Παιδιατρική | Τόμος 67 • Τεύχος 5 • Σεπτέμβριος - Οκτώβριος 2004

COVER September October 04

18-11-04

15:21

™ÂÏ›‰·1

ISSN 0377-2551

¶AI¢IATPIKH

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TOMO™ 67

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TEYXO™ 5

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ETO™ 2004

™   Ù ¤ Ì ‚ Ú ÈÔ˜ - √ Î Ù Ò ‚ Ú È Ô ˜ 200 4 ñ ∆fiÌÔ˜ 6 7 ñ ∆‡¯Ô˜ 5

∞¡∞™∫O¶∏™∂π™ º·ÈÓfiÙ˘ÔÈ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÚfiÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË

REVIEW ARTICLES 301

ª. ªÔ˘ÛÙ¿ÎË

¶·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ¡¤· ÂÈÙ‡ÁÌ·Ù· ÛÙÔÓ ÙÔ̤· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡

M. Moustaki 310

°. ª·ÚÔ‡Ù˘, ª. ¢·ÛÔÔ‡ÏÔ˘

∂ÁÎÔÏ·ÛÌfi˜: ¤Ó· ÁÓˆÛÙfi ÓfiÛËÌ· Ì ·Ó·Óˆ̤ÓÔ ÂӉȷʤÚÔÓ

Pathophysiological mechanisms involved in the pathogenesis of ventilation associated lung trauma. New strategies in mechanical ventilation G. Baroutis, M. Dasopoulou

321

∂. ª. ∫·ÏËÌÂÚ¿ÎË, ¢. ∞. ∫·ÊÂÙ˙‹˜

H ÛËÌ·Û›· ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÙˆÓ Ô‡ÚˆÓ ÛÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ·ı‹ÛÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜

Asthma phenotypes in preschool children. Risk factors, prognosis and management

Intussusception: new interest in a common disease I. M. Kalimeraki, D. A. Kafetzis

328

The importance of urine electrolyte determination in the investigation of children with renal diseases

∂. °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË

H. Georgaki-Angelaki

µƒ∞µ∂Àª∂¡∏ ∂ƒ°∞™π∞

AWARD-WINNING ARTICLE

336 ∂›‰Ú·ÛË ÂȉÈÎÔ‡ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ Î·È ÛÙ¿ıÌÈÛË ˘ËÚÂÛÈÒÓ ˘Á›·˜ Û ·È‰È·ÙÚÈÎfi ÙÌ‹Ì·

The impact of an informative leaflet on the behaviour of hospitalized children and the quality of care-giving in a paediatric department

£. ¶·¿˙ÔÁÏÔ˘, ∂. ™Ô˘Ú¤ÏË, ª. ∫·Ú·Ì·ÙÛ¿ÎË, ¶. ¢ÂÚÌÈÙ˙¿ÎË, ∞. ∫Ô˘ÊÔÔ‡ÏÔ˘, ª. ÷Ù˙Ë„¿ÏÙË, ª. ∑‹‚·-¶ÂÙÚÔÔ‡ÏÔ˘, ™. ¶··‰¿ÎÔ˘-§·ÁÔÁÈ¿ÓÓË

T. Papazoglou, E. Soureli, M. Karabatsaki, P. Dermitzaki, A. Koufopoulou, M. Hatzipsalti, M. Ziva-Petropoulou, S. Papadakou-Lagogianni

∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙË ÓÂÔÁÓÈ΋ Û‹„Ë ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· µ. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, Ã. ¡Ô‡ÙÛÈ·, Ã. ∞Á·Î›‰Ë˜, ¶. ¶··Î˘ÚȷΛ‰Ô˘-∫ÔÏÈÔ‡Ûη, ª. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜

∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·

ORIGINAL ARTICLES 343

Ciprofloxacin treatment for neonatal sepsis due to multi-resistant Gram-negative bacteria V. Drossou-Agakidou, C. Noutsia, C. Agakidis, P. Papakyriakidou-Koliouska, M. Tsivitanidou, G. Kremenopoulos

Continuation of table of contents inside title page

Greek Paediatric Society S e p t e m b e r - October 200 4 ñ V o l u m e 6 7 ñ No 5

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™   Ù ¤ Ì ‚ Ú È Ô ˜ - √ Î Ù Ò ‚ Ú È Ô ˜ 200 4 ñ ∆fiÌÔ˜ 6 7 ñ ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

¶·Ú·ÎÔÏÔ‡ıËÛË ÚˆÙÔ·ıÔ‡˜ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û 182 ·È‰È¿: ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ¤Î‚·ÛË

Continuation of table of contents

349

F. Papachristou, N. Printza, N. Karatzas

º. ¶··¯Ú‹ÛÙÔ˘, ¡. ¶Ú›ÓÙ˙·, ¡. ∫·Ú·Ù˙¿˜

CASE REPORTS

EN¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ ¢ÈÂÈÛ‰˘ÙÈ΋ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ Û ‚Ú¤ÊÔ˜ 4 Ë̤Ú˜ ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ¤Ó·ÓÙÈ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÌ¿‰·˜ C. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘

355

359

Hellenic Paediatric Society

363

CURRENT ISSUE

∂¶π∫∞πƒO £∂ª∞

¢. ∆Ûԇ̷˜, µ. ™Ô‡ÏÔ˘

Relapsing bleeding in a thirteen year-old child with type I intestinal atresia S. Stefanaki, T. Tsekoura, A. Schinaki, D. Keramidas, A. Tsilimigaki

™. ™ÙÂÊ·Ó¿ÎË, £. ∆ÛÂÎÔ˘Ú¿, ∞. ™¯ÔÈÓ¿ÎË, ¢. ∫ÂÚ·Ì›‰·˜, ∞. ∆ÛÈÏÈÌÈÁοÎË

∏ Û˘Ì‚ÔÏ‹ ÙÔ˘ Û˘˙¢Á̤ÓÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒ͈Ó

A neonate with ring chromosome 14 [r(14)] A. Galla-Voumvouraki, S. Kitsiou-Tzeli, A. Kolialexi, A. Mavrou, I. Giannatou, N. Iakovidou, A. Fretzagias, H. Georgouli, A. Patsoura, N. Spyridis, A. Constantopoulos

∞. °·ÏÏ¿-µÔ˘Ì‚Ô˘Ú¿ÎË, ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË, ∞. ∫ÔÏȷϤÍË, ∞. ª·‡ÚÔ˘, ∂. °È·ÓÓ¿ÙÔ˘, ¡. π·Îˆ‚›‰Ô˘, ∞. ºÚÂÙ˙¿ÁÈ·˜, ∂. °ÂˆÚÁÔ‡ÏË, ∞. ¶·ÙÛÔ‡Ú·, ¡. ™˘Ú›‰Ë˜, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜

ÀÔÙÚÔÈ¿˙Ô˘Û· ·ÈÌÔÚÚ·Á›· Û ·È‰› ‰ÂηÙÚÈÒÓ ÂÙÒÓ Ì ·ÙÚËÛ›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ù‡Ô˘ π

Invasive meningococcal disease in an infant 4 days after vaccination with serogroup C meningococcal conjugate vaccine.

A case report V. Tsagris, H. Papadea, S. Kyriakis, M. Vasiliadis, F. Tzifi, A. Kitsopoulou, D. Drakos

µ. ∆Û·ÁÚ‹˜, ∏. ¶··‰¤·, ™. ∫˘ÚÈ¿Î˘, ª. µ·ÛÈÏÂÈ¿‰Ë˜, º. ∆˙ÈÊ‹, ∞. ∫ÈÙÛÔÔ‡ÏÔ˘, ¢. ¢Ú¿ÎÔ˜

¡ÂÔÁÓfi Ì ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 [r(14)]

Follow-up of primary vesicoureteral reflux in 182 children: characteristics and outcome

The contribution of conjugated Hellenic Paediatric Society pneumococcal vaccine to the prevention

367

of pneumococcal infection D. Tsoumas, V. Spoulou

Greek Paediatric Society ™˘Ó¯›˙ÔÓÙ·È

Continued

Greek Paediatric Society S e p t e m b e r - O c t o b e r 200 4 ñ V o l u m e 6 7 ñ No 5

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™   Ù ¤ Ì ‚ Ú È Ô ˜ - √ Î Ù Ò ‚ Ú È Ô ˜ 200 4 ñ ∆fiÌÔ˜ 6 7 ñ ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

Continuation of table of contents

¡∂∞

371

NEWS

¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO

373

NEWS FROM THE INTERNET

¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·

xiii

Scheduled Medical Meetings

™˘ÓÙÔÌÔÁڷʛ˜

xix

Abbreviations

Hellenic Paediatric Society

Hellenic Paediatric Society

Greek Paediatric Society

Greek Paediatric Society S e p t e m b e r - O c t o b e r 200 4 ñ V o l u m e 6 7 ñ No 5

September-October 05 chris

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™ Â  Ù ¤ Ì ‚ Ú È Ô ˜ - √ Î Ù Ò ‚ Ú È Ô ˜ 200 4 ñ ∆ fi Ì Ô ˜ 6 7 ñ ∆ Â ‡ ¯ Ô ˜ 5

¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜

Bimonthly Publication The Official Journal of the Greek Paediatric Society

EΉfiÙ˘ K. °ÚÈ‚¤·˜

Publisher K. Griveas

I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28

Owner Greek 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

EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ : ™. ÷˚‰¿˜ ∞Ó·Ï. ¢È¢ı. ™‡ÓÙ·Í˘ : ∫. ™ÙÂÊ·Ó›‰Ë˜ M¤ÏË : ∂. ∞ÓÙˆÓÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë Ã. ∫ÒÛÙ·ÏÔ˜ °. ªÚÈ·ÛÔ‡Ï˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ¶··‰ÔÔ‡ÏÔ˘ ª. ∆ÛÔÏÈ¿-¶·Û·Ú¿ÎË

Scientific Editorial Board President : A. Constantopoulos Editor : S. Haidas Assistant Editor : C. Stefanidis Members : H. Antonopoulou A. Vazeou-Gerasimidi G. Varlamis ∂. Katsarou-Pectasides Greek Paediatric Society Ch. Costalos Greek Paediatric Society G. Briasoulis N. Papadopoulos ∞. Papadopoulou M. Tsolia-Pasparaki

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘

Manuscript Editing

EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘

English Editing S. Nakou

∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: 210 7771 140 / 210 7771 663, Fax: 210 7758 354

Correspondence Greek Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 210 7771 140 / 210 7771 663, Fax: 210 7758 354

™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜

Publishing Coordinator

Hellenic Paediatric Society

Hellenic Paediatric Society

E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ∞ÚÙ¤ÌȉԘ 3, 151 25 M·ÚÔ‡ÛÈ TËÏ.: 210 87 78 810 Fax: 210 87 78 822

EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹ EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜:

40 € 20 €

Greek Editing I. Karavranou

SCIENTIFIC PUBLICATIONS Ltd Artemidos 3, Marousi Hellenic Paediatric Society 151 25 Tel.: 210 87 78 810 Fax: 210 87 78 822

Annual Subscription All foreign countries: US $ 50

Greek Paediatric Society September - October 2004 ñ Volume 67 ñ No 5

πSSN 0377-2551 ∫ø¢π∫O™ ¢π∂À£À¡™∏™ ∂¶O¶∆∂π∞™ ªª∂: 3889

i

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O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤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‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜).

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· ÂÎ·›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜.

8. ∫ÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ.

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 ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 14. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜.

H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ Î·ıÒ˜ Î·È ¿ÚıÚ· Ì Â›Î·ÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› 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 ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì Â›Î·ÈÚ· 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˘. ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ÌËÓ ¤¯Ô˘Ó ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi. ∂ÈϤÔÓ, ÛÙËÓ ÂÚÁ·Û›· ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. E›Û˘ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏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˘˜ ÂÈÙÚ¤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), ÔÈ Ôԛ˜ ÙÚÔÔÔÈ‹ıËÎ·Ó ÚfiÛÊ·Ù· Î·È ‰ËÌÔÛȇÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.

µ. ÀÔ‚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 ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ‰ÈÛΤٷ ‹ CD, ηıÒ˜ Î·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· 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΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢.

EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘ԉ›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ ‹ CD Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word, ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ.

H ηı˘ÛÙ¤ÚËÛË Ù˘ Â·Ó˘Ô‚ÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘ÓÂ¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹.

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 ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·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˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (21x29.7 cm) Ì ‰ÈÏfi ‰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 ÂȉÔÙ‹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·

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™ÂÏ›‰·12

·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˜ ÂÚÈÙÒÛÂȘ Û 1500-2500 ϤÍÂȘ. Á. ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ‰. ÙȘ ÂÈÛÙÔϤ˜ 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 ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ 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 ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›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˘ÌÂÚ¿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˘ÌÂÚ¿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˘ÌÂÚ¿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˜ ÂÚÈÙÒÛÂȘ ¤¯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· ¯ÚËÛÈÌÔÔÈËıÔ‡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·ÔÌ¤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ì ÏÂÙÔ̤ÚÂȘ 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˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ.

vi

OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ 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 ÂȉÔÙ‹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·ÔÌ¤˜.

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 ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›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·ÔÌ¤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË.

OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· Â›Î·ÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÛÙȘ ÂÈÛÙÔϤ˜.

H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù· ÙÚÔÔÔÈË̤Ó˜ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals, (http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf). 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/bsd/uniform_requirements.html)]. ¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶∂ƒπO¢π∫∞ AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ 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·: Â›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· 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.

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™˘ÌÏËڈ̷ÙÈÎfi 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˘: ÷ڷϷÌ›‰Ë˜ π, ¶··‰fiÔ˘ÏÔ˜ ∞. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·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. µπµ§π∞ ∫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 2931; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã. ∏ ıÂÚ·›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡. [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979.

Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. πππ. CD-ROM Anderson SC, Poulsen KB. Anderson’s electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002.

IV. ™∆O ¢π∞¢π∫∆ÀO ÕÚıÚÔ Û ÂÚÈÔ‰ÈÎfi Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am J Nurs [ÛÙÔ

Internet]. 2002 Jun: ™ÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.nursingworld.org/AJN/2002/june/Wawatch.htm ªÔÓÔÁÚ·Ê›· Foley KM, Gelband H, editors. Improving palliative care for cancer [MoÓÔÁÚ·Ê›· ÛÙÔ Internet]. Washington: National Academy Press; 2001. ™ÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.nap.edu/books/0309074029/html πÛÙÔÛÂÏ›‰Â˜ Cancer-Pain.org [πÛÙÔÛÂÏ›‰· ÛÙÔ Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancer-pain.org/

¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡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 ÂÂÍ‹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 ÔÔ›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. 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜.

2. ¢ÈÛΤٷ ‹ CD Ì fiÏÔ ÙÔ ˘ÏÈÎfi Ù˘ ÂÚÁ·Û›·˜ (ΛÌÂÓÔ, ›Ó·Î˜, ÂÈÎfiÓ˜).

3. ∂ÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ Î·È ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜.

4. ™ÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂÚÈÏ·Ì‚¿ÓÂÈ: ·. Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜, ‚.fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›·, ‰. fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·.

5. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·, ηıÒ˜ Î·È Ï¤ÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·).

6. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·).

7. ∫›ÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·).

8. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢).

9. µÈ‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·).

10. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.

11. ∂ÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· Â¿Óˆ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó.

12. ∆›ÙÏÔ˘˜ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.

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∞¡∞™∫O¶∏™∏

Paediatriki 2004;67:301-309

REVIEW ARTICLE

º·ÈÓfiÙ˘ÔÈ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÚfiÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ª. ªÔ˘ÛÙ¿ÎË

Asthma phenotypes in preschool children.

Risk factors, prognosis and management M. Moustaki

¶ÂÚ›ÏË„Ë: ∆Ô ¿ÛıÌ· ÙˆÓ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ‰È·Ê¤ÚÂÈ ˆ˜ ÚÔ˜ ÙÔÓ Ê·ÈÓfiÙ˘Ô, ÙËÓ ÚfiÁÓˆÛË Î·È ÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·fi ÙÔ ¿ÛıÌ· ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ. ∆ÚÂȘ Ê·ÈÓfiÙ˘ÔÈ Ù˘ ÓfiÛÔ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜: ·) ∂ÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡, ÚÒÈÌ˘ ¤Ó·Ú͢, Ì ÂÎÏ˘ÙÈÎfi ·›ÙÈÔ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÌÂÛԉȷÛÙ‹Ì·Ù· ÂχıÂÚ· Û˘ÌÙˆÌ¿ÙˆÓ Î·È ‡ÊÂÛË ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ. ∏ ÚԉȿıÂÛË ·Ô‰›‰ÂÙ·È ÛÙÔ ÌÈÎÚfiÙÂÚÔ Ì¤ÁÂıÔ˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ, ·fi ÙË Á¤ÓÓËÛË. ‚) ªË ·ÙÔÈο ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡, Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙˆÓ ÔÔ›ˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‡ÊÂÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 11-12 ÂÙÒÓ. ∆Ô ÈÛÙÔÚÈÎfi Ì RSV ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·ÔÙÂÏ› ÙÔÓ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÔÌ¿‰· ·˘Ù‹. Á) ∞ÙÔÈο ·È‰È¿ Ì ÚÔԉ¢ÙÈο ÂÍÂÏÈÛÛfiÌÂÓË ÓfiÛÔ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ˘ÔÏÂÈfiÌÂÓË ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ËÏÈΛ· 11-12 ÂÙÒÓ. ™ÙËÓ ÔÌ¿‰· ·˘Ù‹, Ë ¤Ó·ÚÍË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 3 ÂÙÒÓ Û˘Ó‰˘¿˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ÌÂÁ·Ï‡ÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ ¿ÛıÌ·. £ÂÚ·¢ÙÈο, ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘Ìو̿وÓ, ÂÓÒ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ ¯ÔÚËÁÂ›Ù·È Û ·È‰È¿ Ì Â›ÌÔÓÔ ¿ÛıÌ·. ∆Ô Â›‰Ô˜ Î·È Ë ‰ÔÛÔÏÔÁ›· Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÁˆÁ‹˜ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ ÛÙ¿‰ÈÔ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘. ¶ÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹ ‰ÂÓ ··ÈÙÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‰È·Ï›ÔÓÙÔ˜ ¿ÛıÌ·ÙÔ˜.

Abstract: Asthma in preschool children is different from that observed in older children regarding the phenotypes, prognosis and management. Three distinct asthma phenotypes have been identified in preschool children: a) Children with transient early wheezing induced by viral respiratory infections. Wheezing resolves by the age of 3 years. The susceptibility of this group is attributed to smaller airway size at birth. b) Non atopic wheezers who also experience viral induced wheezing episodes but continue to wheeze at 6 years of age. A history of RSV-bronchiolitis is the main risk factor for this phenotype. c) Atopic persistent wheezers, with progressive lung disease characterized by decreased pulmonary function at 6 and 11 years of age. πn atopic wheezers, the early onset of symptoms before the age of 3 years is associated with increased disease severity.

Bronchodilators are used only as relievers of the acute symptoms. Controller anti-inflammatory therapy is recommended for persistent asthma, following a stepwise approach dependent on the disease severity. Controller medications are not required for the majority of children with intermittent asthma.

§¤ÍÂȘ ÎÏÂȉȿ: ¿ÛıÌ·, ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, Û˘ÚÈÁÌfi˜, Ê·ÈÓfiÙ˘Ô˜.

Key words: asthma, phenotype, preschool children, wheezing.

∂ÈÛ·ÁˆÁ‹ ∆Ô ¿ÛıÌ· ·ÔÙÂÏ› Û˘¯Ófi ÓfiÛËÌ· ÙˆÓ ·È‰ÈÒÓ, Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·

(1). O ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Ë ‚·Ú‡ÙËÙ¿ ÙÔ˘ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜. ªÂ ‚¿ÛË ÙË ÌÂϤÙË ISAAC (International Study of

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

2nd Paediatric Clinic of the University of Athens “P. & A. Kyriakou” Children’s Hospital, Athens

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Asthma and Allergies in Childhood), ÛÙËÓ ÔÔ›· Ô ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Â›Ó·È ÈÛÔ‰‡Ó·ÌÔ˜ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡, Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ÓfiÛÔ˘ ÛÙË ¯ÒÚ· Ì·˜ Â›Ó·È ·fi ÙÔ˘˜ ¯·ÌËÏfiÙÂÚÔ˘˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ ÛÙËÓ ∂˘ÚÒË fiÛÔ Î·È ‰ÈÂıÓÒ˜ (2). ¶·Ú¿ Ù·‡Ù·, ‰ÂÓ ·‡ÂÈ Ó· ·ÔÙÂÏ› Û˘¯Ófi Úfi‚ÏËÌ· Î·È ÛÙËÓ ∂ÏÏ¿‰·, ηıÒ˜ - Ì ‚¿ÛË Ù· ÛÙÔȯ›· Ù˘ ‰Â‡ÙÂÚ˘ Ê¿Û˘ Ù˘ ›‰È·˜ ÌÂϤÙ˘ (3) - Ë Û˘¯ÓfiÙËÙ· ÂÓÂÚÁÔ‡ ¿ÛıÌ·ÙÔ˜ (Û˘ÚÈÁÌfi˜ ηٿ ÙÔ ÙÂÏÂ˘Ù·›Ô ¤ÙÔ˜) ÛÙ· ∂ÏÏËÓfiÔ˘Ï· ËÏÈΛ·˜ 10-11 ÂÙÒÓ ·Ó¤Ú¯ÂÙ·È Û 11%. ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ Â›Ó·È ‰ÈÂıÓÒ˜ Ôχ ˘„ËÏfiÙÂÚË ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÁÂÁÔÓfi˜ Ô˘ ÂȂ‚·ÈÒÓÂÙ·È Î·È ·fi Ù· ÂÏÏËÓÈο ‰Â‰Ô̤ӷ, ηıÒ˜ ÈÛÙÔÚÈÎfi ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ ‰È·ÈÛÙÒıËΠ۠25% ÙˆÓ ∂ÏÏËÓÔ·›‰ˆÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ (3). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ηıÈÛÙ¿ ۷ʤ˜ fiÙÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ı· ÂÌÊ·Ó›ÛÂÈ ‡ÊÂÛË Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ηÈ, ÂÔ̤ӈ˜, ·Ó Î·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ¿ÛıÌ·, Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ ÚfiÁÓˆÛË. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ù· ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ¿ÛıÌ· Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÂÚ›Ô‰Ô˜ ηٿ ÙËÓ ÔÔ›· Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Â›Ó·È ·˘ÍË̤ÓË, ÂÓÒ Ë ÓfiÛÔ˜ ‰ÂÓ ·ÔÙÂÏ› Ê·ÈÓÔÙ˘Èο ÔÌÔÁÂÓ‹ ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· (1,4). ªÂÙ¿ ÙÔ 1970, ‰È·ÈÛÙÒıËΠ۠ÚÔ‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ fiÙÈ ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi ˆ˜ ¿Û¯ÔÓÙ· ·fi ¿ÛıÌ· ‹ ‚ÚÔÁ¯›Ùȉ·. ∏ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜, ˆÛÙfiÛÔ, ¤‰ÂÈÍ fiÙÈ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ·ÏÏËÏÔÂÈÎ¿Ï˘„Ë ÙˆÓ ‰‡Ô ÎÏÈÓÈÎÒÓ ÔÓÙÔًوÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ Î·È ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›· (5-7). ∞ÔÙ¤ÏÂÛÌ· ·˘ÙÒÓ ÙˆÓ ·Ú·ÙËÚ‹ÛÂˆÓ ‹Ù·Ó Ó· ‰È·ÌÔÚʈı› Ë ¿Ô„Ë fiÙÈ Ù· ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ¿Û¯Ô˘Ó Èı·ÓÒ˜ ·fi ¿ÛıÌ· Î·È ÌÔÚÔ‡Ó, ÂÔ̤ӈ˜, Ó· ˆÊÂÏËıÔ‡Ó ·fi ÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹. ∏ ·ÓÙ›ÏË„Ë ·˘Ù‹, ‰ËÏ·‰‹ Ë ÔÌÔÁÂÓÔÔ›ËÛË Ù˘ ‰È¿ÁÓˆÛ˘ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡, ›¯Â ˆ˜ ÛÎÔfi ÙËÓ ÔÚıfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ. ŒÙÛÈ, ÂÁηٷÏ›ÊıËÎÂ Ë ¿Ô„Ë Ô˘ ‰È·¯ÒÚÈ˙ ÙÔ ¿ÛıÌ· Î·È ÙË ‚ÚÔÁ¯›Ùȉ· (Û·ÛÙÈ΋ ‚ÚÔÁ¯›Ùȉ·) ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Ù· ıˆÚԇ۠ͯˆÚÈÛÙ¿ ÓÔÛ‹Ì·Ù·, Ë ÔÔ›· ‰È·Ù˘ÒıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔÓ 19Ô ·ÈÒÓ· (5). ∞fi ÙÔ 1990, Ë ÂÊ·ÚÌÔÁ‹ ‚ÚÔÁ¯ÔÛÎfiËÛ˘, ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋˜ ¤ÎÏ˘Û˘ Î·È ÂÓ‰Ô‚ÚÔÁ¯ÈÎÒÓ ‚ÈÔ„ÈÒÓ ¤‰ÂÈÍ fiÙÈ ÙÔ ¿ÛıÌ· Â›Ó·È ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜, ·ÎfiÌË Î·È Û ·ÛıÂÓ›˜ Ì ‹È· ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‹ ÚfiÛÊ·ÙË ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (8,9). OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ Ô‰‹ÁËÛ·Ó ÛÙËÓ ·Ó·ıÂÒÚËÛË ÙÔ˘ ÔÚÈ-

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ÛÌÔ‡ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Û ¯ÚfiÓÈ· ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó·ÛÙÚ¤„ÈÌË ·fiÊÚ·ÍË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ‚ÚÔÁ¯È΋ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· (10). ∏ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, fï˜, Ù˘ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È Û ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ·È‰ÈÒÓ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ηÈ, ·ÎÔÏÔ‡ıˆ˜, ·ÚÔ˘ÛÈ¿˙ÂÈ ‡ÊÂÛË Î·Ù¿ ÙË Û¯ÔÏÈ΋ ËÏÈΛ·. ∏ ÔÚ›· ·˘Ù‹ ¤¯ÂÈ ÂȂ‚·Èˆı› ·fi ÚÔ‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ·È‰ÈÒÓ ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (11-14). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÒÓ ÙˆÓ ÌÂÏÂÙÒÓ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¿Ô„Ë ˆ˜ Ù· ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ Èı·ÓÒ˜ ¤¯Ô˘Ó ¿ÛıÌ· ‰ÂÓ ÂȂ‚·ÈÒÓÂÙ·È ·fi ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ·Ó¿ÏÔÁ· ÂÂÈÛfi‰È·. ∆Ô 1998 ÚÔÙ¿ıËÎÂ, ·fi ÙËÓ ÙÚ›ÙË ‰ÈÂıÓ‹ ‰È¿ÛÎÂ„Ë ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ (15), Ó· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ¿ÛıÌ· Ù· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ‹ Î·È Â›ÌÔÓÔ˘ ‚‹¯· Û ÂÚÈ‚¿ÏÏÔÓ fiÔ˘ Â›Ó·È Èı·Ó‹ Ë ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜ Î·È ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÔÈ Û¿ÓȘ ηٷÛÙ¿ÛÂȘ ¤¯Ô˘Ó ·ÔÎÏÂÈÛÙ›. ∂Ô̤ӈ˜, Ë ·Ô˘Û›· ·ÙÔ›·˜ ‰˘Û¯ÂÚ·›ÓÂÈ ÙÔÓ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ÓfiÛÔ˘ ˆ˜ ¿ÛıÌ· Ì ÌfiÓÔ ‰Â‰Ô̤ÓÔ Ù· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡. ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ÛÙ·‰È·Î¿ ¢ÎÔÏfiÙÂÚ· Î·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô ÔÚÈÛÌfi˜ Ù˘ Global Initiative for Asthma (GINA), National Institutes of Health and National Heart, Lung and Blood Institute. ∆Ô ÚfiÁÚ·ÌÌ· Ù˘ GINA ÚÔÙ›ÓÂÈ ÙË ¯Ú‹ÛË ÙÔ˘ fiÚÔ˘ “¿ÛıÌ·” ÁÈ· fiϘ ÙȘ ÂÚÈÙÒÛÂȘ (10), ·Ó·ÁÓˆÚ›˙ÔÓÙ·˜, ˆÛÙfiÛÔ, ÙËÓ ‡·ÚÍË ‰È·ÊÔÚÂÙÈÎÒÓ Ê·ÈÓÔÙ‡ˆÓ Î·È ÚfiÁÓˆÛ˘ ·Ó¿ÏÔÁ· Ì ÙÔÓ Ê·ÈÓfiÙ˘Ô. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË 1246 ·È‰ÈÒÓ ·fi ÙË Á¤ÓÓËÛË (1980-1984) ̤¯ÚÈ Û‹ÌÂÚ·, ÛÙÔ Ï·›ÛÈÔ Ù˘ ÌÂϤÙ˘ Ù˘ Tuscon (4,11,16), ¤‰ÂÈÍ fiÙÈ ˘¿Ú¯Ô˘Ó ÙÚÂȘ ͯˆÚÈÛÙÔ› Ê·ÈÓfiÙ˘ÔÈ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ∏ ηٿٷÍË ·˘Ù‹ ·ÔÙÂÏ› Û‹ÌÂÚ· Ì›· ηÙ¢ı˘ÓÙ‹ÚÈ· ÁÚ·ÌÌ‹, Ê˘ÛÈο ˘fi ·ÍÈÔÏfiÁËÛË. ø˜ ·ÙÔ›· ıˆڋıËÎÂ Ë ·ÚÔ˘Û›· Ì›·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ ıÂÙÈ΋˜ ‰ÂÚÌ·ÙÈ΋˜ ‰ÔÎÈÌ·Û›·˜ (>2 mm) Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓÔ Û ËÏÈΛ· 6 ÂÙÒÓ. ·) ¶·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ Ù· 2-3 ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ·ÚfiÌÔÈ· ÂÂÈÛfi‰È· ÛÙË Û˘Ó¤¯ÂÈ·. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ 80% ÙˆÓ ‚ÚÂÊÒÓ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡, ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ Ì ·Ó¿ÏÔÁ· ÂÂÈÛfi‰È· ÙÔÓ ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ Î·È ÙÔ 30-40% ÙˆÓ ·È‰ÈÒÓ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ÙÔÓ ÙÚ›ÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙË Û˘Ó¤¯ÂÈ· ˘ÔÙÚÔ¤˜. ∏ ÂÎÙ¤ÏÂÛË ‰ÔÎÈÌ·ÛÈÒÓ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜

September-October 05 chris

18-11-04

15:18

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¶·È‰È·ÙÚÈ΋ 2004;67:301-309

ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Û ˘ÔÏËı˘ÛÌfi ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ¤‰ÂÈÍ fiÙÈ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË Î·ÙËÁÔÚ›· Â›Ó·È Ë ˘ÔÏÂÈfiÌÂÓË ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÚÈÓ ÙËÓ ÂÌÊ¿ÓÈÛË Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ηıÒ˜ Î·È ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË (11). ∞ÓÙ›ıÂÙ·, Ù· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi ÈÛÙÔÚÈÎfi ¿ÛıÌ·ÙÔ˜, Ù· Â›‰· IgE Î·È ËˆÛÈÓÔÊ›ÏˆÓ Î·È ÙÔ ÈÛÙÔÚÈÎfi ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Û ۇÁÎÚÈÛË Ì ÂΛӷ Ô˘ ‹Ù·Ó ÂχıÂÚ· ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ (11,16). ‚) ªË ·ÙÔÈο ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ Î·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ∏ ‰Â‡ÙÂÚË ÔÌ¿‰· ·È‰ÈÒÓ ÂΉËÏÒÓÂÈ ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ Î·È Î·Ù¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ ÌÂ Û˘ÚÈÁÌfi ηٿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ Â›Ó·È ÌË ·ÙÔÈο ·È‰È¿. ¶ÚÔËÁËı›۷ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ, ηıÒ˜ ·È‰È¿ Ì ·Ó¿ÏÔÁÔ ÈÛÙÔÚÈÎfi ¤¯Ô˘Ó ÙÚÈÏ¿ÛÈÔ ¤ˆ˜ ÂÓÙ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ ̤¯ÚÈ Î·È ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ (16,17). øÛÙfiÛÔ, ·˘Ùfi˜ Ô Î›Ó‰˘ÓÔ˜ ÌÂÈÒÓÂÙ·È ÛÙ·‰È·Î¿ ÛÙË Û˘Ó¤¯ÂÈ· Î·È ÂÍ·Ï›ÊÂÙ·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 13 ÂÙÒÓ.

OÈ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ·Ó·ÛÙÚ¤„ÈÌË ·fiÊÚ·ÍË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, Èı·ÓfiÓ ÏfiÁˆ ÙÚÔÔÔÈË̤Ó˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÙfiÓÔ˘ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ‰È·Ù·Ú·¯‹ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ‡ÊÂÛË Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. ¢ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·Ó ÚfiÎÂÈÙ·È ÁÈ· Û˘ÁÁÂÓ‹ ‰È·Ù·Ú·¯‹ ‹ ÁÈ· ÂÈÏÔ΋ Ù˘ ÚÔËÁËı›۷˜ Ïԛ̈͢ Ì ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi. Á) ∞ÙÔÈο ·È‰È¿ Ì ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ·ÙÔÈÎfi ¿ÛıÌ· ÂÌÊ·Ó›˙Ô˘Ó Ù· ÚÒÙ· Û˘ÌÙÒÌ·Ù· ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ∏ ηÙËÁÔÚ›· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ·È‰È¿ Ì ÚÒÈÌË (ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ) Î·È Ì fi„ÈÌË ¤Ó·ÚÍË Û˘ÌÙˆÌ¿ÙˆÓ (ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ·ÏÏ¿ ÚÈÓ Ù· 6 ¯ÚfiÓÈ· ˙ˆ‹˜). ∏ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·È‰ÈÒÓ Ì ÚÒÈÌË ¤Ó·ÚÍË Û˘ÌÙˆÌ¿ÙˆÓ ˘ÔÏ›ÂÙ·È Û ۯ¤ÛË Ì ÂΛÓË ÙˆÓ ·È‰ÈÒÓ Ì fi„ÈÌË ¤Ó·ÚÍË, Û‡Ìʈӷ Ì ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Û ËÏÈΛ· 6 Î·È 11 ÂÙÒÓ (16). ∂›Ó·È, ÂÔ̤ӈ˜, ۷ʤ˜ fiÙÈ ¤¯ÂÈ ÛËÌ·Û›· Ó· ·Ó·ÁÓˆÚÈÛÙ› Ë Î·ÙËÁÔÚ›· ÙˆÓ ·È‰ÈÒÓ Ì ÚÒÈÌÔ ·ÙÔÈÎfi ¿ÛıÌ·, Ù· ÔÔ›· ·Ó·Ì¤ÓÂÙ·È Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ¯ÚfiÓÈ· ÚÔ‚Ï‹Ì·Ù·. Œ¯Ô˘Ó Á›ÓÂÈ ·ÚÎÂÙ¤˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ‰ÂÈÎÙÒÓ Ô˘ ı· ‰È·¯ÒÚÈ˙·Ó ÙȘ ‰‡Ô ηÙËÁÔڛ˜ ·È‰ÈÒÓ. O ‰Â›ÎÙ˘ Ô˘ ¤¯ÂÈ ÚÔÙ·ı› ·fi ÙËÓ ›‰È· ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÚÔ¸Ôı¤ÙÂÈ Ù· ·ÎfiÏÔ˘ı· (18): ÂÂÈÛfi‰È· Û˘ÚÈÁ-

Paediatriki 2004;67:301-309

ÌÔ‡ ηٿ ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ¤ÙÔ˜ Î·È ¤Ó· ·fi Ù· ‰‡Ô Ì›˙ÔÓ· ÎÚÈÙ‹ÚÈ· (·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ‰È·ÁÓˆṲ̂ÓË ·fi È·ÙÚfi ‹ ¿ÛıÌ· ÂÓfi˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÎ ÙˆÓ ÁÔÓ¤ˆÓ ‰È·ÁÓˆṲ̂ÓÔ, Â›Û˘, ·fi È·ÙÚfi) ‹ ‰‡Ô ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ· (ˈÛÈÓÔÊÈÏ›· >4% ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, Û˘ÚÈÁÌfi ¯ˆÚ›˜ Û˘ÓÔ‰fi ÈÔÁÂÓ‹ Ïԛ̈ÍË, ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‰È·ÁÓˆṲ̂ÓË ·fi È·ÙÚfi). OÈ ÂÚ¢ÓËÙ¤˜ ‰È·›ÛÙˆÛ·Ó fiÙÈ ÂÚÈÛÛfiÙÂÚ· ·fi 75% ÙˆÓ ·È‰ÈÒÓ Ì ıÂÙÈÎfi ÙÔÓ ·Ú·¿Óˆ ‰Â›ÎÙË Â›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÂÂÈÛfi‰ÈÔ ¿ÛıÌ·ÙÔ˜ Û ËÏÈΛ· 6-13 ÂÙÒÓ, ÂÓÒ ÙÔ 68% ÙˆÓ ·È‰ÈÒÓ Ì ·ÚÓËÙÈÎfi ÙÔÓ ·Ú·¿Óˆ ‰Â›ÎÙË ‰ÂÓ ÂΉ‹ÏˆÛÂ Û˘Ìو̷ÙÔÏÔÁ›· ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ∞Ó¿ÏÔÁÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ Â›ÌÔÓ˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ ÚÔÙ¿ıËΠÚfiÛÊ·Ù· (19) Î·È ·fi ¿ÏÏË ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· Ô˘ ·Ú·ÎÔÏÔ‡ıËÛ ·È‰È¿ ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 10 ÂÙÒÓ ÛÙË ª. µÚÂÙ·Ó›·. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Û˘Ìو̷ÙÔÏÔÁ›· ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ Â›Ó·È: ·) ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ (ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ÂÙËÛ›ˆ˜), ‚) ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ¿ÛıÌ·ÙÔ˜ (¿ÛıÌ· ÁÔÓ¤ˆÓ ‹ ·‰ÂÏÊÔ‡), Á) Ë ıÂÙÈ΋ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· (≥3 mm) Û ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓÔ ‹ ÙÚÔÊÈÎfi ·ÏÏÂÚÁÈÔÁfiÓÔ Û ËÏÈΛ· 4 ÂÙÒÓ Î·È ‰) Ë ·Ô˘Û›· Û˘ÌÙˆÌ¿ÙˆÓ ÚÈÓÈ΋˜ Û˘ÌÊfiÚËÛ˘ ‹ ηٷÚÚÔ‹˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ∏ ·ÚÔ˘Û›· Î·È ÙˆÓ ÙÂÛÛ¿ÚˆÓ ·˘ÙÒÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÈÛÔ‰˘Ó·Ì› Ì 83% Èı·ÓfiÙËÙ· ÂÈÌÔÓ‹˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ, ÂÓÒ Ë ·Ô˘Û›· Î·È ÙˆÓ ÙÂÛÛ¿ÚˆÓ ·˘ÙÒÓ ·Ú·ÁfiÓÙˆÓ ÈÛÔ‰˘Ó·Ì› Ì 80% Èı·ÓfiÙËÙ· Ó· Â›Ó·È ·ÚÔ‰È΋ Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ Û˘ÚÈÁÌÔ‡ Î·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ‡ÊÂÛË ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ. ∆· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο Î·È ÛÙÔÓ ¶›Ó·Î· 1. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È ÚÔÛٷ٢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ¿ÛıÌ·ÙÔ˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi ∞ÙÔ›· ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ÚÔÙ·ı› Û˘ÁÎÂÎÚÈ̤ÓÔ˜ ‰Â›ÎÙ˘ ηÙËÁÔÚÈÔÔ›ËÛ˘ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘ÚÈÁÌÔ‡ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Ì ‚¿ÛË ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ·. ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÛÙËÓ ÔÈÎȷ΋ ÛÎfiÓË ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ¿ÛıÌ·ÙÔ˜ (20,21), ·Ó Î·È ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ¤ÎıÂÛË Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË Â˘·ÈÛıËÙÔÔ›ËÛË, fi¯È

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¶·È‰È·ÙÚÈ΋ 2004;67:301-309

Paediatriki 2004;67:301-309

¶›Ó·Î·˜ 1. ¶ÚÔÙÂÈÓfiÌÂÓÔÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ·ÚÔ˘Û›·˜ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ÕÛıÌ· Û ËÏÈΛ·

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£ÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·

>6 ÂÙÒÓ

ªÂ›˙ÔÓ· (ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·) ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· °ÔÓÂ˚Îfi ¿ÛıÌ· ‹ ∂Ï¿ÛÛÔÓ· (ÙÔ˘Ï¿¯ÈÛÙÔÓ 2) ∏ˆÛÈÓÔÊÈÏ›· ÛÙÔ ·›Ì· >4% ™˘ÚÈÁÌfi˜ ¯ˆÚ›˜ ÈÔÁÂÓ‹ Ïԛ̈ÍË ∞ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ·) ÀÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ ‚) OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ¿ÛıÌ·ÙÔ˜ (ÁÔÓ›˜ ‹ ·‰¤ÏÊÈ·) Á) ª›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ıÂÙÈ΋ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Û ËÏÈΛ· 4 ÂÙÒÓ ‰) ∞Ô˘Û›· ÚÈÓÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·Ù¿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·

>75% ÙˆÓ ·È‰ÈÒÓ Ì ¤Ó· Ì›˙ÔÓ ‹ ‰‡Ô ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·

>4 ÂÙÒÓ

fï˜ Î·È ÁÈ· ÂΉ‹ÏˆÛË ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ ‹ ¿ÛıÌ·ÙÔ˜ (23). º·›ÓÂÙ·È, Â›Û˘, fiÙÈ ÙÔ Â›‰Ô˜ ÙÔ˘ ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓÔ˘ Ô˘ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ, ηıÒ˜ ÛÙË ÌÂϤÙË Ù˘ Tuscon (16,24) ‰È·ÈÛÙÒıËΠfiÙÈ Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÛÙËÓ Alternaria Î·È fi¯È ÛÙËÓ ÔÈÎȷ΋ ÛÎfiÓË ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ù· ·ÙÔÈο ·È‰È¿ Ì ¿ÛıÌ·, ÁÂÁÔÓfi˜ Ô˘ ÂӉ¯Ô̤ӈ˜ ÂÚÌËÓ‡ÂÙ·È ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ¤ÎıÂÛ‹˜ ÙÔ˘˜. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ, Â›Û˘, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ‰Â‰Ô̤ӷ Ù˘ ÌÂϤÙ˘ ISAAC, fiÔ˘ Á›ÓÂÙ·È Ê·ÓÂÚfi fiÙÈ ¯ÒÚ˜ Ì ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ ·ÏÏÂÚÁÈ΋˜ ¢·ÈÛıËÙÔÔ›ËÛ˘ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙÔÓ ÂÈÔÏ·ÛÌfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi. ∂Ó‰ÂÈÎÙÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÂÓÒ Ë ∞Ï‚·Ó›· Î·È Ë ªÂÁ¿ÏË µÚÂÙ·Ó›· Â›Ó·È ÔÈ ¯ÒÚ˜ Ì ÙÔÓ ¯·ÌËÏfiÙÂÚÔ Î·È ˘„ËÏfiÙÂÚÔ, ·ÓÙ›ÛÙÔȯ·, ÂÈÔÏ·ÛÌfi ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ó¿ÏÔÁ˜ ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ¢·ÈÛıËÙÔÔ›ËÛ˘ Û ÂÈÛÓÂfiÌÂÓ· ·ÏÏÂÚÁÈÔÁfiÓ· (25). ŒÙÛÈ, ÙÔ ÔÛÔÛÙfi ¢·ÈÛıËÙÔÔ›ËÛ˘ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙËÓ ∞Ï‚·Ó›· Â›Ó·È 15% Î·È ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· 17,8%, ÂÓÒ Ë ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË ÛÙËÓ ∞Ï‚·Ó›· Â›Ó·È ÌfiÏȘ 0,8% Î·È ÛÙË ª. µÚÂÙ·Ó›· Â›Ó·È ÂÚ›Ô˘ ÂÙ·Ï¿ÛÈÔ (5,4%). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ ı¤ÙÔ˘Ó ÚÔ‚ÏËÌ·ÙÈÛÌfi, fiˆ˜ Û¯ÔÏÈ¿˙ÂÙ·È Î·È ÛÙÔ ÚfiÛÊ·ÙÔ ¿ÚıÚÔ ÙˆÓ Beasley Î·È Û˘Ó (26), ÁÈ· ÂӉ¯fiÌÂÓË ˘ÂÚÂÎÙ›ÌËÛË Ù˘ Û˘Û¯¤ÙÈÛ˘ ·ÙÔ›·˜ Î·È ¿ÛıÌ·ÙÔ˜. ∆›ıÂÙ·È Â‡ÏÔÁ· ÙÔ ÂÚÒÙËÌ· ÁÈ· ÙÔ ÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ηıÈÛÙÔ‡Ó ·ÛıÌ·ÙÈÎfi ¤Ó· ¿ÙÔÌÔ Â˘·ÈÛıËÙÔÔÈË̤ÓÔ Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· Î·È fi¯È ÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ÚÔηÏÔ‡Ó ÛÙÔ ¿ÙÔÌÔ ·ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË. O ·ԉȉfiÌÂÓÔ˜ ÛÙËÓ ·ÙÔ›· ΛӉ˘ÓÔ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ¿ÛıÌ·ÙÔ˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi ·Ó¤Ú¯ÂÙ·È Û 34%, fiÙ·Ó ˆ˜ ·ÙÔ›· ıˆÚÂ›Ù·È Ë ‰È·›ÛÙˆÛË ¤ÛÙˆ Î·È Ì›·˜ ıÂÙÈ΋˜ ‰ÂÚÌ·ÙÈ΋˜ ‰ÔÎÈÌ·Û›·˜ (27). ∞Ó, fï˜, Ë ·ÙÔ›· ÔÚÈÛÙ› ·˘ÛÙËÚfiÙÂ-

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1 2 3 4

ÎÚÈÙ‹ÚÈÔ 39% ÎÚÈÙ‹ÚÈ· 47% ÎÚÈÙ‹ÚÈ· 68% ÎÚÈÙ‹ÚÈ· 83%

Ú·, ÁÈ· ·Ú¿‰ÂÈÁÌ· Ù¤ÛÛÂÚȘ ÙÔ˘Ï¿¯ÈÛÙÔÓ ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜, ·˘Í¿ÓÔ˘Ó ÌÂÓ ÔÈ Èı·ÓfiÙËÙ˜ ÙÔ˘ ·ÙÔÈÎÔ‡ ·ÙfiÌÔ˘ Ó· ÂÌÊ·Ó›ÛÂÈ ¿ÛıÌ· Û ۯ¤ÛË Ì ÙÔ ÌË ·ÙÔÈÎfi, ·ÏÏ¿ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Ô ·ԉȉfiÌÂÓÔ˜ ÛÙËÓ ·ÙÔ›· ΛӉ˘ÓÔ˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜ ÌÂÈÒÓÂÙ·È Û 3%, ÏfiÁˆ Ù˘ ·ÓÙ›ÛÙÔȯ˘ Ì›ˆÛ˘ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·ÙÔÈÎÒÓ ·ÙfïÓ, Ì ‚¿ÛË ÙÔÓ ·˘ÛÙËÚfiÙÂÚÔ ·˘Ùfi ÔÚÈÛÌfi (27). ∏ ·Ó·ÛÎfiËÛË ÙˆÓ Pearce Î·È Û˘Ó (27) ¤‰ÂÈÍ fiÙÈ ÏÈÁfiÙÂÚ˜ ·fi ÙȘ ÌÈÛ¤˜ ÂÚÈÙÒÛÂȘ ¿ÛıÌ·ÙÔ˜ ÂÓfi˜ ÏËı˘ÛÌÔ‡ Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ·ÙÔ›·, ÔÛÔÛÙfi Ô˘ Èı·ÓfiÓ Ó· ÔÈΛÏÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Â›Ó·È Èı·Ófi Ó· ·ÔÙÂϤÛÔ˘Ó ¤Ó·˘ÛÌ· ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ηÈ, ÂÔ̤ӈ˜, Ù˘ ÚfiÏË„‹˜ ÙÔ˘. ∂ÎÙfi˜, fï˜, ·fi ÙȘ ÌÂÏÏÔÓÙÈΤ˜ ÂÊ·ÚÌÔÁ¤˜ ÙÔ˘˜, ‰È¢ÎÔχÓÔ˘Ó ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi Ó· ηٷÓÔ‹ÛÂÈ fiÙÈ ÔÈ ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ‹ Ë ÂȉÈ΋ IgE (Rast) Û ·ÏÏÂÚÁÈÔÁfiÓ· ·˘Í¿ÓÔ˘Ó ÌÂÓ ÙËÓ Èı·ÓfiÙËÙ· ÙÔ ·È‰› ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· Û˘ÚÈÁÌÔ‡ Ó· ¤¯ÂÈ ·ÙÔÈÎfi ¿ÛıÌ·, ·ÏÏ¿ ‰ÂÓ ÈÛÔ‰˘Ó·ÌÔ‡Ó Ì ÙË ‰È¿ÁÓˆÛË ·ÙÔÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ªÂ ‚¿ÛË Ù· ÛÙÔȯ›· ·fi Ù· ÂÏÏËÓÈο ‰Â‰Ô̤ӷ Ù˘ ÌÂϤÙ˘ ISAAC (3), ÂÓÂÚÁfi ¿ÛıÌ· (Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 12 Ì‹Ó˜) ‰È·ÈÛÙÒıËΠ۠11% ÙˆÓ ·È‰ÈÒÓ, ÂÓÒ ıÂÙÈ΋ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Û ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÏÏÂÚÁÈÔÁfiÓÔ Û 25% ÙˆÓ ·È‰ÈÒÓ, ÔÛÔÛÙ¿ Ô˘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ‰È·›ÛÙˆÛË ·ÏÏÂÚÁÈ΋˜ ¢·ÈÛıËÙÔÔ›ËÛ˘ ‰ÂÓ ÈÛÔ‰˘Ó·Ì› Ì ‰È¿ÁÓˆÛË ·ÙÔÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. øÛÙfiÛÔ, Û ·È‰È¿ Ì Â›ÌÔÓÔ ¿ÛıÌ· ¯ˆÚ›˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Î·È ÂÚÁ·ÛÙËÚȷο ‰È·ÈÛو̤ÓË ·ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË Û˘ÓÈÛÙ¿Ù·È Ë ·ÔÊ˘Á‹ ÙÔ˘/ÙˆÓ ˘‡ı˘ÓÔ˘/ˆÓ ·ÏÏÂÚÁÈÔÁfiÓÔ˘/ˆÓ (15) Ì ÙË Ï‹„Ë ·ÓÙ›ÛÙÔȯˆÓ ̤ÙÚˆÓ, fiÔ˘ ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi. µÈÔÙÈÎfi Â›Â‰Ô ∞‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› ‰ÈÂıÓÒ˜ (28) Î·È ÂÓ Ì¤ÚÂÈ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ‚ÈÔÙÈÎÔ‡ ÂÈ¤‰Ô˘ (29). ∏

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·305

¶·È‰È·ÙÚÈ΋ 2004;67:301-309

Û˘Û¯¤ÙÈÛË, fï˜, ·˘Ù‹ ‰ÂÓ Â›Ó·È ÁÚ·ÌÌÈ΋, ηıÒ˜ Ë ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ηٿ ÎÂÊ·Ï‹Ó ÂÈÛÔ‰‹Ì·ÙÔ˜ ¤Ú·Ó ÂÓfi˜ ÂÈ¤‰Ô˘ ‰ÂÓ Û˘Ó‰¤ÂÙ·È Ì ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (29), ˘Ô‰ËÏÒÓÔÓÙ·˜ fiÙÈ ÔÚÈṲ̂ÓÔÈ ·fi ÙÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ÓfiÛÔ˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ‚ÈÔÙÈÎfi Â›‰Ô. ∂›Ó·È Èı·Ófi Ë ÚÔÛٷ٢ÙÈ΋ Â›‰Ú·ÛË ÙÔ˘ ¯·ÌËÏÔ‡ ‚ÈÔÙÈÎÔ‡ ÂÈ¤‰Ô˘ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÁÈÂÈÓ‹ Î·È ÙË ‰È·ÙÚÔÊ‹. ∆Ô ˙‹ÙËÌ· Ù˘ ˘ÁÈÂÈÓ‹˜ (30) Ê·›ÓÂÙ·È fiÙÈ ÂÚÌËÓ‡ÂÈ Û οÔÈÔ ‚·ıÌfi ÙËÓ ·‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ÓfiÛÔ˘, ηıÒ˜ ¤¯ÂÈ ‰Âȯı› fiÙÈ ·È‰È¿ Ì ÌÂÁ·Ï‡ÙÂÚ· ·‰¤ÏÊÈ·, ·ÏÏ¿ Î·È ·˘Ù¿ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ·È‰ÈÎfi ÛÙ·ıÌfi ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ‰È·ÙÚ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ‹ ÂÈÌÔÓ‹˜ Û˘ÌÙˆÌ¿ÙˆÓ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 11 ÂÙÒÓ. ∞Ó Î·È Ô ÚfiÏÔ˜ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Â›Ó·È ÚÔÛٷ٢ÙÈÎfi˜ (31), Ë Â›‰Ú·ÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·ÎÔÏÔ˘ı› ‰ÈÊ·ÛÈ΋ ÔÚ›·, ηıÒ˜ ·È‰È¿ Ì ÌÈÎÚfiÙÂÚÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ηٿ ÙË Á¤ÓÓËÛË ÂÌÊ·Ó›˙Ô˘Ó ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ Î·È Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ, Û‡Ìʈӷ Ì ÙË ÌÂϤÙË Ù˘ Tuscon (11), Ì Â·ÎfiÏÔ˘ıË, ˆÛÙfiÛÔ, ‡ÊÂÛË ‹ Î·È ÂÍ·Ê¿ÓÈÛË ÙˆÓ Û˘Ìو̿وÓ. ∆Ô ˙‹ÙËÌ· Ù˘ ˘ÁÈÂÈÓ‹˜ ˘ÔÛÙËÚ›˙ÂÙ·È Î·È ·fi Ù· ‰Â‰Ô̤ӷ Ô˘ ‰Â›¯ÓÔ˘Ó Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Û ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Î·È Î·ÙÔÈÎÔ‡Ó Û ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ Ì ·˘ÍË̤ӷ Â›‰· ÂÓ‰ÔÙÔ͛Ӣ (32). ∏ ‰È·ÙÚÔÊ‹ Û˘Û¯ÂÙ›˙ÂÙ·È ›Ûˆ˜ Ì ÙË ÓfiÛÔ, ηıÒ˜ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ - ·fi ‰Â‰Ô̤ӷ ÔÈÎÔÏÔÁÈ΋˜ ÌÂϤÙ˘ ÛÙËÓ ∂˘ÚÒË - ÁÈ· Èı·Ó‹ Û˘Û¯¤ÙÈÛË Ù˘ ηٷӿψÛ˘ trans-ÏÈ·ÚÒÓ ÔͤˆÓ Ì ÙÔÓ ÂÈÔÏ·ÛÌfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (33). Œ¯ÂÈ, Â›Û˘, ‰È·ÈÛÙˆı› ·ÓÙ›ÛÙÚÔÊË Û˘Û¯¤ÙÈÛË Ù˘ ηٷӿψÛ˘ ‰ËÌËÙÚÈ·ÎÒÓ Î·È Ï·¯·ÓÈÎÒÓ Ì ÙÔÓ ÂÈÔÏ·ÛÌfi ·ÙÔÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (34). ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ ÌÂÙ·‚¿ÏÏÔÓÙ·È, Ù· ÛËÌ›· ·˘Ù¿ ¯Ú‹˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ˘ ÚÔÛÔ¯‹˜ Î·È ÌÂÏÏÔÓÙÈ΋˜ ‰ÈÂÚ‡ÓËÛ˘. Œˆ˜ fiÙÔ˘ ˘¿ÚÍÔ˘Ó Û·Ê¤ÛÙÂÚ· ‰Â‰Ô̤ӷ Ô˘ ı· ‰ÈηÈÔÏÔÁÔ‡Û·Ó Û˘ÛÙ¿ÛÂȘ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓË ‰È·ÈÙËÙÈ΋ ·Ú¤Ì‚·ÛË, Â›Ó·È ÛÎfiÈÌÔ Ó· ÚÔÙÈÌ¿Ù·È Ë ÈÛÔÚÚÔË̤ÓË ‰È·ÙÚÔÊ‹ ÁÈ· ÂӉ¯fiÌÂÓË ÚfiÏË„Ë ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ë ÔÔ›· - ˆ˜ ÁÓˆÛÙfiÓ - ÚÔÊ˘Ï¿ÛÛÂÈ Î·È ·fi ¿ÏÏ· ÓÔÛ‹Ì·Ù·. ∏ ÌfiÏ˘ÓÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ·Ó Î·È ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·ÛıÌ·ÙÈÎÒÓ ÎÚ›ÛˆÓ, ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ÂÈÔÏ·ÛÌfi Ù˘ ÓfiÛÔ˘ (35). ™ËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, fï˜, ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜ ·ÔÙÂÏ› ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙËÓ Î‡ËÛË

Paediatriki 2004;67:301-309

(16). ∆Ô ·ıËÙÈÎfi οÓÈÛÌ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ·ÔÙÂÏ›, Â›Û˘, ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜, ·Ó Î·È Ë Û˘Û¯¤ÙÈÛË ‰ÂÓ Â›Ó·È ÙfiÛÔ ÈÛ¯˘Ú‹ fiÛÔ ÂΛÓË Ô˘ ·Ú·ÙËÚÂ›Ù·È Ì ÙÔ ÌËÙÚÈÎfi οÓÈÛÌ· ηٿ ÙËÓ Î‡ËÛË (35). ∆Ô ·ıËÙÈÎfi οÓÈÛÌ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¤¯ÂÈ ‚Ï·ÙÈ΋ Â›‰Ú·ÛË È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ Ë Û˘Ìو̷ÙÔÏÔÁ›· ÂÚÈÔÚ›˙ÂÙ·È Û ˘ÔÙÚÔÈ¿˙ÔÓÙ· Â›ÌÔÓÔ ‚‹¯· ¯ˆÚ›˜ Û˘ÓÔ‰fi Û˘ÚÈÁÌfi (36). ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÙÂı› ÚÒÙ· Ë ÔÚı‹ ‰È¿ÁÓˆÛË. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ··ÈÙÂ›Ù·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÁÈ·Ù› fiÛÔ ÌÈÎÚfiÙÂÚË Â›Ó·È Ë ËÏÈΛ· ÙfiÛÔ ·˘Í¿ÓÔ˘Ó ÔÈ Èı·ÓfiÙËÙ˜ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ó· ÌËÓ ÔÊ›ÏÔÓÙ·È Û ¿ÛıÌ· (·ÙÔÈÎfi ‹ ÌË), ·ÏÏ¿ Û ¿ÏÏ· Û·ÓÈfiÙÂÚ· ÓÔÛ‹Ì·Ù· Ô˘ ÂÓ›ÔÙ ÚÔ‚¿ÏÏÔ˘Ó Ì ·ÚfiÌÔÈ· Û˘Ìو̷ÙÔÏÔÁ›·, fiˆ˜ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ˜, ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ÂÈÛÚfiÊËÛ˘ Á¿Ï·ÎÙÔ˜, ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·, Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÚÔηÏÔ‡Ó ÛÙ¤ÓˆÛË ÙˆÓ ÂÓ‰ÔıˆÚ·ÎÈÎÒÓ ·ÂÚ·ÁˆÁÒÓ (.¯. ÙÚ·¯ÂÈÔ̷ϷΛ·, ‚ÚÔÁ¯Ô̷ϷΛ·) ‹ ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ (10). °È· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·Ó·˙ËÙÔ‡ÓÙ·È ÂÂÈÛfi‰È· ÂÎÓ¢ÛÙÈÎÔ‡ Û˘ÚÈÁÌÔ‡, ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ‹ ‚‹¯· Ô˘ Û˘Ó‹ıˆ˜ ¯ÂÈÚÔÙÂÚ‡ÂÈ ÙË Ó‡¯Ù·. ∆· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ·ÚÔ˘ÛÈ¿˙Ô˘Ó Âȉ›ӈÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ó‡¯Ù·˜ Î·È ÂÓ›ÔÙ ͢ÓÔ‡Ó ÙÔÓ ·ÛıÂÓ‹. ¶ÚÔÛÔ¯‹ ··ÈÙÂ›Ù·È ÁÈ· ÙÔÓ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ÓfiÛÔ˘ ˆ˜ ¿ÛıÌ·, Â¿Ó ÙÔ ÌfiÓÔ Û‡Ìو̷ Â›Ó·È Â›ÌÔÓÔ˜ ‚‹¯·˜ ¯ˆÚ›˜ Û˘ÓÔ‰fi ÂÎÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi (15,36). ™Ù· ·È‰È¿ Ì ÌÔÓ·‰È΋ ÂΉ‹ÏˆÛË ˘ÔÙÚÔÈ¿˙ÔÓÙ· Â›ÌÔÓÔ ‚‹¯· ¯ˆÚ›˜ Û˘ÚÈÁÌfi, ı· Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏϘ ·Èٛ˜ ¯ÚfiÓÈÔ˘ ‚‹¯· Î·È Ó· ÂÏÂÁ¯ı› Â¿Ó Ù· Û˘ÌÙÒÌ·Ù· ÂȉÂÈÓÒÓÔÓÙ·È Î·Ù¿ ÙË Ó‡¯Ù· ‹ ÙËÓ ¿ÛÎËÛË. ∞ÎfiÌ· Î·È ÛÙ· ·È‰È¿ Ô˘ Ô Â›ÌÔÓÔ˜ ‚‹¯·˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ¿ÛıÌ·, Ë ÔÚ›· ‰È·Ê¤ÚÂÈ ·fi ÂΛÓË ÙÔ˘ Ù˘ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ (36) Î·È Ë ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ‹ (15). ∂È‚¿ÏÏÂÙ·È, Â›Û˘, Ë ·Ó·˙‹ÙËÛË ·ÙÔÌÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ‹ ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜, ‰È·ÁÓˆÛÌ¤ÓˆÓ ·fi È·ÙÚfi, ηıÒ˜ Î·È ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡ (ÙˆÓ ÁÔÓ¤ˆÓ) ¿ÛıÌ·ÙÔ˜, ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜ ‹ ÂÎ˙¤Ì·ÙÔ˜, ‰È·ÁÓˆÛÌ¤ÓˆÓ ·fi È·ÙÚfi. ∂ÍÂÙ¿˙ÂÙ·È Â¿Ó Ù· Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ‹ ÂȉÂÈÓÒÓÔÓÙ·È Ì ÙËÓ Â·Ê‹ Ì ˙Ò·, Ì ÙËÓ ¤ÎıÂÛË Û ÂÈÛÓÂfiÌÂÓ˜ ¯ËÌÈΤ˜ Ô˘Û›Â˜, Á‡ÚË, Ê¿Ú̷η, ÔÈÎȷ΋ ÛÎfiÓË, ·ÏÏ·Á‹ Ù˘ ıÂÚÌÔÎÚ·Û›·˜,

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¶·È‰È·ÙÚÈ΋ 2004;67:301-309

Paediatriki 2004;67:301-309

ηÓfi, ¿ÛÎËÛË ‹ Ì ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∏ ‚·Ú‡ÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·Ó¿ÏÔÁ· Ì ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ ‹ Ù˘ Ó‡¯Ù·˜) Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ÀÔÁÚ·ÌÌ›˙ÂÙ·È fiÙÈ Ô ¶›Ó·Î·˜ 2 ‰Â›¯ÓÂÈ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È fi¯È Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Û˘ Î·È fiÙÈ ·È‰È¿ Ì ‹ÈÔ Â›ÌÔÓÔ ¿ÛıÌ· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÛÔ‚·Ú‹ ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË. ∏ ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Û˘ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·ÓÙÈΛÌÂÓÔ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘. ∆· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÙˆÓ ÔÔ›ˆÓ Ù· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ÂÎχÔÓÙ·È ÌfiÓÔ Ì ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, Ô˘ ‰ÂÓ ¤¯Ô˘Ó Û˘ÌÙÒÌ·Ù· ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÔÈ ÁÔÓ›˜ ÙÔ˘˜ ‰ÂÓ ¤¯Ô˘Ó È·ÙÚÈο ‰È·ÁÓˆṲ̂ÓÔ ¿ÛıÌ·, ÍÂÂÚÓÔ‡Ó Û˘Ó‹ıˆ˜ ÙÔ Úfi‚ÏËÌ·, fiˆ˜ ÚԷӷʤÚıËÎÂ, ̤¯ÚÈ ÙË Û¯ÔÏÈ΋ ËÏÈΛ· (11). ∆· ·È‰È¿ Ì ·˘Ù‹ ÙË ÌÔÚÊ‹ ¿ÛıÌ·ÙÔ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ¿Û¯ÔÓÙ· ·fi ‹ÈÔ ‰È·Ï›ÔÓ ¿ÛıÌ·. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ¯Ú‹˙ÂÈ ·ÓÙÈÌÂÙÒÈÛ˘ ÌfiÓÔ Ë ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË, ÂÓÒ ‰ÂÓ ¤¯ÂÈ ı¤ÛË Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹, Ì ‚¿ÛË Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ (5,37,38). ∂›Ó·È Èı·Ófi Ë ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ Ó· ÌËÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙ· ·È‰È¿ ·˘Ù¿ ÂÍ·ÈÙ›·˜ ‰È·ÊÔÚÂÙÈÎÔ‡ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ÂΉ‹ÏˆÛ˘ ÙÔ˘ Û˘ÚÈÁÌÔ‡. ¶ÂÚÈÔÚÈṲ̂ӷ ‰Â‰Ô̤ӷ ·fi ÙËÓ Î˘ÙÙ·ÚÈ΋ ·Ó¿Ï˘ÛË ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ Û ·È‰È¿ ¤‰ÂÈÍ·Ó ÂÈÎÚ¿ÙËÛË ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙ· ·È‰È¿ Ì ¿ÛıÌ· Î·È Û˘ÓÔ‰fi ÈÔÁÂÓ‹ Ïԛ̈ÍË, ÂÓÒ Û ·˘Ù¿ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ¿ÛıÌ·ÙÔ˜ ¯ˆÚ›˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙˆÓ Ì·ÛÙÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ (9,39). Œ¯ÂÈ, Â›Û˘, ‰ÈÂÚ¢ÓËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÌÂÙ¿ ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ÂÓÒ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› Ë ÚÔÛÙ·Û›· ÙÔ˘˜ Û ÌË ·ÙÔÈο ‚Ú¤ÊË ·fi ÂfiÌÂÓ· ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ (40-42). ™‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ Ù˘ GINA, Ù· ·È‰È¿ Ì ‰È·Ï›ÔÓ ¿ÛıÌ·, ·ÏÏ¿ ÛÔ‚·Ú¤˜ ·ÛıÌ·ÙÈΤ˜ ÎÚ›ÛÂȘ, Û˘ÓÈÛÙ¿Ù·È Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È fiˆ˜ ·˘Ù¿ Ì ̤ÙÚÈÔ Â›ÌÔÓÔ ¿ÛıÌ· (10). ∂›Û˘, Â¿Ó Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ ÎÚ›ÛÂˆÓ Â›Ó·È ÌÈÎÚfiÙÂÚ· ·fi 6 ‚‰ÔÌ¿‰Â˜, Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ National

Asthma Education and Prevention Program (NAEPP), Expert Panel Report (43), ÂӉ›ÎÓ˘Ù·È Ë ¤Ó·ÚÍË ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ·Ó¿ÏÔÁË Â›Ó·È Ë Û‡ÛÙ·ÛË Î·È Ù˘ 3˘ ¢ÈÂıÓÔ‡˜ OÌÔʈӛ·˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ÙÔ 1998, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÌÂ Û˘¯Ó¿ ÂÂÈÛfi‰È· (>1 ÂÂÈÛfi‰ÈÔ Î¿ı 4-6 ‚‰ÔÌ¿‰Â˜) ¯Ú‹˙ÂÈ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÁˆÁ‹˜ (15). ™Â ·ÓÙ›ıÂÛË Ì ÙÔ ‰È·Ï›ÔÓ ¿ÛıÌ·, ÛÙÔ Â›ÌÔÓÔ ¿ÛıÌ· (‹ÈÔ, ̤ÙÚÈÔ ‹ ‚·Ú‡) ··ÈÙÂ›Ù·È fi¯È ÌfiÓÔ ·Ó·ÎÔ‡ÊÈÛË ·fi Ù· Û˘ÌÙÒÌ·Ù· Ì ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο, ·ÏÏ¿ Î·È ¤ÏÂÁ¯Ô˜ Ù˘ ÓfiÛÔ˘ Ì ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹. ∆· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹, ÛÙË ÌÈÎÚfiÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‰fiÛË ÁÈ· ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, ·ÔÙÂÏÔ‡Ó ÙËÓ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ ÂÎÏÔÁ‹˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (10). ŒÏÂÁ¯Ô˜ Ù˘ ÓfiÛÔ˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÈÙ¢¯ı› ÌÂÙ¿ ·fi ¤Ó·Ó Ì‹Ó· ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜. ™Ù·‰È·Î‹ Ì›ˆÛË Ù˘ ‰fiÛ˘, ÂÊfiÛÔÓ Ë ¤Ó·ÚÍË ¤ÁÈÓ Ì ‰fiÛË ·ÓÙ›ÛÙÔÈ¯Ë Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Î·È fi¯È ˘„ËÏfiÙÂÚË, ÂȯÂÈÚÂ›Ù·È ÂÓÙfi˜ ÙÚÈÌ‹ÓÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜. O ·ÛıÂÓ‹˜ Â·ÓÂϤÁ¯ÂÙ·È ·Ó¿ 3-6 Ì‹Ó˜, ÂÊfiÛÔÓ Ë ÓfiÛÔ˜ Â›Ó·È Û ‡ÊÂÛË. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ̤ÙÚÈÔ˘ ‹ ÛÔ‚·ÚÔ‡ Â›ÌÔÓÔ˘ ¿ÛıÌ·ÙÔ˜ ‹ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ì ÌË ÈηÓÔÔÈËÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹, Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ô ·ÛıÂÓ‹˜ Ó· ·Ú·¤ÌÂÙ·È Û ÂȉÈÎfi È·ÙÚfi. ∆ÔÓ›˙ÂÙ·È fiÙÈ ÁÈ· Ó· ıˆÚËı› fiÙÈ Ô ·ÛıÂÓ‹˜ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈο ÛÙËÓ ·ÁˆÁ‹, Ú¤ÂÈ Ó· ¤¯ÂÈ ÂȂ‚·Èˆı› Ë ÔÚı‹, Ù¯ÓÈο, ¯ÔÚ‹ÁËÛ‹ Ù˘. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Â›‰ÂÈÍË ÛÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi Ù˘ ÌÂıfi‰Ô˘ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ Ê·Ú̿ΈÓ. ∏ ·ÁˆÁ‹ Ô˘ ÚÔÙ›ÓÂÙ·È ·fi ÙË GINA ÁÈ· Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ¿ÛıÌ·, ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ ‚·Ú‡ÙËÙ·˜, Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 4 ÂÙÒÓ Á›ÓÂÙ·È Ì ‰ÔÛÈÌÂÙÚÈ΋ Û˘Û΢‹ Ô˘ ÚÔÛ·ÚÌfi˙ÂÙ·È Û ·ÂÚÔı¿Ï·ÌÔ Ì ̿Ûη, ÂÓÒ Û ËÏÈΛ· 4-6 ÂÙÒÓ ÛÙÔÓ ·ÂÚÔı¿Ï·ÌÔ ·ÓÙ› ÁÈ· Ì¿Ûη - ÚÔÛÙ›ıÂÙ·È ÂÈÛÙfiÌÈÔ. ŸÙ·Ó ·ÔÊ·Û›˙ÂÙ·È Ë ÚÔÛı‹ÎË ‚2 ‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ÛÙËÓ ·ÁˆÁ‹ Ì ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹, Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Ì ¤Ó· Û··ÛÌ·

¶›Ó·Î·˜ 2. ™Ù·‰ÈÔÔ›ËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (Ô‰ËÁ›Â˜ Global Strategy for Asthma Management and Prevention GINA)

¢È·Ï›ÔÓ ¿ÛıÌ· ◊ÈÔ Â›ÌÔÓÔ ¿ÛıÌ· ª¤ÙÚÈÔ Â›ÌÔÓÔ ¿ÛıÌ· ™Ô‚·Úfi Â›ÌÔÓÔ ¿ÛıÌ·

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¶·È‰È·ÙÚÈ΋ 2004;67:301-309

Paediatriki 2004;67:301-309

¶›Ó·Î·˜ 3. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ¿ ÙÔ˘ (Ô‰ËÁ›Â˜ Î·È Û¯fiÏÈ· Global Strategy for Asthma Management and Prevention - GINA) ™Ù¿‰ÈÔ ‚·Ú‡ÙËÙ·˜

¶ÚÔÙÂÈÓfiÌÂÓË ÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹

ÕÏϘ ‰˘Ó·ÙfiÙËÙ˜ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ (ηٿ ·ÏÊ·‚ËÙÈ΋ ÛÂÈÚ¿)

¢È·Ï›ÔÓ ¿ÛıÌ· ◊ÈÔ Â›ÌÔÓÔ ¿ÛıÌ·

¢ÂÓ ÂӉ›ÎÓ˘Ù·È Ã·ÌËÏ‹ ‰fiÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ

ª¤ÙÚÈÔ Â›ÌÔÓÔ ¿ÛıÌ·

ª¤ÙÚÈ· ‰fiÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ

™Ô‚·Úfi Â›ÌÔÓÔ ¿ÛıÌ·

À„ËÏ‹ ‰fiÛË ÛÙÂÚÔÂȉԇ˜ Î·È ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ·ÎfiÏÔ˘ı·, ÂÊfiÛÔÓ ¯ÚÂÈ¿˙ÔÓÙ·È: ∞ÓÙÈÏ¢ÎÔÙÚȤÓÈ· ‚2 ‰ÈÂÁ¤ÚÙ˘ Ì·ÎÚ¿˜ ‰Ú¿Û˘ £ÂÔÊ˘ÏÏ›ÓË ‚Ú·‰Â›·˜ ·Ô‰¤ÛÌ¢Û˘ ÃÚˆÌÔÁÏ˘Î›ÓË

∞ÓÙÈÏ¢ÎÔÙÚȤÓÈ· £ÂÔÊ˘ÏÏ›ÓË ‚Ú·‰Â›·˜ ·Ô‰¤ÛÌ¢Û˘ ÃÚˆÌÔÁÏ˘Î›ÓË ª¤ÙÚÈ· ‰fiÛË ÛÙÂÚÔÂȉÒÓ Î·È ∞ÓÙÈÏ¢ÎÔÙÚȤÓÈ· ‹ ‚2 ‰ÈÂÁ¤ÚÙ˘ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‹ £ÂÔÊ˘ÏÏ›ÓË ‚Ú·‰Â›·˜ ·Ô‰¤ÛÌ¢Û˘ ‹ ÃÚˆÌÔÁÏ˘Î›ÓË ‹ À„ËÏ‹ ‰fiÛË ÂÈÛÓÂfiÌÂÓÔ˘ ÛÙÂÚÔÂȉԇ˜

™¯fiÏÈ·: ·) OÈ ‚2 ‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ Û˘ÌÏËڈ̷ÙÈ΋ ·ÁˆÁ‹ Ì ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ Î·È fi¯È ˆ˜ ÌÔÓÔıÂÚ·›·. ∂›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ÚÔÛı‹ÎË ‚2 ‰ÈÂÁ¤ÚÙË Ì·ÎÚ¿˜ ‰Ú¿Û˘ Û ۯ¤ÛË Ì ÙËÓ ·‡ÍËÛË Ù˘ ‰fiÛ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ·fi ̤ÙÚÈ· Û ˘„ËÏ¿ Â›‰·, ηıÒ˜ Ë Û˘Á¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ·ÛΛ Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË ÛÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ÌÔÚÈ·ÎÔ‡˜ ˘ԉԯ›˜ (47). ‚) ∆· Ï¢ÎÔÙÚȤÓÈ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È, Â›Û˘, ˆ˜ ÂÈÚfiÛıÂÙË ·ÁˆÁ‹ ¿ÛıÌ·ÙÔ˜ Ô˘ ‰ÂÓ ÂϤÁ¯ÂÙ·È Ì ̤ÙÚȘ ‰fiÛÂȘ ÛÙÂÚÔÂȉÒÓ. º·›ÓÂÙ·È, fï˜, fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ÂÈÛÓÂfiÌÂÓÔ˘ ÛÙÂÚÔÂȉԇ˜ Î·È ‚2 ‰ÈÂÁ¤ÚÙË Ì·ÎÚ¿˜ ‰Ú¿Û˘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ˜ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ ÂÈÛÓÂfiÌÂÓÔ˘ ÛÙÂÚÔÂȉԇ˜ Î·È ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ. Á) ∏ ıÂÔÊ˘ÏÏ›ÓË ‚Ú·‰Â›·˜ ·Ô‰¤ÛÌ¢Û˘ ÚÔÙÈÌ¿Ù·È ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ·ÁˆÁ‹ ÛÙȘ ¯ÒÚ˜ Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ ÔÈÎÔÓÔÌÈ΋ ‰˘Ó·ÙfiÙËÙ· ÁÈ· ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ Ê·Ú̿ΈÓ. ∏ ¯ÔÚ‹ÁËÛ‹ Ù˘ ÚÔ¸Ôı¤ÙÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÚÈÔ‰ÈÎÔ‡ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi.

(44), ÂÊfiÛÔÓ ÙÔ ÂÈÙÚ¤ÂÈ Ë ‰ÔÛÔÏÔÁ›·, ÏfiÁˆ ηχÙÂÚ˘ Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. ™˘Û΢¤˜ ÍËÚ¿˜ ÛÎfiÓ˘ Û˘Ó‹ıˆ˜ ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÈηÓÔÔÈËÙÈο ·fi ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÂÂȉ‹ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÈÙ‡¯Ô˘Ó ÙËÓ ··ÈÙÔ‡ÌÂÓË ÂÈÛÓ¢ÛÙÈ΋ ÚÔÛ¿ıÂÈ·. OÈ ÓÂÊÂÏÔÔÈËÙ¤˜ ‰ÂÓ ˘ÂÚ¤¯Ô˘Ó ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÂÚÔı·Ï¿ÌÔ˘˜ Ì ‰ÔÛÈÌÂÙÚÈ΋ Û˘Û΢‹, Ì ÂÍ·›ÚÂÛË ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÔÈ ÁÔÓ›˜ ·ԉ‰ÂÈÁ̤ӷ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ó ÛˆÛÙ¿ ÙË ‰ÔÛÈÌÂÙÚÈ΋ Û˘Û΢‹ Ì ·ÂÚÔı¿Ï·ÌÔ (45,46).

OÈ ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂÚ·›˜ Ô˘ ÚÔÙ›ÓÔÓÙ·È ·fi ÙË GINA ηٷÁÚ¿ÊÔÓÙ·È Î·Ù¿ ÛÂÈÚ¿ ÎfiÛÙÔ˘˜, ÂÓÒ ÛÙȘ ·Ó¿ÏÔÁ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ¡∞∂ƒƒ ·Ú·Ù›ıÂÓÙ·È Î·Ù¿ ·ÏÊ·‚ËÙÈ΋ ÛÂÈÚ¿, ÏfiÁˆ ¤ÏÏÂȄ˘ Â·ÚÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ÁÈ· ÙËÓ Î·Ù¿Ù·Í‹ ÙÔ˘˜ Ì ‚¿ÛË ÙË ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·.

