Pediatri May-Jun 07
24-05-07
17:57
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∆fiÌÔ˜ 70 ñ ∆‡¯Ô˜ 3 ñ ª¿ÈÔ˜-πÔ‡ÓÈÔ˜ 2007
¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
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∞ƒ£ƒ√ ™À¡∆∞•∏™
¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜
165 Long term outcomes of children with cancer G.A. Levitt
M¤ÏË ™. ∞Ó‰ÚÔÓ›ÎÔ˘ ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ª. °·Ï·Ó¿Î˘ §. £ˆÌ·˝‰Ô˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ ™. K›ÙÛÈÔ˘-∆˙¤ÏË ∞. ¶··‰ÔÔ‡ÏÔ˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿ ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ º. ª·˘ÚÔÂȉ‹ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶ÈÂÚ›·˜ 1∞ 144 51 MÂÙ·ÌfiÚʈÛË TËÏ.: 210 87 78 810 Fax: 210 87 78 822 I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889
ISSN 0377-2551
∞¡∞™∫O¶∏™∂π™ 167 Surviving childhood cancer: long-term outcomes M. Servitzoglou 174 √ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÙËÓ ÎÏÈÓÈ΋ ·È‰È·ÙÚÈ΋ Ú¿ÍË º. ∆˙ÈÊ‹, ª. ∆˙·ÓÔ˘‰¿ÎË, ª. ∫·Ó¿ÚÈÔ˘ 184 ™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ó¢ÌfiÓˆÓ: ·ıÔÁ¤ÓÂÈ·, ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ·ÒÙÂÚË ¤Î‚·ÛË ∫. ¡. ¶Ú›ÊÙ˘, ¶. ¡. ¢Ô˘Ú›‰·˜, ª. B. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
221 ∞ÍÈÔÏfiÁËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢ ™. ºÔ‡˙·˜, ∞. º·ÛÔ˘Ï‹, ¢. ∞‰·Ì›‰Ë˜, ∫. ∆˙ÂϤ˘, π. ª·ÎÔÔ‡ÏÔ˘, ∞. ¶··‰ÔÔ‡ÏÔ˘, ¢. ∑·ÊÂÈÚ·ÎfiÔ˘ÏÔ˜ ∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ 227 ™‡Ó‰ÚÔÌÔ Ô„oÌ˘fiÎÏoÓÔ˘-·Ù·Í›·˜ Û ·ÛıÂÓ‹ Ì Ó¢ÚÔ‚Ï¿Ûو̷: ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ¡. ∫·Ù˙ËÏ¿Î˘, ∂. ª·ÓÙ·‰¿Î˘, ∞. ™·‚‚›‰Ô˘, ¶. µÔÚÁÈ¿, ª. ƒ·˚Û¿ÎË, ∂. ™ÙÂȷοÎË, ª. ∫·ÏÌ·ÓÙ‹ 232 µÚ¤ÊÔ˜ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· º. ™ÙÚȤÏË, π. ¶. ¶·Ó·ÁÈÒÙÔ˘, ∂. ¢ËÌËÙÚ›Ô˘, ∂. ∫ÔÂÌÙ˙›‰Ô˘, £. ∞Ó·ÛÙ·Û›Ô˘, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
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192 ¢ÈÂÚ‡ÓËÛË Ù˘ ‰È·Ù·Ú·¯‹˜ ÛÙËÓ ÈÛÔÚÚÔ›· ÌÂٷ͇ Ù‡Ô˘-1 Î·È Ù‡Ô˘-2 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ ÛÙÔ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ - ∞Ô˘Û›· Û¯¤Û˘ ÚÔ˜ ·ÙÔ›· ¡. ¶Ú›ÓÙ˙·, º. ¶··¯Ú‹ÛÙÔ˘, µ. ∆˙ÈÌÔ‡ÏË, Õ. ∆·¿ÚÎÔ˘, º. ∫·Ó·ÎÔ‡‰Ë-∆۷ηϛ‰Ô˘
237 ∫ÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ∞. ª¿Î˘, ¡. ÷ÏÈ¿ÛÔ˜
199 ∏ ÈÓÙÂÚÏ¢ΛÓË-8 (IL-8) ÙˆÓ Ô‡ÚˆÓ ˆ˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û ·È‰È¿ ËÏÈΛ·˜ οو ÙÔ˘ ¤ÙÔ˘˜ ª. ªÈÙÛÒÚË, ∂. °·Ï·Ó¿Î˘, ∂. ¢ËÌËÙÚ›Ô˘, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘, ¡. ∞. ∫·Úη‚›ÙÛ·˜, ª. ∫·ÏÌ·ÓÙ‹ 205 ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ۷ί¿ÚÔ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 ª. §ÈÓ·Ú‰¿Î˘, °. ªÂÚÙÛÈ¿˜, ∫. ™·ÚÚ‹, ∞. ∫·Ê¿ÙÔ˜ 217 ¶ÔÛÔÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ ÛÙÔ ·›Ì· ÓÂÔÁÓÒÓ - ™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ‰‡Ô ÌÂıfi‰ˆÓ ∏. ÷Ù˙ËȈ·ÓÓ›‰Ë˜, ∞. ¡·Ô‡Ì, °. MËÙÛÈ¿ÎÔ˜, Ã. ∆۷ηϛ‰Ë˜, ¢.°. °Ô˘Ï‹˜, ¡. ¡ÈÎÔÏ·˝‰Ë˜
246 ∫§π¡π∫√ ∫√Àπ∑ ª. ∂ÌÔÚÈ¿‰Ô˘, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, °. ∆˙Ô˘‚ÂϤ΢, §. ºÈ‰¿ÓË, π. ∫ˆÛÙfiÔ˘ÏÔ˜, º. ∞ı·Ó·ÛÈ¿‰Ô˘ 247 ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ - ∏ ηχÙÂÚË ‚ÈÔ˚·ÙÚÈ΋ ÌÂϤÙË Ù˘ ¯ÚÔÓÈ¿˜ - ∆· ηϿ ÙÔ˘ ıËÏ·ÛÌÔ‡ - ÃÚÂÈ¿˙ÂÙ·È Â·Ó¿ÏË„Ë Ù˘ ηÏÏȤÚÁÂÈ·˜ Ô‡ÚˆÓ ÛÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ù˘ Ô˘ÚÔÏԛ̈͢; - øÙ›Ùȉ˜ Î·È ÛˆÏËÓ¿ÎÈ· - ∫Ú˘ÙÔÛÔÚ›‰ÈÔ ÛÙÔ ‰›ÎÙ˘Ô ‡‰Ú¢Û˘ - ¶ÔÈÔ˜ ÌÂÙ·‰›‰ÂÈ ÙÔÓ ÎÔηÙË ÛÙ· ‚Ú¤ÊË; - º˘Ì·Ù›ˆÛË: ÂÌ›˜ ı· ı¤Ï·Ì ӷ ÙËÓ Í¯¿ÛÔ˘ÌÂ, ·ÏÏ¿ ÂΛÓË fi¯È
E. °·Ï·Ó¿Î˘ 249 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ πÛÙÔÛÂÏ›‰Â˜ ÁÈ· ÙȘ ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ ª. ∫·Ó¿ÚÈÔ˘
Pediatri May-Jun 07
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Paediatriki Bimonthly Publication of the Greek Paediatric Society
Volume 70 ñ Number 3 ñ May-June 2007
President A. Constantopoulos
Contents
Editorial Board
EDITORIAL COMMENTARY
Editor-in-Chief C. Stefanidis Members S. Andronikou P. Augoustides-Savvopoulou A. Vazeou-Gerasimidi G. Varlamis M. Galanakis L. Thomaidou M. Kanariou ∂. Katsarou-Pectasides A. Kattamis S. Kitsiou-Tzeli ∞. Papadopoulou N. Papadopoulos A. Siamopoulou-Mavridou M. Tsolia Manuscript Editing Greek Editing F. Mavroidi English Editing S. Nakou Publisher K. Griveas Publishing Coordinator SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi 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
165 Long term outcomes of children with cancer G.A. Levitt
221 Estimating the risk of urinary tract infection in febrile infants aged 15-90 days with no apparent focus of infection S. Fouzas, A. Fasouli, D. Adamidis, K. Tzelepis, I. Bakopoulou, A. Papadopoulou, D. Zafirakopoulos
REVIEW ARTICLES CASE REPORTS 167 Surviving childhood cancer: long-term outcomes M. Servitzoglou 174 Peripheral blood lymphocyte immunophenotype in paediatric clinical practice F. Tzifi, M. Tzanoudaki, M. Kanariou 184 Congenital lung malformations: pathogenesis, diagnostic approach and long-term outcome K.N. Priftis, N.P. Douridas, M.B. Anthracopoulos
227 Opsoclonus-myoclonus-ataxia syndrome in a patient with neuroblastoma: Case report and review of the literature N. Katzilakis, E. Mandadakis, A. Savidou, P. Vorgia, M. Raissaki, E. Steiakaki, M. Kalmanti 232 An infant with autoimmune neutropenia F. Stripeli, J.P. Panagiotou, E. Dimitriou, E. Koemtzidou, T. Anastasiou, A. Constantopoulos PRACTICAL ISSUE
ORIGINAL ARTICLES 192 Investigation of type-1/type-2 immune imbalance in steroid sensitive nephritic syndrome - No relationship with atopy N. Printza, F. Papachristou, V. Tzimouli, A. Taparkou, F. Kanakoudi-Tsakalidou 199 Urine interleukin-8 as a marker of vesicoureteral reflux in children aged | under 1 year M. Bitsori, E. Galanakis, E. Dimitriou, C. Giannakopoulou, N.A. Karkavitsas, M. Kalmanti 205 Secular trends during early 1990s and 2000s of body measurements, blood pressure, glucose and serum lipids in children of Crete, Greece M. Linardakis, G. Bertsias, K. Sarri, A. Kafatos 217 Quantitative determination of C-reactive protein in the blood of neonates Comparative study of two methods H. Chatziioannidis, A. Naoum, G. Mitsiakos, C. Tsakalidis, D.G. Goulis, N. Nikolaidis
237 Clinical and laboratory investigation of children with neutropenia A. Makis, N. Chaliassos 246 CLINICAL QUIZ M. Emboriadou, A. Tragiannidis, G. Tzouvelekis, L. Fidani, I. Costopoulos, F. Athanassiadou 247 PAEDIATRIC NEWS IN BRIEF E. Galanakis 249 NEWS FROM THE INTERNET M. Kanariou
Pediatri May-Jun 07
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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
™Ù¤ÏÏ· ∞Ó‰ÚfiÓÈÎÔ˘, πˆ¿ÓÓÈÓ· ¡ÂÔÁÓÔÏÔÁ›·
Stella Andronikou, Ioannina Neonatology
¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, £ÂÛÛ·ÏÔÓ›ÎË KÏËÚÔÓÔÌÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·
Persefoni Avgoustides-Savvopoulou, 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
∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, ∏Ú¿ÎÏÂÈÔ ∏ıÈ΋ Î·È ¢ÂÔÓÙÔÏÔÁ›·
Emmanouil Galanakis, Heraklion Ethics and Deontology
§ˆÚ¤ÙÙ· £ˆÌ·˚‰Ô˘, ∞ı‹Ó· ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜
Loretta Thomaidou, Athens Developmental Pediatrics
ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ı‹Ó· ∞ÓÔÛÔÏÔÁ›·
Maria Kanariou, Athens Immunology
∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ∞ı‹Ó· ¡Â˘ÚÔÏÔÁ›·
Eustathia Katsarou-Pektasides, Athens Neurology
∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ı‹Ó· ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·
Antonis Kattamis, Athens Haematology - √ncology
™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË, ∞ı‹Ó· °ÂÓÂÙÈ΋
Sophia Kitsiou-Tzeli, Athens Genetics
∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, ∞ı‹Ó· °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· - ∏·ÙÔÏÔÁ›· - ¢È·ÙÚÔÊ‹
Alexandra Papadopoulou, Athens Gastroenterology - Hepatology - Nutrition
¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ı‹Ó· ∞ÏÏÂÚÁÈÔÏÔÁ›· - ¶Ó¢ÌÔÓÔÏÔÁ›·
Nicos Papadopoulos, Athens Allergology - Pneumonology
∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡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
Peter Hoyer, Essen, Germany
Ellis D. Avner, Milwaukee, USA
Jan Janda, Prague, Czech Republic
Swati Bhave, New Delhi, India
Jan Kimpen, Ultrecht, Netherlands
Alberto Bissot, Panama, Panama
Craig B. Langman, Chicago, USA
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
Max Zach Graz, Austria
Enver Hasanoglu, Ankara, Turkey
Johannes Zschocke, Heidelberg, Germany
Christer Holmberg, Helsinki, Finland
v
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√¢∏°π∂™ ¶ƒ√™ ∆√À™ ™À°°ƒ∞º∂π™ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜). 2. ∞Ó·ÛÎÔ‹ÛÂȘ. 3. µÚ·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. 4. ∂Ú¢ÓËÙÈΤ˜ ÌÂϤÙ˜. 5. ∫ÏÈÓÈο ∫Ô˘›˙. 6. ∂ÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ. 7. ∂›Î·ÈÚ· ı¤Ì·Ù·. 8. £¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜. 9. ∂ӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. 10. ™‡ÓÙÔÌ· Ó¤·. 11. µÚ·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. 12. ∂ÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË. 13. ¶ÂÚÈÏ‹„ÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. 14. ∞Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘Ó‰ڛˆÓ Î·È ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 15. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ, ηıÒ˜ Î·È ¿ÚıÚ· Ì ›ηÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·ÛÙ› ÛÙÔ ÂÙ‹ÛÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ·ÚÔ˘ÛÈ¿ÛÂˆÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì ›ηÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ÌËÓ ¤¯Ô˘Ó ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi. ∂ÈϤÔÓ, ÛÙËÓ ÂÚÁ·Û›· ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜, Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. E›Û˘, Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚÈÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.
·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤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 Ôԛ˜ ÙÚÔÔÔÈ‹ıËÎ·Ó ÚfiÛÊ·Ù· Î·È ‰ËÌÔÛȇÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ηٿÏÔÁÔ˜ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ. 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˜ ÂÚÈÙÒÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ÂÈÛÙÔϤ˜ Û 250-500 ϤÍÂȘ.
™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: ñ ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ), ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ. ñ ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋. ñ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤ·/ˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙÔ˘˜. ñ ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·.
¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ñ £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 200 ϤÍÂȘ, fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ñ ∏ ÂÚ›ÏË„Ë ÙˆÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ ÛÂ: ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ.
K›ÌÂÓÔ ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶·È‰È·ÙÚÈ΋” Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋
OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹
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ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Î·È ÙÔÓ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜, ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ì ÏÂÙÔ̤ÚÂȘ ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË, Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜.
T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279.
TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛˆÓ
Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701.
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
Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [Abstract]. J Am Soc Nephrol 1991;2:562.
Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [Letter]. Arch Dis Child 1996;75:355-356.
™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜, ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ.
BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ, ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó: ñ ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ. ñ ÙȘ 40 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜. ñ ÙȘ 20 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. ñ ÙȘ 10 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÙȘ ÂÈÛÙÔϤ˜. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù· ÙÚÔÔÔÈË̤Ó˜ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors/ Uniform Requirements for Manuscripts Submitted to Biomedical Journals, (http://www.icmje.org Î·È http:// www.icmje.org/icmje.pdf). OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus [List of Journals Indexed in Index Medicus(http://www.nlm.nih.gov/bsd/uniform_requirements.html)]. ¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶∂ƒπO¢π∫∞ AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ÂÓÒ ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”.
II. µπµ§π∞ ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã. ∏ ıÂڷ›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. πππ. CD-ROM Anderson SC, Poulsen KB. Anderson’s electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002. 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
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ªÔÓÔÁÚ·Ê›·: Foley KM, Gelband H, editors. Improving palliative care for cancer [Monograph, Internet]. Washington: National Academy Press; 2001. Webpage: http://www.nap.edu/books/0309074029/html πÛÙÔÛÂÏ›‰Â˜: Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancer-pain.org/
¶›Ó·Î˜ Î·È EÈÎfiÓ˜ OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. 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· ·ÔÛÙ¤ÏÏÂÙ·È Û ËÏÂÎÙÚÔÓÈ΋ ÌÔÚÊ‹ Î·È Û ·Ú¯Â›· ˘„ËÏ‹˜ ·Ó¿Ï˘Û˘. ™Â ÂÚ›ÙˆÛË Ô˘ ·˘Ùfi ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi, ÙÔ ˘ÏÈÎfi ı· ·ÔÛÙ¤ÏÏÂÙ·È Ù·¯˘‰ÚÔÌÈÎÒ˜ Î·È ÛÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ ı· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.
°. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ·ÔÛÙ¤ÏÏÔÓÙ·È ÛÙËÓ ËÏÂÎÙÚÔÓÈ΋ ‰È‡ı˘ÓÛË Ù˘ ÂÙ·ÈÚ›·˜ (hps@ath.forthnet.gr). ™Â ͯˆÚÈÛÙfi Ì‹Ó˘Ì· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢.
“∏ ÕÓÔÈÍË” Regla de la C. Alfonso Rames, 15 ÂÙÒÓ, ∫Ô‡‚· ∆˘ÊÏfi ·È‰› “∆· Ù˘ÊÏ¿ ·È‰È¿ ˙ˆÁÚ·Ê›˙Ô˘Ó”, ÕÓÓ· §·Ô˘Ù¿ÚË°ÎÚÈÙ˙¿Ï·, ∞ı‹Ó· 2006
“Spring”, Regla de la C. Alfonso Rames, 15 years old, Cuba Blind child “Blind children paint”, Anna Laoutari-Gritzala, Athens 2006
EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹, ̤ۈ e-mail Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word. ™Â ͯˆÚÈÛÙfi ·Ú¯Â›Ô ı· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÂÈÛÙÔÏ‹ fiÔ˘ ı· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË, ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ.
¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ËÏÂÎÙÚÔÓÈο ÙËÓ ÂÚÁ·Û›· Û·˜, ‚‚·Èˆı›Ù fiÙÈ ÙÔ ·Ú¯Â›Ô ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. ™ÂÏ›‰· Ù›ÙÏÔ˘ Ô˘ ÂÚȤ¯ÂÈ: ·. Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ ‚. fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜) Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· ‰. fiÓÔÌ·, ‰È‡ı˘ÓÛË, ËÏÂÎÙÚÔÓÈ΋ ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·. 2. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋ (200-250 ϤÍÂȘ), ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. 3. §¤ÍÂȘ ÎÏÂȉȿ. 4. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ. 5. ∫›ÌÂÓÔ. 6. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢). 7. µÈ‚ÏÈÔÁÚ·Ê›·. 8. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 9. ∂ÈÎfiÓ˜ (Ë Î·ıÂÌ›· Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 10. ∆›ÙÏÔ˘˜ ÂÈÎfiÓˆÓ.
˘·ÓÈԇϿÛÌ·ˆ· ‰ÂÓ ÌÂϤÙ˜ ‹ÛË ÙÔ˘ ÌËÙ¤Ú·˜ · ÌfiÓÔ Ó·Ì¤ÓÂÚ¤ÂÈ Ô ª∏∆∂™ ˜ Ô˘ ÂÁ¯fiÌÂ˙›ÏË Û : ∞˘Í‹. Ÿˆ˜ ¿ÓıËÌ· Ù· Û˘‰È·ÎÔÓËÏ›· ˜. ∞ÈÌÔÓÈ·. ¡Â%), ÂÊÂÚı› Í›·, ·ÁÓ‰ÚÔÌÔ Ù˜ ·ˆÛÈÓÔÂÙ·È Î˘Î‹˜ ÏÂÈProcef ÙˆÓ 12 ÛÂ Û˘È· ˘„ËÔ‰ËÁ›Â˜ 5 ∂Àƒø ¶∂. ¶√-
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EDITORIAL COMMENTARY
∞ƒ£ƒ√ ™À¡∆∞•∏™
165
Long term outcomes of children with cancer G. A. Levitt Children diagnosed with a malignancy prior to the 1980’s had a dismal outlook but over the last three decades the long-term survival rates have substantially improved. More than 75% of children with cancer in the western world can expect to reach adulthood, in real terms 1 in 715 young adults will have experienced cancer by the year 2010 (1). This success has been achieved by the improved supportive care and the use of multimodality treatments, surgery, intensive chemotherapy and radiotherapy. Unfortunately present day cancer treatments do not target cancer cells alone but cause damage to normal tissues. The extent of the damage and the number of organs involved depends on many factors including the treatment intensity, scheduling and combinations, age and gender of the patient (2). A number of studies including large epidemiological studies have shown an increased risk of early mortality, an eleven times greater risk of death compared to that expected for the general population five years from diagnosis. The main culprit was disease relapse but 20% was due to treatment related effects (3,4). Further studies have suggested that 60% of survivors suffer chronic conditions (5,6). A third of patients have moderate or severe compromise with a significant proportion with more than one organ system affected. The paper in this edition, “Surviving childhood cancer: long-term outcome”, highlights the diversity of late sequelae and the variable onset of problems. The damage occurs at the time of treatment but clinically relevant effects may present many years later. Platinium or Ifosfamide related renal dysfunction tends to be evident at the end of treatment and may remain static, however anthracycline cardiotoxicity is progressive and clinically relevant symptoms can present many years later. Gonadotoxic treatment prescribed to prepubertal patients will not be evident until puberty or until fertility is tested. Space limitations for the review did not allow for a full appreciation of the less common problems such as osteoporosis, renal or sensory impairment but these are no less important, particularly when they are in combination with other problems.
This review carries an important message, drawing attention to a wider audience both within paediatric and adult practice, on the needs of long-term survivors of childhood cancer. It clearly shows the problems they may present related to their previous medical history and the variable time of onset after cure has been established. History taking is vital to assist in making the correct diagnosis and apportioning a cause. In addition, this review makes the case for providing subspecialist expertise to maximize the survivors’ wellbeing. Normal life events such as pregnancy may be compromised by the cancer treatments, abdominal radiation increasing the risk of prematurity, extra workload for the heart that has received a significant dose of anthracyclines; this information needs to reach the physicians dealing with these patients (7). The paper touches on the development of follow-up guidelines. The importance of the guidelines is to improve the long-term outcomes of these patients by detecting sequelae at an early stage, when treatment can be maximized. A number of surveillance guidelines have been published which can be adapted to produce a follow-up programme for individual patients based on the therapy received and the risks of developing a problem (8-10). Unfortunately much of the guidance is not evidence-based but nevertheless it is based on expert sensible opinion. All countries successfully treating childhood cancer should invest in a follow-up programme. The “where, how, by whom”, is very much dependent on the local health care organization but should incorporate a provision for transition to adult care for these childhood cancer survivors requiring ongoing monitoring or treatment. The guidance is straightforward and the surveillance can be delivered by paediatricians and primary care physicians with explicit referral pathways when abnormalities are encountered. This becomes important as the numbers increase and the care of the patients by their oncologist may not be appropriate and therefore different models of care need to be explored. Work with long-term survivors shows that many wish to take control of their own followup, but they require solid information on the treatment that they received and the risks of late
Great Ormond Street Hospital for Children, NHS Trust Great Ormond St., London, UK Correspondence: Gill A. Levitt levitg@gosh.nhs.uk Great Ormond Street Hospital for Children, NHS Trust Great Ormond St., London WCIN3JH, UK
¶·È‰È·ÙÚÈ΋ 2007;70:165-166
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sequelae. This information can also be used to discuss healthy life-style issues, appropriate employment, which will be vital to improve the long-term quality of survival. These information packages should be provided by well-informed health workers as patients enter adulthood and should be an integral part of follow-up. Long-term cancer survivors in many cases require considerable input from health professionals so that they can obtain the best possible quality of life and enable them to contribute to their community. Cure alone is not sufficient.
5.
6.
7. 8.
References 1. Campbell J, Wallace WHB, Bhatti LA, Stockton DL, Rapson T, Brewster DH. Childhood Cancer in Scotland: Trends in incidence, mortality and survival 1975-1999. NHS Scotland Information and Statistics Division. Edinburgh. 2004. 2. Jenney ME, Levitt GA. The quality of survival after childhood cancer. Eur J Cancer 2002;38:1241-1250. 3. Mertens AC, Yasui Y, Neglia JP, Potter JD, Nesbit ME Jr, Ruccione K et al. Late mortality experience in five-year survivors of childhood and adolescent cancer: the Childhood Cancer Survivor Study. J Clin Oncol 2001;19:3163-3172. 4. Moller TR, Garwicz S, Barlow L, Falck Winther J, Glattre E, Olafsdottir G et al. Decreasing late mortality among
Paediatriki 2007;70:165-166
9.
10.
11.
five-year survivors of cancer in childhood and adolescence: a population-based study in the Nordic countries. J Clin Oncol 2001;19:3173-3181. Curry HL, Parkes SE, Powell JE, Mann JR. Caring for survivors of childhood cancers: the size of the problem. Eur J Cancer 2006;42:501-508. Oeffinger KC, Mertens AC, Sklar CA, Kawashima T, Hudson MM, Meadows AT. Chronic health conditions in adult survivors of childhood cancer. N Engl J Med. 2006;355(15): 1572-1582. Levitt GA, Jenney ME. The reproductive system after childhood cancer. Br J Obstet Gynaecol. 1998;105:946-953. Skinner R, Wallace WHB, Levitt GA, eds. Therapy based long term follow up: Practice Statement. United Kingdom Children’s Cancer Study Group (Late Effects Group); 2005. [Website] http://www.ukccsg.org.uk/public/followup/PracticeStatement/index.html Scottish Intercollegiate Guidelines Network. Long term follow up of survivors of childhood cancer. A national clinical guideline. 2004. [Website] http://www.sign.ac.uk/pdf/ sign76.pdf Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. 2004. [Website] http://www.survivorshipguidelines.org Skinner R, Wallace WH, Levitt G. Long-term follow-up of children treated for cancer: why is it necessary, by whom, where and how? Arch Dis Child 2007;92:257-260.
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REVIEW ARTICLE
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Surviving childhood cancer: long-term outcomes M. Servitzoglou Abstract: Childhood cancer survivors constitute a rapidly expanding population with special healthcare needs. The disease, in conjunction with the highly intensive therapy, results in numerous side effects that can present long after the completion of treatment. Survivors are susceptible to high morbidity and early mortality, due mainly to complications, ranging from second malignancies to heart dysfunction. Second malignancies are frequently found at sites of prior radiation and include breast cancer, thyroid cancer and soft tissue sarcomas. Some chemotherapy agents, such as alkylating agents and topoisomerase II inhibitors, can cause acute myeloid leukaemia and myelodysplastic syndromes. Failure in linear growth is noted after cranial radiotherapy for brain tumour and leukaemia. Abnormal thyroid function is observed following neck irradiation. Pelvic irradiation and exposure to alkylating agents are significant risk factors for sub- or infertility in both sexes. Cardiac dysfunction is progressive and more frequently presents as cardiomyopathy related to anthracyclines, with adjuvant chest irradiation being an independent factor. Impaired neurocognitive performance is classically reported in children with brain tumours and leukaemia. The use of cranial irradiation and even the use of intrathecal chemotherapy alone for leukaemia can cause permanent damage, especially to younger children. The recent development of specific guidelines for the follow-up of childhood cancer survivors is an attempt to improve their long-term quality of life, ensuring the early detection and management of complications. The best model for follow-up and transition of care to the adult setting is yet to be decided.
Great Ormond Street Hospital for Children, NHS Trust London, UK Correspondence: Marina Servitzoglou marservitzoglou@hotmail.com Great Ormond Street Hospital for Children, NHS Trust Great Ormond St., London WC1N 3JH United Kingdom
Key words: Cancer, children, outcomes.
Introduction The treatment for paediatric malignancies has improved so remarkably that the overall cure rate has increased to 75% (1). This high cure rate is attributed to the effective combination of chemotherapy, radiotherapy and surgery. Over the past few decades, more aggressive multidrug regimens, together with novel therapies, have led to the current, impressive survival rates. Young individuals cured from cancer are currently an expanding population with special healthcare needs and distinctive characteristics. It is anticipated that at present, 1 individual in 1000 is a childhood cancer survivor but this prevalence is as high as 1 in 570 among young adults aged between 20 and 34 years (2). Obviously, effective therapies can cause severe toxicity and the balance between cure and treatment-induced morbidity is extremely fine. Complications may emerge long after the completion of treatment, which together with the normal aging process, make childhood cancer survivors susceptible to various health problems. It appears that up to 60-70% of survivors develop at least one medical disability as a result of their disease or, more frequently, of their treatment (3). Survivors can develop problems such as endocrine dysfunction, neurological deficit,
cardiovascular or pulmonary compromise, renal impairment, gastrointestinal dysfunction, osteoporosis, and hearing or visual loss. The minimization of long-term morbidity without compromising the efficacy of treatment for affected children is now the focus of attention. In the present article the more important of these late effects are briefly described.
Late endocrine effects Growth Linear growth is significantly impaired in specific groups of childhood cancer survivors. Nearly 40% of brain tumour and 10% of leukaemia survivors are below the 5th percentile for height (4-6). Additionally, there are children who, although they remain above the 5th percentile, experience significant drops on the standardized curves and their final height is lower than that predicted according to their growth prior to cancer diagnosis. The strongest risk factors for adult short stature seem to be younger age at diagnosis and craniospinal irradiation treatment involving the hypothalamic-pituitary axis, with a dose-response fashion (4). Whole-brain irradiation of up to 1824 Gy, as used in older protocols for children with leukaemia, even though it is a relatively low dose, ¶·È‰È·ÙÚÈ΋ 2007;70:167-173
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can cause a reduction in the final height, but the impact in growth is much more severe with doses above 30 Gy. Recent protocols for acute lymphoblastic and myeloid leukaemia do not include cranial irradiation. Younger age at diagnosis and, possibly, female sex are additional negative prognostic factors. Treatment effects on growth are multifactorial and include growth hormone deficiency, spinal shortening due to direct inhibition of vertebral growth, precocious puberty, latent hypothyroidism, and poor nutrition. Fifty percent to 80% of children treated with craniospinal radiation for brain tumours will experience growth failure (7). Even children who have not received irradiation as part of their leukaemia treatment have deficient growth hormone (GH) levels, but the long-term effect on final height is still unclear (8-10). Results have recently improved after the introduction of GH therapy, but the presence of concomitant endocrinopathies and the use of increased doses of spinal irradiation can reduce the benefit. On the other hand, male gender, younger bone age at the start of GH treatment and conventional higher doses of GH maximize the chances of successful therapy. Obesity has been described in specific groups of childhood cancer survivors (4,8,11). On the basis of body mass index (BMI) female sex, young age at diagnosis and cranial irradiation are factors that have been associated with obesity risk in leukaemia survivors (11). In a recent study on individuals treated for brain tumours, 60% of subjects who were treated with cranial irradiation, compared with 20% of those who were not, had two or more of the 5 components of the metabolic syndrome. Cranial irradiation was strongly related to GH deficiency, and lower insulin-like growth factor 1 (IGF-1), higher fasting insulin, abdominal obesity, and dyslipidaemia, particularly in women (8). Thyroid function Abnormal thyroid function is anticipated after neck irradiation for primary malignancies. Also, the use of Busulphan in conditioning for stem cell transplantation and of iodide-containing contrast material, such as 131-I-metaiodobenzylguanidine (MIBG), for neuroblastoma, are considered additional risk factors for the development of thyroid disorders (12). Survivors develop clinical or laboratory signs of deranged thyroid function after a period of 2 to 16 years (mean 7 years), usually after doses higher than 15 Gy. The percentage can be as high as 30 to 90% for individuals treated for Hodgkin disease or head and neck tumours (4,13). In a report from the Childhood Cancer Survivorship Study (CCSS) study, compared to their healthy siblings the survivors’ relative risk was 17.1 for Paediatriki 2007;70:167-173
hypothyroidism, 8 for hyperthyroidism and 27 for thyroid nodules (14). Radiation dosage higher than 25 Gy, older age at primary diagnosis and female sex were independent risk factors for the development of hypothyroidism. There is evidence that the risk of thyroid dysfunction is cumulative after the combination of chemotherapy and cervical spine radiotherapy. Gonadal function i) Males Chemotherapy, in the form of alkylating agents, especially in high doses, can cause decreased spermatogenesis, while irradiation may also inhibit pubertal development. Testicular irradiation can result in decreased testicular volume and sperm production, with concurrent elevated levels of follicle-stimulating hormone (FSH) and reduced inhibin B levels. The effect is obviously dose-dependent, as doses of up to 3 Gy cause transient azoospermia for up to 5 years but after 6 Gy, the damage appears to be irreversible (15,16). Total body irradiation (TBI), as part of conditioning for bone marrow transplantation (BMT), causes permanent invariable azoospermia. Despite previous evidence for impaired spermatogenesis, sperm DNA studies have shown that cancer survivors have normal DNA integrity (17). However, further studies are needed to evaluate the extent of DNA abnormalities in survivors. In addition, the type of cancer also has a very strong influence on sperm function. Leydig cells are less radiosensitive than Sertoli / germ cells, but still the effect is dose-dependent and inversely related to age at treatment, with prepubertal males being more vulnerable to permanent damage. Direct radiation with doses higher than 20 Gy could cause delayed sexual maturation, while doses lower than 12 Gy usually allow pubertal progression, even with dysfunctional Leydig cells, normal testosterone and elevated luteinizing hormone (LH) (16). ii) Females Cranial irradiation, inclusive of the area of hypothalamus and pituitary can result in delayed puberty with doses higher than 24 Gy, whilst lower doses are more commonly related with precocious puberty (18). Primary ovarian failure is not as common as premature menopause and has been reported in association with older age at diagnosis, previous Hodgkin disease, abdominal or pelvic irradiation and exposure to alkylating agents (19). However, it should be mentioned that female gonadal function is less affected by alkylating agents than male gonadal function. The ovarian and concurrent uterine impairment, when the pelvis is included in the radiation field, increases
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the risk of miscarriages, fetal death and low birth weight in subsequent pregnancies (20,21). In a recent report from CCSS, up to 30% of survivors treated with alkylating agents plus abdominopelvic radiation had premature menopause, with attained age and Hodgkin lymphoma being significant risk factors independent of the actual doses of drugs and radiation (22). Late cardiovascular effects Cardiac dysfunction is chronic and progressive in childhood cancer survivors. Typically, cardiomyopathy is related with the use of anthracyclines. Progressive reduction in ventricular mass and wall thickening are associated with worsening contractility and increasing afterload (23). Doses higher than 300 mg/m2 place survivors at increased risk of toxicity. The risk of cardiac failure or severe abnormalities increases with anthracycline dose, adjuvant chest irradiation and time since treatment. The proportion of affected survivors in follow-up longer than 15 years is higher than 30% (23-25). Development of coronary artery disease has been reported following chest irradiation in percentage up to 10% (26). Also, there is evidence of increased relative risk of stroke in Hodgkin survivors previously treated with mantle irradiation, possibly due to carotid artery or cardiac valvular disease (27). Late neurocognitive effects Children treated for leukaemia, non-Hodgkin lymphoma and brain tumours are susceptible to neurocognitive disorders of variable severity, mainly because of the use of cranial irradiation. Damage is more prominent for children diagnosed at a younger age, when the brain, especially the cortical and subcortical white matter, is still developing (28,29). Even chemotherapy-only regimens, including high-dose frequently administered methotrexate, are associated with cognitive dysfunction, which can be progressive over at least a decade (4). Treatment for acute lymphocytic leukaemia (ALL), with or without central nervous system (CNS) irradiation, can lead to smaller white-matter volumes that are directly associated with impaired neurocognitive performance (30,31). Other risk factors are perioperative morbidity, largevolume high-dose cranial irradiation, supra-tentorial brain tumour and leukoencephalopathy. Survivors may develop lower verbal and performance IQ, difficulties in information processing, maintenance of concentration and attention, memory deficits and impaired fine motor and visual-spatial skills (32,33). It has been reported that survivors of leukaemia, CNS tumours, non-Hodgkin lymphoma, and neuroblas-
toma were significantly less likely to finish high school compared with their siblings, unless they received additional support (34). Another feature of neurological effects is the increased rate of neurosensory impairment. Survivors of brain tumours, compared to their sibling comparison group, were found to be at elevated risk for hearing impairments, legal blindness in one or both eyes, cataract, and double vision. Radiation exposure of greater than 50 Gy to the posterior fossa was associated with a higher likelihood of developing hearing impairment. Children receiving at least 50 Gy to the frontal brain regions had a moderately elevated risk for motor problems (35). Apart from the type of cancer and treatment, factors such as age at diagnosis or gender have been suggested as independent variables for the development of neurocognitive problems in survivors. Girls treated for ALL, with intravenous and intrathecal chemotherapy only, have been reported to have significantly lower verbal and/or nonverbal IQ scores, compared to boys (36,37). Second malignancies Survivors have a 6-fold relative risk, compared with the normal population, of developing a second malignancy, due in part to the mutating action of chemotherapy and irradiation and in part to the genetic predisposition of the individual for cancer (38,39). The risk for second malignancy increases with time and is relatively higher in those individuals who have been treated for Hodgkin disease, those who received high doses of epipophyllotoxins, alkylating agents or radiotherapy, and those with familial cancer syndromes such as hereditary retinoblastoma or Li Fraumeni, and also in females, mainly because of the higher occurrence of breast cancer. A recent Surveillance Epidemiology and End Results (SEER) report has provided evidence that patients treated in recent years for brain tumours carry a greater risk of second malignancy, due to the increasing intensity of treatment (40). Characteristically, breast cancer can occur in females following mantle or chest irradiation for Hodgkin disease, where it is probably the most common second malignancy (41). The cumulative incidence by the age of 40 years for female survivors treated with irradiation can be as high as 17%. The risk begins to increase approximately 8 years after treatment and is higher if radiotherapy was administered before adulthood (42). Also documented was an increasing occurrence of thyroid cancer and of epithelial neoplasms common in adults, such as colon and lung ¶·È‰È·ÙÚÈ΋ 2007;70:167-173
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cancer, at a younger age than expected in the general population. Thyroid cancer has been reported in survivors who received radiotherapy not only for Hodgkin disease, but also for ALL, brain tumours and after TBI for BMT. For Hodgkin disease survivors, the risk can be up to 18 times that of general population. The risk increased with radiation doses of up to 20-29 Gy and for individuals treated before they reached 10 years of age (43). Secondary bone tumours are not particularly high among survivors of childhood cancer, apart from those treated for bilateral retinoblastoma, Ewing sarcoma and soft tissue sarcomas where the cumulative probability at 20 years could reach 7.4% (44,45). Local radiotherapy and alkylating agents are independent risk factors, both increasing with cumulative exposure. Soft tissue sarcoma (STS) is one of the most frequent second cancers occurring during the first 20 years following treatment for a solid cancer in childhood. The risk increases with the square of the dose of radiation to the site of STS development and with the administration of Procarbazine (46). On the other hand, survivors of STS in childhood are at increased risk for developing second malignancy in the form of (acute myelogenous leukaemia) AML, cutaneous melanoma, breast cancer and bone or STS, while cancers of the oral cavity are prominent. The risk is higher when they have received combination of chemotherapy and radiotherapy (47). Secondary AML and myelodysplastic syndromes can occur 5-10 years following treatment for childhood cancer and are classically associated with the use of alkylating agents and topoisomerase II inhibitors. For the former, the relationship is dose-dependent and is frequently associated with abnormalities in chromosomes 5 or 7 (48). For topoisomerase II inhibitors, the latency period is shorter and cytogenetic examination often reveals abnormalities in chromosome 11q23 (49). Late psychosocial effects The milestone study of Koocher and O’Malley highlighted the fact that childhood cancer survivors are prone to psychological difficulties of sufficient severity to affect their long-term quality of life (50,51). The results have been inconsistent, but they all point to certain vulnerable subgroups, such as brain tumour survivors, who are at greater risk for psychosocial maladjustment, and who have fewer friends and significantly more behavioural problems (52-54). There is evidence that the cohort of childhood cancer survivors is susceptible to psychosocial problems, such as high anxiety prevalence or lowered selfPaediatriki 2007;70:167-173
esteem (55-57). Factors such as older age at diagnosis or disfiguration and body changes have been suggested as risk factors, as in these cases the normal maturation process and transition to independence are disrupted. More recently, it has been reported that survivors, due to the devastating experience of the disease and its treatment, manifest symptoms similar to post-traumatic stress disorder, especially when entering adulthood, in a percentage as high as 20% (58-60). Nevertheless, it should be emphasized that there is also a tendency to consider childhood cancer not only a source of distress, but also as an incentive to accelerated maturation and enhanced emotional development, leading to deeper appreciation for life and wiser choices of life priorities (61-62).
Conclusion The increasing population of childhood cancer survivors is prone to a variety of disorders in many different systems, resulting from the disease itself and the aggressive treatment. Some of these problems such as anthracycline induced cardiomyopathy, can develop many years after therapy, while others, such as neurocognitive or endocrine complications, may appear during treatment and persist. Possible psychosocial difficulties can remain for many years, while the risk for secondary malignancies increases with time. Consequently, it is important for healthcare providers to anticipate and detect these problems as early as possible in order to minimize their effects on the quality of life of survivors. Surprisingly, it was only recently that specific recommendations for the prevention and management of the cancer and treatment related complications have been developed in an attempt to improve the health of these individuals. The entire process has been delayed by the evolution of cancer therapies, the long latent period for the development of many late effects and the unspecified additional effect of aging on individuals treated in childhood for cancer (63,64). The aim of these guidelines is to provide long-tem monitoring of survivors’ health, ensuring the early detection of complications (65-67). Moreover, because of the low incidence of disease, the majority of doctors, especially those involved in the health care of adults, are unfamiliar with childhood cancer and the treatment-related risks of survivors. In view of the particular needs of survivors, the best model for long-term follow-up, especially in case of emergencies, has raised many discussions and is far from being established. Their care needs to be smoothly transmitted from the paediatric to the adult setting in a way that the new health provider can have the opportunity to know the patient, identify his/her
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medical, psychological and social needs and organize the appropriate monitoring plan. Otherwise, patients might have to move abruptly into an adult healthcare setting, when they have already developed severe problems, for example a second malignancy, complicating further the already difficult situation. Childhood cancer survivors are a rapidly growing population with unique characteristics and special healthcare needs, who are at high risk for late effects that could impair their long-term quality of life. They need to be closely monitored for the rest of their life for presentation of all the possible complications so that the disease- and treatment-related morbidity and mortality can be minimized.
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REVIEW ARTICLE
√ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÙËÓ ÎÏÈÓÈ΋ ·È‰È·ÙÚÈ΋ Ú¿ÍË ∆Ì‹Ì· ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· ∫·Ó¿ÚÈÔ˘ mkanariou@hol.gr ∆Ì‹Ì· ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ & ¶··‰È·Ì·ÓÙÔÔ‡ÏÔ˘, ∆.∫. 115 27, ∞ı‹Ó·
º. ∆˙ÈÊ‹, ª. ∆˙·ÓÔ˘‰¿ÎË, ª. ∫·Ó¿ÚÈÔ˘ ¶ÂÚ›ÏË„Ë: ∏ ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ ›ӷÈ, Û‹ÌÂÚ·, Ë ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓË Ì¤ıÔ‰Ô˜ ÁÈ· ÙËÓ ¿ÌÂÛË Î·È ÁÚ‹ÁÔÚË ·ÍÈÔÏfiÁËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ÌÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ ÛÙËÓ ·È‰È·ÙÚÈ΋. ∏ ÂÈÛÙËÌÔÓÈ΋ ¤Ú¢ӷ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛÔÏÔÁ›·˜ ·Ó·‰ÂÈÎÓ‡ÂÈ Û˘Ó¯Ҙ ÂÈÊ·ÓÂȷο ‹ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ÌfiÚÈ·, Ì ÁÓˆÛÙ¤˜ Î·È ÌË ÏÂÈÙÔ˘ÚÁ›Â˜. ∆· ÌfiÚÈ· ·˘Ù¿ ÂÎÊÚ¿˙ÔÓÙ·È Û ‰È¿ÊÔÚ· ÛÙ¿‰È· Ù˘ ·ÈÌÔÔ›ËÛ˘ Î·È ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ‰Â›ÎÙ˜ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ ÏËı˘ÛÌÒÓ Î·È ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ T-, B- Î·È NK-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Û˘Ì‚¿ÏÏÔ˘Ó ‰Â ÛÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘˜ Ì ‚¿ÛË ÙÔ ÛÙ¿‰ÈÔ ˆÚ›Ì·ÓÛ‹˜ ÙÔ˘˜ Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜. ∏ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ Á›ÓÂÙ·È Ì ÙË ¯Ú‹ÛË ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ÙËÓ Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Î·È ¯ÚËÛÈ̇ÂÈ ÛÙË ‰È¿ÁÓˆÛË ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ÛËÌ·ÓÙÈÎfi˜ ‰Â Â›Ó·È Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ Ï¢¯·ÈÌÈÒÓ Î·È ÏÂÌʈ̿وÓ. ª¤Û· Û ·˘ÙfiÓ ÙÔÓ Î·Ù·ÈÁÈÛÌfi ÏËÚÔÊÔÚÈÒÓ Î·È Ù¯ÓÔÏÔÁÈÎÒÓ ÂÈÙ¢ÁÌ¿ÙˆÓ, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ô ·È‰›·ÙÚÔ˜ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ù· ΢ÚÈfiÙÂÚ· ÌfiÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ÙÔ Ò˜ ı· ·ÍÈÔÏÔÁ‹ÛÂÈ ·‰Ú¿ Ù· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÔ‡ ÙÔ˘ ÂϤÁ¯Ô˘. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ¤¯ÂÈ ˆ˜ ÛÙfi¯Ô Ó· ··ÓÙ‹ÛÂÈ ÛÙ· ·Ú·¿Óˆ ÂÚˆÙ‹Ì·Ù· Î·È Ó· Û˘ÓÙÂϤÛÂÈ ÛÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ¯Ú‹Û˘ Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË.
§¤ÍÂȘ ÎÏÂȉȿ: ∫˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜, ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜, ÏÂÌÊÔ·ÙÙ·Ú·, ·È‰È·ÙÚÈ΋.
Peripheral blood lymphocyte immunophenotype in paediatric clinical practice Department of Immunology and Histocompatibility, “Aghia Sophia” Children’s Hospital, Athens Correspondence: Maria Kanariou mkanariou@hol.gr Department of Immunology and Histocompatibility, “Aghia Sophia” Children’s Hospital Thivon & Papadiamandopoulou St., 115 27, Athens
F. Tzifi, M. Tzanoudaki, M. Kanariou Abstract: Flow cytometry is used for rapid evaluation of the peripheral blood lymphocyte subpopulations and investigation of immune system disorders. The immunophenotype study of peripheral blood lymphocytes is now used routinely in paediatric clinical practice. Scientific research in immunology has led to the identification of lymphocyte surface or cytoplasmic molecules with a range of functions that have been elucidated to a variable degree. These molecules, which are expressed at certain stages of haemopoiesis, are used as markers for identifying lymphocyte populations and subpopulations according to their cell line, maturational stage and function. They are detected using monoclonal antibodies in conjunction with fluorochromes in the flow cytometry system. ∆hey are useful for the diagnosis of immunodeficiencies, the follow up of infectious, rheumatic and immunological disease and the classification of leukaemias and lymphomas. In view of the vast body of relevant information, it is important for paediatricians to be familiar with the basic markers that characterize the lymphocyte populations and to know how to make a rough interpretation of the immunophenotype results. The purpose of this review is to provide an answer to these questions and to enhance the use of flow cytometry for screening, diagnosis and follow up of immunological diseases. Key words: Flow cytometry, immunophenotype, lymphocytes, paediatrics.
™˘ÓÙÔÌÔÁڷʛ˜ NK HLA MHC TCR BCR Paediatriki 2007;70:174-183
º˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ∞ÓıÚÒÈÓ· Ï¢ÎÔ΢ÙÙ·ÚÈο ·ÓÙÈÁfiÓ· ªÂ›˙ÔÓ Û‡ÌÏÂÁÌ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ÀÔ‰Ô¯¤·˜ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÀÔ‰Ô¯¤·˜ ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ
HIV APC IL RAG PNP
πfi˜ Ù˘ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ ∞ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎfi ·ÙÙ·ÚÔ πÓÙÂÚÏ¢ΛÓË °ÔÓ›‰È· ÂÓÂÚÁÔÔ›ËÛ˘ ·Ó·Û˘Ó‰˘·ÛÌÔ‡ ¶Ô˘ÚÈÓÈ΋ ʈÛÊÔÚ˘Ï¿ÛË
Pediatri May-Jun 07
24-05-07
17:58
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175
√ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜
‹‰Ë ÙÂı› Ë ‰È¿ÁÓˆÛË. øÛÙfiÛÔ, Î·È ÛÙËÓ ÚÔۤϷÛË ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ, Ë ı¤ÛË Ù˘ ÌÂϤÙ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ‚Ú›ÛÎÂÙ·È ÌÂÙ¿ ÙËÓ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·ÏÔ‡ÛÙÂÚÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘, Ô Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ÔÔ›ˆÓ ı· ı¤ÛÂÈ Û˘ÁÎÂÎÚÈ̤ӷ ‰È·ÁÓˆÛÙÈο ÂÚˆÙ‹Ì·Ù· ÚÔ˜ ·¿ÓÙËÛË. ŸÙ·Ó, ϤÔÓ, Ô ·È‰›·ÙÚÔ˜ ÎÚ›ÓÂÈ fiÙÈ Â›Ó·È ··Ú·›ÙËÙÔ˜ Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ı· Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ˘˜ ΢ÚÈfiÙÂÚÔ˘˜ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ Î·È Ó· Â›Ó·È Û ı¤ÛË Ó· ‰È·‚¿ÛÂÈ ÙËÓ ·¿ÓÙËÛË Î·È Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ ·‰Ú¿ ÙÔ ·ÔÙ¤ÏÂÛÌ·.
∂ÈÛ·ÁˆÁ‹ ∏ ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Â›Ó·È Ì›· Ù·¯Â›· Î·È ‰˘Ó·ÌÈ΋ ̤ıÔ‰Ô˜ ÔÏ˘·Ú·ÌÂÙÚÈ΋˜ ·Ó¿Ï˘Û˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ΢ÙÙ¿ÚˆÓ ‹ ¿ÏÏˆÓ ÛˆÌ·Ùȉ›ˆÓ (fiˆ˜ ÛÊ·ÈÚȉ›ˆÓ latex), Ë ÔÔ›· ·Ú¯Èο ¤Ù˘¯Â ¢Ú›·˜ ÂÊ·ÚÌÔÁ‹˜, ÏfiÁˆ Ù˘ ·ÍÈÔÔ›ËÛ‹˜ Ù˘ ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ Ù˘ÔÔ›ËÛË ÙˆÓ Ï¢¯·ÈÌÈÒÓ Î·È ÙˆÓ ÏÂÌʈ̿وÓ, ÂÓÒ Ë ¤ÎÙ·ÛË Ù˘ HIV Ïԛ̈͢ Î·È ÔÈ ÂÍÂÏ›ÍÂȘ ÛÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Â¤‚·Ï·Ó ÙËÓ Â˘Ú‡ÙÂÚË ‰È¿‰ÔÛ‹ Ù˘. ™‹ÌÂÚ·, ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÎÏÈÓÈΤ˜ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ÛÙË ÌÂϤÙË ÙˆÓ Ï¢ÎÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ÛÙËÓ ·È‰È·ÙÚÈ΋ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ·) ‰È¿ÁÓˆÛË ÚˆÙÔ·ıÒÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ, ‚) ·ÓÔÛÔÏÔÁÈ΋ Ù˘ÔÔ›ËÛË ·ÈÌ·ÙÔÏÔÁÈÎÒÓ Î·ÎÔËıÂÈÒÓ, Á) ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘fiÌÂÓˆÓ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ ÙˆÓ ·ÛıÂÓÒÓ, ‰) ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÛÙ·‰ÈÔÔ›ËÛË Ù˘ HIV Ïԛ̈͢ Î·È Â) ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (1). ∏ Ô˘ÛÈ·ÛÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂϤÙ˘ ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÙËÓ ·È‰È·ÙÚÈ΋ ·ÊÔÚ¿ ÛÙȘ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ. √È ¿ÏϘ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ‹ ÛÙËÓ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË ·ÛıÂÓÒÓ, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ¤¯ÂÈ
∞‰Ú‹ Ù·ÍÈÓfiÌËÛË ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ √È ÏËı˘ÛÌÔ› Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›Ó·È Ù· ∆-ÏÂÌÊÔ·ÙÙ·Ú·, Ù· µ-ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ‹ ¡∫- (Natural killer) ·ÙÙ·Ú· (∂ÈÎfiÓ· 1). ªÂ ÙË ¯Ú‹ÛË ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÌÔÚÔ‡Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ÛÙ· ·ÙÙ·Ú· ÌfiÚÈ· Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È ·fi ·˘Ù¿ Î·È Ù· ÔÔ›· ‰ÈÂıÓÒ˜ ÔÓÔÌ¿˙ÔÓÙ·È ˆ˜ CDs (Clusters of differentiation), ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰Â ˆ˜ ‰Â›ÎÙ˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ‰È·ÊfiÚˆÓ ÏËı˘ÛÌÒÓ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ (2). ™Â ¤Ó·Ó ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô
§ÂÌÊÔ·ÙÙ·Ú· FSdim SSdim CD45bright
µ-ÏÂÌÊÔ·ÙÙ·Ú· CD19+CD20+
CD5+ ¶ÚÒÈÌ·
CD5ÒÚÈÌ·
∆-ÏÂÌÊÔ·ÙÙ·Ú· CD3+CD16-CD56-
TCR·‚+
¡∫∆-·ÙÙ·Ú· CD3+CD16+CD56+
TCRÁ‰+
CD4-CD8+dim
CD4-CD8-
CD4+CD8‚ÔËıËÙÈο
CD4+ CD45RA+ ·Úı¤Ó·
CD4+ CD45RO+ ÌÓËÌÔÓÈο
¡∫- ·ÙÙ·Ú· CD3-CD16+/CD56+
CD8-
CD8+dim
CD8-
CD4 CD8+ ΢ÙÙ·ÚÔÙÔÍÈο
CD8+ CD45RA+ ·Úı¤Ó· ‹ ·ÓÔÛÔ‰Ú·ÛÙÈο
CD8+ CD45RO+ ÌÓËÌÔÓÈο
∂ÈÎfiÓ· 1. ∆· ›‰Ë ÙˆÓ ‚·ÛÈÎÒÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ˘ÔÏËı˘ÛÌÒÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜. ∞ÂÈÎÔÓ›˙ÔÓÙ·È ÔÈ ˘Ô‰È·ÈÚ¤ÛÂȘ ÙˆÓ ÏËı˘ÛÌÒÓ Î·È fi¯È Ù· ÂÍÂÏÈÎÙÈο ÙÔ˘˜ ÛÙ¿‰È·. ¶·È‰È·ÙÚÈ΋ 2007;70:174-183
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·176
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º. ∆˙ÈÊ‹ Î·È Û˘Ó.
ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ·Ú¯Èο ÙÔ ÔÛÔÛÙfi ÙˆÓ ∆-, µ- Î·È ¡∫΢ÙÙ¿ÚˆÓ Î·È ÂÌ̤ۈ˜ Ô ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ÙÔ˘˜. ŸÌˆ˜, ÁÈ· ÙËÓ Î·Ù·ÓfiËÛË Î·È ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ·›˙ÂÈ Ë ÁÓÒÛË Ù˘ ‚·ÛÈ΋˜ ·ÓÔÛÔ·¿ÓÙËÛ˘ (∂ÈÎfiÓ· 2). ∆-ÏÂÌÊÔ·ÙÙ·Ú· ∆· ∆-ÏÂÌÊÔ·ÙÙ·Ú· (CD3+) ·›˙Ô˘Ó ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙËÓ Â›ÎÙËÙË ·ÓÔÛȷ΋ ·¿ÓÙËÛË Â›Ù ˆ˜ ‚ÔËıËÙÈο/·ÁˆÁÈο ·ÙÙ·Ú· (CD4+) ›Ù ˆ˜ ΢ÙÙ·ÚÔÙÔÍÈο/ηٷÛÙ·ÏÙÈο ·ÙÙ·Ú· (CD8+). ∆· ∆-ÏÂÌÊÔ·ÙÙ·Ú· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ ÙÔ˘ ·ÓÙÈÁÔÓÈÎÔ‡ ˘Ô‰Ô¯¤· (TCR), Ô˘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È ·fi ‰‡Ô ·Ï˘Û›‰Â˜, ÔÈ Ôԛ˜ Û¯ËÌ·Ù›˙Ô˘Ó ÙÔ ÂÙÂÚÔ‰ÈÌÂÚ¤˜ ·‚ ‹ ÙÔ Á‰ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙÔ ÌfiÚÈÔ CD3. ∂Ô̤ӈ˜, ·Ó¿ÏÔÁ· Ì ÙË ‰ÔÌ‹ ÙÔ˘ ˘Ô‰Ô¯¤·, ‰È·ÎÚ›ÓÔÓÙ·È Û ‰‡Ô ÏËı˘ÛÌÔ‡˜, ÙÔÓ CD3+ TCR·‚+ Î·È ÙÔÓ CD3+ TCRÁ‰+ (4,5). ∆· ÌfiÚÈ· Ô˘ ÂϤÁ¯ÔÓÙ·È ÛÙ· ∆-ÏÂÌÊÔ·ÙÙ·Ú· ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÙËÓ Î·ı’ Ë̤ڷ ÎÏÈÓÈ΋ Ú¿ÍË Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: ∞Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜: CD3: ∆Ô CD3 ÂÎÊÚ¿˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙ· ∆ÏÂÌÊÔ·ÙÙ·Ú· Î·È ÙȘ ÚÔÁÔÓÈΤ˜ ÌÔÚʤ˜ ÙÔ˘˜. ¶·›˙ÂÈ Û˘ÓÂÚÁÈÎfi ÚfiÏÔ ÛÙË ÌÂÙ·‚›‚·ÛË ÌËӇ̷ÙÔ˜ ·fi ÙÔÓ ·ÓÙÈÁÔÓÈÎfi ˘Ô‰Ô¯¤· ÙÔ˘ ∆ ΢ÙÙ¿ÚÔ˘ (TCR). ∂Ô̤ӈ˜, Ù· ·ÙÙ·Ú· Ô˘ ÂÎÊÚ¿˙Ô˘Ó CD3 ªË ÂȉÈ΋ ·ÓÔÛ›·
ÚÔÛ‰ÈÔÚ›˙Ô˘Ó ÙÔÓ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (6). CD4: ∆Ô ÌfiÚÈÔ CD4 ÂÎÊÚ¿˙ÂÙ·È ˆ˜ Û˘Ó˘Ô‰Ô¯¤·˜ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ‚ÔËıËÙÈÎÒÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ù· ÔÔ›· ·Ó·ÁÓˆÚ›˙Ô˘Ó ·ÓÙÈÁfiÓ· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘Ó‰Â‰Â̤ӷ Ì ÌfiÚÈ· MHC II ÙˆÓ APC. ∞˘Í¿ÓÂÈ ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÙÔ˘ TCR Ì ÙÔ APC, ·›˙ÂÈ Û˘ÓÂÚÁÈÎfi ÚfiÏÔ ÛÙË ÌÂÙ¿‰ÔÛË ÌËÓ˘Ì¿ÙˆÓ Î·È ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ‚ÔËıËÙÈÎÒÓ CD4+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆· ‚ÔËıËÙÈο ∆-ÏÂÌÊÔ·ÙÙ·Ú· (CD3+CD4+CD8-) ·ÔÙÂÏÔ‡Ó ÙÔ 50-60% ÙˆÓ Û˘ÓÔÏÈÎÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, Ù· ‰Â ÂÓÂÚÁÔÔÈË̤ӷ CD4+ ·ÙÙ·Ú·, ·Ó¿ÏÔÁ· Ì ÙȘ ΢ÙÙ·ÚÔΛÓ˜ Ô˘ ·Ú¿ÁÔ˘Ó, ‰È·ÎÚ›ÓÔÓÙ·È Û ‰‡Ô ˘ÔηÙËÁÔڛ˜: Th1 Î·È Th2. ŒÓ·˜ ¿ÏÏÔ˜ ÚfiÏÔ˜ ÙˆÓ CD4+ ΢ÙÙ¿ÚˆÓ Â›Ó·È Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (7,8). CD8: √ ‰Â›ÎÙ˘ CD8 Â›Ó·È ÁÏ˘ÎÔÚˆÙ½ÓË Ô˘ ÂÎÊÚ¿˙ÂÙ·È ˆ˜ Û˘Ó˘Ô‰Ô¯¤·˜ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ/΢ÙÙ·ÚÔÙÔÍÈÎÒÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ù· ÔÔ›· ·Ó·ÁÓˆÚ›˙Ô˘Ó Î·È Û˘Ó‰¤ÔÓÙ·È Ì ·ÙÙ·Ú· Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÂÓ‰ÔÁÂÓ‹, .¯. ÈÈο, ·ÓÙÈÁfiÓ· Û˘Ó‰Â‰Â̤ӷ Ì ÌfiÚÈ· MHC π. £ÂˆÚÂ›Ù·È ˆ˜ Û˘Ó˘Ô‰Ô¯¤·˜ fiÙ·Ó ÛÙË Û‡Ó‰ÂÛË Ì ÙÔ ·ÓÙÈÁfiÓÔ-MHC Û˘ÌÌÂÙ¤¯ÂÈ Î·È Ô TCR, ÂÓÒ Â¿Ó Ô TCR ‰ÂÓ Û˘ÌÌÂÙ¤¯ÂÈ, ÏÂÈÙÔ˘ÚÁ› ˆ˜ ÌfiÚÈÔ ÚÔÛÎfiÏÏËÛ˘ (7). ∆· ΢ÙÙ·ÚÔÙÔÍÈο ∆-ÏÂÌÊÔ·ÙÙ·Ú· (CD3+CD4-CD8+) ·›˙Ô˘Ó,
∞ÓÙÈÁfiÓ· HLA ÌfiÚÈÔ
APS
ÂÓ‰Ô΢ÙÙ¿ÚˆÛË ·ÓÙÈÁÔÓÔÂÂÍÂÚÁ·Û›· ·ÓÙÈÁÔÓÔ·ÚÔ˘Û›·ÛË
∂›ÎÙËÙË ·ÓÔÛ›·
∞ÓÙÈÁfiÓ·-ı˘ÌÔ·ÓÂÍ¿ÚÙËÙ· BCR µ-ÏÂÌÊÔ·ÙÙ·ÚÔ
TCR ˘Ô‰Ô¯¤·˜
§ÂÌÊÔΛÓ˜
∆-ÏÂÌÊÔ·ÙÙ·Ú· §ÂÌÊÔΛÓ˜
∂ÓÂÚÁÔÔÈË̤ÓÔ ∆-ÏÂÌÊÔ·ÙÙ·ÚÔ ∞ÓÙÈÛÒÌ·Ù· ∂ÈÎfiÓ· 2. ∞‰Ú‹ ·ÂÈÎfiÓÈÛË Ù˘ ·ÓÔÛÔ·¿ÓÙËÛ˘ (3). Paediatriki 2007;70:174-183
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·177
177
√ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜
›Û˘, ÚfiÏÔ ÛÙËÓ ·fiÚÚÈ„Ë ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (7). ™˘ÌÏËڈ̷ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜: TCR·‚: √ ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜ ·ÓÙÈÁÔÓÈÎfi˜ ˘Ô‰Ô¯¤·˜ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· (>90%) ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ‰È·ÌÂÌ‚Ú·ÓÈΤ˜ ÔÏ˘ÂÙȉÈΤ˜ ·Ï˘Û›‰Â˜, ÙËÓ · Î·È ÙË ‚. AÓ·ÁÓˆÚ›˙ÂÈ ·ÓÙÈÁfiÓ· Û˘Ó‰Â‰Â̤ӷ Ì ÌfiÚÈ· ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ·ÚÔ˘ÛÈ·˙fiÌÂÓ· ·fi Ù· ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈο ·ÙÙ·Ú· (9). TCRÁ‰: ¶ÂÚ›Ô˘ ÛÙÔ 5% fiÏˆÓ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ô TCR ·ÔÙÂÏÂ›Ù·È ·fi Á Î·È ‰ ·Ï˘Û›‰Â˜. ∆· TCRÁ‰+ ·ÙÙ·Ú· Â›Ó·È Î˘Ú›ˆ˜ CD3+CD4-CD8- ·ÙÙ·Ú· Î·È ‰ÂÓ ·Ó·ÁÓˆÚ›˙Ô˘Ó Ô‡ÙÂ Û˘Ó‰¤ÔÓÙ·È Ì ·ÓÙÈÁfiÓ· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì¤Ûˆ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜. √ ÚfiÏÔ˜ ÙÔ˘˜ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ› (10-12). CD45: ∆Ô ÌfiÚÈÔ ·˘Ùfi Â›Ó·È ÁÓˆÛÙfi ˆ˜ ÎÔÈÓfi Ï¢ÎÔ΢ÙÙ·ÚÈÎfi ·ÓÙÈÁfiÓÔ Î·È ÔÈ ‰È¿ÊÔÚ˜ ÈÛÔÌÔÚʤ˜ ÙÔ˘ ÂÎÊÚ¿˙ÔÓÙ·È Û fiÏ· Ù· ¿ˆÚ· Î·È ÒÚÈÌ· Ï¢ÎÔ·ÙÙ·Ú·. £ÂˆÚÂ›Ù·È fiÙÈ ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙˆÓ Ï¢ÎÒÓ ·fi ÙÔ˘˜ ÂÚ˘ıÚÔ‚Ï¿ÛÙ˜. ∆· ÂÚÈÛÛfiÙÂÚ· ·Úı¤Ó· ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÙË CD45R∞ ÈÛÔÌÔÚÊ‹ ÙÔ˘, Ù· ‰Â ÌÓËÌÔÓÈο ·ÙÙ·Ú· ΢ڛˆ˜ ÙË CD45R√ (13,14). HLA-DR (Human leukocyte antigen-DR): ªfiÚÈÔ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù¿Í˘ ππ, ÙÔ ÔÔ›Ô ÛÙ·ıÂÚ¿ ÂÎÊÚ¿˙ÂÙ·È ÛÙ· µ Î·È ÛÙ· ‰ÈÂÁÂṲ́ӷ ∆-ÏÂÌÊÔ·ÙÙ·Ú·. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ CD3 ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ‰ÈÂÁÂÚÌ¤ÓˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (15). CD25: ∆Ô CD25 ·ÔÙÂÏ› ›ÙÔÔ Ù˘ · ·Ï˘Û›‰·˜ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2 (IL-2). π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ¤¯Ô˘Ó Ù· Ú˘ıÌÈÛÙÈο CD4+CD25+ ·ÙÙ·Ú· (Treg), Ù· ÔÔ›· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ‰Â ‰È·Ù·Ú·¯‹ ÙÔ˘˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ. ∂Âȉ‹ ÙÔ ÌfiÚÈÔ CD25 ‰ÂÓ ÂÎÊÚ¿˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙ· Ú˘ıÌÈÛÙÈο, ·ÏÏ¿ Î·È ÛÙ· ÂÓÂÚÁÔÔÈË̤ӷ ∆-ÏÂÌÊÔ·ÙÙ·Ú·, ÂÎÎÚÂÌ› Ë Â‡ÚÂÛË ÂȉÈÎÒÓ ÌÔÚ›ˆÓ Ô˘ Ó· Ù·˘ÙÔÔÈÔ‡Ó Ù· Ú˘ıÌÈÛÙÈο ·ÙÙ·Ú· (16,17). CD69: ∆Ô ÌfiÚÈÔ ·˘Ùfi Â›Ó·È ÁÓˆÛÙfi Î·È ˆ˜ ·ÁˆÁÈÎfi ÌfiÚÈÔ ÂÓÂÚÁÔÔ›ËÛ˘ (Activation inducer molecule - AIM), ÂÎÊÚ¿˙ÂÙ·È Û ÂÓÂÚÁÔÔÈË̤ӷ Ï¢ÎÔ·ÙÙ·Ú·, fiˆ˜ ∆- Î·È µ-ÏÂÌÊÔ·ÙÙ·Ú·, ¡∫·ÙÙ·Ú·, Ô˘‰ÂÙÂÚfiÊÈÏ·, ‚·ÛÂfiÊÈÏ· Î·È ËˆÛÈÓfiÊÈÏ· Î·È Èı·ÓÒ˜ ·›˙ÂÈ ÚfiÏÔ ÛÙË ÌÂÙ¿‰ÔÛË ÌËÓ˘Ì¿ÙˆÓ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÂȉÒÓ Î˘ÙÙ¿ÚˆÓ (18,19). ∂ÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ¤ÏÂÁ¯Ô˜: CD40L: ªfiÚÈÔ Û˘Ó‰È¤ÁÂÚÛ˘ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙË
ÌÂÌ‚Ú¿ÓË ÙˆÓ ‚ÔËıËÙÈÎÒÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Û˘Ó‰¤ÂÙ·È Ì ÙÔ CD40 ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂›Ó·È ÛËÌ·ÓÙÈÎfi ÁÈ· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÁÈ· ÙËÓ ÈÛÔÙ˘È΋ ÌÂÙ·ÛÙÚÔÊ‹ (switching) ·fi ÙËÓ ·ÓÔÛÔÛÊ·ÈÚ›ÓË IgM Û IgG, IgA ‹ IgE (20). CD2: ∂›Ó·È ·fi Ù· ÚÒÙ· ÌfiÚÈ· Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙ· ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙÔÓ ı‡ÌÔ ·‰¤Ó· Î·È ÂÎÊÚ¿˙ÂÙ·È ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂›Ó·È ÌfiÚÈÔ ÚÔÛÎfiÏÏËÛ˘ Î·È ÂÈϤÔÓ ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂›Û˘, ÙÔ CD2 ÂÎÊÚ¿˙ÂÙ·È ÛÙ· ¡∫-·ÙÙ·Ú· (21,22). CD7: ¶ÚfiÎÂÈÙ·È ÁÈ· ÚˆÙ½ÓË Ô˘ ·Ó‹ÎÂÈ ÛÙËÓ ˘ÂÚÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Ì ¿ÁÓˆÛÙË ÏÂÈÙÔ˘ÚÁ›· Î·È ÂÎÊÚ¿˙ÂÙ·È Û ı˘ÌÔ·ÙÙ·Ú·, ¡∫- Î·È ∆-ÏÂÌÊÔ·ÙÙ·Ú·. ÃÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ‰Â›ÎÙ˘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ T-ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ Ï¢¯·ÈÌ›·˜. ∂›Ó·È Èı·Ófi Ó· ·›˙ÂÈ ÚfiÏÔ ÛÙË Ú‡ıÌÈÛË Ù˘ ÔÓÙÔÁ¤ÓÂÛ˘ ÙˆÓ ¡∫∆- Î·È ÙˆÓ Ú˘ıÌÈÛÙÈÎÒÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (23). µ-ÏÂÌÊÔ·ÙÙ·Ú· ∆· µ-ÏÂÌÊÔ·ÙÙ·Ú· ·ÔÙÂÏÔ‡Ó ÙÔ 10-20% ÙÔ˘ ÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜. ∏ ·ÍÈÔÏfiÁËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜ Á›ÓÂÙ·È Ì ÙË Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgG, IgM, IgA) Î·È Ù˘ ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘, ÂÓÒ Ë Ì¤ÙÚËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙÔ˘˜ Á›ÓÂÙ·È Ì ÙË Ì¤ıÔ‰Ô Ù˘ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜. ∆· ÌfiÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ‰Â›ÎÙ˜ ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û ¤Ó·Ó ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: ∞Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜: CD19: ¶ÚfiÎÂÈÙ·È ÁÈ· ÌfiÚÈÔ ÂÈÊ·Ó›·˜ ۯ‰fiÓ fiÏˆÓ ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ·›˙ÂÈ Û˘ÓÂÚÁÈÎfi ÚfiÏÔ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ·˘ÙÒÓ (24,25). CD20: ¶ÚˆÙ½ÓË Ô˘ ÂÎÊÚ¿˙ÂÙ·È Û fiÏ· Ù· ÒÚÈÌ· µ-ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ë ¤ÎÊÚ·Û‹ ÙÔ˘ ÛÙ·Ì·Ù¿ ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ ‰È·ÊÔÚÔÔ›ËÛ˘ ÙÔ˘ µ-ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘ Û ϷÛÌ·ÙÔ·ÙÙ·ÚÔ. ¶·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ‹ ÙË Ú‡ıÌÈÛË ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ·ÔÙÂÏ› ‰›·˘ÏÔ ÈfiÓÙˆÓ ·Û‚ÂÛÙ›Ô˘. ∆· ÂÚÈÛÛfiÙÂÚ· µ-ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ÌÂÙÚÒÓÙ·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Û˘ÓÂÎÊÚ¿˙Ô˘Ó Î·È ÙÔ CD19 Î·È ÙÔ CD20 ÌfiÚÈÔ (26-28). ∂ÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ¤ÏÂÁ¯Ô˜: CD5: H ¤ÎÊÚ·ÛË ÙÔ˘ CD5 ÛÙ· µ-ÏÂÌÊÔ·ÙÙ·Ú· ÌÂÏÂÙ¿Ù·È ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË, ȉ›ˆ˜ ÛÙÔ Ï·›ÛÈÔ Ù˘ ÌÂϤÙ˘ Ù˘ ·˘ÙÔ·ÓÔÛ›·˜ Î·È ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, fiÔ˘ Â›Ó·È Î·È ·˘ÍË̤ÓË. ¶ÚfiÎÂÈÙ·È ÁÈ· ‰È·ÌÂÌ‚Ú·ÓÈ΋ ÁÏ˘ÎÔÚˆÙ½ÓË Ô˘ Ê˘ÛÈÔÏÔÁÈο ˘¿Ú¯ÂÈ ÛÙ· ∆-ÏÂÌÊÔ·ÙÙ·Ú· Î·È ›Ûˆ˜ ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÌÂٷ͇ ∆- Î·È µ-΢ÙÙ¿ÚˆÓ. ∆Ô ¶·È‰È·ÙÚÈ΋ 2007;70:174-183
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º. ∆˙ÈÊ‹ Î·È Û˘Ó.
ÌfiÚÈÔ ·˘Ùfi ‹Ù·Ó ÁÓˆÛÙfi fiÙÈ ÂÎÊÚ¿˙ÂÙ·È Û ηÎÔ‹ıË µ-ÏÂÌÊÔ·ÙÙ·Ú· Î·È ·ÚÁfiÙÂÚ· ‚Ú¤ıËΠfiÙÈ ˘¿Ú¯ÂÈ Û ÌÈÎÚfi ÔÛÔÛÙfi Ê˘ÛÈÔÏÔÁÈÎÒÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÛÙ· ÔÔ›· ÌÂÏÂÙ¿Ù·È Ô È‰È·›ÙÂÚÔ˜ ÚfiÏÔ˜ ÙÔ˘ (30,31). CD23: ∆Ô ÌfiÚÈÔ ·˘Ùfi Â›Ó·È ˘Ô‰Ô¯¤·˜ ¯·ÌËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ ÁÈ· ÙËÓ IgE ·ÓÔÛÔÛÊ·ÈÚ›ÓË (FcÂRIIb) Î·È ‰Ú· ˆ˜ Ú˘ıÌÈÛÙ‹˜ ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ Ù˘ (29). ¡∫-·ÙÙ·Ú· ∆· ¡∫-·ÙÙ·Ú· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· ηٷÛÙÚ¤ÊÔ˘Ó Î‡ÙÙ·Ú· ÛÙfi¯Ô˘˜, ¯ˆÚ›˜ ÙËÓ ·Ó¿ÁÎË ÚÔËÁÔ‡ÌÂÓ˘ ¤ÎıÂÛ˘ Û ·ÓÙÈÁfiÓÔ Î·È ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÎÔÌÌ¿ÙÈ Ù˘ Ê˘ÛÈ΋˜ ·ÓÔÛ›·˜. ∂ÈϤÔÓ, Ù· ¡∫-·ÙÙ·Ú· Â›Ó·È Ì›· ‚·ÛÈ΋ ËÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ, ÔÈ Ôԛ˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ¤Ó·ÚÍË ·ÓÔÛÔÏÔÁÈÎÒÓ ··ÓÙ‹ÛÂˆÓ ÌÂÙ¿ ·fi οÔÈÔ ·ÓÙÈÁÔÓÈÎfi ÂÚ¤ıÈÛÌ· (32). √È ‰Â›ÎÙ˜ ÂÈÊ·Ó›·˜ ÙˆÓ ¡∫-΢ÙÙ¿ÚˆÓ Â›Ó·È ÔÈ ÂÍ‹˜: CD16: ¶ÚfiÎÂÈÙ·È ÁÈ· ˘Ô‰Ô¯¤· ÙÔ˘ Fc ÙÌ‹Ì·ÙÔ˜ Ù˘ IgG Ô˘ Â›Ó·È ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙËÓ ÂÍ·ÚÙÒÌÂÓË ·fi ·ÓÙÈÛÒÌ·Ù· ΢ÙÙ·ÚÔÙÔÍÈÎfiÙËÙ·. ∂ÎÙfi˜ ·fi Ù· ¡∫-·ÙÙ·Ú·, ÙÔ CD16 ÌfiÚÈÔ ÂÎÊÚ¿˙ÂÙ·È Û ̷ÎÚÔÊ¿Á· Î·È Ô˘‰ÂÙÂÚfiÊÈÏ· (33). CD56: ∂ÎÊÚ¿˙ÂÙ·È Û ¡∫-·ÙÙ·Ú·, Û ÌÂÚÈο ∆Î·È µ-·ÙÙ·Ú· Î·È Û ÂÁÎÂÊ·ÏÈο ·ÙÙ·Ú· (ÈÛfiÙ˘Ô˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÌÔÚ›Ô˘ Ó¢ÚÔ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘). ™ÙËÓ Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ ‰È·ÎÚ›ÓoÓÙ·È ‰‡Ô ÏËı˘ÛÌÔ› CD3-CD56+: Ô CD56dim, Û ÔÛÔÛÙfi 90%, Ô ÔÔ›Ô˜ Â›Ó·È CD16+ Î·È ‰Ú· ΢ڛˆ˜ ΢ÙÙ·ÚÔÙÔÍÈο Î·È Ô CD56bright, Û ÔÛÔÛÙfi 10%, Ô ÔÔ›Ô˜ Â›Ó·È CD56+CD16- Î·È ÂÎÎÚ›ÓÂÈ Î˘ÙÙ·ÚÔΛÓ˜ Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó Ù· ÌÔÓÔ·ÙÙ·Ú· (33). NKT-ÏÂÌÊÔ·ÙÙ·Ú· ∆· ¡∫∆-ÏÂÌÊÔ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÙfiÛÔ ‰Â›ÎÙ˜ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD3, TCR), fiÛÔ Î·È ¡∫-΢ÙÙ¿ÚˆÓ (CD16). º·›ÓÂÙ·È Ó· ÂÌϤÎÔÓÙ·È ÛÙË Ú‡ıÌÈÛË Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘. ∆ÂÏÂ˘Ù·›·, ¤¯ÂÈ ‰Ôı› ÛËÌ·Û›· ÛÙËÓ ÔÌÔÈfiÙËÙ¿ ÙÔ˘˜ Ì ٷ CD4+CD25+ Ú˘ıÌÈÛÙÈο ÏÂÌÊÔ·ÙÙ·Ú· (34). ™Â ·ÎfiÌË ÈÔ ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ‹ ·‰È¢ÎÚ›ÓÈÛÙ˜ ÂÚÈÙÒÛÂȘ, ÂϤÁ¯ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ‰Â›ÎÙ˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ, ÔÈ ÔÔ›ÔÈ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË.
∏ ·Ó¿ÁÓˆÛË Ù˘ ·¿ÓÙËÛ˘ ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ °È· ÙËÓ Î·Ù·ÓfiËÛË ÙÔ˘ ÙÚfiÔ˘ ·ÚÔ˘Û›·Û˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ‰Â‰Ô̤ӈÓ, ı· ÌÔÚÔ‡Û·Ó Ó· ·ÎÔÏÔ˘ıËıÔ‡Ó Ù· ·Ú·Î¿Ùˆ ‚‹Ì·Ù·: ·) ∂ϤÁ¯ÂÙ·È Ë ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∂ÎÙfi˜ ·fi ÙË ÁÂÓÈÎfiÙÂÚË ·ÈÌ·ÙÔÏÔÁÈ΋ ÂÈÎfiÓ·, Paediatriki 2007;70:174-183
ȉȷ›ÙÂÚ· ÂӉȷʤÚÂÈ Ô ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ÏÂÌÊÔÂÓ›· ·ÔÙÂÏ› ‚·ÛÈÎfi ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ (37). ∂›Û˘, ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Ì‹ˆ˜ Ì›· Ù˘¯fiÓ ·fiÎÏÈÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÓfi˜ ÏËı˘ÛÌÔ‡ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ·ÔÙÂÏ› ·ÏÒ˜ ·ÚÈıÌËÙÈ΋ Ï¿ÓË, ÏfiÁˆ Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÂÓfi˜ ¿ÏÏÔ˘ ÏËı˘ÛÌÔ‡. ‚) ∞Ó·ÁÓˆÚ›˙ÂÙ·È Ô ÂοÛÙÔÙ ÏËı˘ÛÌfi˜ ÁÈ· ÙÔÓ ÔÔ›Ô ‰›ÓÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù·. ∂ÎÙfi˜ ·fi ÙÔ˘˜ ‚·ÛÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ ÙˆÓ ÔÔ›ˆÓ Ô Û˘Ì‚ÔÏÈÛÌfi˜ Â›Ó·È ·Ïfi˜ (CD3+, CD4+, CD8+, CD19+/20+, CD16+/56+), ÛÙËÓ ·¿ÓÙËÛË ·Ó·Ê¤ÚÔÓÙ·È Î·È ‰È¿ÊÔÚÔÈ ˘ÔÏËı˘ÛÌÔ› ÙÔ˘˜, ÛÙËÓ ÔÓÔÌ·ÙÔÏÔÁ›· ÙˆÓ ÔÔ›ˆÓ ·Ó·ÁÚ¿ÊÂÙ·È ÚÒÙÔ˜ Ô ‚·ÛÈÎfi˜ ÏËı˘ÛÌfi˜ fiÔ˘ ·Ó‹ÎÔ˘Ó. °È· ·Ú¿‰ÂÈÁÌ·, Ë ¤ÎÊÚ·ÛË CD3+CD4+ Û˘Ì‚ÔÏ›˙ÂÈ Ù· ∆-ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÙÔ CD4 ÌfiÚÈÔ. Á) √È ÙÈ̤˜ ÙˆÓ ‰È·ÊfiÚˆÓ ÏËı˘ÛÌÒÓ ÂϤÁ¯ÔÓÙ·È Ì ‚¿ÛË Ù· Ê˘ÛÈÔÏÔÁÈο ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ ›‰·, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙËÓ Â›‰Ú·ÛË Ù˘ ÂıÓÈÎfiÙËÙ·˜, Ë ÔÔ›· Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛËÌ·ÓÙÈ΋ (35,36) (¶›Ó·Î˜ 1 Î·È 2). ‰) ÀÔÏÔÁ›˙ÂÙ·È Ô ÏfiÁÔ˜ CD4+/CD8+, Ô ÔÔ›Ô˜ Ú¤ÂÈ Ó· Â›Ó·È >1 (36). Â) ÀÔÏÔÁ›˙ÂÙ·È Ô ÏfiÁÔ˜ CD4+CD45RA+/ CD4+CD45RO+, Ô ÔÔ›Ô˜ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁÔ˜ Ù˘ ËÏÈΛ·˜ Î·È ÛÙ· ·È‰È¿ Ú¤ÂÈ Ó· Â›Ó·È >1 (36). ÛÙ) ªÂ ·Ï¤˜ ·ÚÈıÌËÙÈΤ˜ Ú¿ÍÂȘ ÌÔÚ› Ó· ÂÏÂÁ¯ı› Ë ‡·ÚÍË ·ıÔÏÔÁÈÎÒÓ ÏËı˘ÛÌÒÓ. √È ‚·ÛÈÎfiÙÂÚ˜ ÂÚÈÁÚ¿ÊÔÓÙ·È ·Ú·Î¿Ùˆ Î·È ·ÊÔÚÔ‡Ó ÛÙ· ÔÛÔÛÙ¿ ÙˆÓ ÏËı˘ÛÌÒÓ: i) CD3+ + CD19+ + CD16+ ≈ 100 ∆Ô ¿ıÚÔÈÛÌ· ÙˆÓ Î˘ÚÈfiÙÂÚˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ ı· Ú¤ÂÈ Ó· ηχÙÂÈ ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (100%) (38). ∏ ΢ÚÈfiÙÂÚË ·ÈÙ›· ·fiÎÏÈÛ˘ ÚÔ˜ Ù· οو Â›Ó·È Ë ‡·ÚÍË ÂÚ˘ıÚÔ‚Ï·ÛÙÒÓ, ÔÈ ÔÔ›ÔÈ ÂÎÏ·Ì‚¿ÓÔÓÙ·È ·fi ÙÔÓ ·Ó·Ï˘Ù‹ ˆ˜ ÏÂÌÊÔ·ÙÙ·Ú·, Ê·ÈÓfiÌÂÓÔ Û˘¯Ófi Û ÓÂÔÁÓ¿ Î·È Û ·ÛıÂÓ›˜ Ì ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ. ŸÔÙ ÚÔ·ÙÂÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi, ›Ù ÂϤÁ¯ÂÙ·È Ô ‰Â›ÎÙ˘ CD45, Ô ÔÔ›Ô˜ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜ Ù˘ Ï¢΋˜ ÛÂÈÚ¿˜ Î·È fi¯È ÙˆÓ ÂÚ˘ıÚÔ‚Ï·ÛÙÒÓ, ›Ù Á›ÓÂÙ·È ÂÍ·Ú¯‹˜ ‰È·ÊÔÚÂÙÈ΋ ηÙÂÚÁ·Û›· ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ (1,39). ∂¿Ó ·ÔÎÏÂÈÛÙ› ÙÔ ÂӉ¯fiÌÂÓÔ ‡·Ú͢ ÂÚ˘ıÚÔ‚Ï·ÛÙÒÓ, ÙfiÙ Èı·Ófiٷٷ ÚfiÎÂÈÙ·È ÁÈ· ·ıÔÏÔÁÈÎfi ÏËı˘ÛÌfi. ™Â ÂÚ›ÙˆÛË ˘¤ÚÌÂÙÚ˘ ·‡ÍËÛ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ¡∫∆-΢ÙÙ¿ÚˆÓ ı· ·Ú·ÙËÚËı› ·‡ÍËÛË ÙÔ˘ ÂÓ ÏfiÁˆ ·ıÚÔ›ÛÌ·ÙÔ˜. ii) CD4+ + CD8+ ≈ CD3+-TCRÁ‰+ ŸÏ· Ù· Ê˘ÛÈÔÏÔÁÈο TCR·‚+ ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÛÙËÓ ÂÈÊ¿ÓÂÈ¿ ÙÔ˘˜ ›Ù ÙÔÓ CD4 ›Ù ÙÔÓ CD8 ‰Â›ÎÙË, ÂÓÒ Ù· ÂÚÈÛÛfiÙÂÚ· TCRÁ‰+ Û˘¯Ó¿ ‰ÂÓ ÂÎÊÚ¿˙Ô˘Ó Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ ‰‡Ô (38). ∂¿Ó CD4++CD8+>CD3+-TCRÁ‰+, ·Ú¯Èο Ú¤ÂÈ
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√ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜
¶›Ó·Î·˜ 1. ∂ηÙÔÛÙÈ·›Â˜ ·Ó·ÏÔÁ›Â˜ (%) ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ. ∫·Ù·ÓÔÌ‹ ηٿ ËÏÈΛ· ÛÙË Ï¢΋ Ê˘Ï‹ (36). ÀÔÏËı˘ÛÌfi˜ CD3
+
CD4+ CD8+ CD4+CD45RA+ CD4+CD45RO+ CD4+HLA-DR+ CD8+HLA-DR+ CD19+ CD16+/CD56+
0-3 ÌËÓÒÓ
3-6 ÌËÓÒÓ
6-12 ÌËÓÒÓ
1-2 ÂÙÒÓ
2-6 ÂÙÒÓ
6-12 ÂÙÒÓ
12-18 ÂÙÒÓ
73% (53-84) 52% (35-64) 18% (12-28) 90% (64-95) 10% (02-22) 3% (02-06) 5% (02-20) 15% (06-32) 8% (04-18)
66% (51-77) 46% (35-56) 16% (12-23) 90% (77-94) 8% (03-16) 5% (02-10) 7% (03-17) 25% (11-41) 6% (03-14)
65% (49-76) 46% (31-56) 17% (12-24) 86% (64-93) 9% (05-18) 5% (02-11) 10% (04-27) 24% (14-37) 7% (03-15)
65% (53-75) 41% (32-51) 20% (14-30) 81% (63-91) 12% (07-20) 6% (02-11) 16% (06-33) 25% (16-35) 7% (03-15)
66% (56-75) 38% (28-47) 23% (16-30) 71% (53-86) 16% (09-26) 7% (03-12) 16% (07-37) 21% (14-33) 9% (04-17)
69% (60-76) 37% (31-47) 25% (18-35) 59% (46-77) 21% (13-30) 6% (03-13) 12% (06-29) 18% (13-27) 9% (04-17)
73% (56-84) 41% (31-52) 26% (18-35) 53% (33-66) 28% (18-38) 7% (04-11) 12% (05-25) 14% (06-23) 9% (03-22)
Ó· ÂÏÂÁ¯ı› ÙÔ ÂӉ¯fiÌÂÓÔ Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ CD8 ›Ù ÛÙ· TCRÁ‰+ ÏÂÌÊÔ·ÙÙ·Ú· (‰ËÏ·‰‹ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ CD3+CD8+TCRÁ‰+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ) (40), ›Ù ÛÙ· ¡∫-·ÙÙ·Ú· (˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ CD3CD8+CD16+) (32) Î·È ÛÙË Û˘Ó¤¯ÂÈ·, Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ·ıÔÏÔÁÈÎÔ‡ ÏËı˘ÛÌÔ‡ ‰ÈÏ¿ ıÂÙÈÎÒÓ CD3+CD4+CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂¿Ó CD4++CD8+<CD3+-TCRÁ‰+, ˘Ê›ÛÙ·Ù·È ÙÔ ÂӉ¯fiÌÂÓÔ ‡·Ú͢ ›Ù ·ıÔÏÔÁÈÎÔ‡ ÏËı˘ÛÌÔ‡ ‰ÈÏ¿ ·ÚÓËÙÈÎÒÓ CD3+TCR·‚+CD4-CD8- ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ‹ ÌÂÁ¿ÏÔ˘ ÔÛÔÛÙÔ‡ ¡∫∆-΢ÙÙ¿ÚˆÓ (34).
∂¿Ó ÛÙËÓ ·¿ÓÙËÛË ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÙÔ ÔÛÔÛÙfi ÙˆÓ TCRÁ‰+ ΢ÙÙ¿ÚˆÓ, ÙfiÙ ÙÔ ¿ıÚÔÈÛÌ· ÙˆÓ CD4+ Î·È ÙˆÓ CD8+ ı· Ú¤ÂÈ Ó· Â›Ó·È Ï›ÁÔ ÌÈÎÚfiÙÂÚÔ ·fi ÂΛÓÔ ÙˆÓ CD3+.
√È ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ˘ÔÏËı˘ÛÌÔ› ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÙȘ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ ªÂÙ¿ ÙËÓ ·Ó¿ÁÓˆÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜, ÛÂÈÚ¿ ¤¯ÂÈ Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ, Ë ÔÔ›· Á›ÓÂÙ·È ¿ÓÙ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ
¶›Ó·Î·˜ 2. ∞fiÏ˘Ù˜ ÙÈ̤˜ (·ÚÈıÌfi˜ ΢ÙÙ¿ÚˆÓ 10-3/Ìl) ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ. ∫·Ù·ÓÔÌ‹ ηٿ ËÏÈΛ· ÛÙË Ï¢΋ Ê˘Ï‹ (36). ÀÔÏËı˘ÛÌfi˜
0-3 ÌËÓÒÓ
3-6 ÌËÓÒÓ
6-12 ÌËÓÒÓ
1-2 ÂÙÒÓ
2-6 ÂÙÒÓ
6-12 ÂÙÒÓ
12-18 ÂÙÒÓ
CD3+
3,68 (2,5-5,5) 2,61 (1,6-4,0) 0,98 (0,56-1,7) 2,27 (1,2-3,7) 0,32 (0,06-0,9) 0,1 (0,04-0,18) 0,05 (0,02-0,16) 0,73 (0,3-2,0) 0,42 (0,17-1,1)
3,93 (2,5-5,6) 2,85 (1,8-4,0) 1,05 (0,59-1,6) 2,32 (1,3-3,7) 0,33 (0,12-0,63) 0,15 (0,06-0,28) 0,08 (0,03-0,17) 1,55 (0,43-3) 0,42 (0,17-0,83)
3,93 (1.9-5,9) 2,67 (1,4-4,3) 1,04 (0,5-1,7) 2,21 (1,1-3,7) 0,34 (0,16-0,8) 0,12 (0,05-0,26) 0,09 (0,04-0,29) 1,52 (0,61-2,6) 0,4 (0,16-0,95)
3,55 (2,1-6,2) 2,16 (1,3-3,4) 1,04 (0,62-2) 1,65 (1,0-2,9) 0,4 (0,21-0,85) 0,13 (0,07-0,28) 0,18 (0,06-0,6) 1,31 (0,72-2,6) 0,36 (0,18-0,92)
2,39 (1,4-3,7) 1,38 (0,7-2,2) 0,84 (0,49-1,3) 0,98 (0,43-1,5) 0,36 (0,22-0,66) 0,09 (0,05-0,18) 0,14 (0,07-0,42) 0,75 (0,39-1,4) 0,3 (0,13-0,72)
1,82 (1,2-2,6) 0,98 (0,65-1,5) 0,68 (0,37-1,1) 0,57 (0,32-1,0) 0,35 (0,23-0,63) 0,07 (0,04-0,12) 0,09 (0,04-0,27) 0,48 (0,27-0,86) 0,23 (0,1-0,48)
1,48 (1,0-2,2) 0,84 (0,53-1,3) 0,53 (0,33-0,92) 0,4 (0,23-0,77) 0,38 (0,24-0,7) 0,06 (0,03-1) 0,07 (0,03-0,18) 0,3 (0,11-0,57) 0,3 (0,11-0,57)
CD4+ CD8+ CD4+CD45RA+ CD4+CD45RO+ CD4+HLA-DR+ CD8+HLA-DR+ CD19+ CD16+/CD56+
¶·È‰È·ÙÚÈ΋ 2007;70:174-183
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180
º. ∆˙ÈÊ‹ Î·È Û˘Ó.
ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ·. ∏ ÌÂϤÙË ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰È¿ÁÓˆÛË ÙˆÓ ÚˆÙÔ·ıÒÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ Î·È ÛÙËÓ Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘˜. ¶·Ú·Î¿Ùˆ ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈÎfiÙÂÚ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ÛÙȘ ΢ÚÈfiÙÂÚ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ (37,41-43), Ì ‚¿ÛË ÙË ‰ÈÂıÓÒ˜ ÈÛ¯‡Ô˘Û· Ù·ÍÈÓfiÌËÛË (41) (∂ÈÎfiÓ· 3). ™ËÌ·ÓÙÈ΋ Ì›ˆÛË ∆- Î·È µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ: ∏ ‚·ÚÈ¿ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ· (SCID) Ì ÂÎÛÂÛËÌ·Ṳ̂ÓË Ì›ˆÛË Î·È ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÏËı˘ÛÌÒÓ ÔÊ›ÏÂÙ·È Û˘ÓËı¤ÛÙÂÚ· Û ‰È·Ù·Ú·¯‹ ÛÙÔ Â›Â‰Ô ÙÔ˘ ·Ó·Û˘Ó‰˘·ÛÌÔ‡ ÙˆÓ ÁÔÓȉ›ˆÓ ÙÔ˘ TCR Î·È ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È Î˘Ú›ˆ˜ Û ÌÂÙ·ÏÏ¿ÍÂȘ ÙˆÓ ÁÔÓȉ›ˆÓ ÙˆÓ ÂÓ˙‡ÌˆÓ RAG1 ‹ RAG2. ™ÙËÓ ·Ó¿ÚÎÂÈ· Ù˘ ··ÌÈÓ¿Û˘ Ù˘ ·‰ÂÓÔÛ›Ó˘ (ADA ·Ó¿ÚÎÂÈ·), ÂËÚ¿˙ÔÓÙ·È Î·È ÔÈ ‰‡Ô ·˘Ù¤˜ ΢ÙÙ·ÚÈΤ˜ ÛÂÈÚ¤˜, ·ÏÏ¿ Ë Ì›ˆÛ‹ ÙÔ˘˜ Â›Ó·È ÚÔԉ¢ÙÈ΋.
™ËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈο ‹ ·˘ÍË̤ӷ µ-ÏÂÌÊÔ·ÙÙ·Ú·: ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ ¡∫-΢ÙÙ¿ÚˆÓ. ™˘Ó‰˘·Ṳ̂ÓË Ì›ˆÛË ÙˆÓ ∆- Î·È ÙˆÓ ¡∫-΢ÙÙ¿ÚˆÓ Û˘ÓËı¤ÛÙÂÚ· ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÎÔÈÓ‹˜ Á-·Ï˘Û›‰·˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ IL-4, IL-7, IL-9 Î·È IL-15 ‹ Û ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÎÈÓ¿Û˘ Jak3. ªÂÌÔӈ̤ÓË ÂÍ·Ú¯‹˜ Ì›ˆÛË ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ IL-7, ÙÔ˘ CD45 ‹ Ù˘ ‰ ·Ï˘Û›‰·˜ ÙÔ˘ CD3. ¶ÚÔԉ¢ÙÈ΋ Ì›ˆÛË ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·Ú·ÙËÚÂ›Ù·È Î·È ÛÙËÓ ·Ó¿ÚÎÂÈ· PNP, ÛÙÔ Û‡Ó‰ÚÔÌÔ Wiskott-Aldrich Î·È ÛÙËÓ ·Ù·Í›·-ÙËÏ·ÁÁÂÈÂÎÙ·Û›·. ™ÙÔ Û‡Ó‰ÚÔÌÔ Di George, ÙÔ ÔÔ›Ô Û˘¯Ó¿ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ‰È·Ù·Ú·¯‹ Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ı‡ÌÔ˘, ·Ú·ÙËÚÂ›Ù·È ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ÌÂÌÔӈ̤ÓË Ì›ˆÛË ÙˆÓ ˆÚ›ÌˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ì ٿÛË ÁÈ· ÚÔԉ¢ÙÈ΋ ÔÏÈÁÔÎψÓÈ΋ ·‡ÍËÛË (42). IgM
ª˘ÂÏfi˜
XLA (·Ó¿ÚÎÂÈ· Btk) ™‡Ó‰ÚÔÌÔ À¤Ú-IgM
·) SCID Ì ÌÂÙ¿ÏÏ·ÍË ÛÙÔ RAG ÁÔÓ›‰ÈÔ ‚) ™‡Ó‰ÚÔÌÔ √ª∂¡
¢ÈÎÙ˘ˆÙ‹ ¢˘ÛÁÂÓÂÛ›·
IgG
Pre-B2 ·ÙÙ·ÚÔ, ÚÒÈÌÔ µ-·ÙÙ·ÚÔ CD10, CD19, CD10/ pre-BCR CD19 Pre-B1 ·ÙÙ·ÚÔ, Tdt, CD34, CD10, cCD79a, CD19 Pro-B ·ÙÙ·ÚÔ, Tdt, CD34, CD10, cCD79a
·Ú¯¤ÁÔÓÔ §ÂÌÊÈÎfi ·ÈÌÔÔÈËÙÈÎfi ÚÔÁÔÓÈÎfi ·ÙÙ·ÚÔ Î‡ÙÙ·ÚÔ/ HLA-DR, CD34, ¶ÚÔı˘ÌÔCD117 ·ÙÙ·ÚÔ Tdt, CD34, CD44
£‡ÌÔ˜ ·) SCID Ì ÌÂÙ¿ÏÏ·ÍË Ù˘ ÎÔÈÓ‹˜ Á ·Ï˘Û›‰·˜ ‚) SCID Ì Jak3 ÌÂÙ¿ÏÏ·ÍË
πg∞ ·Ó¿ÚÎÂÈ· IgA
¶ÂÚÈÊÂÚÈÎfi ∞›Ì· Î·È IgE §ÂÌÊÈÎfi˜ πÛÙfi˜
ÂӉȿÌÂÛÔ ÒÚÈÌÔ ·ÓÔÛÔ‚Ï¿ÛÙË Ï·ÛÌ·ÙÔ·ÙÙ·ÚÔ µ-·ÙÙ·ÚÔ, µ-·ÙÙ·ÚÔ, CD19, CD20 CD19, CD20 CD19, CD20 ∞Ó¿ÚÎÂÈ· Ù˘ ‚ ·Ï˘Û›‰·˜ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ IL 12 IL-12 ∞Ó¿ÚÎÂÈ· ÙÔ˘ IL-12R ˘Ô‰Ô¯¤· Ù˘ π¡FÁ INFÁ INFÁR
‚ÔËıËÙÈÎfi ÒÚÈÌÔ ·) ∞Ó¿ÚÎÂÈ· ADA, ∞ÓÒÚÈÌÔ ı˘ÌÔ·ÙÙ·ÚÔ, ∆-·ÙÙ·ÚÔ PNP ·) SCID Ì ÌÂÙ¿ÏÏ·ÍË ı˘ÌÔ·ÙÙ·ÚÔ CD4CD3 CD4 ‚) ∞Ó¿ÚÎÂÈ· ZAP70 pre-TCR, ÛÙÔ RAG ÁÔÓ›‰ÈÔ TCR CD3 ‚) ™‡Ó‰ÚÔÌÔ DiGeorge Tdt, CD44, ∞ÓÒÚÈÌÔ CD25, CD4 ı˘ÌÔ·ÙÙ·ÚÔ, ÎÔÈÓfi ÒÚÈÌÔ pre-TCR, ΢ÙÙ·ÚÔÙÔÍÈÎfi ı˘ÌÔ·ÙÙ·ÚÔ Tdt, CD25, ı˘ÌÔηٷÛÙ·ÏÙÈÎfi ·ÙÙ·ÚÔ, CD8 TCR CD4 ∆-·ÙÙ·ÚÔ CD8 CD3 Tdt, cCD3, CD3 CD4/CD8
APS
HLA-II ∞Ó¿ÚÎÂÈ· ÙÔ˘ HLA-II ‹ Û‡Ó‰ÚÔÌÔ ÙÔ˘ Á˘ÌÓÔ‡ ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘
∂ÈÎfiÓ· 3. √È Î˘ÚÈfiÙÂÚ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÏfiÁˆ ÁÂÓÂÙÈÎÔ‡ ÂÏÏ›ÌÌ·ÙÔ˜ ÛÙË ‰È·‰Èηۛ· ‰È·ÊÔÚÔÔ›ËÛ˘ Î·È ÂͤÏÈ͢ ÙÔ˘ ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ Ì˘ÂÏfi Î·È ÛÙÔÓ ı‡ÌÔ (36). SCID: µ·ÚÈ¿ ™˘Ó‰˘·Ṳ̂ÓË ∞ÓÔÛÔ·Ó¿ÚÎÂÈ· (Severe Combined Immunodeficiency), XLA: º˘ÏÔÛ‡Ó‰ÂÙË ˘ÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, Btk: T˘ÚÔÛÈÓÈ΋ ÎÈÓ¿ÛË Bruton (Bruton tyrosine kinase), PNP: ¶Ô˘ÚÈÓÈ΋ ʈÛÊÔÚ˘Ï¿ÛË (Purine phoshorylase), ADA: ∞·ÌÈÓ¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ (Adenosine deaminase), Jak3: ∫ÈÓ¿ÛË Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ Á ·Ï˘Û›‰· Î·È Û ·Ó¿ÚÎÂÈ· Ù˘ ÎÈÓ¿Û˘ ·˘Ù‹˜ ÂÌÊ·Ó›˙ÂÙ·È ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi SCID, RAG: °ÔÓ›‰È· ÂÓÂÚÁÔÔ›ËÛ˘ ·Ó·Û˘Ó‰˘·ÛÌÔ‡ (Recombination-activating genes), ZAP70: ∆˘ÚÔÛÈÓÈ΋ ÎÈÓ¿ÛË Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ˙ ·Ï˘Û›‰· ÙÔ˘ TCR Û˘ÌϤÁÌ·ÙÔ˜ Î·È Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÚÒÈÌË ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, IL-1: πÓÙÂÚÏ¢ΛÓË 1, INF-Á: πÓÙÂÚÊÂÚfiÓË Á, INF-ÁR: ÀÔ‰Ô¯¤·˜ Ù˘ INF-Á, Pre-TCR: ¶Úfi‰ÚÔÌË ÌÔÚÊ‹ ÙÔ˘ TCR ηٿ ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Tdt: ∆ÂÏÈ΋ ‰ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂÔÙȉÈ΋ ÙÚ·ÓÛÊÂÚ¿ÛË (terminal deoxyribonucleotidyl transferase) Paediatriki 2007;70:174-183
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·181
181
√ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜
ªÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ÙˆÓ CD4+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·Ú·¤ÌÂÈ Û ·Ó¿ÚÎÂÈ· ÙˆÓ ÌÔÚ›ˆÓ MHC Ù¿Í˘ ππ, ÂÓÒ ÌÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ÙˆÓ CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÌÂÙ¿‰ÔÛ˘ Û‹Ì·ÙÔ˜ ̤ۈ ÙÔ˘ TCR (·Ó¿ÚÎÂÈ· ÙˆÓ ÌÔÚ›ˆÓ CD8, ZAP-70, TAP-1 ‹ TAP-2) (41). ™Â ·‡ÍËÛË ÙˆÓ ‰ÈÏ¿ ·ÚÓËÙÈÎÒÓ CD3+TCR·‚+CD4-CD8- ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ı· Ú¤ÂÈ Ó· ‰ÈÂÚÂ˘Ó¿Ù·È Î·È Ë Èı·ÓfiÙËÙ· ·˘ÙÔ¿ÓÔÛÔ˘ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (1). ªÂÌÔӈ̤ÓË Ì¤¯ÚÈ ÌˉÂÓÈÛÌÔ‡ Ì›ˆÛË ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÁÔÓȉȷ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÎÈÓ¿Û˘ Btk (Ê˘ÏÔÛ‡Ó‰ÂÙË ·Á·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ÓfiÛÔ˜ ÙÔ˘ Bruton), ÌÔÚ›, fï˜, Ó· ÔÊ›ÏÂÙ·È Î·È Û ·˘ÙÔۈ̷ÙÈÎÒ˜ ÎÏËÚÔÓÔÌÔ‡ÌÂÓ˜ ÌÂÙ·ÏÏ¿ÍÂȘ (44). ªÈÎÚ‹ Ì›ˆÛË ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û ÂÚÈÙÒÛÂȘ ÎÔÈÓ‹˜ ÔÈΛÏ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (45), ÂÓÒ Û ·Ó¿ÚÎÂȘ ˘ÔÙ¿ÍÂˆÓ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ·‡ÍËÛË ÙˆÓ ·ÓÒÚÈÌˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. £· Ú¤ÂÈ, fï˜, Ó· ÙÔÓÈÛÙ› fiÙÈ Ê˘ÛÈÔÏÔÁÈο ›‰· µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ‰ÂÓ ·ÔÎÏÂ›Ô˘Ó ÙËÓ ‡·ÚÍË Û˘Ó‰ÚfiÌÔ˘ ˘¤Ú-IgM, ÎÔÈÓ‹˜ ÔÈΛÏ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ ‹ ¿ÏÏ˘ ·ÓÙÈۈ̷ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ∂›Û˘, ÛÙËÓ ·ÚÔ‰È΋ ˘ÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· ÙˆÓ ‚ÚÂÊÒÓ, Ù· ΢ÎÏÔÊÔÚÔ‡ÓÙ· µ-·ÙÙ·Ú· Â›Ó·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· (43,46). ∞Ó·ÊÔÚÈο Ì ÙËÓ ÎÔÈÓ‹ ÔÈΛÏË ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, Ë ÔÔ›· ·ÔÙÂÏ› Ì›· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· Û¯ÂÙÈο Û˘¯ÓÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÎÔÈÓfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙËÓ ·‰˘Ó·Ì›· ˆÚ›Ì·ÓÛ˘ ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÛÂ Â›Â‰Ô ‚Ï·ÛÙÈÎÔ‡ ΤÓÙÚÔ˘ ηÈ, Û˘ÓÂÒ˜, ÙËÓ ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ı· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Û˘¯Ó¿ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ CD4+TCR·‚+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È È‰È·›ÙÂÚ· ÙˆÓ ·Úı¤ÓˆÓ CD4+CD45RA+, ¯ˆÚ›˜, fï˜, ·˘Ùfi ÙÔ Â‡ÚËÌ· Ó· ·ÔÙÂÏ› ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ (45).
¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ÙÈ̤˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ∆Ô ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÌÔÚ› Ó· ÂËÚ·ÛÙ› ·fi Ì›· ÏËıÒÚ· ·Ú·ÁfiÓÙˆÓ: ™‹„Ë: ¶ÔÏÏ¿ ·È‰È¿ Ô˘ ÂϤÁ¯ÔÓÙ·È ÁÈ· ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ¤¯Ô˘Ó ÈÛÙÔÚÈÎfi ÚfiÛÊ·ÙˆÓ ‚·Ú¤ˆÓ ÏÔÈÌÒÍÂˆÓ ‹ ÛËÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ∂›Ó·È Û˘¯Ó‹ Ë ·Ó¿ÁÎË ‰ÈÂÚ‡ÓËÛ˘ ·È‰ÈÒÓ Ì ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ΢ڛˆ˜ ÏfiÁˆ Ù˘ ¤ÏÏÂȄ˘ ÙÔ˘ ¯ÚÔÓÈÎÔ‡ ÂÚÈıˆÚ›Ô˘. ∏ Û‹„Ë, fï˜, ÌÔÚ› Ó· ÂÈʤÚÂÈ ÛËÌ·ÓÙÈÎfiٷ٘ ÌÂÙ·‚ÔϤ˜ ÛÙÔ˘˜ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜, ·ÎfiÌË Î·È ‰‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·Ó¿ÚÚˆÛË, fiˆ˜ ÙÒÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ CD4+ Î·È ÏÈÁfiÙÂÚÔ ÙˆÓ CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· (47), ·Ú¯È΋ ̤¯ÚÈ ÌˉÂÓÈÛÌÔ‡ Ì›ˆÛË Î·È ·ÎÔÏÔ‡ıˆ˜ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ¡∫-΢ÙÙ¿ÚˆÓ, ·‡ÍËÛË ÙˆÓ µ-ÏÂÌ-
ÊÔ΢ÙÙ¿ÚˆÓ Î·È ·‡ÍËÛË ÙˆÓ CD3+HLADR+ ‰ÈÂÁÂÚÌ¤ÓˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (48). HIV Ïԛ̈ÍË: ∏ ÚÔԉ¢ÙÈ΋ Ì›ˆÛË ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ CD4+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (·ÚÈÔ˜ ‰Â›ÎÙ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ) Î·È Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙˆÓ ‰ÂÈÎÙÒÓ ‰È¤ÁÂÚÛ˘ (HLA-DR Î·È CD38) ÛÙ· CD8+ ∆-ÏÂÌÊÔ·ÙÙ·Ú· (‰Â›ÎÙ˘ ÂÈΛÌÂÓ˘ ·‡ÍËÛ˘ ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘) Â›Ó·È ÔÈ Î˘ÚÈfiÙÂÚ˜ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ HIV Ïԛ̈ÍË (49). ∆· ÔÚÔ·ÚÓËÙÈο ÓÂÔÁÓ¿ Ì HIV+ ÌËÙ¤Ú· ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ó¿ÏÔÁ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘, Ô˘ ÌÔÚ› Ó· ‰È·ÙËÚËıÔ‡Ó Ì¤¯ÚÈ ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ (50). ∫ÔÚÙÈÎÔÛÙÂÚÔÂȉ‹-·ÓÔÛÔηٷÛÙ·ÏÙÈο: ∆· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Î·È Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÏfiÁˆ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÂΉËÏÒÛÂˆÓ ÔÚÈÛÌ¤ÓˆÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ ÂËÚ¿˙Ô˘Ó È‰È·›ÙÂÚ· ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô. ∏ ÏÂÌÊÔÂÓ›· Ô˘ ÚÔηÏÂ›Ù·È ·fi Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÔÊ›ÏÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ÛÙË Ì›ˆÛË ÙˆÓ CD4+ Î·È ÏÈÁfiÙÂÚÔ ÛÙË Ì›ˆÛË ÙˆÓ CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∏ Ì›ˆÛË ·˘Ù‹, Ì¿ÏÈÛÙ·, ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ Î˘ÙÙ¿ÚˆÓ (CD3+CD4+CD69+, CD3+ CD8+CD69+) (51). ø˜ Û˘Ó¤ÂÈ· ÙˆÓ ·Ú·¿Óˆ, ·Ó·ÛÙÚ¤ÊÂÙ·È Ô ÏfiÁÔ˜ CD4+/CD8+ Î·È Ë ·Ó·ÛÙÚÔÊ‹ ·˘Ù‹ ‰È·ÚΛ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÏfiÁˆ ÙÔ˘ ÌÂȈ̤ÓÔ˘ Ú˘ıÌÔ‡ ·ÔηٿÛÙ·Û˘ ÙˆÓ CD4+ (28,2 Ë̤Ú˜) Û ۯ¤ÛË Ì ٷ CD8+ (12,6 Ë̤Ú˜) ÏÂÌÊÔ·ÙÙ·Ú· (52). ∂Ô̤ӈ˜, Û˘ÓÈÛÙ¿Ù·È Ë ‰ÈÂÍ·ÁˆÁ‹ ÙÔ˘ Ù˘¯fiÓ ÂÓ‰ÂÈÎÓ˘fiÌÂÓÔ˘ ÂϤÁ¯Ô˘ ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‹ ¿ÏÏ˘ ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋˜ ıÂڷ›·˜. √È ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ˘ÔÏËı˘ÛÌÔ› ÂËÚ¿˙ÔÓÙ·È Î·È ·fi ¿ÏϘ ηٷÛÙ¿ÛÂȘ. ¶·Ú·Î¿Ùˆ ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·fi ·˘Ù¤˜ ·Ó¿ ÏÂÌÊÔ΢ÙÙ·ÚÈÎfi ˘ÔÏËı˘ÛÌfi: ∆-ÏÂÌÊÔ·ÙÙ·Ú· CD4+: ¶ÙˆÙÈ΋ Ù¿ÛË ÙÔ˘˜ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Û ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ (53), ÏfiÁˆ Ù˘ ÌÂÙ·Ó¿ÛÙÂ˘Û‹˜ ÙÔ˘˜ ÛÙ· ÏÂÌÊÈο fiÚÁ·Ó·. CD8+: ∏ Èı·ÓfiÙÂÚË ·ÈÙ›· ·‡ÍËÛ˘ ·ÚÈıÌÔ‡ ÙˆÓ CD8+ Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ (ÈÔÁÂÓ›˜, ‚·ÎÙËÚȷΤ˜). ™Â ·˘Ù¤˜ ·Ô‰›‰ÂÙ·È Î·È Û˘¯Ó‹ ·‡ÍËÛË ÙˆÓ CD8+ ÛÙ· ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓ· ¿ÙÔÌ· (54). CD3HLADR: ∂ÎÙfi˜ ·fi ÙȘ ÏÔÈÌÒÍÂȘ, Ù· ‰ÈÂÁÂṲ́ӷ ∆-ÏÂÌÊÔ·ÙÙ·Ú· ·˘Í¿ÓÔÓÙ·È Î·È Û ¿ÏϘ ÂÚÈÙÒÛÂȘ ‰È¤ÁÂÚÛ˘ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ (·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÌÂÙ·ÌÔۯ‡ÛÂȘ, ÔÏ˘ÌÂÙ·ÁÁÈ˙fiÌÂÓ· ¿ÙÔÌ·) (55). TCRÁ‰: ∏ ·‡ÍËÛË ÙˆÓ TCRÁ‰ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û˘Ó‹ıˆ˜ Û˘Ó·ÓÙ¿Ù·È Û ÏÔÈÌÒÍÂȘ ·fi ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ (ÂÚËÙÔ˚Ô‡˜, Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘). √È ÙÈ̤˜ ÙÔ˘˜ ›ӷÈ, ›Û˘, Û˘¯Ó¿ ·˘ÍË̤Ó˜ Û ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (56). ¶·È‰È·ÙÚÈ΋ 2007;70:174-183
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µ-ÏÂÌÊÔ·ÙÙ·Ú·: ∏ Û˘ÓËı¤ÛÙÂÚË, ϤÔÓ, ·ÈÙ›· ÌˉÂÓÈÛÌÔ‡ ÙˆÓ CD19+CD20+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Â›Ó·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ-CD20 ıÂڷ›·˜. ∞˘ÍËÙÈ΋ Ù¿ÛË ¤¯ÂÈ ·Ú·ÙËÚËı› Û ÏÔÈÌÒÍÂȘ (57), ·ÏÏ¿ Û ˘ÂÚ‚ÔÏÈ΋ ·‡ÍËÛ‹ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙ› οÔÈ· ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ηÎÔ‹ıÂÈ·, Ì ÙÔÓ ¤ÏÂÁ¯Ô ‡·Ú͢ ÌÔÓÔÎψÓÈÎfiÙËÙ·˜ Î ‹ Ï ·Ï˘Û›‰ˆÓ. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ¤¯Ô˘Ó ÔÈ ‰È·Î˘Ì¿ÓÛÂȘ ÙˆÓ CD19+CD5+, ÛÙÔ Ï·›ÛÈÔ Î˘Ú›ˆ˜ Ù˘ ÚÔÛ¿ıÂÈ·˜ Â͇ÚÂÛ˘ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ, fiˆ˜ ÛÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ π (50). ŸÌˆ˜, Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ CD19+CD5+ ÛÙ· ‚Ú¤ÊË Â›Ó·È ‰˘Û¯ÂÚ‹˜, ÏfiÁˆ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈο ·˘ÍË̤ÓÔ˘ ·ÚÈıÌÔ‡ ÙÔ˘˜ (58). ¡∫-·ÙÙ·Ú·: ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙȘ Ù·¯‡ÙÂÚ˜ ‰È·Î˘Ì¿ÓÛÂȘ, ÏfiÁˆ Ù˘ ·Ó·Î·Ù·ÓÔÌ‹˜ ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ (ÌÂÙÚÔ‡ÌÂÓˆÓ) Î·È ÙˆÓ ÚÔÛÎÔÏÏËÌ¤ÓˆÓ ÛÙ· ·ÁÁÂȷο ÙÔȯÒÌ·Ù· (ÌË ÌÂÙÚÔ‡ÌÂÓˆÓ) ¡∫-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ÚÔηÏÂ›Ù·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ˘ÂÚ¤ÎÎÚÈÛË Î·Ù¯ÔÏ·ÌÈÓÒÓ (59,60).
™¯ÔÏÈ·ÛÌfi˜ £· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰È·ÊfiÚˆÓ ÂÚÁ·ÛÙËÚ›ˆÓ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙÂ Û˘ÁÎÚ›ÛÈÌ·, ȉ›ˆ˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ˘ÔÏËı˘ÛÌÔ‡˜ (36). ∏ ÂÈÏÔÁ‹ ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÚÔ˜ ¤ÏÂÁ¯Ô ‰ÂÈÎÙÒÓ ˘·ÁÔÚ‡ÂÙ·È ·fi ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜, ÛËÌÂ›Ô ÛÙÔ ÔÔ›Ô Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋ Ë Û˘ÓÂÚÁ·Û›· ÙˆÓ ÎÏÈÓÈÎÒÓ Ì ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ. ∞˘Ùfi fï˜ Ô˘ ı· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› Â›Ó·È fiÙÈ Ë ÌÂϤÙË ÙˆÓ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ÁÈ· Ó· ··ÓÙ‹ÛÂÈ Û˘ÁÎÂÎÚÈ̤ӷ ÂÚˆÙ‹Ì·Ù· (΢ڛˆ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ) Î·È ‰ÂÓ ¤¯ÂÈ Î·Ó¤Ó· ÚfiÏÔ ˆ˜ ‰ÔÎÈÌ·Û›· ÂϤÁ¯Ô˘ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, ‰ÈfiÙÈ ÔÈ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ÏËı˘ÛÌÔ› ÂËÚ¿˙ÔÓÙ·È ·fi ¿Ú· ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Ë Ù˘¯·›· ‡ÚÂÛË Ì›·˜ ·fiÎÏÈÛ‹˜ ÙÔ˘˜ ·fi ÙȘ ·Ó·ÌÂÓfiÌÂÓ˜ ÙÈ̤˜ ÌÔÚ› Ó· ·Ú·Ï·Ó‹ÛÂÈ ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿ ÙËÓ Î˘Ú›· ŒÊË µÚ·¯ÓÔ‡ ÁÈ· ÙËÓ ÔχÙÈÌË Û˘Ì‚ÔÏ‹ Ù˘ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÁ·Û›·.
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45. Spickett GP. Current perspectives on common variable immunodeficiency (CVID). Clin Exp Allergy 2001;31:536-542. 46. Stewart DM, Lian L, Nelson DL. The clinical spectrum of Bruton’s agammaglobulinemia. Curr Allergy Asthma Rep 2001;1:558-565. 47. Holub M, Kluckova Z, Beneda B, Hobstova J, Huzicka I, Prazak J et al. Changes in lymphocyte subpopulations and CD3+/DR+ expression in sepsis. Clin Microbiol Infect 2000;6:657-660. 48. Wisniewska-Ligier M, Wozniakowska-Gesicka T, Zeman J, Banasik M. Evaluation of lymphocyte subsets and NK cells in septic children. Med Sci Monit 2002;8:CR119-124. 49. Hengel RL, Nicholson JK. An update on the use of flow cytometry in HIV infection and AIDS. Clin Lab Med 2001;21:841-856. 50. Clerici M, Saresella M, Colombo F, Fossati S, Sala N, Bricalli D et al. T-lymphocyte maturation abnormalities in uninfected newborns and children with vertical exposure to HIV. Blood 2000;96:3866-3871. 51. Sharma KC, Stevens D, Casey L, Kesten S. Effects of highdose inhaled fluticasone propionate via spacer on cell-mediated immunity in healthy volunteers. Chest 2000;118: 1042-1048. 52. Fukuda R, Horiki T, Sasao T, Kawada H, Ichikawa Y. Modulation of peripheral blood lymphocyte subsets during methylprednisolone pulse therapy. Tokai J Exp Clin Med 1996;21:77-88. 53. Rodrigues DS, Medeiros EA, Weckx LY, Bonnez W, Salomao R, Kallas EG. Immunophenotypic characterization of peripheral T lymphocytes in Mycobacterium tuberculosis infection and disease. Clin Exp Immunol 2002;128: 149-154. 54. Yadav S, Chattopadhya D, Prakash C, Kumari S, Vergheese T. Role of transfusion-mediated viral infections on the lymphocyte subset profile in multi-transfused children. J Trop Pediatr 1993;39:243-250. 55. Kadziela K, Kowalska H, Rymkiewicz-Kluczynska B, Kowalska M, Miszkurka G, Rybczynska J et al. Changes in lymphocyte subsets in children with newly diagnosed type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2003;16: 185-191. 56. Riccieri V, Spadaro A, Parisi G, Taccari E, Moretti T, Bernardini G et al. Down-regulation of natural killer cells and of gamma/delta T cells in systemic lupus erythematosus. Does it correlate to autoimmunity and to laboratory indices of disease activity? Lupus 2000;9:333-337. 57. Bluth MH, Norowitz KB, Chice S, Shah VN, Nowakowski M, Josephson AS et al. Detection of IgE anti-parvovirus B19 and increased CD23+ B cells in parvovirus B19 infection: relation to Th2 cytokines. Clin Immunol 2003; 108:152-158. 58. O’Gorman MR, Millard DD, Lowder JN, Yogev R. Lymphocyte subpopulations in healthy 1-3-day-old infants. Cytometry 1998;34:235-241. 59. Atanackovic D, Brunner-Weinzierl MC, Kroger H, Serke S, Deter HC. Acute psychological stress simultaneously alters hormone levels, recruitment of lymphocyte subsets, and production of reactive oxygen species. Immunol Invest 2002;31:73-91. 60. Shephard RJ, Shek PN. Effects of exercise and training on natural killer cell counts and cytolytic activity: a metaanalysis. Sports Med 1999;28:177-195.
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™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ó¢ÌfiÓˆÓ: ·ıÔÁ¤ÓÂÈ·, ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ·ÒÙÂÚË ¤Î‚·ÛË 1 ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ 2 ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁÈ΋ ªÔÓ¿‰·, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ AÏÏËÏÔÁÚ·Ê›·: ∫ÒÛÙ·˜ ¡. ¶Ú›ÊÙ˘ kpriftis@otenet.gr ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ T.K. 152 36, ¶. ¶ÂÓÙ¤ÏË
∫. ¡. ¶Ú›ÊÙ˘1, ¶. ¡. ¢Ô˘Ú›‰·˜1, ª. B. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜2 ¶ÂÚ›ÏË„Ë: √È Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ó‡ÌÔÓ· ·ÔÙÂÏÔ‡Ó ÌÈ· ·Û˘Ó‹ıË ·ÏÏ¿ ȉȷ›ÙÂÚ· ÂӉȷʤÚÔ˘Û· ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ô˘ ÌÔÚ› Ó· ·ÓȯÓ¢ıÔ‡Ó Ôχ ¤ÁηÈÚ·, ÛÙÔ Ï·›ÛÈÔ ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ηٿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ÂÚ›Ô‰Ô ‹ ·ÎfiÌ· fi„ÈÌ·, ÛÂ Ù˘¯·›Ô ¤ÏÂÁ¯Ô ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ∏ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰È·Ì·ÚÙÈÒÓ Û˘Ó‰¤ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË Î·È ÙË Ê¿ÛË Î·Ù¿ ÙËÓ ÔÔ›· Û˘Ì‚·›ÓÂÈ Ë ‰È·Ù·Ú·¯‹ ÛÙË ‰È·‰Èηۛ· ·Ó¿Ù˘Í˘ ÙÔ˘ Ó‡ÌÔÓ· ηٿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ÂÚ›Ô‰Ô. ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Û˘Ó·ÚÙ¿Ù·È ¿ÌÂÛ· Ì ÙË ÁÓÒÛË Î·È ÙËÓ ÒÚÈÌË ÎÏÈÓÈ΋ ÛΤ„Ë. ∞Ó Î·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜, Û˘Ó‹ıˆ˜ Â›Ó·È ÌË ÂȉÈ΋ Î·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Û·ÓÈfiÙËÙ· ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ· Â›Ó·È ··Ú·›ÙËÙÔ ÂΠ̤ÚÔ˘˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÁÈ·ÙÚÔ‡ Ó· ˘¿Ú¯ÂÈ ˘„ËÏfi˜ ‰Â›ÎÙ˘ ˘Ô„›·˜. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ì ÙËÓ ÔÚı‹ ¯Ú‹ÛË Ù˘ Û‡Á¯ÚÔÓ˘ Ù¯ÓÔÏÔÁ›·˜, Û˘Ó‹ıˆ˜, Ô‰ËÁ› Û ·ÎÚȂ›˜ ‰È·ÁÓÒÛÂȘ. ∏ ÚfiÁÓˆÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›‰Ô˜ Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘, ηıÒ˜ ›Û˘ ÙËÓ ‡·ÚÍË ‹ ÌË Û˘ÓÔ‰ÒÓ ·ÓˆÌ·ÏÈÒÓ. ø˜ ÚÔ˜ ÙÔÓ ¯ÚfiÓÔ Ù˘ Èı·Ó‹˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘, ÂÊfiÛÔÓ ‰ÂÓ ˘¿Ú¯ÂÈ ·Ó¿ÁÎË Â›ÁÔ˘Û·˜ ·ÓÙÈÌÂÙÒÈÛ˘, ÔÏϤ˜ ‚Ï¿‚˜ ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛıÔ‡Ó Û˘ÓÙËÚËÙÈο ÒÛÙ ӷ ÂÈÏÂÁ› ·ÚÁfiÙÂÚ· Ô Î·Ù·ÏÏËÏfiÙÂÚÔ˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ Â¤Ì‚·ÛË. ∆Ô fiÊÂÏÔ˜ Ù˘ ·ÓÙÈÚÚÔÈÛÙÈ΋˜ ·‡ÍËÛ˘ ÙÔ˘ ·ÚÈıÌÔ‡ ‹ Ù˘ ‰ÔÌ‹˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ ÌÂÙ¿ ·fi Ó¢ÌÔÓÂÎÙÔÌ‹ Û ÌÈÎÚ‹ ËÏÈΛ· ‰ÂÓ ¤¯ÂÈ ÂȂ‚·Èˆı›. §¤ÍÂȘ ÎÏÂȉȿ: ∫˘ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›·, ÏÔ‚ÂÎÙÔÌ‹, Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì·, Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ·, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ, ˘ÔÏ·Û›· Ó‡ÌÔÓ·.
Congenital lung malformations: pathogenesis, diagnostic approach and long-term outcome 1 Department of Allergology, Children’s General Hospital of Penteli 2 Paediatric Pneumonology Unit, University of Patras Paediatric Clinic Correspondence: Kostas N. Priftis kpriftis@otenet.gr Allergology Department, Children’s General Hospital of Penteli 152 36, P. Penteli, Greece
K. N. Priftis1, N. P. Douridas1, M. B. Anthracopoulos2 Abstract: Congenital lung malformations constitute an infrequent but intriguing group of diseases, some of which are diagnosed prenatally while others remain asymptomatic for many years and are incidental findings during adulthood. The pathogenesis is determined by the anatomical location of the lesion and the timing of the intrauterine insult during embryonic lung development. The diagnostic approach is dependent on the expertise and clinical skills of the physician. Clinical manifestations of congenital lung malformations depend on the age of the patient, and in most instances are non-specific. In view of their rareness a high index of suspicion is required for the diagnosis of these clinical entities. Rational use of current imaging and endoscopic techniques can provide an accurate diagnosis. The prognosis of a specific congenital lung malformation depends on the nature and the size of the lesion and the presence or absence of associated developmental defects. With regard to the timing of surgical intervention, if emergency surgery is not required, congenital malformations can be managed conservatively, and programmed surgical resection can be undertaken at a later point in time. The occurrence of postpneumonectomy compensatory lung growth, when surgical intervention takes place early in life, has not been confirmed.
Key words: Congenital lobar emphysema, cystic adenomatoid malformation, lobectomy, pulmonary hypoplasia, pulmonary sequestration, tracheo-oesophageal fistula.
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ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ó¿Ù˘Í˘. ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·ÔÙÂÏ› ¿ÌÂÛË Û˘Ó¿ÚÙËÛË Ì ÙË ÁÓÒÛË, ÙËÓ ÎÏÈÓÈ΋ ÛΤ„Ë, ·ÏÏ¿ Î·È ÙËÓ Ù¯ÓÔÏÔÁ›·. ∏ Ù·ÎÙÈ΋ ÚÔÁÂÓÓËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ˘ÂÚ˯ÔÁÚ·ÊÈο ÂÈÙÚ¤ÂÈ ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, ÂÓÒ Ë ÂÈÏÔÁ‹ ÙˆÓ Î·Ù·ÏÏËÏfiÙÂÚˆÓ ÂÍÂÙ¿ÛÂˆÓ Û‡Ìʈӷ Ì ٷ ÎÏÈÓÈο ‰Â‰Ô̤ӷ, Ô‰ËÁ› Û˘ÓÙÔÌfiÙÂÚ· Î·È ·ÎÚÈ‚¤ÛÙÂÚ· ÛÙË ÛˆÛÙ‹ ‰È¿ÁÓˆÛË. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ Î·È Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ˘ÔÛÙËÚÈÎÙÈ΋ ‚Ô‹ıÂÈ· ¤¯Ô˘Ó ÂÍÂÏȯı›, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÓÙ˘ˆÛȷ΋ Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜. ∆¤ÏÔ˜, ·fi ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ·ÏÏ¿ Î·È ·fi ÌÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ·, ¤ÁÈÓ·Ó ÁÓˆÛÙ¿ ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›· Á‡Úˆ ·fi ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ ¯ÚfiÓÔ˘ ÁÈ· ÙËÓ Â¤Ì‚·ÛË. ¶ÚfiÛÊ·Ù· ÂΉfiıËΠÙfiÌÔ˜ Ô˘ ·Ó·Ê¤ÚÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙȘ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ó‡ÌÔÓ· (1). √ ·Ó·ÁÓÒÛÙ˘ ·Ú·¤ÌÂÙ·È Û ·˘ÙfiÓ ÁÈ· ·Ó·Ï˘ÙÈÎfiÙÂÚË ÂÓË̤ڈÛË ·Ó¿ ¿ıËÛË (2). ™ÙÔ Î›ÌÂÓÔ Ô˘ ·ÎÔÏÔ˘ı› ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û˘ÓÔÙÈο Ë ·ıÔÁ¤ÓÂÈ·, Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ·ÒÙÂÚË ¤Î‚·ÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·. ∆·ÍÈÓfiÌËÛË Î·È ÂÌ‚Ú˘ÔÁ¤ÓÂÛË ∏ ηٿٷÍË ÌÈ·˜ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÙÔ˘ Ó‡ÌÔÓ· Ô˘ ·ÊÔÚ¿ ·ÔÎÏÂÈÛÙÈο Û ÌÈ· ·Ó·ÙÔÌÈ΋ ‰ÔÌ‹, fiˆ˜ Â›Ó·È Ë Û˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ‚ÚfiÁ¯Ô˘ ‹ Ë ‚ÚÔÁ¯ÔÁÂÓ‹˜ ·ÛÙË, Â›Ó·È Û¯ÂÙÈο ·Ï‹. ŸÙ·Ó fï˜, Ë Û˘ÁÁÂÓ‹˜ ‰È·Ì·ÚÙ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÚÈÛÛfiÙÂÚ˜ Û˘ÓÈÛÙÒÛ˜, fiˆ˜ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· Î·È ·ÁÁ›·, Ì ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ·Ú¿‰ÂÈÁÌ· ÙÔ Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì·, Ë Î·Ù¿Ù·ÍË Î·È Ë Î·Ù·ÓfiËÛË Ù˘ ÂÌ‚Ú˘ÔÁ¤ÓÂÛ˘ Ù˘ ‚Ï¿‚˘ ÌÔÚ› Ó· ·ÔÙÂÏ› Ú·ÁÌ·ÙÈο ÔχÏÔÎË ‰È·‰Èηۛ·. ¶·Ï·ÈfiÙÂÚË Î·Ù¿Ù·ÍË ·fi ÙÔ American College of Chest Physicians ·ÚÎÂ›Ù·È Û ·Ï‹ ·Ú¿ıÂÛË, ¯ˆÚ›˜ ·ıÔÁÂÓÂÙÈ΋ ÂÚÌËÓ›· (3). ∞ÎfiÌË Î·È Û‹ÌÂÚ· fï˜, ·Ú¿ ÙȘ ‰È¿ÊÔÚ˜ ıˆڛ˜ Ô˘ ¤¯Ô˘Ó ÚÔÙ·ı› (4-6), ‰ÂÓ ˘¿Ú¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÔÚÈÔı¤ÙËÛË Î·È Î·Ù¿Ù·ÍË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ· Ì ‚¿ÛË ÙËÓ ·Ó·ÙÔÌ›· Î·È ÙËÓ ·ıÔÁ¤ÓÂÈ· (7). ∆Ô 1984, ÛÙËÓ ÂÚ›ÊËÌË ‰È¿ÏÂÍ‹ Ù˘ ÂȘ ÌÓ‹ÌËÓ ÙÔ˘ Tudor Edwards (Tudor Edwards memorial lecture), Ë Lynne Reid ·Ó·Ê¤ÚıËΠÛÙÔ˘˜ “ÙÚÂȘ ÓfiÌÔ˘˜” Ô˘ ‰È¤Ô˘Ó ÙËÓ ÂͤÏÈÍË ÙÔ˘ Ó‡ÌÔÓ· (8): 1) √È ‰È·ÎÏ·‰ÒÛÂȘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘ ¤¯Ô˘Ó ηıÔÚÈÛı› ÚÈÓ ·fi ÙÔ Ù¤ÏÔ˜ Ù˘ 16˘ ÂÌ‚Ú˘˚΋˜ ‚‰ÔÌ¿‰·˜. 2) ∏ ‰È¿Ï·ÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ ·Ú¯›˙ÂÈ ÙËÓ 24Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰· Î·È Û˘Ó¯›˙ÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË. 3) ∆· “ÚÔ-‚ÔÙÚ˘‰È·Î¿ ·ÁÁ›·” (ÚÈÓ ÙÔ ‚ÔÙÚ‡‰ÈÔ ‹ ÚˆÙÔÁÂÓ¤˜ Ó¢ÌÔÓÈÎfi ÏÔ‚›‰ÈÔ, pre-acinar vessels) ·ÎÔÏÔ˘ıÔ‡Ó ÙË ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ ·ÂÚ·ÁˆÁÒÓ,
ÂÓÒ Ù· “ÂÓ‰Ô-‚ÔÙÚ˘‰È·Î¿ ·ÁÁ›·” (intra-acinar vessels) ·ÎÔÏÔ˘ıÔ‡Ó ÂΛÓË ÙˆÓ Î˘„ÂÏ›‰ˆÓ. √È “ÓfiÌÔÈ” ·˘ÙÔ› ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·fi ÙȘ ÂÚÈÁڷʛۘ ÎÏÈÓÈΤ˜ ÂÚÈÙÒÛÂȘ. √È Clements Î·È Warner Û ÙÚ›· ‰È·‰Ô¯Èο ¿ÚıÚ· Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÙÔ 1987 ÛÙÔ ›‰ÈÔ Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Thorax (9-11), ÂÈÛ‹Á·Á·Ó ÙËÓ ¤ÓÓÔÈ· “‰È·Ù·Ú·¯‹ ·Ó·ÛÙfïÛ˘” (malinosculation) ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÚÌËÓ‡ÛÔ˘Ó Î·È Ó· ηٷٿÍÔ˘Ó ÙÔ Û‡ÓÔÏÔ ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·, ·ÏÒÓ Î·È Û‡ÓıÂÙˆÓ. ªÂ ‚¿ÛË ÙËÓ ˘fiıÂÛË Ô˘ ‰È·Ù‡ˆÛ·Ó, Ë Ê˘ÛÈÔÏÔÁÈ΋ ·Ó·ÛÙfïÛË (inosculation) ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÛˆÏ‹ÓˆÓ (·ÁˆÁÒÓ) ÙÔ˘ Ó‡ÌÔÓ· ·ÂÚ·ÁˆÁÒÓ, ·ÚÙËÚÈÒÓ, ÊÏ‚ÒÓ Î·È ÏÂÌÊ·ÁÁ›ˆÓÔ‰ËÁ› ÛÙË ‰È¿Ï·ÛË ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Ó‡ÌÔÓ·. µ¿ÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·, ÏÈÁfiÙÂÚÔ ‹ ÂÚÈÛÛfiÙÂÚÔ Û‡ÓıÂÙˆÓ ·ÔÙÂÏ› Ë ‰È·Ù·Ú·¯‹ ·Ó·ÛÙfïÛ˘ ÂÓfi˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi Ù· ·Ú·¿Óˆ Û˘ÛÙ‹Ì·Ù· ÛˆÏ‹ÓˆÓ (malinosculation). √ ¯ÚfiÓÔ˜ ‰Ú¿Û˘ ÙÔ˘ ‚Ï·ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ηıÔÚ›˙ÂÈ Â¿Ó Ë ‰È·Ì·ÚÙ›· ı· Â›Ó·È ÂÓ‰Ô- ‹ Â͈-Ó¢ÌÔÓÈ΋. ™˘ÓÔÙÈο, ÔÈ ‰È¿ÊÔÚ˜ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó ˆ˜ ÂÍ‹˜: 1. ¢È·Ù·Ú·¯‹ ‰È¿Ï·Û˘ ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ Î·È ÙˆÓ ·ÁÁ›ˆÓ Ô˘ ÙÔÓ ·Ú‰Â‡Ô˘Ó Ô‰ËÁ› Û ·ÁÂÓÂÛ›· ‹ ˘ÔÏ·Û›· Ó‡ÌÔÓ·, ÏÔ‚Ô‡ ‹ ÙÌ‹Ì·ÙÔ˜, ·Ó·ÏfiÁˆ˜ ÙÔ˘ ›‰Ô˘˜, Ù˘ ¤ÓÙ·Û˘ Î·È Ù˘ ¯ÚÔÓÈ΋˜ ÛÙÈÁÌ‹˜ Ô˘ ÂΉËÏÒıËΠÙÔ ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ·. 2. ¶ÂÚÈÔÚÈṲ̂ÓË Î·È ÂÓÙÔÈṲ̂ÓË ‰È·Ù·Ú·¯‹ ‰È¿Ï·Û˘ ÂÚÈÊÂÚÈÎÔ‡ ‚ÚfiÁ¯Ô˘ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ù˘ÍË, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÛÙ¤ÓˆÛË ‚ÚfiÁ¯Ô˘, ‚ÚÔÁ¯ÔÁÂÓ‹ ·ÛÙË ‹ ‰˘ÛÏ·Û›· ¯fiÓ‰ÚÔ˘ Ì ·ÔÙ¤ÏÂÛÌ· ÙÚ·¯ÂÈÔ-/‚ÚÔÁ¯ÔÌ·Ï¿Î˘ÓÛË ‹ Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ·. 3. ™Â Û¿ÓȘ ÂÚÈÙÒÛÂȘ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ‰È¿Ï·ÛË Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ¯ˆÚ›˜ ·ÓÙ›ÛÙÔÈ¯Ë ‰È·Ù·Ú·¯‹ Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ‚ÚfiÁ¯Ô˘, ÒÛÙ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈÎfi ÙÌ‹Ì· Ó· ·Ú‰Â‡ÂÙ·È ·fi ·ÓÒÌ·ÏË ·ÚÙËÚ›· Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜. 4. ∆Ô ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ· ÚÔηÏ› ‰È·Ù·Ú·¯‹ Ù˘ ‰È¿Ï·Û˘ ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È Ù˘ ·ÚÙËÚ›·˜ ÌÂ Û˘Ó¤ÂÈ· ÙÔ “ÎÏ·ÛÈÎfi” ·fiÏ˘Ì· (sequestration), ÙȘ Û˘ÁÁÂÓ›˜ ·ÛÙÂȘ Ì ·ÓÒÌ·ÏË Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁ›ˆÛË Î·È Èı·ÓfiÓ ÙË Û˘ÁÁÂÓ‹ ΢ÛÙÈ΋ ‚ÚÔÁ¯ÂÎÙ·Û›·. 5. ∆¤ÏÔ˜, Â¿Ó ‰È·Ù·Ú·¯ı› Ë ·Ó¿Ù˘ÍË ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ ¯ˆÚ›˜ Û˘ÓÔ‰fi ‰È·Ù·Ú·¯‹ Ù˘ ·ÚÙËÚȷ΋˜ ¿Ú‰Â˘Û˘, ÌÔÚ› Ó· ÚÔ·„ÂÈ Ó¢ÌÔÓÈ΋ ·ÛÙË, ·fiÏ˘Ì· ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ¿Ú‰Â˘ÛË (·fi Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·), ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰È·Ì·ÚÙ›· ‹ Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ·. ∏ ‰È¿Ï·ÛË ÙÔ˘ ÊÏ‚ÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¤¯ÂÈ ‰ÈÂÚ¢ÓËı› ÏÈÁfiÙÂÚÔ. ™Â ÔÔÈ·‰‹ÔÙ ·fi ÙȘ ·Ú·¿Óˆ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ‰È·Ù·Ú·¯‹ ¶·È‰È·ÙÚÈ΋ 2007;70:184-191
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·186
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Ù˘ ÊÏ‚È΋˜ ·ÚÔ¯¤Ù¢Û˘. √È ·ÓÒ̷Ϙ ÊϤ‚˜ (·Ú·ÏÏ·Á‹ Û˘Ó‰ÚfiÌÔ˘ Scimitar) ÌÔÚ› Ó· ηٷϋÁÔ˘Ó ÛÙÔÓ ‰ÂÍÈfi ÎfiÏÔ, ÛÙËÓ ¿Óˆ ‹ οو ÎÔ›ÏË ÊϤ‚· Î·È ÂÓ›ÔÙ ÛÙÔÓ ·ÚÈÛÙÂÚfi ÎfiÏÔ.
¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ∏ ·ıÔÏÔÁ›· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂÎÊÚ¿˙ÂÙ·È Ì ÂÚÈÔÚÈṲ̂ÓÔ Ê¿ÛÌ· Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ, ÔÈ Û˘Ó‰˘·ÛÌÔ› ÙˆÓ ÔÔ›ˆÓ (ÎÏÈÓÈ΋ ÂÈÎfiÓ·) Û¿ÓÈ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÍÈÔÛËÌ›ˆÙË ÂȉÈÎfiÙËÙ·. ∞Ó¿ÏÔÁÔ Úfi‚ÏËÌ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ·Ú·ÎÏÈÓÈο ÂÚÁ·ÛÙËÚȷο ÂÚÁ·Ï›· ÚÒÙ˘ ÁÚ·ÌÌ‹˜ (·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ÛÈÚÔÌÂÙÚ›·, Ô͢ÌÂÙÚ›·, ·¤ÚÈ· ·›Ì·ÙÔ˜, ÁÂÓÈΤ˜ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ). ∫·Ù¿ Û˘Ó¤ÂÈ·, ÙÔ “ÊÙˆ¯fi ÏÂÍÈÏfiÁÈÔ” Ù˘ ·ıÔÏÔÁ›·˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Û·ÓÈfiÙËÙ· ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·, ηıÈÛÙÔ‡Ó ··Ú·›ÙËÙÔ ÙÔÓ ˘„ËÏfi ‰Â›ÎÙË ˘Ô„›·˜ ÂΠ̤ÚÔ˘˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÁÈ·ÙÚÔ‡ ÚÔÎÂÈ̤ÓÔ˘ Ó· Ô‰ËÁËı› ÛÙË ‰È¿ÁÓˆÛ‹ ÙÔ˘˜. ∏ Û˘ÁÁÂÓ‹˜ ‰È·Ì·ÚÙ›· ÙÔ˘ Ó‡ÌÔÓ· ÌÔÚ› Ó· Â›Ó·È ÁÓˆÛÙ‹ ‹‰Ë ·fi ÙÔÓ ÚÔÁÂÓÓËÙÈÎfi ¤ÏÂÁ¯Ô, Ó· ÂΉËψı› ˆ˜ ›ÁÔ˘Û· ηٿÛÙ·ÛË ÛÙȘ ÚÒÙ˜ ÛÙÈÁ̤˜ Ù˘ ˙ˆ‹˜ ‹ Ó· ·ÚÔ˘ÛÈ·Ûı› ·ÚÁfiÙÂÚ· (ÓÂÔÁÓÈ΋, fi„ÈÌË ‚ÚÂÊÈ΋, ·È‰È΋ ËÏÈΛ·, ÂÊ˂›·, ÂÓ‹ÏÈÎÔ ˙ˆ‹). ∂Ó›ÔÙ ÔÈ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ·Ú·Ì¤ÓÔ˘Ó ·Û˘Ìو̷ÙÈΤ˜ Î·È ·ÔÙÂÏÔ‡Ó Ù˘¯·›Ô ·ÎÙÈÓÔÁÚ·ÊÈÎfi ‡ÚËÌ·. Ÿ¯È Û¿ÓÈ· Ù¤ÏÔ˜, Û˘Óԉ‡ÔÓÙ·È ·fi ‰È·Ì·Úٛ˜ ¿ÏÏˆÓ Û˘ÛÙËÌ¿ÙˆÓ -Û˘¯ÓfiÙÂÚ· ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ·ÏÏ¿ Î·È ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, Ì˘ÔÛÎÂÏÂÙÈÎÔ‡, Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡- ‹ ·ÔÙÂÏÔ‡Ó Û˘ÛÙ·ÙÈο ÛÙÔȯ›· Û˘Ó‰ÚfïÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂΉËÏÒÓÔÓÙ·È ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ÂÎÙfi˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (7,12-14). ¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Î·È ÂΉËÏÒÛÂȘ ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ Î·È ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ √È Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ó‡ÌÔÓ· ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ‹‰Ë ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈÔ ˙ˆ‹ Î·È Ó· ÂÓÙÔÈÛıÔ‡Ó Ì ÙËÓ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÂͤٷÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∆Ô ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ Â›Ó·È ÙÔ ‰Â‡ÙÂÚÔ ÛÂ Û˘¯ÓfiÙËÙ· ·›ÙÈÔ Ù˘ ·Ï·Û›·˜ ‹ ˘ÔÏ·Û›·˜ ÙÔ˘ Ó‡ÌÔÓ·. ¶ÔÏ˘˘‰Ú¿ÌÓÈÔ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ë ·ÙÚËÛ›· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Óԉ‡ÂÙ·È ·fi ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ Î·È ÔÔÈ·‰‹ÔÙ ¯ˆÚÔηٷÎÙËÙÈ΋ ÂÓ‰ÔıˆÚ·ÎÈ΋ ‚Ï¿‚Ë, fiÙ·Ó ·˘Ù‹ Ô‰ËÁ› Û ÛÔ‚·Ú‹ Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ, ·ÊÔ‡ Ê˘ÛÈÔÏÔÁÈο ÂÚȤ¯Ô˘Ó ÙÔ ÂÓ‰ÔÓ¢ÌÔÓÈÎfi ˘ÁÚfi, ·Ó¿ÏÔÁÔ ÙÔ˘ ·ÌÓÈ·ÎÔ‡ (Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, ¢ÌÂÁ¤ı˘ ‚ÚÔÁ¯ÔÁÂÓ‹˜ ·ÛÙË, ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›·, Â˘Ì¤ÁÂı˜ ·fiÏ˘Ì·) (15). ¶ÔÏϤ˜ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ó‡ÌÔÓ· ÂΉËÏÒÓÔÓÙ·È ˆ˜ ›ÁÔÓÙ· ·Ó·Ó¢ÛÙÈο ÂÚÈÛÙ·ÙÈο Paediatriki 2007;70:184-191
Ì ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ¤ÚÁÔ˘ ·Ó·ÓÔ‹˜ ‹/Î·È Î˘¿ÓˆÛË (¶›Ó·Î·˜ 1) (3). ∆Ô ÈÛÙÔÚÈÎfi ‰‡ÛÎÔÏÔ˘ ÙÔÎÂÙÔ‡ ı¤ÙÂÈ ˘Ô„›· ÙÚ·˘Ì·ÙÈ΋˜ ·Ú¿Ï˘Û˘ ÙÔ˘ ÊÚÂÓÈÎÔ‡ Ó‡ÚÔ˘ Î·È Ë ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·‰˘Ó·Ì›· ‰È·ÚÚÈÓÈ΋˜ ‰È¿‚·Û˘ ÙÔ˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ˘Ô‰ËÏÒÓÂÈ ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÙÚËÛ›· ÚÈÓÈÎÒÓ ¯Ô·ÓÒÓ. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘, Ë ·Ô˘Û›· ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ ÛÙÔ ¤Ó· ‹ Î·È ÛÙ· ‰‡Ô ËÌÈıˆÚ¿ÎÈ· ı¤ÙÂÈ ˙‹ÙËÌ· Èı·Ó‹˜ ÂÙÂÚfiÏ¢Ú˘ ·Ï·Û›·˜/˘ÔÏ·Û›·˜ (ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ÂȤ‰ˆÛË Î·È ÂÏ·Ùو̤ÓË ÎÈÓËÙÈÎfiÙËÙ· Û‡ÛÙÔȯ·, Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Î·È ·ÓˆÌ·Ï›Â˜ ÚÔÛÒÔ˘), Û˘ÁÁÂÓÔ‡˜ ÏÔ‚Ò‰Ô˘˜ ÂÌÊ˘Û‹Ì·ÙÔ˜, Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ (85% ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ), ÌÂÁ¿Ï˘ ¯ˆÚÔηٷÎÙËÙÈ΋˜ ‚Ï¿‚˘ (Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, Û˘ÁÁÂÓ‹˜ ÌÂÛÔıˆÚ·ÎÈ΋ ‹ ·ÚÂÁ¯˘Ì·ÙÈ΋ ·ÛÙË, ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›·, Ôχ ÌÂÁ¿ÏÔ ·fiÏ˘Ì·) ‹ Û·ÓÈfiÙÂÚ·, ÂÎÛÂÛËÌ·Ṳ̂Ó˘ ‰È¿Ù·Û˘ Ù˘ ÎÔÈÏÈ¿˜, ÔfiÙ ‰ÈÂÚÂ˘Ó¿Ù·È ÙÔ ·›ÙÈÔ Ù˘ ‰È¿Ù·Û˘. ∞ÎÚfi·ÛË ÂÓÙÂÚÈÎÒÓ ‹¯ˆÓ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ÛηÊÔÂȉ‹ ÎÔÈÏÈ¿ ηÙ¢ı‡ÓÔ˘Ó ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë ÚÔ˜ ÙË Û˘ÁÁÂÓ‹ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Ô ·ÂÚÈÛÌfi˜ Ì ·ÛÎfi Î·È Ì¿Ûη ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ¶›Ó·Î·˜ 1. ™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ó‡ÌÔÓ· Ô˘ ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ˆ˜ ›ÁÔÓÙ· ÂÚÈÛÙ·ÙÈο ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ ñ ∞ÙÚËÛ›· ÚÈÓÈÎÒÓ ¯Ô·ÓÒÓ ñ ∞˘¯ÂÓÈΤ˜ Ì¿˙˜ (ÏÂÌÊ·ÁÁ›ˆÌ·, ·ÈÌ·ÁÁ›ˆÌ·, Û˘ÁÁÂÓ‹˜ ‚ÚÔÁ¯Ô΋ÏË, ·ÛÙË ı˘ÚÂÔÁψÛÛÈÎÔ‡ fiÚÔ˘, ‚Ú·Á¯È·Î‹ ·ÛÙË) ñ ÀÂÚÁψÙÙȉÈ΋ Û‡ÓÙËÍË Ï¿Ú˘ÁÁ·, ·ÏËı‹˜ Ï·Ú˘ÁÁÈ΋ ÌÂÌ‚Ú¿ÓË, Ï·Ú˘ÁÁÈ΋ ·ÛÙË, ‰˘ÛÏ·Û›· ÎÚÈÎÔÂȉԇ˜ ¯fiÓ‰ÚÔ˘, ·Ú¿Ï˘ÛË ÊˆÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ ñ ∞ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ (Û¿ÓÈÔ, Û ·ÎÚ·›Â˜ ÂÚÈÙÒÛÂȘ) ñ ∫‡ÛÙÂȘ Î·È fiÁÎÔÈ ÌÂÛÔıˆÚ·Î›Ô˘ (¢ÌÂÁ¤ıÂȘ, › ÛËÌ·ÓÙÈ΋˜ ·fiÊڷ͢) ñ ∞ÙÚËÛ›· ÔÈÛÔÊ¿ÁÔ˘ Ì ‹ ¯ˆÚ›˜ ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ ñ µÚÔÁ¯ÔÁÂÓ›˜ ·ÛÙÂȘ (¢ÌÂÁ¤ıÂȘ, › ÛËÌ·ÓÙÈ΋˜ ·fiÊڷ͢) ñ ∫˘ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›· (75% ÂΉ‹ÏˆÛË ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ) ñ ™˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ· (50% ÂΉ‹ÏˆÛË ÛÙÔÓ ÚÒÙÔ Ì‹Ó· ˙ˆ‹˜) ñ ¶Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· (Û¿ÓÈÔ, ÂÊfiÛÔÓ È‰È·›ÙÂÚ· Â˘Ì¤ÁÂı˜) ñ ∞ÁÂÓÂÛ›·/˘ÔÏ·Û›· Ó‡ÌÔÓ· ñ ¶Ó¢ÌÔıÒڷη˜ (Û˘Ó¤ÂÈ· ڋ͢ ΢ÛÙÈÎÔ‡ Û¯ËÌ·ÙÈÛÌÔ‡) ñ ™˘ÁÁÂÓ‹˜ ÏÂÌÊ·ÁÁÂÈÂÎÙ·Û›·, ¯˘ÏÔıÒڷη˜ ñ ¢˘ÛϷۛ˜ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ ñ ∂ÎÛÂÛËÌ·Ṳ̂ÓË ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜ (ÔÈΛÏ˘ ·ÈÙÈÔÏÔÁ›·˜)
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·187
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™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ó¢ÌfiÓˆÓ
ÏfiÁˆ ‰È¿Ù·Û˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙË ıˆÚ·ÎÈ΋ ÎÔÈÏfiÙËÙ·. ∏ ηډȷ΋ ÛÎÈ¿ ·ˆıÂ›Ù·È ÚÔ˜ Ù· ‰ÂÍÈ¿. ∫ÏÈÓÈο ÛËÌ·ÓÙÈÎfi˜ Ó¢ÌÔıÒڷη˜ ÌÔÚ› Ó· Â›Ó·È Û˘Ó¤ÂÈ· Û˘ÁÁÂÓÔ‡˜ ÏÔ‚Ò‰Ô˘˜ ÂÌÊ˘Û‹Ì·ÙÔ˜ ‹ ÔÔÈ·Û‰‹ÔÙ ¢ÌÂÁ¤ıÔ˘˜ Û˘ÁÁÂÓÔ‡˜ ΢ÛÙÈ΋˜ ·ÓˆÌ·Ï›·˜. ∞‰˘Ó·Ì›· Û›ÙÈÛ˘ Ì ÓÈÁÌÔÓ‹ Î·È Èı·Ó‹ ÂÈÛÚfiÊËÛË, Ì ·Ú¿ÏÏËÏË ·‰˘Ó·Ì›· ÚÔÒıËÛ˘ ÙÔ˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ, ·Ú·¤ÌÂÈ Û ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ Ì ·ÙÚËÛ›· ÔÈÛÔÊ¿ÁÔ˘ (Û˘¯ÓfiÙÂÚÔ˜ Ù‡Ô˜), Ô˘ ÌÔÚ› Ó· ÂȂ‚·Èˆı› ·ÎÙÈÓÔÁÚ·ÊÈο ·fi ÙËÓ ÔÚ›· ÙÔ˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ‹ Ì ÙË ¯Ú‹ÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ˘ÏÈÎÔ‡. ÕÏϘ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ˆ˜ ›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙȘ ÛÔ‚·Ú¤˜ ‰˘ÛϷۛ˜ ÙÔ˘ Ï¿Ú˘ÁÁ· Î·È Ù˘ ÙÚ·¯Â›·˜ (Ï‹Ú˘ Û‡ÓÙËÍË ÙˆÓ ˘ÂÚÁψÙÙȉÈÎÒÓ ·Ó·ÙÔÌÈÎÒÓ ÌÔÚ›ˆÓ, ·ÏËı›˜ Ï·Ú˘ÁÁÈΤ˜ ÌÂÌ‚Ú¿Ó˜, Ï·Ú˘ÁÁÈΤ˜ ·ÛÙÂȘ, ‰˘ÛÏ·Û›· ÎÚÈÎÔÂȉԇ˜ ¯fiÓ‰ÚÔ˘, ·ÌÊÔÙÂÚfiÏ¢ÚË ·Ú¿Ï˘ÛË ÊˆÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ), ÙȘ Ì¿˙˜ ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜ (ÏÂÌÊ·ÁÁ›ˆÌ·, ·ÈÌ·ÁÁ›ˆÌ·, Û˘ÁÁÂÓ‹˜ ‚ÚÔÁ¯Ô΋ÏË, ÌÂÁ¿Ï˜ ‚Ú·Á¯È·Î¤˜ ·ÛÙÂȘ ‹ ·ÛÙÂȘ ı˘ÚÂÔÁψÛÛÈÎÔ‡ fiÚÔ˘) Û·Ó›ˆ˜ ÙȘ ·ÎÚ·›Â˜ ÌÔÚʤ˜ ·ÁÁÂÈ·ÎÔ‡ ‰·ÎÙ˘Ï›Ô˘ (·Á·ÏË ·ÚÈÛÙÂÚ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Ì ÛÙ¤ÓˆÛË ÙÚ·¯Â›·˜ ÏfiÁˆ Ï‹ÚˆÓ ¯fiÓ‰ÚÈÓˆÓ ‰·ÎÙ˘Ï›ˆÓ, ring-sling syndrome) Î·È Ù· ÂÏÏ›ÌÌ·Ù· ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ (ÛÙÂÚÓÈ΋ Û¯ÈÛÙ›·, ·Ô˘Û›· ÙÌËÌ¿ÙˆÓ Ï¢ÚÒÓ Î.Ï.) (7,12-14,16). µÏ¿‚˜ ÛÙÔ Â›Â‰Ô Ù˘ ÁψÙÙ›‰·˜ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ·ÊˆÓ›· ‹ ‚Ú·¯Ófi Î·È ·‰‡Ó·ÌÔ ÎÏ¿Ì·. ∏ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÏfiÁˆ Â͈ıˆÚ·ÎÈ΋˜ ·fiÊڷ͢ ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ ÚÔηÏ› ÚˆÙ›ÛÙˆ˜ ÂÈÛÓ¢ÛÙÈÎfi Î·È Èı·ÓfiÓ ‰ÈÊ·ÛÈÎfi ÛÈÁÌfi, ·Ó Î·È ·˘Ùfi ÙÔ ÎÏÈÓÈÎfi ÛËÌÂ›Ô ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ·ÚÁfiÙÂÚ·, ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. √ ·ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ Ô˘ ÂΉËÏÒÓÂÙ·È ÓˆÚ›˜ Û˘Óԉ‡ÂÙ·È ·fi ÌÔÓÔʈÓÈÎfi ‹ Û˘¯Ó¿ ‰ÈÊ·ÛÈÎfi Û˘ÚÈÁÌfi (ÂÓ‰ÔıˆÚ·ÎÈ΋ ·fiÊÚ·ÍË ÙÚ·¯Â›·˜) ηıÒ˜ Î·È ·fi ÚÔ‚Ï‹Ì·Ù· Û›ÙÈÛ˘, ÛÈÂÏfiÚÚÔÈ· Î·È ÂÈÎfiÓ· ÔÈÛıfiÙÔÓÔ˘. ∏ ÛÔ‚·Ú‹ ÙÚ·¯ÂÈÔÌ·Ï¿Î˘ÓÛË ÏfiÁˆ ·ÁÁÂÈ·ÎÔ‡ ‰·ÎÙ˘Ï›Ô˘ ‹ Ë ·Ú·ÌÔÓ‹ Ù˘ ÌÂÙ¿ ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘ Î·È ÔÈ ÂÈÛÚÔÊ‹ÛÂȘ ÔÈΛÏ˘ ·ÈÙÈÔÏÔÁ›·˜ (ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ, Ï·Ú˘ÁÁÈ΋ Û¯ÈÛÌ‹, ·Û˘Ó¤ÚÁÂÈ· Ì˘ÒÓ Î·Ù¿ÔÛ˘, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË) ÌÔÚ› Ó· ÂΉËψıÔ‡Ó Ì ÂÂÈÛfi‰È· ¿ÓÔÈ·˜ Î·È ‚Ú·‰˘Î·Ú‰›·˜. ∏ Û˘ÁÁÂÓ‹˜ ÏÂÌÊ·ÁÁÂÈÂÎÙ·Û›· ÂΉËÏÒÓÂÙ·È Ì ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Î·È Î˘¿ÓˆÛË ·fi ÙȘ ÚÒÙ˜ ÒÚ˜ ˙ˆ‹˜, ÂÓÒ ÙÔ ·Ó·Ó¢ÛÙÈÎfi „Èı‡ÚÈÛÌ· ·ÎÔ‡ÁÂÙ·È ·ÚÔÛ‰fiÎËÙ· Ê˘ÛÈÔÏÔÁÈÎfi. ∏ ›ÁÔ˘Û· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο ÛÙË ‰È¢ÎÚ›ÓÈÛË ÙˆÓ ·ÓˆÙ¤Úˆ
Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ. ™Â οı ÂÚ›ÙˆÛË, ÚÔ¤¯ÂÈ Ë Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÔÁÓÔ‡, Ô˘ ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ ÂÓÙ·ÙÈ΋ ıÂڷ›· Î·È Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË. ÿÛˆ˜ ¯ÚÂÈ·Ûı› ›ÁÔ˘Û· ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË (.¯. ÙÚ·¯ÂÈÔÛÙÔÌ›·) ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Úı›, ¤ÛÙˆ ÚÔÛˆÚÈÓ¿, ÙÔ ·›ÙÈÔ Ô˘ ‰È·Î˘‚‡ÂÈ ÙË ‚·ÙfiÙËÙ· ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡. √ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ÌÔÚ› Ó· ÂÚÈÏ¿‚ÂÈ ÛÂÈÚ¿ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ (‚·ÚÈÔ‡¯Ô Á‡̷, ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ·ÁÁÂÈÔÁÚ·Ê›· Î.Ï., Ô˘ ‰È¢ÎÚÈÓ›˙Ô˘Ó ÙË ‚Ï¿‚Ë ·Ó·ÙÔÌÈο). ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ Â‡Î·ÌÙÔ ‹/Î·È ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙȘ Û˘Ó¤ÂȘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÛÙÔÓ ·ÂÚ·ÁˆÁfi (ÂÓ‰Ô·˘ÏÈο ·›ÙÈ· ÛÙ¤ÓˆÛ˘, Â͈ÙÂÚÈ΋ Û˘Ì›ÂÛË, ‰˘Ó·ÌÈ΋ ÛÙ¤ÓˆÛË Â› Ï·Ú˘ÁÁÔ-ÙÚ·¯ÂÈÔ-‚ÚÔÁ¯ÔÌ·Ï¿Î˘ÓÛ˘), ÂÓÒ ÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· ÌÔÚ› Ó· ÙÂÎÌËÚÈÒÛÂÈ ÂÈÛÚfiÊËÛË ‹ ·ÈÌÔÚÚ·Á›· (7,12-14,17). §fiÁˆ Û˘¯Ó‹˜ Û˘Ó‡·Ú͢ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜. ™ÙËÓ ÂÚ›ÙˆÛË ·Ôχ̷ÙÔ˜ ‹ Û·Ó›ˆ˜, Û˘ÁÁÂÓÔ‡˜ ·ÛÙ˘ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁ›ˆÛË Î·È ÌÂÁ¿ÏË ‰È·Ê˘Á‹ ·fi ÙËÓ ·ÚÈÛÙÂÚ‹ ÚÔ˜ ÙË ‰ÂÍÈ¿ ΢ÎÏÔÊÔÚ›·, ÚÒÙË ÂΉ‹ÏˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ó¢ÌÔÓÈ΋˜ ‰È·Ì·ÚÙ›·˜ ÌÔÚ› Ó· Â›Ó·È Î·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· (7,12-14). ∂ΉËÏÒÛÂȘ ÛÙËÓ fi„ÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ· Î·È ÛÙ· ÚÒÙ· 2-3 ¤ÙË ˙ˆ‹˜ ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹ ¤¯Ô˘Ó ϤÔÓ ÂΉËψı› ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÎÏÈÓÈο ÛËÌ·ÓÙÈΤ˜ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ fi„ÈÌË ÂΉ‹ÏˆÛË Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ Â›Ó·È Ì¿ÏÏÔÓ Û˘Ó¤ÂÈ· ÂÚÈÔÚÈṲ̂ÓÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ‚Ï¿‚˘ ·Ú¿ Ù˘ ›‰È·˜ Ù˘ ʇÛ˘ Ù˘. ™ÙÔÓ ¶›Ó·Î· 2 ·Ó·Ê¤ÚÔÓÙ·È ÔÈ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÔÈ Ôԛ˜ ηْ ÂÍÔ¯‹Ó ··Û¯ÔÏÔ‡Ó ÙÔÓ ÁÈ·ÙÚfi ÌÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ Î·È Ì¤¯ÚÈ ÙËÓ ÚÒÈÌË ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ¶Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙÔ˘ ÛÈÁÌÔ‡ (stridor) Î·È ÙÔ˘ Û˘ÚÈÁÌÔ‡ (wheezing). √ ÚÒÙÔ˜ Â›Ó·È Î˘Ú›ˆ˜ ÂÈÛÓ¢ÛÙÈÎfi˜ ÌÔÓÔʈÓÈÎfi˜ ÌÔ˘ÛÈÎfi˜ ‹¯Ô˜, ÏfiÁˆ Â͈ıˆÚ·ÎÈ΋˜ ÛÙ¤ÓˆÛ˘ ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡. O ‰Â‡ÙÂÚÔ˜ Â›Ó·È ÚˆÙ›ÛÙˆ˜ ÂÎÓ¢ÛÙÈÎfi˜ ÌÔÓÔʈÓÈÎfi˜ ‹ ÔÏ˘ÊˆÓÈÎfi˜ -·Ó·ÏfiÁˆ˜ Ù˘ ÂÓÙfiÈÛ˘- ÌÔ˘ÛÈÎfi˜ ‹¯Ô˜ Î·È ÔÊ›ÏÂÙ·È Û ÂÓ‰ÔıˆÚ·ÎÈ΋ ÛÙ¤ÓˆÛË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (18). ¶¿ÓÙˆ˜, ÚfiÎÂÈÙ·È ÁÈ· ÂÍ·ÈÚÂÙÈο Û˘¯Ó¿ ·Ó·Ó¢ÛÙÈο Û˘ÌÙÒÌ·Ù· ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ Ô˘ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È ÛÂ Û˘Ó‹ıÂȘ ·ı‹ÛÂȘ. ¶Ôχ Û˘¯Ó¿ Ù· ·ÎÚÔ·ÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÂȉÂÈÓÒÓÔÓÙ·È ÌÂÙ¿ ·fi Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (.¯. Ï·Ú˘ÁÁÔÌ·Ï¿Î˘ÓÛË, ÙÚ·¯ÂÈÔÌ·Ï¿Î˘ÓÛË) Î·È ·˘Ùfi ÌÔÚ› Ó· ÂÚÈϤÍÂÈ ÂÚÈÛÛfiÙÂÚÔ ÙË ‰È¿ÁÓˆÛË. ™˘¯Ó¿ Ë ¶·È‰È·ÙÚÈ΋ 2007;70:184-191
Pediatri May-Jun 07
24-05-07
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∫. ¡. ¶Ú›ÊÙ˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ó‡ÌÔÓ· Ô˘ Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÔÓÙ·È ÌÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Î·È Ì¤¯ÚÈ Ù· 2-3 ÚÒÙ· ¤ÙË ˙ˆ‹˜ ñ ª¿˙˜ (ÏÂÌÊ·ÁÁ›ˆÌ·, ·ÈÌ·ÁÁ›ˆÌ·, ·ÛÙË ı˘ÚÂÔÁψÛÛÈÎÔ‡ fiÚÔ˘, ‚Ú·Á¯È·Î‹ ·ÛÙË, Ï·Ú˘ÁÁÈ΋ ·ÛÙË) ñ ∂ÙÂÚfiÏ¢ÚË ·Ú¿Ï˘ÛË, ¿ÚÂÛË ÊˆÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ ñ §·Ú˘ÁÁÔ-ÙÚ·¯ÂÈÔ-‚ÚÔÁ¯ÔÌ·Ï¿Î˘ÓÛË (Û˘¯Ó‹) ñ ∞ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ (Û˘¯ÓfiÙÂÚË ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ËÏÈÎȷ΋ ÔÌ¿‰·) ñ ∫‡ÛÙÂȘ Î·È fiÁÎÔÈ ÌÂÛÔıˆÚ·Î›Ô˘ ñ ∆Ú·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ Ù‡Ô˘-∏ ñ µÚÔÁ¯ÔÁÂÓ›˜ ·ÛÙÂȘ (·fiÊÚ·ÍË, ÏÔÈÌÒÍÂȘ) ñ ∫˘ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›· (ÌÈÎÚfi Û¯ÂÙÈο ÔÛÔÛÙfi) ñ ™˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ· (ÌÈÎÚ‹ ‰È¿Ù·ÛË) ñ ¶Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· ñ ÀÔÏ·Û›· Ó‡ÌÔÓ· (ÌÈÎÚÔ‡ ‚·ıÌÔ‡)
ÙÚ·¯ÂÈÔÌ·Ï¿Î˘ÓÛË “·ÓÙÈÌÂÙˆ›˙ÂÙ·È” › Ì·ÎÚfiÓ Ì ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ ÚÔÙÔ‡ ‰È·ÁÓˆÛı› ‹ ·ÏÒ˜ ÛÙ·Ì·Ù‹ÛÂÈ Ó· ¤¯ÂÈ ÎÏÈÓÈ΋ ÛËÌ·Û›· (7,1214,18,19). ™˘¯Ófi Û‡Ìو̷ Ù˘ Ï·Ú˘ÁÁÔ-ÙÚ·¯ÂÈÔ-‚ÚÔÁ¯ÔÌ·Ï¿Î˘ÓÛ˘ Î·È ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ Ô˘ Ȥ˙Ô˘Ó Â͈ÙÂÚÈο ÙÔÓ ·ÂÚ·ÁˆÁfi Â›Ó·È Î·È Ô ¯ÚfiÓÈÔ˜ ‹ ˘ÔÙÚÔÈ¿˙ˆÓ ‚‹¯·˜. ™˘Ó‹ıÂȘ ·Ó·Ó¢ÛÙÈΤ˜ ·ı‹ÛÂȘ Ù˘ ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜, fiˆ˜ Ë ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ÌÔÚ› Ó· ÂΉËψıÔ‡Ó Ì ·Û˘Ó‹ıÈÛÙË ‚·Ú‡ÙËÙ· fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ Û˘ÁÁÂÓ‹˜ ‰È·Ì·ÚÙ›· ÙÔ˘ Ó‡ÌÔÓ· (.¯. Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ·, Û˘Ìو̷ÙÈΤ˜ ΢ÛÙÈΤ˜ ‰È·Ì·Úٛ˜). ∂Ó›ÔÙÂ, Ë Û˘ÁÁÂÓ‹˜ ‰È·Ì·ÚÙ›· ÌÔÚ› Ó· ÂΉËÏÒÓÂÙ·È ˆ˜ ˘ÔÙÚÔÈ¿˙Ô˘Û· Ó¢ÌÔÓ›· ÛÙËÓ ›‰È· ¿ÓÙÔÙ ·Ó·ÙÔÌÈ΋ ı¤ÛË (¯ Û˘ÁÁÂÓ‹˜ ·ÛÙË, ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›·, ·fiÏ˘Ì·) ‹ ˆ˜ ÌÂÙ·Ó·ÛÙ¢ÙÈ΋ Ó¢ÌÔÓ›·/·ÙÂÏÂÎÙ·Û›· (.¯. Û˘ÁÁÂÓ›˜ ‚ÚÔÁ¯ÂÎٷۛ˜, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Ì ÂÈÛÚfiÊËÛË ˆ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÏÔ΋ ‰ÈfiÚıˆÛ˘ ·ÙÚËÛ›·˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘). ™ÙËÓ ËÏÈÎȷ΋ ·˘Ù‹ ÔÌ¿‰· Ë ·ÈÌfiÙ˘ÛË ˆ˜ Û‡Ìو̷ Û·Ó›˙ÂÈ. √ÚÈṲ̂Ó˜ Û˘ÁÁÂÓ›˜ ‚Ï¿‚˜ ÌÔÚ› Ó· ·Ó·Î·Ï˘ÊıÔ‡Ó Ù˘¯·›· Û ·ÎÙÈÓÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Ô˘ ¤ÁÈÓ ÁÈ· ¿ÏÏÔ ÏfiÁÔ (18,19). ∂› ˘Ô„›·˜ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ Ë ÂÚÁ·ÛÙËÚȷ΋ ÚÔÛ¤ÁÁÈÛË Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹Ó Ô˘ ÂÚÈÁÚ¿ÊËΠÁÈ· ÙȘ ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘. ∂ΉËÏÒÛÂȘ ÛÙËÓ fi„ÈÌË ÚÔÛ¯ÔÏÈ΋, ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· √È ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ËÏÈÎȷ΋˜ ·˘Ù‹˜ ÔÌ¿‰·˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3 (7,12-14,18,19). ™ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·È‰› Î·È ÛÙÔÓ ¤ÊË‚Ô, fiˆ˜ ÂÍ¿ÏPaediatriki 2007;70:184-191
ÏÔ˘ Î·È ÛÙÔÓ ÂÓ‹ÏÈÎÔ, Ôχ Û˘¯Ó¿ Ë ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ Á›ÓÂÙ·È Ì ·ÊÔÚÌ‹ Ù˘¯·›Ô ·ÎÙÈÓÔÁÚ·ÊÈÎfi ‡ÚËÌ·. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ ·ÔÙÂÏÔ‡Ó ÔÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ‹ ¯ÚfiÓȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Û·ÓÈfiÙÂÚ· Ë ·ÈÌfiÙ˘ÛË ‹ Ô ·ÈÊÓ›‰ÈÔ˜ Ó¢ÌÔıÒڷη˜. ÀÔ„›· Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÌÔÚ› Ó· ÙÂı› ·fi Ù· Â˘Ú‹Ì·Ù· ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ Ó¢ÌfiÓˆÓ (.¯. ÌË ÌÂÙ·‚·ÏÏfiÌÂÓË ·fiÊÚ·ÍË ÏfiÁˆ Â͈ÁÂÓÔ‡˜ Û˘Ì›ÂÛ˘ ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ ·ÛıÂÓÔ‡˜ ÌÂ Û˘ÚÈÁÌfi ‹ ÂÚÈÔÚÈÛÙÈ΋ Ó¢ÌÔÓÔ¿ıÂÈ· ÏfiÁˆ ¯ÚfiÓÈ·˜ ÂÈÛÚfiÊËÛ˘ ÌÂÙ¿ ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘) (19). ∏ ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰˘ÛÏ·Û›· Úԉȷı¤ÙÂÈ Û ηÎÔ‹ıË ÂÍ·ÏÏ·Á‹ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹, ÁÈ’ ·˘Ùfi ¿ÏψÛÙÂ, ÂӉ›ÎÓ˘Ù·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË, ·ÎfiÌË Î·È Â› ·Û˘Ìو̷ÙÈ΋˜ ‚Ï¿‚˘ (19). ∫·ÎÔ‹ı˘ ÂÍ·ÏÏ·Á‹ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È Û ÂÚÈÙÒÛÂȘ ‚ÚÔÁ¯ÔÁÂÓÔ‡˜ ·ÛÙ˘ (20).
¶ÚfiÁÓˆÛË Î·È ·ÒÙÂÚ˜ Û˘Ó¤ÂȘ ∏ ÚfiÁÓˆÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›‰Ô˜ Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘, ηıÒ˜ ›Û˘ ÙËÓ ‡·ÚÍË ‹ ÌË Û˘ÓÔ‰ÒÓ ·ÓˆÌ·ÏÈÒÓ. £· ÂÍ·ÚÙËı› ·fi ÙÔÓ ¯ÚfiÓÔ Ù˘ Èı·Ó‹˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘, ·fi ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ·Ê·ÈÚÔ‡ÌÂÓÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, ·fi ÙȘ ÂÓ·ÔÌ›ӷÛ˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜, ·fi ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ô˘ ›Ûˆ˜ ·ÚÔ˘ÛÈ·ÛıÔ‡Ó, ·fi ÙËÓ ÈηÓfiÙËÙ· Î·È ÂÌÂÈÚ›· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ Î·È Ù¤ÏÔ˜, ·fi ÙËÓ ·ÓÙÈÚÚÔÈÛÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ ÌÂÙ¿ ÙËÓ ÂÎÙÔÌ‹ Ù˘ ‚Ï¿‚˘. ¶›Ó·Î·˜ 3. ∂ΉËÏÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÙÔ˘ Ó‡ÌÔÓ· ηٿ ÙËÓ fi„ÈÌË ÚÔÛ¯ÔÏÈ΋, ÙËÓ ·È‰È΋ Î·È ÙËÓ ÂÊË‚È΋ ËÏÈΛ· ñ ∆˘¯·›Ô ·ÎÙÈÓÔÁÚ·ÊÈÎfi ‡ÚËÌ· ñ ÀÔÙÚÔÈ¿˙Ô˘Û· Ó¢ÌÔÓ›·/·ÙÂÏÂÎÙ·Û›· ‹ ·fiÛÙËÌ· (Û˘ÁÁÂÓ‹˜ ·ÛÙË, ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰È·Ì·ÚÙ›·, ·fiÏ˘Ì·) ñ ™˘¯Ó¤˜ ‹ ¯ÚfiÓȘ ÏÔÈÌÒÍÂȘ ·fi ÙÔ Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi (Û˘ÁÁÂÓ›˜ ‚ÚÔÁ¯ÂÎٷۛ˜, Û‡Ó‰ÚÔÌÔ Mounier-Kuhn, Û‡Ó‰ÚÔÌÔ Williams-Campbell, ÙÚ·¯ÂÈ·Îfi ÂÎÎfiψ̷) ñ ∞ÈÌfiÙ˘ÛË (Û˘ÁÁÂÓ‹˜ ·ÛÙË, ΢ÛÙÈ΋ ·‰ÂÓÔÌ·ÙÔÂȉ‹˜ ‰È·Ì·ÚÙ›·, ·fiÏ˘Ì·, ‚ÚÔÁ¯ÂÎٷۛ˜) ñ ∞ÈÊÓ›‰ÈÔ˜ Ó¢ÌÔıÒڷη˜ (΢ÛÙÈΤ˜ ‰È·Ì·Úٛ˜) ñ ∞ÔÎÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ΢¿ÓˆÛË, ÏËÎÙÚÔ‰·ÎÙ˘Ï›· (·ÚÙËÚÈÔÊÏ‚҉˘ ÂÈÎÔÈÓˆÓ›·) ñ ™ÈÚÔÌÂÙÚÈÎfi ‡ÚËÌ· ηٿ ÙË ‰ÈÂÚ‡ÓËÛË Û˘ÚÈÁÌÔ‡, ÂÚÈÔÚÈÛÙÈ΋ ÓfiÛÔ˜ ÌÂÙ¿ ÂÁ¯ÂÈÚËÙÈ΋ ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘ ñ ™˘ÁÁÂÓ›˜ ‰˘ÛϷۛ˜ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (Û˘ÁÁÂÓ‹˜ ÛÎÔÏ›ˆÛË, Û˘ÁÁÂÓ‹˜ ·ʈÛË), ÛÎÔÏ›ˆÛË ÌÂÙ¿ ıˆÚ·ÎÔÙÔÌ‹ (.¯. ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘)
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·189
189
™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ó¢ÌfiÓˆÓ
™ÙËÓ Ú¿ÍË ˘¿Ú¯Ô˘Ó ÔÈ ÂÍ‹˜ ηÙËÁÔڛ˜ ·ÛıÂÓÒÓ (21): 1) √È ·ÛıÂÓ›˜ Ô˘ ¯ÂÈÚÔ˘ÚÁ‹ıËÎ·Ó ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË. ∆¤ÙÔÈÔÈ Â›Ó·È Î˘Ú›ˆ˜ ÔÈ ·ÛıÂÓ›˜ ÌÂ Û˘ÁÁÂÓ‹ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Î·È ·ÙÚËÛ›· ÔÈÛÔÊ¿ÁÔ˘. 2) √È ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û˘ÓÙËÚËÙÈο Î·È ÛÙÔ˘˜ ÔÔ›Ô˘˜ ·Ó·‚¿ÏÏÂÙ·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË, ÂÊfiÛÔÓ Ë Î·Ù¿ÛÙ·Û‹ ÙÔ˘˜ ÙÔ ÂÈÙÚ¤ÂÈ. ¶·Ú¿‰ÂÈÁÌ· Â›Ó·È ÔÈ ·ÛıÂÓ›˜ Ì ΢ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. 3) √È ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Û ÌÂÁ¿ÏË ËÏÈΛ·, Û˘Ó‹ıˆ˜ Ù˘¯·›·, Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó ‹‰Ë ÂÁηÙÂÛÙË̤Ó˜ ÂÈÏÔΤ˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÔÚ›· ÙˆÓ ·Ú·¿Óˆ ·ÛıÂÓÒÓ Ô˘ ¯ÂÈÚÔ˘ÚÁ‹ıËÎ·Ó ‹ ‰ÂÓ ¯ÂÈÚÔ˘ÚÁ‹ıËηÓ, Ù›ıÂÓÙ·È Ù· ÂÍ‹˜ ‰‡Ô ÂÚˆÙ‹Ì·Ù·: ·) ∂›Ó·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ˘fiÏÔÈÔ˘ ˘ÁÈÔ‡˜ Ó‡ÌÔÓ· ÌÔÚÊÔÏÔÁÈο Î·È ÏÂÈÙÔ˘ÚÁÈο Ê˘ÛÈÔÏÔÁÈ΋; ‚) ™Â ÔÈÔ ‚·ıÌfi ÂËÚ¿˙ÂÙ·È Ë ÂÔ˘ÏˆÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ Ó‡ÌÔÓ· ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜; ∆· ·Ú·¿Óˆ ÂÚˆÙ‹Ì·Ù· ‰ÂÓ ··Û¯ÔÏÔ‡Ó ÌfiÓÔ ÙÔÓ Ó¢ÌÔÓÔÏfiÁÔ ÂÓËϛΈÓ, ·ÊÔ‡ ·˘Ùfi˜ ‰È·ÈÛÙÒÓÂÈ ÙȘ ·ÒÙÂÚ˜ Û˘Ó¤ÂȘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‚Ï¿‚˘ ‹ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘, ·ÏÏ¿ Î·È ÙÔÓ ·È‰›·ÙÚÔ, ÙÔÓ ·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ ‹ ÙÔÓ ·È‰Ô¯ÂÈÚÔ˘ÚÁfi Ô˘ ÚÔÛ·ı› Ó· ÂÈϤÍÂÈ ÙÔÓ Î·Ù·ÏÏËÏfiÙÂÚÔ ¯ÚfiÓÔ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜. ∂¿Ó Ë ·ÓÙÈÚÚÔÈÛÙÈ΋ ·‡ÍËÛË Î·È ·Ó¿Ù˘ÍË Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙȘ ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘, Ë ÂÎÙÔÌ‹ Ù˘ ‚Ï¿‚˘ Ú¤ÂÈ Ó· Á›ÓÂÈ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÓˆÚ›ÙÂÚ·, ÒÛÙ ӷ ÂÈÙ¢¯ı› Ë Ì¤ÁÈÛÙË ·ÔηٿÛÙ·ÛË. ∂¿Ó ‰ÂÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ËÏÈΛ·, Ë Â¤Ì‚·ÛË ÌÔÚ› Ó· ·Ó·‚ÏËı› ÒÛÙ ӷ ÂÍ·ÛÊ·ÏÈÛıÔ‡Ó ÔÈ Î·Ï‡ÙÂÚ˜ ÚÔ¸Ôı¤ÛÂȘ, ÂÊfiÛÔÓ Ë Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ Â›Ó·È ÂÈÛÊ·Ï‹˜. ™·Ê›˜ ··ÓÙ‹ÛÂȘ ÛÙ· ·Ú·¿Óˆ ÂÚˆÙ‹Ì·Ù· Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚÔ˜ ÙÔ ·ÚfiÓ, ÏfiÁˆ Ù˘ ÔÏ˘ÏÔÎfiÙËÙ·˜ ÙÔ˘ ı¤Ì·ÙÔ˜ (21). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ì ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ™Â ·Ï·ÈfiÙÂÚË ÂÚ¢ÓËÙÈ΋ ÂÚÁ·Û›· ‰È·ÈÛÙÒıËΠ̛ˆÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ Î·È Ù˘ ‰È·¯˘ÙÈ΋˜ ÈηÓfiÙËÙ·˜ ·Ó¿ÏÔÁË ÚÔ˜ ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÂÎٷ̤ÓÙÔ˜ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ (22). ™Â ¿ÏϘ ÌÂϤÙ˜ fï˜, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÔÚÈṲ̂ÓÔÈ ‰Â›ÎÙ˜ ÚÔÛÂÁÁ›˙Ô˘Ó Ù· “Ê˘ÛÈÔÏÔÁÈο” ›‰·, ˘Ô‰ËÏÒÓÔÓÙ·˜ ÙËÓ ·ÓÙÈÚÚÔÈÛÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ÂÓ·ÔÌ›ӷÓÙ· Ó‡ÌÔÓ· (23,24). º˘ÛÈÔÏÔÁÈΤ˜ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ‰È·ÈÛÙÒıËÎ·Ó ÌÂÙ¿ ÏÔ‚ÂÎÙÔÌ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ÏÔ‚Ò‰Ô˘˜ ÂÌÊ˘Û‹Ì·ÙÔ˜ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ·Ó Î·È ÔÈ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ˘ÔÛÙ› ·Ê·›ÚÂÛË ÌÂÁ·Ï‡ÙÂÚˆÓ ÏÔ‚ÒÓ Â›¯·Ó ÌÂÁ·Ï‡ÙÂÚ˜ ÙÈ̤˜ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ (25). √È ÌÂÁ·Ï‡ÙÂÚ˜ ÙÈ̤˜ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ ‰ÂÓ ˘Ô-
‰ËÏÒÓÔ˘Ó ··Ú·›ÙËÙ· ηχÙÂÚË ÏÂÈÙÔ˘ÚÁÈ΋ ÈηÓfiÙËÙ·, ‰ÈfiÙÈ ·˘Ùfi ÌÔÚ› Ó· ·ÔÙÂÏ› Û˘Ó¤ÂÈ· Ù˘ “˘ÂډȿٷÛ˘” ÙÔ˘ Ó‡ÌÔÓ·, ·Ê‹ÓÔ˘Ó fï˜ ·ÓÔȯÙfi ÙÔ ÂӉ¯fiÌÂÓÔ ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ·ÓÙÈÚÚÔÈÛÙÈ΋˜ ·¿ÓÙËÛ˘ ÙÔ˘ Ó‡ÌÔÓ· Ó· ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ¤ÎÙ·ÛË Ù˘ ÏÔ‚ÂÎÙÔÌ‹˜. ∞ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó fiÙÈ Ô Ó‡ÌÔÓ·˜ Ô˘ ̤ÓÂÈ ÌÂÙ¿ ÙËÓ ÂÎÙÔÌ‹, ÎÂÚ‰›˙ÂÈ Û fiÁÎÔ Î·È ‚¿ÚÔ˜ Î·È fiÙÈ ·˘Ù‹ Ë ·¿ÓÙËÛË Û˘Ì‚·›ÓÂÈ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ËÏÈΛ· (26). ¶¿ÏÈ fï˜, Ë ·‡ÍËÛË ÙÔ˘ Ó‡ÌÔÓ· Û fiÁÎÔ Î·È ‚¿ÚÔ˜ ‰ÂÓ ÛËÌ·›ÓÂÈ ··Ú·›ÙËÙ· ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡, ·ÊÔ‡ Ô Ó‡ÌÔÓ·˜ Â›Ó·È fiÚÁ·ÓÔ Ô˘ Ú¤ÂÈ Ó· ÚÔÛ·ÚÌfi˙ÂÙ·È ÛÙÔÓ fiÁÎÔ ·ÏÌÔ‡ ȉȷ›ÙÂÚ· ÛÂ Û˘Óı‹Î˜ ̤ÁÈÛÙ˘ ÎfiˆÛ˘. ŒÙÛÈ, ÙÔ ‚·ÛÈÎfi ÂÚÒÙËÌ· Â›Ó·È ·Ó Ë ·‡ÍËÛË Ù˘ Ì¿˙·˜ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ ÌÂÙ¿ ÂÎÙÔÌ‹ ̤ÚÔ˘˜ ÙÔ˘ Ó‡ÌÔÓ· ÔÊ›ÏÂÙ·È Û ۯËÌ·ÙÈÛÌfi Ó¤ˆÓ ΢„ÂÏ›‰ˆÓ ‹ Û ÌÂÁ¤ı˘ÓÛË ÙˆÓ ‹‰Ë ˘·Ú¯Ô˘ÛÒÓ. ™ÙË Û˘Ó¤¯ÂÈ· ÚÔ·ÙÂÈ ÙÔ ÂÚÒÙËÌ· ·Ó ÔÈ “ÌÂÁ·Ï‡ÙÂÚ˜” ΢„ÂÏ›‰Â˜ ÈÛÔ‰˘Ó·ÌÔ‡Ó Ì ÙȘ “ÂÚÈÛÛfiÙÂÚ˜” ΢„ÂÏ›‰Â˜ (26,27). £· ÌÔÚÔ‡Û ӷ ÈÛ¯˘ÚÈÛÙ› ηÓ›˜ fiÙÈ Ë ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó·Ó¢ÛÙÈ΋ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘„ÂÏ›‰ˆÓ ÌÔÚ› Ó· ·˘ÍËı› ¯ˆÚ›˜ ÙË ‰ËÌÈÔ˘ÚÁ›· Ó¤ˆÓ, ·ÏÏ¿ Ì ÙËÓ Â¤ÎÙ·ÛË ÙˆÓ Î˘„ÂÏȉÈÎÒÓ fiÚˆÓ Î·È Û¿ÎˆÓ, Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÂÈÌ‹Î˘ÓÛË ÙˆÓ Î˘„ÂÏȉÈÎÒÓ ÙÔȯˆÌ¿ÙˆÓ Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙËÓ “·Ó·ÚÚ›¯ËÛË” ÛÂ Ê˘ÛÈÔÏÔÁÈο ÏÂÈÙÔ˘ÚÁÈο ›‰· (28). ∂Λ Ô˘ Ë ˘¿Ú¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›· Û˘ÌʈÓ› Â›Ó·È fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ ÌÂÙ¿ ÙËÓ Ó¢ÌÔÓÂÎÙÔÌ‹, ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙÔ ·Ú¤Á¯˘Ì· Î·È ÏÈÁfiÙÂÚÔ ÙÔ ‰›ÎÙ˘Ô ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, Ë ·‡ÍËÛË ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È ·Ó·ÏÔÁÈο ÌÈÎÚfiÙÂÚË ÂΛӢ ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ (29,30). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÂÚÒÙËÌ· Â¿Ó ·˘ÙÔ› ÔÈ Ì˯·ÓÈÛÌÔ› ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙËÓ ÔÔ›· Á›ÓÂÙ·È Ë ÂÎÙÔÌ‹, ÌÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ˘¤ÛÙËÛ·Ó Ó¢ÌÔÓÂÎÙÔÌ‹ Û ‰È·ÊÔÚÂÙÈΤ˜ ËÏÈ˘ ‰È·›ÛÙˆÛ·Ó fiÙÈ Û Ôχ Ó·ڿ ÂÈÚ·Ì·Ùfi˙ˆ· ˘‹ÚÍ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ΢ÚÈ·Ú¯Ô‡ÛÂ Ë ÂÈÌ‹Î˘ÓÛË ÙˆÓ Î˘„ÂÏȉÈÎÒÓ fiÚˆÓ Î·È ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ, ÂÓÒ ÛÙ· ÂÓ‹ÏÈη ˙Ò· ˘‹Ú¯Â ˘ÂÚ¤ÎÙ˘ÍË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ (31). ∞˘Ùfi ÙÔ ÈÛÙÔÏÔÁÈÎfi ‡ÚËÌ· ÙÔ˘ ΢„ÂÏȉÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÌÂÙ¿ Ó¢ÌÔÓÂÎÙÔÌ‹ ÛÙ· Ôχ Ó·ڿ ÂÈÚ·Ì·Ùfi˙ˆ· ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ˘Ô¯ÚˆÙÈο ÂÎÙÂٷ̤ÓË ·ÓÙÈÚÚÔÈÛÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÂÓ·ÔÌ›ӷÓÙ· Ó‡ÌÔÓ·. √ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Ê˘ÛÈÔÏÔÁÈο ÂÂÎÙ›ÓÂÙ·È ¯ÚÔÓÈο Î·È ÛÙË ÌÂÙ·-ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô ÁÈ· ÌÂÚÈο ›‰Ë ˙ÒˆÓ, fiˆ˜ ÛÙ· ÔÓÙ›ÎÈ·, ÂÓÒ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜ ·˘Ù‹ Ë ‰È·‰Èηۛ· Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Û˘Ó¯›˙ÂÙ·È ÂÚ›Ô˘ ̤¯ÚÈ Ù· 2 ¯ÚfiÓÈ· (24-34). ¶·È‰È·ÙÚÈ΋ 2007;70:184-191
Pediatri May-Jun 07
24-05-07
17:58
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™˘ÓÂÒ˜, Ô ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Û Ó¢ÌÔÓÂÎÙÔÌËı¤ÓÙ· ÂÈÚ·Ì·Ùfi˙ˆ·, ÌÔÚ› Ó· Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÓÙÈÚÚÔÈÛÙÈ΋˜ ·‡ÍËÛ˘ Û ÌÈ· ÚÔÛ¿ıÂÈ· ·ÔηٿÛÙ·Û˘ ÙÔ˘ ·ÔÏÂÛı¤ÓÙÔ˜ ÈÛÙÔ‡ ‹ Ó· Â›Ó·È Ì¤ÚÔ˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·‰Èηۛ·˜ ·‡ÍËÛ˘ Ô˘ Û˘Ì‚·›ÓÂÈ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ Ó¢ÌÔÓÂÎÙÔÌ‹. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ì¿ÏÏÔÓ ˘¿Ú¯ÂÈ ÁÂÓÂÙÈο ÚÔηıÔÚÈṲ̂ÓÔ fiÚÈÔ Î˘ÙÙ·ÚÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ Ô˘ ·ÊÔÚ¿ ÛÙËÓ ·‡ÍËÛË ÙÔ˘ Ó‡ÌÔÓ· Î·È ÙÔ fiÚÈÔ ·˘Ùfi ˘Ê›ÛٷٷÈ, ·Û¯¤Ùˆ˜ Â¿Ó Ô Ó‡ÌÔÓ·˜ ˘¤ÛÙË ÂÎÙÔÌ‹ ‹ fi¯È Û ÌÈÎÚ‹ ËÏÈΛ· (21). ∞fi Ù· ·Ú·¿Óˆ ‰ÂÓ ÚÔ·ÙÂÈ Ì ·Ú΋ Û·Ê‹ÓÂÈ· ÙÔ fiÊÂÏÔ˜ Ù˘ ·ÓÙÈÚÚÔÈÛÙÈ΋˜ ·‡ÍËÛ˘, ÛÙÔÓ ·ÚÈıÌfi ‹ ÛÙË ‰ÔÌ‹ ÙˆÓ Î˘„ÂÏ›‰ˆÓ ÌÂÙ¿ ·fi Ó¢ÌÔÓÂÎÙÔÌ‹ Û ÌÈÎÚ‹ ËÏÈΛ·. °È· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi ÙÔ Î‡ÚÈÔ ÎÚÈÙ‹ÚÈÔ Ê·›ÓÂÙ·È Ó· ·Ú·Ì¤ÓÂÈ Ë Î·Ù¿ÛÙ·ÛË Î·È Ë ÈÂÚ¿Ú¯ËÛË ÙˆÓ ·Ó·ÁÎÒÓ ÙÔ˘ οı ·ÛıÂÓÔ‡˜. ∂ÊfiÛÔÓ ‰ÂÓ ˘¿Ú¯ÂÈ Â›ÁÔ˘Û· ·Ó¿ÁÎË ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ÙÔ˘ Ó‡ÌÔÓ· Û ÌÈÎÚ‹ ËÏÈΛ·, ÔÏϤ˜ ‚Ï¿‚˜ ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛıÔ‡Ó Û˘ÓÙËÚËÙÈο ÒÛÙ ӷ ÂÈÏÂÁ› Ô Î·Ù·ÏÏËÏfiÙÂÚÔ˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ Â¤Ì‚·ÛË Î·È ·˘Ùfi ¯ˆÚ›˜ ÛËÌ·ÓÙÈÎfi ΛӉ˘ÓÔ Ó· ¯·ı› οÔÈ· ¢ηÈÚ›· ·ÓÙÈÚÚÔÈÛÙÈ΋˜ ·‡ÍËÛ˘. √È ·Ó·Ó¢ÛÙÈΤ˜ Âʉڛ˜ ÙÔ˘ ÂÓ‹ÏÈÎÔ˘ Ô˘ ¯ÂÈÚÔ˘ÚÁ‹ıËΠÛÙË ‚ÚÂÊÈ΋ ‹ ·È‰È΋ ËÏÈΛ· ηıÔÚ›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ ¤ÎÙ·ÛË Ù˘ ÂÎÙÔÌ‹˜ ·Ú¿ ·fi ÙËÓ ËÏÈΛ· Ô˘ ¤ÁÈÓÂ Ë Â¤Ì‚·ÛË.
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ª, ¶Ú›ÊÙ˘ ∫, ÂÈÌ. ™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ªÔÓÔÁÚ·Ê›· ¶·È‰È·ÙÚÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁ›·˜. ∆‡¯Ô˜ 3, ∞ı‹Ó·; 2004. 2. µ¿Ô˜ °. ÃÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ. ™ÙÔ: ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ª, ¶Ú›ÊÙ˘ ∫, ÂÈÌ. ™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ªÔÓÔÁÚ·Ê›· ¶·È‰È·ÙÚÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁ›·˜. ∆‡¯Ô˜ 3, ∞ı‹Ó·; 2004:194-206. 3. American College of Chest Physicians; Committee on Pulmonary Diseases in Children. Congenital pulmonary anomalies and related thoracic conditions: Report of Subcommittee on Congenital Anomalies of the Lungs. Dis Chest 1966;49:441-446. 4. Thilenius OG, Ruschhaupt DG, Replogle RL, Bharati S, Herman T, Arcilla RA. Spectrum of pulmonary sequestration: association with anomalous pulmonary venous drainage in infants. Pediatr Cardiol 1983;4:97-103. 5. Heitzman ER. The lung: radio-pathologic correlations of anomalies of pulmonary parenchymal and peripheral vascular development: the sequestration spectrum. 2nd ed. St Louis: Mosby Inc; 1984. p. 17-38. 6. Stovin PG. Early lung development. Thorax 1985;40:401404. 7. Clements BS. Congenital malformations of the lungs and airways. In: Taussig LM, Landau L, Le Souef PN, Morgan WJ, Martinez FD, Sly PD, eds. Pediatric Respiratory Paediatriki 2007;70:184-191
Medicine. Missouri: Mosby Inc; 1999. p. 1106-1136. 8. Reid LM. Lung growth in health and disease. Br J Dis Chest 1984;78:113-134. 9. Clements BS, Warner JO. Pulmonary sequestration and related congenital bronchopulmonary-vascular malformations: nomenclature and classification based on anatomical and embryological considerations. Thorax 1987;42:401-408. 10. Clements BS, Warner JO, Shinebourne EA. Congenital bronchopulmonary vascular malformations: clinical application of a simple anatomical approach in 25 cases. Thorax 1987;42:409-416. 11. Clements BS, Warner JO. The crossover lung segment: congenital malformation associated with a variant of scimitar syndrome. Thorax 1987;42:417-419. 12. Krummel T. Congenital malformations of the lower respiratory tract. In: Chernick V, Boat TF Wilmott RB, Bush A, eds. Kendig’s disorders of the respiratory tract in children. 6th. ed. Philadelphia: WB Saunders; 1998. p. 287-328. 13. Hudak B. Congenital malformations of the lung and airways. In: Laughlin G, Eigen H, eds. Respiratory disease in children. Diagnosis and management. Baltimore: Williams & Wilkins; 1994. p. 501-532. 14. Haddad G, Fontan JP. The respiratory system. Development and function. In: Behrman R, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed, Philadelphia: WB Saunders; 2004. p. 1158. 15. Becmeur F, Horta-Geraud P, Donato L, Sauvage P. Pulmonary sequestrations: prenatal ultrasound diagnosis, treatment and outcome. J Pediatr Surg 1998;33:492-496. 16. Kirkpatrick BV, Mueller DG. Respiratory disorders in the newborn. In: Chernick V, Boat TF, Wilmott RB, Bush A, eds. Kendig’s disorders of the respiratory tract in children. 6th ed. Philadelphia: WB Saunders; 1998. p. 328-364. 17. Cooper ML, Slovis TL. Imaging of the respiratory System. In: Taussig LM, Landau L, Le Souef PN, Morgan WJ, Martinez FD, Sly PD, eds. Pediatric Respiratory ªedicine. Missouri: Mosby Inc; 1999. p. 152-194. 18. Brown MA, Morgan WJ. Clinical assessment and diagnostic approach to common problems. In: Taussig LM, Landau L, Le Souef PN, Morgan WJ, Martinez FD, Sly PD, eds. Pediatric Respiratory Medicine. Missouri: Mosby Inc; 1999. p. 136-152. 19. Zach MS, Eber E. Adult outcome of congenital lower respiratory tract malformations. Thorax 2001;56:65-72. 20. de Perrot M, Pache JC, Spiliopoulos A. Carcinoma arising in congenital lung cysts. Thorac Cardiovasc Surg 2001;49:184-185. 21. Zach ª, Eber ∂. Congenital lung malformations and their long-term consequences. Eur Respir Mon 2002;19:81-98. 22. Cook CD, Bucci G. Studies of respiratory physiology in children. IV. The late effects of lobectomy on pulmonary function. Pediatrics 1961;28:234-242. 23. Stiles QR, Meyer BW, Lindesmith GG, Jones JC. The effects of pneumonectomy in children. J Thorac Cardiovasc Surg 1969;58:394-400. 24. Frenckner B, Freyschuss U. Pulmonary function after lobectomy for congenital lobar emphysema and congenital cystic adenomatoid malformation. A follow-up study. Scand J Thorac Cardiovasc Surg 1982;16:293-298. 25. McBride JT, Wohl ME, Strieder DJ, Jackson AC, Morton JR, Zwerdling RG, et al. Lung growth and airway function
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27. 28.
29.
after lobectomy in infancy for congenital lobar emphysema. J Clin Invest 1980;66:962-970. Cagle PT, Thurlbeck WM. Postpneumonectomy compensatory lung growth. Am Rev Respir Dis 1988;138:13141326. Thurlbeck WM. Postnatal growth and development of the lung. Am Rev Respir Dis 1975;111:803-844. Burri PH, Pfrunder HB, Berger LC. Reactive changes in pulmonary parenchyma after bilobectomy: a scanning electron microscopic investigation. Exp Lung Res 1982;4:11-28. Burri PH, Sehovic S. The adaptive response of the rat lung after bilobectomy. Am Rev Respir Dis 1979;119:769-777.
30. McBride JT. Postpneumonectomy airway growth in the ferret. J Appl Physiol 1985;58:1010-1014. 31. Holmes C, Thurlbeck WM. Normal lung growth and response after pneumonectomy in rats at various ages. Am Rev Respir Dis 1979;120:1125-1136. 32. Thurlbeck WM. Postnatal human lung growth. Thorax 1982;37:564-571. 33. Zeltner TB, Caduff JH, Gehr P, Pfenninger J, Burri PH. The postnatal development and growth of the human lung. I. Morphometry. Respir Physiol 1987;67:247-268. 34. Zeltner TB, Burri PH. The postnatal development and growth of the human lung. II. Morphology. Respir Physiol 1987;67:269-282.
Quiz 1. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ÛÙȘ ÚÒÙ˜ ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË; ·. ∞ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ ‚. ™˘ÁÁÂÓ‹˜ ‚ÚÔÁ¯ÂÎÙ·Û›· Á. ™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ‰. ¶Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· Â. ∆Ú·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ Ì ·ÙÚËÛ›· Ù‡Ô˘ ∏ 2. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÈÛÓ¢ÛÙÈÎÔ‡ ÛÈÁÌÔ‡ ηÈ/‹ ÂÎÓ¢ÛÙÈÎÔ‡ ÌÔÓÔʈÓÈÎÔ‡ Û˘ÚÈÁÌÔ‡ ÛÙ· 2-3 ÚÒÙ· ¤ÙË ˙ˆ‹˜ Ú¤ÂÈ Ó· ÂÚÈÏ¿‚ÂÈ: ·. ∆Ë ÌÂÙ·ÙÚ·˘Ì·ÙÈ΋ ÛÙ¤ÓˆÛË ÌÂÙ¿ ·fi ‰È·ÛˆÏ‹ÓˆÛË ‚. ∆Ë Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È ÂÈÛÚfiÊËÛË Á. ∆ËÓ ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ‰. ∆ÔÓ ·ÁÁÂÈ·Îfi ‰·ÎÙ‡ÏÈÔ Â. ŸÏ· Ù· ·Ú·¿Óˆ 3. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ Â›Ó·È ·ÏËı¤˜; ·. µÏ¿‚˜ ÛÙÔ Â›Â‰Ô Ù˘ ÁψÙÙ›‰·˜ Û˘Ó‹ıˆ˜ ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÊˆÓ›· ‹ ‚Ú·¯Ófi ÎÏ¿Ì· ‚. ∆Ô Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ· Û˘Ó‰˘¿˙ÂÙ·È Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ηÎÔ‹ıÔ˘˜ ÂÍ·ÏÏ·Á‹˜ ηٿ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Á. √ ·ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ ÌÔÚ› Ó· ÂΉËψı› ˆ˜ “ÔÈÛıfiÙÔÓÔ˜” ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ‰. ∆Ô Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Ì Ó¢ÌÔıÒڷη ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ Â. ∏ ·Ï·Û›· ÙÔ˘ Ó‡ÌÔÓ· ÂΉËÏÒÓÂÙ·È Ì ÔÏ˘˘‰Ú¿ÌÓÈÔ 4. ∏ ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi: ·. ¢È·Ù·Ú·¯‹ Ù˘ ·‡ÍËÛ˘ ‚. ™˘Ìو̷ÙÔÏÔÁ›· Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Á. ¢˘ÛÎÔÏ›· ηٿ ÙËÓ Î·Ù¿ÔÛË, ȉ›ˆ˜ ÛÙÂÚÂÒÓ ÙÚÔÊÒÓ ‰. ™˘Ìو̷ÙÔÏÔÁ›· ÙÚ·¯ÂÈÔÌ·Ï¿Î˘ÓÛ˘ Â. ŸÏ· Ù· ·Ú·¿Óˆ 5. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ ÈÛ¯‡ÂÈ ÁÈ· ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·; ·. √È ·Ó·Ó¢ÛÙÈΤ˜ Âʉڛ˜ ÙˆÓ ÂÓËÏ›ÎˆÓ Î·ıÔÚ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ ËÏÈΛ· Ô˘ ¤ÁÈÓÂ Ë ÂÎÙÔÌ‹ ‚. √È Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù¿ ηÓfiÓ· ¿ÌÂÛË Â¤Ì‚·ÛË Á. ∏ ·‡ÍËÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ ÌÂÙ¿ ÙËÓ Ó¢ÌÔÓÂÎÙÔÌ‹ ·ÊÔÚ¿ ΢ڛˆ˜ ÙÔ ‰›ÎÙ˘Ô ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ÏÈÁfiÙÂÚÔ ÙÔ ·Ú¤Á¯˘Ì· ‰. ¶ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·‡ÍËÛË ÙÔ˘ Ó‡ÌÔÓ· Û˘Ó¿ÁÂÙ·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ Â. ∫·Ó¤Ó· ·fi Ù· ·Ú·¿Óˆ √È ÛˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÛÙË ÛÂÏ›‰· 204 ¶·È‰È·ÙÚÈ΋ 2007;70:184-191
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ORIGINAL ARTICLE
¢ÈÂÚ‡ÓËÛË Ù˘ ‰È·Ù·Ú·¯‹˜ ÛÙËÓ ÈÛÔÚÚÔ›· ÌÂٷ͇ Ù‡Ô˘-1 Î·È Ù‡Ô˘-2 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ ÛÙÔ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ - ∞Ô˘Û›· Û¯¤Û˘ ÚÔ˜ ·ÙÔ›· ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË
¡. ¶Ú›ÓÙ˙·, º. ¶··¯Ú‹ÛÙÔ˘, µ. ∆˙ÈÌÔ‡ÏË, Õ. ∆·¿ÚÎÔ˘, º. ∫·Ó·ÎÔ‡‰Ë - ∆۷ηϛ‰Ô˘
AÏÏËÏÔÁÚ·Ê›·: ¡ÈÎÔϤٷ ¶Ú›ÓÙ˙· nprintza@in.gr ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË
∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ÚÔÔÙÈ΋ ÌÂϤÙË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (∫∂¡™) ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙË Ê¿ÛË ‡ÊÂÛ˘ Î·È Ì ٷ Â˘Ú‹Ì·Ù· ˘ÁÈÒÓ ·È‰ÈÒÓ Î·È Ë Û˘Û¯¤ÙÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì ÙËÓ ·ÙÔ›·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 20 ·È‰È¿, ËÏÈΛ·˜ 3-14 ÂÙÒÓ, Ì ∫∂¡™ Î·È 20 ˘ÁÈ‹ ·È‰È¿ (Ì¿ÚÙ˘Ú˜). ∆· 12/20 ·È‰È¿ Ì ∫∂¡™ ÌÂÏÂÙ‹ıËÎ·Ó Û ÂÓÂÚÁfi Ê¿ÛË, Û ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Û ʿÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (8/12). ™Â 8 ÂÈϤÔÓ ·È‰È¿ Ì ∫∂¡™, Ô ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ ÌfiÓÔ Û ʿÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ¶ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ô ‚·ÛÈÎfi˜ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ µ Î·È ∆ ΢ÙÙ¿ÚˆÓ, Ù· ÔÛÔÛÙ¿ ÙˆÓ CD23+, CD3+/CD69+/INF-Á+ Î·È CD3+/CD69+/IL-4+ ΢ÙÙ¿ÚˆÓ Î·È Ù· ›‰· ÛÙÔÓ ÔÚfi ÙˆÓ IgE, INF-Á, IL-4, IL-13 Î·È IL-18. ∞ÔÙÂϤÛÌ·Ù·: πÛÙÔÚÈÎfi ·ÙÔ›·˜ ·ÚÔ˘Û›·˙·Ó 4/20 ·È‰È¿ Ì ∫∂¡™ Î·È 3/20 Ì¿ÚÙ˘Ú˜. T· ÔÛÔÛÙ¿ ÙˆÓ CD19+, CD23+ µ ΢ÙÙ¿ÚˆÓ, ÙˆÓ CD3+/CD69+/IL-4+ T ΢ÙÙ¿ÚˆÓ, ηıÒ˜ Î·È Ù· ›‰· ÙˆÓ IgE, IL4, IL-13 Î·È IL-18 ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙË Ê¿ÛË ‡ÊÂÛ˘ ˘fi Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (p<0,05). ∞ÓÙ›ıÂÙ·, ÙÔ ÔÛÔÛÙfi ÙˆÓ CD3+/CD69+/INF-Á+ T ΢ÙÙ¿ÚˆÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓÔ Û fiϘ ÙȘ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (p<0,05). ¢È·ÈÛÙÒıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE Ì ٷ ›‰· ΢ڛˆ˜ Ù˘ πL-13, fiˆ˜ Î·È ÙˆÓ IL-4 Î·È πL-18, ·ÏÏ¿ fi¯È Ì ÙÔ ÈÛÙÔÚÈÎfi ·ÙÔ›·˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ™Ù· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™ ˘ÂÚ¤¯ÂÈ Ë ·ÓÔÛȷ΋ ·¿ÓÙËÛË Ù‡Ô˘-2, Ë ÔÔ›· Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ·˘ÍË̤ÓË ¤ÎÎÚÈÛË Î·È Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ IL-13 Î·È IL-18 Î·È fi¯È Û Ì˯·ÓÈÛÌfi ·ÙÔ›·˜.
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§¤ÍÂȘ ÎÏÂȉȿ: ∫ÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, Ù‡Ô˘-1/Ù‡Ô˘-2 ΢ÙÙ·ÚÔΛÓ˜.
Investigation of type-1/type-2 immune imbalance in steroid sensitive nephrotic syndrome - No relationship with atopy 1st Paediatric Department, Hippokration General Hospital, Thessaloniki Correspondence: Nikoleta Printza nprintza@in.gr 49 Konstantinoupoleos Str. 1st Paediatric Department Hippokration General Hospital
N. Printza, F. Papachristou, V. Tzimouli, A. Taparkou, F. Kanakoudi - Tsakalidou Abstract Background: The purpose of this prospective study was to investigate the immune disturbances in different stages of primary steroid sensitive nephrotic syndrome (SSNS) and identify whether there is a relationship of the findings with atopy. Methods: Twenty children with SSNS, aged 3-14 years, were studied; 12/20 both in active stage before treatment initiation and in remission still on steroid treatment; 8/12 in remission off steroids as well. Eight additional children with previously treated primary SSNS were studied only in remission off steroids. Data were compared with those obtained from 20 age-matched controls. The following parameters were assessed: basic B and T cell populations, percentages of CD23+, CD3+/CD69+/INF-Á+ cells and CD3+/CD69+/IL-4+ as well as serum levels of IgE, INF-Á, IL-4, IL-13 and IL-18. Results: Atopic disease was recorded in 4/20 nephrotic children and in 3/20 controls. Percentages of CD23+ and CD19+ B cells, CD3+/CD69+/IL-4+ T cells and serum levels of IgE, IL-4, IL-13 and IL-18 were significantly higher in the active stage of SSNS compared with the remission stage on steroids, remission off steroids and controls (p<0.05). On the contrary, percentage of CD3+/CD69+/INF-Á+ T cells was significantly lower in patients during different disease stages compared with controls (p<0.05). In the active disease stage, serum IgE concentrations were significantly correlated mainly with serum IL-13 as well as IL-4 and IL-18 levels but not with history of atopy. Conclusions: These findings suggest that the type-2 immune response found in active SSNS may be the result of synergistic action of increased IL-13 and IL-18 produced during this disease stage and not to an atopy induced mechanism.
Key words: Steroid sensitive nephrotic syndrome, type-1/type-2 cytokines. Paediatriki 2007;70:192-198
∏ ÂÚÁ·Û›· ·˘Ù‹ ‚Ú·‚‡ıËΠ̠ÙÔ ÃˆÚ¤ÌÂÈÔ Œ·ıÏÔ, ÛÙÔ 44Ô ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ƒfi‰Ô˜, 9-11 πÔ˘Ó›Ô˘ 2006
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·193
193
∞ÓÔÛȷ΋ ·¿ÓÙËÛË ÛÙÔ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ
∂ÈÛ·ÁˆÁ‹ ªÂ ÙÔÓ fiÚÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ (¡™) ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÛÂÈÚ·Ì·ÙÔ¿ıÂȘ Ì ÛÔ‚·Ú‹ ÚˆÙÂ˚ÓÔ˘Ú›·, Ô˘ ÚÔηÏ› ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· (<2,5 g/dl), ˘ÂÚ¯ÔÏËÛÙÂÚÈÓ·ÈÌ›· Î·È Û˘Ó‹ıˆ˜ Ô›‰ËÌ· (1). ∫ÏÈÓÈο, ·Ó¿ÏÔÁ· Ì ÙËÓ ·¿ÓÙËÛ‹ ÙÔ˘ ÛÙË ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÙÔ ¡™ ‰È·ÎÚ›ÓÂÙ·È Û ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ (∫∂¡™), Ô˘ ·ÔÙÂÏ› ÙÔ 4580% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÛÙ· ·È‰È¿ Î·È Û ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi (2-4). ∏ ·ÎÚÈ‚‹˜ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ∫∂¡™ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›, fï˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ. ∆Ô 1974 Ô Shalhoud RJ ‰È·Ù‡ˆÛ ÚÒÙÔ˜ ÙËÓ ˘fiıÂÛË fiÙÈ Û ÂÓÂÚÁfi ∫∂¡™ ¤Ó·˜ ÎÏÒÓÔ˜ ∆ ΢ÙÙ¿ÚˆÓ ·Ú¿ÁÂÈ Ì›· “ÏÂÌÊÔΛÓË” Ô˘ Â›Ó·È ÙÔÍÈ΋ ÁÈ· ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜, ›Ù ¿ÌÂÛ· ‹ ¤ÌÌÂÛ·, ̤ۈ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ¿Ô„Ë ·˘Ù‹ ‚·Û›ÛÙËΠÛÙȘ ÂÍ‹˜ ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ: ·) ˘‹Ú¯Â ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Û ÏÔÈÌÒÍÂȘ Ô˘ ÚÔηÏÔ‡Ó ·ÓÔÛÔηٷÛÙÔÏ‹, fiˆ˜ Ë ÈÏ·Ú¿, ‚) Ù· ·È‰È¿ Ì ¡™ ›¯·Ó ¢·ÈÛıËÛ›· Û Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ Î·È ¿ÏϘ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ Î·È Á) Ù· ·È‰È¿ Ì ¡™ ··ÓÙÔ‡Û·Ó ÛÙË ıÂڷ›· Ì ÛÙÂÚÔÂȉ‹ Î·È Î˘ÎÏÔʈÛÊ·Ì›‰Ë, Ê¿Ú̷η Ô˘ ηٷÛÙ¤ÏÏÔ˘Ó ÙËÓ Î˘ÙÙ·ÚÈ΋ ·ÓÔÛ›· (5). ™ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜, Ë ·ÎÚÈ‚‹˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ Î·È Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙËÓ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ∫∂¡™ ·ÔÙ¤ÏÂÛ ·ÓÙÈΛÌÂÓÔ ·ÚÎÂÙÒÓ ÂÚ¢ÓÒÓ (6-15). ∫·Ù¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ‰È·Ù˘ÒıËÎÂ Ë ¿Ô„Ë fiÙÈ Ù· ∆ ·ÙÙ·Ú· ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ∫∂¡™ ̤ۈ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Ô˘ ·Ú¿ÁÔ˘Ó (7,9,10,12). ªÂ ‚¿ÛË ÙȘ ·Ú·ÁfiÌÂÓ˜ ΢ÙÙ·ÚÔΛÓ˜, Ù· ∆ ·ÙÙ·Ú· ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ Ù‡Ô˘-1 Î·È Ù‡Ô˘-2. ∆· Ù‡Ô˘-1 ∆ ·ÙÙ·Ú· Ù˘Èο ·Ú¿ÁÔ˘Ó ÈÓÙÂÚÏ¢ΛÓË2 (IL-2), ÙÔÓ ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ ÙˆÓ fiÁÎˆÓ (TNF) Î·È ÈÓÂÚÊÂÚfiÓË-Á (πNF-Á), ‰ËÏ·‰‹ ΢ÙÙ·ÚÔΛÓ˜ Ì ΢ÙÙ·ÚÔÙÔÍÈ΋ Î·È ÊÏÂÁÌÔÓÒ‰Ë ‰Ú¿ÛË. ∆· Ù‡Ô˘-2 ∆ ·ÙÙ·Ú· ·Ú¿ÁÔ˘Ó IL-4, IL-5, IL-9, IL-10 Î·È IL13, ‰ËÏ·‰‹ ΢ÙÙ·ÚÔΛÓ˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË Ú‡ıÌÈÛË ÈÛ¯˘ÚÒÓ ·ÓÔÛÈ·ÎÒÓ ··ÓÙ‹ÛÂˆÓ Û ·ÓÙÈÁfiÓ· Î·È ·ÏÏÂÚÁÈÔÁfiÓ·. √È ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ÛÙÔ ∫∂¡™ ¤‰ÂÈÍ·Ó ·ÔÙÂϤÛÌ·Ù· Ô˘ Û˘¯Ó¿ ‹Ù·Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· (16). ∏ ˘ÂÚÔ¯‹ Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Ù‡Ô˘-2, fiˆ˜ ÚԤ΢„ ·fi ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ (16), ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ·˘ÍË̤ӷ ›‰· Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ∂ (πgE) Ô˘ ‚Ú¤ıËÎ·Ó Û ÂÓÂÚÁfi ∫∂¡™ (15,17), Ô‰‹ÁËÛ·Ó ÛÙË Û‡Ó‰ÂÛË ÙÔ˘ ∫∂¡™ Ì ÙËÓ ·ÙÔ›·. ¶·Ú’ fiÏ· ·˘Ù¿, ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ (18,19) ηıÒ˜ Î·È ÂÚÁ·ÛÙËÚȷο ‰Â‰Ô̤ӷ (20) ¤ıÂÛ·Ó Û ·ÌÊÈÛ‚‹ÙËÛË ÙËÓ ·Ú·¿Óˆ ˘fiıÂÛË.
™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ÚÔÔÙÈ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ·È‰È¿ Ì ∫∂¡™ ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘, Û ۇÁÎÚÈÛË Ì ˘ÁÈ‹ ·È‰È¿, Ì ÂÈΤÓÙÚˆÛË ÛÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ Ù‡Ô˘ Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ (1 ‹ 2) Ô˘ ˘ÂÚÈÛ¯‡ÂÈ Û ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Î·È ÛÙË Û¯¤ÛË Ù˘ Ì ·ÙÔ›·.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 20 ·È‰È¿ (7 ·ÁfiÚÈ· Î·È 13 ÎÔÚ›ÙÛÈ·), ËÏÈΛ·˜ 3-14 ÂÙÒÓ, Ì ∫∂¡™. ∆· 12/20 ·È‰È¿ ÌÂÏÂÙ‹ıËÎ·Ó ·ÊÂÓfi˜ Û ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (3/12 ÛÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ∫∂¡™ Î·È 9/12 Û ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘), ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ·ÊÂÙ¤ÚÔ˘ Û ʿÛË ‡ÊÂÛ˘ Î·È ÂÓÒ Ï¿Ì‚·Ó·Ó ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∞fi ·˘Ù¿ Ù· 12 ·È‰È¿, 8 ÌÂÏÂÙ‹ıËÎ·Ó Î·È Û ʿÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (6 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹). ™Â 8/20 ·È‰È¿ Ì ∫∂¡™, Ô ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ ÌfiÓÔ Û ʿÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∫·È ÔÈ 12 ·ÛıÂÓ›˜, ÔÈ ÔÔ›ÔÈ ÌÂÏÂÙ‹ıËÎ·Ó Û ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ï¿Ì‚·Ó·Ó ÙËÓ ›‰È· ‰fiÛË Ú‰ÓÈ˙fiÓ˘ (40 mg/m2 ·Ó¿ 48ˆÚÔ). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ∫∂¡™ Î·È Ù˘ ˘ÔÙÚÔ‹˜ ‚·Û›ÛÙËΠÛÙ· ‰ÈÂıÓ‹ ÎÚÈÙ‹ÚÈ· (6) Î·È Ô Î·ıÔÚÈÛÌfi˜ Ù˘ ÎÔÚÙÈÎÔ¢·ÈÛıËÛ›·˜ ¤ÁÈÓ Ì ‚¿ÛË ÙËÓ ·Ú¯È΋ ·¿ÓÙËÛË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÂÓÙfi˜ 4 ‚‰ÔÌ¿‰ˆÓ. ∆ËÓ ÔÌ¿‰· Ì·ÚÙ‡ÚˆÓ ·ÔÙ¤ÏÂÛ·Ó 20 ˘ÁÈ‹ ·È‰È¿, ËÏÈΛ·˜ 2,5-14 ÂÙÒÓ, Ô˘ ÚÔÛ‹Ïı·Ó ÛÙÔ ∞ÈÌ·ÙÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÁÈ· ¤ÏÂÁ¯Ô Û˘ÁÁÂÓÔ‡˜ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ Î·È ¯ÚËÛ›ÌÂ˘Û·Ó ˆ˜ ÔÌ¿‰· ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ÂΛӷ ÙˆÓ ·ÛıÂÓÒÓ. ∞ÈÌÔÏË„›· Î·È ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Ì›· ÊÔÚ¿. ∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ÌÂÏÂÙ‹ıËÎ·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ·ÓÔÛÔÏÔÁÈΤ˜ ·Ú¿ÌÂÙÚÔÈ: ‚·ÛÈÎfi˜ ·ÓÔÛÔÛÔÊ·ÈÓfiÙ˘Ô˜, ÏfiÁÔ˜ CD4+/CD8+ ∆ ΢ÙÙ¿ÚˆÓ, CD25+ T ·ÙÙ·Ú·, CD23+ B ·ÙÙ·Ú·, ÔÛÔÛÙfi CD3+/CD69+/INF-Á+ Î·È CD3+/CD69+/IL-4+ T ΢ÙÙ¿ÚˆÓ Î·È Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔÓ ÔÚfi ÙˆÓ πgE, INF-Á, IL-4, IL-13 Î·È IL-18. ·) ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ‚·ÛÈÎÔ‡ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂÈÊ·ÓÂÈ·ÎÒÓ ÌÔÚ›ˆÓ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (‚·ÛÈÎfi˜ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜) ÂÊ·ÚÌfiÛÙËΠÙÚÈÏfi˜ ¿ÌÂÛÔ˜ ·ÓÔÛÔÊıÔÚÈÛÌfi˜ Ì ÙË ‚Ô‹ıÂÈ· ηٿÏÏËÏˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙˆÓ ÂÙ·ÈÚÂÈÒÓ COULTER (Miami, Florida) Î·È IMMUNOTECH (Hamburg, Germany) Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì ÊıÔÚ›˙Ô˘Û˜ ¯ÚˆÛÙÈΤ˜, fiˆ˜ ÈÛÔıÂÈÔ΢·ÓÈ΋ ÊÏÔ˘ÚÂÛνÓË (FITC): CD3, CD4, CD8, CD23, Ê˘ÎÔÂÚ˘ıÚ›ÓË (PE): CD4, CD19, CD25 Î·È Ê˘ÎÔÂÚ˘ıÚ›ÓË-΢·Ó›ÓË 5 (PE-Cy5): CD45. ∆· ÔÛÔÛÙ¿ ÙˆÓ µ ΢ÙÙ¿ÚˆÓ (CD19+), ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ µ ΢ÙÙ¿ÚˆÓ Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÙÔÓ ˘Ô‰Ô¯¤· ππ Ù˘ IgE (CD23+), ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ∆ ΢ÙÙ¿ÚˆÓ Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÙÔÓ ˘Ô‰Ô¯¤· Ù˘ IL-2 (CD25+) Î·È ÔÈ ˘ÔÏËı˘ÛÌÔ› ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ (CD3+/CD4+ Î·È CD3+/CD8+) ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙÔÓ Î˘ÙÙ·ÚÔÌÂÙÚËÙ‹ ÚÔ‹˜ EPICS-XL Ù˘ ÂÙ·ÈÚ›·˜ COULTER, ÌÂÙ¿ ·fi ηٿÏÏËÏË ÂÂÍÂÚÁ·Û›· ÁÈ· χÛË ÙˆÓ ÂÚ˘ıÚÒÓ ÛÙË Û˘Û΢‹ multi Q-PREP Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ Immunoprep Reagent System. T· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿˙ÔÓÙ·È ˆ˜ ÔÛÔÛÙfi ıÂÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (‰ËÏ·‰‹ % ÔÛÔÛÙfi ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÙÔÓ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÈÊ·ÓÂÈ·Îfi ‰Â›ÎÙË). ¶·È‰È·ÙÚÈ΋ 2007;70:192-198
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·194
194
¡. ¶Ú›ÓÙ˙· Î·È Û˘Ó.
‚) EÓ‰Ô΢ÙÙ¿ÚÈÔ˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ INF-Á Î·È IL-4 ∏ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ·Ú·ÁˆÁ‹ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ π¡F-Á Î·È IL-4 ÌÂÙÚ‹ıËΠ۠ÂÚÈÊÂÚÈÎfi ·›Ì· Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· Û ÛËÌ·Ṳ̂ӷ Ì ٷ ηٿÏÏËÏ· ÊıÔÚÈÔ¯ÚÒÌ·Ù·: CD3 (PE-Cy5), CD69 (FITC) (Beckman, COULTER, Maiami, Florida), ηıÒ˜ Î·È ·ÓÙÈ-IL-4 PE Î·È ·ÓÙÈ-INF-Á ƒ∂ (R&D Systems, Abingon, United Kingdom). ŒÁÈÓ ÌË ÂȉÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì ÂÛÙ¤Ú· Ù˘ ÊÔÚÌfiÏ˘ PMA (phorbol-12-mystrate-13-acetate) Î·È ÈÔÓÔÌ˘Î›ÓË (iomycin) Ù˘ ÂÙ·ÈÚ›·˜ SIGMA. ªÂÙ¿ ·fi ÌË ÂȉÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì PMA Î·È ÂÂÍÂÚÁ·Û›· Ì ηٿÏÏËÏ· ·ÓÙȉڷÛÙ‹ÚÈ· (intra-prep kit, Beckman, Coulter), ÌÂÙÚ‹ıËÎÂ Ë ¤ÓÙ·ÛË ÙÔ˘ ÊıÔÚÈÛÌÔ‡ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ¤¯Ô˘Ó ‰ÂÛ̇ÛÂÈ ÙÔ ÂȉÈÎfi ·Óٛۈ̷ ÁÈ· ÙËÓ INF-Á Î·È ÙËÓ IL-4 Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ÙÚÈÏÔ‡ ¿ÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ÛÙÔÓ Î˘ÙÙ·ÚÔÌÂÙÚËÙ‹ ÚÔ‹˜ Coulter EPIX XL. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ ¤ÁÈÓ Ì ÙÔ CD3+ PE-Cy5 (Fluorescence channel 3, FL3) Î·È ÙËÓ ·Ú¿ÌÂÙÚÔ ÙÔ˘ Ï¿ÁÈÔ˘ ÛΉ·ÛÌÔ‡ (Sidescatter, SSC). ™ÙË Û˘Ó¤¯ÂÈ·, Ì ÙË ‚Ô‹ıÂÈ· ÙˆÓ ·Ú·Ì¤ÙÚˆÓ FL1 (Fluorescence channel 1) ÁÈ· ÙÔ CD9 Î·È FL2 (Fluorescence channel 2) ÁÈ· ÙËÓ INF-Á ‹ IL-4, ÚÔÛ‰ÈÔÚ›ÛÙËΠÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ∆ ΢ÙÙ¿ÚˆÓ (CD3+CD69+) Ô˘ ·Ú¿ÁÔ˘Ó ÙȘ ·ÓÙ›ÛÙÔȯ˜ ΢ÙÙ·ÚÔΛÓ˜. °È· ÙËÓ ÂÍ·›ÚÂÛË ÙÔ˘ ÌË ÂȉÈÎÔ‡ Û‹Ì·ÙÔ˜ ·fi ÙËÓ ·Ó¿Ï˘ÛË, ¯ÚËÛÈÌÔÔÈ‹ıËΠÈÛÔÙ˘ÈÎfi ‰Â›ÁÌ· ÂϤÁ¯Ô˘, ηıÒ˜ Î·È ‰Â›ÁÌ· ¯ˆÚ›˜ ÙËÓ ÚÔÛı‹ÎË ÂÓÂÚÁÔÔÈËÙ‹ ƒª∞. ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿˙ÔÓÙ·È ˆ˜ ÙÔ % ÔÛÔÛÙfi ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ Î˘ÙÙ¿ÚˆÓ CD3+ CD69+ Ô˘ ·Ú¿ÁÔ˘Ó INF-Á ‹ IL-4. Á) ª¤ÙÚËÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Ù˘ πgE ÛÙÔÓ ÔÚfi ∆· ›‰· Ù˘ IgE ÌÂÙÚ‹ıËÎ·Ó ÛÙÔÓ ÔÚfi Ì ÙËÓ Ù¯ÓÈ΋ Ù˘ ÎÈÓËÙÈ΋˜ ÓÂÊÂÏÔÌÂÙÚ›·˜ Î·È ÂȉÈÎfiÙÂÚ· Ì ÙËÓ Ù¯ÓÈ΋ Ù˘ ÂÓ›Û¯˘Û˘ Ì ÂȉÈο ۈ̷ٛ‰È· latex (Particle enhanced nephelometry) Ì ÓÂÊÂÏfiÌÂÙÚÔ µ¡∞ (Behring Nephelometry Analyzer) BN100 Ù˘ ÂÙ·ÈÚ›·˜ Behring. °È· ÙȘ ÌÂÙÚ‹ÛÂȘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÂȉÈÎfi ·ÓÙȉڷÛÙ‹ÚÈÔ Ù˘ ÂÙ·ÈÚ›·˜ Behring Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ۈ̷ٛ‰È· ÔÏ˘ÛÙ˘ÚÂÓ›Ô˘ ÂÈÎ·Ï˘ÙfiÌÂÓ· Ì ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· IgE Î·È ÚfiÙ˘Ô˜ ·ÓÙÈÔÚfi˜ Ù˘ ›‰È·˜ ÂÙ·ÈÚ›·˜ (IgE-standard) ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· η̇Ï˘ ·Ó·ÊÔÚ¿˜. ‰) ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÛÙÔÓ ÔÚfi ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ INF-Á, IL-4, IL-13 Î·È IL-18 ∆· ›‰· ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ INF-Á, IL-4, IL-13 Î·È IL18 ÛÙÔÓ ÔÚfi ÌÂÙÚ‹ıËÎ·Ó Ì ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô ELISA (R&D Systems, UK) Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ Ù˘ ·Ú·Û΢¿ÛÙÚÈ·˜ ÂÙ·ÈÚ›·˜. ∆· fiÚÈ· ¢·ÈÛıËÛ›·˜ ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ ÙˆÓ INF-Á, IL-4, IL-13 Î·È IL-18 Â›Ó·È 13,8 pg/ml, 6,6 pg/ml, 14,3 pg/ml Î·È 12,5 pg/ml, ·ÓÙ›ÛÙÔȯ·. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÛÙ·ÙÈÛÙÈÎÔ‡ ·Î¤ÙÔ˘ SPSS ¤Î‰ÔÛË 11.5. °È· fiϘ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ˘ÔÏÔÁ›ÛÙËÎÂ Ë ‰È¿ÌÂÛË ÙÈÌ‹ Î·È Ë ‰È·Î‡Ì·ÓÛË. °È· ÙËÓ Î·Ù¿ ˙‡ÁË ·Ó¿Ï˘ÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌË ·Ú·ÌÂÙÚÈ΋ ‰ÔÎÈÌ·Û›· Wilcoxon signed-rank test Î·È ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ‰È¿ÌÂÛˆÓ ÙÈÌÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ë ÌË ·Ú·ÌÂÙÚÈ΋ ‰ÔÎÈÌ·Û›· Mann-Whitney rank test. ∏ Û˘Û¯¤ÙÈÛË (r) ¤ÁÈÓ Ì ÙË ‰ÔÎÈÌ·Û›· Spearman’s coefficient of correlation. ∏ ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· ÔÚ›ÛÙËΠÛÙÔ Â›Â‰Ô p<0,05. Paediatriki 2007;70:192-198
∞ÔÙÂϤÛÌ·Ù· πÛÙÔÚÈÎfi ·ÏÏÂÚÁ›·˜ πÛÙÔÚÈÎfi ·ÙÔ›·˜ ·ÚÔ˘Û›·˙·Ó 4/20 ·È‰È¿ Ì ∫∂¡™ (2 ·È‰È¿ Ì ¿ÛıÌ·, 1 ·È‰› Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Î·È 1 ·È‰› Ì ¿ÛıÌ· Î·È ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·) Î·È 3/20 Ì¿ÚÙ˘Ú˜ (1 ·È‰› Ì ¿ÛıÌ·, 1 ·È‰› Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Î·È 1 ·È‰› Ì ¿ÛıÌ· Î·È ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·). ÀÔÏËı˘ÛÌÔ› ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ∆· ÔÛÔÛÙ¿ ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ CD3+ fiˆ˜ Î·È CD25+, CD4+ Î·È CD8+ ∆ ΢ÙÙ¿ÚˆÓ ÛÙ· ·È‰È¿ Ì ∫∂¡™ ηٿ ÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Î·È Î·Ù¿ ÙË Ê¿ÛË ‡ÊÂÛ˘ ˘fi Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌ· Ì ·˘Ù¿ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ™ÙËÓ Î·Ù¿ ˙‡ÁË ·Ó¿Ï˘ÛË ÙˆÓ 12 ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÙfiÛÔ Û ÂÓÂÚÁfi Ê¿ÛË, fiÛÔ Î·È Û ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ‚Ú¤ıËΠfiÙÈ Ô ÏfiÁÔ˜ CD4+/CD8+ ∆ ΢ÙÙ¿ÚˆÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ˜ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (p=0,017). ∞˘Ùfi ÔÊÂÈÏfiÙ·Ó Û ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ CD8+ ∆ ΢ÙÙ¿ÚˆÓ. ∆Ô ÔÛÔÛÙfi ÙˆÓ CD19+ µ ΢ÙÙ¿ÚˆÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÌÂÛÔ˜: 17,12, ‰È·Î‡Ì·ÓÛË: 12,22-24,54) Û ۯ¤ÛË Ì ÙË Ê¿ÛË ‡ÊÂÛ˘ ÙfiÛÔ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 14,16, ‰È·Î‡Ì·ÓÛË: 10,23-18,3 Î·È p<0,0001), fiÛÔ Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 13,92, ‰È·Î‡Ì·ÓÛË: 10,8-17,4 Î·È p=0,035), ηıÒ˜ Î·È Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (‰È¿ÌÂÛÔ˜: 13,78, ‰È·Î‡Ì·ÓÛË: 10,2-16,8 Î·È p=0,022). ∂›Û˘, ÙÔ ÔÛÔÛÙfi ÙˆÓ µ ΢ÙÙ¿ÚˆÓ Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÙÔÓ ˘Ô‰Ô¯¤· Ù˘ IgE (CD23+) ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÌÂÛÔ˜: 3,62, ‰È·Î‡Ì·ÓÛË: 1,80-11) Û˘ÁÎÚÈÙÈο Ì ÙË Ê¿ÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 2,02, ‰È·Î‡Ì·ÓÛË: 1,21-8,53 Î·È p=0,002) Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 1,43, ‰È·Î‡Ì·ÓÛË: 0,44-8,06 Î·È p=0,012), ηıÒ˜ Î·È Ì ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ (‰È¿ÌÂÛÔ˜: 1,13, ‰È·Î‡Ì·ÓÛË: 0,37-6,53 Î·È p<0,001). EÓ‰Ô΢ÙÙ¿ÚÈÔ˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ INF-Á Î·È IL-4 ø˜ ÚÔ˜ ÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ, ÙÔ ÔÛÔÛÙfi ÙˆÓ CD3+/CD69+/INF-Á ∆ ΢ÙÙ¿ÚˆÓ (Ù‡Ô˘-1 ·ÙÙ·Ú·) ‹Ù·Ó Ôχ ÂÏ·Ùو̤ÓÔ ÛÙ· ·È‰È¿ Ì ∫∂¡™ Û fiϘ ÙȘ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ (‰È¿ÌÂÛÔ˜: 10,85, ‰È·Î‡Ì·ÓÛË: 8,47-16,49) Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (‰È¿ÌÂÛÔ˜: 23,85, ‰È·Î‡Ì·ÓÛË: 13,4-28,7 Î·È p<0,0001). ∞ÓÙ›ıÂÙ·, ÙÔ ÔÛÔÛÙfi ÙˆÓ CD3+/CD69+/IL4+ ∆ ΢ÙÙ¿ÚˆÓ (Ù‡Ô˘-2 ·ÙÙ·Ú·) ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ, fi¯È ÌfiÓÔ Î·Ù¿ ÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÌÂÛÔ˜: 19,59, ‰È·Î‡Ì·ÓÛË: 13,68-26,29), ·ÏÏ¿ Î·È Î·Ù¿ ÙË Ê¿ÛË ‡ÊÂÛ˘ ÙfiÛÔ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·195
195
∞ÓÔÛȷ΋ ·¿ÓÙËÛË ÛÙÔ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ
∂›Â‰· ÛÙÔÓ ÔÚfi Ù˘ πgE Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1, Ù· ›‰· Ù˘ IgE ÛÙÔÓ ÔÚfi ÛÙ· ·È‰È¿ Ì ∫∂¡™ ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÌÂÛÔ˜: 230 IU/ml, ‰È·Î‡Ì·ÓÛË: 84-2100 IU/ml) Û ۯ¤ÛË Ì ÙË Ê¿ÛË ‡ÊÂÛ˘, ÙfiÛÔ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 102 IU/ml, ‰È·Î‡Ì·ÓÛË: 19-1000 IU/ml Î·È p=0,002), (∂ÈÎfiÓ· 1), fiÛÔ Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 57 IU/ml, ‰È·Î‡Ì·ÓÛË:18-759 IU/ml Î·È p=0,012), ηıÒ˜ Î·È Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (‰È¿ÌÂÛÔ˜: 27 IU/ml, ‰È·Î‡Ì·ÓÛË: 5-125 IU/ml Î·È p<0,0001). ¢ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ Ù˘ IgE Î·È Ù˘ ·ÚÔ˘Û›·˜ ·ÙÔ›·˜ (p>0,05). ∂›Â‰· ÛÙÔÓ ÔÚfi ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ π¡F-Á, IL-4, IL-13 Î·È IL-18 ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο Ù· ·ÔÙÂϤÛÌ·Ù· ·Ó·ÊÔÚÈο Ì ٷ ›‰· ÛÙÔÓ ÔÚfi
2500 2000 IgE (IU/ml)
(‰È¿ÌÂÛÔ˜: 15,158, ‰È·Î‡Ì·ÓÛË: 10,43-19,63 Î·È p=0,015), fiÛÔ Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (‰È¿ÌÂÛÔ˜: 11,68, ‰È·Î‡Ì·ÓÛË: 7,57-14,56 Î·È p=0,004) Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (‰È¿ÌÂÛÔ˜: 2,14, ‰È·Î‡Ì·ÓÛË: 1,25-5,63 Î·È p<0,0001).
1500 1000 500 0
1 2 ∂ÓÂÚÁfi˜ Ê¿ÛË ¡™. ⁄ÊÂÛË ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹
∂ÈÎfiÓ· 1. √È Î·Ù¿ ˙‡ÁË ÙÈ̤˜ Ù˘ πgE ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∫∂¡™ Û ÂÓÂÚÁfi Ê¿ÛË Î·È Û ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹.
ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ π¡F-Á, IL-4, IL-13 Î·È IL-18 .∆· ›‰· Ù˘ INF-Á ÛÙÔÓ ÔÚfi, ÛÂ Û˘Ìʈӛ· Ì ·˘Ù¿ ·fi ÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ÂÎÙ›ÌËÛË, ‹Ù·Ó Ôχ ÂÏ·Ùو̤ӷ ÛÙ· ·È‰È¿ Ì ∫∂¡™ Û ÂÓÂÚÁfi Ê¿ÛË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∞ÓÙ›ıÂÙ·, Ù˘ IL-4 ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ fi¯È ÌfiÓÔ Î·Ù¿ ÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Î·È Î·Ù¿ ÙË Ê¿ÛË ‡ÊÂÛ˘ ÙfiÛÔ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, fiÛÔ Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆· ›‰· Ù˘ IL-13 ÛÙÔÓ ÔÚfi ÙˆÓ ·È‰ÈÒÓ Ì ∫∂¡™ ‹Ù·Ó ›Û˘ ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÛÙËÓ ÂÓÂÚÁfi
¶›Ó·Î·˜ 1. ∂›Â‰· ÛÙÔÓ ÔÚfi, ‰È¿ÌÂÛË ÙÈÌ‹ Î·È ‰È·Î‡Ì·ÓÛË, Ù˘ IgE Î·È ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ INF-Á, IL4, IL-13 Î·È IL-18 ÛÙ· ·È‰È¿ Ì ∫∂¡™ Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ∂›Â‰· ÛÙÔÓ ÔÚfi IgE (IU/ml) ¢È¿ÌÂÛÔ˜ ¢È·Î‡Ì·ÓÛË INF-Á (pg/ml) ¢È¿ÌÂÛÔ˜ ¢È·Î‡Ì·ÓÛË IL-4 (pg/ml) ¢È¿ÌÂÛÔ˜ ¢È·Î‡Ì·ÓÛË IL-13 (pg/ml) ¢È¿ÌÂÛÔ˜ ¢È·Î‡Ì·ÓÛË IL-18(pg/ml) ¢È¿ÌÂÛÔ˜ ¢È·Î‡Ì·ÓÛË
∂ÓÂÚÁfi˜ Ê¿ÛË
⁄ÊÂÛË ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹
⁄ÊÂÛË ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹
ª¿ÚÙ˘Ú˜
2301 84-2100
102 19-1005
57 18-759
27 5-125
14,822 13,7-27,37
21,95 13,92-34,45
24,2 16,9-35,56
19,23 13,96-32,27
583 17,8-194
30,33 12,13-72,04
21,76 10,8-51,65
12,4 6,43-33,53
75,694 20-187
41,03 13,7-134
37 12-88
14,6 14,2-19,2
1613,755 521-4090
926,75 455-1291
670 394-1136
214,8 78,3-386,8
1
p=0,002, p=0,012, p<0,0001 ÁÈ· Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÓÂÚÁÔ‡ Ê¿Û˘ Û ۯ¤ÛË Ì ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ê¿ÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì¿ÚÙ˘Ú˜, ·ÓÙ›ÛÙÔȯ· 2 p<0,0001, p<0,0001, p=0,019 ÁÈ· Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÓÂÚÁÔ‡ Ê¿Û˘ Û ۯ¤ÛË Ì ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ê¿ÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì¿ÚÙ˘Ú˜, ·ÓÙ›ÛÙÔȯ· 3 p<0,0001, p<0,0001, p<0,0001 ÁÈ· Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÓÂÚÁÔ‡ Ê¿Û˘ Û ۯ¤ÛË Ì ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ê¿ÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì¿ÚÙ˘Ú˜, ·ÓÙ›ÛÙÔȯ· 4 p<0,0001, p<0,0001, p<0,0001 ÁÈ· Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÓÂÚÁÔ‡ Ê¿Û˘ Û ۯ¤ÛË Ì ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ê¿ÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì¿ÚÙ˘Ú˜, ·ÓÙ›ÛÙÔȯ· 5 p<0,0001, p<0,0001, p<0,0001 ÁÈ· Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÓÂÚÁÔ‡ Ê¿Û˘ Û ۯ¤ÛË Ì ʿÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ê¿ÛË ‡ÊÂÛ˘ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ì¿ÚÙ˘Ú˜, ·ÓÙ›ÛÙÔȯ· ¶·È‰È·ÙÚÈ΋ 2007;70:192-198
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·196
196
¡. ¶Ú›ÓÙ˙· Î·È Û˘Ó.
™˘Û¯ÂÙ›ÛÂȘ ¶Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Û˘Û¯ÂÙ›ÛÂȘ: ·) ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Ì ÙÔ ÔÛÔÛÙfi ÙˆÓ CD23+ B ΢ÙÙ¿ÚˆÓ, fiÔ˘ ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Î·È ÙˆÓ CD23+ B ΢ÙÙ¿ÚˆÓ (r=0,773 Î·È p<0,0001) ηÈ, ‚) ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Ì ٷ ›‰· ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ πL-13, IL-4 Î·È πL-18 Û ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘, fiÔ˘ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ ΢ڛˆ˜ Ì ٷ ›‰· Ù˘ πL-13 (r=0,628 Î·È p<0,05) Î·È ÏÈÁfiÙÂÚ· Ì ·˘Ù¿ Ù˘ IL-4 Î·È Ù˘ πL-18 (r=0,459 Î·È p<0,05, r=0,502 Î·È p<0,05, ·ÓÙ›ÛÙÔȯ·) (∂ÈÎfiÓ˜ 2, 3, 4).
™˘˙‹ÙËÛË ™ÙËÓ ·ÚÔ‡Û· ÚÔÔÙÈ΋ ÌÂϤÙË ¤ÁÈÓ ÚÔÛ¿ıÂÈ· Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó ÔÈ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙ· ·È‰È¿ Ì ڈÙÔ·ı¤˜ ∫∂¡™ Î·È Ó· Û˘Û¯ÂÙÈÛÙÔ‡Ó ·˘Ù¤˜ Ì ÙËÓ ·ÙÔ›·. ∆· ·ÚÈ· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ù· ·ÎfiÏÔ˘ı·: Ù· ·È‰È¿ Ì ∫∂¡™, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË Ê¿ÛË Ù˘ ÓfiÛÔ˘, ›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ÙfiÛÔ ÙÔÓ ·fiÏ˘ÙÔ ·ÚÈıÌfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ, ÙˆÓ CD4+ ∆ ΢ÙÙ¿ÚˆÓ
2.000,00
0,00
✟ ✟
✟ ✟
100,00 150,00 IL-4 (pg/ml)
200,00
∂ÈÎfiÓ· 3. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Ì ٷ ›‰· Ù˘ πL-4 ÛÙ· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™.
Î·È ÙˆÓ CD8+ ∆ ΢ÙÙ¿ÚˆÓ, fiÛÔ Î·È ÙÔÓ ÏfiÁÔ CD4+/CD8+ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. √ ÏfiÁÔ˜ CD4+/CD8+ ∆ ΢ÙÙ¿ÚˆÓ, ·Ú’ fiÏÔ Ô˘ ‹Ù·Ó ̤۷ ÛÙ· fiÚÈ· ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ, ‚Ú¤ıËΠÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ˜ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Û ۇÁÎÚÈÛË Ì ÙË Ê¿ÛË ‡ÊÂÛ˘ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∞˘Ùfi ÔÊÂÈÏfiÙ·Ó Û ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ CD8+ ∆ ΢ÙÙ¿ÚˆÓ. ∆Ô ÔÛÔÛÙfi ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ∆ ΢ÙÙ¿ÚˆÓ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙˆÓ ·È‰ÈÒÓ Ì ∫∂¡™ ‚È‚ÏÈÔÁÚ·ÊÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û˘Ó‹ıˆ˜ Â›Ó·È ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (10-12), fiˆ˜ Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÛÙËÓ ÔÔ›· ‰ÂÓ ˘‹Ú¯Â ÌÂÙ·‚ÔÏ‹ ÙˆÓ CD25+ ΢ÙÙ¿ÚˆÓ Û η̛· Ê¿ÛË Ù˘ ÓfiÛÔ˘.
2.000,00
IgE IU/ml
✟
r=0,502 p<0,05
✟ ✟
500,00
500,00
0,00
40,00
80,00 120,00 IL-13 (pg/ml)
✟
1.000,00
160,00
∂ÈÎfiÓ· 2. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Ì ٷ ›‰· Ù˘ πL-13 ÛÙ· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™. Paediatriki 2007;70:192-198
✟✟ ✟ ✟✟ ✟ ✟✟✟ ✟✟✟ ✟✟ ✟✟
1.500,00
1.000,00
0,00
✟
50,00
1.500,00 IgE IU/ml
1.000,00
500,00
r=0,628 p<0,05
2.000,00
✟
r=0,459 p<0,05
1.500,00 IgE IU/ml
Ê¿ÛË Ù˘ ÓfiÛÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙË Ê¿ÛË ‡ÊÂÛ˘, ÙfiÛÔ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, fiÛÔ Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ηıÒ˜ Î·È Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆Ô ›‰ÈÔ ‚Ú¤ıËÎÂ Î·È ÁÈ· Ù· ›‰· Ù˘ IL-18 Ô˘ ‹Ù·Ó Ôχ ·˘ÍË̤ӷ ηٿ ÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆· ›‰· ÂÏ·ÙÙÒÓÔÓÙ·Ó ÛËÌ·ÓÙÈο ηٿ ÙË Ê¿ÛË ‡ÊÂÛ˘ ˘fi Î·È ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ·ÏÏ¿ ·Ú¤ÌÂÓ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ Û ۯ¤ÛË Ì ·˘Ù¿ ÙˆÓ Ì·ÚÙ‡ÚˆÓ (p<0,01).
✟ ✟ ✟ ✟ ✟ ✟ ✟ ✟ ✟ ✟ ✟✟✟✟ ✟ ✟✟✟✟
✟
✟ ✟ ✟ ✟ ✟ ✟ ✟ ✟✟
1.000,00
✟
2.000,00 3.000,00 IL-18 (pg/ml)
4.000,00
∂ÈÎfiÓ· 4. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ Ù˘ IgE ÙÔ˘ ÔÚÔ‡ Ì ٷ ›‰· Ù˘ πL-18 ÛÙ· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™.
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·197
197
∞ÓÔÛȷ΋ ·¿ÓÙËÛË ÛÙÔ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ
∞ÓÙ›ıÂÙ·, ÙÔ ÔÛÔÛÙfi ÙˆÓ CD19+ Î·È CD23+ µ ΢ÙÙ¿ÚˆÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘, Û˘ÁÎÚÈÙÈο Ì ÙȘ Ê¿ÛÂȘ ‡ÊÂÛ˘ Î·È Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∂ÈϤÔÓ, ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÙˆÓ CD23+ µ ΢ÙÙ¿ÚˆÓ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ ›Û˘ ·˘ÍË̤ӷ ›‰· Ù˘ IgE ÛÙÔÓ ÔÚfi, ·ÓÂÍ·Úًو˜ ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ·ÙÔ›·˜. ∆· ÈÔ ÂÓÙ˘ˆÛȷο Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· Û‡ÓıÂÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È Ù· ›‰¿ ÙÔ˘˜ ÛÙÔÓ ÔÚfi, ‹Ù·Ó Ù· ÂÍ‹˜: ·È‰È¿ Ì ∫∂¡™ Û fiϘ ÙȘ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ ·ÚÔ˘Û›·˙·Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ CD3+/CD69+/IL-4+ ∆ ΢ÙÙ¿ÚˆÓ (Ù‡Ô˘-2), ÌÂȈ̤ӷ ÔÛÔÛÙ¿ CD3+/CD69+/ INF-Á ∆ ΢ÙÙ¿ÚˆÓ (Ù‡Ô˘-1), ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÍË̤ӷ ›‰· ÛÙÔÓ ÔÚfi ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ IL-4, IL-13 Î·È IL-18 Î·È ·˘ÍË̤ӷ ›‰· IgE, Â˘Ú‹Ì·Ù· Ô˘ Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ·ÓÔÛȷ΋ ·¿ÓÙËÛË Ù‡Ô˘-2. À‹Ú¯Â, ›Û˘, ÛËÌ·ÓÙÈο ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÔÚÔ‡ Ù˘ IgE ΢ڛˆ˜ Ì ·˘Ù¿ Ù˘ πL-13, ·ÏÏ¿ Î·È Ù˘ IL-4 Î·È Ù˘ πL-18. ™¯ÂÙÈο Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô ÙˆÓ µ Î·È ∆ ΢ÙÙ¿ÚˆÓ ÛÙ· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (710,16). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ù· ÌfiÓ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ‹Ù·Ó ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÙˆÓ CD19+ Î·È CD23+ µ ΢ÙÙ¿ÚˆÓ. ø˜ ÚÔ˜ ÙÔÓ ÏfiÁÔ CD4+/CD8+ ∆ ΢ÙÙ¿ÚˆÓ, Û ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Â›Ó·È ÂÏ·Ùو̤ÓÔ˜, ÂÓÒ ÛÙËÓ ‡ÊÂÛË ÔÈ ÙÈ̤˜ ·ӤگÔÓÙ·È ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (8,10), fiˆ˜ ‚Ú¤ıËÎÂ Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. T· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÂϤÙ˘, ·Ó·ÊÔÚÈο Ì ÙȘ ·Ú·ÁfiÌÂÓ˜ ΢ÙÙ·ÚÔΛÓ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∫∂¡™ ˘¿Ú¯ÂÈ ‰È·Ù·Ú·Á̤ÓË ÈÛÔÚÚÔ›· Ù˘ Ù‡Ô˘-1 ÚÔ˜ Ù‡Ô-2 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Ì ˘ÂÚÔ¯‹ Ù˘ Ù‡Ô˘-2 (·ÓÙ› Ù˘ Ù‡Ô˘-1, Ô˘ Û˘Ì‚·›ÓÂÈ Û ˘ÁÈ‹ ¿ÙÔÌ· Î·È fiˆ˜ ‚Ú¤ıËΠÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘), fiˆ˜ ·˘Ù‹ ÂÎÊÚ¿˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ ·˘ÍË̤ÓË Û‡ÓıÂÛË ÙˆÓ Î˘Ù·ÚÔÎÈÓÒÓ IL-4 Î·È IL-13 Î·È ÙË ÌÂȈ̤ÓË Û‡ÓıÂÛË Ù˘ INF-Á. ∞Ó·ÊÔÚÈο Ì ÙËÓ IL-4, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ ÙˆÓ Neuhaus Î·È Û˘Ó (14) Î·È Cho Î·È Û˘Ó (15), ÔÈ ÔÔ›ÔÈ ‚Ú‹Î·Ó ·˘ÍË̤ӷ ›‰· Ù˘ IL-4 ÛÙÔÓ ÔÚfi. ∞ÓÙ›ıÂÙ·, ÔÈ Stachowski Î·È Û˘Ó (21) Û ÂÓÂÚÁfi Ê¿ÛË ÙÔ˘ ∫∂¡™ ·Ú·Ù‹ÚËÛ·Ó ÌÂȈ̤ӷ ›‰· Ù˘ IL-4, Èı·ÓÒ˜ ÁÈ·Ù› ¯ÚËÛÈÌÔÔÈ‹ıËΠ‰È·ÊÔÚÂÙÈ΋ Ù¯ÓÈ΋, Ë ÔÔ›· ‰ÂÓ ÌÂÙÚ¿ÂÈ ¿ÌÂÛ· Ù· ·ÙÙ·Ú· Ô˘ ·Ú¿ÁÔ˘Ó IL-4, fiˆ˜ ¤ÁÈÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰È·ÈÛÙÒıËΠ۠fiϘ ÙȘ Ê¿ÛÂȘ ÙÔ˘ ∫∂¡™ ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ Ù‡Ô˘-2 ·ÓÔÛȷ΋ ·¿ÓÙËÛË. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÂÓÈÛ¯‡ÔÓÙ·È Î·È ·fi ÙËÓ ·Ó‡ÚÂÛË ÌÂȈ̤Ó˘
ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ Û‡ÓıÂÛ˘ Ù˘ INF-Á (΢ÙÙ·ÚÔΛÓË Ù˘ Ù‡Ô˘-1 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘). ™Â ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜, ÔÈ Yap Î·È Û˘Ó (13) ‚Ú‹Î·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÓÂÚÁfi ∫∂¡™, Ì ÙË ¯Ú‹ÛË ËÌÈÔÛÔÙÈ΋˜ PCR Ù¯ÓÈ΋˜, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ mRNA Ù˘ IL-13, ÙfiÛÔ ÛÙ· CD4+ fiÛÔ Î·È ÛÙ· CD8+ ∆ ÏÂÌÊÔ·ÙÙ·Ú· Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ʿÛË ‡ÊÂÛ˘ Ù˘ ÓfiÛÔ˘ Î·È Ì ÙÔ˘˜ ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜. ∏ IL13, Û‡Ìʈӷ Ì ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, Èı·Ófiٷٷ ‰Ú· ÛÙ· ÌÔÓÔ·ÙÙ·Ú·, ¿ÁÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ ÂÓfi˜ ˘ÔıÂÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ô˘ ·˘Í¿ÓÂÈ ÙËÓ ·ÁÁÂȷ΋ ‰È·ÂÚ·ÙfiÙËÙ· (vascular permeability factor) Î·È Û˘Ì‚¿ÏÏÔÓÙ·˜ ¤ÙÛÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÚˆÙÂ˚ÓÔ˘Ú›·˜. ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi˜ Ô Ì˯·ÓÈÛÌfi˜ Ô˘ Û˘ÓÙÂÏ› ÛÙËÓ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ IL-13 ÛÙ· ¿ÙÔÌ· Ì ÂÓÂÚÁfi ∫∂¡™, Ê·›ÓÂÙ·È fï˜ fiÙÈ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÁÂÓÂÙÈÎfi ˘fiÛÙڈ̷, ÙÔ˘Ï¿¯ÈÛÙÔÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÁÓˆÛÙÔ‡˜ ̤¯ÚÈ Û‹ÌÂÚ· ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ IL-13 (22), Ô‡ÙÂ Î·È Ì ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÙˆÓ ÁÔÓȉ›ˆÓ Ô˘ Έ‰ÈÎÔÔÈÔ‡Ó ÙÔ˘˜ ‰È·ÌÂÌ‚Ú·ÓÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Ù˘ IL-4 Î·È Ù˘ IL-13 (23,24). π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û¯ÂÙÈο Ì ٷ ·˘ÍË̤ӷ ›‰· Ù˘ IL-18 Û fiϘ ÙȘ Ê¿ÛÂȘ ÙÔ˘ ∫∂¡™, ȉȷ›ÙÂÚ· ‰Â ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË, Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∏ IL-18 ·ÔÙÂÏ› Ì›· ΢ÙÙ·ÚÔΛÓË Ô˘ ¿ÏÏÔÙ ¿ÁÂÈ ÙËÓ Ù‡Ô˘ π Î·È ¿ÏÏÔÙ ÙËÓ Ù‡Ô˘ ππ ·ÓÔÛȷ΋ ·¿ÓÙËÛË Î·È Ë ‰Ú¿ÛË Ù˘ Û οı ÂÚ›ÙˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙÔ ÔÔ›Ô ‰Ú· (25). ∂›Û˘, Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ Ê¿ÓËΠfiÙÈ Ë IL-18 ˆ˜ ÌÔÓ·‰ÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÌÔÚ› Ó· ¿ÁÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ IL4 Î·È Ù˘ IL-13 ·fi Ù· Ì·ÛÙÔ·ÙÙ·Ú· Î·È Ù· ‚·ÛÂfiÊÈÏ·, ·˘Í¿ÓÔÓÙ·˜ Ù· ›‰· Ù˘ πgE, ηıÒ˜ ›Û˘ fiÙÈ Ë Î·ıËÌÂÚÈÓ‹ ¯ÔÚ‹ÁËÛ‹ Ù˘ ÚÔηÏ› ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË ·‡ÍËÛË Ù˘ IgE ¿ÁÔÓÙ·˜ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Ù˘ IL-4 ·fi Ù· ∆ ·ÙÙ·Ú· (25). ∞Ó·ÊÔÚÈο Ì ÙÔ ∫∂¡™, Û ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ÔÈ Matsumoto Î·È Û˘Ó (26) ‚Ú‹Î·Ó ·˘ÍË̤ӷ ›‰· Ù˘ IL-18 Û ÂÓ‹ÏÈΘ Ì ÂÓÂÚÁfi ∫∂¡™. ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙÔÓ ÚfiÏÔ Ù˘ IL-18 ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ∫∂¡™. ™Â ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ (16,20), fiˆ˜ Î·È ÛÙËÓ ·ÚÔ‡Û·, ¤¯ÂÈ Ê·Ó› fiÙÈ Ù· ›‰· Ù˘ IgE ÌÔÚ› Ó· Â›Ó·È ·˘ÍË̤ӷ ÛÙ· ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Û ÔÛÔÛÙfi ¤ˆ˜ 60%, ȉȷ›ÙÂÚ· ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘. ∆· ·˘ÍË̤ӷ ›‰· ıˆڋıËÎ·Ó ·Ú¯Èο ˆ˜ ‰Â›ÎÙ˘ ·ÚÔ˘Û›·˜ ·ÙÔ›·˜ ÛÙ· ·È‰È¿ ·˘Ù¿ (18,19). ∂›Û˘, ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ¤‰ÂÈÍ·Ó fiÙÈ Û ·È‰È¿ Ì ∫∂¡™ ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ CD23+, ÂÈÊ·ÓÂÈ·ÎÔ‡ ÌÔÚ›Ô˘ Ô˘ Â›Ó·È Ô ˘Ô‰Ô¯¤·˜ II Ù˘ IgE ÛÙ· µ ·ÙÙ·Ú· (15). ™Â ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‚Ú¤ıËΠfiÙÈ ·˘ÍË̤ӷ ¶·È‰È·ÙÚÈ΋ 2007;70:192-198
Pediatri May-Jun 07
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›‰· IgE Î·È ·˘ÍË̤ÓÔ ÔÛÔÛÙfi CD23+ ΢ÙÙ¿ÚˆÓ Â›¯·Ó ÙfiÛÔ Ù· ·ÏÏÂÚÁÈο fiÛÔ Î·È Ù· ÌË ·ÏÏÂÚÁÈο ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™ (20). ªÂ Ù· Â˘Ú‹Ì·Ù· ÙˆÓ ·Ú·¿Óˆ ÌÂÏÂÙÒÓ Â›Ó·È Û˘Ì‚·Ù¿ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Û‡Ìʈӷ Ì ٷ ÔÔ›· Ë ·˘ÍË̤ÓË IgE ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙÔ ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ ÛÙ· ·È‰È¿ Ì ∫∂¡™. √È Cheung Î·È Û˘Ó (20) ‚Ú‹Î·Ó fiÙÈ Ë ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ IgE ÛÙ· ·È‰È¿ Ì ∫∂¡™ Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ IL-13. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËÎÂ, ›Û˘, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ IgE ΢ڛˆ˜ Ì ÙËÓ IL-13. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ Ë ·‡ÍËÛË Ù˘ IgE ·ÔÙÂÏ› Èı·Ófiٷٷ ¤Ó· ÂÈÊ·ÈÓfiÌÂÓÔ, ÏfiÁˆ Ù˘ Ù‡Ô˘-2 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Ô˘ ˘ÂÚÈÛ¯‡ÂÈ ÛÙËÓ ÂÓÂÚÁfi Ê¿ÛË ÙÔ˘ ∫∂¡™. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÛÙ· ·È‰È¿ Ì ÂÓÂÚÁfi ∫∂¡™ ˘ÂÚ¤¯ÂÈ Ë ·ÓÔÛȷ΋ ·¿ÓÙËÛË Ù‡Ô˘-2, Ë ÔÔ›· Â›Ó·È Èı·Ófi Ó· ¿ÁÂÙ·È ·fi ÙË Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ IL-18 Î·È IL-13. ∏ ·‡ÍËÛË Ù˘ IgE, Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û ÂÓÂÚÁfi Ê¿ÛË Ù˘ ÓfiÛÔ˘, Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì Ì˯·ÓÈÛÌfi ·ÙÔ›·˜, ·ÏÏ¿ ·ÔÙÂÏ› ·ÔÙ¤ÏÂÛÌ· ‹ ÂÈÊ·ÈÓfiÌÂÓÔ Ù˘ Ù‡Ô˘-2 ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘. ªÂÏÏÔÓÙÈΤ˜ ÌÂϤÙ˜ ı· Ú›ÍÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ Êˆ˜ ÛÙ· ·›ÙÈ· ‹/Î·È ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ÚÔηÏÔ‡Ó ·˘Ù‹ ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ Ù‡Ô˘-2 ΢ÙÙ·ÚÔÎÈÓÒÓ.
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SH, Shirkey B. T-lymphocyte subsets in nephrotic syndrome. Kidney Int 1991;40:913-916. van den Berg JG, Weening JJ. Role of the immune system in the pathogenesis of idiopathic nephrotic syndrome. Clin Sci 2004;107:125-136. Frank C, Herrmann M, Fernandez S, Dirnecker D, Boswald M, Kolowos W et al. Dominant T cells in idiopathic nephrotic syndrome of childhood. Kidney Int 2000;57:510-517. Neuhaus TJ, Shah V, Callard RE, Barratt TM. T-lymphocyte activation in steroid-sensitive nephrotic syndrome in childhood. Nephrol Dial Transplant 1995;10:1348-1352. Mathieson PW. Immune dysregulation in minimal change nephropathy. Nephrol Dial Transplant 2003;18 (Suppl 6):S26-S29. Yap HK, Cheung W, Murugasu B, Sim SK, Seah CC, Jordan SC. Th1 and Th2 cytokine mRNA profiles in childhood nephrotic syndrome: evidence for increased IL-13 mRNA expression in relapse. J Am Soc Nephrol 1999;10:529-537. Neuhaus TJ, Wadhwa M, Callard R, Barratt TM. Increased IL-2, IL-4 and interferon-Á (INF-Á) in steroid-sensitive nephrotic syndrome. Clin Exp Immunol 1995;100:475-479. Cho BS, Yoon SR, Jang JY, Pyun KH, Lee CE. Up-regulation of interleukin-4 and CD23/FcepsilonRII in minimal change nephrotic syndrome. Pediatr Nephrol 1999;13: 199-204. Araya CE, Wasserfall CH, Brusko TM, Mu W, Segal MS, Johnson RJ et al. A case of unfulfilled expectations. Cytokines in idiopathic minimal lesion nephrotic syndrome. Pediatr Nephrol 2006;21:603-610. Wittig HJ, Goldman AS. Nephrotic syndrome associated with inhaled allergens. Lancet 1970;1:542-543. Lagrue G, Laurent J, Belghiti D, Sainte-Laudy J. Food sensitivity and idiopathic nephrotic syndrome. Lancet 1985; 2:777. Lin CY, Lee BH, Lin CC, Chen WP. A study of the relationship between childhood nephrotic syndrome and allergic diseases. Chest 1990;97:1408-1411. Cheung W, Wei CL, Seah CC, Jordan SC, Yap HK. Atopy, serum IgE, and interleukin-13 in steroid-responsive nephrotic syndrome. Pediatr Nephrol 2004;19:627-632. Stachowski J, Barth C, Michalkiewicz J, Krynicki T, Jarmolinski T, Runowski D et al. Th1/Th2 balance and CD45-positive T cell subsets in primary nephrotic syndrome. Pediatr Nephrol 2000;14:779-785. Anderson KL, Mathieson PW, Gillespie KM, Wills-Karp M, Rosenwasser LJ. Polymorphisms not found in the IL13 gene promoter. Science 1999;284:1431. Parry RG, Gillespie KM, Parnham A, Clark AG, Mathieson PW. Interleukin-4 and interleukin-4 receptor polymorphisms in minimal change nephropathy. Clin Sci 1999;96: 665-668. Tenbrock K, Schubert A, Stapenhorst L, Kemper MJ, Gellermann J, Timmermann K et al. Type I IgE receptor, interleukin 4 receptor and interleukin 13 polymorphisms in children with nephrotic syndrome. Clin Sci 2002;102: 507-512. Nakanishi K, Yoshimoto T, Tsutsui H, Okamura H. Interleukin-18 is a unique cytokine that stimulates both Th1 and Th2 responses depending on its cytokine milieu. Cytokine Growth Factor Rev 2001;12:53-72. Matsumoto K, Kanmatsuse K. Augmented interleukin-18 production by peripheral blood monocytes in patients with minimal-change nephrotic syndrome. Am J Nephrol 2001;21:20-27.
Pediatri May-Jun 07
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
™ÂÏ›‰·199
ORIGINAL ARTICLE
199
∏ ÈÓÙÂÚÏ¢ΛÓË-8 (IL-8) ÙˆÓ Ô‡ÚˆÓ ˆ˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û ·È‰È¿ ËÏÈΛ·˜ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ ª. ªÈÙÛÒÚË1, ∂. °·Ï·Ó¿Î˘1, ∂. ¢ËÌËÙÚ›Ô˘1, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘2, ¡.∞. ∫·Úη‚›ÙÛ·˜3, ª. ∫·ÏÌ·ÓÙ‹1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ‰È¿ÁÓˆÛË Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (∫√¶) ‚·Û›˙ÂÙ·È Û ÂÂÌ‚·ÙÈΤ˜ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ô˘ Û˘Ó¿ÁÔÓÙ·È ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÛËÌ·ÓÙÈÎfi ÎfiÛÙÔ˜. √ ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 8 (IL-8) ÛÙ· Ô‡Ú·, ˆ˜ ÌË ÂÂÌ‚·ÙÈÎÔ‡ ‰Â›ÎÙË ∫√¶ Û ·È‰È¿ ËÏÈΛ·˜ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ IL-8 ÛÙ· Ô‡Ú· 69 ‚ÚÂÊÒÓ ËÏÈΛ·˜ ÂÓfi˜ ÌËÓfi˜ ¤ˆ˜ ÂÓfi˜ ¤ÙÔ˘˜. ∞fi ·˘Ù¿, 37 ›¯·Ó ÂȂ‚·ÈˆÌ¤ÓË ∫√¶ ¯ˆÚ›˜ ÚfiÛÊ·ÙË Ô˘ÚÔÏԛ̈ÍË (ÔÌ¿‰· ∞), 13 ›¯·Ó ·Ó·ÌÓËÛÙÈÎfi ·Ô‰Ú·ÌÔ‡Û·˜ Ô˘ÚÔÏԛ̈͢ ·ÏÏ¿ fi¯È ∫√¶ (ÔÌ¿‰· µ) Î·È Ù· ˘fiÏÔÈ· 19 ‹Û·Ó ÂχıÂÚ· ·Ó·ÌÓËÛÙÈÎÔ‡ ÁÓˆÛÙ‹˜ ÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ ÓfiÛÔ˘ Ô˘ ı· ÌÔÚÔ‡Û ӷ ÂËÚ¿ÛÂÈ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÔÌ¿‰· °). √È ÙÈ̤˜ IL-8 ÌÂÙÚ‹ıËÎ·Ó Ì ELISA Î·È ÌÂÏÂÙ‹ıËÎ·Ó ÌÂÙ¿ ·fi ·Ó·ÁˆÁ‹ ÛÙËÓ ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙˆÓ Ô‡ÚˆÓ. ∞ÔÙÂϤÛÌ·Ù·: ∆· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ∞ ›¯·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ›‰· IL-8 ÛÙ· Ô‡Ú· Û ۯ¤ÛË ÙfiÛÔ Ì ٷ ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ µ (p=0,0491) fiÛÔ Î·È Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ ° (p=0,0095). ∆È̤˜ IL-8/ÎÚ·ÙÈÓ›Ó˘ Ô‡ÚˆÓ >5 mg/Ìmol ›¯·Ó ¢·ÈÛıËÛ›· 73% Î·È ÂȉÈÎfiÙËÙ· 56% ÛÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ·ÚÔ˘Û›· ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ IL-8 ÛÙ· Ô‡Ú· ‚ÚÂÊÒÓ Ì ∫√¶ ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÂÓÂÚÁÔ‡ Ïԛ̈͢, ˘Ô‰ÂÈÎÓ‡ÂÈ Û˘Ó¯È˙fiÌÂÓË ÊÏÂÁÌÔÓÒ‰Ë ‰È·‰Èηۛ· Î·È ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÂÈ ˆ˜ ÌË ÂÂÌ‚·ÙÈÎfi˜ ‰Â›ÎÙ˘ ÈηÓÔÔÈËÙÈ΋˜ ¢·ÈÛıËÛ›·˜ Î·È ÂȉÈÎfiÙËÙ·˜ ÁÈ· ÙÔÓ ·Ú¯ÈÎfi ·ÓȯÓ¢ÙÈÎfi ¤ÏÂÁ¯Ô Ù˘ ∫√¶.
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ 2 ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ 3 ∆Ì‹Ì· ¶˘ÚËÓÈ΋˜ π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, egalanak@med.uoc.gr ∆Ô̤·˜ ªËÙ¤Ú·˜ ¶·È‰ÈÔ‡, ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘, ∆.£. 2208, T.K. 71003, ∏Ú¿ÎÏÂÈÔ
§¤ÍÂȘ ÎÏÂȉȿ: ¢È·ÁÓˆÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜, ÈÓÙÂÚÏ¢ΛÓË-8, ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Ô˘ÚÔÏԛ̈ÍË.
Urine interleukin-8 as a marker of vesicoureteral reflux in children aged under 1 year M. µitsori1, E. Galanakis1, E. Dimitriou1, C. Giannakopoulou2, N.A. Karkavitsas3, M. Kalmanti1 Abstract Background: Diagnosis of vesicoureteral reflux (VUR) is based on imaging modalities that are associated with radiation, invasiveness and expense. The aim of this study was to assess the urine levels of IL-8 as a non-invasive marker of VUR in children aged under 1 year. Methods: Urine concentrations of IL-8 were measured in 69 infants aged 1 month to 1 year. Among the infants, 37 had established VUR without recent UTI (group A), 13 had a history of past UTI without VUR (group B), and 19 had no history of any known acute or chronic condition that might impair renal function (group C). IL-8 concentrations were determined by ELISA and standardized with urine creatinine. Results: The infants in group A had higher urine IL-8 levels than those in groups B (p=0.0491) and C (p=0.0095). Urine IL-8/creatinine concentrations of >5 mg/Ìmol had a sensitivity of 73% and a specificity of 56% for diagnosing VUR. Conclusions: The findings of this study suggest that urinary IL-8 levels remain increased in infants with VUR after acute UTI has resolved, pointing to an ongoing inflammatory process. Increased urinary IL-8 levels may serve as non-invasive marker of adequate sensitivity and specificity for an initial screening for VUR in young infants.
1 Paediatrics Department, University General Hospital of Heraklion, Crete 2 Neonatal Department, University General Hospital of Heraklion, Crete 3 Nuclear Medicine Department, University General Hospital of Heraklion, Crete Correspondence: Emmanouil Galanakis, egalanak@med.uoc.gr University of Crete, Faculty of Medicine Division of Mother and Child Medicine, PO Box 2208, 71003, Heraklion, Crete
Key words: Diagnostic tests, interleukin-8, urinary tract infection, vesicoureteral reflux.
∏ ÂÚÁ·Û›· ·˘Ù‹ ‚Ú·‚‡ıËΠ̠ÙÔ ÃˆÚ¤ÌÂÈÔ Œ·ıÏÔ ÛÙÔ 44Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ƒfi‰Ô˜, 9-11 πÔ˘Ó›Ô˘ 2006 ¶·È‰È·ÙÚÈ΋ 2007;70:199-204
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·200
200
ª. ªÈÙÛÒÚË Î·È Û˘Ó.
∂ÈÛ·ÁˆÁ‹ ∏ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (∫√¶) Â›Ó·È Û˘¯Ófi ‡ÚËÌ· Û ·È‰È¿ Ì ԢÚÔÏÔÈÌÒÍÂȘ, Û ÓÂÔÁÓ¿ Ì ÚÔÁÂÓÓËÙÈ΋ ˘‰ÚÔÓ¤ÊÚˆÛË Î·È ÛÂ Û˘ÁÁÂÓ›˜ ·Û¯fiÓÙˆÓ ·fi ∫√¶ (1). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛ‹ Ù˘, ÚÈÓ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ - ·Ó ÚfiÎÂÈÙ·È ÁÈ· ∫√¶ ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ - Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË, Ë ÔÔ›· ıˆÚÂ›Ù·È ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ·›ÙÈ· ˘¤ÚÙ·Û˘ Î·È ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙ· ·È‰È¿ (2,3). ∏ ∫√¶ ¢ÓÔ› ÙËÓ ·ÓÈÔ‡Û· Ïԛ̈ÍË Î·È ÙË ÌÂÙ·ÊÔÚ¿ Ù˘ ÂÓ‰Ô΢ÛÙÈ΋˜ ›ÂÛ˘ ÛÙÔ˘˜ ÓÂÊÚÔ‡˜, ˆÛÙfiÛÔ ÔÈ ·ÎÚȂ›˜ Ì˯·ÓÈÛÌÔ› Ô˘ Ô‰ËÁÔ‡Ó ·fi ÙËÓ ∫√¶ Î·È ÙËÓ Ô˘ÚÔÏԛ̈ÍË ÛÙË ÓÂÊÚÈ΋ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë Î·È ÙË ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ‰ÂÓ Â›Ó·È ·ÎfiÌË Ï‹Úˆ˜ ηٷÓÔËÙÔ› (4-6). ∏ ·Ó›¯Ó¢ÛË Ù˘ ∫√¶ Î·È Ù˘ ÓÂÊÚÈ΋˜ Ô˘Ï‹˜ ‚·Û›˙ÂÙ·È Â› ÙÔ˘ ·ÚfiÓÙÔ˜ Û ÂÂÌ‚·ÙÈΤ˜ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ô˘ ÂÈ‚·Ú‡ÓÔ˘Ó ÙÔÓ ·ÛıÂÓ‹ Ì ·ÎÙÈÓÔ‚ÔÏ›· Î·È ¤¯Ô˘Ó ˘ÔÏÔÁ›ÛÈÌÔ ÎfiÛÙÔ˜ (1,6-7). ∂Âȉ‹ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ˘Ô‚¿ÏÏÂÙ·È Û ÂÎÙÂٷ̤ÓÔ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, Ë ·Ó‡ÚÂÛË ÌË ÂÂÌ‚·ÙÈÎÒÓ ÌÂıfi‰ˆÓ ·Ó›¯Ó¢Û˘ Ù˘ ∫√¶ ı· ‰È¢ÎfiÏ˘Ó ÛËÌ·ÓÙÈο ÙË ‰È·ÁÓˆÛÙÈ΋ Ù˘ ÚÔÛ¤ÁÁÈÛË. √È ‰Â›ÎÙ˜ ·˘ÙÔ› ı· ÌÔÚÔ‡Û·Ó Ó· ·Ô‰ÂȯÙÔ‡Ó ¯Ú‹ÛÈÌÔÈ Î·È ÁÈ· ÙÔÓ ÚÔÏËÙÈÎfi ¤ÏÂÁ¯Ô, ÛÙÔÓ ÔÔ›Ô Û˘ÓÈÛÙ¿Ù·È Ó· ˘Ô‚ÏËıÔ‡Ó Ù· ·‰¤ÏÊÈ· Î·È Ù· ·È‰È¿ ÙˆÓ ·ÙfiÌˆÓ Ì ∫√¶, ηıÒ˜ Î·È Ù· ‚Ú¤ÊË ÛÙ· ÔÔ›· ¤¯ÂÈ ‰È·ÁÓˆÛÙ› ˘‰ÚÔÓ¤ÊÚˆÛË ÚÔÁÂÓÓËÙÈο (2,8). ∆Ô ÂÈı‹ÏÈÔ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÂÎÙfi˜ ÙÔ˘ fiÙÈ ·ÔÙÂÏ› Ê˘ÛÈÎfi ÊÚ·ÁÌfi ¤Ó·ÓÙÈ ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, ‰È·‰Ú·Ì·Ù›˙ÂÈ Î·È ÂÓÂÚÁfi ·Ì˘ÓÙÈÎfi ÚfiÏÔ Ì ÙËÓ ·Ú·ÁˆÁ‹ ¯ËÌÂÈÔÎÈÓÒÓ Î·È Î˘ÙÙ·ÚÔÎÈÓÒÓ, Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙËÓ ·ÓÙ›‰Ú·ÛË ÛÙË Ïԛ̈ÍË (9). ∏ ÊÏÂÁÌÔÓ҉˘ ·˘Ù‹ ‰È·‰Èηۛ· ‰È·‰Ú·Ì·Ù›˙ÂÈ Ì ÙË ÛÂÈÚ¿ Ù˘ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÓÂÊÚÈ΋˜ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘. ¶Ôχ Ï›Á· Â›Ó·È ÁÓˆÛÙ¿ ÁÈ· ÙÔÓ ÚfiÏÔ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÔÍ›·˜ Ïԛ̈͢ (6,10-15). ∞Ó·˙ËÙÒÓÙ·˜ ÌË ÂÂÌ‚·ÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ∫√¶, ÚÔÛ‰ÈÔÚ›Û·Ì ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙ· Ô‡Ú· Ù˘ ΢ÙÙ·ÚÔΛÓ˘¯ËÌÂÈÔΛÓ˘ ÈÓÙÂÚÏ¢ΛÓ˘-8 (IL-8) Û ‚Ú¤ÊË Ì ·ÏÈÓ‰ÚfiÌËÛË ¯ˆÚ›˜ ÚfiÛÊ·ÙË Ô˘ÚÔÏԛ̈ÍË. ∏ IL-8, ÚÔ-ÊÏÂÁÌÔÓ҉˘ ‰È·ÌÂÛÔÏ·‚ËÙ‹˜ Î·È ¯ËÌÂÈÔÙ·ÎÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈψÓ, ·Ú¿ÁÂÙ·È ·fi Ù· ÂÈıËÏȷο ·ÙÙ·Ú· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ˆ˜ ·¿ÓÙËÛË Û ÊÏÂÁÌÔÓÒ‰Ë ÂÚÂı›ÛÌ·Ù·. √ Ú˘ıÌÈÛÙÈÎfi˜ Ù˘ ÚfiÏÔ˜ ÛÙË ‰È·‰ÚÔÌ‹ Ù˘ ÔÍ›·˜ Ïԛ̈͢ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ¤¯ÂÈ ÂÈÛËÌ·Óı› ·fi ÌÂϤÙ˜ Ì ÚÔÎÏËÙ‹ ˘ÂÏÔÓÂÊÚ›Ùȉ·, Û‡Ìʈӷ Ì ÙȘ Ôԛ˜ ÂÈÚ·Ì·Ùfi˙ˆ· Ì ·ÁfiÌÂÓË ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ IL-8 ·ÚÔ˘Û›·Û·Ó ·˘ÍË̤ÓË ‚·Ú‡ÙËÙ· Paediatriki 2007;70:199-204
Ïԛ̈͢ Î·È ÛÔ‚·Ú¤˜ ÓÂÊÚÈΤ˜ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ‚Ï¿‚˜ (16). ∞˘ÍË̤ӷ ›‰· IL-8 ¤¯Ô˘Ó ‹‰Ë ‰È·ÈÛÙˆı› ÛÙ· Ô‡Ú· ·ÛıÂÓÒÓ Ì ÔÍ›· Ô˘ÚÔÏԛ̈ÍË (8,12-13,15,17-21).
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∞ÛıÂÓ›˜ ∆· ›‰· IL-8 ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙ· Ô‡Ú· 69 ‚ÚÂÊÒÓ ËÏÈΛ·˜ 1 ÌËÓfi˜ ¤ˆ˜ 1 ¤ÙÔ˘˜. ŸÏ· Ù· ·È‰È¿ Ô˘ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË ‹Ù·Ó ÂχıÂÚ· Ô˘ÚÔÏԛ̈͢ ÁÈ· ÙÚÂȘ ÙÔ˘Ï¿¯ÈÛÙÔÓ Â‚‰ÔÌ¿‰Â˜, fiˆ˜ ηıÔÚ›ÛÙËΠ·fi ÙËÓ ÎÏÈÓÈ΋ ÙÔ˘˜ ÂÈÎfiÓ·, ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, Ù˘ Ù·¯‡ÙËÙ·˜ ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ Î·È C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ ηıÒ˜ Î·È ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ (1113). ∏ ‰È¿ÁÓˆÛË Ù˘ Ô˘ÚÔÏԛ̈͢ ‚·Û›ÛÙËΠÛÙËÓ ·ÚÔ˘Û›· ‚·ÎÙËÚÈÔ˘Ú›·˜, Ë ÔÔ›· ÔÚ›ÛÙËΠˆ˜ ÔÔÈ·‰‹ÔÙ ·Ó¿Ù˘ÍË ‚·ÎÙËÚ›ˆÓ Û ηÏÏȤÚÁÂÈ· ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ ·fi ˘ÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË, ÌÔÓÔ·Ó¿Ù˘ÍË ÙÔ˘Ï¿¯ÈÛÙÔÓ 105 ‚·ÎÙËÚ›ˆÓ/ml Û ηÏÏȤÚÁÂÈ· ‰‡Ô ‰È·‰Ô¯ÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ Ô‡ÚˆÓ ‹ ·Ó¿Ù˘ÍË ÙÔ˘Ï¿¯ÈÛÙÔÓ 104 ‚·ÎÙËÚ›ˆÓ/ml Û ηÏÏȤÚÁÂÈ· ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ ·fi ηıÂÙËÚÈ·ÛÌfi Ù˘ ·ÛÙ˘. ∆· ‚Ú¤ÊË Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û 3 ÔÌ¿‰Â˜: ÔÌ¿‰· ∞, ‚Ú¤ÊË Ì ·Ô‰Â‰ÂÈÁ̤ÓË ∫√¶ (37 ‚Ú¤ÊË ËÏÈΛ·˜ 0,13 ¤ˆ˜ 0,99 ÂÙÒÓ, ‰È¿ÌÂÛË ÙÈÌ‹ 0,36), ÔÌ¿‰· µ, ‚Ú¤ÊË Ì ·Ó·ÌÓËÛÙÈÎfi Ô˘ÚÔÏԛ̈͢, ·ÏÏ¿ ·ÚÓËÙÈÎfi ¤ÏÂÁ¯Ô ÁÈ· ∫√¶ (13 ‚Ú¤ÊË ËÏÈΛ·˜ 0,24 ¤ˆ˜ 0,70 ÂÙÒÓ, ‰È¿ÌÂÛË ÙÈÌ‹ 0,39), Î·È ÔÌ¿‰· °, ‚Ú¤ÊË ¯ˆÚ›˜ ·Ó·ÌÓËÛÙÈÎfi ÁÓˆÛÙ‹˜ ÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ ηٿÛÙ·Û˘ Ô˘ ı· ÌÔÚÔ‡Û ӷ ÂËÚ¿ÛÂÈ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (19 ‚Ú¤ÊË ËÏÈΛ·˜ 0,08 ¤ˆ˜ 0,96 ÂÙÒÓ, ‰È¿ÌÂÛË ÙÈÌ‹ 0,28). ∏ ÌÂϤÙË ÂÁÎÚ›ıËΠ·fi ÙËÓ ∂ÈÙÚÔ‹ ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ∂ÈÛÙËÌÔÓÈÎÔ‡ ™˘Ì‚Ô˘Ï›Ô˘ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. ∂Ú¢ÓËÙÈÎfi ÚˆÙfiÎÔÏÏÔ ∆· ‰Â›ÁÌ·Ù· ·fi Ù· ‚Ú¤ÊË ÙˆÓ ÔÌ¿‰ˆÓ ∞ Î·È µ Û˘ÁÎÂÓÙÚÒıËÎ·Ó Î·Ù¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÌÂÙ¿ ·fi ·Ô‰Â‰ÂÈÁ̤ÓË Ô˘ÚÔÏԛ̈ÍË ‹ ÌÂÙ¿ ·fi ‰È·›ÛÙˆÛË ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ¤ÁÈÓ ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ·fi ÙË ‰È¿ÁÓˆÛË Ù˘ Ô˘ÚÔÏԛ̈͢. ∏ ·ÚÔ˘Û›· Î·È Ô ‚·ıÌfi˜ ∫√¶ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì ÎÏ·ÛÈ΋ ·ÓÈÔ‡Û· ΢ÛÙÂÔ-Ô˘ÚËıÚÔÁÚ·Ê›· ηٿ ÙËÓ Ô‡ÚËÛË, Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ6-8 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË Ïԛ̈ÍË. ∏ ·ÏÈÓ‰ÚfiÌËÛË ‚·ıÌÔÏÔÁ‹ıËΠ·fi 0-V Û‡Ìʈӷ Ì ÙË ¢ÈÂıÓ‹ ∂ÈÙÚÔ‹ ÁÈ· ÙË ªÂϤÙË Ù˘ ¶·ÏÈÓ‰ÚfiÌËÛ˘ (International Reflux Study Committee) (1,22). ™Â ÂÚ›ÙˆÛË ·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÏÈÓ‰ÚfiÌËÛ˘, ·Ó·Ê¤ÚÂÙ·È Ô ·ÓÙ›ÛÙÔȯԘ ·ıÚÔÈÛÙÈÎfi˜ ·ÚÈıÌfi˜. ∏ ·ÚÔ˘Û›· Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÂÁ¯˘Ì·ÙÈÎÒÓ ‚Ï·‚ÒÓ ÚÔÛ‰ÈÔÚ›ÛÙËΠ3-6 Ì‹Ó˜ ÌÂÙ¿ ÙË Ïԛ̈ÍË Ì ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì ‰ÈÌÂÚηÙÔÛÔ˘ÎÎÈÓÈÎfi Ô͇ ÛËÌ·Ṳ̂ÓÔ Ì Ù¯ӋÙÈÔ 99m (DMSA). ø˜ ÓÂÊÚÈ΋ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë ÔÚ›ÛÙËΠÙÔ ÂÛÙÈ·Îfi ‹ ÔÏ˘ÂÛÙÈ·Îfi ¤ÏÏÂÈÌÌ· Ï‹ÚˆÛ˘ ‹ Ë Û¯ÂÙÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· οو ·fi 45%. ∏ ÓÂÊÚÈ΋ Ô˘Ï‹ ÔÚ›ÛÙËΠˆ˜ ¤ÏÏÂÈÌÌ· ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÓÂÊÚÈÎfi ÂÚ›ÁÚ·ÌÌ· (1,23). ∏ ÔÌ¿‰· ° ÂÚÈÂÏ¿Ì‚·Ó ‚Ú¤ÊË ÂχıÂÚ· ·Ó·ÌÓËÛÙÈÎÔ‡ Ô˘ÚÔÏԛ̈͢ ‹ ¿ÏÏ˘ ÁÓˆÛÙ‹˜ ˘ÔΛÌÂÓ˘ ηٿÛÙ·Û˘ Ô˘ ı· ÌÔÚÔ‡Û ӷ ÂËÚ¿ÛÂÈ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ IL-8 ™ÙË ÌÂϤÙË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˘ÔÏÂÈÌÌ·ÙÈο ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ ·fi ·˘Ù¿ Ô˘ ›¯·Ó ÏËÊı› ÁÈ· ÙÔÓ Û˘Ó‹ıË ¤ÏÂÁ¯Ô
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·201
201
IL-8 Î·È Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË
™Ù·ÙÈÛÙÈ΋ °È· ÙËÓ ·Ó¿Ï˘ÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÌË ·Ú·ÌÂÙÚÈΤ˜ ‰ÔÎÈ̷ۛ˜ Kruskal-Wallis Î·È Mann-Whitney Î·È Ë ‰ÔÎÈÌ·Û›· Û˘Û¯¤ÙÈÛ˘ Spearman. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÂÊ·ÚÌfiÛÙËΠÙÔ Û˘Ì‚·ÙÈÎfi Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ p<0,05.
∞ÔÙÂϤÛÌ·Ù· ∆· ‚Ú¤ÊË ÛÙȘ ÔÌ¿‰Â˜ ∞ Î·È µ ‹Ù·Ó ÂχıÂÚ· Ô˘ÚÔÏԛ̈͢ ÁÈ· ‰È¿ÛÙËÌ· 3 ¤ˆ˜ 48 (‰È¿ÌÂÛË ÙÈÌ‹ 5) ‚‰ÔÌ¿‰ˆÓ Î·È 3 ¤ˆ˜ 10,3 (‰È¿ÌÂÛË ÙÈÌ‹ 5) ‚‰ÔÌ¿‰ˆÓ, ·ÓÙ›ÛÙÔȯ·, ÚÈÓ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ IL-8. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔÓ ÂχıÂÚÔ Ô˘ÚÔÏԛ̈͢ ¯ÚfiÓÔ ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ (p=0,460). ∆· 35 ·fi Ù· 37 ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ∞ ›¯·Ó ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ ÚÈÓ ÙË ‰È·›ÛÙˆÛË Ù˘ ∫√¶. ™Â 2 ‚Ú¤ÊË ËÏÈΛ·˜ 3 ÌËÓÒÓ, Ë ∫√¶ ›¯Â ‰È·ÁÓˆÛı› ÛÙ· Ï·›ÛÈ· ‰ÈÂÚ‡ÓËÛ˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Î·È Î·Ó¤Ó· ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ ‰ÂÓ Â›¯Â ÙÂÎÌËÚȈı› ¤ˆ˜ ÙÔÓ ¯ÚfiÓÔ Ù˘ ÌÂϤÙ˘. ™ÙËÓ ÔÌ¿‰· ∞, Ë ·ÏÈÓ‰ÚfiÌËÛË ‹Ù·Ó ‰ÂÍÈ¿ Û 10 ‚Ú¤ÊË, ·ÚÈÛÙÂÚ¿ Û 10 Î·È ·ÌÊÔÙÂÚfiÏ¢ÚË Û 17. ¡ÂÊÚÈ΋ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë ÙÂÎÌËÚÈÒıËΠ۠20 ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ∞ Î·È Û ηӤӷ ·fi Ù· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ µ. √È ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘ Ô‡ÚˆÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ∞, µ Î·È ° (‰È¿ÌÂÛ˜ ÙÈ̤˜ 1,06, 1,5 Î·È 1,15 Ìmol/mL ·ÓÙ›ÛÙÔȯ·, p=0,070). √È ‰È¿ÌÂÛ˜ ÙÈ̤˜ IL-8/ÎÚ·ÙÈÓ›ÓË (pg/Ìmol) ‹Ù·Ó 16,97 (0,00-3.874) ÛÙËÓ ÔÌ¿‰· ∞, 4,47 (0,01-386) ÛÙËÓ ÔÌ¿‰· µ Î·È 4,19 (0,00-55,6) ÛÙËÓ ÔÌ¿‰· ° (∂ÈÎfiÓ· 1). √È ÙÈ̤˜ IL-8/ÎÚ·ÙÈÓ›ÓË ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ ÛÙËÓ ÔÌ¿‰· ∞ ÙfiÛÔ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· µ (p=0,0491) fiÛÔ Î·È Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ° (p=0,0095), ¯ˆÚ›˜ Ó· ·Ú·ÙËÚËı› ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ Ù˘ ÔÌ¿‰·˜ µ Î·È Ù˘ ÔÌ¿‰·˜ ° (p=0,759). ™ÙËÓ ÔÌ¿‰· ∞ ‰ÂÓ Î·Ù·‰Â›¯ÙËÎ·Ó ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÙÈÌÒÓ IL8/ÎÚ·ÙÈÓ›ÓË Û ۯ¤ÛË Ì ÙËÓ ·ÚÔ˘Û›· ÓÂÊÚÈ΋˜ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘ (p=0,272), ÓÂÊÚÈ΋˜ Ô˘Ï‹˜ (p=0,266), ‹ Ì ÙÔÓ ‚·ıÌfi Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (Spearman r=-0,049, p=0,775) ‹ ÙÔÓ ¯ÚfiÓÔ Ô˘ ÌÂÛÔÏ¿‚ËÛ ·fi ÙËÓ ÙÂÏÂ˘Ù·›· Ô˘ÚÔÏԛ̈ÍË (Spearman r=-0,091, p=0,601). ™ÙËÓ ∂ÈÎfiÓ· 2 ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë Î·Ì‡ÏË Ù‡Ô˘
3900
™˘ÁÎÂÓÙÚÒÛÂȘ IL-8/ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ
ÙˆÓ ‚ÚÂÊÒÓ. ∆· ‰Â›ÁÌ·Ù· ηٷ„‡¯ıËÎ·Ó ÛÙÔ˘˜ -70ÔC ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË Ê˘ÁÔΤÓÙÚËÛË Î·È ·Ô„‡¯ıËÎ·Ó ÚÈÓ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ IL-8. √È Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ IL-8 ÌÂÙÚ‹ıËÎ·Ó Ì ÔÛÔÙÈ΋ ̤ıÔ‰Ô ELISA (quantitative sandwich enzyme-linked immunosorbent assay, R&D systems, Abingdon, UK). ŸÏ˜ ÔÈ ÌÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó ÂȘ ‰ÈÏÔ‡Ó. ™‡Ìʈӷ Ì ÙÔÓ Î·Ù·Û΢·ÛÙ‹, ÙÔ Î·ÙÒÙÂÚÔ fiÚÈÔ ·Ó›¯Ó¢Û˘ ÁÈ· ÙËÓ IL-8 ‹Ù·Ó <10 pg/mL. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ıÔ‡Ó ÂȉڿÛÂȘ Ù˘ Û˘Ì‡ÎÓˆÛ˘ ÙˆÓ Ô‡ÚˆÓ ÛÙËÓ ÙÈÌ‹ Ù˘ IL-8, Ù· ›‰· IL-8 ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ÏfiÁÔ˜ IL-8/ ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ (pg/Ìmol ÎÚ·ÙÈÓ›Ó˘) (6,11,17).
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∂ÈÎfiÓ· 1. ™˘ÁÎÂÓÙÚÒÛÂȘ IL-8/ÎÚ·ÙÈÓ›ÓË ÛÙ· Ô‡Ú· ‚ÚÂÊÒÓ Ì ·Ô‰Â‰ÂÈÁ̤ÓË ∫√¶ (ÔÌ¿‰· ∞), ‚ÚÂÊÒÓ Ì ·Ó·ÌÓËÛÙÈÎfi Ô˘ÚÔÏԛ̈͢ ·ÏÏ¿ ¯ˆÚ›˜ ∫√¶ (ÔÌ¿‰· µ) Î·È ‚ÚÂÊÒÓ Ì ÂχıÂÚÔ ·Ó·ÌÓËÛÙÈÎfi ·ı‹ÛÂˆÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (ÔÌ¿‰· °).
ROC (receiver-operator curve) Ô˘ ÚԤ΢„ ·fi ÙËÓ ·ÂÈÎfiÓÈÛË Ù˘ ¢·ÈÛıËÛ›·˜ Î·È Ù˘ ÂȉÈÎfiÙËÙ·˜ Û ‰È·ÊÔÚÂÙÈΤ˜ ÙÈ̤˜ ÙÔ˘ ÏfiÁÔ˘ IL-8/ÎÚ·ÙÈÓ›ÓË ÛÙ· Ô‡Ú·. ∞fi ÙËÓ Î·Ì‡ÏË ÚÔ·ÙÂÈ fiÙÈ ÛÙËÓ ÙÈÌ‹ 5 pg/Ìmol ÙÔ˘ ÏfiÁÔ˘ IL-8/ÎÚ·ÙÈÓ›ÓË, Ë Â˘·ÈÛıËÛ›· ·˘ÙÔ‡ ÙÔ˘ ‰Â›ÎÙË ÛÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶ Â›Ó·È 73% Î·È Ë ÂȉÈÎfiÙËÙ· Â›Ó·È 56%. °È· ÙËÓ ›‰È· ÙÈÌ‹ IL8/ÎÚ·ÙÈÓ›ÓË, Ë ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· ˘ÔÏÔÁ›ÛÙËΠ۠66% Î·È Ë ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· Û 64%. ªÂ ÙÔÓ ‰È·ÁÓˆÛÙÈÎfi Ô˘‰fi ÛÙËÓ ÙÈÌ‹ 10 pg/Ìmol ÙÔ˘ ÏfiÁÔ˘ IL-8/ÎÚ·ÙÈÓ›ÓË ÛÙ· Ô‡Ú·, Ë Â˘·ÈÛıËÛ›· ·˘ÙÔ‡ ÙÔ˘ ‰Â›ÎÙË ÛÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶ Â›Ó·È 62%, Ë ÂȉÈÎfiÙËÙ· Â›Ó·È 69%, Ë ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· 70% Î·È Ë ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· 61%. ∏ ¯Ú‹ÛË ˘„ËÏfiÙÂÚˆÓ ÙÈÌÒÓ ÙÔ˘ ÏfiÁÔ˘ IL8/ÎÚ·ÙÈÓ›ÓË ·˘Í¿ÓÂÈ ÙËÓ ÂȉÈÎfiÙËÙ· ·ÏÏ¿ ÌÂÈÒÓÂÈ Ú·Á‰·›· ÙËÓ Â˘·ÈÛıËÛ›·. ∂Ó‰ÂÈÎÙÈο ÁÈ· ÙÈ̤˜ IL8/ÎÚ·ÙÈÓ›ÓË 100 pg/Ìmol, Ë ÂȉÈÎfiÙËÙ· ·˘Í‹ıËΠÛÙÔ 97%, ·ÏÏ¿ Ë Â˘·ÈÛıËÛ›· ÌÂÈÒıËΠÛÙÔ 27%.
™˘˙‹ÙËÛË ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ ÂÚ¢ÓËÙÈÎfi ÂӉȷʤÚÔÓ Û¯ÂÙÈο Ì ÙËÓ ∫√¶ ÛÙÚ¤ÊÂÙ·È ÛÙËÓ ·Ó·˙‹ÙËÛË ÌÂıfi‰ˆÓ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ 2007;70:199-204
Pediatri May-Jun 07
24-05-07
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∂ȉÈÎfiÙËÙ· (%) ∂ÈÎfiÓ· 2. ∂˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÙÈÌÒÓ IL-8/ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ (pg/Ìmol) ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶ Û ‚Ú¤ÊË ¯ˆÚ›˜ ÚfiÛÊ·ÙË Ô˘ÚÔÏԛ̈ÍË.
ηÙËÁÔÚ›· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∫√¶, ÓÂÊÚÈ΋ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë Î·È ÓÂÊÚÔ¿ıÂÈ· ·fi ·ÏÈÓ‰ÚfiÌËÛË. √ Û˘Ó‰˘·ÛÌfi˜ ÎÏÈÓÈÎÒÓ Î·È ·ÏÒÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Â›¯Â ̤ÙÚÈ· ÌfiÓÔ ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ Î·Ù‡ı˘ÓÛË ·˘Ù‹ (24). ∆ÂÏÂ˘Ù·›·, ÔÈ ÂÚ¢ÓËÙÈΤ˜ ÚÔÛ¿ıÂȘ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙÔ˘˜ ‰Â›ÎÙ˜ Î·È ÙÔ˘˜ ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÊÏÂÁÌÔÓ‹˜. ∏ ÚÔηÏÛÈÙÔÓ›ÓË (PCT), ¤Ó·˜ ·fi ÙÔ˘˜ ÙÂÏÂ˘Ù·›· ·Ó·ÁÓˆÚÈÛı¤ÓÙ˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, ÌÂÏÂÙ‹ıËΠ۠‚Ú¤ÊË Î·È Ó‹È· Ì ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ Î·È Ù· ›‰¿ Ù˘ ‚Ú¤ıËÎ·Ó ·˘ÍË̤ӷ ÛÙÔÓ ÔÚfi ·È‰ÈÒÓ Ì ∫√¶ (25,26), fï˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ÁÈ· ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ‰Â›ÎÙË Û ·È‰È¿ Ì ∫√¶ ¯ˆÚ›˜ Ô˘ÚÔÏԛ̈ÍË. ∏ ÌÂϤÙË Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È ÌÂÛÔÏ·‚ËÙÒÓ, fiˆ˜ Ë ÈÓÙÂÚÏ¢ΛÓË-6 (IL-6) Î·È Ô ˘Ô‰Ô¯¤·˜ ÙÔ˘ ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ ÙÔ˘ fiÁÎÔ˘ 1 (TNF-1) ‰ÂÓ Î·Ù¤‰ÂÈÍ ȉȷ›ÙÂÚË ÌÂÙ·‚ÔÏ‹ Û ·È‰È¿ Ì ∫√¶ ¯ˆÚ›˜ ÚfiÛÊ·ÙË ÔÍ›· Ïԛ̈ÍË (5). ∏ ·ÚÔ‡Û· ÌÂϤÙË ˘Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ ·ÎfiÌ· Î·È ¯ˆÚ›˜ ÚfiÛÊ·ÙË Ô˘ÚÔÏԛ̈ÍË, Ù· ›‰· Ù˘ IL-8 ÛÙ· Ô‡Ú· ·Ú·Ì¤ÓÔ˘Ó ˘„ËÏfiÙÂÚ· ÛÙ· ‚Ú¤ÊË Ì ∫√¶ Û˘ÁÎÚÈÙÈο Ì ٷ ‚Ú¤ÊË Ì ·Ó·ÌÓËÛÙÈÎfi Ô˘ÚÔÏԛ̈͢ ¯ˆÚ›˜ ∫√¶ Î·È Ù· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. ∞˘ÍË̤ӷ ›‰· IL-8 ÛÙ· Ô‡Ú· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Û ·È‰È¿ Ì ‰È¿ÊÔÚ˜ ÓÂÊÚÈΤ˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ‰È·Ù·Ú·¯¤˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ Ô˘ÚÔÏԛ̈͢ (6,10,12-15), Î·È Ë ÙÈÌ‹ 200 pg/ml ¤¯ÂÈ ÚÔÙ·ı› ˆ˜ ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ô˘ÚÔÏԛ̈͢ (15). ∏ ·¤ÎÎÚÈÛË Ù˘ IL-8 ÛÙ· Ô‡Ú· ÌÂÈÒÓÂÙ·È ÁÚ‹ÁÔÚ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Paediatriki 2007;70:199-204
Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ (27), ‡ÚËÌ· Ô˘ ÂȂ‚·ÈÒıËÎÂ Î·È ÛÙËÓ ÔÌ¿‰· µ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÂÚ·ÈÙ¤Úˆ fiÙÈ ÙÈ̤˜ IL-8/ÎÚ·ÙÈÓ›ÓË ÌÂÁ·Ï‡ÙÂÚ˜ ÙˆÓ 5-10 pg/Ìmol ¤¯Ô˘Ó ÈηÓÔÔÈËÙÈ΋ ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÛÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶. À„ËÏfiÙÂÚ˜ ÙÈ̤˜ ·˘Í¿ÓÔ˘Ó ÙËÓ ÂȉÈÎfiÙËÙ·, ÌÂÈÒÓÔÓÙ·˜ fï˜ ÛËÌ·ÓÙÈο ÙËÓ Â˘·ÈÛıËÛ›·. Œ¯Ô˘Ó ‹‰Ë ÂÚÈÁÚ·Ê› ·˘ÍË̤ӷ ›‰· IL-8 ÛÙ· Ô‡Ú· ·È‰ÈÒÓ Ì ∫√¶ Î·È ÓÂÊÚÈΤ˜ Ô˘Ï¤˜ ¯ˆÚ›˜ ÚfiÛÊ·ÙË Ô˘ÚÔÏԛ̈ÍË (9,14). ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ‚ÚÂÊÒÓ Ì ∫√¶ Î·È ‚ÚÂÊÒÓ Ì ·Ó·ÌÓËÛÙÈÎfi Ô˘ÚÔÏԛ̈͢ ·ÏÏ¿ fi¯È ∫√¶ ‹ ‚ÚÂÊÒÓ ¯ˆÚ›˜ ·Ó·ÌÓËÛÙÈÎfi ÓfiÛÔ˘ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, Î·È ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÙȘ ·˘ÍË̤Ó˜ ÙÈ̤˜ IL-8/ÎÚ·ÙÈÓ›ÓË ÙˆÓ Ô‡ÚˆÓ ˆ˜ ·ÍÈfiÈÛÙÔ ‰È·ÁÓˆÛÙÈÎfi ‰Â›ÎÙË Ù˘ ∫√¶. ¢Â‰Ô̤ÓÔ˘ fiÙÈ Ù· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ∞ ÂÌÊ¿ÓÈ˙·Ó ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë/ÓÂÊÚÈ΋ Ô˘Ï‹ Û ۷ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·fi Ù· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ µ, Ë ·˘ÍË̤ÓË IL-8 ı· ÌÔÚÔ‡Û ÂӉ¯Ô̤ӈ˜ Ó· ·Ô‰Ôı› ÛÙËÓ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë Ì¿ÏÏÔÓ ·Ú¿ ÛÙËÓ Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË. øÛÙfiÛÔ, ÛÙ· ‚Ú¤ÊË Ù˘ ÔÌ¿‰·˜ ∞ ‰ÂÓ ‰È·ÈÛÙÒıËΠۯ¤ÛË ÙˆÓ ÂȤ‰ˆÓ IL-8 Ì ÙËÓ ‡·ÚÍË ‹ ÌË ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘. √ˆÛ‰‹ÔÙÂ, ÌÂϤÙ˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ÏËı˘ÛÌfi ı· ‹Ù·Ó ÔχÙÈ̘ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ÔÚÈÛÙÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ Û¯ÂÙÈο Ì ·˘Ùfi ÙÔ Ôχ ÂӉȷʤÚÔÓ ÂÚÒÙËÌ·. ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÂÈϤÔÓ fiÙÈ Ë ÊÏÂÁÌÔÓ҉˘ ‰È·‰Èηۛ· ÂÍ·ÎÔÏÔ˘ı› Ó· ˘Ê›ÛÙ·Ù·È ÛÙËÓ ∫√¶ Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ Ô˘ÚÔÏԛ̈͢, Û ·ÓÙ›ıÂÛË Ì ÙËÓ ¿Ô„Ë fiÙÈ Ë ·ÏÈÓ‰ÚfiÌËÛË Ô‡ÚˆÓ ÛÙÂ›ÚˆÓ ÌÈÎÚÔ‚›ˆÓ ‰ÂÓ ‰ËÌÈÔ˘ÚÁ› ÓÂÊÚÈ΋ ‚Ï¿‚Ë (3). ∏ ·‡ÍËÛË Ù˘ IL-8 ÛÙ· ·È‰È¿ Ì ∫√¶ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÓÂÊÚÈ΋˜ Î·È fi¯È Û˘ÛÙËÌ·ÙÈ΋˜ ÚÔ¤Ï¢Û˘, ·ÊÔ‡ Ù· ›‰· IL-8 ÛÙÔÓ ÔÚfi ·È‰ÈÒÓ Ì ∫√¶ ¯ˆÚ›˜ Ô˘ÚÔÏԛ̈ÍË ¤¯Ô˘Ó ·Ó·ÊÂÚı› Ê˘ÛÈÔÏÔÁÈο (13,20). ∏ ·‡ÍËÛË ·˘Ù‹ ‰ÂÓ ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Û ˘ÔÏÂÈfiÌÂÓË ÊÏÂÁÌÔÓ‹ ÏfiÁˆ Ù˘ ÚÔËÁËı›۷˜ Ô˘ÚÔÏԛ̈͢, ηıÒ˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ۠·È‰È¿ Ì ÚÔËÁËı›۷ Ô˘ÚÔÏԛ̈ÍË ¯ˆÚ›˜ ∫√¶. ∂ÈϤÔÓ, Â›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÌÂٷ͇ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘, Ë ‰Â‡ÙÂÚË ˘„ËÏfiÙÂÚË ÙÈÌ‹ IL-8 ·Ú·ÙËÚ‹ıËΠ۠¤Ó· ‚Ú¤ÊÔ˜ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ∫√¶ Î·È ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi Ô˘ÚÔÏԛ̈͢. ∏ ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ҉˘ ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË Ô˘ Û¯ÂÙ›˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ÙË ÓÂÊÚÔ¿ıÂÈ· Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ ·Ú¿ Ì ÙËÓ ›‰È· ÙËÓ ·ÏÈÓ‰ÚfiÌËÛË, ·ÔÙÂÏ› ÂӉ¯Ô̤ӈ˜ ÌÈ· ÂÍ‹ÁËÛË ÁÈ· Ù· ·˘ÍË̤ӷ ›‰· IL-8 ÛÙ· ·È‰È¿ Ì ∫√¶, Ô˘ ÌÔÚ› Ó· Â›Ó·È ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ‚·ıÌfi Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘.
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∏ ÌÂϤÙË ÂÈÎÂÓÙÚÒıËΠÛÙ· ÌÈÎÚ¿ ‚Ú¤ÊË, ÂÂȉ‹ ·˘Ù‹ Ë ËÏÈÎȷ΋ ÔÌ¿‰· ·ÓÙÈÌÂÙˆ›˙ÂÈ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ (1). ∏ ·Ó›¯Ó¢ÛË ∫√¶, ¯ÚfiÓÈ·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È ÓÂÊÚÈ΋˜ Ô˘Ï‹˜ ‚·Û›˙ÂÙ·È Û‹ÌÂÚ· Û ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, fiˆ˜ Ù· Ú·‰ÈÔ˚ÛfiÙÔ· Î·È Ë Î˘ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›·, Ô˘ Û˘Ó¿ÁÔÓÙ·È ¤ÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›·, ÂÂÌ‚·ÙÈÎfiÙËÙ· Î·È ÛËÌ·ÓÙÈÎfi ÎfiÛÙÔ˜. ∏ ¯Ú‹ÛË ÌË ÂÂÌ‚·ÙÈÎÒÓ ÌÂıfi‰ˆÓ ı· ›¯Â ·Ó·ÌÊ›‚ÔÏ· ÛËÌ·ÓÙÈο ÔʤÏË. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È Ì›· ÔχÙÈÌË ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ÁÈ· ÙË ‰È¢ÎÚ›ÓÈÛË Ù˘ ·Ó·ÙÔÌ›·˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ˆÛÙfiÛÔ Â›Ó·È ÁÓˆÛÙ‹ Ë ¯·ÌËÏ‹ ÙÔ˘ ¢·ÈÛıËÛ›· ÛÙË ‰È¿ÁÓˆÛË Ù˘ ∫√¶, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯Ú‹Û˘ ÙÔ˘ ˆ˜ ·ÓȯÓ¢ÙÈ΋˜ ÌÂıfi‰Ô˘ (28). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ IL-8 ÛÙ· Ô‡Ú· Ê·›ÓÂÙ·È Ó· ·ÔÙÂÏ› ˘ÔÛ¯fiÌÂÓÔ ÌË ÂÂÌ‚·ÙÈÎfi ‰È·ÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÁÈ· ÙËÓ ∫√¶ ÛÙ· ÌÈÎÚ¿ ‚Ú¤ÊË. √ ‰Â›ÎÙ˘ ·˘Ùfi˜ ‰ÂÓ Â›Ó·È ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜. ∆· ›‰· Ù˘ IL-8 ÌÔÚ› Ó· ‚ÚÂıÔ‡Ó ·˘ÍË̤ӷ ÛÙÔ Ï·›ÛÈÔ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ ÛÙÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ·, ¿ÏÏ˘ ·ıÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÎÔÏ›Ùȉ·˜/Ô˘ÚËıÚ›Ùȉ·˜ (14), ‹ Ô˘ÚÔÏԛ̈͢ Ô˘ ‰ÂÓ ·ÓȯÓ‡ÙËÎÂ. ¶Èı·ÓfiÓ, ÙÔ ÙÂÏÂ˘Ù·›Ô ÂӉ¯fiÌÂÓÔ ÂÍËÁ› ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË IL-8 Û ¤Ó· ‚Ú¤ÊÔ˜ Ù˘ ¯ˆÚ›˜ ∫√¶ ÔÌ¿‰·˜ µ (∂ÈÎfiÓ· 1). ∆¤ÏÔ˜, Ë ÌÂϤÙË ÂÚȤϷ‚ ÌfiÓÔ ‚Ú¤ÊË, Û˘ÓÂÒ˜ Â›Ó·È ·ÌÊ›‚ÔÏÔ Î·Ù¿ fiÛÔ Ù· Â˘Ú‹Ì·Ù¿ Ù˘ ÈÛ¯‡Ô˘Ó ÁÈ· ÌÂÁ·Ï‡ÙÂÚ· Ó‹È· Î·È ·È‰È¿. ¶·Ú¿ ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ·˘ÙÔ‡˜, Ë Ì¤ÙÚËÛË Ù˘ IL-8 ÛÙ· Ô‡Ú· ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ Ô˘ÚÔÏԛ̈͢ ÌÔÚ› Ó· ÚÔÛʤÚÂÈ Ô˘ÛÈÒ‰Ë ‰È·ÁÓˆÛÙÈ΋ ‚Ô‹ıÂÈ· ˆ˜ ·ÓȯÓ¢ÙÈ΋ ̤ıÔ‰Ô˜ ηٿ ÙËÓ ·Ó·ÁÓÒÚÈÛË ‚ÚÂÊÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙËÓ Î·ÙËÁÔÚ›· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∫√¶, Ì ·ÒÙÂÚÔ ÛÎÔfi ÙËÓ ·˘ÛÙËÚfiÙÂÚË ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ Ô˘ ı· ˆÊÂÏËıÔ‡Ó ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›·˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103:843-852. 2. Stefanidis CJ, Siomou E. Imaging strategies for vesicoureteral reflux diagnosis. Pediatr Nephrol 2007, Jan 10; [Epub ahead of print]. 3. Mak RH, Kuo HJ. Primary ureteral reflux: emerging insights from molecular and genetic studies. Curr Opin Pediatr 2003;15:181-185. 4. Smellie JM. Vesico-ureteric reflux. Acta Paediatr 1999;88: 1182-1183. 5. Hellerstein S. Long-term consequences of urinary tract infections. Curr Opin Pediatr 2000;12:125-128. 6. Ninan GK, Jutley RS, Eremin O. Urinary cytokines as markers of reflux nephropathy. J Urol 1999;162:1739-1742.
7. Kramer, SA. The role of newer modalities in the diagnosis of vesicoureteral reflux. J Urol 1996;155:683-684. 8. Hollowell JG, Greenfield SP. Screening siblings for vesicoureteral reflux. J Urol 2003;168:2138-2141. 9. Jahnukainen T, Chen M, Celsi G. Mechanisms of renal damage owing to infection. Pediatr Nephrol 2005;20:1043-1053. 10. Haraoka M, Senoh K, Ogata N, Furukawa M, Matsumoto T, Kumazawa J. Elevated inerleukin-8 levels in the urine of children with renal scarring and/or vesicoureteral reflux. J Urol 1996;155:678-680. 11. Tullus K, Escobar-Billing R, Fituri O, Burman LG, Karlsson A, Wikstad I et.al. Interleukin-1 alpha and interleukin1 receptor antagonist in the urine of children with acute pyelonephritis and relation to renal scarring. Acta Paediatr 1996;85:158-162. 12. Tullus K, Fituri O, Linne T, Escobar-Billing R, Wikstad I, Karlsson A et al. Urine interleukin-6 and interleukin-8 in children with acute pyelonephritis, in relation to DMSA scintigraphy in the acute phase and at 1-year follow-up. Pediatr Radiol 1994;24:513-515. 13. Benson M, Jodal U, Agace W, Hellstrom M, Marild S, Rosberg S et al. Interleukin (IL)-6 and IL-8 in children with febrile urinary tract infection and asymptomatic bacteriuria. J Infect Dis 1996;174:1080-1084. 14. Jacobson SH, Lu Y, Brauner A. Tumour necrosis factor soluble receptors I and II and interleukin-1 receptor antagonist in acute pyelonephritis in relation to bacterial virulence-associated traits and renal function. Nephrol Dial Transplant 1996;11:2209-2214. 15. Rao WH, Evans GS, Finn A. The significance of interleukin 8 in urine. Arch Dis Child 2001;85:256-262. 16. Svensson M, Irjala H, Alm P, Holmqvist B, Lundstedt AC, Svanborg C. ¡atural history of renal scarring in susceptible mIL-8Rh-/- mice. Kidney Int 2005;67:103-110. 17. Kassir K, Vargas-Shiraishi O, Zaldivar F, Berman M, Singh J, Arrieta A. Cytokine profiles of pediatric patients treated with antibiotics for pyelonephritis: potential therapeutic impact. Clin Diagn Lab Immunol 2001;8:1060-1063. 18. Roilides E, Papachristou F, Gioulekas E, Tsaparidou S, Karatzas N, Sotiriou J, Tsiouris J. Increased urine interleukin6 concentrations correlate with pyelonephritic changes on 99mTc-dimercaptosuccinic acid scans in neonates with urinary tract infections. J Infect Dis 1999;180:904-907. 19. Krzemien G, Roszkowska-Blaim M, Kostro I, Szmigielska A, Karpinska M, Sieniawska M et. al. Urinary levels of interleukin-6 and interleukin-8 in children with urinary tract infections to age 2. Med Sci Monit 2004;10:593-597. 20. Jutley RS, Youngson GG, Eremin O, Ninan GK. Serum cytokine profile in reflux nephropathy. Pediatr Surg Int 2000;16:64-68. 21. Godaly G, Bergsten G, Hang L, Fisher H, Frendeus B, Lundstedt AC et al. Neutrophil recruitment, chemokine receptors, and resistance to mucosal infection. J Leukoc Biol 2001;69:899-906. 22. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteral reflux. International Reflux Study of Children. Pediatr Radiol 1985;15:105-109. 23. Christian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography. Arch Dis Child 2000;82:376-380. ¶·È‰È·ÙÚÈ΋ 2007;70:199-204
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ª. ªÈÙÛÒÚË Î·È Û˘Ó.
24. Leroy S, Marc E, Adamsbaum C, Gendrel D, Breart G, Chalumeau M. Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule. Arch Dis Child 2006;91:241-244. 25. Leroy S, Adamsbaum C, Marc E, Moulin F, Raymond J, Gendrel D et al. Procalcitonin as a predictor of vesicoureteral reflux in children with a first febrile urinary tract infection. Pediatrics 2005;115:e706-709. 26. Leroy S, Romanello C, Galetto-Lacour A, Smolkin V, Korczowski B, Rodrigo C, et al. Procalcitonin to reduce the
number of unnecessary cystographies in children with a urinary tract infection: a European validation study. J Pediatr 2007;150:89-95. 27. Jantausch BA, O’Donnell R, Wiedermann BL. Urinary interleukin-6 and interleukin-8 in children with urinary tract infection. Pediatr Nephrol 2000;15:236-240. 28. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald, ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003;348:195-202.
™ˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÙÔ˘ Quiz ÁÈ· ÙÔ ¿ÚıÚÔ “™˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ó¢ÌfiÓˆÓ” 1. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ÛÙȘ ÚÒÙ˜ ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË; Á. ™˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË 2. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÈÛÓ¢ÛÙÈÎÔ‡ ÛÈÁÌÔ‡ ηÈ/‹ ÂÎÓ¢ÛÙÈÎÔ‡ ÌÔÓÔʈÓÈÎÔ‡ Û˘ÚÈÁÌÔ‡ ÛÙ· 2-3 ÚÒÙ· ¤ÙË ˙ˆ‹˜ Ú¤ÂÈ Ó· ÂÚÈÏ¿‚ÂÈ: Â. ŸÏ· Ù· ·Ú·¿Óˆ (ÙË ÌÂÙ·ÙÚ·˘Ì·ÙÈ΋ ÛÙ¤ÓˆÛË ÌÂÙ¿ ·fi ‰È·ÛˆÏ‹ÓˆÛË, ÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È ÂÈÛÚfiÊËÛË, ÙËÓ ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, ÙÔÓ ·ÁÁÂÈ·Îfi ‰·ÎÙ‡ÏÈÔ) 3. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ Â›Ó·È ·ÏËı¤˜; Á. √ ·ÁÁÂÈ·Îfi˜ ‰·ÎÙ‡ÏÈÔ˜ ÌÔÚ› Ó· ÂΉËψı› ˆ˜ "ÔÈÛıfiÙÔÓÔ˜" ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ 4. ∏ ‰ÈfiÚıˆÛË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi: Â. ŸÏ· Ù· ·Ú·¿Óˆ (‰È·Ù·Ú·¯‹ Ù˘ ·‡ÍËÛ˘, Û˘Ìو̷ÙÔÏÔÁ›· Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ‰˘ÛÎÔÏ›· ηٿ ÙËÓ Î·Ù¿ÔÛË, ȉ›ˆ˜ ÛÙÂÚÂÒÓ ÙÚÔÊÒÓ, Û˘Ìو̷ÙÔÏÔÁ›· ÙÚ·¯ÂÈÔÌ·Ï¿Î˘ÓÛ˘) 5. ¶ÔÈÔ ·fi Ù· ·Ú·Î¿Ùˆ ÈÛ¯‡ÂÈ ÁÈ· ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ‰È·Ì·ÚÙÈÒÓ ÙÔ˘ Ó‡ÌÔÓ·; Â. ∫·Ó¤Ó· ·fi Ù· ·Ú·¿Óˆ (ÔÈ ·Ó·Ó¢ÛÙÈΤ˜ Âʉڛ˜ ÙˆÓ ÂÓËÏ›ÎˆÓ Î·ıÔÚ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ ËÏÈΛ· Ô˘ ¤ÁÈÓÂ Ë ÂÎÙÔÌ‹ - ÔÈ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù¿ ηÓfiÓ· ¿ÌÂÛË Â¤Ì‚·ÛË - Ë ·‡ÍËÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡ ÌÂÙ¿ ÙËÓ Ó¢ÌÔÓÂÎÙÔÌ‹ ·ÊÔÚ¿ ΢ڛˆ˜ ÙÔ ‰›ÎÙ˘Ô ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ÏÈÁfiÙÂÚÔ ÙÔ ·Ú¤Á¯˘Ì· - ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·‡ÍËÛË ÙÔ˘ Ó‡ÌÔÓ· Û˘Ó¿ÁÂÙ·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ Ó¢ÌÔÓÈÎÔ‡ ÈÛÙÔ‡)
Paediatriki 2007;70:199-204
Pediatri May-Jun 07
24-05-07
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
205
ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ۷ί¿ÚÔ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 ª. §ÈÓ·Ú‰¿Î˘, °. ªÂÚÙÛÈ¿˜, ∫. ™·ÚÚ‹, ∞. ∫·Ê¿ÙÔ˜ ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚ‹ÛˆÓ, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (∞¶), ÙÔ˘ ۷ί¿ÚÔ˘ Î·È ÙˆÓ ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ Ù˘ ∫Ú‹Ù˘, ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1989-1993 Î·È 1999-2003. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó ‰‡Ô ·ÓÙÈÚÔÛˆÂ˘ÙÈο ‰Â›ÁÌ·Ù· ·È‰ÈÒÓ ËÏÈΛ·˜ 5-15 ÂÙÒÓ, ·fi ÙȘ ÂÚÈfi‰Ô˘˜ 1989-1993 (¡=987) Î·È 1999-2003 (¡=891). ¶ÚÔ‹Ïı·Ó ·fi ÏËı˘ÛÌfi 5337 ·È‰ÈÒÓ 12 ÌÂÏÂÙÒÓ Ô˘ ‰ÈÂÍ‹¯ıËÛ·Ó ÛÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ ·fi ÙËÓ ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ªÂÙÚ‹ıËÎ·Ó ÙÔ ‚¿ÚÔ˜, ÙÔ ‡„Ô˜, ÔÈ ‰ÂÚÌ·ÙÈΤ˜ Ù˘¯¤˜, Ë ÂÚ›ÌÂÙÚÔ˜ ·ÚÈÛÙÂÚÔ‡ ‚Ú·¯›ÔÓ·, Ë ∞¶, ÙÔ Û¿Î¯·ÚÔ Î·È Ù· ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜. ÀÔÏÔÁ›ÛÙËÎÂ Î·È Ô ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (ªÂÙ™˘Ó) ˆ˜ Ë Û˘ÁΤÓÙÚˆÛË ÙÚÈÒÓ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·fi ÙÔ˘˜ ¤ÓÙ ·Ú¿ÁÔÓÙ˜: ·˘ÍË̤ÓÔ Û¿Î¯·ÚÔ, ·˘ÍË̤ÓË ∞¶, ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›·, ¯·ÌËÏ‹ HDL ¯ÔÏËÛÙÂÚfiÏË Î·È ·¯˘Û·ÚΛ·. ∞ÔÙÂϤÛÌ·Ù·: ªÂٷ͇ ÙˆÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ̤ÛË ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ηٿ 4 kg, ÙÔ˘ ‡„Ô˘˜ ηٿ 3,3 cm, ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ηٿ 0,92 kg/m2 Î·È ÙÔ˘ ·ıÚÔ›ÛÌ·ÙÔ˜ ÙÂÛÛ¿ÚˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ Î·Ù¿ 13,2 mm (p<0,001). √ ÂÈÔÏ·ÛÌfi˜ ÙˆÓ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ ·˘Í‹ıËΠ·fi 21,3% Û 24,7% (p<0,001) Î·È Ù˘ ·¯˘Û·ÚΛ·˜ ·fi 5,4% Û 10,4% (p<0,001). ∆Ô ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ì ·˘ÍË̤ÓË ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË ·Ú¤ÌÂÈÓ ·ÌÂÙ¿‚ÏËÙÔ ÛÙÔ 15,9%, ÂÓÒ ÂÎÂ›ÓˆÓ Ì ·˘ÍË̤ÓË LDL-C ÌÂÈÒıËΠ·fi 18,8% Û 17,1% (p=0,006). ™˘ÓÔÏÈο, ÙÔ 4,5% ÙˆÓ ·È‰ÈÒÓ ‚Ú¤ıËΠÙÔ 1989-1993 Ì ÙÚÂȘ ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ªÂÙ™˘Ó ¤Ó·ÓÙÈ 5,6% ÙÔ 1999-2003 (p>0,05). ™˘ÌÂÚ¿ÛÌ·Ù·: ™ËÌ·ÓÙÈ΋ ·‡ÍËÛË ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ÛÙËÓ ÂÚ›Ô‰Ô ÌÂٷ͇ 1989-1993 Î·È 1999-2003. ¢ÂÓ ‚Ú¤ıËÎÂ, ˆÛÙfiÛÔ, ·Ó¿ÏÔÁË ÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, ÛÙÔ Û¿Î¯·ÚÔ Î·È Ù· ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜, ·ÏÏ¿ ÌÈÎÚ‹ ·‡ÍËÛË ÛÙÔÓ ÂÈÔÏ·ÛÌfi ÙÔ˘ ªÂÙ™˘Ó. ∆· ·ÔÙÂϤÛÌ·Ù· ‰Â›¯ÓÔ˘Ó fiÙÈ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÎÚ›ÓÂÙ·È ·Ó·Áη›· Ë ÂÊ·ÚÌÔÁ‹ ÂıÓÈ΋˜ ÔÏÈÙÈ΋˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ.
¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘, ∆Ì‹Ì· π·ÙÚÈ΋˜, ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ª·ÓfiÏ˘ §ÈÓ·Ú‰¿Î˘ linman@med.uoc.gr ¢È·ÛÙ·‡ÚˆÛË µÔ‡Ù˜-™Ù·˘Ú¿ÎÈ· ∆.∫. 710 03, ∆.£. 2208, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
§¤ÍÂȘ ÎÏÂȉȿ: ¶ÏËı˘ÛÌȷ΋ Ù¿ÛË, ·È‰È¿, ۈ̷ÙÔÌÂÙÚ‹ÛÂȘ, ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜, ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ.
Secular trends during early 1990s and 2000s of body measurements, blood pressure, glucose and serum lipids in children of Crete, Greece M. Linardakis, G. Bertsias, K. Sarri, A. Kafatos Abstract Background: This study aimed at assessing secular changes in anthropometric measurements, blood pressure, glucose, and serum lipids in children and adolescents in Crete between 1989-1993 and 1999-2003. Methods: Two representative samples of children aged 5-15 years were studied during the time periods 1989-1993 (N=987) and 1999-2003 (N=891). The study samples came from a population of 5,337 children who participated in a series of 12 studies conducted by the same study team. Body weight and height, skin fold thickness, blood pressure, glucose, and serum lipids were measured, and body mass index (BMI) was derived. The prevalence of metabolic syndrome (MetSyn) was estimated as the clustering of three or more cardiovascular disease risk factors such as hyperglycaemia, high blood pressure, hypertriglyceridaemia, low HDL cholesterol and obesity. Results: Between 1989-1993 and 1999-2003 there was a significant increase in body weight (by 4 kg), height (by 3.3 cm), BMI (by 0.92 kg/m2), and the sum of skin folds (by 13.2 mm) (p<0.001). The prevalence of overweight children increased from 21.3% to 24.7% (p<0.001) and obesity from 5.4% to 10.4% (p<0.001). The percentage of children with increased total cholesterol remained unchanged, while that of children with elevated LDL-C decreased from 18.8% to 17.1% (p=0.006). Overall, 4.5% of children had ≥3 risk factors for MetSyn in 1989-1993, compared to 5.6% in 1999-2003 (p>0.05).
University of Crete, Faculty of Medicine, Department of Social Medicine, Division of Preventive Medicine and Nutrition, Heraklion, Crete Correspondence: Manolis Linardakis linman@med.uoc.gr Voutes-Stavrakia Junction 710 03, Po Box 2208, heraklion, Crete
¶·È‰È·ÙÚÈ΋ 2007;70:205-216
Pediatri May-Jun 07
24-05-07
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ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
Conclusions: A significant increase in obesity indices was found in children in Crete between 1989-1993
and 1999-2003, but with no significant changes in blood pressure or blood glucose or serum lipid levels. A small increase was also found in the prevalence of the MetSyn. These results highlight the need for implementation of national health promotion policies focusing on childhood obesity in Greece. Key words: Secular trends, children, body measurements, serum lipids, metabolic syndrome.
™˘ÓÙÔÌÔÁڷʛ˜ ¢ª™ ∞¢¶ ¶∞µ ™∞¶ ¢∞¶ ∞¶ GLU TC TG HDL-C LDL-C ∂£ OR
¢Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ÕıÚÔÈÛÌ· 4 ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ ¶ÂÚ›ÌÂÙÚÔ˜ ·ÚÈÛÙÂÚÔ‡ ‚Ú·¯›ÔÓ· ™˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ¢È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ∞ÚÙËÚȷ΋ ›ÂÛË ™¿Î¯·ÚÔ √ÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË ∆ÚÈÁÏ˘ÎÂÚ›‰È· ÃÔÏËÛÙÂÚfiÏË ÙˆÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ ÃÔÏËÛÙÂÚfiÏË ÙˆÓ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ ∂ηÙÔÛÙÈ·›· ı¤ÛË Odds ratio
∂ÈÛ·ÁˆÁ‹ T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙË Ú·Á‰·›· ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÙÔ˘˜ ÌÂÁÂıÒÓ, Ô˘ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ ·¯˘Û·ÚΛ·˜ (1-3). √ ÂÈÔÏ·ÛÌfi˜ ·˘ÍË̤ÓÔ˘ ‚¿ÚÔ˘˜ Î·È ·¯˘Û·ÚΛ·˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 5-17 ÂÙÒÓ, ˘ÔÏÔÁ›˙ÂÙ·È ·ÁÎÔÛÌ›ˆ˜ ÛÙÔ 10% ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1990. ∆ËÓ ÚÒÙË ı¤ÛË Î·Ù¤¯Ô˘Ó ÔÈ ∏¶∞ Ì 36% Î·È ·ÎÔÏÔ˘ı› Ë Â˘Úˆ·˚΋ ‹ÂÈÚÔ˜ Ì 20% (1,2,4). √ ·ÈÙÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜ ıˆÚÂ›Ù·È ÔÏ˘·Ú·ÁÔÓÙÈÎfi˜ ·Ó Î·È ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ηٷÓÔËı›. ∂ÎÙfi˜ ·fi ÙÔÓ ÚˆÙ‡ÔÓÙ· ÚfiÏÔ Ô˘ η٤¯Ô˘Ó Ë ·ÓÈÛÔÚÚÔ›· ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ - ηٷӷÏÈÛÎfiÌÂÓ˘ ÂÓ¤ÚÁÂÈ·˜ Î·È Ë ¤ÏÏÂÈ„Ë ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘, ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÂÚÈ‚·ÏÏÔÓÙÈÎÔ›, ÎÔÈÓˆÓÈÎÔ›, ÔÏÈÙÈÛÌÈÎÔ›, ηıÒ˜ Î·È ‚ÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ (2,5). ∏ ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ ·¯˘Û·ÚΛ·˜ ¿Ú¯ÈÛ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 ÁÈ· Ù· ·È‰È¿ (5). ∏ ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ Ï›Ô˘˜ Û˘Óԉ‡ÂÙ·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, fiˆ˜ ˘¤ÚÙ·ÛË, ·˘ÍË̤ÓÔ Û¿Î¯·ÚÔ ÔÚÔ‡ ·›Ì·ÙÔ˜ (GLU), ˘ÂÚÏÈȉ·ÈÌ›· ‹ ηÈ
Paediatriki 2007;70:205-216
¯·ÌËÏ‹ HDL ¯ÔÏËÛÙÂÚfiÏË, ÂÓÒ Ô Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘˜ (ÙÚÂȘ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜) ηıÔÚ›˙ÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ (ªÂÙ™˘Ó) (6-10). ªÂ ÂӉȷʤÚÔÓ Ù›ıÂÙ·È, ÂÔ̤ӈ˜, ÙÔ ÂÚÒÙËÌ· Â¿Ó Ë ÌÂÙ·‚ÔÏ‹ Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Û˘Óԉ‡ÂÙ·È ·fi ·Ó¿ÏÔÁË ÌÂÙ·‚ÔÏ‹ ÛÙ· ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜, ÛÙÔ GLU Î·È ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË (∞¶). √ J. Eisenmann Û ·Ó·ÛÎfiËÛË, ÙÔ 2003, Û ÌÂϤÙ˜ ·È‰ÈÒÓ ÙˆÓ ∏¶∞ Î·È ÙÔ˘ ∫·Ó·‰¿ (11), ÙÔÓ›˙ÂÈ fiÙÈ “·Ú¿ ÙËÓ ÂȉËÌÈ΋ ·‡ÍËÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ·ÓÙ›ıÂÙË ·ÏÏ·Á‹ ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ Î·È Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘”. ø˜ ηıÔÚÈÛÙÈ΋ ·Ó·Ê¤ÚÂÈ ÙËÓ Â›‰Ú·ÛË Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ Ë ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË, Ô Û‡Á¯ÚÔÓÔ˜ ÙÚfiÔ˜ ˙ˆ‹˜, Ë ‰È·ÙÚÔÊ‹, ÙÔ stress Î·È Ë ‰È·Ù·Ú·¯‹ Î·È ·ÔÚ‡ıÌÈÛË ÙÔ˘ ¿ÍÔÓ· ˘Ôı·Ï¿ÌÔ˘-˘fiÊ˘Û˘ Î·È ÂÈÓÂÊÚȉ›ˆÓ. øÛÙfiÛÔ, ÛÙËÓ ÏËı˘ÛÌȷ΋ Ù¿ÛË (secular trend) ÁÈ· ·‡ÍËÛË ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ .¯. Ë ÌÂÙ·‚ÔÏ‹ ÛÙȘ ÎÔÈÓˆÓÈÎoÔÈÎÔÓÔÌÈΤ˜ Û˘Óı‹Î˜ Î·È ÛÙÔÓ ÙfiÔ Î·ÙÔÈΛ·˜ (12). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, Ù˘ ∞¶, ÙÔ˘ GLU Î·È ÙˆÓ ÏÈȉ›ˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 5-15 ÂÙÒÓ, ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 19992003, ηıÒ˜ Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ªÂÙ™˘Ó.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¶ÂÚÈÔ¯‹ ÌÂϤÙ˘ ∏ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠·È‰È¿ Ù˘ ∫Ú‹Ù˘ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ÌÂϤÙ˜ Ù˘ ∫ÏÈÓÈ΋˜ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, Ù˘ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. √ ÌfiÓÈÌÔ˜ ÏËı˘ÛÌfi˜ ÙÔ˘ ÓËÛÈÔ‡ ·˘Í‹ıËΠÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 ·fi 540.054 Û 594.368 ηÙÔ›ÎÔ˘˜ ‹ 9,1%. ∆Ô 2001, ÙÔ 46% ÙÔ˘ ÏËı˘ÛÌÔ‡ ‹Ù·Ó ·ÛÙÈÎfi˜,
Pediatri May-Jun 07
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ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚ‹ÛˆÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ‰ÂÈÎÙÒÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ
42% ·ÁÚÔÙÈÎfi˜ Î·È 12% ËÌÈ·ÛÙÈÎfi˜. ∆Ô Î·Ù¿ ÎÂÊ·Ï‹Ó ∞∂¶ ÙˆÓ ∫ÚËÙÈÎÒÓ ·˘Í‹ıËΠηٿ 41% (ÛÙÔȯ›· ∂™À∂). ¶ÏËı˘ÛÌfi˜ ÌÂϤÙ˘ ªÂÏÂÙ‹ıËÎ·Ó ‰‡Ô ·ÓÙÈÚÔÛˆÂ˘ÙÈο ‰Â›ÁÌ·Ù· 1878 ·È‰ÈÒÓ ËÏÈΛ·˜ 5-15 ÂÙÒÓ ·fi fiÏË ÙËÓ ∫Ú‹ÙË. ∆Ô ÚÒÙÔ ‰Â›ÁÌ· ·ÔÙÂÏÔ‡Ó 987 ·È‰È¿ (491 ·ÁfiÚÈ·). ∂ÈϤ¯ıËÎ·Ó ·fi 2785 Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ¤ÍÈ ÌÂϤÙ˜, ÔÈ Ôԛ˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ·fi ÙËÓ ∫ÏÈÓÈ΋, ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1989-1993 Î·È ·ÊÔÚÔ‡Û·Ó ¶ÚÔÁÚ¿ÌÌ·Ù· ∞ÁˆÁ‹˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ÁÈ· ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÚfiÏË„Ë ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ (13-18). ¶·ÚfiÌÔÈ·, Ì ·ÓÙÈÛÙÔ›¯ÈÛË (ˆ˜ ÚÔ˜ ʇÏÔËÏÈΛ·-ÂÚÈÔ¯‹ ηÙÔÈΛ·˜) ÂÈϤ¯ıËΠÙÔ ‰Â‡ÙÂÚÔ ‰Â›ÁÌ· ÙˆÓ 891 ·È‰ÈÒÓ (442 ·ÁfiÚÈ·) ·fi Û‡ÓÔÏÔ 2572 Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ¤ÍÈ ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1999-2003 (9,19-21). ∏ ÂÈÏÔÁ‹ ÙÔ˘˜ ÛÙȘ ‰Ò‰Âη ÌÂϤÙ˜ ‹Ù·Ó Ù˘¯·›·-ÔÏ˘ÛÙ·‰È·Î‹. ∞Ú¯Èο, ÂÈϤ¯ıËÎ·Ó Ù˘¯·›· ÔÈ ÂÚÈÔ¯¤˜ ÌÂϤÙ˘ (·ÁÚÔÙÈΤ˜-·ÛÙÈΤ˜-ËÌÈ·ÛÙÈΤ˜) Î·È ÂÓ Û˘Ó¯›·, Ù· Û¯ÔÏ›· ÛÙ· ÔÔ›· ·Ó‹Î·Ó fiÏ· Ù· ·È‰È¿. ∏ ÂÈÏÔÁ‹ ÙÔ˘˜, ˆÛÙfiÛÔ, ÁÈ· ÙË Û˘ÁÎÚfiÙËÛË Î·È ·ÓÙÈÛÙÔ›¯ÈÛË ÙˆÓ ‰‡Ô ‰ÂÈÁÌ¿ÙˆÓ ‹Ù·Ó Ù˘¯·›· Î·È Î·ıÔÚ›ÛÙËΠ·fi ÙË Û‡ÓıÂÛË (ηٿ ʇÏÔ-ËÏÈΛ·ÂÚÈÔ¯‹ ηÙÔÈΛ·˜) ÙÔ˘ ˘ÔÏÔÁÈ˙fiÌÂÓÔ˘ ·È‰ÈÎÔ‡ ÎÚËÙÈÎÔ‡ ÏËı˘ÛÌÔ‡ ËÏÈΛ·˜ 5-15 ÂÙÒÓ, fiˆ˜ ÂÎÙÈÌ‹ıËΠ·fi ÙËÓ ∂™À∂ ÁÈ· Ù· ¤ÙË 1989 Î·È 1999. ªÂÙÚ‹ÛÂȘ √È ÌÂÙÚ‹ÛÂȘ ·ÊÔÚÔ‡Û·Ó ÛÙ· ۈ̷ÙÔÌÂÙÚÈο ÌÂÁ¤ıË, ÙËÓ ∞¶, ηıÒ˜ Î·È ÛÙË Ï‹„Ë ÔÚÔ‡ ·›Ì·ÙÔ˜ ÁÈ· ÙË Ì¤ÙÚËÛË ÙÔ˘ GLU Î·È ÙˆÓ ÏÈȉ›ˆÓ. ∏ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ ¤ÁÈÓ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜ Î·È ·ÊÔ‡ ÚÔËÁ‹ıËΠÁÚ·Ù‹ ÂÓË̤ڈÛË ÁÈ· ÙË ‰È·‰Èηۛ· Î·È Ù· ›‰Ë ÙˆÓ ÌÂÙÚ‹ÛˆÓ. √È ÌÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó ÛÙ· ηٿ ÙfiÔ˘˜ Û¯ÔÏ›·, ÌÂÙ¿ ·fi Û¯ÂÙÈ΋ ¤ÁÎÚÈÛË ÙˆÓ ¶ÚÔÁÚ·ÌÌ¿ÙˆÓ ∞ÁˆÁ‹˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ Î·È ÙˆÓ ·ÍÈÔÏÔÁ‹ÛÂÒÓ ÙÔ˘˜ ·fi ÙÔ ¶·È‰·ÁˆÁÈÎfi πÓÛÙÈÙÔ‡ÙÔ Î·È ÙÔ ÀÔ˘ÚÁÂ›Ô ¶·È‰Â›·˜. ŒÁÎÚÈÛË, ›Û˘, ÚÔËÁ‹ıËÎÂ Î·È ·fi ÙËÓ ∂ÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ™ˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ √È ÛˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ ·ÊÔÚÔ‡Û·Ó ÛÙÔ ‚¿ÚÔ˜, ÙÔ ‡„Ô˜, ÙȘ ‰ÂÚÌ·ÙÈΤ˜ Ù˘¯¤˜ ˆÌÔÏ¿Ù˘, Ï·ÁÔÓ›Ô˘, ‰ÈÎÂÊ¿ÏÔ˘, ÙÚÈÎÂÊ¿ÏÔ˘ Î·È ÛÙËÓ ÂÚ›ÌÂÙÚÔ ·ÚÈÛÙÂÚÔ‡ ‚Ú·¯›ÔÓ· (¶∞µ), ÂÓÒ ˘ÔÏÔÁ›ÛÙËÎÂ Ô ¢ª™ Î·È ÙÔ ¿ıÚÔÈÛÌ· ÙˆÓ 4 ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ. ¶Ï‹Ú˘ ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ-ÌÂÙÚ‹ÛÂˆÓ ·Ó·Ê¤ÚÂÙ·È Û ÚÔËÁÔ‡ÌÂÓ˜ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜ (9,19,20). °È· ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ù· ηٿ ʇÏÔ Î·È ËÏÈΛ· fiÚÈ·, fiˆ˜ ÔÚ›˙ÔÓÙ·È ·fi ÙÔÓ International Obesity Task Force (IOTF) (1). √ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÙÚ‹ıËÎ·Ó ‰È·Ê¤ÚÂÈ ·fi ̤ÙÚËÛË Û ̤ÙÚËÛË. øÛÙfiÛÔ, Ë Û˘ÌÌÂÙÔ¯‹ ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 99% Î·È ÛÙȘ ‰‡Ô ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜, Ì ÂÍ·›ÚÂÛË ÙË Ì¤ÙÚËÛË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ. ŸÛ· ·È‰È¿ ›¯·Ó ̤ÙÚËÛË ¶∞µ ›¯·Ó ÌÂÙÚËı› Û ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ·fi ÙȘ ‰ÂÚÌ·ÙÈΤ˜ Ù˘¯¤˜. ª¤ÙÚËÛË ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ·›Ì·ÙÔ˜ ∏ ∞¶ ÌÂÙÚ‹ıËΠ۠928 ·È‰È¿ (94%) ÙÔ 1989-1993 Î·È Û 563 ·È‰È¿ (63%) ÙÔ 1999-2003, Û ηıÈÛÙ‹ ı¤ÛË Î·È ÌÂÙ¿ ·fi ·Ó¿·˘ÛË 5-10 ÏÂÙÒÓ. ∏ ̤ÙÚËÛË ¤ÁÈÓ Ì ˘‰Ú·Ú-
Á˘ÚÈÎfi ÛÊ˘ÁÌÔÌ·ÓfiÌÂÙÚÔ Î·Ù¿ÏÏËÏÔ Û ̤ÁÂıÔ˜ ÂÚȯÂÈÚ›‰Ô˜, ηχÙÔÓÙ·˜ ÙÔ 50-75% Ù˘ ÂÚÈ̤ÙÚÔ˘ ÙÔ˘ ‰ÂÍÈÔ‡ ‚Ú·¯›ÔÓ·. O ÚÒÙÔ˜ Î·È ¤ÌÙÔ˜ ÙfiÓÔ˜ Korotkoff ·ÔÙ¤ÏÂÛ·Ó ÙË Û˘ÛÙÔÏÈ΋ (™∞¶) Î·È ‰È·ÛÙÔÏÈ΋ (¢∞¶) ∞¶, ·ÓÙ›ÛÙÔȯ·. ∞˘Ù¤˜ ÌÂÙÚ‹ıËÎ·Ó ÙÚÂȘ ÊÔÚ¤˜ Ì ÌÂÛԉȿÛÙËÌ· ÂÓfi˜ Ì ‰‡Ô ÏÂÙÒÓ Î·È ÂÎÙÈÌ‹ıËÎÂ Ô Ì¤ÛÔ˜ fiÚÔ˜, fiˆ˜ ÔÚ›˙ÂÙ·È ÛÙÔ ÚˆÙfiÎÔÏÏÔ MONICA (9,21). ø˜ ·ıÔÏÔÁÈο fiÚÈ· ÂÏ‹ÊıËÛ·Ó ÔÈ Î·Ù¿ ʇÏÔ-ËÏÈΛ· 90¤˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ (∂.£.) Ù˘ ™∞¶ Î·È ¢∞¶, Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÛÙËÓ 50‹ ∂.£. ÙÔ˘ ‡„Ô˘˜ ·È‰ÈÒÓ ÙˆÓ ∏¶∞ (23). §‹„Ë ·›Ì·ÙÔ˜ Î·È ‚ÈÔ¯ËÌÈΤ˜ ·Ó·Ï‡ÛÂȘ ∏ ·ÈÌÔÏË„›· Ú·ÁÌ·ÙÔÔÈ‹ıËΠڈÈÓ¤˜ ÒÚ˜, ÌÂÙ¿ ·fi 12ˆÚË ÓËÛÙ›· Î·È Û ‡ÙÈ· ı¤ÛË. ¢Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÙˆÓ 10 ml ÂÏ‹ÊıËÛ·Ó Û ۈÏËÓ¿ÚÈ· ¯ˆÚ›˜ ·ÓÙÈËÎÙÈÎfi ÁÈ· ÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ÔÚÔ‡. ∞̤ۈ˜ ÌÂÙ¿, ÁÈ· ÙË Û˘ÓÙ‹ÚËÛ‹ ÙÔ˘˜ Û ¯·ÌËÏ‹ ıÂÚÌÔÎÚ·Û›· (3-4ÔC), ÙÔÔıÂÙ‹ıËÎ·Ó Û ÊÔÚËÙfi „˘ÁÂ›Ô Ì ·ÁÔ·ÛÙ˜ Î·È ÌÂٷʤÚıËÎ·Ó ÂÓÙfi˜ 4 ˆÚÒÓ ÛÙ· ÂÚÁ·ÛÙ‹ÚÈ· Ù˘ ∫ÏÈÓÈ΋˜ (9,17-20). ∆Ô GLU ÌÂÙÚ‹ıËΠ۠410 ·È‰È¿ (42%) ÙÔ 1989-1993 Î·È Û 633 ·È‰È¿ (71%) ÙÔ 1999-2003, ÂÓÒ Ù· ÏÈ›‰È·: ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË (TC), ÙÚÈÁÏ˘ÎÂÚ›‰È· (TG), HDL-C, LDL-C Î·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ·ıËڈ̷ÙÈÎÔ‡ ‰Â›ÎÙË TC:HDL-C, Û 591 ·È‰È¿ (60%) ÙÔ 1989-1993 Î·È Û 826 ·È‰È¿ (93%) ÙÔ 1999-2003. ø˜ ·ıÔÏÔÁÈο fiÚÈ· ÂÏ‹ÊıËÛ·Ó Ù· 100 mg/dl ÛÙÔ GLU (6), Ù· 180 Î·È 200 mg/dl ÛÙËÓ TC, Ù· 110 Î·È 130 mg/dl ÛÙËÓ LDL-C Î·È ÙÔ 4,00 ÛÙÔÓ ‰Â›ÎÙË TC:HDL-C. ™Ù· TG Î·È ÙËÓ HDL-C ÂÏ‹ÊıËÛ·Ó ÔÈ Î·Ù¿ ʇÏÔ-ËÏÈΛ· 90‹ & 10Ë ∂.£. ·ÓÙ›ÛÙÔȯ·, 6000 ÂÚ›Ô˘ ÌÂÙÚ‹ÛÂˆÓ Û ·È‰È¿ Ù˘ ∫Ú‹Ù˘ (9). ™ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ·Ú·ÁfiÓÙˆÓ ªÂÙ™˘Ó ÂÚÈÂÏ‹ÊıËÛ·Ó ¤ÓÙ ‰Â›ÎÙ˜, fiˆ˜: ¢ª™ (·¯˘Û·ÚΛ·), ∞¶ (™∞¶ ‹/Î·È ¢∞¶ ≥90‹ ∂.£.), GLU (≥100 mg/dl), TG (≥90‹ ∂.£.) Î·È HDL-C (≤10Ë ∂.£.). ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË °È· ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰Ô̤ӈÓ, ÂÎÙfi˜ ·fi ÙË ÛÙڈ̷ÙÔÔÈË̤ÓË Ù˘¯·›· ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ Û οı ÂÚ›Ô‰Ô (ηٿ ʇÏÔ-ËÏÈΛ·-ÂÚÈÔ¯‹ ηÙÔÈΛ·˜), ·ÎÔÏÔ‡ıËÛ ËÏÈÎȷ΋ ÔÌ·‰ÔÔ›ËÛË Î·È ¤ÏÂÁ¯Ô˜ ·˘ÙÒÓ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ·È‰ÈÒÓ, ÌÂٷ͇ ÙˆÓ ‰‡Ô ‰ÂÈÁÌ¿ÙˆÓ. ∏ ÔÌ·‰ÔÔ›ËÛË ·ÊÔÚÔ‡Û ÛÙȘ ËÏÈ˘ 5-9,9 ÂÙÒÓ Î·È 10-15 ÂÙÒÓ Î·È ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ Ì¤ıÔ‰ÔÈ Student t Î·È χ2 (¶›Ó·Î·˜ 1). ªÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ ‰ÂÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ÂÈÏÂÁÌ¤ÓˆÓ ·È‰ÈÒÓ, ·Ú¿ ÌfiÓÔ ÛÙËÓ ÂÚÈÔ¯‹ ηÙÔÈΛ·˜ ÙÔ˘˜ (·ÁÚÔÙÈ΋: 47,8% ¤Ó·ÓÙÈ 42,9%, ·ÓÙ›ÛÙÔȯ·, p=0,011), ηıÒ˜ ·ÏÏ¿˙ÂÈ ‰È·¯ÚÔÓÈο Ë Î·Ù·ÓÔÌ‹ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÏËı˘ÛÌÔ‡ ˆ˜ ÚÔ˜ ÙËÓ ÂÚÈÔ¯‹ ηÙÔÈΛ·˜. ªÂ ÙȘ ›‰È˜ ÌÂıfi‰Ô˘˜ ÂϤÁ¯ıËÎ·Ó ·ÎfiÌË ÔÈ Î·Ù·ÓÔ̤˜ ˆ˜ ÚÔ˜ ʇÏÔ-ËÏÈΛ·-ÂÚÈÔ¯‹ ηÙÔÈΛ·˜ (·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ›Ó·Î·) ÁÈ· Ù· ·È‰È¿ Ô˘ ›¯·Ó ÏÈÁfiÙÂÚ˜ ÌÂÙÚ‹ÛÂȘ (ÌÈÎÚfi Ú˘ıÌfi Û˘ÌÌÂÙÔ¯‹˜). ¢ÂÓ ‚Ú¤ıËηÓ, ˆÛÙfiÛÔ, ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙÔ˘˜. ªÂ ÙË Ì¤ıÔ‰Ô Student t (equal variances not assumed) ÂϤÁ¯ıËÎ·Ó ·ÎfiÌË ÔÈ ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ Û οı ʇÏÔ, ÌÂٷ͇ ÙˆÓ ‰‡Ô ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ. ªÂ ÙË χ2 ÂϤÁ¯ıËΠÛÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ Ù˘ ∞¶, ÙÔ˘ GLU Î·È ÙˆÓ ÏÈȉ›ˆÓ. ªÂ ÙËÓ ·Ó¿Ï˘ÛË ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (logistic linear regression) ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ ‰Â›ÎÙ˜ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Odds ratio) Î·È Ù· 95% ‰È·ÛÙ‹Ì·Ù· ÂÌÈÛÙÔÛ‡Ó˘ ÛÙȘ ‰‡Ô ¶·È‰È·ÙÚÈ΋ 2007;70:205-216
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·208
208
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο Î·È ‰È·ÊÔÚ¤˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÙˆÓ 1878 ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 5 ¤ˆ˜ 15 ÂÙÒÓ, ÛÙȘ ÂÚÈfi‰Ô˘˜ 1989-1993 Î·È 1999-2003 1989-1993
1999-2003 N (%)
p-value*
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
491 (49,7) 496 (50,3)
442 (49,6) 449 (50,4)
0,952
5,0-9,9 ÂÙÒÓ 10,0-15,0 ÂÙÒÓ
458 (46,4) 429 (53,6)
383 (43,0) 508 (57,0)
0,137
∞ÁÚÔÙÈ΋ ∏ÌÈ·ÛÙÈ΋ ∞ÛÙÈ΋
472 (47,8) 66 (6,7) 449 (46,5)
382 (42,9) 89 (10,0) 420 (47,1)
0,011
ª¤ÛË ËÏÈΛ· ± ∆∞ (¡) ∏ÏÈΛ· (¤ÙË)
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
p-value**
10,4±2,7 (491) 10,4±2,8 (496)
10,5±2,7 (442) 10,5±2,9 (449)
0,298 0,330
10,4±2,8 (987)
10,5±2,8 (891)
0,609
5,0-9,9
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
7,8±1,5 (224) 7,8±1,4 (234)
7,8±1,6 (183) 7,7±1,5 (200)
0,809 0,523
10,0-15,0
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
12,6±1,1 (267) 12,7±1,3 (262)
12,5±1,3 (259) 12,7±1,4 (249)
0,471 0,954
™‡ÓÔÏÔ
* ŒÏÂÁ¯Ô˜ χ2, ** ŒÏÂÁ¯Ô˜ Student t
ÂÚÈfi‰Ô˘˜, ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· Ì ·˘ÍË̤ӷ ›‰· ¢ª™, ·ÚÙËÚȷ΋˜ ›ÂÛ˘, GLU Î·È ÏÈȉ›ˆÓ Î·È ÌÂ Û˘ÌÌÂÙ·‚ÏËÙ‹ ÂϤÁ¯Ô˘ ÙËÓ ËÏÈΛ·. ªÂ ÙË ¯Ú‹ÛË ÔÏ˘ˆÓ˘ÌÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ 3Ô˘ ‚·ıÌÔ‡ ·ÂÈÎÔÓ›ÛÙËΠ۠ÙÚÈۉȿÛÙ·ÙË ÌÔÚÊ‹ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜, Ë Û˘Û¯¤ÙÈÛË ÙÔ˘ ¢ª™ Ì ÙËÓ TC Î·È HDL-C. ∆¤ÏÔ˜, Ì ÙÔ ‰È¿ÁÚ·ÌÌ· ladder ·ÂÈÎÔÓ›ÛÙËÎÂ Ë Û¯ÂÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ: ÙÔ˘ ¢ª™, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÙÔ˘ GLU Î·È ÙˆÓ ÏÈȉ›ˆÓ.
∞ÔÙÂϤÛÌ·Ù· ªÂٷ͇ ÙˆÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003, ÙÔ ‚¿ÚÔ˜ ÙˆÓ ·ÁÔÚÈÒÓ (¶›Ó·Î·˜ 2) ·˘Í‹ıËΠηٿ 4,3 kg ‹ 11,4% (p<0,001), ÙÔ ‡„Ô˜ ηٿ 4 cm ‹ 2,9% (p<0,001), Ô ¢ª™ ηٿ 0,92 kg/m2 ‹ 4,9% (p<0,001), ÙÔ ∞¢¶ ηٿ 12,2 mm (p<0,001) Î·È Ë ¶∞µ ηٿ 1,8 mm (p<0,001). ∏ ™∞¶ ·˘Í‹ıËΠηٿ 6,7 mmHg (p<0,001) ÛÙȘ ËÏÈ˘ 10,0-15,0 ÂÙÒÓ, ÂÓÒ ÌÂÈÒıËÎ·Ó Ë ¢∞¶ ηٿ 8,9 mmHg (p<0,001), ÙÔ GLU ηٿ 2,9 mg/dl (p<0,001) Î·È Ë LDL-C ηٿ 4,4 mg/dl (p=0,036). ™Ù· ÎÔÚ›ÙÛÈ· (¶›Ó·Î·˜ 3) ÙÔ ‚¿ÚÔ˜ ·˘Í‹ıËΠηٿ 3,6 kg ‹ 9,4% (p<0,001), ÙÔ ‡„Ô˜ ηٿ 2,5 cm ‹ 1,8% (p<0,001), Ô ¢ª™ ηٿ 1,02 kg/m2 ‹ 5,4% (p<0,001), ÙÔ ∞¢¶ ηٿ 14,2 mm (p<0,001) Î·È Ë ¶∞µ ηٿ 1,5 mm (p<0,001). ∏ ™∞¶ ·˘Í‹ıËΠηٿ 2,5 mmHg (p=0,020), ÂÓÒ Ì›ˆÛË - fiˆ˜ ÛÙ· ·ÁfiÚÈ· - ‚Ú¤ıËΠÛÙË ¢∞¶ 5,6 mmHg (p=0,020) Î·È ÛÙÔ GLU 4,1 mg/dl (p<0,001). √ ÂÈÔÏ·ÛÌfi˜ ÙˆÓ ˘¤Ú‚·ÚˆÓ ·ÁÔÚÈÒÓ (¶›Ó·Paediatriki 2007;70:205-216
η˜ 4) ·˘Í‹ıËΠηٿ 18,8% ·fi ÙÔ 1989-1993 ÛÙÔ 1999-2003 Î·È Î·Ù¿ 82% ÙˆÓ ·¯‡Û·ÚÎˆÓ (·fi 20,7% Û 24,6% Î·È ·fi 5,0% Û 9,1%, ·ÓÙ›ÛÙÔȯ·, p=0,011) Î·È ÛÙ· ÎÔÚ›ÙÛÈ· ηٿ 13,8% Î·È 96,6%, ·ÓÙ›ÛÙÔȯ· (·fi 21,8 Û 24,8% Î·È ·fi 5,9 Û 11,6%, ·ÓÙ›ÛÙÔȯ·, p=0,002). ™˘ÓÔÏÈο, Ô ÂÈÔÏ·ÛÌfi˜ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ ·˘Í‹ıËΠ·fi 21,3% Û 24,7% (p<0,001) Î·È ÙˆÓ ·¯‡Û·ÚÎˆÓ ·fi 5,4% ÛÙÔ 10,4% (p<0,001). ∆· ÔÛÔÛÙ¿ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ Ì ˘„ËÏ‹ ™∞¶ ·˘Í‹ıËÎ·Ó Î·Ù¿ 48,4% (p=0,001) Î·È 72,2% (p<0,001), ÂÓÒ ÌÂÈÒıËÎ·Ó ÛÙË ¢∞¶ ηٿ 57,5% (p<0,001) Î·È 28,9% (p<0,001), ·ÓÙ›ÛÙÔȯ·. ™ËÌ·ÓÙÈ΋ Ì›ˆÛË ‚Ú¤ıËÎÂ Î·È ÛÙ· ÎÔÚ›ÙÛÈ· Ì LDL-C ÌÂٷ͇ 111-130 mg/dl (Ì›ˆÛË Î·Ù¿ 30,4%, p=0,015). ∂›Û˘, fiÏ· Ù· ·È‰È¿ ·Ú¤ÌÂÈÓ·Ó Ì ·˘ÍË̤ÓË TC ÛÙÔ 15,9% (p>0,05), ÂÓÒ ÂÎÂ›ÓˆÓ Ì ·˘ÍË̤ÓË LDL-C ÌÂÈÒıËÎ·Ó ·fi 18,8% Û 17,1% (p=0,006), ·ÓÙ›ÛÙÔȯ· (·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î·). ™ÙÔÓ Û˘Ó‰˘·ÛÌfi ·Ú·ÁfiÓÙˆÓ ÙÔ˘ ªÂÙ™˘Ó, ‰ÂÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÛÙÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ì ÙÚÂȘ ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜. ™˘ÁÎÂÎÚÈ̤ӷ, ÙÔ 4,5% fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ‚Ú¤ıËΠÙÔ 1989-1993 Ì ªÂÙ™˘Ó ¤Ó·ÓÙÈ 5,6% ÙÔ 1999-2003. ∆¤ÏÔ˜, ÛÙÔÓ ¶›Ó·Î· 5 ÔÈ ‰Â›ÎÙ˜ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Odds Ratio) ¤‰ÂÈÍ·Ó ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 19992003 Û ۯ¤ÛË Ì ÙËÓ ÂÚ›Ô‰Ô 1989-1993, Ù· ·ÁfiÚÈ· Ó· ¤¯Ô˘Ó 2,06 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ·
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·209
209
ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚ‹ÛˆÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ‰ÂÈÎÙÒÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ
¶›Ó·Î·˜ 2. ∂›Â‰· ۈ̷ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·ÁÔÚÈÒÓ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 5-15 ÂÙÒÓ, ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 1989-1993 ª¤ÙÚËÛË
∏ÏÈΛ·
µ¿ÚÔ˜ (kg)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
⁄„Ô˜ (cm)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
¢ª™ (kg/m2)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
∞¢¶ (mm)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
¶∞µ (mm)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
™∞¶ (mmHg)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
¢∞¶ (mmHg)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
GLU (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
TC (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
TG (mg/dl)
5,0-9,9 10,0-15,0
™‡ÓÔÏÔ HDL-C (mg/dl)
5,0-9,9 10,0-15,0
™‡ÓÔÏÔ LDL-C (mg/dl)
5,0-9,9 10,0-15,0
™‡ÓÔÏÔ ¢Â›ÎÙ˘ TC:HDL ™‡ÓÔÏÔ
5,0-9,9 10,0-15,0
1999-2003
¡
ª¤ÛË ÙÈÌ‹ (∆∞)
¡
ª¤ÛË ÙÈÌ‹ (∆∞)
220 259 479 220 258 478 220 258 478 131 170 301 200 181 381 208 256 464 208 256 464 45 162 207 102 188 290 97 171 268 101 187 288 102 188 290 101 187 288
27,7 (6,4) 46,4 (11,5) 37,8 (13,4) 126,8 (9,8) 151,6 (9,3) 140,2 (15,6) 17,07 (2,49) 20,01 (3,49) 18,66 (3,39) 33,6 (18,5) 43,5 (23,8) 39,2 (22,2) 19,3 (2,3) 22,9 (3,7) 21,0 (3,5) 105,1 (10,9) 111,8 (11,7) 108,8 (11,8) 71,8 (10,9) 74,0 (9,3) 73,0 (10,1) 85,0 (10,8) 91,8 (7,7) 90,3 (8,9) 175,5 (29,5) 171,2 (31,3) 172,7 (30,7) 61,5 (30,1) 66,1 (32,5) 64,5 (31,7) 53,3 (13,4) 52,9 (12,6) 53,0 (12,9) 110,9 (28,7) 106,6 (28,6) 108,0 (28,6) 3,47 (0,97) 3,40 (1,00) 3,43 (0,99)
181 258 439 181 258 439 181 258 439 181 258 439 181 258 439 128 135 263 128 135 263 163 148 311 166 241 407 166 241 407 166 241 407 166 241 407 166 241 407
30,2 (9,3) 50,6 (13,0) 42,2 (15,4) 128,1 (10,3) 155,4 (12,4) 144,2 (17,8) 18,00 (3,23) 20,69 (3,65) 19,58 (3,72) 47,5 (24,2) 54,3 (28,9) 51,5 (27,3) 20,4 (3,3) 24,4 (3,4) 22,8 (3,9) 102,7 (15,8) 118,5 (11,0) 110,8 (15,6) 65,1 (11,0) 63,1 (12,9) 64,1 (12,0) 87,1 (8,8) 87,6 (9,7) 87,4 (9,2) 172,8 (25,6) 166,2 (29,4) 168,9 (20,1) 55,7 (21,0) 66,2 (29,0) 61,9 (26,6) 54,3 (11,8) 51,4 (13,3) 52,6 (12,8) 107,1 (23,6) 101,5 (25,3) 103,7 (24,8) 3,30 (0,81) 3,40 (0,89) 3,36 (0,86)
ªÂÙ·‚ÔÏ‹ p-value 2,5 4,2 4,3 1,3 3,9 4,0 0,93 0,67 0,92 13,9 10,8 12,2 1,2 1,6 1,8 -2,4 6,7 2,0 -6,7 -10,9 -8,9 2,1 -4,2 -2,9 -2,7 -5,0 -3,8 -5,9 0,1 -2,6 1,0 -1,5 -0,4 -3,6 -2,6 -4,4 -0,13 0,00 -0,07
0,003 <0,001 <0,001 0,187 <0,001 <0,001 0,002 0,033 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 0,129 <0,001 0,070 <0,001 <0,001 <0,001 0,229 <0,001 <0,001 0,445 0,093 0,094 0,091 0,989 0,270 0,530 0,250 0,673 0,254 0,054 0,036 0,146 0,932 0,340
Student t test (equal variances not assumed)
·¯˘Û·ÚΛ· (95% ¢∂: 1,21-3,49, p=0,008) Î·È Ù· ÎÔÚ›ÙÛÈ· 2,31 ÊÔÚ¤˜ (95% ¢∂: 1,42-3,76, p=0,001). √ ΛӉ˘ÓÔ˜ ÁÈ· ˘„ËÏ‹ ™∞¶ ‚Ú¤ıËΠ1,81 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙ· ·ÁfiÚÈ· (p<0,001) Î·È 2,39 ÛÙ· ÎÔÚ›ÙÛÈ· (p<0,001). ∞ÓÙ›ıÂÙ·, ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ˘„ËÏ‹ ¢∞¶ ‚Ú¤ıËΠηٿ 75% ÛÙ· ·ÁfiÚÈ· (p<0,001) Î·È 46% ÛÙ· ÎÔÚ›ÙÛÈ· (p<0,001). ∂›Û˘, ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ˘„ËÏ¿ ›‰· GLU ‚Ú¤ıËΠÙÔ 1999-2003 ÛÙ· ÎÔÚ›ÙÛÈ· ηٿ 56% (p=0,025). ∂ÈϤÔÓ, Ù· ·ÁfiÚÈ· Ù˘ ÂÚÈfi‰Ô˘ 1999-2003 ‚Ú¤ıËÎ·Ó Û ۯ¤ÛË Ì ÂΛӷ Ù˘ 1989-1993, ÌÂ
ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ηٿ 57% (p=0,098) Ó· ·Ó·Ù‡ÍÔ˘Ó ªÂÙ™˘Ó, ÂÓÒ ÛÙ· ÎÔÚ›ÙÛÈ· Ô Î›Ó‰˘ÓÔ˜ ‹Ù·Ó 2,69 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ (p=0,064). ∆Ô 19891993 ÌfiÏȘ ÙÔ 14,3% ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ‚Ú¤ıËΠ̠ªÂÙ™˘Ó, ÂÓÒ ÙÔ 1999-2003 ÙÔ 37,3% (p<0,001) (·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î·). ∂ÈϤÔÓ, ÛÙ· ·¯‡Û·Úη ·È‰È¿ Ô Î›Ó‰˘ÓÔ˜ Ó· ·Ó·Ù‡ÍÔ˘Ó ªÂÙ™˘Ó ‹Ù·Ó 3,89 ÙÔ 1989-1993 (95% ¢∂: 0,38-20,15, p>0,05), ηıÒ˜ ÙÔ 1999-2003 ·˘Í‹ıËΠÂÙ¿ ÊÔÚ¤˜ Î·È ·Ó‹Ïı ÛÙÔ 27,08 (95% ¢∂: 10,77-69,99, p<0,001). ¶·È‰È·ÙÚÈ΋ 2007;70:205-216
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·210
210
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ∂›Â‰· ۈ̷ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ÎÔÚÈÙÛÈÒÓ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 5-15 ÂÙÒÓ, ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 1989-1993 ª¤ÙÚËÛË
∏ÏÈΛ·
µ¿ÚÔ˜ (kg)
27,8 (7,5)
198
30,4 (7,4)
2,6
0,004
47,9 (10,8) 38,2 (13,7) 126,7 (9,8) 152,1 (8,3) 139,8 (15,6) 17,07 (2,75) 20,55 (3,57) 18,87 (3,64) 34,0 (20,3) 50,6 (21,0) 44,5 (21,8) 19,7 (20,9) 23,4 (3,1) 21,4 (3,5) 103,9 (11,1) 111,0 (11,3) 107,7 (11,8) 69,7 (10,3) 75,8 (7,9) 72,9 (9,6) 83,6 (10,1) 91,4 (8,6) 89,2 (9,7) 180,4 (32,2) 170,4 (28,6) 174,3 (30,5) 63,9 (25,4) 70,0 (30,9) 67,5 (28,9) 52,7 (12,3) 53,5 (15,1) 53,2 (14,0) 115,6 (29,6) 104,3 (28,1) 108,8 (29,2) 3,59 (1,00) 3,39 (0,94) 3,47 (0,96)
249 447 198 249 447 198 249 447 199 248 447 198 249 447 159 141 300 159 141 300 173 149 322 177 242 419 176 242 418 177 242 419 176 242 418 177 242 419
50,9 (11,9) 41,8 (15,1) 126,9 (9,9) 154,5 (8,3) 142,3 (16,5) 18,36 (3,75) 21,12 (3,84) 19,90 (4,03) 55,1 (26,3) 61,7 (25,1) 58,8 (25,8) 20,9 (3,5) 24,6 (3,3) 22,9 (3,9) 102,0 (15,0) 119,4 (10,0) 110,1 (15,6) 66,7 (10,9) 67,5 (11,8) 67,0 (11,3) 85,4 (8,3) 84,7 (8,7) 85,1 (8,5) 173,2 (30,6) 174,6 (34,9) 174,0 (33,2) 63,7 (26,5) 74,8 (31,5) 70,1 (30,0) 52,1 (11,9) 52,5 (12,9) 52,3 (12,4) 108,3 (28,0) 107,2 (30,5) 107,7 (29,5) 3,45 (0,84) 3,50 (1,07) 3,48 (0,98)
2,9 3,6 0,2 2,5 2,5 1,30 0,60 1,02 18,1 11,1 14,2 1,2 1,2 1,5 -1,9 8,4 2,5 -3,0 -8,3 -5,6 1,8 -6,8 -4,1 -7,2 4,2 -0,3 -0,3 4,9 2,6 -0,6 -1,0 -0,9 -7,3 2,9 -1,0 -0,14 0,11 0,01
0,004 <0,001 0,812 0,001 0,020 <0,001 0,088 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 0,174 <0,001 0,020 0,007 <0,001 <0,001 0,112 <0,001 <0,001 0,057 0,174 0,888 0,934 0,120 0,252 0,698 0,475 0,413 0,035 0,315 0,614 0,201 0,300 0,958
™‡ÓÔÏÔ 5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ 5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ ™∞¶ (mmHg)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
¢∞¶ (mmHg)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
GLU (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
TC (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
TG (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
HDL-C (mg/dl)
5,0-9,9 10,0-15,0 ™‡ÓÔÏÔ
LDL-C (mg/dl)
5,0-9,9 10,0-15,0
™‡ÓÔÏÔ ¢Â›ÎÙ˘ TC:HDL ™‡ÓÔÏÔ
p-value
230
5,0-9,9 10,0-15,0
¶∞µ (mm)
ª¤ÛË ÙÈÌ‹ (∆∞)
247 477 230 247 477 230 247 477 134 167 301 205 177 382 217 247 464 217 247 464 58 145 303 119 182 301 113 168 281 119 181 300 119 182 301 119 181 300
™‡ÓÔÏÔ
∞¢¶ (mm)
¡
5,0-9,9
5,0-9,9 10,0-15,0
¢ª™ (kg/m2)
ª¤ÛË ÙÈÌ‹ (∆∞)
ªÂÙ·‚ÔÏ‹
10,0-15,0 ™‡ÓÔÏÔ ⁄„Ô˜ (cm)
¡
1999-2003
5,0-9,9 10,0-15,0
Student t test (equal variances not assumed)
∞fi ÙËÓ ∂ÈÎfiÓ· 1 ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ ÙÔ 19992003 Û ۯ¤ÛË Ì ÙÔ 1989-1993, Ë ÂÈÊ¿ÓÂÈ· ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ¢ª™ Ù›ÓÂÈ Ó· ·˘Í¿ÓÂÙ·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ Î·È Ù˘ TC. ∞ÓÙ›ıÂÙ·, ÌÈÎÚ¤˜ ÙÈ̤˜ HDL-C (∂ÈÎfiÓ· 2) ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÙÔ˘ ¢ª™. ∞fi ÙËÓ ∂ÈÎfiÓ· 3 ‰È·ÈÛÙÒÓÂÙ·È ·‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ (¢ª™) Î·È Ù˘ ·˘ÍË̤Ó˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ·˘ÍË̤Ó˘ TC ηıÒ˜ Î·È Ì›ˆÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ì ·˘ÍË̤ÓÔ Paediatriki 2007;70:205-216
GLU Î·È Ì ¯·ÌËÏ‹ HDL-C. °ÂÓÈο, ÌÈÎÚ‹ ·‡ÍËÛË ‰È·ÈÛÙÒÓÂÙ·È Î·È ÛÙÔÓ ÂÈÔÏ·ÛÌfi ÙÔ˘ ªÂÙ™˘Ó.
™˘˙‹ÙËÛË ∆· ۈ̷ÙÔÌÂÙÚÈο ÌÂÁ¤ıË ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, fiˆ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·˘Í‹ıËÎ·Ó ÛËÌ·ÓÙÈο ÂÓÙfi˜ ÙÔ˘ ‚Ú·¯¤Ô˜ ‰È·ÛÙ‹Ì·ÙÔ˜ ÌÂٷ͇ 1989-1993 Î·È 1999-2003. ∆Ô Ì¤ÛÔ ‚¿ÚÔ˜ ·˘Í‹ıËΠηٿ 4 kg ‹ 10,4% (4,3 kg ÛÙ· ·ÁfiÚÈ· Î·È 3,6 kg ÛÙ· ÎÔÚ›ÙÛÈ·) Ì ·Ú¿ÏÏËÏË ·‡ÍËÛË ÙÔ˘ ‡„Ô˘˜ ηٿ 3,3 cm ‹ 2,4% (4 cm ÛÙ·
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ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚ‹ÛˆÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ‰ÂÈÎÙÒÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ
¶›Ó·Î·˜ 4. ∂ÈÔÏ·ÛÌfi˜ ˘ÂÚ‚ÔÏÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È ·¯˘Û·ÚΛ·˜, ·˘ÍË̤Ó˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ۷ί¿ÚÔ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, ÌÂٷ͇ ÙˆÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003 ∞ÁfiÚÈ· 1989-1993 ª¤ÙÚËÛË
ŸÚÈ·
¢ª™
º˘ÛÈÔÏÔÁÈο À¤Ú‚·Ú· ¶·¯‡Û·Úη p-value*
™∞¶
<90 ∂.£. ≥90 ∂.£. p-value
¢∞¶
<90 ∂.£. ≥90 ∂.£. p-value
GLU
<100 mg/dl ≥100 p-value
TC
<180 mg/dl 180-200 >200 p-value
TG
<90 ∂.£. ≥90 ∂.£. p-value
HDL-C
≥10 ∂.£. <10 ∂.£. p-value
LDL-C
≤110 mg/dl 111-113 >130
p-value ¢Â›ÎÙ˘ TC:HDL ≤4,00 >4,00 p-value ™˘Ó‰˘·ÛÌfi˜ 0 ·Ú·ÁfiÓÙˆÓ 1-2 ÎÈÓ‰‡ÓÔ˘** ≥3 p-value
1999-2003
¡ (%) 355 (74,3) 291 (66,3) 99 (20,7) 108 (24,6) 24 (5,0) 40 (9,1) 0,011 350 (75,4) 167 (63,5) 114 (24,6) 96 (36,5) 0,001 252 (54,3) 212 (80,6) 212 (45,7) 51 (19,4) <0,001 188 (90,8) 283 (91,0) 19 (9,2) 28 (9,0) 0,946 169 (58,3) 268 (65,8) 79 (27,2) 88 (21,6) 42 (14,5) 51 (12,5) 0,119 230 (85,8) 361 (88,7) 38 (14,2) 46 (11,3) 0,268 251 (87,2) 366 (89,9) 37 (12,8) 41 (10,1) 0,254 155 (53,4) 245 (60,2) 83 (28,6) 100 (24,6) 52 (17,9) 62 (15,2) 0,206 232 (80,6) 33,2 (81,6) 56 (19,4) 75 (18,4) 0,736 69 (38,8) 95 (39,7) 98 (55,1) 135 (56,5) 11 (6,2) 9 (3,8) 0,522
∫ÔÚ›ÙÛÈ· ¶ÔÛÔÛÙÈ·›· ÌÂÙ·‚ÔÏ‹ -9,7 18,8 82,0 -15,8 48,4 48,4 -57,5 0,2 -2,2 12,9 -20,6 -13,8 3,3 -25,7 3,0 -26,7 12,7 -14,0 -15,1 1,2 -5,2 2,3 2,5 -63,2
1989-1993
1999-2003
¡ (%) 345 (72,3) 284 (63,5) 104 (21,8) 111 (24,8) 28 (5,9) 52 (11,6) 0,002 349 (75,2) 172 (57,3) 115 (24,8) 128 (42,7) <0,001 260 (56,0) 206 (68,7) 204 (44,0) 94 (31,3) <0,001 182 (89,7) 308 (95,7) 21 (10,3) 14 (4,3) 0,007 179 (59,5) 256 (61,1) 70 (23,3) 83 (19,8) 52 (17,3) 80 (19,1) 0,504 248 (88,3) 362 (86,6) 33 (11,7) 56 (13,4) 0,520 260 (86,7) 371 (88,5) 40 (13,3) 48 (11,5) 0,449 156 (51,8) 256 (61,2) 86 (28,6) 83 (19,9) 59 (19,6) 79 (18,9) 0,015 234 (78,0) 338 (80,7) 66 (22,0) 81 (19,3) 0,382 66 (37,3) 90 (32,4) 106 (59,9) 168 (60,4) 5 (2,8) 20 (7,2) 0,104
¶ÔÛÔÛÙÈ·›· ÌÂÙ·‚ÔÏ‹ -12,2 13,8 96,6 -23,8 72,2 22,7 -28,9 6,7 -58,3 2,7 -15,0 10,4 -2,0 12,7 2,0 -15,7 18,1 -30,4 -3,6 3,5 -12,3 -15,1 0,8 61,1
* ŒÏÂÁ¯Ô˜ χ2, ** √ Û˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ·ÊÔÚ¿ ÛÙÔÓ ¢ª™, ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, ÛÙÔ GLU, ÛÙËÓ HDL-C Î·È ÛÙ· TG
·ÁfiÚÈ· Î·È 2,5 cm ÛÙ· ÎÔÚ›ÙÛÈ·). ø˜ Û˘Ó¤ÂÈ·, fï˜, Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜, Ô ¢ª™ ·˘Í‹ıËΠηٿ 0,97 kg/m2 ‹ 5,2%, Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË Ó· ‰È·ÈÛÙÒÓÂÙ·È ÛÙ· ÎÔÚ›ÙÛÈ· Ì ÔÛÔÛÙfi 5,4%. ∞fi ÌÂϤÙË Û ·ÁfiÚÈ· Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 9-15 ÂÙÒÓ (22) Î·È ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi ·˘Ùfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ (1982 ¤ˆ˜ 2002), ‚Ú¤ıËΠ·‡ÍËÛË 4,4 kg (9,6%) ÛÙÔ ‚¿ÚÔ˜, 1,7 cm (1,1%) ÛÙÔ ‡„Ô˜ Î·È 1,64 kg/m2 (8,4%) ÛÙÔÓ ¢ª™. ∂›Û˘ ·fi ÙË Û‡ÁÎÚÈÛË Ù˘ 50˘ ∂.£. ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÙÔ˘ ‡„Ô˘˜ ÙˆÓ ·È‰ÈÒÓ (∂ÈÎfiÓ· 4) Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Î·È ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ÙÔ˘ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ (24), ‰È·ÈÛÙÒÓÂÙ·È Ë ÌÂÁ·Ï‡-
ÙÂÚË ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ Î·È ÌÈÎÚfiÙÂÚË ÙÔ˘ ‡„Ô˘˜ Û fiϘ ۯ‰fiÓ ÙȘ ËÏÈ˘ ÙˆÓ ·È‰ÈÒÓ, ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 1999-2003. ™Â ÌÂϤÙË ·ÁÔÚÈÒÓ ËÏÈΛ·˜ 6-15 ÂÙÒÓ Ù˘ ™·Ú·ÁfiÛ· (25), ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1980 Î·È 1995, ‚Ú¤ıËÎ·Ó ÌÈÎÚfiÙÂÚ˜ ·˘Í‹ÛÂȘ, Û ۯ¤ÛË Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÛÙÔ ‚¿ÚÔ˜ (3,4 kg ‹ 9,9%), ÛÙÔ ‡„Ô˜ (3,9 cm ‹ 2,8%) Î·È ÛÙÔÓ ¢ª™ (0,64 kg/m2 ‹ 3,6%). øÛÙfiÛÔ, Ù· ·ÁfiÚÈ· Ù˘ ™·Ú·ÁfiÛ· ›¯·Ó, ÙÔ 1995, Û ۯ¤ÛË Ì ٷ ·ÁfiÚÈ· ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ Ù˘ ∫Ú‹Ù˘ Ù˘ ÂÚÈfi‰Ô˘ 1989-1993, ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ‡„Ô˜ (139,2 ¤Ó·ÓÙÈ 141,4 cm, p=0,001, ·ÓÙ›ÛÙÔȯ·) Î·È ¢ª™ (18,2 ¤Ó·ÓÙÈ 18,7 kg/m2, p=0,001, ·ÓÙ›ÛÙÔȯ·). ¶·È‰È·ÙÚÈ΋ 2007;70:205-216
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ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 5. ¢Â›ÎÙ˜ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Odds Ratio) ¢ª™, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÏÈȉ›ˆÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1999-2003 Û ۯ¤ÛË Ì ÙËÓ ÂÚ›Ô‰Ô 1989-1993 ∞ÁfiÚÈ· ª¤ÙÚËÛË
ŸÚÈ·
¢ª™
™∞¶ ¢∞¶ GLU TC
TG HDL-C LDL-C
¢Â›ÎÙ˘ TC:HDL ™˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘**
¡
√R (95% ¢∂)
º˘ÛÈÔÏÔÁÈο À¤Ú‚·Ú· ¶·¯‡Û·Úη <90 ∂.£. ≥90 ∂.£. <90 ∂.£. ≥90 ∂.£. <100 mg/dl ≥100 <180 180-200 >200 <90 ∂.£. ≥90 ∂.£. ≥10 ∂.£. <10 ∂.£. ≤110 mg/dl 111-113 >130 ≤4,00 >4,00
646 207 64 517 210 464 263 471 47 437 167 93 591 84 617 78 400 183 114 564 131
1,00 1,32 (0,96-1,80) 2,06 (1,21-3,49) 1,00 1,81 (1,30-2,52) 1,00 0,25 (0,17-0,36) 1,00 0,95 (0,50-1,79) 1,00 0,70 (0,48-1,00) 0,76 (0,48-1,20) 1,00 0,77 (0,49-1,22) 1,00 0,76 (0,47-1,22) 1,00 0,76 (0,53-1,08) 0,75 (0,49-1,14) 1,00 0,94 (0,64-1,39)
0 1-2 ≥3
164 233 20
1,00 0,88 (0,57-1,34) 0,43 (0,16-1,17)
∫ÔÚ›ÙÛÈ· p*
¡
√R (95% ¢∂)
0,742
629 215 80 521 243 466 298 490 35 435 153 132 610 89 631 88 412 169 138 572 147
1,00 1,29 (0,95-1,77) 2,31 (1,42-3,76) 1,00 2,39 (1,74-3,27) 1,00 0,54 (0,40-0,74) 1,00 0,44 (0,22-0,90) 1,00 0,84 (0,58-1,21) 1,09 (0,73-1,63) 1,00 1,16 (0,74-1,84) 1,00 0,86 (0,55-1,34) 1,00 0,59 (0,41-0,85) 0,83 (0,56-1,23) 1,00 0,85 (0,59-1,23)
0,543 0,098
156 274 25
1,00 1,10 (0,73-1,66) 2,69 (0,95-7,65)
0,087 0,008 <0,001 <0,001 0,870 0,049 0,240 0,265 0,253 0,124 0,179
p* 0,104 0,001 <0,001 <0,001 0,025 0,350 0,666 0,519 0,496 0,005 0,352 0,388 0,636 0,064
* §ÔÁÈÛÙÈ΋ ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘ (ˆ˜ Û˘ÌÌÂÙ·‚ÏËÙ‹ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ËÏÈΛ·), ** √ Û˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ·ÊÔÚ¿ ÛÙÔÓ ¢ª™, ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, ÛÙÔ GLU, ÛÙËÓ HDL-C Î·È ÛÙ· TG
¶·È‰È¿ ÂÚÈfi‰Ô˘ 1999-2003
¶·È‰È¿ ÂÚÈfi‰Ô˘ 1989-1993
¢ª™
¢ª™
√
14 13 12 11 10 9
ÛÙ
8 7 6
)
g/
dl
5
g/
6
(m
(m
7
5
Ë
8
fiÏ
fiÏ
ÂÚ
ÂÚ
ÛÙ
ÈΛ·
ÏË
ÏË
14 13 12 11 10 9
¯Ô
∏Ï
Ë) (¤Ù
¯Ô
΋
΋
ÏÈ
Ë
30,0 28,7 27,3 25,9 24,6 23,2 21,8 20,4 19,1 17,7 16,4 15,0 13,7 12,3 11,00 40375 353025 302075 252025 201075 151025 10075 50
ÏÈ
√
29,4 27,5 26,0 24,6 23,3 21,9 20,6 19,2 17,9 16,5 15,2 13,9 12,5 115,20 3 25 3 00 3 75 2 50 2 25 2 00 2 75 1 50 1 25 1 00 1 75 50 dl )
∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ¢ª™ Î·È TC ÛÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ (ÂÊ·ÚÌÔÁ‹ ÔÏ˘ˆÓ˘ÌÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ 3Ô˘ ‚·ıÌÔ‡). Paediatriki 2007;70:205-216
∏
›· ÏÈÎ
(¤Ù
Ë)
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™ÂÏ›‰·213
213
ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚ‹ÛˆÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ‰ÂÈÎÙÒÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ
¶·È‰È¿ ÂÚÈfi‰Ô˘ 1999-2003
g/dl)
56
78
(¤
ÙË
)
-C (m
·
HDL
Λ
ÙË
(¤
·
78
14 1213 1 1 9 10
ÏÈ
g/dl)
56
Λ
-C (m
ÏÈ
HDL
∏
13 0 11 5 10 0 85 70 55 40 25 10
)
14 1213 1 1 9 10
5 30,,9 28 ,4 27 ,9 25 ,4 24 ,9 22 ,5 21 ,0 20 ,5 18 ,0 17 ,6 15 ,1 14 ,6 12 ,2 11
13 0 11 5 10 0 85 70 55 40 25 10
¢ª™
¢ª™
,5 30 ,9 8 2 ,4 27 ,9 25 ,4 24 ,9 22 ,5 21 ,0 20 ,5 18 ,0 17 ,6 15 ,1 14 ,6 12 ,2 11
∏
¶·È‰È¿ ÂÚÈfi‰Ô˘ 1989-1993
∂ÈÎfiÓ· 2. ™˘Û¯¤ÙÈÛË ¢ª™ Î·È HDL ÛÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ (ÂÊ·ÚÌÔÁ‹ ÔÏ˘ˆÓ˘ÌÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ 3Ô˘ ‚·ıÌÔ‡).
∂›Û˘, ·fi ÌÂϤÙË Û ·È‰È¿ Ù˘ ∆Ô˘ÚΛ·˜ (26), ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ Î·È ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ‚Ú¤ıËÎ·Ó ÌÂÁ·Ï‡ÙÂÚ˜ ·˘Í‹ÛÂȘ ÛÙÔ ‚¿ÚÔ˜ (4,4 kg) Î·È ÛÙÔ ‡„Ô˜ (3,9 cm), ÂÓÒ ÌÂϤÙË Û ¤ÊË‚Ô˘˜ 15-18 ÂÙÒÓ Ù˘ ºÈÓÏ·Ó‰›·˜ (31), ¤‰ÂÈÍ ·‡ÍËÛË 4,8% ÛÙÔÓ ¢ª™ ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1980 Î·È 1992. ∞fi ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËΠ›Û˘ fiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ·˘Í‹ıËΠηٿ 31,5% (·fi 26,7% ·Ó‹Ïı·Ó ÛÂ
ªÂÙ·‚ÔÏ‹ ÂÈÔÏ·ÛÌÔ‡
˘ÂÚ‚ÔÏÈÎfi ‚¿ÚÔ˜ & ·¯˘Û·ÚΛ· ·ÚÙËÚȷ΋ ›ÂÛË GLU TC TG HDL-C LDL-C TC:HDL-C Û˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ 1989-1993
1999-2003
#
À¤Ú‚·Ú· Î·È ·¯‡Û·Úη ·È‰È¿: Ù·ÍÈÓfiÌËÛË IOTF, ·ÚÙËÚȷ΋ ›ÂÛË: ™∞¶ ‹/Î·È ¢∞¶ ≥90‹ ∂.£., GLU ≥100 mg/dl, TC >200 mg/dl, TG ≥90‹ ∂.£., HDL-C <10Ë ∂.£., LDL-C >130 mg/dl, TC:HDL-C >4,00 ## ™˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ: ¢ª™ (·¯˘Û·ÚΛ·), ·ÚÙËÚȷ΋ ›ÂÛË (™∞¶ ‹/Î·È ¢∞¶), GLU, TG Î·È HDL-C
∂ÈÎfiÓ· 3. ™¯ÂÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ ÙÔ˘ ¢ª™, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÙÔ˘ GLU Î·È ÙˆÓ ÏÈȉ›ˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 5-15 ÂÙÒÓ, ÌÂٷ͇ ÙˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ 1989-1993 Î·È 1999-2003.
35,1%), Ì ΢ÚÈfiÙÂÚÔ fï˜, ÙÔÓ ‰ÈÏ·ÛÈ·ÛÌfi ÙˆÓ ·¯‡Û·ÚÎˆÓ (·fi 5,4 Û 10,4%). ¶·Ú¿ÏÏËÏ·, ·fi ÙÔ˘˜ Magkos Î·È Û˘Ó (22) ·Ó·Ê¤ÚıËΠ·‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙˆÓ ˘¤Ú‚·ÚˆÓ ·ÁÔÚÈÒÓ Ù˘ ∫Ú‹Ù˘ ηٿ 63% Î·È ÙˆÓ ·¯‡Û·ÚÎˆÓ Î·Ù¿ 202% ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1982 Î·È 2002, ÂÓÒ Û ÌÂϤÙË ÙÔ 2002 Û 2458 ·È‰È¿ Ù˘ £ÂÛÛ·ÏÔӛ΢ (27), ËÏÈΛ·˜ 6-17 ÂÙÒÓ, ‚Ú¤ıËΠÂÈÔÏ·ÛÌfi˜ ˘¤Ú‚·ÚˆÓ 22,2% Î·È ·¯‡Û·ÚÎˆÓ 4,1% Î·È ·‡ÍËÛË ÙÔ˘ ¢ª™ ηٿ 5% ÂÚ›Ô˘ ·fi ÙÔ 1982. ªÂٷ͇ ÙˆÓ ÂÙÒÓ 1985 Î·È 1995, ‚Ú¤ıËΠ›Û˘ Û ·È‰È¿ Ù˘ ∞˘ÛÙÚ·Ï›·˜ (28), ËÏÈΛ·˜ 2-18 ÂÙÒÓ, 50% ·‡ÍËÛË ÙˆÓ ˘¤Ú‚·ÚˆÓ ·È‰ÈÒÓ (·fi 10% ·Ó‹Ïı·Ó Û 15,4%) Î·È 276% ÙˆÓ ·¯‡Û·ÚÎˆÓ (·fi 1,3% ÛÙÔ 4,9%), Ì 3,28 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÙÔ 1995 ÁÈ· ·Ó¿Ù˘ÍË ·¯˘Û·ÚΛ·˜. ¶·ÚfiÌÔÈ·, ·fi ÌÂϤÙË ÁÈ· ÙË ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ¢ª™ Û ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ‰Â›ÁÌ· ·È‰ÈÒÓ ÙÔ˘ ∫·Ó·‰¿ (29), ËÏÈΛ·˜ 7-13 ÂÙÒÓ, ‚Ú¤ıËΠfiÙÈ Ù· ˘¤Ú‚·Ú· ·È‰È¿ ·˘Í‹ıËÎ·Ó ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1981 Î·È 1996 ·fi 15% Û 21,2% Î·È ˘ÂÚ‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó Ù· ·¯‡Û·Úη (·fi 5% Û 12,7%), Ì ÙÔ Û‡ÓÔÏÔ ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ Ó· ·Ó¤Ú¯ÂÙ·È ÙÔ 1996 Û 38,9%. ∆· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ˘ÂÚ‚ÔÏÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È Ù˘ ·¯˘Û·ÚΛ·˜, ·ÎfiÌ· Î·È ÂÓÙfi˜ ‚Ú·¯¤ˆÓ ¯ÚÔÓÈÎÒÓ ÂÚÈfi‰ˆÓ. ¶·Ú¿ÏÏËÏ·, ηٷ‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ù· ˘¤Ú‚·Ú· ·È‰È¿ ·˘Í¿ÓÔ˘Ó ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ Û˘Ó¯Ҙ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·˘Í¿ÓÂÙ·È ‰È·ÚÎÒ˜ Ë ·È‰È΋ ·¯˘Û·ÚΛ·. °È· ·Ú¿‰ÂÈÁÌ·, ÛÙË ÌÂϤÙË NHANES 1999-2002 ÙˆÓ ∏¶∞ (30), ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 19992000 Î·È 2001-2002, ‚Ú¤ıËΠÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË Î·Ù¿ 10% ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ (·fi 15% ·Ó‹Ïı·Ó Û 16,5%) Û ۯ¤ÛË Ì ÙËÓ ·‡ÍËÛË Î·Ù¿ ¶·È‰È·ÙÚÈ΋ 2007;70:205-216
Pediatri May-Jun 07
24-05-07
17:58
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∂ÈÎfiÓ· 4. ™¯ËÌ·ÙÈ΋ Û‡ÁÎÚÈÛË 50‹˜ ∂.£. ‚¿ÚÔ˘˜ Î·È ‡„Ô˘˜ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Î·È ÙÔ˘ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ (πÀ¶).
5,4% ÙˆÓ ˘¤Ú‚·ÚˆÓ (·fi 29,9% ·Ó‹Ïı·Ó Û 31,5%). ∂ӉȷʤÚÔÓ, fï˜, ·ÚÔ˘ÛÈ¿˙ÂÈ Ë Û˘Û¯¤ÙÈÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ·È‰ÈÒÓ Ì ÙË ÌÂÙ·‚ÔÏ‹ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·. ∞Ó Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ë ™∞¶ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÂÚÈfi‰Ô˘ 1999-2003 ‚Ú¤ıËΠ·˘ÍË̤ÓË Î·Ù¿ 2%, Û ۯ¤ÛË Ì ÂΛÓË Ù˘ ÂÚÈfi‰Ô˘ 1989-1993, ÌË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ‚Ú¤ıËΠÛÙ· ›‰· ÙÔ˘ GLU, Ù˘ TC, Ù˘ HDL-C Î·È Ù˘ LDL-C ηٿ 3,9%, 1,2%, 0,7% Î·È 2,5%, ·ÓÙ›ÛÙÔȯ·. ™Â ÌÂϤÙË ÂÊ‹‚ˆÓ Ù˘ ºÈÓÏ·Ó‰›·˜ (31), ·Ó·Ê¤ÚÔÓÙ·È ÌÂÁ·Ï‡ÙÂÚ˜ ÌÂÈÒÛÂȘ ÌÂٷ͇ 1980 Î·È 1992 ÛÙËÓ TC, ÛÙËÓ HDL-C Î·È ÙËÓ LDL-C ηٿ -8,5%, 19,2% Î·È -7,5%, ·ÓÙ›ÛÙÔȯ·. √È ·ÏÏ·Á¤˜ ·˘Ù¤˜ ·ÔÙÂÏÔ‡Ó Û˘Ó¤ÂÈ· Ù˘ ÂıÓÈ΋˜ ÔÏÈÙÈ΋˜ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ 1970, Ì ·ÚÈÔ Paediatriki 2007;70:205-216
ÛÙfi¯Ô ÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·, ̤ۈ Ù˘ Ì›ˆÛ˘ ηٷӿψÛ˘ ÎÔÚÂṲ̂ÓÔ˘ Ï›Ô˘˜, Ó·ÙÚ›Ô˘ Î·È ÙËÓ ·‡ÍËÛË Î·Ù·Ó¿ÏˆÛ˘ ÊÚÔ‡ÙˆÓ Î·È Ï·¯·ÓÈÎÒÓ (32). ∞ÓÙ›ıÂÙ·, ÔÈ Magkos Î·È Û˘Ó (22) ·Ó·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈΤ˜ ·˘Í‹ÛÂȘ ÛÙ· ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜ ·ÁÔÚÈÒÓ Ù˘ ∫Ú‹Ù˘, Ì ΢ÚÈfiÙÂÚË ÙËÓ ·˘ÍË̤ÓË LDL-C ηٿ 25,3%. ™˘ÓÔÙÈο Î·È Û ۯ¤ÛË Ì ٷ ·Ú·¿Óˆ ·ÔÙÂϤÛÌ·Ù·, Ô Û˘Ó‰˘·ÛÌfi˜ ·Ú·ÁfiÓÙˆÓ ªÂÙ™˘Ó ‚Ú¤ıËΠ·˘ÍË̤ÓÔ˜ ÛÙ· ·È‰È¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ηٿ 24% ÂÓÙfi˜ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ (·fi 4,5% ·Ó‹Ïı Û 5,6%). ∞fi Ù· ·È‰È¿, fï˜, Ì ªÂÙ™˘Ó, ÔÛÔÛÙfi ÌfiÏȘ 14,3% ‹Ù·Ó ·¯‡Û·Úη ÙÔ 1989-1993, ÂÓÒ ˘ÂÚ‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó ÙÔ 1999-2003 Î·È ·Ó‹Ïı·Ó ÛÙÔ 37,3%. ™Ù· ·¯‡Û·Úη ·È‰È¿, Ô Î›Ó‰˘ÓÔ˜ Ó· ·Ó·Ù‡ÍÔ˘Ó ªÂÙ™˘Ó ÙÔ 1989-1993
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·215
215
ªÂÙ·‚ÔÏ‹ ۈ̷ÙÔÌÂÙÚ‹ÛˆÓ, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ‰ÂÈÎÙÒÓ ÔÚÔ‡ ·›Ì·ÙÔ˜ ·È‰ÈÒÓ
‹Ù·Ó 3,89 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ¤Ó·ÓÙÈ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ, ηıÒ˜ ÙÔ 1999-2003 Ô Î›Ó‰˘ÓÔ˜ ·˘Ùfi˜ ‹Ù·Ó ÂÙ¿ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ (27,08). ¢È·ÈÛÙÒÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ·Ó Î·È ÙÔ ªÂÙ™˘Ó ·ÔÙÂÏ› Û˘Ó¿ÚÙËÛË Ù˘ ‰˘Ó·ÌÈ΋˜ ÙˆÓ Û˘ÓÈÛÙˆÛÒÓ ÙÔ˘, ÂÓÙÔ‡ÙÔȘ, ÌÂÙ·‚¿ÏÏÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ Û‡Ìʈӷ Ì ÙË ÌÂÙ·‚ÔÏ‹ Ù˘ ·¯˘Û·ÚΛ·˜. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ Î·Ù·ÁÚ¿ÊÂÙ·È Ë ‰È·¯ÚÔÓÈ΋ Ù¿ÛË ÙÔ˘ ªÂÙ™˘Ó Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜, ·Ú¿ ÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ÛÙ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™Â ·È‰È¿ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 3-18 ÂÙÒÓ, ÛÙÔ ‰È¿ÛÙËÌ· 2001-2003 (9), ‚Ú¤ıËΠfiÙÈ ÂÚ›Ô˘ 4% ›¯·Ó ªÂÙ™˘Ó, ·fi Ù· ÔÔ›· Ù· ‰‡Ô ÙÚ›Ù· ‹Ù·Ó ·¯‡Û·Úη. ∂›Û˘, Û ·¯‡Û·Úη ·È‰È¿ Ù˘ πÙ·Ï›·˜ ËÏÈΛ·˜ 6-14 ÂÙÒÓ (33), ÙÔ 38% ›¯Â ·ÚÔ˘Û›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚÈÒÓ ·Ú·ÁfiÓÙˆÓ ªÂÙ™˘Ó, ÂÓÒ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ›‰· ÈÓÛÔ˘Ï›Ó˘, C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ Î·È ÌÂÁ·Ï‡ÙÂÚË ·ÓÂÏ·ÛÙÈÎfiÙËÙ· ηڈÙȉÈ΋˜ ·ÚÙËÚ›·˜ (carotid artery stiffness). ¶·Ú¿ ÙȘ ·Ú·¿Óˆ ·Ó·ÊÔÚ¤˜ Î·È Û˘ÁÎÚ›ÛÂȘ, ÛÙË ‰È·¯ÚÔÓÈ΋ Û‡ÁÎÚÈÛË ·ÔÙÂÏÂÛÌ¿ÙˆÓ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, Ë ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfiÙËÙ·, Ë Ì¤ıÔ‰Ô˜ ‰ÂÈÁÌ·ÙÔÏË„›·˜, ÔÈ ÌÂıÔ‰ÔÏÔÁÈÎÔ› ÂÚÈÔÚÈÛÌÔ› ‹ ‰È·ÊÔÚ¤˜, ηıÒ˜ Î·È Ë ÌÂÙ·‚ÏËÙfiÙËÙ· ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ (11). ∞Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÌÂÏÂÙÒÓ, fiˆ˜ Î·È Ù˘ ·ÚÔ‡Û·˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·, ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô ·ÔÙÂÏ› Ë ‰È·›ÛÙˆÛË ÙÔ˘ Eisenmann (11) fiÙÈ ·Ó Î·È ÛÙ·ÙÈÛÙÈÎÒ˜ ÔÈ ‰È·ÊÔÚÔÔÈ‹ÛÂȘ Â›Ó·È ÛËÌ·ÓÙÈΤ˜ Î·È ·ÓÙ›ıÂÙ˜, ˆÛÙfiÛÔ ˆ˜ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÔˆÛ‰‹ÔÙ ·ÍÈfiÏÔÁ˜ ÌÂÙ·‚ÔϤ˜. ∏ ¿Ô„Ë ·˘Ù‹ ÂÓÈÛ¯‡ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Â¿Ó ÙÔ ‰È¿ÛÙËÌ· ÌÂϤÙ˘ Â›Ó·È ‚Ú·¯Â›· ÂÚ›Ô‰Ô˜ Î·È ·Ó Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ô ÚfiÏÔ˜ Ù˘ ÂӉ¯fiÌÂÓ˘ ›‰Ú·Û˘ ‹ ÌÂÙ·‚ÔÏ‹˜ ¿ÏÏˆÓ Û˘Ì·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÔÈ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Î·È Ë ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË, Ô˘ ˆÛÙfiÛÔ ‰ÂÓ ÂÎÙÈÌ‹ıËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™˘ÌÂÚ·ÛÌ·ÙÈο, ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ‰È·ÈÛÙÒÓÂÙ·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÛÙÔ˘˜ ‰Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘. ∏ ¤ÏÏÂÈ„Ë ÛˆÛÙÒÓ ÂÈÏÔÁÒÓ ÛÙË ‰È·ÙÚÔÊ‹, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘, Ë ˘ÈÔı¤ÙËÛË ÂÈ‚Ï·‚ÒÓ ÁÈ· ÙËÓ ˘Á›· Û˘ÓËıÂÈÒÓ fiˆ˜ ÙÔ Î¿ÓÈÛÌ· Î·È Ë Î·Ù·Ó¿ÏˆÛË ÔÈÓÔÓ‡̷ÙÔ˜, ·ÔÙÂÏÔ‡Ó ÌÂÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ Û˘ÓÂÈÛʤÚÔ˘Ó ÛÙȘ ·ÚÓËÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÙˆÓ ‰ÂÈÎÙÒÓ ˘Á›·˜. ¢Â‰Ô̤Ó˘ Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Û ̷ıËÙ¤˜ (17,18,21), ÎÚ›ÓÔÓÙ·È ·Ó·Áη›· Ô Û¯Â‰È·ÛÌfi˜ Î·È Ë ÂÊ·ÚÌÔÁ‹ ÂıÓÈ΋˜ ÔÏÈÙÈ΋˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È ÙËÓ ÚfiÏË„Ë Û ·ÚfiÌÔÈÔ Ï·›ÛÈÔ ‰Ú¿Û˘.
∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿ ÁÈ· ÙË ¯ÚËÌ·ÙÔ‰fiÙËÛË Ù˘ ÌÂϤÙ˘ ÙË °ÂÓÈ΋ °Ú·ÌÌ·Ù›· ∞ıÏËÙÈÛÌÔ‡, ÙÔ ÀÔ˘ÚÁÂ›Ô ¶·È‰Â›·˜ Î·È £ÚËÛÎÂ˘Ì¿ÙˆÓ, ÙÔ ¶·È‰·ÁˆÁÈÎfi πÓÛÙÈÙÔ‡ÙÔ, ÙËÓ ÂÙ·ÈÚ›· Kellogg’s, ηıÒ˜ Î·È ÙȘ ‰ËÌÔÙÈΤ˜ ·˘ÙÔ‰ÈÔÈ΋ÛÂȘ ÙˆÓ ¢‹ÌˆÓ ∞Á. ¡ÈÎÔÏ¿Ô˘, ƒÔ‡‚·, ÃÂÚÛÔÓ‹ÛÔ˘ Î·È ∏Ú·ÎÏ›Ԣ. ∂›Û˘, Û˘Ó¤‚·Ï·Ó ·ÔÙÂÏÂÛÌ·ÙÈο ÔÈ Û˘ÓÂÚÁ¿Ù˜: ÃÚ‹ÛÙÔ˜ ÷Ù˙‹˜, ∂ÈÚ‹ÓË ª¿ÚηÙ˙Ë, πˆ¿ÓÓ· ªÔÛ¯·Ó‰Ú¤·, ªÈ¯¿Ï˘ ∫˘Úȷο΢, ™ÔÊ›· ºÏÔ˘Ú‹, ª·Ú›· ªÈÙÛÒÚË, πˆ¿ÓÓ· ∞ÔÛÙÔÏ¿ÎË, ºÚfiÛˆ ªÂÚ‚·Ó¿ÎË Î·È Caroline Codrington.
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ORIGINAL ARTICLE
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¶ÔÛÔÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ ÛÙÔ ·›Ì· ÓÂÔÁÓÒÓ - ™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ‰‡Ô ÌÂıfi‰ˆÓ ∏. ÷Ù˙ËȈ·ÓÓ›‰Ë˜, ∞. ¡·Ô‡Ì, °. MËÙÛÈ¿ÎÔ˜, Ã. ∆۷ηϛ‰Ë˜, ¢. °. °Ô˘Ï‹˜, ¡. ¡ÈÎÔÏ·˝‰Ë˜ ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ıÔψÛÈÌÂÙÚÈ΋ (£√§) ̤ıÔ‰Ô˜ ̤ÙÚËÛ˘ Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ (CRP) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ¿ÏË Ú·ÎÙÈÎfiÙËÙ·, ηıÒ˜ ‰ÂÓ ··ÈÙÂ›Ù·È ÂÚÁ·ÛÙ‹ÚÈÔ, ‰ÈÂÓÂÚÁÂ›Ù·È Ì ϋ„Ë Ôχ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ÙÚȯoÂȉÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ‰È·ı¤ÛÈÌÔ Û Ôχ ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË Ù˘ ·ÍÈÔÈÛÙ›·˜ Ù˘ £√§ ÌÂıfi‰Ô˘ ̤ÙÚËÛ˘ Ù˘ CRP Ì ·˘Ù‹ Ù˘ ÓÂÊÂÏÔÌÂÙÚÈ΋˜ ÌÂıfi‰Ô˘ (¡∂º). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ÌÂϤÙË ÂͤٷÛ 163 ‰Â›ÁÌ·Ù· Ï‹ÚÔ˘˜ ·›Ì·ÙÔ˜ ·fi 79 ÓÂÔÁÓ¿, Ù· ÔÔ›· ÓÔÛËχıËÎ·Ó ÛÙË µ’ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ ÙÔ˘ A.¶.£. ∏ CRP ÌÂÙÚ‹ıËΠ۠97 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ηıÈÂڈ̤Ó˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ (65 ÓÂÔÁÓ¿, ÔÌ¿‰· ∞) Î·È Û 66 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÓÂÔÁÓÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‡ÔÙË ÁÈ· Ïԛ̈ÍË (43 ÓÂÔÁÓ¿, ÔÌ¿‰· µ). √ £√§ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ CRP ‰ÈÂÓÂÚÁ‹ıËΠÛÙËÓ ÎÏÈÓÈ΋ ·fi ÙÔ ÚÔÛˆÈÎfi Ù˘ ÌÔÓ¿‰·˜ Î·È ¤ÁÈÓ Ì ÙËÓ Ù¯ÓÈ΋ Quick Read System, ÂÓÒ Ô ¡∂º Ì ÓÂÊÂÏfiÌÂÙÚÔ Ù˘ ÂÙ·ÈÚ›·˜ µeckman ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. ∞ÔÙÂϤÛÌ·Ù·: ¢È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ CRP Ì ÙË £√§ Î·È ¡∂º ̤ıÔ‰Ô (18,7±22,6 mg/l ¤Ó·ÓÙÈ 14,9±20,7 mg/l, ·ÓÙ›ÛÙÔȯ·, p<0,001). √È £√§ Î·È ¡∂º ̤ıÔ‰ÔÈ ‚Ú›ÛÎÔÓÙ·Ó Û ÈÛ¯˘Ú¿ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË (r2=0,8935, p<0,001). ™ÙËÓ ·Ó¿Ï˘ÛË Bland-Altman ‰È·ÈÛÙÒıËΠ˘ÂÚÂÎÙ›ÌËÛË Ù˘ CRP Ì ÙË £√§ ̤ıÔ‰Ô Û ۯ¤ÛË Ì ÙË ¡∂º ÛÙËÓ ÂÚÈÔ¯‹ ÙÈÌÒÓ Ì¤¯ÚÈ 40 mg/l. ªÂ Ô˘‰fi Ù· 11 mg/l, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ £√§ ÌÂıfi‰Ô˘ ‹Ù·Ó 93% Î·È 55%, ·ÓÙ›ÛÙÔȯ· Û ۯ¤ÛË Ì ÙË ıÂÙÈ΋ ·ÈÌÔηÏÏȤÚÁÂÈ·. ™˘ÌÂÚ¿ÛÌ·Ù·: √ ÁÚ‹ÁÔÚÔ˜ ˘ÔÏÔÁÈÛÌfi˜ Ù˘ CRP Ì ÙË £√§ ̤ıÔ‰Ô Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ·ÍÈfiÈÛÙÔ˜, ηıÒ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ‹ ¢·ÈÛıËÛ›· Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·.
µ’ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ ∞¶£, °¶¡ “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ∏. ÷Ù˙ËȈ·ÓÓ›‰Ë˜ hatziel@med.auth.gr ∫·ÈÛ·Ú›·˜ 52, T.K. 54454, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË, ıÔψÛÈÌÂÙÚÈ΋ ̤ıÔ‰Ô˜, ÓÂÊÂÏÔÌÂÙÚ›·.
Quantitative determination of C-reactive protein in the blood of neonates - Comparative study of two methods H. Chatziioannidis, A. Naoum, G. Mitsiakos, C. Tsakalidis, D. G. Goulis, N. Nikolaidis Abstract Background: The turbidometric (TUR) method of measurement of C-reactive protein (CRP) is characterized by practicality, since it can be carried out at the bedside, it requires a very small quantity of blood and the result is available within a very short period of time. The aim of this study was to compare the TUR method of CRP measurement with that of nephelometry (NEP). Methods: The study included 163 samples of whole blood from 79 neonates hospitalized in the 2nd Unit of Neonatal Intensive Care of the Aristotle University of Thessaloniki. The CRP was measured in 97 samples of blood as a routine examination (65 neonates, group A), and in 66 samples from neonates with possible or suspected sepsis (43 neonates, group B). The TUR determination of CRP was performed by the Quick Read System, and the NEP determination using the Beckman nephelometer. Results: A statistically significant difference was observed between the mean CRP levels measured by the TUR and NEP methods (18.7±22.6 mg/l versus 14.9±20.7 mg/l respectively, p<0.001). The TUR and NEP methods were found to have a strong positive correlation (r2=0.945, p<0.001). On Bland-Altman analysis a CRP over-estimate was noted with the TUR method compared with the NEP, for levels of up to 40 mg/l. With a threshold of 11 mg/l the sensitivity and specificity of the TUR method were 93% and 55% respectively, compared to positive blood culture. Conclusions: Fast CRP determination with the TUR method appears to be reliable, as it is characterized by high sensitivity and a negative predictive value.
2nd Unit of Neonatal Intensive Care, Aristotle University of Thessaloniki, General Hospital “Papageorgiou”, Thessaloniki Correspondence: H. Chatziioannidis hatziel@med.auth.gr 52, Kesarias St., 54454 Thessaloniki
Key words: C-reactive protein, turbidometric method, nephelometry.
¶·È‰È·ÙÚÈ΋ 2007;70:217-220
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·218
218
∏. ÷Ù˙ËȈ·ÓÓ›‰Ë˜ Î·È Û˘Ó.
∂ÈÛ·ÁˆÁ‹ √È ÚˆÙ½Ó˜ ÔÍ›·˜ Ê¿Û˘, fiˆ˜ Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (C-reactive protein, CRP), Ë ·1-Ô͢ÁÏ˘ÎÔÚˆÙ½ÓË, ÙÔ ∞-·Ì˘ÏÔÂȉ¤˜ ÙÔ˘ ÔÚÔ‡, Ë ÛÂÚÔ˘ÏÔÏ·ÛÌ›ÓË, Ù· C3 Î·È C4 ÎÏ¿ÛÌ·Ù· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, Ë ·1-·ÓÙÈıÚ˘„›ÓË, Ë ·ÙÔÛÊ·ÈÚ›ÓË Î·È ÙÔ ÈÓˆ‰ÔÁfiÓÔ ÔÓÔÌ¿ÛıËÎ·Ó ¤ÙÛÈ ÁÈ·Ù› Ë ·‡ÍËÛ‹ ÙÔ˘˜ Á›ÓÂÙ·È Ù·¯‡Ù·Ù·, Û˘¯Ó¿ ÚÈÓ ÔÏÔÎÏËÚˆı› Ë ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ· Ù˘ ·ıÔÏÔÁÈ΋˜ ‰ÈÂÚÁ·Û›·˜ Ô˘ ÚÔοÏÂÛ ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘˜. ∂Ô̤ӈ˜, Ë ‰˘Ó·ÙfiÙËÙ· ÁÚ‹ÁÔÚÔ˘ Î·È Â‡ÎÔÏÔ˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘˜ ‰È¢ÎÔχÓÂÈ Ôχ ÙË ‰È¿ÁÓˆÛË ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙfiÛÔ ÙˆÓ ÂÓËϛΈÓ, fiÛÔ Î·È ÙˆÓ ÓÂÔÁÓÒÓ (1). ∏ CRP ıˆÚÂ›Ù·È Ë Î˘ÚÈfiÙÂÚË ÂÎÚfiÛˆÔ˜ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘ ηıÒ˜ ·˘Í¿ÓÂÙ·È Ù·¯‡ÙÂÚ· Î·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙȘ ¿ÏϘ, ·ӤگÂÙ·È ‰Â ÛÙ· Ê˘ÛÈÔÏÔÁÈο ›‰· Ôχ ÁÚ‹ÁÔÚ· ÌÂÙ¿ ÙËÓ ¿ÚÛË ÙÔ˘ ·ÈÙ›Ô˘ Ô˘ ÚÔοÏÂÛ ÙËÓ ·‡ÍËÛ‹ Ù˘. Œ¯ÂÈ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ 106 kDa ÂÚ›Ô˘ Î·È ‚Ú›ÛÎÂÙ·È ËÏÂÎÙÚÔÊÔÚËÙÈο ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ Á-ÛÊ·ÈÚÈÓÒÓ (2). ∏ CRP ıˆÚÂ›Ù·È Â˘·›ÛıËÙÔ˜ ‰Â›ÎÙ˘ Ïԛ̈͢, ·ÏÏ¿ ÌË ÂȉÈÎfi˜, ηıÒ˜ ·˘Í¿ÓÂÙ·È Û ÊÏÂÁÌÔÓÒ‰ÂȘ ηٷÛÙ¿ÛÂȘ, ˘ÔÍ›·, Ì·È¢ÙÈΤ˜ ηÎÒÛÂȘ, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ÂÈÛÚfiÊËÛË ÌËÎˆÓ›Ô˘ (3). ™ÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ (ª∂¡¡) Ù˘ µã ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ∞.¶.£. ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌÈ· ıÔψÛÈÌÂÙÚÈ΋ ̤ıÔ‰Ô˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ¿ÏË Ú·ÎÙÈÎfiÙËÙ·, ηıÒ˜ ÂÎÙÂÏÂ›Ù·È ÛÙËÓ ›‰È· ÙË ªÔÓ¿‰· Ì ϋ„Ë Ôχ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ÙÚȯÔÂȉÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ‰È·ı¤ÛÈÌÔ Û Ôχ ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË Ù˘ ıÔψÛÈÌÂÙÚÈ΋˜ ÌÂıfi‰Ô˘ (£√§) Ì ÙÔÓ ÎÏ·ÛÈÎfi ÙÚfiÔ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP Ì ÓÂÊÂÏfiÌÂÙÚÔ (¡∂º). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ÌÂϤÙË ‹Ù·Ó ·Ó·‰ÚÔÌÈ΋. ¶ÂÚȤϷ‚ 163 ‰Â›ÁÌ·Ù· Ï‹ÚÔ˘˜ ·›Ì·ÙÔ˜ ·fi 79 ÓÂÔÁÓ¿, Ù· ÔÔ›· ÓÔÛËχıËÎ·Ó ÛÙË ª∂¡¡, ·fi ÙÔÓ ∞Ú›ÏÈÔ ¤ˆ˜ ÙÔÓ ™Â٤̂ÚÈÔ 2004. ∏ CRP ÌÂÙÚ‹ıËΠ۠97 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ˆ˜ ÚÔ˘Ù›Ó· (√Ì¿‰· ∞: n=65) Î·È Û 66 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÓÂÔÁÓÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‡ÔÙË ÁÈ· Ïԛ̈ÍË (OÌ¿‰· µ, n=43). ∂ÈÎfiÓ· ‡ÔÙË ÁÈ· Ïԛ̈ÍË ıˆڋıËÎÂ Ë ·ÚÔ˘Û›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ·fi: (·) ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· (˘ÔÙÔÓ›·, Ï‹ı·ÚÁÔ˜, Û·ÛÌÔ›), (‚) ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· (·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ¿ÓÔÈ·, Ù·¯‡ÓÔÈ·, ΢¿ÓˆÛË), (Á) ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· (‚Ú·‰˘Î·Ú‰›·, Ù·¯˘Î·Ú‰›·, ˘fiÙ·ÛË), (‰) ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· (‰˘Û·ÓÂÍ›· ÛÙË Û›ÙÈÛË, ÌÂÙˆÚÈÛÌfi˜) Î·È Â) ÙË ıÂÚÌÔÚ‡ıÌÈÛË (˘ÔıÂÚÌ›·, ˘ÂÚıÂÚÌ›·). ∆· ›‰· Ù˘ CRP ÚÔÛ‰ÈÔÚ›ÛıËÎ·Ó ÙfiÛÔ Ì ÙË £√§ ̤ıÔ‰Ô, fiÛÔ Î·È Ì ÙË ¡∂º, ˆ˜ ̤ıÔ‰Ô ·Ó·ÊÔÚ¿˜ Û fiÏ· Ù· ‰Â›ÁÌ·Ù·. ∂ÈÚfiÛıÂÙ·, ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ‰Â‡ÙÂÚË Ì¤ıÔ‰Ô˜ ·Ó·ÊÔÚ¿˜, ÂÏ‹ÊıËPaediatriki 2007;70:217-220
Û·Ó Û 37 ÂÚÈÙÒÛÂȘ ·fi 28 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ∞ Î·È Û 45 ÂÚÈÙÒÛÂȘ ·fi 34 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ µ. √ £√§ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ CRP ¤ÁÈÓ Ì ÙËÓ Ù¯ÓÈ΋ Quick Read System (√RION Diagnostica, Espoo, Finland). ¶ÚfiÎÂÈÙ·È ÁÈ· Ù·¯Â›· ̤ıÔ‰Ô ‰È¿ÚÎÂÈ·˜ 2,5 ÏÂÙÒÓ, Ô˘ ÛÙËÚ›˙ÂÙ·È ÛÙË Û‡Ó‰ÂÛË Ù˘ CRP Ì ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷, Ì ÙÔ ÔÔ›Ô ÂÂÓ‰‡ÂÈ ÌÈÎÚÔۈ̷ٛ‰È· latex. ∏ ÌÂÙ·‚ÔÏ‹ Ù˘ ıÔÏÂÚfiÙËÙ·˜ ÌÂÙ¿ ÙË Û‡Ó‰ÂÛË ÌÂÙÚ¿Ù·È Ì ÂȉÈÎfi fiÚÁ·ÓÔ. √ fiÁÎÔ˜ ÙÔ˘ ·›Ì·ÙÔ˜ Ô˘ ··ÈÙÂ›Ù·È Â›Ó·È 20 Ìl Î·È ÙÔ Â‡ÚÔ˜ ̤ÙÚËÛ˘ ‚Ú›ÛÎÂÙ·È ÌÂٷ͇ 8 Î·È 160 mg/l. ™‡Ìʈӷ Ì ÙÔÓ Î·Ù·Û΢·ÛÙ‹, Ë Ì¤ıÔ‰Ô˜ ¤¯ÂÈ Û˘ÓÙÂÏÂÛÙ‹ ÌÂÙ·‚ÏËÙfiÙËÙ·˜ ÛÙËÓ ›‰È· ̤ÙÚËÛË (within-assay CV) 4,9% Î·È Û ·ӷϷ̂·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ (between-assay CV) 8,3%. √ ¡∂º ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ CRP (Ì ϋ„Ë ÔÚÔ‡ ·›Ì·ÙÔ˜) ¤ÁÈÓ Ì ÓÂÊÂÏfiÌÂÙÚÔ Ù˘ ÂÙ·ÈÚ›·˜ Beckman (withinassay CV 2,6% Î·È between-assay CV 3,0%) ÛÙÔ ‚ÈÔ¯ËÌÈÎfi ÂÚÁ·ÛÙ‹ÚÈÔ. √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ CRP ÁÈÓfiÙ·Ó ÛÙËÓ ›‰È· ·ÈÌÔÏË„›· Ù·˘Ùfi¯ÚÔÓ· Î·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜. ∏ ÂÂÍÂÚÁ·Û›· ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ SPSS 11.5 for Windows (SPSS Inc., Chicago, Ill). ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ̤Û˜ ÙÈ̤˜ Ì ÙȘ ÛÙ·ıÂÚ¤˜ ÙÔ˘˜ ·ÔÎÏ›ÛÂȘ (x±SD). °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÙÈÌÒÓ Ù˘ CRP ÌÂٷ͇ Ù˘ £√§ Î·È ¡∂º ÌÂıfi‰Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌË ·Ú·ÌÂÙÚÈ΋ ̤ıÔ‰Ô˜ Wilcoxon Signed Rank test Î·È Ë ·Ó¿Ï˘ÛË BlandAltman, ÂÓÒ ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÔÛÔÛÙÈ·›ˆÓ ·Ó·ÏÔÁÈÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ·ÎÚÈ‚‹˜ ‰ÔÎÈÌ·Û›· Fisher (Fisher’s exact test). ∆¤ÏÔ˜, ÚÔÛ‰ÈÔÚ›ÛıËÎ·Ó Î·Ì‡Ï˜ ROC (Receiver Operative Characteristics) ÙfiÛÔ ÁÈ· ÙË £√§, fiÛÔ Î·È ÁÈ· ÙË ¡∂º ̤ıÔ‰Ô, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ˆ˜ ̤ıÔ‰Ô ·Ó·ÊÔÚ¿˜. TÈÌ‹ p ÌÈÎÚfiÙÂÚË ·fi 0,05 ÔÚ›ÛÙËΠˆ˜ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û fiϘ ÙȘ ‰ÔÎÈ̷ۛ˜.
∞ÔÙÂϤÛÌ·Ù· ∞. ™‡ÁÎÚÈÛË ÙÈÌÒÓ CRP Ì £√§ Î·È ¡∂º ̤ıÔ‰Ô ¢È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ CRP Ì £√§ Î·È ¡∂º ÌÂıfi‰Ô˘˜ (18,7±22,6 mg/l ¤Ó·ÓÙÈ 14,9±20,7 mg/l, ·ÓÙ›ÛÙÔȯ·, Wilcoxon Signed Rank test, p<0,001). √È £√§ Î·È ¡∂º ̤ıÔ‰ÔÈ ‚Ú›ÛÎÔÓÙ·Ó Û ÈÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË (Spearman’s rho, r2=0,945, p<0,001). ™ÙÔ ÁÚ¿ÊËÌ· ‰È·ÛÔÚ¿˜ Ë Â˘ı›· ·ÏÈÓ‰ÚfiÌËÛ˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP ‰Â›¯ÓÂÈ ÙË ıÂÙÈ΋ Û¯¤ÛË (∂ÈÎfiÓ· 1). ™ÙËÓ ·Ó¿Ï˘ÛË Bland-Altman ‰È·ÈÛÙÒÓÂÙ·È ˘ÂÚÂÎÙ›ÌËÛË Ù˘ CRP Ì ÙË £√§ ̤ıÔ‰Ô Û ۯ¤ÛË Ì ÙË ¡∂º ̤ıÔ‰Ô ÛÙËÓ ÂÚÈÔ¯‹ ÙÈÌÒÓ Ì¤¯ÚÈ 40 mg/l („¢‰Ò˜ ıÂÙÈΤ˜ ÙÈ̤˜) (∂ÈÎfiÓ· 2). µ. ™‡ÁÎÚÈÛË £√§ Î·È ¡∂º ÌÂıfi‰ˆÓ Ì ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ™ÙËÓ ÔÌ¿‰· ∞ Ë CRP ‚Ú¤ıËΠ·˘ÍË̤ÓË (>10 mg/l) Û 45 ‰Â›ÁÌ·Ù· Ì ÙË £√§ ̤ıÔ‰Ô Î·È Û 15 ‰Â›ÁÌ·Ù· Ì ÙË ¡∂º ̤ıÔ‰Ô, ÂÓÒ ÛÙËÓ ÔÌ¿‰· µ Û 36 Î·È 18, ·ÓÙ›ÛÙÔȯ·. ™Ë„·ÈÌ›· Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‰È·ÈÛÙÒıËΠ۠6 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ∞ Î·È 8 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ µ. ÀÔÏÔÁ›ÛıËΠfiÙÈ Ë CRP-£√§ ¤¯ÂÈ Â˘·ÈÛıËÛ›· 93% (13/14) Î·È ÂȉÈÎfiÙËÙ· 56% (38/68) ¤Ó·ÓÙÈ Ù˘
Pediatri May-Jun 07
24-05-07
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™ÂÏ›‰·219
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™‡ÁÎÚÈÛË ‰˘Ô ÌÂıfi‰ˆÓ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP
180
ÙÔ˜ ˆ˜ ̤ıÔ‰Ô ·Ó·ÊÔÚ¿˜ (Area Under Curve= 0,782), ‰È·ÈÛÙÒıËΠfiÙÈ Ô ‚¤ÏÙÈÛÙÔ˜ Ô˘‰fi˜ Ù˘ £√§ ÌÂıfi‰Ô˘ ˆ˜ ÚÔ˜ ÙË ‰È¿ÁÓˆÛË ÌÈ·˜ Ïԛ̈͢ Â›Ó·È Ù· 11 mg/l (∂ÈÎfiÓ· 3). ™ÙÔÓ Ô˘‰fi ·˘Ùfi, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ £√§ ÌÂıfi‰Ô˘ Â›Ó·È 93% Î·È 55%, ·ÓÙ›ÛÙÔȯ·. ŒÓ·Ó ÂÓ·ÏÏ·ÎÙÈÎfi Ô˘‰fi ·ÔÙÂÏÔ‡Ó Ù· 14 mg/l. ™ÙÔÓ Ô˘‰fi ·˘Ùfi, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ £√§ ÌÂıfi‰Ô˘ Â›Ó·È 71% Î·È 63%, ·ÓÙ›ÛÙÔȯ·.
160
CRP - £√§ (mg/l)
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y = 0,864 x - 1,213 R2 = 0,8935
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20
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140
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∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ÙÈÌÒÓ Ù˘ CRP Ì ¡∂º Î·È £√§ ̤ıÔ‰Ô.
ηÏÏȤÚÁÂÈ·˜, ÂÓÒ Ë CRP-¡∂º 72% (10/14) Î·È 82% (56/68), ·ÓÙ›ÛÙÔȯ·. H ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (PPV) Ù˘ CRP-£√§ Â›Ó·È 30% (13/43) Î·È Ë ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (NPV) 97% (38/39), ÂÓÒ Ù˘ CRP-¡∂º 46% (10/22) Î·È 94% (56/60), ·ÓÙ›ÛÙÔȯ·. √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ CRP Ì £√§ Î·È ¡∂º ÌÂıfi‰Ô˘˜ ‰ÂÓ ·ÚÔ˘Û›·˙ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ Â˘·ÈÛıËÛ›·, PPV Î·È NPV. ∞ÓÙ›ıÂÙ·, ˆ˜ ÚÔ˜ ÙËÓ ÂȉÈÎfiÙËÙ· ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (Fisher’s exact test, p<0,001).
™˘˙‹ÙËÛË ∏ ̤ÙÚËÛË Ù˘ CRP Û ÊÏÂÁÌÔÓÒ‰ÂȘ ηٷÛÙ¿ÛÂȘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ¢·›ÛıËÙÔ˜ ‰Â›ÎÙ˘ Ù˘ ÓfiÛÔ˘, Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ıÂڷ›· ·ÏÏ¿ Î·È Ù˘ Ïԛ̈͢ ÙÔ˘ ÓÂÔÁÓÔ‡ (4). ∏ ÂÎÙ›ÌËÛË Ù˘ CRP Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ¯Ú‹ÛÈÌË ÛÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ÌÂÙ¿ ·fi ·ӷϷ̂·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ (5). °ÓˆÚ›˙ÔÓÙ·˜ fiÙÈ ·˘Í¿ÓÂÙ·È ÌÂÙ¿ ·fi 4 ¤ˆ˜ 6 ÒÚ˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ‰Â‡ÙÂÚË Ì¤ÙÚËÛË ÌÂÙ¿ ·fi ÌÂÚÈΤ˜ ÒÚ˜, ȉȷ›ÙÂÚ· ·Ó Ë ÚÒÙË Ì¤ÙÚËÛË ¤‰ˆÛ ÔÚÈ·Îfi ·ÔÙ¤ÏÂÛÌ· (2,6). ∏ ¡∂º Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ÁÈ· ÙË Ì¤ÙÚËÛË Ù˘ CRP ÁÈ·Ù› Â›Ó·È Â˘·›ÛıËÙË Î·È ·ÎÚÈ‚‹˜ (7). ∞·ÈÙ› fï˜ ÂÍÔÏÈÛÌfi Î·È ÂȉÈο ÂÎ·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi Î·È ÔÚÁ·ÓˆÌ¤ÓÔ ÂÚÁ·ÛÙ‹ÚÈÔ. ∂ÈÚfiÛıÂÙ·, ÔÏϤ˜ ÊÔÚ¤˜ Ô ¯ÚfiÓÔ˜ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ·Ú·Ï·‚‹ ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ÁÈ· ÙȘ ·ÔÊ¿ÛÂȘ Ô˘ Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó Û ÓÂÔÁÓ¿ Ì ΛӉ˘ÓÔ ÛË„·ÈÌ›·˜. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, Ë ÂÊ·ÚÌÔÁ‹ Ù˘ £√§ ÌÂıfi‰Ô˘ Â›Ó·È Ù·¯‡Ù·ÙË (·ÔÙ¤ÏÂÛÌ·
°. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ô˘‰Ô‡ £√§ ÌÂıfi‰Ô˘ Û ۯ¤ÛË Ì ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ∂Ê·ÚÌfi˙ÔÓÙ·˜ ÙË ‰È·‰Èηۛ· ROC ÁÈ· ÙË £√§ ̤ıÔ‰Ô Î·È ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·-
1,0
50 40 30
0,5
20 10 0
∂˘·ÈÛıËÛ›·
¢È¿ÊÔÚ· CRP £√§ Î·È ¡∂º ÌÂıfi‰ˆÓ
0,8
-10 -20 -30
0
20 40 60 80 100 120 140 160 180 ª¤ÛÔ˜ fiÚÔ˜ CRP £√§ Î·È ¡∂º ÌÂıfi‰ˆÓ
∂ÈÎfiÓ· 2. ∞Ó¿Ï˘ÛË Bland-Altman ÙˆÓ ÙÈÌÒÓ Ù˘ CRP Ì ¡∂º Î·È £√§ ̤ıÔ‰Ô.
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1 - ∂ȉÈÎfiÙËÙ· ∂ÈÎfiÓ· 3. ROC η̇ÏË Ù˘ £√§ ÌÂıfi‰Ô˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP, Ì ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ˆ˜ ̤ıÔ‰Ô ·Ó·ÊÔÚ¿˜. ¶·È‰È·ÙÚÈ΋ 2007;70:217-220
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∏. ÷Ù˙ËȈ·ÓÓ›‰Ë˜ Î·È Û˘Ó.
Û 3 ÏÂÙ¿), ¯ˆÚ›˜ Ó· ··ÈÙ› ÂȉÈÎfi ÂÍÔÏÈÛÌfi Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi, ·ÏÏ¿ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÙÂÎÌËÚȈ̤ÓË Î·ıÒ˜ ÔÈ ÌÂϤÙ˜ Û‡ÁÎÚÈÛ˘ ¡∂º Î·È £√§ ÌÂıfi‰ˆÓ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ (1,7,8). ™ÙËÓ ÂÚÁ·Û›· ÙˆÓ Imad E. Makhoul Î·È S. Esposito Û ÓÂÔÁÓ¿ Î·È ·È‰È¿ ·ÓÙ›ÛÙÔȯ·, ·ÍÈÔÏÔÁ‹ıËÎÂ Ë Ì¤ÙÚËÛË Ù˘ CRP Ì £√§ ̤ıÔ‰Ô ˆ˜ ÈÛÔ‰‡Ó·ÌË Ù˘ ¡∂º ÌÂıfi‰Ô˘, ÂÓÒ Û ·˘Ù‹ Ù˘ °È·ÓÓ¿ÎÔ˘ ª. Î·È Û˘Ó. ‰È·ÈÛÙÒÓÂÙ·È Î·Ï‹ Û˘Ìʈӛ· ÌÂÙÚ‹ÛÂˆÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ. ™ÙË ÌÂϤÙË ·˘Ù‹ Û˘ÁÎÚ›ıËÎÂ Ë £√§ ̤ıÔ‰Ô˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP Ì ·˘Ù‹ Ù˘ ¡∂º Î·È ‰È·ÈÛÙÒıËΠÈÛ¯˘Ú‹ ıÂÙÈ΋ ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË. ¶·Ú¿ ÙË Û˘Û¯¤ÙÈÛË ·˘Ù‹, ÔÈ Ì¤ÛÔÈ fiÚÔÈ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο, Ì ÙË £√§ ̤ıÔ‰Ô Ó· ÂÌÊ·Ó›˙ÂÈ ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜. °È’ ·˘Ùfi ÙÔÓ ÛÎÔfi ÂÊ·ÚÌfiÛ·Ì ÙËÓ ·Ó¿Ï˘ÛË Î·Ù¿ Bland-Altman, fiÔ˘ Û˘ÁÎÚ›ÓÔÓÙ·È ÔÈ ‰È·ÊÔÚ¤˜ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ Ì ÙÔÓ Ì¤ÛÔ fiÚÔ ÙÔ˘˜ Û fiÏÔ ÙÔ Ê¿ÛÌ· ÙÈÌÒÓ Ù˘ CRP. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ·˘Ù‹ ‰È·ÈÛÙÒıËΠfiÙÈ ÁÈ· ÙÈ̤˜ CRP ÌÈÎÚfiÙÂÚ˜ ·fi 40 mg/l, Ë ¡∂º ̤ıÔ‰Ô˜ Û˘ÛÙËÌ·ÙÈο ˘ÂÚÂÎÙÈÌÔ‡Û ٷ ·ÔÙÂϤÛÌ·Ù·. π‰È·›ÙÂÚ· ¤¯ÂÈ ··Û¯ÔÏ‹ÛÂÈ ÙË ‚È‚ÏÈÔÁÚ·Ê›· Ë Û˘ÁΤÓÙÚˆÛË Ù˘ CRP ¿Óˆ ·fi ÙËÓ ÔÔ›· Ë Ïԛ̈ÍË ıˆÚÂ›Ù·È ‚·ÎÙËÚȷ΋. ∫·Ù¿ ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÙÔ fiÚÈÔ Ù›ıÂÙ·È ÛÙ· 20 mg/l. ∫·Ù’ ¿ÏÏÔ˘˜ ÙÔ fiÚÈÔ ÙˆÓ 40 mg/l ·˘Í¿ÓÂÈ ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙËÓ ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ (6). ™ÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÛÙË ROC ·Ó¿Ï˘ÛË ÁÈ· ÙË £√§ ̤ıÔ‰Ô, ˆ˜ ‚¤ÏÙÈÛÙÔ˜ Ô˘‰fi˜ ˆ˜ ÚÔ˜ ÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ Û ۇÁÎÚÈÛË Ì ÙË ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‚Ú¤ıËΠÙÈÌ‹ CRP 11 mg/l. ™ÙÔÓ Ô˘‰fi ·˘Ùfi ˘‹Ú¯Â ¢·ÈÛıËÛ›· 93% Î·È ÂȉÈÎfiÙËÙ· 55%. ŸÙ·Ó Ô Ô˘‰fi˜ ÙÔÔıÂÙ‹ıËΠÛÙ· 14 mg/l, Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ £√§ ÌÂıfi‰Ô˘ ‹Ù·Ó 71% Î·È 63%, ·ÓÙ›ÛÙÔȯ·. £ÂˆÚԇ̠fiÙÈ ÛÙÔ ÎÏÈÓÈÎfi Â›Â‰Ô ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È Ô Ô˘‰fi˜ ÙˆÓ 11 mg/l ηıÒ˜ Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ¤Ó·ÚÍË ıÂڷ›·˜ Û ·Ô˘Û›· ÛË„·ÈÌ›·˜ ·fi ÙȘ Û˘Ó¤ÂȘ ÌË ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÁˆÁ‹˜ Û ÓÂÔÁÓfi Ì ·ÚÔ˘Û›· ÛÔ‚·Ú‹˜ Ïԛ̈͢ (2). ∏ ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (NPV) Î·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ Î˘Ì¿ÓıËΠ۠˘„ËÏ¿ ›‰·. ∏
Paediatriki 2007;70:217-220
˘„ËÏ‹ NPV ÛËÌ·›ÓÂÈ fiÙÈ ·Ó ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂͤٷÛ˘ Â›Ó·È ·ÚÓËÙÈÎfi, Ë Èı·ÓfiÙËÙ· ‡·Ú͢ Ïԛ̈͢ Â›Ó·È ÌÈÎÚ‹. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‚ÔËı¿ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Ïԛ̈͢ Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ¯Ú‹Û˘ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ (9). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ÓÔÛÔÎÔÌÂȷο ÂÚÁ·ÛÙ‹ÚÈ·, ·ÎfiÌË ÎÈ ·Ó ‰È·Ù›ıÂÙ·È ÓÂÊÂÏfiÌÂÙÚÔ, ¯ÚÂÈ¿˙ÂÙ·È Ó· ˘¿Ú¯ÂÈ Î·È ÌÈ· ¿ÏÏË ·ÏÔ‡ÛÙÂÚË Î·È Ù·¯‡ÙÂÚË Ù¯ÓÈ΋. √ ÁÚ‹ÁÔÚÔ˜ ˘ÔÏÔÁÈÛÌfi˜ Ù˘ CRP Ì ÙË £√§ ̤ıÔ‰Ô ¯ˆÚ›˜ ·ÈÌÔÏË„›· Û ÙÚȯÔÂȉÈÎfi ·›Ì· Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ·ÍÈfiÈÛÙÔ˜, ηıÒ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ‹ ¢·ÈÛıËÛ›· Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·. ∏ £√§ ̤ıÔ‰Ô˜ ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ ÓÔÛËÏ›·˜ ηıÒ˜ ÂÚÈÔÚ›˙ÂÈ ÛËÌ·ÓÙÈο ÙȘ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ηÈ, ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ, Ô‰ËÁ› Û ÏÔÁÈ΋ ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Makhoul IR, Smolkin T, Zinder O, Diamond E, ∆amir A, Sujov P. Fast bedside measurement of blood count and Creactive protein in neonates with suspected late-onset sespsis. Acta Paediatr 2005;94:960-963. 2. Jaye DL, Waites KB. Clinical applications of C-reactive protein in pediatrics. Pediatr Infect Dis J 1997;16:735-747. 3. ∆·Ú·ÓÙ˙‹ ¶, ∫Ô˘ÎÔ˘ÏÔÌ¿ÙË-ºÚ¿ÁÎÔ˘ ∂., ∫Ô˘Ú¿Î˘ °. ∏ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (CRP) ÛÙË ‰È¿ÁÓˆÛË ÓÂÔÁÓÈÎÒÓ ÏÔÈÌÒ͈Ó. ¶·È‰È·ÙÚÈ΋ 1989;52:226-230. 4. Stuart J, Whicher JT. Tests for detecting and monitoring the acute phase response. Arch Dis Child 1988;63:115-117. 5. Hengst JM. The role of C-reactive protein in the evaluation and management of infants with suspected sepsis. Adv Neonatal Care 2003;3:3-13. 6. °È·ÓÓ¿ÎË-æÈÓ¿ÎË ª. C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË. ªÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ∂ÚÁ·ÛÙËÚȷ΋ ¢È·ÁÓˆÛÙÈ΋ 1990;5:211-217. 7. °È·ÓÓ¿ÎË ª, µÔ˘Ó¿ÙÛÔ˘ ª, ∆ÛÈÏ¿ÎÔ˘ ™. ∞ÍÈÔÏfiÁËÛË ‰‡Ô ÁÚ‹ÁÔÚˆÓ Ù¯ÓÈÎÒÓ ÔÛÔÙÈÎÔ‡ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ CRP Û ϋÚ˜ ·›Ì·. ªÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ∂ÚÁ·ÛÙËÚȷ΋ ¢È·ÁÓˆÛÙÈ΋ 2001;6:177-181. 8. Esposito S, Tremolati E, Begliatti E, Bosis S, Gualtieri L, Principi N. Evaluation of a rapid bedside test for the quantitative determination of C-reactive protein. Clin Chem Lab Med 2005;43:438-440. 9. Mathai E, Christopher U, Mathai M, Jana AK, Rose D, Bergstrom S. Is C-reactive protein level useful in differentiating infected from uninfected neonates among those at risk of infection? Indian Pediatr 2004;41:895-900.
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
™ÂÏ›‰·221
ORIGINAL ARTICLE
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∞ÍÈÔÏfiÁËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢ ™. ºÔ‡˙·˜, ∞. º·ÛÔ˘Ï‹, ¢. ∞‰·Ì›‰Ë˜, ∫. ∆˙ÂϤ˘, π. ª·ÎÔÔ‡ÏÔ˘, ∞. ¶··‰ÔÔ‡ÏÔ˘, ¢. ∑·ÊÂÈÚ·ÎfiÔ˘ÏÔ˜
¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ •¿Óı˘
¶ÂÚ›ÏË„Ë
AÏÏËÏÔÁÚ·Ê›·: ™ˆÙ‹Ú˘ ºÔ‡˙·˜ sfouzas73@hotmail.com ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ °.¡. •¿Óı˘ ∆.∫. 671 00, ¡Â¿ÔÏË •¿Óı˘
∂ÈÛ·ÁˆÁ‹: √È Ô˘ÚÔÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó Û˘¯Ófi ·›ÙÈÔ ÌÈÎÚԂȷ΋˜ ÓfiÛÔ˘ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Ô‡ÚˆÓ, ÙˆÓ Ï¢ÎÒÓ ÛÙË ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, Ù˘ ∆∫∂ Î·È Ù˘ CRP, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› Ô Î›Ó‰˘ÓÔ˜ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο 115 ‚Ú¤ÊË ËÏÈΛ·˜ 15-90 ËÌÂÚÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÁÈ· ¤ÏÂÁ¯Ô ˘ÚÂÙÔ‡ ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›·. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ›¯Â Á›ÓÂÈ Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ÛË„·ÈÌ›·˜: ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, ÁÂÓÈ΋ Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, ÁÂÓÈ΋ Î·È Î·ÏÏȤÚÁÂÈ· ∂¡À. °È· ÙËÓ Î¿ı ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ Î·ıÔÚ›ÛÙËÎ·Ó Ë Â˘·ÈÛıËÛ›·, Ë ÂȉÈÎfiÙËÙ·, Ë ıÂÙÈ΋ Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ÔÈ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ (LR), ηıÒ˜ Î·È Ë Û˘ÓÔÏÈ΋ ·fi‰ÔÛË ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ η̇Ϙ ROC. ∞ÔÙÂϤÛÌ·Ù·: ∏ Û˘¯ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢ ‹Ù·Ó 23,5%. ∏ ˘Ô˘Ú›· ‹Ù·Ó Ë ÌfiÓË ·Ú¿ÌÂÙÚÔ˜ Ì ηϋ ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· (AUC: 0,825). √ ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ >10 ÎÔ ·ÚÔ˘Û›·Û ¢·ÈÛıËÛ›· 56%, ÂȉÈÎfiÙËÙ· 99%, ÂÍ·ÈÚÂÙÈ΋ ıÂÙÈ΋ LR (48,9) Î·È ·Û‹Ì·ÓÙË ·ÚÓËÙÈ΋ LR (0,45). ∆· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· (>15.000/ÌL ‹ <5.000/ÌL) ›¯·Ó 78% ¢·ÈÛıËÛ›·, 76% ÂȉÈÎfiÙËÙ· Î·È ·Û‹Ì·ÓÙ˜ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ (ıÂÙÈ΋ LR 3,26 Î·È ·ÚÓËÙÈ΋ LR 0,29). °È· ÙËÓ ∆∫∂ Î·È ÙË CRP Ù· ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ‹Ù·Ó ÈηÓÔÔÈËÙÈο. √ Û˘Ó‰˘·ÛÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ Î·È Ï¢ÎÒÓ ı· Ô‰ËÁÔ‡Û Û ·ÔÙ˘¯›· ‰È¿ÁÓˆÛ˘ 3 Ô˘ÚÔÏÔÈÌÒÍÂˆÓ (11%). ™˘ÌÂÚ¿ÛÌ·Ù·: ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡˜ ‰Â›ÎÙ˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‰ÂÓ ·Ô‰Â›¯ıËΠÈηÓfi˜ Ó· ÚԂϤ„ÂÈ Ì ·ÛÊ¿ÏÂÈ· ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ηÏÏȤÚÁÂÈ·˜ Ô‡ÚˆÓ. ∏ ·Ó‡ÚÂÛË >10 ˘ÔÛÊ·ÈÚ›ˆÓ ÎÔ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Ô‡ÚˆÓ Î·Ù¢ı‡ÓÂÈ ÚÔ˜ ÙËÓ Èı·ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢, ·ÏÏ¿ Ë ¤ÏÏÂÈ„Ë ˘Ô˘Ú›·˜ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ÓfiÛÔ. ∞ÎfiÌ· Î·È Ô Û˘Ó‰˘·ÛÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢.
§¤ÍÂȘ ÎÏÂȉȿ: √˘ÚÔÏԛ̈ÍË, ˘Ô˘Ú›·, ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ, ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, Â̇ÚÂÙ· ‚Ú¤ÊË.
Estimating the risk of urinary tract infection in febrile infants aged 15-90 days with no apparent focus of infection S. Fouzas, A. Fasouli, D. Adamidis, K. Tzelepis, I. Bakopoulou, A. Papadopoulou, D. Zafirakopoulos ∞bstract Background: Urinary tract infection (UTI) is a common cause of bacterial disease in infancy. The aim of this study was to assess the usefulness of microscopic urinalysis, peripheral white blood cell count (WBC), CRP and ESR, for estimating the risk of UTI in febrile infants without a focus of infection. Methods: The records of 115 infants aged 15-90 days, hospitalized for investigation of fever with no apparent focus, were evaluated retrospectively. All the patients had undergone a full sepsis investigation: blood culture, urine microscopy and culture, CSF microscopy, biochemistry and culture. The sensitivity, specificity, positive and negative predictive value, likelihood ratio (LR) and overall test performance were determined for each of the laboratory parameters, using ROC curves. Results: The incidence of UTI was 23.5%. Pyuria was the only parameter with good discrimination ability (AUC: 0.825). Pyuria of >10 WBCs/hpf had 56% sensitivity, 99% specificity, an exceptional positive LR (48.9) and insignificant negative LR (0.45). A WBC count of >15,000/ÌL or <5,000/ÌL, had 78% sensitivity, 76% specificity and insignificant likelihood ratios (positive LR 3.26 and negative LR 0.29). The findings for ESR and CRP were not satisfactory indicators. Use of a combination of pyuria and WBC count would have led to misdiagnosis in 3 cases of UTI (11%). Conclusions: None of the tested laboratory parameters can safely predict the results of the urine culture. Pyuria of >10 WBCs/hpf points to the possibility of UTI but the absence of pyuria cannot rule out the disease. Even the use of the combination of pyuria and peripheral WBC count does not eliminate the possibility of UTI.
Paediatric Clinic, General Hospital, Xanthi Correspondence: Sotiris Fouzas sfouzas73@hotmail.com Paediatric Clinic, General Hospital, Xanthi 671 00, Neapoli, Xanthi
Key words: Urinary tract infection, pyuria, microscopic urinalysis, urine culture, febrile infants.
¶·È‰È·ÙÚÈ΋ 2007;70:221-226
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™. ºÔ‡˙·˜ Î·È Û˘Ó.
™˘ÓÙÔÌÔÁڷʛ˜ ∆∫∂ CRP √¡¶ ∂¡À LR ROC curve AUC
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆·¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ ∞ÓÙȉÚÒÛ· ÚˆÙ½ÓË C √ÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ∂ÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ∞Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ ∫·Ì‡ÏË ROC ¶ÂÚÈÔ¯‹ οو ·fi ÙËÓ Î·Ì‡ÏË
∂ÈÛ·ÁˆÁ‹ √È Ô˘ÚÔÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÌÈÎÚԂȷ΋˜ Ïԛ̈͢ ηٿ ÙË ÓÂÔÁÓÈ΋ Î·È ÚÒÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·Ù¿ ÙËÓ ÎÚ›ÛÈÌË ·˘Ù‹ ÂÚ›Ô‰Ô Â›Ó·È ÛËÌ·ÓÙÈ΋, ·ÊÂÓfi˜ ÁÈ·Ù› ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ·ÊÂÙ¤ÚÔ˘ ÁÈ·Ù› Ë ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ ·ÒÏÂÈ· ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡, ‰ËÌÈÔ˘ÚÁ›· Ô˘ÏÒÓ Î·È ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂ÈϤÔÓ, ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ‚ÚÂÊÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È·ÛÔÚ¿ Ù˘ ÓfiÛÔ˘ Î·È ÂÈΛӉ˘ÓË ÁÈ· ÙË ˙ˆ‹ ÁÂÓÈÎÂ˘Ì¤ÓË Ïԛ̈ÍË (1-3). ∏ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ ·Ú·Ì¤ÓÂÈ Ë ÈÔ ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Ô˘ÚÔÏԛ̈͢, ¤¯ÔÓÙ·˜ fï˜ ÙÔ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ηı˘ÛÙ¤ÚËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ŒÙÛÈ, ¤¯Ô˘Ó ·Ó·˙ËÙËı› ÂÚÁ·ÛÙËÚÈ·ÎÔ› ‰Â›ÎÙ˜ Ô˘ ı· ÌÔÚÔ‡Û·Ó ¿ÌÂÛ· Ó· ÚԂϤ„Ô˘Ó ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ηÏÏȤÚÁÂÈ·˜, ÁÂÁÔÓfi˜ Ì ȉȷ›ÙÂÚË ÛËÌ·Û›· ÛÙËÓ ÂÚ›ÙˆÛË ‚ÚÂÊÒÓ Ì ԢÚÔÏԛ̈ÍË, fiÔ˘ Ë Û˘Ìو̷ÙÔÏÔÁ›· ‰ÂÓ Â›Ó·È ÂȉÈ΋ Î·È Ë ¤ÁηÈÚË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Â›Ó·È Ô˘ÛÈ҉˘. ∏ ·Ï‹ ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ÙˆÓ Ô‡ÚˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰È¿ÊÔÚÔ˘˜ ‚ÈÔ¯ËÌÈÎÔ‡˜ ‰Â›ÎÙ˜ (ÓÈÙÚÒ‰Ë, ÂÛÙÂÚ¿ÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ), ηıÒ˜ Î·È Ì¤ıÔ‰ÔÈ ÂÓÈÛ¯˘Ì¤Ó˘ ·Ó¿Ï˘Û˘ Ô‡ÚˆÓ ¤¯Ô˘Ó ·ÍÈÔÏÔÁËı› Û ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ÌÂÏÂÙÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜, ˆÛÙfiÛÔ, Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË, ΢ڛˆ˜ ÂÍ·ÈÙ›·˜ Ù˘ ·‰˘Ó·Ì›·˜ ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ÓfiÛÔ˘ (3-12). ¶·Ú’ fiÏ· ·˘Ù¿, ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË Ë ˘Ô„›· Ô˘ÚÔÏԛ̈͢, ·ÎfiÌ· Î·È Ë ·fiÊ·ÛË ÁÈ· ηÏÏȤÚÁÂÈ·, ‚·Û›˙ÔÓÙ·È Û˘¯Ó¿ ÛÙ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÁÂÓÈ΋˜ ÂͤٷÛ˘ Ô‡ÚˆÓ (3,7,9,11,12). ∂ÈϤÔÓ, Ô ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ ·ÔÙÂÏ› ‚·ÛÈÎfi ÎÚÈÙ‹ÚÈÔ ÛÙ· ÚˆÙfiÎÔÏÏ· ÂÎÙ›ÌËÛ˘ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÛÔ‚·Ú‹˜ ÌÈÎÚԂȷ΋˜ ÓfiÛÔ˘ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢ (13-15), ·Ó Î·È Ë Û¯ÂÙÈ΋ ·‰˘Ó·Ì›· ·˘ÙÒÓ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Ô˘ÚÔÏԛ̈͢ ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› (16-18). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÁÂÓÈ΋ Ô‡ÚˆÓ, ÙÔ˘ ·ÚÈıÌÔ‡ Ï¢ÎÒÓ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, Ù˘ ∆∫∂ Î·È Ù˘ CRP, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ËÏÈΛ·˜ 15-90 ËÌÂÚÒÓ ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢. Paediatriki 2007;70:221-226
ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο ÔÈ Ê¿ÎÂÏÔÈ ‚ÚÂÊÒÓ ËÏÈΛ·˜ 15-90 ËÌÂÚÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 01/06/2001 Î·È 31/05/2005 ÁÈ· ¤ÏÂÁ¯Ô ˘ÚÂÙÔ‡ (ıÂÚÌÔÎÚ·Û›· ÔÚıÔ‡ >38ÔC), ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ›¯Â Á›ÓÂÈ Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ÛË„·ÈÌ›·˜: ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, CRP, ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, ÁÂÓÈ΋ Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, √¡¶ ÁÈ· ÁÂÓÈ΋ ∂¡À, ۿί·ÚÔ, χΈ̷, ¯ÚÒÛË Î·Ù¿ Gram Î·È Î·ÏÏȤÚÁÂÈ· ∂¡À ηÈ, ηٿ ÂÚ›ÙˆÛË, ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Î·È Î·ÏÏȤÚÁÂÈ· ÎÔÚ¿ÓˆÓ. ŸÏ· Ù· ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ Â›¯·Ó ÏËÊı› Ì ˘ÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘. ∞fi ÙË ÌÂϤÙË ·ÔÎÏ›ÛÙËÎ·Ó 3 ‚Ú¤ÊË Ô˘ ›¯·Ó Ï¿‚ÂÈ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜ Î·È 16 ‚Ú¤ÊË Ô˘ ‰ÂÓ ÔÏÔÎÏ‹ÚˆÛ·Ó ÙÔÓ ÚÔηıÔÚÈṲ̂ÓÔ ¤ÏÂÁ¯Ô ÛË„·ÈÌ›·˜. °È· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰ÂÈÎÙÒÓ Î·ıÔÚ›ÛÙËÎ·Ó Ë Â˘·ÈÛıËÛ›·, Ë ÂȉÈÎfiÙËÙ·, Ë ıÂÙÈ΋ Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ηıÒ˜ Î·È ÔÈ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔًوÓ. √È ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ (likelihood ratios - LR), ıÂÙÈ΋ ‹ ·ÚÓËÙÈ΋ (LR + ‹ LR -), ÂÎÊÚ¿˙Ô˘Ó ÙËÓ Èı·ÓfiÙËÙ· Ë ‰ÔÎÈÌ·Û›· Ó· Â›Ó·È ıÂÙÈ΋ ‹ ·ÚÓËÙÈ΋ ÛÙÔ˘˜ ¿Û¯ÔÓÙ˜ Û ۯ¤ÛË Ì ÙËÓ Èı·ÓfiÙËÙ· Ë ‰ÔÎÈÌ·Û›· Ó· Â›Ó·È ·ÓÙ›ÛÙÔȯ· ıÂÙÈ΋ ‹ ·ÚÓËÙÈ΋ ÛÙÔ˘˜ ÌË ¿Û¯ÔÓÙ˜. √È ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ ıˆÚÔ‡ÓÙ·È ÔÈ ÈÔ ·ÍÈfiÈÛÙÔÈ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜ Ì›·˜ ‰ÔÎÈÌ·Û›·˜. ™ËÌ·ÓÙÈΤ˜ ÁÈ· ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ıˆÚÔ‡ÓÙ·È ÙÈ̤˜ ÌÂÁ·Ï‡ÙÂÚ˜ ÙÔ˘ 10 ÁÈ· ÙË ıÂÙÈ΋ Î·È ÌÈÎÚfiÙÂÚ˜ ÙÔ˘ 0,1 ÁÈ· ÙËÓ ·ÚÓËÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ (19,20). ∏ Û˘ÓÔÏÈ΋ ·fi‰ÔÛË Ù˘ οı ‰ÔÎÈÌ·Û›·˜ ·ÍÈÔÏÔÁ‹ıËΠ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ η̇Ϙ ROC (Receiver operating characteristics). √È Î·Ì‡Ï˜ ROC Â›Ó·È ÁÚ·ÊÈΤ˜ ·Ú·ÛÙ¿ÛÂȘ Ù˘ ¢·ÈÛıËÛ›·˜ Û ۯ¤ÛË Ì ÙËÓ ÂȉÈÎfiÙËÙ·. ∞fi ÙÔ ÂÌ‚·‰fiÓ Ù˘ ÂÚÈÔ¯‹˜ ÌÂٷ͇ Ù˘ η̇Ï˘ Î·È ÙÔ˘ ÔÚÈ˙fiÓÙÈÔ˘ ¿ÍÔÓ· (Area under curve - AUC) ÌÔÚ› Ó· ÂÎÙÈÌËı› Ë Û˘ÓÔÏÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÈηÓfiÙËÙ·. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ηÙÒÙÂÚÔ ·Ô‰ÂÎÙfi fiÚÈÔ ÁÈ· ÙËÓ AUC ıˆڋıËÎÂ Ë ÙÈÌ‹ 0,7, ÂÓÒ ÔÈ ÙÈ̤˜ 0,7-0,8 ıˆڋıËΠˆ˜ ÂÎÊÚ¿˙Ô˘Ó Ì¤ÙÚÈ· ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ·, ÔÈ ÙÈ̤˜ 0,8-0,9 ηϋ Î·È ÔÈ ÙÈ̤˜ 0,9-1 ¿ÚÈÛÙË ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· (19,21,22). °È· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ¢·ÈÛıËÛ›·˜, Ù˘ ÂȉÈÎfiÙËÙ·˜, Ù˘ ÚÔÁÓˆÛÙÈ΋˜ ·Í›·˜ Î·È ÙˆÓ ·Ó·ÏÔÁÈÒÓ Èı·ÓÔًوÓ, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰È·ÊÔÚÂÙÈο ÛËÌ›· ÙÔÌ‹˜ (cutoff points) ÁÈ· ÙÔÓ Î¿ı ÂÚÁ·ÛÙËÚÈ·Îfi ‰Â›ÎÙË, ‰È·ÊÔÚÂÙÈΤ˜ ‰ËÏ·‰‹ ÙÈ̤˜ ÁÈ· ÙȘ Ôԛ˜ Ë ‰ÔÎÈÌ·Û›· ıˆڋıËΠıÂÙÈ΋. °È· Ù· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· ·ÍÈÔÏÔÁ‹ıËÎ·Ó ˆ˜ ·ıÔÏÔÁÈΤ˜: ·) ÙÈ̤˜ >15.000/ÌL ‹ <5.000/ÌL (15), ‚) ÙÈ̤˜ >15.000/ÌL (13) Î·È Á) ÙÈ̤˜ >20.000/ÌL (14) (¶›Ó·Î·˜ 1). °È· Ù· ˘ÔÛÊ·›ÚÈ· ÛÙË ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ˆ˜ ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜ >5 ÎÔ (ÙÈÌ‹ Ô˘ ·ÔÙÂÏ› ÙÔÓ ÎÏ·ÛÈÎfi ÔÚÈÛÌfi Ù˘ ÛËÌ·ÓÙÈ΋˜ ˘Ô˘Ú›·˜) Î·È ÙÈ̤˜ >10 ÎÔ (ÎÚÈÙ‹ÚÈÔ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙ· ÚˆÙfiÎÔÏÏ· ÂÎÙ›ÌËÛ˘ ÛÔ‚·Ú‹˜ ÌÈÎÚԂȷ΋˜ ÓfiÛÔ˘). °È· ÙËÓ ∆∫∂ ÛËÌÂ›Ô ÙÔÌ‹˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ 30 mm/h Î·È ÁÈ· ÙË CRP Ë ÙÈÌ‹ 1 mg/dL (16-18,22,23). ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ¤ÁÈÓ Ì ÙÔ ÚfiÁÚ·ÌÌ· SPSS 11.0, ÂÓÒ Ë Î·Ù·Û΢‹ ÙˆÓ Î·Ì˘ÏÒÓ ROC, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙˆÓ AUC Î·È Ë ÌÂٷ͇ ÙÔ˘˜ Û‡ÁÎÚÈÛË, Ì ÙÔ ÚfiÁÚ·ÌÌ· MedCalc 8.1.0.0.
∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 115 ·È‰È¿ Ô˘ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ ÛÙË ÌÂϤÙË, 27 ›¯·Ó ıÂÙÈ΋ ηÏÏȤÚÁÂÈ·
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·223
223
∫›Ó‰˘ÓÔ˜ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË
¶›Ó·Î·˜ 1. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰ÂÈÎÙÒÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ô˘ÚÔÏԛ̈͢ ¶˘ÔÛÊ·›ÚÈ· (ÎÔ)
∂˘·ÈÛıËÛ›· ∂ȉÈÎfiÙËÙ· PPV NPV LR(+)* LR(-)**
§Â˘Î¿ (/ÌL)
∆∫∂
CRP
>5
>10
>20.000
>15.000
>15.000 ‹ <5.000
>30 mm/h
>1 mg/dL
56% 96% 83% 88% 16,3 0,46
56% 99% 94% 88% 48,9 0,45
45% 83% 45% 83% 2,6 0,67
74% 76% 49% 90% 3,1 0,35
78% 76% 50% 92% 3,26 0,29
48% 78% 40% 83% 2,23 0,66
59% 70% 38% 85% 2 0,58
PPV: £ÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, NPV: ∞ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, LR(+): £ÂÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔًوÓ, LR(-): ∞ÚÓËÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔًوÓ, *: ™ËÌ·ÓÙÈΤ˜ ıˆÚÔ‡ÓÙ·È ÙÈ̤˜ >10, **: ™ËÌ·ÓÙÈΤ˜ ıˆÚÔ‡ÓÙ·È ÙÈ̤˜ <0,1
ÛÙ·ÙÈÛÙÈÎÔ‡ Ï¿ıÔ˘˜ (7,3 ± 19 mg/dL ¤Ó·ÓÙÈ 2,8 ± 5,8 mg/dL, p=0,049). √È ROC η̇Ϙ ÁÈ· ÙËÓ Î¿ı ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. √ ·ÚÈıÌfi˜ ÙˆÓ ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÁÂÓÈ΋ Ô‡ÚˆÓ Ì AUC 0,825 (95%CI: 0,743-0,889) ÂÌÊ¿ÓÈÛ ηϋ ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ·, ÂÓÒ Ë ∆∫∂ ›¯Â ̤ÙÚÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÛÙË ‰È¿ÎÚÈÛË Ù˘ ÓfiÛÔ˘ Ì AUC 0,771 (95% CI: 0,684-0,845). ∏ ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· ÙfiÛÔ ÙÔ˘ ·ÚÈıÌÔ‡ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (AUC: 0,683), fiÛÔ Î·È Ù˘ CRP (AUC: 0,663) ‹Ù·Ó ÌÈÎÚ‹. ∞fi ÙË Û‡ÁÎÚÈÛË ÙˆÓ Î·Ì˘ÏÒÓ ROC ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ·ÚÈıÌÔ‡ ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÁÂÓÈ΋ Ô‡ÚˆÓ Û ۯ¤ÛË Ì ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ (p=0,04) Î·È ÙË CRP (p=0,03). ∏ ¢·ÈÛıËÛ›·, Ë ÂȉÈÎfiÙËÙ·, Ë ıÂÙÈ΋ Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· Î·È Ë ıÂÙÈ΋ Î·È ·ÚÓËÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ ÁÈ· ÙËÓ Î¿ı ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. √ ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ >10 ÎÔ ·ÚÔ˘Û›·ÛÂ
1
1
0,9
0,9
0,8
0,8
0,7
0,7
0,6
∂˘·ÈÛıËÛ›·
∂˘·ÈÛıËÛ›·
Ô‡ÚˆÓ. ∞fi ·˘Ù¿, Ù· 14 ‹Ù·Ó ÎÔÚ›ÙÛÈ· Î·È Ù· 13 ·ÁfiÚÈ·. ∏ Û˘¯ÓfiÙËÙ· Ù˘ Ô˘ÚÔÏԛ̈͢ ηٿ ËÏÈÎȷ΋ ÔÌ¿‰· ‹Ù·Ó 16% ÁÈ· Ù· ÓÂÔÁÓ¿ ËÏÈΛ·˜ 15-29 ËÌÂÚÒÓ, 25% ÁÈ· Ù· ‚Ú¤ÊË ËÏÈΛ·˜ 30-59 ËÌÂÚÒÓ Î·È 29% ÁÈ· Ù· ‚Ú¤ÊË ËÏÈΛ·˜ 60-90 ËÌÂÚÒÓ. √È ˘Â‡ı˘ÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ‹Ù·Ó: Escherichia coli 85%, Klebsiella pneumoniae 7%, Enterobacter spp. 4% Î·È Pseudomonas aeruginosa 4%. ¢‡Ô ·ÛıÂÓ›˜ Ì ԢÚÔÏԛ̈ÍË - Î·È ÔÈ ‰‡Ô ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 30 ËÌÂÚÒÓ - ·ÚÔ˘Û›·Û·Ó ‰È·ÛÔÚ¿ Ù˘ ÓfiÛÔ˘ Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ (E. coli). ∆· ‚Ú¤ÊË Ì ԢÚÔÏԛ̈ÍË, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ¯ˆÚ›˜ Ô˘ÚÔÏԛ̈ÍË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ˘ÔÛÊ·ÈÚ›ˆÓ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ (38,8 ± 56,4 ÎÔ ¤Ó·ÓÙÈ 1,6 ± 1,8 ÎÔ, p<0,0001), ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (17.495 ± 7.491 /ÌL ¤Ó·ÓÙÈ 13.356 ± 9.547 /ÌL, p=0,041) Î·È ÌÂÁ·Ï‡ÙÂÚË ∆∫∂ (38,9 ± 27,4 mm/h ¤Ó·ÓÙÈ 17,4 ± 14,6 mm/h, p<0,0001), ÂÓÒ Ë ‰È·ÊÔÚ¿ ÛÙȘ ÙÈ̤˜ Ù˘ CRP ÎÈÓ‹ıËΠÛÙ· fiÚÈ· ÙÔ˘
§Â˘Î¿
0,5 0,4
0,6
CRP
0,5 0,4 0,3
0,3 TKE
0,2 0,1
¶˘ÔÛÊ·›ÚÈ·
0,2 0,1
∞
µ
0
0 0
0,2
0,4 0,6 1 - ∂ȉÈÎfiÙËÙ·
0,8
1
0
0,2
0,4 0,6 1 - ∂ȉÈÎfiÙËÙ·
0,8
1
∂ÈÎfiÓ· 1. ∫·Ì‡Ï˜ ROC. ∞: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ∆∫∂ Î·È µ: ¶˘ÔÛÊ·›ÚÈ· ÛÙË ÁÂÓÈ΋ Ô‡ÚˆÓ Î·È CRP. ∏ ‰È·ÁÓˆÛÙÈ΋ ÈηÓfiÙËÙ· ηıÔÚ›˙ÂÙ·È ·fi ÙËÓ ÂÚÈÔ¯‹ οو ·fi ÙËÓ Î·Ì‡ÏË (AUC). ªÂÁ·Ï‡ÙÂÚË AUC ÛËÌ·›ÓÂÈ Î·È Î·Ï‡ÙÂÚË ·fi‰ÔÛË Ù˘ ‰ÔÎÈÌ·Û›·˜. ¶·È‰È·ÙÚÈ΋ 2007;70:221-226
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·224
224
™. ºÔ‡˙·˜ Î·È Û˘Ó.
˘„ËÏ‹ ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (94%) Î·È ÂÍ·ÈÚÂÙÈ΋ ıÂÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ (48,9), ·ÔÙÂϤÛÌ·Ù· Û·ÊÒ˜ ·ÓÒÙÂÚ· Û ۇÁÎÚÈÛË Ì ÙÔÓ ·ÚÈıÌfi ˘ÔÛÊ·ÈÚ›ˆÓ >5 ÎÔ (ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· 83% Î·È ıÂÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ 16,3, p=0,016 Î·È p<0,001, ·ÓÙ›ÛÙÔȯ·). ∆· ˘ÔÛÊ·›ÚÈ·, ÙfiÛÔ ÁÈ· ÙÈ̤˜ >5 ÎÔ fiÛÔ Î·È ÁÈ· ÙÈ̤˜ >10 ÎÔ, ·ÚÔ˘Û›·Û·Ó ˘„ËÏ‹ ÂȉÈÎfiÙËÙ· (96% Î·È 99%, ·ÓÙ›ÛÙÔȯ·), ·ÏÏ¿ ¯·ÌËÏ‹ ¢·ÈÛıËÛ›· (56%), ¯·ÌËÏ‹ ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (88%) Î·È ÌË ÛËÌ·ÓÙÈ΋ ·ÚÓËÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ (0,46 Î·È 0,45, ·ÓÙ›ÛÙÔȯ·). ™Â fi,ÙÈ ·ÊÔÚ¿ Ù· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÔÈ Ï¤ÔÓ ÈηÓÔÔÈËÙÈÎÔ› ‰È·ÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÚԤ΢„·Ó fiÙ·Ó ıˆڋıËÎ·Ó ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜ ÌÂÁ·Ï‡ÙÂÚ˜ ÙˆÓ 15.000/ÌL ‹ ÌÈÎÚfiÙÂÚ˜ ÙˆÓ 5.000/ÌL. øÛÙfiÛÔ, Ì ÂÍ·›ÚÂÛË ÙËÓ ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (92%), ÔÈ ˘fiÏÔÈÔÈ ‰Â›ÎÙ˜ ‹Ù·Ó ¯·ÌËÏÔ› Î·È ÔÈ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ ÌË ÛËÌ·ÓÙÈΤ˜ (ıÂÙÈ΋ LR: 3,26 Î·È ·ÚÓËÙÈ΋ LR: 0,29). ™Â Û‡ÁÎÚÈÛË Ì ٷ ˘ÔÛÊ·›ÚÈ· ÛÙË ÁÂÓÈ΋ Ô‡ÚˆÓ (>10 ÎÔ), Ù· ÏÂ˘Î¿ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (>15.000/ÌL ‹ <5.000/ÌL) ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· (p<0,001), ·ÚfiÌÔÈ· ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (p=0,42) Î·È ÌÈÎÚfiÙÂÚË ÂȉÈÎfiÙËÙ· (p<0,0001) Î·È ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (p<0,0001) (¶›Ó·Î·˜ 1). °È· ÙËÓ ∆∫∂ Î·È ÙË CRP, Ë Â˘·ÈÛıËÛ›·, Ë ÂȉÈÎfiÙËÙ·, Ë ıÂÙÈ΋ Î·È ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ηıÒ˜ Î·È ÔÈ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔًوÓ, ÎÈÓ‹ıËÎ·Ó Û ÌË ÈηÓÔÔÈËÙÈο ›‰· (¶›Ó·Î·˜ 1).
™˘˙‹ÙËÛË ∏ Û˘¯ÓfiÙËÙ· Ù˘ Ô˘ÚÔÏԛ̈͢ ÛÙ· 115 ‚Ú¤ÊË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó 23,5% (27 ‚Ú¤ÊË), ·Ó·‰ÂÈÎÓ‡ÔÓÙ·˜ ÙËÓ Ô˘ÚÔÏԛ̈ÍË ˆ˜ ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ˘ÚÂÙÔ‡ Û ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ÌËÓÒÓ ¯ˆÚ›˜ ÂÛÙ›· Ïԛ̈͢. ∏ Û˘¯ÓfiÙËÙ· ‹Ù·Ó ›‰È· ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ·, ÂÓÒ ‰È·ÛÔÚ¿ Ù˘ ÓfiÛÔ˘ Î·È ‚·ÎÙËÚÈ·ÈÌ›· ·Ú·ÙËÚ‹ıËΠ۠ÔÛÔÛÙfi 7,4% (2 ·ÛıÂÓ›˜ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 30 ËÌÂÚÒÓ). ∆· ·Ú·¿Óˆ ·ÔÙÂϤÛÌ·Ù· Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· Ì ·˘Ù¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (1-3,6,18). ∞fi ÙË ÌÂϤÙË Ù˘ Û˘ÓÔÏÈ΋˜ ·fi‰ÔÛ˘ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰ÂÈÎÙÒÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ η̇Ϙ ROC, ÚÔ·ÙÂÈ fiÙÈ ÌfiÓÔ Ô ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈ΋ ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· (AUC: 0,825). øÛÙfiÛÔ, Ë ÛËÌ·Û›· Ù˘ ÌÈÎÚÔÛÎÔÈ΋˜ ÂͤٷÛ˘ ÙˆÓ Ô‡ÚˆÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ ¯Ú‹˙ÂÈ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘Û˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ˘Ô˘Ú›· ·ÚÔ˘Û›·Û ˘„ËÏ‹ ÂȉÈÎfiÙËÙ· ÙfiÛÔ ÁÈ· ÙÈ̤˜ >5 ÎÔ (94%), fiÛÔ Î·È ÁÈ· ÙÈ̤˜ >10 ÎÔ (99%). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi, fï˜, ‰ÂÓ Ú¤ÂÈ Ó· ıˆÚËı› Û·Ó ÈηÓfiPaediatriki 2007;70:221-226
ÙËÙ· ·ÔÎÏÂÈÛÌÔ‡ Ù˘ Ô˘ÚÔÏԛ̈͢, ÈηÓfiÙËÙ· Ô˘ ÌÔÚ› Ó· ÂÎÊÚ·ÛÙ› ·ÍÈfiÈÛÙ· ÌfiÓÔ ·fi ÙËÓ ·ÚÓËÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔًوÓ, Ë ÔÔ›· Î˘Ì¿ÓıËΠ۠ÌË ÛËÌ·ÓÙÈο ›‰· (0,46 ÁÈ· ÙÈ̤˜ >5 ÎÔ Î·È 0,45 ÁÈ· ÙÈ̤˜ >10 ÎÔ, Ì ÛËÌ·ÓÙÈΤ˜ ÙȘ ÙÈ̤˜ <0,1). ∂Ô̤ӈ˜, Ô ¯·ÌËÏfi˜ ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ ‰ÂÓ ÌÔÚ› Ó· ıˆÚËı› ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Ô˘ÚÔÏԛ̈͢. ŒÙÛÈ, Â¿Ó Ë ·fiÊ·ÛË ÁÈ· ηÏÏȤÚÁÂÈ· ÛÙ· ‚Ú¤ÊË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‚·ÛÈ˙fiÙ·Ó ÛÙË ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ Î·È ıˆÚÒÓÙ·˜ Û·Ó ·ıÔÏÔÁÈ΋ ÙÈÌ‹ Ù· >10 ˘ÔÛÊ·›ÚÈ· ÎÔ, ÔÈ 12 ·fi ÙȘ 27 Ô˘ÚÔÏÔÈÌÒÍÂȘ ‰ÂÓ ı· ›¯·Ó ‰È·ÁÓˆÛÙ›. ∞ÓÙ›ıÂÙ·, Ë ıÂÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ ‹Ù·Ó ÂÍ·ÈÚÂÙÈ΋ ÙfiÛÔ ÁÈ· ÙÈ̤˜ >5 ÎÔ, fiÛÔ Î·È ÁÈ· ÙÈ̤˜ >10 ÎÔ (16,3 Î·È 48,9, ·ÓÙ›ÛÙÔȯ·, Ì ÛËÌ·ÓÙÈΤ˜ ÙȘ ÙÈ̤˜ >10), ·Ó·‰ÂÈÎÓ‡ÔÓÙ·˜ ÙËÓ ˘Ô˘Ú›· Û ȉȷ›ÙÂÚ· ¯Ú‹ÛÈÌÔ ‰Â›ÎÙË ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Ì ԢÚÔÏԛ̈ÍË. √ ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ >10 ÎÔ ·Ô‰Â›¯ıËΠÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙÔ˜ Û ۯ¤ÛË Ì ٷ >5 ˘ÔÛÊ·›ÚÈ· ÎÔ, ÂÂȉ‹ Û˘Ó‰˘¿ÛÙËΠ̠ÏÈÁfiÙÂÚ· „¢‰Ò˜ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· Î·È ·ÚÔ˘Û›·Û ηχÙÂÚË ıÂÙÈ΋ ·Ó·ÏÔÁ›· Èı·ÓÔًوÓ. ∏ ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ˆ˜ ÌÂÌÔӈ̤ÓË ÂͤٷÛË ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ ·Ô‰Â›¯ıËΠÂÚÈÔÚÈṲ̂ÓË. √È ÙÈ̤˜ Ï¢ÎÒÓ >15.000/ÌL ‹ <5.000/ÌL ˘ÂÚ›¯·Ó ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ ÙÈÌÒÓ Ï¢ÎÒÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ªË ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· ÚԤ΢„·Ó Î·È ·fi ÙË ÌÂϤÙË Ù˘ ∆∫∂ Î·È Ù˘ CRP, Ì ·ÔÙ¤ÏÂÛÌ· Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ Ó· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ˜. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡˜ ‰Â›ÎÙ˜ ‰ÂÓ ·Ô‰Â›¯ıËΠ·fi ÌfiÓÔ˜ ÙÔ˘ ÈηÓfi˜ Ó· ·ÔÎÏ›ÛÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢ Û ‚Ú¤ÊË Ì ˘ÚÂÙfi ¯ˆÚ›˜ ÂÛÙ›·. øÛÙfiÛÔ, Ô Û˘Ó‰˘·ÛÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ <10 ÎÔ Î·È Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 5.000-15.000/ÌL ›¯Â ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ÙÔÓ Î¿ı ‰Â›ÎÙË Í¯ˆÚÈÛÙ¿. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ·Ú·¿Óˆ ÎÚÈÙËÚ›Ô˘ ÛÙ· ‚Ú¤ÊË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ı· Ô‰ËÁÔ‡Û Û ·ÔÙ˘¯›· ‰È¿ÁÓˆÛ˘ 3 Ô˘ÚÔÏÔÈÌÒÍÂˆÓ (11%) Û ۯ¤ÛË Ì ÙȘ 12 Ô˘ÚÔÏÔÈÌÒÍÂȘ (44%) Ô˘ ‰ÂÓ ı· ›¯·Ó ‰È·ÁÓˆÛÙ› Â¿Ó ÎÚÈÙ‹ÚÈÔ ·ÔÎÏÂÈÛÌÔ‡ ‹Ù·Ó ÌfiÓÔ Ù· ˘ÔÛÊ·›ÚÈ· (p<0,0001) Î·È ÙȘ 6 Ô˘ÚÔÏÔÈÌÒÍÂȘ (22%) Ô˘ ‰ÂÓ ı· ›¯·Ó ‰È·ÁÓˆÛÙ› Â¿Ó ÎÚÈÙ‹ÚÈÔ ·ÔÎÏÂÈÛÌÔ‡ ‹Ù·Ó ÌfiÓÔ Ù· ÏÂ˘Î¿ (p=0,38). ∞˘Ù¿ Ù· ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÔÙ˘¯›·˜ ‚Ú›ÛÎÔÓÙ·È Û ·ÓÙÈÛÙÔȯ›· Ì ٷ ÔÛÔÛÙ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ÛÂÈÚ¿ ¿ÏÏˆÓ ÌÂÏÂÙÒÓ (13-18). √È ÂÚÁ·ÛÙËÚÈ·ÎÔ› ‰Â›ÎÙ˜ Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÂÈϤ¯ıËÎ·Ó ‰ÈfiÙÈ Î·ıÔÚ›˙ÔÓÙ·È ¿ÌÂÛ·, Ì ¯·ÌËÏfi ÎfiÛÙÔ˜ Î·È ¯ˆÚ›˜ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÂÚÁ·ÛÙËÚÈ·Îfi ÂÍÔÏÈÛÌfi. ª›· Ó¤· ̤ıÔ‰Ô˜
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·225
225
∫›Ó‰˘ÓÔ˜ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË
ÂÓÈÛ¯˘Ì¤Ó˘ ·Ó¿Ï˘Û˘ Ô‡ÚˆÓ Ì ÙË ¯Ú‹ÛË Î˘ÙÙ·ÚÔÌÂÙÚËÙ‹ Î·È ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ˘Ô˘Ú›·˜ ˆ˜ ÙÔÓ ·ÚÈıÌfi Ï¢ÎÔ΢ÙÙ¿ÚˆÓ/mm3 Û ÌË Ê˘ÁÔÎÂÓÙÚË̤ÓÔ ‰Â›ÁÌ· Ô‡ÚˆÓ, ¤¯ÂÈ ·Ô‰Âȯı› ÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙË ·fi ÙËÓ ·Ï‹ ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ (25). øÛÙfiÛÔ, ÚfiÎÂÈÙ·È ÁÈ· ÂͤٷÛË Ô˘ ··ÈÙ› ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi, Ì ·ÌÊÈÛ‚ËÙÔ‡ÌÂÓË Û¯¤ÛË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜-ÎfiÛÙÔ˘˜ Î·È ·ÛÊ·ÏÒ˜ ‰˘ÛÚfiÛÈÙË ÙfiÛÔ ÛÂ Â›Â‰Ô ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘, fiÛÔ Î·È Û ÌË ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÓÔÛËÏ¢ÙÈΤ˜ ÌÔÓ¿‰Â˜ Ù˘ ÂÚÈʤÚÂÈ·˜ (3-8,18). ∆Ô ˘„ËÏfi ÔÛÔÛÙfi Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Ô˘ ÚԤ΢„ ·fi ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ÌÔÚ› Ó· ıˆÚËı› ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∞Ó Î·È Ë ÂÈÛ·ÁˆÁ‹ ÁÈ· Ï‹ÚË ¤ÏÂÁ¯Ô ÙˆÓ Â̇ÚÂÙˆÓ ‚ÚÂÊÒÓ ¯ˆÚ›˜ ÂÛÙ›· Ïԛ̈͢ ·ÔÙÂÏ› ÔÏÈÙÈ΋ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÎÏÈÓÈ΋˜, Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ Ù¤ÙÔÈˆÓ ‚ÚÂÊÒÓ ‰ÂÓ Î·Ù·Ï‹ÁÂÈ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∂ÈϤÔÓ, ¤Ó· ̤ÚÔ˜ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ›¯·Ó ÂÈÛ·¯ı› ÁÈ· ¤ÏÂÁ¯Ô ‰ÂÓ ÏËÚÔ‡Û ٷ ÎÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ ÛÙË ÌÂϤÙË (Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ÛË„·ÈÌ›·˜, Ï‹„Ë Ô‡ÚˆÓ ÌfiÓÔ Ì ˘ÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË, ¯ˆÚ›˜ ·ÓÙÈ‚›ˆÛË ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹). øÛÙfiÛÔ, Ë ÂÊ·ÚÌÔÁ‹ ·˘ÙÒÓ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÎÚ›ıËΠ·Ó·Áη›· ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë ÔÌÔÈÔÁ¤ÓÂÈ· ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Î·È Ó· ÂÚÈÔÚÈÛÙ› ÙÔ ÂӉ¯fiÌÂÓÔ „¢‰Ò˜ ıÂÙÈÎÒÓ ‹ ·ÚÓËÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ∏ ·ÍÈÔÏfiÁËÛË, Ù¤ÏÔ˜, ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ¤ÁÈÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÓÂfiÙÂÚ˜ Î·È ÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙ˜ ÛÙ·ÙÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, fiˆ˜ ÔÈ ·Ó·ÏÔÁ›Â˜ Èı·ÓÔÙ‹ÙˆÓ Î·È ÔÈ Î·Ì‡Ï˜ ROC ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ·fi‰ÔÛ˘ Ù˘ οı ‰ÔÎÈÌ·Û›·˜. ∂ÈϤÔÓ, Ù· ˘ÔÛÊ·›ÚÈ· ÛÙË ÌÈÎÚÔÛÎÔÈ΋ Ô‡ÚˆÓ Î·È Ù· ÏÂ˘Î¿ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ÂÎÙÈÌ‹ıËÎ·Ó Ì ‚¿ÛË ÂÚÈÛÛfiÙÂÚ˜ ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜, ÙÈ̤˜ Ô˘ ¤¯Ô˘Ó ·ÍÈÔÏÔÁËı› Û ÛÂÈÚ¿ ÌÂÏÂÙÒÓ Î·È Ô˘ ·ÔÙÂÏÔ‡Ó ‚·ÛÈο ÎÚÈÙ‹ÚÈ· ÛÙ· ÚˆÙfiÎÔÏÏ· ÂÎÙ›ÌËÛ˘ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÛÔ‚·Ú‹˜ ÌÈÎÚԂȷ΋˜ Ïԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÛÙ›· (13-15). ŒÙÛÈ, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂȯÂÈÚÂ›Ù·È Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ·˘ÙÒÓ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ Û fi,ÙÈ ·ÊÔÚ¿ Ê˘ÛÈο ÙËÓ ·Ó¿‰ÂÈÍË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· ‰ÂÓ ÌÔÚ› Ó· ‚·ÛÈÛÙ› ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Ô‡ÚˆÓ, ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÛÙËÓ ∆∫∂ Î·È ÛÙË CRP. ∏ ·Ó‡ÚÂÛË >10 ˘ÔÛÊ·ÈÚ›ˆÓ ÎÔ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ÙˆÓ Ô‡ÚˆÓ ı· Ú¤ÂÈ Ó· ηÙ¢ı‡ÓÂÈ ÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi ÚÔ˜ ÙËÓ Èı·ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢. øÛÙfiÛÔ, Û η̛· ÂÚ›ÙˆÛË Ô ¯·ÌËÏfiÙÂÚÔ˜ ·ÚÈıÌfi˜ ˘ÔÛÊ·ÈÚ›ˆÓ (·ÎfiÌ· Î·È <5 ÎÔ)
‰ÂÓ ÌÔÚ› Ó· ıˆÚËı› ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ÓfiÛÔ˘. ∞ÎfiÌË Î·È Ô Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘ ·ÚÈıÌÔ‡ ˘ÔÛÊ·ÈÚ›ˆÓ Ì ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÎÚÈÙ‹ÚÈÔ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÛÔ‚·Ú‹˜ ÌÈÎÚԂȷ΋˜ ÓfiÛÔ˘, ‰ÂÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÛÊ·Ï‹ Û˘ÌÂÚ¿ÛÌ·Ù· Û fi,ÙÈ ·ÊÔÚ¿ ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Ô˘ÚÔÏԛ̈͢. ∂Ô̤ӈ˜, Ë Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ ·ÔÙÂÏ› ÙË ÌfiÓË ·ÍÈfiÈÛÙË ÂͤٷÛË ÁÈ· ÙË ‰È¿ÁÓˆÛË Ô˘ÚÔÏԛ̈͢ Û Â̇ÚÂÙ· ‚Ú¤ÊË ËÏÈΛ·˜ 15-90 ËÌÂÚÒÓ ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÂÛÙ›· Ïԛ̈͢ Î·È ı· Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ¿ÌÂÛ·, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ÚˆÙfiÎÔÏÏÔ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ›ٷÈ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103:843-852. 2. Shaw KN, Gorelick MH, McGowan KL, McDanielYakscoe N, Schwartz JS. Prevalence of urinary tract infection and occult bacteremia in febrile young children in the emergency department. Arch Pediatr Adolesc Med 1996; 150:37. 3. Newman TB, Bernzweig JA, Takayama JI, Finch SA, Wasserman RC, Pantell RH. Urine testing and urinary tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings’ Febrile Infant Study. Arch Pediatr Adolesc Med 2002;156:44-54. 4. Shaw KN, McGowan KL, Gorelick MH, Schwartz JS. Screening for urinary tract infection in infants in the emergency department: which test is best? Pediatrics 1998; 101:E1. 5. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999; 104:E54. 6. Lin DS, Huang SH, Lin CC, Tung YC, Huang TT, Chiu NC et al. Urinary tract infection in febrile infants younger than eight weeks of age. Pediatrics 2000;105:E20. 7. Bachur R, Harper MB. Reliability of the urinalysis for predicting urinary tract infections in young febrile children. Arch Pediatr Adolesc Med 2001;155:60-65. 8. Lin DS, Huang FY, Chiu NC, Koa HA, Hung HY, Hsu CH et al. Comparison of hemocytometer leukocyte counts and standard urinalyses for predicting urinary tract infections in febrile infants. Pediatr Infect Dis J 2000;19:223-227. 9. Doley A, Nelligan M. Is a negative dipstick urinalysis good enough to exclude urinary tract infection in paediatric emergency department patients? Emerg Med 2003;15:77-80. 10. Tamim MM, Alesseh H, Aziz H. Analysis of the efficacy of urine culture as part of sepsis evaluation in the premature infant. Pediatr Infect Dis J 2003;22:805-808. 11. Hoberman A, Wald ER, Reynolds EA, Penchansky L, Charron M. Is urine culture necessary to rule out urinary tract infection in young febrile children? Pediatr Infect Dis J 1996;15:304-309. 12. Martin B, Ghosh A. Towards evidence based emergency ¶·È‰È·ÙÚÈ΋ 2007;70:221-226
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medicine: best BETS from the Manchester Royal Infirmary. Negative urine analysis to exclude urinary tract infection. Emerg Med J 2001;18:462-463. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med 1993;329:1437-1441. Baskin MN, O’Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992;120:22-27. Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Dagan R et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994;94:390-396. Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics 2001;108:311-316. Pantell RH, Newman TB, Bernzweig J, Bergman DA, Takayama JI, Segal M et al. Management and outcomes of care of fever in early infancy. JAMA 2004;291:1203-1212. Herr SM, Wald ER, Pitetti RD, Choi SS. Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness. Pediatrics 2001;108:866-871.
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19. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994;271:703-707. 20. Gallagher EJ. Clinical utility of likelihood ratios. Ann Emerg Med 1998;31:391-397. 21. Swets JA. Measuring the accuracy of diagnostic systems. Science 1988;240:1285-1293. 22. Bonsu BK, Chb M, Harper MB. Identifying febrile young infants with bacteremia: is the peripheral white blood cell count an accurate screen? Ann Emerg Med 2003;42:216-225. 23. Gervaix A, Galetto-Lacour A, Gueron T, Vadas L, Zamora S, Suter S et al. Usefulness of procalcitonin and C-reactive protein rapid tests for the management of children with urinary tract infection. Pediatr Infect Dis J 2001;20:507-511. 24. Gassler N, Paul H, Runge M. Rapid detection of urinary tract infection-evaluation of flow cytometry. Clin Nephrol 2006;66:331-335.
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™‡Ó‰ÚÔÌÔ Ô„oÌ˘fiÎÏoÓÔ˘-·Ù·Í›·˜ Û ·ÛıÂÓ‹ Ì Ó¢ÚÔ‚Ï¿Ûو̷: ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ¡. ∫·Ù˙ËÏ¿Î˘1, ∂. ª·ÓÙ·‰¿Î˘1, ∞. ™·‚‚›‰Ô˘1, ¶. µÔÚÁÈ¿1, ª. ƒ·˚Û¿ÎË2, ∂. ™ÙÂȷοÎË1, ª. ∫·ÏÌ·ÓÙ‹1 ¶ÂÚ›ÏË„Ë: ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ ·ÔÙÂÏ› ÙÔ 7-8% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î·ÎÔËıÂÈÒÓ ÛÙ· ·È‰È¿, ÂÓÒ Â˘ı‡ÓÂÙ·È ÁÈ· ÙÔ 15% ÙˆÓ ı·Ó¿ÙˆÓ ·fi ÓÂÔϷۛ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ Ù·ÍÈÓfiÌËÛË ