÔÔ›Ô˜ Â›Ó·È ·fi ÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ Êfi‚Ô˘˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó. ı) ∆Ô ÌË Û˘Ìو̷ÙÈÎfi ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ Î·È Î·Ù’ ÂÓÙÔÏ‹ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘, ·Ó·Ï·Ì‚¿ÓÂÈ ÁÔÓÈÎfi ÚfiÏÔ ·¤Ó·ÓÙÈ ÛÙÔ ·È‰› Ì ‰È·‚‹ÙË. OÈ ÁÔÓ›˜ Û˘Ó‹ıˆ˜ ϤÓÂ: “º¤Ú ÙÔ˘ ÓÂÚfi”, “∂Û‡ ı· Ú¤ÂÈ Ó· ÙËÓ ÚÔÛ¤¯ÂȘ”, “∆Ô ÌˆÚfi Ú¤ÂÈ Ó· Â›Ó·È ‹Û˘¯Ô ÁÈ· Ó· ÌÔÚÒ Ó· ·Û¯ÔÏÔ‡Ì·È Ì ÙËÓ ¿ÏÏË”. ∆Ô ·È‰› ˘ÈÔıÂÙ› ·˘Ùfi ÙÔ ÚfiÏÔ, Ì ÛÙfi¯Ô Ó· ‚ÔËı‹ÛÂÈ ÙË ÌËÙ¤Ú·, ÙËÓ ÔÔ›· ·ÓÙÈÏ·Ì‚¿ÓÂÙ·È ˆ˜ ÂΛÓË Ô˘ ÂÈ‚·Ú‡ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi fiÏÔ˘˜. °È· ·Ú¿‰ÂÈÁÌ·, ·Ó·Ê¤ÚÔ˘Ó: “∏ Ì·Ì¿ ÎÔ˘Ú¿˙ÂÙ·È ¿Ú· Ôχ Î·È Ú¤ÂÈ Ó· ÙË ‚ÔËı¿Ì”, “∏ ηË̤ÓË Ë Ì·Ì¿ Â›Ó·È Ôχ ÎÔ˘Ú·Ṳ̂ÓË Î·È Ù· οÓÂÈ fiÏ· ÌfiÓË Ù˘”. ø˜ ÂÎ ÙÔ‡ÙÔ˘ Î·È ·˘Ùfi ÙÔ ·È‰› Ï·Ì‚¿ÓÂÈ ·fiÛÙ·ÛË ·fi ÙÔÓ ·Ù¤Ú· Î·È ÛÙÚ¤ÊÂÙ·È ÚÔ˜ ÙË Û˘ÌÌ·¯›· ÌËÙ¤Ú·˜-·ÛıÂÓÔ‡˜. È) ∆Ô ÌË Û˘Ìو̷ÙÈÎfi ·È‰› ·Ú·ÌÂÏÂ›Ù·È Î·È ÂÈÛÚ¿ÙÙÂÈ ·˘Ù‹ ÙËÓ ·Ú·Ì¤ÏËÛË ˆ˜ ·fiÚÚÈ„Ë. ∞ÓÙÈÚÔÛˆÂ˘ÙÈο Â›Ó·È Ù· ·Ú·Î¿Ùˆ ÏfiÁÈ·: “ŸÏÔ ·˘Ù‹ ÚÔÛ¤¯ÂÙ”, “∂̤ӷ ‰ÂÓ ÌÔ˘ ‰›ÓÂÈ Î·Ó›˜ ÛËÌ·Û›·”. ™˘˙‹ÙËÛË ªÂÁ¿ÏÔ Ì¤ÚÔ˜ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ¤Ú¢ӷ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Û ·˘Ù¿ Ù˘ “„˘¯Ôۈ̷ÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜”, fiˆ˜ ·Ó·Ï‡ıËÎ·Ó ·fi ÙÔ˘˜ Minuchin Î·È Û˘Ó (7). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÈ Êfi‚ÔÈ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ˘ÔÁÏ˘Î·ÈÌÈÎÒÓ ÎÚ›ÛÂˆÓ Î·È ÂÈÏÔÎÒÓ ˘¿Ú¯Ô˘Ó ÁÈ· ¤Ó· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÚ›Ô˘ 4 ÂÙÒÓ Î·È Ô‰ËÁÔ‡Ó ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ¤Ú¢ӷ ÛÂ
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Û˘ÁÎÂÎÚÈ̤ÓÔ˘ Ù‡Ô˘ ‰ÔÌ‹ Î·È ÔÚÁ¿ÓˆÛË. ∞Ó·Ù‡ÛÛÂÙ·È Ë Û˘ÌÌ·¯›· ÌËÙ¤Ú·˜-·ÛıÂÓÔ‡˜, Ë ÔÔ›· fiˆ˜ ‰Â›¯ÓÔ˘Ó Î·È ¿ÏϘ ÌÂϤÙ˜ (18,19) ÂÓÈÛ¯‡ÂÙ·È ·fi ÙËÓ ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Ù˘ ÌËÙ¤Ú·˜ ·¤Ó·ÓÙÈ ÛÙÔÓ ·ÛıÂÓ‹ Î·È ÙÔ ‰È·Ú΋ ¤ÏÂÁ¯Ô Ù˘ ˙ˆ‹˜ ÙÔ˘. À¿Ú¯ÂÈ ‰Â Ô Î›Ó‰˘ÓÔ˜ Ó· ·Ú·Ì›ÓÂÈ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ¿ÓÙ· ÂÍ·ÚÙË̤ÓÔ˜ Î·È Ó· ÌËÓ ÌÔÚ¤ÛÂÈ Ó· ·Ó·Ï¿‚ÂÈ Ì ¿ÚÎÂÈ· ÙËÓ Â˘ı‡ÓË ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘ ÙÔ˘ ÛÙÔ Ì¤ÏÏÔÓ (20). ∏ ‰È·Ù‹ÚËÛË Ù˘ Û˘ÌÌ·¯›·˜ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙËÓ ¤ÏÏÂÈ„Ë Ù˘ ·ÙÚÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ ÛÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, Ë ÔÔ›· ˆ˜ ‰È·ÔÏÈÙÈÛÌÈÎfi ÛÙÔÈ¯Â›Ô (21) ¯·Ú·ÎÙËÚ›˙ÂÈ ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› Ì ÊÙˆ¯fi ÌÂÙ·‚ÔÏÈÎfi ¤ÏÂÁ¯Ô. ™Â ·ÓÙ›ıÂÛË Ì ¿ÏÏË ÌÂϤÙË fiÔ˘ Ë ·ÙÚÈ΋ “·Ô˘Û›·” ·ÔÙÂÏ› ¤ÎÊÚ·ÛË Ù˘ Û˘˙˘ÁÈ΋˜ ‰˘ÛÊÔÚ›·˜ (22), ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ Â›Ó·È Û·Ê‹˜ Ë ·ÈÙÈÔÏÔÁ›· Ù˘. ∏ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÂÌÏÔ΋ ÙˆÓ ÁÔÓ¤ˆÓ ‰È·ÙËÚÂ›Ù·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂΛÓÔÈ ¤¯Ô˘Ó ÙËÓ Â˘ı‡ÓË ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÔÙÂÏ› ÁÈ· ÂΛÓÔ˘˜ ηıÔÚÈÛÙÈÎfi ÛËÌÂ›Ô Ù˘ ÔÚÁ¿ÓˆÛ˘ Ù˘ ηıËÌÂÚÈÓfiÙËÙ·˜. O ·ÏËıÈÓfi˜ ·ÛıÂÓ‹˜ Â›Ó·È Ô ÁÔÓ¤·˜ (3). ∆fiÛÔ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË fiÛÔ Î·È Û ¿ÏÏË (23), Â›Ó·È Û·Ê¤˜ fiÙÈ Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ ÁÔÓ¤ˆÓ Â›Ó·È ·ÓÙ›ÛÙÔȯ· ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ Ù˘ ÁÏ˘Îfi˙˘: ¿Á¯Ô˜ Î·È ÂÓÔ¯¤˜. OÈ ÁÔÓ›˜ ·Ì‡ÓÔÓÙ·È Û ·˘Ùfi ÙÔ ¿Á¯Ô˜ Ì ÙË Û˘Ó¯‹ ¯ÚfiÓÈ· ÂÁÚ‹ÁÔÚÛË, ·Ó Î·È ¿ÏÏË ÌÂϤÙË (24) ‰Â›¯ÓÂÈ fiÙÈ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙË ÌËÙÚÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, Ì ÙËÓ ˘ÂÚÚÔÛÙ·Û›· ·¤Ó·ÓÙÈ ÛÙÔ ·È‰› Ì ‰È·‚‹ÙË, ÙËÓ ·Ó¿ıÂÛË ÁÔÓÈÎÔ‡ ÚfiÏÔ˘ ÛÙÔ ÌË Û˘Ìو̷ÙÈÎfi ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Ì ÙË ‰È·ÊˆÓ›· ÌÂٷ͇ ÙÔ˘˜ Û¯ÂÙÈο Ì ÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙfiÛÔ ÙÔ˘ ·È‰ÈÔ‡ fiÛÔ Î·È Ù˘ ›‰È·˜ Ù˘ ·Ûı¤ÓÂÈ·˜. ª¿ÏÈÛÙ·, Ë ‰È·ÊˆÓ›· ÙˆÓ ÁÔÓ¤ˆÓ Ê·›ÓÂÙ·È Ó· ·ÔÙÂÏ› ¿ÁÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ·È‰› Ì ¯ÚfiÓÈÔ ÓfiÛËÌ· (25). OÈ Î›Ó‰˘ÓÔÈ Ô˘ ÂÏÏÔ¯Â‡Ô˘Ó ·fi ·˘Ù‹ ÙËÓ ÔÚÁ¿ÓˆÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È Ë ·ÚÂÌfi‰ÈÛË ·ÊÂÓfi˜ Ù˘ ·Ó¿Ù˘Í˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È ·ÊÂÙ¤ÚÔ˘ Ù˘ „˘¯ÔÛ˘Ó·ÈÛıËÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó‹ÎÔ˘Ó Û ·˘Ù‹, ηıÒ˜ ÙÔ ¤Ó· ·Ó·Ï·Ì‚¿ÓÂÈ ÂÚÈÛÛfiÙÂÚ˜ ¢ı‡Ó˜ ·fi ·˘Ù¤˜ Ô˘ ÙÔ˘ ·ÓÙÈÛÙÔȯԇÓ, ÂÓÒ ÙÔ ¿ÏÏÔ ÏÈÁfiÙÂÚ˜. ∆· ·Ú·¿Óˆ ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË, Ô‰ËÁÔ‡Ó Û ̛· Ù˘ÔÏÔÁ›· Ù˘ ÂÏÏËÓÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ·È‰› Ì ‰È·‚‹ÙË Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰˘ÛÎÔϛ˜ ÛÙÔÓ ÌÂÙ·‚ÔÏÈÎfi ÙÔ˘ ¤ÏÂÁ¯Ô. ∏ ·Û¿ÊÂÈ· ˆ˜ ÚÔ˜ ÙÔ˘˜ ÚfiÏÔ˘˜ Î·È ÙÔ˘˜ ηÓfiÓ˜ ˘ÔÛÙËÚ›˙ÂÙ·È Î·È ·fi ¿ÏÏË ¤Ú¢ӷ (26). ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ ‰˘Ó·ÌÈ΋ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ÂÍ·ÈÙ›·˜ ·˘Ù‹˜ Ù˘ ·Û¿ÊÂÈ·˜ Âȉڿ Ì ÙË ÌÔÚÊ‹ ÙÔ˘ ¯ÚfiÓÈÔ˘ ÛÙÚ˜ Î·È Û˘Ó‰¤ÂÙ·È Ì ÙË Û˘¯Ó‹ ÂÌÊ¿ÓÈÛË ÎÚ›ÛÂˆÓ ÎÂÙÔͤˆÛ˘ (27).
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∏ ÁÂӛ΢ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘Ó·ÓÙ¿ ˆ˜ ÂÌfi‰È· ÙfiÛÔ ÙÔ ÌÈÎÚfi ·ÚÈıÌfi ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ fiÛÔ Î·È ÙÔ ÌÂıÔ‰ÔÏÔÁÈÎfi ۯ‰ȷÛÌfi (ÔÈÔÙÈ΋ ÌÂϤÙË). øÛÙfiÛÔ, ·ÔÙÂÏ› ¤Ó· ÂÊ·ÏÙ‹ÚÈÔ ÁÈ· ÙËÓ „˘¯ÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ì ·È‰› Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ·Ó·Ú΋ ÌÂÙ·‚ÔÏÈÎfi ¤ÏÂÁ¯Ô, ÛÙÚ¤ÊÔÓÙ·˜ ÙËÓ ÚÔÛÔ¯‹ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ˙‡ÁÔ˘˜, ÛÙË ÁÔÓÈÎfiÙËÙ·, ÛÙÔÓ ÚfiÏÔ ÙˆÓ ¿ÏÏˆÓ ÌÂÏÒÓ (·‰¤ÚÊÈ·), ÛÙËÓ ·ÚÔ˘Û›· ‰ÈÎÙ‡ˆÓ ÛÙ‹ÚÈ͢ Î·È ÛÙËÓ ·Ó¿ÏË„Ë Ù˘ ¢ı‡Ó˘ ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜, Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÏËÚÔÊÔÚ› Ì ۷ʋÓÂÈ· ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙË ÓfiÛÔ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂȈı› ÙÔ ¿Á¯Ô˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∂›Û˘, Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÂÈ ·fi ÙËÓ ·Ú¯‹ ÙË Û˘ÓÂÚÁ·Û›· ÙˆÓ ÁÔÓ¤ˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ú‡ıÌÈÛ˘ Î·È Î·ÙfiÈÓ Ó· ÙÔ˘˜ ÚÔÙÚ¤ÂÈ Ó· ÙËÓ ·Ê‹ÛÔ˘Ó ÛÙ·‰È·Î¿ ÛÙÔ ›‰ÈÔ ÙÔ ·È‰›, ηıÒ˜ fiÏË Ë ÔÈÎÔÁ¤ÓÂÈ· ı· ·ӤگÂÙ·È ÛÙËÓ ÔÚ›· ·Ó¿Ù˘Í‹˜ Ù˘, ·ÓÙ·ÔÎÚÈÓfiÌÂÓË ÛÙȘ ·Ó¿ÁΘ fiÏˆÓ ÙˆÓ ÌÂÏÒÓ. ∂Ӊ›ÍÂȘ ÁÈ· ·Ú·ÔÌ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÛÙÔÓ ÂȉÈÎfi Ù˘ „˘¯È΋˜ ˘Á›·˜ ·ÔÙÂÏÔ‡Ó Ë ‰˘ÛÎÔÏ›· Ú‡ıÌÈÛ˘ Ù˘ ÓfiÛÔ˘ ¤Ú·Ó ÙÔ˘ ¤ÙÔ˘˜ Î·È Ë „˘¯È΋ ‰˘ÛÊÔÚ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÓfi˜ ̤ÏÔ˘˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ·ÊÔÚÌ‹ ÙËÓ ·ÚÔ˘Û›· Ù˘ ÓfiÛÔ˘. ª›· ÌÂÏÏÔÓÙÈ΋ Û˘ÁÎÚÈÙÈ΋ ¤Ú¢ӷ Ì ÙË Û˘ÌÌÂÙÔ¯‹ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ ¤¯Ô˘Ó ÚÔÛ·ÚÌÔÛÙ› ·ÚÎÒ˜ ÛÙËÓ Î·Ù¿ÛÙ·ÛË Ù˘ ÓfiÛÔ˘ Î·È ‰ÂÓ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÚÔ‚Ï‹Ì·Ù· Ì ÙÔ ÌÂÙ·‚ÔÏÈÎfi ¤ÏÂÁ¯Ô, ÂӉ¯Ô̤ӈ˜ Ó· ÂÌÏÔ˘Ù›ÛÂÈ ÂÚÈÛÛfiÙÂÚÔ ÙfiÛÔ ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ÁÓÒÛË fiÛÔ Î·È ÙËÓ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋. ∂˘¯·ÚÈÛٛ˜ ∏ ÌÂϤÙË ·˘Ù‹ ÛÙËÚ›¯ÙËΠÔÈÎÔÓÔÌÈο ·fi ÙÔ ÿ‰Ú˘Ì· ∫Ú·ÙÈÎÒÓ ÀÔÙÚÔÊÈÒÓ. ∂˘¯·ÚÈÛٛ˜ ÚÔ˜ ÙÔÓ ∫·ıËÁËÙ‹ ÎÔÓ. Ã. ª·ÚÙÛfiη Î·È ÙËÓ È·ÙÚÈ΋ ÔÌ¿‰· ÙÔ˘ ¢È·‚ËÙÔÏÔÁÈÎÔ‡ ∫¤ÓÙÚÔ˘ ÙÔ˘ ¶.°.¡. “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” ÁÈ· ÙË ÛËÌ·ÓÙÈ΋ ÛÙ‹ÚÈÍË Î·È ‚Ô‹ıÂÈ¿ ÙÔ˘˜.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 24-03-2003 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫·ÏÏÈfiË ∫Ô˘ÓÂÓÔ‡ ¶·ÓÂÈÛÙ‹ÌÈÔ ¶ÂÈÚ·ÈÒ˜ ∫·Ú·ÔÏ‹ & ¢ËÌËÙÚ›Ô˘ 80, ∆.∫. 185 34, ¶ÂÈÚ·È¿˜ E-mail: kkounen@unipi.gr
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ORIGINAL ARTICLE
¶ÂÚÈÁÚ·ÊÈ΋ ÂȉËÌÈÔÏÔÁ›· ·Ù˘¯ËÌ¿ÙˆÓ Û ¿ÙÔÌ· οو ÙˆÓ 24 ÂÙÒÓ Û ÁˆÁÚ·ÊÈο ÔÚÈÔıÂÙË̤ÓË ËÌÈ·ÛÙÈ΋ ÂÚÈÔ¯‹ Ù˘ £ÂÛÛ·Ï›·˜ ∞. ∞Ó·ÛÙ·Û›Ô˘1,2, £. º·Ú̷ο΢1, ¡. ¢ÂÛ‡Ú˘1, ∫. ∫·ÙÛÈ·Ú‰¿Ó˘1, •. ∑·‚ÈÙÛ¿ÓÔ˜1
Descriptive epidemiology of accidents in people aged under 24 years in a semi-urban area of Thessaly A. Anastasiou1,2, T. Farmakakis1, N. Dessypris1, K. Katsiardanis1, X. Zavitsanos1
¶ÂÚ›ÏË„Ë: ∏ ·ÚÈ· ·ÈÙ›· ı·Ó¿ÙÔ˘ Û ¿ÙÔÌ· ËÏÈΛ·˜ οو ÙˆÓ 24 ÂÙÒÓ Â›Ó·È Ù· ·Ù˘¯‹Ì·Ù·, Ù· ÔÔ›· Û˘Ó‰¤ÔÓÙ·È ¿ÚÚËÎÙ· Ì ÙËÓ ·ÓıÚÒÈÓË Ê‡ÛË, ÙË Û˘ÌÂÚÈÊÔÚ¿ Î·È ÙÔ ÌÈÎÚÔ- Î·È Ì·ÎÚÔ-ÂÚÈ‚¿ÏÏÔÓ. ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë ÚÔÔÙÈ΋ ÂȉËÌÈÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ·, Û ËÌÈ·ÛÙÈÎfi ÏËı˘ÛÌfi Ù˘ £ÂÛÛ·Ï›·˜ οو ÙˆÓ 24 ÂÙÒÓ (1327 ¿ÙÔÌ·). ∏ ·ÔÙ‡ˆÛË Î·È Ë ÌÂϤÙË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤ÁÈÓ Ì ·Ï¤˜ ηٷÓÔ̤˜, ·ÏÏ¿ Î·È Ì ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ (Cluster analysis). ∞ÎÔÏÔ‡ıËÛ ۇÁÎÚÈÛË ÙˆÓ ·ÙfiÌˆÓ Ô˘ ¤¯Ô˘Ó ÂÌϷΛ Û ·Ù‡¯ËÌ· Ì ‰‡Ô ÛÂÈÚ¤˜ Ì·ÚÙ‡ÚˆÓ (·ÓÙ›ÛÙÔȯÔÈ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ·), ηٿ ÙËÓ ÔÔ›· Ù· ·Ù˘¯‹Ì·Ù· Û˘Û¯ÂÙ›ÛÙËÎ·Ó ÙfiÛÔ Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÚÒÙˆÓ fiÛÔ Î·È Ì ÂÚÈ‚·ÏÏÔÓÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο (Ê˘ÛÈο, ÎÔÈÓˆÓÈο, ÔÈÎÔÁÂÓÂȷο). OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ· ÌÂÏÂÙ‹ıËÎ·Ó Ì ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘, Û˘Ó¤‚ËÛ·Ó 306 ·Ù˘¯‹Ì·Ù· Û 247 ¿ÙÔÌ·, Ù· ÔÔ›· Û ÔÛÔÛÙfi 66% ·ÊÔÚÔ‡Û·Ó Û ·ÁfiÚÈ·. ∏ ÂÙ‹ÛÈ· ›وÛË ‹Ù·Ó 19 ·Ù˘¯‹Ì·Ù· ·Ó¿ 100 ¿ÙÔÌ· ÏËı˘ÛÌÔ‡, Ì ÎÔڇʈÛË ÛÙȘ ËÏÈ˘ 5-9 ÂÙÒÓ. ∏ ˘„ËÏfiÙÂÚË ÂÙ‹ÛÈ· ›وÛË ·Ú·ÙËÚ‹ıËΠÛÙȘ ËÏÈ˘ 10-14 ÂÙÒÓ ÛÙ· ·ÁfiÚÈ· (29%) Î·È 5-9 ÂÙÒÓ ÛÙ· ÎÔÚ›ÙÛÈ· (25%). ∆· ·Ù˘¯‹Ì·Ù· Û˘Ó¤‚ËÛ·Ó Î˘Ú›ˆ˜ ÛÙÔÓ ÂχıÂÚÔ ¯ÚfiÓÔ ÙÔ˘ ·ÙfiÌÔ˘ (57%), Û˘Ó‹ıˆ˜ ÛÙËÓ ÔÈΛ· ÙÔ˘ (22%), ·ÏÏ¿ Î·È ÛÙÔ Û¯ÔÏÂ›Ô (12%), ÛÙË ‰Ô˘ÏÂÈ¿ (4%) ‹ ‹Ù·Ó ÙÚÔ¯·›· (2%). ∏ ÚfiÎÏËÛË ÙÚ·‡Ì·ÙÔ˜ ‹Ù·Ó ÙÔ Û˘¯ÓfiÙÂÚÔ Â›‰Ô˜ ‚Ï¿‚˘ (63%), ÂÓÒ Ë Û˘ÓËı¤ÛÙÂÚË ÂÓÙfiÈÛË ‚Ï·‚ÒÓ ‹Ù·Ó ÛÙÔ ÎÂÊ¿ÏÈ (29%). ∆· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ÙÔ Î·ÏÔη›ÚÈ (33%), ÙËÓ Ë̤ڷ ¢Â˘Ù¤Ú· (17%), ÙȘ ·ÔÁÂ˘Ì·ÙÈÓ¤˜ ÒÚ˜ (30%) Î·È ÚÔÎÏ‹ıËÎ·Ó ˆ˜
1 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ∫¤ÓÙÚÔ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘ ¡ÔÌÔ‡ ª·ÁÓËÛ›·˜
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Abstract: Accidents, which comprise the main cause of death in persons aged under 24 years, are inseparably linked with human nature, behaviour, and the micro- and macro-environment. The aim of this study was a prospective epidemiological investigation of the risk factors for accidents in a semi-urban population under 24 years of age (1327 persons) in Thessaly. The recording and study of accidents was performed by means of simple distribution and using cluster analysis, followed by a comparison of the accident victims with two sets of controls (sex- and age-matched). Accidents were correlated with environmental features (physical, social, family) and with the accident victim’s own behaviour and the risk factors for accident estimated using multi-factorial analysis. During the study, 306 accidents occurred in 247 individuals, of whom 66% were males. The annual incidence was 19 accidents per 100 individuals of the population, peaking at ages 5-9 years. The highest annual incidence in boys was observed at the ages of 1014 (29%) and in girls at 5-9 years (25%). The accident occurred most frequently during the individual’s leisure time (57%), usually at home (22%) but also at school (12%) or at work (4%), or was a traffic accident (2%). The most common type of injury was direct trauma (63%) and the most frequent localization was the head (29%). Most accidents occurred during the summer (33%), on Monday (17%), in the afternoon (30%) and were caused by a fall (40%). The overall mortality was 0.75ò. The accident risk was reduced to a statistically significant degree with increase in the individual’s weight, when the person was not
1 Department of Hygiene and Epidemiology, University of Athens Medical School 2 Health Centre of Velestino, Magnesia
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
› ÙÔ Ï›ÛÙÔÓ ·fi ÙÒÛË (40%). ∏ ıÓËÛÈÌfiÙËÙ· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙÔ˘ ÏËı˘ÛÌÈ·ÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ·ÓÂÚ¯fiÙ·Ó Û ÔÛÔÛÙfi 0,75ò. O ΛӉ˘ÓÔ˜ ·Ù˘¯‹Ì·ÙÔ˜ ÌÂÈÒÓÂÙ·È, Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ›‰Ô, Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ·ÙfiÌÔ˘, Â¿Ó ‰ÂÓ ÂÚÁ¿˙ÂÙ·È Î·È fiÛÔ ·˘Í¿ÓÂÙ·È Ë ËÏÈΛ· ÙÔ˘ ·Ù¤Ú·. ™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ ÛËÌÂÈÒÓÂÙ·È fiÙ·Ó ÙÔ ¿ÙÔÌÔ ¿Û¯ÂÈ ·fi ÛÙÚ·‚ÈÛÌfi Î·È fiÙ·Ó ‰È·Ì¤ÓÂÈ Û ¢ڇ¯ˆÚÔ Û›ÙÈ. ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ·Ù‡¯ËÌ· Â›Ó·È Ù· ¿ÙÔÌ· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ÔÔ›ˆÓ ¤¯Ô˘Ó ÚÔËÁËı› ÂÚÈÛÛfiÙÂÚ· ·fi ‰‡Ô ·Ù˘¯‹Ì·Ù· ÛÙÔ ·ÚÂÏıfiÓ, ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ ÌÂÈÒÓÂÙ·È fiÛÔ ·Ó‚·›ÓÂÈ ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô ÙÔ˘ ·Ù¤Ú·. ∏ ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ ¤‰ÂÈÍ fiÙÈ: ·) Û ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ, ΢ڛˆ˜ ÎÔÚ›ÙÛÈ·, ΢ÚÈ·Ú¯Ô‡Ó ÔÈ ÙÒÛÂȘ Î·È Ù· ÂÁη‡Ì·Ù·, ̤۷ ÛÙÔ Û›ÙÈ, Ù· ™·‚‚·ÙÔ·Úȷη, ÔÈ ‰Â ηÎÒÛÂȘ ÂÓÙÔ›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÛÙÔÓ ÎÔÚÌfi, ‚) Ù· ·È‰È¿ ËÏÈΛ·˜ 5-9 ÂÙÒÓ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ηÏÔηÈÚÈÔ‡, ¤Íˆ ·fi ÙÔ Û›ÙÈ, ·fi ÎÔÊÙÂÚ¿ Î·È ·È¯ÌËÚ¿ ·ÓÙÈΛÌÂÓ· Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯Ó¿ ·ÓÔȯ٤˜ ηÎÒÛÂȘ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, Á) ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 10-14 ÂÙÒÓ, ·Ù˘¯‹Ì·Ù· ·Ú·ÙËÚÔ‡ÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÛÙ· ·ÁfiÚÈ·, Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È Î˘Ú›ˆ˜ ÎÏÂÈÛÙ¤˜ ηÎÒÛÂȘ Î·È Î·Ù¿ÁÌ·Ù· ¿Óˆ ¿ÎÚˆÓ, ¤Íˆ ·fi ÙÔ Û›ÙÈ, ÌÂÙ¿ ·fi ¯Ù‡ËÌ·, ÁÏ›ÛÙÚËÌ· ‹ Û‡ÁÎÚÔ˘ÛË ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜, ÙȘ ÂÚÁ¿ÛÈ̘ Ë̤Ú˜ ÙÔ˘ ÊıÈÓÔÒÚÔ˘ Î·È Ù˘ ¿ÓÔÈ͢ Î·È ‰) ÛÙÔ˘˜ Ó¤Ô˘˜ (15-24 ÂÙÒÓ), Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó Ù· ™·‚‚·ÙÔ·Úȷη ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ıÏËÛ˘, ÂÓÒ ÔÈ Î·ÎÒÛÂȘ ·ÊÔÚÔ‡Ó ÛÙ· οو ¿ÎÚ· Î·È ÔÊ›ÏÔÓÙ·È Û ÙÒÛÂȘ ÌÂÙ¿ ·fi ÎfiˆÛË ‹ ˘ÂÚÚÔÛ¿ıÂÈ·. ∏ ÂÙ‹ÛÈ· ›وÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ £ÂÛÛ·Ï›·˜ Â›Ó·È ˘„ËÏ‹. ∂˘Ù˘¯Ò˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Â›Ó·È ÌÈÎÚ‹˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ Î·È Û ÔÛÔÛÙfi 56% ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ̛· ÌfiÓÔ Â›ÛÎÂ„Ë ÛÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘. ∏ ÌÂϤÙË Ù˘ Î˘Ì·ÈÓfiÌÂÓ˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘, Ô Î·ıÔÚÈÛÌfi˜ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Î·È Ë Û˘ÓÔÏÈ΋ ÂÈÎfiÓ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ı· ·ÔÙÂϤÛÔ˘Ó ÔÏÈÙÈ΋ ÚÔÙÂÚ·ÈfiÙËÙ· Ô˘ ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÔÚÁ¿ÓˆÛË Î·Ù¿ÏÏËÏˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·Ú¤Ì‚·Û˘ Î·È ÛÙÚ·ÙËÁÈÎÒÓ ÚfiÏ˄˘, ·Ó¿ ËÏÈÎȷ΋ ÔÌ¿‰·, Ì ÛÎÔfi ÙË Ì›ˆÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÈÔ¯‹.
working, and with increase in the father’s age, and increased in individuals with a squint and in those living in a spacious home. Individuals, in whose families more than two accidents had occurred in the past, were at higher risk, while accident risk diminished with the father’s higher educational level. Cluster analysis demonstrated that: a) in children aged <5 years, especially girls, there is a predominance of falls and burns at home during weekends, while injuries are usually localized in the head and trunk, b) 5-9 year-old children suffer trauma in the summer, outside the home, from sharp objects and often suffer open injuries of the lower limbs, c) at age 10-14 years, boys are predominantly affected, and frequently suffer closed injuries and fractures of the upper limbs, outside the home, following a blow, a slide or a collision in the street, on working days in the autumn or spring, and d) among young people (1524 years of age), most accidents occur during weekends, at sport activities, the injuries involve the lower limbs, and are due to falls and as a result of fatigue or overuse. The annual incidence of accidents in the region studied is high. Fortunately, most injuries are of low or moderate severity and require no more than one visit to the local Health Centre. Study of the fluctuating frequency of accidents over the course of the year, definition of the risk factors and of the overall profile of accidents, will be given priority and will contribute to the organization of appropriate intervention programmes and prevention strategies for each age group, aiming at reduction of accidents in the specific area.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ù‡¯ËÌ·, ÙÚ·˘Ì·ÙÈÛÌÔ› ·È‰ÈÒÓ, ÙÚ·˘Ì·ÙÈÛÌÔ› ÂÊ‹‚ˆÓ, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÚfiÏË„Ë, ·Ú¤Ì‚·ÛË.
Key words: accident, childhood injuries, adolescent injuries, risk factors, prevention, intervention.
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¶·È‰È·ÙÚÈ΋ 2003;66:364-380
∂ÈÛ·ÁˆÁ‹ ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜, Ì ÙÔÓ fiÚÔ “·Ù‡¯ËÌ·” ÂÓÓÔԇ̠οı ·ÈÊÓ›‰È· Î·È ÂÈ‚Ï·‚‹ ›‰Ú·ÛË Â͈ÙÂÚÈÎÔ‡ ·Ú¿ÁÔÓÙ· ‹ ÁÂÁÔÓfiÙÔ˜ Û ¤Ó· ¿ÙÔÌÔ, Ô˘ Û˘Ì‚·›ÓÂÈ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ı¤ÏËÛ‹ ÙÔ˘ (1-5). ∆ÂÏÂ˘Ù·›·, ¤¯ÂÈ ·ÓÙÈηٷÛÙ·ı› ·fi ÙÔ˘˜ fiÚÔ˘˜ “οΈÛË”, “ÙÚ·‡Ì·” Î·È “ۈ̷ÙÈ΋ ‚Ï¿‚Ë”, fiÔ˘ ‰ÂÓ ˘ÂÚÙÔÓ›˙ÂÙ·È Ô ÚfiÏÔ˜ ÙÔ˘ “Ù˘¯·›Ô˘ ÁÂÁÔÓfiÙÔ˜” (2,5,6). ™ÙÔÓ fiÚÔ “·Ù‡¯ËÌ·” ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Ô ı¿Ó·ÙÔ˜ Î·È Ë ÂÎÔ‡ÛÈ· ‚Ï¿‚Ë ·fi ‚›· ‹ ·˘ÙÔÎÙÔÓ›· (2). ∆· ·Ù˘¯‹Ì·Ù· ÂÌÊ·Ó›ÛÙËÎ·Ó Ù·˘Ùfi¯ÚÔÓ· Ì ÙË Á¤ÓÂÛË ÙÔ˘ ·ÓıÚÒÔ˘ ηÈ, fiˆ˜ Î·È ¿ÏϘ ÓÔÛÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, ÔÊ›ÏÔÓÙ·È Û ÔÏ˘·Ú·ÁÔÓÙÈο ·›ÙÈ· (13). ∂›Ó·È ÛÙÂÓ¿ Û˘Ó˘Ê·Ṳ̂ӷ Ì ÙË Ê‡ÛË Î·È ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·ÓıÚÒÔ˘, ·ÏÏ¿ Î·È Ì ÙÔ ÌÈÎÚÔ- Î·È Ì·ÎÚÔ-ÂÚÈ‚¿ÏÏÔÓ, ÁÈ’ ·˘Ùfi Î·È ·ÔÙÂÏÔ‡Ó ‰ÈÂıÓÒ˜ ÎÔÈÓˆÓÈÎfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ (2-4,7,8,10). ∆Ô ·Ù‡¯ËÌ· ‹Ù·Ó - Î·È ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È - Ôχ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙË ‰È·ÌfiÚʈÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ÂÓfi˜ ÏËı˘ÛÌÔ‡ (1,10-15). ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘, Û ·ÓÙ›ıÂÛË Ì ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÓfiÛÔ˘˜, ·˘Í¿ÓÂÙ·È ·Ú¿ÏÏËÏ· Ì ÙËÓ ·Ó¿Ù˘ÍË Ù˘ Ù¯ÓÔÏÔÁ›·˜ Î·È ÙÔ˘ ÔÏÈÙÈÛÌÔ‡, ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÔÈÎÔÓÔÌÈο Î·È ÎÔÈÓˆÓÈο ÚÔ‚Ï‹Ì·Ù· ÛÙȘ Û‡Á¯ÚÔÓ˜ ÎÔÈӈӛ˜ (5,7,13,16-18). µ¤‚·È·, ÙÔ ·Ù‡¯ËÌ· ·Ó¤Î·ıÂÓ ··Û¯ÔÏÔ‡Û ÙËÓ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ·, ·ÏÏ¿ Î·È ÙËÓ ÎÔÈÓˆÓ›·. ∏ ÙÚ·˘Ì·ÙÔÏÔÁ›· ‹Ù·Ó ¤Ó·˜ ÎÏ¿‰Ô˜ Ô˘ ÁÓÒÚÈÛ ÌÂÁ¿ÏË ·Ó¿Ù˘ÍË Î·Ù¿ ÙËÓ ÔÌËÚÈ΋ ÂÚ›Ô‰Ô (18). ∞ÚÁfiÙÂÚ·, Ô πÔÎÚ¿Ù˘ ÂÚÈÁÚ¿ÊÂÈ ÙȘ ÙÔÍÈΤ˜ ÂȉڿÛÂȘ ÙÔ˘ ÌÔχ‚‰Ô˘ Û ¿ÙÔÌ· Ô˘ ›¯·Ó ÂÎÙÂı› Û ·˘ÙfiÓ, ‡ÚËÌ· Ô˘ ÂȂ‚·ÈÒÓÂÙ·È ·fi ÏËıÒÚ· ÌÂÙ·ÁÂÓ¤ÛÙÂÚˆÓ ÌÂÏÂÙÒÓ. ™‹ÌÂÚ·, ÛÙȘ ·Ú¯¤˜ Ù˘ 3˘ ¯ÈÏÈÂÙ›·˜, Ù· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ Î·È ·Ó·ËÚ›·˜ Û ·È‰È¿ Î·È Ó¤Ô˘˜ (1-5,8,19,20). ª¿ÏÈÛÙ·, ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Â›Ó·È Ë ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 44 ÂÙÒÓ, Ì ÂÍ·›ÚÂÛË ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ (2,4). ™Ù· ¿ÚÚÂÓ· ·È‰È¿ Î·È Ó¤Ô˘˜ ËÏÈΛ·˜ 5-25 ÂÙÒÓ, ÙÔ 50% ÙˆÓ ı·Ó¿ÙˆÓ οı ¯ÚfiÓÔ ÔÊ›ÏÂÙ·È Û ·Ù‡¯ËÌ· (2,7,14). ∏ ∂ÏÏ¿‰· ¤¯ÂÈ ÙÔ ıÏÈ‚ÂÚfi ÚÔÓfiÌÈÔ Ó· Û˘ÁηٷϤÁÂÙ·È ÛÙȘ ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Ì ÙËÓ ˘„ËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ·Ù˘¯ËÌ¿ÙˆÓ (1-5,7,20). ∫·Ù¤¯ÂÈ ÙËÓ 5Ë ı¤ÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙËÓ 6Ë fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· (Ì 1Ë ÙË ¯ÂÈÚfiÙÂÚË), ·Ó¿ÌÂÛ· ÛÙȘ ¯ÒÚ˜ Ù˘ ∂.∂. (1-3,7). ¶ÈÔ ·Ó·Ï˘ÙÈο, Ë ∂ÏÏ¿‰· ‚Ú›ÛÎÂÙ·È ÛÙËÓ 4Ë ı¤ÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÓËÛÈÌfiÙËÙ· ·fi ÙÚÔ¯·›·, ÙÒÛÂȘ Î·È ÂÁη‡Ì·Ù· Î·È ÛÙËÓ 3Ë fiÛÔÓ ·ÊÔÚ¿ Û ÓÈÁÌÔ‡˜ Î·È ·Ù˘¯‹Ì·Ù· Û ·È‰È¿ ËÏÈΛ·˜ 1-4 ÂÙÒÓ (1,3,7,11,21-26). ∫·Ù¿ ÙËÓ ÂÓÙ·ÂÙ›· 1991-1995, Ë Ì¤ÛË ÂÙ‹ÛÈ· ıÓËÛÈÌfiÙËÙ· ·fi ·Ù˘¯‹Ì·Ù· ÛÙËÓ ∂ÏÏ¿‰· (ÌË Û˘ÌÂÚÈ-
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Ï·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÊfiÓˆÓ Î·È ÙˆÓ ·˘ÙÔÎÙÔÓÈÒÓ) (2,15,20,24,25,27) ‹Ù·Ó ÂÚ›Ô˘ 40 ı¿Ó·ÙÔÈ ·Ó¿ 100.000 ¿ÙÔÌ· ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ (1,5,7). ™‹ÌÂÚ· ÈÛÙ‡ÂÙ·È fiÙÈ ÙÔ 98% ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÔÊ›ÏÂÙ·È ÛÙÔÓ ·Ú¿ÁÔÓÙ· ¿ÓıÚˆÔ, ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· (88% Û ÂÈΛӉ˘Ó˜ Ú¿ÍÂȘ Î·È 10% Û ÂÈΛӉ˘Ó˜ Û˘Óı‹Î˜), ÂÓÒ ÙÔ 2% Û ·Ú¿ÁÔÓÙ˜ ·ÓˆÙ¤Ú·˜ ‚›·˜ (ÛÂÈÛÌÔ‡˜, ıÂÔÌËӛ˜) (2,3). °ÂÓÈο, Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ·Ù‡¯ËÌ· Î·È Ë ÛÔ‚·ÚfiÙËÙ¿ ÙÔ˘, fiˆ˜ ÚԷӷʤÚıËÎÂ, Â›Ó·È Û˘Ó¿ÚÙËÛË ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ. ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÈ Û˘¯ÓfiÙÂÚ˜ ηÙËÁÔڛ˜ ·Ù˘¯ËÌ¿ÙˆÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ù· ÔÈÎȷο ·Ù˘¯‹Ì·Ù·, ÂΛӷ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔÓ ÂχıÂÚÔ ¯ÚfiÓÔ, ÛÙÔ Û¯ÔÏÂ›Ô Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÙÚÔ¯·›· Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· Î·È Ù· ·ÁÁÂÏÌ·ÙÈο (2,8,28-30). ∂ÈϤÔÓ, Ù· ›‰Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÔÌ·‰ÔÔÈÔ‡ÓÙ·È Û (2,9): ·) ÙÒÛÂȘ, ‚) ÂÁη‡Ì·Ù·, Á) ‰ËÏËÙËÚÈ¿ÛÂȘ, ‰) ÓÈÁÌÔ‡˜ Î·È ÓÈÁÌÔÓ¤˜ Î·È Â) ·Ù˘¯‹Ì·Ù· Û ·ıÏԷȉȤ˜ (2,3,6,26,27,31). ™Â fiϘ ۯ‰fiÓ ÙȘ ÌÔÚʤ˜ ·Ù˘¯ËÌ¿ÙˆÓ ˘ÂÚ¤¯Ô˘Ó Ù· ·ÁfiÚÈ· (2/1), ÂÓÒ ÁÈ· ÙÔ ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Ë ·Ó·ÏÔÁ›· ÛÙË £ÂÛÛ·Ï›· Â›Ó·È 3:1. ∆· ·Ù˘¯‹Ì·Ù· ·˘Í¿ÓÔ˘Ó Î˘Ú›ˆ˜ ÙÔ˘˜ ηÏÔηÈÚÈÓÔ‡˜ Ì‹Ó˜ Î·È ÁÂÓÈο Û ÂÚÈfi‰Ô˘˜ ‰È·ÎÔÒÓ (15,7,30,31). ∆· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ÚÔηÏÔ‡ÓÙ·È ·fi ÌÂÙ·ÊÔÚ¿ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Î·È ÏÈÁfiÙÂÚÔ ÏfiÁˆ ıÂÚÌÈ΋˜, ¯ËÌÈ΋˜, ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Î.¿. (2,5,28,32). ∏ ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ ‚Ï·‚ÒÓ Î·È ÙËÓ Â·Ó·‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙˆÓ ı˘Ì¿ÙˆÓ ·Ù˘¯‹Ì·ÙÔ˜ Ô˘ ÂÈ˙Ô‡Ó, ··ÈÙ› ÌÂÁ¿Ï˜ ÔÈÎÔÓÔÌÈΤ˜ ‰·¿Ó˜, ÔÏϤ˜ ÊÔÚ¤˜ ‰˘Û‚¿ÛÙ·¯Ù˜ ÁÈ· Ù· Û˘ÛÙ‹Ì·Ù· ÂÚ›ı·Ï„˘ ÙˆÓ ÎÚ·ÙÒÓ (2,3,5,7,16,17,33). ∂›Ó·È ÂÈÙ·ÎÙÈ΋ Ë ·Ó¿ÁÎË Ó· ˘¿ÚÍÂÈ ‰Ú·ÛÙÈ΋ ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÚÈÔÚÈÛÙÔ‡Ó ÔÈ ÔÈÎÔÓÔÌÈΤ˜, ÎÔÈÓˆÓÈΤ˜ Î·È „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ·ÙÔÌÈÎfi, ·ÏÏ¿ Î·È ÁÂÓÈÎfi ›‰Ô. ∏ ÙÚÔÔÔ›ËÛË ÙˆÓ ÂÈΛӉ˘ÓˆÓ Û˘ÓıËÎÒÓ ÙÔ˘ ÌÈÎÚÔ- Î·È Ì·ÎÚÔ-ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ô˘ ı· ÂÓÙÔÈÛÙÔ‡Ó Î·È, ηٿ ‰Â‡ÙÂÚÔ ÏfiÁÔ, Ë Î·ıȤڈÛË Ì¤ÙÚˆÓ ÂÓÂÚÁËÙÈ΋˜ ÚfiÏ˄˘, ÂÈÎÂÓÙÚˆÌ¤ÓˆÓ ÛÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ ·ÓıÚÒÈÓ˘ Û˘ÌÂÚÈÊÔÚ¿˜, ı· ÌÔÚÔ‡Û·Ó Ó· Û˘Ì‚¿ÏÔ˘Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ (2,3,11,34-36). OÈ ÚÒÙ˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù·ÁÚ¿ÊÔÓÙ·È Û ¤Ó· ‰¿ÊÈÔ Ù˘ µ›‚ÏÔ˘, Û‡Ìʈӷ Ì ÙÔ ÔÔ›Ô ÔÈ Î·Ù·Û΢·ÛÙ¤˜ ·ÚÔÙÚ‡ÓÔÓÙ·È Ó· ÙÔÔıÂÙÔ‡Ó ÚÔÛٷ٢ÙÈο ÎÈÁÎÏȉÒÌ·Ù· Á‡Úˆ ·fi ÙË ÛÙ¤ÁË, ηıÒ˜ ÂÈÛËÌ·›ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÙÒÛ˘ (2,3,11,34). ™‹ÌÂÚ·, Ë ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ı· ÌÔÚÔ‡Û ӷ ÂÈÙ¢¯ı› Ì ÙËÓ Î·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ™ËÌ·ÓÙÈÎfi ‚‹Ì· ÚÔ˜ ·˘Ù‹ ÙËÓ Î·Ù‡ı˘ÓÛË ·ÔÙÂÏ› Ë
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
‰È·ÎÚ·ÙÈ΋ Û˘Ìʈӛ· ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ˘ÔÏÔÁÈÛÙ› Ë ‰È·¯ÚÔÓÈ΋ Ù¿ÛË Ù˘ Û˘¯ÓfiÙËÙ¿˜ ÙÔ˘˜ Î·È Ó· ·ÍÈÔÏÔÁËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÚÔÏËÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ (1-3,6,31). ¶ÔÏϤ˜ ÌÂϤÙ˜ Ù·ÍÈÓÔÌÔ‡Ó Ù· ·Ù˘¯‹Ì·Ù· Û ۯ¤ÛË ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÌÂÙ·‚ÏËÙ¤˜, fiˆ˜ Ô ¯ÒÚÔ˜, Ô ¯ÚfiÓÔ˜ Î·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ·, ‹ ·Ó¿ÏÔÁ· Ì ÙÔÓ Ì˯·ÓÈÛÌfi ÚfiÎÏËÛ˘ Î·È ÙËÓ ÚÔÎÏËı›۷ ‚Ï¿‚Ë (6,31). ™˘Ó‹ıˆ˜, ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·ÏÔ› ‹ ‰ÈÂıÓ›˜ ÎÒ‰ÈΘ, ÔÈ ÔÔ›ÔÈ ÂÚÈÁÚ¿ÊÔ˘Ó ÏÂÙÔÌÂÚÒ˜ ÙË ‚Ï¿‚Ë Î·È ÙȘ Û˘Óı‹Î˜ Ì˯·ÓÈÛÌfi ÚfiÎÏËÛ‹˜ ÙÔ˘˜. Ÿˆ˜ ÙÔÓ›ÛÙËÎÂ, Ë ‰ÈÂıÓ‹˜ ÂÚÈÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÌÂϤÙ˘, ‰ÈÂÚ‡ÓËÛ˘ Î·È Û‡ÁÎÚÈÛ˘, ÒÛÙ ӷ ηıÔÚÈÛÙÔ‡Ó ÔÈ Î·Ù·ÏÏËÏfiÙÂÚ˜ ÎÔÈÓ¤˜ ÛÙÚ·ÙËÁÈΤ˜ ÚfiÏ˄˘ (1-3,19,31,33). ™ÙËÓ ∂ÏÏ¿‰·, ‰ÂÓ ˘¿Ú¯ÂÈ Û‡ÛÙËÌ· ηٷÁÚ·Ê‹˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ·ÓÂÏÏ‹ÓÈ· Îϛ̷η, ÏËÓ Ù˘ ‚¿Û˘ ‰Â‰ÔÌ¤ÓˆÓ ™∫∞∂π (™‡ÛÙËÌ· ∫·Ù·ÁÚ·Ê‹˜ ∞Ù˘¯ËÌ¿ÙˆÓ Û ∂͈ÙÂÚÈο π·ÙÚ›·) ÙÔ˘ ∫∂¶¶∞ (∫¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ ∞Ù˘¯ËÌ¿ÙˆÓ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ), fiÔ˘ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔȯ›· ·fi Ù¤ÛÛÂÚ· ¡ÔÛÔÎÔÌ›· Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙÔ ÚfiÁÚ·ÌÌ· (¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, °¶¡ µfiÏÔ˘, °¶¡ ∫¤Ú΢ڷ˜) (31). ∂ÈÚfiÛıÂÙ·, ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ÏÂÙÔÌÂÚ‹˜ ÚÔÔÙÈ΋ ÌÂϤÙË Ô˘ Ó· ‰ÈÂÚÂ˘Ó¿ ÂȉËÌÈÔÏÔÁÈο ÙÔ ·Ù‡¯ËÌ· Û ÙÔÈÎfi ›‰Ô, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ‰ÈÂıÓ‹ Έ‰ÈÎÔÔ›ËÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚÈÁÚ·Ê‹ ‚Ï¿‚˘ Î·È ÙȘ Û˘Óı‹Î˜ ÚfiÎÏËÛ‹˜ Ù˘. ∏ ·ÚÔ‡Û· ÌÂϤÙË, Ù‡Ô˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ, ۯ‰ȿÛÙËΠÚÔÔÙÈο ÚÔÎÂÈ̤ÓÔ˘ Ó· ÚÔÛÂÁÁ›ÛÂÈ ÂȉËÌÈÔÏÔÁÈο ÙÔ Úfi‚ÏËÌ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ÙÔÈÎfi ›‰Ô, Ó· ‰ÈÂÚ¢ӋÛÂÈ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂΛÓÔ˘˜ Ô˘ Ô‰ËÁÔ‡Ó Û ·Ù˘¯‹Ì·Ù· ÙÔ˘˜ Ó·ÚÔ‡˜ ηÙÔ›ÎÔ˘˜ Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘ Î·È ÙÂÏÈο Ó· ‰È·ÌÔÚÊÒÛÂÈ Ú·ÎÙÈΤ˜ ÚfiÏ˄˘. ∫·Ù·ÁÚ¿ÊËÎ·Ó ·Ó·Ï˘ÙÈο, Ì ‰ÈÂıÓ›˜ ÎÒ‰ÈΘ (ICD 9Ë ·Ó·ıÂÒÚËÛË Î·È EHLASS) (6,31), Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ó¤‚ËÛ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜ Û 1327 ¿ÙÔÌ· ËÏÈΛ·˜ <24 ÂÙÒÓ, ηÙÔ›ÎˆÓ ÙÔ˘ ‰‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘ (37-39). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜ (11 ™ÂÙÂÌ‚Ú›Ô˘ 1994 ¤ˆ˜ 10 ™ÂÙÂÌ‚Ú›Ô˘ 1995), ¤ÁÈÓ ÚÔÔÙÈ΋ ÏÂÙÔÌÂÚ‹˜ ηٷÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó¤‚ËÛ·Ó Û ¿ÙÔÌ· ËÏÈΛ·˜ <24 ÂÙÒÓ, ηÙÔ›ÎˆÓ Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ËÌÈ·ÛÙÈ΋ ÂÚÈÔ¯‹ ÛÙÔÓ ¡ÔÌfi ª·ÁÓËÛ›·˜. °È· ÙËÓ ·ÚÔ‡Û· ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË, Ù‡Ô˘ ·ÛıÂÓÒÓÌ·ÚÙ‡ÚˆÓ, ηٷÛ΢¿ÛÙËΠÂÎÙÂÓ¤˜ ÚÔΈ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ Û˘ÌÏËÚÒıËΠÏÂÙÔÌÂÚÒ˜ Ì ÚÔÛˆÈΤ˜ Û˘ÓÂÓÙ‡ÍÂȘ Î·È ÙÔ ÔÔ›Ô ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 2 ̤ÚË: ÙÔ ÁÂÓÈÎfi Î·È ÙÔ ÂȉÈÎfi. ∂Ï‹ÊıËÛ·Ó ·ÓÒÓ˘Ì˜ ÏËÚÔÊÔ-
Paediatriki 2003;66:364-380
ڛ˜ ÁÈ· 247 ‚·ÛÈΤ˜ ÂÚÈÙÒÛÂȘ ·Ù˘¯‹Ì·ÙÔ˜ (µ¶) ·fi Ù· ›‰È· Ù· ¿ÙÔÌ· Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ· ‹ ÙÔ˘˜ Û˘ÓÔ‰Ô‡˜ ÙÔ˘˜. ∆· ÛÙÔȯ›· Ô˘ Û˘ÓÂϤÁËÛ·Ó ·ÊÔÚÔ‡Û·Ó ÛÙ· ‰ËÌÔÁÚ·ÊÈο Î·È ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·ÙfiÌÔ˘ ·˘ÙÔ‡, ηıÒ˜ Î·È ÛÙÔ Ù˘¯fiÓ ÚÔËÁÔ‡ÌÂÓÔ È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi ·Ù˘¯‹Ì·ÙÔ˜ ‹ ·Ûı¤ÓÂÈ·˜ (ÁÂÓÈÎfi ̤ÚÔ˜). ™ÙÔ ÂȉÈÎfi ̤ÚÔ˜ ηٷÁÚ¿ÊËÎ·Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ÔÈ Û˘Óı‹Î˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ·Ù˘¯‹Ì·ÙÔ˜, ηıÒ˜ ›Û˘ Ë ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË Î·È ¤Î‚·Û‹ ÙÔ˘. ∆Ô ÁÂÓÈÎfi ̤ÚÔ˜ Û˘ÌÏËÚÒıËÎÂ, ›Û˘, ÁÈ· 2 ÛÂÈÚ¤˜ Ì·ÚÙ‡ÚˆÓ, ·ÓÙ›ÛÙÔȯˆÓ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· (·fi ÙÔ ›‰ÈÔ ÏËı˘ÛÌÈ·Îfi ‰Â›ÁÌ·). ∏ ·ÓÒÙ·ÙË ‰È·ÊÔÚ¿ ËÏÈΛ·˜ ·fi ÙȘ ·ÓÙ›ÛÙÔȯ˜ µ¶ ‹Ù·Ó 6 Ì‹Ó˜. ∏ ÌÂϤÙË ·ÔÛÎÔÔ‡Û ÛÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ Î·È ÛÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ÂȉËÌÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ·Ù‡¯ËÌ· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ µÂÏÂÛÙ›ÓÔ˘. ∏ ·ÓˆÙ¤Úˆ ÂÚÈÔ¯‹ ·ÔÙÂÏÂ›Ù·È Î˘Ú›ˆ˜ ·fi ÎÏÂÈÛÙfi ÏËı˘ÛÌfi ·ÙfiÌˆÓ ËÏÈΛ·˜ <24 ÂÙÒÓ, ÏËÓ ÂÓfi˜ ÌÈÎÚÔ‡ ÔÛÔÛÙÔ‡ ·ÙfiÌˆÓ (<2%) Ô˘ ÌÂÙ·‚¿ÏÏÂÙ·È Î¿ı ¯ÚfiÓÔ, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÈ ÙÔÓ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜. ¶ÚfiÎÂÈÙ·È Î˘Ú›ˆ˜ ÁÈ· ·È‰È¿ ÛÙÚ·ÙȈÙÈÎÒÓ Ô˘ ˘ËÚÂÙÔ‡Ó ÛÙÔ ¶∂µ (¶ÚÔίˆÚË̤ÓÔ ∂ÚÁÔÛÙ¿ÛÈÔ µ¿ÛˆÓ) Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘, ÔÈ ÔÔ›ÔÈ ÌÂÙ·Ù›ıÂÓÙ·È Û˘¯Ó¿ Û ¿ÏϘ ÂÚÈÔ¯¤˜. O ÏËı˘ÛÌfi˜ Ù˘ ÌÂϤÙ˘, Û‡Ìʈӷ Ì ٷ ÙÂÏÂ˘Ù·›· ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· Î·È ÏËÚÔÊÔڛ˜, ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 1327 ¿ÙÔÌ· (34,4% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ô˘ ›¯Â ·ÔÁÚ·Ê›). ™ÙË ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ¤Ú¢ӷ˜ ˘‹ÚÍÂ Û˘ÓÂÚÁ·Û›· Ì ÔÏÏÔ‡˜ ÊÔÚ›˜ Î·È ˘ËÚÂۛ˜, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÔÔ›ˆÓ ÌÔÚÔ‡Û ӷ ‰ÒÛÂÈ Û˘ÌÏËڈ̷ÙÈΤ˜ ÏËÚÔÊÔڛ˜ fiÔÙ ˙ËÙ‹ıËÎ·Ó (37-39). ∂ȉÈÎfiÙÂÚ·, ÂÏ‹ÊıËÛ·Ó Û¯ÂÙÈΤ˜ ÏËÚÔÊÔڛ˜ ·fi ÙÔ ·Ú¯Â›Ô ΛÓËÛ˘ ÂÂÈÁfiÓÙˆÓ Î·È ÏÔÈÒÓ È·ÙÚ›ˆÓ ÙÔ˘ ∫¤ÓÙÚÔ˘ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘, ·fi ÙÔ ·Ú¯Â›Ô ΛÓËÛ˘ ·Ú·Ï·‚‹˜ Î·È Â͈ÙÂÚÈÎÒÓ È·ÙÚ›ˆÓ ÙÔ˘ “∞¯ÈÏÏÔÔ‡ÏÂÈÔ˘” °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ µfiÏÔ˘, ·fi Ù· Ê·Ú̷Λ· Î·È Ù· Û¯ÔÏ›· Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘, ·fi ÙÔ ·ÛÙ˘ÓÔÌÈÎfi ÙÌ‹Ì· µÂÏÂÛÙ›ÓÔ˘, ·fi ȉÈÒÙ˜ È·ÙÚÔ‡˜ Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘ Î·È Ù˘ ¢ڇÙÂÚ˘ ÂÚÈÔ¯‹˜, ·fi ÙÔ ·Ú¯Â›Ô ΛÓËÛ˘ ·Ú·Ï·‚‹˜ Î·È Â͈ÙÂÚÈÎÒÓ È·ÙÚ›ˆÓ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ °Ú‚ÂÓÒÓ, ηıÒ˜ Î·È ·fi ¯ÒÚÔ˘˜ ·Ú·ıÂÚÈÛÌÔ‡ ÙˆÓ Î·ÙÔ›ÎˆÓ (ηٷÛÎËÓÒÛÂȘ, ÂÍÔ¯ÈΤ˜ ηÙÔÈ˘, ÓËÛÈ¿ - ΢ڛˆ˜ ÛÙÔÓ ¡ÔÌfi ª·ÁÓËÛ›·˜ - Î.¿.). ∆¤ÏÔ˜, ·fi ÙÔ ·Ú¯Â›Ô ÙÔ˘ ¢ËÌ·Ú¯Â›Ô˘ µÂÏÂÛÙ›ÓÔ˘ ÂÏ‹ÊıËÛ·Ó ÏËÚÔÊÔڛ˜ ·fi ÙÔ ‰ËÌÔÙÔÏfiÁÈÔ ·ÓÙ›ÛÙÔȯˆÓ ËÏÈÎÈÒÓ, ÔÈ Ôԛ˜ ‚Ô‹ıËÛ·Ó ÛËÌ·ÓÙÈο ÛÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÛÙËÓ ·ÚÔ‡Û· ¤Ú¢ӷ. Ÿˆ˜ ÚԷӷʤÚıËÎÂ, Û‡Ìʈӷ Ì ÏËÚÔÊÔڛ˜ ·fi ÙËÓ ˘¿Ú¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›·, Ë ·ÚÔ‡Û· ¤Ú¢ӷ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÚÔÔÙÈ΋ ¤Ú¢ӷ, ÙfiÛÔ ÛÙË £ÂÛÛ·Ï›· fiÛÔ Î·È ÛÙËÓ ˘fiÏÔÈË ∂ÏÏ¿‰·, Ô˘ ÂÚÈÁÚ¿ÊÂÈ ÏÂÙÔÌÂÚÒ˜ Ù· ·Ù˘¯‹Ì·Ù·, Έ‰ÈÎÔÔÈÒÓÙ·˜ Ù· Û‡Ìʈӷ Ì ÎÒ‰ÈΘ ‰ÈÂıÓÔ‡˜ Ù·ÍÈÓfiÌËÛ˘, Ì ·ÒÙÂÚÔ ÛÎÔfi Ó· ·Ú¤Ì‚ÂÈ Û ‰Â‡ÙÂÚË Ê¿ÛË Ì ÂȉÈο ÚÔÁÚ¿ÌÌ·Ù· ÚfiÏ˄˘ Î·È Ì›ˆÛ˘ ÙÔ˘ ·ÚÈıÌÔ‡ ÙÔ˘˜ ÛÙËÓ ÂÚÈÔ¯‹. ∏ ηٷÁÚ·Ê‹ ¤ÁÈÓ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÏÂÙÔÌÂÚ¤ÛÙÂÚ· ·fi ·È‰›·ÙÚÔ Ô˘ ˘ËÚÂÙ› ÌfiÓÈÌ· ÛÙËÓ ÂÚÈÔ¯‹, ÁÂÁÔÓfi˜ Ô˘ ‚Ô‹ıËÛ ÛÙËÓ ÚÔÛ¤ÁÁÈÛË ÙˆÓ
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¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
·ÙfiÌˆÓ Î·È ÛÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ‰È·Ê˘Á‹˜ ·ÙfiÌˆÓ Ô˘ ›¯·Ó ÂÌϷΛ Û ·Ù‡¯ËÌ·. ªÂÏÂÙ‹ıËηÓ, ÙÂÏÈο, 247 µ¶ Ô˘ ˘¤ÛÙËÛ·Ó Û˘ÓÔÏÈο 306 ·Ù˘¯‹Ì·Ù·, 59 ÂÎ ÙˆÓ ÔÔ›ˆÓ ·ÊÔÚÔ‡Û·Ó Û 2Ô, 3Ô Î·È 4Ô ·Ù‡¯ËÌ· ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ù˘ ¤Ú¢ӷ˜. ∂›Û˘, Û˘ÌÏËÚÒıËÎ·Ó ¿ÏÏ· 494 ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·fi ‰‡Ô ÛÂÈÚ¤˜ Ì·ÚÙ‡ÚˆÓ. ∂ϤÁ¯ıËÎ·Ó ÔÈ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ‰ËÌÔÁÚ·ÊÈÎÒÓ, ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ Î·È ·ÙÔÌÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ, ηıÒ˜ Î·È Ï‹ıÔ˜ ¿ÏϘ ÂÚÈÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ (¶ª). ∞ӷχıËÎ·Ó ÏÂÙÔÌÂÚÒ˜ ÙfiÛÔ ÔÈ Û˘Óı‹Î˜ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ (¯ÚfiÓÔ˜, ÙfiÔ˜, Ì˯·ÓÈÛÌfi˜ Î·È Û˘Óı‹Î˜ ÚfiÎÏËÛ˘, ·ÓÙÈΛÌÂÓÔ ‚Ï¿‚˘, ‰Ú·ÛÙËÚÈfiÙËÙ·, Û˘ÓÔ‰Ô›), Ô ÙÚfiÔ˜ ÌÂÙ·ÊÔÚ¿˜, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ›¯Â ÙÔ ·Ù‡¯ËÌ· Î·È Ë ¤Î‚·Û‹ ÙÔ˘ fiÛÔ Î·È Ë Î·ÙËÁÔÚ›· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ÙÔ Â›‰Ô˜ Ù˘ ‚Ï¿‚˘ (Û‡Ìʈӷ Ì ÙËÓ ·Ó·Ï˘ÙÈ΋ ‰ÈÂıÓ‹ Έ‰ÈÎÔÔ›ËÛË). ÃÚËÛÈÌÔÔÈ‹ıËΠÙÔ ICD-CM (9Ë ·Ó·ıÂÒÚËÛË) ÁÈ· ÙËÓ Îˆ‰ÈÎÔÔ›ËÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÂȉÈÎfiÙÂÚ·, Ë Ù·ÍÈÓfiÌËÛË ¡ (¡: Nature of injury) ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ ‚Ï¿‚˘, Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ÙËÓ ÂÓÙfiÈÛË Ù˘ οΈÛ˘ (N-code) Î·È Ë Ù·ÍÈÓfiÌËÛË ∂ (∂: External cause) ÁÈ· ÙȘ Û˘Óı‹Î˜ ÚfiÎÏËÛ˘ Ù˘ οΈÛ˘ Î·È ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ (∂-code) (6,31). ∂›Û˘, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ô ÎÒ‰Èη˜ EHLASS ÁÈ· ÙËÓ Îˆ‰ÈÎÔÔ›ËÛË ÙÔ˘ ›‰Ô˘˜, Ù˘ ÂÓÙfiÈÛ˘ ÛÙÔ ÛÒÌ·, Ù˘ ‚Ï¿‚˘, ÙÔ˘ Ì˯·ÓÈÛÌÔ‡, Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙÔ˘ ÙfiÔ˘ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ (31). ∂Í‹¯ıËÛ·Ó ·ÓÙ›ÛÙÔȯ˜ ηٷÓÔ̤˜ Û˘¯ÓÔًوÓ, ÔÈ Ôԛ˜ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 3 Î·È 4. ∂Ê·ÚÌfiÛÙËÎÂ Ë ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË, ÂÓÙÔ›ÛÙËÎ·Ó Î·È ‰ÈÂÚ¢ӋıËÎ·Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ηıÒ˜ ›Û˘ Î·È Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫). ∆· Â˘Ú‹Ì·Ù· ıˆڋıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÛÂ Â›Â‰Ô 5% (p≤0,05). ª¤ÙÚÔ Ù˘ ‰‡Ó·Ì˘ Û˘Û¯¤ÙÈÛ˘ Â›Ó·È Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫) Î·È fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O∞) 95%. ªÂ ‰ÂÛÌÂ˘Ì¤ÓË ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË (conditional logistic regression-derived), ÂϤÁ¯ıËÎÂ Ë ÂÍ¿ÚÙËÛË ÁÈ· ·Ù‡¯ËÌ· ·fi 11 ÌÂÙ·‚ÏËÙ¤˜, ÔÈ Ôԛ˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ªÂÙ¿ ·fi ÔÌ·‰ÔÔ›ËÛË ÙˆÓ ËÏÈÎÈÒÓ Û 4 ηÙËÁÔڛ˜ [1Ë: <5 (0-4) ÂÙÒÓ, 2Ë: 5-9 ÂÙÒÓ, 3Ë: 10-14 ÂÙÒÓ, 4Ë: ≥15 ÂÙÒÓ], ¤ÁÈÓ ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜, Ë ÔÔ›· Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 7.
ËÏÈÎÈÒÓ Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ÂÙ‹ÛÈ· ›وÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·Ó¿ 100 ¿ÙÔÌ· Û ·ÁfiÚÈ·, ÎÔÚ›ÙÛÈ· Î·È ÛÙÔ Û‡ÓÔÏÔ. ∆Ë ÌÂÁ·Ï‡ÙÂÚË Â›ÙˆÛË ÁÈ· ·Ù‡¯ËÌ· ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ù¿ Êı›ÓÔ˘Û· ÛÂÈÚ¿, ÁÈ· Ù· ·ÁfiÚÈ·, Ë ËÏÈÎȷ΋ ÔÌ¿‰· 10-14 ÂÙÒÓ Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ ÔÌ¿‰Â˜ 5-9 ÂÙÒÓ Î·È 0-4 ÂÙÒÓ (29%, 27% Î·È 23%, ·ÓÙ›ÛÙÔȯ·). ™Ù· ÎÔÚ›ÙÛÈ·, ÚÔËÁÂ›Ù·È Ë ÔÌ¿‰· ËÏÈΛ·˜ 5-9 ÂÙÒÓ Î·È ¤ÔÓÙ·È ÔÈ ÔÌ¿‰Â˜ ËÏÈΛ·˜ 0-4 ÂÙÒÓ Î·È 10-14 ÂÙÒÓ (25%, 21% Î·È 11,5%, ·ÓÙ›ÛÙÔȯ·). ∏ ›وÛË ÁÈ· ·Ù‡¯ËÌ· ÛÙ· ·ÁfiÚÈ· Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (23,5% ¤Ó·ÓÙÈ 13,%). ™ÙÔÓ ¶›Ó·Î· 2 Ê·›ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ, ·Ó¿ÏÔÁ· Ì ‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ (¢ª) ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜. ∞ÔÙ˘ÒÓÂÙ·È Î·È Â‰Ò ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (65,5% ¤Ó·ÓÙÈ 34,5%) Î·È Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ù˘¯‹Ì·ÙÔ˜ ÛÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· 5-9 ÂÙÒÓ (27%). OÈ ¶›Ó·Î˜ 3 Î·È 4 ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙËÓ Î·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ ·Ó¿ÏÔÁ· Ì ÙȘ ¶ª ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È Ù˘ οΈÛ˘. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 3, Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Î·ÏÔηÈÚÈÓÒÓ ‰È·ÎÔÒÓ (33%), ·ÎÔÏÔ˘ı› ÙÔ ÊıÈÓfiˆÚÔ (27%) Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ô ¯ÂÈÌÒÓ·˜ Î·È Ë ¿ÓÔÈÍË Ì ÂÚ›Ô˘ ›‰È· Û˘¯ÓfiÙËÙ· ·Ù˘¯ËÌ¿ÙˆÓ (20%). ∞Ó Ï¿‚Ô˘Ì ˘’ fi„ÈÓ ÙÔÓ ·ÚÈıÌfi fiÏˆÓ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙÔ˘ ÚÒÙÔ˘, ‰Â˘Ù¤ÚÔ˘, ÙÚ›ÙÔ˘ Î·È ÙÂÙ¿ÚÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ 247 ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ·, ηٷÁÚ¿ÊÔÓÙ·È 306 ·Ù˘¯‹Ì·Ù·, Ù· ÔÛÔÛÙ¿ ÙˆÓ ÔÔ›ˆÓ ÙÚÔÔÔÈÔ‡ÓÙ·È ÂÏ·ÊÚÒ˜ ·Ó¿ ÂÔ¯‹, ÒÛÙÂ Ë Êı›ÓÔ˘Û· ÛÂÈÚ¿ ·ÎÔÏÔ˘ı› ÙËÓ ÔÚ›· ηÏÔη›ÚÈ, ÊıÈÓfiˆÚÔ, ¿ÓÔÈÍË, ¯ÂÈÌÒÓ·˜. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙȘ Ë̤Ú˜ Ù˘ ‚‰ÔÌ¿‰·˜ ηٿ ÙȘ Ôԛ˜ ÛËÌÂÈÒÓÂÙ·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ, ÚÔËÁÂ›Ù·È Ë ¢Â˘Ù¤Ú· Î·È ¤ÂÙ·È Ë ¶¤ÌÙË (16,5% Î·È 16%, ·ÓÙ›ÛÙÔȯ·). ∆· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó ÙȘ ·ÔÁÂ˘Ì·ÙÈÓ¤˜ ÒÚ˜ Î·È Î˘Ú›ˆ˜ ÌÂٷ͇ 17.00 Î·È 19.00 (30,5%). ª¿ÏÈÛÙ·, ÙÔ 1/2
∞ÔÙÂϤÛÌ·Ù· ™ÙÔÓ ¶›Ó·Î· 1 Ê·›ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ÌÂÏÂÙ‹ıËÎÂ, ηٿ ÂÓÙ·ÂÙ›˜ ÔÌ¿‰Â˜
¶›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ Î·ÙÔ›ÎˆÓ ÙÔ˘ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘, ËÏÈΛ·˜ ≤24 ÂÙÒÓ (¶), ·ÚÈıÌfi˜ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó¤‚ËÛ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜ ÛÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô ÏËı˘ÛÌfi (¡) Î·È ÂÙ‹ÛÈ· ›وÛË ÁÈ· ·Ù‡¯ËÌ· ·Ó¿ 100 ¿ÙÔÌ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ∏ÏÈΛ· (¤ÙË) ¶
∞ÁfiÚÈ N
∂Ù‹ÛÈ· ›وÛË (%)
¶
∫ÔÚ›ÙÛÈ N ∂Ù‹ÛÈ· ›وÛË (%)
¶
™‡ÓÔÏÔ N ∂Ù‹ÛÈ· ›وÛË (%)
0-4 5-9 10-14 15-19 20-24
96 138 160 171 120
22 37 46 31 26
22,9 26,8 28,8 18,1 21,7
80 119 155 174 114
17 30 18 14 6
21,3 25,2 11,6 8,0 5,3
176 257 315 345 234
39 67 64 45 32
22,2 26,1 20,3 13,0 13,7
™‡ÓÔÏÔ
685
162
23,6
642
85
13,2
1327
247
18,6
368
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù·ÁÚ¿ÊÂÙ·È ÙȘ ÒÚ˜ 14.0019.00 (48%), ÂÓÒ ÙȘ ÒÚ˜ 08.00-13.00 Û˘Ì‚·›ÓÂÈ ÂÚ›Ô˘ ÙÔ 1/3 (31%). ¶Ôχ ÏÈÁfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ÛËÌÂÈÒÓÔÓÙ·È ÙȘ ÒÚ˜ 14.00-16.00 Î·È 20.00-22.00 (18% Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ), ÂÓÒ ÂÏ¿¯ÈÛÙÔ˜ Â›Ó·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ (3%) ÛÙÔ 8ˆÚÔ 23.00-07.00. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, fiˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ, Û˘Ì‚·›ÓÂÈ ÛÙÔÓ “Âχı¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ (0-24 ÂÙÒÓ), ηÙÔ›ÎˆÓ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘, ·Ó¿ÏÔÁ· Ì ‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ ·Ù˘¯‹Ì·ÙÔ˜ ªÂÙ·‚ÏËÙ‹ ∏ÏÈΛ· <5 ÂÙÒÓ (0-4) 5-9 10-14 15-19 20-24 º‡ÏÔ ∞ÁfiÚÈ ∫ÔÚ›ÙÛÈ
N
%
39 67 64 45 32
15,8 27,1 25,9 18,2 13,0
162 85
65,6 34,4
ÚÔ ¯ÚfiÓÔ” (57%). ™Â ·˘Ù¿ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó Î·È Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ó¤‚ËÛ·Ó ÂÓÙfi˜ Ù˘ ·˘Ï‹˜ ‹ Á‡Úˆ ·fi ÙÔ Û›ÙÈ, Ù· ÔÔ›· ¤¯Ô˘Ó Û¯¤ÛË Ì ·È¯Ó›‰È ‹ ¿ÏÏË ‰Ú·ÛÙËÚÈfiÙËÙ· “ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘”. ∞ÎÔÏÔ˘ıÔ‡Ó Ù· ÔÈÎȷο ·Ù˘¯‹Ì·Ù· (22%) ̤۷ ÛÙÔ Û›ÙÈ Î·È ·˘Ù¿ Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ÔÈÎȷ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ηÈ, ÛÙË Û˘Ó¤¯ÂÈ·, Ù· Û¯ÔÏÈο, Ù· ·ÁÁÂÏÌ·ÙÈο, Ù· ÙÚÔ¯·›· (·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο Û ·ÁfiÚÈ·) Î·È ‰È¿ÊÔÚ· ¿ÏÏ·, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ÙˆÓ ·Î·ıfiÚÈÛÙˆÓ (12%, 4%, 2% Î·È 3%, ·ÓÙ›ÛÙÔȯ·). ∆· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó Û¯Â‰fiÓ ÂÍ›ÛÔ˘ ̤۷ Î·È ¤Íˆ - Á‡Úˆ ·fi ÙÔ Û›ÙÈ, Ì ÌÈÎÚ‹ ˘ÂÚÔ¯‹ ·˘ÙÒÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Ì¤Û· ÛÙÔ Û›ÙÈ (21% ¤Ó·ÓÙÈ 19,5%). ∆Ô ˘fiÏÔÈÔ 59,5% ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û˘Ì‚·›ÓÂÈ ¤Íˆ ·fi ÙÔÓ ÂÚ›Á˘ÚÔ ÙÔ˘ ÛÈÙÈÔ‡, ÛÙÔ ‰ÚfiÌÔ, ÛÙÔ˘˜ ·ıÏËÙÈÎÔ‡˜ ¯ÒÚÔ˘˜, ÛÙÔ Û¯ÔÏ›Ô, Û ·ÁÚÔÙÈ΋ ‹ ‚ÈÔÌ˯·ÓÈ΋ ÂÚÈÔ¯‹, Û ¯ÒÚÔ˘˜ ·È¯ÓȉÈÔ‡, ‰È·ÛΤ‰·Û˘ Î·È ·ÏÏÔ‡ (16%, 15%, 10%, 5%, 4,5%, 3%, 3%, 3,5%, ·ÓÙ›ÛÙÔȯ·). ∏ Û˘¯ÓfiÙÂÚË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙËÓ ÒÚ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Â›Ó·È ÙÔ ·È¯Ó›‰È ‹ ¿ÏÏË ‰Ú·ÛÙËÚÈfiÙËÙ·
¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ (0-24 ÂÙÒÓ), ηÙÔ›ÎˆÓ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘, ·Ó¿ÏÔÁ· Ì ÂÚÈÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ (1Ô ·Ù‡¯ËÌ·) ·Ù˘¯‹Ì·ÙÔ˜ ªÂÙ·‚ÏËÙ‹
N
∂Ô¯‹ ηٿ ÙËÓ ÔÔ›· Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ· (1Ô) ÃÂÈÌÒÓ·˜ 50 ÕÓÔÈÍË 50 ∫·ÏÔη›ÚÈ 81 ºıÈÓfiˆÚÔ 66 ∏̤ڷ ηٿ ÙËÓ ÔÔ›· Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ· ∫˘Úȷ΋ 30 ¢Â˘Ù¤Ú· 41 ∆Ú›ÙË 26 ∆ÂÙ¿ÚÙË 38 ¶¤ÌÙË 39 ¶·Ú·Û΢‹ 37 ™¿‚‚·ÙÔ 36 flÚ· ηٿ ÙËÓ ÔÔ›· Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ· 08.00-10.00 17 11.00-13.00 59 14.00-16.00 44 17.00-19.00 75 20.00-22.00 44 23.00-07.00 8 ∂›‰Ô˜ (ηÙËÁÔÚ›·) ·Ù˘¯‹Ì·ÙÔ˜ OÈÎÈ·Îfi 55 ™¯ÔÏÈÎfi 30 ∂χıÂÚÔ˘ ¯ÚfiÓÔ˘ 140 ∂·ÁÁÂÏÌ·ÙÈÎfi 10 ∆ÚÔ¯·›Ô 5 ÕÏÏÔ 7 ∆fiÔ˜ fiÔ˘ Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ· ª¤Û· ÛÙÔ Û›ÙÈ 52 ŒÍˆ (Î·È Á‡Úˆ) ·fi ÙÔ Û›ÙÈ 48 ™ÙÔ ‰ÚfiÌÔ 39 ™Â ·ıÏËÙÈÎÔ‡˜ ¯ÒÚÔ˘˜ 37 ™ÙÔ Û¯ÔÏÂ›Ô 24
% 20,2 20,2 32,8 26,8 12,1 16,6 10,5 15,4 15,8 15,0 14,6 6,9 23,9 17,8 30,4 17,8 3,2 22,3 12,1 56,7 4,0 2,1 2,8 21,1 19,4 15,8 15,0 9,7
ªÂÙ·‚ÏËÙ‹
N
%
™Â ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ 13 5,3 ™Â ‚ÈÔÌ˯·ÓÈ΋ ÂÚÈÔ¯‹ 11 4,5 ™Â ¯ÒÚÔ˘˜ ·È¯ÓȉÈÔ‡ 7 2,8 ™Â ¯ÒÚÔ ‰È·ÛΤ‰·Û˘ 7 2,8 ∞ÏÏÔ‡ 9 3,6 ¢Ú·ÛÙËÚÈfiÙËÙ· ÙËÓ ÒÚ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ ¶·È¯Ó›‰È Î·È ÂχıÂÚÔ˜ ¯ÚfiÓÔ˜ 124 50,2 ™ÔÚ 38 15,4 ∂η›‰Â˘ÛË 14 5,7 ∑ˆÙÈΤ˜ (‚·ÛÈΤ˜) ·Ó¿ÁΘ 12 4,9 ∂·ÁÁÂÏÌ·ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· 10 4,0 ÕÏÏÔ 49 19,8 ªË¯·ÓÈÛÌfi˜ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ ¶ÙÒÛË ÛÙÔ ›‰ÈÔ Â›Â‰Ô 47 19,0 ¶ÙÒÛË ·fi ‡„Ô˜ ‹ ¿ÏÏÔ Â›Â‰Ô 45 18,2 ÕÏÏË ÙÒÛË 7 2,8 ∫fi„ÈÌÔ 34 13,8 °Ï›ÛÙÚËÌ· 32 13,0 ÕÏÏË Ì˯·ÓÈ΋ ·ʋ 12 4,9 ¢ËÏËÙËÚ›·ÛË 24 9,7 ÀÂÚÚÔÛ¿ıÂÈ· 15 6,1 ∑ÂÛÙ¿ ˘ÁÚ¿ - ·ÓÙÈΛÌÂÓ· 10 4,0 ÕÏÏÔ 21 8,5 ÃÚfiÓÔ˜ ÌÂٷ͇ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÛÙÔ ¯ÒÚÔ ·ÚÔ¯‹˜ ÚÒÙˆÓ ‚ÔËıÂÈÒÓ 0-30 ÏÂÙ¿ 206 83,4 30 ÏÂÙ¿ - 24 ÒÚ˜ 8 3,2 >24 ÒÚ˜ 33 13,4 ÕÙÔÌÔ Ô˘ ‹Ù·Ó ·ÚfiÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ °ÔÓ›˜ 74 30,0 ™˘ÁÁÂÓ›˜ 26 10,4 º›ÏÔÈ - ÕÏÏÔÈ 116 47,0 ∫·Ó¤Ó·˜ 31 12,6
369
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
¶›Ó·Î·˜ 4. ∫·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ (0-24 ÂÙÒÓ), ηÙÔ›ÎˆÓ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘, ·Ó¿ÏÔÁ· Ì ÂÚÈÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ οΈÛ˘ ªÂÙ·‚ÏËÙ‹ ∆‡Ô˜ οΈÛ˘ ªÒψ·˜ - ÂΉÔÚ¿ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∫¿Ù·ÁÌ· ¢È¿ÛÙÚÂÌÌ· - ÂÍ¿ÚıÚËÌ· ¢ËÏËÙËÚ›·ÛË ŒÁη˘Ì· ÕÏÏÔ ¶ÚÔÛ‚ÏËı¤Ó ̤ÚÔ˜ ÛÒÌ·ÙÔ˜ ¶ÚfiÛˆÔ ∫ÂÊ¿ÏÈ ™ÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ· ¢¿¯Ù˘Ï· ¶‹¯Ë˜ (·ÓÙÈ‚Ú¿¯ÈÔ) ÕÏÏ· ̤ÚË ÙˆÓ ¿Óˆ ¿ÎÚˆÓ ¶Ô‰ÔÎÓËÌÈ΋ °fiÓ·ÙÔ ÕÏÏ· ̤ÚË ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ∫ÔÚÌfi˜ ∞ÚÈıÌfi˜ ηÎÒÛˆÓ/‚Ï·‚ÒÓ ª›· ¢‡Ô £Âڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∫·Ì›· ıÂڷ›·/·ÓÙÈÌÂÙÒÈÛË ·fi ÙÔÓ ›‰ÈÔ ∂ͤٷÛË Û ȷÙÚÈÎfi ΤÓÙÚÔ Î·È Ô‰ËÁ›Â˜ ¶·ÚÔ¯‹ ıÂڷ›·˜ ·fi È·ÙÚÈÎfi ΤÓÙÚÔ ¶·ÚÔ¯‹ ıÂڷ›·˜ Î·È Â·ÓÂͤٷÛË ∂ÈÛ·ÁˆÁ‹ Û ÓÔÛÔÎÔÌÂ›Ô ∞ÚÈıÌfi˜ ·ÓÂÍÂÙ¿ÛÂˆÓ Û ȷÙÚÈÎfi ΤÓÙÚÔ ‹ ·fi οÔÈÔÓ ÂȉÈÎfi ∫·Ì›· 1 2 3 4+ ŒÏÂÁ¯Ô˜ ÁÈ· ∆e (ηٿ ÙÂÙ¿ÓÔ˘) ÂÌ‚ÔÏÈ·ÛÌfi ¡·È Ÿ¯È ÕÁÓˆÛÙÔ ¢ÂÓ ˘‹ÚÍ ·Ó¿ÁÎË ÁÈ· ¿ÌÂÛÔ ÂÌ‚ÔÏÈ·ÛÌfi
N
%
64 92 14 25 24 11 17
25,9 37,2 5,7 10,1 9,7 4,5 6,9
44 19 9 37 20 27 22 14 32 23
17,8 7,7 3,6 15,0 8,1 10,9 8,9 5,7 13,0 9,3
158 89
64,0 36,0
13 14 125 90 5
5,3 5,7 50,6 36,4 2,0
137 68 22 11 9
55,5 27,5 8,9 4,5 3,6
130 15 15 87
81,3 9,4 9,4 -
“ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘” (50%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÛÔÚ, Ë Âη›‰Â˘ÛË, ÔÈ ˙ˆÙÈΤ˜ ·Ó¿ÁΘ, ÔÈ Â·ÁÁÂÏÌ·ÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Î·È ¿ÏϘ ·ÚÔÛ‰ÈfiÚÈÛÙ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ (15,5%, 6%, 5%, 4%, 20%, ·ÓÙ›ÛÙÔȯ·). ™ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·ÚÔÛ‰ÈfiÚÈÛÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó Î·È ÂΛӷ ÙˆÓ ·Ó‹ÏÈÎˆÓ ·È‰ÈÒÓ Ô˘ ··Û¯ÔÏÔ‡ÓÙ·È ÛÙÔÓ Â·ÁÁÂÏÌ·ÙÈÎfi ¯ÒÚÔ ÙˆÓ ÁÔÓ¤ˆÓ ‹ ¿ÏÏÔ˘ ÂÚÁÔ‰fiÙË. ™˘¯ÓfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ ·Ù˘¯‹Ì·ÙÔ˜ Â›Ó·È ÔÈ ÙÒÛÂȘ (40%), ÂÓÒ ¿ÏÏÔÈ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ Îfi„ÈÌÔ (14%), ÙÔ ÁÏ›ÛÙÚËÌ· (13%), ¿ÏÏË Ì˯·ÓÈ΋ ·ʋ (5%), ‰ËÏËÙËÚ›·ÛË (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ó˘ÁÌÒÓ Î·È ‰ËÏËÙËÚȈ‰ÒÓ ‰ËÁÌ¿ÙˆÓ) (10%), ÙËÓ ˘ÂÚÎfiˆÛË Î·È ÙËÓ ˘ÂÚ‚ÔÏÈ΋ ÚÔÛ¿ıÂÈ·
370
(6%), ÙËÓ Â·Ê‹ Ì ˙ÂÛÙ¿ ˘ÁÚ¿ (ÓÂÚfi ΢ڛˆ˜), ÙËÓ Â·Ê‹ Ì ıÂÚÌ¿ ·ÓÙÈΛÌÂÓ·, fiˆ˜ Ë ËÏÂÎÙÚÈ΋ ÎÔ˘˙›Ó·, Ë ÛfiÌ·, Ë ÂÍ¿ÙÌÈÛË (4%) Î·È ¿ÏÏ· (8,5%). ¶ÂÚÈÛÛfiÙÂÚ· ·fi Ù· 4/5 ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ (83,5%) ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÓÙfi˜ ÙˆÓ 30 ÚÒÙˆÓ ÏÂÙÒÓ, ÂÓÒ 1 ÛÙ· 8 ·Ù˘¯‹Ì·Ù· ÚÔÛ‹Ïı ÛÙËÓ È·ÙÚÈ΋ ˘ËÚÂÛ›· ηı˘ÛÙÂÚË̤ӷ, ‰ËÏ. ÌÂÙ¿ ÙȘ ÚÒÙ˜ 24 ÒÚ˜ ‹ ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔ΋˜. ™ÙȘ ÌÈÛ¤˜ ÂÚ›Ô˘ ÂÚÈÙÒÛÂȘ (47%), ÙËÓ ÒÚ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ ·Ú¢ڛÛÎÔÓÙ·Ó Ê›ÏÔÈ Î·È ‰È¿ÊÔÚ· ͤӷ ¿ÙÔÌ·, Û ÔÛÔÛÙfi 30% ·Ú¢ڛÛÎÔÓÙ·Ó ÔÈ ÁÔÓ›˜, ÛÙÔ 10,5% Û˘ÁÁÂÓ›˜ ‹ ÛÙÔ 12,5% ηӤӷ˜. ™ÙÔÓ ¶›Ó·Î· 4 Ê·›ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ ·Ó¿ÏÔÁ· Ì ÙȘ ¶ª Ù˘ οΈÛ˘, fiˆ˜ ÙÔ Â›‰Ô˜ Ù˘ ‚Ï¿‚˘, ÙÔ ÚÔÛ‚ÏËı¤Ó ̤ÚÔ˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, Ô ·ÚÈıÌfi˜ ÙˆÓ ‚Ï·‚ÒÓ, Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË, Ô ·ÚÈıÌfi˜ ÙˆÓ Â·ÓÂÍÂÙ¿ÛÂˆÓ Î·È Ë Î¿Ï˘„Ë Ì ÂÌ‚fiÏÈÔ ÙÂÙ¿ÓÔ˘ (Te). ∆Ô Û˘¯ÓfiÙÂÚÔ Â›‰Ô˜ ‚Ï¿‚˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È Â›Ó·È ÙÔ ÙÚ·‡Ì· (63%) Î·È È‰È·›ÙÂÚ· ÙÔ ·ÓÔȯÙfi ÙÚ·‡Ì· (37%). ∞ÎÔÏÔ˘ıÔ‡Ó Ù· ‰È·ÛÙÚ¤ÌÌ·Ù·-ÂÍ·ÚıÚ‹Ì·Ù· (10%), ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ (10%), Ù· ηٿÁÌ·Ù· (6%) Î·È Ù· ÂÁη‡Ì·Ù· (4,5%). Ÿˆ˜ ÚԷӷʤÚıËÎÂ, ÛÙȘ ‰ËÏËÙËÚÈ¿ÛÂȘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È Ù· ÙÛÈÌ‹Ì·Ù· ·fi ÛʋΘ - ̤ÏÈÛÛ˜ Î·È ¿ÏÏ· ‰ËÏËÙËÚÈÒ‰Ë ¤ÓÙÔÌ· Î·È ·Ú¿ÛÈÙ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÓÙfiÈÛË ÛÙÔ ÛÒÌ·, ÙÔ 29% ÙˆÓ Î·ÎÒÛÂˆÓ ÂÓÙÔ›˙ÂÙ·È ÛÙËÓ ÎÂÊ·Ï‹ (ÚfiÛˆÔ, ÎÚ·Ó›Ô, ÛÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ·), ÙÔ 34% ÛÙ· ¿Óˆ ¿ÎÚ· (‰¿ÎÙ˘Ï·, ·ÓÙÈ‚Ú¿¯ÈÔ Î·È ¿ÏÏ· ̤ÚË ¿Óˆ ¿ÎÚÔ˘), ÙÔ 27,5% ÛÙ· οو ¿ÎÚ· (Ô‰ÔÎÓËÌÈ΋ ¿ÚıÚˆÛË (¶¢∫∞), ÁfiÓ·ÙÔ, ¿ÏÏ· ̤ÚË Î¿Ùˆ ¿ÎÚˆÓ) Î·È ÙÔ 9% ÛÙÔÓ ÎÔÚÌfi. ∏ ¿ÚıÚˆÛË Ô˘ ÚÔÛ‚¿ÏÏÂÙ·È Û˘¯ÓfiÙÂÚ· Â›Ó·È Ë ¶¢∫∞. ™ÙÔ 1/3 ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û˘Ó˘‹Ú¯·Ó Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ‚Ï¿‚˜, Ë Ì›· ÂÎ ÙˆÓ ÔÔ›ˆÓ ‹Ù·Ó ΢ڛˆ˜ ÙÚ·‡Ì·. £Âڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ¯ÚÂÈ¿ÛÙËΠ۠ÔÛÔÛÙfi >88% ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÂÓÒ Û ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ (36,5%) Û˘ÓÂÛÙ‹ıË Â·ÓÂͤٷÛË. ™Â ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ (2%), Ô ·ÛıÂÓ‹˜ ÂÈÛ‹¯ıË Û ¡ÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ‚·Ú¤Ô˜ ·Ù˘¯‹Ì·ÙÔ˜ (·ÊÔÚ¿ ÛÙÔ ÚÒÙÔ ·Ù‡¯ËÌ·). ∫·Ù·ÁÚ¿ÊËÎÂ, ›Û˘, ¤Ó·˜ ı¿Ó·ÙÔ˜ ·fi ‰Â‡ÙÂÚÔ ·Ù‡¯ËÌ· ÚÈÓ ÚÔÏ¿‚ÂÈ Ô ·ÛıÂÓ‹˜ Ó· ÂÈÛ·¯ı› Û ¡ÔÛÔÎÔÌ›Ô. ¶ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÌÈÛ¿ ¿ÙÔÌ· Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· ÂÈÛΤÊıËÎ·Ó ÌfiÓÔ Ì›· ÊÔÚ¿ ÙÔ È·ÙÚÈÎfi ΤÓÙÚÔ (55,5%), ÂÓÒ ÔÈ ˘fiÏÔÈÔÈ ¯ÚÂÈ¿ÛÙËÎ·Ó 1Ë (27,5%), 2Ë (9%), 3Ë (4,5%) ‹ Î·È 4Ë (3,5%) ·ÓÂͤٷÛË. ∆Ô 81% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ· Î·È ·ÚÔ˘Û›·˙·Ó χÛË Û˘Ó¯›·˜ ‰¤ÚÌ·ÙÔ˜ ‹Ù·Ó Î·Ï˘Ì̤ÓÔ Ì ·ÓÙÈÙÂÙ·ÓÈÎfi ÂÌ‚fiÏÈÔ, ÙÔ 9,5% ÙˆÓ ˘ÔÏÔ›ˆÓ
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
