Exofyllo Paed 05
14-02-05
16:27
™ÂÏ›‰·1
TfiÌÔ˜ 68 ñ ∆‡¯Ô˜ 1 ñ π·ÓÔ˘¿ÚÈÔ˜ 2005 ¶·È‰È·ÙÚÈ΋ ñ TfiÌÔ˜ 68 ñ ∆‡¯Ô˜ 1 ñ π·ÓÔ˘¿ÚÈÔ˜ 2005
www.paediatriki.edu.gr
Volume 68 ñ Number 1 ñ January 2005 ISSN 0377-2551
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·1
¶·È‰È·ÙÚÈ΋ ∆fiÌÔ˜ 68 ñ ∆‡¯Ô˜ 1 ñ π·ÓÔ˘¿ÚÈÔ˜ 2005 ¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹
¶ÂÚȯfiÌÂÓ·
¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ™. ÷˚‰¿˜
∞¡∞™∫O¶∏™∂π™
∞Ó·Ï. ¢È¢ı. ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜ M¤ÏË ∂. ∞ÓÙˆÓÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ Ã. ∫ÒÛÙ·ÏÔ˜ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ¶··‰ÔÔ‡ÏÔ˘ ª. ∆ÛÔÏÈ¿-¶·Û·Ú¿ÎË ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘
1 ¢È·ÙÚÔÊ‹ ÙÔ˘ ÚfiˆÚÔ˘ Î·È ÙÔ˘ ‰˘ÛÙÚÔÊÈÎÔ‡ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Ã. ∫ÒÛÙ·ÏÔ˜, ∞. °Ô‡Ó·Ú˘ 8 IgA ÓÂÊÚÔ¿ıÂÈ· ÛÙ· ·È‰È¿ ∞. ªËÙÛÈÒÓË 18 ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ú·Ó¢ÌÔÓÈÎÒÓ Û˘ÏÏÔÁÒÓ ÛÙ· ·È‰È¿ ¢. ªÂÚÌ›ÚË, ∫. ¶Ú›ÊÙ˘ 29 ¶·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ¶. µÂϤÓÙ˙·˜
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜
37 °ÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿ Î·È ÚfiÏË„Ë ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ¢. §¿ÁÁ·˜, ∂. ¶ÂÙÚ›‰Ô˘, ¡. ¢ÂÛ‡Ú˘, £. £ˆÌ·˝‰Ë˜
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
45 ¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È Ë Û¯¤ÛË Ù˘ Ì ÙȘ ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ Î·È ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ ∂. ∫¿ÎÔ˘ÚÔ˜, ∫. ª·ÓÈ·‰¿ÎË, ∂. ∫·Ó›ÛË
K. °ÚÈ‚¤·˜
I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889
ISSN 0377-2551
∂¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ 62 ∂Ó Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË Ì ÔÏÏ·Ï‹ ÂÓÙfiÈÛË Û ¤ÊË‚Ô. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. µÚ¿ÓÔ˘, °. ∞Ó·ÛÙ·ÛÈ¿‰Ë˜, °. ¶·Ó·ÁȈٷÎfiÔ˘ÏÔ˜, ∂. ¶ÂÚÁ¿ÓÙÔ˘, ∂. ¶Ï·ÙÔÎÔ‡ÎË, ¡. ª¤ÛÈ·˜, ª. µ·Î¿ÎË, ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ 69 ¶ÂÚ›ÙˆÛË ·ÔÌfiÓˆÛ˘ ·‰ÂÓÔ˚Ô‡ µ1 ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Û ·È‰› ËÏÈΛ·˜ 6,5 ÂÙÒÓ Ì ÔÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ· ¶. ¶Ô˘ÏfiÔ˘ÏÔ˜, Õ. ªÂÛÛ·ÚÈÙ¿ÎË, ∫. ∫ÔÙÛÒÓ˘, ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ 74 ∞ÛÂÚÁ›ÏψÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ÙÚ›· ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· º. ∞ı·Ó·ÛÈ¿‰Ô˘, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, £. ¶··ÁˆÚÁ›Ô˘, ª. ™Ù¿ÌÔ˘, ∞. ¢Ú‚ÂϤÁη˜, ∞. µÂÏÂÁÚ¿ÎË
80 ∫§π¡π∫√ ∫√Àπ∑
53 °ÂÓÂÙÈ΋ Î·È ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ·ÛıÂÓÒÓ Ì ۇӉÚÔÌ· DiGeorge/˘ÂÚˆÈÔ-ηډÈÔ-ÚÔÛˆÈÎfi (velo-cardio-facial syndrome) ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË, ∞. ∫ÔÏȷϤÍË, ∂. ºÚ˘Û›Ú·, ∞. °·ÏÏ¿-µÔ˘Ì‚Ô˘Ú¿ÎË, ∞. ™·Ï·‚Ô‡Ú·, ª. ∫·Ó·Ú›Ô˘, ∂. ∫·Ó·‚¿Î˘, ∞. ª·‡ÚÔ˘
81 µπµ§π√¶∞ƒ√À™π∞™∏
82 NEA ∞¶√ ∆√ ¢π∞¢π∫∆À√
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·3
Paediatriki Volume 68 ñ Number 1 ñ January 2005 Bimonthly Publication of the Greek Paediatric Society President A. Constantopoulos Editorial Board
Contents
Editor S. Haidas
REVIEW ARTICLES
Assistant Editor C. Stefanidis Members H. Antonopoulou A. Vazeou-Gerasimidi G. Varlamis ∂. Katsarou-Pectasides A. Kattamis Ch. Costalos N. Papadopoulos ∞. Papadopoulou M. Tsolia-Pasparaki Manuscript Editing Greek Editing I. Karavranou English Editing S. Nakou Publisher K. Griveas Publishing Coordinator SCIENTIFIC PUBLICATIONS Ltd 3 Artemidos str. GR - 151 25, Maroussi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822
7 Nutrition of the preterm and growth retarded baby on discharge from the hospital C. Costalos, A. Gounaris 17 IgA nephropathy in children A. Mitsioni 28 Diagnostic approach and treatment of parapneumonic effusions in children D. Mermiri, K. Priftis 36 Pediatric telephone medicine P. Velentzas
ORIGINAL ARTICLES 44 Parental behavior and childhood injury prevention D. Laggas, E. Petridou, N. Dessypris, T. Thomaidis 52 Childhood obesity and its relationship with parental attitudes and nutritional habits E. Kakouros, K. Maniadaki, E. Kapnisi
CASE REPORTS 68 Deep vein thrombosis in multiple sites in an adolescent. Case report M. Vranou, G. Anastasiadis, G. Panagiotakopoulos, H. Pergantou, H. Platokouki, N. Besias, M. Vakaki, K. Prountzou-Kassiou 73 Isolation of adenovirus B1 in the CNS in a 6.5 year-old boy with acute disseminated encephalomyelitis P. Poulopoulos, A. Messaritaki, K. Kotsonis, K. Prountzou-Kassiou 79 Aspergillosis of the central nervous system in three children with acute lymphoblastic leukemia F. Athanassiadou, A. Tragiannidis, T. Papageorgiou, M. Stamou, A. Drevelegas, A. Velegraki
80 CLINICAL QUIZ
81 BOOK REVIEW
82 NEWS FROM THE INTERNET Owner Greek Paediatric Society© 92 Michalakopoulou str. GR - 115 28, Athens Tel.: +30 210 7771 140 +30 210 7771 663 Fax: +30 210 7758 354 e-mail: hps@ath.forthnet.gr Annual Subscription All foreign countries: US $ 50
61 Genetic and clinical-laboratory investigation of patients with DiGeorge/velo-cardio-facial syndromes S. Kitsiou-Tzeli, A. Kolialexi, H. Fryssira, A. Gala-Voumvouraki, C. Salavoura, ª. Kanariou, E. Kanavakis, A. Mavrou
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·7
∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏
vii
∞Á·ËÙÔ› ™˘Ó¿‰ÂÏÊÔÈ, ∆o ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ Î·È Ë ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ “¶·È‰È·ÙÚÈ΋˜” Û¿˜ ‡¯ÔÓÙ·È Â˘Ù˘¯ÈṲ̂ÓÔ Î·È ‰ËÌÈÔ˘ÚÁÈÎfi ÙÔÓ Î·ÈÓÔ‡ÚÁÈÔ ¯ÚfiÓÔ. Ÿˆ˜ ‰È·ÈÛÙÒÓÂÙ ÙÔ ÂÚÈÔ‰ÈÎfi ΢ÎÏÔÊÔÚ› Û Ӥ· ÌÔÚÊ‹. ∞˘Ùfi Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ÚÔÛ¿ıÂÈ·˜ ·ÊÂÓfi˜ ÌÂÓ ·Ó·‚¿ıÌÈÛ˘ Ù˘ ÌÔÚÊ‹˜, ·ÊÂÙ¤ÚÔ˘ ‰Â ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ÂÚȯÔ̤ÓÔ˘. ∂ÈÚfiÛıÂÙ·, ηχÊıËÎ·Ó Ù· ¯ÚÔÓÈο ÂÏÏ›ÌÌ·Ù· Î·È ÙÔ ÂÚÈÔ‰ÈÎfi ΢ÎÏÔÊÔÚ› ¤ÁηÈÚ·. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ı· Û˘Ì‚¿ÏÂÈ ÛÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ Ó· ÂÓÙ·¯ı› Ë “¶·È‰È·ÙÚÈ΋” ÛÙÔ Medline. ªÂ ÙËÓ Â˘Î·ÈÚ›· ·˘Ù‹ Û·˜ ÚÔÛηÏԇ̠ӷ Û˘ÌÌÂÙ¿Û¯ÂÙ Ì ÙËÓ ˘Ô‚ÔÏ‹ ÂÚÁ·ÛÈÒÓ, ÛÙËÚ›˙ÔÓÙ·˜ ·˘Ù‹ ÙËÓ ÚÔÛ¿ıÂÈ· ·Ó·‚¿ıÌÈÛ˘. ™·˜ ˘ÂÓı˘Ì›˙Ô˘Ì fiÙÈ Ë ˘Ô‚ÔÏ‹ ÙˆÓ ÂÚÁ·ÛÈÒÓ ÌÔÚ› Ó· Á›ÓÂÙ·È Î·È ÛÙ· ·ÁÁÏÈο, ÂÏ›˙ÔÓÙ·˜ fiÙÈ ·˘Ùfi ı· ·ÔÙÂϤÛÂÈ Î›ÓËÙÚÔ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ Î·È ∂ÏÏ‹ÓˆÓ Û˘Ó·‰¤ÏÊˆÓ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡.
ªÂ ıÂṲ́˜ ¢¯¤˜ ÁÈ· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹
O ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
O ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
™Ù·‡ÚÔ˜ ÷˚‰¿˜
∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·11
√¢∏°π∂™ ¶ƒ√™ ∆√À™ ™À°°ƒ∞º∂π™
xi
A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜
µ. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ
∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜). 2. ∞Ó·ÛÎÔ‹ÛÂȘ. 3. µÚ·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. 4. ∂Ú¢ÓËÙÈΤ˜ ÌÂϤÙ˜. 5. ∫ÏÈÓÈο ∫Ô˘›˙ 6. ∂ÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ. 7. ∂›Î·ÈÚ· ı¤Ì·Ù·. 8. £¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜. 9. ∂ӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. 10. ™‡ÓÙÔÌ· Ó¤·. 11. µÚ·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. 12. ∂ÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË. 13. ¶ÂÚÈÏ‹„ÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. 14. ∞Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘Ó‰ڛˆÓ Î·È ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 15. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜.
ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡Ó “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÈÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals), ÔÈ Ôԛ˜ ÙÚÔÔÔÈ‹ıËÎ·Ó ÚfiÛÊ·Ù· Î·È ‰ËÌÔÛȇÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È Ù˘ˆÌ¤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (21x29,7 cm), Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È ÂÚÈıÒÚÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2,5 cm ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ηٿÏÔÁÔ˜ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.
H ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ, ηıÒ˜ Î·È ¿ÚıÚ· Ì ›ηÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·ÛÙ› ÛÙÔ ÂÙ‹ÛÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ·ÚÔ˘ÛÈ¿ÛÂˆÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì ›ηÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. 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. ∂ÈϤÔÓ, ÛÙËÓ ÂÚÁ·Û›· ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜, Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. 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 ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚÈÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶·È‰È·ÙÚÈ΋” Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.
H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ·: ñ ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 2000-3000 ϤÍÂȘ. ñ ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 1500-2500 ϤÍÂȘ. ñ ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ÂÈÛÙÔϤ˜ Û 250-500 ϤÍÂȘ.
™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: ñ ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ), ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ. ñ ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋. ñ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤ·/ˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙÔ˘˜. ñ ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·.
¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ñ £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 200 ϤÍÂȘ, fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ñ ∏ ÂÚ›ÏË„Ë ÙˆÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ ÛÂ: ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο. T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·12
xii
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·Ô̤˜ Î·È ÙÔÓ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜, ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ì ÏÂÙÔ̤ÚÂȘ ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË, Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜.
TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf
™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜, ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ.
BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ, ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó: ñ ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ. ñ ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜. ñ ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. ñ ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÙȘ ÂÈÛÙÔϤ˜. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù· ÙÚÔÔÔÈË̤Ó˜ 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·ÔÌÒÓ I. ¶∂ƒπO¢π∫∞ AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ÂÓÒ ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”.
T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279. Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.
™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: 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 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã. ∏ ıÂڷ›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. πππ. CD-ROM Anderson SC, Poulsen KB. Anderson’s electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·13
xiii
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 [Internet]. 2002 Jun: Webpage: http://www.nursingworld.org/AJN/2002/june/Wawatch.htm
ªÔÓÔÁÚ·Ê›·: Foley KM, Gelband H, editors. Improving palliative care for cancer [Monograph, Internet]. Washington: National Academy Press; 2001. Webpage: http://www.nap.edu/books/0309074029/html πÛÙÔÛÂÏ›‰Â˜: Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancer-pain.org/
°. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ‰ÈÛΤٷ ‹ CD, ηıÒ˜ Î·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹, Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ ‹ CD Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word, ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏÌ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË, ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó·
¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô Î·È ‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (7,5 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (15,5 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, Î.Ï.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜ Î·È ı· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.
¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜, ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜, Ù˘ˆÌ¤Ó· Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜. 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 ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜) Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· ‰.fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·. 5. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·, ηıÒ˜ Î·È Ï¤ÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 6. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 7. ∫›ÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 8. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢). 9. µÈ‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 10. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó. 11. ∂ÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó. 12. ∆›ÙÏÔ˘˜ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
Paediatriki Jan-Feb 05 teliko
xiv
10-02-05
13:36
™ÂÏ›‰·14
™À¡∆√ª√°ƒ∞ºπ∂™ o
A cal cm cm2 cm3 o C g h IU kg l m mg min mm mol n NS ‹ ª™ osm p SD SE sec U
angstrom ıÂÚÌ›‰· ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢‚ÈÎfi ÂηÙÔÛÙfi ‚·ıÌfi˜ ∫ÂÏÛ›Ô˘ ÁÚ·ÌÌ¿ÚÈÔ ÒÚ· ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ¯ÈÏÈfiÁÚ·ÌÌÔ Ï›ÙÚÔ Ì¤ÙÚÔ ¯ÈÏÈfiÁÚ·ÌÌÔ ÏÂÙfi ¯ÈÏÈÔÛÙfiÌÂÙÚÔ ÁÚ·ÌÌÔÌfiÚÈÔ ·ÚÈıÌfi˜ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Èı·ÓfiÙËÙ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ‰Â˘ÙÂÚfiÏÂÙÔ ÌÔÓ¿‰·
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (109) mega- (106) kilo- (103) hector- (102) deca- (101) deci- (10-1) centi- (10-2) milli- (10-3) micro- (10-6) nano- (10-9) pico- (10-12) femto- (10-15) atto- (10-18)
ABBREVIATIONS
Combining prefixes T G M k h da d c m Ì n p f a
angstrom calorie centimeter square centimeter cubic centimeter degree Celsius gram hour international unit kilogram liter meter milligram minute millimeter mole number not significant osmole probability standard deviation standard error second unit
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·17
INSTRUCTIONS TO AUTHORS A. General Information The Greek Paediatric Society is the owner of “Paediatriki”, its official scientific journal, which is distributed to its members. Its objectives are the publication of paediatric scientific work and the continuing education of paediatricians. For this purpose, it publishes a variety of articles, and in particular: 1. Editorials (upon invitation by the Editorial Board). 2. Review articles. 3. Award-winning articles. 4. Original articles. 5. Clinical Quiz 6. Round tables. 7. Current issues. 8. Issues of healthcare management and education. 9. Case reports. 10. News. 11. Brief reports. 12. Letters to the editor. 13. Abstracts. 14. Future congresses and events. 15. Book reviews. The Editorial Board reserves the right to publish articles of special scientific interest and articles on current issues without observing submission order. In addition it publishes upon decision original papers presented at the Annual Paediatric Conference, presentations of special interest - in whole or in part, and letters - in whole or in part - referring to scientific articles published in the journal. Regarding papers on current issues, the author’s request for immediate publication should be quoted on the first page. The Editorial Board reserves the right to accept such papers for immediate publication. All manuscripts should not have been published previously, in whole or in part, and not be under consideration by another publication. Manuscripts should acknowledge any funding, sponsorship or other financial support. All clinical research should have been conducted following informed consent of participants or of their legal representatives according to the Declarations of Helsinki and Tokyo. In addition, the US National Institute of Health guide for the care and use of laboratory animals (DHEW Publication, NIH, 80-23) should have been observed. Clinical trials should have been approved by the Ethics Committee of the Hospital. Authors’ opinions and conclusions expressed in the published papers do not necessarily reflect those of the journal. The Greek Paediatric Society, the Editorial Board and the Publisher of the journal do not necessarily approve the content of the advertisements appearing in the journal. The copyright of all published papers is held by “Paediatriki” and their reproduction in whole or in part is authorized only following written consent of the journal.
B. Manuscript Preparation “Paediatriki” suggests compliance with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals”, recently modified and published on the websites: http://www.icmje.org and http://www.icmje.org/icmje.pdf The entire paper (including figure legends and tables) should be typed on one side of blank paper format A4 (21x29.7 cm), double line spacing and minimum indent 2.5 cm on both sides.
xvii
The paper should have the following structure: title page, short title, abstract in Greek and English, list of abbreviations, text, acknowledgements and quoting of grants, sponsorships or other financial support sources, references, tables, figures, figure legends. Each of these sections should be started on a new page. Pages should be numbered consecutively, beginning with the title page. Text length shall be: ñ review articles 2000-3000 words; ñ original articles and case reports 1500-2500 words; ñ brief reports1000-1500 words; ñ letters 250-500 words. The title page should include: ñ the title (<14 words) and the short title (<5 words) of the article. No abbreviations are permitted in the title; ñ the name and surname of all authors; ñ the centre (institution, clinic, laboratory) of origin of the paper. If there is no affiliation with a specific centre, the status of the author(s) should be cited (e.g., private paediatrician) and home address; ñ the complete address, e-mail and telephone number of the author to whom correspondence should be addressed. Abstracts The abstract should summarize the objectives, methodology, main results and conclusions of the study. ñ It should contain at least 200 words, and not exceed 250 words. ñ It should consist of the following paragraphs: background, methods, results and conclusions. The English abstract should cite at the beginning the title of the paper and the authors’ names in English. The content of the text should consist of the following paragraphs: background, methods, results and conclusions. The abstract in English should not differ in content from the corresponding Greek abstract. Editorials and case reports have an English abstract only. Beneath the Greek and English abstracts, three to five key words in the respective language should be supplied, to be used in the thematic index. Text Original articles include: introduction, methods, results and discussion. The introduction includes the latest research data on the subject and the main references and the objectives of the paper. The description of the methods should be precise and detailed so as to enable reproduction by other researchers. In addition, the statistical methods of analysis and evaluation of the results should be described. Results should be presented clearly, together with the appropriate statistical analysis. Discussion should cover the results ensuing from the research, their significance and possible associations with the observations of other researchers. Case reports comprise a short introduction, case description and brief discussion, with emphasis on differential diagnosis. The structure of all other articles is free, according to the judgment of the authors. Thanks or acknowledgements (reference to grants, sponsorships or other sources of financial support) should be quoted at the end of the text, before references. Units of measures of laboratory analyses Laboratory analyses should be expressed in the Système International (SI) units and in the metric (Conventional) system in parentheses. See conversion tables on the websites: http://www.icmje.org and http://www.icmje.org/icmje.pdf
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·18
xviii
Abbreviations All issues of the journal contain internationally established abbreviations. Complex or long terms often repeated in the text may be replaced by abbreviations explained by the authors in a list submitted with the paper. Abbreviations are reported in parentheses only in abstracts. References The reference section contains all references numbered in the order in which they appear in the text. In the text, references are to be indicated by Arabic numerals in parentheses. References should be no more than: ñ 70 in review articles; ñ 30 in original articles; ñ 12 in current issues and case reports; ñ 5 in brief reports and letters. In listing references follow the recently modified standards of the International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals, (http://www.icmje.org and http:// www.icmje.org/icmje.pdf). Abbreviated names of journals should conform to the Cumulated Index Medicus [List of Journals Indexed in Index Medicus (http://www.nlm.nih.gov/bsd/uniform_requirements.html)]. Examples of reference style I. JOURNALS All authors are cited if they are six or less; if they are 7 or more, the first six are cited, followed by “et al”.
Regular edition: Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. Supplement issue: 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. No author: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. Article type specification: 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. BOOKS Chapter in book: 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.
Book or monograph: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. Publication in a volume of proceedings: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484500. Doctoral dissertation: 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. ON THE INTERNET Article in journal Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am J Nurs [Internet]. 2002 Jun: Webpage: http://www.nursingworld.org/AJN/2002/june/Wawatch.htm
Monograph Foley KM, Gelband H, editors. Improving palliative care for cancer [Monograph, Internet]. Washington: National Academy Press; 2001. Webpage: http://www.nap.edu/books/0309074029/html Websites Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancer-pain.org/ Tables and Figures Three copies should be submitted (original plus 2 copies). Their width should either be equal to the width of one column (7.5 cm) or to the width of the page (15.5 cm). Their maximum length, titles included, should not exceed 22 cm. Tables are numbered with Arabic numerals in the order in which they appear in the text. They should have a short title and abbreviations should be listed at the bottom. Vertical lines in tables should be avoided. All illustration material is considered as figures (graphs, pictures, etc.). They should be of excellent quality. Also, at the back of every picture, the number of the picture and the name of the first author should be noted in pencil, with an arrow showing the top of the picture. The identity of patients should not be recognizable from their pictures nor should their names be stated.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·19
xix
C. Manuscript Submission and Publication All manuscripts should be accompanied by a floppy disk or CD, as well as by a letter, signed by all the authors, in which it is stated that the paper has not been published in part or in whole, or is not under consideration by another journal and that the authors accept its publication in “Paediatriki”. Any funding, sponsorship or other financial support should be acknowledged. Once the manuscript has been accepted, the corrected version, rewritten according to the reviewers’ recommendations should be submitted to the Editorial Board accompanied by a floppy disk or CD, containing the paper in Word format, along with a covering letter specifying in detail the modifications or objections to the reviewers’ suggestions. Delay in submission of the modified paper exceeding 30 days entails new submission. Authors will be charged film and reprint expenses, paid upon dispatch of the first proof directly to the printer. Manuscripts of papers which have not been approved for publication are not returned to the author. The accompanying figures and photographs can be returned upon request within six months. Manuscripts submitted for review and publication in “Paediatriki” should be sent in three copies to the following address: Editorial Board Greek Paediatric Society 92, Michalakopoulou Street 115 28 Athens, Greece
Before submitting your paper, make sure it contains: 1. 3 copies of the text of the paper, printed according to instructions. 2. A floppy disk or CD with the entire material of the paper (text, tables, pictures). 3. A covering letter and a statement that the paper has not been previously published. 4. The title page (on a separate page), which includes: a. the title and short title of the paper; b. the name and surname (full name)of the author(s); c. the academic centre(s) of origin; d. the corresponding authors’ name, address and telephone number; 5. English and Greek abstracts, with the following structure: background, methods, results and conclusions (double space, separate page) and keywords. 6. List of abbreviations (double space, separate page). 7. Text (double space, separate page). 8. Acknowledgements and reference to funding, sponsorships or other financial sources. 9. References (double space, separate page). 10. Tables (one per page) in three copies. 11. Figures with an arrow at the back showing the top, numbered, in two copies. 12. Figure titles (double space - on separate pages) in three copies.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·1
∞¡∞™∫O¶∏™∏
1
¢È·ÙÚÔÊ‹ ÙÔ˘ ÚfiˆÚÔ˘ Î·È ÙÔ˘ ‰˘ÛÙÚÔÊÈÎÔ‡ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Ã. ∫ÒÛÙ·ÏÔ˜1, ∞. °Ô‡Ó·Ú˘2
¶ÂÚ›ÏË„Ë ∆· ‚Ú¤ÊË Ô˘ Â›Ó·È ÂÏÏÈÔ‚·Ú‹ ηٿ ÙË Á¤ÓÓËÛË ‰È·ÙÚ¤¯Ô˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÌÂȈ̤Ó˘ ۈ̷ÙÈ΋˜ Î·È „˘¯ÔÎÈÓËÙÈ΋˜ ÂͤÏÈ͢ Î·È ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ηډȷÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ ÛÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹. OÚÈṲ̂ӷ, ›Û˘, ÚfiˆÚ· ÓÂÔÁÓ¿, ÂÓÒ Î·Ù¿ ÙË Á¤ÓÓËÛË ¤¯Ô˘Ó ηÓÔÓÈÎfi ‚¿ÚÔ˜, ηٿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∂¡ ÂÌÊ·Ó›˙Ô˘Ó ‰˘ÛÙÚÔÊ›·. ∞˘Ùfi ÙÔ ¿ÚıÚÔ ·Ó·ÛÎfiËÛ˘ ÂÍÂÙ¿˙ÂÈ ÙȘ ·ÒÙÂÚ˜ Û˘Ó¤ÂȘ Ù˘ η΋˜ ıÚ¤„˘ Î·È ÙȘ ‰È·ÙÚÔÊÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Ô˘ ı· Ú¤ÂÈ Ó· Á›ÓÔ˘Ó Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÙË ‰ÈfiÚıˆÛË Ù˘ ‰˘ÛÙÚÔÊ›·˜. ∆fiÛÔ ÙÔ ÌËÙÚÈÎfi Á¿Ï· fiÛÔ Î·È ÙÔ Á¿Ï· Ô˘ ÚÔÔÚ›˙ÂÙ·È ÁÈ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ‰ÂÓ Â·ÚÎÔ‡Ó ¿ÓÙ· ÁÈ· ÙËÓ Î¿Ï˘„Ë ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ·Ó·ÁÎÒÓ ÂÓfi˜ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜, Á¿Ï·ÙÔ˜ ÂȉÈÎÔ‡ ÁÈ· ÚfiˆÚ· ‹ ÂÓÈÛ¯˘Ì¤ÓÔ˘ “Á¿Ï·ÙÔ˜ ÂÍfi‰Ô˘”, ‚ÂÏÙÈÒÓÂÈ ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÔÛÙÈ΋ ÌÂÙ¿ÏψÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ˘˜ ÚÒÙÔ˘˜ 18 Ì‹Ó˜ ˙ˆ‹˜. ∆Ô ÂÌÏÔ˘ÙÈṲ̂ÓÔ ÌËÙÚÈÎfi Á¿Ï· ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ χÛË. ∆· ˘fiÏÔÈ· ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· ‰›ÓÔÓÙ·È Û˘ÌÏËڈ̷ÙÈο Ì ÙÔ ÌËÙÚÈÎfi ÌfiÓÔ Û ÚfiˆÚ· ÓÂÔÁÓ¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ÁÈ· ·Ú¿‰ÂÈÁÌ· Û ·˘Ù¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ <1200 g, Û ·˘Ù¿ ÙˆÓ ÔÔ›ˆÓ ÙÔ ‚¿ÚÔ˜ ÂÍfi‰Ô˘ Â›Ó·È <5Ë ÂηÙÔÛÙÈ·›· ı¤ÛË, Û fiÛ· ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· ¿ıËÛË, Ô˘ ηٷӷÏÒÓÔ˘Ó ÏÈÁfiÙÂÚÔ ·fi 180 ml/kg ËÌÂÚËÛ›ˆ˜ Á¿Ï· Î·È Û ·˘Ù¿ ÙˆÓ ÔÔ›ˆÓ Ë ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ˘ÔÏ›ÂÙ·È. ™Â οı ÂÚ›ÙˆÛË, ı· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÂÓ¿ Ë ÛˆÌ·ÙÈ΋ ·‡ÍËÛË Î·È ÔÈ ‚ÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Î¿ı ÚfiˆÚÔ˘ ‹ ‰˘ÛÙÚÔÊÈÎÔ‡ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ∞·ÈÙÔ‡ÓÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ηٷ‰Âȯı› ηٿ fiÛÔ Ì›· ÂÓÈÛ¯˘Ì¤ÓË ‰›·ÈÙ· ‚ÔËı¿ÂÈ Ì·ÎÚÔÚfiıÂÛÌ· ‹ fi¯È ÛÙËÓ Î·Ï‡ÙÂÚË ÛˆÌ·ÙÈ΋ Î·È ÓÔËÙÈ΋ ÂͤÏÈÍË ÙÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡ Î·È ÛÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ηډȷÁÁÂÈ·ÎÒÓ ·ı‹ÛˆÓ.
1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·Ï›·˜ AÏÏËÏÔÁÚ·Ê›·: ÃÚ‹ÛÙÔ˜ ∫ÒÛÙ·ÏÔ˜ ∞ÚÙ¤ÌȉԘ 130, ∆.∫. 175 62, ¶. º¿ÏËÚÔ ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 23-04-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-07-2004
§¤ÍÂȘ ÎÏÂȉȿ ¶ÚfiˆÚÔ ÓÂÔÁÓfi, ÂÏÏÈÔ‚·Ú¤˜, ‰È·ÙÚÔÊ‹.
∂ÈÛ·ÁˆÁ‹ ∏ ÛËÌ·Û›· Ù˘ ÛˆÛÙ‹˜ ‰È·ÙÚÔÊ‹˜ ηٿ ÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô Ù˘ ˙ˆ‹˜ Â›Ó·È ÌÂÁ¿ÏË. ∏ ÛÙ¤ÚËÛË Ù˘ ÙÚÔÊ‹˜ ηٿ ÙËÓ Â˘·›ÛıËÙË ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô fi¯È ÌfiÓÔ ÂËÚ¿˙ÂÈ ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÓÂÔÁÓÔ‡, ·ÏÏ¿ ÌÔÚ› Ó· ηıÔÚ›ÛÂÈ ÙÔ ÙÂÏÈÎfi ̤ÁÂıÔ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (1,2). À¿Ú¯Ô˘Ó, ÂÈϤÔÓ, ÛÙÔȯ›· Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÚÒÈÌË ‰˘ÛÙÚÔÊ›· ‰È·Ù·Ú¿ÛÛÂÈ ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ‚·ÛÈÎÒÓ ÔÚÌÔÓÒÓ (·˘ÍËÙÈ΋, ÈÓÛÔ˘Ï›ÓË, IGF) Î·È Úԉȷı¤ÙÂÈ ÛÙË ÌÂÏÏÔÓÙÈ΋ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ Î·È Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË (3-5). ¶Ú¿ÁÌ·ÙÈ, ÓÂÔÁ¤ÓÓËÙ· Ì ¯·ÌËÏfi ‚¿ÚÔ˜ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ Û˘¯Ó¿ ÂΉËÏÒÓÔ˘Ó ÌÂÙ¤ÂÈÙ· „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ‰È·Ù·Ú·¯¤˜ Ì¿ıËÛ˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ (2). ∂ÎÙfi˜ ·fi Ù· ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿, Ì›· ¿ÏÏË Î·ÙËÁÔÚ›· Ì ÚÔ‚Ï‹Ì·Ù· ıÚ¤„˘ Â›Ó·È Ù· ÚfiˆÚ· ÓÂÔÁÓ¿. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË Â›Ó·È Ì¤ÁÈÛÙË Î·Ù¿ ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, ÂÚ›Ô‰Ô˜ fiÔ˘ ÙÔ ÚfiˆÚÔ ÓÂÔÁÓfi ‰ÂÓ ‚Ú›ÛÎÂÙ·È Ï¤ÔÓ ÛÙË Ì‹ÙÚ· (6). ∆Ô ·ÓÒÚÈÌÔ ÓÂÔÁÓfi, Û˘ÓÂÒ˜, Ô˘ ‰ÂÓ ÙÚ¤ÊÂÙ·È Â·ÚÎÒ˜ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜
˙ˆ‹˜, ‚Ú›ÛÎÂÙ·È Û ÂÍ›ÛÔ˘ ‰ÂÈÓ‹ ı¤ÛË Ì ·˘Ù‹ ÙˆÓ ÂÏÏÈÔ‚·ÚÒÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ. ∏ ‰˘ÛÙÚÔÊ›· Û ·˘Ù¿ Ù· ÓÂÔÁÓ¿ Â›Ó·È Â͈̋ÙÚÈ· Î·È fi¯È ÂÓ‰ÔÌ‹ÙÚÈ· (7-9). ¶Ú¿ÁÌ·ÙÈ, ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÂÓÒ ÙÔ ‚¿ÚÔ˜ Û ÔÏÏ¿ ·fi ·˘Ù¿ Ù· ÚfiˆÚ· ηٿ ÙË Á¤ÓÓËÛË ‚ÚÈÛÎfiÙ·Ó ÛÙËÓ 50‹ ÂηÙÔÛÙÈ·›· ı¤ÛË Ù˘ η̇Ï˘ ·‡ÍËÛ˘, ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Ë ÛˆÌ·ÙÈ΋ ÙÔ˘˜ ·Ó¿Ù˘ÍË ˘ÔÏÂÈfiÙ·Ó Î·Ù¿ 35-41% ÙÔ˘ ηÓÔÓÈÎÔ‡ (6). ŸÛÔ ÈÔ ¯·ÌËÏfi ‹Ù·Ó ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ÙfiÛÔ ÈÔ Ôχ ˘ÔÏÂÈfiÙ·Ó Ë ÛˆÌ·ÙÈ΋ ÙÔ˘˜ ·Ó¿Ù˘ÍË Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∂¡. ŒÙÛÈ, 36% ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ·fi 1500 g ›¯Â Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ οو ·fi ÙË 10Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (10). ∆Ô ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÁÈ· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ·fi 1000 g ‹Ù·Ó 80-98% (11). ∞Ó¿ÏÔÁË ˘ÛÙ¤ÚËÛË ÂÌÊ·Ó›˙ÂÈ Î·È Ë ÔÛÙÈ΋ ÌÂÙ¿ÏψÛË Û ÔÛÔÛÙfi Ô˘ Êı¿ÓÂÈ ÙÔ 50% Û ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ·fi 1000 g (10). π‰È·›ÙÂÚË ·ÓËÛ˘¯›· ÚÔηÏÔ‡Ó ÔÈ Ì·ÎÚfi¯ÚÔÓ˜ Û˘Ó¤ÂȘ Û ·˘Ù¿ Ù· ÚfiˆÚ· ÓÂÔÁÓ¿. OÈ Hack Î·È Û˘Ó ·Ú·ÎÔÏÔ‡ıËÛ·Ó 249 ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÈÎÚfiÙÂÚÔ ·fi 1500 g ÁÈ· 8 ¤ÙË. ∞fi ·˘Ù¿ ¶·È‰È·ÙÚÈ΋ 2005;68:1-6
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·2
2
Ã. ∫ÒÛÙ·ÏÔ˜ Î·È Û˘Ó.
Ô˘ ‹Ù·Ó ηÓÔÓÈÎÔ‡ ‚¿ÚÔ˘˜ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘, ÌfiÓÔ ÙÔ 5% ›¯Â ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ <3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË. ∞ÓÙ›ıÂÙ·, ·fi Ù· ÓÂÔÁÓ¿ Ô˘ ÂÎÙfi˜ ·fi ·ÓˆÚÈÌfiÙËÙ· ›¯·Ó Î·È ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, ÂÚ›Ô˘ 29% ›¯Â ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË Î¿Ùˆ ·fi ÙËÓ 3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (12). OÈ Ford Î·È Û˘Ó (13) ÌÂϤÙËÛ·Ó, ›Û˘, ‰‡Ô ÔÌ¿‰Â˜ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ÂÍ·ÈÚÂÙÈο ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (∂õ°) (<1000 g) Î·È Ì Ôχ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (¶Ãµ°) (<1500 g). ™Â Û‡ÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ Î·È ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ˘ÔÏ›ÔÓÙ·Ó Û ‡„Ô˜ Î·È Û ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 8 ÂÙÒÓ. ªÂٷ͇ ÙˆÓ ËÏÈÎÈÒÓ 8-14 ÂÙÒÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ·‡ÍËÛË ÛÙ· ·È‰È¿ Ì ¶Ãµ°, fi¯È fï˜ ÛÙ· ÓÂÔÁÓ¿ Ì ∂õ°. OÈ Peralta-Carcelen Î·È Û˘Ó (14) ÌÂϤÙËÛ·Ó ÙËÓ ÂͤÏÈÍË ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ‚Ú‹Î·Ó fiÙÈ ÛÙËÓ ËÏÈΛ· ÙˆÓ 15 ÂÙÒÓ ÔÛÔÛÙfi 5,7% ÙˆÓ ÓÂÔÁÓÒÓ Â›¯Â ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË <3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Î·È 21% <10Ë ı¤ÛË. ∏ ·fiÎÏÈÛË ‹Ù·Ó Ôχ ÌÂÁ·Ï‡ÙÂÚË Û fiÛ· ÚfiˆÚ· ‹Ù·Ó Ù·˘Ùfi¯ÚÔÓ· ÂÏÏÈÔ‚·Ú‹ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ηٿ ÙË Á¤ÓÓËÛË. ∆¤ÏÔ˜, Ì›· ¿ÏÏË ÌÂϤÙË 166 ÚÔÒÚˆÓ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ¤‰ÂÈÍ fiÙÈ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ ÙÔ 35% ›¯Â ۈ̷ÙÈÎfi ‚¿ÚÔ˜, ‡„Ô˜ Î·È ¶∫ <5Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (15). O ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ‰ÂÓ ·ÊÔÚ¿ ÙfiÛÔ Ôχ ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË, ·ÏÏ¿ ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·˘Ù‹ Û˘Ó‰˘¿˙ÂÙ·È Ì ÌÈÎÚfiÙÂÚË ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ηÈ, ÂÔ̤ӈ˜, Ì ¯·ÌËÏfiÙÂÚÔ fiÁÎÔ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ô˘ ›Ûˆ˜ ·ÔÙÂÏ› ÙÔÓ ÏfiÁÔ ÁÈ· ÙÔÓ ÔÔ›Ô Ë ‰˘ÛÙÚÔÊ›· ηٿ ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô Û˘¯Ó¿ Û˘Óԉ‡ÂÙ·È ·fi ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÚÔ‚Ï‹Ì·Ù· Ì¿ıËÛ˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ (1). OÈ ÏfiÁÔÈ Ô˘ Ô‰ËÁÔ‡Ó Û ‰˘ÛÙÚÔÊ›· ÙˆÓ ÚÔÒÚˆÓ Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô Â›Ó·È ÔÏÏÔ›, fiˆ˜ ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· Î·È ·ÔÚÚÔÊËÙÈÎfiÙËÙ· ÂÙÈÎÔ‡, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, ηډȷ΋ ·Ó¿ÚÎÂÈ·, ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ÛË„·ÈÌ›· Î·È Ï‹„Ë ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ‰ÈÔ˘ÚËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (16-18). ∂ÊfiÛÔÓ, ÏÔÈfiÓ, Ë ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹ ηٿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ (ª∂¡¡), ȉȷ›ÙÂÚË ÛËÌ·Û›· ‰›ÓÂÙ·È ˘Ô¯ÚˆÙÈο ÛÙË ÛˆÛÙ‹ Û›ÙÈÛË ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô, ÚÔÎÂÈ̤ÓÔ˘ fi¯È ÌfiÓÔ Ó· ‰È·-
ÙËÚ‹ÛÂÈ ¤Ó·Ó Ê˘ÛÈÔÏÔÁÈÎfi Ú˘ıÌfi ·Ó¿Ù˘Í˘, ·ÏÏ¿ Î·È Ó· ·Ó·ÏËÚÒÛÂÈ ÙÔ “¯·Ì¤ÓÔ ¤‰·ÊÔ˜”. ™ÙË Û˘Ó¤¯ÂÈ·, ı· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙȘ ÂÈÎÚ·ÙÔ‡Û˜ ÌÂıfi‰Ô˘˜ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ÛÙȘ ÌÂıfi‰Ô˘˜ ÂÓ›Û¯˘Û‹˜ Ù˘.
∞Ï¿ Á¿Ï·Ù· ªËÙÚÈÎfi Á¿Ï· ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ˘ÂÚ¤¯ÂÈ ÔÈÔÙÈο οı ¿ÏÏÔ˘ ÙÚfiÔ˘ ‰È·ÙÚÔÊ‹˜, ·ÊÔ‡ - ÂÎÙfi˜ ·fi ÙËÓ È‰·ÓÈ΋ ÙÔ˘ Û‡ÓıÂÛË - ¤¯ÂÈ Î·È ¿ÏϘ ÛËÌ·ÓÙÈΤ˜ ȉÈfiÙËÙ˜, fiˆ˜ ·ÓÔÛÔÏÔÁÈΤ˜ Î·È ·ÓÙÈ·ÏÏÂÚÁÈΤ˜ (19), ηχÙÂÚË ·Ó¿Ù˘ÍË ÙÔ˘ ‰ÂÛÌÔ‡ ÌËÙ¤Ú·˜-ÓÂÔÁÓÔ‡ Î·È Î·Ï‡ÙÂÚË Ó¢ÚÔ·Ó¿Ù˘ÍË (20). ∆ÂÏÂ˘Ù·›·, fï˜, ¤¯ÂÈ ÂÎÊÚ·ÛÙ› ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ηٿ fiÛÔ ·˘Ùfi ·ÚΛ ÁÈ· Ó· ηχ„ÂÈ ÙȘ ·Ó¿ÁΘ ÂÓfi˜ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡. ∂›Ó·È, ‚¤‚·È·, ÁÓˆÛÙfi fiÙÈ ÙÔ Á¿Ï· ÌËÙ¤Ú·˜ Ô˘ Á¤ÓÓËÛ ÚfiˆÚ· ÂÚȤ¯ÂÈ ÂÚÈÛÛfiÙÂÚÔ Ï‡Έ̷, Ó¿ÙÚÈÔ Î·È Û›‰ËÚÔ ÙÔÓ ÚÒÙÔ Ì‹Ó· ˙ˆ‹˜. ¶ÚÔԉ¢ÙÈο, fï˜, Ù· ›‰· ÌÂÈÒÓÔÓÙ·È, ÌÂ Û˘Ó¤ÂÈ· ˘ÛÙ¤ÚËÛË (¶›Ó·Î·˜ 1) (21,22). ∆· ÔÛÔÛÙ¿ ·Û‚ÂÛÙ›Ô˘ Î·È ÊˆÛÊfiÚÔ˘ Â›Ó·È ÂÍ·Ú¯‹˜ ·Ó·Ú΋ (23). ŒÙÛÈ, Ô ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÔÛÙÒÓ ‰Â›¯ÓÂÈ ·Ê·Ï¿ÙˆÛË, ηٿÁÌ·Ù·, Ú·¯›Ùȉ·, ˘„ËÏ¿ ›‰· ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘, ¯·ÌËÏ¿ ›‰· ʈÛÊfiÚÔ˘ Î·È ÌÂȈ̤ÓË ÔÛÙÈ΋ Ì¿˙· Î·È Ë ÌÂÏÏÔÓÙÈ΋ ÂȘ Ì‹ÎÔ˜ ·Ó¿Ù˘ÍË ˘ÔÏ›ÂÙ·È ÛËÌ·ÓÙÈο ÛÙ· ÓÂÔÁÓ¿ Ô˘ ›¯·Ó ÙËÓ ˘„ËÏfiÙÂÚË ÙÈÌ‹ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (24). ∞Ó Î·È ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÔÛÙÈ΋ Ì¿˙· ·ÔηٷÛÙ¿ıËΠÛÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ Î·È fiÙÈ Ë Î·Ù·Ó¿ÏˆÛË ÌÂÁ¿Ï˘ ÔÛfiÙËÙ·˜ Á¿Ï·ÙÔ˜ (ÂÚ›Ô˘ 180 ml/kg) ÌÔÚ› Ó· ·ÓÙÈÚÚÔ‹ÛÂÈ ÙË ¯·ÌËÏ‹ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο (25), Ë ÁÓÒÌË ÙˆÓ ÂȉÈÎÒÓ Û˘ÁÎÏ›ÓÂÈ ÛÙÔ fiÙÈ ÁÈ· ÔÚÈṲ̂ӷ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÚfiˆÚ· ÓÂÔÁÓ¿ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ Â·ÚΛ. °¿Ï· ÁÈ· ÙÂÏÂÈfiÌËÓ· ∆Ô Á¿Ï· ÁÈ· ÙÂÏÂÈfiÌËÓ· Â›Ó·È ·Ó·ÚΤ˜ ÙfiÛÔ ÔÛÔÙÈο fiÛÔ Î·È ÔÈÔÙÈο, ÚÔÎÂÈ̤ÓÔ˘ Ó· ηχ„ÂÈ ÙȘ ·Ó¿ÁΘ ÙÔ˘ ÚfiˆÚÔ˘ ‹ ÙÔ˘ ‰˘ÛÙÚÔÊÈÎÔ‡ ÓÂÔÁÓÔ‡ (26,27).
¶›Ó·Î·˜ 1. ¶ÂÚÈÂÎÙÈÎfiÙËÙ· ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο ™˘ÛÙ·ÙÈο (ÌÔÓ¿‰·/kg/Ë̤ڷ) ∂Ó¤ÚÁÂÈ· (KJ) ÀÁÚ¿ (ml) §Â‡ÎˆÌ· (g) ¡¿ÙÚÈÔ (mEq) ∞Û‚¤ÛÙÈÔ (mg) ºÒÛÊÔÚÔ˜ (mg) ¶·È‰È·ÙÚÈ΋ 2005;68:1-6
°¿Ï· ÚÔÒÚÔ˘ (‚‰ÔÌ¿‰·) 1 2 4 504 180 3,9 4,0 53 25
504 180 3,4 2,7 46 27
504 180 2,8 1,8 42 23
flÚÈÌÔ Á¿Ï· 504 190 2,4 2,0 47 26
∂ÎÙÈÌÔ‡ÌÂÓ˜ ·Ó¿ÁΘ 504 150 3,5 3,5 160-200 80-100
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·3
3
¢È·ÙÚÔÊ‹ ÙÔ˘ ÂÏÏÈÔ‚·ÚÔ‡˜ ÓÂÔÁÓÔ‡
ÂÓ›Û¯˘Û˘”, ηٿ ÙËÓ ÔÔ›· ÙÔ ÌËÙÚÈÎfi Á¿Ï· ·Ó·Ï‡ÂÙ·È Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂÓÈÛ¯‡ÂÙ·È ·Ó¿ÏÔÁ· (36).
∂ÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· ∂ÓÈÛ¯˘Ù¤˜ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ∆Ô 1980, Ô Lucas ÂÈÛ‹Á·Á ÙÔÓ fiÚÔ “Á·Ï·ÎÙÔÌ˯·ÓÈ΋”, ‰ËÏ·‰‹ ÙËÓ È‰¤· ÂÓ›Û¯˘Û˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ Ì ÂÈϤÔÓ Û˘ÛÙ·ÙÈο (28). ™‹ÌÂÚ·, ˘¿Ú¯Ô˘Ó ÔÏÏÒÓ ÂȉÒÓ ÂÓÈÛ¯˘Ù¤˜. ¢È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ ÚԤϢÛË (·ÓıÚÒÈÓË ‹ ‚fiÂÈÔ˜), ÙË Û‡ÓıÂÛË (ÌÔÓÔÂÓÈÛ¯˘Ù‹˜ - Ì ¤Ó· ÌfiÓÔ Û˘ÛÙ·ÙÈÎfi, .¯. χΈ̷ ‹ ·Û‚¤ÛÙÈÔ Î·È ÊÒÛÊÔÚÔ - ‹ ÔÏ˘ÂÓÈÛ¯˘Ù‹˜ - Ô˘ ÂÚȤ¯ÂÈ ÔÏÏ¿ Û˘ÛÙ·ÙÈο), ÙÔ Â›‰Ô˜ ÙÔ˘ Ï¢ÎÒÌ·ÙÔ˜ (·Î¤Ú·ÈÔ ÔÚÔχΈ̷ ‹ η˙½ÓË, ˘‰ÚÔÏ˘Ì¤ÓÔ Ï‡Έ̷), ÙÔ Â›‰Ô˜ ÙÔ˘ ˘‰·Ù¿Óıڷη (Ï·ÎÙfi˙Ë, Ì·ÏÙÔ‰ÂÍÙÚ›Ó˜) ‹ ÙȘ Ê˘ÛÈΤ˜ ȉÈfiÙËÙ˜ (˘ÁÚfi ‹ ÛÎfiÓË) (29,30). O ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ Ì ·Û‚¤ÛÙÈÔ Î·È ÊÒÛÊÔÚÔ Ô‰ËÁ› Û ηχÙÂÚË ÂȘ Ì‹ÎÔ˜ ·Ó¿Ù˘ÍË Î·È ÌÂÙ¿ÏψÛË ÙˆÓ ÔÛÙÒÓ (31,32). ∏ ÚÔÛı‹ÎË Ó·ÙÚ›Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰ÈfiÚıˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ó·ÙÚ›Ô˘ ÛÙÔ ·›Ì· Î·È ÛÙËÓ Î·Ï‡ÙÂÚË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË (33). ∆¤ÏÔ˜, Ë ÚÔÛı‹ÎË ÚˆÙ½Ó˘ Î·È ıÂÚÌ›‰ˆÓ ÂÈÙ·¯‡ÓÂÈ ÙÔÓ Ú˘ıÌfi ·Ó¿Ù˘Í˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ·ÔηıÈÛÙ¿ Ù· ›‰· ÚˆÙÂ˚ÓÒÓ ÛÙÔ ·›Ì· ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (34). ∆Ô 1990, Ô Polberger (35) ·Ó¤ÊÂÚ fiÙÈ ¶Ãµ° ÓÂÔÁÓ¿ Ô˘ ¤Ï·‚·Ó Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì Ï‡Έ̷ (3 g/kg) Î·È ÂÈϤÔÓ Ï›Ô˜ Î·È ˘‰·Ù¿ÓıڷΘ (120 kcal/kg ËÌÂÚËÛ›ˆ˜) ›¯·Ó ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË fiÌÔÈ· Ì ÂΛÓË ÂÌ‚Ú‡ˆÓ ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ ·ËÛ˘. ∆Ô ·ÌÈÓfiÁÚ·ÌÌ· ‹Ù·Ó ·ÚfiÌÔÈÔ Ì ·˘Ùfi ÙˆÓ ıËÏ·˙fiÓÙˆÓ ÓÂÔÁÓÒÓ. ™Â Û‡ÁÎÚÈÛË Ì ÙÔ ·Ïfi Á¿Ï·, ›¯·Ó ηχÙÂÚË ÔÛÙÈ΋ ÌÂÙ¿ÏψÛË, ‚ÈÔ¯ËÌÈÎÔ‡˜ ‰Â›ÎÙ˜ (·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ·Û‚¤ÛÙÈÔ, ÊÒÛÊÔÚÔ˜, Ó¿ÙÚÈÔ, Ô˘Ú›·, ÏÂ˘ÎˆÌ·Ù›ÓË, ÚÔ·Ï‚Ô˘Ì›ÓË) Î·È ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË. ∏ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë, Û‹ÌÂÚ·, Â›Ó·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÔÏ˘ÂÓÈÛ¯˘Ù‹˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ (¶›Ó·Î·˜ 2), ·ÏÏ¿ ˘¿Ú¯ÂÈ ‰È¯ÔÁӈ̛· ˆ˜ ÚÔ˜ ÙË Û‡ÛÙ·ÛË ÙˆÓ ÂÓÈÛ¯˘ÙÒÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ¤¯ÂÈ ÛÙ·ıÂÚ‹ Û‡ÓıÂÛË, ·ÏÏ¿ ÂÌÊ·Ó›˙ÂÈ ÛËÌ·ÓÙÈΤ˜ ·˘ÍÔÌÔÈÒÛÂȘ Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο, ·ÏÏ¿ Î·È ÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ οı ÓÂÔÁÓÔ‡ Û ıÚÂÙÈΤ˜ Ô˘Û›Â˜. ŒÙÛÈ, ‰ËÌÈÔ˘ÚÁ‹ıËÎÂ Ë È‰¤· Ù˘ “ÂÍ·ÙÔÌÈÎÂ˘Ì¤Ó˘
°¿Ï· ÁÈ· ÚfiˆÚ· ÓÂÔÁÓ¿ OÈ Cooke Î·È Û˘Ó (37) Û›ÙÈÛ·Ó ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ∏∫ ≤34 ‚‰ÔÌ¿‰Â˜ Î·È µ° <1750 g, ̤¯ÚÈ ÙË ‰ÈÔÚıˆÌ¤ÓË ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Ì Á¿Ï· ÂȉÈÎfi ÁÈ· ÚfiˆÚ·, Ô˘ ˆ˜ ÁÓˆÛÙfiÓ Â›Ó·È È‰È·›ÙÂÚ· ÂÓÈÛ¯˘Ì¤ÓÔ Û Ï‡Έ̷, ıÂÚÌ›‰Â˜, Ó¿ÙÚÈÔ, ·Û‚¤ÛÙÈÔ Î·È ÊÒÛÊÔÚÔ (¶›Ó·Î·˜ 2). ™ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ, Ù· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘ ›¯·Ó ηχÙÂÚË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË, ÔÛÙÈ΋ Ì¿˙· Î·È ÌÂÙ¿ÏψÛË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ô˘ ¤Ï·‚·Ó ·Ïfi Á¿Ï·. ∏ ˘ÂÚÔ¯‹ ·˘Ù‹ Û˘Ó¯›ÛÙËΠ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ. ∆Ô ÛËÌ·ÓÙÈÎfi Â›Ó·È fiÙÈ Ë ·Ó¿Ù˘ÍË Û ۈ̷ÙÈÎfi ‚¿ÚÔ˜ ·ÊÔÚÔ‡Û ΢ڛˆ˜ Û ·‡ÍËÛË Ù˘ Ì˘˚΋˜ Ì¿˙·˜ Î·È fi¯È ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜. OÈ Agosti Î·È Û˘Ó (38) ¯ÔÚ‹ÁËÛ·Ó ÁÈ· 15 ‚‰ÔÌ¿‰Â˜ Á¿Ï· ÁÈ· ÚfiˆÚ· Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì µ° <1500 g. ™ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, Ù· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘ ›¯·Ó ηχÙÂÚË ·Ó¿Ù˘ÍË fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ‚¿ÚÔ˜. ∞ÎfiÌ· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó Û ÂΛӷ Ù· ÚfiˆÚ· Ô˘ ‹Ù·Ó ÂÈϤÔÓ ÂÏÏÈÔ‚·Ú‹. ™Â ·˘Ù¿ ·Ú·ÙËÚ‹ıËÎ·Ó Î·Ï‡ÙÂÚ˜ ÂȉfiÛÂȘ ÛÙËÓ Îϛ̷η Griffith, Ë ÔÔ›· ÂÎÙÈÌ¿ ÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜. °¿Ï· ÂÍfi‰Ô˘ OÈ Lucas Î·È Û˘Ó (39) ÂÈÛ‹Á·Á·Ó ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ Á¿Ï·ÙÔ˜ ÂÍfi‰Ô˘ ÙÔ 1992, ¯ÔÚËÁÒÓÙ·˜ Û 16 ÓÂÔÁÓ¿ Ì µ° <1850 g ÂȉÈο ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï·, Ì ۇÛÙ·ÛË ÌÂٷ͇ Á¿Ï·ÙÔ˜ ÁÈ· ÙÂÏÂÈfiÌËÓ· Î·È ·˘ÙÔ‡ ÁÈ· ÚfiˆÚ·, ÁÈ· 9 Ì‹Ó˜. ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË Î·È Ë ÔÛÙÈ΋ Ì¿˙· ‹Ù·Ó ·ÓÒÙÂÚ˜ Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ Ô˘ ¤Ï·‚·Ó Û‡ÓËı˜ Á¿Ï·. ¢‡Ô ÌÂÁ·Ï‡ÙÂÚ˜ ÌÂϤÙ˜, ÛÙË Û˘Ó¤¯ÂÈ·, ¤‰ÂÈÍ·Ó Â›Û˘ ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù·. ™Â Ì›· ·fi ·˘Ù¤˜, ÙˆÓ Lucas Î·È Û˘Ó (40), ¯ÔÚËÁ‹ıËΠ۠229 ÚfiˆÚ· ÓÂÔÁÓ¿ Á¿Ï· ÂÍfi‰Ô˘ ÁÈ· 9 Ì‹Ó˜ Î·È ‰È·ÈÛÙÒıËΠηχÙÂÚË ÂȘ Ì‹ÎÔ˜ ·Ó¿Ù˘ÍË ÛÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÚÈÛÛfiÙÂÚÔ ˆÊÂÏ‹ıËÎ·Ó Ù· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘ Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·. OÈ Carver Î·È Û˘Ó (41) ÌÂϤÙËÛ·Ó 123 ÚfiˆÚ·, ¯ÔÚËÁÒÓÙ·˜ Á¿Ï· ÂÍfi‰Ô˘ ÁÈ· 12 Ì‹Ó˜.
¶›Ó·Î·˜ 2. ™‡ÁÎÚÈÛË Á·Ï¿ÙˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô (·Ó¿ 100 ml) ™˘ÛÙ·ÙÈο ∂Ó¤ÚÁÂÈ· (Kcal) ¶ÚˆÙ½ÓË (g) §›Ô˜ (g) À‰·Ù¿ÓıڷΘ (g) ∞Û‚¤ÛÙÈÔ (mg) ºÒÛÊÔÚÔ˜ (mg) ¡¿ÙÚÈÔ (mEq)
°È· ÚfiˆÚ·
∂Ífi‰Ô˘
°È· ÙÂÏÂÈfiÌËÓ·
ªËÙÚÈÎfi
ªËÙÚÈÎfi+*
81 2,2-2,4 4,1-4,4 8,6-9,0 133-145 67-81 1,4-1,5
72-73 1,9-2,1 3,9-4,1 7,7-8,0 78-90 46-50 1,1-1,7
67 1,4 3,6 7,3 53 28-36 0,7-0,8
67 1,0 3,5 7,0 26 14 0,9
74-79 1,8-2 3,9-4,2 9,4-10,6 59-112 36-56 1-1,9
* ªËÙÚÈÎfi+: ÂÓÈÛ¯˘Ì¤ÓÔ ÌËÙÚÈÎfi Á¿Ï·
¶·È‰È·ÙÚÈ΋ 2005;68:1-6
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·4
4
Ã. ∫ÒÛÙ·ÏÔ˜ Î·È Û˘Ó.
™ÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘, ÙÔ ‚¿ÚÔ˜ Î·È Ë ¶∫ ‹Ù·Ó ·ÓÒÙÂÚ· ÛÙ· ÓÂÔÁÓ¿ Ô˘ ¤Ï·‚·Ó ÙÔ Á¿Ï· ÂÍfi‰Ô˘. ¶ÂÚÈÛÛfiÙÂÚÔ Â˘ÓÔ‹ıËÎ·Ó Ù· ÈÔ ·ÓÒÚÈÌ· ‚Ú¤ÊË Ù˘ ÌÂϤÙ˘ Î·È Ù· ·ÁfiÚÈ·. ∆· ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÂÌÊ·Ó‹ ̤۷ ÛÙÔ˘˜ ÚÒÙÔ˘˜ 1-3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘. ∏ Û˘Ó¤¯ÈÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ÂȉÈÎÔ‡ Á¿Ï·ÙÔ˜ ‰ÂÓ Â›¯Â ÂÈϤÔÓ fiÊÂÏÔ˜. ∆¤ÏÔ˜, ÔÈ Brunton Î·È Û˘Ó (42) ¯ÔÚ‹ÁËÛ·Ó Á¿Ï· ÂÍfi‰Ô˘ ÁÈ· 3 Ì‹Ó˜ Û 60 ÓÂÔÁÓ¿ Ì ¶Ãµ° Ô˘ ¤·Û¯·Ó ·fi ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘, Ù· ·ÁfiÚÈ·, ΢ڛˆ˜, ›¯·Ó ηχÙÂÚË ·Ó¿Ù˘ÍË Û ̋ÎÔ˜. ∞fi Ù· ·Ú·¿Óˆ ÚÔ·ÙÂÈ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÙÔ˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∂¡ ˆÊÂÏ› ÂÚÈÛÛfiÙÂÚÔ Ù· Ôχ ·ÓÒÚÈÌ· ÓÂÔÁÓ¿ Î·È ÂȉÈο ·˘Ù¿ Ô˘ Â›Ó·È Ù·˘Ùfi¯ÚÔÓ· ÂÏÏÈÔ‚·Ú‹. ∆· ·ÁfiÚÈ· Û·ÊÒ˜ ˆÊÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·’ fi,ÙÈ Ù· ÎÔÚ›ÙÛÈ·. ∆· ÂÚˆÙ‹Ì·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Â›Ó·È: ·) ÔÈ· ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·Ó¿ÁÎË ÂÓÈÛ¯˘Ì¤Ó˘ ‰›·ÈÙ·˜ ηٿ ÙËÓ ¤ÍÔ‰Ô, ‚) ÔÈÔ˜ Â›Ó·È Ô Î·Ï‡ÙÂÚÔ˜ ÙÚfiÔ˜ ÂÓ›Û¯˘Û˘ ÙÔ˘ Á¿Ï·ÙÔ˜ Î·È Á) ÁÈ· fiÛÔ ‰È¿ÛÙËÌ· ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È Ë ÂȉÈ΋ ‰›·ÈÙ·. ∞Ó Î·È ÔÏϤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ·fi ÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙÔ˘ Á¿Ï·ÙÔ˜, ˘¿Ú¯Ô˘Ó Î·È ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ıÂÚÌ›‰ˆÓ Î·È Ï¢ÎÒÌ·ÙÔ˜ fi¯È ÌfiÓÔ ‰ÂÓ ˆÊÂÏ›, ·ÏÏ¿ ÌÔÚ› Î·È Ó· ‚Ï¿„ÂÈ, ·ÊÔ‡ ÌÔÚ› Ì·ÎÚÔÚfiıÂÛÌ· Ó· Ô‰ËÁ‹ÛÂÈ Û ·¯˘Û·ÚΛ·, ·Ó¿Ù˘ÍË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Î·È Î·Ú‰È·ÁÁÂȷΤ˜ ·ı‹ÛÂȘ (43,44). ∂Í¿ÏÏÔ˘, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÏÏ¿ ÚfiˆÚ· Ú˘ıÌ›˙Ô˘Ó ·˘ÙfiÌ·Ù· ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Á¿Ï·ÙÔ˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÈηÓÔÔÈ‹ÛÔ˘Ó ÙȘ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ ·Ó¿ÁΘ (25). ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ¤¯ÂÈ Î·Ï‹ ıÚ¤„Ë. ∞ÏÏ¿ Î·È ·fi ·˘Ù¿ ÙˆÓ ÔÔ›ˆÓ Ë ·Ó¿Ù˘ÍË ˘ÔÏ›ÂÙ·È, ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ¤¯ÂÈ ·˘ÙfiÌ·ÙË ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ·‡ÍËÛË Ì¤Û· ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ Ì‹Ó˜. ŒÙÛÈ, ·Ô̤ÓÂÈ Ì›· ÌÈÎÚ‹ Û¯ÂÙÈο ÌÂÚ›‰· ÓÂÔÁÓÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÓ›Û¯˘ÛË Ù˘ ÙÚÔÊ‹˜ ÙÔ˘˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∂¡ (16).
∂ÈÏÔÁ‹ ÓÂÔÁÓÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· ªÂ ‚¿ÛË Ù· ·Ú·¿Óˆ, Ô Shanler (45) ÚÔÙ›ÓÂÈ Ó· ‰›ÓÂÙ·È ÂÌÏÔ˘ÙÈṲ̂ÓË ‰›·ÈÙ· ÌfiÓÔ ÛÙȘ ·ÎfiÏÔ˘ı˜ ÂÚÈÙÒÛÂȘ: ·) Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì µ° <1250 g, ȉ›ˆ˜ ·Ó Â›Ó·È Ù·˘Ùfi¯ÚÔÓ· Î·È ÂÏÏÈÔ‚·Ú‹, ‚) Û ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ ηٿ ÙËÓ ¤ÍÔ‰Ô <3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË, Á) Û ÓÂÔÁÓ¿ Ô˘ ηٷӷÏÒÓÔ˘Ó <180 ml/kg/24ˆÚÔ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜, ‰) Û ÓÂÔÁÓ¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ‰ËÏ·‰‹ Û fiÛ· ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ·, Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· ‹ ¤¯Ô˘Ó ¯ÂÈÚÔ˘ÚÁËı› ÚfiÛÊ·Ù· ÁÈ· ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›¶·È‰È·ÙÚÈ΋ 2005;68:1-6
Ùȉ·, Â) Û ÓÂÔÁÓ¿ Ì ·ıÔÏÔÁÈÎÔ‡˜ ‚ÈÔ¯ËÌÈÎÔ‡˜ ‰Â›ÎÙ˜, fiˆ˜ ·˘ÍË̤ÓË ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ¯·ÌËÏfi ÊÒÛÊÔÚÔ Î·È ÏÂ˘ÎˆÌ·Ù›ÓË ·›Ì·ÙÔ˜, Ôχ ¯·ÌËÏ‹ ÙÈÌ‹ Ô˘Ú›·˜ ·›Ì·ÙÔ˜ ‹ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ÔÛÙÂÔÂÓ›·˜ Î·È ÛÙ) Û ÓÂÔÁÓ¿ ÙˆÓ ÔÔ›ˆÓ Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈÎfi˜. ™Â οı ÂÚ›ÙˆÛË, Û˘ÓÈÛÙ¿Ù·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô Î·È ¿ÌÂÛË Â¤Ì‚·ÛË Û ÂÚ›ÙˆÛË ·fiÎÏÈÛ˘ ·fi ÙÔ˘˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘.
∂ÈÏÔÁ‹ ÙÔ˘ ϤÔÓ Î·Ù¿ÏÏËÏÔ˘ Á¿Ï·ÙÔ˜ O ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ ÙÚÔÊ‹ Î·È ı· Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÂÙ·È Û οı ÂÚ›ÙˆÛË. ∂ÊfiÛÔÓ ÎÚ›ÓÂÙ·È fiÙÈ ÙÔ ÓÂÔÁÓfi ¯ÚÂÈ¿˙ÂÙ·È ÂÈϤÔÓ ÂÓ›Û¯˘ÛË, ÚÔÙ›ÓÔÓÙ·È ÔÈ ÂÍ‹˜ ÂÓ·ÏÏ·ÎÙÈΤ˜ χÛÂȘ: ∏ ÌËÙ¤Ú·: ·) ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ıËÏ·ÛÌÔ‡ ‚Á¿˙ÂÈ ÙÔ Á¿Ï· Ô˘ ·Ú¤ÌÂÈÓ ÛÙÔ ÛÙ‹ıÔ˜ Î·È ·ÊÔ‡ ÚÔÛı¤ÛÂÈ Û ·˘Ùfi ÂÓÈÛ¯˘Ù‹ Á¿Ï·ÎÙÔ˜, ÙÔ ‰›ÓÂÈ ÛÙÔ ÓÂÔÁÓfi ̤ۈ ıËÏ¿ÛÙÚÔ˘, ‚) ÌÂÙ¿ ÙÔÓ ıËÏ·ÛÌfi ‰›ÓÂÈ Û˘Ìϋڈ̷ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÙÔ˜ (Á¿Ï· ÁÈ· ÚfiˆÚ· ‹ Á¿Ï· ÂÍfi‰Ô˘) Î·È Á) ‰›ÓÂÈ ÂÓ·ÏÏ¿Í ¤Ó· Á‡̷ ·fi ÙÔ ÛÙ‹ıÔ˜ Î·È ¤Ó· ·fi ͤÓÔ ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· (46). ™Â ÂÚ›ÙˆÛË Ô˘ Ë ÌËÙ¤Ú· ·‰˘Ó·Ù› ‹ ‰ÂÓ ı¤ÏÂÈ Ó· ıËÏ¿ÛÂÈ, ÚÔÛʤÚÂÙ·È ÛÙÔ ÓÂÔÁÓfi ÂÓÈÛ¯˘Ì¤ÓÔ Á¿Ï· (30). ∏ ÂÈÏÔÁ‹, Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Â›Ó·È ÌÂٷ͇ Á¿Ï·ÙÔ˜ ÁÈ· ÚfiˆÚ· Î·È Á¿Ï·ÙÔ˜ ÂÍfi‰Ô˘. ÿÛˆ˜ ı· Ú¤ÂÈ Ó· ÚÔÙÈÌ¿Ù·È ÙÔ Á¿Ï· ÂÍfi‰Ô˘, ·ÊÔ‡ ÙÔ Á¿Ï· ÁÈ· ÚfiˆÚ·, Â¿Ó ‰Ôı› ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ·, Ô‰ËÁ› Û ·¯˘Û·ÚΛ·.
¢È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ ÂȉÈ΋˜ ‰›·ÈÙ·˜ ∏ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ ÂȉÈ΋˜ ‰›·ÈÙ·˜ ‰ÂÓ Â›Ó·È Î·ıÔÚÈṲ̂ÓË. ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ÚÔÙ›ÓÔ˘Ó ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ÂȉÈÎÔ‡ Á¿Ï·ÙÔ˜ ·fi 3 ¤ˆ˜ 9 Ì‹Ó˜. Ÿˆ˜ ÚԷӷʤÚıËÎÂ, Ù· ÈÔ ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ 2-3 Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ‹˜ Ù˘. øÛÙfiÛÔ, ›Ûˆ˜ Â›Ó·È ··Ú·›ÙËÙË Ë Û˘Ó¤¯ÈÛË Ù˘ ¯ÔÚ‹ÁËÛ‹˜ Ù˘ ̤¯ÚÈ ÙÔÓ 6Ô Ì‹Ó· ˙ˆ‹˜, ÒÛÙ ӷ ÛÙ·ıÂÚÔÔÈËı› Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘, ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì¤¯ÚÈ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÂÚ¿˜ ÙÚÔÊ‹˜ (47). ¶¿ÓÙˆ˜, ı· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È Û οı ÂÚ›ÙˆÛË. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ ÔÚÈṲ̂ӷ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÚfiˆÚ· ÓÂÔÁÓ¿ ¢ÓÔÔ‡ÓÙ·È ·fi ÙË ¯ÔÚ‹ÁËÛË Ì›·˜ ÂȉÈ΋˜ ‰›·ÈÙ·˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ¶·Ú¿ Ù·‡Ù·, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ fiÔ˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÂȉÈΤ˜
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·5
5
¢È·ÙÚÔÊ‹ ÙÔ˘ ÂÏÏÈÔ‚·ÚÔ‡˜ ÓÂÔÁÓÔ‡
·˘Ù¤˜ ‰›·ÈÙ˜, Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜. ¶ÚÔÎÂÈ̤ÓÔ˘, ÏÔÈfiÓ, Ó· ÂÍ·¯ıÔ‡Ó ÔÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù· ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· ‹ fi¯È Ì›·˜ ÂÌÏÔ˘ÙÈṲ̂Ó˘ ‰›·ÈÙ·˜, ı· Ú¤ÂÈ Ó· Á›ÓÔ˘Ó ÈÔ Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜, ÒÛÙ ӷ Ê·Ó› Â¿Ó Ë ÂÓÈÛ¯˘Ì¤ÓË ‰›·ÈÙ· ÌÔÚ› Ó· ¤¯ÂÈ ıÂÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÙÂÏÈ΋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË Î·È Â¿Ó ÌÂÈÒÓÂÈ ‹ ·˘Í¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ηډȷÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ Î·È Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Dobbing J. Nutritional growth restriction and the nervous system. In: Davison AN, Thompson RHS, editors. The molecular bases of neuropathology. London: Edward Arnold; 1981. p. 221-233. 2. Smart J. Undernutrition, learning, and memory: a review of experimental studies. In: Taylor TG, Jenkins NK, editors. Proceedings of XIII International Congress of Nutrition. London: John Libbey; 1986. p. 74-78. 3. Lucas A. Programming by early nutrition in man. In: Bock GR, Whelan J, editors. The childhood environment and adult disease. Ciba Foundation Symposium 156. Chichester: John Wiley; 1991. p. 38-55. 4. Barker DJ. Fetal origins of cardiovascular disease. Ann Med 1999;31 (Suppl 1):S3-S6. 5. Hales CN, Barker DJ. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia 1992;35:595-601. 6. Ehrenkranz RA, Younes N, Lemons JA, Fanaroff AA, Donovan EF, Wright LL et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics 1999;104:280-289. 7. Cooke RJ, Ford A, Werkman S, Conner C, Watson D. Postnatal growth in infants born between 700 and 1500 g. J Pediatr Gastroenterol Nutr 1993;16:130-135. 8. Cooke RJ, Griffin IJ, McCormick K, Wells JC, Smith JS, Robinson SJ et al. Feeding preterm infants after hospital discharge: effect of dietary manipulation on nutrient intake and growth. Pediatr Res 1998;43:355-360. 9. Griffin IJ. Postdischarge nutrition for high risk neonates. Clin Perinatol 2002;29:327-344. 10. Rigo J, Nyamugabo K, Picaud JC, Gerard P, Pieltain C, De Curtis M. Reference values of body composition obtained by dual energy X-ray absorptiometry in preterm and term neonates. J Pediatr Gastroenterol Nutr 1998;27:184-190. 11. Lucas A. Nutrition, growth and development of post discharge preterm infants. In: Hay WW Jr, Lucas A, editors. Posthospital nutrition in the preterm infant. Report of the 106th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 1996. p. 81-89. 12. Hack M, Weissman B, Borawski-Clark E. Catch-up growth during childhood among very low-birth-weight children. Arch Pediatr Adolesc Med 1996;150:1122-1129. 13. Ford GW, Doyle LW, Davis NM, Callanan C. Very low birth weight and growth into adolescence. Arch Pediatr Adolesc Med 2000;154:778-784. 14. Peralta-Carcelen M, Jackson DS, Goran MI, Royal SA, Mayo MS, Nelson KG. Growth of adolescents who were born at extremely low birth weight without major disability. J Pediatr 2000;136:633-640. 15. Monset-Couchard M, de Bethmann O. Catch-up growth in 166 small-for-gestational age premature infants weighing less than 1000 g at birth. Biol Neonate 2000;78:161-167.
16. De Curtis M, Pieltain C, Rigo J. Nutrition of preterm infants on discharge from hospital. In: Raiha NCR, Rubaltelli FF, editors. Infant formula: closer to the reference. Nestle Nutrition Workshop series, Pediatric program, vol 47, supplement, Nestec Ltd, Vevey/ Lippincott Williams & Wilkins: Philadelphia; 2002. p. 149-163. 17. Atkinson SA. Special nutritional needs of infants for prevention of and recovery from bronchopulmonary dysplasia. J Nutr 2001;131:942S-946S. 18. Hansen SR, Dorup I. Energy and nutrient intakes in congenital heart disease. Acta Paediatr 1993;82:166-172. 19. Narayanan I, Prakash K, Gujral VV. The value of human milk in the prevention of infection in the high-risk lowbirth-weight infant. J Pediatr 1981;99:496-498. 20. Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. Breast milk and subsequent intelligence quotient in children born preterm. Lancet 1992;339:261-264. 21. American Academy of Pediatrics, Committee on Nutrition. Nutritional needs of low-birth-weight infants. Pediatrics 1985;75:976-986. 22. Atkinson SA, Bryan MH, Anderson GH. Human milk: difference in nitrogen concentration in milk from mothers of term and premature infants. J Pediatr 1978;93:67-69. 23. Schanler RJ. Suitability of human milk for the low-birthweight infant. Clin Perinatol 1995;22:207-222. 24. Atkinson SA, Radde IC, Anderson GH. Macromineral balances in premature infants fed their own mothers’ milk or formula. J Pediatr 1983;102:99-106. 25. Atkinson SA. Human milk feeding of the micropremie. Clin Perinatol 2000;27:235-247. 26. Raiha NC, Heinonen K, Rassin DK, Gaull GE. Milk protein quantity and quality in low-birthweight infants: I. Metabolic responses and effects on growth. Pediatrics 1976;57:659-684. 27. Chan GM, Mileur L, Hansen JW. Effects of increased calcium and phosphorous formulas and human milk on bone mineralization in preterm infants. J Pediatr Gastroenterol Nutr 1986;5:444-449. 28. Lucas A, Lucas PJ, Chavin SI, Lyster RL, Baum JD. A human milk formula. Early Hum Dev 1980;4:15-21. 29. O’Connor DL, Barrett Reis BB, Benson J. Quantity and quality of nutrients in human milk fortifiers: consideration in designing a new human milk fortifier. In: ∏uman milk for very low birthweight infants. Report of the 108th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 1999. p. 71-80. 30. Hall RT. Supplementation of breastfed very low birthweight infants. In: Human milk for very low birthweight infants. Report of the 108th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 1999. p. 169-179. 31. Abrams SA, Schanler RJ, Garza C. Bone mineralization in former very low birth weight infants fed either human milk or commercial formula. J Pediatr 1988;112:956-960. 32. Greer FR, McCormick A. Improved bone mineralization and growth in premature infants fed fortified own mother’s milk. J Pediatr 1988;112:961-969. 33. Schanler RJ, Garza C. Improved mineral balance in very low birth weight infants fed fortified human milk. J Pediatr 1988;112:452-456. 34. Polberger SK, Axelsson IA, Raiha NC. Growth of very low birth weight infants on varying amounts of human milk protein. Pediatr Res 1989;25:414-419. 35. Polberger S. Fortified human milk for very low birth weight infants. Lund, Sweden: University of Lund; 1990. 36. Polberger SK, Raiha NC. Individualized fortification of human milk for very low birthweight infants. Milk protein and energy analyses for improved nutritional management. Pediatr Res 1995;37:316A. 37. Cooke RJ, Griffin IJ, McCormick K, Wells JC, Smith JS, Robinson SJ et al. Feeding preterm infants after hospital ¶·È‰È·ÙÚÈ΋ 2005;68:1-6
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·6
6
Ã. ∫ÒÛÙ·ÏÔ˜ Î·È Û˘Ó.
38.
39.
40.
41.
42.
¶·È‰È·ÙÚÈ΋ 2005;68:1-6
discharge: effect of dietary manipulation on nutrient intake and growth. Pediatr Res 1998;43:355-360. Agosti M, Vegni C, Calciolari G, Marini A, GAMMA Study Group. Post-discharge nutrition of the very low-birthweight infant: interim results of the multicentric GAMMA study. Acta Paediatr Suppl 2003;91:39-43. Lucas A, King F, Bishop NB. Post discharge formula consumption in infants born preterm. Arch Dis Child 1992;67:691-692. Lucas A, Fewtrell MS, Morley R, Singhal A, Abbott RA, Isaacs E et al. Randomized trial of nutrient-enriched formula versus standard formula for postdischarge preterm infants. Pediatrics 2001;108:703-711. Carver JD, Wu PY, Hall RT, Ziegler EE, Sosa R, Jacobs J et al. Growth of preterm infants fed nutrient-enriched or term formula after hospital discharge. Pediatrics 2001;107:683-689. Brunton JA, Saigal S, Atkinson SA. Growth and body composition in infants with bronchopulmonary dysplasia up to 3 months corrected age: a randomized trial of high-energy nutrient-enriched formula fed after hospital discharge. J Pediatr 1998;133:340-345.
43. Eriksson JG, Forsen T, Tuomilehto J, Winter PD, Osmond C, Barker DJ. Catch-up growth in childhood and death from coronary heart disease: longitudinal study. BMJ 1999;318:427-431. 44. Singhal A, Fewtrell M, Cole TJ, Lucas A. Low nutrient intake and early growth for later insulin resistance in adolescents born preterm. Lancet 2003;361:1089-1097. 45. Shanler RJ. Post-discharge nutrition for the NICU graduate. IPOKRaTES, Clinical Seminar on Nutrition, Metabolism and Gastro-Intestinal Tract. Lecco: Italy; 3-6 June 2003. 46. Ernst JA, Brine E. Practical use of human milk fortifiers: considerations for infants very low and extremely low in birth weight. In: Human milk for very low birth weight infants. Report of the 108th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 1999. p. 129-143. 47. Heird WC. Determination of nutritional requirements in preterm infants, with special reference to “catch-up” growth. Semin Neonatol 2001;6:365-375.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·7
REVIEW ARTICLE
7
Nutrition of the preterm and growth retarded baby on discharge from the hospital C. Costalos1, A. Gounaris2
Abstract Infants who are small for gestational age are known to be at risk of continued growth failure as well as of having poor neurodevelopmental and health outcomes. Many preterm babies of appropriate birth weight also suffer growth failure during their hospitalization. This review article examines the consequences of this poor growth and the use of nutritional interventions after hospital discharge to correct these deficits. Unfortified human milk may not supply sufficient quantities of nutrients to meet the needs of premature infants. The same applies to ordinary formula intended for term infants. The use of enriched formulas in the form of fortified human milk, preterm formula or post-discharge formula improves the early growth and bone mineralization at least for the first 18 months of life. Fortified human milk is the preferred form of feeding of a growth retarded premature infant. An enriched formula is not always necessary, and should be restricted only to high risk babies, those with a birth weight <1250 g, those whose weight at the time of discharge is less than the 5th centile, those who suffer chronic disease, those who can not consume >180 ml of milk per kg/day and those who fail to grow after discharge. In any case, growth and biochemical indices should be closely monitored in every preterm infant after discharge. Further research is needed to assess whether this improved growth following milk fortification improves developmental outcome and leads to decreased long term morbidity from cardiovascular disease.
1 Department of Neonatology, “Alexandra” General Hospital, Athens 2 Paediatric Clinic of the University of Thessaly Correspondence: Christos Costalos 130 Artemidos str., 175 62, P. Faliro, Athens Date of submission: 23-04-2004 Date of approval: 14-07-2004
Key words Preterm infant, light for dates, nutrition.
Paediatriki 2005;68:7
Paediatriki Jan-Feb 05 teliko
8
10-02-05
13:36
™ÂÏ›‰·8
∞¡∞™∫O¶∏™∏
IgA ÓÂÊÚÔ¿ıÂÈ· ÛÙ· ·È‰È¿ ∞. ªËÙÛÈÒÓË
¶ÂÚ›ÏË„Ë ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∞Ó‰ÚÔÌ¿¯Ë ªËÙÛÈÒÓË ∆›Ú˘ÓıÔ˜ 11, ∆.∫. 175 64, ¶. º¿ÏËÚÔ ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-02-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-09-2004
∏ IgA ÓÂÊÚÔ¿ıÂÈ·, Ô˘ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1969 ·fi ÙÔ˘˜ Berger Î·È Hinglais, Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ÚˆÙÔ·ı‹˜ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· ÛÙÔÓ ÎfiÛÌÔ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÂÓ·fiıÂÛË ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ IgA ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÛÂÈÚ¿Ì·ÙÔ˜. ∞Ú¯Èο, ıˆÚÔ‡ÓÙ·Ó Î·ÏÔ‹ı˘ ÓfiÛÔ˜, ·Ó Î·È ÔÛÔÛÙfi ÂÚ›Ô˘ 20-25% ÙˆÓ ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ· ·Ó·Ù‡ÛÛÂÈ ÂÍÂÏÈÎÙÈ΋ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ·ÎfiÌ· ¿ÁÓˆÛÙË Î·È Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı›. ∏ ÚfiÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙ· ·È‰È¿ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Î·Ï‡ÙÂÚË ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ì ̷ÎÚfi¯ÚÔÓË ·Ú·ÎÔÏÔ‡ıËÛË, ÂÓÒ Ù· ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ·Ó·ÙÚ¤Ô˘Ó ÙË Ì¤¯ÚÈ ÙÒÚ· ÂÈÎÚ·ÙÔ‡Û· ÁÓÒÛË fiÙÈ Ë IgA ÓÂÊÚÔ¿ıÂÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È Î·ÏÔ‹ı˘ ÓfiÛÔ˜.
§¤ÍÂȘ ÎÏÂȉȿ IgA ÓÂÊÚÔ¿ıÂÈ·, ÓfiÛÔ˜ Berger, ·È‰È¿.
∂ÈÛ·ÁˆÁ‹ ∏ IgA ÓÂÊÚÔ¿ıÂÈ·, ÌÂÙ¿ ÙËÓ ÚÒÙË Ù˘ ÂÚÈÁÚ·Ê‹ ·fi ÙÔ˘˜ Berger Î·È Hinglais ÙÔ 1968 (1,2), ·Ó·ÁÓˆÚ›˙ÂÙ·È Û·Ó ¤Ó·˜ ͯˆÚÈÛÙfi˜ Ù‡Ô˜ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜. ∆· Ù˘Èο Â˘Ú‹Ì·Ù· ÙÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡, Ô˘ ı¤ÙÔ˘Ó Î·È ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, Û˘Ó›ÛÙ·ÓÙ·È Û ÂÓ·fiıÂÛË IgA ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÛÙË ÌÂÛ·ÁÁÂȷ΋ Î·È ·Ú·ÌÂÛ·ÁÁÂȷ΋ ÂÚÈÔ¯‹ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·È Û˘Óԉ‡ÔÓÙ·È ·fi ¤Ó· ¢ڇ Ê¿ÛÌ· ÛÂÈÚ·Ì·ÙÈÎÒÓ ‚Ï·‚ÒÓ Ô˘ ‰ÈηÈÔÏÔÁÔ‡Ó ÙËÓ ÔÈÎÈÏÔÌÔÚÊ›· ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÓfiÛÔ˘. ∏ Û˘¯ÓfiÙËÙ· Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÔÈΛÏÏÂÈ Â˘Ú¤ˆ˜ ÛÙȘ ‰È¿ÊÔÚ˜ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜, ÁÂÁÔÓfi˜ Ô˘ ·ÓÙ·Ó·ÎÏ¿ fi¯È ÌfiÓÔ ÛÙË ‰È·ÊÔÚÂÙÈ΋ ›وÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Î·È ÛÙȘ ‰È·ÊÔÚ¤˜ ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ÛÙȘ ÂӉ›ÍÂȘ ÁÈ· ÂÎÙ¤ÏÂÛË ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜ (3,4). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ, Ë IgA ÓÂÊÚÔ¿ıÂÈ· ¤¯ÂÈ ÌÂÏÂÙËı› ·ÚÎÂÙ¿ ηϿ Î·È Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È ¯ÂÈÚfiÙÂÚË ·’ fi,ÙÈ ·Ú¯Èο, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ (20-30%) ›¯Â ÂÍÂÏÈÎÙÈ΋ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· 20 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (5,6). ∏ ÚfiÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙ· ·È‰È¿ ıˆÚÂ›Ù·È Î·Ï‡ÙÂÚË ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (7-9). ¶Ú¤ÂÈ, fï˜, Ó· ÛËÌÂȈı› fiÙÈ ÛÙ· ·È‰È¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚΛ˜ Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜ Î·È Ù· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ·Ú·Ì¤ÓÔ˘Ó ·Û·Ê‹. ∞Ó Î·È ¤¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚÔÈ ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ›, Ë ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
·‰È¢ÎÚ›ÓÈÛÙË Î·È ÂȉÈ΋ ıÂڷ›· ÁÈ· ÙËÓ IgA ÓÂÊÚÔ¿ıÂÈ· ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı›. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÔÏϤ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›·, ÙËÓ ÚfiÁÓˆÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ ¿Ô„Ë fiÙÈ Ë IgA ÓÂÊÚÔ¿ıÂÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ‰ÂÓ Â›Ó·È ·Ôχو˜ ηÏÔ‹ı˘ ÓfiÛÔ˜ (10-12).
∂ȉËÌÈÔÏÔÁ›· ∏ Û˘¯ÓfiÙËÙ· Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÔÈΛÏÏÂÈ Â˘Ú¤ˆ˜ ÛÙȘ ‰È¿ÊÔÚ˜ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜. ™ÙËÓ π·ˆÓ›·, ÙË °·ÏÏ›·, ÙËÓ πÙ·Ï›· Î·È ÙËÓ ∞˘ÛÙÚ·Ï›· ··ÓÙ¿Ù·È Û ÔÛÔÛÙfi 18-40% ÌÂٷ͇ ÙˆÓ ÚˆÙÔ·ıÒÓ ÛÂÈÚ·Ì·ÙÔ·ıÂÈÒÓ, ÂÓÒ ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜, ÙËÓ ∞ÁÁÏ›· Î·È ÙÔÓ ∫·Ó·‰¿ ··ÓÙ¿Ù·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿, Û ÔÛÔÛÙfi ÌfiÓÔ 2-10% (13-16). ∞˘Ù¤˜ ÔÈ ‰È·ÊÔÚ¤˜ ÌÔÚÔ‡Ó Ó· ÂÚÌËÓ¢ıÔ‡Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙË ‰È·ÊÔÚÂÙÈ΋ Ù·ÎÙÈ΋ Ô˘ ÙËÚÂ›Ù·È ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ÂÎÙ¤ÏÂÛË ·Ó¿Ï˘Û˘ Ô‡ÚˆÓ Û ·È‰È¿ Î·È Ó¤Ô˘˜ ÂÓ‹ÏÈΘ, ηıÒ˜ Î·È ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ÂӉ›ÍÂȘ ÁÈ· ÂÎÙ¤ÏÂÛË ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜, ·Ú¿ Û ڷÁÌ·ÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ÁˆÁÚ·ÊÈ΋ Û˘¯ÓfiÙËÙ·. ™ÙËÓ ∞˘ÛÙÚ·Ï›·, fiÔ˘ Ô ÏËı˘ÛÌfi˜ Ù˘ ¯ÒÚ·˜ Â›Ó·È ÂÙÂÚÔÁÂÓ‹˜, Ê·›ÓÂÙ·È fiÙÈ Ë ÓfiÛÔ˜ ÚÔÛ‚¿ÏÏÂÈ ÂÍ›ÛÔ˘ fiϘ ÙȘ Ê˘Ï¤˜. ™ÙËÓ π·ˆÓ›·, fiÏ· Ù· ·È‰È¿ ËÏÈΛ·˜ 6-18 ÂÙÒÓ ˘Ô‚¿ÏÏÔÓÙ·È Î¿ı ¯ÚfiÓÔ Û ·Ó¿Ï˘ÛË Ô‡ÚˆÓ Î·È fiÛ· ¤¯Ô˘Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·Ú·¤ÌÔÓÙ·È ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. ™ÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ÙÔ˘ Kobe, Ë IgA ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏ› ÙËÓ Ï¤ÔÓ Û˘¯Ó‹ ÚˆÙÔ·ı‹ ÛÂÈÚ·Ì·ÙÈ΋ ÓfiÛÔ Î·È
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·9
9
IgA ÓÂÊÚÔ¿ıÂÈ·
··ÓÙ¿ Û ÔÛÔÛÙfi 30% ÙˆÓ ÓÂÊÚÈÎÒÓ ‚ÈÔ„ÈÒÓ (17). ™ÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ¤¯ÂÈ ·Ó·ÊÂÚı› ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙË Ì·‡ÚË Ê˘Ï‹ ·’ fi,ÙÈ ÛÙË Ï¢΋ Ê˘Ï‹ (18). ∞fi ÙËÓ Italian Registry of Pediatric Renal Biopsies, ·fi ÈÛÙÔÏÔÁÈο ‰Â‰Ô̤ӷ 432 ·ÛıÂÓÒÓ ËÏÈΛ·˜ <15 ÂÙÒÓ, ·Ó·Ê¤ÚÂÙ·È Ë ‰È¿ÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ Û ÔÛÔÛÙfi 18,8% ÙˆÓ ·ÛıÂÓÒÓ, ÔÛÔÛÙfi ·ÚfiÌÔÈÔ Ì ÂΛÓÔ Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ (20%). ∂›Û˘, ÛÙËÓ ›‰È· ÌÂϤÙË, IgA ÓÂÊÚÔ¿ıÂÈ· ‰È·ÁÓÒÛÙËΠ۠34,9% ·È‰ÈÒÓ Ì ÌÂÌÔӈ̤ÓË ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Î·È Û 30,4% ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔ˘Ú›· Î·È ÌË ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· (19).
