Παιδιατρική | Τόμος 68 • Τεύχος 6 • Νοέμβριος - Δεκέμβριος 2005

Exof Pediatr Nov-Dec 05

12-12-05

14:05

™ÂÏ›‰·1

¶·È‰È·ÙÚÈ΋ ñ TfiÌÔ˜ 68 ñ ∆‡¯Ô˜ 6 ñ ¡Ô¤Ì‚ÚÈÔ˜-¢ÂΤ̂ÚÈÔ˜ 2005

TfiÌÔ˜ 68 ñ ∆‡¯Ô˜ 6 ñ ¡Ô¤Ì‚ÚÈÔ˜-¢ÂΤ̂ÚÈÔ˜ 2005 www.paediatriki.edu.gr

Volume 68 ñ Number 6 ñ November-December 2005 ISSN 0377-2551

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·1

¶·È‰È·ÙÚÈ΋ ∆fiÌÔ˜ 68 ñ ∆‡¯Ô˜ 6 ñ ¡Ô¤Ì‚ÚÈÔ˜-¢ÂΤ̂ÚÈÔ˜ 2005 ¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜

¶ÂÚȯfiÌÂÓ·

M¤ÏË ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ ∂. ∞ÓÙˆÓÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ Ã. ∫ÒÛÙ·ÏÔ˜ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ¶··‰ÔÔ‡ÏÔ˘ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿-¶·Û·Ú¿ÎË

∞¡∞™∫O¶∏™∂π™

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ·

∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™

∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ 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 I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡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˘ ∂ÔÙ›·˜ ªª∂: 3889

ISSN 0377-2551

399 ¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿ ¢. ¶··Ó‰Ú¤Ô˘, M. ∂ÌÔÚÈ¿‰Ô˘ 409 ∂ÈÏÔΤ˜ ·fi ÙÔ ÎÂÓÙÚÈÎfi Î·È ÂÚÈÊÂÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ÔÌfi˙˘ÁË ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· A. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË, G. Du Toit, G. Lack 417 ¶ÚfiÔ‰ÔÈ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ °. ¢ËÌËÙÚ›Ô˘, Ã. ∞Á·Î›‰Ë˜

450 ™‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘ ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ˆ˜ ÚÒÙË ÂΉ‹ÏˆÛË ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ µ- ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, §. µÔÁÈ·Ù˙‹, π. ∂˘‰ˆÚ›‰Ô˘, £. ™Ù·ıÔÔ‡ÏÔ˘, ∂. ¢È·Ì·ÓÙ‹

¶ƒ∞∫∆π∫∞ £∂ª∞∆∞ 454 ∫·Ú‰È·ÁÁÂȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ¿ÛÎËÛË Û ·È‰È¿, ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ. ¶ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜, ∫. ¢Ô‡ÚÔ˜

461 ∫§π¡π∫√ ∫√Àπ∑ 425 ∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ Ó¢ÌÔÓ›·. ™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË 40 ·È‰ÈÒÓ ÓÔÛËÏ¢fiÌÂÓˆÓ Û ÓÔÛÔÎÔÌÂ›Ô °. ™. µ·ÚÏ¿Ì˘, ¡. ∞Ú‚·ÓÈÙ›‰Ë˜, ™. ∫·Ú·Ì¤Ú˘, ª. ∂ÌÔÚÈ¿‰Ô˘, ™. °·‚ÚÈÈÏ›‰Ë˜

462 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√

467 ¡∂∞ ∞¶√ ™À¡∂¢ƒπ∞ 433 ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ·ÎÚÈÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜ ¶. ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜, π. ª·ÓÈfi˜, Ã. π. ªËÏÈÒÓ˘

471 µπµ§π√¶∞ƒ√À™π∞™∏

472 ∂Àƒ∂∆∏ƒπ√ ∫ƒπ∆ø¡ ∆√À ∆√ª√À 68 ∂¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ 440 ÕÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Û ¿Û¯ÔÓÙ˜ ·fi ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ∞. ∫Ô‡ÛË, ª. OÈÎÔÓfiÌÔ˘, ¢. ∫·Û›ÌÔ˜, ¶. ¶ÏÈ¿ÎË, ª. ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ 446 ªÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ÙÔ˘ ‹·ÙÔ˜. ∞Ó·ÊÔÚ¿ Û ̛· ÂÚ›ÙˆÛË ª. ÷ÛÈÒÙÔ˘, ∂. ™·ÌÌÔ‡ÙË, ¶. ¶ÔÏ˘‚›Ô˘, ∂. ∫ÔÛÎÈÓ¿

473 ∂Àƒ∂∆∏ƒπ√ ™À°°ƒ∞º∂ø¡ ∆√À ∆√ª√À 68

475 ∂Àƒ∂∆∏ƒπ√ §∂•∂ø¡ ∫§∂π¢πø¡ ∆√À ∆√ª√À 68

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·3

Paediatriki Volume 68 ñ Number 6 ñ November-December 2005 Bimonthly Publication of the Greek Paediatric Society President A. Constantopoulos Editorial Board Editor C. Stefanidis Members P. Avgoustidou-Savvopoulou H. Antonopoulou A. Vazeou-Gerasimidi G. Varlamis M. Kanariou ∂. Katsarou-Pectasides A. Kattamis Ch. Costalos N. Papadopoulos ∞. Papadopoulou A. Siamopoulou-Mavridou M. Tsolia-Pasparaki

Contents REVIEW ARTICLES 408 Diet and asthma in children D. Papandreou, M. Emboriadou 416 Central and peripheral nervous system complications in patients with beta-thalassaemia major D. Zafeiriou, M. Oikonomou, M. Athanassiou-Metaxa

453 Intestinal atresia presenting at birth with aspiration of meconium-like-stained amniotic fluid V. Drossou-Agakidou, L. Bogiatzi, I Eudoridou, T. Stathopoulou, E. Diamanti

PRACTICAL ISSUE

424 Advances in the management of congenital diaphragmatic hernia G. Dimitriou, C. Agakidis

460 Cardiovascular conditions associated with sudden death during exercise in children, adolescents and young adults.

Preparticipation evaluation D. Georgakopoulos, K. Douros

ORIGINAL ARTICLES

461 CLINICAL QUIZ

Manuscript Editing Greek Editing I. Karavranou English Editing S. Nakou Publisher

432 Cardiac involvement in pneumonia.

Comparative study in 40 hospitalized children G. S. Varlamis, N. Arvanitidis, S. Karaberis, M. Emboriadou, S. Gavriilidis

462 NEWS FROM THE INTERNET

467 CONGRESS NEWS

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 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

439 Risk factors for obesity in elementary school children in the Greek border region of Thesprotia P. D. Angelopoulos, J. Manios, H. J. Milionis

471 BOOK REVIEW

472 REVIEWERS OF MANUSCRIPTS INDEX, VOLUME 68 CASE REPORTS 445 Immune haemolytic anaemia in patients with beta-thalassaemia. Case report A. Kousi, M. Oikonomou, D. Kassimos, P. Pliaki, M. Athanassiou-Metaxa 449 Liver mesenchymal hamartoma.

A case report M. Hasiotou, E. Sammouti, P. Poliviou, E. Koskina

473 AUTHORS INDEX, VOLUME 68

475 SUBJECT INDEX, VOLUME 68

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·11

√¢∏°π∂™ ¶ƒ√™ ∆√À™ ™À°°ƒ∞º∂π™ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜).

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· ÂÎ·›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜.

9. ∂ӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ.

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 ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 15. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜.

H ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ, ηıÒ˜ Î·È ¿ÚıÚ· Ì Â›Î·ÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·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 ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì Â›Î·ÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ÌËÓ ¤¯Ô˘Ó ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi. ∂ÈϤÔÓ, ÛÙËÓ ÂÚÁ·Û›· ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜, Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. E›Û˘, Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ.

OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚÈÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·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΋

xi

·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.

µ. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ 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 Ôԛ˜ ÙÚÔÔÔÈ‹ıËÎ·Ó ÚfiÛÊ·Ù· Î·È ‰ËÌÔÛȇÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È Ù˘ˆÌ¤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (21x29,7 cm), Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È ÂÚÈıÒÚÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2,5 cm ÛÙȘ ‰‡Ô Ï¢ڤ˜.

TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ηٿÏÔÁÔ˜ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.

H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ·: ñ ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 2000-3000 ϤÍÂȘ. ñ ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 1500-2500 ϤÍÂȘ Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ÂÈÛÙÔϤ˜ 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 ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ. ñ ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋. ñ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤ·/ˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙÔ˘˜. ñ ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·.

¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. 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˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ ÛÂ: ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·12

xii

K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ.

K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Î·È ÙÔÓ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜, ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ì ÏÂÙÔ̤ÚÂȘ ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ.

OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ 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 ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜.

Editors/ Uniform Requirements for Manuscripts Sub-mitted to Biomedical Journals, (http://www.icmje.org Î·È http:// www.icmje.org/icmje.pdf). OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus [List of Journals Indexed in Index Medicus (http://www.nlm.nih.gov/bsd/uniform_requirements.html)]. ¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶∂ƒπO¢π∫∞ AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ÂÓÒ ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”.

T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: Â›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279.

Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578.

TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf

™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜, ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·.

OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ.

BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ, ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó:

¶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.

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

¢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.

H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù· ÙÚÔÔÔÈË̤Ó˜ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal

¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã. ∏ ıÂÚ·›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·13

xiii

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

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

¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡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 ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, Î.Ï.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜ 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 ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.

πÛÙÔÛÂÏ›‰Â˜: Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancer-pain.org/

°. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ‰ÈÛΤٷ ‹ CD, ηıÒ˜ Î·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢.

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

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

T· ¤ÍÔ‰· ÙˆÓ ÊÈÏÌ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ.

T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË, ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ.

OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó·

¶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 ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜) Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· ‰.fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·.

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

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

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

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

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

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

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

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

Pediatr Nov-Dec 05

xiv

12-12-05

15:16

™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 ÏÂÙfi ¯ÈÏÈÔÛÙfiÌÂÙÚÔ ÁÚ·ÌÌÔÌfiÚÈÔ ·ÚÈıÌfi˜ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Èı·ÓfiÙËÙ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ‰Â˘ÙÂÚfiÏÂÙÔ 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

Pediatr Nov-Dec 05

xvi

12-12-05

15:16

™ÂÏ›‰·16

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) Paediatriki 2005;68:16

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.

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 1500-2500 words and case reports 1000-1500 words; ñ brief reports 1000-1500 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.

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.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·17

xvii

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

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.

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.

Book or monograph: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990.

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.

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.

484-500.

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.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·18

xviii

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.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·19

∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏ ∞Á·ËÙÔ› ™˘Ó¿‰ÂÏÊÔÈ, ∆Ô ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ Î·È Ë ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ «¶·È‰È·ÙÚÈ΋˜» Û·˜ ‡¯ÔÓÙ·È Î·Ï¿ ÃÚÈÛÙÔ‡ÁÂÓÓ· Î·È Â˘Ù˘¯ÈṲ̂ÓÔ Î·È ‰ËÌÈÔ˘ÚÁÈÎfi ÙÔ 2006. £· ‹ıÂÏ· Î·È ¿ÏÈ Ó· Û·˜ ¢¯·ÚÈÛÙ‹Ûˆ ÁÈ· ÙÔ ÂӉȷʤÚÔÓ Û·˜ ÁÈ· ÙÔ ÂÚÈÔ‰ÈÎfi. µÏ¤ÔÓÙ·˜ Ù· Ù‡¯Ë ÙÔ˘ 2005 ‰È·›ÛÙˆÛ· Ì ¯·Ú¿ ÙÔ ·ÔÙ¤ÏÂÛÌ· ÙˆÓ Û˘Ó¯ÒÓ ÚÔÛ·ıÂÈÒÓ Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ Î·È ÙˆÓ “∂ÈÛÙËÌÔÓÈÎÒÓ ∂ΉfiÛˆӔ ÁÈ· ÙËÓ ÂÈÌÂÏË̤ÓË ÂÌÊ¿ÓÈÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ŸÏ· Ù· ¿ÚıÚ· ‚ÂÏÙÈÒıËÎ·Ó ÛËÌ·ÓÙÈο Ì ٷ ÂÔÈÎÔ‰ÔÌËÙÈο Û¯fiÏÈ· ÙˆÓ ÎÚÈÙÒÓ Î·È ÙÔ˘˜ ¢¯·ÚÈÛÙԇ̠ıÂÚÌ¿. ™Â ·˘Ùfi ‚Ô‹ıËÛÂ Î·È Ë Ó¤· ÔÚÁ·ÓˆÙÈ΋ ‰ÔÌ‹ Ì ÙȘ ÚˆÙÔ‚Ô˘Ï›Â˜ ÙˆÓ ˘‡ı˘ÓˆÓ Û‡ÓÙ·Í˘ οı ÂÍÂȉ›Î¢Û˘. ™Ù· Ù‡¯Ë Ù˘ “¶·È‰È·ÙÚÈ΋˜” ÙÔ˘ 2005 ‰ËÌÔÛȇıËηÓ: 19 ·Ó·ÛÎÔ‹ÛÂȘ 12 ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ 18 ÂӉȷʤÚÔÓÙ· ÂÚÈÛÙ·ÙÈο 3 Ú·ÎÙÈο ı¤Ì·Ù· ÁÈ· ÙÔ˘˜ «Î·Ú‰ÈÔÏÔÁÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ ÛÙË ·È‰È·ÙÚÈ΋ Ú¿ÍË», ÁÈ· Ù· «Î·Ú‰È·ÁÁÂȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ¿ÛÎËÛË Û ·È‰È¿, ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ» Î·È ÁÈ· «ÙÔÓ ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ ÛÙ· ·È‰È¿» 2 ÂȉÈο ¿ÚıÚ· ÁÈ· «ÙÔÓ ÚÔÏËÙÈÎfi ÁÂÓÂÙÈÎfi ¤ÏÂÁ¯Ô Î·È ı¤Ì·Ù· ËıÈ΋˜» Î·È ÁÈ· «ÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙË ÓÂÔÂÏÏËÓÈ΋ ÏÔÁÔÙ¯ӛ·».

1 Â›Î·ÈÚÔ ı¤Ì· ÁÈ· «ÙËÓ Â›‰Ú·ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘».

1 ÔÌÈÏ›· ÙÔ˘ ∫·ıËÁËÙ‹ ª·ÌÈÓÈÒÙË ÁÈ· ÙËÓ «∂ÏÏËÓÈ΋ ÁÏÒÛÛ·».

1 ÁÚ·Ùfi ™˘ÌfiÛÈÔ ÁÈ· «ÙÔÓ ¤ÊË‚Ô Ì ¯ÚfiÓÈÔ ÓfiÛËÌ·». ∆¤ÏÔ˜ Û·˜ ¢¯·ÚÈÛÙԇ̠ÁÈ· Ù· ¢ÁÂÓÈο Û·˜ Û¯fiÏÈ· ÁÈ· Ù· «¡¤· ·fi ÙÔ ‰È·‰›ÎÙ˘Ô» Î·È Ù· «∫ÏÈÓÈο Quiz». ∞fi ÙȘ 57 ‰ËÌÔÛȇÛÂȘ ÙÔ˘ 2005 ÔÈ: 21 (37%) ‹Ù·Ó ·fi ∫ÏÈÓÈΤ˜ ÙÔ˘ ∂™À Ù˘ ∞ı‹Ó·˜.

12 (21%) ·fi ÙȘ ¶·È‰È·ÙÚÈΤ˜ ¶·ÓÂÈÛÙËÌȷΤ˜ ∫ÏÈÓÈΤ˜ Ù˘ £ÂÛÛ·ÏÔӛ΢ (1 ÛÂ Û˘ÓÂÚÁ·Û›· Ì ∫ÏÈÓÈΤ˜ ÙÔ˘ ∂™À).

10 (18%) ·fi ¶·ÓÂÈÛÙËÌȷΤ˜ ∫ÏÈÓÈΤ˜ Ù˘ ∞ı‹Ó·˜ (2 ÛÂ Û˘ÓÂÚÁ·Û›· Ì ∫ÏÈÓÈΤ˜ ÙÔ˘ ∂™À), 4 ·fi ÙË ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∏Ú·ÎÏ›Ԣ.

3 ·fi ÙË ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ÙˆÓ πˆ·ÓÓ›ÓˆÓ.

3 ·fi Ù· ∆∂π ∞ı‹Ó·˜.

1 ·fi ÙË ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ §¿ÚÈÛ·˜.

1 ·fi ÙË ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∂™À ¶¿ÙÚ·˜.

2 ·fi ∫ÏÈÓÈΤ˜ ÂÎÙfi˜ ∂ÏÏ¿‰·˜. ∂Ï›˙ˆ fiÙÈ Î·È Ë ÂfiÌÂÓË ¯ÚÔÓÈ¿ Ì ÙË ‰È΋ Û·˜ Û˘Ì‚ÔÏ‹ ı· Â›Ó·È ÙÔ ›‰ÈÔ ‰ËÌÈÔ˘ÚÁÈ΋ Î·È ÌÂ Û˘Ó¤¯ÂÈ· Ù˘ ÚÔÛ¿ıÂÈ·˜ ÁÈ· ÔÈÔÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.

°È· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹

∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘

xix

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·399

∞¡∞™∫O¶∏™∏

399

¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿ ¢. ¶··Ó‰Ú¤Ô˘, M. ∂ÌÔÚÈ¿‰Ô˘

¶ÂÚ›ÏË„Ë ∏ Â›‰Ú·ÛË Ù˘ ‰›·ÈÙ·˜ ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ·ÈÙÈÔÏÔÁ›·˜ Î·È Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Â›Ó·È ·‚¤‚·ÈË. ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ù· ·ÓÙÈÔÍÂȉˆÙÈο, ÙÔ Ì·ÁÓ‹ÛÈÔ Î·È Ë Î·Ù·Ó¿ÏˆÛË ÏÈÒÓ ÌÔÚ› Ó· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ·Ú’ fiÏÔ Ô˘ Ë ÛËÌ·Û›· ·˘ÙÒÓ ÙˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÍÂοı·ÚË. ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ÚÔÛ·ıÔ‡Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·ÔÛ·Ê‹ÓÈÛË Ù˘ ÛËÌ·Û›·˜ Ù˘ ‰›·ÈÙ·˜ ÛÙÔ˘˜ ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ÂÓÒ ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ù· ·ÓÙÈÔÍÂȉˆÙÈο ·fi ÌfiÓ· ÙÔ˘˜ ÌÔÚ› Ó· Â›Ó·È Ôχ ˆÊ¤ÏÈÌ·. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ‰È·ÈÙËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÌÔÚ› Ó· Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·ÔÙ¤ÏÂÛ ÛËÌ·ÓÙÈÎfi ı¤Ì· ÌÂϤÙ˘ Ù· ÙÂÏÂ˘Ù·›· 10-15 ¯ÚfiÓÈ·, ÂÓÒ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ÂÓ¤ÏÂÍ·Ó ‰È¿ÊÔÚ· ȯÓÔÛÙÔȯ›·, ‚Èٷ̛Ә Î·È ÏÈ·Ú¿ Ôͤ· ÛÙËÓ ˘fiıÂÛË ·˘Ù‹. §¤ÍÂȘ ÎÏÂȉȿ ÕÛıÌ·, ·È‰È΋ ËÏÈΛ·, ‰È·ÙÚÔÊ‹, ‰›·ÈÙ·, Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹.

∂ÈÛ·ÁˆÁ‹ ∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· (µ∞) ·ÔÙÂÏ› ¤Ó· ·fi Ù· Û˘¯ÓfiÙÂÚ· ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (1,2) Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·fiÊÚ·ÍË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Ì ·Ó·ÛÙÚ¤„ÈÌÔ ¯·Ú·ÎÙ‹Ú· (3). ªÂ ‚¿ÛË Ù· ÈÔ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ, ÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ÔÚ›˙ÂÙ·È ˆ˜ “¯ÚfiÓÈ· ÊÏÂÁÌÔÓ҉˘ ‰È·Ù·Ú·¯‹ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, Ë ÔÔ›· Ô‰ËÁ› ÛÙËÓ ·‡ÍËÛË Ù˘ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ‰È¿ÊÔÚ· ÂÂÈÛfi‰È·, Ù· ÔÔ›· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÔÓÙ·È ·fi ÂÎÙÂٷ̤ÓË ·ÏÏ¿ ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ·fiÊÚ·ÍË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Ô˘ ÌÔÚ› Ó· ·Ó·ÛÙÚ·Ê› ·˘ÙfiÌ·Ù· ‹ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ıÂÚ·›·˜” (4). ∞fi Ù· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ‰È·ÊfiÚˆÓ ¯ˆÚÒÓ ÚÔ·ÙÂÈ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÙÔ˘ µ∞ ·˘Í¿ÓÂÙ·È Î·È ÔÈΛÏÏÂÈ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÏËı˘ÛÌÒÓ ·fi 0% ¤ˆ˜ 30% (4), ÂÓÒ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ófi ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È ·ÁÚÔÙÈÎfi. ∏ ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÂÓÂÚÁÔ‡ ·È‰ÈÎÔ‡ µ∞ ηٷÁÚ¿ÊËΠÛÙËÓ ∞˘ÛÙÚ·Ï›·, ÙË ¡¤· ∑ËÏ·Ó‰›· Î·È ÙËÓ ∞ÁÁÏ›· (5), ÂÓÒ Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ÛÙËÓ ∂ÏÏ¿‰· Î˘Ì·›ÓÂÙ·È Û 7-10%, fiˆ˜ Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ (4). À¿Ú¯Ô˘Ó ÛÙÔȯ›· Ô˘ ÂÈÛËÁÔ‡ÓÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·ÎÔÏÔ˘ı› ·˘ÍËÙÈ΋ ÔÚ›· (6,7). ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ù¿ÛË

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· ∂ÌÔÚÈ¿‰Ô˘ µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ ™Ù. ∫˘ÚȷΛ‰Ë 1, ∆.∫. 546 36, £ÂÛÛ·ÏÔÓ›ÎË ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-11-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-04-2005

ÛÙ·ıÂÚÔÔ›ËÛ˘ ÛÙË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ Î·È ÙË ıÓËÙfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (8-10). ∏ ‰È·›ÛÙˆÛË ·˘Ù‹ Ô‰ËÁ› Û ̛· Ó¤· ÚfiÎÏËÛË: ÙË Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÙfiÙËÙ·˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙÔ µ∞, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤ÙÚˆÓ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘ Î·È ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (11). ∏ ÂΉ‹ÏˆÛË ÙÔ˘ µ∞ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÈÛÙ‡ÂÙ·È fiÙÈ Î·ıÔÚ›˙ÂÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÔÈ ÔÔ›ÔÈ ‰È·ÎÚ›ÓÔÓÙ·È Û ÂÓ‰ÔÁÂÓ›˜ Î·È Â͈ÁÂÓ›˜. OÈ ÚÒÙÔÈ ·ÔÙÂÏÔ‡Ó Û˘ÁÁÂÓ‹ ‹ Â›ÎÙËÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·›˙Ô˘Ó ÚfiÏÔ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (¶›Ó·Î·˜ 1) (12,13). OÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙÚÔÔÔÈÔ‡Ó ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ¿ÛıÌ·ÙÔ˜ Û ¿ÙÔÌ· Ì ÚԉȿıÂÛË, ÂÓÒ ÔÚÈṲ̂ÓÔÈ ·fi ·˘ÙÔ‡˜ ÚÔηÏÔ‡Ó Î·È ¤Í·ÚÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÂÚÈÁÚ¿ÊÔÓÙ·È ˆ˜ ÂÎÏ˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (¶›Ó·Î·˜ 2) (2,14). ∏ Û¯¤ÛË ÌÂٷ͇ ‰›·ÈÙ·˜ Î·È ¿ÛıÌ·ÙÔ˜ ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘ Ì ÔÏϤ˜ ¶›Ó·Î·˜ 1. ∂Ó‰ÔÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ¿ÛıÌ·ÙÔ˜ º˘ÏÂÙÈÎÔ›-ÂıÓÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ °ÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi º‡ÏÔ ∂Ó‰ÔÌ‹ÙÚÈÔÈ Î·È ÂÚÈÁÂÓÓËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ £ËÏ·ÛÌfi˜ ∞ÙÔ›· ¶·È‰È·ÙÚÈ΋ 2005;68:399-407

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·400

400

¢. ¶··Ó‰Ú¤Ô˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 2. ¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ¿ÛıÌ·ÙÔ˜ ∫ÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ∞ÏÏÂÚÁÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË ¶·ıËÙÈÎfi οÓÈÛÌ· ∂·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË ∞ÙÌÔÛÊ·ÈÚÈ΋ Ú‡·ÓÛË §ÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¢›·ÈÙ·

‰È·ÛÙ¿ÛÂȘ. Œ¯ÂÈ ‚ÚÂı› fiÙÈ ˘¿Ú¯ÂÈ Û˘Û¯ÂÙÈÛÌfi˜ ÙÔ˘ ÂÈ¤‰Ô˘ ıÚ¤„˘ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ ¿ÛıÌ·ÙÔ˜, ·ÏÏ¿ Î·È ÙˆÓ ·ÙÔÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÁÂÓÈÎfiÙÂÚ· (15,16). ∞ÚÎÂÙÔ› ÂÚ¢ÓËÙ¤˜ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ Èı·Ó‹ Û¯¤ÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ì ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË Û ‰È¿ÊÔÚ˜ ÙÚÔʤ˜. ∏ Û¯¤ÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÛÙȘ ÙÚÔʤ˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ ¿ÛıÌ·ÙÔ˜ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ‚¤‚·ÈË, ˘¿Ú¯Ô˘Ó ˆÛÙfiÛÔ ÂӉ›ÍÂȘ fiÙÈ Ë ÂΉ‹ÏˆÛË ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜. ∆· ·È‰È¿ Ì ·ÏÏÂÚÁÈΤ˜ ÂÓÙÂÚÔ¿ıÂȘ ÂÌÊ·Ó›˙Ô˘Ó ¿ÛıÌ· Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Û ۇÁÎÚÈÛË Ì ¿ÏÏ· ·È‰È¿, ÈÛÙ‡ÂÙ·È fï˜ fiÙÈ ·˘Ùfi ·ÓÙ·Ó·ÎÏ¿ ÙË ÁÂÓÈÎfiÙÂÚË ÚԉȿıÂÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ó· ·Ó·Ù‡ÍÔ˘Ó ·ÏÏÂÚÁ›Â˜ Î·È fi¯È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Î¿ÔÈ· ÙÚÔÊ‹ ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ ¿ÛıÌ· (15,16). ∏ ÌÂϤÙË ÙˆÓ ·ÈÙ›ˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ¤Ú¢ӷ ÁÂÓÂÙÈÎÒÓ, ·ÙÔÈÎÒÓ, ÈÔÁÂÓÒÓ Î·È ‰È·ÈÙËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (17). ∫·Ù¿ ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ¤Ó·˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ÂȉÈο ÛÙË ‰È·ÙÚÔÊ‹ Î·È ÙÔ ¿ÛıÌ· (18-23). OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Û¯¤ÛË Ù˘ ‰È·ÙÚÔÊ‹˜ ˆ˜ ·ÈÙ›· ¿ÛıÌ·ÙÔ˜ Î·È ÛÙË ¯ÔÚ‹ÁËÛË ÂȉÈ΋˜ ‰›·ÈÙ·˜ ÁÈ· ÙË ıÂÚ·›· ÙÔ˘. ∂›Û˘, ¤¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ÔÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰È·ÈÙËÙÈ΋ ÚfiÛÏË„Ë Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Ô˘ÛÈÒÓ, fiˆ˜ ÔÈ ·ÓÙÈÔÍÂȉˆÙÈΤ˜ Ô˘Û›Â˜, ÙÔ Ì·ÁÓ‹ÛÈÔ Î·È Ù· ÏÈ·Ú¿ Ôͤ·, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ¿ÛıÌ·ÙÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· (3,24).

∂›‰Ú·ÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÛÙÔ ¿ÛıÌ· OÈ ÌÂϤÙ˜ Ô˘ ÂÍÂÙ¿˙Ô˘Ó ÙËÓ Â›‰Ú·ÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙÔÓ ·ÂÚÈÛÌfi ÙˆÓ Ó¢ÌfiÓˆÓ, ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (25-28). ™Â ·˘Ù¤˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› ‰È·Ù·Ú·¯‹ ÛÙȘ ÏÂȶ·È‰È·ÙÚÈ΋ 2005;68:399-407

ÙÔ˘ÚÁÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ·ÂÚÈÛÌÔ‡ ÙˆÓ Ó¢ÌfiÓˆÓ, Ë ÔÔ›· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ‚·ıÌfi Ù˘ ·¯˘Û·ÚΛ·˜, ÙÔ Ê‡ÏÔ Î·È ÙËÓ Î·Ù·ÓÔÌ‹ ÙÔ˘ Ï›Ô˘˜. ªÂÙ¿ ‰Â ÙËÓ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË Ù˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ÂÎÓ¢ÛÙÈÎÔ‡ fiÁÎÔ˘ Û ۯ¤ÛË Ì ÙȘ ·Ú¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ, ·ÎfiÌË Î·È Û ÂΛÓÔ˘˜ Ì ÌÈÎÚfiÙÂÚÔ˘ ‚·ıÌÔ‡ ·¯˘Û·ÚΛ· Î·È ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ·Ó·Ó¢ÛÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Î·Ù¿ ÙÔÓ ·Ú¯ÈÎfi ¤ÏÂÁ¯Ô. øÛÙfiÛÔ, Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ·fi ÌÂϤÙ˜ Û ·¯‡Û·ÚÎÔ˘˜ ÂÓ‹ÏÈΘ ‰ÂÓ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ÈÛ¯‡Ô˘Ó Î·È ÁÈ· ·¯‡Û·Úη ·È‰È¿, ηıÒ˜ Ë Î·Ù·ÓÔÌ‹ ÙÔ˘ Ï›Ô˘˜ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ‰È·Ê¤ÚÂÈ ·fi ÂΛÓË ÙˆÓ ÂÓËÏ›ÎˆÓ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ê‡ÏÔ. ∂›Ó·È Èı·Ófi Ë Â›‰Ú·ÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙÔÓ ıÒڷη Î·È ÙÔ ‰È¿ÊÚ·ÁÌ· Ó· ÂËÚ¿˙ÂÈ ÙȘ ·Ó·Ó¢ÛÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ηٿ ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ ÛÙ· ·È‰È¿ ·’ fi,ÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (25-28). ∏ Â›‰Ú·ÛË ÙÔ˘ ‚¿ÚÔ˘˜, ηٿ ÙË Á¤ÓÓËÛË Î·È ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ ÔÏÏÒÓ ÌÂÏÂÙÒÓ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· (29-31). À¿Ú¯Ô˘Ó ÛÙÔȯ›· Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™) ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (29). ªÂϤÙ˜ Û ÏËı˘ÛÌÔ‡˜ Ù˘ µfiÚÂÈ·˜ ∞ÌÂÚÈ΋˜ Î·È Ù˘ ∂˘ÚÒ˘ ‰È·›ÛÙˆÛ·Ó fiÙÈ Ù· ˘¤Ú‚·Ú· ¿ÙÔÌ· ÂÌÊ·Ó›˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ·ÛıÌ·ÙÈο Û˘ÌÙÒÌ·Ù· (30,31). ∂›Û˘, ¤Ú¢Ó˜ Û ÏËı˘ÛÌÔ‡˜ Ù˘ ∞ÊÚÈ΋˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÛÙȘ ÂÚÈÔ¯¤˜ Ì ¯·ÌËÏ¿ ÔÛÔÛÙ¿ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ Ù· ¿ÙÔÌ· Â›Ó·È ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Î·È ÂÏÏÈÔ‚·Ú‹ Û ۇÁÎÚÈÛË Ì ÙȘ ÂÚÈÔ¯¤˜ Ô˘ Ë ÂΉ‹ÏˆÛË ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ Â›Ó·È Û˘¯ÓfiÙÂÚË (30,31). ¶·Ú’ fiÏ· ·˘Ù¿, ‚Ú¤ıËΠfiÙÈ ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 10 ÂÙÒÓ ‰ÂÓ ÂËÚ¿˙ÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¿ÛıÌ·ÙÔ˜. OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ Û˘ÌʈÓÔ‡Ó Ì ÙË ıˆڛ· fiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ‚Ï¿ÙÔ˘Ó ÙËÓ ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙÔÓ ˘ÔΛÌÂÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ¿ÛıÌ·ÙÔ˜, ÂÓÒ Ë Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ¢ª™ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ÂÚÌËÓ¢Ù›. ∂ÈϤÔÓ, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ë ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ù· Û˘ÌÙÒÌ·Ù·, ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÂÓ Á¤ÓÂÈ ÙËÓ Î·Ù¿ÛÙ·ÛË Ù˘ ˘Á›·˜ ÙˆÓ ·¯‡Û·ÚÎˆÓ ·ÛıÂÓÒÓ Ì ¿ÛıÌ·, ÁÂÁÔÓfi˜ Ô˘ ÂÓÈÛ¯‡ÂÈ ÙËÓ ¿Ô„Ë fiÙÈ Ë ·¯˘Û·ÚΛ· ÌÔÚ› Ó· ÂȉÂÈÓÒÓÂÈ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (32,33).

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·401

401

¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿

¢È·ÈÙËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ¿ÛıÌ· ∞ÓÙÈÔÍÂȉˆÙÈο ¶ÈÛÙ‡ÂÙ·È fiÙÈ ÔÈ ÔÍÂȉˆÙÈΤ˜ ‰È·‰Èηۛ˜ Ô˘ Á›ÓÔÓÙ·È Û οı ·ÙÙ·ÚÔ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Û˘ÓÂÈÛʤÚÔ˘Ó ÛÙËÓ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ‰È¿ÊÔÚ˜ ‚Ï¿‚˜ (34). Œ¯ÂÈ ‚ÚÂı› fiÙÈ Ù· ·ÓÙÈÔÍÂȉˆÙÈο, fiˆ˜ Ë ‚ÈÙ·Ì›ÓË C Î·È Ë ‚ÈÙ·Ì›ÓË ∂, ÌÔÚÔ‡Ó Ó· ÚÔÏ¿‚Ô˘Ó ·˘Ù¤˜ ÙȘ ÔÍÂȉˆÙÈΤ˜ ‚Ï¿‚˜, ÙfiÛÔ ÛÙÔ ¿ÛıÌ· fiÛÔ Î·È ÛÙË ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ ∫›Ó· ·Ú·ÙËÚ‹ıËΠ̛· ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ Ù˘ ‰È·ÈÙËÙÈ΋˜ ÚfiÛÏ˄˘ ‚ÈÙ·Ì›Ó˘ C Î·È Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (35). ™ÙË ÌÂϤÙË ·˘Ù‹ ‚Ú¤ıËΠfiÙÈ Ë ·˘ÍË̤ÓË ÚfiÛÏË„Ë ‚ÈÙ·Ì›Ó˘ C ηٿ 100 mg ËÌÂÚËÛ›ˆ˜ Û¯ÂÙ›˙ÂÙ·È Ì ·‡ÍËÛË ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ ηٿ ÚÔÛ¤ÁÁÈÛË 22 ml ÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ (FEV1) Î·È Î·Ù¿ 25 ml Ù˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (FVC). ™˘Á¯ÚfiÓˆ˜, Ì›· ¿ÏÏË ¤Ú¢ӷ ·fi ÙËÓ ∂Ï‚ÂÙ›· ÂȂ‚·›ˆÛ ÙË Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂÈ¤‰ˆÓ FEV1 Î·È FVC Î·È Ù˘ ÚfiÛÏ˄˘ ‚ÈÙ·Ì›Ó˘ C Î·È ‚-ηÚÔÙÂÓ›ˆÓ (36). ∆Ô 1999, ÔÈ Bodner Î·È Û˘Ó ·fi ÙË ™ÎˆÙ›·, ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ӷ Â›‰· ÚfiÛÏ˄˘ ‚ÈÙ·Ì›Ó˘ ∂, Ì ÌÂȈ̤ӷ Â›‰· ‚ÈÙ·Ì›Ó˘ C ÛÙÔ Ï¿ÛÌ· Î·È Ì ÌÂȈ̤ÓË ·Ó·ÏÔÁ›· ·-ÙÔÎÔÊÂÚfiÏ˘/ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ (37). ¶·Ú·ÙËÚ‹ıËÎÂ, ‰ËÏ·‰‹, fiÙÈ Ë ÚfiÛÏË„Ë ‚ÈÙ·ÌÈÓÒÓ C Î·È ∂, Ù· Â›‰· ·ÛÎÔÚ‚ÈÎÔ‡ ÛÙÔ Ï¿ÛÌ· Î·È Ë ·Ó·ÏÔÁ›· ·-ÙÔÎÔÊÂÚfiÏ˘/ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÙÔ˘ ÔÚÔ‡ Û¯ÂÙ›˙ÔÓÙ·È ·ÓÙ›ÛÙÚÔÊ· Ì ÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ¿ÛıÌ·ÙÔ˜, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ηÓÈÛÙ¤˜. ¶·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ (37,38) ·Ó¤ÊÂÚ·Ó Ì›· Û¯¤ÛË ÌÂٷ͇ Ù˘ ¯·ÌËÏ‹˜ ÚfiÛÏ˄˘ ÊÚÔ‡ÙˆÓ Î·È ‚ÈÙ·Ì›Ó˘ C Î·È Ù˘ ÌÂȈ̤Ó˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ·‡ÍËÛË ÛÙËÓ Î·Ù·Ó¿ÏˆÛË ÊÚÔ‡ÙˆÓ Î·Ù¿ 10% ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û Ì›ˆÛË ÙˆÓ ÔÛÔÛÙÒÓ ¯ÚfiÓÈˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ·ı‹ÛÂˆÓ Î·Ù¿ 51%. ª›· ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ù· ¿ÙÔÌ· Ô˘ Ì›ˆÛ·Ó ÙËÓ Î·Ù·Ó¿ÏˆÛË ÊÚÔ‡ÙˆÓ ÁÈ· 7 ¯ÚfiÓÈ· ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ FEV1 Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ‰ÂÓ Î·Ù·Ó¿ÏˆÓ·Ó Û˘¯Ó¿ ÊÚÔ‡Ù· (39). ¶·Ú’ fiÏ· ·˘Ù¿, Ù· ¿ÙÔÌ· Ô˘ ›¯·Ó Û˘Ó¯Ҙ ¯·ÌËÏ‹ ÚfiÛÏË„Ë ÊÚÔ‡ÙˆÓ ·ÚÔ˘Û›·Û·Ó ÙËÓ ›‰È· Ì›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ٷ ¿ÙÔÌ· Ô˘ ›¯·Ó

˘„ËÏfiÙÂÚ˜ ÚÔÛÏ‹„ÂȘ. ∏ ·Ú·Ù‹ÚËÛË ·˘Ù‹ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋, ηıÒ˜ ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ˆÊ¤ÏÈ̘ ÂȉڿÛÂȘ ÙˆÓ ÊÚÔ‡ÙˆÓ ÛÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ·Ó·ÛÙÚ¤„È̘ (39). ∏ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÙˆÓ ÊÚÔ‡ÙˆÓ ÛÙËÓ ÂÌÊ¿ÓÈÛË ·ÛıÌ·ÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ·Ú·ÙËÚ‹ıËÎÂ Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜, fï˜ Ë ‰Ú¿ÛË ·˘Ù‹ Ê¿ÓËΠӷ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË ÛÙÔ˘˜ ÚÒËÓ Î·È Ó˘Ó Î·ÓÈÛÙ¤˜, Èı·ÓÒ˜ ÏfiÁˆ Ù˘ ¤ÎıÂÛ˘ ÛÙÔÓ Î·Ófi (40). ª›· ¿ÏÏË ÔÌ¿‰· ÙÚÔÊ›ÌˆÓ ÏÔ‡ÛÈ· Û ÔÍÂȉˆÙÈο Â›Ó·È Ù· Ï·¯·ÓÈο. OÈ Grievink Î·È Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ‚ÈÙ·Ì›Ó˘ C Î·È ‚ÈÙ·Ì›Ó˘ ∂ Ì ‹ ¯ˆÚ›˜ ‚-ηÚÔÙ¤ÓÈ· ÁÈ· ÂÚ›Ô˘ 3 Ì‹Ó˜, Ì›ˆÛ ÙË ÛÙ¤ÓˆÛË ÙˆÓ ‚ÚfiÁ¯ˆÓ ·fi ÙÔ fi˙ÔÓ Û Ô‰ËÏ¿Ù˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË (41,42), ÂÓÒ Û ̛· ¿ÏÏË ¤Ú¢ӷ ÛÙÔ ªÂÍÈÎfi, fiÔ˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Û˘ÌÏËÚÒÌ·Ù· ‚ÈÙ·Ì›Ó˘ C, ‚ÈÙ·Ì›Ó˘ ∂ Î·È ‚-ηÚÔÙÂÓ›ˆÓ, ·Ú·ÙËÚ‹ıËΠfiÙÈ ·˘Ù¿ ÂÌfi‰ÈÛ·Ó ÙË Ì›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ÂÚÁ¿Ù˜ Ô˘ ÂÎÙ›ıÂÓÙ·È ÛÙÔ fi˙ÔÓ (43). º·›ÓÂÙ·È Î·È Â‰Ò fiÙÈ Ë Î·Ù·Ó¿ÏˆÛË ÙˆÓ Ï·¯·ÓÈÎÒÓ Û¯ÂÙ›˙ÂÙ·È ·ÓÙ›ÛÙÚÔÊ· Ì ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Ë Â›‰Ú·ÛË ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÛÙ¤ÓˆÛ˘ ÙˆÓ ‚ÚfiÁ¯ˆÓ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ¤ÎıÂÛË ÛÙÔ fi˙ÔÓ ˘ÔÛÙËÚ›˙ÂÈ ÙËÓ ˘fiıÂÛË fiÙÈ Â͈ÁÂÓ‹ ÔÍÂȉˆÙÈο Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ∆· ·ÓÙÈÔÍÂȉˆÙÈο, ÂÔ̤ӈ˜, Â›Ó·È Ì›· ηÙËÁÔÚ›· ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ Ô˘ ·Í›˙ÂÈ Ó· ‰Ôı› ÌÂÁ·Ï‡ÙÂÚË ÚÔÛÔ¯‹.

ª·ÁÓ‹ÛÈÔ ∏ Â›‰Ú·ÛË ÙÔ˘ ‰È·ÈÙËÙÈÎÔ‡ Ì·ÁÓËÛ›Ô˘ ÛÙÔ ¿ÛıÌ· ÚÔÛ¤Ï΢Û ÙËÓ ÚÔÛÔ¯‹ ÔÏÏÒÓ ÂÚ¢ÓËÙÒÓ (34,43,44). µÚ¤ıËÎÂ, ÏÔÈfiÓ, fiÙÈ Ë ÚfiÛÏË„Ë ÙÔ˘ ‰È·ÈÙËÙÈÎÔ‡ Ì·ÁÓËÛ›Ô˘ (·Ì‡Á‰·Ï·, ÊÈÛÙ›ÎÈ·, Û·Ó¿ÎÈ, ÛÔÎÔÏ¿Ù· Î.¿.) Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙË ‚ÚÔÁ¯È΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È ÚÔηÏ› ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ Û ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ™Â Ì›· ¤Ú¢ӷ Ô˘ ¤ÁÈÓ Û ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È Û ·ÛıÂÓ›˜ Ì ÚÈÓ›Ùȉ· ‚Ú¤ıËΠ̛· ·ÓÙ›ÛÙÚÔÊË Û¯¤ÛË ÌÂٷ͇ Ù˘ ‚ÚÔÁ¯È΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ì·ÁÓËÛ›Ô˘ (44), ÂÓÒ Ì›· ·ÚfiÌÔÈ· Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ¯·ÌËÏÒÓ ÂÈ¤‰ˆÓ Ì·ÁÓËÛ›Ô˘ ̤۷ ÛÙÔÓ ÈÛÙfi Î·È Ù˘ ˘ÂÚÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚ÚfiÁ¯ˆÓ ·Ú·ÙËÚ‹ıËΠ̛۠· ·ÎfiÌË ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ·ÛıÌ·ÙÈο Î·È ÌË ¿ÙÔÌ· (45). ™ÙËÓ ›‰È· ¤Ú¢ӷ, Ô Emelyanov (45) ¤‰ÂÈÍ fiÙÈ ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË Î·Ù·ÎÚ¿ÙËÛË Ì·ÁÓËÛ›Ô˘ ÛÙ· ·ÛıÌ·ÙÈο ¶·È‰È·ÙÚÈ΋ 2005;68:399-407

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·402

402

¢. ¶··Ó‰Ú¤Ô˘ Î·È Û˘Ó.

¿ÙÔÌ· fiÙ·Ó ˘Ô‚Ï‹ıËÎ·Ó Û ¤ÏÂÁ¯Ô ‰ÔÎÈÌ·Û›·˜ Ì·ÁÓËÛ›Ô˘, ·Ô‰ÂÈÎÓ‡ÔÓÙ·˜ fiÙÈ ˘¿Ú¯ÂÈ Â›Ù ̛· Èı·Ó‹ ‰È·ÈÙËÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ›Ù ·˘ÍË̤Ó˜ ·Ó¿ÁΘ ÙˆÓ ·ÙfiÌˆÓ Û ̷ÁÓ‹ÛÈÔ ÂÍ·ÈÙ›·˜ Ù˘ ·ıÔÁ¤ÓÂÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (45).

ø-3 Î·È ˆ-6 ÏÈ·Ú¿ Ôͤ· Î·È Ë Û¯¤ÛË ÙÔ˘˜ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ∆· ˆ-3 Î·È ˆ-6 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· ıˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÛÙÔȯ›· ÛÙË ‰›·ÈÙ· ÙÔ˘ ·ÓıÚÒÔ˘. øÛÙfiÛÔ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ fiÛÔ Û˘Ì‚¿ÏÏÔ˘Ó ÔÈ ‰È¿ÊÔÚ˜ ÙÚÔʤ˜ ÛÙËÓ ÚfiÛÏË„‹ ÙÔ˘˜ (46). ∞ÚÎÂÙ¤˜ ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Û ·ÓıÚÒÔ˘˜ ÛÙËÚ›˙Ô˘Ó ÙËÓ Èı·ÓfiÙËÙ· Ó· ˘¿Ú¯ÂÈ Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Ù˘ ‰È·ÙÚÔÊ‹˜ Î·È ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ı‹ÛˆÓ. ∞ӷʤÚÂÙ·È fiÙÈ ÛÙ· ·ÙÔÈο ¿ÙÔÌ· Ë Û¯¤ÛË ˆ-3/ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi Ù· ÌË ·ÙÔÈο ˘ÁÈ‹ ¿ÙÔÌ· (47). ∆Ô ÂӉȷʤÚÔÓ ÁÈ· ÙËÓ ‡·ÚÍË Û¯¤Û˘ ÌÂٷ͇ ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Ù˘ ‰›·ÈÙ·˜ Î·È ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛËÌÂÈÒıËΠÚÈÓ ÔÏÏ¿ ¯ÚfiÓÈ· (48), ·ÏÏ¿ ¤ÁÈÓ ÂÓÙÔÓfiÙÂÚÔ ÌÂÙ¿ ÙËÓ ·ÔÛ·Ê‹ÓÈÛË ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ ÔͤԘ ÛÙË Ú‡ıÌÈÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È Ù˘ ·ÓÔÛ›·˜ Î·È ÙË ÁÓÒÛË fiÙÈ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ ÔͤԘ ÌÔÚ› Ó· ·Ó·ÛÙ·Ï› ·fi ÙÔ ÂÈÎÔÛÈÂÓÙ·ÂÓÔ˚Îfi (∂ƒ∞) Î·È ÙÔ ÂÈÎÔÛȉÈÂÍ·ÂÓÔ˚Îfi Ô͇ (DHA) (49). ™ÙË ÌÂϤÙË ÙˆÓ Haby Î·È Û˘Ó (50) ‚Ú¤ıËΠfiÙÈ Ë ˘„ËÏ‹ ηٷӿψÛË ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Î·È ÚÔÙ¿ıËΠfiÙÈ Ë Ì›ˆÛË Ù˘ ηٷӿψÛ˘ Ù¤ÙÔÈˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÌÔÚ› Ó· ‚ÂÏÙÈÒÛÂÈ Ù· ÔÛÔÛÙ¿ ¿ÛıÌ·ÙÔ˜. ¶·Ú’ fiÏ· ·˘Ù¿, Ê·›ÓÂÙ·È fiÙÈ Ù· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ÙË Û‡ÛÙ·ÛË ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ Î·È fi¯È ·fi ÙË Û˘ÓÔÏÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ¿ ÙÔ˘˜ ÛÙË ‰›·ÈÙ·. ∆Ô Úfi‚ÏËÌ· ËÁ¿˙ÂÈ Î˘Ú›ˆ˜ ·fi ÙËÓ ·ÓÈÛÔÚÚÔ›· ÙˆÓ ˆ-6 Î·È ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ. ∏ ·˘ÍË̤ÓË ÚfiÛÏË„Ë ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ Ì ÙË ‰È·ÙÚÔÊ‹ Ô‰ËÁ› Û ÂÏ¿ÙÙˆÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ ÔͤԘ Î·È Ì›ˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÙˆÓ ‰Ú·ÛÙÈÎÒÓ ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ. ∂ÈϤÔÓ, ÈÛÙ‡ÂÙ·È fiÙÈ ÔÚÈṲ̂ӷ ÏÈ·Ú¿ Ôͤ· ‰ÚÔ˘Ó ¿ÌÂÛ· ˆ˜ ‰È·‚È‚·ÛÙ¤˜ Î·È ÂËÚ¿˙Ô˘Ó ÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (51,52). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ÛÙÔÓ ÂÏÏ·‰ÈÎfi ¯ÒÚÔ (53) ‚Ú¤ıËΠfiÙÈ ˘¿Ú¯ÂÈ Û¯¤ÛË ÌÂٷ͇ ‰›·ÈÙ·˜ (ˆ-3/ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ) Î·È ¿ÛıÌ·ÙÔ˜. ∂ȉȶ·È‰È·ÙÚÈ΋ 2005;68:399-407

ÎfiÙÂÚ·, ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Â›‰· ÌÂȈ̤ÓÔ˘ ·-ÏÈÓÔÏÂ˚ÎÔ‡ ÔͤԘ (18:3ˆ-3), ηıÒ˜ Î·È ·˘ÍË̤ÓÔ˘ ∂ƒ∞ (20:5ˆ-3), ÂÈÎÔÛȉÈÂÓÙ·ÂÓÔ˚ÎÔ‡ ÔͤԘ (22:5ˆ-3) Î·È DHA (22:6ˆ3) ÛÙÔ Ï¿ÛÌ· ÙˆÓ ·È‰ÈÒÓ Ì ¿ÛıÌ· Û ۯ¤ÛË Ì ˘ÁÈ‹ ·È‰È¿. ŸÌˆ˜, Ô Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‰ÂÓ ÂÈÙÚ¤ÂÈ ·ÎfiÌË Ô‰ËÁ›Â˜ ·ÏÏ·Á‹˜ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿. ¶ÏÔ‡ÛÈ· ËÁ‹ ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ EPA Î·È DHA ·ÔÙÂÏÔ‡Ó Ù· ȯı˘¤Ï·È·. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ÛÙÔÓ ¿ÓıÚˆÔ Ô‰ËÁ› Û ·‡ÍËÛË Ù˘ ÔÛfiÙËÙ·˜ ∂ƒ∞ Î·È DHA ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙˆÓ ÌÔÓÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (54,55). ¶·Ú¿ÏÏËÏ·, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ Û ·Ú·¯È‰ÔÓÈÎfi Ô͇. ŒÙÛÈ, ÌÂÈÒÓÂÙ·È Ë ÔÛfiÙËÙ· ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ ÔͤԘ Ô˘ Â›Ó·È ‰È·ı¤ÛÈÌÔ ˆ˜ ˘fiÛÙڈ̷ ÁÈ· ÙË Û‡ÓıÂÛË ÂÈÎÔÛ·ÓÔÂȉÒÓ, ÂÓÒ ÙÔ ∂ƒ∞ ·ÔÙÂÏ› ÂÈϤÔÓ ·Ó·ÛÙÔϤ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ ÔͤԘ, ¤¯ÔÓÙ·˜ ¤ÙÛÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ Û˘Ìو̿وÓ.

OÈ Sakai Î·È Û˘Ó (1990) Î·È ÔÈ Okuyama Î·È Û˘Ó (1992) ÂÈÛËÁ‹ıËÎ·Ó ÙËÓ ¿Ô„Ë fiÙÈ Ë ·‡ÍËÛË Ù˘ Û¯¤Û˘ ÙˆÓ ˆ-3/ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙȘ ÙÚÔʤ˜ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ì›ˆÛË Ù˘ ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘. ∆· ˆ-3 Î·È ˆ-6 ÏÈ·Ú¿ Ôͤ· ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÛÙ· ‰È¿ÊÔÚ· ÛÙ¿‰È· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (56,57). ∫·Ù¿ Û˘Ó¤ÂÈ·, Ù· ˆ-3 Î·È ˆ-6 ÏÈ·Ú¿ Ôͤ· ‰ÂÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ù·˘Ùfi¯ÚÔÓ· ÁÈ· ÙË ıÂÚ·›· Ù˘ ·ÙÔ›·˜. ŒÙÛÈ, Ë ÈÛÔÚÚÔ›· ÙˆÓ ˆ-3 Î·È ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ı¤Ì· ÛÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ™ÙË ¢ÈÂıÓ‹ ŒÚ¢ӷ ÙÔ˘ ÕÛıÌ·ÙÔ˜ Î·È ÙˆÓ ∞ÏÏÂÚÁÈÒÓ ÛÙËÓ ¶·È‰È΋ ∏ÏÈΛ· (58) ‚Ú¤ıËΠ̛· ÈÛ¯˘Ú‹ Û¯¤ÛË ÌÂٷ͇ Ù˘ ηٷӿψÛ˘ Ê˘ÙÈÎÒÓ ÂÏ·›ˆÓ Î·È ÙˆÓ ÂÈ¤‰ˆÓ ÏÈÓÔÏÂ˚ÎÔ‡ ÔͤԘ ÛÙÔÓ ÔÚfi Ì ٷ Û˘ÌÙÒÌ·Ù· ¿ÛıÌ·ÙÔ˜, ÚÈÓ›Ùȉ·˜ Î·È ÂÎ˙¤Ì·ÙÔ˜ ÛÙ· ·È‰È¿. ∂›Û˘, ‚Ú¤ıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ÂıÓÈ΋˜ ÚfiÛÏ˄˘ trans ÏÈ·ÚÒÓ ÔͤˆÓ - Ù· ÔÔ›· ‚Ú›ÛÎÔÓÙ·È ÛÙ· ˘‰ÚÔÁÔӈ̤ӷ Ê˘ÙÈο Ï›Ë (fiˆ˜ Ë Ì·ÚÁ·Ú›ÓË) Î·È ÛÙ· Á·Ï·ÎÙÔÎÔÌÈο ÚÔ˚fiÓÙ· - Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ Î·È ·ÏÏÂÚÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Û ·È‰È¿ Û 10 ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ (59). øÛÙfiÛÔ, ÛÙËÓ ›‰È· ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠη̛· ·ÚfiÌÔÈ· Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÚfiÛÏË„Ë ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·403

403

¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿

∏ ˘fiıÂÛË fiÙÈ Ë Î·Ù·Ó¿ÏˆÛË „·ÚÈÒÓ Î·È ÔÈ ËÁ¤˜ ÏÔ‡ÛȘ Û ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· ÌÔÚÔ‡Ó Ó· ÚÔÛٷهÛÔ˘Ó ·fi ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù· ¤ÁÈÓ ÛÙfi¯Ô˜ Ì›·˜ ÌÂϤÙ˘ (60), ÛÙËÓ ÔÔ›· ‰ÂÓ ‚Ú¤ıËΠη̛· ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ Ù˘ ηٷӿψÛ˘ „·ÚÈÒÓ Î·È ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Û˘Ìو̿وÓ. ∞ÓÙ›ıÂÙ·, Ë ªÂϤÙË ÙˆÓ ∂Ù¿ ÈÚÒÓ ‚ڋΠfiÙÈ ˘¿Ú¯ÂÈ Ì›· ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË Ù˘ ηٷӿψÛ˘ „·ÚÈÒÓ ÛÙË ıÓËÛÈÌfiÙËÙ· ·fi ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÒÛÙ οı ·‡ÍËÛË ÛÙËÓ Î·Ù·Ó¿ÏˆÛË „·ÚÈÒÓ Î·Ù¿ 10% ı· ÌÔÚÔ‡Û ӷ Ô‰ËÁ‹ÛÂÈ Û Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ηٿ 3% (38). ∆ÚÔʤ˜ ÏÔ‡ÛȘ Û ÎÔÚÂṲ̂ӷ ÏÈ·Ú¿ Ôͤ·, fiˆ˜ ÙÔ Ï·Ú‰›, ÙÔ ‚Ô‰ÈÓfi Ï›Ô˜ Î·È ÙÔ ˘‰ÚÔÁÔӈ̤ÓÔ Ï¿‰È Ù˘ ηڇ‰·˜, ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ‰È·ÈÙËÙÈ΋˜ ·Ú¤Ì‚·Û˘ (61). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜, fï˜, ÂÚÈÙÒÛÂȘ Á›ÓÔÓÙ·È Û˘ÁÎÚ›ÛÂȘ Ì ‰›·ÈÙ˜ ¯·ÌËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ϛÔ˜ Î·È fi¯È Ì ‰›·ÈÙ˜ Ì ÛËÌ·ÓÙÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ·ÎfiÚÂÛÙ· ‹ ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ù· ÎÔÚÂṲ̂ӷ ÏÈ·Ú¿ Ôͤ· ‰ÂÓ ·ÛÎÔ‡Ó ÛËÌ·ÓÙÈ΋ Â›‰Ú·ÛË ÛÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÛÙËÓ ·Ú·ÁˆÁ‹ ΢ÙÔÎÈÓÒÓ Ù‡Ô˘ Th1 ‹ Th2 Î·È ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ê˘ÛÈÎÒÓ ÊÔÓ¤ˆÓ (61,62).

∂›‰Ú·ÛË ÙˆÓ ÙÚÔÊ›ÌˆÓ ÛÙÔ ¿ÛıÌ· ∆· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Â›‰Ú·ÛË Ù˘ ‰È·ÙÚÔÊ‹˜ ÛÙÔ ¿ÛıÌ· ·ÊÔÚÔ‡Û·Ó ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ıÚÂÙÈο Û˘ÛÙ·ÙÈο ÙˆÓ ÙÚÔÊ›ÌˆÓ (3,24). ¶ÚfiÛÊ·Ù·, ÚԤ΢„Â Ë ·Ó¿ÁÎË ‰ÈÂÚ‡ÓËÛ˘ ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ÙÚÔÊ›ÌˆÓ ÛÙÔ

¿ÛıÌ·. OÈ Rosalie Woods Î·È Û˘Ó, ÛÙËÓ ¤ÚÂ˘Ó¿ ÙÔ˘˜ Ô˘ ‰ÈÂÍ‹¯ıË ÙÔ 2003, ‰ÈÂÚ‡ÓËÛ·Ó Â¿Ó ÔÈ ÚÔÛÏ‹„ÂȘ ÙÚÔÊ›ÌˆÓ Î·È ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÙfiÌˆÓ ‰È·Ê¤ÚÔ˘Ó ·fi ÂΛӘ ÙˆÓ ·ÙfiÌˆÓ ¯ˆÚ›˜ ¿ÛıÌ·. OÈ Î·ÙËÁÔڛ˜ ÙÚÔÊ›ÌˆÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ¯ˆÚ›ÛÙËÎ·Ó Û 3 ÔÌ¿‰Â˜ Ì ‚¿ÛË ÙË Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙÔ ¿ÛıÌ· (ıÂÙÈ΋, ·ÚÓËÙÈ΋ Î·È Ô˘‰¤ÙÂÚË Û˘Û¯¤ÙÈÛË) Î·È Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∞fi ÙË ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ ÔÚÈṲ̂ӷ ÙÚfiÊÈÌ· - Î·È fi¯È Û˘ÁÎÂÎÚÈ̤ӷ ıÚÂÙÈο Û˘ÛÙ·ÙÈο - Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ¿ÛıÌ·. ∏ Û¯¤ÛË Ô˘ ·Ú·ÙËÚ‹ıËΠÌÂٷ͇ ÙˆÓ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‹Ù·Ó ·ÚÔÛ‰fiÎËÙË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ‚Ú¤ıËΠfiÙÈ ÙÔ Ï‹Ú˜ Á¿Ï· Î·È ÙÔ ‚Ô‡Ù˘ÚÔ Û¯ÂÙ›˙ÔÓÙ·È ·ÚÓËÙÈο Ì ÙÔ ¿ÛıÌ·, ÂÓÒ ¿ÏÏ· ÙÚfiÊÈÌ·, fiˆ˜ Ù· ·Ó·„˘ÎÙÈο ÛfiÁÈ·˜, ÙÔ Ù˘Ú› ÚÈÎfiÙ· Î·È Ù· Ù˘ÚÈ¿ ¯·ÌËÏÒÓ ÏÈ·ÚÒÓ, Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔ ¿ÛıÌ·. ª›· Èı·Ó‹ ÂÍ‹ÁËÛË ·˘ÙÒÓ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Â›Ó·È fiÙÈ ÛÙ· ¿ÙÔÌ· Ì ¿ÛıÌ· Ô˘ ·ÏÏ¿˙Ô˘Ó ÙÔ Â›‰Ô˜ ÙˆÓ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ Ô˘ ηٷӷÏÒÓÔ˘Ó ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ¿ıËÛ˘ (.¯. ·ÓÙÈηıÈÛÙÔ‡Ó ÙÔ Ï‹Ú˜ Á¿Ï· Ì ·Ó·„˘ÎÙÈο ÛfiÁÈ·˜ Î·È Ù˘ÚÈ¿ ¯·ÌËÏÒÓ ÏÈ·ÚÒÓ), ·Ú·ÙËÚÂ›Ù·È ‚ÂÏÙ›ˆÛË Ù˘ ηٿÛÙ·Û‹˜ ÙÔ˘˜. ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ¿ÙÔÌ· Ì ˘„ËÏ‹ ÚfiÛÏË„Ë ÊÚÔ‡ÙˆÓ Î·È Ï·¯·ÓÈÎÒÓ (Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Î·È ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ) ÂÌÊ·Ó›˙Ô˘Ó ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ Î·È Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ·ı‹ÛˆÓ. ¶·Ú’ fiÏ· ·˘Ù¿, Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ô‰Ôı› ·˘Ù‹ Ë ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÌfiÓÔ ÛÙ· ·ÓÙÈÔÍÂȉˆÙÈο, ‰ÈfiÙÈ Ù· ÊÚÔ‡Ù· Î·È Ù· Ï·¯·ÓÈο ÂÚȤ¯Ô˘Ó Î·È ÔÏÏ¿ ¿ÏÏ· Û˘ÛÙ·ÙÈο, Ô ÚfiÏÔ˜ ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ ¤¯ÂÈ

¶›Ó·Î·˜ 3. ™˘Û¯¤ÙÈÛË ÙˆÓ ÙÚÔÊ›ÌˆÓ Ì ÙÔ ¿ÛıÌ· ™˘Û¯¤ÙÈÛË £ÂÙÈ΋ ñ °¿Ï· ÛfiÁÈ·˜ ñ ∆˘ÚÈ¿ ¯·ÌËÏÒÓ ÏÈ·ÚÒÓ ñ ∆˘Ú› ÚÈÎfiÙ·

∞ÚÓËÙÈ΋ ñ ¶Ï‹Ú˜ Á¿Ï· ñ ª‹Ï· ñ ∞¯Ï¿‰È· ñ ¡ÙÔÌ¿Ù˜ ñ µÔ‡Ù˘ÚÔ ñ æ¿ÚÈ·

O˘‰¤ÙÂÚË ñ ¢ËÌËÙÚȷο ÚˆÈÓÔ‡, Ú‡˙È, ˙˘Ì·ÚÈο, „ˆÌ›, ÎÚ¿ÎÂÚ, ÌÈÛÎfiÙ· Î·È Î¤ÈÎ, ›ÙÛ· Î·È hamburger ñ ∫ڤ̷ Á¿Ï·ÎÙÔ˜ Î·È ÁÈ·Ô‡ÚÙÈ ñ ∫fiÎÎÈÓÔ ÎÚ¤·˜, ÎÔÙfiÔ˘ÏÔ, ¿ÏÏ· ÎÚ¤·Ù·, ·˘Á¿, ÍËÚÔ› ηÚÔ› (Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÙÔ˘ ÊÈÛÙÈÎÔ‚Ô‡Ù˘ÚÔ˘), fiÛÚÈ· ñ ŸÏ·, ÂÛÂÚȉÔÂȉ‹, ‚ÂÚ›ÎÔη, ÚÔ‰¿ÎÈÓ·, ·‚ÔοÓÙÔ, Ì·Ó¿Ó˜, ÎÂÚ¿ÛÈ·, ÂfiÓÈ·, Ì‹Ï·, ·¯Ï¿‰È·, ÙÚÔÈο ÊÚÔ‡Ù· (·Ó·Ó¿˜, Ì¿ÓÁÎÔ), ¿ÏÏ· (ÎÔÓÛÂÚ‚ÔÔÈË̤ӷ, ηÙ„˘Á̤ӷ) Î·È ¯˘ÌÔ› ÊÚÔ‡ÙˆÓ ñ ŸÏ·, Ú›˙˜ (·Ù¿Ù˜, ·ÓÙ˙¿ÚÈ·, ηÚfiÙ·), ÌÚfiÎÔÏÔ, ÎÔ˘ÓÔ˘›‰È, Ï¿¯·ÓÔ, Ú¿ÛÈÓ· Ê˘ÏÏÒ‰Ë (Ì·ÚÔ‡ÏÈ, ·ÓÙ›‰È), ·ÁÁÔ‡ÚÈ, ÎÔÏÔ·ıÈ, Û¤ÏÈÓÔ, ‚ÔÏ‚Ô› (ÛÎfiÚ‰Ô, ÎÚÂÌ̇‰È), ÏÔ‚Ô› (·Ú·Î¿˜, Ê·ÛfiÏÈ·), ÈÂÚȤ˜ Î·È Ì·ÓÈÙ¿ÚÈ· ñ ŸÏ·, Ì‡Ú·, ÎÚ·Û› Î·È ¿ÏÏ· ñ ™ÔÎÔÏ¿Ù·, ·Ù·Ù¿ÎÈ· Ì ÓÈÊ¿‰Â˜ ηϷÌÔÎÈÔ‡, ·ÚˆÌ·ÙÈÎfi Á¿Ï·, ˙¿¯·ÚË, Ì·ÚÌÂÏ¿‰·, ̤ÏÈ ¶·È‰È·ÙÚÈ΋ 2005;68:399-407

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·404

404

¢. ¶··Ó‰Ú¤Ô˘ Î·È Û˘Ó.

·ÎfiÌ· ÂÚ¢ÓËı› (63). ™ÙËÓ ·Ú·¿Óˆ ¤Ú¢ӷ ‚Ú¤ıËΠfiÙÈ Ë Î·Ù·Ó¿ÏˆÛË ÊÚÔ‡ÙˆÓ fiˆ˜ Ù· Ì‹Ï· Î·È Ù· ·¯Ï¿‰È·, ÚÔÛٷهÂÈ ·fi ÙÔ ¿ÛıÌ·, ÂÓÒ ‰ÂÓ ‚Ú¤ıËΠη̛· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ∂›Û˘, ‰ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ηٷӿψÛ˘ „·ÚÈÒÓ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ™Ù· ›‰È· Û˘ÌÂÚ¿ÛÌ·Ù· η٤ÏËÍÂ Î·È Ì›· ÌÂÁ¿ÏË ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ (2nd National Health and Nutrition Examination Survey) (64). ∞ÓÙ›ıÂÙ·, Ì›· ÚÔÛٷ٢ÙÈ΋ Û¯¤ÛË ÌÂٷ͇ Ù˘ ηٷӿψÛ˘ ȯı˘ÂÏ·›ˆÓ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‚Ú¤ıËΠ۠·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ∞˘ÛÙÚ·Ï›· (65).

∂›‰Ú·ÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ÛÙÔ ¿ÛıÌ· ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·›˙ÂÈ Ë ‰È·ÙÚÔÊ‹ Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. Œ¯ÂÈ ‚ÚÂı› fiÙÈ Ë ‰›·ÈÙ· ·ÔÊ˘Á‹˜ ·ÓÙÈÁfiÓˆÓ ‰ÂÓ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Á¤ÓÓËÛ˘ ·ÙÔÈÎÒÓ ·È‰ÈÒÓ, ÂÓÒ ÂÎÊÚ¿˙ÔÓÙ·È Êfi‚ÔÈ ÁÈ· ÙȘ ÂÈÙÒÛÂȘ Ì›·˜ Ù¤ÙÔÈ·˜ ‰›·ÈÙ·˜ ÛÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ·ÏÏ¿ Î·È Ù˘ ÌËÙ¤Ú·˜ (66). ∫·Ù¿ ηÈÚÔ‡˜ ¤¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚ˜ ·fi„ÂȘ ÁÈ· ÙȘ ıÂÙÈΤ˜ Î·È ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÙÔ˘ ıËÏ·ÛÌÔ‡ ÛÙÔ ¿ÛıÌ·. ™Â Ì›· ·Ó·ÛÎfiËÛ‹ ÙÔ˘˜, ÔÈ Kramer Î·È Û˘Ó (67) ÙfiÓÈÛ·Ó Ù· ÔʤÏË ÙÔ˘ ıËÏ·ÛÌÔ‡, ÛÙ· ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ Î·È ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒ͈Ó, Ë ‚ÂÏÙ›ˆÛË Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ Ûȉ‹ÚÔ˘ Î·È Ë Ù·¯‡ÙÂÚË ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Ù˘ ÌËÙ¤Ú·˜, ÂÓÒ ‰ÂÓ ·Ú·Ù‹ÚËÛ·Ó Î·Ì›· ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÛÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛıÌ·ÙÔ˜ Û ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó ÛÙË ºÈÓÏ·Ó‰›· Î·È ÙËÓ ∞˘ÛÙÚ·Ï›·.

OÈ Stabell Î·È Û˘Ó (68) ÂÍ¤Ù·Û·Ó ÙË Û¯¤ÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 18 ÚÒÙˆÓ ÌËÓÒÓ Ù˘ ˙ˆ‹˜ Û 15.430 ·È‰È¿, Ì ‹ ¯ˆÚ›˜ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÏÏÂÚÁ›·˜. ¶·Ú·Ù‹ÚËÛ·Ó fiÙÈ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 4 Ì‹Ó˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ÛÙ· ·È‰È¿ Ì ÁÔÓ›˜ ¯ˆÚ›˜ ·ÏÏÂÚÁ›Â˜, ·ÏÏ¿ fi¯È ÛÙ· ·È‰È¿ Ì ¤Ó·Ó ‹ ‰‡Ô ·ÏÏÂÚÁÈÎÔ‡˜ ÁÔÓ›˜. °ÂÓÈο, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· Ô˘ÛÈ·ÛÙÈ΋ Â›‰Ú·ÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ‹ ÙÔ˘ ÂÓ Ì¤ÚÂÈ ıËÏ·ÛÌÔ‡ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ¶·Ú’ fiÏ· ·˘Ù¿, Ë Â›‰Ú·ÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· 4 Ì‹Ó˜ ‹ ÂÚÈÛÛfiÙÂÚÔ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ï¶·È‰È·ÙÚÈ΋ 2005;68:399-407

ÏÂÚÁÈÒÓ (2). OÈ Oddy Î·È Û˘Ó ÙÔ 2004, ·ÊÔ‡ ÌÂϤÙËÛ·Ó ÙË Û¯¤ÛË ÙÔ˘ ıËÏ·ÛÌÔ‡, ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Ù˘ ·ÙÔ›·˜ Ì ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™) 2.195 ·È‰ÈÒÓ ÛÙËÓ ∞˘ÛÙÚ·Ï›·, η٤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÌÈÎÚfiÙÂÚË ‰È¿ÚÎÂÈ· ıËÏ·ÛÌÔ‡ ·˘Í¿ÓÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Ù˘ ·ÙÔ›·˜ ÛÙ· ·È‰È¿, ÂÓÒ Ô ˘„ËÏfi˜ ¢ª™ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ¿ÛıÌ· (69). ™ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÌÔÚ› Ó· ÚÔÛٷهÂÈ ·fi ÙÔ ¿ÛıÌ· Î·È Ó· ÌÂÈÒÓÂÈ Ù· ÂÂÈÛfi‰È· ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·Ù¤ÏËÍ·Ó Î·È ¿ÏϘ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (70-72). ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÔÈ Kull Î·È Û˘Ó (72), ·ÊÔ‡ ·Ú·ÎÔÏÔ‡ıËÛ·Ó 4.089 ·È‰È¿ ÁÈ· 4 ¯ÚfiÓÈ·, ¤‰ÂÈÍ·Ó fiÙÈ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÁÈ· 4 ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ Ì‹Ó˜ ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ. ∏ Û¯¤ÛË ·˘Ù‹ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔ ÈÛ¯˘Ú‹ ÛÙ· ·È‰È¿ ¯ˆÚ›˜ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÏÏÂÚÁÈÒÓ. ∫·Ù¤ÏËÍ·Ó, ÏÔÈfiÓ, ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ô ıËÏ·ÛÌfi˜ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ¿ÛıÌ·ÙÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 4 ÚÒÙˆÓ ÂÙÒÓ. Œˆ˜ fiÙÔ˘, fï˜, ·ÔÛ·ÊËÓÈÛÙ› Ô ÚfiÏÔ˜ ÙÔ˘ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ηÏfi ı· ‹Ù·Ó Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ Ô‰ËÁ›Â˜ Ù˘ ∞ÏÏÂÚÁÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜, Ë ÔÔ›· Û˘ÓÈÛÙ¿ ÁÈ· Ù· ¿ÙÔÌ· Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ ·ÔÎÏÂÈÛÙÈÎfi ıËÏ·ÛÌfi ¤ˆ˜ ÙÔÓ 4Ô Ì‹Ó·, Ì ·Ú¿ÏÏËÏË ‰›·ÈÙ· ·ÔÊ˘Á‹˜ ·ÏÏÂÚÁÈÔÁfiÓˆÓ ÙÚÔÊÒÓ ·fi ÙË ÌËÙ¤Ú·.