O ÛÎÔfi˜ Ù˘ ıÂÚ·›·˜ Â›Ó·È Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ‹ Î·È ÂÍ·Ê¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙˆÓ ÎÚ›ÛˆÓ, Ë ¿ÛÎËÛË ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜ Î·È Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ··ÈÙÔ‡ÌÂÓˆÓ ‰fiÛÂˆÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ô ıÂÚ¿ˆÓ È·ÙÚfi˜ ηÏ›ٷÈ: ·) Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ ·Ó Ë Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·-

Ó¢ÛÙÈÎfi ÈÛÔ‰˘Ó·Ì› Ì ‰È¿ÁÓˆÛË ¿ÛıÌ·ÙÔ˜, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ fiÙÈ Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ Û˘ÚÈÁÌÔ‡ ‰ÂÓ Â›Ó·È Ù·˘ÙfiÛËÌË Ì ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ‚) Ó· ηٷٿÍÂÈ ÙË ÓfiÛÔ ÛÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÛÙ¿‰ÈÔ ‚·Ú‡ÙËÙ·˜, ‰È·ÎÚ›ÓÔÓÙ·˜ ÙËÓ ÂӉ¯fiÌÂÓË ‰È·ÊÔÚ¿ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ·fi ÂΛÓË ÂÓfi˜ ÂÂÈÛÔ‰›Ô˘ Û˘ÚÈÁÌÔ‡, Á) Ó· ÚÔÛ‰ÈÔÚ›ÛÂÈ ÙȘ Èı·ÓfiÙËÙ˜ ·ÚÔ˘Û›·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ· Î·È ‰) Ó· ηıÔÚ›ÛÂÈ ·Ó¿ÏÔÁ· ÙËÓ ÔÚı‹ ·ÁˆÁ‹ Î·È Ù· ̤ÙÚ· ÚfiÏ˄˘ Ô˘ ÂӉ›ÎÓ˘ÓÙ·È. µÈ‚ÏÈÔÁÚ·Ê›· 1. Weinberger M. Clinical patterns and natural history of asthma. J Pediatr 2003;142 (2 Suppl):S15-S20.

2. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema. Lancet 1998;351:1225-1232.

3. Hatziagorou E, Papadopoulou A, Gratziou C, Roussos C, Priftis K, Kirvassilis F et al. Prevalence of atopic diseases and allergic sensitization in children in Greece. 12Ë ¢ÈËÌÂÚ›‰· ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛˆÓ. ¢È·ÁÓˆÛÙÈΤ˜ Î·È £ÂÚ·¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ 2003;123-128.

4. Martinez FD. Development of wheezing disorders and asthma in preschool children. Pediatrics 2002;109 (2 Suppl):S362-S367.

307

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·308

¶·È‰È·ÙÚÈ΋ 2004;67:301-309

5. Doull IJ. Limitations of maintenance therapy for viral respiratory infection-induced asthma. J Pediatr 2003;142 (2 Suppl):S21-S25.

6. Williams H, McNicol KN. Prevalence, natural history, and relationship of wheezy bronchitis and asthma in children. An epidemiological study. BMJ 1969;4:321-325.

7. Speight AN, Lee DA, Hey EN. Underdiagnosis and undertreatment of asthma in childhood. BMJ 1983;286:1253-1256.

8. Guilbert T, Krawiec M. Natural history of asthma. Pediatr Clin North Am 2003;50:523-538.

9. Lemanske RF Jr. Inflammation in childhood asthma and other wheezing disorders. Pediatrics 2002;109 (2 Suppl):S368-S372.

10. Global Strategy for Asthma Management and Prevention.

National Institutes of Health and National Heart, Lung and Blood Institute, revised 2002. www.ginasthma.com.

11. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life.

The Group Health Medical Associates. N Engl J Med 1995;332:133-138.

12. Strachan DP, Butland BK, Anderson HR. Incidence and prognosis of asthma and wheezing illness from early childhood to age 33 in a national British cohort. BMJ 1996;312:1195-1199.

13. Anderson HR, Pottier AC, Strachan DP. Asthma from birth to age 23: incidence and relation to prior and concurrent atopic disease. Thorax 1992;47:537-542.

14. Strachan DP, Griffiths JM, Johnston ID, Anderson HR. Ventilatory function in British adults after asthma or wheezing illness at ages 0-35. Am J Respir Crit Care Med 1996;154:1629-1635.

15. Warner JO, Naspitz CK. Third International Pediatric Consensus statement on the management of childhood asthma. International Pediatric Asthma Consensus Group.

Pediatr Pulmonol 1998;25:1-17.

16. Taussig LM, Wright AL, Holberg CJ, Halonen M, Morgan WJ, Martinez FD. Tuscon Children’s Respiratory Study: 1980 to present. J Allergy Clin Immunol 2003;111:661-675.

17. Stein RT, Sherrill D, Morgan WJ, Holberg CJ, Halonen M, Taussig LM et al. Respiratory syncytial virus in early life and risk of wheeze and allergy by age 13 years. Lancet 1999;354:541-545.

18. Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000;162: 1403-1406.

19. Kurukulaaratchy RJ, Matthews S, Holgate ST, Arshad SH. Predicting persistent disease among children who wheeze during early life. Eur Respir J 2003;22:767-771.

20. Sporik R, Holgate ST, Platts-Mills TA, Cogswell JJ. Exposure to house-dust mite allergen (Der pI) and the development of asthma in childhood. A prospective study. N Engl J Med 1990;323:502-507.

21. Sporik R, Squillace SP, Ingram JM, Rakes G, Honsinger RW, Platts-Mills TA. Mite, cat, and cockroach exposure, allergen sensitization, and asthma in children: a case-control study of three schools. Thorax 1999;54:675-680.

22. Peat JK, Li J. Reversing the trend: reducing the prevalence of asthma. J Allergy Clin Immunol 1999;103:1-10.

308

Paediatriki 2004;67:301-309

23. Lau S, Illi S, Sommerfeld C, Niggemann B, Bergmann R, von Mutius E et al. Early exposure to house-dust mite and cat allergens and development of childhood asthma: a cohort study. Multicentre Allergy Study Group. Lancet 2000;356: 1392-1397.

24. Halonen M, Stern DA, Wright AL, Taussig LM, Martinez FD. Alternaria as a major allergen for asthma in children raised in a desert environment. Am J Respir Crit Care Med 1997;155: 1356-1361.

25. Priftanji A, Strachan D, Burr M, Sinamati J, Shkurti A, Grabocka E et al. Asthma and allergy in Albania and the UK. Lancet 2001;358:1426-1427.

26. Beasley R, Ellwood P, Asher I. International patterns of the prevalence of pediatric asthma: the ISAAC program. Pediatr Clin North Am 2003;50:539-553.

27. Pearce N, Pekkanen J, Beasley R. How much asthma is really attributable to atopy? Thorax 1999;54:268-272.

28. von Mutius E. Worldwide asthma epidemic. Immunol Allergy Clin North Am 2002;22:701-709.

29. Stewart AW, Mitchell EA, Pearce N, Strachan DP, Weilandon SK. The relationship of per capita gross national product to the prevalence of symptoms of asthma and other atopic diseases in children. The International Study of Asthma and Allergies in Childhood (ISAAC). Int J Epidemiol 2001;30:173-179.

30. Liu AH, Szefler SJ. Advances in childhood asthma: hygiene hypothesis, natural history, and management. J Allergy Clin Immunol 2003;111 (3 Suppl):S785-S792.

31. Matricardi PM, Rosmini F, Riondino S, Fortini M, Ferrigno L, Rapicetta M et al. Exposure to foodborne and orofecal microbes versus airborne viruses in relation to atopy and allergic asthma: epidemiological study. BMJ 2000;320:412-417.

32. Braun-Fahrlander C, Riedler J, Herz U, Eder W, Waser M, Grize L et al. Environmental exposure to endotoxin and its relation to asthma in school-age children. N Engl J Med 2002;347:869-877.

33. Weiland SK, von Mutius E, Husing A, Asher MI. Intake of trans fatty acids and prevalence of childhood asthma and allergies in Europe. Lancet 1999;353:2040-2041.

34. Ellwood P, Asher MI, Bjorksten B, Burr M, Pearce N, Robertson CF. Diet and asthma, allergic rhinoconjuctivitis and atopic eczema symptom prevalence: an ecological analysis of the International Study of Asthma and Allergies in Childhood (ISAAC) data. ISAAC Phase One Study Group.

Eur Respir J 2001;17:436-443.

35. von Mutius E. The environmental predictors of allergic disease. J Allergy Clin Immunol 2000;105:9-19.

36. Wright AL, Holberg CJ, Morgan WJ, Taussig LM, Halonen M, Martinez FD. Recurrent cough in childhood and its relation to asthma. Am J Respir Crit Care Med 1996;153:1259-1265.

37. Covar RA, Spahn JD. Treating the wheezing infant. Pediatr Clin North Am 2003;50:631-654.

38. Weinberger M. Consensus statement from a conference on treatment of viral respiratory infection-induced asthma in young children. J Pediatr 2003;142 (2 Suppl):S45-S46.

39. Marguet C, Jouen-Boedes F, Dean TP, Warner JO. Bronchoalveolar cell profiles in children with asthma, infantile wheeze, chronic cough, or cystic fibrosis. Am J Respir Crit Care Med 1999;159:1533-1540.

40. Fox GF, Everard ML, Marsh MJ, Milner AD. Randomized

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·309

¶·È‰È·ÙÚÈ΋ 2004;67:301-309

41.

42.

43.

44.

45.

controlled trial of budesonide for the prevention of postbronchiolitis wheezing. Arch Dis Child 1999;80:343-347.

Richter H, Seddon P. Early nebulized budesonide in the treatment of bronchiolitis and the prevention of postbronchiolitic wheezing. J Pediatr 1998;132:849-853.

Reijonen T, Korppi M, Kuikka L, Remes K. Anti-inflammatory therapy reduces wheezing after bronchiolitis. Arch Pediatr Adolesc Med 1996;150:512-517.

National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Update on Selected Topics - 2002. J Allergy Clin Immunol 2002;110 (5 Suppl):S141-S219.

Barnes PJ. Scientific rationale for inhaled combination therapy with long-acting ‚2-agonists and corticosteroids. Eur Respir J 2002;19:182-191.

Epling J, Chang MH. Are metered-dose inhalers with holding chambers better than nebulizers for treating acute asthma?

Am Fam Physician 2003;67:62-64.

Paediatriki 2004;67:301-309

46. Newhouse MT. Asthma therapy with aerosols: are nebulizers obsolete? A continuing controversy. J Pediatr 1999;135:5-8.

47. Roth M, Johnson PR, Rudiger JJ, King GG, Ge Q, Burgess JK et al. Interaction between glucocorticoids and beta2 agonists on bronchial airway smooth muscle cells through synchronized cellular signaling. Lancet 2002;360:1293-1299.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 11-07-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 24-02-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ªÔ˘ÛÙ¿ÎË µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·

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¶·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ¡¤· ÂÈÙ‡ÁÌ·Ù· ÛÙÔÓ ÙÔ̤· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ °. ª·ÚÔ‡Ù˘, ª. ¢·ÛÔÔ‡ÏÔ˘

Pathophysiological mechanisms involved in the pathogenesis of ventilation associated lung trauma. New strategies in mechanical ventilation G. Baroutis, M. Dasopoulou

¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË Ù˘ Û‡Á¯ÚÔÓ˘ ÁÓÒÛ˘ Á‡Úˆ ·fi Ù· ı¤Ì·Ù· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚˆÓ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ, Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∏ ‰˘ÛÌÂÓ‹˜ Â›‰Ú·ÛË ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ì ˘„ËϤ˜ ȤÛÂȘ Î·È ·˘ÍË̤ÓÔ fiÁÎÔ ·¤Ú·, Ë ÂÚÈÔ‰È΋ Û‡ÌÙˆÛË Î·È ‰È¿ÓÔÈÍË ÙˆÓ ÙÂÏÈÎÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÌÔÓ¿‰ˆÓ, ηıÒ˜ Î·È Ë Â¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÂÍÂÚÁ·Û›·˜ ·fi ÙÔÓ Ó¢ÌÔÓÈÎfi ÈÛÙfi ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· ̤ۈ Ù˘ ÁÂÓ›Î¢Û˘ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ·ÔÙÂÏÔ‡Ó Ó¤· ÛÙÔȯ›· Ô˘ Û˘Óı¤ÙÔ˘Ó ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ıˆڛ· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÙÔ ÔÔ›Ô ıˆÚÂ›Ù·È ˘‡ı˘ÓÔ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘. ∏ ÔÏÔ¤Ó· Î·È ÌÂÁ·Ï‡ÙÂÚË Û˘ÛÛÒÚ¢ÛË ÁÓÒÛ˘ ÁÈ· ÙÔ ı¤Ì· ·˘Ùfi Ô‰ËÁ› ÛÙËÓ ˘ÈÔı¤ÙËÛË Ó¤ˆÓ Ù¯ÓÈÎÒÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ô˘ ÌÂÈÒÓÔ˘Ó ÙȘ ‚Ï·‚ÂÚ¤˜ ÂÈÙÒÛÂȘ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ Î·È ÂÏ·ÙÙÒÓÔ˘Ó ÙË ıÓËÛÈÌfiÙËÙ·, fiˆ˜ ÔÈ Ó¤Â˜ ÌÔÚʤ˜ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (patient triggered ventilation PTV), Ô ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ (HFV), ·ÏÏ¿ Î·È Ë - ·fi ·Ï·ÈfiÙÂÚ· ÂÊ·ÚÌÔ˙fiÌÂÓË - Û˘Ó¯‹˜ ıÂÙÈ΋ ›ÂÛË ·ÂÚ·ÁˆÁÒÓ (CPAP) Î·È Ë ¯Ú‹ÛË ˘ÁÚÔ‡ ·ÂÚÈÛÌÔ‡ (liquid ventilation).

Abstract: The evolution of recent knowledge concerning mechanical ventilation has led to the recognition that multiple pathophysiological mechanisms are involved in the pathogenesis of ventilation associated lung trauma. The deleterious effect of the high ventilator pressures applied, together with the high tidal volumes ventilation mode, the shear forces generated during cyclic closure and reopening of terminal airways, and the spread of pulmonary inflammatory responses to the systemic circulation via the spillover of inflammatory cytokines are factors now believed to contribute to the multimodal concept of ventilation associated trauma, and to the subsequent development of chronic lung disease. The acquisition of new understanding of the mechanisms is leading to the adoption of new strategies of mechanical ventilation, which can minimise the harmful impact from its use and the associated mortality. These include the newly developed modes of synchronised ventilation, which are patient triggered ventilation (PTV) and high frequency ventilation (HFV) as well as the older-established use of continuous positive airway pressure (CPAP) and liquid ventilation.

§¤ÍÂȘ ÎÏÂȉȿ: ÙÚ·‡Ì· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ‚·ÚÔÙÚ·‡Ì·, ÔÁÎÔÙÚ·‡Ì·, ·ÙÂÏÂÎÙÚ·‡Ì·, ‚ÈÔÙÚ·‡Ì·, ΢ÙÙ·ÚÔΛÓ˜, ÚÔÛÙ·Û›· ÙÔ˘ Ó‡ÌÔÓ·, ÚÔÛٷ٢ÙÈÎfi˜ ·ÂÚÈÛÌfi˜.

Key words: mechanical ventilation, ventilatorassociated lung injury, barotrauma, volutrauma, atelectrauma, biotrauma, cytokines, lung protection, protective ventilation.

∂ÈÛ·ÁˆÁ‹ ∞fi ÙÔ 1963, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ̠ÂÈÙ˘¯›· Ô ÚÒÙÔ˜ ·Ó·Ó¢ÛÙ‹Ú·˜ Û ̈ڿ ·fi ÙË ‰È·ÎÂ-

ÎÚÈ̤ÓË ∂ÏÏËÓ›‰· π·ÙÚfi ∫·ıËÁ‹ÙÚÈ· ª·Ú›· ¢ÂÏË‚ÔÚÈ¿-¶··‰ÔÔ‡ÏÔ˘, ̤¯ÚÈ Û‹ÌÂÚ· ¤¯ÂÈ Û˘ÓÙÂÏÂÛÙ› ÙÂÚ¿ÛÙÈ· ÚfiÔ‰Ô˜ ÛÙÔÓ ÙÔ̤· Ù˘ Ì˯·ÓÈ΋˜

¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó·

Department of Neonatology, “Alexandra” General Hospital, Athens

310

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·311

¶·È‰È·ÙÚÈ΋ 2004;67:310-320

˘ÔÛÙ‹ÚÈ͢ ÓÂÔÁÓÒÓ, Ì ÛÙ·ıÌÔ‡˜ ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ·ÏÏ¿ Î·È ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ¶·Ú’ fiÏ· ·˘Ù¿, Ô ÙÚ·˘Ì·ÙÈÛÌfi˜, Ô˘ ˘Ê›ÛÙ·Ù·È Ô Ó‡ÌÔÓ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ·Ú·Ì¤ÓÂÈ Ì›· ·fi ÙȘ ÈÔ Û˘¯Ó¤˜ ·Èٛ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ (ª∂¡¡). ∂›Ó·È, Ú¿ÁÌ·ÙÈ, ·ÏËı‹˜ Ë ÛΤ„Ë ÙÔ˘ Hudson fiÙÈ “Ë È‰¤· Ù˘ ÚfiÎÏËÛ˘ ‚Ï¿‚˘ ÙÔ˘ Ó‡ÌÔÓ· ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ÂÓËÏÈÎÈÒıËΔ (1). ∫‡ÚÈ· ·ÈÙ›· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È Ô ›‰ÈÔ˜ Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ (2), Ô˘ ÂÓÈÛ¯‡ÂÈ ÙË ÊÏÂÁÌÔÓÒ‰Ë ‰ÈÂÚÁ·Û›· ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ÕÏÏÔÈ ˘ÔΛÌÂÓÔÈ Ì˯·ÓÈÛÌÔ› Â›Ó·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë ˘ÔΛÌÂÓË Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜, Ë Ïԛ̈ÍË Î·È Ô ˘ÔÛÈÙÈÛÌfi˜. OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› fi¯È ÌfiÓÔ ÂÓÈÛ¯‡Ô˘Ó ÙË ‚Ï·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì·, ·ÏÏ¿ ÂÏ·ÙÙÒÓÔ˘Ó Î·È ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÈηÓfiÙËÙ· ·Ó¿Ï·Û˘ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ (3).

O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ¤ÎÙ˘ÍË ·ÙÂÏÂÎÙ·ÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ Ó‡ÌÔÓ·, Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ ˘ÂډȿٷÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÌË-·ÙÂÏÂÎÙ·ÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ (4). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ˘ÂډȿٷÛ˘ Â›Ó·È Ë ·Ó¿Ù˘ÍË ‚·ÚÔÙÚ·‡Ì·ÙÔ˜ Î·È ÔÁÎÔÙÚ·‡Ì·ÙÔ˜, ηıÒ˜ Î·È Ë ·Ú·ÁˆÁ‹ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Î¿Ùˆ ·fi ÙËÓ Â›‰Ú·ÛË stress. ∏ ‰Ú¿ÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Û ΢ÙÙ·ÚÈÎfi Î·È ÌÔÚÈ·Îfi Â›Â‰Ô ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚfiÎÏËÛË ‚ÈÔÙÚ·‡Ì·ÙÔ˜ (5), Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÔÁÎÔÙÚ·‡Ì· ÏfiÁˆ ˘ÂډȿٷÛ˘ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∏ Û‡Á¯ÚÔÓË ÁÓÒÛË Î·È Î·Ù·ÓfiËÛË fiÏˆÓ ·˘ÙÒÓ ÙˆÓ Û‡ÌÏÔÎˆÓ Ì˯·ÓÈÛÌÒÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ˘ÈÔı¤ÙËÛË Ó¤ˆÓ ÛÙÚ·ÙËÁÈÎÒÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (6). OÈ ÛÙÚ·ÙËÁÈΤ˜ ·˘Ù¤˜ ÛÙÔ¯Â‡Ô˘Ó ÙfiÛÔ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ fiÛÔ Î·È ÛÙÔÓ ÂÚÈÔÚÈÛÌfi ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ¶·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ OÁÎÔÙÚ·‡Ì· ¶ÔχÏÔÎÔÈ Ì˯·ÓÈÛÌÔ› ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ÙÚ·‡Ì·ÙÔ˜ ÙÔ˘ Ó‡ÌÔÓ· ÂÍ·ÈÙ›·˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∞Ú¯Èο, ıˆڋıËΠfiÙÈ Ë ·ÈÙ›· ‹Ù·Ó Ë ÂÊ·ÚÌÔ˙fiÌÂÓË ›ÂÛË ÛÙȘ ΢„ÂÏ›‰Â˜, ·’ fiÔ˘ Î·È Ô fiÚÔ˜ ‚·ÚÔÙÚ·‡Ì·. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó fiÙÈ fi¯È ÌfiÓÔ Ë ·˘ÍË̤ÓË ›ÂÛË, ·Ï-

Paediatriki 2004;67:310-320

Ï¿ ΢ڛˆ˜ Ô ·˘ÍË̤ÓÔ˜ fiÁÎÔ˜ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú· Â›Ó·È ˘‡ı˘ÓÔ˜ ÁÈ· ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ Ó‡ÌÔÓ·, ÙÔ ÔÁÎÔÙÚ·‡Ì· (7-10). O ÙÚ·˘Ì·ÙÈÛÌfi˜ ·˘Ùfi˜ ·Ó·Ù‡ÛÛÂÙ·È ÛÙÔ ¤‰·ÊÔ˜ ÙÔ˘ ·ÓÒÚÈÌÔ˘ ÓÂÔÁÓÈÎÔ‡ Ó‡ÌÔÓ·, Ë ‰È·Ù·ÛÈÌfiÙËÙ· (compliance) [compliance=tidal volume / ¢ (¢=driving pressure: PIP-PEEP) (11)] ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ∏ ‰È·Ù·ÛÈÌfiÙËÙ· ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÏ·ÛÙÈÎfiÙËÙ· ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÈÛÙÒÓ Î·È ÙËÓ ÔÛfiÙËÙ· Î·È ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Î·È Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ fiÁÎÔ˘ ·Ó·ÓÔ‹˜ (tidal volume) Î·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË Ù˘ ‰È·ÊÔÚ¿˜ ›ÂÛ˘, Ô˘ ÚÔ·ÙÂÈ ·fi ÙË ıÂÙÈ΋ ›ÂÛË ÂÈÛÓÔ‹˜ Î·È ÙË ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË, Ô˘ ‰È·ÙËÚ› ·ÓÔÈÎÙ¤˜ ÙȘ ΢„ÂÏ›‰Â˜ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÂÎÓÔ‹˜. ∞fi ÙË Û¯¤ÛË ·˘Ù‹ Â›Ó·È Ê·ÓÂÚfi fiÙÈ Â¿Ó Ë ‰È·Ù·ÛÈÌfiÙËÙ· Â›Ó·È ÌÂȈ̤ÓË, fiˆ˜ ÛÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ÓÂÔÁÓÒÓ (™∞¢), ı· Ú¤ÂÈ Ó· ·˘ÍËı› Ë ıÂÙÈ΋ ›ÂÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÙËÚËı› Ô ›‰ÈÔ˜ fiÁÎÔ˜ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú·.

OÈ Wada Î·È Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ Ó‡ÌÔÓ· ¤ÁÈÓ Û ·ÚÓ¿ÎÈ·, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠÌ˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ì tidal volume 20 ml/kg ÁÈ· 30 ÏÂÙ¿, ·’ fi,ÙÈ Ì tidal volume 10 ml/kg (12). £· Ú¤ÂÈ Ó· ηٷÓÔËı› fiÙÈ ÛÙ· ÓÂÔÁÓ¿ Ì ™∞¢, ÏfiÁˆ ¤ÏÏÂȄ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë Î·Ù·ÓÔÌ‹ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ù¤ÙÔÈ·, ÒÛÙ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ̤ÚÔ˜ ÙÔ˘ Ó‡ÌÔÓ· ÌÔÚ› Ó· ·ÂÚÈÛÙ› Â·ÚÎÒ˜. ™˘Ó‹ıˆ˜, ÌfiÓÔ ÙÔ 1/3 ÙÔ˘ Ó‡ÌÔÓ· (ÙÔ ÚfiÛıÈÔ ÙÌ‹Ì· ÙÔ˘ Ó‡ÌÔÓ· ÛÙËÓ ‡ÙÈ· ı¤ÛË) ˘Ê›ÛÙ·Ù·È ·ıËÙÈ΋ ‰È¿ÓÔÈÍË Ì Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, Ì ·ÔÙ¤ÏÂÛÌ· - ÁÈ· ¤Ó· ‰Â‰Ô̤ÓÔ tidal volume, .¯. 10 ml/kg - ÙÔ ÙÌ‹Ì· ·˘Ùfi Ó· ˘ÂډȷÙ›ÓÂÙ·È, Û ÔÛÔÛÙfi Ô˘ ·ÓÙÈÛÙÔȯ› Û 30 ml/kg ÂÓfi˜ ˘ÁÈÔ‡˜ Ó‡ÌÔÓ·. ∆· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯Ú‹ÛË ¯·ÌËÏÔ‡ ¤Ó·ÓÙÈ ˘„ËÏÔ‡ ÂÈÛÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ ·¤Ú· ÂȂ‚·ÈÒıËÎ·Ó Î·È ·fi Ì›· ¿ÏÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Û ÂÓ‹ÏÈΘ Ì ™∞¢ (13), Ô˘ Û˘Ó¤ÎÚÈÓ ˘„ËÏÔ‡˜ (12 ml/kg) Ì ¯·ÌËÏÔ‡˜ (6 ml/kg) fiÁÎÔ˘˜ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú· (high vs low tidal volumes) (25). ∏ Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ‰ÈÂÎfiË ÌÂÙ¿ ÙËÓ Ù˘¯·ÈÔÔ›ËÛË 861 ·ÛıÂÓÒÓ, ÂÂȉ‹ Ë ıÓËÛÈÌfiÙËÙ· ÛÙËÓ 1Ë ÔÌ¿‰· ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Û ۇÁÎÚÈÛË Ì ÙË 2Ë ÔÌ¿‰· (39,8% ¤Ó·ÓÙÈ 31%). ∂ÈϤÔÓ, Ë ÔÌ¿‰· ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ¯·ÌËÏfiÙÂÚÔ˜ ÂÈÛÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ ·¤Ú· (lower tidal volumes), ·ÚÔ˘Û›·Û ¯·ÌËÏfiÙÂÚÔ ÔÛÔÛÙfi ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ¯·ÌËÏfiÙÂÚ· Â›‰· IL-6, Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ˘„ËÏfiÙÂÚÔ˜ fiÁÎÔ˜ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú· (higher tidal volumes).

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¶·È‰È·ÙÚÈ΋ 2004;67:310-320

∞ÙÂÏÂÎÙÚ·‡Ì· O fiÚÔ˜ ·ÙÂÏÂÎÙÚ·‡Ì· ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· Ó· ÂÚÈÁÚ¿„ÂÈ ÙÔ ÙÚ·‡Ì· ·fi ÙË ‰È¿ÓÔÈÍË Ì›·˜ ·ÙÂÏÂÎÙ·ÙÈ΋˜ ÂÚÈÔ¯‹˜ ÙÔ˘ Ó‡ÌÔÓ· Î·È ÙËÓ ÂÎ Ó¤Ô˘ Û‡ÌÙˆÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÂÎÓÔ‹˜ (14). O ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ Ó‡ÌÔÓ· ÌÔÚ› Ó· Û˘Ì‚Â› ›Ù ÛÙËÓ ·Ú¯‹ ›Ù ÛÙÔ Ù¤ÏÔ˜ οı ·Ó·ÓÔ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú·. ∂¿Ó ÛÙÔ Ù¤ÏÔ˜ οı ·Ó·ÓÔ‹˜ ÎÏ›ÓÔ˘Ó ÂÓÙÂÏÒ˜ ÔÈ Î˘„ÂÏ›‰Â˜, ÚÔηÏÂ›Ù·È ·ÙÂÏÂÎÙ·Û›·, ‰ËÏ·‰‹ Û‡ÌÙˆÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Â›Ù ÂÂȉ‹ ÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ·Ó·ÓÔ‹ ‰ÂÓ Â›¯·Ó ·ÓÔ›ÍÂÈ ·ÚÎÂÙ¤˜ ΢„ÂÏ›‰Â˜, ›Ù ÂÂȉ‹ Ë ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË ‹Ù·Ó ·ÓÂ·Ú΋˜ ÁÈ· Ó· ‰È·ÙËÚ‹ÛÂÈ ·ÓÔȯ٤˜ ÙȘ ΢„ÂÏ›‰Â˜. ªÂ οı ÂfiÌÂÓË ·Ó·ÓÔ‹ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú·, ÔÈ Ê˘ÛÈÔÏÔÁÈΤ˜ ΢„ÂÏ›‰Â˜ ˘ÂډȷÙ›ÓÔÓÙ·È, ÂÓÒ ÔÈ ·ÙÂÏÂÎÙ·ÙÈΤ˜ ΢„ÂÏ›‰Â˜ Û˘ÌȤ˙ÔÓÙ·È ·fi ÙËÓ ˘ÂډȿٷÛË ÙˆÓ ÁÂÈÙÔÓÈÎÒÓ ‰È·ÙÂÙ·Ì¤ÓˆÓ Î˘„ÂÏ›‰ˆÓ. ∆Ú·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ΢„ÂÏȉÈÎÔ‡ ÂÈıËÏ›Ô˘ Î·È ·Ó·ÙÔÌÈ΋ ‚Ï¿‚Ë Û˘Ì‚·›ÓÔ˘Ó Î·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÈÛ¯˘ÚÒÓ ȤÛÂˆÓ ÁÈ· ÙËÓ ·ıËÙÈ΋ ‰È¿ÓÔÈÍË ÙˆÓ ·ÙÂÏÂÎÙ·ÙÈÎÒÓ Î˘„ÂÏ›‰ˆÓ. ∞˘Ù¤˜ ÔÈ ÌË ·Ó·ÛÙÚ¤„È̘ ‚Ï¿‚˜ ÌÔÚ› Ó· Û˘Ì‚Ô‡Ó ·ÎfiÌË Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿Ó˄˘ ÙÔ˘ ÓÂÔÁÓÔ‡ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÚÒÙˆÓ ·ıËÙÈÎÒÓ ·Ó·ÓÔÒÓ Ì ÙË ¯Ú‹ÛË Ì¿Ûη˜ Î·È ·ÛÎÔ‡ (Ambu-bag). ∏ ˘ÂډȿٷÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ, ÌË ·ÙÂÏÂÎÙ·ÙÈÎÒÓ Î˘„ÂÏ›‰ˆÓ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ ΢„ÂÏȉÈÎÔ‡ ÂÈıËÏ›Ô˘, ÙÔ˘ ÙÚȯÔÂȉÈÎÔ‡ ÂÓ‰ÔıËÏ›Ô˘ Î·È ÙˆÓ ‚·ÛÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ. ∏ ÚÔηÏÔ‡ÌÂÓË Ì˯·ÓÈ΋ ‚Ï¿‚Ë ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÍ›‰ÚˆÛË Ï¿ÛÌ·ÙÔ˜, ·›Ì·ÙÔ˜ Î·È ÚˆÙÂ˚ÓÒÓ Ì¤Û· ÛÙȘ ΢„ÂÏ›‰Â˜, ÙÔ˘˜ ÌÈÎÚÔ‡˜ ·ÂÚ·ÁˆÁÔ‡˜ Î·È ÙÔÓ Ó¢ÌÔÓÈÎfi ‰È¿ÌÂÛÔ ÈÛÙfi (7,15). ™Â ÚfiÛÊ·Ù· ÂÈÚ¿Ì·Ù· Û ÂÈÚ·Ì·Ùfi˙ˆ· ·ԉ›¯ÙËΠfiÙÈ ÙÔ ·Ó·ÙÔÌÈÎfi ÙÚ·‡Ì· ÙˆÓ Î˘„ÂÏ›‰ˆÓ fi¯È ÌfiÓÔ ÂÓÈÛ¯‡ÂÈ ÙËÓ ·Ó¿Ù˘ÍË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜, ·ÏÏ¿ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÂÓÂÚÁfi Â·Ó·ÚÚfiÊËÛË ÙÔ˘ ¡a ̤ۈ Ù˘ ·ÓÙÏ›·˜ ¡a+-∫+-∞∆ƒase ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ÂÈı‹ÏÈÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÌÔ‰›˙ÂÈ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ˘ÁÚÔ‡ ·fi ÙÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· (16). O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Â›Û˘, Âȉڿ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙfiÛÔ ÙÔ˘ ÂÓ‰ÔÁÂÓÔ‡˜ fiÛÔ Î·È ÙÔ˘ Â͈ÁÂÓÔ‡˜ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (surfactant). OÈ Bjorklund (17) Î·È Û˘Ó ‚Ú‹Î·Ó fiÙÈ ÌfiÏȘ 6 ·Ó·ÓÔ¤˜ Ì ·ÛÎfi (manual breaths) Ì 35-40 ml/kg ÚÔ Ù˘ ¯ÔÚ‹ÁËÛ˘ surfactant Î·È ÚÔ Ù˘ ¤Ó·Ú͢ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÂȉÂÈÓÒÓÔ˘Ó ÛËÌ·ÓÙÈο ÙË ‰Ú¿ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. O ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Î·È Ë ÂÍ›‰ÚˆÛË ÚˆÙÂ˚ÓÒÓ Î·È ÔÚÔ‡ ̤۷ ÛÙÔÓ ÂÓ‰Ô΢„ÂÏȉÈÎfi ·˘Ïfi

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·ÏÏÔÈÒÓÔ˘Ó ÙË Û‡ÛÙ·ÛË Î·È ‰È·Ù·Ú¿ÛÛÔ˘Ó ÙË ‰Ú¿ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ™·Ó ·ÔÙ¤ÏÂÛÌ·, ·˘Í¿ÓÂÙ·È Ë Ù¿ÛË Û‡ÌÙˆÛ˘ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÂ Û˘Óı‹Î˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È ÂÏ·Ùو̤ÓË ÛÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ Ó‡ÌÔÓ·, Ì ·ÔÙ¤ÏÂÛÌ· ÔÈ ·ÔÌ·ÎÚ˘Ṳ̂Ó˜ ΢„ÂÏ›‰Â˜ Ó· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË Û‡ÌÙˆÛË, Ô˘ ··ÈÙ› ÙËÓ ÂÊ·ÚÌÔÁ‹ ˘„ËÏfiÙÂÚˆÓ ȤÛˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÙËÚËıÔ‡Ó ·ÓÔȯ٤˜ (18). ∏ ·˘ÍË̤ÓË Ù¿ÛË ÂÈÊ·Ó›·˜ ̤۷ ÛÙȘ ΢„ÂÏ›‰Â˜ ÚÔηÏ› ·‡ÍËÛË Ù˘ ‰È·ÊÔÚ¿˜ ›ÂÛ˘ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÙÚȯÔÂȉÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·‹‰ËÛË ˘ÁÚÒÓ ÚÔ˜ ÙÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· (19). µÈÔÙÚ·‡Ì· ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÂËÚ¿˙ÂÈ Ù· Â›‰· ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ ÌÂÛÔÏ·‚ËÙÒÓ ÊÏÂÁÌÔÓ‹˜ ÛÙÔÓ Ó‡ÌÔÓ· (20). ™˘ÁÎÂÎÚÈ̤ӷ, ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ ÙÔ Â‡ÚÔ˜ Î·È Ë ÂÚÈÔ‰ÈÎfiÙËÙ· ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÂËÚ¿˙Ô˘Ó ÂȉÈÎÔ‡˜ ˘ԉԯ›˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, Ô˘ ÌÂÛÔÏ·‚Ô‡Ó ÛÙËÓ ¤Ó·ÚÍË ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ Ô‰ÒÓ. OÈ Ì˯·ÓÈΤ˜ ȤÛÂȘ Ô˘ ·ÛÎÔ‡ÓÙ·È ÛÙÔÓ Ó‡ÌÔÓ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ‰È·Ù·Ú¿ÛÛÔ˘Ó ÙËÓ ÂÚÈÔ‰ÈÎfiÙËÙ· Î·È ÙÔ Â‡ÚÔ˜ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÎÈÓ‹ÛˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰ÈÂÁ›ÚÔÓÙ·È ÔÈ Î˘ÙÙ·ÚÈÎÔ› ˘ԉԯ›˜, Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó ÙËÓ ·Ï˘Û›‰· ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ ·ÓÙȉڿÛÂˆÓ (21,22). ∂Í¿ÏÏÔ˘, ÙÔ ·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ÙˆÓ Ó¢ÌfiÓˆÓ fi¯È ÌfiÓÔ ‰¤¯ÂÙ·È fiÏÔ ÙÔ ·›Ì· Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜, ·ÏÏ¿ Î·È ·ÔÙÂÏ› ‰ÂÍ·ÌÂÓ‹ Ô˘‰ÂÙÂÚfiÊÈψÓ, ̤¯ÚÈ Î·È ÙÔ˘ 1/3 ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ¤Íˆ ·fi ÙÔÓ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ. O ÙÚ·˘Ì·ÙÈÛÌfi˜ Ù˘ ΢„ÂÏȉÔÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÌÔÚ› Ó· ·ÂÏ¢ıÂÚÒÛÂÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ÌÂÛÔÏ·‚ËÙ¤˜ ·fi ÙÔÓ Î˘„ÂÏȉÈÎfi ¯ÒÚÔ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÙÚ·˘Ì·ÙÈÎfi Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (Ì ¯Ú‹ÛË ÌÂÁ¿ÏÔ˘ ÂÛÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ ·¤Ú·, ˘„ËÏ‹˜ ÙÂÏÔÂÎÓ¢ÛÙÈ΋˜ ›ÂÛ˘, ˘„ËÏ‹˜ ÚÔ‹˜ ÂÈÛÓÂfiÌÂÓÔ˘ Ô͢ÁfiÓÔ˘), ¤‰ÂÈÍ·Ó ÌÂÁ¿ÏË Û˘ÁΤÓÙÚˆÛË Ô˘‰ÂÙÂÚfiÊÈÏˆÓ Î·È ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ (23), ηıÒ˜ Î·È ˘„ËÏÔ‡˜ Ù›ÙÏÔ˘˜ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ˘ÁÚfi Î·È ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· (24,25). ™Â Ù˘¯·ÈÔÔÈË̤Ó˜ ‰ÈϤ˜ Ù˘ÊϤ˜ ÌÂϤÙ˜, fiˆ˜ ÙˆÓ Ranieri Î·È Û˘Ó (26), Ë ÔÔ›· ¤ÁÈÓ Û ‰‡Ô Â˘Úˆ·˚ο ΤÓÙÚ·, Û˘Û¯ÂÙ›ÛÙËΠÙÔ Â›‰Ô˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∞ԉ›¯ıËΠfiÙÈ Ë ¯Ú‹ÛË ˘„ËÏ‹˜ ıÂÙÈ΋˜ ÙÂÏÔÂÎÓ¢ÛÙÈ΋˜ ›ÂÛ˘ (PEEP) Î·È ˘„ËÏÔ‡ ÂÈÛÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ ·¤Ú· (tidal volume: 10-12 ml/kg) ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ

September-October 05 chris

18-11-04

15:18

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¶·È‰È·ÙÚÈ΋ 2004;67:310-320

·Ú·ÌÔÓ‹ ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ IL-1b, TNFa Î·È IL-6 ÛÙÔÓ Ó¢ÌÔÓÈÎfi ÈÛÙfi Î·È ÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ÁÈ· ‰È¿ÛÙËÌ· ÂÚ›Ô˘ 36 ˆÚÒÓ. ∞ÓÙ›ıÂÙ·, Ë ¯Ú‹ÛË ¯·ÌËÏfiÙÂÚ˘ ıÂÙÈ΋˜ ÙÂÏÔÂÎÓ¢ÛÙÈ΋˜ ›ÂÛ˘ (PEEP: 1-2 cm H2O ¿Óˆ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ÔÚ›Ô˘ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙË ‰È¿ÓÔÈÍË ÙˆÓ Î˘„ÂÏ›‰ˆÓ) Î·È ÌÈÎÚfiÙÂÚÔ˘ ·Ó·ÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ ·¤Ú· (tidal volume) ÂÚÈfiÚÈÛ ÙÔÓ ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· Î·È ‚ÂÏÙ›ˆÛ ÙË ÏÂÈÙÔ˘ÚÁ›· ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ. ∞fi ÚfiÛÊ·Ù˜ ÂÚÁ·Û›Â˜ ÙÔ˘ Speer (27) ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ fi¯È ÌfiÓÔ Ô ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ·ÏÏ¿ Î·È ¿ÏÏÔÈ ÌÂÛÔÏ·‚ËÙ¤˜ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ ¯ËÌÂÈÔÙ·ÎÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÊÏÂÁÌÔÓ‹˜ (C5a, leucotriene B4, TNFa, interleukin 8, platelet activating factor, ICAM-1, fibronectin) Î·È ‰È¿ÊÔÚ˜ ÛÂÏÂÎÙ›Ó˜ Ô˘ ‰ÚÔ˘Ó Û·Ó ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ·, ·ÓȯÓ‡ÔÓÙ·È Û ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ˘ÁÚfi ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·. ∏ ‰È·ÛÔÚ¿ ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ·fi ÙÔÓ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¯ÒÚÔ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· Î·È Ë Â¤ÎÙ·ÛË Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ Â›Ó·È ˘‡ı˘Ó˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·Ù·ÏËÍ›·˜ Î·È ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (3). ¢Â‰Ô̤Ó˘ Ù˘ ÌÂÁ¿Ï˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ Ó‡ÌÔÓ· Ô˘ Â›Ó·È Û Â·Ê‹ Ì ÙÔ ·›Ì·, Ë ·ÂÏ¢ı¤ÚˆÛË ·ÎfiÌË Î·È ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ·Ó¿ ·ÙÙ·ÚÔ ı· ηٷϋÍÂÈ ÛÙË ‰ÈÔ¯¤Ù¢ÛË - ÂÓÙfi˜ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ - ÏËıÒÚ·˜ Ù¤ÙÔÈˆÓ ÌÂÛÔÏ·‚ËÙÒÓ. ∞˘ÙÔ›, ÙÂÏÈο, ÔÈ ÌÂÛÔÏ·‚ËÙ¤˜ ÌÔÚ› Ó· ÌÂÙ·‚¿ÏÔ˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÓÂÊÚÒÓ, ÙÔ˘ ‹·ÙÔ˜, Ù˘ ηډȿ˜ Î·È ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÚÔηÏÒÓÙ·˜ ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ı¿Ó·ÙÔ. ∆¤ÏÔ˜, ¤Ó·˜ ·ÎfiÌË Ì˯·ÓÈÛÌfi˜, Ë ‰È·ÛÔÚ¿ ‚·ÎÙËÚȉ›ˆÓ ·fi ÙȘ ΢„ÂÏ›‰Â˜ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ™Â ÂÈÚ¿Ì·Ù· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Û Û·ÏÔ˘˜, ÔÈ Ó‡ÌÔÓ˜ ÙˆÓ ÔÔ›ˆÓ ›¯·Ó ÂÔÈÎÈÛÙ› Ì E. coli, Ë ÂÊ·ÚÌÔÁ‹ ¯·ÌËÏ‹˜ ıÂÙÈ΋˜ ÙÂÏÔÂÎÓ¢ÛÙÈ΋˜ ›ÂÛ˘ (PEEP) Ì ˘„ËÏ‹ ıÂÙÈ΋ ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (PIP: 35 cm H2O) ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÌÂÁ·Ï‡ÙÂÚË ‚·ÎÙËÚÈ·ÈÌ›·, Û ۯ¤ÛË Ì ÂÈÚ·Ì·Ùfi˙ˆ·, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠÏÈÁfiÙÂÚÔ ÙÚ·˘Ì·ÙÈÎfi˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, ‰ËÏ·‰‹ ˘„ËÏfiÙÂÚË PEEP Î·È ¯·ÌËÏfiÙÂÚË PIP (28). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÏÔÈfiÓ, Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÌÔÚ› Ó· ·›˙ÂÈ Ô˘ÛÈ·ÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ¤Ó·ÚÍË Î·È Â¤ÎÙ·ÛË Ì›·˜ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ Î·È ÛË„·ÈÌ›·˜, Ô˘ Û˘¯Ó¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·.

Paediatriki 2004;67:310-320

™˘ÓÔÙÈο, ÔÈ Ì˯·ÓÈÛÌÔ› Ì ÙÔ˘˜ ÔÔ›Ô˘˜ Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÙÚ·‡Ì· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ›ӷÈ: ·) ÙÔ ‚·ÚÔÙÚ·‡Ì·: ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ÂÍ·ÈÙ›·˜ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ˘„ËÏÒÓ ȤÛÂˆÓ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜, ‚) ÙÔ ÔÁÎÔÙÚ·‡Ì·: ÙÚ·‡Ì· ·fi ÂÚÈÔ¯È΋ ˘ÂډȿٷÛË Î·È ¿ÓÈÛË ‰È¿Ù·ÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ Â›ÛÔ‰Ô ÌÂÁ¿ÏÔ˘ fiÁÎÔ˘ ·¤Ú· Î·È fi¯È ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ˘„ËÏÒÓ ȤÛÂˆÓ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜, Á) ÙÔ ·ÙÂÏÂÎÙÚ·‡Ì·: ÙÚ·‡Ì· Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ·ÎÏÔ˘ ·ÓÔ›ÁÌ·ÙÔ˜ Î·È ÎÏÂÈ̷ۛÙÔ˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Î·È ‰) ÙÔ ‚ÈÔÙÚ·‡Ì·: ÙÚ·‡Ì· ·fi ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Î·È ‚·ÎÙËÚȉ›ˆÓ ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, ÌÂ Û˘Ó¤ÂÈ· ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™ÙÚ·ÙËÁÈΤ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ô˘ Û˘ÓÙ›ÓÔ˘Ó ÛÙË Ì›ˆÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ™˘Ó¯‹˜ ıÂÙÈ΋ ›ÂÛË ·ÂÚ·ÁˆÁÒÓ ∏ ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (surfactant) ıˆÚÂ›Ù·È Â·Ó¿ÛÙ·ÛË ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. øÛÙfiÛÔ, ÔÚÈṲ̂ӷ ÚfiˆÚ· ÓÂÔÁÓ¿ ‰ÂÓ Â›Ó·È ·ÓÂÎÙÈο ÛÙËÓ ¤Á¯˘ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (29,30), ¿ÏÏ· ÓÂÔÁÓ¿ ·‰Ú·ÓÔÔÈÔ‡Ó ÙÔÓ ·Ú¿ÁÔÓÙ·, ÂÓÒ Û ¿ÏÏ· ‰ÂÓ Î·Ù·Ó¤ÌÂÙ·È Ô ·Ú¿ÁÔÓÙ·˜ ÔÌÔÈfiÌÔÚÊ· ÛÙÔÓ Ó‡ÌÔÓ·. ∂›Û˘, Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ì ˘„ËÏÔ‡˜ ·Ó·ÓÂfiÌÂÓÔ˘˜ fiÁÎÔ˘˜ ·¤Ú· (high tidal volume) Î·È ¯·ÌËÏ‹ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË (PEEP) ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‰Ú·ÓÔÔ›ËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (31,32). ∏ ‰È·Ù‹ÚËÛË ÂÓÂÚÁÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Â›Û˘, ÂËÚ¿˙ÂÙ·È ·fi ÙÔ ˘ÊÈÛÙ¿ÌÂÓÔ ÙÚ·‡Ì· ÙÔ˘ Ó‡ÌÔÓ· Î·È ·fi ÙË Û‡ÛÙ·ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (33,34). ∂ÈϤÔÓ, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ù· ÓÂÔÁÓ¿ Ô˘ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È Ôχ ÁÚ‹ÁÔÚ· ÛÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (rapid responders), ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó¢ÌÔÓÈ΋˜ Î·È ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ÏfiÁˆ ·fiÙÔÌ˘ ÙÒÛ˘ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È ·‡ÍËÛ˘ Ù˘ ‰È·Ê˘Á‹˜ (shunt) ·fi ·ÚÈÛÙÂÚ¿ ÚÔ˜ Ù· ‰ÂÍÈ¿ (35-38). Œ¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ Û˘Ó¯ԇ˜ ıÂÙÈ΋˜ ›ÂÛ˘ ·ÂÚ·ÁˆÁÒÓ (CPAP) Û·Ó ÂÈÏÔÁ‹ ˘ÔÛÙËÚÈÎÙÈÎÔ‡ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Û Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ (<1500 g), Ô˘ ¤¯Ô˘Ó ·˘ÙfiÌ·ÙË ·Ó·ÓÔ‹ ·fi ÙË Á¤ÓÓËÛË, ¤¯ÂÈ Î·Ù·Ê¤ÚÂÈ Ó· ÌÂÈÒÛÂÈ ÂÓÙ˘ˆÛȷο ÙË ¯Ú‹ÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (39). ∏ ·Ú·Ù‹ÚËÛË ·˘Ù‹ Ô‰ËÁ› ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Â¿Ó ÌÔÚ› Ó· ÂÊ·ÚÌÔÛÙ› Û˘Ó¯‹˜ ıÂÙÈ΋ ›ÂÛË ÛÙÔÓ ÓÂÔÁÓÈÎfi Ó‡ÌÔÓ· ÒÛÙ ӷ ‰È·ÙËÚÔ‡ÓÙ·È ·ÓÔȯÙÔ› ÔÈ ·ÂÚ·ÁˆÁÔ› Ì ‹È· ̤۷, fiˆ˜ ÙÔ CPAP Î·È Ó· ÛÙ·ıÂÚÔÔÈËı› Ë

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ÔÌ·Ï‹ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙfiÙ ÙÔ Ì˯·ÓÈÎfi ÙÚ·‡Ì· ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ·‰Ú·ÓÔÔ›ËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÔÚ› Ó· ·ÔÙÚ·Ô‡Ó. ŒÙÛÈ, Ù· ÓÂÔÁÓ¿ Ì ÔÚȷΤ˜ ·Ôı‹Î˜ ÂÓ‰ÔÁÂÓÔ‡˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÔÚ› Ó· ÌËÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÙÂÏÈο ıÂÚ·›· Ì ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ·, ηıÒ˜ Ô ÌË ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜ Ó‡ÌÔÓ·˜ ··ÈÙ› ÏÈÁfiÙÂÚÔ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· ·’ fi,ÙÈ Ô ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜ (40). ∏ ÂÊ·ÚÌÔÁ‹ PEEP ‹ CPAP ‚ÔËı¿ÂÈ ·ÎfiÌË ÛÙË ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÛÙÚ·ÙÔÏfiÁËÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ (lung recruitment). O Van Marter ·¤‰ÂÈÍÂ, Û ̛· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË, fiÙÈ Ë ¯Ú‹ÛË CPAP Û·Ó ÂÈÏÔÁ‹ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ ÌÔÚ› Ó· ÌÂÈÒÓÂÈ ÙËÓ ·Ó¿ÁÎË Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ Î·È Ó· ÚÔÛٷهÂÈ ·fi ÙÔ ÙÚ·‡Ì· ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (39). ∏ ¯Ú‹ÛË CPAP ·fi ÌfiÓË Ù˘ ÌÔÚ› Ó· ÂÙ‡¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÛÙ·ıÂÚfiÙËÙ· ÙˆÓ Î˘„ÂÏ›‰ˆÓ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ÈηÓÔÔÈËÙÈÎfi ¤ÚÁÔ Ù˘ ·Ó·ÓÔ‹˜ Î·È ÈηÓÔÔÈËÙÈ΋ ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜. ™Ù· ›‰È· ·ÔÙÂϤÛÌ·Ù·, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â˘ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÙÔ˘ CPAP ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ηÈ, ηْ Â¤ÎÙ·ÛË, Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜, η٤ÏËÍ·Ó Î·È ÔÈ Kamper Î·È Û˘Ó (41), ·ÏÏ¿ Î·È ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ÙˆÓ Avery Î·È Û˘Ó ·fi ÙÔ Columbia Ù˘ ¡. ÀfiÚ΢ (42), ÛÙËÓ ÔÔ›· Ë ¯Ú‹ÛË CPAP Û ÓÂÔÁÓ¿ ¤‰ˆÛ ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù·. ∆· ÓÂÔÁÓ¿ ·˘Ù¿ Â¤˙ËÛ·Ó, ¯ˆÚ›˜ Ó· ¯ÚÂÈ¿˙ÔÓÙ·È Ô͢ÁfiÓÔ ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜. ™Â ÂͤÏÈÍË ‚Ú›ÛÎÂÙ·È ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ·fi ÙËÓ ∞˘ÛÙÚ·Ï›·, Ì ÂÈÎÂÊ·Ï‹˜ ÙÔÓ ∫·ıËÁËÙ‹ Colin Morley Î·È ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ ¡ÂÔÁÓÒÓ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ “∞ÏÂÍ¿Ó‰Ú·”, ÛÙËÓ ÔÔ›· ‰ÔÎÈÌ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ CPAP, Û ۇÁÎÚÈÛË Ì ÙÔÓ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, Û Ôχ ÚfiˆÚ· ÓÂÔÁÓ¿ ËÏÈΛ·˜ ·ËÛ˘ 2529 ‚‰ÔÌ¿‰ˆÓ, Ì ÂÓı·ÚÚ˘ÓÙÈο ̤¯ÚÈ ÛÙÈÁÌ‹˜ ·ÔÙÂϤÛÌ·Ù·. OÈ ÏfiÁÔÈ ·ÔÙ˘¯›·˜ ÙÔ˘ CPAP Û ÓÂÔÁÓ¿ ‚¿ÚÔ˘˜ ÌÈÎÚfiÙÂÚÔ˘ ·fi 1500 g ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û˘Ó‹ıˆ˜ ¿ÓÔÈ·, ·˘ÍË̤ÓÔ ¤ÚÁÔ ·Ó·ÓÔ‹˜ Î·È ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· (11). ∏ ÚÔԉ¢ÙÈ΋ ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ÙÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Î·È Ë ·ÓÂ·Ú΋˜ Û›ÙÈÛË, Ì ÎfiˆÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ì˘ÒÓ, ÌÔÚ› Ó· ·ÔÙÂÏÔ‡Ó ·ÈÙ›· ÌÂÙ·‚ÔÏ‹˜ ÙÔ˘ ÙÚfiÔ˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ·fi CPAP Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (11). ∂ÈÙÚÂfiÌÂÓË ˘ÂÚηÓ›· ŒÓ·˜ ·ÎfiÌË ÙÚfiÔ˜ ·ÔÊ˘Á‹˜ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È Ë ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ˘ÂÚηÓ›·˜ (permissive hypercapnia). ∏ ÂÈÙÚÂfiÌÂÓË ˘ÂÚηÓ›·, ‰ËÏ·‰‹ Ë ·ÓÔ¯‹ ÂÓfi˜ ·ÚÙËÚÈ·ÎÔ‡ PCO2 >45-60 mmHg, ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› ÂÈÚ·Ì·ÙÈο Û ÌÂϤÙ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Úfi-

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ˆÚˆÓ ÓÂÔÁÓÒÓ, Ì ÛÎÔfi Ó· ÌÂÈÒÛÂÈ ÙËÓ ·ÓÒÙÂÚË ›ÂÛË ÂÈÛÓÔ‹˜ (peak inspiratory pressure - PIP) Î·È ¤ÙÛÈ Ó· ÂÏ·ÙÙˆı› Ô ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ ·¤Ú·. ™Â Ì›· ÌÂϤÙË, ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 601-1250 g, Ô˘ ¤Ï·‚·Ó ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· Î·È ¯ÚÂÈ¿ÛÙËÎ·Ó Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ ÙȘ ÚÒÙ˜ 24 ÒÚ˜ Ù˘ ˙ˆ‹˜ ÙÔ˘˜, Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Â›Ù Û ÓÔÚÌÔηÓ›· PaCO2 <45, ›Ù Û ˘ÂÚηÓ›· PaCO2 >45. ∞ԉ›¯ıËΠfiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ·Ú¤ÌÂÈÓ ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· 96 ÒÚ˜ ÌÂÙ¿ ÙËÓ Ù˘¯·ÈÔÔ›ËÛË ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ÛÙËÓ ÔÌ¿‰· Ù˘ ˘ÂÚηÓ›·˜ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· Ù˘ ÓÔÚÌÔηÓ›·˜ (43). ∞ÓÙ›ıÂÙ·, Ô Û˘ÓÔÏÈÎfi˜ ¯ÚfiÓÔ˜ Ô͢ÁÔÓÔıÂÚ·›·˜ Î·È Ë Â›ÙˆÛË Ù˘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜, Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ Î·È ÂÚÈÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜, ÙÔ Û‡Ó‰ÚÔÌÔ ‰È·Ê˘Á‹˜ ·¤Ú·, ÙÔ ÔÛÔÛÙfi ÙˆÓ Â·Ó·‰È·ÛˆÏËÓÒÛˆÓ, Ë ‰È¿ÚÎÂÈ· ¯Ú‹Û˘ CPAP ÌÂÙ¿ ÙËÓ ·ԉȷۈϋӈÛË, ηıÒ˜ Î·È Ë ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜. øÛÙfiÛÔ, Û ¿ÏÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ‰ÂÓ ·ԉ›¯ıËΠfiÙÈ Ë ÂÈÙÚÂfiÌÂÓË ˘ÂÚηÓ›· ÛÙË ‰È¿ÚÎÂÈ· ÙˆÓ 10 ÚÒÙˆÓ ËÌÂÚÒÓ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙÔ ÔÛÔÛÙfi ı·Ó¿ÙÔ˘ ‹ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ (44). ¶¿ÓÙˆ˜, Ë ÔÌ¿‰· Ù˘ ˘ÂÚηÓ›·˜ ˘ÂÚÙÂÚÔ‡Û ÛËÌ·ÓÙÈο, ηıÒ˜ ÌfiÓÔ 1% Û˘Ó¤¯È˙ ӷ ¯ÚÂÈ¿˙ÂÙ·È Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ ÛÙȘ 36 ‚‰ÔÌ¿‰Â˜ ˙ˆ‹˜, Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· Ù˘ ÓÔÚÌÔηÓ›·˜, fiÔ˘ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ‹Ù·Ó 16%. ™Ù· ÂÍ·ÈÚÂÙÈο ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ (ELBW), fï˜, Ë ˘ÂÚηÓ›· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ÂÁÎÂÊ·ÏÈ΋ ·ÈÌ¿ÙˆÛË (CBF ÌÂٷ͇ 20-28), ÂÓÒ ·ÓÙ›ıÂÙ· ¯·ÌËÏfiÙÂÚË Û˘ÁΤÓÙÚˆÛË PaCO2, ÌÂٷ͇ 40-45 mmHg, Û˘Ó‰˘¿˙ÂÙ·È Ì ÂÏ·Ùو̤ÓË ÂÁÎÂÊ·ÏÈ΋ ·ÈÌ¿ÙˆÛË (CBF ÌÂٷ͇ 14-17) (45). ∞˘Ù‹ Ë ·Ú·Ù‹ÚËÛË Â›Ó·È ÛËÌ·ÓÙÈ΋, ȉȷ›ÙÂÚ· ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤Ó˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌ¿ÙˆÛ˘, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Û ÂÚ›ÙˆÛË ¯ÔÚ‹ÁËÛ˘ ˘ÂÚÔÛ̈ÙÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, Û ٷ¯Â›· ¤Á¯˘ÛË ˘ÁÚÒÓ, ¯Ú‹Û˘ ÛÙÂÚÔÂȉÒÓ, ÈÓÔÙÚfiˆÓ Ê·ÚÌ¿ÎˆÓ ‹ ÔÍÂȉˆÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ô˘ ı· Ú¤ÂÈ Ó· Û˘Ó‰˘¿˙ÔÓÙ·È Ì ¯·ÌËÏfiÙÂÚÔ PaCO2. ¶Èı·ÓÒ˜, Ë ÛÙÚ·ÙËÁÈ΋ ı· Ú¤ÂÈ Ó· ‰È·ÊÔÚÔÔÈÂ›Ù·È ÛÙ· ÂÍ·ÈÚÂÙÈο ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÙÔ̤· Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ˘ÂÚηÓ›·˜, Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfiÙÂÚÔ ÓÂÔÁÓÈÎfi ÏËı˘ÛÌfi, fiÔ˘ Ì¿ÏÏÔÓ ˘¿Ú¯Ô˘Ó ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ηıÒ˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ¤˜ ÔÈ Û˘Ó¤ÂȘ ·fi ÙËÓ ÂÈÙÚÂfiÌÂÓË ˘ÂÚηÓ›· ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ ÙˆÓ ¿Ú· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ. ™Â ·ÓÒÚÈÌ· ÂÈÚ·Ì·Ùfi˙ˆ·, ¿ÓÙˆ˜, Ë ˘ÂÚ‚ÔÏÈ΋ ˘ÂÚηÓ›· ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (46). ¶Èı·Ó¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ·fi ÙË

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18-11-04

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¶·È‰È·ÙÚÈ΋ 2004;67:310-320

¯Ú‹ÛË Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ˘ÂÚηÓ›·˜ Â›Ó·È Ë Ì›ˆÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ë Ì›ˆÛË Ù˘ ‰È¿ÚÎÂÈ·˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ë ·˘ÍË̤ÓË ·Ô‰¤ÛÌ¢ÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ ·fi ÙËÓ ·ÈÌÔÛÊ·ÈÚ›ÓË Î·È Ë Ì›ˆÛË ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘ ˘ÔηÓ›·˜. ¶Èı·Ó¿ ÌÂÈÔÓÂÎÙ‹Ì·Ù· ·fi ÙË ¯Ú‹ÛË Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ˘ÂÚηÓ›·˜ Â›Ó·È Ë ‰È·ÛÙÔÏ‹ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ, Ë ˘ÔÍ·ÈÌ›·, Ë ˘ÂÚηÏÈ·ÈÌ›·, Ë ÌÂȈ̤ÓË Û‡Ó‰ÂÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ Ì ÙËÓ ·ÈÌÔÛÊ·ÈÚ›ÓË, Ë ·˘ÍË̤ÓË Ó¢ÌÔÓÈ΋ ·ÁÁÂȷ΋ ·ÓÙ›ÛÙ·ÛË, Ë ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ÛÙ· Ôχ ÚfiˆÚ· ÓÂÔÁÓ¿ Î·È Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ (46). À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ ŒÓ· ¿ÏÏÔ, Û‡Á¯ÚÔÓÔ Â›‰Ô˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È Ô ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ (high frequency ventilation - HFV). À¿Ú¯Ô˘Ó 3 ›‰Ë ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡: Ô HFJV (high frequency jet ventilation), Ô HFFI (high frequency flow interrupter) Î·È Ô HFOV (high frequency oscillatory ventilation). OÈ ‰È·ÊÔÚ¤˜ ÛÙÔÓ Ì˯·ÓÈÛÌfi Ì ÙÔÓ ÔÔ›Ô ·˘ÙÔ› ÔÈ ·Ó·Ó¢ÛÙ‹Ú˜ ηٷӤÌÔ˘Ó ÙȘ ˘„›Û˘¯Ó˜ ·Ó·ÓÔ¤˜, ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÔÚÈṲ̂Ó˜ ÌÈÎÚ¤˜ ‰È·ÊÔÚ¤˜ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜. OÈ ‰‡Ô ÚÒÙÔÈ, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ÂÈÙÚ¤Ô˘Ó Ó· Û˘Ó‰˘¿˙ÔÓÙ·È ÔÈ ˘„›Û˘¯Ó˜ ·Ó·ÓÔ¤˜ ÌÂ Û˘Ì‚·ÙÈÎfi Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ÂÓÒ Ô ÙÂÏÂ˘Ù·›Ô˜ ‰›ÓÂÈ ·ÔÎÏÂÈÛÙÈο ˘„›Û˘¯Ó˜ ·Ó·ÓÔ¤˜ Ì Â·Ó·ÚÚfiÊËÛË ÙÔ˘ ·¤Ú· ̤ۈ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· ÂÓ Â›‰ÂÈ ÂÓÂÚÁËÙÈ΋˜ ÂÎÓÔ‹˜. ∏ ·Ó·ÏÔÁ›· ÁÈ· ÙÔÓ HFOV Sensormedics Â›Ó·È 1:2 Û¯¤ÛË ÂÈÛÓÔ‹˜ ÚÔ˜ ÂÎÓÔ‹, ÁÈ· ÙÔÓ HFJV Bunnel Â›Ó·È 1:6, ÂÓÒ ÁÈ· ÙÔÓ HFFI Infrasonics 1:5 (46). ∫·È Ì ÙȘ 3 Û˘Û΢¤˜, Ô fiÁÎÔ˜ ÙˆÓ ÌÂÌÔÓˆÌ¤ÓˆÓ ·Ó·ÓÔÒÓ Ô˘ ¯ÔÚËÁÂ›Ù·È Â›Ó·È Û¯Â‰fiÓ ›ÛÔ˜ Ì ÙÔÓ ÓÂÎÚfi ¯ÒÚÔ ‹ ÌÈÎÚfiÙÂÚÔ˜ ·fi ·˘ÙfiÓ (11). ∂ÈϤÔÓ, Ë ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙÚÂȘ ÙÚfiÔ˘˜: ·) Ì ÙË ÌÔÚÊ‹ ·Î›‰·˜ (spike), fiÔ˘ ¤Ó· ·̷ ˘„ËÏ‹˜ ÂÓ¤ÚÁÂÈ·˜ ‰È·ÂÚÓ¿ÂÈ Ù·¯‡Ù·Ù· ÙÔ Î¤ÓÙÚÔ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Î·È ‰ËÌÈÔ˘ÚÁ› ÂÚÈÛÛfiÙÂÚÔ ÂÎÙÂٷ̤ÓË ÂÚÈÔ¯‹ ·ÓÙ·ÏÏ·Á‹˜ ·ÂÚ›ˆÓ fiÙ·Ó Êı¿ÓÂÈ ÛÙȘ ΢„ÂÏ›‰Â˜, ‚) Ì ÙË ÌÔÚÊ‹ Ù˘ ·˘ÍË̤Ó˘ ‰È¿¯˘Û˘, fiÔ˘ ·˘Í¿ÓÂÙ·È Ë ÌÔÚȷ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Î›ÓËÛË ÙˆÓ ·ÂÚ›ˆÓ, ÔfiÙÂ Î·È ·˘Í¿ÓÂÙ·È Ë ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ ÛÙËÓ Î˘„ÂÏȉÔÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË. ªÂ ·Ï¿ ÏfiÁÈ·, ·˘Ù¤˜ ÔÈ ÌÈÎÚ¤˜, ÁÚ‹ÁÔÚ˜ ·Ó·ÓÔ¤˜, ηıÒ˜ Ù·Ï·ÓÙÒÓÔ˘Ó ÙÔÓ ·¤Ú· ̤۷ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ Î·È ÙȘ ΢„ÂÏ›‰Â˜, ÚÔηÏÔ‡Ó ÈηÓÔÔÈËÙÈ΋ ·Ó¿ÌÂÈÍË ÙÔ˘ ÊÚ¤ÛÎÔ˘ Ô͢ÁfiÓÔ˘ Ô˘ ÌÂٷʤÚÂÙ·È ÛÙȘ ΢„ÂÏ›‰Â˜ Ì ÙÔ ‹‰Ë ˘¿Ú¯ÔÓ Û ·˘Ù¤˜ (46) Î·È Á) Ì ÙË ÌÔÚÊ‹ Ù˘ ÂÏÈÎÔÂȉԇ˜ ‰È¿¯˘Û˘, Ë ÔÔ›· ·ÔÙÂÏ› Ì›· ·Ú·ÏÏ·Á‹ Ù˘ ÌÔÚÊ‹˜ “spike” (11). ªÂ ÙÔÓ HFV, fiÛÔ ·˘Í¿ÓÂÈ Ë Ì¤ÛË ›ÂÛË (mean airway pressure), ÌÂÈÒÓÂÙ·È Ë

Paediatriki 2004;67:310-320

·ÙÂÏÂÎÙ·Û›· Î·È ‚ÂÏÙÈÒÓÂÙ·È Ë Û¯¤ÛË ·ÂÚÈÛÌÔ‡/·ÈÌ¿ÙˆÛ˘ (ventilation/perfusion), Ì ·ÔÙ¤ÏÂÛÌ· ηχÙÂÚË Ô͢ÁfiÓˆÛË. ™ÙÔÓ HFV Û˘Ì‚·›ÓÂÈ Î·Ï‡ÙÂÚË ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ CO2 ÏfiÁˆ ·˘ÍË̤Ó˘ ‰È¿¯˘Û˘, ÂÓÒ Ë ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ CO2 Â›Ó·È ·Ó¿ÏÔÁË Ù˘ Û˘¯ÓfiÙËÙ·˜ (frequency) Î·È ·Ó¿ÏÔÁË ÙÔ˘ ÙÂÙÚ·ÁÒÓÔ˘ ÙÔ˘ fiÁÎÔ˘ ·¤Ú· (tidal volume) (‰ËÏ·‰‹ f . VT2), ÂÓÒ ·ÓÙ›ıÂÙ· ÛÙÔÓ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ fiÁÎÔ˘ ·¤Ú· (‰ËÏ·‰‹ f . VT) (11). ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ÌÈÎÚ¤˜ ·ÏÏ·Á¤˜ ÛÙÔ Â‡ÚÔ˜ Ù˘ Ù·Ï¿ÓÙˆÛ˘ (¢P) ¤¯Ô˘Ó ÌÂÁ¿ÏË Â›ÙˆÛË ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ CO2. ¶·Ú¿ ÙËÓ ÂÓıÔ˘ÛÈÒ‰Ë ˘Ô‰Ô¯‹ ÙÔ˘ Ó¤Ô˘ ÌÔÓÙ¤ÏÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯Ú‹ÛË ÙÔ˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ì›ˆÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÙË ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ, ‰ÂÓ ¤‰ÂÈÍ·Ó ˘ÂÚÔ¯‹ Û ۯ¤ÛË Ì ÙÔÓ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi. ªÂϤÙ˜ Û ÓÂÔÁÓ¿, fiÔ˘ Ë ·ÓÂ¿ÚÎÂÈ· ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ›¯Â ‹‰Ë ÂÈϷΛ Ì ‰È¿ÌÂÛÔ ÂÌʇÛËÌ·, Û ηٿÛÙ·ÛË ‰ËÏ·‰‹ ÛÔ‚·ÚÔ‡ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠHFV ˆ˜ ̤ÛÔ ·Ó¿Ó˄˘ Î·È fi¯È ˆ˜ Û˘Ó‹ı˘ ÙÚfiÔ˜ ·ÂÚÈÛÌÔ‡, ÌÂÙ¿ ·fi ¯Ú‹ÛË Î·Ù¿ ̤ÛÔ fiÚÔ 44 ˆÚÒÓ, Ô HFV Ì›ˆÛ ٷ Ó¤· ÂÂÈÛfi‰È· ‰È·Ê˘Á‹˜ ·¤Ú· (47). ¶ÚfiÛÊ·ÙË ÌÂÁ¿ÏË ¤Ú¢ӷ Ô˘ Ù˘¯·ÈÔÔ›ËÛ 500 ÓÂÔÁÓ¿ Î·È Û˘Ó¤ÎÚÈÓ ÙÔÓ HFV Ì ÙÔÓ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi, ¤‰ˆÛ ıÂÙÈο ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ ÌÈÎÚfiÙÂÚË ‰È¿ÚÎÂÈ· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ (48). øÛÙfiÛÔ, ¿ÏϘ ÌÂϤÙ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ·˘Ù¿ Ù· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ì›ˆÛË ÙÔ˘ ÔÛÔÛÙÔ‡ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ Ì ÙË ¯Ú‹ÛË HFV (47,49-55). ª¤¯ÚÈ ÙÒÚ·, Ô HFV ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ì ÛÙÚ·ÙËÁÈ΋ ¯·ÌËÏÔ‡ fiÁÎÔ‡ (low volume strategies), ‰ËÏ·‰‹ ¯·ÌËÏ‹ ̤ÛË ›ÂÛË (PAW), Ì ÙËÓ ÂÏ›‰· Ó· ·ÔʇÁÂÙ·È ÂÚ·ÈÙ¤Úˆ ÙÚ·‡Ì· ÛÙÔÓ Ó‡ÌÔÓ·. ∞ÓÙ›ıÂÙ·, ˘ÈÔıÂÙÒÓÙ·˜ ÛÙÚ·ÙËÁÈ΋ ˘„ËÏÔ‡ fiÁÎÔ˘ (high volume strategies), ‰ËÏ·‰‹ ÂÊ·ÚÌÔÁ‹ ˘„ËÏ‹˜ ̤Û˘ ›ÂÛ˘, ÂÈÙ˘Á¯¿ÓÂÙ·È Ë Ì¤ÁÈÛÙË ÛÙÚ·ÙÔÏfiÁËÛË ÙÔ˘ Ó‡ÌÔÓ· (lung recruitment). ™Â ÂÈÚ·Ì·Ùfi˙ˆ· Ì ÛÔ‚·Ú‹ ·ÓÂ¿ÚÎÂÈ· ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÁÈ· ·Ú¿‰ÂÈÁÌ·, Ë ÛÙÚ·ÙËÁÈ΋ ˘„ËÏÔ‡ fiÁÎÔ˘ ·¤‰ˆÛ ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÚÔÛÙ·Û›·˜ ·fi ÙÔ ÙÚ·‡Ì·, Û ۯ¤ÛË Ì ÙÔÓ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi ‹ ÙÔÓ HFV Ì ¯·ÌËÏfi fiÁÎÔ (42,13). ªÂÙ·-·Ó¿Ï˘ÛË Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÌÂÏÂÙÒÓ, ÛÙȘ Ôԛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÔÏÈÙÈ΋ ¤ÎÙ˘Í˘ ÙÔ˘ Ó‡ÌÔÓ· (lung recruitment policy), ¤‰ÂÈÍ Ì›ˆÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘, ÂÓÒ ‰ÂÓ ÛËÌÂÈÒıËÎ·Ó ÌÂÙ·‚ÔϤ˜ ÛÙË ıÓËÛÈÌfiÙËÙ·, ·ÏÏ¿ ˘‹Ú¯Â Ù¿ÛË ÁÈ· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ‰È·Ê˘Á‹˜ ·¤Ú· Î·È ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ (56).

315

September-October 05 chris

18-11-04

15:18

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¶·È‰È·ÙÚÈ΋ 2004;67:310-320

∞‡ÍËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ·ÈÌÔÚÚ·Á›·˜ Û ÓÂÔÁÓ¿ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ <1500 g, Ù· ÔÔ›· Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó ÁÈ· ˘ÔÛÙ‹ÚÈÍË Ì HFV, ·Ó·Ê¤ÚıËÎÂ Î·È ÛÙË ÌÂϤÙË Vermont Oxford Network. ∆Ô ÔÛÔÛÙfi ¯Ú‹Û˘ HFV ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË Î˘Ì·ÈÓfiÙ·Ó ·fi 20% ¤ˆ˜ 24% ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1997-2000 Î·È ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÔ‚·Ú‹˜ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ·ÈÌÔÚÚ·Á›·˜ Î˘Ì·ÈÓfiÙ·Ó Û 8%. ŒÓ· ·fi Ù· ΤÓÙÚ· Ô˘ Û˘ÌÌÂÙ›¯·Ó ›¯Â ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ¯Ú‹Û˘ HFV (33%) Î·È ÙÔ ÔÛÔÛÙfi ÛÔ‚·Ú‹˜ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ·ÈÌÔÚÚ·Á›·˜ Û ·˘Ùfi ÙÔ Î¤ÓÙÚÔ ‹Ù·Ó Â›Û˘ ˘„ËÏfiÙÂÚÔ (13%) ÌfiÓÔ Î·Ù¿ ÙÔ ¤ÙÔ˜ 1997. ŸÙ·Ó ·ÔÊ·Û›ÛÙËÎÂ, ηٿ Ù· 2 ÂfiÌÂÓ· ¯ÚfiÓÈ·, Ó· ÌÂȈı› ÙÔ ÔÛÔÛÙfi ¯Ú‹Û˘ ÙÔ˘ HFV Û 19%, ÂÏ·ÙÙÒıËÎÂ Î·È ÙÔ ÔÛÔÛÙfi Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ·ÈÌÔÚÚ·Á›·˜ Û ÔÛÔÛÙfi 4,5% (45). ¶ÚfiÛÊ·ÙË Û˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË Ô˘ ÂͤٷÛ ÙËÓ Â›‰Ú·ÛË ÙÔ˘ HFV ÛÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤÏÈÍË, η٤ÏËÍ fiÙÈ “Ô HFV ‰ÂÓ ÌÔÚ› Ó· Û˘ÓÈÛÙ¿Ù·È ˆ˜ Û˘Ó‹ı˘ ÂÊ·ÚÌÔÁ‹ ÁÈ· Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ” (66). ∆ÂÏÈο, Ô HFV, Û˘ÁÎÚÈÓfiÌÂÓÔ˜ Ì ÙÔÓ CMV (Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi), ‰ÂÓ ıˆÚÂ›Ù·È ·ÓÒÙÂÚÔ˜ ÛÙËÓ ÂÚ›ÙˆÛË ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ™∞¢, ÂÊfiÛÔÓ Ì ÙÔÓ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â·ÚΤ˜ PEEP Î·È ¯·ÌËÏfi˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ (tidal volume). ¡¤Â˜ ÌÔÚʤ˜ Û˘Á¯ÚÔÓÈ˙fiÌÂÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ÂͤÏÈÍË Ù˘ Ù¯ÓÔÏÔÁ›·˜ ÛÙÔÓ ÙÔ̤· ÙÔ˘ HFV, ‚ÂÏÙÈÒÓÂÙ·È Î·È Ë ¯Ú‹ÛË ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ™·Ó ›‰Ô˜ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÛÙ· ÓÂÔÁÓ¿ ¯ÚËÛÈÌÔÔÈ›ٷÈ, ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 20 ¯ÚfiÓÈ·, Ô pressure-limited, time-cycled ventilation. ∆Ô Úfi‚ÏËÌ· Ô˘ ÚÔ·ÙÂÈ ·fi ÙË ¯Ú‹ÛË ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È Ô ÌË-Û˘Á¯ÚÔÓÈÛÌfi˜ ÌÂٷ͇ ÙˆÓ ·Ó·ÓÔÒÓ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· Î·È ÙˆÓ ·˘ÙfiÌ·ÙˆÓ ·Ó·ÓÔÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡, ÌÂ Û˘Ó¤ÂȘ: ·) ·ÓˆÌ·Ï›· ÛÙË ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜, ÙfiÛÔ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ fiÛÔ Î·È Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ÚÔ‹˜, ‚) Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú·, ÏfiÁˆ ÂÓÂÚÁËÙÈ΋˜ ÂÎÓÔ‹˜, Á) Ó¢ÌÔÓÈ΋ ·ÈÌÔÚÚ·Á›·, ‰) Ó¢ÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜ Î·È Â) ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ· (11). °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÒÓ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ, Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ÙÔÓ ÌË Û˘Á¯ÚÔÓÈÛÌfi, ·˘Í¿ÓÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ·Ó·ÓÔÒÓ Û >60 ‹ ÂÏ·ÙÙÒÓÂÙ·È Ô ¯ÚfiÓÔ˜ ÂÈÛÓÔ‹˜, ÒÛÙ ӷ “È·ÛÙ›” Ô Ú˘ıÌfi˜ ÙˆÓ ·Ó·ÓÔÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡ ‹ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ì˘Ô¯·Ï·ÚˆÙÈο, ÒÛÙ ӷ ηٷÛÙ·ÏÔ‡Ó ÔÈ ·˘ÙfiÌ·Ù˜ ·Ó·ÓÔ¤˜. ª›· Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ·ÓÙÈÌÂÙÒÈÛË, fï˜, ÂÓ¤¯ÂÈ ÎÈÓ‰‡ÓÔ˘˜ ·fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ, ÔÈ Ôԛ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÙÚÔÊ›· ÙˆÓ

316

Paediatriki 2004;67:310-320

ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ, ÙÔ ÙÚ·‡Ì· ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÙË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (11). ∂›Û˘, Ì ÙËÓ ÂͤÏÈÍË Ù˘ ÌÈÎÚÔÙ¯ÓÔÏÔÁ›·˜ ηٷÛ΢¿ÛÙËÎ·Ó Ó¤·˜ ÁÂÓÈ¿˜ ‚ÂÏÙȈ̤ÓÔÈ ·Ó·Ó¢ÛÙ‹Ú˜, Ô˘ ÛÙfi¯Ô ¤¯Ô˘Ó Ó· ÂÙ‡¯Ô˘Ó ÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ÂÊÈÎÙfi Û˘Á¯ÚÔÓÈÛÌfi. ∞˘Ùfi ÙÔ Â›‰Ô˜ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ ÔÓÔÌ¿˙ÂÙ·È ·ÂÚÈÛÌfi˜ ˘ÚÔ‰ÔÙÔ‡ÌÂÓÔ˜ ·fi ÙÔÓ ·ÛıÂÓ‹ (patienttriggered ventilation - PTV) Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ Û˘Á¯ÚÔÓÈṲ̂ÓÔ ‰È·Ï›ÔÓÙ· ·ÂÚÈÛÌfi ıÂÙÈ΋˜ ›ÂÛ˘ (synchronised intermittent positive pressure ventilation - SIPPV) ‹, ·ÏÏÈÒ˜, ˘ÔÛÙËÚÈ˙fiÌÂÓÔÂÏÂÁ¯fiÌÂÓÔ ·ÂÚÈÛÌfi (assist/control), Ì ÙÔÓ ÔÔ›Ô fiϘ ÔÈ ·˘ÙfiÌ·Ù˜ ·Ó·ÓÔ¤˜ ÙÔ˘ ÓÂÔÁÓÔ‡, Ô˘ ÍÂÂÚÓÔ‡Ó ¤Ó· ÚÔηıÔÚÈṲ̂ÓÔ fiÚÈÔ ÚÔ‹˜ ·¤Ú·, .¯.