¶·ıÔÁ¤ÓÂÈ· ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË. ∏ ÂÓ·fiıÂÛË ÙˆÓ IgA ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ·ÔÙÂÏ› ÙÔÓ ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ Ù˘ ·ıÔÁ¤ÓÂÛ˘ Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜.
IgA ÓÂÊÚÔ¿ıÂÈ· Î·È ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ∞Ú¯Èο, Ë ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘ ·Ô‰fiıËΠ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ÂÓ·fiıÂÛË ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ IgA ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ (IgA immune complexes - IgA IC). ∞˘Ù‹ Ë ˘fiıÂÛË ÚÔÛʤÚÂÈ ÈηÓÔÔÈËÙÈ΋ ÂÍ‹ÁËÛË ÛÙË Û˘Û¯¤ÙÈÛË Ô˘ ·Ú·ÙËÚÂ›Ù·È ÌÂٷ͇ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Ù˘ ¤Í·ÚÛ˘ Ù˘ ÓfiÛÔ˘ Ì ÂÌÊ¿ÓÈÛË ·ÈÌ·ÙÔ˘Ú›·˜ Î·È ÔÈ Ôԛ˜ Û˘Óԉ‡ÔÓÙ·È ·fi ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ IgA ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ Ô˘ ÂÎÙ›ıÂÓÙ·È Û ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi. ŸÌˆ˜, ˘„ËÏfi˜ Ù›ÙÏÔ˜ ΢ÎÏÔÊÔÚÔ‡ÓÙˆÓ IgA IC ·ÓȯÓ‡ÂÙ·È ÌfiÓÔ Û ÔÛÔÛÙfi 30-70% ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÍ¿ÚÛÂˆÓ Ù˘ ÓfiÛÔ˘ (20,21). ∏ IgA ÚÔ¤Ú¯ÂÙ·È ·fi Â͈ÎÚÈÓ›˜ ÂÎÎÚ›ÛÂȘ ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ, ΢ڛˆ˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ·fi ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi. À¿Ú¯ÂÈ Û ÌÔÓÔÌÂÚ‹ Î·È ÔÏ˘ÌÂÚ‹ ÌÔÚÊ‹. ∏ ÌÔÓÔÌÂÚ‹˜ ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 90% Ù˘ IgA ÙÔ˘ ÔÚÔ‡ Î·È ·Ú¿ÁÂÙ·È Î˘Ú›ˆ˜ ·fi Ù· ΢ÎÏÔÊÔÚÔ‡ÓÙ· ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ï·ÛÌ·ÙÔ·ÙÙ·Ú·, ÛÙÔÓ ÛÏ‹Ó· Î·È ÛÙÔÓ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ. ∏ ÔÏ˘ÌÂÚ‹˜ IgA ·Ú¿ÁÂÙ·È Î˘Ú›ˆ˜ ·fi ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ï·ÛÌ·ÙÔ·ÙÙ·Ú· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™˘ÓÙ›ıÂÙ·È ·fi ÌÔÓÔÌÂÚ‹ ÌfiÚÈ· Ô˘ ÂÓÒÓÔÓÙ·È ÌÂٷ͇ ÙÔ˘˜ Ì ÙË Û˘Ó‰ÂÙÈ΋ ¿Ï˘ÛÔ J, Ù· ÔÔ›· ηıÒ˜ ‰È¤Ú¯ÔÓÙ·È ·fi Ù· ÂÈıËÏȷο ·ÙÙ·Ú·, Û˘Ó‰¤ÔÓÙ·È Ì ÙÔ ÂÎÎÚÈÙÈÎfi ÙÌ‹Ì· Ù˘ IgA (S componement). ∏ IgA ‰È·ÎÚ›ÓÂÙ·È Û ‰‡Ô ˘ÔÙ‡Ô˘˜: IgA1 Î·È IgA2.
OÈ ÂÓ·Ôı¤ÛÂȘ ÙˆÓ IgA ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ·ÔÙÂÏÂ›Ù·È - ¿ÁÓˆÛÙÔ ÁÈ·Ù› - ·fi ÙÔÓ ˘ÔÙ‡Ô IgA1 Û ÔÏ˘ÌÂÚ‹ ÌÔÚÊ‹. ∂›Ó·È Èı·Ófi fiÙÈ ÔÈ ÌÔÓÔÌÂÚ›˜ IgA1 Ô˘ ·Ú¿ÁÔÓÙ·È ÛÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ ÌÂÙ¿ ·fi ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi, ÂÓÒÓÔÓÙ·È Î·È ÔÏ˘ÌÂÚ›˙ÔÓÙ·È ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ, ˘fiıÂÛË Ô˘ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ Û˘Ó‰ÂÙÈ΋˜ ·Ï‡ÛÔ˘ J ›Û˘ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ, fi¯È fï˜ Î·È ÙÔ˘ ÂÎÎÚÈÙÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ (22,23). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÂȉÈÎÒÓ ·ÓÙÈÁfiÓˆÓ Ô˘ ÚÔηÏÔ‡Ó ÙÔÓ ·ÓÔÛÔÏÔÁÈÎfi ÂÚÂıÈÛÌfi ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ IgA ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ, ÔÈ ¤Ú¢Ó˜ ‰ÂÓ ¤¯Ô˘Ó ηٷϋÍÂÈ Û ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. ∞Ó Î·È ¤¯ÂÈ ·Ú·ÙËÚËı› Û˘Û¯¤ÙÈÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ ·˘ÙÒÓ Ì ÙȘ ÂÍ¿ÚÛÂȘ Ù˘ ÓfiÛÔ˘, ÂÓÙÔ‡ÙÔȘ, ‰ÂÓ ·ÓȯÓ‡ıËÎ·Ó ÛÙȘ IgA ÂÓ·Ôı¤ÛÂȘ ÛÙ· ÛÂÈÚ¿Ì·Ù· ÙˆÓ ·ÛıÂÓÒÓ. Œ¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ‰È¿ÊÔÚ· ·ÓÙÈÁfiÓ·, fiˆ˜ Ô ·ÈÌfiÊÈÏÔ˜ parainfluenza (24), ÈÔ› ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÔÈ ÈÔ› EBV, CMV, HSV (25,26) Î·È ‰È¿ÊÔÚ· ÙÚÔÊÈο ·ÓÙÈÁfiÓ· (27,28), ÁÈ· ·Ú¿‰ÂÈÁÌ· ÎfiÎÎÔÈ ÛfiÁÈ·˜, ÚˆÙ½Ó˜ Á¿Ï·ÎÙÔ˜ Î.Ï. À¤Ú ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ ·ıÔÁÂÓÂÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Û˘Ì‚¿ÏÏÂÈ, ›Û˘, Ë Â·ÓÂÌÊ¿ÓÈÛË ÙˆÓ Ig∞ ÂÓ·Ôı¤ÛÂˆÓ ÛÙ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·ÛıÂÓÒÓ Ô˘ ¤·Û¯·Ó ·fi Ig∞ ÓÂÊÚÔ¿ıÂÈ·, ÂÓÒ ·ÓÙ›ıÂÙ· ·Ú·ÙËÚÂ›Ù·È Ì¤¯ÚÈ Î·È ÂÍ·Ê¿ÓÈÛË ÙˆÓ Ig∞ ÂÓ·Ôı¤ÛÂˆÓ ÛÙ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·ÛıÂÓÒÓ Ì Ig∞ ÓÂÊÚÔ¿ıÂÈ· fiÙ·Ó ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Û ·ÛıÂÓ‹ Ì ¿ÏÏË ÚˆÙÔ·ı‹ ÓfiÛÔ (29,30).
¢È·Ù·Ú·¯¤˜ Ù˘ ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ Ù˘ Ig∞ π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÚfiÛÊ·ÙË ıˆڛ· Ù˘ Û‡ÓıÂÛ˘ ‰ÔÌÈο ·ÓÒÌ·Ï˘ Ig∞ ·fi ÙÔ˘˜ ¿Û¯ÔÓÙ˜. ∏ ·ÓıÚÒÈÓË Ig∞1, Ô˘ Â›Ó·È Ë Î‡ÚÈ· ˘ÔÔÌ¿‰· Ô˘ ··ÓÙ¿Ù·È ÛÙȘ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÂÓ·Ôı¤ÛÂȘ Ù˘ ÓfiÛÔ˘, Â›Ó·È Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË Ô˘ ÂÚȤ¯ÂÈ 8% ˘‰·Ù¿ÓıڷΘ. ∏ ÂÚÈÔ¯‹ Ô˘ Û˘Ó‰¤ÔÓÙ·È ÔÈ ˘‰·Ù¿ÓıڷΘ (hinge region) ¤¯ÂÈ Ì›· ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·ÎÔÏÔ˘ı›· 17 ·ÌÈÓÔͤˆÓ Î·È ÔÏϤ˜ ÁÈ· OÁÏ˘ÎÔ˙˘Ï›ˆÛË ÂÚÈÔ¯¤˜ (∂ÈÎfiÓ· 1). OÈ ÂÚÈÔ¯¤˜ ·˘Ù¤˜ Û˘ÓÈÛÙÒÓÙ·È ·fi ¡-·ÎÂÙ˘ÏÁ·Ï·ÎÙÔ˙·Ì›ÓË, O-Û˘Ó‰Â‰Â̤ÓË Ì ٷ ·ÌÈÓÔͤ· ÛÂÚ›ÓË Î·È ıÚÂÔÓ›ÓË (31,32). ¢È·Ù·Ú·¯¤˜ Ù˘ O-ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ Ù˘ Ig∞1 ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ¯ËÌÈ΋˜ Ù˘ Û˘ÁÁ¤ÓÂÈ·˜ Ì ÙË ÊÈÌÚÈÓÔÓÂÎÙ›ÓË, ÙË Ï·ÌÈÓ›ÓË Î·È ÙÔ ÎÔÏÏ·ÁfiÓÔ, Ô˘ Ô‰ËÁ› ÛÙÔÓ Û¯ËÌ·ÙÈÛÌfi ÂÓ·Ôı¤ÛÂˆÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ (33,34). ¢È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÎÔÏÔ˘ı›· ÙˆÓ ·ÌÈÓÔͤˆÓ Ù˘ ÂÚÈÔ¯‹˜ ÙˆÓ ˘‰·Ù·ÓıÚ¿ÎˆÓ ı· ÌÔÚÔ‡Û·Ó Ó· Â›Ó·È ¤Ó·˜ Èı·Ófi˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ı· ÚÔηÏÔ‡Û ‰È·Ù·Ú·¯¤˜ Ù˘ O-ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ Ù˘ Ig∞1, ÁÂÁÔÓfi˜ Ô˘ ‰ÂÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› (35). ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·10
10
∞. ªËÙÛÈÒÓË
Â›Ó·È Ô ÌÂÙ·ÙÚÂÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‚ (transforming growth factor ‚) Ô˘ Î·È ·˘Ùfi˜ ·Ú¿ÁÂÙ·È ÌÂÙ¿ ÙËÓ Â·ÁˆÁ‹ ÙÔ˘ ·fi ÙËÓ ·ÁÁÂÈÔÙ·Û›ÓË ππ Î·È ÚÔηÏ› ›Û˘ ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›· Î·È ÚÔ˚Ô‡Û· ›ÓˆÛË (41,43). ∏ ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›· ‰‡Ó·Ù·È Ó· ·ÔηٷÛÙ·ı› ÌÂÚÈÎÒ˜, Ì Ì˯·ÓÈÛÌÔ‡˜ ΢ÙÙ·ÚÈ΋˜ ·fiÙˆÛ˘, Ë ‚Ï¿‚Ë fï˜ ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ ‰ÂÓ Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ÛÂÈÚ·Ì·ÙÈ΋ ÛÎÏ‹Ú˘ÓÛË (44).
∂ÈÎfiÓ· 1. ªÔÚȷ΋ ‰ÔÌ‹ Ù˘ IgA1.
Œ¯ÂÈ, ›Û˘, ·Ó·ÊÂÚı› fiÙÈ ‰È·Ù·Ú·¯‹ Ù˘ OÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‚ 1,3 Á·Ï·ÎÙÔ˙˘ÏÙÚ·ÓÊÂÚ¿Û˘, ¤Ó˙˘ÌÔ Ô˘ ·Ú¿ÁÂÙ·È ÛÙÔ ‹·Ú Î·È Â›Ó·È ˘Â‡ı˘ÓÔ ÁÈ· ÙËÓ ÙÂÏÈ΋ Á·Ï·ÎÙÔ˙˘Ï›ˆÛË Ù˘ ¡·ÎÂÙ˘ÏÔÁ·Ï·ÎÙÔ˙·Ì›Ó˘. ∏ ‰ÔÌÈ΋ ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ Èı·ÓfiÓ Ó· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÂÓÂÙÈο (36,37). ∏ ·ıÔÏÔÁÈ΋ Ig∞1, ÏfiÁˆ ÌÂȈ̤Ó˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û Á·Ï·ÎÙfi˙Ë, Û¯ËÌ·Ù›˙ÂÈ ·ÓÔÛÔÛ˘ÌϤÁÌ·Ù· Ô˘ ‰ÂÓ Û˘Ó‰¤ÔÓÙ·È Â‡ÎÔÏ· Ì ÙÔ˘˜ Ë·ÙÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Î·È ‰ÂÓ ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›·. ∂›Û˘, ÏÂÈÙÔ˘ÚÁ› Û·Ó ·ÓÙÈÁfiÓÔ Ô˘ ·Ó·ÁÓˆÚ›˙ÂÙ·È ·fi Ù· Ig∞1 ·ÓÙÈÛÒÌ·Ù·, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ‰È·ÊfiÚˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (ÈÓÙÂÚÏ¢ΛÓË 6, ÈÓÙÂÚÏ¢ΛÓË 1, ·Ú¿ÁÔÓÙ·˜ Ó¤ÎÚˆÛ˘ ÙˆÓ ÈÛÙÒÓ Î.Ï.), ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ (ÚÔÛÙ·ÁÏ·Ó‰›Ó˜, ıÚÔÌ‚ÔÍ¿ÓË Î.Ï.), ηıÒ˜ Î·È Ù˘ ÂÓ·ÏÏ·ÎÙÈ΋˜ Ô‰Ô‡ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ (38-40).
ºÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ∏ ÂÓ·fiıÂÛË Ù˘ ÔÏ˘ÌÂÚÔ‡˜ Ig∞ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ‰‡Ó·Ù·È Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ÙË ‰ËÌÈÔ˘ÚÁ›· ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜. À¿Ú¯Ô˘Ó Ï›Á· ÛÙÔȯ›· Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ˘fiıÂÛË fiÙÈ ÔÈ Ì˯·ÓÈÛÌÔ› Ô˘ Ô‰ËÁÔ‡Ó ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ Â›Ó·È ÂȉÈÎÔ› ÛÙËÓ Ig∞ ÓÂÊÚÔ¿ıÂÈ·. ªÂϤÙ˜ in vitro Î·È Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó ÙÔÓ È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Ô˘ ¤¯Ô˘Ó ÔÈ Î˘ÙÔΛÓ˜ Î·È Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (platelet derived growth factor - PDGF) Ô˘ ·Ú¿ÁÂÙ·È ·fi Ù· ÌÂÛ·ÁÁÂȷο ·ÙÙ·Ú· (41,42). ∏ ¤Á¯˘ÛË ·˘ÙÔ‡ ÙÔ˘ ·Ú¿ÁÔÓÙ· Û ÂÈÚ·Ì·Ùfi˙ˆ· ÚÔηÏ› ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›·. ŒÓ·˜ ¿ÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı›, ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
∆Ô Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·ÁÁÂÈÔÙ·Û›Ó˘ ∏ ·ÁÁÂÈÔÙ·Û›ÓË ππ η٤¯ÂÈ ÚˆÙ·ÁˆÓÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ∏ Û˘ÛÙÔÏ‹ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ Ig∞ ÓÂÊÚÔ¿ıÂÈ·˜, ÚÔηÏ› ‚Ï¿‚˜ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ÙÚȯÔÂȉÒÓ ·ÁÁ›ˆÓ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Î·È ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘-·ÁÁÂÈÔÙ·Û›Ó˘. ∏ ·ÁÁÂÈÔÙ·Û›ÓË ·ÊÂÓfi˜ ¤¯ÂÈ ·ÈÌÔ‰˘Ó·ÌÈ΋ ‰Ú¿ÛË ÚÔηÏÒÓÙ·˜ ÛÂÈÚ·Ì·ÙÈ΋ ˘¤ÚÙ·ÛË Î·È ˘ÂډȋıËÛË, ·ÊÂÙ¤ÚÔ˘ ÂÓÂÚÁÔÔÈ› ÙË ‰Ú¿ÛË ‰È·ÊfiÚˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ‰ÚÔ˘Ó ÛÙ· ÌÂÛ·ÁÁÂȷο ·ÙÙ·Ú· Î·È ÚÔηÏÔ‡Ó ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ıÂÌÂÏ›Ô˘ Ô˘Û›·˜ (45). ∂ÈϤÔÓ, Û ‚ÈÔ„›Â˜ ÓÂÊÚÒÓ ·ÛıÂÓÒÓ Ì Ig∞ ÓÂÊÚÔ¿ıÂÈ·, ¤¯ÂÈ ·Ô‰Âȯı› ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ ππ Î·È ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ ̤۷ ÛÙ· ÛÂÈÚ¿Ì·Ù·, ÁÂÁÔÓfi˜ Ô˘ ηıÈÛÙ¿ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ig∞ ϤÔÓ Â˘·ı›˜ ÛÙËÓ Î·Ù·ÛÙÚÔÊÈ΋ ‰Ú¿ÛË Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ ππ, Û˘ÁÎÚÈÙÈο Ì ¿ÏϘ ÛÂÈÚ·Ì·ÙÔ¿ıÂȘ (46,47). °ÂÓÂÙÈÎÔ› ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞Ó Î·È Ë Ig∞ ÓÂÊÚÔ¿ıÂÈ· ÂÌÊ·Ó›˙ÂÙ·È ÛÔÚ·‰Èο, Ê·›ÓÂÙ·È fiÙÈ ÁÂÓÂÙÈÎÔ› ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘. OÈ Rambausek Î·È Û˘Ó (48) ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÛÔÛÙfi 9,6% ÙˆÓ ·ÛıÂÓÒÓ ÛÙË °ÂÚÌ·Ó›· ¤¯ÂÈ ¤Ó·Ó ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÂÓ›˜ Ì Ig∞ ÓÂÊÚÔ¿ıÂÈ·, ÂÓÒ ÛÙËÓ πÙ·Ï›· (49) ‰È·ÈÛÙÒıËΠfiÙÈ 26 ·fi ÙÔ˘˜ 185 ·ÛıÂÓ›˜ (ÔÛÔÛÙfi 14%) ›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·Ó Û˘ÁÁÂÓ‹ Ì ÙËÓ ›‰È· ÓfiÛÔ. ™Â ÌÂϤÙ˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó·Ó ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ ·Ó·Ê¤ÚÂÙ·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Ì ÔÚÈṲ̂ӷ HLA ·ÓÙÈÁfiÓ·, fiˆ˜ BW35, B12, B27, DR1 Î·È DR4 (50,51), ÂÓÒ Û ¿ÏϘ ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù· (52). ∂›Û˘, Ë ÓfiÛÔ˜ Û˘Ó˘¿Ú¯ÂÈ Ì ÔÚÈṲ̂ÓÔ˘˜ Ê·ÈÓÔÙ‡Ô˘˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. OÈ McLean Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ÓfiÛÔ˜ Â›Ó·È Û˘¯ÓfiÙÂÚË Ì ÙÔÓ ÔÌÔ˙˘ÁÒÙË null C4 (53), ÂÓÒ ÔÈ Rambausek Î·È Û˘Ó Ì ÙÔÓ ÔÌÔ˙˘ÁÒÙË C3FF Ê·ÈÓfiÙ˘Ô (48).
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·11
11
IgA ÓÂÊÚÔ¿ıÂÈ·
¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù· ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù›ıÂÙ·È ·ÔÎÏÂÈÛÙÈο Ì ÙË ‚ÈÔ„›· ÓÂÊÚÔ‡ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, ÙËÓ ÂͤٷÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡, fiÔ˘ ‰È·ÈÛÙÒÓÔÓÙ·È ÂÓ·Ôı¤ÛÂȘ IgA ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·È ÛÙ· ÙÔȯÒÌ·Ù· ÙˆÓ ÙÚȯÔÂȉÒÓ, ÏËÛ›ÔÓ Ù˘ ÊÏÔÈÔÌ˘ÂÏÒ‰Ô˘˜ Û˘Ì‚ÔÏ‹˜. ∂Ó·Ôı¤ÛÂȘ IgG Î·È IgM ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Â›Ó·È, ›Û˘, ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËıÔ‡Ó, ·ÏÏ¿ Â›Ó·È ÌÈÎÚfiÙÂÚ˘ ¤ÓÙ·Û˘. ™Â 60% ÙˆÓ ·ÚÚÒÛÙˆÓ ˘¿Ú¯Ô˘Ó Î·È ÎÔÎÎÈÒ‰ÂȘ ÂÓ·Ôı¤ÛÂȘ ÙÔ˘ C3, ˘Ô‰ËÏÒÓÔÓÙ·˜ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÂÓ·ÏÏ·ÎÙÈ΋˜ Ô‰Ô‡ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ∂Ó·Ôı¤ÛÂȘ C4 Î·È C1q ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È. ™ÙÔ ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ, ÙÔ Ï¤ÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· Â›Ó·È Ë ÂÛÙȷ΋ ‹ ‰È¿¯˘ÙË ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›·, ·ÔÙ¤ÏÂÛÌ· Ù˘ ·‡ÍËÛ˘ ÙfiÛÔ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ fiÛÔ Î·È Ù˘ ıÂÌÂÏ›Ô˘ Ô˘Û›·˜. ∏ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û˘Ó‹ıˆ˜ ˘ÂÚÙÂÚ› Ù˘ ·‡ÍËÛ˘ Ù˘ ıÂÌÂÏ›Ô˘ Ô˘Û›·˜ ÛÙȘ ‚ÈÔ„›Â˜ ·ÛıÂÓÒÓ Ì ‚Ú·¯‡ ‰È¿ÛÙËÌ· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ¶ÚÔ˚fiÓÙÔ˜ ÙÔ˘ ¯ÚfiÓÔ˘, Ë ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÌÂÈÒÓÂÙ·È Î·È ·˘Í¿ÓÂÙ·È Ë ıÂ̤ÏÈÔ˜ Ô˘Û›· Î·È Ë ÛÎÏ‹Ú˘ÓÛË. OÈ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ô˘ ‰‡Ó·ÓÙ·È Ó· ··ÓÙËıÔ‡Ó, ηχÙÔ˘Ó fiÏÔ ÙÔ Ê¿ÛÌ· ÙˆÓ Â˘ÚËÌ¿ÙˆÓ, fiˆ˜ ÂÏ¿¯ÈÛÙ˜ ·ÏÏÔÈÒÛÂȘ, ‰È¿¯˘ÙË ÂÓ‰ÔÙÚȯÔÂȉÈ΋ ˘ÂÚÏ·Û›·, Â͈ÙÚȯÔÂȉÈ΋ ˘ÂÚÏ·Û›· Ì ÌËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ‡˜, ˘·Ï›ÓˆÛË Î·È ÛÎÏ‹Ú˘ÓÛË. ªÂ ‚¿ÛË Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ Î·È Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙfiÛÔ ÙËÓ Î·Ù¿Ù·ÍË Ù˘ ¶·ÁÎfiÛÌÈ·˜ OÚÁ¿ÓˆÛ˘ ÀÁ›·˜ fiÛÔ Î·È ÛÙÔȯ›· Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË Î·È ÙË ıÂڷ›·, fiˆ˜ ¤¯ÂÈ Á›ÓÂÈ Î·È ÛÙÔ ™∂§, Ë ÓfiÛÔ˜ ‰È·ÎÚ›ÓÂÙ·È Û 5 ÛÙ¿‰È· (54): ÛÙ¿‰ÈÔ π (ÂÏ¿¯ÈÛÙ˜ ·ÏÏÔÈÒÛÂȘ), ÛÙ¿‰ÈÔ ππ (ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ˘ÂÚÏ·Û›· ‹ ÛÎÏ‹Ú˘ÓÛË), ÛÙ¿‰ÈÔ πππ (ÂÛÙȷ΋ ˘ÂÚÏ·Û›· Û <50% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ± ÌËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ›), ÛÙ¿‰ÈÔ IV (‰È¿¯˘ÙË ˘ÂÚÏ·Û›· Û >50% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ± ÌËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ›) Î·È ÛÙ¿‰ÈÔ V (>40% ÔÏÈ΋ ÛÎÏ‹Ú˘ÓÛË ÛÂÈÚ·Ì¿ÙˆÓ Î·È >40% ·ÙÚÔÊ›· ÛˆÏËÓ·Ú›ˆÓ). ∞˘Ù‹ Ë ÈÛÙÔÏÔÁÈ΋ ηٿٷÍË - ·Ó Î·È ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ·Ô‰ÂÎÙ‹ - ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ÛËÌ·Û›·, ‰Â-
‰Ô̤ÓÔ˘ fiÙÈ 90% ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔ¿ıÂÈ· ÛÙ·‰›Ô˘ π ‹ ππ ‰È·ÙËÚ› ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· 10 ¯ÚfiÓÈ· ÌÂÙ¿, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ÓfiÛÔ ÛÙ·‰›Ô˘ πππ Î·È ÙˆÓ ·ÛıÂÓÒÓ Ì ÓfiÛÔ ÛÙ·‰›Ô˘ πV ‹ V Â›Ó·È ÌfiÓÔ 50% Î·È 20%, ·ÓÙ›ÛÙÔȯ· (55). ∏ ¤ÎÙ·ÛË ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ ·ÓÙ·Ó·ÎÏ¿ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ, ÂÓÒ ·ÏÏÔÈÒÛÂȘ ÙˆÓ ·ÁÁ›ˆÓ Ô˘ Â›Ó·È Û˘¯Ó¤˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Û¿ÓÈ· ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙ· ·È‰È¿. ™ÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ ·ÏÒ˜ ÂȂ‚·ÈÒÓÔÓÙ·È ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÂÓ·Ôı¤ÛÂȘ IgA ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ Î·È ÏÈÁfiÙÂÚÔ ˘ÔÂÓ‰ÔıËÏȷο Î·È ˘ÔÂÈıËÏȷο.
∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∏ ÓfiÛÔ˜ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·, Ì ÌÂÁ·Ï‡ÙÂÚË fï˜ Û˘¯ÓfiÙËÙ· ÛÙË 2Ë ‹ 3Ë ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜. ™¿ÓÈ· ÚÔÛ‚¿ÏÏÂÈ ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 6 ÂÙÒÓ Î·È ·ÎfiÌ· Û·ÓÈfiÙÂÚ· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ÂÙÒÓ, Èı·Ófiٷٷ ÁÈ·Ù› Ë ·Ú·ÁˆÁ‹ ÙˆÓ IgA ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ¶ÚÔÛ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÙÔ˘˜ ¿Ó‰Ú˜ ·fi ÙȘ Á˘Ó·›Î˜ Î·È Ë Û¯¤ÛË ¿ÚÚÂÓ/ı‹Ï˘ Î˘Ì·›ÓÂÙ·È ·fi 6:1 ¤ˆ˜ 2:1, Û‡Ìʈӷ Ì ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (9,17,20). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ηχÙÂÈ fiÏÔ ÙÔ Â‡ÚÔ˜ ÙˆÓ Û˘Ìو̿وÓ, ·fi ·Û˘Ìو̷ÙÈ΋ ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ̤¯ÚÈ ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. øÛÙfiÛÔ, ·Ú’ fiÏË ÙËÓ ÏËıÒÚ· ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, Ë ÓfiÛÔ˜ ÛÙËÓ ¤Ó·ÚÍ‹ Ù˘ ÂÌÊ·Ó›˙ÂÙ·È Ì ¤Ó· ·fi Ù· ·ÎfiÏÔ˘ı· ÎÏÈÓÈο Û‡Ó‰ÚÔÌ· (17): ·) Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›·, ‚) ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ·Û˘Ìو̷ÙÈ΋ ± ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, Á) Ô͇ ÓÂÊÚÈÙȉÈÎfi Û‡Ó‰ÚÔÌÔ (·ÈÌ·ÙÔ˘Ú›·, ˘¤ÚÙ·ÛË ± ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·), ‰) ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Î·È Â) ÓÂÊÚ›Ùȉ· Î·È ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ (¶›Ó·Î·˜ 1). ∏ Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÂÙ·È Ù·˘Ùfi¯ÚÔÓ· ‹ 1-2 Ë̤Ú˜ ÌÂÙ¿ ·fi Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‹ ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂›Ó·È ‰˘Ó·ÙfiÓ ÔÈ ·ÛıÂÓ›˜ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÙÚÔÈ¿˙Ô˘Û· Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ÌÂÙ¿ ·fi ÙËÓ ›‰È· Ïԛ̈ÍË. O ·ÚÈıÌfi˜ ÙˆÓ ˘ÔÙÚÔÒÓ Î·È ÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ ÙÔ˘˜ ‰È·Ê¤ÚÔ˘Ó ·fi ·ÛıÂÓ‹ ÛÂ
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Â˘Ú‹Ì·Ù· ÛÙËÓ ¤Ó·ÚÍË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ Û ·È‰È¿ (%) ∏¶∞ (56)
π·ˆÓ›· (57)
°·ÏÏ›· (58)
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ
62
258
157
ÀÔÙÚÔÈ¿˙Ô˘Û· Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ªÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ± ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ¡ÂÊÚ›Ùȉ· ± ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ
55 30 25
26 62 12
76 24 10 ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·12
12
∞. ªËÙÛÈÒÓË
·ÛıÂÓ‹. ∆· ÂÂÈÛfi‰È· Ù˘ Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜, Û˘Ó‹ıˆ˜, Û˘Óԉ‡ÔÓÙ·È ·fi ‹ÈÔ ¿ÏÁÔ˜ ÛÙËÓ ÔÛÊ˘˚΋ ¯ÒÚ·. ∏ Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ë ˘ÔÙÚÔÈ¿˙Ô˘Û· Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Â›Ó·È ÙÔ Ï¤ÔÓ Û˘¯Ófi ‡ÚËÌ· Ù˘ ÓfiÛÔ˘. ™Â Â˘Úˆ·˚Τ˜ ÌÂϤÙ˜ Î·È ÌÂϤÙ˜ ·fi ÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ·Ó·Ê¤ÚÂÙ·È Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Û ÔÛÔÛÙfi ¤ˆ˜ 80% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Û ÌÂϤÙ˜ ·fi ÙËÓ π·ˆÓ›· ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 26% ÙˆÓ ·ÛıÂÓÒÓ (56-58). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ Èı·Ófiٷٷ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ËÈfiÙÂÚ˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÓˆÚ›ÙÂÚ·, ÏfiÁˆ ÙÔ˘ Û˘ÛÙËÌ·ÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ô˘ ˘Ô‚¿ÏÏÂÙ·È Ô ÏËı˘ÛÌfi˜ ÛÙËÓ π·ˆÓ›·. ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ ·Ó·Ê¤ÚÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ Ó·ÚÔ‡˜ ÂÊ‹‚Ô˘˜ ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ (59). ∏ ·Û˘Ìو̷ÙÈ΋ ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· Û˘Ó‹ıˆ˜ Â›Ó·È ÌfiÓÈÌË Î·È Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Û˘Óԉ‡ÂÙ·È ·fi ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, fi¯È fï˜ ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘. ∏ ·ÚÙËÚȷ΋ ›ÂÛË Î·È Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈΤ˜ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. §Â˘ÎˆÌ·ÙÔ˘Ú›· ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘ ··ÓÙ¿Ù·È ÂÚ›Ô˘ Û ÔÛÔÛÙfi 10% ÙˆÓ ·ÛıÂÓÒÓ. OÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û¿ÓÈ·, ηٿ ηÓfiÓ· Û˘Ó˘¿Ú¯ÂÈ Ì ·ÈÌ·ÙÔ˘Ú›· Î·È Â›Ó·È Û˘Ó‹ıˆ˜ ·Ó·Ù¿ÍÈÌË. ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ Ë Ù·¯¤ˆ˜ ÂÍÂÏÈÛÛfiÌÂÓË IgA ÓÂÊÚÔ¿ıÂÈ· Ì ‡·ÚÍË ÌËÓÔÂȉÒÓ Û¯ËÌ·ÙÈÛÌÒÓ Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿, ‰Â‰Ô̤ÓÔ˘ fiÙÈ 41% ÙˆÓ ·ÛıÂÓÒÓ Ì ·˘Ù‹ ÙË ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Â›Ó·È ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 16 ÂÙÒÓ (60). ∞Í›˙ÂÈ, Ù¤ÏÔ˜, Ó· ÛËÌÂȈı› fiÙÈ Ù· ›‰· Ù˘ IgA ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÛÙÔÓ ÔÚfi Â›Ó·È ˘„ËÏ¿ Û 3050% ÙˆÓ ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ·, ·ÏÏ¿ ÌfiÓÔ Û 8-16% ÙˆÓ ·È‰ÈÒÓ, Ô‡Ùˆ˜ ÒÛÙ ÔÈ ˘„ËϤ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ IgA ÙÔ˘ ÔÚÔ‡ Ó· ÌËÓ ·ÔÙÂÏÔ‡Ó ‰Â›ÎÙË ‰È·ÁÓˆÛÙÈ΋˜ ÛËÌ·Û›·˜ ÛÙ· ·È‰È¿ (17).
¶ÚfiÁÓˆÛË ∏ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ì·ÎÚÔ¯ÚfiÓÈ·, ÁÂÁÔÓfi˜ Ô˘ ‰˘ÛÎÔχÂÈ ÙËÓ ·ÎÚÈ‚‹ ÚfiÁÓˆÛË. ™˘ÁÎÂÎÚÈ̤ӷ, ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ·ÒÙÂÚ˘ ÚfiÁÓˆÛ˘ ·ÛıÂÓÒÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ·, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÓfiÛÔ˜ ‰È·ÁÓÒÛÙËΠÛÙËÓ ·È‰È΋ ËÏÈΛ·, ··ÈÙÂ›Ù·È Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜ Î·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ÁÂÁÔÓfi˜ Ô˘ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ÂÊÈÎÙfi. ∏ Ê˘ÛÈ΋ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ‰È·Ê¤ÚÂÈ Û οı ·ÛıÂÓ‹. ¶Ï‹Ú˘ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ·Ó·Ê¤ÚÂÙ·È Û 30% ÙˆÓ ·ÛıÂÓÒÓ (61). ∞fi ‰Â‰Ô̤ӷ Ù˘ European Dialysis and Transplant Association Registry Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·È‰È¿ Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
ÂÓ‹ÏÈΘ, Ë IgA ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏ› ÙÔ 1,5% ÙˆÓ ÓfiÛˆÓ Ô˘ ηٷϋÁÔ˘Ó Û ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ∫¿ÔÈÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚Ú·‰Â›· Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ (ÙÒÛË ÙÔ˘ GFR 1-3 ml/min/¤ÙÔ˜), ÂÓÒ ÔÈ ·ÛıÂÓ›˜ Ì ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ï¤ÔÓ Ù·¯Â›· Âȉ›ӈÛË (ÙÒÛË ÙÔ˘ GFR ¤ˆ˜ 9 ml/min/¤ÙÔ˜). ∏ ÚÔ‚ÏÂfiÌÂÓË Â›ÙˆÛË (estimated incidence) ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·fi IgA ÓÂÊÚÔ¿ıÂÈ· Î˘Ì·›ÓÂÙ·È ·fi 0,77/1.000.000 ηÙÔ›ÎÔ˘˜ ÛÙËÓ ∞ÁÁÏ›· Î·È 1,8/1.000.000 ηÙÔ›ÎÔ˘˜ ÛÙËÓ πÙ·Ï›· ¤ˆ˜ 2,9/1.000.000 ηÙÔ›ÎÔ˘˜ ÛÙË °·ÏÏ›·, Ì ÙËÓ ÙÂÏÂ˘Ù·›· ¯ÒÚ· Ó· ıˆÚÂ›Ù·È Ë “ÂÛÙ›·” Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ‰˘ÙÈÎfi ÎfiÛÌÔ. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ (67%) Ô˘ ηٷϋÁÔ˘Ó Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ, ·Ú¯›˙Ô˘Ó Â͈ÓÂÊÚÈ΋ οı·ÚÛË Û ËÏÈΛ· 24-54 ÂÙÒÓ (62). O ηıÔÚÈÛÌfi˜ Ù˘ ÚfiÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏÔ˜ Î·È Û·Ê¤Ûٷٷ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û οı ÌÂϤÙË, ·fi ÙȘ Ô‰ËÁ›Â˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜ ηÈ, ‚¤‚·È·, ·fi ÙË ‰È·ÊÔÚ¿ ›وÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙȘ ‰È¿ÊÔÚ˜ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜. ∏ ÚfiÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Î·Ï‡ÙÂÚË ÛÙ· ·È‰È¿ ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ·ÏÏ¿ Ú¤ÂÈ Ó· ÏËÊı› ˘’ fi„ÈÓ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ì ·Ú΋, Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË. ∆· ϤÔÓ Â·Ú΋ ‰Â‰Ô̤ӷ ÓÂÊÚÈ΋˜ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ· Ô˘ ‰È·ÁÓÒÛÙËΠÛÙËÓ ·È‰È΋ ËÏÈΛ· ÚÔ¤Ú¯ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ π·ˆÓ›· Î·È ÙȘ ∏¶∞. ™ÙËÓ π·ˆÓÈ΋ ÌÂϤÙË (57) Û˘ÁÎÚ›ıËÎ·Ó Ù· ÎÏÈÓÈο Î·È ÈÛÙÔÏÔÁÈο ‰Â‰Ô̤ӷ 98 ·È‰ÈÒÓ Î·È 86 ÂÓËÏ›ÎˆÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ·, Ì ̤ÛË ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ÓfiÛÔ˘ Ù· 12±4 ¤ÙË ÁÈ· Ù· ·È‰È¿ Î·È Ù· 27±8 ¤ÙË ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ‹Ù·Ó 11,6±6,3 ¤ÙË ÁÈ· Ù· ·È‰È¿ Î·È 9,5±5,2 ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∆ÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ÓfiÛÔ˜ ·ÚÔ˘ÛÈ¿ÛÙËΠ۠9,2% ÙˆÓ ·È‰ÈÒÓ Î·È 23,3% ÙˆÓ ÂÓËÏ›ÎˆÓ (p<0,01). O ÚÔ‚ÏÂfiÌÂÓÔ˜ Ú˘ıÌfi˜ ÓÂÊÚÈ΋˜ ÂÈ‚›ˆÛ˘ 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ‹Ù·Ó 95% ÁÈ· Ù· ·È‰È¿ Î·È 80% ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÂÓÒ 20 ¯ÚfiÓÈ· ÌÂÙ¿ ‹Ù·Ó 82% Î·È 50%, ·ÓÙ›ÛÙÔȯ·. ∏ ηχÙÂÚË ÚfiÁÓˆÛË ÛÙ· ·È‰È¿ ·Ô‰fiıËΠÛÙÔ fiÙÈ: ·) Ù· ·È‰È¿ ›¯·Ó ÏÈÁfiÙÂÚÔ ÂÎÙÂٷ̤Ó˜ ÛÂÈÚ·Ì·ÙÈΤ˜ ‚Ï¿‚˜ ÛÙË ÓÂÊÚÈ΋ ‚ÈÔ„›· Î·È ‚) Ë Û˘¯ÓfiÙËÙ· Ù˘ ˘¤ÚÙ·Û˘ ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ÛÙ· ·È‰È¿ (27,6%) ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (41,3%). ™ÙË ÌÂϤÙË ·fi ÙȘ ∏¶∞ (11), Û 108 ·È‰È¿ Ì IgA ÓÂÊÚÔ¿ıÂÈ· Ì ̤ÛË ËÏÈΛ· ‰È¿ÁÓˆÛ˘ 10,3 ¤ÙË Î·È Ì¤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 8,5 ¤ÙË ·fi ÙÔÓ ¯ÚfiÓÔ ‚ÈÔ„›·˜, Ë ÚÔ‚ÏÂfiÌÂÓË ÓÂÊÚÈ΋ ÂÈ‚›ˆÛË ·fi ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ ‹Ù·Ó 94% Û 5 ¯ÚfiÓÈ·, 87% Û 10 ¯ÚfiÓÈ·, 82% Û 15 ¯ÚfiÓÈ· Î·È 70% Û 20 ¯ÚfiÓÈ·. ¶·ÚfiÌÔÈ· ÔÛÔÛÙ¿ ·Ó·Ê¤ÚÔÓÙ·È Î·È ÛÂ
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·13
13
IgA ÓÂÊÚÔ¿ıÂÈ·
¿ÏÏË Â˘Úˆ·˚΋ ÌÂϤÙË (63). H ηχÙÂÚË ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ È·ˆÓÈ΋ ÌÂϤÙË Â›Ó·È Èı·Ófi Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ·ÛıÂÓÒÓ Ì ËÈfiÙÂÚ˜ ÌÔÚʤ˜ ÓfiÛÔ˘ ÏfiÁˆ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘, ‚¿ÛÂÈ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ Û˘ÛÙËÌ·ÙÈ΋˜ ÂÎÙ¤ÏÂÛ˘ ·Ó¿Ï˘Û˘ Ô‡ÚˆÓ ÛÙË Û¯ÔÏÈ΋ ÂÚ›Ô‰Ô. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂȉÂÈÓÒÓÂÙ·È Ù·¯‡ÙÂÚ· ÛÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ Û ËÏÈΛ· ·ÛıÂÓ›˜, ÂÓÒ ÔÈ ·ÛıÂÓ›˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÂÈÛfi‰È· ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ·ÚfiÌÔÈ· ÂÂÈÛfi‰È· (7,20,64). ∂›Û˘, ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÛÙ· ·È‰È¿ Ô ‚·ıÌfi˜ Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ (9,56,59) Î·È Â›Ó·È ·fi ÙÔ˘˜ ϤÔÓ ÛËÌ·ÓÙÈÎÔ‡˜ ‰Â›ÎÙ˜ η΋˜ ÚfiÁÓˆÛ˘. OÈ ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙË ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È ·Ó·Ï˘ı› ÈηÓÔÔÈËÙÈο ÙfiÛÔ ·fi ÙÔ South West Pediatric Nephrology Study Group fiÛÔ Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ Î·È ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2, ·Ú¿ÏÏËÏ· Ì ÙË ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙËÙ· (56,65). O ÚfiÏÔ˜ Ù˘ ˘¤ÚÙ·Û˘ ‰ÂÓ Â›Ó·È ·Ôχو˜ ÂÍ·ÎÚÈ‚ˆÌ¤ÓÔ˜. µÂ‚·›ˆ˜, ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ Î·È ÂÍÂÏÈÎÙÈ΋˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘, ·ÏÏ¿ Â›Ó·È Èı·Ófi Ë ˘„ËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË Ó· Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Î·È fi¯È Ë ·ÈÙ›· Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘.
£Âڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∂ȉÈ΋ ıÂڷ›· ÁÈ· ÙËÓ IgA ÓÂÊÚÔ¿ıÂÈ· ‰ÂÓ ˘¿Ú¯ÂÈ. ∏ ȉÂ҉˘ ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË, Ì ‚¿ÛË ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ı· ¤Ú ӷ ¤¯ÂÈ ¶›Ó·Î·˜ 2. ∫ÏÈÓÈÎÔ› Î·È ÈÛÙÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙ· ·È‰È¿ Î·È Ë ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙËÙ· ¶·Ú¿ÁÔÓÙ˜
p-value
∏ÏÈΛ· ÂÌÊ¿ÓÈÛ˘ ÓfiÛÔ˘ <9 ¤ÙË º‡ÏÔ (¿ÚÚÂÓ) º˘Ï‹ (Ì·‡ÚË) ª·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ÚÔ ¡µ ↓GFR ηٿ ÙË ¡µ §Â˘ÎˆÌ·ÙÔ˘Ú›· ηٿ ÙË ¡µ >2+ À¤ÚÙ·ÛË Î·Ù¿ ÙË ¡µ ∂ÛÙȷ΋ ‹ ‰È¿¯˘ÙË ˘ÂÚÏ·Û›· ± ÌÂÛ·ÁÁÂȷ΋ ÛÎÏ‹Ú˘ÓÛË ™ÎÏ‹Ú˘ÓÛË ± ˘ÂÚÏ·Û›· >20% ÛÂÈÚ·Ì¿ÙˆÓ ∂ÛÙȷ΋ ÔÏÈ΋ ÛÎÏ‹Ú˘ÓÛË ªËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ› ¢È·ÌÂÛÔÛˆÏËÓ·ÚȷΤ˜ ·ÏÏÔÈÒÛÂȘ ∂Ó·Ôı¤ÛÂȘ IgA ÛÙ· ÙÚȯÔÂȉ‹ ·ÁÁ›·
1 0,49 0,005 1 0,68 <0,0001 0,003
¡µ: ¡ÂÊÚÈ΋ ‚ÈÔ„›· GFR: ƒ˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘
<0,001 0,001 0,01 0,03 0,03 0,72
‰‡Ô ÛÙfi¯Ô˘˜: ·) Ó· ÂÚÈÔÚ›˙ÂÈ ÙÔÓ Û¯ËÌ·ÙÈÛÌfi Ì·ÎÚÔÌÔÚ›ˆÓ ·ıÔÏÔÁÈ΋˜ IgA, ÒÛÙ ӷ ÂÚÈÔÚ›˙ÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÓ·Ôı¤ÛÂˆÓ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·È ‚) Ó· ÂÚÈÔÚ›˙ÂÈ ÙËÓ ˘ÂÚ·Ú·ÁˆÁ‹ ÙˆÓ IgA ·ÓÙÈÛˆÌ¿ÙˆÓ Û·Ó ·ÓÙÈۈ̷ÙÈ΋ ·ÓÙ·fiÎÚÈÛË Û Â͈ÁÂÓ‹ ‹ ÂÓ‰ÔÁÂÓ‹ ·ÓÙÈÁfiÓ·. OÈ ıˆÚËÙÈÎÔ› ·˘ÙÔ› ÛÙfi¯ÔÈ ·¤¯Ô˘Ó Ôχ ·fi ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· Î·È Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ ‹Ù·Ó Î·È ·Ú·Ì¤ÓÂÈ Ì›· ÚfiÎÏËÛË. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Î·Ó¤Ó· ıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ȉÂ҉˜ Î·È ÂȉÈÎfi ÁÈ· ÙË ÓfiÛÔ, ȉ›ˆ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (66). ∂Ô̤ӈ˜, ÚÈÓ ÂÊ·ÚÌÔÛÙ› ÔÔÈÔ‰‹ÔÙ ıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ, ÂÈ‚¿ÏÏÂÙ·È Ë ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÍÂÏÈÎÙÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘. O ηıÔÚÈÛÌfi˜ ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÙfiÛÔ Ì ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ fiÛÔ Î·È ·fi Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ÂÎÙ¤ÏÂÛË Ù˘ ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜ fi¯È ÌfiÓÔ ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË, ·ÏÏ¿ Û˘Ì‚¿ÏÏÂÈ Î·È ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ϤÔÓ Î·Ù¿ÏÏËÏ˘ ıÂڷ¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ οı ·ÛıÂÓ‹, Ë ÔÔ›· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È. ™Ùfi¯Ô˜ Ù˘ ·ÁˆÁ‹˜ Â›Ó·È Ë ‰È·Ù‹ÚËÛË ÈηÓÔÔÈËÙÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÓÔ‰ÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘, fiˆ˜ Ë ˘¤ÚÙ·ÛË. ™Â ·ÛıÂÓ›˜ Ì ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Î·È ¯ˆÚ›˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ıÂڷ›·, ÂÓÒ Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú¤˜ Î·È ÌË ·Ó·ÛÙÚ¤„È̘ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÏËÊı› Ë ÂͤÏÈÍË Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ∫·Ù¿ ηÈÚÔ‡˜ ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ‰È¿ÊÔÚ· Ê¿Ú̷η Î·È Ù·ÎÙÈΤ˜ ¯ˆÚ›˜ ÛÙ·ıÂÚ¿ ·ÔÙÂϤÛÌ·Ù·. ∏ ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Ë ·Ì˘Á‰·ÏÂÎÙÔÌ‹ ÂÏ¿ÙÙˆÛ·Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÛÙÚÂÙÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Ô˘ Èı·ÓfiÓ ˘ÚÔ‰ÔÙÔ‡Û·Ó ÙËÓ ÂÌÊ¿ÓÈÛË ÂÂÈÛÔ‰›ˆÓ Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜, ·ÏÏ¿ ‰ÂÓ ‰È·ÈÛÙÒıËΠ‚ÂÏÙ›ˆÛË ÛÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘. ∏ ¯ÔÚ‹ÁËÛË ‰·Ó·˙fiÏ˘ Î·È ‰ÈÊÂÓ˘Ï˘‰·ÓÙÔ˝Ó˘ Èı·ÓfiÓ Ô‰‹ÁËÛ Û Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgA, ·ÏÏ¿ ·ÚÔÌÔ›ˆ˜ ‰ÂÓ ÂËÚ¤·Û ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ (67). ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ÂÍÂÏÈÎÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ÛÔ‚·Ú‹ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· (>1 g/m2/24ˆÚÔ), ÂÓÒ ÔÈ Û˘Ó‰ڛ˜ Ï·ÛÌ·Ê·›ÚÂÛ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ΢ÎÏÔʈÛÊ·Ì›‰Ë Ú¤ÂÈ Ó· ÂÚÈÔÚ›˙ÔÓÙ·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ù·¯¤ˆ˜ ÂÍÂÏÈÛÛfiÌÂÓ˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ (68). ∂ȉÈÎfiÙÂÚ·, ÔÈ Niaudet Î·È Û˘Ó (58) ¤¯Ô˘Ó ‰ËÌÔÛȇÛÂÈ ıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ·È‰ÈÒÓ Ì IgA ÓÂÊÚÔ¿ıÂÈ· Î·È ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Ô˘ ›¯·Ó ÛÙË ÓÂÊÚÈ΋ ‚ÈÔ„›· ÌËÓÔÂȉ›˜ Û¯ËÌ·ÙÈÛÌÔ‡˜ Û >50% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÒÛÂȘ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ 1 g/1,73 m2/48ˆÚÔ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ per os. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂڷ›·˜ ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·14
14
∞. ªËÙÛÈÒÓË
fiÛÔÓ ·ÊÔÚ¿ ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÛıÂÓÒÓ, Û ۇÁÎÚÈÛË Ì ÈÛÙÔÚÈÎÔ‡˜ Ì¿ÚÙ˘Ú˜ Ô˘ ‰ÂÓ Â›¯·Ó ˘Ô‚ÏËı› Û ·˘Ù‹ ÙË ıÂڷ›· ‹ ›¯·Ó Ï¿‚ÂÈ ‰È·ÊÔÚÂÙÈ΋, ‹Ù·Ó ÛËÌ·ÓÙÈο ηχÙÂÚ·. ∂Óı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·, ›Û˘, ·Ó·Ê¤ÚÂÈ È·ˆÓÈ΋ ÌÂϤÙË (17,69) ‚·ÚÈ¿˜ IgA ÓÂÊÚÔ¿ıÂÈ·˜ Û ·È‰È¿ ηÙfiÈÓ ıÂڷ›·˜ Ì ‰È˘Úȉ·ÌfiÏË, Ú‰ÓÈ˙fiÓË, ·˙·ıÂÈÔÚ›ÓË Î·È warfarin ‰È¿ÚÎÂÈ·˜ 2 ÂÙÒÓ, ÂÓÒ ÔÈ Andreoli Î·È Bergstein (70) Ì ‰È·‰Ô¯ÈΤ˜ ‚ÈÔ„›Â˜ ·ÛıÂÓÒÓ ¤‰ÂÈÍ·Ó ÌÈÎÚfiÙÂÚÔ ·ÚÈıÌfi ÛÎÏËÚ˘Ì¤ÓˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·ÙfiÈÓ ¯ÔÚ‹ÁËÛ˘ Û˘Ó‰˘·ÛÌÔ‡ ·˙·ıÂÈÔÚ›Ó˘-Ú‰ÓÈ˙fiÓ˘. ¶·È‰È·ÙÚÈÎÔ› ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È Ì¤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ıÂڷ¢ÙÈÎfi ‰›ÏËÌÌ· (71). ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÌÈÎÚ‹˜ ‰fiÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Û ·Ú‹ÌÂÚÔ Û¯‹Ì· ‰ÂÓ Ê·›ÓÂÙ·È - Û‡Ìʈӷ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›· - Ó· ¤¯ÂÈ ıÂڷ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· (72). ¶ÚfiÛÊ·Ù·, ÂÊ·ÚÌfiÛÙËÎÂ Ë ¯ÔÚ‹ÁËÛË È¯ı˘ÂÏ·›Ô˘ Û ÂÓ‹ÏÈÎÔ˘˜ ·ÛıÂÓ›˜ Ì ‹È·˜ ‚·Ú‡ÙËÙ·˜ ÓfiÛÔ, Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ (73,74). O Ì˯·ÓÈÛÌfi˜ Ì ÙÔÓ ÔÔ›Ô ·ÛÎÂ›Ù·È Ë ÚÔÛٷ٢ÙÈ΋ ·˘Ù‹ ‰Ú¿ÛË ÛÙÔÓ ¿Û¯ÔÓÙ· ÓÂÊÚfi ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ› Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ ÂÊ·ÚÌÔÁ‹˜ Û ·È‰È¿. ∆Ô È¯ı˘¤Ï·ÈÔ Â›Ó·È ÏÔ‡ÛÈÔ Û ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, Ô˘ Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙËÓ ÂÈ‚Ï·‚‹ ‰Ú¿ÛË ÙˆÓ ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ Ô˘ ÚÔηÏÔ‡Ó ·ÁÁÂÈÔÛ‡Û·ÛË, Û˘ÚÚ›ÎÓˆÛË ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ¯ËÌÂÈÔÙ·ÎÙÈÛÌfi ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÛÙÔÏ‹ Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÔÈ ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ I (·-ª∂∞) (75-77). ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ·-ª∂∞ ÂӉ›ÎÓ˘Ù·È fi¯È ÌfiÓÔ ÛÙÔ˘˜ ˘ÂÚÙ·ÛÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Î·È Û ·˘ÙÔ‡˜ Ì ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ¯ˆÚ›˜ ˘¤ÚÙ·ÛË. ∏ ¢ÓÔ˚΋ ‰Ú¿ÛË ÙˆÓ ·-ª∂∞ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹ Ô˘ ÚÔηÏÔ‡Ó ÛÙ· ÙÚȯÔÂȉ‹ Î·È ÛÙË Ì›ˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ fiÚˆÓ ÙÔ˘˜, Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ˘¤ÚÙ·Û˘ Î·È Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Ô˘ ·ÔÙÂÏÔ‡Ó ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ù˘ ÓfiÛÔ˘ Î·È Ë ‰¤ÛÌ¢ÛË ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ·Ú·ÁˆÁ‹˜ Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ ππ Ô˘ ˘ÂÈÛ¤Ú¯ÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚÔÛÙ·Û›· Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÂӉ¯Ô̤ӈ˜ ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ Ê˘ÛÈ΋˜ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘. ∂›Û˘, ÛÙËÓ Ï¤ÔÓ ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›· (78) ·Ó·Ê¤ÚÂÙ·È ‚ÂÏÙ›ˆÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ ·ÏÏ¿ Î·È Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÊÏÔ˘‚·ÛÙ·Ù›Ó˘ 20 mg ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰È˘Úȉ·ÌfiÏË (5 mg) Û ·È‰È¿ Ì ‹È· ÌÔÚÊ‹ IgA ÓÂÊÚÔ¿ıÂÈ·˜. ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
µÈ‚ÏÈÔÁÚ·Ê›· 1. Berger J, Hinglais N. Les depots intercapillaires d’ IgA-IgG. J Urol Nephrol 1968;74:694-695. 2. Berger J. IgA glomerular deposits in renal disease. Transplant Proc 1969;1:939-944. 3. Rodicio JL. Idiopathic IgA nephropathy. Kidney Int 1984;25:717-729. 4. D’Amico G. The commonest glomerulonephritis in the world: IgA nephropathy. Q J Med 1987;64:709-727. 5. D’Amico G. Influence of clinical and histological features on actuarial renal survival in adult patients with idiopathic IgA nephropathy, membranous nephropathy, and membranoproliferative glomerulonephritis: survey of the recent literature. Am J Kidney Dis 1992;20:315-323. 6. Donadio JV, Bergstralh EJ, Offord KP, Holley KE, Spencer DC. Clinical and histopathologic associations with impaired renal function in IgA nephropathy. Mayo Nephrology Collaborative Group. Clin Nephrol 1994;41:65-71. 7. Yoshikawa N, Ito H, Yoshiara S, Nakahara C, Yoshiya K, Hasegawa O et al. Clinical course of immunoglobulin A nephropathy in children. J Pediatr 1987;110:555-560. 8. Linne T, Aperia A, Broberger O, Bergstrand A, Bohman SO, Rekola S. Course of renal function in IgA glomerulonephritis in children and adolescents. Acta Paediatr Scand 1982;71:735-743. 9. Levy M, Gonzalez-Burchard G, Broyer M, Dommergues JP, Foulard M, Sorez JP et al. Berger’ s disease in children. Natural history and outcome. Medicine 1985;64:157-180. 10. Hogg RJ, Silva FG, Wyatt RJ, Reisch JS, Argyle JC, Savino DA. Prognostic indicators in children with IgA nephropathy - report of the Southwest Pediatric Nephrology Study Group. Pediatr Nephrol 1994;8:15-20. 11. Wyatt RJ, Kritchevsky SB, Woodford SY, Miller PM, Roy S 3rd, Holland NH et al. IgA nephropathy: long-term prognosis for pediatric patients. J Pediatr 1995;127:913-919. 12. Berger J, Yaneva H, Crosnier J. La glomerulonephrite a depots mesangiaux d’ IgA: Une cause frequente d’ insuffisance renale terminale. Nouv Presse Med 1980;9:219-221. 13. Sakai H, Abe K, Kobayashi Y, Koyama A, Shigematsu H, Harada T et al. Clinical guidelines of IgA nephropathy. Jpn J Nephr 1995;37:417-421. 14. Clarkson AR, Seymour AE, Thompson AJ, Haynes WD, Chan YL, Jackson B. IgA nephropathy: a syndrome of uniform morphology, diverse clinical features and uncertain prognosis. Clin Nephrol 1977;8:459-471. 15. Geddes CC, Ranta V, Gronhagen-Riska C, Bartosik LP, Jardine AG, Ibels LS et al. A tricontinental view of IgA nephropathy. Nephrol Dial Transplant 2003;18:1541-1548. 16. Katz A, Walker JF, Landy PJ. IgA nephritis with nephrotic range proteinuria. Clin Nephrol 1983;20:67-71. 17. Yoshikawa N, Iijima K, Ito H. IgA nephropathy in children. Nephron 1999;83:1-12. 18. Jennette JC, Wall SD, Wilkman AS. Low incidence of IgA nephropathy in blacks. Kidney Int 1985;28:944-950. 19. Coppo R, Gianoglio B, Porcellini MG, Maringhini S. Frequency of renal diseases and clinical indications for renal biopsy in children (report of the Italian National Registry of Renal Biopsies in Children). Group of Renal Immunopathology of the Italian Society of Pediatric Nephrology and Group of Renal Immunopathology of the Italian Society of Nephrology. Nephrol Dial Transplant 1998;13:293-297. 20. Coppo R, Amore A, Hogg R, Emancipator S. Idiopathic nephropathy with IgA deposits. Pediatr Nephrol 2000; 15:139-150. 21. Emancipator SN. Immunoregulatory factors in the pathogenesis of IgA nephropathy. Kidney Int 1990;38:1216-1229. 22. Yoshikawa N. Immunoglobulin A nephropathy. In: Avner ED, Harmon WE, Niaudet P, editors. Pediatric Nephrology. 5th ed. Lippincot Williams Wilkins; 2003. p. 615.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·15
15
IgA ÓÂÊÚÔ¿ıÂÈ·
23. Komatsu N, Nagura H, Watanabe K, Nomoto Y, Kobayashi K. Mesangial deposition of J chain-linked polymeric IgA in IgA nephropathy. Nephron 1983;33:61-64. 24. Suzuki S, Nakatomi Y, Sato H, Tsukada H, Arakawa M. Haemophilus parainfluenzae antigen and antibody in renal biopsy samples and serum of patients with IgA nephropathy. Lancet 1994;343:12-16. 25. Nagy J, Uj M, Szucs G, Trinn C, Burger T. Herpes virus antigens and antibodies in kidney biopsies and sera of IgA glomerulonephritic patients. Clin Nephrol 1984;21:259-262. 26. Russell MW, Mestecky J, Julian BA, Galla JH. IgA-associated renal diseases: antibodies to environmental antigens in sera and deposition of immunoglobulins and antigens in glomeruli. J Clin Immunol 1986;6:74-86. 27. Coppo R, Amore A, Roccatello D. Dietary antigens and primary immunoglobulin A nephropathy. J Am Soc Nephrol 1992;2 (10 Suppl):S173-S180. 28. Coppo R. The pathogenetic potential of environmental antigens in IgA nephropathy. Am J Kidney Dis 1988;12:420-424. 29. Berger J, Yaneva H, Nabarra B, Barbanel C. Recurrence of mesangial deposition of IgA after renal transplantation. Kidney Int 1975;7:232-241. 30. Sanfilippo F, Croker BP, Bollinger RB. Fate of four cadaveric donor renal allografts with mesangial IgA deposits. Transplantation 1982;33:370-376. 31. Feehally J, Allen AC. Structural fractures of IgA molecules which contribute to IgA nephropathy. Nephrol Dial Transplant 1998;13:1980-1983. 32. Allen AC, Harper SJ, Feehally J. Galactosylation of N- and Olinked carbohydrate moieties of IgA1 and IgG in IgA nephropathy. Clin Exp Immunol 1995;100:470-474. 33. Kokubo T, Hiki Y, Iwase H, Tanaka A, Toma K, Hotta K et al. Protective role of IgA1 glycans against IgA1 self-aggregation and adhesion to extracellular matrix proteins. J Am Soc Nephrol 1998;9:2048-2054. 34. Allen AC, Bailey EM, Brenchley PE, Buck KS, Barratt J, Feehally J. Mesangial IgA1 in IgA nephropathy exhibits aberrant O-glycosylation: observations in three patients. Kidney Int 2001;60:969-973. 35. Greer MR, Barratt J, Harper SJ, Allen AC, Feehally J. The nucleotide sequence of the IgA1 hinge region in IgA nephropathy. Nephrol Dial Transplant 1998;13:1980-1983. 36. Allen AC, Topham PS, Harper SJ, Feehally J. Leucocyte beta 1,3 galactosyltransferase activity in IgA nephropathy. Nephrol Dial Transplant 1997;12:701-706. 37. Tomana M, Matousovic K, Julian BA, Radl J, Konecny K, Mestecky J. Galactose-deficient IgA1 in sera of IgA nephropathy patients in present in complexes with IgG. Kidney Int 1997;52:509-516. 38. Tomana M, Novak J, Julian BA, Matousovic K, Konecny K, Mestecky J. Circulating immune complexes in IgA nephropathy consist of IgA1 with galactose-deficient hinge region and antiglycan antibodies. J Clin Invest 1999;104:73-81. 39. Amore A, Goetze O, Cirina P, Peruzzi L, Coppo R. Complement can be activated by aberrantly glycosylated IgA in vitro and in sera from IgAN patients. Nephrol Dial Transplant 1998;13:6,A50. 40. Nikolova EB, Tomana M, Russell MW. The role of the carbohydrate chains in complement (C3) fixation by solidphase-bound human IgA. Immunology 1994;82:321-327. 41. Floege J, Feehally J. IgA nephropathy: recent developments. J Am Soc Nephrol 2000;11:2395-2403. 42. Gesualdo L, Di Paolo S, Milani S, Pinzani M, Grappone C, Ranieri E et al. Expression of platelet-derived growth factor receptors in normal and diseased human kidney. An immunohistochemistry and in situ hybridization study. J Clin Invest 1994;94:50-58. 43. Peters H, Noble NA, Border WA. Transforming growth factor-beta in human glomerular injury. Curr Opin Nephrol Hypertens 1997;6:389-393.
44. Kriz W, Gretz N, Lemley KV. Progression of glomerular diseases: is the podocyte the culprit? Kidney Int 1998;54:687-697. 45. Egido J. Vasoactive hormones and renal sclerosis. Kidney Int 1996;49:578-597. 46. Coppo R, Amore A, Gianoglio B, Cacace G, Picciotto G, Roccatello D et al. Angiotensin II local hyperreactivity in the progression of IgA nephropathy. Am J Kidney Dis 1993;21:593602. 47. Hale GM, Howarth GS, Aarons I, Clarkson AR, Woodroffe AJ. Quantitation of glomerular angiotensin II local hyperactivity in the progression of IgA nephropathy. Am J Kidney Dis 1989;21:593-602. 48. Rambausek MH, Waldherr R, Ritz E. Immunogenetic findings in glomerulonephritis. Kidney Int 1993;39 (Suppl):S3-S8. 49. Scolari F, Amoroso A, Savoldi S, Mazzola G, Prati E, Valzorio B et al. Familial clustering of IgA nephropathy: further evidence in an Italian population. Am J Kidney Dis 1999;33:857-865. 50. Berthoux FC, Gagne A, Sabatier JC, Ducret F, Le Petit JC, Marcellin M et al. HLA-Bw35 and mesangial IgA glomerulonephritis. N Engl J Med 1978;298:1034-1035. 51. Levy M, Lesavre P. Genetic factors in IgA nephropathy (Berger’ s disease). Adv Nephrol Necker Hosp 1992;21:23-51. 52. Scolari F. Familial IgA nephropathy. J Nephrol 1999;12:213219. 53. McLean RH, Wyatt RJ, Julian BA. Complement phenotypes in glomerulonephritis: increased frequency of homozygous null C4 phenotypes in IgA nephropathy and Henoch-Schonlein purpura. Kidney Int 1984;26:855-860. 54. Rajaram V, Liapis H. Immunoglobulin A nephropathy. Nephrol Dial Transplant 2001;16 (Suppl 6):S77-S79. 55. Radford MG Jr, Donadio JV Jr, Bergstralh EJ, Grande JP. Predicting renal outcome in IgA nephropathy. J Am Soc Nephrol 1997;8:199-207. 56. Southwest Pediatric Nephrology Study Group. A multicenter study of IgA nephropathy in children. Kidney Int 1982;22:643-652. 57. Kusumoto Y, Takebayashi S, Taguchi T, Harada T, Naito S. Long-term prognosis and prognostic indices of IgA nephropathy in juvenile and in adult Japanese. Clin Nephrol 1987;28:118-124. 58. Niaudet P, Murcia A, Beaufils H, Broyer M, Habib R. Pronostic et traitement des nephropathies a l’ IgA de l’ enfant. In: Actualites Nephrologiques Jean Hamburger; Hopital Necker 1992; Medecine - Siences Flammarion Paris; 1992. p. 101-116. 59. Emancipator SN, Gallo GR, Lamm ME. IgA nephropathy: perspectives on pathogenesis and classification. Clin Nephrol 1985;24:161-179. 60. Abuelo JG, Esparza AR, Matarese RA, Endreny RG, Garvalho JS, Allegra SR. Crescentic IgA nephropathy. Medicine 1984;63:396-406. 61. Chauveau D, Droz D. Follow-up evaluation of the first patients with IgA nephropathy described at Necker Hospital. Contrib Nephrol 1993;104:1-5. 62. Coppo R, Amore A, Hogg R, Emancipator S. Idiopathic nephropathy with IgA deposits. Pediatr Nephrol 2000;15:139-150. 63. Berg UB. Long-term follow up of renal function in IgA nephropathy. Arch Dis Child 1991;66:588-592. 64. Yoshikawa N, Ito H, Iijima K, Nakahara C, Maehara K, Hasegawa O et al. Macroscopic hematuria in childhood IgA nephropathy. Clin Nephrol 1987;28:217-221. 65. Hogg RJ. Prognostic indicators and treatment of childhood IgA nephropathy. Contrib Nephrol 1995;111:194-200. 66. Wyatt RJ, Hogg RJ. Evidence-based assessment of treatment options for children with IgA nephropathies. Pediatr Nephrol 2001;16:156-167. 67. Clarkson AR, Woodroffe AJ, Aarons IA, Thompson T, Hale GM. Therapeutic options in IgA nephropathy. Am J Kidney Dis 1988;12:443-448. ¶·È‰È·ÙÚÈ΋ 2005;68:8-16
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·16
16
∞. ªËÙÛÈÒÓË
68. Nolin L, Courteau M. Management of IgA nephropathy: evidence-based recommendations. Kidney Int 1999;70 (Suppl):S56-S62. 69. Yoshikawa N, Ito H, Sakai T, Takekoshi Y, Honda M, Awazu M et al. A controlled trial of combined therapy for newly diagnosed severe childhood IgA nephropathy. The Japanese Pediatric IgA Nephropathy Treatment Study Group. J Am Soc Nephrol 1999;10:101-109. 70. Andreoli SP, Bergstein JM. Treatment of severe IgA nephropathy in children. Pediatr Nephrol 1989;3:248-253. 71. Scheinman JI, Trachtman H, Lin CY, Langman CB, Chan JC. IgA nephropathy: to treat or not to treat? Nephron 1997; 75:251-258. 72. Waldo FB, Wyatt RJ, Kelly DR, Herrera GA, Benfield MR, Kohaut EC. Treatment of IgA nephropathy in children: efficacy of alternate-day oral prednisone. Pediatr Nephrol 1993;7:529-532. 73. Pettersson EE, Rekola S, Berglund L, Sundqvist KG, Angelin B, Diczfalusy U et al. Treatment of IgA nephropathy with omega-3-polyunsaturated fatty acids: a prospective, doubleblind, randomized study. Clin Nephrol 1994;41:183-190. 74. Donadio JV Jr, Bergstralh EJ, Offord KP, Spencer DC, Holley
¶·È‰È·ÙÚÈ΋ 2005;68:8-16
75.
76.
77.
78.
KE. A controlled trial of fish oil in IgA nephropathy. Mayo Nephrology Collaborative Group. N Engl J Med 1994;331: 1194-1199. Remuzzi A, Perticucci E, Ruggenenti P, Mosconi L, Limonta M, Remuzzi G. Angiotensin converting enzyme inhibition improves glomerular size-selectivity in IgA nephropathy. Kidney Int 1991;39:1267-1273. Cattran DC, Greenwood C, Ritchie S. Long-term benefits of angiotensin-converting enzyme inhibitor therapy in patients with severe immunoglobulin A nephropathy: a comparison to patients receiving treatment with other antihypertensive agents and to patients receiving no therapy. Am J Kidney Dis 1994;23:247-254. Coppo R. Angiotensin-converting enzyme inhibitors in young patients with IgA nephropathy: effects against deterioration of renal function. A Biomedicine and Health Research Concerted Action. Nephrol Dial Transplant 1999;14:840-841. Kano K, Nishikura K, Yamada Y, Arisaka O. Effect of fluvastatin and dipyridamole on proteinuria and renal function in childhood IgA nephropathy with mild histological findings and moderate proteinuria. Clin Nephrol 2003;60:85-89.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·17
REVIEW ARTICLE
17
IgA nephropathy in children A. Mitsioni
Abstract IgA nephropathy, first described in 1969 by Berger and Hinglais, is the most common variety of primary glomerulonephritis in the world. It is characterized by mesangial deposits of IgA. Initially, it was considered a benign disease, however long-term follow-up studies indicated a progression of the disease to renal failure in 20-25% of the adult patients. The pathogenesis is still unknown and appropriate treatment has not yet been established. However, the favorable prognosis initially attributed in children with IgA nephropathy must be questioned and reviewed in the light of recent studies.
Key words IgA nephropathy, Berger’s disease, children.
Department of Nephrology, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: Andromahi Mitsioni 11 Tirynthos str., 175 64, P. Faliro, Athens Date of submission: 20-02-2004 Date of approval: 28-09-2004
Paediatriki 2005;68:17
Paediatriki Jan-Feb 05 teliko
18
10-02-05
13:36
™ÂÏ›‰·18
∞¡∞™∫O¶∏™∏
¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ú·Ó¢ÌÔÓÈÎÒÓ Û˘ÏÏÔÁÒÓ ÛÙ· ·È‰È¿ ¢. ªÂÚÌ›ÚË, ∫. ¶Ú›ÊÙ˘ ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ¢¤ÛÔÈÓ· ªÂÚÌ›ÚË ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ ∆.∫. 152 36, ¶·Ï·È¿ ¶ÂÓÙ¤ÏË ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 25-02-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-09-2004
¶ÂÚ›ÏË„Ë OÈ ·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜ ·ÔÙÂÏÔ‡Ó Û˘Ó‹ıË Û˘ÓÔ‰fi ÂΉ‹ÏˆÛË ÙˆÓ ÌÈÎÚÔ‚È·ÎÒÓ Ó¢ÌÔÓÈÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÓÔÛËÏ›· ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂÓÒ Ù· ÂÌ˘‹Ì·Ù· ıˆÚÔ‡ÓÙ·È ÂÈÏÔ΋ Ù˘ ·ÚÈ·˜ ÓfiÛÔ˘. ¶·Ú¿ ÙË Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ ·fi ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÌ˘ËÌ¿ÙˆÓ ·˘Í¿ÓÂÈ Î·È ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙËÓ ÂÎÙÂٷ̤ÓË ¯Ú‹ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È ÛÙÔ˘˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜, Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔ‚È·ÎÒÓ ÛÙÂϯÒÓ. ø˜ ÚÔ˜ ÙË Û˘ÓÈÛÙÒÌÂÓË ‰È·ÁÓˆÛÙÈ΋ Ú·ÎÙÈ΋, ‰›‰ÂÙ·È ¤ÌÊ·ÛË ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ˘ ıÒڷη, ÏfiÁˆ Ù˘ Ô˘ÛÈ·ÛÙÈ΋˜ ‚Ô‹ıÂÈ·˜ Ô˘ ·Ú¤¯ÂÈ ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ Û˘ÏÏÔÁ‹˜. ∂ÈÛËÌ·›ÓÂÙ·È Ë ·Í›· Ù˘ ¤ÁηÈÚ˘ ·Ú·Î¤ÓÙËÛ˘ ÙÔ˘ ıÒڷη, ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜, ÏfiÁˆ ÙˆÓ ÔχÙÈÌˆÓ ÏËÚÔÊÔÚÈÒÓ Ô˘ ·Ú¤¯ÂÈ ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ Ù‡Ô˘ Ù˘ Û˘ÏÏÔÁ‹˜. ∏ ıÂڷ›· ÂÈϤÁÂÙ·È Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, ·ÏÏ¿ Î·È ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡. ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ ÂÈÏÂÁ̤Ó˘ ·Ú·Ó¢ÌÔÓÈ΋˜ Û˘ÏÏÔÁ‹˜, Û˘ÓÈÛÙ¿Ù·È ÙÔÔı¤ÙËÛË ÛˆÏ‹Ó· ·ÚÔ¯¤Ù¢Û˘ ‹ ·ÎfiÌ· Î·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂȈı› Ô ¯ÚfiÓÔ˜ ÓÔÛËÏ›·˜ Î·È Ó· ·ÔÊ¢¯ıÔ‡Ó ·ÓÂÈı‡ÌËÙ˜ Û˘Ó¤ÂȘ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ Û‡Á¯ÚÔÓ˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Î·È ·ÚÔ˘Û›·ÛË Ù˘ ÚÔÙÂÈÓfiÌÂÓ˘ ‰È·ÁÓˆÛÙÈ΋˜ Î·È ıÂڷ¢ÙÈ΋˜ Ú·ÎÙÈ΋˜.
§¤ÍÂȘ ÎÏÂȉȿ ¶·Ú·Ó¢ÌÔÓÈ΋ Û˘ÏÏÔÁ‹, Â̇ËÌ·, Ó¢ÌÔÓ›·, ·ÚÔ¯¤Ù¢ÛË.
∂ÈÛ·ÁˆÁ‹ ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ ÛËÌÂȈı› ‰Ú·ÛÙÈ΋ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÙfiÙËÙ·˜ ·fi ÙȘ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿, ÂÚÈÙÒÛÂȘ ÂÈÏÂÁÌ¤ÓˆÓ ·Ú·Ó¢ÌÔÓÈÎÒÓ Û˘ÏÏÔÁÒÓ (¶¶™) ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ··Û¯ÔÏÔ‡Ó Û¯ÂÙÈο Û˘¯Ó¿, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·Ó·ı¤ÚÌ·ÓÛË ÙÔ˘ ÂӉȷʤÚÔÓÙÔ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ (1). ∞Ô‰›‰ÔÓÙ·È ÛÙËÓ Â˘Ú›· ¯Ú‹ÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Î·È ÛÙËÓ ÚÔԉ¢ÙÈο ·˘Í·ÓfiÌÂÓË Î·Ù¿ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ηıÒ˜ Î·È ÛÙËÓ Â˘Ú‡Ù·ÙË ¯Ú‹ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔ‚È·ÎÒÓ ÛÙÂϯÒÓ (2). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÔÛÔÛÙfi ÂÚ›Ô˘ 40% ÙˆÓ Ó¢ÌÔÓÈÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÓÔÛËÏ›· ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Û˘Óԉ‡ÂÙ·È ·fi ˘Â˙ˆÎÔÙÈ΋ Û˘ÏÏÔÁ‹ (3). ∂ÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔ ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi, ÔÈ Ôԛ˜, ˆÛÙfiÛÔ, ¯ÚÂÈ¿˙ÔÓÙ·È ÂȉÈÎfiÙÂÚË ‰È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ·ÚÔ˘Û›·ÛË Ù˘ Û‡Á¯ÚÔÓ˘ ‰È·ÁÓˆÛÙÈ΋˜ Î·È ıÂڷ¢ÙÈ΋˜ ÚfiÙ·Û˘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ¶¶™ ÛÙ· ·È‰È¿, Û‡Ìʈӷ Ì ÙË Û‡Á¯ÚÔÓË ÁÓÒÛË Î·È ÂÌÂÈÚ›·, fiˆ˜ ηٷÁÚ¿ÊÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. ¶·È‰È·ÙÚÈ΋ 2005;68:18-27
√ÚÈÛÌÔ› ∏ ¢ڇÙÂÚ· ·Ô‰ÂÎÙ‹ ÔÓÔÌ·ÙÔÏÔÁ›· ÙˆÓ ˘Â˙ˆÎÔÙÈÎÒÓ Û˘ÏÏÔÁÒÓ Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙȘ ÌÈÎÚԂȷΤ˜ Ó¢ÌÔӛ˜ Â›Ó·È ÂΛÓË ÙÔ˘ Light (4,5). ™‡Ìʈӷ Ì ÙËÓ Ù·ÍÈÓfiÌËÛË ·˘Ù‹, ˆ˜ ·Ú·Ó¢ÌÔÓÈ΋ Û˘ÏÏÔÁ‹ ıˆÚÂ›Ù·È ÔÔÈ·‰‹ÔÙÂ Û˘ÏÏÔÁ‹ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÌÈÎÚԂȷ΋ Ó¢ÌÔÓ›·, Ó¢ÌÔÓÈÎfi ·fiÛÙËÌ· ‹ ‚ÚÔÁ¯ÈÂÎÙ·Û›· Î·È ÔÊ›ÏÂÙ·È ÛÙËÓ ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙÔ˘ ÛÏ·Á¯ÓÈÎÔ‡ ÂÙ¿ÏÔ˘ ÙÔ˘ ˘Â˙ˆÎfiÙ· ÏfiÁˆ ÊÏÂÁÌÔÓ‹˜. ø˜ ÌË ÂÈÏÂÁ̤ÓË ÔÚ›˙ÂÙ·È Ë ¶¶™ Ô˘ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·ÚÔ¯¤Ù¢ÛË ÁÈ· ÙËÓ ·ÔÚÚfiÊËÛ‹ Ù˘. ø˜ ÂÈÏÂÁ̤ÓË ¯·Ú·ÎÙËÚ›˙ÂÙ·È Ë Û˘ÏÏÔÁ‹ Ô˘ ‰ÂÓ ˘Ô¯ˆÚ› ¯ˆÚ›˜ ıˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË Î·Ù·Ù¿ÛÛÂÙ·È Î·È ÙÔ Â̇ËÌ·, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ‡Ô˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. ™ÙÔȯ›· Ê˘ÛÈÔÏÔÁ›·˜ O ˘Â˙ˆÎfiÙ·˜ Â›Ó·È Ì›· ÏÂÙ‹ ÌÂÌ‚Ú¿ÓË Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ÂÊ·ÙfiÌÂÓ· ¤Ù·Ï·, ÙÔ ÂÚ›ÙÔÓÔ Î·È ÙÔ ÂÚÈÛÏ¿Á¯ÓÈÔ. ∫·Ï‡ÙÂÈ ÙÔÓ Ó‡ÌÔÓ· Î·È ÙȘ ÌÂÛÔÏfi‚Ș Û¯ÈṲ̂˜, ÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ, ÙÔ ‰È¿ÊÚ·ÁÌ· Î·È ÙÔ Ï¢ÚÈÎfi ÙÔ›¯ˆÌ·. ™Â οı ¤Ù·ÏÔ ÂÈÔÏ‹˜ ‚Ú›ÛÎÂÙ·È Ì›· ÛÙÈ‚¿‰· ÌÂÛÔıËÏÈ·ÎÒÓ ÌÔÓÔ΢ÙÙ¿ÚˆÓ Ô˘ ÛÙËÚ›˙ÂÙ·È ÛÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË Ì ÈÓÔÂÏ·ÛÙÈο ÛÙÔȯ›· ÛÙȘ ˘ÔΛÌÂÓ˜ ÛÙÈ‚¿‰Â˜
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·19
19
¶·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜
Î·È Ù· ·ÓÙ›ÛÙÔȯ· ·ÁÁ›· Î·È ÏÂÌÊ·ÁÁ›·. O ÚfiÏÔ˜ ÙˆÓ ÌÂÛÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ‰ÂÓ ·ÊÔÚ¿ ÌfiÓÔ ÛÙËÓ Î·Ï˘ÙÈ΋, ·ÏÏ¿ Î·È Û ¢Ú›· ÌÂÙ·‚ÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∆· ·ÙÙ·Ú· ·˘Ù¿ ·Ú¿ÁÔ˘Ó ÚˆÙ½Ó˜, ÔÈ Î˘ÚÈfiÙÂÚ˜ ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ÙÔ ÎÔÏÏ·ÁfiÓÔ Î·È Ë ÂÏ·ÛÙ›ÓË (6). ∏ ·ÈÌ¿ÙˆÛË ÙˆÓ ‰‡Ô ÂÙ¿ÏˆÓ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·. ∆Ô ·Ú·ÁfiÌÂÓÔ ˘ÁÚfi ·ÔÚÚÔÊ¿Ù·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ̤ۈ Ù˘ ÏÂÌÊÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, Ô˘ ‚Ú›ÛÎÂÙ·È ÂȉÈο ·ÓÂÙ˘Á̤ÓË ÛÙÔ Î·ÙÒÙÂÚÔ ËÌÈÌfiÚÈÔ ÙÔ˘ ÂÚÈÙfiÓÔ˘ ÂÙ¿ÏÔ˘. ™ÙËÓ ›‰È· ˙ÒÓË ·ÔÚÚÔÊÒÓÙ·È Ù· ÚÔ˚fiÓÙ· ·Ô‰fiÌËÛ˘ Ô˘ ÊÙ¿ÓÔ˘Ó ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· (7). ø˜ ÚÔ˜ ÙË Ó‡ڈÛË, ·ÈÛıËÙÈΤ˜ Ó¢ÚÈΤ˜ ›Ó˜ ¤¯Ô˘Ó ÌfiÓÔ ÔÈ Ï¢ÚÈΤ˜ Î·È ‰È·ÊÚ·ÁÌ·ÙÈΤ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ ÂÚÈÙfiÓÔ˘ ÂÙ¿ÏÔ˘ ηÈ, Û˘ÓÂÒ˜, Â›Ó·È ÔÈ ÌfiÓ˜ ÈηӤ˜ Ó· ÚÔηϤÛÔ˘Ó fiÓÔ fiÙ·Ó ‰¤¯ÔÓÙ·È Î¿ÔÈÔ ÂÚ¤ıÈÛÌ·. O fiÓÔ˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ÂÚÈÊÂÚÈÎfiÙÂÚË ÏÂ˘Ú¿ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ ·ÓÙ·Ó·ÎÏ¿Ù·È Î·Ù¿ Ì‹ÎÔ˜ ÙˆÓ Ï¢ÚÒÓ, ÂÓÒ ·˘Ùfi˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ÂÛˆÙÂÚÈ΋ ÏÂ˘Ú¿ ·ÓÙ·Ó·ÎÏ¿Ù·È ÚÔ˜ ÙÔÓ ÒÌÔ Ì¤Ûˆ ÙÔ˘ ÊÚÂÓÈÎÔ‡ Ó‡ÚÔ˘. ™Â Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, ÛÙË Ê¿ÛË Ù˘ ‹ÚÂÌ˘ ÂÎÓÔ‹˜, Ë (ÂÓ‰Ô)˘Â˙ˆÎÔÙÈ΋ ›ÂÛË Â›Ó·È ÂÚ›Ô˘ 5 cm H2O ¯·ÌËÏfiÙÂÚË Ù˘ ·ÙÌÔÛÊ·ÈÚÈ΋˜. ∏ ·ÚÓËÙÈ΋ ·˘Ù‹ ›ÂÛË ÔÊ›ÏÂÙ·È ÛÙȘ ‰˘Ó¿ÌÂȘ ÂÏ·ÛÙÈ΋˜ ·ӷÊÔÚ¿˜ ÙˆÓ Ó¢ÌfiÓˆÓ Ô˘ ¤ÏÎÔ˘Ó ÚÔ˜ Ù· ¤Ûˆ, ¤Ó·ÓÙÈ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ (8). ∆· ‰‡Ô ¤Ù·Ï· ÏÂÈÙÔ˘ÚÁÔ‡Ó ˆ˜ ÌÂÌ‚Ú¿Ó˜ ‰È·ÂÚ·Ù¤˜ ·fi Ù· ÌfiÚÈ· ÌÈÎÚÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜, fiˆ˜ Â›Ó·È Ë ÁÏ˘Îfi˙Ë, ·ÏÏ¿ ËÌȉȷÂÚ·Ù¤˜ ·fi Ì·ÎÚÔÌfiÚÈ·, fiˆ˜ Â›Ó·È ÙÔ Ï‡Έ̷. ø˜ Û˘Ó¤ÂÈ· ·˘ÙÔ‡, ÙÔ ˘Â˙ˆÎÔÙÈÎfi ˘ÁÚfi ·ÔÙÂÏ› ˘ÂډȋıËÌ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Ì ÙËÓ ˘ÎÓfiÙËÙ· Ù˘ ÁÏ˘Îfi˙˘ ÛÙ· ›‰· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È Ì ÂΛÓË ÙˆÓ ÚˆÙÂ˚ÓÒÓ Û ¯·ÌËÏfiÙÂÚ·. O fiÁÎÔ˜ ÙÔ˘ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 5-15 ml (0,1-0,2 ml/kg ˘ÁÚÔ‡), Ë ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË Â›Ó·È ›‰È· Ì ÂΛÓË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 5 cm H2O), Ì ÌÈÎÚ‹ ÚˆÙÂ˚ÓÈ΋ Û˘ÁΤÓÙÚˆÛË (<1,5 g/dL), ÙÔ pH Â›Ó·È ·ÏηÏÈÎfi ÏËÛÈ¿˙ÔÓÙ·˜ ÙÔ 7,6 Î·È ÂÚȤ¯ÂÈ ÂÚ›Ô˘ 1500 ·ÙÙ·Ú· ·Ó¿ ml, Ì ÂÈÎÚ·ÙÔ‡ÓÙ· Ù‡Ô Ù· ÌÔÓÔ·ÙÙ·Ú· (1,2).
™ÙÔȯ›· ·ıÔÏÔÁÈ΋˜ Ê˘ÛÈÔÏÔÁ›·˜ ∏ Û˘ÛÛÒÚ¢ÛË ˘ÁÚÔ‡ ‹ ·¤Ú· ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· Û˘Óԉ‡ÂÙ·È ·fi ÂÚÈÔÚÈÛÌfi Ù˘ ¤ÎÙ˘Í˘ ÙÔ˘ Ó‡ÌÔÓ· ÛÙÔ Û‡ÛÙÔÈ¯Ô ËÌÈıˆÚ¿ÎÈÔ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÚfiÎÏËÛË ‚Ï¿‚˘ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘. ∏ ˙ˆÙÈ΋ ¯ˆÚËÙÈÎfiÙËÙ·, Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ˘ÔÏÂÈfiÌÂÓÔ˜ fiÁÎÔ˜ Î·È Ë ÔÏÈ΋ ¯ˆÚËÙÈÎfiÙËÙ· ÙˆÓ Ó¢ÌfiÓˆÓ ÌÂÈÒÓÔÓÙ·È. ÀÂ˙ˆÎÔÙÈ΋ Û˘ÏÏÔÁ‹ ‰ËÌÈÔ˘ÚÁÂ›Ù·È fiÙ·Ó ‰È·Ù·Ú¿ÛÛÂÙ·È ÙÔ ÈÛÔ˙‡ÁÈÔ ÙÔ˘ Ú˘ıÌÔ‡ ·Ú·ÁˆÁ‹˜ ηÈ
·ÔÚÚfiÊËÛ˘ ÙÔ˘ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡. ™‡Ìʈӷ Ì ÙÔÓ Sahn (6) ·˘Ù‹ Ë ‰È·Ù·Ú·¯‹ ÌÔÚ› Ó· Û˘Ì‚Â› Ì ÙÔ˘˜ ÂÍ‹˜ Ì˯·ÓÈÛÌÔ‡˜: ·) ∞‡ÍËÛË Ù˘ ˘‰ÚÔÛÙ·ÙÈ΋˜ ›ÂÛ˘, fiˆ˜ ÛÙËÓ Î·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· (·‡ÍËÛË ÙˆÓ ÙÚȯÔÂȉÈÎÒÓ È¤ÛÂˆÓ Ù˘ Ó¢ÌÔÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜). ‚) ªÂ›ˆÛË Ù˘ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋˜ ›ÂÛ˘, fiˆ˜ ÛÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Î·È ÛÙ· Û‡Ó‰ÚÔÌ· ˘ÔÛÈÙÈÛÌÔ‡. Á) ∞‡ÍËÛË Ù˘ ·ÚÓËÙÈ΋˜ ›ÂÛ˘ ÛÙÔÓ ˘Â˙ˆÎÔÙÈÎfi ¯ÒÚÔ, fiˆ˜ ÛÙË Ì·˙È΋ ·ÙÂÏÂÎÙ·Û›· ÌÂÁ¿ÏÔ˘ ̤ÚÔ˘˜ ÙÔ˘ Ó‡ÌÔÓ·. ‰) ∞‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ Ù˘ ˘Â˙ˆÎÔÙÈ΋˜ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·˜, fiˆ˜ ÛÙȘ ÊÏÂÁÌÔÓÒ‰ÂȘ, ÏÔÈÌÒ‰ÂȘ Î·È ÓÂÔÏ·ÛÌ·ÙÈΤ˜ ·ı‹ÛÂȘ ÙÔ˘ ˘Â˙ˆÎfiÙ·. Â) ¢È·Ù·Ú·¯‹ ÛÙË ÏÂÌÊÈ΋ ·ÚÔ¯¤Ù¢ÛË, fiˆ˜ Û ڋÍË ‹ ·fiÊÚ·ÍË ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘ (¯˘ÏÔıÒڷη˜). ÛÙ) ªÂÙ·ÊÔÚ¿ ˘ÁÚÔ‡ ̤ۈ ÙÔ˘ ÂÚÈÙÔÓ·›Ô˘, ÙÔ ÔÔ›Ô Ì¤Ûˆ ÙˆÓ ÏÂÌÊ·ÁÁ›ˆÓ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ‰È·ÊÚ·ÁÌ·ÙÈÎÒÓ ÙÚËÌ¿ÙˆÓ Êı¿ÓÂÈ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·.
º˘ÛÈ΋ ÂͤÏÈÍË ÙˆÓ ·Ú·Ó¢ÌÔÓÈÎÒÓ Û˘ÏÏÔÁÒÓ ∏ Ê˘ÛÈ΋ ÂͤÏÈÍË ÙˆÓ ¶¶™ ·ÎÔÏÔ˘ı› Û˘Ó‹ıˆ˜ ÙȘ ÂÍ‹˜ Ê¿ÛÂȘ (3,5,9): ·) º¿ÛË Ù˘ ÍËÚ¿˜ Ï¢ڛÙȉ·˜. ∏ ÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÛÙÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· Î·È ÂÂÎÙ›ÓÂÙ·È ÛÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô ˘Â˙ˆÎfiÙ·, fiÔ˘ ÚÔηÏ› ÙÔÈ΋ ·ÓÙ›‰Ú·ÛË ¯ˆÚ›˜ ÙËÓ ·Ú·ÁˆÁ‹ ˘ÁÚÔ‡. ∫ÏÈÓÈο, ·ÓÙÈÛÙÔȯ› ÛÙËÓ ÂÌÊ¿ÓÈÛË Ï¢ÚÈÙÈÎÔ‡ ¿ÏÁÔ˘˜ Î·È ÛÙËÓ ·ÎÚfi·ÛË ‹¯Ô˘ ÙÚÈ‚‹˜. ‚) º¿ÛË ÂÍȉÚÒÌ·ÙÔ˜. ™˘ÛÛˆÚ‡ÂÙ·È ÛÙ›ÚÔ ˘ÁÚfi ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔÓ ‰È¿ÌÂÛÔ Ó¢ÌÔÓÈÎfi ÈÛÙfi Î·È ·fi ÙÔ ÛÏ·Á¯ÓÈÎfi ˘Â˙ˆÎfiÙ· ÂÍ·ÈÙ›·˜ Ù˘ ·‡ÍËÛ˘ Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ÙÔ˘. ∆Ô Ï¢ÚÈÙÈÎfi ˘ÁÚfi Â›Ó·È ‰È·˘Á¤˜, Ì ¯·ÌËÏfi ·ÚÈıÌfi Ï¢ÎÔ΢ÙÙ¿ÚˆÓ (<10.000/mm3), ¯·ÌËÏ‹ LDH (<1000 IU), Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ ÁÏ˘Îfi˙˘ (>60 mg/dl) Î·È pH >7,3. Á) πÓÔ˘Ò‰Ë˜ Ê¿ÛË. OÊ›ÏÂÙ·È ÛÙË ÌÂÙ·ÊÔÚ¿ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ·fi ÙÔÓ Û‡ÛÙÔÈ¯Ô Ó‡ÌÔÓ· Ô˘ ÊÏÂÁÌ·›ÓÂÈ ÛÙÔ ˘Â˙ˆÎÔÙÈÎfi ˘ÁÚfi. ∞˘Ùfi ÌÔÚ› Ó· Û˘Ì‚Â› Ôχ Û‡ÓÙÔÌ·, ·ÎfiÌ· Î·È Û ϛÁ˜ ÒÚ˜, ÂÊfiÛÔÓ ‰ÂÓ ¯ÔÚËÁËı› ¤ÁηÈÚ· ÙÔ Î·Ù¿ÏÏËÏÔ ·ÓÙÈ‚ÈÔÙÈÎfi ‹ Â¿Ó ·˘Ùfi Ô˘ ¯ÔÚËÁÂ›Ù·È Â›Ó·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎfi. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙË Û˘ÛÛÒÚ¢ÛË ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Ì ¿ÊıÔÓ· ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, ÌÈÎÚfi‚È· Î·È ÓÂÎÚ¿ ·ÙÙ·Ú·. ¶·Ú¿ÁÔÓÙ·È ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ÈÓÈ΋˜, Ë ÔÔ›· ηχÙÂÈ Ù· ‰‡Ô ¤Ù·Ï· ÙÔ˘ ˘Â˙ˆÎfiÙ·, ÂÓÒ ·Ó¿ÌÂÛ· ÛÙ· ¤Ù·Ï· Û¯ËÌ·Ù›˙ÔÓÙ·È ÎÔÈÏfiÙËÙ˜ Ì ¶·È‰È·ÙÚÈ΋ ¶·È‰È·ÙÚÈ΋ 2005;68:000-000 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·20
20
¢. ªÂÚÌ›ÚË Î·È Û˘Ó.
‰È·ÊÚ·ÁÌ¿ÙÈ·. ∏ ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ ÌÈÎÚÒÓ ÂÈ̤ÚÔ˘˜ ÎÔÈÏÔÙ‹ÙˆÓ ·ÔÙÚ¤ÂÈ ÙËÓ ÂͤÏÈÍË Û Â̇ËÌ·, Ù·˘Ùfi¯ÚÔÓ· fï˜, ·ÚÂÌÔ‰›˙ÂÈ ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ˘Ò‰Ô˘˜ ˘ÁÚÔ‡. ™Â ·˘Ù‹ ÙË Ê¿ÛË, Ë ÁÏ˘Îfi˙Ë Î·È ÙÔ pH ÌÂÈÒÓÔÓÙ·È ÛÙ·‰È·Î¿ (<50 mg/dl Î·È <7,2, ·ÓÙ›ÛÙÔȯ·), ÂÓÒ Ë LDH ·˘Í¿ÓÂÈ (>1000 IU). ‰) º¿ÛË ÔÚÁ¿ÓˆÛ˘. OÈ ÈÓÔ‚Ï¿ÛÙ˜ ÛÙÔ ÂÍ›‰ÚˆÌ· ·Ó·Ù‡ÛÛÔÓÙ·È ·fi ÙȘ ‰‡Ô ÂÈÊ¿ÓÂȘ ÙˆÓ ˘Â˙ˆÎÔÙÈÎÒÓ ÂٿψÓ, ÒÛÙÂ Ë ÈÓÈ΋ Ó· ÌÂÙ·ÙÚ¤ÂÙ·È Û ·¯È¿, ÌË ÂÏ·ÛÙÈ΋ ÛÙÈ‚¿‰·, Ô˘ ÂÌÔ‰›˙ÂÈ ÙËÓ Ï‹ÚË ¤ÎÙ˘ÍË ÙÔ˘ Ó‡ÌÔÓ·.
∞ÈÙÈÔÏÔÁ›· ÙˆÓ ·Ú·Ó¢ÌÔÓÈÎÒÓ Û˘ÏÏÔÁÒÓ ∏ ·ÔÌfiÓˆÛË ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· ·fi ÙȘ ηÏÏȤÚÁÂȘ ÙÔ˘ ·›Ì·ÙÔ˜ ‹ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ÛÙ· ·È‰È¿ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ 40-75% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (3,9-14). ∆· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ÈÔ Û˘¯Ó¿ ÛÙÔ Â̇ËÌ· Â›Ó·È Ô S. pneumoniae, Ô S. Aureus Î·È Ô S. pyogenes. ÕÏÏ· ÏÔÈÌÒ‰Ë ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ¶¶™ Â›Ó·È ÔÈ ÈÔ› (·‰ÂÓÔ˚Ô›, Áڛ˘, ·Ú·Áڛ˘), ÙÔ Ì˘ÎfiÏ·ÛÌ· Î·È ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘. OÈ ÔÏ˘ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ, ·fi ·ÚÓËÙÈο ηٿ Gram Î·È ·Ó·ÂÚfi‚È· ÌÈÎÚfi‚È·, Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ÛÙ· ·È‰È¿ ·fi fi,ÙÈ ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜. ™Â ·È‰È·ÙÚÈ΋ ÛÂÈÚ¿ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ Ó¢ÌÔÓÈÒÓ (13), ÙÔ 29% Û˘Óԉ¢fiÙ·Ó ·fi ¶¶™, ÙÔ 13,8% ÙˆÓ ÔÔ›ˆÓ ·ÓÙÈÛÙÔȯԇÛ Û Â̇ËÌ·, ÁÂÁÔÓfi˜ ·ÓÙ›ıÂÙÔ Ì fi,ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ (14-16). ™ÙËÓ ›‰È· ÛÂÈÚ¿ ·ÔÌÔÓÒıËΠӢÌÔÓÈfiÎÔÎÎÔ˜ Û ÔÛÔÛÙfi 67% ·˘ÙÒÓ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠıˆÚ·ÎÔΤÓÙËÛË (15). ™˘ÁÎÂÎÚÈ̤ÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, fiˆ˜ Ô S. aureus, Ô S. pyogenes Î·È Ù· ·Ó·ÂÚfi‚È· ÌÈÎÚfi‚È·, “‰È¢ÎÔχÓÔ˘Ó” ÙËÓ ·Ó¿Ù˘ÍË ÂÌ˘ËÌ¿ÙˆÓ. ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ıÂÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ ÛÙ· ÂÌ˘‹Ì·Ù· ·Ó¤Ú¯ÂÙ·È Û 7090% (17-19). ™ÙȘ Ó¢ÌÔӛ˜ ·fi Ì˘ÎfiÏ·ÛÌ· ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û˘ÏÏÔÁ‹ ÛÙÔ 5-20%. OÈ Û˘ÏÏÔÁ¤˜ Â›Ó·È ÁÂÓÈο ÌÈÎÚ¤˜, ·ÏÏ¿ ÂÚÈÛÙ·Ûȷο ÌÔÚ› Ó· ·ÔÌÔÓˆı› ÙÔ Ì˘ÎfiÏ·ÛÌ· ÛÙÔ ˘Â˙ˆÎÔÙÈÎfi ˘ÁÚfi (20). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Û ÛÂÈÚ¿ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ì fiÏÔ ÙÔ Â‡ÚÔ˜ ÙˆÓ ËÏÈÎÈÒÓ Â›Ó·È Ë ÂÍ‹˜: S. aureus 35%, S. pneumoniae 35%, Streptococcus species 15%, H. influenzae 5%, Pseudomonas 5% Î·È ·Ó·ÂÚfi‚È· 5% (9). øÛÙfiÛÔ, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ·Ú·ÙËÚËı› ÌÂÙ·‚ÔÏ‹ Ù˘ Û˘¯ÓfiÙËÙ·˜ ·ÔÌfiÓˆÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ·ÈÙÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ì ÂÓ›Û¯˘ÛË ÂΛӢ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ∂Ó‰ÂÈÎÙÈ΋ Â›Ó·È Ë ÌÂϤÙË 64 ÂÚÈÙÒÛÂˆÓ ÂÈÏÂÁÌ¤ÓˆÓ ¶¶™, fiÔ˘ ·fi ÙȘ 26 ÂÚÈÙÒÛÂȘ Ô˘ ·ÔÌÔÓÒıËΠÌÈÎÚÔ‚È·Îfi˜ ·Ú¿ÁÔÓÙ·˜, ÛÙȘ 23 ·ÔÌÔÓÒıËΠӢÌÔÓÈfiÎÔÎÎÔ˜ (12). ¶·È‰È·ÙÚÈ΋ 2005;68:18-27 2005;68:000-000
∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙˆÓ ·ÛıÂÓÒÓ Ì ¶¶™ ·fi ·ÂÚfi‚ÈÔ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi Â›Ó·È ›‰È· Ì ÂΛÓË Ù˘ ÌÈÎÚԂȷ΋˜ Ó¢ÌÔÓ›·˜ ¯ˆÚ›˜ Û˘ÏÏÔÁ‹: ˘ÚÂÙfi˜, Ù·¯‡ÓÔÈ·, ıˆÚ·ÎÈÎfi ¿ÏÁÔ˜, ·fi¯ÚÂÌ„Ë Î·È ‚‹¯·˜. ™Â ÛÂÈÚ¿ 113 ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ì Ó¢ÌÔÓ›· ¯ˆÚ›˜ Û˘ÏÏÔÁ‹, ıˆÚ·ÎÈÎfi ¿ÏÁÔ˜ ·ÚÔ˘Û›·˙ ÙÔ 59%, ÂÓÒ ·fi 90 ·ÛıÂÓ›˜ ÌÂ Û˘ÏÏÔÁ‹, ÙÔ 64% (14). ÀÔ„›· ¶¶™ Ù›ıÂÙ·È Â¿Ó Ô ˘ÚÂÙfi˜ ·Ú·Ì¤ÓÂÈ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 48 ÒÚ˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜, ·ÏÏ¿ Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ¶¶™ Ú¤ÂÈ Ó· ‰È¢ÎÚÈÓ›˙ÂÙ·È ·fi ÙË ÛÙÈÁÌ‹ Ù˘ ·Ú¯È΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ŸÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì¤¯ÚÈ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ÙfiÛÔ ÂÚÈÛÛfiÙÂÚÔ Èı·ÓÔÏÔÁÂ›Ù·È Ë ·ÚÔ˘Û›· ¶¶™. ∂¿Ó Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Â›Ó·È ÌÂÁ¿ÏË, Ô ·ÛıÂÓ‹˜ ÂÌÊ·Ó›˙ÂÈ ‰‡ÛÓÔÈ·, ÚÒÙ· ÛÙËÓ ÚÔÛ¿ıÂÈ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· Î·È ÛÙËÓ ËÚÂÌ›·. OÈ ÏÔÈÌÒÍÂȘ ·fi ·Ó·ÂÚfi‚È· ÌÈÎÚfi‚È· ¤¯Ô˘Ó ÂȉÈο ¯·Ú·ÎÙËÚÈÛÙÈο. ™˘Ì‚·›ÓÔ˘Ó Û˘Ó‹ıˆ˜ Û ·È‰È¿ Ì ÂÚÈÔ‰ÔÓÙÈΤ˜ ÏÔÈÌÒÍÂȘ, Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ‰˘ÛÊ·Á›·, ¤¯Ô˘Ó ˘ÔÍ›· ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ì ̤ÙÚÈÔ ˘ÚÂÙfi, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, Ï¢ÎÔ΢ÙÙ¿ÚˆÛË Î·È ÂÏ·ÊÚ¿ ·Ó·ÈÌ›· Ô˘ ÂÍÂÏ›ÛÛÂÙ·È ÛÙ·‰È·Î¿ Û ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ Ù˘ ‚‰ÔÌ¿‰·˜.
¢È¿ÁÓˆÛË ∏ ÌÂϤÙË ÙˆÓ ·ÛıÂÓÒÓ Ì ˘Ô„›· ¶¶™ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, CRP, ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô (Î·È Ï¢ÎÒÌ·Ù·), LDH, ·ÈÌÔηÏÏȤÚÁÂȘ, ‰ÔÎÈ̷ۛ˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ıˆÚ·ÎÔΤÓÙËÛË Î·È ‰ÔÎÈÌ·Û›· Mantoux.
∞Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ∏ ÚÔÛıÈÔ›ÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Û fiÚıÈ· ı¤ÛË ‰ÂÓ Â›Ó·È Ôχ ¢·›ÛıËÙË ÛÙËÓ ·Ó›¯Ó¢ÛË ÌÈÎÚÒÓ ÔÛÔÙ‹ÙˆÓ ˘ÁÚÔ‡. ¶Ôχ ÚÒÈÌÔ ÛËÌÂ›Ô ·Ó›¯Ó¢Û˘ ¶¶™ ·ÔÙÂÏ› Ë ÂÍ¿ÏÂÈ„Ë Ù˘ Ï¢ÚԉȷÊÚ·ÁÌ·ÙÈ΋˜ (¶¢) ÁˆÓ›·˜. ∞Ó Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ̤ÙÚÈ·, ·Ú·ÙËÚÂ›Ù·È ıÔÏÂÚfiÙËÙ· Ù˘ Ó¢ÌÔÓÈ΋˜ ‚¿Û˘ Ô˘ ηٷϷ̂¿ÓÂÈ ÙËÓ ¶¢ Î·È ÂÈÎfiÓ· ·ÓÂÛÙÚ·Ì̤ÓÔ˘ ÎÔ›ÏÔ˘ ¿ÓˆıÂÓ ÙÔ˘ ËÌȉȷÊÚ¿ÁÌ·ÙÔ˜, ‰›ÎËÓ ÌËÓ›ÛÎÔ˘, Ì ÙÔ ˘„ËÏfiÙÂÚÔ ÛËÌÂ›Ô ÛÙÔ Ï¿ÁÈÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ·. ∞Ó Ë Û˘ÏÏÔÁ‹ Â›Ó·È ÌÂÁ¿ÏË, ÛËÌÂÈÒÓÂÙ·È ‰È·Ï¿Ù˘ÓÛË ÙˆÓ ÌÂÛÔχÚÈˆÓ ‰È·ÛÙËÌ¿ÙˆÓ Î·È ·ÒıËÛË ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘. ∂¿Ó Ô ·ÛıÂÓ‹˜ ‚Ú›ÛÎÂÙ·È Û ηٷÎÂÎÏÈ̤ÓË ı¤ÛË, fiˆ˜ Û˘Ó‹ıˆ˜ Á›ÓÂÙ·È Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿, ·Ú·ÙËÚÂ›Ù·È ÂÍ¿ÏÂÈ„Ë Ù˘ ¶¢ ÁˆÓ›·˜, ÔÌfiÙÈÌË ÛΛ·ÛË ÛÙÔ ËÌÈıˆÚ¿ÎÈÔ, ÌÂȈ̤ÓË ·ÁÁ›ˆÛË Î·È
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·21
21
¶·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜
ÂÌÊ¿ÓÈÛË ˘Â˙ˆÎÔÙÈ΋˜ ÁÚ·ÌÌ‹˜ ÛÙÔ ¤Íˆ Ï¿ÁÈÔ ÙÌ‹Ì· ÙÔ˘ ËÌÈıˆÚ·Î›Ô˘. ŸÙ·Ó Ù· ËÌȉȷÊÚ¿ÁÌ·Ù· Â›Ó·È ÔÚ·Ù¿ Û fiÏÔ ÙÔ˘˜ ÙÔ Ì‹ÎÔ˜ Î·È ‰È·ÙËÚÂ›Ù·È Ë ¶¢ ÁˆÓ›·, ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÔÛfiÙËÙ· ˘ÁÚÔ‡. ∂¿Ó ··Ï›ÊÂÙ·È Î¿ÔÈÔ ·fi Ù· ËÌȉȷÊÚ¿ÁÌ·Ù· ‹ Ë ¶¢ ÁˆÓ›· Â›Ó·È Î·ÙÂÈÏËÌ̤ÓË, ›Ûˆ˜ ¯ÚÂÈ¿˙ÂÙ·È Î·È Ï¿ÁÈ· ·ÎÙÈÓÔÁÚ·Ê›·.
ÀÂÚ˯ÔÁÚ¿ÊËÌ· ıÒڷη ™˘¯Ó¿ ·ÔÙÂÏ› ÙËÓ ÔÏ˘ÙÈÌfiÙÂÚË ÂͤٷÛË ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ¶¶™. ªÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙȘ ·ÎfiÏÔ˘ı˜ ÂÚÈÙÒÛÂȘ (21): ·) ÛÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ηٷÏÏËÏfiÙÂÚ˘ ı¤Û˘ ÁÈ· ÙË ıˆÚ·ÎÔΤÓÙËÛË ‹ ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘, ‚) ÛÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂÁ΢ÛÙÒÛÂˆÓ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Î·È Á) ÛÙÔÓ ‰È·¯ˆÚÈÛÌfi ÌÂٷ͇ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ Î·È ¿¯˘ÓÛ˘ ÙÔ˘ ˘Â˙ˆÎfiÙ·. ™ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÂχıÂÚÔ ˘ÁÚfi Ì ÌÂȈ̤ÓË Ë¯ÔÁ¤ÓÂÈ· (˘fiË¯Ô ˘ÁÚfi), ÂχıÂÚ˜ Ù·Èӛ˜ Ó· “Ï¤Ô˘Ó” ̤۷ ÛÙÔ Ï¢ÚÈÙÈÎfi ˘ÁÚfi, ·Ï¿ ‰È·ÊÚ·ÁÌ¿ÙÈ· ÂχıÂÚ· ‹ ÂÁ΢Ûو̤ӷ Û ÎÔÈÏfiÙËÙ˜. ∏ ·ÚÔ˘Û›· ˯ÔÁÂÓÒÓ Ù·ÈÓÈÒÓ ‹ ÂÁ΢ÛÙÒÛÂˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ÂÍ›‰ÚˆÌ·. ∏ ·Ó‡ÚÂÛË ˘fiË¯Ô˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÂÍ›‰ÚˆÌ· ‹ ‰È›‰ÚˆÌ·. ∏ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ıˆÚÂ›Ù·È ˆ˜ ¤Ó·˜ ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ηıÔÚ›ÛÔ˘Ó ÙËÓ ÂÚ·ÈÙ¤Úˆ ‰È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË. ∂¿Ó Ë ·fiÛÙ·ÛË ·fi ÙËÓ ÂÛˆÙÂÚÈ΋ ÏÂ˘Ú¿ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Î·È ÙË ‚¿ÛË ÙÔ˘ Ó‡ÌÔÓ· Â›Ó·È <10 mm, Ë Û˘ÏÏÔÁ‹ ‰ÂÓ ıˆÚÂ›Ù·È ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ‰È·ÁÓˆÛÙÈ΋˜ ıˆÚ·ÎÈ΋˜ ·Ú·Î¤ÓÙËÛ˘ (22,23). ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, ÙÔ Ï¢ÚÈÙÈÎfi ˘ÁÚfi ·ÂÈÎÔÓ›˙ÂÙ·È Ì ۯ‹Ì· ‰Ú¤·ÓÔ˘ ÛÙȘ Ô›ÛıȘ ÂÚÈÔ¯¤˜ ÙÔ˘ ıÒڷη Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ÎÏ›ÛË. OÈ ÂÁ΢Ûو̤Ó˜ Û˘ÏÏÔÁ¤˜ ˘ÁÚÔ‡ ·Ú·ÙËÚÔ‡ÓÙ·È Û·Ó Ê·ÎÔÂȉ›˜ ÛÎÈ¿ÛÂȘ (∂ÈÎfiÓ· 1). ∏ ·ÂÈÎÔÓÈ˙fiÌÂÓË ˘ÎÓfiÙËÙ· ‰ÂÓ ‚ÔËı¿ÂÈ ÛÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ‰ÈȉÚÒÌ·ÙÔ˜ ·fi ÙÔ ÂÍ›‰ÚˆÌ·, Ô‡ÙÂ Â›Ó·È Ôχ Û·Ê‹˜ ÛÙËÓ ÚÔÛ¿ıÂÈ· ·Ó·˙‹ÙËÛ˘ ÂÁ΢ÛÙÒÛÂˆÓ (24). ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Û˘ÛÙËÌ·ÙÈο Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘Ô„›· ˘Â˙ˆÎÔÙÈ΋˜ Û˘ÏÏÔÁ‹˜. ∂›Ó·È ηٿÏÏËÏË ÁÈ· ÙËÓ ·ÂÈÎfiÓÈÛË ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, ÔÈ Ôԛ˜ ÂÈηχÙÔÓÙ·È ·fi ÙËÓ ¶¶™ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ∂›Ó·È ȉȷ›ÙÂÚ· ¯Ú‹ÛÈÌË ÁÈ· ÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ÂÌ˘‹Ì·ÙÔ˜ Ì ˘‰Ú·ÂÚÈο ›‰· ·fi ÙÔ Ó¢ÌÔÓÈÎfi ·fiÛÙËÌ·, ÂÓÒ
∂ÈÎfiÓ· 1. ÀÁÚfi Î·È ÓÂÎÚˆÙÈ΋ Ó¢ÌÔÓ›· ‰ÂÍÈ¿. ∞ÒıËÛË ÌÂÛÔıˆÚ·Î›Ô˘ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿.
∂ÈÎfiÓ· 2. ÀÁÚfi Î·È ·ÙÂÏÂÎÙ·Û›·. ŒÏÍË ÌÂÛÔıˆÚ·Î›Ô˘ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿ - ‚ÚÔÁ¯fiÁÚ·ÌÌ·.
·Ú¿ÏÏËÏ· ·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ÂÈÙÒÛÂȘ Ù˘ Û˘ÏÏÔÁ‹˜ ÛÙÔ ˘ÔΛÌÂÓÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì·, fiˆ˜ Â›Ó·È Ë ÂÎÙÂٷ̤ÓË ·ÙÂÏÂÎÙ·Û›· Û ÔÏfiÎÏËÚÔ ÙÔÓ Î¿Ùˆ ÏÔ‚fi (∂ÈÎfiÓ· 2) (25,26).
£ˆÚ·ÎÔΤÓÙËÛË ∏ ‰È·ÁÓˆÛÙÈ΋ ·Ú·Î¤ÓÙËÛË ÂӉ›ÎÓ˘Ù·È ÛÙȘ ¶¶™, Ì ÛÎÔfi ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ·ÏÏ¿ Î·È ÙË ‰È·ÊÔÚԉȿÁÓˆÛË Ù˘ ÂÈÏÂÁ̤Ó˘ ·fi ÙË ÌË ÂÈÏÂÁ̤ÓË Û˘ÏÏÔÁ‹. ∏ ¤ÁηÈÚË ıˆÚ·ÎÔΤÓÙËÛË Û˘ÓÈÛÙ¿Ù·È Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜, ÂÊfiÛÔÓ ·˘Ùfi Â›Ó·È ‰˘Ó·Ùfi, ÁÈ· ÙËÓ ·‡ÍËÛË ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ·ÔÌfiÓˆÛ˘ ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, Ô‡Ùˆ˜ ÒÛÙ ӷ ÂÓÙÔÈÛÙ› ÚÒÈÌ· Ë Î·Ù¿ÏÏËÏË ÛÙÈÁÌ‹ ÙÔÔı¤ÙËÛ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘, ÚÈÓ ÙÔÓ Û¯ËÌ·ÙÈÛÌfi ‰È·ÊÚ·ÁÌ·Ù›ˆÓ Î·È ÂÁ΢ÛÙÒÛˆÓ. OÈ ·ÓÙÂӉ›ÍÂȘ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜. ø˜ Ù¤ÙÔȘ ıˆÚÔ‡ÓÙ·È Ë ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË (ÚÒÙ· ‰ÈÔÚıÒÓÔÓÙ·È ÔÈ ·ÓˆÌ·Ï›Â˜ ‹Í˘), Ë ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë ÛÙÔ ÛËÌÂ›Ô Ù˘ ·Ú·Î¤ÓÙËÛ˘ ‹ Ë ¯ÔÚ‹ÁËÛË Ì˯·ÓÈÎÔ‡ ¶·È‰È·ÙÚÈ΋ ¶·È‰È·ÙÚÈ΋ 2005;68:000-000 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·22
22
¢. ªÂÚÌ›ÚË Î·È Û˘Ó.
·ÂÚÈÛÌÔ‡ Ì ˘„ËϤ˜ ȤÛÂȘ. ¶ÚfiÛÊ·Ù·, ÂÎÊÚ¿ÛÙËÎÂ Ë ¿Ô„Ë fiÙÈ Ë ·Ó¿ÁÎË ıˆÚ·ÎÔΤÓÙËÛ˘ ÂÎÙÈÌ¿Ù·È ·fi ÙËÓ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ fi„Ë ÙÔ˘ ˘ÁÚÔ‡ (23), ·Ó Î·È Û‡Ìʈӷ Ì ÙËÓ ÎÏ·ÛÈ΋ ÁÓÒÛË Û˘ÓÈÛÙ¿Ù·È Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Û οı ¶¶™ Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì¤ÙÚÈ· ÔÛfiÙËÙ· ˘ÁÚÔ‡ (27). ™ÙÔÓ ¶›Ó·Î· 1 ÂÚÈÁÚ¿ÊÂÙ·È Ë Ù¯ÓÈ΋ Ù˘ ·Ú·Î¤ÓÙËÛ˘ (28). ¢ÂÓ ˘¿Ú¯ÂÈ Û·Ê‹˜ ¿Ô„Ë ÁÈ· ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Ô˘ ÌÔÚ› Ó· ·Ê·ÈÚÂı› Ì ·ÛÊ¿ÏÂÈ·. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ¤¯Ô˘Ó ÙË ÁÓÒÌË fiÙÈ ÁÈ· ÙË ıÂڷ¢ÙÈ΋ ·Ú·Î¤ÓÙËÛË Â›Ó·È ÛÎfiÈÌÔ Ó· ·Ê·ÈÚÂ›Ù·È Ë ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÔÛfiÙËÙ· ˘ÁÚÔ‡ (29). øÛÙfiÛÔ, Û ·ÛıÂÓ›˜ Ì ̷˙ÈΤ˜ Û˘ÏÏÔÁ¤˜ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Î·È - ¿Óˆ ·’ fiÏ· - ÛÂ Û˘ÏÏÔÁ‹ Ì ٷ¯Â›· ÂͤÏÈÍË, Ë ·Ê·›ÚÂÛË ÌÂÁ¿ÏˆÓ fiÁÎˆÓ ˘ÁÚÔ‡ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÙÂÚfiÏ¢ÚÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Î·È ˘fiÙ·ÛË, ÏfiÁˆ ·ӷϋڈÛ˘ Ì ·›Ì· Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ Ô˘ ‹Ù·Ó ÚÒÙ· Û˘ÌÈÂṲ̂ӷ. °ÂÓÈο, Û˘ÓÈÛÙ¿Ù·È Ë ·Ê·›ÚÂÛË Ù˘ ÔÛfiÙËÙ·˜ ÙÔ˘ ˘ÁÚÔ‡ Ô˘ Â›Ó·È ·Ó·Áη›· ÒÛÙ ӷ ·Ó·ÎÔ˘ÊÈÛÙ› Ô ·ÛıÂÓ‹˜ ·fi ÙË ‰‡ÛÓÔÈ·, ¯ˆÚ›˜ Ó· ÂȉÈÒÎÂÙ·È Ë Ï‹Ú˘ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ˘ÁÚÔ‡ (30). ™Â ÂÚ›ÙˆÛË ÂÌ˘‹Ì·ÙÔ˜, Ú¤ÂÈ Ó· ·ÔÌ·ÎÚ‡ÓÂÙ·È Ë ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÔÛfiÙËÙ·, Ì ٷ˘Ùfi¯ÚÔÓË ÙÔÔı¤ÙËÛË ÛˆÏ‹Ó· ·ÚÔ¯¤Ù¢Û˘. ∂Í·›ÚÂÛË ·ÔÙÂÏ› Ë Ê˘Ì·ÙÈ҉˘ Û˘ÏÏÔÁ‹, ÛÙËÓ ÔÔ›· ÚÔÙÈÌ¿Ù·È Ë ·ÔÊ˘Á‹ Ù˘ ·ÚÔ¯¤Ù¢Û˘, ‰ÈfiÙÈ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÌÈÎÚԂȷ΋˜ ÂÈÌfiÏ˘ÓÛ˘, Ô˘ ‰˘Û¯ÂÚ·›ÓÂÈ Î·È ÂÈϤÎÂÈ ÙË ıÂڷ›· Ù˘.
¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË °È· ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ¶¶™ Â›Ó·È ··Ú·›ÙËÙ˜ ÔÈ ·ÎfiÏÔ˘ı˜ ‚ÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÛÙÔ
Ï¢ÚÈÙÈÎfi ˘ÁÚfi: pH, LDH, ÁÏ˘Îfi˙Ë, ÚˆÙ½Ó˜, ÏÂ˘Î¿ Î·È Ù‡Ô˜. ∫·Ù¿ ÂÚ›ÙˆÛË, ˙ËÙÂ›Ù·È ·‰ÂÓÔÛ›ÓË ‰È·ÌÈÓ¿ÛË (ADA), ·Ì˘Ï¿ÛË, ¯ÔÏËÛÙÂÚfiÏË Î·È ÙÚÈÁÏ˘ÎÂÚ›‰È·. ∂›Û˘, Â›Ó·È ··Ú·›ÙËÙ˜ ÔÈ ÂÍ‹˜ ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ: ¯ÚÒÛË Î·Ù¿ Gram, Ziehl Neelsen, ·ÂÚfi‚Ș Î·È ·Ó·ÂÚfi‚Ș ηÏÏȤÚÁÂȘ Lowenstein Î·È Hongos. ∆Ô ˘ÁÚfi Ô˘ ·ıÚÔ›˙ÂÙ·È ÛÙÔÓ ˘Â˙ˆÎÔÙÈÎfi ¯ÒÚÔ ÌÔÚ› Ó· Â›Ó·È ‰È›‰ÚˆÌ· ‹ ÂÍ›‰ÚˆÌ·. ∆Ô ‰È›‰ÚˆÌ· ÚÔηÏÂ›Ù·È ·fi Â͈˘Â˙ˆÎÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ô˘ ¢ÓÔÔ‡Ó ÙË Û˘ÛÛÒÚ¢ÛË ˘ÁÚÔ‡ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. ∫·Ù¿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ·ÚÈÛÙÂÚ‹ ηډȷ΋ ·Ó¿ÚÎÂÈ·, ‰ÂÍÈ¿ ηډȷ΋ ·Ó¿ÚÎÂÈ·, ·ÙÂÏÂÎÙ·Û›· ‹ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ. ∆Ô ÂÍ›‰ÚˆÌ· ÔÊ›ÏÂÙ·È ÛÙËÓ ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ·ÁÁ›ˆÓ. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Û ÏÔÈÌÒÍÂȘ, ÓÂÔϷۛ˜, ÎÔÏÏ·ÁÔÓÒÛÂȘ, ÂÚÈÙÒÛÂȘ Ì ÂÓ‰ÔÎÔÈÏȷ΋ ·ıÔÏÔÁ›·, Ê¿Ú̷η, ÙÚ·‡Ì· Î·È ‚Ï¿‚˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ‹ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘. ™Â fiϘ ÙȘ ¶¶™, ÙÔ ˘ÁÚfi ¤¯ÂÈ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÂÍȉÚÒÌ·ÙÔ˜. O ¶›Ó·Î·˜ 2 ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ‚ÈÔ¯ËÌÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó Ù· ‰ÈȉÚÒÌ·Ù· Î·È Ù· ÂÍȉÚÒÌ·Ù·. ∆· ÂÚÈÛÛfiÙÂÚÔ ÌÂÏÂÙË̤ӷ ÎÚÈÙ‹ÚÈ· Ô˘ ‰È·ÊÔÚԉȷÁÈÁÓÒÛÎÔ˘Ó ÙÔ ‰È›‰ÚˆÌ· ·fi ÙÔ ÂÍ›‰ÚˆÌ· Â›Ó·È ·˘Ù¿ ÙÔ˘ Light, Ô˘ ÂÈÙÚ¤Ô˘Ó ÙÔÓ ¯·Ú·ÎÙËÚÈÛÌfi ÂÓfi˜ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ ˆ˜ ÂÍȉÚÒÌ·ÙÔ˜ ÛÙÔ 95% ÙˆÓ ÂÚÈÙÒÛˆÓ, Â¿Ó ÏËÚÔ‡Ù·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 1 ·fi Ù· ·ÎfiÏÔ˘ı· 3 ÎÚÈÙ‹ÚÈ· (31): i) χΈ̷ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ / χΈ̷ ·›Ì·ÙÔ˜ >0,5, ii) LDH ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ / LDH ·›Ì·ÙÔ˜ >0,6, iii) ÙÈÌ‹ LDH ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ ÌÂÁ·Ï‡ÙÂÚË ·fi Ù· 2/3 ÙˆÓ ÙÈÌÒÓ Ô˘ ıˆÚÔ‡ÓÙ·È ˆ˜ Ê˘ÛÈÔÏÔÁÈΤ˜. ∆ÈÌ‹ LDH >1000 ı· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ıÂÙÈ΋.
¶›Ó·Î·˜ 1. ∆¯ÓÈ΋ ıˆÚ·ÎÔΤÓÙËÛ˘ Î·È ÙÔÔı¤ÙËÛ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘ (26,32)
∞·Ú·›ÙËÙÔ ˘ÏÈÎfi 1. ºÏ‚ÔηıÂÙ‹Ú˜ 16-22 G ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÛÙÚfiÊÈÁÁ· ÙÚÈÏ‹˜ ÂÍfi‰Ô˘ Î·È Û‡ÚÈÁÁ· 5 ml. 2. ∏·ÚÈÓÈṲ̂ÓË Û‡ÚÈÁÁ· ÈÓÛÔ˘Ï›Ó˘ Î·È 2 Û‡ÚÈÁÁ˜ ÙˆÓ 20 ml. 3. ∆ÔÈÎfi ·Ó·ÈÛıËÙÈÎfi (.¯. ÏȉÔη˝ÓË 1% Î·È ·‰ÚÂÓ·Ï›ÓË), ‚ÂÏfiÓ˜ 22 Î·È 25 G ÁÈ· ÙÔÈ΋ ¤Á¯˘ÛË. 4. ∞ÔÛÙÂÈڈ̤ӷ Á¿ÓÙÈ·, Ì¿Ûη Î·È ÌÏÔ‡˙· ·ÔÛÙÂÈڈ̤ÓË. ∆¯ÓÈ΋ 1. ∂›Ó·È ÂÈı˘ÌËÙfi Ë ·Ú·Î¤ÓÙËÛË Ó· Á›ÓÂÙ·È ·ÊÔ‡ ¤¯ÂÈ ÚÔËÁËı› ÙÔÈ΋ ·Ó·ÈÛıËÛ›·, ˘fi Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘. ™Ù· ÌÈÎÚ¿ ·È‰È¿, ¤¯ÂÈ ÂÎÊÚ·ÛÙ› Ë ¿Ô„Ë Ó· ¯ÔÚËÁÂ›Ù·È Î·Ù·ÛÙÔÏ‹ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË Û˘ÓÂÚÁ·Û›·. 2. ∏ ÂÚÈÔ¯‹ Ù˘ ·Ú·Î¤ÓÙËÛ˘ ÂÈϤÁÂÙ·È ¿ÓÙÔÙ ÛÙËÓ ÈÔ ¯·ÌËÏ‹ ı¤ÛË Ù˘ Û˘ÏÏÔÁ‹˜ ÁÈ· ÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ ÚÔ‹˜ ̤ۈ Ù˘ ‚·Ú‡ÙËÙ·˜. °ÂÓÈο, Ë Î·Ï‡ÙÂÚË ı¤ÛË ÁÈ· ·Ú·Î¤ÓÙËÛË Â›Ó·È ·ÎÚÈ‚Ò˜ οو ·fi ÙËÓ ÎÔÚ˘Ê‹ Ù˘ ˆÌÔÏ¿Ù˘. 3. O ·ÛıÂÓ‹˜ οıÂÙ·È Ì ٷ fi‰È· Ó· ÎÚ¤ÌÔÓÙ·È ·fi ÙÔ ÂÍÂÙ·ÛÙÈÎfi ÎÚ‚¿ÙÈ Î·È ÙÔ ¯¤ÚÈ Ù˘ ¿Û¯Ô˘Û·˜ ÏÂ˘Ú¿˜ ¿Óˆ ·fi ÙÔÓ ·ÓÙ›ıÂÙÔ ÒÌÔ, ÂÚÓÒÓÙ·˜ ÙÔ ¿Óˆ ·fi ÙÔ ÎÂÊ¿ÏÈ ÁÈ· Ó· ‰È¢ڢÓıÔ‡Ó ÛÙÔ Ì¤ÁÈÛÙÔ ‰˘Ó·Ùfi Ù· ÌÂÛÔχÚÈ· ‰È·ÛÙ‹Ì·Ù·. 4. °›ÓÂÙ·È Î·ı·ÚÈÛÌfi˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙÔÈ΋ ·Ó·ÈÛıËÛ›· ·fi ÙÔ ‰¤ÚÌ· ¤ˆ˜ ÙÔÓ ˘Â˙ˆÎfiÙ·. 5. ∂ÈÛ¿ÁÂÙ·È Ô ÊÏ‚ÔηıÂÙ‹Ú·˜ οıÂÙ· ÛÙÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ·, Ì ÙÔ ¿ÓÔÈÁÌ· Ù˘ Û‡ÚÈÁÁ·˜ ÚÔ˜ ÙËÓ ¿Óˆ ÏÂ˘Ú¿. ∫·Ù¿ ÙËÓ Â›ÛÔ‰Ô, Á›ÓÂÙ·È ÂÏ·ÊÚ¿ ÂÚÈÛÙÚÔÊ‹ ÁÈ· Ó· ÌËÓ Â›Ó·È fiϘ ÔÈ Â›ÛÔ‰ÔÈ ÛÙËÓ ›‰È· ¢ı›·. 6. ∞ÔÛ‡ÚÂÙ·È Ë ‚ÂÏfiÓ· Î·È ÂÈÛ¿ÁÂÙ·È Â‡Î·ÌÙÔ˜ Â͈ÙÂÚÈÎfi˜ ηıÂÙ‹Ú·˜ ¤ˆ˜ ÙËÓ Ï¢ÚԉȷÊÚ·ÁÌ·ÙÈ΋ ÁˆÓ›·. ™˘Ó‰¤ÂÙ·È ·Ì¤Ûˆ˜ Ì ÙË ÛÙÚfiÊÈÁÁ· ÙÚÈÏ‹˜ ÂÍfi‰Ô˘ (ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÂÈÛfi‰Ô˘ ·¤Ú· ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·). 7. ∏ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ˘ÁÚÔ‡ Á›ÓÂÙ·È ·ÚÁ¿. ™Â ÂÚ›ÙˆÛË ‰È·ÁÓˆÛÙÈ΋˜ ·Ú·Î¤ÓÙËÛ˘, ·Ê·ÈÚÂ›Ù·È ÌfiÓÔ fiÛË ÔÛfiÙËÙ· ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· Ó· Á›ÓÔ˘Ó ÔÈ ÂÍÂÙ¿ÛÂȘ. ™ÙË ıÂڷ¢ÙÈ΋ ·Ú·Î¤ÓÙËÛË, ·ÔÌ·ÎÚ‡ÓÂÙ·È fiÛÔ ˘ÁÚfi ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·fi ÙË ‰‡ÛÓÔÈ·. 8. ∆¤ÏÔ˜, Á›ÓÂÙ·È ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘. ¶·È‰È·ÙÚÈ΋ 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·23
23
¶·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜
∂¿Ó ÔÈ ÙÈ̤˜ ÙˆÓ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚˆÓ Â›Ó·È ·ÌÊ›‚ÔϘ, ·ÍÈÔÏÔÁÂ›Ù·È ÂΛÓË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡, Ì fiÚÈÔ ÙËÓ ÙÈÌ‹ ÙˆÓ 60 mg/dl (1,55 mmol/L). ∞Ó ‰ÂÓ ÏËÚÔ‡Ù·È Î·Ó¤Ó· ·fi Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·, ÙÔ ˘ÁÚfi Ù˘ ˘Â˙ˆÎÔÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ıˆÚÂ›Ù·È ‰È›‰ÚˆÌ·. ∆Ô ‰Â›ÁÌ· ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘fi ·Ó·ÂÚfi‚Ș Û˘Óı‹Î˜ Î·È Ë ·Ó¿Ï˘ÛË ÙÔ˘ pH Ó· Á›ÓÂÙ·È Û ·Ó·Ï˘Ù‹ ·ÂÚ›ˆÓ Ì ÙÔ ‰Â›ÁÌ· Û ˷ÚÈÓÈṲ̂ÓË Û‡ÚÈÁÁ· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Ï‹„Ë ‹, ·ÏÏÈÒ˜, Ó· Ê˘Ï¿ÛÛÂÙ·È Û ¿ÁÔ. ™ÙÔÓ ¶›Ó·Î· 3 Û˘ÓÔ„›˙ÔÓÙ·È Ù· ‚ÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ¶¶™. OÈ ·ÛıÂÓ›˜ Ì ÂÈÏÂÁ̤ÓË ¶¶™ ¤¯Ô˘Ó Ôχ ¯·ÌËÏ‹ ÙÈÌ‹ pH Î·È ÁÏ˘Îfi˙˘ Î·È Ôχ ·˘ÍË̤ÓË ÙÈÌ‹ LDH. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙËÓ ÙÔÈ΋ ÌÂÙ·‚ÔÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ (32). ∆Ô pH ·ÔÙÂÏ› ÙËÓ ·Ú¿ÌÂÙÚÔ Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ ·Í›·. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ÙÔ ¯ÚËÛÈÌÔÔÈÔ‡Ó ˆ˜ ÌÔÓ·‰ÈÎfi ·Ú¿ÁÔÓÙ·, ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÙÔ ‰Â›ÁÌ· ÂÏ‹ÊıË ˘fi ȉ·ÓÈΤ˜ Û˘Óı‹Î˜ (33,34). ™Â ·ÛıÂÓ›˜ Ì ÔͤˆÛË, ÙÈÌ‹ ÙÔ˘ pH ηÙÒÙÂÚË ÂΛӢ ÙÔ˘ ·›Ì·ÙÔ˜ ηٿ 0,15 ÌÔÓ¿‰Â˜ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÂÌ˘‹Ì·ÙÔ˜. ™Â ·Û˘Ó‹ıÂȘ ÂÚÈÙÒÛÂȘ ÂÌ˘‹Ì·ÙÔ˜, ÙÔ pH ÌÔÚ› Ó· Â›Ó·È ·ÚÔ‰Èο ·ÏηÏÈÎfi. ¶Ï¢ÚÈÙÈÎfi ˘ÁÚfi Ì pH Ù˘ Ù¿Í˘ ÙÔ˘ 8 ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÁˆÁ‹ ·Ì̈ӛ·˜ ·fi ÛÙÂϤ¯Ë ÙÔ˘ ÚˆÙ¤· Ô˘ ¯ÚËÛÈÌÔÔÈ› ÚˆÙ¿Û˜ ÁÈ· ÙË ‰È¿Û·ÛË Ù˘ Ô˘Ú›·˜. ∂Í·ÈÚÂÙÈο ¯·ÌËÏfi pH, Ù˘ Ù¿Í˘ ÙÔ˘ 6, Û˘Ó·ÓÙ¿Ù·È ÌfiÓÔ Û ÂÌ˘‹Ì·Ù· Î·È Û ڋÍË ÔÈÛÔÊ¿ÁÔ˘. ∏ ̤ÙÚËÛË Ù˘ ·Ì˘Ï¿Û˘ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ÌÔÚ› Ó· ÂÓÙÔ›ÛÂÈ ÛȈËÚ‹ ·ÁÎÚ·ٛÙȉ·.
∞ÓÙÈÌÂÙÒÈÛË ∫‡ÚÈÔÈ ÛÙfi¯ÔÈ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ¶¶™ Â›Ó·È Ë ·ÔηٿÛÙ·ÛË Ù˘ ˘Á›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ë ·ÔÊ˘Á‹ ÙˆÓ ÂÈÏÔÎÒÓ. ∞ÛÊ·ÏÒ˜, ˆ˜ ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ηٿÏÏËÏ˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ ıˆÚÂ›Ù·È Ë ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘˜. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ‰È¿ÊÔÚ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù·. ¢˘ÛÙ˘¯Ò˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ‰È·ı¤ÛÈ̘ Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ·fi
¶›Ó·Î·˜ 2. µÈÔ¯ËÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó Ù· ‰ÈȉÚÒÌ·Ù· Î·È Ù· ÂÍȉÚÒÌ·Ù· (6)
¶ÚˆÙ½Ó˜ §Â˘ÎÒÌ·Ù· Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡/ÔÚÔ‡ LDH LDH Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡/ÔÚÔ‡ pH °Ï˘Îfi˙Ë ÃÔÏËÛÙÂÚfiÏË §Â˘ÎÔ·ÙÙ·Ú·
∂Í›‰ÚˆÌ·
¢È›‰ÚˆÌ·
≥3 g/dl
<3 g/dl
>0,5 >200 IU/L
≤0,5 <200 IU/L
≥0,6 <7,3 <60 mg/dl >60 mg/dl >1000/mm3
<0,6 ≥7,3 >60 mg/dl <60 mg/dl <1000/mm3
ÙȘ Ôԛ˜ Ó· ÚÔ·ÙÔ˘Ó ¿ÌÂÛ· Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· οÔÈˆÓ ¤Ó·ÓÙÈ ÙˆÓ ˘ÔÏÔ›ˆÓ. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó ·ÔÎÏÂÈÛÙÈο ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Û fiϘ ÙȘ ¶¶™, Ì ÙÔ Âȯ›ÚËÌ· fiÙÈ ·ÎfiÌ· Î·È ÔÈ ˘Ò‰ÂȘ Û˘ÏÏÔÁ¤˜ Ì ÂÁ΢ÛÙÒÛÂȘ ˘Ô¯ˆÚÔ‡Ó ¯ˆÚ›˜ ·ÚÔ¯¤Ù¢ÛË, ·ÏÏ¿ ·˘Ùfi Û˘Ó¿ÁÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÈÏÔÎÒÓ. ∏ ÚfiÙ·ÛË ÙÔ˘ Light ·Ó·ÊÔÚÈο Ì ÙȘ ¶¶™ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ηχÙÂÚ˜ ÚÔÛÂÁÁ›ÛÂȘ, fi¯È ÌfiÓÔ ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘˜, ·ÏÏ¿ Î·È ÁÈ· ÙÔÓ ·ÏÁfiÚÈıÌÔ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜. ∆Ô Û¯‹Ì· ¤¯ÂÈ ·Ó·Ù˘¯ı› ÁÈ· ÂÓ‹ÏÈÎÔ˘˜ ·ÛıÂÓ›˜, ηıÒ˜ ‰ÂÓ ¤¯Ô˘Ó Á›ÓÂÈ ·ÚfiÌÔȘ ÌÂϤÙ˜ Û ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi, ·ÎÔÏÔ˘ıÂ›Ù·È ˆÛÙfiÛÔ ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˘˜ (5). ™ÙËÓ ∂ÈÎfiÓ· 3 Û˘ÓÔ„›˙ÂÙ·È ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ô˘ ‚·Û›˙ÂÙ·È Û ·˘Ùfi ÙÔ˘ Light, Ì οÔȘ ·Ú·ÏÏ·Á¤˜ (4,17). ∞Ó¿ÏÔÁÔ ·ÏÁfiÚÈıÌÔ ‰ËÌÔÛ›Â˘Û·Ó ÚfiÛÊ·Ù· ÔÈ Grewall Î·È Û˘Ó (23), Ì ‚¿ÛË ÙËÓ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ fi„Ë ÙÔ˘ ˘ÁÚÔ‡ Î·È ÙËÓ ÚÒÈÌË ıˆÚ·ÎÔÛÎfiËÛË. ∞Ó Î·È Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ôχ ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ¤¯ÂÈ ıˆÚËı› ˘ÂÚ‚ÔÏÈο ÂÈıÂÙÈÎfi, ·ÊÔ‡ ¤ÙÛÈ ˘Ô‚¿ÏÏÔÓÙ·È Î¿ÔÈÔÈ ·ÛıÂÓ›˜ Û ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ¯ˆÚ›˜ ÂӉ¯Ô̤ӈ˜ Ó· Â›Ó·È ··Ú·›ÙËÙÔ.
∞ÓÙÈ‚ÈÔÙÈο ∏ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂڷ›· ·ÔÙÂÏ› ÙÔÓ ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË fiÏˆÓ ÙˆÓ ¶¶™, ÂÈÏÂÁÌ¤ÓˆÓ ‹ ÌË. ∏ ÂÈÏÔÁ‹ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙÔ ·ÓÙÈ‚ÈfiÁÚ·ÌÌ·, ·Ó Î·È Ë Û˘¯ÓfiÙËÙ· ·ÔÌfiÓˆÛ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· Â›Ó·È ÌÈÎÚ‹.
¶›Ó·Î·˜ 3. µÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ¶¶™ (6)
pH §Â˘ÎÔ·ÙÙ·Ú· °Ï˘Îfi˙Ë ∫·ÏÏȤÚÁÂÈ· LDH
∞Ï‹
∂ÈÏÂÁ̤ÓË
∂̇ËÌ·
<7,3 <10.000/mm3 <60 mg/dl ∞ÚÓËÙÈ΋ <1000 IU/L
<7,2 >10.000/mm3 <40 mg/dl £ÂÙÈ΋ >1000 IU/L
<7,0 >15.000/mm3 <40 mg/dl £ÂÙÈ΋ >1000 IU/L ¶·È‰È·ÙÚÈ΋ 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·24
24
¢. ªÂÚÌ›ÚË Î·È Û˘Ó.
∫ÏÈÓÈ΋ ˘Ô„›· ·Ú·Ó¢ÌÔÓÈ΋˜ Û˘ÏÏÔÁ‹˜
¶Ôχ ÌÈÎÚ‹ (<10 mm)
¶ÚÔÛıÈÔ›ÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Ï¿ÁÈ· (;) ηٷÎÂÎÏÈ̤ÓË (;)
∞ÓÙÈ‚ÈÔÙÈο, ÓÔÛËÏ›·, ·Ú·ÎÔÏÔ‡ıËÛË
ªÂÁ¿ÏË (>10 mm)
¢˘ÛÌÂÓ‹˜ ÂͤÏÈÍË
¡ÔÛËÏ›·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ıˆÚ·ÎÔΤÓÙËÛË, ·ÓÙÈ‚ÈÔÙÈο
ÀÁÚfi ‰È·˘Á¤˜ ÃÚÒÛË Î·Ù¿ Gram(-) ÀfiË¯Ô ˘ÁÚfi
ÀÁÚfi ˘Ò‰Â˜ ‹ ıÔÏÂÚfi ‹/Î·È ¯ÚÒÛË Î·Ù¿ Gram(+) ‹/Î·È ÁÏ˘Îfi˙Ë <50 mg/dl ‹/Î·È pH <7,0
pH >7,2 °Ï˘Îfi˙Ë >50 mg/dl
pH >7,0 ‹ pH <7,2 Î·È ÁÏ˘Îfi˙Ë >50 mg/dl
¶·Ú·ÎÔÏÔ‡ıËÛË
¶ÔÏϷϤ˜ ·Ú·ÎÂÓÙ‹ÛÂȘ
Èڛ˜ ‰È·ÊÚ·ÁÌ¿ÙÈ·
∂χıÂÚ˜ Ù·Èӛ˜
¶ÔÏϷϤ˜ ÂÚ›ÏÔΘ ÂÁ΢ÛÙÒÛÂȘ
£ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË
£ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË πÓˆ‰ÔÏ˘ÙÈο
Èڛ˜ ‚ÂÏÙ›ˆÛË
Èڛ˜ ‚ÂÏÙ›ˆÛË
∂·Ó¿ÏË„Ë ·ÚÔ¯¤Ù¢Û˘, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ıˆÚ·ÎÔÛÎfiËÛË ‹ ıˆÚ·ÎÔÙÔÌ‹ ∂ÈÎfiÓ· 3. ¶ÚÔÙÂÈÓfiÌÂÓÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· ÛÙȘ ·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜.
∏ ¯ÔÚËÁÔ‡ÌÂÓË ·ÁˆÁ‹ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ·ÏÏ¿ Î·È Ë ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ÔÏÏÒÓ ÁÈ·ÙÚÒÓ Ó· ÚÔ‚Ô‡Ó ¤ÁηÈÚ· Û ‰È·ÁÓˆÛÙÈ΋ ıˆÚ·ÎÔΤÓÙËÛË, ‰ÂÓ ‰È¢ÎÔχÓÔ˘Ó ÙËÓ ÚÔÛ¿ıÂÈ· ·ÔÌfiÓˆÛ˘ ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂڷ›· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÂÓ‰ÔÊϤ‚È· › 7-10 Ë̤Ú˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ. ∂ÈϤÔÓ, Û˘ÓÈÛÙ¿Ù·È per os ¯ÔÚ‹ÁËÛË ÁÈ· 1-2 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡. ∏ ÂÌÂÈÚÈ΋ ·ÁˆÁ‹ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÓÙÈ‚ÈÔÙÈο Ô˘ ¤¯Ô˘Ó ‰Ú¿ÛË ¤Ó·ÓÙÈ ÙÔ˘ S. pneumoniae Î·È ÙÔ˘ S. aureus. ™ÙÔ˘˜ Ï‹Úˆ˜ ÂÌ‚ÔÏÈ·Ṳ̂ÓÔ˘˜ ·ÛıÂÓ›˜ ηٿ ÙÔ˘ H. influenzae Î·È Û ·˘ÙÔ‡˜ Ô˘ Ë ¯ÚÒÛË Î·Ù¿ Gram Â›Ó·È ·ÚÓËÙÈ΋, ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË Ë Î¿Ï˘„Ë ¤Ó·ÓÙÈ ·˘ÙÔ‡ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘. ŒÓ· ·Ú¯Èο ηٿÏÏËÏÔ ÂÌÂÈÚÈÎfi Û¯‹Ì· ÁÈ· ÙȘ Ó¢ÌÔӛ˜ Ù˘ ÎÔÈÓfiÙËÙ·˜ Ì ¶¶™ Û ˘ÁÈ‹ ·È‰È¿ Â›Ó·È Ë ÎÂÊÔ˘ÚÔÍ›ÌË ‹ Ë ÎÂÊÔÙ·Í›ÌË (200 mg/kg/Ë̤ڷ) ‹ Ë ÎÂÊÙÚÈ·ÍfiÓË (100 mg/kg/Ë̤ڷ) Ì ÎÏÈÓ‰·Ì˘Î›ÓË (40 mg/kg/Ë̤ڷ). ∂Ó·ÏÏ·ÎÙÈο, ¶·È‰È·ÙÚÈ΋ 2005;68:18-27
ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Ë ·ÌÔ͢ÎÈÏ›ÓË Ì ÎÏ·‚Ô˘Ï·ÓÈÎfi (100 mg/kg/Ë̤ڷ Ë ·ÌÔ͢ÎÈÏ›ÓË) (35). ™Â ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ·È‰È¿, Ì ¯ÚfiÓÈÔ ÓfiÛËÌ· ‹ Ïԛ̈ÍË ·fi ÓÔÛÔÎÔÌÂÈ·Îfi Û٤ϯԘ, Â›Ó·È ··Ú·›ÙËÙË Ë ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ (Ë ·ÌÈηۛÓË ·Ó·Ê¤ÚÂÙ·È fiÙÈ ¤¯ÂÈ Î·Ï‡ÙÂÚË ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ· ÛÙÔ Ô͈ÙÈÎfi Ï¢ÚÈÙÈÎfi ˘ÁÚfi) Î·È ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ (‚·ÓÎÔÌ˘Î›ÓË ‹ Ó·ÊÛÈÏ›ÓË) (8). ™Â Û˘ÏÏÔÁ¤˜ Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó Ó¢ÌÔÓ›· ·fi ÂÈÛÚfiÊËÛË, fiˆ˜ Û ·ÛıÂÓ›˜ Ì Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ú¤ÂÈ Ó· ηχÙÂÙ·È Î·È Ë Èı·ÓfiÙËÙ· ÙˆÓ ·Ó·ÂÚfi‚ÈˆÓ ÌÈÎÚÔ‚›ˆÓ Ì ÎÏÈÓ‰·Ì˘Î›ÓË ‹ ÙÈηÚÛÈÏ›ÓË Ì ÎÏ·‚Ô˘Ï·ÓÈÎfi (36). ™Â ·ÛıÂÓ›˜ Ì Ó¢ÌÔÓ›· ·fi Ó¢ÌÔÓÈfiÎÔÎÎÔ, Ë ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ı· ÂÍ·ÚÙËı› ·fi ÙËÓ ÙÈÌ‹ Ù˘ ÂÏ¿¯ÈÛÙ˘ ·Ó·ÛÙ·ÏÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ (MIC) Ù˘ ÂÓÈÎÈÏ›Ó˘. °È· MIC <0,06 mg/L Û˘ÓÈÛÙ¿Ù·È ¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘ ‹ ·ÌÔ͢ÎÈÏ›Ó˘ ÛÂ Û˘Ì‚·ÙÈΤ˜ ‰fiÛÂȘ. °È· MIC ÌÂٷ͇ 0,12 mg/L Î·È 1 mg/L Û˘ÓÈÛÙÒÓÙ·È ·˘ÍË̤Ó˜ ‰fiÛÂȘ ÂÓÈÎÈÏ›Ó˘, ·ÌÔ͢ÎÈÏ›Ó˘ ‹ ·ÌÈÎÈÏ›Ó˘.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·25
25
¶·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜
∆¤ÏÔ˜, ÁÈ· MIC 2-4 mg/L ‹ >4 mg/L ÈηÓÔÔÈËÙÈ΋ ·ÓÙ·fiÎÚÈÛË ·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ ÛÙËÓ ÎÂÊÔÙ·Í›ÌË ‹ ÎÂÊÙÚÈ·ÍfiÓË, fiˆ˜ ›Û˘ ÛÙË ‚·ÓÎÔÌ˘Î›ÓË, ÂÓÒ ˆ˜ ÙÂÏÂ˘Ù·›· ÂÈÏÔÁ‹ ·Ú·Ì¤ÓÔ˘Ó ÔÈ Î·ÚÌ·ÂӤ̘ (35).
¶·ÚÔ¯¤Ù¢ÛË Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Ì ۈϋӷ ∏ ÙÔÔı¤ÙËÛË ÛˆÏ‹Ó· ·ÚÔ¯¤Ù¢Û˘ ÂӉ›ÎÓ˘Ù·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÂÈÏÂÁÌ¤ÓˆÓ ¶¶™. ∞ÓÙÈÎÂÈÌÂÓÈÎfi˜ ÛÎÔfi˜ Â›Ó·È Ë ÚÒÈÌË ÙÔÔı¤ÙËÛË ÙÔ˘ ۈϋӷ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÂÈÏÂÁ̤Ó˘ ¶¶™, ‰ÈfiÙÈ ÙÔ ÂχıÂÚÔ Ï¢ÚÈÙÈÎfi ˘ÁÚfi ÌÔÚ› Ó· ÌÂÙ·Ùڷ› Û ˘ÁÚfi Ì ‰È·ÊÚ·ÁÌ¿ÙÈ· ·ÎfiÌ· Î·È Û ‰È¿ÛÙËÌ· ˆÚÒÓ, Ì ·ÎfiÏÔ˘ıÔ ÙË ‰˘ÛÎÔÏ›· ‹ ›Ûˆ˜ ÙËÓ ·‰˘Ó·Ì›· ·ÚÔ¯¤ÙÂ˘Û‹˜ ÙÔ˘. OÈ ÂӉ›ÍÂȘ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘ ÛÙȘ ¶¶™ ·Ú·Ù›ıÂÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. OÈ ·ÛıÂÓ›˜ Ì pH <7 ‰È·ÙÚ¤¯Ô˘Ó ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÂÌ˘‹Ì·ÙÔ˜ Î·È ÂÁ΢ÛÙÒÛˆÓ, ÁÈ’ ·˘Ùfi ÂÈ‚¿ÏÏÂÙ·È Ë ¤ÁηÈÚË ¤Ó·ÚÍË ·ÚÔ¯¤Ù¢Û˘. ŸÙ·Ó ÙÔ pH Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 7,0 Î·È 7,2, Û˘ÓÈÛÙ¿Ù·È Â·Ó¿ÏË„Ë Ù˘ ıˆÚ·ÎÔΤÓÙËÛ˘ ·Ó¿ 12-24 ÒÚ˜, ‰ÈfiÙÈ ˘¿Ú¯Ô˘Ó ·˘ÍË̤Ó˜ Èı·ÓfiÙËÙ˜ Ó· ÌÂÙ·‚ÏËıÔ‡Ó ÔÈ ÙÈ̤˜ ηÈ, ÙÂÏÈο, Ó· ¯ÚÂÈ¿˙ÂÙ·È ·ÚÔ¯¤Ù¢ÛË (34). O ۈϋӷ˜ Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÛÙÔ ¯·ÌËÏfiÙÂÚÔ ÛËÌÂ›Ô Ù˘ ˘Â˙ˆÎÔÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È Ó· Û˘Ó‰¤ÂÙ·È ·Ú¯Èο Ì ·Ó·ÚÚfiÊËÛË ·ÚÓËÙÈ΋˜ ›ÂÛ˘ (-20 cm H2O). ∏ ÂÊ·ÚÌÔÁ‹ ·ÚÓËÙÈ΋˜ ›ÂÛ˘ ‰È¢ÎÔχÓÂÈ ÙËÓ ¤ÎÙ˘ÍË ÙÔ˘ Ó‡ÌÔÓ·, Ô ÔÔ›Ô˜ ÛÙË Û˘Ó¤¯ÂÈ· ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÎÔÈÏfiÙËÙ· ÙÔ˘ ÂÌ˘‹Ì·ÙÔ˜. ™Â Û˘ÏÏÔÁ¤˜ Ì ÂÁ΢ÛÙÒÛÂȘ, ÌÔÚ› Ó· Â›Ó·È ··Ú·›ÙËÙË Ë ÙÔÔı¤ÙËÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó·Ó ۈϋӈÓ. ∂¿Ó Û 24-48 ÒÚ˜ ·fi ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘ ‰ÂÓ ·Ú·ÙËÚËı› ‡ÊÂÛË ÙÔ˘ ˘ÚÂÙÔ‡, Ë ‚ÂÏÙ›ˆÛË ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋ ‹ Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ ‰ÂÓ ¤¯ÂÈ ÌÂȈı› ·ÎÙÈÓÔÏÔÁÈο, Ú¤ÂÈ Ó· Á›ÓÂÈ Â·Ó¤ÏÂÁ¯Ô˜ ÌÂ Ó¤Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹ ›Ûˆ˜ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È¢ÎÚÈÓÈÛÙ› ·Ó ÚfiÎÂÈÙ·È ÁÈ·: ·) ·Ú·ÌÔÓ‹ ÂÁ΢Ûو̤ÓÔ˘ ˘ÁÚÔ‡, ‚) ·fiÊÚ·ÍË ÙÔ˘ ۈϋӷ ·fi ·¯‡ÚÚ¢ÛÙÔ ‡ÔÓ, ÁˆÓ›·ÛË ‹ η΋ ÙÔÔı¤ÙËÛË ÙÔ˘ ۈϋӷ ‹ Á) ·ÚÔ˘Û›· ÂÎÙÂٷ̤Ó˘ ‹ ÓÂÎÚˆÙÈ΋˜ ˘ÔΛÌÂÓ˘ Ó¢ÌÔÓ›·˜. ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË Ì˯·ÓÈÎÔ‡ Έχ̷ÙÔ˜ Ô˘ ÌÔÚ› Ó· ÂÈÏ˘ı› Ì ÙË ÌÂٷΛÓËÛË ÙÔ˘ ۈϋӷ, ÙfiÙÂ Û˘˙ËÙÂ›Ù·È Ë ¯Ú‹ÛË ÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ‹ Ë
¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË. O ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ô ·ÛıÂÓ‹˜ ‚ÂÏÙÈÒÓÂÙ·È ÎÏÈÓÈο Î·È ·ÎÙÈÓÔÏÔÁÈο, ·ÏÏ¿ ÙÔ ˘ÁÚfi Ô˘ ·ÚÔ¯ÂÙ‡ÂÙ·È Û˘Ó¯›˙ÂÈ Ó· Â›Ó·È ˘Ò‰Â˜. °ÂÓÈο, Ë ÚÒÈÌË ·ÚÔ¯¤Ù¢ÛË ÂÈÏÂÁ̤Ó˘ ¶¶™ ‹ ÂÌ˘‹Ì·ÙÔ˜ Û ·È‰È¿ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙÔ 90% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (36). O ۈϋӷ˜ ·ÚÔ¯¤Ù¢Û˘ Û˘ÓÈÛÙ¿Ù·È Ó· ·Ú·Ì¤ÓÂÈ ¤ˆ˜ fiÙÔ˘ Ë ÔÛfiÙËÙ· ÙÔ˘ ÔÚÒ‰Ô˘˜ ˘ÁÚÔ‡ Ô˘ ·ÚÔ¯ÂÙ‡ÂÙ·È Ó· Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 25-50 ml ·Ó¿ Ë̤ڷ ‹ 1-1,5 ml/kg ·Ó¿ Ë̤ڷ (34). ∏ Û‡Á¯ÚÔÓË Ù¿ÛË Â˘ÓÔ› ÙË ¯Ú‹ÛË ÛˆÏ‹ÓˆÓ ÌÂÁ¿ÏÔ˘ ÌÂÁ¤ıÔ˘˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·fiÊڷ͢ ·fi ·¯‡ÚÚ¢ÛÙÔ ˘ÁÚfi. øÛÙfiÛÔ, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ηϿ ·ÔÙÂϤÛÌ·Ù· Î·È Ì ÙË ¯Ú‹ÛË ÛˆÏ‹ÓˆÓ ÌÈÎÚ‹˜ ‰È·Ì¤ÙÚÔ˘ (8-16 F) ˘fi ÙËÓ Î·ıÔ‰‹ÁËÛË ·ÍÔÓÈÎÔ‡ ÙÔÌÔÁÚ¿ÊÔ˘ ‹ ˘ÂÚ˯ÔÙÔÌÔÁÚ¿ÊÔ˘. ∏ ¯ÚËÛÈÌfiÙËÙ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÓ‰Ô¸Â˙ˆÎÔÙÈο ‰ÂÓ ¤¯ÂÈ ÂȂ‚·Èˆı› (37).
πÓˆ‰ÔÏ˘ÙÈο ™¯ÂÙÈο ÚfiÛÊ·Ù· Ù¤ıËΠÙÔ ı¤Ì· Ù˘ ÙÔÈ΋˜ ¤Á¯˘Û˘ ÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ÁÈ· ÙË ıÂڷ›· ÙˆÓ ÂÈÏÂÁÌ¤ÓˆÓ ¶¶™ Î·È ÙˆÓ ÂÌ˘ËÌ¿ÙˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÚÈÔÚÈÛÙÔ‡Ó ÔÈ ÂÚÈÙÒÛÂȘ fiÔ˘ Â›Ó·È ·Ó·Áη›· Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË, ÌÂÙ¿ ·fi ÙË ıÂÙÈ΋ ÂÌÂÈÚ›· Ô˘ ·ÔÎÔÌ›ÛÙËΠ·fi ÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜. ∆Ô ÔÛÔÛÙfi ÙˆÓ ıÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Î˘Ì·›ÓÂÙ·È ·fi 38% ¤ˆ˜ 100%, ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ Ù˘ Û˘ÏÏÔÁ‹˜ ÛÙÔ ÔÔ›Ô ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó (37-40). ¢È·ÈÛÙÒıËÎ·Ó ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ÙfiÛÔ Ì ÙË ¯Ú‹ÛË Ù˘ ÛÙÚÂÙÔÎÈÓ¿Û˘, fiÛÔ Î·È Ù˘ Ô˘ÚÔÎÈÓ¿Û˘. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó ÙË ¯Ú‹ÛË Ù˘ Ô˘ÚÔÎÈÓ¿Û˘, ηıÒ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÈÁfiÙÂÚ˜ ·ÏÏÂÚÁÈΤ˜ Î·È ˘ÚÂÙÔÁfiÓ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (43,44). ™Â η̛· ÌÂϤÙË ‰ÂÓ ·Ó·Ê¤ÚıËΠ‰È·Ù·Ú·¯‹ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ (39). ∏ ‰fiÛË Ù˘ ÛÙÚÂÙÔÎÈÓ¿Û˘ Â›Ó·È 250.000 ÌÔÓ¿‰Â˜ ·Ó¿ Ë̤ڷ, ÂÓÒ Ù˘ Ô˘ÚÔÎÈÓ¿Û˘ Î˘Ì·›ÓÂÙ·È ·fi 50.000 ̤¯ÚÈ 250.000 ÌÔÓ¿‰Â˜ ·Ó¿ Ë̤ڷ. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ (40) Û˘ÓÈÛÙÔ‡Ó ıÂڷ›· Ì ÈÓˆ‰ÔÏ˘ÙÈο ÁÈ· 3 Ë̤Ú˜ Î·È Â¿Ó ‰ÂÓ ÛËÌÂȈı› ‚ÂÏÙ›ˆÛË, ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÚÔ¯¤Ù¢ÛË. ÕÏÏÔÈ ÚÔÙ›ÓÔ˘Ó Î·È ‰Â‡ÙÂÚË ÚÔÛ¿ıÂÈ· ÈÓˆ‰ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜ (41-43). ∫·È Ù· ‰‡Ô ÈÓˆ‰ÔÏ˘ÙÈο ¯ÔÚËÁÔ‡ÓÙ·È Ì¤Ûˆ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ۈϋӷ, ‰È·Ï˘Ì¤Ó· Û 50-100 ml
¶›Ó·Î·˜ 4. ∂Ӊ›ÍÂȘ ÙÔÔı¤ÙËÛ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘ ÛÙȘ ¶¶™ (6) 1. ¶·ÚÔ˘Û›· ‡Ô˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· 2. £ÂÙÈ΋ ¯ÚÒÛË Î·Ù¿ Gram ÙÔ˘ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ 3. °Ï˘Îfi˙Ë <50 mg/dl ÛÙÔ Ï¢ÚÈÙÈÎfi ˘ÁÚfi 4. pH <7 ÙÔ˘ ˘Â˙ˆÎÔÙÈÎÔ‡ ˘ÁÚÔ‡ 5. ¶·ÚÔ˘Û›· ‰È·ÊÚ·ÁÌ·Ù›ˆÓ Î·È Ù·ÈÓÈÒÓ ÛÙÔ Ï¢ÚÈÙÈÎfi ˘ÁÚfi ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ·
¶·È‰È·ÙÚÈ΋ 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·26
26
¢. ªÂÚÌ›ÚË Î·È Û˘Ó.
Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡. ™ÙË Û˘Ó¤¯ÂÈ·, ‰È·ÎfiÙÂÙ·È Ë ·ÚÔ¯‹ ÁÈ· 2, 4, 6 ‹ 12 ÒÚ˜, Ì ٷ˘Ùfi¯ÚÔÓ˜ ·ÏÏ·Á¤˜ Ù˘ ÛÙ¿Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ·. ∆ÂÏÈο, ÂÏ¢ıÂÚÒÓÂÙ·È Ô ÛˆÏ‹Ó·˜ Î·È Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·Ó·ÚÚfiÊËÛË. ∞Ó ·Ú·ÙËÚÂ›Ù·È ¿ÏÁÔ˜ ηٿ ÙËÓ ÂÓÛÙ¿Ï·ÍË Ù˘ Ô˘ÚÔÎÈÓ¿Û˘, ÌÔÚ› Ó· ¯ÔÚËÁËı› ·Ó·ÏÁËÙÈÎfi ·fi ÙÔ ÛÙfiÌ· ‹ Ó· ÙÔÔıÂÙËı› ÙÔÈÎfi ·Ó·ÈÛıËÙÈÎfi ‰È·Ì¤ÛÔ˘ ÙÔ˘ ۈϋӷ. ∞ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ·ÔÙÂÏÔ‡Ó Ë ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË Û ·˘Ù¤˜ ÙȘ Ô˘Û›Â˜ Û ÚÔËÁÔ‡ÌÂÓË ¯ÔÚ‹ÁËÛË, ÙÔ ÚfiÛÊ·ÙÔ ÙÚ·‡Ì· ‹ ¯ÂÈÚÔ˘ÚÁ›Ô, ÙÔ ÂÁÎÂÊ·ÏÈÎfi ·ÈÌÔÚÚ·ÁÈÎfi ¤ÌÊÚ·ÎÙÔ, ÔÈ ‰È·Ù·Ú·¯¤˜ ‹Íˆ˜, Ë ıÚÔÌ‚ÔÂÓ›·, Ë Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, Ë ÂÁ΢ÌÔÛ‡ÓË Î·È ÙÔ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈÎfi Û˘Ú›ÁÁÈÔ.
ÃÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ ̤ۈ ıˆÚ·ÎÔÙÔÌ‹˜ ‹ ̤ۈ ıˆÚ·ÎÔÛÎfiËÛ˘ O ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ ̤ۈ ÌÈÎÚ‹˜ ıˆÚ·ÎÔÙÔÌ‹˜ ·ÔÙÂÏ› ÙÔÓ ÎÏ·ÛÈÎfi ÙÚfiÔ ·ÚÔ¯¤Ù¢Û˘ ÙÔ˘ ÂÌ˘‹Ì·ÙÔ˜ fiÙ·Ó ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ Î·È Â›Ó·È ¯Ú‹ÛÈÌÔ˜ ÛÙËÓ ÈÓÔ˘Ò‰Ë Ê¿ÛË Ì ÂÁ΢ÛÙÒÛÂȘ Î·È Û˘ÌʇÛÂȘ. ∂Ó·ÏÏ·ÎÙÈ΋ χÛË ·ÔÙÂÏ› Ô Î·ı·ÚÈÛÌfi˜ ̤ۈ ıˆÚ·ÎÔÛÎfiËÛ˘. ¶ÏÂÔÓÂÎÙ› ¤Ó·ÓÙÈ Ù˘ ıˆÚ·ÎÔÙÔÌ‹˜, ‰ÈfiÙÈ Â›Ó·È ÏÈÁfiÙÂÚÔ ÙÚ·˘Ì·ÙÈÎfi˜ Î·È ÚÔηÏ› ÏÈÁfiÙÂÚÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi ¿ÏÁÔ˜. ∞ÓÙÈı¤Ùˆ˜, ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÛÙË Ê¿ÛË Ù˘ ÔÚÁ¿ÓˆÛ˘ Î·È Â›Ó·È ÂÊÈÎÙfi˜ ÌfiÓÔ Û ·ÛıÂÓ›˜ Ô˘ ·ÓÙ¤¯Ô˘Ó ÙËÓ ÂÎÏÂÎÙÈ΋ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘ ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ ÔÈΛÏÏÂÈ, ·Ó¿ÏÔÁ· Ì ÙÔ fiÛÔ ÚÒÈÌ· ÂÎÙÂÏ›ٷÈ, Î˘Ì·ÈÓfiÌÂÓË ·fi 30% ¤ˆ˜ 100% (43-48). ∂¿Ó ·ÔÙ‡¯ÂÈ, Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ıˆÚ·ÎÔÙÔÌ‹. ∞ÔÊÏÔ›ˆÛË Ì¤Ûˆ ıˆÚ·ÎÔÙÔÌ‹˜ ªÂ ·˘Ù‹ ÙË ‰È·‰Èηۛ· ·Ê·ÈÚÂ›Ù·È fiÏÔ˜ Ô ÈÓ҉˘ ÈÛÙfi˜ ÙÔ˘ ÛÏ·Á¯ÓÈÎÔ‡ ÂÙ¿ÏÔ˘ ÙÔ˘ ˘Â˙ˆÎfiÙ· Î·È ·ÚÔ¯ÂÙ‡ÂÙ·È fiÏÔ ÙÔ ‡ÔÓ ·fi ÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. ∂›Ó·È ··Ú·›ÙËÙË Ï‹Ú˘ ıˆÚ·ÎÔÙÔÌ‹. ™ÙËÓ ÔÍ›· Ê¿ÛË ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Ïԛ̈͢ ÙÔ˘ ˘Â˙ˆÎfiÙ·, ·Ó ·˘Ùfi ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ¿ÏϘ Û˘ÓÙËÚËÙÈÎfiÙÂÚ˜ ÌÂıfi‰Ô˘˜. ™ÙË ¯ÚfiÓÈ· Ê¿ÛË Á›ÓÂÙ·È ·Ê·›ÚÂÛË ÙÔ˘ ÈÓÒ‰Ô˘˜ ÙÔȯÒÌ·ÙÔ˜ Ô˘ ÚÔηÏ› ÏÂÈÙÔ˘ÚÁÈÎfi ÂÚÈÔÚÈÛÌfi. ∂›Ó·È Ôχ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ï‡ÛË ÙÔ˘ ÂÌ˘‹Ì·ÙÔ˜ ÛÙÔ 90-95% (48-50). ¢ÂÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ÌfiÓÔ ¿¯˘ÓÛË ÙÔ˘ ˘Â˙ˆÎfiÙ·, ‰ÈfiÙÈ ·˘Ù‹ ˘Ô¯ˆÚ› ·˘ÙfiÌ·Ù· Û ‰È¿ÛÙËÌ· ÌÂÚÈÎÒÓ ÌËÓÒÓ. ∏ ıÓËÙfiÙËÙ· Î·È Ë ÓÔÛËÚfiÙËÙ· ·Ú·Ì¤ÓÔ˘Ó ˘„ËϤ˜ ·ÎfiÌ· Î·È Û‹ÌÂÚ·. ∏ ıÓËÙfiÙËÙ· Î˘Ì·›ÓÂÙ·È Û ÔÛÔÛÙfi 2-15%, ÂÓÒ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ıˆÚÔ‡ÓÙ·È Ë ‰È¿ÚÎÂÈ·, Ë ‚·Ú‡ÙËÙ· Ù˘ Ïԛ̈͢ Î·È Ë ÌÈÎÚ‹ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓ‹ (4). ¶·È‰È·ÙÚÈ΋ 2005;68:18-27
™˘ÌÂÚ¿ÛÌ·Ù· OÈ ¶¶™ Û˘ÓÔ‰Â‡Ô˘Ó Û˘¯Ó¿ ÙȘ Ó¢ÌÔӛ˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÓÔÛËÏ›· ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ÚÔ‚¿ÏÏÔ˘Ó ÎÏÈÓÈο Ì ÔÈΛÏË ‚·Ú‡ÙËÙ·. °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙfiÛÔ ÎÏÈÓÈο fiÛÔ Î·È ÂÚÁ·ÛÙËÚȷο ÎÚÈÙ‹ÚÈ·. ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ·Ú¤¯ÂÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ∏ ıˆÚ·ÎÔΤÓÙËÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÁηÈÚ·. OÈ ÏËÚÔÊÔڛ˜ Ô˘ Ï·Ì‚¿ÓÔÓÙ·È ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ˘ÁÚÔ‡ Â›Ó·È Î·ıÔÚÈÛÙÈΤ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÂÚ·ÈÙ¤Úˆ ıÂڷ¢ÙÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂÚ›Û΄Ë. ∏ ÙÔÔı¤ÙËÛË ÙÔ˘ ۈϋӷ ·ÚÔ¯¤Ù¢Û˘, ÂÊfiÛÔÓ ÎÚÈı› ··Ú·›ÙËÙË, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÓˆÚ›˜, ÙÔ ›‰ÈÔ Î·È Ô ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ fiÙ·Ó ¯ÚÂÈ¿˙ÂÙ·È. ∏ ‚È‚ÏÈÔÁÚ·Ê›· ·Ú·Ì¤ÓÂÈ ÂÈÊ˘Ï·ÎÙÈ΋ ˆ˜ ÚÔ˜ ÙË ¯Ú‹ÛË ÙˆÓ ÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ÛÙ· ·È‰È¿.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Mocelin HT, Fischer GB. Epidemiology, presentation and treatment of pleural effusion. Paediatr Respir Rev 2002;3:292-297. 2. Tan TQ, Mason EO Jr, Wald ER, Barson WJ, Schutze GE, Bradley JS et al. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics 2002;110:1-6. 3. De Luca A, Kurland G. Empyema in children: epidemiology, diagnosis and management. Semin Pediatr Infect Dis 1998;9:205-211. 4. Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir J 1997;10:1150-1156. 5. Light RW. A new classification of parapneumonic effusions and empyema. Chest 1995;108:299-301. 6. Sahn SA. State of the art. The pleura. Am Rev Respir Dis 1988;138:184-234. 7. Structure and function of the respiratory system. πn: Berne RM, Levy MN, editors. Physiology. 4th ed. Saint Louis, MO, U.S.A.: Mosby, Inc; 1998. p. 517-533. 8. Efrati O, Barak A. Pleural effusions in the pediatric population. Pediatr Rev 2002;23:417-426. 9. Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis 1984;3:578-591. 10. Bremont F, Baunin C, Juchet A, Rance F, Puget C, Juricic M et al. Evolution clinique et traitement de l’empyeme pleural chez l’enfant. Arch Pediatr 1996;3:335-341. 11. Sarihan H, Cay A, Aynaci M, Akyazici R, Baki A. Empyema in children. J Cardiovasc Surg 1998;39:113-116. 12. Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998;101:388-392. 13. Tan TQ, Mason EO Jr, Barson WJ, Wald ER, Schutze GE, Bradley JS et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998;102:1369-1375. 14. Bryant RE, Salmon CJ. Pleural empyema. Clin Infect Dis 1996;22:747-762.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·27
27
¶·Ú·Ó¢ÌÔÓÈΤ˜ Û˘ÏÏÔÁ¤˜
15. Taryle DA, Potts DE, Sahn SA. The incidence and clinical correlates of parapneumonic effusions in pneumococcal pneumonia. Chest 1978;74:170-173. 16. Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med 1980;69:507-512. 17. Light RW. Parapneumonic effusions and empyema. πn: Light RW, editor. Pleural diseases. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 1995. p. 129-153. 18. Hendren WH 3rd, Haggerty RJ. Staphylococcic pneumonia in infancy and childhood: analysis of seventy-five cases. J Am Med Assoc 1958;168:6-16. 19. Ginsburg CM, Howard JB, Nelson JD. Report of 65 cases of Haemophilus influenzae b pneumonia. Pediatrics 1979;64:283-286. 20. Mansel JK, Rosenow EC 3rd, Smith TF, Martin JW Jr. Mycoplasma pneumoniae pneumonia. Chest 1989;95:639-646. 21. Yang PC, Luh KT, Chang DB, Wu HD, Yu CJ, Kuo SH. Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol 1992;159:29-33. 22. Ramnath RR, Heller RM, Ben-Ami T, Miller MA, Campbell P, Neblett WW 3rd et al. Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics 1998;101:68-71. 23. Grewal H, Jackson RJ, Wagner CW, Smith SD. Early videoassisted thoracic surgery in the management of empyema. Pediatrics 1999;103:e63. 24. McLoud TC, Flower CD. Imaging the pleura: sonography, CT, and MR imaging. AJR Am J Roentgenol 1991;156:1145-1153. 25. Donnelly LF, Klosterman LA. CT appearance of parapneumonic effusions in children: findings are not specific for empyema. AJR Am J Roentgenol 1997;169:179-182. 26. Paling MR, Griffin GK. Lower lobe collapse due to pleural effusion: a CT analysis. J Comput Assist Tomogr 1985;9:10791083. 27. Park CS, Chung WM, Lim MK, Cho CH, Suh CH, Chung WK. Transcatheter instillation of urokinase into loculated pleural effusion: analysis of treatment effect. AJR Am J Roentgenol 1996;167:649-652. 28. Leonard SR, Nikaidoh H, Thompson WR. Thoracocentesis and chest tube insertion. In: Levin DL, Morriss FC, editors. Essentials of pediatric intensive care. 2nd ed. New York: Churchill Livingstone Inc; 1997. p. 1519-1526. 29. Wood RE. Diagnostic and therapeutic procedures in pediatric pulmonary patients. In: Taussig LM, Landau LI, editors. Pediatric respiratory medicine. St. Louis: Mosby; 1999. p. 244-262. 30. Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45:340345. 31. Light RW. Disorders of the pleura, mediastinum and diaphragm. Harrison’s on line chapter 262. http://www.harrisonsonline.com. 32. Cheng DS, Rodriguez RM, Rogers J, Wagster M, Starnes DL, Light RW. Comparison of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip. Chest 1998;114:1368-1372.
33. Heffner JE, Brown LK, Barbieri C, DeLeo JM. Pleural fluid chemical analysis in parapneumonic effusions. A metaanalysis. Am J Respir Crit Care Med 1995;151:1700-1708. 34. Heffner JE. Indications for draining a parapneumonic effusion: an evidence-based approach. Semin Respir Infect 1999;14:48-58. 35. Lewis RA, Feigin RD. Current issues in the diagnosis and management of pediatric empyema. Semin Pediatr Infect Dis 2002;13:280-288. 36. Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child 2003;88:915-917. 37. Rosen H, Nadkarni V, Theroux M, Padman R, Klein J. Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. Chest 1993;103:11901193. 38. Krishnan S, Amin N, Dozor AJ, Stringel G. Urokinase in the management of complicated parapneumonic effusions in children. Chest 1997;112:1579-1583. 39. Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J Pediatr Surg 1997;32:1473-1475. 40. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Panagou P, Siafakas NM. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study. Am J Respir Crit Care Med 1997;155:291-295. 41. Thomson AH, Hull J, Kumar MR, Wallis C, Balfour Lynn IM. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57:343-347. 42. Bouros D, Schiza S, Siafakas N. Utility of fibrinolytic agents for draining intrapleural infections. Semin Respir Infect 1999;14:39-47. 43. Davies CW, Lok S, Davies RJ. The systemic fibrinolytic activity of intrapleural streptokinase. Am J Respir Crit Care Med 1998;157:328-330. 44. Steinbrecher HA, Najmaldin AS. Thoracoscopy for empyema in children. J Pediatr Surg 1998;33:708-710. 45. Klena JW, Cameron BH, Langer JC, Winthrop AL, Perez CR. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998;187:404-408. 46. Merry CM, Bufo AJ, Shah RS, Schropp KP, Lobe TE. Early definitive intervention by thoracoscopy in pediatric empyema. J Pediatr Surg 1999;34:178-180. 47. Patton RM, Abrams RS, Gauderer MW. Is thoracoscopically aided pleural debridement advantageous in children? Am Surg 1999;65:69-72. 48. Gofrit ON, Engelhard D, Abu-Dalu K. Post-pneumonic thoracic empyema in children: a continued surgical challenge. Eur J Pediatr Surg 1999;9:4-7. 49. Carey JA, Hamilton JR, Spencer DA, Gould K, Hasan A. Empyema thoracis: a role for open thoracotomy and decortication. Arch Dis Child 1998;79:510-513. 50. Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia. Arch Dis Child 2003;88:1009-1014.
¶·È‰È·ÙÚÈ΋ 2005;68:18-27
Paediatriki Jan-Feb 05 teliko
28
10-02-05
13:36
™ÂÏ›‰·28
REVIEW ARTICLE
Diagnostic approach and treatment of parapneumonic effusions in children D. Mermiri, K. Priftis Department of Allergiology, Penteli Children’s Hospital, Athens Correspondence: Despina Mermiri Department of Allergiology, Penteli Children’s Hospital 152 36, P. Penteli, Athens Date of submission: 25-02-2004 Date of approval: 27-09-2004
Abstract Parapneumonic effusions constitute a rather common coexisting presentation of microbial pneumonias that need hospitalization, whereas empyemas are considered as complications of the disease per se. Despite the decrease in morbidity from microbial infections of the respiratory tract, the frequency of empyemas is increasing and that is considered to be the result of the widespread use of antibiotics and vaccine that favor the emergence of resistant microbial strains. In regard to the recommended diagnostic practice, special emphasis is given to the thoracic ultrasound because of the valuable information that could be drawn for the estimation of the effusion. The value of the in time thoracic paracentesis before the start of antibiotic therapy, in order to determine the type of effusion, is highlighted. The appropriate treatment is chosen according to the results of the paracentesis fluid and the imaging findings. In case of a complicated parapneumonic effusion, the positioning of a drainage tube and/or surgical management is recommended, aiming at decreasing hospitalization time and avoiding adverse consequences. In the present review of the literature, the recent diagnostic and therapeutic approaches are discussed.
Key words Parapneumonic effusion, empyema, pneumonia, drainage.
Paediatriki 2005;68:28
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·29
∞¡∞™∫O¶∏™∏
29
¶·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ¶. µÂϤÓÙ˙·˜
¶ÂÚ›ÏË„Ë ∏ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ·ÔÙÂÏ› Ôχ ‰È·‰Â‰Ô̤ÓË Ú·ÎÙÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘ Û˘ÓËıÈÛÌ¤ÓˆÓ ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ. ∆Ô ÙËϤʈÓÔ Â›Ó·È ¤Ó·˜ ‡ÎÔÏÔ˜, ¿ÌÂÛÔ˜, ÊıËÓfi˜ Î·È - οو ·fi Û˘ÁÎÂÎÚÈ̤Ó˜ ÚÔ¸Ôı¤ÛÂȘ - ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜ ÂÈÎÔÈÓˆÓ›·˜ ÙˆÓ ÁÔÓ¤ˆÓ Ì ÙÔÓ ·È‰›·ÙÚÔ. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ô ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ‰È·ı¤ÙÂÈ ·ÚÎÂÙfi ¯ÚfiÓÔ Î·ıËÌÂÚÈÓ¿ - Î·È ÂȉÈο ÙȘ ÌË ÂÚÁ¿ÛÈ̘ ÒÚ˜ - ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰›ÓÂÈ Û˘Ì‚Ô˘Ï¤˜ Î·È Ô‰ËÁ›Â˜ ·fi ÙÔ ÙËϤʈÓÔ. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi Á›ÓÂÙ·È Ì›· Û˘ÓÔÙÈ΋ ·Ó·ÊÔÚ¿ ÛÙËÓ ÈÛÙÔÚ›· Ù˘ ·È‰È·ÙÚÈ΋˜ ·fi ÙÔ ÙËϤʈÓÔ Î·È ÛÙË Û¯¤ÛË ·È‰È¿ÙÚˆÓ-ÙËÏÂʈÓÈ΋˜ È·ÙÚÈ΋˜, ÛÙÔ˘˜ Ù‡Ô˘˜ Î·È ÙȘ ‰˘ÛÎÔϛ˜ Ù˘ ÎÏÈÓÈ΋˜ ÊÚÔÓÙ›‰·˜ ̤ۈ ÙËÏÂÊÒÓÔ˘, ÛÙȘ ·Ó¿ÚÎÂȘ Î·È ÂÏÏ›„ÂȘ ÙÔ˘ ˘ÁÂÈÔÓÔÌÈÎÔ‡ ÚÔÛˆÈÎÔ‡ Ô˘ ‰›ÓÂÈ Û˘Ì‚Ô˘Ï¤˜ ·fi ÙÔ ÙËϤʈÓÔ Î·È ÛÙȘ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙËÏÂʈÓÈο. ∂›Û˘, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘, ÙȘ ›ÁÔ˘Û˜ ÎÏ‹ÛÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋, ηıÒ˜ Î·È ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ̤ÛÔ˘ ·˘ÙÔ‡ ˆ˜ ÙÚfiÔ˘ ‰È·ÏÔÁ‹˜ (triage) Î·È ·ÚÔ¯‹˜ Û˘Ì‚Ô˘ÏÒÓ Û ÎÏÈÓÈο ÂÚÈÛÙ·ÙÈο Ì ÙË ¯Ú‹ÛË ·È‰È·ÙÚÈÎÒÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ Î·È Ì¤Ûˆ ÔÚÁ·ÓˆÌ¤ÓˆÓ ÙËÏÂʈÓÈÎÒÓ Î¤ÓÙÚˆÓ.
∫¤ÓÙÚÔ ÀÁ›·˜ ª·ÚÎfiÔ˘ÏÔ˘ ªÂÛÔÁ·›·˜ AÏÏËÏÔÁÚ·Ê›·: ¶ÔÏ˘˙Ò˘ µÂϤÓÙ˙·˜ ∂˘ÊÚ¿ÓÔÚÔ˜ 25, ∆.∫. 116 35, ∞ı‹Ó· E-mail: polvel@ath.forthnet.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 23-04-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-10-2004
§¤ÍÂȘ ÎÏÂȉȿ TËÏÂʈÓÈ΋ È·ÙÚÈ΋, ·È‰È·ÙÚÈ΋, ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰·, ›ÁÔ˘Û· È·ÙÚÈ΋, ÙËÏÂʈÓÈο ΤÓÙÚ·.
∂ÈÛ·ÁˆÁ‹ ∏ ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· ·ÔÙÂÏ› ··Ú·›ÙËÙÔ Î·È ·Ó·fiÛ·ÛÙÔ ÎÔÌÌ¿ÙÈ Ù˘ Û‡Á¯ÚÔÓ˘ ·È‰È·ÙÚÈ΋˜ Ú·ÎÙÈ΋˜. OÈ ÁÔÓ›˜ ÚÔÛ‰ÔÎÔ‡Ó Ì¤Ûˆ ÙÔ˘ ÙËÏÂÊÒÓÔ˘ Ó· ¤¯Ô˘Ó Ì›· ¿ÌÂÛË, ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È Ì ÂÏ¿¯ÈÛÙÔ ÎfiÛÙÔ˜ ÂÈÎÔÈÓˆÓ›· Ì ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜, Ì ÛÎÔfi ÔÏϤ˜ ÊÔÚ¤˜ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜. ∏ Î¿Ï˘„Ë Ô˘ ·Ú¤¯ÂÙ·È Û ٤ÙÔȘ ÂÚÈÙÒÛÂȘ ̤ۈ ÙÔ˘ ÙËÏÂÊÒÓÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ·È‰È¿ÙÚÔ˘ Î·È ÁÈ· ÙËÓ ÔÈÎÔ‰fiÌËÛË Î·ÏÒÓ Û¯¤ÛÂˆÓ Ì ÙÔ˘˜ ÁÔÓ›˜. ªÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ·Ú¤¯ÔÓÙ·È ·Ó·ÚΛ˜ ÙËÏÂʈÓÈΤ˜ Û˘Ì‚Ô˘Ï¤˜ ·fi ˘Â‡ı˘ÓÔ˘˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ·È‰ÈÒÓ. ŒÙÛÈ, Ë ·Ó¿Ù˘ÍË ÂÎ·È‰Â˘ÙÈÎÒÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ - Ô˘ ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙË ¯ÒÚ· Ì·˜ - ÁÈ· ·˘Ùfi ÙÔ ÛËÌ·ÓÙÈÎfi fiÛÔ Î·È ·ÌÊÈÏÂÁfiÌÂÓÔ ÎÔÌÌ¿ÙÈ Ù˘ ·È‰È·ÙÚÈ΋˜ Ú·ÎÙÈ΋˜, ·ÔÙÂÏ› Ì›· Û‡Á¯ÚÔÓË ·Ó·ÁηÈfiÙËÙ·. ™ÙËÓ Î·Ù‡ı˘ÓÛË ·˘Ù‹ ¤¯Ô˘Ó ·Ó·Ù˘¯ı›, ΢ڛˆ˜ ÛÙȘ ∏¶∞, ÙËÏÂʈÓÈΤ˜ ·È‰È·ÙÚÈΤ˜ Û˘ÛÙ¿ÛÂȘ, Ì ÙȘ Ôԛ˜ ·Ú¤¯ÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ‰È·ÏÔÁ‹˜ ÙˆÓ ·È‰ÈÒÓ Î·È ·ÚÔ¯‹˜ Ô‰ËÁÈÒÓ Î·È Û˘Ì‚Ô˘ÏÒÓ ·fi ÙÔ ÙËϤʈÓÔ. ™ÎÔfi˜ ÙÔ˘ ¿ÚıÚÔ˘ Â›Ó·È Ó· ‰ÒÛÂÈ ÛÙÔÓ ÎÏÈÓÈÎfi ·È‰›·ÙÚÔ Ì›· ÁÂÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡ - fiˆ˜ ·˘Ùfi˜ ÚÔ·ÙÂÈ ·fi ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ - Î·È Ó· ı›ÍÂÈ, ›Ûˆ˜ ÁÈ· ÚÒÙË ÊÔÚ¿, ÔÚÈṲ̂Ó˜ ÂӉȷʤÚÔ˘Û˜ Ù˘¯¤˜ ÙÔ˘ ı¤Ì·ÙÔ˜.
∏ ÙËÏÂʈÓÈ΋ È·ÙÚÈ΋ ÛÙËÓ ·È‰È·ÙÚÈ΋: ÈÛÙÔÚÈ΋ ·Ó·‰ÚÔÌ‹ 1876: £ÂˆÚÂ›Ù·È Ë ¯ÚÔÓÈ¿ ·Ó·Î¿Ï˘„˘ ÙÔ˘ ÙËÏÂÊÒÓÔ˘ ·fi ÙÔÓ Alexander G. Bell, ∞ÌÂÚÈηÓfi™ÎˆÙÛ¤˙Ô ∫·ıËÁËÙ‹ Ù˘ º˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ ÏfiÁÔ˘ ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ Ù˘ µÔÛÙfiÓ˘, Ô ÔÔ›Ô˜ ÂӉȷʤÚıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ·ÓıÚÒÈÓ˘ ʈӋ˜. 1879: ∏ ÚÒÙË ·Ó·ÊÔÚ¿ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·ÓÙÈÌÂÙÒÈÛ˘ ÎÏÈÓÈÎÔ‡ ÂÚÈÛÙ·ÙÈÎÔ‡ ÙËÏÂʈÓÈο (1). ª›· ·Ó‹Û˘¯Ë ÌËÙ¤Ú· ηÏ› ÙÔÓ ·È‰›·ÙÚÔ ÌÂÙ·ÌÂÛÔÓ‡¯ÙÈ· ÒÚ· ÁÈ·Ù› ÓÔÌ›˙ÂÈ fiÙÈ ÙÔ ÌÈÎÚfi ·È‰› Ù˘ ¤¯ÂÈ croup. O ÁÈ·ÙÚfi˜ ϤÂÈ ÛÙË ÌËÙ¤Ú· Ó· ÙÔÔıÂÙ‹ÛÂÈ ÙÔ ·È‰› ‰›Ï· ÛÙÔ ·ÎÔ˘ÛÙÈÎfi ÁÈ· Ó· ·ÎÔ‡ÛÂÈ Ò˜ ‚‹¯ÂÈ Î·È ‰È·ÈÛÙÒÓÔÓÙ·˜ fiÙÈ ‰ÂÓ ¤¯ÂÈ croup, ηıËÛ‡¯·Û ÙË ÌËÙ¤Ú·. 1930-1950: ªÂ ÙËÓ Â˘Ú›· ‰È¿‰ÔÛË ÙÔ˘ ÙËÏÂÊÒÓÔ˘ ÛÙÔÓ ‰˘ÙÈÎfi ÎfiÛÌÔ, ·Ó·Ù‡ÛÛÂÙ·È Î·È Ë ÚÔÛ‰ÔΛ· ÁÈ· ·ÚÔ¯‹ 24ˆÚ˘ ÙËÏÂʈÓÈ΋˜ Î¿Ï˘„˘ ·fi ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜. 1960-1970: ™Â ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó ÛÙȘ ∏¶∞, ‰È·ÈÛÙÒıËΠfiÙÈ Ô ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ ÂÚÓ¿ ÙÔ 12,5% Ù˘ ÂÚÁ¿ÛÈÌ˘ Ë̤ڷ˜ ÛÙÔ ÙËϤʈÓÔ ‹ ··Û¯ÔÏÂ›Ù·È 11,9±2,8 ÒÚ˜ ÙËÓ Â‚‰ÔÌ¿‰· ‰›ÓÔÓÙ·˜ ÙËÏÂʈÓÈΤ˜ Û˘Ì‚Ô˘Ï¤˜ (2,3). OÈ ·È‰›·ÙÚÔÈ Â›Ó·È ÔÈ ÁÈ·ÙÚÔ› Ì ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ¯Ú‹Û˘ Ù˘ ÙËÏÂʈÓÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ ÁÈ· ÎÏÈÓÈ΋ ÊÚÔÓÙ›‰· ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘˜. 1972: ∏ ∞ÌÂÚÈηÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∞η‰ËÌ›· (∞∞P) ÂΉ›‰ÂÈ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·fi ¶·È‰È·ÙÚÈ΋ 2005;68:29-35
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·30
30
¶. µÂϤÓÙ˙·˜
ÙÔ ÙËϤʈÓÔ ÎÔÈÓÒÓ ·È‰È·ÙÚÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ (4). ∞Ú¯›˙ÂÈ Ë ‰ËÌÔÛ›Â˘ÛË ÙˆÓ ÚÒÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛˆÓ. 1985: ∆· ÌÈÛ¿ (51%) ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· ÛÙȘ ∏¶∞ ·Ú¤¯Ô˘Ó ÛÙÔ˘˜ ÂȉÈ΢fiÌÂÓÔ‡˜ ÙÔ˘˜ οÔÈ·˜ ÌÔÚÊ‹˜ Âη›‰Â˘ÛË ÛÙËÓ ÙËÏÂʈÓÈ΋ È·ÙÚÈ΋, fiˆ˜ ‰È·Ï¤ÍÂȘ, ·Ó·ÛÎfiËÛË ÙËÏÂʈÓÈÎÒÓ Û˘Ó‰È·Ï¤ÍˆÓ, ‰È‰·Ûηϛ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÎÏ‹Û˘ Î·È ¯ÚËÛÈÌÔÔ›ËÛË ˘ÔıÂÙÈÎÒÓ ·ÛıÂÓÒÓ (5). ∆ÂÏÂ˘Ù·›·, ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂȉÈο CD-ROM ÁÈ· Âη›‰Â˘ÛË Ì¤Ûˆ ˘ÔÏÔÁÈÛÙ‹ (6). 1988: OÚÁ·ÓÒÓÂÙ·È ÙÔ ÚÒÙÔ ·È‰È·ÙÚÈÎfi ÙËÏÂʈÓÈÎfi ΤÓÙÚÔ (after-hours pediatric call center) ÛÙÔ Denver, Ì ÙËÓ ÂıÂÏÔÓÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ȉȈÙÒÓ ·È‰È¿ÙÚˆÓ Î·È ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ηıÔ‰‹ÁËÛË Î·È ÔÚÁ¿ÓˆÛË ÙÔ˘ ·ÓÂÈÛÙËÌÈ·ÎÔ‡ ·È‰È·ÙÚÈÎÔ‡ ÓÔÛÔÎÔÌ›Ԣ Ù˘ fiÏ˘ (7). ∆Ô 1998, Ë AAP Âͤ‰ˆÛ ԉËÁ›Â˜ ÁÈ· ÙËÓ ÔÚÁ¿ÓˆÛË ·È‰È·ÙÚÈÎÒÓ ÙËÏÂʈÓÈÎÒÓ Î¤ÓÙÚˆÓ (8). ™‹ÌÂÚ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 25% ÙˆÓ ÁÂÓÈÎÒÓ ·È‰È¿ÙÚˆÓ ÛÙȘ ∏¶∞ ηχÙÂÈ ÙȘ ÙËÏÂʈÓÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘ ÛÙȘ ÌË ÂÚÁ¿ÛÈ̘ ÒÚ˜ Î·È Ë̤Ú˜ ̤ۈ Ù¤ÙÔÈˆÓ ÔÚÁ·ÓˆÌ¤ÓˆÓ ΤÓÙÚˆÓ (8). ™ÙËÓ ›‰È· ¯ÒÚ·, ›Û˘, ÂÓı·ÚÚ‡ÓÂÙ·È Ë ÂÚÁ·Û›· ÙˆÓ ·È‰È¿ÙÚˆÓ Û ÌÈÎÚ¤˜ ÔÌ¿‰Â˜ (3-8 ÁÈ·ÙÚÔ›) Î·È Ë ÔÚÁ¿ÓˆÛË ÌÈÎÚfiÙÂÚˆÓ ÙËÏÂʈÓÈÎÒÓ Î¤ÓÙÚˆÓ Ô˘ Ó· ηχÙÔ˘Ó Ù· ̤ÏË Ù˘ ÔÌ¿‰·˜. 1990: ∆Ô American College of Emergency Physicians ıˆÚ› fiÙÈ Ù· ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ ‰ÂÓ Ú¤ÂÈ Ó· ı¤ÙÔ˘Ó ‰È¿ÁÓˆÛË Ô‡Ù ӷ ‰›ÓÔ˘Ó Î¿ÔÈ· ıÂڷ›· ·fi ÙÔ ÙËϤʈÓÔ, ÂÎÙfi˜ Â¿Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ‹‰Ë ÂÍÂÙ·ÛÙ› ÛÙ· ›ÁÔÓÙ· Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ‰È¢ÎÚÈÓ›ÛÂȘ ÁÈ· ÙË ıÂڷ›· ÙÔ˘˜, Â¿Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÚÔ¯‹ ÚÒÙˆÓ ‚ÔËıÂÈÒÓ ‹ ÁÈ· ÙËÓ ˘fi‰ÂÈÍË ÙÚfiÔ˘ ÚfiÛ‚·Û˘ ÁÈ· È·ÙÚÈ΋ ÊÚÔÓÙ›‰· (9). 2000: ∏ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ·ÊÔÚ¿ ÛÙÔ 30% Ù˘ ηıËÌÂÚÈÓ‹˜ ÎÏÈÓÈ΋˜ Ú·ÎÙÈ΋˜ ÙÔ˘ ÁÂÓÈÎÔ‡ ·È‰È¿ÙÚÔ˘ Î·È Êı¿ÓÂÈ ÛÙÔ 80% ÛÙȘ ÌË ÂÚÁ¿ÛÈ̘ ÒÚ˜ Î·È Ë̤Ú˜ (10). ¶·Ú·ÙËÚ›ٷÈ, ‰ËÏ·‰‹, ·‡ÍËÛË Ù˘ ÙËÏÂʈÓÈ΋˜ È·ÙÚÈ΋˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÏfiÁˆ Ù˘ ·Ó¿Ù˘Í˘ Ù˘ Ù¯ÓÔÏÔÁ›·˜ (ÎÈÓËÙ‹ ÙËÏÂʈӛ·) Î·È Î˘Ú›ˆ˜ ÏfiÁˆ ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ÙÚfiÔ˘ ˙ˆ‹˜ (ÂÚÁ·˙fiÌÂÓÔÈ Î·È ÔÈ ‰‡Ô ÁÔÓ›˜, ·È‰ÈÎÔ› ÛÙ·ıÌÔ› Î.¿.). 2002: ∫˘ÎÏÔÊÔÚ› Ë ÙÂÏÂ˘Ù·›· ¤Î‰ÔÛË ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ ·fi ÙËÓ AAP, ÙËÓ ÔÔ›· ÌÔÚ› Ó· ÚÔÌËı¢Ù› οı ÂӉȷÊÂÚfiÌÂÓÔ˜ ̤ۈ Ù˘ ÈÛÙÔÛÂÏ›‰·˜ Ù˘ ∞η‰ËÌ›·˜ (www.aap.org/bst).
™¯¤ÛË ·È‰È¿ÙÚˆÓ-ÙËÏÂÊÒÓÔ˘ ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÔ˘Ó Î·Ï‡ÙÂÚ· ηٷÓÔËÙ¤˜ ÔÈ ·fi„ÂȘ ÙˆÓ ·È‰È¿ÙÚˆÓ ÁÈ· ·˘Ù‹ ÙË Û¯¤ÛË, ·˜ ¶·È‰È·ÙÚÈ΋ 2005;68:29-35
˘ÔÙÂı› fiÙÈ ¤Ó·˜ ·È‰›·ÙÚÔ˜ ·Ú·ÎÔÏÔ˘ı› ÛÙÔ È·ÙÚÂ›Ô ÙÔ˘ 500 ÔÈÎÔÁ¤ÓÂȘ (1000 ·È‰È¿) Î·È fiÙÈ Î¿ı ÔÈÎÔÁ¤ÓÂÈ· ı· ÙÔ˘ ÙËÏÂʈӋÛÂÈ Ó˘ÎÙÂÚÈÓ‹ ÒÚ· 2 ÊÔÚ¤˜ ÙÔÓ ¯ÚfiÓÔ. ∂¿Ó Ë ÓÔÛËÚfiÙËÙ· ÛÙËÓ ÎÔÈÓfiÙËÙ· Â›Ó·È 2%, Ô ·È‰›·ÙÚÔ˜ ı· ‰¤¯ÂÙ·È Î·ıËÌÂÚÈÓ¿ 3 Ó˘ÎÙÂÚÈÓ¤˜ ÎÏ‹ÛÂȘ Î·È 20 ËÌÂÚ‹ÛȘ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ. ∂¿Ó Û ·˘Ù¤˜ ÚÔÛÙÂıÔ‡Ó Î·È ÔÈ ÎÏ‹ÛÂȘ ÁÈ· ÂÓË̤ڈÛË Û ˙ËÙ‹Ì·Ù· ·Ó¿Ù˘Í˘, ‰È·ÙÚÔÊ‹˜ ‹ ÂÌ‚ÔÏÈ·ÛÌÒÓ, ÙfiÙ ÚfiÎÂÈÙ·È ÁÈ· Ú·ÁÌ·ÙÈ΋ “¯ÈÔÓÔÛÙÈ‚¿‰·” ÙËÏÂʈÓËÌ¿ÙˆÓ, ÛÙ· ÔÔ›· Ô ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ ηÏÂ›Ù·È Ó· ·ÓÙ·ÔÎÚÈı› ηıËÌÂÚÈÓ¿. ¢ÂÓ ı· ‹Ù·Ó ˘ÂÚ‚ÔÏ‹, ÂÔ̤ӈ˜, Ó· ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ Û¯¤ÛË “·Á¿Ë˜/Ì›ÛÔ˘˜”. “∞Á¿Ë˜” ÁÈ·Ù› Ë ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Â›Ó·È ¿ÌÂÛË Î·È Â‡ÎÔÏË, ÂÓÒ Ë ÛˆÛÙ‹ Î·È ÏÔÁÈ΋ ¯Ú‹ÛË Ù˘ ‚ÔËı¿ÂÈ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ηÏÒÓ Û¯¤ÛÂˆÓ Ì ÙÔ˘˜ ÁÔÓ›˜. ∂›Û˘, Â›Ó·È ¯Ú‹ÛÈÌË fiÙ·Ó ÌÂÈÒÓÂÈ ÙÔÓ ÊfiÚÙÔ ÂÚÁ·Û›·˜ ÛÙÔ È·ÙÚ›Ô, ¯ˆÚ›˜ Ó· ‰ËÌÈÔ˘ÚÁ› ·›ÛıËÌ· ·Ó·ÛÊ¿ÏÂÈ·˜ ÛÙÔ˘˜ ÁÔÓ›˜. “ª›ÛÔ˘˜” ÁÈ·Ù› ÔÈ ÎÏ‹ÛÂȘ Á›ÓÔÓÙ·È ·ÈÙ›· ÁÈ· Û˘Ó¯›˜ ‰È·ÎÔ¤˜ Ù˘ ÂͤٷÛ˘ ÛÙÔ È·ÙÚ›Ô, ·ÏÏ¿ ΢ڛˆ˜ ÁÈ·Ù› ÙÔ ÙËϤʈÓÔ “ÂÈÛ¿ÁÂÈ” ÙËÓ ÂÚÁ·Û›· ÛÙËÓ ÚÔÛˆÈ΋ Î·È ÔÈÎÔÁÂÓÂȷ΋ ˙ˆ‹ ÙÔ˘ ÁÈ·ÙÚÔ‡, ÂÓÒ ·Ú¿ÏÏËÏ· ·ÔÙÂÏ› Ì›· Ú·ÎÙÈ΋ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· È·ÙÚÈÎfi Ï¿ıÔ˜. ¢ÂÓ ·ÔÙÂÏÔ‡Ó ¤ÎÏËÍË Â˘Ú‹Ì·Ù· ÌÂÏÂÙÒÓ Û‡Ìʈӷ Ì ٷ ÔÔ›· 50,5% ÙˆÓ ·È‰È¿ÙÚˆÓ ÈÛÙ‡ÂÈ fiÙÈ ÙÔ ÙËϤʈÓÔ Â›Ó·È Ë “ÈÔ ·ÔÁÔËÙ¢ÙÈ΋” ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘˜ (11) Î·È 54% fiÙÈ ÔÈ Ó˘ÎÙÂÚÈÓ¤˜ ÎÏ‹ÛÂȘ Â›Ó·È “Ôχ ÂÓÔ¯ÏËÙÈΤ˜” Ì ÔÛÔÛÙfi 35% ·˘ÙÒÓ ÙˆÓ ÎÏ‹ÛÂˆÓ Ó· Â›Ó·È “ÌË ··Ú·›ÙËÙ˜” (12). ∆Ô 31% ÙˆÓ ·È‰È¿ÙÚˆÓ ı· ‹ıÂÏ ÏfiÁˆ ÙˆÓ ÂÓÔ¯ÏËÙÈÎÒÓ ÎÏ‹ÛÂˆÓ Ó· ÛÙ·Ì·Ù‹ÛÂÈ ÙËÓ ÂÚÁ·Û›· ÙÔ˘, ÂÓÒ ÙÔ 60% ıˆÚ› fiÙÈ Ô ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· ·Ì›‚ÂÙ·È ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ÊÚÔÓÙ›‰· Ô˘ ·Ú¤¯ÂÈ Ì¤Ûˆ ÙÔ˘ ÙËÏÂÊÒÓÔ˘ (13). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ ı¤Ì· Ù˘ ·Ô˙ËÌ›ˆÛ˘ ÁÈ· ÙȘ Û˘Ì‚Ô˘Ï¤˜ Î·È ÙȘ Ô‰ËÁ›Â˜ Ô˘ ·Ú¤¯ÔÓÙ·È ·fi ÙÔ ÙËϤʈÓÔ, ˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜. ∞˘ÙÔ› Ô˘ Û˘ÌʈÓÔ‡Ó Ì ÙËÓ ‡·ÚÍË ·ÌÔÈ‚‹˜, ıˆÚÔ‡Ó fiÙÈ Ô ÁÈ·ÙÚfi˜ ·ÓÙÈÌÂÙˆ›˙ÂÈ ÔÏÏ¿ ÎÔÈÓ¿ ·È‰È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù· ·fi ÙÔ ÙËϤʈÓÔ, ¯¿ÓÂÈ ÛËÌ·ÓÙÈÎfi ÂÚÁ¿ÛÈÌÔ ¯ÚfiÓÔ Î·È ¤¯ÂÈ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ˘Ô¤ÛÂÈ Û ȷÙÚÈÎfi ÛÊ¿ÏÌ·. ŸÛÔÈ ‰È·ÊˆÓÔ‡Ó, ıˆÚÔ‡Ó ÙËÓ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ·Ó·fiÛ·ÛÙÔ ÎÔÌÌ¿ÙÈ Ù˘ Û˘ÓÔÏÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ·È‰ÈÔ‡ Î·È ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Â¿Ó ˘¿Ú¯ÂÈ ·ÌÔÈ‚‹, ›Ûˆ˜ ·Ôı·ÚÚ‡ÓÔÓÙ·È ÔÈ ÁÔÓ›˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌËÓ Î·ÏÔ‡Ó ÁÈ· Èı·Ó¤˜ ÛÔ‚·Ú¤˜ ηٷÛÙ¿ÛÂȘ. ∂ÈϤÔÓ, Â›Ó·È Èı·Ófi Ó· ‰ËÌÈÔ˘ÚÁËı› ·ÚÓËÙÈ΋ ÂÈÎfiÓ· ÁÈ· ÙÔ È·ÙÚÈÎfi ÏÂÈÙÔ‡ÚÁËÌ·, Ó· ˘¿ÚÍÔ˘Ó ˘ÂÚ‚ÔÏÈΤ˜ ÔÈÎÔÓÔÌÈΤ˜ ··ÈÙ‹ÛÂȘ ‹, Ù¤ÏÔ˜, Ó· ·˘ÍËıÔ‡Ó ÔÈ ·‰ÈηÈÔÏfiÁËÙ˜ ÂÈÛΤ„ÂȘ ÛÙÔ È·ÙÚ›Ô.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·31
31
¶·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ
∆‡ÔÈ ÎÏÈÓÈ΋˜ ÊÚÔÓÙ›‰·˜ ·fi ÙÔ ÙËϤʈÓÔ ÛÙËÓ ·È‰È·ÙÚÈ΋ ∏ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù¤ÛÛÂÚȘ Ù‡Ô˘˜ ÎÏÈÓÈ΋˜ ÊÚÔÓÙ›‰·˜ (14): ·) ¢È·ÏÔÁ‹ (triage) Î·È ·ÚÔ¯‹ Û˘Ì‚Ô˘ÏÒÓ (advice) Û ·È‰È¿ Ì Ô͇ ÎÏÈÓÈÎfi Úfi‚ÏËÌ·. ∏ ϤÍË “triage” (Á·ÏÏÈ΋˜ ÚÔ¤Ï¢Û˘) ÛËÌ·›ÓÂÈ “οӈ ‰È·ÏÔÁ‹” Î·È ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ Û ÔÏÂÌÈΤ˜ Ì¿¯Â˜ (15). ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ ÙËÏÂʈÓÈ΋˜ È·ÙÚÈ΋˜, ‰È·ÏÔÁ‹ ÛËÌ·›ÓÂÈ fiÙÈ Ô ÁÈ·ÙÚfi˜ Ì ٷ ÛÙÔȯ›· ·fi ÙÔ ÈÛÙÔÚÈÎfi Ô˘ Û˘ÁÎÂÓÙÚÒÓÂÈ ÙËÏÂʈÓÈο - ηıÔÚ›˙ÂÈ ÙÔÓ ‚·ıÌfi ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÂÈϤÁÂÈ ÙÔÓ Î·Ù¿ÏÏËÏÔ - ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË - ¯ÚfiÓÔ, ÙfiÔ Î·È ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ‹˜ Ù˘. ‚) ¶·ÚÔ¯‹ ÏËÚÔÊÔÚÈÒÓ ÁÈ· ı¤Ì·Ù· ˘Á›·˜, ÚfiÏ˄˘, ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ Î·È Âη›‰Â˘Û˘ ÙˆÓ ÁÔÓ¤ˆÓ. ∂›Ó·È ¤Ó· Ôχ ‚·ÛÈÎfi ÎÔÌÌ¿ÙÈ Ù˘ ·È‰È·ÙÚÈ΋˜ ·fi ÙÔ ÙËϤʈÓÔ, Ô˘ ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘. Á) ¶·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ‹‰Ë ÂÍÂÙ·ÛÙ› ÛÙÔ È·ÙÚ›Ô. ‰) ¶·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ì ¯ÚfiÓÈÔ ÓfiÛËÌ·. ∞˘Ùfi˜ Ô Ù‡Ô˜ ÎÏÈÓÈ΋˜ ÊÚÔÓÙ›‰·˜ ·fi ÙÔ ÙËϤʈÓÔ ·ÊÔÚ¿ ΢ڛˆ˜ Û ·È‰È¿ÙÚÔ˘˜ Ì ÂÍÂȉ›Î¢ÛË. ∆ÔÓ ÁÂÓÈÎfi ·È‰›·ÙÚÔ ··Û¯ÔÏ› Î·È ÚÔ‚ÏËÌ·Ù›˙ÂÈ Î˘Ú›ˆ˜ Ô ÚÒÙÔ˜ Ù‡Ô˜ ÎÏÈÓÈ΋˜ ÊÚÔÓÙ›‰·˜ ·fi ÙÔ ÙËϤʈÓÔ, ηıÒ˜ ·˘Ùfi Â›Ó·È ÙÔ ÂÚȯfiÌÂÓÔ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÎÏ‹ÛÂˆÓ Ô˘ ‰¤¯ÂÙ·È - ȉȷ›ÙÂÚ· Û ÌË ÂÚÁ¿ÛÈ̘ ÒÚ˜ - Î·È Û ·˘ÙfiÓ ı· ·Â˘ı˘ÓıÔ‡Ó ÔÈ ÁÔÓ›˜ ÌfiÏȘ ÙÔ ·È‰› ÙÔ˘˜ ·ÚÔ˘ÛÈ¿ÛÂÈ ÔÔÈÔ‰‹ÔÙ ÎÏÈÓÈÎfi Úfi‚ÏËÌ·.
¢˘ÛÎÔϛ˜ Ù˘ ·È‰È·ÙÚÈ΋˜ ·fi ÙÔ ÙËϤʈÓÔ (14) ∏ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÚÎÂÙ¤˜ ‰˘ÛÎÔϛ˜ ÁÈ· ÙÔÓ ·È‰›·ÙÚÔ: ·) ∏ ÂÈÎÔÈÓˆÓ›· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Î·È ·Ô˘ÛÈ¿˙Ô˘Ó ÔÈ ÏËÚÔÊÔڛ˜ ·fi ÙËÓ ÚfiÛˆÔ Ì ÚfiÛˆÔ Â·Ê‹ Ì ÙÔ ·È‰›. ŒÙÛÈ, ÌÔÚ› Ó· ÌËÓ ÂÎÙÈÌËı› ÛˆÛÙ¿ Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡, ÏËÚÔÊÔÚ›· ÎÚ›ÛÈÌ˘ ÔÏϤ˜ ÊÔÚ¤˜ ÛËÌ·Û›·˜, ÂȉÈο Â¿Ó ÚfiÎÂÈÙ·È ÁÈ· ‚Ú¤ÊÔ˜. ‚) O ÁÈ·ÙÚfi˜ ¤¯ÂÈ Û˘Ó‹ıˆ˜ ÏÈÁfiÙÂÚÔ ¯ÚfiÓÔ - Û ۯ¤ÛË Ì ÙËÓ ÂͤٷÛË ÛÙÔ È·ÙÚÂ›Ô - ÁÈ· Ó· ·ÔÊ·Û›ÛÂÈ. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÔÈ ÎÏ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Û ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÔ‡ ÂÚÈÛÙ·ÙÈÎÔ‡ ¤¯Ô˘Ó ̤ÛË ‰È¿ÚÎÂÈ· 3-5 ÏÂÙ¿ Î·È ·˘Ùfi˜ Â›Ó·È Ô ¯ÚfiÓÔ˜ Ô˘ Ô ÁÈ·ÙÚfi˜ ı· Ú¤ÂÈ Ó· ¿ÚÂÈ ÙȘ ·ÔÊ¿ÛÂȘ ÙÔ˘. Á) O ÁÈ·ÙÚfi˜ ‰ÂÓ ÌÔÚ› Ó· ÂÍÂÙ¿ÛÂÈ ÙÔ ·È‰› Î·È Û˘Ó‹ıˆ˜ ‰ÂÓ ÌÈÏ¿ Ì·˙› ÙÔ˘. ∞ÎfiÌ· Î·È ÁÈ· ÌÂÁ¿Ï· ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜, ÙÔ ÈÛÙÔÚÈÎfi Û˘Ó‹ıˆ˜ ‰›ÓÂÙ·È ·fi ÙÔ˘˜ ÁÔÓ›˜.
‰) O ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· ÌËÓ ÁÓˆÚ›˙ÂÈ ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. O ÔÈÎÔÁÂÓÂÈ·Îfi˜ ·È‰›·ÙÚÔ˜ Ô˘ ÁÓˆÚ›˙ÂÈ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÌÔÚ› Ó· ¿ÚÂÈ ÂÚÈÛÛfiÙÂÚ˜ Î·È ÈÔ ·ÍÈfiÈÛÙ˜ ÏËÚÔÊÔڛ˜ ·fi ÙÔ ÙËϤʈÓÔ Î·È ¤ÙÛÈ Ó· ¯ÂÈÚÈÛÙ› ÙËÓ ÂÚ›ÙˆÛË Ì ÌÂÁ·Ï‡ÙÂÚË ·ÛÊ¿ÏÂÈ·, Û ·ÓÙ›ıÂÛË Ì ÙÔÓ ÂÊËÌÂÚ‡ÔÓÙ· ÓÔÛÔÎÔÌÂÈ·Îfi ÁÈ·ÙÚfi, fiÔ˘ Ë ·Ô˘Û›· ÁÓˆÚÈÌ›·˜ Ì ÙÔÓ Û˘ÓÔÌÈÏËÙ‹ ÙÔ˘ Î·È Ô ÊfiÚÙÔ˜ ÂÚÁ·Û›·˜ Ú¤ÂÈ Ó· ÙÔÓ Î¿ÓÔ˘Ó Ôχ ÂÈÊ˘Ï·ÎÙÈÎfi. Â) ∆· ·È‰È¿ Â›Ó·È Û˘Ó‹ıˆ˜ ÂÚ›ÏÔÎÔÈ Î·È ‰‡ÛÎÔÏÔÈ ·ÛıÂÓ›˜. ÛÙ) ∏ ··›ÙËÛË ÁÈ· ÙËÏÂʈÓÈ΋ È·ÙÚÈ΋ ·ÚÔ˘ÛÈ¿˙ÂÈ ·‡ÍËÛË. ∏ ·‡ÍËÛË ·˘Ù‹ ‰ÂÓ Â›Ó·È ÌfiÓÔ ÔÛÔÙÈ΋, ·ÏÏ¿ Î·È ÔÈÔÙÈ΋. OÈ ÁÔÓ›˜ ›Ù ÁÈ· ÔÈÎÔÓÔÌÈÎÔ‡˜ ÏfiÁÔ˘˜ ›Ù ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ٷϷȈڛ·˜ ÌÂÙ¿‚·Û˘ ÛÙÔ È·ÙÚÂ›Ô ‹ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Û˘¯Ó¿ “Ȥ˙Ô˘Ó” ÙÔÓ ·È‰›·ÙÚÔ Ó· ı¤ÛÂÈ ·fi ÙÔ ÙËϤʈÓÔ ÙË ‰È¿ÁÓˆÛË ‹/Î·È Ó· ‰ÒÛÂÈ ıÂڷ›· ÛÙÔ ·È‰›. ∂›Ó·È ηı‹ÎÔÓ ÙÔ˘ ·È‰È¿ÙÚÔ˘ Ó· ÌËÓ “˘Ô·ÙÂÈ” Û ٤ÙÔȘ “‡ÎÔϘ” χÛÂȘ, ÔÈ Ôԛ˜ ÌÂÏÏÔÓÙÈο ÌÔÚ› Ó· ÙÔÓ ÂÎı¤ÛÔ˘Ó, ηıÒ˜ Î·È Ó· ı¤ÙÂÈ ÛÙÔ˘˜ ÁÔÓ›˜ Ù· ÛˆÛÙ¿ fiÚÈ· ÙˆÓ ‰˘Ó·ÙÔÙ‹ÙˆÓ Ô˘ ¤¯ÂÈ ÂÍ·ÛÎÒÓÙ·˜ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ. Œ¯ÂÈ ÂӉȷʤÚÔÓ Ì›· Á·ÏÏÈ΋ ÌÂϤÙË, Ô˘ ›¯Â ÛÎÔfi ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ Ï‹„˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ù˘ Û˘Ì‚Ô˘Ï‹˜ Ô˘ ·Ú¤¯ÂÙ·È Û ̛· ÌËÙ¤Ú·, Ë ÔÔ›· ˙ËÙ¿ ·fi ÙÔ ÙËϤʈÓÔ È·ÙÚÈ΋ ÁÓÒÌË ÁÈ· ÙÔ ·È‰› Ù˘ (16). ∆Ô ÂÚÈÛÙ·ÙÈÎfi ‹Ù·Ó ˘ÔıÂÙÈÎfi Î·È Ì›· ·fi Ù˘ ÂÚ¢ӋÙÚȘ - ÚÔÛÔÈÔ‡ÌÂÓË ÙË ÌËÙ¤Ú· - ¤ÏÂÁÂ: “£¤Ïˆ Ì›· Û˘Ì‚Ô˘Ï‹. ∆Ô ·È‰› ÌÔ˘ ¤¯ÂÈ ˘ÚÂÙfi Î·È ‰ÂÓ Í¤Úˆ ÙÈ Ó· οӈ”. OÈ ˘fiÏÔȘ ÏËÚÔÊÔڛ˜ ‰ÂÓ ‰›ÓÔÓÙ·Ó, ·Ú¿ ÌfiÓÔ Â¿Ó ÙȘ ˙ËÙÔ‡ÛÂ Ô Û˘ÓÔÌÈÏËÙ‹˜. ŒÙÛÈ, ı· ·ÔÎ·Ï˘ÙfiÙ·Ó fiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ı‹Ï˘ ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 4 ÌËÓÒÓ Ì ˘ÚÂÙfi 38,5-39,5ÔC, ÙÔ ÔÔ›Ô Â›¯Â Ï¿‚ÂÈ ‰‡Ô ‰fiÛÂȘ ·ÓÙÈ˘ÚÂÙÈÎÔ‡, ‹Ù·Ó ¢ÂÚ¤ıÈÛÙÔ, ‰ÂÓ Â›¯Â Ê¿ÂÈ Î·Ï¿, ›¯Â οÓÂÈ ¤Ó·Ó ¤ÌÂÙÔ, ·Ó¤Ó ÈÔ ÁÚ‹ÁÔÚ· Î·È ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔ ¯ÏˆÌfi ·fi ¿ÏÏË ÊÔÚ¿. ¢ÂÓ Â›¯Â ÚÈÓ›Ùȉ·, ‚‹¯·, ÂÍ¿ÓıËÌ· ‹ ‰È¿ÚÚÔÈ·. ∞fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÎÚ›ıËÎ·Ó ··Ú·›ÙËÙ˜ 13 ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙËÓ ÔÏÔÎÏËڈ̤ÓË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡, ÂÓÒ Ë ÛˆÛÙ‹ Ô‰ËÁ›· ı· ¤Ú ӷ ‹Ù·Ó Ë ¿ÌÂÛË ÂͤٷÛË ·fi ÙÔÓ ÂÊËÌÂÚ‡ÔÓÙ· ÁÈ·ÙÚfi, Ì Èı·Ó‹ ‰È¿ÁÓˆÛË ÙË ÛË„·ÈÌ›·. ∏ ¤Ú¢ӷ ·ÊÔÚÔ‡Û Û 100 ÓÔÛÔÎÔÌ›· (50 Ì ·È‰È·ÙÚÈÎfi ÙÌ‹Ì· Î·È 50 ¯ˆÚ›˜ ·˘Ùfi), ÂÓÒ Ô‰ËÁ›Â˜ ¤‰ˆÛ·Ó Ù· 94. ¶ÔÛÔÛÙfi 65% ·˘ÙÒÓ Ô˘ ¤‰ˆÛ·Ó ÙȘ Ô‰ËÁ›Â˜ ‹Ù·Ó ÁÈ·ÙÚÔ›, 34% ‹Ù·Ó ÓÔÛËÏÂ˘Ù¤˜ Î·È 1% ÁÚ·ÌÌ·Ù›˜. O ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ ÂÚˆÙ‹ÛÂˆÓ ‹Ù·Ó 3,1 (3,2 ÁÈ· ÁÈ·ÙÚÔ‡˜, 3,1 ÁÈ· ÓÔÛËÏÂ˘Ù¤˜). ¶ÔÛÔÛÙfi 36,1% ‰ÂÓ ÚÒÙËÛ ηıfiÏÔ˘ ÁÈ· ÙËÓ ËÏÈΛ· ‹/Î·È ÙË ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ‚Ú¤ÊÔ˘˜, 85% ÁÈ· ÙËÓ fiÚÂÍË ‹/Î·È ·Ó ¤Î·Ó ¤ÌÂÙÔ, 75% ÁÈ· ÙËÓ ·Ó·ÓÔ‹, ÂÓÒ Î·Ó¤Ó·˜ ‰ÂÓ ÚÒÙËÛ ÁÈ· ÙËÓ fi„Ë Î·È ÙÔ ¯ÚÒÌ· ÙÔ˘. ∞fi ÙȘ Ô‰ËÁ›Â˜ Ô˘ ‰fiıËηÓ, ÙÔ 18,1% ‰ÂÓ Û˘Ó¤ÛÙËÛ ¿ÌÂÛË È·ÙÚÈ΋ ÂͤٷÛË (21% ÁÈ·ÙÚÔ›, 8,6% ¶·È‰È·ÙÚÈ΋ 2005;68:29-35
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·32
32
¶. µÂϤÓÙ˙·˜
ÓÔÛËÏÂ˘Ù¤˜ Î·È 27,7% ÓÔÛÔÎÔÌ›· Ì ·È‰È·ÙÚÈÎfi ÙÌ‹Ì·, 8,5% ÓÔÛÔÎÔÌ›· ¯ˆÚ›˜ ·˘Ùfi), ÂÓÒ ÙÔ 7,5% ·˘ÙÒÓ Û˘Ó¤ÛÙËÛ ·Ú·ÌÔÓ‹ ÛÙÔ Û›ÙÈ. ¶·Ú¿ ÙȘ fiÔȘ ·‰˘Ó·Ì›Â˜ ›¯Â ÙÔ ˘ÔıÂÙÈÎfi ·˘Ùfi ÛÂÓ¿ÚÈÔ, ÔÈ ÂÚ¢ÓËÙ¤˜ ıˆÚÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·ÔÁÔËÙ¢ÙÈο (1 ÛÙ· 5 ÓÔÛÔÎÔÌ›· ÛÙË °·ÏÏ›· ¤‰ˆÛ ϿıÔ˜ ÙËÏÂʈÓÈΤ˜ Ô‰ËÁ›Â˜ ÁÈ· ¤Ó· ‚Ú¤ÊÔ˜ Ì Èı·Ó¿ ÛÔ‚·Ú‹ ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÚÔÙ›ÓÔ˘Ó fiÙÈ Ù· ÓÔÛÔÎÔÌ›· Ô˘ ı¤ÏÔ˘Ó Ó· ‰›ÓÔ˘Ó Ô‰ËÁ›Â˜ ·fi ÙÔ ÙËϤʈÓÔ ı· Ú¤ÂÈ Ó· ‰È·ı¤ÙÔ˘Ó Î·Ù·ÚÙÈṲ̂ÓÔ ÚÔÛˆÈÎfi, ÂȉÈΤ˜ Û˘ÛÙ¿ÛÂȘ, Ó· Á›ÓÂÙ·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏ‹ÛÂˆÓ Î·È Ó· ˘¿Ú¯ÂÈ Û˘Ó¯‹˜ Âη›‰Â˘ÛË ÙÔ˘ ÚÔÛˆÈÎÔ‡. ™Â Ì›· ·ÚfiÌÔÈ· ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙȘ ∏¶∞, 28,3% ·fi 61 ∆∂¶ Û˘Ó¤ÛÙËÛ ·Ú·ÌÔÓ‹ ÛÙÔ Û›ÙÈ ÁÈ· ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 5 ‚‰ÔÌ¿‰ˆÓ Ì ˘ÚÂÙfi 38,8ÔC (17). ∞ÎfiÌË Î·È ÁÈ·ÙÚÔ› Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘, ˆÛÙfiÛÔ, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ›¯·Ó ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ÙËÏÂʈÓÈΤ˜ Ô‰ËÁ›Â˜, ηıÒ˜ 25% ÙˆÓ È‰ÈˆÙÒÓ ·È‰È¿ÙÚˆÓ ÛÙȘ ∏¶∞ ‰ÂÓ ¤Ï·‚ ÙȘ ··Ú·›ÙËÙ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ‚Ú¤ÊÔ˜ Ì Èı·Ó‹ ˘ÏˆÚÈ΋ ÛÙ¤ÓˆÛË (18), ÂÓÒ Û ¿ÏÏË ÌÂϤÙË, 40% ÙˆÓ ·È‰È¿ÙÚˆÓ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘ ÂÎÙ›ÌËÛ ϿıÔ˜ ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ·Ê˘‰¿ÙˆÛ˘ ÂÓfi˜ ‚Ú¤ÊÔ˘˜ (19).
O‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·fi ÙÔ ÙËϤʈÓÔ OÈ ·ÎfiÏÔ˘ı˜ ÁÂÓÈΤ˜ Ô‰ËÁ›Â˜ ·ÊÔÚÔ‡Ó ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·fi ÙÔ ÙËϤʈÓÔ Î·È ÚÔÙ›ÓÔÓÙ·È ·fi ·ÚÎÂÙÔ‡˜ Û˘ÁÁÚ·Ê›˜ (4,20). O ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ÙȘ ÙÚÔÔÔÈ› ‹ Ó· ÙȘ ‚ÂÏÙÈÒÓÂÈ, ·Ó¿ÏÔÁ· Ì ÙȘ ÂÚÈÛÙ¿ÛÂȘ. ŒÙÛÈ, Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ: ·) Ó· Û˘ÛÙ‹ÓÂÙ·È Ì ÙÔ ÔÓÔÌ·ÙÂÒÓ˘ÌÔ Î·È ÙËÓ È‰ÈfiÙËÙ¿ ÙÔ˘. ‚) Ó· ÚˆÙ¿ ¿ÓÙ· ÙÔ fiÓÔÌ·, ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡, ηıÒ˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ Û˘ÓÔÌÈÏËÙ‹ ÙÔ˘ Î·È ÙË Û¯¤ÛË ÙÔ˘ Ì ÙÔ ·È‰›. ∏ ËÏÈΛ· Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ ÏËÚÔÊÔÚ›· ÁÈ· ÙË ÛˆÛÙ‹ ‰È·ÊÔÚԉȿÁÓˆÛË. Á) Ó· ÚˆÙ¿ ÁÈ· ÙËÓ ¤Ó·ÚÍË, ÙË ‰È¿ÚÎÂÈ· Î·È ÙËÓ ÂͤÏÈÍË ÙˆÓ Û˘Ìو̿وÓ, ηıÒ˜ Î·È ÙÔ Ò˜ ·˘Ù¿ ÂËÚ¿˙Ô˘Ó ÙÔÓ ‡ÓÔ, ÙËÓ fiÚÂÍË ÁÈ· Ê·ÁËÙfi Î·È ÙË ‰È¿ıÂÛË ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· ·È¯Ó›‰È. ‰) Ó· ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙȘ ÂÓ¤ÚÁÂȘ Ô˘ ¤¯Ô˘Ó ‹‰Ë οÓÂÈ ÔÈ ÁÔÓ›˜ (Â¿Ó ¤‚·Ï·Ó ıÂÚÌfiÌÂÙÚÔ, Â¿Ó ¤‰ˆÛ·Ó ·ÓÙÈ˘ÚÂÙÈÎfi, fiÛÔ Î·È fiÙ ‹ Â¿Ó ¤‰ˆÛ·Ó ¿ÏÏ· Ê¿Ú̷η). Â) Ó· ¯ÚËÛÈÌÔÔÈ› fiÚÔ˘˜ Ô˘ Â›Ó·È Â‡ÎÔÏ· ·ÓÙÈÏËÙÔ› Î·È Ó· ·ÔʇÁÂÈ ÙȘ ·Û¿ÊÂȘ. ÛÙ) Ó· ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙÔ Î‡ÚÈÔ Û‡Ìو̷ ÙÔ˘ ·È‰ÈÔ‡, ·ÏÏ¿ Î·È ·˘Ù¿ Ô˘ ÚÔηÏÔ‡Ó ÌÂÁ¿ÏÔ ¿Á¯Ô˜ ÛÙÔ˘˜ ÁÔÓ›˜. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ·ÚÈÔ˘ Û˘¶·È‰È·ÙÚÈ΋ 2005;68:29-35
ÌÙÒÌ·ÙÔ˜ Â›Ó·È ÛËÌ›Ô-ÎÏÂȉ›, ÁÈ·Ù› ¿Óˆ Û ·˘Ùfi ÔÈÎÔ‰ÔÌÂ›Ù·È Ë Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ë ‰È·ÏÔÁ‹ ÙÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡. ªÔÚ› Ó· ÌË Û˘Ì›ÙÂÈ Ì ·˘Ùfi Ô˘ ÔÈ ÁÔÓ›˜ ıˆÚÔ‡Ó ÈÔ ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÁÈ· ÙÔ ·È‰› ÙÔ˘˜. ˙) Ó· ·ÔÊ·Û›˙ÂÈ ÙËÓ ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡, Â¿Ó Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È ÂÚ›ÏÔÎË ‹/Î·È ÔÈ ÁÔÓ›˜ ȉȷ›ÙÂÚ· ·Ó‹Û˘¯ÔÈ. Ë) Ó· ÏËÚÔÊÔÚ› ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙËÓ Èı·Ó‹ ÔÚ›· Î·È ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ó· ÙÔ˘˜ ÂÈÛËÌ·›ÓÂÈ Ì ۷ʋÓÂÈ· fiÙ ڤÂÈ Ó· ·ÓËÛ˘¯‹ÛÔ˘Ó Î·È Ó· ÙÔÓ Í·Ó·Î·Ï¤ÛÔ˘Ó. ¶Ú¤ÂÈ Ó· ·ÔʇÁÂÈ Ó· ı¤ÙÂÈ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË ·fi ÙÔ ÙËϤʈÓÔ. ¶Èı·Ó‹ ‹ ÚÔÛˆÚÈÓ‹ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÁÓˆÛÙÔÔÈÂ›Ù·È ÛÙÔ˘˜ ÁÔÓ›˜ ÂÊfiÛÔÓ Ù· Û˘ÌÙÒÌ·Ù· Â›Ó·È Ù˘Èο (.¯. ÎÔÈÓfi ÎÚ˘ÔÏfiÁËÌ·, ·ÓÂÌ¢ÏÔÁÈ¿ ÌÂÙ¿ ·fi ÁÓˆÛÙ‹ ¤ÎıÂÛË ÛÙÔÓ Èfi Î.¿.). ı) Ó· ‚‚·Èˆı› fiÙÈ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Î·È ÙÔÓ ÂÍÔÏÈÛÌfi ÁÈ· Ó· ÂÊ·ÚÌfiÛÔ˘Ó ÙȘ Ô‰ËÁ›Â˜ Ô˘ ÙÔ˘˜ ‰fiıËηÓ. È) Ó· ÚˆÙ¿ ÙÔ˘˜ ÁÔÓ›˜, ÚÈÓ ÙÂÏÂÈÒÛÂÈ Ë Û˘ÓÔÌÈÏ›·, Â¿Ó ¤¯Ô˘Ó ·Ôڛ˜ Î·È Ó· ·ӷϷ̂¿ÓÂÈ ÙȘ Ô‰ËÁ›Â˜ Ô˘ ıˆÚÔ‡ÓÙ·È Ôχ ÛËÌ·ÓÙÈΤ˜. ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi Ó· ηٷÁÚ¿ÊÔÓÙ·È Ù· ·ÚÈ· ÛÙÔȯ›· Ù˘ Û˘ÓÔÌÈÏ›·˜, ÂȉÈο Â¿Ó ‰ÂÓ Â›Ó·È ÁÓˆÛÙÔ› ÔÈ ÁÔÓ›˜ Î·È Â¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ Ë ÚfiıÂÛË Ó· ÂÍÂÙ·ÛÙ› ¿ÌÂÛ· ÙÔ ·È‰› Î·È ¤¯ÂÈ ¯ÔÚËÁËı› ıÂڷ›·. ∏ ηٷÁÚ·Ê‹ ÙˆÓ ÎÏ‹ÛÂˆÓ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ÛÙȘ ∏¶∞, fiÔ˘ Û˘ÓÈÛÙ¿Ù·È ·fi ÙËÓ AAP ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÓÔÌÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ, Ô˘ - ·Ó Î·È Û¿ÓÈ· - Â›Ó·È ˘·ÚÎÙ¿ ÛÙË ¯ÒÚ· ·˘Ù‹ (21,22).
¢Â‰Ô̤ӷ ÁÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ·ÛÊ¿ÏÂÈ· ™ÙË Û˘Ó¤¯ÂÈ·, ·Ó·Ê¤ÚÔÓÙ·È ÂÓ Û˘ÓÙÔÌ›· ÌÂÚÈΤ˜ Ô‰ËÁ›Â˜ Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ı› Ô ·È‰›·ÙÚÔ˜, ÒÛÙ ӷ ¤¯ÂÈ ÂÚÈÛÛfiÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ·ÛÊ¿ÏÂÈ· ÂÍ·ÛÎÒÓÙ·˜ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ (14,23). °È· ÙË ÛˆÛÙ‹ ‰È·ÏÔÁ‹, Ú¤ÂÈ: ·) Ó· Á›ÓÔÓÙ·È ÚÒÙ· ÔÈ ÈÔ ÛËÌ·ÓÙÈΤ˜ ÂÚˆÙ‹ÛÂȘ, ‚) Ó· ÂÈÎÂÓÙÚÒÓÔÓÙ·È ÛÙÔ Î‡ÚÈÔ Û‡Ìو̷ ÙÔ˘ ·È‰ÈÔ‡, Á) Ó· Á›ÓÔÓÙ·È Î·Ù¿ Û‡ÛÙËÌ·, ‰) Ó· ˘¿Ú¯ÂÈ Â›ÁÓˆÛË Ù˘ ÎÏÈÓÈ΋˜ (˘ÔÛ˘Ó›‰ËÙ˘) ÚÔηٿÏ˄˘ (wellness bias/illness bias) ÙˆÓ ·È‰È¿ÙÚˆÓ. OÈ ·È‰›·ÙÚÔÈ Ô˘ ÂÚÁ¿˙ÔÓÙ·È ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë ‰¤¯ÔÓÙ·È ˆ˜ › ÙÔ Ï›ÛÙÔÓ ÎÏ‹ÛÂȘ ÁÈ· ÎÔÈÓ¿ Î·È ‹È· ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù·. OÈ ÓÔÛÔÎÔÌÂÈ·ÎÔ› ·È‰›·ÙÚÔÈ Î·È ÔÈ ÂȉÈ΢fiÌÂÓÔÈ ·Û¯ÔÏÔ‡ÓÙ·È Î˘Ú›ˆ˜ Ì ·È‰È¿ Ì ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ Î·È ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Û˘¯Ó¿ ÙȘ ÂÈÏÔΤ˜ ÙˆÓ ÎÔÈÓÒÓ ·È‰È·ÙÚÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ∏ ·ÓÙÈÎÂÈÌÂÓÈÎfiÙËÙ· Â›Ó·È ‰‡ÛÎÔÏË, ·ÏÏ¿ ··Ú·›ÙËÙË, Â) Ó·
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·33
33
¶·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ
ÂÓËÌÂÚÒÓÔ˘Ó ÔÈ ÁÔÓ›˜ ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ fiÙ·Ó Ù· Û˘ÌÙÒÌ·Ù· ÂÈ̤ÓÔ˘Ó, ·ÏÏ¿˙Ô˘Ó, ÂȉÂÈÓÒÓÔÓÙ·È, ÚÔηÏÔ‡Ó È‰È·›ÙÂÚÔ ¿Á¯Ô˜ ‹ Â›Ó·È ÂȉÈο οÔÈÔ˘ ÓÔÛ‹Ì·ÙÔ˜. °È· ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÂÈÎÔÈÓˆÓÈ·ÎÒÓ ÈηÓÔÙ‹ÙˆÓ (¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· fi¯È ÌfiÓÔ ·˘Ùfi Ô˘ ϤÁÂÙ·È, ·ÏÏ¿ Î·È Ô ÙÚfiÔ˜ Ô˘ ϤÁÂÙ·È), Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ: ·) Ó· ÚÔÛʈÓ› ÙÔÓ Û˘ÓÔÌÈÏËÙ‹ Ì ÙÔ Â›ıÂÙfi ÙÔ˘, ‚) Ó· Â›Ó·È Â˘ÁÂÓ‹˜ Î·È Úfiı˘ÌÔ˜ Ó· ÚÔÛʤÚÂÈ ÙË ‚Ô‹ıÂÈ¿ ÙÔ˘ (smile over phone), Á) Ó· ÌË ‰Â›¯ÓÂÈ ÂÓfi¯ÏËÛË Î·È Ó· ÌË ‚È¿˙ÂÙ·È, ‰) Ó· Â›Ó·È Î·Ïfi˜ ·ÎÚÔ·Ù‹˜ Î·È Î·Ïfi˜ “·Ó·ÎÚÈÙ‹˜”, Â) Ó· Â›Ó·È ¤ÙÔÈÌÔ˜ Ó· ¯ÂÈÚÈÛÙ› ÙÔ˘˜ ‰‡ÛÎÔÏÔ˘˜ Û˘ÓÔÌÈÏËÙ¤˜, fiˆ˜ Â›Ó·È ÔÈ ı˘ÌˆÌ¤ÓÔÈ, ·Á¯ˆÌ¤ÓÔÈ, ٷϷȈÚË̤ÓÔÈ Î·È Û ‰‡ÛÎÔÏË ÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË ÁÔÓ›˜, ηıÒ˜ Î·È ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ Â›Ó·È ÓfiÌÈÌÔÈ ÂÎÚfiÛˆÔÈ ÙÔ˘ ·È‰ÈÔ‡. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ıÔ‡Ó È·ÙÚÈο-ÓÔÌÈο ÚÔ‚Ï‹Ì·Ù·, Ú¤ÂÈ: ·) Ó· ÂÍ·ÛÎÂ›Ù·È ÛˆÛÙ‹ È·ÙÚÈ΋, ‚) Ó· ÔÚÁ·ÓÒÓÂÙ·È Û‡ÛÙËÌ· ηٷÁÚ·Ê‹˜ (documentation) ÙˆÓ ÎÏ‹ÛˆÓ, ÙfiÛÔ ÛÙÔ È·ÙÚÂ›Ô fiÛÔ Î·È ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Á) Ó· ·ÔʇÁÂÙ·È Ë ‰ËÌÈÔ˘ÚÁ›· ·ÈÛıËÌ¿ÙˆÓ ÂÓÔ¯‹˜ ÛÙÔ˘˜ ÁÔÓ›˜, ‰) Ó· ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Ú·ÏÈÛÙÈΤ˜ ÚÔÛ‰Ô˘ ÛÙÔ˘˜ ÁÔÓ›˜, Â) Ó· ÂÌÈÛÙ‡ÔÓÙ·È ÔÈ ÁÈ·ÙÚÔ› ÙÔ ¤ÓÛÙÈÎÙÔ Î·È ÙȘ ÂÌÂÈڛ˜ ÙÔ˘˜. ∏ ‰È·›ÛıËÛË Û ̛· ÙËÏÂʈÓÈ΋ Û˘ÓÔÌÈÏ›· Û˘Ó‰˘¿˙ÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÌÂÈÚ›· ÙÔ˘ ÁÈ·ÙÚÔ‡, ÙË ÁÓÒÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Ù˘ ÎÔÈÓfiÙËÙ·˜, ÙËÓ ·ÍÈÔÈÛÙ›· ÙˆÓ ÁÔÓ¤ˆÓ, ÙËÓ È‰ÈÔÛ˘ÁÎÚ·Û›· ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ÚfiÛ‚·Û˘ Û ȷÙÚÈ΋ ˘ËÚÂÛ›·. ¢ÂÓ Â›Ó·È ·Û˘Ó‹ıÈÛÙÔ, ÂÔ̤ӈ˜, Ë ‰È·›ÛıËÛË Ó· Â›Ó·È ÈÔ ·ÍÈfiÈÛÙË ·fi ÔÔÈÔ‰‹ÔÙ ۇÌو̷ ÙÔ˘ ·È‰ÈÔ‡, ÛÙ) ¿ÓÙ· Ó· ˙ËÙÂ›Ù·È - › ·ÌÊÈ‚ÔÏÈÒÓ - Ë ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡.
¶·È‰È·ÙÚÈΤ˜ ÙËÏÂʈÓÈΤ˜ Û˘ÛÙ¿ÛÂȘ OÈ ·È‰È·ÙÚÈΤ˜ ÙËÏÂʈÓÈΤ˜ Û˘ÛÙ¿ÛÂȘ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙȘ ∏¶∞ Â›Ó·È ÁÚ·Ù¤˜ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÏÈÓÈÎÒÓ ·È‰È·ÙÚÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·fi ÙÔ ÙËϤʈÓÔ, Ì ‚¿ÛË ÙÔ Î‡ÚÈÔ Û‡Ìو̷ ÙÔ˘ ·È‰ÈÔ‡ (23,24). ¢ÂÓ Â›Ó·È ‰ÂÛÌ¢ÙÈΤ˜ Î·È Ô Î¿ı ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÙȘ ‰ÈΤ˜ ÙÔ˘ Ì ‚¿ÛË ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ Î·È ÙËÓ Ú·ÎÙÈ΋ ÙÔ˘. ¢ÂÓ Â›Ó·È ‰È·ÁÓˆÛÙÈÎÔ› ·ÏÁfiÚÈıÌÔÈ Î·È ‰ÂÓ ·ÓÙÈηıÈÛÙÔ‡Ó ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË. OÈ Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ Â›Ó·È ¯Ú‹ÛÈ̘ ÛÙËÓ ÂÓÈ·›· ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ, ÛÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· È·ÙÚÈÎfi Ï¿ıÔ˜, ÛÙËÓ Î·Ï‡ÙÂÚË ÔÚÁ¿ÓˆÛË ÙÔ˘ È·ÙÚ›Ԣ Î·È ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏ‹ÛˆÓ, ηıÒ˜ Î·È ÛÙËÓ Âη›‰Â˘ÛË ÙÔ˘ È·ÙÚÈÎÔ‡ Î·È ÌË È·ÙÚÈÎÔ‡ ÚÔÛˆÈÎÔ‡ (14,22,25). ∏ ‰ÔÌ‹ ÙˆÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ·ÎfiÏÔ˘ı· (14,23,24): ·) ÔÚÈÛÌfi
ÙÔ˘ ·ÚÈÔ˘ Û˘ÌÙÒÌ·ÙÔ˜, ‚) Ï‹„Ë ÈÛÙÔÚÈÎÔ‡ Ì ‚¿ÛË ÙÔ Î‡ÚÈÔ Û‡Ìو̷, Á) ‰È·ÏÔÁ‹, Ì ¤ÓÙ·ÍË ÙÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ Û ̛· ·fi ÙȘ ηÙËÁÔڛ˜: i) ¿ÌÂÛË ÌÂÙ·ÊÔÚ¿ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (ÂÍ·ÈÚÂÙÈο ›ÁÔÓÙ·), ii) ¿ÌÂÛË ÂͤٷÛË ÛÙÔ È·ÙÚÂ›Ô ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (›ÁÔÓÙ·), iii) ÂͤٷÛË ÙËÓ ›‰È· Ë̤ڷ Û 12-24 ÒÚ˜ ‹ ÙËÓ ÂfiÌÂÓË >24 ÒÚ˜ (Ôͤ· ÌË Â›ÁÔÓÙ·), iv) ÂͤٷÛË Ì¤Û· Û 2 ‚‰ÔÌ¿‰Â˜ (¯ÚfiÓÈ· ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ·), v) ·Ú·ÌÔÓ‹ ÛÙÔ Û›ÙÈ (‹È·, ·˘ÙÔ˚ÒÌÂÓ·), ‰) Ô‰ËÁ›Â˜-Û˘Ì‚Ô˘Ï¤˜ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÛÙÔ Û›ÙÈ, Â) Ô‰ËÁ›Â˜ ÁÈ· ÂÚ·ÈÙ¤Úˆ ÂÈÎÔÈÓˆÓ›· Ì ÙÔÓ ·È‰›·ÙÚÔ.
∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ ÛÙËÓ ·È‰È·ÙÚÈ΋ ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ÔÛÔÛÙ¿ ‰È·ÏÔÁ‹˜ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ì ÙË ¯Ú‹ÛË ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (7,26-28). OÈ ‰È·ÊÔÚ¤˜ ÛÙ· ÔÛÔÛÙ¿ ÔÊ›ÏÔÓÙ·È ÙfiÛÔ ÛÙÔ ˘ÏÈÎfi ÙˆÓ ÌÂÏÂÙÒÓ (∆∂¶ ÓÔÛÔÎÔÌ›ˆÓ, È·ÙÚ›· ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘) fiÛÔ Î·È ÛÙÔ ¿ÙÔÌÔ Ô˘ ‹Ù·Ó Ô ·Ô‰¤ÎÙ˘ ÙˆÓ ÎÏ‹ÛÂˆÓ (ÁÈ·ÙÚÔ›, ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi). ™Â ÌÂϤÙ˜ ÛÙȘ ∏¶∞, fiÔ˘ Â›Ó·È Û‡ÓËı˜ ÛÙ· ÙËÏÂʈÓÈο ΤÓÙÚ· Ó· ··ÓÙÔ‡Ó ÓÔÛËÏÂ˘Ù¤˜ ÂȉÈο ÂÎ·È‰Â˘Ì¤ÓÔÈ ÛÙËÓ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÂÍ›ÛÔ˘ ÈηÓÔÔÈËÙÈο, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· (7,14,18). ∏ ÌfiÓË ‰È·ÊÔÚ¿ Ô˘ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Â›Ó·È fiÙÈ ÔÈ ÁÈ·ÙÚÔ› Û˘ÓÈÛÙÔ‡Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÙËÓ ¿ÌÂÛË ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÁÈ’ ·˘Ùfi, Ë ·fiÊ·ÛË ÁÈ· ·Ú·ÔÌ‹ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Ï·Ì‚¿ÓÂÙ·È ·fi ÙÔÓ ˘Â‡ı˘ÓÔ ÁÈ·ÙÚfi (second-level physician triage) (29). ŒÓ· ·ÎfiÌ· ˙‹ÙËÌ· Â›Ó·È Û ÔÈÔ ÔÛÔÛÙfi Â›Ó·È ÔÚı‹ Ë ¿ÌÂÛË ·Ú·ÔÌ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÂÓfi˜ ·È‰ÈÔ‡ ÌÂÙ¿ ÙË ¯Ú‹ÛË ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ (ηٿ οÔÈÔ ÙÚfiÔ Ë ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ·Ú·ÔÌ‹˜). ª›· ÂӉȷʤÚÔ˘Û· ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ÌÂÁ¿ÏÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌÂ›Ô ÙˆÓ ∏¶∞, ¤‰ÂÈÍ fiÙÈ ÙÔ 80,5% ÙˆÓ ·Ú·ÔÌÒÓ Ô˘ ¤ÁÈÓ·Ó Ì¤Ûˆ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ ‹Ù·Ó ÔÚı¤˜, ÂÓÒ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ ÌfiÓÔ 60,8% (30). ∂Ô̤ӈ˜, Ê·›ÓÂÙ·È fiÙÈ Ë ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ - Ì ÙËÓ Î·Ù¿ÏÏËÏË ÔÚÁ¿ÓˆÛË Î·È Âη›‰Â˘ÛË - ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙȘ ÌË ·Ó·Áη›Â˜ ÂÈÛΤ„ÂȘ ÛÙ· ∆∂¶ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÔÈÎÔÓÔÌ›· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜.
¶›Ó·Î·˜ 1. ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ ÛÙËÓ ·È‰È·ÙÚÈ΋ ¢È·ÏÔÁ‹ ∆ËÏÂʈÓÈΤ˜ Ô‰ËÁ›Â˜ ÌfiÓÔ ∂ͤٷÛË ÙËÓ ÂfiÌÂÓË Ë̤ڷ ÕÌÂÛË ÂͤٷÛË
40-60% 25-40% 10-25% ¶·È‰È·ÙÚÈ΋ 2005;68:29-35
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·34
34
¶. µÂϤÓÙ˙·˜
∏ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ Î·ı˘ÛÙÂÚ› ÙË ‰È¿ÁÓˆÛË ‹/Î·È ÙË ıÂڷ›· ÛÔ‚·ÚÒÓ ÂÚÈÙÒÛˆÓ; ∏ ¢·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ·ÔÙÂÏ› Î·È ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙËÓ ·Ô‰Ô¯‹ Ù˘ ˆ˜ Ì›·˜ ÌÂıfi‰Ô˘ ‰È·ÏÔÁ‹˜ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÂÚÈÛÙ·ÙÈÎÒÓ. ™ÙÔ Denver, ÛÙ· 4 ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÙËÏÂʈÓÈÎÔ‡ ΤÓÙÚÔ˘ ‰ÈÂÎÂÚ·ÈÒıËÎ·Ó Ì ÂÈÙ˘¯›· 107.938 ÂÚÈÙÒÛÂȘ. ªÈÎÚ¿ Ï¿ıË ÛÙË ¯Ú‹ÛË ÙˆÓ Û˘ÛÙ¿ÛÂˆÓ ‰È·ÈÛÙÒıËÎ·Ó Û 1/1450 ÎÏ‹ÛÂȘ (0,07%) (7). ™Â Ì›· ÚfiÛÊ·ÙË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË (Denver-Philadelphia-ClevelandPetesbourg) 1561 ÂÚÈÙÒÛˆÓ, Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡ ˘ÔÙÈÌ‹ıËΠ۠5 ÂÚÈÙÒÛÂȘ (1/500 ÎÏ‹ÛÂȘ, 0,3%), ÂÓÒ ÛÙȘ 3 ·fi ·˘Ù¤˜ ¤ÁÈÓ η΋ ¯Ú‹ÛË ÙˆÓ ÙËÏÂʈÓÈÎÒÓ Û˘ÛÙ¿ÛÂˆÓ (31). ™Â ¿ÏÏË, Ôχ ÚfiÛÊ·ÙË ÌÂϤÙË, ÛÙËÓ ÔÔ›· ¤ÁÈÓ ۇÁÎÚÈÛË ÌÂٷ͇ È·ÙÚÈÎÔ‡ Î·È ÂȉÈο ÂÎ·È‰Â˘Ì¤ÓÔ˘ ÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡ fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ˆ˜ ÚÔ˜ ÙË ‰È·ÏÔÁ‹ Î·È ÙȘ Ô‰ËÁ›Â˜, Û 48 (4,2%) ·fi ÙȘ 1182 ÂÚÈÙÒÛÂȘ ηı˘ÛÙ¤ÚËÛÂ Ë ¯ÔÚ‹ÁËÛË “ÛËÌ·ÓÙÈ΋˜” ıÂڷ›·˜ (ÔÛÔÛÙfi 2%, ˆÛÙfiÛÔ, ·ÊÔÚÔ‡Û Û ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚›ˆÛ˘ ÁÈ· ÎÔÈÓ¤˜ ·È‰È·ÙÚÈΤ˜ ÏÔÈÌÒÍÂȘ, Ô˘ ˆ˜ ÁÓˆÛÙfiÓ ‰ÂÓ ÎÚ›ÓÂÙ·È ¿ÓÙ· ·fi fiÏÔ˘˜ ··Ú·›ÙËÙË) (32). ∆· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ¤ˆ˜ Û‹ÌÂÚ· ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Ôχ ıÂÙÈο ÙÔÓ ÚfiÏÔ Ù˘ ÙËÏÂʈÓÈ΋˜ È·ÙÚÈ΋˜ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË, ÂÊfiÛÔÓ ·˘Ù‹ Á›ÓÂÙ·È ÔÚÁ·ÓˆÌ¤Ó·. ™ÙȘ ∏¶∞ ıˆÚÂ›Ù·È fiÙÈ Ù· ·È‰È·ÙÚÈο ÙËÏÂʈÓÈο ΤÓÙÚ· Ô˘ ÏÂÈÙÔ˘ÚÁÔ‡Ó Ì ‚¿ÛË ÂȉÈΤ˜ Û˘ÛÙ¿ÛÂȘ Î·È ˘fi ÙËÓ Â›‚ÏÂ„Ë ÂȉÈÎÒÓ Ì ÙÔ ı¤Ì· - ·È‰È¿ÙÚˆÓ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡, ÚÔÛʤÚÔ˘Ó ˘„ËÏ¿ ÔÛÔÛÙ¿ ÈηÓÔÔ›ËÛ˘ Û ÁÔÓ›˜ Î·È ÁÈ·ÙÚÔ‡˜, ÂÓÒ ÌÂÈÒÓÔ˘Ó ÙȘ ÂÈÛΤ„ÂȘ ÛÙ· ∆∂¶ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ ¯ˆÚ›˜, ·Ú¿ÏÏËÏ·, Ó· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· È·ÙÚÈο Ï¿ıË. ªÂ ‚¿ÛË ·˘Ùfi, ı· ÌÔÚÔ‡Û·Ó Ó· ÔÚÁ·ÓˆıÔ‡Ó ·ÚfiÌÔÈ· ÙËÏÂʈÓÈο ΤÓÙÚ· ÛÙ· ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›·, ÂÓÒ Î·È ÔÈ ·È‰›·ÙÚÔÈ Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘ Ô˘ οÓÔ˘Ó Ú·ÎÙÈ΋ ÌfiÓÔÈ ÙÔ˘˜, ı· ÌÔÚÔ‡Û·Ó Ó· ‰·ÓÂÈÛÙÔ‡Ó ¯Ú‹ÛÈ̘ ȉ¤Â˜ Î·È ÂÌÂÈڛ˜ ÁÈ· ÙËÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‰È·¯Â›ÚÈÛË ÙˆÓ ÙËÏÂʈÓÈÎÒÓ ÎÏ‹ÛÂˆÓ Ô˘ ‰¤¯ÔÓÙ·È (7,14,28,33,34). ∂›Û˘, Â›Ó·È ¯Ú‹ÛÈÌÔ Ó· ÌÂÏÂÙËı› Î·È Ë ÂÌÂÈÚ›· ·fi ¿ÏϘ ¯ÒÚ˜ Ô˘ ÂÊ·ÚÌfi˙Ô˘Ó Û˘ÛÙ‹Ì·Ù· ÙËÏÂʈÓÈ΋˜ È·ÙÚÈ΋˜ (35-38).
∂›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ ™ÙÔÓ ¶›Ó·Î· 2 ·Ó·Ê¤ÚÔÓÙ·È ÔÈ Î·Ù·ÛÙ¿ÛÂȘ Ô˘ Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ ¿ÓÙ· Ó· ·Ó·ÁÓˆÚ›˙ÂÈ ·fi ÙÔ ÙËϤʈÓÔ Î·È ÁÈ· ÙȘ Ôԛ˜ Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿ ÙËÓ ¿ÌÂÛË ÂͤٷÛË ÛÙÔ È·ÙÚÂ›Ô ‹ ÙËÓ ¿ÌÂÛË ÌÂÙ·ÊÔÚ¿ ¶·È‰È·ÙÚÈ΋ 2005;68:29-35
¶›Ó·Î·˜ 2. ∂›ÁÔ˘Û˜ ÙËÏÂʈÓÈΤ˜ ÎÏ‹ÛÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ ñ ¢‡ÛÎÔÏË ·Ó·ÓÔ‹ (¿ÓÔÈ·, ·‰‡Ó·ÌË ·Ó·ÓÔ‹, ÛÈÁÌfi˜, ΢¿ÓˆÛË) ñ ¶Èı·Ó‹ ·Ó·Ê˘Ï·Í›· (‰‡ÛÎÔÏË ·Ó·ÓÔ‹ ÌÂÙ¿ ·fi Ï‹„Ë Ê·ÚÌ¿ÎÔ˘, ‰‹ÁÌ· ÂÓÙfiÌÔ˘, Ê·ÁËÙfi) ñ ¡Â˘ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· (Û·ÛÌÔ›, ·ÒÏÂÈ· Û˘Ó›‰ËÛ˘, Û‡Á¯˘ÛË, Ï‹ı·ÚÁÔ˜) ñ ¢ËÏËÙËÚ›·ÛË, Ï‹„Ë Ê·ÚÌ¿ÎˆÓ ñ ∆Ú·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ·˘¯¤Ó· ‹ ÙˆÓ ÔÊı·ÏÌÒÓ ñ ∞ÓÂͤÏÂÁÎÙË ·ÈÌÔÚÚ·Á›· ñ ∞fiÂÈÚ· ·˘ÙÔÎÙÔÓ›·˜ ‹ ηÎÔÔ›ËÛË ñ ¶˘ÚÂÙfi˜ Û ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ <3 ÌËÓÒÓ ‹ >40,5oC Û ÔÔÈÔ‰‹ÔÙ ·È‰› ñ ∞·ÚËÁfiÚËÙÔ ÎÏ¿Ì·, ÛÔ‚·Úfi˜ fiÓÔ˜ ñ ¶·Ú’ ÔÏ›ÁÔÓ ÓÈÁÌfi˜ ñ ¢È·ÌÂÚ‹ ÙÚ·‡Ì·Ù· ñ ¶Ôχ ·Ó‹Û˘¯ÔÈ ÁÔÓ›˜ ñ ∫¿ÎˆÛË ÎÂÊ·Ï‹˜ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·ÏÏ·Á‹ Û˘ÌÂÚÈÊÔÚ¿˜ ‹ ·ӷϷ̂·ÓfiÌÂÓÔ˘˜ Â̤ÙÔ˘˜ ñ ∞ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·
ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (14). ™Â ÌÂÚÈΤ˜, Ì¿ÏÈÛÙ·, ·fi ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ı· Ú¤ÂÈ Ó· ‰ÒÛÂÈ Ô‰ËÁ›Â˜ ÛÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ·ÚÔ¯‹ ÚÒÙˆÓ ‚ÔËıÂÈÒÓ ÛÙÔ ·È‰› (ÁÈ· ·Ú¿‰ÂÈÁÌ· ¯ÔÚ‹ÁËÛË ÈÂηÎÔ˘¿Ó·˜ Û ʷÚ̷΢ÙÈ΋ ‰ËÏËÙËÚ›·ÛË). ∂˘Ù˘¯Ò˜, ·˘Ù¤˜ ÔÈ ÂÍ·ÈÚÂÙÈο ›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ Â›Ó·È Û¿ÓȘ Î·È ·ÔÙÂÏÔ‡Ó ÔÛÔÛÙfi <1% ÙˆÓ ÎÏ‹ÛÂˆÓ Ô˘ ‰¤¯ÂÙ·È Ô ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜. ¶›Ó·Î·˜ 3. ÃÚ‹ÛÈ̘ ÂÚˆÙ‹ÛÂȘ ÁÈ· Ó· ·Ó·ÁÓˆÚÈÛÙÔ‡Ó Â›ÁÔ˘Û˜ ÎÏ‹ÛÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ (ªÓËÌÔÓ‡ÔÓÙ·È ˆ˜ A, B, C, D, S) ñ A - Airway: “∆Ô ·È‰› Û·˜ ‰˘ÛÎÔχÂÙ·È Ó· ·Ó·Ó‡ÛÂÈ ‹ οÓÂÈ ıfiÚ˘‚Ô Î·ıÒ˜ ·Ó·Ó¤ÂÈ;” ñ B - Breathing: “ª‹ˆ˜ ÙÔ ·È‰› Û·˜ ·Ó·Ó¤ÂÈ ÁÚ‹ÁÔÚ·;” ñ C - Circulation: ∂ÎÙ›ÌËÛË Ù˘ ÂÓ˘‰¿ÙˆÛ˘ “¶fiÛ· ˘ÁÚ¿ ‹È ÙÔ ·È‰› Û·˜;” “¶fiÙ ԇÚËÛ ÁÈ· ÙÂÏÂ˘Ù·›· ÊÔÚ¿;” “¶fiÛÔ˘˜ Â̤ÙÔ˘˜ Î·È ‰È¿ÚÚÔȘ ¤¯ÂÈ Î¿ÓÂÈ;” ñ D - Deficits: ∂ÎÙÈÌԇ̠ÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ Î·È ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· “Œ¯ÂÈ ÙÔ ·È‰› Û·˜ ÙË Û˘ÓËıÈṲ̂ÓË ‰Ú·ÛÙËÚÈfiÙËÙ·;” “∂ӉȷʤÚÂÙ·È ÁÈ· Ù· ·È¯Ó›‰È· ÙÔ˘ Î·È Ù· ÚfiÛˆ· Á‡Úˆ ÙÔ˘;” ñ S - Skin: “Œ¯ÂÈ ÌÂÏ·Ó¤˜ ÎËÏ›‰Â˜ ‹/Î·È ÎfiÎÎÈÓ· ÛÙ›ÁÌ·Ù· ÛÙÔ ‰¤ÚÌ· ÙÔ˘;”
¶›Ó·Î·˜ 4. ™˘¯ÓfiÙÂÚ· ·›ÙÈ· ÎÏ‹Û˘ ·È‰È¿ÙÚˆÓ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
¶˘ÚÂÙfi˜ ŒÌÂÙÔ˜ øÙ·ÏÁ›· ¶ÔÓfiÏ·ÈÌÔ˜ ∫Ú˘ÔÏÔÁ‹Ì·Ù· µ‹¯·˜ ¢È¿ÚÚÔÈ· ∫¿ÎˆÛË ÎÂÊ·Ï‹˜ ∫ÔÈÏÈ·Îfi ¿ÏÁÔ˜ ∆Ú·˘Ì·ÙÈÛÌÔ› ¿ÎÚˆÓ
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
∫fiÎÎÈÓÔ Ì¿ÙÈ ∫Ï¿Ì· ‚ÚÂÊÒÓ ∆Ú·˘Ì·ÙÈÛÌÔ› ‰¤ÚÌ·ÙÔ˜ Croup ∂Í·Óı‹Ì·Ù· ∫Ó›‰ˆÛË ¶·ÚÂÓ¤ÚÁÂȘ ÂÌ‚ÔÏ›ˆÓ ¢˘ÛÎÔÈÏÈfiÙËÙ· ∫ÂÊ·Ï·ÏÁ›· ∫Ú›ÛÂȘ ¿ÛıÌ·ÙÔ˜
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·35
35
¶·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ
™ÙÔÓ ¶›Ó·Î· 3 ·Ó·Ê¤ÚÔÓÙ·È ÂÚˆÙ‹ÛÂȘ Ô˘ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ÔÈ Â›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ.
OÈ Û˘¯ÓfiÙÂÚ˜ ·Èٛ˜ Ô˘ ÔÈ ÁÔÓ›˜ ηÏÔ‡Ó ÙÔÓ ·È‰›·ÙÚÔ ™ÙÔÓ ¶›Ó·Î· 4 ·Ó·Ê¤ÚÔÓÙ·È ÔÈ 20 Û˘¯ÓfiÙÂÚ˜ ·Èٛ˜ ÁÈ· ÙȘ Ôԛ˜ ÔÈ ÁÔÓ›˜ ÙËÏÂʈÓÔ‡Ó ÛÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜. ∞ÔÙÂÏÔ‡Ó >70% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÎÏ‹ÛÂˆÓ Ô˘ ‰¤¯ÂÙ·È Ô ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ (7,14). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, οı ·È‰›·ÙÚÔ˜ Ô˘ ı¤ÏÂÈ Ó· ÂÍ·ÛΛ ·È‰È·ÙÚÈ΋ ·fi ÙÔ ÙËϤʈÓÔ Ì ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ·ÛÊ¿ÏÂÈ·, ı· Ú¤ÂÈ Ó· Ì¿ıÂÈ Ó· ¯ÂÈÚ›˙ÂÙ·È Ì ¢¯¤ÚÂÈ· ÙȘ ÎÏ‹ÛÂȘ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙȘ ·Ú·¿Óˆ ·Èٛ˜ ›Ù ÌÂÏÂÙÒÓÙ·˜ ÙȘ Û˘ÛÙ¿ÛÂȘ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó Î·È ÚÔÛ·ÚÌfi˙ÔÓÙ·˜ ·˘Ù¤˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÙÔ˘ Ú·ÎÙÈ΋, ›Ù - ·ÎfiÌ· ηχÙÂÚ· - Ì ÙËÓ Âη›‰Â˘Û‹ ÙÔ˘ ˆ˜ ÂȉÈ΢fiÌÂÓÔ˜ Û ·˘Ù¿ Ù· ˙ËÙ‹Ì·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÎÏÈÓÈ΋˜ ÙÔ˘ Ú·ÎÙÈ΋˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Practice by telephone [letter]. Lancet 1879:819. 2. Bergman AB, Dassel SW, Wedgwood RJ. Time-motion study of practicing pediatricians. Pediatrics 1966;38:254-263. 3. Hessel SJ, Haggerty RJ. General pediatrics: a study of practice in the mid-1960’s. J Pediatr 1968;73:271-279. 4. Fosarelli PD. The telephone in pediatric medicine. A review. Clin Pediatr 1983;22:293-296. 5. Fosarelli PD. The emphasis of telephone medicine in pediatric training programs. Am J Dis Child 1985;139:555-557. 6. Ottolini MC, Greenberg L. Development and evaluation of a CD-ROM computer program to teach residents telephone management. Pediatrics 1998;101:E2. 7. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics 1993;92:670-679. 8. American Academy of Pediatrics, Provisional Section on Pediatric Telephone Care and Committee on Practice and Ambulatory Medicine. Pediatric call centers and the practice of telephone triage and advice: critical success factors. Strategies for practice management. AAP News 1998;14:1-6. 9. American College of Emergency Physicians. Providing telephone advice from the emergency department. Ann Emerg Med 1990;19:600. 10. Poole SR, Glade G. Cost-efficient telephone care during pediatric office hours. Pediatr Ann 2001;30:256-267. 11. Fosarelli P, Schmitt B. Telephone dissatisfaction in pediatric practice: Denver and Baltimore. Pediatrics 1987;80:28-31. 12. Caplan SE, Orr ST, Skulstad JR, Charney E. After-hours telephone use in urban pediatric primary care centers. Am J Dis Child 1983;137:879-882. 13. Sorum PC, Mallick R. Physicians’ opinions on compensation for telephone calls. Pediatrics 1997;99:E3. 14. Poole SR. The complete guide: developing a telephone triage and advice system for a pediatric office practice. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
15. Smith K. Telephone health care: it’s more than just a phone call. Pediatr Nurs 1999;25:423-429. 16. Carbajal R, Barthez P, Blanc P, Paupe A, Lenclen R, OlivierMartin M et al. Conseils téléphoniques donnés aux urgences pour un cas pédiatrique simulé. Arch Pediatr 1996;3:964-968. 17. Isaacman DJ, Verdile VP, Kohen FP, Verdile LA. Pediatric telephone advice in the emergency department: results of a mock scenario. Pediatrics 1992;89:35-39. 18. Perrin EC, Goodman HC. Telephone management of acute pediatric illnesses. N Engl J Med 1978;298:130-135. 19. Yanovski SZ, Yanovski JA, Malley JD, Brown RL, Balaban DJ. Telephone triage by primary care physicians. Pediatrics 1992;89:701-706. 20. Tripp S. Telephone techniques in pediatric practice. Am J Nurs 1971;71:1722-1724. 21. Katz HP, Wick W. Malpractice, meningitis, and the telephone. Pediatr Ann 1991;20:85-89. 22. Hertz AR. Use of telephone triage protocols can protect patients, curb lawsuits. AAP News 2003;23:110. 23. Brown J. Pediatric telephone medicine. 2nd ed. Philadelphia: Lippincott-Raven; 1997. 24. Schmitt B. Pediatric telephone protocols. 9th ed. Elk Grove Village: American Academy of Pediatrics; 2002. 25. Poole SR. Creating an after-hours telephone triage system for office practice. Pediatr Ann 2001;30:268-273. 26. Benjamin JT. Pediatric residents’ telephone triage experience. Relevant to general pediatric practice? Arch Pediatr Adolesc Med 1997;151:1254-1257. 27. Baker RC, Schubert CJ, Kirwan KA, Lenkauskas SM, Spaeth JT. After-hours telephone triage and advice in private and nonprivate pediatric pediatric populations. Arch Pediatr Adolesc Med 1999;153:292-296. 28. Crane JD, Benjamin JT. Pediatric residents’ telephone triage experience: do parents really follow telephone advice? Arch Pediatr Adolesc Med 2000;154:71-74. 29. Kempe A, Dempsey C, Hegarty T, Frei N, Chandramouli V, Poole SR. Reducing after-hours referrals by an after-hours call center with second-level physician triage. Pediatrics 2000;106:226-230. 30. Barber JW, King WD, Monroe KW, Nichols MH. Evaluation of emergency department referrals by telephone triage. Pediatrics 2000;105:819-821. 31. Kempe A, Luberti A, Belman S, Hertz A, Sherman H, Amin D et al. Outcomes associated with pediatric after-hours care by call centers: a multicenter study. Ambul Pediatr 2003;3: 211-217. 32. Lee TJ, Baraff LJ, Guzy J, Johnson D, Woo H. Does telephone triage delay significant medical treatment? Advice nurse service vs on-call pediatricians. Arch Pediatr Adolesc Med 2003;157:635-641. 33. Kempe A, Luberti AA, Hertz AR, Sherman HB, Amin D, Dempsey C et al. Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance. Pediatrics 2001;108:E111. 34. Luberti AA. After-hours telephone care: options for the pediatrician. Pediatr Ann 2001;30:249-254. 35. Marklund B, Bengtsson C, Blomkvist S, Furunes B, GackeHerbst R, Silfverhielm B et al. Evaluation of the telephone advisory activity at Swedish primary health care centers. Fam Pract 1990;7:184-189. 36. Sher C, Mimouni M, Weitzen T, Waisman Y. Pediatric telephone advice: a new medical service in Israel. Isr J Med Sci 1994;30:651-656. 37. Edmonds E. Telephone triage: 5 years’ experience. Accid Emerg Nurs 1997;5:8-13. 38. Hanson RM, Exley BJ, Ngo P, Fitzpatrick MP, Petering EL, Matthews SJ et al. Paediatric telephone triage and advice: the demand continues. Med J Aust 2004;180:333-335.
¶·È‰È·ÙÚÈ΋ 2005;68:29-35
Paediatriki Jan-Feb 05 teliko
36
10-02-05
13:36
™ÂÏ›‰·36
REVIEW ARTICLE
Pediatric telephone medicine P. Velentzas
Abstract Health Center of Markopoulo, Mesogaia Correspondence: Polizois Velentzas 25 Efranoros str., 116 35, Athens E-mail: polvel@ath.forthnet.gr Date of submission: 23-04-2004 Date of approval: 01-10-2004
Management of several clinical problems in children by telephone is a common practice in pediatrics. Telephone communication between parents and pediatrician is easy, direct, inexpensive and effective, provided some basic terms are fulfilled. General pediatricians may spend considerable time daily, especially after-hours, to provide advice by telephone. The present article reviews the historical background of pediatric telephone medicine and the relations between pediatricians and telephone, types and difficulties of clinical care by telephone, and the inadequacies and deficiencies of the personnel providing information by telephone. Furthermore, some key-points are presented on the effectiveness and safety of the procedure, emergency calls in pediatrics and data to support the role of pediatric call centers using pediatric telephone guidelines for triage and advice.
Key words Telephone medicine, pediatrics, primary care, emergency medicine, call centers.
Paediatriki 2005;68:36
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·37
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
37
°ÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿ Î·È ÚfiÏË„Ë ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ¢. §¿ÁÁ·˜1, ∂. ¶ÂÙÚ›‰Ô˘2, ¡. ¢ÂÛ‡Ú˘2, £. £ˆÌ·˝‰Ë˜1
¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË ·Ú·Ì¤ÙÚˆÓ Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ Èı·Ó‹ ÂÌÏÔ΋ Ù˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙËÓ ÚfiÎÏËÛË ÔÈÎÈ·ÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ∏ Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË 400 ·ÓÒÓ˘ÌˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ Ì ÚÔÛˆÈΤ˜ Û˘ÓÂÓÙ‡ÍÂȘ ·fi ÁÔÓ›˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 2-4 ÂÙÒÓ, 200 ·fi Ù· ÔÔ›· ηÙÔÈÎÔ‡Û·Ó ÛÙËÓ ÂÚÈÔ¯‹ ∞ÌÂÏÔ΋ˆÓ ÙÔ˘ ¢‹ÌÔ˘ ∞ıËÓ·›ˆÓ (ÂÚÈÔ¯‹ Ì ̤ÛÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ›‰Ô) Î·È 200 ÛÙÔÓ ¢‹ÌÔ ÕÓˆ §ÈÔÛ›ˆÓ ÙÔ˘ ¡ÔÌÔ‡ ∞ÙÙÈ΋˜ (ÂÚÈÔ¯‹ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο ˘Ô‚·ıÌÈṲ̂ÓË). OÈ ÂÚˆÙ‹ÛÂȘ ·ÊÔÚÔ‡Û·Ó Û ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÛÙË Û˘¯ÓfiÙËÙ· Î·È ÙÔÓ Ù‡Ô ÂӉ¯fiÌÂÓˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È Û ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‰È·ÌfiÚʈÛË: ·) ÂÓfi˜ ¢Â›ÎÙË °ÔÓÂ˚΋˜ ™˘ÌÂÚÈÊÔÚ¿˜ (¢°™) Û¯ÂÙÈο Ì ÙȘ ÔÚı¤˜ ÁÓÒÛÂȘ Î·È ÛÙ¿ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙÔ ·ÛʷϤ˜ ·È‰ÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·È ‚) ÂÓfi˜ ¢Â›ÎÙË °ÔÓÂ˚΋˜ ∂›‚Ï„˘ (¢°∂) Û¯ÂÙÈο Ì ÙËÓ ÔÈÔÙÈ΋ ÁÔÓÂ˚΋ ›‚Ï„Ë. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÔÏÏ·Ï‹ ÁÚ·ÌÌÈ΋ Î·È ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË.
1 ∂ıÓÈ΋ ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: ¢ËÌ‹ÙÚ˘ §¿ÁÁ·˜ ∫·ÏÏȉÚÔÌ›Ô˘ 6, ∆.∫. 114 72, ∞ı‹Ó· E-mail: dimlag@hol.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 22-03-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-09-2004
∞ÔÙÂϤÛÌ·Ù·: µÚ¤ıËΠfiÙÈ Ë ·‡ÍËÛË ÙÔ˘ ¢°™ ηٿ 1 ÌÔÓ¿‰· Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË Ù˘ ÙÈÌ‹˜ ÙÔ˘ ‰Â›ÎÙË ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ηٿ 0,09 Î·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÚfiÎÏËÛ˘ ·Ù˘¯ËÌ¿ÙˆÓ ¤Íˆ ·fi ÙÔ Û›ÙÈ Î·Ù¿ 15%, ÂÓÒ Ë Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ¢°∂ ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∂›Û˘, ‰È·ÈÛÙÒıËÎ·Ó ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÙÔ˘ ‰Â›ÎÙË ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Û ·È‰È¿ Ô˘ ‰È·Ì¤ÓÔ˘Ó ÛÙËÓ ˘Ô‚·ıÌÈṲ̂ÓË ÂÚÈÔ¯‹ Î·È Û ÂΛӷ ÌËÙ¤ÚˆÓ Ì ¯·ÌËÏfi Â›Â‰Ô ÌfiÚʈÛ˘. ∞ÓÙ›ıÂÙ·, Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ηٷӷψÙÈο ·Á·ı¿, ·ÏÏ¿ Î·È fiÛ· Û˘Ì‚·›ÓÔ˘Ó ¤Íˆ ·fi ÙÔ Û›ÙÈ ‹Ù·Ó Û˘¯ÓfiÙÂÚ· Û ·È‰È¿ ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ˘„ËÏ‹˜ ÌfiÚʈÛ˘. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÚÈṲ̂Ó˜ ·Ú¿ÌÂÙÚÔÈ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ÔÚı¤˜ ÁÓÒÛÂȘ Î·È ÛÙ¿ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙË ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ‰È·‚›ˆÛ˘ ÙÔ˘ ·È‰ÈÔ‡, ÂËÚ¿˙Ô˘Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÔÈÎÈ·ÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·.
§¤ÍÂȘ ÎÏÂȉȿ AÙ‡¯ËÌ·, ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÁÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿.
∂ÈÛ·ÁˆÁ‹ ∆· ·Ù˘¯‹Ì·Ù· Â›Ó·È Û‹ÌÂÚ· Ë Î‡ÚÈ· ·ÈÙ›· ı·Ó¿ÙÔ˘ Î·È ·Ó·ËÚ›·˜ ÛÙ· ·È‰È¿ ÌÂÙ¿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ˙ˆ‹˜ Û fiϘ ÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, ¤¯ÔÓÙ·˜ Ï¿‚ÂÈ Ï¤ÔÓ - ηٿ ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ - ‰È·ÛÙ¿ÛÂȘ ÂȉËÌ›·˜ (1-3). √È ÎÔÈÓˆÓÈΤ˜ ÂÈÙÒÛÂȘ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË Ì¤ıÔ‰Ô ÂÎÙ›ÌËÛ‹˜ ÙÔ˘˜ (·ÒÏÂÈ· ·ÓıÚÒÈÓÔ˘ ‰˘Ó·ÌÈÎÔ‡, ÎfiÛÙÔ˜ ıÂڷ›·˜, ·ÔηٿÛÙ·Û˘ Î·È Â·Ó¤ÓÙ·Í˘), ·Ú·Ì¤ÓÔ˘Ó Û ·Ó›ÙÚÂÙ· ˘„ËÏ¿ ›‰· (4). ™ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ÛÈÙÈÔ‡, fiÔ˘ Ù· ·È‰È¿ ÂÚÓÔ‡Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ¯ÚfiÓÔ˘ ÙÔ˘˜ (5-8). OÈ Û˘¯ÓfiÙÂÚÔÈ Ù‡ÔÈ ·Ù˘¯‹Ì·-
ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙȘ ÙÒÛÂȘ, Ù· ÂÁη‡Ì·Ù· Î·È ÙȘ ‰ËÏËÙËÚÈ¿ÛÂȘ (9-10). ∆Ô Ê‡ÏÔ, ÙÔ ÛÙ¿‰ÈÔ Ù˘ „˘¯ÔÎÈÓËÙÈ΋˜ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡, ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘, Ë ËÏÈΛ· Î·È ÙÔ Â›Â‰Ô ÌfiÚʈÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘ Â›Ó·È ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ (11-14). ∂ȉÈο ÁÈ· ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, fiÔ˘ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ۯ‰fiÓ ·ÔÎÏÂÈÛÙÈο ÙËÓ Â˘ı‡ÓË Ù˘ ÊÚÔÓÙ›‰·˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜, ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Î·È Ë ÁÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿, ˘fi ÙËÓ ¤ÓÓÔÈ· ÙˆÓ ÔÚıÒÓ ÁÓÒÛˆÓ, ÛÙ¿ÛÂˆÓ Î·È Ú·ÎÙÈÎÒÓ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È Ù˘ ‰È·ÌfiÚʈÛ˘ ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ‰È·‚›ˆÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ (15-17). ¶·È‰È·ÙÚÈ΋ 2005;68:37-43
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·38
38
¢. §¿ÁÁ·˜ Î·È Û˘Ó.
∞ÓÙ›ıÂÙ·, Ë ÔÈÔÙÈ΋ ÁÔÓÂ˚΋ ›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ηٿ ÙËÓ ÒÚ· ÙˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ÙÔ˘ ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› ·fi ÌÂÚÈÎÔ‡˜ ÂÚ¢ÓËÙ¤˜ ˆ˜ ·Ú¿ÁˆÓ ÚfiÏ˄˘ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ (18). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ Èı·Ó‹ ›‰Ú·ÛË Ù˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÙfiÛÔ ÛÙËÓ ÚfiÎÏËÛË fiÛÔ Î·È ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ·È‰È¿ ËÏÈΛ·˜ 2-4 ÂÙÒÓ, Ô˘ Û˘Ó¤‚ËÛ·Ó ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ÛÈÙÈÔ‡, ·ÏÏ¿ Î·È ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ¤Íˆ ·fi ·˘Ùfi. OÈ ·Ú¿ÌÂÙÚÔÈ Ô˘ ÂÚ¢ӋıËÎ·Ó Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· Ì ÙËÓ ÔÈÔÙÈ΋ ÁÔÓÂ˚΋ ›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ηٿ ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘ ÛÙÔ ÔÈÎÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ Î·È ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ·Ó·„˘¯‹˜ Î·È ÙË ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ‰È·‚›ˆÛ‹˜ ÙÔ˘, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ·ÛÊ·Ï‹˜ ÂÎÙ›ÌËÛË ÙÔ˘ ‚·ıÌÔ‡ ›‰Ú·Û˘ Ù˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙË ‰È·ÌfiÚʈÛË ÙÔ˘ ÂȉËÌÈÔÏÔÁÈÎÔ‡ ÚÔÙ‡Ô˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ¤Ú¢ӷ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÙËÓ ÂÚ›Ô‰Ô ¢ÂΤ̂ÚÈÔ˜ 1996 - OÎÙÒ‚ÚÈÔ˜ 1998, Û ‰‡Ô ÂÚÈÔ¯¤˜ ÙÔ˘ ¡ÔÌÔ‡ ∞ÙÙÈ΋˜ Ì ‰È·ÊÔÚÂÙÈÎfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ›‰Ô: ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ ∞ÌÂÏÔ΋ˆÓ Î·È ÛÙÔÓ ¢‹ÌÔ ÕÓˆ §ÈÔÛ›ˆÓ (̤ÛÔ Î·È ˘Ô‚·ıÌÈṲ̂ÓÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ›‰Ô, ·ÓÙ›ÛÙÔȯ·). ∏ Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÂȉÈο ‰È·ÌÔÚʈ̤ÓÔ˘ ·ÓÒÓ˘ÌÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ “ÎÏÂÈÛÙÔ‡ Ù‡Ô˘” - Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ ÚÔÛˆÈÎÒÓ Û˘ÓÂÓÙ‡ÍÂˆÓ - ·fi 200 ÔÈÎÔÁ¤ÓÂȘ οı ÂÚÈÔ¯‹˜. ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Î¿Ï˘Ù ٷ ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘ (¶›Ó·Î·˜ 1), η٤ÁÚ·Ê ÏÂÙÔÌÂÚÒ˜ ÙÔÓ Ù‡Ô Î·È ÙË Û˘¯ÓfiÙËÙ· fiÏˆÓ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó¤‚ËÛ·Ó ÛÙÔ ÔÈÎÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ Î·È ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ¤Íˆ ·fi ÙÔ Û›ÙÈ, ̤¯ÚÈ ÙË ÛÙÈÁÌ‹ Ù˘ Û˘Ó¤ÓÙ¢Í˘, ÂÓÒ Û˘ÁΤÓÙÚˆÓÂ Î·È ¤Ó· ¢ڇ Ê¿ÛÌ· ·Ú·Ì¤ÙÚˆÓ ÂϤÁ¯Ô˘ ÙˆÓ ÁÓÒÛˆÓ, ÛÙ¿ÛÂˆÓ Î·È Ú·ÎÙÈÎÒÓ ÙˆÓ ÁÔÓ¤ˆÓ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™ÙËÓ ¤Ú¢ӷ Û˘ÌÌÂÙ›¯·Ó fiÏÔÈ ÔÈ ÁÔÓ›˜ Ô˘ ÚÔÛ‹Ïı·Ó ÛÙ· ¶ÚfiÙ˘· ∂Î·È‰Â˘ÙÈο ∫¤ÓÙÚ· ÙÔ˘ ∂ÏÏËÓÈÎÔ‡ ∂Ú˘ıÚÔ‡ ™Ù·˘ÚÔ‡ οı ÂÚÈÔ¯‹˜ ÁÈ· ·ÚÔ¯‹ ˘ËÚÂÛÈÒÓ ÚfiÏ˄˘ ÛÙ· ·È‰È¿ ÙÔ˘˜ (΢ڛˆ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜). OÈ ÂÚˆÙËı¤ÓÙ˜ ‹Ù·Ó ÛÙË Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔÓfiÙËÙ· (95,5%) ÌËÙ¤Ú˜. ŸÏÔÈ ÔÈ ÁÔÓ›˜ ‹Ù·Ó ÂÏÏËÓÈ΋˜ ηٷÁˆÁ‹˜ Î·È ˘ËÎÔfiÙËÙ·˜, Û˘ÌÌÂÙ›¯·Ó ÂıÂÏÔÓÙÈο Î·È ‰ÂÓ ˘‹ÚÍ·Ó ·ÚÓ‹ÛÂȘ. ∞ÏÏÔ‰·Ô›, ÔÈÎÔÓÔÌÈÎÔ› ÌÂÙ·Ó¿ÛÙ˜ Î·È ŒÏÏËÓ˜ ÌË ÌfiÓÈÌÔÈ Î¿ÙÔÈÎÔÈ ÙˆÓ ÂÚÈÔ¯ÒÓ Ù˘ ¤Ú¢ӷ˜ ·ÔÎÏ›ÛÙËηÓ. ø˜ ·Ù‡¯ËÌ· ÔÚ›ÛÙËΠοı ·ÎÔ‡ÛÈ· ۈ̷ÙÈ΋ ‚Ï¿‚Ë Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÓÂÚÁÂȷ΋ ›‰Ú·ÛË (Ì˯·ÓÈ΋, ¯ËÌÈ΋, ıÂÚÌÈ΋, ËÏÂÎÙÚÈ΋) Ì›·˜ Â͈ÙÂÚÈ΋˜ ‰‡Ó·Ì˘, Ë ÈÛ¯‡˜ Ù˘ ÔÔ›·˜ ˘ÂÚ‚·›ÓÂÈ Ù· ÁÂÓÈο ‹ ÙÔÈο fiÚÈ· ·ÓÙÔ¯‹˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È Î·Ù·ÛÙ¿ÛÂˆÓ ÛÙ¤ÚËÛ˘ ‚·ÛÈÎÒÓ ˙ˆÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, fiˆ˜ ÙÔ Ô͢ÁfiÓÔ Î·È Ë ıÂÚÌfiÙËÙ· (4), ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ‚·Ú‡ÙËÙ¿ ÙÔ˘. ∆· ·Ù˘¯‹Ì·Ù· ηÙËÁÔÚÈÔÔÈ‹ıËηÓ, ·Ó¿ÏÔÁ· Ì ÙÔÓ Ì˯·ÓÈÛÌfi ÚfiÎÏËÛ˘, Û ٤ÛÛÂÚȘ ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 2). °È· ÙËÓ ÚÒÙË ÔÌ¿‰· (·Ù˘¯‹Ì·Ù· ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ¶·È‰È·ÙÚÈ΋ 2005;68:37-43
ÂÓ¤ÚÁÂÈ·˜) ÔÚ›ÛÙËΠ¤Ó·˜ ‰Â›ÎÙ˘ ·Ù˘¯‹Ì·ÙÔ˜ Ô˘ ‚·ıÌÔÏÔÁÔ‡ÓÙ·Ó ·fi 0 (ηӤӷ ·Ù‡¯ËÌ·) ¤ˆ˜ 10 (fiÏ· Ù· ·Ù˘¯‹Ì·Ù·). °È· οı ̛· ·fi ÙȘ ˘fiÏÔȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·Ù˘¯ËÌ¿ÙˆÓ (Ï‹„Ë Î·Ù·Ó·ÏˆÙÈÎÒÓ ·Á·ıÒÓ, ·ʋ Ì ıÂÚÌÈ΋ËÏÂÎÙÚÈ΋ ÂÓ¤ÚÁÂÈ· Î·È ·Ù˘¯‹Ì·Ù· ¤Íˆ ·fi ÙÔ Û›ÙÈ), ‰ËÌÈÔ˘ÚÁ‹ıËΠ·ÓÙ›ÛÙÔȯԘ ‰Â›ÎÙ˘ Ì ÙÈ̤˜ 0 (ηӤӷ ·Ù‡¯ËÌ·) Î·È 1 (¤ÛÙˆ Î·È ¤Ó· ·Ù‡¯ËÌ· Ù˘ ›‰È·˜ ÔÌ¿‰·˜). °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÁÔÓÂ˚΋˜ ¢ı‡Ó˘ ÛÙÔ ·Ù‡¯ËÌ· ‰È·ÌÔÚÊÒıËÎ·Ó Ô ¢Â›ÎÙ˘ °ÔÓÂ˚΋˜ ∂›‚Ï„˘ (¢°∂) Î·È Ô ¢Â›ÎÙ˘ °ÔÓÂ˚΋˜ ™˘ÌÂÚÈÊÔÚ¿˜ (¢°™). ™ÙÔÓ ÚÒÙÔ Û˘ÌÂÚÈÏ‹ÊıËÛ·Ó 5 ÚÔÏËÙÈο ̤ÙÚ· ·ÓÙÈÚÔÛˆÂ˘ÙÈο Ù˘ ÔÈÔÙÈ΋˜ ÁÔÓÂ˚΋˜ ›‚Ï„˘ Î·È ÛÙÔÓ ‰Â‡ÙÂÚÔ 10 ̤ÙÚ· Ô˘ ·ÔÙ˘ÒÓÔ˘Ó ÙȘ ÁÓÒÛÂȘ, ÛÙ¿ÛÂȘ Î·È Ú·ÎÙÈΤ˜ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÔÈÎÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ (¶›Ó·Î·˜ 3), Û‡Ìʈӷ Ì ÙȘ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘ Ù˘ Û‡Á¯ÚÔÓ˘ ÂÏÏËÓÈ΋˜ ÎÔÈÓˆÓ›·˜ (19). OÈ ÙÈ̤˜ ÙˆÓ ‰ÂÈÎÙÒÓ ‹Ù·Ó ·fi 0 (ηӤӷ ̤ÙÚÔ) ¤ˆ˜ 5 ÁÈ· ÙÔÓ ¢°∂ Î·È ¤ˆ˜ 10 ÁÈ· ÙÔÓ ¢°™ (Ï‹„Ë fiÏˆÓ ÙˆÓ Ì¤ÙÚˆÓ). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ¤Ú¢ӷ˜ ¤ÁÈÓ Ì ÔÏÏ·Ï‹ ÁÚ·ÌÌÈ΋ ÂÍ¿ÚÙËÛË, fiÔ˘ ˘ÔÏÔÁ›ÛÙËΠÁÈ· οı ·ÓÂÍ¿ÚÙËÙË ÌÂÙ·‚ÏËÙ‹ Ô Û˘ÓÙÂÏÂÛÙ‹˜ ÌÂÚÈ΋˜ ÂÍ¿ÚÙËÛ˘ (b), Ô˘ ÂÎÊÚ¿˙ÂÈ ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÌÂÙ·‚ÔÏ‹ Ù˘ ÂÍ·ÚÙË̤Ó˘ ÌÂÙ·‚ÏËÙ‹˜ (‰Â›ÎÙ˘ ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜), fiÙ·Ó Ë ·ÓÙ›ÛÙÔÈ¯Ë ·ÓÂÍ¿ÚÙËÙË ÌÂÙ·‚ÏËÙ‹ ÌÂÙ·‚ÏËı› ηٿ Ì›· ÌÔÓ¿‰· ‹ ηٿ Ì›· ηÙËÁÔÚ›·, ÂÓÒ ÔÈ ˘fiÏÔȘ ·ÓÂÍ¿ÚÙËÙ˜ ÌÂÙ·‚ÏËÙ¤˜ ·Ú·Ì¤ÓÔ˘Ó ÛÙ·ıÂÚ¤˜ (20). ∂›Û˘, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙËÓ ÔÏÏ·Ï‹ ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË, ˘ÔÏÔÁ›ÛÙËÎÂ Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ·Ù‡¯ËÌ·, Ô˘ ηٷٿÛÛÂÙ·È Û οÔÈ· ·fi ÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·Ù˘¯ËÌ¿ÙˆÓ, ·Ó¿ÏÔÁ· Ì ÙȘ ‰ËÌÔÁÚ·ÊÈΤ˜, ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜, ·ÏÏ¿ Î·È ÙÔ˘˜ ‰Â›ÎÙ˜ Ù˘ ÁÔÓÂ˚΋˜ ›‚Ï„˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ (20).
∞ÔÙÂϤÛÌ·Ù· O ¶›Ó·Î·˜ 1 ‰Â›¯ÓÂÈ ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ Î·È ÎÔÈÓˆÓÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜. ∏ ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ ·Ó¿ ÂÍ¿ÌËÓÔ Â›Ó·È ·ÚfiÌÔÈ· Î·È Ù· ·ÁfiÚÈ· ˘ÂÚ¤¯Ô˘Ó ÂÏ·ÊÚÒ˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ. ∆Ô Â›Â‰Ô ÌfiÚʈÛ˘ ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ‰È·Ì¤ÓÔ˘Ó ÛÙË ÌÂÛÔ·ÛÙÈ΋ ÂÚÈÔ¯‹ Ù˘ ¤Ú¢ӷ˜ Â›Ó·È Û·ÊÒ˜ ˘„ËÏfiÙÂÚÔ ÂÎÂ›ÓˆÓ Ô˘ ‰È·Ì¤ÓÔ˘Ó ÛÙËÓ ˘Ô‚·ıÌÈṲ̂ÓË ÂÚÈÔ¯‹. ™ÙËÓ ›‰È· ÂÚÈÔ¯‹ ·Ú·ÙËÚ‹ıËΠ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ì ÙÚ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ·È‰È¿ ˘ÂÚ¤¯ÂÈ ÛÙËÓ ˘Ô‚·ıÌÈṲ̂ÓË ÂÚÈÔ¯‹ Û˘ÁÎÚÈÙÈο Ì ÙË ÌÂÛÔ·ÛÙÈ΋. ™ÙÔÓ ¶›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È ÙÔ˘ ›‰Ô˘˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó¤‚ËÛ·Ó ÛÙ· ·È‰È¿ Ù˘ ÌÂϤÙ˘. ∆· Û˘¯ÓfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÔÊ›ÏÔÓÙ·È ÛÙËÓ ¤ÎÏ˘ÛË Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (ÎÙ˘‹Ì·Ù· Û ÔÍ›˜ ÁˆÓ›Â˜ Â›ÏˆÓ 73,3%, ÙÒÛÂȘ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ‚¿‰ÈÛ˘ 50,3%, ÔÏÈÛı‹ÛÂȘ Û ÏÂ›Ô ‰¿Â‰Ô 46,5%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÂÁη‡Ì·Ù· ÏfiÁˆ ·ʋ˜ Ì ıÂÚÌ‹ Û˘Û΢‹ (45,0%). ∏ ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· Ô˘ ·Ú·ÙËÚ‹ıËΠÁÈ· Ù· ·Ù˘¯‹Ì·Ù· ¤Íˆ ·fi ÙÔ Û›ÙÈ (13,3%) ‰ÈηÈÔÏÔÁ›ٷÈ, ηıÒ˜ Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·39
39
¶ÚfiÏË„Ë ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ
¶›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ 400 ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ·Ó¿ÏÔÁ· Ì ٷ ‰ËÌÔÁÚ·ÊÈο Î·È ÎÔÈÓˆÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ηıÒ˜ Î·È ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÂÚÈÔ¯‹˜ ‰È·ÌÔÓ‹˜ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜ ÷ڷÎÙËÚÈÛÙÈο ∏ÏÈΛ· ·È‰ÈÔ‡ (Ì‹Ó˜) 25-30 31-36 37-42 43-48 º‡ÏÔ ∞ÁfiÚÈ ∫ÔÚ›ÙÛÈ ™ÂÈÚ¿ Á¤ÓÓËÛ˘ 1 2 3+ ∞ÚÈıÌfi˜ ·È‰ÈÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· 1 2 3+ ∏ÏÈΛ· ÌËÙ¤Ú·˜ (¤ÙË) ≤26 27-36 37+ ∂η›‰Â˘ÛË ÌËÙ¤Ú·˜ (¤ÙË) ≤6 7-12 13+ ∞·Û¯fiÏËÛË ÌËÙ¤Ú·˜ OÈÎȷο ∂ÚÁ·˙fiÌÂÓË
ªÂÛÔ·ÛÙÈ΋ ÂÚÈÔ¯‹ N (%)
ÀÔ‚·ıÌÈṲ̂ÓË ÂÚÈÔ¯‹ ¡ (%)
™‡ÓÔÏÔ ‰Â›ÁÌ·ÙÔ˜ ¡ (%)
50 59 30 61
25,0 29,5 15,0 30,5
51 53 55 41
25,5 26,5 27,5 20,5
101 112 85 102
25,2 28,0 21,3 25,5
102 98
51,0 49,0
108 92
54,0 46,0
210 190
52,5 47,5
92 85 23
46,0 42,5 11,5
94 67 39
47,0 33,5 19,5
186 152 62
46,5 38,0 15,5
65 111 24
32,5 55,5 12,0
65 89 46
32,5 44,5 23,0
130 200 70
32,5 50,0 17,5
29 146 25
14,5 73,0 12,5
80 106 14
40,0 53,0 7,0
109 252 39
27,3 63,0 9,7
30 128 42
15,0 64,0 21,0
80 106 14
40,0 53,0 7,0
110 234 56
40,0 58,5 14,0
92 108
46,0 54,0
146 54
73,0 27,0
238 162
59,5 40,5
ËÏÈΛ·˜ ÂÚÓÔ‡Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ¯ÚfiÓÔ˘ ÙÔ˘˜ ̤۷ ÛÙÔ Û›ÙÈ. ∞fi ÙÔÓ ¶›Ó·Î· 3 ÚÔ·ÙÂÈ fiÙÈ Ë Û˘ÌÌfiÚʈÛË ¤ÛÙˆ Î·È ÂÓfi˜ ÂÎ ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Ôχ ÈηÓÔÔÈËÙÈ΋ ÛÙË Ï‹„Ë ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ Ì¤ÙÚˆÓ ÚfiÏ˄˘, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÔÈÔÙÈ΋ ÁÔÓÂ˚΋ ›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ÙˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ÙÔ˘ (ÂÓÂÚÁËÙÈ΋ ÚfiÏË„Ë), ÂÓÒ ‹Ù·Ó ȉȷ›ÙÂÚ· ·Ó·Ú΋˜ Û ÔÚÈṲ̂ӷ ̤ÙÚ· Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙË ÁÔÓÂ˚΋ Ú·ÎÙÈ΋ ÁÈ· ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ‰È·‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ (·ıËÙÈ΋ ÚfiÏË„Ë). ªÂÏÂÙÒÓÙ·˜ ·ıÚÔÈÛÙÈο ÙÔÓ ¢°∂ ÚԤ΢„ fiÙÈ 268 ÔÈÎÔÁ¤ÓÂȘ (67,0%) ›¯·Ó Ï¿‚ÂÈ fiÏ· Ù· ÚÔÏËÙÈο ̤ÙÚ· Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ‰Â›ÎÙË. ∞ÓÙ›ıÂÙ·, fiÛÔÓ ·ÊÔÚ¿ Û ·˘Ù¿ Ô˘ Û˘ÌÂÚÈÏ‹ÊıËÛ·Ó ÛÙÔÓ ¢°™, ÌfiÓÔ 38 ÔÈÎÔÁ¤ÓÂȘ (9,5%) ›¯·Ó Ï¿‚ÂÈ Û¯Â‰fiÓ fiÏ· Ù· ̤ÙÚ· (810), ÂÓÒ 82 (20,5%) ›¯·Ó Ï¿‚ÂÈ Ì¤¯ÚÈ Î·È 3 ̤ÙÚ·. ™ÙÔÓ ¶›Ó·Î· 4 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÏÏ·Ï‹˜ ÁÚ·ÌÌÈ΋˜ ÂÍ¿ÚÙËÛ˘ ÙÔ˘ ‰Â›ÎÙË ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Û ۯ¤ÛË Ì ÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ‰Â›ÎÙË ÛÙ· ·ÁfiÚÈ· ‹Ù·Ó ˘„ËÏfiÙÂÚË ÂΛӢ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Î·Ù¿ 0,37 ·Ù˘¯‹Ì·Ù· (Û˘ÓÙÂÏÂÛÙ‹˜ ÌÂÚÈ΋˜ ÂÍ¿ÚÙËÛ˘ b ÙÔ˘ ʇÏÔ˘). ™Ù· ·È‰È¿ Ô˘ ‰È¤ÌÂÓ·Ó ÛÙËÓ ÂÚÈÔ¯‹ Ì ̤ÛÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ›‰Ô, Ë ÙÈÌ‹ ÙÔ˘
›‰ÈÔ˘ ‰Â›ÎÙË ‚Ú¤ıËΠÌÈÎÚfiÙÂÚË Î·Ù¿ 0,61 ·Ù˘¯‹Ì·Ù·, Û˘ÁÎÚÈÙÈο Ì ÂΛӷ Ù˘ ˘Ô‚·ıÌÈṲ̂Ó˘ ÂÚÈÔ¯‹˜. ∂›Û˘, ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÙÔ˘ ‰Â›ÎÙË ·Ú·ÙËÚ‹ıËÎ·Ó Î·È ÛÙ· ·È‰È¿ ÔÈÎÔ΢ÚÒÓ Î·È ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ Ì ¯·ÌËÏfi Â›Â‰Ô ÌfiÚʈÛ˘ (0,86 Î·È 0,74 ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù·, ·ÓÙ›ÛÙÔȯ·), Û ۯ¤ÛË Ì ٷ ·È‰È¿ ÔÈÎÔ΢ÚÒÓ ÌËÙ¤ÚˆÓ Ì¤Û˘ ÌfiÚʈÛ˘, ÂÓÒ Ë ·‡ÍËÛË ÙÔ˘ ¢°™ ηٿ 1 ÌÔÓ¿‰· ÌÂÈÒÓÂÈ ÙËÓ ÙÈÌ‹ ÙÔ˘ ‰Â›ÎÙË Î·Ù¿ 0,09 ·Ù˘¯‹Ì·Ù·. O ¶›Ó·Î·˜ 5 ‰Â›¯ÓÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÔÏÏ·Ï‹˜ ÏÔÁ·ÚÈıÌÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ Û οı ̛· ·fi ÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·Ù˘¯ËÌ¿ÙˆÓ Ì ·ÓÂÍ¿ÚÙËÙ˜ ÌÂÙ·‚ÏËÙ¤˜ ÙȘ ›‰È˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙÔÓ ¶›Ó·Î· 4. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÚfiÎÏËÛ˘ ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ Ï‹„˘ ηٷӷψÙÈÎÒÓ ·Á·ıÒÓ Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ ηٿ 58% ÛÙ· ·È‰È¿ Ô˘ ‰È·Ì¤ÓÔ˘Ó ÛÙËÓ ÂÚÈÔ¯‹ Ì ̤ÛÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ¤Ó·ÓÙÈ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‰È·Ì¤ÓÔ˘Ó ÛÙËÓ ˘Ô‚·ıÌÈṲ̂ÓË ÂÚÈÔ¯‹, ÂÓÒ ÌÂÈÒÓÂÙ·È Î·Ù¿ 39% ÁÈ· οı ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ Ù˘ ÌËÙ¤Ú·˜ ηٿ 10 ¤ÙË. ∂›Û˘, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÚfiÎÏËÛ˘ ·Ù˘¯‹Ì·ÙÔ˜ Ù˘ ›‰È·˜ ÔÌ¿‰·˜ ‚Ú¤ıËΠÂÚ›Ô˘ ÙÂÙÚ·Ï¿ÛÈÔ˜ ÛÙ· ·È‰È¿ ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ˘„ËÏ‹˜ ÌfiÚʈÛ˘ Û ۯ¤ÛË Ì ÂΛӷ ÙˆÓ ÔÈÎÔ΢ÚÒÓ ÌËÙ¤ÚˆÓ Ì¤Û˘ ÌfiÚʈÛ˘. ∆· ·È‰È¿ ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ¯·ÌËÏ‹˜ ÌfiÚʈÛ˘ ¶·È‰È·ÙÚÈ΋ 2005;68:37-43
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·40
40
¢. §¿ÁÁ·˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ ÙˆÓ 400 ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ·Ó¿ÏÔÁ· Ì ÙÔ ·Ù‡¯ËÌ· Ô˘ ˘¤ÛÙËÛ·Ó ∂›‰Ô˜ ·Ù˘¯‹Ì·ÙÔ˜
¶·È‰È¿ Ì ·Ù‡¯ËÌ· ∞ÚÈıÌfi˜ (%)
ŒÎÏ˘ÛË Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ¶ÙÒÛË ÚÈÓ ‹ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ‚¿‰ÈÛ˘ ¶ÙÒÛË ·fi ÙÔ ÎÚ‚¿ÙÈ ¶ÙÒÛË ·fi ÛοϷ ∫Ù‡ËÌ· Û ÔÍ›˜ ÁˆÓ›Â˜ Â›ÏˆÓ ¶ÙÒÛË ·fi ¤ÈÏ· ∆Ú·˘Ì·ÙÈÛÌfi˜ ÌÂÏÒÓ ·fi Í·ÊÓÈÎfi Î·È ‚›·ÈÔ ÎÏ›ÛÈÌÔ fiÚÙ·˜-·Ú¿ı˘ÚÔ˘ ¶ÂÚ›ÛÊÈÍË Ì¤ÏÔ˘˜ ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÎÈÁÎÏȉˆÌ¿ÙˆÓ (ÎÚ‚·ÙÈÔ‡, ÂÍÒÛÙË) ∞Ù‡¯ËÌ· Ì ԉ‹Ï·ÙÔ Ì¤Û· ÛÙÔ Û›ÙÈ OÏ›ÛıËÛË Û ÏÂ›Ô ‰¿Â‰Ô ∞Ù‡¯ËÌ· ÏfiÁˆ ¯Ú‹Û˘ ‚ÚÂÊÔ‚·‰ÈÛÙ‹* §‹„Ë Î·Ù·Ó·ÏˆÙÈÎÒÓ ·Á·ıÒÓ ¢ËÏËÙËÚ›·ÛË ·fi Ê¿ÚÌ·ÎÔ, ηÏÏ˘ÓÙÈÎfi Î.Ï. ª¿ÛËÛË ÙÛÈÁ¿ÚÔ˘ ∂ÂÈÛfi‰ÈÔ ÂÈÛÚfiÊËÛ˘ ÙÚÔÊ‹˜ ‹ ͤÓÔ˘ ÛÒÌ·ÙÔ˜** ∞˘ÙÔ„ÂηÛÌfi˜ Ì ¯ËÌÈ΋ Ô˘Û›· ∂·Ê‹ Ì ıÂÚÌÈ΋-ËÏÂÎÙÚÈ΋ ÂÓ¤ÚÁÂÈ· ŒÁη˘Ì· ·fi ·Ó·Ù‹Ú· ‹ Û›ÚÙ· ŒÁη˘Ì· ÏfiÁˆ ·ʋ˜ Ì ıÂÚÌ‹ Û˘Û΢‹ ŒÁη˘Ì· ÏfiÁˆ ·ʋ˜ Ì ˙ÂÛÙfi ˘ÁÚfi ∂ÂÈÛfi‰ÈÔ ËÏÂÎÙÚÔÏËÍ›·˜ ∞Ù‡¯ËÌ· Û ¯ÒÚÔ˘˜ ¤Íˆ ·fi ÙÔ Û›ÙÈ ∞Ù‡¯ËÌ· Û ·È‰È΋ ¯·Ú¿ ∞Ù‡¯ËÌ· ̤۷ Û ·˘ÙÔΛÓËÙÔ ¢‹ÁÌ· ˙ÒÔ˘ ∫›Ó‰˘ÓÔ˜ ÓÈÁÌÔ‡ ÛÙË ı¿Ï·ÛÛ·
201 161 107 293 162 162 62 118 186 42
50,3 40,3 26,8 73,3 40,5 40,5 15,5 29,5 46,5 17,0
31 80 96 37
7,8 20,0 24,0 9,3
16 180 28 34
4,0 45,0 7,0 8,5
53 43 19 38
13,3 10,8 4,8 9,5
* ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ ·Ó·Ê¤ÚÂÙ·È ÌfiÓÔ ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ‚ÚÂÊÔ‚·‰ÈÛÙ‹ (61,3%) ** ™˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ·È‰› ¤‚·Ï ÛÙÔ ÛÙfiÌ· ÙÔ˘ οÔÈ· ·Î·Ù¿ÏÏËÏË ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ÙÚÔÊ‹ (.¯. ÍËÚfi ηÚfi) ‹ ¿ÏÏÔ Í¤ÓÔ ÛÒÌ·, ·ÏÏ¿ - ÂÂȉ‹ ¤ÁÈÓ ¿ÌÂÛ· ·ÓÙÈÏËÙfi ·fi ÙÔ˘˜ ÁÔÓ›˜ - ·Ê·ÈÚ¤ıËÎÂ Î·È ‰ÂÓ ÚÔοÏÂÛ ÓÈÁÌÔÓ‹ (58 ·È‰È¿, ÔÛÔÛÙfi 14,5% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜)
‰È·ÙÚ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘ ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ ıÂÚÌÈ΋˜ ‹ ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ηٿ 70%, Û ۯ¤ÛË Ì ÂΛӷ ÔÈÎÔ΢ÚÒÓ ÌËÙ¤ÚˆÓ Ì¤Û˘ ÌfiÚʈÛ˘. ∆¤ÏÔ˜, Ô Î›Ó‰˘ÓÔ˜ ÚfiÎÏËÛ˘ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ¤Íˆ ·fi ÙÔ Û›ÙÈ Â›Ó·È ‰ÈÏ¿ÛÈÔ˜ ÛÙ· ·È‰È¿ ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ˘„ËÏ‹˜ ÌfiÚʈÛ˘ Û ۯ¤ÛË Ì ÂΛӷ ÙˆÓ ÔÈÎÔ΢ÚÒÓ ÌËÙ¤ÚˆÓ Ì¤Û˘ ÌfiÚʈÛ˘, ÂÓÒ ÂÏ·ÙÙÒÓÂÙ·È Î·Ù¿ 15% ÁÈ· οı ·‡ÍËÛË ÙÔ˘ ¢°™ ηٿ 1 ÌÔÓ¿‰·.
™˘˙‹ÙËÛË °È· ÙËÓ ÏËÚ¤ÛÙÂÚË ·ÔÙ‡ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È ÙÔ˘ Ù‡Ô˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ¤ÁÈÓ ·Â˘ı›·˜ ÛÙËÓ ÎÔÈÓfiÙËÙ· Î·È fi¯È Û ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ‹ ÚÔÛÎÔÌ›ÛÙËÎ·Ó Û ˘ËÚÂۛ˜ ˘Á›·˜ ÏfiÁˆ ·Ù˘¯‹Ì·ÙÔ˜ (6,21). ∂ÎÙfi˜ ·˘ÙÔ‡, Ë Û˘ÁΤÓÙÚˆÛË ÂÓfi˜ ÌÂÁ¿ÏÔ˘ Ê¿ÛÌ·ÙÔ˜ ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ Î·È ·Ú·Ì¤ÙÚˆÓ ÂϤÁ¯Ô˘ ÙˆÓ ÁÓÒÛˆÓ, ÛÙ¿ÛÂˆÓ Î·È Ú·ÎÙÈÎÒÓ ÙˆÓ ÁÔÓ¤ˆÓ Û ı¤Ì·Ù· ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·Ú¤¯ÂÈ ÙË ¶·È‰È·ÙÚÈ΋ 2005;68:37-43
‰˘Ó·ÙfiÙËÙ· ÁÈ· ÙËÓ ·Ó¿‰ÂÈÍË Ù˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ˆ˜ ¤Ó· Ì›˙ÔÓ· ·Ú¿ÁÔÓÙ· ÚfiÎÏËÛ˘ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË Î·Ù·ÁÚ·Ê‹ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È ÙÔ˘ ‚·ıÌÔ‡ Ï‹„˘ ÙˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙȘ Û˘Á¯ÚÔÓÈΤ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ (crosssectional studies) (22), ‰ÂÓ ÌÔÚ› Ó· ·Ô‰Âȯı› Ì ·ÎÚ›‚ÂÈ· Â¿Ó Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ Ì¤ÙÚˆÓ ¤ÁÈÓ ÚÈÓ ‹ ÌÂÙ¿ ÙËÓ ÚfiÎÏËÛË ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜. ŒÓ· ¿ÏÏÔ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ÌÂϤÙ˘ Â›Ó·È Ë Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ì ÚÔÛˆÈΤ˜ Û˘ÓÂÓÙ‡ÍÂȘ, fiÔ˘ Ô ˘ÔÎÂÈÌÂÓÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂËÚ¿˙ÂÈ ÙËÓ ·ÍÈÔÈÛÙ›· ÙˆÓ ··ÓÙ‹ÛˆÓ. Ÿˆ˜ ¤¯ÂÈ ˘ÔÛÙËÚȯı› Î·È ·fi ¿ÏϘ ÌÂϤÙ˜ (1,2,6,21,23), Ù· Û˘¯ÓfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ÔÊ›ÏÔÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ¤ÎÏ˘ÛË Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜, ÂÂȉ‹ - ηٿ ÙË ÛÙ·‰È·Î‹ „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË - Ë ¤Ó·ÚÍË ÙˆÓ ÎÈÓËÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ Û˘Óԉ‡ÂÙ·È Î·È Ì ·ÓÙ›ÛÙÔÈ¯Ë ÂͤÏÈÍË Ù˘ ÓÔËÙÈ΋˜ ÙÔ˘ ÈηÓfiÙËÙ·˜ (9,24). ∂Âȉ‹ Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤ÁÈÓ ·Â˘ı›·˜ ÛÙËÓ ÎÔÈÓfiÙËÙ·, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÌÈÎÚ‹˜ ‚·Ú‡ÙËÙ·˜ Ô˘ ÌÔÚÔ‡Ó Ó·
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·41
41
¶ÚfiÏË„Ë ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ
¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ ÙˆÓ 400 ÔÈÎÔÁÂÓÂÈÒÓ Ù˘ ÌÂϤÙ˘ ·Ó¿ÏÔÁ· Ì ÙË Û˘ÌÌfiÚʈÛË, ¤ÛÙˆ Î·È ÂÓfi˜ ÁÔÓ¤·, ÛÙ· ÚÔÏËÙÈο ̤ÙÚ· ÁÔÓÂ˚΋˜ ›‚Ï„˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ ¶ÚÔÏËÙÈÎfi ̤ÙÚÔ °ÔÓÂ˚΋ ›‚ÏÂ„Ë ∂›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÛÙ· ÚÒÙ· ÙÔ˘ ‚‹Ì·Ù· ∂›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ fiÙ·Ó ·›˙ÂÈ Ì ԉ‹Ï·ÙÔ ÛÙÔ Û›ÙÈ ∂›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÙËÓ ÒÚ· Ô˘ Ì·ÁÂÈÚ‡ÂÈ Ë ÌËÙ¤Ú· ∂›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÙËÓ ÒÚ· Ô˘ ÛȉÂÚÒÓÂÈ Ë ÌËÙ¤Ú· ∂›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ·È‰È΋ ¯·Ú¿ °ÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿ ∆ÔÔı¤ÙËÛË ÙˆÓ ·È¯ÓȉÈÒÓ Û ηϷı¿ÎÈ fiÙ·Ó ÙÔ ·È‰› ·Ú¯›˙ÂÈ Ó· ÌÂٷʤÚÂÈ ·ÓÙÈΛÌÂÓ· ÛÙÔ ÛÙfiÌ· ∞Ê·›ÚÂÛË ÌÈÎÚÔ·ÓÙÈÎÂÈÌ¤ÓˆÓ ·fi ¤ÈÏ· ¯·ÌËÏÔ‡ ‡„Ô˘˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ‚¿‰ÈÛ˘ ⁄·ÚÍË ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi Ê·ÚÌ·ÎÂ›Ô ÙÔ˘ Û΢¿ÛÌ·ÙÔ˜ ÈÂηÎÔ˘¿Ó·˜ ÁÈ· ÚfiÎÏËÛË Â̤ÙÔ˘ OÚı‹ ÁÓÒÛË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ∫¤ÓÙÚÔ˘ ¢ËÏËÙËÚÈ¿ÛÂˆÓ ∫Ï›‰ˆÌ· ÂÍÒÔÚÙ·˜ ∆ÔÔı¤ÙËÛË ÚÔÛٷ٢ÙÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ÛÙÔ˘˜ ÂÍÒÛÙ˜ ÙÔ˘ ÛÈÙÈÔ‡* ∫Ï›‰ˆÌ· ÂÈΛӉ˘ÓˆÓ Ô˘ÛÈÒÓ Û ·ÛÊ·Ï‹ ÛËÌ›· ∆ÔÔı¤ÙËÛË ÙÛÈÁ¿ÚˆÓ Î·È Û›ÚÙˆÓ Û ·ÛÊ·Ï‹ ÛËÌ›· ∞ÛÊ¿ÏÈÛË ËÏÂÎÙÚÈÎÒÓ ‰È·ÎÔÙÒÓ ⁄·ÚÍË Â›ÏˆÓ Ì ÛÙÚÔÁÁ˘ÏÂ̤Ó˜ ¿ÎÚ˜ ÛÙÔ Û›ÙÈ
∞ÚÈıÌfi˜
(%)
314 355 394 395 381
78,5 88,8 98,5 98,8 95,3
310 167 8 233 286 186 42 310 288 217
77,5 41,8 2,0 58,3 71,5 57,6 10,5 77,5 72,0 54,3
* ∞ӷʤÚÂÙ·È ÌfiÓÔ ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ fiÔ˘ ˘‹Ú¯Â ·Ó·ÁηÈfiÙËÙ· Ï‹„˘ ÙÔ˘ ̤ÙÚÔ˘. ∂‚‰ÔÌ‹ÓÙ· ÂÙ¿ (77) ÔÈÎÔÁ¤ÓÂȘ (19,2%) ‰È¤ÌÂÓ·Ó Û ÈÛfiÁÂȘ ηÙÔÈ˘
·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÛÙÔ Û›ÙÈ (.¯. ÂÁη‡Ì·Ù· ÏfiÁˆ ·ʋ˜ Ì ıÂÚÌ‹ Û˘Û΢‹) ‚Ú¤ıËΠ˘„ËÏfiÙÂÚË Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÂÚ¢ÓÒÓ Ô˘ ¤ÁÈÓ·Ó Û ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ‹ ÚÔÛÎÔÌ›ÛÙËÎ·Ó Û ˘ËÚÂۛ˜ ˘Á›·˜ ÏfiÁˆ ·Ù˘¯‹Ì·ÙÔ˜ (10,21), ÂÓÒ ‹Ù·Ó ·ÚfiÌÔÈ· ÁÈ· Ù· ·Ù˘¯‹Ì·Ù· Ô˘ - ÏfiÁˆ Ù˘ ‚·Ú‡ÙËÙ¿˜ ÙÔ˘˜ - Â›Ó·È ·Ó·Áη›· Ë ÚÔÛ·ÁˆÁ‹ ‹ Î·È ÓÔÛËÏ›· Û ˘ËÚÂۛ˜ ˘Á›·˜, fiˆ˜ ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Î·È Ë Ì¿ÛËÛË ÙÛÈÁ¿ÚÔ˘ (6,25). ∏ ÔÈÔÙÈ΋ ÁÔÓÂ˚΋ ›‚ÏÂ„Ë ‰ÂÓ ·Ô‰ÂÈÎÓ‡ÂÙ·È ÛÙ·ÙÈÛÙÈο fiÙÈ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÚfiÏ˄˘ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ (18,26), ·Ú¿ Ù· ‰È·ÊÔÚÂÙÈο Â˘Ú‹Ì·Ù· ¿ÏÏ˘ ¤Ú¢ӷ˜ (27). ∞ÓÙ›ıÂÙ·, Ë Ï‹„Ë ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ, Û¯ÂÙÈÎÒÓ
Ì ÙȘ ÔÚı¤˜ ÛÙ¿ÛÂȘ Î·È ÁÓÒÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙË ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ‰È·‚›ˆÛ˘ ÙÔ˘ ·È‰ÈÔ‡, Ê·›ÓÂÙ·È fiÙÈ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘ ·Ù˘¯ËÌ¿ÙˆÓ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ÛÙÔ ÔÈÎÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ Î·È ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ·Ó·„˘¯‹˜, ‡ÚËÌ· Ô˘ ‰Â›¯ÓÂÈ ÙË Û·Ê‹ ˘ÂÚÔ¯‹ ÙˆÓ Ì¤ÙÚˆÓ Ù˘ ·ıËÙÈ΋˜ ÚfiÏ˄˘ ¤Ó·ÓÙÈ ÂÎÂ›ÓˆÓ Ù˘ ÂÓÂÚÁËÙÈ΋˜ (28,29). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ¤ÁÈÓ ¤ÌÌÂÛ·, Ì ÎÚÈÙ‹ÚÈÔ ÙËÓ ÂÚÈÔ¯‹ ‰È·ÌÔÓ‹˜ (30,31). ∆Ô ¯·ÌËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ˆ˜ ·Ú¿ÁÔÓÙ·˜ ÚfiÎÏËÛ˘ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÂȂ‚·ÈÒÓÂÙ·È Î·È ·fi ¿ÏϘ ÌÂϤÙ˜
¶›Ó·Î·˜ 4. ¶ÔÏÏ·Ï‹ ÁÚ·ÌÌÈ΋ ÂÍ¿ÚÙËÛË. ™˘ÓÙÂÏÂÛÙ‹˜ ÌÂÚÈ΋˜ ÂÍ¿ÚÙËÛ˘ (b) Î·È 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% O∞) ÙÔ˘ ‰Â›ÎÙË ·Ù˘¯‹Ì·ÙÔ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ·Ó¿ÏÔÁ· Ì ÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ªÂÙ·‚ÏËÙ‹ º‡ÏÔ ∫ÔÚ›ÙÛÈ ∞ÁfiÚÈ ∏ÏÈΛ· ·È‰ÈÔ‡ (·Ó¿ ÂÍ¿ÌËÓË ·‡ÍËÛË) ∫ÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÂÚÈÔ¯‹˜ ‰È·ÌÔÓ‹˜ ÀÔ‚·ıÌÈṲ̂ÓÔ ª¤ÛÔ ∏ÏÈΛ· ÌËÙ¤Ú·˜ (·Ó¿ ‰ÂηÂÙ‹ ·‡ÍËÛË) ∂η›‰Â˘ÛË Î·È ÂÚÁ·Û›· Ù˘ ÌËÙ¤Ú·˜ √ÈÎÔÎ˘Ú¿ Ì ≤6 ¤ÙË ÛÔ˘‰ÒÓ ∂ÚÁ·˙fiÌÂÓË Ì ≤6 ¤ÙË ÛÔ˘‰ÒÓ √ÈÎÔÎ˘Ú¿ Ì 7-12 ¤ÙË ÛÔ˘‰ÒÓ ∂ÚÁ·˙fiÌÂÓË Ì 7-12 ¤ÙË ÛÔ˘‰ÒÓ √ÈÎÔÎ˘Ú¿ Ì >12 ¤ÙË ÛÔ˘‰ÒÓ ∂ÚÁ·˙fiÌÂÓË Ì >12 ¤ÙË ÛÔ˘‰ÒÓ ¢Â›ÎÙ˘ ÁÔÓÂ˚΋˜ ›‚Ï„˘ (·Ó¿ 1 ÌÔÓ¿‰· ·‡ÍËÛË) ¢Â›ÎÙ˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ (·Ó¿ 1 ÌÔÓ¿‰· ·‡ÍËÛË)
b
95% O∞
p
∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ 0,37 (0,06)-(0,67) 0,05 (-0,16)-(0,05)
0,02 0,31
∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ -0,61 (-0,96)-(-0,27) 0,01 (-0,29)-(0,31)
10-4 0,94
0,86 (0,43)-(1,30) 0,74 (-0,09)-(1,58) ∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ -0,15 (-0,55)-(0,25) 0,72 (-0,20)-(1,64) 0,41 (-0,12)-(0,96) -0,11 (-0,34)-(0,14) -0,09 (-0,19)-(0,01)
10-4 0,08 0,47 0,12 0,13 0,39 0,05
¶·È‰È·ÙÚÈ΋ 2005;68:37-43
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·42
42
¢. §¿ÁÁ·˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 5. ¶ÔÏÏ·Ï‹ ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË. ™¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ (™∫) Î·È 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% O∞) ÁÈ· ·Ù‡¯ËÌ· οı ÔÌ¿‰·˜ ·Ó¿ÏÔÁ· Ì ÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ªÂÙ·‚ÏËÙ‹
OÌ¿‰· ·Ù˘¯ËÌ¿ÙˆÓ ÏfiÁˆ Ï‹„˘ ηٷӷψÙÈÎÒÓ ·Á·ıÒÓ ™∫ 95% O∞ p
º‡ÏÔ ∫ÔÚ›ÙÛÈ ∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ ∞ÁfiÚÈ 0,72 0,47-1,10 0,13 ∏ÏÈΛ· ·È‰ÈÔ‡ (·Ó¿ ÂÍ¿ÌËÓË ·‡ÍËÛË) 0,99 0,85-1,15 0,94 ∫ÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÂÚÈÔ¯‹˜ ‰È·ÌÔÓ‹˜ ÀÔ‚·ıÌÈṲ̂ÓÔ ∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ ª¤ÛÔ 0,42 0,26-0,68 10-4 ∏ÏÈΛ· ÌËÙ¤Ú·˜ (·Ó¿ ‰ÂηÂÙ‹ ·‡ÍËÛË) 0,61 0,40-0,94 0,03 ∂η›‰Â˘ÛË Î·È ÂÚÁ·Û›· Ù˘ ÌËÙ¤Ú·˜ √ÈÎÔÎ˘Ú¿ Ì ≤6 ¤ÙË ÛÔ˘‰ÒÓ 1,13 0,78-2,63 0,24 ∂ÚÁ·˙fiÌÂÓË Ì ≤6 ¤ÙË ÛÔ˘‰ÒÓ 1,20 0,39-3,72 0,74 √ÈÎÔÎ˘Ú¿ Ì 7-12 ¤ÙË ÛÔ˘‰ÒÓ ∫·ÙËÁÔÚ›· ·Ó·ÊÔÚ¿˜ ∂ÚÁ·˙fiÌÂÓË Ì 7-12 ¤ÙË ÛÔ˘‰ÒÓ 0,88 0,49-1,56 0,66 √ÈÎÔÎ˘Ú¿ Ì >12 ¤ÙË ÛÔ˘‰ÒÓ 1,03 0,27-3,88 0,95 ∂ÚÁ·˙fiÌÂÓË Ì >12 ¤ÙË ÛÔ˘‰ÒÓ 3,90 1,79-8,47 10-3 ¢Â›ÎÙ˘ ÁÔÓÂ˚΋˜ ›‚Ï„˘ (·Ó¿ 1 ÌÔÓ¿‰· ·‡ÍËÛË) 1,13 0,80-1,59 0,48 ¢Â›ÎÙ˘ ÁÔÓÂ˚΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ (·Ó¿ 1 ÌÔÓ¿‰· ·‡ÍËÛË) 0,88 0,77-1,01 0,07
(13,32,33), ·Ó Î·È ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·Ù‡¯ËÌ· ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· (34). OÈ ÈÔ Èı·Ó¤˜ ÂÚÌËÓ›˜ Â›Ó·È Ë Î·Ï‡ÙÂÚË ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Ì ˘„ËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÚfiÎÏËÛ˘ ·Ù˘¯‹Ì·ÙÔ˜ Ô˘ ‰È·ÙÚ¤¯Ô˘Ó Ù· ·È‰È¿ ÙÔ˘˜ ÛÙ· ‰È¿ÊÔÚ· ÛÙ¿‰È· Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜ Î·È Ë ‰˘Ó·ÙfiÙËÙ· Ï‹„˘ ÔÚÈÛÌ¤ÓˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ, Ô˘ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÈÛÔ‰‹Ì·ÙÔ˜, fiˆ˜ ÙÔ ÂȉÈÎfi οıÈÛÌ· ÁÈ· ÙÔ ·È‰› ÛÙÔ ·˘ÙÔΛÓËÙÔ ‹ Ë ·ÛÊ¿ÏÈÛË ÙˆÓ ËÏÂÎÙÚÈÎÒÓ ‰È·ÎÔÙÒÓ (35). °È· ÙÔ˘˜ ›‰ÈÔ˘˜ ÏfiÁÔ˘˜, ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·Ù˘¯ËÌ¿ÙˆÓ - ΢ڛˆ˜ ÏfiÁˆ ¤ÎÏ˘Û˘ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ - Ê·›ÓÂÙ·È fiÙÈ ‰È·ÙÚ¤¯Ô˘Ó Î·È Ù· ·È‰È¿ ÌËÙ¤ÚˆÓ ¯·ÌËÏ‹˜ ÌfiÚʈÛ˘, ÂÚÁ·˙fiÌÂÓˆÓ Î·È ÔÈÎÔ΢ÚÒÓ (36). ™Â ·˘ÍË̤ÓÔ, fï˜, ΛӉ˘ÓÔ ÁÈ· ·Ù˘¯‹Ì·Ù· ÏfiÁˆ Ï‹„˘ ηٷӷψÙÈÎÒÓ ·Á·ıÒÓ Î·È ÁÈ· ·Ù˘¯‹Ì·Ù· ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ¤Íˆ ·fi ÙÔ Û›ÙÈ ‚Ú›ÛÎÔÓÙ·È Î·È Ù· ·È‰È¿ ÂÚÁ·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ˘„ËÏ‹˜ ÌfiÚʈÛ˘ (12). OÈ Á˘Ó·›Î˜ ·˘Ù¤˜, ÏfiÁˆ ·˘ÍËÌ¤ÓˆÓ Â·ÁÁÂÏÌ·ÙÈÎÒÓ ˘Ô¯ÚÂÒÛˆÓ, ‰È·ı¤ÙÔ˘Ó ÂÚÈÔÚÈṲ̂ÓÔ ¯ÚfiÓÔ ÁÈ· ÙË ÊÚÔÓÙ›‰· Î·È ÙËÓ Âη›‰Â˘ÛË ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ ÛÙË ‰È·ÌfiÚʈÛË ÚÔÙ‡Ô˘ ·ÛÊ·ÏÔ‡˜ Û˘ÌÂÚÈÊÔÚ¿˜. °È· ÙÔÓ ›‰ÈÔ ÏfiÁÔ, Ù· ·È‰È¿ ÙÔ˘˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ̤ÓÔ˘Ó ·ÚÎÂÙfi ¯ÚfiÓÔ ÂÎÙfi˜ ÛÈÙÈÔ‡ (.¯. ·È‰È΋ ¯·Ú¿) Î·È Û˘¯Ó¿ Ó· ÌËÓ Û˘Óԉ‡ÔÓÙ·È ·fi ÙȘ ›‰È˜, ·ÏÏ¿ ·fi οÔÈÔ ¿ÏÏÔ ÚfiÛˆÔ (ÁÈ·ÁÈ¿, ÔÈÎȷ΋ ‚ÔËıfi˜) Ô˘ Èı·ÓfiÓ Ó· ÌËÓ ÂȂϤÂÈ Â·ÚÎÒ˜ ÙÔ ·È‰›. ∞ÓÙ›ıÂÙ·, ·Ú·ÙËÚ‹ıËΠÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· ÁÈ· ·Ù‡¯ËÌ· ÏfiÁˆ ıÂÚÌÈ΋˜-ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ÛÙ· ·È‰È¿ ÙˆÓ ÂÚ¶·È‰È·ÙÚÈ΋ 2005;68:37-43
OÌ¿‰· ·Ù˘¯ËÌ¿ÙˆÓ ÏfiÁˆ ¤ÎÏ˘Û˘ ıÂÚÌÈ΋˜-ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ™∫ 95% O∞ p
OÌ¿‰· ·Ù˘¯ËÌ¿ÙˆÓ Û ¯ÒÚÔ˘˜ ·Ó·„˘¯‹˜ ™∫
1,18 0,93
0,78-1,78 0,41 0,80-1,07 0,33
0,86 0,55-1,35 0,53 1,28 1,09-1,50 10-4
0,95 1,08
0,59-1,50 0,82 0,72-1,63 0,68
0,81 0,49-1,36 0,44 0,85 0,55-1,33 0,49
0,86 0,30
0,47-1,56 0,63 0,09-0,95 0,04
1,33 0,71-2,49 0,36 1,57 0,49-4,96 0,44
0,63 0,89 0,55
0,39-1,08 0,09 0,26-3,08 0,86 0,27-1,14 0,11
0,99 0,52-1,85 0,97 0,49 0,09-2,55 0,40 2,22 1,01-4,89 0,05
0,78
0,56-1,09 0,14
1,07 0,74-1,53 0,70
0,95
0,83-1,07 0,42
0,85 0,74-0,98 0,03
95% O∞
p
Á·˙fiÌÂÓˆÓ ÌËÙ¤ÚˆÓ ¯·ÌËÏ‹˜ ÌfiÚʈÛ˘, ÂÂȉ‹ ·˘Ù¿ Û˘Ì‚·›ÓÔ˘Ó ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÛÙÔÓ ¯ÒÚÔ Ù˘ ÎÔ˘˙›Ó·˜ (37), fiÔ˘ ÔÈ ÂÚÁ·˙fiÌÂÓ˜ ÌËÙ¤Ú˜ ··Û¯ÔÏÔ‡ÓÙ·È Ôχ ÏÈÁfiÙÂÚÔ ·fi ÙȘ ÔÈÎÔ΢ڤ˜. Ÿˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ (14,24,38,39), ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘ ·Ù˘¯ËÌ¿ÙˆÓ ‰È·ÙÚ¤¯Ô˘Ó Î·È Ù· ·È‰È¿ ÙˆÓ ÌËÙ¤ÚˆÓ Ó·ڋ˜ ËÏÈΛ·˜. ∏ ¤ÏÏÂÈ„Ë ÂÌÂÈÚÈÒÓ ÏfiÁˆ ÙÔ˘ Ó·ÚÔ‡ Ù˘ ËÏÈΛ·˜ ηÈ, ηٿ Û˘Ó¤ÂÈ·, Ë ·Ó·Ú΋˜ ›‚ÏÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ¿ÁÓÔÈ· ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ·˘Ùfi ‰È·ÙÚ¤¯ÂÈ ÛÙ· ‰È¿ÊÔÚ· ÛÙ¿‰È· Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘, ÂȉÈο ηٿ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘, Â›Ó·È Ë Ï¤ÔÓ ·Ô‰ÂÎÙ‹ ÂÍ‹ÁËÛË (38). H ÚfiÏË„Ë fiÏˆÓ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Â›Ó·È ¤Ó·˜ ·Ó¤ÊÈÎÙÔ˜ ÛÙfi¯Ô˜. øÛÙfiÛÔ, Ë ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ‰˘ÓËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Ê˘ÛÈÎfi Î·È ÙÔ ÎÔÈÓˆÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜, ÙÔ˘˜ ·ÁÁÂÏ̷ٛ˜ ˘Á›·˜, ·ÏÏ¿ Î·È fiÛÔ˘˜ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ. ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ·Ú¿ÌÂÙÚÔÈ Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙȘ ÔÚı¤˜ ÁÓÒÛÂȘ, ÛÙ¿ÛÂȘ Î·È Ú·ÎÙÈΤ˜ ÙˆÓ ÁÔÓ¤ˆÓ ÛÙË ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡, ηıÒ˜ Î·È ÔÚÈṲ̂ӷ ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, fiˆ˜ ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ›‰Ô, ÙÔ Â›Â‰Ô Âη›‰Â˘Û˘, Ë ··Û¯fiÏËÛË Î·È Ë ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, ÂËÚ¿˙Ô˘Ó Û ÈηÓfi ‚·ıÌfi ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ∏ ÂÈÛ‹Ì·ÓÛË
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·43
43
¶ÚfiÏË„Ë ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ
·˘ÙÒÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Î·È Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ Ô˘ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Î·È ÙËÓ ·ÏÏ·Á‹ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ - ÂÂȉ‹ ÔÈ ÎÔÈÓˆÓÈÎÔ› Î·È ‰ËÌÔÁÚ·ÊÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·ÏÏ¿ÍÔ˘Ó - Â›Ó·È ‰‡Ô ‚·ÛÈΤ˜ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ›وÛ˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Û fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ¯·ÌËÏfiÙÂÚ· ›‰· (40).
µÈ‚ÏÈÔÁÚ·Ê›· 1. Tursz A, Lelong N, Crost M. Home accidents to children under 2 years of age. Paediatr Perinat Epidemiol 1990;4:408-421. 2. Addor V, Santos-Eggimann B. Population-based incidence of injuries among preschoolers. Eur J Pediar 1996;155:130-135. 3. Rivara FP. Pediatric injury control in 1999: where do we go from here? Pediatrics 1999;103:883-888. 4. Rivara FP, Grossman DC, Cummings P. Injury prevention. First of two parts. N Engl J Med 1997;337:543-548. 5. Wadsworth J, Burnell I, Taylor B, Butler N. Family type and accidents in preschool children. J Epidemiol Community Health 1983;37:100-104. 6. Gallagher SS, Finison K, Guyer B, Goodenough S. The incidence of injuries among 87,000 Massachusetts children and adolescents: results of the 1980-81 Statewide Childhood Injury Prevention Program Surveillance System. Am J Public Health 1984;74:1340-1347. 7. Fonseca SS, Victora CG, Halpern R, Barros AJ, Lima RC, Monteiro LA et al. Risk factors for accidental injuries in preschool children. J Pediatr (Rio J) 2002;78:97-104. 8. Brownscombe J, Simpson N, Lenton S, Davis R, Barby T. The potential of emergency department injury surveillance data: an illustration using descriptive analysis of data in 0-4 year olds from the Bath injury surveillance system. Child Care Health Dev 2004;30:161-166. 9. Laflamme L, Eilert-Petersson E. Injuries to pre-school children in a home setting: patterns and related products. Acta Paediatr 1998;87:206-211. 10. Grossman DC. The history of injury control and the epidemiology of child and adolescent injuries. Future Child 2000;10:23-52. 11. Rivara FP, Mueller BA. The epidemiology and causes of childhood injuries. J Social Issues 1987;43:13-31. 12. Bourguet CC, McArtor RE. Unintentional injuries. Risk factors in preschool children. Am J Dis Child 1989;143:556-559. 13. Durkin MS, Davidson LL, Kuhn L, O’Connor P, Barlow B. Low-income neighborhoods and the risk of severe pediatric injury: a small-area analysis in northern Manhattan. Am J Public Health 1994;84:587-592. 14. Scholer SJ, Hickson GB, Ray WA. Sociodemographic factors identify US infants at high risk of injury mortality. Pediatrics 1999;103:1183-1188. 15. Garling A, Garling T. Mothers’ supervision and perception of young children’s risk at unintentional injury in the home. J Pediatr Psychol 1993;18:105-114. 16. Peterson L, Ewigman B, Kivlahan C. Judgments regarding appropriate child supervision to prevent injury: the role of environmental risk and child age. Child Dev 1993;64:934-950. 17. Wills KE, Tanz RR, Christoffel K, Schofer JL, Lavigne JV, Donovan M et al. Supervision in childhood injury cases: a reliable taxonomy. Accid Anal Prev 1997;29:133-137. 18. Roberts I. Parental supervision: a popular myth. Inj Prev 1996;2:9-10. 19. Petridou E, Tolma E, Dessypris N, Trichopoulos D. A controlled evaluation of a community injury project in two Greek islands. Int J Epidemiol 1997;26:173-179.
20. ∆ÚȯfiÔ˘ÏÔ˜ ¢, ∆˙ÒÓÔ˘ ∞, ∫·ÙÛÔ˘ÁÈ¿ÓÓË ∫. µÈÔÛÙ·ÙÈÛÙÈ΋. ∞ı‹Ó·: ∂ÈÛÙËÌÔÓÈΤ˜ ∂ΉfiÛÂȘ °Ú. ¶·ÚÈÛÈ·Ófi˜; 2000. ÛÂÏ. 135-149. 21. ª·Ú·ÁÎfi˜ Ã, µ·Ï¿ÛÛË-∞‰¿Ì ∂, °ÂˆÚÁ›Ô˘ °, ∞‰¿Ì °, ª·ÙÛ·ÓÈÒÙ˘ ¡. ∞Ù˘¯‹Ì·Ù· ÛÙ· ·È‰È¿: ÂÌÂÈڛ˜ Î·È ÙÔÔıÂÙ‹ÛÂȘ ÁÔÓ¤ˆÓ. πÔÎÚ¿Ù˘ 1983;11:383-390. 22. ∆ÚȯfiÔ˘ÏÔ˜ ¢, §¿ÁÈÔ˘ ¶. °ÂÓÈ΋ Î·È ÎÏÈÓÈ΋ ÂȉËÌÈÔÏÔÁ›·. ∞ı‹Ó·: ∂ÈÛÙËÌÔÓÈΤ˜ ∂ΉfiÛÂȘ °Ú. ¶·ÚÈÛÈ¿ÓÔ˜; 2002. ÛÂÏ. 79. 23. ¶·‹˜ ∫Ã, ∫Ô˘ÏÔ˘ÓÙ‹˜ °, äÏÌ˘ π, §Ô˝˙Ô˜ ª, ºÈÏ›Ô˘ ª. ¶Ô‡ Î·È Ò˜ ÎÙ˘Ô‡Ó Ù· ·È‰È¿: ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· ÛÙË ‰ÈÂÙ›· 1980-81. ¶·È‰È·ÙÚÈ΋ 1983;46:35-43. 24. McCormick MC, Shapiro S, Starfield BH. Injury and its correlates among 1-year-old children. Study of children with both normal and low birth weights. Am J Dis Child 1981;135:159-163. 25. Petridou E, Polychronopoulou A, Kouri N, Karpathios T, Koussouri M, Messaritakis Y et al. Unintentional childhood poisoning in Athens: a mirror of consumerism? J Toxicol Clin Toxicol 1997;35:669-675. 26. Levene S. Is there more to parental supervision than political incorrectness? Inj Prev 1996;2:10-11. 27. Glik DC, Greaves PE, Kronenfeld JJ, Jackson KL. Safety hazards in households with young children. J Pediatr Psychol 1993;18:115-131. 28. Rodgers GB. The safety effects of child-resistant packaging for oral prescription drugs. Two decades of experience. JAMA 1996;275:1661-1665. 29. Deal LW, Gomby DS, Zippiroli L, Behrman RE. Unintentional injuries in childhood: analysis and recommendations. Future Child 2000;10:4-22. 30. Runyan CW, Bangdiwala SI, Linzer MA, Sacks JJ, Butts J. Risk factors for fatal residential fires. N Engl J Med 1992;327:859-863. 31. Moustaki M, Petridou E, Trichopoulos D. Person, time and place coordinates of pedestrian injuries: a study in Athens. Acta Paediatr 2001;90:558-562. 32. Morrison A, Stone DH, Doraiswamy N, Ramsay L. Injury surveillance in an accident and emergency department: a year in the life of CHIRPP. Arch Dis Child 1999;80:533-536. 33. Hippisley-Cox J, Groom L, Kendrick D, Coupland C, Webber E, Savelyich B. Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trend 1992-7. BMJ 2002;324:1132-1137. 34. Engstrom K, Diderichsen F, Laflamme L. Socioeconomic differences in injury risks in childhood and adolescence: a nation-wide study of intentional and unintentional injuries in Sweden. Inj Prev 2002;8:137-142. 35. Santer LJ, Stocking CB. Safety practices and living conditions of low-income urban families. Pediatrics 1991;88:1112-1118. 36. Ramsay LJ, Moreton G, Gorman DR, Blake E, Goh D, Elton RA et al. Unintentional home injury in preschool-aged children: looking for the key - an exploration of the inter-relationship and relative importance of potential risk factors. Public Health 2003;117:404-411. 37. Petridou E, Trichopoulos D, Mera E, Papadatos Y, Papazoglou K, Marantos A et al. Risk factors for childhood burn injuries: a case-control study from Creece. Burns 1998;24:123-128. 38. Taylor B, Wadsworth J, Butler NR. Teenage mothering, admission to hospital, and accidents during the first five years. Arch Dis Child 1983;58:6-11. 39. Wicklund K, Moss S, Frost F. Effects of maternal education, age, and parity on fatal infant accidents. Am J Public Health 1984;74:1150-1152. 40. Lie L, Runyan CW, Petridou E, Chang A. American Public Health Association/American Academy of Pediatrics Injury Prevention Standards. Pediatrics 1994;94:1046-1048.
¶·È‰È·ÙÚÈ΋ 2005;68:37-43
Paediatriki Jan-Feb 05 teliko
44
10-02-05
13:36
™ÂÏ›‰·44
ORIGINAL ARTICLE
Parental behavior and childhood injury prevention D. Laggas1, E. Petridou2, N. Dessypris2, T. Thomaidis1 1 National School of Public Health 2 Department of Hygiene and Epidemiology, University of Athens Medical School Correspondence: Dimitris Laggas 6 Kallidromiou str., 114 72, ∞thens E-mail: dimlag@hol.gr Date of submission: 22-03-2004 Date of approval: 28-09-2004
Abstract Background: The aim of this study was to investigate parameters assessing a possible contribution of parental behavior in the causation of injuries among preschool children. Methods: Data were collected through 400 interpersonal structured interviews based on anonymous questionnaires from parents residing in two areas of the Greater Athens, namely an urban, relatively prosperous area and a socially deprived one. The questionnaire covered sociodemographic characteristics, the type of injuries that had been sustained by the study subjects and information concerning two indices: the Parental Behavior Index (PBI) related to parental knowledge and attitudes towards a safe child environment and the Parental Supervision Index (PSI) related to appropriate parental supervision. Statistical analysis was done through multiple linear and logistic regression analysis. Results: The increase of the PBI by one unit was associated with a reduction of the mean number of injuries due to release of mechanical energy by 0.09 and the risk for injuries outside home by 15%, whereas no statistical association of PSI was noted. Increased number of injuries due to release of mechanical energy was found among children from the deprived area and in those with mothers of lower educational level. By contrast, children of higher education working mothers sustained a higher number of injuries due to consumer goods and they were at a higher risk for injuries outside home. Conclusions: Findings of the present study show that certain variables related to higher parental knowledge and attitudes towards a safe child living environment affect the epidemiological profile of injuries in early childhood.
Key words Injury, preschoolers, parental behavior.
Paediatriki 2005;68:44
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·45
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
45
¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È Ë Û¯¤ÛË Ù˘ Ì ÙȘ ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ Î·È ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ ∂. ∫¿ÎÔ˘ÚÔ˜1, ∫. ª·ÓÈ·‰¿ÎË2, ∂. ∫·Ó›ÛË2
¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: µ·ÛÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ·ÚÔ‡Û·˜ ¤Ú¢ӷ˜ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÙÈÏ‹„ÂˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Ú·ÎÙÈÎÒÓ Ô˘ ˘ÈÔıÂÙÔ‡ÓÙ·È ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ηıÒ˜ Î·È Ô Èı·Ófi˜ Û˘Û¯ÂÙÈÛÌfi˜ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ Ì ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ∆Ô ‰Â›ÁÌ· Ù˘ ¤Ú¢ӷ˜ ·ÔÙ¤ÏÂÛ·Ó 498 ·È‰È¿ ËÏÈΛ·˜ 3-7 ÂÙÒÓ Ô˘ ‰È¤ÌÂÓ·Ó ÛÙȘ ÂÚÈÔ¯¤˜ §Â˘ÎˆÛ›·˜ Î·È ¶¿ÊÔ˘ Ù˘ ∫‡ÚÔ˘ Î·È ÔÈ ÌËÙ¤Ú˜ ÙÔ˘˜. ∞ÔÙÂϤÛÌ·Ù·: ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜, ÔÛÔÛÙfi 6,4% ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ‹Ù·Ó ·¯‡Û·Úη Î·È 15,9% ˘¤Ú‚·Ú·. øÛÙfiÛÔ, ‰È·ÈÛÙÒıËΠfiÙÈ ˘„ËÏfi ÔÛÔÛÙfi ÌËÙ¤ÚˆÓ Ì ·¯‡Û·Úη ‹ ˘¤Ú‚·Ú· ·È‰È¿ ‹Ù·Ó ÈηÓÔÔÈË̤ÓÔ Ì ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÔ˘Ó Û˘Ó‹ıˆ˜ Ù· ·È‰È¿ ÙÔ˘˜, ÂÓÒ ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi, ÔÈ ÌÈÛ¤˜ ÂÚ›Ô˘ ÌËÙ¤Ú˜ ı· ‹ıÂÏ·Ó ÙÔ ·È‰› ÙÔ˘˜ Ó· ÙÚÒÂÈ ÂÚÈÛÛfiÙÂÚÔ. ∂›Û˘, ˘„ËÏfi ÔÛÔÛÙfi ÌËÙ¤ÚˆÓ ‰ÂÓ ıˆÚÔ‡Û ٷ ·È‰È¿ Èηӿ Ó· Ú˘ıÌ›˙Ô˘Ó ÌfiÓ· ÙÔ˘˜ ÙËÓ ÔÛfiÙËÙ· ÙÚÔÊ‹˜ Ô˘ Ú¤ÂÈ Ó· ηٷӷÏÒÛÔ˘Ó.
1 ∆Ì‹Ì· µÚÂÊÔÓËÈÔÎÔÌ›·˜, ∆.∂.π. ∞ı‹Ó·˜ 2 æ˘¯ÔÏÔÁÈÎfi ∫¤ÓÙÚÔ ∞Ó·Ù˘ÍÈ·ÎÒÓ Î·È ª·ıËÛÈ·ÎÒÓ ¢˘ÛÎÔÏÈÒÓ “∞ƒ™∏”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∫·ÙÂÚ›Ó· ª·ÓÈ·‰¿ÎË ∫·Ú·Ù¿ÛÔ˘ 52, £Ú·ÎÔ̷ΉfiÓ˜, ∆.∫. 136 76, ∞ı‹Ó· E-mail: katerina@arsi.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-11-2003 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 22-10-2004
™˘ÌÂÚ¿ÛÌ·Ù·: º·›ÓÂÙ·È, fiÙÈ ÔÈ ·ÓÙÈÏ‹„ÂȘ ÙˆÓ ÌËÙ¤ÚˆÓ ÁÈ· ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È Ù· ·È‰È¿ ÙÔ˘˜ Â›Ó·È Û˘¯Ó¿ Ï·Óı·Ṳ̂Ó˜. OÈ ·ÓÙÈÏ‹„ÂȘ ·˘Ù¤˜ ÂÓ‰¤¯ÂÙ·È Ó· Ô‰ËÁÔ‡Ó ÛÙËÓ ˘ÈÔı¤ÙËÛË ·Ó¿ÏÔÁˆÓ ‰È·ÙÚÔÊÈÎÒÓ Ú·ÎÙÈÎÒÓ, ÔÈ Ôԛ˜ Â›Ó·È Èı·Ófi Ó· Û¯ÂÙ›˙ÔÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi Ì ÙËÓ ÂΉ‹ÏˆÛË ·È‰È΋˜ ·¯˘Û·ÚΛ·˜. ªÂ ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜, Û˘˙ËÙÔ‡ÓÙ·È Èı·ÓÔ› ·ÈÙÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ ÛÙÔ Ï·›ÛÈÔ Ù˘ ıˆڛ·˜ Ù˘ ÎÔÈÓˆÓÈ΋˜ Ì¿ıËÛ˘.
§¤ÍÂȘ ÎÏÂȉȿ ¶·È‰È΋ ·¯˘Û·ÚΛ·, ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ, ·È‰È΋ ‰È·ÙÚÔÊ‹.
∂ÈÛ·ÁˆÁ‹ ™‡Ìʈӷ Ì ‰ÈÂıÓ‹ ÂÚ¢ÓËÙÈο ‰Â‰Ô̤ӷ, Ë ·¯˘Û·ÚΛ· ·ÔÙÂÏ› ¤Ó· ·fi Ù· Û˘ÓËı¤ÛÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Ù· ·È‰È¿ (1). ∏ ·¯˘Û·ÚΛ· ¤¯ÂÈ ÔÏϤ˜ ·ÚÓËÙÈΤ˜ ÂȉڿÛÂȘ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ, fiˆ˜ ÂΉ‹ÏˆÛË ˘¤ÚÙ·Û˘, ·˘ÍË̤Ó˘ ¯ÔÏËÛÙÂÚfiÏ˘, ηډȷÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ Î.¿. (2,3). ∞Ó Î·È Ë ·¯˘Û·ÚΛ· ‰ÂÓ ·ÔÙÂÏ› „˘¯È΋ ‰È·Ù·Ú·¯‹, Â›Ó·È ˆÛÙfiÛÔ ¤Ó· ÔχÏÔÎÔ Úfi‚ÏËÌ·, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ, fi¯È ÌfiÓÔ ÔÚÁ·ÓÈΤ˜ ·ÏÏ¿ Î·È „˘¯ÔÏÔÁÈΤ˜, ÔÈ Ôԛ˜ Ê·›ÓÂÙ·È ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ Ó· Â›Ó·È ÈÔ ÛÔ‚·Ú¤˜ ·fi ÙȘ ÔÚÁ·ÓÈΤ˜ (4,5). øÛÙfiÛÔ, ·Ú¿ ÙË ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ Î·È ÙËÓ ÏËıÒÚ· ÙˆÓ ÔÚÁ·ÓÈÎÒÓ Î·È „˘¯ÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙ· ÔÔ›· Û˘¯Ó¿ Ô‰ËÁ›, ÙÔ ÂÚ¢ÓËÙÈÎfi ÂӉȷʤÚÔÓ ÙˆÓ ÂȉÈÎÒÓ ‰ÂÓ ˘‹ÚÍ ̤¯ÚÈ Û‹ÌÂÚ· ·Ó¿ÏÔÁÔ Ì ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ (6). ™ÙȘ ∏¶∞, Û‡Ìʈӷ Ì ÛÙÔȯ›· ÚfiÛÊ·ÙˆÓ
ÂÚ¢ÓÒÓ, ÙÔ 22% ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ Â›Ó·È ˘¤Ú‚·ÚÔ Î·È ÙÔ 11% ·¯‡Û·ÚÎÔ (1). ™ÙȘ ·Ú·‚ÈΤ˜ ¯ÒÚ˜, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ë ·¯˘Û·ÚΛ· ·ÊÔÚ¿ ÛÙÔ 16-25% ÙÔ˘ ·Ó‰ÚÈÎÔ‡ Î·È ÛÙÔ 17-43% ÙÔ˘ Á˘Ó·ÈΛԢ ÏËı˘ÛÌÔ‡ (7). ™Â ¤Ú¢Ó˜ Ô˘ ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› ÛÙÔÓ ÂÏÏ·‰ÈÎfi ¯ÒÚÔ Î·È ÙËÓ ∫‡ÚÔ, Ù· ÔÛÔÛÙ¿ ÙˆÓ ·¯‡Û·ÚÎˆÓ Î·È ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ Î˘Ì·›ÓÔÓÙ·È ·fi 10,3% ¤ˆ˜ 14,4% Î·È ·fi 16,9% ¤ˆ˜ 22,7%, ·ÓÙ›ÛÙÔȯ· (8,9), ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ Ù· ›‰· Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Â›Ó·È ˘„ËÏfiÙÂÚ· ÛÙȘ ·ÁÚÔÙÈΤ˜ Û ۯ¤ÛË Ì ÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ (10). ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Ù›ÓÂÈ Ó· ·˘Í¿ÓÂÙ·È Ú·Á‰·›·. ™Â ÚfiÛÊ·ÙË ¤Ú¢ӷ ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· Û ·È‰È¿ ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜, ‰È·ÈÛÙÒıËΠfiÙÈ ·fi ÙÔ 1988 ¤ˆ˜ ÙÔ 1998, ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ ·˘Í‹ıËΠ·fi 14,7% Û 23,6% Î·È ÙˆÓ ·¯‡Û·ÚÎˆÓ ·fi 5,4% Û 9,2% (11). ™ÙȘ ∏¶∞, ÛÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1971-1974, ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘¤Ú‚·ÚˆÓ ÎÔÚÈÙÛÈÒÓ ËÏÈΛ·˜ ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·46
46
∂. ∫¿ÎÔ˘ÚÔ˜ Î·È Û˘Ó.
4-5 ÂÙÒÓ ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 5,8%, ÂÓÒ ÛÙÔ ‰È¿ÛÙËÌ· 1988-1994 ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ¤ÊÙ·Û ÙÔ 10,8% (12). ¶·ÚfiÌÔȘ Â›Ó·È ÔÈ ‰È·ÈÛÙÒÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ·‡ÍËÛË ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Î·È ÛÙËÓ ∂˘ÚÒË, ȉȷ›ÙÂÚ· ÛÙËÓ ∞Ó·ÙÔÏÈ΋ Î·È ÙË ¡fiÙÈ· (13). ™ÙÔÓ ÂÏÏ·‰ÈÎfi ¯ÒÚÔ, Û ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÛÙËÓ ∫Ú‹ÙË Ì ‰Â›ÁÌ· 6000 Ì·ıËÙ¤˜ ‰ËÌÔÙÈÎÔ‡ Û¯ÔÏ›Ԣ, ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ·˘Í‹ıËÎ·Ó ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 ηÈ, Û˘ÁÎÚÈÓfiÌÂÓÔÈ Ì ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ‰Â›ÎÙ˜ ÛÙËÓ ∞ÌÂÚÈ΋, ‹Ù·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÈÔ ·˘ÍË̤ÓÔÈ ÛÙËÓ ∫Ú‹ÙË (14). ∆· ÂÚ¢ÓËÙÈο ‰Â‰Ô̤ӷ Ô˘ Â›Ó·È ‰È·ı¤ÛÈÌ· Û¯ÂÙÈο Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·¯˘Û·ÚΛ·˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ. OÚÈṲ̂Ó˜ ÊÔÚ¤˜, Ë ÂÌÊ¿ÓÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÌÔÚ› Ó· ·Ô‰Ôı› Û οÔÈ· ÔÚÁ·ÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ˆÛÙfiÛÔ Ë ·ÈÙÈÔÏÔÁ›· ·˘Ù‹ ‰ÂÓ Î·Ï‡ÙÂÈ ·Ú¿ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÂÚÈÙÒÛÂˆÓ ·¯˘Û·ÚΛ·˜. ∂ÈϤÔÓ, ÂÎÙÈÌ¿Ù·È fiÙÈ Ë ÎÏËÚÔÓÔÌÈÎfiÙËÙ· ¢ı‡ÓÂÙ·È ÌfiÓÔ ÁÈ· ÙÔ 10% ÂÚ›Ô˘ Ù˘ ‰È·Î‡Ì·ÓÛ˘ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (15). ™Â ÔÏϤ˜ ¤Ú¢Ó˜ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ÂÚÈÔÚÈṲ̂ÓË ÛˆÌ·ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Ô ·˘ÍË̤ÓÔ˜ ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂÔÙÈÎÒÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ Î·È ÔÈ Î·Î¤˜ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ, Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ (16,17). °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜, ÔÈ ÚÔÛ¿ıÂȘ Ô˘ Á›ÓÔÓÙ·È ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ·¯˘Û·ÚΛ·˜ Û˘Ó‹ıˆ˜ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙËÓ ·ÚfiÙÚ˘ÓÛË ÙˆÓ ·È‰ÈÒÓ Ó· ·ıÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ, Ó· ‚Ï¤Ô˘Ó ÏÈÁfiÙÂÚÔ ÙËÏÂfiÚ·ÛË Î·È Ó· ÚÔÛ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÙÔ ‰È·ÈÙÔÏfiÁÈfi ÙÔ˘˜ ηٷӷÏÒÓÔÓÙ·˜ ˘ÁÈÂÈÓ¤˜ ÙÚÔʤ˜ (18). ™Â ÌÈ· ÛÂÈÚ¿ ÂÚ¢ÓÒÓ ÛÙÔ Ï·›ÛÈÔ Ù˘ ıˆڛ·˜ Ù˘ ÎÔÈÓˆÓÈ΋˜ Ì¿ıËÛ˘, ÙÔÓ›˙ÂÙ·È Ô ÛËÌ·ÓÙÈÎfi˜ ÚfiÏÔ˜ Ô˘ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÔÈ ·¯‡Û·ÚÎÔÈ ÁÔÓ›˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿. OÈ ÁÔÓ›˜ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ÚfiÙ˘· Î·È ÂÓı·ÚÚ‡ÓÔ˘Ó ÙËÓ ·Ó¿ÏÔÁË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ Û ۯ¤ÛË Ì ÙÔ Ê·ÁËÙfi. OÈ Klesges Î·È Û˘Ó (19), Û ¤ÚÂ˘Ó¿ ÙÔ˘˜ Ô˘ ÛÙËÚÈ˙fiÙ·Ó ÛÙËÓ ·Ú·Ù‹ÚËÛË ·È‰ÈÒÓ ËÏÈΛ·˜ 30 ÌËÓÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ê·ÁËÙÔ‡, ‰È·›ÛÙˆÛ·Ó fiÙÈ ÔÈ Ô‰ËÁ›Â˜ ÙˆÓ ÁÔÓ¤ˆÓ Û¯ÂÙ›˙ÔÓÙ·Ó ıÂÙÈο ÙfiÛÔ Ì ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ·ÊÈÂÚˆÓfiÙ·Ó ÛÙÔ Ê·ÁËÙfi fiÛÔ Î·È Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡. ™Â ¤Ú¢ӷ ÙˆÓ Baughcum Î·È Û˘Ó (20) ‚Ú¤ıËΠfiÙÈ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÔÈ ÁÔÓ›˜ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔ Ê·ÁËÙfi ÚÔÎÂÈ̤ÓÔ˘ Ó· ÈηÓÔÔÈ‹ÛÔ˘Ó Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ ‹ fiÙ·Ó Ë Î·Ù·Ó¿ÏˆÛË Ê·ÁËÙÔ‡ ·ÍÈÔÏÔÁÂ›Ù·È ·fi ÙÔ˘˜ ÁÔÓ›˜ ˆ˜ ¤Ó‰ÂÈÍË Ù˘ ηϋ˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·È‰ÈÔ‡, ÙfiÙ ÔÈ ÁÔÓ›˜ Ì ÙÔÓ ÙÚfiÔ ÙÔ˘˜ ÂÓı·ÚÚ‡ÓÔ˘Ó ÙÔ ·È‰› Ó· ÙÚÒÂÈ ÂÚÈÛÛfiÙÂÚÔ Î·È ÙÔ Ô‰ËÁÔ‡Ó Ì ¢ÎÔÏ›· ÛÙËÓ ·¯˘Û·ÚΛ·. ∞Ó¿ÏÔÁ˜ ¤Ú¢Ó˜ ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
ÛÙËÓ ∂ÏÏ¿‰·, fiÔ˘ ÔÚÈṲ̂ÓÔÈ ÂȉÈÎÔ› ÂÎÙÈÌÔ‡Ó fiÙÈ Ë ·È‰È΋ ·¯˘Û·ÚΛ· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÁÔÓ¤ˆÓ, ηıÒ˜ Î·È Ì ÙËÓ Ù¿ÛË ÙÔ˘˜ Ó· Ù·˝˙Ô˘Ó Ù· ·È‰È¿ ·ÎfiÌË Î·È fiÙ·Ó ·˘Ù¿ ‰ÂÓ ÂÈÓÔ‡Ó (21). ∂Ô̤ӈ˜, ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ÙÔ̤·˜ ¤Ú¢ӷ˜ ÁÈ· Ù· ·›ÙÈ· Ù˘ ·¯˘Û·ÚΛ·˜ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È ÙˆÓ ÁÔÓÈÎÒÓ ·ÓÙÈÏ‹„ÂˆÓ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ·fi ÙȘ Ôԛ˜ ËÁ¿˙Ô˘Ó ·˘Ù¤˜ ÔÈ Û˘Ó‹ıÂȘ. ∏ ‰ÈÂÚ‡ÓËÛË ·˘ÙÒÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÌÔÚ› Ó· ‰È¢ڇÓÂÈ ÙË ÁÓÒÛË Ì·˜ ÁÈ· ÙÔ˘˜ ÙÚfiÔ˘˜ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ÁÔÓ›˜ ÂÓ‰¤¯ÂÙ·È Ó· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿. ∆¤ÙÔÈÔ˘ ›‰Ô˘˜ Û˘ÌÂÚ¿ÛÌ·Ù· ÌÔÚÔ‡Ó Ó· ·ÍÈÔÔÈËıÔ‡Ó ÁÈ· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ÂÓËÏ›ÎˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ·›ÙÈ· Î·È ÙȘ Û˘Ó¤ÂȘ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Ì ÛÙfi¯Ô ÙËÓ ÚfiÏË„‹ Ù˘. ªÂ ‚¿ÛË ·˘Ù‹ ÙË Û˘ÏÏÔÁÈÛÙÈ΋, ˘ÈÔıÂÙÂ›Ù·È Ë ¿Ô„Ë fiÙÈ Ë ·¯˘Û·ÚΛ·, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ Ì ÙȘ ·ÓÙÈÏ‹„ÂȘ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹, ηıÒ˜ Î·È Ì ÔÚÈṲ̂ӷ ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ ÙÔ˘ ·ÙfiÌÔ˘, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÙËÓ ·˘ÙÔ΢ÚÈ·Ú¯›·. ™Ùfi¯Ô˜ Ù˘ ·ÚÔ‡Û·˜ ¤Ú¢ӷ˜ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÙÈÏ‹„ÂˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹, ÙˆÓ ÂÎÙÈÌ‹ÛÂÒÓ ÙÔ˘˜ Û¯ÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Î·È ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Ú·ÎÙÈÎÒÓ Ô˘ ˘ÈÔıÂÙÔ‡Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ηıÒ˜ Î·È Ô Èı·Ófi˜ Û˘Û¯ÂÙÈÛÌfi˜ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ Ì ÙËÓ ÂΉ‹ÏˆÛË ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ·ÚÔ‡Û· ¤Ú¢ӷ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙËÓ ∫‡ÚÔ Î·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ¡Ô¤Ì‚ÚÈÔ˜ 2001 ¤ˆ˜ ºÂ‚ÚÔ˘¿ÚÈÔ˜ 2002. ∆Ô ‰Â›ÁÌ· ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 498 ·È‰È¿ ËÏÈΛ·˜ 3-7 ÂÙÒÓ Î·È ÙȘ ÌËÙ¤Ú˜ ÙÔ˘˜. ∆· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ·È‰ÈÎfi ÛÙ·ıÌfi Î·È ÓËÈ·ÁˆÁÂ›Ô ‹ ‹Ù·Ó Ì·ıËÙ¤˜ Ù˘ ∞’ ‰ËÌÔÙÈÎÔ‡. ∆· 302 ·È‰È¿ ‰È¤ÌÂÓ·Ó ÛÙË §Â˘ÎˆÛ›· Î·È Ù· 196 ÛÙËÓ ¶¿ÊÔ. ∞fi ·˘Ù¿, ÙÔ 52,6% ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· ˘fiÏÔÈ· ÎÔÚ›ÙÛÈ·. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ‹Ù·Ó 63,41 Ì‹Ó˜ (SD=10,72). §fiÁˆ ¤ÏÏÂȄ˘ ÛÙ·ıÌÈṲ̂ÓÔ˘ ÂÚÁ·Ï›Ԣ Ô˘ Ó· ‰ÈÂÚÂ˘Ó¿ ÙȘ ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ, ÔÈ ÌËÙ¤Ú˜ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ¤Ú¢ӷ Û˘ÌÏ‹ÚˆÛ·Ó ¤Ó· Έ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Î·Ù·Û΢·Ṳ̂ÓÔ ÁÈ· ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ÔÔ›Ô ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 22 ÂÚˆÙ‹ÛÂȘ, ÔÌ·‰ÔÔÈË̤Ó˜ Û ٤ÛÛÂÚȘ ηÙËÁÔڛ˜: ·) ¶¤ÓÙ ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙË Û˘ÁΤÓÙÚˆÛË ‰ËÌÔÁÚ·ÊÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ Û¯ÂÙÈο Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· (ËÏÈΛ· ÁÔÓ¤ˆÓ, ÌÔÚʈÙÈÎfi ›‰Ô, ÙfiÔ˜ ‰È·ÌÔÓ‹˜). ‚) ¶¤ÓÙ ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ì ‚¿ÛË Ì›· Îϛ̷η ¤ÓÙ ‚·ıÌ›‰ˆÓ (1=¿ÓÙ·, 2=Ôχ Û˘¯Ó¿, 3=ÌÂÚÈΤ˜ ÊÔÚ¤˜, 4=Û¿ÓÈ·, 5=ÔÙ¤). OÈ ÂÚˆÙ‹ÛÂȘ ·˘Ù¤˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÛÙÔÓ ‚·ıÌfi ˘Ô¯ˆÚËÙÈÎfiÙËÙ·˜ ÙˆÓ ÁÔÓ¤ˆÓ ÛÙȘ Èı·Ó¤˜ ··ÈÙ‹ÛÂȘ ÙÔ˘
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·47
47
¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ
·È‰ÈÔ‡ Û¯ÂÙÈο Ì ÙÔ Ê·ÁËÙfi, ÛÙ· ÚfiÛˆ· Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÛÙËÓ Èı·Ó‹ ›‰Ú·ÛË ÙˆÓ ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ‰È·ÙÚÔÊÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. Á) ŒÍÈ ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÙÈÏ‹„ÂˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹ ÁÂÓÈÎfiÙÂÚ·, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÛÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ó· Ú˘ıÌ›˙Ô˘Ó ÌfiÓ· ÙÔ˘˜ ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ηٷӷÏÒÛÔ˘Ó Î·È ÛÙËÓ Èı·ÓfiÙËÙ· ¯Ú‹Û˘ ÙÔ˘ Ê·ÁËÙÔ‡ ·fi Ù· ·È‰È¿ ˆ˜ ̤ÛÔ ÁÈ· Ó· ¢¯·ÚÈÛÙ‹ÛÔ˘Ó ‹ Ó· ‰˘Û·ÚÂÛÙ‹ÛÔ˘Ó ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜. OÈ ·ÓÙÈÏ‹„ÂȘ ·˘Ù¤˜ ·ÍÈÔÏÔÁ‹ıËÎ·Ó Ì ‚¿ÛË ÙËÓ ›‰È· Îϛ̷η ¤ÓÙ ‚·ıÌ›‰ˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ÂÓfiÙËÙ·. ‰) ŒÍÈ ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÙÈÏ‹„ÂˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ Û¯ÂÙÈο Ì ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ Û ۯ¤ÛË Ì ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi, ηıÒ˜ Î·È ÛÙÔÓ ‚·ıÌfi ÈηÓÔÔ›ËÛ‹˜ ÙÔ˘˜ ·fi ·˘Ùfi. ∏ Îϛ̷η ·ÍÈÔÏfiÁËÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ۠·˘Ù‹ ÙËÓ ÂÓfiÙËÙ· ÔÈΛÏ ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÚÒÙËÛË. ∏ Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÛÙÔȯ›ˆÓ ¤ÁÈÓ Û ‰‡Ô Ê¿ÛÂȘ: π. ™ÙËÓ ÚÒÙË Ê¿ÛË, ˙ËÙ‹ıËΠ·fi ÙȘ ÌËÙ¤Ú˜ 700 ·È‰ÈÒÓ Ó· Û˘ÌÏËÚÒÛÔ˘Ó ÙÔ Îˆ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ÙÔ˘˜ ‰È·ÓÂÌ‹ıËÎÂ. ™Â ·˘Ù‹ ÙË Ê¿ÛË, ÂÈÛÙÚ¿ÊËÎ·Ó Û˘ÌÏËڈ̤ӷ 498 ÂÚˆÙËÌ·ÙÔÏfiÁÈ·. ∂Í·ÈÙ›·˜, fï˜, Ú·ÎÙÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ ‰ÂÓ ÛÙ¿ıËΠ‰˘Ó·Ù‹ Ë Û˘ÁΤÓÙÚˆÛË ÛÙÔȯ›ˆÓ Û¯ÂÙÈο Ì ٷ ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÌËÙ¤Ú˜ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘, Ô‡ÙÂ Ë Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ÂӉ¯fiÌÂÓ˘ ·¯˘Û·ÚΛ·˜ ÛÙÔ˘˜ ÁÔÓ›˜. ππ. ™ÙË ‰Â‡ÙÂÚË Ê¿ÛË, ÌÂÙÚ‹ıËΠÙÔ ‚¿ÚÔ˜ Î·È ÙÔ ‡„Ô˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÌËÙ¤Ú˜ ›¯·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ Û˘ÌÏËÚÒÛÂÈ Ù· ÂÚˆÙËÌ·ÙÔÏfiÁÈ·. ™ÙË Û˘Ó¤¯ÂÈ·, Û‡Ìʈӷ Ì ÙÔ ‚¿ÚÔ˜ Î·È ÙÔ ‡„Ô˜ ÙˆÓ ·È‰ÈÒÓ ˘ÔÏÔÁ›ÛÙËÎÂ Ô ¢Â›ÎÙ˘ ª¿˙·˜ ™ÒÌ·ÙÔ˜ (¢ª™) Î·È Ì ‚¿ÛË Ù· fiÚÈ· (cut-off points) Ô˘ ÚÔÙ›ÓÔÓÙ·È ÁÈ· ÙÔÓ ÔÚÈÛÌfi ÙˆÓ ·¯‡Û·ÚÎˆÓ Î·È ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ ÛÙÔ˘˜ ›Ó·Î˜ ÙÔ˘ Cole Î·È Û˘Ó (22), Ù· ·È‰È¿ ηٷٿ¯ÙËÎ·Ó Û ÙÚÂȘ ÔÌ¿‰Â˜. °È· ·Ú¿‰ÂÈÁÌ·, ÛÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ, Ë Î·Ù·ÓÔÌ‹ ¤ÁÈÓ ˆ˜ ÂÍ‹˜: ·) ∆· ·ÁfiÚÈ· Ì ¢ª™ <17,42 Î·È Ù· ÎÔÚ›ÙÛÈ· Ì ¢ª™ <17,15 ηٷٿ¯ÙËÎ·Ó ÛÙËÓ ÔÌ¿‰· ·È‰ÈÒÓ Ì ηÓÔÓÈÎfi ‚¿ÚÔ˜. ‚) ∆· ·ÁfiÚÈ· Ì ¢ª™ 17,42-19,29 Î·È Ù· ÎÔÚ›ÙÛÈ· Ì ¢ª™ 17,15-19,16 ηٷٿ¯ÙËÎ·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ. Á) ∆· ·ÁfiÚÈ· Ì ¢ª™ >19,30 Î·È Ù· ÎÔÚ›ÙÛÈ· Ì ¢ª™ >19,17 ηٷٿ¯ÙËÎ·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ÔÛÔÛÙÈ·›·˜ ηٷÓÔÌ‹˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ·Ó¿ÏÔÁ· Ì ÙȘ ÂÍÂÙ·˙fiÌÂÓ˜ ÌÂÙ·‚ÏËÙ¤˜ Î·È ˘ÔÏÔÁ›ÛÙËÎÂ Ô ‰Â›ÎÙ˘ ¯2 ÌÂٷ͇ ηÙËÁÔÚÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ. ∂›Û˘, ˘ÔÏÔÁ›ÛÙËÎÂ Ô ‰Â›ÎÙ˘ ÛÙ·ÙÈÛÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ Pearson r ÌÂٷ͇ ·ÚÈıÌËÙÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ.
∞ÔÙÂϤÛÌ·Ù· ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜, Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÙˆÓ ÎÔÚÈÙÛÈÒÓ Â›Ó·È ÂÚ›Ô˘ Ë ›‰È·. ™Â fi,ÙÈ ·ÊÔÚ¿, fï˜, ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ, ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ ÙÔ 40% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ·ÔÙÂÏÂ›Ù·È ·fi ·È‰È¿ ËÏÈΛ·˜ 6172 ÌËÓÒÓ (¶›Ó·Î·˜ 1). ¶›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Û‡Ìʈӷ Ì ÙËÓ ËÏÈΛ· ÙÔ˘˜ ∏ÏÈΛ· 3,1-4 ÂÙÒÓ 4,1-5 ÂÙÒÓ 5,1-6 ÂÙÒÓ 6,1-6,9 ÂÙÒÓ ™‡ÓÔÏÔ
N
%
45 144 199 110 498
9 28,9 40 22,1 100
∏ Û˘¯ÓfiÙËÙ· Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 3-7 ÂÙÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ¤Ú¢ӷ ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 6,4%. ™˘Ó˘ÔÏÔÁ›˙ÔÓÙ·˜, fï˜, ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ (15,9%), ÙfiÙ ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ ÂÚÈÛÛfiÙÂÚ· ·fi ¤Ó· ÛÙ· ¤ÓÙ ·È‰È¿ ¤¯ÂÈ ‚¿ÚÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (¶›Ó·Î·˜ 2). ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ·Ó¿ÏÔÁ· Ì ÙÔ Ê‡ÏÔ ÙÔ˘˜, ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ù· ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ Û ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· Â›Ó·È ·ÚfiÌÔÈ· (¶›Ó·Î·˜ 3). ∏ ÌÂϤÙË Ù˘ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙˆÓ ˘ÔÎÂÈÌÂÓÈÎÒÓ ÂÎÙÈÌ‹ÛÂˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ ÁÈ· ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Î·È ÙÔ˘ Ú·ÁÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ ÙÔ˘ ·È‰ÈÔ‡ ‰Â›¯ÓÂÈ fiÙÈ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË (r=0,44, p<0,01). º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÔÈ ÌËÙ¤Ú˜ Â›Ó·È Û ı¤ÛË Ó· ÂÎÙÈÌ‹ÛÔ˘Ó Û ·‰Ú¤˜ ÁÚ·Ì̤˜ ηٿ fiÛÔ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Î˘Ì·›ÓÂÙ·È ÛÙ· Ï·›ÛÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡. øÛÙfiÛÔ, ÔÈ ˘ÔÎÂÈÌÂÓÈΤ˜ ÂÎÙÈÌ‹ÛÂȘ ÙˆÓ ÌËÙ¤ÚˆÓ ÁÈ· ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Ê·›ÓÔÓÙ·È ·Ú¿‰Ô͘ Û ۯ¤ÛË Ì ÙÔÓ ‚·ıÌfi ÈηÓÔÔ›ËÛ‹˜ ÙÔ˘˜ ·fi ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ·˘Ùfi ηٷӷÏÒÓÂÈ. ¢È·ÈÛÙÒÓÂÙ·È fiÙÈ ÛÙÔ 53,1% ÙˆÓ ÂÚÈÙÒÛÂˆÓ fiÔ˘ ÙÔ ·È‰› - Û‡Ìʈӷ ¿ÓÙ· Ì ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ - ¤¯ÂÈ ‚¿ÚÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ
¶›Ó·Î·˜ 2. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Û‡Ìʈӷ Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙÔÓ ¢ª™ ·Ó¿ ËÏÈÎȷ΋ ÔÌ¿‰· ∏ÏÈΛ· º˘ÛÈÔÏÔÁÈÎfi 3,1-4 ÂÙÒÓ (n=45) 4,1-5 ÂÙÒÓ (n=144) 5,1-6 ÂÙÒÓ (n=199) 6,1-6,9 ÂÙÒÓ (n=110) ™‡ÓÔÏÔ (n=498)
80 81,9 76,4 73,6 77,7
∫·Ù·ÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Û‡Ìʈӷ Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ (%) À¤Ú‚·ÚÔ ¶·¯‡Û·ÚÎÔ À¤Ú‚·Ú· Î·È ·¯‡Û·Úη 15,6 13,9 16,6 17,3 15,9
4,4 4,2 7 9,1 6,4
20 18,1 23,6 26,4 22,3
x2=3,95, p=0,683 ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·48
48
∂. ∫¿ÎÔ˘ÚÔ˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Û‡Ìʈӷ Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙÔÓ ¢ª™ ·Ó¿ ʇÏÔ º‡ÏÔ ∞ÁfiÚÈ (n=262) ∫ÔÚ›ÙÛÈ (n=236)
∫·Ù·ÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Û‡Ìʈӷ Ì ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ (%) º˘ÛÈÔÏÔÁÈÎfi À¤Ú‚·ÚÔ ¶·¯‡Û·ÚÎÔ 77,9 77,5
14,5 17,4
7,6 5,1
x2=1,90, p=0,387
ηÓÔÓÈÎfi, Ë ÌËÙ¤Ú· ‰ËÏÒÓÂÈ Â˘¯·ÚÈÛÙË̤ÓË Ì ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÂÈ ÙÔ ·È‰› Ù˘. ∂›Û˘, ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ÔÈ ÌËÙ¤Ú˜ ÂÎÙÈÌÔ‡Ó fiÙÈ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi, ÙÔ 28,3% ·˘ÙÒÓ ‰ËÏÒÓÂÈ fiÙÈ ı· ÂÈı˘ÌÔ‡Û ӷ ÙÚÒÂÈ ÙÔ ·È‰› ÂÚÈÛÛfiÙÂÚÔ (¶›Ó·Î·˜ 4). º·›ÓÂÙ·È, ›Û˘, fiÙÈ ÔÈ ÌËÙ¤Ú˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ Â›Ó·È Ú·ÁÌ·ÙÈο ˘¤Ú‚·Ú· (Û‡Ìʈӷ Ì ÙÔÓ ¢ª™) - Û ÔÛÔÛÙfi 19,2% - ı· ‹ıÂÏ·Ó Ó· ‚Ï¤Ô˘Ó ÙÔ ·È‰› ÙÔ˘˜ Ó· ÙÚÒÂÈ ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ, ÂÓÒ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌËÙ¤ÚˆÓ ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ÈηÓÔÔÈË̤Ó˜ ·fi ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÔ˘Ó Ù· ·È‰È¿ ÙÔ˘˜. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÌËÙ¤ÚˆÓ ÙˆÓ ÔÔ›ˆÓ ÙÔ ·È‰› Â›Ó·È ·¯‡Û·ÚÎÔ, ÌfiÓÔ ÙÔ ¤Ó· ÙÚ›ÙÔ ı· ‹ıÂÏ ӷ ηٷӷÏÒÓÂÈ ÙÔ ·È‰› ÙÔ˘˜ ÌÈÎÚfiÙÂÚË ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ (¶›Ó·Î·˜ 5). ∂ÈϤÔÓ, ÙÔ 19,4% ÙˆÓ ÌËÙ¤ÚˆÓ ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ÈÛÙ‡ÂÈ fiÙÈ Ù· ·È‰È¿ ÙÔ˘˜ ı· ¤ÙÚˆÁ·Ó Ôχ Ï›ÁÔ Â¿Ó ·Ê‹ÓÔÓÙ·Ó Ó· ηıÔÚ›ÛÔ˘Ó ÌfiÓ· ÙÔ˘˜ ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ı¤ÏÔ˘Ó Ó· ηٷӷÏÒÛÔ˘Ó (¶›Ó·Î·˜ 6). ¢È·ÈÛÙÒÓÂÙ·È, ›Û˘, fiÙÈ Ù· ˘¤Ú‚·Ú· ·È‰È¿ Â›Ó·È ·˘Ù¿ Ô˘ ·ÍÈÔÏÔÁÔ‡ÓÙ·È Û˘ÓËı¤ÛÙÂÚ· ·fi ÙȘ ÌËÙ¤Ú˜ ÙÔ˘˜ (ÛÂ
ÔÛÔÛÙfi 59%) ˆ˜ ·È‰È¿ Ô˘, Â¿Ó ·Ê‹ÓÔÓÙ·Ó Ó· Ê¿Ó fiÛÔ ı¤ÏÔ˘Ó, ı· ¤ÙÚˆÁ·Ó ηÓÔÓÈ΋ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡. ∞ÓÙ›ıÂÙ·, ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ηÓÔÓÈÎfi ‚¿ÚÔ˜, ÔÛÔÛÙfi ÌfiÓÔ 46,5% ÙˆÓ ÌËÙ¤ÚˆÓ ÙÔ˘˜ ıˆÚ› fiÙÈ Ù· ·È‰È¿ ·˘Ù¿ ı· ¤ÙÚˆÁ·Ó ηÓÔÓÈο Â¿Ó ·Ê‹ÓÔÓÙ·Ó ÂχıÂÚ· (¶›Ó·Î·˜ 6). ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (59,9%) Ê·›ÓÂÙ·È fiÙÈ ÁÂ˘Ì·Ù›˙Ô˘Ó Ì ÙËÓ ˘fiÏÔÈË ÔÈÎÔÁ¤ÓÂÈ· ·fi ·ÚÎÂÙ¿ ÓˆÚ›˜ (¶›Ó·Î·˜ 7). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰È¢ÎÔχÓÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ÁÔÓÈÎÒÓ ·ÓÙÈÏ‹„ÂˆÓ Î·È Ú·ÎÙÈÎÒÓ ÛÙ· ·È‰È¿. ∂ÈϤÔÓ, ÙÔ 50,3% ÙˆÓ ÁÔÓ¤ˆÓ ÚÔÛʤÚÂÈ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÛÙÔ ·È‰› Î·È ¿ÏϘ ÂÓ·ÏÏ·ÎÙÈΤ˜ χÛÂȘ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ı¤ÏÂÈ Ó· Ê¿ÂÈ ÙÔ ›‰ÈÔ Ê·ÁËÙfi Ì ÙËÓ ˘fiÏÔÈË ÔÈÎÔÁ¤ÓÂÈ·. ª¿ÏÈÛÙ·, ÛÙÔ 15,5% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÙÔ ·›ÙËÌ· ·˘Ùfi Á›ÓÂÙ·È ¿ÓÙ· ·Ô‰ÂÎÙfi ·fi ÙÔ˘˜ ÁÔÓ›˜ (¶›Ó·Î·˜ 7). ™ÙȘ ÂÚÈÙÒÛÂȘ ‰Â Ô˘ ÙÔ ·È‰› ·ÚÓÂ›Ù·È Ó· Ê¿ÂÈ, ·ÚÎÂÙÔ› ÁÔÓ›˜ (17,4%) ·ÛÎÔ‡Ó ›ÂÛË Û ·˘Ùfi, ÂÓÒ ·ÚÎÂÙÔ› ¿ÏÏÔÈ (23%) ÙÔ˘ ‰›ÓÔ˘Ó ‰È¿ÊÔÚ˜ ˘ÔÛ¯¤ÛÂȘ. ¶ÔÛÔÛÙfi 25,1% ÙˆÓ ÌËÙ¤ÚˆÓ ÂÎÙÈÌ¿ fiÙÈ Ú¤ÂÈ ¿ÓÙ· Ó· ηıÔÚ›˙Ô˘Ó ÔÈ ›‰È˜ ÙËÓ ÔÛfiÙËÙ· Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ÙÚÒÂÈ ÙÔ ·È‰› ÙÔ˘˜, ÂÓÒ ÌfiÓÔ ÙÔ 6,3% ÂÎÙÈÌ¿ fiÙÈ ÙÔ ·È‰› Ú¤ÂÈ Ó· ·Ê‹ÓÂÙ·È
¶›Ó·Î·˜ 4. ∏ Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÌËÙ¤Ú·˜ ÁÈ· ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÛÙÔÓ ‚·ıÌfi ÈηÓÔÔ›ËÛ‹˜ Ù˘ ·fi ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ·˘Ùfi ηٷӷÏÒÓÂÈ ∂ÎÙ›ÌËÛË ‚¿ÚÔ˘˜ ·È‰ÈÔ‡
ªÈÎÚfiÙÂÚÔ ÙÔ˘ ηÓÔÓÈÎÔ‡ (n=76) ∫·ÓÔÓÈÎfi (n=390) ªÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ ηÓÔÓÈÎÔ‡ (n=32) ™‡ÓÔÏÔ (n=498)
µ·ıÌfi˜ ÈηÓÔÔ›ËÛ˘ Ù˘ ÌËÙ¤Ú·˜ ·fi ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÂÈ ÙÔ ·È‰› Ù˘ (%) ∂˘¯·ÚÈÛÙË̤ÓË £· ‹ıÂÏ ÂÚÈÛÛfiÙÂÚÔ £· ‹ıÂÏ ÏÈÁfiÙÂÚÔ 7,9 69,9 53,1 59,4
90,8 28,3 0 36
1,3 1,8 46,9 4,6
x2=254,67, p<0,0005
¶›Ó·Î·˜ 5. ∏ Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ (Û‡Ìʈӷ Ì ÙÔÓ ¢ª™) Î·È ÛÙÔÓ ‚·ıÌfi ÈηÓÔÔ›ËÛ˘ Ù˘ ÌËÙ¤Ú·˜ ·fi ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ·˘Ùfi ηٷӷÏÒÓÂÈ µ¿ÚÔ˜ Û‡Ìʈӷ Ì ÙÔÓ ¢ª™
º˘ÛÈÔÏÔÁÈÎfi (n=387) À¤Ú‚·ÚÔ (n=79) ¶·¯‡Û·ÚÎÔ (n=32) ™‡ÓÔÏÔ (n=498) x2=254,67, p<0,0005 ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
µ·ıÌfi˜ ÈηÓÔÔ›ËÛ˘ Ù˘ ÌËÙ¤Ú·˜ ·fi ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÂÈ ÙÔ ·È‰› (%) ∂˘¯·ÚÈÛÙË̤ÓË £· ‹ıÂÏ ÂÚÈÛÛfiÙÂÚÔ £· ‹ıÂÏ ÏÈÁfiÙÂÚÔ 57,1 69,3 62,5 59,4
42,1 19,2 3,1 36
0,8 11,5 34,4 4,6
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·49
49
¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ
¶›Ó·Î·˜ 6. H Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ (·Ó¿ÏÔÁ· Ì ÙÔÓ ¢ª™) Î·È ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÌËÙ¤Ú·˜ ÁÈ· ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ı· ηٷӿψÓ ÙÔ ·È‰› Ù˘ Â¿Ó ÙÔ˘ ÚÔÛÊÂÚfiÙ·Ó Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÙÚÒÂÈ fiÛÔ ÙÔ ›‰ÈÔ ı· ‹ıÂÏ µ¿ÚÔ˜ Û‡Ìʈӷ Ì ÙÔÓ ¢ª™
º˘ÛÈÔÏÔÁÈÎfi (n=387) À¤Ú‚·ÚÔ (n=79) ¶·¯‡Û·ÚÎÔ (n=32) ™‡ÓÔÏÔ (n=498)
∂ÎÙ›ÌËÛË Ù˘ ÌËÙ¤Ú·˜ ÁÈ· ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ ı· ηٷӿψÓ ÙÔ ·È‰› Ù˘ Â¿Ó ÙÔ˘ ÚÔÛÊÂÚfiÙ·Ó Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÙÚÒÂÈ fiÛÔ ÙÔ ›‰ÈÔ ı· ‹ıÂÏ (%) £· ¤ÙÚˆÁ ¿Ú· Ôχ £· ¤ÙÚˆÁ Ôχ Ï›ÁÔ £· ¤ÙÚˆÁ ηÓÔÓÈο 1,8 10,3 29 4,9
51,7 30,8 19,4 46,4
46,5 59 51,6 48,8
x2=62,74, p<0,0005
¶›Ó·Î·˜ 7. ¢È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ¢È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ °Â˘Ì·Ù›˙ÂÈ Ì ÙËÓ ˘fiÏÔÈË ÔÈÎÔÁ¤ÓÂÈ· À¿Ú¯Ô˘Ó ÂÓ·ÏÏ·ÎÙÈΤ˜ χÛÂȘ Â¿Ó ‰ÂÓ ÙÔ˘ ·Ú¤ÛÂÈ Î¿ÔÈÔ Ê·ÁËÙfi °›ÓÔÓÙ·È ‰ÂÎÙ¤˜ ÔÈ ÂÈı˘Ì›Â˜ ÙÔ˘ fiÙ·Ó ˙ËÙ¿ Û˘ÁÎÂÎÚÈ̤ÓÔ Ê·ÁËÙfi
Ó· ηıÔÚ›˙ÂÈ ÌfiÓÔ ÙÔ˘ ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ı¤ÏÂÈ Ó· ηٷӷÏÒÛÂÈ (¶›Ó·Î·˜ 8).
™˘˙‹ÙËÛË ∏ Û˘¯ÓfiÙËÙ· Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙÔÓ ÏËı˘ÛÌfi ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 3-7 ÂÙÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ¤Ú¢ӷ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 6,4%. ∏ Û˘¯ÓfiÙËÙ· ·˘Ù‹, Û˘ÁÎÚÈÓfiÌÂÓË Ì ÛÙÔȯ›· ·fi ·Ó¿ÏÔÁ˜ ¤Ú¢Ó˜ Ô˘ ¤ÁÈÓ·Ó Û ¿ÏϘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ (1,11,12), ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË. ∂¿Ó, fï˜, ÛÙÔ ÔÛÔÛÙfi ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Û˘Ó˘ÔÏÔÁÈÛÙ› Î·È ·˘Ùfi ÙˆÓ ˘¤Ú‚·ÚˆÓ (15,9%), ÙfiÙ ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ ÂÚÈÛÛfiÙÂÚ· ·fi ¤Ó· ÛÙ· ¤ÓÙ ·È‰È¿ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ ¤¯ÂÈ ‚¿ÚÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi. ¢È·ÈÛÙÒÓÂÙ·È, ›Û˘, fiÙÈ ÔÈ ÁÔÓ›˜ - ·Ú’ fiÏÔ Ô˘ Â›Ó·È Û ı¤ÛË Ó· ÂÎÙÈÌ‹ÛÔ˘Ó Â¿Ó ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Î˘Ì·›ÓÂÙ·È ‹ fi¯È ÛÂ Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ· - Û˘Ó‹ıˆ˜ ‰ÂÓ ·ÓËÛ˘¯Ô‡Ó fiÙ·Ó ÙÔ ·È‰› ÙÔ˘˜ Â›Ó·È ˘¤Ú‚·ÚÔ ‹ ·¯‡Û·ÚÎÔ Î·Ù¿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi, ÔÈ ÌÈÛ¤˜ ÂÚ›Ô˘ ÌËÙ¤Ú˜ ı· ‹ıÂÏ·Ó ÙÔ ·È‰› ÙÔ˘˜ Ó· ÙÚÒÂÈ ÂÚÈÛÛfiÙÂÚÔ. ¶·ÚfiÌÔÈ· ÂÈı˘Ì›· ¤¯Ô˘Ó, Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ, ·ÎfiÌË Î·È ÔÈ ÌËÙ¤Ú˜ ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ. º·›ÓÂÙ·È fiÙÈ Ë ·ÓËÛ˘¯›· ÙÔ˘˜ ÂÌÊ·Ó›˙Â-
¶¿ÓÙ·
% ªÂÚÈΤ˜ ÊÔÚ¤˜
™¿ÓÈ·
59,9 15,5 11,9
37 50,3 73,8
3,1 34,2 14,3
Ù·È ÌfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ ηٿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Â›Ó·È ¯·ÌËÏfiÙÂÚÔ ·fi ÂΛÓÔ Ô˘ ÔÈ ›‰È˜ ÂÎÙÈÌÔ‡Ó ˆ˜ ηÓÔÓÈÎfi Î·È fi¯È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È ·˘ÍË̤ÓÔ. ª›· Èı·Ó‹ ÂÚÌËÓ›· Â›Ó·È Ë ÂӉ¯fiÌÂÓË ·ÓÙ›ÏË„Ë ÙˆÓ ÌËÙ¤ÚˆÓ fiÙÈ Ë ·¯˘Û·ÚΛ· ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ Â›Ó·È Ì›· ·ÚÔ‰È΋ ηٿÛÙ·ÛË. øÛÙfiÛÔ, Ë ·ÓÙ›ÏË„Ë ·˘Ù‹ Ê·›ÓÂÙ·È Ó· Û˘ÓÙÂÏ› ÛÙËÓ Â‰Ú·›ˆÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ·¯˘Û·ÚΛ·˜, Û‡Ìʈӷ Ì ÚÔËÁÔ‡ÌÂÓË ÚÔÊÔÚÈ΋ ·Ó·ÎÔ›ÓˆÛ‹ Ì·˜ ÛÙÔ 20th International Human Science Research Conference ÛÙÔ ∆fiÎÈÔ ÙÔ 2001. ∂ÈϤÔÓ, ÔÈ ÌËÙ¤Ú˜ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÂÎÙÈÌÔ‡Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ‰ÂÓ ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· Ú˘ıÌ›˙ÂÈ ÌfiÓÔ ÙÔ˘ ÙËÓ ÔÛfiÙËÙ· Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÂÈ. ∂Ô̤ӈ˜, ÈÛÙÂ‡Ô˘Ó fiÙÈ Ë ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÂÙ·È ¿ÓÙ· - ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ·fi ÙȘ ›‰È˜. ¶·ÚfiÌÔȘ ‹Ù·Ó Î·È ÔÈ ‰È·ÈÛÙÒÛÂȘ Û ̛· ¿ÏÏË ¤Ú¢ӷ Ì ÏËı˘ÛÌfi ∂ÏÏËÓ›‰ˆÓ ÌËÙ¤ÚˆÓ ·fi ÙȘ ÂÚÈÔ¯¤˜ Ù˘ ∞ı‹Ó·˜ Î·È Ù˘ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ (23). º·›ÓÂÙ·È fiÙÈ ÔÈ ÌËÙ¤Ú˜ Û˘¯Ó¿ Ȥ˙Ô˘Ó ÙÔ ·È‰› ÙÔ˘˜ Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜ Ó· ÙÚÒÂÈ fiÛÔ ÂÎÙÈÌÔ‡Ó ÂΛӘ fiÙÈ Ú¤ÂÈ Ó· Ê¿ÂÈ. ∏ ›ÂÛË ÛÙÔ Ê·ÁËÙfi, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ (21), Â›Ó·È Èı·Ófi Ó· ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎÔ‡˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ù˘ ·¯˘Û·ÚΛ·˜. Œ¯ÂÈ
¶›Ó·Î·˜ 8. ∞fi ÔÈÔÓ Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÂÙ·È Ë ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ô˘ ηٷӷÏÒÓÂÈ ÙÔ ·È‰› Û‡Ìʈӷ Ì ÙȘ ·fi„ÂȘ ÙˆÓ ÌËÙ¤ÚˆÓ ∏ ÔÛfiÙËÙ· ÙÔ˘ Ê·ÁËÙÔ‡ Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÂÙ·È ·fi: ÙË ÌËÙ¤Ú· ÙÔ ·È‰›
¶¿ÓÙ·
% ªÂÚÈΤ˜ ÊÔÚ¤˜
™¿ÓÈ·
25,1 38
59,5 55,8
15,4 6,3 ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·50
50
∂. ∫¿ÎÔ˘ÚÔ˜ Î·È Û˘Ó.
‰È·ÈÛÙˆı› fiÙÈ Ë ÈηÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ó· Ú˘ıÌ›˙Ô˘Ó ÌfiÓ· ÙÔ˘˜ ÙËÓ ÔÛfiÙËÙ· Ê·ÁËÙÔ‡ Ô˘ Ú¤ÂÈ Ó· ηٷӷÏÒÓÔ˘Ó, Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ‚¿ÚÔ˜ ÙˆÓ ÌËÙ¤ÚˆÓ ÙÔ˘˜, ηıÒ˜ Î·È Ì ÙÔÓ ÙÚfiÔ Ô˘ ÔÈ ›‰È˜ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È fiÙÈ Ú¤ÂÈ Ó· ·ÛÎÂ›Ù·È ·˘Ùfi˜ Ô ¤ÏÂÁ¯Ô˜. ™˘ÁÎÂÎÚÈ̤ӷ, ‚Ú¤ıËΠfiÙÈ Ù· ·È‰È¿ Ì ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ Î·È Ù· ·È‰È¿ ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ‰‹ÏˆÓ·Ó ·‰˘Ó·Ì›· Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙÔ Ê·ÁËÙfi Ô˘ ηٷӷÏÒÓÔ˘Ó, ›¯·Ó ÂÚÈÔÚÈṲ̂Ó˜ ÈηÓfiÙËÙ˜ Ú‡ıÌÈÛ˘ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘˜ (24). ∂›Û˘, ÔÈ Birch Î·È Fisher (25), Û ÚfiÛÊ·ÙË ¤ÚÂ˘Ó¿ ÙÔ˘˜, ‰È·›ÛÙˆÛ·Ó fiÙÈ ÔÈ Ú·ÎÙÈΤ˜ Ô˘ ˘ÈÔıÂÙÔ‡Ó ÔÈ ÌËÙ¤Ú˜ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ Û¯ÂÙ›˙ÔÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi Ì ÙȘ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ Î·È ÙÔ ‚¿ÚÔ˜ ÙÔ˘. ™Â ¤Ú¢ӷ ÙˆÓ Cutting Î·È Û˘Ó (26) ‚Ú¤ıËΠfiÙÈ ÔÈ ÔÈÎÔÁÂÓÂȷΤ˜ ÂȉڿÛÂȘ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ Ê‡ÏÔ ÙÔ˘ ÁÔÓ¤· Î·È ÙÔ˘ ·È‰ÈÔ‡ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, ‰È·ÈÛÙÒıËΠfiÙÈ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë Â›‰Ú·ÛË ÙˆÓ ÌËÙ¤ÚˆÓ ÛÙȘ ÎfiÚ˜ ÙÔ˘˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ·È‰È¿ ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ó· ˘ÈÔıÂÙ‹ÛÔ˘Ó ÙȘ ·fi„ÂȘ, ÙȘ ÛÙ¿ÛÂȘ Î·È ÙȘ ·ÓÙÈÏ‹„ÂȘ ÙˆÓ ·ÓıÚÒˆÓ Ô˘ ·Á·Ô‡Ó, ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÔÓÙ·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ ·Ô‰ÂÎÙ¿ ·fi ·˘ÙÔ‡˜ (27). °È· Ó· ÌÔÚ›, fï˜, ¤Ó· ·È‰› Ó· ·ÔÎÙ‹ÛÂÈ ÙËÓ ÈηÓfiÙËÙ· ·˘ÙÔÚÚ‡ıÌÈÛ˘ Ù˘ ÔÛfiÙËÙ·˜ Ù˘ ÙÚÔÊ‹˜ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ηٷӷÏÒÛÂÈ, ı· Ú¤ÂÈ Ó· ÂÈÛÚ¿ÍÂÈ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ Ù· ·Ó¿ÏÔÁ· ÌËӇ̷ٷ Î·È Ó· ÂÎ·È‰Â˘Ù› Û ·˘Ùfi, ·Ó¿ÏÔÁ· ‚¤‚·È· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ Î·È Ì ÙÔ Ú·ÁÌ·ÙÈÎfi ÙÔ˘ ‚¿ÚÔ˜. ŸÙ·Ó ÔÈ ÁÔÓ›˜ ·ÛÎÔ‡Ó ›ÂÛË ÛÙÔ ·È‰› ÙÔ˘˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· Ê¿ÂÈ ‹ fiÙ·Ó ÙÔ ÙÈ̈ÚÔ‡Ó ÂÂȉ‹ ·˘Ùfi ‰ÂÓ ÙÚÒÂÈ Û‡Ìʈӷ Ì ÙȘ ‰ÈΤ˜ ÙÔ˘˜ ÂÈı˘Ì›Â˜, ÙfiÙ ÙÔ ·È‰› ‰ÂÓ ÌÔÚ› Ó· ·Ó·Ù‡ÍÂÈ ÙËÓ ·˘ÙÔÓÔÌ›· Î·È ÙÔÓ ·˘ÙÔ¤ÏÂÁ¯Ô ÛÙË ‰È·ÙÚÔÊ‹ ÙÔ˘. °ÂÓÈο, ̤۷ ·fi ÙË ÛÙ¿ÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·¤Ó·ÓÙÈ ÛÙÔ Ê·ÁËÙfi, fiˆ˜ ÂÎÊÚ¿˙ÂÙ·È Ì¤Û· ·fi ÙȘ ηıËÌÂÚÈÓ¤˜ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ, ÌÂÙ·‰›‰ÔÓÙ·È ÛÙÔ ·È‰› ·ÓÙÈÏ‹„ÂȘ Î·È Û˘Ó‹ıÂȘ, ÙȘ Ôԛ˜ ·ÚÁfiÙÂÚ· Û˘Ó‹ıˆ˜ ˘ÈÔıÂÙ› Î·È ÙÔ ›‰ÈÔ. ∂Ô̤ӈ˜, Ë ÌÂÙ¿‰ÔÛË ·Ó¿ÏÔÁˆÓ ·ÓÙÈÏ‹„ÂˆÓ Ì ·˘Ù¤˜ Ô˘ ˘ÈÔıÂÙ› ˘„ËÏfi ÔÛÔÛÙfi ÌËÙ¤ÚˆÓ ÛÙËÓ ·ÚÔ‡Û· ¤Ú¢ӷ Î·È Ë ˘ÈÔı¤ÙËÛË ÙˆÓ Û¯ÂÙÈÎÒÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ ·fi Ù· ·È‰È¿, ÂÓ‰¤¯ÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌÂÁ¿ÏË ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÂÌÊ¿ÓÈÛ˘ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ (28). ∂ȉÈÎfiÙÂÚ·, Ë ˘ÂÚÚÔÛٷ٢ÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÁÔÓ¤ˆÓ, Ë ÔÔ›· ÙÔ˘˜ Ô‰ËÁ› ÛÙÔÓ ˘ÂÚ‚ÔÏÈÎfi ¤ÏÂÁ¯Ô Ù˘ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜, ÌÔÚ› Û˘¯Ó¿ Ó· ÛÙÂÚ› ·fi Ù· ›‰È· Ù· ·È‰È¿ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·Ó·Ù‡ÍÔ˘Ó ÙËÓ ÈηÓfiÙËÙ· ·˘ÙÔÚÚ‡ıÌÈÛ˘ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘˜. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÔ˘Ó Î·Ù·ÓÔËÙ¤˜ ÔÈ ·ÓÙÈÏ‹„ÂȘ ÙˆÓ ·È‰ÈÒÓ, ÔÈ Ôԛ˜ ÚÔÛ‰ÈÔÚ›˙Ô˘Ó ÙÂÏÈο Û Ôχ ÌÂÁ¿ÏÔ ‚·ıÌfi Î·È ÙȘ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ ¶·È‰È·ÙÚÈ΋ 2005;68:45-51
Û˘Ó‹ıÂȘ, Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÔ˘Ó ÚÒÙ· ηٷÓÔËÙ¤˜ ÔÈ ·ÓÙÈÏ‹„ÂȘ ÙˆÓ ›‰ÈˆÓ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙÔ Ê·ÁËÙfi Î·È ÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙȘ Ôԛ˜ ÂÈÙÂÏ› ÁÈ’ ·˘ÙÔ‡˜ Ë Î·Ù·Ó¿ÏˆÛË ÙÚÔÊ‹˜. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ë ·ÚÔ‡Û· ¤Ú¢ӷ ·Ú¤¯ÂÈ ·ÚÎÂÙ¤˜ ÂӉ›ÍÂȘ ÁÈ· ÙË ÛËÌ·Û›· Ù˘ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛ˘ ÙˆÓ ÁÔÓÈÎÒÓ ·ÓÙÈÏ‹„ÂˆÓ Î·È ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ, ÔÈ Ôԛ˜ ÂÓ‰¤¯ÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ‰ÈÂÍ·ÁˆÁ‹ ·Ó¿ÏÔÁˆÓ ÂÚ¢ÓÒÓ ÛÙÔ Ï·›ÛÈÔ ·˘Ù‹˜ Ù˘ Û˘ÏÏÔÁÈÛÙÈ΋˜ Ê·›ÓÂÙ·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ÚfiÏË„Ë fiÛÔ Î·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Strauss RS, Knight J. Influence of the home environment on the development of obesity in children. Pediatrics 1999;103:e85. 2. ÷Ù˙ËÁˆÚÁ›Ô˘ Ã, ∆ÔÚÓ·Ú›Ù˘ ª, ∫ˆÓÛÙ·ÓÙ›ÓÔ˘ ∂, ÷Ù˙Ë˚ˆ¿ÓÓÔ˘ ª, °È·ÓÎÔ˘Ï‹ ∞, µÚ·¯›Ì˘ ƒ. ŒÏÂÁ¯Ô˜ ÂȤ‰Ô˘ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ·¯˘Û·ÚΛ·˜ Û 1132 ·È‰È¿ Ù˘ ™Ù’ Ù¿Í˘ ÙˆÓ ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ ·گ›·˜ §Â˘ÎˆÛ›·˜. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1998;10:238-244. 3. ™¿‚‚·˜ ™, ∆ÔÚÓ·Ú›Ù˘ ª, ∂ÈÊ·Ó›Ô˘-™¿‚‚· ª. ¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È Î·Ú‰È·ÁÁÂȷο ÓÔÛ‹Ì·Ù·. π·ÙÚÈ΋ ∫‡ÚÔ˜ 2000;17:20-26. 4. Stunkard AJ, Wadden TA. Psychological aspects of severe obesity. Am J Clin Nutr 1992;55 (Suppl 2):S524- S532. 5. Wabitsch M. Overweight and obesity in European children: definition and diagnostic procedures, risk factors and consequences for later health outcome. Eur J Pediatr 2000;159 (Suppl 1):S8-S13. 6. Finkelstein MM. Body mass index and quality of life in a survey of primary care patients. J Fam Pract 2000;49:734-737. 7. al-Mahroos F, al-Roomi K. Overweight and obesity in the Arabian Peninsula: an overview. J R Soc Health 1999;119:251-253. 8. Savva SC, Kourides Y, Tornaritis M, Epiphaniou-Savva M, Chadjigeorgiou C, Kafatos A. Obesity in children and adolescents in Cyprus. Prevalence and predisposing factors. Int J Obes Relat Metab Disord 2002;26:1036-1045. 9. §·ÁÁÔ‡Û˘ ∞, OÈÎÔÓÔÌfiÔ˘ÏÔ˜ ª, ÃÚÈÛÙÔÔ‡ÏÔ˘ §, °ÎÈfiη ∂, ƒÔ‰ÔÔ‡ÏÔ˘ ª, ¡ÈÎÔÏÔÔ‡ÏÔ˘ π Î·È Û˘Ó. ¶·¯˘Û·ÚΛ· Î·È ·È‰›. ¶Ú·ÎÙÈο 38Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2000 16-18 πÔ˘Ó›Ô˘; ∫ˆ˜. Abstract No 283. 10. ªÔÛ¯·Ó‰Ú¤· π, ÷Ù˙‹˜ Ã, ª·ÌÌ¿˜ π, ªÂÚÙÛÈ¿˜ °, §ÈÓ·Ú‰¿Î˘ ª, ∫˘Úȷο΢ ª Î·È Û˘Ó. ¢Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ ·ÁÚÔÙÈ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘. ¶·È‰È·ÙÚÈ΋ 2003;66:264-277. 11. Bundred P, Kitchiner D, Buchan I. Prevalence of overweight and obese children between 1989 and 1998: population based series of cross sectional studies. BMJ 2001;322:326-328. 12. Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, Johnson CL. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics 1997;99:E1. 13. Livingstone MB. Childhood obesity in Europe: a growing concern. Public Health Nutr 2001;4:109-116. 14. Mamalakis G, Kafatos A, Manios Y, Anagnostopoulou T, Apostolaki I. Obesity indices in a cohort of primary school children in Crete: a six year prospective study. Int J Obes Relat Metab Disord 2000;24:765-771. 15. Garn SM, Clark DC. Trends in fatness and the origins of obesity: Ad Hoc Committee to Review the Ten-State Nutrition Survey. Pediatrics 1976;57:443-456.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·51
51
¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È ÁÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ
16. Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annu Rev Public Health 2001;22:337-353. 17. Takahashi E, Yoshida K, Sugimori H, Miyakawa M, Izuno T, Yamagami T et al. Influence factors on the development of obesity in 3-year-old children based on the Toyama study. Prev Med 1999;28:293-296. 18. Trost SG, Kerr LM, Ward DS, Pate RR. Physical activity and determinants of physical activity in obese and non-obese children. Int J Obes Relat Metab Disord 2001;25:822-829. 19. Klesges RC, Malott JM, Boschee PF, Weber JM. The effects of parental influences on children’s food intake, physical activity, and relative weight. Int J Eat Disord 1986;5:335346. 20. Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC. Maternal feeding practices and childhood obesity: a focus group study of low-income mothers. Arch Pediatr Adolesc Med 1998;152:1010-1014. 21. Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obes Relat Metab Disord 1996;20:488-492. 22. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a
23.
24. 25.
26.
27. 28.
standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-1243. ∫¿ÎÔ˘ÚÔ˜ ∂, ª·ÓÈ·‰¿ÎË ∫. ∏ ›‰Ú·ÛË ÙˆÓ ÁÔÓÈÎÒÓ ·ÓÙÈÏ‹„ÂˆÓ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜. ¶·È‰È·ÙÚÈ΋ 2000;63:507-518. Johnson SL. Improving preschoolers’ self-regulation of energy intake. Pediatrics 2000;106:1429-1435. Birch L, Fisher J. Mothers’ child-feeding practices influence daughters’ eating and weighting. Am J Clin Nutr 2001;71:1054-1061. Cutting TM, Fisher JO, Grimm-Thomas K, Birch LL. Like mother, like daughter: familial patterns of overweight are mediated by mothers’ dietary disinhibition. Am J Clin Nutr 1999;69:608-613. Bandura A. Social learning theory. Englewood Cliffs, New Jersey: Prentice-Hall; 1977. ∫¿ÎÔ˘ÚÔ˜ ∂, ª·ÓÈ·‰¿ÎË ∫. æ˘¯Ô·ıÔÏÔÁ›· ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ. ∞Ó·Ù˘Íȷ΋ ÚÔÛ¤ÁÁÈÛË. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∆˘ˆı‹Ùˆ; 2002.
¶·È‰È·ÙÚÈ΋ 2005;68:45-51
Paediatriki Jan-Feb 05 teliko
52
10-02-05
13:36
™ÂÏ›‰·52
ORIGINAL ARTICLE
Childhood obesity and its relationship with parental attitudes and nutritional habits E. Kakouros1, K. Maniadaki2, E. Kapnisi2 1 Center of Early Childhood Education, Technological Educational Institute of Athens 2 Psychological Center of Developmental Disabilities “ARSI”, Athens Correspondence: Katerina Maniadaki 52 Karatasou str., Thrakomacedones, 136 76, ∞thens E-mail: katerina@arsi.gr Date of submission: 07-11-2003 Date of approval: 22-10-2004
Abstract Background: The aim of this study was to investigate maternal attitudes regarding nutrition, nutritional habits adopted in the family and the possible relationship of these factors with the development of childhood obesity. Methods: The sample consisted of 498 children aged 3-7 years, residents of Nicosia and Paphos in Cyprus, and their mothers. Results: According to the results, 6.4% of the children of the sample were obese and 15.9% overweight. However, it was found that a high percentage of the mothers with overweight or obese children were satisfied with the amount of food consumed by their children, whereas in the cases of children with normal weight, almost half of the mothers would like their child to eat more. In addition, a high percentage of mothers did not consider children capable of regulating on their own the amount of food they need to consume. Conclusions: It seems, therefore, that mothers’ attitudes about the amount of food children need to consume are often mistaken. It is possible that these attitudes usually lead to the adoption of analogous nutritional habits that may be related, to a certain degree, to the development of childhood obesity. On the basis of the above results, possible etiological mechanisms for the development of obesity in children are discussed within the framework of social learning theory.
Key words Childhood obesity, parental attitudes, nutritional habits.
Paediatriki 2005;68:52
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·53
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
53
°ÂÓÂÙÈ΋ Î·È ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ·ÛıÂÓÒÓ Ì ۇӉÚÔÌ· DiGeorge/˘ÂÚˆÈÔηډÈÔ-ÚÔÛˆÈÎfi (velo-cardio-facial syndrome) ™. ∫›ÙÛÈÔ˘ - ∆˙¤ÏË1, ∞. ∫ÔÏȷϤÍË1, ∂. ºÚ˘Û›Ú·1, ∞. °·ÏÏ¿ - µÔ˘Ì‚Ô˘Ú¿ÎË2, ∞. ™·Ï·‚Ô‡Ú·3, ª. ∫·Ó·Ú›Ô˘3, ∂. ∫·Ó·‚¿Î˘1, ∞. ª·‡ÚÔ˘1
¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË ÂÏÏ›ÌÌ·ÙÔ˜ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÛÙË ı¤ÛË q11.2 ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 22 Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙ· ÁÂÓÂÙÈÎÒ˜ ÔÌÔÂȉ‹ Û‡Ó‰ÚÔÌ· DiGeorge/velo-cardio-facial syndrome (VCFS) Î·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘˜. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ŒÁÈÓ ÌÂϤÙË ÙÔ˘ ηڢÔÙ‡Ô˘ Ì ٷÈӛ˜ G Î·È ·Ó›¯Ó¢ÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ÊıÔÚ›˙ÔÓÙÔ˜ in situ ˘‚ÚȉÈÛÌÔ‡ (FISH). ∞ÔÙÂϤÛÌ·Ù·: ŒÏÏÂÈÌÌ· 22q11.2 ‰È·ÈÛÙÒıËΠ۠17/139 ·ÛıÂÓ›˜ Ô˘ ÂÚ¢ӋıËÎ·Ó (14 ·ÁfiÚÈ· Î·È 3 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 10 ËÌÂÚÒÓ ¤ˆ˜ 17 ÂÙÒÓ. ™Â ÙÚÂȘ ·ÛıÂÓ›˜, ÙÔ ¤ÏÏÂÈÌÌ· ‹Ù·Ó ÎÏËÚÔÓÔÌÈÎfi (2 ÌËÙÚÈ΋˜ Î·È 1 ·ÙÚÈ΋˜ ÚÔ¤Ï¢Û˘). ∂›Û˘, ‰È·ÈÛÙÒıËÎ·Ó ‰‡Ô ·ıÔÏÔÁÈÎÔ› ηڢfiÙ˘ÔÈ Û ‰‡Ô ·È‰È¿ (Û‡Ó‰ÚÔÌÔ Klinefelter Ì ηڢfiÙ˘Ô 47,ÃÃÀ Î·È 46,ÃÃ,2p+), ÔÈ ÔÔ›ÔÈ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ʷÈÓfiÙ˘Ô DGS/VCFS. OÈ ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· ÂÌÊ¿ÓÈ˙·Ó ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ (82%), Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· (70%), ·ÓÔÛÔ·Ó¿ÚÎÂÈ· (47%), ÔÏϷϤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ (64%), ˘·Û‚ÂÛÙÈ·ÈÌ›· (47%), „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË/Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜/‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ (35%), ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (23%), ˘ÂÚˆÈÔÛ¯ÈÛÙ›·/˘ÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ· (23%), Û·ÛÌÔ‡˜/˘ÔÙÔÓ›· (23%) Î·È ÛˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË (12%). ∏ ÎÏÈÓÈ΋ ÁÂÓÂÙÈ΋ ·ÓÂÎÙ›ÌËÛË Û 39/139 ·ÛıÂÓ›˜ ¯ˆÚ›˜ ¤ÏÏÂÈÌÌ· 22q11.2 Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù¿Ù·ÍË ÙˆÓ 14 (37%) ·fi ·˘ÙÔ‡˜ Û ‰È·ÊÔÚÂÙÈο ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ·.
1 ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋˜, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 3 ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜ Î·È πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÃˆÚ¤ÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∆.∫. 115 27, ∞ı‹Ó· E-mail: skitsiou@med.uoa.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-04-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-09-2004
™˘ÌÂÚ¿ÛÌ·Ù·: ∞fi ÙË ÌÂϤÙË ÚÔ·ÙÂÈ Ë ¯ÚËÛÈÌfiÙËÙ· Ù˘ Ù¯ÓÈ΋˜ FISH ÛÙËÓ ·Ó›¯Ó¢ÛË ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 Î·È Ë ·Ó¿ÁÎË ÔÏÔÎÏ‹ÚˆÛ˘ ÙÔ˘ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ·ÛıÂÓÒÓ Ì DGS/VCFS ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙÔÓ ÁÂÓÂÙÈÛÙ‹.
§¤ÍÂȘ ÎÏÂȉȿ DGS/VCFS, FISH, ¤ÏÏÂÈÌÌ· 22q11.2, ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο.
™˘ÓÙÔÌÔÁڷʛ˜ FISH DGS VCFS ª™ µ™ ∂∫ Mb
ºıÔÚ›˙ˆÓ in situ ˘‚ÚȉÈÛÌfi˜ (fluorescent in situ hybridization) ™‡Ó‰ÚÔÌÔ DiGeorge ™‡Ó‰ÚÔÌÔ ˘ÂÚˆÈÔ-ηډÈÔ-ÚÔÛˆÈÎfi ª‹ÎÔ˜ ÛÒÌ·ÙÔ˜ µ¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ∂ηÙÔÛÙÈ·›· ı¤ÛË ª¤Á· ‚¿ÛÂȘ (mega bases)
∂ÈÛ·ÁˆÁ‹ ∆· Û‡Ó‰ÚÔÌ· DiGeorge (DGS) Î·È ˘ÂÚˆÈÔηډÈÔ-ÚÔÛˆÈÎfi (VCFS) Û ÔÛÔÛÙfi ≥90% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ˘ÔÌÈÎÚÔÛÎÔÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ ‹ ¿ÏÏˆÓ ‰È·Ù·Ú·¯ÒÓ ÛÙÔ ¯ÚˆÌfiۈ̷ 22q11.2 (1,2). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ DGS/VCFS
Â›Ó·È 1:4000, ·ÏÏ¿ ·fi ÔÏÏÔ‡˜ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ˘ÂÚ‰ÈÏ¿ÛÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÔÏÏ¿ ÓÂÔÁ¤ÓÓËÙ· ηٷϋÁÔ˘Ó ÏfiÁˆ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜ (3,4). ∆Ô ÎÏÈÓÈÎfi Ê¿ÛÌ· Â›Ó·È Â˘Ú‡ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi 80 ‰È·ÊÔÚÂÙÈΤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Û ‰È¿ÊÔÚÔ˘˜ Û˘Ó‰˘·ÛÌÔ‡˜ (2). ∆· ΢ÚÈfiÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ DGS Î·È VCFS ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ÏfiÁˆ ˘ÔÏ·Û›·˜ ‹ ·Ï·Û›·˜ ÙÔ˘ ı‡ÌÔ˘ ·‰¤Ó·, ˘·Û‚ÂÛÙÈ·ÈÌ›· ÏfiÁˆ ·Ô˘Û›·˜ ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÒÓ ·‰¤ÓˆÓ, Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Ì ÌÂÁ¿ÏË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ·, ηıÒ˜ Î·È ·ÚÎÂÙ¿ Ù˘ÈÎfi ÚÔÛˆÂ›Ô (5,6), ÂÓÒ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ ‰È·ÈÛÙÒÓÂÙ·È ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· „˘¯È·ÙÚÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (Û¯È˙ÔÊÚ¤ÓÂÈ· ‹ ‰ÈÔÏÈ΋ ‰È·Ù·Ú·¯‹) (7). ∆¤ÏÔ˜, ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÙfiÛÔ ‚·Ú‡Ù·Ù˜ ÂÚÈÙÒÛÂȘ Ì ı¿Ó·ÙÔ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· fiÛÔ Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:53-60
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·54
54
¶·È‰È·ÙÚÈ΋ 2005;68:53-60
-
+ + -
ÂÏ·ÊÚ¤˜ ÌÔÚʤ˜ Ì ˘Ô·Ú·ı˘ÚÂÔÂȉÈÛÌfi ‹ ¤ÓÚÈÓË ÔÌÈÏ›· (8-12). OÈ Ê·ÈÓfiÙ˘ÔÈ ÙˆÓ DGS/VCFS ÂÌ‚Ú˘ÔÁÂÓÂÙÈο ·ÔÙÂÏÔ‡Ó ÙËÓ ¤ÎÊÚ·ÛË ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ Ó¢ÚÈ΋˜ ·ÎÚÔÏÔÊ›·˜ ÙÔ˘ ÙÚ›ÙÔ˘ Î·È Ù¤Ù·ÚÙÔ˘ Ê·Ú˘ÁÁÈÎÔ‡ ı˘Ï¿ÎÔ˘ (13,14). ∞ÈÙÈÔÏÔÁÈο Â›Ó·È Èı·Ófi fiÙÈ ÔÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ‡·ÚÍË ÂÓfi˜ ·ÓÙÈÁÚ¿ÊÔ˘ ·ÓÙ› ‰‡Ô ÛÙË ı¤ÛË ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÁÔÓȉ›ˆÓ ÛÙË ¯ÚˆÌÔÛˆÌÈ΋ ÂÚÈÔ¯‹ 22q11.2 (·ÏÔ·Ó¿ÚÎÂÈ·), ·ÏÏ¿ Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÌÔÚÈ·Îfi ÁÂÓÂÙÈÎfi ˘fiÛÙڈ̷ ÙˆÓ DGS/VCFS Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÔχÏÔÎÔ (1518). ™Â ·ÚÎÂÙ¤˜ ÔÈÎÔÁ¤ÓÂȘ ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ô Ê·ÈÓfiÙ˘Ô˜ ‰È·Ê¤ÚÂÈ ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ì ÙÔ ›‰ÈÔ ÌÈÎÚÔ¤ÏÏÂÈÌÌ· 22q11.2 (19). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ‚·Ú‡ÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÛËÌ·Û›· ¤¯ÂÈ Ë ·Ô˘Û›· ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÁÔÓȉ›ˆÓ Ù˘ ÂÚÈÔ¯‹˜, ·Û¯¤Ùˆ˜ Ù˘ ¤ÎÙ·Û˘ ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ (20,21). ∆¤ÏÔ˜, ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ ÛÙȘ Ôԛ˜ ‰ÂÓ ˘‹Ú¯Â ÂÌÊ·Ó¤˜ ÌÈÎÚÔ¤ÏÏÂÈÌÌ· 22q11.2, Ô‡Ù ·ÓȯÓ‡ÙËÎ·Ó ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ. ∞˘Ùfi Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Â›Ù ÚfiÎÂÈÙ·È ÁÈ· ·ÈÙÈÔÏÔÁÈÎÒ˜ ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰·, ›Ù ÁÈ· ÔχÏÔÎË ·ÏÔ·Ó¿ÚÎÂÈ· ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘ ÂÓfi˜ ÁÔÓȉ›ˆÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙËÓ ÂÚÈÔ¯‹ ÂÚȤ¯ÔÓÙ·È ÂÚ›Ô˘ 100 ÁÔÓ›‰È· (2). ∆Ô ¤ÏÏÂÈÌÌ· 22q11.2, ‡ÚÔ˘˜ ≈3 ̤Á· ‚¿ÛÂˆÓ (Mb), ¤¯ÂÈ Èı·ÓfiÙËÙ· ÎÏËÚÔÓÔÌÈ΋˜ ÌÂÙ·‚›‚·Û˘ 5-10% (2,20), Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ÌÂٷ͇ ÙˆÓ ÂӉȿÌÂÛˆÓ ÌÈÎÚÔÂÏÏÂÈÌÌ¿ÙˆÓ Î·È ·ÓȯÓ‡ÂÙ·È Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌÔ‡ (FISH). ªÂ ÛÎÔfi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ DGS/VCFS ¤ÁÈÓÂ
+ -
-
-
-
-
-
-
-
-
+
+ + -
+
+
2900 34 ¤ÙË 22 ¤ÙË + 2650 36 ¤ÙË 24 ¤ÙË
2720 34 ¤ÙË 26 ¤ÙË + 3000 36 ¤ÙË 27 ¤ÙË + 1960 32 ¤ÙË 24 ¤ÙË + 2700 30 ¤ÙË 27 ¤ÙË + 3280 35 ¤ÙË 25 ¤ÙË + 2900 43 ¤ÙË 35 ¤ÙË + + + 2690 34 ¤ÙË 27 ¤ÙË + + 3150 25 ¤ÙË 23 ¤ÙË + 3000 44 ¤ÙË 31 ¤ÙË + 3250 36 ¤ÙË 30 ¤ÙË 2950 32 ¤ÙË 32 ¤ÙË + 3100 3650 2500 35 ¤ÙË 32 ¤ÙË 36 ¤ÙË 28 ¤ÙË 30 ¤ÙË 24 ¤ÙË + + + + + 3700 30 ¤ÙË 24 ¤ÙË + + + -
∞ 11 ¤ÙË ∞ 13 ¤ÙË ∞ 18 Ì‹Ó˜ ∞ 3 ¤ÙË ∫ ∞ 10 Ë̤Ú˜ 15 Ë̤Ú˜ ∞ 2 ¤ÙË ∞ 10 Ë̤Ú˜ ∫ 6 Ì‹Ó˜ ∞ 2 Ì‹Ó˜ ∞ 15 ¤ÙË ∞ 10 ¤ÙË ∞ 11 ¤ÙË ∞ 6 ¤ÙË ∫ 5 ¤ÙË ∞ 3 ¤ÙË ∞ 10 Ë̤Ú˜
º‡ÏÔ ∏ÏÈΛ· ‰ÈÂÚ‡ÓËÛ˘ µ° (g) ∏ÏÈΛ· ·Ù¤Ú· ∏ÏÈΛ· ÌËÙ¤Ú·˜ À·Û‚ÂÛÙÈ·ÈÌ›· ™·ÛÌÔ›/˘ÔÙÔÓ›· ∞ÓÔÛÔ·Ó¿ÚÎÂÈ· æ∫∫/Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ ¢È·Ù·Ú·¯¤˜ Û›ÙÈÛ˘ ™ˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË
8 7 6 5 4 3 2 1 ·/·
¶›Ó·Î·˜ 1. ∞ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ÂͤÏÈÍË ÙˆÓ 17 ·ÛıÂÓÒÓ Ì ¤ÏÏÂÈÌÌ· 22q11.2
9
10
11
12
13
14
15
16
17
™. ∫›ÙÛÈÔ˘-∆˙¤ÏË Î·È Û˘Ó.
∂ÈÎfiÓ· 1. ªÂÙ¿Ê·ÛË ·fi ηÏÏȤÚÁÂÈ· ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ·ÛıÂÓÔ‡˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2 Ì in situ ˘‚ÚȉÈÛÌfi Î·È ·ÓȯÓÂ˘Ù‹ Ù˘ ¯ÚˆÌÔÛˆÌÈ΋˜ ı¤Û˘ 22q11.2 (ÎfiÎÎÈÓÔ Û‹Ì·). ™ÙË ÌÂϤÙË ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÂÏÔÌÂÚȉȷÎfi˜ ‰Â›ÎÙ˘ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 2 (Ú¿ÛÈÓ· Û‹Ì·Ù·).
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·55
55
™‡Ó‰ÚÔÌ· DiGeorge/˘ÂÚˆÈÔ-ηډÈÔ-ÚÔÛˆÈÎfi
ª¿ÁÔ˘Ï· ÁÂÌ¿Ù· ª¿ÙÈ· ÌÈÎÚ¿ ∂ÓÙ‡ˆÌ· Û·ÁÔÓÈÔ‡ µÏÂÊ·ÚÈΤ˜ Û¯ÈṲ̂˜ ÛÙÂÓ¤˜ µÏÂÊ·ÚÈΤ˜ Û¯ÈṲ̂˜ ·ÓÙÈÌÔÁÁÔÏÔÂȉ›˜ µÚ·¯˘Ï·ÈÌ›· ÀÂÚÒ· ıÔψً ªÈÎÚfi ÛÙfiÌ· ÀÂÚÙÂÏÔÚÈÛÌfi˜ ∂›Î·ÓıÔ˜ ªÈÎÚÔÁÓ·ı›· √ÈÛıÔÁÓ·ı›· ª‡ÙË Ì ¢Ú›· ‚¿ÛË/ÚÔ¤¯Ô˘Û· ∞˘ÙÈ¿ ¯·ÌËÏ¿/ÚÔ¤¯ÔÓÙ· 0
2
4
6 8 ∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ
10
12
14
∂ÈÎfiÓ· 2. ¢˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ Û 14/17 ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2 (¿ÍÔÓ·˜ ¯: ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì ÙÔ ‰˘ÛÌÔÚÊÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi, ¿ÍÔÓ·˜ „: ‰˘ÛÌÔÚÊÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi).
ÛÙÔ ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ ·Ó·‰ÚÔÌÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ÈÛÙÔÚÈÎÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·¤ÌÊıËÎ·Ó ·fi ·È‰È¿ÙÚÔ˘˜ Î·È ÁÈ·ÙÚÔ‡˜ ¿ÏÏˆÓ ÂȉÈÎÔÙ‹ÙˆÓ ÛÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, Ì ¤Ó‰ÂÈÍË ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Ù·ÈÓ›·˜ 22q11.2 Ì FISH.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ·Ú·¤ÌÊıËÎ·Ó ÁÈ· ΢ÙÙ·ÚÔÁÂÓÂÙÈÎfi ¤ÏÂÁ¯Ô 139 ·ÛıÂÓ›˜ (82 ·ÁfiÚÈ· Î·È 57 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 10 ËÌÂÚÒÓ ¤ˆ˜ 15 ÂÙÒÓ, Ì Èı·Ó‹ ‰È¿ÁÓˆÛË DGS/VCFS. OÈ ÎÏÈÓÈΤ˜ ÏËÚÔÊÔڛ˜ Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ÙÔ˘˜ ÌÈÛÔ‡˜ (83/139) ÂÚÈÔÚ›˙ÔÓÙ·Ó Û fi,ÙÈ ‹Ù·Ó ηٷÁÂÁÚ·Ì̤ÓÔ ÛÙ· ·Ú·ÂÌÙÈο ÛËÌÂÈÒÌ·Ù·, ΢ڛˆ˜ fiÛˆÓ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙËÓ Â·Ú¯›· Î·È ÙÔ ‰Â›ÁÌ· ›¯Â ÛÙ·Ï› Ù·¯˘‰ÚÔÌÈο ‹ ‰ÂÓ Â›¯Â ÔÏÔÎÏËÚˆı› Ô ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜. ∫ÏÈÓÈÎfi˜ ÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ Û 56/139 ·ÛıÂÓ›˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Û˘ÁÎÂÓÙÚÒıËÎ·Ó Â·Ú΋ ÛÙÔȯ›· ·fi ÙÔ ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ÙÔÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô. ∏ ÌÂϤÙË ÙÔ˘ ηڢÔÙ‡Ô˘ ¤ÁÈÓ ·fi ηÏÏȤÚÁÂÈ· ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È Ë Û‹Ì·ÓÛË ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ Ì ٷÈӛ˜ -G. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ë ·Ó›¯Ó¢ÛË ÙÔ˘ ÌÈÎÚÔÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 ¤ÁÈÓ Ì ÙËÓ Ù¯ÓÈ΋ FISH, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔÓ ÂȉÈÎfi DNA ·ÓȯÓÂ˘Ù‹ TUPLE DiGeorge (Oncor) Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. O ›‰ÈÔ˜ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ ÛÙÔ˘˜ ÁÔÓ›˜ ÙˆÓ ·ÛıÂÓÒÓ, ÛÙÔ˘˜
ÔÔ›Ô˘˜ ‰È·ÈÛÙÒıËΠÙÔ ÌÈÎÚÔ¤ÏÏÂÈÌÌ·. OÈ ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÈÛÙÒıËΠ¤ÏÏÂÈÌÌ· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Ù·ÎÙÈο ÛÙÔ π·ÙÚÂ›Ô ∫ÏÈÓÈ΋˜ °ÂÓÂÙÈ΋˜.
∞ÔÙÂϤÛÌ·Ù· ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ÌÂϤÙË O ¤ÏÂÁ¯Ô˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ 137 ·ÛıÂÓÒÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ (98,56%), ÂÓÒ ‰È·ÈÛÙÒıËÎ·Ó ‰‡Ô ·ıÔÏÔÁÈÎÔ› ηڢfiÙ˘ÔÈ: 47,ÃÃÀ (·ÁfiÚÈ 5 ÂÙÒÓ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·/„˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË) Î·È 46,ÃÃ,2p+, de novo (ÎÔÚ›ÙÛÈ 14 ÌËÓÒÓ Ì ˘ÔÙÔÓ›·, ΢·ÓˆÙÈο ÂÂÈÛfi‰È· Î·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË). ºıÔÚ›˙ˆÓ in situ ˘‚ÚȉÈÛÌfi˜ (FISH) ŒÏÏÂÈÌÌ· 22q11.2 ·ÓȯÓ‡ıËΠ۠17/139 ·ÛıÂÓ›˜ (12%) (∂ÈÎfiÓ· 1). ∆Ô ¤ÏÏÂÈÌÌ· ‹Ù·Ó ÎÏËÚÔÓÔÌÈÎfi Û ÙÚÂȘ ÔÈÎÔÁ¤ÓÂȘ (17,6%), ‰‡Ô ÌËÙÚÈ΋˜ Î·È Ì›· ·ÙÚÈ΋˜ ÚÔ¤Ï¢Û˘, ÂÓÒ ÔÈ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ÛÔÚ·‰ÈΤ˜. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ì ¤ÏÏÂÈÌÌ· 22q11.2 ™ÙÔÓ ¶›Ó·Î· 1 ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔȯ›· ÙÔ˘ ·ÙÔÌÈÎÔ‡ Î·È ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡, ηıÒ˜ Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:53-60
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·56
56
™. ∫›ÙÛÈÔ˘-∆˙¤ÏË Î·È Û˘Ó.
ÙÒÛÂȘ ·Ó·Ê¤ÚÔÓÙ·È Û·ÛÌÔ›/˘ÔÙÔÓ›·, Û 4 (23%) ÚÔ‚Ï‹Ì·Ù· Û›ÙÈÛ˘ Û˘Óԉ¢fiÌÂÓ· Û˘¯Ó¿ ·fi ·ÓˆÌ·Ï›Â˜ Ù˘ ˘ÂÚÒ·˜, Û 8 (47%) ˘·Û‚ÂÛÙÈ·ÈÌ›· Î·È Û 11 (65%) ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ·fi Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·. ™ˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË (M™ Î·È B™ <3Ë E£) ‰È·ÈÛÙÒıËΠ۠2 ·È‰È¿ Ì ÛÔ‚·Ú‹ ηډÈÔ¿ıÂÈ·. ∏ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË ÂÎÙÈÌ‹ıËΠ۠11/17 ·ÛıÂÓ›˜, ‰ÈfiÙÈ ÔÈ ˘fiÏÔÈÔÈ 6 ‹Ù·Ó ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙÔ˘ 1 ¤ÙÔ˘˜, ÂÂȉ‹ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛÙ› ÂÏ·ÊÚÈ¿ ÎÈÓËÙÈ΋ Î·È ÁψÛÛÈ΋ ηı˘ÛÙ¤ÚËÛË. OÈ 6/17 ·ÚÔ˘Û›·˙·Ó „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË/Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Î·È ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ (35%). ¢˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ ÂÌÊ¿ÓÈ˙·Ó 14/17 ·ÛıÂÓ›˜ (82%) Î·È Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ηٷÁÚ¿ÊÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ¢‡Ô ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2 Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 3, Û ËÏÈΛ· 10 ËÌÂÚÒÓ (·ÛıÂÓ‹˜ ¡Ô 1, ¶›Ó·Î·˜ 1 Î·È 2) Î·È 2 ÂÙÒÓ (·ÛıÂÓ‹˜ ¡Ô 12, ¶›Ó·Î·˜ 1 Î·È 2). ∆Ô Ê¿ÛÌ· ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙˆÓ 17 ·È‰ÈÒÓ Ì DGS/VCFS ·Ú·Ù›ıÂÙ·È ·Ó·Ï˘ÙÈο ÛÙÔÓ ¶›Ó·Î· 2. ª›· ‹ ÂÚÈÛÛfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ›¯·Ó Ù· 12/17 ·È‰È¿ ÛÙ· ÔÔ›· ‰È·ÁÓÒÛÙËΠDGS/VCFS (70%), ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙË ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· (35%) Î·È ÙËÓ ÙÂÙÚ·ÏÔÁ›· Fallot (17%). ÕÏϘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ·ÊÔÚÔ‡Û·Ó ÛÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi (35%), ÛÙ· ¿ÎÚ· (53%), ÛÙËÓ ˘ÂÚÒ·/Ï¿Ú˘ÁÁ· (41%) Î·È ÛÙÔÓ ÂÁΤʷÏÔ (17%). ¢È·Ù·Ú·¯‹ ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ‰È·ÈÛÙÒıËΠ۠6 ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙÔ˘ 1 ¤ÙÔ˘˜ ηٿ ÙË ‰È¿ÁÓˆÛË, Ì ÂÏ·Ùو̤ÓÔ ÔÛÔÛÙfi ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD4+) Î·È ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ·‡ÍËÛË ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÂÓÒ Â›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ·ÚÈıÌfi Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ, Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ Î·È ‹È· ÎÏÈÓÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ÂÈÎfiÓ·. ∂Ï·Ùو̤ÓË ÂȉÈ΋ ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË ‰È·ÈÛÙÒıËΠÌfiÓÔ Û 2/6 ·È‰È¿ (·ÛıÂÓ›˜ ¡Ô 8 Î·È 12, ¶›Ó·Î·˜ 3). ™Â 5 ·ÛıÂÓ›˜, Ë ÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ· ·ÔηٷÛÙ¿ıËΠ¤Ó·Ó ¯ÚfiÓÔ ÌÂÙ¿, ÂÓÒ ÛÙÔÓ ·ÛıÂÓ‹ ¡Ô 12 ¯ÚÂÈ¿ÛÙËΠ·Ú·ÙÂٷ̤ÓË ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ÓÔÛËÏ›· ÏfiÁˆ ÛÔ‚·ÚÒÓ ÏÔÈÌÒ͈Ó. ∂ÈÎfiÓ· 3. ¢‡Ô ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2. ¢È·ÎÚ›ÓÔÓÙ·È ÙÔ ÌÈÎÚfi ÛÙfiÌ·, Ë ÌÈÎÚÔ-ÔÈÛıÔÁÓ·ı›· Ì ÂÓÙ‡ˆÌ· Û·ÁÔÓÈÔ‡, Ù· ¯·ÌËÏ¿ Î·È ÚÔ¤¯ÔÓÙ· ·˘ÙÈ¿, Ë ‚Ú·¯˘Ï·ÈÌ›·, Ù· Ì¿ÁÔ˘Ï· ÁÂÌ¿Ù· Î·È Ë ÎÔÓÙ‹ ̇ÙË.
Ù˘ ÂͤÏÈ͢ ÙˆÓ 17 ·ÛıÂÓÒÓ Ì ¤ÏÏÂÈÌÌ· 22q11.2. ∞fi ÙÔ˘˜ 17 ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ·, 14 ‹Ù·Ó ·ÁfiÚÈ· Î·È 3 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 10 ËÌÂÚÒÓ ¤ˆ˜ 5 ÂÙÒÓ (n=11), 6-10 ÂÙÒÓ (n=2) Î·È 11-15 ÂÙÒÓ (n=4). ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ÁÔÓ¤ˆÓ ηٿ ÙË Á¤ÓÓËÛË ‹Ù·Ó 35 (·Ù¤Ú·˜) Î·È 26,5 (ÌËÙ¤Ú·). TÔ Ì¤ÛÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 2864 g ÛÙȘ 38 ‚‰ÔÌ¿‰Â˜ (3018 g Ù· ·ÁfiÚÈ· Î·È 2480 g Ù· ÎÔÚ›ÙÛÈ·), ÂÓÒ 4 ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ÙËÓ 37Ë Â‚‰ÔÌ¿‰· (23,5%). ™ÙÔ ÈÛÙÔÚÈÎfi Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜/ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘, Û 4 (23%) ÂÚȶ·È‰È·ÙÚÈ΋ 2005;68:53-60
™˘˙‹ÙËÛË ∞fi ÙËÓ ·Ó·ÛÎfiËÛË ÙˆÓ 139 ÂÚÈÙÒÛÂˆÓ Ô˘ ·Ú·¤ÌÊıËÎ·Ó ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ·fi ÁÈ·ÙÚÔ‡˜ ‰È·ÊfiÚˆÓ ÂȉÈÎÔÙ‹ÙˆÓ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ‰È¿ÁÓˆÛË ÙˆÓ DGS/VCFS ÂȂ‚·ÈÒıËΠÛÙÔ 12% ÙÔ˘ Û˘ÓfiÏÔ˘. ªÂٷ͇ ÙˆÓ 56 ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‹Ù·Ó ‰È·ı¤ÛÈÌÔ ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È ·Ó·Ï‡ıËÎ·Ó Ù· ÂÈ̤ÚÔ˘˜ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ÛÙÔȯ›·, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÂÚÁ·ÛÙËÚȷ΋ ÂȂ‚·›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ ‰È·Ê¤ÚÂÈ Â¿Ó Á›ÓÂÈ Î·Ù¿Ù·Í‹ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·: DGS/VCFS
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·57
57
™‡Ó‰ÚÔÌ· DiGeorge/˘ÂÚˆÈÔ-ηډÈÔ-ÚÔÛˆÈÎfi
¶›Ó·Î·˜ 2. º¿ÛÌ· Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙÔ˘˜ 17 ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2 1 ∫·Ú‰È·ÁÁÂÈ·Îfi ªÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ∆ÂÙÚ·ÏÔÁ›· Fallot ÀÔ‚·Ï‚ȉÈ΋ ÛÙ¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ ™‡ÌÏÔÎË Î·Ú‰ÈÔ¿ıÂÈ· ¢ÂÍÈfi ·ÔÚÙÈÎfi ÙfiÍÔ ÀÔÏ·Û›· Ó¢ÌÔÓÈ΋˜ ∞ÓÔÈÎÙfi˜ ‚ÔÙ¿ÏÂÈÔ˜ fiÚÔ˜ O˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi ¢È¿Ù·ÛË ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ ªÔÓ‹Ú˘ ÓÂÊÚfi˜ ∫Ú˘„ÔÚ¯›· ÀÔÛ·‰›·˜ º›ÌˆÛË ÕÎÚ· ª·ÎÚÈ¿ ‰¿ÎÙ˘Ï· ∂Ê›Â˘ÛË ‰·ÎÙ‡ÏˆÓ ™˘Ó‰·ÎÙ˘Ï›·/·ÓÒÌ·Ï· Ó‡¯È· ∂ÁΤʷÏÔ˜ °ÏÔ›ˆÌ· ÂÁÎÂÊ¿ÏÔ˘ ÀÔÂÂÓ‰˘Ì·ÙÈ΋ ·ÛÙË ¢È¿Ù·ÛË ÎÔÈÏÈÒÓ ÂÁÎÂÊ¿ÏÔ˘ ÀÂÚÒ·/Ï¿Ú˘ÁÁ·˜ §·Ú˘ÁÁÔ̷ϷΛ· ÀÂÚˆÈÔÛ¯ÈÛÙ›· ÀÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ·
2
3
4
+
5
6
+
+
7
8
9
+
10 11
12
+
+
+
13
14
15
+
+ +
+
16 17
+
+ + +
+ +
+
+ + + + +
+
+
+
+ +
+
+ + + +
+ + +
ÂȂ‚·ÈÒıËÎ·Ó Û 8/8 Ì ˘·Û‚ÂÛÙÈ·ÈÌ›· (100%), Û 6/10 Ì ·ÓÔÛÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (60%), Û 4/7 Ì ˘ÔÙÔÓ›·/Û·ÛÌÔ‡˜ (57%), Û 2/4 Ì ˘ÂÚˆÈÔÛ¯ÈÛÙ›· (50%), Û 11/15 Ì ÔÏϷϤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ (70%), Û 14/37 Ì ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ (38%), Û 2/5 Ì ˘ÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ· (30%), Û 6/23 Ì „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË/Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜/‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ (26%), Û 12/47 ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· (25%) Î·È Û 2/8 Ì ۈ̷ÙÈ΋ ηı˘ÛÙ¤ÚËÛË (25%) (∂ÈÎfiÓ· 4). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ Î˘ÚÈfiÙÂÚˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙ· DGS/VCFS Û ۇÁÎÚÈÛË Ì ٷ ÛÙÔȯ›· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4 (5,12,22). ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ηډÈÔ¿ıÂȘ (¶›Ó·Î·˜ 2), Ô ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ˘ÏÈÎÔ‡ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ì ¤ÏÏÂÈÌÌ· 22q11.2, ‰ÂÓ Â¤ÙÚ„ ÙËÓ ·Ó¿‰ÂÈÍË ¿ÏÏˆÓ Û·ÓÈfiÙÂÚˆÓ ·ÓˆÌ·ÏÈÒÓ Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê›, fiˆ˜ ÌÂÙ¿ıÂÛË ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, ÎÔÈÓfi˜ ·ÚÙËÚÈ·Îfi˜ ÎÔÚÌfi˜ Î·È ‰È·ÎÂÎÔÌ̤ÓÔ ·ÔÚÙÈÎfi ÙfiÍÔ (5,12,23). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÌfiÓÔ Û 5/17 (30%) ÂÚÈÙÒÛÂȘ Ì ¤ÏÏÂÈÌÌ· 22q11.2 ‰ÂÓ ‰È·ÈÛÙÒıËΠηډÈÔ¿ıÂÈ·, ‡ÚËÌ· Û˘Ì‚·Ùfi Ì ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (¶›Ó·Î·˜ 4). ÀÂÚÙÔÓ›˙ÂÙ·È Ë ÛËÌ·Û›· Ù˘ ÚÔÛÂÎÙÈ΋˜ ηډÈÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ οı ÓÂÔÁÓÔ‡, ·ÎfiÌ· ÎÈ ·Ó ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ ÙȘ ˘fiÏÔȘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ DGS/VCFS. ∂›Û˘, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘
+
+ +
+ +
Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ (35%) ÛÙË ÌÂϤÙË (¶›Ó·Î·˜ 2) ·ÔÙÂÏ› ÈÛ¯˘Ú‹ ¤Ó‰ÂÈÍË ÒÛÙ ӷ ηıÈÂÚˆı› Ë ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË ÓÂÊÚÒÓ-Ô˘ÚËÙ‹ÚˆÓ-·ÛÙˆ˜ Û οı ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ¤ÏÏÂÈÌÌ· 22q11.2, ÂÊfiÛÔÓ Ì¿ÏÈÛÙ· ÔÏϤ˜ ·fi ·˘Ù¤˜ ÙȘ ·ÓˆÌ·Ï›Â˜ ¤¯Ô˘Ó ¤Ó‰ÂÈÍË ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. ¢È·Ù·Ú·¯¤˜ Ù˘ ˘ÂÚÒ·˜ (Û¯ÈÛÙ›·/˘ÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ·) ·Ú·ÙËÚ‹ıËÎ·Ó Û ÔÛÔÛÙfi 23% (¶›Ó·Î·˜ 2), ·Ó Î·È ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (5,12,22) ·Ó·Ê¤ÚÔ˘Ó ˘„ËÏfiÙÂÚ˜ Û˘¯ÓfiÙËÙ˜ (¶›Ó·Î·˜ 4). ªÂ ‚¿ÛË ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, Ë Û˘¯ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 ÌÂٷ͇ ·È‰ÈÒÓ Ì ˘ÂÚˆÈÔÛ¯ÈÛÙ›·, ¯ˆÚ›˜ fï˜ ¿ÏÏ· Û˘ÌÙÒÌ·Ù· ÙÔ˘ VCFS, ÂÎÙÈÌ¿Ù·È fiÙÈ Â›Ó·È 1:99, ·ÚÎÂÙ¿ ¯·ÌËÏ‹ ÒÛÙ ӷ ıˆÚËı› fiÙÈ ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌÔÛÙ› Ô ¤ÏÂÁ¯Ô˜ ·˘Ùfi˜ Û fiÏ· Ù· ÓÂÔÁ¤ÓÓËÙ· Ì ۯÈÛٛ˜ (24). ∞Ó·ÌÊ›‚ÔÏ· fï˜, ÂÈ‚¿ÏÏÂÙ·È Ë ÎÏÈÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Î·È Ë Âͤٷۋ ÙÔ˘˜ ·fi ÁÂÓÂÙÈÛÙ‹, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛÙ› ÙÔ VCFS. ∆¤ÏÔ˜, ÔÈ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ ‹Ù·Ó ‹È˜, ‰ÂÓ ¯ÚÂÈ¿ÛÙËÎ·Ó È‰È·›ÙÂÚË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È ·ÚÔ˘Û›·Û·Ó ÛÙ·‰È·Î‹ ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ÙÔ ÚÒÙÔ ¤ÙÔ˜. ªfiÓÔ Û ̛· ·ÛıÂÓ‹ (·ÛıÂÓ‹˜ ¡Ô 12, ¶›Ó·Î·˜ 3) ··ÈÙ‹ıËΠ·Ú·ÙÂٷ̤ÓË ıÂڷ›· Ì ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ¤Ó·˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘, Ì ÌÂÛÔÎÔÈÏȷ΋ ¶·È‰È·ÙÚÈ΋ 2005;68:53-60
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·58
58
™. ∫›ÙÛÈÔ˘-∆˙¤ÏË Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ∞ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û 6/17 ·ÛıÂÓ›˜ Ì ¤ÏÏÂÈÌÌ· 22q11.2 ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ¤Ó·Ó ¯ÚfiÓÔ ÌÂÙ¿ ∞ÛıÂÓ›˜ (·/·)
∫·Ù¿ ÙË ‰È¿ÁÓˆÛË*
1
CD3=27% CD4=20% CD8=15% CD19=34% CD16=17% CD3=55% CD4=35% CD8=16% CD19=32% CD16=12% CD3=34% CD4=18% CD8=16% CD19=50% CD16=11% CD3=32% CD4=23% CD8=8% CD19=57% CD16=6% CD3=36% CD4=27% CD8=12% CD19=44% CD16=17% CD3=23% CD4=14% CD8=9% CD19=60% CD16=14%
8
9
10
12
13
ŒÓ·Ó ¯ÚfiÓÔ ÌÂÙ¿**
IgG=837 IgA<7 IgM=23
CD3=77% CD4=43% CD8=28% CD19=15% CD16=10% CD3=55% CD4=40% CD8=15% CD19=25% CD16=9% CD3=46% CD4=23% CD8=18% CD19=39% CD16=17% CD3=55% CD4=35% CD8=19% CD19=31% CD16=18% CD3=36% CD4=23% CD8=12% CD19=40% CD16=24% CD3=70% CD4=54% CD8=12% CD19=26% CD16=4%
IgG=389 IgA=19 IgM=93
IgG=1135 IgA=47 IgM=67
IgG=705 IgA=33 IgM=59
IgG=503 IgA=10 IgM=76
IgG=710 IgA=29 IgM=52
IgG=343 IgA=41 IgM=30
IgG=647 IgA=23 IgM=86
IgG=1057 IgA=28 IgM=180
IgG=952 IgA=70 IgM=68
IgG=882 IgA=16 IgM=46
IgG=757 IgA=73 IgM=41
* ™‡Ìʈӷ Ì ÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜, ·ıÔÏÔÁÈΤ˜ ıˆڋıËÎ·Ó ÔÈ ÙÈ̤˜ ÌÈÎÚfiÙÂÚ˜ ÙˆÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜
47
50 45
37
40 35 30
23
25 20 15
15
14
12
0
È· ıÂ
¿
Ô
È Ú‰
·Ú
¯ ο
Ù È·
æ∫
‰ ∫/
Û
È ÂÚ
-
Û ıË
¿
Ï
¶Ô
˜
Ϥ
Ï·
˜
Ú¿
Ï›Â
ÊÔ
Ì
Û˘
˘
˜Ì
¤ ·¯
·Ú
ο
6
˜
ÛÒ
8
8
7 5 4
2
Ô˘
Ô Ú
ÙÈ
ÚÈ
ÙË ·Î
ÊÈ
Ú
ÌÔ
Û ¢˘
η
ÂÓ
ÁÁ
™˘
8
6
5
‹˜
10
11
10
· ˆÌ
Ó ˜·
› ÓÂ
ÁÂ
Á Û˘
Ï
ÛÔ
Ô ∞Ó
Ô‚
Ú
¿
ÈÎ ÔÁ
·
·Ù
Ì Ï‹
‚Â
·Û
À
›·
Ë
ÈÌ
È· Û٠΋
η
È
·Ù
ËÛ
›
ÌÔ
¤Ú
ÛÙ ı˘
Û ·
Ô
À
Ì ™ˆ
È·
›· ÛÙ
·Ó
S1
È
Û¯
ÈÔ Úˆ
Â
À
ÔÊ
ˆÈ
Ú Â
‹
ÈÎ
ÁÁ
˘ ·Ú
Â
2
 ÚÎ
¿
/Û
›·
Ó ÙÔ
4
2
À
∂ÈÎfiÓ· 4. ∫ÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ÛÙÔȯ›· ÙˆÓ 56 ·ÛıÂÓÒÓ Ì ·ÚΤ˜ ÈÛÙÔÚÈÎfi Ô˘ ·Ú·¤ÌÊıËÎ·Ó ÁÈ· ¤ÏÂÁ¯Ô ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 (Ì·‡Ú˜ ÛًϘ) Î·È ÙˆÓ 17 ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂȂ‚·ÈÒıËÎÂ Ë ‰È¿ÁÓˆÛË DGS/VCFS (¿ÛÚ˜ ÛًϘ). ¶·È‰È·ÙÚÈ΋ 2005;68:53-60
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·59
59
™‡Ó‰ÚÔÌ· DiGeorge/˘ÂÚˆÈÔ-ηډÈÔ-ÚÔÛˆÈÎfi
¶›Ó·Î·˜ 4. ™˘¯ÓfiÙËÙ· ÙˆÓ Î˘ÚÈfiÙÂÚˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· DGS/VCFS º·ÈÓÔÙ˘ÈΤ˜ ·ÓˆÌ·Ï›Â˜ π‰ÈfiÌÔÚÊÔ ÚÔÛˆÂ›Ô ∫·Ú‰ÈÔ¿ıÂÈ· ∞Ï·Û›· ı‡ÌÔ˘/·ÓÔÛÔ·Ó¿ÚÎÂÈ· ¢È·Ù·Ú·¯¤˜ ·Ú·ı˘ÚÂÔÂȉÒÓ, ˘·Û‚ÂÛÙÈ·ÈÌ›· ™¯ÈÛÙ›·, ˘ÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ· ∞ӈ̷ϛ˜ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡
Goldberg et al, 1993 (12) Leana-Cox et al, 1996 (22) Ryan et al, 1997 (5) ¶·ÚÔ‡Û· ÌÂϤÙË (n=9) (n=12) (n=285) (n=17) 77%
93% 68% 64%
75%
82% 70% 47%
12%, 20%
63%
60%
47%
100%
48%
9%, 32% 36%
23,5% 35%
ÂÈÎÔÈÓˆÓ›· Î·È ‰È¿ÁÓˆÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2 Û ËÏÈΛ· 11 ÂÙÒÓ (·ÛıÂÓ‹˜ ¡Ô 5, ¶›Ó·Î˜ 1 Î·È 2), ‰ÂÓ ÂÌÊ¿ÓÈ˙ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ·ÏÏ¿ ·Ó¤Ù˘Í ϤÌʈ̷ Û ËÏÈΛ· 15 ÂÙÒÓ Î·È Î·Ù¤ÏËÍ ÌÂÙ¿ ‰ÈÂÙ›· ·fi ÓfiÛÔ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ·Ó¿ÏÔÁË ÂÚ›ÙˆÛË DGS Ì ·ÈÌ·ÙÔÏÔÁÈ΋ ηÎÔ‹ıÂÈ·. ∆· ΢ÚÈfiÙÂÚ· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ÎÈÓËÙÔÔÈÔ‡Ó ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi Ó· ·Ú·¤Ì„ÂÈ ·ÛıÂÓ›˜ Ì Èı·Ó‹ ‰È¿ÁÓˆÛË DGS/VCFS ÁÈ· ÁÂÓÂÙÈ΋ ‰ÈÂÚ‡ÓËÛË Ì ¤ÏÂÁ¯Ô ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11.2, Â›Ó·È - ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ - ÔÈ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ù· ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘, ÔÈ ‰È·Ù·Ú·¯¤˜ Ì¿ıËÛ˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜, ÔÈ ÔÏϷϤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, ÔÈ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë ˘·Û‚ÂÛÙÈ·ÈÌ›·, Ë ÛˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË, Ë ˘ÔÙÔÓ›·/ Û·ÛÌÔ›, Ë ˘ÂÚˆÈÔÊ·Ú˘ÁÁÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ë ˘ÂÚˆÈÔÛ¯ÈÛÙ›· (∂ÈÎfiÓ· 4). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ fiÙ·Ó Â·ÓÂÎÙÈÌ‹ıËÎ·Ó ·fi ÎÏÈÓÈÎfi ÁÂÓÂÙÈÛÙ‹ 39 ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ·ÔÎÏ›ÛÙËÎÂ Ë ‰È¿ÁÓˆÛË DGS/VCFS, ÔÈ 14 ηٷٿ¯ıËÎ·Ó Û ‰È·ÊÔÚÂÙÈο ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ·. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËÎ·Ó ÙÚÂȘ ÔÈÎÔÁ¤ÓÂȘ Ì ÎÏËÚÔÓÔÌÈÎfi DGS/VCFS. ∏ Ì›· ÌËÙ¤Ú·ÊÔÚ¤·˜ ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ·ÚÔ˘Û›·˙ ÂÏ·ÊÚ¿ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ÂÓÒ ÛÙȘ ‰‡Ô ¿ÏϘ ÔÈÎÔÁ¤ÓÂȘ, fiÔ˘ ÊÔÚ¤·˜ ‹Ù·Ó Ô ·Ù¤Ú·˜, ‰È·ÈÛÙÒıËÎ·Ó È‰ÈfiÌÔÚÊ· ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ ·ÚfiÌÔÈ· Ì ÙÔ˘ ·È‰ÈÔ‡. ∂›Ó·È Èı·Ófi fiÙÈ Ô ÁÔÓ¤·˜ Ì ÙÔ ¤ÏÏÂÈÌÌ· ·ÚÈÛÙ¿ ÙÔ ÂÏ·ÊÚÈ¿˜ ‚·Ú‡ÙËÙ·˜ ¿ÎÚÔ ÙÔ˘ Â˘Ú¤Ô˜ ÎÏÈÓÈÎÔ‡ Ê¿ÛÌ·ÙÔ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, ÁÈ’ ·˘Ùfi ¿ÏψÛÙ ÙÂÎÓÔÔÈ›. ™ÙÔ˘˜ 2/3 ·ÛıÂÓ›˜, ÙÔ ¤ÏÏÂÈÌÌ· ‹Ù·Ó ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘, ‡ÚËÌ· Û˘Ì‚·Ùfi Ì ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (5). ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÎÏËÚÔÓÔÌÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ 22q11.2 ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‹Ù·Ó 18%, ÂÓÒ Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 10% (23,24). ™Â Ì›· ÌÂÁ¿ÏË Â˘Úˆ·˚΋ Û˘ÓÂÚÁ·ÙÈ΋ ÌÂϤÙË, fiÔ˘ ‰È·ÈÛÙÒıËÎ·Ó ÎÏËÚÔÓÔÌÈο ÌÈÎÚÔÂÏÏ›ÌÌ·Ù· Û ·ÚÎÂÙ¿ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi (28%) (3), Èı·ÓÒ˜ ¤ÁÈÓ ÂÈÏÂÎÙÈÎfiÙÂÚË ‰È·ÏÔÁ‹ ÁÈ· ¤ÏÂÁ¯Ô, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÁÔÓ›˜, ÌÂ
‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ ÙÔ˘˜ ÂÈÎfiÓ·. ∂ÓÙÔ‡ÙÔȘ, ıˆÚÂ›Ù·È ÂȂ‚ÏË̤ÓÔ Û οı ÂÚ›ÙˆÛË ‰È¿ÁÓˆÛ˘ ·È‰ÈÔ‡ Ì DGS/VCFS Ó· ÂϤÁ¯ÔÓÙ·È Î·È ÔÈ ‰‡Ô ÁÔÓ›˜, ·ÎfiÌË Î·È Â¿Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó Û ·˘ÙÔ‡˜ ‹ Û ·‰¤ÏÊÈ· ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÂÌÊ·Ó›˜ Ê·ÈÓÔÙ˘ÈΤ˜ ÂΉËÏÒÛÂȘ ‹ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ηډÈÔ·ıÂÈÒÓ. O ¤ÏÂÁ¯Ô˜ ÙˆÓ ·‰ÂÏÊÒÓ ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ·fi ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÁÔÓ¤ˆÓ ‰È·ÈÛÙˆı› fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÎÏËÚÔÓÔÌÈÎfi ¤ÏÏÂÈÌÌ·. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ô Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ Ì ηڢfiÙ˘Ô Î·È FISH ‰ÂÓ ı· Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Û η̛· ÔÈÎÔÁ¤ÓÂÈ·, ÚÔÎÂÈ̤ÓÔ˘ fi¯È ÌfiÓÔ Ó· ÂÓÙÔ›˙ÂÙ·È Ô ÁÔÓ¤·˜ ‹ Ù· ·‰¤ÏÊÈ· Ì ÙÔ ¤ÏÏÂÈÌÌ· 22q11.2, ÒÛÙ ӷ ·Ú·¤ÌÂÙ·È ÁÈ· ηډÈÔÏÔÁÈ΋ ÂͤٷÛË, ·ÏÏ¿ Î·È Ó· ·Ú¤¯ÂÙ·È ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ÚÈÓ ÙËÓ ÂfiÌÂÓË Î‡ËÛË. ™ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ÎÏËÚÔÓÔÌÈÎfi ¤ÏÏÂÈÌÌ· Û˘ÓÈÛÙ¿Ù·È ÚÔÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, ·ÓÂÍ·Úًو˜ Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘ ÛÙÔÓ ÁÔÓ¤· ‹ ÛÙÔ ÚÔËÁÔ‡ÌÂÓÔ ¿Û¯ÔÓ ·È‰›.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Wilson DI, Burn J, Scambler P, Goodship J. DiGeorge syndrome: part of CATCH 22. J Med Genet 1993;30:852-856. 2. Scambler PJ. The 22q11 deletion syndromes. Hum Mol Genet 2000;9:2421-2426. 3. Shpritzen RJ. Velo-cardio-facial syndrome. In: Cassidy SB, Allanson JE, editors. Management of genetic syndromes. New York: Wiley-Liss; 2001. p. 495-516. 4. McKusick VA. Mendelian inheritance in man. A catalogue of human genes and genetic disorders, OMIM, # 188400: DiGeorge syndrome, # 192430, Velocardiofacial syndrome. 12th ed. Baltimore: The Johns Hopkins University Press; 1998 (http://www.nlm.nih.gov/omim/). 5. Ryan AK, Goodship JA, Wilson DI, Philip N, Levy A, Seidel H et al. Spectrum of clinical features associated with interstitial chromosome 22q11 deletions: a European collaborative study. J Med Genet 1997;34:798-804. 6. Vantrappen G, Devriendt K, Swillen A, Rommel N, Vogels A, Eyskens B et al. Presenting symptoms and clinical features in 130 patients with the velo-cardio-facial syndrome. The Leuven experience. Genet Couns 1999;10:3-9. 7. Berend SA, Spikes AS, Kashork CD, Wu JM, Daw SC, Scambler PJ et al. Dual-probe fluorescence in situ hybridization assay for detecting deletions associated with VCFS/DiGeorge syndrome I and DiGeorge syndrome II loci. Am J Med Genet 2000;91:313-317. ¶·È‰È·ÙÚÈ΋ 2005;68:53-60
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·60
60
™. ∫›ÙÛÈÔ˘-∆˙¤ÏË Î·È Û˘Ó.
8. Lipson A, Emanuel B, Colley P, Fagan K, Driscoll DA. “CATCH 22” sans cardiac anomaly, thymic hypoplasia, cleft palate, and hypocalcaemia: cAtch 22. A common result of 22q11 deficiency? J Med Genet 1994;31:741. 9. Scire G, Dallapiccola B, Iannetti P, Bonaiuto F, Galasso C, Mingarelli R et al. Hypoparathyroidism as the major manifestation in two patients with 22q11 deletions. Am J Med Genet 1994;52:478-482. 10. Greig F, Paul E, DiMartino-Nardi J, Saenger P. Transient congenital hypoparathyroidism: resolution and recurrence in chromosome 22q11 deletion. J Pediatr 1996;128:563-567. 11. Clouthier DE, Williams SC, Yanagisawa H, Wieduwilt M, Richardson JA, Yanagisawa M. Signaling pathways crucial for craniofacial development revealed by endothelin-A receptordeficient mice. Dev Biol 2000;217:10-24. 12. Goldberg R, Motzkin B, Marion R, Scambler PJ, Shprintzen RJ. Velo-cardio-facial syndrome: a review of 120 patients. Am J Med Genet 1993;45:313-319. 13. Lammer EJ, Opitz JM. The DiGeorge anomaly as a developmental field defect. Am J Med Genet 1986;2 (Suppl):S113S127. 14. Van Mierop LH, Kutsche LM. Cardiovascular anomalies in DiGeorge syndrome and importance of neural crest as a possible pathogenetic factor. Am J Cardiol 1986;58:133-137. 15. Lindsay EA, Halford S, Wadey R, Scambler PJ, Baldini A. Molecular cytogenetic characterization of the DiGeorge syndrome region using fluorescence in situ hybridization. Genomics 1993;17:403-407. 16. Levy A, Demczuk S, Aurias A, Depetris D, Mattei MG, Philip N. Interstitial 22q11 microdeletion excluding the ADU breakpoint in a patient with DiGeorge syndrome. Hum Mol Genet 1995;4:2417-2419.
¶·È‰È·ÙÚÈ΋ 2005;68:53-60
17. Rizzu P, Lindsay EA, Taylor C, O’Donnell H, Levy A, Scambler P et al. Cloning and comparative mapping of a gene from the commonly deleted region of DiGeorge and Velocardiofacial syndromes conserved in C. elegans. Mamm Genome 1996;7:639-643. 18. Gottlieb S, Emanuel BS, Driscoll DA, Sellinger B, Wang Z, Roe B et al. The DiGeorge syndrome minimal critical region contains a goosecoid-like (GSCL) homeobox gene that is expressed early in human development. Am J Hum Genet 1997;60:1194-1201. 19. Kasprzak L, Der Kaloustian VM, Elliott AM, Shevell M, Lejtenyi C, Eydoux P. Deletion of 22q11 in two brothers with different phenotype. Am J Med Genet 1998;75:288-291. 20. Carlson C, Papolos D, Pandita RK, Faedda GL, Veit S, Goldberg R et al. Molecular analysis of velo-cardio-facial syndrome patients with psychiatric disorders. Am J Hum Genet 1997;60:851-859. 21. Kimber WL, Hsieh P, Hirotsune S, Yuva-Paylor L, Sutherland HF, Chen A et al. Deletion of 150 kb in the minimal DiGeorge/velocardiofacial syndrome critical region in mouse. Hum Mol Genet 1999;8:2229-2237. 22. Leana-Cox J, Pangkanon S, Eanet KR, Curtin MS, Wulfsberg EA. Familial DiGeorge/ velocardiofacial syndrome with deletions of chromosome 22q11.2: report of five families with a review of the literature. Am J Med Genet 1996;65:309-316. 23. Sullivan KE. DiGeorge syndrome/chromosome 22q11.2 deletion syndrome. Curr Allergy Asthma Rep 2001;1:438-444. 24. Swillen A, Vogels A, Devriendt K, Fryns JP. Chromosome 22q11 deletion syndrome: update and review of the clinical features, cognitive-behavioral spectrum, and psychiatric complications. Am J Med Genet 2000;97:128-135.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·61
ORIGINAL ARTICLE
61
Genetic and clinical-laboratory investigation of patients with DiGeorge/velo-cardio-facial syndromes S. Kitsiou - Tzeli1, A. Kolialexi1, H. Fryssira1, A. Gala - Voumvouraki2, C. Salavoura3, ª. Kanariou3, E. Kanavakis1, A. Mavrou1
Abstract Background/Methods: The aim of the present study was the detection of genetic deletion within q11.2 region of chromosome 22 which is pathognomonic of DiGeorge/velo-cardio-facial syndromes (VCFS), using karyotypic and fluorescent in situ hybridization (FISH) analysis, and the analysis of clinical-laboratory spectrum of the patients studied. Results: A deletion was found in 17/139 patients (14 males/3 females), aged 10 days-17 years. In 3 cases the deletion was inherited (2 maternal and 1 paternal origin). Cytogenetic analysis revealed an abnormal karyotype in 2/139 cases (Klinefelter syndrome 47,XXY and 46,XX,2p+), which most likely did not contribute to the DGS/VCFS phenotype. Patients with 22q11.2 deletion exhibited facial dysmorphic features (82%), congenital heart defects (70%), immunological problems (47%), multiple congenital anomalies (64%), hypocalcemia (47%), mental retardation/behavioral problems/learning difficulties (35%), skeletal abnormalities (23%), cleft palate/velopharyngeal insufficiency (23%), seizures/hypotonia (23%) and growth retardation (12%). The clinical genetic reevaluation of 39/139 patients without 22q11.2 deletion contributed to the classification of 14 (37%) under different genetic syndromes. Conclusions: The present study emphasizes the importance of FISH technique to detect 22q11.2 deletion and the need of thorough clinical and laboratory investigation in patients referred for DG/VCFS.
1 Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital, Athens 2 Cytogenetics Laboratory, 2nd Paediatric Clinic of the University of Athens, “P. & A. Kyriakou” Children’s Hospital, Athens 3 Immunology and Histocompatibility Laboratory, “Aghia Sophia” Children’s Hospital, Athens Correspondence: Sophia Kitsiou-Tzeli Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital 115 27, ∞thens E-mail: skitsiou@med.uoa.gr Date of submission: 30-04-2004 Date of approval: 28-09-2004
Key words DGS/VCFS, FISH, 22q11.2 deletion, clinical spectrum.
Paediatriki 2005;68:61
Paediatriki Jan-Feb 05 teliko
62
10-02-05
13:36
™ÂÏ›‰·62
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
∂Ó Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË Ì ÔÏÏ·Ï‹ ÂÓÙfiÈÛË Û ¤ÊË‚Ô. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. µÚ¿ÓÔ˘1, °. ∞Ó·ÛÙ·ÛÈ¿‰Ë˜1, °. ¶·Ó·ÁȈٷÎfiÔ˘ÏÔ˜1, ∂. ¶ÂÚÁ¿ÓÙÔ˘2, ∂. ¶Ï·ÙÔÎÔ‡ÎË2, ¡. ª¤ÛÈ·˜3, ª. µ·Î¿ÎË4, ∫. ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡1 1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ªÔÓ¿‰· ∞ÈÌÔÚÚ·ÁÈÎÒÓ ¢È·ı¤ÛˆÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 ∞ÁÁÂÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô “∂Ú˘ıÚfi˜ ™Ù·˘Úfi˜” ∞ı‹Ó· 4 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· µÚ¿ÓÔ˘ ∫ÏÂÈÛfi‚˘ 20, ∆.∫. 185 39, ¶ÂÈÚ·È¿˜ ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 09-01-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 19-04-2004
¶ÂÚ›ÏË„Ë ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ¤Ê˂˘, ËÏÈΛ·˜ 12,5 ÂÙÒÓ, Ì ÂÓ Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË Û ÔÏϷϤ˜ ı¤ÛÂȘ. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ÂÓÙfiÈÛË ·ÊÔÚÔ‡Û ÛÙËÓ Î¿Ùˆ ÎÔ›ÏË Î·È ÛÙȘ ÌËÚÈ·›Â˜ ÊϤ‚˜. H ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ¯ˆÏfiÙËÙ·, ¿ÏÁÔ˜ Î·È Ô›‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ·ÚÈÛÙÂÚ‹˜ ηْ ÈÛ¯›ÔÓ ¿ÚıÚˆÛ˘ Î·È ÈÁÓ˘·Î‹˜ ¯ÒÚ·˜, Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ·fi ·Ó·ÊÂÚfiÌÂÓÔ ÙÚ·˘Ì·ÙÈÛÌfi ηٿ ÙË ‰È¿ÚÎÂÈ· ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘. ∏ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË ÂȂ‚·ÈÒıËΠ·Ú¯Èο Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (U/S Doppler) ÊÏ‚ÒÓ Î¿Ùˆ ¿ÎÚˆÓ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (C/T) ÎÔÈÏ›·˜. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÁÈ· ÚÔıÚÔÌ‚ˆÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ·ÛıÂÓ‹˜ ‹Ù·Ó ÂÙÂÚÔ˙˘ÁÒÙ˘ Ù˘ ÌÂÙ¿ÏÏ·Í˘ ÙÔ˘ ÁÔÓȉ›Ô˘ FV Leiden, ηıÒ˜ Î·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ˆ˜ ÚÔ˜ ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ MTHFR. ∏ ıÚÔÌ‚ÔÏ˘ÙÈ΋ Î·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂÚÈ΋ χÛË ÙÔ˘ ıÚfiÌ‚Ô˘ Î·È ÙËÓ Â·Ó·ÛËÚ·ÁÁÔÔ›ËÛË ÙˆÓ ·ÔÊÚ·ÁÌ¤ÓˆÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ.
§¤ÍÂȘ ÎÏÂȉȿ ºÏ‚È΋ ıÚfiÌ‚ˆÛË, ·È‰È΋ ËÏÈΛ·, ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜.
™˘ÓÙÔÌÔÁڷʛ˜ º£ INR MTHFR PS PC FV Leiden ™∂§ C/T U/S ¶∂ LMWH
ºÏ‚È΋ ıÚfiÌ‚ˆÛË International normalizing ratio Methylenetetrahydrofolate reductase ¶ÚˆÙ½ÓË S ¶ÚˆÙ½ÓË C ¶·Ú¿ÁˆÓ V Leiden ™˘ÛÙËÌ·ÙÈÎfi˜ ÂÚ˘ıËÌ·Ù҉˘ χÎÔ˜ ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÀÂÚ˯ÔÁÚ¿ÊËÌ· ¶Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹ ÷ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË
∂ÈÛ·ÁˆÁ‹ ∏ ÂÓ Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË (º£) Â›Ó·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ÂÓÙfiÈÛ‹ Ù˘ Â›Ó·È ÔÏÏ·Ï‹. ¶·Ú·Ì¤ÓÂÈ, fï˜, ˘·ÚÎÙfi˜ o ΛӉ˘ÓÔ˜, ÙÔÓ ÔÔ›Ô Ô È·ÙÚfi˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ·ÁÓÔ‹ÛÂÈ. ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ıÚfiÌ‚ˆÛ˘ Â›Ó·È ¿ÁÓˆÛÙË ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜. º·›ÓÂÙ·È, ¿ÓÙˆ˜, fiÙÈ ·ÔÙÂÏ› ÔÏ˘·Ú·ÁÔÓÙÈÎfi Ê·ÈÓfiÌÂÓÔ.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 12,5 ÂÙÒÓ, ·¯‡Û·ÚÎÔ Ì ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (µMI) 34, Ì ÂχıÂÚÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi, ÚÔÛ‹Ïı ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì ¯ˆÏfiÙËÙ·, ¿ÏÁÔ˜ Î·È Ô›‰ËÌ· Ì·Ï·¶·È‰È·ÙÚÈ΋ 2005;68:62-67
ÎÒÓ ÌÔÚ›ˆÓ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ·ÚÈÛÙÂÚ‹˜ ηْ ÈÛ¯›ÔÓ ¿ÚıÚˆÛ˘ Î·È ÈÁÓ˘·Î‹˜ ¯ÒÚ·˜. ∆· Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›ÛÙËÎ·Ó 10 Ë̤Ú˜ ÌÂÙ¿ ·fi ÙÚ·˘Ì·ÙÈÛÌfi ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÚÔÛ·ÁˆÁÔ‡ Ì˘fi˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ˘ÚÂÙfi˜, ÂÓÒ Ë ·ÚÙËÚȷ΋ ›ÂÛË Î·È ÔÈ ÛʇÍÂȘ ‹Ù·Ó ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. À‹Ú¯Â ÛÙ·ıÂÚ‹ ‰È·ÊÔÚ¿ 2 cm ÌÂٷ͇ Ù˘ ÂÚÈ̤ÙÚÔ˘ ÙˆÓ ÌËÚÒÓ, ÂÓÒ ·Ú¿ÏÏËÏ· ÙÔ ¿ÎÚÔ ÂÌÊ¿ÓÈ˙ ıÂÚÌfiÙËÙ·, ¿ÏÁÔ˜ Î·È ‰ÈfiÁΈÛË Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÈÛ¯›Ô˘. ∞Ú¯Èο, ·ÓÙÈÌÂÙˆ›ÛÙËΠÛÙËÓ OÚıԷȉÈ΋ ∫ÏÈÓÈ΋ ˆ˜ ˘ÌÂÓ›Ùȉ·, ·Ú·Ì¤ÓÔÓÙ·˜ ÎÏÈÓ‹Ú˘ Î·È Û ·ÎÈÓËÙÔÔ›ËÛË ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ÁÈ· 4 Ë̤Ú˜. ªÂÙ¿ ·fi ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô, ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ıÚfiÌ‚Ô˘ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÌËÚÈ·›· ÊϤ‚·, ÂÓÒ Ù· D-‰ÈÌÂÚ‹ (D-dimers) ‹Ù·Ó 8 Ìg/dl (º.∆. <0,5 Ìg/dl), ÁÂÁÔÓfi˜ Û˘Ì‚·Ùfi Ì ÙË ıÚfiÌ‚ˆÛË. ∫·ÙfiÈÓ ÙÔ‡ÙÔ˘, ÍÂΛÓËÛ ˷ÚÈÓÔıÂڷ›· Ì ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ë·Ú›ÓË (LMWH). §›Á˜ ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, Ë ·ÛıÂÓ‹˜ ÂÌÊ¿ÓÈÛ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ‡ÔÙË ÁÈ· Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹ (¶∂) (·ÈÊÓ›‰ÈÔ ÔÈÛıÔÛÙÂÚÓÈÎfi ¿ÏÁÔ˜, ‰‡ÛÓÔÈ·, Ù¿ÛË ÁÈ· ÏÈÔı˘Ì›·, ¤ÓÙÔÓË ÂÊ›‰ÚˆÛË). O ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓ ·Ì¤Ûˆ˜ ÚÔ˜ ÂȂ‚·›ˆÛË Èı·Ó‹˜ ¶∂, ÂÚÈÂÏ¿Ì‚·Ó ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· (∏∫°) (SI QII TIII), ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ (ηٿ ʇÛË), ·¤ÚÈ· ·›Ì·ÙÔ˜ (·Ó·Ó¢ÛÙÈ΋ ·ÏοψÛË). ∂ÈÛ‹¯ıË ÛÙË ª∂£, fiÔ˘ ¤ÁÈÓ ıÚÔÌ‚fiÏ˘ÛË (r-tPA Û ·Ú¯È΋ ‰fiÛË 0,5 mg/kg iv Î·È ÌÂÙ¿ 0,1
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·63
63
∂Ó Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË
mg/kg/h) ÁÈ· ‰‡Ô ÒÚ˜ (D-dimers: 32 Ìg/ml) ηÈ, ÛÙË Û˘Ó¤¯ÂÈ·, Ë·ÚÈÓÔıÂڷ›· (sodium heparin Û ‰fiÛË 100 U/kg/4 h) Û ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË. ∂ÓÓÈ¿ Ë̤Ú˜ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ Èı·Ó‹˜ ¶∂ Î·È ÂÓÒ Ë ·ÛıÂÓ‹˜ ›¯Â ‹‰Ë ÌÂÙ·ÊÂÚı› Û ·È‰È·ÙÚÈÎfi ÙÌ‹Ì· Î·È ‚ÚÈÛÎfiÙ·Ó ˘fi ÎÏÈÓÔÛÙ·ÙÈÛÌfi Î·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ (‚·ÚÊ·Ú›ÓË), ¤ÁÈÓ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ·ÈÌ¿ÙˆÛ˘ Ó¢ÌfiÓˆÓ Ì ∆c99m MAA, ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠÂÏ·ÊÚÒ˜ ÌÂȈ̤ÓË ‰È¿¯˘ÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙË ‚¿ÛË ÙÔ˘ ‰ÂÍÈÔ‡ Ó‡ÌÔÓ·. ™ÈÓıËÚÔÁÚ¿ÊËÌ· ·¤ÚˆÛ˘ Ó¢ÌfiÓˆÓ ‰ÂÓ ¤ÁÈÓÂ, ÏfiÁˆ Ù˘ ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ Ù˘ ÂͤٷÛ˘ (·˘ÍË̤ÓË ÎÈÓËÙÔÔ›ËÛË). ¢‡Ô ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ¿ÏÁÔ˜ Î·È ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ‰ÂÍÈÔ‡ ÚÔÛ·ÁˆÁÔ‡. ™ÙÔ U/S Doppler Ô˘ ·ÎÔÏÔ‡ıËÛÂ, ‰ÂÓ ·ÂÈÎÔÓÈ˙fiÙ·Ó ÚÔ‹ ÙfiÛÔ ÛÙËÓ ·ÚÈÛÙÂÚ‹ fiÛÔ Î·È ÛÙË ‰ÂÍÈ¿ ¤Íˆ Ï·ÁfiÓÈÔ ÊϤ‚·, ÛÙȘ ÎÔÈÓ¤˜ ÌËÚÈ·›Â˜ ÊϤ‚˜ ¿Ìʈ, ηıÒ˜ Î·È ÛÙÔ Î·ÙÒÙÂÚÔ ÙÌ‹Ì· Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È Û ‡„Ô˜ 6,5 cm ÂÚ›Ô˘ ¿Óˆ ·fi ÙÔÓ ‰È¯·ÛÌfi Ù˘. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (C/T) ÎÔÈÏ›·˜ ·ÔÎ¿Ï˘„ ıÚfiÌ‚ˆÛË Î¿Ùˆ ÎÔ›Ï˘ ÊϤ‚·˜ (∂ÈÎfiÓ· 1). ∏ ¤ÎÙ·ÛË ÙÔ˘ ıÚfiÌ‚Ô˘, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÛıÂÓ‹˜ ‚ÚÈÛÎfiÙ·Ó ˘fi ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹, ‹Ù·Ó Ë ·ÊÔÚÌ‹ ÁÈ· ‰Â‡ÙÂÚË ÂÈÛ·ÁˆÁ‹ ÛÙË ª∂£, fiÔ˘ - ·Ú¿ÏÏËÏ· Ì ÙËÓ Ë·ÚÈÓÔıÂڷ›· - ¤ÁÈÓ ÂÎ Ó¤Ô˘ ıÚÔÌ‚fiÏ˘ÛË ÁÈ· 6 ÒÚ˜, ¯ˆÚ›˜ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÈÏÔ΋ (·ÈÌÔÚÚ·Á›·). ∂›ÎÔÛÈ Ë̤Ú˜ ÌÂÙ¿ ÙÔ Û˘Ì‚¿Ó Î·È ÂÓÒ Ë ·ÛıÂÓ‹˜ ÓÔÛËÏ¢fiÙ·Ó Û ·È‰È·ÙÚÈÎfi ÙÌ‹Ì· ˘fi ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ Î·È ·ÓÙÈÌÈÎÚԂȷ΋ ıÂڷ›· ÏfiÁˆ ·Ú·ÙÂÈÓfiÌÂÓÔ˘ Â̇ÚÂÙÔ˘ (ÏfiÁˆ Ù˘ ıÚfiÌ‚ˆÛ˘), ÙÔ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ U/S Doppler ¤‰ÂÈÍ ıÚfiÌ‚ˆÛË Î¿Ùˆ ÎÔ›Ï˘, Ï·ÁÔÓ›ˆÓ Î·È ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ Ì ÌÂÚÈ΋ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ Î·È ÌÈÎÚ‹ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ‰ÂÍÈ¿˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ ÊϤ‚·˜. ∆· ›‰È· Â˘Ú‹Ì·Ù· ÂȂ‚·ÈÒıËÎ·Ó Û ‰Â‡ÙÂÚË C/T ÎÔÈÏ›·˜ (∂ÈÎfiÓ˜ 2 Î·È 3), fiÔ˘ ‹Ù·Ó ÂÌÊ·Ó‹˜ Ë ‰È‡ڢÓÛË ÙˆÓ ÎÔÈÓÒÓ Ï·ÁfiÓÈˆÓ ÊÏ‚ÒÓ (ȉ›ˆ˜ ‰Â-
∂ÈÎfiÓ· 1. (C/T ÎÔÈÏ›·˜) £ÚfiÌ‚ˆÛË Î¿Ùˆ ÎÔ›Ï˘, ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ Î·È ¤Íˆ Ï·ÁfiÓÈˆÓ ÊÏ‚ÒÓ ¿Ìʈ.
∂ÈÎfiÓ· 2. (C/T ÎÔÈÏ›·˜) £ÚfiÌ‚ˆÛË Î¿Ùˆ ÎÔ›Ï˘, Ï·ÁfiÓÈˆÓ Î·È ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ ¿Ìʈ Ì ÌÂÚÈ΋ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ Î·È ÌÈÎÚ‹ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ‰ÂÍÈ¿˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ ÊϤ‚·˜.
ÍÈ¿), ηıÒ˜ Î·È ÙˆÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ Û fiÏÔ ÙÔ Ì‹ÎÔ˜ ÙÔ˘˜ (∂ÈÎfiÓ˜ 4 Î·È 5). ∂Ó¿ÌÈÛË Ì‹Ó· ÌÂÙ¿ ÙÔ Û˘Ì‚¿Ó, Ë C/T ÎÔÈÏ›·˜ Ì ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ - ¤‰ÂÈÍ ÂÏ¿ÙÙˆÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ οو ÎÔ›Ï˘ Î·È ÙˆÓ ÂÈÔÏ‹˜ Ï·ÁÔÓ›ˆÓ ÊÏ‚ÒÓ, ÌÂ Â˘Ú‹Ì·Ù· ÌÂÚÈ΋˜ ·ӷÛËÚ·ÁÁÔÔ›ËÛ˘ Î·È ·Ó¿Ù˘ÍË ·Ú¿Ï¢Ú˘ ΢ÎÏÔÊÔÚ›·˜ ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ οو ÎÔ›Ï˘ ¤ˆ˜ οوıÂÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ (∂ÈÎfiÓ˜ 6 Î·È 7). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ º£ Î·È ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ·Ó·ÁÚ¿ÊÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ªÂÙ¿ ·fi ÁÔÓȉȷÎfi ¤ÏÂÁ¯Ô ÙˆÓ ˘fiÏÔÈˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ù˘ ·ÛıÂÓÔ‡˜ ÚԤ΢„ fiÙÈ Ë ÌËÙ¤Ú· ‹Ù·Ó ÔÌÔ˙˘ÁÒÙ˘ MTHFR Î·È ÂÙÂÚÔ˙˘ÁÒÙ˘ FV Leiden, ÂÓÒ ÔÈ ‰‡Ô ·‰ÂÏʤ˜ Ù˘ ‹Ù·Ó, ›Û˘, ÂÙÂÚÔ˙˘ÁÒÙ˜ MTHFR Î·È FV Leiden. ∏ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠˷ÚÈÓÔıÂڷ›· - Ù¤ÛÛÂÚȘ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, Ì ıÚÔÌ‚ÔÏ˘ÙÈ΋ (rtpA) Î·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ÏfiÁˆ Ù˘ Èı·Ó‹˜ ¶∂ Î·È Ù˘ ¤ÎÙ·Û˘
∂ÈÎfiÓ· 3. (U/S Doppler ÎÔÈÏ›·˜) £ÚfiÌ‚ˆÛË Î¿Ùˆ ÎÔ›Ï˘, Ï·ÁfiÓÈˆÓ Î·È ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ ¿Ìʈ Ì ÌÂÚÈ΋ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ Î·È ÌÈÎÚ‹ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Ù˘ ‰ÂÍÈ¿˜ Ì›˙ÔÓÔ˜ Û·ÊËÓÔ‡˜ ÊϤ‚·˜. ¶·È‰È·ÙÚÈ΋ 2005;68:62-67
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·64
64
ª. µÚ¿ÓÔ˘ Î·È Û˘Ó.
∂ÈÎfiÓ· 4. (C/T ÎÔÈÏ›·˜) ¢È‡ڢÓÛË ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ Û fiÏÔ ÙÔ Ì‹ÎÔ˜ ÙÔ˘˜.
ÙÔ˘ ıÚfiÌ‚Ô˘ Î·È Ì ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ∞Ú¯Èο, ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· Ó·ÙÚÈÔ‡¯Ô˜ Ë·Ú›ÓË, ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ‚·ÚÊ·Ú›ÓË, ÙËÓ ÔÔ›· Ï·Ì‚¿ÓÂÈ ¤ˆ˜ Û‹ÌÂÚ· (19 Ì‹Ó˜ ÌÂÙ¿ ÙÔ Û˘Ì‚¿Ó), ¯ˆÚ›˜ Ó· ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÈÏÔΤ˜ (·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË). ∆Ô π¡R (international normalizing ratio) ‰È·ÙËÚÂ›Ù·È ÌÂٷ͇ 2-3. ™Â η̛· Ê¿ÛË ‰ÂÓ ÎÚ›ıËΠ·Ó·Áη›· Ë ·ÁÁÂÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙÔ˘ ıÚfiÌ‚Ô˘. ∏ ·ÛıÂÓ‹˜ ÂÍ‹Ïı ÌÂÙ¿ ·fi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ‰‡Ô ÌËÓÒÓ, Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ÂÚÈ·ÙËÙÈ΋, ·‡ÚÂÙË, Ì ·ÚÙËÚȷ΋ ›ÂÛË Î·È ÛʇÍÂȘ ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ, ÂÏ¿ÙÙˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ηٿ 10 ÎÈÏ¿ ÌÂÙ¿ ·fi ˘ÔıÂÚÌȉÈ΋ ‰›·ÈÙ· Î·È ‚ÂÏÙ›ˆÛË ÙˆÓ ÙÔÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ (·ÔηٿÛÙ·ÛË Ù˘ ıÂÚÌfiÙËÙ·˜ ÙÔ˘ ÛΤÏÔ˘˜, Ù˘ ‰ÈfiÁΈÛ˘ Î·È ÙÔ˘ ¿ÏÁÔ˘˜). ™˘ÓÂÛÙ‹ıË Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ÂÙÒÓ Î·È Ë ¯ÚËÛÈÌÔÔ›ËÛË ÂȉÈÎÒÓ ÂÏ·ÛÙÈÎÒÓ Î·ÏÙÛÒÓ Î·ıËÌÂÚÈÓ¿. O ·ӤÏÂÁ¯Ô˜ - ·ÂÈÎÔÓÈÛÙÈÎfi˜ Î·È ·ÈÌ·ÙÔÏÔÁÈÎfi˜ - Á›ÓÂÙ·È Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·.
∂ÈÎfiÓ· 5. ¢È‡ڢÓÛË ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ Û fiÏÔ ÙÔ Ì‹ÎÔ˜ ÙÔ˘˜. ¶·È‰È·ÙÚÈ΋ 2005;68:62-67
∂ÈÎfiÓ· 6. (C/T ÎÔÈÏ›·˜) ∂Ï¿ÙÙˆÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ÂÈÔÏ‹˜ Ï·ÁfiÓÈˆÓ ÊÏ‚ÒÓ Î·È Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜, ÌÂ Â˘Ú‹Ì·Ù· ÌÂÚÈ΋˜ ·ӷÛËÚ·ÁÁÔÔ›ËÛ˘ Î·È ·Ó¿Ù˘ÍË ·Ú¿Ï¢Ú˘ ΢ÎÏÔÊÔÚ›·˜ ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ οو ÎÔ›Ï˘ ¤ˆ˜ οوıÂÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ.
∆ÚÂȘ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜, Û ¤Á¯ÚˆÌÔ Doppler ÊÏ‚ÒÓ Î¿Ùˆ ¿ÎÚˆÓ Û fiÚıÈ· Î·È ‡ÙÈ· ı¤ÛË Î·ıÒ˜ Î·È ÎÔÈÏ›·˜ ‰È·ÈÛÙÒıËΠÈηÓÔÔÈËÙÈÎÔ‡ ‚·ıÌÔ‡ ·ӷÛËÚ·ÁÁÔÔ›ËÛË Î¿Ùˆ ÎÔ›Ï˘, Ï·ÁÔÓ›ˆÓ Î·È ÌËÚÈ·›ˆÓ ÊÏ‚ÒÓ, ¯ˆÚ›˜ ·Ó¿ÚÎÂÈ· ÙˆÓ ‚·Ï‚›‰ˆÓ ÛÙÔ ÂÈÔÏ‹˜ ÊÏ‚ÈÎfi Û‡ÛÙËÌ· Ù˘ Ì›˙ÔÓÔ˜ Î·È ÂÏ¿ÛÛÔÓÔ˜ Û·ÊËÓÔ‡˜ ÊϤ‚·˜.
™˘˙‹ÙËÛË ∏ º£ ·ÔÙÂÏ› ÛÔ‚·Ú‹, ·ÏÏ¿ Û¿ÓÈ· ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ∂ÎÙfi˜ ·fi ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Û˘¯ÓfiÙÂÚ· ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙËÓ ÂÊ˂›· (1). ∆Ô ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ Ù˘ Û˘Ìو̷ÙÈ΋˜ º£ ÛÙ· ·È‰È¿ Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚÔ ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Ì ·Ó·ÏÔÁ›·
∂ÈÎfiÓ· 7. ∂Ï¿ÙÙˆÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ÂÈÔÏ‹˜ Ï·ÁfiÓÈˆÓ ÊÏ‚ÒÓ Î·È Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜, ÌÂ Â˘Ú‹Ì·Ù· ÌÂÚÈ΋˜ ·ӷÛËÚ·ÁÁÔÔ›ËÛ˘ Î·È ·Ó¿Ù˘ÍË ·Ú¿Ï¢Ú˘ ΢ÎÏÔÊÔÚ›·˜ ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ οو ÎÔ›Ï˘ ¤ˆ˜ οوıÂÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·65
65
∂Ó Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË
¶›Ó·Î·˜ 1. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·ÛıÂÓÔ‡˜ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ·ÁˆÁ‹˜ ∞ÈÌÔÂÙ¿ÏÈ· 260 x 109 (º.∆.: 150-400 x 109/L) ™˘ÛÙÔÏ‹ ıÚfiÌ‚Ô˘ º˘ÛÈÔÏÔÁÈ΋ ÃÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ 11’’2 (º.∆.: 11’’0-13’’0) ÃÚfiÓÔ˜ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ 27’’4 (º.∆.: 20’’0-40’’0) ÃÚfiÓÔ˜ ıÚÔÌ‚›Ó˘ 11’’3 (º.∆.: 10’’0-14’’0) πÓˆ‰ÔÁfiÓÔ 516 mg% (º.∆.: 200-400%) ¶·Ú¿ÁÔÓÙ·˜ ππ 125% (º.∆.: 60-120%) ¶·Ú¿ÁÔÓÙ·˜ VII 92% (º.∆.: 60-120%) ¶·Ú¿ÁÔÓÙ·˜ VIII >200 u/dl (º.∆.: 50-150 u/dl) ¶·Ú¿ÁÔÓÙ·˜ Ãππ 92% (º.∆.: 50-150%) ∞ÓÙÈıÚÔÌ‚›ÓË ∞∆ 107% (º.∆.: 60-120%) ¶ÚˆÙ½ÓË C (PC) 104% (º.∆.: 65-140%) ¶ÚˆÙ½ÓË S (PS) 78% (º.∆.: 65-140%) ¶Ï·ÛÌÈÓÔÁfiÓÔ 132% (º.∆.: 80-120%) D-dimers 8 Ìg/ml(º.∆.: <0,5 Ìg/ml) APCR 1,83 (º.∆.: >2,20) OÌÔ΢ÛÙ½ÓË 13,3 mmol/l (º.∆.: <10,8 mmol/l) º˘ÏÏÈÎfi Ô͇ 4,8 ng/ml (º.∆.: 3,1-12,4 ng/ml) µÈÙ·Ì›ÓË µ12 775 pg/mL (º.∆.: 223-1132 pg/mL) ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ‚2GP1 (-) ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Î·Ú‰ÈÔÏÈ›Ó˘ (-) ∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ∞ÚÓËÙÈÎfi˜ ¶ÚˆÙ½Ó˜ Ï¿ÛÌ·ÙÔ˜ º˘ÛÈÔÏÔÁÈΤ˜ £˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· ∫·Ù¿ ʇÛË ∂ÙÂÚÔ˙˘ÁÒÙ˘ ˆ˜ ÚÔ˜ ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ G1691A ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (FV Leiden) ∂ÙÂÚÔ˙˘ÁÒÙ˘ MTHFR ∞ÚÓËÙÈ΋ ÁÈ· ÌÂÙ·ÏÏ·Á̤ÓË ÚÔıÚÔÌ‚›ÓË FII20210A
5,3/10000 ÂÈÛ·ÁˆÁ¤˜ (1). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÈηÈÔÏÔÁÂ›Ù·È ÂÓ Ì¤ÚÂÈ ·fi ÙȘ ·˘ÍË̤Ó˜ ÙÈ̤˜ Ù˘ ·2 Ì·ÎÚÔÛÊ·ÈÚ›Ó˘ Î·È ÙÔ˘ ¿ıÈÎÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë ÔÔ›· ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰ËÌÈÔ˘ÚÁ›· ıÚÔÌ‚›Ó˘ ηÈ, ÂӉ¯Ô̤ӈ˜, ÙËÓ ·fiÊÚ·ÍË ÙˆÓ ·ÁÁ›ˆÓ. ∏ ıÚfiÌ‚ˆÛË ÛÙ· ·È‰È¿ ÌÔÚ› Ó· ÂΉËψı› ˆ˜ ÂÓ Ùˆ ‚¿ıÂÈ º£ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, ÙˆÓ ÓÂÊÚÈÎÒÓ, ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ, Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ Î·È ÙÔ˘ ∫¡™. ªÂÙ¿ ÙȘ ıÚÔÌ‚ÒÛÂȘ ÙÔ˘ ∫¡™, Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË ÁÈ· º£ ·ÔÙÂÏ› ÙÔ Î·ÙÒÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ (1). OÈ ÎÂÓÙÚÈÎÔ› ηıÂÙ‹Ú˜ ·ÔÙÂÏÔ‡Ó ÙÔÓ Û˘¯ÓfiÙÂÚÔ Â›ÎÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ıÚfiÌ‚ˆÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì º£ ÛÙÔ ·ÓÒÙÂÚÔ ÊÏ‚ÈÎfi Û‡ÛÙËÌ· ¤¯ÂÈ ÎÂÓÙÚÈÎfi ηıÂÙ‹Ú·. ™˘Ó‰˘·ÛÌfi˜ ÎÏËÚÔÓÔÌÈÎÒÓ ÚÔıÚÔÌ‚ˆÙÈÎÒÓ Î·È Â›ÎÙËÙˆÓ ·Ú·ÁfiÓÙˆÓ ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ÚfiÎÏËÛË º£. ∏ ·ÚÔ˘Û›· ÙˆÓ ÎÏËÚÔÓÔÌÈÎÒÓ ÚÔıÚÔÌ‚ˆÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Û ·È‰È¿ Ì ‰Â˘ÙÂÚÔ·ı‹ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË Êı¿ÓÂÈ Û ÔÛÔÛÙfi 1378% (1). ∞Ó¿ÚÎÂÈ· PC, PS, ·ÚÔ˘Û›· Ù˘ ÌÂÙ¿ÏÏ·Í˘ FII20210A (2), FV Leiden G1691A, MTHFRTT677, ›‰· ÏÈÔÚˆÙ½Ó˘ Lp(a) >30 mg/dl (7) Î·È ıÂÙÈο ·ÓÙÈʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù· (2,4,5) ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ Èo ÛËÌ·ÓÙÈÎÔ‡˜ ÚÔıÚÔÌ‚ˆÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ˘Â‡ı˘ÓÔ˘˜ ÁÈ· ÙË ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ Î·È ÙˆÓ Ë·ÙÈÎÒÓ Î·È ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ (6,7). °È· ÙÔ 95% ÙˆÓ º£ ÛÙ· ·È‰È¿ ÂÓÔ¯Ô-
ÔÈÔ‡ÓÙ·È ÛÔ‚·Ú¤˜ ÓfiÛÔÈ/ηٷÛÙ¿ÛÂȘ, fiˆ˜ ηÎÔ‹ıÂȘ, ·ÁÁÂÈ›Ùȉ˜, ·ÁÁÂȷΤ˜ ‰˘ÛϷۛ˜, ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ™E§, ·ÓÙÈʈÛÊÔÏÈȉÈÎfi Û‡Ó‰ÚÔÌÔ, Û˘ÁÁÂÓ¤˜ ηډȷÎfi ÓfiÛËÌ·, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ÛË„·ÈÌ›·, ÂÌ‚Ú˘˚Îfi˜ ‰È·‚‹Ù˘, ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· Î·È ÔÌÔ΢ÛÙÈÓ·ÈÌ›· (1,6,8). ∂ÎÏ˘ÙÈο ·›ÙÈ· ·ÔÙÂÏÔ‡Ó ÙÔ ÙÚ·‡Ì·, Ë ·¯˘Û·ÚΛ·, Ë ·Ê˘‰¿ÙˆÛË, ÔÈ ÌÂÁ¿Ï˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ (ÎÚ·ÓÈÔÙÔÌ›·, Ï··ÚÔÛÎfiËÛË, ÂÂÌ‚¿ÛÂȘ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË), Ë ıÂڷ›· Ì Lasparginase (·Ó¿ÚÎÂÈ· ∞∆) Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È ÔÈ ÎÂÓÙÚÈÎÔ› ηıÂÙ‹Ú˜ (8). O ÙÚ·˘Ì·ÙÈÛÌfi˜ ÛÙÔÓ ıÒڷη, ÙÔ ÎÚ·Ó›Ô, ÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ· Î·È ÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÂÌÊ¿ÓÈÛË º£ (9). ∂Ô̤ӈ˜, ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ÚÔÛ·ÁˆÁÔ‡ Ì˘fi˜ ÏÂÈÙÔ‡ÚÁËÛ ˆ˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË º£. O ÚfiÏÔ˜ ÙˆÓ ÁÂÓÂÙÈÎÒÓ ÚÔıÚÔÌ‚ˆÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÂÌÊ¿ÓÈÛË º£ ÛÙ· ·È‰È¿ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. ∏ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (FV Leiden) Â›Ó·È Ô ÈÔ Û˘¯Ófi˜ ÂÓÔ¯ÔÔÈËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ·ÈÊÓ›‰È·˜ ıÚfiÌ‚ˆÛ˘ ÛÙË ‚ÚÂÊÈ΋ Î·È ÚÒÙË ·È‰È΋ ËÏÈΛ· (̤ÛË ËÏÈΛ· 2 ÂÙÒÓ) Î·È ÂÌÊ·Ó›˙ÂÙ·È ˆ˜ ıÚfiÌ‚ˆÛË ˘Ï·›·˜, ÓÂÊÚÈ΋˜ Î·È ÂÁÎÂÊ·ÏÈÎÒÓ ÊÏ‚ÒÓ (7,10). ∏ ·ÛıÂÓ‹˜ ·Â‰Â›¯ıË fiÙÈ Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ Ù˘ ÌÂÙ¿ÏÏ·Í˘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÁÔÓȉ›Ô˘. ∏ ÌÂÙ¿ÏÏ·ÍË FV Leiden ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÈÔ Û˘¯Ó¿ ÛÙË Ï¢΋ Ê˘Ï‹, Û ÔÛÔÛÙfi 5,27% (ÛÙËÓ ¶·È‰È·ÙÚÈ΋ 2005;68:62-67
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·66
66
ª. µÚ¿ÓÔ˘ Î·È Û˘Ó.
∂ÏÏ¿‰· 8%). ∆Ô ÔÛÔÛÙfi ÛÙÔ˘˜ ∞ÊÚÔ·ÌÂÚÈηÓÔ‡˜ Â›Ó·È 1,23%, ÛÙÔ˘˜ ∞ÛÈ¿Ù˜ Ô˘ ηÙÔÈÎÔ‡Ó ÛÙËÓ ∞ÌÂÚÈ΋ 0,45%, ÂÓÒ ÛÙÔ˘˜ ∞ÌÂÚÈηÓÔ‡˜ 1,25% (p<0,001) (11). OÈ ÔÌÔ˙˘ÁÒÙ˜ Ù˘ ÌÂÙ¿ÏÏ·Í˘ FV Leiden ¤¯Ô˘Ó 50-100 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ º£, ÂÓÒ ÔÈ ÂÙÂÚÔ˙˘ÁÒÙ˜ 3-7 ÊÔÚ¤˜. Œ¯ÂÈ ·Ó·ÊÂÚı› Û˘Û¯¤ÙÈÛË ÙÔ˘ FV Leiden Ì ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ·fiÚÚȄ˘ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ¯ÚfiÓÈ·˜ ÏÂÈÙÔ˘ÚÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ (12). ∏ ÌÂÙ¿ÏÏ·ÍË 20210∞ ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ππ (FII20210A) ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· º£ ÛÙËÓ ÂÊ˂›· (̤ÛË ËÏÈΛ· 16 ÂÙÒÓ). ∏ ÔÌÔ΢ÛÙÈÓ·ÈÌ›· Û˘Ó·ÓÙ¿Ù·È Û ÔÛÔÛÙfi 1% ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È ÔÈ ÔÌÔ˙˘ÁÒÙ˜ Ù˘ ‰È·Ù·Ú·¯‹˜ ¤¯Ô˘Ó 2-3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ º£. O ΛӉ˘ÓÔ˜ ·˘Ùfi˜ ·˘Í¿ÓÂÈ Î·Ù¿ 10-20 ÊÔÚ¤˜, fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ Ì FV Leiden (11). ∏ ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ FV Leiden, ÂÙÂÚÔ˙˘ÁÒÙ˘ MTHFR Ì ˘ÂÚÔÌÔ΢ÛÙÈÓ·ÈÌ›· (ÎÏËÚÔÓÔÌÈÎÔ› ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜), ›¯Â ·˘ÍË̤ÓÔ˘˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘ π Î·È VIII (›ÎÙËÙÔÈ ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ) Î·È ÂÈϤÔÓ, ‹Ù·Ó ·¯‡Û·ÚÎË. ∂ÓÙ˘ˆÛÈ·Îfi, ¿ÓÙˆ˜, Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙ· ·È‰È¿ ÔÈ ÂÈÏÔΤ˜ ÙÔ˘ ÌÂÙ·ıÚÔÌ‚ˆÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (PTS) (¿ÏÁÔ˜, ÊÏ‚È΋ ·Ó¿ÚÎÂÈ·, ˘¤Ú¯ÚˆÛË ‰¤ÚÌ·ÙÔ˜) ÂÌÊ·Ó›˙ÔÓÙ·È ÎÏÈÓÈο ÌÂ Û˘¯ÓfiÙËÙ· ÌfiÓÔ 10-20%, ÂÓÒ ÔÈ ˘ÔÎÏÈÓÈΤ˜ ÂÚÈÙÒÛÂȘ ˘ÔÏÔÁ›˙ÔÓÙ·È Û ÔÛÔÛÙfi 65% (1). ∏ ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ ÂÌÊ¿ÓÈÛ fiϘ ÙȘ ÂÈÏÔΤ˜ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È. ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ º£ ÌÔÚ› Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: ·) ıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹ (rtpA) ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ıÚfiÌ‚ˆÛ˘ Î·È ‚) ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ (Ë·Ú›ÓË ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ·ÓÙÈ‚Èٷ̛Ә ∫). ∏ ÛÙÚÂÙÔÎÈÓ¿ÛË ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÛÙË º£ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (1). ™ÙËÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, Ô˘ ·ÚÔ˘Û›·Û ıÚfiÌ‚ˆÛË Û ÌÂÁ¿ÏË ¤ÎÙ·ÛË ÙÔ˘ ÊÏ‚ÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ‹‰Ë ·fi ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ, ÎÚ›ıËΠ·Ó·Áη›· Ë ÂÊ·ÚÌÔÁ‹ ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜, Ì ÛÎÔfi ÙËÓ ¿ÌÂÛË Ï‡ÛË ÙÔ˘ ıÚfiÌ‚Ô˘. ™‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ÚˆÙfiÎÔÏÏ·, Ë ·ÁˆÁ‹ Û˘Ó¯›ÛÙËΠ̠·ÓÙÈËÎÙÈο (S. Heparin, LMWHsc Î·È Warfarin p.o.), ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÚÈÔÚÈÛÙ› Ë Â¤ÎÙ·ÛË ÙÔ˘ ıÚfiÌ‚Ô˘ Î·È Ó· ÚÔÏËÊı› Ë ÂӉ¯fiÌÂÓË ¶∂, Ë ÔÔ›· ·Ú’ fiÏ· ·˘Ù¿ Û˘Ó¤‚Ë. ∏ ·ÈÙ›· Ù˘ ˘ÔÙÚÔ‹˜ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË. ∆· ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ù˘ ˘Ô‰fiÚÈ·˜ ¤Á¯˘Û˘ LMWH (ÂÒ‰˘ÓË ‰È·‰Èηۛ·, Âί˘ÌÒÛÂȘ ÛÙ· ÛËÌ›· ¤Á¯˘Û˘ Ì ·Ó¿ÏÔÁÔ ·ÈÛıËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·), Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ¯·ÌËÏ‹ Û˘ÌÌfiÚʈÛË ÙˆÓ Ó·ÚÒÓ ·ÛıÂÓÒÓ. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜, fiˆ˜ Î·È ÛÙËÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, ‰fiıËΠ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÁˆÁ‹ Ì Warfarin, Ë ÔÔ›· ¶·È‰È·ÙÚÈ΋ 2005;68:62-67
‰ÂÓ ¤¯ÂÈ Ù· ·Ú·¿Óˆ ÌÂÈÔÓÂÎÙ‹Ì·Ù·, ÂËÚ¿˙ÂÙ·È fï˜ ·fi ÙË ‰È·ÙÚÔÊ‹ (ÂÚÈÂÎÙÈÎfiÙËÙ· ÙˆÓ ÙÚÔÊÒÓ Û ‚ÈÙ·Ì›ÓË ∫), ÏÔÈÌÒÍÂȘ ‹ Ê¿Ú̷η, ÂÓÒ Ë ‰ÔÛÔÏÔÁ›· Ú˘ıÌ›˙ÂÙ·È Û‡Ìʈӷ Ì ÙËÓ ÙÈÌ‹ ÙÔ˘ π¡R (international normalizing ratio). ∏ Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, fï˜, Â›Ó·È ÈÔ ˘„ËÏ‹, ÁÂÁÔÓfi˜ ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈÎfi, ·ÊÔ‡ Ë ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Â›Ó·È ÌÂÁ¿ÏË (1). ∏ ıÂڷ›· ÚÒÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ÂÓ Ùˆ ‚¿ıÂÈ º£ Û˘Ó‹ıˆ˜ ‰È·ÚΛ 3-6 Ì‹Ó˜, fï˜ fiÙ·Ó Ë ıÚfiÌ‚ˆÛË Â›Ó·È ÂÎÙÂٷ̤ÓË Î·È Û˘Ó˘¿Ú¯Ô˘Ó ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, ¯ÔÚËÁÂ›Ù·È Â› Ì·ÎÚfiÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÚ›· ÙÔ˘ ·ÛıÂÓÔ‡˜. ™ÎÔfi˜ Ù˘ Â›Ó·È Ë ·ÔÊ˘Á‹ ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ º£. ÕÌÂÛË ÂÈÏÔ΋ Ù˘ º£ ·ÔÙÂÏ› Ë Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹. ∞ÒÙÂÚË ·ÔÙÂÏ› ÙÔ ÌÂÙ·ÊÏ‚ÈÙȉÈÎfi Û‡Ó‰ÚÔÌÔ. ™Â ÂÚ›ÙˆÛË ˘ÔÙÚÔ‹˜ ‹ ‰Â‡ÙÂÚÔ˘ ÂÂÈÛÔ‰›Ô˘ º£, ¯ÔÚËÁÂ›Ù·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ‰È¿ ‚›Ô˘. ∏ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ÂÚÈÁÚ¿ÊÂÙ·È ÁÈ·Ù› ÚÔ‚ÏËÌ¿ÙÈÛ ÙÔ˘˜ ıÂÚ¿ÔÓÙ˜ È·ÙÚÔ‡˜. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ·¯‡Û·ÚÎÔ ÎÔÚ›ÙÛÈ Ô˘ ÂÈÛ‹¯ıË, ·Ú¯Èο, ÁÈ· ‰ÈÂÚ‡ÓËÛË Ì›·˜ ·Ï‹˜ οΈÛ˘ ÛÙËÓ OÚıԷȉÈ΋ ∫ÏÈÓÈ΋, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ‰È·ÈÛÙÒıËΠfiÙÈ Â›¯Â ˘ÔÛÙ› ÂÎÙÂٷ̤ÓË ÂÓ Ùˆ ‚¿ıÂÈ º£ (‰˘Û·Ó¿ÏÔÁ· ‚·ÚÈ¿ Û ۯ¤ÛË Ì ÙËÓ ·‚Ï˯ڋ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·), Ë ÔÔ›· ˘ÔÙÚÔ›·ÛÂ Î·È Â›¯Â ÂͤÏÈÍË È‰È·›ÙÂÚ· ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡. ∂›Ó·È ۷ʤ˜ fiÙÈ Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÎfiÛÌÔ˘ Á‡Úˆ ·fi ÙÔ ÎÂÊ¿Ï·ÈÔ Ù˘ ıÚfiÌ‚ˆÛ˘ Â›Ó·È ÂӉ¯Ô̤ӈ˜ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ‚‹Ì· ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙˆÓ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙËÓ ÚfiÏË„Ë ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ ·fi ·˘Ù¿. ∂ÊfiÛÔÓ ‰È·ÈÛÙÒÓÔÓÙ·È Û˘ÁÁÂÓ›˜ ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, Ô ¤ÏÂÁ¯Ô˜ ı· Ú¤ÂÈ Ó· ·ÊÔÚ¿ Û fiÏË ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ó· ηÙ¢ı‡ÓÂÙ·È ·Ó¿ÏÔÁ·.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Chan AK, Deveber G, Monagle P, Brooker LA, Massicotte PM. Venous thrombosis in children. J Thromb Haemost 2003;1:1443-1455. 2. Simioni P, Sanson BJ, Prandoni P, Tormene D, Friederich PW, Girolami B et al. Incidence of venous thromboembolism in families with inherited thrombophilia. Thromb Haemost 1999;81:198-202. 3. Nowak-Gottl U, Schobess R, Kurnik K, Schwabe D, Fleischhack G, Junker R. Elevated lipÔprotein(a) concentration is an independent risk factor of venous thromboembolism. Blood 2002;99:3476-3477. 4. Arnout J. Antiphospholipid syndrome: diagnostic aspects of lupus anticoagulants. Thromb Haemost 2001;86:83-91. 5. Bertina RM. Genetic approach to thrombophilia. Thromb Haemost 2001;86:92-103. 6. Munchow N, Kosch A, Schobess R, Junker R, Auberger K, Nowak-Gottl U. Role of genetic prothrombotic risk factors in childhood caval vein thrombosis. Eur J Pediatr 1999;158 (Suppl 3):S109-S112.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·67
67
∂Ó Ùˆ ‚¿ıÂÈ ÊÏ‚È΋ ıÚfiÌ‚ˆÛË
7. Heller C, Schobess R, Kurnik K, Junker R, Gunther G, Kreuz W et al. Abdominal venous thrombosis in neonates and infants: role of prothrombotic risk factors - a multicentre casecontrol study. For the Childhood Thrombophilia Study Group. Br J Haematol 2000;111:534-539. 8. ∞ÚÒÓË-µÔ˘ÚÓ¿ ™. £ÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™) ‰È¿ÊÔÚ˘ ·ÈÙÈÔÏÔÁ›·˜ ÛÙ· ·È‰È¿. ª›· ÚfiÎÏËÛË ÁÈ· ÙÔ ÁÈ·ÙÚfi. ¶·È‰È·ÙÚÈ΋ 2002;65:4-8. 9. Vavilala MS, Nathens AB, Jurkovich GJ, Mackenzie E, Rivara FP. Risk factors for venous thromboembolism in pediatric trauma. J Trauma 2002;52:922-927. 10. Schobess R, Junker R, Auberger K, Munchow N, Burdach S,
Nowak-Gottl U. Factor V G1691A and prothrombin G20210A in childhood spontaneous venous thrombosis - evidence of an age-dependent thrombotic onset in carriers of factor V G1691A and prothrombin G20210A mutation. Eur J Pediatr 1999;158 (Suppl 3):S105-S108. 11. Price DT, Ridker PM. Factor V Leiden mutation and the risks for thromboembolic disease: a clinical perspective. Ann Intern Med 1997;127:895-903. 12. Hocher B, Slowinski T, Hauser I, Vetter B, Fritsche L, Bachert D et al. Association of factor V Leiden mutation with delayed graft function, acute rejection episodes and long-term graft dysfunction in kidney transplant recipients. Thromb Haemost 2002;87:194-198.
¶·È‰È·ÙÚÈ΋ 2005;68:62-67
Paediatriki Jan-Feb 05 teliko
68
10-02-05
13:36
™ÂÏ›‰·68
CASE REPORT
Deep vein thrombosis in multiple sites in an adolescent. Case report M. Vranou1, G. Anastasiadis1, G. Panagiotakopoulos1, H. Pergantou2, H. Platokouki2, N. Besias3, M. Vakaki4, K. Prountzou - Kassiou1 1 1st Paediatric Clinic, “Aghia Sophia” Children’s Hospital, Athens 2 Hemophilia and Hemostasis Unit, “Aghia Sophia” Children’s Hospital, Athens 3 Vascular Surgery Clinic, “Erythros Stavros” Hospital, Athens 4 Department of Radiology, “Aghia Sophia” Children’s Hospital, Athens Correspondence: ªaria Vranou 20 Klisovis str., 185 39, Piraeus Date of submission: 09-01-2004 Date of approval: 19-04-2004
Paediatriki 2005;68:68
Abstract The case of a girl 12.5 years old with deep vein thrombosis (DVT) in multiple sites (inferior vena cava, right and left femoral veins) is described. The patient presented with limping, pain and oedema of soft tissues in the left hip and the left poplideal region, a few days after experiencing trauma during physical exercise. Thrombosis was confirmed by triplex of veins in the lower limbs and computed tomography scan (C/T) of the abdomen. Laboratory investigation for the presence of prothrombotic factors predisposing to thrombosis revealed that the patient was heterozygote for FV Leiden and MTHFR. Thrombolytic and anticoagulant therapy resulted in partial resolution of the thrombus and recanalization of the obstructed femoral veins.
Key words Vein thrombosis, childhood, prothrombotic factors.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·69
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
69
¶ÂÚ›ÙˆÛË ·ÔÌfiÓˆÛ˘ ·‰ÂÓÔ˚Ô‡ µ1 ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Û ·È‰› ËÏÈΛ·˜ 6,5 ÂÙÒÓ Ì ÔÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ· ¶. ¶Ô˘ÏfiÔ˘ÏÔ˜, Õ. ªÂÛÛ·ÚÈÙ¿ÎË, ∫. ∫ÔÙÛÒÓ˘, ∫. ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 6,5 ÂÙÒÓ Ì ÔÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ·. ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠηٿ ·ÚÈÔ ÏfiÁÔ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ì ÙËÓ ÔÏÏ·ÏfiÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂΉËÏÒÛˆÓ, ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi Î·È ÛÙ· ȉȷ›ÙÂÚ· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ ·ÔÌfiÓˆÛË ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·‰ÂÓÔ˚Ô‡ µ1, Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ ÓfiÛÔ˘, ÌÔÚ› Ó· ÛËÌ·›ÓÂÈ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·‰ÂÓÔ˚Ô‡ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ.
AÏÏËÏÔÁÚ·Ê›·: ∫ÔÛÌ¿˜ ∫ÔÙÛÒÓ˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-01-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-11-2004
§¤ÍÂȘ ÎÏÂȉȿ OÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ·, O¢∂ª, ·‰ÂÓÔ˚fi˜, ·È‰È¿.
™˘ÓÙÔÌÔÁڷʛ˜ O¢∂ª ∂¡À ™¶ ∫¡™ MRI PCR ADEM EBV CMV ECHO HSV1 HSV2 CT HIV BCG
OÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ· ∂ÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ™ÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜ ∫ÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Magnetic resonance imagining Polymerase chain reaction Acute disseminated encephalomyelitis Epstein-Barr virus Cytomegalovirus Enteric cytopathogenic human orphan viruses Herpes simplex virus-1 Herpes simplex virus-2 Computed tomography Human immunodeficiency Bacillus Calmette-Guerin
∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ· (O¢∂ª), Â›Ó·È ÊÏÂÁÌÔÓ҉˘ ·ÔÌ˘ÂÏÈÓˆÙÈ΋ ‰È·Ù·Ú·¯‹, Ë ÔÔ›· ÚÔÛ‚¿ÏÏÂÈ Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÙËÓ ˘ÔÊÏÔÈÒ‰Ë Ï¢΋ Ô˘Û›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. H ÓfiÛÔ˜ Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜. ∏ ÂȉËÌÈÔÏÔÁ›· Ù˘ Â›Ó·È ¿ÁÓˆÛÙË Î·È Ë Â›ÙˆÛ‹ Ù˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Â›Ó·È ÂÚ›Ô˘ 4,5 ÂÚÈÙÒÛÂȘ ·Ó¿ 10.000 ÂÈÛ·ÁˆÁ¤˜ Û ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· (1,2). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ (MRI) Û˘Ì‚¿ÏÏÂÈ ·ÔÊ·ÛÈÛÙÈο ÛÙË ‰È¿ÁÓˆÛ‹ Ù˘, Ì ÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ‰È¿¯˘ÙˆÓ ·ÌÊÔÙÂÚfiÏÂ˘ÚˆÓ ·ÔÌ˘ÂÏÈÓˆÙÈÎÒÓ ‚Ï·‚ÒÓ Ù˘ Ï¢΋˜ Ô˘Û›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜, ÔÈ Ôԛ˜ Â›Ó·È È‰È·›ÙÂÚ· ÂÌÊ·Ó›˜ ÛÙȘ ∆2 ·ÎÔÏÔ˘ı›Â˜ (1,3).
∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Â›Ó·È ¿ÁÓˆÛÙË, ·Ó Î·È Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ·Ú·ÏÔÈÌÒ‰Ë ‹ ÌÂÙ·ÏÔÈÌÒ‰Ë ‰È·Ù·Ú·¯‹. ™˘¯Ó¿ ÚÔËÁÂ›Ù·È (1-2 ‚‰ÔÌ¿‰Â˜) Ù˘ ÂÈÛ‚ÔÏ‹˜ Ù˘ ÓfiÛÔ˘, ÈÔÁÂÓ‹˜ ‹ ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË ‹ ÂÌ‚ÔÏÈ·ÛÌfi˜. ¶ÔÏϤ˜ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Û˘Ó‰¤Ô˘Ó ‰È¿ÊÔÚÔ˘˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ì ÙËÓ O¢∂ª, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· Â›Ó·È ·Ôχو˜ ηٷÓÔËÙfi˜ Ô Ì˯·ÓÈÛÌfi˜ ¤Ó·Ú͢ Ù˘ ·ÔÌ˘ÂϛӈÛ˘. ¶Ôχ Û¿ÓÈ· ·Ó·Ê¤ÚÂÙ·È ·Ó›¯Ó¢ÛË ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ· ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (∂¡À) (4). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ô˘ ¤·Û¯Â ·fi O¢∂ª, ÛÙÔ ∂¡À ÙÔ˘ ÔÔ›Ô˘ ·ÓȯÓ‡ıËΠ- Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR) - ÁÂÓÂÙÈÎfi ˘ÏÈÎfi ·‰ÂÓÔ˚Ô‡ µ1, ÂÓÒ Ô ÏÔÈfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ¿ÏϘ ÏÔÈÌÒÍÂȘ ‹Ù·Ó ·ÚÓËÙÈÎfi˜.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ·ÁfiÚÈ ËÏÈΛ·˜ 6,5 ÂÙÒÓ Ô˘ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ˘ÚÂÙÔ‡ ¤ˆ˜ 40ÔC ·fi ÙÚÈË̤ÚÔ˘, Ô ÔÔ›Ô˜ Û˘Óԉ¢fiÙ·Ó ·fi Ú›ÁÔ˜, ·‰˘Ó·Ì›· ‚¿‰ÈÛ˘ Î·È Î·Ù·‚ÔÏ‹. ¢Âη¤ÓÙ Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, ›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ ‹È· Â̇ÚÂÙË ÈÔÁÂÓ‹ Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠·ÓÙÈ˘ÚÂÙÈο. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚ·. ∫·Ù¿ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÙÔ ·È‰› ‹Ù·Ó Û ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË, Ì ¤ÓÙÔÓË ˘ÓËÏ›·, ˆ¯ÚfiÙËÙ· Î·È ·˘¯ÂÓÈ΋ ‰˘Ûη̄›·. ∏ ¶·È‰È·ÙÚÈ΋ 2005;68:69-72
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·70
70
¶. ¶Ô˘ÏfiÔ˘ÏÔ˜ Î·È Û˘Ó.
ÏÔÈ‹ ηٿ Û˘ÛÙ‹Ì·Ù· ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Ë ‚˘ıÔÛÎfiËÛË ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ·Ú¯ÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: °ÂÓÈ΋ ·›Ì·ÙÔ˜: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 32400/mm3 (¶: 89%, §: 6%, ª: 2%, ƒ: 3%), ∆∫∂: ·/50 mmHg, CRP: 27 mg/L, ∂¡À: §Â˘Î¿: 480/mm3 (¶: 75%, §: 25%), χΈ̷ ∂¡À: 36,5 mg/dl, ÁÏ˘Îfi˙Ë ∂¡À: 55 mg/dl, ÁÏ˘Îfi˙Ë ÔÚÔ‡: 85 mg/dl, Á·Ï·ÎÙÈÎfi Ô͇: 10,89 mg/dl, NH3: 21 Ìg/dl, ηÏÏȤÚÁÂÈ· ∂¡À: ÛÙ›ڷ, ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ: ÛÙ›ڷ, Ô ‰Â ˘fiÏÔÈÔ˜ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. ªÂ ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ‚·ÎÙËÚȷ΋˜ Ïԛ̈͢ ÙÔ˘ ∫¡™, ¯ÔÚËÁ‹ıËΠ·Ú¯Èο ÎÂÊÙÚÈ·ÍfiÓË, ‚·ÓÎÔÌ˘Î›ÓË Î·È ‰ÂÍ·ÌÂı·˙fiÓË. ™ÙÔ ‰Â‡ÙÂÚÔ 24ˆÚÔ Ù˘ ·ÁˆÁ‹˜, ÙÔ ·È‰› ·ÚÔ˘Û›·Û ‰È·Ù·Ú·¯‹ ÛÙËÓ ÂÎÊÔÚ¿ ÙÔ˘ ÏfiÁÔ˘, ·‰˘Ó·Ì›· ÈÛÔÚÚÔ›·˜ Î·È ·Ù·ÍÈÎfi ‚¿‰ÈÛÌ·. ∏ Ì˘˚΋ ÈÛ¯‡˜ ‹Ù·Ó ÌÂȈ̤ÓË, Ù· ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÙÔ˘ Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ Ù· ÎÔÈÏȷο Î·È ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· ηٷÚÁË̤ӷ. §fiÁˆ ÙˆÓ ·ÓˆÙ¤Úˆ ¤ÁÈÓ Ӥ· ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË, Ë ÔÔ›· ¤‰ÂÈÍÂ: ÏÂ˘Î¿: 172/mm3 (¶: 52%, §: 48%), χΈ̷: <20 mg/dl, ÁÏ˘Îfi˙Ë: 78 mg/dl (ÁÏ˘Îfi˙Ë ÔÚÔ‡: 102 mg/dl). ™ÙËÓ PCR ∂¡À ·ÓȯÓ‡ıËΠÁÂÓÂÙÈÎfi ˘ÏÈÎfi ·‰ÂÓÔ˚Ô‡ ÔÌ¿‰·˜ B1, ÂÓÒ ÁÈ· EBV, CMV, HSV-1, HSV-2, ÂÓÙÂÚÔ˚Ô‡˜ Ë PCR ‹Ù·Ó ·ÚÓËÙÈ΋, ÔÏÈÁÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ∂¡À ·ÚÓËÙÈο. OÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ∂¡À Î·È ÔÚÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜, ÙÔ C3 ÔÚÔ‡ ·˘ÍË̤ÓÔ Î·È ÙÔ C4 Ê˘ÛÈÔÏÔÁÈÎfi. OÈ ÔÚÔÏÔÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÁÈ· Ì˘ÎfiÏ·ÛÌ·, Coxsackie, ECHO, Coxiella burnetti, HSV1, HSV2, CMV, EBV, Helicobacter pylori Î·È ÁÈ· ÚÈΤÙÛȘ ‹Ù·Ó ·ÚÓËÙÈΤ˜. ∆Ô ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ·ÚÔ˘Û›·˙ ‰È¿ÁÚ·ÌÌ· ÂÁÚ‹ÁÔÚÛ˘ ÂÏ·ÊÚ¿ ‚Ú·‰˘ÚÚ˘ıÌÈÎfi ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ªÂ ÙËÓ ˘Ô„›· Ù˘ ÂÁÎÂÊ·Ï›Ùȉ·˜, ÚÔÛÙ¤ıËΠÛÙË ıÂڷ›· ·Î˘ÎÏÔ‚›ÚË ÂÓ‰ÔÊÏ‚›ˆ˜. ¢‡Ô 24ˆÚ· ·ÚÁfiÙÂÚ·, ÂÂȉ‹ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ‰ÂÓ ÂÌÊ¿ÓÈ˙ ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÙÔ˘ ÂÈÎfiÓ·˜, ¤ÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (CT), Ë ÔÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ÂÁΤʷÏÔ˘, Ë ÔÔ›· ¤‰ÂÈÍ ·ıÔÏÔÁÈ΋˜ ¤ÓÙ·Û˘ Û‹Ì· (∂ÈÎfiÓ· 1) Û ¤ÏÈΘ ÙÔ˘ ÊÏÔÈÔ‡ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÌÂوȷ›Ô˘ Î·È ÙÔ˘ ‰ÂÍÈÔ‡ ‚ÚÂÁÌ·ÙÈÎÔ‡ ÏÔ‚Ô‡, ÔÈ Ôԛ˜ ÂÚÈ‚¿ÏÏÔÓÙ·Ó ·fi ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÚÈÂÛÙÈ·Îfi Ô›‰ËÌ·, ÌÂÙ¿ ‰Â ÙË ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈ΋˜ Ô˘Û›·˜ ·ÚÔ˘Û›·˙·Ó ÏÂÙÔÌËÓÈÁÁÈ΋ ÚfiÛÏË„Ë. ∂Ûٛ˜ ·ıÔÏÔÁÈÎÔ‡ Ì·ÁÓËÙÈÎÔ‡ Û‹Ì·ÙÔ˜ ˘‹Ú¯·Ó ›Û˘, ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈÛÊ·›ÚÈÔ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜. ∞˘Ù¿ Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ·ÍÈÔÏÔÁ‹ıËÎ·Ó ˆ˜ ·ÏÏÔÈÒÛÂȘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜. ∏ MRI ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡, Ô‰‹ÁËÛ·Ó ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë Ù˘ O¢∂ª. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ¯ÔÚËÁ‹ıËΠÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË 20 mg/kg ÁÈ· 4 Ë̤Ú˜. ∏ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· ‹Ù·Ó ¿ÌÂÛË, Ì ٷ¯Â›· Î·È Ï‹ÚË ·ÔηٿÛÙ·ÛË ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ Û˘Ìو̿وÓ. ∆¤ÛÛÂÚȘ Ì‹Ó˜ ÌÂÙ¿, ¤ÁÈÓ ¶·È‰È·ÙÚÈ΋ 2005;68:69-72
·ӿÏË„Ë Ù˘ MRI ÂÁΤʷÏÔ˘, Ë ÔÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ (∂ÈÎfiÓ· 2). ¢¤Î· ÔÎÙÒ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, ÙÔ ·È‰› ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ Â›Ó·È ··ÏÏ·Á̤ÓÔ ·fi Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù·.
™˘˙‹ÙËÛË ªÔÏÔÓfiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÎÏÈÓÈο ‹ ¿ÏÏ· ÎÚÈÙ‹ÚÈ· Ô˘ Ó· ‰È·ÛÊ·Ï›˙Ô˘Ó ·Ôχو˜ ÙË ‰È¿ÁÓˆÛË Ù˘ O¢∂ª, Ô ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ - Ì ‚¿ÛË ÙËÓ ÚÔËÁÔ‡ÌÂÓË ÓfiÛËÛ‹ ÙÔ˘ ·fi ÈÔÁÂÓ‹ Ïԛ̈ÍË, ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Î·È Ù· ÂÚÁ·ÛÙËÚȷο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· - ıˆڋıËΠfiÙÈ ¤·Û¯Â ·fi O¢∂ª. ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·‰ÂÓÔ˚Ô‡ µ1 ÛÙÔ ∂¡À Û˘Û¯ÂÙ›ÛÙËΠ̠ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘, ·Ó Î·È ·˘Ùfi˜ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ˘˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. O ˘ÚÂÙfi˜, Ë ˆ¯ÚfiÙËÙ·, Ë ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È Ë ÔÏÏ·ÏfiÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂΉËÏÒÛˆÓ, fiˆ˜ Ë ·˘¯ÂÓÈ΋ ‰˘Ûη̄›·, Ë ·Ê·Û›· Î·È Ë ·Ù·Í›· Ô˘ ·ÚÔ˘Û›·˙ ÙÔ ·È‰›, Â›Ó·È Ù· Û˘¯ÓfiÙÂÚ· ·Ó·ÊÂÚfiÌÂÓ· Û˘ÌÙÒÌ·Ù· Ù˘ O¢∂ª Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜. ∏ ÌÈÎÚ‹ ËÏÈΛ· Î·È Ë Ï‹Ú˘ ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË ÌÂÙ¿ ‰‡Ô ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÌÔÓÔÊ·ÛÈ΋˜ ÌÔÚÊ‹˜ Ù˘ ÓfiÛÔ˘, ·fi ÙËÓ ÔÔ›· ¤·Û¯Â ÙÔ ·È‰› (3,5,6). ∏ ·‡ÍËÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ∂¡À ÙÔ˘ ·È‰ÈÔ‡ (480/mm3) Î·È Ë ·Ô˘Û›· ÔÏÈÁÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ˘ÔÛÙËÚ›˙Ô˘Ó ÙË ‰È¿ÁÓˆÛË Ù˘ O¢∂ª, ·ÊÔ‡ Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ·Ó¢ڛÛÎÂÙ·È ÏÂÈÔ·ÙÙˆÛË ÛÙÔ ∂¡À Û ÔÛÔÛÙfi 71-75% Î·È ÔÏÈÁÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· Û ÔÛÔÛÙfi ÌfiÓÔ 6%. ∂›Û˘, ÙÔ ÂÏ·ÊÚ¿ ‚Ú·‰˘ÚÚ˘ıÌÈÎfi ÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· Â›Ó·È Û˘Ì‚·Ùfi Ì ÙË ‰È¿ÁÓˆÛË Ù˘ O¢∂ª (3,5,6). ∏ Ê˘ÛÈÔÏÔÁÈ΋ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ O¢∂ª. ™ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙȘ ∆2 ·ÎÔÏÔ˘ı›Â˜ ‰È¿¯˘Ù˜, ÔÏϷϤ˜, ·Û‡ÌÌÂÙÚ˜, ·ÌÊÔÙÂÚfiÏ¢Ú˜, ·ÔÌ˘ÂÏÈÓˆÙÈΤ˜ ‚Ï¿‚˜, ÂÓÙÔ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ÛÙË Ï¢΋ Î·È ÏÈÁfiÙÂÚÔ ÛÙË Ê·È¿ Ô˘Û›·, ÂÓÒ Ôχ Û˘¯Ó¿ Û˘ÌÌÂÙ¤¯ÂÈ Ë ·ÚÂÁÎÂÊ·Ï›‰·. ∏ ·Ô˘Û›· ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ù¤ÛÛÂÚȘ Ì‹Ó˜ ·ÚÁfiÙÂÚ· Î·È Ë ÌË ‡·ÚÍË ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ÌÂÙ¿ 1,5 ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓÈÛ¯‡Ô˘Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (3,5-7). ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ·Ú¯Èο, ÂÚÈÂÏ¿Ì‚·Ó ÙËÓ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, ÙË Ï‹„Ë Ê·Ú̿ΈÓ, ÙË ‚·ÎÙËÚȉȷ΋ ‹ ÈÔÁÂÓ‹ ÌËÓÈÁÁ›Ùȉ·, ÙËÓ ÈÔÁÂÓ‹ ÂÁÎÂÊ·Ï›Ùȉ·, ÙËÓ ÂÁοÚÛÈ· Ì˘ÂÏ›Ùȉ·, ÌÂÙ·‚ÔÏÈο Î·È ·ÁÁÂȷο ÓÔÛ‹Ì·Ù·, ÙÔ Û‡Ó‰ÚÔÌÔ Guillain-Barre Î·È Î˘Ú›ˆ˜ ÙË ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜ (™¶). ∏ ÙÂÏÂ˘Ù·›· ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿,
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·71
71
∞ÔÌfiÓˆÛË ·‰ÂÓÔ˚Ô‡ µ1 ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·
∂ÈÎfiÓ· 1. MRI ÂÁÎÂÊ¿ÏÔ˘, ÔÈ Ôԛ˜ ‰Â›¯ÓÔ˘Ó ÂÛٛ˜ ·ıÔÏÔÁÈÎÔ‡ Û‹Ì·ÙÔ˜ (‚¤ÏË) ÛÙÔÓ ÊÏÔÈfi Î·È ÙËÓ ·ÚÂÁÎÂÊ·Ï›‰·.
Ù· ÔÔ›· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÚÂÙfi, ·˘¯ÂÓÈ΋ ‰˘Ûη̄›·, ÎÂÊ·Ï·ÏÁ›· ‹ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘. ™˘Ó‹ıˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ˆ˜ ÌÔÓÔÛ˘Ìو̷ÙÈ΋ Û˘Ó‰ÚÔÌ‹, .¯. ÔÙÈ΋ Ó¢ڛÙȘ Î·È Î˘Ú›ˆ˜ Ì ˘ÔÙÚÔ¤˜. ™Â ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ O¢∂ª fiÙ·Ó ˘ÔÙÚÔÈ¿ÛÔ˘Ó ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÂÈÛ‚ÔÏ‹ Ù˘ ÓfiÛÔ˘, Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È ÛÔ‚·Ú¿ ÙÔ ÂӉ¯fiÌÂÓÔ Ù˘ ™¶. ∞ÓÙ›ıÂÙ·, ˘ÔÙÚÔ¤˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÓˆÚ›ÙÂÚ· ÙˆÓ ¤ÍÈ ÌËÓÒÓ ‹ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ Ì ÎÔÚÙÈÎÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ÔÏ˘Ê·ÛÈ΋˜ O¢∂ª. OÈ ·ÔÌ˘ÂÏÈÓˆÙÈΤ˜ ‚Ï¿‚˜ Ù˘ ™¶ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È ÌÈÎÚfiÙÂÚ˜, ÂÚÈÛÛfiÙÂÚÔ Û˘ÌÌÂÙÚÈΤ˜ Î·È ‰È·ÊÔÚÂÙÈ΋˜ ËÏÈΛ·˜, ÂÓÒ Ê·›ÓÔÓÙ·È Î·Ï‡ÙÂÚ· ÛÙȘ ∆1 ·ÎÔÏÔ˘ı›Â˜. ∏ O¢∂ª ıˆÚÂ›Ù·È ÌÂÙ·ÏÔÈÌ҉˘ ‹ ·Ú·ÏÔÈÌ҉˘ ‰ÈÂÚÁ·Û›·, Ë ÔÔ›· Èı·Ófiٷٷ ‰ÈÂÁ›ÚÂÈ
·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜, Ô‰ËÁÒÓÙ·˜ ¤ÙÛÈ Û ·ÔÌ˘ÂϛӈÛË Î‡ÙÙ·Ú· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ¿Ô„Ë ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·Ú·Ù‹ÚËÛË fiÙÈ Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙÔÓ ¯ÂÈÌÒÓ· Î·È ÙËÓ ¿ÓÔÈÍË, ÂÔ¯¤˜ ¤Í·ÚÛ˘ ÙˆÓ ÈÒÛÂˆÓ Î·È fiÙÈ Û ÔÛÔÛÙfi 75% Ù˘ ÓfiÛÔ˘ Û˘¯Ó¿ ÚÔËÁÂ›Ù·È ÈÔÁÂÓ‹˜ ‹ ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË ‹ ÂÌ‚ÔÏÈ·ÛÌfi˜. ™‡Ìʈӷ Ì ÙË ıˆڛ· ·˘Ù‹, ÚˆÙ½Ó˜ ÙˆÓ ÔÏÈÁÔ‰ÂÓ‰ÚÔ΢ÙÙ¿ÚˆÓ, .¯. Ë Ì˘ÂÏ›ÓË, ¤¯Ô˘Ó ·ÚfiÌÔÈÔ˘˜ ·ÓÙÈÁÔÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ì ‚·ÎÙ‹ÚÈ· ‹ ÂÌ‚fiÏÈ·. ŒÙÛÈ, Ë ·¿ÓÙËÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ì ·Ú·ÁˆÁ‹ ·ÓÙÈ-ÈÈÎÒÓ ‹ ·ÓÙÈ‚·ÎÙËÚÈ·ÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË Î·È ÛÙÚ¤ÊÂÙ·È Ù·˘Ùfi¯ÚÔÓ· ¤Ó·ÓÙÈ ÙÔ˘ ÂÚÈ‚Ï‹Ì·ÙÔ˜ ÙˆÓ Ó¢ÚÈÎÒÓ ÈÓÒÓ, ‰ËÏ·‰‹ Ù˘ Ì˘ÂÏ›Ó˘, Ô‰ËÁÒÓÙ·˜ Û ·ÔÌ˘ÂϛӈÛË ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (8). ∂Ì‚fiÏÈ· Ô˘ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Â›Ó·È ÙÔ BCG, Ù˘
∂ÈÎfiÓ· 2. ªRI ÂÁÎÂÊ¿ÏÔ˘ 4 Ì‹Ó˜ ÌÂÙ¿ ÙË ıÂڷ›·. ∞Ô˘Û›· ·ıÔÏÔÁÈÎÔ‡ Û‹Ì·ÙÔ˜. ¶·È‰È·ÙÚÈ΋ 2005;68:69-72
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·72
72
¶. ¶Ô˘ÏfiÔ˘ÏÔ˜ Î·È Û˘Ó.
ÈÏ·Ú¿˜, Ù˘ ÂÚ˘ıÚ¿˜, Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ ∞ Î·È C, Ù˘ È·ˆÓÈ΋˜ ÂÁÎÂÊ·Ï›Ùȉ·˜, Ù˘ ¢ÏÔÁÈ¿˜ Î·È Ù˘ χÛÛ·˜. ∞fi ÈÔ‡˜, ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ·˘ÙÔ› Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, Ù˘ ÈÏ·Ú¿˜, Ù˘ Ë·Ù›Ùȉ·˜ ∞ Î·È µ, ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚Ô‡, ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·, ÙÔ˘ HIV, Ù˘ Áڛ˘, Ù˘ ·Ú·Áڛ˘, Coxsackie, ÎÔÚˆÓ·˚fi˜, Ebstein-Barr. µ·ÎÙËÚ›‰È· Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Â›Ó·È ÙÔ Î·Ì˘ÏÔ‚·ÎÙËÚ›‰ÈÔ, Ë Û·ÏÌÔӤϷ, Ù· ¯Ï·Ì‡‰È·, ÙÔ Ì˘ÎfiÏ·ÛÌ·, ÔÈ ÚÈΤÙÛȘ, Ë ÏÂÁÈÔӤϷ, Ë ÏÂÙÔÛ›ڈÛË, Ë Borrelia burgdorferi Î.¿. (4,9,10). °ÂÓÈÎÒ˜, Ë ·ÔÌfiÓˆÛË ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ· ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ O¢∂ª Û¿ÓÈ· ·Ó·Ê¤ÚÂÙ·È (4). OÈ ·‰ÂÓÔ˚Ô› ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÛÙËÓ O¢∂ª. ™Ù· ·È‰È¿ Û˘Ó‹ıˆ˜ ÚÔÛ‚¿ÏÏÔ˘Ó ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ ÚÔηÏÒÓÙ·˜ ÂÈÂÊ˘Î›Ùȉ· Î·È ÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· ÚÔηÏÒÓÙ·˜ ΢ÛÙ›Ùȉ· Î·È ¤ÏÎË ÛÙËÓ Ô˘ÚÔÁÂÓÓËÙÈ΋ ÂÚÈÔ¯‹ (11). ™Ô‚·Ú¿ Ó¢ÚÔÏÔÁÈο Û‡Ó‰ÚÔÌ· ¤¯Ô˘Ó ·Ô‰Ôı› Û ·‰ÂÓÔ˚Ô‡˜, fiˆ˜ ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ·, Ì˘ÂÏ›Ùȉ·, ˘ÔÍ›· ÂÛÙȷ΋ ÂÁÎÂÊ·Ï›Ùȉ·, Reye-like Û‡Ó‰ÚÔÌÔ Î·È ·ÚÔ‰È΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ∂›Û˘, ÚÔÛ‚¿ÏÏÂÈ ÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÛÙÔ Ï·›ÛÈÔ ÁÂÓÈÎfiÙÂÚ˘ ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘, ȉȷÈÙ¤Úˆ˜ Û ¿ÙÔÌ· Ì ·ÓÔÛÔ·Ó¿ÚÎÂÈ·. ∏ ·ÔÌfiÓˆÛË ·‰ÂÓÔ˚Ô‡ ÔÌ¿‰·˜ µ1 Ì ÔÔÈÔÓ‰‹ÔÙ ÙÚfiÔ Û ·È‰È¿ Ì O¢∂ª, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊËÎÂ, ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. ∂›Û˘, ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘ Ó· ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ·‰ÂÓÔ˚ÒÓ Î·È ÔÈ ÔÔ›ÔÈ Ó· ÚÔηÏÔ‡Ó ·ÔÌ˘ÂϛӈÛË Û Ó¢ÚÈο ·ÙÙ·Ú· in vitro ‹ Û ÂÈÚ·Ì·Ùfi˙ˆ·. øÛÙfiÛÔ, ıˆÚÂ›Ù·È fiÙÈ ÔÈ ·‰ÂÓÔ˚Ô›, fiˆ˜ Î·È ÔÈ ¿ÏÏÔÈ ÈÔ›, ÌÔÚ› Ó· Â›Ó·È ÂÎÏ˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·ÓÔÛÔÏÔÁÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ì ÙÂÏÈ΋ ηٿÏËÍË ÙËÓ ·ÔÌ˘ÂϛӈÛË Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ∫¡™ Î·È ÙËÓ ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ O¢∂ª. OˆÛ‰‹ÔÙÂ, ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ·˘Ù‹˜ Ù˘ ·Ú·Ù‹ÚËÛ˘. ™ÙË ıÂڷ›· Ù˘ O¢∂ª ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÂÌÂÈÚÈο Ù· ÎÔÚÙÈÎÔÂȉ‹ Ì ηϿ ·ÔÙÂϤÛÌ·Ù·. ™˘ÓÈÛÙ¿Ù·È Ë IV ¯ÔÚ‹ÁËÛË ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘, Û ‰fiÛË 20-30 mg/kg/Ë̤ڷ ÁÈ· ÙÚÂȘ ¤ˆ˜ ¤ÓÙ Ë̤Ú˜, Ë ÔÔ›· ÌÔÚ› Ó· Û˘Ó¯ÈÛÙ› Ì ÙË ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙ÔÏfiÓ˘, Û ‰fiÛË 2 mg/kg/Ë̤ڷ Î·È ÛÙ·‰È·Î‹ Ì›ˆÛ‹ Ù˘ Û 4 ¤ˆ˜ 6 ‚‰ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ÚÔÙÈÌ‹ıËΠӷ ÌË Û˘Ó¯ÈÛÙ› Ë ıÂڷ›· ÌÂÙ¿ ÙËÓ IV ·ÁˆÁ‹ ‰È¿ÚÎÂÈ·˜ 5 ËÌÂÚÒÓ Ì Ú‰ÓÈ˙ÔÏfiÓË, ÏfiÁˆ Ù˘ ÂÍ·ÈÚÂÙÈ΋˜ ‚ÂÏÙ›ˆÛ˘ Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡. ∂Ó·ÏÏ·ÎÙÈΤ˜ ıÂڷ›˜, fiˆ˜ Ë ¯ÔÚ‹ÁËÛË ‰ÂÍ·ÌÂı·˙fiÓ˘ Î·È ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ‹ Ë Ï·ÛÌ·Ê·›ÚÂÛË, ¯Ú‹˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ ·ÍÈÔÏfiÁËÛ˘ (3,12). ¶·È‰È·ÙÚÈ΋ 2005;68:69-72
™˘ÌÂÚ·ÛÌ·ÙÈο, Ë O¢∂ª Â›Ó·È Û¯ÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜, ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÔ›·˜ Û˘Ì‚¿ÏÏÔ˘Ó ÙÔ ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ì ÙËÓ ÔÏÏ·ÏfiÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Î˘Ú›ˆ˜, Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ì ٷ ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ÛÙȘ ∆2 ·ÎÔÏÔ˘ı›Â˜. ∏ Ï‹Ú˘ ·Ô‰ÚÔÌ‹ ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ë ·Ô˘Û›· ˘ÔÙÚÔÒÓ Î·È Ë ÂÍ·Ê¿ÓÈÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‰È·ÊÔÚÔÔÈÔ‡Ó ÙËÓ O¢∂ª ·fi ÙË ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ › ÙÔ˘ ·ÚfiÓÙÔ˜ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋, Ì ÙÔ˘˜ ÁÂÓÂÙÈÎÔ‡˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ó· ¤¯Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ. ∏ ·Ó›¯Ó¢ÛË ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘. O ·‰ÂÓÔ˚fi˜ µ1, Ô ÔÔ›Ô˜ ·ÓȯÓ‡ıËΠÛÙÔ ∂¡À ÙÔ˘ ·ÛıÂÓÔ‡˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, ·Ó Î·È ·ÔÙÂÏ› ÙËÓ ÚÒÙË ·Ó·ÊÔÚ¿ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ıˆÚÂ›Ù·È fiÙÈ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Murthy SN, Faden HS, Cohen ME, Bakshi R. Acute disseminated encephalomyelitis in children. Pediatrics 2002;110:e21. 2. Davis LE, Booss J. Acute disseminated encephalomyelitis in children: a changing picture. Pediatr Infect Dis J 2003;22:829-831. 3. Stonehouse M, Gupte G, Wassmer E, Whitehouse WP. Acute disseminated encephalomyelitis: recognition in the hands of general paediatricians. Arch Dis Child 2003;88:122-124. 4. Yeh EA, Collins A, Cohen ME, Duffner PK, Faden H. Detection of coronavirus in the central nervous system of a child with acute disseminated encephalomyelitis. Pediatrics 2004;113:e73-76. 5. Dale RC, de Sousa C, Chong WK, Cox TC, Harding B, Neville BG. Acute disseminated encephalomyelitis, multiphasic disseminated encephalomyelitis and multiple sclerosis in children. Brain 2000:123:2407-2422. 6. Hynson JL, Kornberg AJ, Coleman LT, Shield L, Harvey AS, Kean MJ. Clinical and neuroradiologic features of acute disseminated encephalomyelitis in children. Neurology 2001;56:1308-1312. 7. Andreula CF, Recchia Luciana NMA, Milella D. Magnetic resonance imaging in the diagnosis of acute disseminated encephalomyelitis (ADEM). Int J Neuroradiol 1997;3:21-35. 8. Pohl-Koppe A, Burchett SK, Thiele EA, Hafler DA. Myelin basic protein reactive Th2 T cells are found in acute disseminated encephalomyelitis. J Neuroimmunol 1998;91:19-27. 9. Voudris KA, Vagiakou EA, Skardoutsou A. Acute disseminated encephalomyelitis associated with parainfluenza virus infection of childhood. Brain Dev 2002;24:112-114. 10. Yamamoto K, Takayanagi M, Yoshihara Y, Murata Y, Kato S, Otake M et al. Acute disseminated encephalomyelitis associated with Mycoplasma pneumoniae infection. Acta Paediatr Jpn 1996;38:46-51. 11. Straussberg R, Harel L, Levy Y, Amir J. A syndrome of transient encephalopathy associated with adenovirus infection. Pediatrics 2001;107:E69. 12. Straub J, Chofflon M, Delavelle J. Early high-dose intravenous methylprednisolone in acute disseminated encephalomyelitis: a successful recovery. Neurology 1997;49:1145-1147.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·73
CASE REPORT
73
Isolation of adenovirus B1 in the CNS in a 6.5 year-old boy with acute disseminated encephalomyelitis P. Poulopoulos, A. Messaritaki, K. Kotsonis, K. Prountzou - Kassiou
1st Paediatric Clinic, “Aghia Sophia” Children’s Hospital, Athens
Abstract The case of a 6.5 year-old boy with acute disseminated encephalomyelitis is reported. Diagnosis was mainly based on the clinical presentation, the CSF findings and the specific findings of the brain MRI. The isolation of adenovirus B1 from the CSF through the PCR technique during the acute phase of the disease, may imply the involvement of adenovirus B1 in the pathogenesis of the disease in humans.
Key words Acute disseminated encephalomyelitis, ADEM, adenovirus, children.
Correspondence: Kosmas Kotsonis 1st Paediatric Clinic, “Aghia Sophia” Children’s Hospital, Athens Date of submission: 20-01-2004 Date of approval: 15-11-2004
Paediatriki 2005;68:73
Paediatriki Jan-Feb 05 teliko
74
10-02-05
13:36
™ÂÏ›‰·74
∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
∞ÛÂÚÁ›ÏψÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ÙÚ›· ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· 1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË 2 ∞ÎÙÈÓÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ∞.¶.£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË 3 ∫¤ÓÙÚÔ ∞Ó·ÊÔÚ¿˜ ª˘ÎËÙÈ¿ÛˆÓ, π·ÙÚÈ΋ ™¯ÔÏ‹, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: º·Ó‹ ∞ı·Ó·ÛÈ¿‰Ô˘¶ÈÂÚÔÔ‡ÏÔ˘ ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ ™Ù. ∫˘ÚȷΛ‰Ë 1, ∆.∫. 546 36, £ÂÛÛ·ÏÔÓ›ÎË E-mail: atragian@hotmail.com ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-04-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-09-2004
º. ∞ı·Ó·ÛÈ¿‰Ô˘1, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜1, £. ¶··ÁˆÚÁ›Ô˘1, ª. ™Ù¿ÌÔ˘1, ∞. ¢Ú‚ÂϤÁη˜2, ∞. µÂÏÂÁÚ¿ÎË3
¶ÂÚ›ÏË„Ë OÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ì ηÎÔ‹ıË ÓÔÛ‹Ì·Ù·. OÈ ·Û¤ÚÁÈÏÏÔÈ ·ÔÙÂÏÔ‡Ó ÙË ‰Â‡ÙÂÚË ·ÈÙ›· Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜, fiˆ˜ Ù· ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ. ∏ ·ÛÂÚÁ›ÏψÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™) ·ÔÙÂÏ› ÙËÓ ÙÚ›ÙË Û˘¯ÓfiÙÂÚË ı¤ÛË ÂÓÙfiÈÛ˘ Ù˘ Ïԛ̈͢, ÌÂÙ¿ ÙËÓ Ó¢ÌÔÓÈ΋ Ïԛ̈ÍË ·fi ·Û¤ÚÁÈÏÏÔ Î·È ÙËÓ ·ÛÂÚÁ›ÏψÛË ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎfiψÓ, ÂÓÒ Û¯ÂÙ›˙ÂÙ·È Î·È Ì ˘„ËÏ‹ ıÓËÙfiÙËÙ·. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÔÈ ÂÚÈÙÒÛÂȘ ÙÚÈÒÓ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ô˘ ÂÌÊ¿ÓÈÛ·Ó ·ÛÂÚÁ›ÏψÛË ÙÔ˘ ∫¡™, ËÏÈΛ·˜ 14, 3 Î·È 2 ÂÙÒÓ, ·ÓÙ›ÛÙÔȯ·. ∫·È Ù· ÙÚ›· ·È‰È¿ ‚Ú›ÛÎÔÓÙ·Ó Û ıÂڷ›· ÂÊfi‰Ô˘ Ì ÙÔ ¯ËÌÂÈÔıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95. ∏ ˘Ô„›· Ì˘ÎËÙÈ·ÛÈ΋˜ Ïԛ̈͢ ‚·Û›ÛÙËΠÛÙ· ÎÏÈÓÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· (·Ú·ÙÂÈÓfiÌÂÓÔ˜ ˘ÚÂÙfi˜ >10 Ë̤Ú˜, ‰‡ÛÓÔÈ·, ÎÂÊ·Ï·ÏÁ›·, Ó¢ÚÔÏÔÁÈο ÛËÌ›·). ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÛÙËÓ PCR ÛÙÔÓ ÔÚfi Ô˘ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ ÛÙÔ ·›Ì· fiÏˆÓ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÂÓfi˜ ·fi ·˘ÙÔ‡˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì MRI ÙÔ˘ ∫¡™ ·ÔÎ¿Ï˘„ ÔÏϷϤ˜ ÂÛٛ˜ ÛÙÔÓ ÌÂوȷ›Ô ÏÔ‚fi Û ‰‡Ô ·È‰È¿ Î·È ÙËÓ ·ÚÔ˘Û›· ‚Ï¿‚˘ ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡ Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË Î·È Â·ÎfiÏÔ˘ıÔ Ô›‰ËÌ· ÛÙÔ ÙÚ›ÙÔ. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ¤Ï·‚·Ó ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹ Ì ÏÈÔÛˆÌÈ΋ ·ÌÊÔÙÂÚÈΛÓË µ ÁÈ· 4, 12 Î·È 8 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ™Â Ù·ÎÙÈÎfi ·ӤÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠ‚ÂÏÙ›ˆÛË ÙfiÛÔ ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ fiÛÔ Î·È ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û 2 ·È‰È¿ Î·È ¤ÁÈÓ ‰È·ÎÔ‹ Ù˘ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜. ∆Ô ÙÚ›ÙÔ ·È‰› η٤ÏËÍ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Û‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë ·ÛÂÚÁ›ÏψÛË ÙÔ˘ ∫¡™ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ. ∏ ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ıÂڷ›·˜ Î·È Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÌÔÚÔ‡Ó Ó· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜.
§¤ÍÂȘ ÎÏÂȉȿ AÛÂÚÁ›ÏψÛË ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ·È‰È΋ ËÏÈΛ·.
∂ÈÛ·ÁˆÁ‹ OÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ì ηÎÔ‹ıË ÓÔÛ‹Ì·Ù·. OÈ Î˘ÚÈfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ÏÔÈÌÒÍÂȘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ›ӷÈ: ·) Ô ‚·ıÌfi˜ Î·È Ë ‰È¿ÚÎÂÈ· Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË ¯ËÌÂÈÔıÂڷ›·, ‚) Ë ‰È·Ù·Ú·¯‹ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜, Á) Ë ‰È·Ù·Ú·¯‹ Ù˘ ¯˘ÌÈ΋˜ ·ÓÔÛ›·˜, ‰) ÔÈ ‚Ï¿‚˜ ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ÊÚ·ÁÌÒÓ Î·È Â) ÔÈ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ (ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ΢ÙÙ·ÚÔÛÙ·ÙÈο, ·ÎÙÈÓÔ‚ÔÏ›·) (1). O Aspergillus spp. ·ÔÙÂÏ› ÙÔ ‰Â‡ÙÂÚÔ ·›ÙÈÔ Ì˘ÎËÙÈ¿Ûˆ˜, ÌÂÙ¿ ÙËÓ Candida, Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜, fiˆ˜ Ù· ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ·fi ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ (2). O Aspergillus fumigatus Â›Ó·È ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙÔ ¶·È‰È·ÙÚÈ΋ 2005;68:74-78
80% ÙˆÓ ÂÓ Ùˆ ‚¿ıÂÈ ˘ÊÔÌ˘ÎËÙÈ¿ÛˆÓ, ÂÓÒ Ô Aspergillus flavus ÚÔηÏ› Û˘¯ÓfiÙÂÚ· ÏÔÈÌÒÍÂȘ Ù˘ ÚÈÓfi˜ Î·È ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎfiψÓ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·¤‰ÂÈÍ·Ó fiÙÈ Ë ·ÛÂÚÁ›ÏψÛË ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ıÓËÙfiÙËÙ·˜ Û˘ÁÎÚÈÙÈο Ì ÙËÓ Î·ÓÙÈÓÙ›·ÛË (2,3). ∏ Ó¢ÌÔÓÈ΋ Ïԛ̈ÍË ·fi ·Û¤ÚÁÈÏÏÔ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË, Ì ‰Â‡ÙÂÚË ÙËÓ ·ÛÂÚÁ›ÏψÛË ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎfiψÓ. ∏ ·ÛÂÚÁ›ÏψÛË ÙÔ˘ ∫¡™ ·ÔÙÂÏ› ÙËÓ ÙÚ›ÙË Û˘¯ÓfiÙÂÚË ı¤ÛË ÂÓÙfiÈÛ˘ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ˘„ËÏ‹ ıÓËÙfiÙËÙ·, Ô˘ ÏËÛÈ¿˙ÂÈ ÙÔ 85-90% (3,4). ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÙÚÂȘ ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§), ËÏÈΛ·˜ 14, 3 Î·È 2 ÂÙÒÓ ·ÓÙ›ÛÙÔȯ·, Ô˘ ÂÌÊ¿ÓÈÛ·Ó ·ÛÂÚÁ›ÏψÛË ÙÔ˘ ∫¡™. ∫·È Ù· ÙÚ›· ·È‰È¿ ‚Ú›ÛÎÔÓÙ·Ó Û ıÂڷ›· ÂÊfi‰Ô˘ Ì ÙÔ ¯ËÌÂÈÔıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALLBFM ’95.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·75
75
∞ÛÂÚÁ›ÏψÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜
¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË ÚÒÙË ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 14 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ·Á΢ÙÙ·ÚÔÂÓ›·˜. ªÂ ‚¿ÛË Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Î·È ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi Î·È ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ O§§ Î·È ¿Ú¯ÈÛ ıÂڷ›· Ì ÙÔ ¯ËÌÂÈÔıÂڷ¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALLBFM ’95. ¢‡Ô Ì‹Ó˜ ·ÚÁfiÙÂÚ·, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÂÂÈÛfi‰ÈÔ Â̇ÚÂÙ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ <500/mm3) ‰È¿ÚÎÂÈ·˜ >10 ËÌÂÚÒÓ. ∏ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ¯·Ú·ÎÙËÚ›ÛÙËΠ·fi ˘„ËÏ‹ ˘ÚÂÙÈ΋ ΛÓËÛË (ıÂÚÌÔÎÚ·Û›· >39ÔC), ‰‡ÛÓÔÈ·, ıˆÚ·ÎÈÎfi ¿ÏÁÔ˜, ¤ÓÙÔÓË ÎÂÊ·Ï·ÏÁ›· Î·È Â̤ÙÔ˘˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠ̠MRI ÙÔ˘ ∫¡™ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÂÛÙȷ΋˜ ‚Ï¿‚˘ ÛÙË ‰ÂÍÈ¿ ÌÂوȷ›· ¯ÒÚ·, Ô˘ ·ÚÔ˘Û›·˙ ÛÙÈÎÙfi ÂÌÏÔ˘ÙÈÛÌfi (∂ÈÎfiÓ· 1), ÂÓÒ Ë PCR ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ ÛÙÔ ·›Ì·. ∆Ô ·È‰› ¤Ï·‚ ·ÁˆÁ‹ Ì ÏÈÔÛˆÌÈ΋ ·ÌÊÔÙÂÚÈΛÓË µ. ∆ÚÂȘ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜, ÙÔ ÎÔÚ›ÙÛÈ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™Â Ù·ÎÙÈÎfi ·ӤÏÂÁ¯Ô Ì MRI ÂÁÎÂÊ¿ÏÔ˘, ‰È·ÈÛÙÒıËΠ·Ô˘Û›· ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. ŒÁÈÓ ‰È·ÎÔ‹ Ù˘ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜, ·ÏÏ¿ 10 Ë̤Ú˜ ·ÚÁfiÙÂÚ· Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÙËÓ ·Ú¯È΋ Û˘Ìو̷ÙÔÏÔÁ›· (˘ÚÂÙfi˜, ‰‡ÛÓÔÈ·, ıˆÚ·ÎÈÎfi ¿ÏÁÔ˜). ∆¤ıËΠÂÎ Ó¤Ô˘ Û ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹, fï˜ ÛÙË Û˘Ó¤¯ÂÈ·, ÏfiÁˆ Âȉ›ӈÛ˘ Ù˘ ÎÏÈÓÈ΋˜ ηٿÛÙ·Û˘, ‰È·ÎÔÌ›ÛÙËΠÛÙË ª∂¡ ¶·›‰ˆÓ, fiÔ˘ η٤ÏËÍ 10 Ë̤Ú˜ ·ÚÁfiÙÂÚ·.
∂ÈÎfiÓ· 1. ¶·ÚÔ˘Û›· ÂÛÙȷ΋˜ ÌÔÓ‹ÚÔ˘˜ ‚Ï¿‚˘ ÌÂوȷ›· ‰ÂÍÈ¿ Ì ÛÙÈÎÙfi ÂÌÏÔ˘ÙÈÛÌfi.
¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 2 ÂÙÒÓ, Ì ۇӉÚÔÌÔ Down, ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ·Ó·ÈÌ›·˜, ıÚÔÌ‚ÔÂÓ›·˜ Î·È ˘ÚÂÙÔ‡. ∞fi ÙÔÓ ¤ÏÂÁ¯Ô Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎÂ, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË O§§ Î·È ¿Ú¯ÈÛ ıÂڷ›· Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ê¿Û˘ ÂÊfi‰Ô˘, ·ÚÔ˘Û›·Û ÂÂÈÛfi‰ÈÔ Â̇ÚÂÙ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ‰È¿ÚÎÂÈ·˜ >10 ËÌÂÚÒÓ, Â̤ÙÔ˘˜ Î·È ÎÂÊ·Ï·ÏÁ›·. ∞fi ÙÔÓ ¤ÏÂÁ¯Ô Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠ٤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ·ÛÂÚÁ›ÏψÛ˘ (‡ÚÂÛË ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ Ì PCR ÛÙÔ ·›Ì· Î·È ÛÙÔ ∂¡À). O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì MRI ÙÔ˘ ∫¡™ ·ÔÎ¿Ï˘„ ‰È·Ù·Ú·¯‹ ÙˆÓ ‚·ÛÈÎÒÓ ÁÚ·ÌÌÒÓ Ù˘ ‚¿Û˘ ÙÔ˘ ÎÚ·Ó›Ô˘, ·ÚÔ˘Û›· ÁÏÔȈÙÈ΋˜ ÂÛÙ›·˜ ÛÙË Á¤Ê˘Ú· ÎÂÓÙÚÈο Î·È ÛÙÔÓ ÚÔÌ‹ÎË Ì˘ÂÏfi Î·È ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÔÛÙËÌ·Ù›ˆÓ ¢ηÈÚȷ΋˜ Ïԛ̈͢ ÛÙ· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· ¿Ìʈ (∂ÈÎfiÓ˜ 2, 3, 4). ∆Ô ·È‰› Ù¤ıËΠ۠·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹ Ì ÏÈÔÛˆÌÈ΋ ·ÌÊÔÙÂÚÈΛÓË µ, Ë ÔÔ›· Û˘Ó¯›ÛÙËΠÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 8 ÌËÓÒÓ, ̤¯ÚÈ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÙËÓ Ï‹ÚË ‡ÊÂÛË Ù˘ ÎÏÈÓÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜. ™‹ÌÂÚ·, ÙÔ ÎÔÚ›ÙÛÈ ‚Ú›ÛÎÂÙ·È Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ·ÎÔÏÔ˘ı› ÙË Ê¿ÛË Û˘ÓÙ‹ÚËÛ˘ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘. ¶ÂÚ›ÙˆÛË ÙÚ›ÙË ∞ÁfiÚÈ ËÏÈΛ·˜ 3 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ˘ÚÂÙÔ‡ Î·È ·Á΢ÙÙ·ÚÔÂÓ›·˜. ªÂ ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎÂ, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ O§§ Î·È ¿Ú¯ÈÛ ıÂڷ›· Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95. ŒÓ·Ó Ì‹Ó· ·ÚÁfiÙÂÚ·, Ô ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÂÂÈÛfi‰ÈÔ Â̇ÚÂÙ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î·È Û˘Ìو̷ÙÔÏÔÁ›· ·fiÊڷ͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. §fiÁˆ Ù˘ ·Ú¿Ù·Û˘ Ù˘ Â̇ÚÂÙ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, ¤Ï·‚ ÂÌÂÈÚÈ΋ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ¯ËÌÂÈÔÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹ Ì ÏÈÔÛˆÌÈ΋ ·ÌÊÔÙÂÚÈΛÓË µ. ∏ ‰È¿ÁÓˆÛË Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·ÛÂÚÁ›ÏψÛ˘ Ù¤ıËΠ̠‚¿ÛË Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ CT ıÒÚ·ÎÔ˜ Î·È Ù˘ MRI ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ ›Û˘ Î·È Ù˘ PCR, Ë ÔÔ›· ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ ÛÙÔ ·›Ì·. ∏ MRI ÂÁÎÂÊ¿ÏÔ˘ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÂÛÙ›·˜ Ì ‰·ÎÙ˘ÏÈÔÂȉ‹ ÂÌÏÔ˘ÙÈÛÌfi ÛÙÔÓ ıfiÏÔ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ‚ÚÂÁÌ·ÙÈÎÔ‡ ÏÔ‚Ô‡ (ÂÓÙfiÈÛË ·ÛÂÚÁÈÏÏÒÌ·ÙÔ˜ ÛÙÔ ÂÁÎÂÊ·ÏÈÎfi ·Ú¤Á¯˘Ì·) (∂ÈÎfiÓ· 5). ™Â Ù·ÎÙÈÎÔ‡˜ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˘˜ ·ӤÏÂÁ¯Ô˘˜ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó Î¿ı 2 Ì‹Ó˜, ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ‡ÊÂÛË Ù˘ ÎÏÈÓÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ - Ô‰‹ÁËÛ ÛÙË ‰È·ÎÔ‹ Ù˘ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜ 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍ‹ Ù˘. ∆Ô ·È‰›, Û‹ÌÂÚ·, ¤¯ÂÈ ÔÏÔÎÏËÚÒÛÂÈ ÙË ¯ËÌÂÈÔıÂڷ›· ÂÊfi‰Ô˘ Î·È ‚Ú›ÛÎÂÙ·È ÛÙË Ê¿ÛË Û˘ÓÙ‹ÚËÛ˘. ¶·È‰È·ÙÚÈ΋ 2005;68:74-78
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·76
76
º. ∞ı·Ó·ÛÈ¿‰Ô˘ Î·È Û˘Ó.
∂ÈÎfiÓ˜ 2, 3, 4. ¶·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÔÛÙËÌ·Ù›ˆÓ ¢ηÈÚȷ΋˜ Ïԛ̈͢ ÛÙ· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· ¿Ìʈ.
™˘˙‹ÙËÛË OÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ, ȉȷ›ÙÂÚ· ÌÂÙ¿ ÙËÓ Â˘Ú›· ·Ô‰Ô¯‹ Î·È ¯Ú‹ÛË Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÓÙȶ·È‰È·ÙÚÈ΋ 2005;68:74-78
ÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜, Ô˘ ‚ÂÏÙ›ˆÛ ÛËÌ·ÓÙÈο ÙËÓ ÂÈ‚›ˆÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ. ∞Ú¯Èο, Ë Candida ·ÔÙÂÏÔ‡Û ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒ͈Ó. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, fï˜, ¿ÏÏÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙË Û˘Ó¯‹ ·‡ÍËÛË ·˘ÙÒÓ ÙˆÓ ÏÔÈÌÒ͈Ó, Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Ô ·Û¤ÚÁÈÏÏÔ˜, ÏfiÁˆ Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ Ì ÙËÓ ÔÔ›· ηٷÁÚ¿ÊÂÙ·È (2,3). ∏ ÚÒÙË ÂÚ›ÙˆÛË Û˘ÛÙËÌ·ÙÈ΋˜ ·ÛÂÚÁ›ÏψÛ˘ Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È ÙÔ 1953, Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË (5). ¶·Ú¿ ÙËÓ ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙfiÛÔ ÛÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘, Ë Û˘ÛÙËÌ·ÙÈ΋ ·ÛÂÚÁ›ÏψÛË Û˘Ó¯›˙ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· Ó· ·ÔÙÂÏ› Ïԛ̈ÍË ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ (3,6). ∏ ·ÛÂÚÁ›ÏψÛË ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÛÙÔ˘˜ Ô˘‰ÂÙÂÚÔÂÓÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È È‰È·›ÙÂÚ· Û ÂΛÓÔ˘˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, fiˆ˜ Ù· ·È‰È¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ (5,7). ™Â ÚfiÛÊ·Ù˜ ÌÂϤÙ˜, Ë Û˘¯ÓfiÙËÙ· Ù˘ ·ÛÂÚÁ›ÏψÛ˘ Û ·ÛıÂÓ›˜ Ì ÔÍ›· Ï¢¯·ÈÌ›· ÛÙË Ê¿ÛË ÂÊfi‰Ô˘ Ù˘ ıÂڷ›·˜, fiˆ˜ ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 20-40% (3,7). ∆Ô Û˘¯ÓfiÙÂÚÔ ·ıÔÁfiÓÔ Ô˘ ·ÔÌÔÓÒÓÂÙ·È Â›Ó·È Ô Aspergillus fumigatus. ÕÏÏ· ·ıÔÁfiÓ· ›‰Ë ÁÈ· ÙÔÓ ¿ÓıÚˆÔ Â›Ó·È Ô A. terreus, Ô A. flavus, Ô A. niger Î·È Ô ∞. nidulans. ∏ Ïԛ̈ÍË ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÂÈÛÓÔ‹ ÛfiÚˆÓ Ô˘ ·ÔÈΛ˙Ô˘Ó ÙÔ˘˜ ·Ú·ÚÚ›ÓÈÔ˘˜ ÎfiÏÔ˘˜ Î·È ÙÔ˘˜ Ó‡ÌÔÓ˜. O ¯ÒÚÔ˜ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ËÁ‹ ÌÈÎÚÔÂȉËÌÈÒÓ ·ÛÂÚÁ›ÏψÛ˘, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ Ôԛ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÎÙ¤ÏÂÛË ÔÈÎÔ‰ÔÌÈÎÒÓ ¤ÚÁˆÓ ̤۷ ‹ ÎÔÓÙ¿ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∞fi ÌÂϤÙ˜ ÚÔ·ÙÂÈ fiÙÈ Ë Û˘ÁΤÓÙÚˆÛË ÛfiÚˆÓ ·Û¤ÚÁÈÏÏÔ˘ ·˘Í¿ÓÂÙ·È, fiÛÔ ÈÔ ÎÔÓÙ¿ ÂÎÙÂÏÔ‡ÓÙ·È ÔÈÎÔ‰ÔÌÈΤ˜ ÂÚÁ·Û›Â˜ ÛÙ· ÙÌ‹Ì·Ù· ÓÔÛËÏ›·˜ ·ÓÔÛÔηÙÂÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ (8). ∂ÈϤÔÓ, ·Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÂΉ‹ÏˆÛ˘ Ù˘ ·ÛÂÚÁ›ÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÂÎÙÂÏÔ‡ÓÙ·Ó ÔÈÎÔ‰ÔÌÈΤ˜ ÂÚÁ·Û›Â˜ ÛÙÔÓ ¯ÒÚÔ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘, ÏËÛ›ÔÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ∞Ã∂¶∞. O Ó‡ÌÔÓ·˜ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË Ù˘ Ïԛ̈͢, Û ÔÛÔÛÙfi Ô˘ ÏËÛÈ¿˙ÂÈ ÙÔ 70%, ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ÙÔ˘˜ ·Ú·ÚÚ›ÓÈÔ˘˜ ÎfiÏÔ˘˜ (15%) Î·È ÙÔ ∫¡™ (10-15%) (3). ∞fi ‰Â‰Ô̤ӷ ÌÂϤÙ˘ Û 66 ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ‰ÈËıËÙÈ΋ ·ÛÂÚÁ›ÏψÛË Ê·›ÓÂÙ·È fiÙÈ Ë ıÓËÙfiÙËÙ· ·ÁÁ›˙ÂÈ ÙÔ 90% ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÓÙfiÈÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔ ∫¡™, ÂÓÒ Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ Â›Ó·È Î·Ï‡ÙÂÚ· fiÙ·Ó Ë Ïԛ̈ÍË ÂÓÙÔ›˙ÂÙ·È ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ‹ ÛÙÔ˘˜ ·Ú·ÚÚ›ÓÈÔ˘˜ ÎfiÏÔ˘˜ (70% Î·È 60%, ·ÓÙ›ÛÙÔȯ·) (3,7). ∆· Û˘ÌÙÒÌ·Ù· Î·È Ù· ÛËÌ›· Ô˘
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·77
77
∞ÛÂÚÁ›ÏψÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜
∂ÈÎfiÓ· 5. ¶·ÚÔ˘Û›· ÂÛÙ›·˜ Ì ‰·ÎÙ˘ÏÈÔÂȉ‹ ÂÌÏÔ˘ÙÈÛÌfi ÛÙÔÓ ıfiÏÔ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ‚ÚÂÁÌ·ÙÈÎÔ‡ ÏÔ‚Ô‡.
Û˘¯ÓfiÙÂÚ· ·Ó·Ê¤ÚÔÓÙ·È Û ÂÚÈÙÒÛÂȘ ÂÓÙfiÈÛ˘ Ù˘ ‰ÈËıËÙÈ΋˜ ·ÛÂÚÁ›ÏψÛ˘ ÛÙÔ ∫¡™ Â›Ó·È Ë ÎÂÊ·Ï·ÏÁ›·, Ù· ÂÛÙȷο Ó¢ÚÔÏÔÁÈο Â˘Ú‹Ì·Ù·, Ô Ï‹ı·ÚÁÔ˜, ÔÈ ¤ÌÂÙÔÈ Î·È Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘, Ù· ÔÔ›· ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ·ÚÔ˘Û›·˙·Ó Î·È ÔÈ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÂÎÙfi˜ ÙÔ˘ Ï‹ı·ÚÁÔ˘, Ô˘ fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ·Ú·ÙËÚÂ›Ù·È Û ÂÚÈÙÒÛÂȘ ÔÏÏ·ÏÒÓ Î·È ÌÂÁ¿ÏˆÓ ÂÓÙÔ›ÛÂˆÓ (3). ∏ ‰È¿ÁÓˆÛË Ù˘ ·ÛÂÚÁ›ÏψÛ˘ ÙÔ˘ ∫¡™ ‚·Û›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ÙfiÛÔ ÙÔ˘ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ fiÛÔ Î·È ÙÔ˘ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘. ∏ ˘Ô„›· Ù˘ Ïԛ̈͢ Ù›ıÂÙ·È ·fi ÙË Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ú·ÙÂٷ̤ÓË Â̇ÚÂÙË Ô˘‰ÂÙÂÚÔÂÓ›·. ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ Ïԛ̈͢ ·fi ·Û¤ÚÁÈÏÏÔ, Ë ·Ô˘Û›· Ì›·˜ “ȉ·ÓÈ΋˜” ÂÚÁ·ÛÙËÚȷ΋˜ ÂͤٷÛ˘ ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ô‰ËÁ› ÛÙË ‰ÈÂÓ¤ÚÁÂÈ· ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ì MRI ÂÁÎÂÊ¿ÏÔ˘, Ì ÛÙfi¯Ô fi¯È ÌfiÓÔ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ¤ÎÙ·Û˘ Î·È Ù˘ ı¤Û˘ Ù˘ ‚Ï¿‚˘, ·ÏÏ¿ Î·È Ù˘ ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ‰È¿ÁÓˆÛ˘ (3). ªÂ ÙËÓ MRI ÂÁÎÂÊ¿ÏÔ˘ ·ÔηχÙÂÙ·È Û˘¯ÓfiÙÂÚ· Ë ·ÚÔ˘Û›· ÌÔÓ‹ÚˆÓ ‹ ÔÏÏ·ÏÒÓ ÂÛÙÈÒÓ Ì ÛÙÈÎÙfi ÂÌÏÔ˘ÙÈÛÌfi (3). ™·ÓÈfiÙÂÚ· Â˘Ú‹Ì·Ù· ·fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Û ·È‰È¿ Ì ·ÛÂÚÁ›ÏψÛË ∫¡™ ·ÔÙÂÏÔ‡Ó Ë ·ÚÔ˘Û›· ıÚÔÌ‚ˆÙÈÎÒÓ ÂÛÙÈÒÓ, ÂÌÊÚ¿ÎÙˆÓ Î·È Ô Û¯ËÌ·ÙÈÛÌfi˜ ·ÔÛÙËÌ¿ÙˆÓ (3,4). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë MRI ·ÔÎ¿Ï˘„ ÙËÓ ‡·ÚÍË ÔÏÏ·ÏÒÓ ÂÛÙÈÒÓ Û ‰‡Ô ·fi ·˘ÙÔ‡˜ Î·È ÙËÓ ·ÚÔ˘Û›· ÌÔÓ‹ÚÔ˘˜ ·ÔÛÙËÌ·ÙÈ΋˜ ‚Ï¿‚˘ ÛÙÔÓ ÙÚ›ÙÔ, fiϘ ÂÓ‰ÂÈÎÙÈΤ˜ Ïԛ̈͢ ·fi ·Û¤ÚÁÈÏÏÔ. ∞fi Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ÚÔ·ÙÂÈ fiÙÈ Ë ·Ó‡ÚÂÛË ÙÔ˘ ̇ÎËÙ· Û ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ·ÔÙÂÏ› ÙÔ ‚¤‚·ÈÔ ÂÚÁ·ÛÙËÚÈ·Îfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ Ïԛ̈͢. øÛÙfiÛÔ, Ë
·ÔÌfiÓˆÛ‹ ÙÔ˘ ·fi ˘ÏÈÎfi ·ÈÌÔηÏÏȤÚÁÂÈ·˜ Â›Ó·È ‰‡ÛÎÔÏË Î·È Û˘Ó‹ıˆ˜ ·Ô‚·›ÓÂÈ ·ÚÓËÙÈ΋, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó¿Ù˘ÍË - Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ó¤ˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· ÙËÓ ·ÔÌfiÓˆÛË ÙˆÓ ·Û¤ÚÁÈÏÏˆÓ Û ‚ÈÔÏÔÁÈο ˘ÁÚ¿ ÙÔ˘ ÛÒÌ·ÙÔ˜. ∂ÈϤÔÓ, Û˘¯Ó¿ ÔÈ ·ÛıÂÓ›˜ Ì ˘Ô„›· Ì˘ÎËÙÈ·ÛÈ΋˜ Ïԛ̈͢ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÂÌ‚·ÙÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ì ÛÎÔfi ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ̇ÎËÙ· ·fi ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ˘ÏÈÎfi, Ù¯ÓÈ΋ Ô˘ ·ÔʇÁÂÙ·È ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∞ÓÙ›ıÂÙ·, ÛÙ· ·È‰È¿ Û˘Ó‹ıˆ˜ ÂÈϤÁÂÙ·È Ë ÙÂÎÌËÚ›ˆÛË Ù˘ Ïԛ̈͢ Ì Ù¯ÓÈΤ˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ (·Ó‡ÚÂÛË ÙÔ˘ Ì˘ÎËÙÈ·ÛÈÎÔ‡ DNA Ì ̤ıÔ‰Ô PCR), ·Ó·˙‹ÙËÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ Ì ̤ıÔ‰Ô ELISA ‹, Ù¤ÏÔ˜, Ì ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ galactomannan, Ì›· ÚfiÛÊ·ÙË Î·È ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË Ì¤ıÔ‰Ô˜ (912). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë ÙÂÎÌËÚ›ˆÛË Ù˘ ·ÛÂÚÁ›ÏψÛ˘ ¤ÁÈÓ Ì ÙËÓ ·Ó‡ÚÂÛË ÙÔ˘ DNA ÙÔ˘ ·Û¤ÚÁÈÏÏÔ˘ Ì Ù¯ÓÈ΋ PCR, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ‹ ¢·ÈÛıËÛ›· (100%) Î·È ÈηÓÔÔÈËÙÈ΋ ÂȉÈÎfiÙËÙ· (60-80%) (9,11-14). ∏ ÂͤٷÛË ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙË Û˘Ó¤¯ÂÈ· Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ıÂڷ›· ηٿ ÙËÓ ÂÍÂÏÈÎÙÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘, fiˆ˜ ˘ÔÛÙËÚ›˙ÂÙ·È Î·È ·fi Ù· ‰Â‰Ô̤ӷ ¿ÏÏˆÓ ÌÂÏÂÙÒÓ (11-13). ∂Ô̤ӈ˜, Ë ·Ô˘Û›· Ì›·˜ “ȉ·ÓÈ΋˜” ÂÚÁ·ÛÙËÚȷ΋˜ ÂͤٷÛ˘ ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ Ïԛ̈͢ ·fi ·Û¤ÚÁÈÏÏÔ, ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙË ı¤ÛÈÛË ‰ÈÂıÓÒÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÎÚÈÙËÚ›ˆÓ, ‚¿ÛÂÈ ÙˆÓ ÔÔ›ˆÓ Ë ‰È¿ÁÓˆÛË Ù˘ ·ÛÂÚÁ›ÏψÛ˘ ÂȂ‚·ÈÒÓÂÙ·È (·Ó‡ÚÂÛË ÙÔ˘ ̇ÎËÙ· Ì ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜), Èı·ÓÔÏÔÁÂ›Ù·È (Û˘Ó‡·ÚÍË ÂÓfi˜ ÎÏÈÓÈÎÔ‡/·ÂÈÎÔÓÈÛÙÈÎÔ‡ Î·È ÂÓfi˜ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ Â˘Ú‹Ì·ÙÔ˜) Î·È Â›Ó·È ÂӉ¯fiÌÂÓË (‡·ÚÍË ‹ ÂÓfi˜ ÎÏÈÓÈÎÔ‡/·ÂÈÎÔÓÈÛÙÈÎÔ‡ ‹ ÂÓfi˜ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ Â˘Ú‹Ì·ÙÔ˜) (2,3). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÚÔ·ÙÂÈ fiÙÈ Ë ‰ÈËıËÙÈ΋ ·ÛÂÚÁ›ÏψÛË ·ÔÙÂÏ› ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ Ïԛ̈ÍË Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈ΋ ηÎÔ‹ıÂÈ· Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ‹ ıÓËÙfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ·, ȉȷ›ÙÂÚ· fiÙ·Ó ÂÓÙÔ›˙ÂÙ·È ÛÙÔ ∫¡™. ∏ ÂÌÂÈÚÈ΋ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹ › ˘Ô„›·˜ Ù˘ Ïԛ̈͢ (15,16), ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ¯ÔÚ‹ÁËÛË Ó¤ˆÓ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ Û ˘„ËϤ˜ ‰fiÛÂȘ ‹ ÛÂ Û˘Ó‰˘·ÛÌÔ‡˜ ÙÔ˘˜ (16,17), ηıÒ˜ Î·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ì ÙË ¯Ú‹ÛË Ó¤ˆÓ ÌÂıfi‰ˆÓ, ÌÔÚÔ‡Ó ÛÙÔ Ì¤ÏÏÔÓ Ó· Û˘Ì‚¿ÏÔ˘Ó Ô˘ÛÈ·ÛÙÈο ÛÙË Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ Î·È ÛÙËÓ Ï‹ÚË ›·ÛË ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Klont RR, Meis JF, Verweij PE. Critical assessment of issues in the diagnosis of invasive aspergillosis. Clin Microbiol Infect 2001;7 (Suppl 2):S32-S37. ¶·È‰È·ÙÚÈ΋ 2005;68:74-78
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·78
78
º. ∞ı·Ó·ÛÈ¿‰Ô˘ Î·È Û˘Ó.
2. Groll A, Shal P, Mentzel C, Schneider M. Changing pattern of invasive mycoses at autopsy [abstract]. In: Program and abstracts of the 34th Interscience Conference on Antimicrobial Agents and Chemotherapy (Orlando, Florida). Washington, DC: Americal Society for Microbiology; 1994. Abstract No J 109. 3. Lin SJ, Schranz J, Teutsch SM. Aspergillosis case-fatality rate: systematic review of the literature. Clin Infect Dis 2001;32:358-366. 4. Ng A, Gadong N, Kelsey A, Denning DW, Leggate J, Eden OB. Successful treatment of aspergillus brain abscess in a child with acute lymphoblastic leukemia. Pediatr Hematol Oncol 2000;17:497-504. 5. Rankin NE. Disseminated aspergillosis and moniliasis associated with agranulocytosis and antibiotic therapy. Br Med J 1953;1:918-919. 6. Stevens DA. Diagnosis of fungal infections: current status. J Antimicrob Chemother 2002;49 (Suppl 1):S11-S19. 7. Gozdasoglu S, Ertem M, Buyukkececi Z, Yavuzdemir S, Bengisun S, Ozenci H et al. Fungal colonization and infection in children with acute leukemia and lymphoma during induction therapy. Med Pediatr Oncol 1999;32:344-348. 8. Anderson K, Morris G, Kennedy H, Croall J, Michie J, Richardson MD et al. Aspergillosis in immunocompromised paediatric patients: associations with building hygiene, design, and indoor air. Thorax 1996;51:256-261. 9. Lass-Florl C, Aigner J, Gunsilius E, Petzer A, Nachbaur D, Gastl G et al. Screening for Aspergillus spp. using polymerase chain reaction of whole blood samples from patients with haematological malignancies. Br J Haematol 2001;113:180-184.
¶·È‰È·ÙÚÈ΋ 2005;68:74-78
10. Kawamura S, Maesaki S, Noda T, Hirakata Y, Tomono K, Tashiro T et al. Comparison between PCR and detection of antigen in sera for diagnosis of pulmonary aspergillosis. J Clin Microbiol 1999;37:218-220. 11. Buchheidt D, Hummel M, Schleiermacher D, Spiess B, Schwerdtfeger R, Cornely OA et al. Prospective clinical evaluation of a LightCycler-mediated polymerase chain reaction assay, a nested-PCR assay and a galactomannan enzyme-linked immunosorbent assay for detection of invasive aspergillosis in neutropenic cancer patients and haematological stem cell transplant recipients. Br J Haematol 2004;125:196-202. 12. Wheat LJ. Rapid diagnosis of invasive aspergillosis by antigen detection. Transpl Infect Dis 2003;5:158-166. 13. Challier S, Boyer S, Abachin E, Berche P. Development of a serum-based Taqman real-time PCR assay for diagnosis of invasive aspergillosis. J Clin Microbiol 2004;42:844-846. 14. Kwak EJ, Husain S, Obman A, Meinke L, Stout J, Kusne S et al. Efficacy of galactomannan antigen in the Platelia Aspergillus enzyme immunoassay for diagnosis of invasive aspergillosis in liver transplant recipients. J Clin Microbiol 2004;42:435-438. 15. Hope WW, Denning DW. Invasive aspergillosis: current and future challenges in diagnosis and therapy. Clin Microbiol Infect 2004;10:2-4. 16. Baden LR, Katz JT, Fishman JA, Koziol C, DelVecchio A, Doran M et al. Salvage therapy with voriconazole for invasive fungal infections in patients failing or intolerant to standard antifungal therapy. Transplantation 2003;76:1632-1637. 17. Wingard JR, Leather H. A new era of antifungal therapy. Biol Blood Marrow Transplant 2004;10:73-90.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:36
™ÂÏ›‰·79
CASE REPORT
79
Aspergillosis of the central nervous system in three children with acute lymphoblastic leukemia F. Athanassiadou1, A. Tragiannidis1, T. Papageorgiou1, M. Stamou1, A. Drevelegas2, A. Velegraki3
Abstract Fungal infections represent a serious cause of morbidity and mortality in patients with malignancies. Aspergilli are the second cause of fungal infection in immunocompromised patients such as children with hematological malignancies. Aspergillosis of the central nervous system (CNS) represents the third most frequent site of infection, after lung and sinonasal cavity and carries a high mortality. The cases of three children aged 14, 3 and 2 years old respectively with acute lymphoblastic leukemia, which presented CNS aspergillosis are reported. All of them were under remission induction therapy with ALL-BFM ’95 protocol. Suspicion of fungal infection was based on the clinical signs and symptoms (prolonged fever >10 days, dyspnea, headache, neurological signs). Diagnosis was based on plasma PCR that detected aspergillus DNA in all patients and in CSF in one of them. Radiological findings on MRI of CNS showed multiple foci on frontal lobe in two children and the presence of a temporal lobe lesion with central necrosis and concomitant edema in the third one. All patients received antifungal therapy with liposome amphotericin B for 4, 12 and 8 months respectively. On controls made periodically an improvement of radiological as well as clinical/laboratory findings was found in two children and antifungal therapy was discontinued. The third one died while on therapy. In conclusion, the findings suggest that CNS aspergillosis represents a serious cause of morbidity and mortality in children with hematological malignancies. The early initiation and the long-term administration of antifungal therapy may decrease mortality in these patients.
1 2nd Paediatric Clinic of Aristotelion University, AHEPA Hospital, Thessaloniki 2 Laboratory of Radiology of Aristotelion University, AHEPA Hospital, Thessaloniki 3 Mycology Reference Laboratory, Medical School, Athens Correspondence: Fani AthanassiadouPiperopoulou AHEPA Hospital, 1 St. Kyriakidi str., 546 36, Thessaloniki E-mail: atragian@hotmail.com Date of submission: 28-04-2004 Date of approval: 28-09-2004
Key words Aspergillosis of the central nervous system, acute lymphoblastic leukemia, childhood.
Paediatriki 2005;68:79
Paediatriki Jan-Feb 05 teliko
80
10-02-05
13:36
™ÂÏ›‰·80
∫§π¡π∫√ ∫√Àπ∑ ∞. BÈÏÏÈÒÙ˘, °. ƒÔ˘Ì¿Ó˘, Ã. ∫ÔÙÛÒÓ˘, ∞. ¶··‰ÔÔ‡ÏÔ˘
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘ E-mail: papadop5@otenet.gr
∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 24 ÌËÓÒÓ ÚÔÛÎÔÌ›ÛÙËΠÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ·Ù› ·ÚÔ˘Û›·˙ ·fi ¤ÙÔ˘˜ ÂÏÏÈ‹ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ Î·È ‰È¿Ù·ÛË ÎÔÈÏ›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÔÏÙÒ‰ÂȘ, ·ÓÔÈÎÙfi¯ÚˆÌ˜ ÎÂÓÒÛÂȘ. ∞fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÚԤ΢„ ˘ÔıÚ„›· (‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ 8,8 kg <3Ë ÂηÙ. ı¤ÛË, ‡„Ô˜ 84 cm ~10Ë ÂηÙ. ı¤ÛË) Î·È ÌÂÙˆÚÈÛÌfi˜ ÎÔÈÏ›·˜, ¯ˆÚ›˜ ¿ÏÏ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÚԤ΢„ ·Ó·ÈÌ›· (Ht 30,6 g/L), ÂÏ·Ùو̤ÓË ¯ÔÏËÛÙÂÚ›ÓË ÔÚÔ‡ (68 mg/dL, º.∆. >130), ÂÏ·Ùو̤ÓË HDL (20 mg/dL, º.∆. >40), ÂÓÒ Ë Û˘ÁΤÓÙÚˆÛË ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÛÙÔÓ ÔÚfi ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ (53 mg/dL), fiˆ˜ Î·È Ù· ÔÏÈο Ï¢ÎÒÌ·Ù· Î·È Ë ÏÂ˘ÎˆÌ·Ù›ÓË ÔÚÔ‡, Ù· Ë·ÙÈο ¤Ó˙˘Ì· Î·È Ô ¤ÏÂÁ¯Ô˜ ÓÂÊÚÒÓ. H ¯˘ÌÔıÚ˘„›ÓË ÎÔÚ¿ÓˆÓ Î·È Ë ·1-·ÓÙÈıÚ˘„›ÓË ÎÔÚ¿ÓˆÓ ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ, ÂÓÒ ÔÈ ÌÈÎÚÔÛÎÔÈΤ˜ ÎÔÚ¿ÓˆÓ ¤‰ÂÈÍ·Ó ÔÏÏ¿ ÏÈÔÛÊ·›ÚÈ·. OÈ Î·ÏÏȤÚÁÂȘ Î·È ÔÈ ·Ú·ÛÈÙÔÏÔÁÈΤ˜ ÎÔÚ¿ÓˆÓ ‹Ù·Ó ·ÚÓËÙÈΤ˜. ∆Ô test ȉÚÒÙ·, ηıÒ˜ Î·È Ù· ·ÓÙÈÛÒÌ·Ù· ηٿ Ù˘ ÁÏÈ·‰›Ó˘, ÚÂÙÈÎÔ˘Ï›Ó˘ Î·È ÂÓ‰ÔÌ˘›Ô˘ ‹Ù·Ó fiÏ· ·ÚÓËÙÈο. ∆· ›Â-
‰· ÙˆÓ ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ (∞ Î·È ∂) ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Î·ÙÒÙÂÚˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ∏ ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË Ì ۯÈÛÌÔÂȉ‹ Ï˘¯Ó›· ‰ÂÓ ·Ó¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ·ÓÂÈÏËÌ̤ÓÔ˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÁÈ· ·Î·ÓıÔ·ÙÙ·Ú· ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∏ ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎÔ‡ ˘ÁÚÔ‡ ÁÈ· Ï¿Ì‚ÏȘ ‹Ù·Ó ·ÚÓËÙÈ΋. ∏ ËÏÂÎÙÚÔÊfiÚËÛË ÏÈÔÚˆÙÂ˚ÓÒÓ ÌÂÙ¿ ·fi ÊfiÚÙÈÛË Ì ϛԘ (50 g Ï›Ô˘˜ ·Ó¿ 1,73 m2 ÂÈÊ¿ÓÂÈ·˜ ÛÒÌ·ÙÔ˜) ¤‰ÂÈÍ ÌË ·‡ÍËÛË Ù˘ ¯ÔÏËÛÙÂÚ›Ó˘, Ù˘ HDL, ÙˆÓ ApoA Î·È B ÛÙȘ 2 Î·È ÛÙȘ 6 ÒÚ˜ ÌÂÙ¿ ÙË ÊfiÚÙÈÛË Î·È, ·Ú¿ÏÏËÏ·, ·ÓÙÂÏ‹ ·Ô˘Û›· ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ ·fi ÙÔÓ ÔÚfi. ∏ ‚ÈÔ„›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ ÛÙÔ ·Ïfi ÌÈÎÚÔÛÎfiÈÔ ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ·Ú¯ÈÙÂÎÙÔÓÈ΋ ÙˆÓ Ï·¯ÓÒÓ Ì ‡·ÚÍË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÎÂÓÔÙÔ›ˆÓ. ∏ ÌÔÚÊÔÌÂÙÚÈ΋ ÌÂϤÙË ÙÔ˘ ÈÛÙÔÙÂÌ·¯›Ô˘ ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ ¤‰ÂÈÍ ÙËÓ ‡·ÚÍË ÔÏ˘¿ÚÈı̈Ó, ¢ÌÂÁ¤ıˆÓ ÏÈÔÛÙ·ÁÔÓȉ›ˆÓ ‰È·Ì¤ÙÚÔ˘ 0,5-0,1 Ìm ÂÓÙfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘, Ì ·‰˘Ó·Ì›· ÂÍÔ·ÙÙˆÛ˘ ÙÔ˘ Ï›Ô˘˜ ÛÙÔ˘˜ ÌÂÛÔ΢ÙÙ¿ÚÈÔ˘˜ ¯ÒÚÔ˘˜ (∂ÈÎfiÓ·). ¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ: 1. ∫ÔÈÏÈÔοÎË 2. ∞‚ËÙ·ÏÈÔÚˆÙÂ˚Ó·ÈÌ›· 3. OÈÎÔÁÂÓ‹˜ ˘Ô‚ËÙ·ÏÈÔÚˆÙÂ˚Ó·ÈÌ›· 4. ¡fiÛÔ˜ ηٷÎÚ¿ÙËÛ˘ ¯˘ÏÔÌÈÎÚÒÓ 5. ∂ÓÙÂÚÈ΋ ÏÂÌÊ·ÁÁÂÈÂÎÙ·Û›·
∂ÈÎfiÓ·. µÈÔ„›· ÂÓÙ¤ÚÔ˘ ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ.
∏ ·¿ÓÙËÛË ·ÎÔÏÔ˘ı› ÛÙË ÛÂÏ›‰· 84
¶·È‰È·ÙÚÈ΋ 2005;68:80,84
Paediatriki Jan-Feb 05 teliko
10-02-05
µπµ§πO¶∞ƒOÀ™π∞™∏
13:36
™ÂÏ›‰·81
BOOK REVIEW
81
∂ÓÙ·ÙÈ΋ ÓÔÛËÏ›· ÓÂÔÁÓÒÓ Àfi ¡. ¡ÈÎÔÏ·˝‰Ë £ÂÛÛ·ÏÔÓ›ÎË, 2004 ªÂ ¯·Ú¿ ‰¤¯ÙËη Ó· Û¯ÔÏÈ¿Ûˆ ÙÔ ‚È‚Ï›Ô ·˘Ùfi ÙÔ˘ ∫·ıËÁËÙ‹ Ù˘ ¡ÂÔÁÓÔÏÔÁ›·˜ Î·È ¢È¢ı˘ÓÙ‹ Ù˘ µ’ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”. Ÿˆ˜ ·Ó·Ê¤ÚÂÈ Ô Î·ıËÁËÙ‹˜ ÛÙÔÓ ÚfiÏÔÁÔ ÙÔ˘ ‚È‚Ï›Ô˘, ‰ÂÓ ÚfiÎÂÈÙ·È ÁÈ· Û‡ÁÁÚ·ÌÌ· ¡ÂÔÁÓÔÏÔÁ›·˜, ·ÏÏ¿ ÁÈ· Û˘ÁΤÓÙÚˆÛË ÙˆÓ Ú·ÎÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈ› Ë ∫ÏÈÓÈ΋ ÙÔ˘ Û˘ÁÁڷʤ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·ıËÌÂÚÈÓÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙË ª∂¡¡. •ÂÊ˘ÏÏ›˙ÔÓÙ¿˜ ÙÔ, ‰È·›ÛÙˆÛ· fiÙÈ ÙfiÛÔ ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘ (ÌfiÓÔ 280 ÛÂÏ›‰Â˜) fiÛÔ Î·È ÙÔ ‰¤ÛÈÌfi ÙÔ˘ ˘fi ÌÔÚÊ‹ ÛÈÚ¿Ï, ‚ÔËıÔ‡Ó Ôχ ÛÙËÓ ÂÈÙ˘¯›· ÙÔ˘ ÛÙfi¯Ô˘ ÙÔ˘, ‰ËÏ·‰‹ ÛÙËÓ Â‡ÎÔÏË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ·fi ÙÔÓ ÓÂÔÁÓÔÏfiÁÔ Î·È ÛÙË ÁÚ‹ÁÔÚË ÚfiÛ‚·ÛË Û ÔÔÈÔ‰‹Ô٠›ÁÔÓ ÓÂÔÁÓÔÏÔÁÈÎfi Úfi‚ÏËÌ· Î·È fi¯È ÌfiÓÔ. ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi ÛËÌÂ›Ô Ô˘ ‚ÔËı¿ÂÈ ÛÙÔ Ó· ·Á·Ëı› ·fi οı ÁÈ·ÙÚfi Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÙÔ ÚÔ‚ÏËÌ·ÙÈÎfi ÓÂÔÁ¤ÓÓËÙÔ, Â›Ó·È Î·È Ô ÙÚfiÔ˜ Û˘ÁÁÚ·Ê‹˜ ÙÔ˘. ∆Ô Î›ÌÂÓÔ Â›Ó·È ÁÚ·Ì̤ÓÔ Ì ÌÂÁ¿Ï· ÁÚ¿ÌÌ·Ù·, ˘¿Ú¯Ô˘Ó ·ÓÙÔ‡ ›Ó·Î˜, ÂÓÒ Ù· ÛËÌ·ÓÙÈο ÛËÌ›· ÙÔÓ›˙ÔÓÙ·È Ì ÎfiÎÎÈÓÔ ÌÂÏ¿ÓÈ. ∫¿ı ı¤Ì· ÂÚÈÁÚ¿ÊÂÙ·È ÌÂ Û˘ÓÔÙÈÎfi, ·ÏÏ¿ Û·Ê‹ ÙÚfiÔ Î·È ·ÎÔÏÔ˘ıÂ›Ù·È ·fi Û‡Á¯ÚÔÓË ‚È‚ÏÈÔÁÚ·Ê›·. ™Ù· ıÂÙÈο ÙÔ˘ ‚È‚Ï›Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÙ·È, ›Û˘, ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ÂÚÈÔÚ›˙ÂÙ·È ·ÏÒ˜ ÛÙËÓ ÂÚÈÁÚ·Ê‹ ÙˆÓ ÔÍÂÈÒÓ Î·Ù·ÛÙ¿ÛˆÓ, ·ÏÏ¿ ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÂÊ¿Ï·È· Ô˘ ‰È·Ú·ÁÌ·Ù‡ÔÓÙ·È ÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ÁÔÓ¤ˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÔÓÙ·È ÛÙË ª∂¡¡, ηıÒ˜ Î·È ÙËÓ Â͈ÓÔÛÔÎÔÌÂȷ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙË ª∂¡¡. ™Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù¿ ÙÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ·Ó·Ï‡ÂÈ Ì ÂÚÈÛÛfiÙÂÚ˜ ÏÂÙÔ̤ÚÂȘ Ӥ˜ Ù¯ÓÈΤ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, .¯. Û˘Á¯ÚÔÓÈṲ̂ÓÔ˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, ¢·ÈÛıËÛ›· ›ÎÏËÛ˘ (trigger sensitivity), ·ÂÓÂÚÁÔÔ›ËÛË Î‡ÎÏÔ˘ ÂÈÛÓÔ‹˜ (termination sensitivity), ˘ÔÛÙ‹ÚÈÍË ›ÂÛ˘ (pressure support), Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ fiÁÎÔ˘, ηıÒ˜ Î·È Ò˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·˘Ù¤˜ ÛÙËÓ Ú¿ÍË. ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È ·ÔÎÏÂÈÛÙÈο Û ¤Ó·Ó ÌfiÓÔ Ù‡Ô ·Ó·Ó¢ÛÙ‹Ú· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ÎÏÈÓÈ΋ ÙˆÓ Û˘ÁÁڷʤˆÓ. ™ÙÔ ÎÂÊ¿Ï·ÈÔ Ù˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘, ‰ÂÓ ·Ó·Ï‡ÂÙ·È Ô ÙÚfiÔ˜ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ NO. £· ‹Ù·Ó ¯Ú‹ÛÈÌÔ, ›Ûˆ˜, Ó· ÚÔÛÙÂıÔ‡Ó ÔÚÈṲ̂ӷ ÛÙÔȯ›· Û¯ÂÙÈο Ì ÙËÓ Ô͢ÌÂÙÚ›·, Ù· ·›ÙÈ· Ì›·˜ ˘ÔÍ›·˜, ÙË ‰‰ ÙÔ˘ ΢·ÓˆÙÈÎÔ‡ ÓÂÔÁÓÔ‡, ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ Oµπ Î·È ÙËÓ ¤ÓÓÔÈ· Ù˘ ̤Û˘ ›ÂÛ˘ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ (ª∞P). ™ÙȘ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ ı· ‚ÔËıÔ‡ÛÂ Ë ÚÔÛı‹ÎË ÌÂÚÈÎÒÓ ÂÈÎfiÓˆÓ. ¶·Ú¿ ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜, ıˆÚÒ fiÙÈ ÙÔ ‚È‚Ï›Ô ·˘Ùfi ¤Ú¯ÂÙ·È Ó· ηχ„ÂÈ ¤Ó· ÎÂÓfi Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·, ·ÊÔ‡ ‚ÔËı¿ÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Ó¤Ô È·ÙÚfi Ô˘ οÓÂÈ Ù· ÚÒÙ· ÙÔ˘ ‚‹Ì·Ù· ÛÙË ¡ÂÔÁÓÔÏÔÁ›·, ÂÓÒ ·Ú¿ÏÏËÏ· ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ ÂÚÁ·ÏÂ›Ô Î·È ÁÈ· ÂÌ¿˜, ÙÔ˘˜ ·Ï·ÈfiÙÂÚÔ˘˜ ÓÂÔÁÓÔÏfiÁÔ˘˜. ¶ÔÏÏ¿ Û˘Á¯·ÚËÙ‹ÚÈ· ÛÙÔÓ Î. ¡ÈÎÔÏ·˝‰Ë Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ÁÈ· ÙÔ ¤ÚÁÔ ÙÔ˘˜.
¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·” AÏÏËÏÔÁÚ·Ê›·: ÃÚ‹ÛÙÔ˜ ∫ÒÛÙ·ÏÔ˜ E-mail: ccostalos@yahoo.gr
Ã. ∫ÒÛÙ·ÏÔ˜ ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶° ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”
¶·È‰È·ÙÚÈ΋ 2005;68:81
Paediatriki Jan-Feb 05 teliko
82
¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ E-mail: stefanid@hol.gr
10-02-05
13:37
™ÂÏ›‰·82
¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√
∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ¶·È‰›·ÙÚÔ˜ - ¡ÂÊÚÔÏfiÁÔ˜
∏ ∂˘Úˆ·˚΋ ∂ÈÙÚÔ‹ ÂÓ¤ÎÚÈÓ ÚfiÙ·ÛË Î·ÓÔÓÈÛÌÔ‡ ÁÈ· ÙËÓ ÚÔÒıËÛË Ê·ÚÌ¿ÎˆÓ ÁÈ· Ù· ·È‰È¿ ∆Ô Ï‹Ú˜ ΛÌÂÓÔ Ù˘ ÚfiÙ·Û˘ Â›Ó·È ÛÙË ‰È‡ı˘ÓÛË: http://europa.eu.int/hellas/5news/5.6press290904c.htm ∏ ∂˘Úˆ·˚΋ ∂ÈÙÚÔ‹ ÂÓ¤ÎÚÈÓ ÚfiÙ·ÛË Î·ÓÔÓÈÛÌÔ‡ Û¯ÂÙÈο Ì ٷ Ê¿Ú̷η ÁÈ· ·È‰È·ÙÚÈ΋ ¯Ú‹ÛË Ô˘ ÛÙԯ‡ÂÈ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ ÛÂ Â›Â‰Ô ∂∂, Ì ÙË ‰È·ÛÊ¿ÏÈÛË fiÙÈ Ù· Ê¿Ú̷η ·˘Ù¿, ÚÔÙÔ‡ ÙÂıÔ‡Ó Û ΢ÎÏÔÊÔÚ›·, ı· ¤¯Ô˘Ó ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ ÂȉÈ΋˜ ¤Ú¢ӷ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ ·Ó·ÁÎÒÓ. ¶¿Óˆ ·fi ÙÔ 50% ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· ·È‰È¿ ‰ÂÓ ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ÚÔÙÔ‡ ÙÂıÔ‡Ó ÛÙËÓ Î˘ÎÏÔÊÔÚ›·. ŒÓ· Ê¿ÚÌ·ÎÔ Ô˘ ¯ÔÚËÁÂ›Ù·È ÌÂ Û˘ÓÙ·Á‹ ÁÈ·ÙÚÔ‡ ¯ˆÚ›˜ fï˜ Ó· ¤¯ÂÈ ÚÔËÁÔ˘Ì¤Óˆ˜ ‰ÔÎÈÌ·ÛÙ› ÁÈ· Ó· ‰È·ÈÛÙˆı› ηٿ fiÛÔÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ÔÈ· Â›Ó·È Ë Î·Ù¿ÏÏËÏË ‰ÔÛÔÏÔÁ›· Î·È ÔȘ Â›Ó·È ÔÈ ·ÚÂÓ¤ÚÁÂȤ˜ ÙÔ˘, ÌÔÚ› Ó· ‚Ï¿„ÂÈ ÛÔ‚·Ú¿ ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. µ·ÛÈÎÔ› ÛÙfi¯ÔÈ ÙÔ˘ ÚÔÙÂÈÓfiÌÂÓÔ˘ ηÓÔÓÈÛÌÔ‡ Â›Ó·È Ë ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ Ê·ÚÌ¿ÎˆÓ Ô˘ ÚÔÔÚ›˙ÔÓÙ·È ÂȉÈο ÁÈ· Ù· ·È‰È¿, ηıÒ˜ Î·È Ë ÂÍ·ÛÊ¿ÏÈÛË ÙÔ˘ ·˘ÛÙËÚÔ‡ ÂϤÁ¯Ô˘ Ù˘ ÔÈfiÙËÙ¿˜ ÙÔ˘˜ ÚÔÙÔ‡ ÙÂıÔ‡Ó Û ΢ÎÏÔÊÔÚ›·, ‰›¯ˆ˜ fï˜ Ù· ·È‰È¿ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÚÈÙÙ¤˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜. ∏ ÚfiÙ·ÛË ÛÙԯ‡ÂÈ Â›Û˘ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È·ı¤ÛÈÌ˘ ÏËÚÔÊfiÚËÛ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· Ê¿Ú̷η ÁÈ· ·È‰È¿.
¢ËÌÔÛȇıËÎÂ Ë ÀÔ˘ÚÁÈ΋ ∞fiÊ·ÛË ÁÈ· ÙË ™‡ÛÙ·ÛË Î·È ÙÔÓ ∫·ÓÔÓÈÛÌfi §ÂÈÙÔ˘ÚÁ›·˜ Ù˘ ∂ıÓÈ΋˜ ∂ÈÙÚÔ‹˜ ¢ÂÔÓÙÔÏÔÁ›·˜ ÁÈ· ÙȘ ∫ÏÈÓÈΤ˜ ªÂϤÙ˜ ∆Ô Î›ÌÂÓÔ Ù˘ ÀÔ˘ÚÁÈ΋˜ ∞fiÊ·Û˘ Â›Ó·È ÛÙË ‰È‡ı˘ÓÛË: http://www.sfee.gr/download/english/387
™ÙËÓ ÈÛÙÔÛÂÏ›‰· ÙÔ˘ º·Ú̷΢ÙÈÎÔ‡ ™˘ÏÏfiÁÔ˘ ∞ÙÙÈ΋˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÏËÚÔÊÔڛ˜ ÁÈ· 989 ÓÔÛÔÎÔÌÂȷο Ê¿Ú̷η OÈ ÏËÚÔÊÔڛ˜ ·˘Ù¤˜ Â›Ó·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.fsa.gr
¶·È‰È·ÙÚÈ΋ 2005;68:82-83
Paediatriki Jan-Feb 05 teliko
10-02-05
13:37
™ÂÏ›‰·83
NEWS FROM THE INTERNET
83
∏ ÈÛÙÔÛÂÏ›‰· Ù˘ ∞ÌÂÚÈηÓÈ΋˜ π·ÙÚÈ΋˜ µÈ‚ÏÈÔı‹Î˘ (NLM) ÂÚÈÏ·Ì‚¿ÓÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· Ê¿Ú̷η, Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ÂÈΛӉ˘ÓË ÁÈ· Ù· ·È‰È¿ OÈ ÏËÚÔÊÔڛ˜ ·˘Ù¤˜ Â›Ó·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.nlm.nih.gov/medlineplus/druginformation.html
∂›Û˘, ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· Ê¿Ú̷η ˘¿Ú¯Ô˘Ó ÛÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.rxlist.com
ŒÓ· ¯Ú‹ÛÈÌÔ ‚È‚Ï›Ô ÁÈ· ÙËÓ ·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ (∆he Handbook of Parenteral Drug Administration) ‚Ú›ÛÎÂÙ·È ÛÙÔ ‰È·‰›ÎÙ˘Ô ÛÙË ‰È‡ı˘ÓÛË: http://members.ozemail.com.au/~jamesbc/frames.htm
ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÁÔÓ›˜ ·È‰ÈÒÓ Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ http://www.e-child.gr/NefrosikoSyndromo.pdf ™ÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ¤Î‰ÔÛË ÙÔ˘ ¡ÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” “ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÁÔÓ›˜ ·È‰ÈÒÓ Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ”, ÂÈ̤ÏÂÈ·: ∫. ™ÙÂÊ·Ó›‰Ë˜ Î·È ∞. ∏Ï›·.
¶·È‰È·ÙÚÈ΋ 2005;68:82-83
Paediatriki Jan-Feb 05 teliko
84
10-02-05
13:37
™ÂÏ›‰·84
CLINICAL QUIZ ∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ ¶Èı·Ó‹ ‰È¿ÁÓˆÛË: ¡Ô 4. NfiÛÔ˜ ηٷÎÚ¿ÙËÛ˘ ¯˘ÏÔÌÈÎÚÒÓ
™¯fiÏÈÔ ∏ ÓfiÛÔ˜ ηٷÎÚ¿ÙËÛ˘ ¯˘ÏÔÌÈÎÚÒÓ (ÓfiÛÔ˜ Anderson) Â›Ó·È Û¿ÓÈ· ÓfiÛÔ˜ Ô˘ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙfiÛˆÌÔ ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ÌÂÙ·ÊÔÚ¿˜ Ù˘ ·ÔÏÈÔÚˆÙ½Ó˘ µ48, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‰˘Ó·Ì›· Û˘ÁΤÓÙÚˆÛ˘ ‹/Î·È ÂÍÔ·ÙÙˆÛ˘ ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ ·fi ÙÔ ¤ÓÙÂÚÔ (1,2). ∫ÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ÛÙ·ÛÈÌfiÙËÙ· ‚¿ÚÔ˘˜ Î·È ÛÙ·ÙfiÚÚÔÈ· (3,4). ™Â ÂÚ›ÙˆÛË ÌË ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘, Ô‰ËÁ› Û ·Ó¿ÚÎÂÈ· ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ Î·È Ó¢ÚÔÏÔÁÈΤ˜ Î·È ÔÊı·ÏÌÔÏÔÁÈΤ˜ ‰È·Ù·-
µÈ‚ÏÈÔÁÚ·Ê›· 1. Levy E, Marcel Y, Deckelbaum RJ, Milne R, Lepage G, Seidman E et al. Intestinal apoB synthesis, lipids, and lipoproteins in chylomicron retention disease. J Lipid Res 1987;28:1263-1274. 2. Raabe M, Kim E, Veniant M, Nielsen LB, Young SG. Using genetically engineered mice to understand apolipoprotein-B deficiency syndromes in humans. Proc Assoc Am Physicians 1998;110:521-530.
¶·È‰È·ÙÚÈ΋ 2005;68:80,84
Ú·¯¤˜. ∆· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÌÂȈ̤ӷ ›‰· Ù˘ ¯ÔÏËÛÙÂÚ›Ó˘ ÛÙÔ ÔÚfi, Ù˘ LDL, Ù˘ HDL Î·È ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ A Î·È B, ÌÂ Ê˘ÛÈÔÏÔÁÈο Ù· ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ. ÷ڷÎÙËÚÈÛÙÈ΋ Â›Ó·È Ë ÌË ·‡ÍËÛË ÙˆÓ ·Ú·¿Óˆ ÛÙÔÓ ÔÚfi ÌÂÙ¿ ÙË ÊfiÚÙÈÛË Ì ϛԘ Î·È Ë Ï‹Ú˘ ·Ô˘Û›· ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ (3,4). ∏ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Á›ÓÂÙ·È Ì ÙË ÌÔÚÊÔÌÂÙÚÈ΋ ÌÂϤÙË ÙÔ˘ ÈÛÙÔÙÂÌ·¯›Ô˘ Ù˘ ‚ÈÔ„›·˜ ÂÓÙ¤ÚÔ˘ ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ, fiÔ˘ ·Ó¢ڛÛÎÔÓÙ·È ÔÏ˘¿ÚÈıÌ·, ¯·Ú·ÎÙËÚÈÛÙÈο ÏÈÔÛÙ·ÁÔÓ›‰È· ÛÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ Ì ·ÓÙÂÏ‹ ·Ô˘Û›· Ï›Ô˘˜ ÛÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ (5). ∏ ¯·ÌËÏ‹ Û ÏÈ·Ú¿ ‰›·ÈÙ· Ì ÚÔÛı‹ÎË Ì¤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ fiÙ·Ó ¯ÚÂÈ¿˙ÔÓÙ·È, ·ÔÙÂÏÔ‡Ó ÂÁÁ‡ËÛË ÁÈ· ÙËÓ ÔÌ·Ï‹ ·Ó¿Ù˘ÍË ÙÔ˘ ·ÛıÂÓÔ‡˜. 3. Roy CC, Levy E, Green PH, Sniderman A, Letarte J, Buts JP et al. Malabsorption, hypocholesterolemia, and fat-filled enterocytes with increased intestinal apoprotein B. Chylomicron retention disease. Gastroenterology 1987;92:390-399. 4. Lacaille F, Bratos M, Bouma ME, Jos J, Schmitz J, Rey J. Anderson’s disease. Clinical and morphologic study of 7 cases. Arch Fr Pediatr 1989;46:491-498. 5. Boldrini R, Biselli R, Bosman C. Chylomicron retention disease - the role of ultrastructural examination in differential diagnosis. Pathol Res Pract 2001;197:753-757.
Paediatriki Jan-Feb 05 teliko
10-02-05
13:37
™ÂÏ›‰·89
¶ƒ√™∂Ã∏ ™À¡∂¢ƒπ∞
xxv
3-4 ª·ÚÙ›Ô˘ 2005
2nd International Conference on Infant Development in Neonatal Intensive Care ¶ÏËÚÔÊÔڛ˜: Maria McHugh ∆ËÏ.: 01 414 341 500 E-mail: idmic@meetingmakers.co.uk
London, England
4-6 ª·ÚÙ›Ô˘ 2005
Updates on Hernia Repair, 1st Winter Meeting •ÂÓÔ‰Ô¯Â›Ô Club Montana ¶ÏËÚÔÊÔڛ˜: PRC Congress & Travel ∆ËÏ.: +30 210 7711 673, 210 7756 336 Fax: +30 210 7711 289 E-mail: secretariat@prctravel.gr
∫·ÚÂÓ‹ÛÈ
17-20 ª·ÚÙ›Ô˘ 2005
9Ô ¶·ÓÂÏÏ‹ÓÈÔ ¢È·‚ËÙÔÏÔÁÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô Rodos Palace ∂ÏÏËÓÈ΋ ¢È·‚ËÙÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ¶ÏËÚÔÊÔڛ˜: Œ„ÈÏÔÓ Congress ∆ËÏ.: +30 210 7254 360-2 Fax: +30 210 7254 363 E-mail: diab2005@epsiloncongress.gr Website: www.diab2005.epsiloncongress.gr
ƒfi‰Ô˜
31 ª·ÚÙ›Ô˘2 ∞ÚÈÏ›Ô˘ 2005
32o ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·˜ Î·È ªÂÙ·‚ÔÏÈÛÌÔ‡ ™˘Ó‰ÚÈ·Îfi Î·È ¶ÔÏÈÙÈÛÙÈÎfi ∫¤ÓÙÚÔ ¶·Ó/Ì›Ô˘ ¶·ÙÚÒÓ ∂ÏÏËÓÈ΋ ∂Ó‰ÔÎÚÈÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ¶·ÓÂÏÏ‹ÓÈ· ŒÓˆÛË ∂Ó‰ÔÎÚÈÓÔÏfiÁˆÓ ¶ÏËÚÔÊÔڛ˜: ™˘Ó¤‰Ú· ∆ËÏ.: +30 2610 432 200, 2610 461 551 Fax: +30 2610 430 884 E-mail: endocrinology@synedra.gr Website: www.synedra.gr
¶¿ÙÚ·
7-9 ∞ÚÈÏ›Ô˘ 2005
6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ & ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ ª¤Á·ÚÔ ªÔ˘ÛÈ΋˜ ∞ıËÓÒÓ ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ & ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: Œ„ÈÏÔÓ Congress ∆ËÏ.: +30 210 7254 360-2 Fax: +30 210 7254 363 E-mail: info@epsiloncongress.gr Website: www.epsiloncongress.gr
∞ı‹Ó·
17-21 ª·˝Ô˘ 2005
31Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô Hilton ¶ÏËÚÔÊÔڛ˜: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ ∆ËÏ.: +30 210 7211 845, 7243 161 Fax: +30 210 7215 082 E-mail: iea@mednet.gr Website: www.mednet.gr
∞ı‹Ó·
26-29 ª·˝Ô˘ 2005
4Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰Ô„˘¯È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress ∆ËÏ.: +30 210 7499 300 Fax: +30 210 7705 752 E-mail: info@triaenatours.gr
∞ı‹Ó·
Paediatriki Jan-Feb 05 teliko
10-02-05
13:37
™ÂÏ›‰·90
xxvi
17-19 πÔ˘Ó›Ô˘ 2005
43Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô Kipriotis Village ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ¶ÏËÚÔÊÔڛ˜: C&C International ∆ËÏ.: +30 210 6889 100 Fax. +30 210 6844 777 E-mail: pediatric2005@cnc.gr Website: www.pediatric2005.gr
∫ˆ˜
4-9 ™ÂÙÂÌ‚Ú›Ô˘ 2005
ESPGHAN Summer School on Nutrition “Research Challenges in Clinical Nutrition” European Society for Paediatric Gastroenterology, Hepatology and Nutrition Eden Beach Hotel Club ¶ÏËÚÔÊÔڛ˜: ∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘ ∆ËÏ.: +30 210 77 26 355, 6945 29 30 71 E-mail: papadop5@otenet.gr
∞Ó¿‚˘ÛÛÔ˜
7-9 ™ÂÙÂÌ‚Ú›Ô˘ 2005
The History of Diabetes Mellitus ¢ÔÚ˘ÊÔÚÈÎfi ™˘ÌfiÛÈÔ ÚÈÓ ·fi ÙÔ ÂÙ‹ÛÈÔ Û˘Ó¤‰ÚÈÔ Ù˘ EASD ¶ÏËÚÔÊÔڛ˜: C&C International ∆ËÏ.: +30 210 6889 100 Fax. +30 210 6844 777 E-mail: easdsymposium2005@cnc.gr Website: www.easdsymposium2005.com
¢ÂÏÊÔ›
10-15 ™ÂÙÂÌ‚Ú›Ô˘ 2005 41st Annual Meeting of the European Association for the Study of Diabetes ™Ù¿‰ÈÔ ∂ÈÚ‹Ó˘ & ºÈÏ›·˜ ∆ËÏ.: +30 210 7297 565, 7230 680, 7201 730 Fax: +30 210 7239 472 E-mail: secretariat@easd2005athens.gr Website: www.easd2005athens.gr
∞ı‹Ó·
14-18 ™ÂÙÂÌ‚Ú›Ô˘ 2005 29th UMEMPS - Union Middle Eastern & Mediterranean Pediatric Societies Congress •ÂÓÔ‰Ô¯Â›Ô Hilton ¶ÏËÚÔÊÔڛ˜: Pr. Enver Hasanoglu Fax: +90 312 2237 469, +90 216 3477 095 E-mail: enverh@gazi.edu.tr Website: www.istanbul-umemps2005.org
Istanbul, Turkey
29 ™ÂÙÂÌ‚Ú›Ô˘2 OÎÙˆ‚Ú›Ô˘ 2005
4th Aegean Postgraduate Radiology Course •ÂÓÔ‰Ô¯Â›Ô Hilton ¶ÏËÚÔÊÔڛ˜: PRC Congress & Travel ∆ËÏ.: +30 210 7711 673, 210 7756 336 Fax: +30 210 7711 289 E-mail: secretariat@prctravel.gr
ƒfi‰Ô˜
25-30 ∞˘ÁÔ‡ÛÙÔ˘ 2007
25th International Congress of Pediatrics ¶ÏËÚÔÊÔڛ˜: C&C International ∆ËÏ.: +30 210 6889 100 Fax. +30 210 6844 777 E-mail: icp2007@cnc.gr Website: www.icp2007.gr
∞ı‹Ó·