Παιδιατρική | Τόμος 69 • Τεύχος 5 • Σεπτέμβριος - Οκτώβριος 2006

Pediatr Sept_Oct 06

26-09-06

12:52

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¶·È‰È·ÙÚÈ΋ ∆fiÌÔ˜ 69 ñ ∆‡¯Ô˜ 5 ñ ™Â٤̂ÚÈÔ˜-√ÎÙÒ‚ÚÈÔ˜ 2006 ¢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˜ 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¿

¶ÂÚȯfiÌÂÓ· ∞¡∞™∫O¶∏™∂π™ 327 ∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡: ‰Â‰Ô̤ӷ Î·È ÚÔÔÙÈΤ˜ ∞. ¶¿Ì·ÓÔ˜, Ã. ™ÔÊÔÎÏ¤Ô˘˜, ∫. µÔÏ¿ÎË, ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË 336 ∂Ê¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰È·ÙÚÈÎÒÓ ÏÔÈÌÒÍÂˆÓ °. ∆ÛfiÏ·˜, ™. ºˆÙÈ¿ 350 ¢È¿ÁÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ¶. ™ËÊÈ·ÓÔ‡

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ º. ª·˘ÚÔÂȉ‹ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘

381 ¡ÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË: ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫. ™·Ú·Ê›‰Ë˜, µ. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, £. ™Ù·ıÔÔ‡ÏÔ˘, ∫. ¶·ÙÛÈ·Ô‡Ú·, ™. ∞ÁÁÂÏ›‰Ô˘ 385 ™‡Ó‰ÚÔÌÔ Rubinstein-Taybi ™. ∆fiÁη, ª. ª·˘Ú›ÎÔ˘, ¶. ¡¤Ô˘, §. ™Ù·ÌÔÁÈ¿ÓÓÔ˘ 390 √ÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ· Û ÓÂÔÁÓfi ∂. ∫ÔڷοÎË, ª. ∞Ó·ÙÔÏȈٿÎË, ∞. ∞ÏÈÁÈ˙¿Î˘, ∞. ª·ÓÔ˘Ú¿, ∂. ÷Ù˙ˉ¿ÎË, ∂. ™·˚Ù¿Î˘, ∂. µÂÏË‚·Û¿Î˘, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ¶ƒ∞∫∆π∫O £∂ª∞

∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 361 ªÂϤÙË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÛÙËÓ ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, π. ƒÔ‡ÛÛÔ, °. ∫·Ù˙fi˜, ª. ∫·Ú·ÌÔ‡˙˘, π. ∫·Ú·ÌÔ‡˙˘, £. ¶··ÁˆÚÁ›Ô˘, π. ∆ÛÈÙÔ˘Ú›‰Ë˜

395 ∏ ·ÍÈÔÈÛÙ›· ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô °. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜ 405 ∫§π¡π∫√ ∫√Àπ∑

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

369 ∂ÌÂÈڛ˜ ÁÔÓ¤ˆÓ ·Ó·ÊÔÚÈο Ì ÙËÓ ÚfiÙ·ÛË ‰ˆÚ¿˜ ÈÛÙÒÓ/ÔÚÁ¿ÓˆÓ ÛÒÌ·ÙÔ˜ ÙÔ˘ ·Ó‹ÏÈÎÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ £. MÂÏÏ¿ÏË, ¢. ¶··‰¿ÙÔ˘

Ã. ∫ÒÛÙ·ÏÔ˜ 406 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ ¡. ¶··‰fiÔ˘ÏÔ˜

∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ 376 ¡ÂÔÁÓfi Ì ÂÈÎfiÓ· ÛË„·ÈÌ›·˜ Î·È ÔÏÏ·Ï¿ Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· µ. ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘-∆ÛÈÎڛη, ∞. ∞ÓÙˆÓÔ‡ÏË, ∫. °·˚Ù·Ó¿, ƒ. ªˆ˘Û›‰Ô˘, ª. °Ô˘‰ÂÛ›‰Ô˘, ∞. ¶ÈÙÂÚÔ‡

Pediatr Sept_Oct 06

26-09-06

12:52

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Paediatriki Volume 69 ñ Number 5 ñ September-October 2006 Bimonthly Publication of the Greek Paediatric Society President A. Constantopoulos Editorial Board Editor-in-Chief C. Stefanidis

Contents

Members P. Augoustides-Savvopoulou H. Antonopoulou A. Vazeou-Gerasimidi G. Varlamis M. Kanariou ∂. Katsarou-Pectasides A. Kattamis Ch. Costalos N. Papadopoulos ∞. Papadopoulou A. Siamopoulou-Mavridou M. Tsolia

REVIEW ARTICLES

350 Diagnosis of in utero growth restricted neonates P. Sifianou

390 Osteomyelitis and septic arthritis in a neonate E. Korakaki, M. Anatoliotaki, A. Aligizakis, A. Manoura, E. Chatzidaki, E. Saitakis, E. Velivasakis, C. Giannakopoulou

Manuscript Editing

ORIGINAL ARTICLES

PRACTICAL ISSUE

361 Evaluation of bone metabolism in children with acute lymphoblastic leukaemia F. Athanassiadou-Piperopoulou, A. Tragiannidis, I. Rousso, G. Katzos, M. Karamouzis, I. Karamouzis, T. Papageorgiou, I. Tsitouridis

395 The accuracy of immunological markers in the diagnosis of infection during the neonatal period G.S. Tigani, D.A. Kafetzis

Greek Editing F. Mavroidi English Editing S. Nakou Publisher

327 The genetic basis of autism: facts and perspectives A. Pampanos, C. Sophocleous, K. Volaki, S. Kitsiou-Tzeli 336 Once-daily dosing (ODD) of aminoglycosides in paediatric infections G. Tsolas, S. Fotia

381 Neonatal haemochromatosis: a case report K. Sarafidis, V. Drossou-Agakidou, T. Stathopoulou, K. Patsiaoura, S. Aggelidou 385 Rubinstein-Taybi syndrome S. Togka, M. Mavrikou, P. Neou, L. Stamoyannou

405 CLINICAL QUIZ

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

369 Parents’ experiences of the request for organ and tissue donation of their underage child T. Bellali, D. Papadatou

C. Costalos 406 NEWS FROM THE INTERNET N. Papadopoulos

CASE REPORTS 376 A neonate with signs of sepsis and multiple hepatic abscesses V. Alexandropoulou-Tsikrika, A. Antonouli, K. Gaitana, R. Moisidou, M. Goudesidou, A. Piterou

Pediatr Sept_Oct 06

26-09-06

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™À¡∆∞∫∆π∫∏ E¶π∆ƒ√¶∏

EDITORIAL BOARD

¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘

Editor-in-Chief

∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ∞ı‹Ó·

Constantinos Stefanidis, Athens

À‡ı˘ÓÔÈ ™‡ÓÙ·Í˘ ∂ÍÂȉÈ·ۈÓ

Section Editors

∂ϤÓË ∞ÓÙˆÓÔÔ‡ÏÔ˘, ∞ı‹Ó· ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ - ¶ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜

Eleni Antonopoulou, Athens Developmental and Behavioral Pediatrics

¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, £ÂÛÛ·ÏÔÓ›ÎË KÏËÚÔÓÔÌÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·

Persefoni Avgoustidou-Savopoulou, Thessaloniki Metabolic Disorders

∞Ó‰ÚÈ·Ó‹ µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë, ∞ı‹Ó· ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·

Andriani Vazaiou-Gerasimidi, Athens Endocrinology

°ÂÒÚÁÈÔ˜ µ·ÚÏ¿Ì˘, £ÂÛÛ·ÏÔÓ›ÎË ∫·Ú‰ÈÔÏÔÁ›·

George Varlamis, Thessaloniki Cardiology

ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ı‹Ó· ∞ÓÔÛÔÏÔÁ›·

Maria Kanariou, Athens Immunology

∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ∞ı‹Ó· ¡Â˘ÚÔÏÔÁ›·

Eustathia Katsarou-Pektasidou, Athens Neurology

∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ı‹Ó· ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·

Antonis Kattamis, Athens Haematology - √ncology

ÃÚ‹ÛÙÔ˜ ∫ÒÛÙ·ÏÔ˜, ∞ı‹Ó· ¡ÂÔÁÓÔÏÔÁ›·

Christos Kostalos, Athens Neonatology

∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, ∞ı‹Ó· °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· - ∏·ÙÔÏÔÁ›· - ¢È·ÙÚÔÊ‹

Alexandra Papadopoulou, Athens Gastroenterology - Hepatology - Nutrition

¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ı‹Ó· ∞ÏÏÂÚÁÈÔÏÔÁ›· - ¶Ó¢ÌÔÓÔÏÔÁ›·

Nicos Papadopoulos, Athens Allergology - Pneumonology

∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, πˆ¿ÓÓÈÓ· ƒÂ˘Ì·ÙÔÏÔÁ›·

Antigoni Siamopoulou-Mavridou, Ioannina Rheumatology

ª·Ú›˙· ∆ÛÔÏÈ¿, ∞ı‹Ó· §ÔÈ̈ÍÈÔÏÔÁ›·

Marisa Tsolia, Athens Infectious Diseases

ª¤ÏË Ù˘ ¢ÈÂıÓÔ‡˜ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ ñ Members of the International Editorial Board Alexis Arzimanoglou, Paris, France

Christer Holmberg, Helsinki, Finland

Ellis D. Avner, Milwaukee, USA

Peter Hoyer, Essen, Germany

Swati Bhave, New Delhi, India

Jan Janda, Prague, Czech Republic

Alberto Bissot, Panama, Panama

Jan Kimpen, Ultrecht, Netherlands

David Branski, Jerusalem, Israel

John Manis, Boston, USA

Francesco Chiarelli, Chieti, Italy

Manuel Moya, Alicante, Spain

Chok-Wan Chan, Hong Kong, China

Hugh O'Brodovich, Toronto, Canada

Denis Daneman, Toronto, Canada

Ross Petty, Vancouver, Canada

Jochen Ehrich, Hannover, Germany

Willem Proesmans, Leuven, Belgium

Demetrius Ellis, Pittsburgh, USA

Jose Ramet, Antwerp, Belgium

Yoshikatsu Eto, Tokyo, Japan

Alan Sinaiko, Minneapolis, USA

Richard N. Fine, Stony Brook, USA

Nick J. Spencer, Coventry, UK

Margaret C. Fisher, Philadelphia, USA

Alfred Tenore, Udine, Italy

Raif Geha, Boston, USA

Alkis Togias, Bethesda, USA

Adenike Grange, Lagos, Nigeria

Eva Tsalikian, Iowa City, USA

Judith G. Hall, Vancouver, Canada

Catherine Weil-Olivier, Paris, France

Patricia Hamilton, London, UK

Johannes Zschocke, Heidelberg, Germany

Enver Hasanoglu, Ankara, Turkey

v

Pediatr Sept_Oct 06

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√¢∏°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˜.

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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.

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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΋

xiii

·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 Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·14

xiv

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.

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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.

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™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

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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.

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12. Letters to the editor.

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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.

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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)

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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.

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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.

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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.

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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.

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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).

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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.

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ª·Ú›· ¶··Ê›ÏË °È· ÏËÚÔÊÔڛ˜: www.euran.com ªaria Papafili For information: www.euran.com

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∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

327

∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡: ‰Â‰Ô̤ӷ Î·È ÚÔÔÙÈΤ˜ ∞. ¶¿Ì·ÓÔ˜, Ã. ™ÔÊÔÎÏ¤Ô˘˜, ∫. µÔÏ¿ÎË, ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË

¶ÂÚ›ÏË„Ë √ ·˘ÙÈÛÌfi˜ ·Ó‹ÎÂÈ ÛÙȘ Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰˘ÛÎÔϛ˜ ÛÙËÓ ÎÔÈÓˆÓÈ΋ ·ÏÏËÏÂ›‰Ú·ÛË Î·È ÂÈÎÔÈÓˆÓ›·, ηıÒ˜ Î·È ·fi ÛÙÂÚÂfiÙ˘Ë Û˘ÌÂÚÈÊÔÚ¿. √È ÚÒÙ˜ ÂӉ›ÍÂȘ Ù˘ ‰È·Ù·Ú·¯‹˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ·˘Ù‹ ÂÍÂÏ›ÛÛÂÙ·È fï˜, Ì ‰È·ÊfiÚˆÓ ‚·ıÌÒÓ ‚·Ú‡ÙËÙ· Î·È ÎÏÈÓÈ΋ ÔÈÎÈÏÔÌÔÚÊ›·. ∏ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ·˘ÙÈÛÌÔ‡ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È·Ï¢ηÓı›. ∂ÌϤÎÔÓÙ·È ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÁÂÓÂÙÈÎÔ›, Ó¢ÚÔ·Ó·ÙÔÌÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÔÏÔÁÈÎÔ› Î·È Û˘Ó˘¿Ú¯Ô˘Û˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ·ÏÏËÏÂȉÚÔ‡Ó Î·È Û˘Ì‚¿ÏÏÔ˘Ó Ì ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ Î·È ‚·ıÌfi ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÂͤÏÈÍË Ù˘ ‰È·Ù·Ú·¯‹˜. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯Ô˘Ó Á›ÓÂÈ ÛËÌ·ÓÙÈΤ˜ ÚfiÔ‰ÔÈ ‰ÈÂıÓÒ˜ ÛÙË ‰ÈÂÚ‡ÓËÛË ÚԉȷıÂÛÈÎÒÓ ÁÔÓȉ›ˆÓ Î·È ÁÂÓÂÙÈÎÒÓ ÙfiˆÓ. ŒÙÛÈ Û‹ÌÂÚ·, ıˆÚÂ›Ù·È fiÙÈ Ô ·˘ÙÈÛÌfi˜ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ‹ ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÏËıÒÚ·˜ ·˘ÙÔۈ̷ÙÈÎÒÓ Î·È Ê˘ÏÔÛ‡Ó‰ÂÙˆÓ ÁÔÓȉ›ˆÓ, Ù· ÔÔ›· ˘ÔÏÔÁ›˙ÔÓÙ·È Û 383 Î·È ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ˘˜ ÁÂÓÂÙÈÎÔ‡˜ ÙfiÔ˘˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ 1p, 2q, 3q, 6p, 6q, 7q, 9q, 15q, 16p, 17q, 19p, 19q, Xp Î·È Xq. µ¿ÛÂÈ ‰Â ÙÔ˘ ÎÏ·ÛÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜, fiÛÔÓ ·ÊÔÚ¿ Ù· ÔÏ˘·Ú·ÁÔÓÙÈο ÓÔÛ‹Ì·Ù·, ÂÎÙÈÌ¿Ù·È fiÙÈ Î·Ó¤Ó· ÁÔÓ›‰ÈÔ ·fi ÌfiÓÔ ÙÔ˘ ‰ÂÓ Â·ÚΛ ÁÈ· ÙËÓ ÚfiÎÏËÛË Ù˘ ‰È·Ù·Ú·¯‹˜. ∂ÓÙÔ‡ÙÔȘ, ÔÈ ·fi„ÂȘ Ù˘ ‰ÈÂıÓÔ‡˜ ÂÈÛÙËÌÔÓÈ΋˜ ÎÔÈÓfiÙËÙ·˜ ¤¯Ô˘Ó ÂÈÎÂÓÙÚˆı› ÛÙË ÌÂϤÙË ·ıÔÏÔÁÈÎÒÓ ÁÔÓȉ›ˆÓ ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· 7, 9, 15, 17 Î·È Ã, Ë ·ÏÏËÏÂ›‰Ú·ÛË ÙˆÓ ÔÔ›ˆÓ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Î·ıÔÚÈÛÙÈ΋ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡ Î·È ÙˆÓ ‰È¿¯˘ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ.

∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ∫›ÙÛÈÔ˘-∆˙¤ÏË ™ÔÊ›· ∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ· °ÂÓÂÙÈ΋˜ ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÃˆÚ¤ÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ £Ë‚ÒÓ Î·È §Â‚·‰›·˜ ∆.∫. 115 27, ∞ı‹Ó· E-mail: skitsiou@med.uoa.gr

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2006 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 17-04-2006

§¤ÍÂȘ ÎÏÂȉȿ: ∞˘ÙÈÛÌfi˜, ÁÂÓÂÙÈ΋, ¯ÚˆÌÔÛÒÌ·Ù·, ·Ó¿Ï˘ÛË ÁÔÓȉÈÒÌ·ÙÔ˜.

The genetic basis of autism: facts and perspectives A. Pampanos, C. Sophocleous, K. Volaki, S. Kitsiou-Tzeli

Abstract: Autism belongs to the category of neurodevelopmental disorders and is characterized by difficulties in social interaction and communication, and stereotypical types of behaviour. The first signs of the disorder present at the age of 3 years, and its evolution is variable with respect to the severity and clinical heterogeneity. The aetiology of autism has not yet been elucidated, but many factors are involved, including genetic, neuroanatomic, environmental and a variety of pathological situations which all interact and contribute in different ways and varying percentages to the onset and evolution of the disorder. During the past decade, predisposing genes and genetic loci for autism have been under international investigation. It is believed that autism may be due to mutations or polymorphisms in autosomal and X-linked genes, amounting to 383 at the genetic loci of chromosomes 1p, 2q, 3q, 6p, 6q, 7q, 9q, 15q, 16p, 17q, 19p, 19q, Xp and Xq. According to the classic multilocus-epistatic model regarding multifactorial disorders, no single gene is believed to be sufficient for the cause of the disorder.

However, researchers internationally are focusing on the investigation of chromosomes 7, 9, 15, 17 and X, as it is believed that these chromosomes contain pathological genes crucial for the manifestation of autism and pervasive developmental disorders.

Key words: ∞utism, genetics, chromosomes, linkage analysis.

™˘ÓÙÔÌÔÁڷʛ˜ ¢∞¢ ¢È¿¯˘Ù˜ ∞Ó·Ù˘ÍȷΤ˜ ¢È·Ù·Ú·¯¤˜ DSM-IV ¢È·ÁÓˆÛÙÈÎfi Î·È ™Ù·ÙÈÛÙÈÎfi ∂Á¯ÂÈÚ›‰ÈÔ ¢È·ÓÔËÙÈÎÒÓ ¶·ı‹ÛÂˆÓ - IV

Medical Genetics Unit of Athens University, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital

Correspondence: Kitsiou-Tzeli Sophia Associate Professor of Genetics Medical Genetics Unit of Athens University, Choremio Research Laboratory, Thivon & Levadias, 115 27 Athens E-mail: skitsiou@med.uoa.gr

Date of submission: 18-01-2006 Date of approval: 17-04-2006

IMGSAC ¢ÈÂıÓ‹˜ √Ì¿‰· ªÂϤÙ˘ ªÔÚȷ΋˜ °ÂÓÂÙÈ΋˜ ∞˘ÙÈÛÙÈÎÒÓ ¢È·Ù·Ú·¯ÒÓ MLS ª¤ÁÈÛÙÔ ¿ıÚÔÈÛÌ· ÙÔ˘ ÏÔÁ·Ú›ıÌÔ˘ ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ¶·È‰È·ÙÚÈ΋ 2006;69:327-335

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328

∞. ¶¿Ì·ÓÔ˜ Î·È Û˘Ó.

∂ÈÛ·ÁˆÁ‹ √ fiÚÔ˜ ·˘ÙÈÛÌfi˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ÂÏÏËÓÈ΋ ϤÍË “·˘Ùfi˜” Ô˘ ÛËÌ·›ÓÂÈ ÂÁÒ Ô ›‰ÈÔ˜ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó·‰›ψÛË ÙÔ˘ ·ÙfiÌÔ˘ ÛÙÔÓ Â·˘Ùfi ÙÔ˘, ˘Ô‰ËÏÒÓÔÓÙ·˜ ·fiÛÙ·ÛË ·fi ÙËÓ Â͈ÙÂÚÈ΋ Ú·ÁÌ·ÙÈÎfiÙËÙ· Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ÌÈ· ¤ÓÙÔÓË ÂÛˆÙÂÚÈ΋ ˙ˆ‹ (1). √ÚfiÛËÌÔ ·Ó·ÁÓÒÚÈÛ˘ ÙÔ˘ ·˘ÙÈÛÌÔ‡ ıˆÚÂ›Ù·È Ë ·ÚÔ˘Û›·ÛË ·fi ÙÔÓ Kanner ÙÔ 1943 ÙˆÓ 11 ÚÒÙˆÓ Ú·ÁÌ·ÙÈÎÒÓ ÂÚÈÛÙ·ÙÈÎÒÓ Û ·È‰È¿ (2).

O ·˘ÙÈÛÌfi˜ ıˆÚÂ›Ù·È ˆ˜ ÈÛfi‚È· ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰˘ÛÎÔϛ˜ ÛÙËÓ ÎÔÈÓˆÓÈ΋ ηٷÓfiËÛË, ÙË Û˘Ó·ÏÏ·Á‹ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·ÌÔÈ‚·ÈfiÙËÙ·, ÛÙËÓ ÂÈÎÔÈÓˆÓ›·, Ì ÂÚÈÔÚÈṲ̂ÓÔ Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ ÚfiÙ˘Ô ‰Ú·ÛÙËÚÈÔًوÓ, ηıÒ˜ Î·È ÛÙËÓ ·Ó¿Ù˘ÍË ÁÓˆÛÈ·ÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÌÂ Û˘¯Ó¿ ·Ó·ÎfiÏÔ˘ıË ÂÂÍÂÚÁ·Û›· ·ÈÛıËÙËÚÈ·ÎÒÓ ÚÔÛÏ‹„ˆÓ. ∂ÌÊ·Ó›˙ÂÙ·È Ì ‚·Ú‡ÙËÙ· ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ Î·È ÎÏÈÓÈ΋ ÔÈÎÈÏÔÌÔÚÊ›·, Ë ÔÔ›· Û˘ÓÈÛÙ¿ ÙÔ ·˘ÙÈÛÙÈÎfi Ê¿ÛÌ· ‹ ÙȘ ‰È¿¯˘Ù˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘ (¢∞¢) (3).

∂ȉËÌÈÔÏÔÁ›· ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ·Û¯fiÓÙˆÓ Ì ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ‚·Ú‡ÙËÙ· Â›Ó·È ÂÚ›Ô˘ 5-10 ·Ó¿ 10.000 (4), Ì ·Ó·ÏÔÁ›· ·ÚÚ¤ÓˆÓ/ıËϤˆÓ 3-4:1 (4,5). ∞Ó¿ÏÔÁ· Â›Ó·È Î·È Ù· ÂÏÏËÓÈο ‰Â‰Ô̤ӷ, ÂÎÙÈÌ¿Ù·È ‰Â, ‚¿ÛÂÈ ÛÙÔȯ›ˆÓ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶ÚÔÛÙ·Û›·˜ ∞˘ÙÈÛÙÈÎÒÓ ∞ÙfïÓ, fiÙÈ ˘¿Ú¯Ô˘Ó 4.000-5.000 ¿Û¯ÔÓÙ˜ (·È‰È¿ Î·È ÂÓ‹ÏÈΘ) Ì ÎÏ·ÛÈÎfi ·˘ÙÈÛÌfi Î·È ÂÚ› ÙȘ 20.000 Ì 30.000 Ì ¢∞¢. ∆· Â˘Ú‹Ì·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÓÔËÙÈÎfi Â›Â‰Ô ÙˆÓ ·˘ÙÈÛÙÈÎÒÓ ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙˆÓ ‰ÈÂıÓÒÓ ÌÂÏÂÙÒÓ, Ì ÙÔÓ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ¯·ÌËÏfiÙÂÚÔ ÙÔ˘ 50 Ó· ·Ó¢ڛÛÎÂÙ·È Û 35% ¤ˆ˜ 57% ÙˆÓ ·Û¯fiÓÙˆÓ (6,7). ∏ Û˘Ì‚ÔÏ‹ ÁÂÓÂÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË È‰ÈÔ·ıÔ‡˜ ·˘ÙÈÛÌÔ‡ ›¯Â ‹‰Ë Ê·Ó› ·fi ·ÚÎÂÙ¤˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜. ™˘ÁÎÂÎÚÈ̤ӷ, ‚¿ÛÂÈ ÛÙ·ÙÈÛÙÈÎÒÓ ÛÙÔȯ›ˆÓ, Ë Èı·ÓfiÙËÙ· Ó· ÂΉËÏÒÛÔ˘Ó ·˘ÙÈÛÌfi Û˘ÁÁÂÓ›˜ ·Û¯fiÓÙˆÓ ÚÒÙÔ˘ ‚·ıÌÔ‡, Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 2 ¤ˆ˜ Î·È 8% Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ Â·ÓÂÌÊ¿ÓÈÛ˘ Ù˘ ¿ıËÛ˘ Û ÔÈÎÔÁ¤ÓÂÈ· Ì ¤Ó· ‹‰Ë ¿Û¯ÔÓ Ù¤ÎÓÔ ˘ÔÏÔÁ›˙ÂÙ·È Û ~3-10% (8). ∂ÓÙ˘ˆÛȷΤ˜ Â›Ó·È Â›Û˘ ÔÈ ÌÂϤÙ˜ Û ÂȉËÌÈÔÏÔÁÈÎfi ‰Â›Á¶·È‰È·ÙÚÈ΋ 2006;69:327-335

°ÓˆÛÙÈ΋ ‰È·Ù·Ú·¯‹ 4,0% ∫·Ì›· ‰È·Ù·Ú·¯‹ 8,0%

∞˘ÙÈÛÌfi˜ 60,0% ∫ÔÈÓˆÓÈ΋ Î·È ÁÓˆÛÙÈ΋ ‰È·Ù·Ú·¯‹ 16,0%

∫ÔÈÓˆÓÈ΋ ‰È·Ù·Ú·¯‹ 12,0%

∂ÈÎfiÓ· 1. ™˘ÌÙˆÙÈÎfiÙËÙ· ÌÔÓÔ˙˘ÁˆÙÈÎÒÓ ‰È‰‡ÌˆÓ ȉ›Ô˘ ʇÏÔ˘ Û ÂȉËÌÈÔÏÔÁÈÎfi ‰Â›ÁÌ·.

Ì· ·fi ÙË µÚÂÙ·Ó›· Ô˘ ·ÊÔÚÔ‡Ó ‰›‰˘Ì· ·‰¤ÚÊÈ·, ȉ›Ô˘ ¿ÓÙ· ʇÏÔ˘: ÔÈ ÌÔÓÔ˙˘ÁˆÙÈÎÔ› ‰›‰˘ÌÔÈ Â›Ó·È Û˘ÌÙˆÙÈÎÔ› (concordant), ‰ËÏ·‰‹ ÂÌÊ·Ó›˙Ô˘Ó Î·È ÔÈ ‰‡Ô ·˘ÙÈÛÌfi, ÛÙÔ 60% ÂÚ›Ô˘, Î·È ÙÔ ÔÛÔÛÙfi ·˘Ùfi ‰‡Ó·Ù·È Ó· ·˘ÍËı› ¤ˆ˜ 92% Â¿Ó ÂÚÈÏËÊıÔ‡Ó Û˘ÌÙÒÌ·Ù· ¢ڇÙÂÚ˘ „˘¯ÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ‰È˙˘ÁˆÙÈÎÔ‡˜ ‰›‰˘ÌÔ˘˜, ÌfiÓÔ ÙÔ 10% ·ÚÔ˘ÛÈ¿˙ÂÈ ÁÓˆÛÙÈ΋ ‰È·Ù·Ú·¯‹ (∂ÈÎfiÓ· 1) (9-11). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ ·ÎfiÌ· Î·È ÁÈ· ÙÔ˘˜ ÌÔÓÔ˙˘ÁˆÙÈÎÔ‡˜ ‰›‰˘ÌÔ˘˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ô ÁÂÓÂÙÈÎfi˜ ÎÒ‰Èη˜ Â›Ó·È Ù·˘ÙfiÛËÌÔ˜ - Ë ÂÌÊ¿ÓÈÛË Ù˘ ¿ıËÛ˘ ÌfiÓÔ Û ¤Ó·Ó (Î·È fi¯È ¿ÓÙ· Î·È ÛÙÔ˘˜ ‰‡Ô fiˆ˜ ÏÔÁÈο ı· ·Ó·ÌÂÓfiÙ·Ó) Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÂÎÙfi˜ ÙˆÓ ÁÂÓÂÙÈÎÒÓ, fiˆ˜ ÂÚÈ‚·ÏÏÔÓÙÔÏÔÁÈÎÒÓ, ÔÈ ÔÔ›ÔÈ ‰‡Ó·ÓÙ·È Ó· ¤¯Ô˘Ó ÂÈÁÂÓÂÙÈ΋ ‰Ú¿ÛË (12).

∞ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ∞Ó Î·È ·Ú¯Èο Ô ·˘ÙÈÛÌfi˜ ›¯Â ¯·Ú·ÎÙËÚÈÛı› ˆ˜ ÔχÏÔÎË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ‰È·Ù·Ú·¯‹, Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ·ÔÛ·ÊËÓÈÛÙ›. ∂ÌϤÎÔÓÙ·È ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÁÂÓÂÙÈÎÔ›, Ó¢ÚÔ·Ó·ÙÔÌÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÔÏÔÁÈÎÔ› Î·È ‰È¿ÊÔÚ˜ Û˘Ó˘¿Ú¯Ô˘Û˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ·ÏÏËÏÂȉÚÔ‡Ó Î·È Û˘Ì‚¿ÏÏÔ˘Ó Ì ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ Î·È ÔÛÔÛÙfi ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÂͤÏÈÍË Ù˘ ‰È·Ù·Ú·¯‹˜ (12) (∂ÈÎfiÓ· 2). ™ˆÚ›· ÌÂÏÂÙÒÓ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ·˘ÙÈÛÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÔÊ›ÏÂÙ·È Û ÔÚÁ·ÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. √È ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ÂÁÎÂÊ·ÏÈΤ˜ ·ÓˆÌ·Ï›Â˜, fiˆ˜ Ë ·ÒÏÂÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Purkinje Î·È Ë Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ Ù˘ ̤Û˘ ÌÔ›Ú·˜ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜,

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·329

329

∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡

º‡ÏÔ

°ÂÓÂÙÈ΋ ÚԉȿıÂÛË

™˘Ó˘¿Ú¯Ô˘Û˜ ÔÚÁ·ÓÈΤ˜ ·ı‹ÛÂȘ

¶ÂÚÈ‚·ÏÏÔÓÙÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜

∂Ó‰ÔÌ‹ÙÚÈÔÈ ·Ú¿ÁÔÓÙ˜

ÙËÚËı› Û ·ÛıÂÓ›˜ Ì ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, fiˆ˜ Ë Ê·ÈÓ˘ÏÔÎÂÙÔÓÔ˘Ú›· (22), ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ Ô˘ÚÈÓÒÓ (∞, G) (23), ‹ ·ÎfiÌ· Î·È Û ÌÈÙÔ¯ÔÓ‰ÚȷΤ˜ ·ı‹ÛÂȘ (24). ∞˘ÙÈÛÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÌÔÚ› Ó· Û˘Óԉ‡ÂÈ Î·È ¿ÏϘ ÁÂÓÂÙÈΤ˜ ·ı‹ÛÂȘ ÌÂ Û˘ÓËı¤ÛÙÂÚË ÙÔ Û‡Ó‰ÚÔÌÔ ÙÔ˘ ∂‡ıÚ·˘ÛÙÔ˘ à (25), ηıÒ˜ Â›Û˘ Ù· Û‡Ó‰ÚÔÌ· Sotos (26), Moebius (27), Prader-Willi Î·È Angelman (28,29). ∂ӉȷʤÚÔÓ ÚÔηÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·Û¯fiÓÙˆÓ ÌfiÓÔ ÙÔ 7,4% ·ÚÔ˘ÛÈ¿˙ÂÈ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ (30). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÛ‰ÈÔÚÈÛı› ¤Ó·˜ Û·Ê‹˜ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ô ·˘ÙÈÛÌfi˜ ÔÓÔÌ¿˙ÂÙ·È “ȉÈÔ·ı‹˜”.

∂ÈÎfiÓ· 2. ∞ÏÏËÏÂ›‰Ú·ÛË ·Ú·ÁfiÓÙˆÓ ˘·›ÙÈˆÓ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ·˘ÙÈÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ.

¢È¿ÁÓˆÛË Ô˘ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› ÛÙÔ 50%-60% ÙˆÓ ÂÍÂÙ·Ûı¤ÓÙˆÓ ·˘ÙÈÛÙÈÎÒÓ, Â›Ó·È Û˘Ì‚·Ù¤˜ Ì ÙÔÓ ÚfiÏÔ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙÔÓ ¤Ûˆ ÎÚÔÙ·ÊÈÎfi ÏÔ‚fi ÁÈ· ÙË ÁψÛÛÈ΋-Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·ÙfiÌÔ˘ Ì ·˘ÙÈÛÌfi (13,14). ™Â ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ·˘ÙÈÛÙÈÎÒÓ ·ÛıÂÓÒÓ (~10%), Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰È·ÁÓˆÛıÔ‡Ó ·ı‹ÛÂȘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ ÂÈÏËÙfiÌÔÚÊ· Â˘Ú‹Ì·Ù· Ì ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ ÎÚÔÙ·ÊÈÎÔ‡ Ù‡Ô˘ (ÙÔ 1/3 ÂÚ›Ô˘ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Û¯fiÓÙˆÓ), ·ıÔÏÔÁÈÎfi ∏∂° (15) ‹ ·ıÔÏÔÁÈΤ˜ Ó¢ÚÔ-·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÈÎfiÓ˜ (16). ∂›Û˘, Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ Û ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ‹ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ÙÔÓ ÙÔÎÂÙfi (17), ‹ ¿ÏϘ ÔÚÁ·ÓÈΤ˜ ·ı‹ÛÂȘ fiˆ˜ Ë √˙҉˘ ™ÎÏ‹Ú˘ÓÛË (ÙÔ 25% ÙˆÓ ·ÙfiÌˆÓ Ì √™ ÏËÚÔ‡Ó Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÙÔ˘ ·˘ÙÈÛÌÔ‡) (18). ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÁÚ¿ÊÔÓÙ·È ·ÎfiÌË ÂÚÈÙÒÛÂȘ ·˘ÙÈÛÌÔ‡ Ô˘ ·Ô‰›‰ÔÓÙ·È Û ϋ„Ë Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ Î·Ù¿ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ·ËÛ˘, fiˆ˜ Ë ı·ÏȉÔÌ›‰Ë Î·È ÙÔ ‚·ÏÚÔ˚Îfi Ô͇. ∆· Ê¿Ú̷η ·˘Ù¿ ‰‡Ó·ÓÙ·È Ó· ÂÈʤÚÔ˘Ó ·ÓˆÌ·Ï›Â˜ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ (19,20). ¶ÂÚÈÙÒÛÂȘ ·ÙfiÌˆÓ Ì ·˘ÙÈÛÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·Ó·Ê¤ÚÔÓÙ·È ÌÂÙ¿ ·fi ÚÔÁÂÓÓËÙÈ΋ ¤ÎıÂÛË Û Ïԛ̈ÍË ·fi ÂÚ˘ıÚ¿, Haemophilus influenzae Î·È Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi, ÂÓÒ ·ÂÓÔ¯ÔÔÈÂ›Ù·È ÔÚÈÛÙÈο ÙÔ ÙÚÈÏfi ÂÌ‚fiÏÈÔ ÁÈ· ÂÚ˘ıÚ¿, ·ÚˆÙ›Ùȉ· Î·È ÈÏ·Ú¿ (21). ∞˘ÙÈÛÌfi˜ ¤¯ÂÈ ·ÎfiÌ· ·Ú·-

∏ ‰È¿ÁÓˆÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡ ‰ÂÓ ‰‡Ó·Ù·È Ó· ‚·ÛÈÛÙ› Û ¤Ó· Î·È ÌfiÓÔ Û‡Ìو̷ ·ÏÏ¿ Û ¤Ó· Ê¿ÛÌ· Û˘ÌÂÚÈÊÔÚÒÓ ÂÈÎÔÈÓˆÓ›·˜ Î·È ÎÔÈÓˆÓÈÎfiÙËÙ·˜, ÔÈ Ôԛ˜ ‰È·Ê¤ÚÔ˘Ó ÔÈÔÙÈο Î·È ÔÛÔÙÈο ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (31,32), ÛÙËÚ›˙ÂÙ·È ‰Â, ÛÙ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ηٿ DSM-πV (33).

¢È·ÁÓˆÛÙÈο ∫ÚÈÙ‹ÚÈ· ηٿ DSM-IV ÁÈ· ∞˘ÙÈÛÙÈ΋ ¢È·Ù·Ú·¯‹ ∞. ∞·ÈÙÔ‡ÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤ÍÈ ÎÚÈÙ‹ÚÈ· ·fi ÙÔ 1, 2 Î·È 3 (≥ ‰‡Ô ·fi ÙÔ 1 Î·È ≥ ¤Ó· ·fi ÙÔ 2 Î·È 3): 1. ¶ÔÈÔÙÈ΋ ¤ÎÙˆÛË ÛÙËÓ ÎÔÈÓˆÓÈ΋ ·ÏÏËÏÂ›‰Ú·ÛË, Ô˘ ÂΉËÏÒÓÂÙ·È Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·fi Ù· ÂÍ‹˜: ·) ¤ÓÙÔÓË ¤ÎÙˆÛË ÛÙË ¯ÚËÛÈÌÔÔ›ËÛË ÔÏÏ·ÏÒÓ ÌË ÏÂÎÙÈÎÒÓ Û˘ÌÂÚÈÊÔÚÒÓ, fiˆ˜ ‚ÏÂÌÌ·ÙÈ΋˜ Â·Ê‹˜, ¤ÎÊÚ·Û˘ ÚÔÛÒÔ˘, ÛÙ¿ÛÂˆÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ¯ÂÈÚÔÓÔÌÈÒÓ ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ ÎÔÈÓˆÓÈ΋˜ ·ÏÏËÏÂ›‰Ú·Û˘ ‚) ·‰˘Ó·Ì›· ·Ó¿Ù˘Í˘ Û¯¤ÛÂˆÓ ÌÂ Û˘ÓÔÌ‹ÏÈÎÔ˘˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó·Ù˘ÍÈ·Îfi ÙÔ˘˜ Â›Â‰Ô Á) ¤ÏÏÂÈ„Ë ·˘ıfiÚÌËÙ˘ ·Ó·˙‹ÙËÛ˘ ÁÈ· Ó· ÌÔÈÚ·ÛÙ› ¯·Ú¿, ÂӉȷʤÚÔÓÙ· ‹ ÂȉfiÛÂȘ Ì ¿ÏÏ· ¿ÙÔÌ· (.¯. Ó· ÂȉÂÈÎÓ‡ÂÈ, Ó· ʤÚÓÂÈ ÛÙËÓ ÎÔ˘‚¤ÓÙ· ‹ Ó· ÂÈÛËÌ·›ÓÂÈ ·ÓÙÈΛÌÂÓ· ÂӉȷʤÚÔÓÙÔ˜) ‰) ¤ÏÏÂÈ„Ë ÎÔÈÓˆÓÈ΋˜ ‹ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ·ÌÔÈ‚·ÈfiÙËÙ·˜ ¶·È‰È·ÙÚÈ΋ 2006;69:327-335

Pediatr Sept_Oct 06

26-09-06

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330

∞. ¶¿Ì·ÓÔ˜ Î·È Û˘Ó.

2. ¶ÔÈÔÙÈ΋ ¤ÎÙˆÛË ÛÙËÓ ÂÈÎÔÈÓˆÓ›·, Ô˘ ÂΉËÏÒÓÂÙ·È Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ·fi Ù· ÂÍ‹˜: ·) ηı˘ÛÙ¤ÚËÛË ‹ Ï‹Ú˘ ¤ÏÏÂÈ„Ë ·Ó¿Ù˘Í˘ Ù˘ ÔÌÈÏÔ‡ÌÂÓ˘ ÁÏÒÛÛ·˜ (¯ˆÚ›˜ Ó· Û˘Óԉ‡ÂÙ·È ·fi ÚÔÛ¿ıÂÈ· ·ÓÙÈÛÙ¿ıÌÈÛ˘ ̤۷ ·fi ÂÓ·ÏÏ·ÎÙÈÎÔ‡˜ ÙÚfiÔ˘˜ ÂÈÎÔÈÓˆÓ›·˜, fiˆ˜ ¯ÂÈÚÔÓƠ̂˜ ‹ Ì›ÌËÛË) ‚) ¤ÓÙÔÓË ¤ÎÙˆÛË ÛÙËÓ ÈηÓfiÙËÙ· Ó· ÍÂÎÈÓ‹ÛÔ˘Ó, ‹ Ó· ‰È·ÙËÚ‹ÛÔ˘Ó Û˘˙‹ÙËÛË Ì ¿ÏÏÔ˘˜ - ¿ÙÔÌ· Ì Â·Ú΋ ÔÌÈÏ›· Á) ÛÙÂÚÂfiÙ˘Ë, Â·Ó·ÏËÙÈ΋ ‹ ȉÈÔÛ˘ÁÎÚ·Ûȷ΋ ¯Ú‹ÛË Ù˘ ÁÏÒÛÛ·˜ ‰) ¤ÏÏÂÈ„Ë ÔÈΛÏÔ˘, ·˘ıfiÚÌËÙÔ˘ ·È¯ÓȉÈÔ‡ Ê·ÓÙ·Û›·˜, ‹ ÎÔÈÓˆÓÈ΋˜ Ì›ÌËÛ˘ Ô˘ Ó· Ù·ÈÚÈ¿˙ÂÈ ÛÙÔ ·Ó·Ù˘ÍÈ·Îfi Â›Â‰Ô ÙÔ˘ ·ÙfiÌÔ˘ 3. ¶ÂÚÈÔÚÈṲ̂ÓÔÈ, Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔÈ Î·È ÛÙÂÚÂfiÙ˘ÔÈ Ù‡ÔÈ Û˘ÌÂÚÈÊÔÚ¿˜, ÂӉȷÊÂÚfiÓÙˆÓ Î·È ‰Ú·ÛÙËÚÈÔًوÓ, Ô˘ ÂΉËÏÒÓÔÓÙ·È Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ·fi Ù· ÂÍ‹˜: ·) ·ÔÎÏÂÈÛÙÈ΋ ··Û¯fiÏËÛË Ì ¤Ó·Ó ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜, ÛÙÂÚÂfiÙ˘Ô˘˜ Î·È ÂÚÈÔÚÈṲ̂ÓÔ˘˜ Ù‡Ô˘˜ ÂӉȷÊÂÚfiÓÙˆÓ Ô˘ Â›Ó·È ÌË Ê˘ÛÈÔÏÔÁÈ΋, ›Ù ˆ˜ ÚÔ˜ ÙËÓ ¤ÓÙ·ÛË, ›Ù ˆ˜ ÚÔ˜ ÙË Û˘ÁΤÓÙÚˆÛË ‚) ÚÔÛÎfiÏÏËÛË ÂÌÊ·ÓÒ˜ ¿Î·ÌÙË ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜, ÌË ÏÂÈÙÔ˘ÚÁÈΤ˜ ÚÔ˘Ù›Ó˜ ‹ ÙÂÏÂÙÔ˘ÚÁ›Â˜ Á) ÛÙÂÚÂfiÙ˘˜ Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÎÈÓËÙÈΤ˜ ȉÈÔÌÔÚʛ˜ (.¯. Ù›Ó·ÁÌ· ‹ Û˘ÛÙÚÔÊ‹ ÙˆÓ ¯ÂÚÈÒÓ ‹ ÙˆÓ ‰·ÎهψÓ, ‹ ÂÚ›ÏÔΘ ÎÈÓ‹ÛÂȘ fiÏÔ˘ ÙÔ˘ ÛÒÌ·ÙÔ˜) ‰) Â›ÌÔÓË ÂÓ·Û¯fiÏËÛË Ì ̤ÚË ·ÓÙÈÎÂÈÌ¤ÓˆÓ µ. ∫·ı˘ÛÙ¤ÚËÛË ‹ ÌË Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·Ó ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ÙÔÌ›˜, Ì ¤Ó·ÚÍË ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ¯ÚfiÓˆÓ: 1. ∫ÔÈÓˆÓÈ΋ ·ÏÏËÏÂ›‰Ú·ÛË 2. °ÏÒÛÛ·, fiˆ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ÎÔÈÓˆÓÈ΋ ÂÈÎÔÈÓˆÓ›· 3. ™˘Ì‚ÔÏÈÎfi ‹ Ê·ÓÙ·ÛÈ·Îfi ·È¯Ó›‰È °. ∏ ‰È·Ù·Ú·¯‹ ‰ÂÓ ıˆÚÂ›Ù·È ˆ˜ ¢È·Ù·Ú·¯‹ Rett ‹ ˆ˜ ∞Ô‰ÈÔÚÁ·ÓˆÙÈ΋ ¢È·Ù·Ú·¯‹ Ù˘ ¶·È‰È΋˜ ∏ÏÈΛ·˜. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ‰È¿ÊÔÚ˜ ¿ÏϘ ·Ó·Ù˘ÍȷΤ˜ Î·È „˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, fiˆ˜: ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÎÔ‹˜, ÂȉÈΤ˜ ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÏfiÁÔ˘, Û¯È˙ÔÊÚ¤ÓÂÈ·, ÂÎÏÂÎÙÈ΋ ·Ï·Ï›·, ‰È·Ù·Ú·¯‹ ÛÙÂÚÂfiÙ˘ˆÓ ÎÈÓ‹ÛˆÓ, ÎÔÈÓˆÓÈ΋ ÊÔ‚›·, ·ÓÙȉڷÛÙÈ΋ ‰È·Ù·Ú·¯‹ ÚÔÛÎfiÏÏËÛ˘ Î·È ÛÔ‚·Ú‹ ÚÒÈÌË ·ÔÛÙ¤ÚËÛË (34). ¶·È‰È·ÙÚÈ΋ 2006;69:327-335

°ÔÓ›‰È· Î·È ÁÂÓÂÙÈÎÔ› ÙfiÔÈ ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· Á›ÓÂÙ·È ‰ÈÂıÓÒ˜ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ¤Ú¢ӷ ÙˆÓ ÚԉȷıÂÛÈÎÒÓ ÁÔÓȉ›ˆÓ ÛÙÔÓ ·˘ÙÈÛÌfi Î·È ¤¯Ô˘Ó ‹‰Ë ‰È·Ê·Ó› Ù· ÚÒÙ· ·ÔÙÂϤÛÌ·Ù·. £ÂˆÚÂ›Ù·È ‰Â‰Ô̤ÓÔ Û‹ÌÂÚ· fiÙÈ Ô ·˘ÙÈÛÌfi˜ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÏËıÒÚ·˜ ·˘ÙÔۈ̷ÙÈÎÒÓ Î·È Ê˘ÏÔÛ‡Ó‰ÂÙˆÓ Ã ÁÔÓȉ›ˆÓ, Ù· ÔÔ›· ·Ó¤Ú¯ÔÓÙ·È Û 383 ÛÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ÁÂÓÂÙÈÎÔ‡˜ ÙfiÔ˘˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ 1p, 2q, 3q, 6p, 6q, 7q, 9q, 15q, 16p, 17q, 19p, 19q, Xp Î·È Xq ¯ˆÚ›˜, fï˜, Ó· ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ÌÂÙ·‚È‚¿˙ÔÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏÔ˘˜ Â͈ÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ (30,35). µ¿ÛÂÈ ‰Â ÙÔ˘ ˘¿Ú¯ÔÓÙÔ˜ ÂÈÛÙ·ÙÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘, fiÛÔÓ ·ÊÔÚ¿ Ù· ÔÏ˘·Ú·ÁÔÓÙÈο ÓÔÛ‹Ì·Ù·, ÂÎÙÈÌ¿Ù·È fiÙÈ Î·Ó¤Ó· ÁÔÓ›‰ÈÔ ·fi ÌfiÓÔ ÙÔ˘ ‰ÂÓ Â·ÚΛ ÁÈ· ÙËÓ ÚfiÎÏËÛË Ù˘ ‰È·Ù·Ú·¯‹˜ (12). ŒÓ·˜ ¿ÏÏÔ˜ ÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ô˘ Èı·ÓÒ˜ ÂÍËÁ› ÙËÓ ˘ÂÚÔ¯‹ ·ÚÚ¤ÓˆÓ Ì ·˘ÙÈÛÌfi, Â›Ó·È Ë ÁÂÓÂÙÈ΋ ·ÔÙ‡ˆÛË (imprinting) ÂÓfi˜ ÙfiÔ˘ Ô ÔÔ›Ô˜ ÂÎÊÚ¿˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙÔ ·ÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ à ¯ÚˆÌfiۈ̷ Î·È ıˆڋıËΠ˘‡ı˘ÓÔ˜ ÁÈ· ÙÔÓ ·˘ÙÈÛÌfi Û ¿ÚÚÂÓ˜ ·ÛıÂÓ›˜ (36,37). ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÔÚÈṲ̂ÓÔÈ ÁÂÓÂÙÈÎÔ› ÙfiÔÈ Î·È ‰Â›ÎÙ˜ ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· Ô˘ Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ¤¯Ô˘Ó ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ ÂͤÏÈÍË Î·È ÔÚ›· Ù˘ ¿ıËÛ˘ ·˘Ù‹˜ (¶›Ó·Î·˜ 1). ª·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 7 ™‡Ìʈӷ Ì ÙË ¢ÈÂıÓ‹ √Ì¿‰· ªÂϤÙ˘ ªÔÚȷ΋˜ °ÂÓÂÙÈ΋˜ ∞˘ÙÈÛÙÈÎÒÓ ¢È·Ù·Ú·¯ÒÓ (IMGSAC), ˆ˜ Ô ϤÔÓ Èı·Ófi˜ ÁÂÓÂÙÈÎfi˜ ÙfiÔ˜ ˘‡ı˘ÓÔ˜ ÁÈ· ÂΉ‹ÏˆÛË ·˘ÙÈÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ıˆÚÂ›Ù·È Ô AUTS1 ÛÙÔ 7q31-q35. ∂ÎÙÈÌ¿Ù·È fiÙÈ Î·Ï‡ÙÂÈ ÙËÓ ÂÚÈÔ¯‹ ÌÂٷ͇ ÙˆÓ ‰ÂÈÎÙÒÓ D7S496 Î·È D7S2418, Ì 4.5ªb ÁÂÓˆÌÈÎÔ‡ DNA Î·È ÂÚÈÎÏ›ÂÈ ÂÚÈÛÛfiÙÂÚ· ÙˆÓ 50 ÁÔÓȉ›ˆÓ, ·fi Ù· ÔÔ›· Èı·ÓfiÙÂÚ· ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÛÙȘ ·˘ÙÈÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Ù· RELN, FOXP2, WNT2, EN2 Î·È LAMB1 (38).

RELN °ÔÓ›‰ÈÔ: Œ¯ÂÈ Ì¤ÁÂıÔ˜ 45 kb, ·ÔÙÂÏÂ›Ù·È ·fi 63 ÂÍÒÓÈ·, Î·È Îˆ‰ÈÎÔÔÈ› ÙËÓ ÚˆÙ½ÓË ÚÂÏ›ÓË. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÌ‚Ú˘ÔÁ¤ÓÂÛ˘, ηٿ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ‰È¿Ï·ÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ë ÚÂÏ›ÓË ıˆÚÂ›Ù·È ˘‡ı˘ÓË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ÂÁηı›‰Ú˘ÛË ÙˆÓ Ó¢ÚÒÓˆÓ, Ô‰ËÁÒÓÙ·˜ ÙÔ˘˜ ÛÙȘ ÙÂÏÈΤ˜ ÏÂÈÙÔ˘ÚÁÈΤ˜ ÙÔ˘˜ ı¤ÛÂȘ ÙfiÛÔ ÛÙÔ ÎÂÓÙÚÈÎfi fiÛÔ Î·È ÛÙÔ ÂÚÈÊÂÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ∏ ÌÔÚȷ΋ ‰ÔÌ‹

Pediatr Sept_Oct 06

26-09-06

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331

∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡

¶›Ó·Î·˜ 1. °ÔÓ›‰È· Î·È ÁÂÓÂÙÈÎÔ› ÙfiÔÈ Ô˘ Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ¤¯Ô˘Ó ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ ÂͤÏÈÍË Î·È ÔÚ›· ÙˆÓ ·˘ÙÈÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ °ÔÓ›‰ÈÔ / ¶ÚˆÙ½ÓË

°ÂÓÂÙÈÎfi˜ ÙfiÔ˜

RELN / Reelin

7q22

WNT2 / Wingless-related MMTV integration site 2

7q31.2

LAMB1 / Laminin beta-1

7q31.1-q31.3

FOXP2 / Forkhead box P2 EN2 / Engrailed 2 DBH / Dopamine ‚ hydroxylase

7q31 7q36 9q34

UBE3A / Ubiquitin protein ligase E3A ATP10C / mitochondrial ATPase complex subunit ATP10 GABRA5, GABRB3, GABRG3 / Gamma aminobutyric acid (GABA), A receptor, subunit A5, B3, G3 HOXB1 Homeobox µ1

15q11-q13 15q11-q13

ARX / Aristaless-related homeobox X-linked NLGN3 / Neuroligin 3 NLGN4 / Neuroligin 4

Xp22

15q11-q13

17q21.32

Xq13 Xp22.33

ÙˆÓ ·ÌÈÓÔͤˆÓ Ù˘ ÚÂÏ›Ó˘ Â›Ó·È ·ÚÂÌÊÂÚ‹˜ Ì ÂΛÓË ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ÛÙËÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ÌÂÌ‚Ú¿ÓË Ô˘ ÂÚÈ‚¿ÏÏÂÈ ÙÔ˘˜ Ó¢ÚÒÓ˜. ¢˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ÚˆÙ½Ó˘ ·˘Ù‹˜ ·ÔÙÂÏ› Î·Ù·Ï˘ÙÈÎfi ·Ú¿ÁÔÓÙ· Û Ó¢ÚÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ fiˆ˜ Û¯È˙ÔÊÚ¤ÓÂÈ·, ‰ÈÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜, ηٿıÏÈ„Ë Î·È ÏÂÈÂÁÎÂÊ·Ï›·, ‰ÈfiÙÈ ‰È·Ù·Ú¿ÛÛÂÈ ÙË ÌÂÙ·‚›‚·ÛË ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ (39-41). √ Persico Î·È Û˘Ó (2001) ‰È·›ÛÙˆÛ·Ó ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ·˘ÙÈÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È Ì›·˜ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˘ GGC ÙÚÈϤٷ˜ ÛÙËÓ 5ã ·ÌÂÙ¿ÊÚ·ÛÙË ÂÚÈÔ¯‹ ÙÔ˘ ÁÔÓȉ›Ô˘ RELN, ηıÒ˜ Î·È Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÏÔÙ‡ˆÓ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ·˘ÙfiÓ ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi Ì ·ÓÙÈηٿÛÙ·ÛË 2 ‚¿ÛˆÓ. ∂ÎÙÈÌÔ‡Ó ‰Â, fiÙÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ÙÚÈÏÂÙÒÓ (>10) Úԉȷı¤ÙÂÈ ÛÙËÓ ÂΉ‹ÏˆÛË ·˘ÙÈÛÌÔ‡ (42).

WNT2 °ÔÓ›‰ÈÔ: ¶ÂÚÈÛÛfiÙÂÚ· ·fi 12 ÁÔÓ›‰È· Ù‡Ô˘ WNT ÂÎÊÚ¿˙ÔÓÙ·È Û ·ÚÎÂÙÔ‡˜ ÈÛÙÔ‡˜ (ÂȉÈο ÛÙÔÓ ı¿Ï·ÌÔ) Î·È Îˆ‰ÈÎÔÔÈÔ‡Ó ¤Ó·Ó ·˘ÍËÙÈÎfi ·Ú¿ÁÔÓÙ· Ô˘ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË, ÙË Ú‡ıÌÈÛË, ÙË ‰È·ÊÔÚÔÔ›ËÛË Î·È ÙËÓ ÔÁÎÔÁ¤ÓÂÛË. √ Wassink Î·È Û˘Ó (2001) ÌÂϤÙËÛ·Ó ÔÈÎÔÁ¤ÓÂÈ· ÛÙËÓ ÔÔ›· Ô ·Ù¤Ú·˜ Î·È Ù· ‰‡Ô ·˘ÙÈÛÙÈο ·È‰È¿ ÙÔ˘ ¤ÊÂÚ·Ó Ì›· ÛËÌÂȷ΋ ÌÂÙ¿ÏÏ·ÍË, Û˘ÁÎÂÎÚÈ̤ӷ ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ı˘ÌÈ-

ƒfiÏÔ˜

∞Ó¿Ù˘ÍË Î·È ÂÁηı›‰Ú˘ÛË ÙˆÓ Ó¢ÚÒÓˆÓ ÛÙÔ ÎÂÓÙÚÈÎfi Î·È ÂÚÈÊÂÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ªÂÙ·‚›‚·ÛË ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ù˘ ·Ó¿Ù˘Í˘, Ú‡ıÌÈÛ˘ Î·È ‰È·ÊÔÚÔÔ›ËÛ˘ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¶ÚÔÛÎfiÏÏËÛË Î·È ÂÍ¿ψÛË Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¶ÚÔ·ÁˆÁ‹ Ù˘ ¤ÎÊ˘Û˘ Ó¢ڷÍfiÓˆÓ ∞Ó¿Ù˘ÍË Î·È ÂͤÏÈÍË ÏfiÁÔ˘ ∞Ó¿Ù˘ÍË ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ªÂÙ·ÙÚÔ‹ Ù˘ ÓÙÔ·Ì›Ó˘ Úfi˜ ÓÔÚÂÈÓÂÊÚ›ÓË ÛÙ· Û˘Ó·ÙÈο ΢ÛÙ›‰È· ÙˆÓ Ó¢ÚÒÓˆÓ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∞Ó¿Ù˘ÍË Î·È ‰È·ÊÔÚÔÔ›ËÛË ‰ÔÌÒÓ ÂÁÎÂÊ¿ÏÔ˘ ¶ÚfiÛ‰ÂÛË Û˘ÓÔ‰ÒÓ Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÒÓ ÚˆÙÂ˚ÓÒÓ ∞Ó·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÛÙÔ˘˜ ÚÔÛ˘Ó·ÙÈÎÔ‡˜ Ó¢ÚÒÓ˜ ƒ‡ıÌÈÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÎÔÈÓˆÓÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ∞Ú¯È΋ ‰È·ÌfiÚʈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ªÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÒÓˆÓ Î·Ù¿ ÙËÓ ÂÌ‚Ú˘ÔÁ¤ÓÂÛË ∞Ó¿Ù˘ÍË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∫˘ÙÙ·ÚÈ΋ ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ Ó¢ÚÒÓˆÓ ∫˘ÙÙ·ÚÈ΋ ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ Ó¢ÚÒÓˆÓ

‰›Ó˘ ·fi ΢ÙÔÛ›ÓË ÛÙÔ ÂÍÒÓÈÔ 5, Έ‰ÈÎÔÔÈÒÓÙ·˜ Ì›· ÚˆÙ½ÓË ÌÂȈ̤Ó˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ (43). ∞Ó Î·È ÙÔ WNT2 ÂÍÂÙ¿ÛÙËÎÂ Î·È ·fi ÙËÓ ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÙÔ˘ McCoy (2002) Î·È ‰ÂÓ ‰È·ÈÛÙÒıËΠ·ÍÈfiÏÔÁË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÁÈ· ¢∞¢, ÂÍ·ÎÔÏÔ˘ı› Ó· ıˆÚÂ›Ù·È fiÙÈ ÂÓ¤¯ÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ·˘ÙÈÛÌÔ‡ (44).

LAMB1 °ÔÓ›‰ÈÔ: Œ¯ÂÈ Ì¤ÁÂıÔ˜ 80kb Î·È ·ÔÙÂÏÂ›Ù·È ·fi 34 ÂÍÒÓÈ·, Έ‰ÈÎÔÔÈ› Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË ÌÂÁ¿ÏÔ˘ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ (Ï·ÌÈÓ›ÓË) Ô˘ Â›Ó·È Î‡ÚÈÔ Û˘ÛÙ·ÙÈÎfi Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ. ∏ Ï·ÌÈÓ›ÓË Â¿ÁÂÈ ÙËÓ ÚÔÛÎfiÏÏËÛË Î·È ÂÍ¿ψÛË ÔÏÏÒÓ ÂȉÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÚÔ¿ÁÂÈ ÙËÓ ¤ÎÊ˘ÛË Ó¢ڷÍÒÓˆÓ. ∂Èο˙ÂÙ·È fiÙÈ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÚԉȿıÂÛË ÁÈ· ·˘ÙÈÛÌfi, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì ·Ó¿Ï˘ÛË Û˘Û¯¤ÙÈÛ˘ ·ÏÏËÏÔÌfiÚÊˆÓ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔȯ›· Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙË ıÂÙÈ΋ Û‡Ó‰ÂÛË ÂÓfi˜ SNP Î·È ÙÚÈÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ·ÏÔÙ‡ˆÓ Ì 2 SNP's ηٿ Ì‹ÎÔ˜ ÙÔ˘ ÁÔÓȉ›Ô˘ (45,46).

FOXP2 °ÔÓ›‰ÈÔ: Œ¯ÂÈ Ì¤ÁÂıÔ˜ 275kb, ·ÔÙÂÏÂ›Ù·È ·fi 17 ÂÍÒÓÈ· Î·È ÂÌϤÎÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘. ¶ÚfiÛÊ·Ù·, Ô Li Î·È Û˘Ó (2005) ÂÓÙfiÈÛ·Ó Û ·˘ÙÈÛÙÈÎÔ‡˜ π¿ˆÓ˜ Ì›· ¤ÏÏÂÈ„Ë Ù˘ ÙÚÈϤٷ˜ CGG, Ì›· ÂÚÌËÓ‡ÛÈÌË ÌÂÙ¿ÏÏ·ÍË Î·È Ù¤ÛÛÂÚȘ ÔÏ˘ÌÔÚÊÈΤ˜ ·ÏÏ·Á¤˜ ÂÓÙfi˜ ÙˆÓ ÂÛˆÓ›ˆÓ (47). ∂¡2 °ÔÓ›‰ÈÔ: ∞ÔÙÂÏÂ›Ù·È ·fi 2 ÂÍÒÓÈ· Ô˘ ¶·È‰È·ÙÚÈ΋ 2006;69:327-335

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·332

332

∞. ¶¿Ì·ÓÔ˜ Î·È Û˘Ó.

‰È·¯ˆÚ›˙ÔÓÙ·È ·fi ¤Ó· ÂÛÒÓÈÔ 3.3kb, Î·È ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌÔÚÊÔÔ›ËÛË Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ Î·È ÙȘ ¢∞¢ (48). ŒÙÛÈ ÛÙËÚ›˙ÂÙ·È Ë ¿ÁÈ· ı¤ÛË ÔÏÏÒÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÙËÓ ÚԉȿıÂÛË ÙÔ˘ ∂¡2 ÛÙȘ ·˘ÙÈÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÂÁÎÂÊ·ÏÈΤ˜ ·Ó·Ù˘ÍȷΤ˜ ·ÓˆÌ·Ï›Â˜. ª·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 9 DBH °ÔÓ›‰ÈÔ ∆Ô ÁÔÓ›‰ÈÔ DBH Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 9 ÛÙË ı¤ÛË q34, ıˆڋıËΠ·fi ÙÔ˘˜ Robinson Î·È Û˘Ó ÙÔ 2001 ˆ˜ ¤Ó· ·fi Ù· ˘‡ı˘Ó· ÁÔÓ›‰È· ÁÈ· ÙÔÓ ·˘ÙÈÛÌfi. Œ¯ÂÈ Ì¤ÁÂıÔ˜ 23kb, ·ÔÙÂÏÂ›Ù·È ·fi 12 ÂÍÒÓÈ·, Î·È Îˆ‰ÈÎÔÔÈ› ÙÔ ¤Ó˙˘ÌÔ ÓÙÔ·Ì›ÓË ‚-˘‰ÚÔÍ˘Ï¿ÛË (DBH), Ô˘ ηٷχÂÈ ÙË ÌÂÙ·ÙÚÔ‹ Ù˘ ÓÙÔ·Ì›Ó˘ Û ÓÔÚÂÈÓÂÊÚ›ÓË. ∞ÏÏËÏfiÌÔÚÊ· ÙÔ˘ DBH ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È ·fi Ì›· ÔÏ˘ÌÔÚÊÈ΋ Â·Ó¿ÏË„Ë Ù˘ AC ·ÏÏËÏÔ˘¯›·˜ Î·È ÙËÓ ·ÚÔ˘Û›· ‹ ·Ô˘Û›· (DBH+ ‹ DBH-) 19 Û˘Ó¯fiÌÂÓˆÓ ‚¿ÛˆÓ. ™Â ÂÚÈÙÒÛÂȘ ÔÌÔ˙˘ÁˆÙ›·˜ (DBH-/DBH-) ÚÔηÏÂ›Ù·È ÌÂȈ̤ÓË Û˘ÁΤÓÙÚˆÛË ÓÙÔ·Ì›Ó˘ ‚-˘‰ÚÔÍ˘Ï¿Û˘ ÛÙȘ ÌËÙ¤Ú˜ Î·È ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο Ô Î›Ó‰˘ÓÔ˜ ÂΉ‹ÏˆÛ˘ ·˘ÙÈÛÌÔ‡ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ ÙÔ˘˜ (49). ª·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 15 ∏ ÂÚÈÔ¯‹ 15q11-q13 Â›Ó·È È‰È·›ÙÂÚ· ÔχÏÔÎË Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÏËıÒÚ· Small Low Copy Repeats (ÚÂÏÈÎfiÓÈ·) ÌÂÁ¤ıÔ˘˜ ̤¯ÚÈ Î·È 60kb. ∞ÔÙÂÏÔ‡Ó Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÙËÓ ·ÈÙ›· Û˘¯ÓÒÓ ‰ÔÌÈÎÒÓ ·ÏÏ·ÁÒÓ Û ÛËÌ›· ıÚ·‡Û˘, ÌÂÚÈο ·fi Ù· ÔÔ›· (µƒ1µƒ2-µƒ3) ‰‡Ó·ÓÙ·È Ó· ÚÔηϤÛÔ˘Ó Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ fiÌÔȘ ÂÎÂ›ÓˆÓ ÙÔ˘ ·˘ÙÈÛÙÈÎÔ‡ Ê¿ÛÌ·ÙÔ˜ (50,51). ∆· ÁÔÓ›‰È· Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÂÚÈÔ¯‹ ·˘Ù‹ Î·È ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙÔÓ ·˘ÙÈÛÌfi Â›Ó·È Ù· ÂÍ‹˜: UBE3A Î·È ATP10C °ÔÓ›‰È·: ∆· ÁÔÓ›‰È· ·˘Ù¿, ÌÂÁ¤ıÔ˘˜ 68Kb Î·È 186.5kb ·ÓÙÈÛÙÔ›¯ˆ˜, ÂÎÊÚ¿˙ÔÓÙ·È Û ÌÔÓ·ÏÏËÏfiÌÔÚÊË Î·Ù¿ÛÙ·ÛË Û ÔÚÈṲ̂ÓÔ˘˜ ÈÛÙÔ‡˜ Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÂÓÂÚÁ¿ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ó¿Ù˘ÍË. ∫ÏËÚÔÓÔÌÈΤ˜ ÂÏÏ›„ÂȘ ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ ÙÔ˘ UBE3A ıˆÚÔ‡ÓÙ·È ˘‡ı˘Ó˜ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ Angelman Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙȘ ¢∞¢ (52).

GABA °ÔÓ›‰È· (GABRA5, GABRB3, GABRG3): ∏ ÔÌ¿‰· ÙˆÓ ÁÔÓȉ›ˆÓ ·˘ÙÒÓ Îˆ‰ÈÎÔÔÈ› ÙÔ˘˜ ∞ ˘ԉԯ›˜ ÙÔ˘ Á-·ÌÈÓÔ‚Ô˘Ù˘ÚÈÎÔ‡ ÔͤԘ (GABA), ÙÔ ÔÔ›Ô ·ÛΛ ·Ó·ÛÙ·ÏÙȶ·È‰È·ÙÚÈ΋ 2006;69:327-335

΋ ‰Ú¿ÛË ÛÙÔ˘˜ ÚÔÛ˘Ó·ÙÈÎÔ‡˜ Ó¢ÚÒÓ˜. ∆Ô ·ÌÈÓÔ͇ GABA Â›Ó·È Ó¢Úԉȷ‚È‚·ÛÙ‹˜ Î·È ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ú˘ıÌ›˙ÂÈ ÙË Û˘ÌÂÚÈÊÔÚ¿, ÂËÚ¿˙ÔÓÙ·˜ ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÙÔ˘ ·ÙfiÌÔ˘, ηıÒ˜ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓËÛ˘¯›·˜, ÂÓÒ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙËÓ ÔÌÈÏ›· Î·È ÙËÓ ÂÂÍÂÚÁ·Û›· ÙÔ˘ ‹¯Ô˘. ∂Èο˙ÂÙ·È fiÙÈ ÂÏÏ›„ÂȘ ÛÙ· ÁÔÓ›‰È· ÙÔ˘ ∞ ˘Ô‰Ô¯¤· (ÙˆÓ ˘ÔÌÔÓ¿‰ˆÓ ‚3 Î·È Á3) Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ·˘ÙÈÛÌfi ηıÒ˜ Î·È ÌÂ Û˘Ó·Ê›˜ ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙ· Û‡Ó‰ÚÔÌ· Angelman Î·È Prader-Willi (53). ª·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 17 HOXB1 °ÔÓ›‰ÈÔ ™Â ÚfiÛÊ·ÙË ÌÔÚȷ΋ ·Ó¿Ï˘ÛË fiÏÔ˘ ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ·Ú·ÙËÚ‹ıËΠۇӉÂÛË Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 17q (45-52cM), ÏËÛ›ÔÓ Ù˘ ı¤Û˘ ÙÔ˘ ªÂÙ·ÊÔÚ¤· ™ÂÚÔÙÔÓ›Ó˘ (5-HTT), Ì ÁÔÓ›‰ÈÔ ÙÔ ÔÔ›Ô ıˆÚÂ›Ù·È ˘‡ı˘ÓÔ ÁÈ· ÙÔÓ ·˘ÙÈÛÌfi (54). ∂›Û˘, ÛÙÔ 17q21.32 ÌÂÏÂÙ¿Ù·È ÙÔ ÁÔÓ›‰ÈÔ homeobox µ1 Ô˘ ÂÌϤÎÂÙ·È ÛÙËÓ ·Ú¯È΋ ‰È·ÌfiÚʈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ú˘ıÌ›˙ÔÓÙ·˜ ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÒÓˆÓ Î·Ù¿ ÙËÓ ÂÌ‚Ú˘ÔÁ¤ÓÂÛË (55). ∏ ¤ÓıÂÛË 9 ‚¿ÛÂˆÓ ÛÙÔ ÂÍÒÓÈÔ 1 ÙÔ˘ HOXB1 ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ÙȘ ¢∞¢ (56). Ÿˆ˜ Ê·›ÓÂÙ·È Û ÌÂϤÙ˜ Û‡Ó‰ÂÛ˘, ¿ÏÏÔÈ Èı·ÓÔ› ÁÂÓÂÙÈÎÔ› ÙfiÔÈ ¿ÌÂÛ· ÂÌÏÂÎfiÌÂÓÔÈ Ì ÙÔÓ ·˘ÙÈÛÌfi Â›Ó·È ÔÈ ‰Â›ÎÙ˜ D17S1294 Î·È D17S1299 (57). à ¯ÚˆÌfiۈ̷: ARX, NLGN3 Î·È NLGN4 °ÔÓ›‰È· ∏ Û¯¤ÛË ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à Ì ÙÔÓ ·˘ÙÈÛÌfi ÚÔ·ÙÂÈ ·fi ÂȉËÌÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ Û˘ÓËÁÔÚÔ‡Ó ÌÂ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ÙÚfiÔ ÌÂÙ·‚›‚·Û˘, fiˆ˜ Â›Ó·È Ë ˘ÂÚÔ¯‹ ·ÚÚ¤ÓˆÓ ·Û¯fiÓÙˆÓ Î·È Ë ·˘ÍË̤ÓË Û˘Ó‡·ÚÍË ·˘ÙÈÛÌÔ‡ Ì ·ÓˆÌ·Ï›Â˜ ÙÔ˘ à ¯ÚˆÌÔÛÒÌ·ÙÔ˜ (Ì ·Ú¿‰ÂÈÁÌ· ÙÔ ∂‡ıÚ·˘ÛÙÔ Ã) (25). ™ÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à (Xp22) ÂÓÙÔ›˙ÂÙ·È ÙÔ ÁÔÓ›‰ÈÔ ARX, ÙÔ ÔÔ›Ô Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ·˘ÙÈÛÌfi (58). ∂›Û˘ Û ¿ÏÏÔ ÁÔÓ›‰ÈÔ, ÙÔ NLGN4, ÛÙËÓ ÂÚÈÔ¯‹ Xq22.33, ÂÓÙÔ›ÛÙËΠ̛· ÌÂÙ¿ÏÏ·ÍË Ï·ÈÛ›Ô˘ (1186insT) Û ‰‡Ô ·‰ÂÏÊÔ‡˜ ÛԢˉÈ΋˜ ηٷÁˆÁ‹˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ô ¤Ó·˜ ›¯Â Ù˘Èο Û˘ÌÙÒÌ·Ù· ·˘ÙÈÛÌÔ‡ Î·È Ô ¿ÏÏÔ˜ Û‡Ó‰ÚÔÌÔ Asperger. ∆Ô Â‡ÚËÌ· Â›Ó·È ÛËÌ·ÓÙÈÎfi ‰ÈfiÙÈ Ë ÌÂÙ¿ÏÏ·ÍË ‰ÂÓ ‰È·ÈÛÙÒıËΠ۠ÙÚ›ÙÔ ˘ÁÈ‹ ·‰ÂÏÊfi Ô‡Ù ÛÙËÓ ÔÌ¿‰· 350 Ì·ÚÙ‡ÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ·Ú¿ÏÏËÏ·, ηÈ

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∏ ÁÂÓÂÙÈ΋ ‚¿ÛË ÙÔ˘ ·˘ÙÈÛÌÔ‡

ÁÈ· ÙÔÓ ÏfiÁÔ ·˘Ùfi ·Ú·Ì¤ÓÂÈ ÙÔ ı¤Ì· ·ÓÔȯÙfi ÛÙËÓ ¤Ú¢ӷ (59). ™ÙÔ ›‰ÈÔ ÁÔÓ›‰ÈÔ (NLGN4), ÚÔÛÊ¿Ùˆ˜, ÔÈ Laumonnier Î·È Û˘Ó (2004) ·ÚÔ˘Û›·Û·Ó ÙËÓ ÂÚ›ÙˆÛË ¿ÏÏ˘ ÌÂÙ¿ÏÏ·Í˘, Û˘ÁÎÂÎÚÈ̤ӷ ÌÈ·˜ ¤ÏÏÂȄ˘ 2 ‚¿ÛÂˆÓ Û ÔÈÎÔÁ¤ÓÂÈ· Á·ÏÏÈ΋˜ ηٷÁˆÁ‹˜, Ì ¿ÚÚÂÓ˜ ¿Û¯ÔÓÙ˜ ·fi ÌË ÂȉÈ΋ Ê˘ÏÔÛ‡Ó‰ÂÙË ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Î·È ‹ ¯ˆÚ›˜ ·˘ÙÈÛÌfi ‹ ¢∞¢ (60). ∞˘Ù‹ Ë ÌÂÙ¿ÏÏ·ÍË Ô‰ËÁ› Û ÚÒÈÌÔ Îˆ‰ÈÎfiÓÈÔ Ï‹Í˘ ηٷÛÙ¤ÏÏÔÓÙ·˜ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‰È·ÌÂÌ‚Ú·ÓÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ô˘ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ΢ÙÙ·ÚÈΤ˜ ·ÏÏËÏÂȉڿÛÂȘ. ∏ ·Ó‡ÚÂÛË ·˘Ù‹˜ Ù˘ ÌÂÙ¿ÏÏ·Í˘ Û ¿ÚÚÂÓ˜ ·˘ÙÈÛÙÈÎÔ‡˜ ‹ ÌË, Ì ÓÔËÙÈ΋ fï˜ ˘ÛÙ¤ÚËÛË, ˘Ô‰ËÏÒÓÂÈ ÙȘ ÎÔÈÓ¤˜ ÁÂÓÂÙÈΤ˜ Ú›˙˜ ÙˆÓ ÂÓ ÏfiÁˆ ‰È·Ù·Ú·¯ÒÓ. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÛÙËÓ ÂÚÈÔ¯‹ Xq13 ÂÓÙÔ›ÛÙËΠ̛· ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ Ó¢ÚÔÏÈÁ›Ó˘ 3 (NLGN3) - ·ÓÙÈηٿÛÙ·ÛË Î˘ÙÔÛ›Ó˘ Ì ı˘Ìȉ›ÓË - Û ‰‡Ô ¿ÏÏÔ˘˜ ¿Û¯ÔÓÙ˜ ÛԢˉԇ˜ ·‰ÂÏÊÔ‡˜, Ô ¤Ó·˜ Ì ·˘ÙÈÛÌfi Î·È Ô ‰Â‡ÙÂÚÔ˜ Ì ۇӉÚÔÌÔ Asperger. ∆Ô ÂÓ ÏfiÁˆ ÔÈÎÈÏfiÌÔÚÊÔ ‰ÂÓ ·ÓȯÓ‡ıËΠÛÙ· ‰Â›ÁÌ·Ù· ÙˆÓ 200 Ì·ÚÙ‡ÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ÁÂÁÔÓfi˜ Ô˘ ÈÛ¯˘ÚÔÔÈ› ÙË ÛËÌ·Û›· ÙÔ˘ Â˘Ú‹Ì·ÙÔ˜ (59). ™ÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à (Xq13-q26.1), ¤¯ÂÈ ÙÔÓÈÛı› ȉȷÈÙ¤Úˆ˜ Û ÙÚÂȘ ÁÔÓȉȈ̷ÙÈΤ˜ ÌÂϤÙ˜ Ë Û‡Ó‰ÂÛË ÙÚÈÒÓ ‰ÂÈÎÙÒÓ [DXS1047 (MLS=2,67) (61), DXS6789 (MLS=2,54) (62) Î·È DXS7132 (MLS=2,75)] Ì ÙÔÓ ·˘ÙÈÛÌfi (63). ∞Ó Î·È ÙËÓ ›‰È· ¯ÚÔÓÈ¿ Û ¿ÏÏË ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËÎ·Ó ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙ· ÁÔÓ›‰È· NLGN3 Î·È NLGN4, ÂÍ·ÎÔÏÔ˘ı› Ó· Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ·ıÔÏÔÁÈο ÁÔÓ›‰È· NLGN3 ‹ NLGN4 ÂÓ‰¤¯ÂÙ·È Ó· ÂÌÔ‰›˙Ô˘Ó ÙÔÓ Û¯ËÌ·ÙÈÛÌfi, ÙË ÛÙ·ıÂÚÔÔ›ËÛË Î·È ÙËÓ ·Ó·ÁÓÒÚÈÛË Î¿ÔÈˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Û˘Ó¿„ÂˆÓ ·Ó·Áη›ˆÓ ÁÈ· ÙËÓ ÂÈÎÔÈÓˆÓ›· ÌÂٷ͇ Ó¢ÚÒÓˆÓ. ∞Ó·ÌÊÈÛ‚‹ÙËÙ·, ··ÈÙÂ›Ù·È ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Û ÏËı˘ÛÌfi ‰È·ÊfiÚˆÓ Ê˘ÏÒÓ Î·È ÂıÓÈÎÔÙ‹ÙˆÓ ÁÈ· Ó· ηıÔÚÈÛÙ› Ô ‚·ıÌfi˜ Ù˘ Û˘Ì‚ÔÏ‹˜ ÙÔ˘˜ ÛÙÔÓ ·˘ÙÈÛÌfi (64). ŒÓ· ¿ÏÏÔ È‰È·›ÙÂÚ· ÂӉȷʤÚÔÓ ı¤Ì· Â›Ó·È fiÙÈ Û ÌÂϤÙË ÙˆÓ Skuse Î·È Û˘Ó (1997) ·Ó·Ê¤ÚÔÓÙ·È 4 ÂÚÈÛÙ·ÙÈο Û˘Ó‰ÚfiÌÔ˘ Turner Ì ·˘ÙÈÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÛÙ· ÔÔ›· ÙÔ Ã ¯ÚˆÌfiۈ̷ ‹Ù·Ó ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ (36). ∞ÚÁfiÙÂÚ· ÔÈ Donnelly Î·È Û˘Ó (2000) ·ÚÔ˘Û›·Û·Ó Ì›· ¿ÏÏË ·ÛıÂÓ‹ Ì ۇӉÚÔÌÔ Turner, ÛÙËÓ ÔÔ›· ÙÔ ¯ÚˆÌfiۈ̷ à ‹Ù·Ó ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘, Ì ·˘ÙÈÛÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Î·È ÎÔÈÓˆÓÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÌÂȈ̤ÓË Û ۇÁÎÚÈÛË Ì ÙȘ ·ÛıÂ-

Ó›˜ ÂΛӘ ÙˆÓ ÔÔ›ˆÓ ÙÔ ¯ÚˆÌfiۈ̷ à ‹Ù·Ó ·ÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ (65). ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÛÙ·ÙÈο ·˘ÙÈÛÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙÔ Û‡Ó‰ÚÔÌÔ Turner fiÔ˘ ÙÔ Ã ¯ÚˆÌfiۈ̷ ‹Ù·Ó ·ÙÚÈ΋˜ ÚÔ¤Ï¢Û˘. §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜, Èı·ÓÔÏÔÁÂ›Ù·È Ë ‡·ÚÍË ÂÓfi˜ ÁÂÓÂÙÈÎÔ‡ ÙfiÔ˘, ÁÂÓÂÙÈο ·ÔÙ˘ˆÌ¤ÓÔ˘ (genetic imprinting) Î·È ÌË ÂÎÊÚ·˙fiÌÂÓÔ˘ ·fi ÙÔ ÌËÙÚÈÎfi à ¯ÚˆÌfiۈ̷, ˘‡ı˘ÓÔ˘ ˆ˜ ¤Ó·Ó ‚·ıÌfi ÁÈ· ÙËÓ ÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ·˘ÙÈÛÙÈÎÒÓ ·ÙfïÓ. ∏ ˘fiıÂÛË ·˘Ù‹ ÂȂ‚·ÈÒÓÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¿ÚÚÂÓ˜ Ì à ¯ÚˆÌfiۈ̷ ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂȈ̤ÓË ÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Û ۇÁÎÚÈÛË ÌÂ Ê˘ÛÈÔÏÔÁÈο ı‹Ï· ¿ÙÔÌ· (37). ¶·Ú¿ ÙȘ ÂӉ›ÍÂȘ ·˘Ù¤˜ fiÙÈ ¤Ó· ·ÔÙ˘ˆÌ¤ÓÔ ÁÔÓ›‰ÈÔ ÛÙÔ Ã ¯ÚˆÌfiۈ̷ Û˘ÓÙÂÏ›, ÙÔ˘Ï¿¯ÈÛÙÔÓ ˆ˜ ¤Ó·Ó ‚·ıÌfi, ÛÙËÓ ÂΉ‹ÏˆÛË ÎÔÈÓˆÓÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÂÎÙÈÌ¿Ù·È fiÙÈ ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÁÔÓ›‰ÈÔ ‰ÂÓ ·ÔÙÂÏ› ÙËÓ ·ÔÎÏÂÈÛÙÈ΋ ·ÈÙ›· ·˘ÙÈÛÌÔ‡, ·ÏÏ¿ ÂËÚ¿˙ÂÈ ¿ÌÂÛ· ¿ÏÏ· ÁÔÓ›‰È· Ù· ÔÔ›· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙȘ ¢∞¢. ªÂÙ¿ ÙËÓ ÂÓÙfiÈÛË ÙˆÓ ÛËÌ›ˆÓ ‰Ú¿Û˘ ÙÔ˘ Ê˘ÏÔÛ‡Ó‰ÂÙÔ˘ ·˘ÙÔ‡ ÁÔÓȉ›Ô˘, Ë ¤Ú¢ӷ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó‡ÚÂÛË ·˘ÙÔۈ̷ÙÈÎÒÓ ÁÔÓȉ›ˆÓ Ì ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÚԉȿıÂÛ˘ ÁÈ· ·˘ÙÈÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∞fi fiÛ· ‹‰Ë ·Ó·Ê¤ÚıËηÓ, ÚÔ·ÙÂÈ fiÙÈ Ë ÔÏ˘ÏÔÎfiÙËÙ· Î·È ÔÏ˘·Ú·ÁÔÓÙÈÎfiÙËÙ· Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÓfiÛÔ˘ ·ÔÙÂÏ› ÙÔ Î˘ÚÈfiÙÂÚÔ ÂÌfi‰ÈÔ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ Û·ÊÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ˆ˜ ÚÔ˜ ÙÔ ÁÂÓÂÙÈÎfi Ù˘ ˘fiÛÙڈ̷. ¶·Ú’ fiÏ· ·˘Ù¿, ÂÂȉ‹ Ô ·˘ÙÈÛÌfi˜ Î·È ÔÈ ¢∞¢ Û˘Óı¤ÙÔ˘Ó ¤Ó· ÂÚ›ÏÔÎÔ ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi Úfi‚ÏËÌ·, ÂÓÒ ·ÔÙÂÏÔ‡Ó ‰˘Û‚¿ÛÙ·¯ÙÔ Û˘Ó·ÈÛıËÌ·ÙÈÎfi ÊÔÚÙ›Ô ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, Û˘Ó¯›˙ÔÓÙ·È ÔÈ ÚÔÛ¿ıÂȘ Ù˘ ·ÁÎfiÛÌÈ·˜ ÂÚ¢ÓËÙÈ΋˜ ÎÔÈÓfiÙËÙ·˜ Ì ÛÙfi¯Ô Ó· ÚÔÛÊÂÚı› ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ Î·È ·ÎfiÌË Ë ‰˘Ó·ÙfiÙËÙ· ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÛÙÔ Ì¤ÏÏÔÓ.

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64. Talebizadeh Z, Bittel DC, Kibiryeva N, Butler MG. X chromosome inactivation and candidate gene studies in females with autism. Am J Hum Genet 2003;73(5 Suppl):S514.

65. Donnelly SL, Wolpert CM, Menold MM, Bass MP, Gilbert JR, Cuccaro ML, et al. Female with autistic disorder and monosomy X (Turner syndrome): parent-of-origin effect of the X chromosome. Am J Med Genet 2000;96:312-316.

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∂Ê¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰È·ÙÚÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ, ¶ÂÈÚ·È¿˜ AÏÏËÏÔÁÚ·Ê›·: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ ¶¿ÚÓËıÔ˜ 32 ∆.∫. 190 13, ™·ÚˆÓ›‰· ∞ÙÙÈ΋˜ ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 16-02-2006

°. ∆ÛfiÏ·˜, ™. ºˆÙÈ¿

¶ÂÚ›ÏË„Ë: √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ·ÔÙÂÏÔ‡Ó ·ÓÙÈ‚ÈÔÙÈο ÚÒÙ˘ ÁÚ·ÌÌ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÏÏÒÓ ÏÔÈÌÒÍÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÂÓÒ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ì ÂÈÙ˘¯›· Î·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÏÔÈÌÒÍÂˆÓ ÙˆÓ ÂÓËϛΈÓ. √ ÎÏ·ÛÈÎfi˜ ÙÚfiÔ˜ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘ Û ‰‡Ô ‹ ÙÚÂȘ ÂÈ̤ÚÔ˘˜ ‰fiÛÂȘ, ¯ÔÚËÁÔ‡ÌÂÓ˜ οı 8-12 ÒÚ˜. ªÂϤÙ˜ Û ÂÓ‹ÏÈΘ Î·È ·È‰È¿ ¤‰ÂÈÍ·Ó Ì ÙÔÓ ·Ú·¿Óˆ ÙÚfiÔ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, ÂÊ¿ÌÈÏÏË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÌÈÎÚfiÙÂÚË ÙÔÍÈÎfiÙËÙ· fiÙ·Ó ÔÏfiÎÏËÚË Ë ËÌÂÚ‹ÛÈ· ‰fiÛË ·˘ÙÒÓ ¯ÔÚËÁ›ÙÔ ÂÊ¿·Í, ¯ˆÚ›˜ Ó· ‰È·ÈÚÂ›Ù·È Û ÂÈ̤ÚÔ˘˜ ‰fiÛÂȘ. ∏ Ú·ÎÙÈ΋ ·˘Ù‹, fï˜, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ˘ÈÔıÂÙËı› ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· Î·È ·˘Ùfi Û˘Ì‚·›ÓÂÈ ÂÂȉ‹ Ë Î¿ı·ÚÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Â›Ó·È Ù·¯‡ÙÂÚË, Ë ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÙÂٷ̤Ó˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ‰Ú¿Û˘ ÙÔ˘˜ (post-antibiotic effect) ¿ÁÓˆÛÙË, ÂÓÒ Ù· ÛÙÔȯ›· Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ‰ÔÛÔÏÔÁÈÎÔ‡ ·˘ÙÔ‡ Û¯‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ. ∂ÓÙÔ‡ÙÔȘ, ÙÂÏÂ˘Ù·›Â˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ¯Ú‹ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙȘ ÏÔÈÌÒÍÂȘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ηٷ‰ÂÈÎÓ‡Ô˘Ó fiÙÈ ÙÔ ÂÊ¿·Í ËÌÂÚ‹ÛÈÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Â›Ó·È ·ÛʷϤ˜, ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ·ÏÏ¿ Î·È ÈÔ ÔÈÎÔÓÔÌÈÎfi. º·›ÓÂÙ·È, Û˘ÓÂÒ˜, fiÙÈ Ô ÙÚfiÔ˜ ·˘Ùfi˜ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÂÓ‰¤¯ÂÙ·È Ó· ηıÈÂÚˆı› ÛÙÔ ÚÔÛ¯¤˜ ̤ÏÏÔÓ Î·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÂÎÂ›ÓˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙȘ Ôԛ˜ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Î·È ·ÊÔ‡, ‚‚·›ˆ˜, ÏËÊıÔ‡Ó ˘’ fi„ÈÓ ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ ÙÔ˘ οı ·ÛıÂÓÔ‡˜ Î·È ÙÔ˘ ›‰Ô˘˜ Ù˘ Ïԛ̈͢. £· ··ÈÙËı›, ¿ÓÙˆ˜, ÂÚ·ÈÙ¤Úˆ ÌÂϤÙË ÙÔ˘ ı¤Ì·ÙÔ˜, ÚÔÙÔ‡ ηıÈÂÚˆı› ÙÔ ÂÊ¿·Í ËÌÂÚ‹ÛÈÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ˆ˜ ¿ÁÈ· Ú·ÎÙÈ΋ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. §¤ÍÂȘ ÎÏÂȉȿ: ∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, ÂÊ¿·Í ËÌÂÚ‹ÛÈ· ‰fiÛË, ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·, ˆÙÔÙÔÍÈÎfiÙËÙ·, ·Ú·ÙÂٷ̤ÓË ·ÓÙÈ‚ÈÔÙÈ΋ ‰Ú¿ÛË

Once-daily dosing of aminoglycosides in paediatric infections Paediatric Clinic, General Hospital of Nikea “Aghios Panteleimon”, Piraeus Correspondence: Georgios Tsolas 32, Parnithos Str. 190 13, Saronida, Attica Date of submission: 18-01-2005 Date of approval: 16-02-2006

G. Tsolas, S. Fotia

Abstract: Aminoglycoside antibiotics constitute a first-line treatment for many infections in the paediatric population and are also effective in adults. The traditional dosing interval for children is 8-12 hourly. Studies in adults have reported equivalent efficacy and equal or lower toxicity with once-daily treatment regimens. Despite evidence from many studies in the adult population, this approach is not yet standard practice in most paediatric hospitals. Reasons for lack of acceptance of this strategy for treatment of children include rapid aminoglycoside clearance in children, the unknown duration of postantibiotic effect, safety concerns, and limited clinical and efficacy data. Recent studies in paediatric infections suggest a therapeutic advantage and a decrease in toxicity with once-daily aminoglycoside administration, and the cost saving aspects also make this approach appealing. As with any medical regimen, the decision to use once-daily dosing (ODD) of aminoglycoside agents must take into account the individual patient characteristics in each case and the particular infection to be treated. Further data are needed to clarify the role of ODD in paediatric infections.

Key words: Aminoglycosides, once-daily dosing, nephrotoxicity, ototoxicity, postantibiotic effect.

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∂ÈÛ·ÁˆÁ‹ √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ·ÔÙÂÏÔ‡Ó ·ÓÙÈ‚ÈÔÙÈο ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÏÏÒÓ ÏÔÈÌÒÍÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÔÈ Ôԛ˜ ÔÊ›ÏÔÓÙ·È Û ·ÚÓËÙÈο ηٿ Gram ‚·ÎÙ‹ÚÈ·. ™ÙÔȯ›· ·fi Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Î·È ÌÂÙ··Ó·Ï‡ÛÂȘ Û ÂÓ‹ÏÈΘ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ÂÊ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Â›Ó·È ÙÔ ›‰ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ÂӉ¯Ô̤ӈ˜ ‰Â, Î·È ÏÈÁfiÙÂÚÔ ÓÂÊÚÔÙÔÍÈ΋ (1-16). ™‡Ìʈӷ Ì ̛· ÌÂϤÙË, ÛÙÔ 75% ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ Ô˘ ÂÎÏ‹ıËÛ·Ó Ó· ··ÓÙ‹ÛÔ˘Ó Û ۯÂÙÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ì¤Ûˆ Ù·¯˘‰ÚÔÌ›Ԣ, ¯ÚËÛÈÌÔÔÈ›ÙÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Ì ÌÂÁ¿ÏÔ ÌÂÛԉȿÛÙËÌ· ·Ó¿ÌÂÛ· ÛÙȘ ‰fiÛÂȘ, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÏÔÈÌÒÍÂȘ ÂÓËϛΈÓ. ∞ÓÙ›ıÂÙ·, ÌfiÓÔ ÛÙÔ 23% ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ ·˘ÙÒÓ ¯ÚËÛÈÌÔÔÈ›ÙÔ Ë ›‰È· Ù·ÎÙÈ΋, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ 1-18 ÂÙÒÓ (17). √È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙÒÓ ·Ú¤¯Ô˘Ó ÂӉ›ÍÂȘ ˘¤Ú Ù˘ ·ÛÊ¿ÏÂÈ·˜ Î·È Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÂÊ¿·Í ËÌÂÚ‹ÛÈ·˜ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Û ÛÂÈÚ¤˜ ·È‰È·ÙÚÈÎÒÓ, ·ÎfiÌË ‰Â Î·È ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (18-21). ™Â ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË 23 ÌÂÏÂÙÒÓ, ÔÈ Ôԛ˜ ‰ÈÂÍ‹¯ıËÛ·Ó ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 19992003 Î·È ÂÚÈÂÏ¿Ì‚·Ó·Ó ·È‰È¿ Ì ÔÈΛϘ Gram(-) ÏÔÈÌÒÍÂȘ, Ù· ÔÔ›· ›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ˘fiÛÙڈ̷ ‹ ¤·Û¯·Ó ·fi ηÚΛÓÔ, ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ ‹ ÓÔÛËχÔÓÙ·Ó Û ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÂÊ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Î·È ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ·ÛÊ·Ï‹˜ Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· (22). ™ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜ ÂϤÁ¯ıËÎ·Ó ÙfiÛÔ Ë ÎÏÈÓÈ΋ Î·È ‚·ÎÙËÚÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, fiÛÔ Î·È Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· Î·È ˆÙÔÙÔÍÈÎfiÙËÙ·. ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ·¤‰ˆÛ ÌÂÙ·-·Ó¿Ï˘ÛË ÌÂÏÂÙÒÓ Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÂÊ¿·Í ËÌÂÚ‹ÛÈ·˜ ¯ÔÚ‹ÁËÛ˘ Ù˘ ÁÂÓÙ·ÌÈΛÓ˘, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ (19). ∞Ó¿ÏÔÁ· ‹Ù·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Î·È ¿ÏÏˆÓ ÚfiÛÊ·ÙˆÓ ÌÂÏÂÙÒÓ, ÔÈ Ôԛ˜ η٤‰ÂÈÍ·Ó ÙËÓ ·ÔÙÂÏÂ-

ÛÌ·ÙÈÎfiÙËÙ· Î·È ·ÛÊ¿ÏÂÈ· Ù˘ ÂÊ¿·Í ËÌÂÚ‹ÛÈ·˜ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Û ·È‰È¿ Ì ԢÚÔÏԛ̈ÍË (23,24), ·ÏÏ¿ Î·È Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ·È‰È¿ Ì Ԣ‰ÂÙÂÚÔÂÓ›· Î·È ˘ÚÂÙfi (25), ηıÒ˜ Î·È Û ÙÂÏÂÈfiÌËÓ· ‹ Î·È ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÛË„·ÈÌ›· ‹ ¿ÏϘ ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ (26-28). ∏ ȉ·ÓÈ΋ ‰fiÛË, ÙÔ ÌÂÛԉȿÛÙËÌ· ·Ó¿ÌÂÛ· ÛÙȘ ‰fiÛÂȘ, Ë ·Ú·ÎÔÏÔ‡ıËÛË, Ë ·ÛÊ¿ÏÂÈ· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ¿·Í ËÌÂÚËÛ›ˆ˜ ‰ÔÛÔÏÔÁÈÎÔ‡ Û¯‹Ì·ÙÔ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ¯ÚfiÓÔ Ô˘ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi Â›Ó·È ¿Óˆ ·fi ÙËÓ ÂÏ¿¯ÈÛÙË ·Ó·ÛÙ·ÏÙÈ΋ ˘ÎÓfiÙËÙ· (minimum inhibitory concentration - MIC) ÁÈ· ÙÔÓ Û˘ÁÎÂÎÚÈ̤ÓÔ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi, Â›Ó·È Ù· ·ÚÈ· ˙ËÙ‹Ì·Ù· Ô˘ ··Û¯ÔÏÔ‡Ó Î·È Ù· ÔÔ›· ı· ·Ó·Ï˘ıÔ‡Ó ÛÙË Û˘Ó¤¯ÂÈ·.

º·ÚÌ·ÎÔÏÔÁ›· ∞. ªË¯·ÓÈÛÌfi˜ ‰Ú¿Û˘ √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¤¯Ô˘Ó ‚·ÎÙËÚÈÔÎÙfiÓÔ ‰Ú¿ÛË ¤Ó·ÓÙÈ ÔÏÏÒÓ Gram(-) ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ Pseudomonas aeruginosa. ∞Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ÚˆÙÂ˚ÓÔÛ‡ÓıÂÛË, Û˘Ó‰ÂfiÌÂÓ˜ Ì ÙÔ 30S ‚·ÎÙËÚÈ·Îfi ÚÈ‚fiۈ̷. ∏ ‰Ú¿ÛË ÙÔ˘˜ ·˘Ù‹ ··ÈÙ› ¤Ó·Ó Ô͢ÁÔÓÔÂÍ·ÚÙÒÌÂÓÔ Ì˯·ÓÈÛÌfi ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘˜ ̤۷ ÛÙÔ ‚·ÎÙËÚÈ·Îfi ·ÙÙ·ÚÔ (29). µ. º·ÚÌ·ÎÔÎÈÓËÙÈ΋ - º·ÚÌ·ÎÔ‰˘Ó·ÌÈ΋ ∆· Â›‰· ÙˆÓ ‚-Ï·ÎÙ·ÌÒÓ Ú¤ÂÈ Ó· Â›Ó·È Û˘Ó¯Ҙ ¿Óˆ ·fi ÙËÓ MIC ÁÈ· Ó· ÂÈÙ¢¯ı› Ë Ì¤ÁÈÛÙË ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË. ∞ÓÙ›ıÂÙ·, Ë Ì¤ÁÈÛÙË ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË (15-17). ŸÛÔ ·˘Í¿ÓÂÙ·È Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi, ÙfiÛÔ ·˘Í¿ÓÂÈ Î·È Ë ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË ÙÔ˘. ¶·Ú’ fiÏ· ·˘Ù¿, ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi Û ÔÈ· Û˘ÁΤÓÙÚˆÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ë Ì¤ÁÈÛÙË ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË. ™Â ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜, ̤ÁÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ >5 Ìg/ml ÁÈ· ÙË ÁÂÓÙ·ÌÈΛÓË Î·È ÙËÓ ÙÔÌÚ·Ì˘Î›ÓË Î·È >20 Ìg/ml ÁÈ· ÙËÓ ·ÌÈηۛÓË Â›¯·Ó Û˘Ó‰Âı› Ì ÌÂȈ̤ÓË ıÓËÙfiÙËÙ· ·fi Gram(-) ‚·ÎÙËÚÈ·ÈÌ›· (29). ∂ÈϤÔÓ, ÂÈÙ˘¯‹˜ ·ÓÙÈÌÂÙÒÈÛË Ó¢ÌÔÓ›·˜ ·fi Gram(-) ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ ÂÈÙ‡¯ıËΠ۠·ÛıÂÓ›˜ Ì ̤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË ≥7 Ìg/ml ÁÈ· ÙË ÁÂÓÙ·ÌÈΛÓË Î·È ÙËÓ ÙÔÌÚ·Ì˘Î›ÓË Î·È ≥28 Ìg/ml ÁÈ· ÙËÓ ·ÌÈηۛÓË (30). ™Â ¿ÏÏË ÌÂϤÙË, Ë ÎÏÈÓÈ΋ ›·ÛË Ó¢ÌÔÓ›·˜ ·fi ·ÚÓËÙÈο ηٿ Gram ‚·ÎÙ‹ÚÈ· ›¯Â ۷ʤÛÙÂÚË ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

Pediatr Sept_Oct 06

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°. ∆ÛfiÏ·˜ Î·È Û˘Ó.

ÂÈÙ˘¯›·, fiÙ·Ó Ë Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ÁÂÓÙ·ÌÈΛÓ˘ ‹Ù·Ó >8 Ìg/ml. ∂fiÌÂÓ˜ ÌÂϤÙ˜ η٤‰ÂÈÍ·Ó fiÙÈ Ë ÎÏÈÓÈ΋ ·¿ÓÙËÛË ÛÙË ıÂÚ·›· ÙˆÓ ·Û¯fiÓÙˆÓ ·fi Gram(-) Ïԛ̈ÍË Û˘Ó‰¤ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ÙË Û¯¤ÛË Ù˘ ̤ÁÈÛÙ˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (peak concentration) ÚÔ˜ ÙËÓ ÂÏ¿¯ÈÛÙË ·Ó·ÛÙ·ÏÙÈ΋ ˘ÎÓfiÙËÙ· (MIC) [Cpeak/MIC], ·Ú¿ Ì ÙË Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ÌfiÓÔ (31,32). ŒÙÛÈ, ‰È·ÈÛÙÒıËΠfiÙÈ ıÂÙÈ΋ ÎÏÈÓÈο ·¿ÓÙËÛË ÌÔÚ› Ó· ÂÈÙ¢¯ı› Ì ÌÈ· ·Ó·ÏÔÁ›· Cpeak:MIC, ÌÂٷ͇ 8 ‹ 10:1, Û ÔÛÔÛÙfi 90% ÂÚ›Ô˘ (16,33). £ÂˆÚËÙÈο, Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, Ë ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË ÙÔ˘˜ ÌÔÚ› Ó· ÌÂÁÈÛÙÔÔÈËı›, fiÙ·Ó Ë ·Ú·¿Óˆ ·Ó·ÏÔÁ›· Â›Ó·È ÌÂٷ͇ 8 ‹ 10:1. ∏ ·Ó·ÏÔÁ›·, fï˜, ·˘Ù‹ ‰ÂÓ ÌÔÚ› Ó· ÂÈÙ¢¯ı› Ì ÙÔ Û¯‹Ì· ·˘Ùfi, fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÂÓ·ÓÙ›ÔÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, ÔÈ ÔÔ›ÔÈ Â›Ó·È ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙÔÈ ‹ ·ÓıÂÎÙÈÎÔ› ÛÙÔ Ê¿ÚÌ·ÎÔ, ÂÓÒ ·ÓÙ›ıÂÙ· ı· ÌÔÚÔ‡Û ӷ ÂÈÙ¢¯ı› Ì ÙËÓ ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ÔÏfiÎÏËÚ˘ Ù˘ ‰fiÛ˘ ÙÔ˘ 24ÒÚÔ˘. °. ¶ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· (Adaptive resistance) ¶ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· Â›Ó·È Ë ·Ó·ÛÙÚ¤„ÈÌË, ÌÂȈ̤ÓË ‚·ÎÙËÚȷ΋ ·¿ÓÙËÛË ÛÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ¤ÎıÂÛË ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ ÛÙÔ Ê¿ÚÌ·ÎÔ. √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¤¯Ô˘Ó ‰ÈÊ·ÛÈ΋ ‚·ÎÙËÚÈÔÎÙfiÓÔ ‰Ú¿ÛË. ∏ ·Ú¯È΋ Ê¿ÛË Â›Ó·È Ù·¯Â›· Î·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË, ÂÓÒ Ë ‰Â‡ÙÂÚË Â›Ó·È ‚Ú·‰Â›· Î·È ·ÓÂÍ¿ÚÙËÙË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (34-37). ∏ ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· ·ÊÔÚ¿ ÛÙË ‰Â‡ÙÂÚË ‚Ú·‰Â›· Ê¿ÛË Î·È ÔÊ›ÏÂÙ·È Û ÌÂȈ̤ÓË ÚfiÛÏË„Ë ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·fi ÙÔ ‚·ÎÙËÚÈ·Îfi ·ÙÙ·ÚÔ, ÙÔ ÔÔ›Ô ÙÂÏÈÎÒ˜ ηı›ÛÙ·Ù·È ÌË ‰È·ÂÚ·Ùfi Û fiϘ ÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ (34,35). ∏ ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· ‰È·ÈÛÙÒıËΠ·Ú¯ÈÎÒ˜ Û ÌÂϤÙ˜ in vitro Ì ÛÙÂϤ¯Ë Ù˘ P. aeruginosa (19). ŸÌˆ˜, ÂÌÊ·Ó›ÛÙËÎÂ Î·È in vivo, Û Ԣ‰ÂÙÂÚÔÂÓÈο ÈÓ‰Èο ¯ÔÈÚ›‰È· ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÓÂÙÈÏÌÈΛÓË Û ‰fiÛË 30 mg/kg ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ïԛ̈͢ (35). ™ÙË ÌÂϤÙË ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÙÚÂȘ ÔÌ¿‰Â˜. ™ÙËÓ ÚÒÙË ¯ÔÚËÁ‹ıËΠÌfiÓÔ Ë ·Ú¯È΋ ‰fiÛË, ÛÙË ‰Â‡ÙÂÚË ¿ÏÏË Ì›· ‰fiÛË 20 mg/kg ‰‡Ô ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË, ÂÓÒ ÛÙËÓ ÙÚ›ÙË ÔÌ¿‰· ¯ÔÚËÁ‹ıËÎ·Ó ¿ÏϘ ¤ÓÙ ‰fiÛÂȘ, 20 mg/kg ¤Î·ÛÙË, ·Ó¿ 2 ÒÚ˜. √È ‰‡Ô ÚÒÙ˜ ‰fiÛÂȘ ÓÂÙÈÏÌÈΛÓ˘ ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

Ì›ˆÛ·Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÔÈÎÈÒÓ (colony forming units - CFU), ·ÏÏ¿ ÔÈ ÂfiÌÂÓ˜ ÙÚÂȘ, 4, 6 Î·È 8 ÒÚ˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰fiÛË, ‰ÂÓ Â›¯·Ó ‚·ÎÙËÚÈÔÎÙfiÓÔ ·ÔÙ¤ÏÂÛÌ·. √ ·ÚÈıÌfi˜ ÙˆÓ ·ÔÈÎÈÒÓ ·Ó¿ ÈÓ‰ÈÎfi ¯ÔÈÚ›‰ÈÔ ¿Ú¯ÈÛ ӷ ·˘Í¿ÓÂÙ·È 6 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·Ú’ fiÏÔ Ô˘ Ù· Â›‰¿ ÙÔ˘ ÛÙÔ Ï¿ÛÌ· ‹Ù·Ó ¿Óˆ ·fi ÙËÓ MIC. ∏ ·ÓÙÔ¯‹ ÛÙȘ ÂÈϤÔÓ ‰fiÛÂȘ Ù˘ ÓÂÙÈÏÌÈΛÓ˘ ˘Ô¯ÒÚËÛ 8 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰fiÛË. √ ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ Ù˘ ÓÂÙÈÏÌÈΛÓ˘ ÛÙ· ÈÓ‰Èο ¯ÔÈÚ›‰È· ‹Ù·Ó Û ·˘Ù‹ ÙË ÌÂϤÙË 25 min ‹ Î·È ÌÈÎÚfiÙÂÚÔ˜ (35). ÃÔÚ‹ÁËÛË Ù˘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ οı 4-5 ¯ÚfiÓÔ˘˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÛÙ· ÈÓ‰Èο ¯ÔÈÚ›‰È· ÚÔÛÔÌÔÈ¿˙ÂÈ Ì ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘ οı 8 ÒÚ˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜. ∞˘Ùfi ÚÔ·ÙÂÈ ·fi ÙË ÁÓÒÛË fiÙÈ Ô ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ÂÚ›Ô˘ 1,5-2,5 ÒÚ˜ (38). ÕÚ·, Ë ıˆÚËÙÈο Èı·Ó‹ ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ·fi ÙË ÌÂϤÙË ¿Óˆ ÛÙËÓ ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· ÚÔ·ÙÂÈ ·fi ÙË ÁÓÒÛË fiÙÈ Ë ‰È·Ù‹ÚËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ·ıÂÚ¿ ¿Óˆ ·fi ÙËÓ MIC Ì¿ÏÏÔÓ ‰ÂÓ ÚÔÛ‰›‰ÂÈ ÌÂÁ·Ï‡ÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ŒÓ· ÈηÓfi ‰È¿ÛÙËÌ· ÂχıÂÚÔ Ê·ÚÌ¿ÎÔ˘ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ‹ Ó· ·ÓÙÈÛÙÚ¤„ÂÈ ÙËÓ ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· Î·È Ó· ‚ÂÏÙÈÒÛÂÈ ÙË ‚·ÎÙËÚÈÔÎÙfiÓÔ ‰Ú¿ÛË Ù˘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜. ªÂ ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙ· ·È‰È¿ ÌÔÚ› ÌÂÓ ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ Ó· ˘Ô¯ˆÚÔ‡Ó Î¿Ùˆ ·fi ÙËÓ MIC, ¤¯Ô˘Ó fï˜ Â›Û˘ ·Ú·ÙËÚËı› ›Û˜ ‹ Î·È ·ÓÒÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ·fi ÙËÓ MIC ÁÈ· ÌÂÁ¿Ï· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ∞ÓÙ›ıÂÙ·, Ë ÂÊ¿·Í ËÌÂÚ‹ÛÈ· ‰fiÛË (ODD) ÌÔÚ› Ó· ÂÈÙ‡¯ÂÈ Â˘ÎÔÏfiÙÂÚ· ¤Ó· ÈηÓÔÔÈËÙÈÎfi ‰È¿ÛÙËÌ· ÂχıÂÚÔ Ê·ÚÌ¿ÎÔ˘, ÏfiÁˆ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ÌÂÛԉȷÛÙ‹Ì·ÙÔ˜ ·Ó¿ÌÂÛ· ÛÙȘ ‰È·‰Ô¯ÈΤ˜ ‰fiÛÂȘ. ™˘ÓÂÒ˜, ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ¤¯ÂÈ ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· Ó· ÌÂÈÒÛÂÈ ‹ Ó· ·ÓÙÈÛÙÚ¤„ÂÈ ÙËÓ ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜. ¶·Ú’ fiÏ· ·˘Ù¿, Ë ÚÔÛ·ÚÌÔÛÙÈ΋ ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¤¯ÂÈ ÌÂÏÂÙËı› ÌfiÓÔ in vitro Î·È ÌfiÓÔ Û ˙Ò·. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Â›Ó·È ·Û·Ê¤˜ Â¿Ó ÙÔ Û¯ÂÙÈο ÌÂÁ¿ÏÔ ÂχıÂÚÔ Ê·ÚÌ¿ÎÔ˘ ‰È¿ÛÙËÌ· Ô˘ ·Ú¤¯ÂÈ Ë ODD ÚÔÛʤÚÂÈ ÙÂÏÈο ıÂÚ·¢ÙÈÎfi ÏÂÔÓ¤ÎÙËÌ·. ∆Ô Î·Ï‡ÙÂÚÔ ‰˘Ó·Ùfi ÂχıÂÚÔ Ê·ÚÌ¿ÎÔ˘ ‰È¿ÛÙËÌ· ‰ÂÓ ¤¯ÂÈ ÚÔÛ‰ÈÔÚÈÛÙ›. ∂¿Ó ÍÂÂÚ·ÛÙ› ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ· ηٿ Ôχ, ı· ÌÔÚÔ‡Û ӷ ·˘ÍËı› ÙÔ ‚·ÎÙËÚÈ·Îfi ÊÔÚÙ›Ô Î·È Ó· ÊÙ¿ÛÂÈ ÛÙ·

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·339

339

∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¿·Í ËÌÂÚËÛ›ˆ˜

·Ú¯Èο ÙÔ˘ Â›‰·, ÛÙË Ê¿ÛË ÙÔ˘ ÂÓÔÊı·ÏÌÈÛÌÔ‡ (38). ∂›Ó·È, ¿ÓÙˆ˜, Èı·Ófi fiÙÈ Ë ODD ·˘Í¿ÓÂÈ Î·Ù¿ Ôχ ÙÔ ÂχıÂÚÔ Ê·ÚÌ¿ÎÔ˘ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ì ‰Â‰Ô̤ÓÔ ÙÔÓ ÌÈÎÚfi ¯ÚfiÓÔ ËÌÈ˙ˆ‹˜ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿. ¢. ¶·Ú·ÙÂٷ̤ÓË ·ÓÙÈ‚ÈÔÙÈ΋ ‰Ú¿ÛË (Post antibiotic effect - PAE) ∏ ·Ú·ÙÂٷ̤ÓË ·ÓÙÈ‚ÈÔÙÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· ·ÚÂÌÔ‰›˙Ô˘Ó ÙË ÌÈÎÚԂȷ΋ ·Ó¿Ù˘ÍË, ·ÎfiÌË Î·È ÌÂÙ¿ ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ οو ·fi ÙËÓ ÂÏ¿¯ÈÛÙË ·Ó·ÛÙ·ÏÙÈ΋ Û˘ÁΤÓÙÚˆÛË ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Û٤ϯԘ (39,40). ¶·Ú·ÙËÚ‹ıËΠ۠ÌÂϤÙ˜ Ì ˙Ò·, ÙfiÛÔ in vitro fiÛÔ Î·È in vivo. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Û˘Ì‚·›ÓÂÈ Î·È ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜, ·Ú’ fiÏÔ Ô˘ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› in vivo. ¢È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ô Ù‡Ô˜ ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡, Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È Ë Î·ÙËÁÔÚ›· ÙÔ˘ ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ‡, ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ PAE. √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ PAE ¤Ó·ÓÙÈ ÙˆÓ Gram(-) ‚·ÎÙËÚ›ˆÓ. ™Â Ô˘‰ÂÙÂÚÔÂÓÈο ÈÓ‰Èο ¯ÔÈÚ›‰È·, Ô ¯ÚfiÓÔ˜ Ù˘ PAE ¤Ó·ÓÙÈ ‰È¿ÊÔÚˆÓ Gram(-) ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ‹Ù·Ó 1,4-7,3 ÒÚ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÁÂÓÙ·ÌÈΛÓ˘ Û ‰fiÛË 8 mg/kg (41). ™ÙÂϤ¯Ë Ù˘ Klebsiella pneumoniae ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ PAE ·’ fi,ÙÈ ÛÙÂϤ¯Ë Escherichia coli. ∂ÈϤÔÓ, ·˘ÍË̤Ó˜ ‰fiÛÂȘ ÙÔÌÚ·Ì˘Î›Ó˘ Ô‰‹ÁËÛ·Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ PAE ÁÈ· ÙËÓ P. aeruginosa Î·È ÙËÓ K. pneumoniae ÛÙ· ÈÓ‰Èο ¯ÔÈÚ›‰È· (42). À¿Ú¯Ô˘Ó, fï˜, ÂÏ¿¯ÈÛÙ· Û¯ÂÙÈο ‰Â‰Ô̤ӷ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜. ™Â Ì›· ÌÂϤÙË, ÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË 15 Î·È 30 mg/kg ·ÌÈηۛÓ˘, Ë in vitro PAE ÁÈ· Gram(-) ‚·ÎÙ‹ÚÈ·, Î˘Ì·ÈÓfiÙ·Ó ·fi 1 ¤ˆ˜ 2 ÒÚ˜ (43). ∏ ›‰È· ÌÂϤÙË ¤‰ÂÈÍ ¿ÌÂÛË Û˘Û¯¤ÙÈÛË ·Ó¿ÌÂÛ· ÛÙË Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ÙËÓ PAE.

∆ÔÍÈÎfiÙËÙ· ∞. ¡ÂÊÚÔÙÔÍÈÎfiÙËÙ· ∆Ô ÂӉ¯fiÌÂÓÔ ÂΉ‹ÏˆÛ˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ·ÓËÛ˘¯›·˜, ÙfiÛÔ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ¶·Ú¿ Ù·‡Ù·, ˘¿Ú¯Ô˘Ó Ôχ Ï›Á· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙË Û˘¯ÓfiÙËÙ· Î·È ÙȘ ÎÏÈÓÈΤ˜ Û˘Ó¤ÂȘ ·˘Ù‹˜ Ù˘ ·ÓÂÈı‡ÌËÙ˘ ÂÓ¤ÚÁÂÈ·˜. ∆· ÛÙÔȯ›· Ô˘ ˘¿Ú¯Ô˘Ó ·ÊÔÚÔ‡Ó Î·Ù¿ ‚¿ÛË Û ·È‰È¿ ÛÙ· ÔÔ›· ¯ÔÚËÁÔ‡-

ÓÙ·È ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. ∏ ÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ¿Óˆ ÛÙ· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ·, Ô‰ËÁ› Û ·Ó·ÛÙÚ¤„ÈÌË ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË (√™¡) Î·È ÌÂȈ̤ÓË ÛÂÈÚ·Ì·ÙÈ΋ οı·ÚÛË (GFR) (15,44). ª›· ıˆڛ· fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ Ì˯·ÓÈÛÌfi Ù˘ √™¡ ÂÌϤÎÂÈ Ù· Ï˘ÛÔۈ̿ÙÈ· ̤۷ ÛÙ· ·ÙÙ·Ú· ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ, ÛÙ· ÔÔ›· Ë ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë ·ÔıË·ÂÙ·È ÌÂÙ¿ ÙËÓ Â·Ó·ÚÚfiÊËÛ‹ Ù˘ ÛÙÔ ÂÁÁ‡˜ ÛˆÏËÓ¿ÚÈÔ. ∏ ÙÔÍÈÎfiÙËÙ·, Û‡Ìʈӷ Ì ÙË ıˆڛ· ·˘Ù‹, ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ̤۷ ÛÙÔ Ï˘ÛÔۈ̿ÙÈÔ. ÕÏÏË ıˆڛ· ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ fiÙ·Ó Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ̤۷ ÛÙÔ Ï˘ÛÔۈ̿ÙÈÔ ÊÙ¿ÛÂÈ Û ÔÚÈṲ̂ÓÔ Ô˘‰fi, ÙÔ Ê¿ÚÌ·ÎÔ ·ÂÏ¢ıÂÚÒÓÂÙ·È Î·È ¿ÌÂÛ· ÚÔηÏ› ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë (44,45). ∏ ÚfiÛÏË„Ë ÔÚÈÛÌ¤ÓˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Â›Ó·È ‰È·‰Èηۛ· Ë ÔÔ›· ÎÔÚ¤ÓÓ˘Ù·È (45-47), fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ·, ·Ú·ÙËÚ‹ıËΠ̠ÙËÓ ÚfiÛÏË„Ë Ù˘ ÓÂÙÈÏÌÈΛÓ˘ ‹ Ù˘ ÁÂÓÙ·ÌÈΛÓ˘ ·fi ÙÔÓ ÓÂÊÚÈÎfi ÊÏÔÈfi Û ÈÓ‰Èο ¯ÔÈÚ›‰È·, ÛÙ· ÔÔ›· Ì¿ÏÈÛÙ· Ë Û˘Ó¯‹˜ ¤Á¯˘ÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ Ô‰‹ÁËÛ Û ·‡ÍËÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘˜ Û ۯ¤ÛË Ì ÙËÓ ÂÊ¿·Í ¯ÔÚ‹ÁËÛË (45). ∞ÓÙ›ıÂÙ·, Ë ÚfiÛÏË„Ë Ù˘ ÙÔÌÚ·Ì˘Î›Ó˘ ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ ÛËÌÂ›Ô ÎÔÚÂÛÌÔ‡ ·fi ÙÔÓ ÓÂÊÚÈÎfi ÊÏÔÈfi Î·È ·ÚÈÛÙ¿ ÁÚ·ÌÌÈ΋ Û˘Ó¿ÚÙËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ Ï¿ÛÌ·, fiˆ˜ ·Ú·ÙËÚ‹ıËΠÛÙ· ÈÓ‰Èο ¯ÔÈÚ›‰È· (31). ™ÙÔ˘˜ ·ÓıÚÒÔ˘˜, fï˜, Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ÙÔÌÚ·Ì˘Î›Ó˘ ÛÙÔÓ ÓÂÊÚÈÎfi ÊÏÔÈfi Â›Ó·È ¯·ÌËÏfiÙÂÚË ÌÂÙ¿ ·fi Ì›· ÌfiÓÔ ¤ÓÂÛË ·’ fi,ÙÈ ÌÂÙ¿ ·fi ÔÏÏ·Ϥ˜ ÂÓ¤ÛÂȘ ‹ ÌÂÙ¿ ·fi Û˘Ó¯‹ ¤Á¯˘ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. √È Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ ÁÂÓÙ·ÌÈΛÓ˘, Ù˘ ÓÂÙÈÏÌÈΛÓ˘ ‹ Ù˘ ·ÌÈηۛÓ˘ ÛÙÔÓ ÓÂÊÚÈÎfi ÊÏÔÈfi ‹Ù·Ó ¯·ÌËÏfiÙÂÚ˜ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË Ì›·˜ ÂÊ¿·Í ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘, Û ·ÓÙ›ıÂÛË Ì ÙȘ ÔÏÏ·Ϥ˜ ÂÓ¤ÛÂȘ ‹ ÙË Û˘Ó¯‹ ¤Á¯˘ÛË Ù˘ ›‰È·˜ ÔÛfiÙËÙ·˜ Ê·ÚÌ¿ÎÔ˘ (46,47). ∏ ÓÂÊÚÈ΋ Û˘ÛÛÒÚ¢ÛË Î·È ÙÔÍÈÎfiÙËÙ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÌÔÚ› Ó· ÌÂȈı› Ì ÙËÓ ODD, ÂÊfiÛÔÓ Â¤Ú¯ÂÙ·È ÎÔÚÂÛÌfi˜ ÛÙËÓ ÚfiÛÏË„Ë ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ ·fi ÙÔÓ ÓÂÊÚÈÎfi ÊÏÔÈfi. ÕÌÂÛ· Û˘Ó‰Â‰Â̤ÓË Ì ÙË ÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Â›Ó·È Ë ·˘ÍË̤ÓË ÂÏ¿¯ÈÛÙË (trough) Û˘ÁΤÓÙÚˆÛ‹ ÙÔ˘˜ ÛÙÔÓ ÔÚfi Î·È fi¯È Ë ÙÈÌ‹ Ù˘ ̤ÁÈÛÙ˘ (peak) Û˘ÁΤÓÙÚˆÛ˘ (48). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È Ë ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜, ηıÒ˜ Î·È Ë Ù·˘Ùfi¯ÚÔÓË ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·340

340

°. ∆ÛfiÏ·˜ Î·È Û˘Ó.

¯ÔÚ‹ÁËÛË Î·È ¿ÏÏˆÓ ÓÂÊÚÔÙÔÍÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (48-50). ™Â ÌÂϤÙ˜ Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ODD Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Û ÂÓ‹ÏÈΘ, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ‹ - ÛÙË ¯ÂÈÚfiÙÂÚË ÂÚ›ÙˆÛË - η̛· ‰È·ÊÔÚÔÔ›ËÛË Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ÂΉ‹ÏˆÛË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ (1-3,49,50). µ. øÙÔÙÔÍÈÎfiÙËÙ· ™ËÌ·ÓÙÈ΋ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ·ÔÙÂÏ› Î·È Ë ˆÙÔÙÔÍÈ΋ ÙÔ˘˜ ‰Ú¿ÛË. ∆· ‰Â‰Ô̤ӷ, fï˜, Ô˘ ˘¿Ú¯Ô˘Ó fiÛÔÓ ·ÊÔÚ¿ Î·È Û ·˘Ù‹ ÙËÓ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙËÓ ·È‰È΋ ËÏÈΛ·. ∏ ˆÙÔÙÔÍÈÎfiÙËÙ· ÂÓ‰¤¯ÂÙ·È Ó· ÂΉËψı› ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔÓ Îԯϛ· ‹ ÙËÓ ·›ıÔ˘Û· ÙÔ˘ ˆÙfi˜ (15). √ ·ÎÚÈ‚‹˜ ·ıÔÊ˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜, Ê·›ÓÂÙ·È fï˜, fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÂÎÊ˘ÏÈÛÙÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ¿Óˆ ÛÙ· ÙÚȯÔÊfiÚ· ·ÙÙ·Ú· ÙˆÓ ˘Ô‰Ô¯¤ˆÓ, ÙfiÛÔ ÙÔ˘ Îԯϛ· fiÛÔ Î·È Ù˘ ·›ıÔ˘Û·˜ (51,52). Œ¯Ô˘Ó ÚÔÙ·ı› ‹/Î·È ·Ó·ÁÓˆÚÈÛÙ› ·ÚÎÂÙÔ› ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Ó·È Ë ¿ıÚÔÈÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, Ë ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜, Ë ËÏÈΛ·, Ë ‰ÔÛÔÏÔÁ›·, ηıÒ˜ Î·È Ë Ù·˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË Î·È ¿ÏÏˆÓ ˆÙÔÙÔÍÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (53). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ˘¿Ú¯ÂÈ Û·Ê‹˜ ı¤ÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂÏ¿¯ÈÛÙ˘ Î·È Ì¤ÁÈÛÙ˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ·ÎÔ˘ÛÙÈ΋˜ ‹ ·ÈıÔ˘Û·›·˜ ÙÔÍÈÎfiÙËÙ·˜. ™Â Ì›· ÌÂϤÙË ÂÍÂÙ¿ÛÙËΠÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·Ú·ÁfiÓÙˆÓ Û ۯ¤ÛË Ì ÙËÓ ˆÙÔÙÔÍÈÎfiÙËÙ· ·fi ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ (54). ªÂÙ¿ ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ Û˘ÁÎÂÓÙÚÒıËηÓ, ÌfiÓÔ Ë ÚÔ¯ˆÚË̤ÓË ËÏÈΛ· ·ÍÈÔÏÔÁ‹ıËΠˆ˜ ÛÔ‚·Úfi˜ ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (54).

º·ÚÌ·ÎÔÎÈÓËÙÈ΋ ·Ó¿Ï˘ÛË ™ÙȘ ¤ÍÈ ·fi ÙȘ 13 ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ ¤ÁÈÓ ̤ÙÚËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙÔÓ ÔÚfi, Û˘ÁÎÚ›ıËÎÂ Ë ODD Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· (55-59). ™Â fiϘ ÙȘ ÌÂϤÙ˜, ÔÈ Ì¤ÁÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÌÂÙÚ‹ıËÎ·Ó 30 ÏÂÙ¿ ÌÂÙ¿ ·fi ÙËÓ ¤Á¯˘ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (55-59). Ÿˆ˜ ı· ·Ó·ÌÂÓfiÙ·Ó, ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ODD, ÔÈ ÌÂÓ Ì¤ÁÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜, ÂÓÒ ÔÈ ÂÏ¿¯ÈÛÙ˜ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ˜ ·’ fi,ÙÈ Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì·. ¶·ÚfiÌÔȘ ˘„ËϤ˜ ̤ÁÈÛÙ˜ Î·È ¯·ÌËϤ˜ ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

ÂÏ¿¯ÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ηÙÂÁÚ¿ÊËÛ·Ó ÛÙȘ 7 ÌÂϤÙ˜ Ô˘ ·ÍÈÔÏfiÁËÛ·Ó ÌfiÓÔ ÙÔ ODD ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· (60-67).

∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÛÙ· ·È‰È¿ ™Â 700 ·È‰È¿ Î·È ‚Ú¤ÊË ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙÔ˘ ÂÓfi˜ Ì‹Ó· ÌÂÏÂÙ‹ıËΠ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Ì ÌÂÁ¿Ï· ÌÂÛԉȷÛÙ‹Ì·Ù· ·Ó¿ÌÂÛ· ÛÙȘ ‰È·‰Ô¯ÈΤ˜ ‰fiÛÂȘ (6,11,55-67). √È ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¯ÔÚËÁ‹ıËÎ·Ó Û Ԣ‰ÂÙÂÚÔÂÓÈο ·È‰È¿ Ì ˘ÚÂÙfi, Û ·È‰È¿ Ì ÂȂ‚·ÈˆÌ¤Ó˜ ‹ Èı·Ó¤˜ Gram (-) ÏÔÈÌÒÍÂȘ, ΢ÛÙÈ΋ ›ÓˆÛË, ηıÒ˜ Î·È Û ·ÛıÂÓ›˜ Ì ÂȂ‚·ÈˆÌ¤Ó˜ ‹ Èı·Ó¤˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÏÔÈÌÒÍÂȘ. ∂ÓÓ¤· ÌÂϤÙ˜ ·ÍÈÔÏfiÁËÛ·Ó ÙËÓ ÎÏÈÓÈ΋ ηÈ/‹ ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ODD Û ÂÚ›Ô˘ 450 ·È‰È¿ (5562). ŸÌˆ˜, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÛËÌÂȈı› fiÙÈ ÔÈ ÌÂϤÙ˜ ·˘Ù¤˜ ‰ÂÓ ‹Ù·Ó ·ÚÎÂÙ¿ ÌÂÁ¿Ï˜, ÒÛÙ ӷ ÚÔ·„ÂÈ ·fi ·˘Ù¤˜ οÔÈ· ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿. ∞. ∫ÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ¶¤ÓÙ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÌÂϤÙËÛ·Ó ÙËÓ ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È ¿·Í ËÌÂÚËÛ›ˆ˜, Û ۇÁÎÚÈÛË Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· ÙˆÓ ÔÏÏ·ÏÒÓ ‰fiÛˆÓ. ™ÙȘ ÙÚÂȘ ·fi ·˘Ù¤˜ ÌÂÏÂÙ‹ıËÎÂ Ë ÁÂÓÙ·ÌÈΛÓË Î·È ÛÙȘ ¿ÏϘ ‰‡Ô Ë ÙÔÌÚ·Ì˘Î›ÓË Î·È Ë ·ÌÈηۛÓË, ·ÓÙ›ÛÙÔȯ· (55-59). ∫ÏÈÓÈ΋ ›·ÛË ‰È·ÈÛÙÒıËΠÛÙÔ 88-92% ÙˆÓ ·ÛıÂÓÒÓ Ì ÙËÓ ODD Î·È ÛÙÔ 90-98% ÙˆÓ ·ÛıÂÓÒÓ Ì ÙȘ ÔÏϤ˜ ‰fiÛÂȘ. √È ‰‡Ô ÌÂϤÙ˜ ıÂÒÚËÛ·Ó ˆ˜ ÎÏÈÓÈ΋ ›·ÛË ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ÛËÌ›ˆÓ Î·È Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ Ïԛ̈͢ (55,56). ª›· ÌÂϤÙË fiÚÈÛ ˆ˜ ÎÏÈÓÈ΋ ·ÔÙ˘¯›· ‹ ÂÈÏÔ΋ Ù˘ ·Ú¯È΋˜ ıÂÚ·›·˜ ÙËÓ ·Ó¿ÁÎË ÁÈ· ¿ÏÏË ·ÚÂÓÙÂÚÈ΋ ·ÁˆÁ‹ (55). ÕÏϘ ÌÂϤÙ˜ fiÚÈÛ·Ó ˆ˜ ·ÔÙ˘¯Ë̤ÓË ·ÓÙ·fiÎÚÈÛË ÙËÓ ÂÈÌÔÓ‹ ÙÔ˘ ˘ÚÂÙÔ‡ Î·È Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÌÂÙ¿ ÙËÓ ¤ÌÙË Ë̤ڷ Ù˘ ·ÁˆÁ‹˜ (57,58). ª›· ÔÌ¿‰· ÌÂϤÙ˘ ¯ÚËÛÈÌÔÔ›ËÛ ÙËÓ ¤ÓÓÔÈ· Ù˘ ÎÏÈÓÈ΋˜ ‚ÂÏÙ›ˆÛ˘ ÛÙË Ì¤ıÔ‰fi Ù˘, ·ÓÙ› ·˘Ù‹ Ù˘ ›·Û˘ (59). ™Â Ù¤ÛÛÂÚȘ ·ÎfiÌË ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·ÌÈÁÒ˜ Ë ODD (60-63). ™ÙË Ì›· ·fi ·˘Ù¤˜, 76% ÙˆÓ ÂÌ‡ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ (86/113) ·¿ÓÙËÛ ÛÙËÓ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÚÒÙ˘ ÂÎÏÔÁ‹˜ (ÁÂÓÙ·ÌÈΛÓË Ì ÎÂÊÙÚÈ·ÍfiÓË) Ì ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡ ÌÂÙ¿ ·fi 48 ÒÚ˜ (60). ∆Ô ˘fiÏÔÈÔ 24% ÙˆÓ ·ÛıÂÓÒÓ ¯ÚÂÈ¿ÛÙËÎÂ

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∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¿·Í ËÌÂÚËÛ›ˆ˜

‚·ÓÎÔÌ˘Î›ÓË Î·È ÎÂÊÙ·˙ȉ›ÌË ÏfiÁˆ ÂÈÌÔÓ‹˜ ÙÔ˘ ˘ÚÂÙÔ‡ Ì ‹ ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ·ÓıÂÎÙÈÎÒÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÚÒÙ˘ ÂÎÏÔÁ‹˜ (60). ÕÏϘ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó 90% ÙˆÓ ÂÌ‡ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ (273/303) Ó· ÈÒÓÙ·È ÎÏÈÓÈο, ¯ˆÚ›˜ ·ÏÏ·Á‹ ÛÙËÓ ÂÌÂÈÚÈ΋ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ (61). ∞ÓÙ›ÛÙÔȯ·, ÔÛÔÛÙfi ÎÏÈÓÈ΋˜ ›·Û˘ 100% (25/25) ÂÈÙ‡¯ıËΠ۠·ÛıÂÓ›˜ Ì ÛÔ‚·Ú¤˜ Gram(-) ÏÔÈÌÒÍÂȘ, ÔÈ ÔÔ›ÔÈ Ï¿Ì‚·Ó·Ó ODD ·ÌÈηۛÓË (62). ∆¤ÏÔ˜, Û ¿ÏÏË ÌÂϤÙË, 98% ÙˆÓ ·ÛıÂÓÒÓ ·ÓÙ·ÔÎÚ›ıËΠÈηÓÔÔÈËÙÈο ÛÙËÓ ODD ·ÌÈηۛÓË, ·Ú’ fiÏ· ·˘Ù¿ οÔÈÔÈ ·ÛıÂÓ›˜ ¯ÚÂÈ¿ÛÙËÎ·Ó Û˘ÌÏËڈ̷ÙÈ΋ ·ÓÙÈ‚·ÎÙËÚȷ΋ ·ÁˆÁ‹ (63) (¶›Ó·Î·˜ 1). µ. ªÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ∞fi ÙȘ ÌÂϤÙ˜ Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ODD Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, ÌfiÓÔ Û ‰‡Ô Û˘ÁÎÚ›ıËÎÂ Î·È Ë ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ (55,56). ™ÙË Ì›· ·fi ·˘Ù¤˜, Ë ÔÔ›· ·ÊÔÚÔ‡Û Û ·ÛıÂÓ›˜ Ì Ïԛ̈ÍË ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, Ë ÂÎÚ›˙ˆÛË ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ¤Êı·Û ÛÙÔ 97% (58/60) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Ï¿Ì‚·Ó·Ó ODD ÁÂÓÙ·ÌÈΛÓË Î·È ÛÙÔ 98% (58/59) Û ·˘ÙÔ‡˜ Ô˘ ÙË Ï¿Ì‚·Ó·Ó ÙÚȘ ËÌÂÚËÛ›ˆ˜ (55). √ Û˘¯ÓfiÙÂÚÔ˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi˜ Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó Ë E.

Coli. ∞ÔÌÔÓÒıËηÓ, Â›Û˘, Gram(-) ‚¿ÎÈÏÏÔÈ, ÂÓÙÂÚfiÎÔÎÎÔÈ Î·È Staphylococcus sp. Î·È Staphylococcus epidermidis. À‹ÚÍ·Ó ÙÚÂȘ Èı·Ó¤˜ ÂÚÈÙÒÛÂȘ ·Ó·ÌfiÏ˘ÓÛ˘ Ì Staph. epidermidis, ‰‡Ô Ì ÙÔ ODD Û¯‹Ì· Î·È Ì›· Ì ÙÔ ÎÏ·ÛÈÎfi. ™Â η̛· ·fi ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠ˘Ô˘Ú›· Î·È fiϘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÎÏÈÓÈÎÒ˜ ˆ˜ ÌË ÛËÌ·ÓÙÈΤ˜. √ÌÔ›ˆ˜, Û ¿ÏÏË ÌÂϤÙË, ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ›·ÛË ÂÈÙ‡¯ıËΠÛÙÔ 100% (10/10) Î·È ÛÙÔ 92% (12/13) ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ÁÂÓÙ·ÌÈΛÓË ¿·Í Î·È ÙÚȘ ËÌÂÚËÛ›ˆ˜, ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÛÙÔȯ›· Û¯ÂÙÈο ÌÂ Ù˘¯fiÓ ·Ó·ÌfiÏ˘ÓÛË ‰ÂÓ ·Ó·ÎÔÈÓÒıËÎ·Ó (56). ™Â ¿ÏÏË ÌÂϤÙË, Ì ÂÚÈÛÛfiÙÂÚÔ ÏÂÙÔÌÂÚ‹ ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙË ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, 56 ·ÛıÂÓ›˜ Ì ·ԉ‰ÂÈÁ̤ÓË ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË ¤Ï·‚·Ó ·ÌÈηۛÓË ¿·Í ËÌÂÚËÛ›ˆ˜ ›Ù ·ÔÎÏÂÈÛÙÈο, ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ·ÎfiÌË ·ÓÙÈ‚ÈÔÙÈÎfi (63). ∏ ηÙËÁÔÚÈÔÔ›ËÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·¤‰ˆÛÂ: Ó¢ÌÔÓ›· (16 ·ÛıÂÓ›˜), ¯Ú. ˆÙ›Ùȉ· (7), ÌËÓÈÁÁ›Ùȉ· - ‚·ÎÙËÚÈ·ÈÌ›· - ÛË„·ÈÌ›· (9), ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· (12), ˘ÂÏÔÓÂÊÚ›Ùȉ· (7) Î·È ÂÚÈÙÔÓ›Ùȉ· (5). §ÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ‹Ù·Ó: Pseudomonas sp. (27), Enterobacter sp. (4), E. coli (120), Klebsiella sp. (2), Acinetobacter sp. (8) Î·È H. influenzae (5). √ÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ ÂÌÊ¿ÓÈÛ·Ó

¶›Ó·Î·˜ 1. ∫ÏÈÓÈ΋ Î·È ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ì ÙËÓ ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ ÛÙ· ·È‰È¿ Î·È Û‡ÁÎÚÈÛË Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· º¿ÚÌ·ÎÔ

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ÿ·ÛË: 83/96 (86%)

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (55)

ÿ·ÛË: 86/90 (96%)

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (55)

ÿ·ÛË: 87/89 (98%)

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (56)

ÿ·ÛË: 23/26 (88%)

∂ÎÚ›˙ˆÛË ÙÔ˘ ‚·ÎÙËÚ›Ô˘: 58/60 (97%) ∂ÎÚ›˙ˆÛË ÙÔ˘ ‚·ÎÙËÚ›Ô˘: 58/59 (98%) ÿ·ÛË: 10/10 (100%)

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°ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (56)

ÿ·ÛË: 22/24 (91%)

ÿ·ÛË: 12/13 (92%)

∞ÌÈηۛÓË (63) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (57)

ÿ·ÛË: 46/56 (82%) µÂÏÙ›ˆÛË: 9/56 (16%) ÿ·ÛË: 12/13 (92%)

∂ÎÚ›˙ˆÛË ÙÔ˘ ‚·ÎÙËÚ›Ô˘: 49/55 (89%) ¢ÂÓ ·ÍÈÔÏÔÁ‹ıËÎÂ

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°ÂÓÙ·ÌÈΛÓË (60)

86/113 (76%) ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠ·ÏÏ·Á‹ Ù˘ ·Ú¯È΋˜ ıÂÚ·›·˜ ÿ·ÛË: 25/25 (100%) µÂÏÙ›ˆÛË: 12/12 (100%) µÂÏÙ›ˆÛË: 10/10 (100%)

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∞ÌÈηۛÓË (62) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 24 ÒÚ˜ (59) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 8 ÒÚ˜ (59)

∫·Ó¤Ó·

¶·È‰È·ÙÚÈ΋ 2006;69:336-349

Pediatr Sept_Oct 06

26-09-06

12:53

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342

°. ∆ÛfiÏ·˜ Î·È Û˘Ó.

ÏÔÈÌÒÍÂȘ ·fi ÂÚÈÛÛfiÙÂÚÔ˘˜ ÙÔ˘ ÂÓfi˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ÃÔÚËÁ‹ıËÎ·Ó Ù· ηٿÏÏËÏ· ·ÓÙÈ‚ÈÔÙÈο Ì ¢ڇ Gram(-) Î·È Gram(+) Ê¿ÛÌ·, ÛÙÔ 71% Î·È 21% ÙˆÓ ·ÛıÂÓÒÓ, ·ÓÙ›ÛÙÔȯ·. ∂ÈÙ‡¯ıËÎÂ Ë ÂÎÚ›˙ˆÛË ÙÔ˘ ˘‡ı˘ÓÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ ÛÙÔ 89% (49/55), ÂÓÒ 6 ·ÛıÂÓ›˜ ›¯·Ó ÂÈÌfiÓˆ˜ ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ÌÂÙ¿ ÙË ıÂÚ·›· Î·È ¤Ó·˜ ·ÛıÂÓ‹˜ ‹Ù·Ó ·‰‡Ó·ÙÔ Ó· Â·ÓÂÎÙÈÌËı›. ™Â Ì›· ¿ÏÏË ÌÂϤÙË (62), Ë ‚·ÎÙËÚÈÔÏÔÁÈ΋ ›·ÛË ·fi Ì›· ÔÈÎÈÏ›· Gram(-) ÏÔÈÌÒÍÂˆÓ ¤Êı·Û ÛÙÔ 100% (25/25). √È Î·ÏÏȤÚÁÂȘ ‹Ù·Ó ıÂÙÈΤ˜ ÁÈ· E. coli (18), Klebsiella pneumoniae (4), Enterobacter sp. (1), Providencia sp. (1) Î·È P. aeruginosa (1). ª›· ¿ÏÏË ÔÌ¿‰· ÂÚ¢ÓËÙÒÓ ·Ó¤ÊÂÚ 99 ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ Û 96 (32%) ·fi 303 ÂÌ‡ÚÂÙ· ÂÂÈÛfi‰È· (61). ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÛÙȘ 85 ·fi ÙȘ 99 ·˘Ù¤˜ ηÏÏȤÚÁÂȘ ÂÚfiÎÂÈÙÔ ÂÚ› ·ÈÌÔηÏÏÈÂÚÁÂÈÒÓ (‚·ÎÙËÚÈ·ÈÌ›·). ™ÙÔ 47% (40/85) ÙˆÓ ıÂÙÈÎÒÓ ·ÈÌÔηÏÏÈÂÚÁÂÈÒÓ ·Ó¢ڤıË Staph. epidermidis Î·È ÌfiÓÔ ÛÙÔ 22% (19/85) ·Ó·Ù‡¯ıËÎ·Ó Gram(-) ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›. ∏ ·ÁˆÁ‹ ·¤Ù˘¯Â ÛÙÔ 13,5% (13/96) ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ·, ÂȉÈÎfiÙÂÚ· ‰Â ÛÙÔ 36% Î·È 8% (p<0,001) ÙˆÓ Gram(-) Î·È Gram(+) ÏÔÈÌÒÍÂˆÓ ·ÓÙ›ÛÙÔȯ· (61). ∆¤ÏÔ˜, Û ¿ÏÏË ÌÂϤÙË ·ÔÌÔÓÒıËÎ·Ó Û ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ¤Ó·˜ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Û 29 (25,5%) ·fi Ù· 113 ÂÂÈÛfi‰È· ˘ÚÂÙÔ‡ Û Ԣ‰ÂÙÂÚÔÂÓÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Ë ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ Î·Ù¤ÛÙË ÂÊÈÎÙfi Ó· ÌÂÏÂÙËı› (60) (¶›Ó·Î·˜ 1).

∆ÔÍÈÎfiÙËÙ· ÛÙ· ·È‰È¿ ∞. ¡ÂÊÚÔÙÔÍÈÎfiÙËÙ· À¿Ú¯Ô˘Ó 11 ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ ‰ÈÂÚ¢ӋıËΠÙÔ ı¤Ì· Ù˘ ÓÂÊÚÔÙÔÍÈ΋˜ ‰Ú¿Û˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿, ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È Ì ÙÔ ODD Û¯‹Ì· (55,56,5866). √È ÂÚÈÛÛfiÙÂÚ˜ fiÚÈÛ·Ó ˆ˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙËÓ ÔÛÔÛÙÈ·›· ·‡ÍËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ ¿Óˆ ·fi οÔÈÔ fiÚÈÔ ‹ ÙËÓ ÂηÙÔÛÙÈ·›· Ì›ˆÛË Ù˘ οı·ÚÛ˘ Ù˘ ÎÚ·ÙÈÓ›Ó˘ Û ۯ¤ÛË Ì ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÁÈ· ÙËÓ ËÏÈΛ· οı·ÚÛË. ∂ÈϤÔÓ Ù˘ οı·ÚÛ˘ Ù˘ ÎÚ·ÙÈÓ›Ó˘, ÌÂÙÚ‹ıËÎ·Ó ÙfiÛÔ Ë ÚˆÙÂ˚ÓÔ˘Ú›· Û ԇڷ 24ÒÚÔ˘ fiÛÔ Ë Ï˘ÛÔ˙˘ÌÔ˘Ú›· Î·È ‚2-ÌÈÎÚÔÛÊ·ÈÚÈÓÔ˘Ú›· (59). ™Â Ì›· ÌÂϤÙË ‰ÂÓ ÛËÌÂÈÒıËΠÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȶ·È‰È·ÙÚÈ΋ 2006;69:336-349

‰ÒÓ, ‰ÂÓ ·Ó·Ê¤ÚıËÎ·Ó fï˜ ÔÈ Ì¤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓÂÈı‡ÌËÙ˘ ·˘Ù‹˜ ÂÓ¤ÚÁÂÈ·˜ (63). √È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ηٿ ηÓfiÓ· ‰ÂÓ ÚÔηÏÔ‡Ó ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·, ·Ú¿ ÙËÓ ÂÚ› ÙÔ˘ ·ÓÙÈı¤ÙÔ˘ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Î·È ÙÔ‡ÙÔ Ì¿ÏÈÛÙ· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. ™˘ÓÔÏÈο, Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÂϤÁ¯ıËΠ۠140 (79%) ·fi ÙÔ˘˜ 177 Î·È Û 530 (75%) ·fi ÙÔ˘˜ 707 ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó οÔÈÔ, ÎÏ·ÛÈÎfi ‹ ODD, ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ·ÓÙ›ÛÙÔȯ·. ¢ÂÓ ÛËÌÂÈÒıËΠÓÂÊÚÔÙÔÍÈÎfiÙËÙ· Û η̛· ·fi ÙȘ 140 ÂÚÈÙÒÛÂȘ Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÂÓÒ ‰È·ÈÛÙÒıËΠ۠4 (0,75%) ·fi ÙȘ 530 ÂÚÈÙÒÛÂȘ ÙÔ˘ ODD Û¯‹Ì·ÙÔ˜ (60,62,64). ™Â ¿ÏÏË ÂÚÁ·Û›·, ˆ˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÔÚ›ÛÙËÎÂ Ë ·‡ÍËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ ¿Óˆ ·fi ÙÔ 50% Ù˘ ηıÔÚÈṲ̂Ó˘ ‚·ÛÈ΋˜ ÙÈÌ‹˜ (60). ∏ ̤ÛË Û˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ·Ú¤ÌÂÈÓ ÛÙ·ıÂÚ‹ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÁÂÓÙ·ÌÈΛÓ˘. ¶·Ú’ fiÏ· ·˘Ù¿, ‰‡Ô ÂÂÈÛfi‰È· ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ™Â ·ÌÊfiÙÂÚ· Ù· ·È‰È¿ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÓÔÚÌfiÁÚ·ÌÌ· Hartford (8), ÚÔÎÂÈ̤ÓÔ˘ ÙÔ ÌÂÛԉȿÛÙËÌ· ÙˆÓ ‰fiÛÂˆÓ Ù˘ ÁÂÓÙ·ÌÈΛÓ˘ Ó· ÂÂÎÙ·ı› ÛÙȘ 36 ÒÚ˜. ∏ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡ Â·Ó‹Ïı ÛÙË ‚·ÛÈ΋ ÙÈÌ‹ ̤۷ Û 14 Ë̤Ú˜ ·fi ÙË ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ÛÙ· ‰‡Ô ·È‰È¿ (60). ∂›Û˘, Ì›· ÂÚ›ÙˆÛË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÛËÌÂÈÒıËΠÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ODD ·ÌÈηۛÓ˘ (62). ∏ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ·˘Í‹ıËΠηٿ 93% Û ¤Ó· Ó‹ÈÔ ËÏÈΛ·˜ 15 ÌËÓÒÓ Ì ˘ÂÏÔÓÂÊÚ›Ùȉ· Î·È Ï¢¯·ÈÌ›·, ‰ÂÓ ˘‹ÚÍ fï˜ ‰˘Ó·ÙfiÙËÙ· ÂÚ·ÈÙ¤Úˆ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ¤Î‚·Û˘ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÂÚ›ÙˆÛ˘. ∂›Û˘, ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ‰È·ÈÛÙÒıËΠÙË 14Ë Ë̤ڷ ıÂÚ·›·˜ Ì ODD ·ÌÈηۛÓË, Û ·È‰› Ô˘ fï˜ Ù·˘Ùfi¯ÚÔÓ· Ï¿Ì‚·Ó ΢ÎÏÔÛÔÚ›ÓË. ÀÔ¯ÒÚËÛ Ì ÙË ‰È·ÎÔ‹ Ù˘ ·ÌÈηۛÓ˘ Î·È ÙËÓ ·Ó·ÚÔÛ·ÚÌÔÁ‹ Ù˘ ‰fiÛ˘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ (64) (¶›Ó·Î·˜ 2). µ. øÙÔÙÔÍÈÎfiÙËÙ· ™Â ÔÎÙÒ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·ÎÔÔÏÔÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Ì ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë Î·È Î·ÙfiÈÓ Û ÚÔηıÔÚÈṲ̂ӷ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (55,56,59,60,6366). ™˘ÓÔÏÈο, 57% (171/300) Î·È 56% (83/147) ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ODD Î·È ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ·ÓÙ›ÛÙÔȯ·, ·ÍÈÔÏÔÁ‹ıËηÓ

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·343

343

∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¿·Í ËÌÂÚËÛ›ˆ˜

¶›Ó·Î·˜ 2. ¡ÂÊÚÔÙÔÍÈÎfiÙËÙ· Ì ÙËÓ ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Î·È Û‡ÁÎÚÈÛË Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· º¿ÚÌ·ÎÔ

ª¤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜

∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·/ Û‡ÓÔÏÔ ·ÛıÂÓÒÓ

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (65) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (65) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (61) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 24 ÒÚ˜ (66) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (55) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (55) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (56) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (56) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (63) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (58) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (58) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (60) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (62) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 24 ÒÚ˜ (59)

∂·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘

0/31 0/17 0/155 Û¯‹Ì·Ù· 0/7 0/64 0/52 0/32 0/31 0/56 0/22 0/30 2/113 (1,8%) Û¯‹Ì·Ù· 1/25 (4%) 0/12

∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 8 ÒÚ˜ (55) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (64)

™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ∏ÌÂÚ‹ÛÈ· Û˘ÁΤÓÙÚˆÛË ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ¢ÂÓ ·Ó·Ê¤ÚıËΠ™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ™˘ÁΤÓÙÚˆÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ¡ÂÊÚÈÎÔ› ‰Â›ÎÙ˜ ÛÙȘ Ë̤Ú˜ 1 Î·È 14 ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜

0/10 1/13 (7,7%)

∫¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘

Ì ·ÎÔÔÌÂÙÚÈΤ˜ ‰ÔÎÈ̷ۛ˜. ∆¤ÛÛÂÚȘ ÌÂϤÙ˜ ·Ó¤ÊÂÚ·Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÂÈÛfi‰ÈÔ ˆÙÔÙÔÍÈÎfiÙËÙ·˜, ÌÂ Û˘¯ÓfiÙËÙ· Ë ÔÔ›· Î˘Ì·ÈÓfiÙ·Ó ·fi 8% ¤ˆ˜ 14% (56,60,64,66). ™Â Ì›· ¿ÏÏË, Ë ·ÓÂÈı‡ÌËÙË ·˘Ù‹ ÂÓ¤ÚÁÂÈ· ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËΠˆ˜ ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋ (66), ÂÓÒ ÛÙȘ ¿ÏϘ ÙÚÂȘ ÌÂϤÙ˜ ‰ÂÓ Û¯ÔÏÈ·˙fiÙ·Ó Ë ÎÏÈÓÈ΋ Ù˘ ÛËÌ·Û›· (56,60,64). ∏ Û˘ÓÔÏÈ΋ ˆÙÔÙÔÍÈÎfiÙËÙ· Î·È ÛÙȘ ÔÎÙÒ ÌÂϤÙ˜ ‹Ù·Ó Ù˘ ٿ͈˜ ÙÔ˘ 3,5% (9/254). ∂ȉÈÎfiÙÂÚ·, ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 4,1% (7/171) ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ODD Î·È ÛÙÔ 2,4% (2/83) fiÛˆÓ Ï¿Ì‚·Ó·Ó ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· (p=0,158, Fisher’s exact test) (¶›Ó·Î·˜ 3).

°È·Ù› Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ ÙÔ ÂÊ¿·Í ËÌÂÚ‹ÛÈÔ ‰·ÛÔÏÔÁÈÎfi Û¯‹Ì· (ODD) ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ οı 8 ÒÚ˜. ™Ù· ÓÂÔÁÓ¿ ¯ÔÚËÁÔ‡ÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚ· ÌÂÛԉȷÛÙ‹Ì·Ù· (οı 12 ÒÚ˜), ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (38). ∏ ÚÔÙ›ÌËÛË ÚÔ˜ ÙÔ ÂÊ¿·Í ËÌÂÚ‹ÛÈÔ Û¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ (ODD) Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‚·Û›˙ÂÙ·È ÛÙË Ê·ÚÌ·ÎÔ‰˘Ó·ÌÈ΋ ÙÔ˘˜ Î·È È‰›ˆ˜ Û ‰‡Ô ÛËÌ›·-ÎÏÂȉȿ: ·) ∏ ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Â›Ó·È ·Ó¿ÏÔÁË Ù˘ Û˘ÁΤÓÙÚˆÛ‹˜ ÙÔ˘˜ ÛÙÔÓ ÔÚfi. ∂Ô̤ӈ˜, ˘„ËÏfiÙÂÚ˜ ̤ÁÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ, ÏfiÁˆ ˘„ËÏfiÙÂÚ˘ ‰fiÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ı· ¤¯Ô˘Ó ηχÙÂÚÔ ·ÔÙ¤ÏÂÛÌ·. ªÂ ÙËÓ ODD Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÈÙ¢¯ı› Ë

ÂÈı˘ÌËÙ‹ ·Ó·ÏÔÁ›· Cpeak: MIC=8-10:1, ·ÎfiÌË Î·È ÁÈ· ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ì ˘„ËÏ‹ MIC, οÙÈ Ô˘ ‰ÂÓ ÌÔÚ› Ó· Á›ÓÂÈ Â‡ÎÔÏ· Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. £ÂˆÚËÙÈο, fiˆ˜ ‹‰Ë ÂÈÛËÌ¿ÓıËÎÂ, Ë ÂÊ¿·Í ηıËÌÂÚÈÓ‹ ¯ÔÚ‹ÁËÛË ı· ÌÂÈÒÛÂÈ Î·È ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·Ó¿Ù˘Í˘ ÚÔÛ·ÚÌÔÛÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ (34,35). ‚) £ÂˆÚÂ›Ù·È fiÙÈ Ë ODD Èı·Ófiٷٷ ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜, ηıfiÛÔÓ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ¯·ÌËϤ˜ ‹ Î·È ÌË ·ÓȯÓ‡ÛÈ̘ ÂÏ¿¯ÈÛÙ˜ (trough) Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ¶·Ú’ fiÏ· Ù· ·Ú·¿Óˆ, ·Ú·Ì¤ÓÔ˘Ó ÔÏÏ¿ ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙËÓ ODD ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ‚Ú¤ÊË, Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜.

™˘˙‹ÙËÛË ∏ ‰ËÌÔÛÈÂ˘Ì¤ÓË ‚È‚ÏÈÔÁÚ·Ê›· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÂÊ¿·Í ¯ÔÚ‹ÁËÛ˘ ÔÏfiÎÏËÚ˘ Ù˘ ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ (ODD) ÛÙ· ‚Ú¤ÊË Î·È ÛÙ· ·È‰È¿ ‰ÂÓ Â›Ó·È ÙfiÛÔ ÂÎÙÂÓ‹˜, fiÛÔ ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ. øÛÙfiÛÔ, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚ¢ÓÒÓ Ô˘ ‹‰Ë ˘¿Ú¯Ô˘Ó ÛÙ· ·È‰È¿, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÌÔÈfiÙËÙ˜ Ì ·˘Ù¿ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ŒÙÛÈ, Û ·È‰È·ÙÚÈΤ˜ ÌÂϤÙ˜, fiÔ˘ ÂȯÂÈÚ‹ıËΠۇÁÎÚÈÛË Ù˘ ODD Î·È ÙÔ˘ ÎÏ·ÛÈÎÔ‡ ‰ÔÛÔÏÔÁÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, Ù· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ Î·È ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

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°. ∆ÛfiÏ·˜ Î·È Û˘Ó.

¶›Ó·Î·˜ 3. øÙÔÙÔÍÈÎfiÙËÙ· Ì ÙËÓ ¿·Í ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ Î·È Û‡ÁÎÚÈÛË Ì ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· º¿ÚÌ·ÎÔ

ª¤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ˆÙÔÙÔÍÈÎfiÙËÙ·˜

∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì ˆÙÔÙÔÍÈÎfiÙËÙ·/ Û‡ÓÔÏÔ ·ÛıÂÓÒÓ

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (65) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (65)

∂·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ ∞ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Î·È ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜

0/31 0/31

°ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (65) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 24 ÒÚ˜ (66) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (55) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (55) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (56) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 8 ÒÚ˜ (56) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (63) °ÂÓÙ·ÌÈΛÓË ·Ó¿ 24 ÒÚ˜ (60) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 24 ÒÚ˜ (59) ∆ÔÌÚ·Ì˘Î›ÓË ·Ó¿ 8 ÒÚ˜ (59) ∞ÌÈηۛÓË ·Ó¿ 24 ÒÚ˜ (64)

∞ÎÔÔÌÂÙÚ›· ÚÈÓ Î·È ÛÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜ ∞ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È Ì¤Û· Û 2 Ì‹Ó˜ ·fi ÙËÓ ¤ÍÔ‰Ô ∞ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Î·È Ì¤Û· Û 7 Ë̤Ú˜ ·fi ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜ ∞ÎÔÔÌÂÙÚ›· ÚÈÓ Î·È ÌÂÙ¿ ÙË ıÂÚ·›· ∞ÎÔÔÌÂÙÚ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜ ∞ÎÔfiÁÚ·ÌÌ· ÙȘ Ë̤Ú˜ 1 Î·È 14 Ù˘ ıÂÚ·›·˜ ∞ÎÔÔÌÂÙÚ›· ηٿ ÙËÓ ¤Ó·ÚÍË Î·È Ì¤Û· Û 1 ‚‰ÔÌ¿‰· ·fi ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜

ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ‹Ù·Ó ·ÚfiÌÔÈ·. √È Ì¤ÁÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔÓ ÔÚfi ‹Ù·Ó ηٿ Ôχ ˘„ËÏfiÙÂÚ˜ Ì ÙËÓ ODD ·’ fi,ÙÈ Ì ٷ ÎÏ·ÛÈο Û¯‹Ì·Ù·. ∂›Ó·È ‰‡ÛÎÔÏÔ Ó· ηıÔÚÈÛÙ› Â¿Ó Ë ‚·ÎÙËÚÈÔÎÙfiÓÔ˜ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ‹Ù·Ó ·ÓÒÙÂÚË Ì ÙËÓ ODD, ηıÒ˜ Û η̛· ·fi ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È Ë MIC ÙÔ˘ ˘‡ı˘ÓÔ˘ ÁÈ· ÙË Ïԛ̈ÍË ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡. ™˘ÓÂÒ˜, ‰ÂÓ ÌÔÚ› Ó· ÂÍ·¯ı› Ì ·fiÏ˘ÙË ‚‚·ÈfiÙËÙ· ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ODD ÌÂÁÈÛÙÔÔ›ËÛ ÙËÓ ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÂÊfiÛÔÓ ÚԤ΢„·Ó ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· Î·È Ì ÙȘ ‰‡Ô ıÂÚ·¢ÙÈΤ˜ ÌÂıfi‰Ô˘˜. ¶Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘’ fi„ÈÓ, ÙfiÛÔ Ù· ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó fiÛÔ Î·È ÔÈ ‰È·ÊÔÚÂÙÈÎÔ› ÏËı˘ÛÌÔ› ÙˆÓ ·ÛıÂÓÒÓ, ÚÔÙÔ‡ ÂÊ·ÚÌÔÛÙÔ‡Ó Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÎÚÈÙÈÎÒÓ ÌÂÏÂÙÒÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ∂ÈϤÔÓ, Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ηıÔÚÈÛÙ› Â¿Ó Ë ODD ÚÔÛ¤ÊÂÚ οÔÈÔ fiÊÂÏÔ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Ú·ÁÌ·ÙÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ÔÏÏ¿ ·fi Ù· ·È‰È¿ ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ ¯ÔÚËÁ›ÙÔ Î·È ¤Ó· ÚfiÛıÂÙÔ ·ÓÙÈ‚ÈÔÙÈÎfi Â˘Ú¤Ô˜ Ê¿ÛÌ·ÙÔ˜. ∞fi ÙȘ ÂÓÓ¤· ÌÂϤÙ˜ Ô˘ ·ÍÈÔÏfiÁËÛ·Ó ÙËÓ ÎÏÈÓÈ΋ ‹/Î·È ÙË ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, ÌfiÓÔ ÛÙË Ì›· ‰ÂÓ Û˘Á¯ÔÚËÁ‹ıËÎÂ Î·È ¿ÏÏÔ ·ÓÙÈ‚ÈÔÙÈÎfi. ™Â ·˘Ù‹ ÙË ÌÂϤÙË ÂÚfiÎÂÈÙÔ ÁÈ· ·ÛıÂÓ›˜ Ì ԢÚÔÏԛ̈ÍË ¯ˆÚ›˜ ÂÈÏÔΤ˜, ÔÈ ÔÔ›ÔÈ ¤Ï·¶·È‰È·ÙÚÈ΋ 2006;69:336-349

0/17 1/7 (14%) 0/39 ÌÂÙ¿ ÙË ıÂÚ·›· 0/33 ÌÂÙ¿ ÙË ıÂÚ·›· 2/26 (7,7%) 2/24 (8,3%) 0/25 3/30 (10%) 0/10 0/9 1/10 (10%)

‚·Ó ÌÔÓÔıÂÚ·›· Ì ÁÂÓÙ·ÌÈΛÓË (55). ™ÙȘ ˘fiÏÔÈ˜ ÔÎÙÒ ÌÂϤÙ˜ Û˘Á¯ÔÚËÁÔ‡ÓÙ·Ó ÎÂÊ·ÏÔÛÔÚ›Ó˜, ÂÓÈÎÈÏÏ›ÓË ‹ ηڂ·ÂӤ̘, ηıÒ˜ Î·È ·ÓÙÈ‚ÈÔÙÈο fiˆ˜ Ë ÎÏÈÓ‰·Ì˘Î›ÓË Î·È Ë ÌÂÙÚÔÓȉ·˙fiÏË (56-63). ™ËÌÂÈÒÓÂÙ·È, ˆÛÙfiÛÔ, fiÙÈ Ë Û˘Á¯ÔÚ‹ÁËÛË ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· Û˘ÁÎÂÎÚÈ̤Ó˜ ·È‰È·ÙÚÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏ› Û˘Ó‹ıË Î·È ‰fiÎÈÌË ÎÏÈÓÈ΋ Ú·ÎÙÈ΋. ŒÓ· ÚfiÛıÂÙÔ ÛËÌ·ÓÙÈÎfi Âȯ›ÚËÌ· ˘¤Ú Ù˘ ODD Â›Ó·È fiÙÈ Ë ÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ Â›‰· ÂÏ¿¯ÈÛÙ˘ Û˘ÁΤÓÙÚˆÛ˘ ÛÙÔÓ ÔÚfi, fiˆ˜ Î·È Ì ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ Î·È ÙËÓ ¿ıÚÔÈÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∂Ô̤ӈ˜, ¤Ó· ÌÂÁ¿ÏÔ ÌÂÛԉȿÛÙËÌ· ·Ó¿ÌÂÛ· ÛÙȘ ‰fiÛÂȘ ı· Ô‰ËÁÔ‡Û Û ¯·ÌËÏfiÙÂÚ˜ ¤ˆ˜ ÌË ·ÓȯÓ‡ÛÈ̘ ÂÏ¿¯ÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÓÂÊÚÔÙÔÍÈ΋˜ ÙÔ˘ ‰Ú¿Û˘. ¶¿ÓÙˆ˜, Û fiϘ ÙȘ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙÔ ı¤Ì· Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜, ηӤӷ˜ ·ÛıÂÓ‹˜ Ô˘ Ï¿Ì‚·Ó ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì·, ‰ÂÓ ·ÚÔ˘Û›·Û ‰È·Ù·Ú·¯‹ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∞ÓÙ›ıÂÙ·, Ë ·ÓÂÈı‡ÌËÙË ·˘Ù‹ ÂÓ¤ÚÁÂÈ· ·ÚÔ˘ÛÈ¿ÛÙËΠ۠4 ·ÛıÂÓ›˜ Ô˘ Ï¿Ì‚·Ó·Ó ODD (60,62,64). ™ÙȘ Û˘ÁÎÚÈÙÈΤ˜, fï˜, ÌÂϤÙ˜ ÌÂٷ͇ ODD Î·È ÎÏ·ÛÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ‰ÂÓ ·Ó·Ê¤ÚıËΠηӤӷ ÂÚÈÛÙ·ÙÈÎfi ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∏ ıˆڛ·, ÂÔ̤ӈ˜, fiÙÈ Ë ODD ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ‰ÂÓ ·Ô‰ÂÈÎÓ‡ÂÙ·È ÛÙȘ

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∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¿·Í ËÌÂÚËÛ›ˆ˜

·È‰È·ÙÚÈΤ˜ ÌÂϤÙ˜. ∞˘Ùfi, fï˜, ÂÓ‰¤¯ÂÙ·È ÂÓ Ì¤ÚÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ - Ó· ÔÊ›ÏÂÙ·È Î·È ÛÙËÓ ·˘ÍË̤ÓË Î¿ı·ÚÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. µ·ÛÈÎfi ÌÂÈÔÓ¤ÎÙËÌ· ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ı¤Ì· Ù˘ ˆÙÔÙÔÍÈÎfiÙËÙ·˜, Â›Ó·È Ô ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù¤˜. ∏ Û˘ÓÔÏÈ΋ ˆÙÔÙÔÍÈÎfiÙËÙ· ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 3,5%, ·ÏÏ¿ ÌfiÓÔ ÙÔ 57% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó ODD Î·È ÙÔ 56% fiÛˆÓ ˘Ô‚¿ÏÏÔÓÙ·Ó ÛÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ·ÍÈÔÏÔÁ‹ıËηÓ, ÙfiÛÔ ÛÙËÓ ·Ú¯‹ fiÛÔ Î·È ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ·ÁˆÁ‹˜. øÙÔÙÔÍÈÎfiÙËÙ· ‰È·ÈÛÙÒıËΠÛÙÔ 4,1% ¤Ó·ÓÙÈ 2,4% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ODD Î·È ÎÏ·ÛÈÎfi Û¯‹Ì·, ·ÓÙ›ÛÙÔȯ·, ‰È·ÊÔÚ¿ ÌË ÛËÌ·ÓÙÈ΋ (55,56,59,60,64-66). ÃÚÂÈ¿˙ÔÓÙ·È, ‚‚·›ˆ˜, ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ı› ¤Ó· ·ÛʷϤ˜ Û˘Ì¤Ú·ÛÌ· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË Ù˘ ODD ÛÙÔ ÂӉ¯fiÌÂÓÔ ÂΉ‹ÏˆÛ˘ ˆÙÔÙÔÍÈÎfiÙËÙ·˜. ∞ÍÈÔÛËÌ›ˆÙ· ›ӷÈ, Â›Û˘, Ù· Ê·ÚÌ·ÎÔÔÈÎÔÓÔÌÈο ÔʤÏË ·fi ÙËÓ ODD ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ. ÷ڷÎÙËÚÈÛÙÈο, ·Ó·Ê¤ÚÔÓÙ·È Ë Ì›ˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ ÓÔÛËÏ›·˜ ÏfiÁˆ Ì›ˆÛ˘ ÙˆÓ ˆÚÒÓ ÂÚÁ·Û›·˜ ÙÔ˘ ÚÔÛˆÈÎÔ‡, Ë Ì›ˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙˆÓ ·Ó·ÏÒÛÈÌˆÓ Î·È Ë Ì›ˆÛË ÙˆÓ ÂÍÂÙ¿ÛÂˆÓ ˘ÔÏÔÁÈÛÌÔ‡ ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔÓ ÔÚfi. ªÂ ‚¿ÛË ÙȘ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚÔ˘˜, ˘ÔÏÔÁ›ÛÙËΠ̛ˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ ÓÔÛËÏ›·˜ ·Ó¿ ·ÛıÂÓ‹ ηٿ 66% Ì ÙËÓ ODD (68). ¶ÚfiÎÂÈÙ·È, Â›Û˘, ·Ó·ÌÊÈ‚fiψ˜ ÁÈ· Ì›· ÈÔ Â‡ÎÔÏË Ì¤ıÔ‰Ô ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ Û›ÙÈ. ¢ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· fiÙÈ ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Â›Ó·È ·ÓÙÈ‚ÈÔÙÈο Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ¯ËÌÈ΋ ÛÙ·ıÂÚfiÙËÙ· Î·È Ù·¯Â›· ·ÓÙÈ‚·ÎÙËÚȷ΋ ‰Ú¿ÛË Î·Ù¿ ÙˆÓ ·ÂÚfi‚ÈˆÓ ·ÚÓËÙÈÎÒÓ Î·Ù¿ Gram ‚·ÎÙËÚ›ˆÓ. ∏ Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙËÓ Î·Ù·ÔϤÌËÛË ÙˆÓ ÛÔ‚·ÚÒÓ ÏÔÈÌÒÍÂˆÓ Î·Ù¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ˘‹ÚÍ ·Ó·ÌÊÈÛ‚‹ÙËÙË. ∏ ODD ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Ê·›ÓÂÙ·È fiÙÈ ·ÔÙÂÏ› Ì›· ÈηÓÔÔÈËÙÈ΋ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË, fi¯È fï˜ Î·È ÙË Û˘Ó‹ıË Ú·ÎÙÈ΋ Û ÔÏÏ¿ ÓÔÛÔÎÔÌ›·. ∞Ó·ÛÙ·ÏÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ¤ÏÏÂÈ„Ë ÛÙÔȯ›ˆÓ, ÂȉÈο fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿, Ë ¤ÏÏÂÈ„Ë ÂÓ‰ÂÈÎÙÈ΋˜ ‰ÔÛÔÏÔÁ›·˜ ‹/Î·È ‰ÔÛÔÏÔÁÈÎÒÓ ÓÔÚÌÔÁÚ·ÌÌ¿ÙˆÓ, ηıÒ˜ Î·È Ë ·˘ÍË̤ÓË Î¿ı·ÚÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘. √È ‰fiÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ì¤¯ÚÈ Û‹ÌÂÚ· Î˘Ì·›ÓÔÓÙ·È ·fi 4,5 ¤ˆ˜ 15 mg/kg/24ˆÚÔ ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙË ÁÂÓÙ·ÌÈΛÓË Î·È ÙËÓ ÙÔ-

ÌÚ·Ì˘Î›ÓË Î·È ·fi 15 ¤ˆ˜ 20 mg/kg/24ˆÚÔ ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙËÓ ·ÌÈηۛÓË. ∂›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ Û οÔȘ ÂÚÈÙÒÛÂȘ, ÔÈ ‰fiÛÂȘ ·˘Ù¤˜ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ˜ ·fi fi,ÙÈ ÛÙ· Û˘Ó‹ıË ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù·. ™˘ÓÂÒ˜, ‰ÂÓ ÌÔÚ› Ó· ÚÔ·„ÂÈ Ì›· ·Ô‰ÂÎÙ‹ ‰ÔÛÔÏÔÁ›· ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙËÓ ODD ·fi ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜. ¶·È‰È¿ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηٷ‚ÔÏ›˙Ô˘Ó ÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Ù·¯‡ÙÂÚ· ·’ fi,ÙÈ ÔÈ ÂÓ‹ÏÈΘ. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ÂÓ‰¤¯ÂÙ·È ¤Ó· ·È‰› Ó· Ï·Ì‚¿ÓÂÈ ODD ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë Î·È Ó· ¤¯ÂÈ Â›‰· ÌË ·ÓȯÓ‡ÛÈÌ· ÛÙÔÓ ÔÚfi ÁÈ· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ÌÂÛÔÏ·‚› ·Ó¿ÌÂÛ· ÛÙȘ ‰fiÛÂȘ, Ô˘ ÌÔÚ› Ó· Êı¿ÓÂÈ ÙȘ 12-16 ÒÚ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ Î¿ı·ÚÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·fi ÙÔÓ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ÛıÂÓ‹. ªÔÏÔÓfiÙÈ ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·Ú·ÙÂٷ̤ÓË ·ÓÙÈ‚ÈÔÙÈ΋ ‰Ú¿ÛË, Ë ‰È¿ÚÎÂÈ¿ Ù˘ Û ˙ˆÈο Î·È in vitro ·ÓıÚÒÈÓ· ÚfiÙ˘· Î˘Ì¿ÓıËΠ·fi 1-8 Î·È ·fi 1-2 ÒÚ˜, ·ÓÙ›ÛÙÔȯ· (41,43). ™Â ¤Ó· ÚfiÙ˘Ô, Ì¿ÏÈÛÙ·, Ì ÔÓÙ›ÎÈ·, Ù· ‚·ÎÙ‹ÚÈ· ·Ó·Ù‡¯ıËÎ·Ó ÂÎ Ó¤Ô˘ Î·È ¤Êı·Û·Ó ÛÙ· ·Ú¯Èο ÏÔÈÌÔÁfiÓ· Â›‰·, ÂÚ›Ô˘ 6 ÒÚ˜ ÌÂÙ¿ ·fi Ì›· ÌfiÓÔ ˘„ËÏ‹ ‰fiÛË ÓÂÙÈÏÌÈΛÓ˘, ·Ú¿ ÙËÓ ·ÚÔ˘Û›· ·Ú·ÙÂٷ̤Ó˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ‰Ú¿Û˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (35). ∆Ô ÂÚÒÙËÌ·, ÂÔ̤ӈ˜, Ô˘ ·Ó·Î‡ÙÂÈ Â˘ÏfiÁˆ˜, ÌÂÙ¿ ÙËÓ ÚÔ·Ó·ÊÂÚı›۷ ÂÎ Ó¤Ô˘ ·Ó¿Ù˘ÍË ‚·ÎÙËÚ›ˆÓ, Â›Ó·È Â¿Ó Î·È Î·Ù¿ fiÛÔÓ ÌÂÈÒÓÂÙ·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ fiÙ·Ó Ù· Â›‰¿ ÙÔ˘˜ ηٷÛÙÔ‡Ó ÌË ·ÓȯÓ‡ÛÈÌ· ÁÈ· ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ∞fi Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ - Ô‡Ùˆ˜ ‹ ¿Ïψ˜ ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ - ·È‰È·ÙÚÈÎÒÓ ÌÂÏÂÙÒÓ ‰ÂÓ ÚÔ·ÙÂÈ Î¿ÙÈ Ù¤ÙÔÈÔ ÁÈ· ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë Ì ODD. ŸÌˆ˜, fiˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ Â›Ó·È ·ÛÊ·Ï‹, ηıÒ˜ Û οÔȘ ÂÚÈÙÒÛÂȘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·ÓÂ·ÚΛ˜ ‰fiÛÂȘ fiÙ·Ó Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÁÈÓfiÙ·Ó Ì ÙÔ ÎÏ·ÛÈÎfi ‰È·ÈÚÂ̤ÓÔ Û¯‹Ì·. ∂ÈϤÔÓ, ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Û·Ó›ˆ˜ ¯ÔÚËÁÔ‡ÓÙ·È ˆ˜ ÌÔÓÔıÂÚ·›· Û Èı·Ó‹ ‹ ·ԉ‰ÂÈÁ̤ÓË ‚·ÎÙËÚÈ·ÈÌ›· ·fi Gram(-) ‚·ÎÙ‹ÚÈ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Û˘Ó‰˘¿˙ÔÓÙ·È Î·Ù¿ ηÓfiÓ· Ì ̛· ‚-Ï·ÎÙ¿ÌË. ŒÓ·˜ ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Èı·ÓÒ˜ ÌÂȈ̤Ó˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ fiÙ·Ó Ù· Â›‰· Ù˘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ Â›Ó·È ÌË ·ÓȯÓ‡ÛÈÌ· ÁÈ· ÌÂÁ¿Ï· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·, ı· ‹Ù·Ó Ë ÛÌ›ÎÚ˘ÓÛË ÙˆÓ ÌÂÛԉȷÛÙËÌ¿ÙˆÓ ·Ó¿ÌÂÛ· ÛÙȘ ‰fiÛÂȘ, Û‡Ìʈӷ Ì ÓÔÚÌfiÁÚ·ÌÌ· ·ÚfiÌÔÈÔ Ì ÂΛÓÔ ÙÔ˘ Hartford. ∆Ô ‰È¿ÛÙËÌ· ÁÈ· ÙÔ ÔÔ›Ô ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

Pediatr Sept_Oct 06

26-09-06

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°. ∆ÛfiÏ·˜ Î·È Û˘Ó.

ÌÔÚ› Ó· Ì›ÓÔ˘Ó Ù· Â›‰· οو ·fi ÙÔ ·ÓȯÓ‡ÛÈÌÔ fiÚÈÔ ÚÔÙÔ‡ ¯ÚÂÈ·ÛÙ› Ó· Á›ÓÂÈ ·ÏÏ·Á‹ ÛÙÔ ÌÂÛԉȿÛÙËÌ· ÙˆÓ ‰fiÛˆÓ, Â›Ó·È ¿ÁÓˆÛÙÔ Î·È Ú¤ÂÈ Ó· ηıÔÚÈÛÙ› ÚÈÓ ÙÔÓ Û¯Â‰È·ÛÌfi ÙÔ˘ ÓÔÚÌÔÁÚ¿ÌÌ·ÙÔ˜. ÕÏÏË ÂÈÏÔÁ‹ ı· ‹Ù·Ó Ë Â·Ó·ÊÔÚ¿ ÛÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. ∞˘Ùfi ı· ‹Ù·Ó ÏÔÁÈÎfi ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ù· Â›‰· ·Ú¤ÌÂÓ·Ó ÌË ·ÓȯÓ‡ÛÈÌ· Â› Ì·ÎÚfiÓ ‹ fiÙ·Ó ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·Ó ÛÙÔ Ê¿ÚÌ·ÎÔ. ŸÌˆ˜, Ë ·ÏÏ·Á‹ ·˘Ù‹ ı· ‰˘Û¯¤Ú·ÈÓ ÙËÓ Î·Ù¿ÎÙËÛË ÙÔ˘ ηχÙÂÚÔ˘ Cpeak: MIC ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ ̤ÙÚÈ·˜ ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÌÔÏÔÓfiÙÈ Ù· ÛÙÔȯ›· ÁÈ· ÙËÓ ODD ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙ· ·È‰È¿ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, Ù· ÂÚÈÛÛfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ϤÔÓ ÚÔÛÊ¿ÙˆÓ ÌÂÏÂÙÒÓ ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ Â›Ó·È ÙfiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ·ÛÊ·Ï‹˜ fiÛÔ Î·È ÙÔ ÎÏ·ÛÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ·ÎfiÌË Î·È Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· (69-73). ŸÌˆ˜, Â›Ó·È ··Ú·›ÙËÙ· ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›·, ȉȷ›ÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÌÂıfi‰Ô˘. √È Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˘ ÂÌ‚¤ÏÂÈ·˜, ηıÒ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ÌÈÎÚfi ‰Â›ÁÌ· ·ÛıÂÓÒÓ, Ì ‰fiÛÂȘ ÌÈÎÚfiÙÂÚ˜ ·fi ÙȘ Û˘Ó‹ıˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜, ÂÓÒ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·ÎÔÔÏÔÁÈÎfi Î·È ·ÈıÔ˘Û·›Ô ¤ÏÂÁ¯Ô ηٿ ÙËÓ ¤Ó·ÚÍË Î·È ÌÂÙ¿ ÙË Ï‹ÍË Ù˘ ıÂÚ·›·˜. ∂›Û˘, ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ Ì ·ԉ‰ÂÈÁ̤ÓË Gram(-) ‚·ÎÙËÚÈ·ÈÌ›·. ∏ ÂÊ¿·Í ËÌÂÚ‹ÛÈ· ‰fiÛË ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Ë˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È Î·Ù¿ÏÏËÏË ˆ˜ ÌÔÓÔıÂÚ·›· ÁÈ· ÙȘ ÌË ÂÈÏÂÁ̤Ó˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ·ÏÏ¿ Î·È ˆ˜ ıÂÚ·›· ‹ ÚÔʇϷÍË ·fi ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÏÔÈÌÒÍÂȘ. ∂ÈϤÔÓ, Ë ODD Ê·›ÓÂÙ·È Î·Ù¿ÏÏËÏË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ·ÓÙÈ„Â˘‰ÔÌÔÓ·‰ÈÎfi ·ÓÙÈ‚ÈÔÙÈÎfi, ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ô˘‰ÂÙÂÚÔÂÓÈÎÒÓ ·ÛıÂÓÒÓ Ì ˘ÚÂÙfi. ªÂ ‰Â‰Ô̤ÓË ÙË ¯Ú‹ÛË ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì οÔÈÔ ¿ÏÏÔ ·ÓÙÈ‚ÈÔÙÈÎfi ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Gram(-) ‚·ÎÙËÚÈ·ÈÌ›·˜, Ë ODD ı· ÌÔÚÔ‡Û ӷ Â›Ó·È Ì›· ·Ô‰ÂÎÙ‹ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ÁÈ· Ù· ·È‰È¿ ·˘Ù¿. ¶·Ú¿ Ù·‡Ù·, Ú¤ÂÈ Ó· ‰ÈÂÍ·¯ıÔ‡Ó ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ‚·ÎÙËÚÈ·ÈÌ›· ·fi Gram(-) ÛË„·ÈÌ›· ηÈ/‹ ÛËÙÈÎfi shock, ÒÛÙ ӷ ÌÔÚ› Ó· ÚÔÙ·ı› Ë ODD Ì ·ÛÊ¿ÏÂÈ·. ∏ ODD, Â›Û˘, Ê·›ÓÂÙ·È Î·Ù¿ÏÏËÏË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ¿ÏÏÔ ·ÓÙÈ„Â˘‰ÔÌÔÓ·‰ÈÎfi, ÁÈ· Ù· ·È‰È¿ Ì ΢ÛÙÈ΋ ›Óˆ¶·È‰È·ÙÚÈ΋ 2006;69:336-349

ÛË, ÛÙ· ÔÔ›· fï˜, ›Ûˆ˜ ··ÈÙËıÔ‡Ó ÌÂÁ·Ï‡ÙÂÚ˜ ‰fiÛÂȘ. ∏ ODD ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ·È‰È¿ Ô˘ ¤¯Ô˘Ó ˘ÔÛÙ› ÂÁη‡Ì·Ù·, ·ÊÂÓfi˜ ÂÂȉ‹ Ë Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜, ·ÊÂÙ¤ÚÔ˘ ÂÂȉ‹ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÍÈfiÈÛÙ· ÛÙÔȯ›· Ô˘ Ó· ÛÙËÚ›˙Ô˘Ó ÙÔÓ ÙÚfiÔ ·˘Ùfi ¯ÔÚ‹ÁËÛ˘ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ·È‰È¿ Ì ‰È·Ù·Ú·Á̤ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ªÂ ‚¿ÛË ÙȘ ‰ÔÛÔÏÔÁ›Â˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙȘ ˘¿Ú¯Ô˘Û˜ ÌÂϤÙ˜ Î·È ÙËÓ ›ڷ ÙˆÓ Û˘ÁÁڷʤˆÓ ¿Óˆ ÛÙȘ Ê·ÚÌ·ÎÔÎÈÓËÙÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡, Û˘ÓÈÛÙ¿Ù·È ˆ˜ ·Ú¯È΋ ıÂÚ·›· Ë ¯ÔÚ‹ÁËÛË ÁÂÓÙ·ÌÈΛÓ˘ ‹ ÙÔÌÚ·Ì˘Î›Ó˘ Û ‰fiÛË 7-8 mg/kg/24/ˆÚÔ, ÂÎÙfi˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î˘ÛÙÈ΋˜ ›ÓˆÛ˘. ªÂ ÙË ‰ÔÛÔÏÔÁ›· ·˘Ù‹ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ı· ÚÔ·„ÂÈ Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ٿ͈˜ ÙˆÓ 20 Ìg/ml Î·È ÂÏ¿¯ÈÛÙË Î¿Ùˆ ÙÔ˘ 1 Ìg/ml. ∂ÈϤ¯ıËΠˆ˜ Û˘ÁΤÓÙÚˆÛË-ÛÙfi¯Ô˜ ·˘Ù‹ ÙˆÓ 20 Ìg/ml, ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ·Ó·ÏÔÁ›· Cpeak: MIC=10:1 ÁÈ· ¤Ó·Ó ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi Ì MIC 2 Ìg/ml ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙË ÁÂÓÙ·ÌÈΛÓË ‹ ÙËÓ ÙÔÌÚ·Ì˘Î›ÓË. ∞ÓÙ›ÛÙÔÈ¯Ë Û‡ÛÙ·ÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰ÔÛÔÏÔÁ›· Ù˘ ·ÌÈηۛÓ˘ ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹ ·˘Ù‹ ÙËÓ ÒÚ·. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË Î·Ù¿ÏÏËÏ· ÁÈ· ·È‰È¿ ÓÔÚÌÔÁÚ¿ÌÌ·Ù·, ÂÈ‚¿ÏÏÂÙ·È Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi. ¶ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ODD Î·È ¤¯Ô˘Ó ÚÔÛ‰ÔÎÒÌÂÓÔ ¯ÚfiÓÔ ıÂÚ·›·˜ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 72 ˆÚÒÓ, Ú¤ÂÈ Ó· ÌÂÙÚÒÓÙ·È Ù· Â›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÚÈÓ ·fi ÙË ‰Â‡ÙÂÚË ‰fiÛË, ÒÛÙ ӷ ÂȂ‚·Èˆı› fiÙÈ Ë ÂÏ¿¯ÈÛÙË Û˘ÁΤÓÙÚˆÛË Â›Ó·È ÌÈÎÚfiÙÂÚË ÙÔ˘ 1 Ìg/ml. ∂¿Ó Ô ÚÔÛ‰ÔÎÒÌÂÓÔ˜ ¯ÚfiÓÔ˜ ıÂÚ·›·˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi 72 ÒÚ˜, ˘¿Ú¯Ô˘Ó ‰‡Ô ÂÈÏÔÁ¤˜: ›Ù ӷ ÌÂÙÚËıÔ‡Ó Ù· Â›‰· ÚÈÓ ·fi ÙË ‰Â‡ÙÂÚË ‰fiÛË, ·ÏÏ¿ Î·È 30 min ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ¤Á¯˘Û˘ ·˘Ù‹˜, ÒÛÙ ӷ ÂȂ‚·Èˆı› Ë ·Ó·ÏÔÁ›· Cpeak: MIC=8-10:1, ›Ù ӷ ÌÂÙÚËıÔ‡Ó Ù· Â›‰· 30 min ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Ù˘ ÚÒÙ˘ ‰fiÛ˘ (peak concentration), ÒÛÙ ӷ ÂȂ‚·Èˆı› Ë Î·Ù·ÏÏËÏfiÙËÙ¿ Ù˘. ¶Ú¤ÂÈ Û ·˘Ù‹ ÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË Ó· ÌÂÙÚËı› Î·È Ì›· ÂӉȿÌÂÛË Û˘ÁΤÓÙÚˆÛË 8-10 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ı› Ì›· ÂÏ¿¯ÈÛÙË Û˘ÁΤÓÙÚˆÛË. ŸÛÔÓ ·ÊÔÚ¿ Û ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ ÛÙȘ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· Î·È ¿Ú· ηıfiÏÔ˘ ÛÙÔȯ›· Û ۯ¤ÛË Ì ÙËÓ MIC, Ë Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË Ú¤ÂÈ Ó·

Pediatr Sept_Oct 06

26-09-06

12:53

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∞ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ¿·Í ËÌÂÚËÛ›ˆ˜

‰È·ÙËÚÂ›Ù·È ÌÂٷ͇ 16 Î·È 20 Ìg/ml. ∏ ·ÛÊ¿ÏÂÈ· Ù˘ ıÂÚ·›·˜ Ì ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÂÓ¿, fiÔÈÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Î·È Â¿Ó ÂÈÏÂÁ›. ∏ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡ Ú¤ÂÈ Ó· ÌÂÙÚ¿Ù·È Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Î·È Û˘¯Ó¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Èı·Ó‹˜ ÂΉ‹ÏˆÛ˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∂ÈϤÔÓ, Ô fiÁÎÔ˜ ÙˆÓ Ô‡ÚˆÓ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Î·ıËÌÂÚÈÓ¿, ηıÒ˜ ·ÔÙÂÏ› ηÏfi ÎÏÈÓÈÎfi ‰Â›ÎÙË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∞ÍÈÔÏÔÁÂ›Ù·È Ë ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÛÙËÓ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡ ‹ Ë Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ô‡ÚˆÓ, ÔfiÙ ı· Ú¤ÂÈ Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ Ó· ÛÎÂÊÙ› Ó· ·ÏÏ¿ÍÂÈ ÙË ‰fiÛË Î·È/‹ ÙÔ ÌÂÛԉȿÛÙËÌ· ‹ Ó· ÌÂÙÚ‹ÛÂÈ ÂÎ Ó¤Ô˘ ÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ·ÎÔÔÌÂÙÚÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ÙÔ Î·Ï‡ÙÂÚÔ ı· ‹Ù·Ó Ó· ›¯·Ó ÔÏÔÎÏËÚˆı› ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È Ó· Â·Ó·Ï·Ì‚¿ÓÔÓÙ·Ó Î¿ÔÈ· ÛÙÈÁÌ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘Ù‹˜. ŸÌˆ˜, ·˘Ùfi ‰ÂÓ Â›Ó·È ¿ÓÙ· ÂÊÈÎÙfi ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋, Â¿Ó Ì¿ÏÈÛÙ· ˘ÔÏÔÁ›ÛÂÈ Î·Ó›˜ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ¯Ú‹Û˘ ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∞·Ú·›ÙËÙÔ˜ Â›Ó·È Ô Û˘¯Ófi˜ ¤ÏÂÁ¯Ô˜, ÙfiÛÔ ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ÂΉ‹ÏˆÛ˘ ˆÙÔÙÔÍÈÎfiÙËÙ·˜ fiÛÔ Î·È ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÛÙ· ·È‰È¿ Ì ΢ÛÙÈ΋ ›ÓˆÛË, ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ Û¯ËÌ¿ÙˆÓ Ì ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, Ù· ÔÔ›· Â›Ó·È ˘Ô¯Úˆ̤ӷ Ó· Ï·Ì‚¿ÓÔ˘Ó. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ··ÓÙËıÔ‡Ó Ù· ¤ˆ˜ Û‹ÌÂÚ· ·Ó·¿ÓÙËÙ·, ·ÏÏ¿ Î·È ÛËÌ·ÓÙÈο ·fi ÎÏÈÓÈ΋˜ ¿Ԅ˘ ÂÚˆÙ‹Ì·Ù·, ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙË ‰ÔÛÔÏÔÁ›· ÙˆÓ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ, ÔÈ Ôԛ˜ ı· Â›Ó·È ÂÈÎÂÓÙڈ̤Ó˜ ÙfiÛÔ ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Ù˘ ·ÛÊ¿ÏÂÈ¿˜ ÙÔ˘˜, fiÛÔ Î·È ÛÙËÓ ·Ó¿Ù˘ÍË Û¯ÂÙÈÎÒÓ ÓÔÚÌÔÁÚ·ÌÌ¿ÙˆÓ.

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¢È¿ÁÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË: Ú·ÎÙÈ΋ ÚÔÛ¤ÁÁÈÛË Dept. of Paediatrics, University of Cambridge & ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, °¡ ª·ÈÂ˘Ù‹ÚÈÔ “∂. µÂÓÈ˙¤ÏÔ˘” AÏÏËÏÔÁÚ·Ê›·: ¶fiË ™ËÊÈ·ÓÔ‡, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, °¡ ª·ÈÂ˘Ù‹ÚÈÔ “∂. µÂÓÈ˙¤ÏÔ˘”, ¶Ï. ∂. µÂÓÈ˙¤ÏÔ˘ 2, 11521 ∞ı‹Ó· ∂-mail: posifi@ntlworld.com ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 02-09-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-06-2006

¶. ™ËÊÈ·ÓÔ‡

¶ÂÚ›ÏË„Ë √ fiÚÔ˜ ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ‹ ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ (IUGR, intrauterine growth restriction) ·Ó·Ê¤ÚÂÙ·È ÛÙÔ ¤Ì‚Ú˘Ô ‹ ÙÔ ÓÂÔÁÓfi Ë ·‡ÍËÛË ÙÔ˘ ÔÔ›Ô˘ ·ÔÎÏ›ÓÂÈ ·fi ·˘Ù‹Ó Ô˘ ı· ›¯Â ‚¿ÛÂÈ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ‰˘Ó·ÌÈÎÔ‡ ÙÔ˘. ∏ ‰È¿ÁÓˆÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÏfiÁˆ Ù˘ ‰˘ÛÌÂÓ¤ÛÙÂÚ˘ ¤Î‚·Û˘ ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Û ۇÁÎÚÈÛË Ì ٷ ÓÂÔÁÓ¿ Ô˘ ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘ ÂÓ‰ÔÌËÙÚ›ˆ˜, ·ÏÏ¿ Î·È Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ÓÔÛËÚfiÙËÙ·˜ Ô˘ ÂӉ¯Ô̤ӈ˜ ¤¯Ô˘Ó ÌÂÙ¿ ÙËÓ ÂÓËÏÈΛˆÛË, ‚¿ÛÂÈ ÂÚ¢ÓËÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÓÙ·ÂÙ›·˜. ™‹ÌÂÚ·, Ë ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ‚·Û›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, Î·È IUGR ÓÂÔÁÓ¿ ıˆÚÔ‡ÓÙ·È ·˘Ù¿ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ÔÔ›ˆÓ ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi Û˘ÁÎÂÎÚÈ̤ÓË ÂηÙÔÛÙÈ·›· ı¤ÛË ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ‹ οو ·fi 2500 g ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. øÛÙfiÛÔ ·˘Ù‹ Â›Ó·È Ë ‰È¿ÁÓˆÛË ÙˆÓ ÌÈÎÚÒÓ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ÓÂÔÁÓÒÓ (SGA, small for gestational age), ÓÂÔÁÓ¿ Ù· ÔÔ›· ‰ÂÓ Â›Ó·È Î·Ù’ ·Ó¿ÁÎËÓ IUGR, ÂÓÒ ÂÈϤÔÓ Ù· IUGR ÓÂÔÁÓ¿ ‰ÂÓ Â›Ó·È Î·Ù’ ·Ó¿ÁÎËÓ SGA. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi ·Ó·Ù‡ÛÛÔÓÙ·È ÔÈ ‰È·ı¤ÛÈ̘ ̤ıÔ‰ÔÈ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ™Â ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Ô ÂÓÙÔÈÛÌfi˜ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ˘ÔıÚ„›·˜, Ë ¯Ú‹ÛË ·ÓıÚˆÔÌÂÙÚÈÎÒÓ ‰ÂÈÎÙÒÓ Î·È ÙÔ ÚÔÁÂÓÓËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ∂Âȉ‹ ηÌÈ¿ ·fi ÙȘ ÌÂıfi‰Ô˘˜ ·˘Ù¤˜ ‰ÂÓ ¤¯ÂÈ Â·Ú΋ ‰È·ÁÓˆÛÙÈ΋ ÈÛ¯‡, ÂÓÒ Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ ‰ÂÓ ˘¿Ú¯ÂÈ ‰È·ı¤ÛÈÌË ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÌÂϤÙË, ÛÎfiÈÌÔ Â›Ó·È Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘Ó‰˘·ÛÌÔ› ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ̤ÁÈÛÙ˘ ‰˘Ó·Ù‹˜ ‰È·ÁÓˆÛÙÈ΋˜ ·ÎÚ›‚ÂÈ·˜. §¤ÍÂȘ ÎÏÂȉȿ: ∞ÓıÚˆÔÌÂÙÚ›·, ˘ÛÙ¤ÚËÛË ·‡ÍËÛ˘, ‰È¿ÁÓˆÛË, ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›·, ÓÂÔÁÓfi.

Diagnosis of in utero growth restricted neonates Dept. of Paediatrics, University of Cambridge & Dept. of Neonatology, General and Maternity Hospital “Elena Venizelou” Correspondence: Dr. Popi Sifianou Dept. of Neonatology, General and Maternity Hospital “Elena Venizelou”, Elenas Venizelou 2, 115 21 Athens, GR ∂-mail: posifi@ntlworld.com Date of submission: 02-09-2005 Date of approval: 28-06-2006

P. Sifianou

Abstract: Intrauterine growth restriction (IUGR) denotes a fetus that has not reached its genetic growth potential at a given gestational age (GA). Diagnosis of IUGR babies is of paramount importance given their worse early postnatal outcome than that of well-grown babies and the possible long-term consequences of in-utero malnutrition. The identification of IUGR babies is usually based on cut-offs of birth weight for GA, that is, on the criteria for small for gestational age (SGA) babies. However, IUGR babies cannot all be identified in this way since they may not necessarily be SGA and SGA babies are not necessarily IUGR. In this paper, the tools available for the identification of term IUGR babies are presented and discussed and the distinction between IUGR and SGA babies is exemplified. These tools include clinical assessment of nutritional status by means of a relevant scoring system, anthropometric indicators of proportionality, mainly the ponderal index and the mid-upper-arm to head circumference ratio and sonographic evaluation of fetal growth patterns in at least two consecutive measurements.

Each of these diagnostic tools is associated with certain limitations, but if used in combination the strengths of the one tool can outweigh the deficiencies of the other. Following this path the diagnosis of in-utero growth restriction can be made with considerable accuracy even in cases where information concerning fetal growth is lacking.

Key words: Anthropometry, diagnosis, intrauterine growth restriction, newborn, small for gestational age.

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™˘ÓÙÔÌÔÁڷʛ˜ AGA µ° IGF I IUGR PI ¶ªµ ¶∫ SGA

appropriate for gestational age ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ insulin-like growth factor I intrauterine growth restriction ponderal index ÂÚ›ÌÂÙÚÔ˜ Ù˘ ÌÂÛfiÙËÙ·˜ ÙÔ˘ ‚Ú·¯›ÔÓ· ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ small for gestational age

∂ÈÛ·ÁˆÁ‹ √ fiÚÔ˜ ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ‹ ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ (intrauterine growth restriction) ˘Ô‰ËÏÒÓÂÈ ÙËÓ ÂÈ‚Ú¿‰˘ÓÛË ÙˆÓ Ú˘ıÌÒÓ ·‡ÍËÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·fiÎÏÈÛ‹ ÙÔ˘ ·fi ÙȘ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ Ô˘ ı· ·ÎÔÏÔ˘ıÔ‡Û ‚¿ÛÂÈ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ‰˘Ó·ÌÈÎÔ‡ ÙÔ˘. ∫‡ÚÈ· ·ÈÙ›· Â›Ó·È Ë ÌÂȈ̤ÓË ÙÚÔÊÔ‰ÔÛ›· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi ÙË ÌËÙÚÔÏ·ÎÔ˘ÓÙȷ΋ ÌÔÓ¿‰·, ÂÓÒ ÂÓ‰ÔÁÂÓ‹ ·›ÙÈ· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ¢ı‡ÓÔÓÙ·È Û Ôχ ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi. øÛÙfiÛÔ, Â› ·ÚÎÂÙ¤˜ ‰ÂηÂٛ˜ Î·È ¤ˆ˜ Û‹ÌÂÚ·, ÂÈÎÚ·Ù› Û‡Á¯˘ÛË ·Ó·ÊÔÚÈο Ì ÙÔ˘˜ fiÚÔ˘˜ Î·È ÙÔ˘˜ ÔÚÈÛÌÔ‡˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÂÚÈÁÚ·Ê‹ Î·È ÙË ‰È¿ÁÓˆÛË ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ. IUGR ÓÂÔÁÓ¿ ıˆÚÔ‡ÓÙ·È ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÁÈ· ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜ Î·È ÂȉÈÎfiÙÂÚ· ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ οو ·fi ÙË 10Ë, ÙËÓ 5Ë ‹ ÙËÓ 3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ‹ ‰‡Ô ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ οو ·fi ÙË Ì¤ÛË ÙÈÌ‹ ‚¿ÚÔ˘˜ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ‹ Ù¤ÏÔ˜ Ì µ° οو ·fi 2500 g fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ∞˘Ùfi˜ Ô ÔÚÈÛÌfi˜, fï˜, Â›Ó·È Ô ÔÚÈÛÌfi˜ ÙˆÓ ÌÈÎÚÒÓ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ÓÂÔÁÓÒÓ, ÙˆÓ small for gestational age, fiˆ˜ ¤¯ÂÈ ÂÈÎÚ·Ù‹ÛÂÈ Ó· ÔÓÔÌ¿˙ÔÓÙ·È ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ‹ ÙˆÓ small-for-dates, fiˆ˜ ÔÓÔÌ¿˙ÔÓÙ·Ó ·ÏÈfiÙÂÚ·. ∂Ô̤ӈ˜, ‚¿ÛÂÈ ·˘ÙÔ‡ ÙÔ˘ ÔÚÈÛÌÔ‡ ÔÈ fiÚÔÈ IUGR Î·È SGA ʤÚÔÓÙ·È Ó· Â›Ó·È Ù·˘ÙfiÛËÌÔÈ. µÂ‚·›ˆ˜, ÙÔ ÂÚÒÙËÌ· Ô˘ ·Ó·Î‡ÙÂÈ ·Ì¤Ûˆ˜ ÌÂÙ¿ Â›Ó·È ÁÈ·Ù› Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈԇ̠‰‡Ô ÂÓÓÔÈÔÏÔÁÈο ‰È·ÊÔÚÂÙÈÎÔ‡˜ fiÚÔ˘˜ ÁÈ· ÙËÓ ›‰È· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·.

√È fiÚÔÈ IUGR Î·È SGA ‰ÂÓ Â›Ó·È Ù·˘ÙfiÛËÌÔÈ √È fiÚÔÈ IUGR Î·È SGA, Î·È Î·Ù’ ·ÎÔÏÔ˘ı›·Ó ÔÈ ÏËı˘ÛÌÔ› ÙˆÓ ÓÂÔÁÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ fiÚÔÈ ·˘ÙÔ› ·Ú·¤ÌÔ˘Ó, ·ÏÏËÏÔÂÈηχÙÔ-

ÓÙ·È ˆ˜ ¤Ó· ‚·ıÌfi, fï˜, Û ηÌÈ¿ ÂÚ›ÙˆÛË ‰ÂÓ Ù·˘Ù›˙ÔÓÙ·È. ™ÙÔÓ ÏËı˘ÛÌfi ÙˆÓ SGA ÓÂÔÁÓÒÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÌÂÓ ÓÂÔÁÓ¿ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ˘¿Ú¯Ô˘Ó fï˜ Î·È ÓÂÔÁÓ¿ ȉÈÔÛ˘ÁÎÚ·Ûȷο ÌÈÎÚ¿, Ù· ÔÔ›· ›¯·Ó Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘. ∫·Ù’ ·ÓÙÈÛÙÔȯ›·, ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ù· ÔÔ›· ıˆÚÔ‡ÌÂ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ (appropriate for gestational age) ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÓÂÔÁÓ¿ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË. °ÂÓÈο, Ë ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÂÓfi˜ ÓÂÔÁÓÔ‡ Â› ÙË ‚¿ÛÂÈ ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È ÌfiÓÔ, ÂÓ¤¯ÂÈ ÌÂÁ¿ÏË Èı·ÓfiÙËÙ· Ï¿ıÔ˘˜. ¢‡Ô ÓÂÔÁÓ¿ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ 3000 g ‰ÂÓ Â›¯·Ó ˘Ô¯ÚˆÙÈο ÙÔ˘˜ ›‰ÈÔ˘˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘ ÂÓ‰ÔÌËÙÚ›ˆ˜, Ô‡Ù ¤¯Ô˘Ó ˘Ô¯ÚˆÙÈο ÙËÓ ›‰È· ıÚ¤„Ë. ∞Ó ÙÔ ¤Ó· ¤¯ÂÈ Ì‹ÎÔ˜ Á¤ÓÓËÛ˘ 53 cm Î·È ÙÔ ¿ÏÏÔ 50 cm Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÙÔ ÚÒÙÔ ı· ¤¯ÂÈ ÏÈÁfiÙÂÚÔ ˘Ô‰fiÚÈÔ Ï›Ô˜ Û ۯ¤ÛË Ì ÙÔ ‰Â‡ÙÂÚÔ. ∂ÈϤÔÓ, Ë ‰È·›ÛÙˆÛË fiÙÈ ¤Ó· ÓÂÔÁÓfi Â›Ó·È ÌÈÎÚfiÛˆÌÔ ‰ÂÓ ÛÙÔȯÂÈÔıÂÙ› ÙËÓ ‡·ÚÍË ÓfiÛÔ˘ (1). ™‡Ìʈӷ Ì ÌÂϤÙ˜ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ›ÎÔÛÈ ÂÚ›Ô˘ ÂÙÒÓ, Ù· ÔÛÔÛÙ¿ ÙˆÓ IUGR ÓÂÔÁÓÒÓ ÛÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÙˆÓ SGA Î·È AGA ÓÂÔÁÓÒÓ Î˘Ì·›ÓÔÓÙ·È Â˘Ú¤ˆ˜. °È· ÙËÓ ÔÌ¿‰· ÙˆÓ SGA ·Ó·Ê¤ÚÔÓÙ·È ÔÛÔÛÙ¿ ·fi 13% ˆ˜ 55% (2,3,4,5) - Û ηÌÈ¿ fï˜ ÌÂϤÙË ‰ÂÓ ÚÔÛÂÁÁ›˙Ô˘Ó ÙÔ 100% - Î·È ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ AGA Ù· IUGR ÓÂÔÁÓ¿ ˘ÔÏÔÁ›˙ÔÓÙ·È ÌÂٷ͇ 5% Î·È 35% (3,5,6). ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÁÈ· ÙË ‰È·Î‡Ì·ÓÛË ÙˆÓ ÔÛÔÛÙÒÓ ·˘ÙÒÓ Â˘ı‡ÓÂÙ·È Ë ·Û¿ÊÂÈ· ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ, Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· Ù· Î˘Ì·ÈÓfiÌÂÓ· fiÚÈ· µ° ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ SGA ÓÂÔÁÓÒÓ Ô˘ ÚԷӷʤÚıËηÓ, fiˆ˜ Î·È Ë ¤ÏÏÂÈ„Ë ÂÓÈ·›·˜ ‰È·ÁÓˆÛÙÈ΋˜ ÌÂıfi‰Ô˘. ∏ Û‡Á¯˘ÛË ÙˆÓ fiÚˆÓ Î·È ÙˆÓ ÔÚÈÛÌÒÓ ÁÈ· ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ οÓÂÈ ·Ï˘ÛÈÙÂϤ˜ ÙÔ ¤ÚÁÔ Ì·˜ Û ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Â›‰·: ·) ™Ù· ÓÂÔÁÓ¿ Ì µ° ÈηÓfi Ó· Ù· ÂÓÙ¿ÍÂÈ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ AGA, Ë ÂӉ¯fiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ Ô˘ ¤¯Ô˘Ó ˘ÔÛÙ› ·Ú·Ì¤ÓÂÈ ·‰È¿ÁÓˆÛÙË. ŒÙÛÈ, ÁÈ· ÙËÓ ˘ÔıÂÚÌ›· Ô˘ ÂÌÊ·Ó›˙ÂÈ, Ï›ÁÔ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ¤Ó· ̈Úfi “Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜” ¢ı‡ÓÂÙ·È ·ÔÎÏÂÈÛÙÈο Ë ÌËÙ¤Ú· ‹ Ë Ì·›· Ô˘ ‰ÂÓ ÊÚfiÓÙÈÛ·Ó Ó· ÙÔ˘ ÂÍ·ÛÊ·Ï›ÛÔ˘Ó Î·Ï‹ ıÂÚÌÔÌfiÓˆÛË, ÂÓÒ Ë ˘ÔÁÏ˘Î·ÈÌ›· οÔÈÔ˘ ¿ÏÏÔ˘ ÓÂÔÁÓÔ‡ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ¤Ó· ÌÈÌÂÚfi Á¿Ï· Î·È ÂÊfiÛÔÓ Ë ˘ÔÁÏ˘Î·ÈÌ›· ˘Ô¯ˆÚ‹ÛÂÈ ‰ÂÓ Ù›ıÂÙ·È ı¤Ì· ÂÚ·ÈÙ¤Úˆ ÚÔ‚ÏËÌ·ÙÈÛÌÒÓ. øÛÙfiÛÔ, Î·È Ù· ‰‡Ô ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·352

352

¶. ™ËÊÈ·ÓÔ‡

ÌÔÚ› Ó· Â›Ó·È ÓÂÔÁÓ¿ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË, Ù· ÔÔ›·, ¤ÛÙˆ Î·È “Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜” ¤¯Ô˘Ó ·ÚfiÌÔȘ Èı·ÓfiÙËÙ˜ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó fiϘ ÂΛӘ ÙȘ ÂΉËÏÒÛÂȘ ÙȘ Ôԛ˜ ıˆÚԇ̠Èı·Ó¤˜ ÌfiÓÔ ÛÙ· SGA ÓÂÔÁÓ¿, fiˆ˜ ·ÛÊ˘Í›·, ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÌÂ Û˘¯ÓfiÙÂÚË ÙËÓ ˘ÔÁÏ˘Î·ÈÌ›·, ·ÚÈıÌËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ¤ÌÌÔÚÊˆÓ ÛÙÔȯ›ˆÓ ÙÔ˘ ·›Ì·ÙÔ˜, ‰È·Ù·Ú·¯¤˜ ıÂÚÌÔÚ‡ıÌÈÛ˘ Î.Ï. ‚) ∞ÓÙ›ıÂÙ· Ì ٷ AGA Ù· SGA ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·ÓÙÈÌÂÙÒÈÛË ÓÂÔÁÓÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ·ÓÂÍ·Úًو˜ ·Ó ¤¯Ô˘Ó ˘ÔÛÙ› Ú¿ÁÌ·ÙÈ ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›· ‹ fi¯È. ∞ÎfiÌ· Î·È Ù· ȉÈÔÛ˘ÁÎÚ·Ûȷο ÌÈÎÚ¿ ÓÂÔÁÓ¿ Â›Ó·È Ôχ Èı·Ófi Ó· ·ÔÌ·ÎÚ˘ÓıÔ‡Ó ·fi ÙË ÌËÙ¤Ú· ÙÔ˘˜, ÂÈ‚·Ú‡ÓÔÓÙ·˜ ÙȘ ÓÂÔÁÓÔÏÔÁÈΤ˜ ÌÔÓ¿‰Â˜, ¯ˆÚ›˜ ·ԉ‰ÂÈÁ̤ÓÔ È·ÙÚÈÎfi ÏfiÁÔ. ŒÓ· Ì›˙ÔÓ Úfi‚ÏËÌ· Ô˘ ¤¯ÂÈ ·Ó·Î‡„ÂÈ ÁÈ· Ù· ÓÂÔÁÓ¿ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ Â›Ó·È ÔÈ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÚÈÓ ·fi ‰Âη¤ÓÙ ÂÚ›Ô˘ ¯ÚfiÓÈ· Î·È ¤ÁÈÓ·Ó ·ÊÔÚÌ‹ ÁÈ· ÂηÙÔÓÙ¿‰Â˜ ‰ËÌÔÛȇÛÂȘ fiÏˆÓ ÙˆÓ Î·ÙËÁÔÚÈÒÓ, Ô˘ Û˘Ó¯›˙ÔÓÙ·È ˆ˜ Û‹ÌÂÚ·. ™‡Ìʈӷ Ì ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜, ÔÈ Ôԛ˜ Ô‰‹ÁËÛ·Ó ÛÙË ‰È·Ù‡ˆÛË Ù˘ ˘fiıÂÛ˘ fiÙÈ ÓÔÛ‹Ì·Ù· ÙˆÓ ÂÓËÏ›ÎˆÓ ¤¯Ô˘Ó ÙËÓ ·ÊÂÙËÚ›· ÙÔ˘˜ ÛÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ (Developmental Origins Hypothesis), ÓÂÔÁÓ¿ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›· ¤¯Ô˘Ó ÚԉȿıÂÛË Ó· ÂΉËÏÒÛÔ˘Ó Î·Ú‰ÈÔ·ÁÁÂȷ΋ ÓfiÛÔ, ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2 ‹ ¿ÏÏ· “ÓÔÛ‹Ì·Ù· ÊıÔÚ¿˜” ÛÙÔ ·ÒÙÂÚÔ Ì¤ÏÏÔÓ (7,8). ∏ ÌË ‰È¿ÎÚÈÛË ÙˆÓ IUGR ÓÂÔÁÓÒÓ, Ù· ÔÔ›· ÂÓ Ù¤ÏÂÈ ˘fiÎÂÈÓÙ·È Û ·˘ÙfiÓ ÙÔÓ Î›Ó‰˘ÓÔ, Î·È Ë Ù·‡ÙÈÛ‹ ÙÔ˘˜ Ì ٷ SGA ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ¤ÓÙ·ÍË ÙˆÓ ·ÙfiÌˆÓ Ì ÈÛÙÔÚÈÎfi SGA - Î·È ÌfiÓÔÓ ·˘ÙÒÓ - ÛÙ· ¿ÙÔÌ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂΉ‹ÏˆÛË Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ÓÔÛËÌ¿ÙˆÓ ÌÂÙ¿ ÙËÓ ÂÓËÏÈΛˆÛË (9). ∏ ·ÚÂÚÌËÓ›· ·˘ÙÒÓ ÙˆÓ ÂÚ¢ÓËÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ¤¯ÂÈ Â˘ÓfiËÙ˜ È·ÙÚÔÎÔÈÓˆÓÈΤ˜ Û˘Ó¤ÂȘ.

∞›ÙÈ· Î·È Ê·ÈÓfiÙ˘ÔÈ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ∆· ·›ÙÈ· Î·È ÔÈ ÓÔÛÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ Ù˘ ˘ÔıÚ„›·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÔÈΛÏÏÔ˘Ó ‹ Â›Ó·È ¿ÁÓˆÛÙ· Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ. ™Â Û¯¤ÛË Ì ÙËÓ ÙÔÔÁÚ·ÊÈ΋ ÚÔ¤ÏÂ˘Û‹ ÙÔ˘˜ ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û ·›ÙÈ· ÚÔÂÚ¯fiÌÂÓ· ·fi ÙË ÌËÙ¤Ú·, ÙÔÓ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ ¤Ì‚Ú˘Ô. ∞fi ·ıÔÊ˘ÛÈÔÏÔÁÈ΋ ¿Ô„Ë, Ë ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ¯·Ì˶·È‰È·ÙÚÈ΋ 2006;69:350-360

Ï¿ ·Ôı¤Ì·Ù· ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi Î·È ÙËÓ Î˘ÎÏÔÊÔÚ›· Ù˘ ÌËÙ¤Ú·˜ (.¯. ·ÓÂ·Ú΋˜ Û›ÙÈÛË ÂÁ·Ԣ, ˘ÂÚ¤ÌÂÛË Ù˘ ·ËÛ˘), Û ·Ú·ÎÒÏ˘ÛË Ù˘ ÌËÙÚÔÏ·ÎÔ˘ÓÙȷ΋˜ ΢ÎÏÔÊÔÚ›·˜ (.¯. Û‡Ó‰ÚÔÌ· ˘¤ÚÙ·Û˘ Ù˘ ÌËÙ¤Ú·˜ - ÙÔÍÈÓ·ÈÌ›· Ù˘ ·ËÛ˘), Û ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ï·ÎÔ‡ÓÙ· (.¯. ‰È·Ù·Ú·¯‹ Ù˘ Ï·ÎÔ˘ÓÙÔÁ¤ÓÂÛ˘, Ï·ÎÔ˘ÓÙȷο ¤ÌÊÚ·ÎÙ·) ‹ ·‰˘Ó·Ì›· ÙÔ˘ ÂÌ‚Ú‡Ô˘ Ó· ÂˆÊÂÏËı› ·fi ÙȘ ÚÔÛÊÂÚfiÌÂÓ˜ ıÚÂÙÈΤ˜ Ô˘Û›Â˜ (.¯. Ì›ˆÛË ÙˆÓ ÌÈÙÒÛÂˆÓ Û ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù· ÙÔ˘ ÂÌ‚Ú‡Ô˘). ªÈ· ÈÔ ·‰Ú‹ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ·ÊÔÚ¿ ÛÙË ‰È¿ÎÚÈÛ‹ ÙÔ˘˜ Û ÂÚÈ‚·ÏÏÔÓÙÈο Î·È ÁÂÓÂÙÈο, Ì ÙÔ ·ıÔÏÔÁÈÎfi ÁÔÓȉ›ˆÌ· ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË Ó· ‰ڿ˙ÂÙ·È ÛÙÔ˘˜ ÁÔÓ›˜, ÛÙÔÓ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ ¤Ì‚Ú˘Ô. ™Â Û¯¤ÛË Ì ÙÔ˘˜ ÁÔÓ›˜, Ë ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ıÚÔÌ‚ÔÊÈÏ›· Â›Ó·È ¤Ó· ·fi Ù· ÈÔ Û˘˙ËÙË̤ӷ ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù· Ô˘ Û˘Ó‰¤ÂÙ·È Ì ·ÓÂ·Ú΋ ·‡ÍËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ (10), ÂÓÒ Û ۯ¤ÛË Ì ÙÔÓ Ï·ÎÔ‡ÓÙ· ÙÔ ÌÔÓÔÌÂÚ¤˜ Ï·ÎÔ˘ÓÙÈ·Îfi ̈۷˚Îfi (CPM, confined placental mosaicism). ∫·Ù¿ ηÓfiÓ·, Ô Ï·ÎÔ‡ÓÙ·˜ ¤¯ÂÈ Ù·˘ÙfiÛËÌÔ ÁÔÓȉ›ˆÌ· Ì ÙÔ ¤Ì‚Ú˘Ô, ˆÛÙfiÛÔ, Û οÔȘ ÂÚÈÙÒÛÂȘ ·Ú·ÙËÚÂ›Ù·È ÌˆÛ·˚Îfi ÛÙÔÓ Ï·ÎÔ‡ÓÙ· (΢ڛˆ˜ ÙÚÈۈ̛·), fi¯È fï˜ Î·È ÛÙÔ ¤Ì‚Ú˘Ô. ∏ ‰È·Ù·Ú·¯‹ ·˘Ù‹ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÌ‚Ú˘˚Îfi ı¿Ó·ÙÔ, ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ‹ Ó· ÌËÓ ¤¯ÂÈ Î·ÌÈ¿ Â›ÙˆÛË ÛÙËÓ ¤Î‚·ÛË Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ (11,12). ™Ù· ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ¯ÚˆÌÔÛˆÌÈÎÒÓ ‹ ÁÔÓȉȷÎÒÓ ·ÓˆÌ·ÏÈÒÓ. ∞ÍÈÔÛËÌ›ˆÙË ·Ú·Ù‹ÚËÛË ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙÒÓ Â›Ó·È Ë ÂÓÙfiÈÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙ· ÁÔÓ›‰È· ÙfiÛÔ ÙÔ˘ IGF I (·˘ÍËÙÈÎfi˜ ·Ú¿ÁˆÓ ‰›ÎËÓ ÈÓÛÔ˘Ï›Ó˘ π), ‚·ÛÈÎÔ‡ Û˘ÓÙÂÏÂÛÙ‹ Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, fiÛÔ Î·È ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ Û ÂÚÈÙÒÛÂȘ ·ıÔÏÔÁÈ΋˜ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·‡ÍËÛ˘ (13). ªÈ· ¿ÏÏË ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹, Ô˘ ¤¯ÂÈ Û˘Ó‰Âı› ÚfiÛÊ·Ù· Ì ÙËÓ ·ıÔÏÔÁÈ΋ ·‡ÍËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Â›Ó·È Ë ÌÔÓÔÁÔÓÂ˚΋ ‰Èۈ̛· (UPD, uniparental disomy), Ë ÌÂÙ·‚›‚·ÛË, ‰ËÏ·‰‹, ‰‡Ô ÔÌfiÏÔÁˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ·fi ÙÔÓ ¤Ó· ÌfiÓÔ ÁÔÓ¤·, ηٿ ·Ú¤ÎÎÏÈÛË Ù˘ ÌÂÓÙÂÏÈ΋˜ ıˆڛ·˜. ∆ËÓ ·ÊÔÚÌ‹ ·ÔÙ¤ÏÂÛÂ Ë ‰È·›ÛÙˆÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ Û ۇӉÚÔÌ· Ô˘ Û˘Ó‰˘¿˙ÔÓÙ·È Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ Silver-Russell. øÛÙfiÛÔ, ·Ú¿ ÙÔÓ ·Ú¯ÈÎfi ÂÓıÔ˘ÛÈ·ÛÌfi ÁÈ· ¢ڇÙÂÚË ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ì ÙËÓ ·ıÔÏÔÁÈ΋ ·‡ÍËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘, Ô ¤ÏÂÁ¯Ô˜ ÈηÓÔ‡ ·ÚÈıÌÔ‡ ÓÂÔÁÓÒÓ Ì “ÂÓ‰ÔÌ‹ÙÚÈ·

Pediatr Sept_Oct 06

26-09-06

12:53

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353

¢È¿ÁÓˆÛË ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜

˘ÔıÚ„›·” (ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· SGA ÓÂÔÁÓÒÓ) ‰ÂÓ Î·Ù¤ÏËÍ ÛÙË ‰È·›ÛÙˆÛË ÌÔÓÔÁÔÓÂ˚΋˜ ‰Èۈ̛·˜, Ì ÂÍ·›ÚÂÛË Ï›Á· ÓÂÔÁÓ¿ Ô˘ ›¯·Ó ‰‡ÛÌÔÚÊ· ¯·Ú·ÎÙËÚÈÛÙÈο (14-16). ∏ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ·ıÔÏÔÁÈ΋˜ ·‡ÍËÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ‰˘Û¯ÂÚ·›ÓÂÙ·È ÛËÌ·ÓÙÈο ·fi ÙËÓ ¤ÏÏÂÈ„Ë ¿ÁÈˆÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ IUGR ÓÂÔÁÓÒÓ. ŒÙÛÈ, ÔÈ Û¯ÂÙÈΤ˜ ÌÂϤÙ˜ Ú·ÁÌ·Ù‡ÔÓÙ·È Î·Ù’ Ô˘Û›·Ó ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÈÙ›ˆÓ ÙÔ˘ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘, ·ÊÔ‡ Ù· ÓÂÔÁÓ¿ Ô˘ ÌÂÏÂÙÒÓÙ·È ÂÈϤÁÔÓÙ·È Ì ·˘Ùfi ÙÔ ÎÚÈÙ‹ÚÈÔ. ™Â ÚfiÛÊ·ÙÔ, Ì¿ÏÈÛÙ·, ÁÚ·Ùfi Û˘ÌfiÛÈÔ ÂÈϤ¯ıËΠ¢ı¤ˆ˜ Ô Ù›ÙÏÔ˜ “... ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘” (17), ÂÈÏÔÁ‹ ÈÔ Û˘ÓÂ‹˜ Ì ٷ ˘¿Ú¯ÔÓÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ˆÛÙfiÛÔ, ηıfiÏÔ˘ ‰È·ÊˆÙÈÛÙÈ΋ ÁÈ· Ù· Ú·ÁÌ·ÙÈο ·›ÙÈ· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜. ∂ÈϤÔÓ, ÏfiÁˆ Ù˘ Û˘Ó‡·Ú͢ ˘ÔıÚ„ÈÎÒÓ Î·È Ê˘ÛÈÔÏÔÁÈÎÒÓ ÌÈÎÚÒÓ ÓÂÔÁÓÒÓ ÛÙÔÓ ÏËı˘ÛÌfi ÙˆÓ SGA Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÛÙȘ Û¯ÂÙÈΤ˜ ÌÂϤÙ˜, Ë Û˘¯ÓfiÙËÙ· ÔÔÈÔ˘‰‹ÔÙ Ú·ÁÌ·ÙÈÎÔ‡ ·ÈÙ›Ô˘ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ı· Â›Ó·È ÂÍ·ÈÚÂÙÈο ÌÂȈ̤ÓË Ï·ÛÌ·ÙÈο. ∞Ó ÂÚ·ÈÙ¤Úˆ ÂÈÏÂÁ› Ô ÏËı˘ÛÌfi˜ ÙˆÓ AGA ˆ˜ ÏËı˘ÛÌfi˜ ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ ÁÈ· Û‡ÁÎÚÈÛË, Ë Û‡Á¯˘ÛË ı· Â›Ó·È ÚÔÊ·Ó‹˜, ·ÊÔ‡ Î·È Û ·˘ÙfiÓ ÙÔÓ ÏËı˘ÛÌfi Ô ·ÚÈıÌfi˜ ÙˆÓ IUGR ÓÂÔÁÓÒÓ ‰ÂÓ Â›Ó·È Î·ıfiÏÔ˘ ·ÌÂÏËÙ¤Ô˜. ∆Ô Úfi‚ÏËÌ· ·˘Ùfi Û¯ÔÏÈ¿ÛÙËΠ(18) ‡ÛÙÂÚ· ·fi ÚfiÛÊ·ÙË ÌÂϤÙË, Ë ÔÔ›· ηٷϋÁÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÚÔÂÎÏ·Ì„›· ‰ÂÓ ·ÔÙÂÏ› ˘Ô¯ÚˆÙÈο ·ÈÙ›· ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜, ·ÏÏ¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙË Á¤ÓÓËÛË Î·È ˘¤Ú‚·ÚˆÓ ÓÂÔÁÓÒÓ (19). ™ÙÔ Û˘Ì¤Ú·ÛÌ· ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ‚·ıÌfi˜ ·Ï‹ıÂÈ·˜ (20), Ô˘ Â›Ó·È ·ÔÊ·ÛÈÛÙÈ΋˜ ÛËÌ·Û›·˜ Î·È ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÚÔÂÎÏ·Ì„›·˜. ∂›Ó·È ÚÔÊ·Ó¤˜, fiÙÈ Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ·Ó·Î·Ï˘Êı›, ÂÎÙfi˜ ÌfiÓÔ ·Ó ÛÙȘ Û¯ÂÙÈΤ˜ ÌÂϤÙ˜ ÂÚÈÏËÊıÔ‡Ó Î˘‹ÛÂȘ Î·È ÓÂÔÁÓ¿ Ô˘ ¤¯Ô˘Ó Ú¿ÁÌ·ÙÈ ˘ÔÛÙ› ˘ÔıÚ„›· ÂÓ‰ÔÌËÙÚ›ˆ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì ÙË ‚Ô‹ıÂÈ· Ù˘ ÎÏÈÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ‹ Ù˘ ·ÓıÚˆÔÌÂÙÚ›·˜, ˆ˜ ‰È·ÁÓˆÛÙÈÎÒÓ Ì¤ÛˆÓ, ¤¯Ô˘Ó ÂÓÙÔÈÛÙ› ˘ÔıÚ„Èο ÓÂÔÁÓ¿ Ì µ° ˆ˜ Î·È 3800 g (21) ‹ Ì µ° Ô˘ ˘ÂÚ‚·›ÓÂÈ ÙËÓ 90‹ ÂηÙÔÛÙÈ·›· ı¤ÛË ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ (3). ∏ ÂÙÂÚÔÁ¤ÓÂÈ· ÙˆÓ ·ÈÙ›ˆÓ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ¤Ì‚Ú˘Ô ÌÂÙ·‚·›ÓÂÈ ‰È·‰Ô¯Èο ·fi ‰È¿ÊÔÚ· ·Ó·Ù˘Íȷο ÛÙ¿‰È·, Û˘ÓÂ¿ÁÂÙ·È ÙËÓ Ê·ÈÓÔÙ˘È΋ ·ÓÔÌÔÈÔÁ¤ÓÂÈ· ÙˆÓ ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›·. øÛÙfiÛÔ ¤¯ÂÈ ÂÈÎÚ·Ù‹ÛÂÈ Ó· ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ·ÚÈÔÈ Ù‡-

ÔÈ IUGR ÓÂÔÁÓÒÓ: Ù· Û˘ÌÌÂÙÚÈο Î·È Ù· ·Û‡ÌÌÂÙÚ·. ∆· Û˘ÌÌÂÙÚÈο IUGR ÓÂÔÁÓ¿ η٤¯Ô˘Ó ¯·ÌËϤ˜ ·ÏÏ¿ ÈÛÔ¸„›˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ Î·È ˆ˜ ÚÔ˜ ÙȘ ÙÚÂȘ ‚·ÛÈΤ˜ ۈ̷ÙÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ‰ËÏ·‰‹ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ÙÔ Ì‹ÎÔ˜ Î·È ÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ Î·È Â›Ó·È Î·Ù¿ ηÓfiÓ· SGA. ∆· ÓÂÔÁÓ¿ ·˘Ù¿ ‰ÂÓ ¤¯Ô˘Ó ÎÏÈÓÈ΋ ÂÈÎfiÓ· ˘ÔıÚ„›·˜, ˘fi ÙËÓ ¤ÓÓÔÈ· Ù˘ Ì›ˆÛ˘ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜, Ô‡Ù ‰Â›¯ÓÔ˘Ó ÂÈÚÚ¤ÂÈ· ÚÔ˜ ÙȘ ÂÈÏÔΤ˜ ÙˆÓ ÚÒÙˆÓ 24ÒÚˆÓ ˙ˆ‹˜, ÔÈ Ôԛ˜ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙ· ˘ÔıÚ„Èο ÓÂÔÁÓ¿ (˘ÔÁÏ˘Î·ÈÌ›·, ˘·Û‚ÂÛÙÈ·ÈÌ›· Î.Ï). ∫·Ù¿ ηÓfiÓ·, ÈÛÙ‡ÂÙ·È fiÙÈ Ù· Û˘ÌÌÂÙÚÈο IUGR ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·ÓÙÈÌÂÙˆ›ÛÂÈ Î¿ÔÈÔ ÓÔÛÔÁfiÓÔ ·Ú¿ÁÔÓÙ· Û ÚÒÈÌ· ÛÙ¿‰È· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜ Î·È fiÙÈ Ô ÓÔÛÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÂÓ‰ÔÁÂÓ‹˜. ∞ÓÙÈı¤Ùˆ˜, ÛÙ· ·Û‡ÌÌÂÙÚ· IUGR ÓÂÔÁÓ¿ ÙÔ µ° ˘ÔÏ›ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Û ۯ¤ÛË Ì ÙÔ Ì‹ÎÔ˜ Á¤ÓÓËÛ˘ Î·È ÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜. ∆· ÓÂÔÁÓ¿ ·˘Ù¿ ¤¯Ô˘Ó ÎÏÈÓÈο ¤Î‰ËÏË, ·ÏÏ¿ ÔÈΛÏÔ˘ ‚·ıÌÔ‡ Ì›ˆÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Î·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÙÔ ÎÂÊ¿ÏÈ Ê·›ÓÂÙ·È Û˘ÁÎÚÈÙÈο ÌÂÁ¿ÏÔ. √ ÓÔÛÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ÛÙ· ÓÂÔÁÓ¿ ·˘Ù¿ ıˆÚÂ›Ù·È Èı·ÓfiÙÂÚÔ fiÙÈ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ “ÂÚÈ‚¿ÏÏÔÓ” ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È fiÙÈ ¤‰Ú·Û ΢ڛˆ˜ ηٿ ÙÔ 3Ô ÙÚ›ÌËÓÔ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜, ‰È¿ÛÙËÌ· ÛÙÔ ÔÔ›Ô ·Ú·ÙËÚÂ›Ù·È Ë ÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡.

¢È¿ÁÓˆÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ˘ÔÏÂÈfiÌÂÓË ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ∏ ·Î·Ù·ÏÏËÏfiÙËÙ· ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ˆ˜ ‰Â›ÎÙË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÂÈÛËÌ·›ÓÂÙ·È ·fi ÌÈÛfi ÂÚ›Ô˘ ·ÈÒÓ· Î·È ·ÔÙÂÏ› ϤÔÓ Î·ıÔÏÈο ·Ô‰ÂÎÙfi ÁÂÁÔÓfi˜ (22). ¶·Ú·Ù·‡Ù·, ÂÓÙ‡ˆÛË ÚÔηÏ› Ô Û¯ÂÙÈο ÌÈÎÚfi˜ fiÁÎÔ˜ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ȉȷ›ÙÂÚ· Ù˘ ÚfiÛÊ·Ù˘, Ô˘ ¤¯ÂÈ ·ÓÙÈΛÌÂÓÔ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›·, Û ·ÓÙ›ıÂÛË Ì ÙÔ Ï‹ıÔ˜ ÙˆÓ ‰ËÌÔÛȇÛÂˆÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹. µ·ÛÈÎfi ‰È·ÁÓˆÛÙÈÎfi ̤ÛÔ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·‡ÍËÛ˘ Â›Ó·È Ë Ì¤ÙÚËÛË ÙˆÓ ‚ÈÔÌÂÙÚÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (·ÌÊÈ‚ÚÂÁÌ·ÙÈ΋ ‰È¿ÌÂÙÚÔ˜, Ì‹ÎÔ˜ ÌËÚÈ·›Ô˘ Î.Ï.) Ì ÙÔ ÚÔÁÂÓÓËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ∆Ô ¤Ì‚Ú˘Ô Ô˘ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈÎfi Ú˘ıÌfi ·‡ÍËÛ˘ (‚ÈÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Û ÛÙ·ıÂÚ‹ ÙÚԯȿ), ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

Pediatr Sept_Oct 06

26-09-06

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354

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Û ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰È·‰Ô¯Èο ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù·, Â›Ó·È Ôχ Èı·ÓfiÓ fiÙÈ ·Ó·Ù‡ÛÛÂÙ·È Ê˘ÛÈÔÏÔÁÈο (23), ÂÓÒ Ë ÂÎÙ›ÌËÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ì ¤Ó· ÌfiÓÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (24,25). ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ‰È·ÁÓˆÛÙÈ΋ ‚Ô‹ıÂÈ· ÙˆÓ ÌÂÏÂÙÒÓ Doppler (26,27), fiˆ˜ Î·È ¿ÏÏˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ˆ˜ ‚¿ÛË ÙÔ ÚÔÁÂÓÓËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (28). ¶·Ú·Ù·‡Ù·, ÔÈ ‰È·ı¤ÛÈ̘ ̤ıÔ‰ÔÈ ‰È¿ÎÚÈÛ˘ ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ·ıÔÏÔÁÈÎÔ‡˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘ ‰ÂÓ Â›Ó·È ··ÏÏ·Á̤Ó˜ ·‰˘Ó·ÌÈÒÓ (29,30). ∂ÈϤÔÓ, ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È fiÏ· Ù· ÓÂÔÁÓ¿ ·fi ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù·, ÂÓÒ ‰ÂÓ Â›Ó·È Ï›Á˜ ÔÈ ÂÚÈÙÒÛÂȘ ÂÈÙfiΈÓ, ÔÈ Ôԛ˜ ‰ÂÓ Â›¯·Ó ηıfiÏÔ˘ È·ÙÚÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÂÔ̤ӈ˜, Ë ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ÂÓ·fiÎÂÈÙ·È ·ÔÎÏÂÈÛÙÈο Î·È ÌfiÓÔ ÛÙÔÓ ·È‰›·ÙÚÔ. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË Ë ‰È¿ÁÓˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÌÔÚ› Ó· Á›ÓÂÈ Ì ‰‡Ô ÙÚfiÔ˘˜: Ì ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È ÙËÓ ·ÓıÚˆÔÌÂÙÚ›·. ∫ÏÈÓÈ΋ ‰È¿ÁÓˆÛË ∏ ÚÒÙË ÚÔÛ¿ıÂÈ· ηٿÚÙÈÛ˘ ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ IUGR ÓÂÔÁÓÒÓ ‚¿ÛÂÈ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ·Ó¿ÁÂÙ·È ÛÙÔ 1958 (31). ∞ÎÔÏÔ‡ıËÛ ÌÈ· ‰Â‡ÙÂÚË ÚÔÛ¿ıÂÈ· ÙÔ 1984 (32), Ë ÔÔ›· Û˘Ó¯›ÛÙËΠÂ› Ì›· ‰ÂηÂÙ›· Î·È Î·Ù¤ÏËÍ Û ÌÈ· ·ÚÎÂÙ¿ ηϿ ‰ÔÌË̤ÓË ‰È·ÁÓˆÛÙÈ΋ ̤ıÔ‰Ô Ì ÙËÓ ÂˆÓ˘Ì›· CANS score, ·fi Ù· ·Ú¯Èο ÙˆÓ Ï¤ÍÂˆÓ Clinical Assessment of Nutritional Status (5). ∏ ηٿÚÙÈÛË ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘ ·ÔÛÎÔÔ‡Û ÛÙËÓ ¿ÚÛË Ù˘ Û˘Ó¯È˙fiÌÂÓ˘ Û‡Á¯˘Û˘ Ì ÙËÓ ÔÓÔÌ·ÙÔÏÔÁ›· ÙˆÓ SGA ÓÂÔÁÓÒÓ Î·È ·˘ÙÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›·. øÛÙfiÛÔ, Ú¤ÂÈ Ó· ‰È¢ÎÚÈÓÈÛÙ› fiÙÈ Ô ÂÈÛËÁËÙ‹˜ Ù‹˜ ÌÂıfi‰Ô˘ J. Metcoff ·Ó·Ê¤ÚÂÈ fiÙÈ Ë Ì¤ıÔ‰Ô˜ ÚÔÔÚ›˙ÂÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ì ÂÌ‚Ú˘˚΋ ˘ÔıÚ„›· (fetal malnutrition), ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· ÙËÓ ÔÔ›· ıˆÚ› ÌË Ù·˘ÙfiÛËÌË Ì ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ (IUGR). ªÂ ÙË ‰È¿ÎÚÈÛË ·˘Ù‹ Ô J. Metcoff ı¤ÏÂÈ Ó· ÂÈÛËÌ¿ÓÂÈ, fiÙÈ Ë Ì¤ıÔ‰Ô˜ ‰ÂÓ Â›Ó·È Î·Ù¿ÏÏËÏË ÁÈ· ÙË ‰È¿ÁÓˆÛË fiÏˆÓ ÙˆÓ IUGR ÓÂÔÁÓÒÓ, ·ÏÏ¿ ÌfiÓÔÓ ÂÎÂ›ÓˆÓ Ô˘ ¤¯Ô˘Ó ÎÏÈÓÈο ÛËÌ›· ˘ÔıÚ„›·˜. ∞ÓÙ›ıÂÙ·, Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÁÓˆÛË IUGR ÓÂÔÁÓÒÓ Ô˘ ‰ÂÓ ¤¯Ô˘Ó Ì›ˆÛË ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜. ∏ ̤ıÔ‰Ô˜ CANS score (¶›Ó·Î·˜ 1) ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÓÓ¤· ‰È·ÁÓˆÛÙÈο ÛËÌ›·, Ù· ÔÔ›· ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

‚·ıÌÔÏÔÁÔ‡ÓÙ·È Ì Êı›ÓÔ˘Û· ‚·Ú‡ÙËÙ· ·fi ÙÔ 1 ˆ˜ ÙÔ 4. °È· οı ‰È·ÁÓˆÛÙÈÎfi ÛËÌÂ›Ô Ë ‚·ıÌÔÏÔÁ›· 4 ·ÓÙÈÛÙÔȯ› ÛÙ· ÓÂÔÁÓ¿ ¯ˆÚ›˜ ÎÏÈÓÈο ÛËÌ›· ˘ÔıÚ„›·˜. ™˘ÓÔÏÈ΋ ‚·ıÌÔÏÔÁ›· ÌÈÎÚfiÙÂÚË ·fi 24 ıˆÚÂ›Ù·È ÂÓ‰ÂÈÎÙÈ΋ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜. ∏ ¯ÚËÛÈÌfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ¤ÁÎÂÈÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‚ÔËı¿ ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi Ó· Û˘ÛÙËÌ·ÙÔÔÈ‹ÛÂÈ ÙËÓ Âͤٷۋ ÙÔ˘, ·ÏÏ¿ Î·È Ó· ÂÎÊÚ¿ÛÂÈ Ù· Â˘Ú‹Ì·Ù¿ ÙÔ˘ ·ÚÈıÌËÙÈο, ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·˜ ¤ÙÛÈ Î·È ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ˘ÔıÚ„›·˜. ™ÙËÓ ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÙÔ˘ ÓÂÔÁÓÔ‡ ı· ÌÔÚÔ‡Û·Ó Ó· ÏËÊıÔ‡Ó ˘fi„Ë ÎÈ ¿ÏÏ· ÛËÌ›·, Ù· ÔÔ›· ‰ÂÓ ¤¯Ô˘Ó ÂÚÈÏËÊı› ÛÙË Ì¤ıÔ‰Ô. ŒÓ· ·fi ·˘Ù¿ Â›Ó·È Ë ÍËÚfiÙËÙ· Î·È Ë ·ÔϤÈÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÂÎÙÂٷ̤ÓË ÛÙȘ ÈÔ ÛÔ‚·Ú¤˜ ÂÚÈÙÒÛÂȘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜ ‹ ·ÎfiÌ· Î·È Ë Î·ıÔÏÈ΋ ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÂÓ Â›‰ÂÈ ÂÚÁ·ÌËÓ‹˜. ∏ ÍËÚfiÙËÙ· Û˘Ó‰˘¿˙ÂÙ·È Ì ÙËÓ ·Ô˘Û›· ÛÌ‹ÁÌ·ÙÔ˜ Î·È ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë ·˘Ù‹, ÏfiÁˆ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ¤ÎıÂÛ˘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÛÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi. ∂Ô̤ӈ˜, ÙÔ ÓÂÔÁÓfi Ì ηϋ ÂÓ‰ÔÌ‹ÙÚÈ· ·‡ÍËÛË ·Ó·Ì¤ÓÂÙ·È Ó· ¤¯ÂÈ Î·Ï¿ ˘‰·ÙˆÌ¤ÓÔ ‰¤ÚÌ·, ÂÓÒ ÌÔÚ› Ó· ¤¯ÂÈ ˘ÔÏ›ÌÌ·Ù· ÛÌ‹ÁÌ·ÙÔ˜, ȉȷ›ÙÂÚ· ÛÙȘ Ù˘¯¤˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, ÂÊfiÛÔÓ ÚfiÎÂÈÙ·È ÁÈ· ÓÂÔÁÓfi 37-38 ‚‰ÔÌ¿‰ˆÓ, ‰Â‰Ô̤Ó˘ Ù˘ ·Ó·ÛÙÔÏ‹˜ ·Ú·ÁˆÁ‹˜ ÛÌ‹ÁÌ·ÙÔ˜ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘ Ì ÙËÓ ÚfiÔ‰Ô Ù˘ ÎÂÚ·ÙÈÓÔÔ›ËÛ˘. √ ·ıÔÊ˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ˘fiÎÂÈÙ·È Ù˘ ÍËÚÔ‰ÂÚÌ›·˜ Â›Ó·È Ë ÌÂȈ̤ÓË ·ÈÌ¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÛÂ Û˘Óı‹Î˜ ÌÂȈ̤Ó˘ ÙÚÔÊÔ‰ÔÛ›·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ÏfiÁˆ ÙˆÓ ÌÂÙ·‚ÔÏÒÓ Ù˘ ΢ÎÏÔÊÔÚ›·˜ Ô˘ Â¤Ú¯ÔÓÙ·È Û ٤ÙÔȘ ηٷÛÙ¿ÛÂȘ Î·È Ù˘ ·Ó·Î·Ù·ÓÔÌ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÚÔ˜ fiÊÂÏÔ˜ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ, fiˆ˜ Ô ÂÁΤʷÏÔ˜, Ë Î·Ú‰È¿ Î·È Ù· ÂÈÓÂÊÚ›‰È·. ∂›Ó·È Ô ›‰ÈÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ ·ÚfiÛÎÔÙË ·‡ÍËÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Î·È Ù˘ ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜, ·Ú¿ ÙËÓ ÙÒÛË ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ ÙÔ˘ ‚¿ÚÔ˘˜, Ì Â·ÎfiÏÔ˘ıÔ ÙË ‰˘Û·Ó·ÏÔÁ›· ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ - ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ÛÙ· ·Û‡ÌÌÂÙÚ· IUGR ÓÂÔÁÓ¿. ÕÏÏ· ÎÏÈÓÈο ÛËÌ›· Â›Ó·È ÔÈ Û¯ÂÙÈο ÌÈÎÚÔ› Ì·˙ÈÎÔ› ·‰¤Ó˜ ÛÙ· ˘ÔıÚ„Èο ÓÂÔÁÓ¿, fiˆ˜ Î·È Ô ÏÂÙfi˜ ÔÌÊ¿ÏÈÔ˜ ÏÒÚÔ˜ Ì ÌÈÎÚ‹ ÔÛfiÙËÙ· Wharton’s jelly, Ô ÔÔ›Ô˜ ·ÔÍËÚ·›ÓÂÙ·È Û ۇÓÙÔÌÔ Û¯ÂÙÈο ¯ÚfiÓÔ. ∆· ÓÂÔÁÓ¿ Ì ÛÔ‚·Ú‹ ÂÓ‰ÔÌ‹ÙÚÈ· ˘ÔıÚ„›· ‰ÂÓ ¤¯Ô˘Ó ηٿ ηÓfiÓ· ˘ÎÓ¿ Ì·ÏÏÈ¿, ˆÛÙfiÛÔ ÙÔ ÚÒÙÔ ÎÚÈÙ‹ÚÈÔ ÙÔ˘ CANS score Â›Ó·È Û¯ÂÙÈο ·Û·Ê¤˜. ∞ÓÙ’ ·˘ÙÔ‡ ı· ÌÔÚÔ‡Û ӷ ¯ÚËÛÈÌÔÔÈËı› ÙÔ ÎÚÈÙ‹ÚÈÔ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜,

Pediatr Sept_Oct 06

26-09-06

12:53

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¶›Ó·Î·˜ 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÙÔ˘ ÓÂÔÁÓÔ‡ - CANS Score (5) ∞ª:......................... µ°:........................... º‡ÏÔ:......................

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™˘ÓÔÏÈ΋ ‚·ıÌÔÏÔÁ›· ÌÈÎÚfiÙÂÚË ÙˆÓ 24 ‚·ıÌÒÓ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜. ª·ÏÏÈ¿: ¶˘ÎÓ¿, ̷Ϸο Û·Ó ÌÂÙ¿ÍÈ, ¢ÎÔÏÔ¯Ù¤ÓÈÛÙ· (4 ‚·ıÌÔ›). §›Á·, ›ÛÈ·, ·›ı·Ú¯· ÛÙÔ ‚Ô‡ÚÙÛÈÛÌ·, Èı·ÓfiÓ Ì ı¤ÛÂȘ ·ԯڈ̷ÙÈÛÌÔ‡ (1 ‚·ıÌfi˜). ¶·ÚÂȤ˜: ™ÙÚÔÁÁ˘Ïfi ÚfiÛˆÔ, ÁÂÌ¿Ù· “Ì‹Ï·” (4 ‚·ıÌÔ›). ™ÙÂÓfiÌ·ÎÚÔ, Â›Â‰Ô ÚfiÛˆÔ, ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ Ï›Ô˘˜ ÛÙȘ ·ÚÂȤ˜ (1 ‚·ıÌfi˜). ∆Ú¿¯ËÏÔ˜: ™ÙËÓ ˘ÔÁÓ¿ıÈÔ ¯ÒÚ· 2 ‹ 3 Ù˘¯¤˜, Ô ÙÚ¿¯ËÏÔ˜ ‰ÂÓ Ê·›ÓÂÙ·È (4 ‚·ıÌÔ›). ∞Ô˘Û›· ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ ÛÙËÓ ˘ÔÁÓ¿ıÈÔ ¯ÒÚ·, ÙÚ¿¯ËÏÔ˜ Ï‹Úˆ˜ ÔÚ·Ùfi˜ Ì ¯·Ï·Úfi, Ú˘ÙȉˆÌ¤ÓÔ ‰¤ÚÌ· (1 ‚·ıÌfi˜). µÚ·¯›ÔÓ˜: °ÂÌ¿ÙÔÈ, ÛÙÚÔÁÁ˘ÏÔ›, ‰ÂÓ ÂÁ›ÚÂÙ·È ‰ÂÚÌ·ÙÈ΋ Ù˘¯‹ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÁÎÒÓ· Î·È ÙÔ˘ ÙÚÈÎÂÊ¿ÏÔ˘ (4 ‚·ıÌÔ›). ™ÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÁÎÒÓ· ‰¤ÚÌ· ¯·Ï·Úfi, ‡ÎÔÏ· ÂÁÂÈÚfiÌÂÓÔ Û Ù˘¯‹. ¢ËÌÈÔ˘ÚÁ›· Ù˘¯ÒÓ ‰›ÎËÓ ·ÎÔÚÓÙÂfiÓ fiÙ·Ó Ô ÂÍÂÙ·ÛÙ‹˜ ÂÚÈ‚¿ÏÂÈ ÙÔ ‚Ú·¯›ÔÓ·, ¿Óˆ ·fi ÙÔÓ ·ÁÎÒÓ·, Ì ÙÔÓ ·Ú. ‰Â›ÎÙË Î·È ·ÓÙ›¯ÂÈÚ· Î·È Ì ÙÔ ‰ÂÍ› ‰Â›ÎÙË Î·È ·ÓÙ›¯ÂÈÚ· ÙÔ ·ÓÙÈ‚Ú¿¯ÈÔ Î·È ÚÔÛ·ı‹ÛÂÈ Ó· Û˘ÌÏËÛÈ¿ÛÂÈ Ù· ¯¤ÚÈ· ÙÔ˘ (1 ‚·ıÌfi˜). ƒ¿¯Ë: ¢‡ÛÎÔÏË Û‡ÏÏË„Ë Î·È ¤ÁÂÚÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÛÙË ÌÂÛÔˆÌÔÏ¿ÙÈÔ ¯ÒÚ· (4 ‚·ıÌÔ›). X·Ï·Úfi ‰¤ÚÌ·, ‡ÎÔÏ· ÂÁÂÈÚfiÌÂÓÔ Û Ù˘¯‹ (1 ‚·ıÌfi˜). °ÏÔ˘ÙÔ›: °ÂÌ¿ÙÔÈ, ÛÙÚÔÁÁ˘ÏÔ› (4 ‚·ıÌÔ›). ¶Ï‹Ú˘ ۯ‰fiÓ ¤ÏÏÂÈ„Ë Ï›Ô˘˜, ¯·Ï·Úfi Î·È Ú˘ÙȉˆÌ¤ÓÔ ‰¤ÚÌ· ÛÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜ Î·È ÙËÓ Ô›ÛıÈ· ÂÈÊ¿ÓÂÈ· ÙˆÓ ÌËÚÒÓ (1 ‚·ıÌfi˜). ∫Ӌ̘: Ÿˆ˜ ÛÙÔ˘˜ ‚Ú·¯›ÔÓ˜. £Òڷη˜: °ÂÌ¿ÙÔ˜, ‰ÂÓ Ê·›ÓÔÓÙ·È ÔÈ Ï¢ڤ˜ (4 ‚·ıÌÔ›). ¶ÚÔԉ¢ÙÈ΋ ÂÌÊ¿ÓÈÛË Ï¢ÚÒÓ. ¶ÚÔ‚ÔÏ‹ ÙˆÓ Ï¢ÚÒÓ Î·È Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ï›Ô˘˜ ÛÙ· ÌÂÛÔχÚÈ· ‰È·ÛÙ‹Ì·Ù· (1 ‚·ıÌfi˜). ∫ÔÈÏÈ¿: °ÂÌ¿ÙË, ÚÔ¤¯Ô˘Û· ¯ˆÚ›˜ ¯·Ï·ÚfiÙËÙ· ‰¤ÚÌ·ÙÔ˜ (4 ‚·ıÌÔ›). ∂›Â‰Ë ‹ Î·È ÛηÊÔÂȉ‹˜, Ôχ ¯·Ï·Úfi ‰¤ÚÌ· Ô˘ ‡ÎÔÏ· ÂÁ›ÚÂÙ·È Û Ù˘¯‹ Î·È Ú˘ÙȉÒÓÂÙ·È Û ·Ú¿ÏÏËϘ Ù˘¯¤˜ (1 ‚·ıÌfi˜).

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∂Ó·ÏÏ·ÎÙÈÎfi ∫ÚÈÙ‹ÚÈÔ ¢¤ÚÌ·: ∫·Ï¿ ÂÓ˘‰·ÙˆÌ¤ÓÔ, ÛÊÚÈÁËÏfi, ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÛÌ‹ÁÌ· ȉȷ›ÙÂÚ· ÛÙȘ Ù˘¯¤˜ (ÙÚ¿¯ËÏÔ˜, Ì·Û¯¿Ï˜ Î.Ï.) (4 ‚·ıÌÔ›). ¢¤ÚÌ· ÍËÚfi, Ú·Á¿‰Â˜ ÛÙ· ¤ÏÌ·Ù· (3). ∞ÔϤÈÛË Î·Ù¿ ÙfiÔ˘˜, ¤ÏÌ·Ù· Î·È ·Ï¿Ì˜ Ì ڷÁ¿‰Â˜, ¤ÏÏÂÈ„Ë ÛÌ‹ÁÌ·ÙÔ˜ (2). °ÂÓÈÎÂ˘Ì¤ÓË ·ÔϤÈÛË ‰¤ÚÌ·ÙÔ˜ ‹ Î·È ÂÚÁ·ÌÈÓÔÂȉ¤˜ ‰¤ÚÌ· (1).

¶·È‰È·ÙÚÈ΋ 2006;69:350-360

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·356

356

¶. ™ËÊÈ·ÓÔ‡

fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Ì ÙËÓ ¤Ó‰ÂÈÍË ÂÓ·ÏÏ·ÎÙÈÎfi ÎÚÈÙ‹ÚÈÔ.

∞ÓıÚˆÔÌÂÙÚ›· ∏ ·ÓıÚˆÔÌÂÙÚ›· Â›Ó·È ÌÈ· ·Ï‹ Î·È ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ ÙˆÓ ÌÂÁÂıÒÓ Î·È ·Ó·ÏÔÁÈÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. µ·Û›˙ÂÙ·È Û ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ‚¿ÚÔ˘˜, ÙÔ˘ Ì‹ÎÔ˘˜, ÂÚÈ̤ÙÚˆÓ ÔÈÎ›ÏˆÓ ÌÂÏÒÓ Î·È ÙÔ˘ ¿¯Ô˘˜ Ù˘ ‰ÂÚÌ·ÙÈ΋˜ Ù˘¯‹˜ Û ‰È¿ÊÔÚ˜ Â›Û˘ ı¤ÛÂȘ. ªÔÏÔÓfiÙÈ Ë Ù¯ÓÔÏÔÁ›· ¤¯ÂÈ ·ÓÙÈ·Ú·ı¤ÛÂÈ ÌÂıfi‰Ô˘˜ ˘„ËÏ‹˜ ·ÎÚ›‚ÂÈ·˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ (.¯. DEXA, Dual-Energy Xray Absorptiometry) Ë ·ÓıÚˆÔÌÂÙÚ›· ·Ú·Ì¤ÓÂÈ ÚÒÙË Û ¯Ú‹ÛË ‰ÈÂıÓÒ˜ ·ÊÔ‡ Â›Ó·È ·Û‡ÁÎÚÈÙ· ÈÔ ÚfiÛÊÔÚË, ÂÓÒ ‰ÂÓ ˘ÛÙÂÚ› ·fi ·˘Ù¤˜ ˆ˜ ‰È·ÁÓˆÛÙÈÎfi ̤ÛÔ (33). √È ·ÓıÚˆÔÌÂÙÚÈÎÔ› ‰Â›ÎÙ˜ Ô˘ ¤¯Ô˘Ó ηÙÂÍÔ¯‹Ó ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ¤Ú· ·fi ÙÔ ‚¿ÚÔ˜, ÙÔ Ì‹ÎÔ˜ Î·È ÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜, Â›Ó·È Ô ponderal index, ÙÔ ËÏ›ÎÔ ‚¿ÚÔ˘˜ ÚÔ˜ ÙÔ Ì‹ÎÔ˜ Á¤ÓÓËÛ˘, Ë ÂÚ›ÌÂÙÚÔ˜ Ù˘ ÌÂÛfiÙËÙ·˜ ÙÔ˘ ‚Ú·¯›ÔÓ· Î·È ÙÔ ËÏ›ÎÔ ·˘Ù‹˜ Ù˘ ÂÚÈ̤ÙÚÔ˘ ÚÔ˜ ÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ (¶ªµ/¶∫). √È ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ¿¯Ô˘˜ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ ·ÔÙÂÏÔ‡Ó ·ÍÈfiÏÔÁÔ ÎÚÈÙ‹ÚÈÔ Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ Û ÂÚ¢ÓËÙÈÎfi Â›Â‰Ô (34), fi¯È fï˜ Î·È ÛÙËÓ Î·ı’ Ë̤ڷ Ú¿ÍË, ·ÊÔ‡ ÚÔ¸Ôı¤ÙÔ˘Ó ˘„ËÏ‹ ‰ÂÍÈfiÙËÙ· Î·È ÂÌÂÈÚ›· ÙÔ˘ ÂÍÂÙ·ÛÙ‹, ÂÓÒ ÂÈϤÔÓ ·ÔʇÁÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙ· ÓÂÔÁÓ¿ ÏfiÁˆ Ù˘ ‰˘ÛÊÔÚ›·˜ Ô˘ ÚÔηÏÔ‡Ó. √ ponderal index ·ÔÙÂÏ› ÙÔ ËÏ›ÎÔ ÙÔ˘ ‚¿ÚÔ˘˜, Û ÁÚ·ÌÌ¿ÚÈ· ‰È¿ ÙÔ˘ ·‚Ô˘ ÙÔ˘ Ì‹ÎÔ˘˜ ÛÒÌ·ÙÔ˜, Û ÂηÙÔÛÙ¿ ÔÏÏ·Ï·ÛÈ·Ṳ̂ÓÔ Â› ÂηÙfi: Ponderal Index = µ° (g)/ ª°3 (cm) x 100 ªÂ ÙË Û˘ÓÂÎÙ›ÌËÛË ‚¿ÚÔ˘˜ Î·È Ì‹ÎÔ˘˜ Á¤ÓÓËÛ˘ Á›ÓÂÙ·È ÂÌÊ·Ó‹˜ Ë Û˘ÌÌÂÙÚÈÎfiÙËÙ· ‹ ÌË ÙÔ˘ ÛÒÌ·ÙÔ˜. °È· ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‰Â›ÎÙË, ‚·ÛÈ΋ ÚÔ¸fiıÂÛË Â›Ó·È Ó· ˘¿Ú¯Ô˘Ó ·ÎÚȂ›˜ ÌÂÙÚ‹ÛÂȘ ‚¿ÚÔ˘˜ Î·È È‰È·›ÙÂÚ· ÙÔ˘ Ì‹ÎÔ˘˜, ·ÊÔ‡ Ù˘¯fiÓ Ï¿ıÔ˜ ı· ·Ó˘„ˆı› ÛÙËÓ 3Ë ‰‡Ó·ÌË. °È· Ó· Â›Ó·È ÛˆÛÙ‹ Ë Ì¤ÙÚËÛË ÙÔ˘ Ì‹ÎÔ˘˜ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù’ ·Ú¯¿˜ ‰‡Ô ¿ÙÔÌ·, ÙÔ ¤Ó· Ó· ÎÚ·Ù¿ ÛÙ·ıÂÚfi ÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔ ¿ÏÏÔ ÁÈ· Ó· ¢ıÂÈ¿ÛÂÈ Ù· fi‰È· Î·È Ó· ηٷÁÚ¿„ÂÈ ÙÔ Ì‹ÎÔ˜. ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ÛÙ· ÓÂÔÁÓ¿ ÏfiÁˆ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ο̄˘ ÙˆÓ ÈÛ¯›ˆÓ Î·È Î¿Ùˆ ¿ÎÚˆÓ, Ë Ì¤ÙÚËÛË ·ÚÔ˘ÛÈ¿˙ÂÈ ÔÚÈṲ̂Ó˜ ‰˘ÛÎÔϛ˜ ÌÔÚ›, fï˜, Ó· ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

Á›ÓÂÈ Ì ·ÎÚ›‚ÂÈ· ·ÚΛ Ó· ˘¿Ú¯ÂÈ Ë ·Ó¿ÏÔÁË ÂÎ·›‰Â˘ÛË ·ÏÏ¿ Î·È Ë ·Ó¿ÏÔÁË ·È‰Â›· Î·È Ë Û˘ÓÂȉÔÔ›ËÛË Ù˘ ÛÔ˘‰·ÈfiÙËÙ¿˜ Ù˘ (35). °È· ·ÎÚȂ›˜ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ Ì‹ÎÔ˘˜ ÙˆÓ ÓÂÔÁÓÒÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯ÓfiÙÂÚ· ÙÔ Rollametre (35,36) ‹ ÙÔ Î·Ù¿ Ôχ ·ÎÚÈ‚fiÙÂÚÔ Harpenden Neonatometer (37). °È· Ù· ÌÈÎÚ¿ ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ıÂÚÌÔÎÔÈÙ›‰· ˘¿Ú¯ÂÈ ·ÏÔ‡ÛÙÂÚÔ ·Ó·ÛÙËÌfiÌÂÙÚÔ ÙÔ Pedobaby ruler (35) Î·È ÙÔ ÓÂfiÙÂÚÔ Neorule (38), ·Ï¿ fiÚÁ·Ó· Ô˘ ÌÔÈ¿˙Ô˘Ó Ì ¯¿Ú·Î·. °È· ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ÙÈÌ‹˜ ÙÔ˘ ponderal index ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ¤Ó·˜ ·fi ÙÔ˘˜ Ï›ÁÔ˘˜ Ï‹ÚÂȘ ›Ó·Î˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ fiÏÔ ÙÔ Ê¿ÛÌ· ËÏÈÎÈÒÓ Î‡ËÛ˘ (¶›Ó·Î·˜ 2). ∆· ÛÙÔȯ›· ÙÔ˘ ›Ó·Î· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Û ¤Ó· ÌfiÓÔ ÓÔÛÔÎÔÌÂ›Ô (ÂÔ̤ӈ˜ ‰ÂÓ ‚·Û›˙ÂÙ·È Û ÌÂÙÚ‹ÛÂȘ ÏËı˘ÛÌÔ‡), ÏËÓ fï˜ Ô ·ÚÈıÌfi˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ˘ÂÚ‚·›ÓÂÈ ÙȘ 33.000 (39). ∏ ÂÚ›ÌÂÙÚÔ˜ ÙÔ˘ ‚Ú·¯›ÔÓ· ·ÓÙ·Ó·ÎÏ¿ ÙË Ì˘˚΋ Î·È ÏÈÒ‰Ë Ì¿˙· Ù˘ ÂÚÈÔ¯‹˜. ∆Ô ËÏ›ÎÔ ¶ªµ/¶∫ ıˆÚÂ›Ù·È ÈÔ ¯Ú‹ÛÈÌÔ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ÂÂȉ‹ Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Â¤¯ÂÈ ı¤ÛË ·ÓÂÍ¿ÚÙËÙ˘ ÌÂÙ·‚ÏËÙ‹˜, ·ÊÔ‡ ‰ÂÓ ·ÎÔÏÔ˘ı› Ù· ¿ÏÏ· ۈ̷ÙÔÌÂÙÚÈο Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜. ∞fi ·ÚÎÂÙÔ‡˜ Ô ‰Â›ÎÙ˘ ·˘Ùfi˜ ıˆÚÂ›Ù·È ÈÔ ÂȉÈÎfi˜ ·fi ÙÔÓ ponderal index ÛÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ ÙÔ˘ ÓÂÔÁÓÔ‡ (40). ∆Ô ·Ó·Áη›Ô ·ÏÏ¿ ÈηÓfi ̤ÛÔ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· ÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙÔ˘ ‰Â›ÎÙË Â›Ó·È ÌÈ· ηϋ ÌÂÙÚÔÙ·ÈÓ›·. ∏ ıˆÚËÙÈο ηχÙÂÚË ÌÂÙÚÔÙ·ÈÓ›· ÁÈ· ̤ÙÚËÛË ÂÚÈ̤ÙÚˆÓ Â›Ó·È Ë ÌÂÙ·ÏÏÈ΋ ÂÂȉ‹ ÌÔÚ› Ó· ‰È·ÙËÚËı› ‡ÎÔÏ· ÛÙÔ ˘fi ̤ÙÚËÛË Â›‰Ô, ‰ÂÓ ‰È·Ù›ÓÂÙ·È Î·È ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Â·ÓÂȂ‚·›ˆÛË Ù˘ ·ÎÚ›‚ÂÈ¿˜ Ù˘. øÛÙfiÛÔ ÂÂȉ‹ Û˘Ó‰¤ÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚÔ, ¤ÛÙˆ ıˆÚËÙÈÎfi, ΛӉ˘ÓÔ Î¿ÎˆÛ˘, ·Ô‰ÂÎÙ¤˜ Â›Ó·È Ë Ï·ÛÙÈ΋ Î·È Ë ¯¿ÚÙÈÓË, ÔÈ Ôԛ˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ‰È·‚¿ıÌÈÛË ¯ÈÏÈÔÛÙÒÓ Î·È Ï¿ÙÔ˜ 6-7 ¯ÈÏÈÔÛÙ¿ (41). °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ‰Â›ÎÙË ¶ªµ/¶∫ ÌÂÙÚ¿Ù·È ·Ú¯Èο ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ‚Ú·¯›ÔÓ·, ·fi ÙÔ ·ÎÚÒÌÈÔ ˆ˜ ÙÔ ˆÏ¤ÎÚ·ÓÔ, ÁÈ· Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ÙÔ Ì¤ÛÔ ÙÔ˘, ı¤ÛË ÛÙËÓ ÔÔ›· Ú¤ÂÈ Ó· ÌÂÙÚËı› Ë ÂÚ›ÌÂÙÚÔ˜. ∏ ̤ÙÚËÛË ÙÔ˘ Ì‹ÎÔ˘˜ Á›ÓÂÙ·È Ì ÙÔÓ ‚Ú·¯›ÔÓ· ÙÔ˘ ÓÂÔÁÓÔ‡ Û ı¤ÛË ·Ú¿ÏÏËÏË ÛÙÔÓ ÎÔÚÌfi Î·È ÙÔ ·ÓÙÈ‚Ú¿¯ÈÔ Û ÁˆÓ›· 70Ô-90Ô ÚÔ˜ ÙÔÓ ‚Ú·¯›ÔÓ· (∂ÈÎfiÓ· 1), fï˜ Ë Ì¤ÙÚËÛË Ù˘ ÂÚÈ̤ÙÚÔ˘ ÙÔ˘ ‚Ú·¯›ÔÓ· Á›ÓÂÙ·È ÌÂÙ¿ ÙÔÓ Â˘ıÂÈ·ÛÌfi ÙÔ˘ ·ÓÙÈ‚Ú¿¯ÈÔ˘ Î·È ÙÔ ¿Óˆ ¿ÎÚÔ ·Ú¿ÏÏËÏÔ ÛÙÔÓ ÎÔÚÌfi. ∏

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·357

357

¢È¿ÁÓˆÛË ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜

¶›Ó·Î·˜ 2. Ponderal Index (39) ∏ÏÈΛ· ·ËÛ˘ Û ‚‰ÔÌ¿‰Â˜

ª¤ÛË ÙÈÌ‹ (™∞)

10Ë ÂÎ. ı¤ÛË

50‹ ÂÎ. ı¤ÛË

90‹ ÂÎ. ı¤ÛË

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

2,08 (0,26) 2,08 (0,35) 2,13 (0,30) 2,11 (0,33) 2,18 (0,35) 2,18 (0,45) 2,22 (0,34) 2,29 (0,43) 2,31 (0,29) 2,34 (0,34) 2,42 (0,32) 2,48 (0,55) 2,55 (0,45) 2,61 (0,35) 2,66 (0,41) 2,72 (1,00) 2,75 (1,22) 2,74 (0,79) 2,77 (1,59) 2,78 (0,43)

1,66 1,72 1,72 1,74 1,84 1,78 1,83 1,91 1,97 1,95 2,06 2,09 2,14 2,22 2,24 2,29 2,32 2,31 2,32 2,35

2,15 2,06 2,14 2,09 2,16 2,17 2,19 2,23 2,26 2,31 2,39 2,42 2,51 2,58 2,62 2,66 2,69 2,70 2,70 2,74

2,36 2,38 2,45 2,49 2,53 2,48 2,55 2,57 2,64 2,73 2,78 2,88 2,97 3,04 3,07 3,12 3,14 3,16 3,16 3,12

™∞=ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË

·ÍÈÔÏfiÁËÛË ÙÔ˘ ËÏ›ÎÔ˘ ¶ªµ/¶∫ ÌÔÚ› Ó· Á›ÓÂÈ Ì ‚¿ÛË Ù· fiÚÈ· Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∆· ÛÙÔȯ›· ÙÔ˘ ¶›Ó·Î· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÈÎÚ‹ ·ÏÏ¿ ÙË ÌÔÓ·‰È΋, ηٿ ¿Û· Èı·ÓfiÙËÙ·, ËÁ‹ ‰Â‰ÔÌ¤ÓˆÓ ÁÈ’ ·˘ÙfiÓ ÙÔ ‰Â›ÎÙË, ÙfiÛÔ ÁÈ· ÚfiˆÚ· fiÛÔ Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (42). ∂˘ÓfiËÙÔ Â›Ó·È fiÙÈ ÙfiÛÔ ÔÈ ÌÂÙÚ‹ÛÂȘ ·˘Ù¤˜ fiÛÔ Î·È ÔÈ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ Ì‹ÎÔ˘˜ ÛÒÌ·ÙÔ˜ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Ì ÙÔ ÓÂÔÁÓfi Û ηٿÛÙ·ÛË ËÚÂÌ›·˜ (.¯. ‡ÛÙÂÚ· ·fi Ì¿ÓÈÔ Î·È Á‡̷). ∂› ÙË ‚¿ÛÂÈ fiÛˆÓ ÂÎÙ¤ıËηÓ, Ë ‰È¿ÁÓˆÛË ÙˆÓ IUGR ÓÂÔÁÓÒÓ ÌÔÚ› Ó· Á›ÓÂÈ Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÎÏÈÓÈÎÒÓ Î·È ·ÓıÚˆÔÌÂÙÚÈ-

∂ÈÎfiÓ· 1.

ÎÒÓ ÎÚÈÙËÚ›ˆÓ. ŒÙÛÈ, ·ÎfiÌ· Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ˘ÂÚ˯ÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ÁÈ· ÙÔ˘˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ Ú˘ıÌÔ‡˜ ·‡ÍËÛ˘, ÙÔ ÓÂÔÁÓfi Ô˘ ‰ÂÓ ¤¯ÂÈ ÂÌÊ·ÓÒ˜ ηϋ ıÚ¤„Ë ÌÔÚ› Ó· ÂÏÂÁ¯ı› ÌÂ Û˘Ó‰˘·ÛÌfi ÙˆÓ ‰‡Ô ¿ÏÏˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ Ì¤ÛˆÓ. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ·ÓıÚˆÔÌÂÙÚÈÎÔ‡˜ ‰Â›ÎÙ˜, ÙÈ̤˜ 2 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ οو ·fi ÙË Ì¤ÛË ÙÈÌ‹ (Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÂÚ›Ô˘ ÛÙËÓ 3Ë ÂÎ. ı¤ÛË) Ú¤ÂÈ Ó· ıˆÚËıÔ‡Ó ÂÓ‰ÂÈÎÙÈΤ˜ ˘ÔıÚ„›·˜ Î·È ÙÔ ÓÂÔÁÓfi Ó· ˘Ô‚ÏËı› Û ¤ÏÂÁ¯Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ›‰ÈÔ Ì ·˘ÙfiÓ Ô˘ ÚԂϤÂÙ·È ÁÈ· Ù· SGA ÓÂÔÁÓ¿. øÛÙfiÛÔ, ‰˘ÛÌÂÓ‹˜ ¤Î‚·ÛË ÓÂÔÁÓÒÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› Î·È Ì ÙÈ̤˜ ÌÈÎÚfiÙÂÚ˜ Ù˘ 10˘ ÂÎ. ı¤Û˘ (3). °È· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÓıÚˆÔÌÂÙÚÈÎÒÓ ‰ÂÈÎÙÒÓ ··ÈÙÂ›Ù·È ÁÓÒÛË Ù˘ ËÏÈΛ·˜ ·ËÛ˘, ·Ú¿ÌÂÙÚÔ˜ Ô˘ Â›Ó·È ‹‰Ë ··Ú·›ÙËÙË Î·È ÁÈ· ÙË ‰È¿ÎÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Û SGA Î·È AGA. °ÂÓÈο, Ë ÂÎÙ›ÌËÛË Ù˘ ËÏÈΛ·˜ ·ËÛ˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ - ÂÊfiÛÔÓ Â›Ó·È ÁÓˆÛÙ‹ Î·È ÂÊfiÛÔÓ Ë ÌËÙ¤Ú· ›¯Â ηÓÔÓÈÎÔ‡˜ ·ÎÏÔ˘˜ - ÛÙËÓ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÂÎÙ›ÌËÛË (ηٿ ÚÔÙ›ÌËÛË ÙÔ˘ 1Ô˘ ÙÚÈÌ‹ÓÔ˘), ÂÊfiÛÔÓ ‰ÂÓ ÏËÚÔ‡ÓÙ·È ÔÈ ·Ú·¿Óˆ fiÚÔÈ ‹ ‰È·Ê¤ÚÔ˘Ó ÔÈ ‰‡Ô ÂÎÙÈÌ‹ÛÂȘ ÌÂٷ͇ ÙÔ˘˜ ¿Óˆ ·fi 7-10 Ë̤Ú˜, Î·È Ù¤ÏÔ˜, ÛÙËÓ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Ù˘ ˆÚÈÌfiÙËÙ·˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ∏ ·Ó¿ÁÎË ÁÈ· ÙË ¯Ú‹ÛË Û˘Ó‰˘·ÛÌÔ‡ ‰È·ÁÓˆÛÙÈÎÒÓ Ì¤ÛˆÓ ÁÈ· ÙË ‰È¿ÎÚÈÛË ÙˆÓ IUGR ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

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¶›Ó·Î·˜ 3. ¶ªµ Î·È ¶ªµ/¶∫ (̤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË) (42) ∏ÏÈΛ· ·ËÛ˘ (‚‰.)

¶ªµ (ÂÎ.)

¶ªµ/¶∫

25-26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

4,90 ± 0,7 5,25 ± 0,3 5,50 ± 0,5 5,70 ± 0,4 6,00 ± 0,7 6,40 ± 1,0 7,00 ± 0,5 7,00 ± 0,8 8,30 ± 0,5 8,10 ± 0,6 8,30 ± 0,6 9,50 ± 0,7 9,50 ± 0,7 9,70 ± 0,9 10,10 ± 0,6 10,20 ± 0,6 10,60 ± 0,5

0,22 ± 0,02 0,22 ± 0,01 0,23 ± 0,02 0,23 ± 0,02 0,23 ± 0,02 0,23 ± 0,03 0,24 ± 0,02 0,24 ± 0,02 0,27 ± 0,01 0,26 ± 0,01 0,26 ± 0,02 0,28 ± 0,02 0,28 ± 0,01 0,28 ± 0,02 0,29 ± 0,02 0,29 ± 0,02 0,30 ± 0,01

ÓÂÔÁÓÒÓ ·ÔÚÚ¤ÂÈ ·fi ÙË ¯·ÌËÏ‹ ‰È·ÁÓˆÛÙÈ΋ ÈÛ¯‡ ÙˆÓ ·ÓıÚˆÔÌÂÙÚÈÎÒÓ ‰ÂÈÎÙÒÓ (43,44) Î·È ÙËÓ ·˘ÍË̤ÓË ‰È·Î‡Ì·ÓÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌÂٷ͇ ÂÍÂÙ¿ÛˆÓ/ÂÍÂÙ·ÛÙÒÓ, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ̤ıÔ‰Ô (5). ∏ ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Ù˘ Û˘Ó‰˘·Ṳ̂Ó˘ ¯Ú‹Û˘ Ù˘ ÎÏÈÓÈ΋˜ ÌÂıfi‰Ô˘ Ì ÙÔ˘˜ ·ÓıÚˆÔÌÂÙÚÈÎÔ‡˜ ‰Â›ÎÙ˜ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÎÙÈÌËı›. √È ÌÂϤÙ˜ Ô˘ ·ÔÛÎÔÔ‡Û·Ó ÛÙË ‰È¿ÁÓˆÛË ÙˆÓ IUGR ÓÂÔÁÓÒÓ ‰ÂÓ ÏËÚÔ‡Ó ÙȘ ÚÔ‚ÏÂfiÌÂÓ˜ ÚԉȷÁڷʤ˜ ÂϤÁ¯Ô˘ ‰È·ÁÓˆÛÙÈÎÒÓ Ì¤ÛˆÓ (45), ÂÔ̤ӈ˜ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ¿ÓÙÏËÛË ÛÙÔȯ›ˆÓ ·fi ·˘Ù¤˜ Î·È Ë ÛÙ·ÙÈÛÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ Û¯ÂÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ (ÂȉÈÎfiÙËÙ·, ¢·ÈÛıËÛ›· Î.Ï.) ̤ۈ Ù¯ÓÈÎÒÓ ÌÂÙ··Ó¿Ï˘Û˘ Î·È Û˘ÛÙËÌ·ÙÈ΋˜ ·Ó·ÛÎfiËÛ˘. øÛÙfiÛÔ, ·fi ¿Ù˘Ë ÂÎÙ›ÌËÛË ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ (3,40), Ô˘ ÚÔÛʤÚÔÓÙ·Ó ÁÈ· Â·Ó·ÍÈÔÏfiÁËÛË, ÌÔÚ› Ó· ÂÍ·¯ı› ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÙˆÓ ‰ÂÈÎÙÒÓ PI Î·È ¶ªµ/¶∫, ÙÔ ËÏ›ÎÔ Èı·ÓÔÙ‹ÙˆÓ ÁÈ· ÙËÓ ÚfiÁÓˆÛË ‰˘ÛÌÂÓÔ‡˜ ¤Î‚·Û˘ ˘ÔıÚ„ÈÎÒÓ ÓÂÔÁÓÒÓ ÛÙËÓ ÚÒÈÌË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Â›Ó·È ÂÚ›Ô˘ 3,5, ÂÊfiÛÔÓ Â›Ó·È ·ıÔÏÔÁÈÎfi˜ Ô ¤Ó·˜ ·fi ÙÔ˘˜ ‰‡Ô ‰Â›ÎÙ˜, ÂÓÒ ˘ÂÚ‚·›ÓÂÈ Î·Ù¿ Ôχ ÙÔ 10 - fiÚÈÔ ÁÈ· Ó· ¯·Ú·ÎÙËÚÈÛÙ› ηϋ ÌÈ· ‰È·ÁÓˆÛÙÈ΋ ̤ıÔ‰Ô˜ (46) fiÙ·Ó Î·È ÔÈ ‰‡Ô ‰Â›ÎÙ˜ Â›Ó·È ·ıÔÏÔÁÈÎÔ›. ∂ÈϤÔÓ, ·Ó Ì ÙÔ˘˜ ·Ú·¿Óˆ ‰Â›ÎÙ˜ Û˘Ó‰˘·ÛÙÔ‡Ó Ù· 9 ÛËÌ›· Ù˘ ÎÏÈÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘, Ë ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· Ù˘ Û˘Ó‰˘·Ṳ̂Ó˘ ÌÂıfi‰Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ·˘ÍËı› ·ÎfiÌ· ÂÚÈÛfiÙÂÚÔ (47). ∆Ô ÂÓ·ÏÏ·ÎÙÈÎfi ÎÚÈÙ‹ÚÈÔ ·ÍÈÔÏfiÁËÛ˘ ¶·È‰È·ÙÚÈ΋ 2006;69:350-360

ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, Ô˘ ÚÔÙ¿ıËΠ·Ú·¿Óˆ, ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ıÂÙÈο ÂÂȉ‹ ·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ ·ÓÂÍ¿ÚÙËÙ˜ ·fi ÙËÓ ÂÓ·fiıÂÛË Ï›Ô˘˜, ÙËÓ ÔÔ›· ·ÍÈÔÏÔÁÔ‡Ó ÙfiÛÔ Ù· ˘fiÏÔÈ· fiÛÔ Î·È ÔÈ ·ÓıÚˆÔÌÂÙÚÈÎÔ› ‰Â›ÎÙ˜. ∆¤ÏÔ˜, Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÁÓˆÛË ÙÔ˘ ·Û‡ÌÌÂÙÚÔ˘ IUGR Î·È ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡. ∆· Û˘ÌÌÂÙÚÈο IUGR ÓÂÔÁÓ¿ ¤¯Ô˘Ó Â·ÚΤ˜ ˘Ô‰fiÚÈÔ Ï›Ô˜ Î·È ÛˆÌ·ÙÔÌÂÙÚÈο ÛÙËÓ ›‰È· ÂÚ›Ô˘ ÂηÙÔÛÙÈ·›· ı¤ÛË, ÂÔ̤ӈ˜ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ Ô‡Ù Ì ÙË Ì¤ıÔ‰Ô CANS Ô‡Ù Ì ÙÔ˘˜ ·ÓıÚˆÔÌÂÙÚÈÎÔ‡˜ ‰Â›ÎÙ˜, ÔÈ ÙÈ̤˜ ÙˆÓ ÔÔ›ˆÓ ·Ó·Ì¤ÓÔÓÙ·È Ê˘ÛÈÔÏÔÁÈΤ˜. µÂÏÙÈÒÓÔÓÙ·˜ ÙȘ ÈηÓfiÙËÙ¤˜ Ì·˜ Ó· ‰È·ÎÚ›ÓÔ˘Ì ٷ IUGR ÓÂÔÁÓ¿ ı· ÌÔÚ¤ÛÔ˘Ì ӷ ÚÔÛ‰ÈÔÚ›ÛÔ˘Ì ¢ÎÔÏfiÙÂÚ· Ù· ·›ÙÈ· Î·È ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˘ÔıÚ„›·˜, ÙË Û˘¯ÓfiÙËÙ· Î·È ÙȘ ÂÈÙÒÛÂȘ Ù˘. ∞˘Ù¤˜ Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ ·ÏÏ¿ Î·È ÙȘ Èı·Ó¤˜ Ì·ÎÚÔÚfiıÂÛ̘. ™ˆÛÙ‹ ÌÂϤÙË ·˘ÙÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· Á›ÓÂÈ Û ÌÈÎÙÔ‡˜ ÏËı˘ÛÌÔ‡˜ ˘ÔıÚ„ÈÎÒÓ Î·È Î·Ï‹˜ ıÚ¤„˘ ÓÂÔÁÓÒÓ, fiˆ˜ Â›Ó·È Ô ÏËı˘ÛÌfi˜ ÙˆÓ SGA, Ô‡Ù Ì ÌÔÓ·‰ÈÎfi ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘.

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¶·È‰È·ÙÚÈ΋ 2006;69:350-360

43. Drossou V, Diamanti E, Noutsia H, Konstantinidis T, Katsougiannopoulos V. Accuracy of anthropometric measurements in predicting symptomatic SGA and LGA neonates. Acta Paediatr 1995;84:1-5.

44. Haggarty P, Campbell DM, Bendomir A, Gray ES, Abramovich DR. Ponderal index is a poor predictor of in utero growth retardation. BJOG 2004;111: 113-119.

45. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Standards for Reporting of Diagnostic Accuracy. Clin Chem 2003;49:1-6.

46. Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005;365:1500-1505.

47. Halkin A, Reichman J, Schwaber M, Paltiel O, Brezis M. Likelihood ratios: getting diagnostic testing into perspective. QJM 1998;91:247-258.

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361

ªÂϤÙË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÛÙËÓ ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· º. ∞ı·Ó·ÛÈ¿‰Ô˘ - ¶ÈÂÚÔÔ‡ÏÔ˘1, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜1, π. ƒÔ‡ÛÛÔ1, °. ∫·Ù˙fi˜2, ª. ∫·Ú·ÌÔ‡˙˘3, π. ∫·Ú·ÌÔ‡˙˘3, £. ¶··ÁˆÚÁ›Ô˘1, π. ∆ÛÈÙÔ˘Ú›‰Ë˜4

¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ηٿ ÙËÓ

¤Ó·ÚÍË Î·È ÙË ‰È¿ÚÎÂÈ· ıÂÚ·›·˜ ·È‰ÈÒÓ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (√§§). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 26 ·È‰È¿ Ì √§§, Ô˘ ¤Ï·‚·Ó ÙÔ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95. √È ·ÛıÂÓ›˜ ÌÂÏÂÙ‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÁÓˆÛË (t=0), ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ÂÊfi‰Ô˘/Â·ÓÂÊfi‰Ô˘ (t=0,5), ¤Ó·Ó ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË (ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ Û˘ÓÙ‹ÚËÛ˘) (t=1) ηÈ, Ù¤ÏÔ˜, ‰‡Ô ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (t=2). °È· οı ·ÛıÂÓ‹ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, ÙˆÓ Ì˘ÔÛÎÂÏÂÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ (ÔÛÙÈο ¿ÏÁË, ¯ˆÏfiÙËÙ·) Î·È ÙˆÓ Ì˘ÔÛÎÂÏÂÙÈÎÒÓ ÂÈÏÔÎÒÓ (ηٿÁÌ·Ù·, ÔÛÙÂÔÓ¤ÎÚˆÛË) ÛÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ¯ÚfiÓÔ˘˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ¤ÁÈÓ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ (bone mineral density - BMD) Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (O1-O4) Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·ÔÚÚfiÊËÛ˘ ‰ÈÏ‹˜ ÂÓ¤ÚÁÂÈ·˜ ‰¤ÛÌ˘ ʈÙÔÓ›ˆÓ ˘„ËÏ‹˜ ÂÓ¤ÚÁÂÈ·˜ (DEXA) (Norland bone densitometer), ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ (Ca, P, ALP), Ù˘ ÔÏÈ΋˜ ·Ú·ıÔÚÌfiÓ˘ (iPTH) Î·È ÙˆÓ ‰ÂÈÎÙÒÓ ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜ Î·È ·ÔÚÚfiÊËÛ˘ [·ÌÈÓÔÙÂÏÈÎfi ÂÙ›‰ÈÔ ÙÔ˘ ÚÔÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ π (PINP) Î·È Î·Ú‚Ô͢ÙÂÏÈÎfi ÙÂÏÔÂÙ›‰ÈÔ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ π (ICTP)] ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 0, 0,5, 1 Î·È 2, ·ÓÙ›ÛÙÔȯ·. √È ÙÈ̤˜ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÂÙ·ÙÚ¿ËÎ·Ó Û ÙÈ̤˜ z-scores, ÔÈ Ôԛ˜ ÂÎÊÚ¿˙Ô˘Ó ÙËÓ ·fiÎÏÈÛË ·fi ÙË Ì¤ÛË ÙÈÌ‹ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ ‚¿ÚÔ˜, ÙÔ ‡„Ô˜ Î·È ÙÔ Ê‡ÏÔ. ∆· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ ÌÂϤÙ˘ Û˘ÁÎÚ›ıËÎ·Ó Ì ٷ ·ÓÙ›ÛÙÔȯ· 26 ÎÏÈÓÈο ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ ›‰È·˜ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘. ∞ÔÙÂϤÛÌ·Ù·: ∏ ̤ÛË ÙÈÌ‹ z-score Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (zLS) ÌÂÙ¿ ÙË ¯ËÌÂÈÔıÂÚ·›· ÂÊfi‰Ô˘/Â·ÓÂÊfi‰Ô˘ (t=0,5) ‹Ù·Ó -1,04 (ÂÓ‰ÂÈÎÙÈ΋ ÔÛÙÂÔÂÓ›·˜) Î·È ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Î·Ù¿ ÙË ‰È¿ÁÓˆÛË (-0,43) (p<0,05). ∂›Û˘, Ë Ì¤ÛË ÙÈÌ‹ zLS ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο Û fiÏÔ˘˜ ÙÔ˘˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ‹˜ Ù˘ (0, 0,5, 1, 2) ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∏ ̤ÛË ÙÈÌ‹ Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ PINP, ˆ˜ ‰Â›ÎÙË ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜, ‹Ù·Ó ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹ ηٿ ÙË ‰È¿ÁÓˆÛË, ·˘Í‹ıËΠÛËÌ·ÓÙÈο ÛÙÔ ¯ÚfiÓÔ t=0,5 Î·È ·Ú¤ÌÂÈÓ ˘„ËÏ‹ ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 1 Î·È 2 (p<0,05). ∆¤ÏÔ˜, Ë Ì¤ÛË ÙÈÌ‹ Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ICTP (‰Â›ÎÙ˘ ÔÛÙÈ΋˜ ·Ô‰fiÌËÛ˘) ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ·˘Í‹ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 0,5 Î·È 1 (p<0,05). ™˘ÌÂÚ¿ÛÌ·Ù·: ∞fi ÙË ÌÂϤÙË ÚÔ·ÙÂÈ fiÙÈ ·Ú·ÙËÚÂ›Ù·È ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ Ù˘ ·È‰È΋˜ √§§. √ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ‹˜ Ù˘ Â›Ó·È Èı·Ófiٷٷ ÔÏ˘·Ú·ÁÔÓÙÈÎfi˜ Î·È Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ÙË ¯ËÌÂÈÔıÂÚ·›· Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi Ì ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ Î·È ÙË ÌÂȈ̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·.

* µ’ ÈڤÌÂÈÔ Œ·ıÏÔ 43Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 2005 1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË 2 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË 3 ∂ÚÁ·ÛÙ‹ÚÈÔ µÈÔ¯ËÌ›·˜ ∞.¶.£., £ÂÛÛ·ÏÔÓ›ÎË 4 ∞ÎÙÈÓÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶··ÁˆÚÁ›Ô˘, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: º·Ó‹ ∞ı·Ó·ÛÈ¿‰Ô˘¶ÈÂÚÔÔ‡ÏÔ˘ µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ ™Ù. ∫˘ÚȷΛ‰Ë 1, ∆.∫. 546 36 E-mail: tragian@hotmail.com, atriagia@auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-04-2006 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-06-2006

§¤ÍÂȘ ÎÏÂȉȿ: √ÛÙÈ΋ ˘ÎÓfiÙËÙ·, ÔÛÙÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜, ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·.

Evaluation of bone metabolism in children with acute lymphoblastic leukaemia F. Athanassiadou - Piperopoulou1, A. Tragiannidis1, I. Rousso1, G. Katzos2, M. Karamouzis3, I. Karamouzis3, T. Papageorgiou1, I. Tsitouridis4

Abstract: Background: The aim of this prospective study was to evaluate bone metabolism in children with

acute lymphoblastic leukaemia (ALL) at diagnosis, after intensive chemotherapy and during consolidation treatment.

Methods: The study subjects were 26 children with ALL, treated according to the ALL-BFM ’95 ∏ ÂÚÁ·Û›· ·˘Ù‹ ‚Ú·‚‡ıËΠ̠ÙÔ Bã ÈڤÌÂÈÔ Œ·ıÏÔ ÛÙÔ 43Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ∫ˆ˜ 17-19 πÔ˘Ó›Ô˘ 2005

* 2nd Choremio Award 43rd Panhellenic Paediatric Meeting, 2005 1 2nd Paediatric Clinic, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki 2 1st Paediatric Clinic, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki 3 Laboratory of Biochemistry, Aristotle University of Thessaloniki, Thessaloniki 4 Laboratory of Radiology, Papageorgiou Hospital, Thessaloniki ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

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Correspondence: Fani AthanassiadouPiperopoulou 2nd Paediatric Clinic of Aristotelion University, AHEPA University Hospital 1, St. Kyriakidi Str., 546 36, Thessaloniki E-mail: tragian@hotmail.com, atriagia@auth.gr Date of submission: 13-04-2006 Date of approval: 28-06-2006

º. ∞ı·Ó·ÛÈ¿‰Ô˘ - ¶ÈÂÚÔÔ‡ÏÔ˘ Î·È Û˘Ó.

chemotherapy protocol. They were studied at diagnosis (t=0), 6 months after initiation of intensive chemotherapy (after completion of the induction/reinduction treatment) (t=0.5), one year after diagnosis (during consolidation treatment) (t=1) and finally, two years after diagnosis and start of therapy (t=2). Demographic data, musculoskeletal symptoms (bone pain, limb) and skeletal complications (fractures, osteonecrosis) were registered. On each child were measured: lumbar spine bone mineral density (BMD; g/cm2) by dual energy X-ray absorptiometry (DEXA) (Norland bone densitometer), biochemical parameters (Ca, P, ALP), intact parathormone (iPTH) and biochemical markers of bone formation and absorption respectively [N-terminal propeptide of type I collagen (PINP) and C-terminal telopeptide of type I collagen (ICTP)]. All measurements were performed at diagnosis and during chemotherapy (t=0.5, 1 and 2). Bone mineral density results were expressed as age- and sex-standardized z-scores. All parameters measured were compared with those of 26 age and sex matched clinically healthy controls.

Results: The mean z-score of lumbar spine (zLS) after induction/reinduction of chemotherapy (t=0.5) was -1.04 (indicative of osteopenia), which differed significantly from the mean value at diagnosis (-0.43) (p<0.05). Moreover, the mean zLS differed significantly at t=0, t=0.5, t=1 and t=2 from the mean values of the controls. The mean value of PINP, as bone formation marker, was found reduced at diagnosis and significantly increased at t=0.5, t=1 and t=2 (p<0.05). The mean ICTP value, a bone degradation marker, was normal at diagnosis and increased significantly at t=0.5, t=1 and t=2 (p<0.05).

Conclusions: These data indicate that bone metabolism is affected in childhood ALL, both by the disease itself at diagnosis and during the chemotherapy treatment. The causes probably are multifactorial, related mainly to chemotherapy and to a lesser degree to the disease itself and the associated physical inactivity.

Key words: Bone mineral density, bone metabolism, acute lymphoblastic leukaemia.

∂ÈÛ·ÁˆÁ‹ ™ËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ¤¯ÂÈ ÂÈÙ¢¯ı› ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÁÓˆÛË Î·È ÙË ıÂÚ·›· Ù˘ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÁÂÁÔÓfi˜ Ô˘ ÂȂ‚·ÈÒÓÂÙ·È Î·È ·fi ÙËÓ ˘„ËÏ‹ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË (eventfree survival) ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ¤Î‚·Û˘ Ù˘ ÓfiÛÔ˘ ÔÊ›ÏÂÙ·È ÂÓ Ì¤ÚÂÈ ÛÙË ¯Ú‹ÛË Ó¤ˆÓ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Ê·Ú̿ΈÓ, ηıÒ˜ Î·È ÛÙÔ Û˘Ó‰˘·ÛÌfi ¯ËÌÂÈÔıÂÚ·›·˜ Î·È ·ÎÙÈÓÔıÂÚ·›·˜. ∏ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘, fï˜, Û¯ÂÙ›˙ÂÙ·È Ì ÔÏϤ˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ıÂÚ·›·˜. ∏ ÔÛÙÂÔÂÓ›· Î·È Ë ÔÛÙÂÔfiÚˆÛË ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Û‹ÌÂÚ· ˆ˜ ÛËÌ·ÓÙÈ΋˜ ÛËÌ·Û›·˜ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ Ù˘ ıÂÚ·›·˜ ·È‰ÈÒÓ Ì Ï¢¯·ÈÌ›·, ÏfiÁˆ Ù˘ Â›ÙˆÛ‹˜ ÙÔ˘˜ ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘˜, ÂÍ·ÈÙ›·˜ Ù˘ ÂÏ¿ÙÙˆÛ˘ Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ (1). ∏ ÔÛÙÂÔÂÓ›· Î·È Ë ÔÛÙÂÔfiÚˆÛË ¤¯Ô˘Ó ·Ú·ÙËÚËı› Û fiϘ ÙȘ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘: ηٿ ÙË ‰È¿ÁÓˆÛË, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜, ·ÏÏ¿ Î·È ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜, ̤¯ÚÈ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÙÔ˘˜ (2-5). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÔÛÙÂÔÛÎÏ‹Ú˘ÓÛË, ÔÛÙÂÔÓ¤ÎÚˆÛË Î·È ·ıÔÏÔÁÈο ηٿÁÌ·Ù· Û ·È‰È¿ ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ÁÈ· √§§, ηıÒ˜ Â›Û˘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ÔÛÙÂÔÂÓ›· Î·È ÔÛÙÂÔfiÚˆÛË (6-9). √È ·ÎÚȂ›˜ Ì˯·ÓÈÛÌÔ› Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ù¤˜ ÙȘ ÂÈÏÔΤ˜ ‰ÂÓ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ηٿ ÙË ıÂÚ·›· Ù˘ √§§ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÚˆÙÂ‡Ô˘Û· ı¤ÛË Î·Ù¤¯Ô˘Ó Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë Â˘·ÈÛıËÛ›· ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·ÔÙÂÏ› ıÂÙÈÎfi ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ Ï¢¯·ÈÌ›·˜, fï˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Û¯ÂÙ›˙ÔÓÙ·È Â›Û˘ Ì ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ ‹ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛ‹ Ù˘, fiˆ˜ Â›Ó·È Ë ·¯˘Û·ÚΛ·, Ë ÔÛÙÂÔÓ¤ÎÚˆÛË Î·È Ë ÂΉ‹ÏˆÛË ÔÛÙÂÔÂÓ›·˜-ÔÛÙÂÔfiÚˆÛ˘ (10). ∂ÎÙfi˜, fï˜, ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹, ÙÂÏÂ˘Ù·›· ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Î·È ¯ËÌÂÈÔıÂÚ·¢ÙÈο Ê¿Ú̷η, fiˆ˜ Ë ÌÂıÔÙÚÂÍ¿ÙË. ∞fi ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË Ù˘ Û ·È‰È¿ ÚÔηÏ› ÔÛÙÈο ¿ÏÁË, ÔÛÙÂÔÂÓ›·-ÔÛÙÂÔfiÚˆÛË Î·È Î·Ù¿ÁÌ·Ù· (11). ∂ÈϤÔÓ, Ë Ì›ˆÛË ÙÔ˘ ÊÔÚÙ›Ô˘, ˆ˜ Û˘Ó¤ÂÈ· Ù˘ ·ÎÈÓËÙÔÔ›ËÛ˘, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÔÛÙÔ‡ ·fi ÙÔ˘˜ ÔÛÙÂÔ‚Ï¿ÛÙ˜ ηÈ

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·363

363

√ÛÙÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ÛÙËÓ ·È‰È΋ √§§

˘ÚÔ‰ÔÙ› ÙËÓ ÔÛÙÂÔÎÏ·ÛÙÈ΋ ·ÔÚÚfiÊËÛË, Ô‰ËÁÒÓÙ·˜ ÛÙË ‰Â˘ÙÂÚÔ·ı‹ ÔÛÙÂÔfiÚˆÛË ·fi ·ÎÈÓËÙÔÔ›ËÛË (12). ¶ÚÔ·ÙÂÈ, ÂÔ̤ӈ˜, fiÙÈ Ë ·ıÔÁ¤ÓÂÛË Ù˘ ÔÛÙÂÔÂÓ›·˜-ÔÛÙÂÔfiÚˆÛ˘ ÛÙ· ·È‰È¿ Ì √§§ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ (ÏfiÁˆ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ÔÛÙÂÔÎÏ·ÛÙÒÓ Ì¤Ûˆ ·Ú·ÁˆÁ‹˜ ΢ÙÙ·ÚÔÎÈÓÒÓ ·fi ÙÔ˘˜ ÏÂÌÊÔ‚Ï¿ÛÙ˜), ÙË ¯ËÌÂÈÔıÂÚ·›· Î·È ÙËÓ ÂÚÈÔÚÈṲ̂ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 26 ·È‰È¿ Ì √§§, Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙÔ ∞ÈÌ·ÙÔÏÔÁÈÎfi/√ÁÎÔÏÔÁÈÎfi ∆Ì‹Ì· Ù˘ µã ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ Î·È ¤Ï·‚·Ó ÙÔ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95 (¶›Ó·Î·˜ 1). ∂Ï‹ÊıË ÁÚ·Ù‹ Û˘ÁηٿıÂÛË ·fi ÙÔ˘˜ ÁÔÓ›˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ ÛÙË ÌÂϤÙË. ∫·Ó›˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ ¤·Û¯Â ·fi ÓfiÛÔ Û˘Ì‚·Ù‹ Ì ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ηٿ ÙË ‰È¿ÁÓˆÛË. ∞fi Ù· 26 ·È‰È¿ Ù˘ ÌÂϤÙ˘, 14 (53,8%) ‹Ù·Ó ·ÁfiÚÈ· Î·È 12 (46,2%) ‹Ù·Ó ÎÔÚ›ÙÛÈ·, ÂÓÒ Ë Ì¤ÛË ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 6,15 (±3,20) ¤ÙË. ø˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (standard risk - SR) ÎÚ›ıËÎ·Ó 18 (69,2%) ·ÛıÂÓ›˜, ˆ˜ ÂӉȿÌÂÛÔ˘ 3 (11,5%) Î·È ˆ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 5 (19,2%). ªÂ ‚¿ÛË ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ Ù·ÍÈÓfiÌËÛË, 20 ·È‰È¿ (76,9%) ›¯·Ó ¯·Ú·ÎÙ‹Ú˜ √§§ µÎ·È 6 (23,1%) ∆-΢ÙÙ·ÚÈ΋˜ ·Ú¯‹˜. √È ÌÂÙÚ‹ÛÂȘ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ ¤ÁÈÓ·Ó Î·Ù¿ ÙË ‰È¿ÁÓˆÛË (t=0), ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ÂÊfi‰Ô˘/Â·ÓÂÊfi‰Ô˘ (t=0,5), ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË (ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ Û˘ÓÙ‹ÚËÛ˘) (t=1) ηÈ, Ù¤ÏÔ˜, ‰‡Ô ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (ÚÈÓ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ Û˘ÓÙ‹ÚËÛ˘) (t=2). °È· οı ·È‰› ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙÔ˘ ʇÏÔ˘, Ù˘ ËÏÈΛ·˜, ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Î·È ÙÔ˘ Ù‡Ô˘ Ù˘ √§§ (¯·ÌËÏÔ‡, ÂӉȿÌÂÛÔ˘ Î·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ·ÓÙ›ÛÙÔȯ·). ∂›Û˘, ¤ÁÈÓ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (Ca), ÙÔ˘ ʈÛÊfiÚÔ˘ (P), ÙÔ˘ Ì·ÁÓËÛ›Ô˘ (Mg) Î·È Ù˘ ÔÏÈ΋˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ÙÔ˘ ÔÚÔ‡ (ALP) ÛÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ¯ÚfiÓÔ˘˜. √ ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ˘ÔÏÔÁ›ÛÙËΠ̠ÙÔÓ Ù‡Ô: ‚¿ÚÔ˜/‡„Ô˜2 (kg/m2, ‰Â›ÎÙ˘ Quatelet). ∏ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (bone mineral density) (g/cm2) Ù˘ ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (√1-√4) ÌÂÙÚ‹ıËΠ̠ÙË Ì¤ıÔ‰Ô ·ÔÚÚfiÊËÛ˘ ‰ÈÏ‹˜ ÂÓ¤ÚÁÂÈ·˜ ‰¤ÛÌ˘ ʈÙÔÓ›ˆÓ ˘„ËÏ‹˜ ÂÓ¤ÚÁÂÈ·˜ (DEXA) (Norland bone densitometer). √È ·fiÏ˘Ù˜ ÙÈ̤˜ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ·È‰ÈÒÓ ÂÎÊÚ¿ÛÙËÎ·Ó Û ÙÈ̤˜ z-scores, ÔÈ Ôԛ˜ ÂÎÊÚ¿˙Ô˘Ó ÙËÓ ·fiÎÏÈÛË ·fi ÙË Ì¤ÛË ÙÈÌ‹ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ ‚¿ÚÔ˜, ÙÔ ‡„Ô˜ Î·È ÙÔ Ê‡ÏÔ (13). ∂ÈϤÔÓ, ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙÚ‹ıËÎ·Ó ÛÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ¯ÚfiÓÔ˘˜ ÙÔ ·ÌÈÓÔÙÂÏÈÎfi ÂÙ›‰ÈÔ ÙÔ˘ ÚÔÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ π (PINP) Î·È ÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ÙÂÏÔÂÙ›‰ÈÔ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ π (ICTP), ˆ˜ ‰Â›ÎÙ˜ ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜ Î·È ·ÔÚÚfiÊË-

Û˘, ·ÓÙ›ÛÙÔȯ·, Ì ڷ‰ÈÔ·ÓÔÛÔ‚ÈÔ¯ËÌÈ΋ ̤ıÔ‰Ô (RIA), ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ kit Ù˘ ÂÙ·ÈÚ›·˜ Orion (Finland). °È· ÙÔÓ ÔÛÔÙÈÎfi ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ iPTH ÛÙÔÓ ÔÚfi ¯ÚËÛÈÌÔÔÈ‹ıËΠڷ‰ÈÔ·ÓÔÛÔÌÂÙÚÈ΋ ̤ıÔ‰Ô˜ (IRMA). ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 26 ·È‰È¿ ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘, ÛÙ· ÔÔ›· ηٷÁÚ¿ÊËÎ·Ó Î·È ÌÂÙÚ‹ıËÎ·Ó ÔÈ ÚÔ·Ó·ÊÂÚfiÌÂÓ˜ ·Ú¿ÌÂÙÚÔÈ.

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS (version 7.5). ∏ ̤ıÔ‰Ô˜ Ù˘ ÛÙ·ÙÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘ ÂÚÈÂÏ¿Ì‚·Ó ˘ÔÏÔÁÈÛÌfi ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ Ù˘ ̤Û˘ ÙÈÌ‹˜ (mean), Ù˘ ‰È·Ì¤ÛÔ˘ ÙÈÌ‹˜ (median), Ù˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ (standard deviation - SD) Î·È ÙÔ˘ ÛÙ·ıÂÚÔ‡ ÛÊ¿ÏÌ·ÙÔ˜ ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘ (standard error of the mean - SEM). °È· ÙÔÓ ¤ÏÂÁ¯Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜, ÂÊ·ÚÌfiÛÙËÎÂ Ë ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·Ú·ÙËÚ‹ÛÂȘ ηٿ ˙‡ÁË (t-test for paired observations) ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·ÛıÂÓÒÓ Î·È Ë ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·ÓÂÍ¿ÚÙËÙ· ‰Â›ÁÌ·Ù· (independent samples t-test) ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ ·ÛıÂÓÒÓ Î·È Ì·ÚÙ‡ÚˆÓ. ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.

∞ÔÙÂϤÛÌ·Ù· ∞fi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ Ì˘ÔÛÎÂÏÂÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘˜ ηٿ ÙË ‰È¿ÁÓˆÛË, ÚԤ΢„ fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·Ó¤ÊÂÚ·Ó ÙËÓ ·ÚÔ˘Û›· ÔÛÙÈÎÒÓ ·ÏÁÒÓ Û ÔÛÔÛÙfi 42,3% (11 ·È‰È¿). ÈÏfiÙËÙ· ·ÚÔ˘Û›·˙·Ó 3 (11%) ·È‰È¿, ÂÓÒ ·fi ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î¿Ù·ÁÌ· ›¯Â ÔÛÔÛÙfi 11,5% (3 ·È‰È¿) ηٿ ÙË ‰È¿ÁÓˆÛË. √ÛÙÂÔÓ¤ÎÚˆÛË ÂÌÊ¿ÓÈÛ·Ó 2 ·È‰È¿ ËÏÈΛ·˜ 11 Î·È 13 ÂÙÒÓ, ·ÓÙ›ÛÙÔȯ·, ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ıÂÚ·›·˜ ÂÊfi‰Ô˘/Â·ÓÂÊfi‰Ô˘ Î·È ÙË ‰È·ÎÔ‹ Ù˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ˘„ËϤ˜ ‰fiÛÂȘ (10 mg/m2) Î·È ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (28 Ë̤Ú˜). ∏ ηٷÁÚ·Ê‹ ÙˆÓ Ì˘ÔÛÎÂÏÂÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ (ÔÛÙÈο ¿ÏÁË, ¯ˆÏfiÙËÙ·) Î·È ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ ÂÈÏÔÎÒÓ (ηٿÁÌ·Ù·, ÔÛÙÂÔÓ¤ÎÚˆÛË) Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ªÂ ‚¿ÛË ÙË Ì¤ÙÚËÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ÚԤ΢„ ÌÂȈ̤ÓË Ì¤ÛË ÙÈÌ‹ z-score (zLS) Ô˘ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ Ì·ÚÙ‡ÚˆÓ (p<0,05). ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ıÂÚ·›·˜ ÂÊfi‰Ô˘/Â·ÓÂÊfi‰Ô˘ (t=0,5) ηٷÁÚ¿ÊËΠÂÚ·ÈÙ¤Úˆ Ì›ˆÛË Ù˘ zLS [ÙÈÌ‹ ÂÓ‰ÂÈÎÙÈ΋ ÔÛÙÂÔÂÓ›·˜ Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ¶·ÁÎfiÛÌÈ·˜ √ÚÁ¿ÓˆÛ˘ ÀÁ›·˜ (WHO)] (¶›Ó·Î·˜ 3). ∏ zLS ·Ú¤ÌÂÈÓ ¯·ÌËÏ‹ ÛÙÔ ¯ÚfiÓÔ t=1 (‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û ۇÁÎÚÈÛË Ì ÙË Ì¤ÛË ÙÈÌ‹ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹) Î·È ·ÚÔ˘Û›·˙ ۷ʋ ‚ÂÏÙ›ˆÛË Ù˘ ÙÈÌ‹˜ Ù˘ ÛÙÔ ¯ÚfiÓÔ t=2. ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

Pediatr Sept_Oct 06

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º. ∞ı·Ó·ÛÈ¿‰Ô˘ - ¶ÈÂÚÔÔ‡ÏÔ˘ Î·È Û˘Ó.

∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ z-scores ÛÙÔÓ ¯ÚfiÓÔ Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ PINP (ˆ˜ ‰Â›ÎÙË ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜) ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÙˆÓ ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ (p<0,05). √È ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÙÔ˘ PINP ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 0,5, 1 Î·È 2 ηٷÁÚ¿ÊËÎ·Ó ·˘ÍË̤Ó˜ Î·È ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Î·Ù¿ ÙË ‰È¿ÁÓˆÛË (p<0,05). ∏ ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÙÈÌÒÓ ÙÔ˘ PINP Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ICTP (ˆ˜ ‰Â›ÎÙË ÔÛÙÈ΋˜ ·ÔÚÚfiÊËÛ˘) ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙË Ì¤ÛË ÙÈÌ‹ ÙˆÓ Ì·ÚÙ‡ÚˆÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, fï˜ ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 0,5 Î·È 1 ·ÚÔ˘Û›·˙ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË (p<0,05), ·ÓÙ·Ó·ÎÏÒÓÙ·˜ ÙËÓ ÔÛÙÈ΋ ·ÔÚÚfiÊËÛË, ˆ˜ Û˘Ó¤ÂÈ· Ù˘ ÂÓÙ·ÙÈ΋˜ ¯ËÌÂÈÔıÂÚ·›·˜. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ÛÙÔÓ ¯ÚfiÓÔ t=2, ‰ÂÓ ‰È¤ÊÂÚ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ Ì·ÚÙ‡ÚˆÓ, fï˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË Û ۇÁÎÚÈÛË Ì ÙË Ì¤ÛË ÙÈÌ‹ ηٿ ÙË ‰È¿ÁÓˆÛË (∂ÈÎfiÓ· 3). ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ BMI ·˘Í‹ıËΠÛËÌ·ÓÙÈο ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 0,5, 1 Î·È 2, fï˜ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ

Ì·ÚÙ‡ÚˆÓ ÌfiÓÔ ÛÙÔÓ ¯ÚfiÓÔ t=2 (p<0,05). ∏ ̤ÛË ÙÈÌ‹ Ù˘ ALP ‹Ù·Ó ¯·ÌËÏ‹ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ·˘Í‹ıËΠÛËÌ·ÓÙÈο ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ t=1 Î·È t=2 (p<0,05). ∆¤ÏÔ˜, ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ˘fiÏÔÈˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó (Ca, P, iPTH) ‰ÂÓ Î·Ù·ÁÚ¿ÊËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÙˆÓ ÙÈÌÒÓ ÙÔ˘˜. ∆· ·ÔÙÂϤÛÌ·Ù· fiÏˆÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∞fi ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ‚¿ÛË ÙÔ Ê‡ÏÔ ‰ÂÓ ÚԤ΢„·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ. ∞ÓÙ›ıÂÙ·, ·fi ÙËÓ ·Ó¿Ï˘ÛË Ì ‚¿ÛË ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ Ù·ÍÈÓfiÌËÛË Ù˘ √§§ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ ICTP ηٿ ÙË ‰È¿ÁÓˆÛË. ™˘ÁÎÂÎÚÈ̤ӷ, Ù· ·È‰È¿ Ì µ-΢ÙÙ·ÚÈ΋˜ ·Ú¯‹˜ √§§ ›¯·Ó ̤ÛË ÙÈÌ‹ 10,33±3,38, ÂÓÒ Ë ·ÓÙ›ÛÙÔÈ¯Ë ÙÈÌ‹ ÙˆÓ ·È‰ÈÒÓ Ì ∆-΢ÙÙ·ÚÈ΋˜ ·Ú¯‹˜ √§§ ‹Ù·Ó 16,25±7,25 (p=0,009). ∞fi ÙȘ ˘fiÏÔÈ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‰ÂÓ Î·Ù·ÁÚ¿ÊËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ì µ- Î·È ∆-΢ÙÙ·ÚÈ΋˜ ·Ú¯‹˜ √§§.

¶›Ó·Î·˜ 1. ÃËÌÂÈÔıÂÚ·¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95 º¿ÚÌ·ÎÔ

¢fiÛË

ÃÚÔÓԉȿÁÚ·ÌÌ· ¯ÔÚ‹ÁËÛ˘

º¿ÛË ÂÊfi‰Ô˘ (protocol I) ¶Ú‰ÓÈ˙fiÓË (os) µÈÓÎÚÈÛÙ›ÓË iv ¢·Ô˘ÓÔÚÔ˘‚ÈΛÓË iv L-·Û·Ú·ÁÈÓ¿ÛË iv ∫˘ÎÏÔʈÛÊ·Ì›‰Ë iv ∫˘ÙÙ·Ú·‚›ÓË iv 6-ÌÂÚηÙÔÔ˘Ú›ÓË (os) ªÂıÔÙÚÂÍ¿ÙË IT ¶ÚÔʇϷÍË ∫¡™ (protocol M) 6-ÌÂÚηÙÔÔ˘Ú›ÓË (os) ªÂıÔÙÚÂÍ¿ÙË iv ªÂıÔÙÚÂÍ¿ÙË IT º¿ÛË Â·ÓÂÊfi‰Ô˘ (protocol II) ¢ÂÍ·ÌÂı·˙fiÓË (os) ¢ÔÍÔÚÔ˘‚ÈΛÓË iv L-·Û·Ú·ÁÈÓ¿ÛË iv ∫˘ÎÏÔʈÛÊ·Ì›‰Ë iv ∫˘ÙÙ·Ú·‚›ÓË iv 6-ıÂÈÔÁÔ˘·Ó›ÓË (os) ªÂıÔÙÚÂÍ¿ÙË IT £ÂÚ·›· Û˘ÓÙ‹ÚËÛ˘ 6-ÌÂÚηÙÔÔ˘Ú›ÓË (os) ªÂıÔÙÚÂÍ¿ÙË (Ôs) ¢ÂÍ·ÌÂı·˙fiÓË (os) µÈÓÎÚÈÛÙ›ÓË iv

60 mg/m2 1-25, ÛÙ·‰È·Î‹ Ì›ˆÛË (3x3 Ë̤Ú˜) 1,5 mg/m2 (max 2 mg) 8, 15, 22, 29 8, 15, 22, 29 30 mg/m2 12, 15, 18, 21, 24, 27, 30, 33 10000 IU/m2 1000 mg/m2 36, 64 38-41, 45-48, 52-55, 59-62 75 mg/m2 60 mg/m2 36-63 12 mg 1, 15, 29, 45, 59 25 mg/m2 5 g/m2 12 mg

1-56 8, 22, 36, 60 8, 22, 36, 60

10 mg/m2 30 mg/m2 10000 IU/m2 1000 mg/m2 75 mg/m2 60 mg/m2 12 mg

1-21, ÛÙ·‰È·Î‹ Ì›ˆÛË (3x3 Ë̤Ú˜) 8, 15, 29 8, 11, 15, 18 36 36-41,45-48 36-49 36, 45

50 mg/m2 20 mg/m2 6 mg/m2 1,5 mg/m2 (max 2 mg)

∫·ıËÌÂÚÈÓ¿ ª›· ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰· °È· 7 Ë̤Ú˜ οı 10 ‚‰ÔÌ¿‰Â˜ ¢‡Ô ÒÛÂȘ οı 10 ‚‰ÔÌ¿‰Â˜

iv: ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË, IT: ÂÓ‰ÔÚ·¯È·›· ¯ÔÚ‹ÁËÛË ∆Ô ÚˆÙfiÎÔÏÏÔ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (high risk - HR) ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÈϤÔÓ ‚ÈÓÙÂÛ›ÓË, ÈʈÛÊ·Ì›‰Ë Î·È ÂÙÔÔÛ›‰Ë ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·365

365

√ÛÙÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ÛÙËÓ ·È‰È΋ √§§

™˘˙‹ÙËÛË ∞fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ηٷÁÚ¿ÊÂÙ·È ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ÙfiÛÔ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È Î·Ù¿ ÙË ıÂÚ·›· ·È‰ÈÒÓ Ì √§§. ∏ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ √§§ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ›‰È·˜ Ù˘ ÓfiÛÔ˘. ∆· ÔÛÙÈο ¿ÏÁË ·ÔÙÂÏÔ‡Ó Û˘¯Ófi Û‡Ìو̷ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ √§§, ·ÊÔ‡ ·Ó·Ê¤ÚÔÓÙ·È Û ÔÛÔÛÙfi 21-59% ÙˆÓ ·È‰ÈÒÓ Î·È ÔÊ›ÏÔÓÙ·È Û ‰È‹ıËÛË ÙÔ˘ ÂÚÈÔÛÙ¤Ô˘ ·fi Ù· Ï¢¯·ÈÌÈο ·ÙÙ·Ú·, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ó‹Ïı Û 42,3% (1). ∏ ›‰È· Ë ÓfiÛÔ˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ¿ÌÂÛË ‹ ¤ÌÌÂÛË ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÔÛÙÂÔÎÏ·ÛÙÒÓ, ̤ۈ ·Ú·ÁˆÁ‹˜ ΢ÙÙ·ÚÔÎÈÓÒÓ ·fi ÙÔ˘˜ ÏÂÌÊÔ‚Ï¿ÛÙ˜ (1). ∫·Ù¿ÁÌ·Ù· ÌÔÚÔ‡Ó Ó· Û˘Ì‚Ô‡Ó ÙfiÛÔ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ‹ ÙÔ ¤Ú·˜ Ù˘ ıÂÚ·›·˜, ·ÎfiÌË Î·È ÌÂÙ¿ Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ‰È·ÎÔ‹ Ù˘. ∞ӷʤÚÂÙ·È fiÙÈ Î·Ù¿ÁÌ·Ù· ÛÔÓ‰‡ÏˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÛÙÈο ¿ÏÁË Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ 3-39% ÙˆÓ ·È‰ÈÒÓ Ì √§§, ÂÓÒ ÛÙ· ·È‰È¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ηٷÁÚ¿ÊËÎ·Ó Î·Ù¿ÁÌ·Ù· ÛÙÔ 11,5% ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Û 7,6% ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ Û˘ÓÙ‹ÚËÛ˘ (1,14). ∂ÎÙfi˜ fï˜ ·fi ÙËÓ ›‰È· ÙË ÓfiÛÔ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Û fiϘ ÙȘ Ê¿ÛÂȘ Ù˘ ıÂÚ·›·˜, ¤¯Ô˘Ó Â›Û˘ ÂÓÔ¯ÔÔÈËı› Ù· ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉ‹ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘ Û ·È‰È¿ Ì √§§, ·ÊÔ‡ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â˘Ú¤ˆ˜ ηٿ ÙË Ê¿ÛË ÂÊfi‰Ô˘ Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜. √ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ Ù˘ ÔÛÙÂÔÂÓ›·˜ÔÛÙÂÔfiÚˆÛ˘ ·fi ÎÔÚÙÈÎÔÂȉ‹ Â›Ó·È ÔχÏÔÎÔ˜ Î·È ıˆÚÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÔÌÔÈfiÛÙ·Û˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Î·È ÙÔ˘ ηٷ‚ÔÏÈÛÌÔ‡ ÁÂÓÈÎfiÙÂÚ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÔÛÙÂÔfiÚˆÛ˘ ·fi ÎÔÚÙÈÎÔÂȉ‹, ‰‡Ô Â›Ó·È ÔÈ Î‡ÚÈÔÈ Ì˯·ÓÈÛÌÔ› Ô˘ ÂϤÁ¯Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘. √ ÚÒÙÔ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Î·Ù·ÛÙÔÏ‹ Ù˘ ÔÛÙÂÔ‚Ï·ÛÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ¿ÌÂÛ· ̤ۈ ÂȉÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·ÛÙÔÏ‹ Ù˘ ‰È·ÊÔÚÔÔ›-

ËÛ˘ ÙˆÓ Úfi‰ÚÔÌˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ (10). √ ‰Â‡ÙÂÚÔ˜ ‰Ú· ¤ÌÌÂÛ· ̤ۈ Ù˘ ·‡ÍËÛ˘ Ù˘ ÔÛÙÈ΋˜ ·ÔÚÚfiÊËÛ˘ (ÏfiÁˆ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡) Î·È Ù˘ ÌÂȈ̤Ó˘ ·ÔÚÚfiÊËÛ˘ ·Û‚ÂÛÙ›Ô˘ ·fi ÙÔ ¤ÓÙÂÚÔ. ¶·Ú¿ÏÏËÏ·, ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË Ù˘ ÓÂÊÚÈ΋˜ ·Ô‚ÔÏ‹˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, Ô˘ ÔÊ›ÏÂÙ·È ÛÙË ÌÂȈ̤ÓË Â·Ó·ÚÚfiÊËÛ‹ ÙÔ˘ ÛÙÔ ÛˆÏËÓ¿ÚÈÔ. ∞ÔÙ¤ÏÂÛÌ· ·˘ÙÒÓ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Â›Ó·È Ë ·Ó¿Ù˘ÍË ˘·Û‚ÂÛÙÈ·ÈÌ›·˜, Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ Ô‰ËÁ› Û ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi Î·È ÛÙË Û˘Ó¤¯ÂÈ· Û ÛÔ‚·Ú‹ ÔÛÙÈ΋ ·ÒÏÂÈ· (10). ∞Ó·ÊÔÚÈο Ì ÙÔÓ Ú˘ıÌfi ·ÒÏÂÈ·˜ Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹, ¤¯ÂÈ ·Ú·ÙËÚËı› Ù·¯Â›· ÚÒÈÌË ·ÒÏÂÈ· ÛÙÔ˘˜ 6 ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·ÁˆÁ‹˜ Î·È ÂÓ Û˘Ó¯›·, ·Ó¿Ù˘ÍË plateau. ∏ ÔÛÙÈ΋ ·ÒÏÂÈ· ·fi ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, fiÙ·Ó ·Ú¯›ÛÂÈ Ó· ÂÌÊ·Ó›˙ÂÙ·È, ¤¯ÂÈ Ù· ·ÎfiÏÔ˘ı· ¯·Ú·ÎÙËÚÈÛÙÈο: ·) Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Î·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜, ‚) ·ÊÔÚ¿ ΢ڛˆ˜ Û Ï·Ù¤·, ÛÔÁÁÒ‰Ë ÔÛÙ¿, Á) ÂÌÊ·Ó›˙ÂÙ·È Û¯Â‰fiÓ ¿ÓÙ· ÌÂÙ¿ ·fi ˘„ËϤ˜ ‰fiÛÂȘ Î·È ‰) Â›Ó·È ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„ÈÌË. ∏ ‚Ï·ÙÈ΋, ÏÔÈfiÓ, ‰Ú¿ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÙ· ÔÛÙ¿ Â›Ó·È ÔÈÎÈÏfiÌÔÚÊË Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋, Ì ·ÏÏËÏÔÂÍ·ÚÙÒÌÂÓÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ (10). ∆Ô ‰ÔÎȉ҉˜ Î·È ÙÔ ÊÏÔÈ҉˜ ÂÚ›ÁÚ·ÌÌ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙˆÓ ÛÔÓ‰‡ÏˆÓ Â›Ó·È Ù· ϤÔÓ Â˘·ı‹ ÛËÌ›· ÙÔ˘ ÛÎÂÏÂÙÔ‡ ÁÈ· ÙËÓ ÚfiÎÏËÛË ÔÛÙÂÔfiÚˆÛ˘ Î·È Î·Ù·ÁÌ¿ÙˆÓ ·fi ÎÔÚÙÈÎÔÂȉ‹, ¯ˆÚ›˜ Ó· ˘Ô‚·ıÌ›˙ÂÙ·È Ë ‚Ï·ÙÈ΋ ÙÔ˘˜ Â›‰Ú·ÛË ÛÙÔ ÂÁÁ‡˜ ÙÌ‹Ì· ÙÔ˘ ÌËÚÈ·›Ô˘ Î·È ÛÙÔ ÙÚ›ÁˆÓÔ ÙÔ˘ Ward. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, ˘¿Ú¯Ô˘Ó ‰‡Ô ›‰Ë ÔÛÙ›ÙË ÈÛÙÔ‡: Ô ‰ÔÎȉ҉˘ ‹ ÛÔÁÁ҉˘ Î·È Ô ÊÏÔÈ҉˘ ‹ Û˘Ì·Á‹˜. ∆Ô 80% ÂÚ›Ô˘ ÙÔ˘ ÛÎÂÏÂÙÔ‡ ·ÔÙÂÏÂ›Ù·È ·fi ÊÏÔÈÒ‰Ë ÈÛÙfi Î·È ÙÔ 20% ·fi ‰ÔÎȉ҉Ë. ∂ÈϤÔÓ, Ë ·Ó·ÏÔÁ›· ÌÂٷ͇ Û˘Ì·ÁÔ‡˜ (ÊÏÔÈÒ‰Ô˘˜) Î·È ‰ÔÎÈ‰Ò‰Ô˘˜ (ÛÔÁÁÒ‰Ô˘˜) ÔÛÙ›ÙË ÈÛÙÔ‡ ‰ÂÓ Â›Ó·È Ë ›‰È· Û fiÏ· Ù· ÔÛÙ¿. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ÛfiÓ‰˘ÏÔÈ, Ù· Ï·Ù¤· ÔÛÙ¿ Ù˘ ˘¤ÏÔ˘ Î·È ÙÔ ÎÂÓÙÚÈÎfi ̤ÚÔ˜ ÙˆÓ ÂÈʇÛÂˆÓ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ ÂÚȤ¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ‰ÔÎÈ‰Ò‰Ë ÈÛÙfi ·’ fi,ÙÈ ¿ÏϘ ÂÚÈÔ¯¤˜ ÙÔ˘ ÛÎÂÏÂÙÔ‡,

¶›Ó·Î·˜ 2. ª˘ÔÛÎÂÏÂÙÈο Û˘ÌÙÒÌ·Ù· Î·È ÛÎÂÏÂÙÈΤ˜ ÂÈÏÔΤ˜ ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ √ÛÙÈο ¿ÏÁË ÃˆÏfiÙËÙ· ∫¿Ù·ÁÌ· √ÛÙÂÔÓ¤ÎÚˆÛË

t=0

t=0,5

t=1

t=2

11 (42,3%) 3 (11,5%) 3 (11,5%) 0

4 (15,3%) 2 (7,6%) 0 2 (7,6%)

2 (7,6%) 1 (3,8%) 2 (7,6%) 0

0 1 (3,8%) 0 0 ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·366

366

º. ∞ı·Ó·ÛÈ¿‰Ô˘ - ¶ÈÂÚÔÔ‡ÏÔ˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 3. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÔÛÙÈ΋˜ ·ÒÏÂÈ·˜ Ì ‚¿ÛË ÙËÓ ·fiÎÏÈÛË ·fi ÙÔÓ Ì¤ÛÔ fiÚÔ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ˘ÁÈÒÓ ·ÙfiÌˆÓ Û˘ÁÎÚ›ÛÈÌ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘ (WHO, 1994) ∞fiÎÏÈÛË

¶ÚÔÛ‰ÈÔÚÈÛÌfi˜

<1 SD 1-2,5 SD >2,5 SD

º˘ÛÈÔÏÔÁÈ΋ ·ÒÏÂÈ· √ÛÙÂÔÂÓ›· √ÛÙÂÔfiÚˆÛË

500 400 300 200 100

ÂÓÒ Ù· Ì·ÎÚ¿ ÔÛÙ¿ ·ÔÙÂÏÔ‡ÓÙ·È Î˘Ú›ˆ˜ ·fi ÊÏÔÈÒ‰Ë ÈÛÙfi (15-17). ∆Ô ÊÏÔÈ҉˜ ÔÛÙÔ‡Ó Â›Ó·È ˘ÎÓ‹˜ Î·È Û˘Ì·ÁÔ‡˜ Û˘ÛÙ¿Ûˆ˜ Î·È ·Ó¢ڛÛÎÂÙ·È ÛÙËÓ ÂÚÈÊÂÚÈ΋ ÌÔ›Ú· ÙÔ˘ ÔÛÙÔ‡. ∞ÓÙ›ıÂÙ·, ÙÔ ÛÔÁÁ҉˜ ÔÛÙÔ‡Ó Â›Ó·È ÏÈÁfiÙÂÚÔ ˘ÎÓfi ÛÙË Û‡ÛÙ·Û‹ ÙÔ˘ Î·È ·Ó¢ڛÛÎÂÙ·È ÛÙËÓ ÎÂÓÙÚÈ΋ ÌÔ›Ú· ÙÔ˘ ÔÛÙÔ‡. ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ô ‰ÔÎȉ҉˘ ÈÛÙfi˜ Â›Ó·È ÈÔ ·Ú·Èfi˜ ·fi ÙÔÓ Û˘Ì·Á‹, ¿Ú· Ë ‰ÔÌ‹ ÙÔ˘ ηٷÛÙÚ¤ÊÂÙ·È Â˘ÎÔÏfiÙÂÚ·. °È’ ·˘ÙfiÓ ·ÎÚÈ‚Ò˜ ÙÔÓ ÏfiÁÔ, Ë ÔÛÙÂÔfiÚˆÛË ÚÔÛ‚¿ÏÏÂÈ ÂÚÈÛÛfiÙÂÚÔ ÔÛÙ¿ Ô˘ Â›Ó·È ÏÔ‡ÛÈ· Û ‰ÔÎÈ‰Ò‰Ë ÈÛÙfi, fiˆ˜ Â›Ó·È Ë ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, Ù· ÈÛ¯›· Î·È ÔÈ Î·ÚÔ›. ™ËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Û ·È‰È¿ Ì √§§ ·ÔÙÂÏ› Ë Ì›ˆÛË ÙÔ˘ ÊÔÚÙ›Ô˘, Û˘ÓÂ›· ·ÎÈÓËÙÔÔ›ËÛ˘, Ô˘ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÔÛÙÔ‡ ·fi ÙÔ˘˜ ÔÛÙÂÔ‚Ï¿ÛÙ˜ Î·È ˘ÚÔ‰ÔÙ› ÙËÓ ÔÛÙÂÔÎÏ·ÛÙÈ΋ ·ÔÚÚfiÊËÛË, Ô‰ËÁÒÓÙ·˜ ÛÙË ‰Â˘ÙÂÚÔ·ı‹ ÔÛÙÂÔfiÚˆÛË ·fi ·ÎÈÓËÙÔÔ›ËÛË. ∆· ÔÛÙ¿ Ô˘ ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ 2

0 -100 N=

26

26

26

26

PINP0

PINP0.5

PINP1

PINP2

∂ÈÎfiÓ· 2. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ PINP Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ (mean) (ÔÚÈ˙fiÓÙÈ· ÁÚ·ÌÌ‹ ÂÓÙfi˜ ÙˆÓ ·Ú·ÏÏËÏfiÁÚ·Ì̈Ó) ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ˘. ∆Ô 1Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (25% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) Î·È ÙÔ 3Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (75% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ÙÔ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘. ∆¤ÏÔ˜, ÔÈ ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘ ‰ËÏÒÓÔ˘Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ PINP.

‰¤¯ÔÓÙ·È ÌÂÁ¿Ï· ÊÔÚÙ›· Â›Ó·È Ù· ϤÔÓ ÂÈÚÚÂ‹ ÛÙËÓ ÔÛÙÂÔfiÚˆÛË ·fi ·ÎÈÓËÙÔÔ›ËÛË, Û˘ÁÎÚÈÙÈο Ì ٷ ˘fiÏÔÈ·. ™‡Ìʈӷ Ì ٷ ‰Â‰Ô̤ӷ ÌÂϤÙ˘ ÙÔ˘ Minaire, Ë ·Ó·ÛÙÚÔÊ‹ Ù˘ ‚Ï¿‚˘ ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÁηٿÛÙ·Û‹ Ù˘ (12). ∞fi Ù· ‰Â‰Ô̤ӷ ÚfiÛÊ·ÙˆÓ ÌÂÏÂÙÒÓ ÚÔ·ÙÂÈ fiÙÈ Ë ÌÂÁ·Ï‡ÙÂÚË Ì›ˆÛË Ù˘ ÔÛÙÈ΋˜ 40

1 30 0 20

-1 -2

10 -3 -4

0 N=

26

26

26

26

ZLS0

ZLS0.5

ZLS1

ZLS2

∂ÈÎfiÓ· 1. ¢È·Î‡Ì·ÓÛË ÙˆÓ z-scores Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È Ë Ì¤ÛË ÙÈÌ‹ Ù˘ (mean) (ÔÚÈ˙fiÓÙÈ· ÁÚ·ÌÌ‹ ÂÓÙfi˜ ÙˆÓ ·Ú·ÏÏËÏfiÁÚ·Ì̈Ó) ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ˘. ∆Ô 1Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (25% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) Î·È ÙÔ 3Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (75% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ÙÔ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘. ∆¤ÏÔ˜, ÔÈ ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘ ‰ËÏÒÓÔ˘Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ z-score. ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

N=

26

26

26

26

ICTP0

ICTP0.5

ICTP1

ICTP2

∂ÈÎfiÓ· 3. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ICTP Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ (mean) (ÔÚÈ˙fiÓÙÈ· ÁÚ·ÌÌ‹ ÂÓÙfi˜ ÙˆÓ ·Ú·ÏÏËÏfiÁÚ·Ì̈Ó) ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ˘. ∆Ô 1Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (25% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) Î·È ÙÔ 3Ô ÙÂÙ·ÚÙËÌfiÚÈÔ (75% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ÙÔ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘. ∆¤ÏÔ˜, ÔÈ ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘ ‰ËÏÒÓÔ˘Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ ICTP.

Pediatr Sept_Oct 06

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™ÂÏ›‰·367

367

√ÛÙÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ÛÙËÓ ·È‰È΋ √§§

¶›Ó·Î·˜ 4. ∞ÔÙÂϤÛÌ·Ù· ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ Î·È ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ t=0

t=0,5

t=1

z-score -1,04 (±0,74)*† -0,77 (±0,69)*† (ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË) -0,43 (±0,72)† Ca (mg/dl) 9,91 (±0,86) 9,86 (±0,51) 9,76 (±0,48) P (mg/dl) 5,06 (±0,68) 5,19 (±0,61) 5,07 (±0,49) ALP (U/L) 161,1 (±55) 190,5 (±70,2) 197,6 (±44,3)* 16,28 (±3,1) 17,54 (±2,9)* 17,77 (±3,2)* BMI (kg/m2) iPTH (pg/ml) 18,85 (±10,91) 20,39 (±9,77) 19,35 (±7,86) ICTP (Ìg/l) 11,70 (±5,07) 17,23 (±4,72)*† 15,47 (±4,88)*† PINP (Ìg/l) 111,59 (±84,39)† 263,03 (±77,55)* 237,85 (±68,64)*

t=2

ª¿ÚÙ˘Ú˜

-0,58 (±0,84)† 9,71 (±0,33) 4,91 (±0,38) 196,1 (±37,7)* 18,11 (±2,9)*† 21,69 (±5,83) 14,32 (±2,01)* 241,21 (±39,68)*

-0,07 (±0,64) 9,91 (±0,4) 5,13 (±0,57) 182,07 (±63,19) 16,61 (±1,86) 20,03 (±4,82) 12,3 (±4,92) 239,84 (±65,84)

* p<0,05 Û ۯ¤ÛË Ì ÙȘ ÙÈ̤˜ ÛÙË ‰È¿ÁÓˆÛË † p<0,05 Û ۯ¤ÛË Ì ÙȘ ÙÈ̤˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ

˘ÎÓfiÙËÙ·˜ ηٷÁÚ¿ÊÂÙ·È ÛÙÔ˘˜ ÚÒÙÔ˘˜ 12 Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ηÈ, ÂÔ̤ӈ˜, Û˘Ì‚·‰›˙ÂÈ Ì ÙÔÓ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ Û ˘„ËϤ˜ ‰fiÛÂȘ (2,3,18). ™ÙÔÓ Â·Ó¤ÏÂÁ¯Ô Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠÛÙÔ˘˜ 6 Ì‹Ó˜ ·fi ÙË ‰È¿ÁÓˆÛË (t=0,5) ηٷÁÚ¿ÊËÎÂ Ë Ì¤ÁÈÛÙË Ì›ˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ™ÙÔ ¯ÚÔÓÈÎfi ·˘Ùfi ‰È¿ÛÙËÌ·, ÂÎÙfi˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ÌÂıÔÙÚÂÍ¿Ù˘, Ê·›ÓÂÙ·È fiÙÈ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Ë ·Ú·ÙÂٷ̤ÓË ·ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ·È‰ÈÒÓ, ÏfiÁˆ Ù˘ ıÂÚ·›·˜ ‹ ÂÈÏÔÎÒÓ Ù˘ (11,12,19,20). ™ÙË Û˘Ó¤¯ÂÈ· (t=1, t=2), ηٷÁÚ¿ÊÂÙ·È ‚ÂÏÙ›ˆÛË Ù˘ ̤Û˘ ÙÈÌ‹˜ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜, fiˆ˜ ÚÔ·ÙÂÈ Î·È ·fi ¿ÏϘ ÌÂϤÙ˜ (2,3). ™Â ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·È‰ÈÒÓ Ì √§§ ηٷÁÚ¿ÊËΠ̛· ÌÈÎÚ‹ ÂÏ¿ÙÙˆÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ Î·È Ù˘ ÔÏÈ΋˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ηٿ ÙË ‰È¿ÁÓˆÛË (21). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ¿ÏÏ˘ ÌÂϤÙ˘, Ë ¯·ÌËÏ‹ ÙÈÌ‹ ÔÛÙÂÔηÏÛ›Ó˘ ηٿ ÙË ‰È¿ÁÓˆÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙË Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ¯ˆÚ›˜ Ó· ·ÓÙÈηÙÔÙÚ›˙ÂÈ Ì ·ÎÚ›‚ÂÈ· ÙËÓ ÔÛÙÈ΋ ·Ú·ÁˆÁ‹ (22). ¡ÂfiÙÂÚÔÈ ‰Â›ÎÙ˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, fiˆ˜ ÙÔ PINP, Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û‹ÌÂÚ· ¢ڤˆ˜, ¤¯Ô˘Ó ηٷÁÚ·Ê› ȉȷ›ÙÂÚ· ¯·ÌËÏÔ› ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ √§§, ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ÏÂÌÊÔ‚Ï·ÛÙÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ‰Â˘ÙÂÚÔ·ıÒ˜ Ó· ·Ú·ÙËÚÂ›Ù·È Î·Ù·ÛÙÔÏ‹ Ù˘ Û‡ÓıÂÛ˘ ¿ÏÏˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, fiˆ˜ ÙÔ˘ ÚÔÎÔÏÏ·ÁfiÓÔ˘ ηÈ, ÂÔ̤ӈ˜, ÙÔ˘ PINP (18,23,24). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ van der Sluis Î·È Û˘Ó Î·È ÙˆÓ Sovra Î·È Û˘Ó, ÌÂÙ¿ ÙÔ˘˜ 6 Î·È ÙÔ˘˜ 3 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·, ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ËÌÂÈ-

ÔıÂÚ·›·˜ ηٷÁÚ¿ÊÂÙ·È Û·Ê‹˜ ·‡ÍËÛË ÙˆÓ ‰ÂÈÎÙÒÓ ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜ (18,24). ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ICTP, ˆ˜ ‰Â›ÎÙË ÔÛÙÈ΋˜ ·ÔÚÚfiÊËÛ˘, Û‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ ›‰ÈˆÓ ÌÂÏÂÙÒÓ, ηٷÁÚ¿ÊÂÙ·È Ê˘ÛÈÔÏÔÁÈ΋ ηٿ ÙË ‰È¿ÁÓˆÛË, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο Î·È ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ t=0,5 Î·È t=1, Â˘Ú‹Ì·Ù· Ô˘ Û˘ÌʈÓÔ‡Ó ·fiÏ˘Ù· Î·È Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ (18,24). ∏ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfiÙÂÚË ˘„ËÏ‹ ̤ÛË ÙÈÌ‹ ICTP ÛÙ· ·È‰È¿ Ì ∆-√§§ ¤Ó·ÓÙÈ ÂΛӢ ÙˆÓ ·È‰ÈÒÓ Ì µ-√§§, ÔÊ›ÏÂÙ·È ÛÙË Û˘¯ÓfiÙÂÚË Î·È ÌÂÁ·Ï‡ÙÂÚÔ˘ ‚·ıÌÔ‡ ÔÛÙÈ΋ ‰È‹ıËÛË ÙÔ˘ ÂÚÈÔÛÙ¤Ô˘ ·fi ‚Ï¿ÛÙ˜ ÛÙËÓ ÚÒÙË ÔÌ¿‰· (∆-√§§), Ì ·ÔÙ¤ÏÂÛÌ· ÌÂÁ·Ï‡ÙÂÚË ÔÛÙÈ΋ ·ÔÚÚfiÊËÛË ÛÙ· ·È‰È¿ ·˘Ù¿. ∂ÈϤÔÓ, Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Û˘ÌʈÓÔ‡Ó ÛÙÔ fiÙÈ Ë Ì›ˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÙÔ˘ PINP Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi ÂΛÓË ÙÔ˘ ICTP ηٿ ÙË ‰È¿ÁÓˆÛË (3,18,24). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ Û˘ÌʈÓÔ‡Ó ·fiÏ˘Ù· Ì ·˘Ù¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Î·È ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë Ì¤ÙÚËÛ‹ ÙÔ˘˜ Ì ·ÓÔÛÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ ÌÂÁ¿Ï˘ ÂȉÈÎfiÙËÙ·˜ ÛÙÔÓ ÔÚfi ·È‰ÈÒÓ Ì √§§, ·ÔÙÂÏ› ¿ÚÈÛÙÔ ‰Â›ÎÙË ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ηٷ‚ÔÏÈ΋˜ Î·È ·Ó·‚ÔÏÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡. ∞fi Ù· Â˘Ú‹Ì·Ù· ¿ÏÏˆÓ ÌÂÏÂÙÒÓ ÚÔ·ÙÂÈ fiÙÈ Ù· ·È‰È¿ Ì √§§ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÔÛÙÂÔÂÓ›·˜-ÔÛÙÂÔfiÚˆÛ˘ Î·È Ì˘ÔÛÎÂÏÂÙÈÎÒÓ ÂÈÏÔÎÒÓ, ÙfiÛÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ fiÛÔ Î·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÙÔ˘˜ (25-29). ™‡Ìʈӷ Ù· ‰Â‰Ô̤ӷ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÚÔÙ›ÓÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì √§§, ÒÛÙ ӷ ‰È¢ÎÚÈÓÈÛÙ› Ë ‚·Ú‡ÙËÙ· Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ¶·È‰È·ÙÚÈ΋ 2006;69:361-368

Pediatr Sept_Oct 06

26-09-06

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368

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369

∂ÌÂÈڛ˜ ÁÔÓ¤ˆÓ ·Ó·ÊÔÚÈο Ì ÙËÓ ÚfiÙ·ÛË ‰ˆÚ¿˜ ÈÛÙÒÓ/ÔÚÁ¿ÓˆÓ ÛÒÌ·ÙÔ˜ ÙÔ˘ ·Ó‹ÏÈÎÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ £. MÂÏÏ¿ÏË, ¢. ¶··‰¿ÙÔ˘

¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·fiÊ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ Ó· ‰ˆÚ›ÛÔ˘Ó ÙÔ˘˜ ÈÛÙÔ‡˜/fiÚÁ·Ó· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ·È‰ÈÔ‡ ÙÔ˘˜, ηıÒ˜ Î·È ÙˆÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ï‹„˘ Ù˘ ·fiÊ·Û˘ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ·˘Ù‹. ∏ Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ·ÔÙÂÏ› ̤ÚÔ˜ ¢ڇÙÂÚ˘ ¤Ú¢ӷ˜ Ô˘ ‰ÈÂÚÂ˘Ó¿ -Ì ÙË ¯Ú‹ÛË ÔÈÔÙÈ΋˜ ÌÂıÔ‰ÔÏÔÁ›·˜- ÙË Û˘ÓÔÏÈ΋ ÂÌÂÈÚ›· ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó ‹ ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿, ηıÒ˜ Î·È ÙȘ ÂÈÙÒÛÂȘ Ù˘ ·fiÊ·Û˘ ÛÙÔ ¤ÓıÔ˜ ÙÔ˘˜. ¶Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ËÌÈ-‰ÔÌË̤Ó˜ Û˘ÓÂÓÙ‡ÍÂȘ Ì 22 ÁÔÓ›˜, 14 ·È‰ÈÒÓ ‰ÔÙÒÓ Î·È ÌË-‰ÔÙÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó Û ‰‡Ô ÌÂÁ¿Ï˜ ¶·È‰È·ÙÚÈΤ˜ ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ Ù˘ ∂ÏÏ¿‰·˜. ¢È·ÈÛÙÒıËΠfiÙÈ Ë ·fiÊ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰ˆÚ¿ ÙˆÓ ÔÚÁ¿ÓˆÓ ÂËÚ¿˙ÂÙ·È ·fi: ·) ÚÔÛˆÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‚) ÙȘ Û˘Óı‹Î˜ ÚfiÙ·Û˘ Ù˘ ‰ˆÚ¿˜, ‰) ÙËÓ ÚÔ¸¿Ú¯Ô˘Û· ÁÓÒÛË Î·È ÂÌÂÈÚ›· Û¯ÂÙÈο Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ Î·È ‰) ÔÈÎÔÁÂÓÂÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ¶·ÚfiÏÔ Ô˘ Ë ›‰È· Ë ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜ ‰ÂÓ Ê¿ÓËΠӷ ÂÈ‚·Ú‡ÓÂÈ ÙÔ ‹‰Ë ·˘ÍË̤ÓÔ ÛÙÚ˜ ÙˆÓ ÁÔÓ¤ˆÓ, Ë Î˘ÚÈfiÙÂÚË ‰˘ÛÎÔÏ›· ·˘ÙÒÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó, ·ÊÔÚÔ‡Û ÛÙËÓ ¤ÏÏÂÈ„Ë ÂÓË̤ڈÛ˘ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∆· Â˘Ú‹Ì·Ù· Ô‰ËÁÔ‡Ó ÛÙË ‰È·Ù‡ˆÛË ÔÚÈÛÌ¤ÓˆÓ ÙÂÎÌËÚÈˆÌ¤ÓˆÓ ÂÌÂÈÚÈο ÚÔÙ¿ÛÂˆÓ ÚÔÎÂÈ̤ÓÔ˘ ÙÔ È·ÙÚÔÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Ó· ÚÔÛÂÁÁ›˙ÂÈ Î·È Ó· ÛÙËÚ›˙ÂÈ ·ÔÙÂÏÂÛÌ·ÙÈο ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ·È‰ÈÔ‡. °È· Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ë ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ ‰ÂÓ ·ÚΛ Ó· ÂÛÙÈ¿˙ÂÙ·È ÌfiÓÔ ÛÙËÓ ÎÏÈÓÈ΋ ·Í›· Ù˘ Ï‹„˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÏÏ¿ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙË ÛÙ‹ÚÈÍË ÙˆÓ ÁÔÓ¤ˆÓ, ÔÈ ÔÔ›ÔÈ Î·ÏÔ‡ÓÙ·È Ó· Ï¿‚Ô˘Ó ÌÈ· ÙfiÛÔ ‰‡ÛÎÔÏË ·fiÊ·ÛË, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ·Ó Û˘Ó·ÈÓÔ‡Ó ‹ ·ÚÓÔ‡ÓÙ·È ÙÂÏÈο ÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜.

∆Ô̤·˜ æ˘¯È΋˜ ÀÁ›·˜ Î·È ∂ÈÛÙËÌÒÓ ™˘ÌÂÚÈÊÔÚ¿˜ ∆Ì‹Ì· ¡ÔÛËÏ¢ÙÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: £¿ÏÂÈ· ªÂÏÏ¿ÏË •¿ÓıÔ˘ 31∞, ¡. æ˘¯ÈÎfi, ∆.∫. 154 51 ∂-mail: bellalithalia@yahoo.com ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-07-06 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 13-09-06

§¤ÍÂȘ ÎÏÂȉȿ: ¢ˆÚ¿ ÔÚÁ¿ÓˆÓ, ·fiÊ·ÛË, ÔÈÎÔÁ¤ÓÂÈ·, ·È‰›, ÛÙ‹ÚÈÍË.

Parents’ experiences of request for donation of organs and tissue from their underage children T. Bellali, D. Papadatou

Abstract: The purpose of this study was to explore the factors that affect parents’ decisions regarding organ donation from their brain-dead children, and the difficulties they encounter throughout the decision-making process. The study was undertaken as part of a larger project that investigated the experiences of bereaved parents who consented to or declined organ donation. Qualitative methodology was used and semi-structured interviews were conducted with 22 parents of 14 donor and non-donor children, hospitalized in two paediatric intensive care units in Athens. The factors that influenced the parental decision-making process with regard to organ donation involved: a) personal variables, b) the conditions under which the donation request was made, d) parents’ previous knowledge and experience with illness and organ donation, d) family-related variables. Even though the request for organ donation was not perceived as causing additional stress to the distraught parents, those who consented reported increased distress because of lack of information about the transplantation outcome. The findings of this study can help in the formulation of empirically based guidelines for health professionals on how to approach parents to propose organ donation. The donation request is meaningful and effective when it enables parents to reach decisions that have meaning for them.

Department of Mental Health and Behavioural Sciences Faculty of Nursing, University of Athens Correspondence: Thalia Bellali Xanthou 31∞, ¡eo Psychiko, 154 51 ∂-mail: bellalithalia@yahoo.com Date of submission: 20-07-06 Date of approval: 13-09-06

Key words: Organ donation, decision, family, child, support.

¶·È‰È·ÙÚÈ΋ 2006;69:369-375

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·370

370

£. MÂÏÏ¿ÏË, ¢. ¶··‰¿ÙÔ˘

∂ÈÛ·ÁˆÁ‹ ∏ ‰È·‰Èηۛ· Ù˘ ÌÂÙ·ı·Ó¿ÙÈ·˜ ‹ و̷ÙÈ΋˜ ‰ˆÚ¿˜ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ ÛÒÌ·ÙÔ˜ ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ Û ÔÏfiÎÏËÚË ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. √È ÁÔÓ›˜, ÙˆÓ ÔÔ›ˆÓ ÙÔ ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ, ¤Ú¯ÔÓÙ·È ·ÓÙÈ̤وÔÈ Ì ÔÏϤ˜ ÚˆÙfiÁÓˆÚ˜, ÛÙÚÂÛÛÔÁfiÓ˜ ηٷÛÙ¿ÛÂȘ. ∞fi ÙË ÌÈ· ÏÂ˘Ú¿, ηÏÔ‡ÓÙ·È Ó· ‰Â¯ıÔ‡Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ¤¯ÂÈ Âı¿ÓÂÈ Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ “ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘”, ÁÂÁÔÓfi˜ Ô˘ Û˘Ì‚·›ÓÂÈ Í·ÊÓÈο Î·È ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ οو ·fi ¿ÁÓˆÛÙ˜ ·Èٛ˜ ‹ ‚›·ÈÔ ÙÚfiÔ. ∞fi ÙËÓ ¿ÏÏË, ηÏÔ‡ÓÙ·È Ó· ¿ÚÔ˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÔÊ¿ÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Èı·ÓfiÙËÙ· Ó· ‰ˆÚ›ÛÔ˘Ó Ù· fiÚÁ·Ó¿ ÙÔ˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ ‰ÈÂÚ¢ÓÔ‡Ó ÙȘ ÂÌÂÈڛ˜ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ ‚›ˆÛ·Ó ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ ·Á·Ë̤ÓÔ˘ ÚÔÛÒÔ˘, Ô˘ ÎÚ›ıËΠ‰˘ÓËÙÈÎfi˜ ‰fiÙ˘ ÈÛÙÒÓ/ÔÚÁ¿ÓˆÓ ÛÒÌ·ÙÔ˜, Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ˜. √È ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÂÚÈÁÚ¿ÊÔ˘Ó ÙȘ ·ÓÙȉڿÛÂȘ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó ÛÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÂÓ‹ÏÈÎÔ˘ ̤ÏÔ˘˜ ÙÔ˘˜ (1-11), ÂÓÒ ÂÏ¿¯ÈÛÙ˜ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙȘ ÂÌÂÈڛ˜ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ ·ÓÙÈÌÂÙÒÈÛ·Ó ÙÔ ‰›ÏËÌÌ· Ù˘ ‰ˆÚ¿˜ ÂÓfi˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ·È‰ÈÔ‡ (12-13). ∂ÈϤÔÓ, ÂÏ¿¯ÈÛÙ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙȘ ·ÓÙȉڿÛÂȘ ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ô˘ ·ÚÓ‹ıËÎ·Ó Ó· Û˘Ó·ÈÓ¤ÛÔ˘Ó ÛÙË ‰ˆÚ¿ (14-18) Î·È ·ÎfiÌË ÏÈÁfiÙÂÚ˜ ‰ÈÂÚ¢ÓÔ‡Ó ÙȘ ÂÌÂÈڛ˜ ÔÈÎÔÁÂÓÂÈÒÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ Ô˘ ÔÙ¤ ‰ÂÓ ÚÔÛÂÁÁ›ÛÙËÎ·Ó ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ Ì ·›ÙËÌ· ÙË ‰ˆÚ¿ ÈÛÙÒÓ/ÔÚÁ¿ÓˆÓ (19-21). ∞Ó Î·È ÔÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜ ‰È·Ù˘ÒÓÔ˘Ó Î¿ÔÈ· Û˘ÌÂÚ¿ÛÌ·Ù· Û¯ÂÙÈο Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·fiÊ·ÛË Ù˘ Û˘Ó·›ÓÂÛ˘ ‹ ¿ÚÓËÛ˘ ÛÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ ‰ÂÓ Â›Ó·È Â‡ÎÔÏ· Û˘ÁÎÚ›ÛÈÌ·, ηıÒ˜ ‰È·Ê¤ÚÔ˘Ó ÙfiÛÔ Ë ÌÂıÔ‰ÔÏÔÁ›· ˆ˜ ÚÔ˜ ÙÔÓ Û¯Â‰È·ÛÌfi Î·È ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰Ô̤ӈÓ, fiÛÔ Î·È Ë Û‡ÓıÂÛË ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·fiÊ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ Ó· ‰ˆÚ›ÛÔ˘Ó ÙÔ˘˜ ÈÛÙÔ‡˜/fiÚÁ·Ó· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ·È‰ÈÔ‡ ÙÔ˘˜, ηıÒ˜ Î·È ÙˆÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ï‹„˘ Ù˘ ·fiÊ·Û˘ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ·˘Ù‹. ∏ Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ·ÔÙÂÏ› ̤ÚÔ˜ ÌÈ·˜ ¢ڇÙÂÚ˘ ¤Ú¢ӷ˜ Ô˘ ‰ÈÂÚÂ˘Ó¿ ÙË Û˘ÓÔÏÈ΋ ÂÌÂÈÚ›· ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó ‹ ¶·È‰È·ÙÚÈ΋ 2006;69:369-375

·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿, ηıÒ˜ Î·È ÙȘ ÂÈÙÒÛÂȘ Ù˘ ·fiÊ·Û˘ ÛÙÔ ¤ÓıÔ˜ ÙÔ˘˜ (23).

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ·ÚÔ‡Û· ÌÂϤÙË ‚·Û›ÛÙËΠ۠ÔÈÔÙÈ΋ ÌÂıÔ‰ÔÏÔÁ›· ÁÈ· ÙË Û˘ÏÏÔÁ‹ Î·È ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰Ô̤ӈÓ, ÏfiÁˆ ÙˆÓ ÂÚÈÔÚÈÛÌ¤ÓˆÓ ÁÓÒÛÂˆÓ Ô˘ ˘¿Ú¯Ô˘Ó ‰ÈÂıÓÒ˜. ø˜ ÌÂıÔ‰ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë “ıÂÌÂÏȈ̤ÓË ıˆڛ·” (grounded theory) ÙˆÓ Strauss & Corbin (23) ÁÈ· ÙËÓ ÂÚÌËÓ¢ÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÊËÁ‹ÛÂˆÓ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ Î·È ÙËÓ ·Ó¿‰ÂÈÍË ÂÓfi˜ ÌÔÓÙ¤ÏÔ˘ Ô˘ ÂÚÈÁÚ¿ÊÂÈ ÙÔÓ ıÚ‹ÓÔ ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ Û˘Ó·ÈÓÔ‡Ó ‹ ·ÚÓÔ‡ÓÙ·È ÙËÓ ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜. ∏ÌȉÔÌË̤Ó˜ Û˘ÓÂÓÙ‡ÍÂȘ ÂÏ‹ÊıËÛ·Ó ·fi ÛÎfiÈÌÔ ‰Â›ÁÌ· ¢ÎÔÏ›·˜ 22 ÁÔÓ¤ˆÓ (13 ÌËÙ¤Ú˜ Î·È 9 ·Ù¤Ú˜), 14 ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó ·fi ÙÔ 1995 ¤ˆ˜ ÙÔ 2002 Û ‰‡Ô ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ (ª∂£) ÌÂÁ¿ÏˆÓ ·È‰È·ÙÚÈÎÒÓ ÓÔÛÔÎÔÌ›ˆÓ. ∏ ÔÌ¿‰· ∞ ÂÚÈÂÏ¿Ì‚·Ó 11 ÁÔÓ›˜ ·È‰ÈÒÓ ‰ÔÙÒÓ (50,0%) Î·È Ë ÔÌ¿‰· µ, 11 ÁÔÓ›˜ ·È‰ÈÒÓ ÌË-‰ÔÙÒÓ (50,0%). √È Û˘ÓÂÓÙ‡ÍÂȘ Ì ÙÔÓ Î¿ı ÁÔÓ¤· ¯ˆÚÈÛÙ¿, Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Î˘Ú›ˆ˜ ÛÙ· Û›ÙÈ· ÙÔ˘˜ Î·È Â›¯·Ó ‰È¿ÚÎÂÈ·, ηٿ ̤ÛÔÓ fiÚÔ, ‰‡Ô ÒÚ˜ (60-200 ÏÂÙ¿). √È ··ÓÙ‹ÛÂȘ ÙÔ˘˜ ÔÌ·‰ÔÔÈ‹ıËÎ·Ó Û ηÙËÁÔڛ˜ Î·È ˘Ô-ηÙËÁÔڛ˜, ÂÓÒ Ì¤Ûˆ Ù˘ Û˘ÁÎÚÈÙÈ΋˜ ·Ó¿Ï˘Û˘ (constant comparative analysis) ·Ó·‰Â›¯ÙËÎ·Ó ÔÈ ·Ú¿ÁÔÓÙ˜ (˘ÚËÓÈΤ˜ ηÙËÁÔڛ˜) Ô˘ ÂËÚ¤·Û·Ó ÙË Û˘Ó·›ÓÂÛË ‹ ¿ÚÓËÛË ÛÙË ‰ˆÚ¿, ηıÒ˜ Î·È ÔÈ ‰˘ÛÎÔϛ˜ Ô˘ ·ÓÙÈÌÂÙÒÈÛ·Ó Î·Ù¿ ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ Î·È ÌÂÙ¿ ·fi ·˘Ù‹. ∆¤ÏÔ˜, Ë Î·ÙËÁÔÚÈÔÔ›ËÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ‰È·ÛÙ·˘ÚÒıËΠ̤ۈ Ù˘ ·Ó¿Ï˘Û˘ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·fi ÙÚÂȘ ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ (method of triangulation) (24).

∞ÔÙÂϤÛÌ·Ù· 1. ∞fiÊ·ÛË ‰ˆÚ¿˜ ª¤Û· ·fi ÙȘ ·ÊËÁ‹ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Ê·›ÓÂÙ·È fiÙÈ ÂËÚ¤·Û·Ó ÙËÓ ·fiÊ·Û‹ ÙÔ˘˜ ÂÓÙ¿ÛÛÔÓÙ·È Û ٤ÛÛÂÚȘ ‚·ÛÈΤ˜ ηÙËÁÔڛ˜: ·) ÚÔÛˆÈÎÔ› ·Ú¿ÁÔÓÙ˜, ‚) Û˘Óı‹Î˜ ÚfiÙ·Û˘ Ù˘ ‰ˆÚ¿˜, ‰) ÚÔ¸¿Ú¯Ô˘Û· ÁÓÒÛË Î·È ÂÌÂÈÚ›· Û¯ÂÙÈο Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ Î·È ‰) ÔÈÎÔÁÂÓÂÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜.

1.1. ¶ÚÔÛˆÈÎÔ› ·Ú¿ÁÔÓÙ˜ ŒÓ·˜ ·fi ÙÔ˘˜ ÈÔ ‚·ÛÈÎÔ‡˜ ÏfiÁÔ˘˜ Û˘Ó·›ÓÂÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Ë ·Ô‰Ô¯‹ Ù˘ ÔÚÈÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ·È‰ÈÔ‡, ÂÓÒ ¤Ó·˜ ·fi ÙÔ˘˜ ‚·ÛÈÎfiÙÂÚÔ˘˜ ÏfiÁÔ˘˜ ¿ÚÓËÛ˘ ‹Ù·Ó Ë ·‰˘Ó·Ì›· Ó· ·ԉ¯ıÔ‡Ó ÁÓˆÛÙÈο Î·È Û˘Ó·ÈÛıËÌ·ÙÈο ÙÔ ı¿Ó·ÙÔ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. √È ÙÂÏÂ˘Ù·›ÔÈ ·ÚÓÔ‡ÓÙ·Ó ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ·È‰ÈÔ‡, ÂÏ›˙ÔÓÙ·˜ Û ¤Ó· ı·‡Ì·, ·Ú¿ ÙȘ ‰È·‚‚·ÈÒÛÂȘ ÙˆÓ ÁÈ·ÙÚÒÓ ÁÈ· ÙÔ ·ÓÙ›ıÂÙÔ.

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∂ÌÂÈڛ˜ ÁÔÓ¤ˆÓ ·fi ÙËÓ ÚfiÙ·ÛË ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ

“ª¤Û· ÌÔ˘ ‰ÂÓ ‹ıÂÏ· Ó· ÈÛÙ¤„ˆ fiÙÈ ÙÔ ·È‰› ı· Âı¿ÓÂÈ, fiÙÈ ı· ÙÔ ¯¿ÛÔ˘Ì ÙÂÏ›ˆ˜”. “¶·Ú’ fiÏÔ Ô˘ ‰ÂÓ ˘‹Ú¯Â η̛· ÂÏ›‰· ¤ˆ˜ ÙËÓ ÙÂÏÂ˘Ù·›· ÛÙÈÁÌ‹ οÔ˘ ̤۷ ÌÔ˘ ‹ÏÈ˙·, ·ÊÔ‡ ¯Ù˘Ô‡ÛÂ Ë Î·Ú‰È¿ ÙÔ˘”. À‹Ú¯·Ó Â›Û˘ ÁÔÓ›˜ Ô˘ ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿ ÁÈ·Ù› ·Ú’ fiϘ ÙȘ ÂÂÍËÁ‹ÛÂȘ ÙˆÓ È·ÙÚÒÓ ›ÛÙ¢·Ó fiÙÈ Ì ÙË Û˘ÁηٿıÂÛ‹ ÙÔ˘˜ ı· “·Ê·ÈÚÔ‡Û·Ó’’ ÙË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ “ÂÊfiÛÔÓ Ë Î·Ú‰È¿ ÙÔ˘ ·ÎfiÌË ¯Ù˘Ô‡ÛÂ Î·È ‹Ù·Ó ˙ˆÓÙ·Ófi”. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó ÛÙË ‰ˆÚ¿, ¤Ï·‚·Ó ÙËÓ ·fiÊ·ÛË Ù˘ Û˘Ó·›ÓÂÛ˘ Û ÚÔÛˆÈÎfi Â›Â‰Ô Ì¤Û· ·fi ÌÈ· ÔÚıÔÏÔÁÈ΋ ‰È·‰Èηۛ·, ‰ËÏ·‰‹ ÌÂÙ¿ ·fi ÚÔÛˆÈ΋ ÛΤ„Ë ‹ Û˘˙‹ÙËÛË Ì ¿ÏÏÔ˘˜ Î·È ‰È·ÛÙ·‡ÚˆÛË ‰È·ÊfiÚˆÓ È·ÙÚÈÎÒÓ ·fi„ˆÓ. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ·ÚÓ‹ıËηÓ, ·ÎÔÏÔ‡ıËÛ·Ó ÌÈ· ·ÚÔÚÌËÙÈ΋ ‰È·‰Èηۛ·, ·ÔÊ·Û›˙ÔÓÙ·˜ ÛÙÈÁÌÈ·›·/¿ÌÂÛ·, ¯ˆÚ›˜ ‰Â‡ÙÂÚË ÛΤ„Ë. ∞˘Ùfi Û˘Ó¤‚Ë Î˘Ú›ˆ˜ ÁÈ·Ù› ‰ÂÓ ÌÔÚÔ‡Û·Ó Ó· ·ԉ¯ıÔ‡Ó ÙËÓ ÔÚÈÛÙÈÎfiÙËÙ· ÙÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. ÕÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¤·Û ÙË Û˘Ó·›ÓÂÛË ÛÙË ‰ˆÚ¿ ·ÊÔÚÔ‡Û ÛÙËÓ ÂÔ›ıËÛË ÙˆÓ ÁÔÓ¤ˆÓ fiÙÈ Ì ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ı· ‰È·ÛÊ·ÏÈÛÙ› Ë “Û˘Ó¤¯ÂÈ·” ÙÔ˘ ·È‰ÈÔ‡ ηıÒ˜ Ù· fiÚÁ·Ó¿ ÙÔ˘ ı· ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘¿Ú¯Ô˘Ó ÛÙÔÓ Ï‹ÙË. “¢ÂÓ ‹Ù·Ó ·ÏÙÚÔ˘ÈÛÙÈÎfi˜ Ô ÏfiÁÔ˜ Ô˘ ›· ÙÔ Ó·È ÛÙË ‰ˆÚ¿ Î·È ·˘Ùfi Â›Ó·È ·Ï‹ıÂÈ·. ∂ÁÒ ‹ıÂÏ· Ó· ·Ê‹Ûˆ ˙ˆÓÙ·Ófi ¤Ó· ÎÔÌÌ¿ÙÈ ·fi ÙÔ ·È‰› ÌÔ˘. ¡· ÌË Á›ÓÂÈ fiÏÔ ¯ÒÌ·, Ó· ˘¿Ú¯ÂÈ Î¿Ô˘, ·ÊÔ‡ ·ÂÏ¢ıÂÚÒÓÂÙ·È ÌÂÙ¿ Ë „˘¯‹”. ÕÏÏÔÈ ¿ÏÈ ÁÔÓ›˜, ˆıÔ‡ÌÂÓÔÈ ·fi ·ÏÙÚÔ˘ÈÛÙÈο ΛÓËÙÚ·, Û˘Ó·›ÓÂÛ·Ó ÁÈ· Ó· ‚ÔËı‹ÛÔ˘Ó Î¿ÔÈÔ ¿ÏÏÔ ·È‰› Ó· ˙‹ÛÂÈ, ‹/Î·È ÁÈ· Ó· ··Ï‡ÓÔ˘Ó ÙÔÓ fiÓÔ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘. “™Î¤ÊÙÂÛ·È Ó· ‰ÒÛÂȘ ÂÏ›‰· Û ¿ÏÏ· ·È‰È¿ Î·È ÛÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ·ÊÔ‡ ÙÔ ‰ÈÎfi ÛÔ˘ ¤ı·Ó”. ªÂÚÈÎÔ› ÁÔÓ›˜ ÂÎÏÔÁ›ÎÂ˘Û·Ó ÙË Û˘Ó·ÈÓÂÙÈ΋ ·fiÊ·Û‹ ÙÔ˘˜, ·Ó·ÊÂÚfiÌÂÓÔÈ ÛÙËÓ ÂÈη˙fiÌÂÓË ÂÈı˘Ì›· ÙÔ˘ ·È‰ÈÔ‡. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û¯Â‰fiÓ Û η̛· ÔÈÎÔÁ¤ÓÂÈ· ‰ÂÓ Â›¯Â Û˘˙ËÙËı› ÂÎ ÙˆÓ ÚÔÙ¤ÚˆÓ ÙÔ ı¤Ì· Ù˘ ‰ˆÚ¿˜, ÔÈ ÁÔÓ›˜ ·˘ÙÔ› ıÂÒÚËÛ·Ó ‰Â‰Ô̤ÓË ÙË ıÂÙÈ΋ ÛÙ¿ÛË ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ ÏfiÁˆ ÙÔ˘ ¯·Ú·ÎÙ‹Ú· Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·¤Ó·ÓÙÈ ÛÙË ˙ˆ‹. ∞ÓÙ›ıÂÙ·, οÔÈÔÈ ÁÔÓ›˜ ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿ ÂÂȉ‹ ¤ÓÈˆÛ·Ó ı˘Ìfi Î·È Î·Î›· ÚÔ˜ ÙÔ˘˜ ¿ÏÏÔ˘˜ Î·È ÙË ˙ˆ‹ ÁÂÓÈÎfiÙÂÚ·, ÁÈ·Ù› ¯·ÓfiÙ·Ó ÙÔ ‰ÈÎfi ÙÔ˘˜ ·È‰›, ‹ ÁÈ·Ù› ÊÔ‚‹ıËÎ·Ó fiÙÈ ı·

ηÎÔÔÈËı› ÙÔ ÛÒÌ· Î·È Ë ÂÌÊ¿ÓÈÛ‹ ÙÔ˘ Ì ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ.

1.2. ™˘Óı‹Î˜ ÚfiÙ·Û˘ ™˘Ó‹ıˆ˜ Ô ˘‡ı˘ÓÔ˜ ·È‰›·ÙÚÔ˜ ·ÊÔ‡ ÂÓË̤ڈÓ ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙË ÌË-·Ó·ÛÙÚ„ÈÌfiÙËÙ· Ù˘ ηٿÛÙ·Û˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜, Ï›Á˜ ÒÚ˜ ÌÂÙ¿ ηÏÔ‡Û ÛÙÔ ÁÚ·ÊÂ›Ô ÙÔ˘ ÙÔÓ ¤Ó·Ó ‹ Î·È ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜ Î·È ¤ıÂÙ ÙËÓ Èı·ÓfiÙËÙ· ‰ˆÚ¿˜. ™Â ·ÚÎÂÙ¤˜ fï˜ ÂÚÈÙÒÛÂȘ, ¤Ó· ̤ÏÔ˜ ÙÔ˘ È·ÙÚÔÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡ ÚÔÛ¤ÁÁÈÛ ‰ÈÂÚ¢ÓËÙÈο ¤Ó·Ó Û˘ÁÁÂÓ‹, ÒÛÙ ӷ ÏËÚÔÊÔÚËı› ÁÈ· ÙË ÛÙ¿ÛË ÙˆÓ ÁÔÓ¤ˆÓ ·¤Ó·ÓÙÈ ÛÙÔ ı¤Ì· Ù˘ ‰ˆÚ¿˜ ÚÈÓ Á›ÓÂÈ Ë Â›ÛËÌË ÚfiÙ·ÛË ·fi ÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi. ∞˘Ù‹ Ë ¤ÌÌÂÛË ÚÔÛ¤ÁÁÈÛË Ê¿ÓËΠӷ ÏÂÈÙÔ˘ÚÁ› ıÂÙÈο ÁÈ· ÔÚÈṲ̂ÓÔ˘˜ ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ Ì ‰È΋ ÙÔ˘˜ ÚˆÙÔ‚Ô˘Ï›· ˙‹ÙËÛ·Ó Ó· ‰ˆÚ›ÛÔ˘Ó Ù· fiÚÁ·Ó· ÙÔ˘ ·È‰ÈÔ‡. ŒÓ·˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ‰È¢ÎfiÏ˘Ó ÙË Ï‹„Ë Ù˘ Û˘Ó·ÈÓÂÙÈ΋˜ ·fiÊ·Û˘ ÔÏÏÒÓ ÁÔÓ¤ˆÓ, ‹Ù·Ó Ë Î·Ï‹ Û¯¤ÛË Ô˘ ·Ó¤Ù˘Í·Ó Ì ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ Ù˘ ª∂£ ηٿ ÙË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ÙÔ˘ ·È‰ÈÔ‡. ∂ÚfiÎÂÈÙÔ ÁÈ· ÌÈ· Û¯¤ÛË ÂÈÏÈÎÚ›ÓÂÈ·˜ Î·È ÂÌÈÛÙÔÛ‡Ó˘, ÂÊfiÛÔÓ ÔÈ ÁÈ·ÙÚÔ› ÙÔ‡˜ ÂÓËÌ¤ÚˆÓ·Ó ·ÓÔȯٿ ÁÈ· ÙËÓ ÎÚÈÛÈÌfiÙËÙ· Ù˘ ηٿÛÙ·Û˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡. ∞ÚÎÂÙÔ› ÁÔÓ›˜ ‚¤‚·È·, ·Ó·˙‹ÙËÛ·Ó ÙËÓ ÚfiÛıÂÙË ÁÓÒÌË ÁÓˆÛÙÒÓ ÙÔ˘˜ ÁÈ·ÙÚÒÓ Ô˘ ‰ÂÓ ÂÚÁ¿˙ÔÓÙ·Ó ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ª∂£. ÕÏÏÔ˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¤·Û ÙËÓ ÙÂÏÈ΋ ·fiÊ·ÛË Î¿ÔÈˆÓ ¿ÏÏˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Î·È Ô ÙÚfiÔ˜ Ô˘ ¤ÁÈÓÂ Ë ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜. °ÔÓ›˜ Ô˘ Û˘Ó·›ÓÂÛ·Ó, ·Ó¤ÊÂÚ·Ó fiÙÈ ÔÈ ÁÈ·ÙÚÔ› ÙÔ˘˜ ÂÍ‹ÁËÛ·Ó ·Ó·Ï˘ÙÈο fiÛ· ‹ıÂÏ·Ó ‹ fiÛ· ¿ÓÙ¯·Ó Ó· Ì¿ıÔ˘Ó, ‹Ù·Ó Ôχ ¢ÁÂÓÈÎÔ›, Ê·ÈÓfiÙ·Ó Ó· Û˘Ì¿Û¯Ô˘Ó Ì·˙› ÙÔ˘˜, ‰ÂÓ ÙÔ˘˜ ›ÂÛ·Ó Ó· Û˘Ó·ÈÓ¤ÛÔ˘Ó ÛÙË ‰ˆÚ¿ Î·È ÙÔ˘˜ ¿ÊËÛ·Ó ¯ÒÚÔ Î·È ¯ÚfiÓÔ Ó· ·ÔÊ·Û›ÛÔ˘Ó. °ÔÓ›˜ Ô˘ ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿, ·Ó·Ê¤ÚıËÎ·Ó ÛÙËÓ ·Î·Ù¿ÏÏËÏË ÚÔÛ¤ÁÁÈÛ‹ ÙÔ˘˜ ·fi ÙÔ ÚÔÛˆÈÎfi Ù˘ ªÔÓ¿‰·˜ Ô˘ ÙÔ˘˜ ›ÂÛ ӷ Ï¿‚Ô˘Ó ÌÈ· ·fiÊ·ÛË Û Ôχ ÂÚÈÔÚÈṲ̂ÓÔ ¯ÚfiÓÔ ‹ ‰ÂÓ ¤‰ÂÈÍ·Ó ÙËÓ ··ÈÙÔ‡ÌÂÓË Â˘·ÈÛıËÛ›·, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË ÌÈ·˜ ÌËÙ¤Ú·˜ fiÔ˘ Ë ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜ ¤ÁÈÓ ÌÚÔÛÙ¿ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ù˘, Ô˘ ·ÓÙ¤‰Ú·Û·Ó ¤ÓÙÔÓ· Î·È ÛÙËÓ ÂÚ›ÙˆÛË ‰‡Ô ·Ù¤ÚˆÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ˙ËÙ‹ıËΠӷ ·Ó·Ï¿‚Ô˘Ó Ó· ÂÓËÌÂÚÒÛÔ˘Ó ÙË Û‡˙˘Áfi ÙÔ˘˜ ÁÈ· ÙËÓ ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜, ÁÂÁÔÓfi˜ Ô˘ ÙÂÏÈο ·¤Ê˘Á·Ó Ó· οÓÔ˘Ó. ¶·È‰È·ÙÚÈ΋ 2006;69:369-375

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372

£. MÂÏÏ¿ÏË, ¢. ¶··‰¿ÙÔ˘

1.3. °ÓÒÛË Î·È ÂÌÂÈÚ›· √ÚÈṲ̂ÓÔÈ ÁÔÓ›˜ Ô˘ Û˘Ó·›ÓÂÛ·Ó ÛÙË ‰ˆÚ¿ ÁÓÒÚÈ˙·Ó οÔÈÔ ¿ÙÔÌÔ ·fi ÙÔ ÎÔÓÙÈÓfi ÙÔ˘˜ ÂÚÈ‚¿ÏÏÔÓ Ô˘ ›¯Â οÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ ‹ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ‹ ‚ÚÈÛÎfiÙ·Ó Û ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ÁÂÁÔÓfi˜ Ô˘ ÂËÚ¤·Û ıÂÙÈο ÙËÓ ·fiÊ·Û‹ ÙÔ˘˜. “∂›¯Â οÓÂÈ Ô ÎÔ˘Ì¿ÚÔ˜ Ì·˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ ÚÈÓ ‰‡Ô ¯ÚfiÓÈ· Î·È ÙÔ Â›¯·Ì ˙‹ÛÂÈ ·fi ÎÔÓÙ¿ fiÏÔ ·˘Ùfi… Ó· ÂÚÈ̤ÓÂȘ… ÙËÓ ·ÔÁÔ‹Ù¢ÛË Ô˘ ¤ÓȈÛ fiÙ·Ó ÌÈ· ÊÔÚ¿ ÙÔÓ ÂȉÔÔ›ËÛ·Ó Ó· ¤ÚıÂÈ ·fi ÙÔ ¡·‡ÏÈÔ Î·È ‰ÂÓ ¤Î·Ó ÙÔ ÌfiÛ¯Â˘Ì·…”. ∆Ô ÔÛÔÛÙfi Ù˘ ¿ÚÓËÛ˘ ÛÙË ‰ˆÚ¿ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ fiÙ·Ó ÔÈ ÁÔÓ›˜ ›¯·Ó ÂÏÏÈ›˜ ÁÓÒÛÂȘ ÁÈ· ÙÔ ı¤Ì· Ù˘ ‰ˆÚ¿˜, fiÙ·Ó ‰ÂÓ ÁÓÒÚÈ˙·Ó ÙË ÛÙ¿ÛË Ù˘ ÂÎÎÏËÛ›·˜ ‹ fiÙ·Ó ÂÓËÌÂÚÒıËÎ·Ó fiÙÈ ı· ÙËÚËı› Ë ·ÓˆÓ˘Ì›· ÙˆÓ ·ÙfiÌˆÓ Ô˘ ı· Ï¿Ì‚·Ó·Ó Ù· ÌÔۯ‡̷ٷ. ∆¤ÏÔ˜, ÁÔÓ›˜ Ô˘ ÙÔ ·È‰› ÙÔ˘˜ ¤·Û¯Â ·fi ÌÈ· ¯ÚfiÓÈ· ¿ıËÛË, ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿ ÁÈ·Ù› ÈÛ¯˘Ú›ÛÙËÎ·Ó fiÙÈ ‰ÂÓ ‹ıÂÏ·Ó Ó· ÙÔ ˘Ô‚¿ÏÔ˘Ó Û “Ó¤· Ù·Ï·ÈˆÚ›·”, ¤ÛÙˆ ÎÈ ·Ó ÙÔ ›‰ÈÔ ‰ÂÓ Î·Ù·Ï¿‚·ÈÓÂ.

1.4. √ÈÎÔÁÂÓÂÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ √È ÙÚfiÔÈ Ô˘ ÔÈ ÁÔÓ›˜ ¤Ï·‚·Ó ÙËÓ ·fiÊ·ÛË ÁÈ· ‰ˆÚ¿ ÛÂ Û˘˙˘ÁÈÎfi/ÔÈÎÔÁÂÓÂÈ·Îfi Â›Â‰Ô ‹Ù·Ó ηÙfiÈÓ: ·) ÎÔÈÓ‹˜ Û˘Ìʈӛ·˜ ‚) Û˘Ì‚È‚·ÛÌÔ‡ ÛÙËÓ ·ÓÙ›ıÂÙË ·fiÊ·ÛË ÙÔ˘ Û˘ÓÙÚfiÊÔ˘ Î·È Á) ÂÈ‚ÔÏ‹˜ Ù˘ ·fiÊ·Û˘ ÙÔ˘ ÂÓfi˜ Û˘˙‡ÁÔ˘. ∂ÓÒ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ Û˘Ó·›ÓÂÛ·Ó, ˘‹Ú¯Â Û˘Ìʈӛ· ÌÂٷ͇ ÙˆÓ Û˘˙‡ÁˆÓ, Û οÔȘ ÂÚÈÙÒÛÂȘ ¿ÚÓËÛ˘, Ô ‚·ÛÈÎfi˜ ÏfiÁÔ˜ ‹Ù·Ó Ë ·Û˘Ìʈӛ· ÌÂٷ͇ ÙÔ˘˜. ™˘Ó‹ıˆ˜, fiÙ·Ó Ô ¤Ó·˜ Û‡˙˘ÁÔ˜ ‹Ù·Ó ·ÓÙ›ıÂÙÔ˜ ÛÙË ‰ˆÚ¿, Ô ¿ÏÏÔ˜ Ï¿Ì‚·Ó ˘fi„Ë ÙËÓ ÂÈı˘Ì›· ÙÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÓÂ›Ù·È Î·È Ô ›‰ÈÔ˜. ∂›Û˘, Ë ¿ÚÓËÛË Î¿ÔÈˆÓ ·Ù¤ÚˆÓ ÔÊÂÈÏfiÙ·Ó ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÏfiÁˆ Û˘ÓıËÎÒÓ ‰ÂÓ ‹Ù·Ó Û ı¤ÛË Ó· ÂÓËÌÂÚÒÛÔ˘Ó ÙË Û‡ÓÙÚÔÊfi ÙÔ˘˜, ÔfiÙ ‰ÂÓ ‹ıÂÏ·Ó Ó· ·Ó·Ï¿‚Ô˘Ó ÌfiÓÔÈ ÙÔ˘˜ ÙËÓ ·ÔÎÏÂÈÛÙÈ΋ ¢ı‡ÓË Ù˘ ·fiÊ·Û˘ ÁÈ· ÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ. “∏ Á˘Ó·›Î· ÌÔ˘ ‹Ù·Ó ÛÙÔ Û›ÙÈ Û η΋ ηٿÛÙ·ÛË. ¶Ò˜ Ó· Ù˘ ÙÔ ¤ÏÂÁ·; ∂ÁÒ ‹ÌÔ˘Ó ıÂÙÈÎfi˜ Ó· ‰ÒÛˆ Ù· fiÚÁ·Ó·, ·ÏÏ¿ ‰ÂÓ ‹ÍÂÚ· Ò˜ ı· ÙÔ ¤·ÈÚÓ ÂΛÓË Ë ÔÔ›· ‰ÂÓ ‹ÍÂÚ ٛÔÙ·. ∏ ·fiÊ·ÛË ı· ¤ÚÂ ӷ Â›Ó·È Î·È ‰È΋ Ù˘, ÙÔ ·È‰› ‰ÂÓ ·Ó‹Î ÌfiÓÔ Û ̤ӷ”. ∆¤ÏÔ˜, ˘‹Ú¯·Ó ÂÚÈÙÒÛÂȘ ÁÔÓ¤ˆÓ Ô˘ ·ÚÓ‹ıËÎ·Ó ÙË ‰ˆÚ¿ ÁÈ·Ù› ‚›ˆÓ·Ó ·Ú¿ÏÏËÏ· ¿ÏϘ ÛÙÚÂÛÛÔÁfiÓ˜ ηٷÛÙ¿ÛÂȘ fiˆ˜ ÙÂÙ·¶·È‰È·ÙÚÈ΋ 2006;69:369-375

̤Ó˜ ÂÓ‰ÔÔÈÎÔÁÂÓÂȷΤ˜ Û¯¤ÛÂȘ, ‹ ÔÏÏ·Ϥ˜ ·ÒÏÂȘ.

2. ¢˘ÛÎÔϛ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ŒÓ· ı¤Ì· Ô˘ ··Û¯fiÏËÛ ·ÚÎÂÙÔ‡˜ ÁÔÓ›˜ ‹Ù·Ó Ë ÂÈÏÔÁ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ Ô˘ ı· ‰ˆÚÈıÔ‡Ó Î·È È‰È·›ÙÂÚ· Ë ‰ˆÚ¿ Ù˘ ηډȿ˜ Î·È ÙˆÓ Ì·ÙÈÒÓ ÙÔ˘ ·È‰ÈÔ‡. ÕÏÏÔÈ ¿ÏÈ ÁÔÓ›˜ ‰˘ÛÎÔχÙËÎ·Ó ÛÙËÓ ·fiÊ·Û‹ ÙÔ˘˜ ÁÈ·Ù› ‰ÂÓ Â›¯·Ó Â·ÚΛ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‰È·‰Èηۛ· ·Ê·›ÚÂÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ, ÙÔÓ ÚfiÏÔ ÙÔ˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘Ù‹˜, ηıÒ˜ Î·È ÁÈ· ÙË ÌÂÙ¤ÂÈÙ· ÂÈÎfiÓ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡. “¢ÂÓ Í¤Ú·Ì ÙÈ Ó· οÓÔ˘ÌÂ. ¡· ʇÁÔ˘ÌÂ; ¡· Ì›ÓÔ˘ÌÂ Î·È Ó· ÂÚÈ̤ÓÔ˘ÌÂ; ∫·Ó›˜ ‰ÂÓ Ì·˜ › ٛÔÙ·. ¶fiÛË ÒÚ· ı· ¤ÚÂ ӷ ÂÚÈ̤ÓÔ˘Ì ӷ ÙÂÏÂÈÒÛÂÈ ÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô; ¶Ò˜ ı· ‹Ù·Ó ¿Ú·Á ÙÔ ·È‰› ÌÂÙ¿; £· ÙÔ ‚Ϥ·ÌÂ; ∂Ì›˜ ‰ÂÓ Â›¯·ÌÂ Ì˘·Ïfi Ó· ÚˆÙ‹ÛÔ˘Ì ÂΛӘ ÙȘ ÛÙÈÁ̤˜. ŒÚÂ ӷ Ì·˜ Ô˘Ó ·fi ÌfiÓÔÈ ÙÔ˘˜, ¯ˆÚ›˜ Ó· ÂÚÈ̤ÓÔ˘ÌÂ Î·È ¯ˆÚ›˜ Ó· ÁÈÓfiÌ·ÛÙ ÂÌ›˜ ÂÓÔ¯ÏËÙÈÎÔ›”. ªÈ· ¿ÏÏË ÛËÌ·ÓÙÈ΋ ·Ó¿ÁÎË ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ÚԤ΢„ ÌÂÙ¿ ÙË Û˘Ó·›ÓÂÛË ÛÙË ‰ˆÚ¿ ‹Ù·Ó Ë ÏËÚÔÊfiÚËÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÛÙËÓ Ù·˘ÙfiÙËÙ· ÙÔ˘ Ï‹ÙË Î·È ÛÙË ‰˘Ó·ÙfiÙËÙ· ÂÈÎÔÈÓˆÓ›·˜ Ì·˙› ÙÔ˘. ™¯Â‰fiÓ fiÏÔÈ ÔÈ ÁÔÓ›˜ ‰‹ÏˆÛ·Ó fiÙÈ ı· ‹ıÂÏ·Ó Ó· ÁÓˆÚ›˙Ô˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÒÛÙ ӷ ÓÈÒÛÔ˘Ó fiÙÈ ¿ÍÈ˙ ÙÔÓ ÎfiÔ Ë ÚÔÛÊÔÚ¿ ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ÂÓËÌÂÚÒıËηÓ, ÙÔ˘˜ ‰˘ÛÎfiÏ„ ÛÙËÓ ÔÚ›· ÙÔ˘˜ ¤ÓıÔ˘˜ ÙÔ˘˜. “¢ÂÓ ¤Ì·ı· ÙÈ ·¤ÁÈÓ ÙÂÏÈο... ı· ‹ıÂÏ· ÌÈ· ÊÔÚ¿ ÙÔÓ ¯ÚfiÓÔ ‹ οı ¤ÓÙ ¯ÚfiÓÈ· Ó· Ì·ı·›Óˆ Ò˜ Â›Ó·È ·˘ÙÔ› ÔÈ ¿ÓıÚˆÔÈ, fi¯È ÔÈÔÈ Â›Ó·È ·ÏÏ¿ ·Ó Â›Ó·È Î·Ï¿ ÁÈ· Ó· ͤڈ fiÙÈ ¿ÍÈ˙ ÙÔÓ ÎfiÔ”. ∫¿ÔÈÔÈ ÁÔÓ›˜ ¤Ì·ı·Ó ÙÂÏÈο ÔÈ· fiÚÁ·Ó· ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Î·È ÁÈ· ÙËÓ Î·Ï‹ ηٿÛÙ·ÛË Ù˘ ˘Á›·˜ ÙˆÓ ÏËÙÒÓ. ∞˘Ùfi ÂÈÙ‡¯ıËΠ̠Ôχ ÎfiÔ, ηıÒ˜ ·fi ÙËÓ ÀËÚÂÛ›· ªÂÙ·ÌÔۯ‡ÛÂˆÓ ‰ÂÓ ˘‹Ú¯Â Â›ÛËÌË ÂÓË̤ڈÛË. ŸÛÔÈ ÁÔÓ›˜ fï˜, ¤Ì·ı·Ó fiÙÈ ·¤Ù˘¯Â Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ ‰ÂÓ ‚Ú¤ıËΠ‰fiÙ˘ -΢ڛˆ˜ ÁÈ· ÙËÓ Î·Ú‰È¿ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜- ¤ÓÈˆÛ·Ó ¤ÓÙÔÓË ‰˘Û·Ú¤ÛÎÂÈ· Î·È ·ÔÁÔ‹Ù¢ÛË. ™¯ÂÙÈο Ì ÙËÓ ÂÈı˘Ì›· ÙˆÓ ÁÔÓ¤ˆÓ Ó· ¤ÚıÔ˘Ó Û Â·Ê‹ Ì ÙÔÓ Ï‹ÙË Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ‚›ˆÓ·Ó ·ÌÊÈı˘ÌÈο Û˘Ó·ÈÛı‹Ì·Ù·. ∫¿ÔÈÔÈ ‹ıÂÏ·Ó Ó· ÁÓˆÚ›ÛÔ˘Ó ÌfiÓÔ ÙÔÓ Ï‹ÙË Ù˘ ηډȿ˜ Î·È fi¯È ÙÔ˘˜

Pediatr Sept_Oct 06

26-09-06

12:53

™ÂÏ›‰·373

373

∂ÌÂÈڛ˜ ÁÔÓ¤ˆÓ ·fi ÙËÓ ÚfiÙ·ÛË ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ

˘fiÏÔÈÔ˘˜. ÕÏÏÔÈ ¿ÏÈ, ›¯·Ó ·ÎfiÌ· Î·È ÙË ÛÙÈÁÌ‹ Ù˘ Û˘Ó¤ÓÙ¢Í˘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ·Ù› ‰ÂÓ ‹ÍÂÚ·Ó Â¿Ó Ë ÂÈÎÔÈÓˆÓ›· Ì ÙÔÓ Ï‹ÙË ı· ÙÔ˘˜ ·Ó·ÎÔ‡ÊÈ˙Â, ‹ ı· ÙÔ˘˜ ‰˘ÛÎfiÏ¢Â. ªÂÚÈÎÔ› ÂͤÊÚ·Û·Ó ·ÓÔȯٿ ÙËÓ ÂÈı˘Ì›· Ó· ›¯·Ó ·Ó·Ï¿‚ÂÈ ÔÈ Ï‹Ù˜ ÙËÓ ÚˆÙÔ‚Ô˘Ï›· Ó· ÂÈÎÔÈÓˆÓ‹ÛÔ˘Ó Ì·˙› ÙÔ˘˜. ∂·Ê‹ Ì ÙÔÓ Ï‹ÙË Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘ ˘‹Ú¯Â Û ÌÈ· ÂÚ›ÙˆÛË ÁÔÓ¤ˆÓ, ÔÈ ÔÔ›ÔÈ ÂÚÈÁÚ¿ÊÔ˘Ó Ôχ ıÂÙÈο ÙËÓ ÂÌÂÈÚ›· ÙÔ˘˜. ∏ ÂÈÎÔÈÓˆÓ›· ÌÂٷ͇ ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ ·ÌÊ›‰ÚÔÌË, ÌÂ Û˘¯ÓfiÙÂÚË ÙËÓ Î·Ù‡ı˘ÓÛË ·fi ÙÔÓ Ï‹ÙË Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘ ÚÔ˜ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ‰fiÙË.

™˘˙‹ÙËÛË ™‡Ìʈӷ Ì ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, Ë ÚfiÙ·ÛË Ù˘ ‰ˆÚ¿˜ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÙÔ È·ÙÚÈÎfi ÚÔÛˆÈÎfi ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ‰fiÙË (1-2,10,20). ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ Û˘¯Ó¿ ÚÔÛÂÁÁ›˙ÂÈ Û ÚÒÙË Ê¿ÛË Ì ¤ÌÌÂÛÔ Î·È ‰ÈÂÚ¢ÓËÙÈÎfi ÙÚfiÔ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Î·È Û˘˙ËÙ¿ ¿Ù˘· ÙË ‰˘Ó·ÙfiÙËÙ· Ù˘ ‰ˆÚ¿˜ Ì ÙÔÓ ÁÔÓ¤· Ô˘ Ê·›ÓÂÙ·È ÈÔ ¤ÙÔÈÌÔ˜ Ó· ·ÎÔ‡ÛÂÈ, ‹ ÌÂ Û˘ÁÁÂÓ›˜ Ô˘ ·Ó·Ï·Ì‚¿ÓÔ˘Ó Ó· ı¤ÛÔ˘Ó ÙÔ ı¤Ì· ÛÙÔ˘˜ ÁÔÓ›˜. ™ÙË Û˘Ó¤¯ÂÈ·, Ô ıÂÚ¿ˆÓ È·ÙÚfi˜ ÂÓËÌÂÚÒÓÂÈ Î·È ÚÔÙ›ÓÂÈ Â›ÛËÌ· ÛÙÔ˘˜ ÁÔÓ›˜ Ó· ‰ˆÚ›ÛÔ˘Ó Ù· fiÚÁ·Ó· ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. √ “¤ÌÌÂÛÔ˜” ·˘Ùfi˜ ÙÚfiÔ˜ ÚÔÛ¤ÁÁÈÛ˘, ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÂÏÏËÓÈ΋˜ Ú·ÁÌ·ÙÈÎfiÙËÙ·˜, Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ıÂÙÈο ÙËÓ ·fiÊ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ ηıÒ˜ ¤¯Ô˘Ó ÛÙË ‰È¿ıÂÛ‹ ÙÔ˘˜ οÔÈÔ ¯ÚfiÓÔ Ó· ÛÎÂÊÙÔ‡Ó ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ‰ˆÚ¿˜ ÚÈÓ ÙÔ˘˜ ÙÂı› Â›ÛËÌ· ·fi ÙÔÓ ·È‰›·ÙÚÔ. ™Â Û˘Ìʈӛ· Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ Cleiren & Zoelen (20), Ë ·ÚÔ‡Û· ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÙfiÛÔ ÔÈ ÁÔÓ›˜ Ô˘ Û˘Ó·›ÓÂÛ·Ó, fiÛÔ Î·È ÔÈ ÁÔÓ›˜ Ô˘ ·ÚÓ‹ıËηÓ, ‰ÂÓ ‚›ˆÛ·Ó ÚfiÛıÂÙÔ „˘¯ÈÎfi ÛÙÚ˜ ÂÍ·ÈÙ›·˜ Ù˘ ÚfiÙ·Û˘ Ù˘ ‰ˆÚ¿˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ·Ó·‰ÂÈÎÓ‡ÂÈ ·‚¿ÛÈÌÔ ÙÔÓ Û˘¯Ófi Êfi‚Ô Ô˘ ‚ÈÒÓÂÈ ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ fiÙ·Ó Î·ÏÂ›Ù·È Ó· Û˘˙ËÙ‹ÛÂÈ Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ó¤‚·Ï·Ó ÛÙË Û˘ÁηٿıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ, ‰ÂÓ ‹Ù·Ó ¿ÓÙ· ·ÏÙÚÔ˘ÈÛÙÈÎÔ›. ∂ÓÒ Î¿ÔÈÔÈ ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë Ï‹„Ë Ù˘ Û˘Ó·ÈÓÂÙÈ΋˜ ·fiÊ·Û˘ Â›Ó·È ÎÏ·ÛÈÎfi ·Ú¿‰ÂÈÁÌ· ÌÈ·˜ ‰È·‰Èηۛ·˜ “Ï‹„˘ ¿ÌÂÛˆÓ ·ÔÊ¿ÛÂˆÓ ‚¿ÛÂÈ ËıÈÎÒÓ ÂÈÙ·ÁÒÓ” ηıÒ˜ Ë ‰ˆÚ¿ ·ÊÔÚ¿ ÌÈ·

¢ÁÂÓ‹ Ú¿ÍË Î·È ËıÈ΋ ˘Ô¯Ú¤ˆÛË (1,25), ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÔÈ ÁÔÓ›˜ Ô˘ Û˘Ó·›ÓÂÛ·Ó ‰ÂÓ ˆı‹ıËÎ·Ó ¿ÓÙ· ·fi ÎÔÈÓˆÓÈÎfi ÂӉȷʤÚÔÓ. ™˘¯Ó¿ ·Ó¤ÊÂÚ·Ó fiÙÈ Û˘Ó·›ÓÂÛ·Ó ÁÈ·Ù› ‰ÂÓ Â›¯·Ó ¿ÏÏË ÂÈÏÔÁ‹ ÂÊfiÛÔÓ ‰ÂÓ ˘‹Ú¯Â ÂÏ›‰· ÂÈ‚›ˆÛ˘, ÂÓÒ Û οÔȘ ÂÚÈÙÒÛÂȘ ˆı‹ıËÎ·Ó ·fi ÙËÓ ÂÈı˘Ì›· Ó· Û˘Ó¯›ÛÂÈ Ó· ˙ÂÈ ÙÔ ·È‰› ÙÔ˘˜ ¤ÛÙˆ Î·È Ì¤Û· ÛÙÔ ÛÒÌ· ͤÓÔ˘ ·ÓıÚÒÔ˘. Ÿˆ˜ ‰Â›¯ÓÔ˘Ó ÎÈ ¿ÏϘ ÌÂϤÙ˜, ‚Ú‹Î·Ó ·Ó·ÎÔ‡ÊÈÛË Î·È ·ÚËÁÔÚÈ¿ ÛÙË ÛΤ„Ë fiÙÈ Ô ¿ÓıÚˆfi˜ ÙÔ˘˜ “˘¿Ú¯ÂÈ” ̤۷ ÛÙÔ ÛÒÌ· ¿ÏÏÔ˘ (5,7,9,12). £ÂÙÈο Â›Û˘ ÏÂÈÙÔ‡ÚÁËÛÂ Ë ÂÈη˙fiÌÂÓË ÂÈı˘Ì›· ÙÔ˘ ·È‰ÈÔ‡ Ì ‚¿ÛË Ù· ÎÔÈÓˆÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÚÔÛˆÈÎfiÙËÙ¿˜ ÙÔ˘ (7,10-11,16-17,26). ∫·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙË Û˘Ó·›ÓÂÛË ¤·ÈÍÂ Ë ıÂÙÈ΋ ÂÌÂÈÚ›· ÙˆÓ ÁÔÓ¤ˆÓ ·fi ÙË ÓÔÛËÏ›· ÙÔ˘ ·È‰ÈÔ‡ ÛÙË ª∂£ Î·È Ë ÂÈÏÈÎÚÈÓ‹˜ Î·È ıÂÚÌ‹ Û¯¤ÛË ÂÌÈÛÙÔÛ‡Ó˘ Ô˘ ·Ó¤Ù˘Í·Ó Ì ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜. ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ¿ÏψÛÙÂ, ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ fiÙ·Ó Ù· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÚÔÛÂÁÁ›˙ÔÓÙ·È Ì ¢·ÈÛıËÛ›· ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜, fiÙ·Ó ·Ó·Ù‡ÛÛÔ˘Ó ÌÈ· Û¯¤ÛË ÂÌÈÛÙÔÛ‡Ó˘ Ì ·˘Ùfi Î·È Á›ÓÔÓÙ·È Ì¿ÚÙ˘Ú˜ Ù˘ ÂÓÙ·ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ Ô˘ ‰¤¯ÂÙ·È Ô ¿ÓıÚˆfi˜ ÙÔ˘˜, ÙfiÙÂ Û˘Ó·ÈÓÔ‡Ó ÈÔ Â‡ÎÔÏ· (7,10-13,17-18,21,26-27). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¤·Û·Ó ÙÔ˘˜ ÁÔÓ›˜ ÛÙÔ Ó· Û˘Ó·ÈÓ¤ÛÔ˘Ó ÛÙË ‰ˆÚ¿ ‹Ù·Ó Î·È Ë ıÂÙÈο ‰È·ÌÔÚʈ̤ÓË ¿Ô„Ë ÂÍ·ÈÙ›·˜ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÁÓÒÛ˘ Ô˘ ηÙ›¯·Ó ÁÈ· ÙÔ ı¤Ì· Ù˘ ‰ˆÚ¿˜, ·ÏÏ¿ Î·È Ù˘ ÂÌÂÈÚ›·˜ ÙÔ˘˜ ·fi ¿ÙÔÌ· Ô˘ ¤ÁÈÓ·Ó Ï‹Ù˜ ‹ ¤¯ÚË˙·Ó ÌÂÙ·ÌfiÛ¯Â˘Û˘ (19). ∆¤ÏÔ˜, ηıÔÚÈÛÙÈ΋ ‹Ù·Ó Ë Û˘Ìʈӛ· ÌÂٷ͇ ÙˆÓ ‰‡Ô Û˘˙‡ÁˆÓ, ·ÏÏ¿ Î·È Ë ıÂÙÈ΋ ÛÙ¿ÛË ÙˆÓ ¿ÏÏˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™‡Ìʈӷ Ì ÙÔÓ Waissmann (28) “Ë Ú¿ÍË Ù˘ ‰ˆÚ¿˜ ‰ÂÓ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÌfiÓÔ ÌÈ·˜ ÂχıÂÚ˘ ÚÔÛˆÈ΋˜ ·fiÊ·Û˘, ·ÏÏ¿ ·ÔÙ¤ÏÂÛÌ· Û˘ÏÏÔÁÈ΋˜ ÂÈÏÔÁ‹˜ ·fi ÙËÓ Â˘Ú‡ÙÂÚË ÔÈÎÔÁ¤ÓÂÈ·, ÏfiÁˆ ·ÏÏËÏÂ›‰Ú·Û˘ Î·È ˘ÔÛÙ‹ÚÈ͢ Û ¤Ó· ÎÔÈÓfi Úfi‚ÏËÌ·”. ™Â Û˘Ìʈӛ· Ì ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜, ÔÈ ‚·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Ô‰‹ÁËÛ·Ó ÔÚÈṲ̂ÓÔ˘˜ ŒÏÏËÓ˜ ÁÔÓ›˜ ÛÙËÓ ¿ÚÓËÛË Ù˘ ‰ˆÚ¿˜, ‹Ù·Ó Ë ‰˘ÛÎÔÏ›· ·Ô‰Ô¯‹˜ Ù˘ ÔÚÈÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ı·Ó¿ÙÔ˘, Ë ÂÈı˘Ì›· ‰È·Ù‹ÚËÛ˘ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, Ô Êfi‚Ô˜ Ì‹ˆ˜ ηÎÔÔÈËı› ÙÔ ÛÒÌ·, ·ÏÏ¿ Î·È Ô ı˘Ìfi˜ Ô˘ ¤ÓȈı·Ó ÁÈ· ÙÔÓ “·Ê‡ÛÈÎÔ” Î·È “¿Î·ÈÚÔ” ı¿Ó·ÙÔ ÙÔ˘ ·È‰ÈÔ‡, ÁÂÁÔÓfi˜ Ô˘ ÙÔ˘˜ ¤Î·Ó ÏÈÁfiÙÂÚÔ Û˘ÌÔÓÂÙÈÎÔ‡˜ ·¤Ó·ÓÙÈ ÛÙÔÓ fiÓÔ ÙˆÓ Û˘Ó·ÓıÚÒˆÓ ÙÔ˘˜ (6,10,15,19). ¶·È‰È·ÙÚÈ΋ 2006;69:369-375

Pediatr Sept_Oct 06

26-09-06

12:53

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374

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ÕÏÏÔÈ ÏfiÁÔÈ ¿ÚÓËÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Ô “ÙÚ·˘Ì·ÙÈÎfi˜” ÙÚfiÔ˜ Ô˘ ¤ÁÈÓÂ Ë ÚfiÙ·ÛË ·fi ÙÔÓ È·ÙÚfi, Ô˘ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ¤ıÂÛ ÙÔ ı¤Ì· ÌÚÔÛÙ¿ Î·È Û ·Ó‹ÏÈη ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‹ ‰ÂÓ Û˘ÌÂÚȤϷ‚ ÛÙË Û˘˙‹ÙËÛË Î·È ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜ (14,19). ∂›Û˘, Ë ¤ÏÏÂÈ„Ë ÁÓÒÛ˘ ‹ ÚÔËÁÔ‡ÌÂÓ˘ ÂÌÂÈÚ›·˜ Û¯ÂÙÈο Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ ηıÒ˜ Î·È Ë ¿ÁÓÔÈ· ÁÈ· ÙË ÛÙ¿ÛË Ù˘ ÂÎÎÏËÛ›·˜ ·¤Ó·ÓÙÈ ÛÙÔ ı¤Ì· Ù˘ ‰ˆÚ¿˜, Û˘Ó¤‚·Ï ÛÙËÓ ¿ÚÓËÛ‹ ÙÔ˘˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ‰Â›¯ÓÂÈ fiÛÔ ··Ú·›ÙËÙË Â›Ó·È Ë ÂÓË̤ڈÛË Î·È Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ÎÔÈÓÔ‡ ·¤Ó·ÓÙÈ ÛÙË ‰ˆÚ¿, ·fi fiÏÔ˘˜ ÙÔ˘˜ ·ÚÌfi‰ÈÔ˘˜ ÊÔÚ›˜ (ÔÏÈÙ›·, ÚÔÛˆÈÎfi ˘Á›·˜, ÂÎÎÏËÛ›· Î.Ï.). ∏ ÚÔËÁÔ‡ÌÂÓË ÓfiÛÔ˜ Î·È Ù·Ï·ÈˆÚ›· ÙÔ˘ ·È‰ÈÔ‡ ÂËÚ¤·Û ·ÚÓËÙÈο ÙËÓ ·fiÊ·ÛË Î¿ÔÈˆÓ ÁÔÓ¤ˆÓ (13,19,21). ™ËÌ·ÓÙÈÎfi˜, Ù¤ÏÔ˜, ·Ú¿ÁÔÓÙ·˜ ¿ÚÓËÛ˘ ‹Ù·Ó Ë ·Û˘Ìʈӛ· ÌÂٷ͇ ÙˆÓ ‰‡Ô Û˘˙‡ÁˆÓ, ηıÒ˜ Î·È Ù· ÚÔÛˆÈο ‹ ÔÈÎÔÁÂÓÂȷο ÚÔ‚Ï‹Ì·Ù· ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ï‹„˘ Ù˘ ·fiÊ·Û˘. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô È·ÙÚfi˜ ÂÓË̤ڈÓ ÌÔÓ¿¯· ÙÔÓ ¤Ó·Ó ·fi ÙÔ˘˜ ‰˘Ô ÁÔÓ›˜, ‹ fiÙ·Ó -ÏfiÁˆ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ‹ ı·Ó¿ÙÔ˘- ‰ÂÓ ˘‹Ú¯Â Û‡ÓÙÚÔÊÔ˜ ÁÈ· Ó· Û˘Ó·ÔÊ·Û›ÛÂÈ, ÙfiÙÂ Ô ÁÔÓÈfi˜ ·ÚÓ›ÙÔ Ó· ‰ÒÛÂÈ ÙË Û˘ÁηٿıÂÛ‹ ÙÔ˘ (1,11,18). ŸÚÁ·Ó· fiˆ˜ Ë Î·Ú‰È¿ Î·È Ù· Ì¿ÙÈ· Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ȉȷ›ÙÂÚË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·Í›· Î·È ÁÈ· ÙÔ˘˜ ŒÏÏËÓ˜ ÁÔÓ›˜ Ô˘ ‰˘ÛÎÔχÙËÎ·Ó Ó· Ù· ‰ˆÚ›ÛÔ˘Ó. °È· ÔÏÏÔ‡˜ Ï·Ô‡˜ Ë ‰ˆÚ¿ Ù˘ ηډȿ˜ ÂÌÂÚȤ¯ÂÈ Î¿ÔÈ· Ì˘ÛÙÈÎÈÛÙÈ΋, ·Ó fi¯È ıÚËÛ΢ÙÈ΋, ÛËÌ·Û›· Ô˘ ÙË ‰È·ÎÚ›ÓÂÈ Û˘Ì‚ÔÏÈο ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¿ÏÏˆÓ ÔÚÁ¿ÓˆÓ (10). ∏ ηډȿ ıˆÚÂ›Ù·È ÙÔ “ΤÓÙÚÔ Ù˘ ˙ˆ‹˜”, Ô “Ô›ÎÔ˜ Ù˘ „˘¯‹˜”, ηıÒ˜ Î·È ÙÔ ·ÁÎfiÛÌÈÔ Û‡Ì‚ÔÏÔ Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜, ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ Î·È Ù˘ ‰‡Ó·Ì˘ ÙÔ˘ ·ÓıÚÒÔ˘ (29), ÂÓÒ ·fi ÙËÓ ¿ÏÏË, Ù· Ì¿ÙÈ· ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó “ÙËÓ ÂÈÎfiÓ· Ù˘ „˘¯‹˜” ÙÔ Û‡Ì‚ÔÏÔ Ù˘ Ù·˘ÙfiÙËÙ·˜ Î·È Ù˘ ÔÌÔÚÊÈ¿˜ (30). ∏ ·fiÊ·ÛË Ù˘ Û˘Ó·›ÓÂÛ˘ ‹ ¿ÚÓËÛ˘ ÛÙË ‰ˆÚ¿ Ê·›ÓÂÙ·È fiÙÈ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ fiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈο οı ÁÔÓÈfi˜ Â›Ó·È Û ı¤ÛË Ó· ··ÓÙ‹ÛÂÈ ÛÙ· ·Ú·Î¿Ùˆ ÂÚˆÙ‹Ì·Ù·: Œ¯ÂÈ ÂÏ›‰· ÙÔ ·È‰› Ó· ˙‹ÛÂÈ; ∆Ô ı·Ó·ÙÒÓˆ ·Ó Û˘Ó·ÈÓ¤Ûˆ; ∆È ÓfiËÌ· ¤¯ÂÈ Ë Ú¿ÍË Ù˘ ‰ˆÚ¿˜; Œ¯ˆ ÂÌÈÛÙÔÛ‡ÓË ÛÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ Ô˘ Ì ÂÓË̤ڈÛ ÁÈ· ÙÔÓ ı¿Ó·ÙÔ Î·È ı· ·Ó·Ï¿‚ÂÈ ÙË ‰ˆÚ¿; £· ηÎÔÔÈËı› ÙÔ ÛÒÌ· ÙÔ˘; ¶Ò˜ ı· ÂËÚ¿ÛÂÈ Ë Ú¿ÍË Ù˘ ‰ˆÚ¿˜ Â̤ӷ, ÙÔÓ Û‡ÓÙÚÔÊÔ Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÌÔ˘; ¶·È‰È·ÙÚÈ΋ 2006;69:369-375

ŸÙ·Ó Ô È·ÙÚfi˜ ÂÓËÌÂÚÒÓÂÈ Î·È ‚ÔËı¿ ÙÔ˘˜ ÁÔÓ›˜ Ó· ‰ÒÛÔ˘Ó ··ÓÙ‹ÛÂȘ ÛÙȘ ·Ú·¿Óˆ ÂÚˆÙ‹ÛÂȘ, ÌÂÈÒÓÂÈ ÙȘ ‰˘ÛÎÔϛ˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÚÈÓ Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ï‹„˘ Ù˘ ·fiÊ·Û˘, ·˘Í¿ÓÔÓÙ·˜ ÙȘ Èı·ÓfiÙËÙ˜ Ó· ¿ÚÔ˘Ó ÌÈ· ·fiÊ·ÛË Ì ÙËÓ ÔÔ›· ı· Â›Ó·È ÈηÓÔÔÈË̤ÓÔÈ ÁÈ· ÙÔ ˘fiÏÔÈÔ Ù˘ ˙ˆ‹˜ ÙÔ˘˜. √È ·ÊËÁ‹ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ·Ó¤‰ÂÈÍ·Ó Î¿ÔȘ ·Ó¿ÁΘ Î·È ÚÔÛ‰Ô˘ Ô˘ ¤¯Ô˘Ó ·fi ÙÔ˘˜ È·ÙÚÔ‡˜ Î·È ÙÔ ÏÔÈfi ÚÔÛˆÈÎfi ˘Á›·˜. ªÈ· ·fi ÙȘ ÈÔ ‚·ÛÈΤ˜ ·Ó¿ÁΘ Â›Ó·È Ë ‰ÈÂÍÔ‰È΋ ÂÓË̤ڈÛË Î·È ‰È·‚‚·›ˆÛË Ù˘ ÌË Î·ÎÔÔ›ËÛ˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡, ηıÒ˜ Î·È Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÙÔ ‰Ô˘Ó Î·È Ó· ÙÔ ·Ô¯·ÈÚÂÙ›ÛÔ˘Ó ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ. ™ËÌ·ÓÙÈ΋, Â›Û˘, ·Ó¿ÁÎË Â›Ó·È Î·È Ë ÂÓË̤ڈۋ ÙÔ˘˜ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ÏËÚÔÊfiÚËÛ‹ ÙÔ˘˜ ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ˘Á›·˜ ÙÔ˘ Ï‹ÙË ·ÔÙÂÏ› ÂÈ‚Ú¿‚¢ÛË Ù˘ ÚÔÛÊÔÚ¿˜ ÙÔ˘˜, ηıÒ˜ Û˘Ì‚¿ÏÂÈ ÛÙË Û˘ÓÂȉËÙÔÔ›ËÛË fiÙÈ ‰ÂÓ ‹Ù·Ó Ì¿Ù·ÈÔ ·˘Ùfi Ô˘ ¤Î·Ó·Ó, fiÙÈ Ù· “fiÚÁ·Ó· ‰ÂÓ ‹Á·Ó ¯·Ì¤Ó·” (5-6,8,19). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· Â˘Ú‹Ì·Ù· ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÁÂÓÈ΢ÙÔ‡Ó ÏfiÁˆ ÙÔ˘ ÂÚÈÔÚÈṲ̂ÓÔ˘ ‰Â›ÁÌ·ÙÔ˜ Î·È ÙˆÓ ÔÏÈÙÈÛÌÈÎÒÓ È‰È·ÈÙÂÚÔÙ‹ÙˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ÁÔÓ¤ˆÓ, Û˘Ì‚¿ÏÏÔ˘Ó fï˜ ÛÙËÓ Î·Ù·ÓfiËÛË Î·È “ηٿÏÏËÏË” ÚÔÛ¤ÁÁÈÛË ÙˆÓ ÁÔÓ¤ˆÓ ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜. ∏ ÚÔÛ¤ÁÁÈÛË ·˘Ù‹ ‰ÂÓ Ú¤ÂÈ Ó· ¤¯ÂÈ ˆ˜ ÚˆÙ·Ú¯ÈÎfi ÛÙfi¯Ô ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ, ·ÏÏ¿ ΢ڛˆ˜ ÙÔ Û˘ÌʤÚÔÓ Î·È ÙË ÛÙ‹ÚÈÍË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÛÙË Ï‹„Ë ÔÔÈ·Û‰‹ÔÙ ·fiÊ·Û˘ ÙÔ ÂÎÊÚ¿˙ÂÈ.

∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌfiٷٷ ÙÔ˘˜ ÁÔÓ›˜ Ô˘ ‰¤¯ÙËÎ·Ó Ó· Û˘ÌÌÂÙ¿Û¯Ô˘Ó ÛÙË ÌÂϤÙË Î·È Ó· ÌÔÈÚ·ÛÙÔ‡Ó Ì·˙› Ì·˜ ÙËÓ ÂÌÂÈÚ›· ÙÔ˘˜ ·fi ÙË ÓÔÛËÏ›· Î·È ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. ∂˘¯·ÚÈÛÙԇ̠Â›Û˘, ÙÔ˘˜ È·ÙÚÔ‡˜ ÙˆÓ ‰‡Ô ª∂£ Ô˘ ÛÙ‹ÚÈÍ·Ó ÙËÓ ÚÔÛ¿ıÂÈ·, ηıÒ˜ Î·È ÙȘ ÎÎ. ∂ÈÚ‹ÓË ¶·¿˙ÔÁÏÔ˘ Î·È ¢‹ÌËÙÚ· ¶ÂÙÚ¿ÎË ÁÈ· ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰Ô̤ӈÓ. ∏ ¤Ú¢ӷ ¯ÚËÌ·ÙÔ‰ÔÙ‹ıËΠ·fi ÙÔÓ ∂§∫∂ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ.

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CASE REPORT

¡ÂÔÁÓfi Ì ÂÈÎfiÓ· ÛË„·ÈÌ›·˜ Î·È ÔÏÏ·Ï¿ Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· 1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô §¿ÚÈÛ·˜ 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÎÙÈÓԉȷÁÓˆÛÙÈ΋˜ π·ÙÚÈ΋˜ ∞ÂÈÎfiÓÈÛ˘, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô §¿ÚÈÛ·˜ AÏÏËÏÔÁÚ·Ê›·: µ·ÛÈÏÈ΋ ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘∆ÛÈÎڛη ª·Ó‰ËÏ·Ú¿ 49 ∆.∫. 412 23, §¿ÚÈÛ· E-mail: tsikrika@hol.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-07-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-11-2005

µ. ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘ - ∆ÛÈÎڛη1, ∞. ∞ÓÙˆÓÔ‡ÏË1, ∫. °·˚Ù·Ó¿1, ƒ. ªˆ¸Û›‰Ô˘2, ª. °Ô˘‰ÂÛ›‰Ô˘1, ∞. ¶ÈÙÂÚÔ‡1

¶ÂÚ›ÏË„Ë ∆· Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· Â›Ó·È Ôχ Û¿ÓÈ· ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ª¤¯ÚÈ ÚfiÛÊ·Ù· Ë ‰È¿ÁÓˆÛË ÁÈÓfiÙ·Ó Î˘Ú›ˆ˜ ÓÂÎÚÔÙÔÌÈο. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÔÚȷο ÚfiˆÚÔ˘ (¢∫: 36 ‚‰ÔÌ¿‰Â˜) ı‹ÏÂÔ˜ ÓÂÔÁÓÔ‡ Ì ÔÏÏ·Ï¿ Ë·ÙÈο ·ÔÛÙ‹Ì·Ù·. ∆Ô ÓÂÔÁÓfi ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÙËÓ 3Ë Ë̤ڷ ˙ˆ‹˜ Ì ÂÈÎfiÓ· Û‹„˘, Ë·ÙÔÌÂÁ·Ï›· Î·È ÛËÌ›· ·Ú¯fiÌÂÓÔ˘ ˘ÚËÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ (ÓˆıÚfiÙËÙ·, ˘„›Û˘¯ÓÔ ÎÏ¿Ì·, ÂÏ·Ùو̤Óo ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ıËÏ·ÛÌÔ‡). ∂›¯Â ÁÂÓÓËı› Û ȉȈÙÈÎfi Ì·ÈÂ˘Ù‹ÚÈÔ Ì Â›ÁÔ˘Û· ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ηÎÔ‡ ‚ÈÔÊ˘ÛÈÎÔ‡ ÚÔÊ›Ï (ÙÔ Î·Ú‰ÈÔÙÔÎÔÁÚ¿ÊËÌ· ‹Ù·Ó ·ıÔÏÔÁÈÎfi). ∞fi ÙË Á¤ÓÓËÛË Î·È Ì¤¯ÚÈ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ï¿Ì‚·Ó ·ÌÈÎÈÏÏ›ÓË ÂÓ‰ÔÌ˘˚ο, ÂÓÒ ÛÙËÓ ÎÏÈÓÈ΋ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÚÔÛı‹ÎË Î·È ¿ÏÏˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜. ∂ÈϤÔÓ ¤ÁÈÓ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ı·̷ÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜. O ›ÎÙÂÚÔ˜ (¤ÌÌÂÛË Î·È ¿ÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·) ·Ô‰fiıËΠ۠·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂÈ· ∏ Î·È ÛÙË Û‹„Ë. §fiÁˆ ÂÈÌÔÓ‹˜ Ù˘ Ë·ÙÔÌÂÁ·Ï›·˜ ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹·ÙÔ˜, Ô˘ ·ÔÎ¿Ï˘„ ÔÏÏ·Ï¿ Ë·ÙÈο ·ÔÛÙ‹Ì·Ù·. £ÂˆÚÂ›Ù·È fiÙÈ Ù· ·ÔÛÙ‹Ì·Ù· ‹Ù·Ó Û˘Ó¤ÂÈ· Ù˘ Û‹„˘ ÏfiÁˆ ÂÓ‰ÔÌ‹ÙÚÈ·˜ Ïԛ̈͢. ªÈÎÚfi‚È· ‰ÂÓ ·ÔÌÔÓÒıËÎ·Ó ·fi ÙȘ ηÏÏȤÚÁÂȘ Èı·ÓÒ˜ ÏfiÁˆ Ù˘ ÚÔËÁËı›۷˜ ¯ÔÚ‹ÁËÛ˘ Ù˘ ·ÌÈÎÈÏÏ›Ó˘. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ¤ÁÈÓ Ì Â·ÓÂÈÏËÌ̤ӷ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù·, ηıÒ˜ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·ÔÙÂÏ› ÙËÓ ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô ÂÎÏÔÁ‹˜ ÙfiÛÔ ÁÈ· ÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ Ë·ÙÈÎÒÓ ·ÔÛÙËÌ¿ÙˆÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË ‹Ù·Ó Û˘ÓÙËÚËÙÈ΋ Î·È ÂÚÈÂÏ¿Ì‚·Ó ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜ Â› 8 ‚‰ÔÌ¿‰Â˜. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ıÂÚ·›·˜ ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ˘‹ÚÍ·Ó ¿ÚÈÛÙ·. §¤ÍÂȘ ÎÏÂȉȿ: ∏·ÙÈο ·ÔÛÙ‹Ì·Ù·, ÓÂÔÁÓfi, Û‹„Ë, ÔÌÊ·ÏÈÎfi˜ ηıÂÙ‹Ú·˜.

A neonate with signs of sepsis and multiple hepatic abscesses 1 Neonatology Department, University Hospital of Larissa 2 Laboratory of Diagnostic Radiology & Medical Imaging, University Hospital of Larissa Correspondence: Vassiliki AlexandropoulouTsikrika 49, Mandilara Str. 412 23, Larissa E-mail: tsikrika@hol.gr Date of submission: 05-07-2005 Date of approval: 15-11-2005

V. Alexandropoulou - Tsikrika1, A. Antonouli1, K. Gaitana1, R. Moisidou2, M. Goudesidou1, A. Piterou1

Abstract: Hepatic abscesses are very rare during the neonatal period. Until recently diagnosis was usually made on postmortem examination. The case described is of a borderline premature (GA: 36 weeks) female neonate with multiple hepatic abscesses. She was admitted to the NICU on the third day of life with signs of sepsis, hepatomegaly and stage 1 kernicterus (lethargy, high-pitched cry, poor suck). She was born at a private maternity clinic by emergency caesarian section due to a poor biophysical profile (abnormal electronic fetal heart rate monitoring). From birth until her admission to the NICU she had been given intramuscular ampicilline. On admission she was immediately treated with additional intravenous antibiotics, and exchange transfusion led to dramatic improvement of her clinical status.

Jaundice (unconjugated and conjugated hyperbilirubinaemia) was attributed to haemoglobinopathy H and to sepsis. Due to the persistence of hepatomegaly a liver ultrasound (US) was performed, which revealed multiple hepatic abscesses. The abscesses were considered to be a consequence of sepsis due to intrauterine infection. No bacteria were detected on culture, probably because of ampicilline treatment.

The management of the abscesses was conservative; by intravenous antibiotics for 8 weeks. Follow-up was made by serial US, which is the imaging method of choice for both diagnosis and monitoring of hepatic abscesses. The results of conservative treatment were excellent in this case.

Key words: Hepatic abscess, neonate, sepsis, umbilical catheter.

¶·È‰È·ÙÚÈ΋ 2006;69:376-380

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26-09-06

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∏·ÙÈο ·ÔÛÙ‹Ì·Ù· Û ÓÂÔÁÓfi

™˘ÓÙÔÌÔÁڷʛ˜ ¢∫ µ° ¶∫ ∂¡À GA U/S NICU

¢È¿ÚÎÂÈ· ·ËÛ˘ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ ¶ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ∂ÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi Gestational age Ultrasound Neonatal intensive care unit

∂ÈÛ·ÁˆÁ‹ ∆· Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· Â›Ó·È Ôχ Û¿ÓÈ· ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ∂ÌÊ·Ó›˙ÔÓÙ·È Î˘Ú›ˆ˜ Û ÓÂÔÁÓ¿ Ì ۋ„Ë ‹ ÔÌÊ·Ï›Ùȉ· (1) ηıÒ˜ Î·È Û ÓÂÔÁÓ¿ Ì ηıÂÙ‹Ú· ÛÙËÓ ÔÌÊ·ÏÈ΋ ÊϤ‚· Î·È ÛË„·ÈÌ›· ÏfiÁˆ ÙÔ˘ ηıÂÙ‹Ú· (2). ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Û˘Ó‰˘¿˙ÔÓÙ·È Ì ·ÓÔÛÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Î·È È‰È·›ÙÂÚ· Ì ¯ÚfiÓÈ· ÎÔÎÎȈ̷ÙÒ‰Ë ÓfiÛÔ ‹ Ï¢¯·ÈÌ›· (1). °È· ÙË ‰È¿ÁÓˆÛË ¤Ú·Ó Ù˘ ÎÏÈÓÈ΋˜ ˘Ô„›·˜ (3) ··ÈÙÂ›Ù·È ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ΢ڛˆ˜ Ì ˘ÂÚ‹¯Ô˘˜ (3), Ô˘ ·ÔÙÂÏÔ‡Ó ÙËÓ ·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË ÂÎÏÔÁ‹˜ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÚȷο ÚfiˆÚÔ ı‹Ï˘ ÓÂÔÁÓfi Ô˘ ÚÔÛÎÔÌ›ÛÙËΠÛÙËÓ ÎÏÈÓÈ΋ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 3Ô˘ 24ÒÚÔ˘ ˙ˆ‹˜ ÏfiÁˆ ÈÎÙ¤ÚÔ˘ Ô˘ ÂÌÊ·Ó›ÛÙËΠÛÙÔ 2Ô 24ˆÚÔ. ∂›Ó·È ÙÔ 2Ô ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ. ∆Ô 1Ô ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ËÏÈΛ·˜ 1,5 ¤ÙÔ˘˜, ·Ó·Ê¤ÚÂÙ·È ˘ÁȤ˜. °ÂÓÓ‹ıËΠ۠ȉȈÙÈÎfi Ì·ÈÂ˘Ù‹ÚÈÔ ÌÂÙ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË ‰È¿ÚÎÂÈ·˜ 36 ‚‰ÔÌ¿‰ˆÓ. ∏ ÌËÙ¤Ú· ‰ÂÓ ·Ó·Ê¤ÚÂÈ Û˘ÌÙÒÌ·Ù· ÙȘ ÙÂÏÂ˘Ù·›Â˜ Ë̤Ú˜ Ù˘ ·ËÛ˘. √ ÙÔÎÂÙfi˜ ¤ÁÈÓ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚÔËÁËı›۷˜ ηÈÛ·ÚÈ΋˜ Î·È ÏfiÁˆ ηÎÔ‡ ‚ÈÔÊ˘ÛÈÎÔ‡ ÚÔÊ›Ï. ∞fi ÙÔÓ Ì·ÈÂ˘Ù‹Ú· ‰ÂÓ ‰È¢ÎÚÈÓ›ÛÙËΠÔȘ ·fi ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ÙÔ˘ ‚ÈÔÊ˘ÛÈÎÔ‡ ÚÔÊ›Ï ‹Ù·Ó ·ıÔÏÔÁÈΤ˜. ∞ӷʤÚıËΠÌfiÓÔ fiÙÈ ÙÔ Î·Ú‰ÈÔÙÔÎÔÁÚ¿ÊËÌ· ‹Ù·Ó ·ıÔÏÔÁÈÎfi. ∏ Ú‹ÍË ÙˆÓ ˘Ì¤ÓˆÓ ¤ÁÈÓ ηٿ ÙÔÓ ÙÔÎÂÙfi Î·È ÙÔ ÂÓ¿ÌÓÈÔ ˘ÁÚfi ·Ó·Ê¤ÚÂÙ·È ÂÏ·ÊÚÒ˜ ίڈṲ̂ÓÔ. ∆Ô Apgar score ‹Ù·Ó 6 ÛÙÔ 1Ô ÏÂÙfi Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 2800 g. ∞fi ÙË Á¤ÓÓËÛË Î·È Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÌÔÓ‹˜ ÙÔ˘ ÛÙÔ È‰ÈˆÙÈÎfi Ì·ÈÂ˘Ù‹ÚÈÔ ÙÔ ÓÂÔÁÓfi ÂÏ¿Ì‚·Ó ·ÌÈÎÈÏÏ›ÓË ÂÓ‰ÔÌ˘˚ο. ∏ ÔÌ¿‰· ·›Ì·ÙÔ˜ Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó √ Rh(+). ∆· ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÂÈÛfi‰Ô˘ ‹Ù·Ó: µ™: 2420 g, ª™: 47 cm Î·È ¶∫: 31,5 cm.

∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ ‰È·ÈÛÙÒıËΠfiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ÓÂÔÁÓfi Û ‚·ÚÈ¿ ηٿÛÙ·ÛË, ÓˆıÚfi, Ì ÈÎÙÂÚÈ΋ ¯ÚÔÈ¿ ‰¤ÚÌ·ÙÔ˜, Ô˘ ¤‰ÈÓ ÙËÓ ÂÓÙ‡ˆÛË Ù˘ ·Ì¤ÛÔ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, Ì ÌÂȈ̤ӷ Ù· ·Ú¯¤ÁÔÓ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο, ˘„›Û˘¯ÓÔ ÎÏ¿Ì· Î·È Î·Î‹ ÂÚÈÊÂÚÈ΋ ΢ÎÏÔÊÔÚ›·. ∆Ô ‹·Ú ‹Ù·Ó „ËÏ·ÊËÙfi (ÂÚ›Ô˘ 5 cm), ̷Ϸ΋˜ Û˘ÛÙ¿Ûˆ˜, Ì Ï›· ÂÈÊ¿ÓÂÈ· Î·È ÂÏ·ÊÚÒ˜ ¢·›ÛıËÙÔ, ÂÓÒ Ô ÛÏ‹Ó·˜ ‹Ù·Ó „ËÏ·ÊËÙfi˜ (ÂÚ›Ô˘ 2 cm). §fiÁˆ Ù˘ ‚·ÚÈ¿˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÂÏ‹ÊıËÛ·Ó ·Ì¤Ûˆ˜ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, Ô‡ÚˆÓ Î·È ∂¡À Î·È ¯ÔÚËÁ‹ıËΠ·ÓÙÈ‚›ˆÛË (·ÌÈÎÈÏÏ›ÓË Î·È ÓÂÙÈÏÌ˘Î›ÓË) ÂÓ‰ÔÊÏ‚›ˆ˜. ∆· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó Ù· ·ÎfiÏÔ˘ı·: °ÂÓÈ΋ ·›Ì·ÙÔ˜: Ht: 45%, Hb: 11,6 g/dl, MCV: 93,7 fL, MCH: 24,4 pg, ÂÌ‡ÚËÓ· ·ÙÙ·Ú· 45200/mm3 ÂÎ ÙˆÓ ÔÔ›ˆÓ 90% ÂÚ˘ıÚÔ‚Ï¿ÛÙ˜, Ï¢ÎÔ·ÙÙ·Ú· 4520/mm3 ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 40%, Û¯¤ÛË ·ÒÚˆÓ/ÒÚÈ̈Ó: 0,2, ÏÂÌÊÔ·ÙÙ·Ú· 50% Î·È ÌÔÓÔ‡ÚËÓ· 10%, ·ÈÌÔÂÙ¿ÏÈ· 120000/mm3, ÔÌ¿‰· ·›Ì·ÙÔ˜ ÓÂÔÁÓÔ‡ √ Rh(+), ¿ÌÂÛÔ˜ Coombs (-), ¯ÔÏÂÚ˘ıÚ›ÓË ÔÏÈ΋: 17,19 mg/dl, ¯ÔÏÂÚ˘ıÚ›ÓË ¿ÌÂÛÔ˜: 4,28 mg/dl, SGOT: 407 U/L, SGPT: 154 U/L, ÁGT: 198 U/L, LDH: 3588 U/L, CRP: 2,00 mg/dl, Ô˘Ú›·: 67 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,93 mg/dl, ALP: 190 U/L. ∆Ș ÚÒÙ˜ ÒÚ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÔÈ ÙÈ̤˜ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Û Â·ÓÂÈÏËÌ̤Ó˜ Û˘¯Ó¤˜ ÌÂÙÚ‹ÛÂȘ ¤‰ÂÈÍ·Ó Ù¿ÛË ·Ófi‰Ô˘ Î·È ¤ÊÙ·Û·Ó Ì¤¯ÚÈ 19,7 mg/dl. ∞ÔÊ·Û›ÛÙËÎÂ Ë ‰ÈÂÓ¤ÚÁÂÈ· ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘, Ë ÔÔ›· Î·È ¤ÁÈÓ 3 ÂÚ›Ô˘ ÒÚ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ÌÂÙ¿ ÙËÓ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË ˘‹ÚÍ ı·̷ÙÈ΋. ∆Ô ÓÂÔÁÓfi ¤ÁÈÓ ÈÔ ˙ˆËÚfi, ‚ÂÏÙÈÒıËÎÂ Ë Î˘ÎÏÔÊÔÚ›· ÙÔ˘ Î·È ÙÔ ÎÏ¿Ì· ÙÔ˘ ‰ÂÓ ‹Ù·Ó ϤÔÓ ˘„›Û˘¯ÓÔ. §fiÁˆ Ù˘ ·Ú¯Èο ‚·ÚÈ¿˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Î·È Ù˘ ·‰˘Ó·Ì›·˜ ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ ÏfiÁˆ Ù˘ ÚÔËÁËı›۷˜ ¯ÔÚ‹ÁËÛ˘ ·ÌÈÎÈÏÏ›Ó˘, ·Ú¿ ÙËÓ ¤ÏÏÂÈ„Ë ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·fi ÙËÓ ÂͤٷÛË ÙÔ˘ ∂¡À ÚÔÛÙ¤ıËΠÛÙËÓ ·ÁˆÁ‹ ÎÂÊÔÙ·Í›ÌË ÂÓ‰ÔÊÏ‚›ˆ˜. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜ Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ‚ÂÏÙȈÓfiÙ·Ó ÛÙ·ıÂÚ¿, ·Ú¤ÌÂÓ fï˜ Ë ‰ÈfiÁΈÛË ÙÔ˘ ‹·ÙÔ˜, ÙÔ ÔÔ›Ô ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ Â›Ó·È ÂÏ·ÊÚÒ˜ ¢·›ÛıËÙÔ ÛÙËÓ „ËÏ¿ÊËÛË. √È Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, Ô‡ÚˆÓ Î·È ∂¡À Ù˘ ÂÈÛ·ÁˆÁ‹˜ ‹Ù·Ó ÛÙ›Ú˜. ∂Ù¿ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹·ÙÔ˜. ∆ËÓ Ë̤ڷ ÙÔ˘ ˘ÂÚ˯ÔÁÚ·ÊÈÎÔ‡ ¶·È‰È·ÙÚÈ΋ 2006;69:376-380

Pediatr Sept_Oct 06

26-09-06

12:53

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378

µ. ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘ - ∆ÛÈÎڛη Î·È Û˘Ó.

∂ÈÎfiÓ˜ 1-3. (U/S ‹·ÙÔ˜, ËÏÈΛ· 9 ËÌÂÚÒÓ). ◊·Ú Ì ÔÏÏ·Ϥ˜ ·ÏÏÔÈÒÛÂȘ, ‰È·ÊfiÚˆÓ ÌÂÁÂıÒÓ, ‰È¿Û·ÚÙ˜ Û ·ÌÊfiÙÂÚÔ˘˜ ÙÔ˘˜ ÏÔ‚Ô‡˜, ÌÂÚÈΤ˜ ÌÈÎÚ¤˜ Î·È ˘Ô˯Ô˚Τ˜ Ì ˘ÂÚ˯ÔÁÂÓ¤˜ ΤÓÙÚÔ, ÂÓÒ ÛÙÔÓ ‰ÂÍÈfi ÏÔ‚fi ·ÂÈÎÔÓ›˙ÔÓÙ·È Î·È ÌÂÚÈΤ˜ ÌÂÁ·Ï‡ÙÂÚ˜ Ì ·ÓÔÌÔÈÔÁÂÓ‹ ˯ԉÔÌ‹ (·ÔÛÙ‹Ì·Ù·).

ÂϤÁ¯Ô˘, ÙÔ ÓÂÔÁÓfi ‹Ù·Ó Û ¿ÚÈÛÙË Î·Ù¿ÛÙ·ÛË Î·È ÙÔ ‹·Ú ‹Ù·Ó „ËÏ·ÊËÙfi ÂÚ› Ù· 2 cm Î·È Ô ÛÏ‹Ó·˜ ÌfiÏȘ „ËÏ·ÊËÙfi˜. ™ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹·ÙÔ˜ ‚Ú¤ıËÎ·Ó ÔÏÏ·Ϥ˜ ·ÏÏÔÈÒÛÂȘ, ‰È·ÊfiÚˆÓ ÌÂÁÂıÒÓ, ‰È¿Û·ÚÙ˜ Û ·ÌÊfiÙÂÚÔ˘˜ ÙÔ˘˜ ÏÔ‚Ô‡˜, ÌÂÚÈΤ˜ ÌÈÎÚ¤˜ Î·È ˘Ô˯Ô˚Τ˜ Ì ˘ÂÚ˯ÔÁÂÓ¤˜ ΤÓÙÚÔ, ÂÓÒ ÛÙÔÓ ‰ÂÍÈfi ÏÔ‚fi ·ÂÈÎÔÓ›ÛÙËÎ·Ó Î·È ÌÂÚÈΤ˜ ÌÂÁ·Ï‡ÙÂÚ˜ Ì ·ÓÔÌÔÈÔÁÂÓ‹ ˯ԉÔÌ‹. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ¶·È‰È·ÙÚÈ΋ 2006;69:376-380

·ÔÛÙËÌ¿ÙˆÓ. §fiÁˆ ÙÔ˘ ·ÚÈıÌÔ‡ Î·È ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ·ÔÛÙËÌ¿ÙˆÓ ·ÔÊ·Û›ÛÙËÎÂ Ë Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ Ì ٷ ›‰È· ÂÓ‰ÔÊϤ‚È· ·ÓÙÈ‚ÈÔÙÈο, ÂÓÒ Ë ·Ú·ÎÔÏÔ‡ıËÛË ÁÈÓfiÙ·Ó Ì ٷÎÙÈÎfi ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô. ªÂÙ¿ ÙËÓ 8Ë Ë̤ڷ ıÂÚ·›·˜ ‰ÈÂÎfiË Ë ÓÂÙÈÏÌ˘Î›ÓË ÚÔ˜ ·ÔÊ˘Á‹ Ù˘¯fiÓ ·ÚÂÓÂÚÁÂÈÒÓ Î·È Û˘Ó¯›ÛÙËÎÂ Ë ıÂÚ·›· Ì ·ÌÈÎÈÏÏ›ÓË Î·È ÎÂÊÔÙ·Í›ÌË, ÂÓÒ ÌÂÙ¿ ÙË 10Ë Ë̤ڷ ÚÔÛÙ¤ıËÎÂ Î·È ÌÂÙÚÔÓȉ·˙fiÏË ÁÈ· ÙËÓ Î¿Ï˘„Ë Ù˘¯fiÓ ·Ó·ÂÚfi‚ÈˆÓ ÌÈÎÚÔ‚›ˆÓ, ÂÂȉ‹ ıˆڋıËΠfiÙÈ ·Ú¿ ÙËÓ Î·Ï‹ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‰ÂÓ ˘‹ÚÍÂ Ë ·Ó·ÌÂÓfiÌÂÓË ‚ÂÏÙ›ˆÛË Ù˘ ˘ÂÚ˯ÔÁÚ·ÊÈ΋˜ ÂÈÎfiÓ·˜. √ ÌÂÙ¤ÂÈÙ· ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ÚÔԉ¢ÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ Î·È ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ·ÔÛÙËÌ¿ÙˆÓ. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜ Û˘Ó¯›ÛÙËΠÂ› 8 ‚‰ÔÌ¿‰Â˜ ̤¯ÚÈ ÙËÓ Ï‹ÚË ˘Ô¯ÒÚËÛË ÙˆÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. ™˘ÁÎÂÎÚÈ̤ӷ Ô ¤ÏÂÁ¯Ô˜ 15 Ë̤Ú˜ ÚÈÓ ·fi ÙË ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ¤‰ÂÈÍ ÙËÓ ‡·ÚÍË Ì›·˜ ÌfiÓÔ ÂÛÙ›·˜ Ì ̤ÁÈÛÙË ‰È¿ÌÂÙÚÔ 0,97 cm, Ë ÔÔ›· ÂÌÊ¿ÓÈ˙ ¯·Ú·ÎÙ‹Ú˜ ÈÓÒÛˆ˜-ÂÔ˘ÏÒÛˆ˜ Î·È Ù˘ ÔÔ›·˜ ÙÔ Ì¤ÁÂıÔ˜ ηٿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ¤ÊÙ·Û ٷ 0,25 cm. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ì›· ‚‰ÔÌ¿‰· ÚÈÓ ·fi ÙË ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ¤‰ÂÈÍ ̛· ÌÈÎÚ‹ ÂÛÙ›· ÛÙÔ Ô›ÛıÈÔ ÙÌ‹Ì· ÙÔ˘ ‰ÂÍÈÔ‡ ÏÔ‚Ô‡ ÙÔ˘ ‹·ÙÔ˜ Û ʿÛË ›ÓˆÛ˘-ÂԇψÛ˘ Î·È Ë ÔÔ›· ·ÓÙÈÛÙÔȯԇÛ ÛÙË ‚Ï¿‚Ë Ô˘ ›¯Â Ê·Ó› ÛÙÔ ÙÂÏÂ˘Ù·›Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Ô˘ ¤ÁÈÓ ¤Ó·Ó Ì‹Ó· ·ÚÁfiÙÂÚ· ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆Ô ‚Ú¤ÊÔ˜ - ËÏÈΛ·˜ Û‹ÌÂÚ· 7 ÌËÓÒÓ - Ê·›ÓÂÙ·È ˘ÁȤ˜, ¯ˆÚ›˜ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ ·fi ÙËÓ Ë̤ڷ Ù˘ ÂÍfi‰Ô˘ ÙÔ˘ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ∂Âȉ‹ ÛÙË ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ·Ú·ÙËÚ‹ıËΠ˘ԯڈ̛· Î·È ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË, ıˆڋıËΠfiÙÈ ·ÈÙ›· ÙÔ˘ ›ÎÙÂÚÔ˘ ÏËÓ Ù˘ Û‹„˘ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È Î·È Î¿ÔÈ· Û˘ÁÁÂÓ‹˜ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Ô˘ ÂΉËÏÒÓÂÙ·È ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, fiˆ˜ .¯. Ë ·-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. §fiÁˆ Ù˘ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘ ‰ÂÓ ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· Á›ÓÂÈ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, ¤ÁÈÓ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Ô˘ ¤‰ÂÈÍ ¿ÏÈ ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË Î·È ˘ԯڈ̛· (Ht: 41,8%, Hb: 11,4 g/dl, MCV: 66 fL, MCH: 18 pg), ÂÓÒ Ë ÊÂÚÚÈÙ›ÓË ÔÚÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. √ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ fiÙÈ ÙÔ ‚Ú¤ÊÔ˜ ¤·Û¯Â ·fi ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂÈ· ∏, ÂÓÒ Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ¤‰ÂÈÍ fiÙÈ Ô ÌÂÓ ·Ù¤Ú·˜

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·379

379

∏·ÙÈο ·ÔÛÙ‹Ì·Ù· Û ÓÂÔÁÓfi

2,04 cm

1,04 cm

∂ÈÎfiÓ˜ 4, 5. (U/S ‹·ÙÔ˜, ËÏÈΛ· 15 ËÌÂÚÒÓ). ÀÔ¯ÒÚËÛË ÙˆÓ ÂÛÙÈ·ÎÒÓ ‚Ï·‚ÒÓ ÙÔ˘ ‹·ÙÔ˜ ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi Î·È ÙÔ Ì¤ÁÂıÔ˜. √È ÌÂÁ·Ï‡ÙÂÚ˜ ·ÂÈÎÔÓ›˙ÔÓÙ·È ϤÔÓ ¯ˆÚ›˜ ·Ó˯Ô˚Τ˜ ÂÚÈÔ¯¤˜.

¤ÊÂÚ ‰‡Ô ·ıÔÏÔÁÈο ÁÔÓ›‰È· (··/--) Î·È Ë ÌËÙ¤Ú· ¤ÊÂÚ ¤Ó· ·ıÔÏÔÁÈÎfi ÁÔÓ›‰ÈÔ (··/·-).

™˘˙‹ÙËÛË ∏ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÏfiÁˆ Ù˘ Û·ÓÈfiÙËÙ¿˜ Ù˘. ∞Ó Î·È Ù· Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· Â›Ó·È Ôχ Û¿ÓÈ·, Ë ·ÎÚÈ‚‹˜ Â›ÙˆÛ‹ ÙÔ˘˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ηıÔÚÈÛÙ›, ‰ÈfiÙÈ Â›Ù ˘Ô¯ˆÚÔ‡Ó Ì ÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›· ¯ˆÚ›˜ Ó· ‰È·ÁÓˆÛÙÔ‡Ó ÔÙ¤, ›ÙÂ Û˘Ó‹ıˆ˜ ÛÙȘ ÛÔ‚·ÚfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÓÂÎÚÔÙÔÌÈο (4). ∞ӷʤÚÂÙ·È fiÙÈ Û ̛· ·Ó·ÛÎfiËÛË Ì 7500 ÓÂÎÚÔÙÔ̤˜ ·È‰ÈÒÓ ·fi ÙÔ 1917 ̤¯ÚÈ ÙÔ 1967, ‚Ú¤ıËÎ·Ó ÌfiÓÔ 3 ÓÂÔÁÓ¿ Ì ÌÈÎÚ¿ ˘ÔÁfiÓ· Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· (4). ∆· Ë·ÙÈο ·ÔÛÙ‹Ì·Ù· ÌÔÚ› Ó· Â›Ó·È ÌÔÓ‹ÚË ‹ Û˘ÓËı¤ÛÙÂÚ· ÔÏÏ·Ï¿ (2,4) Î·È Ó· ÔÊ›ÏÔÓÙ·È Û ÌÈÎÚfi‚È· Gram(+), Gram(-), ·ÂÚfi‚È· ‹ ·Ó·ÂÚfi‚È·. ∆Ô ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ·ÚÔ˘Û›·˙ ÂÈÎfiÓ· Û‹„˘ Î·È ÔÏÏ·Ï¿ Ë·ÙÈο ·ÔÛÙ‹-

Ì·Ù·. ∏ ‰È¿ÁÓˆÛË Ù˘ Û‹„˘ ¤ÁÈÓ ÎÏÈÓÈο (ÓˆıÚfiÙËÙ·, ›ÎÙÂÚÔ˜, η΋ ÂÚÈÊÂÚÈ΋ ΢ÎÏÔÊÔÚ›·) Î·È ÂÚÁ·ÛÙËÚȷο (Ï¢ÎÔÂÓ›· Ì Ԣ‰ÂÙÂÚÔÂÓ›·, ¿ÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ıÂÙÈ΋ CRP). ∏ ÌË ·ÔÌfiÓˆÛË ÌÈÎÚÔ‚›Ô˘ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË Î·È Â›Ó·È Èı·Ófiٷٷ Û˘Ó¤ÂÈ· Ù˘ ÚÔËÁËı›۷˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ Ì ·ÌÈÎÈÏÏ›ÓË. ∏ Û‹„Ë Ê·›ÓÂÙ·È Ó· ÚÔ‹Ïı ·fi Ïԛ̈ÍË Ô˘ ÍÂΛÓËÛ ÂÓ‰ÔÌ‹ÙÚÈ·. ∆Ô ·ıÔÏÔÁÈÎfi ηډÈÔÙÔÎÔÁÚ¿ÊËÌ· Ô˘ ˘Ô¯Ú¤ˆÛ ÙÔÓ Ì·ÈÂ˘Ù‹Ú· Û Â›Û¢ÛË Ù˘ ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜ Î·È ı· ÌÔÚÔ‡Û ӷ ÚÔ·„ÂÈ ·fi ‰È¿ÊÔÚ˜ ·Èٛ˜ (˘ÔÍ›·, Ì˯·ÓÈ΋ ›ÂÛË, Ïԛ̈ÍË) (5) ÛÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË ÔÊÂÈÏfiÙ·Ó Èı·Ófiٷٷ Û ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÈÎfiÓ· ÙÔ˘ ÓÂÔÁÓÔ‡ ˘Ô¯Ú¤ˆÛ ÙÔÓ ıÂÚ¿ÔÓÙ· ·È‰›·ÙÚÔ Ó· ¯ÔÚËÁ‹ÛÂÈ ·ÓÙÈ‚ÈÔÙÈÎfi (·ÌÈÎÈÏÏ›ÓË) ÂÓ‰ÔÌ˘˚ο ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÂÓÈÛ¯‡ÂÈ ÙËÓ ¿Ô„Ë ·˘Ù‹. ™¯ÂÙÈο Ì ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ·ÔÛÙËÌ¿ÙˆÓ ı· ÌÔÚÔ‡Û ηÓ›˜ Ó· ÛÎÂÊÙ› fiÙÈ ·˘Ù¿ ‹Ù·Ó Û˘Ó¤ÂÈ· ÙÔ˘ ηıÂÙ‹Ú· Ô˘ ÙÔÔıÂÙ‹ıËΠÛÙËÓ ÔÌÊ·ÏÈ΋ ÊϤ‚· ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘. Œ¯ÂÈ ·Ó·ÊÂÚı› (4) fiÙÈ ·Ó·Ì¤ÓÂÙ·È ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Ë·ÙÈÎÒÓ ·ÔÛÙËÌ¿ÙˆÓ ÏfiÁˆ Ù˘ ·˘Í·ÓfiÌÂÓ˘ ¯Ú‹Û˘ ÔÌÊ·ÏÈÎÒÓ Î·ıÂÙ‹ÚˆÓ. ø˜ ¢ԉˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÚfiÎÏËÛË ·ÔÛÙËÌ¿ÙˆÓ ıˆÚÔ‡ÓÙ·È Ë ¤Á¯˘ÛË ˘¤ÚÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ ̤ۈ ÙˆÓ Î·ıÂÙ‹ÚˆÓ Î·È ÔÈ ·Ú·ÙÂٷ̤ÓÔÈ Î·ıÂÙËÚÈ·ÛÌÔ› (4). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ıˆÚÂ›Ù·È fiÙÈ Ù· ·ÔÛÙ‹Ì·Ù· ‹Ù·Ó Û˘Ó¤ÂÈ· Ù˘ Û‹„˘ ÏfiÁˆ ÂÓ‰ÔÌ‹ÙÚÈ·˜ Ïԛ̈͢ Î·È fi¯È ÙÔ˘ ηıÂÙ‹Ú·, ‰ÈfiÙÈ Ë Ë·ÙÔÌÂÁ·Ï›· Î·È Ù· ¿ÏÏ· Û˘ÌÙÒÌ·Ù· Ù˘ Û‹„˘ ÚÔ¸‹Ú¯·Ó Ù˘ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ηıÂÙ‹Ú·, ·ÏÏ¿ Î·È ‰ÈfiÙÈ ¤Á¯˘ÛË ˘¤ÚÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ ̤ۈ ÙÔ˘ ηıÂÙ‹Ú· ‰ÂÓ ¤ÁÈÓÂ, Ô Î·ıÂÙËÚÈ·ÛÌfi˜ ¤ÁÈÓ ̛· ÊÔÚ¿ Î·È Ô Î·ıÂÙ‹Ú·˜ ·Ú¤ÌÂÈÓ ÛÙËÓ ÔÌÊ·ÏÈ΋ ÊϤ‚· ÁÈ· ÏÈÁfiÙÂÚÔ ·fi 2 ÒÚ˜, fiÛÔ ‰ËÏ·‰‹ ¯ÚÂÈ¿ÛÙËΠÁÈ· Ó· Á›ÓÂÈ Ë ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË. ªÈÎÚÔ‚È·Îfi˜ ·Ú¿ÁˆÓ ˘‡ı˘ÓÔ˜ ÁÈ· Ù· ·ÔÛÙ‹Ì·Ù· ‰ÂÓ ·ÔÌÔÓÒıËΠÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ø˜ Û˘ÓËı¤ÛÙÂÚÔ ·›ÙÈÔ Ë·ÙÈÎÒÓ ·ÔÛÙËÌ¿ÙˆÓ ÛÙÔ ÓÂÔÁÓfi ·Ó·Ê¤ÚÂÙ·È Ë ÏÈÛÙ¤ÚÈ· Ë ÌÔÓÔ΢ÙÙ·ÚÈ΋ (4). ™ÙÔ ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛÙ› ˆ˜ ·›ÙÈÔ ÙˆÓ ·ÔÛÙËÌ¿ÙˆÓ Ë ÏÈÛÙ¤ÚÈ·. ∏ ÏÈÛÙ¤ÚÈ· ÌÔÚ› Ó· ÚÔÛ‚¿ÏÂÈ ÙÔ ¤Ì‚Ú˘Ô Ì¤Ûˆ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ÌÂÙ¿ ·fi ÌfiÏ˘ÓÛË Ù˘ ÌËÙ¤Ú·˜ Î·È Ó· ÚÔηϤÛÂÈ ÛÙÔ ÓÂÔÁÓfi ÚÒÈÌË ‹ fi„ÈÌË ÓfiÛÔ (6). ∏ ÚÒÈÌË ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÈ ¶·È‰È·ÙÚÈ΋ 2006;69:376-380

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·380

380

µ. ∞ÏÂÍ·Ó‰ÚÔÔ‡ÏÔ˘ - ∆ÛÈÎڛη Î·È Û˘Ó.

Û˘ÌÙÒÌ·Ù· ÙËÓ 1Ë Ë̤ڷ Ù˘ ˙ˆ‹˜ Î·È ÔÌÔÈ¿˙ÂÈ Ì ÙËÓ ÚÒÈÌË ÓfiÛÔ ·fi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘ ÔÌ¿‰·˜ µ. ™˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ÁÚÈÒ‰Ë Û˘Ó‰ÚÔÌ‹ Ù˘ ÌËÙ¤Ú·˜ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 10 Ë̤Ú˜ Ù˘ ·ËÛ˘, ¯ˆÚ›˜ ·˘Ùfi Ó· Â›Ó·È ··Ú·›ÙËÙÔ. ™ÙÔ ÓÂÔÁÓfi Ë ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Ì Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, ÂÙ¯ÂÈ҉˜ ÂÍ¿ÓıËÌ· Î·È ÌÈÎÚÔ·ÔÛÙ‹Ì·Ù· Û ‰È¿ÊÔÚ· fiÚÁ·Ó·, Ô˘ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ë Ïԛ̈ÍË ÚÔËÁ‹ıËΠÙÔ˘ ÙÔÎÂÙÔ‡ (6). À¤Ú Ù˘ ÏÈÛÙÂÚ›ˆÛ˘ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È Î·È Ë ·ÚÔ˘Û›· ίڈṲ̂ÓÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ Û ÔÚȷο ÚfiˆÚÔ ÙÔÎÂÙfi (7). ∆Ô Î¯ڈṲ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi ηٿ ηÓfiÓ· ·Ó¢ڛÛÎÂÙ·È Û ÙÂÏÂÈfiÌËÓ˜ ΢‹ÛÂȘ Î·È Ë Û˘¯ÓfiÙËÙ· ·ÚÔ˘Û›·˜ ÙÔ˘ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ΢‹Ûˆ˜, Â›Ó·È ‰Â ȉȷ›ÙÂÚ· Û˘¯Ófi ÌÂÙ¿ ÙËÓ 40‹ ‚‰ÔÌ¿‰·. ∏ ·ÚÔ˘Û›· ÙÔ˘ Û ÚfiˆÚÔ˘˜ ÙÔÎÂÙÔ‡˜ ȉȷ›ÙÂÚ· ÚÈÓ ·fi ÙȘ 33 ‚‰ÔÌ¿‰Â˜ ıˆÚÂ›Ù·È ¤Ó‰ÂÈÍË ÏÈÛÙÂÚ›ˆÛ˘, ·Ó Î·È Û‡Ìʈӷ Ì ÚfiÛÊ·ÙË ÌÂϤÙË ‰ÂÓ ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ ‰Â›ÎÙË ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÏÈÛÙÂÚ›ˆÛ˘ (8). À¤Ú Ù˘ Èı·ÓfiÙËÙ·˜ Ù˘ ÏÈÛÙÂÚ›ˆÛ˘ Û˘ÓËÁÔÚ› Î·È Ë ·Ó‡ÚÂÛË ÙˆÓ ·ÚÓËÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ ÌÂÙ¿ ÙËÓ ÂÓ‰ÔÌ˘˚΋ ıÂÚ·›· Ì ·ÌÈÎÈÏÏ›ÓË ·fi ÙË Á¤ÓÓËÛË, ‰ÈfiÙÈ Ë ÏÈÛÙ¤ÚÈ· Â›Ó·È Î·Ù¿ ηÓfiÓ· ¢·›ÛıËÙË ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ›ÎÙÂÚÔ ÁÈ· ÙÔÓ ÔÔ›Ô Î·È ÚÔÛÎÔÌ›ÛÙËΠÙÔ ÓÂÔÁÓfi ıˆÚÂ›Ù·È fiÙÈ ÔÊÂÈÏfiÙ·Ó ÛÙËÓ ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂÈ· ∏ Î·È ÛÙË Û‹„Ë. ∏ ÂÎÙ¤ÏÂÛË ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘ ˘‹ÚÍ ¢ÂÚÁÂÙÈ΋, fiˆ˜ Ê¿ÓËΠ·fi ÙÔ ·ÔÙ¤ÏÂÛÌ·. ∏ ·fiÊ·ÛË ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘ ÂËÚ¿ÛÙËΠ·fi ÙËÓ Ù·¯Â›· ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ (>0,5 mg/dl/h) ·Ú¿ ÙË ÊˆÙÔıÂÚ·›· Ô˘ ÂÊ·ÚÌfiÛÙËΠÚÈÓ ·fi ÙË Ï‹„Ë ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ô˘ ¤‰ÂÈÍ·Ó ˘„ËÏ‹ ÙÈÌ‹ ·Ì¤ÛÔ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘. ∂ËÚ¿ÛÙËΠÂ›Û˘ ·fi ÙËÓ ‡·ÚÍË ·ÈÌfiÏ˘Û˘ (ÂÚ˘ıÚÔ‚Ï¿ÛÙ˜ 90%), ·fi ÙËÓ ¤ÛÙˆ Î·È ÔÚȷ΋ ÚÔˆÚfiÙËÙ·, ·fi ÙËÓ ·‰˘Ó·Ì›· ÂÊ·ÚÌÔÁ‹˜ ʈÙÔıÂÚ·›·˜ ÏfiÁˆ Ù˘ ·Ì¤ÛÔ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ·fi ÙÔ ˘„›Û˘¯ÓÔ ÎÏ¿Ì· ÙË ÓˆıÚfiÙËÙ· Î·È ÙÔ ÂÏ·Ùو̤ÓÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ıËÏ·ÛÌÔ‡, Ù· ÔÔ›· ıˆڋıËÎ·Ó ÎÏÈÓÈο ÛËÌ›· ·Ú¯fiÌÂÓÔ˘ ˘ÚËÓÈÎÔ‡ ÈÎÙ¤ÚÔ˘ Î·È Ù¤ÏÔ˜ ·fi ÙÔ fiÙÈ Ë ¿ÌÂÛÔ˜ ¯ÔÏÂÚ˘ıÚ›ÓË ıˆÚÂ›Ù·È ÂÈΛӉ˘ÓË Î·ıÒ˜ ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙË Û‡Ó‰ÂÛË Ù˘ ¤ÌÌÂÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Ì ÏÂ˘ÎˆÌ·Ù›ÓË (9). ∏ Û˘Ì‚ÔÏ‹ ÙˆÓ ˘ÂÚ‹¯ˆÓ ˘‹ÚÍ η›ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Á›ÓÂÈ ·fi Û˘ÁÁÂÓ›˜ ·ÛÙÂȘ, ·ÚÙËÚÈÔ-

¶·È‰È·ÙÚÈ΋ 2006;69:376-380

ÊÏ‚҉ÂȘ ·ÓˆÌ·Ï›Â˜ Î·È fiÁÎÔ˘˜ Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË ‹ ·ÈÌÔÚÚ·Á›· Ô˘ ÌÔÚÔ‡Ó Ó· ÌÈÌÔ‡ÓÙ·È ·ÔÛÙ‹Ì·Ù· (4). √ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔÙÂÏ› ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË, ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÓfiÛÔ˘ (2,4), ÂÓÒ Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‰ÈÂÓÂÚÁÂ›Ù·È ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ. ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë ·Ú¯È΋ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒıËÎÂ Î·È ·fi ÙËÓ ÔÚ›· Ù˘ ·ÛıÂÓÔ‡˜. ∆¤ÏÔ˜, Ë ıÂÚ·›· ÙˆÓ Ë·ÙÈÎÒÓ ·ÔÛÙËÌ¿ÙˆÓ ÌÔÚ› Ó· Â›Ó·È ¯ÂÈÚÔ˘ÚÁÈ΋, ÂÂÌ‚·ÙÈ΋ ‹ Û˘ÓÙËÚËÙÈ΋ (4). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ ›¯Â ¿ÚÈÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∆· ·ÓÙÈ‚ÈÔÙÈο Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó ¤ÁÈÓ ÚÔÛ¿ıÂÈ· Ó· ηχÙÔ˘Ó Â˘Ú‡ Ê¿ÛÌ· ÌÈÎÚÔ‚›ˆÓ Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ·Ó·ÂÚfi‚ȈÓ, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË Ù˘ ·ÌÈÎÈÏÏ›Ó˘ Û˘Ó¯›ÛÙËΠ۠fiÏË ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 8 ‚‰ÔÌ¿‰ˆÓ Ù˘ ıÂÚ·›·˜ ÏfiÁˆ Ù˘ ˘Ô„›·˜ ÁÈ· ÏÈÛÙÂÚ›ˆÛË.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Chusid MJ. Pyogenic hepatic abscess in infancy and childhood. Pediatrics 1978;62:554-559.

2. Moens E, Dooy JD, Jansens H, Lammens C, Op de Beeck B, Mahieu L. Hepatic abscesses associated with umbilical catheterisation in two neonates. Eur J Pediatr 2003;162:406-409.

3. Seeto RK, Rockey DC. Pyogenic liver abscess.

Changes in etiology, management, and outcome.

Medicine (Baltimore) 1996;75:99-113.

4. Marcy SM, Overturf GD. Focal bacterial infections.

In: Remington JS, Klein JO, editors. Infectious diseases of the fetus and the newborn infant. 4th ed.

W.B. Saunders Co: Philadelphia; 1995. p. 935-979.

5. Schifrin BS. Medicolegal ramifications of electronic fetal monitoring during labor. Clin Perinatol 1995;22:837-854.

6. Zeichner SL, Plotkin SA. Mechanisms and pathways of congenital infections. Clin Perinatol 1988;15:163-188.

7. Alliet P, Van Lierde S, Bruylants B, Van Laer P, Devlieger H, Eggermont E. Neonatal listeriosis. Tijdschr Kindergeneeskd 1992;60:18-21.

8. Tybulewicz AT, Clegg SK, Fonfe GJ, Stenson BJ. Preterm meconium staining of the amniotic fluid: associated findings and risk of adverse clinical outcome. Arch Dis Child Fetal Neonatal Ed 2004;89: F328-F330.

9. Maisels MJ. Jaundice. In: Avery GB, Fletcher MA, MacDonald MG, editors. Neonatology: pathophysiology and management of the newborn. 5th ed.

Lippincott Williams & Wilkins: Philadelphia; 1999. p. 805.

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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

381

¡ÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË: ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫. ™·Ú·Ê›‰Ë˜1, µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘1, £. ™Ù·ıÔÔ‡ÏÔ˘1, ∫. ¶·ÙÛÈ·Ô‡Ú·2, ™. ∞ÁÁÂÏ›‰Ô˘2

¶ÂÚ›ÏË„Ë ∏ ÓÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË ·ÔÙÂÏ› Û¿ÓÈ· Î·È Û˘Ó‹ıˆ˜ ı·Ó·ÙËÊfiÚÔ ‰È·Ù·Ú·¯‹, ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÂÚ‚ÔÏÈ΋ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ Û ‰È¿ÊÔÚ· fiÚÁ·Ó· Î·È Î˘Ú›ˆ˜ ÛÙÔ ‹·Ú, Ë ÔÔ›· Ô‰ËÁ› Û ΛÚÚˆÛË. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ¡Â∞ Û ÙÂÏÂÈfiÌËÓÔ ÓÂÔÁÓfi, ÛÙÔ ÔÔ›Ô Ë ‰È¿ÁÓˆÛË ¤ÁÈÓÂ Ù˘¯·›· ÌÂÙ¿ ·fi ÓÂÎÚÔÙÔÌÈ΋ ÂͤٷÛË. ∆· ·ÚÈ· Â˘Ú‹Ì·Ù· ÂÚÈÂÏ¿Ì‚·Ó·Ó ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, ˘ÂÚÙÚÔÊÈÎfi Ï·ÎÔ‡ÓÙ·, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ Î·È ‰ÈfiÁΈÛË ÛÏËÓfi˜, ÂÓÒ ‰ÂÓ ˘‹Ú¯·Ó ÂӉ›ÍÂȘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∆Ô ÓÂÔÁÓfi ·‚›ˆÛ Û ËÏÈΛ· 16 ˆÚÒÓ, ÏfiÁˆ ·Ú·Ì¤ÓÔ˘Û·˜ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘, ˆ˜ Â·ÎfiÏÔ˘ıÔ ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜. ™˘˙ËÙÔ‡ÓÙ·È ÔÈ ‰˘ÛÎÔϛ˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÛÔ‚·Ú‹˜ ·˘Ù‹˜ ÓfiÛÔ˘ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È Ë ÛËÌ·Û›· Ù˘ ÁÈ· ÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË.

1 ∞’ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ & ∂ÓÙ·ÙÈ΋ ¡ÔÛËÏ›· ¡ÂÔÁÓÒÓ ∞.¶.£., πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 2 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £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‹˜: 02-09-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-01-2006

§¤ÍÂȘ ÎÏÂȉȿ: ¡ÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË, Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·.

Neonatal haemochromatosis: a case report K. Sarafidis1, V. Drossou - Agakidou1, T. Stathopoulou1, K. Patsiaoura2, S. Aggelidou2

Abstract: Neonatal haemochromatosis is a rare and usually fatal disorder of unknown aetiology, characterized by iron overload in the parenchymal organs, mainly in the liver, where it leads to destruction of the normal liver architecture. The case is described of neonatal haemochromatosis in a full-term neonate, diagnosed on autopsy. The main features included oligohydramnios, placental oedema, intrauterine growth retardation and splenomegaly but minimal evidence of liver failure. The infant died at the age of 16 hours due to persistent pulmonary hypertension secondary to perinatal asphyxia. The difficulties in diagnosis of this severe disease in neonates and the importance of correct diagnosis for genetic counseling are discussed.

Key words: Neonatal haemochromatosis, liver failure.

™˘ÓÙÔÌÔÁڷʛ˜ ¡Â∞ ¶¶À

¡ÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË ¶·Ú·Ì¤ÓÔ˘Û· Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË

∂ÈÛ·ÁˆÁ‹ ∏ ÓÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË (¡Â∞) ·ÔÙÂÏ› Û¿ÓÈ· ‰È·Ù·Ú·¯‹ Ô˘ ÚÔÛ‚¿ÏÂÈ ¤Ì‚Ú˘·/ÓÂÔÁÓ¿ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÂÚ‚ÔÏÈ΋ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘, ΢ڛˆ˜ ÛÙÔ ‹·Ú, Ë ÔÔ›· Ô‰ËÁ› ÙÂÏÈο Û ηٷÛÙÚÔÊ‹ Ù˘ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙÔ˘. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Â›Ó·È ÁÓˆÛÙ‹ Î·È ˆ˜ ÓÂÔÁÓÈ΋ ÓfiÛÔ˜ ÂÓ·fiıÂÛ˘ Ûȉ‹ÚÔ˘ (neonatal iron storage disease) (1). ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Â›Ó·È ¿ÁÓˆÛÙË. πÔÁÂÓ›˜ Î·È ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ, Ë ·ÚÔ˘Û›· ÌËÙÚÈÎÒÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Ro/SS-A Î·È La/SS-B, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ, ·ÎfiÌË Î·È ¯ÚˆÌ·ÙÔ-

1 1st Department of Neonatology & Neonatal Intensive Care Unit, Aristotle University of Thessaloniki, Ippokratio Hospital, Thessaloniki 2 Laboratory of Pathology, Ippokratio Hospital, Thessaloniki Correspondence: Vassiliki Drossou-Agakidou 28, Glinou Str. 543 52, Thessaloniki E-mail: agaki@med.auth.gr Date of submission: 02-09-2005 Date of approval: 11-01-2006

ÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ·˘Ù‹ ÙË ‰È·Ù·Ú·¯‹, ÂÓÒ Û οÔȘ ÂÚÈÙÒÛÂȘ Ë ÓfiÛÔ˜ ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· (1-3). ª¿ÏÈÛÙ·, fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÏÔÈÌ҉˘ ·Ú¿ÁÔÓÙ·˜, Ë Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Û ÂfiÌÂÓ˜ ΢‹ÛÂȘ Â›Ó·È ·˘ÍË̤ÓË Î·È - Û‡Ìʈӷ Ì ÔÚÈṲ̂ÓÔ˘˜ Û˘ÁÁÚ·Ê›˜ - ˘ÂÚ‚·›ÓÂÈ ÙÔ 25% (4). ∏ ¡Â∞ ‰ÂÓ ¤¯ÂÈ ÁÂÓÂÙÈ΋ Û¯¤ÛË Ì ÙËÓ ÎÏËÚÔÓÔÌÈ΋ ·ÈÌÔÛȉ‹ÚˆÛË, Ì›· ÓfiÛÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È Â›Û˘ ·fi Ë·ÙÈ΋ ‚Ï¿‚Ë Î·È ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ Î·È ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·. ∏ ¡Â∞ ÂÚÈÁÚ¿ÊËΠ·Ú¯Èο ÙÔ 1957. ∞fi ÙfiÙÂ, ‰ÈÂıÓÒ˜, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ‰È¿ÊÔÚ˜ ÔÈÎÔÁÂÓ›˜ ‹ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ Ôԛ˜ ›¯·Ó η΋ ÚfiÁÓˆÛË ¶·È‰È·ÙÚÈ΋ 2006;69:381-384

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382

K. ™·Ú·Ê›‰Ë˜ Î·È Û˘Ó.

(2,3,5-7). ∏ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ·Ó·ÊÔÚ¿ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ‰È·ÁÓˆṲ̂Ó˘ ¡Â∞ ÛÙËÓ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ Ô˘ ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ·ËÛË 40 ‚‰ÔÌ¿‰ˆÓ ·fi ‰Â˘ÙÂÚÔÙfiÎÔ ÌËÙ¤Ú·. √È ÁÔÓ›˜ ‹Ù·Ó ÂÏÏËÓÈ΋˜ ηٷÁˆÁ‹˜, ‰ÂÓ Â›¯·Ó Û˘ÁÁ¤ÓÂÈ· ·›Ì·ÙÔ˜ Î·È ‹Ù·Ó ˘ÁÈ›˜, fiˆ˜ Î·È Ù· ‰‡Ô ÌÂÁ·Ï‡ÙÂÚ· ‰›‰˘Ì· ·‰¤ÏÊÈ·. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ. ™ÙËÓ ·ÚÔ‡Û· ·ËÛË ÂÌÊ·Ó›ÛÙËΠÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ Î·È ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜. √ ¤ÏÂÁ¯Ô˜ Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜, ÙÔÍfiÏ·ÛÌ·, ÂÚ˘ıÚ¿, Èfi˜ ÙÔ˘ ¤ÚËÙ·, Ë·Ù›Ùȉ· µ) ‹Ù·Ó ·ÚÓËÙÈÎfi˜ Î·È Ë ·-ÂÌ‚Ú˘˚΋ ÚˆÙ½ÓË Ê˘ÛÈÔÏÔÁÈ΋. ∆Ô ÓÂÔÁÓfi ÁÂÓÓ‹ıËΠ۠ÂÚÈÊÂÚÂÈ·Îfi ÓÔÛÔÎÔÌÂ›Ô ÌÂÙ¿ ·fi ·˘ÙfiÌ·ÙÔ ÎÔÏÈÎfi ÙÔÎÂÙfi Ì Apgar score 5 Î·È 7 ÛÙÔ 1Ô Î·È 5Ô ÏÂÙfi, ·ÓÙ›ÛÙÔȯ·. ∏ Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ Û˘Ó¤‚Ë Ì›· ÒÚ· ÚÈÓ ÙÔÓ ÙÔÎÂÙfi Î·È ÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi ‹Ù·Ó ‰È·˘Á¤˜, ÂÓÒ Ô Ï·ÎÔ‡ÓÙ·˜ ‹Ù·Ó ˘ÂÚÙÚÔÊÈÎfi˜ (>1 kg). ∞̤ۈ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Î·È ÌÂٷʤÚıËΠ۠ËÏÈΛ· 6 ˆÚÒÓ ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜ ÓÂÔÁÓÒÓ ÁÈ· ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ¤‰ÂÈÍ fiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ¤Ó· Û˘ÌÌÂÙÚÈο ÌÈÎÚfi ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ ÓÂÔÁÓfi [‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2232 g (<10Ë ∂£), ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ 28,5 cm (<10Ë ∂£) Î·È Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ 45 cm (<10Ë ∂£)], ÙÔ ÔÔ›Ô ·ÚÔ˘Û›·˙ ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, fiˆ˜ ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ·˘ÙÈÒÓ, Ú·È‚ÔÔ‰›·, ÂÚ›ÛÛÂÈ· ‰¤ÚÌ·ÙÔ˜ ÛÙȘ ÎӋ̘ Î·È ÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜ Î·È ÌÔÓ‹ÚË ÔÌÊ·ÏÈ΋ ·ÚÙËÚ›·. ∫ÏÈÓÈο ‰È·ÈÛÙÒıËΠÛÏËÓÔÌÂÁ·Ï›·, ·ÏÏ¿ ‰ÂÓ ˘‹Ú¯Â ‰ÈfiÁΈÛË ‹·ÙÔ˜, ·ÛΛÙ˘ ‹ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ·ÚÔ˘Û›·˙ ‚·ÚÈ¿ ˘ÔÍ·ÈÌ›· Î·È ÙÔÔıÂÙ‹ıËΠ·Ì¤Ûˆ˜ ÛÂ Û˘Ì‚·ÙÈÎfi Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Ì ̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (PIP): 30 cmH2O, ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË (PEEP): 4 cmH2O, ¯ÚfiÓÔ ÂÈÛÓÔ‹˜: 0,4 sec, ·Ó·ÓÔ¤˜: 60/min Î·È FiO2: 1. ∆· ·¤ÚÈ· ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ‹Ù·Ó: pH: 7,09, PaO2: 20 mmHg, PaCO2: 86 mmHg Î·È ¤ÏÏÂÈÌÌ· ‚¿Û˘: 3,4 mmol/L. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó ·Ú¯Èο Ê˘ÛÈÔÏÔÁÈ΋, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ÂÌÊ¿ÓÈÛ ·ÌÊÔÙÂÚfiÏ¢ÚÔ Ó¢ÌÔıÒڷη. ™ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ‰È·ÈÛÙÒ¶·È‰È·ÙÚÈ΋ 2006;69:381-384

ıËΠ·Ú·Ì¤ÓÔ˘Û· Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (¶¶À) Î·È ·ÚÔ˘Û›· ‰ÂÍÈÔ-·ÚÈÛÙÂÚÔ‡ shunt ̤ۈ ÙÔ˘ ‚ÔÙ¿ÏÏÂÈÔ˘ fiÚÔ˘, ÂÓÒ ‰ÂÓ Û˘Ó˘‹Ú¯·Ó ‰ÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ù˘ ηډȿ˜. √ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜, Ì ÂÍ·›ÚÂÛË ÙËÓ ·‡ÍËÛË Ù˘ Û¯¤Û˘ SGOT/ALT (250 IU/L). ™ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠ·Ó·ÈÌ›· (Hb: 9,5 g/dL), ıÚÔÌ‚ÔÂÓ›· (·ÈÌÔÂÙ¿ÏÈ·: 46000/mm3) Î·È Ï¢ÎÔ΢ÙÙ¿ÚˆÛË [ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 52500/mm3 (28,9% Ô˘‰ÂÙÂÚfiÊÈÏ·)]. ∏ ¿ÌÂÛË Coombs ‹Ù·Ó ·ÚÓËÙÈ΋ Î·È Ô Î·Ú˘fiÙ˘Ô˜ Ê˘ÛÈÔÏÔÁÈÎfi˜ (46,ÃÀ). ¶·Ú¿ ÙËÓ ÂÈıÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (Û˘Ì‚·ÙÈÎfi˜ Î·È ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜) Î·È ÙË ÁÂÓÈÎfiÙÂÚË ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹, ‰ÂÓ ·ÔηٷÛÙ¿ıËÎÂ Ë Ô͢ÁfiÓˆÛ‹ ÙÔ˘ Î·È ÙÔ ÓÂÔÁÓfi η٤ÏËÍ 14 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ·fi ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™Â ÔÏfiÎÏËÚË ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô ·Ú¤ÌÂÈÓ ·ÓÔ˘ÚÈÎfi. ™ÙÔ ÓÂÔÁÓfi ‰ÈÂÓÂÚÁ‹ıËΠÓÂÎÚÔÙÔÌÈ΋ ÂͤٷÛË ÌÂÙ¿ ·fi ¤ÁÎÚÈÛË ÙˆÓ ÁÔÓ¤ˆÓ. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÓÂÎÚÔÙÔÌÈ΋˜ ÂͤٷÛ˘, Ì·ÎÚÔÛÎÔÈο, ÙÔ ‹·Ú ‹Ù·Ó ÎÈÚÚˆÙÈÎfi ÌÂ Û˘Ì·Á›˜, ÂÚ˘ıÚfiÊ·ÈÔ˘˜, ·ÓÒÌ·ÏÔ˘˜ fi˙Ô˘˜ (0,2-1 cm) Î·È ˙‡ÁÈ˙ 82,6 g (‚¿ÚÔ˜ ·Ó·ÊÔÚ¿˜: 113±17 g), ÂÓÒ Ô ÛÏ‹Ó·˜ ‹Ù·Ó ÌÂÁ¿ÏÔ˜ Î·È Û˘ÌÊÔÚË̤ÓÔ˜ (˘ÂÚ·ÈÌÈÎfi˜) (∂ÈÎfiÓ· 1A). ¢ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜, ÙËÓ Î·Ú‰È¿ (Ì ÂÍ·›ÚÂÛË ÙÔÓ ·ÓÔÈÎÙfi ·ÚÙËÚÈ·Îfi fiÚÔ), ÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÙÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ·. √È Ó‡ÌÔÓ˜ ˙‡ÁÈ˙·Ó 44 g Î·È Ë Û¯¤ÛË ÙÔ˘ ‚¿ÚÔ˘˜ Ó¢ÌfiÓˆÓ ÚÔ˜ ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó 0,014 (Ê˘ÛÈÔÏÔÁÈÎfi: >0,012). ∏ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· ‰ÂÓ ÂÚÈ›¯Â ˘ÁÚfi. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ‹·ÙÔ˜ ¤‰ÂÈÍ ӤÎÚˆÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ÌÂ Û˘ÓÔ‰fi ¤ÓÙÔÓË ˘ÂÚÏ·Û›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ·Ó¿Ù˘ÍË ÓÂÔ¯ÔÏÔ·ÁÁÂÈÔÏ›ˆÓ (∂ÈÎfiÓ· 2µ). ™ÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ· ·ÚÎÂÙÒÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, fiˆ˜ Î·È ÛÙ· ·ÙÙ·Ú· ÙÔ˘ Kuppfer, ·Ú·ÙËÚ‹ıËÎ·Ó ÎÔÎΛ· ¯ÚˆÛÙÈ΋˜ ıÂÙÈο (+++) ÛÙË ¯ÚÒÛË Perl ÁÈ· ·ÈÌÔÛȉËÚ›ÓË (∂ÈÎfiÓ· 1°). ¶·ÚfiÌÔÈ· ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ (·ÈÌÔÛȉËÚ›Ó˘) ‰È·ÈÛÙÒıËΠÛÙȘ ηډȷΤ˜ Ì˘˚Τ˜ ›Ó˜ Î·È ÛÙ· ·ÙÙ·Ú· ÙˆÓ ·‰ÂÓÔ΢„ÂÏÒÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ (∂ÈÎfiÓ· 1¢). ¢ÂÓ ‰È·ÈÛÙÒıËΠÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ ÛÙÔ˘˜ ÏÂÌÊ·‰¤Ó˜ Î·È ÙÔÓ ÛÏ‹Ó·. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ Û˘ÓËÁÔÚÔ‡Û·Ó ÁÈ· ÓÂÔÁÓÈ΋ ·ÈÌԯڈ̿وÛË.

™˘˙‹ÙËÛË ∏ ¡Â∞ ·ÔÙÂÏ› ·ÈÙ›· Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Ì ÂÓ‰ÔÌ‹ÙÚÈ· ¤Ó·ÚÍË. ∏

Pediatr Sept_Oct 06

26-09-06

12:54

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∂ÈÎfiÓ· 1. ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù·: ∞) ¶ÔÏ˘Ô˙҉˘ ÂÌÊ¿ÓÈÛË Ù˘ οو ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ‹·ÙÔ˜. ¢È·ÎÚ›ÓÂÙ·È ·ÚÈÛÙÂÚ¿ Ô Û˘ÌÊÔÚË̤ÓÔ˜ ÛÏ‹Ó·˜. µ) ÃÚÒÛË ·ÈÌ·ÙÔÍ˘Ï›Ó˘-ˈۛÓ˘. ¡¤ÎÚˆÛË Ë·ÙÔ΢ÙÙ¿ÚˆÓ (‰È·ÎÂÎÔÌ̤ÓÔ ‚¤ÏÔ˜) Î·È ˘ÂÚÏ·Û›· ÓÂÔ¯ÔÏÏ·ÁÁÂÈÔÏ›ˆÓ (Û˘Ì·Á¤˜ ‚¤ÏÔ˜). ∞Ú¯È΋ ÌÂÁ¤ı˘ÓÛË Ã 200. °) ÃÚÒÛË Perl. ™È‰‹ÚˆÛË ‹·ÙÔ˜ (+++) (‚¤ÏÔ˜). ∞Ú¯È΋ ÌÂÁ¤ı˘ÓÛË Ã 200. ¢) ÃÚÒÛË Perl. ∂Ó·fiıÂÛË ·ÈÌÔÛȉËÚ›Ó˘ ÛÙ· ·ÙÙ·Ú· ÙˆÓ ·‰ÂÓÔ΢„ÂÏÒÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜. ∞Ú¯È΋ ÌÂÁ¤ı˘ÓÛË Ã 400.

·ËÛË ÂÈϤÎÂÙ·È Û˘Ó‹ıˆ˜ Ì ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ ‹ ÔÏ˘¸‰Ú¿ÌÓÈÔ, Ô›‰ËÌ· ÙÔ˘ Ï·ÎÔ‡ÓÙ· Î·È ÌË ·ÓÔÛÔÏÔÁÈÎfi ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· ‹ ·ÛΛÙË (1,3). ∏ ÓfiÛÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÓ‰ÔÌ‹ÙÚÈÔ ı¿Ó·ÙÔ, ÚÔˆÚfiÙËÙ· ‹ ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, fiˆ˜ Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË (1). ™˘¯Ó¿, Ù· ÓÂÔÁÓ¿ ÂΉËÏÒÓÔ˘Ó ·fi ÙȘ ÚÒÙ˜ ̤Ú˜ Ù˘ ˙ˆ‹˜ ÔÚÁ·ÓÔÌÂÁ·Ï›·, ˘ÔÁÏ˘Î·ÈÌ›·, ‰È·Ù·Ú·¯¤˜ Ù˘ ËÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ·›Ì·ÙÔ˜, ¿ÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· Î·È ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·, ÂÓÒ Ù· Â›‰· ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Û˘Ó‹ıˆ˜ Â›Ó·È ¯·ÌËÏ¿ (2,5-7). øÛÙfiÛÔ, ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ - Î·È ÁÂÓÈÎfiÙÂÚ· Ù˘ Ë·ÙÔ¿ıÂÈ·˜ - ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ÂÌÊ·Ó›˜ ÛÙË Á¤ÓÓËÛË (7). ¶Ú¿ÁÌ·ÙÈ, ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ‰ÂÓ ˘‹Ú¯·Ó ÂΉËÏÒÛÂȘ ÛÔ‚·Ú‹˜ Ë·ÙÈ΋˜ ‚Ï¿‚˘ ÙÔ 1Ô 24ˆÚÔ Ù˘ ˙ˆ‹˜, ÂÓÒ ÔÈ ·˘ÍË̤Ó˜ ÙÚ·ÓÛ·ÌÈÓ¿Û˜ ÔÚÔ‡ ·Ô‰fiıËÎ·Ó Û ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·. ∏ ·ÚÈ· ÂΉ‹ÏˆÛË ‹Ù·Ó Ë ·ÓıÂÎÙÈ΋ ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÏfiÁˆ ¶¶À, ÒÛÙ ÙÔ Û‡Ó‰ÚÔÌÔ Potter Ó· ·ÔÙÂϤÛÂÈ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË. ∞˘Ù‹ ‚·Û›ÛÙËΠÛÙÔÓ Û˘Ó‰˘·ÛÌfi ÙˆÓ ‰˘ÛÌÔÚÊÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ, Ù˘ ·ÓÔ˘Ú›·˜, ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ·Ó·ÁÎÒÓ Û Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Î·È ÛÙȘ ÂÈÏÔΤ˜ Ù˘ ·ËÛ˘ (ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, ÂÓ‰ÔÌ‹-

ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘), ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‰ÂÓ ‹Ù·Ó ÂÓ‰ÂÈÎÙÈ΋ Ó¢ÌÔÓÈ΋˜ ˘ÔÏ·Û›·˜. øÛÙfiÛÔ, Ë ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË ·¤ÎÏÂÈÛ ÙËÓ Ó¢ÌÔÓÈ΋ ˘ÔÏ·Û›· Î·È ÓÂÊÚÈ΋ ·ÁÂÓÂÛ›· ‹ ¿ÏÏË ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›·, ÒÛÙÂ Ë ¶¶À Î·È Ë ·ÓÔ˘Ú›· ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ÛÙËÓ ˘ÔÍ›· Ô˘ ˘¤ÛÙË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Î·È ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Î·È ÂӉ¯Ô̤ӈ˜ ÂÓ‰ÔÌ‹ÙÚÈ·. ∏ ‰È¿ÁÓˆÛË Ù¤ıËΠ̠ÙË ‚ÈÔ„›· ÙÔ˘ ‹·ÙÔ˜, Ô˘ ¤‰ÂÈÍ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Û˘Ì‚·Ù¤˜ Ì ¡Â∞. ÷ڷÎÙËÚÈÛÙÈο, ÛÙË ‚ÈÔ„›· ‹·ÙÔ˜ ‰È·ÈÛÙÒÓÂÙ·È Ë·ÙÈ΋ ›ÓˆÛË Î·È ˘ÂÚ‚ÔÏÈ΋ ÂÓ·fiıÂÛË Ûȉ‹ÚÔ˘ ÛÙ· Ë·ÙÔ·ÙÙ·Ú·. ªÈÎÚfiÙÂÚ˜ ÔÛfiÙËÙ˜ Ûȉ‹ÚÔ˘ ·Ó¢ڛÛÎÔÓÙ·È ÛÙ· ·ÚÂÁ¯˘Ì·ÙÈο ·ÙÙ·Ú· ÙˆÓ ÂÓ‰ÔÎÚÈÓÒÓ ·‰¤ÓˆÓ (ÂÈÓÂÊÚ›‰È·, ı˘ÚÂÔÂȉ‹˜, ¿ÁÎÚ·˜, ˘fiÊ˘ÛË), ÛÙËÓ Î·Ú‰È¿ Î·È ÛÙ· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ·, ÂÓÒ ‰ÂÓ ÚÔÛ‚¿ÏÏÂÙ·È ÙÔ ‰ÈÎÙ˘ÔÂÓ‰ÔıËÏÈ·Îfi Û‡ÛÙËÌ· (8). ∂Ó·ÏÏ·ÎÙÈο, Ë ‚ÈÔ„›· ÙˆÓ ÌÈÎÚÒÓ ÛÈÂÏÔÁfiÓˆÓ ·‰¤ÓˆÓ ·ÔÙÂÏ› ·ÛÊ·Ï‹ Î·È Â˘·›ÛıËÙÔ ÙÚfiÔ ‰È¿ÁÓˆÛ˘, ȉȷ›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ Ì ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ (9). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ë Û¯ÂÙÈο ÌÈÎÚ‹ Ì›ˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ‹·ÙÔ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ô˘Û›· ˘ÔÚˆÙÂ˚Ó·ÈÌ›·˜, ·ÛΛÙË ‹ Ôȉ‹Ì·ÙÔ˜, Û˘ÓËÁÔÚ› ÛÙËÓ ¶·È‰È·ÙÚÈ΋ 2006;69:381-384

Pediatr Sept_Oct 06

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12:54

™ÂÏ›‰·384

384

K. ™·Ú·Ê›‰Ë˜ Î·È Û˘Ó.

˘fiıÂÛË fiÙÈ Ë Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë ‰ÂÓ ‹Ù·Ó ·ÎfiÌË ‚·ÚÈ¿. ∏ ¤ÏÏÂÈ„Ë ÎÏÈÓÈο ·ÈÌÔÚÚ·ÁÈ΋˜ ‰È¿ıÂÛ˘, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ÚÒÈÌÔ ı¿Ó·ÙÔ, ‰ÈηÈÔÏÔÁ› ÙË ÌË ‰ÈÂÓ¤ÚÁÂÈ· ÂϤÁ¯Ô˘ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ∂Í¿ÏÏÔ˘, ÌÂÚÈο ÓÂÔÁÓ¿ Ì ¡Â∞ ·Ó·Ù‡ÛÛÔ˘Ó ÎÏÈÓÈο ·ÓÙÈÏËÙ‹ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· fi„ÈÌ· ÛÙË ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô (10). ÕÏÏ· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË, Û˘Ó‹ıˆ˜ ·ÚÎÂÙ¤˜ Ë̤Ú˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, fiÙ·Ó ϤÔÓ Ù›ıÂÙ·È ÈÛ¯˘Ú¿ Ë ˘fiÓÔÈ· Ù˘ ÓfiÛÔ˘ ÏfiÁˆ Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Â›Ó·È Ù· ·˘ÍË̤ӷ Â›‰· ÊÂÚÚÈÙ›Ó˘ Î·È ÎÔÚÂÛÌÔ‡ Ù˘ ÙÚ·ÓÛÊÂÚ›Ó˘ (95-100%), Ë ¯·ÌËÏ‹ ÙÚ·ÓÛÊÂÚ›ÓË Î·È Ë ·˘ÍË̤ÓË ·-ÂÌ‚Ú˘˚΋ ÚˆÙ½ÓË (1,7). ∂ÓÙÔ‡ÙÔȘ, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ·‡ÍËÛË Ù˘ ÊÂÚÚÈÙ›Ó˘ ÙÔ˘ ÔÚÔ‡ ·ÔÙÂÏ› ÌË ÂȉÈÎfi ‰Â›ÎÙË Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ‚Ï¿‚˘ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· (11). ∏ ·Ó·ÈÌ›· Î·È Ë ıÚÔÌ‚ÔÂÓ›· ·ÔÙÂÏÔ‡Ó ÌË ÂȉÈΤ˜ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ, ÔÈ Ôԛ˜ Â›Û˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙË ¡Â∞ (6). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ‰È·ÈÛÙÒıËÎ·Ó ‰È¿ÊÔÚ· ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, Ô˘ ·Ô‰fiıËÎ·Ó ÛÙÔ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ, ηıÒ˜ Î·È ÌÔÓ‹Ú˘ ÔÌÊ·ÏÈ΋ ·ÚÙËÚ›·. ªÂ›˙ÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Û¿ÓÈ· Û ¡Â∞ (·ÙÚËÛ›· ÂÓÙ¤ÚÔ˘, ÙÚ·¯ÂÈÔ-ÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ, ÂÙ·ÏÔÂȉ‹˜ ÓÂÊÚfi˜ Î·È Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·), ÂÓÒ ˘¿Ú¯ÂÈ ÌfiÓÔ Ì›· ·Ó·ÊÔÚ¿ ÌÔÓ‹ÚÔ˘˜ ÔÌÊ·ÏÈ΋˜ ·ÚÙËÚ›·˜ (12). ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË, ηıÒ˜ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÔÈÎÔÁÂÓ›˜ ÂÚÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ (2). ∂ÈϤÔÓ, Ë ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ ¡Â∞ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÁÈ· ÙËÓ ÚfiÁÓˆÛË. Èڛ˜ ıÂÚ·›·, Ù· ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÚÔۂ‚ÏË̤ӷ ÓÂÔÁÓ¿ ‹ ‚Ú¤ÊË Âı·›ÓÔ˘Ó ·fi Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ‹ ÛË„·ÈÌ›·, ÂÓÒ Û·Ó›ˆ˜ ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÙÒÛÂȘ Ì ·˘ÙfiÌ·ÙË ‚ÂÏÙ›ˆÛË Î·È ÂÈ‚›ˆÛË (13). ™ÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, Ô ı¿Ó·ÙÔ˜ ‹Ù·Ó Û˘Ó¤ÂÈ· Ù˘ ¶¶À Î·È fi¯È Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘. ∏ ·Ú¯È΋ ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û˘Ìو̷ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÂÓÒ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ ·ÔÙÂÏ› ÙË ıÂÚ·›· ÂÎÏÔÁ‹˜ (2,14). ∏ ¯Ú‹ÛË ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ-¯ËÏÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (‰ÂÛÊÂÚÔÍ·Ì›ÓË, ‚ÈÙ·Ì›ÓË ∂, ¡-·ÎÂÙ˘ÏÔ΢ÛÙ½ÓË, ÛÂÏ‹ÓÈÔ Î·È ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂1) ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‚ÂÏÙÈÒÓÂÈ ÙËÓ ¤Î‚·ÛË (14), ·Ó Î·È ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ÂÈÙ˘¯Ô‡˜ ıÂÚ·›·˜ Ù˘ ¡Â∞ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ (7). ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Ù˘ ¶·È‰È·ÙÚÈ΋ 2006;69:381-384

¡Â∞ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ Â›Ó·È ‰‡ÛÎÔÏË. ™Â ÂÚÈÙÒÛÂȘ ı·Ó¿ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÈÛÙÔÚÈÎfi ÔÏ˘¸‰Ú·ÌÓ›Ô˘, ˘ÂÚÙÚÔÊÈÎÔ‡ Ï·ÎÔ‡ÓÙ· Î·È ÂÓ‰ÔÌ‹ÙÚÈ·˜ ηı˘ÛÙ¤ÚËÛ˘ ÛÙËÓ ·Ó¿Ù˘ÍË, ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ë Èı·ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ - ·Ú¿ ÙË Û·ÓÈfiÙËÙ¿ Ù˘ - Î·È Ó· Á›ÓÂÙ·È ÓÂÎÚÔÙÔÌÈ΋ ÂͤٷÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰Ôı› Ë Î·Ù¿ÏÏËÏË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Murray KF, Kowdley KV. Neonatal hemochromatosis. Pediatrics 2001;108:960-964.

2. Kelly AL, Lunt PW, Rodrigues F, Berry PJ, Flynn DM, McKiernan PJ et al. Classification and genetic features of neonatal haemochromatosis: a study of 27 affected pedigrees and molecular analysis of genes implicated in iron metabolism. J Med Genet 2001;38:599-610.

3. Cheung PC, Ng WF, Chan AK. Neonatal haemochromatosis associated with Down syndrome. J Paediatr Child Health 1995;31:249-252.

4. Shneider BL. Genetic counseling in neonatal hemochromatosis. J Pediatr Gastroenterol Nutr 2002; 34:328.

5. Singh S, Sills JH, Waffarn F. Interesting case presentation: neonatal hemochromatosis as a cause of ascites. J Perinatol 1990;10:214-216.

6. Chase MC, Riedinger D. Neonatal hemochromatosis: a case report. Neonatal Netw 1995;14:7-12.

7. Vohra P, Haller C, Emre S, Magid M, Holzman I, Ye MQ et al. Neonatal hemochromatosis: the importance of early recognition of liver failure. J Pediatr 2000;136:537-541.

8. Blisard KS, Bartow SA. Neonatal hemochromatosis.

Hum Pathol 1986;17:376-383.

9. Knisely AS, O’Shea PA, Stocks JF, Dimmick JE. Oropharyngeal and upper respiratory tract mucosal-gland siderosis in neonatal hemochromatosis: an approach to biopsy diagnosis. J Pediatr 1988;113: 871-874.

10. Ku SW, Luk IS, Yuen MK, Wong CP. Subacute hepatic failure after the perinatal period with haemochromatotic siderosis at the age of 11 months: an unusual perspective on neonatal haemochromatosis.

Acta Paediatr 2002;91:856-858.

11. Lee WS, McKiernan PJ, Kelly DA. Serum ferritin level in neonatal fulminant liver failure. Arch Dis Child Fetal Neonatal Ed 2001;85:F226.

12. Taucher SC, Bentjerodt R, Hubner ME, Nazer J. Multiple malformations in neonatal hemochromatosis.

Am J Med Genet 1994;50:213-214.

13. Colletti RB, Clemmons JJ. Familial neonatal hemochromatosis with survival. J Pediatr Gastroenterol Nutr 1988;7:39-45.

14. Sigurdsson L, Reyes J, Kocoshis SA, Hansen TW, Rosh J, Knisely AS. Neonatal hemochromatosis: outcomes of pharmacologic and surgical therapies. J Pediatr Gastroenterol Nutr 1998;26:85-89.

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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

385

™‡Ó‰ÚÔÌÔ Rubinstein-Taybi ™. ∆fiÁη, ª. ª·˘Ú›ÎÔ˘, ¶. ¡¤Ô˘, §. ™Ù·ÌÔÁÈ¿ÓÓÔ˘

¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ Rubinstein-Taybi (RTS) Â›Ó·È ÌÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· ÔÏÏ·ÏÒÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÓÔËÙÈ΋ Î·È ÛˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË (ηı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘, ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÌÈÎÚÔÎÂÊ·Ï›·), ¢Ú›˜ ·ÓÙ›¯ÂÈÚ˜, ¢ڤ· ÌÂÁ¿Ï· ‰¿¯Ù˘Ï· οو ¿ÎÚˆÓ Î·È ‰‡ÛÌÔÚÊ· ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ (Ú·ÌÊÔÂȉ‹˜ ̇ÙË, ÚÔ¤¯ÔÓ Ì¤ÙˆÔ, Â›Î·ÓıÔ˜, ˘ÂÚÙÂÏÔÚÈÛÌfi˜, ÌÈÎÚÔÁÓ·ı›·). ™˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÔÊı·ÏÌÒÓ, ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡, ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Î·È ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô Û‡Ó‰ÚÔÌÔ Rubinstein-Taybi ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ·ÏÏ¿ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛÔÚ·‰ÈΤ˜. °È· ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ¢ı‡ÓÔÓÙ·È ¯ÚˆÌÔÛˆÌÈο ÌÈÎÚÔÂÏÏ›ÌÌ·Ù· ‹ ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP (c AMP- Responsive element binding protein), Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÓË›Ô˘ Ì ۇӉÚÔÌÔ Rubinstein-Taybi. ™˘˙ËÙÔ‡ÓÙ·È Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο, Ë ·ıÔÁ¤ÓÂÈ· Î·È Ë ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Î·È Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ Û¯ÂÙÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜.

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ™Ù·˘ÚԇϷ ∆fiÁη ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· E-mail: xk1164@otenet.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-06-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 31-03-2006

§¤ÍÂȘ ÎÏÂȉȿ: ™‡Ó‰ÚÔÌÔ Rubinstein-Taybi, ¢Ú›˜ ·ÓÙ›¯ÂÈÚ˜, ¢ڤ· ‰¿¯Ù˘Ï· Ô‰ÈÒÓ, ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘.

Rubinstein-Taybi syndrome S. Togka, M. Mavrikou, P. Neou, L. Stamoyannou

Abstract: Rubinstein-Taybi syndrome (RTS) is a multiple congenital anomaly syndrome characterized by mental and growth retardation (speech delay, short stature, microcephaly), broad thumbs, broad great toes and specific dysmorphic facial features (prominent beaked nose, epicanthus, hypertelorism, hypoplastic maxilla). Patients may present ocular abnormalities, skin lesions, abnormalities of the cardiovascular system, malformations of the kidneys and urogenital system and musculoskeletal deformities. The RTS syndrome has an autosomal dominant pattern of inheritance but most cases are sporadic. Chromosomal deletions or point mutations of the gene CREBBP (c AMPResponsive element binding protein), which is located on the short arm of chromosome 16, are responsible for the phenotype of RTS. The case is described of an infant with RTS. The clinical manifestations, the pathogenetic mechanisms and the appropriate management of this patient are discussed and the current literature is reviewed.

1st Paediatric Clinic, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: Stavroula Togka 1st Paediatric Clinic “P. & A. Kyriakou” Children’s Hospital, Athens E-mail: xk1164@otenet.gr Date of submission: 10-06-2005 Date of approval: 31-03-2006

Key words: Rubinstein-Taybi syndrome, broad thumbs, great toes, mental retardation, growth retardation.

∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ Rubinstein-Taybi (RTS) Â›Ó·È ÌÈ· Û¿ÓÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·, Ë ÔÔ›· ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1963 ·fi ÙÔ˘˜ Rubinstein Î·È Taybi. ŒÎÙÔÙÂ, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÛfiÙÂÚ˜ ·fi 730 ÂÚÈÙÒÛÂȘ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·. √È ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛÔÚ·‰ÈΤ˜. ™¿ÓÈ· ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ÂÈÎÚ·ÙÔ‡ÓÙ· ۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·. ∫‡ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ›-

Ó·È Ë Î·ı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, Ë ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ÔÈ ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÔÈ Â˘Ú›˜ ·ÓÙ›¯ÂÈÚ˜ Î·È Ù· ¢ڤ· ÌÂÁ¿Ï· ‰¿¯Ù˘Ï· ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ. ™˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó ·ÓˆÌ·Ï›Â˜ ·fi ‰È¿ÊÔÚ· ¿ÏÏ· Û˘ÛÙ‹Ì·Ù·, fiˆ˜ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi, ÙÔ Ô˘ÚÔÔÈËÙÈÎfi, ÙÔ ÁÂÓÓËÙÈÎfi, ÙÔ Ì˘ÔÛÎÂÏÂÙÈÎfi, ηıÒ˜ Î·È ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 2 ÂÙÒÓ Ì ۇӉÚÔÌÔ Rubinstein-Taybi, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È¢ÎÔÏ˘Óı› Ë ·Ó·ÁÓÒÚÈÛË ¶·È‰È·ÙÚÈ΋ 2006;69:385-389

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™. ∆fiÁη Î·È Û˘Ó.

∂ÈÎfiÓ· 1. ÷ڷÎÙËÚÈÛÙÈÎfi ÚÔÛˆÂ›Ô (˘ÂÚÙÂÏÔÚÈÛÌfi˜, Â›Î·ÓıÔ˜, ÚÔ¤¯ÔÓ ÛÙÚÔÁÁ˘Ïfi ̤وÔ, Ú·ÌÊÔÂȉ‹˜ ̇ÙË, ÌÈÎÚÔÁÓ·ı›· οو ÁÓ¿ıÔ˘).

∂ÈÎfiÓ· 2. ∂˘Ú‡˜ ıÒڷη˜ Ì ÌÂÁ¿ÏË ·fiÛÙ·ÛË ÌÂٷ͇ ÙˆÓ ıËÏÒÓ Î·È ÂÓÙ‡ˆÌ· ÛÙÔ ‡„Ô˜ Ù˘ ÍÈÊÔÂȉԇ˜ ·fiÊ˘Û˘.

·Ó¿ÏÔÁˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Î·È Ë ÈηÓfiÙËÙ· Ù·˘ÙÔÔ›ËÛ˘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘.

ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ¿ÎÚÔ˘ Ù˘ Î·È ÌÈÎÚÔÁÓ·ı›· οو ÁÓ¿ıÔ˘. √ ıÒڷο˜ ÙÔ˘ ‹Ù·Ó ¢ڇ˜, Ì ÌÂÁ¿ÏË ·fiÛÙ·ÛË ÌÂٷ͇ ÙˆÓ ıËÏÒÓ (∂ÈÎfiÓ· 2), ÂÓÒ ÂÌÊ¿ÓÈ˙ ÂÓÙ‡ˆÌ· ÛÙÔ ‡„Ô˜ Ù˘ ÍÈÊÔÂȉԇ˜ ·fiÊ˘Û˘. √È ¿ÎÚ˜ ¯Â›Ú˜ Î·È ÔÈ ¿ÎÚÔÈ fi‰Â˜ ‹Ù·Ó ÔȉËÌ·ÙÒ‰ÂȘ, Ì ¢ڤ· Î·È ÎÔÓÙ¿ ‰¿¯Ù˘Ï· (΢ڛˆ˜ ·ÓÙ›¯ÂÈÚ˜) Î·È ÎÔÓÙ¤˜ ÔÓ˘¯ÔÊfiÚ˜ Ê¿Ï·ÁÁ˜ (∂ÈÎfiÓ˜ 3 Î·È 4). √È fiÚ¯ÂȘ ‹Ù·Ó ÌÈÎÚÔ› Î·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÔÛ¯¤Ô˘ ·ÙÂÏ‹˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË, ÙÔ ·È‰› ÛÙÂÎfiÙ·Ó Û fiÚıÈ· ı¤ÛË, ¯ˆÚ›˜ Ó· ‚·‰›˙ÂÈ Î·È ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈ΋ ηı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘ Î·È ¿ÏÏˆÓ ÎÚÈÙËÚ›ˆÓ ÂͤÏÈ͢ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (·ÈÌ·ÙÔÏÔÁÈÎfi˜, ‚ÈÔ¯ËÌÈÎfi˜, ÔÚÌÔÓÔÏÔÁÈÎfi˜) ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. √ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜, Ë ·ÎÔÔÏÔÁÈ΋ ÂͤٷÛË Ì ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο, ÙÔ ∏∂° Î·È Ë ªRI ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÓÂÊÚÒÓ ¤‰ÂÈÍ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¿Ìʈ, ÂÓÒ Ë Î˘ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ·Ó¤‰ÂÈÍ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ¿Ìʈ (‚ÂÏÙȈ̤ÓË Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÚÔËÁÔ‡ÌÂÓË). ∏ ÔÛÙÈ΋ ËÏÈΛ· ˘ÔÏÂÈfiÙ·Ó ÂÓÓ¤· Ì‹Ó˜. ∫·Ù¿ ÙË ÓÔÛËÏ›· ÙÔ˘, ¤ÁÈÓ ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË, ÛÙËÓ ÔÔ›· ‰È·ÈÛÙÒıËΠÁÏ·‡ÎˆÌ· Î·È ÌÂÁ·ÎÂÚ·ÙÔÂȉ‹ ÙÔ˘ ‰ÂÍÈÔ‡ ÔÊı·ÏÌÔ‡, ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙË ‚˘ıÔÛÎfiËÛË. ªÂ Ù· ·ÓˆÙ¤Úˆ ¯·Ú·ÎÙËÚÈÛÙÈο, ÂÙ¤ıË Ë ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Rubinstein-Taybi. ™˘ÓÂÛÙ‹ıË ÏÔÁÔıÂÚ·›· Î·È ÔÊı·ÏÌÔÏÔÁÈ΋ Î·È ÓÂÊÚÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 2 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÁÈ· ¤ÏÂÁ¯Ô „˘¯ÔÎÈÓËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ Î·È ÌÈÎÚÔÎÂÊ·Ï›·˜. ∂ÚfiÎÂÈÙÔ ÁÈ· ÙÔ ÙÚ›ÙÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, Ô˘ ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ·ËÛË 38 ‚‰ÔÌ¿‰ˆÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2840 g (10Ë ∂£), Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ 50 cm (50Ë ∂£) Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ 32 cm (5Ë ∂£). ™ÙÔ Ï·›ÛÈÔ ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘, Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠÏfiÁˆ Ù˘ ËÏÈΛ·˜ Ù˘ ÌËÙ¤Ú·˜ (>35 ÂÙÒÓ), ›¯Â Á›ÓÂÈ Î·Ú˘fiÙ˘Ô˜, Ô ÔÔ›Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ‡ ¿ÚÚÂÓÔ˜ (46ÃÀ), ¯ˆÚ›˜ ÂÌÊ·Ó›˜ ¯ÚˆÌÔÛˆÌÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∫·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ ‰È·ÈÛÙÒıËΠÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (∫√¶) ¿Ìʈ, Ì ÂÓ‰ÔÓÂÊÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È ÎÚ˘„ÔÚ¯›·, ÁÈ· ÙËÓ ÔÔ›· ¯ÂÈÚÔ˘ÚÁ‹ıËΠ۠ËÏÈΛ· 18 ÌËÓÒÓ. ∫·Ù¿ ÙÔ 1Ô ¤ÙÔ˜ ˙ˆ‹˜, ÏfiÁˆ Ù˘ „˘¯ÔÎÈÓËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘, ¤ÁÈÓ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, Ô ÔÔ›Ô˜ ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ ηٿ ÙË ÓÔÛËÏ›· ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋, ‰È·ÈÛÙÒıËΠηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ [µ™ 10 kg (<3Ë ∂£), ‡„Ô˜ 78 cm (<3Ë ∂£ ), ¶∫ 45,5 cm (<3Ë ∂£ )] Î·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÚÔÛˆÂ›Ô (∂ÈÎfiÓ· 1) Ì ˘ÂÚÙÂÏÔÚÈÛÌfi, Â›Î·ÓıÔ, ÚÔ¤¯ÔÓ ÛÙÚÔÁÁ˘Ïfi ̤وÔ, ȉÈfiÌÔÚÊË Ú·ÌÊÔÂȉ‹ ̇ÙË Ì ¿¯˘ÓÛË Î·È ÂÈÌ‹Î˘Ó¶·È‰È·ÙÚÈ΋ 2006;69:385-389

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™‡Ó‰ÚÔÌÔ Rubinstein-Taybi

∂ÈÎfiÓ· 3. ∂˘Ú¤· Î·È ÎÔÓÙ¿ ‰¿¯Ù˘Ï· ¿ÎÚˆÓ ¯ÂÈÚÒÓ (΢ڛˆ˜ ·ÓÙ›¯ÂÈÚ˜).

™˘˙‹ÙËÛË ∆Ô RTS Â›Ó·È Û¿ÓÈ· ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÔÔ›·˜ ·Ó¤Ú¯ÂÙ·È Û 1:10000 ÁÂÓÓ‹ÛÂȘ Î·È ·ÊÔÚ¿ ÂÍ›ÛÔ˘ Î·È ÛÙ· ‰‡Ô ʇϷ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ·ÓˆÌ·Ï›Â˜ ÙˆÓ ‰·¯Ù‡ÏˆÓ ÙˆÓ ¿ÎÚˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÒÓ (·ÔÏ·Ù˘Ṳ̂ÓÔÈ ·ÓÙ›¯ÂÈÚ˜ Î·È ÌÂÁ¿Ï· ‰¿¯Ù˘Ï· Ô‰ÈÒÓ), ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ Î·È „˘¯ÔÎÈÓËÙÈ΋˜ ·Ó¿Ù˘Í˘, ηı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘, ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜, ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù·, ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘, ÛÎÂÏÂÙÈΤ˜ ‰˘ÛÌÔÚʛ˜ Î·È Ô˘ÚÔÁÂÓÓËÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (1). √ Ê·ÈÓfiÙ˘Ô˜ Î·È Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÔÈΛÏÏÔ˘Ó Î·Ù¿ ÂÚ›ÙˆÛË. ∆Ô RTS ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÔÚ·‰Èο, ÂÓÒ Û¿ÓÈ· ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ÂÈÎÚ·ÙÔ‡ÓÙ· ·˘ÙfiÛˆÌÔ ¯·Ú·ÎÙ‹Ú·. ª¿ÏÈÛÙ·, Û¯ÂÙÈο ÚfiÛÊ·Ù· Ê¿ÓËΠfiÙÈ ÁÈ· ÙÔ RTS ¢ı‡ÓÔÓÙ·È ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP (c AMP Responsive element binding protein), ÙÔ ÔÔ›Ô Â‰Ú¿˙ÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16 (16p13.3). ∆Ô ÁÔÓ›‰ÈÔ CREBBP Έ‰ÈÎÔÔÈ› Ì›· ˘ÚËÓÈ΋ ÚˆÙ½ÓË, Ë ÔÔ›· ¤¯ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Û ‰È·ÊÔÚÂÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ΢ÙÙ¿ÚÔ˘, fiˆ˜ ÛÙËÓ ÂȉÈfiÚıˆÛË ÙÔ˘ DNA, ÛÙËÓ ·‡ÍËÛË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ÛÙËÓ ·fiÙˆÛË, ÂÓÒ ¤¯ÂÈ Î·È ÔÁÎÔηٷÛÙ·ÏÙÈΤ˜ ȉÈfiÙËÙ˜. √È ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP ·Ó¢ڛÛÎÔÓÙ·È ÂÚ›Ô˘ ÛÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ Ì RTS Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â›Ù ¯ÚˆÌÔÛˆÌÈο ÌÈÎÚÔÂÏÏ›ÌÌ·Ù· (chromosomal microdeletions) Ù˘ ÂÚÈÔ¯‹˜ p13.3 ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16, ›Ù ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ (point mutations). ™˘ÁÎÂÎÚÈ̤ӷ, Ù· ¯ÚˆÌÔÛˆÌÈο ÌÈÎÚÔÂÏÏ›ÌÌ·Ù· ·Ó¢ڛÛÎÔÓÙ·È

∂ÈÎfiÓ· 4. ∂˘Ú¤· Î·È ÎÔÓÙ¿ ‰¿¯Ù˘Ï· ¿ÎÚˆÓ Ô‰ÒÓ.

Ì ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌfi (̤ıÔ‰Ô˜ FISH) ÛÙÔ 8-12% ÙˆÓ ·ÛıÂÓÒÓ Ì RTS, Â›Ó·È Ù˘ Ù¿Í˘ ÙˆÓ 50-650 kb Î·È ÚÔηÏÔ‡Ó ÌÂÚÈ΋ ‹ Ï‹ÚË ¤ÏÏÂÈ„Ë ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP. ™ÙȘ ˘fiÏÔÈ˜ ÂÚÈÙÒÛÂȘ ·Ó¢ڛÛÎÔÓÙ·È ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP (2,3). ∂›Ó·È ÂӉȷʤÚÔÓ Î·È Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Ô Ê·ÈÓfiÙ˘Ô˜ ÙˆÓ ·ÛıÂÓÒÓ Ì RTS ‰ÂÓ ‰È·Ê¤ÚÂÈ, ›Ù ÚfiÎÂÈÙ·È ÁÈ· ¯ÚˆÌÔÛˆÌÈο ÌÈÎÚÔÂÏÏ›ÌÌ·Ù·, ›Ù ÁÈ· ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP. ™ÙÔÓ ·ÛıÂÓ‹ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ù‹ Ë ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ÌÔÚÈ·ÎÔ‡ Î˘Ù·ÚÔÁÂÓÓÂÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ì ÊıÔÚ›˙ÔÓÙ· in situ ˘‚ÚȉÈÛÌfi (FISH) ÁÈ· ÙËÓ ÂÚÈÔ¯‹ p13.3 ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Ù· ‚Ú¤ÊË Ì RTS ¤¯Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ·fi Ù· ‰¿¯Ù˘Ï· ÙˆÓ ¿ÎÚˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÒÓ, Ù· ÔÔ›· Â›Ó·È ÔȉËÌ·ÙÒ‰Ë, Ì ¢Ú›˜ ·ÓÙ›¯ÂÈÚ˜ Î·È Â˘Ú¤· ÌÂÁ¿Ï· ‰¿¯Ù˘Ï· ÙˆÓ ¿ÎÚˆÓ Ô‰ÒÓ, ÌÂ Û˘ÓÔ‰fi ·ÙÂÏ‹ ·Ó¿Ù˘ÍË ÙˆÓ ÙÂÏÈÎÒÓ Ê·Ï¿ÁÁˆÓ. ∂›Û˘, ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ÎÏÈÓÔ‰·ÎÙ˘Ï›·, Û˘Ó‰·ÎÙ˘Ï›·, ÔÏ˘‰·ÎÙ˘Ï›· Î·È ·ıÔÏÔÁÈο ‰ÂÚÌ·ÙÔÁÏ˘ÊÈο (4,5). ™Â fiϘ ۯ‰fiÓ ÙȘ ÂÚÈÙÒÛÂȘ ·Ú·ÙËÚÂ›Ù·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜. ∆Ô ‡„Ô˜ ‚Ú›ÛÎÂÙ·È Û˘Ó‹ıˆ˜ οو ·fi ÙËÓ 3Ë ∂£. ∆Ô Ì¤ÛÔ ÙÂÏÈÎfi ‡„Ô˜ ÁÈ· Ù· ¿ÚÚÂÓ· Â›Ó·È 153 cm, ÂÓÒ ÁÈ· Ù· ı‹Ï· Â›Ó·È 147 cm. ™Ù· ·È‰È¿ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ·Ú·ÙËÚÂ›Ù·È ÂÈ‚Ú¿‰˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ÚÔÛ¤ÁÁÈÛ˘ ÙˆÓ ÈηÓÔÙ‹ÙˆÓ Ô˘ ·Ó·ÏÔÁÔ‡Ó ÛÙË ¯ÚÔÓÔÏÔÁÈ΋ ÙÔ˘˜ ËÏÈΛ·. √ ‰Â›ÎÙ˘ ÓÔËÌÔÛ‡Ó˘ (IQ) Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 30-79, ·Ó Î·È ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ¤¯Ô˘Ó IQ ÌÈÎÚfiÙÂÚÔ ·fi 50. ∂ÌÊ·Ó›˙Ô˘Ó ÛËÌ·ÓÙÈ΋ ηı˘ÛÙ¤ÚËÛË ¶·È‰È·ÙÚÈ΋ 2006;69:385-389

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·388

388

™. ∆fiÁη Î·È Û˘Ó.

ÏfiÁÔ˘, Û¯ÂÙÈ΋ ˘ÔÙÔÓ›· Î·È ¿Î·ÌÙÔ, ÌË ÛÙ·ıÂÚfi ‚¿‰ÈÛÌ·. ªÂÚÈο ·È‰È¿ Ì RTS ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÂÈÛfi‰È· Û·ÛÌÒÓ (4,5). ∆· ‚Ú¤ÊË Ì RTS ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈÎÈÏ›· ÎÚ·ÓÈÔÚÔÛˆÈÎÒÓ ‰˘ÛÌÔÚÊÈÒÓ. ÷ڷÎÙËÚÈÛÙÈ΋ Â›Ó·È Ë ÌÈÎÚÔÎÂÊ·Ï›· ÌÂ Û˘ÓÔ‰fi ÚÔ¤¯ÔÓ Ì¤ÙˆÔ, Ú·ÌÊÔÂȉ‹ ̇ÙË Ì ¿¯˘ÓÛË Î·È ÂÈÌ‹Î˘ÓÛË ÙÔ˘ ÙÂÏÈÎÔ‡ Ù˘ ¿ÎÚÔ˘, Â›Î·ÓıÔ, ˘ÂÚÙÂÏÔÚÈÛÌfi, ÙÒÛË ‚ÏÂÊ·ÚÈÎÒÓ Û¯ÈÛÌÒÓ, ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË ÙÚȯÒÓ ÛÙÔ Ì¤ÙˆÔ Î·È ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ù˘ ÎÂÊ·Ï‹˜, ıÔψً ˘ÂÚÒ·, ÌÈÎÚÔÁÓ·ı›·, ÏÂÙfi ¿Óˆ ¯Â›ÏÔ˜, ·ÓÒÌ·ÏË ¤ÎÊ˘ÛË Ô‰fiÓÙˆÓ, Ì·ÎÚÔÁψÛÛ›· Î·È ‰Èۯȉ‹ ÛÙ·Ê˘Ï‹. ∏ Ì·ÎÚÔÁψÛÛ›· Û˘¯Ó¿ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ηٿÔÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜. ™Ù· ‚Ú¤ÊË ·Ú·ÙËÚÂ›Ù·È ÌÂÁ¿ÏË ÚfiÛıÈ· ËÁ‹ Î·È Î·ı˘ÛÙ¤ÚËÛË Û‡ÁÎÏÂÈÛ˘ ·˘Ù‹˜. ™˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó ·ÓˆÌ·Ï›Â˜ ÒÙˆÓ Ì ‰˘ÛÏ·ÛÙÈο ÙÂÚ‡ÁÈ· ‹ ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË (4,5). ∞fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ Û˘¯Ó¿ ·Ó¢ڛÛÎÔÓÙ·È ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, Ì˘ˆ›·, ·ÛÙÈÁÌ·ÙÈÛÌfi˜, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ¯ÈÙÒÓ·, ÁÏ·‡ÎˆÌ·, ηٷÚÚ¿ÎÙ˘, ÎÔÏfi‚ˆÌ· Ù˘ ›Úȉ·˜, Ó˘ÛÙ·ÁÌfi˜ Î·È ·fiÊÚ·ÍË ÙˆÓ ÚÈÓÔ‰·ÎÚ˘˚ÎÒÓ fiÚˆÓ (4-6). ∞fi ÙÔ Ì˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ· Û˘¯Ó¿ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÎÔÏ›ˆÛË, ·ʈÛË, ·ÓˆÌ·Ï›Â˜ ÛÙ¤ÚÓÔ˘ Î·È ÍÈÊÔÂȉԇ˜ ·fiÊ˘Û˘ Î·È ·ÓˆÌ·Ï›Â˜ ÛÔÓ‰‡ÏˆÓ Î·È Ï¢ÚÈÎÒÓ ÙfiÍˆÓ (4,5). ∆· ¿ÚÚÂÓ· ‚Ú¤ÊË Ì RTS ÂÓ›ÔÙ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â˘Ú‹Ì·Ù· ·fi ÙÔ ÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ·, fiˆ˜ ˘ÔÛ·‰›·, ÎÚ˘„ÔÚ¯›· Î·È ·ÙÂÏ‹ ·Ó¿Ù˘ÍË ÔÛ¯¤Ô˘. ∞fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Î·È Ù· ‰‡Ô ʇϷ Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÏ·ÛÙÈÎÔ‡˜ ÓÂÊÚÔ‡˜, ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ˘‰ÚÔÓ¤ÊÚˆÛË Î·È ÓÂÊÚÔÏÈı›·ÛË Ì ·ÔÙ¤ÏÂÛÌ· ÙȘ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÏÔÈÌÒÍÂȘ (4,5). ∞fi ÙÔ ‰¤ÚÌ· ·Ó¢ڛÛÎÔÓÙ·È ·ÈÌ·ÁÁÂÈÒÌ·Ù·, café au lait ÎËÏ›‰Â˜ Î·È ‰·Û˘ÙÚȯÈÛÌfi˜ (7). ∆Ô 33% ÙˆÓ ·È‰ÈÒÓ Ì RTS ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·. ∏ ·Ú·ÌÔÓ‹ ÙÔ˘ ·ÓÔȯÙÔ‡ ‚ÔÙ¿ÏÏÂÈÔ˘ fiÚÔ˘ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ· Û ·˘Ù¿ Ù· ·È‰È¿. ∞ÎfiÌË, ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó ÛÙ¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ ‹ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ Î·È ‰È·Ù·Ú·¯¤˜ ÌÂÛÔÎÔÏÈÎÔ‡ ‹ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ (8). ∆¤ÏÔ˜, Ù· ·È‰È¿ Ì RTS ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ηÎÔËıÂÈÒÓ (fiˆ˜ fiÁÎÔÈ ÂÁÎÂÊ¿ÏÔ˘, ÚÈÓÔÊ·Ú˘ÁÁÈÎfi Ú·‚‰ÔÌ˘ÔÛ¿ÚΈ̷, Ï¢¯·ÈÌ›· Î.Ï.) Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi (9,10). ∏ ·˘ÍË̤ÓË Â›ÙˆÛË Î·ÚΛÓÔ˘ ıˆÚÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ CREBBP, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë Úˆ¶·È‰È·ÙÚÈ΋ 2006;69:385-389

Ù½ÓË ÌÂÙ·ÁÚ·Ê‹˜ ÙÔ˘ ¤¯ÂÈ ÔÁÎÔηٷÛÙ·ÏÙÈΤ˜ ȉÈfiÙËÙ˜ Î·È ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·fiÙˆÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ (9,10). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ RTS ÛÙËÚ›˙ÂÙ·È ÛÙÔÓ ·Ó·ÁÓˆÚ›ÛÈÌÔ Ê·ÈÓfiÙ˘Ô, fiˆ˜ ·˘Ùfi˜ ÂÚÈÁÚ¿ÊËΠ·Ú·¿Óˆ. √ ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ ʤÚÂÈ Ù· ·ÚÈ· - ÛÂ Û˘¯ÓfiÙËÙ· - ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, Ù· ÔÔ›· Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È Î·ı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘, ¢ڤ· ‰¿¯Ù˘Ï· Ô‰ÒÓ, ¢Ú›˜ ·ÓÙ›¯ÂÈÚ˜ Î·È Â˘Ú¤· ¿ÏÏ· ‰¿¯Ù˘Ï· ¿ÎÚˆÓ ¯ÂÈÚÒÓ, ÌÈÎÚÔÎÂÊ·Ï›·, ˘ÔÏ·ÛÙÈ΋ ÁÓ¿ıÔ˜ Ì ıÔψً ˘ÂÚÒ·, Ú·ÌÊÔÂȉ‹˜ ̇ÙË, ÁÏ·‡ÎˆÌ· Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ¯ÈÙÒÓ·, ÎÚ˘„ÔÚ¯›·. ªÂ ‚¿ÛË Ù· Ê·ÈÓÔÙ˘Èο ¯·Ú·ÎÙËÚÈÛÙÈο, ÛÙË ‰È·ÊÔÚÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ fiˆ˜ Ù· Û‡Ó‰ÚÔÌ· Aarskog, Greig Î·È Larsen. ∫Ú›ÓÂÙ·È ··Ú·›ÙËÙÔ˜ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ó›¯Ó¢ÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı›, ÒÛÙ ӷ ηٷÛÙ› ‰˘Ó·Ù‹ Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ∞Ó¿ÏÔÁ· Ì ٷ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Î·È Û˘ÌÙÒÌ·Ù·, ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÔÛÙÒÓ, ∏∂°, CT Î·È MRI ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È ·ÎÔÔÏÔÁÈÎfi˜, ÔÊı·ÏÌÔÏÔÁÈÎfi˜, ÓÂÊÚÔÏÔÁÈÎfi˜ Î·È Î·Ú‰ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜. °È· ÙÔÓ ·ÔÎÏÂÈÛÌfi ¯ÚˆÌÔÛˆÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ, Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î·Ú˘fiÙ˘Ô˜ (11). ∏ ÚfiÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È Î·Ï‹. √È ·Ó·Ó¢ÛÙÈΤ˜ ÏÔÈÌÒÍÂȘ Î·È ÔÈ ÂÈÏÔΤ˜ Ù˘ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜ Â›Ó·È ÔÈ Î˘ÚÈfiÙÂÚ˜ ·Èٛ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ∂›Û˘, ¯ÚÂÈ¿˙ÂÙ·È Â·ÁÚ‡ÓËÛË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·ÎÔËıÂÈÒÓ (10,11). ∂Âȉ‹ ÔÚÈṲ̂ӷ ¿ÙÔÌ· Ì RTS ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÈÏÔΤ˜ (·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· Î·È Î·Ú‰È·Î¤˜ ·ÚÚ˘ı̛˜) ηٿ ÙË ¯ÔÚ‹ÁËÛË Î¿ÔÈˆÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ (succinlycholine) Î·È ·Ó·ÈÛıËÙÈÎÒÓ Ê·Ú̿ΈÓ, ¯ÚÂÈ¿˙ÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ηٿ ÙË ¯Ú‹ÛË ÙÔ˘˜ (11,12). ∏ ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·È‰ÈÒÓ Ì RTS Â›Ó·È Û˘Ìو̷ÙÈ΋ Î·È ˘ÔÛÙËÚÈÎÙÈ΋. ∏ ˘ÔÛÙ‹ÚÈÍË ·ÊÔÚ¿ ÙfiÛÔ ÛÙÔ ·È‰› Ì RTS fiÛÔ Î·È ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ô Î›Ó‰˘ÓÔ˜ Â·Ó¿Ï˄˘ RTS ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ·, fiˆ˜ ¤¯ÂÈ Ê·Ó› ·fi ÌÂϤÙ˜, ·Ó¤Ú¯ÂÙ·È Û 0,1%. ∞ÓÙ›ıÂÙ·, ÔÈ ·ÛıÂÓ›˜ Ì RTS - ÂÊfiÛÔÓ Â›Ó·È ÁfiÓÈÌÔÈ - ¤¯Ô˘Ó Èı·ÓfiÙËÙ· 50% Ó· ·ÔÎÙ‹ÛÔ˘Ó ·È‰› Ì RTS, ‰Â‰Ô̤Ó˘ Ù˘ ·˘ÙÔۈ̷ÙÈ΋˜ ÂÈÎÚ·ÙËÙÈ΋˜ ÌÔÚÊ‹˜ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÙÔ˘ RTS (11).

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™‡Ó‰ÚÔÌÔ Rubinstein-Taybi

µÈ‚ÏÈÔÁÚ·Ê›· 1. Rubinstein JH, Taybi H. Broad thumbs and toes and facial abnormalities. A possible mental retardation syndrome. Am J Dis Child 1963;105:588-608.

2. Blough RI, Petrij F, Dauwerse JG, Milatovich-Cherry A, Weiss L, Saal HM et al. Variation in microdeletions of the cyclic AMP-responsive elementbinding protein gene at chromosome band 16p13.3 in the Rubinstein-Taybi syndrome. Am J Med Genet 2000;90:29-34.

3. Petrij F, Dauwerse HG, Blough RI, Giles RH, van der Smagt JJ, Wallerstein R et al. Diagnostic analysis of the Rubinstein-Taybi syndrome: five cosmids should be used for microdeletion detection and low number of protein truncating mutations. J Med Genet 2000;37:168-176.

4. Cantani A, Gagliesi D. Rubinstein-Taybi syndrome.

Review of 732 cases and analysis of the typical traits.

Eur Rev Med Pharmacol Sci 1998;2:81-87.

5. Jones KL. Smith’s recognizable patterns of human malformation. 5th ed. Philadelphia: WB Saunders; 1996.

6. van Genderen MM, Kinds GF, Riemslag FC, Hennekam RC. Ocular features in Rubinstein-Taybi syndrome: investigation of 24 patients and review of the literature. Br J Ophthalmol 2000;84:11771184.

7. Hendrix JD Jr, Greer KE. Rubinstein-Taybi syndrome with multiple flamboyant keloids. Cutis 1996;57:346-348.

8. Stevens CA, Bhakta MG. Cardiac abnormalities in the Rubinstein-Taybi syndrome. Am J Med Genet 1995;59:346-348.

9. Verstegen MJ, van den Munckhof P, Troost D, Bouma GJ. Multiple meningiomas in a patient with Rubinstein-Taybi syndrome. Case report. J Neurosurg 2005;102:167-168.

10. Miller RW, Rubinstein JH. Tumors in RubinsteinTaybi syndrome. Am J Med Genet 1995;56:112-115.

11. Wiley S, Swayne S, Rubinstein JH, Lanphear NE, Stevens CA et al. Rubinstein-Taybi syndrome medical guidelines. Am J Med Genet A 2003;119:101-110.

12. Critchley LA, Gin T, Stuart JC. Anaesthesia in an infant with Rubinstein-Taybi syndrome. Anaesthesia 1995;50:37-38.

¶·È‰È·ÙÚÈ΋ 2006;69:385-389

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CASE REPORT

√ÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ· Û ÓÂÔÁÓfi 1 ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ 2 √ÚıÔ·È‰È΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37 ∆.∫. 713 05, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: aligisak@med.uoc.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-11-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 19-05-2006

∂. ∫ÔڷοÎË1, ª. ∞Ó·ÙÔÏȈٿÎË1, ∞. ∞ÏÈÁÈ˙¿Î˘2, ∞. ª·ÓÔ˘Ú¿1, ∂. ÷Ù˙ˉ¿ÎË1, ∂. ™·˚Ù¿Î˘1, ∂. µÂÏË‚·Û¿Î˘2, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘1

¶ÂÚ›ÏË„Ë ∏ ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ· ·ÔÙÂÏ› ȉȷ›ÙÂÚ· Û¿ÓÈ· ÓfiÛÔ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‰È·ÊÔÚÂÙÈ΋ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ. ªÔÏÔÓfiÙÈ Ì ÙȘ ıÂÚ·¢ÙÈΤ˜ ÚÔfi‰Ô˘˜ Ë ÂÈ‚›ˆÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì Ïԛ̈ÍË ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο, ÂÍ·ÎÔÏÔ˘ı› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ‰˘ÛÌÂÓ›˜ Ì·ÎÚÔ¯ÚfiÓȘ Û˘Ó¤ÂȘ ÁÈ· ÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÓÂÔÁÓfi. ∏ ¤ÁηÈÚË Î·È ÂÈÙ˘¯‹˜ ıÂÚ·›· Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ. ∫·ıÒ˜ Ù· Û˘ÌÙÒÌ·Ù· ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â›Ó·È ÌË ÂȉÈο Î·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÚÓËÙÈÎfi˜, Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË Î·È ··ÈÙ› ˘„ËÏfi ‰Â›ÎÙË ˘Ô„›·˜ Î·È ÏÂÙÔÌÂÚ‹ ‰ÈÂÚ‡ÓËÛË. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡ Ì ÔÍ›· ÔÏ˘ÂÛÙȷ΋ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ· ÔÊÂÈÏfiÌÂÓË Û ·ÓıÂÎÙÈÎfi ÛÙË ÌÂıÈÎÈÏÏ›ÓË ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ. °›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÛÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Î·È ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜. §¤ÍÂȘ ÎÏÂȉȿ: ¡ÂÔÁÓÈ΋ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, ÛËÙÈ΋ ·ÚıÚ›Ùȉ·, ·ÓıÂÎÙÈÎfi˜ ÛÙË ÌÂıÈÎÈÏÏ›ÓË ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜.

Osteomyelitis and septic arthritis in a neonate 1 Neonatology Clinic, University of Crete, Heraklion, Crete 2 Orthopedic Clinic, University of Crete, Heraklion, Crete Correspondence: Christina Giannakopoulou 37, Atlantidos Str. 713 05, Heraklion, Crete E-mail: aligisak@med.uoc.gr Date of submission: 28-11-2005 Date of approval: 19-05-2006

E. Korakaki1, M. Anatoliotaki1, A. Aligizakis2, A. Manoura1, E. Chatzidaki1, E. Saitakis1, E. Velivasakis2, C. Giannakopoulou1

Abstract: Acute osteomyelitis in the neonatal period although rare, represents a diagnostic and therapeutic challenge. Early diagnosis and therapy are essential for a successful outcome. As the clinical symptoms are vague, a high index of suspicion is necessary and observation of the clinical signs is crucial. The case is presented of a full-term neonate with acute multifocal osteomyelitis and septic arthritis due to methicillin-resistant Staphylococcus aureus. The clinical presentation, aetiology, diagnostic evaluation, treatment and long-term outcome of neonatal osteomyelitis are reviewed.

Key words: Neonatal osteomyelitis, septic arthritis, methicillin-resistant Staphylococcus aureus.

∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ·ÔÙÂÏ› Û¿ÓÈ· ÓfiÛÔ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‰È·ÊÔÚÂÙÈ΋ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ Û ËÏÈΛ· ·È‰ÈÒÓ. ∏ Â›ÙˆÛ‹ Ù˘ Â›Ó·È 1-3 ÂÚÈÙÒÛÂȘ ·Ó¿ 1.000 ÂÈÛ·ÁˆÁ¤˜ ÛÙȘ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (1-3). ∏ ÓfiÛÔ˜ ÛÙ· ÓÂÔÁÓ¿ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÈÌ·ÙÔÁÂÓ‹˜, Ì ·ÚÈÔ ·ıÔÁfiÓÔ ·›ÙÈÔ ÙÔÓ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ (1,4). ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, Ë ·˘Í·ÓfiÌÂÓË ÂÌÊ¿ÓÈÛË ÛÙËÓ ÎÔÈÓfiÙËÙ· ·ÓıÂÎÙÈÎÔ‡ ÛÙË ÌÂıÈÎÈÏÏ›ÓË ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ (methicillin-resistant Staphylococcus ¶·È‰È·ÙÚÈ΋ 2006;69:390-394

aureus - MRSA) ηıÈÛÙ¿ ‰˘Û¯ÂÚ¤ÛÙÂÚË ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ (5-7). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡, ¯ˆÚ›˜ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÙÔ ÔÔ›Ô ÂÌÊ¿ÓÈÛ ÔÏ˘ÂÛÙȷ΋ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È Û˘ÓÔ‰fi ÛËÙÈ΋ ·ÚıÚ›Ùȉ· ÔÊÂÈÏfiÌÂÓË Û MRSA Î·È Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË ÙˆÓ ÓÂfiÙÂÚˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ‰Â‰Ô̤ӈÓ.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¡ÂÔÁÓfi ¿ÚÚÂÓ, ËÏÈΛ·˜ 28 ËÌÂÚÒÓ, ÂÈÛ‹¯ıË ÛÙË ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÏfiÁˆ „ËÏ·ÊËÙÔ‡

Pediatr Sept_Oct 06

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391

¡ÂÔÁÓÈ΋ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·

ÌÔÚÊÒÌ·ÙÔ˜ ÛÙÔ ·ÚÈÛÙÂÚfi Ï¿ÁÈÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ· Î·È Ôȉ‹Ì·ÙÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘. ∆Ô ÓÂÔÁÓfi ÁÂÓÓ‹ıËΠÙÂÏÂÈfiÌËÓÔ, Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2700 g. ¶¤ÓÙ Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹, ·ÚÔ˘Û›·Û ÌfiÚʈ̷ ÛÙÔ ·ÚÈÛÙÂÚfi Ï¿ÁÈÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ· Ì ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘. ∆Ô ÙÂÏÂ˘Ù·›Ô 24ˆÚÔ ·ÚÔ˘Û›·Û ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È Ô›‰ËÌ· Ù˘ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ∏ ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ‹Ù·Ó 38,3ÔC. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ„ËÏ·ÊËÙfi ÌfiÚʈ̷, ‰È·ÛÙ¿ÛÂˆÓ 2x3 cm, ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÚfiÛıÈ· Ì·Û¯·ÏÈ·›· ÁÚ·ÌÌ‹, ÛÙÔ ‡„Ô˜ ÙˆÓ Î·ÙÒÙÂÚˆÓ Ï¢ÚÒÓ. ∆Ô ÌfiÚʈ̷ ‹Ù·Ó ÛÎÏËÚfi, ·Î›ÓËÙÔ, ¢·›ÛıËÙÔ ÛÙËÓ „ËÏ¿ÊËÛË. ¶·Ú¿ÏÏËÏ·, ‰È·ÈÛÙÒıËΠԛ‰ËÌ·, ÂÚ˘ıÚfiÙËÙ· Î·È ıÂÚÌfiÙËÙ· Ù˘ ·ÚÈÛÙÂÚ‹˜ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘, Ì ÂÚÈÔÚÈÛÌfi Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜. ∞fi ÙËÓ ˘fiÏÔÈË ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 33700/mm3 (¶: 46%, §: 40%, ª: 12%, ƒ: 2%), Hb: 12 g/dl, Ht: 36,3%, PLT: 762000/mm3, ∆∫∂: 82 mm/1Ë ÒÚ·, CRP: 8 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,3 mg/dl, ·Û‚¤ÛÙÈÔ: 10 mg/dl, ʈÛÊfiÚÔ˜: 6,7 mg/dl, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË: 251 IU/L. ∞fi ÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, Ì ·Ϥ˜ ·ÎÙÈÓÔÁڷʛ˜ ‰È·ÈÛÙÒıËÎ·Ó ÔÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ‡„Ô˜ Ù˘ 10˘ ÏÂ˘Ú¿˜ Î·È ÔÛÙÈ΋ ·ÏÏÔ›ˆÛË ÛÙËÓ ¿ˆ ÌËÚÈ·›· ÌÂÙ¿Ê˘ÛË Ì ԛ‰ËÌ· ÙˆÓ ·Ú·Î›ÌÂÓˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, ˘¤ÁÂÚÛË ÙÔ˘ ÂÚÈÔÛÙ¤Ô˘ Î·È ‰È‡ڢÓÛË ÙÔ˘ ·ÚıÚÈÎÔ‡ ‰È·ÛÙ‹Ì·ÙÔ˜ (∂ÈÎfiÓ· 1). √ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ԛ‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Ì ‰È·Ù·Ú·¯‹ Ù˘ ·Ú˘Ê‹˜ Ù˘ ıˆÚ·ÎÈ΋˜ ÏÂ˘Ú¿˜ Î·È Ô›‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Á‡Úˆ ·fi ÙË ÌÂÙ¿Ê˘ÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÌËÚÈ·›Ô˘, ÌÂ Û˘ÓÔ‰fi ‰È·Ù·Ú·¯‹ Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ÊÏÔÈÔ‡ Î·È Ù˘ ·Ú˘Ê‹˜ Ù˘ ·˘ÍËÙÈ΋˜ Ͽη˜. ªÂ ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ Î·È ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ·, Ì ÙËÓ ˘Ô„›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÌÂ Û˘ÓÔ‰fi ÛËÙÈ΋ ·ÚıÚ›Ùȉ·, ¤ÁÈÓ ·ÎÈÓËÙÔÔ›ËÛË Ù˘ ÚÔۂ‚ÏË̤Ó˘ ¿ÚıÚˆÛ˘ Î·È ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ Ì ‚·ÓÎÔÌ˘Î›ÓË Î·È ÁÂÓÙ·Ì˘Î›ÓË. √ ÂÈÚfiÛıÂÙÔ˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÌËÚÔ‡ ¤‰ÂÈÍ ÂÈÎfiÓ· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙËÓ ¿ˆ ÌÂÙ¿Ê˘ÛË ·ÚÈÛÙÂÚÔ‡ ÌËÚÈ·›Ô˘ ÔÛÙÔ‡, Ì ˘ÔÂÚÈÔÛÙÈÎfi ÊϤÁÌÔÓ·, ‰È¿Û·ÛË ÙÔ˘ ÂÚÈÔÛÙ¤Ô˘ Î·È Û¯ËÌ·ÙÈÛÌfi ÂÓ‰ÔÌ˘˚ÎÔ‡ Î·È ¤ÚÈÍ ÙÔ˘ ÔÛÙÔ‡

∂ÈÎfiÓ· 1. ¶ÚÔÛıÈÔ›ÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ·ÚÈÛÙÂÚÔ‡ ÁfiÓ·ÙÔ˜. √ÛÙÈ΋ ‚Ï¿‚Ë ÛÙËÓ ¿ˆ ÌËÚÈ·›· ÌÂÙ¿Ê˘ÛË Î·È ÂÚÈÔÛÙÈ΋ ·ÓÙ›‰Ú·ÛË Î·Ù¿ Ì‹ÎÔ˜ Ù˘ ÌÂÙ¿Ê˘Û˘ ÙÔ˘ ÌËÚÈ·›Ô˘ ÔÛÙÔ‡.

ÊϤÁÌÔÓ· Î·È ·ÔÛÙ‹Ì·ÙÔ˜. À‹Ú¯Â ÌÈÎÚ‹ Û˘ÌÌÂÙÔ¯‹ Ù˘ ·Ú·Î›ÌÂÓ˘ Â›Ê˘Û˘ (∂ÈÎfiÓ· 2). ∆Ô ÓÂÔÁÓfi ˘Ô‚Ï‹ıËΠ۠¯ÂÈÚÔ˘ÚÁÈ΋ ·ÚÔ¯¤Ù¢ÛË Ù˘ ÚÔۂ‚ÏË̤Ó˘ ¿ÚıÚˆÛ˘ ÙÔ

∂ÈÎfiÓ· 2. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆2 ÛÙÂÊ·ÓÈ·›· ÙÔÌ‹. ¶·ıÔÏÔÁÈÎfi Ì·ÁÓËÙÈÎfi Û‹Ì· ÛÙËÓ ¿ˆ ÌËÚÈ·›· ÌÂÙ¿Ê˘ÛË Ì ·Ú·ÔÛÙÈÎfi ·fiÛÙËÌ·. ¶·È‰È·ÙÚÈ΋ 2006;69:390-394

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K. ∆·Ì¿ÎË Î·È Û˘Ó.

3Ô 24ˆÚÔ ÓÔÛËÏ›·˜. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÂȂ‚·›ˆÛ ÙË ‰È¿ÁÓˆÛË. ∞fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ ·ÔÌÔÓÒıËΠMRSA. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ‹Ù·Ó ÔÌ·Ï‹ Î·È Ë ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁ‹ıËΠÁÈ· 6 ‚‰ÔÌ¿‰Â˜, Ì ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Ê·Ú̿ΈÓ. ∞fi ÙÔÓ ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÛËÌ›· ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Û¯ÂÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜. √ ·ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ™Â ËÏÈΛ· 6 ÌËÓÒÓ, Ë ·/· ·ÚÈÛÙÂÚÔ‡ ÌËÚÈ·›Ô˘ ¤‰ÂÈÍ ‰ËÌÈÔ˘ÚÁ›· Ó¤Ô˘ ÔÛÙÔ‡ ˘ÔÂÚÈÔÛÙÈο, ÌÂÚÈ΋ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÊÏÔÈÔ‡ Î·È ·Ú·ÌÔÓ‹ ÔÛÙÈÎÔ‡ ÂÏÏ›ÌÌ·ÙÔ˜ ÛÙË ÌÂÙ¿Ê˘ÛË. ∆Ô ·È‰›, Û ËÏÈΛ· 2 ÂÙÒÓ, ·ÚÔ˘ÛÈ¿˙ÂÈ 3 cm ‚Ú¿¯˘ÓÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ οو ¿ÎÚÔ˘, ‰˘Ûη̄›· Î·È ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· Ù˘ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘.

™˘˙‹ÙËÛË ∏ ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, ·Ú¿ ÙÔ fiÙÈ Â›Ó·È Û¿ÓÈ· ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ‰È·ÁÓˆÛÙÈÎfi Î·È ıÂÚ·¢ÙÈÎfi Úfi‚ÏËÌ·, ηıÒ˜ ÌÔÚ› Ó· Û˘Ó‰¤ÂÙ·È Ì ÛÔ‚·Ú¤˜ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜. ∏ ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË Î·È ··ÈÙ› ˘„ËÏfi ‰Â›ÎÙË ˘Ô„›·˜, ηıÒ˜ Ù· Û˘ÌÙÒÌ·Ù· ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â›Ó·È ÌË ÂȉÈο Î·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÚÓËÙÈÎfi˜ (1-3). ¶ÔÏ˘ÂÛÙȷ΋ ÂÓÙfiÈÛË ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 22-47% ÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ Ë ·ÓÙ›ÛÙÔÈ¯Ë Û˘¯ÓfiÙËÙ· ÛÙ· ·È‰È¿ Â›Ó·È 10% (2). ∏ ÛËÙÈ΋ ·ÚıÚ›Ùȉ· ·ÔÙÂÏ› Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ ÓÂÔÁÓÈ΋˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜, ÏfiÁˆ Ù˘ ·ÁÁ›ˆÛ˘ ÙˆÓ ÔÛÙÒÓ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (1-3,8). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ ÛÙ· ÓÂÔÁÓ¿ ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ‚Ú¤ÊË Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ™˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Ì ‹È·, ÌË ÂȉÈο Û˘ÌÙÒÌ·Ù·, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ·Ó·˙‹ÙËÛ˘ È·ÙÚÈ΋˜ ‚Ô‹ıÂÈ·˜, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È. ∏ ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ Î˘Ì·›ÓÂÙ·È ·fi 2 ¤ˆ˜ 4 ‚‰ÔÌ¿‰Â˜ (2). ∆· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘Ó‹ıˆ˜ ¤ÓÙÔÓÔ ÎÏ¿Ì· Î·È - Ì ÙËÓ ÚfiÔ‰Ô Ù˘ ÓfiÛÔ˘ - ÂÚÈÔÚÈÛÌfi Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Ù˘ ÚÔۂ‚ÏË̤Ó˘ ¿ÚıÚˆÛ˘ (1,9,10). ¶˘ÚÂÙfi˜ ·Ó·Ê¤ÚÂÙ·È Û¿ÓÈ·, ÂÓÒ Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î˘Ú›ˆ˜ ÚfiˆÚ· ÓÂÔÁÓ¿ ‹ ÓÔÛËÏ¢fiÌÂÓ· Û ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ (1,2,9,10). ¶·È‰È·ÙÚÈ΋ 2006;69:390-394

√È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÂΛÓÔ˘˜ Ù˘ ‚·ÎÙËÚÈ·ÈÌ›·˜, ÌÂ Û˘¯ÓfiÙÂÚÔ ÙËÓ ‡·ÚÍË ÂÓ‰Ô·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ, ΢ڛˆ˜ ÔÌÊ·ÏÈÎÔ‡. ÕÏÏÔÈ ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ÚÔˆÚfiÙËÙ·, ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Î·È ‡·ÚÍË ÎÂÊ·Ï·ÈÌ·ÙÒÌ·ÙÔ˜ (1,2,9,10). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ¯ˆÚ›˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ‰ÂÓ Â›Ó·È ·ÎÚÈ‚Ò˜ ÁÓˆÛÙ‹. ™‡Ìʈӷ Ì ÙË ÌÂϤÙË ÙˆÓ Mok Î·È Û˘Ó, ÙÔ 68% ÙˆÓ ÓÂÔÁÓÒÓ Ì ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Â›Ó·È ÙÂÏÂÈfiÌËÓ·, ÂÓÒ Û‡Ìʈӷ Ì ¿ÏÏË ÌÂϤÙË, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ fiˆ˜ ÂÈÏÔΤ˜ ηٿ ÙËÓ Î‡ËÛË ‹ ÙÔÓ ÙÔÎÂÙfi ·Ó·Ê¤ÚÔÓÙ·È Û 30-50% ÙˆÓ ÓÂÔÁÓÒÓ Ì ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· (1). ∫‡ÚÈÔÈ ˘‡ı˘ÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Â›Ó·È ÔÈ Gram ıÂÙÈÎÔ› ÎfiÎÎÔÈ, ÌÂ Û˘¯ÓfiÙÂÚÔ ÙÔÓ Staphylococcus aureus Î·È Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ¢ı‡ÓÔÓÙ·È Ô group µ ÛÙÚÂÙfiÎÔÎÎÔ˜ Î·È Gram ·ÚÓËÙÈο ‚·ÎÙ‹ÚÈ·, fiˆ˜ Escherichia coli, Salmonella Î·È Klebsiella (1,2,8,9,11). √ ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ È‰È·›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ‰˘Û¯ÂÚ·›ÓÔ˘Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢ Î·È Î·ıÈÛÙÔ‡Ó ··Ú·›ÙËÙË ÙË ¯ÔÚ‹ÁËÛË Ì·ÎÚÔ¯ÚfiÓÈˆÓ ıÂÚ·¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ. ªÔÚ› Ó· ÂÈ‚ÈÒÛÂÈ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ηÈ, Â›Û˘, ÌÔÚ› Ó· ÚÔÛÎÔÏÏËı› ÛÙÔ ÔÛÙfi ÂÎÊÚ¿˙ÔÓÙ·˜ ˘ԉԯ›˜ ÁÈ· Û˘ÛÙ·ÙÈο Ù˘ ÌÂÛÔ΢ÙÙ¿ÚÈ·˜ Ô˘Û›·˜, ·Ó·Ù‡ÛÛÔÓÙ·˜ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›· (1,8,9). ∂ȉÈÎfiÙÂÚ·, Ô MRSA ·ÔÙÂÏ› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÔ‚·Úfi ıÂÚ·¢ÙÈÎfi Úfi‚ÏËÌ·, ηıÒ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÓÙÔ¯‹ Û fiϘ ÙȘ ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ‚-Ï·Îٿ̘ Î·È Â˘ı‡ÓÂÙ·È ÁÈ· Â›ÌÔÓ˜ Î·È ‰‡ÛÎÔÏ· ·ÓÙÈÌÂÙˆ›ÛÈ̘ ÏÔÈÌÒÍÂȘ. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, Ô MRSA ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙËÓ ÎÔÈÓfiÙËÙ· ·ıÔÁfiÓÔ ·Ú¿ÁÔÓÙ·, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ÚÔËÁÔ˘Ì¤Óˆ˜ ˘ÁÈ‹ ·È‰È¿, ¯ˆÚ›˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (5,6). ™Ù· ÓÂÔÁÓ¿ ÚÔηÏ› Û˘Ó‹ıˆ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Î·È Û·ÓÈfiÙÂÚ· ÏÔÈÌÒÍÂȘ ÙˆÓ ÔÛÙÒÓ ‹ ÙˆÓ ·ÚıÚÒÛÂˆÓ (12). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ë ÌË ‡·ÚÍË ÂÌÊ·ÓÔ‡˜ ÙÔÈÎÔ‡ ÙÚ·‡Ì·ÙÔ˜, Ë ÔÏ˘ÂÛÙȷ΋ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘, ηıÒ˜ Î·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ›‰ÈÔ˘ ·ıÔÁfiÓÔ˘, Ì ÙȘ ›‰È˜ ¢·ÈÛıËۛ˜ ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È ˘ÏÈÎÔ‡ ·fi ÙËÓ ¿Û¯Ô˘Û· ¿ÚıÚˆÛË, ηıÈÛÙ¿ ÙËÓ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Èı·ÓÒ˜ ˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· ·ÈÌ·ÙÔÁÂÓÔ‡˜ ‰È·ÛÔÚ¿˜ ÏfiÁˆ MRSA ÌÈÎÚÔ‚È·ÈÌ›·˜.

Pediatr Sept_Oct 06

26-09-06

12:54

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∏ ‰È¿ÁÓˆÛË Ù˘ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙ· ÓÂÔÁÓ¿ ÛÙËÚ›˙ÂÙ·È ÛÙË ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ÙÔ˘ ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜, ÛÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Î·È ÛÙ· ÎÏÈÓÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· ÂÓ‰ÂÈÎÙÈο Ù˘ ÓfiÛÔ˘. ∏ ÏÂÙÔÌÂÚ‹˜ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋. ŸÙ·Ó ÂÍÂÙ¿˙ÂÙ·È ¤Ó· ÓÂÔÁÓfi Ì ÌË ÂȉÈο Û˘ÌÙÒÌ·Ù· ‚·ÎÙËÚÈ·ÈÌ›·˜, ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Î·È ÁÈ· Èı·Ó‹ ÔÛÙÈ΋ Û˘ÌÌÂÙÔ¯‹. ∏ ·ÚÔ˘Û›· Ôȉ‹Ì·ÙÔ˜ Î·È Ë „¢‰Ô¿ÚÂÛË ·ÔÙÂÏÔ‡Ó Ù· ÈÔ ÛËÌ·ÓÙÈο ‰È·ÁÓˆÛÙÈο ÛËÌ›·. √ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË. øÛÙfiÛÔ, ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ ÔÈ ·Ϥ˜ ·ÎÙÈÓÔÁڷʛ˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â˘Ú‹Ì·Ù·. √È ÚÒÙ˜ ·ÎÙÈÓÔÏÔÁÈΤ˜ ÂӉ›ÍÂȘ Ù˘ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ô›‰ËÌ· ÙˆÓ ÂÓ Ùˆ ‚¿ıÂÈ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÁÂÈÙÔÓÈο ÛÙÔ ÚÔۂ‚ÏË̤ÓÔ ÔÛÙfi. √ÛÙÈ΋ ηٷÛÙÚÔÊ‹ ·Ó·ÁÓˆÚ›˙ÂÙ·È 7-14 Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (1-3,9). ∏ ·Í›· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ÙˆÓ ÔÛÙÒÓ ·ÌÊÈÛ‚ËÙÂ›Ù·È ÛÙ· ÓÂÔÁÓ¿, ηıÒ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘„ËÏfi ÔÛÔÛÙfi „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ÙÔ ÔÔ›Ô ·Ô‰›‰ÂÙ·È ‚È‚ÏÈÔÁÚ·ÊÈο ÛÙËÓ Ôχ ÂÓÂÚÁfi Â›Ê˘ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ô˘ ÚÔÛÏ·Ì‚¿ÓÂÈ ˘„ËÏ‹ ÔÛfiÙËÙ· Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘, ‰˘Û¯ÂÚ·›ÓÔÓÙ·˜ ÙËÓ ·Ó›¯Ó¢ÛË ·˘ÍË̤Ó˘ ÚfiÛÏ˄˘ ·fi ÙËÓ ÌÂÙ¿Ê˘ÛË, ηıÒ˜ Î·È ÛÙË ÌÂȈ̤ÓË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙË Ïԛ̈ÍË Ù· ÓÂÔÁÓ¿ (1,3). ¶ÏÂÔÓ¤ÎÙËÌ· ÙÔ˘ ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂϤÁ¯ÂÈ ÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÛÎÂÏÂÙÔ‡, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ·Û·Ê‹˜ ‹ ÔÏ˘ÂÛÙȷ΋ (1,2,9). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ ¤¯ÂÈ ÚÔÛÙÂı› Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Ô˘ ·ÔÙÂÏ› ·Ï‹ Î·È Â‡¯ÚËÛÙË Ì¤ıÔ‰Ô, fï˜ ÔÈ ·Ó·ÊÔÚ¤˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ¯Ú‹ÛË ÙÔ˘ ÛÙ· ÓÂÔÁÓ¿ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ (3,13). ∏ ·ÍÔÓÈ΋ Î·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÚÔÛʤÚÔ˘Ó ÔχÙÈÌË ‚Ô‹ıÂÈ·, ÙfiÛÔ ÛÙËÓ ·Ó›¯Ó¢ÛË ÚÒÈÌˆÓ ÛËÌ›ˆÓ Ù˘ ÓfiÛÔ˘ fiÛÔ Î·È ÛÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·ÔÙÂÏ› ÙËÓ ÈÔ Â˘·›ÛıËÙË Ì¤ıÔ‰Ô ÁÈ· ÙËÓ ÚÒÈÌË ·Ó›¯Ó¢ÛË Ôȉ‹Ì·ÙÔ˜ ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Î·È ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ηıÒ˜ Î·È ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÚÔ˘Û›·˜ Û˘ÏÏÔÁ‹˜ Î·È ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¤ÎÙ·Û˘ Ù˘ ‚Ï¿‚˘ (1,9). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ô ·Ú¯ÈÎfi˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ Ì ·ÎÙÈÓÔÁÚ·Ê›· Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙˆÓ ıˆÚ·ÎÈÎÒÓ Ï¢ÚÒÓ Î·È ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÌËÚÔ‡, ÂÚÈÔ¯¤˜ Ì ÛËÌ›· ÊÏÂÁÌÔÓ‹˜ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ηÈ

‹Ù·Ó ÂÓ‰ÂÈÎÙÈÎfi˜ Ù˘ ÓfiÛÔ˘ ÏfiÁˆ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÚÔÛ¤Ï¢Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡. ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ ‰ÂÓ ¤ÁÈÓ ÏfiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ∂ÈϤÔÓ, ¤ÁÈÓ ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› ÚÔÂÁ¯ÂÈÚËÙÈο Ë ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ÌËÚfi. ∏ ıÂÚ·›· Ù˘ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙ· ÓÂÔÁÓ¿ Â›Ó·È ÂÓ‰ÔÊϤ‚È·, ÂÓÒ ÂÍ·ÙÔÌÈ·ÂÙ·È ÙÔ Â›‰Ô˜ Î·È Ë ‰È¿ÚÎÂÈ·, Ë ÔÔ›· Î˘Ì·›ÓÂÙ·È ·fi 3 ¤ˆ˜ 6 ‹ ÂÚÈÛÛfiÙÂÚ˜ ‚‰ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ÔÛÙÈ΋˜ ‚Ï¿‚˘, ÙËÓ ‡·ÚÍË ·ÔÛÙ‹Ì·ÙÔ˜ Î·È ÙËÓ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹ (1). ŸÙ·Ó ˘¿Ú¯ÂÈ ˘Ô„›· ‹ ÙÂÎÌËÚȈ̤ÓË Ïԛ̈ÍË ·fi MRSA, Û˘ÓÈÛÙ¿Ù·È Ô Û˘Ó‰˘·ÛÌfi˜ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ‚·ÓÎÔÌ˘Î›ÓË. ¶ÔÏ˘ÂÛÙȷΤ˜ ÌÔÚʤ˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ·fi MRSA, Ô ÔÔ›Ô˜ Û¯ÂÙ›˙ÂÙ·È Ì Â›ÌÔÓ˜ Î·È ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ, ··ÈÙÔ‡Ó ·Ú·ÙÂٷ̤ÓË ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹. ÃÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÔÚ› Ó· ··ÈÙËı› ÛÙȘ ÂÚÈÙÒÛÂȘ Ì ·ÓÂ·Ú΋ ÎÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË, ηıÒ˜ Î·È Û ÂÚÈÙÒÛÂȘ ˘Ò‰Ô˘˜ Û˘ÏÏÔÁ‹˜ ˘ÔÂÚÈÔÛÙÈο ‹ ÛÙËÓ ¿ÚıÚˆÛË (1,2,9). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË Ù˘ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙ· ÓÂÔÁÓ¿, Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ηıÔÚÈÛÙ› ηıÒ˜ ÂÍ·ÚÙ¿Ù·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÍÈfiÈÛÙ· ÎÚÈÙ‹ÚÈ·. ∫·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ Â›Ó·È Ô ¯ÚfiÓÔ˜ ¤Ó·Ú͢ Ù˘ ıÂÚ·›·˜ Î·È Ë ‰È¿ÚÎÂÈ¿ Ù˘ (1,14). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÓÂÔÁÓÈ΋ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ·ÔÙÂÏ› Û¿ÓÈ· ·ÏÏ¿ ÛÔ‚·Ú‹ ¿ıËÛË Î·È Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÛÙȘ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Ì ÙÔÈο ÛËÌ›· ÊÏÂÁÌÔÓ‹˜ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, ηıÒ˜ Î·È Û ÂΛӷ Ì ÌË ÂȉÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· ‚·ÎÙËÚÈ·ÈÌ›·˜. ∆· Â˘Ú‹Ì·Ù· ·fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË.

µÈ‚ÏÈÔÁÚ·Ê›· 1. McPherson DM. Osteomyelitis in the neonate.

Neonatal Netw 2002;21:9-22.

2. Asmar BI. Osteomyelitis in the neonate. Infect Dis Clin North Am 1992;6:117-132.

3. Frederiksen B, Christiansen P, Knudsen FU. Acute osteomyelitis and septic arthritis in the neonate, risk factors and outcome. Eur J Pediatr 1993;152:577-580.

4. Cooperman DR, Thompson GH. Bone and joint infections. In: Fanaroff AA, Martin RJ, editors.

Neonatal and Perinatal Medicine: Diseases of the fetus and Infant. 6th ed. St. Louis: Mosby-Year Book; 1997. p. 1716-1721. ¶·È‰È·ÙÚÈ΋ 2006;69:390-394

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6. Healy CM, Hulten KG, Palazzi DL, Campbell JR, Baker CJ. Emergence of new strains of methicillinresistant Staphylococcus aureus in a neonatal intensive care unit. Clin Infect Dis 2004;39:1460-1466.

7. Stott NS. Paediatric bone and joint infection. J Orthop Surg 2001;9:83-90.

8. Knudsen CJ, Hoffman EB. Neonatal osteomyelitis. J Bone Joint Surg Br 1990;72:846-851.

9. Overturf GD, Marcy SM. Bacterial infections of the bones and joints. In: Remington JS, Klein JO, editors. Infectious diseases of the fetus and newborn infant. 5th ed. Philadelphia: W.B. Saunders Co; 2001. p. 1019-1034.

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10. Mok PM, Reilly BJ, Ash JM. Osteomyelitis in the neonate. Clinical aspects and the role of radiography and scintigraphy in diagnosis and management. Radiology 1982;145:677-682.

11. Bergdahl S, Ekengren K, Eriksson M. Neonatal hematogenous osteomyelitis: risk factors for longterm sequelae. J Pediatr Orthop 1985;5:564-568.

12. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus - an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003;16:103-124.

13. Vazquez M. Osteomyelitis in children. Curr Opin Pediatr 2002;14:112-115.

14. Peters W, Irving J, Letts M. Long-term effects of neonatal bone and joint infection on adjacent growth plates. J Pediatr Orthop 1992;12:806-810.

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∏ ·ÍÈÔÈÛÙ›· ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô °. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜

¶ÂÚ›ÏË„Ë: √È ‰˘ÛÎÔϛ˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢, ¤¯Ô˘Ó Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË ‰È·ÊfiÚˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÂÍÂÙ¿ÛˆÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ (CRP), ÂÓfi˜ Ôχ Û˘¯Ó¿ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ˘ ‰Â›ÎÙË, ηıÒ˜ Î·È ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (΢ڛˆ˜ ÈÓÙÂÚÏ¢ΛÓË-6 Î·È ÈÓÙÂÚÏ¢ΛÓË-8), ÌfiÓˆÓ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË CRP. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ·Ó·˙‹ÙËÛË ‰È·ÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ ¤¯ÂÈ ÛÙÚ·Ê› ÛÙËÓ ÚÔηÏÛÈÙÔÓ›ÓË (PCT), ¤Ó· ÚÔÂÙ›‰ÈÔ Ù˘ ηÏÛÈÙÔÓ›Ó˘, Ô˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È ¤Ó·˜ ˘ÔÛ¯fiÌÂÓÔ˜ ‰Â›ÎÙ˘ ÊÏÂÁÌÔÓ‹˜ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. ∂ȉÈο ·ÓÙÈÁfiÓ· ÂÈÊ·Ó›·˜ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, ΢ڛˆ˜ Ô CD11b Î·È Ô CD64, ¤¯Ô˘Ó ÂÏ·ÛÂÈ ÙËÓ ÚÔÛÔ¯‹ ÙˆÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÙËÓ Èı·Ó‹ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘˜ ÛÙË Ïԛ̈ÍË, ηıÒ˜ Ë ÚÔfi‰Ô˜ ÛÙË Ù¯ÓÈ΋ Ù˘ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜ Â¤ÙÚ„ ÙËÓ Â‡ÎÔÏË ·Ó›¯ÓÂ˘Û‹ ÙÔ˘˜ Î·È Ô‰‹ÁËÛ ÛÙË ‰È·›ÛÙˆÛË fiÙÈ Ë ¤ÎÊÚ·Û‹ ÙÔ˘˜ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο ÌÂÙ¿ ·fi ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ·fi ‚·ÎÙ‹ÚÈ· ‹ ÚÔ˚fiÓÙ· ·˘ÙÒÓ. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÔÈ ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙË ‰È·ÁÓˆÛÙÈ΋ ·fi‰ÔÛ‹ ÙÔ˘˜, ÂÓÒ Ë Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÙÔ˘˜ ·˘Í¿ÓÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ ·ÎÚ›‚ÂÈ¿ ÙÔ˘˜ ÛÙËÓ ÚÒÈÌË ·Ó›¯Ó¢ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì Ïԛ̈ÍË. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ÂÍÂÙ¿ÛÂÈ ÙÔÓ ÚfiÏÔ ·˘ÙÒÓ ÙˆÓ ÚfiÛÊ·Ù· ‰È·ı¤ÛÈÌˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ‰ÂÈÎÙÒÓ Î·È Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ ÙËÓ ÈÛ¯‡ Î·È ÙËÓ ·ÍÈÔÈÛÙ›· ÙÔ˘˜ ÛÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘.

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ¢ËÌ‹ÙÚÈÔ˜ ∫·ÊÂÙ˙‹˜ µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ & §ÂÈ‚·‰Â›·˜, ∆.∫. 115 27, °Ô˘‰›, ∞ı‹Ó· ∂-mail: kafetzis@ath.forthnet.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-06-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-06-2006

§¤ÍÂȘ ÎÏÂȉȿ: ¡ÂÔÁÓÈ΋ Ïԛ̈ÍË, ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË, ΢ÙÙ·ÚÔΛÓ˜, ÚÔηÏÛÈÙÔÓ›ÓË, ·ÓÙÈÁfiÓ· ÂÈÊ·Ó›·˜ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ-΢ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜.

The accuracy of immunological markers in the diagnosis of infection during the neonatal period G.S. Tigani, D.A. Kafetzis

Abstract: The diagnosis of early onset neonatal infection presents a clinical dilemma that has led to the use of several inflammation markers, including C-reactive protein (CRP), a commonly used marker, and cytokines (mainly interleukin-6 and interleukin-8) either alone or in combination with CRP. In recent years, the search for diagnostic tests has turned to procalcitonin (PCT), a propeptide of calcitonin, which appears to be a promising marker of infection in newborn infants. Specific leukocyte cell surface antigens (mainly CD11b and CD64) have also attracted attention for their possible diagnostic value in infection. Advances in flow cytometric techniques have permitted their easy detection, leading to the observation that the expression of these surface antigens on the cell membrane increases substantially after leukocyte activation by bacteria or their cellular products. Serial measurement of the inflammatory indices has been reported to improve their diagnostic performance, and the combined use of these parameters enhances their accuracy in the early detection of infection in neonates. This review examines the role of these newly available immunological indices and assesses their accuracy as diagnostic markers of infection during the neonatal period.

2nd Paediatric Clinic of the University of Athens, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: D.A. Kafetzis 2nd Paediatric Clinic of the University of Athens “P. & A. Kyriakou” Children’s Hospital Thevon & Livadias Str., 115 27, Goudi, Athens E-mail: kafetzis@ath.forthnet.gr Date of submission: 10-06-2005 Date of approval: 14-06-2006

Key words: Neonatal infection, immunological markers, C-reactive protein, cytokines, procalcitonin, leukocyte cell surface antigens.

¶·È‰È·ÙÚÈ΋ 2006;69:395-404

Pediatr Sept_Oct 06

26-09-06

12:54

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°. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜

™˘ÓÙÔÌÔÁڷʛ˜ CRP IL-6 IL-8 PCT TNF-· ª∂¡¡ ™∞¢

C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË πÓÙÂÚÏ¢ΛÓË-6 πÓÙÂÚÏ¢ΛÓË-8 ¶ÚÔηÏÛÈÙÔÓ›ÓË Tumor necrosis factor · ªÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ ™‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜

∂ÈÛ·ÁˆÁ‹ ∏ Ïԛ̈ÍË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ Î·È È‰È·›ÙÂÚ· Ë ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›·, ·Ú¿ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ Î·È ıÂÚ·¢ÙÈÎÒÓ Ì¤ÛˆÓ, ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ ˘ÔÏÔÁ›˙ÂÙ·È Û 1-8 ·Ó¿ 1000 ÁÂÓÓ‹ÛÂȘ ˙ÒÓÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ ‰È·ÎÚ›ÓÂÙ·È - ·Ó¿ÏÔÁ· Ì ÙÔÓ ¯ÚfiÓÔ ÂΉ‹ÏˆÛ˘ - Û ÚÒÈÌË (0-7 Ë̤Ú˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û˘Ó‹ıˆ˜ ≤72 ÒÚ˜ ˙ˆ‹˜) Î·È fi„ÈÌË (7-28 Ë̤Ú˜ ˙ˆ‹˜, Û˘Ó‹ıˆ˜ ≥72 ÒÚ˜ ˙ˆ‹˜). ∏ ÚÒÈÌË ÔÊ›ÏÂÙ·È Û˘Ó‹ıˆ˜ Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ·ÔÈΛ˙Ô˘Ó ÙÔ ÓÂÔÁÓfi ηٿ ÙÔÓ ÙÔÎÂÙfi (group B Streptococcus, E. coli, Listeria monocytogenes, Klebsiella spp, Herpes simplex virus Î.¿.), ÂÓÒ Ë fi„ÈÌË ÔÊ›ÏÂÙ·È Â›Ù ÛÙÔ˘˜ ›‰ÈÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ÚÔηÏÔ‡Ó ÙËÓ ÚÒÈÌË ÛË„·ÈÌ›· ›Ù Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ÂÓ‰ËÌÔ‡Ó ÛÙȘ ª∂¡¡ (Staphylococcus aureus, S. epidermidis, E. coli, Klebsiella spp, Pseudomonas spp Î.¿.). ∏ ¤ÏÏÂÈ„Ë ÂȉÈÎÒÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ηٿ ÙË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›· Î·È Ë ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ô‰ËÁÔ‡Ó Û˘¯Ó¿ Û ÚÔ‚Ï‹Ì·Ù· ‰È·ÊÔÚÈ΋˜ ‰È¿ÁÓˆÛ˘ ·fi ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÙÔ˘ ÓÂÔÁÓÔ‡, fiˆ˜ Â›Ó·È ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (™∞¢), Ë ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ÙÔ ÔÏÈÁ·ÈÌÈÎfi shock, ÙÔ Û‡Ó‰ÚÔÌÔ ÂÈÛÚfiÊËÛ˘, Ë ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, Ë ˘ÔÁÏ˘Î·ÈÌ›·, Ë ˘·Û‚ÂÛÙÈ·ÈÌ›· Î·È ¿ÏϘ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ¤ÁηÈÚË, Û˘ÓÂÒ˜, ‰È¿ÁÓˆÛË Ù˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ ÂӉȷʤÚÂÈ ¿ÌÂÛ·, ·ÏÏ¿ Î·È ÚÔ‚ÏËÌ·Ù›˙ÂÈ ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi. ∞˘Ùfi ÂÚÈϤÎÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ηÏÏȤÚÁÂÈ·˜ ·›Ì·ÙÔ˜ Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·˘Ù‹ ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·ÌËÏ‹ ¢·ÈÛıËÛ›·. √È ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (¶›Ó·Î·˜ 1) ¤¯Ô˘Ó ÚÔÛʤÚÂÈ ÌÈ· ‰È¤ÍÔ‰Ô, ηıÒ˜ ·Ú¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÂÓÙÔÈÛÌÔ‡ ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ Ì ˘„ËÏ‹ Èı·ÓfiÙËÙ· Ïԛ̈͢. π‰È·›ÙÂÚ· ¯Ú‹ÛÈÌÔÈ ı· ‹Ù·Ó ÂΛÓÔÈ ÔÈ ‰Â›ÎÙ˜ Ô˘ ı· ‰È¤ıÂÙ·Ó ˘„ËÏ‹ ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÙȘ ÚÒÙ˜ ÒÚ˜ ‹ ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

Ë̤Ú˜ ·fi ÙË Á¤ÓÓËÛË, ‹ - ·ÎfiÌË Î·Ï‡ÙÂÚ· ÂΛÓÔÈ Ô˘ ı· ‹Ù·Ó ÈηÓÔ› Ó· ÚԂϤ„Ô˘Ó Î·Ù¿ ÙÔÓ ÙÔÎÂÙfi, ·fi ‰Â›ÁÌ· ·›Ì·ÙÔ˜ ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘, ÙËÓ ÚÒÈÌË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›·. ¶Ú¿ÁÌ·ÙÈ, ·fi ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯Ô˘Ó ·˘Í·ÓfiÌÂÓ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ¤Ó·ÚÍË Ù˘ Ïԛ̈͢ ÌÔÚ› Ó· Û˘Ì‚·›ÓÂÈ ÂÓ‰ÔÌ‹ÙÚÈ· Û ¤Ó·Ó ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ÓÂÔÁÓÒÓ Ì ÚÒÈÌË ÛË„·ÈÌ›·, ÂÓÙÔ‡ÙÔȘ Ë ¯Ú‹ÛË ÙˆÓ ‰ÂÈÎÙÒÓ ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ‰ÂÓ ¤¯ÂÈ ÂÚ¢ÓËı› Â·ÚÎÒ˜.