0,2-0,5 L/min, ˘ÔÛÙËÚ›˙ÔÓÙ·È ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Û ›ÂÛË, ÚÔ‹ Î·È fiÁÎÔ Î·È ÙÔÓ Û˘Á¯ÚÔÓÈṲ̂ÓÔ ‰È·Ï›ÔÓÙ· ηْ Â›ÎÏËÛË ·ÂÚÈÛÌfi (synchronised intermittent mandatory ventilation SIMV), Ì ÙÔÓ ÔÔ›Ô ÌfiÓÔ ÔÚÈṲ̂Ó˜ ·fi ÙȘ ·Ó·ÓÔ¤˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ˘ÔÛÙËÚ›˙ÔÓÙ·È Ì˯·ÓÈο. ŒÓ·˜ ‰Â‡ÙÂÚÔ˜ ·ÈÛıËÙ‹Ú·˜, Û ÔÚÈṲ̂ÓÔ˘˜ ·Ó·Ó¢ÛÙ‹Ú˜, ÂÈÙÚ¤ÂÈ ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ Û˘Á¯ÚÔÓÈÛÌfi, ÛÙË Ê¿ÛË Ù˘ ÛÙ·‰È·Î‹˜ ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· (weaning), Ô˘ ÔÓÔÌ¿˙ÂÙ·È Â˘·ÈÛıËÛ›· ÔÏÔÎÏ‹ÚˆÛ˘ ‹ ·‡Û˘ ÙÔ˘ ·ÂÚÈÛÌÔ‡ (termination sensitivity) Î·È ˘ÔÏÔÁ›˙ÂÈ ÙËÓ ÙÒÛË ÛÙËÓ ÂÈÛÓ¢ÛÙÈ΋ ÚÔ‹ ·¤Ú·. °È· ·Ú¿‰ÂÈÁÌ·, fiÙ·Ó Ë ÚÔ‹ ÙÔ˘ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú· ÌÂȈı› Û 0-25%, ÛÙË Ê¿ÛË Ô˘ ÙÔ ÓÂÔÁÓfi ÂÎÓ¤ÂÈ ÂÓÂÚÁËÙÈο, Ô ·ÈÛıËÙ‹Ú·˜ ÛÙ·Ì·Ù¿ ÙË Ì˯·ÓÈ΋ ·Ó·ÓÔ‹, ÂÈÙÚ¤ÔÓÙ·˜ ÛÙÔ ÓÂÔÁÓfi Ó· ÂÎÓ‡ÛÂÈ. ¡¤ÔÈ Û‡Á¯ÚÔÓÔÈ ÙÚfiÔÈ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Î·È Ì ÙÔ˘˜ Ù¤ÛÛÂÚȘ ·Ú·Î¿Ùˆ ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ·Ó·Ó¢ÛÙ‹Ú˜, ·ÏÏ¿ ÁÈ· Ó· ηıÈÂÚˆıÔ‡Ó ·˘ÙÔ› ÔÈ ·Ó·Ó¢ÛÙ‹Ú˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋ Î·È Ó· ·Ô‰ÂȯıÔ‡Ó Ì ‚‚·ÈfiÙËÙ· Ù· Ù˘¯fiÓ ÏÂÔÓÂÎÙ‹Ì·Ù¿ ÙÔ˘˜, ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ÂÚ¢ÓËÙÈΤ˜ ÌÂϤÙ˜. ∞˘ÙÔ› ›ӷÈ: ·) ∞ÂÚÈÛÌfi˜ Ì ˘ÔÛÙËÚÈ˙fiÌÂÓË ›ÂÛË (pressure support ventilation - PSV) (57), Ì ÙÔÓ ÔÔ›Ô Ô ›‰ÈÔ˜ Ô ·ÛıÂÓ‹˜ ˘ÚÔ‰ÔÙ› Ì›· ·Ó·ÓÔ‹ ˘ÔÛÙËÚÈ˙fiÌÂÓË ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ˆ˜ ÚÔ˜ ¤Ó· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ fiÚÈÔ ›ÂÛ˘. ‚) ∞ÂÚÈÛÌfi˜ Ì ·Ó·ÏÔÁÈ΋ ˘Ô‚Ô‹ıËÛË (proportional assist ventilation - PAV) (58), Ì ÙÔÓ ÔÔ›Ô Ë ›ÂÛË ·˘Í¿ÓÂÈ Û ·Ó·ÏÔÁ›· Ì ÙÔÓ ÂÈÛÓÂfiÌÂÓÔ fiÁÎÔ (tidal volume) Î·È ÙËÓ ÂÈÛÓ¢ÛÙÈ΋ ÚÔ‹ ÙˆÓ ·˘ÙfiÌ·ÙˆÓ ·Ó·ÓÔÒÓ, ÂÓÒ Ô ›‰ÈÔ˜ Ô ·ÛıÂÓ‹˜ Ú˘ıÌ›˙ÂÈ ÙË Û˘¯ÓfiÙËÙ·, ÙÔÓ ¯ÚfiÓÔ Î·È ÙÔ ‚¿ıÔ˜ ÙˆÓ ·Ó·ÓÔÒÓ. ªÂ ÙÔ ÚfiÁÚ·ÌÌ· “enhancement” ÌÂÈÒÓÂÙ·È ÙÔ Ì˯·ÓÈÎfi ¤ÚÁÔ Ù˘ ·Ó·ÓÔ‹˜. Á) ∞ÂÚÈÛÌfi˜ Ì ÂÏÂÁ¯fiÌÂÓÔ ÂÍ·ÛÊ·ÏÈṲ̂ÓÔ

September-October 05 chris

18-11-04

15:18

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fiÁÎÔ (volume-controlled ventilation guaranteed) (59), Ì ÙÔÓ ÔÔ›Ô ¤Ó·˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˜ fiÁÎÔ˜ ·¤Ú· ¤¯ÂÈ ÚÔÁÚ·ÌÌ·ÙÈÛÙ› Ó· ‰Ôı› ›Ù ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ›Ù ·fi ÙÔÓ ·ÛıÂÓ‹, ÂÓÒ Ë ÂÈÛÓÔ‹ ÙÂÚÌ·Ù›˙ÂÙ·È fiÙ·Ó ¤¯ÂÈ ¯ÔÚËÁËı› ·˘Ùfi˜ Ô ÚÔηıÔÚÈṲ̂ÓÔ˜ fiÁÎÔ˜ ·¤Ú·. ‰) ∆Ú·¯Âȷ΋ ÂÌʇÛËÛË ·ÂÚ›Ô˘ (tracheal gas insufflation) (TGI) (60), Ì ÙÔÓ ÔÔ›Ô Ô ·¤Ú·˜ Ô˘ ÊÙ¿ÓÂÈ ÛÙÔ ¿Óˆ ÙÌ‹Ì· ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ ηٿ ÙËÓ ÂÈÛÓÔ‹, ·ÔÌ·ÎÚ‡ÓÂÙ·È ·fi ÙÔÓ ÓÂÎÚfi ¯ÒÚÔ Î·È Ì·˙› ÙÔ˘, ‚¤‚·È·, ÙÔ CO2, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ PaCO2 ηÈ/‹ Ù˘ PIP ηÈ, ÂÔ̤ӈ˜, ÙÔ˘ tidal volume Î·È ÙÔ˘ ÔÁÎÔÙÚ·‡Ì·ÙÔ˜ Ô˘ ÙÔÓ Û˘Óԉ‡ÂÈ. ¢˘ÛÙ˘¯Ò˜, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙÔÓ PTV Ì ÙÔÓ IMV ‰ÂÓ ¤‰ÂÈÍ ˘ÂÚÔ¯‹ ÙÔ˘ ÚÒÙÔ˘ ¤Ó·ÓÙÈ ÙÔ˘ ‰Â‡ÙÂÚÔ˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÍ¿ÚÙËÛË ·fi ÙÔ Ô͢ÁfiÓÔ ÛÙȘ 28 Ë̤Ú˜ ˙ˆ‹˜ ‹ ÛÙȘ 36 ‚‰ÔÌ¿‰Â˜ (46). ¶·Ú’ fiÏ· ·˘Ù¿, ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË ÙÔ˘ PTV Ì ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ Î·È Ô͢ÁÔÓÔıÂÚ·›·˜. ¶Èı·Ófi˜ ÏfiÁÔ˜ ·ÔÙ˘¯›·˜ ÙÔ˘ PTV Â›Ó·È Ë ¯Ú‹ÛË ‰È·ÊÔÚÂÙÈÎÒÓ Ù‡ˆÓ ·Ó·Ó¢ÛÙ‹Ú· Ì ‰È·ÊÔÚÂÙÈÎfi ¤Ó·˘ÛÌ· ˘ÚÔ‰fiÙËÛ˘ (airway or airflow trigger) Ô˘ ÂËÚ¿˙ÂÈ ÙÔÓ ¯ÚfiÓÔ, ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ˘ÚÔ‰fiÙËÛ˘ Î·È ÙË Û˘¯ÓfiÙËÙ· ÌË Û˘Á¯ÚÔÓÈÛÌÔ‡ (46). À¿Ú¯Ô˘Ó, ·ÎfiÌË, ‰È·ÊÔÚ¤˜ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ԉȉfiÌÂÓÔ˘ fiÁÎÔ˘ ÙˆÓ ·Ó·Ó¢ÛÙ‹ÚˆÓ (volume delivery), fiÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ôχ Û‡ÓÙÔÌÔÈ ¯ÚfiÓÔÈ ÂÈÛÓÔ‹˜ (<0,4 sec) Î·È ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ·Ó·ÓÔÒÓ (>90 bpm) (46). ¡¤Â˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙË ‰È·Û¿ÊËÛË ÙˆÓ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ ·fi ÙË ¯Ú‹ÛË PTV, Èı·ÓÒ˜ Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ·Ó·Ó¢ÛÙ‹ÚˆÓ Ì ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ ˘ÚÔ‰fiÙËÛ˘ (trigger delay). ÀÁÚfi˜ ·ÂÚÈÛÌfi˜ ∞fi ÙÔ 1966, ÔÈ Clark Î·È Gollan ¿Ú¯ÈÛ·Ó Ó· ÂÈÚ·Ì·Ù›˙ÔÓÙ·È ¿Óˆ ÛÙË ¯Ú‹ÛË ÙÔ˘ ˘ÁÚÔ‡ ·ÂÚÈÛÌÔ‡ (liquid ventilation) Ì ÙË ¯ÔÚ‹ÁËÛË Û ıËÏ·ÛÙÈο Ô͢ÁÔӈ̤ÓÔ˘ ˘ÂÚÊıÔÚÈÔ¸‰ÚÔÁÔÓ¿Óıڷη (perfluorocarbon - PFC) (61). ∏ ȉ¤· Ù˘ ¯Ú‹Û˘ ·ÚfiÌÔÈˆÓ ˘ÁÚÒÓ ÛÙÔÓ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, Ô˘ Ó· ¤¯Ô˘Ó ÙËÓ Ù¿ÛË Ó· ÂÍ·ÂÚÒÓÔÓÙ·È Ì¤Û· ÛÙȘ ΢„ÂÏ›‰Â˜, ÚÔÛʤÚÔÓÙ·˜, ˆÛÙfiÛÔ, ηϋ ‰È·Ï˘ÙfiÙËÙ· ÙfiÛÔ ÛÙÔ Ô͢ÁfiÓÔ fiÛÔ Î·È ÛÙÔ ‰ÈÔÍ›‰ÈÔ, ÒÛÙ ӷ ÂÈÙÚ¤ÂÙ·È Ë Î·Ï‹ ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ, ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ›‰È· ÙË Ê˘ÛÈÔÏÔÁ›· ·Ó¿Ù˘Í˘ ÙÔ˘ Ó‡ÌÔÓ· ÛÙ· ÓÂÔÁÓ¿. ŸÙ·Ó Ô ·ÓÒÚÈÌÔ˜ Ó‡ÌÔÓ·˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ‚Ú›ÛÎÂÙ·È Û ÂÚÈ‚¿ÏÏÔÓ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡, ·ÎfiÌË Î·È ÛÙËÓ ÂÚ›ÙˆÛË ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ¤¯ÂÈ ÛËÌ·ÓÙÈο ηχÙÂÚË ÂÏ·ÛÙÈ΋ Â·Ó·ÊÔÚ¿. ∞ÓÙ›ıÂÙ·, ÙÔ ¤Ì‚Ú˘Ô Ô˘

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·Ó·Ù‡ÛÛÂÙ·È Û ÂÚÈ‚¿ÏÏÔÓ ·ÓÂ·ÚΤ˜ Û ·ÌÓÈ·Îfi ˘ÁÚfi, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÛÂ Û˘Óı‹Î˜ ¯ÚfiÓÈ·˜ ‰È·ÚÚÔ‹˜ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡, Û˘¯Ó¿ ·Ó·Ù‡ÛÛÂÈ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· Î·È ·˘ÍË̤ÓË Ó¢ÌÔÓÈ΋ ·ÓÙ›ÛÙ·ÛË. ¶·ÚfiÌÔÈ·, ÛÙÔ Ôχ ÚfiˆÚÔ ÓÂÔÁÓfi, Ë ·fiÙÔÌË ÌÂÙ¿‚·ÛË ·fi ÙÔ È‰·ÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ Ù˘ Ì‹ÙÚ·˜ ÛÙÔÓ ·¤Ú· ÌÔÚ› Ó· ¤¯ÂÈ ‚Ï·ÙÈΤ˜ Û˘Ó¤ÂȘ ÛÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ Ó‡ÌÔÓ·, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ (11). ∆Ô Ô͢ÁfiÓÔ ¤¯ÂÈ 20 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ‰È·Ï˘ÙfiÙËÙ· ÛÙÔÓ Ô͢ÁÔӈ̤ÓÔ ˘ÂÚÊıÔÚÈÔ¸‰ÚÔÁÔÓ¿Óıڷη Û ۯ¤ÛË Ì ÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙÔ ‰ÈÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη. ∂ÈϤÔÓ, ÙÔ PFC Â›Ó·È ¿¯ÚˆÌÔ Î·È ¿ÔÛÌÔ, ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·ÌËÏ‹ Ù¿ÛË ÂÈÊ·Ó›·˜ Î·È Â›Ó·È ·‰È¿Ï˘ÙÔ Û ÏÈ›‰È·, ·ÏÎÔfiÏË Î·È ÓÂÚfi, ·ÔÙÂÏ› Ê˘ÛÈÎfi ‚ÈÔÏÔÁÈÎfi ÚÔ˚fiÓ Î·È ·ÔÚÚÔÊ¿Ù·È ·fi ÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· Û ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ‹ Û ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∂Í·ÂÚÒÓÂÙ·È ÁÚ‹ÁÔÚ· ÛÙÔÓ ·ÙÌÔÛÊ·ÈÚÈÎfi ·¤Ú· (11). ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤¯Ô˘Ó ‰Â›ÍÂÈ Î·Ï‹ ·ÓÔ¯‹ (62). ¶¿ÓÙˆ˜, Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯Ú‹ÛË ÙÔ˘ PFC ·Ú·Ì¤ÓÔ˘Ó ¿ÁÓˆÛÙ·. ◊È· ·‡ÍËÛË Ù˘ ÂÈÊ·ÓÂȷ΋˜ Ù¿Û˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Èı·Ó¿ ÏfiÁˆ Ù˘ ·Ú·ÌÔÓ‹˜ ˘ÔÏÂÈÌÌ¿ÙˆÓ ÙÔ˘ ˘ÂÚÊıÔÚÈÔ¸‰ÚÔÁÔÓ¿Óıڷη ÛÙȘ ΢„ÂÏ›‰Â˜. πÛÙÔÏÔÁÈ΋ ·Ó¿Ï˘ÛË ·Ú·Û΢·ÛÌ¿ÙˆÓ ·fi ÚfiˆÚ· ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ¤Ï·‚·Ó PFC ¤‰ÂÈÍ Ì›ˆÛË Ù˘ ÓfiÛÔ˘ Ù˘ ˘·Ï›Ó˘ ÌÂÌ‚Ú¿Ó˘ Î·È Ì›ˆÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÈıËÏ›Ô˘ (63).

O Greenspan ¯ÚËÛÈÌÔÔ›ËÛ ÌÂÚÈ΋ liquid ventilation ̤¯ÚÈ Î·È 96 ÒÚ˜ ÁÈ· ÙË ‰È¿ÛˆÛË 6 ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ·Ú·ÙÂٷ̤ÓÔ (>2 ‚‰ÔÌ¿‰Â˜) ECMO, Ì ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙ·ÏÏ·Á‹˜ ·ÂÚ›ˆÓ (64). ™Â Ì›· ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, 24 ÓÂÔÁÓ¿ Ì ‰È¿¯˘ÙË ÛÔ‚·Ú‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ ÚÔ Ù˘ ¤Ó·Ú͢ ECMO, Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó ˆ˜ ÚÔ˜ ÙË Ï‹„Ë liquid ventilation. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘, Ë ÔÔ›· ‰ÈÂÎfiË, ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ·Ó·ÎÔÈÓˆı› (46). ™˘ÌÂÚ¿ÛÌ·Ù· O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ÛÒ˙ÂÈ ˙ˆ¤˜ Î·È ÂӉ›ÎÓ˘Ù·È ˆ˜ ıÂÚ·›· ÛÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. ¶·Ú’ fiÏ· ·˘Ù¿, Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘ fiÛÔÓ ·ÊÔÚ¿ Û ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÙÔÍÈÎfiÙËÙ· ÙÔ˘ Ô͢ÁfiÓÔ˘ Â›Ó·È ·ÚÓËÙÈο. ∂ÈϤÔÓ, ÔÏϤ˜ ÌÂϤÙ˜ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· Û˘ÁÎÏ›ÓÔ˘Ó ÛÙË ‰È·›ÛÙˆÛË Ù˘ ‚Ï·ÙÈ΋˜ ‰Ú¿Û˘ Ô˘ ·ÛΛ Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÛÙË Á¤ÓÂÛË ‹ Âȉ›ӈÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ηÌ‡Ï˘ ›ÂÛ˘-¯ÚfiÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÈÛÓÔ‹˜ ÌÔÚ›

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Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÚfiÏË„Ë Î·È ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ÕÏϘ Ù¯ÓÈΤ˜ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙ·ÏÏ·Á‹˜ ·ÂÚ›ˆÓ, Ù˘ ηٷÓÔÌ‹˜ ÙÔ˘ ·ÂÚÈÛÌÔ‡ Î·È Ù˘ Ì˯·ÓÈ΋˜ ÙÔ˘ Ó‡ÌÔÓ· ·ÔÙÂÏÔ‡Ó Ë ÚËÓ‹˜ ı¤ÛË Î·È ÙÔ ÂÈÛÓÂfiÌÂÓÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (ENO). º·Ú̷΢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ‰ÂÛÌÂ‡Ô˘Ó ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÙ·ÚÔÎÈÓÒÓ, fiˆ˜ ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÂÓ‰ÔıËÏ›Ó˘, ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ì ηϿ ·ÔÙÂϤÛÌ·Ù· Û ÂÈÚ·Ì·Ùfi˙ˆ· (65). ∂›Û˘, Â›Ó·È ·Ú·‰ÂÎÙfi Û‹ÌÂÚ· ·fi fiÏÔ˘˜ ÙÔ˘˜ ÂȉÈÎÔ‡˜ fiÙÈ ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË ÛËÌ·Û›· ÙÔ fiÛÔ Î·Ï¿ ¯ÂÈÚÈ˙fiÌ·ÛÙ ¤Ó·Ó ·Ó·Ó¢ÛÙ‹Ú· ·Ú¿ ÔÈÔÓ Ù‡Ô ·Ó·Ó¢ÛÙ‹Ú· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂ. ∞Ó Î·È ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ ·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌË ˘fi ‰ÈÂÚ‡ÓËÛË Û¯ÂÙÈο Ì ÙÔ˘˜ Èı·ÓÔ‡˜ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ ÂÎ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, Ë ˘ÈÔı¤ÙËÛË, ˆÛÙfiÛÔ, ÚÔÛٷ٢ÙÈÎÒÓ Ì¤ÛˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ıÂÚ·›˜ Ô˘ ÛÙÔ¯Â‡Ô˘Ó ÛÙË Ì›ˆÛË Ù˘ ‚Ï¿‚˘ Û ΢ÙÙ·ÚÈÎfi Î·È ÌÔÚÈ·Îfi Â›‰Ô, ηıÒ˜ Î·È Ë ·Ú¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÓÔÛËÚfiÙËÙ·˜, ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂÈÒÛÔ˘Ó ·ÔÊ·ÛÈÛÙÈο ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘.

Paediatriki 2004;67:310-320

10.

11.

12.

13.

14.

15.

16.

17.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Milberg JA, Davis DR, Steinberg KP, Hudson LD. Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983-1993. JAMA 1995;273:306-309.

2. Ranieri VM, Zhang H. Respiratory mechanics in acute respiratory distress syndrome: relevance to monitoring and therapy of ventilator-induced lung injury. Curr Opin Crit Care 1999;5:17-20.

3. Slutsky AS, Tremblay LN. Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 1998;157:1721-1725.

4. Gattinoni L, D’ Andrea L, Pelosi P, Vitale G, Pesenti A, Fumagalli R. Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome. JAMA 1993;269:2122-2127.

5. Zhang H, Ranieri VM, Slutsky AS. Cellular effects of ventilatorinduced lung injury. Curr Opin Crit Care 2000;6:71-74.

6. International consensus conference in intensive care medicine. Ventilator-associated lung injury in ARDS. American Thoracic Society, European Society of Intensive Care Medicine, Societe de Reanimation Langue Francaise.

Intensive Care Med 1999;25:1444-1452.

7. Dreyfuss D, Martin-Lefevre L, Saumon G. Hyperinflationinduced lung injury during alveolar flooding in rats: effect of perfluorocarbon instillation. Am J Respir Crit Care Med 1999;159:1752-1757.

8. Dreyfuss D, Saumon G. Barotrauma is volutrauma, but which volume is the one responsible? Intensive Care Med 1992;18:139-141.

9. Dreyfuss D, Saumon G. Role of tidal volume, FRC, and endinspiratory volume in the development of pulmonary edema

318

18.

19.

20.

21.

22.

23.

24.

25.

following mechanical ventilation. Am Rev Respir Dis 1993;148:1194-1203.

Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998;157:294-323.

Goldsmith JP, Karotkin EH. Assisted ventilation of the neonate. 3rd ed. Philadelphia: WB Saunders; 1996.

Wada K, Jobe AH, Ikegami M. Tidal volume effects on surfactant treatment responses with the initiation of ventilation in preterm lambs. J Appl Physiol 1997;83:1054-1061.

The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-1308.

Slutsky AS. Lung injury caused by mechanical ventilation.

Chest 1999;116 (1 Suppl):S9-S15.

Broccard AF, Hotchkiss JR, Suzuki S, Olson D, Marini JJ. Effects of mean airway pressure and tidal excursion on lung injury induced by mechanical ventilation in an isolated perfused rabbit lung model. Crit Care Med 1999;27:1533-1541.

Lecuona E, Saldias F, Comellas A, Ridge K, Guerrero C, Sznajder JI. Ventilator-associated lung injury decreases lung ability to clear edema in rats. Am J Respir Crit Care Med 1999;159:603-609.

Bjorklund LJ, Ingimarsson J, Curstedt T, John J, Robertson B, Werner O et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 1997;42:348-355.

Ito Y, Veldhuizen RA, Yao LJ, McCaig LA, Bartlett AJ, Lewis JF. Ventilation strategies affect surfactant aggregate conversion in acute lung injury. Am J Respir Crit Care Med 1997;155:493-499.

Taskar V, John J, Evander E, Robertson B, Jonson B. Surfactant dysfunction makes lungs vulnerable to repetitive collapse and reexpansion. Am J Respir Crit Care Med 1997;155:313-320.

Tremblay LN, Slutsky AS. Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians 1998;110:482-488.

Tremblay L, Valenza F, Ribeiro SP, Li J, Slutsky AS. Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Invest 1997;99:944-952.

Vlahakis NE, Schroeder MA, Limper AH, Hubmayr RD. Stretch induces cytokine release by alveolar epithelial cells in vitro. Am J Physiol 1999;277:167-173.

Sugiura M, McCulloch PR, Wren S, Dawson RH, Froese AB. Ventilator pattern influences neutrophil influx and activation in atelectasis-prone rabbit lung. J Appl Physiol 1994;77: 1355-1365. von Bethmann AN, Brasch F, Nusing R, Vogt K, Volk HD, Muller KM et al. Hyperventilation induces release of cytokines from perfused mouse lung. Am J Respir Crit Care Med 1998;157:263-272.

Chiumello D, Pristine G, Slutsky AS. Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. Am J Respir Crit Care Med 1999;160:109-116.

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·319

¶·È‰È·ÙÚÈ΋ 2004;67:310-320

26. Ranieri VM, Giunta F, Suter PM, Slutsky AS. Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome. JAMA 2000;284:43-44.

27. Speer CP. Inflammation and bronchopulmonary dysplasia.

Semin Neonatol 2003;8:29-38.

28. Nahum A, Hoyt J, Schmitz L, Moody J, Shapiro R, Marini JJ. Effect of mechanical ventilation strategy on dissemination of intratracheally instilled Escherichia coli in dogs. Crit Care Med 1997;25:1733-1743.

29. Liechty EA, Donovan E, Purohit D, Gilhooly J, Feldman B, Noguchi A et al. Reduction of neonatal mortality after multiple doses of bovine surfactant in low birth weight neonates with respiratory distress syndrome. Pediatrics 1991;88:19-28.

30. Zola EM, Overbach AM, Gunkel JH, Mitchell BR, Nagle BT, DeMarco NG et al. Treatment investigational new drug experience with Survanta (beractant). Pediatrics 1993;91:546-551.

31. Ito Y, Manwell SE, Kerr CL, Veldhuizen RA, Yao LJ, Bjarneson D et al. Effects of ventilation strategies on the efficacy of exogenous surfactant therapy in a rabbit model of acute lung injury. Am J Respir Crit Care Med 1998;157:149-155.

32. Tremblay LN, Slutsky AS, Dreyfuss D, Saumon G. Ventilatorinduced lung injury: mechanisms and clinical correlates. In: Marini JJ, Slutsky AS, editors. Physiological basis of ventilatory support. New York: Markel Dekker; 1998; p. 395-451.

33. Michna J, Jobe AH, Ikegami M. Positive end-expiratory pressure preserves surfactant function in preterm lambs. Am J Respir Crit Care Med 1999;160:634-639.

34. Naik AS, Kallapur S, Bachurski CJ, Michna J, Jobe AH, Ikegami M. Effects of different styles of ventilation on cytokine expression in preterm lamb lung. Pediatr Res 2000;47:370A. 35. Long W. Synthetic surfactant. Semin Perinatol 1993;17:275284.

36. Long W, Corbet A, Allen A, McMillan D, Boros S, Vaughan R et al. Retrospective search for bleeding diathesis among premature newborn infants with pulmonary hemorrhage after synthetic surfactant treatment. J Pediatr 1992;120:S40.

37. Long WA, Wold D, Mallett H. Pulmonary hemorrhage after Exosurf Neonatal. In: Long WA, Tilson HH, editors.

Proceedings of the Exosurf Neonatal Treatment IND Investigators’ Meeting. Langhorne PA: Adis International Inc; 1992. p. 65-74.

38. Van Houten J, Long W, Mullett M, Finer N, Derleth D, McMurray B et al. Pulmonary hemorrhage in premature infants after treatment with synthetic surfactant: an autopsy evaluation. The American Exosurf Neonatal Study Group I, and the Canadian Exosurf Neonatal Study Group. J Pediatr 1992;120:S40-S44.

39. Van Marter LJ, Allred EN, Pagano M, Sanocka U, Parad R, Moore M et al. Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network. Pediatrics 2000;105:1194-1201.

40. Seidner SR, Ikegami M, Yamada T, Rider ED, Castro R, Jobe AH. Decreased surfactant dose-response after delayed administration to preterm rabbits. Am J Respir Crit Care Med 1995;152:113-120.

41. Kamper J, Wulff K, Larsen C, Lindequist S. Early treatment with nasal continuous positive airway pressure in very low-

Paediatriki 2004;67:310-320

birth-weight infants. Acta Paediatr 1993;82:193-197.

42. Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 1987;79:26-30.

43. Mariani G, Cifuentes J, Carlo WA. Randomized trial of permissive hypercapnia in preterm infants. Pediatrics 1999;104:1082-1088.

44. Carlo WA, Stark AR, Bauer C, Donovan E, Oh W, Papile LA et al. Effects of minimal ventilation in a multicenter randomised controlled trial of ventilator support and early corticosteroid therapy in extremely low birth weight infants. Pediatrics 1999;104 (3 Suppl):S738-S739.

45. Gramajo H, Vigliocco G, Sola A. Does high PaCO2 affect mean cerebral blood flow velocities in ventilated preterm infants? Ped Res 2000;47:459A. 46. Update on Mechanical Ventilation and Exogenous Surfactant. Clin Perinatol 2001.

47. Keszler M, Donn SM, Bucciarelli RL, Alverson DC, Hart M, Lunyong V et al. Multicenter controlled trial comparing highfrequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991;119:85-93.

48. Courtney SE, Durand DJ, Asselin JM, Hudak ML, Aschner JL, Mc Artor RD. Early high-frequency oscillatory ventilation versus synchronised intermittent mandatory ventilation in very low birth weight infants [abstract]. Pediatr Res 2001;49:387A. 49. Clark RH, Gerstmann DR, Null DM Jr, deLemos RA. Prospective randomised comparison of high-frequency oscillatory and conventional ventilation in respiratory distress syndrome. Pediatrics 1992;89:5-12.

50. The HiFO Study Group. Randomised study of high frequency oscillatory ventilation in infants with severe respiratory distress syndrome. J Pediatr 1993;122:609-619.

51. Ogawa Y, Miyasaka K, Kawano T, Imura S, Inukai K, Okuyama K et al. A multicenter randomised trial of high frequency oscillatory ventilation as compared with conventional mechanical ventilation in preterm infants with respiratory failure. Early Hum Dev 1993;32:1-10.

52. Wiswell TE, Graziani LJ, Kornhauser MS, Cullen J, Merton DA, McKee L et al. High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes. Pediatrics 1996;98:1035-1043.

53. Thome U, Kossel H, Lipowsky G, Porz F, Furste HO, GenzelBoroviczeny O et al. Randomised comparison of highfrequency ventilation with high-rate intermittent positive pressure ventilation in preterm infants with respiratory failure.

J Pediatr 1999;135:39-46.

54. Moriette G, Paris-Llado J, Walti H, Escande B, Magny JF, Cambonie G et al. Prospective randomised multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome. Pediatrics 2001;107:363-372.

55. Rettwitz-Volk W, Veldman A, Roth B, Vierzig A, Kachel W, Varnholt V et al. A prospective, randomised, multicenter trial of high-frequency oscillatory ventilation compared with

319

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·320

¶·È‰È·ÙÚÈ΋ 2004;67:310-320

56.

57.

58.

59.

60.

61.

62.

63.

320

conventional ventilation in preterm infants with respiratory distress syndrome receiving surfactant. J Pediatr 1998;132:249-254.

Bhuta T, Henderson-Smart DJ. Rescue high frequency oscillatory ventilation versus conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2000;2:CD000438.

McGettigan MC, Adolph VR, Ginsberg HG, Goldsmith JP. New ways to ventilate newborns in acute respiratory failure.

Pediatr Clin North Am 1998;45:482-483.

Schulze A, Bancalari E. Proportional assisted ventilation in infants. Clin Perinatol 2001;28:561-578.

Sinha SK, Donn SM. Volume-controlled ventilation. Variations on a theme. Clin Perinatol 2001;28:547-560.

Carlo WA. eMedicine Journal 2001;2:12-13.

Clark LC Jr, Gollan F. Survival of mammals breathing organic liquids equilibrated with oxygen at atmospheric pressure.

Science 1966;152:1755-1756.

Modell JH, Newby EJ, Ruiz BC. Long-term survival of dogs after breathing oxygenated fluorocarbon liquid. Fed Proc 1970;29:1731-1736.

Shaffer TH, Rubenstein D, Moskowitz D, DelivoriaPapadopoulos M. Gaseous exchange acid-base balance in premature lambs during liquid ventilation since birth. Pediatr Res 1976;10:227-231.

Paediatriki 2004;67:310-320

64. Greenspan JS, Fox WW, Rubenstein SD, Wolfson MR, Spinner SS, Shaffer TH. Partial liquid ventilation in critically ill infants receiving extracorporeal life support. Philadelphia Liquid Ventilation Consortium. Pediatrics 1997;99:E2.

65. Schmect J, Krafft P, Groschler A, Heller A, Neuhof H, van Ackern K et al. Characterization and distribution of endothelin receptors in the pulmonary circulation: investigation of isolated, perfused, and ventilated rabbit lungs. Shock 1999;12:247-254.

66. Moriette G, Paris-Llado J, Walti H, Escande B, Magny JF, Cambonie G et al. Prospective randomized multicenter comparison of high-frequency ventilation add benefits to VLBW with lung disease? J Invest Med 2000;48:26A.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 11-07-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 19-12-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ¢·ÛÔÔ‡ÏÔ˘ ¶··‰È·Ì·ÓÙÔÔ‡ÏÔ˘ 11, ∆.∫. 115 28, πÏ›ÛÛÈ· ∂-mail: kpaplos@med.uoa.gr

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∞¡∞™∫O¶∏™∏

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REVIEW ARTICLE

∂ÁÎÔÏ·ÛÌfi˜: ¤Ó· ÁÓˆÛÙfi ÓfiÛËÌ· Ì ·Ó·Óˆ̤ÓÔ ÂӉȷʤÚÔÓ ∂. ª. ∫·ÏËÌÂÚ¿ÎË, ¢. ∞. ∫·ÊÂÙ˙‹˜

Intussusception: new interest in a common disease I. M. Kalimeraki, D. A. Kafetzis

¶ÂÚ›ÏË„Ë: O ÂÁÎÔÏ·ÛÌfi˜, ¤Ó· ÎÔÈÓfi ÓfiÛËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Â·Ó‹Ïı ÛÙËÓ ÂÈηÈÚfiÙËÙ· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÏfiÁˆ Ù˘ Èı·Ó‹˜ Û¯¤Û˘ ÙÔ˘ Ì ÙÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ Rota. O ÂÁÎÔÏ·ÛÌfi˜ ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ȉȷ›ÙÂÚ· ÌÂٷ͇ 5 Î·È 9 ÌËÓÒÓ, ÚÔÛ‚¿ÏÏÔÓÙ·˜ Û˘¯ÓfiÙÂÚ· Ù· ·ÁfiÚÈ· (2-3:1). ∆· ·›ÙÈ· Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙÔ˘˜ Â›Ó·È È‰ÈÔ·ı‹, ÂÓÒ Û ÌÈÎÚfi ÔÛÔÛÙfi ·Ó¢ڛÛÎÂÙ·È “ÛËÌÂ›Ô ¤Ó·Ú͢” (ÂÎÎfiÏˆÌ· Meckel, ÔÚʇڷ Henoch-Schonlein, ΢ÛÙÈ΋ ›ÓˆÛË Î.¿.). ™˘ÓËı¤ÛÙÂÚÔ˜ Ù‡Ô˜ Â›Ó·È Ô ÂÈÏÂÔΈÏÈÎfi˜ Î·È Ù· Û˘ÓËı¤ÛÙÂÚ· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· Â›Ó·È ÙÔ ÎˆÏÈÎÔÂȉ¤˜ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÔÈ ¤ÌÂÙÔÈ Î·È ÔÈ - ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÁÈ· ÙË ÓfiÛÔ - ‚ÏÂÓÓÔ·ÈÌ·ÙËÚ¤˜ ÎÂÓÒÛÂȘ, ÁÓˆÛÙ¤˜ ˆ˜ “ÎfiÎÎÈÓË Ì·ÚÌÂÏ¿‰·”. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ·ÔÙÂÏ› ·ÍÈfiÈÛÙÔ ‰È·ÁÓˆÛÙÈÎfi ̤ÛÔ, Ë ·Ó‡ÚÂÛË ÙˆÓ ÛËÌ›ˆÓ “ÓÙfiÓ·Ù˜” Î·È “Û¿ÓÙÔ˘ÈÙ˜” Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ Î·È Ë Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ˘„ËÏ‹. O ‚·ÚÈÔ‡¯Ô˜ ˘ÔÎÏ˘ÛÌfi˜ ·ÔÙÂÏ› ÙÔ Î‡ÚÈÔ ‰È·ÁÓˆÛÙÈÎfi Î·È ıÂÚ·¢ÙÈÎfi ̤ÛÔ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, ¤¯ÔÓÙ·˜ ˆ˜ ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ÙÔ ÛËÌÂ›Ô ÙÔ˘ “ÂÏ·ÙËÚ›Ô˘” ‹/Î·È ÙÔ ÛËÌÂ›Ô ÙÔ˘ “ÌËÓ›ÛÎÔ˘”. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÓÔÛ‹Ì·Ù· Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, ·ÏÏ¿ Î·È ÔÚÈṲ̂ӷ Â͈ÂÓÙÂÚÈο ÓÔÛ‹Ì·Ù· fiˆ˜ Ë ÛΈÏËÎÔÂȉ›Ùȉ·, ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, Ë ÌÂÛÂÓÙ¤ÚÈ· ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÙÔ ÂÎÎfiÏˆÌ· Meckel Î.¿. ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì¤Ûˆ ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ‚¿ÚÈÔ, ·¤Ú· ‹ ¿ÏÏÔ ˘‰·ÙÔ‰È·Ï˘Ùfi Û··ÛÌ· ˘fi ·ÎÙÈÓÔÛÎÔÈ΋ ‹ - ηٿ ÚÔÙ›ÌËÛË - ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ηıÔ‰‹ÁËÛË. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÂȯÂÈÚÂ›Ù·È ÌfiÓÔ Û ÂÚ›ÙˆÛË Ô˘ ˘¿Ú¯ÂÈ ·ÓÙ¤Ó‰ÂÈÍË ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡, fiˆ˜ Û ÂÁηÙÂÛÙË̤ÓË ‰È¿ÙÚËÛË ‹ Û ηٷÏËÍ›· Ô˘ ‰ÂÓ ‰ÈÔÚıÒÓÂÙ·È ÌÂ

Abstract: Intussusception, a common and wellknown disease affecting infants, has recently gained new interest due to its possible relationship with rotavirus vaccine. Intussusception mainly affects infants of 5 to 9 months, in particular boys (23:1). Although its aetiology remains unknown in most cases (idiopathic), in a small proportion “lead points” can be found, (Meckel’s diverticulum, Henoch-Schonlein purpura, cystic fibrosis etc). The predominant site of intussusception is ileocolic. The commonest symptoms include colicky abdominal pain, vomiting, and characteristic blood and mucus filled stools “like redcurrant jelly” which are pathognomonic for the disease. Barium enema so far remains the most important diagnostic procedure, revealing the specific “meniscus” and “spring” signs of the condition. However, its diagnostic value is strongly rivalled by ultrasonography, which displays its own caserelated features: the “donut” and “sandwich” signs.

Differential diagnosis includes intestinal obstruction related syndromes and extra-intestinal diseases such as appendicitis, viral gastro-intestinal infections, mesenteric lymphadenitis, Meckel’s diverticulum, etc. Treatment is usually achieved through enema reduction under radiological or preferably - ultrasonographic monitoring, with the use of barium, air, or other water-soluble substances. Surgical treatment is applied in cases where enema reduction is not indicated: intestinal perforation, shock non-responsive to the administration of iv fluid and cases that involve “lead points”, as well as in enema treatment failure.

Recurrence of intussusception following hydrostatic enema treatment occurs in 5% to 10% of cases and usually takes place within 72 hours post reduction.

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

2nd Paediatric Clinic of University of Athens, “P. & A. Kyriakou” Children’s Hospital, Athens

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ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, Û ÂÁÎÔÏ·ÛÌfi Ì “ÛËÌÂ›Ô ¤Ó·Ú͢”, fiˆ˜ Â›Û˘ Î·È Û ·ÔÙ˘¯›· ·Ó¿Ù·Í˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ̤ۈ ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡. ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÌÂÙ¿ ·fi ˘‰ÚÔÛÙ·ÙÈÎfi ˘ÔÎÏ˘ÛÌfi Î˘Ì·›ÓÂÙ·È Û ÔÛÔÛÙfi 5-10% Î·È Û˘Ó‹ıˆ˜ Û˘Ì‚·›ÓÂÈ 72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ·Ó¿Ù·ÍË. §¤ÍÂȘ ÎÏÂȉȿ: ÂÁÎÔÏ·ÛÌfi˜, ‚Ú¤ÊÔ˜, ‚·ÚÈÔ‡¯Ô˜ ˘ÔÎÏ˘ÛÌfi˜, ˘ÔÙÚÔ‹, ‚ÏÂÓÓÔ·ÈÌ·ÙËÚ¤˜ ÎÂÓÒÛÂȘ.

Key words: intussusception, infant, barium enema, blood and mucus filled stools.

∂ÈÛ·ÁˆÁ‹ O ÂÁÎÔÏ·ÛÌfi˜ ·ÔÙÂÏ› Û˘¯Ófi ·È‰È·ÙÚÈÎfi ‹/Î·È ·È‰Ô¯ÂÈÚÔ˘ÚÁÈÎfi Úfi‚ÏËÌ· Î·È ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û˘¯ÓfiÙÂÚ· ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ø˜ ÂÁÎÔÏ·ÛÌfi˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Î·Ù¿ÛÙ·ÛË Î·Ù¿ ÙËÓ ÔÔ›· ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÂÈÛ¤Ú¯ÂÙ·È ÂÓÙfi˜ ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ÂÚÈÊÂÚÈÎfiÙÂÚÔ˘ ÙÌ‹Ì·ÙÔ˜ (1).

¶·ıÔÊ˘ÛÈÔÏÔÁ›· O ÂÁÎÔÏ·ÛÌfi˜ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ÛÙ· ¢ÙÚ·Ê‹, Ê·ÈÓÔÌÂÓÈο ˘ÁÈ‹ ·È‰È¿. ∆· ·È‰È¿ Ì ηϋ ıÚ¤„Ë ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ ·Ó¿Ù˘Í˘ ÂÁÎÔÏ·ÛÌÔ‡ ·fi fi,ÙÈ ÂΛӷ Ì η΋ ıÚ¤„Ë, ÂÂȉ‹ ÈÛÙ‡ÂÙ·È fiÙÈ Ë ÔÛfiÙËÙ· ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÂÈÏÂÔÙ˘ÊÏÈ΋ ÂÚÈÔ¯‹ ·˘ÙÒÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË (10).

O ıËÏ·ÛÌfi˜ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› fiÙÈ Â˘ÓÔ› ÙËÓ ÂΉ‹ÏˆÛË ÂÁÎÔÏ·ÛÌÔ‡. ™˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 12 ÌËÓÒÓ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÁÈ· ÙÔÓ ÛÎÔfi ·˘Ùfi, ¤‰ÂÈÍ·Ó fiÙÈ Ù· ·È‰È¿ Ô˘ ÙÚ¿ÊËÎ·Ó ·ÔÎÏÂÈÛÙÈο Ì ıËÏ·ÛÌfi ·ÚÔ˘Û›·Û·Ó ¤ÍÈ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Â›ÙˆÛË ÂÁÎÔÏ·ÛÌÔ‡ Û ۇÁÎÚÈÛË Ì ÂΛӷ Ô˘ Ë ‰È·ÙÚÔÊ‹ ÙÔ˘˜ ·ÔÙÂÏÔ‡ÓÙ·Ó ·ÔÎÏÂÈÛÙÈο ·fi ͤÓÔ Á¿Ï·. ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ ÂΛӷ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÈÎÙ‹ ‰È·ÙÚÔÊ‹ ·ÚÔ˘Û›·Û·Ó ‰ÈÏ¿ÛÈ· ¤ˆ˜ ÙÚÈÏ¿ÛÈ· Â›ÙˆÛË ·Ó¿Ù˘Í˘ ÂÁÎÔÏ·ÛÌÔ‡ Û ۇÁÎÚÈÛË Ì ÂΛӷ Ô˘ ¤Ï·‚·Ó ÌfiÓÔ Í¤ÓÔ Á¿Ï· (10). Œ¯ÂÈ ‰È·Ù˘ˆı› Ë ıˆڛ· fiÙÈ Ô ÂÁÎÔÏ·ÛÌfi˜ ·Ú·ÙËÚÂ›Ù·È ‡ÛÙÂÚ· ·fi ‰È·Ù·Ú·¯‹ ÙˆÓ ‰˘Ó¿ÌÂˆÓ Ô˘ ·ÛÎÔ‡ÓÙ·È Î·Ù¿ Ì‹ÎÔ˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜. ∏ ‰È·Ù·Ú·¯‹ ·˘Ù‹ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÎÏËı› ·fi ¿ÁÓˆÛÙË ·ÈÙ›· (ȉÈÔ·ıÒ˜) ‹ ·fi Ì›· Ì¿˙· Ô˘ ÏÂÈÙÔ˘ÚÁ› ˆ˜ “ÛËÌÂ›Ô ¤Ó·Ú͢” ‹, ·ÎfiÌË, ·fi ‰È·Ù·Ú·¯‹ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÚÈÛÙ·ÏÙÈÛÌÔ‡, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙÔÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi ÂÈÏÂfi. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ Ô‰ËÁÔ‡Ó ÛÙËÓ ÚfiÙˆÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÂÓÙfi˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ·˘ÏÔ‡ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ ÂÁÁ‡˜ ÙÌ‹Ì· ·˘ÙÔ‡. ∂¿Ó ÙÔ ÌÂÛÂÓÙ¤ÚÈÔ Â›Ó·È ¯·Ï·Úfi Î·È Ë ÂͤÏÈÍË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Ù·¯Â›·, Ë ÚfiÙˆÛË ÌÔÚ› Ó· ÊÙ¿ÛÂÈ ÛÙÔÓ ÚˆÎÙfi (1). ªÂ ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, ·Ú¯Èο ·ÚÂÌÔ‰›˙ÂÙ·È Ë ÏÂÌÊÈ΋ ÂÈÛÙÚÔÊ‹. ∏ Û˘Ó¯È˙fiÌÂÓË, fï˜, ›ÂÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÛÙÔ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ô˘ ¤¯ÂÈ ÂÁÎÔÏ·ÛÙ›, ÌÂÈÒÓÂÈ ÙË ÊÏ‚È΋ ·ÔÚÚÔ‹, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ôȉ‹Ì·ÙÔ˜ Î·È ÊÏÂÁÌÔÓ‹˜. ∆ÂÏÈο, ÂÁηı›ÛÙ·Ù·È ·ÚÂÌfi‰ÈÛË Î·È Ù˘ ·ÚÙËÚȷ΋˜ ÚÔ‹˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË ¤ÌÊÚ·ÎÙÔ˘ Î·È ·ÈÌÔÚÚ·Á›·˜. O ÈÛ¯·ÈÌÈÎfi˜ ‚ÏÂÓÓÔÁfiÓÈÔ˜ ¯ÈÙÒÓ·˜ ÙÔ˘ ÂÁÎÔÏ·Ûı¤ÓÙÔ˜ ÂÓÙ¤ÚÔ˘ ·ÔÚÚ›ÙÂÙ·È Ì¤Ûˆ ÙˆÓ ÎÔÚ¿ÓˆÓ. ∆· ÎfiÚ·Ó·, ÛÂ

∂ȉËÌÈÔÏÔÁ›· O ÂÁÎÔÏ·ÛÌfi˜ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ Î·È ·ÊÔÚ¿ ΢ڛˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ 3 ÌËÓÒÓ ¤ˆ˜ 6 ÂÙÒÓ. ∂›Ó·È Û˘¯ÓfiÙÂÚÔ˜ ÛÙ· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Î·È È‰È·›ÙÂÚ· ηٿ ÙËÓ ËÏÈΛ· ÙˆÓ 5-9 ÌËÓÒÓ. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Â›Ó·È 1:1000 ·È‰È¿ Î·È Ë Û¯¤ÛË ÙÔ˘ ʇÏÔ˘ Â›Ó·È ·ÁfiÚÈ·:ÎÔÚ›ÙÛÈ· 2-3:1 (6). øÛÙfiÛÔ, Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙ· ·ÁfiÚÈ· ·˘Í¿ÓÂÙ·È ÛÙ·‰È·Î¿ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 4 ÂÙÒÓ, Ë Û¯¤ÛË ·ÁÁ›˙ÂÈ ÙÔ 8:1 (7).

O ÂÁÎÔÏ·ÛÌfi˜ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Â›Ó·È Û¿ÓÈÔ˜, ÂÓÒ fiÙ·Ó ‰È·ÁÓˆÛÙ›, Û˘Ó‹ıˆ˜ ·Ó¢ڛÛÎÂÙ·È ¯ÂÈÚÔ˘ÚÁÈÎfi “ÛËÌÂ›Ô ¤Ó·Ú͢”. ∏ ÂÓ‰ÔÔÈÎÔÁÂÓÂȷ΋ Â›ÙˆÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Â›Ó·È ·˘ÍË̤ÓË, Ì 15-20 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ÓfiÛÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÔ¯È΋ ¤Í·ÚÛË ÙËÓ ¿ÓÔÈÍË Î·È ÙÔ ÊıÈÓfiˆÚÔ, ÁÂÁÔÓfi˜ Ô˘ ·fi ÔÚÈṲ̂ÓÔ˘˜ ·Ô‰›‰ÂÙ·È Û Ïԛ̈ÍË ·fi ÈÔ‡˜ Rota, ÔÈ ÔÔ›ÔÈ Â›Ó·È ·˘ÍË̤ÓÔÈ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹ (3,8). ∆‡ÔÈ ÂÁÎÔÏ·ÛÌÔ‡ O ÂÁÎÔÏ·ÛÌfi˜, ÛÙÔ 75-90% ÙˆÓ ÂÚÈÙÒÛˆÓ, Â›Ó·È ÂÈÏÂÔΈÏÈÎfi˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ηٿ ÙȘ Ôԛ˜ ÙÔ ÏÂÙfi ¤ÓÙÂÚÔ ÂÈÛ¯ˆÚ› ÛÙÔ ‰ÂÍÈfi ÎfiÏÔÓ, Ô ÂÁÎÔÏ·ÛÌfi˜ Â›Ó·È Û˘Ó‹ıˆ˜ ȉÈÔ·ı‹˜ Î·È ·Ú·ÙËÚÂ›Ù·È Û ‚Ú¤ÊË Î·È ÌÈÎÚ¿ Ó‹È·. ÕÏÏÔÈ Ù‡ÔÈ ÂÁÎÔÏ·ÛÌÔ‡ Â›Ó·È Ô ÂÈÏÂÔÂÈÏÂ˚Îfi˜ Î·È Ô ÎÔÏÔΈÏÈÎfi˜, ÔÈ ÔÔ›ÔÈ fï˜ ··ÓÙÒÓÙ·È Û·ÓÈfiÙÂÚ· Î·È Û˘Ó‰˘¿˙ÔÓÙ·È Û˘Ó‹ıˆ˜ Ì ·ıÔÏÔÁÈÎfi “ÛËÌÂ›Ô ¤Ó·Ú͢” ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ‹ Ì ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ (1,3,7).

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¶·È‰È·ÙÚÈ΋ 2004;67:321-327

Û˘Ó‰˘·ÛÌfi Ì ÙÔ ·›Ì· Î·È ÙË ‚ϤÓÓË, ·ÔÎÙÔ‡Ó ÙËÓ fi„Ë “ÎfiÎÎÈÓ˘ Ì·ÚÌÂÏ¿‰·˜”, Ô˘ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÁÈ· ÙË ÓfiÛÔ. ¶ÚÔԉ¢ÙÈο Â¤Ú¯ÂÙ·È ÂÓÙÂÚÈ΋ Ó¤ÎÚˆÛË Î·È ‰È¿ÙÚËÛË Î·È Ë Î·Ù¿ÛÙ·ÛË Á›ÓÂÙ·È ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ (1,7). ∞›ÙÈ· O ȉÈÔ·ı‹˜ ‹ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ ÂÁÎÔÏ·ÛÌfi˜ ·ÔÙÂÏ› ÙË Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ (90%) (6). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘, ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ‰È¿ÊÔÚÔÈ Ì˯·ÓÈÛÌÔ›, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È Ë ‰ÈfiÁΈÛË ÙˆÓ ·¸¤ÚÈˆÓ Ï·ÎÒÓ, Ì˯·ÓÈÛÌfi˜ Ô˘ ÂÓÔ¯ÔÔÈÂ›Ù·È ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜. ∏ ıˆڛ· ·˘Ù‹ ‚·Û›˙ÂÙ·È ÛÙȘ ·ÎfiÏÔ˘ı˜ ·Ú·ÙËÚ‹ÛÂȘ (1,10): ·) O ÂÁÎÔÏ·ÛÌfi˜, Ôχ Û˘¯Ó¿, ¤ÂÙ·È Ù˘ Ïԛ̈͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‹ Ù˘ ÈÔÁÂÓÔ‡˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜, ηٿ ÙȘ Ôԛ˜ ·Ú·ÙËÚÂ›Ù·È ‰ÈfiÁΈÛË ÙˆÓ ·¸¤ÚÈˆÓ Ï·ÎÒÓ. ‚) ∏ ÂÈÏÂÔΈÏÈ΋ ÂÚÈÔ¯‹, ÛÙËÓ ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û˘¯ÓfiÙÂÚ· Ô ÂÁÎÔÏ·ÛÌfi˜, ‰È·ı¤ÙÂÈ ÙËÓ ˘„ËÏfiÙÂÚË Û˘ÁΤÓÙÚˆÛË ÏÂÌÊ·‰¤ÓˆÓ ÛÙÔ ÌÂÛÂÓÙ¤ÚÈÔ. Á) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, ·Ó¢ڛÛÎÔÓÙ·È Û˘¯Ó¿ ˘ÂÚÙÚÔÊÈÎÔ› ÏÂÌÊ·‰¤Ó˜.

OÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÏfiÁˆ Ù˘ ·ÏÏ·Á‹˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÚÈÛÙ·ÏÙÈÛÌÔ‡, ¤¯Ô˘Ó, Â›Û˘, ÂÓÔ¯ÔÔÈËı› ·fi ÔÚÈṲ̂ÓÔ˘˜ ˆ˜ ·ÈÙ›· Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÁÎÔÏ·ÛÌfi.

O ÂÁÎÔÏ·ÛÌfi˜ Ì “ÛËÌÂ›Ô ¤Ó·Ú͢” ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÂ Û˘¯ÓfiÙËÙ· 2-12% Î·È Û˘Ó‹ıˆ˜ ··ÈÙ› ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ ·˘Í¿ÓÂÈ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. ∆· ·›ÙÈ· Ô˘ Û˘¯ÓfiÙÂÚ· ·Ó¢ڛÛÎÔÓÙ·È Û ·˘Ùfi ÙÔÓ Ù‡Ô Â›Ó·È (1,7): ·) ∆Ô ÂÎÎfiÏˆÌ· Meckel, Ô˘ ·Ó¢ڛÛÎÂÙ·È Û ÔÛÔÛÙfi 2% ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÔÌÊ·ÏÔÂÓÙÂÚÈÎÔ‡ fiÚÔ˘. ∞ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÂÁÎÔÏ·ÛÌÔ‡ Ì “ÛËÌÂ›Ô ¤Ó·Ú͢” (6). ‚) ∏ ÔÚʇڷ Henoch-Schonlein, ηٿ ÙËÓ ÔÔ›· Ô ÂÁÎÔÏ·ÛÌfi˜ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÈÏÔ΋ Î·È ·Ú·ÙËÚÂ›Ù·È Û 1,3-13,6% ÙˆÓ ·È‰ÈÒÓ Ì ÙË ÓfiÛÔ. ∞Ô‰›‰ÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË ˘Ô‚ÏÂÓÓÔÁfiÓÈˆÓ ·ÈÌ·ÙˆÌ¿ÙˆÓ Ô˘ ÏÂÈÙÔ˘ÚÁÔ‡Ó ˆ˜ “ÛËÌ›· ¤Ó·Ú͢” ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (2,11). Á) ∏ ·ÈÌÔÚÚÔÊÈÏ›· ‹ ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ‹Í˘, ηٿ ÙȘ Ôԛ˜ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó¿Ù˘ÍË ˘Ô‚ÏÂÓÓÔÁfiÓÈÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜, Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Î·È ‰ËÌÈÔ˘ÚÁ›· ÂÁÎÔÏ·ÛÌÔ‡ (8,1).

Paediatriki 2004;67:321-327

‰) O ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ ÂÁÎÔÏ·ÛÌfi˜, Ô˘ Â›Ó·È Û¿ÓÈÔ˜ ÛÙ· ·È‰È¿. ∞˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ, ˆÛÙfiÛÔ, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ·È‰È¿ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÁ¿ÏË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Ì ·Ú·ÙÂٷ̤ÓÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi ÂÈÏÂfi (4,6). Â) ∏ ΢ÛÙÈ΋ ›ÓˆÛË, Ô˘ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ·›ÙÈÔ ÂÁÎÔÏ·ÛÌÔ‡ Û ÔÛÔÛÙfi 1% ÙˆÓ ·ÛıÂÓÒÓ. ø˜ ÂÎÏ˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Ù· ÛÎÏËÚ¿ Î·È ÔÁÎÒ‰Ë ÎfiÚ·Ó·, Ù· ÔÔ›· Â›Ó·È Û ı¤ÛË Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ “ÛËÌÂ›Ô ¤Ó·Ú͢” ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (5). ÛÙ) ∏ ÌÂÛÂÓÙ¤ÚÈÔ˜ ÏÂÌÊ·‰ÂÓ›Ùȉ·, Ë ÔÔ›· Â›Ó·È Û˘Ó‹ı˘ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ˙) OÈ Ôχԉ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, ȉȷ›ÙÂÚ· ÙÔ˘ ÏÂÙÔ‡, Ô˘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÂÁÎÔÏ·ÛÌfi, Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· ÙËÓ ÔÈÎÔÁÂÓ‹ ÔÏ˘Ô‰›·ÛË Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Peutz-Jeghers. Ë) ∫ÔÈÏÈ·Îfi ÙÚ·‡Ì· ÛÙÔÓ ÔÈÛıÔÂÚÈÙÔÓ·˚Îfi ¯ÒÚÔ Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÓÙÂÚÈÎÔ‡ ‹ ÌÂÛÂÓÙ¤ÚÈÔ˘ ·ÈÌ·ÙÒÌ·ÙÔ˜. ı) ∏ ·ÚÔ˘Û›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔ ¤ÓÙÂÚÔ. È) ∆Ô Ï¤Ìʈ̷ ÂÓÙ¤ÚÔ˘ ‹ ÌË-Hodgkin ϤÌʈ̷. ∂Ì‚ÔÏÈ·ÛÌfi˜ ηٿ ÙÔ˘ ÈÔ‡ Rota Î·È ÂÁÎÔÏ·ÛÌfi˜ ∆Ô ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ Rota ÂÁÎÚ›ıËΠ·fi ÙÔÓ OÚÁ·ÓÈÛÌfi ∆ÚÔÊ›ÌˆÓ Î·È º·ÚÌ¿ÎˆÓ ÙˆÓ ∏¶∞ ÁÈ· ¯Ú‹ÛË ÛÙËÓ ·È‰È·ÙÚÈ΋ ÙÔÓ ∞‡ÁÔ˘ÛÙÔ ÙÔ˘ 1998. Œˆ˜ ÙÔÓ πÔ‡ÏÈÔ ÙÔ˘ 1999 ›¯·Ó ¯ÔÚËÁËı› 1,5 ÂηÙÔÌ̇ÚÈÔ ‰fiÛÂȘ Î·È ·Ó·Ê¤ÚıËÎ·Ó 15 ÂÚÈÙÒÛÂȘ ÂÁÎÔÏ·ÛÌÔ‡ Û ·È‰È¿, ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, Ô˘ ·Ô‰fiıËÎ·Ó Û ·˘ÙfiÓ. ∆ÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1999, ÙÔ ÂÌ‚fiÏÈÔ ·ÔÛ‡ÚıËΠ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›·. ∏ Èı·Ó‹ Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Rotashield Î·È ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ¤ÁÈÓ ·ÓÙÈΛÌÂÓÔ ÂÚ¢ÓÒÓ, ÔÈ Ôԛ˜ Û˘Ó¯›˙ÔÓÙ·È Ì¤¯ÚÈ Û‹ÌÂÚ·, ¯ˆÚ›˜, ˆÛÙfiÛÔ, Ó· ¤¯ÂÈ ÂȂ‚·Èˆı› Ë ÌÂٷ͇ ÙÔ˘˜ Û‡Ó‰ÂÛË (18,19). ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∏ ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Ì ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÙÚÈ¿‰· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Â̤ÙÔ˘˜ Î·È ‚ÏÂÓÓÔ·ÈÌ·ÙËÚ¤˜ ÎÂÓÒÛÂȘ. ∏ ÙÚÈ¿‰· ·˘Ù‹, ˆÛÙfiÛÔ, ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û ÔÛÔÛÙfi ÌfiÏȘ 2025% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (7). ∆Ô ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ Â›Ó·È ÚÔԉ¢ÙÈο ·˘Í·ÓfiÌÂÓÔ, ΈÏÈÎÔÂȉ¤˜, Ì ·Ú¯È΋ ‰È¿ÚÎÂÈ· ÌÂÚÈÎÒÓ ÏÂÙÒÓ, Û˘Óԉ¢fiÌÂÓÔ ·fi ¤ÓÙÔÓË ·ÓËÛ˘¯›·, ÎÏ¿Ì· Î·È Â˘ÂÚÂıÈÛÙfiÙËÙ·. ∆Ô ·È‰› Û˘Ó‹ıˆ˜ ·›ÚÓÂÈ ·ÓÙ·ÏÁÈ΋ ı¤ÛË, ʤÚÓÔÓÙ·˜ Ù· ÁfiÓ·Ù· ÛÙËÓ ÎÔÈÏÈ¿. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÎÚ›Û˘ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ˆ¯ÚfiÙËÙ· ÚÔÛÒÔ˘, ‰È·Ù·Ú·¯‹ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È Ù·¯˘Î·Ú‰›·, ÂÓÒ Û·Ó›ˆ˜ ‰È·ÈÛÙÒÓÂÙ·È ˘fiÙ·ÛË. ¢È¿ÚÚÔÈ· ÌÔÚ› Ó· ÂΉËψı› ˆ˜ ÚÒÈÌÔ

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Û‡Ìو̷ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡. ∆Ô ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ ·ÎÔÏÔ˘ı› ÂÚ›Ô‰Ô˜ Ê·ÈÓÔÌÂÓÈ΋˜ ËÛ˘¯›·˜, Ì ÂΉ‹ÏˆÛË Ó¤·˜ ÎÚ›Û˘ ÌÂÙ¿ ·fi Ï›Á· ÏÂÙ¿. O ·ÎÏÔ˜ ·˘Ùfi˜ Â·Ó·Ï·Ì‚¿ÓÂÙ·È ÂÚ›Ô˘ οı 15-30 ÏÂÙ¿ (6,7,12). ™·Ó›ˆ˜, ÙÔ ‚Ú¤ÊÔ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ï‹ı·ÚÁÔ Î·È ·¿ıÂÈ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÎÚ›Û˘. ∆Ô ÎÔÈÏÈ·Îfi ΈÏÈÎÔÂȉ¤˜ ¿ÏÁÔ˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ÎÏÈÓÈÎfi ‡ÚËÌ·, ·ÓÙÈÚÔÛˆ‡ÔÓÙ·˜ ÙÔ 80% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛˆÓ.

OÈ ¤ÌÂÙÔÈ ·ÔÙÂÏÔ‡Ó ÙÔ ‰Â‡ÙÂÚÔ - ηٿ ÛÂÈÚ¿ ÂÌÊ¿ÓÈÛ˘ Î·È Û˘¯ÓfiÙËÙ·˜ - ÎÏÈÓÈÎfi ‡ÚËÌ·. ™ÙËÓ ·Ú¯‹ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ˆ˜ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÎÚ›Û˘, Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, fï˜, ÔÈ ¤ÌÂÙÔÈ Â›Ó·È Û˘¯ÓfiÙÂÚÔÈ, ÂÓÒ Á›ÓÔÓÙ·È ¯ÔÏÒ‰ÂȘ fiÙ·Ó Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Â›Ó·È Ï‹Ú˘.

OÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÁÈ· ÙË ÓfiÛÔ ‚ÏÂÓÓÔ·ÈÌ·ÙËÚ¤˜ ÎÂÓÒÛÂȘ, ÁÓˆÛÙ¤˜ ˆ˜ “ÎfiÎÎÈÓË Ì·ÚÌÂÏ¿‰·”, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û 20-30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ·ÊÔ‡ ¤¯Ô˘Ó ÂÚ¿ÛÂÈ 12-24 ÒÚ˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (1,6). ÕÏÏ· ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÎÔÈÏȷ΋ ‰È¿Ù·ÛË ‹ ÌÂÙˆÚÈÛÌfi, Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙ· ÙÂÏÈο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘, fiÙ·Ó Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Â›Ó·È Ï‹Ú˘, ηıÒ˜ Î·È ˘ÚÂÙfi Î·È Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, Ô˘ Û·Ó›ˆ˜ ‰È·ÈÛÙÒÓÔÓÙ·È ·fi ÙËÓ ·Ú¯‹ Ù˘ ÓfiÛÔ˘ Î·È ˘Ô‰ÂÈÎÓ‡Ô˘Ó ‰È·ÙÔȯˆÌ·ÙÈ΋ Á¿ÁÁÚ·ÈÓ· Î·È ¤ÌÊÚ·ÎÙÔ. ∂¿Ó Ô ÂÁÎÔÏ·ÛÌfi˜ ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ·, Â¤Ú¯ÂÙ·È Ú‹ÍË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÂÚÈÙÔÓ›Ùȉ·, Ô‰ËÁÒÓÙ·˜ ÙÔÓ ·ÛıÂÓ‹ Û ηٷÏËÍ›· Î·È ›Ûˆ˜ ÛÙÔÓ ı¿Ó·ÙÔ ÂÓÙfi˜ 2-5 ËÌÂÚÒÓ. ∆· ÎÏÈÓÈο ÛËÌ›· ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ÌÔÚ› Ó· ‰È·Ê‡ÁÔ˘Ó ‹ Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ۇÁ¯˘ÛË. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ 30-68% ÙˆÓ ·È‰ÈÒÓ Ì ٷ Ù˘Èο ÎÏÈÓÈο ÛËÌ›· ÓÔÛ› Ú¿ÁÌ·ÙÈ ·fi ÂÁÎÔÏ·ÛÌfi. ∫ÏÈÓÈο, Ù· ÓÂÔÁÓ¿ Ì ÂÁÎÔÏ·ÛÌfi ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ¿ÏË ‰È¿Ù·ÛË Ù˘ ÎÔÈÏ›·˜, ÂÈÛÚfiÊËÛË Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ΢ڛˆ˜ ¯ÔÏ‹˜ ηÈ, Û·Ó›ˆ˜, „ËÏ·ÊËÙ‹ Ì¿˙· ÛÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ· (9). ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ·ÔÙÂÏ› ÙË ‚·ÛÈÎfiÙÂÚË ÚÔÛ¤ÁÁÈÛË ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡. ∆· ·ÚÈ· Â˘Ú‹Ì·Ù· ηٿ ÙËÓ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏÈ¿˜ ·ÔÙÂÏÔ‡Ó Ë ·Ó‡ÚÂÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ô˘ ¤¯ÂÈ ÂÁÎÔÏ·ÛÙ› Ì ÙË ÌÔÚÊ‹ ΢ÏÈÓ‰ÚÈ΋˜ Ì¿˙·˜, Ô˘ Â›Ó·È ÁÓˆÛÙ‹ ˆ˜ “ÏÔ˘Î¿ÓÈÎÔ”, ÛÙÔ ‰ÂÍÈfi ˘Ô¯fiÓ‰ÚÈÔ Î·È, Ù·˘Ùfi¯ÚÔÓ·, Ë ·›ÛıËÛË ÙÔ˘ ÎÂÓÔ‡ ÛÙÔ ‰ÂÍÈfi ˘ÔÁ¿ÛÙÚÈÔ. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ Â›Ó·È ·ıÔÁÓˆÌÔÓÈο ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Î·È Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÔÎ·Ï˘ÊıÔ‡Ó ÛÙÔ 50-55% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (6). ∂¿Ó Ë ‰È¿ÁÓˆÛË ÙÂı› ̤۷ ÛÙȘ ÚÒÙ˜ 24

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Paediatriki 2004;67:321-327

ÒÚ˜, ÙÔ 75-85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÁÎÔÏ·ÛÌÔ‡ ı· ·ÓÙÈÌÂÙˆÈÛÙ› ÂÈÙ˘¯Ò˜ Ì ‚·ÚÈÔ‡¯Ô ‹ ˘ÔÎÏ˘ÛÌfi Ì ·¤Ú·.

O ·Ú·ÎÏÈÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ÌÔÚ› Ó· ÂȂ‚·ÈÒÛÂÈ ‹/Î·È Ó· ı¤ÛÂÈ ÙË ‰È¿ÁÓˆÛË, Û˘ÓÔ„›˙ÂÙ·È ÛÙ· ·ÎfiÏÔ˘ı·: ·) ∞ÈÌ·ÙÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜. O ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ - Ô ÔÔ›Ô˜ Û˘Ó‹ıˆ˜ ·˘Í¿ÓÂÈ ÛÙ· ÙÂÏÈο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ - ‰ÂÓ Â›Ó·È ‰È·ÁÓˆÛÙÈÎfi˜. øÛÙfiÛÔ, Ë ·‡ÍËÛ‹ ÙÔ˘ Û Â›‰· >20.000 ·ÔÙÂÏ› Û¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË Û˘ÓÙËÚËÙÈ΋˜ ·Ó¿Ù·Í˘. ‚) ∞ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ (Û fiÚıÈ· ı¤ÛË). ™Ù· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. øÛÙfiÛÔ, Ì ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Á›ÓÔ˘Ó ÂÌÊ·Ó‹ Ù· ·ÎfiÏÔ˘ı· (1,12,13): i) Ì¿˙· ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÛÙÔ ‰ÂÍÈfi ˘Ô¯fiÓ‰ÚÈÔ Ô˘ Ó· ÂÍ·Ï›ÊÂÈ ÙÔ Ë·ÙÈÎfi ÂÚ›ÁÚ·ÌÌ·, ii) Ì›ˆÛË ‹ ·Ô˘Û›· ·¤Ú· ÛÙÔ ‰ÂÍ› ¿Óˆ Î·È Î¿Ùˆ ÙÂÙ·ÚÙËÌfiÚÈÔ Ù˘ ÎÔÈÏÈ¿˜ Î·È iii) Â˘Ú‹Ì·Ù· ·fiÊڷ͢ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, fiˆ˜ ‰È¿Ù·ÛË Î·È ˘‰Ú·ÂÚÈο Â›‰·. ∂¿Ó Ë ‰È¿Ù·ÛË Â›Ó·È ÁÂÓÈÎÂ˘Ì¤ÓË, Ù· ˘‰Ú·ÂÚÈο Â›‰· ÌÔÚ› Ó· Â›Ó·È ÂÌÊ·Ó‹ Î·È ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ. Á) ÀÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ (6,12). Œ¯ÂÈ ÂÚÈÔÚ›ÛÂÈ ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ÂÍ·ÛÊ·Ï›˙ÂÈ ˘„ËÏ‹ ¢·ÈÛıËÛ›· ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (98-100%) Î·È ÂȉÈÎfiÙËÙ· 88-100%. ∞ÔÙÂÏ› ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô, ÈηӋ Ó· ‰È·ÁÓÒÛÂÈ fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ÂÁÎÔÏ·ÛÌÔ‡. ∂ÈϤÔÓ, ηٿ ÙË Û¿ÓÈ· ·Ú·ÌÔÓ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ÙË Û˘ÓÙËÚËÙÈ΋ ·Ó¿Ù·ÍË, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È ¯Ú‹ÛÈÌÔ ÁÈ· ÙË ‰È¿ÁÓˆÛË Èı·Ó‹˜ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘. ªÂ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Â› ÂÁÎÔÏ·ÛÌÔ‡, Ë Û˘Ó‹ı˘ ÂÈÎfiÓ· Ô˘ Ï·Ì‚¿ÓÂÙ·È Â›Ó·È ·˘Ù‹ Ù˘ - ÌÂÁ¿ÏˆÓ Û¯ÂÙÈο ‰È·ÛÙ¿ÛÂˆÓ (5 x 2,5 cm) - Ì¿˙·˜ οو ·fi ÙÔ ‹·Ú, Ô˘ ·ÚÂÎÙÔ›˙ÂÈ ÙȘ ÂÓÙÂÚÈΤ˜ ηÌ¤˜. ∏ ÂÈÎfiÓ· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋, ηıÒ˜ ηٿ ÙÔÓ Î¿ıÂÙÔ ¿ÍÔÓ· ‰›ÓÂÈ ÙÔ ÛËÌÂ›Ô “ÓÙfiÓ·Ù˜” (doughnut sign), ÂÓÒ Î·Ù¿ ÙÔÓ ÂÈÌ‹ÎË ¿ÍÔÓ· ÙÔ ÛËÌÂ›Ô “Û¿ÓÙÔ˘ÈÙ˜” (sandwich sign) ‹/Î·È ÙÔ ÛËÌÂ›Ô “„¢‰ÔÓÂÊÚÔ‡”. ‰) ∞ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙÔ U/S Doppler (12). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ fiÙ·Ó ‰ÂÓ ·ÂÈÎÔÓ›˙ÂÙ·È Ë ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙÔ Doppler, Ë Èı·ÓfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ·Ó¿Ù·Í˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Â›Ó·È ÌÈÎÚfiÙÂÚË. Â) µ·ÚÈÔ‡¯Ô˜ ˘ÔÎÏ˘ÛÌfi˜ (12). ∞ÔÙÂÏ› ÙÔ Î‡ÚÈÔ ‰È·ÁÓˆÛÙÈÎfi Î·È ıÂÚ·¢ÙÈÎfi ̤ÛÔ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡. ÷ڷÎÙËÚÈÛÙÈο ÙÔ˘ Â˘Ú‹Ì·Ù· ›ӷÈ: i) ÙÔ ÛËÌÂ›Ô ÙÔ˘ “ÂÏ·ÙËÚ›Ô˘”, ÙÔ ÔÔ›Ô ‰ËÌÈÔ˘ÚÁÂ›Ù·È ·fi ÙËÓ ·Ó·ÛÙÔÏ‹ ÚÔÒıËÛ˘ ÙÔ˘ ‚·Ú›Ô˘ ÛÙÔ ÛËÌÂ›Ô ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, ÂÓÒ ÂÚÈÊÂÚÈο, ÌÂٷ͇ ÙˆÓ ‰‡Ô ÙÔȯˆÌ¿ÙˆÓ, ÂÈÛ¤Ú¯ÂÙ·È ÌÈÎÚ‹ ÔÛfiÙËÙ· ‚·Ú›Ô˘, ¤ÙÛÈ ÒÛÙÂ Ë ÂÈÎfiÓ· Ó· ÚÔÛÔÌÔÈ¿˙ÂÈ

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·325

¶·È‰È·ÙÚÈ΋ 2004;67:321-327

·ÎÙÈÓÔÏÔÁÈο Ì “ÂÏ·Ù‹ÚÈÔ”. ¶ÚÔÛÔ¯‹ ··ÈÙÂ›Ù·È ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ÎÔÈÏ›·˜, Ë ÔÔ›· ÚÔËÁ›ٷÈ. ∂¿Ó ˘¿Ú¯ÂÈ ·¤Ú·˜ ÛÙÔ ÂÚÈÙfiÓ·ÈÔ, ·˘Ùfi ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ‚·ÚÈÔ‡¯Ô ˘ÔÎÏ˘ÛÌfi, ηıfiÙÈ ÛËÌ·›ÓÂÈ fiÙÈ ¤¯ÂÈ Â¤ÏıÂÈ ‰È¿ÙÚËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ii) ÙÔ ÛËÌÂ›Ô ÙÔ˘ “ÌËÓ›ÛÎÔ˘”, ÙÔ ÔÔ›Ô ·ÂÈÎÔÓ›˙ÂÈ ÙËÓ ÎÔ›ÏË ÎÔÚ˘Ê‹ ÙÔ˘ ÂÁÎÔÏ·Ûı¤ÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜ Ô˘ Ê·›ÓÂÙ·È Ó· ÚÔÂͤ¯ÂÈ ÛÙËÓ ·ÎÙÈÓÔÛÎÈÂÚ‹ ÛÙ‹ÏË. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ∆· ÎÏÈÓÈο ÛËÌ›· ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ Â›Ó·È ÎÔÈÓ¿ Ì ÔÏÏ¿ ÓÔÛ‹Ì·Ù· Ô˘ ÚÔηÏÔ‡Ó ‹ ‰ÂÓ ÚÔηÏÔ‡Ó ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, ·ÏÏ¿ Î·È Ì ÔÚÈṲ̂ӷ Â͈ÂÓÙÂÚÈο. ∆· ÛËÌ·ÓÙÈÎfiÙÂÚ· ·fi Ù· ÓÔÛ‹Ì·Ù· Ô˘ ı· Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó Â›Ó·È: ·) ∏ ÛΈÏËÎÔÂȉ›Ùȉ·, ηıÒ˜ fiÙ·Ó ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ¤ÓÙÔÓË Î·È ÁÚ‹ÁÔÚ· ÂÍÂÏÈÛÛfiÌÂÓË ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ô‰Ôı› Û ÂÁÎÔÏ·ÛÌfi. øÛÙfiÛÔ, Ë ÔÍ›· ÛΈÏËÎÔÂȉ›Ùȉ· Û˘Ó‹ıˆ˜ Û˘Ì‚·›ÓÂÈ Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ (5-14 ÂÙÒÓ) Î·È ÂÍÂÏ›ÛÛÂÙ·È Û‡ÓÙÔÌ· Û ‰È¿ÙÚËÛË Î·È ÂÚÈÙÔÓ›Ùȉ· ÏfiÁˆ Ù˘ ÌÈÎÚfiÙÂÚ˘ Ì¿˙·˜ ÂÈÏfiÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (20). ‚) OÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ΢ڛˆ˜ ·fi Shigella sp, Salmonella sp, Escherichia coli ‹ Î·È Rotavirus, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ÛÔ‚·Ú‹ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Î·È Û˘Óԉ‡ÔÓÙ·È Û˘Ó‹ıˆ˜ ·fi ˘„ËÏfi ˘ÚÂÙfi, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ·ıÔÏÔÁÈ΋ ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜ Î·È ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ÎÔÚ¿ÓˆÓ. Á) ∏ ÌÂÛÂÓÙ¤ÚÈ· ÏÂÌÊ·‰ÂÓ›Ùȉ·, Ô˘ Â›Ó·È Û˘¯Ó‹ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ‚·Û›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ (1). ‰) ÕÏÏ· ·›ÙÈ· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢, fiˆ˜ ÂÚÈÛÊÈÁ̤ÓË ‚Ô˘‚ˆÓÔ΋ÏË, Û˘ÛÙÚÔÊ‹ ÙÔ˘ Ù˘ÊÏÔ‡ ‹ ÙÔ˘ ÛÈÁÌÔÂȉԇ˜ ÂÓÙ¤ÚÔ˘, ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, fiˆ˜ ÙÔ ÂÎÎfiÏˆÌ· Meckel, ÙÔ Û‡Ó‰ÚÔÌÔ Peutz-Jeghers, ηıÒ˜ Î·È Ë ÔÚʇڷ Henoch-Schonlein (1,11). Â) ¶ÚfiÙˆÛË ÙÔ˘ ÔÚıÔ‡, ηıÒ˜ Û·Ó›ˆ˜ ·Ú·ÙËÚÂ›Ù·È ÚfiÙˆÛË ÙÔ˘ ÂÁÎÔÏ·Ûı¤ÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜ ‰È¿ ÙÔ˘ ÚˆÎÙÔ‡. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì ÙË ‰·ÎÙ˘ÏÈ΋ ÂͤٷÛË, Ë ÔÔ›· Â›Ó·È ·‰‡Ó·ÙË ÛÙËÓ ÂÚ›ÙˆÛË ÚfiÙˆÛ˘ ÙÔ˘ ÔÚıÔ‡ (1). £ÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∆Ô 1836, Ô Samuel Mitchell Âȯ›ÚËÛ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙË ÌË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ó¿Ù·ÍË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡. ∆Ô 1876, Ô Harold Hirschsprung ·Ó¤Ù·Í Ì ÂÈÙ˘¯›· ÂÁÎÔÏ·ÛÌfi ̤ۈ ˘‰ÚÔÛÙ·ÙÈÎÔ‡ ˘ÔÎÏ˘ÛÌÔ‡ Î·È ‰È·ÎÔÈÏÈ·ÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜. ŒÎÙÔÙÂ, ¤¯Ô˘Ó

Paediatriki 2004;67:321-327

ÂÚÈÁÚ·Ê› ÔÈΛÏÔÈ ÙÚfiÔÈ Û˘ÓÙËÚËÙÈ΋˜ ·Ó¿Ù·Í˘ (12). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ ·˘ÙfiÌ·Ù˘ ·Ó¿Ù·Í˘ ¯ÚfiÓÈˆÓ ‹ ˘ÔÙÚÔÈ·˙fiÓÙˆÓ ÂÁÎÔÏ·ÛÌÒÓ, Ë Û˘Ó‹ı˘ ¤Î‚·ÛË ÂÓfi˜ ÂÁÎÔÏ·ÛÌÔ‡ Ô˘ ‰ÂÓ ¤¯ÂÈ ·ÓÙÈÌÂÙˆÈÛÙ› Â›Ó·È Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Î·È Ë ‰È¿ÙÚËÛË Ô˘ ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ. ∏ ÙÂÏÂ˘Ù·›· Ô‰ËÁ› Û ÂÚÈÙÔÓ›Ùȉ· Î·È ÛËÙÈÎfi shock. ∏ Û˘¯ÓfiÙËÙ· ‰È¿ÙÚËÛ˘ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Â›Ó·È ¯·ÌËÏ‹ (0-3%). ∏ ‰È¿ÙÚËÛË ÌÔÚ› Ó· Ï¿‚ÂÈ ¯ÒÚ· ›Ù ÚÈÓ ÙÔÓ ˘ÔÎÏ˘ÛÌfi ›Ù ηٿ ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘ (14). ∏ Èı·ÓfiÙËÙ· ‰È¿ÙÚËÛ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÚÈÓ ÙË ıÂÚ·›· ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙÔÓ ¯ÚfiÓÔ Ô˘ ÌÂÛÔÏ·‚› ̤¯ÚÈ ÙË ‰È¿ÁÓˆÛË, ηıÒ˜ Î·È ·fi ÙËÓ ÔÈfiÙËÙ· Ù˘ È·ÙÚÈ΋˜ ÂÚ›ı·Ï„˘, ÂÓÒ Ë ‰È¿ÙÚËÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡ ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙËÓ ›ÂÛË Ô˘ ·ÛΛٷÈ, ·fi ÙË ‰È¿ÚÎÂÈ¿ Ù˘ Î·È ·fi ÙȘ Ê˘ÛÈΤ˜ ȉÈfiÙËÙ˜ ÙÔ˘ ˘ÏÈÎÔ‡ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙÔÓ ˘ÔÎÏ˘ÛÌfi. Œ¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ ·˘ÙfiÌ·Ù˘ ·Ó¿Ù·Í˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ Û ÌÈÎÚfi ÂÈÏÂÔ-ÂÈÏÂ˚Îfi ÂÁÎÔÏ·ÛÌfi Û ·Û˘Ìو̷ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, Ô ÔÔ›Ô˜ ‰È·ÈÛÙÒıËΠÛÂ Ù˘¯·›Ô ¤ÏÂÁ¯Ô Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ™Â ·Û˘Ìو̷ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ô ÂÁÎÔÏ·ÛÌfi˜ Â›Ó·È Ù˘¯·›Ô ‡ÚËÌ·, Û˘ÓÈÛÙ¿Ù·È Û˘ÓÙËÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË (6,15). ∆¯ÓÈ΋ ·Ó¿Ù·Í˘ (12,16,17) ™Ùfi¯Ô˜ ÔÔÈÔ˘‰‹ÔÙ هÔ˘ ˘ÔÎÏ˘ÛÌÔ‡ Â›Ó·È Ë ·Ó¿Ù·ÍË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ̤ۈ Ù˘ ›ÂÛ˘ Ô˘ ·ÛÎÂ›Ù·È ÛÙËÓ ÎÔÚ˘Ê‹ ÙÔ˘ ÂÁÎÔÏ·Ûı¤ÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜. ∏ ›ÂÛË Ô˘ ·ÛÎÂ›Ù·È Ì¤Ûˆ ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡ Â›Ó·È ÎÚ›ÛÈÌË Î·È ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù·ÍË ‹ Ó· ÚÔηϤÛÂÈ ‰È¿ÙÚËÛË. ∞ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘ Î·È Û˘˙‹ÙËÛ˘ ¤¯ÂÈ Á›ÓÂÈ, Â›Û˘, Ô ·ÚÈıÌfi˜ ÙˆÓ ÚÔÛ·ıÂÈÒÓ ·Ó¿Ù·Í˘ Ì ˘ÔÎÏ˘ÛÌfi Ô˘ ı· Ú¤ÂÈ Ó· ÂȯÂÈÚÔ‡ÓÙ·È ÛÙËÓ ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜ Ù˘ ÚÒÙ˘ ÚÔÛ¿ıÂÈ·˜, ηıÒ˜ Î·È ÙÔ ·ÛʷϤ˜ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ‰‡Ô ÚÔÛ·ıÂÈÒÓ. OÈ ·fi„ÂȘ ‰È›ÛÙ·ÓÙ·È, ηıÒ˜ ÔÚÈṲ̂ÓÔÈ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÌÂÙ¿ ÙËÓ ÚÒÙË ·ÔÙ˘¯›· ı· Ú¤ÂÈ Ó· ÂȯÂÈÚÂ›Ù·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ó¿Ù·ÍË, ÂÓÒ ¿ÏÏÔÈ ÂȯÂÈÚÔ‡Ó ‰Â‡ÙÂÚË, ÙÚ›ÙË ‹ Î·È ÂÚÈÛÛfiÙÂÚ˜ ÚÔÛ¿ıÂȘ ˘‰ÚÔÛÙ·ÙÈ΋˜ ·Ó¿Ù·Í˘, ÔÚ›˙ÔÓÙ·˜ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ‰‡Ô ÚÔÛ·ıÂÈÒÓ Û ϛÁ· ÏÂÙ¿ ¤ˆ˜ Ï›Á˜ ÒÚ˜. ∏ ηı˘ÛÙ¤ÚËÛË ·Ó¿ÌÂÛ· ÛÙȘ ÚÔÛ¿ıÂȘ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ˆ˜ ·ÈÙ›· ·˘ÙfiÌ·Ù˘ ·Ó¿Ù·Í˘ Û 5-6% ÙˆÓ ·ÛıÂÓÒÓ. ∞ÎfiÌË, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ ÌÂÚÈ΋˜ χÛ˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ÌÂÙ¿ ÙËÓ ÚÒÙË ÚÔÛ¿ıÂÈ·, ÏfiÁˆ Ù˘ Ì›ˆÛ˘ ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÙÔ˘

325

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18-11-04

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¶·È‰È·ÙÚÈ΋ 2004;67:321-327

ÂÁÎÔÏ·Ûı¤ÓÙÔ˜ ÂÓÙ¤ÚÔ˘ Î·È ‚ÂÏÙ›ˆÛ˘ Ù˘ ÊÏ‚È΋˜ ÚÔ‹˜ (1). Œ¯ÂÈ ‰È·ÈÛÙˆı›, Â›Û˘, fiÙÈ Ë Î·ı˘ÛÙ¤ÚËÛË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ χÛ˘ Î·È Ë Â·Ó¿ÏË„Ë ÙˆÓ ÚÔÛ·ıÂÈÒÓ ˘‰ÚÔÛÙ·ÙÈ΋˜ ·Ó¿Ù·Í˘ ‰ÂÓ ¤¯Ô˘Ó ÚÔηϤÛÂÈ ÚÔ‚Ï‹Ì·Ù· ηٿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ó¿Ù·ÍË Ô˘ ›Ûˆ˜ ¯ÚÂÈ·ÛÙ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ‹ ·‡ÍËÛË Ù˘ ıÓËÙfiÙËÙ·˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ˘ÔÎÏ˘ÛÌfi Ì ·¤Ú·, ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂٷ͇ Ù˘ ÚÒÙ˘ Î·È Ù˘ ‰Â‡ÙÂÚ˘ ÚÔÛ¿ıÂÈ·˜ ·Ó¿Ù·Í˘ Â›Ó·È 2-4 ÒÚ˜. ∏ ÂÌÊ¿ÓÈÛË ˘ÚÂÙÔ‡ Î·È Ù·¯˘Î·Ú‰›·˜, ηıÒ˜ Î·È Ë ÂÈÌÔÓ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÂÚÈÛÛfiÙÂÚÔ ·fi 36 ÒÚ˜ ·ÔÙÂÏÔ‡Ó Û¯ÂÙÈΤ˜ ·ÓÙÂӉ›ÍÂȘ ÁÈ· ‰Â‡ÙÂÚË ÚÔÛ¿ıÂÈ· ·Ó¿Ù·Í˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ̤ۈ ˘ÔÎÏ˘ÛÌÔ‡ Ì ·¤Ú· (16,17). ∞fiÏ˘Ù˜ ·ÓÙÂӉ›ÍÂȘ ÁÈ· ÙËÓ ÚÔÛ¿ıÂÈ· ·Ó¿Ù·Í˘ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ ̤ۈ ˘ÔÎÏ˘ÛÌÔ‡ Â›Ó·È ÙÔ shock Ô˘ ‰ÂÓ ‰ÈÔÚıÒÓÂÙ·È Ì ÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È Ë ÂÁηÙÂÛÙË̤ÓË ‰È¿ÙÚËÛË Ì ÎÏÈÓÈο ÛËÌ›· ÂÚÈÙÔÓ›Ùȉ·˜ (12).

O ˘ÔÎÏ˘ÛÌfi˜ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Û ÂÈÏÂÔ-ÂÈÏÂ˚Îfi ÂÁÎÔÏ·ÛÌfi, Ô ÔÔ›Ô˜ Â›Ó·È Û˘¯ÓfiÙÂÚÔ˜ Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi “ÛËÌÂ›Ô ¤Ó·Ú͢” (HSP, ·ÈÌÔÊÈÏ›·, Û‡Ó‰ÚÔÌÔ Peutz-Jeghers, ηÎÔ‹ıÂÈ·).

OÈ ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ˘ÔÎÏ˘ÛÌÔ‡ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ·) µ·ÚÈÔ‡¯Ô ˘ÔÎÏ˘ÛÌfi (8,12). ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ÈÔ Û˘¯Ó¿ ÂÊ·ÚÌÔ˙fiÌÂÓË Ì¤ıÔ‰Ô, Ë ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÔÏÏ¿ ¯ÚfiÓÈ·. ∏ ‰È¿ÚÎÂÈ· Ù˘ ÚÔÛ¿ıÂÈ·˜ ·Ó¿Ù·Í˘ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ Ù· 3 ÏÂÙ¿ Î·È ‰ÂÓ ÂÈÙÚ¤ÂÙ·È Ë „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏȷ΋˜ ¯ÒÚ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ¿ Ù˘. ∏ Û˘¯ÓfiÙÂÚË ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È Ô ¤ÌÂÙÔ˜. ‚) ÀÔÎÏ˘ÛÌfi Ì ·¤Ú· (8,12). ∂›Ó·È ·Ï‹ Î·È Ù·¯Â›· ̤ıÔ‰Ô˜, Ì ˘„ËÏfi ÔÛÔÛÙfi ·Ó¿Ù·Í˘ (7095%) Î·È ÌÈÎÚfiÙÂÚË ¤ÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›· Û ۯ¤ÛË Ì ÙÔÓ ‚·ÚÈÔ‡¯Ô ˘ÔÎÏ˘ÛÌfi, ηıÒ˜ Ë ‰È¿ÚÎÂÈ· ¯ÂÈÚÈÛÌÒÓ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ·Ó¿Ù·ÍË Â›Ó·È ‚Ú·¯‡ÙÂÚË. Á) ÃÚËÛÈÌÔÔ›ËÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ ÁÈ· ÙËÓ Î·ıÔ‰‹ÁËÛË ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡ (12). i) ÀÔÎÏ˘ÛÌfi˜ Ì ·Ï·ÙÔ‡¯Ô Û··ÛÌ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ ÛÙËÓ ∂˘ÚÒË. ∆Ô ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È Ë ·Ô˘Û›· ·ÎÙÈÓÔ‚ÔÏ›·˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ÂÚÈfiÚÈÛÙÔ˘ ·ÚÈıÌÔ‡ ÚÔÛ·ıÂÈÒÓ ·Ó¿Ù·Í˘. ii) ÀÔÎÏ˘ÛÌfi˜ Ì ·¤Ú· ˘fi ÙËÓ Î·ıÔ‰‹ÁËÛË U/S. ª¤¯ÚÈ Û‹ÌÂÚ· ‰È·Ù›ıÂÙ·È ÌÈÎÚ‹ ÂÌÂÈÚ›· Ì ·˘Ù‹ ÙË Ì¤ıÔ‰Ô. ∏ ̤ıÔ‰Ô˜ ÛÙԯ‡ÂÈ ÛÙÔÓ Û˘Ó‰˘·ÛÌfi ÙˆÓ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ ÙÔ˘ ˘ÔÎÏ˘ÛÌÔ‡ Ì ·¤Ú· (Ù·¯Â›· Î·È Î·ı·Ú‹ ̤ıÔ‰Ô˜ Ì ˘„ËÏfi ÔÛÔÛÙfi ·Ó¿Ù·Í˘) Ì ÂΛӷ Ù˘ U/S ηıÔ‰‹ÁËÛ˘ (¯ˆÚ›˜ ¤ÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›·). ‰) ÃÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË (12). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ 25% ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ ÛÙËÓ

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ÎÔÈÏȷ΋ ¯ÒÚ· Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ ÔÊ›ÏÂÙ·È ÛÙÔÓ ÂÁÎÔÏ·ÛÌfi. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÂӉ›ÎÓ˘Ù·È fiÙ·Ó ˘¿Ú¯ÂÈ ÛÔÎ Ô˘ ‰ÂÓ ‰ÈÔÚıÒÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, ÛËÌÂ›Ô ¤Ó·Ú͢, ÂÁηÙÂÛÙË̤ÓË ‰È¿ÙÚËÛË ‹ ·ÔÙ˘¯›· ·Ó¿Ù·Í˘ Ì ˘ÔÎÏ˘ÛÌfi (1). OÈ ¯ÂÈÚÈÛÌÔ› ηٿ ÙËÓ Â¤Ì‚·ÛË ı· Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Ì ÚÔÛÔ¯‹, ÒÛÙ ӷ ·ÔÊ¢¯ı› È·ÙÚÔÁÂÓ‹˜ ‰È¿ÙÚËÛË. ªÂÙ¿ ÙËÓ ˘‰ÚÔÛÙ·ÙÈ΋ ·Ó¿Ù·ÍË, Ë ·Ú·ÌÔÓ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤Ú·Ó ÙÔ˘ 24ÒÚÔ˘ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË. ªÂÙ¿ ¯ÂÈÚÔ˘ÚÁÈ΋ χÛË ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡, Ë ·Ú·ÌÔÓ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ (5-7 Ë̤Ú˜). ÀÔÙÚÔ‹ ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÌÂÙ¿ ˘‰ÚÔÛÙ·ÙÈÎfi ˘ÔÎÏ˘ÛÌfi Â›Ó·È 5-10% (Ë ˘„ËÏfiÙÂÚË Ô˘ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Â›Ó·È 20%). ªÔÚ› Ó· Û˘Ì‚Â› ÔÔÈ·‰‹ÔÙ ÛÙÈÁÌ‹ Î·È ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË Ó¤·˜ ÚÔÛ¿ıÂÈ·˜ ·Ó¿Ù·Í˘ Ì ‚¿ÚÈÔ. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ˘ÔÙÚÔ‹˜ Û˘Ì‚·›ÓÔ˘Ó ÙȘ ÚÒÙ˜ 72 ÒÚ˜ ÌÂÙ¿ ÙÔÓ ˘ÔÎÏ˘ÛÌfi, ¤¯Ô˘Ó fï˜ ηٷÁÚ·Ê› Î·È ÂÚÈÙÒÛÂȘ ˘ÔÙÚÔ‹˜ ÌÂÙ¿ 36 Ì‹Ó˜. ªÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ˘ÔÙÚÔ¤˜. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, ÂÓÈÛ¯‡ÂÙ·È Ë ˘Ô„›· ‡·Ú͢ ÛËÌ›Ԣ ¤Ó·Ú͢ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡. ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Â›Ó·È ÌÈÎÚfiÙÂÚË ÌÂÙ¿ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ó¿Ù·ÍË (1-4%). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÙÚÔ‹˜ Â›Ó·È Û˘Ó‹ıˆ˜ fiÌÔÈ· Ì ÂΛÓË ÙÔ˘ ÚÒÙÔ˘ ÂÂÈÛÔ‰›Ô˘ (1,6,7). ¶ÚfiÏË„Ë ¢ÂÓ ˘¿Ú¯Ô˘Ó ̤ÙÚ· ÚfiÏ˄˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ È‰ÈÔ·ı‹ ÂÁÎÔÏ·ÛÌfi. °È· ÙÔ˘˜ ·ÛıÂÓ›˜, fï˜, Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ıÂÚ·¢ÙÈÎfi ˘ÔÎÏ˘ÛÌfi, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜, ÒÛÙ ӷ ·ÔÊ¢¯ı› Ë Î·ı˘ÛÙ¤ÚËÛË ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (1). µÈ‚ÏÈÔÁÚ·Ê›· 1. Chahine A. Intussusception. www.e-medicine.com. topic 1208; 2002.

2. Cull DL, Rosario V, Lally KP, Ratner I, Mahour GH. Surgical implications of Henoch-Schonlein purpura. J Pediatr Surg 1990;25:741-743.

3. Dennison WM, Shaker M. Intussusception in infancy and childhood. Br J Surg 1970;57:679-684.

4. Holcomb GW 3rd, Ross AJ 3rd, O’Neill JA Jr. Postoperative intussusception: increasing frequency or increasing awareness? South Med J 1991;84:1334-1339.

5. Holsclaw DS, Rocmans C, Shwachman H. Intussusception in patients with cystic fibrosis. Pediatrics 1971;48:51-58.

6. Wood BP. Intussusception, Child. www.e-medicine.com. topic 366; 2001.

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7. King L. Pediatrics, Intussusception. www.e-medicine.com. topic 385; 2001.

8. DiFiore JW. Intussusception. Semin Pediatr Surg 1999;8: 214-220.

9. Gorgen-Pauly U, Schultz C, Kohl M, Sigge W, Moller J, Gortner L. Intussusception in preterm infants: case report and literature review. Eur J Pediatr 1999;158:830-832.

10. Kombo LA, Gerber MA, Pickering LK, Atreya CD, Breiman RF. Intussusception, infection, and immunization: summary of a workshop on rotavirus. Pediatrics 2001;108:E37.

11. Navarro O, Dugougeat F, Kornecki A, Shuckett B, Alton DJ, Daneman A. The impact of imaging in the management of intussusception owing to pathologic lead points in children.

A review of 43 cases. Pediatr Radiol 2000;30:594-603.

12. del-Pozo G, Albillos JC, Tejedor D, Calero R, Rasero M, dela-Calle U et al. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics 1999;19:299-319.

13. Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr Radiol 1994;24:17-20.

14. Naylor HG. Hydrostatic perforation of intussusception. Br J Surg 1970;57:79-80.

15. Swischuk LE, John SD, Swischuk PN. Spontaneous reduction of intussusception: verification with US. Radiology 1994;192:269-271.

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16. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17year review. Pediatr Radiol 1998;28:913-919.

17. Sandler AD, Ein SH, Connolly B, Daneman A, Filler RM. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15:214-216.

18. Chang EJ, Zangwill KM, Lee H, Ward JI. Lack of association between rotavirus infection and intussusception: implications for use of attenuated rotavirus vaccines. Pediatr Infect Dis J 2002;21:97-102.

19. Peter G, Myers MG. Intussusception, rotavirus and oral vaccines: summary of a workshop. Pediatrics 2002;110:e67.

20. Davenport M. Acute abdominal pain in children. BMJ 1996;312:498-501.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 27-06-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-03-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ÈÚ‹ÓË ∫·ÏËÌÂÚ¿ÎË µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

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Paediatriki 2004;67:328-335

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H ÛËÌ·Û›· ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÙˆÓ Ô‡ÚˆÓ ÛÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ·ı‹ÛÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ∂. °ÂˆÚÁ¿ÎË - ∞ÁÁÂÏ¿ÎË

The importance of urine electrolyte determination in the investigation of children with renal diseases H. Georgaki - Angelaki

¶ÂÚ›ÏË„Ë: O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú· ·ÔÙÂÏ› Ì›· ¯Ú‹ÛÈÌË ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ, Ô˘ Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÓÂÊÚÈÎÒÓ ·ı‹ÛÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ηıÒ˜ Î·È ÙˆÓ ‰È·ÊfiÚˆÓ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ, ÛÙȘ Ôԛ˜ ÂÌϤÎÂÙ·È ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∂›Ó·È Ì›· ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË Ô˘ ‰ÈÂÓÂÚÁÂ›Ù·È Â‡ÎÔÏ·, ÂÓÒ Ë ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛ‹ Ù˘ ÛÙ· ¯¤ÚÈ· ÙÔ˘ ÎÏÈÓÈÎÔ‡, ΢ڛˆ˜, ·È‰È¿ÙÚÔ˘, ÌÔÚ› Ó· ÚÔÛʤÚÂÈ ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜, ‰È·ÁÓˆÛÙÈÎÔ‡ Î·È ıÂÚ·¢ÙÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. ∏ ·ÚÔ‡Û· ÌÂϤÙË ÛÙԯ‡ÂÈ ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ì›·˜ ·Ï‹˜ ÂÚÁ·ÛÙËÚȷ΋˜ ·Ú·Ì¤ÙÚÔ˘ ÙˆÓ Ô‡ÚˆÓ ÛÙËÓ Î·ı’ Ë̤ڷ ÎÏÈÓÈ΋ ·È‰È·ÙÚÈ΋ Ú¿ÍË.

Abstract: The determination of the level of electrolytes in the urine is a useful test for investigating children suffering from renal disease or other conditions related directly or indirectly to renal function. It consists of a simple laboratory test, assessed on a daily basis, which offers the paediatrician very important diagnostic and therapeutic information. This review attempts to simplify the knowledge regarding the usefulness of urine electrolytes, so that the paediatrician will become familiar with the use of this test on a daily basis.

§¤ÍÂȘ ÎÏÂȉȿ: ËÏÂÎÙÚÔχÙ˜ Ô‡ÚˆÓ, ÓÂÊÚÔ¿ıÂȘ.

Key words: urine electrolytes, renal diseases.

∂ÈÛ·ÁˆÁ‹ ∏ ·Ô‚ÔÏ‹ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ Na+, ∫+, Cl-, Ca++ Î·È Mg++ ÛÙ· Ô‡Ú· ˘ÁÈÒÓ ·ÙfiÌˆÓ ÔÈΛÏÏÂÈ Î·È ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙȘ ‰È·ÈÙËÙÈΤ˜ ÙÔ˘˜ Û˘Ó‹ıÂȘ. ™ÙËÓ Î·ı’ Ë̤ڷ ÎÏÈÓÈ΋ Ú¿ÍË, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘˜ ÛÙ· Ô‡Ú· ·ÔÙÂÏ› ÂͤٷÛË ÚÔ˘Ù›Ó·˜ ÁÈ· Ù· ÂÚÈÛÛfiÙÂÚ· ‚ÈÔ¯ËÌÈο ÂÚÁ·ÛÙ‹ÚÈ·, ۯ‰fiÓ ¿ÓÙÔÙ ¿ÌÂÛ· ‰È·ı¤ÛÈÌË. ªÂ ‚¿ÛË Ù· ‰Â‰Ô̤ӷ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ‰È·Î˘Ì¿ÓÛÂˆÓ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·, Ô ÎÏÈÓÈÎfi˜, ΢ڛˆ˜, ÁÈ·ÙÚfi˜ ¤¯ÂÈ Û‹ÌÂÚ· ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ÂÚÌËÓ‡ÛÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ·ıÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ Î·È Ó· ·ÓÙÏ‹ÛÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔÓ ¤ÏÂÁ¯Ô ÚÔ˘Ù›Ó·˜, Û οı ÂÚ›ÙˆÛË Ô˘ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηÈ, ȉȷ›ÙÂÚ· ÂΛÓË ÙˆÓ Ô˘ÚÔÊfiÚˆÓ

ÛˆÏËÓ·Ú›ˆÓ, ÂËÚ¿˙ÂÙ·È ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· ·fi Ì›· ·ıÔÏÔÁÈ΋ ηٿÛÙ·ÛË (1). ªÂ ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂȯÂÈÚÂ›Ù·È Ë ·Ó·ÛÎfiËÛË ÂÓfi˜ Ôχ ÛËÌ·ÓÙÈÎÔ‡ ı¤Ì·ÙÔ˜ Ù˘ ηıËÌÂÚÈÓ‹˜ ÎÏÈÓÈ΋˜ ·È‰È·ÙÚÈ΋˜ Ú¿Í˘, Ì ÛÎÔfi ÙËÓ ÂÍÔÈΛˆÛË ÙÔ˘ ÎÏÈÓÈÎÔ‡, ΢ڛˆ˜, ·È‰›·ÙÚÔ˘ ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ì›·˜ ‡ÎÔÏ· ‰È·ı¤ÛÈÌ˘ ÂÚÁ·ÛÙËÚȷ΋˜ ·Ú·Ì¤ÙÚÔ˘ ÙˆÓ Ô‡ÚˆÓ. °ÂÓÈΤ˜ ·fi„ÂȘ ª›· ·fi ÙȘ ‚·ÛÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ÓÂÊÚÒÓ· Î·È ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÂΛӢ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ ÙÔ˘ - Â›Ó·È Ë Ú‡ıÌÈÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ¤ÎÎÚÈÛ˘, Â·Ó·ÚÚfiÊËÛ˘ Î·È ·¤ÎÎÚÈÛ˘ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·. ∂›Ó·È ÁÓˆÛÙfi, ÁÈ· ·Ú¿‰ÂÈÁÌ·, fiÙÈ ÂÎ ÙÔ˘ ·Ú¯ÈÎÔ‡ ‰ÈËı‹Ì·ÙÔ˜ 60% ÙÔ˘ Na+ Î·È 70% ÙÔ˘ Ca++ Â·Ó·ÚÚÔÊÒÓÙ·È ÛÙÔ ÂÁÁ‡˜ ÙÌ‹Ì·

¶·È‰ÔÓÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

Department of Paediatric Nephrology, “Aghia Sophia” Children’s Hospital, Athens

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ÙÔ˘ Ô˘ÚÔÊfiÚÔ˘ ÛˆÏËÓ·Ú›Ô˘, ÂÓÒ 30% Î·È 20% ÂÎ ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ·ÓÙ›ÛÙÔȯ·, ηıÒ˜ Î·È Ë ÏÂÈÔÓfiÙËÙ· ÙÔ˘ Mg++ Î·È Cl-, Â·Ó·ÚÚÔÊÒÓÙ·È ÛÙÔ ·¯‡ ·ÓÈfiÓ ÙÌ‹Ì· Ù˘ ·Á·Ï˘ ÙÔ˘ Henle (2). µ¿ÛÂÈ ÙˆÓ ϤÔÓ ÚfiÛÊ·ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜, ·ÚÈÔ ÚfiÏÔ ÛÙË ÏÂÈÙÔ˘ÚÁ›· Â·Ó·ÚÚfiÊËÛ˘ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô˘ÚÔÊfiÚ· ÛˆÏËÓ¿ÚÈ· ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÔÈ ‰›·˘ÏÔÈ Cl-, Ô˘ ··ÓÙÒÓÙ·È Û fiÏÔ ÙÔ Ì‹ÎÔ˜ ·˘ÙÒÓ Î·È ÙˆÓ ÔÔ›ˆÓ Ë ‚·ÛÈ΋ ÏÂÈÙÔ˘ÚÁ›· ¤¯ÂÈ Û‹ÌÂÚ· Έ‰ÈÎÔÔÈËı› (3). ∂›Ó·È, Â›Û˘, ÁÓˆÛÙfi Û‹ÌÂÚ· fiÙÈ Ë ÙÂÏÈ΋ ÂÈÎfiÓ· ÔÌÔÈfiÛÙ·Û˘ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙÔ ·›Ì· ÂÍ·ÚÙ¿Ù·È Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi Î·È ·fi ÙÔÓ ÚfiÏÔ Ô˘ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÔÏÏÔ› ¿ÏÏÔÈ Ú˘ıÌÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, fiˆ˜ Â›Ó·È ÔÈ ÂÓ‰ÔÎÚÈÓ›˜ ·‰¤Ó˜ ‹ Î·È ÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘·ÁÁÂÈÔÙÂÓÛ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘. ∞ÓÂÍ¿ÚÙËÙ·, ˆÛÙfiÛÔ, ·fi ÙËÓ fiÔÈ· ÔÚÌÔÓÈ΋ ‹ ¿ÏÏË ‰È·ÌÂÛÔÏ¿‚ËÛË, ÛÙÔÓ ‚·ıÌfi Ô˘ Ë ÔÌÔÈfiÛÙ·ÛË ·˘Ù‹ ÂËÚ¿˙ÂÙ·È ÚˆÙÔ·ıÒ˜ ‹ ‰Â˘ÙÂÚÔ·ıÒ˜ ·fi ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ, Ë ÌÂϤÙË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú· ‰›ÓÂÈ - ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ - Ì›· Û·Ê‹ ÂÈÎfiÓ· Ù˘ ˘ÔΛÌÂÓ˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ (1,6). ™ÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ, ÔÈ Ôԛ˜ ÔÈΛÏÏÔ˘Ó ·Ó¿ ¯ÒÚ· Î·È Ê˘Ï‹, Ë ‰È·Î‡Ì·ÓÛË ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ Na+, ∫+, ClÎ·È Ca++, ¤¯ÂÈ ˆ˜ ·ÎÔÏÔ‡ıˆ˜: Na+ 2-3 mEq/kg/Ë̤ڷ, K+ 1-2 mEq/kg/Ë̤ڷ, Cl- 3-5 mEq/kg/Ë̤ڷ Î·È Ca++ <4 mg/kg/Ë̤ڷ (4). °È· ÙÔ Mg++ ÙˆÓ Ô‡ÚˆÓ, ÔÈ Ê˘ÛÈÔÏÔÁÈο ·Ô‚·ÏÏfiÌÂÓ˜ ·fi Ù· Ô‡Ú· ÔÛfiÙËÙ˜ Î˘Ì·›ÓÔÓÙ·È ·Ó¿ ËÏÈΛ·, ÂÓÒ ¤¯ÂÈ ÂÈÎÚ·Ù‹ÛÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ˆ˜ Ô ÏfiÁÔ˜ Ù˘ Û˘ÁΤÓÙÚˆÛ‹˜ ÙÔ˘˜ ÚÔ˜ ÙËÓ ·Ô‚·ÏÏfiÌÂÓË ÛÙ· Ô‡Ú· ÎÚ·ÙÈÓ›ÓË (5). ø˜ ÚÔ˜ ÙË ÌÂıÔ‰ÔÏÔÁ›·, ı· Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÂ Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘, ·ÔÙÂÏ› ÙÔÓ È‰·ÓÈÎfi ÙÚfiÔ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ì›·˜ ·ıÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘. ∂ÓÙÔ‡ÙÔȘ, ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ·È‰È·ÙÚÈ΋ Ú¿ÍË ¤¯ÂÈ ÂÈÎÚ·Ù‹ÛÂÈ - Î·È ıˆÚÂ›Ù·È È‰È·›ÙÂÚ· Â·Ú΋˜ ÙÚfiÔ˜ ÂÎÙ›ÌËÛ˘ - Ë Ì¤ÙÚËÛË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ Û ¤Ó· ÌfiÓÔ ‰Â›ÁÌ· Ô‡ÚˆÓ, Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 24ÒÚÔ˘. O ÏfiÁÔ˜ ÁÈ· ·˘Ù‹ ÙËÓ ÂÈÏÔÁ‹, ÁÈ· ÙËÓ ÔÔ›· ¿ÏψÛÙÂ Û˘ÌʈÓÔ‡Ó ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, Â›Ó·È fiÙÈ Ë Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘ Â›Ó·È Ú·ÎÙÈο ·ÓÂÈÙ˘¯‹˜ ÛÙ· ·È‰È¿, ÏfiÁˆ ÙˆÓ Ôχ Èı·ÓÒÓ ·ˆÏÂÈÒÓ. ¡ÂÔÁÓÈ΋ ËÏÈΛ· ∂Í·›ÚÂÛË ÛÙÔÓ ·Ú·¿Óˆ ηÓfiÓ·, ˆ˜ ÚÔ˜ ÙËÓ ·Ô‚ÔÏ‹ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·, ·ÔÙÂÏÔ‡Ó

Paediatriki 2004;67:328-335

Ù· ÓÂÔÁ¤ÓÓËÙ· ‚Ú¤ÊË Î·È È‰È·›ÙÂÚ· Ù· ÚfiˆÚ·, ÛÙ· ÔÔ›·, ˆ˜ ÁÓˆÛÙfiÓ, ÙfiÛÔ Ë ÛÂÈÚ·Ì·ÙÈ΋ fiÛÔ Î·È Ë ÛˆÏËÓ·Úȷ΋ ÏÂÈÙÔ˘ÚÁ›· ˘ÔÏ›ÂÙ·È, ·Ú¿ ÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi ·ÚÈıÌfi ÙˆÓ ÓÂÊÚÒÓˆÓ Ô˘ ‰È·ı¤ÙÔ˘Ó Î·Ù¿ ÙËÓ 34Ë Â‚‰ÔÌ¿‰· ·ËÛ˘. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ô Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) Â›Ó·È ÌÂȈ̤ÓÔ˜ ηٿ ÙË Á¤ÓÓËÛË, ÂÓÒ ÙÔ ›‰ÈÔ Û˘Ì‚·›ÓÂÈ Ì ÙË Ì¤ÁÈÛÙË Û˘Ì˘ÎÓˆÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ÓÂÊÚÒÓ. ∫·Ù¿ ÙËÓ ËÏÈΛ· ·˘Ù‹, Â›Ó·È ÌÂȈ̤ÓË, Â›Û˘, Ë ÈηÓfiÙËÙ· Â·Ó·ÚÚfiÊËÛ˘ ÙˆÓ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ ·fi Ù· Ô˘ÚÔÊfiÚ· ÛˆÏËÓ¿ÚÈ·, ÂÓÒ Â›Ó·È ·˘ÍË̤ÓË Ë ·Ô‚ÔÏ‹ ÙÔ˘˜ ÛÙ· Ô‡Ú·. ™˘Ó¤ÂÈ· Ù˘ ηٿÛÙ·Û˘ ·˘Ù‹˜ Â›Ó·È Ù· ¯·ÌËÏfiÙÂÚ· Â›‰· ÙˆÓ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ Ô˘ Û˘Ó‹ıˆ˜ ‰È·ÈÛÙÒÓÔÓÙ·È ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ, Û ۯ¤ÛË Ì ÂΛӷ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ. Àfi ÙȘ ·Ú·¿Óˆ ÚÔ¸Ôı¤ÛÂȘ, ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ Û ·˘Ù‹ ÙËÓ ÂȉÈ΋ ÔÌ¿‰· ·ÓÒÚÈÌˆÓ ÓÂÔÁÓÒÓ Î·È ‚ÚÂÊÒÓ Â›Ó·È “Ê˘ÛÈÔÏÔÁÈο” ·˘ÍË̤ÓÔ. OÈ ÌÂȈ̤Ó˜ ÙÈ̤˜ ÛÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·˘Í¿ÓÔÓÙ·È Î·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ Î·È Ù·˘Ù›˙ÔÓÙ·È Ì ÂΛӘ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ, ÂÚ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-18 ÌËÓÒÓ (7). ∂͈ÓÂÊÚÈÎÔ› Ú˘ıÌÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ŒÓ·˜ Ôχ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ô˘ ÂËÚ¿˙ÂÈ ÙȘ ·Ô‚·ÏÏfiÌÂÓ˜ ÔÛfiÙËÙ˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·, Â›Ó·È Ë Î·Ù¿ÛÙ·ÛË ÂÓ˘‰¿ÙˆÛ˘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∂¿Ó, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ ÚÔÛ‰ÈÔÚÈÛÙ› ÛÙ· Â›‰· ÙˆÓ 100 mEq ËÌÂÚËÛ›ˆ˜, Ë ÙÈÌ‹ ·˘Ù‹ ÌÔÚ› - ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ - Ó· ·ÓÙÈÚÔÛˆ‡ÂÈ ÙË ‰È·ÈÙËÙÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÙfiÌÔ˘ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË Ë̤ڷ. øÛÙfiÛÔ, ˘fi Û˘Óı‹Î˜ ˘ÔÔÁηÈÌ›·˜, ·ÔÙÂÏ› Ì›· ·ıÔÏÔÁÈο ·˘ÍË̤ÓË ÙÈÌ‹, ÁÈ· ÙËÓ ÔÔ›· Ú¤ÂÈ - ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ˘fiÏÔÈ· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ‰Â‰Ô̤ӷ - Ó· ·Ó·˙ËÙËı› Ë ·Ó¿ÏÔÁË ÂÚÌËÓ›·. ∏ ηٿÛÙ·ÛË ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ÂÓfi˜ ·ÙfiÌÔ˘ ÂËÚ¿˙ÂÈ ÙÔ p∏ ÙˆÓ Ô‡ÚˆÓ Î·È fiÙ·Ó ·˘Ù‹ ‰È·Ù·Ú¿ÛÛÂÙ·È ·fi Â͈ÓÂÊÚÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (‰È¿ÚÚÔÈ·, ˘ÔÔÁηÈÌ›·), Â›Ó·È ÁÓˆÛÙfi fiÙÈ Î·È ÙÔ p∏ ÙˆÓ Ô‡ÚˆÓ ÙÚÔÔÔÈÂ›Ù·È ·Ó·ÏfiÁˆ˜, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙÔ˘˜ ·ÓÙÈÛÙ·ıÌÈÛÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÚÔÛ·ÚÌÔÁ‹˜ ÂÓfi˜ Ô˘ÚÔÊfiÚÔ˘ ÛˆÏËÓ·Ú›Ô˘ Ô˘ ÏÂÈÙÔ˘ÚÁ› Ê˘ÛÈÔÏÔÁÈο. ∂ÓÙÔ‡ÙÔȘ, Ë ÙÂÏÈ΋ ·˘Ù‹ Ú‡ıÌÈÛË ı· ÂËÚ¿ÛÂÈ ÙÔ ÔÛfi ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ÛÙ· Ô‡Ú· ËÏÂÎÙÚÔÏ˘ÙÒÓ. £· Ú¤ÂÈ, ÂÔ̤ӈ˜, Ó· ÂÎÙÈÌ¿Ù·È ÎÏÈÓÈο Ô ·ÛıÂÓ‹˜ ÁÈ· ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ˘ÔÔÁηÈÌ›·˜, ηٿÛÙ·ÛË Ë ÔÔ›· ·ÓÙÈÛÙÔȯ› Û Ì›ˆÛË ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ fiÁÎÔ˘. ∂›Ó·È ‰Â ÛËÌ·ÓÙÈÎfi Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ˘ÔÔÁηÈÌ›· ÛÙ· ·È‰È¿ ‰ÂÓ Ù·˘Ù›˙ÂÙ·È ¿ÓÙÔÙ ‹

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ÌfiÓÔ Ì ÙËÓ ¤ÓÓÔÈ· Ì›·˜ ÛÔ‚·Ú‹˜ ·ÈÌÔÚÚ·Á›·˜ ‹ ·Ê˘‰¿ÙˆÛ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ôχ Û˘¯Ó¿ ÌÔÚ› Ó· Û˘Ó‰˘¿˙ÂÙ·È Ì Ôȉ‹Ì·Ù·, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ȉÈÔ·ıÔ‡˜ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ™Â οıÂ, ÏÔÈfiÓ, ·ıÔÏÔÁÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ô˘ ı· Ú¤ÂÈ Ó· ÂÚÌËÓ¢ÙÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÂÎ ÙÔ˘ ÂϤÁ¯Ô˘ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú·, Â›Ó·È ··Ú·›ÙËÙÔ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ ÔÈ ·ÎfiÏÔ˘ıÔÈ ·Ú¿ÁÔÓÙ˜: ·) Ë Î·Ù¿ÛÙ·ÛË ÂÓ˘‰¿ÙˆÛ˘ ÙÔ˘ ¿Û¯ÔÓÙÔ˜, ‚) Ë ·ÚÔ˘Û›· ‹ fi¯È ˘ÔÔÁηÈÌ›·˜, Á) Ë ·ÚÔ˘Û›· ‹ fi¯È ÔÏÈÁÔ˘Ú›·˜, ÔÏ˘Ô˘Ú›·˜ Î·È ÔÏ˘‰È„›·˜, ‰) Ë ·ÚÔ˘Û›· ‹ fi¯È Ôȉ‹Ì·ÙÔ˜, Â) Ë ÛÔ‚·Ú‹ ÂÊ›‰ÚˆÛË, ÛÙ) Ë Î·Ù¿ÛÙ·ÛË Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜, ˙) Ë ˆÛ̈ÙÈÎfiÙËÙ·, ÙÔ ÂȉÈÎfi ‚¿ÚÔ˜ Î·È ÙÔ p∏ ÙˆÓ Ô‡ÚˆÓ Î·È Ë) Ë Èı·Ó‹ Ï‹„Ë ‰ÈÔ˘ÚËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ‰ÚÔ˘Ó ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ·Á·Ï˘ ÙÔ˘ Henle Î·È ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÙËÓ ÂχıÂÚË ‰È·Î›ÓËÛË ÙÔ˘ ÓÂÚÔ‡ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙ· Ô‡Ú· (1). ∫·Ù¿ ηÓfiÓ·, ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Û˘Ó˘¿Ú¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔÈ ÙÔ˘ ÂÓfi˜ ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜. ∆Ô ·Ô‚·ÏÏfiÌÂÓÔ Na+ ÙˆÓ Ô‡ÚˆÓ Àfi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, Ë ·Ô‚·ÏÏfiÌÂÓË ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ ÔÛfiÙËÙ· ÙÔ˘ Na+ ·ÓÙÈÚÔÛˆ‡ÂÈ ÂÚ›Ô˘ ÙËÓ ÚÔÛÏ·Ì‚·ÓfiÌÂÓË ·fi ÙËÓ ÙÚÔÊ‹ ÔÛfiÙËÙ¿ ÙÔ˘ ˘fi ÙË ÌÔÚÊ‹ ·Ï¿ÙˆÓ. O ÚÔÛ‰ÈÔÚÈÛÌfi˜, ÂÔ̤ӈ˜, ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ Na+ ÛÂ Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘, ı· ÌÔÚÔ‡Û ӷ ıˆÚËı› ˆ˜ Ô Î·Ï‡ÙÂÚÔ˜ ‰Â›ÎÙ˘ Û˘ÌÌfiÚʈÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙȘ ‰È·ÈÙËÙÈΤ˜ Ô‰ËÁ›Â˜, fiÙ·Ó ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙËÓ ·ÔÊ˘Á‹ ÙÔ˘, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÛÙËÓ ÂÚ›ÙˆÛË ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ ‹ Â› ·ÚÔ˘Û›·˜ ˘¤ÚÙ·Û˘ ‹ Ù¿Û˘ ÁÈ· ˘¤ÚÙ·ÛË (20). ™ÙȘ ‰È¿ÊÔÚ˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, Ë ·Ô‚·ÏÏfiÌÂÓË ÔÛfiÙËÙ· Na+ Û ¤Ó· Ù˘¯·›Ô ‰Â›ÁÌ· Ô‡ÚˆÓ ·ÔÙÂÏ› Ôχ ηÏfi ‰Â›ÎÙË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘. °È· ·Ú¿‰ÂÈÁÌ·, ÌÂȈ̤ÓË ·Ô‚ÔÏ‹ Na+ ÛÙ· Ô‡Ú· Û Â›‰· <15-20 mEq/l, ·ÓÙÈÚÔÛˆ‡ÂÈ Û˘Ó‹ıˆ˜ ηٿÛÙ·ÛË ˘ÔÔÁηÈÌ›·˜ Î·È Ë ÁÓÒÛË ·˘Ù‹ Â›Ó·È Î·ıÔÚÈÛÙÈ΋ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ οÔÈ·˜ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ·Î·ıfiÚÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ Î·È Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ˆ˜ Â› ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ™ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË (˘ÔÓ·ÙÚÈ·ÈÌ›· ·Î·ıfiÚÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜), Ù· ‰‡Ô ·ÚÈ· ·›ÙÈ· Ô˘ ÌÔÚÔ‡Ó Ó· ÙËÓ ÚÔηϤÛÔ˘Ó Â›Ó·È Â›ÙÂ Ë ˘ÔÔÁηÈÌ›· ÏfiÁˆ ˘ÔÙÔÓÈ΋˜ ·Ê˘‰¿ÙˆÛ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÛÔ‚·Ú‹ ÂÊ›‰ÚˆÛË ‹ ÙÔ Û‡Ó‰ÚÔÌÔ Ù˘ ·ÚfiÛÊÔÚ˘ ¤ÎÎÚÈÛ˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ, ÙËÓ ·¿ÓÙËÛË ı· ‰ÒÛÂÈ ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ, ‰ÈfiÙÈ ÛÙËÓ ÚÒÙË ÂÚ›ÙˆÛË ı· Â›Ó·È ÌÂȈ̤ÓÔ, ÂÓÒ ÛÙË ‰Â‡-

330

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ÙÂÚË ı· Â›Ó·È Û Â›‰· >40-50 mEq/l. ™ÙËÓ ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (O¡∞) ˆ˜ Û˘Ó¤ÂÈ·, Â›Û˘, ˘ÔÔÁηÈÌ›·˜ (ÔÏÈÁ·ÈÌÈÎfi shock, ÂÁη‡Ì·Ù·), ·ÎÔÏÔ˘ı› ·ıÔÁÂÓÂÙÈο ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÔÍ›·˜ ÛˆÏËÓ·Úȷ΋˜ Ó¤ÎÚˆÛ˘. ∞ÔÙ¤ÏÂÛÌ· ·˘Ù‹˜ Ù˘ ηٿÛÙ·Û˘ Â›Ó·È Ë ‚Ï¿‚Ë ÛÙ· ·ÙÙ·Ú· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ·ÓÈηÓfiÙËÙ· Â·Ó·ÚÚfiÊËÛ˘ ÙÔ˘ ÈfiÓÙÔ˜ ÙÔ˘ Na+ ÛÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÛΤÏÔ˜ Ù˘ ‚Ï¿‚˘ Î·È ·˘ÍË̤ÓË, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ·Ô‚ÔÏ‹ (>40-50 mEq/l) ÛÙ· Ô‡Ú·. ™Â ηٷÛÙ¿ÛÂȘ O¡∞, Ì ÌÂÁ·Ï‡ÙÂÚË ÂӉ¯Ô̤ӈ˜ ·ÍÈÔÈÛÙ›· ·fi ÙË Ì¤ÙÚËÛË ÌfiÓÔ ÙÔ˘ Na+ Ô‡ÚˆÓ, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ‰Â›ÎÙ˘ ÂÎÙ›ÌËÛ˘ Ù˘ ÛˆÏËÓ·Úȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÎÏ·ÛÌ·ÙÈ΋˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ Na+ (22). °È· ÙËÓ ÂÎÙ›ÌËÛË ·˘ÙÔ‡ ÙÔ˘ ‰Â›ÎÙË, ··ÈÙÂ›Ù·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÙÈÌ‹˜ ÙÔ˘ Na+ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÂ Ù˘¯·›Ô ‰Â›ÁÌ· Ô‡ÚˆÓ Î·È, Ù·˘Ùfi¯ÚÔÓ·, ÛÙÔ ·›Ì·. ∞fi ÙȘ ÙÈ̤˜ ·˘Ù¤˜ Î·È Ì ‚¿ÛË ÙËÓ Â͛ۈÛË: FE¡a+%=

Na+ Ô‡ÚˆÓ (mEq/L) x Cr oÚÔ‡ (mg/dL) x 100 Na+ ÔÚÔ‡ (mEq/L) x Cr Ô‡ÚˆÓ (mg/dL)

ÚÔ·ÙÂÈ Ô ‰Â›ÎÙ˘ Ù˘ ÎÏ·ÛÌ·ÙÈ΋˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ Na+, Ô ÔÔ›Ô˜ ¤¯ÂÈ È‰È·›ÙÂÚË ·Í›· ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ÚÔÓÂÊÚÈ΋˜ Î·È ÓÂÊÚÈ΋˜ O¡∞ (22). ™ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË, Ô ‰Â›ÎÙ˘ FE¡a+ ÂÎÙÈÌ¿Ù·È ¤ˆ˜ 1%, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ˆ˜ >2,5-3%. ™ÙȘ ÂÚÈÙÒÛÂȘ, ˆÛÙfiÛÔ, O¡∞ ˆ˜ Û˘Ó¤ÂÈ· ÔÍ›·˜ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜ ‹ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜, Ô ‰Â›ÎÙ˘ FE¡a+ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ È‰È·›ÙÂÚË ·Í›·. ™Ù· ÚfiˆÚ·, Â›Û˘, Ê·›ÓÂÙ·È fiÙÈ Ë ·Í›· ÙÔ˘ ‰Â›ÎÙË ·˘ÙÔ‡ ·ÌÊÈÛ‚ËÙ›ٷÈ, ‰ÈfiÙÈ ÏfiÁˆ ÛˆÏËÓ·Úȷ΋˜ ·ÓˆÚÈÌfiÙËÙ·˜, ÙÔ ·ÂÎÎÚÈÓfiÌÂÓÔ Na+ Â›Ó·È ·˘ÍË̤ÓÔ, ÙÚÔÔÔÈÒÓÙ·˜ ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ÙÔÓ ‰Â›ÎÙË FE¡a+. ŒÙÛÈ, ÁÈ· ÓÂÔÁÓ¿ Û ηٿÛÙ·ÛË O¡∞ Ì ËÏÈΛ· ·ËÛ˘ 29-30 ‚‰ÔÌ¿‰ˆÓ, ¤¯ÂÈ ÚÔÙ·ı› Ô ‰Â›ÎÙ˘ FE¡a+ Ó· ·ÍÈÔÏÔÁÂ›Ù·È fiÙ·Ó ÔÈ ÙÈ̤˜ ÙÔ˘ ‰È·ÈÛÙÒÓÔÓÙ·È Û Â›‰· >6%, ÂÓÒ ÂΛӷ >31 ‚‰ÔÌ¿‰ˆÓ ·ÍÈÔÏÔÁÔ‡ÓÙ·È ÙÈ̤˜ >3% (23). ª›· ¿ÏÏË, Â›Û˘, ÂӉȷʤÚÔ˘Û· ÂÚ›ÙˆÛË ÛÔ‚·Ú‹˜ ˘ÔÔÁηÈÌ›·˜ ÛÙ· ·È‰È¿ ›ӷÈ, fiˆ˜ ÚԷӷʤÚıËÎÂ, Ô Û˘Ó‰˘·ÛÌfi˜ ÔÏÈÁÔ˘Ú›·˜ Î·È ÔȉËÌ¿ÙˆÓ Ì ¯·ÌËÏfi Na+ ÛÙ· Ô‡Ú· (<15 mEq/l). ∆ËÓ ÂÈÎfiÓ· ·˘Ù‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· Ô‡Ú· Â› ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ΢ڛˆ˜ ηٿ ÙË Ê¿ÛË ÙˆÓ ÂÎÙÂÙ·Ì¤ÓˆÓ ÔȉËÌ¿ÙˆÓ, ÏfiÁˆ ÛÔ‚·Ú‹˜ ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·˜ (ÏÂ˘ÎˆÌ·Ù›Ó˜ <2,5 g/dl), ηٿÛÙ·ÛË Î·Ù¿ ÙËÓ ÔÔ›· ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÈÛÔÚÚÔ›· ÌÂٷ͇ ÙˆÓ ȤÛÂˆÓ ˘‰ÚÔÛÙ·ÙÈ΋˜ Î·È ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋˜ (‰˘Ó¿ÌÂȘ Starling), ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÍ·ÁÁ›ˆÛË ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ÓÂÚÔ‡ Î·È Na+ ÛÙÔÓ ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ÔȉËÌ¿ÙˆÓ. ™Â ·˘Ù‹ ÙËÓ ÂȉÈ΋ ÂÚ›ÙˆÛË ˘ÔÔÁηÈÌ›·˜, Ô

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·331

¶·È‰È·ÙÚÈ΋ 2004;67:328-335

ÓÂÊÚfi˜ ÚÔÛ·ı› Ó· ÂÍÔÈÎÔÓÔÌ‹ÛÂÈ Na+ Î·È ÓÂÚfi ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰· ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ Î·È ·˘Ùfi ÙÔ ÂÈÙ˘Á¯¿ÓÂÈ Î˘Ú›ˆ˜ Ì ÙËÓ ·˘ÍË̤ÓË Â·Ó·ÚÚfiÊËÛË ÙÔ˘ Na+ ÛÙÔ ·¯‡ ·ÓÈfiÓ ÛΤÏÔ˜ Ù˘ ·Á·Ï˘ Î·È ÙË ÌÂȈ̤ÓË, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ·Ô‚ÔÏ‹ ÙÔ˘ ÛÙ· Ô‡Ú·. ™ÙË ÏÂÈÙÔ˘ÚÁ›· ·˘Ù‹, ‚‚·›ˆ˜, Â›Ó·È ÁÓˆÛÙfi fiÙÈ Î‡ÚÈÔ ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙ÂÈ Î·È ÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ·Ô‚ÔÏ‹ ÙÔ˘ ÈfiÓÙÔ˜ ·˘ÙÔ‡ ÛÙ· Ô‡Ú· (8). ∂ÓÙÔ‡ÙÔȘ, ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ˘¿Ú¯Ô˘Ó ‰‡Ô ηٷÛÙ¿ÛÂȘ ˘ÔÔÁηÈÌ›·˜ Ô˘ Û˘Ó‰˘¿˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Na+ ÛÙ· Ô‡Ú·. ∏ Ì›· ·ÊÔÚ¿ ÛÙËÓ ÂÚ›ÙˆÛË ·Ú·ÙÂٷ̤Ó˘ ˘ÔÔÁηÈÌ›·˜, Ô˘ ‰ÂÓ ·Ó·Ù¿¯ÙËΠÂÁη›Úˆ˜ Î·È ÂËÚ¿ÛÙËÎÂ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË). ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ·˘ÍË̤ÓÔ, ·ÓÂÍ·Úًو˜ Ù˘ ·ÚÔ˘Û›·˜ ‹ fi¯È ÔÏÈÁÔ˘Ú›·˜, Ù· Ô‡Ú· ÂÚȤ¯Ô˘Ó ÎÔÎÎÒ‰ÂȘ Î˘Ï›Ó‰ÚÔ˘˜ Î·È Ë ÎÏ·ÛÌ·ÙÈ΋ ·¤ÎÎÚÈÛË ÙÔ˘ Na+ (FENa+) Â›Ó·È Ôχ ·˘ÍË̤ÓË. ∏ ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ·ÊÔÚ¿ ÛÙËÓ ÚÒÈÌË Ê¿ÛË Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ·ÏοψÛ˘ ˆ˜ Û˘Ó¤ÂÈ· Â̤وÓ, ηٿÛÙ·ÛË Ë ÔÔ›· Û˘Ó‰˘¿˙ÂÙ·È Ì ˘Ô¯ÚˆÙÈ΋ ·ÒÏÂÈ· Na+ ÛÙ· Ô‡Ú·, ÏfiÁˆ Ù˘ ÚÔÛ¿ıÂÈ·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ó· ·Ô‚¿ÏÂÈ ÙËÓ ÂÚ›ÛÛÂÈ· ÙˆÓ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ ÙÔ˘ ·›Ì·ÙÔ˜ ̤ۈ ÙˆÓ Ô‡ÚˆÓ (7,9). À¿Ú¯Ô˘Ó, Ù¤ÏÔ˜, ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È Î·Ù·ÛÙ¿ÛÂȘ ηٿ ÙȘ Ôԛ˜ Ë ·Ô‚ÔÏ‹ ÙÔ˘ Na+ ÛÙ· Ô‡Ú· fi¯È ÌfiÓÔ ‰ÂÓ Î·Ù¢ı‡ÓÂÈ ÔÚı¿ ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë, ·ÏÏ¿ ÂӉ¯Ô̤ӈ˜ ÙËÓ ·ÔÚÔÛ·Ó·ÙÔÏ›˙ÂÈ. ª›· Ù¤ÙÔÈ· ÂÚ›ÙˆÛË Â›Ó·È ÂΛÓË ÙÔ˘ ¿ÔÈÔ˘ ‰È·‚‹ÙË ÎÂÓÙÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, fiÔ˘ Ë ¤ÏÏÂÈ„Ë ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘ ·Ó·ÛÙ¤ÏÏÂÈ Ï‹Úˆ˜ ÙËÓ Â·Ó·ÚÚfiÊËÛË ÙÔ˘ ÓÂÚÔ‡ ÛÙ· ·ıÚÔÈÛÙÈο ÛˆÏËÓ¿ÚÈ· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÔÏ˘Ô˘Ú›· (5-10 Ï›ÙÚ· Ô‡Ú·/24ˆÚÔ), ÚÔηÏÒÓÙ·˜ ÙËÓ „¢‰‹ ÂÈÎfiÓ· ÙÔ˘ ÌÂȈ̤ÓÔ˘ Na+ ÛÙ· Ô‡Ú· (<10 mEq/l). ∆Ô Â‡ÚËÌ· ·˘Ùfi, ÛÙËÓ ÚÔ·Ó·ÊÂÚı›۷ ÂÚ›ÙˆÛË, ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ˘ÔÔÁηÈÌ›·, ·ÏÏ¿ Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ó˘¿Ú¯ÂÈ Ì ·Ê˘‰¿ÙˆÛË, fiÙ·Ó ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÔÈ ·Ó¿ÏÔÁ˜ ÚÔ˜ ÙȘ ·ÒÏÂȘ ÔÛfiÙËÙ˜ ˘ÁÚÒÓ. ∂›Û˘, ÌÂȈ̤ÓË Û˘ÁΤÓÙÚˆÛË Na+ ÛÙ· Ô‡Ú·, ¯ˆÚ›˜ Ú·ÁÌ·ÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ˘ÔÔÁηÈÌ›·˜, ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÔÍ›· ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· ‹ ÛÙËÓ ·ÌÊÔÙÂÚfiÏ¢ÚË ÛÙ¤ÓˆÛË Ù˘ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜. ∞ÓÙ›ıÂÙ·, ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Na+ ÛÙ· Ô‡Ú· (>50 mEq/l), ·Ú¿ ÙËÓ ·ÚÔ˘Û›· ˘ÔÔÁηÈÌ›·˜, ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÚ›ÙˆÛË Î·Ù¿¯ÚËÛ˘ ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È Â› ¤ÏÏÂȄ˘ ·Ï‰ÔÛÙÂÚfiÓ˘. ∫·Ù·ÛÙ¿ÛÂȘ ηٿ ÙȘ Ôԛ˜ ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ·˘ÍË̤ÓÔ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹

Paediatriki 2004;67:328-335

fi¯È ˘ÔÔÁηÈÌ›·˜, Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜: ·) ‰˘ÛÏ·ÛÙÈÎÔ›-˘ÔÏ·ÛÙÈÎÔ› ÓÂÊÚÔ› (salt loosing nephropathies), ‚) „¢‰Ô¸ԷωÔÛÙÂÚÔÓÈÛÌfi˜ Ù‡Ô˘ π Î·È Á) ÓÔÛ‹Ì·Ù· ·ÒÏÂÈ·˜ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ ·fi Ù· Ô˘ÚÔÊfiÚ· ÛˆÏËÓ¿ÚÈ·, fiˆ˜ ÓÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË Ù‡Ô˘ π Î·È ππ, Û‡Ó‰ÚÔÌÔ Fanconi Î·È ‰È·ÌÂÛÔÛˆÏËÓ·Úȷ΋ ÓÂÊÚ›Ùȉ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔ·Ó·ÊÂÚı›۷, ·ÚÎÂÙ¿ Û¿ÓÈ· ηٿÛÙ·ÛË ÙÔ˘ „¢‰Ô¸ԷωÔÛÙÂÚÔÓÈÛÌÔ‡ Ù‡Ô˘ π, Ì ·ÚÈÔ Â‡ÚËÌ· ÙËÓ ·ÒÏÂÈ· Na+ ÛÙ· Ô˘Ú¿, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÚfiÎÂÈÙ·È ÂÚ› ÎÏËÚÔÓÔÌÈ΋˜ ÓfiÛÔ˘, ÂÌÊ·Ó›˙ÂÙ·È ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ ·Ï‰ÔÛÙÂÚfiÓ˘ Ï¿ÛÌ·ÙÔ˜, Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ˘ÂÚηÏÈ·ÈÌ›· Ì ÔͤˆÛË Î·È ·˘ÍË̤Ó˜ ÙÈ̤˜ Na+ ÛÙ· Ô˘Ú¿. °È· ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÔÔÁηÈÌ›·˜, Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË NaCl ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰È·ÙÚÔÊ‹ ·˘ÍË̤ÓË Û Na+. ™ÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2 ·Ó·Ê¤ÚÔÓÙ·È Û˘ÓÔÙÈο ÔÈ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓÔ Î·È ÌÂȈ̤ÓÔ Na+ ÛÙ· Ô‡Ú·. ∆Ô ¯¿ÛÌ· ·ÓÈfiÓÙˆÓ ÛÙ· Ô‡Ú· O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ¯¿ÛÌ·ÙÔ˜ ·ÓÈfiÓÙˆÓ Ô‡ÚˆÓ (Na++K+-Cl-) ·ÔÙÂÏ› Ì›· ¿ÏÏË ·Ú¿ÌÂÙÚÔ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ÛÙ· Ô‡Ú· ËÏÂÎÙÚÔÏ˘ÙÒÓ. O Û˘Ó‰˘·ÛÌfi˜ ·˘Ùfi˜ ·ÍÈÔÏÔÁÂ›Ù·È ÛÙË ‰È¿ÎÚÈÛË ÌÂٷ͇ Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘ ÓÂÊÚÈ΋˜ Î·È ÌË ·ÈÙÈÔÏÔÁ›·˜, Ô˘ Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ¯¿ÛÌ· ÈfiÓÙˆÓ ÛÙÔ ·›Ì·. O Ê˘ÛÈÔÏÔÁÈÎfi˜ ÓÂÊÚfi˜ ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ÚÔÛ·ı›, ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ÔÛÔ‡ NH4+, Ó· ·Ô‚¿ÏÂÈ Ôͤ· ÛÙ· Ô‡Ú·. Àfi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, Ë Û¯¤ÛË Û‡ÓÔÏÔ Î·ÙÈfiÓÙˆÓ Û‡ÓÔÏÔ ·ÓÈfiÓÙˆÓ ÛÙ· Ô‡Ú· ıˆÚÂ›Ù·È ÌˉÂÓÈ΋ Î·È ·˘Ùfi Û˘Ì‚·›ÓÂÈ ÂÂȉ‹, ÁÈ· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ¶›Ó·Î·˜ 1. ∫·Ù·ÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓÔ Na+ Ô‡ÚˆÓ ¶ÚÔˆÚfiÙËÙ· OÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ªÂÙ·‚ÔÏÈ΋ ·ÏοψÛË Ì Â̤ÙÔ˘˜ (ÚÒÈÌË Ê¿ÛË) ÀԷωÔÛÙÂÚÔÓÈÛÌfi˜ 梉ԸԷωÔÛÙÂÚÔÓÈÛÌfi˜ Ù‡Ô˘ π ÃÚ‹ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ù˘ ·Á·Ï˘ ÙÔ˘ Henle (ÊÔ˘ÚÔÛÂÌ›‰Ë) ¢˘ÛÏ·ÛÙÈÎÔ›-˘ÔÏ·ÛÙÈÎÔ› ÓÂÊÚÔ› ¡ÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË Ù‡Ô˘ π Î·È ππ ¢È·ÌÂÛÔÛˆÏËÓ·Úȷ΋ ÓÂÊÚ›Ùȉ· ™‡Ó‰ÚÔÌÔ Fanconi

¶›Ó·Î·˜ 2. ∫·Ù·ÛÙ¿ÛÂȘ Ì ÌÂȈ̤ÓÔ Na+ Ô‡ÚˆÓ ÀÔÔÁηÈÌ›· ˆ˜ Â› ˘ÔÙÔÓÈ΋˜ ·Ê˘‰¿ÙˆÛ˘ ÀÔÔÁηÈÌ›· ˆ˜ Â› ÔÍ›·˜ Ê¿Û˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ OÍ›· ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· ∞ÌÊÔÙÂÚfiÏ¢ÚË ÛÙ¤ÓˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ÕÔÈÔ˜ ‰È·‚‹Ù˘

331

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·332

¶·È‰È·ÙÚÈ΋ 2004;67:328-335

‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ó˘ÔÏÔÁ›˙ÔÓÙ·È Û ·˘Ù‹ ÔÈ Ôχ ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ÛÙ· Ô‡Ú· ÏÔÈÒÓ ·ÓÈfiÓÙˆÓ, fiˆ˜ Â›Ó·È Ù· ıÂÈÈο, ʈÛÊÔÚÈο, Á·Ï·ÎÙÈο ‹ Ù· ‰ÈÙÙ·ÓıÚ·ÎÈο ·ÓÈfiÓÙ·. ™ÙËÓ ÔͤˆÛË ÓÂÊÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ù‡Ô˘ π Ì ‹ ¯ˆÚ›˜ ˘ÂÚηÏÈ·ÈÌ›· Î·È ÛÙÔÓ ˘ԷωÔÛÙÂÚÔÓÈÛÌfi, ÙÔ ¯¿ÛÌ· ·ÓÈfiÓÙˆÓ ÛÙ· Ô‡Ú· Â›Ó·È ıÂÙÈÎfi, ÂÓÒ Â› ˘ÂگψڷÈÌÈ΋˜ ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘ ÌË ÓÂÊÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ (fiˆ˜ Û ηٷÛÙ¿ÛÂȘ ˘ÂÚ·Ì̈ÓÈ·ÈÌ›·˜, ¯ÚfiÓÈ·˜ ‰È¿ÚÚÔÈ·˜ ‹ ˘ÔÔÁηÈÌ›·˜) Á›ÓÂÙ·È ·ÚÓËÙÈÎfi, ÏfiÁˆ Ù˘ ·˘ÍË̤Ó˘ ÔÛfiÙËÙ·˜ ÛÙ· Ô‡Ú· ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ NH4+.

O ÚÔÛ‰ÈÔÚÈÛÌfi˜, ÂÔ̤ӈ˜, ÙÔ˘ ¯¿ÛÌ·ÙÔ˜ ÈfiÓÙˆÓ ÛÙ· Ô‡Ú· Ô˘ ÚÔ·ÙÂÈ ·fi ÙËÓ ÚÔ·Ó·ÊÂÚı›۷ Û¯¤ÛË ‰È·ÊÔÚ¿˜ ηÙÈfiÓÙˆÓ Î·È ·ÓÈfiÓÙˆÓ ÛÙ· Ô‡Ú·, fiÙ·Ó Â›Ó·È ıÂÙÈ΋ ‚ÔËı¿ÂÈ ÛËÌ·ÓÙÈο ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi, ˆ˜ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ Â› ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘, ÂÓÒ fiÙ·Ó Â›Ó·È ·ÚÓËÙÈ΋ Â͢ËÚÂÙ› ÛÙÔÓ ¤ÌÌÂÛÔ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ÔÛÔ‡ NH4+ ÛÙ· Ô‡Ú·. ∂Í·›ÚÂÛË ÛÙÔÓ Î·ÓfiÓ· ·˘Ùfi ·ÔÙÂÏ› Ë ÓÂÊÚÈ΋ ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Ù‡Ô˘ ππ, fiÔ˘ Ë ˘ÂÚ‚ÔÏÈ΋ ·ÒÏÂÈ· ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ (·ÓÈfiÓÙˆÓ) ÛÙ· Ô‡Ú· ÌÂÙ·ÙÚ¤ÂÈ ÙË Û¯¤ÛË ·˘Ù‹ ·fi ıÂÙÈ΋ Û ·ÚÓËÙÈ΋ (10-13). ∆Ô ·Ô‚·ÏÏfiÌÂÓÔ K+ ÙˆÓ Ô‡ÚˆÓ ™Â Ê˘ÛÈÔÏÔÁÈο ÂÓ‹ÏÈη ¿ÙÔÌ·, fiÙ·Ó ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË Ï‹„Ë K+ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È ·ÓÙ›ÛÙÔÈ¯Ë ·‡ÍËÛË ÛÙ· ·ÂÎÎÚÈÓfiÌÂÓ· ÔÛ¿ ÙÔ˘ K+ ·fi Ù· Ô‡Ú·, Ô˘ ÌÔÚ› Ó· ˘ÂÚ‚·›ÓÔ˘Ó Î·È Ù· 400 mEq ËÌÂÚËÛ›ˆ˜. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi, ÚÔÛٷهÂÙ·È Ô ÔÚÁ·ÓÈÛÌfi˜ Î·È È‰È·›ÙÂÚ· Ô Î·Ú‰È·Îfi˜ Ì˘˜, ·fi ÙËÓ È‰È·›ÙÂÚ· ÂÈΛӉ˘ÓË Î·Ù¿ÛÙ·ÛË Ù˘ ˘ÂÚηÏÈ·ÈÌ›·˜. ∂› ·Ú¯fiÌÂÓ˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ì›· ·ÓÂ·Ú΋˜ ·¤ÎÎÚÈÛË ÙÔ˘ ÈfiÓÙÔ˜ ÙÔ˘ K+ ÛÙ· Ô‡Ú· Û˘Ó‰˘¿˙ÂÙ·È Ì ‹È· ˘ÂÚηÏÈ·ÈÌ›·, ·ÏÏ¿ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë Ì¤ÙÚËÛË ÙÔ˘ K+ ÛÙ· Ô‡Ú· Û˘ÓÂÈÛʤÚÂÈ Ôχ Ï›ÁÔ ‰È·ÁÓˆÛÙÈο (21). π‰È·›ÙÂÚ· ¯·ÌËÏ¿ Â›‰· K+ ÛÙ· Ô‡Ú·, ÏËÓ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ „¢‰Ô¸ԷωÔÛÙÂÚÔÓÈÛÌÔ‡. ∞ÓÙ›ıÂÙ·, Â› ¤Ó‰ÂÈ·˜ K+ ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, ÙÔ ·Ô‚·ÏÏfiÌÂÓÔ ÔÛfi ÙÔ˘ ηÙÈfiÓÙÔ˜ ·˘ÙÔ‡ ÛÙ· Ô‡Ú· ÌÔÚ› Ó· ÌÂȈı› ÛÙ· ¯·ÌËÏ¿ Â›‰· ÙˆÓ 5-25 mEq ËÌÂÚËÛ›ˆ˜, ·ÔÙÂÏÒÓÙ·˜, ÂÔ̤ӈ˜, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÛÙ· Ô‡Ú· - Û ηٷÛÙ¿ÛÂȘ ·ÓÂÚÌ‹Ó¢Ù˘ ˘ÔηÏÈ·ÈÌ›·˜ - Ì›· ¯Ú‹ÛÈÌË ÂͤٷÛË. ŸÙ·Ó ‰ÂÓ Û˘ÓÙÚ¤¯Ô˘Ó ÏfiÁÔÈ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ¯·ÌËÏ¿ Â›‰· K+ ÛÙ· Ô‡Ú· ÛËÌ·›ÓÔ˘Ó ·ÒÏÂÈ· ÙÔ˘ ÈfiÓÙÔ˜ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·,

332

Paediatriki 2004;67:328-335

˘ÂÚ‚ÔÏÈ΋ ÂÊ›‰ÚˆÛË, ηٿ¯ÚËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‹ ·ÓÒÌ·ÏË ·Ó·Î·Ù·ÓÔÌ‹, fiˆ˜ ÌÔÚ› Ó· Û˘Ì‚Â› ÛÙË ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË ‹ ηٿ ÙË ¯Ú‹ÛË ÈÓÛÔ˘Ï›Ó˘. ∞ÓÙ›ıÂÙ·, ÙÈ̤˜ K+ Ô‡ÚˆÓ >25 mEq ËÌÂÚËÛ›ˆ˜, Â› ‰¿ÊÔ˘˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, Ì ‹ ¯ˆÚ›˜ ˘ÂÚÂÓÈÓ·ÈÌ›·, ˘Ô‰ËÏÒÓÔ˘Ó Î·Ù·ÛÙ¿ÛÂȘ ˘ÂÚηÏÈÔ˘Ú›·˜, fiˆ˜ ÛÙ· Û‡Ó‰ÚÔÌ· Liddle, Bartter, Gitelman Î·È Fanconi, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÊÚÈ΋˜ ÛˆÏËÓ·Úȷ΋˜ ÔͤˆÛ˘ Ù‡Ô˘ π, ηٿ ÙȘ ÔÏ˘Ô˘ÚÈΤ˜ Ê¿ÛÂȘ Ù˘ ·Ó¿ÚÚˆÛ˘ ÌÂÙ¿ ·fi ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ‹ ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, ηıÒ˜ Î·È ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ÓÂÊÚÔÏÈı›·Û˘ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·. ∞˘ÍË̤ӷ Â›‰· K+ ÛÙ· Ô‡Ú·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘¤ÚÙ·ÛË Î·È ¯·ÌËÏ¿ Â›‰· ÚÂÓ›Ó˘ ÛÙÔÓ ÔÚfi, Ú¤ÂÈ Ó· ηÙ¢ı‡ÓÔ˘Ó ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë Â›Ù ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ ˘ÂڷωÔÛÙÂÚÔÓÈÛÌÔ‡ (·Ï‰ÔÛÙÂÚfiÓË Ï¿ÛÌ·ÙÔ˜ ·˘ÍË̤ÓË), Ùo Û‡Ó‰ÚÔÌÔ Liddle, ÙËÓ ¤ÏÏÂÈ„Ë Ù˘ 11‚ ˘‰ÚÔÍ˘Ï¿Û˘ Î·È ÙȘ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ¤ÎÎÚÈÛË ÙˆÓ ·Ï·ÙÔÎÔÚÙÈÎÔÂȉÒÓ, ηٷÛÙ¿ÛÂȘ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ÌÂȈ̤ÓË ·Ï‰ÔÛÙÂÚfiÓË ÛÙÔ Ï¿ÛÌ· (14-16). ™ÙÔ˘˜ ¶›Ó·Î˜ 3 Î·È 4 ·Ó·Ê¤ÚÔÓÙ·È ÔÈ Î·Ù·ÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓÔ Î·È ÌÂȈ̤ÓÔ K+ ÛÙ· Ô‡Ú·, ·ÓÙ›ÛÙÔȯ·. ∂›Û˘, ÛÙÔÓ ¶›Ó·Î· 3 ÂÈÛËÌ·›ÓÂÙ·È Ë Û¯¤ÛË ·Ô‚ÔÏ‹˜ ÙÔ˘ ÈfiÓÙÔ˜ ·˘ÙÔ‡ Ì ٷ Â›‰· Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ù˘ ÚÂÓ›Ó˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ¶›Ó·Î·˜ 3. ∫·Ù·ÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓÔ K+ Ô‡ÚˆÓ (>25 mEq/24ˆÚÔ) Î·È Ê˘ÛÈÔÏÔÁÈ΋ ∞¶ ™‡Ó‰ÚÔÌÔ Bartter ™‡Ó‰ÚÔÌÔ Gitelman ™‡Ó‰ÚÔÌÔ Fanconi ¡ÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË Ù‡Ô˘ π ¶ÔÏ˘Ô˘ÚÈ΋ Ê¿ÛË O¡∞ ¶ÔÏ˘Ô˘ÚÈ΋ Ê¿ÛË ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ ¡ÂÊÚÔÏÈı›·ÛË Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ∫·Ù·ÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓÔ K+ Ô‡ÚˆÓ Î·È ˘¤ÚÙ·ÛË Ì ÚÂÓ›ÓË Ï¿ÛÌ·ÙÔ˜ ¶ÚˆÙÔ·ı‹˜ ˘ÂڷωÔÛÙÂÚÔÓÈÛÌfi˜ ™‡Ó‰ÚÔÌÔ Liddle ŒÏÏÂÈ„Ë Ù˘ 11‚ ˘‰ÚÔÍ˘Ï¿Û˘ ¢È·Ù·Ú·¯¤˜ ÛÙËÓ ¤ÎÎÚÈÛË ·Ï·ÙÔÎÔÚÙÈÎÔÂȉÒÓ ¶›Ó·Î·˜ 4. ∫·Ù·ÛÙ¿ÛÂȘ Ì ÌÂȈ̤ÓÔ K+ Ô‡ÚˆÓ (<25 mEq/24ˆÚÔ) ¡ÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· 梉ԸԷωÔÛÙÂÚÔÓÈÛÌfi˜ ŒÓ‰ÂÈ· K+ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ∞ÒÏÂÈ· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÀÂÚ‚ÔÏÈ΋ ÂÊ›‰ÚˆÛË ∫·Ù¿¯ÚËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ∞ÓÒÌ·ÏË ·Ó·Î·Ù·ÓÔÌ‹ (ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË, ÈÓÛÔ˘ÏÈÓÔıÂÚ·›·)

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·333

¶·È‰È·ÙÚÈ΋ 2004;67:328-335

∆Ô ·Ô‚·ÏÏfiÌÂÓÔ Cl- ÙˆÓ Ô‡ÚˆÓ ∆· ÈfiÓÙ· ÙÔ˘ Cl- Â·Ó·ÚÚÔÊÒÓÙ·È Î·ı’ fiÏÔ ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÓÂÊÚÒÓ·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ Na+. O ÚÔÛ‰ÈÔÚÈÛÌfi˜, ÂÓÙÔ‡ÙÔȘ, ÙÔ˘ Cl- ÛÙ· Ô‡Ú· ·Ô‰ÂÈÎÓ‡ÂÈ Û˘¯Ó¿ fiÙÈ Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ÈfiÓÙÔ˜ ·˘ÙÔ‡ ˘ÂÚ‚·›ÓÂÈ ÛËÌ·ÓÙÈο ÂΛÓË ÙÔ˘ Na+, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ ·Ô‰Ôı› ÛÂ Û˘Ó·Ô‚·ÏÏfiÌÂÓ· ÔÛ¿ ClÌ ¿ÏÏ· ÏËÓ ÙÔ˘ Na+ ηÙÈfiÓÙ·, fiˆ˜ Â›Ó·È ÙÔ Î·ÙÈfiÓ ÙÔ˘ NH4+. ∞˘Ùfi, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ‰È·ÈÛÙÒÓÂÙ·È Û˘¯Ó¿ ÛÙÔ˘˜ ˘ÔÔÁηÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, ˘¿Ú¯Ô˘Ó ηٷÛÙ¿ÛÂȘ ˘ÔÔÁηÈÌ›·˜ ηٿ ÙȘ Ôԛ˜ Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Na+ ÛÙ· Ô‡Ú· Â›Ó·È ‰˘Û·Ó¿ÏÔÁ· ·˘ÍË̤ÓË Û ۯ¤ÛË Ì ÙËÓ Ú·ÁÌ·ÙÈ΋ ˘ÔÔÁηÈÌ›·. ∞˘Ùfi ›Ûˆ˜ Û˘Ì‚·›ÓÂÈ ‰ÈfiÙÈ ÛÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜, Ô˘ Û˘Óԉ‡ÔÓÙ·È Î·È ·fi ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË, ¤Ó· ÔÛfi Na+ ·Ô‚¿ÏÏÂÙ·È ÛÙ· Ô‡Ú· ˘fi ÌÔÚÊ‹ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ, ·˘Í¿ÓÔÓÙ·˜ Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi ÙËÓ ÙÂÏÈ΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ÈfiÓÙÔ˜ ÛÙ· Ô‡Ú·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Ë ÌÂȈ̤ÓË ·¤ÎÎÚÈÛË Cl- ÛÙ· Ô‡Ú· ·Ó·‰ÂÈÎÓ‡ÂÈ ÛÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi ÙËÓ Ú·ÁÌ·ÙÈ΋ ηٿÛÙ·ÛË ˘ÔÔÁηÈÌ›·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∂›Û˘, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ Cl- ÛÙ· Ô‡Ú· ·Ô‚·›ÓÂÈ È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË ·Ú¿ÌÂÙÚÔ˜ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ‰È·ÊfiÚˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ Û˘Ó‰˘¿˙ÔÓÙ·È Ì ˘ÔηÏÈ·ÈÌ›· Î·È ˘ԯψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË (18), ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 5. ∆Ô ·Ô‚·ÏÏfiÌÂÓÔ Ca++ ÙˆÓ Ô‡ÚˆÓ ∆· ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ Ca++ ÛÙ· Ô‡Ú· ·ÔÙÂÏÔ‡Ó ·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· ÛÙȘ ηٷÛÙ¿ÛÂȘ ÓÂÊÚ·Û‚¤ÛÙˆÛ˘, ÔÈ Ôԛ˜ ıˆÚÔ‡ÓÙ·È ˆ˜ Â·ÎfiÏÔ˘ıÔ Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜. ŒÓ· ¶›Ó·Î·˜ 5. To Cl- ÙˆÓ Ô‡ÚˆÓ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î·Ù·ÛÙ¿ÛÂˆÓ ˘ÔηÏÈ·ÈÌ›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘ԯψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË π. Cl- Ô‡ÚˆÓ <10 mEq/l ªÂȈ̤ÓË ÚfiÛÏË„Ë Cl∞ÒÏÂÈ· ÂÎ ÙÔ˘ ÂÙÈÎÔ‡ (¤ÌÂÙÔÈ, fiÁÎÔÈ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ηٿ¯ÚËÛË ˘·ÎÙÈÎÒÓ) ¶·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË ˘·ÎÙÈÎÒÓ ∫˘ÛÙÈ΋ ›ÓˆÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ππ. Cl- Ô‡ÚˆÓ >10 mEq/l ∂› Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ™‡Ó‰ÚÔÌÔ Bartter ™‡Ó‰ÚÔÌÔ Gitelman µÚ·¯Â›· ¯Ú‹ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ ∂› ˘¤ÚÙ·Û˘ Ì ÚÂÓ›ÓË Î·È ·Ï‰ÔÛÙÂÚfiÓË ™Ù¤ÓˆÛË Ù˘ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ŸÁÎÔÈ Ô˘ ÂÎÎÚ›ÓÔ˘Ó ÚÂÓ›ÓË ∂› ˘¤ÚÙ·Û˘ Ì ÚÂÓ›ÓË Î·È ·Ï‰ÔÛÙÂÚfiÓË ¶ÚˆÙÔ·ı‹˜ ˘ÂڷωÔÛÙÂÚÔÓÈÛÌfi˜ (·‰¤ÓˆÌ· ‹ ˘ÂÚÏ·Û›·) ÀÂڷωÔÛÙÂÚÔÓÈÛÌfi˜ ·ÓÙ·ÔÎÚÈÓfiÌÂÓÔ˜ ÛÙË ‰ÂÍ·ÌÂı·˙fiÓË ∂› ˘¤ÚÙ·Û˘ Ì ÚÂÓ›ÓË Î·È ·Ï‰ÔÛÙÂÚfiÓË ™˘ÁÁÂÓ‹˜ ˘ÂÚÏ·Û›· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ ∂› ¯ÔÚ‹ÁËÛ˘ ·Ï·ÙÔÎÔÚÙÈÎÔÂȉÒÓ

Paediatriki 2004;67:328-335

Ù¤ÙÔÈÔ ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› Ë ÂÚ›ÙˆÛË Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘ÚÈ΋˜ ÓÂÊÚÔÏÈı›·Û˘, Ë ÔÔ›· ÌÔÚ› Ó· ÚÔ‚¿ÏÂÈ Ì ‰È¿ÊÔÚÔ˘˜ Ê·ÈÓÔÙ‡Ô˘˜. O ϤÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜ Ù‡Ô˜, Ô˘ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È ˆ˜ ÓfiÛÔ˜ ÙÔ˘ Dent, ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ·ÁfiÚÈ· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ìو̷ÙÔÏÔÁ›· ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÂÁÁ‡˜ Ô˘ÚÔÊfiÚÔ˘ ÛˆÏËÓ¿ÚÈÔ˘, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜, ÓÂÊÚ·Û‚¤ÛÙˆÛË, Ú·¯›Ùȉ· Î·È ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (24). ™Â 70 ÔÈÎÔÁ¤ÓÂȘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÛfiÙÂÚ˜ ·fi 55 ‰È·ÊÔÚÂÙÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ·˘Ù‹˜ Ù˘ ÓfiÛÔ˘, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Ó ÛÙËÓ ÚˆÙ½ÓË Ô˘ Έ‰ÈÎÔÔÈ› ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÁÔÓȉ›Ô˘ CLCN5 (25). ∂›Û˘, Ôχ ·˘ÍË̤Ó˜ ÙÈ̤˜ Ca++ ÛÙ· Ô‡Ú· ‰È·ÈÛÙÒÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Û‡Ó‰ÚÔÌÔ Bartter, ÂÓÒ ·ÓÙ›ıÂÙ· ÔÈ ÙÈ̤˜ Â›Ó·È ÌÂȈ̤Ó˜ ÛÙÔ Û‡Ó‰ÚÔÌÔ Gitelman. ∆Ô ÙÂÏÂ˘Ù·›Ô ·˘Ùfi ‡ÚËÌ· ·ÔÙÂÏ› Û˘¯Ó¿ ¤Ó· ۷ʤ˜ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ ÌÂٷ͇ ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ·˘ÙÒÓ, Ù· ÔÔ›· ηٿ Ù· ¿ÏÏ· ÚÔ‚¿ÏÏÔ˘Ó Ì ·ÚÎÂÙ¿ ÎÔÈÓ‹ ÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ· (˘ÔηÏÈ·ÈÌ›·, ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË, ˘ÂÚÂÓÈÓ·ÈÌ›· Î·È ˘ÂڷωÔÛÙÂÚÔÓÈÛÌfi˜ ¯ˆÚ›˜ ˘¤ÚÙ·ÛË), ÂÓÒ Ë ÎÏÈÓÈ΋ ÙÔ˘˜ ÂÈÎfiÓ· ·ÚÔ˘ÛÈ¿˙ÂÈ Û·Ê›˜ ‰È·ÊÔÚ¤˜. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÛÙÔ Û‡Ó‰ÚÔÌÔ Bartter Î·È ·Ó·ÏfiÁˆ˜ ÙÔ˘ Ù‡Ô˘ ÙÔ˘, ÙÔ ÓÂÔÁÓfi ‹ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÈÎfiÓ· ÔÏ˘Ô˘Ú›·˜ Î·È ¤ÓÙÔÓ˘ ·Ê˘‰¿ÙˆÛ˘, Â̤ÙÔ˘˜, Ì˘˚΋ ·‰˘Ó·Ì›· Î·È Û·ÊÒ˜ ηı˘ÛÙÂÚË̤ÓË ·Ó¿Ù˘ÍË, ÂÓÒ ÛÙÔ ÚÔÁÂÓÓËÙÈÎfi ÙÔ˘ ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ÔÏ˘¸‰Ú¿ÌÓÈÔ. ∫·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ ‹ Ï›ÁÔ ·ÚÁfiÙÂÚ·, Ë ÓÂÊÚ·Û‚¤ÛÙˆÛË ·ÔÙÂÏ› ۯ‰fiÓ ¿ÓÙÔÙ ÛÙ·ıÂÚfi ‡ÚËÌ·, ÂÓÒ Ë ˘ÔÌ·ÁÓËÛÈ·ÈÌ›· ·Ó·Ê¤ÚÂÙ·È Û 20-80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (2,14,21). ∆¤ÏÔ˜, ·Ó·Ê¤ÚÔÓÙ·È ‹Ș ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·˘ÙÔ‡, ÔÈ Ôԛ˜ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ·ÚÈÔ ÂÚÁ·ÛÙËÚÈ·Îfi ‡ÚËÌ· ÙË ¯ÚfiÓÈ· ˘ÔηÏÈ·ÈÌ›· Î·È ÙȘ Â·ÎfiÏÔ˘ı˜ ÎÏÈÓÈΤ˜ Î·È ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ·ÏÏÔÈÒÛÂȘ (15,21). ∞ÓÙ›ıÂÙ·, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡ Ì ۇӉÚÔÌÔ Gitelman Â›Ó·È Î·Ù¿ ηÓfiÓ· ‹È·, ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ·Ó·Ù˘Íȷο ÚÔ‚Ï‹Ì·Ù·. ∏ ˘ÔÌ·ÁÓËÛÈ·ÈÌ›·, Ô˘ ·ÔÙÂÏ› ÛÙ·ıÂÚfi ÂÚÁ·ÛÙËÚÈ·Îfi ‡ÚËÌ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, Û˘¯Ó¿ ÚÔηÏ› ÙÚfiÌÔ, Ì˘˚Τ˜ Û˘Û¿ÛÂȘ Î·È Û·Ó›ˆ˜ ÙÂÙ·Ó›· (16,21). ™‹ÌÂÚ·, Ì ÙȘ ÚÔfi‰Ô˘˜ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ¤¯ÂÈ ÂÓÙÔÈÛÙ› Î·È Ë ‰È·ÊÔÚÂÙÈ΋ ı¤ÛË Ù˘ ‚Ï¿‚˘ ÛÙÔ ¯ÚˆÌfiۈ̷ Ô˘ Έ‰ÈÎÔÔÈ› ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‰È·‡ÏˆÓ Na+, K+, Cl- Î·È Ca++ Î·È Ô˘ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙȘ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·ÊÔÚ¤˜ Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È ÌÂٷ͇ ÙˆÓ ‰‡Ô ·˘ÙÒÓ Û˘Ó‰ÚfiÌˆÓ (16,17).