‹Ù·Ó ·Î¿Ï˘ÙÔ, ÂÓÒ ¤Ó· ÔÛÔÛÙfi 9,5% ‰ÂÓ ÁÓÒÚÈ˙ ÙËÓ Î·Ù¿ÛÙ·ÛË ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙÔ˘. ™ÙÔÓ ¶›Ó·Î· 5, Ê·›ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ì ‚¿ÛË ÎÔÈÓˆÓÈÎÔ-‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ (∫¢ª) Î·È Û ۯ¤ÛË Ì 2 ÛÂÈÚ¤˜ Ì·ÚÙ‡ÚˆÓ, ·ÓÙ›ÛÙÔȯ˜ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ. OÈ ∫¢ª Ô˘ ÂÍÂÙ¿ÛÙËηÓ, Û‡Ìʈӷ Ì ÙÔÓ ¶›Ó·Î·, ‹Ù·Ó ÙÔ Ê‡ÏÔ Î·È Ë ËÏÈΛ· ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ›¯Â ÙÔ ·Ù‡¯ËÌ·, Ë ËÏÈΛ· Î·È Ë Âη›‰Â˘ÛË ÙÔ˘ ·Ù¤Ú·, Ë ··Û¯fiÏËÛË ÙÔ˘ ·ÙfiÌÔ˘ ·˘ÙÔ‡, Ë ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∂›Û˘, ÂÍÂÙ¿ÛÙËÎ·Ó Ë ÛÂÈÚ¿ Á¤ÓÓËÛ˘, Ô ·ÚÈıÌfi˜ ÙˆÓ ‰ˆÌ·Ù›ˆÓ ÙÔ˘ ÛÈÙÈÔ‡ ·Ó¿ ¿ÙÔÌÔ, ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi ·Ù˘¯‹Ì·ÙÔ˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ‰È¿ÊÔÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜, fiˆ˜ Ô ÛÙÚ·‚ÈÛÌfi˜ ‹ ¿ÏϘ ÔÊı·ÏÌÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ, ηıÒ˜ Î·È Ù· ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο (™ªª) Î·È ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ. OÈ Û˘Û¯ÂÙ›ÛÂȘ ÙÔ˘ ¶›Ó·Î· 5 Â›Ó·È ÌÂÓ ÂÓ‰ÂÈÎÙÈΤ˜, ‰ÂÓ ÌÔÚÔ‡Ó fï˜ Ó· ıˆÚËıÔ‡Ó ·ÈÙÈÔÏÔÁÈΤ˜ ÏfiÁˆ ·ÌÔÈ‚·›ˆÓ Û˘Á¯˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ™ÙÔÓ ¶›Ó·Î· 6, Ô ÔÔ›Ô˜ Û˘Ì‚¿ÏÏÂÈ È‰È·›ÙÂÚ· ÛÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ, ‰ÈÂÚ¢ӋıËΠ̠ÙË Ì¤ıÔ‰Ô Ù˘ ‰ÂÛÌÂ˘Ì¤Ó˘ ÏÔÁ·ÚÈıÌÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘, Ë ÂÍ¿ÚÙËÛË ÁÈ· ·Ù‡¯ËÌ· ·fi 11 ∫¢ª Ô˘ ÂÍÂÙ¿ÛÙËηÓ. º·›ÓÂÙ·È, ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫), Ù· 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O∞) Î·È Ë ÙÈÌ‹ ÙÔ˘ ÎÚÈÙËÚ›Ô˘ ƒ ÁÈ· ·Ù‡¯ËÌ· Ì ‚¿ÛË ÙȘ ∫¢ª Ô˘ ÌÂÏÂÙ‹ıËηÓ. O ΛӉ˘ÓÔ˜ ‹ Ë ÚԉȿıÂÛË ÁÈ· ·Ù‡¯ËÌ· ÌÂÈÒÓÂÙ·È Î·Ù¿ 16% ÁÈ· οı ¤ÓÙ ¤ÙË ·‡ÍËÛ˘ Ù˘ ËÏÈΛ·˜ ÙÔ˘ ·Ù¤Ú·, ÛÂ Â›Â‰Ô ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi (p=0,04) Î·È Î·Ù¿ 8% ÁÈ· οı 3 ÂÈϤÔÓ ¤ÙË Âη›‰Â˘Û˘ ÙÔ˘ ·Ù¤Ú·, ÛÂ Â›Â‰Ô Ô˘ Ù›ÓÂÈ Ó· Á›ÓÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi (p=0,09). ™ÙÔÓ ›‰ÈÔ ¶›Ó·Î· Ê·›ÓÂÙ·È fiÙÈ Ë ÚÔÛˆÈ΋ ÂÚÁ·Û›· Î·È Ë ··Û¯fiÏËÛË ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ù˘¯‹Ì·ÙÔ˜. §·Ì‚¿ÓÔÓÙ·˜ ˆ˜ ÏËı˘ÛÌfi ·Ó·ÊÔÚ¿˜ Ù· ¿ÙÔÌ· Ô˘ ‰ÂÓ ÂÚÁ¿˙ÔÓÙ·È, ‚Ï¤Ô˘Ì fiÙÈ Ë ÌË ··Û¯fiÏËÛË ÌÂÈÒÓÂÈ Î·Ù¿ 48% ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ·Ù‡¯ËÌ· ÛÂ Â›Â‰Ô ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi (p=0,03). ∏ Û˘Ì‚›ˆÛË Ì ¤ÁÁ·ÌË ÌËÙ¤Ú· Î·È ÁÂÓÈο Ë ‡·ÚÍË ÔÈÎÔÁ¤ÓÂÈ·˜ fiÔ˘ ‰ÂÓ ·Ô˘ÛÈ¿˙ÂÈ Ë ÌËÙ¤Ú· (ÏfiÁˆ ı·Ó¿ÙÔ˘ ‹ ‰È·˙˘Á›Ô˘), Ë ‡·ÚÍË ÂÓfi˜ ÂÈϤÔÓ Ì¤ÏÔ˘˜ Î·È Ë ÛÂÈÚ¿ Á¤ÓÓËÛ˘ ÙÔ˘ ·ÙfiÌÔ˘ ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ·Ù‡¯ËÌ·. ∂ÈϤÔÓ, ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÚԉȿıÂÛ˘ ÁÈ· ·Ù‡¯ËÌ· Î·È ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÈÙÈÔ‡ (·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi ‰ˆÌ·Ù›ˆÓ ·Ó¿ ¿ÙÔÌÔ) Ô˘ ‰È·Ì¤ÓÂÈ ÙÔ ¿ÙÔÌÔ Ô˘ ÂÌϤÎÂÙ·È Û ·Ù‡¯ËÌ·. £ÂˆÚÒÓÙ·˜ ˆ˜ ÏËı˘ÛÌfi ·Ó·ÊÔÚ¿˜ Ù· ¿ÙÔÌ· Ô˘ ‰È·Ì¤ÓÔ˘Ó Û ۛÙÈ· fiÔ˘ ·Ó·ÏÔÁÔ‡Ó 0,5-0,74 ‰ˆÌ¿ÙÈ· ·Ó¿ ¿ÙÔÌÔ ÔÈÎÔÁ¤ÓÂÈ·˜, ‚Ú¤ıËΠfiÙÈ Û ۛÙÈ· Ì ÔÏ-
Paediatriki 2003;66:364-380
Ï¿ ‰ˆÌ¿ÙÈ· Î·È Ì ·Ó·ÏÔÁ›· ‰ˆÌ·Ù›ˆÓ ¿Óˆ ·fi 0,75 ·Ó¿ ¿ÙÔÌÔ, Ô Î›Ó‰˘ÓÔ˜ ·Ù˘¯‹Ì·ÙÔ˜ Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈÔ˜ (™∫: 1,78 Ì 95% O∞: 1,11-2,88) Î·È Ë Û¯¤ÛË Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p=0,02). ∏ ·Ó·ÏÔÁ›· <0,5 ‰ˆÌ¿ÙÈ· ·Ó¿ ¿ÙÔÌÔ ‚Ú¤ıËΠӷ ÌËÓ Û¯ÂÙ›˙ÂÙ·È Ì ·Ù‡¯ËÌ· (™∫: 1,29 Ì 95% O∞: 0,87-1,93) (p=0,20). ∆Ô ÂÈ‚·Ú˘Ì¤ÓÔ ÈÛÙÔÚÈÎfi Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ÂÚÈÛÛfiÙÂÚ· ·fi 2 ·Ù˘¯‹Ì·Ù· ÛÙÔ ·ÚÂÏıfiÓ (Û˘ÓÔÏÈο Û fiÏ· Ù· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜), Û ۯ¤ÛË Ì ÙÔÓ ÏËı˘ÛÌfi ·Ó·ÊÔÚ¿˜ (ÏÈÁfiÙÂÚ· ·fi 2 ·Ù˘¯‹Ì·Ù· Û˘ÓÔÏÈο), Úԉȷı¤ÙÂÈ Û ÚfiÎÏËÛË ·Ù˘¯‹Ì·ÙÔ˜ Û ¿ÙÔÌ· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ËÏÈΛ·˜ οو ÙˆÓ 24 ÂÙÒÓ, ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ¿Óˆ ·fi ÌÈ¿ÌÈÛË ÊÔÚ¿ (™∫: 1,59 Ì 95% O∞: 0,94-2,67), ÛÂ Â›Â‰Ô Ô˘ Ù›ÓÂÈ Ó· Â›Ó·È ÛËÌ·ÓÙÈÎfi (p=0,08). ∆¤ÏÔ˜, Ë Î·Ù¿ÛÙ·ÛË ÙˆÓ ÔÊı·ÏÌÒÓ Î·È Ù· ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο (™ªª) ‚Ú¤ıËÎ·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ Î›Ó‰˘ÓÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ ÔÊı·ÏÌÒÓ, Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ fiÏ· Ù· ·È‰È¿ Ô˘ ›¯·Ó ÔÊı·ÏÌÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ÊÔÚÔ‡Û·Ó ‰ÈÔÚıˆÙÈο Á˘·ÏÈ¿. ∂ȉÈÎfiÙÂÚ·, ·Ú·ÙËÚ‹ıËΠfiÙÈ Ù· ¿ÙÔÌ· Ì ÔÊı·ÏÌÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÁÈ· ÂÌÊ¿ÓÈÛË ·Ù˘¯‹Ì·ÙÔ˜, Ë ÔÔ›· ‹Ù·Ó ¤ÓÙ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Û ·˘ÙÔ‡˜ Ô˘ ¤·Û¯·Ó ·fi ÛÙÚ·‚ÈÛÌfi (™∫: 5,43 Ì 95% O∞: 1,02-28,09) Î·È ÛÂ Â›Â‰Ô ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi (p=0,04), Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙÒÈ˙·Ó ·Ó¿ÏÔÁ· ÚÔ‚Ï‹Ì·Ù·. µ¤‚·È·, ·˘Ùfi ÙÔ Â‡ÚËÌ· Ú¤ÂÈ Ó· ‰ÈÂÚ¢ÓËı›, ÁÈ·Ù› ÙÔ ‰Â›ÁÌ· ÙˆÓ ·È‰ÈÒÓ Ì ÛÙÚ·‚ÈÛÌfi ‹Ù·Ó Ôχ ÌÈÎÚfi, fiˆ˜ Ê·›ÓÂÙ·È Î·È ·fi ÙÔÓ ¶›Ó·Î·. °È· ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ··ÈÙÂ›Ù·È Ô ¤ÏÂÁ¯Ô˜ ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈıÌÔ‡ ·ÙfïÓ. ÕÏϘ ·ı‹ÛÂȘ fiˆ˜ ·Ì‚Ï˘ˆ›·, Ì˘ˆ›·, Ù‡ÊψÛË, ˘ÂÚÌÂÙÚˆ›·, Ó˘ÛÙ·ÁÌfi˜ ‹ ·ÛÙÈÁÌ·ÙÈÛÌfi˜ (™∫: 1,24), ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ·Ù‡¯ËÌ· (p=0,45). À‹Ú¯Â, ›Û˘, ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ·. ™˘ÁÎÂÎÚÈ̤ӷ, ‚Ú¤ıËΠfiÙÈ ÁÈ· οı 15% ÂÈϤÔÓ ·‡ÍËÛË Ù˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜, Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ·Ù‡¯ËÌ· ÌÂÈÒÓÂÙ·È Î·Ù¿ 14% Î·È Ë Ì›ˆÛË ·˘Ù‹ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p=0,04). ∞ÓÙ›ıÂÙ·, ÙÔ ‡„Ô˜ ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ Î›Ó‰˘ÓÔ ·Ù˘¯‹Ì·ÙÔ˜. ™ÙÔÓ Û˘ÁÎÂÓÙÚˆÙÈÎfi ¶›Ó·Î· ÔÌ·‰ÔÔ›ËÛ˘ ËÏÈÎÈÒÓ Î·È ·Ó¿Ï˘Û˘ ηٿ Û˘ÛÙ¿‰Â˜ (¶›Ó·Î·˜ 7), Û˘ÁÎÚ›ÓÔÓÙ·˜ ÔÚÈ˙fiÓÙÈ· ·ÏÏ¿ Î·È Î¿ıÂÙ· Ù· ·ÔÙÂϤÛÌ·Ù·, Ê·›ÓÂÙ·È fiÙÈ: ·) ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ, ΢ڛˆ˜ ÎÔÚ›ÙÛÈ·, ˘Ê›ÛÙ·ÓÙ·È ÂÁη‡Ì·Ù· ·fi ·ʋ Ì ˙ÂÛÙ¿ ·ÓÙÈΛÌÂÓ· Î·È ˘ÁÚ¿ ‹ ÂÏ·ÊÚ¤˜ ηÎÒÛÂȘ ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔÓ ÎÔÚÌfi ·fi ÙÒÛÂȘ ̤۷ Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ, Ù· ™·‚‚·ÙÔ·Úȷη (™∫) ÙÔ˘ ÊıÈÓÔÒÚÔ˘, ‚) ·È‰È¿ ËÏÈΛ·˜ 5-9 ÂÙÒÓ ˘Ê›ÛÙ·ÓÙ·È ·ÓÔȯٿ
371
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Paediatriki 2003;66:364-380
¶›Ó·Î·˜ 5. ∫·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ (0-24 ÂÙÒÓ), ηÙÔ›ÎˆÓ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘ Î·È ÙˆÓ 494 Ì·ÚÙ‡ÚˆÓ ·ÓÙ›ÛÙÔȯˆÓ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ, ·Ó¿ÏÔÁ· Ì ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ ªÂÙ·‚ÏËÙ‹ º‡ÏÔ ∞ÁfiÚÈ ∫ÔÚ›ÙÛÈ ∏ÏÈΛ· (¤ÙË) <5 5-9 10-14 15-19 20+ ¶·ÙÚÈ΋ ËÏÈΛ· (¤ÙË) <35 35-39 40-44 45-49 50-54 55-59 60+ ∂η›‰Â˘ÛË ÙÔ˘ ·Ù¤Ú· (¤ÙË) <6 6 7-9 10-11 12 13-15 16+ ∂ÚÁ·˙fiÌÂÓÔ˜ ¡·È Ÿ¯È OÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË ÌËÙ¤Ú·˜ ÕÁ·ÌË ‹ ·Ô‚ÈÒÛ·Û· ŒÁÁ·ÌË ∞ÚÈıÌfi˜ ·È‰ÈÒÓ 1 2 3 4+ ™ÂÈÚ¿ Á¤ÓÓËÛ˘ 1 2 3 ≥4 ∞ÚÈıÌfi˜ ‰ˆÌ·Ù›ˆÓ ·Ó¿ ¿ÙÔÌÔ <0,5 0,5 0,51-0,74 0,75+ πÛÙÔÚÈÎfi ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· <2 ·Ù˘¯‹Ì·Ù· 2+ ¶Úfi‚ÏËÌ· fiÚ·Û˘ ™ÙÚ·‚ÈÛÌfi˜ ÕÏÏÔ ÃˆÚ›˜ Úfi‚ÏËÌ· ¶Úfi‚ÏËÌ· ·ÎÔ‹˜ ¡·È Ÿ¯È ∂ηÙÔÛÙÈ·›· ı¤ÛË ‚¿ÚÔ˘˜ (%) <25
372
¶ÂÚÈÙÒÛÂȘ N (%)
ª¿ÚÙ˘Ú˜ N (%)
∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘ (p-value) ∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹
162 85
65,6 34,4
324 170
65,6 34,4
39 67 64 45 32
15,8 27,1 25,9 18,2 13,0
78 135 124 93 64
15,8 27,3 25,1 18,8 13,0
35 42 69 39 27 20 15
14,2 17,0 27,9 15,8 10,9 8,1 6,1
49 96 110 102 56 44 37
9,9 19,4 22,3 20,7 11,3 8,9 7,5
21 84 48 18 42 20 14
8,5 34,0 19,4 7,3 17,0 8,1 5,7
38 158 96 29 83 42 48
7,7 32,0 19,4 5,9 16,8 8,5 9,7
43 204
17,4 82,6
59 435
11,9 88,1
7 240
2,8 97,2
8 486
1,6 98,4
32 142 62 11
13,0 57,5 25,1 4,5
47 292 126 29
9,5 59,1 25,5 5,9
117 93 34 3
47,4 37,6 13,8 1,2
218 198 65 13
44,1 40,1 13,2 2,6
67 82 55 43
27,1 33,2 22,3 17,4
119 191 124 60
24,1 38,7 25,1 12,1
217 30
87,9 12,1
451 43
91,3 8,7
6 26 215
2,5 10,5 87,0
2 49 443
0,4 9,9 89,7
3 244
1,2 98,8
9 485
1,8 98,2
18
7,3
23
4,7
∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹
0,13
0,17
0,04
0,26
0,23
0,36
0,45
0,13
0,04
0,53
0,06
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
ªÂÙ·‚ÏËÙ‹
¶ÂÚÈÙÒÛÂȘ N (%)
ª¿ÚÙ˘Ú˜ N (%)
25-49 50-74 75-89 90-96 97+ ∂ηÙÔÛÙÈ·›· ı¤ÛË ‡„Ô˘˜ (%) <25 25-49 50-74 75-89 90-96 97+
24 53 58 51 43
9,7 21,5 23,5 20,6 17,4
41 96 127 101 106
8,3 19,4 25,7 20,4 21,5
23 22 47 56 44 55
9,3 8,9 19,0 22,7 17,8 22,3
38 45 98 99 103 111
7,7 9,1 19,8 20,0 20,9 22,5
∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘ (p-value)
0,56
΢ڛˆ˜ ÙÚ·‡Ì·Ù· (Ì›· οΈÛË) ÛÙ· οو ¿ÎÚ· Î·È ÙÔÓ ÎÔÚÌfi ·fi ÎÔÊÙÂÚ¿/·È¯ÌËÚ¿ ·ÓÙÈΛÌÂÓ· Î·È Î·Ù¿ ‰Â‡ÙÂÚÔ ÏfiÁÔ ·fi ÙÒÛÂȘ, ÙÔ˘˜ ηÏÔηÈÚÈÓÔ‡˜ Ì‹Ó˜, ¤Íˆ ·fi ÙÔ Û›ÙÈ, Û ¯ÒÚÔ˘˜ ·ıÏԷȉÈÒÓ Î·È „˘¯·ÁˆÁ›·˜/·È¯ÓȉÈÔ‡, Á) ÛÙȘ ËÏÈ˘ 10-14 ÂÙÒÓ ÂÈÎÚ·ÙÔ‡Ó Ù· ·ÁfiÚÈ·, Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È Û˘Ó‹ıˆ˜ 2 ›‰Ë ηÎÒÛˆÓ, ÎÏÂÈÛÙ¤˜ ηÎÒÛÂȘ Î·È Î·Ù¿ÁÌ·Ù· ÛÙ· ¿Óˆ ¿ÎÚ· ·fi ¯Ù˘‹Ì·Ù· Î·È ¿ÏϘ Ì˯·ÓÈΤ˜ ·ʤ˜, ηıÒ˜ Î·È ÙÒÛÂȘ, ÙȘ ÂÚÁ¿ÛÈ̘ Ë̤Ú˜ ÙÔ˘ ÊıÈÓÔÒÚÔ˘ Î·È Ù˘ ¿ÓÔÈ͢, ¤Íˆ ·fi ÙÔ Û›ÙÈ, ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜ Î·È ÙÔ˘˜ ¯ÒÚÔ˘˜ ·È¯ÓȉÈÒÓ, ·ıÏԷȉÈÒÓ Î·È ÙÔ˘ Û¯ÔÏ›Ԣ Î·È ‰) ÔÈ ¤ÊË‚ÔÈ Î·È ÔÈ Ó¤ÔÈ ËÏÈΛ·˜ 15-24 ÂÙÒÓ ˘Ê›ÛÙ·ÓÙ·È Î·ÎÒÛÂȘ οو ¿ÎÚˆÓ (‰È·ÛÙÚ¤ÌÌ·Ù·, ÂÍ·ÚıÚ‹Ì·Ù·, ηٿÁÌ·Ù·) ÌÂÙ¿ ·fi ÎfiˆÛË/ ˘ÂÚÚÔÛ¿ıÂÈ· Î·È ÙÒÛÂȘ, ηٿ ÙË ‰È¿ÚÎÂÈ· ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔًوÓ, Ù· ™·‚‚·ÙÔ·Úȷη Ù˘ ¿ÓÔÈ͢ Î·È ÙÔ˘ ¯ÂÈÌÒÓ·. ™˘˙‹ÙËÛË ∏ ·ÚÔ‡Û· ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË Î·Ù¤ÁÚ·„ ÚÔÔÙÈο Î·È ·ÓÙÈÚÔÛˆÂ˘ÙÈο, ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜ (1994-1995), fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Î·Ï‡ÙÂÚ· ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ¤Ó· ÁÓˆÛÙfi ËÌÈ·ÛÙÈÎfi ÏËı˘ÛÌfi 1327 ·ÙfïÓ, ËÏÈΛ·˜ οو ÙˆÓ 24 ÂÙÒÓ. ∂Ȃ‚·›ˆÛ ÁÈ· ¿ÏÏË Ì›· ÊÔÚ¿ ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·ÈÙÈÔÏÔÁ›· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È ÙÔ Ì¤ÁÂıÔ˜ ·˘ÙÔ‡ ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ Û ÙÔÈÎfi Î·È ÂıÓÈÎfi Â›Â‰Ô (2-7,11,13,31-36,40,41). ™ËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô Ù˘ ¤Ú¢ӷ˜ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ 50% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠˆ˜ Û‡ÓÔÏÔ ‚·ÛÈÎÒÓ ÂÚÈÙÒÛÂˆÓ Î·È Ì·ÚÙ‡ÚˆÓ (741 ¿ÙÔÌ·), ÂÓÒ 69 Ì¿ÚÙ˘Ú˜ ÂÓÂÏ¿ÎËÛ·Ó ÙÂÏÈο Û ·Ù‡¯ËÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ Ô˘ ÌÂÏÂÙ‹ıËÎÂ. OÈ Ì¿ÚÙ˘Ú˜ ·˘ÙÔ› ‰ÂÓ ÂÍ·ÈÚ¤ıËηÓ, ·ÏÏ¿ ÌÂÏÂÙ‹ıËÎ·Ó Î·È ˆ˜ Ì¿ÚÙ˘Ú˜ Î·È ˆ˜ ¿ÙÔÌ· Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ·, Û‡Ìʈӷ Ì fi,ÙÈ ÚÔÙ›ÓÂÙ·È ·fi ÙÔÓ Miettinen (1985). ∂Í¿ÏÏÔ˘, Ô ÂÚÈÔÚÈÛÌfi˜ Ô˘ Ù›ıÂ-
Ù·È ÛÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ¤Ú¢ӷ˜ ·ÊÔÚ¿ ÛÙÔ ÁÂÁÔÓfi˜ Ó· ÌËÓ ¤¯ÂÈ ¿ıÂÈ ·Ù‡¯ËÌ· Ô Ì¿ÚÙ˘Ú·˜ ÙÔÓ ÙÂÏÂ˘Ù·›Ô Ì‹Ó· ÚÈÓ ·fi ÙÔ ·Ù‡¯ËÌ· Ù˘ ·ÓÙ›ÛÙÔȯ˘ µ¶. ∂ÈϤÔÓ, Ë Û˘ÏÏÔÁ‹ ÙˆÓ ÛÙÔȯ›ˆÓ, fiˆ˜ ÚԷӷʤÚıËÎÂ, ¤ÁÈÓ ·fi Ì›· ·È‰›·ÙÚÔ Ù˘ ÂÚÈÔ¯‹˜, Ë ÔÔ›· ÁÓÒÚÈ˙ Ôχ ηϿ ÙÔ ‰Â›ÁÌ· Î·È Û˘Ó¤‚·Ï ÛÙÔ Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ï‹Ú˘ Û˘ÓÂÚÁ·Û›· Î·È ÂÈÏÈÎÚÈÓ‹˜ ¤ÎıÂÛË ÙˆÓ ÛÙÔȯ›ˆÓ. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ, ÌÂÈÒıËÎÂ Ë Èı·ÓfiÙËÙ· ÛÊ¿ÏÌ·ÙÔ˜ ÏfiÁˆ ‰È·ÊÔÚÂÙÈÎÒÓ Ù¯ÓÈÎÒÓ Ï‹„˘ ÏËÚÔÊÔÚÈÒÓ, Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ¤Ú¢Ó˜ Ô˘ ··Û¯ÔÏÔ‡Ó ÔÏÏ¿ ¿ÙÔÌ· ÛÙË Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ (33). ∏ ηıÔÏÈÎfiÙËÙ· ÛÙË Û˘ÌÌÂÙÔ¯‹ Î·È Ë ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙȘ Û˘ÓÂÓÙ‡ÍÂȘ ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ, ‰›ÓÔ˘Ó ÌÂÁ·Ï‡ÙÂÚË ·Í›· ÛÙË ÌÂϤÙË. ∏ ηٷÁÚ·Ê‹ ‹Ù·Ó fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Î·Ï‡ÙÂÚË, ·Ó ÏËÊı› ˘’ fi„ÈÓ fiÙÈ Û 247 ¿ÙÔÌ· Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ· ηٷÁÚ¿ÊËÎ·Ó 306 ·Ù˘¯‹Ì·Ù·, ÛÙ· ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È 59 ‰Â‡ÙÂÚ·, ÙÚ›Ù· Î·È Ù¤Ù·ÚÙ· ·Ù˘¯‹Ì·Ù· ·ıÚÔÈÛÙÈο Ô˘ ·ÊÔÚÔ‡Û·Ó 53 ¿ÙÔÌ· ·fi Ù· 247 Ô˘ ÌÂÏÂÙ‹ıËηÓ. ∞fi ÙËÓ ˘¿Ú¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔÈ¯Ë ÚÔÔÙÈ΋ ÌÂϤÙË Ô˘ Ó· ηٷÁÚ¿ÊÂÈ ÙfiÛÔ ÏÂÙÔÌÂÚÒ˜ ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Û ÙÔÈÎfi ›‰Ô. ∏ ÔÏÔÎÏËڈ̤ÓË Î·È Ï‹Ú˘ ηٷÁÚ·Ê‹ ·fi fiÏÔ˘˜ ÙÔ˘˜ ¯ÒÚÔ˘˜ fiÔ˘ Û˘Ó¤‚ËÛ·Ó ·Ù˘¯‹Ì·Ù· ÙËÓ ÂÚ›Ô‰Ô Ô˘ ÌÂÏÂÙ‹ıËÎÂ, η٤‰ÂÈÍ ȉȷ›ÙÂÚ· ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ £ÂÛÛ·Ï›·˜ Î·È ÂȉÈο ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘. ª¿ÏÈÛÙ·, Ë Â›ÙˆÛË ÛÙ· ·ÁfiÚÈ· ËÏÈΛ·˜ 10-14 ÂÙÒÓ ÊÙ¿ÓÂÈ ÙÔ 29%. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ Î¿ÙÔÈÎÔÈ Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘ ÂÈÛΤÙÔÓÙ·È Û˘¯ÓfiÙÂÚ· Î·È Â˘ÎÔÏfiÙÂÚ· ÙËÓ È·ÙÚÈ΋ ˘ËÚÂÛ›· ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜, Û ۯ¤ÛË Ì ÙÔ˘˜ ηÙÔ›ÎÔ˘˜ Ô˘ ‰È·Ì¤ÓÔ˘Ó Û ÌÂÁ·Ï‡ÙÂÚË ·fiÛÙ·ÛË Î·È ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÚÔ‚Ï‹Ì·Ù· ÌÂÙ·ÊÔÚ¿˜ ÚÔ˜ ÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜. ¶ÚÔÙÈÌÔ‡Ó Ó· ·Â˘ı‡ÓÔÓÙ·È ÛÙÔ˘˜ ÂȉÈÎÔ‡˜, ·ÎfiÌË Î·È ÁÈ· ·Ù˘¯‹Ì·Ù· ÂÏ·ÊÚÈ¿˜ ÌÔÚÊ‹˜. ∏ ηٿ¯ÚËÛË ÙˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È
373
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
Î·È ·fi ÚfiÛÊ·ÙË ÌÂϤÙË Ô˘ ·ÊÔÚ¿ ÛÙËÓ ·ÓˆÙ¤Úˆ ˘ÁÂÈÔÓÔÌÈ΋ ÂÚÈʤÚÂÈ·, Ë ÔÔ›· Û˘ÁÎÚ›ÓÂÈ ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ¤¯ÂÈ ˘ÔÛÙ› ·Ù‡¯ËÌ· Ù˘ ÂÚÈÔ¯‹˜ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘ Î·È Ù˘ Á‡Úˆ ˘ÁÂÈÔÓÔÌÈ΋˜ ÂÚÈʤÚÂÈ·˜, fiˆ˜ ÙÔ˘ ¢‹ÌÔ˘ ∫¿ÚÏ·˜, ηıÒ˜ ›Û˘ Î·È ÙˆÓ ‰ÈÂÚ¯fiÌÂÓˆÓ Ô˘ ‰ÂÓ ‹Ù·Ó οÙÔÈÎÔÈ Ù˘ ˘ÁÂÈÔÓÔÌÈ΋˜ ÂÚÈʤÚÂÈ·˜ (13,42). ∏ Û˘ÁÎÂÎÚÈ̤ÓË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Î·ÙÔ›ÎˆÓ ÙÔ˘ µÂÏÂÛÙ›ÓÔ˘ Û˘Ì‚¿ÏÏÂÈ ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÛÙËÓ ·‡ÍËÛË Ù˘ ›وÛ˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÂÚÈÔ¯‹. ™‡Ìʈӷ Ì ÏËıÒÚ· ÌÂÏÂÙÒÓ, Ë Â›ÙˆÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙ· ·ÁfiÚÈ·, Ì ‰È·Î˘Ì¿ÓÛÂȘ ÛÙË Û˘¯ÓfiÙËÙ· ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔÓ Ù‡Ô ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ (2-7,11-13,30,35,43). ª¿ÏÈÛÙ·, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Â›ÙˆÛË ÁÈ· ·Ù‡¯ËÌ· ÛÙ· ·ÁfiÚÈ· Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈ· Û ۯ¤ÛË Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÎÔÚ›ÙÛÈ· (2:1) (2,3,5,7,1115,19,20,24,25,30,42), ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÚÔ¯·›·, Ë ·Ó·ÏÔÁ›· ͤڷÛ ÙË ‰ÈÂıÓÒ˜ ·Ó·ÊÂÚfiÌÂÓË 3/1 (·ÁfiÚÈ·/ÎÔÚ›ÙÛÈ·). ∂›Ó·È Èı·Ófi Ù· ·ÁfiÚÈ· Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÚÈ„ÔΛӉ˘Ó· ‹ Ó· ÂÎÙ›ıÂÓÙ·È ÂÚÈÛÛfiÙÂÚÔ Û ÎÈÓ‰‡-
ÓÔ˘˜, ηıÒ˜ Ô‰ËÁÔ‡Ó Û˘¯ÓfiÙÂÚ· ·fi Ù· ÎÔÚ›ÙÛÈ·. ∂›Û˘, ¤Ó·˜ ÏfiÁÔ˜ Ô˘ ›Ûˆ˜ Û˘Ì‚¿ÏÏÂÈ ÛÙË ÌÂÁ·Ï‡ÙÂÚË ¤ÎıÂÛË ÙˆÓ ·ÁÔÚÈÒÓ Û ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Â›Ó·È fiÙÈ ÔÏÏ¿ ·fi Ù· ·ÁfiÚÈ· Ù˘ ÂÚÈÔ¯‹˜ ËÏÈΛ·˜ οو ÙˆÓ 18 ÂÙÒÓ ÂÚÁ¿˙ÔÓÙ·È Î·È, ¿Ú·, ÌÂÙ·ÎÈÓÔ‡ÓÙ·È ÈÔ Û˘¯Ó¿. ∏ ÏÂÙÔÌÂÚ¤ÛÙÂÚË ·Ó¿Ï˘ÛË ÙÔ˘ ˘ÏÈÎÔ‡ Î·È ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ›Ûˆ˜ Ô‰ËÁ‹ÛÂÈ Û ·ÎfiÌË ÛËÌ·ÓÙÈÎfiÙÂÚ· Û˘ÌÂÚ¿ÛÌ·Ù·, ·Ó ÏËÊı› ˘’ fi„ÈÓ fiÙÈ Û ·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù·, ·Ó·ÊÔÚÈο Ì ÙËÓ ˘ÂÚÔ¯‹ ·ÁÔÚÈÒÓ, ηٷϋÁÔ˘Ó Î·È ·Ï·ÈfiÙÂÚ˜ ÌÈÎÚ¤˜ ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ Ô˘ ‰ÈÂÍ‹¯ıËÛ·Ó ·fi ÙËÓ ›‰È· È·ÙÚfi Î·È ÔÈ Ôԛ˜ Û˘ÌʈÓÔ‡Ó Ì ٷ ·ÓÙ›ÛÙÔȯ· ÛÙÔȯ›· Ù˘ ÂÏÏËÓÈ΋˜ Î·È ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ (13,42,44). ªÈÎÚ‹ ·Ó·‰ÚÔÌÈ΋ ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÚÔ 12ÂÙ›·˜ ·fi ÙËÓ ›‰È· ÂÚ¢ӋÙÚÈ·, η٤ÁÚ·„ ÁÈ· ÂÚ›Ô‰Ô ‰‡Ô ÂÙÒÓ Ù· ·Ù˘¯‹Ì·Ù· fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ ÛÙËÓ ›‰È· ÂÚÈÔ¯‹ (ÌfiÓÔ fï˜ fiÛ· ·Â˘ı‡ÓıËÎ·Ó ÛÙËÓ ˘ËÚÂÛ›· ÙÔ˘ ∫¤ÓÙÚÔ˘ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘) (42,44). ™Â ÂΛÓË ÙËÓ ¤Ú¢ӷ ‰È·ÈÛÙÒıËÎ·Ó ÏÈÁfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ·Ó·ÏÔÁÈο ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ËÏÈ˘, ÚÔÊ·ÓÒ˜ ÏfiÁˆ ‰È·Ê˘Á‹˜ ÂÚÈÛÙ·ÙÈÎÒÓ, ȉ›ˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘
¶›Ó·Î·˜ 6. ™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫), 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O∞) Î·È ÙÈÌ‹ ÎÚÈÙËÚ›Ô˘ (p-value) ÁÈ· ·Ù‡¯ËÌ· ·Ó¿ÏÔÁ· Ì ÙȘ ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó (ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ Ù˘ ‰ÂÛÌÂ˘Ì¤Ó˘ ÏÔÁ·ÚÈıÌÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘) ªÂÙ·‚ÏËÙ‹
∫·ÙËÁÔÚ›· ‹ ÌÔÓ¿‰·
™∫
95% O∞
∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘
∏ÏÈΛ· ÙÔ˘ ·Ù¤Ú·
5 ¤ÙË ÂÚÈÛÛfiÙÂÚÔ
0,84
0,72
0,99
0,04
∂η›‰Â˘ÛË ÙÔ˘ ·Ù¤Ú·
3 ¯ÚfiÓÈ· ÂÚÈÛÛfiÙÂÚÔ
0,92
0,83
1,01
0,09
OÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË ÌËÙ¤Ú·˜
ÕÁ·ÌË ‹ ·Ô‚ÈÒÛ·Û· ŒÁÁ·ÌË
¶ÏËı. ·Ó·Ê. 0,50
0,17
1,51
0,21
∞ÚÈıÌfi˜ ·È‰ÈÒÓ ÔÈÎÔÁ¤ÓÂÈ·˜
ŒÓ· ·È‰› ÂÈϤÔÓ
0,88
0,65
1,18
0,39
∞ÚÈıÌfi˜ ‰ˆÌ·Ù›ˆÓ ·Ó¿ ¿ÙÔÌÔ
<0,5 0,5-0,74 0,75+
1,29 ¶ÏËı. ·Ó·Ê. 1,78
0,87
1,93
0,20
1,11
2,88
0,02
<2 ·Ù˘¯‹Ì·Ù· 2+
¶ÏËı. ·Ó·Ê. 1,59
0,94
2,67
0,08
¡·È Ÿ¯È
¶ÏËı. ·Ó·Ê. 0,52
0,29
0,94
0,03
0,94
0,72
1,23
0,67
¶ÏËı. ·Ó·Ê. 5,43 1,24
1,02 0,71
28,9 2,15
0,04 0,45
πÛÙÔÚÈÎfi ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ∞·Û¯fiÏËÛË ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ÂÓÂÏ¿ÎË Û ·Ù‡¯ËÌ· ™ÂÈÚ¿ Á¤ÓÓËÛ˘ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ÂÓÂÏ¿ÎË Û ·Ù‡¯ËÌ· ¶Úfi‚ÏËÌ· fiÚ·Û˘ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ÂÓÂÏ¿ÎË Û ·Ù‡¯ËÌ·
ŒÓ· ÂÈϤÔÓ ÃˆÚ›˜ Úfi‚ÏËÌ· ™ÙÚ·‚ÈÛÌfi˜ ÕÏÏÔ Úfi‚ÏËÌ·
∂ηÙÔÛÙÈ·›· ı¤ÛË ‚¿ÚÔ˘˜ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ÂÓÂÏ¿ÎË Û ·Ù‡¯ËÌ·
15% ÂÈϤÔÓ
0,86
0,75
0,99
0,04
∂ηÙÔÛÙÈ·›· ı¤ÛË ‡„Ô˘˜ ÙÔ˘ ·ÙfiÌÔ˘ Ô˘ ÂÓÂÏ¿ÎË Û ·Ù‡¯ËÌ·
15% ÂÈϤÔÓ
1,07
0,93
1,22
0,33
374
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
Paediatriki 2003;66:364-380
¶›Ó·Î·˜ 7. ∫·Ù·ÓÔÌ‹ Û˘¯ÓÔÙ‹ÙˆÓ ÙˆÓ 247 ·Ù˘¯ËÌ¿ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ (0-24 ÂÙÒÓ), ηÙÔ›ÎˆÓ ¢‹ÌÔ˘ µÂÏÂÛÙ›ÓÔ˘, Û‡Ìʈӷ Ì ‰ËÌÔÁÚ·ÊÈΤ˜ Î·È ÂÚÈÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ οΈÛ˘ Î·È ·Ó¿Ï˘Û˘ ηٿ Û˘ÛÙ¿‰Â˜ ªÂÙ·‚ÏËÙ‹
1Ë Û˘ÛÙ¿‰· ¡ %
∏ÏÈΛ· (¤ÙË) <5 (0-4) 28 5-9 29 10-14 3 15+ 16 º‡ÏÔ ÕÚÚÂÓ 38 £‹Ï˘ 38 ∂Ô¯‹ ·Ù˘¯‹Ì·ÙÔ˜ ÃÂÈÌÒÓ·˜ 16 ÕÓÔÈÍË 10 ∫·ÏÔη›ÚÈ 23 ºıÈÓfiˆÚÔ 27 ∏̤ڷ ·Ù˘¯‹Ì·ÙÔ˜ ∫·ıËÌÂÚÈÓ‹ 48 ™·‚‚·ÙÔ·ÚÈ·ÎÔ 28 ∆fiÔ˜ ·Ù˘¯‹Ì·ÙÔ˜ ª¤Û· ÛÙÔ Û›ÙÈ 42 ŒÍˆ ·fi ÙÔ Û›ÙÈ 15 ™ÙÔ ‰ÚfiÌÔ 10 ™ÙȘ ·ıÏԷȉȤ˜ 0 ™ÙÔ Û¯ÔÏÂ›Ô 3 ∞ÏÏÔ‡ 6 ªË¯·ÓÈÛÌfi˜ ·Ù˘¯‹Ì·ÙÔ˜ ¶ÙÒÛË ÛÙÔ ›‰ÈÔ Â›Â‰Ô 7 ¶ÙÒÛË ·fi ‡„Ô˜ ‹ ¿ÏÏË ÙÒÛË 22 ∫fi„ÈÌÔ 17 ÃÙ‡ËÌ· - Û‡ÁÎÚÔ˘ÛË ‹ ¿ÏÏÔ 3 ªË¯·ÓÈ΋ ·ʋ ÀÂÚÚÔÛ¿ıÂÈ· 1 ∑ÂÛÙ¿ ˘ÁÚ¿, ·ÓÙÈΛÌÂÓ· 9 ÕÏÏÔ 17 ∂›‰Ô˜ ‚Ï¿‚˘ ∫¿ÎˆÛË - ÂΉÔÚ¿ 37 ∞ÓÔȯً ÏËÁ‹ 17 ∫¿Ù·ÁÌ· 0 ¶·Ú·ÌfiÚʈÛË - ÂÍ¿ÚıÚˆÛË 0 ŒÁη˘Ì· 9 ÕÏÏÔ 13 ª¤ÚÔ˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ô˘ ¤¯ÂÈ ˘ÔÛÙ› ÙË ‚Ï¿‚Ë ∫ÂÊ¿ÏÈ Î·È ÚfiÛˆÔ 42 ÕÓˆ ¿ÎÚ· 19 ∫¿Ùˆ ¿ÎÚ· 6 ∫ÔÚÌfi˜ 9 ∞ÚÈıÌfi˜ ‚Ï·‚ÒÓ ª›· 45 ¢‡Ô 31
2Ë Û˘ÛÙ¿‰· ¡ %
3Ë Û˘ÛÙ¿‰· ¡ %
4Ë Û˘ÛÙ¿‰· ¡ %
36,8 38,2 3,9 21,1
1 13 38 20
1,4 18,1 52,8 27,7
1 2 5 28
2,8 5,5 13,9 77,8
9 23 18 13
14,3 36,5 28,6 20,6
50,0 50,0
61 11
84,7 15,3
28 8
77,8 22,2
35 28
55,6 44,4
21,0 13,2 30,3 35,5
14 21 13 24
19,4 29,2 18,1 33,3
11 11 9 5
30,6 30,6 25,0 13,8
9 8 36 10
14,3 12,7 27,1 15,9
63,2 36,8
56 16
77,8 22,2
23 13
63,9 36,1
54 9
85,7 14,3
55,3 19,7 13,2 0,0 3,9 7,9
5 4 33 16 10 4
6,9 5,6 45,8 22,2 13,9 5,6
0 0 10 20 4 2
0,0 0,0 27,8 55,6 11,1 5,0
5 29 10 1 7 11
7,39 46,0 15,9 1,6 11,1 17,5
9,2 28,9 22,4 3,9
8 18 3 38
11,1 25,0 4,2 52,8
16 3 0 2
44,4 8,3 0,0 5,6
16 9 33 1
25,4 14,3 52,4 1,6
1,3 11,8 22,4
0 0 5
0,0 0,0 6,9
14 0 1
38,9 0,0 2,8
0 1 3
0,0 1,6 4,7
48,7 22,4 0,0 0,0 11,8 17,1
35 24 6 4 1 2
48,6 33,3 8,3 5,6 1,4 2,8
4 2 8 22 0 0
11,1 5,6 22,2 61,1 0,0 0,0
7 53 0 2 1 0
11,1 84,1 0,0 3,2 1,6 0,0
55,3 25,0 7,9 11,8
15 42 10 5
20,8 58,3 13,9 7,0
2 7 25 2
5,6 19,4 69,4 5,6
13 16 27 7
20,6 25,4 42,9 11,1
59,2 40,8
39 33
54,7 45,8
22 14
61,1 38,9
52 11
82,5 17,5
ηÏÔηÈÚÈÓ‹˜ ÂÚÈfi‰Ô˘. ™ÙËÓ ·ÚÔ‡Û· ÚÔÔÙÈ΋ ÌÂϤÙË, ÂÂȉ‹ ¤ÁÈÓ ÂÈϤÔÓ ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ ¤Ï·‚·Ó ¯ÒÚ· ÂÎÙfi˜ Ù˘ ÂÚÈÔ¯‹˜ µÂÏÂÛÙ›ÓÔ˘, fiˆ˜ Û ¯ÒÚÔ˘˜ ‰È·ÎÔÒÓ, ηٷÛÎËÓÒÛˆÓ, ÂΉÚÔÌÒÓ, ¯ÒÚÔ˘˜ „˘¯·ÁˆÁ›·˜ ÂÎÙfi˜ µÂÏÂÛÙ›ÓÔ˘, ‚Ú¤ıËΠfiÙÈ ·ÎfiÌË Î·È ÙÔ˘˜ ηÏÔηÈÚÈÓÔ‡˜ Ì‹Ó˜ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ‰Â‰Ô̤-
Ó· ÙÔ˘ ™∫∞∂π Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ·Ù˘¯ËÌ¿ÙˆÓ ∂͈ÙÂÚÈÎÒÓ π·ÙÚ›ˆÓ ¡ÔÛÔÎÔÌ›ˆÓ ‹ Ì ‰Â‰Ô̤ӷ ¿ÏÏˆÓ ÂÚ¢ÓÒÓ, ·Ô‰ÂÈÎÓ‡Ô˘Ó ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÔÏÔÎÏËڈ̤ÓË Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È Ì¿ÏÈÛÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ηÏÔηÈÚÈÓ‹˜ ÂÚÈfi‰Ô˘ (7,13,30,31). ∏ ËÏÈΛ· Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ÚԉȿıÂÛË ÁÈ· ·Ù˘¯‹Ì·Ù· ·ıÚÔÈÛÙÈο Î·È ÛÙ· ‰‡Ô ʇϷ Â›Ó·È 5-9 ÂÙÒÓ (27,5%), Ù· Û˘¯ÓfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Â›Ó·È ·˘Ù¿ Ô˘
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Û˘Ì‚·›ÓÔ˘Ó ÛÙÔÓ ÂχıÂÚÔ ¯ÚfiÓÔ (56,5%) Î·È Ë Û˘¯ÓfiÙÂÚË ‚Ï¿‚Ë Â›Ó·È ÙÔ ÙÚ·‡Ì· (63%). ∆· Â˘Ú‹Ì·Ù· Û˘ÌʈÓÔ‡Ó ÙfiÛÔ Ì ÌÈÎÚfiÙÂÚ˜ ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ÂÚÈÔ¯‹ fiÛÔ Î·È Ì ·ÚfiÌÔȘ ÂÏÏËÓÈΤ˜ Î·È Í¤Ó˜ ÌÂϤÙ˜ (2-4,23,30,45-47). ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ (1/3) Û˘Ì‚·›ÓÂÈ ÙÔ Î·ÏÔη›ÚÈ, ÂÓÒ 1 ÛÙ· 3 ¿ÙÔÌ· Ô˘ ÂÌϤÎÔÓÙ·È Û ·Ù‡¯ËÌ· ˘Ê›ÛÙ·Ù·È Î¿ÎˆÛË ÛÙÔ ÎÂÊ¿ÏÈ (31,42,44). ∆· ·ÔÁ‡̷ٷ (ÒÚ˜ 17.00-19.00) Û˘Ì‚·›ÓÔ˘Ó Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· (2,3,23, 31). ∆Ô Â‡ÚËÌ· ·˘Ùfi Û˘ÌʈÓ› Î·È Ì ¿ÏϘ ¤Ú¢Ó˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ¡ÔÌfi ª·ÁÓËÛ›·˜, fiˆ˜ Î·È Ì ٷ ‰Â‰Ô̤ӷ ÙÔ˘ ™∫∞∂π (23,31). ∏ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÚÔÊ·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙȘ ÂÍfi‰Ô˘˜ ÙˆÓ ÌÈÎÚfiÙÂÚˆÓ ·È‰ÈÒÓ ÁÈ· ·È¯Ó›‰È Î·È ·ıÏԷȉȤ˜, ÂÓÒ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÛÙȘ „˘¯·ÁˆÁÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ‹ ÙȘ ·ÔÁÂ˘Ì·ÙÈÓ¤˜ - ‚Ú·‰ÈÓ¤˜ ÂÍfi‰Ô˘˜. ∆· ·Ù˘¯‹Ì·Ù· ÙÔ˘ “ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘”, fiˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ, η٤¯Ô˘Ó ÙËÓ ÚÒÙË ı¤ÛË ÛÂ Û˘¯ÓfiÙËÙ·, ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Ù· ·ÁÁÂÏÌ·ÙÈο Î·È Ù· ÙÚÔ¯·›·, ÁÂÁÔÓfi˜ ·Ó·ÌÂÓfiÌÂÓÔ ÏfiÁˆ ÙˆÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ∞˘ÙÔÓfiËÙÔ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ˘ÂÚÙÂÚÔ‡Ó ÔÈ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘ (1,2,23,31,48). ∆Ô ÔÛÔÛÙfi ÙˆÓ ‰ËÏËÙËÚÈ¿ÛÂˆÓ Ê·ÈÓÔÌÂÓÈο ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·˘ÍË̤ÓÔ, ηıÒ˜ Û ·˘Ùfi Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È - ÏËÓ Ù˘ Ï‹„˘ Ê·Ú̷΢ÙÈ΋˜ ‹ ÙÔÍÈ΋˜ Ô˘Û›·˜ - Î·È ÔÈ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ̤ı˘, ηıÒ˜ Î·È ÔÈ ‰ËÏËÙËÚÈÒ‰ÂȘ Ó˘ÁÌÔ›, Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·˘ÍË̤ӷ Û ۯ¤ÛË Ì ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (3,30). ∏ ÚÒÙË Ë̤ڷ Ù˘ ‚‰ÔÌ¿‰·˜ (¢Â˘Ù¤Ú·) ¤‰ÂÈÍ ·˘ÍË̤ÓË ÚԉȿıÂÛË ÁÈ· ·Ù‡¯ËÌ· (16,5%), ÂÓÒ ·ÎÔÏÔ˘ı› Ì ÌÈÎÚ‹ ‰È·ÊÔÚ¿ Ë ¶¤ÌÙË (16%). ™˘Ó‹ıˆ˜, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÌÂÏÂÙÒÓ ‰Â›¯ÓÂÈ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ù· ™·‚‚·ÙÔ·Úȷη, ÂȉÈο Û ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜ Ô˘ ·Ó·Áο˙ÔÓÙ·È Ó· ·Ú·Ì¤ÓÔ˘Ó ÔÏϤ˜ ÒÚ˜ ̤۷ ÛÙÔ Û›ÙÈ ‹ ˘Ê›ÛÙ·ÓÙ·È ÌÂÙ·ÎÈÓ‹ÛÂȘ ‹ ¿ÏÏÔ˘ ›‰Ô˘˜ ÂÍÔÚÌ‹ÛÂȘ Î·È „˘¯·ÁˆÁÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ (3,4,49). ∞˘Ùfi ÂȂ‚·ÈÒÓÂÈ Î·È Ë ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ (¶›Ó·Î·˜ 7) ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, fiÔ˘ ÂÓÙÔ›˙ÂÙ·È ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ· Ù· ™·‚‚·ÙÔ·Úȷη Û ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ·‡ÍËÛË ÂÁη˘Ì¿ÙˆÓ (2,3,22) Î·È ÙÒÛˆÓ. ∆Ô ›‰ÈÔ ·Ú·ÙËÚÂ›Ù·È Î·È Û ÂÊ‹‚Ô˘˜/Ó¤Ô˘˜ ËÏÈΛ·˜ 15-24 ÂÙÒÓ, ÔÈ ÔÔ›ÔÈ ˘Ê›ÛÙ·ÓÙ·È Î·ÎÒÛÂȘ ΢ڛˆ˜ Ù· ™·‚‚·ÙÔ·Úȷη, ηٿ ÙË ‰È¿ÚÎÂÈ· ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ (΢ڛˆ˜ Ô‰ÔÛÊ·›ÚÔ˘) ‹ ÂÍfi‰ˆÓ „˘¯·ÁˆÁ›·˜ Î·È Î˘Ú›ˆ˜ ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·. OÈ Î·ÎÒÛÂȘ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ Û˘Ó·ÓÙÒÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (ηٿÁÌ·Ù·, ‰È·ÛÙÚ¤ÌÌ·Ù·/ÂÍ·ÚıÚ‹Ì·Ù·) (17,19,48). ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ ·Ù˘¯Ë-