C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (CRP) ∏ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (CRP) Â›Ó·È Ì›· ÁÓˆÛÙ‹ ÚˆÙ½ÓË ÔÍ›·˜ Ê¿Û˘ Î·È ·Ú·Ì¤ÓÂÈ Û ¢Ú›· ¯Ú‹ÛË, ·Ú¿ ÙȘ Û˘Ó¯È˙fiÌÂÓ˜ ·ÓËÛ˘¯›Â˜ ÁÈ· ÙËÓ ·ÍÈÔÈÛÙ›· Ù˘. ∞˘Í¿ÓÂÙ·È ÛÙÔÓ ÔÚfi ·ÚÔ˘Û›· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜ ‹ ÂÓÂÚÁÔ‡ ÈÛÙÈ΋˜ ‚Ï¿‚˘, ÂÓÒ Ë ÈÓÙÂÚÏ¢ΛÓË-1‚, Ë ÈÓÙÂÚÏ¢ΛÓË-6 Î·È Ô TNF-· Â›Ó·È ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ Û‡ÓıÂÛ‹˜ Ù˘ ÛÙÔ ‹·Ú. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë CRP ‰ÂÓ ÂÈÛ¤Ú¯ÂÙ·È Ì¤Ûˆ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ÛÙËÓ ÂÌ‚Ú˘˚΋ ΢ÎÏÔÊÔÚ›·, ÂÓÙÔ‡ÙÔȘ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Ôχ ÌÈÎÚfi ¶›Ó·Î·˜ 1. ∂ÚÁ·ÛÙËÚÈ·ÎÔ› ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ ∞ÈÌ·ÙÔÏÔÁÈÎÔ› ∞ÚÈıÌfi˜ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, Ô˘‰ÂÙÂÚÔʛψÓ, Ú·‚‰Ô‡ÚËÓˆÓ ™¯¤ÛË ·ÒÚˆÓ ÚÔ˜ ÔÏÈÎfi ·ÚÈıÌfi ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ (π/∆ ratio) ∆·¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (∆∫∂) ™‡ÛÙËÌ· ‹Í˘: ÈÓˆ‰ÔÁfiÓÔ, Ï·ÛÌÈÓÔÁfiÓÔ, ÈÛÙÈÎfi˜ ÂÓÂÚÁÔÔÈËÙ‹˜ Ï·ÛÌÈÓÔÁfiÓÔ˘ (tƒ∞), D-dimers ¶ÚˆÙ½Ó˜ ÔÍ›·˜ Ê¿Û˘ Î·È ¿ÏϘ ÚˆÙ½Ó˜ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (CRP) ¶ÚÔηÏÛÈÙÔÓ›ÓË (PCT) ºÈÌÚÔÓÂÎÙ›ÓË ∞Ì˘ÏÔÂȉ¤˜ ∞ ÙÔ˘ ÔÚÔ‡ ºÂÚÚÈÙ›ÓË ¶ÚˆÙ½Ó˜ ÌÂÙ·ÊÔÚ¿˜: ÛÂÚÔ˘ÏÔÏ·ÛÌ›ÓË, ·ÙÔÛÊ·ÈÚ›ÓË ∞Ó·ÛÙÔÏ›˜ ÚˆÙÂ˚Ó·ÛÒÓ: ·1-·ÓÙÈıÚ˘„›ÓË, ·Ó·ÛÙÔϤ·˜ ·1-ÚˆÙ¿Û˘ ™‡ÛÙËÌ· Û˘ÌÏËÚÒÌ·ÙÔ˜: C3, C4, C9 ∫˘ÙÙ·ÚÔΛÓ˜ Î·È ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ πÓÙÂÚÏ¢ΛÓ˜: IL-1‚, IL-6, IL-8, IL-2, IL-10 Tumor necrosis factor-· πÓÙÂÚÊÂÚfiÓË-Á (IFN-Á) Soluble intracellular adhesion molecule-1 (sICAM-1) Adhesion molecule-1 (VCAM-1) E-selectin, L-selectin ∫˘ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜ √˘‰ÂÙÂÚÔʛψÓ: CD11b, CD64, CD33 §ÂÌÊÔ΢ÙÙ¿ÚˆÓ: CD3, CD19, CD25, CD45RO ªÔÓÔ΢ÙÙ¿ÚˆÓ: HLA-DR

Pediatr Sept_Oct 06

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397

¢Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ

ÔÛÔÛÙfi Ù˘ Èı·ÓÒ˜ ‰È·Û¯›˙ÂÈ ÙÔÓ Ï·ÎÔ˘ÓÙÈ·Îfi ÊÚ·ÁÌfi (1,2). ø˜ ‰Â›ÎÙ˘ ÊÏÂÁÌÔÓ‹˜ ÛÙ· ÓÂÔÁÓ¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ·fi ÙÔÓ ·fiÏ˘ÙÔ ·ÚÈıÌfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Î·È ÙËÓ ·Ó·ÏÔÁ›· ÙˆÓ ¿ˆÚˆÓ ÚÔ˜ ÙÔÓ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (π/∆ ratio) (3). √ ¯ÚfiÓÔ˜ ËÌÈ˙ˆ‹˜ Ù˘ Â›Ó·È Ì¿ÏÏÔÓ Û‡ÓÙÔÌÔ˜ (4) Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Â›Ó·È Èı·Ófi Ì›· ¿ÓÔ‰Ô˜ ÙÔ˘ Ù›ÙÏÔ˘ Ù˘ Ó· ÌËÓ ‰È·ÈÛÙˆı› Â¿Ó Á›ÓÂÈ Ì›· ÌfiÓÔ Ì¤ÙÚËÛË Û ¤Ó·Ó “·Î·Ù¿ÏÏËÏÔ” ¯ÚfiÓÔ, ÂÓÒ ·ÓÙÈı¤Ùˆ˜ ÔÈ ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ Ù˘ ¤¯Ô˘Ó ·Ô‰Âȯı› fiÙÈ ·˘Í¿ÓÔ˘Ó ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ (5,6). ∏ ‰È·ÁÓˆÛÙÈ΋ Ù˘ ·Í›· ÛÙÔ ·Ú¯ÈÎfi ÛÙ¿‰ÈÔ Ù˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ Â›Ó·È ÌÈÎÚ‹ Î·È Ê·›ÓÂÙ·È fiÙÈ Ô ÚfiÏÔ˜ Ù˘ ¤ÁÎÂÈÙ·È ÂÚÈÛÛfiÙÂÚÔ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ‹ ÛÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÓfiÛÔ˘ 24 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ÎÏÈÓÈ΋ ˘Ô„›· Î·È ·ÊÔ‡ ÚÒÙ· ‰È·ÈÛÙˆı› ·‡ÍËÛË ÙÔ˘ ÏfiÁÔ˘ ÙˆÓ ¿ˆÚˆÓ ÚÔ˜ ÙÔÓ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (π/∆ ratio) (7). ¶Ú¿ÁÌ·ÙÈ, Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ CRP ·˘Í¿ÓÂÙ·È Ì ÙÔÓ ¯ÚfiÓÔ Î·È Â›Ó·È Î·Ï‡ÙÂÚË ÌÂٷ͇ 24 Î·È 48 ˆÚÒÓ, ·ÊfiÙÔ˘ ÙÂı› ÎÏÈÓÈο Ë ˘Ô„›· ÓfiÛÔ˘ (5,7). ∆· ·ÓÒÙÂÚ· fiÚÈ· ÁÈ· ÙË CRP ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ ¤¯Ô˘Ó ηıÔÚÈÛÙ› ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ‰ËÌÔÛȇÛÂˆÓ ÛÂ Û˘Ìو̷ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ¯ˆÚ›˜ Ïԛ̈ÍË (2,7,8). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ ˆ˜ ÚÔ˜ ÙȘ ÙÈ̤˜ ·Ó·ÊÔÚ¿˜ (1,5-20 mg/L) ÁÈ· Ù· ·ÓÒÙÂÚ· fiÚÈ¿ Ù˘, ·ÏÏ¿ Î·È ¤Ó· ¢ڇ Ê¿ÛÌ· ÙÈÌÒÓ Â˘·ÈÛıËÛ›·˜ (47-100%) Î·È ÂȉÈÎfiÙËÙ·˜ (6-97%) ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ (9). ∞˘Ù‹ Ë ÂÙÂÚÔÁ¤ÓÂÈ· Â›Ó·È ÂӉ¯Ô̤ӈ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ¯Ú‹Û˘ ‰È·ÊÔÚÂÙÈÎÒÓ ÌÂıfi‰ˆÓ ̤ÙÚËÛ˘, ‰È·ÊÔÚÂÙÈÎÒÓ ÌÂÁÂıÒÓ ‰ÂÈÁÌ¿ÙˆÓ ‹ ¯ÚfiÓˆÓ ‰ÂÈÁÌ·ÙÔÏË„›·˜ ‹ Ù˘ ¯Ú‹Û˘ Ì›·˜ ÌfiÓÔ Ì¤ÙÚËÛ˘ ·ÓÙ› ‰È·‰Ô¯ÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ (3,5). √È Philip Î·È Mills (10) ηıfiÚÈÛ·Ó Ì›· ÙÈÌ‹ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙË CRP ≥10 mg/L, Ë ÔÔ›· fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÂÓfi˜ (‹ ÂÚÈÛÛfiÙÂÚˆÓ) ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ‹ ÂÓfi˜ (‹ ÂÚÈÛÛfiÙÂÚˆÓ) ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ïԛ̈͢, ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ ÂÓfi˜ ÓÂÔÁÓÔ‡ ·fi ÙÔ ÙÌ‹Ì· Ê˘ÛÈÔÏÔÁÈÎÒÓ ÓÂÔÁÓÒÓ ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÓÂÔÁÓÒÓ (ª∂¡¡) Î·È ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ıÂÚ·›·˜. ∏ CRP ‰ÂÓ Â›Ó·È 100% ÂȉÈ΋ ÁÈ· ÙË ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË. ∏ ·ÍÈÔÈÛÙ›· Ù˘ ˆ˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ïԛ̈͢ ÂÚÈÔÚ›˙ÂÙ·È, ηıÒ˜ ·˘ÍË̤ӷ Â›‰· ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È Û ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÚÈÁÂÓÓËÙÈ΋ ˘ÔÍ›·, fiˆ˜ Ë ÂÈÛÚfiÊËÛË ÌË-

ÎˆÓ›Ô˘ ‹ Ë ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ (2). √ÌÔ›ˆ˜ ¤¯Ô˘Ó ·Ó¢ÚÂı› ·˘ÍË̤Ó˜ ÙÈ̤˜ Î·È Û ÂÚÈÙÒÛÂȘ ÈÛÙÈ΋˜ ‚Ï¿‚˘, ÏfiÁˆ ÂÈÏÔÎÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡, fiˆ˜ Û ÎÂÊ·Ï·È̿و̷ ‹ Âί˘ÌÒÛÂȘ (2). ∞ÊÂÙ¤ÚÔ˘, Ë ¯Ú‹ÛË Ù˘ CRP ηٿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ ÂÚÈϤÎÂÙ·È ·fi Ì›· ÌË ÂȉÈ΋ ·‡ÍËÛË ÙË 2Ë-3Ë Ë̤ڷ (2,9,11), ηıÒ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· Â›‰¿ Ù˘ Û ˘ÁÈ‹ ÓÂÔÁÓ¿ Â›Ó·È ¯·ÌËÏfiÙÂÚ· ηٿ ÙË Á¤ÓÓËÛË ·’ fi,ÙÈ Î·Ù¿ ÙȘ 24-48 ÒÚ˜ ˙ˆ‹˜ (5), ÂÓÒ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ (≥18 ÒÚ˜), Ë ˘¤ÚÙ·ÛË Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ÙÔ ÂÚÈÁÂÓÓËÙÈÎfi stress ‹ Î·È ÙÔ stress ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÙÔÎÂÙÔ‡ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÛËÌ·ÓÙÈο ÙËÓ ÎÈÓËÙÈ΋ Ù˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ˆÚÒÓ ˙ˆ‹˜ (5,12). Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ë Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË Ù˘ CRP Î·È ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (IL-6, IL-8) ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ï‡ÙÂÚË ‰È·ÁÓˆÛÙÈ΋ ·fi‰ÔÛË ·’ fi,ÙÈ Ë CRP ÌfiÓË (6,13). ∂ÓÙÔ‡ÙÔȘ, Ë ¯Ú‹ÛË ÙˆÓ ‰È·‰Ô¯ÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Ù˘ CRP ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·¿ÓÙËÛ˘ ÛÙËÓ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›·, ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ıÂÚ·›·˜ Î·È ÛÙËÓ ·Ó›¯Ó¢ÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙË Ïԛ̈ÍË ıˆÚÂ›Ù·È Ì¤¯ÚÈ Û‹ÌÂÚ· fiÙÈ ¤¯ÂÈ ·Í›· (14,15). ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ·ÍÈÔÏÔÁ‹ÛÂÈ ÙÔÓ ÚfiÏÔ ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ Ù˘ CRP ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Î·È ¤¯Ô˘Ó ‰È·ÈÛÙÒÛÂÈ fiÙÈ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˘ ‰È·ÁÓˆÛÙÈ΋˜ ·ÎÚ›‚ÂÈ·˜ (2,16). √ ˘ÚÂÙfi˜ Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙÔÓ ÙÔÎÂÙfi, Ë ÚfiˆÚË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ, Ë ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ¿ÏÏ· Û˘Ì‚¿Ì·Ù· Ô˘ ‰ÂÓ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‚·ÎÙËÚȷ΋˜ Ïԛ̈͢, ‚Ú¤ıËΠfiÙÈ Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ CRP ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ (16). ¶ÚfiÛÊ·Ù·, ˆÛÙfiÛÔ, ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· Â›‰¿ Ù˘ Â›Ó·È ·˘ÍË̤ӷ ηٿ ÙË Á¤ÓÓËÛË ÛÙÔ ÔÌÊ·ÏÈÎfi ·›Ì· ÓÂÔÁÓÒÓ Ì ÛË„·ÈÌ›·, ÔÌÊ·Ï›Ùȉ· ‹ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi ÌËÙ¤Ú˜ Ì ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ· (17).

∫˘ÙÙ·ÚÔΛÓ˜ πÓÙÂÚÏ¢ΛÓË-6 (IL-6) ∏ ÈÓÙÂÚÏ¢ΛÓË-6 (IL-6), Ë ÈÓÙÂÚÏ¢ΛÓË-8 (IL-8) Î·È Ô TNF-· ¤¯Ô˘Ó ·ÍÈÔÏÔÁËı› ÁÈ· ÙË ¯ÚËÛÈÌfiÙËÙ¿ ÙÔ˘˜ ˆ˜ ‰Â›ÎÙ˜ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓÂÔÁÓÈ΋˜ ‚·ÎÙËÚȷ΋˜ ÌfiÏ˘ÓÛ˘. ∆Ô ÂӉȷʤÚÔÓ ÛÙÚ¿ÊËΠ΢ڛˆ˜ ÛÙËÓ IL-6, Ì›· ÏÂÈÔÙÚfiÔ Î˘ÙÙ·ÚÔΛÓË Ô˘ ÌÂÙ¤¯ÂÈ Û ÔÏϤ˜ ‰ÈÂÚÁ·Û›Â˜ ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

Pediatr Sept_Oct 06

26-09-06

12:54

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398

°. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜

™˘ÓÙ›ıÂÙ·È Î·È ·ÂÏ¢ıÂÚÒÓÂÙ·È Ù·¯‡Ù·Ù· ˆ˜ ·¿ÓÙËÛË Û ÊÏÂÁÌÔÓÒ‰Ë ÂÚÂı›ÛÌ·Ù·, ÂÓÒ Ë ¿ÓÔ‰fi˜ Ù˘ ÚÔËÁÂ›Ù·È ÂΛӢ Ù˘ CRP. ∞ÔÙÂÏÒÓÙ·˜ ÙÔÓ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Â·ÁˆÁ¤· Ù˘ Û‡ÓıÂÛ˘ Ù˘ CRP ÛÙÔ ‹·Ú, Ë IL-6 Â›Ó·È ¤Ó·˜ ÂӉ¯Ô̤ӈ˜ ¯Ú‹ÛÈÌÔ˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ (6,18,19), ·ÏÏ¿ ÔÈ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ˜, ÂȉÂÈÎÓ‡ÔÓÙ·˜ ‰È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ Â˘·ÈÛıËÛ›·˜ ·fi 69% ¤ˆ˜ 100% Î·È ÂȉÈÎfiÙËÙ·˜ ·fi 36% ¤ˆ˜ 93% (20). ∏ ¢Ú›· ‰È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ¯Ú‹Û˘ ‰È·ÊÔÚÂÙÈÎÒÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ (20-150 ng/L), ‰È·ÊÔÚÂÙÈÎÔ‡ ¯ÚfiÓÔ˘ Ï‹„˘ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ‹ ÙÚfiÔ˘ ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ (6,13,19,21-23). Œ¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ Ë IL6, ·Ó Î·È ¯Ú‹ÛÈÌË ˆ˜ ÚÒÈÌÔ˜ ‰Â›ÎÙ˘ Ïԛ̈͢, ‰ÂÓ ı· ÌÔÚÔ‡Û ӷ ¯ÚËÛÈÌÔÔÈËı› ÌfiÓË Ù˘, ÏfiÁˆ ÙÔ˘ Û‡ÓÙÔÌÔ˘ ¯ÚfiÓÔ˘ ËÌÈ˙ˆ‹˜ Ù˘ (6,22), ÂÓÒ ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ Ù˘ Ì ÙË CRP ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ·’ fi,ÙÈ Î¿ı ‰Â›ÎÙ˘ ÌfiÓÔ˜ ÙÔ˘ (6,20,23-25). ∏ IL-6 Â›Ó·È ¤Ó·˜ ÂÍ›ÛÔ˘ ¯Ú‹ÛÈÌÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ fi„ÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ (9,20), ÂÓÒ Ì›· ÌÂϤÙË ¤ıÂÛ ÙËÓ ˘fiıÂÛË fiÙÈ Â›Ó·È ÈηӋ Ó· ÚԂϤ„ÂÈ ÙË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›· 1 ‹ 2 Ë̤Ú˜ ÚÈÓ ·fi ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË (21). ∞˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ IL-6 ¤¯Ô˘Ó ·Ú·ÙËÚËı› Û ÓÂÔÁÓ¿ Ì ÛÔ‚·Ú‹ ÓfiÛÔ ÌË ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜ [ÛÔ‚·Ú‹ ·ÛÊ˘Í›·, ·ÚÔ‰È΋ Ù·¯‡ÓÔÈ· ÓÂÔÁÓÔ‡, Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (™∞¢), Ó¢ÌÔıÒڷη˜] (19,23,26), Â˘Ú‹Ì·Ù· Ô˘ Ô‰‹ÁËÛ·Ó ÛÙË ‰È·›ÛÙˆÛË fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 24 ˆÚÒÓ Ù˘ ˙ˆ‹˜ ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ·Í›· ÛÙË ‰È·ÊÔÚԉȿÁÓˆÛË Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ ·fi ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÛÙË ª∂¡¡, ÂÓÒ Û ̛· ÌÂϤÙË Ë IL-6 ·ԉ›¯ıËΠfiÙÈ Â›Ó·È ·ÚÎÂÙ¿ ÂȉÈÎfi˜ ‰Â›ÎÙ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂfiÌÂÓˆÓ 24 ˆÚÒÓ ˙ˆ‹˜ (19). Œ¯Ô˘Ó ‰È·ÈÛÙˆı› ¯·ÌËÏfiÙÂÚ· Â›‰· IL6 Û ÚfiˆÚ· ÓÂÔÁÓ¿, ÂÓÒ ÌÔÓÔ·ÙÙ·Ú· ÚfiˆÚˆÓ ‚Ú¤ıËÎ·Ó fiÙÈ ·Ú¿ÁÔ˘Ó ÏÈÁfiÙÂÚË IL-6 ˆ˜ ·¿ÓÙËÛË ÛÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ·fi IL-1 ‹ ‚·ÎÙ‹ÚÈ· (27). ∂ÓÙÔ‡ÙÔȘ, Û ̛· ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ÙÈ̤˜ Ù˘ IL-6 ÙfiÛÔ ÛÙȘ ÌËÙ¤Ú˜ ηٿ ÙÔÓ ÙÔÎÂÙfi fiÛÔ Î·È ÛÙ· ˘ÁÈ‹ ÓÂÔÁ¤ÓÓËÙ¿ ÙÔ˘˜, Û¯ÂÙ›˙ÔÓÙ·È ·ÚÓËÙÈο Ì ÙËÓ ËÏÈΛ· ·ËÛ˘ (5), ˘Ô‰ÂÈÎÓ‡ÔÓÙ·˜ fiÙÈ Èı·ÓÒ˜ Ó· ˘¿Ú¯ÂÈ Ì›· ÂÍ¿ÚÙËÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ Ù˘ ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ ÙȘ ÚÒÙ˜ 48 ÒÚ˜ ˙ˆ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

‹˜. ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· Â›‰¿ Ù˘ ÛÙÔ ÔÌÊ·ÏÈÎfi ·›Ì· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì›· ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ Â›‰· ·˘Ù‹˜ ÛÙÔÓ ÌËÙÚÈÎfi ÔÚfi, ÙfiÛÔ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÙÔÎÂÙÔ‡ fiÛÔ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ (5,28), ˘ÔÛÙËÚ›˙ÔÓÙ·˜ ÙËÓ ˘fiıÂÛË Ù˘ Èı·Ó‹˜ ÌÂÙ·ÊÔÚ¿˜ Ù˘ ̤ۈ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ·fi ÙË ÌËÙÚÈ΋ ÛÙËÓ ÂÌ‚Ú˘˚΋ ΢ÎÏÔÊÔÚ›·. ∞‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ IL-6 ÙȘ ÚÒÙ˜ 24 ÒÚ˜ ˙ˆ‹˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ˘ÁÈ‹ ÓÂÔÁÓ¿ Î·È Èı·ÓÒ˜ ·ÓÙÈηÙÔÙÚ›˙ÂÈ Ì›· ·ÓÙ›‰Ú·ÛË ÛÙÔ Ê˘ÛÈÎfi stress Ù˘ Á¤ÓÓËÛ˘ (5,29). ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ÎÈÓËÙÈ΋ Ù˘ IL-6 Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÍÈÔÏÔÁÂ›Ù·È Ë ¯Ú‹ÛË Ù˘ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. §ÈÁfiÙÂÚ· ÛÙÔȯ›· Â›Ó·È ÁÓˆÛÙ¿ ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ó›¯Ó¢ÛË ÓÂÔÁÓÒÓ Ô˘ ı· ·Ó·Ù‡ÍÔ˘Ó ÚÒÈÌË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›·. Œ¯Ô˘Ó ‰È·ÈÛÙˆı› ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ IL-6 ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ ÓÂÔÁ¤ÓÓËÙˆÓ Ô˘ ·Ó·Ù‡ÛÔ˘Ó ÛË„·ÈÌ›· ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ 48-72 ˆÚÒÓ ˙ˆ‹˜ (18,27,3033), ÂÓÒ Ë ·Ó·ÊÂÚfiÌÂÓË Â˘·ÈÛıËÛ›· Î·È Ë ·ÚÓËÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· Î˘Ì·›ÓÔÓÙ·È ·fi 87% ¤ˆ˜ 100% Î·È ·fi 93% ¤ˆ˜ 100%, ·ÓÙ›ÛÙÔȯ· (18,32,34). ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ IL-6 ÛÙÔ ÔÌÊ·ÏÈÎfi ·›Ì· ›Ûˆ˜ Û¯ÂÙ›˙ÂÙ·È Ì ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ Ì ÂÈÏÔΤ˜ Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ÂÚÈfi‰Ô˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰È·ÈÛÙÒıËΠfiÙÈ Û ÓÂÔÁÓ¿ Ì Ïԛ̈ÍË ÌfiÓÔ Ù· Â›‰· Ù˘ IL-6 ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ ‹Ù·Ó Ôχ ˘„ËÏfiÙÂÚ· Û ۇÁÎÚÈÛË Ì ÌË ˘ÁÈ‹ ÓÂÔÁÓ¿ ¯ˆÚ›˜ Ïԛ̈ÍË (35). ∂ÈϤÔÓ, ·Ú·ÙËÚ‹ıËÎ·Ó ˘„ËÏ¿ Â›‰· IL-6 Û ‰Â›ÁÌ· ÔÌÊ·ÏÈÎÔ‡ ·›Ì·ÙÔ˜ ÓÂÔÁÓÒÓ Ô˘ ·ÎÔÏÔ‡ıˆ˜ ·Ó¤Ù˘Í·Ó ÛË„·ÈÌ›·, ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, Ó¢ÌÔÓ›·, ·ÏÏ¿ Î·È ÓÂÔÁÓÒÓ Ì ¿ÏϘ, ÌË ÏÔÈÌÒ‰ÂȘ ÂÈÏÔΤ˜, fiˆ˜ ‚·ÚÈ¿ ·ÈÌÔÚÚ·Á›· ÎÔÈÏÈÒÓ ÂÁÎÂÊ¿ÏÔ˘ (36). ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÚÔÛ‰ÈÔÚ›ÛÂÈ Ì›· ÈÛ¯˘Ú‹ Û¯¤ÛË ÌÂٷ͇ Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ IL-6 ÛÙÔ ÔÌÊ·ÏÈÎfi ·›Ì· Î·È Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ‰È¿ÁÓˆÛ˘ Ù˘ ¯ÔÚÈÔ·ÌÓÈÔÓ›Ùȉ·˜ (30,37). πÓÙÂÚÏ¢ΛÓË-8 (IL-8) ∏ ÈÓÙÂÚÏ¢ΛÓË-8 (IL-8), Ì›· ΢ÙÙ·ÚÔΛÓË Ì ·ÚfiÌÔÈ· ÎÈÓËÙÈ΋ Ì ÙËÓ IL-6, ¤¯ÂÈ ÌÂÏÂÙËı› Û ÓÂÔÁÓ¿ Ì ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË (13,14,18,38) Î·È ıˆÚÂ›Ù·È ¤Ó·˜ ȉȷ›ÙÂÚ· ·ÎÚÈ‚‹˜ ‰Â›ÎÙ˘, Ì ¢·ÈÛıËÛ›· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 80% ¤ˆ˜ 91% Î·È ÂȉÈÎfiÙËÙ· ·fi 76% ¤ˆ˜ 100% (13,14,39). √ÌÔ›ˆ˜ Ì ÙËÓ IL-6, Ë IL-8 ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ÈÔ Â˘·›ÛıËÙÔ˜, ·ÏÏ¿ ÏÈÁfiÙÂÚÔ ÂȉÈÎfi˜, ‰Â›ÎÙ˘ ·fi ÙË CRP ÛÙËÓ ¤Ó·ÚÍË Ù˘ Ïԛ̈͢

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·399

399

¢Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ

(13,14), ÂÓÒ ‰È·ÈÛÙÒıËΠfiÙÈ ·˘Í¿ÓÂÙ·È Ù·¯‡ÙÂÚ· ·fi ÙË CRP, ·ÎfiÌË Î·È ÚÔÙÔ‡ ˘¿ÚÍÂÈ ÔÔÈ·‰‹ÔÙ ·ÓȯÓ‡ÛÈÌË ·‡ÍËÛË ·˘Ù‹˜ (14). ∏ ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ¿ Ù˘ ·˘Í¿ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË Ì¤ÙÚËÛË Ù˘ CRP (13,14,40), fiˆ˜ Â›Û˘ ‰È·ÈÛÙÒıËÎÂ Î·È Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË Ì¤ÙÚËÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ‰Â›ÎÙË ÂÈÊ·Ó›·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ CD11b (39). ∞˘ÍË̤ӷ Â›‰· IL-8 ¤¯Ô˘Ó ·Ú·ÙËÚËı› Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ¯ˆÚ›˜ Û‡Á¯ÚÔÓË ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË (38), ÂÓÒ ‰È·Ù˘ÒıËÎÂ Ë ˘fiıÂÛË fiÙÈ Ë ˘ÔÍ·ÈÌ›· ÂÓÂÚÁÔÔÈ› ÙÔÓ ·ÓÔÛÔÏÔÁÈÎfi ηٷÚÚ¿ÎÙË Ô˘ Ô‰ËÁ› ÛÙËÓ ¿ÓÔ‰Ô Ù˘ IL-8 (40,41). ∂›Û˘, ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ IL-8 ÛÙÔ ·›Ì· ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘, ÙfiÛÔ ÚfiˆÚˆÓ fiÛÔ Î·È ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ì ÙÂÎÌËÚȈ̤ÓË ÚÒÈÌË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›·, ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ÌÂϤÙ˜, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ¢·ÈÛıËۛ˜ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 69% ¤ˆ˜ 91% (18,31,32). ∏ IL-8 ¤¯ÂÈ Û‡ÓÙÔÌÔ ¯ÚfiÓÔ ËÌÈ˙ˆ‹˜ Î·È Ë Û˘ÁΤÓÙÚˆÛ‹ Ù˘ ÛÙÔ Ï¿ÛÌ· ·ÓÙÈÚÔÛˆ‡ÂÈ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÎÏ¿ÛÌ· Ù˘ Û˘ÓÔÏÈ΋˜ IL-8 ÙÔ˘ ·›Ì·ÙÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ÌÂÁ·Ï‡ÙÂÚ‹ Ù˘ ÔÛfiÙËÙ· Â›Ó·È Û˘Ó‰Â‰Â̤ÓË Ì ÙÔ Î‡ÙÙ·ÚÔ (42). ¶ÚfiÛÊ·Ù·, ÂÊ·ÚÌfiÛÙËΠ̛· ·Ï‹ ̤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ Ù˘ Û˘Ó‰Â‰Â̤Ó˘ Ì ÙÔ Î‡ÙÙ·ÚÔ IL-8 (χÛË ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ) Î·È ·ÍÈÔÏÔÁ‹ıËÎÂ Ë ÌÂÙÚÔ‡ÌÂÓË ÔÏÈ΋ IL-8 ÙÔ˘ ·›Ì·ÙÔ˜ ÚÔÂÚ¯fiÌÂÓË Î·È ·fi ÙË Ï‡ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ, Ô˘, fiˆ˜ ‰È·ÈÛÙÒıËÎÂ, ·ÚÔ˘Û›·˙ ˘„ËÏfiÙÂÚË Â˘·ÈÛıËÛ›· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ (ÂÓÙfi˜ 6 ˆÚÒÓ ·fi ÙËÓ ÚÒÙË ÎÏÈÓÈ΋ ˘Ô„›· Ù˘ ÓfiÛÔ˘) ·’ fi,ÙÈ Ë ÌÂÙÚÔ‡ÌÂÓË ÛÙÔ Ï¿ÛÌ· IL-8, ÂÓÒ ·Ú¤ÌÂÓ ·˘ÍË̤ÓË ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (43).

TNF-· √ TNF-· ıˆÚÂ›Ù·È ‚·ÛÈÎfi˜ ÂÎÎÈÓËÙ‹˜ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘. ™Â ÌÂϤÙ˜ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› ˘„ËÏ¿ Â›‰· TNF-· ÛÙÔÓ ÔÚfi Û ÓÂÔÁÓ¿ Ì ÛË„·ÈÌ›· Î·È ·ÎfiÌ· ˘„ËÏfiÙÂÚ· Û ÂΛӷ Ô˘ ·Ó·Ù‡ÛÔ˘Ó ÛËÙÈÎfi shock (6,18). √ÌÔ›ˆ˜ Ì ÙËÓ IL-6, Ô TNF-· Â›Ó·È ¤Ó·˜ Ù·¯‡˜ ÌÂÛÔÏ·‚ËÙ‹˜ Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ Î·È Ë Â˘·ÈÛıËÛ›· ÙÔ˘ ‚ÂÏÙÈÒÓÂÙ·È fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÙÔÓ ÈÔ ·ÚÁfi ‰Â›ÎÙË CRP ‹ Ì ÙËÓ IL-6 (6), ÂÓÙÔ‡ÙÔȘ ‰ÂÓ ıˆÚÂ›Ù·È ÙfiÛÔ Î·Ïfi˜ ‰Â›ÎÙ˘ fiÛÔ Ë IL-6 ‹ Ë IL-8 (6,18). Œ¯Ô˘Ó ‰È·ÈÛÙˆı›, Â›Û˘, ·˘ÍË̤ӷ Â›‰· TNF-· ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Û ÓÂÔÁÓ¿ Ì Ïԛ̈ÍË (18,31), ˆÛÙfiÛÔ, Ë ¯ÚËÛÈÌfiÙËÙ¿ ÙÔ˘ ˆ˜

ÚÒÈÌÔ˘ ‰È·ÁÓˆÛÙÈÎÔ‡ ‰Â›ÎÙË ‰È·ÈÛÙÒıËΠfiÙÈ ‰ÂÓ Â›Ó·È ÙfiÛÔ ÛËÌ·ÓÙÈ΋ fiÛÔ Ù˘ IL-6 ‹ Ù˘ IL-8 (16,30,31). ¶ÚÔηÏÛÈÙÔÓ›ÓË (PCT) À„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÚÔηÏÛÈÙÔÓ›Ó˘ (PCT) ÛÙÔÓ ÔÚfi ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ·È‰È¿ Î·È ÂÓËÏ›ÎÔ˘˜ Ì ‰ÈÂÈÛ‰˘ÙÈΤ˜ ‚·ÎÙËÚȷΤ˜ ‹ Ì˘ÎËÙÈ·ÛÈΤ˜ ÌÔχÓÛÂȘ (44,45). ∏ ÚÔηÏÛÈÙÔÓ›ÓË Â›Ó·È ÚÔÔÚÌfiÓË Ù˘ ηÏÛÈÙÔÓ›Ó˘ Î·È ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Î·Ïfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Î·È Ù˘ ıÂÚ·¢ÙÈ΋˜ ¤Î‚·Û˘. ∏ PCT ·ÂÏ¢ıÂÚÒÓÂÙ·È ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ˘ÁÈÒÓ ÂıÂÏÔÓÙÒÓ ÂÓÙfi˜ 4 ˆÚÒÓ ÌÂÙ¿ ·fi Ì›· ÌfiÓÔ ¤Á¯˘ÛË ÂÓ‰ÔÙÔ͛Ӣ, ÊÙ¿ÓÂÈ Û ¤Ó· plateau Û 6-8 ÒÚ˜ Î·È ·Ú·Ì¤ÓÂÈ Û ·˘ÍË̤ӷ Â›‰· ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 24 ÒÚ˜, ÁÂÁÔÓfi˜ Ô˘ ÙËÓ Î·ıÈÛÙ¿ ¤Ó·Ó ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓÔ Ó¤Ô ‰Â›ÎÙË ÁÈ· ÙËÓ ÚÒÈÌË ·Ó›¯Ó¢ÛË Ù˘ Ïԛ̈͢ (46). ¢È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰È·ÈÛÙÒÛÂÈ fiÙÈ Ù· Â›‰¿ Ù˘ ÛÙÔÓ ÔÚfi Â›Ó·È ¤Ó·˜ ‰Â›ÎÙ˘ ˘„ËÏ‹˜ ¢·›ÛıËÛ›·˜, ÙfiÛÔ Ù˘ ÚÒÈÌ˘ fiÛÔ Î·È Ù˘ fi„ÈÌ˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ (47-51). ∏ ‰È·ÁÓˆÛÙÈ΋ Ù˘ ·Í›· ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ·ÓÒÙÂÚË ·’ fi,ÙÈ ¿ÏÏˆÓ ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ CRP, Ì ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·Î‡Ì·ÓÛË ·fi 87% ¤ˆ˜ 100% (47-52). º˘ÛÈÔÏÔÁÈο ‹ ÂÏ·ÊÚÒ˜ ·˘ÍË̤ӷ Â›‰· PCT ÔÚÔ‡ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ÓÂÔÁÓ¿ Ì ÈÔÁÂÓ‹ Ïԛ̈ÍË, ‚·ÎÙËÚÈ·Îfi ·ÔÈÎÈÛÌfi ‹ Ì ‰˘Û¯¤ÚÂÈ· ÔÈΛÏÔ˘ Ù‡Ô˘ (47). ∏ ÎÈÓËÙÈ΋ Ù˘ PCT ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 48 ˆÚÒÓ ˙ˆ‹˜ ÌÂÏÂÙ‹ıËΠ۠˘ÁÈ‹ ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Î·È ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Ù˘ ÌÂÙ·‚¿ÏÏÔÓÙ·È ÙȘ ÚÒÙ˜ ÒÚ˜ ˙ˆ‹˜ (48). ∆· ÚÔ‚ÏÂfiÌÂÓ· ·ÓÒÙÂÚ· fiÚÈ· Ù˘ PCT ·Ú·ÙËÚÔ‡ÓÙ·È Û‡ÓÙÔÌ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÛÙËÓ ÙÈÌ‹ ÙˆÓ 0,7 ng/ml, ·˘Í¿ÓÔÓÙ·È Î·ÙfiÈÓ ‚·ıÌÈ·›· ÁÈ· Ó· ÊÙ¿ÛÔ˘Ó ÛÙË Ì¤ÁÈÛÙË ÙÈÌ‹ ÙˆÓ 21 ng/ml ÌÂٷ͇ 21 Î·È 24 ˆÚÒÓ ˙ˆ‹˜ Î·È ¤ÂÈÙ· ÌÂÈÒÓÔÓÙ·È ‚·ıÌÈ·›· ÛÙËÓ ÙÈÌ‹ ÙˆÓ 2 ng/ml ÂÓÙfi˜ 48 ˆÚÒÓ (48). ∂ÎÙfi˜ Ù˘ ‚·ÎÙËÚȷ΋˜ ÛË„·ÈÌ›·˜, Ô ‰È·‚‹Ù˘ Ù˘ ÌËÙ¤Ú·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Â›Ó·È Ë ÌfiÓË ÓfiÛÔ˜ Ô˘ ‰‡Ó·Ù·È Ó· Ô‰ËÁ‹ÛÂÈ Û ̛· ÛËÌ·ÓÙÈ΋ ·fiÎÏÈÛË ·fi ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜, ÂÓÒ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, Ë ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ‹ ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÂÁÁÂÓÒ˜ ›Ù Û ÚÔˆÚfiÙËÙ· ›Ù ÛÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‰ÂÓ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ Â›ÙˆÛË ÛÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Ù˘ PCT (48). ¶·Ú’ fiÏ· ·˘Ù¿, Û ÓÂÔÁÓ¿ Ô˘ ·ÚÔ˘Û›·Û·Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ïԛ̈ÍË (ÚfiˆÚË Ú‹ÍË ÙˆÓ ˘Ì¤ÓˆÓ >12 ÒÚ˜, ÎÏÈÓÈο ÛËÌ›· ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

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26-09-06

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400

°. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜

Ïԛ̈͢ Ù˘ ÌËÙ¤Ú·˜) ‹ Û ·ÚÔ˘Û›· ÌËÙÚÈÎÔ‡ ‰È·‚‹ÙË ‹ ÚÔÂÎÏ·Ì„›·˜ ‰È·ÈÛÙÒıËÎ·Ó ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ PCT (48,53), fiˆ˜ Î·È Û ÓÂÔÁÓ¿ ¯ˆÚ›˜ Ïԛ̈ÍË ·ÏÏ¿ Ì ™∞¢, ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, ˘ÔÍ·ÈÌ›·, ÙÚ·‡Ì· ‹ ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· (54), Â˘Ú‹Ì·Ù· Ô˘ fï˜ ·ÌÊÈÛ‚ËÙÔ‡ÓÙ·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (55). ™Â Ì›· ¿ÏÏË ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο Ù· Â›‰· Ù˘ PCT ηٿ ÙË Á¤ÓÓËÛË Â›Ó·È Ë Û˘ÁΤÓÙÚˆÛË Ù˘ PCT ÛÙÔÓ ÔÚfi Ù˘ ÌËÙ¤Ú·˜, Ô ·ÔÈÎÈÛÌfi˜ Ù˘ ÌËÙ¤Ú·˜ ·fi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ µ Î·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ≥18 ÒÚ˜, ÂÓÒ ÙfiÛÔ Î·Ù¿ ÙȘ 24 fiÛÔ Î·È Î·Ù¿ ÙȘ 48 ÒÚ˜ ˙ˆ‹˜, Ë ÌfiÓË ·Ú¿ÌÂÙÚÔ˜ Ô˘ ·Ú·ÙËÚ‹ıËΠfiÙÈ Â›¯Â ÛËÌ·ÓÙÈ΋ Â›ÙˆÛË ÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ PCT ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó Ë Ú‹ÍË ÙˆÓ ˘Ì¤ÓˆÓ ≥18 ÒÚ˜ (56). ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi ‡ÚËÌ· ‹Ù·Ó fiÙÈ ÂÎÙfi˜ ·fi ÙÔÓ ·ÔÈÎÈÛÌfi Ù˘ ÌËÙ¤Ú·˜ Ì ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ µ Î·È ÙË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ≥18 ÒÚ˜, Ù· ÔÔ›· ‰È·ÈÛÙÒıËΠfiÙÈ Û˘Ó‰¤ÔÓÙ·È Ì ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÛÙË ÓÂÔÁÓÈ΋ Û˘ÁΤÓÙÚˆÛË Ù˘ PCT ηٿ ‹ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ηӤӷ˜ ¿ÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ‰ÂÓ Û˘Ó‰¤ıËΠ̛̠· ·ÓÙ›ÛÙÔÈ¯Ë ¿ÓÔ‰Ô Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ PCT Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡ (56). ∞Ó Î·È Ë ÌÂÙ·ÊÔÚ¿ ̤ۈ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ¤¯ÂÈ ÚÔÙ·ı› ˆ˜ Èı·Ó‹ ËÁ‹ Ù˘ ÌÂÙ·ÁÂÓÓËÙÈ΋˜ ·‡ÍËÛ˘ Ù˘ PCT (57), ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰È·ÈÛÙÒıËÎ·Ó ˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ PCT ÛÙÔ ·›Ì· ÙÔ˘ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ Û ۇÁÎÚÈÛË Ì ٷ ·ÓÙ›ÛÙÔȯ· ‰Â›ÁÌ·Ù· ÌËÙÚÈÎÔ‡ ·›Ì·ÙÔ˜ ηٿ ÙË Á¤ÓÓËÛË, Ì ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚ˜ ‰È·ÊÔÚ¤˜ ηٿ ÙȘ 24 Î·È 48 ÒÚ˜ ˙ˆ‹˜, ‰ÂÓ ‰‡Ó·Ù·È Ó· ÂÚÌËÓ¢Ù› ÌfiÓÔ ‚¿ÛÂÈ Ù˘ ‰È·Ï·ÎÔ˘ÓÙȷ΋˜ ÌÂÙ·ÊÔÚ¿˜, ı¤ÙÔÓÙ·˜ ÙËÓ ˘fiıÂÛË fiÙÈ Ë ÂÌ‚Ú˘˚΋ ‹ Ë ÌÂÙ·ÁÂÓÓËÙÈ΋ ·‡ÍËÛË Ù˘ PCT ·ÓÙÈÚÔÛˆ‡ÂÈ Èı·Ófiٷٷ ÂÓ‰ÔÁÂÓ‹ Û‡ÓıÂÛË (56). ¶ÚfiÛÊ·Ù·, ÂÍÂÙ¿ÛÙËÎÂ Â¿Ó Î·È Û ÔÈÔ ‚·ıÌfi Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ Â›ÙˆÛË ÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ΢ÎÏÔÊÔÚÔ‡Û·˜ PCT, Ù˘ IL6 Î·È Ù˘ CRP, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È Ïԛ̈͢ ÛÙËÓ ¿ÌÂÛË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô (0-48 ÒÚ˜ ˙ˆ‹˜) (53). ∏ CRP, Ë IL-6 Î·È Ë PCT ‰È·ÈÛÙÒıËΠfiÙÈ ·‡Í·ÓÔÓÙ·È Î·Ù¿ ÙË ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË Î·È fiÙÈ ÔÈ ·˘Í‹ÛÂȘ ÙÔ˘˜ Â›Ó·È ·ÓÂÍ¿ÚÙËÙ˜ ·fi ÙË ‚·Ú‡ÙËÙ¿ Ù˘. ŸÌˆ˜, Û ·Ô˘Û›· Ïԛ̈͢, Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ‰‡Ó·Ù·È Ó· ÂËÚ¿˙ÂÈ ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ IL-6, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ÓÂÔÁÓ¿ ¯ˆÚ›˜ Ïԛ̈ÍË, Ë ‚·Ú‡ÙÂÚË ÓfiÛÔ˜ Û˘Ó‰¤ıËΠ̠˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ IL-6, ȉȷ›ÙÂÚ· ηٿ ÙË Á¤ÓÓËÛË (53). ∂ÈϤÔÓ, ÂȂ‚·ÈÒıËΠfiÙÈ Ë Â˘·ÈÛıËÛ›· Î·È ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

Ë ÂȉÈÎfiÙËÙ· ÙˆÓ ÙÚÈÒÓ ·˘ÙÒÓ ‰ÂÈÎÙÒÓ ÌÂÙ·‚¿ÏÏÔÓÙ·È Ì ÙÔÓ ¯ÚfiÓÔ Î·È, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ¯Ú‹ÛË ÙÔ˘˜ ··ÈÙ› ÙÔÓ Î·ıÔÚÈÛÌfi Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ ÁÈ· οı ¯ÚÔÓÈÎfi ÛËÌÂ›Ô Ù˘ ·ÍÈÔÏfiÁËÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 48 ˆÚÒÓ ˙ˆ‹˜. ŸÙ·Ó ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰È·ÊÔÚÂÙÈΤ˜ ÙÈ̤˜ ·Ó·ÊÔÚ¿˜ ÁÈ· οı ËÏÈΛ· (ηٿ ÙË Á¤ÓÓËÛË, ÙȘ 24 Î·È ÙȘ 48 ÒÚ˜ ˙ˆ‹˜), Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ PCT ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÙˆÓ CRP Î·È IL-6 (53).

∞ÓÙÈÁfiÓ· ÂÈÊ·Ó›·˜ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ (΢ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜) ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙÒÓ ‰È¿ÊÔÚ· ·ÓÙÈÁfiÓ· ÂÈÊ·Ó›·˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ·›Ì·ÙÔ˜, ÁÓˆÛÙ¿ ˆ˜ CD ·ÓÙÈÁfiÓ·, ¤¯Ô˘Ó ÂÏ·ÛÂÈ ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÚ¢ÓËÙÒÓ. ªÂٷ͇ ÂÎÂ›ÓˆÓ Ô˘ ÌÂÏÂÙÒÓÙ·È, Ù· ·ÓÙÈÁfiÓ· CD11b Î·È CD64 ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ıˆÚÔ‡ÓÙ·È fiÙÈ Â›Ó·È ÈÔ ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ ÚÒÈÌ˘ Î·È fi„ÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢, ·ÓÙ›ÛÙÔȯ· (39,58-61). √ CD11b (MAC-1, CR3) Â›Ó·È Ë ˘ÔÌÔÓ¿‰· · ÙÔ˘ ÌÔÚ›Ô˘ ÚÔÛÎfiÏÏËÛ˘ ‚2integrin, Ô˘ ÂÓ¤¯ÂÙ·È ÛÙȘ ‰È·‰Èηۛ˜ ÚÔÛÎfiÏÏËÛ˘, ‰È·›‰˘Û˘ Î·È Ê·ÁÔ΢ÙÙ¿ÚˆÛ˘ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. ∂›Ó·È Ô ˘Ô‰Ô¯¤·˜ ÙÔ˘ C3bi, ÂÓfi˜ Û˘ÛÙ·ÙÈÎÔ‡ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ Î·È Ê˘ÛÈÔÏÔÁÈο ÂÎÊÚ¿˙ÂÙ·È Û Ôχ ¯·ÌËÏ¿ Â›‰· ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÌË ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, ÂÓÒ ÚˆÙ›ÛÙˆ˜ ‚Ú›ÛÎÂÙ·È ·ÔıËÎÂ˘Ì¤ÓÔ Û ÂÎÎÚÈÙÈο ÎÔÎΛ· ̤۷ ÛÙÔ Î‡ÙÙ·ÚÔ (58,59). ∆· Ô˘‰ÂÙÂÚfiÊÈÏ· ÙˆÓ ÓÂÔÁÓÒÓ, ·Ó Î·È ÂÚȤ¯Ô˘Ó ÌÈÎÚfiÙÂÚË ÔÛfiÙËÙ· ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ CD11b ·fi ÂΛӷ ÙˆÓ ÂÓËϛΈÓ, ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ·˘Í¿ÓÔ˘Ó ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi ÙËÓ ¤ÎÊÚ·Û‹ ÙÔ˘ ÛÙËÓ ÂÈÊ¿ÓÂÈ¿ ÙÔ˘˜ Â› ‚·ÎÙËÚÈ·ÈÌ›·˜ (62), ÂÓÒ Ë ¤ÎÊÚ·Û‹ ÙÔ˘ Â›Ó·È ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË Û ÌÔÓÔ·ÙÙ·Ú· ÚÔÂÚ¯fiÌÂÓ· ·fi ÚfiˆÚ· Û ۯ¤ÛË Ì ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (63). ∏ Ù·¯Â›· ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ CD11b ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Û ·¿ÓÙËÛË ÛÙË ÌÈÎÚԂȷ΋ ÂÈÛ‚ÔÏ‹ ÙÔÓ Î·ıÈÛÙ¿ ¤Ó·Ó ¯Ú‹ÛÈÌÔ ÚÒÈÌÔ ‰Â›ÎÙË Ïԛ̈͢. ™Â ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Ô˘ ·ÍÈÔÏfiÁËÛ·Ó ÙÔÓ ÚfiÏÔ ÙÔ˘ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (39,58,64,65) ‰È·ÈÛÙÒıËΠ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û‹˜ ÙÔ˘ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Û ÓÂÔÁÓ¿ Ì Ïԛ̈ÍË Û˘ÁÎÚÈÙÈο Ì ˘ÁÈ‹ ÓÂÔÁÓ¿, Ë ÔÔ›· ‹Ù·Ó ·ÚÎÂÙ¿ ÛËÌ·ÓÙÈ΋ Û ÂΛӷ Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜. ™ÙËÓ ÚÒÙË ÌÂϤÙË (58), Ë Â˘·ÈÛıËÛ›·, Ë ÂȉÈÎfiÙËÙ· Î·È Ë ·ÚÓËÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ÁÈ·

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·401

401

¢Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ

ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ ‹Ù·Ó Ôχ ˘„ËϤ˜ (96%, 100% Î·È 100%, ·ÓÙ›ÛÙÔȯ·), ÂÈÛ¿ÁÔÓÙ·˜ ÙÔÓ CD11b ˆ˜ ÂÏȉÔÊfiÚÔ Ó¤Ô ‰Â›ÎÙË ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ÚÒÈÌ˘ Ïԛ̈͢ ÛÙ· ÓÂÔÁÓ¿. ŸÙ·Ó Ë ¤ÎÊÚ·ÛË ÙÔ˘ CD11b ÌÂÙÚ‹ıËΠÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Î˘ÎÏÔÊÔÚÔ‡Û· IL-8, ‰È·ÈÛÙÒıËΠfiÙÈ Î·È ÔÈ ‰‡Ô ‰Â›ÎÙ˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔÈ Û ÓÂÔÁÓ¿ Ì ۋ„Ë, ÂÓÒ Ù· ÓÂÔÁÓ¿ Ì ÛËÌ›· ‡ÔÙ˘ Ïԛ̈͢ ›¯·Ó ÂÏ·ÊÚÒ˜ ·˘ÍË̤ӷ Â›‰· Î·È ÙˆÓ ‰‡Ô ‰ÂÈÎÙÒÓ (39). ∆· Â›‰· ¤ÎÊÚ·Û˘ ÙÔ˘ CD11b ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Û¯ÂÙ›˙ÔÓÙ·Ó ıÂÙÈο Ì ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ IL-8, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ Û˘ÁÎÚ›ÛÈÌË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· (100% ÁÈ· ÙÔ CD11b) Î·È Èı·Ó‹ Û˘Û¯¤ÙÈÛË Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ Ïԛ̈͢, ÂÓÒ Î·È ÔÈ ‰‡Ô ‰Â›ÎÙ˜ ·ԉ›¯ıËÎ·Ó ·ÓÒÙÂÚÔÈ ·fi ÙË CRP ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢ Û ·Ú¯ÈÎfi ÛÙ¿‰ÈÔ. ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠfiÙÈ Ë ¤ÎÊÚ·ÛË ÙÔ˘ CD11b ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ·˘Í¿ÓÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÙfiÛÔ Û ÙÂÏÂÈfiÌËÓ· fiÛÔ Î·È Û ÚfiˆÚ· ÓÂÔÁÓ¿, ·Ú¿ ÙËÓ ·Ô˘Û›· Ïԛ̈͢ (64), ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ Ë ¤ÎÊÚ·Û‹ ÙÔ˘ ÂËÚ¿˙ÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (66) ‹ Ë ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (67). ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ Ô CD11b ÌÔÚ› Ó· Â›Ó·È ¤Ó·˜ ¯Ú‹ÛÈÌÔ˜ ÚÒÈÌÔ˜ ‰Â›ÎÙ˘ fi„ÈÌ˘ Ïԛ̈͢ Û ÚfiˆÚ· ÓÂÔÁÓ¿ ÂÍ·ÈÚÂÙÈο ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘, ηıÒ˜ Û ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ ·Ú·ÙËÚ‹ıËΠÛÙ·‰È·Î‹ ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û‹˜ ÙÔ˘, ·ÎfiÌË Î·È ÚÈÓ ÙËÓ ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ (65), ·Ú’ fiÙÈ ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ·ÌÊÈÛ‚ËÙÔ‡Û ÙË ‰È·ÁÓˆÛÙÈ΋ ÙÔ˘ ·Í›· ÛÙËÓ fi„ÈÌË Ïԛ̈ÍË ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (60).

O ΢ÙÙ·ÚÈÎfi˜ ‰Â›ÎÙ˘ CD64 (FcÁR1) Â›Ó·È ¤Ó·˜ ˘„ËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ ˘Ô‰Ô¯¤·˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, Ô ÔÔ›Ô˜ ·ÏÏËÏÂȉڿ Ì ÙÔ F ÎÏ¿ÛÌ· ÙÔ˘ ÌÔÚ›Ô˘ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, Â¿ÁÔÓÙ·˜ ÔÈΛϘ ‚ÈÔÏÔÁÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÛÙÔ Î‡ÙÙ·ÚÔ, fiˆ˜ Ë Ê·ÁÔ΢ÙÙ¿ÚˆÛË, Ë ·ÔÎÔÎΛˆÛË Î·È Ë ÂÍ·ÚÙÒÌÂÓË ·fi ·ÓÙÈÛÒÌ·Ù· ΢ÙÙ·ÚÔÙÔÍÈÎfiÙËÙ·. ∂ÎÊÚ¿˙ÂÙ·È Ê˘ÛÈÔÏÔÁÈο Û Ôχ ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÌË-ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, ·ÏÏ¿ Ë ¤ÎÊÚ·Û‹ ÙÔ˘ ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο ηٿ ÙË ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË (59,60). ∏ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ CD64 ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ¤Ó·˜ ȉȷ›ÙÂÚ· ÂȉÈÎfi˜ ‰Â›ÎÙ˘ ÓÂÔÁÓÈ΋˜ ÛË„·ÈÌ›·˜ Î·È ·ÓÒÙÂÚÔ˜ Û ۇÁÎÚÈÛË Ì ¿ÏÏÔ˘˜ ΢ÙÙ·ÚÈÎÔ‡˜ ‰Â›ÎÙ˜ ‹ ΢ÙÙ·ÚÔΛÓ˜ (68), ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ÂËÚ¿˙ÂÙ·È ·fi ·Ú¿ÁÔÓÙ˜ ¿ÏÏÔ˘˜, ÂÎÙfi˜ Ù˘ Ïԛ̈͢, Ô˘ Û¯Â-

Ù›˙ÔÓÙ·È Ì ÙËÓ ÚÔˆÚfiÙËÙ·, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ‹ Ë ÚfiˆÚË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ (64). ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË fiÔ˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ‰‡Ô Ô˘‰ÂÙÂÚÔÊÈÏÈÎÔ› (CD11b, CD64) Î·È ‰‡Ô ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜ ÂÈÊ·Ó›·˜ (CD25, CD45R0), Ô CD64 ·ÚÔ˘Û›·Û ÙËÓ ˘„ËÏfiÙÂÚË Â˘·ÈÛıËÛ›· (97%), ÂȉÈÎfiÙËÙ· (90%) Î·È ·ÚÓËÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· (99%), ÂÓÒ ‰È·ÈÛÙÒıËΠfiÙÈ Â›Ó·È ¤Ó·˜ ȉȷ›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË Ù˘ fi„ÈÌ˘ Ïԛ̈͢ Û ÚfiˆÚ· ÓÂÔÁÓ¿, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ¿ ÙÔ˘ ÛÙËÓ ·Ú¯‹ Ù˘ ÌfiÏ˘ÓÛ˘ Î·È 24 ÒÚ˜ ·ÚÁfiÙÂÚ· Â›Ó·È ÂÍ›ÛÔ˘ ˘„ËϤ˜ (60). √È Û˘Ó‰˘·ÛÌÔ› ÙÔ˘ Ì ÙËÓ IL-6 ‹ ÙË CRP ÂÓÈÛ¯‡Ô˘Ó ÂÚ·ÈÙ¤Úˆ ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙËÓ ·ÚÓËÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ¤ˆ˜ Î·È 100% (60). ∆· ÈÔ ÚfiÛÊ·Ù· ‡ÚËÌ·Ù· (69), Â›Û˘, ·ÍÈÔÏÔÁÔ‡Ó ÙË ¯ÚËÛÈÌfiÙËÙ¿ ÙÔ˘ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÚÒÈÌ˘ Ïԛ̈͢ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰È·ÈÛÙÒıËΠfiÙÈ ·ÚÔ˘ÛÈ¿˙ÂÈ Ôχ ˘„ËÏ‹ ¢·ÈÛıËÛ›· Î·È ·ÚÓËÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú¯È΋˜ ·ÍÈÔÏfiÁËÛ˘ Î·È 24 ÒÚ˜ ·ÚÁfiÙÂÚ·.

™˘ÌÂÚ¿ÛÌ·Ù· ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÔËÁÔ‡ÌÂÓˆÓ ÂÙÒÓ ‰ÈÂÍ‹¯ıË ¤Ó·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ ÛÙԯ‡ÔÓÙ·˜ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‰È·ÁÓˆÛÙÈÎÔ‡ ÚfiÏÔ˘ ‰È·ÊfiÚˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ‰ÂÈÎÙÒÓ ÛÙË ÓÂÔÁÓÈ΋ Ïԛ̈ÍË Î·È ÙË ÛË„·ÈÌ›·, fï˜ ̤¯ÚÈ Û‹ÌÂÚ· ηӤӷ˜ ‰Â›ÎÙ˘ ‰ÂÓ ÏËÚÔ› Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ȉ·ÓÈ΋˜ ‰È·ÁÓˆÛÙÈ΋˜ ‰ÔÎÈÌ·Û›·˜. √È ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ ·˘ÙÒÓ ÙˆÓ ‰ÂÈÎÙÒÓ ÌÔÚÔ‡Ó Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË ‰È·ÁÓˆÛÙÈ΋ ·fi‰ÔÛË Î·È Â˘·ÈÛıËÛ›· ÙÔ˘˜, ÂÓÒ Ë Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÂÓfi˜ “ÚÒÈÌÔ˘ Î·È Â˘·›ÛıËÙÔ˘” ‰Â›ÎÙË Ì ¤Ó·Ó “·ÚÁfi Î·È ÂȉÈÎfi” ‰Â›ÎÙË ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ·˘Í¿ÓÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ ·ÍÈÔÈÛÙ›· ÙÔ˘˜ ÛÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì Ïԛ̈ÍË. ∏ CRP Â›Ó·È Ì›· ÛËÌ·ÓÙÈ΋ Î·È ÂȉÈ΋ ‰È·ÁÓˆÛÙÈ΋ ‰ÔÎÈÌ·Û›·, ÂÓÙÔ‡ÙÔȘ, ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ÙË ıˆÚÔ‡Ó ˆ˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ·ÏÏ¿ fi„ÈÌÔ ‰Â›ÎÙË. ∏ IL-6 Î·È Ë IL-8 ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ˆ˜ ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ΢ÙÙ·ÚÔΛÓ˜, Ë Â˘·ÈÛıËÛ›· ÙˆÓ ÔÔ›ˆÓ ‚ÂÏÙÈÒÓÂÙ·È fiÙ·Ó Û˘Ó‰˘¿˙ÔÓÙ·È Ì ÙË CRP, fiˆ˜ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙËÓ PCT Ô˘ ıˆÚÂ›Ù·È ÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙË ‰ÔÎÈÌ·Û›·. øÛÙfiÛÔ, fiÏÔÈ ·˘ÙÔ› ÔÈ ‰Â›ÎÙ˜, ·Ó Î·È Â›Ó·È ÔχÙÈÌÔÈ, ‰ÂÓ Â›Ó·È ·Ï¿Óı·ÛÙÔÈ, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ¿ ÙÔ˘˜ ÔÈΛÏÏÔ˘Ó Ì ÙÔÓ ¯ÚfiÓÔ Î·È, ˆ˜ ÂÎ ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

Pediatr Sept_Oct 06

26-09-06

12:54

™ÂÏ›‰·402

402

°. ∆ËÁ¿ÓË, ¢. ∫·ÊÂÙ˙‹˜

¶›Ó·Î·˜ 2. ÷ڷÎÙËÚÈÛÙÈο ‰È·ÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ¢È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘

ªË¯·ÓÈÛÌfi˜ ‰Ú¿Û˘

÷ڷÎÙËÚÈÛÙÈο

C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (CRP0)

¶ÚˆÙ½ÓË ÔÍ›·˜ Ê¿Û˘, ↑·ÚÔ˘Û›· ÊÏÂÁÌÔÓ‹˜ ‹ ÈÛÙÈ΋˜ ‚Ï¿‚˘ ¢È·Î˘ÙÙ·ÚÈÎÔ› ÌÂÛÔÏ·‚ËÙ¤˜ Ô˘ ‰ÚÔ˘Ó Ì¤Ûˆ ˘Ô‰Ô¯¤ˆÓ Û ·ÙÙ·Ú·-ÛÙfi¯Ô˘˜ ∞˘Í¿ÓÂÙ·È Ù·¯‡Ù·Ù· ÛÙÔ ·›Ì· ˆ˜ ·¿ÓÙËÛË Û ‚·ÎÙËÚȷ΋ ÂÈÛ‚ÔÏ‹

∂ȉÈÎfi˜, ·ÏÏ¿ fi„ÈÌÔ˜ ‰Â›ÎÙ˘ Ïԛ̈͢, ¯·ÌËÏ‹˜ ¢·ÈÛıËÛ›·˜

∫˘ÙÙ·ÚÔΛÓ˜ IL-6, IL-8

¶ÚÔηÏÛÈÙÔÓ›ÓË (PCT)

∫˘ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜ CD11b, CD64

∞ÓÙÈÁfiÓ· ÂÈÊ·Ó›·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ - Ë ÂÎÊÚ·Û‹ ÙÔ˘˜ ·˘Í¿ÓÂÙ·È ˆ˜ ·¿ÓÙËÛË Û ÂÓÂÚÁÔÔ›ËÛË ·fi ‚·ÎÙ‹ÚÈ· ‹ ÚÔ˚fiÓÙ· ·˘ÙÒÓ

ÙÔ‡ÙÔ˘, Ë ¯Ú‹ÛË ÙÔ˘˜ ··ÈÙ› ÙÔÓ Î·ıÔÚÈÛÌfi Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ Û οı ËÏÈΛ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ËÌÂÚÒÓ Ù˘ ˙ˆ‹˜. √È Î˘ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜ (CD ·ÓÙÈÁfiÓ·), ΢ڛˆ˜ Ô CD11b Î·È Ô CD64, ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ¤Ó· Ó¤Ô ‰›Ô ¤Ú¢ӷ˜, ηıÒ˜ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ˆ˜ ¢·›ÛıËÙÔÈ ‰Â›ÎÙ˜ Ù˘ ÚÒÈÌ˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢, ÂÓÒ Ô CD64 ›Ûˆ˜ ·Ô‰Âȯı› Ì›· ¯Ú‹ÛÈÌË ‰È·ÁÓˆÛÙÈ΋ ‰ÔÎÈÌ·Û›· ÁÈ· ÙË ÓÔÛÔÎÔÌÂȷ΋ fi„ÈÌË ÓÂÔÁÓÈ΋ ÛË„·ÈÌ›· (¶›Ó·Î·˜ 2). ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÛÙÔ Ì¤ÏÏÔÓ, Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ‰ÂÈÁÌ¿ÙˆÓ Î·È Ì ÈÔ ·˘ÛÙËÚ‹ ÌÂıÔ‰ÔÏÔÁ›·, ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÔÚÈÛÙ› Ë Û˘Ì‚ÔÏ‹ ·˘ÙÒÓ ÙˆÓ ÚfiÛÊ·Ù· ‰È·ı¤ÛÈÌˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ‰ÂÈÎÙÒÓ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÓÂÔÁÓÈ΋˜ Ïԛ̈͢, ÂÎÙfi˜ ·fi ÙȘ ·Ï·ÈfiÙÂÚ˜ ‰ÔÎÈ̷ۛ˜, fiˆ˜ Ë CRP Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. de Villiers WJ, Louw JP, Strachan AF, Etsebeth SM, Shephard EG, de Beer FC. C-reactive protein and serum amyloid A protein in pregnancy and labour.

Br J Obstet Gynaecol 1990;97:725-730.

2. Ainbender E, Cabatu EE, Guzman DM, Sweet AY. Serum C-reactive protein and problems of newborn infants. J Pediatr 1982;101:438-440.

3. Da Silva O, Ohlsson A, Kenyon C. Accuracy of leukocyte indices and C-reactive protein for diagnosis of neonatal sepsis: a critical review. Pediatr Infect Dis J 1995;14:362-366. ¶·È‰È·ÙÚÈ΋ 2006;69:395-404

¶ÈÔ Â˘·›ÛıËÙÔÈ, ·ÏÏ¿ ÏÈÁfiÙÂÚÔ ÂȉÈÎÔ› ‰Â›ÎÙ˜ Û ۇÁÎÚÈÛË Ì ÙË CRP - Û‡ÓÙÔÌÔ˜ ¯ÚfiÓÔ˜ ËÌÈ˙ˆ‹˜ ¶ÈÔ ÚÒÈÌÔ˜, ¢·›ÛıËÙÔ˜ Î·È ÂȉÈÎfi˜ ‰Â›ÎÙ˘ Û ۇÁÎÚÈÛË Ì ÙË CRP Î·È ÙȘ ΢ÙÙ·ÚÔΛÓ˜. ∞·ÈÙÂ›Ù·È ÌÈÎÚ‹ ÔÛfiÙËÙ· ·›Ì·ÙÔ˜ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ (20-200 ÌL) - ÈÔ ¿ÌÂÛ· ·ÔÙÂϤÛÌ·Ù· (Û 30 min-2 h, ·Ó¿ÏÔÁ· Ì ÙË Ì¤ıÔ‰Ô) ¢Â›ÎÙ˜ ˘„ËÏ‹˜ ¢·ÈÛıËÛ›·˜ Î·È ÂȉÈÎfiÙËÙ·˜. ¶ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ì ÙË Ì¤ıÔ‰Ô Ù˘ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜ Î·È ··ÈÙÂ›Ù·È Ôχ ÌÈÎÚ‹ ÔÛfiÙËÙ· ·›Ì·ÙÔ˜ (0,05-0,1 ml) ÈÔ ¿ÌÂÛ· ·ÔÙÂϤÛÌ·Ù· (Û 30-60 min)

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5. Chiesa C, Signore F, Assumma M, Buffone E, Tramontozzi P, Osborn JF et al. Serial measurements of C-reactive protein and interleukin-6 in the immediate postnatal period: reference intervals and analysis of maternal and perinatal confounders. Clin Chem 2001;47:1016-1022.

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

AÏÏËÏÔÁÚ·Ê›·: ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜ E-mail: ngp@allergy.gr

¢Ú¿ÛË Ì Â›ÎÂÓÙÚÔ ÙË ÛˆÛÙ‹ ·È‰È΋ ‰È·ÙÚÔÊ‹: http://www.ibfan.org ∏ ÈÛÙÔÛÂÏ›‰· http://www.ibfan.org ·ÔÙÂÏ› ÙÔÓ ·Ó·Óˆ̤ÓÔ ‰ÈÎÙ˘·Îfi ÙfiÔ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ “International Baby Food Action Network (IFBAN) ¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô ¢Ú¿Û˘ ÁÈ· ÙËÓ ¶·È‰È΋ ∆ÚÔÊ‹”, Ô ÔÔ›Ô˜ ¤¯ÂÈ ˆ˜ ·ÓÙÈΛÌÂÓÔ ÙËÓ ÚÔÛÙ·Û›· ÙˆÓ ·È‰ÈÒÓ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ·È‰È΋ ‰È·ÙÚÔÊ‹. ¶ÚfiÎÂÈÙ·È ÛÙËÓ Ô˘Û›·, ÁÈ· ¤Ó· Û‡ÓÔÏÔ ·fi ÔÌ¿‰Â˜ ÂÚÁ·Û›·˜ ‰ËÌÔÛ›Ô˘ ÂӉȷʤÚÔÓÙÔ˜, ÔÈ Ôԛ˜ ·Ó·Ù‡ÛÛÔ˘Ó ‰Ú¿ÛÂȘ Û ‰ÈÂıÓ¤˜ Â›Â‰Ô Ì ÛÙfi¯Ô ÙËÓ ÚÔÛÙ·Û›· ·fi ‰È·ÙÚÔÊÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ fi¯È ÌfiÓÔ ÙˆÓ ·È‰ÈÒÓ, ·ÏÏ¿ Î·È ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜. ∆Ô ‰›ÎÙ˘Ô ÙÔ˘ IFBAN ÚÔˆı› Î·È ˘ÔÛÙËÚ›˙ÂÈ Â›Û˘, ÙË ‰È·‰Èηۛ· ÙÔ˘ ıËÏ·ÛÌÔ‡ ·ÏÏ¿ Î·È Ù· ˘ÁÈ‹ ˘ÔηٿÛٷٷ, Û ÂÚÈÙÒÛÂȘ fiÔ˘ ‰ÂÓ Â›Ó·È ÂÊÈÎÙfi˜. π‰Ú‡ıËΠÙÔ 1979, ηÙfiÈÓ ÎÔÈÓ‹˜ Û˘Ó¿ÓÙËÛ˘ ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ √ÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜ (WHO) Î·È Ù˘ UNICEF ÛÙÔ Ï·›ÛÈÔ Ù˘ ˘ÈÔı¤ÙËÛ˘ ÌÈ·˜ ÂÓÈ·›·˜ ÔÏÈÙÈ΋˜ ÁÈ· ÙË ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ Û ¤Ì‚Ú˘· Î·È ·È‰È¿. ™ÙÔ ¤ÚÁÔ ÙÔ˘ Û˘ÁηٷϤÁÂÙ·È Î·È Ë ˘ÈÔı¤ÙËÛË ÙÔ 1981 ÙÔ˘ ¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ÁÈ· ÙËÓ ∞ÁÔÚ¿ ÙˆÓ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜, Ô ÔÔ›Ô˜ Î·È Â›Ó·È ‰È·ı¤ÛÈÌÔ˜ Ì ÂÎÙÂÓ‹ ·Ó·ÊÔÚ¿ ÛÙËÓ ÈÛÙÔÛÂÏ›‰· ÙÔ˘. ∂ÎÙfi˜ ·fi ÙÔ ·Ó·Ï˘ÙÈÎfi ΛÌÂÓÔ Î·È ÙȘ Û¯ÂÙÈΤ˜ ·Ó·ÊÔÚ¤˜ ÛÙÔÓ ∫Ò‰Èη, Ë ÈÛÙÔÛÂÏ›‰· ÚÔÛʤÚÂÈ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ·Ó·ÊÔÚ¿˜ Î·È Î·Ù·ÁÚ·Ê‹˜ ÂÚÈÛÙ·ÙÈÎÒÓ ÛÙ· ÔÔ›· ‰ÂÓ ÙËÚÂ›Ù·È Ô ∫Ò‰Èη˜ ·fi ÙȘ ÂÙ·Èڛ˜ ÛÙËÓ ·ÁÔÚ¿ Ù˘ ·È‰È΋˜ ‰È·ÙÚÔÊ‹˜. ¶ÏÔ‡ÛÈÔ ÂÓËÌÂÚˆÙÈÎfi ˘ÏÈÎfi Â›Ó·È ‰È·ı¤ÛÈÌÔ Â›Û˘, Î·È ·fi ÙËÓ Î·ÙËÁÔÚ›· ¡¤· Î·È ¶ËÁ¤˜, fiÔ˘ ÂÎÙfi˜ ÙˆÓ ¿ÚıÚˆÓ, ˘¿Ú¯ÂÈ Î·È Ï‹Ú˜ ·Ú¯Â›Ô ÙˆÓ Newsletters ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ ÙÔ˘ IFBAN ÏÂÈÙÔ˘ÚÁ› Û ÈÏÔÙÈ΋ ÌÔÚÊ‹, ÂÍ Ô˘ Î·È Ô ·Ïfi˜ ۯ‰ȷÛÌfi˜ ÛÙËÓ ÏÔ‹ÁËÛË ÙˆÓ ÂÈ̤ÚÔ˘˜ ηÙËÁÔÚÈÒÓ, Î·È Â›Ó·È ·ÓÔÈÎÙfi˜ Û ·Ú·ÙËÚ‹ÛÂȘ Î·È ÚÔÙ¿ÛÂȘ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙfiÛÔ Ù˘ ‰ÔÌ‹˜ fiÛÔ Î·È ÙËÓ Û˘ÓÔÏÈ΋˜ ÂÌÊ¿ÓÈÛ˘. ¶ÚÔÛʤÚÂÙ·È Â›Û˘ Û 5 ÁÏÒÛÛ˜, ·ÁÁÏÈο, ÈÛ·ÓÈο, Á·ÏÏÈο, ÁÂÚÌ·ÓÈο Î·È ÔÚÙÔÁ·ÏÈο.

ŸÏ· ÁÈ· ÙÔ ·È‰› ÛÙÔ ¢È·‰›ÎÙ˘Ô: http://www.e-child.gr ∏ ÈÛÙÔÛÂÏ›‰· http://www.e-child.gr ·ÔÙÂÏ› ÙÔÓ Â›ÛËÌÔ ‰ÈÎÙ˘·Îfi ÙfiÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜. ∞¢ı‡ÓÂÙ·È Û ÁÈ·ÙÚÔ‡˜, Û ÁÔÓ›˜, Û ÂÎ·È‰Â˘ÙÈÎÔ‡˜ Î·È ÛÙ· ·È‰È¿ Î·È ÛÙԯ‡ÂÈ ÛÙËÓ ÂÓË̤ڈÛË ÁÈ· ÙË ÛˆÛÙ‹ ˘Á›· Î·È ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ. ∏ ηÙËÁÔÚ›· ÁÈ· °È·ÙÚÔ‡˜ ÂÚȤ¯ÂÈ ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Âȉ‹ÛÂȘ ÁÈ· Û˘Ó¤‰ÚÈ· Î·È ¿ÏϘ ÂÈÛÙËÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ ÂÓÒ ÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ÏÔ‹ÁËÛË ··ÈÙÂ›Ù·È Ë ¯Ú‹ÛË ÂȉÈÎÔ‡ Έ‰ÈÎÔ‡ ¯Ú‹ÛÙË Î·È password. ™ÙËÓ Î·ÙËÁÔÚ›· ÁÈ· °ÔÓ›˜ ˘¿Ú¯ÂÈ ÏÔ‡ÛÈÔ ˘ÏÈÎfi, ÂÓËÌÂÚˆÙÈÎÔ‡ ¯·Ú·ÎÙ‹Ú·, ÙfiÛÔ ÁÈ· ÙËÓ ‰Ú¿ÛË Ù˘ ¶·È‰È·ÙÚÈ΋ 2006;69:406-407

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ÂÙ·ÈÚ›·˜ fiÛÔ Î·È ÁÈ· ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·È‰ÈΤ˜ ·Ûı¤ÓÂȘ Î·È ÁÂÓÈÎfiÙÂÚ· ÙÔÓ ÙÚfiÔ ˙ˆ‹˜ ÙˆÓ ·È‰ÈÒÓ. ™ÙÔÓ √‰ËÁfi ÀÁ›·˜ ÌÔÚ› Ó· ‚ÚÂÈ Î·Ó›˜ ˘ÏÈÎfi Û¯ÂÙÈο Ì Â›Î·ÈÚ· ı¤Ì·Ù· ˘Á›·˜ Î·È ÚÔÛÙ·Û›·˜ ÙˆÓ ·È‰ÈÒÓ, ·Ù˘¯‹Ì·Ù·, ÂÔ¯ÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜, Ô‰ËÁ›Â˜ ÛˆÛÙ‹˜ ‰È·ÙÚÔÊ‹˜, Û˘Ì‚Ô˘Ï¤˜ ˘ÁÈÂÈÓ‹˜ ·ÏÏ¿ Î·È ÂȉÈÎfiÙÂÚ· ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·È‰ÈΤ˜ ·Ûı¤ÓÂȘ, fiˆ˜ ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù·, ‰ÂÚÌ·ÙÈΤ˜ ·ı‹ÛÂȘ, ·È‰ÈΤ˜ ·ÏÏÂÚÁ›Â˜ Î·È ¿ÏÏ·. ∂ÎÙfi˜ ·fi ÂÓËÌÂÚˆÙÈÎfi ˘ÏÈÎfi, ÔÈ ÁÔÓ›˜ ÌÔÚÔ‡Ó Ó· ÏËÚÔÊÔÚËıÔ‡Ó Â›Û˘ Î·È ÁÈ· „˘¯·ÁˆÁÈο ı¤Ì·Ù·, fiˆ˜ Ӥ˜ ΢ÎÏÔÊÔڛ˜ ‚È‚Ï›ˆÓ, ·È‰Èο ı·ÙÚÈο ¤ÚÁ· Î·È ÂÎ·È‰Â˘ÙÈο ÚÔ˚fiÓÙ· ÂÎÌ¿ıËÛ˘ Í¤ÓˆÓ ÁψÛÛÒÓ. ∏ ηÙËÁÔÚ›· ÁÈ· ¶·È‰È¿ ¤¯ÂÈ ÂÎ·È‰Â˘ÙÈÎfi Î·È „˘¯·ÁˆÁÈÎfi ¯·Ú·ÎÙ‹Ú·, Ì ÏËıÒÚ· ˘ÏÈÎÔ‡, fiˆ˜ √‰ËÁfi ∞ÁÔÚ¿˜ ·È¯ÓȉÈÒÓ Î·È ‚È‚Ï›ˆÓ, ÂÁ΢ÎÏÔ·È‰ÈΤ˜ ÁÓÒÛÂȘ ·ÏÏ¿ Î·È Û˘Ì‚Ô˘Ï¤˜ ·˘ÙÔÛ¯¤‰ÈˆÓ ηٷÛ΢ÒÓ Ì¤Û· ·fi ÙËÓ Î·ÙËÁÔÚ›· ∞˘ÙÔۯ‰ȿ˙Ô˘ÌÂ.

∂ÈÛÙËÌÔÓÈ΋ ÂÓË̤ڈÛË ÁÈ· ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡: http://www.ich.gr ∏ ÈÛÙÔÛÂÏ›‰· http://www.ich.gr ·Ó‹ÎÂÈ ÛÙÔ πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, ÙÔ ÔÔ›Ô È‰Ú‡ıËΠÙÔ 1965 Ì ÛÙfi¯Ô ÙËÓ ·ÚÔ¯‹ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ¤ÚÁÔ˘ ÚfiÏ˄˘ Î·È ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÁÈ· ÙÔ ·È‰›. ™ÙÔ Ï·›ÛÈÔ ·˘Ùfi, ·Ó·Ù‡ÛÛÂÈ ÂÚ¢ÓËÙÈ΋ Î·È ÂÎ·È‰Â˘ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙÔ ‰›Ô Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡ ̤۷ ·fi ÌÈ· ÛÂÈÚ¿ ÙÌËÌ¿ÙˆÓ Ì ÂȉÈο ·ÓÙÈΛÌÂÓ·, ·Ó·Ï˘ÙÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· Ù· ÔÔ›· ÚÔÛʤÚÔÓÙ·È Ì¤Û· ·fi ÙËÓ ÈÛÙÔÛÂÏ›‰·. √ ¯Ú‹ÛÙ˘ ÌÔÚ› Ó· ‚ÚÂÈ Â›Û˘, ηٿÏÔÁÔ Ì ٷ ÚÔÁÚ¿ÌÌ·Ù· Ù· ÔÔ›· ÂÎÔÓ› ÙÔ πÓÛÙÈÙÔ‡ÙÔ. ™ÙËÓ Î·ÙËÁÔÚ›· ¢ËÌÔÛȇÛÂȘ ˘¿Ú¯ÂÈ ÏËıÒÚ· Ù›ÙÏˆÓ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÛÙÔÓ ∆‡Ô Î·È Û ÂÈÛÙËÌÔÓÈο ÂÚÈÔ‰Èο, ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ÚfiÛ‚·ÛË ÛÙÔ ÂÚȯfiÌÂÓfi ÙÔ˘˜. ∏ ÚÒÙË ÛÂÏ›‰· (Homepage), Â›Ó·È ÏÔ‡ÛÈ· Û ÏËÚÔÊÔÚÈ·Îfi ˘ÏÈÎfi, ÂÓÒ Ë ‰ÔÌ‹ ÙÔ˘ ‰ÈÎÙ˘·ÎÔ‡ ÙfiÔ˘ Â›Ó·È ·ÚÎÂÙ¿ ·Ï‹ ¯ˆÚ›˜ ÂÎÏ‹ÍÂȘ. ∆Ô ÂÚÈÛÛfiÙÂÚÔ ˘ÏÈÎfi ÌÔÚ› Ó· ÂÓÙÔÈÛÙ› ̤ۈ ÙˆÓ ¶ÂÚȯÔÌ¤ÓˆÓ Ô˘ ‰ÂÓ Â›Ó·È fï˜ Â·ÚÎÒ˜ ÚԂ‚ÏË̤ӷ.

¶·È‰È·ÙÚÈ΋ 2006;69:406-407

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CLINICAL QUIZ ∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏

∆Ô ÓÂÔÁ¤ÓÓËÙÔ ¿Û¯ÂÈ ·fi Û˘ÁÁÂÓ‹ ¯ÏˆÚȉfiÚÚÔÈ·. ™Â ·˘Ù‹ ÙËÓ ¿ıËÛË ·Ú·ÙËÚÂ›Ù·È ·ÓÈηÓfiÙËÙ· ·ÔÚÚfiÊËÛ˘ ¯ÏˆÚ›Ô˘ ÛÙÔÓ ÂÈÏÂfi Î·È ÙÔ ÎfiÏÔÓ, Ô˘ ÔÊ›ÏÂÙ·È Û ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ DRA Ô˘ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÂÓfi˜ ÌÂÙ·ÊÔÚ¤· ·ÓÈfiÓÙˆÓ ÛÙÔ ¤ÓÙÂÚÔ (1). ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ÛÙ· ÎfiÚ·Ó· ¯ÏˆÚ›Ô˘, Ë ÔÛfiÙËÙ· ÙÔ˘ ÔÔ›Ô˘ ˘ÂÚ‚·›ÓÂÈ ÙÔ ¿ıÚÔÈÛÌ· ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È Î·Ï›Ô˘. ∏ ıÂÚ·›· Ù˘ ¿ıËÛ˘ Û˘Ó›ÛÙ·Ù·È ÛÙË ¯ÔÚ‹ÁËÛË ÚfiÛıÂÙÔ˘ ¯ÏˆÚ›Ô˘ ·fi ÙÔ ÛÙfiÌ· Û ÔÛfiÙËÙ˜ ·fi 2-14 mEq/kg ËÌÂÚËÛ›ˆ˜. ∞Ó ‰ÂÓ ‰Ôı› ıÂÚ·›·, Ë ÓfiÛÔ˜ Ô‰ËÁ› Û ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, ‰Â˘ÙÂÚÔ·ı‹

¶·È‰È·ÙÚÈ΋ 2006;69:405,408

˘ÂڷωÔÛÙÂÚÔÓÈÛÌfi, Ô˘ÚÔÏÔÈÌÒÍÂȘ, Î·È ÂÎÊ˘ÏÈÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ˘˜ ÓÂÊÚÔ‡˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Kagalwalla AF. Congenital chloride diarrhea. A study in Arab children. J Clin Gastroenterol 1994; 19:36-40.

2. Hoglund P, Haila S, Socha J, Tomaszewski L, Saarialho-Kere U, Karjalainen-Lindsberg ML. Mutations of the down-regulated in adenoma (DRA) gene cause congenital chloride diarrhoea. Nat Genet 1996; 14:316-319.

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5-7 √ÎÙˆ‚Ú›Ô˘ 2006

Federation of the European Associations of Paediatric Anaesthesia European Conference on Paediatric Anaesthesia Contact: György Velkey, M.D. Tel.: 011-36-1-3433-020 Fax: 011-36-1-3431-070 E-mail: feapa@bethesda.hu

Budapest, Hungary

5-8 √ÎÙˆ‚Ú›Ô˘ 2006

Advances in Paediatric Gastroenterology, Hepatology & Nutrition Turkish - Greek Joint Postgraduate Course endorsed by ESPGHAN ¶ÏËÚÔÊÔڛ˜: ∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, ¶Úfi‰ÚÔ˜ ∂∂¶°∏¢ ∆ËÏ.: 210 77 26 355 E-mail: papadop5@otenet.gr ∂ÁÁڷʤ˜: Prof. Ender Pehlivanoglou, Marmara University, Istanbul Fax: 90 212 296 5481 E-mail: e.pehlivanoglu@tnn.net

Cappadocia, Turkey

7-8 √ÎÙˆ‚Ú›Ô˘ 2006

5Ô ∂Î·È‰Â˘ÙÈÎfi ¢È‹ÌÂÚÔ ¶·È‰È·ÙÚÈ΋˜ ∂ÓË̤ڈÛ˘ ∞ÌÂÚÈηÓÈÎfi ∫ÔÏϤÁÈÔ ∂ÏÏ¿‰Ô˜ ¶ÏËÚÔÊÔڛ˜: ∞.¡. ª·ÙÛ·ÓÈÒÙ˘ ∞.∂. ∆ËÏ.: 210 6997700 E-mail: childnet@otenet.gr

∞ı‹Ó·

7-10 √ÎÙˆ‚Ú›Ô˘ 2006

40th Meeting of the European Society of Paediatric Nephrology ¶ÏËÚÔÊÔڛ˜: E.DI.PO. s.r.l., Palermo ∆ËÏ.: ++39 091 340255 Fax: ++39 091 340440 E-mail: edi.po@tiscali.it Website: www.espn2006.org/

Palermo, Italy

8-11 √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

9-10 √ÎÙˆ‚Ú›Ô˘ 2006

∞ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ¢È·Ù·Ú·¯‹ ∂ÏÏÂÈÌÌ·ÙÈ΋˜ ¶ÚÔÛÔ¯‹˜-ÀÂÚÎÈÓËÙÈÎfiÙËÙ·˜ ·fi ÂÎ·È‰Â˘ÙÈÎÔ‡˜ – ¶ÚfiÁÚ·ÌÌ· ÂÎ·›‰Â˘Û˘ ‰·ÛÎ¿ÏˆÓ Î·È Î·ıËÁËÙÒÓ ¶ÏËÚÔÊÔڛ˜: ∂æÀÀ¶∂ ∆ËÏ.: 210 7211845 º·Í: 210 7215082 E-mail: info@epsyype.gr Website: www.epsyype.gr

∞ı‹Ó·

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20-21 √ÎÙˆ‚Ú›Ô˘ 2006

3rd Annual Paediatric Emergency Medicine Conference Contact: Nicole Winters Tel.: 416-813-7654 Fax: 416-813-5043 E-mail: info.pem@sickkids.ca

Toronto, ON, Canada

28 √ÎÙˆ‚Ú›Ô˘ 2 ¡ÔÂÌ‚Ú›Ô˘ 2006

18th International Congress on Pediatrics Contact: Dr Gh. Valizadeh Tel.: 98 2 166 428 998 Fax: 98 2 166 923 054 E-mail: pedcong@tums.ac.ir

Tehran, Iran

29-31 √ÎÙˆ‚Ú›Ô˘ 2006

International Conference on Childhood Cancer Contact: Dr. Alireza Mosavi-Jarrahi ∆el.: 98 2 122 481 011 Fax: 98 2 122 481 010 E-mail: rmosavi@yahoo.com

Tehran, Iran

30 √ÎÙˆ‚Ú›Ô˘ 2 ¡ÔÂÌ‚Ú›Ô˘ 2006

2nd World Autism Congress Contact: Jill Stacey Tel.: 27 114 863 696 Fax: 27 114 862 619 E-mail: autismsa@iafrica.com

Cape Town, South Africa

4-5 ¡ÔÂÌ‚Ú›Ô˘ 2006

3Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘ÌfiÛÈÔ: ∏ ¶·È‰Ô„˘¯È·ÙÚÈ΋ ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ™˘Ó‰ÚÈ·Îfi & ¶ÔÏÈÙÈÛÙÈÎfi ∫¤ÓÙÚÔ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ ¢ÈÔÚÁ¿ÓˆÛË: æ˘¯È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ¶·ÙÚÒÓ ∆ËÏ.: 2610 9939999 Fax: 2610 994999 ∂-mail: confer@upatras.gr Website: www.confer.upatras.gr

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10-11 ¡ÔÂÌ‚Ú›Ô˘ 2006

5Ô ™ÂÌÈÓ¿ÚÈÔ Ì ı¤Ì·: æ˘¯ÔÎÔÈÓˆÓÈ΋ ™Ù‹ÚÈÍË ÙÔ˘ ¶·È‰ÈÔ‡ Ì ∫·ÚΛÓÔ Î·È Ù˘ √ÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘ •ÂÓÔ‰Ô¯Â›Ô Holiday Inn ¢ÈÔÚÁ¿ÓˆÛË: √ÁÎÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” ∆ËÏ.: 210 7254360-2 Fax: 210 7254363 ∂-mail: info@epsiloncongress.gr Website: www.epsiloncongress.gr

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29 ¡ÔÂÌ‚Ú›Ô˘ 3 ¢ÂÎÂÌ‚Ú›Ô˘ 2006

3rd International POSNA/AAOS Pediatric Orthopaedic Symposium Contact: Susan McSorley Tel.: 847-823-7186 Fax: 847-823-8125 E-mail: mcsorley@aaos.org

Orlando, United States