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∆Ô ·Ô‚·ÏÏfiÌÂÓÔ Mg++ ÙˆÓ Ô‡ÚˆÓ ∆Ô 80% ÙÔ˘ ËÌÂÚ‹ÛÈÔ˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ ·fi ÙȘ ÙÚÔʤ˜ Mg++ (ÂÚ›Ô˘ 2500 mg) ‰ÈËıÂ›Ù·È ÛÙÔ ·ÁÁÂÈ҉˜ Û›ڷ̷ ÙÔ˘ ÓÂÊÚÒÓ·. ∞fi ÙÔ ÔÛfi ·˘Ùfi, ÙÔ 96% Â·Ó·ÚÚÔÊ¿Ù·È Î·Ù¿ Ì‹ÎÔ˜ ÙÔ˘ Ô˘ÚÔÊfiÚÔ˘ ÛˆÏËÓ¿ÚÈÔ˘, Ì ·ÚÈ· ı¤ÛË Â·Ó·ÚÚfiÊËÛ˘ (72%) ÙÔ ·¯‡ ·ÓÈfiÓ ÛΤÏÔ˜ Ù˘ ·Á·Ï˘ ÙÔ˘ Henle, ÂÓÒ ¤Ó· ÔÛÔÛÙfi ÌfiÓÔ 4% ·Ô‚¿ÏÏÂÙ·È ÛÙ· Ô‡Ú·. ™Ù· ‚Ú¤ÊË, ˆÛÙfiÛÔ, Ë Î‡ÚÈ· ı¤ÛË Â·Ó·ÚÚfiÊËÛ˘ ÙÔ˘ Mg++ Î·È Ì¿ÏÈÛÙ· Û ÔÛÔÛÙfi 70%, Â›Ó·È ÙÔ ÂÁÁ‡˜ ÙÌ‹Ì· ÙÔ˘ Ô˘ÚÔÊfiÚÔ˘ ÛˆÏËÓ·Ú›Ô˘. ∞fi ÌÂϤÙ˜, fï˜, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ì ÙËÓ ÚÔԉ¢ÙÈ΋ ˆÚ›Ì·ÓÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÒÓ·, Ë ı¤ÛË Ù˘ ̤ÁÈÛÙ˘ Â·Ó·ÚÚfiÊËÛ˘ ÙÔ˘ Mg++ ÌÂÙ·Ù›ıÂÙ·È ˆ˜ Â› ÂÓËÏ›ÎˆÓ ÛÙÔ ·¯‡ ·ÓÈfiÓ ÛΤÏÔ˜ Ù˘ ·Á·Ï˘ (7). °ÂÓÈο, ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ô Ì˯·ÓÈÛÌfi˜ Â·Ó·ÚÚfiÊËÛ˘ ÙÔ˘ Mg++ Â›Ó·È ·ÚfiÌÔÈÔ˜ Ì ÂΛÓÔÓ ÙÔ˘ Ca++. ™ÙË ÏÂÈÙÔ˘ÚÁ›· ·˘Ù‹ ·ÚÈÔ ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÔÈ ‰›·˘ÏÔÈ Mg++ Ù˘ ·˘ÏÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È Ô Û˘ÌÌÂÙ·ÊÔÚ¤·˜ Na+-Mg++ Ù˘ ‚·ÛÈÎÔÏ¿ÁÈ·˜ ÌÂÌ‚Ú¿Ó˘ (17). ™Ù· ÚˆÙÔ·ı‹ ÎÏËÚÔÓÔÌÈο Û‡Ó‰ÚÔÌ· Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ˘ÔÌ·ÁÓËÛÈ·ÈÌ›·, ¿ÏÏÔÙ ¢ı‡ÓÂÙ·È ÁÈ’ ·˘Ù‹ Ë ÌË ·ÔÚÚfiÊËÛË ÙÔ˘ ÈfiÓÙÔ˜ ·fi ÙÔ Ô˘ÚÔÊfiÚÔ ÛˆÏËÓ¿ÚÈÔ (.¯. Û‡Ó‰ÚÔÌ· Bartter Î·È Gitelman), ¿ÏÏÔÙÂ Ë ·˘ÍË̤ÓË ·Ô‚ÔÏ‹ ÙÔ˘ ÛÙ· Ô‡Ú· (ȉÈÔ·ı‹˜ ˘ÂÚÌ·ÁÓËÛÈÔ˘Ú›·, Û‡Ó‰ÚÔÌÔ Gitelman) Î·È ¿ÏÏÔÙ ÔÈ Û˘Ó˘¿Ú¯Ô˘Û˜ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ Â·Ó·ÚÚfiÊËÛË ‹ ÙËÓ ·Ô‚ÔÏ‹ ÙÔ˘ Ca++. ∞fi ÎÏÈÓÈ΋˜ ·fi„ˆ˜, ¤¯ÂÈ ÛËÌ·Û›· Ë ÁÓÒÛË fiÙÈ fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È Ì ٷ ¿ÏÏ· ·Ô‚·ÏÏfiÌÂÓ· ÛÙ· Ô‡Ú· ÈfiÓÙ·, Ë Â·Ó·ÚÚfiÊËÛË ÙÔ˘ Mg++ ÛÙÔ Ô˘ÚÔÊfiÚÔ ÛˆÏËÓ¿ÚÈÔ ÂËÚ¿˙ÂÙ·È, Â›Û˘, ·fi ηٷÛÙ¿ÛÂȘ ÌÂÙ·‚ÔÏÈ΋˜ ·ÏοψÛ˘, ˘ÔηÏÈ·ÈÌ›·˜, ˘ÔÔÁηÈÌ›·˜ Î·È ˘ÂÚ¤ÎÎÚÈÛ˘ ‚·ÛÔÚÂÛ›Ó˘ (15,19). µÈ‚ÏÈÔÁÚ·Ê›· 1. Kamel KS, Ethier JH, Richardson RM, Bear RA, Halperin ML. Urine electrolytes and osmolality: when and how to use them.

Am J Nephrol 1990;10:89-102.

2. Arant BS Jr. Developmental patterns of renal functional maturation compared in the human neonate. J Pediatr 1978;92:705-712.

3. Pearce SH. Straightening out the renal tubule: advances in the molecular basis of the inherited tubulopathies. Q J Med 1998;91:5-12.

4. Endom EE. MD Volume depletion and dehydration from vomiting and diarrhea in children. www.uptodata.com. Up To Date® 2001. Vol 9, No 2.

5. Matos V, van Melle G, Boulat O, Markert M, Bachmann C, Guignard JP. Urinary phosphate/creatinine, calcium/ creatinine, and magnesium/creatinine ratios in a healthy pediatric population. J Pediatr 1997;131:252-257.

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6. Sherman RA, Eisinger RP. The use (and misuse) of urinary sodium and chloride measurements. J∞ª∞ 1982;247:31213124.

7. Drukker A, Guignard JP. Renal aspects of the term and preterm infant: a selective update. Curr Opin Pediatr 2002;14:175-182.

8. Reid CJ, Marsh MJ, Murdoch IM, Clark G. Nephrotic syndrome in childhood complicated by life threatening pulmonary oedema. BMJ 1996;312:36-38.

9. Mathew OP, Jones AS, James E, Bland H, Groshong T. Neonatal renal failure: usefulness of diagnostic indices.

Pediatrics 1980;65:57-60.

10. Batlle DC, Hizon M, Cohen E, Gutterman C, Gupta R. The use of the urinary anion gap in the diagnosis of hyperchloremic metabolic acidosis. N Engl J Med 1988;318:594-599.

11. Goldstein MB, Bear R, Richardson RM, Marsden PA, Halperin ML. The urine anion gap: a clinically useful index of ammonium excretion. Am J Med Sci 1986;292:198-202.

12. Hanna JD, Scheinman JI, Chan JC. The kidney in acid-base balance. Pediatr Clin North Am 1995;42:1365-1395.

13. Gabows PA, Kaeny WD. The anion gap: its meaning and clinical utility. Kidney Int 1977;12:5-11.

14. Rodriguez-Soriano J. Potassium homeostasis and its disturbances in children. Pediatr Nephrol 1995;9:364-374.

15. Rodriguez-Soriano J. Bartter and related syndromes: the puzzle is almost solved. Pediatr Nephrol 1998;12:315-327.

16. Bettinelli A, Bianchetti MG, Girardin E, Caringella A, Cecconi M, Appiani AC et al. Use of calcium excretion values to distinguish two forms of primary renal tubular hypokalemic alkalosis: Bartter and Gitelman syndromes. J Pediatr 1992;120:38-43.

17. Simon DB, Nelson-Williams C, Bia MJ, Ellison D, Karet FE, Molina AM et al. Gitelman’s variant of Bartter’s syndrome, inherited hypokalaemic alkalosis, is caused by mutations in the thiazide-sensitive NaCl cotransporter. Nat Genet 1996;12:24-30.

18. Clive DM. Bartter’s syndrome: the unsolved puzzle. Am J Kidney Dis 1995;25:813-823.

19. Bettinelli A, Bianchetti MG, Borella P, Volpini E, Metta MG, Basilico E et al. Genetic heterogeneity in tubular hypomagnesemia-hypokalemia with hypocalcuria (Gitelman’s syndrome). Kidney Int 1995;47:547-551.

20. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? I. Analysis of observational data among populations. III. Analysis of data from trials of salt reduction. BMJ 1991;302:811-819.

21. Rudin A, Bosaeus I, Hessov I. Total body potassium, skeletal muscle potassium and magnesium in patients with Bartter’s syndrome. Scand J Clin Lab Invest 1990;50:273-277.

22. Steiner RW. Interpreting the fractional excretion of sodium.

Am J Med 1984;77:699-702.

23. Ishizaki Y, Isozaki-Fukuda Y, Kojima T, Sasai M, Matsuzaki S, Kobayashi Y. Evaluation of diagnostic criteria of acute renal failure in premature infants. Acta Paediatr Jpn 1993;35:311315.

24. Wrong OM, Norden AG, Feest TG. Dent’s disease: a familial proximal renal tubular syndrome with low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, metabolic bone disease, progressive renal failure and a marked male

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predominance. QJM 1994;87:473-493.

25. Yamamoto K, Cox JP, Friedrich T, Christie PT, Bald M, Houtman PN et al. Characterization of renal chloride channel (CLCN5) mutations in Dent’s disease. J Am Soc Nephrol 2000;11:1460-1468.

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∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 26-09-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 30-03-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË ∆ÂÂÏÂÓ›Ô˘ 23, ∆.∫. 154 52, ¶. æ˘¯ÈÎfi

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µƒ∞µ∂Àª∂¡∏ ∂ƒ°∞™π∞

Paediatriki 2004;67:336-342

AWARD-WINNING ARTICLE

∂›‰Ú·ÛË ÂȉÈÎÔ‡ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ Î·È ÛÙ¿ıÌÈÛË ˘ËÚÂÛÈÒÓ ˘Á›·˜ Û ·È‰È·ÙÚÈÎfi ÙÌ‹Ì·* £. ¶·¿˙ÔÁÏÔ˘, ∂. ™Ô˘Ú¤ÏË, ª. ∫·Ú·Ì·ÙÛ¿ÎË, ¶. ¢ÂÚÌÈÙ˙¿ÎË, ∞. ∫Ô˘ÊÔÔ‡ÏÔ˘, ª. ÷Ù˙Ë„¿ÏÙË, ª. ∑‹‚· - ¶ÂÙÚÔÔ‡ÏÔ˘, ™. ¶··‰¿ÎÔ˘ - §·ÁÔÁÈ¿ÓÓË

The impact of an informative leaflet on the behaviour of hospitalized children and the quality of care-giving in a paediatric department* T. Papazoglou, E. Soureli, M. Karabatsaki, P. Dermitzaki, A. Koufopoulou, M. Hatzipsalti, M. Ziva - Petropoulou, S. Papadakou - Lagogianni

¶ÂÚ›ÏË„Ë: ∏ ÂÈÛ·ÁˆÁ‹ ÂÓfi˜ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ·ÔÛÙ·ıÂÚÔÔ›ËÛ˘ ÁÈ· ÙÔ ›‰ÈÔ Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. £ÂˆÚÒÓÙ·˜ fiÙÈ Ë ÏËÚÔÊfiÚËÛË ÁÈ· ÙË ÓÔÛËÏ›· ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙÔ ¿Á¯Ô˜ ÙfiÛÔ ÙˆÓ ·È‰ÈÒÓ fiÛÔ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ÙÔ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¤¯ÂÈ ÚÔ¯ˆÚ‹ÛÂÈ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Â›‰Ú·Û˘ ÙÔ˘ ÂÓÙ‡Ô˘ Û ·È‰È¿ Î·È ÁÔÓ›˜, ηıÒ˜ Î·È Ë ÛÙ¿ıÌÈÛË ÙˆÓ ·Ú¯fiÌÂÓˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÙÌ‹Ì·. ŒÁÈÓÂ Ù˘¯·ÈÔÔÈË̤ÓË (¤Ó· ·Ú¿ ¤Ó·) ‰È·ÓÔÌ‹ ÙÔ˘ ÂÓÙ‡Ô˘ Î·È Û˘ÌÏ‹ÚˆÛË ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ ·fi 80 ·È‰È¿ Î·È 100 ÁÔÓ›˜. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÚԤ΢„ fiÙÈ Ù· ·È‰È¿ Ô˘ ›¯·Ó ‰È·‚¿ÛÂÈ ÙÔ ¤ÓÙ˘Ô ÊÔ‚‹ıËÎ·Ó ÏÈÁfiÙÂÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ (24% ¤Ó·ÓÙÈ 63%, p<0,001), ·Ó¤¯ÙËÎ·Ó Î·Ï‡ÙÂÚ· ÙȘ ÂÍÂÙ¿ÛÂȘ Î·È ÙË ıÂÚ·›· (76% ¤Ó·ÓÙÈ 58%, p<0,01) Î·È ·Ó¤Ù˘Í·Ó ÊÈÏÈΤ˜ Û¯¤ÛÂȘ Ì ٷ ¿ÏÏ· ·È‰È¿ Û ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi (81% ¤Ó·ÓÙÈ 68,5%, p<0,05). °ÂÓÈο, ‰ÂÓ ÙÔ˘˜ ÚÔοÏÂÛ Êfi‚Ô Ë ÛÙ¿ÛË ÙÔ˘ ÚÔÛˆÈÎÔ‡ ˘Á›·˜ (73,5%). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÁÔÓ›˜, 74% ·˘ÙÒÓ Ô˘ ‰È¿‚·Û·Ó ÙÔ ¤ÓÙ˘Ô ıÂÒÚËÛ fiÙÈ ÙÔ ·È‰› ˘‹ÚÍ ÏÈÁfiÙÂÚÔ ÊÔ‚ÈṲ̂ÓÔ Î·Ù¿ ÙË ÓÔÛËÏ›· (¤Ó·ÓÙÈ 47% ·˘ÙÒÓ Ô˘ ‰ÂÓ ÙÔ ‰È¿‚·Û·Ó, p=0,003). OÈ ÁÔÓ›˜, ÁÂÓÈο, ›¯·Ó ıÂÙÈ΋ ÚÒÙË ÂÓÙ‡ˆÛË ÁÈ· ÙÔ ÙÌ‹Ì· (88%), Ë ÔÔ›· ÛÙËÓ ÔÚ›· ¤ÁÈÓ ηχÙÂÚË (93%) Î·È ¤ÌÂÈÓ·Ó Â˘¯·ÚÈÛÙË̤ÓÔÈ ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ (91%). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¯Ú‹ÛË ÙÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÛËÌ·ÓÙÈ΋ ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ·È‰ÈÔ‡ Î·È ÁÔÓ¤ˆÓ ηٿ ÙË ÓÔÛËÏ›·, ÚÔ˜

Abstract: The admission of a child to hospital is a stressful experience for the child itself and for the parents. With the expectation that information about hospitalization might reduce the anxiety of the children and their parents, the Paediatric Department of the Asclepeion Hospital undertook the systematic distribution of an informative leaflet soon after the admission of each child. The aim of this study was to determine the impact of the leaflet on children and parents, as well as to assess the quality of the care-providing services in the department. The leaflet was distributed at random (one in two), and 80 children and 100 parents subsequently completed a relevant questionnaire.

Analysis of the questionnaire responses showed that the children who had read the leaflet felt less fear during hospitalization (24% versus 63%, p<0.001), showed more tolerance towards blood drawing or therapy (76% versus 58%, p<0.01) and developed friendly relations with other children in a higher proportion (81% versus 68.5%, p<0.05).

Generally, the caregivers’ attitude did not frighten the children (73.5%). Regarding the parents, 74% of those who read the leaflet considered their child less fearful during hospitalization (compared with 47% of those who did not read it, p=0.003). Even though the parents’ first impression of the department was reported to be good (88%), in the process of hospitalization it became better (93%) and they remained satisfied with the caregivers (91%). In conclusion, the use of the leaflet was associated with a significant change in the attitude of children and parents during hospitalization,

¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, ∞ı‹Ó·

Paediatric Department, District General Hospital “Asclepeion”, Voula, Athens

* ∞’ µÚ·‚Â›Ô ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ 41Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 2003

* 1st Prize of Social Paediatrics 41st Panhellenic Paediatric Meeting, 2003

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Paediatriki 2004;67:336-342

fiÊÂÏÔ˜ Ù˘ „˘¯ÔÏÔÁÈ΋˜ ·ÔÊfiÚÙÈÛ˘ Î·È Ù˘ ·‡ÍËÛ˘ Ù˘ Û˘ÓÂÚÁ·ÛÈÌfiÙËÙ·˜.

encouraged psychological dissipation and enhanced compliance.

§¤ÍÂȘ ÎÏÂȉȿ: È·ÙÚÈ΋ ÂÓË̤ڈÛË, ‰ÈηÈÒÌ·Ù· ·È‰ÈÔ‡, Û˘ÓÂÚÁ·ÛÈÌfiÙËÙ·.

Key words: medical information, children’s rights, compliance.

∂ÈÛ·ÁˆÁ‹ ∏ ÂÈÛ·ÁˆÁ‹ Î·È ÓÔÛËÏ›· ÂÓfi˜ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂËÚ¿˙ÔÓÙ·˜ Û˘Ó·ÈÛıËÌ·ÙÈο ÙfiÛÔ ÙÔ ›‰ÈÔ ÙÔ ·È‰› fiÛÔ Î·È ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓ, ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ·ÔÛÙ·ıÂÚÔÔ›ËÛ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∆Ô ÌÈÎÚfiÙÂÚÔ ·È‰› ¤Ú¯ÂÙ·È ·ÓÙÈ̤وÔ Î˘Ú›ˆ˜ Ì ÙÔÓ Êfi‚Ô (¿ÁÓˆÛÙÔ ÂÚÈ‚¿ÏÏÔÓ, È·ÙÚÈ΋ ÂͤٷÛË, ÂÒ‰˘Ó˜ ·Ú·ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ıÂÚ·›˜). ∆· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ‚ÈÒÓÔ˘Ó ÂÈϤÔÓ ÙËÓ ¤ÏÏÂÈ„Ë ·ÙÔÌÈÎÔ‡ ¯ÒÚÔ˘, ÙËÓ ·Ô˘Û›· ÙˆÓ Ê›ÏˆÓ ÙÔ˘˜, ηıÒ˜ Î·È ÙÔ ¿Á¯Ô˜ ÁÈ· ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ıÂÚ·›·˜.

OÈ ÁÔÓ›˜, ÂÎÙfi˜ ·fi ÙÔÓ Êfi‚Ô Î·È ÙÔ ¿Á¯Ô˜, ¤¯Ô˘Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ÙfiÛÔ ÙȘ Ú·ÎÙÈΤ˜ ‰˘ÛÎÔϛ˜ (ÂÚÈÔ›ËÛË Î·È Î·ıËÛ˘¯·ÛÌfi˜ ÂÓfi˜ ·Ó‹Û˘¯Ô˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÊÚÔÓÙ›‰· ÙˆÓ ˘fiÏÔÈˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ¿‰ÂÈ· ·fi ÙËÓ ÂÚÁ·Û›·) fiÛÔ Î·È Î¿ÔȘ ˘ÔÛ˘Ó›‰ËÙ˜ ÂÓÔ¯¤˜ ÁÈ· ÙÔ ÙÈ Ô‰‹ÁËÛ ÛÙËÓ Âȉ›ӈÛË Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ò˜ ı· ÌÔÚÔ‡Û ӷ ›¯Â ·ÔÊ¢¯ı›. ŸÏ· ·˘Ù¿ Ù· ·ÚÓËÙÈο Û˘Ó·ÈÛı‹Ì·Ù· ÌÔÚÔ‡Ó Û ÚÒÙË Ê¿ÛË Ó· ÌÂÙ·ÙÚ·Ô‡Ó Û ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ·¤Ó·ÓÙÈ ÛÙÔ È·ÙÚÈÎfi Î·È ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ‹ ·ÎfiÌ· Î·È Û ¿ÚÓËÛË Û˘ÌÌfiÚʈÛ˘ Ì ÙËÓ ÂӉ‰ÂÈÁ̤ÓË ıÂÚ·›·. ∆· ·ÔÙÂϤÛÌ·Ù· ÌÔÚ› Ó· Â›Ó·È Î·ıÔÚÈÛÙÈο ÁÈ· ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡ (Û ·ÎÚ·›Â˜ ÂÚÈÙÒÛÂȘ), ·ÏÏ¿ ΢ڛˆ˜ ÁÈ· ÙËÓ „˘¯È΋ ÙÔ˘ ηٿÛÙ·ÛË. ∂›Ó·È ϤÔÓ ·Ó·ÁÓˆÚÈṲ̂ÓÔ fiÙÈ ÙÔ ¿Á¯Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ÌÔÚ› Ó· Û˘Ó‰¤ÂÙ·È Ì ·˘ÍË̤ÓË ·ÓËÛ˘¯›· Î·È ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È fiÙÈ ·˘Ù¿ Ù· ÚÔ‚Ï‹Ì·Ù· ÌÔÚ› ̤¯ÚÈ ¤Ó· ‚·ıÌfi Ó· Û˘Ó¯ÈÛÙÔ‡Ó Î·È ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô, ÚÔηÏÒÓÙ·˜ Ì›· Û˘Ó¯È˙fiÌÂÓË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ÔÈÎÔÁÂÓÂȷ΋ ˙ˆ‹. ∏ ÏËÚÔÊfiÚËÛË ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÁÔÓ¤ˆÓ Û¯ÂÙÈο Ì ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙË ÓÔÛËÏ›· ÙˆÓ ·È‰ÈÒÓ, ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙÔ ¿Á¯Ô˜ Ô˘ ËÁ¿˙ÂÈ ·fi ÙÔ ¿ÁÓˆÛÙÔ Î·È ÙȘ ·ÔÚÚ¤Ô˘Û˜ ·ÚÓËÙÈΤ˜ ÂΉËÏÒÛÂȘ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰›ÓÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÚÔ‚ÏÂÊıÔ‡Ó Î¿ÔȘ ηٷÛÙ¿ÛÂȘ ̤ۈ ÂÚÈÁÚ·ÊÒÓ Î·È Ô‰ËÁÈÒÓ. ™ÙÔ ·ÚÂÏıfiÓ, ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÙÚÂȘ ·ÚȘ ̤ıÔ‰ÔÈ ÚÔÂÙÔÈÌ·Û›·˜ ÁÈ· ÙËÓ ÂÈÛ·ÁˆÁ‹: ·) ‰È·ÓÔÌ‹ ÂÓËÌÂÚˆÙÈÎÒÓ Ê˘ÏÏ·‰›ˆÓ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜, Û¯ÂÙÈÎÒÓ Ì ÙË ÓÔÛËÏ›· Î·È ÙȘ Ù¯ÓÈΤ˜ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ‚)

ÂÈÛΤ„ÂȘ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÚÔÛˆÈÎÔ‡ ÛÙÔ Û›ÙÈ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È Á) ÚÔ‚ÔÏ‹ ÂÓËÌÂÚˆÙÈÎÒÓ Ù·ÈÓÈÒÓ. OÈ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ̤ıÔ‰ÔÈ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Î˘Ú›ˆ˜ ÛÙȘ ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ¶ÚˆÙÔfiÚÔ˜ ÛÙÔ ‰›Ô Ù˘ ÚÔÂÙÔÈÌ·Û›·˜ ÙˆÓ ·È‰ÈÒÓ ÁÈ· ÚÔÛ·ÁˆÁ‹ ÁÈ· ·Ó·ÈÛıËÛ›· ‹Ù·Ó Ô Vernon (1973). O Vernon ¯ÚËÛÈÌÔÔ›ËÛ ÙËÓ ÚÔ‚ÔÏ‹ Ù·ÈÓ›·˜, Ë ÔÔ›· ¤‰ÂȯÓ ·È‰È¿, ‰È·ÊfiÚˆÓ ËÏÈÎÈÒÓ, Ó· ·ÓÙȉÚÔ‡Ó ‹ÚÂÌ· ηٿ ÙËÓ ÚÔÛ·ÁˆÁ‹ ÁÈ· ·Ó·ÈÛıËÛ›· Î·È Û˘Ì¤Ú·Ó fiÙÈ Ë ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ô˘ ›‰Â ÙËÓ Ù·ÈÓ›· ¤ÓȈÛ ÏÈÁfiÙÂÚÔ Êfi‚Ô Î·Ù¿ ÙËÓ ÚÔÛ·ÁˆÁ‹, Û ۯ¤ÛË Ì ÔÌ¿‰· ÂϤÁ¯Ô˘, ÛÙËÓ ÔÔ›· ‰ÂÓ ÚÔ‚Ï‹ıËÎÂ Ë Ù·ÈÓ›·. ¶·Ú’ fiÏ· ·˘Ù¿, fï˜, Ë ÌÂϤÙË ‹Ù·Ó ÊÙˆ¯¿ ۯ‰ȷṲ̂ÓË Î·È ‰ÂÓ ˘‹ÚÍ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ÌÂÙ¿ ÙË ÓÔÛËÏ›·, ÁÂÁÔÓfi˜ ÛËÌ·ÓÙÈÎfi ηıÒ˜ ÔÈ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ÓÔÛËÏ›·˜ ÂÈÙ›ÓÔÓÙ·È ÌÂÙ¿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹˜ (Quinton Î·È Rutter, 1976) Î·È Ù· ıÂÚ·¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ÔÔÈ·Û‰‹ÔÙ ·Ú¤Ì‚·Û˘ Ú¤ÂÈ Ó· ·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌ· Î·È fiÙ·Ó ÙÔ ·È‰› ¤¯ÂÈ Ê‡ÁÂÈ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô.

OÈ Vernon Î·È Bailey (1974) Û˘Ó¤¯ÈÛ·Ó ÙȘ ¤Ú¢Ӥ˜ ÙÔ˘˜, ÚÔ‚¿ÏÏÔÓÙ·˜ ·Ó¿ÏÔÁ˜ Ù·Èӛ˜ Û ·È‰È¿ ËÏÈΛ·˜ 4-9 ÂÙÒÓ, 45 ÏÂÙ¿ ÚÈÓ ·fi ÙËÓ ÚÔÛ·ÁˆÁ‹ - ÙˆÓ ˘fi ÌÂϤÙË ·È‰ÈÒÓ - ÁÈ· ·Ó·ÈÛıËÛ›·. ∆· ·È‰È¿ ›‰·Ó ÙËÓ Ù·ÈÓ›· ¯ˆÚ›˜ ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ·ÏÏ¿ ·ÚÔ˘Û›· ÙÔ˘ ÂÚ¢ÓËÙ‹, Ô ÔÔ›Ô˜ Û¯ÔÏ›·˙ ÙȘ ‰È·‰Èηۛ˜ ηٿ ÙËÓ ÚÔ‚ÔÏ‹ Ù˘ Ù·ÈÓ›·˜. ∆· ·È‰È¿ ·˘Ù¿, ÂÔ̤ӈ˜, ¤Ï·‚·Ó ÛËÌ·ÓÙÈ΋ ·ÙÔÌÈ΋ ˘ÔÛÙ‹ÚÈÍË Î·È ÚÔÂÙÔÈÌ·Û›·, ·ÓÂÍ¿ÚÙËÙË ·fi ÙÔÓ ÚfiÏÔ Ù˘ ›‰È·˜ Ù˘ Ù·ÈÓ›·˜. ∆· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ ÂÚ›ÌÂÓ·Ó Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ‰ÂÓ Â›‰·Ó ÙËÓ Ù·ÈÓ›· Î·È ‰ÂÓ Â›¯·Ó Â·Ê‹ Ì ÙÔÓ ·Ó·ÈÛıËÛÈÔÏfiÁÔ. OÈ Vernon Î·È Bailey Û˘Ì¤Ú·Ó·Ó fiÙÈ Ù· ·È‰È¿ Ô˘ ¤Ï·‚·Ó ÙËÓ ·Ú·¿Óˆ ÚÔÂÙÔÈÌ·Û›· ‹Ù·Ó ÏÈÁfiÙÂÚÔ ·Ó‹Û˘¯· Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÙÔÈÌ·Û›·˜ ÁÈ· ÙËÓ ·Ó·ÈÛıËÛ›·. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¤·Û·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û¯ÂÙÈο ÌÂÁ·Ï‡ÙÂÚË Ì¤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Ï·‚·Ó ÙËÓ ÚÔÂÙÔÈÌ·Û›· Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (6 ÂÙÒÓ ¤Ó·ÓÙÈ 5,6 ÂÙÒÓ) ‹ Ë ÚÔËÁÔ‡ÌÂÓË ÂÌÂÈÚ›· ˆ˜ ÚÔ˜ ÙËÓ ·Ó·ÈÛıËÛ›· (4 ¤Ó·ÓÙÈ 2 ·È‰ÈÒÓ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘) Î·È ÌÂÚÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙÔ Â›‰Ô˜ Ù˘ ·Ó·ÈÛıËÛ›·˜. ∂ÈÚfiÛıÂÙ·, ÔÈ ıÂÙÈΤ˜ ÂÈÙÒÛÂȘ Ô˘ ·Ú¯Èο

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¶·È‰È·ÙÚÈ΋ 2004;67:336-342

·Ú·ÙËÚ‹ıËÎ·Ó ‰ÂÓ Û˘Ó¯›ÛÙËÎ·Ó Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·ÈÛıËÛ›·˜. ∫·Ï‡ÙÂÚ· ÂÏÂÁ¯fiÌÂÓ˜ ‹Ù·Ó ÔÈ ÌÂϤÙ˜ ÙˆÓ Melamed Î·È Û˘ÓÂÚÁ·ÙÒÓ. OÈ Melamed Î·È Siegel (1975) ÌÂϤÙËÛ·Ó 60 ·È‰È¿, ËÏÈΛ·˜ 4-12 ÂÙÒÓ. ∏ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔÂÙÔÈÌ¿ÛÙËΠ‚ϤÔÓÙ·˜ ÂȉÈ΋ Ù·ÈÓ›·, ·ÚÔ˘Û›·Û ÏÈÁfiÙÂÚÔ ¿Á¯Ô˜ Û ÔÈΛϘ ÌÂÙÚ‹ÛÂȘ Î·È ÏÈÁfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ ¤Ó·Ó Ì‹Ó· ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô, Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ ÛÙËÓ ÔÔ›· ÚÔ‚Ï‹ıËΠٷÈÓ›· ÂϤÁ¯Ô˘, ÌË Û¯Â‰È·Ṳ̂ÓË ÁÈ· ÚÔÂÙÔÈÌ·Û›·. °ÂÓÈο, ÔÈ ¤Ú¢Ó˜ ¤‰ÂÈÍ·Ó Â˘ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÙˆÓ Ù·ÈÓÈÒÓ ÚÔÂÙÔÈÌ·Û›·˜ ÛÙËÓ „˘¯ÔÏÔÁ›· ÙˆÓ ·È‰ÈÒÓ, ·Ó Î·È ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· ‰È·Û·ÊËÓÈÛÙ› ÙÔ Ò˜ Ë ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ Î·È Ô ¯ÚfiÓÔ˜ Ù˘ ÚÔÂÙÔÈÌ·Û›·˜ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÏÏËÏÂȉڿÛÔ˘Ó, ÒÛÙ ӷ ˘¿ÚÍÂÈ ÙÔ Ì¤ÁÈÛÙÔ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÁÈ· ÙÔ ·È‰›.

O Fergusson (1979) ·ÌÊÈÛ‚‹ÙËÛ ÙËÓ ÚÔ‚ÔÏ‹ ÙˆÓ Ù·ÈÓÈÒÓ ˆ˜ ÙËÓ Î·Ï‡ÙÂÚË Ì¤ıÔ‰Ô ÚÔÂÙÔÈÌ·Û›·˜ ÁÈ· Ù· ·È‰È¿, ȉȷ›ÙÂÚ· ÁÈ· Ù· ÌÂÁ·Ï‡ÙÂÚ·. ¶ÚÔ¤‚Ë, ÏÔÈfiÓ, ÛÂ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË, fiÔ˘ ÙË Ì›· ÔÌ¿‰· ·È‰ÈÒÓ ·ÔÙ¤ÏÂÛ·Ó ·È‰È¿ Ô˘ ‰¤¯ÔÓÙ·Ó ÂÈÛΤ„ÂȘ ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÓÔÛÔÎfi̘ 5-7 Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜, ·ÏÏ¿ Î·È Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, Ì ÛÎÔfi ÙËÓ ·ÚÔ¯‹ Ô‰ËÁÈÒÓ ÁÈ· ÙË ÓÔÛÔÎÔÌÂȷ΋ ·Ú·ÌÔÓ‹, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯ÔÚ‹ÁËÛË ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ ÁÈ· ÙË ÓÔÛËÏ›· ÛÙȘ ÌËÙ¤Ú˜. ∆Ë ‰Â‡ÙÂÚË ÔÌ¿‰· ·ÔÙ¤ÏÂÛ·Ó ·È‰È¿ Ô˘, ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË Â·Ê‹ Ì ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi Î·È ¯ˆÚ›˜ ÂÓË̤ڈÛË, ÚÔÛ‹Ïı·Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Â›‰·Ó Ù·ÈÓ›· ۯ‰ȷṲ̂ÓË ÁÈ· ÚÔÂÙÔÈÌ·Û›·. O Fergusson ·Ó¤ÊÂÚ ÌÂÁ·Ï‡ÙÂÚË ·ÓËÛ˘¯›· ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ (3-4 ÂÙÒÓ), Û ۯ¤ÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· (6-7 ÂÙÒÓ). OÈ ÂÚ¢ÓËÙ¤˜ η٤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë Â›ÙˆÛË ·ÓÂÈı‡ÌËÙ˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÌÂÙ¿ ÙË ÓÔÛÔÎÔÌÂȷ΋ ·Ú·ÌÔÓ‹ ÌÂÈÒÓÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚ· ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ Ì ÙËÓ ÚÔ‚ÔÏ‹ Ù·ÈÓÈÒÓ (ÔÙÈ΋ ÚÔÂÙÔÈÌ·Û›·), Û ·ÓÙ›ıÂÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ô˘ ·ÓÙȉÚÔ‡Ó ÂÍ›ÛÔ˘ ıÂÙÈο Ì ÙËÓ ÚÔÓÔÛÔÎÔÌÂȷ΋ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÂÓË̤ڈÛË (ÏÂÎÙÈ΋ ÚÔÂÙÔÈÌ·Û›·). O Fergusson η٤ÏËÍ fiÙÈ ÔÔÈ·‰‹ÔÙ ̤ıÔ‰Ô˜ ÚÔÂÙÔÈÌ·Û›·˜ Â›Ó·È Î·Ï‡ÙÂÚË ·fi η̛· ÚÔÂÙÔÈÌ·Û›·. ¶ÂÚ·ÈÙ¤Úˆ ¤Ú¢Ó˜ (Wolfer Î·È Visintainer, 1979) Ô˘ ÂÚÈÂÏ¿Ì‚·Ó·Ó ‰È¿ÊÔÚ˜ ÌÂıfi‰Ô˘˜ ÚÔÂÙÔÈÌ·Û›·˜, ¤‰ÂÈÍ·Ó fiÙÈ ÔÔÈ·‰‹ÔÙ ÚÔÛ¿ıÂÈ· ‚ÂÏÙ›ˆÛ˘ Ù˘ ÂÈÎÔÈÓˆÓ›·˜ Ì ÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È ÙÔ˘˜ ÁÔÓ›˜ Â›Ó·È Î·Ï‡ÙÂÚË ·fi ÙËÓ ·Ï‹, ÓÔÛÔÎÔÌÂȷ΋ Ú·ÎÙÈ΋, ¯ˆÚ›˜ η̛· ̤ıÔ‰Ô˜ Ó· ¤¯ÂÈ Û·Ê‹ ÏÂÔÓÂÎÙ‹Ì·Ù· ¤Ó·ÓÙÈ Ù˘ ¿ÏÏ˘. ∂›Ó·È ۷ʤ˜ fiÙÈ Ô ·È‰›·ÙÚÔ˜, Ô˘ Â›Ó·È Ô ÚÒ-

338

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ÙÔ˜ Â·ÁÁÂÏÌ·Ù›·˜ ˘Á›·˜ Ô˘ ÏËÛÈ¿˙ÂÈ ¤Ó· ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘, Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÈ ˆ˜ Ú·ÁÌ·ÙÈÎfiÙËÙ· ÙËÓ ÙÚ·˘Ì·ÙÈ΋ ÂÌÂÈÚ›· Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ó· ÊÚÔÓÙ›˙ÂÈ - Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ˘Á›·˜ ÙÔ˘ ¿ÚÚˆÛÙÔ˘ ·È‰ÈÔ‡ - ÙË ‰È·Ê‡Ï·ÍË ÙˆÓ ‰ÔÌÒÓ Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÙÔ˘ ˘ÔÛÙ‹ÚÈ͢, ÚÔ˜ fiÊÂÏÔ˜ Ù˘ ÌË ‰È·ÎÔ‹˜ Ù˘ ÂÍÂÏÈÎÙÈ΋˜ ÔÚ›·˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓÔ‡˜, ¤ÛÙˆ Î·È ·Ó Ë ·ÚÔ˘Û›· ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â›Ó·È ‚Ú·¯‡‚È·. ∆Ô ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, ÙfiÛÔ ÛÙÔÓ ¯ˆÚÔÙ·ÍÈÎfi fiÛÔ Î·È ÛÙÔÓ ÏÂÈÙÔ˘ÚÁÈÎfi ۯ‰ȷÛÌfi ÙÔ˘, ÂÓۈ̿وÛ ÙË ‰ËÌÈÔ˘ÚÁ›· Û˘ÓıËÎÒÓ Ô˘ Ó· ·ÔÊÔÚÙ›˙Ô˘Ó - ·fi Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÏÂ˘Ú¿˜ ÙËÓ Â›ÁÔ˘Û· ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·È‰ÈÔ‡. ŒÙÛÈ, ¯ˆÚÔÙ·ÍÈο, ÎÔÓÙ¿ Û οı ÓÔÛËÏ¢fiÌÂÓÔ ·È‰› ÙÔÔıÂÙ‹ıËΠ·Ó·ÎÏÈÓfiÌÂÓË ÔÏ˘ıÚfiÓ·, ÒÛÙ ӷ ÌÔÚ› ÙÔ ¿ÚÚˆÛÙÔ ·È‰› Ó· ¤¯ÂÈ ÙÔÓ ÁÔÓ¤· ‰›Ï· ÙÔ˘, ·ÎfiÌ· Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ó‡ÎÙ·˜. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ, ‰ÂÓ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ·›ÛıËÛË ·ÛÊ¿ÏÂÈ·˜ ÙÔ˘ ·È‰ÈÔ‡ (∂ÈÎfiÓ˜ 1 Î·È 2). ∏ „˘¯Ô‰˘Ó·ÌÈ΋ ÚÔÛ¤Ï·ÛË ÙÔ˘ ı¤Ì·ÙÔ˜ Ô‰‹ÁËÛÂ, Â›Û˘, ÛÙÔÓ Û¯Â‰È·ÛÌfi ÂÓfi˜ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ ÁÈ· Ù· ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È ÛÙÔ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜ (∂ÈÎfiÓ˜ 3, 4, 5, 6 Î·È 7). ∆Ô ¤ÓÙ˘Ô ·˘Ùfi, Ô˘ ¯ÔÚËÁÂ›Ù·È Û fiÏ· Ù· ·È‰È¿ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, ·Ú¤¯ÂÈ - ̤ۈ ·Ï‹˜ ÁÏÒÛÛ·˜ Î·È ÂÈÎÔÓÔÁÚ¿ÊËÛ˘ - Û˘Ì‚Ô˘Ï¤˜ Û¯ÂÙÈο Ì ÙÔ Ò˜ ÌÔÚÔ‡Ó ÔÈ ÁÔÓ›˜ Ó· ÚÔÂÙÔÈÌ¿ÛÔ˘Ó ÙÔ ·È‰› ÁÈ· ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÚÔÙ›ÓÂÈ ÙÚfiÔ˘˜ ÁÈ· Ó· ÌÂÈÒÛÔ˘Ó ÙÔ˘˜ Êfi‚Ô˘˜ ÙÔ˘˜ Î·È Ó· ÙÔ ‚ÔËı‹ÛÔ˘Ó Ó· ‰Â¯ı› ηχÙÂÚ· ÙȘ ‰È¿ÊÔÚ˜ ÂÍÂÙ¿ÛÂȘ Î·È Ó· ÍÂÂÚ¿ÛÂÈ ÙÔ ¿Á¯Ô˜ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÌÂÙ¿ ÙÔ ÂÍÈÙ‹ÚÈÔ. ¶ÂÚȤ¯ÂÈ, Â›Û˘, ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔÓ ÙÚfiÔ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜. ∂›Ó·È, ¿ÏψÛÙÂ, ÙÂÎÌËÚȈ̤ÓÔ Î·È ‚È‚ÏÈÔÁÚ·ÊÈο fiÙÈ Ë ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙˆÓ ·È‰ÈÒÓ fi¯È ÌfiÓÔ ÌÂÈÒÓÂÈ ÙÔÓ Êfi‚Ô ‹ Î·È ÙÔÓ fiÓÔ ÙˆÓ ·È‰ÈÒÓ, ·ÏÏ¿ ·ÓÔ›ÁÂÈ Î·È ÙÔÓ ‰ÚfiÌÔ ÚÔ˜ Ì›· ÈÔ ÂÓÂÚÁfi Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ·ÔÊ¿ÛÂȘ Û¯ÂÙÈο Ì ÙË ÓÔÛËÏ›· ÙÔ˘˜. ∞˘Ù‹ Ë ÚÔÔÙÈ΋ Â›Ó·È Û‡ÌʈÓË Ì ÙË Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓË ·Ó·ÁÓÒÚÈÛË ÙˆÓ ‰ÈÎ·ÈˆÌ¿ÙˆÓ ÙÔ˘ ·È‰ÈÔ‡ (United Nations Convention on the Rights of the Child, 1989, cited by Fulton, 1996; National Children’s Bureau, 1992). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Â›‰Ú·Û˘ ÙÔ˘ ¯ÔÚËÁËı¤ÓÙÔ˜ ÂÓÙ‡Ô˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ηıÒ˜ Î·È Ù· Èı·Ó¿ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ „˘¯ÔÏÔÁ›· ÙÔ˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜. ¶·Ú¿ÏÏËÏ·, ¤ÁÈÓ ÚÔÛ¿ıÂÈ· ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·Ú¯fiÌÂÓˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ∆Ì‹Ì·.

September-October 05 chris

18-11-04

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¶·È‰È·ÙÚÈ΋ 2004;67:336-342

∂ÈÎfiÓ· 1. £¿Ï·ÌÔ˜ ÓÔÛËÏ›·˜.

Paediatriki 2004;67:336-342

¶ÚÔÂÙÔÈÌ·Û›· ∆Ô ·È‰› ÊÔ‚¿Ù·È ÙÔ ¿ÁÓˆÛÙÔ. ∏ ηϋ ÚÔÂÙÔÈÌ·Û›· ‚ÔËı¿ÂÈ Ôχ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·È‰› Î·È ·ÎfiÌ· ÙÔ ÈÔ ÌÈÎÚfi ·È‰› ÌÔÚ› Ó· ηٷϿ‚ÂÈ ·Ϥ˜ ÂÍËÁ‹ÛÂȘ. ¶Ú¤ÂÈ Ó· ›Ù ÛÙÔ ·È‰› ÙËÓ ·Ï‹ıÂÈ· Î·È Ó· ÙÔ˘ ÂÍËÁ‹ÛÂÙ fiÙÈ ÔÈ ÁÈ·ÙÚÔ› Î·È ÔÈ ·‰ÂÏʤ˜ ͤÚÔ˘Ó Ó· ÙÔ Î¿ÓÔ˘Ó Î·Ï¿. ¡· ÙÔ˘ ›Ù fiÙÈ ı· ÂÈÛÙÚ¤„ÂÈ ÛÙÔ Û›ÙÈ ÌfiÏȘ Á›ÓÂÈ Î·Ï¿ (ÔÏÏ¿ ·È‰È¿ ÊÔ‚Ô‡ÓÙ·È fiÙÈ ‰ÂÓ ı· Í·Ó·¿Ó Û›ÙÈ) Î·È fiÙÈ ÂÛ›˜ ı· Ì›ÓÂÙ fiÛÔ ÌÔÚ›Ù ÎÔÓÙ¿ ÙÔ˘. ªËÓ ÙÔ˘ ›Ù „¤Ì·Ù· ÁÈ·Ù› Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ¤¯ÂÈ ÙÔ ·È‰› ÂÌÈÛÙÔÛ‡ÓË Î·È Û ۷˜ Î·È ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∂ÈÎfiÓ· 3. ∂ÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô.

∂ÈÎfiÓ· 2. £¿Ï·ÌÔ˜ ÓÔÛËÏ›·˜.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ °È· ÙÔÓ ÛÎÔfi Ù˘ ÌÂϤÙ˘, ¤ÁÈÓÂ Ù˘¯·ÈÔÔÈË̤ÓË (¤Ó· ·Ú¿ ¤Ó·) ‰È·ÓÔÌ‹ ÙÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ Ô˘ ·Ó·Ê¤ÚıËΠ·ÓˆÙ¤Úˆ, ÛÙ· ·È‰È¿ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 2 ÌËÓÒÓ. ŸÏ˜ ÔÈ ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Û·Ó Û ÔÍ›· ÓfiÛÔ. ∆Ô ÂÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô Û¯Â‰È¿ÛÙËΠ„˘¯Ô‰˘Ó·ÌÈο. ∏ „˘¯Ô‰˘Ó·ÌÈ΋ ıÂÒÚËÛË ‚·Û›˙ÂÙ·È Û „˘¯·Ó·Ï˘ÙÈΤ˜ ·Ú¯¤˜ (Sifneos, 1987). O ıÂÚ·Â˘Ù‹˜, ‰È·ÙËÚÒÓÙ·˜ ÂÓÂÚÁËÙÈ΋ Î·È ‰È‰·ÎÙÈ΋ ÛÙ¿ÛË, ·Ú¤¯ÂÈ ÙȘ ηٿÏÏËϘ Û˘Óı‹Î˜ Ô˘ ı· ÌÂÙ·ÙÚ¤„Ô˘Ó ÙÔ ¿Á¯Ô˜ Î·È Ù· ‰˘Û¿ÚÂÛÙ· Û˘Ó·ÈÛı‹Ì·Ù· Û ΛÓËÙÚÔ ÁÈ· ·Ó¿Ù˘ÍË, ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó ˘„ËÏfiÙÂÚ· Â›‰· ÔÚÁ¿ÓˆÛ˘.

∂ÈÛ·ÁˆÁ‹ OÈ ÚÒÙ˜ ÂÓÙ˘ÒÛÂȘ Â›Ó·È Ôχ ÛÔ˘‰·›Â˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·‰Èηۛ·˜ Ù˘ ÂÈÛ·ÁˆÁ‹˜ Ó· ÊÚÔÓÙ›ÛÂÙ ӷ ›ÛÙÂ Î·È ÂÛ›˜ ‹ÚÂÌÔÈ. ¶ÔÏÏ¿ ·È‰È¿ ¤¯Ô˘Ó Ì›· ·Á·Ë̤ÓË ÎÔ‡ÎÏ·, Ì›· ÎÔ˘‚¤ÚÙ· ‹ οÔÈÔ ¿ÏÏÔ ·ÓÙÈΛÌÂÓÔ, Ô˘ ÎÚ·Ù¿Ó fiÙ·Ó ÎÔÈÌÔ‡ÓÙ·È. ∞Ó ÙÔ ‰ÈÎfi Û·˜ ·È‰› ¤¯ÂÈ ¤Ó· Ù¤ÙÔÈÔ ·ÓÙÈΛÌÂÓÔ, Ó· ÙÔ Ê¤ÚÂÙ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ¶Èı·ÓfiÓ ı· ÚÔÙÈÌ¿Ù ӷ ÊÔÚ¤ÛÂÈ ÙÔ ·È‰› Ù· ‰Èο ÙÔ˘ ÚÔ‡¯· ̤۷ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∞Ó, fï˜, ‰ÂÓ Ê¤Ú·Ù Ӣ¯ÙÈο Ì·˙›, ÌËÓ ·ÓËÛ˘¯Â›Ù - ÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤¯ÂÈ ÚÔ‡¯· ÁÈ· Ù· ·È‰È¿. ∆· ÓÂÔÁÓ¿, Ì¿ÏÈÛÙ·, ÁÈ· ÏfiÁÔ˘˜ ·ÔÛÙ›ڈÛ˘, ı· ÊÔÚ¤ÛÔ˘Ó ÌfiÓÔ Ù· ÚÔ‡¯· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. ŸÙ·Ó ʇÁÂÙÂ Î·È ·Ê‹ÓÂÙ ÙÔ ·È‰› Û·˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Â›Ó·È Ôχ ηχÙÂÚ· Ó· ÙÔ˘ ›Ù fiÙÈ Ê‡ÁÂÙÂ Î·È fiÙÈ ı· Í·Ó·Úı›ÙÂ Î·È Ó· ÙÔ ·Ô¯·ÈÚÂÙ‹ÛÂÙÂ. ŸÙ·Ó ʇÁÂÙ “ÎÚ˘Ê¿”, ÙÔ ·È‰› ÛÙÂÓ·¯ˆÚÈ¤Ù·È ÂÚÈÛÛfiÙÂÚÔ. ∏ ÚÔ˚Ûٷ̤ÓË ÌÔÚ› Ó· Û·˜ ··ÓÙ‹ÛÂÈ ÛÙȘ ÂÚˆÙ‹ÛÂȘ Á‡Úˆ ·fi ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÙÌ‹Ì·ÙÔ˜. ∂ÈÎfiÓ· 4. ∂ÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô.

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π·ÙÚÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ıÂÚ·›· ŸÏÔÈ Í¤ÚÔ˘Ì fiÙÈ ÔÈ ‰È¿ÊÔÚ˜ ÂÍÂÙ¿ÛÂȘ Î·È ÂÂÌ‚¿ÛÂȘ Â›Ó·È ÂÓÔ¯ÏËÙÈΤ˜ ÁÈ· ÙÔ ·È‰›. ∆Ô ·È‰› Û·˜ ı· ‰Â¯ı› ηχÙÂÚ· ÙȘ ··Ú·›ÙËÙ˜ ·ÈÌÔÏË„›Â˜, ÙȘ ÂÓ¤ÛÂȘ Î·È ÙȘ ÂÂÌ‚¿ÛÂȘ Î·È ı· ÔÓ¤ÛÂÈ ÏÈÁfiÙÂÚÔ, fiÙ·Ó Î·Ù·Ï¿‚ÂÈ fiÙÈ Á›ÓÔÓÙ·È ÁÈ· ÙÔ Î·Ïfi ÙÔ˘ Î·È fiÙ·Ó ÙȘ ·ÓÙÈÌÂÙˆ›˙ÂÙÂ Î·È ÂÛ›˜ Ì „˘¯Ú·ÈÌ›·. ŸÛÔ Â›Ó·È ‰˘Ó·Ùfi, Ú¤ÂÈ Ó· ÂÍËÁ‹ÛÔ˘Ì ÛÙÔ ·È‰› ÙÈ ı· ÙÔ˘ οÓÔ˘ÌÂ, Ò˜ Î·È ÁÈ·Ù›. ¶ÔÙ¤ ‰ÂÓ Ú¤ÂÈ ÙÔ ·È‰› Ó· ‚ϤÂÈ ÙÔÓ ÁÈ·ÙÚfi Û·Ó Ì¤ÛÔ ÙÈ̈ڛ·˜. ¶ÔÏÏ¿ ·È‰È¿ ÍÂÂÚÓÔ‡Ó ÙȘ ·ÓËÛ˘¯›Â˜ ÙÔ˘˜ ÁÈ· ÙÔ ÓÔÛÔÎÔÌÂ›Ô ·›˙ÔÓÙ·˜ ‹ ˙ˆÁÚ·Ê›˙ÔÓÙ·˜. ŸÙ·Ó Ô ÁÈ·ÙÚfi˜ ¤¯ÂÈ ÛÙÔȯ›·, ı· Û·˜ ÂÓËÌÂÚÒÛÂÈ ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù· Î·È ÙËÓ ÔÚ›· Ù˘ ·ÚÚÒÛÙÈ·˜. ∂ÈÎfiÓ· 5. ∂ÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô.

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∆Ô ·È‰› ʇÁÂÈ ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ∆Ô ·È‰› ÂÚÈ̤ÓÂÈ Ì ·ÁˆÓ›· Ó· Í·Ó·Á˘Ú›ÛÂÈ Û›ÙÈ ÙÔ˘. ¢ÂÓ Ú¤ÂÈ Ó· ÙÔ˘ ϤÌ ·ÎÚÈ‚Ò˜ fiÙ ı· ʇÁÂÈ, ÚÈÓ ÙÔ Í¤ÚÔ˘Ì Ì ÛÈÁÔ˘ÚÈ¿, ·ÏÏÈÒ˜ ı· ·ÔÁÔËÙ¢Ù›. ŸÙ·Ó ·›ÚÓÂÙ ÙÔ ÂÍÈÙ‹ÚÈÔ, Ô ÁÈ·ÙÚfi˜ ı· Û·˜ ‰ÒÛÂÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÌÂÙ¤ÂÈÙ· ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡. ¡· ‚ÔËı‹ÛÂÙ ÙÔ ·È‰› Û·˜ Ó· ·Ô¯·ÈÚÂÙ‹ÛÂÈ ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ Ì ÊÈÏÈÎfiÙËÙ·, ÁÈ·Ù› ·˘Ùfi ÙÔ ‚ÔËı¿ÂÈ Ó· ÌËÓ ‚ϤÂÈ ÙÔ ÓÔÛÔÎÔÌÂ›Ô Û·Ó Â¯ıÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·È Ó· ÌËÓ ÊÔ‚¿Ù·È Û ÂÚ›ÙˆÛË Ô˘ Á›ÓÂÈ ‰Â‡ÙÂÚË ÂÈÛ·ÁˆÁ‹. ¶ÂÚ·ÛÙÈο! ∂ÈÎfiÓ· 7. ∂ÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô.

∂ÈÛÎÂÙ‹ÚÈÔ ∆Ô ÌÈÎÚfi ·È‰› ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ Î·È È‰È·›ÙÂÚ· fiÙ·Ó Â›Ó·È ¿ÚÚˆÛÙÔ. ∏ ·ÚÔ˘Û›· Ù˘ ÌËÙ¤Ú·˜ (‹ ÂÓfi˜ ·Á·Ë̤ÓÔ˘ ÙÔ˘ ÚÔÛÒÔ˘) ÂÓı·ÚÚ‡ÓÂÈ ÙÔ ·È‰› ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÌÂÈÚÈÒÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. ∂›Û˘, Ë ‚Ô‹ıÂÈ· Ù˘ ÌËÙ¤Ú·˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ ·ÂÏ¢ıÂÚÒÓÂÈ ÙȘ ·‰ÂÏʤ˜ ÁÈ· ÙȘ ÈÔ ÂȉÈÎÂ˘Ì¤Ó˜ ‰Ô˘ÏÂȤ˜. ∏ ·Ú¤· ÙÔ˘ ·Ù¤Ú· Â›Ó·È ÂÈı˘ÌËÙ‹ ÁÈ· ÙÔ ·È‰›. OÈ ¿Ó‰Ú˜, fï˜, ‰ÂÓ ÂÈÙÚ¤ÂÙ·È Ó· ‰È·Ó˘ÎÙÂÚÂ‡Ô˘Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∂ÈÛΤ„ÂȘ ·fi ¿ÏÏÔ˘˜ ÛÙÂÓÔ‡˜ Û˘ÁÁÂÓ›˜ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔ ·È‰›, ·ÏÏ¿ Â›Ó·È Î·Ï‡ÙÂÚ· Î·È ÁÈ· ÙÔ ‰ÈÎfi Û·˜ ·È‰› Î·È ÁÈ· Ù· ¿ÏÏ· ¿ÚÚˆÛÙ· ·È‰È¿ Ó· ÌËÓ Ì·˙‡ÔÓÙ·È ÔÏÏÔ› ÂÈÛΤÙ˜. ¢ÂÓ Ú¤ÂÈ Ó· ʤÚÓÂÙ ÌÈÎÚ¿ ·È‰È¿ ÁÈ· Â›ÛÎÂ„Ë Î·È ÔÈ ¿ÓıÚˆÔÈ Ô˘ ¿Û¯Ô˘Ó ·fi ÏÔÈÌ҉˜ ÓfiÛËÌ· ‰ÂÓ Ú¤ÂÈ Ó· ÂÈÛΤÙÔÓÙ·È ·È‰È¿ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ¶·Ú·Î·Ïԇ̠ӷ ÌËÓ Î·Ó›˙ÂÙ ̤۷ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∆Ô Î¿ÓÈÛÌ· ‚Ï¿ÙÂÈ ÙËÓ ˘Á›· ÙÔ˘ ¿ÚÚˆÛÙÔ˘ ·È‰ÈÔ‡. ∂ÈÎfiÓ· 6. ∂ÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô.

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O ıÂÚ·Â˘Ù‹˜ ÚÔ¿ÁÂÈ ÙËÓ ÚÔÛˆÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÓ‰˘Ó·ÌÒÓÔÓÙ·˜ ÙËÓ ·›ÛıËÛË ·˘ÙÔÂÎÙ›ÌËÛ˘, ÙË ‰˘Ó·ÙfiÙËÙ· ·fiÎÙËÛ˘ Ó¤·˜ Ì¿ıËÛ˘ Î·È ÙËÓ ÈηÓfiÙËÙ· Â›Ï˘Û˘ ÚÔ‚ÏËÌ¿ÙˆÓ (Sifneos 1987, Svartberg et al. 1995, Davanloo H. 1978, ¶··‰¿ÎÔ˘-§·ÁÔÁÈ¿ÓÓË ™Ù. Î·È ¶·ÓÙÂÏ¿Î˘ ™. 1982, ¢ÔÍÈ¿‰Ë˜ ™. 1964). ªÂÙ¿ ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÂÚ›Ô˘ ÙËÓ ÙÚ›ÙË Ë̤ڷ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹, ‰fiıËÎ·Ó ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜ ͯˆÚÈÛÙ¿, ηٿÏÏËÏ· ۯ‰ȷṲ̂ӷ ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Û¯ÂÙÈο Ì ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ™ÎÔfi˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ Èı·ÓÒÓ ‰È·ÊÔÚÒÓ ÛÙË ÛÙ¿ÛË, ÙË Û˘ÌÂÚÈÊÔÚ¿, ·ÏÏ¿ Î·È ÛÙȘ ÂÓÙ˘ÒÛÂȘ ÌÂٷ͇ ·È‰ÈÒÓ Î·È ÁÔÓ¤ˆÓ Ô˘ ‰È¿‚·Û·Ó ÙÔ ÂÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô Î·È ·˘ÙÒÓ Ô˘ ‰ÂÓ ÙÔ ‰È¿‚·Û·Ó, ̤۷ Û ¤Ó· Ï·›ÛÈÔ ÛÙ¿ıÌÈÛ˘ ÙˆÓ ·Ú¯fiÌÂÓˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ÛÙÔ ∆Ì‹Ì·. ™˘ÓÔÏÈο, ¯ÔÚËÁ‹ıËÎ·Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Û 80 ·È‰È¿ Î·È 100 ÁÔÓ›˜ (Ô ÂÈϤÔÓ ·ÚÈıÌfi˜ ÙˆÓ ÁÔÓ¤ˆÓ ·ÊÔÚ¿ Û ÎˉÂÌfiÓ˜ ·È‰ÈÒÓ Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜). °È· Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë ·ÓÙÈÚÔÛˆ¢ÙÈÎfiÙËÙ· ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, ‰ÂÓ ˘‹ÚÍ ÂÚÈÔÚÈÛÌfi˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ËÏÈΛ· ‹ ÙËÓ Î·Ù·ÁˆÁ‹ ÙˆÓ ·È‰ÈÒÓ.

∞ÔÙÂϤÛÌ·Ù· ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ ÚԤ΢„ fiÙÈ Ù· ·È‰È¿ Ô˘ ›¯·Ó ‰È·‚¿ÛÂÈ ÙÔ ÂÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô ÊÔ‚‹ıËÎ·Ó ÏÈÁfiÙÂÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ·

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Ù˘ ÓÔÛËÏ›·˜ Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ‰ÂÓ ÙÔ ‰È¿‚·Û·Ó (24% ¤Ó·ÓÙÈ 63%, p<0,001) Î·È ·Ó¤¯ÙËÎ·Ó Î·Ï‡ÙÂÚ· ÙȘ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ, fiˆ˜ ÔÈ ·ÈÌÔÏË„›Â˜ Î·È Ë ÙÔÔı¤ÙËÛË ÊÏ‚ÔηıÂÙ‹Ú· (76% ¤Ó·ÓÙÈ 58%, p<0,01). ∂ÈÚfiÛıÂÙ·, Ù· ·È‰È¿ ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÙÔ ÂÓËÌÂÚˆÙÈÎfi ¤ÓÙ˘Ô, ·Ó¤Ù˘Í·Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÊÈÏÈΤ˜ Û¯¤ÛÂȘ Ì ٷ ¿ÏÏ· ÓÔÛËÏ¢fiÌÂÓ· ·È‰È¿ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ‰ÂÓ ·Ú¤Ï·‚·Ó ÙÔ ¤ÓÙ˘Ô (81% ¤Ó·ÓÙÈ 68,5%, p<0,05) Î·È Ù· ÔÔ›· ÚÔÙÈÌÔ‡Û·Ó, ·ÓÙ›ıÂÙ·, Ó· ‰È·‚¿˙Ô˘Ó ‹ Ó· ‚ϤÔ˘Ó ÙËÏÂfiÚ·ÛË. °ÂÓÈο, Ë ÛÙ¿ÛË ÙÔ˘ ÚÔÛˆÈÎÔ‡ ˘Á›·˜ ‹Ù·Ó ·ÚÂÛÙ‹ ÛÙ· ·È‰È¿ (95%) Î·È ‰ÂÓ ÙÔ˘˜ ÚÔοÏÂÛ Êfi‚Ô (73,5%). ∆¤ÏÔ˜, ‡ÚÈÛÎ·Ó Â˘¯¿ÚÈÛÙË ÙË ‰È·ÎfiÛÌËÛË Ù˘ ÎÏÈÓÈ΋˜ Î·È ÙˆÓ ‰ˆÌ·Ù›ˆÓ (50%), ÙËÓ ·˘Ï‹ (20%) Î·È ÙÔ ‹Û˘¯Ô ÂÚÈ‚¿ÏÏÔÓ (15%). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÁÔÓ›˜, ·˘ÙÔ› Ô˘ ‰È¿‚·Û·Ó ÙÔ ¤ÓÙ˘Ô ıˆÚÔ‡Û·Ó fiÙÈ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ ·È‰› ¤ÁÈÓ ÂÚÈÛÛfiÙÂÚÔ ÛÎÂÙfiÌÂÓÔ Î·È ÏÈÁfiÙÂÚÔ ÊÔ‚ÈṲ̂ÓÔ (74%), ·Ô‰›‰ÔÓÙ¿˜ ÙÔ ÛÙËÓ ÂÂÍ‹ÁËÛË ÙÔ˘ ÚfiÏÔ˘ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ Î·È ¿ÏÏˆÓ ‚È‚Ï›ˆÓ. ∆ËÓ ›‰È· ¿Ô„Ë Â›¯Â ÌfiÓÔ ÙÔ 47% ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ‰ÂÓ ¤Ï·‚ ÙÔ ¤ÓÙ˘Ô (74% ¤Ó·ÓÙÈ 47%, p=0,003).

OÈ ÁÔÓ›˜, Û˘ÓÔÏÈο, ›¯·Ó ıÂÙÈ΋ ÚÒÙË ÂÓÙ‡ˆÛË ÁÈ· ÙÔ ÙÌ‹Ì· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ (88%), Ë ÔÔ›· - ÛÙËÓ ÔÚ›· - ¤ÁÈÓ ·ÎfiÌË Î·Ï‡ÙÂÚË (93%), ÂÌÈÛÙ‡ÔÓÙ·Ó ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ ÁÈ· ÙË ıÂÚ·›· (85,5%) Î·È ¤ÌÂÈÓ·Ó Â˘¯·ÚÈÛÙË̤ÓÔÈ ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ (91%), ΢ڛˆ˜ ˆ˜ ÚÔ˜ ÙË Û˘ÌÂÚÈÊÔÚ¿, ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ηٿÚÙÈÛË, ηıÒ˜ Î·È ÙË ÛˆÛÙ‹ ÔÚÁ¿ÓˆÛË Î·È ·Ó·Ï˘ÙÈ΋ ÂÓË̤ڈÛË.

Paediatriki 2004;67:336-342

ÛÌ·ÙÈο οı ÂÚ›ÙˆÛË ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ, ÙȘ ÚÔÛ‰Ô˘, ÙÔ ÌÔÚʈÙÈÎfi Â›‰Ô, ÙÔ ÎÔÈÓˆÓÈÎfi ˘fi‚·ıÚÔ Î·È ÙÔ˘˜ Û˘Ó·ÈÛıËÌ·ÙÈÎÔ‡˜ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∞˘Ù‹ Ë „˘¯Ô‰˘Ó·ÌÈ΋ ·ÓÙÈÌÂÙÒÈÛË ‰È‰¿ÛÎÂÙ·È ·fi ÙÔ˘˜ ÂÌÂÈÚfiÙÂÚÔ˘˜ ÂȉÈÎÂ˘Ì¤ÓÔ˘˜ ·È‰È¿ÙÚÔ˘˜. ∏ Û˘ÌÂÚÈÊÔÚ¿, ÂÔ̤ӈ˜, ÙÔ˘ ÚÔÛˆÈÎÔ‡ ˘Á›·˜ Â›Ó·È Î·ıÔÚÈÛÙÈ΋ ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ ¿Á¯Ô˘˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙÔ˘ Êfi‚Ô˘ ÙˆÓ ·È‰ÈÒÓ. ∏ ÚfiÛıÂÙË ¯Ú‹ÛË ÙÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘, ÂȉÈο ۯ‰ȷṲ̂ÓÔ˘ ÁÈ· ÂÓË̤ڈÛË Î·È Û˘ÌÌfiÚʈÛË (compliance), ÂÎÔÚ¢fiÌÂÓÔ˘ ΢ڛˆ˜ ·fi ÙÔÓ Û‚·ÛÌfi Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡, ·¤‰ÂÈÍ ÙË ÛËÌ·ÓÙÈ΋ ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·È‰ÈÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘, ÚÔ˜ fiÊÂÏÔ˜ Ù˘ Ì›ˆÛ˘ Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÊfiÚÙÈÛ˘ ÙˆÓ ÂÒ‰˘ÓˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ù˘ ÂÈÛ·ÁˆÁ‹˜, Ù˘ ·‡ÍËÛ˘ Ù˘ Û˘ÓÂÚÁ·ÛÈÌfiÙËÙ·˜ ÙÔ˘ ›‰ÈÔ˘ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ·ÏÏ¿ Î·È ÙË ‰È·ÌfiÚʈÛË ıÂÙÈÎÒÓ Ù¿ÛÂˆÓ ·ÓÙ› Ù˘ ·Ó·ÌÂÓfiÌÂÓ˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ÏfiÁˆ Ù˘ ÓÔÛÔÎÔÌÂȷ΋˜ ·Ú·ÌÔÓ‹˜. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ‚Ú¤ıËÎ·Ó ÂÚÁ·Û›Â˜ Ô˘ Ó· ·Ó·Ï‡Ô˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯Ú‹Û˘ ·ÚfiÌÔÈˆÓ ÂÓÙ‡ˆÓ, ·Ú’ fiÏÔ Ô˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÙȘ ·ÁÁÏÔÛ·ÍÔÓÈΤ˜ ¯ÒÚ˜ ¤¯ÂÈ Â˘Ú›· ÂÊ·ÚÌÔÁ‹. ∂Ô̤ӈ˜, ˘‹ÚÍ ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈÎfi ‡ÚËÌ· Ë ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È·Ù‹ÚËÛ˘ ıÂÙÈÎfiÙÂÚ˘ ÛÙ¿Û˘ ˆ˜ ÚÔ˜ ÙË ÓÔÛËÏ›· Î·È ÙËÓ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ıÂÚ·›· ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ¤Î·Ó·Ó ¯Ú‹ÛË ÙÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘ Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ ¯ÔÚËÁ‹ıËÎÂ. µÈ‚ÏÈÔÁÚ·Ê›·

™˘˙‹ÙËÛË ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ ·Ú¯fiÌÂÓˆÓ ˘ËÚÂÛÈÒÓ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, ÔÈ Ôԛ˜ ‰ÂÓ ·ÊÔÚÔ‡Ó ÌfiÓÔ ÛÙȘ ÎÏ·ÛÈο ÚÔÛÊÂÚfiÌÂÓ˜ È·ÙÚÈΤ˜, ÓÔÛËÏ¢ÙÈΤ˜ Î·È ÍÂÓÔ‰Ô¯ÂȷΤ˜ ˘ËÚÂۛ˜, ηıÒ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ηıËÌÂÚÈÓ‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙÔÓ ¯ÒÚÔ Ù˘ ·ÁˆÁ‹˜ ˘Á›·˜, Ì ÙË ¯Ú‹ÛË ÙÔ˘ „˘¯Ô‰˘Ó·ÌÈο ۯ‰ȷṲ̂ÓÔ˘ ÂÓËÌÂÚˆÙÈÎÔ‡ ÂÓÙ‡Ô˘. ∂›Ó·È ·fiÏ˘Ù· ηٷÓÔËÙfi fiÙÈ ·˘Ùfi Ô˘ ˙ËÙ¿ÂÈ Ë ÔÈÎÔÁ¤ÓÂÈ· ·fi ÙÔÓ ·È‰›·ÙÚÔ, ÂÎÙfi˜ ·fi ÙËÓ Ï‹ÚË ÁÓÒÛË ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ È·ÙÚÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜, Â›Ó·È Ë Â˘Á¤ÓÂÈ· Î·È Ë ·ÓıÚˆÈ¿.