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Paediatriki 2003;66:364-380
Ì¿ÙˆÓ ÙËÓ ÚÒÙË ÂÚÁ¿ÛÈÌË Ë̤ڷ Ù˘ ‚‰ÔÌ¿‰·˜, ÙË ¢Â˘Ù¤Ú·, ı· ÌÔÚÔ‡Û ӷ ÂÍËÁËı› Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ™·‚‚·ÙÔ·ÚÈ·ÎÔ˘ ‰ËÏÒÓÔÓÙ·È ˆ˜ ·Ù˘¯‹Ì·Ù· Ù˘ Ë̤ڷ˜ ·˘Ù‹˜ (¢Â˘Ù¤Ú·˜) Î·È ÂÈ‚·Ú‡ÓÔ˘Ó ÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘ Î·È ÙȘ ¿ÏϘ È·ÙÚÈΤ˜ ˘ËÚÂۛ˜ ÙËÓ Ë̤ڷ Ô˘ ηٷÁÚ¿ÊÂÙ·È Ë ÚÒÙË Â›ÛÎÂ„Ë ÁÈ· ÙÔ ·Ù‡¯ËÌ·. ∂Í¿ÏÏÔ˘, Ù· ™·‚‚·ÙÔ·Úȷη ÔÏϤ˜ ÔÈÎÔÁ¤ÓÂȘ Ú·ÁÌ·ÙÔÔÈÔ‡Ó ÂΉÚÔ̤˜ Ì·ÎÚÈ¿ ·fi ÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜ ÙÔ˘˜ Î·È ‰ÂÓ ÌÂÚÈÌÓÔ‡Ó ÁÈ· Ù· ÂÏ·ÊÚ¿ ·Ù˘¯‹Ì·Ù·, ·Ú¿ ÌfiÓÔ fiÙ·Ó ÂÈÛÙÚ¤„Ô˘Ó, ‹ ·Â˘ı‡ÓÔÓÙ·È Û οÔÈ· È·ÙÚÈ΋ ˘ËÚÂÛ›· ·ÊÔ‡ Û˘Ì‚Â› οÔÈ· ÂÈÏÔ΋. ™˘¯ÓfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ ·Ù˘¯‹Ì·ÙÔ˜ Â›Ó·È ÔÈ ÙÒÛÂȘ, ÁÂÁÔÓfi˜ Ô˘ ¤Ú¯ÂÙ·È ÛÂ Û˘Ìʈӛ· Ì ÏËıÒÚ· ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ ÌÂÏÂÙÒÓ, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÔÔ›ˆÓ Â›Ó·È Î˘Ú›ˆ˜ ·Ó·‰ÚÔÌÈΤ˜ (1,2,7,9,17,23). ∂›Û˘, fiˆ˜ ÚԷӷʤÚıËÎÂ, Ù· ‰Â‰Ô̤ӷ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰ÂÓ ·ÚÂÎÎÏ›ÓÔ˘Ó È‰È·›ÙÂÚ· ·fi Ù· ‰ËÌÔÛÈÂ˘Ì¤Ó· ÛÙÔȯ›· ÙÔ˘ ∫∂¶¶∞, ÏËÓ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ Û˘¯ÓfiÙËÙ·˜ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Î·ÏÔηÈÚÈÓÒÓ ÌËÓÒÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË (42,43,47). ∏ ¤Ú¢ӷ ¤‰ÂÈÍ fiÙÈ ÙÔ Û˘¯ÓfiÙÂÚÔ Â›‰Ô˜ οΈÛ˘ Â›Ó·È ÙÔ ÙÚ·‡Ì· (ȉȷ›ÙÂÚ· ÙÔ ·ÓÔȯÙfi ÙÚ·‡Ì·), ÁÂÁÔÓfi˜ Ô˘ ÂȂ‚·ÈÒÓÂÙ·È ·fi ¿ÏϘ ÂÏÏËÓÈΤ˜ Î·È Í¤Ó˜ ÌÂϤÙ˜ (1,5,23,42,43,47). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È, ›Û˘, ÙÔ Â‡ÚËÌ· fiÙÈ 9% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚Ï¿‚Ë Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi χÛË Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ (ÙÚ·‡Ì· ‹ ¤Áη˘Ì· ‹ ÂÈÊ·ÓÂȷ΋ οΈÛË) ‰ÂÓ ‹Ù·Ó Î·Ï˘Ì̤ÓÔ Ì ÙÔ ·ÓÙÈÙÂÙ·ÓÈÎfi ÂÌ‚fiÏÈÔ, ÂÓÒ ¤Ó· ¿ÏÏÔ 9% ‰ÂÓ ÁÓÒÚÈ˙ ÙËÓ Î·Ù¿ÛÙ·ÛË ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙÔ˘. ∏ ÏÂÈÔ„ËÊ›· ·ÊÔÚ¿ Û ÂÊ‹‚Ô˘˜ Î·È Ó¤Ô˘˜ ËÏÈΛ·˜ >15 ¯ÚfiÓˆÓ. ∞˘Ùfi ÔÊ›ÏÂÙ·È Û ‰‡Ô ÏfiÁÔ˘˜: ·) ÔÈ ËÏÈ˘ ·˘Ù¤˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·Ì¤ÏÂÈ· (ÌÂÙ·‚·ÙÈ΋ ËÏÈΛ·: ·fi ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ¶·È‰È¿ÙÚÔ˘ ÛÙË ÊÚÔÓÙ›‰· ÙÔ˘ ¶·ıÔÏfiÁÔ˘) Î·È ‚) ÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜ µÂÏÂÛÙ›ÓÔ˘, ÛÙÔ ÔÔ›Ô ‰ÈÂÓÂÚÁÂ›Ù·È ·ÔÙÂÏÂÛÌ·ÙÈο ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ, ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi 12ÂÙ›·˜ Î·È ¿Ú· ‰ÈηÈÔÏÔÁÔ‡ÓÙ·È Ù˘¯fiÓ “ÂÎÎÚÂÌfiÙËÙ˜” ÂÌ‚ÔÏÈ·ÛÌÒÓ Û ·È‰È¿ ËÏÈΛ·˜ >12 ¯ÚfiÓˆÓ. ÕÏÏÔ ÛËÌ·ÓÙÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ·ÚÔ‡Û·˜ ¤Ú¢ӷ˜ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·Ú¿ ÙËÓ ÔÏÔÎÏËڈ̤ÓË Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ‰ÂÓ ‰È·ÈÛÙÒıËΠηӤӷ˜ ı¿Ó·ÙÔ˜ ÛÙ· 247 ÚÒÙ· ·Ù˘¯‹Ì·Ù· Ô˘ ηٷÁÚ¿ÊËÎ·Ó Î·È Î·Ó¤Ó·˜ ÓÈÁÌfi˜ - ÓÈÁÌÔÓ‹ (Ô‡Ù ·Ú’ ÔÏ›ÁÔÓ ÓÈÁÌfi˜). ∏ ¤ÏÏÂÈ„Ë ÓÈÁÌÔ‡ ÔÊ›ÏÂÙ·È Î·Ù¿ ¤Ó· ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÚÈÔ¯‹ Ô˘ ÌÂÏÂÙ‹ıËΠ‰ÂÓ Â›Ó·È ÎÔÓÙ¿ Û ı¿Ï·ÛÛ· Î·È ‰ÂÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‡·ÚÍË ÈÛ›Ó·˜ ÛÙȘ ηÙÔÈ˘. ∂ÓÙÔ‡ÙÔȘ, ÛËÌÂÈÒıËΠ¤Ó·˜ ı¿Ó·ÙÔ˜ ÛÙ· 247 ¿ÙÔÌ· Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ·, ÛÂ
¶·È‰È·ÙÚÈ΋ 2003;66:364-380
‰Â‡ÙÂÚÔ ·Ù‡¯ËÌ· Î·È Û˘ÁÎÂÎÚÈ̤ӷ Û ÙÚÔ¯·›Ô ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÍÂÙ·˙fiÌÂÓ˘ ÂÚÈfi‰Ô˘ (ıÓËÛÈÌfiÙËÙ· 0,75ò). ∆Ô ı·Ó·ÙËÊfiÚÔ ·Ù‡¯ËÌ· ·ÊÔÚÔ‡Û ÛÂ Ó¤Ô ËÏÈΛ·˜ 19 ÂÙÒÓ, Ô ÔÔ›Ô˜ ‚Ú¤ıËΠÓÂÎÚfi˜ Ù˘¯·›· ÙÔÓ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 1995. ∆Ô ·Ù‡¯ËÌ· Û˘Ó¤‚Ë Ì ÙÔ Ì˯·Ó¿ÎÈ ÙÔ˘ Û ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ô˘ Û˘ÓfiÚ¢ Ì ‰ÚfiÌÔ Ù·¯Â›·˜ ΢ÎÏÔÊÔÚ›·˜ ÏËÛ›ÔÓ ÙÔ˘ µÂÏÂÛÙ›ÓÔ˘ Î·È ÙÔ˘ ∞Á. °ÂˆÚÁ›Ô˘ ºÂÚÒÓ. O ı¿Ó·Ùfi˜ ÙÔ˘ ‹Ù·Ó ·Î·ÚÈ·›Ô˜, fiˆ˜ ·¤‰ÂÈÍÂ Ë ÓÂÎÚÔ„›· Ô˘ ¤ÁÈÓ ÙËÓ ÂfiÌÂÓË Ë̤ڷ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ÙÔ˘ µfiÏÔ˘ (Ô ı·ÓÒÓ Â›¯Â ÔÏÏ·Ï¿ ηٿÁÌ·Ù· Î·È ·ÈÌÔÚÚ·Á›Â˜). ™‡Ìʈӷ Ì ÏËÚÔÊÔڛ˜ ·fi ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘, ÍÂΛÓËÛ ÛÙȘ 23:30 ÛÙȘ 18/02/1995 Ì ÚÔÔÚÈÛÌfi οÔÈÔÓ ¯ÒÚÔ ‰È·ÛΤ‰·Û˘. ∂Ȃ‚·ÈÒÓÂÙ·È Î·È Â‰Ò fiÙÈ Ù· ÙÚÔ¯·›· ¢ı‡ÓÔÓÙ·È ÁÈ· ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ·, Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ηÙËÁÔڛ˜ ·Ù˘¯ËÌ¿ÙˆÓ (1-3,5,14,19, 21,24,25,31,46). O ·ÚÈıÌfi˜ ÙˆÓ ÂÈÛ·¯ı¤ÓÙˆÓ Û ¡ÔÛÔÎÔÌÂ›Ô (5 ÂÈÛ·ÁˆÁ¤˜) ·fi ÙÔ ‰Â›ÁÌ· ÏËı˘ÛÌÔ‡ Ô˘ ÂÍÂÙ¿ÛÙËÎÂ, ·ÏÏ¿ Î·È ·fi ÙÔ ‰Â›ÁÌ· ÙˆÓ ·ÙfiÌˆÓ Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ·, Â›Ó·È Ôχ ÌÈÎÚfi˜ Û ۯ¤ÛË Ì ÙȘ ÂÈÛ·ÁˆÁ¤˜ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ·Ó¿ÏÔÁÔ ·ÚÈıÌfi ÂÚÈÙÒÛÂˆÓ ÙˆÓ ∆∂¶ (∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ ¡ÔÛÔÎÔÌ›ˆÓ). ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ·Ú¿ ÙÔÓ ·˘ÍË̤ÓÔ ·ÚÈıÌfi ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ù· ÛÔ‚·Ú¿ ·Ù˘¯‹Ì·Ù· ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ÌÈÎÚfi ·ÚÈıÌfi. ∂›Ó·È, fï˜, ·Ó·ÌÂÓfiÌÂÓÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÁÈ· ‚·Ú‡ ·Ù‡¯ËÌ· ·fi ¤Ó· Û‡ÓÔÏÔ ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ· Ô˘ ·Â˘ı‡ÓÂÙ·È Û ¤Ó· ¯ÒÚÔ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜ Ó· Â›Ó·È ·Ó·ÏÔÁÈο ÌÈÎÚfiÙÂÚÔ˜ ÙÔ˘ ·ÓÙ›ÛÙÔÈ¯Ô˘ ·ÚÈıÌÔ‡ ÂÈÛ·ÁˆÁÒÓ ·fi ¤Ó· ¿ÏÏÔ Û‡ÓÔÏÔ ·ÙfiÌˆÓ Ô˘ ·Â˘ı‡ÓÔÓÙ·È ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ÂÓfi˜ ‰Â˘ÙÂÚÔ‚¿ıÌÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Î·È ·ÎfiÌË ÌÈÎÚfiÙÂÚÔ˜ ·fi ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ ¡ÔÛÔÎÔÌÂ›Ô (19,30,50). ŒÓ· ȉȷ›ÙÂÚÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Î·È Ù·˘Ùfi¯ÚÔÓ· ÂÈϤÔÓ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÙÔ ÔÔ›Ô ÚÔ·ÙÂÈ ·ÊÂÓfi˜ ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÍÂÙ¿˙ÂÈ ÎÏÂÈÛÙfi ÏËı˘ÛÌfi Î·È ·ÊÂÙ¤ÚÔ˘ ·fi ÙË ‰ÈÂÓÂÚÁËı›۷ Ôχ ηϋ ηٷÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, Â›Ó·È Ë ‰È·›ÛÙˆÛË 2Ô˘, 3Ô˘ Î·È 4Ô˘ ·Ù˘¯‹Ì·ÙÔ˜ Û 53 ¿ÙÔÌ· Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ·Ù‡¯ËÌ· ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 247 ·ÙfiÌˆÓ Ô˘ ·Ó·Ï‡ıËηÓ. ŒÙÛÈ, Ë ·ÚÔ‡Û· ¤Ú¢ӷ ÚˆÙÔÙ˘Â› Î·È ÏÂÔÓÂÎÙ› fi¯È ÌfiÓÔ ÔÛÔÙÈο, ·ÏÏ¿ Î·È ÔÈÔÙÈο, ηıÒ˜ Ë ÌÂϤÙË ÏËıÒÚ·˜ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Û˘ÓÙÂÏ› ÛÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ Ô˘ Â›Ó·È Û ı¤ÛË Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙË ‰È·ÌfiÚʈÛË Î·Ù·ÏÏËÏfiÙÂÚˆÓ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚˆÓ ÙÚfiˆÓ Î·È ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÓÂÚÁËÙÈ΋˜ Î·È ·ıËÙÈ΋˜ ·Ú¤Ì‚·Û˘. ø˜ ÁÓˆÛÙfi, Ù· ·Ù˘¯‹Ì·Ù· ÔÊ›ÏÔÓÙ·È: ·) ÛÙ· ›‰È· Ù· ¿ÙÔÌ· Î·È ÙË Ê‡ÛË
Paediatriki 2003;66:364-380
ÙÔ˘˜ Î·È ‚) ÛÙȘ ÂÈΛӉ˘Ó˜ Û˘Óı‹Î˜ - ÂÈΛӉ˘ÓÔ ÂÚÈ‚¿ÏÏÔÓ (Ê˘ÛÈÎfi, ÎÔÈÓˆÓÈÎfi, ÔÈÎÔÁÂÓÂÈ·Îfi) (2,3,11,13,45,51-54). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÌÂÙ¿ ÙË ‰ÈÂÚ‡ÓËÛË ÏËıÒÚ·˜ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ, ÂÓÙÔ›ÛÙËÎ·Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÔÈ ÔÔ›ÔÈ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6, fiÔ˘ ÂϤÁ¯ÂÙ·È Ë ÂÍ¿ÚÙËÛË ÁÈ· ·Ù‡¯ËÌ· ·fi 11 ÌÂÙ·‚ÏËÙ¤˜. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ÚԉȿıÂÛË ÁÈ· ·Ù‡¯ËÌ· ‚Ú¤ıËÎ·Ó Ó· Â›Ó·È Î˘Ú›ˆ˜ Ë ··Û¯fiÏËÛË ÙÔ˘ ·ÙfiÌÔ˘, Ô ÛÙÚ·‚ÈÛÌfi˜ ηÈ, ηٿ ‰Â‡ÙÂÚÔ ÏfiÁÔ, ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi ·˘ÍË̤ÓÔ˘ ·ÚÈıÌÔ‡ ·Ù˘¯ËÌ¿ÙˆÓ (¿Óˆ ·fi 2) ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· (4,17,19,55). ∞ÓÙ›ıÂÙ·, Ë Âη›‰Â˘ÛË Î·È Ë ËÏÈΛ· ÙÔ˘ ·Ù¤Ú· (3 Î·È 5 ÂÈϤÔÓ ¤ÙË, ·ÓÙ›ÛÙÔȯ·) Î·È Ë Î·Ù¿ 15% ·‡ÍËÛË Ù˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ‚¿ÚÔ˘˜ ‚Ú¤ıËÎ·Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙË Ì›ˆÛË Ù˘ ÚԉȿıÂÛ˘ ÁÈ· ·Ù‡¯ËÌ·, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô Û˘ÌʈÓ›, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÚÒÙÔ ÛΤÏÔ˜, Î·È Ì ¿ÏϘ ÌÂϤÙ˜ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ∂ÏÏ¿‰·˜ (Petridou et al, 1995) (55). ∏ ·Ó·ÏÔÁ›· ‰ˆÌ·Ù›ˆÓ ·Ó¿ ¿ÙÔÌÔ >0,75 Úԉȷı¤ÙÂÈ ÁÈ· ·Ù‡¯ËÌ· Û ‚·ıÌfi ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi Û ۯ¤ÛË Ì ·Ó·ÏÔÁ›· ·Ó·ÊÔÚ¿˜ ÙÔ 0,5-0,74 ‰ˆÌ¿ÙÈ· ·Ó¿ ¿ÙÔÌÔ. ŒÙÛÈ, ÛÙËÓ ·ÚÔ‡Û· ¤Ú¢ӷ ηٷ‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ô ÌÂÁ¿ÏÔ˜ ¯ÒÚÔ˜ ‰ÂÓ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ·Ù‡¯ËÌ·, ·ÏÏ¿ ·ÓÙ›ıÂÙ· Û˘ÓÙÂÏ› ÛÙËÓ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Î·È ÙËÓ ˘ÂÚÂÎÙ›ÌËÛË Ù˘ ÂÏ¢ıÂÚ›·˜ ÎÈÓ‹ÛˆÓ, Ù· ÔÔ›· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯‹Ì·ÙÔ˜. ∆· ÚÔ‚Ï‹Ì·Ù· ·ÎÔ‹˜ ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ٷ ·Ù˘¯‹Ì·Ù·, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó Î·È ¿ÏϘ ¤Ú¢Ó˜. ∂ÓÙÔ‡ÙÔȘ, Û ÌÂÚÈΤ˜ ¤Ú¢Ó˜ ·Ó·Ê¤ÚÂÙ·È ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË, ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋, ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (56). ∏ ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ Ô‰ËÁ›, ›Û˘, Û Ôχ ÛËÌ·ÓÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ∂Ȃ‚·ÈÒÓÂÙ·È fiÙÈ ÔÈ ËÏÈ˘ οو ÙˆÓ 5 ÂÙÒÓ ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ΢ڛˆ˜ ÔÈÎȷο (55,5% ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË), Ù· ™·‚‚·ÙÔ·Úȷη, ÏfiÁˆ ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ·Ú·ÌÔÓ‹˜ ÛÙÔ Û›ÙÈ, Ì ˘ÂÚÔ¯‹ ÙˆÓ ÂÁη˘Ì¿ÙˆÓ ΢ڛˆ˜ Û ÎÔÚ›ÙÛÈ· (2,3,13,22,28,32, 36). ∞ÎÔÏÔ˘ıÔ‡Ó ÔÈ ÙÒÛÂȘ, ÁÂÁÔÓfi˜ ·Ó·ÌÂÓfiÌÂÓÔ, ·Ó ÏËÊı› ˘’ fi„ÈÓ fiÙÈ ÂȉÈο Ù· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ Û˘Ó‹ıˆ˜ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È ÛÙÔ ÎÂÊ¿ÏÈ ‹ ÛÙÔÓ ÎÔÚÌfi ÏfiÁˆ Ù˘ ·ÛÙ¿ıÂÈ·˜ ÛÙÔ ‚¿‰ÈÛÌ·, ·ÏÏ¿ Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ™ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÙˆÓ 5-9 ÂÙÒÓ, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ ÂÌÊ·Ó›˙ÂÙ·È Î·È ¿ÏÈ Ù· ÎÔÚ›ÙÛÈ·, Ì ÚÔÂÍ¿Ú¯Ô˘Û· ‚Ï¿‚Ë ÙÔ ÙÚ·‡Ì· ÛÙ· οو ¿ÎÚ· ·fi ·È¯ÌËÚ¿ ·ÓÙÈΛÌÂÓ· Î·È ÙÒÛÂȘ, Û˘Ó‹ıˆ˜ ¤Íˆ Î·È Á‡Úˆ ·fi ÙÔ Û›ÙÈ (19,47,57,58). ™ÙËÓ ·Ì¤Ûˆ˜ ÂfiÌÂÓË ËÏÈÎȷ΋ ÔÌ¿‰· (10-14
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ÂÙÒÓ), fï˜, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ ÂÌÊ·Ó›˙ÂÙ·È ÛÙ· ·ÁfiÚÈ·, Ì ÚÔÂÍ¿Ú¯Ô˘Û· ‚Ï¿‚Ë ÙÔ Î¿Ù·ÁÌ· ÙˆÓ ¿Óˆ ¿ÎÚˆÓ. ∆· ·ÁfiÚÈ· ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÂÚÈÛÛfiÙÂÚÔ ÂÈΛӉ˘Ó· ·È¯Ó›‰È· Î·È ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜, ¤Íˆ ·fi ÙÔ Û›ÙÈ Î·È Î˘Ú›ˆ˜ ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜. OÈ ‰Â ÙÒÛÂȘ (Û˘Ó‹ıˆ˜ ·fi Ô‰‹Ï·ÙÔ) Î·È Û˘ÁÎÚÔ‡ÛÂȘ Â›Ó·È ÛÔ‚·ÚfiÙÂÚ˜ (2,11,19,31,58). ∆¤ÏÔ˜, fiˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ, Ë ÙÂÏÂ˘Ù·›· ËÏÈÎȷ΋ ÔÌ¿‰· (>15 ÂÙÒÓ), Ë ÔÔ›· ·ÓÙÈÛÙÔȯ› ÛÙÔ 14,6% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ÏËı˘ÛÌÔ‡ Ô˘ ÂϤÁ¯ıËÎÂ Î·È ·ÔÙÂÏÂ›Ù·È Î·Ù¿ 77,8% ·fi ¿Ó‰Ú˜, ·ÚÔ˘Û›·Û ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ηÎÒÛÂˆÓ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, Û ۯ¤ÛË Ì ÙÔ ˘fiÏÔÈÔ ÛÒÌ·, Û·Ó ·ÔÙ¤ÏÂÛÌ· Ù˘ ʇÛ˘ ÙˆÓ ·È¯ÓȉÈÒÓ Ì ٷ ÔÔ›· ·Û¯ÔÏÂ›Ù·È (΢ڛˆ˜ Ô‰fiÛÊ·ÈÚÔ) Î·È ÙˆÓ ÂÍfi‰ˆÓ ÁÈ· „˘¯·ÁˆÁ›·. ∆· ·ÁfiÚÈ· ·˘Ù‹˜ Ù˘ ËÏÈÎȷ΋˜ ÔÌ¿‰·˜ ¢ı‡ÓÔÓÙ·È ÔÏÔÎÏËÚˆÙÈο ÁÈ· Ù· ÙÚÔ¯·›· Ô˘ ηٷÁÚ¿ÊËÎ·Ó Î·È Ù· ÔÔ›· Ô‰ËÁÔ‡Ó Û ‚·ÚȤ˜ ηÎÒÛÂȘ Î·È ‚Ï¿‚˜, fiˆ˜ Ù· ηٿÁÌ·Ù· (΢ڛˆ˜ οو ¿ÎÚˆÓ). ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ηٷÁÚ¿ÊËÎÂ Î·È ÙÔ ı·Ó·ÙËÊfiÚÔ ·Ù‡¯ËÌ· ·fi ÙÚÔ¯·›Ô (Ô‰ËÁÔ‡ ‰È·ÎÏÔ˘), ÂÈÛËÌ·›ÓÔÓÙ·˜ ÁÈ· Ì›· ·ÎfiÌË ÊÔÚ¿ fiÙÈ ÙÔ ÙÚÔ¯·›Ô Â›Ó·È ÙÔ ·Ù‡¯ËÌ· Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ıÓËÛÈÌfiÙËÙ·, ·ÏÏ¿ Î·È ıÓËÙfiÙËÙ·, Ô˘ Ï‹ÙÙÂÈ Î˘Ú›ˆ˜ ÙÔ˘˜ ¿Ó‰Ú˜ (1-5,7,24,25,58,59). ™‡Ìʈӷ Ì ÌÂϤÙ˜, Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ·Ó ·˘Í·ÓfiÙ·Ó Ë ¯Ú‹ÛË ÎÚ¿ÓÔ˘˜ ·fi ÙÔ˘˜ ÂÈ‚¿Ù˜ ÙˆÓ ‰È·ÎψÓ, ı· ÌÔÚÔ‡Û ӷ ÂÈÙ¢¯ı› Ì›ˆÛË ÙˆÓ Û˘ÓÔÏÈÎÒÓ ı·Ó¿ÙˆÓ ·fi ÙÚÔ¯·›· ηٿ 200 ¿ÙÔÌ· ÂÙËÛ›ˆ˜ (2,11,24,25). ∂›Û˘, ·Ó Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÌÂٷʤÚÔÓÙ·Ó Ì ÂȉÈο ηı›ÛÌ·Ù· ÚfiÛ‰ÂÛ˘, ı· ÛËÌÂȈÓfiÙ·Ó Ì›ˆÛË ÙˆÓ ı·Ó¿ÙˆÓ ·fi ÙÚÔ¯·›· ηٿ 30% ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ËÏÈ˘ (2,11,24,25,50). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ù· ·Ù˘¯‹Ì·Ù· Û ·È‰È¿ Î·È Ó¤Ô˘˜ ‚Ú¤ıËΠӷ ¤¯Ô˘Ó ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·ÈÙÈÔÏÔÁ›· (2,3,11,13,30-36,41,51, 52,61,62). ™¯ÂÙ›˙ÔÓÙ·È ‰Â Ì ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi (Âη›‰Â˘ÛË Î·È ËÏÈΛ· ÙÔ˘ ·Ù¤Ú·, ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·) Î·È ÙÔ Ê˘ÛÈÎfi ÂÚÈ‚¿ÏÏÔÓ (Û¯¤ÛË ·Ó·ÏÔÁ›·˜ ÙÂÙÚ·ÁˆÓÈÎÒÓ Ì¤ÙÚˆÓ ÙÔ˘ ¯ÒÚÔ˘ ‰È·‚›ˆÛ˘ ·Ó¿ ¿ÙÔÌÔ, ÂÈΛӉ˘Ó· ·ÓÙÈΛÌÂÓ·, ÂÈΛӉ˘Ó˜ Û˘Óı‹Î˜), Ì ÙË Ê‡ÛË Î·È ÙËÓ ÚԉȿıÂÛË ÁÈ· ·Ù‡¯ËÌ· ÙÔ˘ ·ÙfiÌÔ˘ (ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜, fiÚ·Û˘, ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›·, ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿), ·ÏÏ¿ Î·È Ì ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÙÔ˘ ·ÙfiÌÔ˘ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ (··Û¯fiÏËÛË Û ÂÚÁ·Û›· ÚÈÓ ÙËÓ ÂÓËÏÈΛˆÛ‹ ÙÔ˘, Û˘ÌÌÂÙÔ¯‹ Û ÂÈΛӉ˘Ó· ·È¯Ó›‰È·). ª¿ÏÈÛÙ·, Ë ··Û¯fiÏËÛË ·Ó‹ÏÈÎˆÓ ·È‰ÈÒÓ Û ÂÚÁ·Û›· Û˘ÓËı›˙ÂÙ·È ÛÙËÓ ∂ÏÏ¿‰· Î·È ÂÈÛËÌ·›ÓÂÙ·È ˆ˜ Úfi‚ÏËÌ· Î·È ·fi ¿ÏϘ ÌÂϤÙ˜, ηıÒ˜ ÂÎı¤ÙÂÈ Ù· ·È‰È¿ Û ÎÈÓ‰‡ÓÔ˘˜ ·Ù˘¯‹Ì·ÙÔ˜ (58,62).
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™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÌÂÙ¿ ÙËÓ ÂÓÙfiÈÛË ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘, ·Ó·‰ÂÈÎÓ‡ÂÙ·È ÙÔ Ì¤ÁÂıÔ˜ Î·È Ë ¤ÎÙ·ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ËÏÈ˘ Ô˘ ÂÎÙ›ÓÔÓÙ·È ·fi 0 ¤ˆ˜ 24 ÂÙÒÓ ÛÙËÓ ËÌÈ·ÛÙÈ΋ ÂÚÈÔ¯‹ Ù˘ ª·ÁÓËÛ›·˜. ∆ÔÓ›˙ÂÙ·È fiÙÈ Ë ÌÂϤÙË ÙˆÓ ÂȉËÌÈÔÏÔÁÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, fiˆ˜ ‰È·ÌÔÚÊÒÓÂÙ·È ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÈÔ¯‹, Ë ‰ÈÂÚ‡ÓËÛË, Ë ÂÓÙfiÈÛË Î·È Ë Î·Ù·ÔϤÌËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ı· ÌÔÚÔ‡Û·Ó Â‡ÛÙÔ¯· Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÁÈ· ÙËÓ ÚfiÏË„Ë ‹ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ·˘Ù¤˜ ÙȘ ËÏÈ˘. ∏ ÂÓÙfiÈÛË ÙˆÓ ËÏÈÎÈÒÓ Î·È ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÙÔÓ Î›Ó‰˘ÓÔ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ÙˆÓ ÏÔÈÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘, ı· ÌÔÚÔ‡Û ӷ ‚ÔËı‹ÛÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË ÚÔÛ¤ÁÁÈÛË ·˘ÙÔ‡ ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ (2,3,7,14,20,24,34,36,40,41,44,49,54,57). O ÊÈÏfiÛÔÊÔ˜ ∞ÚÈÛÙÔÙ¤Ï˘ ÙÔÓ›˙ÂÈ ÛÙ· “π·ÙÚÈο” ÙÔ˘ fiÙÈ: “∆· ηχÙÂÚ· ¤ÚÁ· Á›ÓÔÓÙ·È ·fi ·ÓÒÙÂÚÔ˘˜ ·ÓıÚÒÔ˘˜”, ÂÓÒ Ô C. Everett Koop ·Ó·Ê¤ÚÂÈ fiÙÈ: “∂¿Ó οÔÈ· ·Ûı¤ÓÂÈ· ÛÎfiÙˆÓ ٷ ·È‰È¿ Ì·˜ Ì ÙËÓ ›‰È· ·Ó·ÏÔÁ›· Ô˘ ÛÎÔÙÒÓÔ˘Ó Ù· ·Ù˘¯‹Ì·Ù·, Ô ÎfiÛÌÔ˜ ı· ÍÂÛËΈÓfiÙ·Ó Î·È ı· ˙ËÙÔ‡Û ӷ ÛÙ·Ì·Ù‹ÛÂÈ ·˘Ùfi˜ Ô ‰ÔÏÔÊfiÓÔ˜, ·˘Ù‹ Ë ÂηÙfiÌ‚Ë”. OÈ ÏÂÈÙÔ˘ÚÁÔ› ˘Á›·˜, ÛÂ Û˘ÓÂÚÁ·Û›· Ì ¿ÏÏÔ˘˜ ÊÔÚ›˜ (ÙÔÈ΋ ·˘ÙÔ‰ÈÔ›ÎËÛË, Âη›‰Â˘ÛË, Û‡ÏÏÔÁÔÈ ÎÔÈÓˆÓÈ΋˜ ˆÊ¤ÏÂÈ·˜, Û‡ÏÏÔÁÔÈ ÁÔÓ¤ˆÓ, ÂÙ·ÈÚ›˜ fiˆ˜ Ë ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· Î·È ¿ÏϘ ÂÙ·ÈÚ›˜ ÚÔÏËÙÈÎÔ‡ ¯·Ú·ÎÙ‹Ú· fiˆ˜ Ë ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜, ·ÛÙ˘ÓÔÌÈο ÙÌ‹Ì·Ù· Î.¿.), ı· ÌÔÚÔ‡Û·Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÒÛÙ ӷ ¤ÏıÂÈ ËıÈ΋ ÈηÓÔÔ›ËÛË Î·È ÎÔÈÓˆÓÈ΋ ‰Èη›ˆÛË ÁÈ· ÙË ‰›Î·ÈË Ì¿¯Ë Ô˘ ‰fiıËΠ¤ÛÙˆ Î·È ·Ó ‰ÂÓ ‹Ù·Ó ÂÈÛÙËÌÔÓÈο ÙfiÛÔ ÁÔËÙ¢ÙÈ΋, Ô‡Ù ¿ÓÙ· ·fiÏ˘Ù· ·ÔÙÂÏÂÛÌ·ÙÈ΋ (2,10), fiˆ˜ ¿ÏϘ ÂÈÛÙËÌÔÓÈΤ˜ Ì¿¯Â˜ ÂÚ¢ÓËÙÈÎÔ‡ ¯·Ú·ÎÙ‹Ú·. ∞ӷηÏÒÓÙ·˜ Ù· ÏfiÁÈ· ÙÔ˘ ·Ù¤Ú· Ù˘ π·ÙÚÈ΋˜ “∫¿ÏÏÈÔÓ ÙÔ ÚÔÏ·Ì‚¿ÓÂÈÓ ·fi ÙÔ ıÂڷ‡ÂÈÓ” Î·È ÂÚÌËÓ‡ÔÓÙ¿˜ Ù· ÛˆÛÙ¿, ÌÔÚ› Ó· ÂÈÙ¢¯ı› Ô ÈÂÚfi˜ Î·È ÎÔÈÓˆÓÈÎfi˜ ÛÎÔfi˜ Ù˘ ·Ú¤Ì‚·Û˘ ÁÈ· ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ fi¯È ÌfiÓÔ Û ÙÔÈÎfi, ·ÏÏ¿ Û ÂıÓÈÎfi Î·È ‰ÈÂıÓ¤˜ ›‰Ô. µÈ‚ÏÈÔÁÚ·Ê›· 1. World Health Organization. World Health Statistics (Annual). Geneva: WHO; 1980-1994. 2. ∆ÚȯfiÔ˘ÏÔ˜ ¢, ∫·Ï·Ôı¿ÎË µ, ¶ÂÙÚ›‰Ô˘ ∂. ¶ÚÔÏËÙÈ΋ È·ÙÚÈ΋ Î·È ‰ËÌfiÛÈ· ˘Á›·. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∑‹Ù·; 2000. 3. ∞Ó·ÛÙ·Û›Ô˘-∫·ÙÛÈ·Ú‰¿ÓË ∞. ™Ô‚·Ú¿ ·È‰Èο ·Ù˘¯‹Ì·Ù·: ·›ÙÈ· - ÚfiÏË„Ë - ·Ú¤Ì‚·ÛË. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1998;10:13-19. 4. ∞ÁÁÂÏ‹˜ ∞. ∞Ù‡¯ËÌ·. ™ÙÔ: “π·ÙÚÈ΋ Ù˘ ÂÚÁ·Û›·˜ ηÈ
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∞. ∫Ô˘ÚÙ¤Û˘ , °. ∫·Ï·‚ÚÔ˘˙ÈÒÙ˘ , Ã. ¶·Ê›Ù˘ , °. ¶··‰fiÔ˘ÏÔ˜ , ∂. ª¿ÛÙ· , ¶. ∞˙·ÚÈ¿‰Ë˜
Anomalous origin of the right pulmonary artery from the ascending aorta. A case report A. Kourtesis1, G. Kalavrouziotis1, C. Paphitis1, G. Papadopoulos2, E. Basta2, P. Azariadis1
¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚ›ÙˆÛË ·ÓÒÌ·Ï˘ ¤ÎÊ˘Û˘ Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹. ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈ· Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·, ÛÙËÓ ÔÔ›· ·Ô˘ÛÈ¿˙Ô˘Ó Ù· Û˘Ó‹ıË ÎÏÈÓÈο ÛËÌ›· ÙˆÓ ÏÔÈÒÓ Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ (΢¿ÓˆÛË, ʇÛËÌ·). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ··ÈÙ› ÂÁÚ‹ÁÔÚÛË ·fi ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi, ÚÔÎÂÈ̤ÓÔ˘ Ó· Ô‰ËÁËı› Û ÂÚ·ÈÙ¤Úˆ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Ô˘ ı· ÂȂ‚·ÈÒÛÂÈ ÙË ‰È¿ÁÓˆÛË. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÙÂÏÂÈfiÌËÓÔ˘ ¿ÚÚÂÓÔ˜ ÓÂÔÁÓÔ‡, Ô˘ ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi Î·È ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3650 g, ÙÔ ÔÔ›Ô ÂÈÛ‹Ïı Û ËÏÈΛ· 26 ËÌÂÚÒÓ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ Ì ¤ÓÙÔÓË ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Ô˘ ·o‰fiıËΠ۠Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. O ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹, ·ÚÔ˘Û›· ¢ÌÂÁ¤ıÔ˘˜ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘ Î·È Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, Â˘Ú‹Ì·Ù· Ô˘ ÂȂ‚·›ˆÛÂ Î·È Ô Î·Ú‰È·Îfi˜ ηıÂÙËÚÈ·ÛÌfi˜. ∏ ·Ú¯È΋ ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÂÏ¿Ì‚·Ó ¯ÔÚ‹ÁËÛË ‰·ÎÙ˘Ï›Ùȉ·˜ Î·È ‰ÈÔ˘ÚËÙÈÎÒÓ. ªÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ‰ÂÈÎÙÒÓ Ïԛ̈͢ (CRP, ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ˘ÚÂÙÔ‡), ÙÔ ÓÂÔÁÓfi Ô‰ËÁ‹ıËΠÛÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô, fiÔ˘ Ì ÙË ¯Ú‹ÛË Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, ¤ÁÈÓ ·Ó·ÙÔÌÈ΋ ‰ÈfiÚıˆÛË Ù˘ ·ÓˆÌ·Ï›·˜, ÒÛÙ ϤÔÓ Ë ‰ÂÍÈ¿ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›· Ó· ÂͤگÂÙ·È Ê˘ÛÈÔÏÔÁÈο ·fi ÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó ÔÌ·Ï‹ ηÈ, ÌÂÙ¿ ·fi ÓÔÛËÏ›· 8 ËÌÂÚÒÓ, ÂÍ‹Ïı ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË.
Abstract: A rare case of anomalous origin of the right pulmonary artery from the ascending aorta is presented. This rare congenital heart disease lacks characteristic clinical signs of congenital heart disease such as murmur or cyanosis, and a high index of suspicion is required for the clinician to proceed to further evaluation with cardiac echogram and/or catheterization in order for the diagnosis to be established. A 26 day-old neonate (38 weeks gestation, vaginal delivery, birth weight 3650 g) was admitted to the NICU with severe respiratory distress, which was attributed to a respiratory infection. Cardiac echogram revealed a patent ductus arteriosus, the right pulmonary artery originating from the ascending aorta, and pulmonary hypertension. Supportive management with digitalis and diuretics was immediately commenced. After the infection indices returned to normal levels, the infant underwent surgical repair of the anomaly by means of extracorporeal circulation. The postoperative course was uneventful, and the baby was discharged on postoperative day 8 in good condition.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÓÒÌ·ÏË Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·, Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ.
Key words: anomalous pulmonary artery, pulmonary hypertension, congenital heart disease.
1 µ’ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó· 2 ∫·Ú‰ÈÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó·
1 2nd Cardiac Surgery Department, “Aghia Sophia” Children’s Hospital, Athens 2 Cardiology Department, “Aghia Sophia” Children’s Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2003;66:381-386
Paediatriki 2003;66:381-386
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡, ‚¿ÚÔ˘˜ 3650 g, Ô˘ ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi. ™ÙÔÓ ·Ú¯ÈÎfi ÎÏÈÓÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ ‰È·ÈÛÙÒıËΠ΢¿ÓˆÛË ‹ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ·Ú¿ ÌfiÓÔ Û˘Ó¯¤˜ ʇÛËÌ· 3/6 ÛÙËÓ ·ÚÈÛÙÂÚ‹ ·Ú·ÛÙÂÚÓÈ΋ ÂÚÈÔ¯‹, ÏfiÁˆ ·ÓÔÈÎÙÔ‡ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘ (PDA). OÈ ·Ó·›Ì·ÎÙ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ
‹Ù·Ó: ∞¶: 80/41 mmHg, ÛʇÍÂȘ: 148/min, Ú˘ıÌÈΤ˜ Î·È ÂÚÈÊÂÚÈΤ˜ ÛʇÍÂȘ „ËÏ·ÊËÙ¤˜, ·ÚÈıÌfi˜ ·Ó·ÓÔÒÓ: 46/min. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ‰ÂÓ ·ÚÔ˘Û›·Û οÙÈ ÙÔ ·ÍÈfiÏÔÁÔ. ∆¤ÛÛÂÚȘ Ë̤Ú˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘ ‰È·ÎÔÌ›ÛÙËΠÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ Ì ÛËÌÂÈÔÏÔÁ›· ¤ÓÙÔÓ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (75-80 ·Ó·ÓÔ¤˜/min) Î·È Ì¤ÙÚÈ· ˘ÚÂÙÈ΋ ΛÓËÛË (38,3ÔC). ∏ ·Ú¯È΋ ÂÎÙ›ÌËÛË ‹Ù·Ó ·Ó·Ó¢ÛÙÈ΋ Ïԛ̈ÍË Î·È ÙÔ ÓÂÔÁÓfi ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠IV ·ÓÙÈ‚›ˆÛË. O ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηډȿ˜ ¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ¢ÌÂÁ¤ıÔ˘˜ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘ (PDA), ¢ÌÂÁ¤ıË Î·È ‰È·ÙÂٷ̤ÓÔ ÙÔÓ ‰ÂÍÈfi ÎfiÏÔ Ì ·Ó¿ÚÎÂÈ· 2Ô˘ ‚·ıÌÔ‡ Ù˘ ÙÚÈÁÏÒ¯ÈÓ·˜ ‚·Ï‚›‰·˜, ·ÓÔÈÎÙfi ˆÔÂȉ¤˜ ÙÚ‹Ì·, ˘ÂÚÙÚÔÊÈ΋ Î·È ‰È·ÙÂٷ̤ÓË ÙË ‰ÂÍÈ¿ ÎÔÈÏ›· ÌÂ Û˘ÓÔ‰fi Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (RVP: 110 mmHg), ÛËÌ·ÓÙÈ΋ ·Ó¿ÚÎÂÈ· 2Ô˘-3Ô˘ ‚·ıÌÔ‡ Ù˘ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ Ì ‰È¿Ù·ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ·ÏÏ¿ Ì ηϋ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ·˘Ù‹˜ ηÈ, Ù¤ÏÔ˜, ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ (∂ÈÎfiÓ˜ 1 Î·È 2). O ‰È·‰ÂÚÌÈÎfi˜ ÎÔÚÂÛÌfi˜ ‹Ù·Ó 85% Ì FiO2 50%. ™ÙÔ ÓÂÔÁÓfi ¯ÔÚËÁ‹ıËΠDigoxin, Lasix, Aldactone Î·È ‰ÈÏÔ‡ Û¯‹Ì·ÙÔ˜ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹. ¡¤Ô˜ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηډȿ˜ Ï›Á˜ Ë̤Ú˜ ·ÚÁfiÙÂÚ· ¤‰ÂÈÍ ÙȘ ›‰È˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ì Âȉ›ӈÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÔfiÙ ÚÔÛÙ¤ıËΠDobutamine IV Û ‰ÔÛÔÏÔÁ›· 5 g/kg/min. O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ η٤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ˘ÂÚÊfiÚÙˆÛ˘ ÙÔ˘ ‰ÂÍÈÔ‡ Ó‡ÌÔÓ· (∂ÈÎfiÓ· 3). ∞ÎÔÏÔ‡ıËÛ ηıÂÙËÚÈ·ÛÌfi˜ ηډȿ˜ Ô˘ ·¤‰ÂÈÍ ÙËÓ ·ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ (RPA), ÙËÓ ·ÚÔ˘Û›· ¢ÌÂÁ¤ıÔ˘˜ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘ (PDA) Î·È ÙËÓ ÔÌ·Ï‹ ¤ÎÊ˘ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜
∂ÈÎfiÓ· 1. ŒÎÊ˘ÛË ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ Î·È ·Ó¿ÚÎÂÈ· ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜.