™˘ÌÂÚ¿ÛÌ·Ù· ∏ Â›‰Ú·ÛË Ù˘ ‰È·ÙÚÔÊ‹˜ ÛÙÔ ¿ÛıÌ· Â›Ó·È ÔχÏÔÎË Î·È - fiˆ˜ ‰Â›¯ÓÔ˘Ó ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ - Èı·ÓÒ˜ ÂÌϤÎÔÓÙ·È ÔÏÏ¿ ‰È·ÊÔÚÂÙÈο ıÚÂÙÈο Û˘ÛÙ·ÙÈο. ∂›Û˘, Ù· ıÚÂÙÈο Û˘ÛÙ·ÙÈο ÌÔÚ› Ó· ·ÏÏËÏÂȉÚÔ‡Ó ÌÂٷ͇ ÙÔ˘˜, fiˆ˜ Ë ÚÔÛÙ·Û›· ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ÛÙËÓ ÔÍ›‰ˆÛË ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ. ∂ÈÚfiÛıÂÙ·, ˘¿Ú¯Ô˘Ó Ì·ÚÙ˘Ú›Â˜ fiÙÈ Ù· ÙÚfiÊÈÌ· Î·È fi¯È Ù· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ¿ÛıÌ· ÛÙ· ·È‰È¿. µ¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ, Ì›· ÈÛÔÚÚÔË̤ÓË ‰È·ÙÚÔÊ‹ ÏÔ‡ÛÈ· Û ÊÚÔ‡Ù· Î·È Ï·¯·ÓÈο, Ì›· ̤ÙÚÈ· ÚfiÛÏË„Ë ÏÈ·ÚÒÓ ÔͤˆÓ Î·È Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰· ÌÔÚ› Ó· Â›Ó·È Ôχ ˆÊ¤ÏÈÌ·. ∞·ÈÙÂ›Ù·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÂÚÈÛÛfiÙÂÚˆÓ ÌÂÏÂÙÒÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Î·È ÛÙ· ÙÚfiÊÈÌ· Î·È ÙȘ ·ÏÏËÏÂȉڿÛÂȘ ÙÔ˘˜ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· Û ·È‰È¿ ηÈ

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·405

405

¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿

Ó¤Ô˘˜, fiˆ˜ Â›Û˘ Î·È ÁÈ· ÙÔÓ ÚfiÏÔ ÙÔ˘ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Boner AL, Martinati LC. Diagnosis of asthma in children and adolescents. Eur Respir Rev 1997;7:3-7.

2. Peroni D, Piacentini G, Sabbion A, Boner A. Asthma in children. Eur Respir Mon 2003;23:278-292.

3. Kercsmar CM. Asthma. In: Chernick V, Boat TF, editors. Kendig’s disorders of the respiratory tract in children. 6th ed. Philadelphia: WB Saunders Company; 1998. p. 688-730.

4. Global Initiative for Asthma. Global strategy for asthma management and prevention. National Institutes of ∏ealth, National Heart, Lung and µlood πnstitute. Revised 2002.

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

6. ∑·ÚÎÈÓfi˜ º, ∆۷ӿη˜ π, ¶··ÛÙ·‡ÚÔ˘ª·˘ÚÔ˘‰‹ £, æ·Ú¿ÎÔ˜ ∫, ∫·ÚÔ‡˙·˜ π. ¶·ÓÂÏÏ‹ÓÈ· ÌÂϤÙË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÎÔ‡ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1995;7:123-130.

7. Anthracopoulos M, Karatza A, Liolios E, Triga M, Triantou K, Priftis K. Prevalence of asthma among schoolchildren in Patras, Greece: three surveys over 20 years. Thorax 2001;56:569-571.

8. Ronchetti R, Villa MP, Barreto M, Rota R, Pagani J, Martella S et al. Is the increase in childhood asthma coming to an end? Findings from three surveys of schoolchildren in Rome, Italy. Eur Respir J 2001;17:881-886.

9. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma United States, 1980-1999. MMWR Surveill Summ 2002;51:1-13.

10. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics 2002;110:315-322.

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

12. Brooks AM, Byrd RS, Weitzman M, Auinger P, McBride JT. Impact of low birth weight on early childhood asthma in the United States. Arch Pediatr Adolesc Med 2001;155:401-406.

13. Von Mutius E, Sears MR. Risk factors for development of asthma. Eur Respir Mon 2003;8:57-73.

14. Viegi G, Annesi I, Matteelli G. Epidemiology of asthma. Eur Respir Mon 2003;23:1-25.

15. Stanaland BE. Therapeutic measures for prevention of allergic rhinitis/asthma development. Allergy Asthma Proc 2004;25:11-15.

16. Halken S. What causes allergy and asthma? The role of dietary factors. Pediatr Pulmonol 2004;26 (Sup-

pl):S223-S224.

17. Monteleone CA, Sherman AR. Nutrition and asthma. Arch Itern Med 1997;157:23-34.

18. Heinrich J, Holscher B, Bolte G, Winkler G. Allergic sensitization and diet: ecological analysis in selected European cities. Eur Respir J 2001;17:395-402.

19. Knippels LM, Penninks AH. Assessment of protein allergenicity: studies in brown norway rats. Ann NY Acad Sci 2002;964:151-161.

20. Woods RK, Walters EH, Raven JM, Wolfe R, Ireland PD, Thien FC et al. Food and nutrient intakes and asthma risk in young adults. Am J Clin Nutr 2003;78:414-421.

21. Farchi S, Forastiere F, Agabiti N, Corbo G, Pistelli R, Fortes C et al. Dietary factors associated with wheezing and allergic rhinitis in children. Eur Respir J 2003;22:772-780.

22. Harik-Khan RI, Muller DC, Wise RA. Serum vitamin levels and the risk of asthma in children. Am J Epidemiol 2004;159:351-357.

23. McKeever TM, Britton J. Diet and asthma. Am J Respir Crit Care Med 2004;170:725-729.

24. Burney P. Asthma. Eur Respir Mon 2000;15:384399.

25. Fung KP, Lau SP, Chow OK, Lee J, Wong TW. Effects of overweight on lung function. Arch Dis Child 1990;65:512-515.

26. Luder E, Melnik TA, DiMaio M. Association of being overweight with greater asthma symptoms in inner city black and Hispanic children. J Pediatr 1998;132:699-703.

27. Lazarus R, Sparrow D, Weiss ST. Effects of obesity and fat distribution on ventilatory function: the normative aging study. Chest 1997;111:891-898.

28. Collins LC, Hoberty PD, Walker JF, Fletcher EC, Peiris AN. The effect of body fat distribution on pulmonary function tests. Chest 1995;107:1298-1302.

29. Shaheen SO, Sterne JA, Montgomery SM, Azima H. Birth weight, body mass index and asthma in young adults. Thorax 1999;54:396-402.

30. Moreau D, Annesi-Maesano I. Alcohol consumption related to asthma in women. A longitudinal study. Eur Respir J 1998;12:6S. 31. Chen Y, Dales R, Krewski D, Breithaupt K. Increased effects of smoking and obesity on asthma among female Canadians: the National Population Health Survey, 1994-1995. Am J Epidemiol 1999;150:255-262.

32. Hakala K, Stenius-Aarniala B, Sovijarvi A. Effects of weight loss on peak flow variability, airways obstruction, and lung volumes in obese patients with asthma. Chest 2000;118:1315-1321.

33. Stenius-Aarniala B, Poussa T, Kvarnstrom J, Gronlund EL, Ylikahri M, Mustajoki P. Immediate and long term effects of weight reduction in obese people with asthma: randomised controlled study. BMJ 2000;320:827-832.

34. Fogarty A, Britton J. Nutritional issues and asthma.

Curr Opin Pulm Med 2000;6:86-89.

35. Hu G, Zhang X, Chen J, Peto R, Campbell TC, Cassano PA. Dietary vitamin C intake and lung function in rural China. Am J Epidemiol 1998;148:594-599. ¶·È‰È·ÙÚÈ΋ 2005;68:399-407

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·406

406

¢. ¶··Ó‰Ú¤Ô˘ Î·È Û˘Ó.

36. Grievink L, Smit HA, Ocke MC, van’t Veer P, Kromhout D. Dietary intake of antioxidant (pro)-vitamins, respiratory symptoms and pulmonary function: the MORGEN study. Thorax 1998;53:166-171.

37. Bodner C, Godden D, Brown K, Little J, Ross S, Seaton A. Antioxidant intake and adult-onset wheeze: a case-control study. Aberdeen WHEASE Study Group. Eur Respir J 1999;13:22-30.

38. Tabak C, Feskens EJ, Heederik D, Kromhout D, Menotti A, Blackburn HW. Fruit and fish consumption: a possible explanation for population differences in COPD mortality (The Seven Countries Study). Eur J Clin Nutr 1998;52:819-825.

39. Carey IM, Strachan DP, Cook DG. Effects of changes in fresh fruit consumption on ventilatory function in healthy British adults. Am J Respir Crit Care Med 1998;158:728-733.

40. Butland BK, Strachan DP, Anderson HR. Fresh fruit intake and asthma symptoms in young British adults: confounding or effect modification by smoking? Eur Respir J 1999;13:744-750.

41. Grievink L, Jansen SM, van’t Veer P, Brunekreef B. Acute effects of ozone on pulmonary function of cyclists receiving antioxidant supplements. Occup Environ Med 1998;55:13-17.

42. Grievink L, Zijlstra AG, Ke X, Brunekreef B. Double-blind intervention trial on modulation of ozone effects on pulmonary function by antioxidant supplements. Am J Epidemiol 1999;149:306-314.

43. Romieu I, Meneses F, Ramirez M, Ruiz S, Perez Padilla R, Sienra JJ et al. Antioxidant supplementation and respiratory functions among workers exposed to high levels of ozone. Am J Respir Crit Care Med 1998;158:226-232.

44. Dominguez LJ, Barbagallo M, Di Lorenzo G, Drago A, Scola S, Morici G et al. Bronchial reactivity and intracellular magnesium: a possible mechanism for the bronchodilating effects of magnesium in asthma. Clin Sci 1998;95:137-142.

45. Emelyanov A, Fedoseev G, Barnes PJ. Reduced intracellular magnesium concentrations in asthmatic patients. Eur Respir J 1999;13:38-40.

46. Ollis TE, Meyer BJ, Howe PR. Australian food sources and intakes of omega-6 and omega-3 polyunsaturated fatty acids. Ann Nutr Metab 1999;43:346-355.

47. Sakai K, Okuyama H, Shimazaki H, Katagiri M, Torii S, Matsushita T et al. Fatty acid compositions of plasma lipids in atopic dermatitis/asthma patients. Arerugi 1994;43:37-43.

48. Meade CJ, Mertin J. Fatty acids and immunity. Adv Lipid Res 1978;16:127-165.

49. Roper RL, Phipps RP. Prostaglandin E2 regulation of the immune response. Adv Prostaglandin Thromboxane Leukot Res 1994;22:101-111.

50. Haby MM, Peat JK, Marks GB, Woolcock AJ, Leeder SR. Asthma in preschool children: prevalence and risk factors. Thorax 2001;56:589-595.

51. Oddy WH, de Klerk NH, Kendall GE, Mihrshahi S, Peat JK. Ratio of omega-6 to omega-3 fatty acids and childhood asthma. J Asthma 2004;41:319-326.

52. Das UN. Perinatal supplementation of long-chain ¶·È‰È·ÙÚÈ΋ 2005;68:399-407

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

polyunsaturated fatty acids, immune response and adult diseases. Med Sci Monit 2004;10:19-25. ÷˚‰ÔÔ‡ÏÔ˘ ∞, ∂ÌÔÚÈ¿‰Ô˘ ª, ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡ ª, ∆۷ӿη˜ π. ¢ÈÂÚ‡ÓËÛË Î·È Û˘Û¯¤ÙÈÛË ÙˆÓ ÂÈ¤‰ˆÓ ˆÌ¤Á·-3, ˆÌ¤Á·-6 ÏÈ·ÚÒÓ ÔͤˆÓ Î·È Î˘ÙÔÎÈÓÒÓ ÛÙÔ Ï¿ÛÌ· ·È‰ÈÒÓ Ì ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· [¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. £ÂÛÛ·ÏÔÓ›ÎË: ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢; 2003.

Woods RK, Raven JM, Walters EH, Abramson MJ, Thien FC. Fatty acid levels and risk of asthma in young adults. Thorax 2004;59:105-110.

Yaqoob P, Newsholme EA, Calder PC. The effect of dietary lipid manipulation on rat lymphocyte subsets and proliferation. Immunology 1994;82:603-610.

Culp BR, Titus BG, Lands WE. Inhibition of prostaglandin biosynthesis by eicosapentaenoic acid. Prostaglandins Med 1979;3:269-278.

Lands WEM. Fish and human health. Orlando: Academic Press Inc; 1986. p. 96-110.

Black PN. The prevalence of allergic disease and linoleic acid in the diet. J Allergy Clin Immunol 1999;103:351-352.

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

Fluge O, Omenaas E, Eide GE, Gulsvik A. Fish consumption and respiratory symptoms among young adults in a Norwegian community. Eur Respir J 1998;12:336-340.

Calder PC, Bond JA, Harvey DJ, Gordon S, Newsholme EA. Uptake and incorporation of saturated and unsaturated fatty acids into macrophage lipids and their effect upon macrophage adhesion and phagocytosis. Biochem J 1990;269:807-814.

Kelley DS, Dougherty RM, Branch LB, Taylor PC, Iacono JM. Concentration of dietary N-6 polyunsaturated fatty acids and the human immune status.

Clin Immunol Immunopathol 1992;62:240-244.

Mackerras D. Antioxidants and health. Fruits and vegetables or supplements? Food Australia 1995;47 (Suppl):S1-21.

Schwartz J, Weiss ST. Dietary factors and their relation to respiratory symptoms. The Second National Health and Nutrition Examination Survey. Am J Epidemiol 1990;132:67-76.

Hodge L, Salome CM, Peat JK, Haby MM, Xuan W, Woolcock AJ. Consumption of oily fish and childhood asthma risk. Med J Aust 1996;164:137-140.

Kramer MS. Maternal antigen avoidance during pregnancy for preventing atopic disease in infants of women at high risk. Cochrane Database Syst Rev 2000;2:CD000133.

Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol 2004;554:63-77.

Benn CS, Wohlfahrt J, Aaby P, Westergaard T, Benfeldt E, Michaelsen KF et al. Breastfeeding and risk of atopic dermatitis, by parental history of allergy, during the first 18 months of life. Am J Epidemiol 2004;160:217-223.

Oddy WH, Sherriff JL, de Klerk NH, Kendall GE, Sly

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·407

407

¢È·ÙÚÔÊ‹ Î·È ¿ÛıÌ· ÛÙ· ·È‰È¿

PD, Beilin LJ et al. The relation of breastfeeding and body mass index to asthma and atopy in children: a prospective cohort study to age 6 years. Am J Public Health 2004;94:1531-1537.

70. Oddy WH. A review of the effects of breastfeeding on respiratory infections, atopy, and childhood asthma. J Asthma 2004;41:605-621.

71. Kemp A, Kakakios A. Asthma prevention: breast is best? J Paediatr Child Health 2004;40:337-339.

72. Kull I, Almqvist C, Lilja G, Pershagen G, Wickman M. Breast-feeding reduces the risk of asthma during the first 4 years of life. J Allergy Clin Immunol 2004;114:755-760.

¶·È‰È·ÙÚÈ΋ 2005;68:399-407

Pediatr Nov-Dec 05

408

12-12-05

15:16

™ÂÏ›‰·408

REVIEW ARTICLE

Diet and asthma in children D. Papandreou, M. Emboriadou

Correspondence: Maria Emboriadou 2nd Paediatric Clinic, Aristotle University, AHEPA Hospital 1 Kyriakidi Str., 546 36, Thessaloniki

Abstract The effect of the diet in determining the cause and clinical severity of asthma is uncertain.

Epidemiological studies suggest that antioxidants, magnesium and fat consumption may have an important role in the aetiology, although the relative importance of these individual nutrients is not clear. Interventional studies are beginning to clarify the importance of diet in patients with asthma, and early studies suggest that antioxidants in particular may be beneficial. The concept that dietary factors may be implicated in the aetiology of asthma has attracted a great deal of attention in the last 10-15 years, and epidemiologic studies have revealed associations with various minerals, vitamins and fatty acids in this context.

Date of submission: 15-11-2004 Date of approval: 27-04-2005

Key words Asthma, childhood, nutrition, diet, wheezing.

2nd Paediatric Clinic, Aristotle University, Thessaloniki

Paediatriki 2005;68:408

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·409

∞¡∞™∫O¶∏™∏

409

∂ÈÏÔΤ˜ ·fi ÙÔ ÎÂÓÙÚÈÎfi Î·È ÂÚÈÊÂÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ÔÌfi˙˘ÁË ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· ¢. ∑·ÊÂÈÚ›Ô˘, ª. OÈÎÔÓfiÌÔ˘, ª. ∞ı·Ó·Û›Ô˘ - ªÂÙ·Í¿

¶ÂÚ›ÏË„Ë ∏ ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· (‚-ª∞) Â›Ó·È Ì›· ÁÂÓÂÙÈο ηıÔÚÈ˙fiÌÂÓË ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ ··ÈÙÂ›Ù·È Ë ÂÊ·ÚÌÔÁ‹ ‰È¿ ‚›Ô˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛÂˆÓ Î·È ·ÔÛȉ‹ÚˆÛ˘. ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ‚-ª∞ ·Ó·Ê¤ÚÂÙ·È ·fi Ù· ÚÒÙ· ¯ÚfiÓÈ· Û˘ÛÙËÌ·ÙÈ΋˜ ÌÂϤÙ˘ Ù˘ ÓfiÛÔ˘. °È· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ ÂÈÏÔÎÒÓ ·fi ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ¯ÚfiÓÈ· ˘ÔÍ›·, Ë ·ÈÌÔÛȉ‹ÚˆÛË Î·È Ë Ê·Ú̷΢ÙÈ΋ ÙÔÍÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ ·ÔÛȉ‹ÚˆÛ˘ Ì ‰ÂÛÊÂÚÚÈÔÍ·Ì›ÓË (DFO). ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, ÔÈ ‰È·Ù·Ú·¯¤˜ ÙˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ Á›ÓÔÓÙ·È ·ÓÙÈÏËÙ¤˜ ÌfiÓÔ Î·Ù¿ ÙËÓ ÂͤٷÛË Ì Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÌÂıfi‰Ô˘˜, ¯ˆÚ›˜ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ·ÓÙ›ÛÙÔȯ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ. ∆· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ·ÔÙÂÏÔ‡Ó Ì›· ·Ó·›Ì·ÎÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ ̤ıÔ‰Ô ÂͤٷÛ˘ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™), Ë ÔÔ›· ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÚÒÈÌ˘ ·Ó›¯Ó¢Û˘ ˘ÔÎÏÈÓÈÎÒÓ ‚Ï·‚ÒÓ. ∏ ¯Ú‹ÛË ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ ÂÚÈÁÚ¿ÊÂÙ·È ‹‰Ë ·fi Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980. ∞ÓÙ›ıÂÙ·, Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙËÓ ÂͤٷÛË ÙˆÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ Û ·ÛıÂÓ›˜ Ì ‚-ª∞ Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂ӷ. ∞ÓÙ›ÛÙÔȯ· ÂÚÈÔÚÈṲ̂ÓË Â›Ó·È Î·È Ë ‚È‚ÏÈÔÁÚ·Ê›· Ô˘ ·ÊÔÚ¿ ÛÙÔ Ó¢ÚÔ„˘¯ÔÏÔÁÈÎfi ÚÔÊ›Ï ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ Â›Ó·È Û˘¯Ó¿ ·ÓÙÈÎÚÔ˘fiÌÂÓ· Î·È fi¯È ¿ÓÙ· ‚·ÛÈṲ̂ӷ Û ·Ô‰ÂÎÙ¤˜ „˘¯ÔÌÂÙÚÈΤ˜ ÌÂıfi‰Ô˘˜. ∫·ıÒ˜ ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ Û˘Ó¯Ҙ ·˘Í¿ÓÂÈ, Ë ¯Ú‹ÛË ÙˆÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ Î·È Ó¢ÚÔ„˘¯ÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ÂͤٷÛ˘ ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›·, ÂÈÙÚ¤ÔÓÙ·˜ ÙËÓ ¤ÁηÈÚË ‰È·›ÛÙˆÛË ÚÔÛ‚ÔÏ‹˜ ÙˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ Î·È Î·ıÈÛÙÒÓÙ·˜ ‰˘Ó·Ù‹ ÙË ÛˆÛÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙËÓ ·Ó¿ÏÔÁË ÙÚÔÔÔ›ËÛË Ù˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜, Ì ·ÒÙÂÚÔ ÛÎÔfi ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÁÈ· ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ.

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: ¢ËÌ‹ÙÚÈÔ˜ ∑·ÊÂÈÚ›Ô˘ πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 ∆.∫. 546 42, £ÂÛÛ·ÏÔÓ›ÎË E-mail: jeff@med.auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-09-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-04-2005

§¤ÍÂȘ ÎÏÂȉȿ ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ‰ÂÛÊÂÚÚÈÔÍ·Ì›ÓË, Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο, Ù·¯‡ÙËÙ˜ ·ÁˆÁÈÌfiÙËÙ·˜ Ó‡ڈÓ, Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·, Ó¢ÚÔ„˘¯ÔÏÔÁ›·, ÓÔËÙÈÎfi ËÏ›ÎÔ.

™˘ÓÙÔÌÔÁڷʛ˜ ‚-ª∞ BAEP DFO MRI VEP SEP

‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· ™ÙÂϯȷ›· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ¢ÂÛÊÂÚÚÈÔÍ·Ì›ÓË ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· OÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ™ˆÌ·ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο

∂ÈÛ·ÁˆÁ‹ ∏ ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· (‚-ª∞) Â›Ó·È Ì›· ÁÂÓÂÙÈο ηıÔÚÈ˙fiÌÂÓË ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ ··ÈÙÂ›Ù·È Ë ‰È¿ ‚›Ô˘ ˘Ô‚ÔÏ‹ ÙˆÓ ·ÛıÂÓÒÓ ÛÂ

ÚfiÁÚ·ÌÌ· ÌÂÙ·ÁÁ›ÛÂˆÓ Î·È ·ÔÛȉ‹ÚˆÛ˘. ∏ ÂÊ·ÚÌÔÁ‹ ·˘Ù‹˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ Ô‰‹ÁËÛ ٷ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Û ÂÍ·ÈÚÂÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÚfiÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘, Ì ٷ˘Ùfi¯ÚÔÓË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ. øÛÙfiÛÔ, Ë ÂΉ‹ÏˆÛË ÂÈÏÔÎÒÓ ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ·, ·ÎfiÌË Î·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi Ù·ÎÙÈ΋ È·ÙÚÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÈηÓÔÔÈËÙÈ΋ Û˘ÌÌfiÚʈÛË ÛÙ· ··ÈÙÔ‡ÌÂÓ· ıÂÚ·¢ÙÈο Û¯‹Ì·Ù·. ∏ ‚-ª∞ ·ÔÙÂÏ› ÙÔ ÛÔ‚·ÚfiÙÂÚÔ ÂÎ ÙˆÓ Î·ÏÔ‡ÌÂÓˆÓ ÌÂÛÔÁÂÈ·ÎÒÓ ‹ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·410

410

¢. ∑·ÊÂÈÚ›Ô˘ Î·È Û˘Ó.

Û˘Ó‰ÚfïÓ, Ù· ÔÔ›· ·ÔÙÂÏÔ‡Ó Ì›· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ÎÏËÚÔÓÔÌÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ, ·ıÔÏÔÁÈÎÒÓ ˆ˜ ÚÔ˜ ÙË Û‡ÓıÂÛË ÙÔ˘ ÌÔÚ›Ô˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘. O ˘‡ı˘ÓÔ˜ ÌÔÚÈ·Îfi˜ Ì˯·ÓÈÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÂÙ·ÏÏ¿ÍÂȘ ̤۷ ‹ Á‡Úˆ ·fi Ù· ÁÔÓ›‰È·, ÔÈ Ôԛ˜ ÌÔÚ› Ó· Â›Ó·È ÌÂÁ¿Ï˜ ‹ ÌÈÎÚ¤˜ ÂÏÏ›„ÂȘ, ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ, ÌÈÎÚ¤˜ ÚÔÛı‹Î˜ ‹ ‰ÈÏ·ÛÈ·ÛÌÔ› (1). ∞ÔÙ¤ÏÂÛÌ· ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Â›Ó·È Ë ‰È·Ù·Ú·¯‹ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ · ‹ ‚ ·Ï‡ÛÂˆÓ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, Ë ÔÔ›· Ô‰ËÁ› ·ÓÙ›ÛÙÔȯ· Û ÂΉ‹ÏˆÛË ·- ‹ ‚-ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. ™ÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÛfiÙÂÚ˜ ·fi 40 ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ‚ ÁÔÓ›‰ÈÔ Î·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 10 ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙÔ · (2-5). O ȉȷ›ÙÂÚ· ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÌÂÙ·ÏϿ͈Ó, Ë ÂÚÈÔ¯‹ ÛÙËÓ ÔÔ›· ‰ڿ˙ÔÓÙ·È ·˘Ù¤˜, ηıÒ˜ Î·È Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÙÔ˘˜ ÚfiÏÔ˜ Ô‰ËÁÔ‡Ó Û ÌÂÁ¿ÏË ÔÈÎÈÏ›· Ê·ÈÓÔÙ˘È΋˜ ¤ÎÊÚ·Û˘. ∫‡ÚÈÔ˘˜ ÎÏÈÓÈÎÔ‡˜ Ê·ÈÓÔÙ‡Ô˘˜ Ù˘ ‚-ª∞ ·ÔÙÂÏÔ‡Ó Ë ÂÙÂÚfi˙˘ÁË, Ë ÂӉȿÌÂÛË Î·È Ë Ì›˙ˆÓ ‚-ª∞, Ë ÙÂÏÂ˘Ù·›· ÂÎ ÙˆÓ ÔÔ›ˆÓ ·ÔÙÂÏ› ÙË ÛÔ‚·ÚfiÙÂÚË Û˘ÁÁÂÓ‹ ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·. ¶ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù·ÎÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛˆÓ-·ÔÛȉ‹ÚˆÛ˘, ÔÈ ¿Û¯ÔÓÙ˜ ·fi ‚-ª∞ η٤ÏËÁ·Ó Ôχ ÓˆÚ›˜, Û˘¯Ó¿ ÚÈÓ ÙË ‰Â‡ÙÂÚË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ (6). ªÂ ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, Ë ÂÊ·ÚÌÔÁ‹ Ó¤ˆÓ Û¯ËÌ¿ÙˆÓ ÌÂÙ¿ÁÁÈÛ˘ Î·È Î˘Ú›ˆ˜ Ë ÂÈÛ·ÁˆÁ‹ Ù˘ ·ÔÛȉ‹ÚˆÛ˘ Ô‰‹ÁËÛ·Ó Û ‰Ú·Ì·ÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘, ˆÛÙfiÛÔ, ·ÚȘ ·Èٛ˜ ı·Ó¿ÙÔ˘ ·Ú¤ÌÂÈÓ·Ó Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· (60%), ÔÈ ÏÔÈÌÒÍÂȘ (13%) Î·È Ë Ë·ÙÈ΋ ÓfiÛÔ˜ (6%) (7). ™‹ÌÂÚ·, Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘, Ì ·Ó·ÊÂÚfiÌÂÓÔ ÔÛÔÛÙfi Ô˘ Êı¿ÓÂÈ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 35 ÂÙÒÓ Û ÔÚÈṲ̂ӷ ΤÓÙÚ· (8). ∏ ˘ÈÔı¤ÙËÛË Ó¤ˆÓ, ¢·›ÛıËÙˆÓ, ÌË-ÂÂÌ‚·ÙÈÎÒÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÌÂıfi‰ˆÓ, fiˆ˜ Â›Ó·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI), ηıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË Ù˘ ·ÈÌÔÛȉ‹ÚˆÛ˘ ÚÈÓ ÙËÓ ÂÁηٿÛÙ·ÛË ÔÚÁ·ÓÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ (9). H ¯Ú‹ÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·˘ÙÒÓ Ù¯ÓÈÎÒÓ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ËÏÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ Î·Ï‡ÙÂÚË Û˘ÌÌfiÚʈÛË ÛÙË ıÂÚ·›· ·ÔÛȉ‹ÚˆÛ˘, ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÚ·ÈÙ¤Úˆ ‚ÂÏÙ›ˆÛË, ÙfiÛÔ Ù˘ ÚfiÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ fiÛÔ Î·È Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ. ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

∂ÈÏÔΤ˜ ·fi ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÛÙË ‚-ª∞ ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ‚-ª∞ ›¯Â ‹‰Ë ÂÚÈÁÚ·Ê› ·fi Ù· ÚÒÙ· ¯ÚfiÓÈ· Û˘ÛÙËÌ·ÙÈ΋˜ ÌÂϤÙ˘ Ù˘ ÓfiÛÔ˘ (10). °È· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ ÂÓÔ¯ÔÔÈ‹ıËÎ·Ó ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ¯ÚfiÓÈ· ˘ÔÍ›·, Ë ·ÈÌÔÛȉ‹ÚˆÛË Î·È Ë Ê·Ú̷΢ÙÈ΋ ÙÔÍÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ ·ÔÛȉ‹ÚˆÛ˘ Ì ‰ÂÛÊÂÚÚÈÔÍ·Ì›ÓË (DFO).

ÀÔÍ›· ™Â ·ÓÂ·ÚÎÒ˜ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜, Ë ¯ÚfiÓÈ· ·Ó·ÈÌ›· Ô‰ËÁ› Û ̷˙È΋ Â¤ÎÙ·ÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, Ë ÔÔ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂΉ‹ÏˆÛË ‰È·Ù·Ú·¯ÒÓ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙË Û˘Ì›ÂÛË Ó‡ڈÓ, ÙfiÛÔ ÎÚ·ÓÈ·ÎÒÓ fiÛÔ Î·È ÂÚÈÊÂÚÈÎÒÓ (11,12). ¶ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ Û˘ÛÙËÌ·ÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛˆÓ, Û˘ÓËı¤ÛÙÂÚË ‹Ù·Ó Ë ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿ ‰È·Ù·Ú·¯ÒÓ Ù˘ ·ÎÔ‹˜, ÔÈ Ôԛ˜ ·ÚÔ˘Û›·˙·Ó ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ÙËÓ ˘Ô‚ÔÏ‹ ÙˆÓ ·ÛıÂÓÒÓ Û ٷÎÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ (13,14). ∏ ¯ÚfiÓÈ· ˘ÔÍ›· Ê·›ÓÂÙ·È Ó· ¢ı‡ÓÂÙ·È, Â›Û˘, ÁÈ· ÙËÓ ÚÔÛ‚ÔÏ‹ ·ÓÒÙÂÚˆÓ ÊÏÔÈÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. OÈ Logothetis Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Û ¤ÏÂÁ¯Ô ·ÛıÂÓÒÓ Ì ÔÌfi˙˘ÁË ‚-ª∞ ‰È·›ÛÙˆÛ·Ó ÙËÓ ·ÚÔ˘Û›· ¯·ÌËÏfiÙÂÚÔ˘ ÓÔËÙÈÎÔ‡ ËÏ›ÎÔ˘ ÌÂٷ͇ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÁÁ›˙ÔÓÙ·Ó ·ÓÂ·ÚÎÒ˜ (15). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ¯ÚfiÓÈ·˜ ˘ÔÍ›·˜ ıˆÚ›ٷÈ, Â›Û˘, Ë ÂÌÊ¿ÓÈÛË ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙÔ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ·ÛıÂÓÒÓ Ì ‚-ª∞ (16). ∆¤ÏÔ˜, ÔÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜ ·Ô‰›‰Ô˘Ó ÂÚÈÙÒÛÂȘ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙËÓ ÂΉ‹ÏˆÛË ÈÛ¯·ÈÌÈÎÒÓ ‹ ·ÈÌÔÚÚ·ÁÈÎÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, ˆ˜ Û˘Ó¤ÂÈ· Ù˘ ¯ÚfiÓÈ·˜ ˘ÔÍ›·˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ˘˜ ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ (17,18). ∞ÈÌÔÛȉ‹ÚˆÛË ∏ Â›‰Ú·ÛË ÙÔ˘ ÏÂÔÓ¿˙ÔÓÙÔ˜ Ûȉ‹ÚÔ˘ ÛÙȘ Ó¢ÚÈΤ˜ Ô‰Ô‡˜ ·ÛıÂÓÒÓ Ì ‚-ª∞ ·Ú¯Èο ÂÓÙÔ›ÛÙËΠÛÙËÓ ÂΉ‹ÏˆÛË Ó¢ÚÔ·ÈÛıËÙËÚȷ΋˜ ‚·ÚËÎÔ˝·˜, Ë ÔÔ›· ·Ô‰fiıËΠÛÙËÓ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ ÛÙÔÓ Îԯϛ· (19). ∏ ¯Ú‹ÛË ÓÂfiÙÂÚˆÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ÂͤٷÛ˘, fiˆ˜ Ù· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο, η٤ÛÙËÛ ‰˘Ó·Ù‹ ÙËÓ ·Ó›¯Ó¢ÛË ˘ÔÎÏÈÓÈÎÒÓ Ó¢ÚÔÏÔÁÈÎÒÓ ‚Ï·‚ÒÓ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜, ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ ÔÔ›ˆÓ ÂÓÔ¯Ô-

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·411

∂ÈÏÔΤ˜ ·fi ÙÔ ∫¡™ Î·È ÙÔ ¶¡™ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜

ÔÈ‹ıËΠ- ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÓ Ì¤ÚÂÈ - Ë ÙÔÍÈ΋ Â›‰Ú·ÛË ÙÔ˘ Ûȉ‹ÚÔ˘ (20). ¶ÚfiÛÊ·Ù·, Ë ¯Ú‹ÛË Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÂȂ‚·›ˆÛ ÂÚÁ·ÛÙËÚȷο ÙËÓ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ Û ÂÁÎÂÊ·ÏÈΤ˜ ‰Ô̤˜ ·ÛıÂÓÒÓ Ì ‚-ª∞, fiˆ˜ Ô ÊÏÔÈfi˜, ÙÔ Î¤Ï˘ÊÔ˜ ÙÔ˘ Ê·ÎÔÂȉԇ˜ ˘Ú‹Ó· Î·È Ô ÎÂÚÎÔÊfiÚÔ˜ ˘Ú‹Ó·˜ (21). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÌÊ¿ÓÈÛË ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ·ÓÒÙÂÚˆÓ ÓÔËÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó Û ·ÛıÂÓ›˜ Ì ‚-ª∞ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ Î·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·, ˆÛÙfiÛÔ, ÙÔ ·˘ÍË̤ÓÔ ÊÔÚÙ›Ô Ûȉ‹ÚÔ˘ Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ Î¿ÔÈÔ ÚfiÏÔ. ™ÙËÓ ÈÔ ÚfiÛÊ·ÙË ·fi ÙȘ Û¯ÂÙÈΤ˜ ÌÂϤÙ˜, ÔÈ Monastero Î·È Û˘Ó Î·Ù·‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ ·ÓÙ›Ï˄˘ Û ·˘ÍË̤ÓÔ ÔÛÔÛÙfi, ΢ڛˆ˜ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÛËÌ›· ¤ÓÙÔÓ˘ ·ÈÌÔÛȉ‹ÚˆÛ˘ (22). ∆¤ÏÔ˜, ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘, ÔÈ Ôԛ˜ ˆ˜ ÁÓˆÛÙfiÓ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ ÛÙÔ ¿ÁÎÚ·˜, ·ÔÙÂÏÔ‡Ó ¤Ó·Ó ·ÎfiÌË ·Ú¿ÁÔÓÙ· ÂΉ‹ÏˆÛ˘ ÂÈÏÔÎÒÓ ·fi ÙÔ ÎÂÓÙÚÈÎfi ηÈ/‹ ÙÔ ÂÚÈÊÂÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚-ª∞ (23).

∆ÔÍÈÎfiÙËÙ· DFO ∏ ‰ÂÛÊÂÚÚÈÔÍ·Ì›ÓË ÂÍ·ÎÔÏÔ˘ı›, ÚÔ˜ ÙÔ ·ÚfiÓ, Ó· ·ÔÙÂÏ› ÙÔÓ ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ ÛÙË ıÂÚ·›· ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ, ·Ú¿ ÙȘ ‰˘ÛÎÔϛ˜ Ô˘ ÂÓ¤¯ÂÈ Ë ‰È¿ ‚›Ô˘ Û˘ÌÌfiÚʈÛË ÛÙËÓ ·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛ‹ Ù˘ Î·È ÙÔ ˘„ËÏfi ÎfiÛÙÔ˜ Ù˘ ıÂÚ·›·˜. ª¤¯ÚÈ Ó· Á›ÓÂÈ Â˘Ú¤ˆ˜ ÚÔÛÈÙ‹ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ‹ Ó· Á›ÓÂÈ Ú·ÁÌ·ÙÈÎfiÙËÙ· Ë ÁÔÓȉȷ΋ ıÂÚ·›·, Ë ·ÔÛȉ‹ÚˆÛË ·ÔÙÂÏ› ÙÔ ÌÔÓ·‰ÈÎfi ̤ÛÔ ÚfiÏ˄˘ ÙˆÓ ı·Ó·ÙËÊfiÚˆÓ ÂÈÏÔÎÒÓ Ù˘ ÓfiÛÔ˘. øÛÙfiÛÔ, Ë ıÂÚ·›· Ì DFO ‰ÂÓ Â›Ó·È ¿ÌÔÈÚË ÎÈÓ‰‡ÓˆÓ, ηıÒ˜ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÂÈÏÔÎÒÓ ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (24). ∏ ¯Ú‹ÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ DFO, ·ÏÏ¿ Î·È Ë ¯Ú‹ÛË Û˘ÓËıÈÛÌ¤ÓˆÓ ‰fiÛÂˆÓ Û ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi ÊÔÚÙ›Ô Ûȉ‹ÚÔ˘, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÔÈÎ›ÏˆÓ Ó¢ÚÔ·ÈÛıËÙËÚÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÔÈ Ôԛ˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓ˜ Î·È ·Ó·ÛÙÚ¤„È̘ ÌÂÙ¿ ÙËÓ ·ÚÔ‰È΋ ‰È·ÎÔ‹ ‹ ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ ‰ÔÛÔÏÔÁ›·˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (25). ∏ Ó¢ÚÔÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DFO ¤¯ÂÈ ·Ô‰Ôı› Û ‰È¿ÊÔÚÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜, fiˆ˜ Û ÌÂÙ·‚ÔϤ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ·Ó·Áη›ˆÓ ÛȉËÚÔÂÍ·ÚÙÒÌÂÓˆÓ ÂÓ˙‡ÌˆÓ (26), ÛÙËÓ Ù·˘Ùfi¯ÚÔÓË ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙÔÓ ÔÚÁ·-

411

ÓÈÛÌfi ··Ú·›ÙËÙˆÓ ÛÙÔȯ›ˆÓ ÂÎÙfi˜ ÙÔ˘ Ûȉ‹ÚÔ˘ fiˆ˜ Â›Ó·È Ô ¯·ÏÎfi˜ Î·È Ô „¢‰¿ÚÁ˘ÚÔ˜ (27,28), ηıÒ˜ Î·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÂχıÂÚˆÓ ÚÈ˙ÒÓ (29). ™ËÌ·ÓÙÈ΋ Ê·›ÓÂÙ·È Ó· Â›Ó·È Î·È Ë Û˘ÌÌÂÙÔ¯‹ ȉÈÔÛ˘ÛÙ·ÛÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÔÈ ÔÔ›ÔÈ Î·ıÈÛÙÔ‡Ó ÙË ‰Ú¿ÛË Ù˘ DFO ·Úfi‚ÏÂÙË Î·È ‰È·ÊÔÚÂÙÈ΋ Û οı ÂÚ›ÙˆÛË (30). ∞ÓÂÍ·Úًو˜ ÙÔ˘ ˘‡ı˘ÓÔ˘ Ì˯·ÓÈÛÌÔ‡, Ë ÙÔÍÈ΋ Â›‰Ú·ÛË Ù˘ DFO Ê·›ÓÂÙ·È Ó· Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Î·È Ó· ÌËÓ ÔÊ›ÏÂÙ·È ÛÙË Û˘ÛÛÒÚÂ˘Û‹ Ù˘, ˆ˜ Û˘Ó¤ÂÈ· ¯·ÌËÏÔ‡ Ú˘ıÌÔ‡ οı·ÚÛ˘ ·˘Ù‹˜ (31).

OÈ ·Ó·ÊÂÚfiÌÂÓ˜ Ó¢ÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜ Ù˘ DFO ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙË ÌÂÌÔӈ̤ÓË ‹ Ù·˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ Ù˘ fiÚ·Û˘ Î·È Ù˘ ·ÎÔ‹˜ (32-34). OÈ ÂΉËÏÒÛÂȘ ·˘Ù¤˜ ÂÚÈÁÚ¿ÊÔÓÙ·È Û˘Ó‹ıˆ˜ Û ·ÛıÂÓ›˜ Ì ̷ÎÚÔ¯ÚfiÓÈ· Ï‹„Ë ˘„ËÏÒÓ ‰fiÛÂˆÓ DFO Î·È Î·Ù’ ÂÍÔ¯‹Ó ¯·ÌËÏfi ÊÔÚÙ›Ô Ûȉ‹ÚÔ˘, ˆÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó Î·È ÂÚÈÙÒÛÂȘ ÔͤˆÓ ‚Ï·‚ÒÓ ÌÂÙ¿ ·fi ÌÂÌÔӈ̤Ó˜ ‰fiÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (35).

OÈ ÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ÙÔÍÈ΋ Â›‰Ú·ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙȘ ›Ó˜ ÙÔ˘ ÔÙÈÎÔ‡ Ó‡ÚÔ˘ (32). ∏ ‰Ú¿ÛË Ù˘ DFO Ô‰ËÁ› ÛÙËÓ ÂÌÊ¿ÓÈÛË Û¯ÂÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ ÛÙË ÌÂÙ¿‰ÔÛË ÙÔ˘ ÔÙÈÎÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜, ÂÓ‰¤¯ÂÙ·È ˆÛÙfiÛÔ Ó· ÚÔηϤÛÂÈ ·ÎfiÌË Î·È Ï‹ÚË ·ÒÏÂÈ· Ù˘ fiÚ·Û˘. OÈ Orton Î·È Û˘Ó ÂÚÈÁÚ¿ÊÔ˘Ó ÙËÓ ÂÚ›ÙˆÛË ‰‡Ô ·‰ÂÏÊÒÓ Ì ÂΉ‹ÏˆÛË ÔÙÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜ ·ԉȉfiÌÂÓ˘ ÛÙËÓ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DFO, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ô ¤Ó·˜ ·ÚÔ˘Û›·Û Ï‹ÚË ·ÔηٿÛÙ·ÛË Ù˘ ‚Ï¿‚˘ ÌÂÙ¿ ÙËÓ ·ÚÔ‰È΋ ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ÂÓÒ Ô ‰Â‡ÙÂÚÔ˜ ÂÌÊ¿ÓÈÛ ÌË ·Ó·ÛÙÚ¤„ÈÌË ÂÙÂÚfiÏ¢ÚË ·ÒÏÂÈ· Ù˘ fiÚ·Û˘ (36). ™¯ÂÙÈο Ì ÙËÓ ˆÙÔÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DFO, Ì·ÎÚÔ¯ÚfiÓÈ· ·ÎÔ˘ÔÏÔÁÈ΋ ÌÂϤÙË, Ë ÔÔ›· Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ ÙÔ˘ ÂÏÏ·‰ÈÎÔ‡ ¯ÒÚÔ˘, ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÂÙÂÚfiÏ¢Ú˘ ‹ ·ÌÊÔÙÂÚfiÏ¢Ú˘ Ó¢ÚÔ·ÈÛıËÙËÚȷ΋˜ ‚·ÚËÎÔ˝·˜ ÛÙÔ 27% ÙˆÓ ·ÛıÂÓÒÓ, Ì ·ÎfiÏÔ˘ıË ·ÔηٿÛÙ·ÛË ‹ ·Ó·ÛÙÔÏ‹ Ù˘ Âȉ›ӈÛ˘ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÌÂÙ¿ ÙËÓ ·ÚÔ‰È΋ ‰È·ÎÔ‹ ‹ Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (37). ∆· ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù·, ηٷ‰ÂÈÎÓ‡ÔÓÙ·˜ ÙË Û˘ÌÌÂÙÔ¯‹ Ù˘ DFO ÛÙËÓ ÂΉ‹ÏˆÛË ·ÎÔ˘ÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ·ÎfiÌË Î·È fiÙ·Ó ·˘Ù‹ ¯ÔÚËÁÂ›Ù·È Û ‰fiÛÂȘ Ô˘ ıˆÚÔ‡ÓÙ·È ÌË ÙÔÍÈΤ˜ (38). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÔÈ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÔÙÈÎÒÓ Î·È ·ÎÔ˘ÛÙÈÎÒÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ Á›ÓÔÓÙ·È ·ÓÙÈÏËÙ¤˜ ÌfiÓÔ Î·Ù¿ ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·412

412

¢. ∑·ÊÂÈÚ›Ô˘ Î·È Û˘Ó.

ÙËÓ ÂͤٷÛË Ì Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ ÂϤÁ¯Ô˘, ¯ˆÚ›˜ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ·ÓÙ›ÛÙÔȯ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ (39,40). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ó¢ÚÔÙÔÍÈÎfiÙËÙ·˜ Ô˘ ·Ô‰›‰ÔÓÙ·È ÛÙË ¯Ú‹ÛË DFO, ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ‚·ıÌfi Ù˘ ‚Ï¿‚˘. ™Â ηٷÛÙ¿ÛÂȘ ·Û˘Ìو̷ÙÈΤ˜ ‹ Û˘Óԉ¢fiÌÂÓ˜ ·fi ‹Ș ÌfiÓÔ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û˘ÓÈÛÙ¿Ù·È Ë Ì›ˆÛË Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ‰ÔÛÔÏÔÁ›·˜, Ì ٷÎÙÈ΋ ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ (41). ∞ÓÙ›ıÂÙ·, Û ÂÚÈÙÒÛÂȘ ·ÚÔ˘Û›·˜ ÎÏÈÓÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ ‹ Âȉ›ӈÛ˘ Ù˘ ÂÚÁ·ÛÙËÚȷ΋˜ ÂÈÎfiÓ·˜ ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË Ë ‰È·ÎÔ‹ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, Ì ÚÔÛÂÎÙÈ΋ Â·Ó·¯ÔÚ‹ÁËÛË Û ¯·ÌËϤ˜ ‰fiÛÂȘ. ∆¤ÏÔ˜, ÂÈÚfiÛıÂÙ· Ù˘ ÁÓˆÛÙ‹˜ Î·È Î·Ï¿ ÌÂÏÂÙË̤Ó˘ ·ÎÔ˘ÛÙÈ΋˜ Î·È ÔÙÈ΋˜ Ó¢ÚÔÙÔÍÈÎfiÙËÙ·˜ Ù˘ DFO, ·Ó·Ê¤ÚÂÙ·È Û˘Û¯¤ÙÈÛË Ù˘ ıÂÚ·›·˜ ·ÔÛȉ‹ÚˆÛ˘ Ì ÙËÓ ÂΉ‹ÏˆÛË ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ (42-44). ø˜ Û˘ÓÔ‰¤˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÂÚÈÁÚ¿ÊÔÓÙ·È ·È̈‰›Â˜, ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜, Ì˘·ÏÁ›Â˜ Î·È Ì˘˚΋ ·‰˘Ó·Ì›·, ÂÓÒ ·Ó·Ê¤ÚÔÓÙ·È ·ÎfiÌË ÂÚÈÙÒÛÂȘ ·Û˘Ìو̷ÙÈ΋˜ ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÈ΋˜ ‚Ï¿‚˘, ·ÓȯÓ‡ÛÈÌ˘ ÌfiÓÔ Î·Ù¿ ÙÔÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô (45).

¡Â˘ÚÔÊ˘ÛÈÔÏÔÁ›· - ¡Â˘ÚÔ„˘¯ÔÏÔÁ›· ¶ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Î·È ‚-ª∞ ∆· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ·ÔÙÂÏÔ‡Ó Ì›· ·Ó·›Ì·ÎÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ ̤ıÔ‰Ô ÂͤٷÛ˘ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™). ∂Ê·ÚÌfi˙ÔÓÙ·È Â˘Ú¤ˆ˜ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970, ΢ڛˆ˜ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ·ÔÌ˘ÂÏÈÓˆÙÈÎÒÓ ÓfiÛˆÓ Î·È ÂÍÂÚÁ·ÛÈÒÓ Ù˘ Á¤Ê˘Ú·˜ Î·È ÙÔ˘ ÛÙÂϤ¯Ô˘˜, ÂÓÒ Ë ¯Ú‹ÛË ÙÔ˘˜ ÛÙÔÓ Ó¢ÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ ·Ó·Ê¤ÚÂÙ·È ‚È‚ÏÈÔÁÚ·ÊÈο ·fi Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 (46). ∏ ÌÂÁ¿ÏË Û˘Ì‚ÔÏ‹ ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ ÛÙËÓ ÂͤٷÛË ÙÔ˘ ∫¡™ ¤ÁÎÂÈÙ·È ÛÙË ‰˘Ó·ÙfiÙËÙ· ÚÒÈÌ˘ ·Ó›¯Ó¢Û˘ ˘ÔÎÏÈÓÈÎÒÓ ‚Ï·‚ÒÓ. °È· ÙËÓ ·ÚÔ˘Û›· ·ıÔÏÔÁÈÎÒÓ ÔÙÈÎÒÓ (VEP) Î·È ÛÙÂϯȷ›ˆÓ ·ÎÔ˘ÛÙÈÎÒÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ (BAEP) ÂÓÔ¯ÔÔÈÂ›Ù·È ‚È‚ÏÈÔÁÚ·ÊÈο, ΢ڛˆ˜ Ë Ó¢ÚÔÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DFO (23,39,40,45). ÷ڷÎÙËÚÈÛÙÈο, ÛÙË ÌÂϤÙË ÙˆÓ Triantafyllou Î·È Û˘Ó (40) ·Ó·Ê¤ÚÔÓÙ·È ·ıÔÏÔÁÈο VEP Î·È BAEP Û ÔÛÔÛÙfi 32,5% Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

17,5%, ·ÓÙ›ÛÙÔȯ·. OÈ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DFO Î·È Â›Ó·È ·Ó·ÛÙÚ¤„È̘ - ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ - ÌÂÙ¿ ÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ‰ÔÛÔÏÔÁÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ‹ ÙËÓ ·ÚÔ‰È΋ ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ·ÔÛȉ‹ÚˆÛ˘. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂͤٷÛË ÙˆÓ ÛˆÌ·ÙÔ·ÈÛıËÙÈÎÒÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ (SEP), Ë Û¯ÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ÂÍ·ÈÚÂÙÈο ÂÚÈÔÚÈṲ̂ÓË. ™ÙË ÌÂϤÙË ÙˆÓ Wong Î·È Û˘Ó (23) ·Ó·Ê¤ÚÂÙ·È Ë Î·Ù·ÁÚ·Ê‹ ·ıÔÏÔÁÈÎÒÓ SEP Û 4 ·fi 34 Û˘ÓÔÏÈο ÂÍÂÙ·˙fiÌÂÓÔ˘˜ ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜, ‰ËÏ·‰‹ Û ÔÛÔÛÙfi 11,76%. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÔÈ 2 ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ¿Û¯ÔÓÙ˜ ·fi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, Ë ·ÚÔ˘Û›· ÙÔ˘ ÔÔ›Ô˘ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È ÛÙ·ÙÈÛÙÈο Ì ÙËÓ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛˆÌ·ÙÔ·ÈÛıËÙÈÎÒÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ.

∆·¯‡ÙËÙ˜ ·ÁˆÁÈÌfiÙËÙ·˜ Î·È ‚-ª∞ ∆· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙËÓ ÂͤٷÛË ÙˆÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂ӷ. OÈ Papanastasiou Î·È Û˘Ó, ÌÂÏÂÙÒÓÙ·˜ ¿Û¯ÔÓÙ˜ ÙfiÛÔ ·fi ÔÌfi˙˘ÁË fiÛÔ Î·È ·fi ÂӉȿÌÂÛË ‚-ª∞, ·Ó·Ê¤ÚÔ˘Ó ÙËÓ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜, ÂÓÙÔÈ˙fiÌÂÓ˘ ΢ڛˆ˜ ÛÙ· οو ¿ÎÚ·, Û ÔÛÔÛÙfi 20% (43). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÚÔÛ‚ÔÏ‹ ÙˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ ÂÚÈÁÚ¿ÊÂÙ·È Ë ÌÂÌÔӈ̤ÓË ·ÚÔ˘Û›· ·ıÔÏÔÁÈÎÒÓ ÎÈÓËÙÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ ¯ˆÚ›˜ ·ÓÙ›ÛÙÔÈ¯Ë Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·ÈÛıËÙÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜, ·Ó·Ê¤ÚÂÙ·È fï˜ ·ÎfiÌË ·ÚÔ˘Û›· ÙÈÌÒÓ ÎÈÓËÙÈÎÒÓ Î·È ·ÈÛıËÙÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ ÏËÛ›ÔÓ ÙÔ˘ ·ÓÒÙ·ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ - ‚¿ÛÂÈ Ù˘ ÔÌ¿‰·˜ Ì·ÚÙ‡ÚˆÓ - Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ. OÈ Û˘ÁÁÚ·Ê›˜ Û˘Ó‰¤Ô˘Ó Ù· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ì ÙËÓ ·ÚÔ˘Û›· ¯·ÌËÏÒÓ ÂÈ¤‰ˆÓ ·ÈÌ·ÙÔÎÚ›ÙË, ‰ËÏ·‰‹ Ì ÙËÓ ·ÚÔ˘Û›· ˘ÔÍ›·˜, ηıÒ˜ Î·È Ì ÙËÓ ÚfiÔ‰Ô Ù˘ ËÏÈΛ·˜, Ë ÔÔ›· ÚÔÊ·ÓÒ˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi.

OÈ Wong Î·È Û˘Ó ÂÚÈÁÚ¿ÊÔ˘Ó ÌÂÌÔӈ̤ÓË Î·Ù·ÁÚ·Ê‹ ·ıÔÏÔÁÈÎÒÓ ·ÈÛıËÙÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ Û 7 ·fi 34 ÂÍÂÙ·˙fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ Ì ÔÌfi˙˘ÁË ‚-ª∞ (20,59%), 3 ÂÎ ÙˆÓ ÔÔ›ˆÓ ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ¿Û¯ÔÓÙ˜ ·fi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (23). ™ÙËÓ ÂÓ ÏfiÁˆ ÌÂϤÙË, Ë ·ÚÔ˘Û›· ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û˘Û¯ÂÙ›˙ÂÙ·È ÛÙ·ÙÈÛÙÈο Ì ÙËÓ ·ÈÌÔÛȉ‹ÚˆÛË, ›Ù ·˘Ù‹ Ô‰ËÁ› Û ‰È·Ù·Ú·¯‹ ÙÔ˘

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·413

∂ÈÏÔΤ˜ ·fi ÙÔ ∫¡™ Î·È ÙÔ ¶¡™ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜

ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘ ›Ù fi¯È. ∆· ·Ú·¿Óˆ ÔÛÔÛÙ¿ ÎÈÓÔ‡ÓÙ·È ÛÙËÓ ›‰È· Îϛ̷η Ì ÙÔ 25% ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ Ô˘ ‰È·ÈÛÙÒÓÔ˘Ó Û ÌÂϤÙË ÙÔ˘˜ ÔÈ Zafeiriou Î·È Û˘Ó (45). ™ÙË ÌÂϤÙË ·˘Ù‹ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È Û˘Û¯¤ÙÈÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Ù·¯˘Ù‹ÙˆÓ ·ÁˆÁÈÌfiÙËÙ·˜ Ì οÔÈÔÓ ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙËÓ ›‰È· ÙË ÓfiÛÔ ‹ ÙË ıÂÚ·›·, ÏËÓ ÙˆÓ ¯·ÌËÏÒÓ ÂÈ¤‰ˆÓ ¯·ÏÎÔ‡ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜.

¡Â˘ÚÔ„˘¯ÔÏÔÁ›· Î·È ‚-ª∞ ∏ Ó¢ÚÔ„˘¯ÔÏÔÁ›· ÂϤÁ¯ÂÈ ÙÔ ÓÔËÙÈÎfi ËÏ›ÎÔ, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÂȉÈΤ˜ „˘¯ÔÌÂÙÚÈΤ˜ ÌÂıfi‰Ô˘˜, fiˆ˜ Â›Ó·È ÔÈ ∫ϛ̷Θ ¡ÔËÌÔÛ‡Ó˘ Wechsler ÁÈ· ·È‰È¿, ÔÈ Ôԛ˜ ·ÔÙÂÏÔ‡Ó ÙÔ ÙÂÛÙ WISC (Weschler Intelligence Scale for Children - WISC) (47,48). ¶·Ú¿ ÙËÓ ÂÎÙÂٷ̤ÓË, Û ‰ÈÂıÓ¤˜ Â›‰Ô, ¯Ú‹ÛË ÙÔ˘ WISC ˆ˜ ̤ÛÔ ÌÂϤÙ˘ ÂÁÎÂÊ·ÏÈÎÒÓ ‰˘ÛÏÂÈÙÔ˘ÚÁÈÒÓ Û ÔÈΛϘ ηٷÛÙ¿ÛÂȘ Î·È ·ı‹ÛÂȘ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ‰ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜ (49), ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ì›· ·Ó·ÊÔÚ¿ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÙÂÛÙ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÓÔËÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÛıÂÓÒÓ Ì ‚-ª∞. ∂ÈÚfiÛıÂÙ·, Ë Ì¤¯ÚÈ Û‹ÌÂÚ· Û¯ÂÙÈ΋ ‰ÈÂıÓ‹˜ ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ÂÍ·ÈÚÂÙÈο ÂÚÈÔÚÈṲ̂ÓË, ¯ÚÔÓÈο ÍÂÂÚ·Ṳ̂ÓË Î·È fi¯È ¿ÓÙ· „˘¯ÔÌÂÙÚÈο “ÛÙ·ÓÙ·ÚÈṲ̂ÓË”, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (15,22,50-53). ™ÙË ÌÔÓ·‰È΋, ›Ûˆ˜, Û˘ÛÙËÌ·ÙÈ΋ Ó¢ÚÔ„˘¯ÔÏÔÁÈ΋ ÌÂϤÙË ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ, ÔÈ Monastero Î·È Û˘Ó ÂÓÔ¯ÔÔÈÔ‡Ó ÁÈ· Ù· ·ıÔÏÔÁÈο ·ÔÙÂϤÛÌ·Ù· ÙËÓ ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ Ûȉ‹ÚÔ˘, ηٷ‰ÂÈÎÓ‡ÔÓÙ·˜ ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ ·ÓÙ›Ï˄˘ Û ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ΢ڛˆ˜ ÛÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ì ÛËÌ›· ¤ÓÙÔÓ˘ ·ÈÌÔÛȉ‹ÚˆÛ˘ (22).

™˘ÌÂÚ¿ÛÌ·Ù· ∫·ıÒ˜ ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ Û˘Ó¯Ҙ ·˘Í¿ÓÂÈ, Ë ¯Ú‹ÛË ÙˆÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ Î·È Ó¢ÚÔ„˘¯ÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ÂͤٷÛ˘ ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›·, ÂÈÙÚ¤ÔÓÙ·˜ ÙËÓ ¤ÁηÈÚË ‰È·›ÛÙˆÛË ÚÔÛ‚ÔÏ‹˜ ÙˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ Î·È Î·ıÈÛÙÒÓÙ·˜ ‰˘Ó·Ù‹ ÙË ÛˆÛÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙËÓ ·Ó¿ÏÔÁË ÙÚÔÔÔ›ËÛË Ù˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜, Ì ·ÒÙÂÚÔ ¿ÓÙ· ÛÎÔfi ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÁÈ· ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ.

413

µÈ‚ÏÈÔÁÚ·Ê›· 1. ™ÈÓÔÔ‡ÏÔ˘ ∫. ªÔÚȷ΋ ‚¿ÛË Î·È ‰È¿ÁÓˆÛË ÙˆÓ ÌÂÛÔÁÂÈ·ÎÒÓ Û˘Ó‰ÚfïÓ. Haema 2000;3 (Suppl): S44-S47.

2. Kanavakis E, Tzotzos S, Liapaki A, MetaxotouMavromati A, Kattamis C. Frequency of alpha-thalassemia in Greece. Am J Hematol 1986;22:225-232.

3. Kattamis C, Hu H, Cheng G, Reese AL, GonzalezRedondo JM, Kutlar A et al. Molecular characterization of beta-thalassaemia in 174 Greek patients with thalassaemia major. Br J Haematol 1990;74:342-346.

4. Traeger-Synodinos J, Kanavakis E, Tzetis M, Kattamis A, Kattamis C. Characterization of nondeletion alpha-thalassemia mutations in the Greek population. Am J Hematol 1993;44:162-167.

5. Traeger-Synodinos J, Maragoudaki E, Vrettou C, Kanavakis E, Kattamis C. Rare beta-thalassemia alleles in the Greek and Greek Cypriot populations. Hemoglobin 1998;22:89-94.

6. Sivestroni E, Bianco I. Screening for microcytemia in Italy: analysis of data collected in the past 30 years. Am J Hum Genet 1975;27:198-212.

7. Zurlo MG, De Stefano P, Borgna-Pignatti C, Di Palma A, Piga A, Melevendi C et al. Survival and causes of death in thalassaemia major. Lancet 1989;2:27-30.

8. Modell B, Khan M, Darlison M. Survival in betathalassaemia major in the UK: data from the UK Thalassaemia Register. Lancet 2000;355:2051-2052.

9. Anderson LJ, Holden S, Davis B, Prescott E, Charrier CC, Bunce NH et al. Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. Eur Heart J 2001;22:21712179.

10. Logothetis J, Constantoulakis M, Economidou J, Stefanis C, Hakas P, Augoustaki O et al. Thalassemia major (homozygous beta-thalassemia). A survey of 138 cases with emphasis on neurologic and muscular aspects. Neurology 1972;22:294-304.

11. Aarabi B, Haghshenas M, Rakeii V. Visual failure caused by suprasellar extramedullary hematopoiesis in beta thalassemia: case report. Neurosurgery 1998;42:922-925.

12. Gouliamos A, Dardoufas C, Papailiou I, Kalovidouris A, Vlahos L, Papavasiliou C. Low back pain due to extramedullary hemopoiesis. Neuroradiology 1991;33:284-285.

13. McIntosh N. Beneficial effects of transfusing a patient with nontransfusion-dependent thalassaemia major. Arch Dis Child 1976;51:471-472.

14. Hazell JW, Modell CB. E.N.T. complications in thalassaemia major. J Laryngol Otol 1976;90:877-881.

15. Logothetis J, Haritos-Fatouros M, Constantoulakis M, Economidou J, Augoustaki O, Loewenson RB. Intelligence and behavioral patterns in patients with Cooley’s anemia (homozygous beta-thalassemia): a study based on 138 consecutive cases. Pediatrics 1971;48:740-744.

16. Mollica F, Romeo MA, Di Gregorio F, Grasso A, Pavone L. Les manifestations nerveuses et musculaires au cours de la thalassemie majeure. Arch Fr Pediatr 1980;37:173-175. ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·414

414

¢. ∑·ÊÂÈÚ›Ô˘ Î·È Û˘Ó.

17. Incorpora G, Di Gregorio F, Romeo MA, Pavone P, Trifiletti RR, Parano E. Focal neurological deficits in children with beta-thalassemia major. Neuropediatrics 1999;30:45-48.

18. Manfre L, Giarratano E, Maggio A, Banco A, Vaccaro G, Lagalla R. MR imaging of the brain: findings in asymptomatic patients with thalassemia intermedia and sickle cell-thalassemia disease. Am J Roentgenol 1999;173:1477-1480.

19. De Virgiliis S, Argiolu F, Sanna G, Cornacchia G, Cossu P, Cao A et al. Auditory involvement in thalassemia major. Acta Haematol 1979;61:209-215.

20. Gelmi C, Borgna-Pignatti C, Franchin S, Tacchini M, Trimarchi F. Electroretinographic and visual-evoked potential abnormalities in patients with beta-thalassemia major. Ophthalmologica 1988;196:29-34.

21. Metafratzi Z, Argyropoulou MI, Kiortsis DN, Tsampoulas C, Chaliassos N, Efremidis SC. T(2) relaxation rate of basal ganglia and cortex in patients with betathalassaemia major. Br J Radiol 2001;74:407-410.

22. Monastero R, Monastero G, Ciaccio C, Padovani A, Camarda R. Cognitive deficits in beta-thalassemia major. Acta Neurol Scand 2000;102:162-168.

23. Wong V, Li A, Lee AC. Neurophysiologic study of beta-thalassemia patients. J Child Neurol 1993;8: 330-335.

24. Giardina PJ, Grady RW. Chelation therapy in betathalassemia: the benefits and limitations of desferrioxamine. Semin Hematol 1995;32:304-312.

25. Porter JB. A risk-benefit assessment of iron-chelation therapy. Drug Saf 1997;17:407-421.

26. Olivieri NF, Buncic JR, Chew E, Gallant T, Harrison RV, Keenan N et al. Visual and auditory neurotoxicity in patients receiving subcutaneous deferoxamine infusions. N Engl J Med 1986;314:869-873.

27. Zaino EC, Roberts RH, editors. Chelation therapy in chronic iron overload. New York: Ciba Medical Horizons Symposium; 1977. p. 95-107.

28. De Virgiliis S, Congia M, Turco MP, Frau F, Dessi C, Argiolou F et al. Depletion of trace elements and acute ocular toxicity induced by desferrioxamine in patients with thalassaemia. Arch Dis Child 1988;63:250-255.

29. Klebanoff SJ, Waltersdorph AM, Michel BR, Rosen H. Oxygen-based free radical generation by ferrous ions and deferoxamine. J Biol Chem 1989;264: 19765-19771.

30. Ambrosetti U, Donde E, Piatti G, Cappellini MD. Audiological evaluation in adult beta-thalassemia major patients under regular chelation treatment.

Pharmacol Res 2000;42:485-487.

31. Bentur Y, Koren G, Tesoro A, Carley H, Olivieri N, Freedman MH. Comparison of deferoxamine pharmacokinetics between asymptomatic thalassemic children and those exhibiting severe neurotoxicity.

Clin Pharmacol Ther 1990;47:478-482.

32. Amabile G, Stefano E, Bianco I, Aliquo M, Giunti P, Pierelli F. Electrophysiologic study in patients with beta-thalassemia major. Acta Neurol 1987;87:181190.

33. Sacco M, Meleleo D, Tricarico N, Greco Miani A, Serra E, Parlatore L. Evaluation of desferrioxamine ¶·È‰È·ÙÚÈ΋ 2005;68:409-415

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

ototoxicity in thalassemic patients. Follow-up over a 5-year period and results. Minerva Pediatr 1994;46:225-230.

Chiodo AA, Alberti PW, Sher GD, Francombe WH, Tyler B. Desferrioxamine ototoxicity in an adult transfusion-dependent population. J Otolaryngol 1997;26:116-122.

Bene C, Manzler A, Bene D, Kranias G. Irreversible ocular toxicity from single "challenge" dose of deferoxamine. Clin Nephrol 1989;31:45-48.

Orton RB, De Veber LL, Sulh HM. Ocular and auditory toxicity of long-term, high-dose subcutaneous deferoxamine therapy. Can J Ophthalmol 1985;20:153-156.

Kontzoglou G, Koussi A, Tsatra J, Noussios G, Vital V, Sagarakis G et al. Sensorineural hearing loss in children with thalassemia major in Northern Greece.

Int J Pediatr Otorhinolaryngol 1996;35:223-230.

Styles LA, Vichinsky EP. Ototoxicity in hemoglobinopathy patients chelated with desferrioxamine. J Pediatr Hematol Oncol 1996;18:42-45.

Marciani MG, Cianciulli P, Stefani N, Stefanini F, Peroni L, Sabbadini M et al. Toxic effects of high-dose deferoxamine treatment in patients with iron overload: an electrophysiological study of cerebral and visual function. Haematologica 1991;76:131-134.

Triantafyllou N, Fisfis M, Sideris G, Triantafyllou D, Rombos A, Vrettou H et al. Neurophysiological and neuro-otological study of homozygous beta-thalassemia under long-term desferrioxamine (DFO) treatment. Acta Neurol Scand 1991;83:306-308. ∏iggs DR, Thein SL, Wood WG. The pathology of the thalassemias. In: Weatherall DJ, Clegg JB, editors. The thalassemia syndromes. 4th ed. Oxford: Blackwell Science; 2001. p. 192-236.

Giardina PJ, Nealon N, McQueen M. Sensorimotor neuropathy associated with high dose desferrioxamine. Blood 1991;78:199-205.

Papanastasiou DA, Papanicolaou D, Magiakou AM, Beratis NG, Tzebelikos E, Papapetropoulos T. Peripheral neuropathy in patients with beta-thalassaemia. J Neurol Neurosurg Psychiatry 1991;54:9971000.

Levine JE, Cohen A, MacQueen M, Martin M, Giardina PJ. Sensorimotor neurotoxicity associated with high-dose deferoxamine treatment. J Pediatr Hematol Oncol 1997;19:139-141.

Zafeiriou DI, Kousi AA, Tsantali CT, Kontopoulos EE, Augoustidou-Savvopoulou PA, Tsoubaris PD et al. Neurophysiologic evaluation of long-term desferrioxamine therapy in beta-thalassemia patients.

Pediatr Neurol 1998;18:420-424.

Lakhanpal V, Schocket SS, Jiji R. Deferoxamine (Desferal)-induced toxic retinal pigmentary degeneration and presumed optic neuropathy. Ophthalmology 1984;91:443-451.

Weschler D. Manual for the Weschler Intelligence Scale for Children. 3rd ed. Sidcup: The Psychologcal Corporation; 1991. °ÂˆÚÁ¿˜ ¢, ¶·Ú·Û΢fiÔ˘ÏÔ˜ π, ªÂ˙ÂÌ¤Î˘ π, °È·ÓÓ›ÙÛ·˜ N. Weschler Intelligence Scale for Children - III - ∂Á¯ÂÈÚ›‰ÈÔ, ∂ÏÏËÓÈ΋ ŒÎ‰ÔÛË.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·415

∂ÈÏÔΤ˜ ·fi ÙÔ ∫¡™ Î·È ÙÔ ¶¡™ Û ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜

∞ı‹Ó·: ∂ÏÏËÓÈο °Ú¿ÌÌ·Ù·; 1997.

49. Wang W, Enos L, Gallagher D, Thompson R, Guarini L, Vichinsky E et al. Neuropsychologic performance in school-aged children with sickle cell disease: a report from the Cooperative Study of Sickle Cell Disease. J Pediatr 2001;139:391-397.

50. Davidson C, Weschler I. Erythroblastic anemia and neurological complications. Am J Dis Child 1939;58: 362-366.

51. Matoth Y, Shamir Z, Freundlich E. Thalassemia in

415

Jews from Kurdistan. Blood 1955;10:176-189.

52. Orsini A, Soulayrol R, Tramini F, Tasso-Perrimond AM. Nervous manifestations associated with thalassemia (critical study of the concept of thalassemic neurohemolytic syndrome). Pediatrie 1967;22:771784.

53. ª¯ڿ΢ °, ™·ÎÂÏÏ·Ú›‰Ë˜ N, ∆˙·ÌÔ˘Ú¿Ó˘ °, µÏ¿¯Ô˘ ¶. ¡Â˘ÚÔ„˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙË ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. ∂ÏÏËÓÈ΋ π·ÙÚÈ΋ 1968;37:10431048.

¶·È‰È·ÙÚÈ΋ 2005;68:409-415

Pediatr Nov-Dec 05

12-12-05

416

15:16

™ÂÏ›‰·416

REVIEW ARTICLE

Central and peripheral nervous system complications in patients with beta-thalassaemia major 1st Paediatric Clinic of Aristotelion University, “Ippokration” General Hospital, Thessaloniki Correspondence: Dimitrios Zafeiriou “Ippokration” General Hospital 49 Konstantinoupoleos Str., 546 42, Thessaloniki E-mail: jeff@med.auth.gr Date of submission: 03-09-2004 Date of approval: 27-04-2005

D. Zafeiriou, M. Oikonomou, M. Athanassiou - Metaxa

Abstract Beta-thalassaemia major (BTM) is the most severe form in a group of inherited disorders of haemoglobin. Thalassaemic patients require regular red cell transfusions and concomitant iron chelation therapy in order to eliminate anaemia and the complications of haemosiderosis. During recent decades, there have been several reports of involvement of the nervous system in BTM patients. Neurological complications have been attributed to chronic hypoxia, iron overload and desferrioxamine (DFO) chelation treatment. In most cases, the neurological involvement does not present with overt relevant signs or symptoms and can only be detected by neurophysiological testing. Evoked potential study is a non-invasive method, capable of selectively exploring the function of specific brain structures, thus enabling the discovery of abnormalities in the sub-clinical phase. Evoked potential investigation has been applied in the neurological evaluation of patients with thalassaemia since the mid 1980s. In contrast, literature concerning nerve conduction velocity studies in BTM patients remains limited. Equally scarce are reports concerning the neuropsychological profile of thalassaemic patients, with results that are conflicting and not always psychometrically standardized. As the life expectancy of BTM patients increases, application of neurophysiology and neuropsychology becomes of the utmost importance, in order to detect early involvement of the neural pathways and institute appropriate care for this group of patients.

Key words Beta-thalassaemia, desferrioxamine, neurotoxicity, evoked potentials, nerve conduction velocity, neurophysiology, neuropsychology, intelligent quotient.

Paediatriki 2005;68:416

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·417

∞¡∞™∫O¶∏™∏

417

¶ÚfiÔ‰ÔÈ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ °. ¢ËÌËÙÚ›Ô˘, Ã. ∞Á·Î›‰Ë˜

¶ÂÚ›ÏË„Ë ∏ Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË (™¢∫) Â›Ó·È Ì›· ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ó¿Ù˘Í˘ ÌÂ Û˘¯ÓfiÙËÙ· 1 ·Ó¿ 2.000-5.000 ÁÂÓÓ‹ÛÂȘ. ªÂ ÙËÓ Â˘Ú›· ¯Ú‹ÛË ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜, Ë ‰È¿ÁÓˆÛ‹ Ù˘ Á›ÓÂÙ·È fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· ÚÔÁÂÓÓËÙÈο. O ÚfiÏÔ˜ ÙˆÓ ÂÓ‰ÔÌ‹ÙÚÈˆÓ ÂÂÌ‚¿ÛÂˆÓ Î·È ÙˆÓ Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, fiˆ˜ Â›Ó·È Ô ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜, ÙÔ ÂÈÛÓÂfiÌÂÓÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘, Ë Â͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË Ì ÙË ¯Ú‹ÛË ÌÂÌ‚Ú¿Ó˘ Î·È Ô ·ÂÚÈÛÌfi˜ Ì ˘ÁÚfi, ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·ÎfiÌË. ªÂÏÏÔÓÙÈÎÔ› ÛÙfi¯ÔÈ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Î·È Ô Î·ıÔÚÈÛÌfi˜ ÈÔ ·ÍÈfiÈÛÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÎÚÈÛË ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ™¢∫ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂˆÊÂÏËıÔ‡Ó ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ·Ú¤Ì‚·ÛË, ηıÒ˜ Î·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ Ô˘ ÌÂÈÒÓÔ˘Ó ÙÔ ‚·ÚÔ-/ÔÁÎÔÙÚ·‡Ì·.

Guy’s, Kings’ & St. Thomas’ School of Medicine, London, UK AÏÏËÏÔÁÚ·Ê›·: ÷ڿϷÌÔ˜ ∞Á·Î›‰Ë˜ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E-mail: agaki@med.auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 01-12-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-05-2005

§¤ÍÂȘ ÎÏÂȉȿ ¢È·ÊÚ·ÁÌ·ÙÔ΋ÏË, ¤Ì‚Ú˘Ô, ÂÌ‚Ú˘˚΋ ¯ÂÈÚÔ˘ÚÁÈ΋, Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Ô͢ÁfiÓˆÛË.

™˘ÓÙÔÌÔÁڷʛ˜ ™¢∫ ™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ¡O ªÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ ECMO ∂͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË Ì ÙË ¯Ú‹ÛË ÌÂÌ‚Ú¿Ó˘ ¢¶/¢∫ §fiÁÔ˜ Ù˘ ‰È·Ì¤ÙÚÔ˘ Ó‡ÌÔÓ· ÚÔ˜ ÙË ‰È¿ÌÂÙÚÔ Ù˘ ÎÂÊ·Ï‹˜

∂ÈÛ·ÁˆÁ‹ ∏ Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË (™¢∫) Â›Ó·È Ì›· ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ó¿Ù˘Í˘ ÌÂ Û˘¯ÓfiÙËÙ· 1 ·Ó¿ 2.000-5.000 ÁÂÓÓ‹ÛÂȘ (1,2). ∏ ·ÚÈÛÙÂÚ‹ ÂÓÙfiÈÛË Ù˘ ™¢∫, Ô˘ ¤¯ÂÈ ÙË ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË, ·ÓÙÈÚÔÛˆ‡ÂÈ ÙÔ 80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (3). ¶·Ú’ fiÏË ÙËÓ Ù¯ÓÔÏÔÁÈ΋ ÚfiÔ‰Ô, Ë Û˘ÓÔÏÈ΋ ıÓËÙfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ Â›Ó·È ÂÚ›Ô˘ 40% (8-79%) (2,4). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤¯Ô˘Ó ÂÊ·ÚÌÔÛÙ› ‰È¿ÊÔÚ˜ Ӥ˜ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ™¢∫, fiˆ˜ Ô ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜, ÙÔ ÂÈÛÓÂfiÌÂÓÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (¡O), Ë Â͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË Ì ÌÂÌ‚Ú¿ÓË (extracorporeal membrane oxygenation ECMO), Ô ·ÂÚÈÛÌfi˜ Ì ˘ÁÚfi Î·È ÔÈ ÂÓ‰ÔÌ‹ÙÚȘ ÂÂÌ‚¿ÛÂȘ. øÛÙfiÛÔ, ··ÈÙÔ‡ÓÙ·È Î·Ï¿ ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› Ô ÚfiÏÔ˜ ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ

·˘ÙÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫.

¶ÚÔÁÂÓÓËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ªÂ ÙËÓ Â˘Ú›· ¯Ú‹ÛË ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜, Ë ‰È¿ÁÓˆÛË Ù˘ ™¢∫ Á›ÓÂÙ·È ÚÔÁÂÓÓËÙÈο fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· Î·È Ì¿ÏÈÛÙ· Û ÚÒÈÌÔ ÛÙ¿‰ÈÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. ∆˘ÈÎfi ‡ÚËÌ· ·ÔÙÂÏ› Ë ·ÚÔ˘Û›· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ (·ÚÈÛÙÂÚ‹ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË) Ì ·ÚÂÎÙfiÈÛË ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÛÙËÓ ·ÓÙ›ıÂÙË ÏÂ˘Ú¿. √È ™¢∫ Ô˘ ÂÛÙÈ¿˙ÔÓÙ·È ‰ÂÍÈ¿ Â›Ó·È ÈÔ ‰‡ÛÎÔÏÔ Ó· ‰È·ÁÓˆÛÙÔ‡Ó, ηıÒ˜ Ë ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ‰È·Ê‡ÁÂÈ, Â¿Ó ÙÔ ÛÙÔÌ¿¯È ‹ ÙÔ ‹·Ú ‰ÂÓ ‚Ú›ÛÎÂÙ·È ÛÙÔÓ ıÒڷη ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ‰ÈÂÍ¿ÁÂÙ·È Ô ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜. ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ™¢∫ ·ÔÙÂÏ› ÙÔ ¤Ó·˘ÛÌ· ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Û¯ÂÙÈο Ì ¯ÚˆÌÔÛˆÌÈΤ˜ ‹ ¿ÏϘ Ì›˙ÔÓ˜ ·ÓˆÌ·Ï›Â˜. ∏ ™¢∫ Û¿ÓÈ· ·ÔÙÂÏ› ÌÂÌÔӈ̤ÓË ‰È·Ù·Ú·¯‹, ηıÒ˜ Û 40-50% ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ™¢∫ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏϘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ (3). ∏ ·Ó¿Ù˘ÍË Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÚÔÁÂÓÓËÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Û¯ÂÙÈο Ì ÙËÓ ÚfiÁÓˆÛË Ù˘ ¤Î‚·Û˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¶·È‰È·ÙÚÈ΋ 2005;68:417-423

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·418

418

°. ¢ËÌËÙÚ›Ô˘ Î·È Û˘Ó.

Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÎÚÈ‚‹ Î·È ÏÂÙÔÌÂÚ‹ ÚÔÁÂÓÓËÙÈ΋ ηıÔ‰‹ÁËÛË. ø˜ ÚÔÁÂÓÓËÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ¤Î‚·Û˘ ¤¯Ô˘Ó ÚÔÙ·ı› ÔÏÏ¿ ÚÔÁÂÓÓËÙÈο ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù·, fiˆ˜ ÙÔ ÔÏ˘˘‰Ú¿ÌÓÈÔ, Ë ·ÚÔ˘Û›· ÛÙfiÌ·¯Ô˘ ‹ ‹·ÙÔ˜ ÛÙÔÓ ıÒڷη, Ô ÏfiÁÔ˜ ‰È·Ì¤ÙÚÔ˘ Ó‡ÌÔÓ· ÚÔ˜ ÙË ‰È¿ÌÂÙÚÔ ÎÂÊ·Ï‹˜ (¢¶/¢∫) Î·È Ô ÏfiÁÔ˜ Ó‡ÌÔÓ· ÚÔ˜ ÙËÓ ÂÁοÚÛÈ· ‰È¿ÌÂÙÚÔ ÙÔ˘ ıÒڷη. °È· ÙÔ˘˜ ‰Â›ÎÙ˜ ·˘ÙÔ‡˜, Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂȂ‚·Èˆı› Ë ·ÍÈÔÈÛÙ›· ÙÔ˘˜ ˆ˜ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ Ù˘ ¤Î‚·Û˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ̤۷ ·fi ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ (5,6). ¶ÔÏÏ¿ ΤÓÙÚ· ıˆÚÔ‡Ó ÙÔÓ Û˘Ó‰˘·ÛÌfi ÙÔ˘ ÏfiÁÔ˘ ¢¶/¢∫ <1,0 Ì ÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ‹·ÙÔ˜ ÛÙÔÓ ıÒڷη ˆ˜ ηÎfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË (7,8). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ Û ¤Ì‚Ú˘· Ì ™¢∫ Ë ÙÈÌ‹ ÙÔ˘ ‰Â›ÎÙË ¢¶/¢∫ <0,6 Û¯ÂÙ›˙ÂÙ·È Ì ıÓËÙfiÙËÙ· 100% (9,10). ¶ÚfiÛÊ·Ù˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ·ÂÈÎÔÓÈÛÙÈ΋, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÂÌ‚Ú˘˚΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ÙËÓ ÂÌ‚Ú˘˚΋ ˘ÂÚ˯ÔÁÚ·Ê›·, ¤¯Ô˘Ó ·Ó·‰Â›ÍÂÈ ÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ fiÁÎÔ˘, Ù˘ Ì¿˙·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È Ù˘ ‰È·Ì¤ÙÚÔ˘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ˆ˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ¤Î‚·Û˘ ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ™¢∫ (11,12).

- ·ÓÙÈÌÂÙÒÈÛË. ∆· ·ÔÁÔËÙ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ηıÈÛÙÔ‡Ó ·‰ÈηÈÔÏfiÁËÙË ÙËÓ ¤ÎıÂÛË ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ (1618). ∏ ·Ú·Ù‹ÚËÛË fiÙÈ Ù· ÓÂÔÁÓ¿ Ì ·ÙÚËÛ›· Ï¿Ú˘ÁÁ· ›¯·Ó ‰ÈÔÁΈ̤ÓÔ˘˜ ˘ÂÚÏ·ÛÙÈÎÔ‡˜ Ó‡ÌÔÓ˜ Ô‰‹ÁËÛ ÛÙËÓ ·Ó¿Ù˘ÍË ÔÈÎ›ÏˆÓ ÌÂıfi‰ˆÓ Ô˘ ‚·Û›˙ÔÓÙ·Ó ÛÙËÓ ·Ú¯‹ “ÂÈˆÌ¿ÙÈÛ ÙÔÓ Ó‡ÌÔÓ· ̤¯ÚÈ Ó· ÌÂÁ·ÏÒÛÂÈ” (PLUG) (19). ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ ÂÏ¿¯ÈÛÙ· ÂÂÌ‚·ÙÈÎÒÓ Ù¯ÓÈÎÒÓ Â¤ÙÚ„ ÙËÓ ÂÌ‚Ú˘ÔÛÎÔÈ΋ ÙÔÔı¤ÙËÛË Û˘Û΢ÒÓ ·fiÊڷ͢ Ù˘ ÙÚ·¯Â›·˜, Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ, ÌÂ Û˘Ó·ÎfiÏÔ˘ıË Û˘Ó¤¯ÈÛË Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ Ó¢ÌfiÓˆÓ (7). ∏ ÂÌ‚Ú˘˚΋ ÙÚ·¯Â›· ·ÔÊÚ¿ÛÛÂÙ·È ÂÓ‰ÔÌ‹ÙÚÈ· Î·È ·Ú·Ì¤ÓÂÈ ÎÏÂÈÛÙ‹ ̤¯ÚÈ ÙË ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ‰È·‰Èηۛ·˜ EXIT (ex-utero intrapartum treatment), Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÂÎÏÂÎÙÈ΋ ηÈÛ·ÚÈ΋ ÙÔÌ‹ (20). ¶·Ú’ fiÏÔ Ô˘ ÔÈ ·ÚÂÌ‚¿ÛÂȘ ·˘Ù¤˜ Â›Ó·È ÚÔ˜ ÙÔ ·ÚfiÓ ÂÚÈÔÚÈṲ̂Ó˜, Ì›· ˘ÔÔÌ¿‰· ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ÛÔ‚·Ú‹ ÌÔÚÊ‹ ™¢∫ ı· ÌÔÚÔ‡Û Èı·Ófiٷٷ Ó· ˆÊÂÏËı› ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· Â¤Ì‚·ÛË.

¶ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ √È Ó‡ÌÔÓ˜ ÂÈÚ·Ì·Ùfi˙ˆˆÓ Ì ™¢∫ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚ÈÔ¯ËÌÈ΋ Î·È ÌÔÚÊÔÏÔÁÈ΋ ·ÓˆÚÈÌfiÙËÙ·. ∂›Ó·È ϤÔÓ ·ԉ‰ÂÈÁ̤ÓÔ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ Û ÚfiˆÚ· ÓÂÔÁÓ¿, fiˆ˜ Î·È Û ˙Ò·, Ì ™¢∫ ÚÔ¿ÁÂÈ ÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ Ó‡ÌÔÓ· (14). øÛÙfiÛÔ, Ë ˆÊ¤ÏÂÈ· ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Û ÓÂÔÁÓ¿ Ì ™¢∫ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› (15). ª›· ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Â›Ó·È Û ÂͤÏÈÍË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ Û ·ÓıÚÒÈÓ· ¤Ì‚Ú˘· Ì ™¢∫ (15).

∞ÓÙÈÌÂÙÒÈÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË

∂Ì‚Ú˘˚΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ∏ ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ ÒıËÛ ÙÔ˘˜ ·È‰Ô¯ÂÈÚÔ˘ÚÁÔ‡˜ ÛÙËÓ ÚÔÛ¿ıÂÈ· ÚÔÁÂÓÓËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∂›¯Â ‰È·Ù˘ˆı› Ë ˘fiıÂÛË fiÙÈ Ë ·Ó¿Ù·ÍË Ù˘ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ ÛÙÔ ¤Ì‚Ú˘Ô ı· ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ¿ÚÛË ÙˆÓ Û˘ÌÈÂÛÙÈÎÒÓ ‰˘Ó¿ÌÂˆÓ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ Ó‡ÌÔÓ· Î·È ı· Â¤ÙÚÂ ÙËÓ ·Ó¿Ù˘Í‹ ÙÔ˘ ηÈ, ηٿ Û˘Ó¤ÂÈ·, ı· ‚ÂÏÙ›ˆÓ ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ‚ÚÂÊÒÓ Ì ™¢∫. √È ·Ú¯ÈΤ˜ ÌÂϤÙ˜ ·¤Ù˘¯·Ó Ó· ·ԉ›ÍÔ˘Ó Î¿ÔÈÔ fiÊÂÏÔ˜ ÛÙËÓ ÂÈ‚›ˆÛË Û ۇÁÎÚÈÛË Ì ÙËÓ ÎÏ·ÛÈ΋ - ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¶·È‰È·ÙÚÈ΋ 2005;68:417-423

∆· ÛÔ‚·ÚfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ Â›Ó·È Ë ˘ÔÏ·Û›· ÙÔ˘ Ó‡ÌÔÓ· Î·È Ë Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË. ∏ ·ÓÙÈÌÂÙÒÈÛË ÛÙԯ‡ÂÈ ÛÙËÓ È‰·ÓÈ΋, fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ, ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Ì ÙË ÌÈÎÚfiÙÂÚË ‰˘Ó·Ù‹ ‚Ï¿‚Ë ÙˆÓ Ó¢ÌfiÓˆÓ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú·.

ÕÌÂÛË ·ÓÙÈÌÂÙÒÈÛË ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ™¢∫ Â›Ó·È ÔχÙÈÌË. ªÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, Ë ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒÓÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÛηÊÔÂȉԇ˜ ÎÔÈÏ›·˜, ÙËÓ ·Ô˘Û›· ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜ ÂÙÂÚfiÏ¢ڷ, ÙË ÌÂÙ·ÙfiÈÛË Ù˘ ηډȷ΋˜ ÒÛ˘ Î·È ÙËÓ ‡·ÚÍË ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È Î˘¿ÓˆÛ˘. ∫·Ù¿ ÙÔÓ ÙÔÎÂÙfi ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË, ÙÔ ÓÂÔÁÓfi Ú¤ÂÈ Ó· ‰È·ÛˆÏËÓˆı› ¿ÌÂÛ·, ÒÛÙ ӷ ·ÔÊ¢¯ı› Ô ·ÂÚÈÛÌfi˜ Ì ̿Ûη Î·È ·ÛÎfi (ambu). ∂›Û˘, Ú¤ÂÈ Ó· ÙÔÔıÂÙËı› ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ηıÂÙ‹Ú·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÛ˘ÌÊÔÚËı› ÙÔ ÙÌ‹Ì· ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔÓ ıÒڷη. ∏ ÚfiÎÏËÛË

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·419

419

™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË

Ó¢ÌÔıÒڷη ÛÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ËÌÈıˆÚ¿ÎÈÔ ·ÔÙÂÏ› Ôχ ÁÓˆÛÙ‹ ÂÈÏÔ΋ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿Ó˄˘.

¢Â›ÎÙ˜ ¤Î‚·Û˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Œ¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÚÔÛ¿ıÂȘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ ™¢∫ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È Ó· ÚÔ‚ÏÂÊı› ÂӉ¯fiÌÂÓË Î·Î‹ ¤Î‚·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡, Ì ÛÎÔfi ÙËÓ Î·Ï‡ÙÂÚË Î·ıÔ‰‹ÁËÛË. Œ¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ‰È·›ÛÙˆÛË ¯·ÌËÏ‹˜ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ ‹ ÂÓ‰ÔÙÈÎfiÙËÙ·˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (21,22), ÙÔÓ ˘„ËÏfi ‰Â›ÎÙË ·ÂÚÈÛÌÔ‡ ‹ Ù¿ÛË ‰ÈÔÍÂȉ›Ô˘ ÙÔ˘ ¿Óıڷη (23-25) Î·È ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÛÙÔ Û‡ÛÙÔÈ¯Ô ËÌÈıˆÚ¿ÎÈÔ (26). ∏ Û‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ ·˘ÙÒÓ ·ÔηχÙÂÈ fiÙÈ Ë ¯·ÌËÏ‹ ÙÈÌ‹ Ù˘ ÂÓ‰ÔÙÈÎfiÙËÙ·˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È Ô ÈÔ ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ η΋˜ ¤Î‚·Û˘. ∂ÈϤÔÓ, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰È·‰Ô¯ÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Ù˘ ÂÓ‰ÔÙÈÎfiÙËÙ·˜ ·ԉ›¯ÙËÎ·Ó ÈÔ ¯Ú‹ÛÈÌ· ·fi ÙÔÓ fiÁÎÔ ÙÔ˘ Ó‡ÌÔÓ· ÛÙËÓ Úfi‚ÏÂ„Ë Ù˘ ¤Î‚·Û˘ (28). ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ fiÁÎÔ˘ Ó‡ÌÔÓ·, Ô˘ Á›ÓÂÙ·È Ì ·Ó¿Ï˘ÛË Ì¤Ûˆ ˘ÔÏÔÁÈÛÙ‹ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ Ó‡ÌÔÓ· ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË Û ÓÂÔÁÓ¿ Ì ™¢∫ (29). ª›· ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘, Ô˘ ‰ËÌÔÛ›Â˘Û ٷ ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ 71 ΤÓÙÚˆÓ, ¤‰ÂÈÍ fiÙÈ ÔÈ ÈÔ ÛËÌ·ÓÙÈÎÔ› ‰Â›ÎÙ˜ Ù˘ ¤Î‚·Û˘ ‹Ù·Ó ÙÔ Apgar score ÛÙÔ 5Ô ÏÂÙfi Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (30). ™ÙÚ·ÙËÁÈΤ˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ O ÛÙfi¯Ô˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Â›Ó·È Ó· ÂÈÙ‡¯ÂÈ Â·Ú΋ Ô͢ÁfiÓˆÛË Ì ÙË ¯·ÌËÏfiÙÂÚË ‰˘Ó·Ù‹ ÙÈÌ‹ ıÂÙÈ΋˜ ÂÈÛÓ¢ÛÙÈ΋˜ ›ÂÛ˘ (PIP). O ·ÓÙÈÎÂÈÌÂÓÈÎfi˜ ÛÙfi¯Ô˜ Â›Ó·È Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ ÚÈÓ ·fi ÙÔÓ ·ÚÙËÚÈ·Îfi fiÚÔ Û Â›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙÔ˘ 85%, ÂÊ·ÚÌfi˙ÔÓÙ·˜ PIP ÌÈÎÚfiÙÂÚË ·fi 25-30 cm H2O (31). ∏ ÛÙÚ·ÙËÁÈ΋ Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ˘ÂÚηÓ›·˜ ÂÏ·ÙÙÒÓÂÈ ÙË ‚Ï¿‚Ë Ô˘ ÚÔηÏ› Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÛÙÔÓ Ó‡ÌÔÓ·, ˆÛÙfiÛÔ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ·Ó¿Ù˘ÍË ÔͤˆÛ˘. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› Ë ÂΉ‹ÏˆÛË Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ‰È·ÙËÚÂ›Ù·È ÙÔ p∏ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·, ÂÓÒ ·Ú¿ÏÏËÏ· ÔÈ ¯ÂÈÚÈÛÌÔ› ÛÙÔ ÓÂÔÁÓfi ÂÚÈÔÚ›˙ÔÓÙ·È ÛÙÔ˘˜ ÂÏ¿¯ÈÛÙÔ˘˜ ··Ú·›ÙËÙÔ˘˜. ∏ ηıÈÂڈ̤ÓË ÂÊ·ÚÌÔÁ‹ ηٷÛÙÔÏ‹˜ Ì ‹ ¯ˆ-

Ú›˜ Ì˘Ô¯¿Ï·ÛË ÂÚÈÔÚ›˙ÂÈ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ¤Ó·ÓÙÈ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· Î·È ÂÏ·¯ÈÛÙÔÔÈ› ÙȘ ÎÚ›ÛÂȘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘. ∏ ÂÏ¿ÙÙˆÛË ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛÙ·‰È·Î¿, ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜ ‰ÂÓ Â·ÚΛ ÁÈ· ÙËÓ ÈηÓÔÔÈËÙÈ΋ Ô͢ÁfiÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡, ÙfiÙ ÂÈÚfiÛıÂÙ· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÙÔ ÂÈÛÓÂfiÌÂÓÔ NO, Ô ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ ‹ Î·È Ë ECMO.

∂ÈÛÓÂfiÌÂÓÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ ∆Ô ÂÈÛÓÂfiÌÂÓÔ ¡O ·ÔÙÂÏ› ÂÎÏÂÎÙÈÎfi ‰È·ÛÙÔϤ· ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ. Œ¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ÌÂÈÒÓÂÈ ÙËÓ ·Ó¿ÁÎË ¯Ú‹Û˘ Ù˘ ECMO Û ÓÂÔÁÓ¿ Ì ·Ú·Ì¤ÓÔ˘Û· Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (33). øÛÙfiÛÔ, ÌÂϤÙ˜ Û ÓÂÔÁÓ¿ Ì ™¢∫ ‰Â›¯ÓÔ˘Ó Ì›· ÈÔ ÔÈΛÏË ·¿ÓÙËÛË ÛÙÔ ¡O, Ì ÔÏÏ¿ ·fi ·˘Ù¿ Ó· ÌËÓ ˆÊÂÏÔ‡ÓÙ·È Î·ıfiÏÔ˘. O ÚfiÏÔ˜ ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ Ô˘ÛÈÒÓ, fiˆ˜ Ù˘ ÙÔÏ·˙ÔÏ›Ó˘, ÙÔ˘ ıÂÈÈÎÔ‡ Ì·ÁÓËÛ›Ô˘ Î·È Ù˘ ÚÔÛÙ·Î˘ÎÏ›Ó˘, Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ˜. ŸÏ· Ù· ·ÁÁÂÈԉȷÛÙ·ÏÙÈο Ê¿Ú̷η ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó Û˘ÛÙËÌ·ÙÈ΋ ˘fiÙ·ÛË, ÔfiÙÂ Â›Ó·È ··Ú·›ÙËÙË Ë ˘ÔÛÙ‹ÚÈÍË Ù˘ ΢ÎÏÔÊÔÚ›·˜ Ì ÈÓfiÙÚÔ· Ê¿Ú̷η (35). À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ O ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ ·ÔÙÂÏ› Ì›· ÂÏ΢ÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÈÛÙÚ·Ù¢ÙÔ‡Ó fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚ˜ ΢„ÂÏ›‰Â˜ Î·È Ó· ÂÚÈÔÚÈÛÙ› ÙÔ ‚·ÚÔÙÚ·‡Ì· Î·È ÔÁÎÔÙÚ·‡Ì· ÙÔ˘ Ó‡ÌÔÓ· Û ÓÂÔÁÓ¿ Ì ™¢∫. ∏ ηχÙÂÚË ÂÈÛÙÚ¿Ù¢ÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ Î˘„ÂÏ›‰ˆÓ Û˘ÓÙÂÏ› Î·È ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ¡O ÛÙ· Ó¢ÌÔÓÈο ·ÁÁ›· (36). ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÓÂÔÁÓ¿ Ì ™¢∫, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜, ›¯·Ó ηχÙÂÚË ¤Î‚·ÛË (37,38). øÛÙfiÛÔ, Û ¿ÏϘ ÌÂϤÙ˜ ‰ÂÓ ‚Ú¤ıËΠη̛· ‰È·ÊÔÚ¿ (39,40). ¶ÔÏÏ¿ ΤÓÙÚ· ÂÊ·ÚÌfi˙Ô˘Ó ÙÔÓ ˘„›Û˘¯ÓÔ ·ÂÚÈÛÌfi ˆ˜ ‡ÛÙ·ÙË ıÂÚ·›· Û ÓÂÔÁÓ¿ Ì ™¢∫. ∂͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË Ì ÙË ¯Ú‹ÛË ÌÂÌ‚Ú·ÓÒÓ ∏ ECMO ÚˆÙÔÂÌÊ·Ó›ÛÙËΠÛÙ· Ù¤ÏË Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’70. ∞ÊÔÚÔ‡Û ÛÙË ¯Ú‹ÛË ÌÂÚÈ΋˜ ηډÈÔÓ¢ÌÔÓÈ΋˜ ·Ú¿Î·Ì„˘, Ô˘ Â¤ÙÚÂ ÛÙÔÓ Ó‡ÌÔÓ· Ó· ÍÂÎÔ˘Ú·ÛÙ› Î·È Ó· ÌÂȈıÔ‡Ó ÔÈ Ó¢ÌÔÓÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ, ÂÓÒ Ë ¶·È‰È·ÙÚÈ΋ 2005;68:417-423

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·420

420

°. ¢ËÌËÙÚ›Ô˘ Î·È Û˘Ó.

Ô͢ÁfiÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈÓfiÙ·Ó Ì¤Ûˆ Ù¯ÓËÙ‹˜ ΢ÎÏÔÊÔÚ›·˜. ∏ ·ÚÈ· ¤Ó‰ÂÈÍË ÁÈ· ÙË ¯Ú‹ÛË Ù˘ ECMO ‹Ù·Ó Ë ·ÔÙ˘¯›· Ù˘ Û˘Ì‚·ÙÈ΋˜ ıÂÚ·›·˜, fiˆ˜ ÔÚÈ˙fiÙ·Ó ·fi ÙÈ̤˜ ÙÔ˘ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ >40 (‰Â›ÎÙ˘ Ô͢ÁfiÓˆÛ˘ = ̤ÛË ›ÂÛË ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ x FiO2 x 100/PaO2 ÌÂÙ¿ ÙÔÓ ·ÚÙËÚÈ·Îfi fiÚÔ) (41). ∆· ·ÔÙÂϤÛÌ·Ù· Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË ‹ ÌË Ù˘ ECMO ÛÙË ™¢∫ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ∏ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫ Ô˘ ·Ó·Ê¤ÚÂÈ Ô OÚÁ·ÓÈÛÌfi˜ ∂͈ۈ̷ÙÈ΋˜ ÀÔÛÙ‹ÚÈ͢ Ù˘ ∑ˆ‹˜ (Extracorporeal Life Support Organization - ELSO) Â›Ó·È ÂÚ›Ô˘ 60%, ÔÛÔÛÙfi Ô˘ Â›Ó·È ÙÔ ¯·ÌËÏfiÙÂÚÔ ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ì ÔÍ›· ˘ÔÍ·ÈÌÈ΋ ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó ˘ÔÛÙ‹ÚÈÍË ·fi ÙËÓ ECMO (31). ∆· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ÔÏ˘ÎÂÓÙÚÈ΋˜ ÌÂϤÙ˘ ÛÙË ª. µÚÂÙ·Ó›· ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯Ú‹ÛË Ù˘ ECMO ˆÊ¤ÏËÛ ٷ ·È‰È¿ Ì ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÂÓÒ ‰ÂÓ Â›¯Â ηӤӷ fiÊÂÏÔ˜ ÁÈ· Ù· ÓÂÔÁÓ¿ Ì ™¢∫ (41). Œ¯ÂÈ ÚÔÙ·ı› fiÙÈ Ë ECMO Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÚÔÂÍ¿Ú¯ÂÈ Ë Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ·ÏÏ¿ fi¯È ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ˘¿Ú¯ÂÈ ‚·ÚÈ¿ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· (42).

∂͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ¶·Ú’ fiÏÔ Ô˘ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ·ÓˆÚÈÌfiÙËÙ· ÛÙË Û‡ÛÙ·ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙ· ÓÂÔÁÓ¿ Ì ™¢∫, ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Â¿Ó ÛÙ· ÓÂÔÁÓ¿ ·˘Ù¿ ¤¯ÂÈ ¤Ó‰ÂÈÍË Ë ¯ÔÚ‹ÁËÛË Â͈ÁÂÓÔ‡˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ª›· Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ‰ÂÓ ¤‰ÂÈÍ ÂÌÊ·Ó‹ ÔʤÏË Û ÓÂÔÁÓ¿ Ì ™¢∫ (44). ¶·ÚfiÌÔÈ·, Ì›· ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘, Ô˘ ÚfiÛÊ·Ù· ‰ËÌÔÛ›Â˘Û ‰Â‰Ô̤ӷ 2.284 ·ÛıÂÓÒÓ ·fi 81 ΤÓÙÚ·, 67 ÛÙȘ ∏¶∞ Î·È 14 ÂÎÙfi˜ ∏¶∞, ‰ÂÓ ‰È·›ÛÙˆÛ ηӤӷ ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ™¢∫ (45). ∞ÂÚÈÛÌfi˜ Ì ˘ÁÚfi ∏ ¯Ú‹ÛË ÙÔ˘ ·ÂÚÈÛÌÔ‡ Ì ˘ÁÚfi ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ˘fiÛ¯ÂÙ·È ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ™¢∫. £ÂˆÚËÙÈο, ÙÔ ÏÂÔÓ¤ÎÙËÌ· ÙÔ˘ ·ÂÚÈÛÌÔ‡ Ì ˘ÁÚfi Â›Ó·È fiÙÈ - ·ÓÙ›ıÂÙ· Ì ٷ ·¤ÚÈ· - ÙÔ ˘ÁÚfi ‰È·Ó¤ÌÂÙ·È ÔÌÔÈfiÌÔÚÊ· ÛÙÔÓ Ó‡ÌÔÓ·, ÂÓÒ ·Ú¿ÏÏËÏ· ÂÏ·ÙÙÒÓÂÈ ÙfiÛÔ ÙËÓ ÂӉȿÌÂÛË Ê¿ÛË (interface) ·¤Ú·-˘ÁÚÔ‡ fiÛÔ Î·È ¶·È‰È·ÙÚÈ΋ 2005;68:417-423

ÙËÓ ÂÈÊ·ÓÂȷ΋ Ù¿ÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ. √È ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË Ù˘ ÌÂıfi‰Ô˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ™¢∫ ‚Ú›ÛÎÔÓÙ·È ·ÎfiÌË Û ÂÈÚ·Ì·ÙÈÎfi ÛÙ¿‰ÈÔ (46). ª¤¯ÚÈ Û‹ÌÂÚ·, Ù· ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ‹Ù·Ó ȉȷ›ÙÂÚ· ÈηÓÔÔÈËÙÈο, ·Ó Î·È Â›Ó·È ÂÓÙ˘ˆÛȷ΋ Ë ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË Ì¤ıÔ‰Ô (47).

ÃÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ™¢∫ ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Ù˘ ·Ó·ÙÔÌÈ΋˜ ‚Ï¿‚˘ ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ (31). ∞ÓÙ›ıÂÙ·, ÌÔÚ› ÌÂÙÂÁ¯ÂÈÚËÙÈο Ó· ˘¿ÚÍÂÈ ·ÎfiÌ· Î·È Âȉ›ӈÛË Ù˘ Ì˯·ÓÈ΋˜ Ù˘ ·Ó·ÓÔ‹˜ (22). ¶Ôχ ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë Î·Ï‹ ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÚÔÂÁ¯ÂÈÚËÙÈο (48). ∏ ÂÁ¯Â›ÚËÛË Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì¤Ûˆ Ì›·˜ ˘ÔχÚÈ·˜ ÙÔÌ‹˜, ·Ó Î·È Û ‚Ï¿‚˜ Ô˘ ‰ڿ˙ÔÓÙ·È ‰ÂÍÈ¿ Û¿ÓÈ· ÂÎÙÂÏÂ›Ù·È ıˆÚ·ÎÔÙÔÌ‹. ∞Ú¯Èο, ÙÔ ¤ÏÏÂÈÌÌ· Û˘ÁÎÏ›ÂÙ·È fiÔ˘ Â›Ó·È ‰˘Ó·Ùfi. ∂¿Ó ÙÔ ¤ÏÏÂÈÌÌ· Â›Ó·È ÌÂÁ¿ÏÔ, ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ÚfiÛıÂÙÔ ÙÂÌ¿¯ÈÔ. ∂¿Ó Ô Ê˘ÛÈÎfi˜ ÈÛÙfi˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‰ÂÓ Â·ÚΛ, ÙfiÙ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÚÔÛıÂÙÈο ˘ÏÈο, fiˆ˜ GoretexTM (WL Gore, Flagstaff, AZ) ÚÔÎÂÈ̤ÓÔ˘ Ó· ÎÏ›ÛÂÈ ÙÔ ¤ÏÏÂÈÌÌ· (49). ™¿ÓÈ·, ·ÓÙ› Ù˘ Û˘ÚÚ·Ê‹˜ ÙˆÓ Ì˘ÒÓ, ·Ê‹ÓÂÙ·È ·ÓÔÈÎÙfi ÙÔ ÙÚ·‡Ì· Ù˘ Ï··ÚÔÙÔÌ›·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› Ë ·Ó¿Ù˘ÍË ˘„ËÏ‹˜ ÂÓ‰ÔÎÔÈÏȷ΋˜ ›ÂÛ˘ ÌÂÙ¿ ÙËÓ ·Ó¿Ù·ÍË ÙˆÓ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ ·fi ÙÔÓ ıÒڷη. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ÙÔÔıÂÙÂ›Ù·È ÚÔÛıÂÙÈÎfi ˘ÏÈÎfi ÛÙÔ ÙÚ·‡Ì·.

ª·ÎÚÔÚfiıÂÛÌË ¤Î‚·ÛË ∆· ÓÂÔÁÓ¿ Ì ™¢∫ Ô˘ ÙÂÏÈο ÂÈ‚ÈÒÓÔ˘Ó, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Ô˘ ÔÊ›ÏÂÙ·È ÛÙË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (50,51), ÛÙËÓ ·ÔÊÚ·ÎÙÈ΋ Ó¢ÌÔÓÔ¿ıÂÈ· (51), ÛÙȘ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (52), ÛÙË ÌË ÈηÓÔÔÈËÙÈ΋ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ Î·È ÛÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (53,54), ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ (55) Î·È ÛÙËÓ ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË (55). ∂ÈϤÔÓ, Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ ˘¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ·Ó·Ëڛ˜, fiˆ˜ ËÌÈÏËÁ›· (56) ‹ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË (55). ∆¤ÏÔ˜, ··Ú·›ÙËÙË Â›Ó·È Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó (55).

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·421

421

™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË

ªÂÏÏÔÓÙÈΤ˜ ÚÔÔÙÈΤ˜ ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Î·È Ô Î·ıÔÚÈÛÌfi˜ ÈÔ ·ÍÈfiÈÛÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÎÚÈÛË ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ™¢∫ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂˆÊÂÏËıÔ‡Ó ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ·Ú¤Ì‚·ÛË, ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ ÂÏȉÔÊfiÚ· ÚÔÔÙÈ΋. ∏ ÛˆÛÙ‹ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË ··ÈÙ› ÈÔ ·ÍÈfiÈÛÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ η΋˜ ÂÚÈÁÂÓÓËÙÈ΋˜ ¤Î‚·Û˘. ∏ ÂÓ‰ÔÌ‹ÙÚÈ· Â¤Ì‚·ÛË Î¿Ùˆ ·fi ÂÓ‰ÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ ÂÌ‚Ú‡Ô˘, Â›Ó·È Èı·Ófi Ó· ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÁÈ· ÙȘ ™¢∫ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, Ë ‰È¿ÁÓˆÛË ÙˆÓ ÔÔ›ˆÓ Á›ÓÂÙ·È ÚÔÁÂÓÓËÙÈο. ∏ ȉ¤· Ù˘ ·fiÊڷ͢ Ù˘ ÙÚ·¯Â›·˜ ÁÈ· Ó· ÚÔÏËÊı› Ë Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›·, ·ÔÙÂÏ› ÙÔÓ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÌÂÏÏÔÓÙÈÎfi ÛÙfi¯Ô. ªÂÙ¿ ÙË Á¤ÓÓËÛË, Ë ÂÊ·ÚÌÔÁ‹ ıÂÚ·¢ÙÈÎÒÓ Ì¤ÛˆÓ Ô˘ ÌÂÈÒÓÔ˘Ó ÙÔ ‚·ÚÔ-/ÔÁÎÔÙÚ·‡Ì· ÌÔÚ› Ó· ÛÒÛÂÈ Ù· ÓÂÔÁ¤ÓÓËÙ· Ì ÌÈÎÚ‹˜ ‚·Ú‡ÙËÙ·˜ ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ. O ÚfiÏÔ˜ ÙÔ˘ ÂÈÛÓÂfiÌÂÓÔ˘ ¡O Ú¤ÂÈ Ó· ‰È¢ÎÚÈÓÈÛÙ› Ì ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, ÒÛÙ ӷ ηıÈÂÚˆıÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈο ıÂÚ·¢ÙÈο ÚˆÙfiÎÔÏÏ·. ∂ÈϤÔÓ, Û˘Ó¯›˙ÂÙ·È Ë ¤Ú¢ӷ ÁÈ· Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜ Ì ‰Ú¿ÛË ÛÙËÓ ·ÓÙ›ÛÙ·ÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ. ∏ ÊÏ‚Ô-ÊÏ‚È΋ Â͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË, Èı·ÓÒ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰È¿Ù·ÛË ÙˆÓ Ó¢ÌfiÓˆÓ Ì ÂÚÊÏÔ˘ÔÚ¿ÓıڷΘ, ›ÛÔ˜ Ó· ·ÔÙÂϤÛÂÈ ÙËÓ È‰·ÓÈ΋ ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÁÈ· ÓÂÔÁÓ¿ Ì ™¢∫ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È Û ÏÈÁfiÙÂÚÔ ÂÈıÂÙÈΤ˜ ıÂÚ·›˜.

6.

7.

8.

9.

10.

11.

12.

13.

14.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Weinstein S, Stolar CJ. Newborn surgical emergencies. Congenital diaphragmatic hernia and extracorporeal membrane oxygenation. Pediatr Clin North Am 1993;40:1315-1333.

2. Langham MR Jr, Kays DW, Ledbetter DJ, Frentzen B, Sanford LL, Richards DS. Congenital diaphragmatic hernia. Epidemiology and outcome. Clin Perinatol 1996;23:671-688.

3. Wenstrom KD, Weiner CP, Hanson JW. A five-year statewide experience with congenital diaphragmatic hernia. Am J Obstet Gynecol 1991;165:838-842.

4. Skari H, Bjornland K, Haugen G, Egeland T, Emblem R. Congenital diaphragmatic hernia: a metaanalysis of mortality factors. J Pediatr Surg 2000;35:1187-1197.

5. Metkus AP, Filly RA, Stringer MD, Harrison MR, Adzick NS. Sonographic predictors of survival in fe-

15.

16.

17.

18.

tal diaphragmatic hernia. J Pediatr Surg 1996;31:148-151.

Kamata S, Hasegawa T, Ishikawa S, Usui N, Okuyama H, Kawahara H et al. Prenatal diagnosis of congenital diaphragmatic hernia and perinatal care: assessment of lung hypoplasia. Early Hum Dev 1992;29:375-379.

Harrison MR, Mychaliska GB, Albanese CT, Jennings RW, Farrell JA, Hawgood S et al. Correction of congenital diaphragmatic hernia in utero IX: fetuses with poor prognosis (liver herniation and low lungto-head ratio) can be saved by fetoscopic temporary tracheal occlusion. J Pediatr Surg 1998;33:10171022.

Flake AW, Crombleholme TM, Johnson MP, Howell LJ, Adzick NS. Treatment of severe congenital diaphragmatic hernia by fetal tracheal occlusion: clinical experience with fifteen cases. Am J Obstet Gynecol 2000;183:1059-1066.

Lipshutz GS, Albanese CT, Feldstein VA, Jennings RW, Housley HT, Beech R et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 1997;32:1634-1636.

Sbragia L, Paek BW, Filly RA, Harrison MR, Farrell JA, Farmer DL et al. Congenital diaphragmatic hernia without herniation of the liver: does the lung-tohead ratio predict survival? J Ultrasound Med 2000;19:845-848.

Paek BW, Coakley FV, Lu Y, Filly RA, Lopoo JB, Qayyum A et al. Congenital diaphragmatic hernia: prenatal evaluation with MR lung volumetry - preliminary experience. Radiology 2001;220:63-67.

Sokol J, Bohn D, Lacro RV, Ryan G, Stephens D, Rabinovitch M et al. Fetal pulmonary artery diameters and their association with lung hypoplasia and postnatal outcome in congenital diaphragmatic hernia. Am J Obstet Gynecol 2002;186:1085-1090.

Suen HC, Catlin EA, Ryan DP, Wain JC, Donahoe PK. Biochemical immaturity of lungs in congenital diaphragmatic hernia. J Pediatr Surg 1993;28:471475.

Suen HC, Bloch KD, Donahoe PK. Antenatal glucocorticoid corrects pulmonary immaturity in experimentally induced congenital diaphragmatic hernia in rats. Pediatr Res 1994;35:523-529.

Van Tuyl M, Hosgor M, Tibboel D. Tracheal ligation and corticosteroids in congenital diaphragmatic hernia: for better for worse? Pediatr Res 2001;50:441-444.

Harrison MR, Adzick NS, Longaker MT, Goldberg JD, Rosen MA, Filly RA et al. Successful repair in utero of a fetal diaphragmatic hernia after removal of herniated viscera from the left thorax. N Engl J Med 1990;322:1582-1584.

Harrison MR, Adzick NS, Flake AW, Jennings RW, Estes JM, MacGillivray TE et al. Correction of congenital diaphragmatic hernia in utero: VI. Hardearned lessons. J Pediatr Surg 1993;28:1411-1417.

Harrison MR, Adzick NS, Bullard KM, Farrell JA, Howell LJ, Rosen MA et al. Correction of congenital diaphragmatic hernia in utero VII: a prospective tri¶·È‰È·ÙÚÈ΋ 2005;68:417-423

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·422

422

°. ¢ËÌËÙÚ›Ô˘ Î·È Û˘Ó.

al. J Pediatr Surg 1997;32:1637-1642.

19. Hedrick MH, Estes JM, Sullivan KM, Bealer JF, Kitterman JA, Flake AW et al. Plug the lung until it grows (PLUG): a new method to treat congenital diaphragmatic hernia in utero. J Pediatr Surg 1994;29:612-617.

20. Mychaliska GB, Bealer JF, Graf JL, Rosen MA, Adzick NS, Harrison MR. Operating on placental support: the ex utero intrapartum treatment procedure.

J Pediatr Surg 1997;32:227-230.

21. Tracy TF Jr, Bailey PV, Sadiq F, Noguchi A, Silen ML, Weber TR. Predictive capabilities of preoperative and postoperative pulmonary function tests in delayed repair of congenital diaphragmatic hernia. J Pediatr Surg 1994;29:265-269; discussion 269-270.

22. Sakai H, Tamura M, Hosokawa Y, Bryan AC, Barker GA, Bohn DJ. Effect of surgical repair on respiratory mechanics in congenital diaphragmatic hernia.

J Pediatr 1987;111:432-438.

23. Bohn D, Tamura M, Perrin D, Barker G, Rabinovitch M. Ventilatory predictors of pulmonary hypoplasia in congenital diaphragmatic hernia, confirmed by morphologic assessment. J Pediatr 1987;111:423-431.

24. Norden MA, Butt W, McDougall P. Predictors of survival for infants with congenital diaphragmatic hernia. J Pediatr Surg 1994;29:1442-1446.

25. Bohn DJ, James I, Filler RM, Ein SH, Wesson DE, Shandling B et al. The relationship between PaCO2 and ventilation parameters in predicting survival in congenital diaphragmatic hernia. J Pediatr Surg 1984;19:666-671.

26. Burge DM, Atwell JD, Freeman NV. Could the stomach site help predict outcome in babies with left sided congenital diaphragmatic hernia diagnosed antenatally? J Pediatr Surg 1989;24:567-569.

27. Dimitriou G, Greenough A, Chan V, Gamsu HR, Howard ER, Nicolaides KH. Prognostic indicators in congenital diaphragmatic hernia. J Pediatr Surg 1995;30:1694-1697.

28. Kavvadia V, Greenough A, Laubscher B, Dimitriou G, Davenport M, Nicolaides KH. Perioperative assessment of respiratory compliance and lung volume in infants with congenital diaphragmatic hernia: prediction of outcome. J Pediatr Surg 1997;32:1665-1669.

29. Dimitriou G, Greenough A, Davenport M, Nicolaides K. Prediction of outcome by computer-assisted analysis of lung area on the chest radiograph of infants with congenital diaphragmatic hernia. J Pediatr Surg 2000;35:489-493.

30. The Congenital Diaphragmatic Hernia Study Group. Estimating disease severity of congenital diaphragmatic hernia in the first 5 minutes of life. J Pediatr Surg 2001;36:141-145.

31. Bohn D. Congenital diaphragmatic hernia. Am J Respir Crit Care Med 2002;166:911-915.

32. Wung JT, Sahni R, Moffitt ST, Lipsitz E, Stolar CJ. Congenital diaphragmatic hernia: survival treated with very delayed surgery, spontaneous respiration, and no chest tube. J Pediatr Surg 1995;30:406-409.

33. Kinsella JP, Neish SR, Ivy DD, Shaffer E, Abman SH. ¶·È‰È·ÙÚÈ΋ 2005;68:417-423

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

Clinical responses to prolonged treatment of persistent pulmonary hypertension of the newborn with low doses of inhaled nitric oxide. J Pediatr 1993;123:103-108.

Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Syst Rev. 2001;(4):CD000399.

Smith NP, Jesudason EC, Losty PD. Congenital diaphragmatic hernia. Paediatr Respir Rev 2002;3:339348.

Kinsella JP, Truog WE, Walsh WF, Goldberg RN, Bancalari E, Mayock DE et al. Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn. J Pediatr 1997;131:55-62.

Cacciari A, Ruggeri G, Mordenti M, Ceccarelli PL, Baccarini E, Pigna A et al. High-frequency oscillatory ventilation versus conventional mechanical ventilation in congenital diaphragmatic hernia. Eur J Pediatr Surg 2001;11:3-7.

Desfrere L, Jarreau PH, Dommergues M, Brunhes A, Hubert P, Nihoul-Fekete C et al. Impact of delayed repair and elective high-frequency oscillatory ventilation on survival of antenatally diagnosed congenital diaphragmatic hernia: first application of these strategies in the more “severe” subgroup of antenatally diagnosed newborns. Intensive Care Med 2000;26:934-941.

Azarow K, Messineo A, Pearl R, Filler R, Barker G, Bohn D. Congenital diaphragmatic hernia - a tale of two cities: the Toronto experience. J Pediatr Surg 1997;32:395-400.

Kamata S, Usui N, Ishikawa S, Okuyama H, Kitayama Y, Sawai T et al. Prolonged preoperative stabilization using high-frequency oscillatory ventilation does not improve the outcome in neonates with congenital diaphragmatic hernia. Pediatr Surg Int 1998;13:542-546.

UK Collaborative ECMO Trail Group. UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation. Lancet 1996;348:75-82.

Stolar C, Dillon P, Reyes C. Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia. J Pediatr Surg 1988;23:207-211.

Wilcox DT, Glick PL, Karamanoukian HL, Azizkhan RG, Holm BA. Pathophysiology of congenital diaphragmatic hernia. XII: Amniotic fluid lecithin/sphingomyelin ratio and phosphatidylglycerol concentrations do not predict surfactant status in congenital diaphragmatic hernia. J Pediatr Surg 1995;30:410-412.

Lotze A, Knight GR, Anderson KD, Hull WM, Whitsett JA, O’Donnell RM et al. Surfactant (beractant) therapy for infants with congenital diaphragmatic hernia on ECMO: evidence of persistent surfactant deficiency. J Pediatr Surg 1994;29:407-412.

Van Meurs K, Congenital Diaphragmatic Hernia Study Group. Is surfactant therapy beneficial in the treatment of the term newborn infant with congenital diaphragmatic hernia? J Pediatr 2004;145:312-316.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·423

423

™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË

46. Pranikoff T, Gauger PG, Hirschl RB. Partial liquid ventilation in newborn patients with congenital diaphragmatic hernia. J Pediatr Surg 1996;31:613-618.

47. Fauza DO, Hirschl RB, Wilson JM. Continuous intrapulmonary distension with perfluorocarbon accelerates lung growth in infants with congenital diaphragmatic hernia: initial experience. J Pediatr Surg 2001;36:1237-1240.

48. Langer JC, Filler RM, Bohn DJ, Shandling B, Ein SH, Wesson DE et al. Timing of surgery for congenital diaphragmatic hernia: is emergency operation necessary? J Pediatr Surg 1988;23:731-734.

49. de Kort LM, Bax KM. Prosthetic patches used to close congenital diaphragmatic defects behave well: a long-term follow-up study. Eur J Pediatr Surg 1996;6:136-138.

50. Bos AP, Hussain SM, Hazebroek FW, Tibboel D, Meradji M, Molenaar JC. Radiographic evidence of bronchopulmonary dysplasia in high-risk congenital diaphragmatic hernia survivors. Pediatr Pulmonol 1993;15:231-234.

51. Muratore CS, Kharasch V, Lund DP, Sheils C, Friedman S, Brown C et al. Pulmonary morbidity in 100

52.

53.

54.

55.

56.

survivors of congenital diaphragmatic hernia monitored in a multidisciplinary clinic. J Pediatr Surg 2001;36:133-140.

Naik S, Greenough A, Zhang YX, Davenport M. Prediction of morbidity during infancy after repair of congenital diaphragmatic hernia. J Pediatr Surg 1996;31:1651-1654.

Stolar CJ, Levy JP, Dillon PW, Reyes C, Belamarich P, Berdon WE. Anatomic and functional abnormalities of the esophagus in infants surviving congenital diaphragmatic hernia. Am J Surg 1990;159:204-207.

Lally KP, Paranka MS, Roden J, Georgeson KE, Wilson JM, Lillehei CW et al. Congenital diaphragmatic hernia. Stabilization and repair on ECMO. Ann Surg 1992;216:569-573.

Lund DP, Mitchell J, Kharasch V, Quigley S, Kuehn M, Wilson JM. Congenital diaphragmatic hernia: the hidden morbidity. J Pediatr Surg 1994;29:258262.

Davenport M, Rivlin E, D’Souza SW, Bianchi A. Delayed surgery for congenital diaphragmatic hernia: neurodevelopmental outcome in later childhood.

Arch Dis Child 1992;67:1353-1356.

¶·È‰È·ÙÚÈ΋ 2005;68:417-423

Pediatr Nov-Dec 05

424

12-12-05

15:16

™ÂÏ›‰·424

REVIEW ARTICLE

Advances in the management of congenital diaphragmatic hernia G. Dimitriou, C. Agakidis Guy’s, Kings’ & St. Thomas’ School of Medicine, London, UK Correspondence: Charalambos Agakidis 28 Glinou, Str., 543 52, Thessaloniki E-mail: agaki@med.auth.gr Date of submission: 01-12-2004 Date of approval: 05-05-2005

Abstract Congenital diaphragmatic hernia (CDH) is a life-threatening malformation with an incidence of 1 in 2,000-5,000 live births. With the widespread use of antenatal ultrasound CDH is being diagnosed prenatally with increasing frequency. The benefits of prenatal intervention and postnatal use of new therapeutic modalities, including high frequency oscillation, inhaled nitric oxide, extracorporeal membrane oxygenation and liquid ventilation, have not yet been proved. Future directions for improving the outcome include improved antenatal diagnosis and definition of more accurate indicators to identify the fetuses with CDH who might benefit from fetal intervention, as well as better assessment of the role of postnatal therapies in reducing the baro-/volume-trauma and the pulmonary vascular resistance.

Key words Diaphragmatic hernia, fetus, fetal surgery, mechanical ventilation, oxygenation.

Paediatriki 2005;68:424

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·425

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

425

∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ Ó¢ÌÔÓ›·. ™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË 40 ·È‰ÈÒÓ ÓÔÛËÏ¢fiÌÂÓˆÓ Û ÓÔÛÔÎÔÌÂ›Ô °. ™. µ·ÚÏ¿Ì˘1, ¡. ∞Ú‚·ÓÈÙ›‰Ë˜1, ™. ∫·Ú·Ì¤Ú˘1, ª. ∂ÌÔÚÈ¿‰Ô˘1, ™. °·‚ÚÈÈÏ›‰Ë˜2

¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÎÏÈÓÈ΋ Î·È Ë¯ÔηډÈÔÁÚ·ÊÈ΋ ÂÎÙ›ÌËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È Ù˘ ÌÔÚÊ‹˜ Ù˘ ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜ ÛÙËÓ Ó¢ÌÔÓ›· Û ·È‰È¿. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ∫·Ù·ÁÚ¿ÊËÎ·Ó Î·È ·Ó·Ï‡ıËÎ·Ó Ù· ÎÏÈÓÈο, ·ÈÌ·ÙÔÏÔÁÈο, ‚ÈÔ¯ËÌÈο, ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο Î·È Ë¯ÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ 40 ÓÔÛËÏ¢fiÌÂÓˆÓ Û ÓÔÛÔÎÔÌÂ›Ô ·È‰ÈÒÓ Ì Ó¢ÌÔÓ›·, ¯ˆÚ›˜ ÚÔ¸¿Ú¯Ô˘Û· Û˘ÛÙËÌ·ÙÈ΋ ¿ıËÛË. ™˘ÁÎÚ›ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÔÈ ÙÈ̤˜ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ·ÊÔ‡ ÔÈ ·ÛıÂÓ›˜ ¯ˆÚ›ÛÙËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜: ∞ (n=20) Î·È µ (n=20), ÌÂ Î·È ¯ˆÚ›˜ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹, ·ÓÙ›ÛÙÔȯ·. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Î·È Û¯ÔÏÈ¿˙ÔÓÙ·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ÚÒÙ˘ ÂͤٷÛ˘. ∞ÔÙÂϤÛÌ·Ù·: ∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ˘‹Ú¯Â ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÌÂϤÙ˘. ∫ÏÈÓÈΤ˜ ÂӉ›ÍÂȘ ·˘Ù‹˜ ›¯·Ó ¤Ó·˜ ·ÛıÂÓ‹˜ ÌÂ Ì˘Ôηډ›Ùȉ· Î·È ÂÚÈηډ›Ùȉ· Î·È 4/19 Ì ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹ ÛËÌ·ÓÙÈ΋˜ ÔÛfiÙËÙ·˜, ÂÓÒ Û 15/19 Ë ‰È¿ÁÓˆÛË Ù˘ ÂÚÈηډ›Ùȉ·˜ ‹Ù·Ó ˯ÔηډÈÔÁÚ·ÊÈ΋. ∞ÚÚ˘ıÌ›· ‰ÂÓ Â›¯Â ηÓ›˜. ∏ÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ÂӉ›ÍÂȘ ˘‹Ú¯·Ó ÛÙÔ 21,05% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· ‹Ù·Ó ‰È·ÁÓˆÛÙÈÎfi ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÚÈÙÒÛˆÓ. ™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ·fi ÙË Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ‚Ú¤ıËΠˆ˜ ÚÔ˜ ÙȘ ‰È·Ì¤ÙÚÔ˘˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, ÙÔÓ Û˘ÛÙÔÏÈÎfi fiÁÎÔ ÂÍÒıËÛ˘ Î·È ÙÔ Î‡Ì· ∂ ÙÔ˘ ÛÊ˘ÁÌÈÎÔ‡ Doppler.

1 ¶·È‰ÔηډÈÔÏÔÁÈÎfi ¢È·ÁÓˆÛÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ¢’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢, ¡ÔÛÔÎÔÌÂ›Ô ∞.Ã.∂.¶.∞., £ÂÛÛ·ÏÔÓ›ÎË 2 ∞’ ∫·Ú‰ÈÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢, ¡ÔÛÔÎÔÌÂ›Ô ∞.Ã.∂.¶.∞., £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: °. ™. µ·ÚÏ¿Ì˘ µ·Û. ŸÏÁ·˜ 85, ∆.∫. 546 42, £ÂÛÛ·ÏÔÓ›ÎË E-mail: varlamisgeorge@yahoo.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-07-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 31-05-2005

™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹ Û ·È‰È¿ Ì Ó¢ÌÔÓ›· ÔÈΛÏ˘ ·ÈÙÈÔÏÔÁ›·˜ Ô˘ ÓÔÛËχÔÓÙ·È Û ÓÔÛÔÎÔÌ›Ô, Â›Ó·È Ôχ Èı·Ó‹ Î·È Ú¤ÂÈ Ó· ·Ó·˙ËÙ›ٷÈ. OÈ ÎÏÈÓÈΤ˜ Î·È ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ÂӉ›ÍÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ÛÔ‚·Ú‹ ηډȷ΋ ‚Ï¿‚Ë. O ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ÌÔÚ› Ó· ‰È·ÎÚ›ÓÂÈ Ì ÌÂÁ¿ÏË ·ÎÚ›‚ÂÈ· ÙȘ ÂÚÈÙÒÛÂȘ Ì ‹ ¯ˆÚ›˜ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹. ∏ ÏÂÈÙÔ˘ÚÁ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÂËÚ¿˙ÂÙ·È ÛÔ‚·Ú¿ ÛÂ Ì˘Ôηډ›Ùȉ·, ÂÓÒ Û ÂÚÈηډ›Ùȉ· ÂËÚ¿ÛÙËÎ·Ó ÔÈ ÂÍ‹˜ ·Ú¿ÌÂÙÚÔÈ: ‰È¿ÌÂÙÚÔÈ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ÂÍÒıËÛ˘ Î·È Î‡Ì· ∂ ÙÔ˘ Doppler.

§¤ÍÂȘ ÎÏÂȉȿ ∫·Ú‰È·Î¤˜ ‚Ï¿‚˜, Ó¢ÌÔÓ›·, ·È‰È¿.

∂ÈÛ·ÁˆÁ‹ ∫·Ù¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÔÏÏÔ› Û˘ÁÁÚ·Ê›˜ ¤¯Ô˘Ó ÂÈÛËÌ¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (ÂÚÈηډ›Ùȉ·, Ì˘Ôηډ›Ùȉ·, ·ÚÚ˘ı̛˜) ÛÙË ‰È¿ÚÎÂÈ· Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢, ÙfiÛÔ Û ÂÓ‹ÏÈΘ fiÛÔ Î·È Û ·È‰È¿ (1-6), ÂÓÒ ‚ÈÔÏÔÁÈΤ˜ Î·È ÌÔÚȷΤ˜ ¤Ú¢Ó˜ Èı·ÓÔÏÔÁÔ‡Ó ÙËÓ ÂͤÏÈÍË Ì›·˜ ÔÍ›·˜ ÈÔÁÂÓÔ‡˜ Ì˘Ôηډ›Ùȉ·˜ Û ‰È·Ù·ÙÈ΋ Ì˘ÔηÚ-

‰ÈÔ¿ıÂÈ·. ∏ Û˘¯ÓfiÙËÙ·, Ë ‚·Ú‡ÙËÙ· Î·È Ô ¯ÚfiÓÔ˜ ¤Ó·Ú͢ ÙˆÓ Â›ÎÙËÙˆÓ ·˘ÙÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ ÛÙË ‰È¿ÚÎÂÈ· Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢ ‰ÂÓ ¤¯Ô˘Ó ‰È·Û·ÊËÓÈÛÙ› (7,8), ·Ú¿ ÙË ÌÂÁ¿ÏË ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Î·È ÙËÓ Â˘ÎÔÏ›· Ô˘ ‰È·ı¤ÙÂÈ Ë ˘ÂÚ˯ÔηډÈÔÁÚ·Ê›· (9-13). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ Â›Ó·È Ë ÌÂϤÙË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜ Û ·È‰È¿ ¯ˆÚ›˜ ηډÈÔÏÔÁÈÎfi ‹ ¿ÏÏÔ - ÂÈ‚·Ú˘ÓÙÈÎfi Ù˘ ÚfiÁÓˆÛ˘ ¶·È‰È·ÙÚÈ΋ 2005;68:425-431

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·426

426

°. ™. µ·ÚÏ¿Ì˘ Î·È Û˘Ó.

Úfi‚ÏËÌ·, Ô˘ ÓÔÛËχÔÓÙ·È Û ÓÔÛÔÎÔÌÂ›Ô ÁÈ· Ó¢ÌÔÓ›·, Ì ÙË ¯Ú‹ÛË ÌË ·ÈÌ·ÙËÚÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 40 ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. ÁÈ· Ó¢ÌÔÓ›·, 22 ·ÁfiÚÈ· (55%) Î·È 18 ÎÔÚ›ÙÛÈ· (45%), ËÏÈΛ·˜ 1-13 ÂÙÒÓ (̤ÛË ËÏÈΛ·: 5,83 ± 3,46 ¤ÙË). ŸÏÔÈ ÔÈ ÁÔÓ›˜ ÂÓËÌÂÚÒıËÎ·Ó ÁÈ· ÙÔ ÛÎÔfi Ù˘ ÌÂϤÙ˘ Î·È ‰ÂÓ ˘‹ÚÍ η̛· ·ÓÙ›ÚÚËÛË. ∏ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓ›·˜ ‚·Û›ÛÙËΠÛÙ· ÎÏ·ÛÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· (14,15). ªÂ ‚¿ÛË ÙÔÓ ÙËÚÔ‡ÌÂÓÔ Ê¿ÎÂÏÔ ÓÔÛËÏ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· ÁÓˆÛÙÔ‡˜ ·ÛıÂÓ›˜ ‹ ÙÔ ÈÛÙÔÚÈÎfi, ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÁÈ· ·ÛıÂÓ›˜ Ô˘ ÂÈÛ¿ÁÔÓÙ·Ó ÁÈ· ÚÒÙË ÊÔÚ¿, ·ÔÎÏ›ÛÙËÎ·Ó ·fi ÙË ÌÂϤÙË Ù· ·È‰È¿ ÛÙ· ÔÔ›· ˘‹Ú¯Â Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·, ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ·, ÚÔˆÚfiÙËÙ·, ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·, ·ÓÔÛÔÏÔÁÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Î·È Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·. ∫·Ù·ÁÚ¿ÊËÎ·Ó Î·È ·Ó·Ï‡ıËÎ·Ó ÔÈ ÙÈ̤˜ ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜, ÙˆÓ ‰ÂÈÎÙÒÓ ·fi ÙËÓ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ‚·ıÌÔ‡ ‰‡ÛÓÔÈ·˜, ÙÔ˘ ÎÔÚÂÛÌÔ‡ Û O2 Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ì ÛÊ˘ÁÌÈ΋ Ô͢ÌÂÙÚ›· Î·È ÔÈ ÙÈ̤˜ ÙˆÓ Ë¯ÔηډÈÔÁÚ·ÊÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ·fi ÙË ÌÔÚÊÔÏÔÁÈ΋-·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË Î·È ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜. ∏ ÂͤٷÛË ÙˆÓ ·È‰ÈÒÓ ¤ÁÈÓ Û ÙÚ›· ÛÙ¿‰È·: ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ηٿ ÙË 15Ë Ë̤ڷ ÓfiÛËÛ˘ Î·È Î·Ù¿ ÙËÓ 60‹ Ë̤ڷ. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Î·È Û¯ÔÏÈ¿˙ÔÓÙ·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ÚÒÙ˘ ÂͤٷÛ˘ (ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹). ªÂ ÎÏÈÓÈο, ÔÚÔÏÔÁÈο Î·È ÌÈÎÚÔ‚ÈÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· ·ԉ›¯ÙËηÓ: ·) ÈÔÁÂÓ‹˜ ·ÈÙÈÔÏÔÁ›· Û 13 ·ÛıÂÓ›˜, ‚) Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜ Û 5 Î·È Á) ÌÈÎÚÔ‚È·Îfi˜ ·Ú¿ÁˆÓ Û 22 ·ÛıÂÓ›˜. ∏ ·ÈÙÈÔÏÔÁÈ΋ ÌÂϤÙË ¤ÁÈÓ ÛÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜ Î·È πÔÏÔÁ›·˜ ÙÔ˘ ∞.¶.£. ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ÙÔ˘˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ηډÈÔÏÔÁÈ΋ ÂͤٷÛË ÂÚÈÂÏ¿Ì‚·Ó ÎÏÈÓÈ΋ ÂͤٷÛË, ∏∫°, ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Î·È Ë¯ÔηډÈÔÁÚ¿ÊËÌ· m-mode, ‰ÈۉȿÛÙ·ÙÔ Î·È Doppler, Û˘Ì‚·Ùfi Î·È ¤Á¯ÚˆÌÔ, Ì ‰È·ıˆÚ·ÎÈ΋ ÚÔÛ¤Ï·ÛË. ∏ ˯ÔηډÈÔÁÚ·ÊÈ΋ ÂͤٷÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·fi ÙÔÓ ›‰ÈÔ ¿ÓÙÔÙ ÂÍÂÙ·ÛÙ‹. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÌÔÚÊÔÙÚÔ›˜ ÙˆÓ 5 Î·È 2,8 MHz, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙË Ì¿˙· ÛÒÌ·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Û η̛· ÂÚ›ÙˆÛË ‰ÂÓ ··ÈÙ‹ıËΠ¯ÔÚ‹ÁËÛË ËÚÂÌÈÛÙÈÎÒÓ. °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÌÂÙÚ‹ıËÎ·Ó Î·È Î·Ù·ÁÚ¿ÊËηÓ: Ë ‰È·ÛÙÔÏÈ΋ (LVPWd) Î·È Û˘ÛÙÔÏÈ΋ (LVPWs) ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ (∞∫), Ë ‰È·ÛÙÔÏÈ΋ (LVDd) Î·È Û˘ÛÙÔÏÈ΋ (LVDs) ‰È¿ÌÂÙÚÔ˜ Ù˘ ∞∫, Ë ‰È·ÛÙÔÏÈ΋ (IVSd) Î·È Û˘ÛÙÔÏÈ΋ (IVSs) ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, Ô ‰È·ÛÙÔÏÈÎfi˜ (DV) Î·È Û˘ÛÙÔÏÈÎfi˜ (SV) fiÁÎÔ˜ Ù˘ ∞∫, Ô ‰Â›ÎÙ˘ ‚Ú¿¯˘ÓÛ˘ ÈÓÒÓ (SF), ÙÔ ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ (EF), Ô Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ÂÍÒıËÛ˘ (SVã) Ù˘ ∞∫, Ë Ì¤ÁÈÛÙË Ù·¯‡ÙËÙ· ÚˆÙԉȷÛÙÔÏÈ΋˜ ÚÔ‹˜ (E), Ë Ì¤ÁÈÛÙË Ù·¯‡ÙËÙ· ÙÂÏԉȷÛÙÔÏÈ΋˜ ÚÔ‹˜ ¶·È‰È·ÙÚÈ΋ 2005;68:425-431

(A), Ô ¯ÚfiÓÔ˜ ˘ÛÙ¤ÚËÛ˘ ‰È·ÛÙÔÏÈ΋˜ ÚÔ‹˜ (drt) Î·È Ë Û¯¤ÛË ∂/∞, ·fi ÙË ÌÂϤÙË Ì Doppler Ù˘ ‰È·ÌÈÙÚÔÂȉÈ΋˜ ÚÔ‹˜. ∞fi ÙȘ ‰‡Ô ÌÂÙÚ‹ÛÂȘ Ô˘ Á›ÓÔÓÙ·Ó ÁÈ· οı ·ÛıÂÓ‹, ηٷÁÚ¿ÊËÎ·Ó ÔÈ ·ÓÒÙÂÚ˜ ÙÈ̤˜. ∏ ‰È¿ÁÓˆÛË Ù˘ Ì˘Ôηډ›Ùȉ·˜ Î·È Ù˘ ÂÚÈηډ›Ùȉ·˜ ÛÙËÚ›¯ÙËΠÛÙ· ÎÏÈÓÈο, ·ÎÙÈÓÔÏÔÁÈο, ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο Î·È Ë¯ÔηډÈÔÁÚ·ÊÈο ÎÚÈÙ‹ÚÈ· Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ (9,10,16-19) Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó Î·È ¿ÏÏÔÈ Û˘ÁÁÚ·Ê›˜. ªÂ ÎÚÈÙ‹ÚÈÔ Ù· ıÂÙÈο ‹ Ù· ·ÚÓËÙÈο Â˘Ú‹Ì·Ù·, Ù· ÂÓ‰ÂÈÎÙÈο ‹ ·Ô‰ÂÈÎÙÈο ÁÈ· Ì˘Ôηډ›Ùȉ· ‹ ÂÚÈηډ›Ùȉ· ‹ ÌÈÎÙ‹ ηډȷ΋ ‚Ï¿‚Ë, ÔÈ ·ÛıÂÓ›˜ ¯ˆÚ›ÛÙËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜: ÙËÓ ÔÌ¿‰· ∞ (20 ·ÛıÂÓ›˜ Ì ηډȷ΋ Û˘ÌÌÂÙÔ¯‹) Î·È ÙËÓ ÔÌ¿‰· µ (20 ·ÛıÂÓ›˜ ¯ˆÚ›˜ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÂÚÈÂÏ¿Ì‚·ÓÂ: ·) ¤ÏÂÁ¯Ô Ù˘ ÔÌ·Ï‹˜ ηٷÓÔÌ‹˜ fiÏˆÓ ÙˆÓ ÔÛÔÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ (“ÌË ·Ú·ÌÂÙÚÈ΋ ‰ÔÎÈÌ·Û›· ÙˆÓ KolmogorowSmirnoff”), ‚) ˘ÔÏÔÁÈÛÌfi Ù˘ ̤Û˘ ÙÈÌ‹˜, Ù˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ Î·È ÙÔ˘ ÛÙ·ıÂÚÔ‡ ÛÊ¿ÏÌ·ÙÔ˜, Á) ‰ÔÎÈÌ·Û›· t (“student-t test ÁÈ· ·ÓÂÍ¿ÚÙËÙ· ‰Â›ÁÌ·Ù·”), ‰) ÂÎÙ›ÌËÛË ÙˆÓ Û˘ÓÙÂÏÂÛÙÒÓ Û˘Û¯¤ÙÈÛ˘ [¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÙ·ÙÈÛÙÈ΋ ‰¤ÛÌË SPSS for Windows 98 (1998, SPSS Inc)] Î·È Â) ÛÙ·ÙÈÛÙÈ΋ Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ Ë¯ÔηډÈÔÁÚ·ÊÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ·fi ÙËÓ Ë¯ÔηډÈÔÁÚ·ÊÈ΋ ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ∞ Î·È µ, ÌÂÙ¿ ·fi ÂÍ·›ÚÂÛË ÙÔ˘ ÌÔÓ·‰ÈÎÔ‡ ·ÛıÂÓÔ‡˜ Ù˘ ÔÌ¿‰·˜ ∞ ÌÂ Ì˘Ôηډ›Ùȉ·, ÙÔ˘ ÔÔ›Ô˘ ÔÈ ÙÈ̤˜ ·ÚÔ˘Û›·˙·Ó ÌÂÁ¿ÏË ·fiÎÏÈÛË ·fi ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÙˆÓ ˘fiÏÔÈˆÓ ·ÛıÂÓÒÓ Ù˘ ›‰È·˜ ÔÌ¿‰·˜ (20). ŸÙ·Ó ÙÔ p ‚Ú¤ıËΠ>0,05 Ë ÛÙ·ÙÈÛÙÈ΋ ‰È·ÊÔÚ¿ ıˆڋıËΠˆ˜ ÌË ÛËÌ·ÓÙÈ΋, fiÙ·Ó ‹Ù·Ó p<0,05 ıˆڋıËΠˆ˜ ÛËÌ·ÓÙÈ΋ Î·È fiÙ·Ó p<0,001 ˆ˜ Ôχ ÛËÌ·ÓÙÈ΋.

∞ÔÙÂϤÛÌ·Ù· ∫ÏÈÓÈο Î·È ·ÈÌ·ÙÔÏÔÁÈο ‰Â‰Ô̤ӷ OÈ ·ÛıÂÓ›˜ ÚÔÛÎÔÌ›˙ÔÓÙ·Ó Î·Ù¿ ̤ÛÔ fiÚÔ ÙËÓ 4Ë-5Ë Ë̤ڷ Ù˘ ÓfiÛÔ˘, Ì ·ÚÈÔ ÎÚÈÙ‹ÚÈÔ ÙÔÓ ˘ÚÂÙfi. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ˘‹Ú¯·Ó: ˘ÚÂÙfi˜ >38ÔC, ‚‹¯·˜, ·‡ÍËÛË Ù˘ ∆∫∂ (30-85 ÙËÓ 1Ë ÒÚ·) Î·È ·‡ÍËÛË Ù˘ C·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘. ¶ÚÔÊ·Ó‹˜ ·ÓËÛ˘¯›· Î·È ÂÚÂıÈÛÙÈÎfiÙËÙ· ˘‹Ú¯Â ÛÙÔ 68,4% ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÛÙÔ 50% Ù˘ ÔÌ¿‰·˜ µ. ™Ô‚·Ú‹ ‰‡ÛÓÔÈ·, ¯ˆÚ›˜ ΢¿ÓˆÛË, Û˘Óԉ¢fiÌÂÓË ·fi Ù·¯˘Î·Ú‰›·, Ë·ÙÔÌÂÁ·Ï›· Î·È Î·Ú‰ÈÔıˆÚ·ÎÈÎfi ‰Â›ÎÙË >0,60 ›¯Â Ô ·ÛıÂÓ‹˜ Ù˘ ÔÌ¿‰·˜ A ÌÂ Ì˘Ôηډ›Ùȉ·. ª¤ÙÚÈÔ˘ ‚·ıÌÔ‡ ‰‡ÛÓÔÈ· (score 5-7) Ì ηډÈÔıˆÚ·ÎÈÎfi ‰Â›ÎÙË 0,55-0,599 ÂÌÊ¿ÓÈÛ·Ó 4/20 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ (12,5%), Û ‰‡Ô ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Ë ·ÈÙ›· Ù˘ Ó¢ÌÔÓ›·˜ ‹Ù·Ó ÈÔÁÂÓ‹˜ Î·È Û ‰‡Ô Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ∆· ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ‹Ù·Ó ÂÓ‰ÂÈÎÙÈο ÁÈ·

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·427

427

∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ Ó¢ÌÔÓ›·

ÂÚÈηډ›Ùȉ· Î·È Ì˘Ôηډ›Ùȉ· Û 1 ·ÛıÂÓ‹ Î·È ÁÈ· ÂÚÈηډ›Ùȉ· Û 4/19 (21,05% Ù˘ ÔÌ¿‰·˜ ∞, 10% ÙÔ˘ Û˘ÓfiÏÔ˘). ∫·Ó¤Ó·˜ ·ÛıÂÓ‹˜ ‰ÂÓ ·ÚÔ˘Û›·Û ·ÚÚ˘ıÌ›·.