O ¢·ÈÛıËÙÔÔÈË̤ÓÔ˜ ·È‰›·ÙÚÔ˜ ¤¯ÂÈ ·ÓÂÙ˘Á̤ÓË ÈηÓfiÙËÙ· ÚÔÛ¤ÁÁÈÛ˘ (ÏfiÁˆ ÂȉÈ΋˜ ÂÎ·›‰Â˘Û˘) Î·È ‰ÂÓ Ê›‰ÂÙ·È ¯ÚfiÓÔ˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÎÔ‡ÛÂÈ ÙÔ ·È‰› Î·È ÙÔ˘˜ ÁÔÓ›˜, ÌÈÏ¿ÂÈ Û ·Ï‹ ÁÏÒÛÛ· Î·È Í¤ÚÂÈ Ò˜ Ó· ¯ÂÈÚÈÛÙ› ·ÔÙÂÏÂ-

1. Peri G, Molinari E, Taverna A. Parental perceptions of childhood illness. J Asthma 1991;28:91-101.

2. Thompson N, Irwin MG, Gunawardene WM, Chan L. Preoperative parental anxiety. Anaesthesia 1996;51:1008-1012.

3. Rushforth H. Practitioner review: communicating with hospitalized children: review and application of research pertaining to children’s understanding of health and illness. J Child Psychol Psychiatry 1999;40:683-691.

4. Eiser C. Communicating with sick and hospitalized children. J Child Psychol Psychiatry 1984;25:181-189.

5. Beverley B. The effect of illness upon emotional development.

J Pediatr 1936;8:533-543.

6. Fergusson BF. Preparing young children for hospitalization: a comparison of two methods. Pediatrics 1979;64:656-664.

7. Buckman W, Gofman H, Schade GH. The child’s emotional response to hospitalization. Am J Dis Child 1957;93:157-164.

8. Haller JA. The hospitalized child and his family. Baltimore, MD: The Johns Hopkins Press; 1967.

9. Holaday B, LaMontagne L, Marciel J. Vygotsky’s zone of proximal development: implications for nurse assistance of children's learning. Issues Compr Pediatr Nurs 1994;17:15-27.

341

September-October 05 chris

18-11-04

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10. Kalnins I, Love R. Children’s concepts of health and illness and implications for health education: an overview. Health Educ Q 1982;9:104-115.

11. Kister MC, Patterson CJ. Children’s conceptions of the causes of illness: understanding of contagion and use of immanent justice. Child Dev 1980;51:839-846.

12. Lewis CE, Lewis MA. Children’s health-related decision making. Health Educ Q 1982;9:225-237.

13. Perrin EC, Perrin JM. Clinicians’ assessments of children’s understanding of illness. Am J Dis Child 1983;137:874-878.

14. Rushforth H. Nurses’ knowledge of how children view health and illness. Paediatr Nurs 1996;8:23-27.

15. Saile H, Burgmeier R, Schmidt LR. A meta-analysis of studies on psychological preparation of children facing medical procedures. Psychol Health 1988;2:107-132.

16. While AE, Wilcox VK. Paediatric day surgery: day-case unit admission compared with general paediatric ward admission.

J Adv Nurs 1994;19:52-57.

17. Eiser C, Patterson D. Children’s perceptions of hospital: a preliminary study. Int J Nurs Stud 1984;21:45-50.

18. ∫ÔÌÌ·Ù¿˜ K, ∫ÔÓÙfiÔ˘ÏÔ˜ ∂, ∆Û›ÎÔ˘Ï·˜ π, ∞Ì·Ù˙fiÁÏÔ˘ °, ¶·‡ÏÔ˘ ∂, ª·Ï·Î¿-∑·ÊÂÈÚ›Ô˘ ∫. ∂ÌÂÈڛ˜ ·È‰ÈÒÓ Î·È ÙˆÓ Û˘ÓÔ‰ÒÓ ÌËÙ¤ÚˆÓ ÙÔ˘˜ ηٿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ¡¤· ¶·È‰È·ÙÚÈο ÃÚÔÓÈο 2002;2:45-52.

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Paediatriki 2004;67:336-342

19. Sifneos EP. Short-term dynamic psychotherapy: evaluation and technique. New York: Plenum Medical Book Company; 1987.

20. Svartberg M, Seltzer MH, Stiles TC, Khoo ST. Symptom improvement and its temporal course in short-term dynamic psychotherapy. A growth curve analysis. J Nerv Ment Dis 1995;183:242-248.

21. Davanloo H. Basic principles and techniques in short-term dynamic psychotherapy. New York: Spectrum Publications; 1978.

22. ¶··‰¿ÎÔ˘-§·ÁÔÁÈ¿ÓÓË ™, ¶·ÓÙÂÏ¿Î˘ ™. ™Ê·ÈÚÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ¯ÚfiÓÈÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ¶·È‰È·ÙÚÈ΋ 1982;45: 418-421.

23. ¢ÔÍÈ¿‰Ë˜ ™. O ·È‰›·ÙÚÔ˜ Û·Ó ·È‰·ÁˆÁfi˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. π·ÙÚÈ΋ 1964;5:5-11.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: £¿ÏÂÈ· ¶·¿˙ÔÁÏÔ˘ £‹ÚˆÓÔ˜ 7, ∆.∫. 116 34, ¶·ÁÎÚ¿ÙÈ

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Paediatriki 2004;67:343-348

ORIGINAL ARTICLE

∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙË ÓÂÔÁÓÈ΋ Û‹„Ë ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘1, Ã. ¡Ô‡ÙÛÈ·1, Ã. ∞Á·Î›‰Ë˜1, ¶. ¶··Î˘ÚȷΛ‰Ô˘ - ∫ÔÏÈÔ‡Ûη1, ª. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘2, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜1

Ciprofloxacin treatment for neonatal sepsis due to multi-resistant Gram-negative bacteria V. Drossou - Agakidou1, C. Noutsia1, C. Agakidis1, P. Papakyriakidou - Koliouska1, M. Tsivitanidou2, G. Kremenopoulos1

¶ÂÚ›ÏË„Ë: ∏ ·˘ÍË̤ÓË ¯Ú‹ÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ÛÙȘ ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ÓÂÔÁÓÒÓ Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ ÔÏ˘·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È·. ¶ÚfiÎÂÈÙ·È ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÌÂϤÙË ·Ú·Ù‹ÚËÛ˘ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· Û ÓÂÔÁÓ¿, ÁÈ· Ù· ÔÔ›· ¯ÔÚËÁ‹ıËΠÛÈÚÔÊÏÔÍ·Û›ÓË ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ ·Ú¯ÈÎÔ‡ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÛÙÔ ‰È¿ÛÙËÌ· 1994-1999. ∫·Ù·ÁÚ¿ÊËÎ·Ó Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Ë ÂͤÏÈÍË ÙˆÓ ÓÂÔÁÓÒÓ, Ù· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ë Â˘·ÈÛıËÛ›· ÙÔ˘˜ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο. ø˜ ·ÔÙ˘¯›· Ù˘ ıÂÚ·›·˜ ıˆڋıËÎÂ Ë ·‰˘Ó·Ì›· ·ÚÓËÙÈÎÔÔ›ËÛ˘ ÙˆÓ Î·ÏÏÈÂÚÁÂÈÒÓ ·›Ì·ÙÔ˜ ‹ Ô ı¿Ó·ÙÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆· ÎÚÈÙ‹ÚÈ· Ù˘ ÌÂϤÙ˘ ÏËÚÔ‡Û·Ó 49 ÂÂÈÛfi‰È· Û‹„˘ Û ÈÛ¿ÚÈıÌ· ÓÂÔÁÓ¿ (43 ÚfiˆÚ· Î·È 6 ÙÂÏÂÈfiÌËÓ·). ™Â 35/49 ÓÂÔÁÓ¿, Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ÚÔÛÙ¤ıËΠÛÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ Ô˘ ‹‰Ë Ï¿Ì‚·Ó ÙÔ ÓÂÔÁÓfi Î·È Û 14 ¯ÔÚËÁ‹ıËΠˆ˜ ÌÔÓÔıÂÚ·›·. ∆· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒıËÎ·Ó ‹Ù·Ó ÎÏÂÌÛȤÏÏ· (n=29), ÂÓÙÂÚÔ‚·ÎÙËÚ›‰ÈÔ (n=6), ·ÎÈÓÂÙÔ‚·ÎÙËÚ›‰ÈÔ (n=5), ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ (n=4), ÂÓÙÂÚfiÎÔÎÎÔ˜ (n=3) Î·È ÛÂÚÚ¿ÙÈ· (n=2). ªfiÓÔ ÙÔ 12% ÙˆÓ ÛÙÂϯÒÓ ‹Ù·Ó ·ÓıÂÎÙÈÎfi ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË. ∞ÓÙ›ıÂÙ·, Ë ·ÓÙÔ¯‹ ÛÙ· ¿ÏÏ· ·ÓÙÈÌÈÎÚԂȷο Ô˘ Û˘Ó‹ıˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔ ∆Ì‹Ì· Î˘Ì·ÈÓfiÙ·Ó ·fi 73% ¤ˆ˜ 100%. ™Â 45/49 (90%) ÓÂÔÁÓ¿ ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ·ÚÓËÙÈÎÔÔÈ‹ıËηÓ, Û 3 ÓÂÔÁÓ¿ ¯ÚÂÈ¿ÛÙËΠӷ ·ÏÏ¿ÍÂÈ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ÏfiÁˆ

Abstract: The overuse of antimicrobial agents in neonatal intensive care units has led to increased incidence of multi-resistant species of Gramnegative bacteria. ∆he aim of this observational prospective study was to evaluate the effectiveness of ciprofloxacin in treating Gram-negative neonatal sepsis caused by multi-resistant bacteria. Episodes of neonatal sepsis due to Gram-negative bacteria, for which ciprofloxacin was administered after failure of the initial antimicrobial regime, were studied during a 6-year period (1994-1999). The clinical characteristics, the outcome, the microbes isolated from blood cultures and their resistance to antimicrobials were recorded. Failure to eradicate the microbe and sepsis-associated death were defined as treatment failure. During the study period, 49 episodes in 49 neonates fulfilled the entry criteria. In 35/49 episodes ciprofloxacin was added to the antimicrobial treatment already given to the neonate and in 14 of them it was administered as monotherapy. Isolated microbes included Klebsiella pneumoniae (n=29), Enterobacter spp. (n=6), Acinetobacter spp. (n=5), E. coli (n=4), Enterococcus spp. (n=3) and Serratia marcescens (n=2).

Only 12% of the isolated pathogens were resistant to ciprofloxacin. Resistance to other commonly used antibiotics ranged from 73% to 100%. With ciprofloxacin treatment, blood cultures became negative in 45/49 (90%) neonates, whereas antimicrobial therapy failed in 3 who had repeatedly positive blood culture results and in 1 who died. No adverse effects regarding platelets, liver or renal function were observed. The study showed that ciprofloxacin is a very effective treatment for

1 ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË 2 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË

1 Department of Neonatology, Aristotle University Hippokration General Hospital, Thessaloniki 2 Laboratory of Microbiology, Hippokration General Hospital, Thessaloniki

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¶·È‰È·ÙÚÈ΋ 2004;67:343-348

Paediatriki 2004;67:343-348

Â·ÓÂÈÏËÌÌ¤ÓˆÓ ıÂÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ, ÂÓÒ 1 ÓÂÔÁÓfi ·‚›ˆÛ ·fi Û‹„Ë. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi Ù· ·ÈÌÔÂÙ¿ÏÈ· Î·È ÙËÓ Ë·ÙÈ΋ ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ÛÈÚÔÊÏÔÍ·Û›ÓË ·ÔÙÂÏ› Ì›· Ôχ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÓ·ÏÏ·ÎÙÈ΋ ÚfiÙ·ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ, ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÚÒÙ˘ ÁÚ·ÌÌ‹˜.

neonatal sepsis caused by multi-resistant species of Gram-negative bacteria, after failure of the conventional therapy.

§¤ÍÂȘ ÎÏÂȉȿ: Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È·, ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο, ÛÈÚÔÊÏÔÍ·Û›ÓË, ÓÂÔÁÓÈ΋ Û‹„Ë.

Key words: Gram-negative bacteria, antimicrobial resistance, ciprofloxacin, neonatal sepsis.

™˘ÓÙÔÌÔÁڷʛ˜

‚È· Î·È ÚÔÁÚ·ÌÌ·Ù›ÛÙËÎÂ Ë ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Û ÂÂÈÛfi‰È· Û‹„˘ ·fi Ù· ·Ú·¿Óˆ ÌÈÎÚfi‚È·, ·ÓıÂÎÙÈ΋˜ ÛÙË Û˘Ó‹ıË ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹.

ª∂¡¡

ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ

∂ÈÛ·ÁˆÁ‹ ∏ ÛÈÚÔÊÏÔÍ·Û›ÓË Â›Ó·È ÊÏÔ˘ÔÚÔÎÈÓÔÏfiÓË Â˘Ú¤Ô˜ Ê¿ÛÌ·ÙÔ˜, Ë ÔÔ›· ¤¯ÂÈ ·Ô‰Âȯı› Ôχ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÛÔ‚·ÚÒÓ ÏÔÈÌÒÍÂˆÓ ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· Û ÂÓ‹ÏÈΘ. °È· ÔÏÏ¿ ¯ÚfiÓÈ·, Ë ·È‰È΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Û ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘ (1), ÁÈ·Ù› ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÙÔÍÈ΋ ‚Ï¿‚Ë ÛÙÔÓ Û˘˙¢ÎÙÈÎfi ¯fiÓ‰ÚÔ Ó·ÚÒÓ ÂÈÚ·Ì·Ùfi˙ˆˆÓ (2-4). ŒÙÛÈ, ̤¯ÚÈ ÚÈÓ ·fi Ï›Á· ¯ÚfiÓÈ· ÂÈÙÚÂfiÙ·Ó Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÌfiÓÔ Û ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 3 ÂÙÒÓ Ì ÂȉÈΤ˜ ÂӉ›ÍÂȘ, fiˆ˜ ¯ÚfiÓÈ· ˘ÔÙÚÔÈ¿˙Ô˘Û· ˘ÂÏÔÓÂÊÚ›Ùȉ·, Ó¢ÌÔÓ›· Û ΢ÛÙÈ΋ ›ÓˆÛË Î·È ÏÔÈÌÒÍÂȘ ÙÔ˘ ∫¡™, ηıÒ˜ Î·È Û ‡·ÚÍË ·ÚÔ¯ÂÙ‡ÛÂˆÓ ÙÔ˘ ∂¡À ‹ Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ·È‰È¿ (5). øÛÙfiÛÔ, ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÂÓ ¤‰ÂÈÍ·Ó ÙÔÍÈ΋ ‚Ï¿‚Ë ÙˆÓ ·ÚıÚÒÛÂˆÓ ·È‰ÈÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ıÂÚ·›· Ì ÛÈÚÔÊÏÔÍ·Û›ÓË (6,7). ™Ù· ÓÂÔÁÓ¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ (ª∂¡¡), ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÔÏ˘·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ Â›Ó·È Û˘¯Ó¤˜ Î·È ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ˘„ËÏ‹ ıÓËÙfiÙËÙ· (8-11). ª¤¯ÚÈ ÙÔ 1990 ˘‹ÚÍ·Ó ÂÏ¿¯ÈÛÙ˜ ·Ó·ÊÔÚ¤˜ ¯ÔÚ‹ÁËÛ˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Û ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Ì ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ, ΢ڛˆ˜ ÌËÓÈÁÁ›Ùȉ· (12-15). ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋, Ë ¯ÔÚ‹ÁËÛË ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÍÂΛÓËÛ ÙÔ 1994, fiÙ·Ó ÂÌÊ·Ó›ÛÙËÎ·Ó ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÈ΋˜ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ, ÙȘ Ôԛ˜ ‰ÂÓ ÌfiÚÂÛ·Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó Ù· ¿ÏÏ· ·ÓÙÈÌÈÎÚԂȷο. ª›· Úfi‰ÚÔÌË ÌÂϤÙË Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ÓÂÔÁÓÒÓ ¤‰ÂÈÍ fiÙÈ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ‹Ù·Ó ·ÔÙÂÏÂÛÌ·ÙÈ΋, ¯ˆÚ›˜ Ó· ÚÔηÏ› ÛÔ‚·Ú¤˜ ¿ÌÂÛ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ŒÙÛÈ, ‰È¢ڇÓıËÎÂ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÓÂÔÁÓ¿ Ì ۋ„Ë ·fi ÔÏ˘·ÓıÂÎÙÈο Gram ·ÚÓËÙÈο ÌÈÎÚfi-

344

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¢ÈÂÍ‹¯ıË ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÌÂϤÙË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ Û ÓÂÔÁÓ¿ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙË MENN Ù˘ A’ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ ·fi ÙÔ 1994 ̤¯ÚÈ ÙÔ 1999 Î·È ÁÈ· Ù· ÔÔ›· ¯ÔÚËÁ‹ıËΠÛÈÚÔÊÏÔÍ·Û›ÓË ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ ·Ú¯ÈÎÔ‡ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ™‡Ìʈӷ Ì ÙËÓ Ù·ÎÙÈ΋ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜, Ë ·Ú¯È΋ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›· ÁÈ· Ù· ÓÂÔÁÓ¿ Ì ۋ„Ë ÛÙÔ ‰È¿ÛÙËÌ· Ù˘ ÌÂϤÙ˘ ÂÚÈÂÏ¿Ì‚·Ó ÙË ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÌÈÎÈÏÏ›ÓË-ÛÔ˘Ï‚·ÎÙ¿ÌË ‹ Ì›· ÎÂÊ·ÏÔÛÔÚ›ÓË 3˘ ÁÂÓ¿˜. ∆ÚÂȘ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, Ï·Ì‚·ÓfiÙ·Ó Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ηÈ, ÂÊfiÛÔÓ ‹Ù·Ó ıÂÙÈ΋, Ë ·ÁˆÁ‹ ¿ÏÏ·˙ Ì ·ÓÙÈηٿÛÙ·ÛË ·fi ¿ÏÏË ÎÂÊ·ÏÔÛÔÚ›ÓË ‹ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë ‹ ÚÔÛı‹ÎË ÙÚÈÌÂıÔÚ›Ó˘ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏ˘ ‹ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ‹ ¯ÔÚ‹ÁËÛË ÛÈÚÔÊÏÔÍ·Û›Ó˘ ˆ˜ ÌÔÓÔıÂÚ·›·˜. ∏ ·fiÊ·ÛË ÁÈ· ÙÔ Â›‰Ô˜ ÙˆÓ ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ Ï·Ì‚·ÓfiÙ·Ó ·fi ÙÔ˘˜ ıÂÚ¿ÔÓÙ˜ È·ÙÚÔ‡˜, ÂÓÒ ÔÈ ÂÚ¢ÓËÙ¤˜ ·ÏÒ˜ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Î·È Î·Ù¤ÁÚ·Ê·Ó ÙËÓ ÂͤÏÈÍË ÙˆÓ ÓÂÔÁÓÒÓ, ¯ˆÚ›˜ Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙȘ ·ÔÊ¿ÛÂȘ. ∏ ÌÂϤÙË Û˘ÌÂÚȤϷ‚ 49 ÂÂÈÛfi‰È· Û‹„˘ Ô˘ ÂÌÊ·Ó›ÛÙËÎ·Ó Û ÈÛ¿ÚÈıÌ· ÓÂÔÁÓ¿ (43 ÚfiˆÚ· Î·È 6 ÙÂÏÂÈfiÌËÓ·), ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÔÔ›ˆÓ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ¯ÔÚËÁ‹ıËΠˆ˜ ÌÔÓ·‰È΋ ·ÏÏ·Á‹ ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ ·Ú¯ÈÎÔ‡ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ™Ù· ÂÂÈÛfi‰È·, ‰ËÏ·‰‹, Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ‹Ù·Ó ÙÔ ÌÔÓ·‰ÈÎfi Ê¿ÚÌ·ÎÔ Ô˘ ÚÔÛÙ¤ıËΠÛÙÔ ·ÓÙÈÌÈÎÚÔ‚È·Îfi Û¯‹Ì· Ô˘ ‹‰Ë Ï¿Ì‚·Ó ÙÔ ÓÂÔÁÓfi ‹ ¯ÔÚËÁ‹ıËΠˆ˜ ÌÔÓÔıÂÚ·›·, ·ÓÙÈηıÈÛÙÒÓÙ·˜ Ù· ÚÔËÁÔ‡ÌÂÓ· ·ÓÙÈÌÈÎÚԂȷο. ø˜ ·ÔÙ˘¯›· Ù˘ ıÂÚ·›·˜ Ì ÛÈÚÔÊÏÔÍ·Û›ÓË ıˆڋıËÎÂ Ë ·Ó¿ÁÎË ÁÈ· ·ÏÏ·Á‹ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜ ÏfiÁˆ Â·ÓÂÈÏËÌÌ¤ÓˆÓ ıÂÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ ·›Ì·ÙÔ˜ ‹ Ô ı¿Ó·ÙÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË Û‹„Ë. ∏ ÛÈÚÔÊÏÔÍ·Û›ÓË ¯ÔÚËÁ‹ıËΠ۠‰fiÛË 10 mg/kg ·Ó¿ Ë̤ڷ ÁÈ· 10-20 Ë̤Ú˜.

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·345

¶·È‰È·ÙÚÈ΋ 2004;67:343-348

Paediatriki 2004;67:343-348

∫·Ù·ÁÚ¿ÊËÎ·Ó Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Ù· ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ, Ë ÂͤÏÈÍË Ù˘ Ïԛ̈͢, Ù· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ë Â˘·ÈÛıËÛ›· ÙÔ˘˜ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ¤ÁÈÓ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ÌÂıfi‰Ô˘˜ ÙÔ˘ ÂÚÁ·ÛÙËÚ›Ô˘ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. ™˘ÁÎÂÎÚÈ̤ӷ, ¤ÁÈÓ ÂÒ·ÛË ÛÙÔ ·˘ÙÔÌ·ÙÔÔÈË̤ÓÔ Û‡ÛÙËÌ· BACT/ALERT, fiÔ˘ ÔÈ ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ‰›ÓÔ˘Ó ÔÙÈÎfi Î·È Ë¯ËÙÈÎfi Û‹Ì· Î·È Î·ÙfiÈÓ ·Ó·Î·ÏÏÈÂÚÁÔ‡ÓÙ·È Û ·ÈÌ·ÙÔ‡¯Ô ¿Á·Ú. ∏ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÌÈÎÚÔ‚›ˆÓ Î·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο ¤ÁÈÓ Ì ÙÔ Û‡ÛÙËÌ· Vitek.

Û 1 ÂÚ›ÙˆÛË ·ÔÌÔÓÒıËΠÂÓÙÂÚfiÎÔÎÎÔ˜ ÙˆÓ ÎÔÚ¿ÓˆÓ Â˘·›ÛıËÙÔ˜ in vitro Î·È Û 1 ·ÎÈÓÂÙÔ‚·ÎÙËÚ›‰ÈÔ ·ÓıÂÎÙÈÎfi in vitro. ∏ ÂÚÁ·ÛÙËÚȷ΋ ·Ú·ÎÔÏÔ‡ıËÛË ¤‰ÂÈÍ ıÚÔÌ‚ÔÂÓ›· Û 27 ÓÂÔÁÓ¿ - Û 23 ·fi Ù· ÔÔ›· ˘Ô¯ÒÚËÛ Ì ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û‹„˘ - Î·È ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ Û 3, 7 Î·È 1 ÓÂÔÁÓ¿, ·ÓÙ›ÛÙÔȯ·. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ÔÈ ÙÈ̤˜ ·˘ÙÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Â·Ó‹Ïı·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÌÂÙ¿ ·fi 5-20 Ë̤Ú˜, ÂÎÙfi˜ ·fi 2 ÓÂÔÁÓ¿ Ô˘ η٤ÏËÍ·Ó.

∞ÔÙÂϤÛÌ·Ù· ∆· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Ù· ·ÚÈ· ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™Â 14 ÓÂÔÁÓ¿ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ¯ÔÚËÁ‹ıËΠˆ˜ ÌÔÓÔıÂÚ·›· Î·È ÛÙ· ˘fiÏÔÈ· 35 ÚÔÛÙ¤ıËΠÛÙËÓ ·ÁˆÁ‹ Ô˘ ‹‰Ë Ï¿Ì‚·Ó ÙÔ ÓÂÔÁÓfi. ∆· ·ıÔÁfiÓ· Ô˘ ·ÔÌÔÓÒıËÎ·Ó Î·È Ë ·ÓÙÔ¯‹ ÙÔ˘˜ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ªfiÓÔ ÙÔ 12% ·˘ÙÒÓ ÙˆÓ ·ıÔÁfiÓˆÓ ‹Ù·Ó ·ÓıÂÎÙÈÎfi ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË. ªÂÁ·Ï‡ÙÂÚË ·ÓÙÔ¯‹ ·ÚÔ˘Û›·˙·Ó ÙÔ ·ÎÈÓÂÙÔ‚·ÎÙËÚ›‰ÈÔ (40%) Î·È Ô ÂÓÙÂÚfiÎÔÎÎÔ˜ (33%). ∏ ·ÓÙÔ¯‹ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ Ô˘ ·ÔÌÔÓÒıËÎ·Ó ÛÙ· ˘fiÏÔÈ· ·ÓÙÈÌÈÎÚԂȷο ‹Ù·Ó Ôχ ˘„ËÏ‹ Î·È Î˘Ì·ÈÓfiÙ·Ó ·fi 73% ¤ˆ˜ 100%, Ì ÂÏ¿¯ÈÛÙ˜ ÂÍ·ÈÚ¤ÛÂȘ (¶›Ó·Î·˜ 3). ™Â 44/49 (90%) ÓÂÔÁÓ¿ ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ·ÚÓËÙÈÎÔÔÈ‹ıËηÓ, Û 3 ··ÈÙ‹ıËΠ·ÏÏ·Á‹ Ù˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜ ÏfiÁˆ ·‰˘Ó·Ì›·˜ ·ÔÛÙ›ڈÛ˘, ÂÓÒ 1 ÓÂÔÁÓfi ·‚›ˆÛ ̤۷ Û 24 ÒÚ˜ ·fi ÙËÓ ÚÔÛı‹ÎË Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹. ∞fi ÙȘ 4 ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ fiÔ˘ Ë ıÂÚ·›· ·¤Ù˘¯Â, Û 2 ·ÔÌÔÓÒıËΠÎÏÂÌÛȤÏÏ· Ù˘ Ó¢ÌÔÓ›·˜, ·fi Ù· ÔÔ›· ¤Ó· Û٤ϯԘ ‹Ù·Ó ¢·›ÛıËÙÔ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË in vitro,

™˘˙‹ÙËÛË ™Ù· ÓÂÔÁÓ¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ª∂¡¡ Ì ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· Â›Ó·È Û˘¯Ó¤˜ ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ, Ù· ÔÔ›· Û˘Ó‹ıˆ˜ Â›Ó·È ·ÓıÂÎÙÈο Û ÔÏÏ¿ ·ÓÙÈÌÈÎÚԂȷο, ÏfiÁˆ Ù˘ ¢Ú›·˜ ¯Ú‹Û˘ ÙÔ˘˜ ÛÙȘ ª∂¡¡ (8-11). ∆· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi Ù· ÓÂÔÁÓ¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÚÔ˘Û›·˙·Ó Ôχ ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÓÙÔ¯‹˜ ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ (78-97%), Ì ÂÍ·›ÚÂÛË ÙËÓ ÎÂÊÔÍÈÙ›ÌË (34%), Ë ÔÔ›· ‰ÂÓ Â›¯Â ¯ÚËÛÈÌÔÔÈËı› ηıfiÏÔ˘ ÛÙÔ ∆Ì‹Ì·. ∂›Û˘, Ôχ ˘„ËÏfi ÔÛÔÛÙfi ‹Ù·Ó ·ÓıÂÎÙÈÎfi ÛÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜

¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Î‡ÚÈ· ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ Ã·Ú·ÎÙËÚÈÛÙÈο N ∏ÏÈΛ· ·ËÛ˘ (x±SD) µ¿ÚÔ˜ Á¤ÓÓËÛ˘ (x±SD) º‡ÏÔ (·ÁfiÚÈ·/ÎÔÚ›ÙÛÈ·) ∏ÏÈΛ· ηٿ ÙË ¯ÔÚ‹ÁËÛË ÛÈÚÔÊÏÔÍ·Û›Ó˘ (ËÌ., x±SD) ™‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (n, %) ÕÏÏ· ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· (n, %) µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (n, %) ¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· (n, %) ªËÓÈÁÁ›Ùȉ· (n) ¢È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ (x±SD) ∂È‚›ˆÛË ·fi ÙË Û‹„Ë (n, %) ™˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË (n, %)

∆ÈÌ‹ 49 31,9±3,8 1733±813 30/19 12±7 31 (63) 16 (33) 5 (10) 3 (6) 2 (4) 1 39±18 48 (98) 43 (88)

¶›Ó·Î·˜ 2. ªÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È ·ÓÙÔ¯‹ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË

¡ ∫ÏÂÌÛȤÏÏ· Ó¢ÌÔÓ›·˜ ™ÙÂϤ¯Ë ÂÓÙÂÚÔ‚·ÎÙËÚȉ›Ô˘ ™ÙÂϤ¯Ë ·ÎÈÓÂÙÔ‚·ÎÙËÚȉ›Ô˘ ∫ÔÏÔ‚·ÎÙËÚ›‰ÈÔ ™ÂÚÚ¿ÙÈ· ™ÙÂϤ¯Ë ÂÓÙÂÚfiÎÔÎÎÔ˘ ™‡ÓÔÏÔ

29 6 5 4 2 3 49

∞ÓÙÔ¯‹ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË ¡ % 2 1 2 0 0 1 6

7 17 40 0 0 33 12

¶›Ó·Î·˜ 3. ¶ÔÛÔÛÙfi ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ ÙˆÓ Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ∞ÓÙÈÌÈÎÚÔ‚È·Îfi ™ÈÚÔÊÏÔÍ·Û›ÓË ∞ÌÈηۛÓË °ÂÓÙ·Ì˘Î›ÓË ¡ÂÙÚÔÌ˘Û›ÓË ∆Ô‚Ú·Ì˘Î›ÓË ∫ÂÊÔÙ·Í›ÓË ∫ÂÊÔÍÈÙ›ÓË ∫ÂÊÙ·˙ȉ›ÌË ∫ÂÊÙÚÈ·ÍfiÓË ∫ÂÊÔ˘ÚÔÍ›ÓË ∞˙ÚÂÔÓ¿ÌË ∞ÌÔ͢ÛÈÏ›ÓË/ÛÔ˘Ï‚·ÎÙ¿ÌË ∞ÌÈÎÈÏ›ÓË

% 12 73 96 55 86 78 34 91 92 97 97 77 100

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18-11-04

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(55-96%) Î·È ÛÙËÓ ·˙ÚÂÔÓ¿ÌË (97%), ·Ó Î·È Ë ÙÂÏÂ˘Ù·›· ‰ÂÓ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÛÙÔ ∆Ì‹Ì·. ™Â ·ÚfiÌÔȘ ÂÚÈÙÒÛÂȘ Û‹„˘ ·fi ÔÏ˘·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ, Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ÌÔÚ› Ó· ·ÔÙÂÏ› Ì›· ÛËÌ·ÓÙÈ΋ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ÁÈ· ÙË ‰È¿ÛˆÛË ÙˆÓ ÓÂÔÁÓÒÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ - Û‡Ìʈӷ Ì ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ‰ÈÂıÓÒ˜ Ë in vitro ¢·ÈÛıËÛ›· ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ·˘ÙÒÓ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË Î˘Ì·›ÓÂÙ·È ·fi 20% ¤ˆ˜ 96%, ·Ó¿ÏÔÁ· Ì ÙÔ ÌÈÎÚfi‚ÈÔ Î·È ÙË ‰È¿ÚÎÂÈ· ¯Ú‹Û˘ Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Û οı ¡ÂÔÁÓÈÎfi ∆Ì‹Ì· (8,9,1619). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË ‹Ù·Ó ȉȷ›ÙÂÚ· ¯·ÌËÏfi (12%), Ì ÂÍ·›ÚÂÛË ÙÔ ·ÎÈÓÂÙÔ‚·ÎÙËÚ›‰ÈÔ, ÙÔ 40% ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ÔÔ›Ô˘ ‹Ù·Ó ·ÓıÂÎÙÈÎfi. ∏ Ôχ ˘„ËÏ‹ ¢·ÈÛıËÛ›· ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ë ·fiÊ·ÛË ¯ÔÚ‹ÁËÛ˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ‚·Û›ÛÙËΠÛÙÔ test ¢·ÈÛıËÛ›·˜ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Ô˘ ›¯Â ·ÔÌÔÓˆı› ÛÙËÓ ÚÒÙË Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜. øÛÙfiÛÔ, Û ¿ÏÏË ÌÂÁ·Ï‡ÙÂÚË ÌÂϤÙË, Ô ¤ÏÂÁ¯Ô˜ Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ Gram ·ÚÓËÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ∆Ì‹Ì·ÙÔ˜ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË Î·Ù¿ ÙËÓ ›‰È· ÂÍ·ÂÙ›· (1994-1999) ¤‰ÂÈÍ ·ÚfiÌÔÈ· ˘„ËÏ¿ ÔÛÔÛÙ¿ ¢·ÈÛıËÛ›·˜ (ÌË ‰ËÌÔÛÈÂ˘Ì¤Ó· ‰Â‰Ô̤ӷ). ™ÙËÓ ˘„ËÏ‹ ¢·ÈÛıËÛ›· ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË Î·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ ÌÂϤÙ˘ ÚÔÊ·ÓÒ˜ Û˘Ó¤‚·Ï ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·Ó ÛÙÔ ∆Ì‹Ì· ̤¯ÚÈ ÙÔ 1994. ¶ÚÔηÏ› ÂӉȷʤÚÔÓ Ë ‰ÈÂÚ‡ÓËÛË ÂӉ¯fiÌÂÓˆÓ ÌÂÙ·‚ÔÏÒÓ Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ÌÂÙ¿ ·fi 9 ¯ÚfiÓÈ· ¯Ú‹Û˘ Ù˘ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ∆Ì‹Ì·. ª¤¯ÚÈ ÙÔ 1990 ˘‹ÚÍ·Ó ÂÏ¿¯ÈÛÙ˜ ·Ó·ÊÔÚ¤˜ ¯ÔÚ‹ÁËÛ˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Û ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Ì ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ Î·È Î˘Ú›ˆ˜ ÌËÓÈÁÁ›Ùȉ· (12-15). ∏ ¯ÔÚ‹ÁËÛ‹ Ù˘ ·˘Í‹ıËΠÛÙË ‰ÂηÂÙ›· ÙÔ˘ ’90, ÒÛÙ ̤¯ÚÈ Û‹ÌÂÚ· Ó· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯ÔÚ‹ÁËÛË ÛÈÚÔÊÏÔÍ·Û›Ó˘ Û ·ÚÎÂÙ¿ ÓÂÔÁÓ¿ Ì ۋ„Ë ‹/Î·È ÌËÓÈÁÁ›Ùȉ· ·fi Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· (9,13-16,19-30). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÍÂΛÓËÛ ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙˆÓ ÚÔËÁÔ‡ÌÂÓˆÓ ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ Û¯ËÌ¿ÙˆÓ, Ù· ÔÔ›· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ›¯·Ó ¯ÔÚËÁËı› ÂÌÂÈÚÈο, ÚÈÓ ·fi ÙËÓ ·ÔÌfiÓˆÛË ÙˆÓ ·ıÔÁfiÓˆÓ. ªÂ ÙË ¯ÔÚ‹ÁËÛË Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘, ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ·ÚÓËÙÈÎÔÔÈ‹ıËÎ·Ó ÛÙÔ 90%. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ú¤ÂÈ Ó· ·Ô‰Ôı› ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË, ÁÈ·Ù› - ·Ó Î·È Û ϛÁ˜ ÂÚÈÙÒÛÂȘ ÙÔ Ê¿ÚÌ·ÎÔ ¯ÔÚËÁ‹ıËΠˆ˜ ÌÔÓÔıÂÚ·›· - Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ·ÔÙÂÏÔ‡Û ÙË ÌÔÓ·‰È΋ ·ÏÏ·Á‹ ÛÙÔ ·ÓÙÈÌÈÎÚÔ‚È·Îfi Û¯‹Ì· Ô˘ ‹‰Ë Ï¿Ì‚·ÓÂ

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ÙÔ ÓÂÔÁÓfi. ¶·ÚfiÌÔÈ· Â›Ó·È Ù· ·ÔÙÂϤÛÌ·Ù· ¿ÏÏˆÓ ÌÂÏÂÙÒÓ, Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÛÔ‚·ÚÒÓ ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (10,19,21,23,25, 28,31). ∂›Û˘, Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ï‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ· ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi, fiÔ˘ Ù· Â›‰¿ Ù˘ Î˘Ì·›ÓÔÓÙ·È Û ÔÛÔÛÙfi 1050% ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÛÙÔÓ ÔÚfi (30,32). ∞fi Ù· ÓÂÔÁÓ¿ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ÌfiÓÔ 1 ›¯Â ÌËÓÈÁÁ›Ùȉ·, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËΠÂÈÙ˘¯Ò˜ ÌÂÙ¿ ÙËÓ ÚÔÛı‹ÎË Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘. OÈ ‰fiÛÂȘ Ô˘ ¤¯Ô˘Ó ¯ÔÚËÁËı› ÛÙ· ÓÂÔÁÓ¿ ÔÈΛÏÏÔ˘Ó ·fi 10 mg/kg ¤ˆ˜ 60 mg/kg ·Ó¿ Ë̤ڷ (31). OÈ ÌÂÁ·Ï‡ÙÂÚ˜ ‰fiÛÂȘ ¤¯Ô˘Ó ¯ÔÚËÁËı› Û ÓÂÔÁÓ¿ Ì ÌËÓÈÁÁ›Ùȉ· (13), ·Ó Î·È Ë Î·Ï‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ¿ Ù˘ ÛÙÔ ∂¡À ÂÈÙÚ¤ÂÈ ÙË ¯Ú‹ÛË ÌÈÎÚfiÙÂÚˆÓ ‰fiÛÂˆÓ (̤¯ÚÈ 30 mg/kg/Ë̤ڷ), ·ÎfiÌË Î·È Û ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜. ∞fi ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂȂ‚·ÈÒÓÂÙ·È fiÙÈ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘, ·ÎfiÌË Î·È ·Ó ¯ÔÚËÁÂ›Ù·È ÛÙË ÌÈÎÚfiÙÂÚË ‰fiÛË (10 mg/kg/Ë̤ڷ). ∞fi ÙȘ 4 ÂÚÈÙÒÛÂȘ fiÔ˘ ıˆڋıËΠfiÙÈ Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ·¤Ù˘¯Â, 1 ÓÂÔÁÓfi η٤ÏËÍ ÚÈÓ ÂÚ¿ÛÔ˘Ó 24 ÒÚ˜ ·fi ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘ Î·È ¤ÙÛÈ ‰ÂÓ ˘‹Ú¯Â ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢. ™‡ÁÎÚÈÛË ÌÂٷ͇ Ù˘ in vitro ¢·ÈÛıËÛ›·˜ Î·È Ù˘ in vivo ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ¤‰ÂÈÍ fiÙÈ Û ‰‡Ô ·fi ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ·¤Ù˘¯Â Ë ¯ÔÚ‹ÁËÛË Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Ù· ÌÈÎÚԂȷο ÛÙÂϤ¯Ë ‹Ù·Ó ¢·›ÛıËÙ· Û ·˘Ù‹Ó, ÂÓÒ ·ÓÙ›ıÂÙ·, Û ÙÚ›· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· Ë Û‹„Ë ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÂÈÙ˘¯›·, Ù· ÛÙÂϤ¯Ë Ô˘ ·ÔÌÔÓÒıËÎ·Ó ‹Ù·Ó ·ÓıÂÎÙÈο in vitro. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ Ë in vitro ¢·ÈÛıËÛ›· ‰ÂÓ ÚԉȷÁÚ¿ÊÂÈ ¿ÓÙÔÙ ÙËÓ in vivo ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙȘ ¿ÌÂÛ˜ Î·È Ì·ÎÚÔ¯ÚfiÓȘ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙ· ÓÂÔÁÓ¿ Â›Ó·È ÂÏ¿¯ÈÛÙ·. OÈ Û˘¯ÓfiÙÂÚ˜ ¿ÌÂÛ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ‹Ù·Ó Ë ıÚÔÌ‚ÔÂÓ›· Î·È Ë ·‡ÍËÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ (20-22). ∂›Ó·È, fï˜, ÁÓˆÛÙfi fiÙÈ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‚·ÚÈ¿˜ ÓÂÔÁÓÈ΋˜ Û‹„˘ ÌÔÚ› Ó· ÂËÚ·ÛÙÔ‡Ó Ù· ·ÈÌÔÂÙ¿ÏÈ·, ηıÒ˜ Î·È Ë ÓÂÊÚÈ΋ Î·È Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ¯ÔÚ‹ÁËÛË Ê·Ú̿ΈÓ. ŸÏ· Ù· ÓÂÔÁÓ¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ¤·Û¯·Ó ·fi ‚·ÚÈ¿ Û‹„Ë Î·È Û ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ·fi ·˘Ù¿ ·Ú·ÙËÚ‹ıËΠıÚÔÌ‚ÔÂÓ›·, Ë ÔÔ›· ·ÔηٷÛÙ¿ıËΠ̠ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û‹„˘. ∂›Û˘, Ë ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ Ô˘ ÂÌÊ·Ó›ÛÙËΠ۠ÔÚÈṲ̂ӷ ÓÂÔÁÓ¿, ·ÔηٷÛÙ¿ıËÎÂ. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ÛÙË ÛÈÚÔÊÏÔÍ·Û›ÓË, Â¿Ó ‰ÂÓ ·ÔÎÏÂÈÛÙ› Ë

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Û˘ÌÌÂÙÔ¯‹ Ù˘ Û‹„˘, Ù˘ ÔÏÈ΋˜ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ Î·È ÂӉ¯Ô̤ӈ˜ ÙˆÓ ¿ÏÏˆÓ ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·Ó Ù·˘Ùfi¯ÚÔÓ· ÛÙ· ÂÚÈÛÛfiÙÂÚ· ÓÂÔÁÓ¿. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È¢ÎÚÈÓÈÛÙ› Ë Û˘Ì‚ÔÏ‹ Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ ÛÙȘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚ‹ıËηÓ, ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔÈ¯Ë ÔÌ¿‰· Ì·ÚÙ‡ÚˆÓ. ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË, fiÔ˘ Û˘ÁÎÚ›ıËÎÂ Ë ¿ÌÂÛË Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ÙÔÍÈÎfiÙËÙ· Ù˘ ÛÈÚÔÊÏÔÍ·Û›Ó˘ Ì ÂΛÓË ¿ÏÏˆÓ ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ, ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÔÍ›˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙÔ ·›Ì·, Ô‡Ù Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ Î·È Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂ÈϤÔÓ, ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜, fiˆ˜ ·ÚıÚÔ¿ıÂÈ· ‹ ‰˘ÛÌÂÓ‹˜ Â›‰Ú·ÛË ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ‚ÚÂÊÒÓ Ì¤Û· ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ (33). ¶·ÚfiÌÔÈ· ‹Ù·Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘, ÛÙËÓ ÔÔ›· ‰È·ÈÛÙÒıËΠfiÙÈ 9 ‚Ú¤ÊË Ô˘ ›¯·Ó Ï¿‚ÂÈ ÛÈÚÔÊÏÔÍ·Û›ÓË Â›¯·Ó ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË ·ÚfiÌÔÈ· Ì ·ÓÙ›ÛÙÔÈ¯Ô˘˜ Ì¿ÚÙ˘Ú˜ (24). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë ÛÈÚÔÊÏÔÍ·Û›ÓË ·ÔÙÂÏ› Ì›· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÓ·ÏÏ·ÎÙÈ΋ ÚfiÙ·ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÔÁÓÈ΋˜ Û‹„˘ ·fi Gram ·ÚÓËÙÈο ÔÏ˘·ÓıÂÎÙÈο ÌÈÎÚfi‚È·, ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÚÒÙ˘ ÁÚ·ÌÌ‹˜.

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8.

9.

10.

11.

12.

13.

14.

15.

16.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Schaad UB, Sander E, Wedgwood J, Schaffner T. Morphologic studies for skeletal toxicity after prolonged ciprofloxacin therapy in two juvenile cystic fibrosis patients.

Pediatr Infect Dis J 1992;11:1047-1049.

2. Burkhardt JE, Walterspiel JN, Schaad UB. Quinolone arthropathy in animals versus children. Clin Infect Dis 1997;25:1196-1204.

3. Linseman DA, Hampton LA, Branstetter DG. Quinoloneinduced arthropathy in the neonatal mouse. Morphological analysis of articular lesions produced by pipemidic acid and ciprofloxacin. Fundam Appl Toxicol 1995;28:59-64.

4. Stahlmann R, Merker HJ, Hinz N, Chahoud I, Webb J, Heger W et al. Ofloxacin in juvenile non-human primates and rats.

Arthropathia and drug plasma concentrations. Arch Toxicol 1990;64:193-204.

5. Schaad UB, abdus Salam M, Aujard Y, Dagan R, Green SD, Peltola H et al. Use of fluoroquinolones in pediatrics: consensus report of an International Society of Chemotherapy commission. Pediatr Infect Dis J 1995;14:1-9.

6. Richard DA, Nousia-Arvanitakis S, Sollich V, Hampel BJ, Sommerauer B, Schaad UB. Oral ciprofloxacin vs. intravenous ceftazidime plus tobramycin in pediatric cystic fibrosis patients: comparison of antipseudomonas efficacy and assessment of safety with ultrasonography and magnetic resonance imaging. Cystic Fibrosis Study Group.

Pediatr Infect Dis J 1997;16:572-578.

7. Hampel B, Hullmann R, Schmidt H. Ciprofloxacin use in pediatrics: worldwide clinical experience based on

17.

18.

19.

20.

21.

22.

23.

24.

compassionate use - safety report. Pediatr Infect Dis J 1997; 16:127-129.

Kumhar GD, Ramachandran VG, Gupta P. Bacteriological analysis of blood culture isolates from neonates in a tertiary care hospital in India. J Health Popul Nutr 2002;20:343-347.

Choi SH, Kim YS, Chung JW, Kim TH, Choo EJ, Kim MN et al.

Serratia bacteremia in a large university hospital: trends in antibiotic resistance during 10 years and implications for antibiotic use. Infect Control Hosp Epidemiol 2002;23:740-747.

Joshi SG, Ghole VS, Niphadkar KB. Neonatal Gram-negative bacteremia. Indian J Pediatr 2000;67:27-32.

Rodriguez CH, Juarez J, de Mier C, Pugliese L, Blanco G, Vay C et al. Bacterial resistance to antibiotics in Gramnegative rods isolated from intensive care units. Comparative analysis between two periods (1998 and 2001). Medicina (B Aires) 2003;63:21-27.

Bannon MJ, Stutchfield PR, Weindling AM, Damjanovic V. Ciprofloxacin in neonatal Enterobacter cloacae septicaemia.

Arch Dis Child 1989;64:1388-1391.

Isaacs D, Slack MP, Wilkinson AR, Westwood AW. Successful treatment of Pseudomonas ventriculitis with ciprofloxacin. J Antimicrob Chemother 1986;17:535-538.

Ragunathan PL, Potkins DV, Watson JG, Kearns AM, Carroll A. Neonatal meningitis due to Salmonella typhimurium treated with ciprofloxacin. J Antimicrob Chemother 1990;26:727-728.

Humphrey B, Sanders G, Marviak J. Flavobacterium odoratum sepsis in neonate treated with ciprofloxacin. Arch Dis Child 1989;64:1119-1120.

Leelarasamee A, Janyapoon K. Antimicrobial resistance of 100 serial Gram-negative isolates in two intensive care units.

J Med Assoc Thai 1992;75:680-687.

Karki BM, Parija SC. Analysis of blood culture isolates from hospitalized neonates in Nepal. Southeast Asian J Trop Med Public Health 1999;30:546-548.

Rahman S, Hameed A, Roghani MT, Ullah Z. Multidrug resistant neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal Ed 2002;87:F52-54.

Mishra A, Mishra S, Jaganath G, Mittal RK, Gupta PK, Patra DP. Acinetobacter sepsis in newborns. Indian Pediatr 1998;35:27-32.

Lumbiganon P, Pengsaa K, Sookpranee T. Ciprofloxacin in neonates and its possible adverse effect on the teeth. Pediatr Infect Dis J 1991;10:619-620.

Wlazlowski J, Krzyzanska-Oberbek A, Sikora JP, ChlebnaSokol D. Use of the quinolones in treatment of severe bacterial infections in premature infants. Acta Pol Pharm 2000;57 (Suppl):S28-S31. van den Oever HL, Versteegh FG, Thewessen EA, van den Anker JN, Mouton JW, Neijens HJ. Ciprofloxacin in preterm neonates: case report and review of the literature. Eur J Pediatr 1998;157:843-845.

Khaneja M, Naprawa J, Kumar A, Piecuch S. Successful treatment of late-onset infection due to resistant Klebsiella pneumoniae in an extremely low birth weight infant using ciprofloxacin. J Perinatol 1999;19:311-314.

Gurpinar AN, Balkan E, Kilic N, Kiristioglu I, Dogruyol H. The effects of a fluoroquinolone on the growth and development of infants. J Int Med Res 1997;25:302-306.

347

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25. Chotigeat U, Khorana M, Waranawat N. Successful treatment of late onset infection due to multi-drug resistant Acinetobacter Lwoffii in a low birth weight neonate using ciprofloxacin. J Med Assoc Thai 2001;84:910-913.

26. Beloborodova NV, Birggarkov AV, Kurchavov VA. Clinical and bacteriological experience with ciprofloxacin in neonates. 5th International Symposium on New Quinolones. Singapore, 2830/8/1994. E. Rubinstein (editor). Abstract No 129.

27. Aujard Y. Quinolones in neonates. Advan Antimicrob Antineopl Chemother 1992;11:133-140.

28. Pillay T, Pillay DG, Adhikari M, Pillay A, Sturm AW. An outbreak of neonatal infection with Acinetobacter linked to contaminated suction catheters. J Hosp Infect 1999;43:299-304.

29. van Ogtrop ML, van Zoeren-Grobben D, Verbakel-Salomons EM, van Boven CP. Serratia marcescens infections in neonatal departments: description of an outbreak and review of the literature. J Hosp Infect 1997;36:95-103.

30. Green SD, Ilunga F, Cheesbrough JS, Tillotson GS, Hichens M, Felmingham D. The treatment of neonatal meningitis due to Gram-negative bacilli with ciprofloxacin: evidence of satisfactory penetration into the cerebrospinal fluid. J Infect 1993;26:253-256.

348

Paediatriki 2004;67:343-348

31. Krcmery V Jr, Filka J, Uher J, Kurak H, Sagat T, Tuharsky J et al. Ciprofloxacin in treatment of nosocomial meningitis in neonates and in infants: report of 12 cases and review. Diagn Microbiol Infect Dis 1999;35:75-80.

32. Gilbert DN, Moellering RC, Sande MA. Cerebrospinal fluid concentrations of antimicrobials. The Sanford Guide to Antimicrobial Therapy. 28th ed. Antimicrobial Therapy Inc.: Vienna, VA; 1998. p. 58-59.

33. Drossou-Agakidou V, Roilides E, Papakyriakidou-Koliouska P, Agakidis C, Nikolaides N, Sarafidis K et al. Use of ciprofloxacin in neonatal sepsis: lack of adverse effects up to one year. Pediatr Infect Dis J 2004;23:346-349.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-12-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-06-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ·ÛÈÏÈ΋ ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E-mail: agaki@med.auth.gr

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ORIGINAL ARTICLE

¶·Ú·ÎÔÏÔ‡ıËÛË ÚˆÙÔ·ıÔ‡˜ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û 182 ·È‰È¿: ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ¤Î‚·ÛË º. ¶··¯Ú‹ÛÙÔ˘1, ¡. ¶Ú›ÓÙ˙·1, ¡. ∫·Ú·Ù˙¿˜2

Follow-up of primary vesicoureteral reflux in 182 children: characteristics and outcome F. Papachristou1, N. Printza1, N. Karatzas2

¶ÂÚ›ÏË„Ë: ∏ ·ÚÔ‡Û· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ¤¯ÂÈ ÛÎÔfi Ó· ÌÂÏÂÙ‹ÛÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË, ÙȘ ÂÈÏÔΤ˜ Î·È ÙËÓ ¤Î‚·ÛË Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (∫O¶) ÛÙ· ·È‰È¿. ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο ÔÈ È·ÙÚÈÎÔ› Ê¿ÎÂÏÔÈ 182 ·È‰ÈÒÓ Ì ∫O¶. ∏ ̤ÛË ËÏÈΛ· ‰È¿ÁÓˆÛ˘ Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ‹Ù·Ó 23,2 Ì‹Ó˜ (‡ÚÔ˜: 10 Ë̤Ú˜ ¤ˆ˜ 120 Ì‹Ó˜). ∏ ‰È¿ÁÓˆÛË Ù˘ ∫O¶ ÛÙËÚ›¯ıËΠÛÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ΢ÛÙÂÔÁÚ·Ê›· Û ‰‡Ô Ê¿ÛÂȘ. ™Â fiÏ· Ù· ·È‰È¿, ηٿ ÙË ‰È¿ÁÓˆÛË, ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì 99m-Tc DMSA. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÂÚÈÂÏ¿Ì‚·Ó ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ, Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ΢ÛÙÂÔÁÚ·Ê›·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Î·È ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì DMSA. ∏ ̤ÛË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó 33,4 Ì‹Ó˜ (‡ÚÔ˜: 12-120 Ì‹Ó˜). ∏ ·ÏÈÓ‰ÚfiÌËÛË ‰È·ÁÓÒÛÙËΠӈڛÙÂÚ· ÛÙ· ·ÁfiÚÈ· (̤ÛË ËÏÈΛ·: 9,9 Ì‹Ó˜) Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (̤ÛË ËÏÈΛ·: 33,3 Ì‹Ó˜). ™Â 118 ·È‰È¿ Ë ·ÏÈÓ‰ÚfiÌËÛË ˘Ô¯ÒÚËÛÂ Û˘ÓÙËÚËÙÈο, Û 53 ¤ÁÈÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ‹ ÂÓ‰ÔÛÎÔÈ΋ ‰ÈfiÚıˆÛË Î·È Û 11 Û˘Ó¯›˙ÂÙ·È Ë ·Ú·ÎÔÏÔ‡ıËÛË. ÀÔ¯ÒÚËÛË Û˘ÓÙËÚËÙÈο ÌÂÙ¿ ·fi ¯ËÌÂÈÔÚÔʇϷÍË ·Ú·ÙËÚ‹ıËΠ΢ڛˆ˜ ÛÙ· ÌÈÎÚ¿ ·È‰È¿ (p<0,001), Ì ÈÛÙÔÚÈÎfi ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ Ô˘ÚÔÏÔÈÌÒ͈Ó, ¯ˆÚ›˜ Ô˘Ï¤˜ Î·È Ì ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÙÂÚfiÏ¢ÚË ·ÏÈÓ‰ÚfiÌËÛË Î·Ù¿ ÙË ‰È¿ÁÓˆÛË (p<0,001, p<0,0001, p<0,0001 Î·È p<0,005, ·ÓÙ›ÛÙÔȯ·). ÀÔÙÚÔÈ¿˙Ô˘Û˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Â›¯·Ó 69 ·È‰È¿, ÛÙÔÈ¯Â›Ô Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ˘Ô¯ÒÚËÛ˘ (p<0,001). §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Î‚·ÛË Ù˘

Abstract: A retrospective study was made of the presentation, evaluation, management, complications and outcome of children with vesicoureteral reflux (VUR). The medical records of 182 children were reviewed. The mean age at entry was 23.2 months (range: 10 days to 120 months). Diagnosis was established by radiographic voiding cystourethrogram. All children at entry were routinely investigated by renal ultrasound and dimercaptosuccinic acid renal scan (DMSA). The follow-up included blood pressure measurements, serial urine cultures, haematological and biochemical tests, DMSA scan, renal ultrasound and nuclear cystography. The mean follow-up period was 33.4 months (range: 12-60 months). VUR was diagnosed earlier in boys (mean age: 9.9 months), than in girls (mean age: 33.3 months). In 118 children VUR resolved spontaneously with chemoprophylaxis, 53 underwent surgical or endoscopic corrections and in 11 monitoring was continued. Spontaneous resolution after prophylaxis was better achieved in younger patients (p<0.001), and in those with minimal recurrent urinary tract infections, with no scarring and with low grade and unilateral VUR at diagnosis (p<0.001, p<0.0001, p<0.0001 and p<0.005, respectively). Breakthrough infections were observed in 69 children, and were related to lower resolution rates (p<0.001). In view of the factors which influence spontaneous resolution of VUR, early screening is suggested as it may prevent scarring and future reflux nephropathy.

1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË 2 ∆Ì‹Ì· ¶˘ÚËÓÈ΋˜ π·ÙÚÈ΋˜ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢

1 1st Paediatric Department, Aristotle University, Hippokration General Hospital, Thessaloniki 2 Department of Nuclear Medicine, Aristotle University, Thessaloniki

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¶·È‰È·ÙÚÈ΋ 2004;67:349-354

Paediatriki 2004;67:349-354

∫O¶, ÚÔÙ›ÓÂÙ·È Ë Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÚÒÈÌË ‰È¿ÁÓˆÛ‹ Ù˘, Ë ÔÔ›· ÌÔÚ› Ó· ÚÔÏ¿‚ÂÈ ÙË ‰ËÌÈÔ˘ÚÁ›· Ô˘ÏÒÓ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. §¤ÍÂȘ ÎÏÂȉȿ: ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·È‰È¿, Ô˘ÚÔÏÔÈÌÒÍÂȘ.

Key words: vesicoureteral reflux, children, urinary tract infections.

™˘ÓÙÔÌÔÁڷʛ˜

ÛÎÔfi ÙËÓ ·Ó‡ÚÂÛË Èı·ÓÒÓ ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ÛÈÓıËÚÔÁÚ¿ÊËÌ· DMSA. ∆· ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ¤ÁÈÓ·Ó Ì ˘ÂÚ˯ÔÙÔÌÔÁÚ¿ÊÔ Philips Ù‡Ô˘ ƒ700, Ì ÎÂʷϤ˜ 7.5 Î·È 5 ª∏∑ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. °È· ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì 99m-Tc DMSA (DMSA), ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ∆Ì‹Ì· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Á-οÌÂÚ· Ì ÌÔÓ‹ ÎÂÊ·Ï‹ Ù‡Ô˘ Toshiba GCA602A/SA. ¶·ıÔÏÔÁÈ΋ ıˆڋıËÎÂ Ë ÂͤٷÛË fiÔ˘ ‚Ú¤ıËΠÂÏ¿ÙÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÓfi˜ ÓÂÊÚÔ‡ (ÔÛÔÛÙÈ·›· Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÓfi˜ ÓÂÊÚÔ‡ <45%), ‡·ÚÍË Ì›·˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÚÈÔ¯ÒÓ ˘ÔÚfiÛÏ˄˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È ·ÚÔ˘Û›· ÌÈÎÚÒÓ ‹ ·Ú·ÌÔÚÊˆÌ¤ÓˆÓ ÓÂÊÚÒÓ (6). ¶ÂÚÈÔ¯‹ ÂÏ·Ùو̤Ó˘ ÚfiÛÏ˄˘ Ô˘ Â¤ÌÂÓÂ Î·È ÌÂÙ¿ ·fi ¤ÍÈ Ì‹Ó˜ ·fi ÙÔ ÂÂÈÛfi‰ÈÔ OÀƒ§, Ì ϤÙ˘ÓÛË ÙÔ˘ ÊÏÔÈÔ‡, ıˆڋıËÎÂ Ô˘Ï‹. ™Â fiÏ· Ù· ·È‰È¿ Ì ‰È¿ÁÓˆÛË ∫O¶ ÁÈÓfiÙ·Ó Î·Ù·ÁÚ·Ê‹ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Î·È ÁÂÓÈ΋ ÂͤٷÛË Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ. ª¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÁÈÓfiÙ·Ó ÙÚÂȘ ‰È·‰Ô¯ÈΤ˜ ÊÔÚ¤˜ Ì ˘‰Ú·ÚÁ˘ÚÈÎfi Ì·ÓfiÌÂÙÚÔ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ Î·È Ì ËÏÂÎÙÚÔÓÈÎfi ÈÂÛfiÌÂÙÚÔ (Ù·Ï·ÓÙˆÛÈÌÂÙÚÈ΋ ̤ıÔ‰Ô˜) ÛÙ· ˘fiÏÔÈ·. ∏ ÌÈÎÚfiÙÂÚË ÙÈÌ‹ ·fi ÙȘ ÙÚÂȘ ÌÂÙÚ‹ÛÂȘ Û˘ÁÎÚÈÓfiÙ·Ó Ì ٷ ÈÛ¯‡ÔÓÙ· ‰ÈÂıÓÒ˜ ÓÔÚÌÔÁÚ¿ÌÌ·Ù· (7,8). ∏ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÎÙÈÌ‹ıËΠۇÌʈӷ Ì ÙÔÓ Ù‡Ô ÙˆÓ Schwartz Î·È Û˘Ó (9). ŸÏ· Ù· ·È‰È¿ Ù¤ıËÎ·Ó ˘fi ¯ËÌÂÈÔÚÔʇϷÍË Ì ÎÔÙÚÈÌÔÍ·˙fiÏË ‹ ·ÌÔ͢ÎÈÏÏ›ÓË ‹ ÎÂÊ·ÏÔÛÔÚ›ÓË Û ̛· ‰fiÛË ÙÔ ‚Ú¿‰˘, ›ÛË Ì ÙÔ ¤Ó· ÙÚ›ÙÔ Ù˘ Û˘Ó‹ıÔ˘˜ ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘. ∏ ̤ÛË ‰È¿ÚÎÂÈ· ¯ËÌÂÈÔÚÔʇϷ͢ ‹Ù·Ó 27,3 Ì‹Ó˜. ¢Â›ÁÌ·Ù· Ô‡ÚˆÓ Ï·Ì‚¿ÓÔÓÙ·Ó ÁÈ· ηÏÏȤÚÁÂÈ· Ì›· ÊÔÚ¿ ÙÔÓ Ì‹Ó·, ηıÒ˜ Î·È Û ÂÚÈÙÒÛÂȘ ˘ÚÂÙÔ‡ ‹ ¿ÏÏ˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ‡ÔÙ˘ ÁÈ· OÀƒ§. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÂÚÈÂÏ¿Ì‚·ÓÂ, Â›Û˘, ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ‚ÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ·›Ì·ÙÔ˜, Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ΢ÛÙÂÔÁÚ·Ê›· (ƒπ∫) Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Î¿ı ¯ÚfiÓÔ. O ¯ÚfiÓÔ˜ Â·Ó¿Ï˄˘ ÙÔ˘ DMSA ÂÍ·ÙÔÌÈ΢fiÙ·Ó. ∫ÚÈÙ‹ÚÈÔ ·Ô‰ÚÔÌ‹˜ Ù˘ ∫O¶ ıˆڋıËÎ·Ó ‰‡Ô ‰È·‰Ô¯ÈΤ˜ Ê˘ÛÈÔÏÔÁÈΤ˜ ƒπ∫ Ì ÌÂÛԉȿÛÙËÌ· ¤ÍÈ ÌËÓÒÓ. ø˜ ¯ÚfiÓÔ˜ ›·Û˘ ıˆڋıËΠ·˘Ùfi˜ Ù˘ ÚÒÙ˘ ƒπ∫. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÚfiÁÚ·ÌÌ· SPSS 10.1. ∏ ̤ıÔ‰Ô˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ‹Ù·Ó ÙÔ ¯2 test ÁÈ· ÙË Û‡ÁÎÚÈÛË ÔÛÔÛÙÒÓ. ™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ıˆڋıËΠÙÈÌ‹ p≤0,005.

OÀƒ§ ∫O¶ ƒπ∫ DMSA

O˘ÚÔÏԛ̈ÍË ∫˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ƒ·‰ÈÔ˚ÛÔÙÔÈ΋ ΢ÛÙÂÔÁÚ·Ê›· ™Ù·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì 99m-Tc DMSA

∂ÈÛ·ÁˆÁ‹ ∏ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (∫O¶), ÌÂ Û˘¯ÓfiÙËÙ· ÂÚ›Ô˘ 1% ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È 30-50% ÛÙ· ‚Ú¤ÊË Î·È Ù· ·È‰È¿ Ô˘ ‰ÈÂÚ¢ÓÒÓÙ·È ÌÂÙ¿ ·fi ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ (OÀƒ§), ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ¤Ó· Ôχ ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi (1). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ 30% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ ‹‰Ë Ô˘Ï¤˜ ηٿ ÙË ‰È¿ÁÓˆÛË (2). ∏ ‡·ÚÍË ÌÂÁ¿ÏˆÓ Ô˘ÏÒÓ Û˘Ó‰¤ÂÙ·È Ì ÂÏ¿ÙÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ˘¤ÚÙ·ÛË, ÂÏ¿ÙÙˆÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË (3,4). ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ı· ·ÔʇÁÔ˘Ó ·˘Ù¤˜ ÙȘ Û˘Ó¤ÂȘ, ÂÊfiÛÔÓ ·Ú·Ì›ÓÔ˘Ó ¯ˆÚ›˜ ÂÂÈÛfi‰È· ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ∏ ·ÚÔ‡Û· ·Ó·‰ÚÔÌÈ΋ ÎÏÈÓÈ΋ ÌÂϤÙË ¤¯ÂÈ ÛÎÔfi Ó· ÌÂÏÂÙ‹ÛÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË, ÙȘ ÂÈÏÔΤ˜ Î·È ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¤·Û·Ó ÙËÓ ¤Î‚·ÛË Ù˘ ∫O¶ Û 182 ·È‰È¿ Ô˘ ¤Ï·‚·Ó Ì·ÎÚÔ¯ÚfiÓÈ· ¯ËÌÂÈÔÚÔʇϷÍË Î·È/‹ ¯ÂÈÚÔ˘ÚÁ‹ıËÎ·Ó Û ÂÚ›Ô‰Ô 1-5 ÂÙÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο ÔÈ È·ÙÚÈÎÔ› Ê¿ÎÂÏÔÈ 182 ·È‰ÈÒÓ, 78 ·ÁÔÚÈÒÓ Î·È 104 ÎÔÚÈÙÛÈÒÓ, Ì ‰È¿ÁÓˆÛË ∫O¶ ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 1995 ¤ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ ÙÔ˘ 2001. ∏ ·Ó·ÁÓÒÚÈÛË Î·È Ù·ÍÈÓfiÌËÛË Ù˘ ∫O¶ Û ‚·ıÌÔ‡˜ ÛÙËÚ›¯ıËΠÛÙ· Â˘Ú‹Ì·Ù· Ù˘ ·ÓÈÔ‡Û·˜ ·ÎÙÈÓÔÁÚ·ÊÈ΋˜ ΢ÛÙÂÔÁÚ·Ê›·˜. ∏ ÂͤٷÛË ¤ÁÈÓ Û ‰‡Ô Ê¿ÛÂȘ, ÙfiÛÔ Î·Ù¿ ÙËÓ Ï‹ÚˆÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ fiÛÔ Î·È Î·Ù¿ ÙËÓ Ô‡ÚËÛË. ∏ ∫O¶ Ù·ÍÈÓÔÌ‹ıËΠ۠‚·ıÌÔ‡˜ ·fi I ¤ˆ˜ V Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ÎÚÈÙ‹ÚÈ· (5). ™Â ÂÚ›ÙˆÛË OÀƒ§, ÌÂÛÔÏ·‚Ô‡Û ‰È¿ÛÙËÌ· ÂÚ›Ô˘ 4 ‚‰ÔÌ¿‰ˆÓ ÌÂٷ͇ Ù˘ Ïԛ̈͢ Î·È Ù˘ ÂͤٷÛ˘. ¶·È‰È¿ Ì ∫O¶ ‚·ıÌÔ‡ V ·ÔÎÏ›ÛÙËÎ·Ó ·fi ÙË ÌÂϤÙË. ªÂ ÙË ‰È¿ÁÓˆÛË Ù˘ ∫O¶, Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·Ó Û fiÏ· Ù· ·È‰È¿ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ÌÂ

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¶·È‰È·ÙÚÈ΋ 2004;67:349-354

∞ÔÙÂϤÛÌ·Ù· ªÂÏÂÙ‹ıËÎ·Ó ÔÈ È·ÙÚÈÎÔ› Ê¿ÎÂÏÔÈ 182 ·È‰ÈÒÓ, 78 ·ÁÔÚÈÒÓ Î·È 104 ÎÔÚÈÙÛÈÒÓ, Ì 283 Û˘ÓÔÏÈο ·ÏÈÓ‰ÚÔÌÔ‡ÓÙ˜ Ô˘ÚËÙ‹Ú˜. ∏ ̤ÛË ËÏÈΛ· ‰È¿ÁÓˆÛ˘ Ù˘ ∫O¶ ‹Ù·Ó 23,2 Ì‹Ó˜ (‡ÚÔ˜: 10 Ë̤Ú˜ ¤ˆ˜ 120 Ì‹Ó˜). ∏ ‰È¿ÁÓˆÛË ¤ÁÈÓ ӈڛÙÂÚ· ÛÙ· ·ÁfiÚÈ· (̤ÛË ËÏÈΛ·: 9,9 Ì‹Ó˜) Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (̤ÛË ËÏÈΛ·: 33,3 Ì‹Ó˜). ∞fi Ù· 104 ·È‰È¿ ËÏÈΛ·˜ ≤1 ¤ÙÔ˘˜ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ∫O¶, Ù· 71 (68%) ‹Ù·Ó ·ÁfiÚÈ· Î·È ·fi Ù· 19 ·È‰È¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ Ù· 16 (84%) ‹Ù·Ó ÎÔÚ›ÙÛÈ·. ∞fi ÙÔ˘˜ 283 ·ÏÈÓ‰ÚÔÌÔ‡ÓÙ˜ Ô˘ÚËÙ‹Ú˜, ÔÈ 9, 126, 122 Î·È 26 ›¯·Ó I, Iπ, III Î·È IV ‚·ıÌÔ‡ ·ÏÈÓ‰ÚfiÌËÛË, ·ÓÙ›ÛÙÔȯ·. ¢ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ·Ó¿ ‚·ıÌfi ·ÏÈÓ‰ÚfiÌËÛ˘ ·Ó¿ÌÂÛ· ÛÙ· ·ÁfiÚÈ· Î·È Ù· ÎÔÚ›ÙÛÈ·. ∫·Ù¿ ÙË ‰È¿ÁÓˆÛË, Ë ∫O¶ ‹Ù·Ó ·ÌÊÔÙÂÚfiÏ¢ÚË Û 101 (55,5%) Î·È ÂÙÂÚfiÏ¢ÚË Û 81 (44,5%) ·È‰È¿. ™Â 178/182 (98%) ·È‰È¿, Ë ‰È¿ÁÓˆÛË Ù˘ ∫O¶ ¤ÁÈÓ ηٿ ÙË ‰ÈÂÚ‡ÓËÛË, ÏfiÁˆ ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÂÈÛÔ‰›ˆÓ Ô˘ÚÔÏԛ̈͢. ∆· Û˘ÓËı¤ÛÙÂÚ· Û˘ÌÙÒÌ·Ù· Ì ٷ ÔÔ›· ÚÔÛ‹Ïı·Ó Ù· ·È‰È¿ ·˘Ù¿ ‹Ù·Ó ˘ÚÂÙfi˜ (78%), ·ÓÔÚÂÍ›· (35%), ‰˘ÛÔ˘Ú›· (19%), ·ÓËÛ˘¯›· (15%), ¤ÌÂÙÔÈ (5%) Î·È ‰È¿ÚÚÔÈ· (5%). ™Â ‰‡Ô ·È‰È¿ Ë ·ÏÈÓ‰ÚfiÌËÛË ·ÔηχÊıËΠηٿ ÙË ‰ÈÂÚ‡ÓËÛË ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Î·È Û ¿ÏÏ· ‰‡Ô ηٿ ÙÔÓ ¤ÏÂÁ¯fi ÙÔ˘˜ ÏfiÁˆ ‡·Ú͢ ·‰ÂÏÊÔ‡ Ì ÈÛÙÔÚÈÎfi ∫O¶. £ÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÁÈ· ·ÏÈÓ‰ÚfiÌËÛË Â›¯·Ó 21 (11,5%) ·È‰È¿. ™Â 118 ·È‰È¿ (65%) Ë ·ÏÈÓ‰ÚfiÌËÛË ˘Ô¯ÒÚËÛÂ Û˘ÓÙËÚËÙÈο, Û 49 (27%) ¤ÁÈÓ Â·ÓÂÌʇÙ¢ÛË ÙÔ˘ Ô˘ÚËÙ‹Ú·, Û 4 (2%) Ú·ÁÌ·ÙÔÔÈ‹ıËΠÂÓ‰ÔÛÎÔÈ΋ ‰ÈfiÚıˆÛË, ÂÓÒ 11 (6%) ·È‰È¿ ‚Ú›ÛÎÔÓÙ·È ·ÎfiÌ· Û ·Ú·ÎÔÏÔ‡ıËÛË. ∞fi Ù· 49 ·È‰È¿ Ô˘ ¯ÂÈÚÔ˘ÚÁ‹ıËηÓ, 6 ·ÚÔ˘Û›·˙·Ó ‰ÈÏfi ˘ÂÏÔÎ·Ï˘ÎÈÎfi Û‡ÛÙËÌ· Ì ‰ÈÏ·ÛÈ·ÛÌfi ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ Î·È 1 ÂÙ·ÏÔÂȉ‹ ÓÂÊÚfi. OÈ Î‡ÚȘ ÂӉ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ‹Ù·Ó Ë ·Ó·Î¿Ï˘„Ë Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ Û ËÏÈΛ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 5 ÂÙÒÓ, Ë ·Ú·ÌÔÓ‹ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÏÈÓ‰ÚfiÌËÛ˘ ÌÂÙ¿ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ¯ËÌÂÈÔÚÔʇϷÍË (ÂÚÈÛÛfiÙÂÚÔ ·fi 5 ¯ÚfiÓÈ·), ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ fiˆ˜ ‰ÈÏ·ÛÈ·ÛÌÔ›, ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· OÀƒ§ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ËÌÂÈÔÚÔʇϷ͢, ÂÌÊ¿ÓÈÛË Ó¤ˆÓ Ô˘ÏÒÓ Î·È Ë ÂÏÏÈ‹˜ Û˘ÌÌfiÚʈÛË ÛÙȘ È·ÙÚÈΤ˜ Ô‰ËÁ›Â˜ Î·È ÛÙÔ ÚˆÙfiÎÔÏÏÔ ·Ú·ÎÔÏÔ‡ıËÛ˘. ªÂÚÈο ·È‰È¿ ÏËÚÔ‡Û·Ó Ù· ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·. ∂·ÓÂÁ¯Â›ÚËÛË ¤ÁÈÓÂ Î·È ÛÙ· ‰‡Ô ·È‰È¿ Ì ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·fiÊÚ·ÍË. ∞fi Ù· 11 ·È‰È¿ ÛÙ· ÔÔ›· Ë ·Ú·ÎÔÏÔ‡ıËÛË Û˘Ó¯È˙fiÙ·Ó, Ù· ‰‡Ô ‹Ù·Ó ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 5 ÂÙÒÓ, Ì ÂÙÂÚfiÏ¢ÚË ·ÏÈÓ‰ÚfiÌËÛË πππ ‚·ıÌÔ‡ Î·È Ô˘Ï¤˜

Paediatriki 2004;67:349-354

ηٿ ÙË ‰È¿ÁÓˆÛË, ηıÒ˜ Î·È ˘ÔÙÚÔ¤˜ OÀƒ§ ·Ú¿ ÙË ¯ÔÚ‹ÁËÛË ¯ËÌÂÈÔÚÔʇϷ͢. ∏ ·ÏÈÓ‰ÚfiÌËÛË ·Ú¤ÌÂÓ ÛÙ·ıÂÚ‹ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÔÈ ÁÔÓ›˜ ·ÚÓ‹ıËÎ·Ó ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË. ∞fi Ù· ˘fiÏÔÈ· 9 ·È‰È¿, Ù· 6 Â›Û˘ ÏËÚÔ‡Û·Ó ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÎÚÈÙ‹ÚÈ· ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘, ÁÂÁÔÓfi˜ Ô˘ ·ÚÓ‹ıËÎ·Ó ÔÈ ÁÔÓ›˜, ÂÓÒ Ù· ˘fiÏÔÈ· ÙÚ›· ›¯·Ó ‚ÂÏÙ›ˆÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘. ∫·Ù¿ ÙË ‰È¿ÁÓˆÛË, 68 (37%) ·È‰È¿ ›¯·Ó ·ıÔÏÔÁÈÎfi DMSA. ∞fi ·˘Ù¿, 48 (26%) ·ÚÔ˘Û›·˙·Ó ÂÈÎfiÓ· Ô˘Ï‹˜, ÂÓÒ Ù· ˘fiÏÔÈ· ·ıÔÏÔÁÈο ÛÈÓıËÚÔÁÚ·Ê‹Ì·Ù· ·ÊÔÚÔ‡Û·Ó Û ÂÈÎfiÓ˜ ÌÈÎÚÒÓ ‰˘ÛÏ·ÛÙÈÎÒÓ ÓÂÊÚÒÓ Î·È ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ¶·ıÔÏÔÁÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ›¯·Ó 44 (24%) ·È‰È¿. ™Â ÔÛÔÛÙfi 73%, Ë ˘Ô¯ÒÚËÛË Ù˘ ∫O¶ Û˘Ó¤‚Ë Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ‚Ú¤ıËΠӷ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË ‹Ù·Ó Ë ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ, Ô ‚·ıÌfi˜ Î·È Ë ÂÓÙfiÈÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘, ÙÔ ÈÛÙÔÚÈÎfi OÀƒ§ Î·È Ë ‡·ÚÍË Ô˘ÏÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ηıÒ˜ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ OÀƒ§ ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ËÌÂÈÔÚÔʇϷ͢. ™˘Û¯¤ÙÈÛË Ù˘ ËÏÈΛ·˜ ηٿ ÙË ‰È¿ÁÓˆÛË Ì ÙËÓ ˘Ô¯ÒÚËÛË Ù˘ ∫O¶ (¶›Ó·Î·˜ 1) ∏ ˘Ô¯ÒÚËÛË Ù˘ ∫O¶ Ê¿ÓËΠfiÙÈ Û¯ÂÙ›˙ÂÙ·È ·ÓÙÈÛÙÚfiʈ˜ Ì ÙËÓ ËÏÈΛ· ‰È¿ÁÓˆÛ˘. ŒÙÛÈ, ÔÈ ÌÈÎÚÔ› Û ËÏÈΛ· ·ÛıÂÓ›˜ ›¯·Ó ηχÙÂÚË ÚfiÁÓˆÛË (p<0,001). ™˘ÁÎÂÎÚÈ̤ӷ, Ù· ÔÛÔÛÙ¿ ˘Ô¯ÒÚËÛ˘, ·ÓÂÍ·Úًو˜ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ∫O¶, ‹Ù·Ó 84%, 64% Î·È 29% ÁÈ· ·È‰È¿ ËÏÈΛ·˜ ≤12 ÌËÓÒÓ, 13-36 ÌËÓÒÓ Î·È >36 ÌËÓÒÓ, ·ÓÙ›ÛÙÔȯ·. ™˘Û¯¤ÙÈÛË ÙÔ˘ ‚·ıÌÔ‡ Î·È Ù˘ ÂÓÙfiÈÛ˘ Ù˘ ∫O¶ ηٿ ÙË ‰È¿ÁÓˆÛË Ì ÙËÓ ˘Ô¯ÒÚËÛ‹ Ù˘ (¶›Ó·Î·˜ 1) O ÌÈÎÚfi˜ ·Ú¯ÈÎfi˜ ‚·ıÌfi˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û¯ÂÙ›˙ÂÙ·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ì ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ˘Ô¯ÒÚËÛ˘ Ù˘ ∫O¶ (p<0,0001). ∏ ∫O¶ ˘Ô¯ÒÚËÛ Û ÔÛÔÛÙ¿ 100%, 92%, 60% Î·È 35% Û ԢÚËÙ‹Ú˜ Ì I, II, III Î·È IV ‚·ıÌfi, ·ÓÙ›ÛÙÔȯ· (p<0,0001). ∂ÈϤÔÓ, Ë ÂÙÂÚfiÏ¢ÚË ∫O¶ ›¯Â ηχÙÂÚË ÚfiÁÓˆÛË (p<0,005). ™˘ÁÎÂÎÚÈ̤ӷ, Ë ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÏÈÓ‰ÚfiÌËÛË ·ÓÂÍ·Úًو˜ ‚·ıÌÔ‡ ˘Ô¯ÒÚËÛ Û ÔÛÔÛÙfi 61% ÙˆÓ ·È‰ÈÒÓ, ÂÓÒ Ë ÂÙÂÚfiÏ¢ÚË ·ÚÈÛÙÂÚ¿ Î·È ‰ÂÍÈ¿ ˘Ô¯ÒÚËÛ Û ÔÛÔÛÙfi 78% Î·È 79%, ·ÓÙ›ÛÙÔȯ·. ¶·ÚÔ˘Û›· Ô˘ÏÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ¤Î‚·ÛË Ù˘ ∫O¶ (¶›Ó·Î·˜ 1) O˘Ï¤˜ ηٿ ÙË ‰È¿ÁÓˆÛË Â›¯·Ó 48 (26%) ·È‰È¿. ∆Ô ÔÛÔÛÙfi ÙˆÓ Ô˘ÏÒÓ ‹Ù·Ó 12% ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ˘Ô¯ÒÚËÛË Ù˘ ∫O¶ Û˘ÓÙËÚËÙÈο Î·È 53% Û ÂΛӷ Ì ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË. ∂ÈϤÔÓ, Ë ·ÚÔ˘Û›· Ô˘ÏÒÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ OÀƒ§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ‹Ù·Ó 38% ÛÙ·

351

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·352

¶·È‰È·ÙÚÈ΋ 2004;67:349-354

Paediatriki 2004;67:349-354

·È‰È¿ Ì ÂÚÈÛÛfiÙÂÚ· ·fi ÙÚ›· ÂÂÈÛfi‰È·. ∏ ·ÏÈÓ‰ÚfiÌËÛË ˘Ô¯ÒÚËÛÂ Û˘ÓÙËÚËÙÈο ÛÙÔ 80% ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ Ô˘Ï¤˜, ÛÙÔ 44% ÂÎÂ›ÓˆÓ Ì ÂÙÂÚfiÏ¢ÚË ÂÓÙfiÈÛË ÙˆÓ Ô˘ÏÒÓ Î·È ÌfiÓÔ ÛÙÔ 17% ·˘ÙÒÓ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË (p<0,0001). ∫·Ó¤Ó· ·È‰› ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ ˘fi ¯ËÌÂÈÔÚÔʇϷÍË ‰ÂÓ ÂÌÊ¿ÓÈÛ ηÈÓÔ‡ÚÁȘ Ô˘Ï¤˜. ∞fi Ù· 104 ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 12 ÌËÓÒÓ, Ô˘Ï¤˜ ·ÚÔ˘Û›·˙·Ó Ù· 22 (21%). πÛÙÔÚÈÎfi OÀƒ§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ˘Ô¯ÒÚËÛË Ù˘ ∫O¶ (¶›Ó·Î·˜ 2) ∆· 182 ·È‰È¿ ›¯·Ó, ηٿ ÙË ‰È¿ÁÓˆÛË, ÈÛÙÔÚÈÎfi 321 Û˘ÓÔÏÈο OÀƒ§. ™Ù· 115 (63%) Ë ∫O¶ ‰È·ÁÓÒÛÙËΠÌÂÙ¿ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢. ∂Í·ÈÚÒÓÙ·˜ Ù· 4 ·È‰È¿ ¯ˆÚ›˜ OÀƒ§ ηٿ ÙË ‰È¿ÁÓˆÛË, Ù· ˘fiÏÔÈ· 63 (35%) ‰È·ÁÓÒÛÙËÎ·Ó ÌÂÙ¿ ÙÔ ‰Â‡ÙÂÚÔ ‹ ·ÎfiÌ· Î·È ÌÂÙ¿ ÙÔ ¤ÎÙÔ ÂÂÈÛfi‰ÈÔ OÀƒ§. ∆· Û˘¯ÓfiÙÂÚ· ÌÈÎÚfi‚È· ‹Ù·Ó E. coli (94%)

Î·È Proteus (5%). O ·ÚÈıÌfi˜ ÙˆÓ OÀƒ§ ηٿ ÙË ‰È¿ÁÓˆÛË Û¯ÂÙÈ˙fiÙ·Ó Ì ÙËÓ ¤Î‚·ÛË, Ì ηχÙÂÚÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÙË ÌË ‡·ÚÍË ‹ ÙÔ ¤Ó· ÌfiÓÔ ÂÂÈÛfi‰ÈÔ OÀƒ§ (p<0,001). ÀÔÙÚÔ¤˜ OÀƒ§ ηٿ ÙË ¯ËÌÂÈÔÚÔʇϷÍË Î·È ¤Î‚·ÛË Ù˘ ∫O¶ (¶›Ó·Î·˜ 2) ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, 69 (38%) ·È‰È¿ ·ÚÔ˘Û›·Û·Ó ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· OÀƒ§. ∂ȉÈÎfiÙÂÚ·, ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ì ∫O¶ IV ‚·ıÌÔ‡, ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘ÔÙÚÔÒÓ ‹Ù·Ó 70%. ∆· ·È‰È¿ Ì ·Ú·È¤˜ ‹ ηıfiÏÔ˘ ˘ÔÙÚÔ¤˜ ›¯·Ó ηχÙÂÚË ÚfiÁÓˆÛË Î·È ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ˘Ô¯ÒÚËÛ˘ Ù˘ ∫O¶ (p<0,001). ∫·Ó¤Ó· ·È‰› ‰ÂÓ ·ÚÔ˘Û›·Û ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÚˆÙÂ˚ÓÔ˘Ú›·, ÂËÚ·Ṳ̂ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ˘¤ÚÙ·ÛË. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· Ï‹„Ë ¯ËÌÂÈÔÚÔʇϷ͢ ¤ÁÈÓ ηϿ ·ÓÂÎÙ‹ ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ.

¶›Ó·Î·˜ 1. ∏ÏÈΛ·, ‚·ıÌfi˜, ÂÓÙfiÈÛË Î·È ‡·ÚÍË Ô˘ÏÒÓ: ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Ô¯ÒÚËÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· 11 ·È‰È¿ Û ·Ú·ÎÔÏÔ‡ıËÛË)

∏ÏÈΛ·

µ·ıÌfi˜ ·Ó¿ Ô˘ÚËÙ‹Ú·

∂ÓÙfiÈÛË

O˘Ï¤˜

1 Ì‹Ó· ¤ˆ˜ Î·È 1 ¤ÙÔ˘˜ 1 ¤ÙÔ˘˜ ¤ˆ˜ Î·È 3 ÂÙÒÓ >3 ÂÙÒÓ π ππ πππ πV ∂ÙÂÚfiÏ¢ڷ ∞ƒ ∂ÙÂÚfiÏ¢ڷ ¢∂ ∞ÌÊÔÙÂÚfiÏ¢ڷ Èڛ˜ Ô˘Ï¤˜ ∂ÙÂÚfiÏ¢ڷ ∞ÌÊÔÙÂÚfiÏ¢ڷ

ÀÔ¯ÒÚËÛË ∫O¶ (%) (¯ËÌÂÈÔÚÔʇϷÍË) ¡Ô (%)

ÃÂÈÚÔ˘ÚÁÂ›Ô (%)

86 (84) 23 (58) 10 (34) 9 (100) 114 (92) 65 (60) 9 (35) 36 (78) 23 (79) 59 (61) 99 (80) 18 (44) 1 (17)

16 (16) 17 (42) 19 (66) 0 (0) 10 (8) 43 (40) 17 (65) 10 (22) 6 (21) 37 (39) 25 (20) 23 (56) 5 (83)

¡Ô (%)

¶›Ó·Î·˜ 2. πÛÙÔÚÈÎfi OÀƒ§ Î·È ˘ÔÙÚÔ¤˜ OÀƒ§ ηٿ ÙË ¯ËÌÂÈÔÚÔʇϷÍË: ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Ô¯ÒÚËÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· 11 ·È‰È¿ Û ·Ú·ÎÔÏÔ‡ıËÛË)

πÛÙÔÚÈÎfi OÀƒ§

ÀÔÙÚÔ¤˜ OÀƒ§

352

¡Ô

ÀÔ¯ÒÚËÛË ∫O¶ (%) (¯ËÌÂÈÔÚÔʇϷÍË) ¡Ô (%)

ÃÂÈÚÔ˘ÚÁÂ›Ô (%)

0 1 2 3 4 5 6 0 1 2 3 4 5

4 (100) 82 (73) 13 (62) 13 (72) 4 (36) 1 (16) 1 (25) 85 (8) 13 (65) 9 (50) 8 (38) 1 (20) 4 (80)

0 (0) 24 (27) 8 (38) 5 (28) 7 (64) 6 (84) 3 (75) 18 (18) 7 (35) 9 (50) 13 (62) 4 (80) 1 (20)

¡Ô (%)

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·353

¶·È‰È·ÙÚÈ΋ 2004;67:349-354

™˘˙‹ÙËÛË ∏ ÚˆÙÔ·ı‹˜ ·ÏÈÓ‰ÚfiÌËÛË ·Ó¢ڛÛÎÂÙ·È ÛÙÔ 50% ÙˆÓ ‚ÚÂÊÒÓ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙÔ˘ 1 ¤ÙÔ˘˜ Î·È ÛÙÔ 25% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 4 ÂÙÒÓ Ô˘ ‰ÈÂÚ¢ÓÒÓÙ·È ÌÂÙ¿ ·fi ÂÂÈÛfi‰ÈÔ OÀƒ§ (10). º·›ÓÂÙ·È fiÙÈ Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ Ù˘ Ï¢΋˜ Ê˘Ï‹˜ (11,12). ∂ÈϤÔÓ, ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ· (·Ó·ÏÔÁ›· 4:1), ÂÓÒ Î·Ù¿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ Î·È Û¯ÔÏÈ΋ ËÏÈΛ· Ë ·Ú·¿Óˆ ·Ó·ÏÔÁ›· ·ÓÙÈÛÙÚ¤ÊÂÙ·È ˘¤Ú ÙˆÓ ÎÔÚÈÙÛÈÒÓ (13). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÁÔÚÈÒÓ ‹Ù·Ó 43%, ÂÓÒ ÙÔ 57% ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó ËÏÈΛ·˜ ≤1 ¤ÙÔ˘˜. ∏ ·ÏÈÓ‰ÚfiÌËÛË ‰È·ÈÛÙÒÓÂÙ·È Û ÔÛÔÛÙfi 1020% ÌÂٷ͇ ÙˆÓ ·ÈÙÈÒÓ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ (14). ™Â ·˘Ù¿ Ù· ‚Ú¤ÊË, Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È ·ÁfiÚÈ· Ì ÛÔ‚·Ú‹ ·ÏÈÓ‰ÚfiÌËÛË, ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi ÂÚ›Ô˘ 40% (15). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Î·È Ù· ‰‡Ô ·È‰È¿ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ‹Ù·Ó ·ÁfiÚÈ· Ì ∫O¶ III ‚·ıÌÔ‡. ∏ ‰È¿ÁÓˆÛË Ù˘ ∫O¶ ÛÙËÚ›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· Ù˘ ·ÎÙÈÓÔÏÔÁÈ΋˜ ΢ÛÙÂÔÁÚ·Ê›·˜ Û ‰‡Ô Ê¿ÛÂȘ (Ï‹ÚˆÛ˘ Î·È Ô‡ÚËÛ˘) (16). ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÂÍÂÙ¿ÛÙËÎ·Ó Î·È Î·Ù¿ ÙË Ê¿ÛË Ù˘ Ô‡ÚËÛ˘ Ì ÛÎÔfi ÙËÓ ·ÎÚÈ‚¤ÛÙÂÚË ÛÙ·‰ÈÔÔ›ËÛË. ∞Ó·ÊÔÚÈο Ì ÙË ƒπ∫, ÔÈ Polito Î·È Û˘Ó ıˆÚÔ‡Ó fiÙÈ Ë Ì¤ıÔ‰Ô˜ Â›Ó·È ÈÔ ·ÎÚÈ‚‹˜ ·fi ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ Î·È Û ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÏÈÓ‰ÚÔÌ‹ÛÂȘ (17). µ¤‚·È·, ÛÙ· ·ÁfiÚÈ· ··ÈÙÂ›Ù·È Î·Ù¿ ÙË ‰È¿ÁÓˆÛË ·ÎÙÈÓÔÏÔÁÈ΋ ΢ÛÙÂÔÁÚ·Ê›·, ÒÛÙ ӷ ·ÔÎÏÂÈÛÙÔ‡Ó ÛÙÂÓÒÛÂȘ Ù˘ Ô˘Ú‹ıÚ·˜, fiˆ˜ ‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, Ô˘ Ô‰ËÁÔ‡Ó Û ‰Â˘ÙÂÚÔ·ı‹ ·ÏÈÓ‰ÚfiÌËÛË. ™ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ∆Ì‹Ì·, Ë ƒπ∫ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ∫O¶ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì 99m-Tc DMSA ıˆÚÂ›Ù·È ÔχÙÈÌË Î·È ·ÎÚÈ‚‹˜ ̤ıÔ‰Ô˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È ÛÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÓÂÊÚÈÎÒÓ Ô˘ÏÒÓ Î·È Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏ·Û›·˜ (18). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, fiÔ˘ Ë ÂͤٷÛË ‰ÂÓ ÁÈÓfiÙ·Ó ¿ÓÙ· Û ÔÍ›· Ê¿ÛË Ïԛ̈͢, Ù· Â˘Ú‹Ì·Ù· ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÍÈÔÏÔÁËıÔ‡Ó ˆ˜ ÚÔ˜ ÙË ‰È¿ÁÓˆÛË ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ªÂ ‰Â‰Ô̤ÓÔ, Â›Û˘, fiÙÈ ÔÈ ÂÛÙȷΤ˜ ‚Ï¿‚˜ Ù˘ ÔÍ›·˜ Ïԛ̈͢ Û˘Ó¯›˙Ô˘Ó Ó· ˘Ô¯ˆÚÔ‡Ó Ì¤¯ÚÈ Î·È ¤ÓÙ ̋Ó˜ ÌÂÙ¿ ÙÔ ÂÂÈÛfi‰Èfi Ù˘, Ë ·Ó‡ÚÂÛË ÙˆÓ Ô˘ÏÒÓ ‚·Û›ÛÙËΠ΢ڛˆ˜ ÛÙÔ Â·Ó·ÏËÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ·, Ô˘ ¤ÁÈÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ÙÔ ÚÒÙÔ ·ıÔÏÔÁÈÎfi. ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ, fiˆ˜ Ê¿ÓËÎÂ Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ¤¯ÂÈ ‹‰Ë Ô˘Ï¤˜ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (19). O˘Ï¤˜ Ô˘ ·ÓȯÓ‡ÙËÎ·Ó ÛÙÔ ÚÒ-

Paediatriki 2004;67:349-354

ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙÔ‡Ó ·fi Û˘ÁÁÂÓ›˜ ‰˘ÛÏ·ÛÙÈΤ˜ ÂÛÙȷΤ˜ ‚Ï¿‚˜. ∞Ó·ÊÔÚÈο Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ó¤ˆÓ Ô˘ÏÒÓ, ·Ú·ÙËÚÔ‡ÓÙ·È Î˘Ú›ˆ˜ Û ·È‰È¿ ˘fi ¯ËÌÂÈÔÚÔʇϷÍË Ì ˘ÔÙÚÔÈ¿˙Ô˘Û˜ OÀƒ§ (20). ∂ÈϤÔÓ, Â›Ó·È Û¿ÓȘ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ηıÒ˜ Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÓÂÊÚÔ‡ Ô‰ËÁ› Û Ì›ˆÛË Ù˘ ÂÓ‰ÔÓÂÊÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Î·ÈÓÔ‡ÚÁȘ Ô˘Ï¤˜ Û ·È‰È¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ ˘fi ¯ËÌÂÈÔÚÔʇϷÍË. ∂›Û˘, ÌÈÎÚÔ› ÚÈÎÓÔ› ÓÂÊÚÔ› ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó, ȉȷ›ÙÂÚ· Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÏÈÓ‰ÚfiÌËÛË. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË Ù˘ ∫O¶ Â›Ó·È Ë ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ, Ô ‚·ıÌfi˜ Î·È Ë ÂÓÙfiÈÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘, ÙÔ ÈÛÙÔÚÈÎfi OÀƒ§ Î·È Ë ‡·ÚÍË Ô˘ÏÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ηıÒ˜ Î·È ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ OÀƒ§ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË (4,21). ∏ Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ¤¯ÂÈ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù·, ΢ڛˆ˜ ÛÙ· ‚Ú¤ÊË Î·È Ù· ÌÈÎÚ¿ ·È‰È¿ Ì ·ÏÈÓ‰ÚfiÌËÛË ¤ˆ˜ Î·È III ‚·ıÌÔ‡ Î·È ÈÛÙÔÚÈÎfi ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ OÀƒ§ (4). ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔÈ·˙Ô˘ÛÒÓ OÀƒ§ Û ∫O¶ III Î·È IV ‚·ıÌÔ‡ Â›Ó·È 2,5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙ· ·È‰È¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ¯ËÌÂÈÔÚÔʇϷÍË Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ¯ÂÈÚÔ˘ÚÁ‹ıËÎ·Ó (4). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ê¿ÓËΠfiÙÈ ÔÈ ·Ú·¿Óˆ ·Ú¿ÁÔÓÙ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ˘Ô¯ÒÚËÛË Ù˘ ∫O¶. ø˜ Èı·Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ ·fi ÙË ¯ËÌÂÈÔÚÔʇϷÍË ·Ó·Ê¤ÚÔÓÙ·È Ë Ù¿ÛË ÁÈ· ¤ÌÂÙÔ, Ô ¤ÌÂÙÔ˜, ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Ë Î·Î‹ Á‡ÛË, Ë ·˘ÍË̤ÓË ·ÓÙ›ÛÙ·ÛË ÛÙ· ·ÓÙÈ‚ÈÔÙÈο Î·È Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÂÏ¿ÛÛÔÓ˜ ÌfiÓÔ ·ÚÂÓ¤ÚÁÂȘ Î·È ‰ÂÓ Û˘ÓÂÛÙ‹ıË ÛÂ Î·Ó¤Ó·Ó ‰È·ÎÔ‹ Ù˘ ¯ËÌÂÈÔÚÔʇϷ͢.

OÈ ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ∫O¶, Ì ‰ÈÏ·ÛÈ·ÛÌÔ‡˜ ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ, ÈÛÙÔÚÈÎfi ˘ÔÙÚÔÈ·˙Ô˘ÛÒÓ OÀƒ§ Î·È ÌË Û˘ÌÌfiÚʈÛË ÛÙËÓ ·ÁˆÁ‹ Ô‰ËÁÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· Û ¯ÂÈÚÔ˘ÚÁÈ΋ ‹ ÂÓ‰ÔÛÎÔÈ΋ ‰ÈfiÚıˆÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (20). ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂÂϤÁË ¤Ó·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ (53/182) ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ‹ ÂÓ‰ÔÛÎÔÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·Ô‰›‰ÂÙ·È ÛÙÔ fiÙÈ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·Ó Î·È ·È‰È¿ ËÏÈΛ·˜ ¤ˆ˜ 10 ÂÙÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË. ∞Ó·ÊÔÚÈο Ì ÙËÓ ÂÓ‰ÔÛÎÔÈ΋ ̤ıÔ‰Ô, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·ÊÔÚÔ‡Ó ÛÙË ¯Ú‹ÛË Teflon, fiÔ˘ ÙÔ ÔÛÔÛÙfi ˘Ô¯ÒÚËÛ˘ Ù˘ ∫O¶ Â›Ó·È 77,1% (4). ∏ ÂÌÂÈÚ›· Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂ÓË, ÒÛÙ ӷ ÂÍ·¯ı› Ì ‚‚·ÈfiÙËÙ· οÔÈÔ Û˘Ì¤Ú·ÛÌ·. ™Â ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË, Ë Î˘ÚÈfiÙÂÚË ÂÈÏÔ΋ Â›Ó·È Ë ·fiÊÚ·ÍË, Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 0-9,1% (4). ™ÙËÓ

353

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¶·È‰È·ÙÚÈ΋ 2004;67:349-354

·ÚÔ‡Û· ÌÂϤÙË, ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·fiÊÚ·ÍË ·Ú·ÙËÚ‹ıËΠ۠2 ·fi Ù· 49 ·È‰È¿. £ÂˆÚÂ›Ù·È fiÙÈ Ô ÌfiÓÔ˜ ÙÚfiÔ˜ Ó· ·ÔÊ¢¯ıÔ‡Ó ÔÈ Û˘¯Ó¿ ‰Ú·Ì·ÙÈΤ˜ Û˘Ó¤ÂȘ Ù˘ ∫O¶ Â›Ó·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛ‹ Ù˘. ™Â ·˘Ùfi ÙÔ ÛËÌÂ›Ô ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ Ë ÚÔÏËÙÈ΋ ΢ÛÙÂÔÁÚ·Ê›· ÙˆÓ ·‰ÂÏÊÒÓ ÙˆÓ ·È‰ÈÒÓ Ì ∫O¶, ηıÒ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ‚ÚÂÊÒÓ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘. ∂ÈϤÔÓ, Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë ÂÚ·ÈÙ¤Úˆ ÛˆÛÙ‹ Î·È ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘, Û˘ÓÙËÚËÙÈ΋ ‹ ¯ÂÈÚÔ˘ÚÁÈ΋, ÒÛÙ ӷ ·ÔʇÁÔÓÙ·È Ù· ÂÂÈÛfi‰È· ˘ÂÏÔÓÂÊÚ›Ùȉ·˜, Ù· ÔÔ›· Û˘Ó‰¤ÔÓÙ·È Ì η΋ ÚfiÁÓˆÛË Ù˘ ¿ıËÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. International Reflux Study Committee. Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children. J Urol 1981;125:277-283.

2. Olbing H, Claesson I, Ebel KD, Seppanen U, Smellie JM, Tamminen-Mobius T et al. Renal scars and parenchymal thinning in children with vesicoureteral reflux: a 5-year report of the International Reflux Study in Children (European branch). J Urol 1992;148:1653-1656.

3. Smellie JM, Prescod NP, Shaw PJ, Risdon RA, Bryant TN. Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults. Pediatr Nephrol 1998;12:727-736.

4. Elder JS, Peters CA, Arant BS Jr, Ewalt DH, Hawtrey CE, Hurwitz RS et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997;157:1846-1851.

5. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105-109.

6. Piepsz A, Hahn K, Roca I, Ciofetta G, Toth G, Gordon I et al.

A radiopharmaceuticals schedule for imaging in paediatrics.

Paediatric Task Group European Association Nuclear Medicine. Eur J Nucl Med 1990;17:127-129.

7. de Man SA, Andre JL, Bachmann H, Grobbee DE, Ibsen KK, Laaser U et al. Blood pressure in childhood: pooled findings of six European studies. J Hypertens 1991;9:109-114.

8. Report of the Second Task Force on Blood Pressure Control in Children - 1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics 1987;79:1-25.

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9. Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 1976;58:259-263.

10. Baker R, Maxted W, Maylath J. Relation of age, sex, and infection to reflux: data indicating high spontaneous cure rate in pediatric patients. J Urol 1966;95:27-32.

11. Tsai C, Huang Y, Lee C, Lin L. Evaluation of childhood urinary tract infection: results of radiological and ultrasonography studies. Acta Paediatr Sin 1987;28:17-20.

12. Arant BS Jr. Vesicoureteric reflux and renal injury. Am J Kidney Dis 1991;17:491-511.

13. Steele BT, De Maria J. A new perspective on the natural history of vesicoureteric reflux. Pediatrics 1992;90:30-32.

14. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. Br J Urol Int 2002;89:149-156.

15. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology 1993;187:157-160.

16. Papadopoulou F, Efremidis SC, Oiconomou A, Badouraki M, Panteleli M, Papachristou F et al. Cyclic voiding cystourethrography: is vesicoureteral reflux missed with standard voiding cystourethrography? Eur Radiol 2002;12:666-670.

17. Polito C, Rambaldi PF, La Manna A, Mansi L, Di Toro R. Enhanced detection of vesicoureteric reflux with isotopic cystography. Pediatr Nephrol 2000;14:827-830.

18. Jakobsson B, Nolstedt L, Svensson L, Soderlundh S, Berg U. 99mTechnetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings. Pediatr Nephrol 1992;6:328-334.

19. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003;348:195-202.

20. White RH. Management of urinary tract infection. Arch Dis Child 1987;62:421-427.

21. Shapiro E, Elder JS. The office management of recurrent urinary tract infection and vesicoureteral reflux in children.

Urol Clin North Am 1998;25:725-734.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-11-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 30-06-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ºÒÙ˘ ¶··¯Ú‹ÛÙÔ˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49, ∆.∫. 546 42, £ÂÛÛ·ÏÔÓ›ÎË

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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2004;67:355-358

CASE REPORT

¢ÈÂÈÛ‰˘ÙÈ΋ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ Û ‚Ú¤ÊÔ˜ 4 Ë̤Ú˜ ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ¤Ó·ÓÙÈ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÌ¿‰·˜ C. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ µ. ∆Û·ÁÚ‹˜, ∏. ¶··‰¤·, ™. ∫˘ÚÈ¿Î˘, ª. µ·ÛÈÏÂÈ¿‰Ë˜, º. ∆˙ÈÊ‹, ∞. ∫ÈÙÛÔÔ‡ÏÔ˘, ¢. ¢Ú¿ÎÔ˜

Invasive meningococcal disease in an infant 4 days after vaccination with serogroup C meningococcal conjugate vaccine. A case report V. Tsagris, H. Papadea, S. Kyriakis, M. Vasiliadis, F. Tzifi, A. Kitsopoulou, D. Drakos

¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ ËÏÈΛ·˜ 5 ÌËÓÒÓ, ÙÔ ÔÔ›Ô ÂÌÊ¿ÓÈÛ ‰ÈÂÈÛ‰˘ÙÈ΋ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ (ÌËÓÈÁÁ›Ùȉ· ·fi N. meningitidis) 4 Ë̤Ú˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÌÂ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÚÔÔÌ¿‰·˜ C. ∂ÍÂÙ¿˙ÂÙ·È Ë Èı·ÓfiÙËÙ· Û‡ÌÙˆÛ˘ ‹ ‡·Ú͢ ·ÈÙÈÔÏÔÁÈ΋˜ Û˘Û¯¤ÙÈÛ˘, ηıÒ˜ Î·È Ë Û˘¯ÓfiÙËÙ· Î·È ÙÔ Â›‰Ô˜ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Û‡Ìʈӷ Ì ·Ó·ÊÔÚ¤˜ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·.

Abstract: The case is presented of a 5-month old infant who was diagnosed with invasive meningococcal disease (meningitis from N. meningitidis) 4 days after vaccination with serogroup C meningococcal conjugate vaccine.

The possibility of coincidence or the existence of a causal association, as well as the frequency and nature of known adverse reactions to vaccination, are discussed.

§¤ÍÂȘ ÎÏÂȉȿ: ÌËÓÈÁÁ›Ùȉ·, ·È‰È¿, ÂÌ‚ÔÏÈ·ÛÌfi˜, ÂÌ‚fiÏÈÔ, ·ÚÂÓ¤ÚÁÂȘ.

Key words: meningitis, children, vaccination, vaccine, reactions.

∂ÈÛ·ÁˆÁ‹ ∏ neisseria Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ ·ÔÙÂÏ› Û˘¯Ófi ·›ÙÈÔ ÌËÓÈÁÁ›Ùȉ·˜ Î·È ÛË„·ÈÌ›·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ™‡Ìʈӷ Ì ÌÂϤÙË Ô˘ ‰ËÌÔÛȇıËΠÙÔ 2000 ÛÙË ¯ÒÚ· Ì·˜ (ÁÈ· ÙÔ ‰È¿ÛÙËÌ· 1984-1998), ˆ˜ ·›ÙÈÔ ÌÈÎÚԂȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙÔ 54,6% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ Ù˘ÔÔ›ËÛË ÙˆÓ ÛÙÂϯÒÓ N. meningitidis ¤‰ÂÈÍ fiÙÈ 55,7% ·Ó‹Î ÛÙËÓ ÔÚÔÔÌ¿‰· µ, 38,9% ÛÙËÓ ÔÚÔÔÌ¿‰· C, 2,7% ÛÙËÓ ÔÚÔÔÌ¿‰· ∞ Î·È 5,1% ‹Ù·Ó ÌË Ù˘ÔÔÈ‹ÛÈÌÔ (1). ™˘Ì‚·Ù¿ Â›Ó·È Î·È Ù· Â˘Ú‹Ì·Ù· ¿ÏÏ˘ ÂÚ¢ÓËÙÈ΋˜ ÔÌ¿‰·˜ (ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 19961998), fiÔ˘ Ë N. meningitidis ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙÔ 65% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÌÈÎÚԂȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜, Ì ÙÔ ÔÛÔÛÙfi Ù˘ ÔÚÔÔÌ¿‰·˜ C Ó· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 33,3% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ (2). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi ÙÔ 1995, Ì ÔÏ˘¿ÚÈı̘ ÌÂϤÙ˜ ÛÙȘ ¯ÒÚ˜ ÚÒÙ˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘. OÈ ·Ó·ÊÂÚfiÌÂÓ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·Ú·Ì¤ÓÔ˘Ó ÂÚÈÔÚÈṲ̂Ó˜, ·Ú¿ ÙÔÓ ÙÂÚ¿ÛÙÈÔ ·ÚÈıÌfi ÙˆÓ ·È-

‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·ÛÙ› (30 ÂηÙÔÌ̇ÚÈ· ‰fiÛÂȘ ¯ÔÚËÁ‹ıËÎ·Ó ÛÙË µÚÂÙ·Ó›· ¤ˆ˜ ÙÔÓ ª¿ÈÔ ÙÔ˘ 2000). ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÌËÓÈÁÁ›Ùȉ·˜ ·fi N. meningitidis, Ë ÔÔ›· ÂÌÊ·Ó›ÛÙËΠ۠ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ÌÂ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ N. meningitidis ÔÚÔÔÌ¿‰·˜ C. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ÕÚÚÂÓ ‚Ú¤ÊÔ˜, ËÏÈΛ·˜ 5 ÌËÓÒÓ, ÂÈÛ‹¯ıË ÛÙËÓ ∫ÏÈÓÈ΋ ÏfiÁˆ ÂÌ‡ÚÂÙÔ˘ (·fi ˆÚÒÓ, ¤ˆ˜ 40oC ·fi ÔÚıfi) Î·È ¿ÚÓËÛ˘ Ï‹„˘ ÙÚÔÊ‹˜. ∆Ô ÂÚÈÁÂÓÓËÙÈÎfi Î·È ÏÔÈfi ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó ÂχıÂÚÔ. ∆¤ÛÛÂÚȘ Ë̤Ú˜ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, ·Ó·Ê¤ÚÂÙ·È ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙËÓ ÚÒÙË ‰fiÛË ÙÔ˘ Û˘˙¢Á̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÚÔÔÌ¿‰·˜ C. ™ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ̤ÙÚÈ· ÁÂÓÈ΋ ηٿÛÙ·ÛË (∫ϛ̷η ∫ÒÌ·ÙÔ˜ °Ï·ÛÎ҂˘ 6/9) Î·È ÌÂȈ̤ÓË ÂÚÈÊÂÚÈ΋ ·ÈÌ¿ÙˆÛË, ÂÓÒ Ë ÂͤٷÛË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ·ÔÎ¿Ï˘„ ÂÛÙ›· ˘ÚÂÙÔ‡. ∞fi Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Î·È ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∂ÏÂ˘Û›Ó·˜ “£ÚÈ¿ÛÈÔ”, ∞ı‹Ó·

Department of Paediatrics, “Thriassio” General Hospital, Athens

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(‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, Â˘Ú‹Ì·Ù· ·fi ÙÔ ∂¡À) Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ Î·È ·ÎÔÏÔ‡ıËÛÂ Ë ¯ÔÚ‹ÁËÛË Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ Î·È ¿ÏÏ˘ (ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù·, ÌÂÙ¿ÁÁÈÛË Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ) ·ÁˆÁ‹˜. ∏ ÔÚ›· Ù˘ ÓfiÛÔ˘ ˘‹ÚÍ ÔÌ·Ï‹, ¯ˆÚ›˜ Âȉ›ӈÛË Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ‚Ú¤ÊÔ˘˜, Ì ÛÙ·‰È·Î‹ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘ Î·È ‡ÊÂÛË ÙÔ˘ ˘ÚÂÙÔ‡ ÂÓÙfi˜ ÙÔ˘ ÙÚ›ÙÔ˘ 24ÒÚÔ˘ ÓÔÛËÏ›·˜. O ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ó‡ÚÂÛË ·ÙfiÌˆÓ ÊÔÚ¤ˆÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ‚Ú¤ÊÔ˘˜ (Ì ηÏÏȤÚÁÂȘ ˘ÏÈÎÔ‡ ÚÈÓÔÊ¿Ú˘ÁÁ·) ˘‹ÚÍ ·ÚÓËÙÈÎfi˜. ÕÏÏÔ ÎÚÔ‡ÛÌ· ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘, ÙfiÛÔ ÛÙÔ ÛÙÂÓfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ‚Ú¤ÊÔ˘˜ fiÛÔ Î·È ÛÙËÓ Â˘Ú‡ÙÂÚË ÎÔÈÓfiÙËÙ·, ‰ÂÓ ·Ó·Ê¤ÚıËÎÂ. ™ÙËÓ ÂͤٷÛË ÙÔ˘ ∂¡À Ì PCR ‚Ú¤ıËΠÌË Ù˘ÔÔÈË̤ÓÔ Û٤ϯԘ N. meningitidis, ÂÓÒ ÙfiÛÔ Ë Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ fiÛÔ Î·È Ë PCR ÛÙÔ ·›Ì· ˘‹ÚÍ·Ó ·ÚÓËÙÈΤ˜. ™˘˙‹ÙËÛË ™ËÌ·ÓÙÈ΋ ÂÌÂÈÚ›· Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤¯ÂÈ ·ÔÎÙËı› ÛÙË µÚÂÙ·Ó›·, fiÔ˘ ¤¯Ô˘Ó ‹‰Ë Û˘ÌÏËÚˆı› 4 ¯ÚfiÓÈ· Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ô Î‡ÚÈÔ˜ fiÁÎÔ˜ ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ó·ÊÔÚÒÓ. ∏ Û˘ÓÔÏÈ΋ ÂÙ‹ÛÈ· Â›ÙˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ˘ÔÏÔÁ›˙ÂÙ·È Û 5 ÂÚÈÛÙ·ÙÈο ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜ (3). ∏ Â›ÙˆÛË Î·È Ë ıÓËÛÈÌfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ê·›ÓÔÓÙ·È ÛÙȘ ∂ÈÎfiÓ˜ 1 Î·È 2. ªÂÙ¿ ÙËÓ Î·ıÔÏÈ΋ ÂÈÙ˘¯›· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ¤Ó·ÓÙÈ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù˘ ÁÚ›˘, Ë ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ·ÔÙÂÏ› ÙË Û˘ÓËı¤ÛÙÂÚË ÏÔÈÌÒ‰Ë ·ÈÙ›· ı·Ó¿ÙÔ˘ Û ¿ÙÔÌ· ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ, ηıÒ˜ Î·È ÙË Û˘ÓËı¤ÛÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÁÂÓÈο, Û ·È‰È¿ ËÏÈΛ·˜ 1-5 ÂÙÒÓ (4). ∆Ô ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ ·fi ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ ·Ó¤Ú¯ÂÙ·È Û˘ÓÔÏÈο ÛÙÔ 10%, Ì ÙË ÛË„·ÈÌ›·

Paediatriki 2004;67:355-358

Ó· ÚÔËÁÂ›Ù·È ‰ÈÂΉÈÎÒÓÙ·˜ ÔÛÔÛÙfi 20% Î·È ÙË ÌËÓÈÁÁ›Ùȉ· Ó· ¤ÂÙ·È Ì ÔÛÔÛÙfi 7%. ∞fi ÙÔ˘˜ ÂÈ˙‹Û·ÓÙ˜ Ù˘ ÓfiÛÔ˘, ÔÛÔÛÙfi 25% ·Ó·Ê¤ÚÂÈ Âȉ›ӈÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ (5). ∫·ıÒ˜ Ë Û˘¯ÓfiÙËÙ· ·ÔÌfiÓˆÛ˘ Ù˘ N. meningitidis ÔÚÔÔÌ¿‰·˜ C ·fi ‚ÈÔÏÔÁÈο ˘ÁÚ¿ ÓÔÛÔ‡ÓÙˆÓ ‰ÂÓ Â›Ó·È Û η̛· ÂÚ›ÙˆÛË ·ÌÂÏËÙ¤· (1,2), ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ Ì¿ÏÈÛÙ· ·˘ÍËÙÈΤ˜ Ù¿ÛÂȘ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÚÔ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ Û˘˙¢Á̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘, Ë ÛËÌ·Û›· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰ÂÓ ÌÔÚ› Û η̛· ÂÚ›ÙˆÛË Ó· ˘ÔÙÈÌËı›. ∏ ·ÓÔÛÔÁÔÓÈÎfiÙËÙ· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤¯Ô˘Ó Ì ·ÛÊ¿ÏÂÈ· ÙÂÎÌËÚȈı› Ì ÔÏ˘¿ÚÈı̘ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜, ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ (6-9). ø˜ Û˘Ó¤ÂÈ·, ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·fi ÔÚÔÔÌ¿‰· C, Û ÔÛÔÛÙ¿ Ô˘ ·Ó¤Ú¯ÔÓÙ·È ÛÙÔ 75% ÛÙË µÚÂÙ·Ó›· ‹ ·ÎfiÌ· ˘„ËÏfiÙÂÚ· Û ¿ÏϘ ¯ÒÚ˜ (10,11). ™ÙËÓ ∂ÏÏ¿‰·, Ë ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙÔ˘ ‚·ıÌÔ‡ ‰È›ۉ˘Û˘ Î·È Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Û˘Ó·ÓÙ¿ ÛËÌ·ÓÙÈΤ˜ ÌÂıÔ‰ÔÏÔÁÈΤ˜ ‰˘ÛÎÔϛ˜, ηıÒ˜ ·Ú·Ì¤ÓÂÈ ÏËÌÌÂÏ‹˜ Ë ‰‹ÏˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ ·fi ȉȈÙÈÎÔ‡˜, ÌË ÂÏÂÁ¯fiÌÂÓÔ˘˜, ÊÔÚ›˜ ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜.

OÈ ÁÓˆÛÙ¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÂÌÊ·Ó›˙ÔÓÙ·È Û¿ÓÈ· Î·È Â›Ó·È ‹ÛÛÔÓÔ˜ ÛËÌ·Û›·˜, Û ¯ÒÚ˜ fiÔ˘ ÌÂÚ›‰· ÙÔ˘ ∆‡Ô˘ ηÏÏȤÚÁËÛ ηٿ ÙÔ ·ÚÂÏıfiÓ Îϛ̷ “ÂÌ‚ÔÏÈÔÊÔ‚›·˜” ÙÔ ÚfiÁÚ·ÌÌ· Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ¤Ù˘¯Â ·ÚÓËÙÈ΋˜ ‰ËÌÔÛÈfiÙËÙ·˜ (12). [™ÙË µÚÂÙ·Ó›·, ·ÚÓËÙÈ΋ ‰ËÌÔÛÈfiÙËÙ· ÂÈÛΛ·Û ÙÔÓ Ì·˙ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi Ì MMR ÙÔ 1995, fiÙ·Ó ÂÈÛÙËÌÔÓÈΤ˜ Î·È ¿ÏϘ ·Ó·ÊÔÚ¤˜ Û˘Ó¤‰ÂÛ·Ó ÙÔ ÂÌ‚fiÏÈÔ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÈÛÌÔ‡ ‹ ÊÏÂÁÌÔÓˆ‰ÒÓ

∂ÈÎfiÓ· 1. ∞ÚÈıÌfi˜ ÂȂ‚·ÈˆÌ¤ÓˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘, ηٿ ËÏÈΛ· Î·È ÔÚÔÔÌ¿‰·, ÛÙË µÚÂÙ·Ó›·, ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1998-1999 (¶ËÁ‹: Department of Health and the Health Education Authority, µÚÂÙ·Ó›·, 1999).

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∂ÈÎfiÓ· 2. ∞ÚÈıÌfi˜ ı·Ó¿ÙˆÓ ·fi ÌËÓÈÁÁÈÙȉÈÎÔÎÎÈ΋ ÓfiÛÔ, ηٿ ËÏÈΛ· Î·È ÔÚÔÔÌ¿‰·, ÛÙË µÚÂÙ·Ó›·, ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1994-1995 ¤ˆ˜ 1998-1999 (¶ËÁ‹: Department of Health and the Health Education Authority, µÚÂÙ·Ó›·, 1999). ¶›Ó·Î·˜ 1. ™˘ÓËı¤ÛÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ÌÂ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÚÔÔÌ¿‰·˜ C (¶ËÁ‹: Department of Health and the Health Education Authority, µÚÂÙ·Ó›·, 1999) ∏ÏÈÎȷ΋ ÔÌ¿‰·

∆ÔÈΤ˜ ·ÓÙȉڿÛÂȘ

µÚ¤ÊË (<12 ÌËÓÒÓ)

∂Ú˘ıÚfiÙËÙ· (>3 (2-4%) ∂Ú˘ıÚfiÙËÙ· (>3 (2-3%) ∂Ú˘ıÚfiÙËÙ· (>3 (29%) ∂Ú˘ıÚfiÙËÙ· (>3 (26%)

¡‹È· (12-17 ÌËÓÒÓ) ¶·È‰È¿ ¢ËÌÔÙÈÎÔ‡ (4-11 ÂÙÒÓ) ¶·È‰È¿ °˘ÌÓ·Û›Ô˘ (12-18 ÂÙÒÓ)

ÓÔÛËÌ¿ÙˆÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ™·Ó ·ÔÙ¤ÏÂÛÌ·, ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÔÈÎÔÁÂÓÂÈÒÓ (ÌÂٷ͇ ·˘ÙÒÓ Î·È ÙÔ˘ ¶Úˆı˘Ô˘ÚÁÔ‡ Ù˘ ¯ÒÚ·˜) ·ÚÓ‹ıËΠÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi.] ™ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ô˘ ¤¯Ô˘Ó ηٷÁÚ·Ê›, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È 12 ı¿Ó·ÙÔÈ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ÛÙËÓ ∂ÈÙÚÔ‹ ÁÈ· ÙËÓ ∞ÛÊ¿ÏÂÈ· ÙˆÓ º·ÚÌ¿ÎˆÓ Ù˘ µÚÂÙ·Ó›·˜ (CSM), ÂÎ ÙˆÓ ÔÔ›ˆÓ 7 ·Ô‰fiıËÎ·Ó Û SIDS (·ÈÊÓ›‰ÈÔ ‚ÚÂÊÈÎfi ı¿Ó·ÙÔ), 2 Û ÌËÓÈÁÁ›Ùȉ· ·fi ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ ÔÌ¿‰·˜ µ, 1 Û ‚ÚÔÁ¯ÈÔÏ›Ùȉ· (Û ‚Ú¤ÊÔ˜ Ì ΢·ÓˆÙÈ΋ ηډÈÔ¿ıÂÈ·) Î·È 1 Û Ó¢ÌÔÓ›·. ™·ÛÌÔ›, ÛÙÔ Ï·›ÛÈÔ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ·Ú·ÙËÚÔ‡ÓÙ·È ÌÂ Û˘¯ÓfiÙËÙ· ÌÈÎÚfiÙÂÚË ·fi 1 ÚÔ˜ 10.000 (13). ™Â η̛· ÂÚ›ÙˆÛË ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ù‹ Ë ·ÈÙÈÔÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔ ÂÌ‚fiÏÈÔ. ∂ÈϤÔÓ, Û‡Ìʈӷ Ì ÌÂϤÙË ÙÔ˘ ∫¤ÓÙÚÔ˘ ∞Ó·ÊÔÚ¿˜ ªËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù˘ µÚÂÙ·Ó›·˜, ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ÔÈ ·ÓËÛ˘¯›Â˜ Ô˘ ÂÎÊÚ¿ÛÙËÎ·Ó Î·Ù¿ ηÈÚÔ‡˜ ÁÈ· ÌÂÙ·ÙfiÈÛË Ù˘ “η„ȉÈ΋˜ Ù·˘ÙfiÙËÙ·˜” ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ·fi ÙËÓ ÔÌ¿‰· C ÛÙËÓ ÔÌ¿‰· µ ‹ Û ¿ÏϘ ÔÌ¿‰Â˜, ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Û˘˙¢Á̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘ (10). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ‰ÂÓ ‰È·ÈÛÙÒıËΠÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Ë ‡·ÚÍË ¿ÏÏˆÓ ·Ó·ÊÔÚÒÓ - ÏËÓ ÙˆÓ ‚ÚÂÙ·ÓÈÎÒÓ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÌÂ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Ì ÂÚÈÛÙ·ÙÈο ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘. ∫·-

cm) cm) cm) cm)

™˘ÛÙËÌ·ÙÈΤ˜ ·ÓÙȉڿÛÂȘ ∂˘ÂÚÂıÈÛÙfiÙËÙ· (50%) ¶˘ÚÂÙfi˜ (2-4%) ∂˘ÂÚÂıÈÛÙfiÙËÙ· (19%) ¶˘ÚÂÙfi˜ (5%) ¶˘ÚÂÙfi˜ (1,1%) ∫ÂÊ·Ï·ÏÁ›· (10%) ¶˘ÚÂÙfi˜ (2,5%) ∫ÂÊ·Ï·ÏÁ›· (14%)

Ó¤Ó·˜ Û˘Ó·Ê‹˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ‰ÂÓ ¤¯ÂÈ ÚÔÙ·ı› ¤ˆ˜ ÙÒÚ·. Àfi ÙÔ Êˆ˜ ·˘ÙÒÓ ÙˆÓ ‰Â‰Ô̤ӈÓ, ÔÈ Û˘ÁÁÚ·Ê›˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ¿ÚıÚÔ˘ ‰ÂÓ ÌÔÚÔ‡Ó ·Ú¿ Ó· ÂÓÛÙÂÚÓÈÛÙÔ‡Ó ÙȘ ·fi„ÂȘ Ù˘ µÚÂÙ·ÓÈ΋˜ ∂ÈÙÚÔ‹˜ ÁÈ· ÙËÓ ∞ÛÊ¿ÏÂÈ· ÙˆÓ º·Ú̿ΈÓ, fiˆ˜ ·˘Ù¤˜ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙËÓ ÂÈÛ‹ÁËÛË ÙÔ˘ ∞˘ÁÔ‡ÛÙÔ˘ 2000: “§fiÁˆ Ù˘ Ì·˙È΋˜ ʇÛ˘ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Ë ·Ó·ÊÔÚ¿ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ˘‹ÚÍ ÂÎÙÂٷ̤ÓË. ™ÙÔ Ï·›ÛÈÔ ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÂηÙÔÌÌ˘Ú›ˆÓ ·ÙfïÓ, Ê·ÈÓfiÌÂÓ· fiˆ˜ ı¿Ó·ÙÔÈ ·fi SIDS ‹ ¿ÏÏ· ·›ÙÈ· Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÈÛ˘Ì‚Ô‡Ó ÏfiÁˆ Ù˘¯·›·˜ Û‡ÌÙˆÛ˘. ¢ÂÓ ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ Ô˘ Ó· ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ·ÈÙÈÔÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ì ٷ ·Ó·ÊÂÚfiÌÂÓ· ÂÚÈÛÙ·ÙÈο. ∏ Û˘Û¯¤ÙÈÛË ÔʤÏÔ˘˜ Î·È Èı·ÓÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÎÏ›ÓÂÈ Û·ÊÒ˜ ˘¤Ú Ù˘ Û˘Ó¤¯ÈÛ˘ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ÙÔÓ ÔÔ›Ô Î·È Û˘ÓÈÛÙԇ̠·ÓÂÈʇϷÎÙ·. ∏ Â·ÁÚ‡ÓËÛË, ˆÛÙfiÛÔ, ı· Ú¤ÂÈ Ó· Û˘Ó¯ÈÛÙ› Î·È Î¿ı Ӥ· ·ÓÂÈı‡ÌËÙË ·ÓÙ›‰Ú·ÛË Ó· ÂÍÂÙ¿˙ÂÙ·È Ì ȉȷ›ÙÂÚË ÚÔÛÔ¯‹” (13). µÈ‚ÏÈÔÁÚ·Ê›· 1. ¶·Ú·ÛοÎË ∂, ∫·ÏϤÚÁË ∫, ∆ÛÈÚ¤· ª, ª·ÚfiÔ˘ÏÔ˜ °, ª·ÏÙ¤˙Ô˘ ∂, ºˆÙÂÈÓÔ‡ ∞ Î·È Û˘Ó. µ·ÎÙËÚȷ΋ ÌËÓÈÁÁ›Ùȉ· ÛÙ· ·È‰È¿ ηٿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1984-1998. 38Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. 2000. ¶ÂÚ. 210.

2. ∫·‚·ÏÈÒÙ˘ π, ∫·ÓÛÔ˘˙›‰Ô˘ ∞, ºÈÏÈÒÙË π, §ÈıÔÍÔÔ‡ÏÔ˘ ª,

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3.

4.

5.

6.

7.

8.

9.

358

∆Û·ÁηÚÔÔ‡ÏÔ˘ ∏. ∆Ô ÎÏÈÓÈÎfi ÚÔÊ›Ï Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ Ïԛ̈͢ ÙËÓ ÂÚ›Ô‰Ô 1996-1998. 37Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. 1999. ¶ÂÚ. 359∂∞.

Office for National Statistics. Mortality Statistics: Childhood, infant and perinatal, England and Wales. London: ONS; 1997, Series DH3, no. 30. p. 37.

Jones D. Epidemiology of meningococcal disease in Europe and the USA. In: Cartwright K, editor. Meningococcal disease. Chichester: John Wiley & Sons; 1995. p. 147-158.

Erickson L, De Wals P. Complications and sequelae of meningococcal disease in Quebec, Canada, 1990-1994. Clin Infect Dis 1998;26:1159-1164.

Richmond P, Borrow R, Miller E, Clark S, Sadler F, Fox A et al. Meningococcal serogroup C conjugate vaccine is immunogenic in infancy and primes for memory. J Infect Dis 1999;179:1569-1572.

Ruggeberg J, Heath PT. Safety and efficacy of meningococcal group C conjugate vaccines. Expert Opin Drug Saf 2003;2:7-19.

McVernon J, MacLennan J, Buttery J, Oster P, Danzig L, Moxon ER. Safety and immunogenicity of meningococcus serogroup C conjugate vaccine administered as a primary or booster vaccination to healthy four-year-old children. Pediatr Infect Dis J 2002;21:747-753.

MacLennan JM, Shackley F, Heath PT, Deeks JJ, Flamank C, Herbert M et al. Safety, immunogenicity, and induction of immunologic memory by a serogroup C meningococcal conjugate vaccine in infants: a randomized controlled trial.

JAMA 2000;283:2795-2801.

Paediatriki 2004;67:355-358

10. Balmer P, Borrow R, Miller E. Impact of meningococcal C conjugate vaccine in the UK. J Med Microbiol 2002;51:717722.

11. Salleras L, Dominguez A, Cardenosa N. Dramatic decline of serogroup C meningococcal disease in Catalonia (Spain) after a mass vaccination campaign with meningococcal C conjugated vaccine. Vaccine 2003;21:729-733.

12. Bright M. Hell of families hit by “cover-up”. England: The Observer; Sunday August 27, 2000. http://www.observer. co.uk/uk_news/story/0,6903,359753,00.html 13. Summary of the Meeting of the Committee on Safety of Medicines sub-Committee on pharmacovigilance held on Tuesday 20 June 2000. Committee on Safety of Medicines.

England; 2000.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-12-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 30-03-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ·Û›ÏÂÈÔ˜ ∆Û·ÁÚ‹˜ ∞ÚÂÔfiψ˜ 30, ∆.∫. 124 62, ¢¿ÛÔ˜ ÷˚‰·Ú›Ô˘, ∞ı‹Ó· E-mail: billtsag@yahoo.com

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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2004;67:359-362

CASE REPORT

¡ÂÔÁÓfi Ì ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 [r(14)] ∞. °·ÏÏ¿ - µÔ˘Ì‚Ô˘Ú¿ÎË1, ™. ∫›ÙÛÈÔ˘ - ∆˙¤ÏË3, ∞. ∫ÔÏȷϤÍË3, ∞. ª·‡ÚÔ˘3, ∂. °È·ÓÓ¿ÙÔ˘1, ¡. π·Îˆ‚›‰Ô˘1, ∞. ºÚÂÙ˙¿ÁÈ·˜1, ∂. °ÂˆÚÁÔ‡ÏË1, ∞. ¶·ÙÛÔ‡Ú·2, ¡. ™˘Ú›‰Ë˜1, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜1

A neonate with ring chromosome 14 [r(14)] A. Galla - Voumvouraki1, S. Kitsiou - Tzeli3, A. Kolialexi3, A. Mavrou3, I. Giannatou1, N. Iakovidou1, A. Fretzagias1, H. Georgouli1, A. Patsoura2, N. Spyridis1, A. Constantopoulos1

¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ¿ÚÚÂÓÔ˜ ÓÂÔÁÓÔ‡ ËÏÈΛ·˜ 5 ËÌÂÚÒÓ, Ì ȉÈfiÌÔÚÊÔ ÚÔÛˆ›Ô, ‰˘ÛÏ·Û›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ‚Ú·¯‡ ·˘¯¤Ó·, ÌÔÓ‹ÚÂȘ ¯ÂÈÚÔÌ·ÓÙÈΤ˜ ÁÚ·Ì̤˜, ·ÓÔÈÎÙfi ˆÔÂȉ¤˜ ÙÚ‹Ì·, ÌÂÛÔÎÔÏÈ΋ ÂÈÎÔÈÓˆÓ›· Î·È ‰È¿Ù·ÛË ‰ÂÍÈÒÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ, ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠηڢfiÙ˘Ô˜ 46,ÃÀ,-14+ r(14), de novo. ∏ ‰È¿ÁÓˆÛË ·˘ÙÔ‡ ÙÔ˘ Û¿ÓÈÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÂȂ‚·ÈÒıËΠ̠ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌfi (FISH). ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÎÏÈÓÈ΋ ÔÚ›· ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓ‹ ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 16 ÌËÓÒÓ, Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙË Û¯ÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· Î·È ÛÙȘ Û‡Á¯ÚÔÓ˜ ΢ÙÙ·ÚÔÁÂÓÂÙÈΤ˜ ÌÂıfi‰Ô˘˜ ÁÈ· ÙËÓ Ù·˘ÙÔÔ›ËÛË Û¿ÓÈˆÓ ‰ÔÌÈÎÒÓ ¯ÚˆÌÔÛˆÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ηıÒ˜ Î·È ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË.

Abstract: The case is reported of a 5 day-old male infant with peculiar facies, retinal dysplasia, short neck, bilateral simian creases, patent ductus arteriosus, atrial septal defect and dilatation of the right ventricle. His karyotype was 46,ÃÀ,-14+ r(14), de novo. The diagnosis of this rare chromosome syndrome was confirmed using fluorescence in situ hybridization (FISH). The clinical course of the patient up to the age of 16 months is presented and the relative literature is reviewed, focusing on the molecular cytogenetic assays and on genetic counselling.

§¤ÍÂȘ ÎÏÂȉȿ: ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14, ÊıÔÚ›˙ˆÓ in situ ˘‚ÚȉÈÛÌfi˜ (FISH).

Key words: ring chromosome 14, fluorescence in situ hybridization (FISH).

∂ÈÛ·ÁˆÁ‹ ∆Ô ¯ÚˆÌÔÛˆÌÈÎfi Û‡Ó‰ÚÔÌÔ ÙÔ˘ ‰·ÎÙ˘ÏÈÔÂȉԇ˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 14 [r(14)] ·ÔÙÂÏ› Û¿ÓÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ì ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘ ÔÈΛÏÏÔ˘Ó Û ¤ÎÙ·ÛË Î·È ‚·Ú‡ÙËÙ·. ∆· ·ÚÈ· ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È Ë ÂÈÏË„›· ·fi ÙËÓ ÚÒÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, Ë „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È Ë ÌÈÎÚÔÎÂÊ·Ï›·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÈΛϷ ÂÏ¿ÛÛÔÓ· ‰˘ÛÌÔÚÊÈο ÛËÌ›· (1-12). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ¿ÚÚÂÓÔ˜ ÓÂÔÁÓÔ‡ ËÏÈΛ·˜ 5 ËÌÂÚÒÓ, Ì ȉÈfiÌÔÚÊÔ ÚÔÛˆ›Ô, Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Î·È ‰˘ÛÏ·Û›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠηڢfiÙ˘Ô˜ Ì ‰·-

ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 [r(14)] ÛÙË ı¤ÛË ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 14. ∏ ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒıËΠ̠ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌfi (FISH).

1 ∂ÚÁ·ÛÙ‹ÚÈÔ °ÂÓÂÙÈ΋˜, ∆Ì‹Ì· ¡ÂÔÁ¤ÓÓËÙˆÓ, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 2 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 3 ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1 Genetics Laboratory, Neonatal Unit, 2nd Paediatric Clinic of Athens University, “P. & A. Kyriakou” Children’s Hospital, Athens 2 Intensive Care Unit, “P. & A. Kyriakou” Children’s Hospital, Athens 3 Laboratory of Medical Genetics of Athens University, “Aghia Sophia” Children’s Hospital, Athens

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ™Â ¿ÚÚÂÓ ÓÂÔÁÓfi ËÏÈΛ·˜ 5 ËÌÂÚÒÓ, ÙÔ ÔÔ›Ô ÓÔÛËÏ¢fiÙ·Ó ÛÙÔ ∆Ì‹Ì· ¡ÂÔÁ¤ÓÓËÙˆÓ Ì Ó¢ÌÔıÒڷη, ˙ËÙ‹ıËΠÁÂÓÂÙÈ΋ ÂÎÙ›ÌËÛË ÏfiÁˆ ȉÈfiÌÔÚÊˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ‰Â‡ÙÂÚÔ ·È‰› ÙÂÙÚ·ÌÂÏÔ‡˜ ÔÈÎÔÁ¤ÓÂÈ·˜, Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ (Ë ÌËÙ¤Ú· ËÏÈΛ·˜ 32 ÂÙÒÓ Î·È Ô ·Ù¤Ú·˜ 40 ÂÙÒÓ), ÙÔ ÔÔ›Ô ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË ÔÌ·Ï‹ ·ËÛË ÌÂ

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ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ Èۯȷ΋˜ ÚÔ‚ÔÏ‹˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, Ë ÌËÙ¤Ú· ‰ÂÓ ÓfiÛËÛÂ, Ô‡Ù ÂÎÙ¤ıËΠ۠ʿÚ̷η Ì ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË ‹ Û ÛËÌ·ÓÙÈ΋ ‰fiÛË ·ÎÙÈÓÔ‚ÔÏ›·˜. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙÔ ÓÂÔÁÓfi ›¯Â ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ 3200 g (10Ë-50‹ ∂£), Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ 50 cm (10Ë-50‹ ∂£), ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ 35 cm (10Ë50‹ ∂£) Î·È ‰È·ÈÛÙÒıËÎ·Ó Ù· ·ÎfiÏÔ˘ı· ȉÈfiÌÔÚÊ· Ê·ÈÓÔÙ˘Èο ¯·Ú·ÎÙËÚÈÛÙÈο: ÛÙÂÓ¤˜ ‚ÏÂÊ·ÚÈΤ˜ Û¯ÈṲ̂˜, Â›Î·ÓıÔ˜, ·ÓÂÛÙÚ·Ì̤ӷ ÚÈÓÈο ÙÂÚ‡ÁÈ·, ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ˆÙfi˜, ÌÈÎÚÔÁÓ·ı›·, ‚Ú·¯‡˜ ·˘¯¤Ó·˜ Î·È ÌÔÓ‹Ú˘ ¯ÂÈÚÔÌ·ÓÙÈ΋ ÁÚ·ÌÌ‹ ¿Ìʈ. O ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ›¯Â Ê˘ÛÈÔÏÔÁÈο ÁÂÓÓËÙÈο fiÚÁ·Ó·. ™ÙÔÓ ·ÛıÂÓ‹ ¤ÁÈÓ ΢ÙÙ·ÚÔÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÌÂÙ¿ ·fi ηÏÏȤÚÁÂÈ· ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Ì ÚÔÛı‹ÎË PHA Î·È Û‹Ì·ÓÛË GTG. ¢È·ÈÛÙÒıËΠfiÙÈ Û fiϘ ÙȘ ÌÂÙ·Ê¿ÛÂȘ ›¯Â ηڢfiÙ˘Ô ¿ÚÚÂÓÔ˜ Ì 46 ¯ÚˆÌÔÛÒÌ·Ù·, ·ÏÏ¿ ÛÙË ı¤ÛË ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ ÙÔ˘ ˙‡ÁÔ˘˜ 14 ¤ÊÂÚ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ (∂ÈÎfiÓ· 1). ∏ Ù¯ÓÈ΋ ÙÔ˘ ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌÔ‡ (FISH), Ì ÙË Ì¤ıÔ‰Ô ‚·Ê‹˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ (chromosome painting) Î·È ·ÓȯÓÂ˘Ù‹ ÁÈ· ÙÔ ¯ÚˆÌfiۈ̷ 14, ÂȂ‚·›ˆÛ fiÙÈ ÙÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ Â›Ó·È ¯ÚˆÌfiۈ̷ 14 (∂ÈÎfiÓ· 2). ªÂÙ¿ ÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰·ÎÙ˘ÏÈÔÂȉԇ˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 14, ·ÎÔÏÔ‡ıËÛ ·Ú·ÎÏÈÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ (˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜/ÓÂÊÚÒÓ, ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË/‚˘ıÔÛÎfiËÛË) ÁÈ· ·Ó·˙‹ÙËÛË ÌÂÈ˙fiÓˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ. ∆· ÌÔÓ·‰Èο ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ ‰È·ÈÛÙÒıËÎ·Ó ‹Ù·Ó ÙÔ ·ÓÔÈÎÙfi ˆÔÂȉ¤˜ ÙÚ‹Ì· Î·È Ë ‰˘ÛÏ·Û›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ™ÙÔ Ï·›ÛÈÔ Ù˘ ·Ú¯È΋˜ ÁÂÓÂÙÈ΋˜ ηıÔ‰‹ÁËÛ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Û˘ÛÙ‹ıËΠÎÏÈÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡, Ì ÂÈΤÓÙÚˆÛË ÛÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ·‡ÚÂÙˆÓ Û·ÛÌÒÓ, ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË Î·È ÙËÓ Î·Ú‰ÈÔÏÔÁÈ΋ Â·ÓÂÎÙ›ÌËÛË.

O ΢ÙÙ·ÚÔÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÂÎÙ¿ıËΠÛÙÔ˘˜ ÁÔÓ›˜ Î·È ÙÔÓ ·‰ÂÏÊfi ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓ‹, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·ÚÈıÌËÙÈ΋ ‹ ‰ÔÌÈ΋ ¯ÚˆÌÔÛˆÌÈ΋ ‰È·Ù·Ú·¯‹, ·ÏÏ¿ Û˘ÛÙ‹ıËΠÚÔÁÂÓÓËÙÈÎfi˜ ¯ÚˆÌÔÛˆÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û οı ÂfiÌÂÓË Î‡ËÛË Ù˘ ÌËÙ¤Ú·˜.

O ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 16 ÌËÓÒÓ (∂ÈÎfiÓ· 3) ›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÂÈÛfi‰È· ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ÙÔÓÈÎÔÎÏÔÓÈÎÒÓ Û·ÛÌÒÓ, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ›¯Â ÓÔÛËÏ¢ı› Â·ÓÂÈÏËÌ̤ӷ Î·È ‚Ú›ÛÎÂÙ·È Û ·ÁˆÁ‹ Ì ʷÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È Î·Ú‚·Ì·˙Â›ÓË. ∫·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ·˘Ùfi ‰È¿ÛÙËÌ·, ÓÔÛËχıËΠÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÁÈ· Ô˘ÚÔÏԛ̈ÍË ·fi E. coli, ‚ÚÔÁ¯ÔÓ¢ÌÔÓ›· Î·È Ó¢ÌÔÓ›·

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¯Ú#14

r(14)

¯Ú#14

r(14)

∂ÈÎfiÓ· 1. ªÂÚÈÎÔ› ηڢfiÙ˘ÔÈ ÙÔ˘ ·ÛıÂÓÔ‡˜ (GTG-banding).

M ٷ ‚¤ÏË ÛËÌÂÈÒÓÔÓÙ·È Ù· ‰·ÎÙ˘ÏÈÔÂȉ‹ ¯ÚˆÌÔÛÒÌ·Ù· 14 [r(14)].

∂ÈÎfiÓ· 2. ªÔÚȷ΋ ΢ÙÙ·ÚÔÁÂÓÂÙÈ΋ ÌÂϤÙË Ì ÙË Ì¤ıÔ‰Ô ‚·Ê‹˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ Ì ·ÓȯÓÂ˘Ù‹ ÁÈ· ÙÔ ¯ÚˆÌfiۈ̷ 14. ªÂ ÙÔ ‚¤ÏÔ˜ ÛËÌÂÈÒÓÂÙ·È ÙÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14.

∂ÈÎfiÓ· 3. O ·ÛıÂÓ‹˜ Û ËÏÈΛ· 16 ÌËÓÒÓ.

·ÚÈÛÙÂÚÔ‡ οو ÏÔ‚Ô‡ ÌÂ Û˘ÓÔ‰fi ÌÈÎÚÔ‚È·ÈÌ›· ·fi Haemophilus influenzae. ™Â ËÏÈΛ· 16 ÌËÓÒÓ Â›¯Â ÌÈÎÚÔÎÂÊ·Ï›· (¶∫: <3Ë ∂£), ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ (µ™: <3Ë ∂£), ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·

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ÙÔ˘ Ù‡Ô˘ Ù˘ ÌÂÛÔÎÔÏÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Î·È ÙÔ˘ ·ÓÔÈÎÙÔ‡ ˆÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ ÌÂ Û˘ÓÔ‰fi ‰È¿Ù·ÛË ÙˆÓ ‰ÂÍÈÒÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ. ™˘˙‹ÙËÛË ∆Ô ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 [r(14)] Â›Ó·È Û¿ÓÈÔ ¯ÚˆÌÔÛˆÌÈÎfi Û‡Ó‰ÚÔÌÔ. ∞fi ÙÔ 1971 Ô˘ ÂÚÈÁÚ¿ÊËΠÙÔ ¯ÚˆÌÔÛˆÌÈÎfi Û‡Ó‰ÚÔÌÔ Ì¤¯ÚÈ Û‹ÌÂÚ·, ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› 37 ÂÚÈÙÒÛÂȘ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÂÓfi˜ ˙‡ÁÔ˘˜ ÌÔÓÔˆÔÁÂÓÒÓ ‰È‰‡ÌˆÓ (1,11,12).

OÈ ÌÔÚÊÔÏÔÁÈΤ˜ Ê·ÈÓÔÙ˘ÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ¿ÙÔÌ· Ì ÙÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 [r(14)] ÔÈΛÏÏÔ˘Ó Î·È ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ Û ÂÏ¿ÛÛÔÓ˜ ‰˘ÛÌÔÚʛ˜, fiˆ˜ Â›Î·ÓıÔ, ‚Ú·¯‡ ·˘¯¤Ó·, ˘„ËÏ‹ ˘ÂÚÒ·, ÂÈ¤‰ˆÛË Ù˘ Ú›˙·˜ Ù˘ ̇Ù˘ Î·È ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ÒÙˆÓ (1,8,12). ∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ r(14), ÂÓÒ ÂÚÈÁÚ¿ÊÂÙ·È fiÙÈ ‚Ú›ÛÎÂÙ·È ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘, ÛÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ηı˘ÛÙ¤ÚËÛË, fiˆ˜ Î·È ÛÙÔÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ (1,8).

OÈ ·ÛıÂÓ›˜, ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙÔ˘˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÈÎÚÔÎÂÊ·Ï›· Î·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, Ë ÔÔ›· ÔÈΛÏÏÂÈ Î·È Î˘Ì·›ÓÂÙ·È ·fi Ôχ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ¤ˆ˜ ‚·ÚÈ¿ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Ô˘ Â›Û˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ô ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ (1,2,7,8). ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, Ì¿ÏÈÛÙ·, ¤¯ÂÈ ‰È·ÈÛÙˆı› ·ÙÚÔÊ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ì ‰È¿Ù·ÛË ÙˆÓ Ï¿ÁÈˆÓ ÎÔÈÏÈÒÓ ‹ ˘ÔÏ·Û›· ÙÔ˘ ÌÂÛÔÏÔ‚›Ô˘ (2). ∫ÔÈÓfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi fiÏˆÓ Û¯Â‰fiÓ ÙˆÓ ·È‰ÈÒÓ Ì ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 Â›Ó·È Ë ÂÌÊ¿ÓÈÛË ·‡ÚÂÙˆÓ Û·ÛÌÒÓ ·fi ÙËÓ ÚÒÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. OÈ Û·ÛÌÔ› ÂÓÙ¿ÛÛÔÓÙ·È ÛÙË ÁÂÓÈÎÂ˘Ì¤ÓË ÌÔÚÊ‹ ÂÈÏË„›·˜, ÂÎÊÚ¿˙ÔÓÙ·È Î˘Ú›ˆ˜ ˆ˜ Ì˘ÔÎÏÔÓÈ΋ ÂÈÏË„›· ηÈ, Û·ÓÈfiÙÂÚ·, ˆ˜ Û‡ÓıÂÙÔÈ ÂÛÙÈ·ÎÔ› Û·ÛÌÔ›, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È ÌÂ Û˘ÁÎÂÎÚÈ̤ÓË ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ô‡Ù ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·ıÔÁÓˆÌÔÓÈÎfi ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (1,2,7,8). ™Â ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ (8/37, 22%) ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÛÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ÂÌÊ·Ó‹˜ ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (1,5,8). ¶·ÚfiÌÔÈ· ¢·ÈÛıËÛ›· ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Ô ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ Î·È ÙË Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ¿ ÙÔ˘, Ë ÔÔ›· ·ÔÙÂÏ› ÂÈϤÔÓ ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ·. OÈ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ·ÔÙÂÏÔ‡Ó Ôχ Û¿ÓÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ· ÙÔ˘ Ù‡Ô˘ Ù˘ ÛÙ¤ÓˆÛ˘ Ù˘ ·ÔÚÙ‹˜ ‹ Ù˘ Ó¢ÌÔ-

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ÓÈ΋˜ ·ÚÙËÚ›·˜ ÌfiÓÔ Û ÙÚÂȘ ·ÛıÂÓ›˜ (8,12). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ Ì˯·ÓÈÛÌfi ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ r(14), ıˆÚÂ›Ù·È fiÙÈ ÚÔËÁÂ›Ù·È ·ÒÏÂÈ· ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi Ù· ‰‡Ô ¿ÎÚ· ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ (Ì·ÎÚ¿ Î·È ‚Ú·¯¤·), Ù· ÔÔ›· ÛÙË Û˘Ó¤¯ÂÈ· Û˘Ó‰¤ÔÓÙ·È Û ۯËÌ·ÙÈÛÌfi ‰·ÎÙ˘Ï›Ô˘. ∆Ô r(14) ‰ËÌÈÔ˘ÚÁÂ›Ù·È “·˘ÙfiÌ·Ù·” ‹ ÂÎ Ó¤Ô˘ (de novo) ÛÙ· ·Ú¯Èο ÛÙ¿‰È· ·Ó¿Ù˘Í˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∆· ‰˘ÛÌÔÚÊÈο ÛËÌ›· Î·È ÔÈ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ·ÛıÂÓ›˜ Ì ÙÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14, ÂÍ·ÚÙÒÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ·fi ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·ÔÏÂÛı¤ÓÙÔ˜ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ηٿ ÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘, ηıÒ˜ Î·È ·fi ÙÔ Î·Ù¿ fiÛÔ ÚfiÎÂÈÙ·È ÁÈ· ̈۷˚Îfi ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÛÂÈÚ¿ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ (1-9). £ÂˆÚ›ٷÈ, fï˜, fiÙÈ ·ÎfiÌË Î·È Ôχ ÌÈÎÚ‹ ·ÒÏÂÈ· ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 14 (14q) ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔÓ Ê·ÈÓfiÙ˘Ô. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ÛËÌ›· ÙÔÌ‹˜ (breakpoints), Ê·›ÓÂÙ·È fiÙÈ ÁÈ· ÙÔ ÌÂÓ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ (14p) Â›Ó·È Î˘Ú›ˆ˜ Ë ÂÚÈÔ¯‹ 1.1 (14p1.1) Î·È ÏÈÁfiÙÂÚÔ ÔÈ ÂÚÈÔ¯¤˜ 1.3 (14p1.3) Î·È 1.2 (14p1.2), ÂÓÒ ÁÈ· ÙÔ Ì·ÎÚfi ÛΤÏÔ˜ (14q) Â›Ó·È Î˘Ú›ˆ˜ Ë ÂÚÈÔ¯‹ 3.2 (14q3.2) Î·È ÏÈÁfiÙÂÚÔ ÔÈ ÂÚÈÔ¯¤˜ 3.1 (14q3.1) Î·È 2.4 (14q2.4) (8).

OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ Ì ÙË ¯ÚˆÌÔÛˆÌÈ΋ ·˘Ù‹ ‰È·Ù·Ú·¯‹ ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈÎfi ηڢfiÙ˘Ô, fiˆ˜ Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ∂Ô̤ӈ˜, Ë Èı·ÓfiÙËÙ· Ó· ·ÔÎÙ‹ÛÂÈ ·˘Ù‹ Ë ÔÈÎÔÁ¤ÓÂÈ· Î·È ‰Â‡ÙÂÚÔ ·È‰› Ì ÙËÓ ›‰È· ¯ÚˆÌÔÛˆÌÈ΋ ‰È·Ù·Ú·¯‹ Â›Ó·È Ôχ ÌÈÎÚ‹. ™˘ÓÈÛٿٷÈ, fï˜, Ó· Á›ÓÂÙ·È ÚÔÁÂÓÓËÙÈÎfi˜ ¯ÚˆÌÔÛˆÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û οı ÂfiÌÂÓË Î‡ËÛË Ù˘ ÌËÙ¤Ú·˜. µÂ‚·›ˆ˜, Ë Û‡ÛÙ·ÛË ÁÈ· ÚÔÁÂÓÓËÙÈÎfi ¯ÚˆÌÔÛˆÌÈÎfi ¤ÏÂÁ¯Ô ÈÛ¯‡ÂÈ È‰È·›ÙÂÚ· ÁÈ· ÂΛӘ ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ Ô ¤Ó·˜ ÁÔÓ¤·˜ ‚ÚÂı› fiÙÈ Ê¤ÚÂÈ Â›Û˘ ÙÔ ›‰ÈÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14, ‰ÈfiÙÈ ÙfiÙ ÔÈ Èı·ÓfiÙËÙ˜ Ó· ÁÂÓÓËı› Î·È ‰Â‡ÙÂÚÔ ·È‰› Ì ÙËÓ ›‰È· ¯ÚˆÌÔÛˆÌÈ΋ ‰È·Ù·Ú·¯‹ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ˜. ŸÌˆ˜, Ô ÂÌÂÈÚÈÎfi˜ ΛӉ˘ÓÔ˜ Â·Ó¿Ï˄˘ Û ÔÈÎÔÁ¤ÓÂȘ Ì ÁÔÓ¤· ÊÔÚ¤· ÙÔ˘ r(14) ‰ÂÓ ¤¯ÂÈ ÚÔÛ‰ÈÔÚÈÛÙ›, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ Ù¤ÙÔÈˆÓ ÂÚÈÙÒÛÂˆÓ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ Á˘Ó·ÈÎÒÓ Ì r(14) Î·È ÔÚȷ΋ ÓÔËÌÔÛ‡ÓË, ·fi ÙȘ Ôԛ˜ ÁÂÓÓ‹ıËÎ·Ó ·È‰È¿ Ô˘ ›¯·Ó ÙËÓ ›‰È· ¯ÚˆÌÔÛˆÌÈ΋ ‰È·Ù·Ú·¯‹ Î·È ·ÚÔ˘Û›·˙·Ó ÙȘ ·ÚȘ ÂΉËÏÒÛÂȘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (1,3,10). ∆Ô ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì r(14) Â›Ó·È ÂÏ·Ùو̤ÓÔ Î·È Û·Ó›ˆ˜ ÍÂÂÚÓ¿ ÙËÓ ÙÚ›ÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ (1). ∆¤ÏÔ˜, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ fiˆ˜ Û fiÏ· Ù· ÔÏ˘Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù· - Ë Û˘ÓÔÏÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ Ì ÙÔ ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ 14 ÚÔ¸Ôı¤ÙÂÈ ÙË Û˘ÓÂÚÁ·Û›·

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ÔÏÏÒÓ ·È‰È·ÙÚÈÎÒÓ ÂȉÈÎÔÙ‹ÙˆÓ Î·È ı· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È È‰È·›ÙÂÚË ÛËÌ·Û›· ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÔÏfiÎÏËÚ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (1-9). µÈ‚ÏÈÔÁÚ·Ê›· 1. Schinzel A. Ring chromosome 14 [r(14)] and r(14) mosaicism. In: de Grugter W, editor. Catalogue of unbalanced chromosome aberration in man. 2nd ed. New York: Walter de Gruyter and Co; 2001. p. 605.

2. Ono J, Nishiike K, Imai K, Otani K, Okada S. Ring chromosome 14 complicated with complex partial seizures and hypoplastic corpus callosum. Pediatr Neurol 1999;20:70-72.

3. Matalon R, Supple P, Wyandt H, Rosenthal IM. Transmission of ring 14 chromosome from mother to two sons. Am J Med Genet 1990;36:381-385.

4. Howard PJ, Clark D, Dearlove J. Retinal/macular pigmentation in conjunction with ring 14 chromosome. Hum Genet 1988;80:140-142.

5. Schmidt R, Eviatar L, Nitowsky HM, Wong M, Miranda S. Ring chromosome 14: a distinct clinical entity. J Med Genet 1981;18:304-307.

6. Krawczun M, Melink G, Cervenka J. Ring chromosome 14 and immunoglobulin locus. Am J Med Genet 1984;17:465-469.

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7. Shirasaka Y, Ito M, Okuno T, Fujii T, Nozaki K, Mikawa H. Ring 14 chromosome with complex partial seizures: a case report. Brain Dev 1992;14:257-260.

8. Zelante L, Torricelli F, Calvano S, Mingarelli R, Dallapiccola B. Ring chromosome 14 syndrome. Report of two cases, including extended evaluation of a previously reported patient and review. Ann Genet 1991;34:93-97.

9. de Blois MC, Caille B, Rethore MO, Dufier JL, Lejeune J. r(14) syndrome without major dysmorphism. Ann Genet 1990;33:155-158.

10. Riley SB, Buckton KE, Ratcliffe SG, Syme J. Inheritance of a ring 14 chromosome. J Med Genet 1981;18:209-213.

11. Sparkes RS, Klisak I, Sparkes MC. Extended evaluation of previously reported twins with a ring 14 chromosome. Ann Genet 1977;20:273-275.

12. Schintzel A. Human cytogenetic database. In: Baraitser M, Winter RM, editors. London: Oxford University Press; 1993. ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-10-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-05-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÁÁÂÏÈ΋ °·ÏÏ¿-µÔ˘Ì‚Ô˘Ú¿ÎË ∂ÚÁ·ÛÙ‹ÚÈÔ °ÂÓÂÙÈ΋˜ µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” E-mail: acgalla@yahoo.gr

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CASE REPORT

ÀÔÙÚÔÈ¿˙Ô˘Û· ·ÈÌÔÚÚ·Á›· Û ·È‰› ‰ÂηÙÚÈÒÓ ÂÙÒÓ Ì ·ÙÚËÛ›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ù‡Ô˘ π ™. ™ÙÂÊ·Ó¿ÎË1, £. ∆ÛÂÎÔ˘Ú¿1, ∞. ™¯ÔÈÓ¿ÎË1, ¢. ∫ÂÚ·Ì›‰·˜2, ∞. ∆ÛÈÏÈÌÈÁοÎË1

Relapsing bleeding in a thirteen year-old child with type I intestinal atresia S. Stefanaki1, T. Tsekoura1, A. Schinaki1, D. Keramidas2, A. Tsilimigaki1

¶ÂÚ›ÏË„Ë: ∞ÈÌÔÚÚ·Á›· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Û ÔÔÈÔ‰‹ÔÙ ÛËÌÂ›Ô ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ Î·È Ë ·Ó›¯Ó¢ÛË Ù˘ ÂÓÙfiÈÛ‹˜ Ù˘ ÌÔÚ› Ó· Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏË. ∏ ÂÛÙ›· Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, Ô˘ Â›Ó·È ÙÔ ÏÈÁfiÙÂÚÔ Èı·Ófi ÛËÌÂ›Ô ·ÈÌÔÚÚ·Á›·˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ, Â›Ó·È ÈÔ ‰‡ÛÎÔÏÔ Ó· ·ÓȯÓ¢Ù›, Ì ÂÍ·›ÚÂÛË ÙËÓ ·ÈÌÔÚÚ·Á›· Ù˘ ·fiÊ˘Û˘ ÙÔ˘ Meckel Ô˘ ·ÓȯÓ‡ÂÙ·È Û¯ÂÙÈο ‡ÎÔÏ·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ ËÏÈΛ·˜ 13 ÂÙÒÓ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ·ÈÌÔÚÚ·Á›·˜ ÙÔ˘ ÂÙÈÎÔ‡, Ô˘ ÂΉËÏÒıËÎ·Ó Ì ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ Î·È ¯ÚfiÓÈ· ·Ó·ÈÌ›·. O Û˘Ó‹ı˘ ·Ú¯ÈÎfi˜ - ·ÏÏ¿ Î·È Ô ÂÓ‰Âϯ‹˜ - ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ÓfiÛÔ˘, ·¤‚Ë ¿Î·ÚÔ˜ ÌÂÙ¿ ·fi ¤ÍÈ Û˘ÓÔÏÈο ÓÔÛËÏ›˜ Ù˘ ·ÛıÂÓÔ‡˜ Û ÓÔÛÔÎÔÌ›·. ∏ ·ÛıÂÓ‹˜ ¯ÚÂÈ¿ÛÙËΠӷ ˘Ô‚ÏËı› Û ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›·, Ë ÔÔ›· ¤‰ÂÈÍ ÌÂÁ¿ÏË ‰È¿Ù·ÛË ¤ÏÈη˜ ÙÔ˘ ÂÈÏÂÔ‡ ·fi Û˘ÁÁÂÓ¤˜ ·ÙÂϤ˜ ‚ÏÂÓÓÔÁfiÓÈÔ ‰È¿ÊÚ·ÁÌ· Ô˘ ÚÔηÏÔ‡Û ¯ÚfiÓÈ· ÛÙ¿ÛË Ì ÈÛ¯·ÈÌ›· ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÂÍÂÏÎÒÛÂȘ. ™˘Ó˘‹Ú¯Â ·ÓˆÌ·Ï›· ÛÙÚÔÊ‹˜ Î·È Î·ı‹ÏˆÛ˘ (malrotation) ¯ˆÚ›˜ ·fiÊÚ·ÍË. ŒÁÈÓ ÂÎÙÔÌ‹ Ù˘ ‰È·ÙÂٷ̤Ó˘ ¤ÏÈη˜ Î·È ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ÙÂÏÈÎÔÙÂÏÈ΋ ·Ó·ÛÙfïÛË. ∆Ú›· ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÂÁ¯Â›ÚËÛË, Ë ·ÛıÂÓ‹˜ Â›Ó·È ·Û˘Ìو̷ÙÈ΋ Î·È Ì ¿ÚÈÛÙË ˘Á›·.

Abstract: Bleeding may occur at any site in the gastrointestinal tract and the detection of the bleeding site can present a challenge. Bleeding from the small bowel is rare and its source is quite difficult to diagnose, with the exception of Meckel’s diverticulum. A case report is presented of a girl of thirteen years who had suffered from relapsing incidents of melaena and chronic anaemia for 6.5 years. The initial thorough examinations performed to identify the diagnosis proved to be unsuccessful after six hospital admissions. The patient was then submitted to exploratory laparotomy, which revealed huge dilatation of an ileal loop secondary to a congenital incomplete mucosal diaphragm, causing chronic stasis, ischaemia and ulcerations.

This anomaly was combined with non-obstructing malrotation. Excision and anastomosis was performed and the patient remains asymptomatic and in perfect health three years after the operation.

§¤ÍÂȘ ÎÏÂȉȿ: ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ, ·ÙÚËÛ›· ÂÓÙ¤ÚÔ˘ Ù‡Ô˘ I, ·ÈÌÔÚÚ·Á›· ÂÙÈÎÔ‡.

Key words: melaena, intestinal atresia type I, gastrointestinal bleeding.

∂ÈÛ·ÁˆÁ‹ ∏ ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Â›Ó·È ¤Ó· Û‡Ìو̷ Ô˘ ÚÔηÏ› ·ÓËÛ˘¯›· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ËÏÈΛ· Î·È Û˘¯Ó¿ ÚÔηÏ› ·ÓÈÎfi ÛÙÔ˘˜ ÁÔÓ›˜ ηÈ

ÚÔ‚ÏËÌ·Ù›˙ÂÈ ÙÔÓ ·È‰›·ÙÚÔ (1). ∂¿Ó Ë ·ÈÌÔÚÚ·Á›· Â›Ó·È ÌÂÁ¿ÏË, ÌÔÚ› Ó· ÚÔηϤÛÂÈ shock Î·È ı¿Ó·ÙÔ. ∆¤ÙÔȘ ·ÈÌÔÚÚ·Á›Â˜, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Â›Ó·È Û¿ÓȘ (2). O Á·ÛÙÚÂÓÙÂÚÈÎfi˜

1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ 2 ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1 2nd Paediatric Clinic, Venizelion General Hospital, Heraklion, Crete 2 Paediatric Surgery Clinic, “Aghia Sophia” Children’s Hospital, Athens

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¶·È‰È·ÙÚÈ΋ 2004;67:363-366

ۈϋӷ˜, ÏfiÁˆ Ù˘ ÌÂÁ¿Ï˘ ‚ÏÂÓÓÔÁfiÓÈ·˜ ÂÈÊ¿ÓÂÈ·˜ Î·È Ù˘ ÏÔ‡ÛÈ·˜ ·ÁÁ›ˆÛ˘ Ô˘ ‰È·ı¤ÙÂÈ, ÌÔÚ› ‡ÎÔÏ· Ó· ·ÈÌÔÚÚ·Á‹ÛÂÈ (1). ¶·Ú’ fiÏÔ Ô˘ Ô Û˘ÓÔÏÈÎfi˜ fiÁÎÔ˜ ·›Ì·ÙÔ˜ ÛÙ· ·È‰È¿ Â›Ó·È ÌÈÎÚfi˜ Î·È Â‡ÎÔÏ· ÂÍ·ÓÙÏ›ٷÈ, Ë ¤Î‚·ÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ ÂÙÈÎfi ÛÙ· ·È‰È¿ Â›Ó·È ÁÂÓÈο ηϋ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÓÙ·ÙÈ΋ ÊÚÔÓÙ›‰· Ô˘ ÙÔ˘˜ ·Ú¤¯ÂÙ·È Î·È ÙËÓ Î·Ï‹ Ê˘ÛÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË (3). ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 13 ÂÙÒÓ ÚÔÛ‹Ïı ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ Ì ÎÂÊ·Ï·ÏÁ›·, Ó·˘Ù›·, ˙¿ÏË, ·‰˘Ó·Ì›·, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ Î·È Ì¤Ï·ÈÓ˜ ÎÂÓÒÛÂȘ ·fi ÂÈÎÔÛÈÙÂÙÚ·ÒÚÔ˘. ∏ ·ÛıÂÓ‹˜ ‚ÚÈÛÎfiÙ·Ó Û ·ÁˆÁ‹ Ì ۛ‰ËÚÔ ÏfiÁˆ ·Ó·ÈÌ›·˜. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi Ù˘ ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ. ∞fi ÙÔ ·ÙÔÌÈÎfi Ù˘ ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÔÓÙ·È Û˘ÓÔÏÈο ¤ÍÈ ÓÔÛËÏ›˜ Û ¶·È‰È·ÙÚÈο ∆Ì‹Ì·Ù· ÁÈ· ¤ÏÂÁ¯Ô ̤ϷÈÓˆÓ ÎÂÓÒÛÂˆÓ Î·È ˘fi¯ÚˆÌ˘ ÌÈÎÚÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜. ∏ ÚÒÙË ÂÈÛ·ÁˆÁ‹ Ù˘ ¤ÁÈÓ ÁÈ· ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ Û ËÏÈΛ· 7 ÂÙÒÓ Î·È ‹Ù·Ó Û‡ÓÙÔÌ˘ ‰È¿ÚÎÂÈ·˜. ∏ ·ÛıÂÓ‹˜ ÓÔÛËχÙËΠÛÙËÓ ÎÏÈÓÈ΋ ¯ˆÚ›˜ Ó· ‰È·ÈÛÙˆı› Û·Ê‹˜ ·ÈÙÈÔÏÔÁ›· Ù˘ ·ÈÌÔÚÚ·Á›·˜. O ·Ú¯ÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ÏÂ˘Î¿ 10,7x103/mm3, ¶: 48%, §: 44%, ª: 8%, Hb: 11 g/dl, ∏t: 34%, PLT: 390x103/mm3, MCV: 79 fl, MCH: 25 pg, Û›‰ËÚÔ˜: 40 Ìg/dl, ÊÂÚÈÙ›ÓË: 20 ng/ml, ¿ÌÂÛË Coombs ·ÚÓËÙÈ΋, ËÏÂÎÙÚÔÊfiÚËÛË Hb Ê˘ÛÈÔÏÔÁÈ΋, Ë·ÙÈÎfi˜, ÓÂÊÚÈÎfi˜ Î·È ¤ÏÂÁ¯Ô˜ ‹Í˘ Ê˘ÛÈÔÏÔÁÈÎfi˜, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Ê˘ÛÈÔÏÔÁÈÎfi, ·/· ıÒÚ·ÎÔ˜ Î·È ÎÔÈÏ›·˜ Ê˘ÛÈÔÏÔÁÈΤ˜, Mayer ÎÔÚ¿ÓˆÓ (+++). ∆ÚÂȘ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰fi Ù˘ Â·ÓÂÌÊ¿ÓÈÛ ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ Î·È ˘Ô‚Ï‹ıËΠ۠Á·ÛÙÚÔÛÎfiËÛË, Ë ÔÔ›· ¤‰ÂÈÍ ‹È· ÂÈÎfiÓ· Á·ÛÙÚ›Ùȉ·˜. ∂Ó¿ÌÈÛË ¯ÚfiÓÔ ÌÂÙ¿, Ë ·ÛıÂÓ‹˜ Â·Ó‹Ïı Ì ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ Î·È ·Ó·ÈÌ›·. ∂›¯Â Í·Ó¿ Mayer ÎÔÚ¿ÓˆÓ (+++) Î·È Ë Ó¤· ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ¤‰ÂÈÍÂ: ÏÂ˘Î¿: 11x103/mm3, ¶: 65%, §: 25%, ª: 10%, Hb: 10,5 g/dl, Ht: 31%, MCV: 72 fl, MCH: 25 pg, PLT: 240x103/mm3. ŒÁÈÓ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ªÂÎÂÏ›Ԣ, fiÔ˘ ·Ú·ÙËÚ‹ıËΠ‰È¿¯˘Ù· ·˘ÍË̤ÓË ÚfiÛÏË„Ë ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ Ó‹ÛÙȉ·˜, ¯ˆÚ›˜ ÂÈÎfiÓ· ‡·Ú͢ ªÂΤÏÂÈÔ˘ ·fiÊ˘Û˘. ∏ ·ÛıÂÓ‹˜ ·Ú·¤ÌÊıËΠ۠¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ÙˆÓ ∞ıËÓÒÓ ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. ŒÁÈÓ ÂÈÚfiÛıÂÙÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ì ·ÍÔÓÈ΋ ÎÔÈÏ›·˜ Ô˘ ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÂÓÒ Â·Ó·Ï‹ÊıËÎ·Ó Ë ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ Î·È ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ªÂÎÂÏ›Ԣ Ì ٷ ›‰È· Â˘Ú‹Ì·Ù·. §fiÁˆ Ó¤·˜ ·ÈÌÔÚÚ·Á›·˜, ˘Ô‚Ï‹ıËΠ۠ÎÔÏÔÓÔÛÎfiËÛË Î·È „ËÊȷ΋ ·ÁÁÂÈÔÁÚ·Ê›· ÎÔÈÏ›·˜ Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜ Î·È Ù˘ Û˘ÓÂÛÙ‹ıË Ó· Û˘Ó¯›ÛÂÈ ÙË ıÂÚ·›· Ì ۛ‰ËÚÔ ÁÈ· ÙËÓ ·Ó·ÈÌ›· Ô˘ ›¯Â. ŒÓ· ¯ÚfiÓÔ ÌÂÙ¿,

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Paediatriki 2004;67:363-366

ÛÙËÓ ÙÂÏÂ˘Ù·›· ÂÈÛ·ÁˆÁ‹ Ù˘, ·ÚÔ˘Û›·˙ ¤ÓÙÔÓË ˆ¯ÚfiÙËÙ· Î·È ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË. ∞fi ÙËÓ ÂͤٷÛË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ‚Ú¤ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÂÎÙfi˜ ·fi ¤Ó· ‹ÈÔ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· ÛÙÔ 4Ô ·ÚÈÛÙÂÚfi ÌÂÛÔχÚÈÔ ‰È¿ÛÙËÌ·. ∏ ·ÚÙËÚȷ΋ Ù˘ ›ÂÛË ‹Ù·Ó 110/75 mmHg, ÔÈ ÛʇÍÂȘ 112/min, ÙÔ ‚¿ÚÔ˜ 50 kg (50‹ ∂£) Î·È ÙÔ ‡„Ô˜ Ù˘ 153 cm (ÌÂٷ͇ 25˘ Î·È 50‹˜ ∂£). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓ ÛÙËÓ ·ÛıÂÓ‹ ¤‰ÂÈÍÂ: ÏÂ˘Î¿: 18x103/mm3, ¶: 89%, §: 8%, ª: 3%, PLT: 403x103/mm3, Hb: 10,2 g/dl, Hct: 29,7%, MCV: 75,9 fl, MCH: 26,1 pg, RDW: 17,9, ÂÓ‰ÂÈÎÙÈο ˘fi¯ÚˆÌ˘ ÌÈÎÚÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜ Ô˘ ›¯Â ‰ÈÂÚ¢ÓËı› ÛÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÂÈÛ·ÁˆÁ¤˜ Ù˘, ¢∂∫: 2,3%. ∏ ∆∫∂ ‹Ù·Ó 13 mm ÙËÓ 1Ë ÒÚ· Î·È Ô Ë·ÙÈÎfi˜ Î·È ÓÂÊÚÈÎfi˜ ¤ÏÂÁ¯Ô˜, ηıÒ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ‹Í˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ›. º˘ÛÈÔÏÔÁÈο ‹Ù·Ó, Â›Û˘, Ë ÁÂÓÈ΋ Ô‡ÚˆÓ, Ë ·/· ıÒÚ·ÎÔ˜ Î·È ÙÔ ∏∫° Ù˘ ·ÛıÂÓÔ‡˜. ∏ Mayer ÎÔÚ¿ÓˆÓ ‹Ù·Ó ıÂÙÈ΋ (+++). ŒÁÈÓ Ӥ· Á·ÛÙÚÔÛÎfiËÛË ÛÙËÓ ·ÛıÂÓ‹, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· Ô ÔÈÛÔÊ¿ÁÔ˜ Î·È Ô ‚ÔÏ‚fi˜ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ™ÙÔÓ ÛÙfiÌ·¯Ô ·Ú·ÙËÚ‹ıËÎ·Ó ÂÚÈÔ¯¤˜ Ì ԛ‰ËÌ· Î·È ÂÚ˘ıÚfiÙËÙ·, ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì Á·ÛÙÚ›Ùȉ·. ∏ ÎÔÏÔÓÔÛÎfiËÛË, Ô˘ ¤ÏÂÁÍ ÙÔ ¤ÓÙÂÚÔ ˆ˜ ÙËÓ Ë·ÙÈ΋ ηÌ‹, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∏ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎÂ Û˘ÓÙËÚËÙÈο Ì ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú·, ¯ÔÚ‹ÁËÛË Ú·ÓÈÙȉ›Ó˘ ÂÓ‰ÔÊϤ‚È· Î·È Î·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÈÌ·ÙÔÎÚ›ÙË Î·È Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ù˘. OÈ Ì¤Ï·ÈÓ˜ ÎÂÓÒÛÂȘ ÛÙ·Ì¿ÙËÛ·Ó 4 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘.

O ·ÈÌ·ÙÔÎÚ›Ù˘ Î·È Ë ·ÈÌÔÛÊ·ÈÚ›ÓË Ù˘ ÛÙ·ıÂÚÔÔÈ‹ıËÎ·Ó ÛÙÔ 27% Î·È 8,3 g/dl, ·ÓÙ›ÛÙÔȯ·. §fiÁˆ ÙÔ˘ ÔÏ˘ÂÙÔ‡˜ ÈÛÙÔÚÈÎÔ‡ Ì ٷ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ· ÂÂÈÛfi‰È· Ì ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ, ÙË ¯ÚfiÓÈ· ·Ó·ÈÌ›· Î·È ÙÔÓ ·ÚÓËÙÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Ô˘ ‰ÂÓ Î·Ù¿ÊÂÚ ӷ ·Ó·‰Â›ÍÂÈ ÙËÓ ·ÈÙ›· Ù˘ ·ÈÌÔÚÚ·Á›·˜, ˙ËÙ‹ıËÎÂ Ë ÁÓÒÌË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡. ŒÁÈÓ ·/· ÎÔÈÏ›·˜ Û fiÚıÈ· ı¤ÛË, Ë ÔÔ›· ¤‰ÂÈÍ ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ‰È¿Ù·ÛË ¤ÏÈη˜ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘. ªÂ ÙÔ ÈÛÙÔÚÈÎfi ÙˆÓ ·ÈÌÔÚÚ·ÁÈÒÓ Î·È ÙÔ˘ ·ÎÙÈÓÔÏÔÁÈÎÔ‡ Â˘Ú‹Ì·ÙÔ˜, Ë ·ÛıÂÓ‹˜ ˘Ô‚Ï‹ıËΠ۠ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›·. ∆· ÂÁ¯ÂÈÚËÙÈο Â˘Ú‹Ì·Ù· ‹Ù·Ó: ·) ∞ÙÂÏ‹˜ ÛÙÚÔÊ‹ Î·È Î·ı‹ÏˆÛË ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (malrotation). ∆Ô Ù˘ÊÏfi ‹Ù·Ó Û ˘ÊË·ÙÈ΋ ı¤ÛË. ¶ÂÚÈÙÔÓ·˚Τ˜ Ù˘¯¤˜ (Ladd) Ȥ˙Ô˘Û˜ ÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ, ¯ˆÚ›˜ Ó· ÚÔηÏÔ‡Ó ·fiÊÚ·ÍË. ŒÁÈÓ ‰È·ÙÔÌ‹ ÙˆÓ Ù˘¯ÒÓ Î·È ¿ÚÛË Ù˘ ›ÂÛ˘. ‚) ªÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ‰È¿Ù·ÛË ¤ÏÈη˜ ÙÔ˘ ÂÈÏÂÔ‡, ÙÔ ÙÔ›¯ˆÌ· Ù˘ ÔÔ›·˜ ‹Ù·Ó ÈÛ¯·ÈÌÈÎfi ÏfiÁˆ Û˘ÛÛÒÚ¢Û˘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ÙÔ ÔÔ›Ô ·ÛÎÔ‡Û ÂÓ‰Ô·˘ÏÈ΋ ›ÂÛË. ™ÙÔ ÂÚÈÊÂÚÈÎfi ̤ÚÔ˜ Ù˘ ‰È·ÙÂٷ̤Ó˘ ¤ÏÈη˜ ˘‹Ú¯Â ‰È¿ÙÚËÙÔ (·ÙÂϤ˜)

September-October 05 chris

18-11-04

15:18

™ÂÏ›‰·365

¶·È‰È·ÙÚÈ΋ 2004;67:363-366

‚ÏÂÓÓÔÁfiÓÈÔ ‰È¿ÊÚ·ÁÌ·, ÙÔ ÔÔ›Ô ÚÔηÏÔ‡Û ‰·ÎÙ˘ÏÈÔÂȉ‹ ÛÙ¤ÓˆÛË Î·È ·ÙÂÏ‹ ·fiÊÚ·ÍË (·ÙÚËÛ›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ù‡Ô˘ π). ŒÁÈÓ ÂÎÙÔÌ‹ Ù˘ ‰È·ÙÂٷ̤Ó˘ ¤ÏÈη˜ (Ì‹ÎÔ˘˜ 22 cm) Î·È ·ÔηٿÛÙ·ÛË Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ì ÙÂÏÈÎÔÙÂÏÈ΋ ·Ó·ÛÙfïÛË Â› ˘ÁÈÒÓ ÈÛÙÒÓ. ∏ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÈÏÂÔ‡ Ô˘ ·Ê·ÈÚ¤ıËΠ¤‰ÂÈÍ ·ÙÂϤ˜ ‰È¿ÊÚ·ÁÌ· Ì ‰È¿ÌÂÙÚÔ 2 cm Û ·fiÛÙ·ÛË 8 cm ·fi ÙÔ ¤Ó· fiÚÈÔ ÂÎÙÔÌ‹˜. ∆Ô ÙÌ‹Ì· ·fi ÙÔ fiÚÈÔ ÂÎÙÔÌ‹˜ ̤¯ÚÈ ÙË ÛÙ¤ÓˆÛË ‹Ù·Ó ‰È·ÙÂٷ̤ÓÔ, Ú˘·Úfi Î·È ·ÈÌÔÚÚ·ÁÈÎfi. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÛÙË ‰È·ÙÂٷ̤ÓË ÂÚÈÔ¯‹ Î·È ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÛÙ¤ÓˆÛ˘ ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈΤ˜ ÈÛ¯·ÈÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ì ¤ÏÎË. ∏ ÌÔÚÊÔÏÔÁ›· ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÛÙ¤ÓˆÛ˘ ¤ÌÔÈ·˙ Ì ·˘Ù‹ ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Ì ¤ÎÙÔ· ·‰¤ÓÈ· Brunner. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ‹Ù·Ó ÔÌ·Ï‹ Î·È ÙÚ›· ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ·ıÔÏÔÁÈÎÔ‡ ÂÓÙ¤ÚÔ˘ Ë ·ÛıÂÓ‹˜ Â›Ó·È ·Û˘Ìو̷ÙÈ΋, Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ¯ˆÚ›˜ ·Ó·ÈÌ›· (∏b: 13,5 g/dl, Ht: 39%). ™˘˙‹ÙËÛË ∏ ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi ÌÔÚ› Ó· ÂΉËψı› ˆ˜ ·ÈÌ·Ù¤ÌÂÛË (ηʤ ‹ ÎfiÎÎÈÓÔ ·›Ì· ÛÙÔÓ ¤ÌÂÙÔ ‹ Â̤ÛÌ·Ù· Û·Ó ÎfiÎÎÔÈ Î·Ê¤), ̤ϷÈÓ· (Ì·‡Ú· Û·Ó ›ÛÛ· ÎÔÏÏÒ‰Ë, Ï·ÌÂÚ¿ Î·È ‰‡ÛÔÛÌ· ÎfiÚ·Ó·) ‹ ·ÈÌ·ÙÔ¯ÂÛ›· (ÎfiÎÎÈÓÔ ‹ ηÛÙ·Ófi¯ÚˆÔ ·›Ì· ÛÙ· ÎfiÚ·Ó·) (1,2). ∆Ô ¯ÚÒÌ· ÙˆÓ ÎÂÓÒÛÂˆÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ Ú˘ıÌfi Ù˘ ·ÈÌÔÚÚ·Á›·˜ Î·È ·fi ÙÔÓ ¯ÚfiÓÔ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· Ó· ÂÚ¿ÛÂÈ ÙÔÓ ÂÙÈÎfi ۈϋӷ, ηıÔÚ›˙ÔÓÙ·˜ ·‰Ú¿ ÙÔ Â›Â‰Ô Ù˘ ·ÈÌÔÚÚ·Á›·˜ (2). ∏ ·ÈÌ·Ù¤ÌÂÛË ‰ËÏÒÓÂÈ ·ÈÌÔÚÚ·Á›· ·fi ÙÔÓ Û‡Ó‰ÂÛÌÔ ÙÔ˘ Treitz Î·È ¿Óˆ. OÈ Ì¤Ï·ÈÓ˜ ÎÂÓÒÛÂȘ ‰Â›¯ÓÔ˘Ó Û˘Ó‹ıˆ˜ ·ÈÌÔÚÚ·Á›· Û Â›Â‰Ô ¿Óˆ ·fi ÙËÓ ÂÈÏÂÔÙ˘ÊÏÈ΋ ‚·Ï‚›‰·. ∏ ·ÈÌ·ÙÔ¯ÂÛ›· ˘Ô‰ËÏÒÓÂÈ Ù˘Èο ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ·ÚÈÛÙÂÚfi ÎfiÏÔÓ (2). ª·˙ÈΤ˜, fï˜, ·ÈÌÔÚÚ·Á›Â˜ ·fi ÙÔ ·ÓÒÙÂÚÔ ÂÙÈÎfi ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ˆ˜ ·ÈÌ·ÙÔ¯ÂÛ›·, ηıÒ˜ Î·È ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÔÚıÔÛÈÁÌÔÂȉ¤˜ Ì ·Ô‚ÔÏ‹ ÂÚ˘ıÚfiÊ·ÈÔ˘ ¯ÚÒÌ·ÙÔ˜. ∏ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi ··ÈÙ› ÙËÓ ·fi‰ÂÈÍË Ù˘ ·ÈÌÔÚÚ·Á›·˜, ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓ‹, ÙËÓ ·ÔÎ¿Ï˘„Ë Ù˘ ·ÈÙ›·˜ Î·È Ù˘ ı¤Û˘ Ù˘ ·ÈÌÔÚÚ·Á›·˜ Î·È ÙË ıÂÚ·›· Ù˘. ∆Ô ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÔÙÂÏ› ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ ÛÙËÓ ÂÈÙ˘¯‹ ‰ÈÂÚ‡ÓËÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi. £· ·ÎÔÏÔ˘ı‹ÛÂÈ Ë ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË, Ë ÔÔ›· ··ÈÙ› ÚÈÓ ·fi fiÏ· ÙËÓ ÈÛÙÔÔ›ËÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜, ηıÒ˜ ÔÏϤ˜ ÙÚÔʤ˜ Î·È Ê¿Ú̷η (·ÌÔ͢ÎÈÏÏ›ÓË, ‚ÈÛÌÔ‡ıÈÔ, Û›‰ËÚÔ˜) ÚÔηÏÔ‡Ó ‰˘-

Paediatriki 2004;67:363-366

ۯڈ̷ÙÈÛÌfi ÙˆÓ ÎÔÚ¿ÓˆÓ Î·È ÌÔÚ› Ó· ‰›ÓÔ˘Ó ÂÛÊ·Ï̤ӷ ÙË ‰È¿ÁÓˆÛË Ì¤Ï·ÈÓ·˜ ‹ ·ÈÌ·ÙÔ¯ÂÛ›·˜. ∆· ÎfiÚ·Ó· ÂÍÂÙ¿˙ÔÓÙ·È Ì ÙË ÁÓˆÛÙ‹ ̤ıÔ‰Ô Mayer Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙËÓ Ô˘Û›· guaiac, Ì›· Ê˘ÙÈ΋ ÚËÙ›ÓË Ô˘ Ì peroxidase like activity ·ÓÙȉڿ Ì ÙËÓ ·ÈÌÔÛÊ·ÈÚ›ÓË ÙˆÓ ÎÔÚ¿ÓˆÓ Î·È ÚÔηÏ› ÌÏ ¯ÚÒÌ· ÛÙ· ÎfiÚ·Ó· (4). 梉Ҙ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÌÔÚ› Ó· ÚÔ·„Ô˘Ó ·fi ÙÚÔʤ˜ fiˆ˜ ÙÔ ÎÚ¤·˜, Ù· ·ÓÙ˙¿ÚÈ·, Ù· ÁÔÁÁ‡ÏÈ·, ÔÈ ÓÙÔÌ¿Ù˜, Ù· ÎÂÚ¿ÛÈ· Î·È Ù· ‚·ÙfiÌÔ˘Ú·. ∞ÓÙ›ıÂÙ·, „¢‰Ò˜ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ÚÔ·ÙÔ˘Ó ·fi ηٷӿψÛË ‚ÈÙ·Ì›Ó˘ C (·ÎfiÌË Î·È Û ÔÛfiÙËÙ˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙ· ÔÏ˘‚ÈÙ·ÌÈÓÔ‡¯· Û΢¿ÛÌ·Ù·), fiÙ·Ó ÙÔ ‰Â›ÁÌ· ÙˆÓ ÎÔÚ¿ÓˆÓ ÂÍÂÙ¿˙ÂÙ·È 4 Ë̤Ú˜ ÌÂÙ¿ ÙË Û˘ÏÏÔÁ‹ ÙÔ˘ ‹ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÏËÁ̤ӷ ·ÓÙȉڷÛÙ‹ÚÈ· (6). ªÂÙ¿ ÙËÓ ·fi‰ÂÈÍË Ù˘ ‡·Ú͢ Ù˘ ·ÈÌÔÚÚ·Á›·˜, ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Ë Hb Î·È Ô Hct, ·ÏÏ¿ Î·È Ô Ú˘ıÌfi˜ ÙÒÛ˘ ÙÔ˘˜, ηıÒ˜ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. ∏ ·Ó·ÈÌ›· Ù˘ ¯ÚfiÓÈ·˜ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ ÂÙÈÎfi Â›Ó·È Û˘Ó‹ıˆ˜ ˘fi¯ÚˆÌË ÌÈÎÚÔ΢ÙÙ·ÚÈ΋. ∂ÈϤÔÓ, ··ÈÙÂ›Ù·È ¤ÏÂÁ¯Ô˜ Ù˘ Ë·ÙÈ΋˜ Î·È ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ¤ÏÂÁ¯Ô˜ ‹Í˘. OÈ ·ÎÙÈÓÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ¤¯Ô˘Ó ÂÚÈÔÚÈṲ̂ÓÔ ÚfiÏÔ ÛÙËÓ ·Ú¯È΋ ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ (3). ∏ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ Â›Ó·È ¯Ú‹ÛÈÌË Û ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯ÂÈ ˘Ô„›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜, ÂÓÙÂÚÈ΋ ‰È¿ÙÚËÛË ‹ ·fiÊÚ·ÍË. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË Â›¯Â Á›ÓÂÈ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ ‰‡Ô ÊÔÚ¤˜, ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ªfiÓÔ ÛÙËÓ ÙÚ›ÙË ·ÎÙÈÓÔÁÚ·Ê›· η٤ÛÙË ‰˘Ó·Ù‹ Ë ·ÂÈÎfiÓÈÛË Ù˘ ‰È·ÙÂٷ̤Ó˘ ÂÓÙÂÚÈ΋˜ ¤ÏÈη˜. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏÈ¿˜ Î·È Ë ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È ¯Ú‹ÛÈÌ· Û ÂÓ‰ÔÎÔÈÏȷΤ˜ Ì¿˙˜ ‹ ·ÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜. ÕÏϘ ÂÍÂÙ¿ÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ Â›Ó·È Ë ÂÓ‰ÔÛÎfiËÛË, Ë ·ÁÁÂÈÔÁÚ·Ê›· Î·È ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì ÛÂÛËÌ·Ṳ̂ӷ Ì technetium 99m ÂÚ˘ıÚ¿, ÁÈ· ÙÔ ÔÔ›Ô - ÚÔÎÂÈ̤ÓÔ˘ Ó· Â›Ó·È ıÂÙÈÎfi - Ë ·ÒÏÂÈ· ÙÔ˘ ·›Ì·ÙÔ˜ Ú¤ÂÈ Ó· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 0,1 ml/min (4). ∏ ·ÛıÂÓ‹˜ ›¯Â ·ÙÚËÛ›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ù‡Ô˘ π. ∏ ·ÚÔ˘Û›· ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Ì ٷ ¤ÎÙÔ· ·‰¤ÓÈ· Brunner ÛÙËÓ ÂÚÈÔ¯‹ ·˘Ù‹ ÙÔ˘ ÂÈÏÂÔ‡, ηıÒ˜ Î·È Ë ÈÛ¯·ÈÌ›· Ô˘ ÔÊÂÈÏfiÙ·Ó ÛÙËÓ ÂÓ‰Ô·˘ÏÈ΋ ›ÂÛË ·fi ÙË ¯ÚfiÓÈ· ÛÙ¿ÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÏfiÁˆ Ù˘ Û˘ÁÁÂÓÔ‡˜ ÛÙ¤ÓˆÛ˘, ÚÔηÏÔ‡Û·Ó ‰È·‚ÚÒÛÂȘ Î·È ·ÈÌÔÚÚ·Á›Â˜ ÛÙÔÓ ·ıÔÏÔÁÈÎfi ÂÈÏÂfi, Ì ·ÔÙ¤ÏÂÛÌ· ÙȘ ̤ϷÈÓ˜ ÎÂÓÒÛÂȘ Î·È ÙË ¯ÚfiÓÈ· ·Ó·ÈÌ›·. ∏ Û˘ÁÁÂÓ‹˜ ·˘Ù‹ ·ÓˆÌ·Ï›· ·ÔÙÂÏ› ÙÔÓ Û˘ÓËı¤ÛÙÂÚÔ Ù‡Ô ·ÙÚËÛ›·˜ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘. ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÂÓ‰Ô·˘ÏÈÎfi ‰È¿ÊÚ·ÁÌ· Ô˘ ·ÔÊÚ¿ÛÛÂÈ

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ÙÔÓ ·˘Ïfi ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ·Û˘Ó¤¯ÂÈ· ÂÁÁ‡˜ Î·È ¿ˆ ¿ÎÚÔ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ·ÙÚËÛ›· ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Ô˘ Û˘Óԉ‡ÂÙ·È Û ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ·fi ¿ÏϘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, Ë ·ÙÚËÛ›· Ù˘ Ó‹ÛÙȉ·˜ Î·È ÙÔ˘ ÂÈÏÂÔ‡ ·Ó¢ڛÛÎÂÙ·È Û˘Ó‹ıˆ˜ Û·Ó ÌÂÌÔӈ̤ÓË ·ÓˆÌ·Ï›· (5). ∏ ηٿÛÙ·ÛË ·˘Ù‹ ÛÙÔ 1/5 ÙˆÓ ·ÛıÂÓÒÓ ÂΉËÏÒÓÂÙ·È ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ˙ˆ‹ Ì ÔÏ˘¸‰Ú¿ÌÓÈÔ Î·È ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ÛËÌ›· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ù· ÚÒÙ· Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›ÛÙËÎ·Ó Û ËÏÈΛ· 7 ÂÙÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ ·È‰› Ó· Ù·Ï·ÈˆÚÂ›Ù·È ÁÈ· 6 ÔÏfiÎÏËÚ· ¯ÚfiÓÈ· Ì Â·ÓÂÈÏËÌ̤Ó˜ ÂÈÛ·ÁˆÁ¤˜ Û ÓÔÛÔÎÔÌ›· Î·È Ó· ¤¯ÂÈ ˘Ô‚ÏËı› ÔÏϤ˜ ÊÔÚ¤˜ Û ÂÓ‰ÔÛÎÔ‹ÛÂȘ Î·È ¿ÏϘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ. ™Â ·˘Ùfi Û˘Ó¤‚·ÏÂ Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÓÒ Ë ÂÛÙ›· Ù˘ ·ÈÌÔÚÚ·Á›·˜ ÂÓÙÔÈ˙fiÙ·Ó ÛÙÔ Î·ÙÒÙÂÚÔ ÂÙÈÎfi, ÚÔ¤‚·ÏÂ Û·Ó Ì¤Ï·ÈÓ· ÏfiÁˆ Ù˘ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ÙÔ˘ ·ÔÏÂÛı¤ÓÙÔ˜ ·›Ì·ÙÔ˜. ∂›Û˘, Ë ·ÛıÂÓ‹˜ ‹Ù·Ó ·Û˘Ìو̷ÙÈ΋ ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÈÌÔÚÚ·Á›·˜ Î·È ‰ÂÓ ÂÌÊ¿ÓÈ˙ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ·fi ÙË ÛÙ¤ÓˆÛË ‹ ÙËÓ ·ÙÂÏ‹ ÛÙÚÔÊ‹ ÙÔ˘ ÂÓÙ¤ÚÔ˘, fiˆ˜ Â̤ÙÔ˘˜, ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜, ÎÔÈÏȷο ¿ÏÁË ‹ ÛÙ·ÙfiÚÚÔÈ·. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Â›Ó·È ¤Ó· Úfi‚ÏËÌ· Ô˘ Ô ·È‰›·ÙÚÔ˜ ηÏÂ›Ù·È Û˘¯Ó¿ Ó· ÂÈχÛÂÈ. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ÔÈ Û˘Ó‹ıÂȘ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ·ÔηχÙÔ˘Ó Â‡ÎÔÏ· ÙËÓ ·ÈÙ›· Ù˘ ·ÈÌÔÚÚ·Á›·˜. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó Î·È Û¿ÓȘ ·Èٛ˜, fiˆ˜ Ë ·ÙÂÏ‹˜ ·fiÊÚ·ÍË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ô˘ ÚÔηÏÔ‡Û ÙÔ ‚ÏÂÓÓÔÁfiÓÈÔ ‰È¿-

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ÊÚ·ÁÌ· ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ∏ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ηı˘ÛÙÂÚ‹ÛÂÈ fiÙ·Ó Ù· ·ÔÊÚ·ÎÙÈο Ê·ÈÓfiÌÂÓ· ‰ÂÓ Â›Ó·È Ôͤ·. ∏ ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· ·Ԃ› ÛˆÙ‹ÚÈ· ÁÈ· ÙÔÓ ·ÛıÂÓ‹, ‚ÂÏÙÈÒÓÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ÙËÓ ÔÈfiÙËÙ· Ù˘ ˙ˆ‹˜ ÙÔ˘ Î·È ı· Ú¤ÂÈ Ó· Û˘ÛÙ‹ÓÂÙ·È. µÈ‚ÏÈÔÁÚ·Ê›· 1. Rayhorn N, Thrall C, Silber G. A review of the causes of upper gastrointestinal tract bleeding in children. Gastroenterol Nurs 2001;24:23-27.

2. Ament ME. Diagnosis and management of upper gastrointestinal tract bleeding in the pediatric patient. Pediatr Rev 1990;12:107-116.

3. Fox VL. Gastrointestinal bleeding in infancy and childhood.

Gastroenterol Clin North Am 2000;29:37-47.

4. Squires RH Jr. Gastrointestinal bleeding. Pediatr Rev 1999;20:95-101.

5. Sweeney B, Surana R, Puri P. Jejunoileal atresia and associated malformations: correlation with the timing of in utero insult. J Pediatr Surg 2001;36:774-776.

6. ¡ÙfiÏ·Ù˙·˜ £. ∂›ÁÔÓÙ· ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ·È‰È·ÙÚÈ΋ Î·È ·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋. ∞ı‹Ó·: ∂ΉfiÛÂȘ ¶·ÚÈÛÈ¿ÓÔ˜; 1994. ÛÂÏ.

89-90.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-10-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-06-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞Ì·Ï›· ∆ÛÈÏÈÌÈÁοÎË ∏ÚÔ‰fiÙÔ˘ 214, ¡¤· ∞ÏÈηÚÓ·ÛÛfi˜, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘

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Paediatriki 2004;67:367-370

CURRENT ISSUE

∏ Û˘Ì‚ÔÏ‹ ÙÔ˘ Û˘˙¢Á̤ÓÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ¢. ∆Ûԇ̷˜, µ. ™Ô‡ÏÔ˘

The contribution of conjugated pneumococcal vaccine to the prevention of pneumococcal infection D. Tsoumas, V. Spoulou

¶ÂÚ›ÏË„Ë: ∆Ô Ó¤Ô 7-‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ (CPV) ÚfiÎÂÈÙ·È Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙÔ 23-‰‡Ó·ÌÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ (PPV) Î·È ·Ó·Ì¤ÓÂÙ·È Ó· ·›ÍÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÚÔÛÙ·Û›· ÙˆÓ ·ÙfiÌˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË, fiˆ˜ Ù· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ, ÔÈ ËÏÈÎȈ̤ÓÔÈ Î·È Ù· ¿ÙÔÌ· Ì ÏÂÈÙÔ˘ÚÁÈ΋ ‹ ·Ó·ÙÔÌÈ΋ ·ÛÏËÓ›· Î·È ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·. ∏ Û‡˙¢ÍË ÙÔ˘ ÔÏ˘Û·Î¯·ÚȉÈÎÔ‡ ÂÚÈ‚Ï‹Ì·ÙÔ˜ 7 Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÔÚÔÙ‡ˆÓ Ì ÙËÓ ÚˆÙ½ÓË CRM197 o‰ËÁ› ÛÂ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ·ÓÙÈÁÔÓÈÎfiÙËÙ·˜ ÙÔ˘ CPV Û ۯ¤ÛË Ì ÙÔ PPV Î·È ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓÔÛÔÏÔÁÈ΋˜ ÌÓ‹Ì˘. H ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ CPV, Ô˘ ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 94% Û ·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ, ı· Ú¤ÂÈ Ó· ÙÂÎÌËÚȈı› Ì ηٿÏÏËÏ· ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ Î·È Û ¿ÏϘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, ¤ÙÛÈ ÒÛÙ ӷ ÂÈÙ·¯˘Óı› Ë ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘ Î·È Û ¿ÏÏ· ¿ÙÔÌ·.

Abstract: A new 7-valent conjugate pneumococcal vaccine (CPV), is expected to provide a useful option for the protection of individuals at risk for invasive pneumococcal disease, such as children under 2 years, the elderly, patients with anatomical or functional asplenia and various other chronic conditions. Conjugation of the pneumococcal polysaccharide with protein CRM197 leads to T-cell involvement in the immune response, which improves vaccine immunogenicity and establishes immunological memory associated with long-term protection of the vaccinee. CPV clinical effectiveness, which was found to be 94% in children younger than 2 years, needs to be established among other highrisk groups through appropriately designed studies using immunological correlates of protection.

§¤ÍÂȘ ÎÏÂȉȿ: Û˘˙¢Á̤ÓÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ, Ó¢ÌÔÓÈfiÎÔÎÎÔ˜, ·ÓÔÛÔÏÔÁÈ΋ ÌÓ‹ÌË, Û˘ÁÁ¤ÓÂÈ·.

Key words: conjugated pneumococcal vaccine, pneumococcus, immunologic memory, avidity.

™˘ÓÙÔÌÔÁڷʛ˜

O Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ·Ú·Ì¤ÓÂÈ ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ·ÁÎfiÛÌÈÔ Â›‰Ô. ∂›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ‚·ÎÙËÚȷ΋˜ Ó¢ÌÔÓ›·˜, ÔÍ›·˜ ̤Û˘ ˘Ò‰Ô˘˜ ˆÙ›Ùȉ·˜ Î·È ÌËÓÈÁÁ›Ùȉ·˜, ÂÓÒ Â˘ı‡ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 1,2 Âη-

ÙÔÌ̇ÚÈ· ı·Ó¿ÙÔ˘˜ ÂÙËÛ›ˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ (1). ™ÙËÓ ∂ÏÏ¿‰·, Ë Â›ÙˆÛË Ù˘ ‰ÈÂÈÛ‰˘ÙÈ΋˜ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ Û ·È‰È¿ ËÏÈΛ·˜ <14 ÂÙÒÓ ˘ÔÏÔÁ›˙ÂÙ·È Û 44 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ÂÙËÛ›ˆ˜, ÂÓÒ ÛÙȘ ËÏÈ˘ <5 ÂÙÒÓ Ë Û˘¯ÓfiÙËÙ· Â›Ó·È ˘ÂÚ‰ÈÏ¿ÛÈ· (2). ¶·Ú¿ ÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›·, Ë ıÓËÙfiÙËÙ·, ȉȷ›ÙÂÚ· Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜, ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ (>20%) ΢ڛˆ˜ Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

1st Paediatric Clinic of University of Athens, “Aghia Sophia” Children’s Hospital, Athens

CPV PPV Hib

7-‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ 23-‰‡Ó·ÌÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ∞ÈÌfiÊÈÏÔ˜ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜ Ù‡Ô˘ b

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ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË, fiˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ Î·È ËÏÈÎȈ̤ÓÔ˘˜, Û ¿ÙÔÌ· Ì ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ, Ì ·Ó·ÙÔÌÈ΋ ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ·ÛÏËÓ›·, HIV Ïԛ̈ÍË, ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·, Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ë·ÙÈ΋ ΛÚÚˆÛË, ¯ÚfiÓȘ ·ı‹ÛÂȘ ηډȿ˜-Ó¢ÌfiÓˆÓ, ηıÒ˜ Î·È Û ¿ÙÔÌ· Ô˘ ˙Ô˘Ó ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤ÓÔ˘ Û˘Á¯ÚˆÙÈÛÌÔ‡ (‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜, ȉڇ̷ٷ Î.Ï.). O ΛӉ˘ÓÔ˜ ÁÈ· ÙȘ ÔÌ¿‰Â˜ ·˘Ù¤˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÏfiÁˆ Ù˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ Ù˘ ·ÓÙÔ¯‹˜ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ÛÙ· ·ÓÙÈÌÈÎÚԂȷο Ê¿Ú̷η, ÙfiÛÔ ÛÙË ¯ÒÚ· Ì·˜ fiÛÔ Î·È ·ÁÎfiÛÌÈ· (3). ∆· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ηٷÛÙ‹ÛÂÈ ·Ó·Áη›· ÙËÓ ÚfiÏË„Ë ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. øÛÙfiÛÔ, ÙÔ 23‰‡Ó·ÌÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ (PPV, PneuImmune 23; Lederle Laboratories, Pearl River, NY) ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÚÔÛٷ٢ÙÈ΋ ÈηÓfiÙËÙ· Û ÔÌ¿‰Â˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (4,5). ŒÓ· Ó¤Ô 7-‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ (CPV, Prevenar, Wyeth Lederle Vaccines, Pearl River, NY) ÚfiÎÂÈÙ·È Ó· ΢ÎÏÔÊÔÚ‹ÛÂÈ Û‡ÓÙÔÌ· Î·È ÛÙË ¯ÒÚ· Ì·˜. ∆Ô ÂÌ‚fiÏÈÔ ·˘Ùfi ÂÁÎÚ›ıËΠÙÔÓ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 2000 ÛÙȘ ∏¶∞ Î·È ÂÈÛ‹¯ıË ÛÙÔ ÚfiÁÚ·ÌÌ· ‚·ÛÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ ÙˆÓ ·È‰ÈÒÓ. ∏ ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ CPV ‚·Û›ÛÙËΠÛÙËÓ Ù¯ÓÔÏÔÁ›· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙÔ ÂÍ·ÈÚÂÙÈο ÂÈÙ˘¯Ë̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜ Ù‡Ô˘ b (Hib). ™˘ÁÎÂÎÚÈ̤ӷ, ¤ÁÈÓ ۇ˙¢ÍË ÙÔ˘ ÎÂηı·Ṳ́ÓÔ˘ ÔÏ˘Û·Î¯·ÚȉÈÎÔ‡ ÂÚÈ‚Ï‹Ì·ÙÔ˜ ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÔÚÔÙ‡ˆÓ 4, 6µ, 9V, 14, 19F Î·È 23F Î·È ÙÔ˘ ÔÏÈÁÔ۷ί·Ú›ÙË ÙÔ˘ ÔÚÔÙ‡Ô˘ 18C, Ì ÙËÓ ÚˆÙ½ÓË CRM197 (ÌË ÙÔÍÈ΋ ·Ú·ÏÏ·Á‹ Ù˘ ‰ÈÊıÂÚÈÙÈ΋˜ ÙÔ͛Ӣ). ∏ Û‡˙¢ÍË ·˘Ù‹ ·ÏÏ¿˙ÂÈ ÙÔÓ ÙÚfiÔ ·ÚÔ˘Û›·Û˘ ÙÔ˘ ÔÏ˘Û·Î¯·ÚȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ Î·È ÙÔ ÌÂÙ·ÙÚ¤ÂÈ ·fi ı˘ÌÔ·ÓÂÍ¿ÚÙËÙÔ (Tindependent) Û ı˘ÌÔÂÍ·ÚÙÒÌÂÓÔ (T-dependent). ∏ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ·˘Í¿ÓÂÈ ÙËÓ ·ÓÙÈÁÔÓÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Î·È ÚÔ¿ÁÂÈ ÙȘ ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙ· ÁÔÓ›‰È· Ù˘ ÌÂÙ·‚ÏËÙ‹˜ ÂÚÈÔ¯‹˜ ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓÔÛÔÏÔÁÈ΋˜ ÌÓ‹Ì˘, Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ̷ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ·ÓÔÛ›· (6). O ‰È·ÊÔÚÂÙÈÎfi˜ ÙÚfiÔ˜ ·ÚÔ˘Û›·Û˘ ÙÔ˘ ÔÏ˘Û·Î¯·ÚȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ·˘Í¿ÓÂÈ ÙËÓ ·ÓÙÈÁÔÓÈÎfiÙËÙ· ÙÔ˘ CPV Û ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ, ÂÂȉ‹ Ë Û‡˙¢ÍË Ù˘ ÚˆÙ½Ó˘ Ì ÙÔÓ ÔÏ˘Û·Î¯·Ú›ÙË ÂÈÙÚ¤ÂÈ ÛÙ· ∆ ‚ÔËıËÙÈο ÏÂÌÊÔ·ÙÙ·Ú· Ó· ·Ó·ÁÓˆÚ›ÛÔ˘Ó ÙË ‰ÔÌ‹ Ù˘ ÚˆÙ½Ó˘ Î·È Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÙÔ Û‡ÌÏÔÎÔ

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ÚˆÙ½Ó˘-ÔÏ˘Û·Î¯·Ú›ÙË ÛÙ· µ ÏÂÌÊÔ·ÙÙ·Ú·, ·Ú·Î¿ÌÙÔÓÙ·˜ ÙËÓ ·Ó¿ÁÎË ¤ÎÊÚ·Û˘ ÙÔ˘ ˘Ô‰Ô¯¤· CD21, Ô˘ ‰ÂÓ ÂÎÊÚ¿˙ÂÙ·È ÛÙ· ·ÓÒÚÈÌ· µ ÏÂÌÊÔ·ÙÙ·Ú· (7). ™Â Ù˘¯·ÈÔÔÈË̤ÓË ÚÔÔÙÈ΋ ÎÏÈÓÈ΋ ÌÂϤÙË ÙˆÓ µlack Î·È Û˘Ó, Û ÂÚ›Ô˘ 38.000 ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ, Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ CPV ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ‰ÈÂÈÛ‰˘ÙÈ΋˜ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·Ó‹Ïı ÛÙÔ ÂÓÙ˘ˆÛÈ·Îfi ÔÛÔÛÙfi ÙÔ˘ 94% (8). ™‡Ìʈӷ Ì ÚfiÛÊ·ÙË ÌÂϤÙË Ù˘ ›‰È·˜ ÂÚ¢ÓËÙÈ΋˜ ÔÌ¿‰·˜, ÙÔ ÂÌ‚fiÏÈÔ Ì›ˆÛ ηٿ 7,8% ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ˆÙ›Ùȉ·˜, ηٿ 5,8% ÙË Û˘ÓÙ·ÁÔÁÚ¿ÊËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Î·Ù¿ 24% ÙËÓ ÙÔÔı¤ÙËÛË ÛˆÏËÓ›ÛÎˆÓ ·ÂÚÈÛÌÔ‡ (9). OÈ ÂӉ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ CPV, fiˆ˜ ‰È·Ù˘ÒÓÔÓÙ·È ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ, ÂÚÈÏ·Ì‚¿ÓÔ˘Ó fiÏ· Ù· ·È‰È¿ ËÏÈΛ·˜ 2-23 ÌËÓÒÓ, ηıÒ˜ Î·È Ù· ˘ÁÈ‹ ·È‰È¿ ËÏÈΛ·˜ 24-59 ÌËÓÒÓ, ȉȷ›ÙÂÚ· ·˘Ù¿ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜ (10). ∆¤ÏÔ˜, ·Ú¿ ÙËÓ ¤ÏÏÂÈ„Ë Û¯ÂÙÈÎÒÓ ÌÂÏÂÙÒÓ, Û˘ÛÙ‹ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ Î·È Û ÌÈÎÚ¿ ·È‰È¿ (<5 ÂÙÒÓ) Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘. ∏ ·ÓÙÈÁÔÓÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ı· Ú¤ÂÈ Ó· ÌÂÏÂÙËı› Û οı ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ͯˆÚÈÛÙ¿, ÂÂȉ‹ Ë Â˘·ÈÛıËÛ›· ÛÙÔÓ Ó¢ÌÔÓÈfiÎÔÎÎÔ ·Ô‰›‰ÂÙ·È Û ‰È·ÊÔÚÂÙÈÎfi ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·. ∆·˘Ùfi¯ÚÔÓ·, ı· Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌÒÓÙ·È Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ·Ú·ÁfiÌÂÓˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ Ô„ˆÓÈ΋˜ ÙÔ˘˜ ÈηÓfiÙËÙ·˜ Î·È Ë ·ÓÔÛÔÏÔÁÈ΋ ÌÓ‹ÌË Ô˘ ÂÎÊÚ¿˙ÂÙ·È ¤ÌÌÂÛ· Ì ÙËÓ ·‡ÍËÛË Ù˘ Û˘ÁÁ¤ÓÂÈ·˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (avidity maturation) ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi (11). ∏ Ô„ˆÓÈ΋ ÈηÓfiÙËÙ· Î·È Ë Û˘ÁÁ¤ÓÂÈ· ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ·ÓÔÛÔÏÔÁÈÎo› ‰Â›ÎÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÎÚÈ‚¤ÛÙÂÚË ·ÍÈÔÏfiÁËÛË ÙˆÓ ÚÔÛٷ٢ÙÈÎÒÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ··ÓÙ‹ÛˆÓ, Û ÔÌ¿‰Â˜ Ô˘ Ë ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ CPV Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ô‰Âȯı› Ì ÌÂÁ¿Ï˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜. ™ÎfiÈÌÔ ÎÚ›ÓÂÙ·È, Â›Û˘, Ó· ÌÂÏÂÙËı› Ë Â›‰Ú·ÛË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì CPV ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÊÔÚ›·˜ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ™Â ÌÂϤÙË ÙˆÓ Dagan Î·È Û˘Ó (12) ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ CPV Ô‰‹ÁËÛ Û Ì›ˆÛË Ù˘ ÊÔÚ›·˜ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·fi 25% Û 7%, ‡ÚËÌ· Ô˘ ÂÓÈÛ¯‡ÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÚ·ÈÙ¤Úˆ ÂÏ¿ÙÙˆÛ˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ·. ∂ÈϤÔÓ, ÂÂȉ‹ ÙÔ CPV ÛÙԯ‡ÂÈ Û ÌÈÎÚfi ÌfiÓÔ ·ÚÈıÌfi ·ıÔÁfiÓˆÓ ÔÚÔÙ‡ˆÓ, ı· Ú¤ÂÈ Ó· ÙÂÎÌËÚȈı› Ì ÙËÓ Î·Ù¿ÏÏËÏË ÂȉËÌÈÔÏÔÁÈ΋ ÂÈÙ‹ÚËÛË fiÙÈ ‰ÂÓ ·˘Í¿ÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·fi ·ıÔÁfiÓÔ˘˜

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ÔÚÔÙ‡Ô˘˜ Ô˘ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ (replacement disease). ∏ ˘fiıÂÛË ·˘Ù‹ ÂÓÈÛ¯‡ÂÙ·È ·fi ÌÂϤÙË ÙˆÓ Eskola Î·È Û˘Ó, Ë ÔÔ›· ¤‰ÂÈÍ fiÙÈ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ Ì›ˆÛ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ̤Û˘ ˆÙ›Ùȉ·˜ Ô˘ ÔÊ›ÏÔÓÙ·Ó Û ÔÚÔÙ‡Ô˘˜ Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ Î·Ù¿ 57%, ·‡ÍËÛ ·Ú¿ÏÏËÏ· ηٿ 33% ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·fi ¿ÏÏÔ˘˜ ÔÚÔÙ‡Ô˘˜ (13). ¶·Ú’ fiÏ· ·˘Ù¿, ÔÈ Black Î·È Û˘Ó ‰ÂÓ ‰È·›ÛÙˆÛ·Ó ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ‰ÈÂÈÛ‰˘ÙÈ΋˜ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·fi ÔÚÔÙ‡Ô˘˜ Ô˘ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ (8). ™ËÌ·ÓÙÈ΋ ·Ó·Ì¤ÓÂÙ·È Ó· Â›Ó·È Ë Û˘Ì‚ÔÏ‹ ÙÔ˘ CPV ÛÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ·fi ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ∆Ô ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·ÓÙÔ¯‹˜ ÛÙËÓ ÂÓÈÎÈÏ›ÓË, ÙfiÛÔ ÛÙË ¯ÒÚ· Ì·˜ fiÛÔ Î·È ·ÁÎfiÛÌÈ·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ÔÚfiÙ˘ÔÈ 6µ, 9V, 14, 19F Î·È 23F, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ (14,15). OÈ Whitney Î·È Û˘Ó ·Ó¤ÊÂÚ·Ó fiÙÈ 2 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ∏¶∞, ÙÔ ÔÛÔÛÙfi Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·fi ·ÓıÂÎÙÈο ÛÙËÓ ÂÓÈÎÈÏ›ÓË ÛÙÂϤ¯Ë Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ÌÂÈÒıËΠηٿ 35% (16). O ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ CPV ·Ó·Ì¤ÓÂÙ·È, Â›Û˘, Ó· Û˘Ì‚¿ÏÏÂÈ ıÂÙÈο ÛÙË Ì›ˆÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ÔÏ˘·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ∆Ô Ó¤Ô Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·ÏÏ¿ÍÂÈ Ô˘ÛÈ·ÛÙÈο Ù· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘, ÂÓ‰¤¯ÂÙ·È fï˜ Ó· ÌËÓ ·ÔÙÂϤÛÂÈ ÙËÓ ÙÂÏÈ΋ χÛË ÛÙÔ Úfi‚ÏËÌ· Û ·ÁÎfiÛÌÈÔ Â›‰Ô. OÈ 7 ÔÚfiÙ˘ÔÈ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ CPV Â›Ó·È ˘‡ı˘ÓÔÈ ÁÈ· ÙÔ 83% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÈÂÈÛ‰˘ÙÈ΋˜ ÓfiÛÔ˘ ÛÙ· ·È‰È¿, ·ÏÏ¿ ÌfiÓÔ ÁÈ· ÙÔ 56% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ (15). ™˘ÓÂÒ˜, Ó¤· Û΢¿ÛÌ·Ù· Ì 9, 11 ‹ Î·È ÂÚÈÛÛfiÙÂÚÔ˘˜ ÔÚÔÙ‡Ô˘˜ ı· ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔ ˆÊ¤ÏÈÌ· ÁÈ· ÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜. £· Ú¤ÂÈ, Ù¤ÏÔ˜, Ó· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙÔ ˘„ËÏfi ÎfiÛÙÔ˜ ÙÔ˘ CPV, ÙÔ ÔÔ›Ô ÚÔ˜ ÙÔ ·ÚfiÓ ÂÌÔ‰›˙ÂÈ ÙË ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘ ÛÙ· ˘ÔÛÈÙÈ˙fiÌÂÓ· ·È‰È¿ ÙÔ˘ ∆Ú›ÙÔ˘ ∫fiÛÌÔ˘ Ô˘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÔÏ˘ÏËı¤ÛÙÂÚË ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ªÂ ‰Â‰Ô̤ÓË ÙË ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒ͈Ó, Ë ·ÍÈÔÏfiÁËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙˆÓ Û˘˙¢ÁÌ¤ÓˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÂÌ‚ÔÏ›ˆÓ, ΢ڛˆ˜ Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ÚÔÙÂÚ·ÈfiÙËÙ·. ∏ ÙÂÎÌËÚ›ˆÛË Ù˘ ˘ÂÚÔ¯‹˜ ÙˆÓ Û˘˙¢ÁÌ¤ÓˆÓ Û΢·ÛÌ¿ÙˆÓ Û ۯ¤ÛË Ì ٷ ÔÏ˘Û·Î¯·ÚȉÈο ı· ÂÈÙ·¯‡ÓÂÈ ÙË ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜ Î·È Û ¿ÏÏ· ¿ÙÔÌ· Ô˘ Ù· ¯ÚÂÈ¿˙ÔÓÙ·È.

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∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙËÓ ∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ· ¶·È‰È·ÙÚÈ΋˜ ΢ڛ· ª·Ú›· £ÂÔ‰ˆÚ›‰Ô˘ ÁÈ· ÙȘ ÔχÙÈ̘ ÂÈÛËÌ¿ÓÛÂȘ Ù˘ ηٿ ÙË Û˘ÁÁÚ·Ê‹ ·˘ÙÔ‡ ÙÔ˘ ¿ÚıÚÔ˘.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Hausdorff WP, Bryant J, Paradiso PR, Siber GR. Which pneumococcal serogroups cause the most invasive disease: implications for conjugate vaccine formulation and use, part I. Clin Infect Dis 2000;30:100-121.

2. Syriopoulou V, Daikos GL, Soulis K, Michos A, Alexandrou H, Pavlopoulou I et al. Epidemiology of invasive childhood pneumococcal infections in Greece. Acta Paediatr 2000;89 (Suppl):S30-S34.

3. Syrogiannopoulos GA, Grivea IN, Beratis NG, Spiliopoulou AE, Fasola EL, Bajaksouzian S et al. Resistance patterns of Streptococcus pneumoniae from carriers attending daycare centers in southwestern Greece. Clin Infect Dis 1997;25:188-194.

4. Spoulou V, Victoratos P, Ioannidis JP, Grafakos S. Kinetics of antibody concentration and avidity for the assessment of immune response to pneumococcal vaccine among children with bone marrow transplants. J Infect Dis 2000;182:965-969.

5. French N, Nakiyingi J, Carpenter LM, Lugada E, Watera C, Moi K et al. 23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults: double-blind, randomized and placebo controlled trial. Lancet 2000;355:2106-2111.

6. Eskola J, Anttila M. Pneumococcal conjugate vaccines.

Pediatr Infect Dis J 1999;18:543-551.

7. Rijkers GT, Sanders EA, Breukels MA, Zegers BJ. Infant B cell responses to polysaccharide determinants. Vaccine 1998;16:1396-1400.

8. Black S, Shinefield H, Fireman B, Lewis E, Ray P, Hansen JR et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group.

Pediatr Infect Dis J 2000;19:187-195.

9. Fireman B, Black SB, Shinefield HR, Lee J, Lewis E, Ray P. Impact of the pneumococcal conjugate vaccine on otitis media. Pediatr Infect Dis J 2003;22:10-16.

10. Advisory Committee on Immunization Practices.

Preventing pneumococcal disease among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2000;49:1-35.

11. Goldblatt D, Vaz AR, Miller E. Antibody avidity as a surrogate marker of successful priming by Haemophilus influenzae type b conjugate vaccines following infant immunization. J Infect Dis 1998;177:1112-1115.

12. Dagan R, Melamed R, Muallem M, Piglansky L, Greenberg D, Abramson O et al. Reduction of nasopharyngeal carriage of pneumococci during the second year of life by a heptavalent conjugate pneumococcal vaccine. J Infect Dis 1996;174:1271-1278.

13. Eskola J, Kilpi T, Palmu A, Jokinen J, Haapakoski J, Herva E et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med 2001;344:403-409.

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14. Syrogiannopoulos GA, Katopodis GD, Grivea IN, Beratis NG. Antimicrobial use and serotype distribution of nasopharyngeal Streptococcus pneumoniae isolates recovered from Greek children younger than 2 years old.

Clin Infect Dis 2002;35:1174-1182.

15. Whitney CG, Pickering LK. The potential of pneumococcal conjugate vaccines for children. Pediatr Infect Dis J 2002;21:961-970.

16. Whitney CG, Farley MM, Hadler J, Harrison LH, Bennett NM, Lynfield R et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med 2003;348:1737-1746.

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∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 16-05-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-06-2004 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢ËÌ‹ÙÚ˘ ∆Ûԇ̷˜ ∂ıÓ¿Ú¯Ô˘ ª·Î·Ú›Ô˘ 20, ∆.∫. 164 52, ∞ÚÁ˘ÚÔ‡ÔÏË E-mail: dtsoumas@hotmail.com

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∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÚÁ·ÛÈÒÓ ÙÔ˘ 24Ô˘ ¶·ÁÎfiÛÌÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó¤‰ÚÈÔ˘ Ô˘ ‰ÈÂÍ‹¯ıË ÛÙȘ 15-20 ∞˘ÁÔ‡ÛÙÔ˘ 2004 ÛÙÔ Cancun ÙÔ˘ ªÂÍÈÎfi, Ô ¶Úfi‰ÚÔ˜ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ∫·ıËÁËÙ‹˜ ∞Ó‰Ú¤·˜ ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜, ÚÔ·Ó‹ÁÁÂÈÏ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÙÔ˘ 25Ô˘ ¶·ÁÎfiÛÌÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó¤‰ÚÈÔ˘ ÛÙËÓ ∂ÏÏ¿‰·, ÛÙȘ 25-30 ∞˘ÁÔ‡ÛÙÔ˘ 2007.

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Paediatriki 2004;67:373-374

¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO

¢øƒ∂∞¡ ¶∞π¢π∞∆ƒπ∫∞ ¶∂ƒπO¢π∫∞ ™∆O ¢π∞¢π∫∆ÀO ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ¶·È‰›·ÙÚÔ˜ - ¡ÂÊÚÔÏfiÁÔ˜

∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÂÚÈÏ‹„ÂȘ ÂÚÁ·ÛÈÒÓ ÌÔÚÔ‡Ó Â‡ÎÔÏ· - Î·È ‰ˆÚÂ¿Ó - Ó· ‚ÚÂıÔ‡Ó ÛÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ ∂ıÓÈ΋˜ π·ÙÚÈ΋˜ µÈ‚ÏÈÔı‹Î˘ ÙˆÓ ∏¶∞: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ÁÈ· ¤Ó· ÂÚÈÔ‰ÈÎfi Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ ‰ÈÎÙ˘·ÎÔ‡ ·˘ÙÔ‡ ÙfiÔ˘ (MEDLINE), ηıÒ˜ ÌÔÚ› Ó· ¤¯Ô˘Ó ÚfiÛ‚·ÛË ÛÙ· ¿ÚıÚ· ÙÔ˘ Û˘Ó¿‰ÂÏÊÔÈ ·fi fiÏÔ ÙÔÓ ÎfiÛÌÔ.

∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤ÁÈÓ ÂÊÈÎÙ‹ Î·È Ë ‰ˆÚÂ¿Ó ÚfiÛ‚·ÛË ÛÙÔ ‰È·‰›ÎÙ˘Ô Û ÂÚÁ·Û›Â˜ ÔÏÏÒÓ È·ÙÚÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ. ∞Ú¯Èο, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÍÈfiÏÔÁˆÓ ÂÚÈÔ‰ÈÎÒÓ Ì ‰ˆÚÂ¿Ó ÚfiÛ‚·ÛË ‹Ù·Ó ÂÚÈÔÚÈṲ̂ÓÔ˜, ˆÛÙfiÛÔ ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο οı ¯ÚfiÓÔ. ∏ ÚfiÛ‚·ÛË ÛÙË ‰ˆÚÂ¿Ó ÁÓÒÛË ıˆÚÂ›Ù·È fiÙÈ ı· ¤¯ÂÈ ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ ÏËÚ¤ÛÙÂÚË ËÏÂÎÙÚÔÓÈ΋ ÂÎ·›‰Â˘ÛË Î·È ÂÓË̤ڈÛË. ∆· ÂÚÈÔ‰Èο Ì ‰ˆÚÂ¿Ó ÚfiÛ‚·ÛË ÛÙÔ ‰È·‰›ÎÙ˘Ô ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.freemedicaljournals.com ∂ȉÈÎfiÙÂÚ·, Ô Î·Ù¿ÏÔÁÔ˜ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜ Ì ‰ˆÚÂ¿Ó ÚfiÛ‚·ÛË ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.freemedicaljournals.com/htm/spec12.htm ∆· ÈÔ ÛËÌ·ÓÙÈο ÂÚÈÔ‰Èο ·˘ÙÔ‡ ÙÔ˘ ηٷÏfiÁÔ˘ ›ӷÈ: 1. AAP Policy ¶ÔÏϤ˜ ¯Ú‹ÛÈ̘ ÎÏÈÓÈΤ˜ Ô‰ËÁ›Â˜ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://aappolicy.aappublications.org/practice_guidelines 2. Archives of Disease in Childhood Fetal and Neonatal (¢ˆÚÂ¿Ó ÁÈ· ¿ÚıÚ· ·Ï·ÈfiÙÂÚ· ÙˆÓ 12 ÌËÓÒÓ) http://fn.bmjjournals.com/contents-by-date.0.shtml

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¶·È‰È·ÙÚÈ΋ 2004;67:373-374

Paediatriki 2004;67:373-374

¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO

3. Archives of Disease in Childhood (¢ˆÚÂ¿Ó ÁÈ· ¿ÚıÚ· ·Ï·ÈfiÙÂÚ· ÙˆÓ 12 ÌËÓÒÓ) http://adc.bmjjournals.com/contents-by-date.0.shtml 4. BMC Pediatrics http://www.biomedcentral.com/bmcpediatr 5. Clinical Pediatric Endocrinology http://www.jstage.jst.go.jp/browse/cpe/_vols/-char/en 6. Contemporary Pediatrics http://www.contemporarypediatrics.com/contpeds/ 7. Early Childhood Research and Practice http://ecrp.uiuc.edu 8. Future of Children http://www.futureofchildren.org/homepage2824/index.htm 9. Indian Journal of Pediatrics http://www.ijppediatricsindia.org 10. Indian Pediatrics (Ù˘ πÓ‰È΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜) http://www.indianpediatrics.net 11. International Pediatrics (Ù˘ π·ˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜) http://int-pediatrics.org 12. Italian Journal of Pediatrics (Ù˘ πÙ·ÏÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜) http://www.ijp.it/englishversion/index.htm 13. Jornal de Pediatria (Ù˘ ¶ÔÚÙÔÁ·ÏÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜) http://www.scielo.br/scielo.php?script=sci_serial&pid=0021-7557&lng=en&nrm=iso 14. Paediatric Asthma Virtual Journal (¢ˆÚÂ¿Ó ÁÈ· ¿ÚıÚ· ·Ï·ÈfiÙÂÚ· ÙˆÓ 12 ÌËÓÒÓ) http://www.bmjjournals.com/misc/pavj.shtml 15. Pediatric Research (¢ˆÚÂ¿Ó ÁÈ· ¿ÚıÚ· ·Ï·ÈfiÙÂÚ· ÙˆÓ 12 ÌËÓÒÓ) http://www.pedresearch.org 16. Pediatrics (¢ˆÚÂ¿Ó ÚfiÛ‚·ÛË ÌfiÓÔ Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ‰ËÌÔÛȇۈÓ) http://pediatrics.aappublications.org 17. Turkish Journal of Pediatrics (Ù˘ ∆Ô˘ÚÎÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜) http://tjp.dergisi.org

∆¤ÏÔ˜, Û·˜ ˘ÂÓı˘Ì›˙Ô˘Ì fiÙÈ ÌÂÙ¿ ·fi ‰ˆÚÂ¿Ó ÂÁÁÚ·Ê‹, ÌÔÚ›Ù ӷ ¤¯ÂÙ ÚfiÛ‚·ÛË ÛÙ· Ù‡¯Ë Ù˘ “¶·È‰È·ÙÚÈ΋˜” (·fi ÙÔ ¤ÙÔ˜ 2000) ÛÙË ‰È‡ı˘ÓÛË: http://www.e-child.gr/PeriodikoPaidiatrikiList.asp

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¶PO™EXH ™YNE¢PIA 10-11 ¢ÂÎÂÌ‚Ú›Ô˘ 2004

2Ë ¶·ÓÂÏÏ‹ÓÈ· ™˘Ó¿ÓÙËÛË “∏ ¶·È‰Ô„˘¯È·ÙÚÈ΋ ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ԕ “∞fi Î·È ¶ÚÔ˜ ÙËÓ ∫ÔÈÓfiÙËÙ·” ¶·È‰Ô„˘¯È·ÙÚÈ΋ ∂Ù·ÈÚ›· ∂ÏÏ¿‰Ô˜ (∆ÔÈ΋ ∂ÈÙÚÔ‹ £ÂÛÛ·ÏÔӛ΢) ∫Ù›ÚÈÔ ¶·Ï·È¿˜ ºÈÏÔÛÔÊÈ΋˜ ™¯ÔÏ‹˜ ∞.¶.£. ¶ÏËÚÔÊÔڛ˜: ¡. ∑ËÏ›ÎË ∆ËÏ.: 2310 994629

£ÂÛÛ·ÏÔÓ›ÎË

10-12 ¢ÂÎÂÌ‚Ú›Ô˘ 2004

8th Congress of the European Society of Magnetic Resonance in Neuropediatrics ¶ÏËÚÔÊÔڛ˜: Studio P.R. & Congressi Tel.: 011-39-01-3123-6155 Fax: 011-39-01-3144-5858 E-mail: prcongr@tin.it Website: www.esmrn.com/esmrn2004.html

Genoa, Italy

28-30 π·ÓÔ˘·Ú›Ô˘ 2005

3Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ æ˘¯È·ÙÚÈ΋˜ £ÂÛÛ·ÏÔÓ›ÎË ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∏ æ˘¯È·ÙÚÈ΋ ÛÙËÓ ·Ú¯‹ Ù˘ 3˘ ¯ÈÏÈÂÙ›·˜” ¶·ÓÂÏÏ‹ÓÈ· ∂Ù·ÈÚ›· æ˘¯È·ÙÚÈ΋˜ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ •ÂÓÔ‰Ô¯Â›Ô ª·Î‰ÔÓ›· ¶·ÏÏ¿˜ ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress ∞.∂. ∆ËÏ.: 2310 256 194-5 Fax: 2310 256 196 E-mail: salonica@triaenatours.gr

7-9 ∞ÚÈÏ›Ô˘ 2005

6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ ∞ı‹Ó· & ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ & ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: Œ„ÈÏÔÓ ∆ËÏ.: 210 72 54 360-2 Fax: 210 72 54 363 E-mail: info@epsiloncongress.gr Website: www.epsiloncongress.gr

21-23 ∞ÚÈÏ›Ô˘ 2005

3rd World Conference on the Prevention and Treatment of Caustic Esophageal Burns in Children and Live Operative Workshop ¶ÏËÚÔÊÔڛ˜: Oktay Mutaf Tel.: 90-232-388-112 Fax: 902-323-751-288 E-mail: omutaf@med.ege.edu.tr

Izmir, Turkey

11-14 ª·˝Ô˘ 2005

3rd International Conference on Children's Bone Health ¶ÏËÚÔÊÔڛ˜: Maria Luisa Bianchi Tel.: 39-02-619-112-483 / 25-05 Fax: 39-02-619-112-519 E-mail: ml.bianchi@auxologico.it

Sorrento, Italy

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¶PO™EXH ™YNE¢PIA 17-21 ª·˝Ô˘ 2005

31Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ •ÂÓÔ‰Ô¯Â›Ô Hilton ¶ÏËÚÔÊÔڛ˜: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ ∆ËÏ.: +30 210 72 11 845 Fax: +30 210 72 15 082 E-mail: iea@mednet.gr

∞ı‹Ó·

18-20 ª·˝Ô˘ 2005

23rd Annual Meeting of the European Society for Paediatric Infectious Diseases (ESPID) ¶ÏËÚÔÊÔڛ˜: Kenes International Tel.: +41 22 908 0488 Fax: +41 22 732 2850 E-mail: espid@kenes.com Website: http://www.kenes.com/espid/

Valencia, Spain

26-29 ª·˝Ô˘ 2005

6th European Congress of Pediatric Surgery ¶ÏËÚÔÊÔڛ˜: Darek Wyrzykowski Tel.: 00-48-583-026-427 Fax: 00-48-583-026-427 E-mail: pedsurg@amg.gda.pl

Gdansk, Poland

26 πÔ˘Ó›Ô˘1 πÔ˘Ï›Ô˘ 2005

World Allergy Congress 2005 (WAC 2005) World Allergy Organization (WAO) European Academy of Allergy and Clinical Immunology (EAACI) German Society for Allergy and Clinical Immunology (DGAI) ¶ÏËÚÔÊÔڛ˜: Interplan Congress, Meeting & Event Management AG Tel.: +49 (0)89 54 82 34-0 Fax: +49 (0)89 54 82 34-44 E-mail: wac2005@i-plan.de

Munich, Germany

1-4 ™ÂÙÂÌ‚Ú›Ô˘ 2005

4th World Congress of the World Society for Pediatric Infectious Diseases ¶ÏËÚÔÊÔڛ˜: Kenes International Tel.: +41 22 908 0488 Fax: +41 22 732 2850 E-mail: wspid2005@kenes.com Website: http://www.kenes.com/wspid2005/

Warsaw, Poland

31 OÎÙˆ‚Ú›Ô˘5 ¡ÔÂÌ‚Ú›Ô˘ 2005

20th International Congress of Paediatric Dentistry ¶ÏËÚÔÊÔڛ˜: IAPD Congress Secretariat Tel.: 61-292-411-478 Fax: 61-292-513-552 E-mail: iapd2005@icmsaust.com.au

Sydney, NSW, Australia

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™YNTOMO°PAºIE™

ABBREVIATIONS

™˘ÓÙÔÌÔÁڷʛ˜

EÏÏËÓÈÎÔ› fiÚÔÈ

AÁÁÏÈÎÔ› fiÚÔÈ

AIDS

Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿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˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ 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΋˜ ıÂÚ·›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚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 ÏÂÙfi ·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

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™˘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˘ÙÂÚfiÏÂÙÔ ˘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

xx

Combining prefixes T G M k h da d c m Ì n p f a