∂ÈÎfiÓ· 2. ŒÎÊ˘ÛË ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹.
∂ÈÛ·ÁˆÁ‹ ∏ ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (¢¶∞ - RPA) ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ (∞∞) ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1868 ·fi ÙÔÓ Fraentzel (1) Î·È ·ÊÔÚ¿ Û ̛· Û¿ÓÈ· Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·, ÛÙËÓ ÔÔ›· ¤¯Ô˘Ó ·Ô‰Ôı› ÔÏÏÔ› ÔÚÈÛÌÔ›. ŒÙÛÈ, ¤¯ÂÈ ·Ó·ÊÂÚı› ˆ˜ “Û˘ÁÁÂÓ‹˜ ¤ÏÏÂÈ„Ë Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜” ‹ ·ÎfiÌË Î·È ˆ˜ “hemitruncus” (2-4). ¶ÚfiÎÂÈÙ·È ÁÈ· ÓfiÛÔ Ì ¤ÏÏÂÈ„Ë ¿ÏÏˆÓ ÂÓ‰ÔηډȷÎÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ¤ÎÊ˘ÛË Ù˘ Û˘Ó‹ıˆ˜ ηϿ ·ÓÂÙ˘Á̤Ó˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹. ∞ӷʤÚÔÓÙ·È ‰‡Ô Ù‡ÔÈ: Ô ÎÂÓÙÚÈÎfi˜ Î·È Ô ÂÚÈÊÂÚÈÎfi˜. ∏ ·Ú¯È΋ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì ∏ÃO∫° ‰‡Ô ‰È·ÛÙ¿ÛÂˆÓ Î·È Doppler, ÂÓÒ o ηıÂÙËÚÈ·ÛÌfi˜ Ù˘ ηډȿ˜ Ô˘ ·ÎÔÏÔ˘ı›, ηıÔÚ›˙ÂÈ Ì ·ÎÚ›‚ÂÈ· ÙËÓ ¤ÎÊ˘ÛË Ù˘ RPA ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹, ÂÈÙÚ¤ÂÈ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ È¤ÛÂˆÓ ÛÙËÓ Ó¢ÌÔÓÈ΋ ΢ÎÏÔÊÔÚ›· ÁÈ· ÙËÓ ·ÔÎ¿Ï˘„Ë Ù˘ ˘¿Ú¯Ô˘Û·˜ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ Î·È Î·ıÔÚ›˙ÂÈ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÛÙÚ·ÙËÁÈ΋ Ô˘ ı· ·ÎÔÏÔ˘ıËı›. ∞Ó Î·È ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ ÂÈÙÚ¤Ô˘Ó ÙËÓ Ù·¯Â›· ‰ÈfiÚıˆÛË (5), ÂÓÙÔ‡ÙÔȘ, Ë ıÓËÙfiÙËÙ· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹, ÏfiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ Ù˘ ÌË ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ Î·È Ù˘ ·ÚÔ˘Û›·˜ Ù˘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ Ó¢ÌÔÓÈ΋˜ ·ÁÁÂȷ΋˜ ˘¤ÚÙ·Û˘, Ë ·ıÔÁ¤ÓÂÛË Ù˘ ÔÔ›·˜ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÍÂοı·ÚË.
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Ó¢ÌÔÓÈ΋˜ (LPA) ·fi ÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (∂ÈÎfiÓ˜ 4 Î·È 5). OÈ ÌÂÙÚ‹ÛÂȘ ÙˆÓ È¤ÛÂˆÓ ÛÙ· ‰È¿ÊÔÚ· ‰È·ÌÂÚ›ÛÌ·Ù· Ù˘ ηډȿ˜ ‹Ù·Ó: ‰ÂÍÈ¿ ÎÔÈÏ›· (RV): 90/10 mmHg, Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›· (PA): 80/30 mmHg, ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›· (LV): 80/10 mmHg Î·È ·ÔÚÙ‹ (Ao): 80/44 mmHg. ÃÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË: ∆· ÂÁ¯ÂÈÚËÙÈο Â˘Ú‹Ì·Ù· ‹Ù·Ó Ë ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ‰È·Ì¤ÙÚÔ˘ 4-5 mm ·fi ÙË ‰ÂÍÈ¿ ÔÈÛıÈÔÏ¿ÁÈ· ÏÂ˘Ú¿ Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ ÂÚ›Ô˘ 2 cm ¿Óˆ ·fi ÙËÓ ·ÔÚÙÈ΋ ‚·Ï‚›‰·, Ë ·ÚÔ˘Û›· ÙÔ˘ ¢ÌÂÁ¤ıÔ˘˜ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘, ηıÒ˜ ›Û˘ Î·È Ë ·ÚÔ˘Û›· Ï›·Ó ‰È·ÙÂÙ·Ì¤ÓˆÓ ‰ÂÍÈÒÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ. ªÂÙ¿ ÙËÓ ·Ó·ÙÔÌÈ΋ ·Ú·Û΢‹ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙˆÓ ÎÏ¿‰ˆÓ Ù˘, ·ÔÏÈÓÒıËÎÂ Ô Â˘ÌÂÁ¤ı˘ ‚ÔÙ¿ÏÂÈÔ˜ fiÚÔ˜. ∞ÎÔÏÔ‡ıËÛÂ Ë Â›ÛÔ‰Ô˜ ÛÙËÓ Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›·, Ì ˘ÔıÂÚÌ›· 18ÔC Î·È Î·Ú‰È·Î‹ ·‡ÛË Ì ÔÚıfi‰ÚÔÌË ˘ÂÚηÏÈ·ÈÌÈ΋ ·ÈÌ·ÙÈ΋ ηډÈÔÏËÁ›·. ŒÁÈÓÂ
∂ÈÎfiÓ· 3. ÀÂÚÊfiÚÙˆÛË ‰ÂÍÈÔ‡ Ó‡ÌÔÓ· Î·È Î·Ú‰ÈÔÌÂÁ·Ï›·.
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Paediatriki 2003;66:381-386
·ÔÎfiÏÏËÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹, ÌÂÙ·ÊÔÚ¿ Ù˘ ›Ûˆ ·fi ÙË ‰È·ÙÌËı›۷ ·ÓÈÔ‡Û· ·ÔÚÙ‹ Î·È ·Ó·ÛÙfïۋ Ù˘ Ì ÙËÓ Î‡ÚÈ· Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·. ∞ÎÔÏÔ‡ıËÛ ·ӤӈÛË Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ Î·È Ë Û˘Ó‹ı˘ ‰È·‰Èηۛ· ·ӷı¤ÚÌ·ÓÛ˘ Î·È ÛÙ·‰È·Î‹˜ ·ÔÛ‡Ó‰ÂÛ˘ ·fi ÙËÓ Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù·. ∆Ô ÓÂÔÁÓfi ÌÂٷʤÚıËΠÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ Û ηϋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË, fiÔ˘ ÌÂÙ¿ ·fi ÓÔÛËÏ›· 8 ËÌÂÚÒÓ ÌÂٷʤÚıËΠÛÙËÓ Î·Ú‰ÈÔÏÔÁÈ΋ ÎÏÈÓÈ΋. ªÂÙ¿ ·fi ·Ú·ÌÔÓ‹ 4 ËÌÂÚÒÓ, ÂϤÁ¯ıËΠ̠˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ηډȿ˜ (∂ÈÎfiÓ· 6) Î·È ·ÎÙÈÓÔÁڷʛ˜ ıÒÚ·ÎÔ˜, Ù· ÔÔ›· ÂȂ‚·›ˆÛ·Ó ÙËÓ ÔÌ·Ï‹ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÙÔ˘ ÔÚ›· (∂ÈÎfiÓ· 7). ™˘˙‹ÙËÛË ∏ ·ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ Â›Ó·È Ì›· Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·. ∞fi ÙËÓ ÚÒÙË ÂÚÈÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘, ÙÔ 1868 ·fi ÙÔÓ Fraentzel, ̤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚ›Ô˘ 100 ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ·ÓÙÈÌÂÙˆÈÛÙ› ¯ÂÈÚÔ˘ÚÁÈο Ì ÂÈÙ˘¯›·. Œ¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô Ù‡ÔÈ ·ÓÒÌ·Ï˘ ¤ÎÊ˘Û˘: Ô ÎÂÓÙÚÈÎfi˜ Î·È Ô ÂÚÈÊÂÚÈÎfi˜. ™ÙÔÓ ÎÂÓÙÚÈÎfi, Ô˘ Â›Ó·È Ô Û˘¯ÓfiÙÂÚÔ˜ (ÔÛÔÛÙfi 85%) (6), Ë ¤ÎÊ˘ÛË Á›ÓÂÙ·È ·fi ÙÔ ‰ÂÍÈfi Ï¿ÁÈÔ ÙÔ›¯ˆÌ· Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ Î·È Â›Ó·È ÎÔÓÙ¿ ÛÙËÓ ·ÔÚÙÈ΋ ‚·Ï‚›‰·. ™ÙÔÓ ÂÚÈÊÂÚÈÎfi Ù‡Ô, Ô˘ Â›Ó·È Û·ÓÈfiÙÂÚÔ˜, Ë ¤ÎÊ˘ÛË Á›ÓÂÙ·È ÎÔÓÙ¿ ÛÙËÓ ·ÓÒÓ˘ÌË ·ÚÙËÚ›· Î·È ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ ÂÌ‚Ú˘ÔÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Û ۯ¤ÛË Ì ÙÔÓ ÎÂÓÙÚÈÎfi Ù‡Ô. ŒÙÛÈ, Û‡Ìʈӷ Ì ÙÔÓ Schneiderman (7), Ë ·‰˘Ó·Ì›· ·ÚÈÛÙÂÚ‹˜ ÛÙÚÔÊ‹˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ù˘ ‰ÂÍÈ¿˜ ¤ÎÙ˘ ·ÚÙËÚ›·˜ ÙÔ˘ ·ÔÚÙÈÎÔ‡ ÙfiÍÔ˘, ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ‰ÂÍÈ¿ Ó¢ÌÔÓÈ΋,
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∂ÈÎfiÓ· 4. ∞ÚÈÛÙÂÚ‹ Ï¿ÁÈ· ·ÁÁÂÈÔÁÚ·Ê›·. ŒÎÊ˘ÛË ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹.
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·ÔÙÂÏ› ÙËÓ ·ÈÙ›· Ù˘ ·ıÔÁ¤ÓÂÈ·˜, ÂÓÒ ÔÈ Cucci Î·È Û˘Ó (8) Î·È ÔÈ Richardson Î·È Û˘Ó (9) ÈÛÙÂ‡Ô˘Ó fiÙÈ Ë ·‰˘Ó·Ì›· ÙÔ˘ Ï‹ÚÔ˘˜ ‰È·¯ˆÚÈÛÌÔ‡ ÙÔ˘ ÎÔÚÌÔ‡ Ô‰ËÁ› Û ·˘Ù‹ ÙËÓ ·ÓˆÌ·Ï›· ÎÂÓÙÚÈÎÔ‡ Ù‡Ô˘. ™ÙÔÓ ÂÚÈÊÂÚÈÎfi Ù‡Ô, ÙÔ ÓˆÙÈ·›Ô ÙÌ‹Ì· ÙÔ˘ 6Ô˘ ·ÔÚÙÈÎÔ‡ ÙfiÍÔ˘ ·Ú·Ì¤ÓÂÈ Âӈ̤ÓÔ Ì ÙÔ 5Ô ·ÔÚÙÈÎfi ÙfiÍÔ (ÚԤϢÛË PDA) Î·È ÙËÓ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·. ∞˘Ùfi ÂÍËÁ› Î·È ÙËÓ ·ÚÔ˘Û›· Û˘¯Ó¿ ÛÙÂÓˆÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Î·Ù¿ Ì‹ÎÔ˜ Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. ∏ ‰È·ÊÔÚÂÙÈ΋ ÂÌ‚Ú˘ÔÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ ÂÚÌËÓ‡ÂÙ·È Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ‰‡Ô Ù‡ÔÈ Û˘Óԉ‡ÔÓÙ·È Î·È ·fi ‰È·ÊÔÚÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ŒÙÛÈ, Ù· ÂÏÏ›ÌÌ·Ù· ÙÔ˘ ·ÔÚÙÔÓ¢ÌÔÓÈÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ (15%) Î·È ÔÈ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ‰È·ÎÔ‹˜ ÙÔ˘ ·ÔÚÙÈÎÔ‡ ÙfiÍÔ˘ (8%) Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙÔÓ ÎÂÓÙÚÈÎfi Ù‡Ô. ∏ ϤÔÓ Û˘¯Ó‹ Û˘ÓÔ‰fi˜ ¿ıËÛË Â›Ó·È Ë ·Ú·ÌÔÓ‹ ·ÓÔÈÎÙÔ‡ ÙÔ˘ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘ (50%), ηٿÛÙ·ÛË Ô˘ ˘‹Ú¯Â Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË.
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Paediatriki 2003;66:381-386
∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ∏ÃO∫° ‰‡Ô ‰È·ÛÙ¿ÛÂˆÓ Î·È ÙÔ Doppler, ÙÔ ÔÔ›Ô ı¤ÙÂÈ ÙË ‰È¿ÁÓˆÛË ÛÙË Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛˆÓ, fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. µÂ‚·›ˆ˜, Ë ¤ÏÏÂÈ„Ë ¿ÏÏˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ, fiˆ˜ ΢¿ÓˆÛË, ÂÌÊ·Ó‹˜ ηډȷ΋ ·Ó¿ÚÎÂÈ· ‹ ·ÚÔ˘Û›· “Ê˘Û‹Ì·ÙÔ˜”, ηıÈÛÙ¿ ÙË ‰È¿ÁÓˆÛË ‰˘Û‰È¿ÎÚÈÙË. O Ì˯·ÓÈÛÌfi˜ Ù˘ ·ÚÔ˘Û›·˜ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ Â›Ó·È Ì›· ‰È·‰Èηۛ· Ô˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ·È‰È¿ ËÏÈΛ·˜ <1 ¤ÙÔ˘˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÈÛÙÔÏÔÁÈο ·ÔÊÚ·ÎÙÈΤ˜ ‰È·‰Èηۛ˜ ÛÙ· Ó¢ÌÔÓÈο ·ÁÁ›·, ηٿÛÙ·ÛË fï˜ Ô˘ ‰È·ÈÛÙÒıËΠ۠·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ (10). ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰ÂÍÈ¿ ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ı· ÌÔÚÔ‡Û ӷ ÂÍËÁËı› ·Ó·Ï‡ÔÓÙ·˜ ÙË Ê˘ÛÈÔÏÔÁ›· ÙÔ˘ ‰ÂÍÈÔ‡ Î·È ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ Ó‡ÌÔÓ·. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ˘¿Ú¯Ô˘Ó ‰‡Ô ÌË ·Ú¿ÏÏËϘ
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∂ÈÎfiÓ· 5. ŒÎÊ˘ÛË ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹, ·ÚÔ˘Û›· PDA.
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∂ÈÎfiÓ· 6. ªÂÙÂÁ¯ÂÈÚËÙÈÎfi ECHO ηډȿ˜. ŒÎÊ˘ÛË ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜.
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Ó¢ÌÔÓÈΤ˜ ΢ÎÏÔÊÔڛ˜ Ì ·ÓÂÍ¿ÚÙËÙ˜ ÚÔ¤˜ Î·È ·ÓÙÈÛÙ¿ÛÂȘ. ∏ ‰ÂÍÈ¿ ΢ÎÏÔÊÔÚ›· ¤¯ÂÈ Û˘ÛÙËÌ·ÙÈΤ˜ ȤÛÂȘ ÛÙË ‰ÂÍÈ¿ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›· Î·È ·˘ÍË̤ÓË ÚÔ‹ ÛÙÔ ‰ÂÍÈfi Ó‡ÌÔÓ·, ηٿÛÙ·ÛË Ô˘ “ı˘Ì›˙ÂÈ” ·ÓÔÈÎÙfi ‚ÔÙ¿ÏÂÈÔ fiÚÔ ‹/Î·È ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙȘ ·ÓÙÈÛÙ¿ÛÂȘ ÙÔ˘ ‰ÂÍÈÔ‡ Ó¢ÌÔÓÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘. ™ÙÔÓ ·ÚÈÛÙÂÚfi Ó‡ÌÔÓ·, Ë ÚÔ‹ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ÊÏ‚È΋ ÂÈÛÙÚÔÊ‹ Î·È Î¿ı ·ÏÏ·Á‹ ÛÙËÓ ·ÓÙ›ÛÙ·ÛË ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘ ı· ›¯Â ¿ÌÂÛË Â›‰Ú·ÛË ÛÙË ‰ÂÍÈ¿ ÎÔÈÏ›· Î·È ÛÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹ Û˘ÓÔÏÈο. ∏ ·Ú·ÙËÚÔ‡ÌÂÓË Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ÛÙÔÓ ·ÚÈÛÙÂÚfi Ó‡ÌÔÓ· ‰ÂÓ Ú¤ÂÈ Ó· ÔÊ›ÏÂÙ·È ÌfiÓÔ ÛÙËÓ ·˘ÍË̤ÓË ÚÔ‹, ·ÊÔ‡ - Û ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ ·Ô˘Û›·˜ ÙÔ˘ ÂÓfi˜ Ó‡ÌÔÓ· - ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ·ÍÈfiÏÔÁË ·‡ÍËÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛˆÓ, ·ÏÏ¿ Û˘ÌÌÂÙ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔÈ ÙÔ˘ ÂÓfi˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜: ·) Ë ·Ó·ÙÔÌ›· ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ·ÚÈıÌfi, ÛÙË ‰È¿ÌÂÙÚÔ Î·È ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ·ÁÁ›ˆÓ, ‚) Ô ÙfiÓÔ˜ ÙˆÓ ·ÁÁ›ˆÓ Î·È Á) Ë ‰˘Ó·ÌÈ΋ Ù˘ ÚÔ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙ· Ó¢ÌÔÓÈο ·ÁÁ›· (11). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹˜ Ù˘ ·ÓˆÌ·Ï›·˜, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· fiÙÈ ·ÔÙÂÏ› ÙË ÌfiÓË Î·È ·ÔÎÏÂÈÛÙÈ΋ ‰È·‰Èηۛ· ÂÈ‚›ˆÛ˘. ¶·ÚËÁÔÚÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ ÂÊ·ÚÌfiÛÙËÎ·Ó ÛÙÔ ÚfiÛÊ·ÙÔ ·ÚÂÏıfiÓ, fiˆ˜ ·ÔϛӈÛË ÙÔ˘ ‚ÔÙ¿ÏÂÈÔ˘ fiÚÔ˘, ·ÔϛӈÛË Ù˘ ·ÓÒÌ·Ï˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ‹ ÂÚ›‰ÂÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜, ¤¯Ô˘Ó ˘„ËÏ‹ ıÓËÙfiÙËÙ· Ô˘ ·ÁÁ›˙ÂÈ ÙÔ 82%, Û ۯ¤ÛË Ì ÙÔ 25% Ù˘ ÔÏÈ΋˜ ‰ÈfiÚıˆÛ˘ (12,13). ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÎÙÔÌ‹ Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Ì “ÎÔÌ‚›Ô” ÈÛÙÔ‡ ·fi ÙËÓ ·ÔÚÙ‹, ÙËÓ ÔÚ›· Ù˘ οو ·fi ÙËÓ ·ÔÚÙ‹ Î·È ÙËÓ ÂÌʇÙÂ˘Û‹ Ù˘ ÛÙÔ Û٤ϯԘ
Paediatriki 2003;66:381-386
Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. OÈ ÚÒÙ˜ ÂÂÌ‚¿ÛÂȘ ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ ¤ÁÈÓ·Ó ¯ˆÚ›˜ ÙË ¯Ú‹ÛË Ù˘ Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜. ∞ÚÁfiÙÂÚ·, fï˜, Ì ÙËÓ ÂͤÏÈÍ‹ Ù˘ ÛÙ· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË, ¤ÁÈÓ ·Ó·Áη›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë Î·Ù·Û΢‹ Ù˘ ·Ó·ÛÙfïÛ˘ ÌfiÓÔ Ì ÙË ¯Ú‹ÛË Ï·‚›‰·˜ Ï¿ÁÈ·˜ Û‡ÁÎÏÂÈÛ˘ Ù˘ ·ÓÈÔ‡Û˘ ·ÔÚÙ‹˜ ‰ÂÓ Â›Ó·È Â‡ÎÔÏË Ô‡Ù ·ÛÊ·Ï‹˜. ™Â ÂÚÈÙÒÛÂȘ ÂÚÈÊÂÚÈÎÔ‡ Ù‡Ô˘ ·ÓÒÌ·Ï˘ Â΂ÔÏ‹˜ Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜, Ë ¯Ú‹ÛË Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Â›Ó·È ¿ÎÚˆ˜ ··Ú·›ÙËÙË ÁÈ·Ù› Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfi ÔÛÔÛÙfi ·ÚÔ˘Û›·˜ ÛÙÂÓˆÙÈÎÒÓ ÂÚÈÔ¯ÒÓ, ÏfiÁˆ Ù˘ ·ÚÔ˘Û›·˜ ÈÛÙÔ‡ ·fi ‚ÔÙ¿ÏÂÈÔ fiÚÔ Î·È Û˘Ó‹ıˆ˜ ¯ÚÂÈ¿˙ÂÙ·È ÙÔÔı¤ÙËÛË Û˘ÓıÂÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (14,15). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ¤̂·Û˘ ·fi ÏÂ˘Ú¿˜ ˘ÔÛÙÚÔÊ‹˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘, ·˘Ù‹ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛˆÓ. ∆· Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ÙËÓ ÔÚ›· Ù˘ ·Ó·ÛÙfïÛ˘ ÛÙ· ¯ÂÈÚÔ˘ÚÁË̤ӷ ·È‰È¿ ‰Â›¯ÓÔ˘Ó ‰˘ÛÙ˘¯Ò˜ ÙËÓ ·ÚÔ˘Û›· ·ӷÛÙ¤ÓˆÛ˘ ÛÙË ‰ÂÍÈ¿ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Â›Ù Ì ÙËÓ ·Ï‹ ‰È·ÛÙÔÏ‹ Ì “Ì·ÏfiÓÈ” ›Ù Ì ÙËÓ ÙÔÔı¤ÙËÛË ÂÓ‰Ô·ÁÁÂȷ΋˜ ÚfiıÂÛ˘ (stent) ‹ ·ÎfiÌË Î·È Ì ·Ó¤̂·ÛË. (16) ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·ÓÒÌ·ÏË Â΂ÔÏ‹ Ù˘ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ Â›Ó·È Ì›· ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·, Ë ‰È¿ÁÓˆÛË Ù˘ ÔÔ›·˜ ··ÈÙ› ˘„ËÏfi ‚·ıÌfi ÎÏÈÓÈ΋˜ ˘Ô„›·˜. ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÙË ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ ηډȿ˜ (17), ÂÓÒ Ë ·ÁÁÂÈÔÁÚ·Ê›· ÂȂ‚·ÈÒÓÂÈ Î·È Î·ıÔÚ›˙ÂÈ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÛÙÚ·ÙËÁÈ΋ Ô˘ ı· ·ÎÔÏÔ˘ıËı›. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›· Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË. Œ¯ÂÈ Ôχ ηϿ ¿ÌÂÛ· ·ÔÙÂϤÛÌ·Ù·, ˆÛÙfiÛÔ, Ë ·ÚÔ˘Û›· ·ӷÛÙ¤ÓˆÛ˘ ÛÙËÓ ·Ó·ÛÙfïÛË ‰ÂÓ Â›Ó·È ·Û˘Ó‹ı˘ (17). µÈ‚ÏÈÔÁÚ·Ê›·
∂ÈÎfiÓ· 7. ªÂÙÂÁ¯ÂÈÚËÙÈ΋ Ro ıÒÚ·ÎÔ˜.
1. Fraentzel O. Ein Fall von abnormer Communication der Aorta mit der Arteria pulmonalis. Arch Path Anat Physiol Klin Med 1868;43:420-426. 2. Anderson RC, Char F, Adams P. Proximal interruption of a pulmonary arch (absence of one pulmonary artery): case report and a new embryologic interpretation. Dis Chest 1958;34:73-86. 3. Bahler RC, Carson P, Traks E, Levene A, Gillespie D. Absent right pulmonary artery. Problems in diagnosis and management. Am J Med 1969;46:64-71. 4. Coehl E, Paiva ED, Nunes A. Malformation of the pulmonary artery and its branches, including two cases of absence of the right pulmonary artery. Am J Cardiol 1964;13:462-470. 5. Kirkpatrick SE, Girod DA, King H. Aortic origin of the right pulmonary artery. Surgical repair without a graft. Circulation 1967;36:777-782.
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6. Kutsche LM, Van Mierop LH. Anomalous origin of a pulmonary artery from the ascending aorta: associated anomalies and pathogenesis. Am J Cardiol 1988;61:850-856. 7. Schneiderman LJ. Isolated congenital absence of the right pulmonary artery: a caution as to its diagnosis and a proposal for its embryogenesis. Report of a case with review. Am Heart J 1958;55:772-780. 8. Cucci CE, Doyle EF, Lewis EW. Absence of a primary division of the pulmonary trunk: an ontogenetic theory. Circulation 1964;29:124-131. 9. Richardson JV, Doty DB, Rossi NP, Ehrenhaft JL. The spectrum of anomalies of aortopulmonary septation. J Thorac Cardiovasc Surg 1979;78:21-27. 10. Wagenvoort CA, Wagenvoort N. Pathology of pulmonary hypertension. New York: John Wiley; 1977. p. 294-298. 11. Agarwala B, Waldman JD, Sand M, Loe WA Jr, Ruschhaupt DG. Aortic origin of the RPA: immediate resolution of severe pulmonary artery hypertension by surgical repair. Pediatr Cardiol 1994;15:41-44. 12. Nakamura Y, Yasui H, Kado H, Yonenaga K, Shiokawa Y, Tokunaga S. Anomalous origin of the right pulmonary artery from the ascending aorta. Ann Thorac Surg 1991;52:1285-1291. 13. Abu-Sulaiman RM, Hashmi A, McCrindle BW, Williams WG, Freedom RM. Anomalous origin of one pulmonary artery
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14.
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from the ascending aorta: 36 years’ experience from one center. Cardiol Young 1998;8:449-454. Igarashi K, Horimoto M. Origin of the right pulmonary artery from the ascending aorta. Longest survivor without receiving surgical repair. Chest 1994;105:1280-1282. Miyazaki K, Murashita T, Kubota T, Matsuzaki K, Miyazaki YJ, Yasuda K. Neonatal repair of anomalous origin of the right pulmonary artery from the ascending aorta. A case report and review in the literature. J Cardiovasc Surg 2000;41:863-868. Prifti E, Crucean A, Bonacchi M, Bernabei M, Leacche M, Murzi B et al. Postoperative outcome in patients with anomalous origin of one pulmonary artery branch from the aorta. Eur J Cardiothorac Surg 2003;24:21-27. Trapali CJ, Thanopoulos BD. Severe right ventricular dysfunction in a neonate with aortic origin of the RPA. Pediatr Cardiol 1998;19:425-427.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 04-04-2003 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 09-09-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÒÓ˘ ∫Ô˘ÚÙ¤Û˘ µ. ∞ı·Ó·Û›Ô˘ 65, ∆.∫. 185 39, ¶ÂÈÚ·È¿˜ E-mail: akourt@ath.forthnet.gr
¶·È‰È·ÙÚÈ΋ 2003;66:387-391
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2003;66:387-391
CASE REPORT
µ·ÚÈ¿ Û˘Ìو̷ÙÔÏÔÁ›· ıÚfiÌ‚ˆÛ˘ Û ‚Ú¤ÊÔ˜ °. ™È‰ÂÚ‹1, ∫. ¶·¿˙ÔÁÏÔ˘1, ª. ∆ÛÔÏÈ¿2, ∫. µÔ‡‰Ú˘3, ∞. ™Î·Ú‰Ô‡ÙÛÔ˘2, ™. ∞ÚÒÓË4, π. ¶··‰¿ÙÔ˜1
Severe symptomatology of thrombosis in a baby G. Sideri1, K. Papazoglou1, M. Tsolia2, K. Voudris3, A. Skardoutsou2, S. Aroni4, I. Papadatos1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ı‹ÏÂÔ˜ ‚Ú¤ÊÔ˘˜ ËÏÈΛ·˜ 50 ËÌÂÚÒÓ Ô˘ ·ÚÔ˘Û›·Û ıÚfiÌ‚ˆÛË ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ ÌÂÙ¿ ·fi ÛË„·ÈÌ›·, ·Ê˘‰¿ÙˆÛË Î·È ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË. ™ÙÔ Ï·›ÛÈÔ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ‚·Ú‡Ù·Ù˘ ηٿÛÙ·Û‹˜ ÙÔ˘, ›¯Â ÙÔÔıÂÙËı› ηıÂÙ‹Ú·˜ ÛÙË ÌËÚÈ·›· ·ÚÙËÚ›·, Ô ÔÔ›Ô˜ ·ÔÛ‡ÚıËΠϛÁ˜ ÒÚ˜ ·ÚÁfiÙÂÚ· ÏfiÁˆ ÈÛ¯·ÈÌÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ Û‡ÛÙÔÈ¯Ô ¿ÎÚÔ. OÈ ·ÏÏÔÈÒÛÂȘ ·˘Ù¤˜ ‹Ù·Ó Û˘Ì‚·Ù¤˜ Ì ıÚfiÌ‚ˆÛË Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ Î·È ÎÚ›ıËÎ·Ó ÌË ·Ó·ÛÙÚ¤„È̘. ¶·Ú¿ Ù· ‰Â‰Ô̤ӷ ·˘Ù¿, ¯ÔÚËÁ‹ıËΠıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹ Ì ·ÚfiÛÌÂÓ· ηϿ ·ÔÙÂϤÛÌ·Ù·. ¶·ÚÔ˘ÛÈ¿ÛÙËΠ‚ÂÏÙ›ˆÛË ÛÙË ÚÔ‹ ÙˆÓ ·ÚÙËÚÈÒÓ: ÌËÚÈ·›·˜, ÈÁÓ˘·Î‹˜ Î·È ÚfiÛıÈ·˜ ÎÓËÌÈ·›·˜. ∆ÂÏÈο, ¯ÚÂÈ¿ÛÙËΠӷ Á›ÓÂÈ ·ÎÚˆÙËÚÈ·ÛÌfi˜ ÛÙÔ ‡„Ô˜ ÌfiÓÔ Ù˘ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘. ™ÙÔÓ ¤ÏÂÁ¯Ô ıÚÔÌ‚ÔÊÈÏ›·˜ Ô˘ ¤ÁÈÓ ‚Ú¤ıËΠfiÙÈ Ë ·ÛıÂÓ‹˜ ‹Ù·Ó ÂÙÂÚÔ˙˘ÁÒÙ˘ ÁÈ· ÌÂÙ·ÏÏ·Á̤ÓÔ ·Ú¿ÁÔÓÙ· V (FV Leiden). ∞˘Ù‹ ‹Ù·Ó Èı·ÓÒ˜ Î·È Ë ·ÈÙ›· Û¯ËÌ·ÙÈÛÌÔ‡ ÂÌÊÚ¿ÎÙˆÓ ÛÙÔÓ ÂÁΤʷÏÔ ÙÔ˘ ·È‰ÈÔ‡, Ù· ÔÔ›· ‰È·ÈÛÙÒıËÎ·Ó Û ËÏÈΛ· 1ó ¤ÙÔ˘˜.
Abstract: The case is reported of a female infant aged 50 days whÔ presented with femoral artery thrombosis following sepsis, dehydration and metabolic acidosis. The infant was catheterized with short IV cannula (G 20) in the femoral artery, but a few hours later the catheter had to be removed due to ischaemic changes in the limb. Although these changes were considered irreversible, thrombolytic treatment was administered with some improvement of circulation in the femoral, popliteal and anterior tibial arteries. Amputation of the limb at the knee joint was eventually performed. Investigation for thrombophilic factors revealed that the patient was a heterozygote for mutated factor V (FV Leiden) and was genetically predisposed to thrombosis. This was probably the cause of the cerebral infarctions which were diagnosed at the age of 1ó years.
§¤ÍÂȘ ÎÏÂȉȿ: ıÚÔÌ‚ÔÊÈÏ›·, ıÚfiÌ‚ˆÛË, ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È·, ÌÂÙ·ÏÏ·Á̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ FV Leiden.
Key words: thrombophilic factors, thrombosis, thromboembolic disease, factor V Leiden.
™˘ÓÙÔÌÔÁڷʛ˜ rtPA FVL
∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˜ ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ ªÂÙ·ÏÏ·Á̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ V
1 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 2 µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 3 ¡Â˘ÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 4 ªÔÓ¿‰· ∞ÈÌÔÚÚ·ÁÈÎÒÓ ¢È·ı¤ÛˆÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á. ™ÔÊ›·”, ∞ı‹Ó·
APCR Factor Va Factor VIIIa
∞ÓÙ›ÛÙ·ÛË ÛÙËÓ ÂÓÂÚÁÔÔÈË̤ÓË ÚˆÙ½ÓË C ∂ÓÂÚÁÔÔÈË̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ V ∂ÓÂÚÁÔÔÈË̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ VIII
1 Intensive Care Unit, “P. & A. Kyriakou” Children’s Hospital, Athens 2 2nd Paediatric Clinic of University of Athens, “P. & A. Kyriakou” Children’s Hospital, Athens 3 Department of Neurology, “P. & A. Kyriakou” Children’s Hospital, Athens 4 Haemophilia and Haemostatic Unit, “Aghia Sophia” Children’s Hospital, Athens
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∂ÈÛ·ÁˆÁ‹ ¶ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó·˜ ·ÈÒÓ·˜ ¤¯ÂÈ ÂÚ¿ÛÂÈ ·fi ÙfiÙ Ԣ Ô ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˜ Rudolph Virchow ÂÚȤÁÚ·„ fiÙÈ ÁÈ· ÙËÓ ·ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË Â›Ó·È ˘Â‡ı˘ÓÔÈ ÙÚÂȘ ·Ú¿ÁÔÓÙ˜: ÔÈ ·ÁÁÂȷΤ˜ ‚Ï¿‚˜, Ë ·ÏÏ·Á‹ ÛÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ Î·È ÔÈ ·ÏÏÔÈÒÛÂȘ ÛÙËÓ ËÎÙÈÎfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜ (1). ¶·Ú’ fiÏË ÙËÓ ·ÏfiÙËÙ· ÙÔ˘ ·ÓˆÙ¤Úˆ ÛÎÂÙÈÎÔ‡, Ë ÂÎÙ›ÌËÛË ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ì ÛÔ‚·Ú‹ ÂΉ‹ÏˆÛË ıÚfiÌ‚ˆÛ˘ ·Ú·Ì¤ÓÂÈ ÁÂÁÔÓfi˜ Û‡ÓıÂÙÔ. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ Ì ÔÏϷϤ˜ ·ÁÁÂȷΤ˜ ıÚÔÌ‚ÒÛÂȘ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜, ËÏÈΛ·˜ 50 ËÌÂÚÒÓ, ‰È·ÎÔÌ›ÛÙËΠ·fi ·گȷÎfi ÓÔÛÔÎÔÌÂ›Ô Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ·Ê˘‰¿ÙˆÛ˘. ∂›ÎÔÛÈ Ù¤ÛÛÂÚȘ ÒÚ˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, ÙÔ ‚Ú¤ÊÔ˜ ·ÚÔ˘Û›·Û Â̤ÙÔ˘˜ Î·È ‰È¿ÚÚÔȘ. ™‡Ìʈӷ Ì ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi, Ë ËÏÈΛ· ·ËÛ˘ ‹Ù·Ó 36 ‚‰ÔÌ¿‰Â˜, Ô ÙÔÎÂÙfi˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2450 g. ∂›¯Â ·Ú·Ì›ÓÂÈ Û ÙÌ‹Ì· ÚÔÒÚˆÓ ÁÈ· 21 Ë̤Ú˜ ÏfiÁˆ ˘ÚÂÙÔ‡, ÂÌ¤ÙˆÓ Î·È ‰È·ÚÚÔÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ˆ˜ ÛË„·ÈÌ›·. ¡ÔÛËχıËΠÏfiÁˆ ÂÌ¤ÙˆÓ ÚÔ 4Ë̤ÚÔ˘ Û ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ·’ fiÔ˘ ÂÍ‹Ïı Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ∆Ô ‚Ú¤ÊÔ˜, ηٿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ, ·ÚÔ˘Û›·˙ ·Ê˘‰¿ÙˆÛË 10%, Ù·¯‡ÓÔÈ·, ¤ÓÙÔÓË ˆ¯ÚfiÙËÙ· Î·È ·ÁÁÂÈÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ‹Ù·Ó 100/49 mmHg Î·È ÔÈ ÛʇÍÂȘ 170/min. §fiÁˆ Ù˘ ÛÔ‚·Ú‹˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ô˘ ·ÚÔ˘Û›·˙Â, ÂÈÛ‹¯ıË ¿ÌÂÛ· ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£). ∏ ¤ÓÙÔÓË Ù·¯‡ÓÔÈ·, Ë ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË (pH: 6,79), ÔÈ ·ÁÁÂÈÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Ë Ù·¯¤ˆ˜ ÂȉÂÈÓÔ‡ÌÂÓË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ô‰‹ÁËÛ·Ó ÛÙË ‰È·ÛˆÏ‹ÓˆÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜. ÕÚ¯ÈÛ ¿ÌÂÛ· Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ê˘‰¿ÙˆÛ˘ Î·È Ù˘ ÔͤˆÛ˘ Ì ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ. ∆· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó: ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜: 3500 g (<5Ë ÂηÙÔÛÙÈ·›· ı¤ÛË - ∂£), ‡„Ô˜: 55 cm (<5Ë ∂£), ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜: 35 cm (<5Ë ∂£). ¢‡Ô ÒÚ˜ ÌÂÙ¿ ·fi ÙËÓ ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜, ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ·ÁÁÂÈÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÂÚ› ÙÔ ÛËÌÂ›Ô ·Ú·Î¤ÓÙËÛ˘. ∞˘Ùfi Ô‰‹ÁËÛ ÛÙËÓ ¿ÌÂÛË ·fiÛ˘ÚÛË ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ηıÂÙ‹Ú·. ∆Ô ÂfiÌÂÓÔ 24ˆÚÔ ·ÚÔ˘ÛÈ¿ÛÙËΠڷÁ‰·›· Âȉ›ӈÛË Ù˘ ÂÈÎfiÓ·˜ ÙÔ˘ ‰ÂÍÈÔ‡ ÌËÚÔ‡ Î·È Î¿Ùˆ ¿ÎÚÔ˘ Ì ÛËÌ›· ÛÔ‚·Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È ‰ÂÚÌ·ÙÈΤ˜ ÓÂÎÚÒÛÂȘ. ∂ÎÙÈÌ‹ıËΠ¿ÌÂÛ· ·fi ·ÁÁÂÈÔ¯ÂÈÚÔ˘ÚÁÔ‡˜, ÔÈ ÔÔ›ÔÈ ÂȂ‚·›ˆÛ·Ó ÙËÓ ‡·ÚÍË ıÚfiÌ‚ˆÛ˘ ÛÙÔ ‡„Ô˜ Ù˘ ¤Íˆ Ï·ÁÔÓ›Ô˘. OÈ ‚·ÚȤ˜ ·˘Ù¤˜ ÈÛ¯·ÈÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÎÚ›ıËÎ·Ó ÌË ·Ó·ÛÙÚ¤„È̘ Î·È Ù¤ıËΠı¤Ì· ˘„ËÏÔ‡ ·ÎÚˆÙËÚÈ·ÛÌÔ‡ ÙÔ˘
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̤ÏÔ˘˜. ∆Ô ·È‰›, ÛÙÔ Ï·›ÛÈÔ Ù˘ ÛË„·ÈÌ›·˜, ›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË: PT: 30,5 sec (Prothrombin time - ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘, Ê.Ù.: 10-14,2 sec), INR: 3 (Û¯¤ÛË Ì¿ÚÙ˘Ú· ÚÔ˜ ÙËÓ ÙÈÌ‹ ·ÛıÂÓÔ‡˜, Ê.Ù.: 0,53-1,26), PTTK: 107,49 sec (Partial thromboplastin time of kaolin - ÌÂÚÈÎfi˜ ¯ÚfiÓÔ˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ Ì ηÔÏ›ÓË, Ê.Ù.: 29-50,1 sec), ·ÓÙÈıÚÔÌ‚›ÓË πππ: 20% (Ê.Ù.: 70-120%), ÚˆÙ½ÓË C: 12% (Ê.Ù.: 25-80%), ·ÈÌÔÂÙ¿ÏÈ·: 30.000/mm3. ¶·Ú’ fiÙÈ ‰ÂÓ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÔÈ ÂÈ̤ÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘, Ë ÂÎÛÂÛËÌ·Ṳ̂ÓË ·Ú¿Ù·ÛË ÙˆÓ PT Î·È PTTK ‹Ù·Ó ÂÓ‰ÂÈÎÙÈ΋ ‚·ÚÈ¿˜ ‰È·Ù·Ú·¯‹˜ ËÎÙÈÎfiÙËÙ·˜, ÁÈ’ ·˘Ùfi Î·È ¯ÔÚËÁ‹ıËΠ¿ÌÂÛ· ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì ϿÛÌ·, Û˘Ì‡Îӈ̷ ·ÓıÚÒÈÓ˘ ·ÓÙÈıÚÔÌ‚›Ó˘ πππ (20 IU/kg) Î·È ÚˆÙ½ÓË C (100 IU/kg ‰fiÛË ÂÊfi‰Ô˘ Î·È ÂÓ Û˘Ó¯›· 15 IU/kg/h). ™˘ÛÙ‹ıËΠ¤Ó·ÚÍË ıÂڷ›·˜ Ì ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Ó·ÙÚÈÔ‡¯Ô˘ Ë·Ú›Ó˘, ·ÏÏ¿ ÏfiÁˆ Ù˘ ıÚÔÌ‚ÔÂÓ›·˜ Ë ‰fiÛË ÂÊfi‰Ô˘ ¤ÁÈÓ Ì 50 IU/kg, ·ÓÙ› ÁÈ· 100 IU/kg Î·È Ë ‰fiÛË Û˘ÓÙ‹ÚËÛ˘ Ì 10 IU/h Ë·Ú›Ó˘. ™Ùfi¯Ô˜ ‹Ù·Ó Ë Â·Ó·ÛËÚ·ÁÁÔÔ›ËÛË ÙÔ˘ ıÚfiÌ‚Ô˘ Î·È Ë Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ̤ÏÔ˘˜. ∆Ô ·È‰› Û˘Ó¤¯È˙ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË: PT: 36,7 sec, PTTK: 54,75 sec, ÈÓˆ‰ÔÁfiÓÔ: ÌË ÌÂÙÚ‹ÛÈÌÔ, ·ÓÙÈıÚÔÌ‚›ÓË πππ: 28%, ÚˆÙ½ÓË C: 13,9%, ÚÔ˚fiÓÙ· ·Ô‰fiÌËÛ˘ ÈÓÒ‰Ô˘˜ (D-Dimers): 10.000 (Ê.Ù.: <250). ÃÔÚËÁ‹ıËÎ·Ó Â·ÓÂÈÏËÌ̤ӷ Ï¿ÛÌ·, ÈÓˆ‰ÔÁfiÓÔ, Û˘Ì‡Îӈ̷ ·ÓıÚÒÈÓ˘ ·ÓÙÈıÚÔÌ‚›Ó˘ πππ Î·È ÚˆÙ½ÓË C. ∂Ó Û˘Ó¯›·, Û ηıËÌÂÚÈÓ‹ ‚¿ÛË ÁÈÓfiÙ·Ó Ô ¤ÏÂÁ¯Ô˜ fiÏˆÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ·ÈÌfiÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡. ŒÁÈÓ ˘ÂÚ˯ÔÁÚ·Ê›· Triplex Ù˘ ‰ÂÍÈ¿˜ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ ÙÚÂȘ ÊÔÚ¤˜. ™ÙÔ ÚÒÙÔ Triplex (3Ë Ë̤ڷ ÓÔÛËÏ›·˜), ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜, ˘‹Ú¯Â ÚÔ‹ ÌfiÓÔ Ì¤¯ÚÈ ÙË Ï·ÁfiÓÈÔ ·ÚÙËÚ›·, ÂÓ‰ÂÈÎÙÈ΋ Ï‹ÚÔ˘˜ ·fiÊڷ͢ Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜. ∏ ÁÓÒÌË ÙˆÓ ÂȉÈÎÒÓ Û˘ÓËÁÔÚÔ‡Û ˘¤Ú Ù˘ ¤Ó·Ú͢ ıÚÔÌ‚fiÏ˘Û˘, ·ÊÔ‡ ‰ÈÔÚıˆı› ÙÔ ·ÈÌÔÛÙ·ÙÈÎfi ¤ÏÏÂÈÌÌ· (ÈÓˆ‰ÔÁfiÓÔ >100 mg/dl), ·Ó Î·È ÂÈÛËÌ¿ÓıËΠfiÙÈ ÌÂÙ¿ ·fi ÙfiÛÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, Èı·Ófiٷٷ ‰ÂÓ ı· ÚfiÛÊÂÚ ‚Ô‹ıÂÈ·. ÕÚ¯ÈÛ ıÚÔÌ‚fiÏ˘ÛË Ì rtPA ÙËÓ 4Ë Ë̤ڷ ÓÔÛËÏ›·˜ (‰fiÛË ÂÊfi‰Ô˘ 0,5 mg/kg Û 10-20 min ηÈ, ÂÓ Û˘Ó¯›·, ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË 0,1 mg/kg/h). ŒÁÈÓ·Ó ·ÎfiÌ· ‰‡Ô Triplex. ™ÙÔ ‰Â‡ÙÂÚÔ (7Ë Ë̤ڷ ÓÔÛËÏ›·˜ Î·È 4Ë ıÚÔÌ‚fiÏ˘Û˘) ·Ú·ÙËÚ‹ıËÎÂ, ·ÚfiÛÌÂÓ· ۯ‰fiÓ, ÚÔ‹ ÛÙË ‰ÂÍÈ¿ ÌËÚÈ·›· ·ÚÙËÚ›· ̤¯ÚÈ ÙËÓ ÈÁÓ˘·Î‹, ÂÓÒ ÛÙÔ ÙÚ›ÙÔ (14Ë Ë̤ڷ ÓÔÛËÏ›·˜ Î·È 10Ë ıÚÔÌ‚fiÏ˘Û˘) ·Ú·ÙËÚ‹ıËΠÚÔ‹ ÛÙË ‰ÂÍÈ¿ ÌËÚÈ·›·, ÙËÓ ÈÁÓ˘·Î‹ Î·È ÌÂȈ̤ÓË ÚÔ‹ ÛÙËÓ ÚfiÛıÈ· ÎÓËÌÈ·›· ·ÚÙËÚ›·. ∂Âȉ‹ ·ÚÔ˘ÛÈ¿ÛÙËÎÂ
¶·È‰È·ÙÚÈ΋ 2003;66:387-391
·ÈÌÔÚÚ·Á›· ·fi ÙȘ ÓÂÎÚˆÙÈΤ˜ ÂÛٛ˜ ÙÔ˘ ̤ÏÔ˘˜ ÙËÓ 11Ë Ë̤ڷ ıÚÔÌ‚fiÏ˘Û˘, ‰ÈÂÎfiË Ë ·ÁˆÁ‹ Ì rtPA Î·È ¿Ú¯ÈÛ ·ÁˆÁ‹ Ì Fraxiparine 0,01 ml/kg ˘Ô‰fiÚÈ· ·Ó¿ 12ˆÚÔ. ∏ ·ÛıÂÓ‹˜, ÙËÓ 5Ë Ë̤ڷ ÓÔÛËÏ›·˜ Ù˘, ›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÂÈÛfi‰ÈÔ ÂÛÙÈ·ÎÒÓ Û·ÛÌÒÓ ÛÙ· ¿Óˆ ¿ÎÚ·, Ô˘ ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·ÙfiÓ Ó· ·Ô‰Ôı› Û οÔÈÔ ·›ÙÈÔ. ∂›¯Â ¯ÔÚËÁËı› ¿·Í Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÂÓ‰ÔÊÏ‚›ˆ˜ (10 mg/kg) Î·È ÔÈ Û·ÛÌÔ› ›¯·Ó ÂÏÂÁ¯ı›. ∂›¯Â Á›ÓÂÈ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (ECHO) ÂÁÎÂÊ¿ÏÔ˘, ÙÔ ÔÔ›Ô ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∂›Û˘, Ë Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó Î·È ·Ú¤ÌÂÓÂ Ê˘ÛÈÔÏÔÁÈ΋. ∏ ·ÛıÂÓ‹˜ ·ÔÛˆÏËÓÒıËΠÌÂÙ¿ ·fi Û˘ÓÔÏÈο 11 Ë̤Ú˜ ÂÏÂÁ¯fiÌÂÓÔ˘ Î·È ˘Ô‚ÔËıÔ‡ÌÂÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‹Ù·Ó ηϋ Î·È Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ‚ÂÏÙÈÒÓÔÓÙ·Ó Û˘Ó¯Ҙ. ∏ ÂÈÎfiÓ·, fï˜, ÙÔ˘ ‰ÂÍÈÔ‡ οو ¿ÎÚÔ˘ ·Ú¤ÌÂÓ ·ıÔÏÔÁÈ΋: ÈÛ¯·ÈÌÈÎfi ̤ÏÔ˜, ηÊÂfi¯ÚˆÌÔ ‰¤ÚÌ· Î·È ˘ÁÚ‹ ÂÚÈÔ¯‹ ÔÚÔÚÚÔÔ‡Û· οو ·fi ÙȘ ÂÊÂÏΛ‰Â˜ (∂ÈÎfiÓ˜ 1 Î·È 2). ÕÚ¯ÈÛ ·ÁˆÁ‹ Ì ÎÂÊ·ÏÔÛÔÚ›ÓË 1˘ ÁÂÓÈ¿˜ Î·È ÌÂÙÚÔÓȉ·˙fiÏË. ∆Ë 17Ë Ë̤ڷ ÓÔÛËÏ›·˜, ÌÂÙ¿ ·fi Û˘Ó¯›˜ ÂÎÙÈÌ‹ÛÂȘ ÙÔ˘ ̤ÏÔ˘˜ ·fi ÙÔ˘˜ ÔÚıԷȉÈÎÔ‡˜, ·ÔÊ·Û›ÛÙËΠӷ Á›ÓÂÈ ·ÎÚˆÙËÚÈ·ÛÌfi˜ ÛÙÔ ‡„Ô˜ Ù˘ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌËÓ ÙÂı› Û ΛӉ˘ÓÔ Ë ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡. §fiÁˆ Ù˘ ȉȷ›ÙÂÚ· ÛÔ‚·Ú‹˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·˘Ù‹˜ Ù˘ ıÚfiÌ‚ˆÛ˘, ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ ÙˆÓ Èı·ÓÒÓ
1
Paediatriki 2003;66:387-391
·Ú·ÁfiÓÙˆÓ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ıÚÔÌ‚ÒÛÂȘ. ∂ϤÁ¯ıËÎ·Ó ÙÔ ·ÓÙÈËÎÙÈÎfi χÎÔ˘, ÔÈ ·Ú¿ÁÔÓÙ˜ VIII Î·È XII, ÙÔ Ï·ÛÌÈÓÔÁfiÓÔ, Ù· ·ÓÙÈʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù·, Ù· ·ÓÙÈÛÒÌ·Ù· ηډÈÔÏÈ›Ó˘, Ô ·Ú¿ÁˆÓ V Leiden (ÌÂÙ·ÏÏ·Á̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ V) Ì ÙË Ì¤ıÔ‰Ô ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR) Î·È Ô FII20210A (ÌÂÙ·ÏÏ·Á̤ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ππ). µÚ¤ıËΠfiÙÈ Ë ·ÛıÂÓ‹˜ Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ÁÈ· ÌÂÙ·ÏÏ·Á̤ÓÔ ·Ú¿ÁÔÓÙ· V (FV Leiden) ηÈ, Û˘ÓÂÒ˜, ¤¯ÂÈ ÎÏËÚÔÓÔÌÈ΋ ÚԉȿıÂÛË ÁÈ· ıÚÔÌ‚ÒÛÂȘ. ŒÁÈÓ ¤ÏÂÁ¯Ô˜ Î·È ÛÙÔ˘˜ ÁÔÓ›˜ Î·È ‚Ú¤ıËΠfiÙÈ Ë ÌËÙ¤Ú· Â›Ó·È Â›Û˘ ÂÙÂÚÔ˙˘ÁÒÙ˘ ÁÈ· FV Leiden. ∏ ·ÁˆÁ‹ Ì Fraxiparine 0,03 ml ˘Ô‰ÔÚ›ˆ˜ Û˘Ó¯›ÛÙËΠÁÈ· 6 Ì‹Ó˜, Ì ‰fiÛË 110 IU/kg ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ. ™Â ËÏÈΛ· 1ó ¤ÙÔ˘˜, ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙËÓ OÚıԷȉÈ΋ ∫ÏÈÓÈ΋ Î·È ÙËÓ ∫ÔÈÓˆÓÈ΋ ÀËÚÂÛ›·, ÚÔÁÚ·ÌÌ·Ù›ÛÙËÎÂ Ë ÙÔÔı¤ÙËÛË Ù¯ÓËÙÔ‡ ̤ÏÔ˘˜ ÁÈ· Ó· ÂÈÙ¢¯ı› Ë ÚÔÛ¿ıÂÈ· ‚¿‰ÈÛ˘ Ù˘ ÌÈÎÚ‹˜. O ¤ÏÂÁ¯Ô˜ Ù˘ ·ÈÌfiÛÙ·Û˘ Ô˘ ¤ÁÈÓ ÙfiÙ ¤‰ÂÈÍÂ: PT: 12,8 sec, INR: 1,16, PTTK: 41,4 sec, ÈÓˆ‰ÔÁfiÓÔ: 4,44 g/l, ·ÓÙÈıÚÔÌ‚›ÓË πππ: 117,10%, ˘„ËÏ¿ ›‰· ·Ú¿ÁÔÓÙ· VIII (fiˆ˜ Û ηٷÛÙ¿ÛÂȘ ÚÔıÚÔÌ‚ÈÙÈ΋˜ ·ÁÁÂÈ›Ùȉ·˜) ÚˆÙ½ÓË C: 92,21%, ·ÓÙÈËÎÙÈÎfi χÎÔ˘: 1,2 (Ê.Ù.: <1,3). ¢¤Î· Ë̤Ú˜ ÌÂÙ¿, ÙÔ ·È‰› ÂÈÛ‹¯ıË ¿ÏÈ Û ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÏfiÁˆ ·Ó·ÊÂÚfiÌÂÓˆÓ ‰È·Ù·Ú·¯ÒÓ fiÚ·Û˘ ·fi 7Ì‹ÓÔ˘, ÙȘ Ôԛ˜ ÔÈ ÁÔÓ›˜ ‰ÂÓ Â›¯·Ó ·Ó·Ê¤ÚÂÈ
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∂ÈÎfiÓ˜ 1 Î·È 2. ¶·ıÔÏÔÁÈ΋ ÂÈÎfiÓ· ‰ÂÍÈÔ‡ οو ¿ÎÚÔ˘.
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¶·È‰È·ÙÚÈ΋ 2003;66:387-391
̤¯ÚÈ ÙfiÙ ηٿ ÙÔ˘˜ ·ÓÂϤÁ¯Ô˘˜ ÙÔ˘ ·È‰ÈÔ‡. ∞fi ÙËÓ ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ·È‰› ‰ÂÓ ·Ú·ÎÔÏÔ˘ıÔ‡ÛÂ. ∆· ÎÔÚÈο ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÂÎχÔÓÙ·Ó ˘ÔÙ˘ˆ‰Ò˜. ∫·Ù¿ ÙËÓ ÂͤٷÛË ÙÔ˘ ‚˘ıÔ‡, ·Ú·ÙËÚ‹ıËΠ̤ÙÚÈ· ·ÙÚÔÊ›· ÔÙÈÎÒÓ ıËÏÒÓ, ΢ڛˆ˜ ÎÚÔÙ·ÊÈο. ™˘ÛÙ‹ıËΠ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ÂÁÎÂÊ¿ÏÔ˘ Î·È ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÈÓÈ·ÎÔ‡ ÏÔ‚Ô‡. ∆· Â˘Ú‹Ì·Ù· Ù˘ MRI ÂÚÈÂÏ¿Ì‚·Ó·Ó ÂÈÎfiÓ· ÌÈÎÚÔÎÂÊ·Ï›·˜, Ì ‰˘Û·ÚÌÔÓ›· ÛÙËÓ ·Ó·ÏÔÁ›· ˘fi-˘¤Ú ÛÎËÓȉȷÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘, ÛËÌ·ÓÙÈ΋ Ï¤Ù˘ÓÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÊÏÔÈÔ‡ ÌÂ Û˘ÚÚ›ÎÓˆÛË ÙˆÓ ÂÏ›ÎˆÓ ÙˆÓ ÌÂوȷ›ˆÓ ÏÔ‚ÒÓ Î·È ÛËÌ·ÓÙÈ΋ Ï¤Ù˘ÓÛË ÙÔ˘ ÌÂÛÔÏÔ‚›Ô˘ Û fiÏË ÙÔ˘ ÙËÓ ¤ÎÙ·ÛË. ∞Ó¿ÏÔÁ· Â˘Ú‹Ì·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙȘ ¤ÏÈΘ ÙˆÓ ÈÓÈ·ÎÒÓ ÏÔ‚ÒÓ Î·È È‰È·›ÙÂÚ· ‰ÂÍÈ¿, fiÔ˘ Ê¿ÓËΠÔÚÂÁÎÂÊ·ÏÈÎfi˜ Û¯ËÌ·ÙÈÛÌfi˜, ÂÓÙÔÓfiÙÂÚË ‰Â ‹Ù·Ó Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÛÊËÓÔÂȉԇ˜ ÏÔ‚›Ô˘ Î·È Ù˘ ÏËÎÙÚ·›·˜ ¤ÏÈη˜. ∆Ô ÎÔÈÏÈ·Îfi Û‡ÛÙËÌ· ·ÂÈÎÔÓÈ˙fiÙ·Ó ‰ÈÂ˘Ú˘Ì¤ÓÔ ÛÙÔ Â›Â‰Ô ÙˆÓ Ï¿ÁÈˆÓ ÎÔÈÏÈÒÓ. ∆· Â˘Ú‹Ì·Ù· ›¯·Ó ¯·Ú·ÎÙ‹Ú· ‚Ï¿‚˘ ÈÛ¯·ÈÌÈÎÔ‡-˘ÔÍ·ÈÌÈÎÔ‡ Ù‡Ô˘, ÔÊÂÈÏfiÌÂÓ· Èı·Ófiٷٷ Û ¤ÌÊÚ·ÎÙ·. ∞fi ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ Â›¯Â ·Ó·ÊÂÚı› ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·. ◊Ù·Ó ·È‰› ·ı›ÁÁ·ÓˆÓ Î·È Ë ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ Èı·ÓÒÓ ÂÌÊÚ¿ÎÙˆÓ ‹Ù·Ó ·‰‡Ó·ÙÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ¯ÚÔÓÈο. ∂›Û˘, ¤ÁÈÓ ̷ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›·, Ë ÔÔ›· ¤‰ÂÈÍ ÛÙ¤ÓˆÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ¤Ûˆ ηڈٛ‰·˜. ∏ ·ÛıÂÓ‹˜ ÂÎÙÈÌ‹ıËΠ·ÓÙÈÎÂÈÌÂÓÈο [¶∫: 39 cm (<5Ë ∂£), µ™: 8 kg (<5Ë ∂£), ‡„Ô˜: 77 cm (<5Ë ∂£)] Î·È ÁÂÓÂÙÈο ÏfiÁˆ Ù˘ ÌÈÎÚÔÎÂÊ·Ï›·˜ Ô˘ ‰È·ÈÛÙÒıËΠÂÎ Ó¤Ô˘. ™ÙË ÁÂÓÂÙÈ΋ ÂÎÙ›ÌËÛË ·fi ÙË Ê·ÈÓÔÙ˘È΋ ÂͤٷÛË ·ÚÔ˘Û›·˙ ٷ ÂÍ‹˜ ȉÈfiÌÔÚÊ· Ê·ÈÓÔÙ˘Èο ¯·Ú·ÎÙËÚÈÛÙÈο: ·) ÌÈÎÚÔÎÂÊ·Ï›·, ‚) ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ÙÚȯˆÙÔ‡ ÛÙÔ Ì¤ÙˆÔ, Á) ÌÂÁ¿Ï· ÒÙ·, ΢ڛˆ˜ ·ÚÈÛÙÂÚ¿ Î·È ‰) ÎÏÈÓÔ‰·ÎÙ˘Ï›· 5Ô˘ ‰·ÎÙ‡ÏÔ˘ ¿ÎÚ·˜ ¯Â›Ú·˜ ¿Ìʈ. ™˘ÛÙ‹ıËΠηڢfiÙ˘Ô˜, Ô ÔÔ›Ô˜ ¤ÁÈÓÂ Î·È ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ŒÁÈÓ ¤ÏÂÁ¯Ô˜ ÁÈ· Ì›˙ÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ECHO ηډȿ˜, ÙÔ ÔÔ›Ô ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi, ECHO ÓÂÊÚÒÓ, Ô˘ÚËÙ‹ÚˆÓ Î·È Î‡ÛÙˆ˜, Ù· ÔÔ›· ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ™˘˙‹ÙËÛË ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· Â›Ó·È Û¿ÓÈ· ÛÙ· ·È‰È¿, ˆÛÙfiÛÔ Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ‚Ú¤ÊË Î·È Ù· ÓÂÔÁÓ¿ (3). ∏ ıÚfiÌ‚ˆÛË ÛÙ· ·È‰È¿ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÓfiÛÔ˜ (2). ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯Ô˘Ó ¤Ó·˜ ‹ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÂÓ›˜ ‹ Î·È Â›ÎÙËÙÔÈ ıÚÔÌ‚ÔÊÈÏÈÎÔ› ·Ú¿ÁÔÓÙ˜. ™ÙÔ˘˜ Û˘ÁÁÂÓ›˜ ıÚÔÌ‚ÔÊÈÏÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (1) ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: Ë ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÂÓÂÚÁÔÔÈË̤ÓË ÚˆÙ½ÓË C (·Ú¿ÁÔÓÙ·˜ V Leiden Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 20-50% ÙˆÓ
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Paediatriki 2003;66:387-391
·ÛıÂÓÒÓ Ì ıÚfiÌ‚ˆÛË), Ô FII20210A, Ë ·Ó¿ÚÎÂÈ· ÚˆÙ½Ó˘ C ‹ S (·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÓÙ›ıÂÓÙ·È ÛÙÔ ‹·Ú Î·È ÂÍ·ÚÙÒÓÙ·È ·fi ÙË ‚ÈÙ·Ì›ÓË ∫), Ë ·Ó¿ÚÎÂÈ· ·ÓÙÈıÚÔÌ‚›Ó˘ πππ (ÎÏËÚÔÓÔÌÂ›Ù·È Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ÂÓÒ Ë Û˘¯ÓfiÙËÙ· Â›Ó·È 1 ·Ó¿ 2000 ÂÚÈÙÒÛÂȘ), Ë ·Ó¿ÚÎÂÈ· Ï·ÛÌÈÓÔÁfiÓÔ˘, Ë ˘ÂÚÔÌÔ΢ÛÙÈÓ·ÈÌ›· Î·È Ë ‰˘ÛÈÓˆ‰ÔÁÔÓ·ÈÌ›·. ™Ù· ›ÎÙËÙ· ·›ÙÈ· ıÚfiÌ‚ˆÛ˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ÙÔ ·ÓÙÈʈÛÊÔÏÈȉÈÎfi Û‡Ó‰ÚÔÌÔ, Ë ÛË„·ÈÌ›·, Ë ¯Ú‹ÛË Î·ıÂÙ‹ÚˆÓ, Ù· ·Ú·ÙÂٷ̤ӷ ¯ÂÈÚÔ˘ÚÁ›·, ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ›, ÔÈ Î·ÎÔ‹ıÂȘ, ÔÈ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·ÎÈÓËÛ›· Î.¿. ∏ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÂÓÂÚÁÔÔÈË̤ÓË ÚˆÙ½ÓË C (APCR) ÔÊ›ÏÂÙ·È ÛÙÔ 90% ÙˆÓ ıÚÔÌ‚ˆÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ÛÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ·Ú¿ÁÔÓÙ· V Leiden (4). O FV Leiden ÔÊ›ÏÂÙ·È Û ÁÂÓÂÙÈ΋ ÌÂÙ¿ÏÏ·ÍË (·ÓÙÈηٿÛÙ·ÛË Ù˘ ·ÚÁÈÓ›Ó˘ ·fi ÙË ÁÏÔ˘Ù·Ì›ÓË ÛÙË ı¤ÛË 506 ÙÔ˘ ·Ú¿ÁÔÓÙ· V) (6), Ô ÔÔ›Ô˜ Á›ÓÂÙ·È ·ÓıÂÎÙÈÎfi˜ ÛÙË ‰Ú¿ÛË Ù˘ APC (ÂÓÂÚÁÔÔÈË̤Ó˘ ÚˆÙ½Ó˘ C) ηÈ, Û˘ÓÂÒ˜, Ô FVa ‰ÂÓ ·ÂÓÂÚÁÔÔÈÂ›Ù·È Î·È Â˘Ô‰ÒÓÂÈ ÙÔÓ Û¯ËÌ·ÙÈÛÌfi ÙÔ˘ ÈÓÒ‰Ô˘˜ (1). ∏ ·Ó‡ÚÂÛË ÙÔ˘ FV Leiden ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î˘Ì·›ÓÂÙ·È Û ÔÛÔÛÙfi 2-15% (1) Î·È ÛÙËÓ ∂ÏÏ¿‰· ÂÚ›Ô˘ 8%. ¶ÔÛÔÛÙfi 10% ÙˆÓ ·ÛıÂÓÒÓ Ì APC-R ¤¯ÂÈ ¿ÏÏË ÁÔÓȉȷ΋ ‰È·Ù·Ú·¯‹ (3). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë ·ÛıÂÓ‹˜ ‹Ù·Ó ÂÙÂÚÔ˙˘ÁÒÙ˘ ÁÈ· FV Leiden, ›¯Â fï˜ Î·È ¿ÏÏÔ˘˜ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ŒÓ·˜ ÂÍ ·˘ÙÒÓ ‹Ù·Ó Ô Î·ıÂÙËÚÈ·ÛÌfi˜ Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜. ∆Ô 25% ÙˆÓ ·È‰ÈÒÓ Ô˘ ʤÚÔ˘Ó Î·ıÂÙ‹Ú˜ Û ·ÚÙËÚ›· ‹ ÊϤ‚· ·ÚÔ˘ÛÈ¿˙ÂÈ ıÚÔÌ‚ÒÛÂȘ (7). ™Â ηډÈÔÏÔÁÈο ÂÚÈÛÙ·ÙÈο, ÙÔ ÔÛÔÛÙfi ıÚfiÌ‚ˆÛ˘ ÙˆÓ ÌËÚÈ·›ˆÓ ·ÁÁ›ˆÓ ÌÂÙ¿ ·fi ηıÂÙËÚÈ·ÛÌfi, ·Ú¿ ÙÔÓ Ë·ÚÈÓÈÛÌfi, Â›Ó·È 8% (7). ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ·ÛıÂÓ‹ Û˘Ó˘‹Ú¯·Ó ·Ê˘‰¿ÙˆÛË, ÛË„·ÈÌ›· Î·È ÔͤˆÛË. ∂Ô̤ӈ˜, ›¯Â ¤Ó·Ó Û˘ÁÁÂÓ‹ ıÚÔÌ‚ÔÊÈÏÈÎfi ·Ú¿ÁÔÓÙ· Î·È Ù¤ÛÛÂÚȘ ›ÎÙËÙÔ˘˜. O Û˘Ó‰˘·ÛÌfi˜ ‰Â ·˘ÙÒÓ Û˘Ó¤‚·Ï ÛÙËÓ ÚfiÎÏËÛË ıÚfiÌ‚ˆÛ˘ Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜, ηٷϋÁÔÓÙ·˜ ÛÙÔÓ ·ÎÚˆÙËÚÈ·ÛÌfi ÙÔ˘ ¿ÎÚÔ˘. ∏ Û˘Ìو̷ÙÔÏÔÁ›· Ô˘ ·ÚÔ˘Û›·˙ ‹Ù·Ó Ë ÎÏ·ÛÈ΋ Ù˘ ·ÚÙËÚȷ΋˜ ıÚfiÌ‚ˆÛ˘: ˆ¯ÚfiÙËÙ·, ÌÂȈ̤ÓË ıÂÚÌÔÎÚ·Û›·, ·Ô˘Û›· ÛʇÍÂˆÓ ÛÙÔ Û‡ÛÙÔÈ¯Ô Ì¤ÏÔ˜ (2). ∏ ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ ·ÚÔ˘Û›·ÛÂ, fiˆ˜ Ê¿ÓËΠÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) Î·È ·ÁÁÂÈÔÁÚ·Ê›· Ô˘ ¤ÁÈÓ·Ó ÛÙËÓ ËÏÈΛ· 1ó ¤ÙÔ˘˜, ¤ÌÊÚ·ÎÙ· Ô˘ Ô‰‹ÁËÛ·Ó Û ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›· Î·È ÛÙ¤ÓˆÛË Ù˘ ¤Ûˆ ηڈٛ‰·˜. ∏ ÔÚÂÁÎÂÊ·ÏÈ΋ ·ÛÙË ‹Ù·Ó Èı·ÓfiÓ ÙÔ ·ÔÙ¤ÏÂÛÌ· ·Ï·ÈÔ‡ ÈÛ¯·ÈÌÈÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘. ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È È‰ÈÔ·ı‹ ‹
¶·È‰È·ÙÚÈ΋ 2003;66:387-391
‰Â˘ÙÂÚÔ·ı‹, fiÙ·Ó ˘¿Ú¯ÂÈ ˘ÔΛÌÂÓË ÓfiÛÔ˜ ‹ Èı·Ófi ÂÎÏ˘ÙÈÎfi ·›ÙÈÔ Ô˘ ‰Ú· ˆ˜ ÚԉȷıÂÛÈ·Îfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ıÚfiÌ‚Ô˘ (10). ∏ ·ÚÔ˘Û›· ÙÔ˘ ·Ú¿ÁÔÓÙ· V Leiden Û ÓÂÔÁÓ¿ Ì ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›· Û˘Óԉ‡ÂÙ·È ·fi ÊÙˆ¯‹ Ó¢ÚÔÏÔÁÈ΋ ¤Î‚·ÛË ÛÙÔ 80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (5). ∏ ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÌÂÙ·ÏÏ·Á̤ÓÔ˘ ·Ú¿ÁÔÓÙ· V Leiden ÛÙÔÓ ÏËı˘ÛÌfi, Û ·ÓÙ›ıÂÛË Ì ÙË ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· Ù˘ “ȉÈÔ·ıÔ‡˜” ÂÁÎÂÊ·ÏÈ΋˜ ÈÛ¯·ÈÌ›·˜, ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÂӉ¯Ô̤ӈ˜ Û˘Ó˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜, ÔÈ ÔÔ›ÔÈ ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ë ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÂÓÂÚÁÔÔÈË̤ÓË ÚˆÙ½ÓË C ·ÔÙÂÏ› ¤Ó·Ó Ô˘ÛÈ·ÛÙÈÎfi ΛӉ˘ÓÔ ÛÙËÓ ·ÚÙËÚȷ΋ ıÚfiÌ‚ˆÛË ÛÙ· ·È‰È¿ (8). ∏ ıÂڷ›· ÂÓfi˜ ıÚÔÌ‚ˆÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜. ∆· Û˘ÓËı¤ÛÙÂÚ· Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ó·È Ù· ·ÓÙÈËÎÙÈο Î·È Ù· ıÚÔÌ‚ÔÏ˘ÙÈο. ∏ Ë·Ú›ÓË Â›Ó·È ·ÓÙÈËÎÙÈÎfi, ‰ÂÓ Ï‡ÂÈ ÙÔÓ ıÚfiÌ‚Ô, ·ÚÂÌÔ‰›˙ÂÈ fï˜ ÙËÓ Â¤ÎÙ·Û‹ ÙÔ˘ Î·È ·Ó·¯·ÈÙ›˙ÂÈ ÙËÓ ÂÌ‚ÔÏ‹ (7). OÈ Ë·Ú›Ó˜ ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ‰ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È Ú‡ıÌÈÛË Î·È ¯ÔÚËÁÔ‡ÓÙ·È ˘Ô‰ÔÚ›ˆ˜. ∆· ıÚÔÌ‚ÔÏ˘ÙÈο Ê¿Ú̷η ‰ÚÔ˘Ó ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÙÔ Ï·ÛÌÈÓÔÁfiÓÔ ÁÈ· Ó· Û¯ËÌ·ÙÈÛÙ› Ï·ÛÌ›ÓË, Ë ÔÔ›· ·ÔÈÎÔ‰ÔÌ› ÙÔ ÈÓ҉˜ Î·È ‰È·Ï‡ÂÈ ÙÔ˘˜ ıÚfiÌ‚Ô˘˜. °È· Ó· Á›ÓÂÈ ıÚÔÌ‚fiÏ˘ÛË, ı· Ú¤ÂÈ Ó· ÌËÓ Â›Ó·È ÌÂȈ̤ӷ Ù· ›‰· ÈÓˆ‰ÔÁfiÓÔ˘, ‰ÈfiÙÈ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ·ÈÌÔÚÚ·Á›·˜. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë ıÚÔÌ‚fiÏ˘ÛË ¿Ú¯ÈÛ ·ÊÔ‡ ‰ÈÔÚıÒıËΠÙÔ ·ÈÌÔÛÙ·ÙÈÎfi ¤ÏÏÂÈÌÌ·. ¶·Ú’ fiÏ· ·˘Ù¿, ÙÔ ·È‰› ·ÚÔ˘Û›·Û ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·Á›· ·fi ÙȘ ÓÂÎÚÒÛÂȘ ÙÔ˘ ̤ÏÔ˘˜. ∆· ıÚÔÌ‚ÔÏ˘ÙÈο Ê¿Ú̷η Â›Ó·È Ë ÛÙÚÂÙÔÎÈÓ¿ÛË, Ë Ô˘ÚÔÎÈÓ¿ÛË Î·È Ô ·Ó·Û˘ÓÙÂıÂÈ̤ÓÔ˜ ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (rtPA). ∂Âȉ‹ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ÂÁÎÂÊ·ÏÈο ¤ÌÊÚ·ÎÙ· ÛÙ· ·È‰È¿ Ô˘ ¤¯Ô˘Ó FVL, Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È (8). ™˘ÓÈÛÙ¿Ù·È Ì·ÎÚ¿ ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ › ÛÔ‚·Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È ÁÈ· ÙËÓ ÚfiÏË„Ë ˘ÔÎÏÈÓÈÎÒÓ ÈÛ¯·ÈÌÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ (8). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹, ‰ÂÓ ı· Û˘ÛÙËÓfiÙ·Ó ‰È¿ ‚›Ô˘ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ÛÙËÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, Â¿Ó ‰ÂÓ ˘‹Ú¯·Ó ÔÈ ÙÂÏÂ˘Ù·›Â˜ ÂÍÂÏ›ÍÂȘ, ·Ú¿ ÌfiÓÔ ÌÂÙ¿ ·fi ÂfiÌÂÓÔ ıÚÔÌ‚ˆÙÈÎfi ÂÂÈÛfi‰ÈÔ. £· ¤ÚÂÂ, fï˜, Ó· Û˘ÛÙ‹ÓÔÓÙ·È Ù· ÂÍ‹˜: ·) ··ÁfiÚ¢ÛË Ï‹„˘ ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ (9) Î·È ‚) Ï‹„Ë ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ Û ÌÂÁ¿Ï· ¯ÂÈÚÔ˘ÚÁ›·, ÂÁ΢ÌÔÛ‡ÓË, ·Ú·ÙÂٷ̤ÓË Î·Ù¿ÎÏÈÛË. ∆ÂÏÈο, ·ÔÊ·Û›ÛÙËΠӷ Û˘ÛÙËı› ÛÙÔ˘˜ ÁÔÓ›˜ Ù˘ Ë ¯ÔÚ‹ÁËÛË ‰È¿ ‚›Ô˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙËÓ ·ÛıÂÓ‹. ∆Ô ÁÂÁÔÓfi˜ Ù˘ ‚·ÚÈ¿˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ ÙÔ˘ ·È‰ÈÔ‡ Ô˘ η٤ÏËÍ Û ·ÎÚˆÙËÚÈ·ÛÌfi ÙÔ˘
Paediatriki 2003;66:387-391
¿ÎÚÔ˘, ÂËÚ¤·Û fiÏÔ ÙÔ ÚÔÛˆÈÎfi Ù˘ ª∂£ (È·ÙÚÔ‡˜, Ê˘ÛÈÎÔıÂÚ·Â˘Ù¤˜, ÓÔÛËÏÂ˘Ù¤˜). ¢ÂÓ ‹Ù·Ó Ë ÚÒÙË ÊÔÚ¿ Ô˘ ›¯Â ÙÔÔıÂÙËı› ·ÚÙËÚÈ·Îfi˜ ηıÂÙ‹Ú·˜ Û ·ÛıÂÓ‹ Ì ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ™ÙËÓ ·Ú¯‹ ıˆڋıËΠfiÙÈ Ë ·ÈÙ›· Ù˘ ıÚfiÌ‚ˆÛ˘ Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ Èı·ÓfiÓ Ó· ‹Ù·Ó Ë Â˘ıÚ·˘ÛÙfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ ÏfiÁˆ Ù˘ ÌÈÎÚ‹˜ ËÏÈΛ·˜, Ù˘ ÔͤˆÛ˘, Ù˘ ·Ê˘‰¿ÙˆÛ˘ Î·È Ù˘ ÛË„·ÈÌ›·˜, Ô˘ ·ÔÙÂÏÔ‡Ó ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (2). ∂Âȉ‹, fï˜, Ë Û˘Ìو̷ÙÔÏÔÁ›· ‹Ù·Ó Ôχ ÛÔ‚·Ú‹ Î·È ·ÎÚ·›·, ÂÍÂÙ¿ÛÙËÎ·Ó fiϘ ÔÈ Èı·Ó¤˜ ·Èٛ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ıÚÔÌ‚ÒÛÂȘ ÛÙ· ·È‰È¿. O ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓÂ, η٤ÏËÍ ÛÙ· Â˘Ú‹Ì·Ù· Ô˘ ·ÓˆÙ¤Úˆ ÂÎÙÂٷ̤ӷ ·Ó·Ê¤ÚıËÎ·Ó Î·È ·Ó·Ï‡ıËηÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Harris JM, Abramson N. Evaluation of recurrent thrombosis and hypercoagulability. Am Fam Physician 1997;56:15911596. 2. Streif W, Monagle P, South M, Leaker M, Andrew M. Spontaneous arterial thrombosis in children. J Pediatr 1999;134:110-112. 3. Hagstrom JN, Walter J, Bluebont-Langner R, Amatniek J, Manno C, High K. Prevalence of the factor V Leiden mutation in children and neonates with thromboembolic disease. J Pediatr 1998;133:777-781. 4. Chrobak L, Dulicek P. Thrombophilic states. Vnitr Lek 1998;44:481-486. 5. Mercuri E, Cowan F, Gupte G, Manning R, Laffan M, Rutherford M et al. Prothrombotic disorders and abnormal neurodevelopmental outcome in infants with neonatal cerebral infarction. Pediatrics 2001;107:1400-1404. 6. Garcia-Doval I, Losada A, de La Torre C, Gonzalez A, Cruces MJ. Abdominal nodules as a presentation of obstruction of the inferior vena cava and factor V Leiden mutation. J Am Acad Dermatol 2000;42:862-864. 7. Nowak-Gottl U, Dubbers A, Kececioglu D, Koch HG, Kotthoff S, Runde J et al. Factor V Leiden, protein C, and lipoprotein (a) in catheter-related thrombosis in childhood: a prospective study. J Pediatr 1997;131:608-612. 8. Verdu A, Cazorla MR, Granados MA, Alonso JA, Casado LF. Basilar artery thrombosis in a child heterozygous for factor V Leiden mutation. Pediatr Neurol 2001;24:69-71. 9. Dulicek P, Maly J, Safarova M. Risk of thrombosis in patients homozygous and heterozygous for factor V Leiden in the East Bohemian region. Clin Appl Thromb Hemost 2000;6:87-89. 10. deVeber G, Roach ES, Riela AR, Wiznitzer M. Stroke in children: recognition, treatment, and future directions. Semin Pediatr Neurol 2000;7:309-317. ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-07-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-09-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔÓ›ÎË ¶·¿˙ÔÁÏÔ˘ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
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CASE REPORT
NfiÛÔ˜ Kawasaki. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È Ó¤· ‰Â‰Ô̤ӷ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ª. ¶ÔÏ˘¯ÚÔÓ¿ÎË, µ. ∞ÁÁÂÏ¿ÎÔ˘, π. ÷ڈӛÙË
Kawasaki disease. A case report and new aspects of the pathogenesis of the disease ª. Polichronaki, V. Aggelakou, I. Charoniti
¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È Ì›· ÔÍ›· Â̇ÚÂÙË ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ·, Ô˘ ÚÔÛ‚¿ÏÂÈ Î˘Ú›ˆ˜ ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË. ∏ ÔÍ›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË Ê‡ÛË Ù˘, Ô ˘ÚÂÙfi˜, ÙÔ ÂÍ¿ÓıËÌ· Î·È Ë ÂÌÊ¿ÓÈÛË Ì ÂȉËÌÈΤ˜ ÂÍ¿ÚÛÂȘ Ô‰ËÁÔ‡Ó ÛÙËÓ Èı·ÓfiÙËÙ· Ó· ÂÌϤÎÂÙ·È ÏÔÈÌÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜. ªÂ ÙËÓ ¿Ô„Ë ·˘Ù‹ Ù·˘Ù›˙ÔÓÙ·È ÔÏϤ˜ ÓÂfiÙÂÚ˜ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ Ôԛ˜ ÂÚ¢ÓÔ‡Ó ÙÔÓ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ, ΢ڛˆ˜ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Î·È ÙÔ˘ ‚-·ÈÌÔÏ˘ÙÈÎÔ‡ ÛÙÚÂÙfiÎÔÎÎÔ˘ Ù˘ ÔÌ¿‰·˜ ∞, ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ˆ˜ ÚÔ˜ ÙÔ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÛÙË ÓfiÛÔ Kawasaki Î·È ·Ú¿ÏÏËÏ· ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 6 ¯ÚfiÓˆÓ Ô˘ ÚfiÛÊ·Ù· ÓÔÛËχıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì ÙÂÎÌËÚȈ̤ÓË ÛÙÚÂÙÔÎÔÎÎÈ΋ ·Ì˘Á‰·Ï›Ùȉ· Î·È ÙÚ·¯ËÏÈ΋ ·‰ÂÓ›Ùȉ·, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘Û›·Û ÙËÓ Ï‹ÚË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ Kawasaki, Ì ‰È¿Ù·ÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ.
Abstract: Kawasaki disease is an acute febrile systemic vasculitis which affects mainly infants and young children. The aetiology of the disease remains unknown, but its acute self-limiting nature, the presence of fever and rash and its occurrence in epidemics raise the possibility that an infectious agent may be involved in its pathogenesis. This notion is in accordance with many recent reports supporting the role of staphylococcal and streptococcal toxins as superantigens in the pathogenesis of Kawasaki disease. The case is reported of a six year-old boy with group A streptococcal pharyngitis and cervical lymphadenitis, who subsequently developed Kawasaki disease with dilatation of the coronary vessels. The recent literature is reviewed with regard to the role of superantigens in the pathogenesis of the disease.
§¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ Kawasaki, ˘ÂÚ·ÓÙÈÁfiÓ·.
Key words: Kawasaki disease, superantigens.
∂ÈÛ·ÁˆÁ‹ ∏ ÚÒÙË ÂÚÈÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘ Kawasaki ¤ÁÈÓ ÙÔ 1967 ÛÙËÓ π·ˆÓ›·. ŒÎÙÔÙÂ, ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› ‰ÈÂıÓÒ˜ ˆ˜ Ì›· ÛÔ‚·Ú‹ ÓfiÛÔ˜ Ù˘ ‚ÚÂÊÈ΋˜ Î·È ÚÒÙ˘ ·È‰È΋˜ ËÏÈΛ·˜ Ô˘ ·ÊÔÚ¿ Û fiϘ ÙȘ Ê˘Ï¤˜, Ì ÌÂÁ·Ï‡ÙÂÚË Â›ÙˆÛË ÛÙ· ·È‰È¿ È·ˆÓÈ΋˜ ηٷÁˆÁ‹˜. ∏ ÛËÌ·Û›· Ù˘ ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ ·ÔÙÂÏ› ÙË ÛËÌ·ÓÙÈÎfiÙÂÚË ·ÈÙ›· ›ÎÙËÙ˘ ηډȷ΋˜ ÓfiÛÔ˘ ÛÙ· ·È‰È¿. ™ÙÔ 15-30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·Ó·Ù‡ÛÛÂÙ·È ÊÏÂÁÌÔÓ҉˘ ·ÚÙËÚ›Ùȉ·, ÂÓÒ ÛÙÔ 1-3% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¤¯ÂÈ ı·Ó·ÙËÊfiÚÔ ÂͤÏÈÍË ÏfiÁˆ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ‹ ڋ͢
·Ó¢ڇÛÌ·ÙÔ˜ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ (1). ¶ÔÏÏÔ› ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Û·Ó ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ÓfiÛÔ˘, fiˆ˜ ·Î¿Ú·, ÚÈΤÙÛȘ, ÙÔ ·Ó·ÂÚfi‚ÈÔ Propionibacterium acnes, ‰È¿ÊÔÚÔÈ ÈÔ› fiˆ˜ Ô parvovirus B19, Ô Èfi˜ Epstein Barr Î·È ÚÂÙÚÔ˚Ô›. À¿Ú¯ÂÈ ÂÓÙ˘ˆÛȷ΋ ÔÌÔÈfiÙËÙ· ÌÂٷ͇ Ù˘ Ó. Kawasaki, ÙÔ˘ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ ÙÔÍÈÎÔ‡ shock Î·È Ù˘ ÔÛÙÚ·ÎÈ¿˜. ∆· ÓÔÛ‹Ì·Ù· ·˘Ù¿ Û˘Óԉ‡ÔÓÙ·È ·fi ÂÚ˘ıËÌ·Ù҉˜ ÂÍ¿ÓıËÌ·, ˘„ËÏfi ˘ÚÂÙfi, ·ÔϤÈÛË Î·Ù¿ ÙË Ê¿ÛË Ù˘ ·Ô‰ÚÔÌ‹˜, ÊÏÂÁÌÔÓ‹ ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ Î·È ÙˆÓ ÂÈÂÊ˘ÎfiÙˆÓ Î·È
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
1st Paediatric Clinic of Venizelion Hospital, ∏eraklion, Crete
392
¶·È‰È·ÙÚÈ΋ 2003;66:392-396
Paediatriki 2003;66:392-396
ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ¤ÓÙÔÓ˘ ·¿ÓÙËÛ˘ ÔÍ›·˜ Ê¿Û˘ (2). ™‹ÌÂÚ· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ÙÔÍÈÎfi ÛÙ·Ê˘ÏÔÎÔÎÎÈÎfi Î·È ÛÙÚÂÙÔÎÔÎÎÈÎfi shock ÔÊ›ÏÔÓÙ·È Û ̛· ÔÈÎÔÁ¤ÓÂÈ· ÚˆÙÂ˚ÓÈÎÒÓ ÙÔÍÈÓÒÓ, Ô˘ ¤¯Ô˘Ó ¤Ó·Ó ÎÔÈÓfi ÙÚfiÔ ‰Ú¿Û˘. ∏ ÈηÓfiÙËÙ· ·˘ÙÒÓ ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ó· ÂÓÂÚÁÔÔÈÔ‡Ó Ù· ∆-·ÙÙ·Ú· ÌË ÂȉÈο, Ô‰‹ÁËÛ ÛÙÔ Ó· Ù·ÍÈÓÔÌËıÔ‡Ó ˆ˜ ˘ÂÚ·ÓÙÈÁfiÓ· (3). ∆· ÁÓˆÛÙfiÙÂÚ· ˘ÂÚ·ÓÙÈÁfiÓ· Â›Ó·È ÔÈ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ÂÓÙÂÚÔÙÔ͛Ә B Î·È C (SEB, SEC), Ë ÙÔÍ›ÓË ÙÔ˘ ÙÔÍÈÎÔ‡ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ shock (TSST-1) Î·È ÔÈ ÛÙÚÂÙÔÎÔÎÎÈΤ˜ ˘ÚÂÙÔÁfiÓ˜ Â͈ÙÔ͛Ә B Î·È C (SPEB, SPEC). ŒÓ· ÎÔÈÓfi ·ÓÙÈÁfiÓÔ, ·Ú¯Èο, ˘Ê›ÛÙ·Ù·È ÂÂÍÂÚÁ·Û›· ·fi ¤Ó· ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎfi ·ÙÙ·ÚÔ (APC) Î·È ÌÂÙ¿ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ˆ˜ ÂÙ›‰ÈÔ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ APC Û˘Ó‰Â‰Â̤ÓÔ Ì ¤Ó· ÌfiÚÈÔ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù¿Í˘ II (MHC II) ÛÙË Û¯ÈÛÌÔÂȉ‹ ı‹ÎË. ∆Ô Û‡ÌÏÂÁÌ· ·ÓÙÈÁfiÓÔ˘ - MHC II ·Ó·ÁÓˆÚ›˙ÂÙ·È ·fi Ï›Á· ∆-·ÙÙ·Ú· (<1 ·Ó¿ 104 ·ÙÙ·Ú·) Ô˘ ʤÚÔ˘Ó ÂȉÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ ÁÈ· ÙÔ ·ÓÙÈÁfiÓÔ. ∞˘Ù‹ Ë ˘„ËÏ‹˜ ÂȉÈÎfiÙËÙ·˜ ·ÏÏËÏ›‰Ú·ÛË ·ÊÔÚ¿ ÛÙË ÌÂÙ·‚ÏËÙ‹ ÂÚÈÔ¯‹ (variable “V”), ÛÙÔ Û˘Ó‰ÂÙÈÎfi ÙÌ‹Ì· (joining “J”) Î·È ÛÙËÓ ÂÚÈÔ¯‹ ÂÙÂÚÔÁ¤ÓÂÈ·˜ (diversity “D”) ÙˆÓ · Î·È ‚ ·Ï˘Û›‰ˆÓ ÙÔ˘ ˘Ô‰Ô¯¤· ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ (T-cell receptor “TCR”) (∂ÈÎfiÓ· 1·). ™Â ·ÓÙ›ıÂÛË Ì ٷ ÎÔÈÓ¿ ·ÓÙÈÁfiÓ·, Ù· ˘ÂÚ·ÓÙÈÁfiÓ· Â›Ó·È Èηӿ Ó· ÂÓÂÚÁÔÔÈ‹ÛÔ˘Ó ¤Ó· ÌÂÁ¿ÏÔ ·ÚÈıÌfi ∆-΢ÙÙ¿ÚˆÓ, Û˘Ó‰ÂfiÌÂÓ· ·Â˘ı›·˜ ÛÙÔ MHC II ¿Óˆ ÛÙ· APC Î·È ÛÙÔÓ TCR, ¤Íˆ ‰ËÏ·‰‹ ·fi ÙË Û¯ÈÛÌÔÂȉ‹ ı‹ÎË (∂ÈÎfiÓ· 1‚). ∏ ·ÓÙ›‰Ú·ÛË ·˘Ù‹ ÂÚÈÔÚ›˙ÂÙ·È ÌfiÓÔ ·fi ÙËÓ ÂȉÈÎfiÙËÙ· Ù˘ V ÂÚÈÔ¯‹˜ Ù˘ ‚ ·Ï˘Û›‰·˜ (V‚) ÙÔ˘ ˘Ô‰Ô¯¤· TCR. ∫¿ı ˘ÂÚ·ÓÙÈÁfiÓÔ ÂÓÂÚÁÔÔÈ› Ì›· ÔÌ¿‰· V‚+ ΢ÙÙ¿ÚˆÓ, .¯. Ë ÙÔÍ›ÓË TSST-1 ÂÓÂÚÁÔÔÈ› fiÏ· Ù· AÓÙÈÁfiÓÔ
ÀÂÚ·ÓÙÈÁfiÓÔ
TCR V·
TCR V‚
V·
V‚
·
‚ MHC class II
MHC class II
∂ÈÎfiÓ· 1. ¶·ÚÔ˘Û›·ÛË ÂÓfi˜ ÎÔÈÓÔ‡ ·ÓÙÈÁfiÓÔ˘ (·) Î·È ÂÓfi˜ ˘ÂÚ·ÓÙÈÁfiÓÔ˘ (‚) ·fi ÙÔ ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎfi ·ÙÙ·ÚÔ ÛÙÔ T-ÏÂÌÊÔ·ÙÙ·ÚÔ.
∆-·ÙÙ·Ú· Ô˘ ¤¯Ô˘Ó V‚2. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ, Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ÂÓÂÚÁÔÔÈÔ‡Ó ¤Ó· Ôχ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ∆-΢ÙÙ¿ÚˆÓ, Ô˘ ÌÔÚ› Ó· ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 20% ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∞˘Ùfi˜ Ô ¤ÓÙÔÓÔ˜ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ Î·È Ë ·ÓÔÛÔÏÔÁÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ¤ÎÎÚÈÛ˘ ΢ÙÙ·ÚÔÎÈÓÒÓ, Ú¤ÂÈ Ó· Â›Ó·È Ì›˙ÔÓÔ˜ ÛËÌ·Û›·˜ ÛÙË Á¤ÓÂÛË ÙÔ˘ ÙÔÍÈÎÔ‡ shock. ∏ ÔÌÔÈfiÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ù˘ ÓfiÛÔ˘ Kawasaki Î·È ÙÔ˘ ÙÔÍÈÎÔ‡ shock Ô‰‹ÁËÛ ÛÙÔ Ó· Á›ÓÔ˘Ó ÔÏϤ˜ ÌÂϤÙ˜ Ì ı¤Ì· ÙÔÓ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ Kawasaki. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË Ó. Kawasaki, Ë ÔÔ›· ÂΉËÏÒıËΠÌÂÙ¿ ·fi Ïԛ̈ÍË ·fi ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞. ™ÙË Û˘Ó¤¯ÂÈ·, Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ÙÔÓ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 6 ÂÙÒÓ, Ì ÂχıÂÚÔ ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ·Ó·ÌÓËÛÙÈÎfi, ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ˘„ËÏÔ‡ ˘ÚÂÙÔ‡ (40,5ÔC) ·fi 4Ë̤ÚÔ˘ Î·È ÂËÚ·Ṳ̂Ó˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘. ∞fi 2Ë̤ÚÔ˘ ›¯Â ¯ÔÚËÁËı› ·ÌÔ͢ÎÈÏÏ›ÓË Ì ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇ ·fi ÙÔ ÛÙfiÌ·, ÏfiÁˆ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·Ì˘Á‰·Ï›Ùȉ·˜. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ¤ÓÙÔÓË ˆ¯ÚfiÙËÙ·, ηٷ‚ÔÏ‹, ÂͤڢıÚ· ·Ú›ÛıÌÈ·, ‰ÈÔÁΈ̤Ó˜ ·Ì˘Á‰·Ï¤˜ Ì ˘Ò‰Â˜ ÂÍ›‰ÚˆÌ·, ÌÂÁ¿ÏË ÂÒ‰˘ÓË ‰ÈfiÁΈÛË ‰ÂÍÈ¿˜ ÚfiÛıÈ·˜ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜, ÂÓÒ ·fi Ù· ˘fiÏÔÈ· Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó Ï¢ÎÔ΢ÙÙ¿ÚˆÛË Ì ·fiÏ˘ÙÔ ·ÚÈıÌfi Ï¢ÎÒÓ 23.300/mm3 (Ô˘‰ÂÙÂÚfiÊÈÏ·: 75%, ÏÂÌÊÔ·ÙÙ·Ú·: 9%, ÌÔÓÔ‡ÚËÓ·: 13%), Ht: 35,2%, Hb: 12,6 g/dl, PLT: 288.000/mm3, CRP: 199,7 mg/L, TKE: 73 mm/1Ë ÒÚ· Î·È ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT: 83 U/L, SGPT: 43 U/L). ∆· ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ EBV, CMV Î·È Toxoplasma ‹Ù·Ó ·ÚÓËÙÈο. O Ù›ÙÏÔ˜ ASTO ‹Ù·Ó 760 πU/L. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜. ∏ ηÏÏȤÚÁÂÈ· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·Ó¤Ù˘Í ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ ∞. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÚ·¯‹ÏÔ˘ ¤‰ÂÈÍ ÌÂÁ¿ÏË ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ, ¤Ó·˜ ÂÎ ÙˆÓ ÔÔ›ˆÓ ‹Ù·Ó ¢ÌÂÁ¤ı˘, ¯ˆÚ›˜ ÛËÌ›· ·ÔÛÙËÌ·ÙÔÔ›ËÛ˘. ÃÔÚËÁ‹ıËΠ·Ú¯Èο ÂÓÈÎÈÏ›ÓË ÂÓ‰ÔÊÏ‚›ˆ˜. ∫·Ù¿ ÙËÓ 3Ë Ë̤ڷ Ù˘ ÓÔÛËÏ›·˜ Î·È ÂÓÒ Ô ˘ÚÂÙfi˜ ·Ú¤ÌÂÓ ˘„ËÏfi˜ (40ÔC), ·ÚÔ˘ÛÈ¿ÛÙËΠ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ· Î·È Ô›‰ËÌ· ÙÔ˘ ˘ÂÚΛÌÂÓÔ˘ Ù˘ ÙÚ·¯ËÏÈ΋˜ ‰ÈfiÁΈÛ˘ ‰¤ÚÌ·ÙÔ˜. ¶ÚÔÛÙ¤ıËΠÛÙË ıÂڷ›· ÎÏÈÓ‰·Ì˘Î›ÓË ÂÓ‰ÔÊÏ‚›ˆ˜.
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∆ËÓ 5Ë Ë̤ڷ ÓÔÛËÏ›·˜ (9Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡), Ô ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÂÚ˘ıÚfiÙËÙ· ÂÈÂÊ˘ÎfiÙˆÓ ¯ˆÚ›˜ ¤ÎÎÚÈÌ·, ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÍËÚfiÙËÙ· ¯ÂÈϤˆÓ Ì ۯÈṲ̂˜, ÂÚ˘ıÚfiÙËÙ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ Î·È ÂÍ¿ÓıËÌ· ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤oÓ ÎÔÚÌÔ‡ Î·È ¿ÎÚˆÓ. ¶·Ú¿ÏÏËÏ·, Ô ˘ÚÂÙfi˜ ·Ú¤ÌÂÓ ˘„ËÏfi˜. ∆· ·ÓˆÙ¤Úˆ Â˘Ú‹Ì·Ù· ÏËÚÔ‡Û·Ó fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki (¶›Ó·Î·˜ 1) Î·È ÁÈ’ ·˘Ùfi ¯ÔÚËÁ‹ıËΠÁ-ÛÊ·ÈÚ›ÓË ÂÓ‰ÔÊÏ‚›ˆ˜ Î·È ·ÛÈÚ›ÓË Û ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ‰fiÛË. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ‚ÂÏÙÈÒıËΠ¿ÌÂÛ· Î·È Ô ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛÂ. ∆ËÓ 11Ë Ë̤ڷ Ù˘ ÓÔÛËÏ›·˜ ·ÚÔ˘Û›·Û ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (809.000/mm3) Î·È ÙË 15Ë Ë̤ڷ ϤÔÓ Ù˘ ÓfiÛÔ˘ ·ÚÔ˘Û›·Û ÂÚÈÔÓ‡¯È· ·ÔϤÈÛË ÛÙ· ¯¤ÚÈ· Î·È Ù· fi‰È·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ¤‰ÂÈÍ ‰È¿Ù·ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ Î·È ‰ÂÍÈ¿˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ∏ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÌÂϤÙË Ù˘ ηډȿ˜ ÌÂÙ¿ ·fi 30 Ë̤Ú˜ ¤‰ÂÈÍ ˘Ô¯ÒÚËÛË Ù˘ ‰È¿Ù·Û˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ, ¯ˆÚ›˜ Ó· ·Ú·Ì›ÓÔ˘Ó ˘ÔÏÂÈÌÌ·ÙÈΤ˜ ‚Ï¿‚˜. ™˘˙‹ÙËÛË Œ¯Ô˘Ó ÂÚ¿ÛÂÈ 25 ¯ÚfiÓÈ· ·fi ÙËÓ ÚÒÙË ÂÚÈÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘ Kawasaki Î·È ÔÈ ÚÔÛ¿ıÂȘ ÔÏÏÒÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÙË Ï‡ÛË ÙÔ˘ ·ÈÓ›ÁÌ·ÙÔ˜ Ù˘ ·ıÔÁ¤ÓÂÈ¿˜ Ù˘ ‰ÂÓ ¤¯Ô˘Ó ηٷϋÍÂÈ Û οÔÈÔ ÎÔÈÓ¿ ·Ô‰ÂÎÙfi ·ıÔÁfiÓÔ ·›ÙÈÔ. ∆Ô ÛËÌ›Ô, fï˜, ÛÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó ÔÈ ÌÂϤÙ˜ Â›Ó·È fiÙÈ Ë ÔÍ›· Ê¿ÛË Ù˘ Ó. Kawasaki ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÎÛÂÛËÌ·Ṳ̂ÓË ·ÓÔÛÔÏÔÁÈ΋ ‰È¤ÁÂÚÛË, Ë ÔÔ›· ‰ÂÓ Û˘Ó·ÓÙ¿Ù·È Û ¿ÏÏ· Â̇ÚÂÙ· ÂÍ·ÓıËÌ·ÙÈο ÓÔÛ‹Ì·Ù·. ∆· ·ÓÔÛÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ Ó. ∫awasaki Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ ·Û˘Ó‹ıÈÛÙË ·˘Ù‹ ·ÓÔÛÔÏÔÁÈ΋ ‰È¤ÁÂÚÛË Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÓfiÛˆÓ Ô˘ ÔÊ›ÏÔÓÙ·È Û ‚·ÎÙËÚȷΤ˜ Î·È ÈÔÁÂÓ›˜ ÚˆÙ½Ó˜ Ô˘ ‰ÚÔ˘Ó ˆ˜ ˘ÂÚ·ÓÙÈÁfiÓ·. ∆· ‰Â‰Ô̤ӷ ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ ÂÚ¢ÓÔ‡Ó ÙÔÓ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ Ó. Kawasaki Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. OÈ ÚÒÙ˜ ·Ó·ÊÔÚ¤˜ ¤ÁÈÓ·Ó ÙÔ 1992 Î·È 1993 ·fi ÙÔ˘˜ Abe Î·È Û˘Ó,
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ÔÈ ÔÔ›ÔÈ ·Ú·Ù‹ÚËÛ·Ó ·‡ÍËÛË ∆-΢ÙÙ¿ÚˆÓ Ô˘ ÂÎÊÚ¿˙Ô˘Ó V‚2 ÂÚÈÔ¯‹ Û ·ÛıÂÓ›˜ Ì Ó. Kawasaki (4,5). ∞fi ÙËÓ ÔÌ¿‰· ÙˆÓ Leung Î·È Û˘Ó, ÙÔ 1993, ÌÂÏÂÙ‹ıËÎ·Ó Î·ÏÏȤÚÁÂȘ Ô˘ Ï‹ÊıËÎ·Ó ·fi ÔÏϤ˜ ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ, Û 16 ·ÛıÂÓ›˜ Ì ÓfiÛÔ Kawasaki Î·È 15 ·ÛıÂÓ›˜ Ô˘ ¤·Û¯·Ó ·fi ¿ÏÏ· Â̇ÚÂÙ· ÓÔÛ‹Ì·Ù· (ÔÌ¿‰· ÂϤÁ¯Ô˘). ∏ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Û 13/16 ·ÛıÂÓ›˜ Ì Ó. Kawasaki ·ÔÌÔÓÒıËÎ·Ó ‚·ÎÙ‹ÚÈ· Ô˘ ·Ú‹Á·Á·Ó ˘ÂÚ·ÓÙÈÁfiÓ·, Û ·ÓÙ›ıÂÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, ÛÙËÓ ÔÔ›· Ù· ·ÓÙ›ÛÙÔȯ· ‚·ÎÙ‹ÚÈ· ·ÔÌÔÓÒıËÎ·Ó ÌÔÓ¿¯· Û 1/15 ·ÛıÂÓ›˜ (p<0,01). ∂›Û˘, ·fi ÙÔ˘˜ 13 ·ÛıÂÓ›˜ Ì Ó. Kawasaki Ô˘ ›¯·Ó ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ, ÔÈ 11 ·Ó¤Ù˘Í·Ó ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ Ô˘ ·Ú‹Á·Á TSST-1 Î·È ÔÈ 2 ·Ó¤Ù˘Í·Ó ÛÙÚÂÙfiÎÔÎÎÔ Ô˘ ·Ú‹Á·Á SPEB Î·È SPEC. ªÂÈÔÓ¤ÎÙËÌ· Ù˘ ·Ú·¿Óˆ ÌÂϤÙ˘ ‹Ù·Ó ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‹Ù·Ó ÌÔÓÔÎÂÓÙÚÈ΋ (6). OÈ Leung Î·È Û˘Ó, ÙÔ 1995, ÌÂϤÙËÛ·Ó ÈÛÙÔ‡˜ Ô˘ Ï‹ÊıËÎ·Ó ·fi ÓÂÎÚÔÙÔÌ‹ Û ‚Ú¤ÊÔ˜ 5 ÌËÓÒÓ Ô˘ ÓfiÛËÛ ·fi Ó. Kawasaki Î·È ÙËÓ 32Ë Ë̤ڷ ÓÔÛËÏ›·˜ ÙÔ˘ ·Â‚›ˆÛÂ. ¶·Ú·Ù‹ÚËÛ·Ó fiÙÈ ∆-·ÙÙ·Ú· Ì V‚2 ÂÚÈÔ¯‹ ÛÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘˜ ÂÎÊÚ¿˙ÔÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ Ó. Kawasaki (7). ¶ÂÚ›Ô˘ ÙÔ ›‰ÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÔÈ Curtis Î·È Û˘Ó ÌÂϤÙËÛ·Ó 21 ·ÛıÂÓ›˜ Ì Ó. Kawasaki Î·È 28 ·ÛıÂÓ›˜ Ì ÈÔÁÂÓ›˜ Î·È ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ (·ÔÎÏ›ÛÙËÎ·Ó ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ Î·È ÛÙÚÂÙÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ), ηıÒ˜ Î·È 22 ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÙË Ì¤ıÔ‰Ô ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ V‚2,5,8,12,19 ÂÚÈÔ¯ÒÓ ÙÔ˘ TCR, ‚Ú‹Î·Ó fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ó. Kawasaki Ù· ∆-·ÙÙ·Ú· Ì V‚2 ÛÙÔÓ TCR ‹Ù·Ó ·˘ÍË̤ӷ, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· ÙˆÓ ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ Î·È ÙËÓ ÔÌ¿‰· fiÛˆÓ ÓÔÛÔ‡Û·Ó ·fi ÈÔÁÂÓ‹ Î·È ‚·ÎÙËÚȷο ·›ÙÈ· (1). ∏ ÔÌ¿‰· ÙˆÓ Yoshioka Î·È Û˘Ó, ÙÔ 1999, ÂÎÙ›ÌËÛ ÙËÓ ¤ÎÊÚ·ÛË ÙˆÓ TCR, ÙËÓ ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ Î·È ÙËÓ ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ˘ÂÚ·ÓÙÈÁfiÓ· Û ̛· ÔÌ¿‰· 22 ·ÛıÂÓÒÓ Ì Ó. Kawasaki, 10 ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ Î·È 14 ·ÛıÂÓÒÓ Ì ¿ÏÏ· Â̇ÚÂÙ· ÓÔÛ‹Ì·Ù·. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘
¶›Ó·Î·˜ 1. ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki ñ ¶˘ÚÂÙfi˜ ÁÈ· 5 Ë̤Ú˜ ‹ ÂÚÈÛÛfiÙÂÚÔ ñ ∞ÌÊÔÙÂÚfiÏ¢ÚË ÌË ÂÍȉڈ̷ÙÈ΋ ÂÈÂÊ˘Î›Ùȉ· ñ ∞ÏÏÔÈÒÛÂȘ ·fi ÙÔÓ ÔÚÔÊ¿Ú˘ÁÁ·: ÂÚ‡ıËÌ· ‚ÏÂÓÓÔÁfiÓˆÓ, ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ·, ÂÚ˘ıÚ¿ ‹ ÍËÚ¿ ¯Â›ÏË Ì ڈÁ̤˜ ñ ∞ÏÏÔÈÒÛÂȘ ÛÙËÓ ÂÚÈʤÚÂÈ· ÙˆÓ ¿ÎÚˆÓ, ‰ËÏ·‰‹ ÂÚ‡ıËÌ· Û ·Ï¿Ì˜ Î·È ¤ÏÌ·Ù·, Ô›‰ËÌ· ÛÙ· ¯¤ÚÈ· Î·È fi‰È· ‹ ÂÚÈÔÓ‡¯È· ·ÔϤÈÛË ñ ¶ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ· ñ OÍ›·, ÌË ‰È·˘ËÙÈ΋ ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Â¿Ó ˘¿Ú¯ÂÈ ˘ÚÂÙfi˜ Î·È 4 ·fi Ù· ·ÓˆÙ¤Úˆ Û˘ÌÙÒÌ·Ù·, ·ÊÔ‡ ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏÏ· ÓÔÛ‹Ì·Ù· Ì ٷ ›‰È· ¯·Ú·ÎÙËÚÈÛÙÈο
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ÌÂϤÙ˘ ÂÂÛ‹Ì·Ó·Ó ÙËÓ ‡·ÚÍË ÂÎÏÂÎÙÈ΋˜ ·‡ÍËÛ˘ ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ, Ô˘ ›¯·Ó V‚2 Î·È V‚6 ÂÚÈÔ¯‹, fiˆ˜ Î·È ·˘ÍË̤ӷ ›‰· ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ SPEC ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì Ó. Kawasaki (8). ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ Ó. Kawasaki. ÕÏÏÔÈ ÌÂÏÂÙËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ Ó. Kawasaki. OÈ Terai Î·È Û˘Ó, ÙÔ 1995, ÂÚ¢ÓÒÓÙ·˜ ÙÔÓ ÚfiÏÔ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ, ·Ó·˙‹ÙËÛ·Ó ‚·ÎÙ‹ÚÈ· Ô˘ ·Ú¿ÁÔ˘Ó ˘ÂÚ·ÓÙÈÁfiÓ· Î·È Ì¤ÙÚËÛ·Ó ÛÙÔÓ ÔÚfi 11 ·ÛıÂÓÒÓ Ì Ó. Kawasaki ηٿ ÙËÓ ÔÍ›·, ˘ÔÍ›· Î·È ÙË Ê¿ÛË ·Ó¿ÚÚˆÛ˘ Ù˘ ÓfiÛÔ˘, IgM Î·È IgG ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ TSST-1, ÂÓÒ ·Ó¿ÏÔÁ˜ ÌÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó Î·È Û ÔÌ¿‰· ˘ÁÈÒÓ ·ÙfïÓ. ∏ ·Ú·¿Óˆ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ IgG ÔÚÔÌÂÙ·ÙÚÔ‹ Û˘Ì‚·›ÓÂÈ ÌfiÓÔ Û 10% ÙˆÓ ·ÛıÂÓÒÓ Ì Ó. Kawasaki, ÂÓÒ ÛÂ Î·Ó¤Ó·Ó ·ÛıÂÓ‹ ‰ÂÓ ·ÔÌÔÓÒıËΠIgM ·Óٛۈ̷. ∂›Û˘, ‰ÂÓ ·ÔÌÔÓÒıËΠÛÂ Î·Ó¤Ó·Ó ·ÛıÂÓ‹ ‚·ÎÙ‹ÚÈÔ Ô˘ ·Ú¿ÁÂÈ ˘ÂÚ·ÓÙÈÁfiÓ· (9). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ıˆڋıËÎ·Ó ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ù˘ ÌÂϤÙ˘ ˆ˜ ·fi‰ÂÈÍË fiÙÈ Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ‰ÂÓ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ¶›Ó·Î·˜ 2. ∞ÓÔÛÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ Kawasaki – – – –
∞˘ÍË̤ÓÔÈ ‰Â›ÎÙ˜ ÔÍ›·˜ Ê¿Û˘ ∂ÓÂÚÁÔÔ›ËÛË Û˘ÌÏËÚÒÌ·ÙÔ˜ ∫˘ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÔÛÔÛ˘ÌϤÁÌ·Ù· ∂ÓÂÚÁÔÔ›ËÛË ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ñ ŒÎÊÚ·ÛË MHC-II ñ ŒÎÊÚ·ÛË ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ – ¢È‹ıËÛË ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ·fi: + ñ ∂ÓÂÚÁÔÔÈË̤ӷ CD4 T-·ÙÙ·Ú· ñ ª·ÎÚÔÊ¿Á· ñ µ-·ÙÙ·Ú· ñ µ-·ÙÙ·Ú· Ô˘ ·Ú¿ÁÔ˘Ó IgA – ∆-·ÙÙ·Ú· ñ ªÂȈ̤ӷ ΢ÎÏÔÊÔÚÔ‡ÓÙ· CD8+ T-·ÙÙ·Ú· ñ ∫˘ÎÏÔÊÔÚÔ‡ÓÙ· ÂÓÂÚÁÔÔÈË̤ӷ CD4+ T-·ÙÙ·Ú· ñ ∞˘ÍË̤ӷ ‹ ÌÂȈ̤ӷ CD8+ T-·ÙÙ·Ú· Ì V‚2+ ÂÚÈÔ¯‹ – µ-·ÙÙ·Ú· ñ ¶ÔÏ˘ÎψÓÈ΋ ‰È¤ÁÂÚÛË – ∞˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ ñ IFN-Á, TNF-· ñ IL-1, IL-2, IL-4, IL-6, IL-10 ñ ¢È·Ï˘Ùfi˜ ˘Ô‰Ô¯¤·˜ TNF – ∞˘ÙÔ·ÓÙÈÛÒÌ·Ù· ñ ∫˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ñ ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ ηډÈÔÏÈ›Ó˘ ñ IgM ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ Ì˘ÔÛ›Ó˘
Paediatriki 2003;66:392-396
Ù˘ ÓfiÛÔ˘. ŸÌˆ˜, Û ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Û ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ô˘ ÏËÚÔ‡Û·Ó Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÙÔ˘ ÙÔÍÈÎÔ‡ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ shock, ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ, ›Û˘, ÔÚÔÌÂÙ·ÙÚÔ‹ (10). À¿Ú¯Ô˘Ó ÔÏϤ˜ Èı·Ó¤˜ ÂÍËÁ‹ÛÂȘ ÁÈ· ÙËÓ ¤ÏÏÂÈ„Ë ÔÚÔÌÂÙ·ÙÚÔ‹˜, ·ÎfiÌ· Î·È ÛÙËÓ ·ÚÔ˘Û›· ‚·ÎÙËÚ›ˆÓ Ô˘ ·Ú¿ÁÔ˘Ó TSST-1 ÙÔÍ›ÓË. OÈ Meissner Î·È Û˘Ó ÚÔÙ›ÓÔ˘Ó ‰‡Ô Èı·ÓfiÙËÙ˜. ∏ ÚÒÙË Â›Ó·È fiÙÈ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ Ó. Kawasaki, ·ÏÏ¿ Î·È ÙÔ˘ ÙÔÍÈÎÔ‡ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ shock, Â›Ó·È Èı·Ófi Ó· ·Ú¿ÁÔÓÙ·È ÌfiÓÔ IgA ·ÓÙÈÛÒÌ·Ù· Î·È fi¯È IgG ‹ IgM ¤Ó·ÓÙÈ ÙÔ˘ TSST-1 ‹ ÙÔ˘ SPEC. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ÁÈ·Ù› Â¿Ó Ë ÚˆÙÔ·ı‹˜ ı¤ÛË ¤ÎıÂÛ˘ Û Â͈ÙÔ͛Ә ‚Ú›ÛÎÂÙ·È ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, Ë ·Ú·ÁˆÁ‹ IgA ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È Ë Î˘Ú›·Ú¯Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË. ∏ ‰Â‡ÙÂÚË Èı·Ó‹ ÂÍ‹ÁËÛË Â›Ó·È fiÙÈ ÛÙË Ó. Kawasaki ÌÔÈ¿˙ÂÈ Ó· ˘¿Ú¯ÂÈ ·ÔÈÎÈÛÌfi˜ Ì¿ÏÏÔÓ Î·È fi¯È ÓfiÛÔ˜ ·fi ‚·ÎÙ‹ÚÈ· Ô˘ ·Ú¿ÁÔ˘Ó TSST-1 ηÈ, ¤ÙÛÈ, Ô Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ TSST-1 Â›Ó·È Ôχ ¯·ÌËÏfi˜ ‹ ÌË ·ÓȯÓ‡ÛÈÌÔ˜, ·ÏÏ¿ ÈηÓfi˜ Ó· ÚÔηϤÛÂÈ ÌÂÁ¿ÏË ·ÓÔÛÔÏÔÁÈ΋ ‰È¤ÁÂÚÛË (11). ∏ ÔÌ¿‰· ÙˆÓ Choi Î·È Û˘Ó, ÙÔ 1997, Û ÌÂϤÙË ÙÔ˘˜ Û ·ÛıÂÓ›˜ Ì Ó. Kawasaki ‚Ú‹Î·Ó ÎψÓÈ΋ ‰È¤ÁÂÚÛË ÙˆÓ CD8 ∆-΢ÙÙ¿ÚˆÓ Î·È ÂÚÌËÓÂ‡Ô˘Ó ÙÔ Â‡ÚËÌ· ·˘Ùfi Û·Ó ·¿ÓÙËÛË Û ¤Ó· ÎÔÈÓfi ·ÓÙÈÁfiÓÔ Ì¿ÏÏÔÓ, ·Ú¿ Û ˘ÂÚ·ÓÙÈÁfiÓÔ (12). ∆ËÓ ›‰È· ¿Ô„Ë ÂÎÊÚ¿˙ÂÈ Ë ÔÌ¿‰· ÙˆÓ Rowley Î·È Û˘Ó, ÙÔ 1999 (13). ¶ÚÔÛ·ıÒÓÙ·˜ Ó· ÂÍËÁ‹ÛÔ˘Ó Ù· ·ÓÙÈÎÚÔ˘fiÌÂÓ· Â˘Ú‹Ì·Ù· ·fi ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜, ÔÈ Fisher Î·È Û˘Ó (14) ÚÔÙ›ÓÔ˘Ó Ì›· ˘fiıÂÛË Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÁÈ· Ó· ÚÔÎÏËı› Ë Ó. Kawasaki ··ÈÙÂ›Ù·È Ó· Û˘Ó˘¿ÚÍÔ˘Ó Ì›· Ïԛ̈ÍË ·fi ÎÔÈÓfi ·ıÔÁfiÓÔ, Ë ‡·ÚÍË ˘ÂÚ·ÓÙÈÁfiÓÔ˘ Î·È ÂȉÈÎfi˜ Ù‡Ô˜ HLA. ∆Ô ÎÔÈÓfi ·ıÔÁfiÓÔ ÌÔÚ› Ó· Â›Ó·È ‚·ÎÙ‹ÚÈÔ ‹ Èfi˜, Û‡Ìʈӷ Ì ÙË ÌÂϤÙË ÙÔ˘ Takahashi ÙÔ 1997 (15). ™Â Ôχ ÚfiÛÊ·ÙË ¤Ú¢ӷ (2002), ÔÈ Nomura Î·È Û˘Ó ÌÂϤÙËÛ·Ó 20 ·ÛıÂÓ›˜ Ì Ó. Kawasaki ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 6 ÌËÓÒÓ, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Û·Ó ÔÌ¿‰· ÂϤÁ¯Ô˘ 22 ‚Ú¤ÊË ·ÓÙ›ÛÙÔȯˆÓ ËÏÈÎÈÒÓ Ô˘ ÓÔÛÔ‡Û·Ó ·fi ¿ÏÏË Â̇ÚÂÙË Ïԛ̈ÍË. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ÙÔ˘˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ‚Ú¤ÊË Ô˘ ÓfiÛËÛ·Ó ·fi Ó. Kawasaki ›¯·Ó ˘„ËÏfiÙÂÚÔ Ù›ÙÏÔ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ TSST-1, Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. ∂›Û˘, ·˘Ù‹ Ë ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ô Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ TSST-1 ÙˆÓ ÌËÙ¤ÚˆÓ ·ÛıÂÓÒÓ Ì Ó. Kawasaki ‹Ù·Ó ¯·ÌËÏfiÙÂÚÔ˜ ·fi ÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Ù›ÙÏÔ ˘ÁÈÒÓ ·ÙfiÌˆÓ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. ∏ ÌÂϤÙË ·˘Ù‹ ÂͤٷÛ ÙÔÓ ÚfiÏÔ ÂÓfi˜ ÌfiÓÔ ·Ú¿ÁÔÓÙ·, Ù˘ TSST-1 Î·È Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ÚÔÛٷ٢ÙÈ΋˜ ‰Ú¿Û˘ ÙˆÓ ÌËÙÚÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÒÛÙ ٷ ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 6 ÌËÓÒÓ Ó· ÌË ÓÔÛÔ‡Ó ·fi Ó. Kawasaki (16). ∆Ô 2002, ÔÈ Leung Î·È Û˘Ó, ·ÓÂÚ¯fiÌÂÓÔÈ ÛÙË ÌÂϤÙË ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÙÔ˘
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ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Î·È ÛÙÚÂÙfiÎÔÎÎÔ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ Ó. Kawasaki, ۯ‰›·Û·Ó Ì›· ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, ÚÔÛ·ıÒÓÙ·˜ Ó· ÍÂÂÚ¿ÛÔ˘Ó ÙȘ ·‰˘Ó·Ì›Â˜ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ ÙÔ˘˜ (6,17). ªÂϤÙËÛ·Ó 45 ·ÛıÂÓ›˜ Ì Ó. Kawasaki Î·È 37 ·ÛıÂÓ›˜ Ì ¿ÏÏË Â̇ÚÂÙË Ïԛ̈ÍË (ÔÌ¿‰· ÂϤÁ¯Ô˘). ∂Ï‹ÊıË ·fi fiÏÔ˘˜ ηÏÏȤÚÁÂÈ· ÁÈ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ Î·È ÛÙÚÂÙfiÎÔÎÎÔ, ‚·ÎÙ‹ÚÈ· Ô˘ ·Ú¿ÁÔ˘Ó ˘ÂÚ·ÓÙÈÁfiÓ· (TSST-1, SEB, SEC, SPEC, SPEB). ™Â 25/45 ·ÛıÂÓ›˜ Ì Ó. Kawasaki (ÔÛÔÛÙfi 56%) Î·È Û 13/37 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (ÔÛÔÛÙfi 35%) ·ÔÌÔÓÒıËΠ‚·ÎÙ‹ÚÈÔ (p=0,078). ∂Âȉ‹ ÔÈ ÛÙ·Ê˘ÏfiÎÔÎÎÔÈ Ô˘ ·Ú¿ÁÔ˘Ó SEB Î·È SEC ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi Ó. Kawasaki Î·È ÏfiÁˆ ÙÔ˘ fiÙÈ ‰ÂÓ ÂÎÏ‡Ô˘Ó V‚2+ ∆-΢ÙÙ·ÚÈ΋ ·¿ÓÙËÛË, ÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó¤Ï˘Û·Ó ÙË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Û ۯ¤ÛË Ì ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ TSST-1 ‹ SPEC Î·È SPEB Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì V‚2 T-΢ÙÙ·ÚÈ΋ ·¿ÓÙËÛË. ™Ù·Ê˘ÏfiÎÔÎÎÔÈ Ô˘ ÂÎÎÚ›ÓÔ˘Ó TSST-1 ‹ ÛÙÚÂÙfiÎÔÎÎÔÈ Ô˘ ·Ú¿ÁÔ˘Ó SPEC Î·È SPEB, ·ÔÌÔÓÒıËÎ·Ó Û 20/45 ·ÛıÂÓ›˜ Ì Ó. ∫awasaki (ÔÛÔÛÙfi 44%) Û ۇÁÎÚÈÛË Ì 7/37 Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (ÔÛÔÛÙfi 19%) (p=0,019, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi). ∆Ô Û˘Ì¤Ú·ÛÌ· Ù˘ ÌÂϤÙ˘ ‹Ù·Ó fiÙÈ Ë Û˘ÓÔÏÈ΋ ·ÔÌfiÓˆÛË ÙˆÓ ‚·ÎÙËÚ›ˆÓ Ô˘ ·Ú¿ÁÔ˘Ó ˘ÂÚ·ÓÙÈÁfiÓ·, ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì Ó. Kawasaki Î·È Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘, ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ÃÚÂÈ¿˙ÔÓÙ·È, fï˜, ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÁÈ· Ó· ‰È¢ÎÚÈÓÈÛÙ› Ô ÚfiÏÔ˜ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ TSST1, SPEC Î·È SPEB Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË V‚2 ÂÚÈÔ¯‹ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÛÙË ÓfiÛÔ Kawasaki. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Kawasaki ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË, ·Ú¿ ÙÔÓ ÙÂÚ¿ÛÙÈÔ ·ÚÈıÌfi ÌÂÏÂÙÒÓ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ. ∆· ‰Â‰Ô̤ӷ ÙˆÓ ÌÂÏÂÙÒÓ ·fi ‰È¿ÊÔÚ˜ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Ó. Kawasaki ¤¯ÂÈ ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙÔÓ ÚÂ˘Ì·ÙÈÎfi ˘ÚÂÙfi, ˆ˜ ·ÚÈ· ·ÈÙ›· ›ÎÙËÙ˘ ηډȷ΋˜ ÓfiÛÔ˘ ÛÙ· ·È‰È¿. ∂›Ó·È ÛËÌ·ÓÙÈÎfi, ÏÔÈfiÓ, Ó· Û˘Ó¯ÈÛÙ› Ë ÚÔÛ¿ıÂÈ· ·Ó‡ÚÂÛ˘ ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ùfi Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂȉÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È Ó· ˘¿ÚÍÂÈ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. O ÚfiÏÔ˜ ÙˆÓ ˘ÂÚ·ÓÙÈÁfiÓˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ Kawasaki ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fiÏ˘Ù·. À¿Ú¯Ô˘Ó, fï˜, ¿Ú· ÔÏϤ˜ ÂӉ›ÍÂȘ ˘¤Ú Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘˜. ¶ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ›Ûˆ˜ ‰È¢ÎÚÈÓ›ÛÔ˘Ó ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÛÔ‚·Ú‹˜ ·˘Ù‹˜ ÓfiÛÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Curtis N, Zheng R, Lamb JR, Levin M. Evidence for a superantigen mediated process in Kawasaki disease. Arch Dis Child 1995;72:308-311.
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2. Torres-Martinez C, Mehta D, Butt A, Levin M. Streptococcus associated toxic shock. Arch Dis Child 1992;67:126-130. 3. Roitt I, Brostoff J, Male D. Immunology. 6th edition. Mosby; 2001. p. 117. 4. Abe J, Kotzin BL, Jujo K, Melish ME, Glode MP, Kohsaka T et al. Selective expansion of T cells expressing T-cell receptor variable regions V beta 2 and V beta 8 in Kawasaki disease. Proc Natl Acad Sci USA 1992;89:4066-4070. 5. Abe J, Kotzin BL, Meissner C, Melish ME, Takahashi M, Fulton D et al. Characterization of T cell repertoire changes in acute Kawasaki disease. J Exp Med 1993;177:791-796. 6. Leung DY, Meissner HC, Fulton DR, Murray DL, Kotzin BL, Schlievert PM. Toxic shock syndrome toxin-secreting Staphylococcus aureus in Kawasaki syndrome. Lancet 1993;342:1385-1388. 7. Leung DY, Giorno RC, Kazemi LV, Flynn PA, Busse JB. Evidence for superantigen involvement in cardiovascular injury due to Kawasaki syndrome. J Immunol 1995;155:5018-5021. 8. Yoshioka T, Matsutani T, Iwagami S, Toyosaki-Maeda T, Yutsudo T, Tsuruta Y et al. Polyclonal expansion of TCRBV2- and TCRBV6-bearing T cells in patients with Kawasaki disease. Immunology 1999;96:465-472. 9. Terai M, Miwa K, Williams T, Kabat W, Fukuyama M, Okajima Y et al. The absence of evidence of staphylococcal toxin involvement in the pathogenesis of Kawasaki disease. J Infect Dis 1995;172:558-561. 10. Stolz SJ, Davis JP, Vergeront JM, Crass BA, Chesney PJ, Wand PJ et al. Development of serum antibody to toxic shock toxin among individuals with toxic shock syndrome in Wisconsin. J Infect Dis 1985;151:883-889. 11. Meissner HC, Leung DY. Superantigens, conventional antigens and the etiology of Kawasaki syndrome. Pediatr Infect Dis J 2000;19:91-94. 12. Choi IH, Chwae YJ, Shim WS, Kim DS, Kwon DH, Kim JD et al. Clonal expansion of CD8+ T cells in Kawasaki disease. J Immunol 1997;159:481-486. 13. Rowley AH. The etiology of Kawasaki disease: superantigen or conventional antigen? Pediatr Infect Dis J 1999;18:69-70. 14. Fischer P, Uttenreuther-Fischer MM, Naoe S, Gaedicke G. Kawasaki disease: update on diagnosis, treatment, and a still controversial etiology. Pediatr Hematol Oncol 1996;13:487-501. 15. Takahashi M. Kawasaki disease. Curr Opin Pediatr 1997;9:523-529. 16. Nomura Y, Yoshinaga M, Masuda K, Takei S, Miyata K. Maternal antibody against toxic shock syndrome toxin-1 may protect infants younger than 6 months of age from developing Kawasaki syndrome. J Infect Dis 2002;185:1677-1680. 17. Leung DY, Meissner HC, Shulman ST, Mason WH, Gerber MA, Glode MP et al. Prevalence of superantigen-secreting bacteria in patients with Kawasaki disease. J Pediatr 2002;140:742-746.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 02-01-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-09-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ·ÛÈÏÈ΋ ∞ÁÁÂÏ¿ÎÔ˘ °Ô‡ÚÓ˜ ∆Â̤ÓÔ˘˜ ∆.∫. 715 00, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: vaagge3@yahoo.gr
¶·È‰È·ÙÚÈ΋ 2003;66:397-400
Paediatriki 2003;66:397-400
¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
¡∂∞ ∏ ÛΈÏËÎÔÂȉ›Ùȉ· ÂÍ·ÎÔÏÔ˘ı› Ó· ÚÔ‚ÏËÌ·Ù›˙ÂÈ È‰È·›ÙÂÚ·, ÙfiÛÔ ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ fiÛÔ Î·È ÙÔ˘˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜. ∆· ·È‰È¿ Ô˘ ÂÈÛ¿ÁÔÓÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Ì ÙËÓ ˘Ô„›· ÛΈÏËÎÔÂȉ›Ùȉ·˜, Û˘Ó‹ıˆ˜ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÂÓ¿ ÁÈ· ÔÚÈṲ̂ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ì ÛÎÔfi ÙËÓ ·ÎÚÈ‚¤ÛÙÂÚË ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰È¿ÁÓˆÛË. ∞˘Ùfi, fï˜, Ô‰ËÁ› Û ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘, Ô˘ Û˘¯Ó¿ ·˘Í¿ÓÂÈ Ù· ÔÛÔÛÙ¿ ‰È¿ÙÚËÛ˘. ∂ÈÚfiÛıÂÙ·, Ë Î·ı˘ÛÙ¤ÚËÛË ·˘Ù‹ ¤¯ÂÈ Â›ÙˆÛË ÛÙÔÓ ¯ÚfiÓÔ Î·È ÛÙÔ ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÈÙ›ÓÂÈ ÙÔ ¿Á¯Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙÔ˘ ·È‰ÈÔ‡. À¿Ú¯ÂÈ, ÏÔÈfiÓ, ÂÈÙ·ÎÙÈ΋ ·Ó¿ÁÎË ·Ó‡ÚÂÛ˘ ·ÍÈfiÈÛÙˆÓ Î·È ¿ÌÂÛˆÓ ÂÍÂÙ¿ÛÂˆÓ Ô˘ Ó· ÌÔÚÔ‡Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙË ‰È¿ÁÓˆÛË. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (CT) Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (U/S) ¤¯Ô˘Ó ˆ˜ › ÙÔ Ï›ÛÙÔÓ ¯ÚËÛÈÌÔÔÈËı› ÁÈ’ ·˘Ùfi ÙÔ ÛÎÔfi Ì ·ÏÏËÏÔÛ˘ÁÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. À¿Ú¯ÂÈ ‰È·ÊˆÓ›· ÛÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ηٿ fiÛÔ ·˘Ù¤˜ ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ‚ÔËıÔ‡Ó ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi Ó· ηٷϋÍÂÈ Û ıÂÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙË Û˘Ó¤¯ÂÈ·, ·Ó·Ê¤ÚÔÓÙ·È ‰‡Ô Û‡Á¯ÚÔÓ˜ ÂÚÁ·Û›Â˜ Ì ÂÎ ‰È·Ì¤ÙÚÔ˘ ·ÓÙ›ıÂÙ· ·ÔÙÂϤÛÌ·Ù·. ∆· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ÌÂϤÙ˘ Ì ÙË ‚Ô‹ıÂÈ· ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ÛÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ·È‰ÈÒÓ Ì ÛΈÏËÎÔÂȉ›Ùȉ· ÕÓÓ· ªÂÛÛ·ÚÈÙ¿ÎË, ¶·È‰›·ÙÚÔ˜
™ÙËÓ ÂÚÁ·Û›· ·˘Ù‹ ·Ó·Ê¤ÚÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ Ô˘ ÂÊ·ÚÌfiÛÙËΠ۠·ÛıÂÓ›˜ ÛÙÔ ¶·È‰È·ÙÚÈÎfi ¡ÔÛÔÎÔÌÂ›Ô Ù˘ µÔÛÙfiÓ˘. ∏ ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ (U/S) Î·È Ù˘ ·ÍÔÓÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ (CT) Û ·È‰È¿ Ô˘ ˘‹Ú¯Â ÈÛ¯˘Ú‹ ÎÏÈÓÈ΋ ˘Ô„›· ÛΈÏËÎÔÂȉ›Ùȉ·˜ Ê·›ÓÂÙ·È fiÙÈ ÂÏ¿ÙÙˆÛ ÛËÌ·ÓÙÈο ÙȘ ‰È·ÙÚ‹ÛÂȘ, ·ÏÏ¿ Î·È ÙȘ ÛΈÏËÎÔÂȉÂÎÙÔ̤˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÛΈÏËÎÔÂȉ‹ ·fiÊ˘ÛË, Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ Ô‰ËÁ‹ıËÎ·Ó ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ¯ˆÚ›˜ Ó· ÚÔËÁËı› ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜. ∞ÓÙ›ıÂÙ·, ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ (<5 ÂÙÒÓ) ÙÔ U/S Î·È Ë CT ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó Ù· ›‰È· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ·Ú’ fiÙÈ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·È ÛÙȘ ËÏÈ˘ ·˘Ù¤˜. Pediatrics 2002;110:1088-1093 ∏ ·˘ÍË̤ÓË ¯Ú‹ÛË Ù˘ ·ÍÔÓÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Ù˘ ÛΈÏËÎÔÂȉ›Ùȉ·˜ ÛÙ· ·È‰È¿ ÕÓÓ· ªÂÛÛ·ÚÈÙ¿ÎË, ¶·È‰›·ÙÚÔ˜
∏ ÛΈÏËÎÔÂȉ›Ùȉ· Â›Ó·È Ë ÈÔ Û˘ÓËıÈṲ̂ÓË Â›ÁÔ˘Û· ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ÛÙ· ·È‰È¿. ∆Ô Ì¤ÁÈÛÙÔ Ù˘ ›وۋ˜ Ù˘ ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ ÌÂٷ͇ 10 Î·È 19 ÂÙÒÓ Î·È ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ô ‰È¿ ‚›Ô˘ ΛӉ˘ÓÔ˜ Ù˘ ÓfiÛÔ˘ ÂÎÙÈÌ¿Ù·È ÛÙÔ 8,6% ÁÈ· ÙÔ˘˜ ¿Ó‰Ú˜ Î·È ÛÙÔ 6,7% ÁÈ· ÙȘ Á˘Ó·›Î˜. ¶·Ú¿ ÙËÓ ÙfiÛË ÂÍÔÈΛˆÛË Ì ÙË ÓfiÛÔ, Ë ‰È¿ÁÓˆÛË ÂÍ·ÎÔÏÔ˘ı› Ó· ÚÔ‚ÏËÌ·Ù›˙ÂÈ ÙÔÓ ·È‰›·ÙÚÔ Î·È ÙÔÓ ¯ÂÈÚÔ˘ÚÁfi. ∆Ô Úfi‚ÏËÌ· ·˘Ùfi Â›Ó·È ÂÓÙÔÓfiÙÂÚÔ ÛÙ· Ôχ ÌÈÎÚ¿ ·È‰È¿, ÙÔ ÈÛÙÔÚÈÎfi ÙˆÓ ÔÔ›ˆÓ ÌÔÚ› Ó· ÌËÓ Â›Ó·È Ù˘ÈÎfi Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÍÂÙ¿ÛÂˆÓ Û˘Ó‹ıˆ˜ ‰ÂÓ Â›Ó·È ·ÍÈfiÈÛÙ·. ∆· ‰Â‰Ô̤ӷ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Â›Ó·È ÊÚfiÓÈÌÔ Ó· ÂÚÈÔÚ›˙ÂÙ·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Û ·È‰È¿ Ô˘ ¤¯Ô˘Ó ÂÍÂÙ·ÛÙ› ÎÏÈÓÈο Î·È Ô ¯ÂÈÚÔ˘ÚÁfi˜
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Paediatriki 2003;66:397-400
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‰ÂÓ Â›Ó·È ÈηÓÔÔÈË̤ÓÔ˜ ‹ ·ÌÊÈ‚¿ÏÏÂÈ ÁÈ· ÙÔ ÎÏÈÓÈÎfi ‡ÚËÌ·. °ÓˆÚ›˙ÔÓÙ·˜ Û‹ÌÂÚ· Ù· ‚Ï·‚ÂÚ¿ ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÎÙÈÓÔ‚ÔÏ›·˜, Ë ¯Ú‹ÛË ·ÍÔÓÈÎÒÓ ÙÔÌÔÁÚ·ÊÈÒÓ ·‰È·ÎÚ›Ùˆ˜ ÛÙÔÓ ÏËı˘ÛÌfi ·È‰ÈÒÓ Ì Èı·Ó‹ ÛΈÏËÎÔÂȉ›Ùȉ· ‰ÂÓ Û˘ÓÈÛٿٷÈ. ªÔÏÔÓfiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¯Ú˘Ûfi˜ ηÓfiÓ·˜ Ô˘ Ó· ÂÁÁ˘¿Ù·È 100% ·ÎÚ›‚ÂÈ· ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÛΈÏËÎÔÂȉ›Ùȉ·˜ ÛÙ· ·È‰È¿, Ô ÂÂÈڷ̤ÓÔ˜ ¯ÂÈÚÔ˘ÚÁfi˜ ·Ú·Ì¤ÓÂÈ ÙÔ Ï¤ÔÓ ·ÍÈfiÈÛÙÔ ÂÚÁ·Ï›Ô. J Pediatr Surg 2003;38:659-662 ∏ ıÈÌÂÚÔÛ¿ÏË, Û˘ÓÙËÚËÙÈÎfi ÂÌ‚ÔÏ›ˆÓ Ô˘ ÂÚȤ¯ÂÈ ˘‰Ú¿ÚÁ˘ÚÔ, Û ۯ¤ÛË Ì ÙËÓ Â›ÙˆÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡ ∫ÔÚ›Ó· ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡, ¶·È‰›·ÙÚÔ˜
∏ ·Ó·ÊÔÚ¿ ·˘Ù‹ ·fi ÙË ¢·Ó›· ÂÍÂÙ¿˙ÂÈ ÙËÓ ˘fiıÂÛË Ó· Û¯ÂÙ›˙ÂÙ·È Ë ¯Ú‹ÛË ÂÌ‚ÔÏ›ˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ˆ˜ Û˘ÓÙËÚËÙÈ΋ Ô˘Û›· ÙË ıÈÌÂÚÔÛ¿ÏË, Ì ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙÔ˘ ·˘ÙÈÛÌÔ‡ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÙÂÏÂ˘Ù·›·. ∞˘Ù‹ Ë ˘fiıÂÛË ‚·Û›ÛÙËΠÙfiÛÔ ÛÙËÓ ·Ú·Ù‹ÚËÛË fiÙÈ Ë ¤ÎıÂÛË Û ÌÂı˘ÏÈÎfi ˘‰Ú¿ÚÁ˘ÚÔ Û¯ÂÙ›˙ÂÙ·È Ì Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ fiÛÔ Î·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·˘ÙÈÛÌÔ‡ Î·È Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ·fi ˘‰Ú¿ÚÁ˘ÚÔ Â›Ó·È ·ÚfiÌÔÈ·. ™ÙË ¢·Ó›·, ·˘Ùfi ÙÔ Û˘ÓÙËÚËÙÈÎfi ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙ· ÂÌ‚fiÏÈ· ̤¯ÚÈ ÙÔ 1992. ™Ùfi¯Ô ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘, ÏÔÈfiÓ, ·ÔÙ¤ÏÂÛÂ Ë Û‡ÁÎÚÈÛË Ù˘ ›وÛ˘ ÙÔ˘ ·˘ÙÈÛÌÔ‡ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·fiÛ˘ÚÛË Ù˘ ıÈÌÂÚÔÛ¿Ï˘. ∞ӷχıËÎ·Ó ÛÙÔȯ›· ·fi ÙÔ „˘¯È·ÙÚÈÎfi ·Ú¯Â›Ô Ù˘ ¯ÒÚ·˜, fiÔ˘ ›¯·Ó ηٷ¯ˆÚËı› 956 ·È‰È¿ Ì ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡, ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1971-2000. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠٿÛË ·‡ÍËÛ˘ Ù˘ ›وÛ˘ ÙÔ˘ ·˘ÙÈÛÌÔ‡ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1971-1992. ∂ÓÙÔ‡ÙÔȘ, ·fi ÙÔ 1992 ̤¯ÚÈ ÙÔ 2000 Î·È ·ÊÔ‡ ›¯Â ·ÔÛ˘Úı› Ë ıÈÌÂÚÔÛ¿ÏË ·fi Ù· ÂÌ‚fiÏÈ·, Ë Â›ÙˆÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡ ÛËÌ›ˆÛ ·‡ÍËÛË ·fi ¤ÙÔ˜ Û ¤ÙÔ˜. OÈ ÂÚ¢ÓËÙ¤˜ ηٷϋÁÔ˘Ó fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡ Ì ÙË ıÈÌÂÚÔÛ¿ÏË, ¯ˆÚ›˜ fï˜ ·˘Ùfi Ó· ·ÔÙÂÏ› ÏfiÁÔ ÁÈ· ÙËÓ Â·Ó·ÊÔÚ¿ ·˘ÙÔ‡ ÙÔ˘ Û˘ÓÙËÚËÙÈÎÔ‡. µÂ‚·›ˆ˜, ·˘Ù‹ Ë ÌÂϤÙË ‰ÂÓ ·ÔÎÏ›ÂÈ ÙËÓ ·˘ÍË̤ÓË ¤ÎıÂÛË Û ˘‰Ú¿ÚÁ˘ÚÔ ·fi ¿ÏϘ ËÁ¤˜ ˆ˜ ·›ÙÈ· Ù˘ ·˘ÍË̤Ó˘ ›وÛ˘ ·˘ÙÈÛÌÔ‡ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ∞˘Ù‹ Ë ·‡ÍËÛË ·ÁÎÔÛÌ›ˆ˜ ·Ú·Ì¤ÓÂÈ ¤Ó· ·›ÓÈÁÌ·, ÂÓÒ ÔÈ Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÎıÂÛË ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÙÔ͛Ә. Pediatrics 2003;112:604-606 ∆Ô ÚÔ¯·ÏËÙfi ÛÙËÓ ·È‰È΋ ËÏÈΛ· ·ÓÙ·Ó·ÎÏ¿ ÛÙË Û¯ÔÏÈ΋ ›‰ÔÛË ÕÓÓ· ªÂÛÛ·ÚÈÙ¿ÎË, ¶·È‰›·ÙÚÔ˜
ªÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙË °ÂÚÌ·Ó›· ¤‰ÂÈÍ fiÙÈ Ù· ·È‰È¿ Ô˘ ÚÔ¯·Ï›˙Ô˘Ó ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÈηÓÔÔÈËÙÈο ÛÙÔ Û¯ÔÏ›Ô, Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ¤¯Ô˘Ó ‹Û˘¯Ô ‡ÓÔ. ∏ ÌÂϤÙË, ÛÙËÓ ÔÔ›· ‹Ú·Ó ̤ÚÔ˜ 1144 Ì·ıËÙ¤˜ Ù˘ °’ Ù¿Í˘ ÙÔ˘ ‰ËÌÔÙÈÎÔ‡ Û¯ÔÏ›Ԣ, ÂÚÈÂÏ¿Ì‚·Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ‰fiıËΠÛÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ηıÒ˜ Î·È Ì¤ÙÚËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ (SatO2%) ηٿ ÙËÓ ÒÚ· ÙÔ˘ ‡ÓÔ˘ Ì ÙË ¯Ú‹ÛË ÔÍ˘Ì¤ÙÚÔ˘ ÛÙÔ Û›ÙÈ.
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Paediatriki 2003;66:397-400
¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
∆Ô ÚÔ¯·ÏËÙfi, ›Ù ÂÌÊ·ÓÈ˙fiÙ·Ó Î¿ı Ӈ¯Ù· ›Ù ۷ÓÈfiÙÂÚ·, Û˘Û¯ÂÙ›ÛÙËΠ̠ÌÂȈ̤ÓË ÚÔÛÔ¯‹ Î·È Ì¤ÙÚÈ· Û¯ÔÏÈ΋ ›‰ÔÛË, ȉȷ›ÙÂÚ· ÛÙ· Ì·ıËÌ·ÙÈο Î·È ÙËÓ ÔÚıÔÁÚ·Ê›·. ¶·Ú’ fiÏ· ·˘Ù¿, fiÙ·Ó ÙÔ ÚÔ¯·ÏËÙfi Û˘Óԉ¢fiÙ·Ó ·fi ‰È·ÏÂ›Ô˘Û· ˘Ô͢ÁÔÓ·ÈÌ›· (ÎÔÚÂÛÌfi˜ O2≤90%), ‰ÂÓ ‚Ú¤ıËΠӷ ÂËÚ¿˙ÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ Â›‰ÔÛË ÙˆÓ Ì·ıËÙÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÙÔ ÚÔ¯·ÏËÙfi ˆ˜ Û‡Ìو̷ Û ̷ıËÙ¤˜ Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ Âη›‰Â˘Û˘ Û¯ÂÙ›˙ÂÙ·È Ì ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË Û¯ÔÏÈ΋ ÚfiÔ‰Ô. Am J Respir Crit Care Med 2003;168:464-468
∂§§∏¡π∫∏ µπµ§πO°ƒ∞ºπ∞ ON-LINE ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
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¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
·ÚÔ˘ÛÈ¿˙ÂÈ ‰˘ÛÎÔϛ˜, ‰ÈfiÙÈ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi˜ Ô‡ÙÂ Ô ÏÔÁÈÎfi˜ Û˘Ó‰˘·ÛÌfi˜ fiÚˆÓ, Ô‡ÙÂ Ë ·Ó·˙‹ÙËÛË Ì ‚¿ÛË ÙËÓ ËÌÂÚÔÌËÓ›·. ∆¤ÏÔ˜, Ë “¶·È‰È·ÙÚÈ΋”, fiˆ˜ Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ¿ÏÏ· ÂÚÈÔ‰Èο, ηχÙÂÙ·È ÌfiÓÔ Ì¤¯ÚÈ ÙÔ ¤ÙÔ˜ 2000! ∂ıÓÈÎfi ∫¤ÓÙÚÔ ∆ÂÎÌËÚ›ˆÛ˘ - http://www.ekt.gr/index.html ™‡Ìʈӷ Ì ÙÔ ÂÈÛ·ÁˆÁÈÎfi ÛËÌ›ˆÌ· ÙÔ˘ ‰ÈÎÙ˘·ÎÔ‡ ÙÔ˘ ÙfiÔ˘, “ÙÔ ∂∫∆ Â›Ó·È ÂıÓÈ΋ ˘Ô‰ÔÌ‹ Ô˘ Û˘ÁÎÂÓÙÚÒÓÂÈ, ÙÂÎÌËÚÈÒÓÂÈ Î·È ‰È·ı¤ÙÂÈ ÂÚȯfiÌÂÓÔ Û ı¤Ì·Ù· ÂÈÛÙ‹Ì˘, ¤Ú¢ӷ˜ Î·È Ù¯ÓÔÏÔÁ›·˜ Î·È ·ÚÂÌ‚·›ÓÂÈ Û ı¤Ì·Ù· ÂÚȯÔ̤ÓÔ˘ Ù˘ ∫ÔÈÓˆÓ›·˜ Ù˘ ¶ÏËÚÔÊÔÚ›·˜”. ∆Ô ∂∫∆ ¤¯ÂÈ ·ÚÎÂÙ¿ ÂÎÙÂٷ̤ÓÔ Î·È ÂÚ›ÏÔÎÔ ‰ÈÎÙ˘·Îfi ÙfiÔ, ‰Â‰Ô̤ÓÔ˘ ¿ÏψÛÙ fiÙÈ ·Ó·Ê¤ÚÂÙ·È Û fiÏÔ ÙÔ Ê¿ÛÌ· Ù˘ ÂÈÛÙ‹Ì˘. ™¯ÂÙÈο Ì ٷ ÂÚ› ËÌÒÓ, ˘¿Ú¯Ô˘Ó ‰‡Ô ‚¿ÛÂȘ: Ë π·ÙÚÈ΋ µÈ‚ÏÈÔÁÚ·Ê›· πÔÎÚ¿Ù˘ Î·È ÙÔ ∂ıÓÈÎfi ∞Ú¯Â›Ô ¢È‰·ÎÙÔÚÈÎÒÓ ¢È·ÙÚÈ‚ÒÓ. ∏ Ì˯·Ó‹ ·Ó·˙‹ÙËÛ˘ Â›Ó·È ÎÔÈÓ‹ ÁÈ· fiϘ ÙȘ ‚¿ÛÂȘ ηÈ, ·Ó Î·È ÂÈÙÚ¤ÂÈ Û˘Ó‰˘·ÛÌfi fiÚˆÓ, ˘ÔÏ›ÂÙ·È Î·È ·˘Ù‹ ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ Ô˘ Û˘Ó·ÓÙ¿ ηÓ›˜ Û ‰ÈÂıÓ›˜ ‚¿ÛÂȘ ‰Â‰Ô̤ӈÓ. ∆Ô ÈÔ ·ÓËÛ˘¯ËÙÈÎfi, fï˜, Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Â‰Ò Ë ·Ó·˙‹ÙËÛË ÙÔ˘ fiÚÔ˘ “¿ÛıÌ·” Û ÔÔÈÔ‰‹ÔÙ ‰›Ô ÛÙÔÓ πÔÎÚ¿ÙË, ¤‰ˆÛ 118 ÂÁÁڷʤ˜ (ÏÈÁfiÙÂÚ˜ ·fi ÂΛӘ ÙÔ˘ π∞∆ƒO∆∂∫), ÂÓÒ ÛÙË ‚¿ÛË ÙˆÓ ‰È‰·ÎÙÔÚÈÎÒÓ ‰È·ÙÚÈ‚ÒÓ ÌfiÏȘ 18! OÈ ¯ÚÔÓÔÏÔÁ›Â˜ ‰Â Û˘ÁÁÚ·Ê‹˜ ÙˆÓ ‰È·ÙÚÈ‚ÒÓ ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È, ·Ó Î·È Ô ÁÚ¿ÊˆÓ ·Ó·ÁÓÒÚÈÛ 5 ÔÓfiÌ·Ù· ‰È¢ı˘ÓÙÒÓ ÎÏÈÓÈÎÒÓ Î·È ÂÓfi˜ Û˘ÓÙ·ÍÈÔ‡¯Ô˘. ∂ÏÏËÓÈο È·ÙÚÈο ÂÚÈÔ‰Èο on-line £· ‹Ù·Ó, fï˜, ¿‰ÈÎÔ Ó· ÎÚ›ÓÔ˘Ì ·˘ÛÙËÚ¿ ÙÔ˘˜ Ù·ÍÈÓÔÌËÙ¤˜, ¯ˆÚ›˜ Ó· ·Ó·ÊÂÚıԇ̠ۇÓÙÔÌ· Î·È ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ ›‰ÈˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ. ŒÓ·˜ ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ·fi ·˘Ù¿ ¤¯ÂÈ ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ‰ÈÎÙ˘·Îfi ÙfiÔ, ÚÔÛʤÚÔÓÙ·˜ Ï‹Ú˜ ÂÚȯfiÌÂÓÔ ‹ ÌfiÓÔ ÂÚÈÏ‹„ÂȘ. ∞ÚÎÂÙ¿ ·fi ·˘Ù¿ Ù· sites Â›Ó·È Î·Ï·›ÛıËÙ· Î·È ÏÂÈÙÔ˘ÚÁÈο. ™¯ÂÙÈο, fï˜, Ì ÙÔ ÂÚȯfiÌÂÓÔ, ÙÔ ÌfiÓÔ Ô˘ ı· ·Ó·Ê¤ÚÔ˘ÌÂ Â›Ó·È Ë ËÌÂÚÔÌËÓ›· Ù˘ ÈÔ ÚfiÛÊ·Ù˘ ÂÓË̤ڈÛ˘ ÌÂÚÈÎÒÓ ·fi ·˘Ù¿: ñ ∂ÏÏËÓÈ΋ ÃÂÈÚÔ˘ÚÁÈ΋ - http://www.mednet.gr/hss/ach.htm (OÎÙÒ‚ÚÈÔ˜ 1998) ñ ∞گ›· ¶·ıÔÏÔÁÈ΋˜ ∞Ó·ÙÔÌÈ΋˜ - http://www.mednet.gr/hsap/apa.htm (¢ÂΤ̂ÚÈÔ˜ 2001) ñ ¶ÚˆÙÔ‚¿ıÌÈ· ºÚÔÓÙ›‰· ÀÁ›·˜ - http://www.mednet.gr/elegeia/phc_g.htm (πÔ‡ÓÈÔ˜ 2000) ñ ¢ÂÏÙ›ÔÓ ∂ÏÏËÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ http://www.mednet.gr/greek/soc/eme/amh.htm (¢ÂΤ̂ÚÈÔ˜ 1995) ñ ∞گ›· ∂ÏÏËÓÈ΋˜ π·ÙÚÈ΋˜ - http://www.mednet.gr/archives/index.html (¢ÂΤ̂ÚÈÔ˜ 2000) ñ OÊı·ÏÌÔÏÔÁÈο ÃÚÔÓÈο - http://www.eyenet.gr/edition_gr/ (π·ÓÔ˘¿ÚÈÔ˜ 2000) ñ ¶ÓÂ‡ÌˆÓ - http://www.mednet.gr/pneumon/top.htm (¢ÂΤ̂ÚÈÔ˜ 2002) (!) £· ÌÔÚÔ‡Û ӷ ÛÎÂÊÙ› ηÓ›˜ fiÙÈ Ô ·Ú¯ÈÎfi˜ ÂÓıÔ˘ÛÈ·ÛÌfi˜ ηٿ Ù· ¤ÙË 1995-1997 ‰È‹ÚÎÂÛ ϛÁÔ, ηıÒ˜ ÌÂÙ¿ ÙÔ 2000 Ë ·ÚÔ˘Û›· ÙˆÓ ÂÏÏËÓÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ ÛÙÔ ‰È·‰›ÎÙ˘Ô ·ÙfiÓÈÛÂ. ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ ı· ·ÎÔÏÔ˘ı‹ÛÂÈ, Û ÌÈÎÚfi ‹ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ó¤Ô Î‡Ì· ‰È·‰ÈÎÙ˘·Î‹˜ ·ÚÔ˘Û›·˜ ÙˆÓ ÂÏÏËÓÈÎÒÓ È·ÙÚÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ (ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ “¶·È‰È·ÙÚÈ΋˜”). ∂Ï›˙Ô˘Ì fiÙÈ Ë Ù¿ÛË ·˘Ù‹ ı· ÂÌÊ·ÓÈÛÙ› ÁÚ‹ÁÔÚ· ηÈ, ·˘Ù‹ ÙË ÊÔÚ¿, ·ÔÙÂÏÂÛÌ·ÙÈο.
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ANNOUNCEMENT
∆Ô ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ “∂§§∏¡π∫∏™ ¶∞π¢π∞∆ƒπ∫∏™ ∂∆∞πƒ∂π∞™” ¢ڛÛÎÂÙ·È ÛÙËÓ Â˘¯¿ÚÈÛÙË ı¤ÛË Ó· Û·˜ ·Ó·ÎÔÈÓÒÛÂÈ fiÙÈ ÔÏÔÎÏËÚÒıËÎ·Ó ÔÈ ‰È·‰Èηۛ˜ ÙÚÔÔÔ›ËÛ˘ ÙÔ˘ ∫·Ù·ÛÙ·ÙÈÎÔ‡ Ù˘, fiˆ˜ ·˘Ù‹ ·ÔÊ·Û›ÛıËΠ·fi ÙËÓ ¤ÎÙ·ÎÙË °ÂÓÈ΋ ™˘Ó¤Ï¢ÛË ÙˆÓ ªÂÏÒÓ Ù˘ ∂Ù·ÈÚ›·˜ ηٿ ÙËÓ ·fi 26 ™ÂÙÂÌ‚Ú›Ô˘ 2002 ™˘Ó‰ڛ·ÛË ·˘Ù‹˜. OÈ ·ÏÏ·Á¤˜ ·˘Ù¤˜ Â›Ó·È ÔÏϤ˜ Î·È Ô˘ÛÈ·ÛÙÈΤ˜ ÁÈ· ÙËÓ Â‡Ú˘ıÌË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ∂.¶.∂. ∏ ÈÛ¯‡˜ ÙÔ˘ ÙÚÔÔÔÈËı¤ÓÙÔ˜ ∫·Ù·ÛÙ·ÙÈÎÔ‡ ¿Ú¯ÈÛ ÙËÓ 9Ë OÎÙˆ‚Ú›Ô˘ 2003. ™‡Ìʈӷ Ì ÙÔ Ó¤Ô ∫·Ù·ÛÙ·ÙÈÎfi, ÌÂٷ͇ ÙˆÓ ¿ÏÏˆÓ ·ÏÏ·ÁÒÓ Ô˘ ÂÊÂÍ‹˜ ÈÛ¯‡Ô˘Ó, ÚÔ·ÙÂÈ fiÙÈ ÔÈ ∞Ú¯·ÈÚÂۛ˜ ÙˆÓ ªÂÏÒÓ ÙÔ˘ ¢ÈÔÈÎËÙÈÎÔ‡ ™˘Ì‚Ô˘Ï›Ô˘ ı· Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È Î¿ı ¯ÚfiÓÔ Î·È ı· ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ÙÚ›· (3) Ó¤· ª¤ÏË Ì ÙÚÈÂÙ‹ ıËÙ›· Û ·ÓÙÈηٿÛÙ·ÛË ÙÚÈÒÓ (3) ·Ï·ÈÒÓ ªÂÏÒÓ ·˘ÙÔ‡. ∫¿ı ‰Â ·ÚfiÓ ÛÙȘ ÁÂÓÈΤ˜ Û˘ÓÂχÛÂȘ ̤ÏÔ˜, ‰ÂÓ ‰‡Ó·Ù·È ÂȘ ÙÔ ÂÍ‹˜ Ó· ·ÓÙÈÚÔۈ‡ÂÈ ÂÚÈÛÛfiÙÂÚ· ·fi ‰‡Ô (2) ·fiÓÙ· ̤ÏË Ù˘ ∂Ù·ÈÚ›·˜.
°È· ÙÔ ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ ∂Ù·ÈÚ›·˜ O ¶Úfi‰ÚÔ˜ ÙÔ˘ ¢.™. ∫·ı. ∞Ó‰Ú¤·˜ ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
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∞ÓÔȯً ÂÈÛÙÔÏ‹ ÚÔ˜ Ù· ª¤ÏË Ù˘ ∂.¶.∂.
∞ÍÈfiÙÈÌ· ª¤ÏË Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜, ™·˜ ˘ÂÓı˘Ì›˙Ô˘Ì fiÙÈ ÁÈ· Ù· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· Ë ÂÙ‹ÛÈ· Û˘Ó‰ÚÔÌ‹ Û·˜ ÛÙËÓ ∂.¶.∂. ·ÓÂÚ¯fiÙ·Ó ÛÙÔ ÔÛfi ÙˆÓ 30,00 ¢ÚÒ Î·È ÌfiÏȘ ʤÙÔ˜ ·Ó·ÚÔÛ·ÚÌfiÛÙËΠÛÙ· 40,00 ¢ÚÒ. ∞fi ÙË Û˘Ó‰ÚÔÌ‹ ·˘Ù‹ ηٷ‚¿ÏÏÔÓÙ·È ÂÙËÛ›ˆ˜ ÁÈ· οı ª¤ÏÔ˜ ÂÚ›Ô˘ 10,00 ¢ÚÒ ÁÈ· Û˘Ó‰ÚÔ̤˜ ÛÙËÓ ¶·ÁÎfiÛÌÈ· ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·, ÙË ªÂÛÔÁÂȷ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·, ÙËÓ ∂˘Úˆ·˚΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· (UNEPSA) Î·È ÙËÓ CESP. ∂Âȉ‹ Ë ∂.¶.∂. ·ÔÏËÚÒÓÂÈ ·ÓÂÏÏÈÒ˜ ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Î·È ÙËÓ ÂÙ‹ÛÈ¿ Û·˜ Û˘Ó‰ÚÔÌ‹ ÛÙȘ ‰ÈÂıÓ›˜ ÂÙ·ÈÚ›˜ Î·È ÔÚÁ·ÓÈÛÌÔ‡˜, ·ÓÂÍ¿ÚÙËÙ· ·Ó ÂÛ›˜ ›ÛÙ ‹ fi¯È Ù·ÌÂÈ·ÎÒ˜ ÂÓÙ¿ÍÂÈ, ·Ú·Î·Ïԇ̠fiˆ˜ ÙÔ Ù·¯‡ÙÂÚÔ ‰˘Ó·Ùfi ÂÍÔÊÏ‹ÛÂÙ ÙȘ Û˘Ó‰ÚÔ̤˜ Û·˜. ∂ÈÚÔÛı¤Ùˆ˜, Û‡Ìʈӷ Ì ÙÔ ¿ÚıÚÔ 22 ·Ú¿ÁÚ. 1 ÙÔ˘ ηٷÛÙ·ÙÈÎÔ‡: “¢Èη›ˆÌ· Û˘ÌÌÂÙÔ¯‹˜ Î·È „‹ÊÔ˘ ÛÙË °.™. ¤¯Ô˘Ó fiÏ· Ù· Ù·ÎÙÈο ̤ÏË ·˘Ù‹˜ Ô˘ ¤¯Ô˘Ó Ù·ÎÙÔÔÈËı› Ù·ÌÂÈ·ÎÒ˜ ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÚÁ¿ÛÈ̘ Ë̤Ú˜ ÚÔ Ù˘ ÚÒÙ˘ ηÓÔÓÈ΋˜ (Î·È fi¯È Ù˘ ·ӷÏËÙÈ΋˜) Û˘Ó‰ÚÈ¿Ûˆ˜ Ù˘ °.™., ÚÔÎÂÈ̤ÓÔ˘ Ó· ηı›ÛÙ·Ù·È ÂÊÈÎÙ‹ Ë Û‡ÓÙ·ÍË Î·Ù·ÏfiÁÔ˘ ÙˆÓ ÌÂÏÒÓ Ù˘ ∂Ù·ÈÚ›·˜ Ô˘ ‰ÈηÈÔ‡ÓÙ·È Ó· Û˘ÌÌÂÙ¿Û¯Ô˘Ó ÛÙË ™˘Ó¤Ï¢ÛË”. ∆Ô ¿ÚıÚÔ 5 ·Ú¿ÁÚ. 1™∆’, ÂÍ¿ÏÏÔ˘, ·Ó·Ê¤ÚÂÈ fiÙÈ: “¢È·ÁÚ¿ÊÂÙ·È Î¿ı ̤ÏÔ˜ ÏfiÁˆ ·Ú¿ÏÂȄ˘ ηٷ‚ÔÏ‹˜ Ù˘ ÂÙ‹ÛÈ·˜ ˘Ô¯ÚˆÙÈ΋˜ Û˘Ó‰ÚÔÌ‹˜ ÙÔ˘ › ‰‡Ô Û˘Ó·Ù¿ ¤ÙË. ∆Ë ‰È·ÁÚ·Ê‹ ·ÔÊ·Û›˙ÂÈ ÙÔ ¢.™. ¯ˆÚ›˜ Ó· ··ÈÙÂ›Ù·È ÚÔËÁÔ‡ÌÂÓË ÂÓË̤ڈÛË ÙÔ˘ ̤ÏÔ˘˜ Ù˘ ÂÙ·ÈÚ›·˜ ÂÚ› ÙˆÓ ¯ÚÂÒÓ ÙÔ˘”. °È· Ó· ÌÔÚ¤ÛÔ˘Ì ӷ ·ÓÙ·ÔÎÚÈıÔ‡ÌÂ Î·È ÂÌ›˜ ÛÙȘ ˘Ô¯ÚÂÒÛÂȘ Ì·˜, οÓÔ˘Ì ¤ÎÎÏËÛË fiˆ˜ ÏËÚÒÛÂÙ ÙȘ Û˘Ó‰ÚÔ̤˜ Û·˜. ∂˘¯·ÚÈÛÙԇ̠ÁÈ· ÙË Û˘ÓÂÚÁ·Û›· Û·˜ ªÂ ÂÎÙ›ÌËÛË °È· ÙÔ ¢.™. O ¶Úfi‰ÚÔ˜ ÙÔ˘ ¢.™. ∫·ı. ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
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∂¶π™∆O§∏ ¶ƒO™ ∆∏ ™À¡∆∞•∏
Paediatriki 2003;66:403-404
LETTER TO THE EDITOR
∫‡ÚÈ ¢È¢ı˘ÓÙ¿, ∆Ô ÙÂÏÂ˘Ù·›Ô ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ›¯· ÙËÓ ÙÈÌ‹ Ó· Â›Ì·È ¤Ó·˜ ·fi ÙÔ˘˜ ÎÚÈÙ¤˜ Û 3 ÂÚÁ·Û›Â˜ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÛÙÔ ÂÚÈÔ‰ÈÎfi. ∫·È ÔÈ 3 ‹Ù·Ó ·ÍÈfiÏÔÁ˜, ÛˆÛÙ¿ ÙÂÎÌËÚȈ̤Ó˜ Î·È Ì ÏÔ‡ÛÈ· ‚È‚ÏÈÔÁÚ·Ê›·. ŸÌˆ˜, η̛· ÂÚÁ·Û›· ‰ÂÓ Â›¯Â ¤ÛÙˆ Î·È ªπ∞ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿. ™Î¤ÊÙËη Ì‹ˆ˜ ÙÔ Â‡ÚËÌ· ‹Ù·Ó Ù˘¯·›Ô (‰ÂÓ Â›¯· “·Ó·Ï‡ÛÂÈ” ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ‰Â›ÁÌ·, fiˆ˜ ϤÓ ÔÈ ÛÙ·ÙÈÛÙÈÎÔÏfiÁÔÈ) Î·È ÎÔ›Ù·Í· 3 ·fi Ù· ÙÂÏÂ˘Ù·›· Ù‡¯Ë Ù˘ ¶∞π¢π∞∆ƒπ∫∏™, Û˘ÁÎÂÎÚÈ̤ӷ ÙÔ Ù‡¯Ô˜ 5 (™Â٤̂ÚÈÔ˜-OÎÙÒ‚ÚÈÔ˜ ÙÔ˘ 2002), ÙÔ Ù‡¯Ô˜ 1 (π·ÓÔ˘¿ÚÈÔ˜-ºÂ‚ÚÔ˘¿ÚÈÔ˜ ÙÔ˘ 2003) Î·È ÙÔ Ù‡¯Ô˜ 2 (ª¿ÚÙÈÔ˜-∞Ú›ÏÈÔ˜ ÙÔ˘ 2003). ∆· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ·ÚfiÌÔÈ·. ™Ù· 3 ·˘Ù¿ Ù‡¯Ë ‰ËÌÔÛȇıËηÓ: 1 ¿ÚıÚÔ Û‡ÓÙ·Í˘, 7 ·Ó·ÛÎÔ‹ÛÂȘ, 14 ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, 9 ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, 3 ›ηÈÚ· ı¤Ì·Ù· Î·È 1 ÂȉÈÎfi ¿ÚıÚÔ. ∆Ô Û‡ÓÔÏÔ ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ó·ÊÔÚÒÓ Û fiÏ· ·˘Ù¿ Ù· ¿ÚıÚ· ‹Ù·Ó 1.028, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÂÏÏËÓÈΤ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ (ÂÍ·ÈÚÔ˘Ì¤ÓˆÓ ÙˆÓ ·˘ÙÔ·Ó·ÊÔÚÒÓ) ‹Ù·Ó ÌfiÓÔ 10 (‰¤Î·)!!! ∆Ô Úfi‚ÏËÌ·, Ê˘ÛÈο, ‰ÂÓ ·ÊÔÚ¿ ÌfiÓÔ ÛÙËÓ ¶∞π¢π∞∆ƒπ∫∏. ∆Ô ›‰ÈÔ Ê·ÈÓfiÌÂÓÔ ·Ú·ÙËÚÂ›Ù·È Î·È ÛÙÔ “¢ÂÏÙ›Ô Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ”, ÛÙÔ ÔÔ›Ô ¤¯ˆ ÙËÓ ÙÈÌ‹ Ó· Â›Ì·È ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘. ∂ÈϤÔÓ, Ë ‰È·›ÛÙˆÛË ‰ÂÓ Â›Ó·È Î·ÈÓÔ‡ÚÁÈ·. Œ¯ÂÈ ·fi ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ÂÈÛËÌ·Óı› ·fi ·ÍÈfiÏÔÁÔ˘˜ ÁÈ·ÙÚÔ‡˜-Û˘ÁÁÚ·Ê›˜, ÔÈ ÔÔ›ÔÈ Ì ‰ÈηÈÔÏÔÁË̤ÓÔ ·Ú¿ÔÓÔ ·Ú·ÙËÚÔ‡Ó ·˘Ùfi Ô˘ ‰È·ÈÛÙÒıËΠ·Ú·¿Óˆ, fiÙÈ ‰ËÏ. Û ÔÔÈÔ‰‹ÔÙ ¿ÚıÚÔ ‹ ÂÈÛÙËÌÔÓÈ΋ ÂÚÁ·Û›· ‰ËÌÔÛÈÂ˘Ì¤ÓË Û ÂÏÏËÓÈÎfi È·ÙÚÈÎfi ÂÚÈÔ‰ÈÎfi, ÛÙÔÓ ‚È‚ÏÈÔÁÚ·ÊÈÎfi ηٿÏÔÁÔ ·Ó·Ê¤ÚÂÙ·È Ì›· ÛÂÈÚ¿ ·fi ÍÂÓfiÁψÛÛ˜ ÂÚÁ·Û›Â˜ (‰ËÌÔÛÈÂ˘Ì¤Ó˜ ·ÎfiÌ· Î·È Û ۯÂÙÈο ¿ÁÓˆÛÙ· ÂÚÈÔ‰Èο), ÂÓÒ Û¿ÓÈ· ·Ó·Ê¤ÚÂÙ·È ÂÏÏËÓÈ΋ ÂÚÁ·Û›· (1,2). ∏ ÂÍ‹ÁËÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ‰ÂÓ Â›Ó·È Â‡ÎÔÏË. ∂›Ó·È ·Ï‹ıÂÈ· fiÙÈ Ì¤¯ÚÈ ÚÈÓ ·fi 5 ¯ÚfiÓÈ· ‰ÂÓ ˘‹Ú¯Â ‡ÎÔÏË ÚfiÛ‚·ÛË ÛÙËÓ ÂÏÏËÓÈ΋ È·ÙÚÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·. ŒÙÛÈ, ÂÓÒ ‹Ù·Ó Û¯ÂÙÈο ‡ÎÔÏÔ Ó· ‚ÚÂı› ÙÈ ¤¯ÂÈ ‰ËÌÔÛÈ¢ı› Î·È ÙÈ Á›ÓÂÙ·È (.¯. Ì ÙË Ïԛ̈ÍË ·fi ÙÔÓ Èfi ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·) ÛÙËÓ π·ˆÓ›· ‹ ÛÙË ¡. ∑ËÏ·Ó‰›·, ‹Ù·Ó Û¯ÂÙÈο ‰‡ÛÎÔÏÔ Ó· ‚ÚÂı› ÙÈ ¤¯ÂÈ ‰ËÌÔÛÈ¢ı› Î·È ÙÈ Á›ÓÂÙ·È ÛÙË µ. ∂ÏÏ¿‰· ‹ ÛÙËÓ ∫Ú‹ÙË. ∂ÓÙÔ‡ÙÔȘ, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ô ŒÏÏËÓ·˜ ÁÈ·ÙÚfi˜-Û˘ÁÁڷʤ·˜ ¤¯ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ‰˘Ó·ÙfiÙËÙ˜: ·) ÙËÓ ÚfiÛ‚·ÛË Ì¤Ûˆ Internet (www.mednet.gr/iatrotek) ÛÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó·˙‹ÙËÛË ¿ÚıÚˆÓ ÙˆÓ ÂÏÏËÓÈÎÒÓ ‚ÈÔ˚·ÙÚÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ ·fi ÙÔ ∫¤ÓÙÚÔ ∂ÏÏËÓÈ΋˜ π·ÙÚÈ΋˜ ¶ÏËÚÔÊÔÚÈ΋˜ OÚÔÏÔÁ›·˜ Î·È ∆ÂÎÌËÚ›ˆÛ˘ (π∞∆ƒO∆∂∫) (2) Î·È ‚) ÙËÓ ÚfiÛ‚·ÛË ÛÙÔ πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË ¿ÚıÚˆÓ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÛÙ· ÂÏÏËÓÈο ·È‰È·ÙÚÈο ÂÚÈÔ‰Èο (3). O ˘ÔÁÚ¿ÊˆÓ Â›Ó·È ·fi ·˘ÙÔ‡˜ Ô˘ ÈÛÙ‡ԢÓ, Ì·˙› Ì ÔÏÏÔ‡˜ ¿ÏÏÔ˘˜ Ô˘ ¤¯Ô˘Ó ·Û¯ÔÏËı› Ì ÙÔ ı¤Ì· (1,2,4), fiÙÈ Ô ÂÏÏËÓÈÎfi˜ È·ÙÚÈÎfi˜ Ù‡Ô˜ ¤¯ÂÈ ÛËÌ·ÓÙÈÎfi ÏfiÁÔ ‡·Ú͢. ™Â ¤Ó· ÂÏÏËÓÈÎfi È·ÙÚÈÎfi ÂÚÈÔ‰ÈÎfi ı· ‰ËÌÔÛÈ¢ıÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÏÂÙÒÓ Ô˘ ·ÊÔÚÔ‡Ó Û ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ ÂıÓÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜, ¯ˆÚ›˜ ȉȷ›ÙÂÚË ÛËÌ·Û›· ÁÈ· ¿ÏϘ ¯ÒÚ˜, ˆ˜ Î·È ·Ú·ÙËÚ‹ÛÂȘ, ÛÙ·ÙÈÛÙÈο Î·È ÓÔÛÔÏÔÁÈο ÛÙÔȯ›· ÁÈ· ÓÔÛ‹Ì·Ù· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙË ¯ÒÚ· Ì·˜ (.¯. Ë ÙÂÏÂ˘Ù·›· ÂȉËÌ›· ÂÚ˘ıÚ¿˜ ÌÂ Û˘Ó·ÎfiÏÔ˘ıÔ Ù· ÎÚÔ‡ÛÌ·Ù· Û˘ÁÁÂÓÔ‡˜ ÂÚ˘ıÚ¿˜ ‹ Ù· ÎÚÔ‡ÛÌ·Ù· ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ Ô˘ ÂÚÈÁÚ¿ÊËÎ·Ó ÚÔ ÂÙÒÓ). ∞ÎfiÌË, Ô ÂÏÏËÓÈÎfi˜ È·ÙÚÈÎfi˜ Ù‡Ô˜ ı· Û˘Ì‚¿ÏÂÈ ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ÂÏÏËÓÈ΋˜ È·ÙÚÈ΋˜ ÔÚÔÏÔÁ›·˜ Î·È ı· Âηȉ‡ÛÂÈ ÙÔ˘˜ Ó¤Ô˘˜ ŒÏÏËÓ˜ È·ÙÚÔ‡˜ ÛÙËÓ ÔÚı‹ Û‡ÓÙ·ÍË ÂÓfi˜ ÂÈÛÙËÌÔÓÈÎÔ‡ ÎÂÈ̤ÓÔ˘. ∆¤ÏÔ˜, ÔÈ ÂΉfiÛÂȘ ÙˆÓ ÙÔ̤ˆÓ ÀÁ›·˜ ÙˆÓ ∞∂π, ÂÎÙfi˜ ·fi ÙȘ ηı·Ú¿ ÂÈÛÙËÌÔÓÈΤ˜ ÏËÚÔÊÔڛ˜, ÂÎÊÚ¿˙Ô˘Ó ÙÔ Ó‡̷ Ù˘ ·Î·‰ËÌ·˚΋˜ È·ÙÚÈ΋˜ Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ÚÔ‚Ï‹Ì·Ù· Ù˘ È·ÙÚÈ΋˜ Âη›‰Â˘Û˘ ÛÙË ¯ÒÚ· Ì·˜ (Ù· ÔÔ›·, ·ÛÊ·ÏÒ˜, Â›Ó·È ‰È·ÊÔÚÂÙÈο ·fi ÂΛӷ ÙˆÓ ¿ÏÏˆÓ ¯ˆÚÒÓ) (5).
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°È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ú¤ÂÈ fiÏÔÈ Ó· ÚÔÛ·ı‹ÛÔ˘Ì ӷ ·Ó·‚·ıÌ›ÛÔ˘Ì ÙÔÓ ÂÏÏËÓÈÎfi È·ÙÚÈÎfi Ù‡Ô. ¶ÈÛÙ‡ˆ fiÙÈ Ì›· ·fi ÙȘ ÈÔ ÛËÌ·ÓÙÈΤ˜ ÚÔÛ¿ıÂȘ Â›Ó·È Ó· ‰È·‚¿˙Ô˘Ì ٷ ·ÍÈfiÏÔÁ· ÂÏÏËÓÈο È·ÙÚÈο ÂÚÈÔ‰Èο Î·È Ó· ·Ó·Ê¤ÚÔ˘Ì ÛÙ· ¿ÚıÚ· Ì·˜ ÙȘ ‰ËÌÔÛȇÛÂȘ ∂ÏÏ‹ÓˆÓ Û˘Ó·‰¤ÏʈÓ. ∏ ·Ó·ÁÚ·Ê‹ ÛÙȘ ÂÚÁ·Û›Â˜ Ì·˜ ÂÓfi˜ ηٷÏfiÁÔ˘ Ô˘ ÂÚȤ¯ÂÈ ÌfiÓÔ Í¤Ó˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜, ÂÎÙfi˜ ÙÔ˘ fiÙÈ ‰Â›¯ÓÂÈ ·¯·Ú·ÎÙ‹ÚÈÛÙË ÂÚÈÊÚfiÓËÛË ÚÔ˜ ÙÔ˘˜ ŒÏÏËÓ˜ È·ÙÚÔ‡˜ Ô˘ ¤¯Ô˘Ó ·Û¯ÔÏËı› Ì ÙÔ ı¤Ì·, ·ÔÙÂÏ› Î·È ¤ÎÊÚ·ÛË ··Ú¿‰ÂÎÙ˘ ÍÂÓÔÏ·ÙÚ›·˜ Î·È ÛÔ˘ÛÔ˘‰ÈÛÌÔ‡. £· ÚfiÙÂÈÓ· ÔÈ Û˘ÓÙ·ÎÙÈΤ˜ ÂÈÙÚÔ¤˜ ÙˆÓ ÂÏÏËÓÈÎÒÓ ‚ÈÔ˚·ÙÚÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ Ó· ·Û¯ÔÏËıÔ‡Ó Ì ÙÔ ı¤Ì· Î·È ›Ûˆ˜ Ì›· Û˘Ó¿ÓÙËÛË ÙˆÓ ÂÈÙÚÔÒÓ ·˘ÙÒÓ ı· ‹Ù·Ó ¯Ú‹ÛÈÌË. ªÂ ÂÎÙ›ÌËÛË ¢ËÌ. ∞Ó·ÁÓˆÛÙ¿Î˘ ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¡ÂÔÁÓÔÏÔÁ›·˜ µÈ‚ÏÈÔÁÚ·Ê›· 1. 2. 3. 4. 5.
µ·Ï¿ÛË-∞‰¿Ì ∂. ∂‡ÊÔÚË ÁË ÚÔ˜ ÂÓÙ·ÙÈ΋ ηÏÏȤÚÁÂÈ·. ¶·È‰È·ÙÚÈ΋ 1999;62:92-94. ªÔ˘ÓÙÔηϿ΢ £. O ÂÏÏËÓÈÎfi˜ È·ÙÚÈÎfi˜ Ù‡Ô˜ Û ÎÚ›ÛÈÌË Î·Ì‹. π·ÙÚÈ΋ 1999;76:19-20. πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡. πƒπ™ µ¿ÛË ÂÏÏËÓÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÁÈ· ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡. ¶·È‰È·ÙÚÈ΋ 1999;62:247. ™¿ÌÈÔ˜ µ, ∞¿ÎË ∫. ∏ ¯ÚfiÓÈ· ΢ÎÏÔÊÔÚȷ΋ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ÂÚÈÔ‰ÈÎÔ‡ È·ÙÚÈÎÔ‡ Ù‡Ô˘. π·ÙÚÈ΋ 1985;48:60-61. ∞Ó·ÁÓˆÛÙ¿Î˘ ¢. ™Î¤„ÂȘ ¿Óˆ ÛÙÔÓ ÂÏÏËÓÈÎfi È·ÙÚÈÎfi Ù‡Ô. ¢ÂÏÙ›Ô ∞’ ¶·‰È·ÙÚ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1999;46:185-187.
∏ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ˘ÈÔıÂÙ› ÔÌfiʈӷ ÙËÓ ÚfiÙ·ÛË Ì ÙËÓ ÂÈÛÙÔÏ‹ ÙÔ˘ ÎÔ˘ ¢. ∞Ó·ÁÓˆÛÙ¿ÎË Î·È Û˘ÓÈÛÙ¿ ÛÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ˘¿Ú¯Ô˘Û· ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·. °È· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ O ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫·ıËÁËÙ‹˜ ™Ù·‡ÚÔ˜ ∞. ÷˚‰¿˜
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¶PO™EXH ™YNE¢PIA
8-9 ¡ÔÂÌ‚Ú›Ô˘ 2003
ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ¶·È‰È·ÙÚÈ΋˜ ∞ı‹Ó· ∞›ıÔ˘Û· £Â¿ÙÚÔ˘ ∫ÔÏÏÂÁ›Ô˘ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” ∆ËÏ.: 210-77 93 000 Fax: 210-77 74 383
8-11 ¡ÔÂÌ‚Ú›Ô˘ 2003
8th World Congress for Infectious and Immunological Diseases in Obstetrics and Gynaecology ¶ÏËÚÔÊÔڛ˜: Key Congressi Tel.: 39-040-660-352 Fax: 39-040-660-353 E-mail: venice2003@keycongressi.it
Venice, Italy
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·
2-5 ¢ÂÎÂÌ‚Ú›Ô˘ 2003
1st International Congress on Pulmonary Diseases, Intensive Care and Tuberculosis ¶ÏËÚÔÊÔڛ˜: Shaheed Bahonar Ave Darabad, Tehran 19569, Iran or P.O. Box : 19575/154-Tehran, Iran Tel.: 98-212-803-563 / 22-82-111 Fax: 98-2-803-565 / 22-85-777 E-mail: fic@nritld.ac.ir
Tehran, Iran
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
28 ºÂ‚ÚÔ˘·Ú›Ô˘2 ª·ÚÙ›Ô˘ 2004
6th International Congress on Pediatric Pulmonology ¶ÏËÚÔÊÔڛ˜: Annie Bidart Tel.: 33-0-497-038-597 Fax: 33-0-497-038-598 E-mail: cipp@cipp-meeting.com
Lisbon, Portugal
xi
¶PO™EXH ™YNE¢PIA
23-25 ∞ÚÈÏ›Ô˘ 2004
16Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ “¶·È‰› Î·È ∞ıÏËÙÈÛÌfi˜” ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: ∂‡Ë ∞Ù˙¤ÌË, ÃÚ‡Û· ª·˘Ú›‰Ô˘ Tel.: 22410-99101 Website: www.socped.gr
ƒfi‰Ô˜
27 ∞ÚÈÏ›Ô˘1 ª·˝Ô˘ 2004
30Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô Hilton ¶ÏËÚÔÊÔڛ˜: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ ∆ËÏ.: 210-72 11 845 Fax: 210-72 15 082 E-mail: iea@mednet.gr
∞ı‹Ó·
6-8 ª·˝Ô˘ 2004
2nd International Congress on Adult Consequences of Childhood Endocrine Diseases ¶ÏËÚÔÊÔڛ˜: ÕÓÓ· °È·Ï·ÓÙ˙‹ Tel.: (0030) 2310-447.444 Fax: (0030) 2310-447.444 & 2310-282476 E-mail: info@ghsociety.gr Website: www.ghsociety.gr
∞ı‹Ó·
6-9 πÔ˘Ó›Ô˘ 2004
7Ô ¶·ÁÎfiÛÌÈÔ ™˘Ó¤‰ÚÈÔ ÁÈ· ÙËÓ ¶ÚfiÏË„Ë ∞Ù˘¯ËÌ¿ÙˆÓ Î·È ÙËÓ ¶ÚÔ·ÁˆÁ‹ ÀÁ›·˜/∞ÛÊ¿ÏÂÈ·˜ ¶ÏËÚÔÊÔڛ˜: ∫∂¶¶∞ ∆ËÏ.: 210-74 62 187 & 74 62 201 Fax: 210-74 62 105 Website: www.safety2004.info
Vienna, Austria
10-13 πÔ˘Ó›Ô˘ 2004
9th Congress of the European Hematology Association ¶ÏËÚÔÊÔڛ˜: Eurocongres Conference Management ∆el.: +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