∫·Ú‰ÈÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË O ·ÛıÂÓ‹˜ Ù˘ ÔÌ¿‰·˜ ∞ Ì ÎÏÈÓÈο ÛËÌ›· Ì˘Ôηډ›Ùȉ·˜ ÏËÚÔ‡Û ٷ ˯ÔηډÈÔÁÚ·ÊÈο ÎÚÈÙ‹ÚÈ· Ù˘ Ì˘Ôηډ›Ùȉ·˜ Î·È Ù˘ ÂÚÈηډȷ΋˜ Û˘ÏÏÔÁ‹˜. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Ó¢ÌÔÓ›·˜ ÙÔ˘ ‹Ù·Ó ÌÈÎÚԂȷ΋. ∆Ô ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó 46% Î·È Ë ·ÓÂ¿ÚÎÂÈ· Ù˘ ÌÈÙÚÔÂȉԇ˜ ‚·Ï‚›‰·˜ ‹Ù·Ó 3Ô˘ ÛÙ·‰›Ô˘. OÈ ˘fiÏÔÈÔÈ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ ›¯·Ó ˯ÔηډÈÔÁÚ·ÊÈο ÎÚÈÙ‹ÚÈ· ÂÚÈηډȷ΋˜ Û˘ÏÏÔÁ‹˜. ∞fi ·˘ÙÔ‡˜, Û 15 Ë ÔÛfiÙËÙ· ÙÔ˘ ÂÚÈηډȷÎÔ‡ ˘ÁÚÔ‡ ‹Ù·Ó ÌÂÙÚ›ˆ˜ ·˘ÍË̤ÓË, ÂÓÒ Û 4 Ôχ ·˘ÍË̤ÓË, ¯ˆÚ›˜ ÎÚÈÙ‹ÚÈ· ηډȷÎÔ‡ ÂÈˆÌ·ÙÈÛÌÔ‡. ªÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ OÈ ÙÈ̤˜ ÙˆÓ Ë¯ÔηډÈÔÁÚ·ÊÈÎÒÓ ÛÙ·ıÂÚÒÓ ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ (Ù˘ ÔÌ¿‰·˜ ∞) ÌÂ Ì˘Ôηډ›Ùȉ·, Ô˘ ÂÍ·ÈÚ¤ıËΠ·fi ÙË Û‡ÁÎÚÈÛË, ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1, ÂÓÒ ÙˆÓ ˘fiÏÔÈˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜

µ ÛÙÔ˘˜ ¶›Ó·Î˜ 2 Î·È 3, ·ÓÙ›ÛÙÔȯ·. ™ÙÔÓ ÌÔÓ·‰ÈÎfi ·ÛıÂÓ‹ ÌÂ Ì˘Ôηډ›Ùȉ· Î·È ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹, ÔÈ ·Ú¿ÌÂÙÚÔÈ: ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ (∞∫) (LVPWd), ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ∞∫ (LVDs), Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ (ª∫¢) (IVSd), Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ∞∫ (SV) Î·È ‰È·ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ∞∫ (DV) ‹Ù·Ó ·ÓÒÙÂÚ˜ ·fi ÙȘ ̤Û˜ ÙÈ̤˜ ÙˆÓ ·ÛıÂÓÒÓ ÙˆÓ ÔÌ¿‰ˆÓ ∞ Î·È µ, ÂÓÒ ÔÈ ·Ú¿ÌÂÙÚÔÈ: Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ∞∫ (LVPWs), ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ª∫¢ (IVSd), fiÁÎÔ˜ ÂÍÒıËÛ˘ (SVã), ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ (EF) Î·È ‰Â›ÎÙ˘ ‚Ú¿¯˘ÓÛ˘ ÈÓÒÓ Ù˘ ∞∫ (SF) ‹Ù·Ó ηÙÒÙÂÚ˜ ·fi ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÙˆÓ ˘fiÏÔÈˆÓ ·ÛıÂÓÒÓ. ∞fi ÙË ÛÙ·ÙÈÛÙÈ΋ Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ Ë¯ÔηډÈÔÁÚ·ÊÈÎÒÓ ÛÙ·ıÂÚÒÓ Î·È ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ∞ (n=19) Î·È µ (n=20) (¶›Ó·Î˜ 2 Î·È 3) ‚Ú¤ıËÎÂ: ·) ªË ÛËÌ·ÓÙÈ΋ ÛÙ·ÙÈÛÙÈο ‰È·ÊÔÚ¿ (p>0,05) ˆ˜ ÚÔ˜ ÙȘ ÙÈ̤˜ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ: ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ∞∫ (LVPWd), Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ∞∫ (LVPWs), ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ∞∫ (LVDd), Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ∞∫ (LVDs), Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ∞∫ (SV), ‰È·ÛÙÔÏÈÎfi˜ fiÁÎÔ˜

¶›Ó·Î·˜ 1. ¶·Ú¿ÌÂÙÚÔÈ ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ù˘ ÔÌ¿‰·˜ ∞ ÌÂ Ì˘Ôηډ›Ùȉ· Î·È ÂÚÈηډ›Ùȉ· (ÂÍ·ÈÚ¤ıËÎ·Ó ·fi ÙË ÛÙ·ÙÈÛÙÈ΋ Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ) ¶·Ú¿ÌÂÙÚÔ˜

ª¤ÛË ÙÈÌ‹

™Ù·ıÂÚfi ÛÊ¿ÏÌ·

¢È¿ÌÂÛË ÙÈÌ‹

™Ù·ıÂÚ‹ ·fiÎÏÈÛË

¢È·Î‡Ì·ÓÛË

∂Ï¿¯ÈÛÙË ÙÈÌ‹

ª¤ÁÈÛÙË ÙÈÌ‹

LVPWd LVDd IVSd LVPWs LVDs IVSs DV SV SF EF SVã E A dt E/A

1 3,8 0,64 0,92 2,94 2,94 61,95 33,31 22,63 46,23 28,64 0,74 0,53 148 1,39

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 3,8 0,64 0,92 2,94 2,94 61,95 33,31 22,63 46,23 28,64 0,74 0,53 148 1,39

# # # # # # # # # # # # # # #

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 3,8 0,64 0,92 2,94 2,94 61,95 33,31 22,63 46,23 28,64 0,74 0,53 148 1,39

1 3,8 0,64 0,92 2,94 2,94 61,95 33,31 22,63 46,23 28,64 0,74 0,53 148 1,39

LVPWd: ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ (∞∫), LVDd: ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ∞∫, IVSd: ‰È·ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ (ª∫¢), LVPWs: Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ∞∫, LVDs: Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ∞∫, IVSs: Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ª∫¢, DV: ‰È·ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ∞∫, SV: Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ∞∫, SF: ‰Â›ÎÙ˘ ‚Ú¿¯˘ÓÛ˘ ÈÓÒÓ, EF: ÎÏ¿ÛÌ· ÂÍÒıËÛ˘, SVã: Â͈ıËÙÈÎfi˜ fiÁÎÔ˜, E: ̤ÁÈÛÙË Ù·¯‡ÙËÙ· ÚˆÙԉȷÛÙÔÏÈ΋˜ ÚÔ‹˜, A: ̤ÁÈÛÙË Ù·¯‡ÙËÙ· ÙÂÏԉȷÛÙÔÏÈ΋˜ ÚÔ‹˜ dt: ¯ÚfiÓÔ˜ ˘ÛÙ¤ÚËÛ˘ ‰È·ÛÙÔÏÈ΋˜ ÚÔ‹˜ E/A: Û¯¤ÛË Î‡Ì·ÙÔ˜ ∂ /∞ ¶·È‰È·ÙÚÈ΋ 2005;68:425-431

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·428

428

°. ™. µ·ÚÏ¿Ì˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 2. ¶·Ú¿ÌÂÙÚÔÈ ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ (n=19) Ì ÂÚÈηډ›Ùȉ· ¶·Ú¿ÌÂÙÚÔ˜*

ª¤ÛË ÙÈÌ‹

™Ù·ıÂÚfi ÛÊ¿ÏÌ·

¢È¿ÌÂÛË ÙÈÌ‹

™Ù·ıÂÚ‹ ·fiÎÏÈÛË

¢È·Î‡Ì·ÓÛË

∂Ï¿¯ÈÛÙË ÙÈÌ‹

ª¤ÁÈÛÙË ÙÈÌ‹

LVPWd LVPWd LVDd IVSd LVPWs LVDs IVSs DV SV SF EF SVã E A dt E/A

1 0,696 3,475 0,728 1,076 2,167 1,116 53,725 17,692 38,47 64,82 35,283 0,887 0,556 130,21 1,664

0 0,055 0,157 0,043 0,066 0,122 0,084 4,065 1,469 3,335 1,668 2,984 0,037 0,039 2,907 0,079

1 0,65 3,3 0,7 1,05 2,12 1 46,76 14,5 35,28 65,67 32,35 0,84 0,52 130 1,6

# 0,241 0,687 0,188 0,29 0,536 0,367 17,719 6,406 14,537 7,273 13,01 0,161 0,172 12,673 0,346

0 1 3,17 0,71 1,12 2,61 1,71 58,92 23,59 69,88 28,85 45,65 0,56 0,53 43 1,02

1 0,35 1,78 0,44 0,68 0,34 0,72 31,13 10 24,84 50,59 19,79 0,61 0,39 107 1,18

1 1,35 4,95 1,15 1,8 2,95 2,43 90,05 33,59 94,72 79,44 65,44 1,17 0,92 150 2,2

p**

>0,05 >0,05 <0,05 >0,05 >0,05 <0,05 >0,05 >0,05 >0,05 >0,05 <0,05 <0,05 >0,05 >0,05 >0,05

* ∏ ÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ ÛÙÔÓ ¶›Ó·Î· 1 ** p: ·Ó·Ê¤ÚÂÙ·È ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ∞ Î·È µ

¶›Ó·Î·˜ 3. ¶·Ú¿ÌÂÙÚÔÈ ·fi ÙË ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ µ (n=20) ¯ˆÚ›˜ Ì˘Ôηډ›Ùȉ·, Ô‡Ù ÂÚÈηډ›Ùȉ· ¶·Ú¿ÌÂÙÚÔ˜*

ª¤ÛË ÙÈÌ‹

™Ù·ıÂÚfi ÛÊ¿ÏÌ·

¢È¿ÌÂÛË ÙÈÌ‹

™Ù·ıÂÚ‹ ·fiÎÏÈÛË

¢È·Î‡Ì·ÓÛË

∂Ï¿¯ÈÛÙË ÙÈÌ‹

ª¤ÁÈÛÙË ÙÈÌ‹

p**

LVPWd LVDd IVSd LVPWs LVDs IVSs DV SV SF EF SVã E A dt E/A

0,682 3,499 0,633 1,018 2,355 0,951 51,193 24,291 32,879 62,306 32,313 0,797 0,5145 127,45 1,584

0,033 0,142 0,031 0,041 0,116 0,038 5,311 4,543 1,188 1,684 2,953 0,022 0,023 3,026 0,098

0,7 3,57 0,59 1,045 2,415 0,88 48,485 20,485 33,035 62,72 29,105 0,79 0,51 127 1,575

0,15 0,637 0,138 0,187 0,52 0,174 23,751 20,318 5,315 7,534 13,206 0,101 0,107 13,535 0,442

0,6 2,47 0,46 0,71 2,08 0,57 104,56 86,97 16,21 22,76 51,24 0,34 0,41 50 1,96

0,4 2,61 0,44 0,56 1,6 0,68 24,84 7,17 26,24 52,55 13,97 0,64 0,32 105 0,32

1 5,08 0,9 1,27 3,68 1,25 129,4 94,14 42,45 75,31 65,21 0,98 0,73 155 2,28

>0,05 >0,05 <0,05 >0,05 >0,05 <0,05 >0,05 >0,05 >0,05 >0,05 <0,05 <0,05 >0,05 >0,05 >0,05

* ∏ ÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ ÛÙÔÓ ¶›Ó·Î· 1 ** p: ·Ó·Ê¤ÚÂÙ·È ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ∞ Î·È µ (‚Ï. Î·È ¶›Ó·Î· 2)

∞∫ (DV), ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ (EF), ‰Â›ÎÙ˘ ‚Ú¿¯˘ÓÛ˘ ÈÓÒÓ ∞∫ (SF). ¢ÂÓ ˘‹Ú¯Â, Â›Û˘, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ, ˆ˜ ÚÔ˜ ÙË Ì¤ÁÈÛÙË ÙÂÏԉȷÛÙÔÏÈ΋ Ù·¯‡ÙËÙ· Ù˘ ‰È·ÌÈÙÚÔÂȉÈ΋˜ ÚÔ‹˜ (·̷ ∞ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ÛÊ˘ÁÌÈÎÔ‡ Doppler), ˆ˜ ÚÔ˜ ÙÔÓ ¯ÚfiÓÔ Î·ı˘ÛÙ¤ÚËÛ˘ Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÚÔ‹˜ Ù˘ ÌÈÙÚÔÂȉԇ˜ (dt) Î·È ˆ˜ ÚÔ˜ ÙÔÓ ‰Â›ÎÙË ∂/∞ (p>0,05). ¶·È‰È·ÙÚÈ΋ 2005;68:425-431

‚) ™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p<0,05) ˘‹Ú¯Â ˆ˜ ÚÔ˜ ÙȘ ÙÈ̤˜ Ù˘ ‰È·ÛÙÔÏÈ΋˜ ‰È·Ì¤ÙÚÔ˘ ÙÔ˘ ª∫¢ (IVSd), Ù˘ Û˘ÛÙÔÏÈ΋˜ ‰È·Ì¤ÙÚÔ˘ ÙÔ˘ ª∫¢ (IVSs) Î·È ÙÔ˘ Û˘ÛÙÔÏÈÎÔ‡ fiÁÎÔ˘ ÂÍÒıËÛ˘ (SVã). ∆¤ÏÔ˜, Ë Ì¤ÛË ÙÈÌ‹ Ù˘ ̤ÁÈÛÙ˘ Ù·¯‡ÙËÙ·˜ ÚˆÙԉȷÛÙÔÏÈ΋˜ Ï‹ÚˆÛ˘ Ù˘ ‰È·ÌÈÙÚÔÂȉÈ΋˜ ÚÔ‹˜ (·̷ ∂ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ÛÊ˘ÁÌÈÎÔ‡ Doppler) ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· ∞ Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· µ,

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·429

429

∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ Ó¢ÌÔÓ›·

Ì ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p<0,05) (∂ÈÎfiÓ· 1·,‚). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ·ÙÈÛÙÈο Ôχ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ‰ÂÓ ‚Ú¤ıËΠ۠η̛· ·Ú¿ÌÂÙÚÔ, ÂÓÒ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ‚Ú¤ıËΠ۠4 ˯Ô·Ú·Ì¤ÙÚÔ˘˜: ‰È·ÛÙÔÏÈ΋ Î·È Û˘ÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, Û˘ÛÙÔÏÈÎfi˜ fiÁÎÔ˜ ÂÍÒıËÛ˘ Î·È Ì¤ÁÈÛÙË Ù·¯‡ÙËÙ· Ù˘ ÚˆÙԉȷÛÙÔÏÈ΋˜ Ï‹ÚˆÛ˘.

µ·ÛÈο ÁÓˆÚ›ÛÌ·Ù· Ù˘ Û‡Á¯ÚÔÓ˘ ˯ÔηډÈÔÁÚ·Ê›·˜ Â›Ó·È fiÙÈ ·ÔÙÂÏ› ÌË ·ÈÌ·ÙËÚ‹ ‰È·ÁÓˆÛÙÈ΋ ̤ıÔ‰Ô, Ì ÌÂÁ¿ÏË Â˘ÎÔÏ›· ÂÊ·ÚÌÔÁ‹˜ Î·È Â·Ó¿Ï˄˘ Î·È ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ·, Ô˘ ÁÈ· ÙËÓ ÂÚÈηډ›Ùȉ· Â›Ó·È ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏË (·ÁÁ›˙ÂÈ ÙÔ 100%) (19). ø˜ ÚÔ˜ ÙË Ì˘Ôηډ›Ùȉ·, Ë ÂÓ‰ÔÌ˘Ôηډȷ΋ ‚ÈÔ„›· Â›Ó·È ·Ô‰ÂÎÙ‹ ˆ˜ Ë Î·Ï‡ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ ̤ıÔ‰Ô˜, ·ÏÏ¿ ÚÔ˜ ÙÔ ·ÚfiÓ ˘¿Ú¯Ô˘Ó ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ Â˘Ú›· ÂÊ·ÚÌÔÁ‹ Ù˘, ȉȷ›ÙÂÚ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· (13,22).

™˘˙‹ÙËÛË ∆ËÓ ÙÂÏÂ˘Ù·›· ÂÈÎÔÛ·ÂÙ›· ¤¯ÂÈ ·Ô‰Âȯı› ·ıÔÁÂÓÂÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÈÔÁÂÓÔ‡˜ Ì˘Ôηډ›Ùȉ·˜ Î·È ‰È·Ù·ÙÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ (7,8,21), ÂÓÒ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÂÚÈÙÒÛÂȘ Ì ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË ÌÂٷ͇ Ó¢ÌÔÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·È Ì˘Ô- ‹ ÂÚÈηډ›Ùȉ·˜ (1,6) ÛÙ· ·È‰È¿. ™ÙËÓ ·ÚÔ‡Û· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÌÂϤÙË ‰ÈÂÚ¢ӋıËÎÂ Ë Èı·ÓfiÙËÙ· Û˘ÌÌÂÙÔ¯‹˜ Ù˘ ηډȿ˜ Û ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È ÁÈ· Ó¢ÌÔÓ›·, ‚¿ÛÂÈ ÎÏ·ÛÈ΋˜ Î·È Ë¯ÔηډÈÔÁÚ·ÊÈ΋˜ ‰È·ÁÓˆÛÙÈ΋˜ ÂÎÙ›ÌËÛ˘.

1·

EF

100 Series 1 50

Series 2 Series 3

0 1

1‚

IVSd=1, IVSs=2, ·̷ ∂=3

3 Series 1

2

Series 2 1

Series 3

0 1

2

3

∂ÈÎfiÓ· 1. ¢È·ÁÚ·ÌÌ·ÙÈ΋ Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ EF (∂ÈÎfiÓ· 1·), IVSd, IVSs Î·È Î‡Ì·ÙÔ˜ ∂ (∂ÈÎfiÓ· 1‚) Ù˘ ‰È·ÌÈÙÚÔÂȉÈ΋˜ ÚÔ‹˜ ·fi ÙËÓ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈ΋ ÌÂϤÙË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜: i) ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂ Ì˘Ôηډ›Ùȉ· Ù˘ ÔÌ¿‰·˜ ∞ (ÛÂÈÚ¿ 1), ii) ÙˆÓ ˘fiÏÔÈˆÓ 19 ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ ∞ (ÛÂÈÚ¿ 2) Î·È iii) ÙˆÓ 20 ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ µ (ÛÂÈÚ¿ 3). ™ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ·˘Ù¤˜ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (p<0,05). °È· ÙËÓ ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ ‚Ï. ÛÙÔÓ ¶›Ó·Î· 1.

∫ÏÈÓÈο Î·È ·ÈÌ·ÙÔÏÔÁÈο ‰Â‰Ô̤ӷ OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ (2,22) ·Ó·Ê¤ÚıËÎ·Ó ÛÙËÓ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË ÌÂٷ͇ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ Î·È Î·Ú‰›Ùȉ·˜, ÂÓÒ Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ (23-26) ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ë ÂÌÊ¿ÓÈÛË ÛËÌ›ˆÓ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·ÔÙÂÏ› ÙÔ ‰È·ÁÓˆÛÙÈÎfi ÎÏÂȉ› ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜. µ¿ÛÂÈ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ ÙÔ ›‰ÈÔ ÌÔÚ› Ó· ıˆÚËı› Î·È ÁÈ· ÙËÓ Ó¢ÌÔÓ›·. ™ÙÔÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÌÂ Ì˘Ôηډ›Ùȉ· Î·È ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹, fiˆ˜ Î·È ÛÙÔ˘˜ 4/15 Ù˘ ÔÌ¿‰·˜ ∞ Ì ÌÂÁ¿ÏË ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹, Ù· ÛËÌ›· ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ÔÈ ˘„ËÏÔ› ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ ‹Ù·Ó ·ÚÎÂÙ¿ ÁÈ· ÙËÓ ˘fiÓÔÈ· Ù˘ ‰È¿ÁÓˆÛ˘, Ô˘ ÂȂ‚·ÈÒıËΠ˯ÔηډÈÔÁÚ·ÊÈο. ™ÙÔ˘˜ 15 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ ÌÂ Â˘Ú‹Ì·Ù· ‹È·˜ ÂÚÈηډ›Ùȉ·˜, Ë ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Ù˘ ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜ ‰ÂÓ ‹Ù·Ó ÚÔÊ·Ó‹˜, ·ÏÏ¿ Ù· ˯ÔηډÈÔÁÚ·ÊÈο ÎÚÈÙ‹ÚÈ· ‹Ù·Ó ·Ó·ÌÊÈÛ‚‹ÙËÙ·. ∏ ·ÈÌ·ÙÔÏÔÁÈ΋ ÂÈÎfiÓ· (Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÛË, ˘„ËϤ˜ ÙÈ̤˜ ∆∫∂ Î·È C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ Î.Ï.) ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÁÓˆÛÙ‹ ˆ˜ Û˘ÓÔ‰fi˜ ÂÈÎfiÓ· Ù˘ ›‰È·˜ Ù˘ Ó¢ÌÔÓ›·˜, ‰ÂÓ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ‰È·ÁÓˆÛÙÈÎfi ÎÏÂȉ› ÁÈ· ˘fiÓÔÈ· ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜, ÛÙ· ·Ú¯Èο ÛÙ¿‰È·. ™Â ÚfiÛÊ·Ù˜ ‰ËÌÔÛȇÛÂȘ ·Ó·Ê¤ÚÂÙ·È Ï¢ÎÔÂÓ›· Û ·È‰› ̠Ϣ¯·ÈÌ›· Î·È Ï¢ÚÔÂÚÈηډ›Ùȉ·(25) Î·È ˘„ËϤ˜ ÙÈ̤˜ CK-MB Û ÔÛÔÛÙfi 68%, Û ·È‰È¿ ·Ó¿ÏÔÁ˘ - Ì ÙËÓ ·ÚÔ‡Û· - ÌÂϤÙ˘ (26). ∏ Èı·ÓfiÙËÙ· ÛÔ‚·Ú‹˜ ÂÚÈηډȷ΋˜ Û˘ÏÏÔÁ‹˜ 12,5% Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÌÔÚ› Ó· ıˆÚËı› ˆ˜ ‚¿ÛË ÂÚ·ÈÙ¤Úˆ ÌÂÏÂÙÒÓ Î·È Û˘ÁÎÚ›ÛˆÓ. ∏ÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ∏ ÂÌÊ¿ÓÈÛË ·ÚÚ˘ıÌÈÒÓ ‹ ¿ÏÏˆÓ ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙË ‰È¿ÚÎÂÈ· Ó¢ÌÔÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È ÁÓˆÛÙ‹ (2,2730). ™Â ÌÈÎÚ¿ ·È‰È¿ Ì ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, Ë ¶·È‰È·ÙÚÈ΋ 2005;68:425-431

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·430

430

°. ™. µ·ÚÏ¿Ì˘ Î·È Û˘Ó.

Û˘¯ÓfiÙËÙ· ·ÚÚ˘ıÌ›·˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 0% ¤ˆ˜ 2% (23,24), ·Ú¿ ÙË ÛËÌ·ÓÙÈ΋ Û˘¯ÓfiÙËÙ· (9,8%) (24) ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜. ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›·, Ë Û˘¯ÓfiÙËÙ· ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÂÓ‰ÂÈÎÙÈÎÒÓ Èı·Ó‹˜ ηډȷ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (‰È·Ù·Ú·¯¤˜ ÙÔ˘ ∆) ‹Ù·Ó 21,05%, Ôχ ÌÈÎÚfiÙÂÚË ·fi ÂΛÓË ÙˆÓ Ilten Î·È Û˘Ó (26) (68% ·È‰ÈÒÓ ËÏÈΛ·˜ 2-24 ÌËÓÒÓ Ì Ó¢ÌÔÓ›·), ÂÓÒ Ë Û˘¯ÓfiÙËÙ· ·ÚÚ˘ıÌÈÒÓ ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ‹Ù·Ó ÌˉÂÓÈ΋.

∏¯ÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· OÈ ÏËÚÔÊÔڛ˜ ˆ˜ ÚÔ˜ ÙȘ ‰È·ÛÙ¿ÛÂȘ Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ Û ÛÔ‚·Ú‹ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Â›Ó·È Ï›Á˜ Î·È ‰È·Ê¤ÚÔ˘Ó ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ (17,18,23,24,26). ™Â ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÙˆÓ Goldberg Î·È Û˘Ó (12), ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ·fi 19 ¿Û¯ÔÓÙ˜ Ì ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ 17 ›¯·Ó ËÏÈΛ· 5 ËÌÂÚÒÓ ¤ˆ˜ 16 ÂÙÒÓ, ˘‹Ú¯Â ·Ó·ÌÓËÛÙÈÎfi Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢ Î·È Û ÔÚÈṲ̂ÓÔ˘˜ ·Ó·ÌÓËÛÙÈÎfi Ó¢ÌÔÓ›·˜. ∞fi ·‰ËÌÔÛ›Â˘ÙË ·Ó·‰ÚÔÌ‹ ÛÙÔ ∞Ú¯Â›Ô ÙÔ˘ ∂ÚÁ·ÛÙËÚ›Ô˘, Û 12 ·fi 15 ·È‰È¿ Ì ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ËÏÈΛ·˜ 3 ÌËÓÒÓ ¤ˆ˜ 12 ÂÙÒÓ, ηٿ ÙËÓ ÚÒÙË ‰È¿ÁÓˆÛË, ˘‹Ú¯Â ·Ó·ÌÓËÛÙÈÎfi ÛÔ‚·Ú‹˜ Ó¢ÌÔÓ›·˜ ‹ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜. √È Nissen Î·È Û˘Ó (5) ÂÚȤÁÚ·„·Ó ÂÚ›ÙˆÛË Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢ ·fi Ì˘ÎfiÏ·ÛÌ·, fiÔ˘ Ô ·ÛıÂÓ‹˜ ÙÔ˘˜ ÂÌÊ¿ÓÈÛ ˯ÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ˘ÂÚÙÚÔÊÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (30,31) ‚Ú‹Î·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÙÂÏԉȷÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ Û ·È‰› Ô˘ ¤·Û¯Â ·fi ÈÔÁÂÓ‹ Ì˘Ôηډ›Ùȉ· Ì Ôχ ¯·ÌËÏfi ÎÏ¿ÛÌ· ÂÍÒıËÛ˘. ∞fi ÙË ÌÂϤÙË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ˘‹Ú¯Â ˆ˜ ÚÔ˜ ÙȘ ‰È·Ì¤ÙÚÔ˘˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ì ‹È· ÂÚÈηډ›Ùȉ·. ™˘ÓÂÒ˜, ‚¿ÛÂÈ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ·Ú¿ Ù· ÂÓ‰ÂÈÎÙÈο ÁÈ· Èı·Ó‹ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹ ÎÏÈÓÈο ‰Â‰Ô̤ӷ, ÔÈ ‰È·ÛÙ¿ÛÂȘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÌÔÚÔ‡Ó Ó· ·Ú·Ì¤ÓÔ˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ∂›Ó·È Èı·Ófi, ˆÛÙfiÛÔ, Ó· ˘¿Ú¯Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ‰È·ÛÙ¿ÛÂȘ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ÛÙÔÓ Û˘ÛÙÔÏÈÎfi fiÁÎÔ ÂÍÒıËÛ˘. ∆Ô ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ Î·È Ô ‰Â›ÎÙ˘ ‚Ú¿¯˘ÓÛ˘ ÈÓÒÓ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÂËÚ¿ÛÙËÎ·Ó ÛÙÔÓ ·ÛıÂÓ‹ Ì ηıÔÏÈ΋ Û˘ÌÌÂÙÔ¯‹ Ù˘ ηڶ·È‰È·ÙÚÈ΋ 2005;68:425-431

‰È¿˜ Î·È ÏÈÁfiÙÂÚÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ̷˙È΋ ·‡ÍËÛË Ù˘ ÔÛfiÙËÙ·˜ ÙÔ˘ ÂÚÈηډȷÎÔ‡ ˘ÁÚÔ‡. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÙÈ̤˜ ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÂÍÒıËÛ˘ (EF) Î·È ÙÔ˘ fiÁÎÔ˘ ·ÏÌÔ‡ Â›Ó·È ·ÚÎÂÙ¿ ·ÍÈfiÈÛÙÔÈ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ·ÏÏ¿ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔÓ ÙÂÏÔÛ˘ÛÙÔÏÈÎfi Î·È ÙÂÏԉȷÛÙÔÏÈÎfi fiÁÎÔ ·›Ì·ÙÔ˜, ·fi ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È ·fi ÙÔ ‚·ıÌfi ‰È¿Ù·Û˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜. ™˘ÓÂÒ˜, ‰ÂÓ Â›Ó·È ·fiÏ˘ÙÔÈ ‰È·ÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜, ÁÂÁÔÓfi˜ Ì ÙÔ ÔÔ›Ô Û˘ÌʈÓÔ‡Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ªÔÚÔ‡Ó, fï˜, Ó· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Û˘ÌÌÂÙÔ¯‹˜ Ù˘ ηډȿ˜ Û Ó¢ÌÔÓÈ΋ Ïԛ̈ÍË (9,10). ∏ ·Ó‡ÚÂÛË ÚÒÈÌ˘ ·ÓÂ¿ÚÎÂÈ·˜ Ù˘ ÌÈÙÚÔÂȉԇ˜ Û ·È‰È¿ ÌÂ Ì˘Ôηډ›Ùȉ·, fiˆ˜ ‰È·ÈÛÙÒÛ·Ì ÛÙÔÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Â›Ó·È Û˘¯Ó‹, ·ÏÏ¿ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (31). Œ¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ·ÓÂ¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜, Ô˘ ‰È·ÈÛÙÒıËΠÛÙË ‰È¿ÚÎÂÈ· Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢ ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜ Î·È ÈÔ‡˜ (5,29). ∆¤ÏÔ˜, Ë Û˘¯ÓfiÙËÙ· ÌÂÌÔӈ̤Ó˘ ÛËÌ·ÓÙÈ΋˜ ÂÚÈηډȷ΋˜ Û˘ÏÏÔÁ‹˜ Û ÂÚÈÙÒÛÂȘ Ó¢ÌÔÓ›·˜ ‰ÂÓ Â›Ó·È Î·ıÔÚÈṲ̂ÓË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Û˘¯ÓfiÙËÙ· (50%) Û˘ÌÌÂÙÔ¯‹˜ ÁÂÓÈο ÙÔ˘ ÂÚÈηډ›Ô˘ Î·È ÂȉÈÎfiÙÂÚ· (10%) ÛËÌ·ÓÙÈ΋˜ ÂÚÈηډȷ΋˜ Û˘ÏÏÔÁ‹˜ Â›Ó·È ÌÂÁ¿ÏË Û˘ÁÎÚÈÙÈο Ì ٷ Â˘Ú‹Ì·Ù· ¿ÏÏˆÓ Û˘ÁÁڷʤˆÓ (5,29,32), ·ÏÏ¿ ÔÈ Roodpeyma Î·È Û˘Ó (33) Û ·Ó·‰ÚÔÌÈ΋ ÙÔ˘˜ ÌÂϤÙË ·Ó·Ê¤ÚÔ˘Ó ·ÎÚÈ‚Ò˜ ÙËÓ ›‰È· Û˘¯ÓfiÙËÙ·. ¶Èı·Ó‹ ÂÍ‹ÁËÛË Ù˘ ÛËÌ·ÓÙÈ΋˜ Û˘¯ÓfiÙËÙ·˜ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ¤ÛÙˆ ÁÈ· ·Ï‹ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÚÈηډ›Ô˘, Â›Ó·È fiÙÈ ÔÈ 40 ·ÛıÂÓ›˜ ·ÔÙÂÏÔ‡Ó ÂÈÏÂÁ̤ÓÔ ÏËı˘ÛÌfi, ‰ËÏ·‰‹ ·È‰È¿ Ì ÛËÌ·ÓÙÈ΋ ÎÏÈÓÈ΋ ÂÈ‚¿Ú˘ÓÛË ‰Â‰Ô̤Ó˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘, Ô˘ ›¯·Ó ·Ó¿ÁÎË ÓÔÛËÏ›·˜ Û ÓÔÛÔÎÔÌ›Ô.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Menahem S, Uren EC. Respiratory syncytial virus and heart block - cause and effect? Aust NZJ Med 1985;15:55-57.

2. Thomas JA, Raroque S, Scott WA, Toro-Figueroa LO, Levin DL. Successful treatment of severe dysrhythmias in infants with respiratory syncytial virus infections: two cases and a literature review. Crit Care Med 1997;25:880-886.

3. Schindler JM, Neftel KA. Simultaneous primary infection with HIV and CMV leading to severe

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·431

431

∫·Ú‰È·Î‹ Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ Ó¢ÌÔÓ›·

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

pancytopenia, hepatitis, nephritis, perimyocarditis, myositis, and alopecia totalis. Klin Wochenschr 1990;68: 237-240.

Campbell PW, Stokes DC. Pneumonia. In: Loughlin GM, Eigen H, editors. Respiratory disease in children. Diagnosis and management. Baltimore: Williams and Wilkins; 1994. p. 351-372.

Nissen M, McEniery J, Delbridge G, Pearn J, Sloots T, Wright C. Acute hypertrophic cardiomyopathy possibly associated with Mycoplasma pneumoniae infection. Pediatr Infect Dis J 1995;14:74-76.

Akhtar N, Ni J, Stromberg D, Rosenthal GL, Bowles NE, Towbin JA. Tracheal aspirate as a substrate for polymerase chain reaction detection of viral genome in childhood pneumonia and myocarditis. Circulation 1999;99:2011-2018.

Kereiakes DJ, Parmley WW. Myocarditis and cardiomyopathy. Am Heart J 1984;108:1318-1326.

Goodwin JF. Cardiomyopathies and specific heart muscle diseases. Definitions, terminology, classifications and new and old approaches. Postgrad Med J 1992;68 (Suppl 1):S3-S6.

Feigenbaum H. Echocardiography. 4th ed. Philadelphia: Lea and Febiger; 1986. p. 157-167.

Feigenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26:475-479.

Ginzton LE, Laks MM. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation 1982;65:10041009.

Goldberg SJ, Valdes-Cruz LM, Sahn DJ, Allen HD. Two-dimensional echocardiographic evaluation of dilated cardiomyopathy in children. Am J Cardiol 1983;52:1244-1248.

Vare D, Vare B, Dauphin C, Lafeuille H, Gaulme J, Labbe A et al. Acute myocarditis in children. Study of 11 clinical cases. Arch Mal Coeur 2000;93:571-579.

Arguedas AG, Stutman HR, Marks MI. Bacterial pneumonias. In: Cherning V, Kendig El, editors.

Kending’s disorders of the respiratory tract in children. 5th ed. Philadelphia: W.B. Saunders Co; 1992. p. 1977-1978.

Miller MA, Ben-Ami T, Daum RS. Bacterial pneumonia in neonates and older children. In: Taussig LM, Landau LI, editors. Pediatric respiratory medicine. 1st ed. St Louis: Mosby & Co Ed; 1999. p. 595-664.

Gouton M, Di Filippo S, Sassolas F, Stamm D, Bozio A, Floret D. Les myocardites aiguës infectieuses de l’enfant. A propos de deux séries lyonnaises. Arch Mal Coeur 1995;88:753-759.

Pahl E, Gidding SS. Echocardiographic assessment of cardiac function during respiratory syncytial virus infection. Pediatrics 1988;81:830-834.

Friedman RA. Myocarditis. In: Garson A, Bricker TJ, McNamara GD, editors. The science and prac-

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

tice of pediatric cardiology. Philadelphia, London: Lea & Febiger; 1990. p. 1577-1589.

Trouillet JL, Dahan M, Touche T, Kitzis M, Groussard O, Cohen-Solal A et al. Évaluation de l’échographie bidimensionnelle dans l’orientation étiologique des maladies du péricarde. A propos de 39 confrontations anatomo-échographiques. Arch Mal Coeur 1987;80:1238-1245.

Armitage P, Berry G. Statistical methods in medical research. 2nd ed. Oxford: Blackwell Scientific Publication; 1989.

Towbin JA. Pediatric myocardial disease. Pediatr Clin North Am 1999;46:289-312.

Ackerman VL, Salva SP. Bronchiolitis. In: Loughlin GM, Eigen H, editors. Respiratory disease in children. Diagnosis and management. Baltimore: William and Wilkins Co; 1998. p. 291.

Scott LP 3rd, Gutelius MF, Parrott RH. Children with acute respiratory tract infections. An electrocardiographic survey. Am J Dis Child, 1970;119:111-113.

Tsiligiri M, Eboriadou M, Varlamis G, Aivazis V, Haidopoulou K, Diamantopoulou M et al. Clinical and laboratory investigation of acute bronchiolitis with associated acquired heart disease. Eur Respir J 2001;18 (Suppl 33):S169.

Heath JA, Kiehn TE, Brown AE, LaQuaglia MP, Steinherz LJ, Bearman G et al. Pythium insidiosum pleuropericarditis complicating pneumonia in a child with leukemia. Clin Infect Dis 2002;35:E60-64.

Ilten F, Senocak F, Zorlu P, Tezic T. Cardiovascular changes in children with pneumonia. Turk J Pediatr 2003;45:306-310.

Agarwala BN,Ruschhaupt DG. Complete heart block from mycoplasma pneumoniae infection. Pediatr Cardiol 1991;12:233-236.

Donnerstein RL, Berg RA, Shehab Z, Ovadia M. Complex atrial tachycardias and respiratory syncytial virus infections in infants. J Pediatr 1994;125:23-28.

Huang M, Bigos D, Levine M. Ventricular arrhythmia associated with respiratory syncytial viral infection. Pediatr Cardiol 1998;19:498-500.

Gonwa TA, Capehart JE, Pilcher JW, Alivizatos PA. Cytomegalovirus myocarditis as a cause of cardiac dysfunction in a heart transplant recipient. Transplantation 1989;47:197-199.

Inoue Y, Kaneko H, Yoshizawa Y, Morikawa A. Rescue of a child with fulminant myocarditis using percutaneous cardiopulmonary support. Pediatr Cardiol 2000;21:158-160.

Friedland IR, du Plessis J, Cilliers A. Cardiac complications in children with Staphylococcus aureus bacteremia. J Pediatr 1995;127:746-748.

Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol 2000;21:363-367.

¶·È‰È·ÙÚÈ΋ 2005;68:425-431

Pediatr Nov-Dec 05

432

12-12-05

15:16

™ÂÏ›‰·432

ORIGINAL ARTICLE

Cardiac involvement in pneumonia.

Comparative study in 40 hospitalized children G. S. Varlamis1, N. Arvanitidis1, S. Karaberis1, M. Emboriadou1, S. Gavriilidis2 1 Laboratory of Paediatric Cardiology, 4th Paediatric Clinic, Aristotelion University of Thessaloniki, AHEPA Hospital, Thessaloniki 2 1st Cardiology Clinic, Aristotelion University of Thessaloniki, AHEPA Hospital, Thessaloniki Correspondence: G. S. Varlamis 85 Vas. Olgas Str., 546 42, Thessaloniki E-mail: varlamisgeorge@yahoo.gr Date of submission: 13-07-2004 Date of approval: 31-05-2005

Abstract Background: The purpose of this study was to estimate the clinical and echocardiographic incidence of cardiac involvement in children with pneumonia.

Methods: The clinical, haematological, biochemical and echocardiographic findings were compared on the day of admission and during the hospitalization of 40 children with pneumonia and with no preexisting systemic disease. Statistical comparison was made of the parameters of systolic and diastolic function of the left ventricle between two groups: A (n=20) and B (n=20) with and without cardiac involvement, respectively. The findings of the initial examination are presented here.

Results: Cardiac involvement was established in half of the 40 patients. One patient had myocarditis and pericarditis, 4/19 had severe pericardial effusion presenting with clinical signs, while in 15/19 a mild pericardial effusion was diagnosed by echocardiography. No patient presented arrhythmia. In 21% of the patients the ECG indicated possible cardiac involvement, while the echocardiogram was diagnostic in 100% of the cases with cardiac involvement. Comparing the left ventricular function in the two groups, statistically significant differences were found in the thickness of the interventricular septum, the systolic ejection volume and the maximum velocity of the rapid ventricular filling period.

Conclusions: Cardiac involvement is a possibility in children hospitalized with pneumonia and should always be checked. In the study group, clinical and electrocardiographic indications were apparent in the severe forms. The echocardiogram on admission may accurately detect the cases without cardiac involvement. Left ventricular is severely affected in cases of myocarditis, while pericarditis affects the thickness of the interventricular septum, the systolic ejection volume and the maximum velocity of the rapid ventricular filling period.

Key words Cardiac involvement, pneumonia, children.

Paediatriki 2005;68:432

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·433

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

433

¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ·ÎÚÈÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜ ¶. ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜1, π. ª·ÓÈfi˜2, Ã. π. ªËÏÈÒÓ˘1

¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ¤ÏÏÂÈ„Ë Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Ë ˘ÈÔı¤ÙËÛË ÌË ˘ÁÈÂÈÓÒÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ΢ÚÈfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ÎÔÈӈӛ˜. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÈÏÔÙÈ΋ ÌÂϤÙË Î·Ù·ÁÚ·Ê‹˜ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ Î·È Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Û˘Û¯¤ÙÈÛ‹˜ ÙÔ˘˜ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ·ÎÚÈÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ™˘ÌÌÂÙ›¯·Ó 73 Ì·ıËÙ¤˜ (39 ·ÁfiÚÈ· Î·È 34 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 7-12 ÂÙÒÓ, ÂÙ¿ ÔÏÈÁÔı¤ÛÈˆÓ ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜ ηٿ ÙÔ Û¯ÔÏÈÎfi ¤ÙÔ˜ 2002-2003. ™Â fiÏ· Ù· ·È‰È¿ ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™) Î·È Ë ÂÚÈʤÚÂÈ· Ù˘ ̤Û˘ (¶ª). ∂ÈÚfiÛıÂÙ·, Û˘ÌÏËÚÒıËÎ·Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Û¯ÂÙÈο Ì ÙË Û˘¯ÓfiÙËÙ· ηٷӿψÛ˘ ÙÚÔÊ›ÌˆÓ Î·È ÙË ÛˆÌ·ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·.

1 ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ 2 ∆Ì‹Ì· ∂ÈÛÙ‹Ì˘ ¢È·ÈÙÔÏÔÁ›·˜-¢È·ÙÚÔÊ‹˜, ÷ÚÔÎfiÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: ÷ڿϷÌÔ˜ ªËÏÈÒÓ˘ ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ∆.∫. 451 10, πˆ¿ÓÓÈÓ· E-mail: hmilioni@cc.uoi.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-02-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 31-05-2005

∞ÔÙÂϤÛÌ·Ù·: ¶·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ¢ª™ Î·È Ù˘ ¶ª (r=0,92331, p<0,0001). ¶ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÏÔÁÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ ¤‰ÂÈÍ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ Ì ÙË Û¯ÔÏÈ΋ Ù¿ÍË [Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio - OR) 1,950, 95% CI (1,165-3,265), p=0,01], ÙÔÓ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ [OR 1,425, 95% CI (1,026-1,979), p=0,03] Î·È ÙËÓ Î·Ù·Ó¿ÏˆÛË ÙÔÛÙ [OR 1,058, 95% CI (1,012-1,106), p=0,01] Î·È ÛÔÎÔÏ¿Ù·˜ [OR 1,071, 95% CI (1,014-1,131), p=0,014]. ∏ Ï‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜ Ê¿ÓËΠӷ ¤¯ÂÈ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ [OR 0,183, 95% CI (0,033-1,020), p=0,05]. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ˘ÈÔı¤ÙËÛË ÌË ˘ÁÈÂÈÓÒÓ ‰È·ÈÙËÙÈÎÒÓ ÚÔÙ‡ˆÓ, Ë Ì›ˆÛË Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, Ë Î·ıÈÛÙÈ΋ ˙ˆ‹ Î·È Ô ·˘ÍË̤ÓÔ˜ ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ ÛÙÔ˘˜ Ì·ıËÙ¤˜ ÙÔ˘ Û¯ÔÏ›Ԣ ÛÙȘ ·ÁÚÔÙÈΤ˜ Î·È ·Ú·ÌÂıfiÚȘ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Ì·˜.

§¤ÍÂȘ ÎÏÂȉȿ ¶·¯˘Û·ÚΛ·, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ÂÚÈʤÚÂÈ· ̤Û˘, ‰È·ÙÚÔÊ‹, ÂχıÂÚÔ˜ ¯ÚfiÓÔ˜, ÙËÏÂfiÚ·ÛË.

∂ÈÛ·ÁˆÁ‹ ∏ ·È‰È΋ ·¯˘Û·ÚΛ· ·ÔÙÂÏ› È·ÙÚÈÎfi Î·È ÎÔÈÓˆÓÈÎfi Úfi‚ÏËÌ· Ù˘ Û‡Á¯ÚÔÓ˘ ÂÔ¯‹˜ Î·È ¤¯ÂÈ ¿ÚÂÈ ÌÂÁ¿Ï˜ ‰È·ÛÙ¿ÛÂȘ Û fiÏÔ ÙÔÓ ‰˘ÙÈÎfi ÎfiÛÌÔ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ (1,2). ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË Î·È Ë ÌÂıÔ‰È΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË Ê˘ÛÈ΋, ÙËÓ ÎÔÈÓˆÓÈ΋ Î·È ÙËÓ „˘¯È΋ ˘Á›· ÙˆÓ ·È‰ÈÒÓ (3-5).

O ¡ÔÌfi˜ £ÂÛÚˆÙ›·˜ ·ÔÙÂÏ› Ì›· Û¯ÂÙÈο ·ÔÌÔӈ̤ÓË Î·È ÌË ‚ÈÔÌ˯·ÓÔÔÈË̤ÓË Â-

ÚÈÔ¯‹ Ù˘ ∂ÏÏ¿‰·˜ Ô˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ì ÙËÓ Â›ÛÔ‰Ô ÙˆÓ ÌÂÙ·Ó·ÛÙÒÓ, ‚ÈÒÓÂÈ Ì›· ÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ Ù˘ Û‡ÓıÂÛ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘, fiˆ˜ ·˘Ùfi ·ÓÙ·Ó·ÎÏ¿ ÛÙË Û¯ÔÏÈ΋ ÎÔÈÓfiÙËÙ·. ™˘ÓÂÒ˜, ·ÚÔ˘ÛÈ¿˙ÂÈ È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ Ë ¤Ú¢ӷ Î·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÚÔÙ‡ˆÓ ‰È·ÙÚÔÊÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙËÓ ·¯˘Û·ÚΛ·, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÎfiÓËÛË ÚÔÁÚ·ÌÌ¿ÙˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ·ÁˆÁ‹˜ ˘Á›·˜ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÚÔÙ‡ˆÓ ·˘ÙÒÓ (6,7). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÈÏÔÙÈ΋˜ ÌÂϤÙ˘ ¶·È‰È·ÙÚÈ΋ 2005;68:433-438

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·434

434

¶. ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜ Î·È Û˘Ó.

‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ, Ù˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ Î·È Ù˘ ηıËÌÂÚÈÓ‹˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Û ۯÔÏ›· Ù˘ ·ÎÚÈÙÈ΋˜ ˙ÒÓ˘ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ·ÚÔ‡Û· ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠ÂÙ¿ ÔÏÈÁÔı¤ÛÈ· (ÌÔÓÔı¤ÛÈ· Î·È ‰Èı¤ÛÈ·) ‰ËÌÔÙÈο Û¯ÔÏ›· ÙÔ˘ ¢‹ÌÔ˘ ºÈÏÈ·ÙÒÓ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜ ηٿ ÙÔ Û¯ÔÏÈÎfi ¤ÙÔ˜ 2002-2003. ∏ ÌÂϤÙË ·ÊÔÚÔ‡Û Û fiÏ· Ù· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ·ÎÚÈÙÈ΋˜ ˙ÒÓ˘ ÙÔ˘ ÓÔÌÔ‡ Û ¤Ó· Û‡ÓÔÏÔ 33 ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ ÙÔ˘ ¡ÔÌÔ‡ £ÂÛÚˆÙ›·˜. ™˘ÌÌÂÙ›¯·Ó 73 Ì·ıËÙ¤˜ (39 ·ÁfiÚÈ· Î·È 34 ÎÔÚ›ÙÛÈ·) ËÏÈΛ·˜ 7-12 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 9 ¤ÙË). ∏ ηٷÁÚ·Ê‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ ÌÂÙ¿ ·fi ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÂÍ·ÛÊ·Ï›ÛÙËÎÂ Ë Û˘ÁηٿıÂÛË ÙÔ˘ ™˘ÏÏfiÁÔ˘ °ÔÓ¤ˆÓ Î·È ∫ˉÂÌfiÓˆÓ Î¿ı ۯÔÏ›Ԣ ÁÈ· ÙË ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘˜ ÂÂÍÂÚÁ·Û›·. ™ˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ ¶ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ·fi ÙÔÓ Ù‡Ô: ¢ª™ = ‚¿ÚÔ˜ (kg) / ‡„Ô˜ (m)2 Î·È Ë ÂÚÈʤÚÂÈ· Ù˘ ̤Û˘ [¶ª (cm)]. ∆Ô ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ÌÂÙÚ‹ıËΠ̠ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˙˘ÁÔ‡ ‰¿ÊÔ˘˜ (Seca alpha) Ì ·ÎÚ›‚ÂÈ· 100 g. ∏ ̤ÙÚËÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ¯ˆÚ›˜ ˘Ô‰‹Ì·Ù· Î·È Ì ÂÏ·ÊÚ‡ ÈÌ·ÙÈÛÌfi. ∏ ̤ÙÚËÛË ÙÔ˘ ‡„Ô˘˜ ¤ÁÈÓ Û fiÚıÈ· ÛÙ¿ÛË, ¯ˆÚ›˜ ˘Ô‰‹Ì·Ù·, Ì ÙÔ˘˜ ÒÌÔ˘˜ Û ı¤ÛË ·Ó¿·˘Û˘ Î·È Ù· ¿Óˆ ¿ÎÚ· Ó· ·ÈˆÚÔ‡ÓÙ·È ÂχıÂÚ·. ÃÚËÛÈÌÔÔÈ‹ıËΠ·Ó·ÛÙËÌfiÌÂÙÚÔ Û Â›Â‰Ô ÙÔ›¯Ô, Ô˘ Û¯ËÌ¿ÙÈ˙ Ì ÙÔ ‰¿Â‰Ô ÔÚı‹ ÁˆÓ›·. O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ‡„Ô˘˜ ¤ÁÈÓ ÛÙÔ ÏËÛȤÛÙÂÚÔ 0,5 cm. ∏ ÂÚ›ÌÂÙÚÔ˜ Ù˘ ̤Û˘ ÌÂÙÚ‹ıËΠ̠Ï·ÛÙÈ΋ ÌÂÙÚÔÙ·ÈÓ›· (Seca) ÛÙÔ ‡„Ô˜ ÙÔ˘ ÔÌÊ·ÏÔ‡ Î·È Î¿Ùˆ ·fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ (ÛÙÔ Ì¤ÛÔ Ù˘ ·fiÛÙ·Û˘ ÌÂٷ͇ Ï¢ÚÈÎÔ‡ ÙfiÍÔ˘ Î·È Ï·ÁfiÓÈ·˜ ·ÎÚÔÏÔÊ›·˜) (8). ¢ÂÓ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙÔ˘ ÛÙ·‰›Ô˘ ÂÊ˂›·˜ ηٿ Tanner, ÏfiÁˆ ¯ÚÔÓÈÎÔ‡ ÂÚÈıˆÚ›Ô˘ Î·È ‰È·ı¤ÛÈÌÔ˘ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÚÔÛˆÈÎÔ‡ (Ê˘ÛÈο, ·˘Ùfi ·ÔÙÂÏ› ·‰˘Ó·Ì›· Ù˘ ÌÂϤÙ˘). ∂ÚˆÙËÌ·ÙÔÏfiÁÈ· ™Â fiÏ· Ù· ·È‰È¿ Ô˘ Û˘ÌÌÂÙ›¯·Ó ηٷÁÚ¿ÊËÎ·Ó ·Ú¿ÌÂÙÚÔÈ fiˆ˜ Ë ËÏÈΛ·, Ë Û¯ÔÏÈ΋ Ù¿ÍË, ÙÔ Ê‡ÏÔ, Ë Î·Ù·ÁˆÁ‹ (ŒÏÏËÓ˜ ‹ ·ÏÏÔ‰·Ô›) Î·È ÙÔ Â›Â‰Ô ÌfiÚʈÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ. ŸÏ· Ù· ·È‰È¿ ÁÂÓÓ‹ıËÎ·Ó ÛÙËÓ ∂ÏÏ¿‰· ÂÎÙfi˜ ·fi 3 (1 ·ÁfiÚÈ Î·È 2 ÎÔÚ›ÙÛÈ·) Î·È ÁÓÒÚÈ˙·Ó ηϿ ÙËÓ ÂÏÏËÓÈ΋ ÁÏÒÛÛ·. ™ÙË Û˘Ó¤¯ÂÈ·, ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ Î·È ÙˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ÙˆÓ Ì·ıËÙÒÓ Ì ÙË ÌÔÚÊ‹ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘. ™˘ÁÎÂÎÚÈ̤ӷ, ‰fiıËΠÛÙÔ˘˜ Ì·ıËÙ¤˜ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û˘¯ÓfiÙËÙ·˜ ηٷӿψÛ˘ ÙÚÔÊ›ÌˆÓ Î·È Î·Ù·ÁÚ·Ê‹˜ Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ÙÔ ÔÔ›Ô Û˘ÌÏËÚÒıËΠÛÙÔÓ ¯ÒÚÔ ÙÔ˘ Û¯ÔÏ›Ԣ Ì ÙË ‚Ô‹ıÂÈ· ÙˆÓ ÂÎ·È‰Â˘ÙÈÎÒÓ. ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û˘¯ÓfiÙËÙ·˜ ηٷӿψÛ˘ ÙÚÔÊ›ÌˆÓ ‹Ù·Ó ÚfiÙ˘Ô, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙ· ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ï˶·È‰È·ÙÚÈ΋ 2005;68:433-438

ı˘ÛÌÔ‡ Î·È ‰È·ÌÔÚÊÒıËΠ̠‚¿ÛË ÙȘ ȉȷ›ÙÂÚ˜ ÁÓˆÛÙÈΤ˜ ÈηÓfiÙËÙ˜, ·ÏÏ¿ Î·È ÙȘ ÂÈ̤ÚÔ˘˜ ··ÈÙ‹ÛÂȘ ÙÔ˘˜ Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο. ÃÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û˘¯ÓfiÙËÙ·˜ ηٷӿψÛ˘ ÙÚÔÊ›ÌˆÓ ÙˆÓ Willett Î·È Û˘Ó, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙ· ‰Â‰Ô̤ӷ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÂÚÈÔ¯‹˜ (9). ∞Ú¯Èο, Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ÂϤÁ¯ıËΠ۠15 Ì·ıËÙ¤˜, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ˙ËÙ‹ıËÎÂ Î·È Ì›· 24ˆÚË ·Ó¿ÎÏËÛË Î·Ù·Ó¿ÏˆÛ˘ ÙÚÔÊ›ÌˆÓ Ô˘ Û˘ÌÏËÚÒıËΠÛÙÔÓ ¯ÒÚÔ ÙÔ˘ Û¯ÔÏ›Ԣ ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜, ÒÛÙ ӷ ÈÛÙÔÔÈËı› Ë ·ÍÈÔÈÛÙ›· ÙÔ˘. ∂ȉÈÎfiÙÂÚ·, Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÂÚˆÙ‹ÛÂȘ Û¯ÂÙÈο Ì ÙË Ï‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜, ÙËÓ Î·Ù·Ó¿ÏˆÛË ÙÚÔÊ‹˜ ÛÙ· ‰È·Ï›ÌÌ·Ù· Î·È ÙËÓ ‡·ÚÍË Î˘ÏÈΛԢ, ÂÓÒ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó Û˘ÁÎÂÎÚÈ̤ӷ ÙÚfiÊÈÌ· ÁÈ· Ù· ÔÔ›· Ô Î¿ı ̷ıËÙ‹˜ ·Ó¤ÊÂÚ ÙË Û˘¯ÓfiÙËÙ· ηٷӿψÛ˘ ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜. ∆¤ÏÔ˜, ÂÎÙÈÌ‹ıËÎÂ Ë Î·ıËÌÂÚÈÓ‹ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ Ì·ıËÙÒÓ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ·Ú¿ÌÂÙÚÔÈ, fiˆ˜ ÔÈ ÒÚ˜ ·Ó¿·˘Û˘, ÌÂϤÙ˘, ¿ıÏËÛ˘, ·È¯ÓȉÈÔ‡, ÂÚÈ¿ÙÔ˘, ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ Î·È ‚Ú·‰ÈÓÔ‡ ‡ÓÔ˘. ∏ ‰È·ÛÙ·‡ÚˆÛË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Û¯ÂÙÈο Ì ÙȘ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ Î·È ÙȘ ηıËÌÂÚÈÓ¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÙˆÓ Ì·ıËÙÒÓ (ÂχıÂÚÔ˜ ¯ÚfiÓÔ˜, ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ Î.Ï.), ηıÒ˜ Î·È Ì ÙËÓ ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË Î·È ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô ÙˆÓ ÁÔÓ¤ˆÓ, ¤ÁÈÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ Î·È ÛÙÔ Û›ÙÈ, Ì ÙË Û˘ÓÂÚÁ·Û›· ÙˆÓ ÁÔÓ¤ˆÓ. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ŸÏ· Ù· ·È‰È¿ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË Ù·ÍÈÓÔÌ‹ıËÎ·Ó ˆ˜ ÚÔ˜ ÙÔ ‚¿ÚÔ˜ (Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜, ˘¤Ú‚·Ú· Î·È ·¯‡Û·Úη) Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ‰ÈÂıÓÒÓ ÛÙ·ÙÈÛÙÈÎÒÓ ÔÚ›ˆÓ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜, Û‡Ìʈӷ Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (10) (¶›Ó·Î·˜ 1). OÈ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ, fiˆ˜ Ô ¢ª™ Î·È Ë ÂÚ›ÌÂÙÚÔ˜ Ù˘ ̤Û˘, ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË Ù˘ ÌÂÙ·‚ÏËÙ‹˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ Pearson (Pearson correlation coefficient). ™ÙË Û˘Ó¤¯ÂÈ·, ÌÂÏÂÙ‹ıËÎ·Ó ÔÈ Û˘Û¯ÂÙ›ÛÂȘ Ù˘ ·¯˘Û·ÚΛ·˜ Ì Èı·ÓÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ·˘Ù‹, Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÛÙ·ÙÈÛÙÈÎÒÓ ÌÔÓÙ¤ÏˆÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋˜ ·Ó¿Ï˘Û˘ ÏÔÁÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ (logistic regression ¶›Ó·Î·˜ 1. ∆È̤˜ ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™, kg/m2) ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (10) ∏ÏÈΛ· (¤ÙË) 7 7,5 8 8,5 9 9,5 10 10,5 11 11,5 12

À¤Ú‚·Ú· ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· 17,92 18,16 18,44 18,76 19,10 19,46 19,84 20,20 20,55 20,89 21,22

17,75 18,03 18,35 18,69 19,07 19,45 19,86 20,29 20,74 21,20 21,68

¶·¯‡Û·Úη ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· 20,63 21,09 21,60 22,17 22,77 23,39 24,00 24,57 25,10 25,58 26,02

20,63 21,09 21,60 22,17 22,77 23,39 24,00 24,57 25,10 25,58 26,67

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·435

435

¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘

analysis), fiÔ˘ Ë ·ÚÔ˘Û›· ·¯˘Û·ÚΛ·˜ ·ÔÙ¤ÏÂÛ ÙËÓ ÂÍ·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹ (dependent variable) Î·È ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ Û¯ÂÙÈÎÔ› ÏfiÁÔÈ Û˘ÌÏËڈ̷ÙÈÎÒÓ Èı·ÓÔÙ‹ÙˆÓ (odds ratio - OR) Î·È Ù· ·ÓÙ›ÛÙÔȯ· 95% ‰È·ÛÙ‹Ì·Ù· ÂÌÈÛÙÔÛ‡Ó˘ (confidence interval) ÁÈ· ÙȘ Û˘ÌÌÂÙ·‚ÏËÙ¤˜ (covariates). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̠ÙË ‚Ô‹ıÂÈ· ÙˆÓ ÛÙ·ÙÈÛÙÈÎÒÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ SPSS 10.0 for Windows (SPSS Inc., 1989-1999) Î·È Statistica (1998, Statsoft, Inc. Tulsa, OK, USA).

∞ÔÙÂϤÛÌ·Ù· ∏ Ù·ÍÈÓfiÌËÛË ÙˆÓ Ì·ıËÙÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË, Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÙÚ‹ÛˆÓ, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. OÈ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ. ™˘ÁÎÂÎÚÈ̤ӷ, Ô ¢ª™ ‹Ù·Ó 18,5±4,9 kg/m2 ÛÙ· ·ÁfiÚÈ· Î·È 18,4±5 kg/m2 ÛÙ· ÎÔÚ›ÙÛÈ·, ÂÓÒ Ë ¶ª ‹Ù·Ó 66±13 cm ÛÙ· ·ÁfiÚÈ· Î·È 65±12 cm ÛÙ· ÎÔÚ›ÙÛÈ·. À‹Ú¯Â ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ¢ª™ Î·È Ù˘ ¶ª (r=0,92331, p<0,0001) (∂ÈÎfiÓ· 1).

¶›Ó·Î·˜ 2. ™ˆÌ·ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ÌÂϤÙ˘ (n=73) ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ™‡ÓÔÏÔ n (%) n (%) n (%) À¤Ú‚·Ú· 13 (33) ¶·¯‡Û·Úη (¢ª™) 9 (23) ¶·¯‡Û·Úη (¶ª) 6 (15) ¶ÏËı˘ÛÌfi˜ Ù˘ ÌÂϤÙ˘ 39 (53)

11 (32) 24 (33) 8 (23) 17 (23) 5 (15) 11 (15) 34 (47) 73 (100)

BMI vs. WAIST WAIST= .21937 + .02364 * BMI r= .92331

∂ӉȷʤÚÔÓÙ· Â˘Ú‹Ì·Ù· ÚԤ΢„·Ó ·fi ÙË ÌÂϤÙË ‰‡Ô ÌÔÓÙ¤ÏˆÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋˜ ·Ó¿Ï˘Û˘ ÏÔÁÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ (backward stepwise likelihood ratio) (¶›Ó·Î·˜ 3): ™ÙÔ ÚÒÙÔ ÌÔÓÙ¤ÏÔ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÔÈ ·Ú¿ÌÂÙÚÔÈ: ËÏÈΛ·, ʇÏÔ, Ù¿ÍË, ÌÔÚʈÙÈÎfi Â›Â‰Ô ÁÔÓ¤ˆÓ, ηٷÁˆÁ‹, ÒÚ˜ ÌÂϤÙ˘, ÂχıÂÚÔ˜ ¯ÚfiÓÔ˜/·È¯Ó›‰È, ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘. ¶·Ú·ÙËÚ‹ıËÎÂ Û˘Û¯¤ÙÈÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ Ì ÙË Û¯ÔÏÈ΋ Ù¿ÍË [OR 1,950, 95% CI (1,1653,265), p=0,011] Î·È ÙȘ ÒÚ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÙËÏÂfiÚ·Û˘ [OR 1,425, 95% CI (1,026-1,979), p=0,035], ÂÓÒ ÔÈ Â͈ۯÔÏÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙÔÓ ÂχıÂÚÔ ¯ÚfiÓÔ ¤ÙÂÈÓ·Ó Ó· ¤¯Ô˘Ó ¢ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ‰È·Ù‹ÚËÛË ÂÈı˘ÌËÙÔ‡ ÁÈ· ÙËÓ ËÏÈΛ· ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ [OR 0,243, 95% CI (0,053-1,116), p=0,069]. ™ÙÔ ‰Â‡ÙÂÚÔ ÌÔÓÙ¤ÏÔ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÔÈ ·Ú¿ÌÂÙÚÔÈ: ËÏÈΛ·, ʇÏÔ, ηٷӿψÛË ÛÔÎÔÏ¿Ù·˜ (·ÚÈıÌfi˜/Ë̤ڷ), Á¿Ï· (ÔÙ‹ÚÈ·/Ë̤ڷ), ÙÔÛÙ, Ï‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜, ηٷӿψÛË ÙËÁ·ÓËÙÒÓ ·Ù·ÙÒÓ, ·˘ÁÒÓ Î·È ÊÚÔ‡ÙˆÓ. µÚ¤ıËÎÂ Û˘Û¯¤ÙÈÛË Ì ÙËÓ Î·Ù·Ó¿ÏˆÛË ÛÔÎÔÏ¿Ù·˜ [OR 1,071, 95% CI (1,014-1,131), p=0,014] Î·È ÙËÓ Î·Ù·Ó¿ÏˆÛË ÙÔÛÙ [OR 1,058, 95% CI (1,012-1,106), p=0,013], ÂÓÒ Ê¿ÓËΠfiÙÈ Ë Ï‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜ ¤¯ÂÈ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ [OR 0,183, 95% CI (0,033-1,020), p=0,05]. ∏ ÙÂÏÂ˘Ù·›· Û˘Û¯¤ÙÈÛË ‹Ù·Ó ÛÙ· fiÚÈ· Ù˘ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ˆ˜ ÚÔ˜ ÙËÓ Î·Ù·Ó¿ÏˆÛË ¿ÏÏÔ˘ ›‰Ô˘˜ ÙÚÔÊ›ÌˆÓ (.¯. ÎfiÎÎÈÓÔ˘ ÎÚ¤·ÙÔ˜, Ô˘ÏÂÚÈÎÒÓ, „·ÚÈÒÓ, Á·Ï·ÎÙÔÎÔÌÈÎÒÓ, ÂÏ·ÈfiÏ·‰Ô˘). ∞fi ÙË ÌÂϤÙË ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ηٷÁÚ¿ÊËηÓ, ÒÛÙ ӷ ÏËÊıÔ‡Ó ˘’ fi„ÈÓ Û˘Á¯˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÙȘ Û˘Û¯ÂÙ›ÛÂȘ, ‰ÂÓ ÚԤ΢„·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜.

1,1 1,0

0,8

¶›Ó·Î·˜ 3. ∞ÔÙÂϤÛÌ·Ù· ÔÏ˘·Ú·ÁÔÓÙÈ΋˜ ·Ó¿Ï˘Û˘ ÏÔÁÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ ·¯‡Û·ÚÎˆÓ Î·È ÓÔÚÌÔ‚·ÚÒÓ ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ (backward stepwise likelihood ratio)

0,7

¶·Ú¿ÌÂÙÚÔÈ

0,6

ªÔÓÙ¤ÏÔ 1 ™¯ÔÏÈ΋ Ù¿ÍË ÃÚfiÓÔ˜ ÙËÏÂı¤·Û˘ (ÒÚ˜) ∂χıÂÚÔ˜ ¯ÚfiÓÔ˜ (ÒÚ˜) ªÔÓÙ¤ÏÔ 2 ∫·Ù·Ó¿ÏˆÛË ÛÔÎÔÏ¿Ù·˜ ∫·Ù·Ó¿ÏˆÛË ÙÔÛÙ §‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜

WAIST

0,9

0,5 0,4 10

14

18

22

26

30

34

38

BMI

∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (BMI) Î·È ÂÚÈʤÚÂÈ·˜ ̤Û˘ (WAIST).

Odds ratio (95% CI)* p 1,950 (1,165-3,265) 0,011 1,425 (1,026-1,979) 0,035 0,243 (0,053-1,116) 0,069 1,071 (1,014-1,131) 0,014 1,058 (1,012-1,106) 0,013 0,183 (0,033-1,020) 0,05 ¶·È‰È·ÙÚÈ΋ 2005;68:433-438

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·436

436

¶. ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜ Î·È Û˘Ó.

™˘˙‹ÙËÛË OÈ ·ÏÏ·Á¤˜ ÙÔ˘ ÙÚfiÔ˘ ˙ˆ‹˜ Î·È Ë ˘ÈÔı¤ÙËÛË ‰˘ÙÈÎÒÓ ÚÔÙ‡ˆÓ ‰È·ÙÚÔÊ‹˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ·‡ÍËÛË Ù˘ Â›ÙˆÛ˘ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ÛÙËÓ ∂ÏÏ¿‰· (2). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ÂȂ‚·ÈÒÓÔ˘Ó Ù· Â˘Ú‹Ì·Ù· ÚÔËÁÔ‡ÌÂÓˆÓ ÌÂÏÂÙÒÓ, Ù· ÔÔ›· ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ Úfi‚ÏËÌ· Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ‰ÂÓ ÂÚÈÔÚ›˙ÂÙ·È ÌfiÓÔ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜, ·ÏÏ¿ ·ÊÔÚ¿ Î·È ÛÙȘ ·ÔÌ·ÎÚ˘Ṳ̂Ó˜ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Ì·˜ (11,12). °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÙfiÛÔ Ô Î·ıÈÂڈ̤ÓÔ˜ ¢ª™ fiÛÔ Î·È Ë ¶ª. À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë ¶ª ·ÔÙÂÏ› Ôχ ηÏfi ‰Â›ÎÙË Ù˘ ηٷÓÔÌ‹˜ Ï›Ô˘˜ Î·È ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÙˆÓ ·È‰ÈÒÓ ÌÂ Û˘Ó˘¿Ú¯ÔÓÙ˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Ë ‰˘ÛÏÈȉ·ÈÌ›·, Ë ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· Î·È Ë ·ÚÔ˘Û›· ·˘ÍËÌ¤ÓˆÓ ÙÈÌÒÓ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (11,13-16). ™¯ÂÙÈο ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ¶ª ·ÔÙÂÏ› ÙÔÓ Î·Ï‡ÙÂÚÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi (17). øÛÙfiÛÔ, ·Ú·Ì¤ÓÂÈ ·Ó·¿ÓÙËÙÔ ÙÔ ÂÚÒÙËÌ· Â¿Ó Ë ¶ª ·ÔÙÂÏ› ÂÍ›ÛÔ˘ ηÏfi ‰Â›ÎÙË Ì ÙÔÓ ¢ª™ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ¶ª Î·È ÙÔ˘ ¢ª™ ÛÙ· ·È‰È¿. ¶Ú¿ÁÌ·ÙÈ, Û ̛· ÚfiÛÊ·ÙË ÌÂϤÙË Û ·È‰È¿ Ù˘ ·ÁÚÔÙÈ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ¶ª ¤¯ÂÈ ÛÙÂÓ‹ Û¯¤ÛË Ì ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÛÙ· ·È‰È¿ - fiˆ˜ Î·È Ô ¢ª™ - Î·È Â›Ó·È È‰È·›ÙÂÚ· ‡¯ÚËÛÙÔ˜ ‰Â›ÎÙ˘ ηıÒ˜ ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ‡ÎÔÏ˘ ̤ÙÚËÛ˘ (8,11). ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, fiÙ·Ó ÂÏ‹ÊıË ˘’ fi„ÈÓ Ë ¶ª, ·ÓȯÓ‡ÙËÎ·Ó 6 ·fi Ù· 9 ·¯‡Û·Úη ·ÁfiÚÈ· Î·È 5 ·fi Ù· 8 ÎÔÚ›ÙÛÈ· ‹ 11 ·fi Ù· 17 Û˘ÓÔÏÈο ·¯‡Û·Úη ·È‰È¿. ¢ËÏ·‰‹, Ë Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 64,7%, ÂÓÒ Ë ÂȉÈÎfiÙËÙ¿ Ù˘ Â›Ó·È Ôχ ˘„ËÏ‹, ηıÒ˜ fiÏ· Ù· ·È‰È¿ Ô˘ ›¯·Ó ¶ª ·˘ÍË̤ÓË Â›¯·Ó Î·È ·ıÔÏÔÁÈÎfi ¢ª™. ™˘ÓÂÒ˜, Ë ¶ª ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙÔÓ ¢ª™ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·¯˘Û·ÚΛ·˜, ÂÓÒ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÈÏÔÙÈ΋˜ ÌÂϤÙ˘ ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙË ‰È·Ù‡ˆÛË ÔÚÈÛÙÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ. ∞Ó Î·È Ë ¶ª ıˆÚÂ›Ù·È ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÂÚÈÛÛfiÙÂÚÔ ÂȉÈÎfi˜ ‰Â›ÎÙ˘ ÈÓÛÔ˘ÏÈÓÔ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Î·È Û˘Û¯Â¶·È‰È·ÙÚÈ΋ 2005;68:433-438

Ù›˙ÂÙ·È Ì ·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÈÔ ÈÛ¯˘Ú¿ Û ۇÁÎÚÈÛË Ì ÙÔÓ ¢ª™ (11,13-17), ·˘Ùfi ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ·ÎfiÌË ·Ô‰ÂÎÙfi. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ‰ÂÓ ÂÎÙÈÌ‹ıËÎ·Ó ¿ÏÏ· ÛÙÔȯ›· ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÏËÓ Ù˘ ·¯˘Û·ÚΛ·˜. ÕÚ·, Ë ¶ª ÌÔÚ› Ó· Â›Ó·È ¤Ó·˜ ¯Ú‹ÛÈÌÔ˜ ‰Â›ÎÙ˘ Î·È Ó· Ï·Ì‚¿ÓÂÙ·È ·Ú¿ÏÏËÏ· Ì ÙÔÓ ¢ª™, ˆÛÙfiÛÔ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙÔÓ ¢ª™ Û ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜.

O Û‡Á¯ÚÔÓÔ˜ ÙÚfiÔ˜ ˙ˆ‹˜, Ë ÂÚÈÔÚÈṲ̂ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ë ÛÙ¿ÛË ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙˆÓ ÂÎ·È‰Â˘ÙÈÎÒÓ Û ı¤Ì·Ù· ‰È·ÙÚÔÊ‹˜ ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ˘ÈÔı¤ÙËÛË ˘ÁÈÂÈÓÒÓ ‰È·ÈÙËÙÈÎÒÓ ÚÔÙ‡ˆÓ ·fi Ù· ·È‰È¿. O ÂÈÔÏ·ÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙ· ·È‰È¿ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ Ù¿ÍÂˆÓ ÙÔ˘ Û¯ÔÏ›Ԣ. º·›ÓÂÙ·È fiÙÈ Ë ·‡ÍËÛË ÙˆÓ Û¯ÔÏÈÎÒÓ ˘Ô¯ÚÂÒÛÂˆÓ Î·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘ Î·È Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÌÂÙ·‚ÔÏ‹ ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ, ·ÔÙÂÏÔ‡Ó ‰˘ÛÌÂÓ›˜ ·Ú¿ÁÔÓÙ˜ Ì ·ıÚÔÈÛÙÈ΋ ‰Ú¿ÛË ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ËÏÈÎÈÒÓ. ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë ‡·ÚÍË ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘ ·ÔÙÂÏ› ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙË Ì›ˆÛË Ù˘ ·¯˘Û·ÚΛ·˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi Â›Ó·È ÏÔÁÈÎfi, ηıÒ˜ Ë ÂÓ·Û¯fiÏËÛË Ì ÙÔ ·È¯Ó›‰È Î·È ÙȘ ·ıÏÔ·È‰È¤˜ Î·È Ë Ì›ˆÛË Ù˘ Û˘Ó¯ԇ˜ ÚfiÛÏ˄˘ ÌÈÎÚÔÁÂ˘Ì¿ÙˆÓ ‚ÔËıÔ‡Ó ÛÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (18,19). ∞ÓÙ›ıÂÙ·, ÛÙË ÌÂϤÙË ÂȂ‚·ÈÒÓÂÙ·È fiÙÈ Ë ˘ÈÔı¤ÙËÛË ÙˆÓ Û‡Á¯ÚÔÓˆÓ ÚÔÙ‡ˆÓ Ù˘ ηıÈÛÙÈ΋˜ ˙ˆ‹˜ - ÙÔ ÏÂÁfiÌÂÓÔ “Û‡Ó‰ÚÔÌÔ ÙÔ˘ ηӷ¤” - Î·È Ë ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ (20,21). π‰È·›ÙÂÚ· ÛËÌ·ÓÙÈο ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Â›Ó·È Ù· ÚfiÙ˘· ‰È·ÙÚÔÊ‹˜ Î·È ÔÈ Û˘Ó‹ıÂȘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (7). ∏ ·Ú¿ÏÂÈ„Ë ÙÔ˘ ÚˆÈÓÔ‡ Á‡̷ÙÔ˜ ·ÔÙÂÏ› ÎÔÈÓ‹ Ú·ÎÙÈ΋ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. Ÿˆ˜ ‰È·ÈÛÙÒÓÂÙ·È ·fi Ù· ‰Â‰Ô̤ӷ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë ÂÈÌÔÓ‹ ÛÙË Ï‹„Ë ÚˆÈÓÔ‡ Á‡̷ÙÔ˜ Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË ÁÈ· Ù· ·È‰È¿ Î·È ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·¯˘Û·ÚΛ·˜ (22,23). ∆· ·È‰È¿ Ô˘ ·›ÚÓÔ˘Ó ÚˆÈÓfi Û˘Ó‹ıˆ˜ ‰ÂÓ Âȉ›‰ÔÓÙ·È ÛÙËÓ Î·Ù·Ó¿ÏˆÛË ÚÔ˚fiÓÙˆÓ ÙÔ˘ ΢ÏÈΛԢ ÙÔ˘ Û¯ÔÏ›Ԣ, ¤¯Ô˘Ó Â·Ú΋ ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë Î·È ÈηÓÔÔÈËÙÈÎfi ·›ÛıËÌ· ÎÔÚÂÛÌÔ‡.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·437

437

¶·È‰È΋ ·¯˘Û·ÚΛ· Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘

∞ÓÙ›ıÂÙ·, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë Î·Ù·Ó¿ÏˆÛË ÛÔÎÔÏ¿Ù·˜ Î·È ÙÔÛ٠ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰È·ÏÂÈÌÌ¿ÙˆÓ Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ (24).

O ÂÈÔÏ·ÛÌfi˜ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜, ·ÎfiÌË Î·È ÛÙȘ ·ÎÚÈÙÈΤ˜ ·Ú·ÌÂıfiÚȘ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Ì·˜. ∏ ˘ÈÔı¤ÙËÛË ÙˆÓ ‰˘ÙÈÎÒÓ ÚÔÙ‡ˆÓ ‰È·ÙÚÔÊ‹˜, Ë Ì›ˆÛË Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙÔ˘ ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘, Ë Î·ıÈÛÙÈ΋ ˙ˆ‹ Î·È Ë ·˘ÍË̤ÓË ¤ÎıÂÛË ÛÙËÓ ÙËÏÂfiÚ·ÛË ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ ÛÙÔ˘˜ Ì·ıËÙ¤˜ ÙÔ˘ Û¯ÔÏ›Ԣ. ∂›Ó·È, ÏÔÈfiÓ, ÚÔÊ·Ó‹˜ Ë ·Ó·ÁηÈfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÓË̤ڈÛ˘ ÁÔÓ¤ˆÓ, ·È‰ÈÒÓ Î·È ÂÎ·È‰Â˘ÙÈÎÒÓ Î·È ·Ó¿Ù˘Í˘ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ·ÁˆÁ‹˜ ˘Á›·˜ ÛÙÔÓ ¯ÒÚÔ ÙÔ˘ Û¯ÔÏ›Ԣ.

∞Ó·ÁÓÒÚÈÛË ∏ ÌÂϤÙË ¯ÚËÌ·ÙÔ‰ÔÙ‹ıËΠ·fi ÙÔ ÿ‰Ú˘Ì· ∂ıÓÈ΋˜ ¡ÂfiÙËÙ·˜ (π∂¡).

µÈ‚ÏÈÔÁÚ·Ê›· 1. Schwartz MB, Puhl R. Childhood obesity: a societal problem to solve. Obes Rev 2003;4:57-71.

2. Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obes Relat Metab Disord 1996;20:488492.

3. Dietz WH. Childhood weight affects adult morbidity and mortality. J Nutr 1998;128 (2 Suppl):S411S414.

4. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167-177.

5. Hill JO, Trowbridge FL. Childhood obesity: future directions and research priorities. Pediatrics 1998;101:570-574.

6. Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. Br Med J 2001;323:1029-1032.

7. ª·ÓÈfi˜ °, ªÔÛ¯·Ó‰Ú¤· π, ÷Ù˙‹˜ Ã, ∫·Ê¿ÙÔ˜ ∞. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ Û ·È‰È¿ ‰ËÌÔÙÈÎÔ‡ Ù˘ ∫Ú‹Ù˘ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÂÍ·ÂÙÔ‡˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ·ÁˆÁ‹˜ ˘Á›·˜. ¶·È‰È·ÙÚÈ΋ 2002;65:66-76.

8. ∫·Ê¿ÙÔ˜ ∞, ª·ÓÈfi˜ °, ÷Ù˙‹˜ Ã, ªÔÛ¯·Ó‰Ú¤· π, ª·ÏˆÌÂÓ¿ÎË ∂, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢ Î·È Û˘Ó. ∞ÍÈÔÏfiÁËÛË ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∞ÁˆÁ‹˜ ÀÁ›·˜ ÌÂÙ¿ ·fi ÙÚ›· ¯ÚfiÓÈ· ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙ· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ∫Ú‹Ù˘. ¶·È‰È·ÙÚÈ΋ 1998;61:483-497.

9. Willett WC, Sampson L, Stampfer MJ, Rosner B, Bain C, Witschi J et al. Reproducibility and validity of a semiquantitative food frequency questionnaire.

Am J Epidemiol 1985;122:51-65.

10. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. Br Med J 2000;320:1240-1243.

11. ªÔÛ¯·Ó‰Ú¤· π, ÷Ù˙‹˜ Ã, ª·ÌÌ¿˜ π, ªÂÚÙÛÈ¿˜ °, §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.

12. Krassas GE, Tzotzas T, Tsametis C, Konstantinidis T. Prevalence and trends in overweight and obesity among children and adolescents in Thessaloniki, Greece. J Pediatr Endocrinol Metab 2001;14 (5 Suppl):S1319-S1326.

13. Maffeis C, Pietrobelli A, Grezzani A, Provera S, Tato L. Waist circumference and cardiovascular risk factors in prepubertal children. Obes Res 2001;9:179-187.

14. Savva SC, Tornaritis M, Savva ME, Kourides Y, Panagi A, Silikiotou N et al. Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord 2000;24:1453-1458.

15. Freedman DS, Serdula MK, Srinivasan SR, Berenson GS. Relation of circumferences and skinfold thicknesses to lipid and insulin concentrations in children and adolescents: the Bogalusa Heart Study. Am J Clin Nutr 1999;69:308-317.

16. Dobbelsteyn CJ, Joffres MR, MacLean DR, Flowerdew G. A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. Int J Obes Relat Metab Disord 2001;25:652-661.

17. Moreno LA, Pineda I, Rodriguez G, Fleta J, Sarria A, Bueno M. Waist circumference for the screening of the metabolic syndrome in children. Acta Paediatr 2002;91:1307-1312.

18. Manios Y, Kafatos A, Mamalakis G. The effects of a health education intervention initiated at first grade over a 3 year period: physical activity and fitness indices. Health Educ Res 1998;13:593-606.

19. Tremblay MS, Willms JD. Is the Canadian childhood obesity epidemic related to physical inactivity?

Int J Obes Relat Metab Disord 2003;27:1100-1105.

20. Robinson TN. Television viewing and childhood obesity. Pediatr Clin North Am 2001;48:1017-1025.

21. Lowry R, Wechsler H, Galuska DA, Fulton JE, Kann L. Television viewing and its associations with overweight, sedentary lifestyle, and insufficient consumption of fruits and vegetables among US high school students: differences by race, ethnicity, and gender. J Sch Health 2002;72:413-421.

22. Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United States from 1965-1991. Am J Clin Nutr 1998;67:S748-S756. ¶·È‰È·ÙÚÈ΋ 2005;68:433-438

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·438

438

¶. ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜ Î·È Û˘Ó.

23. Ortega RM, Requejo AM, Lopez-Sobaler AM, Quintas ME, Andres P, Redondo MR et al. Difference in the breakfast habits of overweight/obese and normal weight schoolchildren. Int J Vitam Nutr Res 1998;68:125-132.

¶·È‰È·ÙÚÈ΋ 2005;68:433-438

24. Matthiessen J, Fagt S, Biltoft-Jensen A, Beck AM, Ovesen L. Size makes a difference. Public Health Nutr 2003;6:65-72.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·439

ORIGINAL ARTICLE

439

Risk factors for obesity in elementary school children in the Greek border region of Thesprotia P. D. Angelopoulos1, J. Manios2, H. J. Milionis1

Abstract Background: Lack of physical activity and the adoption of unhealthy dietary habits constitute the principal risk factors for children’s obesity in the developed countries. This is a pilot study recording dietary habits and physical activity and their correlations with obesity in children of school age in the border area of the Prefecture of Thesprotia.

Methods: A total 73 students (39 boys and 34 girls), aged 7-12 years, pupils of seven municipal elementary schools in the Prefecture of Thesprotia, participated in the study during the school period 2002-2003. Body mass index (BMI) and waist circumference (WC) were measured in all participants.

In addition, a questionnaire on the frequency of consumption of various foods and physical activity was completed for each child.

1 Department of Internal Medicine, Medical School, University of Ioannina 2 Department of Dietetics and Nutritional Science, Harokopio University of Athens Correspondence: Haralampos J. Milionis Department of Pathology, Medical School, University of Ioannina 451 10, Ioannina E-mail: hmilioni@cc.uoi.gr Date of submission: 03-02-2004 Date of approval: 31-05-2005

Results: A positive correlation was found between BMI and WC (r=0.92331, p<0.0001). In multivariate logistic regression analysis, obesity was positively associated with the school class [odds ratio - OR 1.950, 95% confidence interval - CI (1.165-3.265), p=0.01], television-viewing hours [OR 1.425, 95% CI (1.026-1.979), p=0.03], toast [OR 1.058, 95% CI (1.012-1.106), p=0.01] and chocolate consumption [OR 1.071, 95% CI (1.014-1.131), p=0.014]. Eating breakfast appeared to have protective role [OR 0.183, 95% CI (0.033-1.020), p=0.05].

Conclusions: Adoption of unhealthy dietary habits, decrease in physical activity, sedentary lifestyle and increase in television-viewing time constitute significant predictors of obesity in children of school age in the rural border regions of Greece.

Key words Obesity, risk factors, body mass index, waist circumference, diet, free time, television-viewing.

Paediatriki 2005;68:439

Pediatr Nov-Dec 05

12-12-05

440

15:16

™ÂÏ›‰·440

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

ÕÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Û ¿Û¯ÔÓÙ˜ ·fi ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ∞. ∫Ô‡ÛË1, ª. OÈÎÔÓfiÌÔ˘1, ¢. ∫·Û›ÌÔ˜2, ¶. ¶ÏÈ¿ÎË3, ª. ∞ı·Ó·Û›Ô˘ - ªÂÙ·Í¿1 1 ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜, ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¢ËÌÔÎÚ›ÙÂÈÔ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô £Ú¿Î˘ 3 ∫¤ÓÙÚÔ ∞ÈÌÔ‰ÔÛ›·˜, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ªÈÚ¿ÓÙ· ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 ∆.∫. 546 42, £ÂÛÛ·ÏÔÓ›ÎË E-mail: miranda@med.auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-09-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-04-2005

¶·È‰È·ÙÚÈ΋ 2005;68:440-444

¶ÂÚ›ÏË„Ë ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ÔÌfi˙˘ÁË ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Î·È ÂΉ‹ÏˆÛË ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ (·ÏÏÔ- Î·È ·˘ÙÔ¿ÓÔÛ˘, ·ÓÙ›ÛÙÔȯ·). ™ÎÔfi˜ Ù˘ ÂÚÈÁÚ·Ê‹˜ Â›Ó·È Ó· ÙÔÓÈÛÙÔ‡Ó Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ Û˘Ó‡·Ú͢ ¿ÓÔÛ˘ ÌÂ Û˘ÁÁÂÓ‹ ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Î·È Ù· ÎÏÈÓÈο Î·È ıÂÚ·¢ÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Î·Ù¿ ÙË Û˘Ó‡·ÚÍË ÙˆÓ ‰‡Ô ÓÔÛÔÏÔÁÈÎÒÓ ÔÓÙÔًوÓ. §¤ÍÂȘ ÎÏÂȉȿ ‚-ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ·ÏÏÔ·ÓÔÛÔÔ›ËÛË, ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ·ÓÙ›‰Ú·ÛË Coombs.

∂ÈÛ·ÁˆÁ‹

¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛˆÓ

∏ ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· (‚-ª∞) Â›Ó·È Ì›· ÁÂÓÂÙÈο ηıÔÚÈ˙fiÌÂÓË ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ ··ÈÙÂ›Ù·È Ë ÂÊ·ÚÌÔÁ‹ ‰È¿ ‚›Ô˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛˆÓ. ™Â ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜, ÔÈ Ù·ÎÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ Ô‰ËÁÔ‡Ó ÛÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ Í¤ÓˆÓ ÚÔ˜ ÙÔÓ ÔÚÁ·ÓÈÛÌfi ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË Î·È ÙËÓ Â›Ù·ÛË Ù˘ ‹‰Ë ˘¿Ú¯Ô˘Û·˜ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. ∏ ·ÏÏÔ·ÓÔÛÔÔ›ËÛË Û ÂÚ˘ıÚÔ΢ÙÙ·ÚÈο ·ÓÙÈÁfiÓ·, ÂÎÙfi˜ ÙˆÓ ∞µ√ Î·È D, Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Û˘¯Ó‹ Û ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ (1,2). ∞ÓÂÍ·Úًو˜ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ ÏfiÁˆ ÌÂÙ¿ÁÁÈÛ˘ ·›Ì·ÙÔ˜ ·Û‡Ì‚·ÙÔ˘ ˆ˜ ÚÔ˜ οÔÈÔ ·ÓÙÈÁÔÓÈÎfi Û‡ÛÙËÌ·, ÔÈ ı·Ï·ÛÛ·ÈÌÈÎÔ› ·ÛıÂÓ›˜ ÂÓ‰¤¯ÂÙ·È Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ·˘ÙÔ·ÓÔÛÔÔ›ËÛË ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ÙÔ˘˜ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎÒÓ ·ÓÙÈÁfiÓˆÓ (3). ∞Ó Î·È Ù· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· ·Ú·ÙËÚÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û ۯ¤ÛË Ì ٷ ·ÏÏÔ·ÓÙÈÛÒÌ·Ù·, Ë ·ÚÔ˘Û›· ÙÔ˘˜ ‰‡Ó·Ù·È Ó· Ô‰ËÁ‹ÛÂÈ Û Ì›ˆÛË Ù˘ ˙ˆ‹˜ ÙˆÓ ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ, Ì ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË ·ÈÌfiÏ˘Û˘ (4). ∞ÎÔÏÔ˘ı› Ë ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛÂˆÓ ·È‰ÈÒÓ Ì ‚-ª∞ Î·È ÂΉ‹ÏˆÛË ·ÏÏÔ- Î·È ·˘ÙÔ·ÓÔÛÔÔ›ËÛ˘, ·ÓÙ›ÛÙÔȯ·, Ì ÛÎÔfi Ó· ÙÔÓÈÛÙÔ‡Ó Ù· ÎÏÈÓÈο Î·È ıÂÚ·¢ÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ÂÓ‰¤¯ÂÙ·È Ó· ÚÔ·„Ô˘Ó ·fi ÙË Û˘Ó‡·ÚÍË ¿ÓÔÛ˘ ÌÂ Û˘ÁÁÂÓ‹ ¯ÚfiÓÈ· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·.

¶ÂÚ›ÙˆÛË ÚÒÙË ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 6 ÂÙÒÓ, Ì ÚfiÛÊ·Ù· ‰È·ÁÓˆṲ̂ÓË ‚-ª∞, ·Ú·¤ÌÊıËΠ·fi ÂÚÈÊÂÚÈÎfi ÓÔÛÔÎÔÌÂ›Ô Ù˘ µ. ∂ÏÏ¿‰·˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ‰Â‡ÙÂÚÔ ·È‰› Ê·ÈÓÔÌÂÓÈο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ë ÌËÙ¤Ú· ·Ó·Ê¤ÚÂÙ·È ÊÔÚ¤·˜ ‚ª∞ Î·È Ô ·Ù¤Ú·˜ Ê˘ÛÈÔÏÔÁÈÎfi˜. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÂÙ·È ¤ÏÂÁ¯Ô˜ ÛÏËÓÔÌÂÁ·Ï›·˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Û ÓÔÛÔÎÔÌÂ›Ô Ù˘ °ÂÚÌ·Ó›·˜, ÛÙËÓ fiÏË fiÔ˘ Ë ÌÈÎÚ‹ ·ÛıÂÓ‹˜ ÁÂÓÓ‹ıËÎÂ Î·È ‰È¤ÌÂÓ ٷ ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Ù˘, Ì ‰È¿ÁÓˆÛË ÂÙÂÚfi˙˘Á˘ ‚ª∞. ∏ ·ÚÔ‡Û· ÓfiÛÔ˜ ÍÂΛÓËÛ 20 Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ÎÏÈÓÈ΋, Ì ÙË ‰È·›ÛÙˆÛË - ·fi ȉÈÒÙË ·È‰›·ÙÚÔ - ˆ¯ÚfiÙËÙ·˜, ÛÏËÓÔÌÂÁ·Ï›·˜ Î·È ÚÔÛˆ›Ԣ ‚-ª∞. ∏ ·ÛıÂÓ‹˜ ·Ú·¤ÌÊıËΠÛÙËÓ ÎÏÈÓÈ΋, fiÔ˘ ‰È·ÈÛÙÒıËΠ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÌÔÁÁÔÏÔÂȉ¤˜ ÚÔÛˆ›Ô, ÎÔÓÙfi ·Ó¿ÛÙËÌ· (Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ 104 cm, <3Ë ∂£), Ë·ÙÔÌÂÁ·Ï›· (4 cm) Î·È ÛÏËÓÔÌÂÁ·Ï›· (9 cm). ∫·Ù¿ ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ë ËÏÂÎÙÚÔÊfiÚËÛË ‹Ù·Ó Ù˘È΋ ÔÌfi˙˘Á˘ ‚-ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜ (HbF 98,5%, HbA2 1,5%) Î·È Ô ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ codon 39/IVS-1n.1 (‚0/‚0). ∏ ·ÎÙÈÓÔÁÚ·Ê›· ÎÚ·Ó›Ô˘ ¤‰ÂÈÍ ÁÂÓÈÎÂ˘Ì¤ÓË ·Ê·Ï¿ÙˆÛË Ì „ËÎÙÚÔÂȉ‹ ·Ú˘Ê‹, ÂÈÎfiÓ· ¯·Ú·ÎÙËÚÈÛÙÈ΋ Ù˘ ÔÌfi˙˘Á˘ ‚-ª∞, ÂÓÒ Ë ÔÛÙÈ΋ ËÏÈΛ· ·ÓÙÈÛÙÔȯԇÛ Û ·È‰› ËÏÈΛ·˜ 3 ÂÙÒÓ. OÈ ·ÓÙȉڿÛÂȘ Coombs, ¿ÌÂÛË Î·È ¤ÌÌÂÛË, ‹Ù·Ó

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·441

441

ÕÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·

·ÚÓËÙÈΤ˜. ∏ ËÏÂÎÙÚÔÊfiÚËÛË Hb ·ÌÊfiÙÂÚˆÓ ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Ù˘È΋ ÂÙÂÚfi˙˘Á˘ ‚-ª∞. ªÂ ‚¿ÛË ÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜ Ù˘ ·ÛıÂÓÔ‡˜ [O Rh(-) ce Du(-) Cw(-) K(-)] Î·È Û‡Ìʈӷ Ì ÙȘ ‰ÈÂıÓ›˜ Ô‰ËÁ›Â˜, ÍÂΛÓËÛ ÚfiÁÚ·ÌÌ· ÌÂÙ¿ÁÁÈÛ˘ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Û˘Ì‚·ÙÒÓ ˆ˜ ÚÔ˜ Ù· ·ÓÙÈÁÔÓÈο Û˘ÛÙ‹Ì·Ù· ∞µO, Rh Î·È Kell, ¯ˆÚ›˜ ˆÛÙfiÛÔ, ¿ÓÔ‰Ô ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ Hb (4,5-5 g/dl). ŒÓ·Ó Ì‹Ó· ÌÂÙ¿ Î·È ·ÊÔ‡ ›¯·Ó ÚÔËÁËı› ÙÚÂȘ ÌÂÙ·ÁÁ›ÛÂȘ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ, Ë ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË Coombs ıÂÙÈÎÔÔÈ‹ıËΠ[C3d (+)], fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ ·Ó‡ÚÂÛË Û˘Ì‚·ÙÒÓ ÌÔÓ¿‰ˆÓ ·›Ì·ÙÔ˜ ¤ÁÈÓ ÂÍ·ÈÚÂÙÈο ‰˘Û¯ÂÚ‹˜ Î·È Ì ÙË ‰È¿ÁÓˆÛË Èı·Ó‹˜ ·˘ÙÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ ·ÔÊ·Û›ÛÙËÎÂ Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ (3 g/kg) Î·È Ë ¤Ó·ÚÍË ıÂÚ·›·˜ Ì ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (pulse therapy: 30 mg/kg/Ë̤ڷ ÁÈ· 3 Ë̤Ú˜), Ì ·ÎfiÏÔ˘ıË ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙ÔÏfiÓ˘ per os (2 mg/kg/Ë̤ڷ). ªÂÙ¿ ÙËÓ ¿ÚÔ‰Ô Ì›·˜ ‚‰ÔÌ¿‰·˜ ıÂÙÈÎÔÔÈ‹ıËÎÂ Î·È Ë ¤ÌÌÂÛË ·ÓÙ›‰Ú·ÛË Coombs, ¯ˆÚ›˜ Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë Ù·˘ÙÔÔ›ËÛË Î¿ÔÈÔ˘ ·ÓÙÈÛÒÌ·ÙÔ˜. ¶·Ú¿ ÙËÓ ·ÁˆÁ‹ Î·È ÙȘ Â·ÓÂÈÏËÌ̤Ó˜ ÌÂÙ·ÁÁ›ÛÂȘ, Ù· Â›‰· Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·Ú¤ÌÂÓ·Ó Û ¯·ÌËÏ¿ Â›‰·. ∏ ·ÛıÂÓ‹˜ ¤Ï·‚ ÂÍÈÙ‹ÚÈÔ 12 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ÂÓÒ Ë ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ Â›Ó·È ¯·ÌËÏ‹ (8 g/dl) Î·È ÔÈ ·ÓÙȉڿÛÂȘ Coombs - ¿ÌÂÛË Î·È ¤ÌÌÂÛË - ıÂÙÈΤ˜. ∏ ¿ÌÂÛË Coombs ·ÚÓËÙÈÎÔÔÈ‹ıËΠÙËÓ 60‹ Ë̤ڷ Ù˘ ÓfiÛÔ˘, ÂÓÒ ·Ú¿ÏÏËÏ· ÛÙËÓ ¤ÌÌÂÛË ‰ÔÎÈÌ·Û›· Coombs ·ÓȯÓ‡ıËÎÂ Ë ·ÚÔ˘Û›· ·ÏÏÔ·ÓÙÈÛÒÌ·ÙÔ˜ ·ÓÙÈkidd a, ı¤ÙÔÓÙ·˜, ÙÂÏÈο, ÙË ‰È¿ÁÓˆÛË Ù˘ ·ÏÏÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. ∞ÎÔÏÔ‡ıËÛ ÛÙ·‰È·Î‹ ‰È·ÎÔ‹ Ù˘ ·ÁˆÁ‹˜ Ì ÎÔÚÙÈ˙fiÓË Î·È

Ù·˘Ùfi¯ÚÔÓË ÂÊ·ÚÌÔÁ‹ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛÂˆÓ ·ÔÎÏÂÈÛÙÈÎÒ˜ Î·È ÌfiÓÔÓ ÌÂ Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿ kidd a ·ÚÓËÙÈο, Ì ÚÔԉ¢ÙÈ΋ ¿ÓÔ‰Ô ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ Hb Ù˘ ·ÛıÂÓÔ‡˜ Û ÂÈı˘ÌËÙ¿ Â›‰· ≥9 g/dl (¶›Ó·Î·˜ 1).

¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË ∞ÁfiÚÈ ËÏÈΛ·˜ 2ó ÂÙÒÓ ·Ú·¤ÌÊıËΠ·fi ÂÚÈÊÂÚÈÎfi ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ Èı·Ó‹˜ ÔÌfi˙˘Á˘ ‚-ª∞ Î·È ·˘ÙÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ¤ÎÙÔ ·È‰› ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÔ˘ÛÔ˘ÏÌ¿ÓˆÓ. OÈ ÁÔÓ›˜ ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ÁÓˆÛÙÔ› ÊÔÚ›˜ ‚-ª∞ Î·È ¤Ó·˜ ·fi ÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ·‰ÂÏÊÔ‡˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ˆ˜ ¿Û¯ˆÓ ·fi ÔÌfi˙˘ÁË ‚-ª∞, ˘Ô‚·ÏÏfiÌÂÓÔ˜ Û ٷÎÙÈÎfi ÚfiÁÚ·ÌÌ· ÌÂÙ·ÁÁ›ÛˆÓ. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÂÙ·È ·ÚÔ˘Û›· ÈÎÙÂÚÈ΋˜ ¯ÚÔÈ¿˜ ‰¤ÚÌ·ÙÔ˜ ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ‰È¿ÁÓˆÛË ÂÙÂÚfi˙˘Á˘ ‚-ª∞. ∏ ·ÚÔ‡Û· ÓfiÛÔ˜ ÍÂΛÓËÛ ¤Ó·Ó Ì‹Ó· ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ÎÏÈÓÈ΋, Ì ¤ÏÂÁ¯Ô ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓÔ‡˜ ÛÙÔ ÂÚÈÊÂÚÈÎfi ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ˆ¯ÚfiÙËÙ·˜, fiÔ˘ ‚¿ÛÂÈ ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Èı·Ó‹˜ ÔÌfi˙˘Á˘ ‚-ª∞, ¯ˆÚ›˜ Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÚÁ·ÛÙËÚȷ΋ ÂȂ‚·›ˆÛ‹ Ù˘. ¶·Ú¿ ÙËÓ ¤Ó·ÚÍË ÌÂÙ·ÁÁ›ÛÂˆÓ Û˘Ì‚·ÙÒÓ ˆ˜ ÚÔ˜ Ù· ·ÓÙÈÁÔÓÈο Û˘ÛÙ‹Ì·Ù· ∞µO, Rh Î·È Kell, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÈηÓÔÔÈËÙÈ΋ ¿ÓÔ‰Ô˜ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ÂÓÒ Ô ¤ÏÂÁ¯Ô˜ Ô˘ ·ÎÔÏÔ‡ıËÛ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ıÂÙÈ΋˜ ¿ÌÂÛ˘ ·ÓÙ›‰Ú·Û˘ Coombs Î·È Ô ·ÛıÂÓ‹˜ ·Ú·¤ÌÊıËΠÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô Î·È ·ÓÙÈÌÂÙÒÈÛË. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‰È·ÈÛÙÒıËΠÈÎÙÂÚÈ΋ ¯ÚÔÈ¿ ‰¤ÚÌ·ÙÔ˜ Î·È ÂÈÂÊ˘ÎfiÙˆÓ, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· (4 cm Î·È 7 cm, ·ÓÙ›ÛÙÔȯ·) ηÈ

¶›Ó·Î·˜ 1. ¶ÔÚ›· ·ÛıÂÓÔ‡˜ Ì ‚-ª∞ Î·È ·ÏÏÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· ∏̤ڷ ÓfiÛÔ˘

10Ë

35Ë

38Ë

45Ë

50‹

65Ë

100‹

Hb (g/dl) Ht (%) ÕÌÂÛË Coombs ŒÌÌÂÛË Coombs

4,5 13,7 (-) (-)

4,7 14 (+) C3d (-)

5,7 16 (+) C3d (+) Ì ¤Ó˙˘ÌÔ ·ÓÛ˘ÁÎfiÏÏËÛË

4,1 12 (+) C3d (+) Ì ¤Ó˙˘ÌÔ ·ÓÛ˘ÁÎfiÏÏËÛË

8 23 (+) C3d (+) Ì ¤Ó˙˘ÌÔ ·ÓÛ˘ÁÎfiÏÏËÛË

>9 >28 (-) (-)

∫ÔÚÙÈ˙fiÓË i.v.

IVIG

ÎÔÚÙÈ˙fiÓË per os

∂ÍÈÙ‹ÚÈÔ

8,3 25 (-) ∞ÓÙÈkidd a (+) ∞ÏÏÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· * µ·ıÌÈ·›· ‰È·ÎÔ‹ ÎÔÚÙÈ˙fiÓ˘

∞˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·

¢È¿ÁÓˆÛË

∞ÓÙÈÌÂÙÒÈÛË

: ªÂÙ¿ÁÁÈÛË Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Û‡Ìʈӷ Ì ÁÔÓfiÙ˘Ô *: ªÂÙ¿ÁÁÈÛË ÌÂ Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿ kidd a (-) ™ËÌ›ˆÛË: ˆ˜ 1Ë Ë̤ڷ ÓfiÛÔ˘ ˘ÔÏÔÁ›˙ÂÙ·È Ë ËÌÂÚÔÌËÓ›· ‰È¿ÁÓˆÛ˘ Ù˘ ‚-ª∞ ¶·È‰È·ÙÚÈ΋ 2005;68:440-444

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·442

442

∞. ∫Ô‡ÛË Î·È Û˘Ó.

ÚÔÛˆÂ›Ô ÔÌfi˙˘Á˘ ‚-ª∞. ∂ÚÁ·ÛÙËÚȷο ‰È·ÈÛÙÒıËÎ·Ó Hb 7,6 g/dl, Ht 24,7%, ¢∂∫ 1,4%, ·ıÔÏÔÁÈ΋ ÌÔÚÊÔÏÔÁ›· ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Ì ¤ÓÙÔÓË ·ÓÈÛÔ- ÔÈÎÈÏÏÔ- ÛÙÔ¯Ô΢ÙÙ¿ÚˆÛË, ÂÓÒ Ë ·ÎÙÈÓÔÁÚ·Ê›· ÎÚ·Ó›Ô˘ ‹Ù·Ó ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÔÌfi˙˘Á˘ ‚-ª∞. OÈ ÚÔËÁËı›Û˜ ÌÂÙ·ÁÁ›ÛÂȘ ηıÈÛÙÔ‡Û·Ó ·‰‡Ó·ÙË ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘ Hb. ¶·Ú¿ ÙËÓ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û˘Ì‚·ÙÒÓ Ì ÔÌfi˙˘ÁË ‚-ª∞, Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ‚ ÁÔÓȉ›ˆÓ ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Ù˘ ÎÏÈÓÈ΋˜ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÌfiÓÔÓ Ù˘ ÌÂÙ¿ÏÏ·Í˘ codon 39 (‚0), ¯ˆÚ›˜ Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó›¯Ó¢ÛË Ì›·˜ ‰Â‡ÙÂÚ˘ ÌÂÙ¿ÏÏ·Í˘, ÌÂٷ͇ ·˘ÙÒÓ Ô˘ Û˘Ó·ÓÙÒÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi. ∞ÓÙ›ÛÙÔȯ·, Ë ÌÂÙ¿ÏÏ·ÍË ‚0 39 ·ÓȯÓ‡ıËΠÛÙÔÓ ·Ù¤Ú·, ÂÓÒ ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ù‹ Ë Ù·˘ÙÔÔ›ËÛË ÌÂÙ¿ÏÏ·Í˘ ‚ ÁÔÓȉ›ˆÓ ÛÙË ÌËÙ¤Ú·, ·Ó Î·È Ë ËÏÂÎÙÚÔÊfiÚËÛ‹ Ù˘ ‹Ù·Ó Ù˘È΋ ÂÙÂÚfi˙˘Á˘ ‚-ª∞. ¶ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ÛÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· Ù˘ ÌÂÙ¿ÏÏ·Í˘ codon 8 (‚0), ÙfiÛÔ ÛÙÔÓ ·ÛıÂÓ‹ fiÛÔ Î·È ÛÙË ÌËÙ¤Ú· ÙÔ˘, Ì›· ÌÂÙ¿ÏÏ·ÍË Ô˘ ··ÓÙ¿Ù·È Î˘Ú›ˆ˜ ÛÙÔÓ ÙÔ˘ÚÎÈÎfi ÏËı˘ÛÌfi. ø˜ ÚÔ˜ ÙȘ ‰ÔÎÈ̷ۛ˜ Coombs, Ë ¿ÌÂÛË ‚Ú¤ıËΠ·ÛıÂÓÒ˜ ıÂÙÈ΋ Î·È Ë ¤ÌÌÂÛË ·ÚÓËÙÈ΋ ÛÙÔ Û˘Ìϋڈ̷ (¶›Ó·Î·˜ 2).

O ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÌÂÙ·ÁÁ›ÛÂȘ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ, Ì ۯÂÙÈο ‚Ú·‰Â›· ¿ÓÔ‰Ô ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ Hb Î·È ÂÎ Ó¤Ô˘ ÙÒÛË ÛÙ· 5 g/dl ÙË 12Ë Ë̤ڷ ÓÔÛËÏ›·˜. ∆·˘Ùfi¯ÚÔÓ·, Ë ¿ÌÂÛË Coombs ¤ÁÈÓ ÂÓÙfiÓˆ˜ ıÂÙÈ΋ ÛÙÔ Û˘Ìϋڈ̷, ÂÓÒ ıÂÙÈÎÔÔÈ‹ıËΠ- ·ÚÔ‰Èο - Î·È Ë ¤ÌÌÂÛË Coombs. ªÂ ÙË ‰È¿ÁÓˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ ·ÔÊ·Û›ÛÙËÎÂ Ë ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ (2 g/kg) Î·È Ë ¯ÔÚ‹ÁËÛË, ·Ú¯Èο, ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ (pulse

therapy: 30 mg/kg/Ë̤ڷ, ÁÈ· 3 Ë̤Ú˜) ηÈ, ÛÙË Û˘Ó¤¯ÂÈ·, Ú‰ÓÈ˙ÔÏfiÓ˘ per os (2 mg/kg/Ë̤ڷ) (¶›Ó·Î·˜ 2). ∆· Â›‰· Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·Ó‹Ïı·Ó, ÙÂÏÈο, ÛÙ· ÂÈı˘ÌËÙ¿ Â›‰· ÌÂÙ¿ ÙËÓ 20‹ Ë̤ڷ ÓfiÛÔ˘ Î·È Ô ·ÛıÂÓ‹˜ ÂÍ‹ÏıÂ, ÂÓÒ Ë ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË Coombs ·Ú¤ÌÂÓ ıÂÙÈ΋. O ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ˘Ô‚Ï‹ıËΠ۠ÌÂÙ¿ÁÁÈÛË Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Î¿ı 15 Ë̤Ú˜, Ì ‰È·Ù‹ÚËÛË Ì¤ÛÔ˘ fiÚÔ˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ~9 g/dl Î·È Ë ÎÔÚÙÈ˙fiÓË ‰È·ÎfiËΠÛÙ·‰È·Î¿. ∏ ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË Coombs ‰ÂÓ ·ÚÓËÙÈÎÔÔÈ‹ıËÎÂ, ·Ú¿ ¤ÓÙ ̋Ó˜ ·ÚÁfiÙÂÚ·.

™˘˙‹ÙËÛË ∏ ·ÏÏÔ¿ÓÔÛË Î·È Ë ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Û˘ÓÈÛÙÔ‡Ó ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓ˜ ÂÚÁ·ÛÙËÚȷο ·fi ÙËÓ ·ÚÔ˘Û›· ıÂÙÈ΋˜ Ù˘ ‰ÔÎÈÌ·Û›·˜ ·ÓÙÈÛÊ·ÈÚÈÓÈÎÔ‡ ÔÚÔ‡, Ë ÔÔ›· Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙ‹ ˆ˜ ·ÓÙ›‰Ú·ÛË Coombs. M ÙËÓ ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË Coombs ·ÔηχÙÂÙ·È Ë ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ, ÂÓÒ Ì ÙËÓ ¤ÌÌÂÛË ‰ÔÎÈÌ·Û›· ·ÓȯÓ‡ÂÙ·È Ë ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi ÙÔ˘ ·ÛıÂÓÔ‡˜ (5). Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ· ·fi 100 ÌfiÚÈ· ·ÓÙÈÛÒÌ·ÙÔ˜ ÛÙË ÌÂÌ‚Ú¿ÓË Î¿ı ÂÚ˘ıÚÔ΢ÙÙ¿ÚÔ˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ԃ› ıÂÙÈ΋ Ë ¿ÌÂÛË Coombs (6). ∂ÓÙÔ‡ÙÔȘ, ÔÚÈṲ̂ӷ ·ÓÙÈÛÒÌ·Ù· ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ηٷÛÙÚÔÊ‹ ÙˆÓ ÂÚ˘ıÚÒÓ, ·ÎfiÌË Î·È Ì ˘ÎÓfiÙËÙ· Ù˘ Ù¿Í˘ ÙˆÓ 10 ÌÔÚ›ˆÓ ·Ó¿ ÂÚ˘ıÚfi. ™˘ÓÂÒ˜, ·ÈÌfiÏ˘ÛË ÌÔÚ› Ó· ˘¿Ú¯ÂÈ Î·È Ì ·ÚÓËÙÈ΋ ÙË ‰ÔÎÈÌ·Û›· Coombs (7). ∞ÓÙ›ÛÙÚÔÊ·, Ë ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙ· ÂÚ˘ıÚ¿ ‰ÂÓ Ô‰ËÁ› ¿ÓÙÔÙ Û Ì›ˆÛË Ù˘ ÂÈ‚›ˆÛ‹˜ ÙÔ˘˜.

¶›Ó·Î·˜ 2. ¶ÔÚ›· ·ÛıÂÓÔ‡˜ Ì ‚-ª∞ Î·È ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· ∏̤ڷ ÓfiÛÔ˘

1Ë

4Ë

6Ë

8Ë

Hb (g/dl) Ht (%) ÕÌÂÛË Coombs ŒÌÌÂÛË Coombs

7,5 24,7 (±) (-)

5,1 17

6,6 21,5 (±) (-)

¢È¿ÁÓˆÛË

∞˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·

∞ÓÙÈÌÂÙÒÈÛË

9Ë

12Ë

15Ë

19Ë

20‹

21Ë

150‹

7,8 9 25,2 29

5,0 16,1 (+) C3d (+) Ì ¤Ó˙˘ÌÔ ·ÓÛ˘ÁÎfiÏÏËÛË

4,8 15 (+) (±)

5,3 18,2

7,9 26

10,5 33,6 (+) (±)

9,5 28 (-) (-)

∫ÔÚÙÈ˙fiÓË i. v.

IVIG

∫ÔÚÙÈ˙fiÓË per os

: ªÂÙ¿ÁÁÈÛË Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Û‡Ìʈӷ Ì ÁÔÓfiÙ˘Ô ¶·È‰È·ÙÚÈ΋ 2005;68:440-444

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·443

443

ÕÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·

ŒÙÛÈ, Ë ¿ÌÂÛË ‰ÔÎÈÌ·Û›· Coombs ·Ó·Ê¤ÚÂÙ·È ıÂÙÈ΋ ÛÂ Û˘¯ÓfiÙËÙ· 1:10.000 ÌÂٷ͇ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·ÈÌÔ‰ÔÙÒÓ (8,9). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÚÔ˘Û›· ıÂÙÈ΋˜ ¿ÌÂÛ˘ ·ÓÙ›‰Ú·Û˘ Coombs ¯·Ú·ÎÙËÚ›˙ÂÈ Û˘Ó‹ıˆ˜ ÙËÓ ·˘ÙÔ¿ÓÔÛË, ÂÓÒ Ë ·ÚÔ˘Û›· ¤ÌÌÂÛ˘ ÙËÓ ·ÏÏÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ·˘Ùfi ‰ÂÓ ·ÔÙÂÏ› ηÓfiÓ·. ™˘¯Ó¿, ·ÌÊfiÙÂÚ˜ ÔÈ ·ÓÙȉڿÛÂȘ ‚Ú›ÛÎÔÓÙ·È ıÂÙÈΤ˜ ηÈ, ÙfiÙÂ, ÌfiÓÔÓ Ë ÂÈÎÚ¿ÙËÛË Ù˘ Ì›·˜ ÂÎ ÙˆÓ ‰‡Ô ‹ Ë Ù·˘ÙÔÔ›ËÛË Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ·ÏÏÔ- ‹ ·˘ÙÔ·ÓÙÈÛÒÌ·ÙÔ˜, ÛÙËÓ ÔÚ›· ÙÔ˘ ¯ÚfiÓÔ˘, ı¤ÙÂÈ ÙË ‰È¿ÁÓˆÛË Ì ‚‚·ÈfiÙËÙ· - fiˆ˜ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊËηÓ. ™ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË, Ë ·ÚÔ˘Û›· ıÂÙÈ΋˜ ¿ÌÂÛ˘ Coombs ·Ú·Ï¿ÓËÛ ·ÚÔ‰Èο, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· Ë ÂÈÎÚ¿ÙËÛË Ù˘ ¤ÌÌÂÛ˘ ·ÓÙ›‰Ú·Û˘ Î·È Ë Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ·ÏÏÔ·ÓÙÈÛÒÌ·ÙÔ˜ ·ÓÙÈ-kidd a ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ·ÏÏÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. ∞ÓÙ›ıÂÙ·, ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË, Ë ·ÈÌfiÏ˘ÛË ÔÊÂÈÏfiÙ·Ó Û ·˘ÙÔ·ÓÔÛÔÔ›ËÛË, Ì ·ÚÔ‰È΋ ÌfiÓÔÓ ıÂÙÈÎÔÔ›ËÛË Ù˘ ¤ÌÌÂÛ˘ Coombs Î·È ÂÈÎÚ¿ÙËÛË Ù˘ ¿ÌÂÛ˘ ·ÓÙ›‰Ú·Û˘, Ë ÔÔ›· ·Ú¤ÌÂÈÓ ıÂÙÈ΋ ÁÈ· ‰È¿ÛÙËÌ· ÔÏÏÒÓ ÌËÓÒÓ. ∏ Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ·ÏÏÔ¿ÓÔÛ˘ ·Ó·ÈÌ›·˜ ÛÙÔ˘˜ ŒÏÏËÓ˜ ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 5-20% (10-12), ÂÓÒ ‰ÂÓ ˘¿Ú¯ÂÈ Â›ÛËÌË Î·Ù·ÁÚ·Ê‹ Û¯ÂÙÈο Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Û˘¯ÓfiÙËÙ· Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. ™‡Ìʈӷ Ì ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ Î˘ÚÈfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂΉ‹ÏˆÛË ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ Û ¿ÙÔÌ· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÁÁ›ÛÂȘ Â›Ó·È Ë ·Û˘Ì‚·ÙfiÙËÙ· ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ ·›Ì·ÙÔ˜ - ˆ˜ ÚÔ˜ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈο ·ÓÙÈÁÔÓÈο Û˘ÛÙ‹Ì·Ù· ÁÈ· Ù· ÔÔ›· ‰ÂÓ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ¤ÏÂÁ¯Ô˜ ÛÙËÓ Î·ı’ Ë̤ڷ Ú¿ÍË, Ë ·ÓÔÛÔÏÔÁÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ‰¤ÎÙË Î·È, Ù¤ÏÔ˜, Ë ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋ Â›‰Ú·ÛË ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ·›Ì·ÙÔ˜ (13). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ¯ÔÚ‹ÁËÛË ·›Ì·ÙÔ˜ Û˘Ì‚·ÙÔ‡ ˆ˜ ÚÔ˜ Ù· ·ÓÙÈÁÔÓÈο Û˘ÛÙ‹Ì·Ù· ∞µ√, Rh Î·È Kell Û fiϘ ÙȘ ÔÚÁ·ÓˆÌ¤Ó˜ ÌÔÓ¿‰Â˜ - fiˆ˜ Î·È Û ·˘Ù‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ - ¤¯ÂÈ ÂÚÈÔÚ›ÛÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ ÛÙÔ˘˜ ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ (13). À„ËÏ‹ Û˘¯ÓfiÙËÙ· ·Ó·Ê¤ÚÂÙ·È ‚È‚ÏÈÔÁÚ·ÊÈο Û ¯ÒÚ˜ Ì ·ÓÔÌÔÈÔÁÂÓ›˜ ÏËı˘ÛÌÔ‡˜, fiÔ˘ Ë ÂÚ˘ıÚÔ΢ÙÙ·ÚÈ΋ ·ÓÙÈÁÔÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Â›Ó·È ÌÂÁ¿ÏË (13,15). ™Â ÂÚ›ÙˆÛË ·ÏÏÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜, Ë ·ÚÔ˘Û›· ıÂÙÈ΋˜ ¤ÌÌÂÛ˘

·ÓÙ›‰Ú·Û˘ Coombs ‰‡Ó·Ù·È Ó· ÂÈ̤ÓÂÈ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙËÓ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÓÒ Ë ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ·Û‡Ì‚·ÙÔ˘ ˆ˜ ÚÔ˜ ÙÔ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎfi ·ÓÙÈÁfiÓÔ Ô˘ ÚÔοÏÂÛ ÙËÓ ·ÓÙ›‰Ú·ÛË ÂÓ‰¤¯ÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÎ Ó¤Ô˘ ıÂÙÈÎÔÔ›ËÛ‹ Ù˘, Ì ÂΉ‹ÏˆÛË ÎÏÈÓÈο ¤ÓÙÔÓ˘ ·ÈÌfiÏ˘Û˘ (6). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË Û¯¤ÛË ÌÂٷ͇ ·ÓÔÛÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ·ÛıÂÓÔ‡˜ Î·È ÂΉ‹ÏˆÛ˘ ·ÏÏÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜, ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙÔ˘˜ ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘˜ ı·Ï·ÛÛ·ÈÌÈÎÔ‡˜ ·ÛıÂÓ›˜ Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ Ë ·ÚÔ˘Û›· ‹ fi¯È ÛÏËÓÂÎÙÔÌ‹˜. ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ˘ÔÛÙ› ÛÏËÓÂÎÙÔÌ‹, ÂÍËÁÂ›Ù·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ·Ô˘Û›· ÙÔ˘ ÛÏ‹Ó·, Ù˘ ı¤Û˘ ‰ËÏ·‰‹ fiÔ˘ ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ ÊÈÏÙÚ¿ÚÔÓÙ·È Ù· ͤӷ ·ÓÙÈÁfiÓ·, Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÛÙ· ÂÈÛÂÚ¯fiÌÂÓ· ·ÓÙÈÁfiÓ· ÂÈÙ›ÓÂÙ·È (13). ∂›Û˘, Ë ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ ÌÂÙ·ÁÁ›ÛÂˆÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂΉ‹ÏˆÛË ·ÏÏÔ¿ÓÔÛ˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜. OÈ ÂÚ¢ÓËÙ¤˜ Û˘ÌʈÓÔ‡Ó fiÙÈ Ë ¤Ó·ÚÍË ÂÊ·ÚÌÔÁ‹˜ ÌÂÙ·ÁÁ›ÛÂˆÓ Û ÌÈÎÚ‹ ËÏÈΛ·, ›Ûˆ˜ ÌÈÎÚfiÙÂÚË ·ÎfiÌË Î·È ÙˆÓ 12 ÌËÓÒÓ, Ô‰ËÁ› Û ·ÓÔÛÔÏÔÁÈ΋ ·ÓÔ¯‹ Î·È ÚÔÛÙ·Û›· ¤Ó·ÓÙÈ Ù˘ ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ (11,12). ∆¤ÏÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÔ·ÓÔÛÔÔ›ËÛ˘ Î·È ¿ÏÈ ÂÓÔ¯ÔÔÈÂ›Ù·È Ë ·Ô˘Û›· ÙÔ˘ ÛÏ‹Ó· ÏfiÁˆ ÂÚÈÔÚÈṲ̂Ó˘ ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙˆÓ ÌË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ, ·ÏÏ¿ Î·È Ë ¤ÎıÂÛË Û ÌË ÏÂ˘Î·Ê·ÈÚÂ̤ӷ ÌÂÙ·ÁÁÈ˙fiÌÂÓ· ÂÚ˘ıÚÔ·ÙÙ·Ú·, Ì Ì˯·ÓÈÛÌfi fi¯È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ (17,18). µ¿ÛÂÈ ·˘ÙÒÓ, ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ, ‰ÈfiÙÈ ·ÊÔÚÔ‡Ó Û ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Â›¯·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ˘Ô‚ÏËı› Û ÛÏËÓÂÎÙÔÌ‹ Î·È ÔÈ ÔÔ›ÔÈ ·ÚÔ˘Û›·Û·Ó ·ÈÌfiÏ˘ÛË ¿ÓÔÛ˘ ·ÈÙÈÔÏÔÁ›·˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ÌÂÙ·ÁÁ›ÛˆÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ¿Û¯ÔÓÙ˜ ·fi ‚-ª∞, fiˆ˜ fiÏÔÈ ÔÈ ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓÔÈ ·ÛıÂÓ›˜, ÂÓ‰¤¯ÂÙ·È Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ·ÏÏÔ- ‹ ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·. ∏ ÎÏÈÓÈ΋ ÛËÌ·Û›· Ù˘ Û˘Ó‡·Ú͢ Û˘ÁÁÂÓÔ‡˜ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ Ì ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Â›Ó·È ÌÂÁ¿ÏË, ηıÒ˜ Ô‰ËÁ› Û Â›Ù·ÛË Ù˘ ‹‰Ë ÌÂȈ̤Ó˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Î·È ‰˘Û¯ÂÚ·›ÓÂÈ ÙËÓ ·Ó‡ÚÂÛË ·›Ì·ÙÔ˜ Û˘Ì‚·ÙÔ‡ ÚÔ˜ ÌÂÙ¿ÁÁÈÛË, ηıÈÛÙÒÓÙ·˜ ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏË ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ·ÛıÂÓÒÓ. ¶·È‰È·ÙÚÈ΋ 2005;68:440-444

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·444

444

∞. ∫Ô‡ÛË Î·È Û˘Ó.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Blumberg N, Ross K, Avila E, Peck K. Should chronic transfusions be matched for antigens other than ABO and Rho(D)? Vox Sang 1984;47:205-208.

2. Weatherall DJ, Clegg JB, editors. The thalassaemia syndromes. 4th ed. Oxford: Blackwell Science; 2001. p. 630-685.

3. Argiolu F, Diana G, Arnone M, Batzella MG, Piras P, Cao A. High-dose intravenous immunoglobulin in the management of autoimmune hemolytic anemia complicating thalassaemia major. Acta Haematol 1990;83:65-68.

4. Smit Sibinga CT. Immune effects of blood transfusion. Curr Opin Hematol 1999;6:442-445.

5. Nathan DG, Oski FA. Hematology of infancy and childhood. 5th ed. Philadelphia: WB Saunders Co; 1998. p. 496-522.

6. Jandl J. Blood: Textbook of Hematology. 1st ed. Boston: Little, Brown and Company; 1987. p. 281-319.

7. Lee GR, Bithell TC, Foerster J, Athens JW, Lukens JN. Wintrobe’s Clinical Hematology. 9th ed.

Philadelphia: Lea and Febiger; 1993. p. 1170-1193.

8. Bareford D, Longster G, Gilks L, Tovey LA. Followup of normal individuals with a positive antiglobulin test. Scand J Haematol 1985;35:348-353.

9. Win N, Islam SI, Peterkin MA, Walker ID. Positive direct antiglobulin test due to antiphospholipid antibodies in normal healthy blood donors. Vox Sang 1997;72:182-184.

10. Economidou J, Constantoulakis M, Augoustaki O, Adinolfi M. Frequency of antibodies to various antigenic determinants in polytransfused patients with homozygous thalassaemia in Greece. Vox Sang 1971;20:252-258.

¶·È‰È·ÙÚÈ΋ 2005;68:440-444

11. Michail-Merianou V, Pamphili-Panousopoulou L, Piperi-Lowes L, Pelegrinis E, Karaklis A. Alloimmunization to red cell antigens in thalassemia: comparative study of usual versus better-match transfusion programmes. Vox Sang 1987;52:95-98.

12. Spanos T, Karageorga M, Ladis V, Peristeri J, Hatziliami A, Kattamis C. Red cell alloantibodies in patients with thalassemia. Vox Sang 1990:58:50-55.

13. Singer ST, Wu V, Mignacca R, Kuypers FA, Morel P, Vichinsky EP. Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly Asian descent.

Blood 2000;96;3369-3373.

14. Hmida S, Mojaat N, Maamar M, Bejaoui M, Mediouni M, Boukef K. Red cell alloantibodies in patients with haemoglobinopathies. Nouv Rev Fr Hematol 1994;36:363-366.

15. Ameen R, Al-Shemmari S, Al-Humood S, Chowdhury RI, Al-Eyaadi O, Al-Bashir A. RBC alloimmunization and autoimmunization among transfusion-dependent Arab thalassemia patients. Transfusion 2003;43:1604-1610.

16. Blajchman MA. Immunomodulatory effects of allogeneic blood transfusions: clinical manifestations and mechanisms. Vox Sang 1998;74 (Suppl 2):S315-S319.

17. Hodge G, Lloyd JV, Hodge S, Story C, Han P. Functional lymphocyte immunophenotypes observed in thalassaemia and haemophilia patients receiving current blood product preparations. Br J Haematol 1999;105:817-825.

18. Pistillo MP, Tazzari PL, Gaudiano C, Cilla V, Kato T, Matsui T et al. Patients with neoplastic and nonneoplastic hematologic diseases acquire CTLA-4 antibodies after blood transfusion. Transfusion 2001;41:462-469.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·445

CASE REPORT

445

Immune haemolytic anaemia in patients with beta-thalassaemia. Case report A. Kousi1, M. Oikonomou1, D. Kassimos2, P. Pliaki3, M. Athanasiou - Metaxa1

Abstract Two cases of beta-thalassaemia with immune haemolytic anaemia (allo- and autoimmune, respectively) are described. The objective is to emphasize the possible co-existence and interaction of immune haemolysis with chronic congenital haemolytic anemia, and to highlight the clinical and therapeutic problems that may arise in such cases.

Key words Beta-thalassaemia, alloimmunization, autoimmune haemolytic anemia, Coombs test.

1 Thalassaemia Unit, 1st Paediatric Clinic of Aristotelion University, Ippokration General Hospital, Thessaloniki 2 Paediatric Clinic, Dimokritio University Hospital, Thrace 3 Blood Center, Ippokration General Hospital, Thessaloniki Correspondence: Miranda Athanasiou-Metaxa 1st Paediatric Clinic, Ippokration General Hospital 49 Konstantinoupoleos Str. 546 42, Thessaloniki E-mail: miranda@med.auth.gr Date of submission: 28-09-2004 Date of approval: 01-04-2005

Paediatriki 2005;68:445

Pediatr Nov-Dec 05

12-12-05

446

15:16

™ÂÏ›‰·446

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

ªÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ÙÔ˘ ‹·ÙÔ˜. ∞Ó·ÊÔÚ¿ Û ̛· ÂÚ›ÙˆÛË ª. ÷ÛÈÒÙÔ˘1, ∂. ™·ÌÌÔ‡ÙË2, ¶. ¶ÔÏ˘‚›Ô˘2, ∂. ∫ÔÛÎÈÓ¿2 1 ∆Ì‹Ì· ∞ÍÔÓÈÎÔ‡ Î·È ª·ÁÓËÙÈÎÔ‡ ∆ÔÌÔÁÚ¿ÊÔ˘, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∂. ™·ÌÌÔ‡ÙË ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-05-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-07-2005

¶ÂÚ›ÏË„Ë OÈ ÚˆÙÔ·ı›˜ fiÁÎÔÈ ÙÔ˘ ‹·ÙÔ˜ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈÔÈ. ∞fi ·˘ÙÔ‡˜ Û˘¯ÓfiÙÂÚÔÈ Â›Ó·È ÔÈ Î·ÎÔ‹ıÂȘ (Ë·ÙÔ‚Ï¿Ûو̷) Ì ˘„ËÏfi ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜. ∞fi ÙÔ˘˜ ηÏÔ‹ıÂȘ Û˘¯ÓfiÙÂÚÔ˜ Â›Ó·È ÙÔ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ·, ÂÓÒ ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ Â›Ó·È Û¿ÓÈÔ. ∆Ô ÙÂÏÂ˘Ù·›Ô ÌÔÚ› Ó· ·ÚÈÛÙ¿ Î·È Û˘ÁÁÂÓ‹ ‰˘ÛÏ·Û›·. OÈ ÚfiÔ‰ÔÈ ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÙÔ˘ ‹·ÙÔ˜ ÚÔÛʤÚÔ˘Ó ϤÔÓ ÂÍ·ÈÚÂÙÈ΋ ÚfiÁÓˆÛË ÛÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 8 ÌËÓÒÓ Ì ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ÙÔ˘ ‹·ÙÔ˜ Î·È ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË ÙÔ˘ fiÁÎÔ˘. §¤ÍÂȘ ÎÏÂȉȿ ¶·È‰È¿, ‹·Ú, ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 8 ÌËÓÒÓ ÌÂٷʤÚıËΠÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ Ù·¯Â›·˜ ‰ÈfiÁΈÛ˘ Ù˘ ÎÔÈÏÈ¿˜ ÙÔ˘ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 20 Ë̤Ú˜. OÈ ÁÔÓ›˜ ·Ó¤ÊÂÚ·Ó ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ÂÚ›Ô˘ 500 g. ∞fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ˘‹Ú¯Â ÂÎÛÂÛËÌ·Ṳ̂ÓË Ë·ÙÔÌÂÁ·Ï›·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (US) ¤‰ÂÈÍ Ë·ÙÔÌÂÁ·Ï›· Î·È ·ÚÔ˘Û›· Ôχ¯ˆÚÔ˘ ΢ÛÙÈÎÔ‡ ÌÔÚÊÒÌ·ÙÔ˜ ÛÙÔÓ ‰ÂÍÈfi Ë·ÙÈÎfi ÏÔ‚fi, ‰È·ÛÙ¿ÛÂˆÓ 14,3 x 13,4 x 8,2 cm. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¤‰ÂÈÍ ÂÎÙÂٷ̤ÓË ÂÍÂÚÁ·Û›·, Ë ÔÔ›· ‰ÈËıÔ‡Û ηı’ ÔÏÔÎÏËÚ›·Ó ÙÔÓ ‰ÂÍÈfi Ë·ÙÈÎfi ÏÔ‚fi. ∂›¯Â ÔÏÏ·ÏÔ‡˜ ΢ÛÙÈÎÔ‡˜ ¯ÒÚÔ˘˜ Û˘ÚÚ¤ÔÓÙ˜, Ô˘ ‰È·¯ˆÚ›˙ÔÓÙ·Ó Ì ÏÂÙ¿ ‰È·ÊÚ·ÁÌ¿ÙÈ·. ∆Ô ‰ÈÔÁΈ̤ÓÔ ‹·Ú ·ˆıÔ‡Û ٷ ÁÂÈÙÔÓÈο fiÚÁ·Ó· (¿ÁÎÚ·˜, ¤ÓÙÂÚÔ, ‰ÂÍÈfi ÓÂÊÚfi). ªÂÙ¿ ÙËÓ ÂÓ‰ÔÊϤ‚È· (∂º) ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ·Ú·ÙËÚ‹ıËΠÂÓ›Û¯˘ÛË ÛÙÔ ÙÔ›¯ˆÌ· Î·È Ù· ‰È·ÊÚ¿ÁÌ·Ù· Ù˘ ÂÍÂÚÁ·Û›·˜ (∂ÈÎfiÓ· 1). ¢ÂÓ ˘‹Ú¯·Ó ‰ÈÔÁΈ̤ÓÔÈ ÏÂÌÊ·‰¤Ó˜ Ô‡Ù ÂÚÈÙÔÓ·˚΋ Û˘ÏÏÔÁ‹.

OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ÔÈ ÙÈ̤˜ ·ÊÂÙÔÚˆÙ½Ó˘ Î·È ‚-¯ÔÚȷ΋˜ ÁÔÓ·‰ÔÙÚÔ›Ó˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ∞ÊÔ‡ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË ÚˆÙÔ·ıÔ‡˜ ÓÂÔÏ¿ÛÌ·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜, ¤ÁÈÓ ·ÓÔȯً ‚ÈÔ„›· Î·È Ë ÈÛÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË ‹Ù·Ó ÌÂÛÂÁ¯˘Ì·ÙÈÎfi Ë·ÙÈÎfi ·Ì¿Úو̷. ŒÁÈÓ ¢Ú›· ËÌÈË·ÙÂÎÙÔÌ‹ Î·È Ô fiÁÎÔ˜ ·Ê·ÈÚ¤ıËΠÏ‹Úˆ˜. ªÂÙÂÁ¯ÂÈÚËÙÈο ‰ÂÓ ¶·È‰È·ÙÚÈ΋ 2005;68:446-448

∂ÈÎfiÓ· 1. ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÌÂÙ¿ ·fi ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡. ∫˘ÛÙÈ΋ Ôχ¯ˆÚË ÂÍÂÚÁ·Û›·, Ì ÂÓ›Û¯˘ÛË ÌfiÓÔ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ Î·È ÙˆÓ ‰È·ÊÚ·ÁÌ·Ù›ˆÓ Ù˘ ÂÍÂÚÁ·Û›·˜.

˘‹Ú¯·Ó ÂÈÏÔΤ˜. ∆Ô ·È‰› - 3 ¤ÙË ÌÂÙ¿ - Â›Ó·È Î·Ï¿.

™˘˙‹ÙËÛË ∆Ô Î˘ÛÙÈÎfi ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ Â›Ó·È Û¿ÓÈÔ˜ fiÁÎÔ˜ (1,3,4). ∞ÔÙÂÏÂ›Ù·È ·fi ¯·Ï·Úfi ÔȉËÌ·ÙÒ‰Ë ÈÛÙfi, ·ÈÌÔÊfiÚ· ·ÁÁ›·, ÌÈÎÚ¤˜ ÔÌ¿‰Â˜ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È ¯ÔÏËÊfiÚ· (3). Œ¯ÂÈ Ù·¯Â›· ·Ó¿Ù˘ÍË Î·È ÂΉËÏÒÓÂÙ·È ÎÏÈÓÈο Ì ·ÓÒ‰˘ÓË ‰ÈfiÁΈÛË Ù˘ ¿Óˆ ÎÔÈÏ›·˜ (1). ™ÙÔ

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·447

447

ªÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ÙÔ˘ ‹·ÙÔ˜

·È‰› Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ì ÔÈ ÁÔÓ›˜ ·Ú·Ù‹ÚËÛ·Ó ÙË ‰ÈfiÁΈÛË Ù˘ ÎÔÈÏÈ¿˜ ηٿ ÙÔ ÙÂÏÂ˘Ù·›Ô 20‹ÌÂÚÔ. ∆Ô Î·ÏfiËı˜ ÌÂÛÂÁ¯˘Ì·ÙÔÁÂÓ¤˜ ·Ì¿Úو̷ ·ÊÔÚ¿ Û ӋÈ· ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ÂÙÒÓ Î·È Û ‰ÈÏ¿ÛÈÔ ÔÛÔÛÙfi ÛÙ· ·ÁfiÚÈ· (3), ·Ó Î·È ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ fiÙÈ Ë ÚÔÛ‚ÔÏ‹ ·ÊÔÚ¿ ÂÍ›ÛÔ˘ Û ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· (4,5). À¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ÁÈ· ‰È¿ÁÓˆÛË ÌÂÛÂÁ¯˘Ì·ÙÔÁÂÓÔ‡˜ ·Ì·ÚÙÒÌ·ÙÔ˜ ηٿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈÔ ·Ó¿Ù˘ÍË (1,5). √È ·Ó·ÊÔÚ¤˜ ÁÈ· ÌÂÛÂÁ¯˘Ì·ÙÔÁÂÓ¤˜ ·Ì¿Úو̷ Û ÂÓ‹ÏÈΘ Â›Ó·È Ï›Á˜ (4). ∏ ÂÍÂÚÁ·Û›· ¤¯ÂÈ Ù·¯Â›· ·Ó¿Ù˘ÍË, ÂÚȤ¯ÂÈ ÔÏÏ·Ϥ˜ ΢ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Î·È ·ÊÔÚ¿ ηı’ ˘ÂÚÔ¯‹Ó ÛÙÔÓ ‰ÂÍÈfi ÏÔ‚fi (>80%). ™ÙÔÓ ‰ÂÍÈfi Ë·ÙÈÎfi ÏÔ‚fi ÂÓÙÔÈ˙fiÙ·Ó Ë ÂÍÂÚÁ·Û›· Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ∏ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ÌÂÛÂÁ¯˘Ì·ÙÈÎÔ‡ Ë·ÙÈÎÔ‡ ·Ì·ÚÙÒÌ·ÙÔ˜ ÔÊ›ÏÂÙ·È Û ·ÓÒÌ·ÏË ·Ó¿Ù˘ÍË ÙÔ˘ ·Ú¯¤ÁÔÓÔ˘ ÌÂÛÂÁ¯‡Ì·ÙÔ˜. ∂Ô̤ӈ˜, Ë ÂÍÂÚÁ·Û›· ·ÊÔÚ¿ Û ·ÓÙȉڷÛÙÈ΋, ÌË ÓÂÔÏ·ÛÌ·ÙÈ΋ ·ÏÏÔ›ˆÛË (4). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ˆÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó Î·È ·Ó·ÊÔÚ¤˜ Ô˘ Û˘Û¯ÂÙ›˙Ô˘Ó ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ Ì ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi Û¿ÚΈ̷ (4). ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Ë Î˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË ÙÔ˘ fiÁÎÔ˘ ·ÔηχÙÂÈ ÌÂÙ¿ıÂÛË Ù˘ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 19 (6).

OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È Ô˘ÛÈ·ÛÙÈΤ˜ ÁÈ· ÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰È¿ÁÓˆÛË (1,3). ™ÙÔ US ·Ó·‰ÂÈÎÓ‡ÂÙ·È Ì›· ÔÏ˘ÏÔ‚ˆÙ‹ Ì¿˙· Ì ÔÏÏ·Ϥ˜ ¿Ó˯˜ ÂÚÈÔ¯¤˜ (·ÛÙÂȘ) Î·È ·ÚÔ˘Û›· ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ Û˘Ì·ÁÒÓ ÙÌËÌ¿ÙˆÓ. ŸÙ·Ó Ô fiÁÎÔ˜ ¤¯ÂÈ ÂÍˆÊ˘ÙÈ΋ ·Ó¿Ù˘ÍË, Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ηıÔÚÈÛÙ› Ë Ë·ÙÈ΋ ÙÔ˘ ÚԤϢÛË (7). ∆Ô Ì¤ÁÂıÔ˜ Ù˘ ÂÍÂÚÁ·Û›·˜ Î˘Ì·›ÓÂÙ·È ·fi 5 cm ¤ˆ˜ 30 cm, Ì ÔÏÏ·Ϥ˜ ·ÛÙÂȘ ‰È·Ì¤ÙÚÔ˘ ·fi Ï›Á· ¯ÈÏÈÔÛÙ¿ ̤¯ÚÈ 10 cm.

OÈ Î‡ÛÙÂȘ ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¤¯Ô˘Ó ˘ÎÓfiÙËÙ· ·Ó¿ÏÔÁË Ì ÙËÓ ·ÚÔ˘Û›· Û˘Ì·ÁÒÓ ÛÙÔȯ›ˆÓ. ªÂÙ¿ ÙËÓ ∂º ¯ÔÚ‹ÁËÛË ÙÔ˘ ÛÎÈ·ÁÚ·ÊÈÎÔ‡, ÂÓ›Û¯˘ÛË ·Ú·ÙËÚÂ›Ù·È ÌfiÓÔ ÛÙ· ÙÌ‹Ì·Ù· Ô˘ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ·ÁÁ›ˆÛË (4,7). ™ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÙÔ Ì·ÁÓËÙÈÎfi Û‹Ì· ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ÌÂÛÂÁ¯˘Ì·ÙÈÎÒÓ ÛÙÔȯ›ˆÓ Î·È ÙËÓ ·ÚÔ˘Û›· ÚˆÙÂ˚ÓÒÓ ÛÙÔ˘˜ ΢ÛÙÈÎÔ‡˜ ¯ÒÚÔ˘˜. ∂›Ó·È Ì›· ÂÙÂÚÔÁÂÓ‹˜ Ì¿˙· Ì ¯·ÌËÏ‹ ¤ÓÙ·ÛË Û‹Ì·ÙÔ˜ ÛÙȘ ∆1 ·ÎÔÏÔ˘ı›Â˜ Î·È ˘„ËÏ‹ ÛÙȘ ∆2 ·ÎÔÏÔ˘ı›Â˜. ∏ ‰ÈfiÁΈÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙÔ˘

˘ÂÚΛÌÂÓÔ˘ ÙÌ‹Ì·ÙÔ˜ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜ ·Ú·ÙËÚÂ›Ù·È ÌfiÓÔ fiÙ·Ó Ô fiÁÎÔ˜ ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ·ÁÁ›ˆÛË (1,3,7). ™ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ·, ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ÂÌÊ·Ó›˙ÂÙ·È Û·Ó ¤ÏÏÂÈÌÌ· Ï‹ÚˆÛ˘. ™ÙËÓ ·ÁÁÂÈÔÁÚ·Ê›· ·Ú·ÙËÚÔ‡ÓÙ·È ·ÁÁ›· ÌÈÎÚ‹˜ ‰È·Ì¤ÙÚÔ˘ ÛÙÔ ÂÛˆÙÂÚÈÎfi ·Ó¿ÁÁÂÈˆÓ (΢ÛÙÈÎÒÓ) ÂÚÈÔ¯ÒÓ, Ô˘ ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó Ù· ·ÁÁ›· ÙˆÓ ‰È·ÊÚ·ÁÌ·Ù›ˆÓ. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË (8,9) Ú¤ÂÈ Ó· Á›ÓÂÈ ·fi ÙÔ Î·ÎfiËı˜ ÌÂÛÂÁ¯‡ÌˆÌ·, ÙÔ Ë·ÙÔ‚Ï¿Ûو̷ Î·È ÙÔ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ·. ∆Ô ÙÂÏÂ˘Ù·›Ô ‰È·ÁÈÁÓÒÛÎÂÙ·È Û ÚˆÈÌfiÙÂÚË ËÏÈΛ· (Û˘¯Ó¿ ÙÔÓ ÚÒÙÔ Ì‹Ó· ˙ˆ‹˜), ‰ÈfiÙÈ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È, ÂÎÙfi˜ ·fi ÙËÓ Ë·ÙÔÌÂÁ·Ï›·, ·fi Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, ·ÈÌÔÚÚ·Á›· Î·È ‰ÂÚÌ·ÙÈο ·ÈÌ·ÁÁÂÈÒÌ·Ù·. ∆Ô Ë·ÙÔ‚Ï¿Ûو̷ ·ÊÔÚ¿ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (Û˘Ó‹ıˆ˜ ̤¯ÚÈ ¤ÓÙ ÂÙÒÓ) Ì ˘„ËϤ˜ ÙÈ̤˜ ·-ÊÂÙÔÚˆÙ½Ó˘. ∏ ÂÍÂÚÁ·Û›· ·˘Ù‹ ¤¯ÂÈ ·ÓÔÌÔÈÔÁ¤ÓÂÈ· ÌÂ Û˘Ì·Á‹ ÛÙÔȯ›·, ÂÚÈÔ¯¤˜ Ó¤ÎÚˆÛ˘, ·ÔÙÈÙ·ÓÒÛÂȘ Î·È ÛÙ¿وÛË. ∆· Â›‰· Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘ ÛÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ Â›Ó·È Ê˘ÛÈÔÏÔÁÈο (7). ∆Ô Î·ÎfiËı˜ ÌÂÛÂÁ¯‡ÌˆÌ· ·ÊÔÚ¿ Û˘Ó‹ıˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ 5-10 ÂÙÒÓ. ∞ÂÈÎÔÓÈÛÙÈο, Ô fiÁÎÔ˜ ¤¯ÂÈ ÌÂÁ¿Ï˜ ΢ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Ì ‰È·ÊÚ·ÁÌ¿ÙÈ· Î·È ÙÔȯˆÌ·ÙÈο Ô˙›‰È·. ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË ÈÛÙÔÔÈÂ›Ù·È ·fi ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË, ›Ù Û ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‚ÈÔ„›· ›Ù ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ê·›ÚÂÛ˘ ÙÔ˘ fiÁÎÔ˘ ÛÙËÓ Ù·¯Â›· ‚ÈÔ„›· (4). ∏ ıÂÚ·›· ÂÎÏÔÁ‹˜ Â›Ó·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË ÙÔ˘ fiÁÎÔ˘, Ë ÔÔ›· ÂÍ·ÚÙ¿Ù·È ¿ÌÂÛ· ·fi ÙËÓ ÂÓÙfiÈÛË Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎ˘Ú‹ÓÈÛË ÙÔ˘ fiÁÎÔ˘, ËÌÈË·ÙÂÎÙÔÌ‹ Î·È - Û¿ÓÈ· - ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (1,4,10,11). ªÂÙ¿ ÙËÓ Ï‹ÚË ·Ê·›ÚÂÛË ÙÔ˘ fiÁÎÔ˘, Ë ÚfiÁÓˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈ΋ Î·È ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÙÒÛÂȘ ˘ÔÙÚÔ‹˜ (3,4). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi Ë·ÙÈÎfi ·Ì¿Úو̷ Â›Ó·È ¤Ó·˜ Û¿ÓÈÔ˜ ηÏÔ‹ı˘ fiÁÎÔ˜. ∏ ÂÈÙ˘¯‹˜ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ÂͤÏÈÍË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È ÛÙËÓ ÂͤÏÈÍË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÙÔ˘ ‹·ÙÔ˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Stringer MD. Liver tumors. Semin Pediatr Surg 2000;9:196-208.

2. Okada A, Fukuzawa M, Oue T, Kohmoto Y, Kusafuka T, Fukui Y et al. Thirty-eight years experience ¶·È‰È·ÙÚÈ΋ 2005;68:446-448

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·448

448

ª. ÷ÛÈÒÙÔ˘ Î·È Û˘Ó.

3.

4.

5.

6.

7.

¶·È‰È·ÙÚÈ΋ 2005;68:446-448

of malignant hepatic tumors in infants and childhood. Eur J Pediatr Surg 1998;8:17-22.

Horton KM, Bluemke DA, Hruban RH, Soyer P, Fishman EK. CT and MR imaging of benign hepatic and biliary tumors. Radiographics 1999;19:431-451.

Balmer B, Le Coultre C, Feldges A, Hanimann B. Mesenchymal liver hamartoma in a newborn. Case report. Eur J Pediatr Surg 1996;6:303-305.

Bartho S, Schulz HJ, Bollmann R, Specht U. Prenatally diagnosed mesenchymal hamartoma of the liver. Zentralbl Pathol 1992;138:141-144.

Mascarello JT, Krous HF. Second report of a translocation involving 19q13.4 in a mesenchymal hamartoma of the liver. Cancer Genet Cytogenet 1992;58:141-142. von Schweinitz D, Gluer S, Mildenberger H. Liver tumors in neonates and very young infants: diag-

8.

9.

10.

11.

nostic pitfalls and therapeutic problems. Eur J Pediatr Surg 1995;5:72-76.

Men S, Hekimoglu B, Tuzun M, Arda IS, Pinar A. Unusual US and CT findings in hepatoblastoma: a case report. Pediatr Radiol 1995;25:507-508.

Kaufman RA. Is cystic mesenchymal hamartoma of the liver similar to infantile hemangioendothelioma and cavernous hemangioma on dynamic computed tomography? Pediatr Radiol 1992;22:582-583.

Shuto T, Kinoshita H, Yamada C, Hirohashi K, Shiokawa C, Kubo S et al. Bilateral lobectomy excluding the caudate lobe for giant mesenchymal hamartoma of the liver. Surgery 1993;113:215-222.

Tepetes K, Selby R, Webb M, Madariaga JR, Iwatsuki S, Starzl TE. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg 1995;130:153156.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·449

CASE REPORT

449

Liver mesenchymal hamartoma. A case report M. Hasiotou1, E. Sammouti2, P. Poliviou2, E. Koskina2

Abstract Primary liver tumours are rare in children, and most are malignant (hepatoblastoma) and associated with a high mortality rate. Of the benign tumours the most common is haemangioendothelioma.

Benign mesenchymal hamartoma is a rare entity, seen mainly in children under the age of two years, which probably represents a developmental anomaly, rather than a true neoplasm. Recent progress in imaging techniques and operating procedures offer, in this case, an excellent prognosis. The case is described of an 8 month-old boy with mesenchymal hamartoma, including the diagnostic approach and the surgical procedure.

Key words Children, liver, mesenchymal hamartoma, computed tomography.

1 Department of CT and MRI Imaging, “Aghia Sophia” Children’s Hospital, Athens 2 Department of Radiology, “Aghia Sophia” Children’s Hospital, Athens Correspondence: E. Sammouti Department of Radiology, “Aghia Sophia” Children’s Hospital, Athens Date of submission: 13-05-2004 Date of approval: 04-07-2005

Paediatriki 2005;68:449

Pediatr Nov-Dec 05

12-12-05

450

15:16

™ÂÏ›‰·450

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

™‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘ ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ˆ˜ ÚÒÙË ÂΉ‹ÏˆÛË ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, §. µÔÁÈ·Ù˙‹, π. ∂˘‰ˆÚ›‰Ô˘, £. ™Ù·ıÔÔ‡ÏÔ˘, ∂. ¢È·Ì·ÓÙ‹ ∞’ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ Î·È ∂ÓÙ·ÙÈ΋ ¡ÔÛËÏ›· ¡ÂÔÁÓÒÓ ∞.¶.£., πÔÎÚ¿ÙÂÈÔ °.¶.¡. £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: µ·ÛÈÏÈ΋ ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E mail: agaki@med.auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-01-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 24-06-2005

¶ÂÚ›ÏË„Ë ¶ÂÚÈÁÚ¿ÊÂÙ·È Û¿ÓÈ· ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ ̠ίڈṲ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi (∫∞À) Î·È ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Ì ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û˘Ó‰ÚfiÌÔ˘ ÂÈÛÚfiÊËÛ˘ ÌËÎˆÓ›Ô˘ (™∂ª), Ô˘ ÔÊ›ÏÔÓÙ·Ó Û ¯ÔÏÒ‰ÂȘ Â̤ÙÔ˘˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÏfiÁˆ ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ Î·È ÌËΈÓȷ΋˜ „¢‰Ô·ÛÙ˘. ∆Ô ÓÂÔÁÓfi ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙËÓ ÎÔÈÏÈ¿. ∏ ˘Ô„›· Ù˘ ÌËΈÓȷ΋˜ „¢‰Ô·ÛÙ˘ Ù¤ıËΠ·fi ÙËÓ „ËÏ¿ÊËÛË ˘fiÛÎÏËÚ˘ Ì¿˙·˜ ˘ÂÚÔÌÊ·ÏÈο. ∏ ‰È¿ÁÓˆÛË Ù˘ ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ ÂȂ‚·ÈÒıËΠ̠˘ÂÚ˯ÔÁÚ·ÊÈÎfi Î·È ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Î·È ·ÓÙÈÌÂÙˆ›ÛÙËΠ¯ÂÈÚÔ˘ÚÁÈο. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ‹Ù·Ó ÔÌ·Ï‹ Î·È ÙÔ ÓÂÔÁÓfi ÂÍ‹Ïı Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. §¤ÍÂȘ ÎÏÂȉȿ ªËΈÓȷ΋ „¢‰Ô·ÛÙË, ¯ÔÏÒ‰ÂȘ ¤ÌÂÙÔÈ, Û‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘ ÌËÎˆÓ›Ô˘.

∂ÈÛ·ÁˆÁ‹ ∏ ·ÚÔ˘Û›· ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ (∫∞À) ·ÔÙÂÏ› Ì›· ·fi ÙȘ Û˘¯ÓfiÙÂÚ˜ ÂÚÈÁÂÓÓËÙÈΤ˜ ÂÈÏÔΤ˜, Ô˘ ··ÈÙ› ÙËÓ ·ÚÔ˘Û›· ÓÂÔÁÓÔÏfiÁÔ˘ ‹ ÂÎ·È‰Â˘Ì¤ÓÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡. ∆Ô ∫∞À ·Ú·ÙËÚÂ›Ù·È Û 6-25% ÙˆÓ ÙÔÎÂÙÒÓ Ô˘ ·ÊÔÚÔ‡Ó Û ÙÂÏÂÈfiÌËÓ· ‹ ·Ú·Ù·Ûȷο ÓÂÔÁÓ¿, ÂÓÒ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Û˘Ó·ÓÙ¿Ù·È Û·ÓÈfiÙÂÚ· (1). ∏ Û˘Ó‹ı˘ ·ÈÙ›· Â›Ó·È Ë ÂÓ‰ÔÌ‹ÙÚÈ· ‹ ÂÚÈÁÂÓÓËÙÈ΋ ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘, Ô˘ ÌÔÚ› Ó· Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ‡·ÚÍË ÂÌ‚Ú˘˚΋˜ ‰˘ÛÚ·Á›·˜. ∆Ô ∫∞À Ú¤ÂÈ Ó· ‰È·¯ˆÚ›˙ÂÙ·È ·fi ÙÔ ˘Ò‰Â˜ ·ÌÓÈ·Îfi ˘ÁÚfi ÏfiÁˆ ÂÓ‰ÔÌ‹ÙÚÈ·˜ Ïԛ̈͢. ∞ÎfiÌË, ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û¿ÓȘ ÂÚÈÙÒÛÂȘ, ÛÙȘ Ôԛ˜ ÙÔ ∫∞À ÔÊ›ÏÂÙ·È fi¯È Û ÂÓ‰ÔÌ‹ÙÚÈ· ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘, ·ÏÏ¿ Û ¯ÔÏÒ‰ÂȘ Â̤ÙÔ˘˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (2-5). ¶ÂÚÈÁÚ¿ÊÂÙ·È Û¿ÓÈ· ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ∫∞À Î·È ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Ì ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û˘Ó‰ÚfiÌÔ˘ ÂÈÛÚfiÊËÛ˘ ÌËÎˆÓ›Ô˘ (™∂ª), Ô˘ ÔÊ›ÏÔÓÙ·Ó Û ¯ÔÏÒ‰ÂȘ Â̤ÙÔ˘˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÏfiÁˆ ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ Î·È ÌËΈÓȷ΋˜ „¢‰Ô·ÛÙ˘.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiˆÚÔ ÓÂÔÁÓfi, ·ÁfiÚÈ, ÁÂÓÓ‹ıËΠÛÙÔ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ·fi ‰Â˘Ù¶·È‰È·ÙÚÈ΋ 2005;68:450-452

ÚÔÙfiÎÔ ÌËÙ¤Ú·, Ì ÁÔÓ›˜ Ê·ÈÓÔÙ˘Èο ˘ÁÈ›˜, ¯ˆÚ›˜ Û˘ÁÁ¤ÓÂÈ· ÌÂٷ͇ ÙÔ˘˜. ∏ ÌËÙ¤Ú·, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ›¯Â Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÛÙ· ∂͈ÙÂÚÈο π·ÙÚ›· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Î·È ‰ÂÓ ·ÚÔ˘Û›·Û ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù·. ∫·Ù¿ ÙÔÓ ÎÔÏÈÎfi ÙÔÎÂÙfi, ·Ú·ÙËÚ‹ıËΠίڈṲ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi. ∆Ô ÓÂÔÁÓfi ›¯Â ∞pgar score 1 ÛÙÔ 1Ô ÏÂÙfi Î·È ˘Ô‚Ï‹ıËΠ۠ÂÓ‰ÔÙÚ·¯Âȷ΋ ‰È·ÛˆÏ‹ÓˆÛË Î·È ·Ó·ÚÚfiÊËÛË, Ë ÔÔ›· ·¤‰ˆÛ ·ÌÓÈ·Îfi ˘ÁÚfi ÎÈÙÚÈÓÔÚ¿ÛÈÓ˘ ¯ÚÔÈ¿˜. ∆Ô ∞pgar score ÛÙÔ 5Ô ÏÂÙfi ‹Ù·Ó 8. ªÂٷʤÚıËΠÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ (ª∂¡¡), fiÔ˘ ÂÊ·ÚÌfiÛÙËΠÌ˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜. ∏ ·/· ıÒÚ·ÎÔ˜ ¤‰ÂÈÍ Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ ¿Ìʈ, Û˘Ì‚·Ù¤˜ Ì ™∂ª. ∞fi ÙȘ ÚÒÙ˜ ÒÚ˜ Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ·Ú·ÙËÚ‹ıËÎ·Ó ÎÈÙÚÈÓÔÚ¿ÛÈÓ· Á·ÛÙÚÈο ˘ÁÚ¿, Ô˘ ·Ô‰fiıËÎ·Ó Û ηٿÔÛË ÌËÎˆÓ›Ô˘ ηٿ ÙÔÓ ÙÔÎÂÙfi. ∆Ô 2Ô ÂÈÎÔÛÈÙÂÙÚ¿ˆÚÔ Ù˘ ÓÔÛËÏ›·˜, ÔÈ ¯ÔÏÒ‰ÂȘ Á·ÛÙÚÈΤ˜ ÂÎÎÚ›ÛÂȘ Â¤ÌÂÓ·Ó. ∫·Ù¿ ÙË Ê˘ÛÈ΋ ÂͤٷÛË Ù˘ ÎÔÈÏ›·˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠÌÂÙˆÚÈÛÌfi˜ ‹ ¢·ÈÛıËÛ›·, ·ÏÏ¿ „ËÏ·Ê‹ıËΠ‰ÈÛÎÔÂȉ‹˜ ˘fiÛÎÏËÚË Ì¿˙· ·ÚÈÛÙÂÚ¿ ˘ÂÚÔÌÊ·ÏÈο, ‰È·Ì¤ÙÚÔ˘ ÂÚ›Ô˘ 2 cm. ¢ÂÓ Â›¯Â ·Ú·ÙËÚËı› ̤¯ÚÈ ÙfiÙ ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘. ™ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ ‰È·ÈÛÙÒıËΠÂ·Û‚ÂÛو̤ÓÔ ÌfiÚʈ̷ ÌÂÁ¤ıÔ˘˜ ÂÚ›Ô˘ 3 cm, Ì ·Ô˘Û›· ·¤Ú· ÛÙËÓ Î¿Ùˆ ÎÔÈÏ›·. ªÂÙ¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÎÔÈÏ›·˜ Î·È ÙË ‰È¿‚·ÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ì ÛÎÈ·ÛÙÈÎfi, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ·ÙÚËÛ›·˜ ÏÂÙÔ‡

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·451

451

™‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘ ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡

ÂÓÙ¤ÚÔ˘ ÛÙÔ ‡„Ô˜ Ù˘ Ó‹ÛÙȉ·˜, Ì Èı·Ó‹ ÌËΈÓȷ΋ ·ÛÙË ÛÙÔ ÛËÌÂ›Ô Ù˘ ·ÙÚËÛ›·˜ (∂ÈÎfiÓ· 1). ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ¤‰ÂÈÍ ÌËΈÓȷ΋ ÂÚÈÙÔÓ›Ùȉ· Ì ۯËÌ·ÙÈÛÌfi „¢‰Ô·ÛÙ˘ Î·È ÔÏÏ·Ϥ˜ Û˘ÌʇÛÂȘ, ηıÒ˜ Î·È ·ÙÚËÛ›· ÛÙË ÌÂÛfiÙËÙ· Ù˘ Ó‹ÛÙȉ·˜. ∞Ê·ÈÚ¤ıËÎÂ Ë ·ÔÙÈٷӈ̤ÓË ÌËΈÓȷ΋ ·ÛÙË, χıËÎ·Ó ÔÈ Û˘ÌʇÛÂȘ Î·È ¤ÁÈÓ ÙÂÏÈÎÔÏ¿ÁÈ· ·Ó·ÛÙfïÛË ÙÔ˘ ÂÁÁ‡˜ Î·È ÙÔ˘ ¿ˆ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ªÂÙ¿ ·fi 26 Ë̤Ú˜ ÓÔÛËÏ›·˜, ÙÔ ÓÂÔÁÓfi ÂÍ‹Ïı Û ηϋ ηٿÛÙ·ÛË. O ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Î·È Ô ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ΢ÛÙÈ΋ ›ÓˆÛË ‹Ù·Ó ·ÚÓËÙÈÎÔ›.

™˘˙‹ÙËÛË ∆Ô ™∂ª ÔÊ›ÏÂÙ·È Û˘Ó‹ıˆ˜ Û ÂÓ‰ÔÌ‹ÙÚÈ· ‹ ÂÚÈÁÂÓÓËÙÈ΋ ÂÈÛÚfiÊËÛË ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ Ô˘ ÂÚȤ¯ÂÈ ÌËÎÒÓÈÔ. ªÔÚ›, fï˜, Ó· ÔÊ›ÏÂÙ·È Î·È Û ÂÈÛÚfiÊËÛË ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ Ô˘ ÂÚȤ¯ÂÈ ¯ÔÏ‹ ÏfiÁˆ ÂÓ‰ÔÌ‹ÙÚÈˆÓ ¯Ôψ‰ÒÓ Â̤وÓ. ∏ ‰È¿ÁÓˆÛË ·˘Ù‹ Â›Ó·È Èı·ÓfiÙÂÚË Û ÂÚÈÙÒÛÂȘ fiÔ˘ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘ ÛÙ· ÚÒÙ· ‰‡Ô ÂÈÎÔÛÈÙÂÙÚ¿ˆÚ· Ù˘

∂ÈÎfiÓ· 1. ∂˘Ú‹Ì·Ù· ·fi ÙË ‰È¿‚·ÛË ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ¢È·ÎÚ›ÓÂÙ·È ÙÔ ÌÈÎÚfiÎÔÏÔ ÏfiÁˆ Ù˘ ·fiÊڷ͢ ÙÔ˘ ÂÈÏÂÔ‡ Î·È Ë Â·Û‚ÂÛو̤ÓË ÌËΈÓȷ΋ „¢‰Ô·ÛÙË ÛÙÔ ÛËÌÂ›Ô ‰È·ÎÔ‹˜ Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘.

˙ˆ‹˜ Î·È È‰È·›ÙÂÚ· Û ÂÚÈÙÒÛÂȘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, ÛÙ· ÔÔ›· ÂÓ‰ÔÌ‹ÙÚÈ· ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘ Û˘Ì‚·›ÓÂÈ Û·ÓÈfiÙÂÚ·. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ∫∞À ÏfiÁˆ ¯Ôψ‰ÒÓ ÂÌ¤ÙˆÓ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, ÁÈ·Ù› Ë ‰È¿ÁÓˆÛË ÌÔÚ› Ó· Á›ÓÂÈ ÌfiÓÔ Â¿Ó ·ÔÎÏÂÈÛÙ› ÙÔ ÂӉ¯fiÌÂÓÔ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ô‚ÔÏ‹˜ ÌËÎˆÓ›Ô˘. ∂Ô̤ӈ˜, ÙÔ ∫∞À ÌÔÚ› Ó· ·Ô‰Ôı› Û ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ ¯ÔÏÒ‰ÂȘ Â̤ÙÔ˘˜ ÌfiÓÔ Û ÂÚÈÙÒÛÂȘ Ì ·fiÊÚ·ÍË ÙÔ˘ ÂÓÙ¤ÚÔ˘, fiˆ˜ ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ∂Ӊ¯Ô̤ӈ˜, ·˘Ùfi˜ Â›Ó·È Ô ÏfiÁÔ˜ ÁÈ· ÙÔÓ ÔÔ›Ô ÂÏ¿¯ÈÛÙ˜ ÂÚÈÙÒÛÂȘ ∫∞À ÏfiÁˆ ¯Ôψ‰ÒÓ ÂÌ¤ÙˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· (2-5). OÈ Griffiths Î·È Burge (5) ÂÚȤÁÚ·„·Ó ÙÚÂȘ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Ì ∫∞À Ô˘ ›¯·Ó ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Î·È ·¤‰ˆÛ·Ó ÙÔ ∫∞À Û ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ ¯ÔÏÒ‰ÂȘ Â̤ÙÔ˘˜. ∆· ¯ÔÏÈο ¿Ï·Ù· Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÌËÎÒÓÈÔ Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÙÔ˘ ™∂ª, ÁÈ·Ù› Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·Ó¿Ù˘ÍË ¯ËÌÈ΋˜ Ó¢ÌÔÓ›Ùȉ·˜, ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ÙË ‰Ú¿ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (6). ªÂ ÙÔ˘˜ ›‰ÈÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜, Ë ‡·ÚÍË ¯ÔÏ‹˜ ÛÙÔ ÂÈÛÚÔÊËı¤Ó ·ÌÓÈ·Îfi ˘ÁÚfi ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·. ∏ ·Í›· Ù˘ ‰È·ÊÔÚÈ΋˜ ‰È¿ÁÓˆÛ˘ ÌÂٷ͇ ∫∞À ÏfiÁˆ ·Ô‚ÔÏ‹˜ ÌËÎˆÓ›Ô˘ Î·È ∫∞À ÏfiÁˆ ¯Ôψ‰ÒÓ ÂÌ¤ÙˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ¤ÁÎÂÈÙ·È ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔΛÌÂÓ˘ ηٿÛÙ·Û˘. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë ·Ú¯È΋ ‰È¿ÁÓˆÛË ‹Ù·Ó ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ·fi ™∂ª, ÏfiÁˆ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ô‚ÔÏ‹˜ ÌËÎˆÓ›Ô˘. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÓ‰ÔÌ‹ÙÚÈ· ·Ô‚ÔÏ‹ ÌËÎˆÓ›Ô˘ ıˆڋıËΠ‰Â‰Ô̤ÓË Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ ÁÈ· 24 ÂÚ›Ô˘ ÒÚ˜, ÂÓÒ Ë ·Ô‚ÔÏ‹ ¯Ôψ‰ÒÓ ÂÎÎÚ›ÛÂˆÓ ·fi ÙÔÓ ÛÙÔÌ·ÙÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· ·Ú¯Èο ·Ô‰fiıËΠÛÙËÓ Î·Ù¿ÔÛË ∫∞À. ™ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ Û˘Ó¤‚·Ï·Ó, Â›Û˘, Ë Î·Ï‹ ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ë ¤ÏÏÂÈ„Ë ‰È¿Ù·Û˘ ‹ ¿ÏÏˆÓ ÂÌÊ·ÓÒ˜ ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·fi ÙËÓ ÎÔÈÏÈ¿. ∏ ˘Ô„›· ·ıÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ·fi ÙÔ ¤ÓÙÂÚÔ Ù¤ıËΠfiÙ·Ó Î·Ù¿ ÙË Û¯ÔÏ·ÛÙÈ΋ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏÈ¿˜ ‰È·ÈÛÙÒıËÎÂ Ë ‡·ÚÍË ÌÈÎÚ‹˜ „ËÏ·ÊËÙ‹˜ Ì¿˙·˜. ∏ ·Ó‡ÚÂÛË ÂÓÙÔÈÛÌ¤ÓˆÓ Â·Û‚ÂÛÙÒÛÂˆÓ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏÈ¿˜ ¤ıÂÛ ÙËÓ ˘Ô„›· ÌËΈÓȷ΋˜ „¢‰Ô·ÛÙ˘, Ô˘ ÂȂ‚·ÈÒıËΠ̠ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜. ™ÙË Û˘Ó¤¯ÂÈ·, Ë ‰È¿‚·ÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·ÔÎ¿Ï˘„ ÙËÓ ·fiÊÚ·ÍË ÙÔ˘ ÂÈÏÂÔ‡. ¶·È‰È·ÙÚÈ΋ 2005;68:450-452

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·452

452

µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘ Î·È Û˘Ó.

∏ ÌËΈÓȷ΋ „¢‰Ô·ÛÙË ·ÔÙÂÏ› ÂÓÙÔÈṲ̂ÓË ÌÔÚÊ‹ Ù˘ ÌËΈÓȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜ (7). ∏ ÌËΈÓȷ΋ ÂÚÈÙÔÓ›Ùȉ· Â›Ó·È ¿ÛËÙË ÊÏÂÁÌÔÓ‹ - ÏfiÁˆ ÂÍfi‰Ô˘ ÌËÎˆÓ›Ô˘ ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· - Î·È ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË ÌËΈÓȷ΋˜ „¢‰Ô·ÛÙ˘, ‰È¿¯˘Ù˘ ÌËΈÓȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜ ‹ ·ÛΛÙË ·fi ÌËÎÒÓÈÔ fiÙ·Ó ‰È¿ÙÚËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Û˘Ì‚Â› Ï›Á˜ ÌfiÓÔ Ë̤Ú˜ ÚÈÓ ÙÔÓ ÙÔÎÂÙfi. ∂¿Ó Ë ‰È¿ÙÚËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÂÍ·ÎÔÏÔ˘ı› Ó· ˘Ê›ÛÙ·Ù·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÌÔÚ› Ó· Â¤ÏıÂÈ ÌÈÎÚԂȷ΋ ÂÈÌfiÏ˘ÓÛË Ù˘ ÌËΈÓȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜ Î·È ÂÈ‚¿Ú˘ÓÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ Î·È Ù˘ ÚfiÁÓˆÛ˘ (7). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÔÈΛÏÏÂÈ Û ‚·Ú‡ÙËÙ·, ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÂÌ‚Ú˘˚ÎÔ‡ ‡‰Úˆ· Ì Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· ̤¯ÚÈ ÙË Á¤ÓÓËÛË ·Û˘Ìو̷ÙÈÎÔ‡ ÓÂÔÁÓÔ‡ ÌÂ Ù˘¯·›· ‰È·›ÛÙˆÛË Â·Û‚ÂÛÙÒÛÂˆÓ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏÈ¿˜ (8). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ˘‹Ú¯·Ó ÂÏ¿¯ÈÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙËÓ ÎÔÈÏÈ¿. ÷ڷÎÙËÚÈÛÙÈÎfi ·ÎÙÈÓÔÁÚ·ÊÈÎfi ‡ÚËÌ· Â›Ó·È ÔÈ Â·Û‚ÂÛÙÒÛÂȘ, Ô˘ ÌÔÚ› Ó· ÂÓÙÔ›˙ÔÓÙ·È fi¯È ÌfiÓÔ ÛÙËÓ ÂÚÈÙÔÓ·˚΋, ·ÏÏ¿ Î·È ÛÙË ıˆÚ·ÎÈ΋ ÎÔÈÏfiÙËÙ· Î·È ÛÙÔ fiÛ¯ÂÔ Ì ÙË ÌÔÚÊ‹ ˘‰ÚÔ΋Ï˘ (9,10). ŒÓ· ¿ÏÏÔ ‰È·ÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· ‹Ù·Ó Ë ·ÈÙ›· Ù˘ ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ Î·È Ù˘ ÌËΈÓȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ ·ÔÙÂÏ› Ë Î˘ÛÙÈ΋ ›ÓˆÛË. ∏ Â›ÙˆÛ‹ Ù˘ Û ÓÂÔÁÓ¿ Ì ÌËΈÓȷ΋ ÂÚÈÙÔÓ›Ùȉ· ÔÈΛÏÏÂÈ ·fi 15% ¤ˆ˜ 40% (11). O ΢ÚÈfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ Â›Ó·È Ô ÂÈÏÂfi˜ ·fi ÌËÎÒÓÈÔ, Ô˘ ·ÔÙÂÏ› ÙËÓ Ù˘È΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ∏ ΢ÛÙÈ΋ ›ÓˆÛË ·Ó·Ê¤ÚÂÙ·È Î·È Û ÂÚÈÙÒÛÂȘ ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ Ì Â›ÙˆÛË 5-12% (11). ∂Ô̤ӈ˜, fiÏ· Ù· ÓÂÔÁÓ¿ Ì ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· ΢ÛÙÈ΋ ›ÓˆÛË, Ë ÔÔ›· Û˘Ó‰¤ÂÙ·È Ì ‚·ÚÈ¿ ÚfiÁÓˆÛË. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ¤ÁÈÓ ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜, ÛÙÔÓ ÔÔ›Ô ‰ÂÓ ‰È·ÈÛÙÒıËΠοÔÈ· ÁÓˆÛÙ‹ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘. ∏ ·fiÊÚ·ÍË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·Ô‰fiıËΠÛÂ Û˘ÁÁÂÓ‹ ·ÙÚËÛ›· ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ÂÓÒ Î·Ù¿ ÙËÓ Â¤Ì‚·ÛË ·ÔÎÏ›ÛÙËÎ·Ó ¿ÏϘ ηٷÛÙ¿ÛÂȘ, fiˆ˜ Â›Ó·È Ë ·ÙÂÏ‹˜ ÂÚÈÛÙÚÔÊ‹ ÙÔ˘ ÂÓÙ¤ÚÔ˘ (malrotation) Î·È Ë Û˘ÛÙÚÔÊ‹ ÙÔ˘ (volvulus), Ô

¶·È‰È·ÙÚÈ΋ 2005;68:450-452

ÂÁÎÔÏ·ÛÌfi˜ Î·È Ë ·ÚÔ˘Û›· Ù·ÈÓÈÒÓ ÙÔ˘ Ladd. ∞fi ÙËÓ ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ ηٷ‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ë ·ÚÔ˘Û›· ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ ‰ÂÓ ÔÊ›ÏÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ‡·ÚÍË ÌËÎˆÓ›Ô˘, ·ÏÏ¿ Î·È Û ¿ÏÏ· ·›ÙÈ·, fiˆ˜ ·ÚÔ˘Û›· ¯ÔÏ‹˜ ÛÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi ÏfiÁˆ ·fiÊڷ͢ ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ÂÓÙ¤ÚÔ˘, Ô˘ ·Ó ‰ÂÓ ‰È·ÁÓˆÛÙ› ¤ÁηÈÚ·, ÌÔÚ› Ó· ¤¯ÂÈ Î·Î‹ ¤Î‚·ÛË.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Ghidini A, Spong CY. Severe meconium aspiration syndrome is not caused by aspiration of meconium.

Am J Obstet Gynecol 2001;185:931-938.

2. Akindele JA. Intestinal bilious vomiting: an unusual presentation of intestinal atresia in the newborn. Afr J Med Med Sci 1994;23:193-194.

3. Williams J, Zakut H, Cohen D, Nissan S. Meconium-like staining of amniotic fluid due to high fetal intestinal obstruction. Case report. Br J Obstet Gynaecol 1978;85:713-714.

4. Swarte RM, Hack WW, Roex AJ, Ekkelkamp S. Green amniotic fluid as initial symptom of high intestinal obstruction in infants. Ned Tijdschr Geneeskd. 1997;141:202-204.

5. Griffiths DM, Burge DM. When is meconium stained liquor actually bile stained vomit? Arch Dis Child 1988;63:201-202.

6. Moses D, Holm BA, Spitale P, Liu MY, Enhorning G. Inhibition of pulmonary surfactant function by meconium. Am J Obstet Gynecol 1991;164:477-481.

7. Ryckman FC. Selected anomalies and intestinal obstruction. In: Fanaroff AA, Martin RJ, editors.

Neonatal-Perinatal Medicine. 7th ed. St. Louis: Mosby, Inc; 2002. p. 1291.

8. Estroff JA, Bromley B, Benacerraf BR. Fetal meconium peritonitis without sequelae. Pediatr Radiol 1992;22:277-278.

9. Salman AB, Karaoglanoglu N, Suma S. Abdominal, scrotal, and thoracic calcifications owing to healed meconium peritonitis. J Pediatr Surg 1999;34:14151416.

10. Das A, Murphy A, McMahon M, Gormally SM, Corbally M. Fetal meconium peritonitis: the “vanishing hydrocele” sign [Images in neonatal medicine]. Arch Dis Child Fetal Neonatal Ed 2003;88:F74.

11. Casaccia G, Trucchi A, Nahom A, Aite L, Lucidi V, Giorladino C et al. The impact of cystic fibrosis on neonatal intestinal obstruction: the need for prenatal/neonatal screening. Pediatr Surg Int 2003;19: 75-78.

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·453

CASE REPORT

453

Intestinal atresia presenting at birth with aspiration of meconium-like-stained amniotic fluid V. Drossou - Agakidou, L. Bogiatzi, I. Eudoridou, T. Stathopoulou, E. Diamanti

Abstract A rare case is reported of a neonate born with meconium-like-stained amniotic fluid (M-L-SAF), who presented with respiratory distress and radiological findings compatible with meconium aspiration syndrome. The M-L-SAF was attributed to bilious vomiting in utero secondary to intestinal atresia and the formation of a meconium pseudocyst. The baby’s general condition was good. The meconium pseudocyst was suspected on palpation of a mass in the supra-umbilical region. The intestinal atresia and pseudocyst were confirmed by ultrasound and X-ray examination and were treated surgically. The baby had an uneventful post-operative course and was discharged home in good condition.

1st Department of Neonatology and Neonatal Intensive Care Unit of Aristotle University, Ippokration General Hospital, Thessaloniki Correspondence: Vassiliki Drossou-Agakidou 28 Glinou Str., 543 52, Thessaloniki E mail: agaki@med.auth.gr Date of submission: 10-01-2005 Date of approval: 24-06-2005

Key words Meconium pseudocyst, bilious vomiting, meconium aspiration syndrome.

Paediatriki 2005;68:453

Pediatr Nov-Dec 05

12-12-05

454

15:16

™ÂÏ›‰·454

¶ƒ∞∫∆π∫√ £∂ª∞

∫·Ú‰È·ÁÁÂȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ¿ÛÎËÛË Û ·È‰È¿, ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ. ¶ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ 1 ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” 2 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÙÙÈÎfiÓ”, ÷˚‰¿ÚÈ AÏÏËÏÔÁÚ·Ê›·: ¢ËÌ‹ÙÚ˘ °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ ∏Úȉ·ÓÔ‡ 16, ∆.∫. 115 28, ∞ı‹Ó· E-mail: geodim4@hotmail.com

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-06-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-07-2005

¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜1, ∫. ¢Ô‡ÚÔ˜2

¶ÂÚ›ÏË„Ë O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÂÓfi˜ Ó·ÚÔ‡ ·ıÏËÙ‹ Â›Ó·È ¤Ó· ÙÚ·ÁÈÎfi Î·È ÌË ·Ó·ÌÂÓfiÌÂÓÔ ÁÂÁÔÓfi˜, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ ÙfiÛÔ ÛÙÔ Â˘Ú‡ ÎÔÈÓfi fiÛÔ Î·È ÛÙËÓ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ·. ∆· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ÔÊ›ÏÔÓÙ·È Û ηډȷÁÁÂȷο ·›ÙÈ·, Ë ÁÓÒÛË ÙˆÓ ÔÔ›ˆÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ ÚÔ·ıÏËÙÈÎfi ¤ÏÂÁ¯Ô. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ˘ÔÏÔÁ›˙ÂÙ·È Û ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ·Ó¿ 200.000 ·ıÏËÙ¤˜ ÂÙËÛ›ˆ˜. ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Û ¿ÙÔÌ· Ó·ڋ˜ ËÏÈΛ·˜ (<35 ÂÙÒÓ) Â›Ó·È Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· (36%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ (19%). ™ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù·, ›Ù ·Ì¤Ûˆ˜ ÚÈÓ ·fi ÙÔ Û˘Ì‚¿Ó ›Ù ηٿ ÙÔ˘˜ Ì‹Ó˜ Ô˘ ÚÔËÁ‹ıËηÓ, ÂÓÒ Ô ı¿Ó·ÙÔ˜ Â¤Ú¯ÂÙ·È ·ÈÊÓȉ›ˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· οÔÈÔ˘ ·ÁÒÓ· ‹, Û˘¯ÓfiÙÂÚ·, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚÔfiÓËÛ˘ (64%). ∂ÊfiÛÔÓ ˘¿Ú¯ÂÈ Î¿ÔÈÔ Úfi‰ÚÔÌÔ Û‡Ìو̷, ·˘Ùfi Û˘Ó‹ıˆ˜ Â›Ó·È ˙¿ÏË Î·È Û·ÓÈfiÙÂÚ· ÚÔοډÈÔ ¿ÏÁÔ˜, ‰‡ÛÓÔÈ·, Ì˘˚΋ ·‰˘Ó·Ì›· Î·È Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È·. ∞ÎÚÔÁˆÓÈ·›Ô˜ Ï›ıÔ˜ ÙÔ˘ ÚÔ·ıÏËÙÈÎÔ‡ ÂϤÁ¯Ô˘ Â›Ó·È ÙÔ ÈÛÙÔÚÈÎfi - ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi - Î·È Ë ÚÔÛÂÎÙÈ΋ ÂͤٷÛË ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. π‰È·›ÙÂÚË ‚·Ú‡ÙËÙ· Ú¤ÂÈ Ó· ‰›‰ÂÙ·È ÛÙËÓ ·Ó·˙‹ÙËÛË Û˘ÌÙˆÌ¿ÙˆÓ Î·Ù¿ ÙËÓ ÎfiˆÛË Î·È ÛÙËÓ ‡·ÚÍË ÂÚÈÛÙ·ÙÈÎÒÓ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ÛÂ Û˘ÁÁÂÓÈο ¿ÙÔÌ· Ó·ڋ˜ ËÏÈΛ·˜. ¶·Ú·ÔÌ‹ Û ηډÈÔÏfiÁÔ ··ÈÙÂ›Ù·È Û ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, ηıÒ˜ Â›Û˘ Î·È Û ‰Â‰Ô̤Ó˜ ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜ (.¯. ¤Ó·ÚÍË Û˘ÛÙËÌ·ÙÈ΋˜ ÂÓ·Û¯fiÏËÛ˘ Ì οÔÈÔ ¿ıÏËÌ·). O Û˘Ó‹ı˘ ηډÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· Î·È Ë¯ÔηډÈÔÁÚ¿ÊËÌ·, ÂÓÒ - ·Ó·ÏfiÁˆ˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ - ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› Ó· Á›ÓÔ˘Ó ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘, ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· 24ÒÚÔ˘, ·ÎfiÌË Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· - ·ÁÁÂÈÔÁÚ·Ê›· ηډȿ˜. §¤ÍÂȘ ÎÏÂȉȿ ÕÛÎËÛË, ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜, ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜.

∂ÈÛ·ÁˆÁ‹ O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ηٿ ÙËÓ ¿ÛÎËÛË ·ÔÙÂÏ› ·‰È·ÊÈÏÔÓ›ÎËÙ· ¤Ó· ÙÚ·ÁÈÎfi ÁÂÁÔÓfi˜, ÙÔ ÔÔ›Ô - ·Ó Î·È Û¿ÓÈÔ - Û˘ÁÎÏÔÓ›˙ÂÈ ÙËÓ ÎÔÈÓ‹ ÁÓÒÌË, ‰ÈfiÙÈ ·ÊÂÓfi˜ Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ Û Ó·ڿ ¿ÙÔÌ·, Ù· ÔÔ›· ÏfiÁˆ Ù˘ ÂÓ·Û¯fiÏËÛ‹˜ ÙÔ˘˜ Ì ÙÔÓ ·ıÏËÙÈÛÌfi ıˆÚÔ‡ÓÙ·È ÚfiÙ˘· ˘Á›·˜, ·ÊÂÙ¤ÚÔ˘ ÛÙË ÛËÌÂÚÈÓ‹ ÂÔ¯‹ Ù˘ “ÙËÏÂÔÙÈ΋˜ ΢ÚÈ·Ú¯›·˜” Ôχ Û˘¯Ó¿ ÙÔ ÎÔÈÓfi ηı›ÛÙ·Ù·È Ì¿ÚÙ˘Ú·˜ Ù˘ ˙ˆÓÙ·Ó‹˜ ·Ó·ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ı·Ó¿ÙÔ˘ ÂÓfi˜ ·ıÏËÙ‹. ª›· ¿ÏÏË ·Ú¿ÌÂÙÚÔ˜ Ô˘ ‰ÈηÈÔÏÔÁ› ÙÔ ˙ˆËÚfi ÂӉȷʤÚÔÓ Â›Ó·È Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚ· Ó·ڿ ¿ÙÔÌ·, ·fi ÌÈÎÚ‹ Ì¿ÏÈÛÙ· ËÏÈΛ·, ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔÓ ·ıÏËÙÈÛÌfi. ∏ ÂÓ·Û¯fiÏËÛË ·˘Ù‹, ÂÊfiÛÔÓ ‚¤‚·È· Á›ÓÂÙ·È Û ÔÚÁ·ÓˆÌ¤Ó· ¶·È‰È·ÙÚÈ΋ 2005;68:454-459

·ıÏËÙÈο ΤÓÙÚ· Î·È ˘fi ·Ú·ÎÔÏÔ‡ıËÛË, ÚÔÛʤÚÂÈ ÔÏÏ¿ ÔʤÏË ÛÙÔ ·È‰›, ÙfiÛÔ ¿ÌÂÛ· fiÛÔ Î·È Ì·ÎÚÔÚfiıÂÛÌ·. ∆Ô ÂÚÒÙËÌ·, fï˜, Ô˘ ‰ÈηÈÔÏÔÁË̤ӷ ··Û¯ÔÏ› ÙÔ˘˜ ÁÔÓ›˜ Â›Ó·È fiÛÔ ·ÛÊ·Ï‹˜ Â›Ó·È Ë ¿ıÏËÛË ÂÓ Á¤ÓÂÈ Î·È ÙÈ Ú¤ÂÈ Ó· Á›ÓÂÈ ÒÛÙ ӷ ÚÔÏËÊıÔ‡Ó Ù· Û¿ÓÈ· ¤ÛÙˆ - ÂÚÈÛÙ·ÙÈο ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘. ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ Ù˘ ÚfiÏ˄˘ ı· ÙÔ ÂˆÌÈÛÙÔ‡Ó ÔÈ ÁÂÓÈÎÔ› È·ÙÚÔ›, ÔÈ ·ıÔÏfiÁÔÈ Î·È ÔÈ ·È‰›·ÙÚÔÈ, ÂÓÒ ÔÈ ·È‰ÔηډÈÔÏfiÁÔÈ Î·È ÔÈ Î·Ú‰ÈÔÏfiÁÔÈ ı· ·ÔÙÂϤÛÔ˘Ó ÙË ‰Â‡ÙÂÚË ÁÚ·ÌÌ‹ ¿Ì˘Ó·˜, ÂϤÁ¯ÔÓÙ·˜ ÂÈÏÂÁ̤ӷ ÂÚÈÛÙ·ÙÈο. ™˘ÓÂÒ˜, ÁÈ· Ó· ÌÔÚ¤ÛÔ˘Ó ÔÈ ÂӉȷÊÂÚfiÌÂÓÔÈ È·ÙÚÔ› Ó· Ú·ÁÌ·ÙÔÔÈ‹ÛÔ˘Ó ¤Ó·Ó fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ ÚÔ·ıÏËÙÈÎfi ¤ÏÂÁ¯Ô, ı· Ú¤ÂÈ Ó· ÁÓˆÚ›˙Ô˘Ó ÔÈ· Â›Ó·È Ù· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·455

455

ÕÛÎËÛË Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜

ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ¿ÛÎËÛË, Ò˜ Â›Ó·È ‰˘Ó·Ùfi Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË ‹ ¤ÛÙˆ Ë ˘Ô„›· ÁÈ· ÙËÓ ‡·ÚÍ‹ ÙÔ˘˜ Î·È Ò˜ ÂÓ Á¤ÓÂÈ Ú¤ÂÈ Ó· ÔÚÁ·Óˆı› ¤Ó· ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ÂϤÁ¯Ô˘ Ì ÙË Û˘ÓÂÚÁ·Û›· ·ıÔÏfiÁˆÓ, ·È‰È¿ÙÚˆÓ, ηډÈÔÏfiÁˆÓ Î·È ·È‰ÔηډÈÔÏfiÁˆÓ.

OÚÈÛÌfi˜ - ™˘¯ÓfiÙËÙ· ø˜ ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ηٿ ÙËÓ ¿ÛÎËÛË ÔÚ›˙ÂÙ·È Ô ı¿Ó·ÙÔ˜ Ô˘ Â›Ó·È ÌË ·Ó·ÌÂÓfiÌÂÓÔ˜ Î·È Â¤Ú¯ÂÙ·È Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù·, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ıÏËÛ˘, Ù˘ ÚÔfiÓËÛ˘ ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿. °ÂÓÈο, ‰ÂÓ ˘¿Ú¯Ô˘Ó Ï‹ÚË Î·È Û·Ê‹ ÛÙÔȯ›· ÁÈ· ÙË Û˘¯ÓfiÙËÙ¿ ÙÔ˘, ·ÎfiÌË Î·È Û ÚÔËÁ̤Ó˜ ¯ÒÚ˜ fiˆ˜ ÔÈ ∏¶∞. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ 5/100.000 ·ıÏËÙ¤˜ ¿Û¯Ô˘Ó ·fi οÔÈ· ¿ıËÛË, Ë ÔÔ›· ‰˘ÓËÙÈο ı· ÌÔÚÔ‡Û ӷ ÚÔηϤÛÂÈ ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ (1). ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ˘ÔÏÔÁ›˙ÂÙ·È Û 1:100.000 - 1:300.000 ·ıÏËÙ¤˜ ·Ó¿ ¤ÙÔ˜ (2) Ì ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ó· Û˘ÌʈÓÔ‡Ó Û ̛· ̤ÛË Û˘¯ÓfiÙËÙ· 1:200.000 ÂÚÈÛÙ·ÙÈο ·Ó¿ ¤ÙÔ˜ (1). ™ÙȘ ∏¶∞ οı ¯ÚfiÓÔ Û˘ÌÌÂÙ¤¯Ô˘Ó Û ÔÚÁ·ÓˆÌ¤Ó˜ ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÂÚ›Ô˘ 6.000.000 ¿ÙÔÌ· ÚÔÂÊË‚È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ (Ô˘ ÊÔÈÙÔ‡Ó Û Á˘ÌÓ¿ÛÈÔ ‹ ÎÔϤÁÈÔ) (3) Î·È ÙÂÏÈο Û˘Ì‚·›ÓÔ˘Ó 25-30 ÂÚÈÛÙ·ÙÈο ÂÙËÛ›ˆ˜ (4). °È· ÙËÓ ∂ÏÏ¿‰· ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ·ÓÙ›ÛÙÔȯ· ÛÙÔȯ›·, ·ÏÏ¿ Ì ‚¿ÛË Ù· ·ÓˆÙ¤Úˆ Ë ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· Ú¤ÂÈ Ó· Â›Ó·È 1 ÂÚÈÛÙ·ÙÈÎfi ·Ó¿ ¤ÙÔ˜. À¿Ú¯ÂÈ, ¿ÓÙˆ˜, ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ʇϷ, Ì ÙË Û˘¯ÓfiÙËÙ· ÛÙÔ˘˜ ¿Ó‰Ú˜ Ó· Î˘Ì·›ÓÂÙ·È Û 1:133.000 Û‡Ìʈӷ Ì ̛· ÌÂϤÙË (5), ÂÓÒ ÛÙȘ Á˘Ó·›Î˜ ·ÓÙ›ÛÙÔȯ· ÌÂÈÒÓÂÙ·È Û 1:769.000.

ÛÎÚÔ˘ÛË Ì ¿ÏÏÔ ·ıÏËÙ‹. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, Ô ı¿Ó·ÙÔ˜ Ê·›ÓÂÙ·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ÚfiÎÏËÛË ÎÔÈÏȷ΋˜ ·ÚÚ˘ıÌ›·˜. ∆· ÂÚÈÛÛfiÙÂÚ· ÂÚÈÛÙ·ÙÈο Û˘Ì‚·›ÓÔ˘Ó ÂÚ› ÙËÓ ËÏÈΛ· ÙˆÓ 17 ÂÙÒÓ. ™ÙË Û˘ÓÙÚÈÙÈ΋ ÙÔ˘˜ ÏÂÈÔ„ËÊ›· ÚfiÎÂÈÙ·È ÁÈ· ·ÁfiÚÈ· (90%) Î·È ÙÔ 70% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·ÊÔÚ¿ Û ·ıÏËÙ¤˜ ÙÔ˘ Ô‰ÔÛÊ·›ÚÔ˘ Î·È Ù˘ ηϷıÔÛÊ·›ÚÈÛ˘. ∆Ô 90% ÙˆÓ ı·Ó¿ÙˆÓ Â‹Ïı ηٿ ÙËÓ ¿ÛÎËÛË ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿, ÂÓÒ ÙÔ ˘fiÏÔÈÔ 10% Û ¿ÙÔÌ· Ô˘ ·Û¯ÔÏÔ‡ÓÙ·Ó ÌÂÓ Û˘ÛÙËÌ·ÙÈο Ì ÙÔÓ ·ıÏËÙÈÛÌfi, ·ÏÏ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ‹È·˜ ¿ÛÎËÛ˘ (Û˘Ó‹ıˆ˜ ¯·Ï·Úfi ÙÚ¤ÍÈÌÔ) Ô˘ ‰ÂÓ Â›¯Â ¿ÌÂÛË Û¯¤ÛË Ì ÙÔ ¿ıÏËÌ·. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Ù· 2/3 ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ (64%) Û˘Ó¤‚ËÛ·Ó fi¯È ηٿ ÙË ‰È¿ÚÎÂÈ· οÔÈÔ˘ ·ÁÒÓ·, ·ÏÏ¿ ηٿ ÙËÓ ÚÔfiÓËÛË. ∂›Ó·È ÛËÌ·ÓÙÈÎfi fiÙÈ ÌfiÓÔ ÙÔ 10% ÙˆÓ ·Ôı·ÓfiÓÙˆÓ Â›¯Â ÂÌÊ·Ó›ÛÂÈ Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· Ï›ÁÔ ÚÈÓ ·fi ÙÔ Û˘Ì‚¿Ó (ÚÔοډÈÔ ¿ÏÁÔ˜, ˙¿ÏË, ‰‡ÛÓÔÈ·, Ì˘˚΋ ·‰˘Ó·Ì›·). ∂›Û˘, ηٿ ÙÔ˘˜ ÚÔËÁÔ‡ÌÂÓÔ˘˜ ‰ÂηÔÎÙÒ Ì‹Ó˜, ÔÛÔÛÙfi ÌfiÓÔ 18% ›¯Â ·Ú·ÔÓÂı› ÁÈ· οÔȘ ·fi ÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ ÂÓԯϋÛÂȘ ηٿ ÙËÓ ¿ÛÎËÛË, ¯ˆÚ›˜ fï˜ Ó· ÙÔ˘˜ ‰Ôı› Ë ··Ú·›ÙËÙË ÚÔÛÔ¯‹. ∞fi ÙȘ ÂÓԯϋÛÂȘ, Ë Û˘¯ÓfiÙÂÚË ‹Ù·Ó Ë ˙¿ÏË (ÙÔ ‹ÌÈÛ˘ ÙˆÓ ·ÙfiÌˆÓ ·˘ÙÒÓ, ‰ËÏ·‰‹ ÙÔ 9%, ›¯Â ÂÌÊ·Ó›ÛÂÈ 1-10 ÂÂÈÛfi‰È·). ™ÙȘ Á˘Ó·›Î˜, Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ¿Ó‰Ú˜, ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ‰ÂÓ Â›Ó·È Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· (15%), ·ÏÏ¿ ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ (40%). Ÿˆ˜ ÚԷӷʤÚıËÎÂ, ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ - Î·È Ì¿ÏÈÛÙ· Ì ‰È·ÊÔÚ¿ Â›Ó·È Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· (1). µ¤‚·È·, ÙÔ Ú·ÁÌ·ÙÈÎfi ÔÛÔÛÙfi ÌÔÚ› Ó· Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚÔ Î·È Ó· ÊÙ¿ÓÂÈ ÙÔ ¶›Ó·Î·˜ 1. ∫·Ú‰È·ÁÁÂȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘

∞›ÙÈ· - ∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ∆· Û˘¯ÓfiÙÂÚ· ηډȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û ¿ÙÔÌ· Ó·ڋ˜ ËÏÈΛ·˜ (οو ÙˆÓ 35 ÂÙÒÓ) Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (6). ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 35-40 ÂÙÒÓ, ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›Ó·È Û·ÊÒ˜ Ë ÈÛ¯·ÈÌÈ΋ ηډÈÔ¿ıÂÈ·. ∂ÎÙfi˜, fï˜, ·fi Ù· ηډȷÁÁÂȷ΋˜ ÚÔ¤Ï¢Û˘ ·›ÙÈ·, ˘¿Ú¯Ô˘Ó Î·È Â͈ηډȷο, Ù· ÔÔ›· ·Ó¤Ú¯ÔÓÙ·È ÛÙÔ 15% ÙÔ˘ Û˘ÓfiÏÔ˘. ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ˘¿ÁÔÓÙ·È Ë Î·Ù¿¯ÚËÛË Ô˘ÛÈÒÓ (Ó·ÚΈÙÈο, ·Ó·‚ÔÏÈο), Ë ıÂÚÌÔÏËÍ›·, Ë ÓÈÁÌÔÓ‹, Ô ‚ÚÔÁ¯fiÛ·ÛÌÔ˜ Î·È ÙÔ ÎÙ‡ËÌ· ÛÙÔ ÚÔοډÈÔ, ›Ù ·fi Ì¿Ï· ›Ù ·fi Úfi-

∞›ÙÈ· ÀÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ∞‡ÍËÛË Î·Ú‰È·Î‹˜ Ì¿˙·˜ ƒ‹ÍË ·Ó¢ڇÛÌ·ÙÔ˜ ·ÔÚÙ‹˜ ™Ù¤ÓˆÛË ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ π‰ÈÔ·ı‹˜ ›ÓˆÛË ª˘Ôηډ›Ùȉ· ¢È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ∞ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰ÂÍÈ¿ ÎÔÈÏ›· ¶ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜ ™ÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ™˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ¢È¿ÊÔÚ·

™˘¯ÓfiÙËÙ· 36% 19% 10% 5% 5% 3% 3% 3% 3% 2% 2% 1,5% 1,5% ¶·È‰È·ÙÚÈ΋ 2005;68:454-459

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·456

456

¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ Î·È Û˘Ó.

46%, Â¿Ó Û˘Ó˘ÔÏÔÁÈÛÙÔ‡Ó Î·È ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ·‡ÍËÛË Ù˘ ηډȷ΋˜ Ì¿˙·˜ (10%). ¶ÚfiÎÂÈÙ·È ÁÈ· ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜, ηٿ ÙË ÓÂÎÚÔ„›·, ‰È·ÈÛÙÒÓÂÙ·È ˘ÂÚÙÚÔÊ›· Ù˘ ηډȿ˜ ¯ˆÚ›˜ οÔÈÔ ·ÓȯÓ‡ÛÈÌÔ ·›ÙÈÔ, ·ÏÏ¿ Î·È ¯ˆÚ›˜ Û·Ê‹ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ˘ÂÚÙÚÔÊÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ Î·È ÁÈ· ÙÔÓ ÏfiÁÔ ·˘Ùfi Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û ȉȷ›ÙÂÚË Î·ÙËÁÔÚ›·. ∏ ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Â›Ó·È ÓfiÛÔ˜ ÎÏËÚÔÓÔÌÔ‡ÌÂÓË Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ·ÏÏ¿ Ì ÌÂÙ·‚ÏËÙ‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ·. ∞Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÓÙÔÈṲ̂ÓË, ·Û‡ÌÌÂÙÚË ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, Û˘ÓËı¤ÛÙÂÚ· ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜. πÛÙÔÏÔÁÈο ·Ú·ÙËÚÂ›Ù·È ·ÓÒÌ·ÏË ‰È¿Ù·ÍË ÙˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ (myocardial disarray). §fiÁˆ Ù˘ ˘ÂÚÙÚÔÊ›·˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÎÏËı› ‰˘Ó·ÌÈ΋ ·fiÊÚ·ÍË ÙÔ˘ ¯ÒÚÔ˘ ÂÍfi‰Ô˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, Û˘ÓËı¤ÛÙÂÚ· ηٿ ÙËÓ ¿ÛÎËÛË. ™˘¯Ó¤˜ ›ӷÈ, Â›Û˘, ÔÈ ÎÔÈÏȷΤ˜ ·ÚÚ˘ı̛˜ ηÈ, Ì¿ÏÈÛÙ·, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· Î·È ÙÔÓ ‚·ıÌfi Ù˘ ·fiÊڷ͢. OÈ ·ÚÚ˘ı̛˜ ·˘Ù¤˜ ıˆÚÔ‡ÓÙ·È Î·Ù’ ÂÍÔ¯‹Ó ˘‡ı˘Ó˜ ÁÈ· Ù· ÂÂÈÛfi‰È· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘. ∂Âȉ‹ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ‰ÂÓ ¤¯Ô˘Ó ÙȘ ›‰È˜ Èı·ÓfiÙËÙ˜ ÁÈ· ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ, ¤¯Ô˘Ó Á›ÓÂÈ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·Ú·ÁfiÓÙˆÓ Ô˘ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·˘Ùfi (7). ∆¤ÙÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ıˆÚÔ‡ÓÙ·È: ·) ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘, ‰ËÏ·‰‹ ‰‡Ô ÂÂÈÛfi‰È· ÛÂ Û˘ÁÁÂÓ›˜ ·ã ‚·ıÌÔ‡ ËÏÈΛ·˜ <40 ÂÙÒÓ, ‚) ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ Û˘ÁÎÔÙÈÎfi ÂÂÈÛfi‰ÈÔ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 12 Ì‹Ó˜, Á) ÌË ÂÈ̤ÓÔ˘Û· ÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›· ÛÙÔ Holter Ú˘ıÌÔ‡ (3 ÙÔ˘Ï¿¯ÈÛÙÔÓ Û˘ÌϤÁÌ·Ù· QRS ÌÂ Û˘¯ÓfiÙËÙ· >120/min, ‰È¿ÚÎÂÈ·˜ <30 sec), ‰) ÌË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÛÙË ‰ÔÎÈÌ·Û›· ÎÔÒÛˆ˜ (ÙÒÛË ‹ ÌË ·‡ÍËÛË) Î·È Â) ¿¯Ô˜ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ ≥30 mm. ∏ ·ÚÔ˘Û›· ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ·Ú·ÁfiÓÙˆÓ Û˘Óԉ‡ÂÙ·È ·fi ÂÙ‹ÛÈÔ Î›Ó‰˘ÓÔ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ 4-5%, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË Û˘ÌÌÂÙÔ¯‹ ‹ ÌË Û ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜. ŒÓ· Ôχ ÂӉȷʤÚÔÓ Î·È Û˘¯Ó¿ ‰˘ÛÂ›Ï˘ÙÔ Úfi‚ÏËÌ· Â›Ó·È Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·Ó¿ÌÂÛ· ÛÙËÓ ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Î·È ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ˘ÂÚÙÚÔÊ›· Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÌÂÚÈÎÔ‡˜ ·ıÏËÙ¤˜ ˘„ËÏÒÓ ÂȉfiÛÂˆÓ (8). ∞ıÏËÙ¤˜ Ô˘ Á˘ÌÓ¿˙ÔÓÙ·È ÁÈ· ÌÂÁ¿¶·È‰È·ÙÚÈ΋ 2005;68:454-459

ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Û Â›Â‰Ô ÚˆÙ·ıÏËÙÈÛÌÔ‡, ÂÌÊ·Ó›˙Ô˘Ó Ì›· Ê˘ÛÈÔÏÔÁÈ΋ ¿¯˘ÓÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ÙÔȯˆÌ¿ÙˆÓ ̤۷ ÛÙÔ Ï·›ÛÈÔ Ù˘ ÚÔÛ·ÚÌÔÁ‹˜ ÛÙȘ ··ÈÙ‹ÛÂȘ Ù˘ ¤ÓÙÔÓ˘ ¿ÛÎËÛ˘. ∂ȉÈο Û ÔÚÈṲ̂ӷ ·ıÏ‹Ì·Ù·, fiˆ˜ ÔÈ ‰ÚfiÌÔÈ ÌÂÁ¿ÏˆÓ ·ÔÛÙ¿ÛˆÓ, Ë ÎÔχ̂ËÛË, Ë Ô‰ËÏ·Û›· Î·È Ë ÎˆËÏ·Û›·, Ë Ê˘ÛÈÔÏÔÁÈ΋ ·˘Ù‹ ˘ÂÚÙÚÔÊ›· Â›Ó·È ÈÔ ÛËÌ·ÓÙÈ΋ Î·È ÈÔ Û˘¯Ó‹. ™ÙÔȯ›· Ù· ÔÔ›· ‚ÔËıÔ‡Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: ·) ™ÙÔ˘˜ ·ıÏËÙ¤˜ Û˘Ó‹ıˆ˜ Ë ˘ÂÚÙÚÔÊ›· Â›Ó·È Û˘ÌÌÂÙÚÈ΋. ‚) ŸÙ·Ó Ë ˘ÂÚÙÚÔÊ›· ·ÊÔÚ¿ ÌfiÓÔ ÛÙÔ ÌÂÛÔÎÔÈÏÈ·Îfi ‰È¿ÊÚ·ÁÌ·, ÙfiÙÂ Û˘Ó‹ıˆ˜ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 12-13 mm, ÂÓÒ ÛÙËÓ ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Û˘Ó‹ıˆ˜ Â›Ó·È ≥16 mm. Á) ªfiÓÔ ÛÙÔ 2ò ÙˆÓ ·ıÏËÙÒÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› ¿¯Ô˜ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ >13 mm Î·È ·˘Ùfi ·ÊÔÚÔ‡Û ·ÔÎÏÂÈÛÙÈο Û ·ıÏËÙ¤˜ ·Û¯ÔÏÔ‡ÌÂÓÔ˘˜ Ì ÙËÓ Ô‰ËÏ·Û›· Î·È ÙËÓ ÎˆËÏ·Û›·. ‰) ™Â η̛· Á˘Ó·›Î·-·ıÏ‹ÙÚÈ· ‰ÂÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› ¿¯Ô˜ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ >13 mm. Â) ™ÙÔ ∏∫° Â› ˘ÂÚÙÚÔÊÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ Û˘Ó‹ıˆ˜ ˘¿Ú¯Ô˘Ó ‚·ıÈ¿ Q Î·È ·ÚÓËÙÈο ∆. ÛÙ) ™ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·, Ë ÙÂÏԉȷÛÙÔÏÈ΋ ‰È¿ÌÂÙÚÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Â›Ó·È Û˘Ó‹ıˆ˜ >55 mm, ÂÓÒ ÛÙËÓ ˘ÂÚÙÚÔÊÈ΋ <45 mm. ˙) ™ÙÔ Doppler Ù˘ ÌÈÙÚÔÂȉԇ˜ ÛÙËÓ ˘ÂÚÙÚÔÊÈ΋ Ë Û¯¤ÛË Ù˘ ÚÒÈÌ˘ (·̷ ∂) ÚÔ˜ ÙËÓ ÎÔÏÈ΋ ÚÔ‹ (·̷ ∞) Â›Ó·È Û˘Ó‹ıˆ˜ <1. ∂ÊfiÛÔÓ Ì ٷ ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· ‰ÂÓ ÌÔÚ› Ó· ÙÂı› Ì ‚‚·ÈfiÙËÙ· Ë ‰È¿ÁÓˆÛË, ÙfiÙÂ Ë ÌfiÓË ·ÛÊ·Ï‹˜ χÛË Â›Ó·È Ë ‰È·ÎÔ‹ Ù˘ ¿ÛÎËÛ˘ ÁÈ· 2-3 Ì‹Ó˜, ÔfiÙÂ Â¿Ó Ë ˘ÂÚÙÚÔÊ›· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ¿ıÏËÛ˘ ı· ˘Ô¯ˆÚ‹ÛÂÈ Î·Ù¿ 2-5 mm. ∆¤ÏÔ˜, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Û Ó·ڿ ¿ÙÔÌ·, ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 18 ÂÙÒÓ, Â›Ó·È ‰˘Ó·ÙfiÓ Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Ó· ÌËÓ ¤¯ÂÈ ÂΉËψı› Ï‹Úˆ˜ Ê·ÈÓÔÙ˘Èο Î·È Ó· ÌËÓ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ˘ÂÚÙÚÔÊ›· ÛÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·, ÂÓÒ ˘Ê›ÛÙ·ÓÙ·È fiÏÔÈ ÔÈ Î›Ó‰˘ÓÔÈ ·fi ÙË ÓfiÛÔ. ∞fi ÙȘ ˘fiÏÔÈ˜ ·Èٛ˜ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘, Û˘¯ÓfiÙÂÚË Â›Ó·È ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ÔÈ Ôԛ˜ Â›Ó·È ˘‡ı˘Ó˜ ÁÈ· ÙÔ 19% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™˘Ó‹ıˆ˜ ÚfiÎÂÈÙ·È ÁÈ· ·ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜ ·fi ÙÔÓ ‰ÂÍÈfi

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·457

457

ÕÛÎËÛË Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜

ÎfiÏÔ ÙÔ˘ Valsalva. O ı¿Ó·ÙÔ˜ ·Ô‰›‰ÂÙ·È ÛÙËÓ ÈÛ¯·ÈÌ›· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË Û˘Ì›ÂÛË Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜, ¤ÙÛÈ fiˆ˜ ÔÚ‡ÂÙ·È ·Ó¿ÌÂÛ· ·fi ÙËÓ ·ÔÚÙ‹ Î·È ÙËÓ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·. ¢˘ÛÙ˘¯Ò˜, Û·Ó›ˆ˜ ‰›ÓÂÈ Û˘ÌÙÒÌ·Ù· Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ Ó· ‰È·ÁÓˆÛÙ›. ∂ÊfiÛÔÓ ˘¿Ú¯ÂÈ Û˘Ìو̷ÙÔÏÔÁ›· ηٿ ÙËÓ ¿ÛÎËÛË, ·˘Ù‹ Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁËı› Ì ÚÔÛÔ¯‹ Î·È ÙfiÙÂ Ë ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÙÂı› Ì ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È Ó· ÂȂ‚·Èˆı› Ì ÛÙÂÊ·ÓÈÔÁÚ·Ê›· ‹ Ì·ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›·. ŸÙ·Ó Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ Î·Ï¿ ˯ÔηډÈÔÁÚ·ÊÈο ·Ú¿ı˘Ú·, Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÓȯÓ¢Ù› Ë ¤ÎÊ˘ÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ·fi ÙÔ˘˜ ÎfiÏÔ˘˜ ÙÔ˘ Valsalva, Ú¤ÂÈ fï˜ Ó· Á›ÓÂÙ·È ÂȂ‚·›ˆÛË Ì ·ÁÁÂÈÔÁÚ·Ê›·. ∆· ˘fiÏÔÈ· ·›ÙÈ· - ·Ó Î·È Û¯ÂÙÈο Û¿ÓÈ· - ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂӉȷʤÚÔÓ, ‰ÈfiÙÈ Û ÔÏÏ¿ ·fi ·˘Ù¿ Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰˘Ó·Ùfi Ó· Á›ÓÂÈ ÂÁη›Úˆ˜, ·ÚΛ Ó· ˘¿Ú¯ÂÈ ˘„ËÏfi˜ ‚·ıÌfi˜ Â·ÁÚ‡ÓËÛ˘. ∆Ô ·Ó‡ڢÛÌ· Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ (5%) Û˘Ó‹ıˆ˜ ·Ó¢ڛÛÎÂÙ·È Û ·ÛıÂÓ›˜ Ì ۇӉÚÔÌÔ Marfan, ÔfiÙ Ì ÙËÓ ÂÈÛÎfiËÛË Î·È ÌfiÓÔ Â›Ó·È Â‡ÎÔÏÔ Ó· ˘¿ÚÍÂÈ Ë ˘Ô„›· Î·È Ó· Á›ÓÂÈ ·Ú·ÔÌ‹ ÁÈ· ηډÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∏ ÛÙ¤ÓˆÛË Ù˘ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ (5%) ÌÔÚ› Â›Û˘ Ó· ‰È·ÁÓˆÛÙ› Û¯ÂÙÈο ‡ÎÔÏ·, ‰ÈfiÙÈ ˘¿Ú¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Û˘ÛÙÔÏÈÎfi ʇÛËÌ·, ÙÔ ÔÔ›Ô Û η̛· ÂÚ›ÙˆÛË ‰ÂÓ ÂÈÙÚ¤ÂÙ·È Ó· ÂÎÏËÊı› ˆ˜ ·ıÒÔ. ∆Ô Ë¯ÔηډÈÔÁÚ¿ÊËÌ· ı· ÂȂ‚·ÈÒÛÂÈ ÙË ‰È¿ÁÓˆÛË Î·È ÙÔÓ ‚·ıÌfi Ù˘ ÛÙ¤ÓˆÛ˘. ™Â ·ÓÙ›ıÂÛË Ì ÙȘ ‰‡Ô ÚÔËÁÔ‡ÌÂÓ˜ ηٷÛÙ¿ÛÂȘ, Ë Ì˘Ôηډ›Ùȉ· Î·È ÏÈÁfiÙÂÚÔ Ë ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Â›Ó·È ‡Ô˘Ï˜ ·Ûı¤ÓÂȘ, ÔÈ Ôԛ˜ ÌÔÚÔ‡Ó Ó· ‰È·Ï¿ıÔ˘Ó Ù˘ ÚÔÛÔ¯‹˜. ŸÙ·Ó ÙÂı› Ë ˘Ô„›·, Ë ‰È¿ÁÓˆÛË Â›Ó·È Â‡ÎÔÏË Ì ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·. ™Â Ì›· ÌÂϤÙË (6), ·fi ÙÔ˘˜ Ù¤ÛÛÂÚȘ ·ÛıÂÓ›˜ Ì ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ÌfiÓÔ ¤Ó·˜ ›¯Â ÂÌÊ·Ó›ÛÂÈ Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· Ì ÙË ÌÔÚÊ‹ ÂÂÈÛÔ‰›ˆÓ ÎÔÏÈ΋˜ Ì·ÚÌ·Ú˘Á‹˜, Ù· ÔÔ›· fï˜ ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÛˆÛÙ¿. ∏ ·ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰˘ÛÏ·Û›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ (9,10) Â›Ó·È Ì›· Û¿ÓÈ· ¿ıËÛË, Ë ÔÔ›· ÛÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÎÏËÚÔÓÔÌÂ›Ù·È Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·. πÛÙÔÏÔÁÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÏÈÒ‰Ë ‰È‹ıËÛË ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ÌÂ Û˘Ó¤ÂÈ· ÙË ‰È¿Ù·Û‹ Ù˘ Î·È ÙËÓ ˘ÔÛ˘ÛÙ·ÏÙÈÎfiÙËÙ¿ Ù˘. ∫ÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ·ÚÚ˘ı̛˜ Î·È Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Û ÂÊ‹‚Ô˘˜ Î·È Ó·-

ÚÔ‡˜ ÂÓ‹ÏÈΘ. ∏ ‰È¿ÁÓˆÛË ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ Û˘Ìو̿وÓ, ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË, ÛÙȘ ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ·ÓˆÌ·Ï›Â˜ (·ÚÓËÙÈο Â¿ÚÌ·Ù· ∆ ÛÙȘ ‰ÂÍȤ˜ ÚÔοډȘ ··ÁˆÁ¤˜) Î·È ÛÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·, ÙÔ ÔÔ›Ô ‰Â›¯ÓÂÈ Ì›· ‰È·ÙÂٷ̤ÓË Î·È Ì ¯·ÌËÏ‹ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ‰ÂÍÈ¿ ÎÔÈÏ›·, ÂÓÒ Ë ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›· Û˘Ó‹ıˆ˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‚ÔËı¿ÂÈ ÛÙË ‰È¿ÁÓˆÛË, ‰Â›¯ÓÔÓÙ·˜ - ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ - Î·È ÙË ÏÈÒ‰Ë ‰È‹ıËÛË ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. ª›· ·Ú·ÏÏ·Á‹ Ù˘ ·ÚÚ˘ıÌÈÔÁfiÓÔ˘ ‰˘ÛÏ·Û›·˜ Ì ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙËÓ ∂ÏÏ¿‰· Â›Ó·È Ë ÓfiÛÔ˜ Ù˘ ¡¿ÍÔ˘ (11,12), Ë ÔÔ›· ÎÏËÚÔÓÔÌÂ›Ù·È Ì ۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú·, Ì ˘„ËÏ‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ· Î·È Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ê·ÈÓfiÙ˘Ô (˘ÂÚÎÂÚ¿ÙˆÛË ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ Î·È È‰ÈfiÌÔÚÊ· ηÙÛ·Ú¿ Ì·ÏÏÈ¿ Ô˘ ˘¿Ú¯Ô˘Ó ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·). ∏ ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ (13) Â›Ó·È Ôχ Û˘¯Ó‹ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5%). ™˘ÓÔÏÈο, ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ¤¯Ô˘Ó ·Ó·ÊÂÚı› 60 ÂÚÈÛÙ·ÙÈο ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û ·ÛıÂÓ›˜ Ì ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜, ÙÚ›· ·fi Ù· ÔÔ›· Û˘Ó¤‚ËÛ·Ó Î·Ù¿ ÙËÓ ¿ÛÎËÛË. øÛÙfiÛÔ, Î·È ÛÙȘ ÙÚÂȘ ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ ‰È·ÈÛÙÒıËÎ·Ó ÛÙË ÓÂÎÚÔ„›· Î·È ¿ÏϘ ·ÓˆÌ·Ï›Â˜ (˘ÔÏ·Û›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜, ·‡ÍËÛË Ù˘ ηډȷ΋˜ Ì¿˙·˜), ÔÈ Ôԛ˜ ı· ‹Ù·Ó ‰˘Ó·Ùfi Ó· ¤¯Ô˘Ó ÚÔηϤÛÂÈ ÙÔÓ ı¿Ó·ÙÔ. ¶·Ú’ fiÏ· ·˘Ù¿, Û˘ÓÈÛÙ¿Ù·È ·Ô¯‹ ·fi ÙËÓ ¿ÛÎËÛË fiÙ·Ó: ·) ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù· ηٿ ÙËÓ ¿ÛÎËÛË (ȉ›ˆ˜ Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È·), ‚) Û˘Ó˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ·ÓÂ¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜ Ì ‰È¿Ù·ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È Á) ˘¿Ú¯ÂÈ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘. ∏ ·ıËڈ̿وÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ (2%) Â›Ó·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· Î·È ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏÔ Ó· ‰È·ÁÓˆÛÙ›, fiˆ˜ Î·È ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ÂÎÙfi˜ Â¿Ó ˘¿Ú¯Ô˘Ó Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· Î·È ·˘Ù¿ ¤¯Ô˘Ó ·ÍÈÔÏÔÁËı› ÛˆÛÙ¿. ∆¤ÏÔ˜, Ì›· ÂӉȷʤÚÔ˘Û· ÔÓÙfiÙËÙ·, ÌË ÔÊÂÈÏfiÌÂÓË fï˜ Û ·ıÔÏÔÁÈο ηډȷο ·›ÙÈ·, Â›Ó·È Ô ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ·fi ÎÙ‡ËÌ· ÛÙÔ ÚÔοډÈÔ (Ì¿Ï· ‹ ‚›·ÈË ÚfiÛÎÚÔ˘ÛË ‰‡Ô ·ıÏËÙÒÓ), Ô ÔÔ›Ô˜ ·Ô‰›‰ÂÙ·È ÛÙËÓ ÚfiÎÏËÛË ÎÔÈÏȷ΋˜ Ì·ÚÌ·Ú˘Á‹˜ (14) ‹ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ (15), Û ¤‰·ÊÔ˜ fï˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ηډȷ΋˜ ·Ó·ÙÔÌ›·˜. ¶·È‰È·ÙÚÈ΋ 2005;68:454-459

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·458

458

¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ Î·È Û˘Ó.

∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÂϤÁ¯Ô˘ ∞fi Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ê·›ÓÂÙ·È fiÙÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÚÔ·ıÏËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋. ™Â Û˘ÁÎÂÓÙÚˆÙÈΤ˜ ÌÂϤÙ˜ (5), Â› Û˘ÓfiÏÔ˘ 5.500 ·ıÏËÙÒÓ Ô˘ ÂϤÁ¯ıËÎ·Ó Ì ˯ÔηډÈÔÁÚ¿ÊËÌ·, ‰ÂÓ ‰È·ÈÛÙÒıËΠԇÙ ̛· ÂÚ›ÙˆÛË ˘ÂÚÙÚÔÊÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜. ∆Ô Û˘¯ÓfiÙÂÚÔ Â‡ÚËÌ· ‹Ù·Ó Ë ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ (9) Î·È Ì¿ÏÈÛÙ· Û ·Û˘Ó‹ıÈÛÙ· ˘„ËÏ¿ ÔÛÔÛÙ¿ (10% ÙˆÓ ·Ó‰ÚÒÓ Î·È 20% ÙˆÓ Á˘Ó·ÈÎÒÓ). ∏ ‰ÔÎÈÌ·Û›· ÎÔÒÛˆ˜, Â›Û˘, ‰ÂÓ ÂӉ›ÎÓ˘Ù·È ˆ˜ ÁÂÓÈÎÂ˘Ì¤ÓË Ì¤ıÔ‰Ô˜ ÏËı˘ÛÌÈ·ÎÔ‡ ÂϤÁ¯Ô˘, ÏfiÁˆ Ù˘ ÌÈÎÚ‹˜ Â›ÙˆÛ˘ Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÛÙȘ ËÏÈ˘ ·˘Ù¤˜ (9). µÂ‚·›ˆ˜, ÂӉ›ÎÓ˘Ù·È Û οı ÂÚ›ÙˆÛË Ô˘ ˘¿Ú¯ÂÈ ¤ÛÙˆ Î·È Ë ·Ú·ÌÈÎÚ‹ ·ÌÊÈ‚ÔÏ›· (‡ÔÙÔ ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈÎfi ‡ÚËÌ· ‹ Û‡Ìو̷ ηٿ ÙËÓ ¿ÛÎËÛË). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Û ̛· ÌÂϤÙË 134 ÂÚÈÙÒÛÂˆÓ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ (6), ÔÈ 130 ·ıÏËÙ¤˜ ›¯·Ó ˘Ô‚ÏËı› Û ÚÔ·ıÏËÙÈÎfi ¤ÏÂÁ¯Ô. ∞fi ·˘ÙÔ‡˜ ÔÈ 15 (11%) ›¯·Ó ·Ú·ÂÌÊı› Û ηډÈÔÏfiÁÔ ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô ÏfiÁˆ ˘¿Ú͈˜ Ê˘Û‹Ì·ÙÔ˜. ∏ ÛˆÛÙ‹ ‰È¿ÁÓˆÛË Â›¯Â ÙÂı› Ì ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Û 7 ·fi ÙÔ˘˜ 15 ·ÛıÂÓ›˜ (ÛÙ¤ÓˆÛË ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜), ÔÈ ÔÔ›ÔÈ fï˜ - ·Ú¿ ÙË ‰È¿ÁÓˆÛË Û˘Ó¤¯ÈÛ·Ó Ó· ·ıÏÔ‡ÓÙ·È. ∞fi ÙÔ˘˜ 115 ·ıÏËÙ¤˜ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÌfiÓÔ ÎÏÈÓÈο, Û ¤Ó·Ó Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Marfan Ì ‚¿ÛË ÙÔÓ Ê·ÈÓfiÙ˘Ô, ·ÏÏ¿ Ô ·ÛıÂÓ‹˜ fi¯È ÌfiÓÔ ‰ÂÓ ÂÍÂÙ¿ÛÙËΠ·fi ηډÈÔÏfiÁÔ, ·ÏÏ¿ Û˘Ó¤¯ÈÛ ӷ Á˘ÌÓ¿˙ÂÙ·È Ì¤¯ÚȘ fiÙÔ˘ Û˘Ó¤‚Ë ÙÔ ÌÔÈÚ·›Ô. ¢È·ÈÛÙÒÓÂÙ·È, Û˘ÓÂÒ˜, fiÙÈ Ô ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜, ·ÎfiÌË Î·È Û ÚÔËÁ̤Ó˜ ¯ÒÚ˜, ‰ÂÓ ¤¯ÂÈ Ù· ·Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·.

™˘ÓÈÛÙÒÌÂÓÔ˜ ¤ÏÂÁ¯Ô˜ ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ ÙÔ˘ ÂϤÁ¯Ô˘ ·Ó·fiÊ¢ÎÙ· ı· ÙÔ ÂˆÌÈÛÙÔ‡Ó ÔÈ ·È‰›·ÙÚÔÈ, ÔÈ ÔÔ›ÔÈ ı· ÂÍÂÙ¿ÛÔ˘Ó ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ Ì›·˜ ÂÚÈÔ¯‹˜ Î·È ı· ·Ú·¤Ì„Ô˘Ó ÛÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ ÂÈÏÂÁ̤ӷ ÂÚÈÛÙ·ÙÈο. O ¤ÏÂÁ¯Ô˜ ı· Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÂÙ·È Û ÏÂÙÔÌÂÚ‹ Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡, ÙfiÛÔ ÙÔ˘ ·ÙÔÌÈÎÔ‡ fiÛÔ Î·È ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡, ηıÒ˜ Î·È Û ÚÔÛÂÎÙÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË. ∞fi ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi Ú¤ÂÈ Ó· ‰›‰ÂÙ·È ÌÂÁ¿ÏË ‚·Ú‡ÙËÙ· ÛÙËÓ ·Ó·˙‹ÙËÛË Û˘Ìو̿¶·È‰È·ÙÚÈ΋ 2005;68:454-459

ÙˆÓ Î·Ù¿ ÙËÓ ¿ÛÎËÛË, fiˆ˜ ÚÔοډÈÔ ¿ÏÁÔ˜, ˙¿ÏË, ·›ÛıËÌ· ÚÔÎ¿Ú‰ÈˆÓ ·ÏÌÒÓ, Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ‰‡ÛÓÔÈ·. π‰È·›ÙÂÚË ÛËÌ·Û›· ¤¯Ô˘Ó Ë ˙¿ÏË Î·È ÙÔ ÚÔοډÈÔ ¿ÏÁÔ˜, Ù· ÔÔ›· ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Ì ÚÔÛÔ¯‹. ∞fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ó·˙ËÙÂ›Ù·È Ë ‡·ÚÍË ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û ¿ÙÔÌÔ ÙÔ˘ ÛÙÂÓÔ‡ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 40 ÂÙÒÓ (Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ ÙÔ Û‡ÓËı˜ ·›ÙÈÔ Â›Ó·È Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜), ηıÒ˜ Î·È Ë ·ÚÔ˘Û›· ·ÛıÂÓÂÈÒÓ fiˆ˜ Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ÙÔ Ì·ÎÚfi Q-T ‹ ÙÔ Û‡Ó‰ÚÔÌÔ Marfan. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË, ÂÎÙfi˜ ·fi Ù· ˘fiÏÔÈ· Û˘ÛÙ‹Ì·Ù·, Ù· ÔÔ›· ‰ÂÓ Ú¤ÂÈ Ó· ·Ú·‚ϤÔÓÙ·È, ÂÈÎÂÓÙÚÒÓÂÙ·È fiˆ˜ Â›Ó·È Ê˘ÛÈÎfi ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi. ∏ ÂÈÛÎfiËÛË Â›Ó·È ÛËÌ·ÓÙÈ΋, ‰ÈfiÙÈ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó›¯Ó¢ÛË ˆ¯ÚfiÙËÙ·˜, ΢¿ÓˆÛ˘, ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ÛÎÂÏÂÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ÌÔÚ› Ó· ı¤ÛÂÈ ÙËÓ ˘Ô„›· ÁÈ· ÙË ‰È¿ÁÓˆÛË Û˘Ó‰ÚfïÓ, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ Marfan. ∏ ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ȤÛˆ˜ Î·È Ë „ËÏ¿ÊËÛË ÙˆÓ ÌËÚÈ·›ˆÓ ÛʇÍÂˆÓ Ú¤ÂÈ Ó· ·ÔÙÂÏÔ‡Ó ·Ó·fiÛ·ÛÙÔ ÙÌ‹Ì· Ù˘ ÂͤٷÛ˘ Î·È ‰ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÔÓÙ·È Û η̛· ÂÚ›ÙˆÛË. ∆¤ÏÔ˜, Ë ·ÎÚfi·ÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÚÔÛÔ¯‹ Î·È Û˘ÁΤÓÙÚˆÛË, Û ‹Û˘¯Ô ÂÚÈ‚¿ÏÏÔÓ. ∞ÎÚÔ¿Ù·È ÔÏfiÎÏËÚÔ ÙÔ ÚÔοډÈÔ Û ηٷÎÂÎÏÈ̤ÓË Î·È fiÚıÈ· ı¤ÛË, ·Ó·˙ËÙÔ‡ÓÙ·È Ô ÚÒÙÔ˜ Î·È Ô ‰Â‡ÙÂÚÔ˜ ÙfiÓÔ˜, Ë ·ÚÔ˘Û›· Ê˘ÛËÌ¿ÙˆÓ Î·È Ë ÌÂÙ·‚ÔÏ‹ ÙÔ˘˜ Ì ÙË ı¤ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜. ŸÙ·Ó ˘¿Ú¯ÂÈ ¤ÛÙˆ Î·È ÌÈÎÚ‹ ·ÌÊÈ‚ÔÏ›· ÁÈ· ÙË Ê‡ÛË ÂÓfi˜ Ê˘Û‹Ì·ÙÔ˜, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·Ú·¤ÌÂÙ·È ÁÈ· ηډÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, Ô˘ ÂÎÙfi˜ ·fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË - ÂÚÈÏ·Ì‚¿ÓÂÈ ∏∫° Î·È Ë¯ÔηډÈÔÁÚ·ÊÈ΋ ÂͤٷÛË. ∞Ó¿ÏÔÁ· Ì ٷ Â˘Ú‹Ì·Ù· Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘ÛÙ·ı› Î·È ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ Ì ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘, ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· 24ÒÚÔ˘ (Holter Ú˘ıÌÔ‡), ·ÎfiÌË Î·È ÛÙÂÊ·ÓÈÔÁÚ·Ê›· ‹ Ì·ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›·. ŒÓ· ˙‹ÙËÌ· Ô˘ ‰ÂÓ ¤¯ÂÈ ··ÓÙËı› Ì ۷ʋÓÂÈ· Î·È ÔÌÔʈӛ· ·ÊÔÚ¿ ÛÙÔ fiÛÔ Û˘¯Ó¿ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ô ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Î·È ÙÈ ·ÎÚÈ‚Ò˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ (2). ™Â οı ÂÚ›ÙˆÛË, Ù· ·È‰È¿ Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÔÓÙ·È ÛÙËÓ ·Ú¯‹ Ù˘ Û¯ÔÏÈ΋˜ ¯ÚÔÓÈ¿˜ ·fi ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜ Î·È Ó· ·Ú·¤ÌÔÓÙ·È ÛÙÔÓ Î·Ú‰ÈÔÏfiÁÔ Â¿Ó ˘¿Ú¯Ô˘Ó ‡ÔÙ· Û˘ÌÙÒÌ·Ù· ‹ Â˘Ú‹Ì·Ù·. ∂›Û˘, ηÏfi Â›Ó·È Ó· ÂϤÁ¯ÔÓÙ·È ·fi ηډÈÔÏfiÁÔ ·ÓÂÍ·Úًو˜ ¢ÚËÌ¿ÙˆÓ ÛÙËÓ ·Ú¯‹ ÙÔ˘ Á˘ÌÓ·Û›Ô˘ Î·È ÙÔ˘ Ï˘Î›Ԣ, ηıÒ˜ ηÈ

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·459

459

ÕÛÎËÛË Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜

fiÙ·Ó ÚfiÎÂÈÙ·È Ó· ·Ú¯›ÛÔ˘Ó Î¿ÔÈÔ ¿ıÏËÌ· ¤Ú·Ó Ù˘ Û¯ÔÏÈ΋˜ Á˘ÌÓ·ÛÙÈ΋˜.

™˘ÌÂÚ¿ÛÌ·Ù· O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ηٿ ÙËÓ ¿ÛÎËÛË Â›Ó·È Û¿ÓÈÔ˜. øÛÙfiÛÔ, Â›Ó·È Ú·ÎÙÈο ·Ó¤ÊÈÎÙÔ Û ÏËı˘ÛÌÈ·Îfi Â›Â‰Ô Ó· ÚÔÏËÊıÔ‡Ó fiÏ· Ù· ÂÚÈÛÙ·ÙÈο, ›Ù ‰ÈfiÙÈ Ë ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ ··ÈÙ› ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÂÍÂÙ¿ÛÂȘ Ô˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Û ÁÂÓÈÎÂ˘Ì¤ÓË Îϛ̷η (.¯. Ë ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘) ›Ù ‰ÈfiÙÈ ÏfiÁˆ Ù˘ Ê˘ÛÈ΋˜ ÈÛÙÔÚ›·˜ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ÌËÓ ¤¯Ô˘Ó ·Ó·Ù‡ÍÂÈ ÙËÓ Ï‹ÚË ÂÈÎfiÓ· Ù˘ ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· (.¯. Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·). O ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÚÔÛÔ¯‹ Î·È Ó· ‰›‰ÂÙ·È ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡, ÙfiÛÔ ÙÔ˘ ·ÙÔÌÈÎÔ‡ fiÛÔ Î·È ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡, ηıÒ˜ Î·È ÛÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË. µ¤‚·È·, Ô ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ηډÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ı· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Û ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ ‹ ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜ (.¯. ¤Ó·ÚÍË Û˘ÛÙËÌ·ÙÈ΋˜ ÂÓ·Û¯fiÏËÛ˘ Ì οÔÈÔ ¿ıÏËÌ·). ¶Ú¤ÂÈ Ó· ‰›‰ÂÙ·È È‰È·›ÙÂÚË ‚·Ú‡ÙËÙ· ÛÙ· Û˘ÌÙÒÌ·Ù· ηٿ ÙËÓ ÒÚ· Ù˘ ¿ıÏËÛ˘ Î·È Ó· ÂÓËÌÂÚÒÓÔÓÙ·È ÔÈ ·ıÏËÙ¤˜ ÁÈ· ÙË ÛËÌ·Û›· ·˘ÙÒÓ ÙˆÓ Û˘Ìو̿وÓ, ÒÛÙ ӷ ÌÔÚÔ‡Ó Ó· Ù· ·Ó·ÁÓˆÚ›˙Ô˘Ó Î·È Ó· ‰È·ÎfiÙÔ˘Ó ÂÁη›Úˆ˜ ÙËÓ ÚÔÛ¿ıÂÈ¿ ÙÔ˘˜. ªÂ ÙÔÓ ÚÔÛÂÎÙÈÎfi Î·È Û˘ÛÙËÌ·ÙÈÎfi ¤ÏÂÁ¯Ô Â›Ó·È Èı·Ófi fiÙÈ ·˘Ù¿ Ù· ‰˘Û¿ÚÂÛÙ· ÂÚÈÛÙ·ÙÈο ı· ÌÂȈıÔ‡Ó ÛÙÔ ÂÏ¿¯ÈÛÙÔ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Hillis WS, McIntyre PD, Maclean J, Goodwin JF, McKenna WJ. ABC of sports medicine. Sudden death in sport. BMJ 1994;309:657-660.

2. Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association.

Circulation 1996;94:850-856.

3. Group on Science and Technology, American Medical Association. Athletic preparticipation examinations for adolescents. Report of the Board of Trustees. Arch Pediatr Adolesc Med 1994;148:93-98.

4. Wren C. Sudden death in children and adolescents.

Heart 2002;88:426-431.

5. Thompson PD. The cardiovascular complications of vigorous physical activity. Arch Intern Med 1996;156:2297-2302.

6. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.

7. Elliott PM, Poloniecki J, Dickie S, Sharma S, Monserrat L, Varnava A et al. Sudden death in hypertrophic cardiomyopathy: identification of high risk patients. J Am Coll Cardiol 2000;36:2212-2218.

8. Maron BJ, Pellicia A, Spirito P. Cardiac disease in young trained athletes. Insights into methods for distinguishing athlete’s heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation 1995;91:1596-1601.

9. McKenna WJ, Thiene G, Nava A, Fontaliran F, Blomstrom-Lundqvist C, Fontaine G et al. Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Task Force of the Working Group Myocardial and Pericardial Disease of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the International Society and Federation of Cardiology. Br Heart J 1994;71:215-218.

10. Fontaine G, Fontaliran F, Lascault G, Aouate P, Tonet J, Frank R. Arrhythmogenic right ventricular dysplasia. In: Zipes DP, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. 2nd ed.

Philadelphia: WB Saunders Co; 1995. p. 754-769.

11. ∆Û·ÙÛÔÔ‡ÏÔ˘ ∞, ¶ÚˆÙÔÓÔÙ¿ÚÈÔ˜ ¡, ∞Ó·ÛÙ·Û¿Î˘ Õ, £ÂÔ›ÛÙÔ˘ Õ, ∫·Ú‚Ô‡ÓË ∂, ™ËÏÈÔÔ‡ÏÔ˘ Ã Î·È Û˘Ó. ¡Â·ÓÈÎfi˜ ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜, ·ÚÚ˘ıÌÈÔÁfiÓÔ˜ Ì˘ÔηډÈÔ¿ıÂÈ· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ Î·È ÓfiÛÔ˜ Ù˘ ¡¿ÍÔ˘. ¶·È‰È·ÙÚÈ΋ 1998;61:402-407.

12. ¶ÚˆÙÔÓÔÙ¿ÚÈÔ˜ ¡, ∆Û·ÙÛÔÔ‡ÏÔ˘ ∞. ∞ÚÚ˘ıÌÈÔÁfiÓÔ˜ Ì˘ÔηډÔ¿ıÂÈ·/‰˘ÛÏ·Û›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ Î·È ÓfiÛÔ˜ ¡¿ÍÔ˜. ∂ÏÏËÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂ÈıÂÒÚËÛË 2004;45:423-432.

13. Wight JN Jr, Salem D. Sudden cardiac death and the “athlete’s heart”. Arch Intern Med 1995;155:14731480.

14. Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med 1995;333:337-342.

15. Dixon AE, Shulman S. Sudden death during sports activities. N Engl J Med 1995;333:1784.

¶·È‰È·ÙÚÈ΋ 2005;68:454-459

Pediatr Nov-Dec 05

12-12-05

460

1 Department of Cardiology, “P. & A. Kyriakou” Athens’ Children Hospital 2 3rd Paediatric Clinic, University of Athens “Attikon” University Hospital, Haidari, Athens Correspondence: Dimitris Georgakopoulos 16 Iridanou Str., 115 28, Athens E-mail: geodim4@hotmail.com Date of submission: 29-06-2004 Date of approval: 14-07-2005

15:16

™ÂÏ›‰·460

PRACTICAL ISSUE

Cardiovascular conditions associated with sudden death during exercise in children, adolescents and young adults.

Preparticipation evaluation D. Georgakopoulos1, K. Douros2

Abstract The sudden death of a young athlete is a tragic and unexpected event with an impact on both the public and the medical community. Most of the episodes are due to cardiovascular conditions.

Understanding of the causes of sudden death can help in the organization of a more effective protocol for preparticipation evaluation. The incidence of sudden death in this group is estimated at 1:200,000 young athletes per year. The most common cause of sudden death in young persons (<35 years) is hypertrophic cardiomyopathy (36%), followed by congenital abnormalities of the coronary arteries (19%). In the majority of cases no prodromal symptoms had been reported, either in the months preceding or immediately before death, which occurred suddenly and unexpectedly either during a competition or, more frequently, during a training session (64%). When present, the most common symptoms are dizziness or syncope. A detailed medical history, both family and personal, and careful clinical examination of the cardiovascular system constitute the cornerstone of preathletic evaluation.

Special attention must be given to the detection of symptoms during exercise and to a history of sudden death in a close relative at young age. Evaluation by a paediatric cardiologist is advised when indicated by the history, symptoms or findings, and on specific occasions (e.g., before starting systematic participation in athletic activity, particularly in competition sports). The usual cardiological examination includes ECG and echocardiography. More specific tests, such as Holter monitoring, exercise test or magnetic resonance imaging may be required depending on initial findings.

Key words Exercise, sudden death, preparticipation evaluation.

Paediatriki 2005;68:460

Pediatr Nov-Dec 05

12-12-05

15:16

™ÂÏ›‰·461

∫§π¡π∫O ∫OÀπ∑

CLINICAL QUIZ

461

µÚ¤ÊÔ˜ Ì ˘ÔηÏÈ·ÈÌÈ΋ ˘ԯψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ∞‰¿ÌÔ˜ ÷Ù˙Ë·Ó·Á‹˜1, ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜2

∞ÁfiÚÈ ËÏÈΛ·˜ ¤ÍÈ ÌËÓÒÓ ÂÈÛ‹¯ıË ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ÈÛÙÔÚÈÎÔ‡ ÚfiÛÊ·Ù˘ ·ÒÏÂÈ·˜ ‚¿ÚÔ˘˜. √È ÁÔÓ›˜ ·Ó¤ÊÂÚ·Ó fiÙÈ ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË Ï‹„Ë ÙÚÔÊ‹˜ ÙÔÓ ÙÂÏÂ˘Ù·›Ô Ì‹Ó· Î·È ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó 5,6 kg (sds: -3,2), ÂÓÒ ¤Ó· Ì‹Ó· ÚÈÓ ‹Ù·Ó 6,9 kg (sds: -1,4) Î·È Â›¯Â Ì‹ÎÔ˜ 66 cm (sds: - 0,7). ∂›Ó·È ÙÔ ÚÒÙÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. °ÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi ÌÂÙ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË (‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÔÏ˘‰Ú¿ÌÓÈÔ). ∏ ËÏÈΛ· ·ËÛ˘ ‹Ù·Ó 39 ‚‰ÔÌ¿‰Â˜ Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3,7 kg. ™ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ·Ê˘‰¿ÙˆÛË Î·È ˘ÔÙÔÓ›·. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ‹Ù·Ó 85/57 mmHg Î·È Â›¯Â 110 ÛʇÍÂȘ/ÏÂÙfi. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ·ÈÌÔÛÊ·ÈÚ›ÓË 11,4 g/dl, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 15.300/mm3, ·ÈÌÔÂÙ¿ÏÈ· 362.000/mm3, ÎÚ·ÙÈÓ›ÓË 0,7 mg/dl, Ô˘Ú›· 45 mg/dl, Ó¿ÙÚÈÔ 125 mEq/L, οÏÈÔ 2,4 mEq/L, ¯ÏÒÚÈÔ 66 mEq/L, Ô˘ÚÈÎfi Ô͇ 10,8 mg/dl, ·Û‚¤ÛÙÈÔ 10 mg/dl, ÊÒÛÊÔÚÔ˜ 6,1 mg/dl, pH 7,47, PO2 96.3 mmHg, PCO2 27 mmHg Î·È ‰ÈÙÙ·ÓıÚ·ÎÈο 32 mmol/L. ∆Ô ÂȉÈ-

Îfi ‚¿ÚÔ˜ Ô‡ÚˆÓ ‹Ù·Ó 1003 Î·È ÔÈ ËÏÂÎÙÚÔχÙ˜ Ô‡ÚˆÓ ‹Ù·Ó: οÏÈÔ 85 m∂q/L, Ó¿ÙÚÈÔ 12 m∂q/L, ¯ÏÒÚÈÔ 7,4 m∂q/L. ∏ ÚÂÓ›ÓË ÔÚÔ‡ ‹Ù·Ó >77 ng/dl ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ̤¯ÚÈ 2 ng/dl, ÂÓÒ Ë ·Ï‰ÔÛÙÂÚfiÓË ÔÚÔ‡ ‹Ù·Ó 290 ng/dl ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ̤¯ÚÈ 60 ng/dl. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ‰ÂÓ ¤‰ÂÈÍ ÓÂÊÚ·Û‚¤ÛÙˆÛË ‹ οÔÈÔ ¿ÏÏÔ ·ıÔÏÔÁÈÎfi ‡ÚËÌ·.

1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô §¿Úӷη˜, ∫‡ÚÔ˜ 2 ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ π. ™ÙÂÊ·Ó›‰Ë˜ E-mail: stefanid@hol.gr

¶·ÚfiÙÈ ¯ÔÚËÁ‹ıËÎ·Ó ÂÓ‰ÔÊϤ‚È· ˘ÁÚ¿ Î·È ËÏÂÎÙÚÔχÙ˜, Ù· ‚ÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ÙË ‰Â‡ÙÂÚË Ë̤ڷ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ·Ú¤ÌÂÈÓ·Ó ·ıÔÏÔÁÈο: ÎÚ·ÙÈÓ›ÓË 0,6 mg/dl, Ô˘Ú›· 18 mg/dl, Ó¿ÙÚÈÔ 129 mEq/L, οÏÈÔ 2,8 mEq/L, ¯ÏÒÚÈÔ 77 mEq/L, Ì·ÁÓ‹ÛÈÔ 0,98 mg%. ∆ËÓ ÙÚ›ÙË Ë̤ڷ Ù˘ ÓÔÛËÏ›·˜, Ë fiÚÂÍË ÙÔ˘ ·È‰ÈÔ‡ ›¯Â ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Î·È Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó 6,3 Kg Î·È ÔÈ ÙÈ̤˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ ÛÙÔÓ ÔÚfi ›¯·Ó Â·Ó¤ÏıÂÈ ÛÙ· Ê˘ÛÈÔÏÔÁÈο Â›‰·. ∆Ô ‚Ú¤ÊÔ˜, ¤Ó·Ó ¯ÚfiÓÔ ·ÚÁfiÙÂÚ·, ›¯Â Ê˘ÛÈÔÏÔÁÈÎfi ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜, ηıÒ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ, ¯ˆÚ›˜ η̛· Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹.

¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ: 1. ™‡Ó‰ÚÔÌÔ Bartter 2. ™‡Ó‰ÚÔÌÔ Gitleman 3. ™‡Ó‰ÚÔÌÔ „¢‰Ô-Bartter

∏ ·¿ÓÙËÛË ·ÎÔÏÔ˘ı› ÛÙË ÛÂÏ›‰· 464

¶·È‰È·ÙÚÈ΋ 2005;68:461

Pediatr Nov-Dec 05

12-12-05

462

µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜ E-mail: ngp@allergy.gr

15:16

™ÂÏ›‰·462

¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√

¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜ - ∞ÏÏÂÚÁÈÔÏfiÁÔ˜

¶Ú·ÎÙÈÎfi˜ √‰ËÁfi˜ ∂Á΢ÌÔÛ‡Ó˘ - http://www.apregnancyguide.com/ ∏ ÈÛÙÔÛÂÏ›‰· apregnancyguide.com/ Ì ¤‰Ú· ÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ, ·ÔÙÂÏ› ¤Ó·Ó Ï‹ÚË ËÏÂÎÙÚÔÓÈÎfi Ô‰ËÁfi Ì ÏËÚÔÊÔڛ˜, Ô‰ËÁ›Â˜ Î·È ¯Ú‹ÛÈ̘ Û˘Ì‚Ô˘Ï¤˜ ÁÈ· fiÏ· Ù· ÛÙ¿‰È· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ηıÒ˜ Î·È ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ÌËÙÚfiÙËÙ·˜. ™ÙȘ ÂÈ̤ÚÔ˘˜ ÂÓfiÙËÙ˜ ˘¿Ú¯ÂÈ ÏÔ‡ÛÈÔ ÏËÚÔÊÔÚÈ·Îfi ˘ÏÈÎfi ·fi ÌÈ· ¢Ú›· Áο̷ ıÂÌ¿ÙˆÓ ˘Á›·˜ Î·È ˘ÁÂÈÈÓ‹˜ Ô˘ ··Û¯ÔÏÔ‡Ó ÙË Ì¤ÏÏÔ˘Û· ÌËÙ¤Ú·, fiˆ˜ Â›Ó·È Ë ÁÔÓÈÌfiÙËÙ·, Ù· ÚÒÙ· Û˘ÌÙÒÌ·Ù· ÂÁ΢ÌÔÛ‡Ó˘ Î·È Û˘Ì‚Ô˘Ï¤˜ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜, ÔÈÎÔÁÂÓÂÈ·Îfi˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜, ‰È·ÙÚÔÊ‹ ÁÈ· ‰‡Ô, ÂÁ΢ÌÔÛ‡ÓË Î·È ·Ûı¤ÓÂȘ, ıËÏ·ÛÌfi˜ Î·È ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ ‰‡ÛÎÔÏ˘ ÂÁ΢ÌÔÛ‡Ó˘. ∂ÎÙfi˜ ·fi ÙËÓ ÂÓË̤ڈÛË, ·Ú¤¯ÂÙ·È Î·È ËÏÂÎÙÚÔÓÈÎfi ËÌÂÚÔÏfiÁÈÔ ÁÈ· fiÏ· Ù· ÛÙ¿‰È· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ ηıÒ˜ Î·È ËÏÂÎÙÚÔÓÈ΋ ·ÁÔÚ¿ ‚È‚Ï›ˆÓ, CDs, DVDs ̤۷ ·fi ‰È·Û‡Ó‰ÂÛË Ì Â͈ÙÂÚÈÎfi ‰ÈÎÙ˘·Îfi ÙfiÔ. ∏ ÈÛÙÔÛÂÏ›‰· Â›Ó·È ·ÚÎÂÙ¿ ·Ï‹ ÛÙËÓ ÏÔ‹ÁËÛ‹ Ù˘ Ì ¢‰È¿ÎÚÈÙ˜ ÙȘ ÂÈ̤ÚÔ˘˜ ÂÓfiÙËÙ˜ ÁÈ· ÁÚ‹ÁÔÚË Î·È Â‡ÎÔÏË Â˘ÚÂÙËÚ›·ÛË, ÂÓÒ ÚÔÛʤÚÂÈ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ‰ˆÚÂ¿Ó Û˘Ì‚Ô˘ÏÒÓ Î·È ¿ÌÂÛ˘ ÂÈÎÔÈÓˆÓ›·˜ Ì ÂÈÛÙËÌÔÓÈο ÎÂÓÙÚ· ·È‰È·ÙÚÈ΋˜.

∏ÏÂÎÙÚÔÓÈο Ì·ı‹Ì·Ù· ÙÔÎÂÙÔ‡ - http://www.birth.com.au/ √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ www.birth.com.au, Ì ÌÔÓÙ¤ÚÓ· ·ÈÛıËÙÈ΋ Î·È Û¯Â‰È·ÛÌfi, ·ÔÙÂÏ› ÙÔ ÚÔ˚fiÓ ÌÈ·˜ ·Ú¤·˜ ÁÔÓ¤ˆÓ ·fi ÙËÓ ∞˘ÛÙÚ·Ï›·, ÔÈ ÔÔ›ÔÈ ı¤ÏËÛ·Ó Ó· ÚÔÛʤÚÔ˘Ó fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÏËÚ¤ÛÙÂÚË ÏËÚÔÊfiÚËÛË Û¯ÂÙÈο Ì ÙËÓ ÂÁ΢ÌÔÛ‡ÓË Î·È ÙÔÓ ÙÔÎÂÙfi. ŒÙÛÈ ‰ËÌÈÔ‡ÚÁËÛ·Ó ÙÔ ‰ÈÎÙ˘·Îfi ÙfiÔ birth.com Ô ÔÔ›Ô˜ ‰›ÓÂÈ ¤ÌÊ·ÛË ÛÙËÓ ËÏÂÎÙÚÔÓÈ΋ ÂÎ·›‰Â˘ÛË Ì “Ì·ı‹Ì·Ù·” ÁÈ· fiÏ· Ù· ÛÙ¿‰È· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ÙÔ˘ ÙÔÎÂÙÔ‡ Î·È ÙËÓ ÚÒÙË ÂÚ›Ô‰Ô Ù˘ ÌËÙÚfiÙËÙ·˜. ∆· Ì·ı‹Ì·Ù·, ÔÚÁ·ÓˆÌ¤Ó· Û ‰È·ÎÚÈÙ¤˜ ηÙËÁÔڛ˜ ÁÈ· ‡ÎÔÏË ·Ó·˙‹ÙËÛË, ÚÔÛʤÚÔÓÙ·È ‰ˆÚ¤·Ó ÛÙÔ˘˜ ¯Ú‹ÛÙ˜ ·ÊÔ‡ ÂÁÁÚ·ÊÔ‡Ó ÚÒÙ· ˆ˜ ̤ÏË. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·Ó·Ï˘ÙÈ΋ ÂÚÈÁÚ·Ê‹ fiÏˆÓ ÙˆÓ Ê¿ÛÂˆÓ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ·fi ÙÔÓ ÚÒÙÔ ÎÈfiÏ·˜ Ì‹Ó· Ù˘ ·ËÛ˘, Î·È Û˘Ì‚Ô˘Ï¤˜ ÚÔ˜ ÙË Ì¤ÏÏÔ˘Û· ÌËÙ¤Ú· ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ·fi Ù· ¶·È‰È·ÙÚÈ΋ 2005;68:462-463

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·463

NEWS FROM THE INTERNET

463

‰˘Û¿ÚÂÛÙ· Û˘ÌÙÒÌ·Ù· ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ÌÂÙ¿ ÙË Á¤ÓÓ·. ∂ÎÙfi˜ ·fi ÙËÓ ÂÎ·›‰Â˘ÛË, Ô ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ birth.com ÚÔÛʤÚÂÈ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ·ÓÔȯً˜ ÁÚ·ÌÌ‹˜ ÂÈÎÔÈÓˆÓ›·˜ ̤۷ ·fi ÙËÓ ÂÓfiÙËÙ· birthtalk ÁÈ· ÂÚÈÛÛfiÙÂÚË ÏËÚÔÊfiÚËÛË Ì¤Û· ·fi ËÏÂÎÙÚÔÓÈΤ˜ ÂÊ·ÚÌÔÁ¤˜, fiˆ˜ message boards Î·È chatrooms, ËÏÂÎÙÚÔÓÈÎfi Newsletter Î·È Â‚‰ÔÌ·‰È·›· ·ÔÛÙÔÏ‹ ËÏÂÎÙÚÔÓÈÎÔ‡ Ù·¯˘‰ÚÔÌ›Ԣ ÛÙ· ÂÁÁÂÁڷ̤ӷ ̤ÏË Ù˘.

O ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ ÂÓËÌÂÚÒÓÂÙ·È Û ٷÎÙÈ΋ ‚¿ÛË Î·È ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÈÔ ‰ËÌÔÊÈÏ‹ ÂÚÁ·Ï›· ÂÓË̤ڈÛ˘ Û ı¤Ì·Ù· ÂÁ΢ÌÔÛ‡Ó˘ Î·È ÙÔÎÂÙÔ‡ ÛÙËÓ ∞˘ÛÙÚ·Ï›·.

ªÂ Â›ÎÂÓÙÚÔ ÙÔ ·È‰› - http://www.babycentre.co.uk/ √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ babycentre.co.uk ÚÔÛʤÚÂÈ ÂÓË̤ڈÛË ÚÔ˜ ÙÔ˘˜ Ó¤Ô˘˜ ÁÔÓ›˜ ÂȉÈÒÎÔÓÙ·˜ Ó· ηχ„ÂÈ Î·›ÚÈ· ÂÚˆÙ‹Ì·Ù· Û¯ÂÙÈο Ì ÙÔ ÛËÌ·ÓÙÈÎfi ÁÂÁÔÓfi˜ Ù˘ Á¤ÓÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙȘ ·ÏÏ·Á¤˜ Ô˘ ·˘Ùfi ÂÈʤÚÂÈ ÛÙË ˙ˆ‹ ÙÔ˘˜. √È ‚·ÛÈΤ˜ ıÂÌ·ÙÈΤ˜ Ô˘ ηχÙÔ˘Ó Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ÂÓË̤ڈÛË Î·È ÂÎ·›‰Â˘ÛË Û ı¤Ì·Ù· ·ËÛ˘ Î·È ÙÔÎÂÙÔ‡ Î·È Ë ¤ÓÙ·ÍË ÙÔ˘ ¯Ú‹ÛÙË Û ÌÈ· “ÎÔÈÓfiÙËÙ· ÁÔÓ¤ˆÓ” ÔÈ ÔÔ›ÔÈ ÌÔÚÔ‡Ó Ó· ÂÈÎÔÈÓˆÓÔ‡Ó Ì¤Ûˆ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ‰ÈÎÙ˘·ÎÔ‡ ÎfiÌ‚Ô˘. ∂ȉÈÎfiÙÂÚ·, Ë ÔÌ¿‰· ÙÔ˘ babycentre.co.uk ÛÙԯ‡ÂÈ ÛÙËÓ ·ÚÔ¯‹ Û˘Ì‚Ô˘ÏÒÓ ÚÔ˜ ÙÔ˘˜ ̤ÏÏÔÓÙ˜ ÁÔÓ›˜ ̤۷ ·fi ¤Ó· ÔÏ˘‰È¿ÛÙ·ÙÔ ÂÚÁ·ÏÂ›Ô ÂÓË̤ڈÛ˘. ∂ÎÙfi˜ ·fi ÙȘ ıÂÌ·ÙÈΤ˜ ÂÓfiÙËÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ÚÔÁÂÓÓËÙÈÎfi ÛÙ¿‰ÈÔ, ÙÔÓ ÙÔÎÂÙfi Î·È ÙËÓ ÂÚ›Ô‰Ô ÌÂÙ¿ ÙË Á¤ÓÓ·, ÛÙÔ babycentre.co.uk ÌÔÚ› Ó· ‚ÚÂÈ Î·Ó›˜ ‰È·‰Ú·ÛÙÈΤ˜ ÂÊ·ÚÌÔÁ¤˜, fiˆ˜ ‰ËÌÔÛÎÔ‹ÛÂȘ, ÎÔ˘›˙, ËÏÂÎÙÚÔÓÈÎfi ËÌÂÚÔÏfiÁÈÔ, ÂÚÁ·ÏÂ›Ô ÂÈÏÔÁ‹˜ ÔÓfiÌ·ÙÔ˜ ηıÒ˜ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ‰ËÌÈÔ˘ÚÁ›·˜ ÚÔÛˆÈ΋˜ ÈÛÙÔÛÂÏ›‰·˜ ÁÈ· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ Ê›ÏˆÓ Î·È Û˘ÁÁÂÓÒÓ ÁÈ· ÙÔ ÂÂÚ¯fiÌÂÓÔ ÁÂÁÔÓfi˜. √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ ÂÓËÌÂÚÒÓÂÙ·È Û ٷÎÙÈ΋ ‚¿ÛË Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ Ôχ ˘„ËÏ‹ ÂÈÛ΄ÈÌfiÙËÙ·.

¶·È‰È·ÙÚÈ΋ 2005;68:462-463

Pediatr Nov-Dec 05

12-12-05

464

15:17

™ÂÏ›‰·464

∫§π¡π∫O ∫OÀπ∑

CLINICAL QUIZ

∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ ™‡Ó‰ÚÔÌÔ „¢‰Ô-Bartter ∆· ‚ÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È Û˘Ì‚·Ù¿ Ì ˘ÔηÏÈ·ÈÌÈ΋ ˘ԯψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË, ı· ÌÔÚÔ‡Û·Ó Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Bartter ‹ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ „¢‰Ô-Bartter, ÛÙÔ ÔÔ›Ô ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ÚˆÙÔ·ı‹˜ ÓÂÊÚÈ΋ ÓfiÛÔ˜ Î·È ÙÔ ¯ÏÒÚÈÔ ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ¯·ÌËÏfi (Û˘Ó‹ıˆ˜ <10 mEq/L). ∆Ô Û‡Ó‰ÚÔÌÔ ˘ÔηÏÈ·ÈÌÈ΋˜ ˘ԯψڷÈÌÈ΋˜ ÌÂÙ·‚ÔÏÈ΋˜ ·ÏοψÛ˘ ‹ Û‡Ó‰ÚÔÌ· Bartter Â›Ó·È Ì›· ÔÌ¿‰· Û·Ó›ˆÓ ·ı‹ÛˆÓ, Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È Ì ÙÔÓ ˘ÔÏÂÈfiÌÂÓÔ ÛˆÌ·ÙÈÎfi ¯·Ú·ÎÙ‹Ú· Î·È ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙË ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ Â·Ó·ÚÚfiÊËÛ˘ ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È ÙÔ˘ ¯ÏˆÚ›Ô˘ ÛÙÔ ·¯‡ ÙÌ‹Ì· Ù˘ ·Á·Ï˘ ÙÔ˘ Henle. √È ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Bartter ¤¯Ô˘Ó ·ÚÎÂÙ¿ ÎÔÈÓ¿ Â˘Ú‹Ì·Ù·, ·ÏÏ¿ Î·È ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ (1,2,3). ∆· ÎÔÈÓ¿ Â˘Ú‹Ì·Ù· ›ӷÈ: 1. ∏ ·˘ÍË̤ÓË ÓÂÊÚÈ΋ ·¤ÎÎÚÈÛË Ó·ÙÚ›Ô˘ Î·È ¯ÏˆÚ›Ô˘ (>20 mEq/L), Ô˘ ÚÔηÏ› ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ Î·È ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘·Ï‰ÔÛÙÂÚfiÓ˘.

2. √È ˘„ËϤ˜ ÙÈ̤˜ ÚÂÓ›Ó˘ Î·È ·Ï‰ÔÛÙÂÚfiÓ˘ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË. ™ÙËÓ ·‡ÍËÛË Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘ ÔÊ›ÏÂÙ·È ÙfiÛÔ Ë ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË fiÛÔ Î·È Ë ˘ÔηÏÈ·ÈÌ›·.

3. ∏ ˘ÔηÏÈ·ÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË. √ÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Î·È ÓÂÊÚ·Û‚¤ÛÙˆÛË, ™‹ÌÂÚ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚÂȘ ‰È·ÊÔÚÂÙÈÎÔ› Ê·ÈÓfiÙ˘ÔÈ ¤¯Ô˘Ó Ù·˘ÙÔÔÈËı›:

π. ∆Ô ÎÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ Bartter ∆· ÚÒÙ· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ÎÏ·ÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Bartter ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙ· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜. ™˘¯Ó¿ ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ÔÏ˘‰Ú·ÌÓ›Ô˘ Î·È ÚÔˆÚfiÙËÙ·˜ (1,2,3). ∂ÎÙfi˜ ·fi Ù· ÎÏ·ÛÈο Â˘Ú‹Ì·Ù· Û˘Ó‹ıˆ˜ ‰È·ÈÛÙÒÓÂÙ·È: 1. ¶ÔÏ˘‰È„›· Î·È ÔÏ˘Ô˘Ú›·, Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ Û˘Ì‡ÎÓˆÛ˘ ÙˆÓ Ô‡ÚˆÓ, Ô˘ ÚÔηÏ› Ë ˘ÔηÏÈ·ÈÌ›·. ∫fiˆÛË Î·È Ì˘˚΋ ·‰˘Ó·Ì›·, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ˘ÔηÏÈ·ÈÌ›·. ∞ÓÂ·Ú΋˜ ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÙÔ˘ ‡„Ô˘˜ Î·È ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË. ¶·È‰È·ÙÚÈ΋ 2005;68:464-466

2. ∏ ·¤ÎÎÚÈÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ‹ Ï›ÁÔ ·˘ÍË̤ÓË Î·È ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ÓÂÊÚ·Û‚¤ÛÙˆÛË.

3. ÀÔÌ·ÁÓËÛÈ·ÈÌ›· ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ, fï˜, fiÙ·Ó ‰È·ÈÛÙÒÓÂÙ·È ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·fi ÙÔ Û‡Ó‰ÚÔÌÔ Gitelman. ∏ ÚÒÙË ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÎÏ·ÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Bartter ÛÙËÓ ∂ÏÏ¿‰· ¤ÁÈÓ ÚÈÓ ·fi 20 ¯ÚfiÓÈ· (4) Î·È ·Ú·Ì¤ÓÂÈ ¤Ó· Û¿ÓÈÔ Úfi‚ÏËÌ·. ªÂ ÙȘ Ù¯ÓÈΤ˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Û˘Ó‹ıˆ˜ ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ Ô˘ Έ‰ÈÎÔÔÈ› ÙÔÓ ‰›·˘ÏÔ ¯ÏˆÚ›Ô˘ ClC-Kb (∂ÈÎfiÓ· 1,3) (5).

ππ. ∆Ô Û‡Ó‰ÔÌÔ Gitelman ™˘¯Ó¿ Ë ‰È¿ÁÓˆÛË Á›ÓÂÙ·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ·ÊÔ‡ Û˘Ó‹ıˆ˜ ÛÙ· ·È‰È¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù· Ì ÂÍ·ÈÚ¤ÛÂȘ ÙËÓ ÂÌÊ¿ÓÈÛË ·ÚÔ‰ÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Ì˘˚΋˜ ·‰˘Ó·Ì›·˜, ÎÔÈÏÈ·ÎÒÓ fiÓˆÓ Î·È ÙÂÙ·Ó›·˜ (1,2,3). ∏ ÔÏ˘Ô˘Ú›· Î·È Ë ·ÓÂ·Ú΋˜ ·‡ÍËÛË ÌÔÚ› Ó· ÌË ‰È·ÈÛÙÒÓÔÓÙ·È ‹ Ó· Â›Ó·È ‹Ș. ¢ÂÓ ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ÔÏ˘‰Ú·ÌÓ›Ô˘ ‹ ÚÔˆÚfiÙËÙ·˜. ∏ ˘ÔÌ·ÁÓËÛÈ·ÈÌ›· Î·È Ë ÂÏ·Ùو̤ÓË ÓÂÊÚÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ Â›Ó·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (1,2,3). ™˘Ó‹ıˆ˜ ‰È·ÈÛÙÒÓÔÓÙ·È ÌÂÙ·ÏÏ¿ÍÂȘ √‡Ú· £ÂÈ·˙›‰Ë Na* Cl-

∞›Ì·

4 NCCT

Ca2+

CIC-Kb Cl-

Ca2+ Na+

√‡Ú·

∞›Ì·

ÊÔ˘ÚÔÛÂÌ›‰Ë Na+ 2ClK+ Ca2+ Na+ 2+ Mg

N∫CC2 1

Cl- 3 CIC-Kb

+ 2 K+ K ROMK Cl-

∂ÈÎfiÓ· 1. ªÔÚȷΤ˜ ‚Ï¿‚˜ ÛÙ· Û‡Ó‰ÚÔÌ· µartter.

1 Î·È 2: ÓÂÔÁÓÈÎÔ‡ Ù‡Ô˘ Û‡Ó‰ÚÔÌÔ µartter, 3: ÎÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ µartter, 4: Û‡Ó‰ÚÔÌÔ Gitelman (11)

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·465

∫§π¡π∫O ∫OÀπ∑

CLINICAL QUIZ

465

¶›Ó·Î·˜ 1. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ Û˘Ó‰ÚfiÌˆÓ µartter (1)

∏ÏÈΛ· ‰È¿ÁÓˆÛ˘ ¶ÔÏ˘‰Ú¿ÌÓÈÔ / ÚÔˆÚfiÙËÙ· ∞ÓÂ·Ú΋˜ ·‡ÍËÛË ¶ÔÏ˘Ô˘Ú›· / ÔÏ˘‰È„›· ∆ÂÙ·Ó›· ∂Ï·Ùو̤ÓÔ Mg ÔÚÔ‡ Ca Ô‡ÚˆÓ ¡ÂÊÚ·Û‚¤ÛÙˆÛË PGE2 Ô‡ÚˆÓ

KÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ Bartter

™‡Ó‰ÚÔÌÔ Gitelman

NÂÔÁÓÈÎÔ‡ Ù‡Ô˘ Û‡Ó‰ÚÔÌÔ Bartter

¡ÂÔÁÓÈ΋ / ·È‰È΋ + ++ ++ ™¿ÓÈ· 20% ·ÛıÂÓÒÓ º˘ÛÈÔÏÔÁÈÎfi ‹ ·˘ÍË̤ÓÔ +/∞˘ÍË̤ÓË

¶·È‰È΋ / ÂÊË‚È΋ +/+ ++ 100% ·ÛıÂÓÒÓ Ã·ÌËÏfi º˘ÛÈÔÏÔÁÈ΋

∂Ì‚Ú˘˚΋ / ÓÂÔÁÓÈ΋ ++ +++ +++ ™¿ÓÈ· ¶Ôχ ·˘ÍË̤ÓÔ ++ ¶Ôχ ·˘ÍË̤ÓË

ÛÙÔ ÁÔÓ›‰ÈÔ Ô˘ Έ‰ÈÎÔÔÈ› ÙÔÓ Â˘·›ÛıËÙÔ ÛÙË ¯ÏˆÚÔıÂÈ·˙›‰Ë ÌÂÙ·ÊÔÚ¤· Ó·ÙÚ›Ô˘ Î·È ¯ÏˆÚ›Ô˘, ÙÔÓ ‰›·˘ÏÔ ¯ÏˆÚ›Ô˘ (¡CCT), Ô ÔÔ›Ô˜ ‚Ú›ÛÎÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ¿ˆ ÂÛÂÈÚ·Ì̤ÓÔ ÛˆÏËÓ¿ÚÈÔ (∂ÈÎfiÓ· 1,4) (5).

πππ. ¡ÂÔÁÓÈÎÔ‡ Ù‡Ô˘ Û‡Ó‰ÚÔÌÔ Bartter Ÿˆ˜ Î·È ÛÙÔ ÎÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ Bartter ‰È·ÈÛÙÒÓÂÙ·È ÈÛÙÔÚÈÎfi ÛÔ‚·ÚÔ‡ ÔÏ˘‰Ú·ÌÓ›Ô˘ Î·È ÚÔˆÚfiÙËÙ·˜. ¢È·ÎÚ›ÓÔÓÙ·È ‰‡Ô ÌÔÚʤ˜: ∆Ô Û‡Ó‰ÚÔÌÔ Bartter Ù‡Ô˘ π, Ô˘ ‰È·ÈÛÙÒıËÎ·Ó ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ÌÂÙ·ÊÔÚ¤· ÙÔ Ó·ÙÚ›Ô˘-Î·Ï›Ô˘-¯ÏˆÚ›Ô˘ (NKCC2) (∂ÈÎfiÓ· 1,1) Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÛÔ‚·Ú‹˜ ·Ê˘‰¿ÙˆÛ˘ Ì ÔÏ˘Ô˘Ú›· ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ (4,6). ™¯Â‰fiÓ ¿ÓÙ· Û˘Ó˘¿Ú¯ÂÈ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ì ÓÂÊÚ·Û‚¤ÛÙˆÛË Î·È Û˘¯Ó¿ ÂÂÈÛfi‰È· ‰È·ÚÚÔ˚ÎÒÓ ÎÂÓÒÛˆÓ, Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ∂2. ∞ÓÙ›ıÂÙ·, ÙÔ Û‡Ó‰ÚÔÌÔ Bartter Ù‡Ô˘ ππ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‹È· ÓÂÊÚÈ΋ ·¤ÎÎÚÈÛË Ó·ÙÚ›Ô˘ Î·È ¯ÏˆÚ›Ô˘ Î·È Û˘¯Ó¿ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ‰È·ÈÛÙÒÓÂÙ·È ˘ÂÚηÏÈ·ÈÌ›·. √Ê›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ÌÂÙ·ÊÔÚ¤· ÙÔ˘ Î·Ï›Ô˘ (ROMK) (∂ÈÎfiÓ· 1,3). ™‡Ó‰ÚÔÌÔ „¢‰Ô-Bartter ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È

µÈ‚ÏÈÔÁÚ·Ê›· 1. Guay-Woodford LM. Bartter syndrome: unravelling the pathophysiologic enigma. Am J Med 1998; 105(2):151-161.

2. Rodr›guez-Soriano J. Bartter and related syndromes; the puzzle is almost solved. Pediatr Nephrol 1998;12:315-327.

3. Hebert SC. Bartter syndrome. Curr Opin Nephrol Hypertens 2003;12(5):527-532.

·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÙËÓ ÎÏ·ÛÈ΋ ÂÈÎfiÓ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Bartter, ‰ËÏ·‰‹ ˘ÔηÏÈ·ÈÌ›·, ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË, ·˘ÍË̤ÓË ·Ï‰ÔÛÙÂÚfiÓË Î·È ÚÂÓ›ÓË, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ›ÂÛË, ¯ˆÚ›˜ fï˜ Ó· ÂÌÊ·Ó›˙Ô˘Ó ÚˆÙÔ·ı‹ ‚Ï¿‚Ë ÛÙ· ÓÂÊÚÈο ÙÔ˘˜ ÛˆÏËÓ¿ÚÈ·. ÷ڷÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· Â›Ó·È ÙÔ ¯·ÌËÏfi ¯ÏÒÚÈÔ Ô‡ÚˆÓ. ∆Ô ÛÙÔÈ¯Â›Ô ·˘Ùfi ‚Ô‹ıËÛ ÛÙÔ Ó· ÙÂı› Ë ˘Ô„›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ „¢‰Ô-Bartter ÛÙÔÓ ·ÛıÂÓ‹. ∆· ÈÔ Û˘ÓËıÈṲ̂ӷ ÓÔÛ‹Ì·Ù· Ô˘ ÚÔηÏÔ‡Ó ÙÔ Û‡Ó‰ÚÔÌÔ Â›Ó·È: ·. ∏ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ˜ (7), Ô˘ ·ÔÎÏ›ÛıËΠÌÂÙ¿ ·fi ÁÂÓÂÙÈ΋ ÌÂϤÙË. ‚. ∏ ¯ÚfiÓÈ· ¯Ú‹ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ (8), Ô˘ ·ÔÎÏ›ÛıËΠ·fi ÙÔ ÈÛÙÔÚÈÎfi. Á. √È Î˘ÎÏÈÎÔ› ¤ÌÂÙÔÈ (2), Ô˘ ·ÔÎÏ›ÛıËÎ·Ó ·fi ÙÔ ÈÛÙÔÚÈÎfi. ‰. ∏ ¯ÔÚ‹ÁËÛË Î·ı·ÚÙÈÎÒÓ (9,10). ªÂÙ¿ ·fi ÏÂÙÔÌÂÚ‹ Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡, Ë ÌËÙ¤Ú· ·Ó¤ÊÂÚ fiÙÈ Ì ‰È΋ Ù˘ ÚˆÙÔ‚Ô˘Ï›·, Û ‰È¿ÛÙËÌ· ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ ÚÈÓ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹, ›¯Â ¯ÔÚËÁ‹ÛÂÈ ÛÙÔ ‚Ú¤ÊÔ˜ ÂÓÓ¤· ÎχÛÌ·Ù· Ì sodium citrate dehydrate Î·È sodium lauryl sulphate. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯Ô˘Ó ‰ËÌÔÛÈÂ˘Ì¤Ó· ·Ó¿ÏÔÁ· ÂÚÈÛÙ·ÙÈο Û ÂÓ‹ÏÈΘ, fï˜ ·˘Ù‹ Â›Ó·È Ë ÚÒÙË ÂÚÈÁÚ·Ê‹ Û ·È‰›.

4. µ·‚·Ï¤· ™, ™ÙÂÊ·Ó›‰Ë˜ ∫, ¶··‰ËÌËÙÚ›Ô˘ ª, XÚÈÛÙÔÊÔÚ¿ÎË ª, ª·ÚÙ˙fiη˜ Ã: ™‡Ó‰ÚÔÌÔ Bartter Ù‡Ô˘ π. Materia Medica Greca 1985;13:95-100.

5. Peters M, Jeck N, Reinalter S, Leonhardt A, Tonshoff B, Klaus GG, Konrad M, Seyberth HW. Clinical presentation of genetically defined patients with hypokalemic salt-losing tubulopathies. Am J Med 2002 Feb 15;112(3):183-190.

6. Proesmans WC. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.

7. Kurlandsky LE. Failure to recognize the association ¶·È‰È·ÙÚÈ΋ 2005;68:464-466

Pediatr Nov-Dec 05

12-12-05

466

15:17

™ÂÏ›‰·466

∫§π¡π∫O ∫OÀπ∑ of cystic fibrosis and metabolic alkalosis. Clin Pediatr 2002 Nov-Dec;41(9):715-719.

8. Colussi G, Rombolà G, Airaghi C, De Ferrari ME, Minetti L. Pseudo-Bartter's syndrome from surreptitious diuretic intake: differential diagnosis with true Bartter's syndrome. Nephrol Dial Transplant 1992;7:896-901.

9. Meyers AM, Feldman C, Sonnekus MI, Ninin DT, Margolius LP, Whalley NA. Chronic laxative abusers with pseudo-idiopathic oedema and au-

¶·È‰È·ÙÚÈ΋ 2005;68:464-466

CLINICAL QUIZ tonomous pseudo-Bartter's syndrome. A spectrum of metabolic madness, or new lights on an old disease? S Afr Med J 1990;178(11):631-636.

10. S. Zacharieva, E. Natchev, M. Orbetzova. ¢Â˘ÙÂÚÔÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ „¢‰Ô-µartter ·Ô ÚÔÎÏËÙÔ‡˜ Â̤ÙÔ˘˜ Î·È Î·Ù¿¯ÚËÛË ˘·ÎÙÈÎÒÓ. Aگ›· ∂ÏÏËÓÈ΋˜ π·ÙÚÈ΋˜ 1999;16: 68-71.

11. Reinalter SC, Jeck N, Peters M, Seyberth HW: Pharmacotyping of hypokalaemic salt-losing tubular disorders. Acta Physiol Scand 2004;181:513-521.

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·467

¡∂∞ ∞¶√ ™À¡∂¢ƒπ∞

467

¡ÂfiÙÂÚ· ·fi ÙÔ 23Ô ∂Ù‹ÛÈÔ ™˘Ó¤‰ÚÈÔ Ù˘ ∂˘Úˆ·˚΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈÎÒÓ §ÔÈÌÒÍÂˆÓ µ·Ï¤ÓıÈ·, πÛ·Ó›·, ª¿ÈÔ˜ 2005 ª·Ú›˙· ∆ÛÔÏÈ¿

∂Ì‚fiÏÈÔ ÚÔÙ·˚Ô‡ √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ì ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ Ô Èfi˜ ÚÔηÏ› οı ¯ÚfiÓÔ ÂÚ›Ô˘ 1,9 ÂηÙÔÌ̇ÚÈ· ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È 440.000 ı·Ó¿ÙÔ˘˜ ÛÙ· ·È‰È¿, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜. √È ¯ÒÚ˜ ·˘Ù¤˜ ·Ó·Ì¤ÓÂÙ·È fiÙÈ ı· ¤¯Ô˘Ó ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ™ÙËÓ ∂˘ÚÒË ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ô ÚÔÙ·˚fi˜ ÚÔηÏ› 100.000 ÂÈÛ·ÁˆÁ¤˜ ·È‰ÈÒÓ ËÏÈΛ·˜ <5 ÂÙÒÓ Î·È 300 ÂÚ›Ô˘ ı·Ó¿ÙÔ˘˜ ÙÔÓ ¯ÚfiÓÔ. √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› Î·È ÛËÌ·ÓÙÈÎfi ÓÔÛÔÎÔÌÂÈ·Îfi ·ıÔÁfiÓÔ, ΢ڛˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·, ÚÔηÏÒÓÙ·˜ ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ ÛÙÔ Û‡ÛÙËÌ· ˘Á›·˜ ÌÈ·˜ ¯ÒÚ·˜. ∆o 1998 ΢ÎÏÔÊfiÚËÛ ÙÔ ÚÒÙÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÚÔÙ·˚Ô‡ (Rotashiled) ÙÔ ÔÔ›Ô ÂÚÈ›¯Â ÛÙÂϤ¯Ë rhesus Ô˘ ›¯·Ó ÚÔ¤ÏıÂÈ ·fi ·Ó¿ÌÈÍË Î·È ·Ó·‰È¿Ù·ÍË (reassortment) ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ÙÔ˘˜ ˘ÏÈÎÔ‡ Ì ·ÓıÚÒÈÓ· ÛÙÂϤ¯Ë. ∆Ô ÂÌ‚fiÏÈÔ fï˜ ·˘Ùfi ·ÔÛ‡ÚıËΠÙÔ 1999 ‰ÈfiÙÈ Û˘Û¯ÂÙ›ÛÙËΠ̠ÙËÓ ÂÌÊ¿ÓÈÛË ÂÁÎÔÏ·ÛÌÔ‡ Û ‚Ú¤ÊË. ¢‡Ô Ó¤· ÂÌ‚fiÏÈ· ηٿ ÙÔ˘ ÚÔÙ·˚Ô‡ ‰ÔÎÈÌ¿˙ÔÓÙ·È Û‹ÌÂÚ·. ∆Ô ¤Ó· Â›Ó·È ÙÔ ÂÓÙ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Rota-Teq Ù˘ Merck (G1, G2, G3, G4, P) Î·È ÙÔ ¿ÏÏÔ ÙÔ ÌÔÓÔ‰‡Ó·ÌÔ (Rotarix, Ù˘ GSK) Ô˘ ÂÚȤ¯ÂÈ ·ÓıÚÒÈÓÔ, ˙ˆÓÙ·Ófi ÂÍ·ÛıÂÓË̤ÓÔ Û٤ϯԘ (RIX4414) Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ Û٤ϯԘ GIP1A. To ÙÂÏÂ˘Ù·›Ô ·˘Ùfi ÂÌ‚fiÏÈÔ ¯ÔÚËÁÂ›Ù·È Û ‰‡Ô ‰fiÛÂȘ Î·È ‰ÔÎÈÌ¿ÛÙËΠ۠ÂÚÈÛÛfiÙÂÚ· ·fi 9.400 ·È‰È¿ Û ÌÂϤÙ˜ Ê¿Û˘ π Î·È ππ ÛÙËÓ ∂˘ÚÒË, ÙËÓ ∞Û›·, ÙË µfiÚÂÈ· Î·È ÙË ¡fiÙÈ· ∞ÌÂÚÈ΋. ªÂÏÂÙ¿Ù·È Û‹ÌÂÚ· Û ÌÂϤÙ˜ Ê¿Û˘ πππ Î·È ¤¯ÂÈ ¯ÔÚËÁËı› Û ÂÚÈÛÛfiÙÂÚ· ·fi 63.000 ·È‰È¿. ∆· ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ ·˘Ùfi, fiÙ·Ó ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· ÛÙ· ‚Ú¤ÊË Û ‰‡Ô ‰fiÛÂȘ, Â›Ó·È ·ÛʷϤ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÛÙËÓ ÚfiÏË„Ë Ù˘ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi. ∞Ó Î·È ÙÔ ÂÌ‚fiÏÈÔ ÂÚȤ¯ÂÈ ÚÔÙ·˚fi Ù‡Ô˘ G1 Ê·›ÓÂÙ·È fiÙÈ

·Ú¤¯ÂÈ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÚÔÛÙ·Û›· Î·È ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÈÔ‡. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ˘ÔÏÔÁ›˙ÂÙ·È Û 90% ÁÈ· ÛÔ‚·Ú‹ ‰È¿ÚÚÔÈ· Î·È Û 73% ·fi ÔÔÈ·‰‹ÔÙ ‰È¿ÚÚÔÈ· ÚÔηÏÔ‡ÌÂÓË ·fi ÙÔ ÚÔÙ·˚fi. ¢ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› ̤¯ÚÈ Û‹ÌÂÚ· ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (Abstracts ¡Ô 1, 7, 31, 32, 51). ∏ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÂÓÙ·‰‡Ó·ÌÔ˘ ÂÌ‚ÔÏ›Ô˘, Â›Û˘, ‰ÔÎÈÌ¿ÛÙËΠ۠70.301 ‚Ú¤ÊË ËÏÈΛ·˜ 6 ¤ˆ˜ 12 ‚‰ÔÌ¿‰ˆÓ, ·fi Ù· ÔÔ›· Ù· ÌÈÛ¿ ¤Ï·‚·Ó ·fi ÙÔ ÛÙfiÌ· 3 ‰fiÛÂȘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ì ‰È·ÊÔÚ¿ 4 ¤ˆ˜ 10 ‚‰ÔÌ¿‰ˆÓ Î·È ÛÙ· ˘fiÏÔÈ· ¯ÔÚËÁ‹ıËΠÂÈÎÔÓÈÎfi ÂÌ‚fiÏÈÔ (placebo). ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ‚ÚÂÊÒÓ ¤‰ÂÈÍ fiÙÈ ‰ÂÓ ÛËÌÂÈÒıËΠ·‡ÍËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÁÎÔÏ·ÛÌÔ‡ (Abstract No 46).

§¤ÎÙÔÚ·˜ µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

∂Ì‚fiÏÈÔ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ‰ÈÂÈÛ‰˘ÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ·fi Ó¢ÌÔÓÈfiÎÔÎÎÔ ÌÂÏÂÙ‹ıËΠ۠¯ÒÚ˜ fiˆ˜ Ë °ÂÚÌ·Ó›·, Ë √ÏÏ·Ó‰›· Î·È Ë πÛ·Ó›· fiÔ˘ ÂÊ·ÚÌfi˙ÂÙ·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙÔ Û˘˙¢Á̤ÓÔ ÂÙ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Î·È ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË. ™Â Ì›· ÌÂϤÙË ·fi ÙËÓ πÙ·Ï›· (Principi N, Abstract No 13) ¯ÔÚËÁ‹ıËΠÂÍ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Û ‚Ú¤ÊË ÛÙËÓ ËÏÈΛ· ÙˆÓ 3, 5 Î·È 11 ÌËÓÒÓ. ™Ù· ÌÈÛ¿ ‚Ú¤ÊË ¯ÔÚËÁ‹ıËΠٷ˘Ùfi¯ÚÔÓ· Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘. ∆· ·È‰È¿ ·˘Ù¿ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· ‰‡Ô ¯ÚfiÓÈ· Î·È ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ (29% vs 48%) Î·È Ó¢ÌÔÓ›·˜ (3,3% vs 8,8%) ÛÙ· ·È‰È¿ Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó Î·Ù¿ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘. ™Â ¿ÏÏË ·ÚÔ˘Û›·ÛË (Dagan R, Abstract No 25) Û¯ÔÏÈ¿ÛÙËÎÂ Ë Â›‰Ú·ÛË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÙÔ ÂÙ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÛÙËÓ ÔÈÎÔÏÔÁ›· ÙˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ. √È ˘¿Ú¯Ô˘Û˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ì ÙÔÓ ÂÌ‚ÔÏÈ·¶·È‰È·ÙÚÈ΋ 2005;68:467-470

Pediatr Nov-Dec 05

12-12-05

468

15:17

™ÂÏ›‰·468

CONGRESS NEWS ÛÌfi ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ‰ÈÂÈÛ‰˘ÙÈÎÒÓ ÏÔÈÌÒ͈Ó, ‰ÂÓ Û˘Ì‚·›ÓÂÈ fï˜ ÙÔ ›‰ÈÔ Ì ÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· Î·È ÙÔÓ ·ÔÈÎÈÛÌfi ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ·. ŸÏ˜ ÔÈ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÌÂÈÒÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ Ì ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÚÔÙ‡Ô˘˜ Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ∂ÓÒ ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ·Ú¯Èο fiÙÈ ÌÂÈÒÓÂÙ·È Ë Û˘ÓÔÏÈ΋ Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ Ì ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë, ·˘Ùfi ‰ÂÓ ÂȂ‚·ÈÒÓÂÙ·È ÛÙȘ ÈÔ ÚfiÛÊ·Ù˜ ÂÚÁ·Û›Â˜. √È ÙÂÏÂ˘Ù·›Â˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ·Ó Î·È ÌÂÈÒÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ Ì ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë ÔÚÔÙ‡ˆÓ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ·˘Í¿ÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ Ì ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë ¿ÏÏˆÓ ÔÚÔÙ‡ˆÓ Ô˘ ‰ÂÓ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ¶·Ú·ÙËÚÂ›Ù·È ‰ËÏ·‰‹ Ê·ÈÓfiÌÂÓÔ ·ÓÙÈηٿÛÙ·Û˘, ÙfiÛÔ ÛÙÔÓ ·ÔÈÎÈÛÌfi ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ· fiÛÔ Î·È ÛÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. √ ·ÔÈÎÈÛÌfi˜ ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ· Ì ÔÚÈṲ̂ÓÔ˘˜ ·ÓıÂÎÙÈÎÔ‡˜ ÔÚÔÙ‡Ô˘˜ Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ, fiˆ˜ ÔÈ 19F, 19∞ Î·È 6∞ ‰ÂÓ ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο. ¢È·ÈÛÙÒıËΠ‰Â, fiÙÈ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘¯Ó¿ ·ÓıÂÎÙÈÎÔ› ÎÏÒÓÔÈ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙÔ˘˜ ÔÚfiÙ˘Ô˘˜ 6∞, 10A, 19∞, 15A Î·È 15C, 35B, 33F ÔÚÈṲ̂ÓÔÈ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ¤¯Ô˘Ó ÙÔ ‰˘Ó·ÌÈÎfi Ó· ÚÔηϤÛÔ˘Ó √ªø ·ÏÏ¿ Î·È ‰ÈÂÈÛ‰˘ÙÈΤ˜ ÏÔÈÌÒÍÂȘ (Abstract No 280). º·›ÓÂÙ·È ÂÔ̤ӈ˜ fiÙÈ ÁÈ· Ó· ÌÂȈı› Ë ·ÓÙÔ¯‹ ‰ÂÓ ·ÚΛ Ë ¯Ú‹ÛË ÂÌ‚ÔÏ›ˆÓ, ·ÏÏ¿ ı· Ú¤ÂÈ Ó· ÌÂȈı› Î·È Ë ¯Ú‹ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ.

™˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C ∏ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ·fi ÙËÓ ÔÚÔÔÌ¿‰· C ¤¯ÂÈ ÌÂȈı› ‰Ú·Ì·ÙÈο ÛÙȘ ¯ÒÚ˜ fiÔ˘ ÂÊ·ÚÌfiÛÙËÎÂ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ (Abstracts No 17, 18, 22). ¶ÚfiÛÊ·Ù·, fï˜, ‰È·ÈÛÙÒıËΠÛÙË ª. µÚÂÙ·Ó›· (Abstract No 16) fiÙÈ Ô ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ Ù›ÙÏÔ˜ ÙÔ˘ ÔÚÔ‡ ÌÂÈÒÓÂÙ·È Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. ™ÙËÓ ›‰È· ¯ÒÚ· ÛËÌÂÈÒıËΠ̛ˆÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÂÚÈÙÒÛÂˆÓ ÓfiÛÔ˘ Û ÂÌ‚ÔÏÈ·Ṳ̂ӷ ·È‰È¿. ∏ Ì›ˆÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰È·ÈÛÙÒıËΠ΢ڛˆ˜ Û ·È‰È¿ Ô˘ ›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÛÙÔÓ 2Ô, 3Ô Î·È 4Ô Ì‹Ó· Ù˘ ˙ˆ‹˜, ¯ˆÚ›˜ ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÌÓËÛÙÈ΋˜ ‰fiÛ˘. √È ÎÏÈÓÈΤ˜ ·ÔÙ˘¯›Â˜ Û ÌÈÎÚ¿ ·È‰È¿ ÛËÌÂÈÒıËÎ·Ó ·Ú¿ ÙËÓ ·Ó¿Ù˘ÍË ·ÓÔÛȷ΋˜ ÌÓ‹Ì˘ ·fi ÙÔÓ ·Ú¯ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ∞ÓÙ›ıÂÙ·, ¶·È‰È·ÙÚÈ΋ 2005;68:467-470

·È‰È¿ Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ¤ÛÙˆ Î·È Ì ̛· ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ Ê¿ÓËΠfiÙÈ ‰È·ÙËÚÔ‡Û·Ó Î·Ï‡ÙÂÚ· ÚÔÛٷ٢ÙÈÎfi Ù›ÙÏÔ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÚÔÛÙ·Û›· ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. ∆›ıÂÙ·È, ÂÔ̤ӈ˜, ÙÔ ÂÚÒÙËÌ· Â¿Ó ˘¿Ú¯ÂÈ ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ·Ó·ÌÓËÛÙÈ΋˜ ‰fiÛ˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·˘ÙÔ‡. ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ·Ó·Ù˘¯ı› Î·È ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÙÂÙÚ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ Ô˘ ÂÚȤ¯ÂÈ ÙȘ ÔÚÔÔÌ¿‰Â˜ A,C,Y Î·È W135. ™Â ÌÂϤÙË Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËΠ‰È·ÈÛÙÒıËΠfiÙÈ Ë ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi Ì ÙÔ ÙÂÙÚ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ ‹Ù·Ó Ôχ ηϋ ÁÈ· fiϘ ÙȘ ÔÚÔÔÌ¿‰Â˜ Û ¿ÙÔÌ· Ô˘ ›¯·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÌ‚ÔÏÈ·ÛÙ› Ì ÙÔ ÌÔÓÔ‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ (Abstract No 26). ™ÙȘ ∏.¶.∞. Û˘ÓÈÛÙ¿Ù·È Û‹ÌÂÚ· Ô Î·ıÔÏÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ÂÊ‹‚ˆÓ Ì ÙÂÙÚ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘.

∂ÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ٷ Û˘˙¢Á̤ӷ ÂÌ‚fiÏÈ· ∏ ÚfiÛÊ·ÙË ÂÌÂÈÚ›· ·fi ÙË ¯Ú‹ÛË ÙˆÓ Û˘˙¢ÁÌ¤ÓˆÓ ÂÌ‚ÔÏ›ˆÓ Haemophilus influenzae type b Î·È ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· ¤‰ÂÈÍ ÙË ÛËÌ·Û›· ÙÔ˘ ¯ÚÔÓԉȷÁÚ¿ÌÌ·ÙÔ˜ Î·È ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ Ì ٷ Û˘˙¢Á̤ӷ ÂÌ‚fiÏÈ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ‰È·Ù‹ÚËÛË Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÚÔÛÙ·Û›·˜. ∏ ÂÌÂÈÚ›· Î·È Ì ٷ ‰‡Ô ·˘Ù¿ ÂÌ‚fiÏÈ· ¤‰ÂÈÍ fiÙÈ Ë ·ÓÔÛÔÁÔÓÈÎfiÙËÙ· ÙˆÓ Û˘˙¢ÁÌ¤ÓˆÓ ÂÌ‚ÔÏ›ˆÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË fiÙ·Ó ÙÔ ÂÌ‚fiÏÈÔ Á›ÓÂÙ·È Û ·È‰È¿ ¿Óˆ ÙÔ˘ ¤ÙÔ˘˜ Û ۇÁÎÚÈÛË Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÛÙȘ ËÏÈ˘ 2, 3 Î·È 4 ÌËÓÒÓ Ô˘ Á›ÓÂÙ·È ÛÙË ª. µÚÂÙ·Ó›·. ∂‰Â›¯ıË Â›Û˘, ÛÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ Hib, fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·Ó·ÌÓËÛÙÈ΋˜ ‰fiÛ˘ ÌÂÙ¿ ÙÔÓ ¯ÚfiÓÔ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÔÛ›·˜. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ÚÒÙˆÓ ‰fiÛÂˆÓ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ô‰ËÁ› ÛÙËÓ ·Ú·ÁˆÁ‹ ·ÓÔÛȷ΋˜ ÌÓ‹Ì˘ ÛÙÔ˘˜ ÂÌ‚ÔÏÈ·Ṳ̂ÓÔ˘˜. ∞ԉ›¯ıËΠfï˜, fiÙÈ ÁÈ· Ó· ˘¿Ú¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÚÔÛÙ·Û›· Ë ·ÓÔÛȷ΋ ÌÓ‹ÌË ‰ÂÓ Â›Ó·È ·ÚÎÂÙ‹, ·ÏÏ¿ ··ÈÙÂ›Ù·È Ë ‰È·Ù‹ÚËÛË Î·È ·ÚÔ˘Û›· ˘„ËÏÔ‡ Ù›ÙÏÔ˘ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi ηٿ ÙË ÛÙÈÁÌ‹ ¤ÎıÂÛ˘ ÂÓfi˜ ·ÙfiÌÔ˘ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ıÔÁfiÓÔ.

(Abstracts ¡Ô 16, 24). ∏ ÂÌÂÈÚ›· Ì ÙÔÓ Hib ¤‰ÂÈÍ Â›Û˘, fiÙÈ Ë Ì›ˆÛË Ù˘ ÌÈÎÚÔ‚ÈÔÊÔÚ›·˜ ÛÙÔ ÚÈÓÔÊ¿Ú˘ÁÁ·

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·469

¡∂∞ ∞¶√ ™À¡∂¢ƒπ∞ ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌ¤ÓˆÓ ÌÔÚ› Ó· ¤¯ÂÈ Û˘Ó¤ÂȘ ÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ‰È·Ù‹ÚËÛË Ù˘ ·ÓÔÛ›·˜. ∏ Ì›ˆÛË Ù˘ ÌÈÎÚÔ‚ÈÔÊÔÚ›·˜ Â›Ó·È Ì›˙ÔÓ ÏÂÔÓ¤ÎÙËÌ· ÙˆÓ Û˘˙¢ÁÌ¤ÓˆÓ ÂÌ‚ÔÏ›ˆÓ Î·È Û ·˘Ù‹ ÔÊ›ÏÂÙ·È Ë Ù·¯Â›· Â›Ù¢ÍË Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ ÛÙËÓ ÎÔÈÓfiÙËÙ·, ·ÎfiÌË Î·È fiÙ·Ó ÙÔ Â›Â‰Ô ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰ÂÓ Â›Ó·È Ôχ ˘„ËÏfi. ∏ ÂÎÚ›˙ˆÛË fï˜ ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ ·fi ÙÔÓ ÚÈÓÔÊ¿Ú˘ÁÁ· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· Î·È ÂÔ̤ӈ˜ ÙË Ì›ˆÛË ÙˆÓ Â˘Î·ÈÚÈÒÓ ÁÈ· ÂÓ›Û¯˘ÛË Ù˘ ·ÓÔÛ›·˜ Ì Èı·Ó‹ Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË Ù˘ ‰È¿ÚÎÂÈ¿˜ Ù˘. °È· fiÏÔ˘˜ ÙÔ˘˜ ˆ˜ ¿Óˆ ÏfiÁÔ˘˜, ··ÈÙÂ›Ù·È Û˘Ó¯‹˜ Â·ÁÚ‡ÓËÛË Î·È ÂȉËÌÈÔÏÔÁÈ΋ ÂÈÙ‹ÚËÛË ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ÁÈ· Ù· ÔÔ›· ÂÊ·ÚÌfi˙ÂÙ·È ÂÌ‚ÔÏÈ·ÛÌfi˜ ÌÂ Û˘˙¢Á̤ӷ ÂÌ‚fiÏÈ·. ∆· ÂÌ‚fiÏÈ· ·˘Ù¿ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÂÓÙÂÏÒ˜ ÔÌÔÈÔÁÂÓ‹ ÔÌ¿‰· Î·È Ë ‰È·ÊÔÚÂÙÈ΋ ÔÈÎÔÏÔÁ›· ÙˆÓ ÂÏ˘ÙÚÔÊfiÚˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ (Hib, Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ Î·È ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘) Û˘ÓÂ¿ÁÂÙ·È ÙËÓ ÂÌÊ¿ÓÈÛË ‰È·ÊÔÚÂÙÈÎÒÓ Û˘ÓÂÂÈÒÓ ·fi ÙËÓ Â˘Ú›· ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ηıÂÓfi˜ ·fi Ù· ÂÌ‚fiÏÈ· ·˘Ù¿ (Abstract ¡Ô24).

∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜ ∆Ô ÔÏ˘‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Ô˘ ÂÚȤ¯ÂÈ ÙÔÓ Û˘Ó‰˘·ÛÌfi ÂÌ‚ÔÏ›Ô˘ ÈÏ·Ú¿˜-ÂÚ˘ıÚ¿˜-·ÚˆÙ›Ùȉ·˜ (MMR) Î·È ·ÓÂÌ¢ÏÔÁÈ¿˜ (V) (ProQuad) Â›Ó·È ·ÛʷϤ˜ Î·È ¤¯ÂÈ ÈÛÔ‰‡Ó·ÌË ·ÓÔÛÔÁÔÓÈÎfiÙËÙ· Ì ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ ¯ˆÚÈÛÙ¿ (Abstracts No 3, 52). ∆o Û··ÛÌ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·˘ÙÔ‡ Ô˘ ‰È·ÙËÚÂ›Ù·È ÛÙË Û˘ÓÙ‹ÚËÛË Â›Ó·È ÈÛÔ‰‡Ó·ÌÔ Ì ÙÔ ‰È·ÙËÚÔ‡ÌÂÓÔ ÛÙËÓ Î·Ù¿„˘ÍË. √ÔÈÔ‰‹ÔÙ ·fi Ù· Û΢¿ÛÌ·Ù· ·˘Ù¿ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ Ù· ÂÌ‚fiÏÈ· MMR Î·È V Î·È Ó· ηٷÛÙ‹ÛÂÈ Â˘ÎÔÏfiÙÂÚÔ ÙÔÓ Î·ıÔÏÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ηٿ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ.

469

ÙËÓ ÂÓ‰ÔÁÂÓ‹ ·ÓÔÛȷ΋ ·¿ÓÙËÛË ‰ÂÓ Â›Ó·È ·ÎÚÈ‚Ò˜ ÁÓˆÛÙfi˜. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ÚfiˆÚ· ·Ú¿ÁÔ˘Ó ¯·ÌËÏfiÙÂÚÔ˘˜ Ù›ÙÏÔ˘˜ ·ÓÙÈÛˆÌ¿ÙˆÓ fiÙ·Ó ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È ·˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ ¤¯Ô˘Ó ·ÓÔÛÔÏÔÁÈ΋ ·ÓˆÚÈÌfiÙËÙ· Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ÙËÓ ËÏÈΛ· ΢‹Ûˆ˜. ∞̤ۈ˜, fï˜, ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ ·ÓÔÛÈ·Îfi Û‡ÛÙËÌ· ÙˆÓ ÚÔÒÚˆÓ ˆÚÈÌ¿˙ÂÈ ÁÚ‹ÁÔÚ· ˘fi ÙËÓ Â›‰Ú·ÛË ÙˆÓ Â͈ÙÂÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ÚfiˆÚ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ ·ÚÈıÌfi ∆ Î·È µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆· ‚Ï·ÛÙÈο ΤÓÙÚ· ¤¯Ô˘Ó ÌÂȈ̤ÓË ··ÓÙËÙÈ΋ ÈηÓfiÙËÙ· Î·È ÙÔ ›‰ÈÔ Û˘Ì‚·›ÓÂÈ Ì ٷ ı˘Ï·ÎÈο ‰ÂÓ‰ÚÈÙÈο ·ÙÙ·Ú·. ∂›Û˘ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Î¿ı ‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ Ô Ù›ÙÏÔ˜ ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÌÂٷʤÚÔÓÙ·È ·fi ÙË ÌËÙ¤Ú· ·˘Í¿ÓÂÈ Î·Ù¿ 10%. ∆ÂÏÂ˘Ù·›· ·Ú·ÙËÚ‹ıËΠfiÙÈ Ù· Ôχ ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚ· ÓÂÔÁ¤ÓÓËÙ· ÂÌÊ·Ó›˙Ô˘Ó Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋ ÂÈ‚¿Ú˘ÓÛË (¿ÓÔÈ·, ‚Ú·‰˘Î·Ú‰›·, ·˘ÍË̤ÓË ·Ó¿ÁÎË ÁÈ· Ô͢ÁfiÓÔ) ÌÂÙ¿ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÂÈ‚¿Ú˘ÓÛË ·˘Ù‹ Â›Ó·È Û˘Ó‹ıˆ˜ ‹È· Î·È Ù· ÂÂÈÛfi‰È· ˘Ô¯ˆÚÔ‡Ó ·˘ÙfiÌ·Ù· ‹ Ì ۇÓÙÔÌÔ ÂÚÂıÈÛÌfi. ∆· ÂÂÈÛfi‰È· ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ÂÈ‚¿Ú˘ÓÛ˘ Â›Ó·È ÈÔ Û˘¯Ó¿ Û ·È‰È¿ Ì ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÔÚ›· ‹ Û ·˘Ù¿ Ô˘ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ¤¯Ô˘Ó ηډÈÔ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· ηٿ ÙË ÛÙÈÁÌ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ∆· ÂÂÈÛfi‰È· ·˘Ù¿ ÂΉËÏÒÓÔÓÙ·È ÂÓÙfi˜ 48 ˆÚÒÓ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Û ‚Ú¤ÊË Ô˘ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ÓÔÛËχÔÓÙ·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 60 ËÌÂÚÒÓ. ™Â ·˘Ù¿ Ù· ‚Ú¤ÊË ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. ¶ÚfiˆÚ· ÓÂÔÁ¤ÓÓËÙ· Ô˘ ›¯·Ó ÔÌ·Ï‹ ÔÚ›· Î·È ¤¯Ô˘Ó ¿ÂÈ Û›ÙÈ ÛÙËÓ ËÏÈΛ· ·˘Ù‹ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· Â·ÓÂÈÛ¿ÁÔÓÙ·È ÁÈ· Ó· ÂÌ‚ÔÏÈ·ÛÙÔ‡Ó ˘fi ·Ú·ÎÔÏÔ‡ıËÛË. (Abstracts ¡Ô 29, 53).

¶ÔÈÔ Â›Ó·È ÙÔ ÛˆÛÙfi ̤ÁÂıÔ˜ ‚ÂÏfiÓ˘ ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ; ∂Ì‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ÚÔÒÚˆÓ ∆· ÚfiˆÚ· ÓÂÔÁ¤ÓÓËÙ· ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚË ÔÌ¿‰· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÏÔÈÌÒÍÂȘ. ∂ÎÙ›ıÂÓÙ·È Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ıÔÁfiÓˆÓ Û ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Î·Ù¿ ÙËÓ ÔÔ›· ÙÔ ·ÓÔÛÈ·Îfi ÙÔ˘˜ Û‡ÛÙËÌ· Â›Ó·È ·ÓÒÚÈÌÔ, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË ÚÔÛÙ·Û›· ·fi Ù· ÌËÙÚÈο ·ÓÙÈÛÒÌ·Ù· Û ۇÁÎÚÈÛË Ì ٷ ÙÂÏÂÈfiÌËÓ· ÓÂÔÁ¤ÓÓËÙ·. √ ÙÚfiÔ˜ Ì ÙÔÓ ÔÔ›Ô Ë ÚÔˆÚfiÙËÙ· ÂËÚ¿˙ÂÈ

™Â ÌÈ· ÌÂϤÙË ·fi ÙË ª. µÚÂÙ·Ó›· Û˘ÁÎÚ›ıËÎÂ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÙÔÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ·ÓÙȉڿÛÂˆÓ Û ‚Ú¤ÊË Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙËÓ ËÏÈΛ· ÙˆÓ 2, 3 Î·È 4 ÌËÓÒÓ Ì ÙÂÙÚ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ DTwP/Hib ‰È·ÈÛÙÒıËΠ̠̤ÁÂıÔ˜ ‚ÂÏfiÓ˘ 23G Î·È Ì‹ÎÔ˜ 25mm ÂÌÊ·Ó›˙Ô˘Ó ÏÈÁfiÙÂÚ˜ ÙÔÈΤ˜ ·ÓÙȉڿÛÂȘ Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ‚ÂÏfiÓË 23G Î·È Ì‹ÎÔ˜ 16mm (Abstract ¡Ô 47). ¶·È‰È·ÙÚÈ΋ 2005;68:467-470

Pediatr Nov-Dec 05

12-12-05

470

15:17

™ÂÏ›‰·470

CONGRESS NEWS ∂Ì‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ·ÈÏÏÒÌ·ÙÔ˜ (human papilloma virus, HPV)

Ó·È Ôχ ÂÓı·ÚÚ˘ÓÙÈο, ·Ó ÂȂ‚·ÈˆıÔ‡Ó Î·È ·fi ¿ÏϘ ÌÂϤÙ˜.

O Èfi˜ ÙÔ˘ ·ÈÈÏÏÒÌ·ÙÔ˜ ÚÔηÏ› ÙËÓ ÂÌÊ¿ÓÈÛË ÎÔÓ‰˘ÏˆÌ¿ÙˆÓ ÛÙË ÁÂÓÓËÙÈ΋ ÂÚÈÔ¯‹ Î·È Â›Ó·È ÙÔ Î‡ÚÈÔ ·›ÙÈÔ ÙÔ˘ ηÚΛÓÔ˘ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ Ù˘ Ì‹ÙÚ·˜. ™ÙËÓ ∂˘ÚÒË 33.500 Á˘Ó·›Î˜ ÂÌÊ·Ó›˙Ô˘Ó Î·ÚΛÓÔ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ Ù˘ Ì‹ÙÚ·˜ οı ¯ÚfiÓÔ Î·È 15.000 Âı·›ÓÔ˘Ó ·fi ÙË ÓfiÛÔ ·˘Ù‹. √È Ù‡ÔÈ 6 Î·È 11 ÙÔ˘ ÈÔ‡ ÚÔηÏÔ‡Ó ÙÔ 70% ÎÔÓ‰˘ÏˆÌ¿ÙˆÓ ÛÙË ÁÂÓÓËÙÈ΋ ÂÚÈÔ¯‹ Î·È ÔÈ Ù‡ÔÈ 16 Î·È 18 ÚÔηÏÔ‡Ó ÙÔ 90% ÙˆÓ Î·ÚÎ›ÓˆÓ ÙÔ˘ ÙÚ·¯‹ÏÔ˘. ¶ÚfiÛÊ·Ù· ·Ó·Ù‡¯ıËΠÙÂÙÚ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Ì ÙÔ˘˜ Ù‡Ô˘˜ 6, 11, 16 Î·È 18 ÙÔ˘ ÈÔ‡, ÙÔ ÔÔ›Ô ‚Ú¤ıËΠfiÙÈ ‹Ù·Ó ·ÛʷϤ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ¤Ó·ÓÙÈ ÙˆÓ ÓfiÛˆÓ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙÔÓ Èfi ·˘Ùfi. ∆Ô ÂÌ‚fiÏÈÔ ·˘Ùfi ı· ÂÈÛ·¯ı› ÛÙÔ Ì¤ÏÏÔÓ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ÎÔÚÈÙÛÈÒÓ ÚÔÂÊË‚È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ ·ÏÏ¿ Î·È ÙˆÓ Á˘Ó·ÈÎÒÓ. ∞Ú¯ÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ Â›Ó·È ·ÛʷϤ˜ Î·È ¤¯ÂÈ ·ÓÔÛÔÁÔÓÈ΋ ÈηÓfiÙËÙ·. ∆Ô ÂÌ‚fiÏÈÔ ·˘Ùfi ı· Â›Ó·È ÙÔ ÚÒÙÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ηÎÔ‹ıÔ˘˜ ÓfiÛÔ˘ Ô˘ ı· ÂÈÛ·¯ı› ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË (Abstracts ¡Ô 4, 34).

¡¤Â˜ Ù¯ÓÔÏÔÁ›Â˜ Î·È ÂÊ·ÚÌÔÁ¤˜ ÛÙËÓ ¤Ú¢ӷ Î·È ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ

∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ∂Ú¢ÓËÙ¤˜ ·fi ÙËÓ ∆Û¯›· ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙËÓ GlaxoSmithKline Biologics ·ÚÔ˘Û›·Û·Ó ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ÌÂϤÙË ÂÓfi˜ Ó¤Ô˘ Ó¢ÌÔÓÈÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÁÈ· ÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. ∆Ô ÂÌ‚fiÏÈÔ ÂÚȤ¯ÂÈ ÔÏ˘Û·Î¯·Ú›Ù˜ ·fi 11 ÔÚÔÙ‡Ô˘˜ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ Û˘˙¢Á̤ÓÔ˘˜ Ì ÚˆÙ½ÓË D Ô˘ Â›Ó·È Û˘ÛÙ·ÙÈÎfi ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ Haemophilus influenzae. ¶ÂÚ›Ô˘ 5.000 ·È‰È¿ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó Ù˘¯·ÈÔÔÈË̤ӷ Ì ÙÔ ÂÌ‚fiÏÈÔ ·˘Ùfi ‹ Ì ÂÌ‚fiÏÈÔ Ë·Ù›Ùȉ·˜ ∞. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ 11-‰‡Ó·ÌÔ˘ ÂÌ‚ÔÏ›Ô˘ ‹Ù·Ó 57% ÁÈ· ÔÔÈ·‰‹ÔÙ √ªø ·fi ÛÙÂϤ¯Ë ÓÂÌÔÓÈÔÎfiÎÎÔ˘ Ô˘ ·Ó‹Î·Ó Û ÔÚÔÙ‡Ô˘˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Î·È 35% ÁÈ· √ªø ·fi ÌË Ù˘ÔÔÈÔ‡ÌÂÓÔ Haemophilus influenzae. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÁÈ· οı √ªø ‹Ù·Ó 33,6%. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ›-

¶·È‰È·ÙÚÈ΋ 2005;68:467-470

∫¿ı ¯ÚfiÓÔ ÛËÌÂÈÒÓÔÓÙ·È 4,1 ÂηÙÔÌ̇ÚÈ· ı¿Ó·ÙÔÈ ·È‰ÈÒÓ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· 2,5 ÂηÙÔÌ̇ÚÈ· ÚÔηÏÔ‡ÓÙ·È ·fi ÓÔÛ‹Ì·Ù· Ù· ÔÔ›· ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó Ì ÙÔ˘˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜. ∞Ó·˙ËÙÔ‡ÓÙ·È ÂÔ̤ӈ˜ ÙÚfiÔÈ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ı· ‰È¢ÎÔÏ˘Óı› Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ Ì ٷ ‰È·ı¤ÛÈÌ· ÂÌ‚fiÏÈ·, ÂÓÒ Á›ÓÔÓÙ·È Î·È ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ¿ÏÏˆÓ ÓÂfiÙÂÚˆÓ ÂÌ‚ÔÏ›ˆÓ, fiˆ˜ ·˘Ù¿ Ù˘ Ê˘Ì·Ù›ˆÛ˘, Ù˘ ÂÏÔÓÔÛ›·˜, Ù˘ HIV Ïԛ̈͢, Î·È ¿ÏÏ·. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÏÔÔÈËı› Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ˘·Ú¯fiÓÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ, Â›Ó·È ÂÈı˘ÌËÙfi Ó· ˘¿ÚÍÔ˘Ó ÂÌ‚fiÏÈ· Ô˘ ‰ÂÓ ı· ÂËÚ¿˙ÔÓÙ·È ·fi ÙË ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ÒÛÙ ӷ Â›Ó·È ··Ú·›ÙËÙË Ë ‰È·Ù‹ÚËÛ˘ „˘¯Ú‹˜ ·Ï˘Û›‰·˜, ı· Â›Ó·È ¤ÙÔÈÌ· ÁÈ· ¯ÔÚ‹ÁËÛË, ÒÛÙ ӷ ÌËÓ ··ÈÙÂ›Ù·È ·Ó·Û‡ÛÙ·ÛË Î·È ı· ÌÔÚÔ‡Ó Ó· ¯ÔÚËÁÔ‡ÓÙ·È ¯ˆÚ›˜ ÙË ¯Ú‹ÛË ‚ÂÏfiÓ˘. ∂Èı˘ÌËÙfi Â›Ó·È Â›Û˘, Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÌ‚fiÏÈ· Ô˘ ·Ú¿ÁÔ˘Ó ·ÓÔÛ›· Ì ̛· ÌfiÓÔ ‰fiÛË, ηıÒ˜ Î·È ÔÏ˘‰‡Ó·Ì· ÂÌ‚fiÏÈ·. ªÂÏÂÙ¿Ù·È ÏÔÈfiÓ Ë ¯ÔÚ‹ÁËÛË ÂÌ‚ÔÏ›ˆÓ Ì ÚÔÁÂÌÈṲ̂ÓË Û˘Û΢‹ ¤ÓÂÛ˘ ÌÈ·˜ ¯Ú‹Û˘ Ô˘ ¤¯ÂÈ, fï˜, οˆ˜ ˘„ËÏfiÙÂÚÔ ÎfiÛÙÔ˜. ™ÙÔ ªÂÍÈÎfi ¯ÔÚËÁ‹ıËΠÂÌ‚fiÏÈÔ ÈÏ·Ú¿˜ ˘fi ÌÔÚÊ‹ ·ÂÚÔÛfiÏ˘ Û ‚Ú¤ÊË Ì ηϿ ·ÔÙÂϤÛÌ·Ù· Î·È ÌÂÏÂÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË Î·È ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ÂÚ˘ıÚ¿˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ÁÚ›˘ ·ÔÙÂÏ› ηÏfi ·Ú¿‰ÂÈÁÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÚÈÓÈÎfi „ÂηÛÌfi, Ô˘ ÌÔÚ› Ó· ÂÂÎÙ·ı› Î·È Û ¿ÏÏ· ÂÌ‚fiÏÈ·. ∂ÍÂÙ¿˙ÂÙ·È, Â›Û˘, Ë ÂÓ‰Ô‰ÂÚÌÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈÁfiÓˆÓ Ì ÌÈÎÚÔÛ˘Û΢¤˜ Ô˘ ‰È·ı¤ÙÔ˘Ó ÌÈÎÚÔ‚ÂÏfiÓ˜ Î·È ÂÎı¤ÙÔ˘Ó ¿ÌÂÛ· ÙÔ ·ÓÙÈÁfiÓÔ ÛÙ· ·ÓÙÈÁoÓÔ-·ÚÔ˘ÛÈ·ÛÙÈο ·ÙÙ·Ú· Ù˘ ‰ÂÚÌ›‰·˜ ‹ Ì ‚·ÏÏÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ ¯ÔÚ‹ÁËÛË ÍËÚÔ‡ ÂÌ‚ÔÏ›Ô˘ ¯ˆÚ›˜ ·Ó·Û‡ÛÙ·ÛË. ªÂÏÂÙ¿Ù·È Ë ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›ˆÓ Ô˘ Ì ̛· ¤ÓÂÛË ı· ¯ÔÚËÁÂ›Ù·È Ù·˘Ùfi¯ÚÔÓ· Ë ·Ú¯È΋ ‰fiÛË Î·È Ë ·Ó·ÌÓËÛÙÈ΋ (booster) Ì ‚Ú·‰Â›· ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘.

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·471

µπµ§πO¶∞ƒOÀ™π∞™∏

BOOK REVIEW

471

¶Ú·ÎÙÈÎfi˜ Ô‰ËÁfi˜ ·Ó¿Ó˄˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Àfi ¡. ¡ÈÎÔÏ·˝‰Ë, ∞. ¡·Ô‡Ì

ªÂ ȉȷ›ÙÂÚË ÈηÓÔÔ›ËÛË ‰¤¯ıËη ¤Ó· ·Ó¿Ù˘Ô ÙÔ˘ ‚È‚Ï›Ô˘ “¶Ú·ÎÙÈÎfi˜ O‰ËÁfi˜ ∞Ó¿Ó˄˘ ÙÔ˘ ¡ÂÔÁÓÔ‡” ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ Î. ¡ÈÎÔÏ·˝‰Ë Î·È Î. ¡·Ô‡Ì. ¶ÚfiÎÂÈÙ·È ÁÈ· Ôχ ÂÈÌÂÏË̤ÓË ÌÂÙ¿ÊÚ·ÛË ·fi Ù· ·ÁÁÏÈο ÙÔ˘ ‚È‚Ï›Ô˘ Ô˘ Âͤ‰ˆÛÂ Ë ∂ÈÙÚÔ‹ ∞Ó¿Ó˄˘ ÙÔ˘ ∏ӈ̤ÓÔ˘ µ·ÛÈÏ›Ԣ. ∏ ·fi‰ÔÛË ÙÔ˘ ‚È‚Ï›Ô˘ ÛÙ· ÂÏÏËÓÈο Â›Ó·È ÂÍ·ÈÚÂÙÈ΋. ª¤Û· ÛÙȘ 135 ÛÂÏ›‰Â˜ ÙÔ˘ ÂÚȤ¯ÂÙ·È ÙfiÛÔ Ë Ê˘ÛÈÔÏÔÁ›· Ù˘ ÓÂÔÁÓÈ΋˜ ˘ÔÍ·ÈÌ›·˜ fiÛÔ Î·È Ù· ‚·ÛÈο ‚‹Ì·Ù· Ù˘ ·Ó¿Ó˄˘. ∂ÈϤÔÓ, ˘¿Ú¯Ô˘Ó ¯ˆÚÈÛÙ¿ ÎÂÊ¿Ï·È· Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ÚfiÁÓˆÛË ÓÂÔÁÓÒÓ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ÛÙË ÊÚÔÓÙ›‰· ÙÔ˘ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ·Ó¿ÓË„Ë, fiˆ˜ Î·È ÛÙËÓ ÂÈÎÔÈÓˆÓ›· Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆Ô ‚È‚Ï›Ô ‰È·‚¿˙ÂÙ·È Ôχ ¢¯¿ÚÈÛÙ·, ¯¿ÚË ÛÙ· ÌÂÁ¿Ï· ÙÔ˘ ÁÚ¿ÌÌ·Ù·, ÛÙË ¯ÚËÛÈÌÔÔ›ËÛË Ï‹ıÔ˘˜ ÂÈÎfiÓˆÓ Î·È Û¯ËÌ¿ÙˆÓ, ÛÙËÓ ·Ó·ÊÔÚ¿ ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘ ÎÂÊ·Ï·›Ô˘ ÛÙËÓ ·Ú¯‹ οı ÂÓfi˜ ·fi ·˘Ù¿, ÛÙË ¯ÚËÛÈÌÔÔ›ËÛË ÎfiÎÎÈÓÔ˘ ¯ÚÒÌ·ÙÔ˜ ÁÈ· ÙÔÓ ÙÔÓÈÛÌfi ÛËÌ·ÓÙÈÎÒÓ ÛËÌ›ˆÓ, ηıÒ˜ Î·È ÛÙÔ ÛÈÚ¿Ï ‰¤ÛÈÌfi ÙÔ˘. ŒÚ¯ÂÙ·È ¤ÙÛÈ Ó· ηχ„ÂÈ ¤Ó· ÎÂÓfi Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· ¿Óˆ Û ¤Ó· ÙfiÛÔ ÎÚ›ÛÈÌÔ ÎÂÊ¿Ï·ÈÔ fiˆ˜ Â›Ó·È Ë ·Ó¿ÓË„Ë, ÂÓÒ ·ÔÙÂÏ› Û˘Ìϋڈ̷ ÙÔ˘ ÚÒÙÔ˘ ÂÈÙ˘¯Ë̤ÓÔ˘ ‚È‚Ï›Ô˘ ÙˆÓ ›‰ÈˆÓ Û˘ÁÁڷʤˆÓ ˘fi ÙÔÓ Ù›ÙÏÔ “∂ÓÙ·ÙÈ΋ ¡ÔÛËÏ›· ¡ÂÔÁÓÒÓ”. ™Â ÌÂÏÏÔÓÙÈ΋ ÙÔ˘ ¤Î‰ÔÛË ›Ûˆ˜ ı· Ú¤ÂÈ Ó· ÚÔÛÙÂı› ¤Ó· ÌÈÎÚfi Û˘Ìϋڈ̷, ÛÙÔ ÔÔ›Ô ı· ·Ó·Ê¤ÚÂÙ·È Ë ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿Ó˄˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ÙÔ ÓÂÔÁÓfi ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙȘ ÚÔÛ¿ıÂȤ˜ Ì·˜, fiˆ˜ Î·È ¤Ó·˜ ›Ó·Î·˜ Ì ·ı‹ÛÂȘ Ô˘ ıˆÚÔ‡ÓÙ·È ·Û‡Ì‚·Ù˜ Ì ÙË ˙ˆ‹. ªÂ ‰Â‰Ô̤ÓÔ fiÙÈ ‰ÂÓ ÓÔÂ›Ù·È Û‹ÌÂÚ· ·È‰›·ÙÚÔ˜ Ô˘ Ó· ÌËÓ Î·Ù¤¯ÂÈ Ù· ‚·ÛÈο Ù˘ ·Ó¿Ó˄˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ÈÛÙ‡ˆ fiÙÈ ÙÔ ÌÈÎÚfi ·˘Ùfi ‚È‚Ï›Ô ı· Ú¤ÂÈ Ó· ÌËÓ Ï›ÂÈ ·fi ηӤӷ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·.

¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·” AÏÏËÏÔÁÚ·Ê›·: Ã. ∫ÒÛÙ·ÏÔ˜ E-mail: ccostalos@yahoo.gr

Ã. ∫ÒÛÙ·ÏÔ˜ ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶° ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·”

¶·È‰È·ÙÚÈ΋ 2005;68:471

Pediatr Nov-Dec 05

472

12-12-05

15:17

™ÂÏ›‰·472

∂Àƒ∂∆∏ƒπ√ ∫ƒπ∆ø¡

∂˘¯·ÚÈÛٛ˜ ÚÔ˜ ÙÔ˘˜ ∫ÚÈÙ¤˜ Ù˘ «¶·È‰È·ÙÚÈ΋˜» ∏ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ¢¯·ÚÈÛÙ› ıÂÚÌ¿ ÙÔ˘˜ ÎÚÈÙ¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ «¶·È‰È·ÙÚÈ΋» Ô˘ ÚÔÛ¤ÊÂÚ·Ó ÙËÓ ›ڷ Î·È ÙÔÓ ¯ÚfiÓÔ ÙÔ˘˜ ÁÈ· Ó· ÂÍ·ÛÊ·Ï›Ûo˘Ó Û˘ÛÙËÌ·ÙÈΤ˜, ÙÂÎÌËÚȈ̤Ó˜ Î·È ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ ÁÈ· ÙȘ ÂÈÛÙËÌÔÓÈΤ˜ ÂÚÁ·Û›Â˜ Ô˘ ‰ËÌÔÛȇıËÎ·Ó Î·Ù¿ ÙÔ ¤ÙÔ˜ 2005.

∫ÚÈÙ¤˜ ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÛÙÔÓ ÙfiÌÔ 68 ÙÔ˘ ¤ÙÔ˘˜ 2005 ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ º·Ó‹ ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ ªÈÚ¿ÓÙ· ∞˚‚¿˙˘ µ›ÎÙˆÚ ∞˚‚¿˙ÔÁÏÔ˘ £Âfi‰ˆÚÔ˜ ∞Ó·ÁÓˆÛÙ¿Î˘ ¢ËÌ‹ÙÚÈÔ˜ ∞Ó·ÁÓˆÛÙ¿Î˘ πˆÛ‹Ê ∞Ó‰Ú¤Ô˘ ∞ϤͷӉÚÔ˜ ∞Ó‰ÚÔÓ›ÎÔ˘ ™Ù˘ÏÈ·Ó‹ ∞ÓÙˆÓÈ¿‰Ë˜ ™Ù˘ÏÈ·Ófi˜ ∞ÓÙˆÓÈ¿‰Ô˘-∫Ô˘Ì¿ÙÔ˘ πˆ¿ÓÓ· ∞ÓÙˆÓÔÔ‡ÏÔ˘ ∂ϤÓË ∞ÚÁ˘ÚÔÔ‡ÏÔ˘ ª·Ú›· ∞ÚÒÓË-µÔ˘ÚÓ¿ ™ÔÊ›· ∞˘ÁÔ˘ÛÙ›‰Ô˘ ¶ÂÚÛÂÊfiÓË µ·Ú‚·Ú‹ÁÔ˘-ºÚ›Ì· ∞Ó·ÛÙ·Û›· µ·ÚÏ¿Ì˘ °ÂÒÚÁÈÔ˜ µ¤ÎÈÔ˘-™·Ì·Ú¿ ∞ıËÓ¿ µÏ·¯Ô··‰ÔÔ‡ÏÔ˘ ∂Ï›‰· µÔ‡‰Ú˘ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ °·Ï¿-µ·Ì‚Ô˘Ú¿ÎË ∞ÁÁÂÏÈ΋ °·Ï·Ó¿Î˘ ∂ÌÌ·ÓÔ˘‹Ï °·ÏÏ‹-∆ÛÈÓÔÔ‡ÏÔ˘ ∞ÛË̛ӷ °·ÚÔ‡ÊË-∫Ô‡ÙÛ· ∞Ó·ÛÙ·Û›· °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË ∂ϤÓË °ÂˆÚÁÔ‡ÏË ∂ϤÓË °ÈÔ˘ÚÔ‡ÎÔ˜ ™ˆÙ‹ÚÈÔ˜ °Ú·Ê¿ÎÔ˜ ™Ù¤ÏÈÔ˜ °ÚËÁÔÚ¤·˜ ÃÚ‹ÛÙÔ˜ ¢ËÌËÙÚ›Ô˘ πˆ¿ÓÓ˘ ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ µ·ÛÈÏÈ΋ ∏Ï›· ª·Ú›· ∏ÏÈ¿‰Ô˘-§·˙ÔÔ‡ÏÔ˘ ¢¤ÛÔÈÓ· ∫·‚·˙·Ú¿Î˘ ∂ÌÌ·ÓÔ˘‹Ï ∫·‚·ÏÈÒÙ˘ πˆ¿ÓÓ˘ ∫·ÏÔÁÈ¿ÓÓ˘ ¡ÈÎfiÏ·Ô˜ ∫·Ó·‚¿Î˘ ∂ÌÌ·ÓÔ˘Ï‹ ∫·Ó¿ÚÈÔ˘ ª·Ú›· ∫·Ô˘Ï¤·˜ °ÂÒÚÁÈÔ˜ ∫·Ú·ÁÈ¿ÓÓË ÃÚÈÛÙ›Ó· ∫·Ú·ÁÎÈfi˙ÔÁÏÔ˘-§·ÌÔ‡‰Ë £ˆÌ·‹ ∫·Ú·ÌÂÚfiÔ˘ÏÔ˜ ¢ËÌ‹ÙÚÈÔ˜ ∫·Ú·Ó›Î·˜ ∏Ï›·˜ ∫·ÙÚÈÔ‡-¡ÈÎÔϷοÎË ¢ˆÚÔı¤·

¶·È‰È·ÙÚÈ΋ 2005;68:472

∫·ÙÛ·Ú‰‹˜ ÷ڿϷÌÔ˜ ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë ∂˘ÛÙ·ı›· ∫·ÙÙ¿Ì˘ ∞ÓÙÒÓ˘ ∫·ÊÂÙ˙‹˜ ¢ËÌ‹ÙÚÈÔ˜ ∫·ÊÚ›ÙÛ· ¶·Ó·ÁÈÒÙ· ∫ÂÚ·Ì›‰·˜ ¢ËÌ‹ÙÚÈÔ˜ ∫ÂÚ·ÛÈÒÙË-∫·Ú·Î·ÙÛ¿ÓË ∑ˆ‹ ∫›ÙÛÈÔ˘-∆˙¤ÏË ™ÔÊ›· ∫Ô‚¿Ó˘ ∞ı·Ó¿ÛÈÔ˜ ∫Ô˝‰Ô˘ ∞ÊÚÔ‰›ÙË ∫ÔÏ·˝Ù˘ °ÂÚ¿ÛÈÌÔ˜ ∫ÔÏÏÈfi˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ∫ÔÌÈ·ÓÔ‡ ºÈÏ·‰¤ÏÊÂÈ· ∫ÔÛÌ›‰Ë-µ·ÛÈÏ¿ÙÔ˘ ∂ϤÓË ∫Ô˘Ú¿Î˘ °ÂÒÚÁÈÔ˜ ∫Ô˘Ú‹ ∞Á·ı‹ ∫Ô˘ÙÛÔ˘ÏȤÚ˘ ∏Ï›·˜ ∫ÚÂÌÂÓfiÔ˘ÏÔ˜ °ÂÒÚÁÈÔ˜ ∫ÒÛÙ·ÏÔ˜ ÃÚ‹ÛÙÔ˜ §··ÙÛ¿Ó˘ ¶¤ÙÚÔ˜ §È·ÎÔÔ‡ÏÔ˘ ª¿Á‰· §È¿Ë-∞‰·Ì›‰Ô˘ °ÂˆÚÁ›· ª·ıÈÔ˘‰¿Î˘ πˆ¿ÓÓ˘ ª¿Ó‰ËÏ·-∫Ô˘ÛÔ˘Ó‹ ª·Ú›· ª·ÓÔ˘Û¿Î˘ ª·ÓÒÏ˘ ª·ÓˆÏ¿ÎË ¡›Ó·-∞Ú¯ÔÓÙ›· ª·ÚfiÔ˘ÏÔ˜ °ÂÒÚÁÈÔ˜ ª·ÛÙÚÔÁÈ¿ÓÓË ™ˆÙËÚ›· ªfiÙÙË ºÚfiÛˆ ªÂÚ¿Ù˘ ¡ÈÎfiÏ·Ô˜ ªÏ¿ÎÌÂÚÓ-¡¿ÎÔ˘ ™›Ó· ªÚÈ·ÛÔ‡Ï˘ °ÂÒÚÁÈÔ˜ ¡·Ó¿˜ ÃÚ‹ÛÙÔ˜ ¡ÈÎÔÏ·˝‰Ô˘ ¶ÔÏ˘Í¤ÓË ¡ÈÎÔÏ¿Ô˘-¶··Ó·ÁÈÒÙÔ˘ ∞ÏÂÍ¿Ó‰Ú· ¡Ô‡ÛÈ·-∞Ú‚·ÓÈÙ¿ÎË ™¿ÓÙ· ¡Ù·Ú›Ï˘ ∂ÌÌ·ÓÔ˘‹Ï ¡ÙfiÏ·Ù˙·˜ £Âfi‰ˆÚÔ˜ •¿ÓıÔ˘ ª·ÚȤÙÙ· •Â··‰¿ÎË ¶·Ú·Û΢‹ √ÈÎÔÓÔÌfiÔ˘ÏÔ˜ ÃÚ‹ÛÙÔ˜ ¶¿ÈÎÔ˜ ¶¤ÙÚÔ˜ ¶·Ó·ÁȈÙfiÔ˘ÏÔ˜ ∆¿Î˘

¶·Ó·ÁÈÒÙÔ˘ πˆ¿ÓÓ˘ ¶·Ó·ÁÈÒÙÔ˘-∞ÁÁÂÏ·ÎÔÔ‡ÏÔ˘ πˆ¿ÓÓ· ¶·ÓÙÂÏÈ¿‰Ë˜ ÃÚ‹ÛÙÔ˜ ¶··ÁÈ¿ÓÓ˘ πˆ¿ÓÓ˘ ¶··ÁÚËÁÔÚ›Ô˘-£ÂÔ‰ˆÚ›‰Ô˘ ª·Ú›· ¶··‰¿Î˘ µ·Û›ÏÂÈÔ˜ ¶··‰¿ÙÔ˘ ¢·Ó¿Ë ¶··‰ËÌËÙÚ›Ô˘ ∞Ó·ÛÙ¿ÛÈÔ˜ ¶··‰ÔÔ‡ÏÔ˘ ∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ ∑ˆ‹ ¶··‰fiÔ˘ÏÔ˜ °ÂÒÚÁÈÔ˜ ∆Ú¿·ÏË ÃÚÈÛÙ›Ó· ¶··Â˘·ÁÁ¤ÏÔ˘ µ¿Ó· ¶ÂÙÚ›‰Ô˘-™Î·ÏΛ‰Ô˘ ∂ϤÓË ¶Ú›ÊÙ˘ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ ∫ÔÚ›Ó· ƒ¿ÌÌÔ˜ ™˘Ú›‰ˆÓ ƒÔ‡ÛÛÔ˘ ∞ÏÂÍ¿Ó‰Ú· ™·ÍÒÓË-¶··ÁˆÚÁ›Ô˘ ºˆÙÂÈÓ‹ ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ∞ÓÙÈÁfiÓË ™ÎÂÓÙ¤Ú˘ ¡ÈÎfiÏ·Ô˜ ™ÎÈ·‰¿˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™˘Ú›‰Ë˜ ¶·Ó·ÁÈÒÙ˘ ™Ù·ÌÔÁÈ¿ÓÓÔ˘-ª·˘ÚÔÂȉ‹ §¤Ï· ™Ù·ÌÔ˘Ï·Î¿ÙÔ˘ ∞Ϥη ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ ∞ÓÙÈÁfiÓË ∆·Ú·ÓÙ˙‹ ¶ÔÏ˘Í¤ÓË ∆˙ˆÚÙ˙¿ÙÔ˘-™Ù·ıÔÔ‡ÏÔ˘ ºˆÙÂÈÓ‹ ∆۷ӿη˜ πˆ¿ÓÓ˘ ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘ ∆¿ÏÈ· ∆ÛÈÏÈÁÈ¿ÓÓ˘ £ÂÔÊ¿Ó˘ ∆ÛÈÏÈÌÈÁοÎË ∞Ì·Ï›· ∆Û›ÙÔ˘Ú· ™Ù¤ÏÏ· ∆ÛfiÏ·˜ °ÂÒÚÁÈÔ˜ ∆ÛÔÏÈ¿-¶·Û·Ú¿ÎË ª·Ú›˙· ºÚ˘Û›Ú·-∫·ÓÈÔ‡Ú· ∂ϤÓË ºˆÙfiÔ˘ÏÔ˜ ™˘Ú›‰ˆÓ ÷Ù˙Ë·ı·Ó·Û›Ô˘ ÷ڿϷÌÔ˜ ÷Ù˙‹˜ ∞Ó·ÛÙ¿ÛÈÔ˜ ÷Ù˙ËÛ‚·ÛÙÔ‡-§Ô˘Î›‰Ô˘ ÷ڛÎÏÂÈ· ÃȈٛÓ˘ ÃÚ‹ÛÙÔ˜ ÃÚËÛÙfiÔ˘ÏÔ˜-°ÂÚÔ˘Ï¿ÓÔ˜ °ÂÒÚÁÈÔ˜

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·473

∂Àƒ∂∆∏ƒπ√ ™À°°ƒ∞º∂ø¡

473

∂˘ÚÂÙ‹ÚÈÔ Û˘ÁÁڷʤˆÓ ÙÔ˘ ∆fiÌÔ˘ 68 C. van Viet-∫ˆÛÙ·ÓÙÈÓ›‰Ô˘ Du Toit G. Lack G. Rachman N. ∞ ∞Á·Î›‰Ë˜ Ã. ∞ÁÁÂÏfiÔ˘ÏÔ˜ ¶. ¢. ∞ı·Ó·ÛÈ¿‰Ô˘ º. ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ ª. ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘-∆ÛÈÎڛη µ. ∞ÏÈÊÈÂÚ¿ÎË ∆. ∞Ó·ÛÙ·ÛÈ¿‰Ë˜ °. ∞Ó‰Ú¤Ô˘ ∞. ∞ÓÙˆÓÈ¿‰Ë˜ ™. ∞ÔÛÙfiÏÔ˘ ∂. ∞ÔÛÙfiÏÔ˘ ª. ∞Ú‚·ÓÈÙ›‰Ë˜ ¡. ÕÚÛÔ˜ °. ∞˘ÏˆÓ›Ù˘ ™. µ µ·ÁÈ¿ÎÔ˘ ∂. µ·Î¿ÎË ª. µ·ÚÏ¿Ì˘ °. ™. µÂÏÂÁÚ¿ÎË ∞. µÂϤÓÙ˙·˜ ¶. µÏ·¯¿ÎË °. µÔÁÈ·Ù˙‹ §. µÔ‡‰Ú˘ ∫. ∞. µÚ¿ÓÔ˘ ª. ° °·‚ÚÈÈÏ›‰Ë˜ ™. °·Ï·Ó¿Î˘ ∂. °·ÏÏ¿-µÔ˘Ì‚Ô˘Ú¿ÎË ∞. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ ¢. °È·ÓÓ·ÎÔÔ‡ÏÔ˘ Ã. °ÎÈÒÓ˘ ¢. °Ô˘‰ÂÛ›‰Ô˘ ª. °Ô‡Ó·Ú˘ ∞. °Ú·ÌÌ·ÙÈο΢ π. ¢ ¢·Ú˙¤ÓÙ·˜ ∞. ¢·ÛÔÔ‡ÏÔ˘ ª. ¢ÂÛ‡Ú˘ ¡. ¢ËÌËÙÚ›Ô˘ °. ¢ËÌËÙÚ›Ô˘ ∂. ¢È·Ì·ÓÙ‹ ∂. ¢È·Ì·ÓÙfiÔ˘ÏÔ˜ ¡. ¢Ô‡ÚÔ˜ ∫. ¢Ô‡ÙÛ˘ √. ¢Ú‚ÂϤÁη˜ ∞. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ µ. ∂ ∂ÌÔÚÈ¿‰Ô˘ ª. ∂˘‰ˆÚ›‰Ô˘ π. ∂˘Ù‡¯Ë Ã.

133 337 337 366 417 433 74 329, 409, 440 372 308 62 372 155, 301 120 150 425 112 289 210 62, 133 204, 425 74 29 120 450 93, 210 62 425 85, 120 53, 245 454 85 352 372 1 128 222 150 37 417 103 450 257 454 217 74 450 399, 425 450 245

∑ ∑·ÊÂÈÚ›Ô˘ ¢.

409

£ £ˆÌ·˝‰Ë˜ £.

37

π πÔ˘ÏÈ·Ófi˜ ∞.

245

∫ ∫·Î·‚¿ º. ∫¿ÎÔ˘ÚÔ˜ ∂. ∫·Ï·Ìfi΢ ∞. ∫·ÏÌ·ÓÙ‹ ª. ∫·ÌÔ˘Ú›‰Ô˘ ¶. ∫·Ó·‚¿Î˘ ∂. ∫·Ó·Î¿-Gantenbein Ã. ∫·Ó·Ú›Ô˘ ª. ∫·Ó›ÛË ∂. ∫·Ú·‚·Ó¿ÎË ∫. ∫·Ú·Ì¤Ú˘ ™. ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘ ∂. ∫·Û›ÌÔ˜ ¢. ∫·Ù˙ËÏ¿Î˘ ¡. ∫·ÙÛÈÁÈ·ÓÓ¿ÎË ∂. ∫›ÙÛÈÔ˘-∆˙¤ÏË ™. ∫ÈÙÛÔÔ‡ÏÔ˘ ∞. ∫ÏËÌÂÓÙÔÔ‡ÏÔ˘ ∞. ∫Ô‚¿Ó˘ £. ∫fiÎÔÚË ∂. ∫ÔÏȷϤÍË ∞. ∫ÔÛÎÈÓ¿ ∂. ∫ÔÛÌ·˝‰Ô˘ ∑. ∫ÔÙÛÒÓ˘ ∫. ∫Ô˘‰Ô˘ÌÓ¿Î˘ ∂. ∫Ô˘Ì·Ú‹˜ °. ∫Ô‡ÚÙË ª. ∫Ô‡ÛË ∞. ∫Ô˘ÛÔ˘Ï›‰Ô˘ §. ∫Ô˘ÙÚÔ‡Ì· ¶. ∫Ô˘ÙÛ·Ó¤ÏÏÔ˘-Meyer ª. ∫ˆÓÛÙ·ÓÙÈÓ›‰Ô˘ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞. ∫ÒÛÙ·ÏÔ˜ Ã.

222 45 217 103 358 53 308 53 45 289 425 329 440 103 128 53, 245 342 366 308 120 53 446 245 69 133 245 204 440 245 189 308 366 245 1, 81, 150, 162, 321, 471

§ §¿ÁÁ·˜ ¢. §·˙·Ú›‰Ô˘ ™. §··ÙÛ¿Ó˘ ¢. §È·ÎÔÔ‡ÏÔ˘ ª. §Ô˘Î¿ÙÔ˘ ∂. §Ô˘Ú›‰· ∞.

37 204 279 308 150 145

ª ª·Î·‚fi˜ ∞. ª·Î¤‰Ô˘ ∞. ª·Î¤‰Ô˘ ∫. ª·ÓÈ·‰¿ÎË ∫. ª·ÓÈfi˜ π. ª·ÓÈfi˜ ¡. ª·ÓÔ˘Ú¿ ∞.

112 204 204 45 433 296 85 ¶·È‰È·ÙÚÈ΋ 2005;68:473-474

Pediatr Nov-Dec 05

12-12-05

474

15:17

™ÂÏ›‰·474

∂Àƒ∂∆∏ƒπ√ ™À°°ƒ∞º∂ø¡ ª·ÓÙ˙Ô˘Ú¿ÓË ∂. ª·ÓˆÏ¿ÎË ¡. ª·Ú¿ÎË ™. ª·ÛÙÚÔÁÈ¿ÓÓË ™. ª·Ù·ÊÈ¿ °. ª¿ÙÛ·˜ ¡. ª·‡ÚÔ˘ ∞. ªÂÚÌ›ÚË ¢. ªÂÛÛ·ÚÈÙ¿ÎË Õ. ªËÏÈÒÓ˘ Ã. π. ªËÙÛÈÒÓË ∞. ªÈÎÚ¿ÎË µ. ªÈ¯·ËÏ›‰Ô˘ ∂. ªÈ¯·Ï¤ÙÔ˘ ∂. ª›¯·˜ ∫. ªÈ¯ÂϷοÎË ∂. ªfiÓÙË ∫. ªfiÙÙË ∂. ªÔ˘Ï¿˜ ∞. ª¿Ï·˜ ∫. ª·ÌÈÓÈÒÙ˘ °. ¢. ª·ÓÙÔ˘Ú¿ÎË ª. ª·ÚÔ‡Ù˘ °. ª·ÚÙÛfiη˜ Ã. ™. ª¤ÛÈ·˜ ¡. ªfiÓÔ˘ ¶. ªÔ‡˙· ∂.

128 145 120 352 140 395 53 18 69 433 8 140 128 112 342 150 296 398 279 103 325 358 150 164 62 222 377

¡ ¡ÈÎÔÏ·˝‰Ô˘-∫·Ú·ı›Ô˘ ¶. ¡ÙÂÏ›ÎÔ˘ ™.

342 289

• •˘ÔÏ˘Ù¿-∑·¯·ÚÈ¿‰Ë ∞.

366

√ √ÈÎÔÓfiÌÔ˘ ª. ¶ ¶·Ó·ÁȈٷÎfiÔ˘ÏÔ˜ °. ¶¿ÓÔ˘ £. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã. ¶··Á·ÚÔ˘Ê¿Ï˘ ∫. ¶··ÁˆÚÁ›Ô˘ £. ¶··‰¿Î˘ ∞. ¶··‰¿ÙÔ˜ π. ¶··‰ËÌËÙÚ›Ô˘ ∂. ¶··‰ÔÔ‡ÏÔ˘ ∂. ¶··‰fiÔ˘ÏÔ˜ ¡. ¶·¿˙ÔÁÏÔ˘ ∫. ¶··Ó‰Ú¤Ô˘ ¢. ¶··Ó‰Ú¤Ô˘ √. ¶·ÙÛ·Ï‹˜ º. ∫. ¶·˘Ï›‰Ô˘ ∂. ¶ÂÚÁ¿ÓÙÔ˘ ∂. ¶ÂÚ‰ÈÎÔÁÈ¿ÓÓË Ã. ¶ÂÙÚ›‰Ô˘ ∂. ¶ÈÙÛÔ˘Ï¿Î˘ °. ¶Ï·ÙÔÎÔ‡ÎË ∂. ¶Ï·ÙÔÎÔ‡ÎË-∫ÔÌÈÙÔÔ‡ÏÔ˘ ∂.

¶·È‰È·ÙÚÈ΋ 2005;68:473-474

409, 440 62 112 112 377 74 103 222, 352 140 128 166, 241, 322, 396, 462 222 399 366 245 112 62 199 37, 226 133 62 308

¶ÏÈ¿ÎË ¶. ¶ÔÏ˘‚›Ô˘ ¶. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘-∞Ó‰ÚÔ˘Ï·Î¿ÎË ™. ¶ÔÓËÚfi˜ ¡. ¶Ô˘Ï¿ÎÔ˘-ƒÂÌÂÏ¿ÎÔ˘ Œ. ¶Ô˘ÏfiÔ˘ÏÔ˜ ¶. ¶Ú›ÊÙ˘ ∫. ¶ÚÔ‰ÚfiÌÔ˘ º. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ ∫. ™ ™·ÎÂÏÏ·ÚÔÔ‡ÏÔ˘ ∞. ™·Ï·‚Ô‡Ú· ∞. ™·ÌÌÔ‡ÙË ∂. ™ÂÚ‚ÈÙ˙fiÁÏÔ˘ ª. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ∞. ™ÈÛÌ¿ÓË ∫. ™ÈÒÌÔ˘ ∞. ™Î·Ú‰Ô‡ÙÛÔ˘ ∞. ™ÎÂÓÙ¤Ú˘ ¡. ™ÎÔÚ‰‹˜ ¡. +™Ì˘Ú¿ÎȘ ™. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË ∞. ™Ô‡ÏÔ˘ µ. ™˘Ú›‰Ë˜ ¶. ™Ù·ıÔÔ‡ÏÔ˘ £. ™Ù¿ÌÔ˘ ª. ™Ù·˘Ú›‰Ë˜ °. ™ÙÂȷοÎË ∂. ™ÙÂÊ·Ó¿ÎË ™. ™ÙÂÊ·Ó›‰Ë˜ ∫. ™Ù¤ÊÔ˜ ∂. ™ˆÙËÚ›‰Ô˘ ∂. ∆ ∆˙ËÙËÚ›‰Ô˘ ª. ∆˙Ô‡ÊË ª. ∆Ú·ÁÈ·ÓÓ›‰Ë˜ ∞. ∆Û·ÁÚ‹˜ µ. ∆ÛÈÏÈÌÈÁοÎË ∞. ∆Û›ÙÛÈη Õ. ∆ÛfiÏ·˜ °. ∆ÛÔÏÈ¿ ª. ∆ÛÔ˘Ì¿Î·˜ ∫. ∆ÛÔ‡ÙÛÔ˘ ∞. º ºÏˆÚÂÓÙ›Ó-∞Ú¿Ú §. ºÚ˘Û›Ú· ∂. à ÷ÏÈ¿ÛÔ˜ ¡. ÷ÏÈÒÙ˘ º. ÿÏÏ· Õ. ÷ÛÈÒÙÔ˘ ª. ÷Ù˙Ë·ı·Ó·Û›Ô˘ Ã. °. ÷Ù˙Ë·Ó·Á‹˜ ∞. ÷Ù˙ËÛ‚·ÛÙÔ‡-§Ô˘Î›‰Ô˘ Ã. ÷Ù˙ÔÔ‡ÏÔ˘ µ. ÃÔϤ‚·˜ µ. ÃÚÔ‡ÛÔ˜ °.

440 446 189 366 226 69 18 289 62, 69 372 53 133, 446 210 279 245 240, 268, 279 180, 210 140 245 120 337 199 163 450 74 245 103 120 82, 240, 461 210 358 112 279 74 342 120 145 169 466 217 352 372 53, 145 279 289 268, 279 133, 446 245 461 358, 386 140 279 366

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·475

∂Àƒ∂∆∏ƒπ√ §∂•∂ø¡-∫§∂π¢πø¡

475

∂˘ÚÂÙ‹ÚÈÔ Ï¤ÍˆÓ-ÎÏÂȉÈÒÓ ÙÔ˘ ∆fiÌÔ˘ 68 AZF Campylobacter jejuni Corona Èfi˜ DGS/VCFS FISH IgA ÓÂÊÚÔ¿ıÂÈ· Listeria monocytogenes PAR2 SARS

245 128 199 53 53 8 289 245 199

∞ ∞ÁÁÂÈÔ·ÔÊÚ·ÎÙÈο ÂÂÈÛfi‰È· 329 ∞‰ÂÓÔ˚fi˜ 69 ∞ıËÚÔÛÎÏ‹ÚˆÛË 204 ∞ıËڈ̿وÛË 169 ∞ÈÌ·ÁÁ›ˆÌ· 145 ∞ÈÌÔÚÚ·ÁÈΤ˜ ‰È·ı¤ÛÂȘ 308 ∞ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ 155, 454 ∞ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ 358 ∞ÏÏÔ·ÓÔÛÔÔ›ËÛË 440 ∞Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· 150 ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ 337 ∞ÓÔÛÔÂÓÂÚÁfi˜ ıÚ˘„›ÓË 386 ∞ÓÔÛÔηٷÛÙÔÏ‹ 289 ∞ÓÙ›‰Ú·ÛË Coombs 440 ∞ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· 189 ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· 446 ∞ÂÈÎfiÓÈÛË 133 ÕÛıÌ· 399 ÕÛÎËÛË 454 ∞ÛÂÚÁ›ÏψÛË ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ 74 ∞ÙÏ·ÓÙÔ·ÍÔÓÈ΋ ·ÛÙ¿ıÂÈ· 358 ∞ÙÏ·ÓÙÔ·ÍÔÓÈÎfi ÂÍ¿ÚıÚËÌ· 358 ∞ÙÏ·ÓÙÔ·ÍÔÓÈÎfi ˘ÂÍ¿ÚıÚËÌ· 358 ∞Ù‡¯ËÌ· 37 ∞‡ÍËÛË 268 ∞˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· 440 µ µÈÔ¯ËÌÈÎÔ› ÔÛÙÈÎÔ› ‰Â›ÎÙ˜ µÏ·ÈÛfi˜ ̤Á·˜ ‰¿¯Ù˘ÏÔ˜ Ô‰ÈÔ‡ µÏ·Ù›‰Â˜ ‚-ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· µÚÂÊÈ΋ ·ÏÏ·ÓÙ›·ÛË µÚÂÊÈ΋ ËÏÈΛ· ° °ÓˆÛÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ °ÔÓÂ˚΋ Û˘ÌÂÚÈÊÔÚ¿ °ÔÓÈΤ˜ ·ÓÙÈÏ‹„ÂȘ ¢ ¢Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ¢ÂÛÊÂÚÚÈÔÍ·Ì›ÓË ¢›·ÈÙ· ¢È·ÙÚÔÊ‹ ¢È·ÊÚ·ÁÌ·ÙÔ΋ÏË ¢ÈÎÙ˘ÔÂÚ˘ıÚÔ·ÙÙ·Ú· ÙÔ˘ stress ¢ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ˜

268, 279 217 366 440 222 128

112 37 45

433 409 399 1, 399, 433 417 329 329

¢˘ÛÏÂÈÙÔ˘ÚÁ›· ·ÚÙËÚÈ·ÎÔ‡ ÂÓ‰ÔıËÏ›Ô˘ ¢‡ÛÓÔÈ· ∂ ∂ÁÎÂÊ·ÏÈÎfi ·fiÛÙËÌ· ∂ÁΤʷÏÔ˜ ŒÎÙÔË ÔÛÙÂÔÔ›ËÛË ŒÏÂÁ¯Ô˜ ∂χıÂÚÔ˜ ¯ÚfiÓÔ˜ ŒÏÏÂÈÌÌ· 22q11.2 ∂ÏÏËÓÈ΋ ÏÔÁÔÙ¯ӛ· ∂ÏÏÈÔ‚·Ú¤˜ ∂Ì‚fiÏÈ· ∂Ì‚Ú˘˚΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ŒÌ‚Ú˘Ô ∂Ì‡ËÌ· ∂Ó‰Ôı‹ÏÈÔ ∂Ó‰ÔÊϤ‚È· Á-ÛÊ·ÈÚ›ÓË ∂Ó‰ÔÊϤ‚Ș ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ∂ÍÂÙ¿ÛÂȘ DNA ∂›ÁÔ˘Û· È·ÙÚÈ΋ ∂ȉËÌÈÔÏÔÁ›· ∂ÈÏË„›· ∂ÙȉÚÔÓ¿ÙË ∂Ê˂›·

169 189

289 377 217 155 433 53 226 1 120 417 417 18 329 352 180 386 29 120 93, 112, 257, 308 217 308

∏ ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ◊·Ú £ £¤Ì·Ù· ËıÈ΋˜ £ÂÚ·›· £ÂÚ·›· Ì ÛÙÂÚÔÂȉ‹ π πÓÔ΢ÛÙÈ΋ ÓfiÛÔ˜ πÓÔÌ˘·ÏÁ›· πÓÙÂÚÊÂÚfiÓË-· πӈ̿وÛË ÿÚȉ· ∫ ∫·Ú‰È·Î¤˜ ‚Ï¿‚˜ ∫·Ú‰ÈÔÏÔÁÈÎfi Úfi‚ÏËÌ· ∫·Ú‰ÈÔÏÔÁÈÎÔ› ΛӉ˘ÓÔÈ ∫·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ∫ÔÏfi‚ˆÌ· ∫ÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ∫Ú‹ÙË ∫˘ÎÏÔÛÔÚ›ÓË ∫‡ÛÙÂȘ ¯ÔÏˉfi¯Ô˘ ∫˘ÛÙÈ΋ ›ÓˆÛË § §È›‰È· §Ô›ÌˆÍË §Ô›ÌˆÍË ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜

93 446

386 199, 342 180

308 342 145 366 296

425 155 301 189 53 296 279, 377 120 289 140 386

204 85 289 ¶·È‰È·ÙÚÈ΋ 2005;68:475-476

Pediatr Nov-Dec 05

12-12-05

476

15:17

™ÂÏ›‰·476

∂Àƒ∂∆∏ƒπ√ §∂•∂ø¡-∫§∂π¢πø¡ ª ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ª·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ ªÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· ªÂÙ·ÏÔÈÌ҉˘ Ì˘ÂÏ›ÙȘ ªËΈÓȷ΋ „¢‰Ô·ÛÙË ªËÓÈÁÁ›Ùȉ· ªËÓÈÁÁÈÙȉfiÎÔÎÎÔ˜ ªË¯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ª˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne ª˘ÔÛÎÂÏÂÙÈÎfi˜ ¡ ¡ÂÔÁÓÈ΋ ËÏÈΛ· ¡ÂÔÁÓfi ¡ÂÔÏ¿ÛÌ·Ù· ¡Â˘ÚÔÙÔÍÈÎfiÙËÙ· ¡Â˘ÚÔÊ˘ÛÈÔÏÔÁ›· ¡Â˘ÚÔ„˘¯ÔÏÔÁ›· ¡ÔËÙÈÎfi ËÏ›ÎÔ ¡ÔÛ‹Ì·Ù· ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÔÛÙÒÓ ¡fiÛÔ˜ Berger ¡fiÛÔ˜ Caroli ¡fiÛÔ˜ Crohn √ √¢∂ª √˙›‰È· √ÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi √ÈÎÔÁÂÓ‹˜ ÂÌÊ¿ÓÈÛË √ÈÎÔÁÂÓ‹˜ ˘Ô¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· √Í›· ‰È¿¯˘ÙË ÂÁÎÂÊ·ÏÔÌ˘ÂÏ›Ùȉ· √Í›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· √Í›· ¯·Ï·Ú‹ ·Ú¿Ï˘ÛË √Íηڂ·˙Â›ÓË √͢ÁfiÓˆÛË √ÛÙÈÎfi˜ ·Ó·Û¯ËÌ·ÙÈÛÌfi˜ √Êı·ÏÌÈΤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ √Êı·ÏÌÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ ¶ ¶·È‰È¿

358 112 446 409 180 450 120 120 222, 352, 417 386 342

85 150, 377 189 409 409 409 409 259 8 140 128

69 366 204 372 169 69 74, 103 180 112 417 268 296 145

8, 69, 93, 133, 155, 199, 204, 210, 268, 279, 342, 425, 446 ¶·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ 37 ¶·È‰È·ÙÚÈ΋ 29 ¶·È‰È·ÙÚÈ΋ Ú¿ÍË 301 ¶·È‰Èο ·Ù˘¯‹Ì·Ù· 226 ¶·È‰È΋ ‰È·ÙÚÔÊ‹ 45 ¶·È‰È΋ ËÏÈΛ· 62, 74, 103, 189, 226, 399 ¶·È‰È΋ ·¯˘Û·ÚΛ· 45 ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ 204, 433 ¶·Ú·Ó¢ÌÔÓÈ΋ Û˘ÏÏÔÁ‹ 18 ¶·ÚÔ¯¤Ù¢ÛË 18 ¶·¯˘Û·ÚΛ· 433 ¶ÂÚÈʤÚÂÈ· ̤Û˘ 433

¶·È‰È·ÙÚÈ΋ 2005;68:475-476

¶Ï·ÛÌ·Ê·›ÚÂÛË ¶Ó¢ÌÔÓ›· ¶Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ¶Ó¢ÌÔÓÔ¿ıÂÈ· ¶fiÓÔ˜ ¶Ú‰ÓÈ˙ÔÏfiÓË ¶ÚÔ·ıÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ¶ÚÔıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¶ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ¶ÚfiÏË„Ë ¶ÚfiˆÚÔ ÓÂÔÁÓfi ¶ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· ¶˘ÚÂÙÈÎÔ› Û·ÛÌÔ› ¶˘ÚÂÙfi˜ ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜

180 18, 425 145 217 342 289 454 372 62 409 155 1 29 210 128

™ ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ™Ë„·ÈÌ›· ™ÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ ™Ô‚·Úfi Ô͇ ·Ó·Ó¢ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ™Ù·Ù›Ó˜ ™ÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ™˘ÁÁÂÓ‹˜ Ë·ÙÈ΋ ›ÓˆÛË ™˘ÁÁÂÓ‹˜ ˘ÔÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ ™˘ÌÙÒÌ·Ù· ™‡Ó‰ÚÔÌÔ Dandy-Walker ™‡Ó‰ÚÔÌÔ Down ™‡Ó‰ÚÔÌÔ Guillain-Barré ™‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘ ÌËÎˆÓ›Ô˘ ™‡Ó‰ÚÔÌÔ ÂÏÏ›ÌÌ·ÙÔ˜ 22q11 ™˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹

308 85 217 199 169 169 140 150 199 145 358 180, 352 450 372 399

∆ ∆·¯‡ÙËÙ˜ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ ∆¯ÓÈ΋ FISH ∆ËÏÂfiÚ·ÛË ∆ËÏÂʈÓÈο ΤÓÙÚ· ∆ËÏÂʈÓÈ΋ È·ÙÚÈ΋ ∆Ú·¯ËÏÈο ÙÂÚ·ÙÒÌ·Ù· ∆ÚÔ¯·›· ·Ù˘¯‹Ì·Ù·

409 372 257, 433 29 29 133 226

À À ¯ÚˆÌfiۈ̷ ÀÔÙÚÔ‹ ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ

245 210

º º·Ú̷΢ÙÈΤ˜ ÚÔÎÏ‹ÛÂȘ º·Ú̷΢ÙÈ΋ ·ÏÏÂÚÁ›· º·ÛÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ºÏ‚È΋ ıÚfiÌ‚ˆÛË º˘ÏÂÙÈÎfi˜ ̈۷˚ÎÈÛÌfi˜ ºˆÙÔ¢·ÈÛıËÛ›·

337 337 103 62 245 257

à ÃËÌÂÈÔΛÓ˜ ÃÔÏÒ‰ÂȘ ¤ÌÂÙÔÈ

85 450

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·479

¶ƒ√™∂Ã∏ ™À¡∂¢ƒπ∞

xxiii

26-28 π·ÓÔ˘·Ú›Ô˘ 2006 6Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ •ÂÓÔ‰Ô¯Â›Ô Holiday Inn ¶ÏËÚÔÊÔڛ˜: PRC Congress & Travel ∆ËÏ.: (+30) 210 7711 673, 210 7756 336 Fax: (+30) 210 7711 289 E-mail: info@prctravel.gr

∞ı‹Ó·

4 ºÂ‚ÚÔ˘·Ú›Ô˘ 17 ™ÂÙÂÌ‚Ú›Ô˘ 2006

¶ÚfiÁÚ·ÌÌ· ∫·Ù¿ÚÙÈÛ˘ ∂·ÁÁÂÏÌ·ÙÈÒÓ ÀÁ›·˜ ÛÙËÓ ∞Ó·ÎÔ˘ÊÈÛÙÈ΋ ºÚÔÓÙ›‰· ¶·È‰ÈÒÓ Ì ∞ÂÈÏËÙÈ΋ ∞ÚÚÒÛÙÈ· ¶ÏËÚÔÊÔڛ˜: ª∂ƒπª¡∞ ∂Ù·ÈÚ›· ÁÈ· ÙË ºÚÔÓÙ›‰· ¶·È‰ÈÒÓ Î·È √ÈÎÔÁÂÓÂÈÒÓ ÛÙËÓ ∞ÚÚÒÛÙÈ· Î·È ÛÙÔ £¿Ó·ÙÔ, Î. µ¿Ó· ∑¿¯Ô˘ ∆ËÏ.: +30 210 6452013 Fax: +30 210 6463367 ∂-mail: merimna@softlab.ece.ntua.gr Website: www.merimna.org.gr

∞ı‹Ó·

7-9 ºÂ‚ÚÔ˘·Ú›Ô˘ 2006

8th UAE International Congress for Pediatrics Dubai, Al Habtoor Grand Resort and SPA, Dubai, United Arab United Arab Emirates Emirates ¶ÏËÚÔÊÔڛ˜: Infomed Events, Sheikh Rached Building, Al Mamzar, next to the Labor Office / Ministry of Labor, Deira, Dubai - UAE ∆ËÏ.: +971 4 2689040 Fax: +971 4 2689030 E-mail: infodubai@infomedweb.com Website: www.infomedweb.com/ourevents/uaeiac2005.htm

18-19 ª·ÚÙ›Ô˘ 2006

4Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ •ÂÓÔ‰Ô¯Â›Ô Divani Caravel ¶ÏËÚÔÊÔڛ˜: C&C International, Conventions and Congresses ∆ËÏ.: (+30) 210 6889 100 Fax: (+30) 210 6844 777 E-mail: ped-subspec2006@cnc.gr Website: www.ped-subspec2006.gr

∞ı‹Ó·

7-9 ∞ÚÈÏ›Ô˘ 2006

1Ô ¶·ÓÂÏÏ‹ÓÈÔ ¡ÂÔÁÓÔÏÔÁÈÎfi ™˘Ó¤‰ÚÈÔ •ÂÓÔ‰Ô¯Â›Ô Ledra Marriott ¶ÏËÚÔÊÔڛ˜: Triaena Tours ∆ËÏ.: (+30) 210 7499 300 Fax: (+30) 210 7705 752 E-mail: congress@triaenatours.gr

∞ı‹Ó·

26-29 ∞ÚÈÏ›Ô˘ 2006

XVIIth Annual Congress of the European Society for Paediatric Urology •ÂÓÔ‰Ô¯Â›Ô Athens Hilton ¶ÏËÚÔÊÔڛ˜: Erasmus Conferences Tours & Travel S.A. ∆ËÏ.: (+30) 210 7257 693 Fax: (+30) 210 7257 532 E-mail: info@espu2006.com Website: www.espu2006.com

∞ı‹Ó·

Pediatr Nov-Dec 05

12-12-05

15:17

™ÂÏ›‰·480

xxiv

2-5 ª·˝Ô˘ 2006

11o ¢ÈÂıÓ¤˜ ™˘Ó¤‰ÚÈÔ ∂Ù·ÈÚ›·˜ æ˘¯ÔÏÔÁÈ΋˜ æ˘¯È·ÙÚÈ΋˜ ∂ÓËÏ›ÎÔ˘ Î·È ¶·È‰ÈÔ‡ (∂ææ∂¶) “ºÈÏ›· & ∂ÓfiÙËÙ·, æ˘¯ÔÏÔÁ›· & ∂ÈÎÔÈÓˆÓ›·” •ÂÓÔ‰Ô¯Â›Ô Athens Hilton ¶ÏËÚÔÊÔڛ˜: ∂Ù·ÈÚ›· æ˘¯ÔÏÔÁÈ΋˜ æ˘¯È·ÙÚÈ΋˜ ∂ÓËÏ›ÎÔ˘ Î·È ¶·È‰ÈÔ‡ ∆ËÏ.: (+30) 210 6842 663, 210 6857 319 Fax: (+30) 210 6842 079 E-mail: appachellas@yahoo.gr Website: www.epsep.org.gr

∞ı‹Ó·

3-5 ª·˝Ô˘ 2006

24th Annual Meeting of the European Society for Paediatric Infectious Diseases - ESPID ¶ÏËÚÔÊÔڛ˜: Kenes International / ESPID 2006 ∆ËÏ.: +41 22 908 0488 Fax: +41 22 732 2850 E-mail: espid@kenes.com Website: www.kenes.com/espid/index2006.asp

Basel, Switzerland

10-14 πÔ˘Ó›Ô˘ 2006

XXV Congress of the European Academy of Allergology and Clinical Immunology ¶ÏËÚÔÊÔڛ˜: Congrex Sweden ∆ËÏ.: +46 8 459 66 00 Fax: +46 8 661 91 25 E-mail: eaaci2006@congrex.se Website: www.congrex.com/eaaci2006

Vienna, Austria

30 πÔ˘Ó›Ô˘3 πÔ˘Ï›Ô˘ 2006

45th Annual Meeting of the European Society for Paediatric Endocrinology ¶ÏËÚÔÊÔڛ˜: Congrex Sweden AB ∆ËÏ.: +46 8 459 66 00 Fax: +46 8 661 91 25 E-mail: espe2006@congrex.se Website: www.espe2006.org

8-11 πÔ˘Ï›Ô˘ 2006

7th International Congress on Pediatric Pulmonology ¶ÏËÚÔÊÔڛ˜: Annie Bidart, MD ∆ËÏ.: +33 0 497 038 597 Fax: +33 0 497 038 598 E-mail: cipp@cipp-meeting.com Website: www.cipp-meeting.com

Montreal, Canada

7-10 √ÎÙˆ‚Ú›Ô˘ 2006

European Academy of Paediatrics – CESP 2006 Centre Convencions Internacional Barcelona ¶ÏËÚÔÊÔڛ˜: Kenes International / Europaediatrics 2006 17 Rue du Cendrier PO Box 1726, CH-1211 Geneva 1, Switzerland Tel: +41 22 908 0488 Fax: +41 22 732 2850 E-mail: europaediatrics@kenes.com Website: www.kenes.com/europaediatrics

Barcelona, Spain

Rotterdam, The Netherlands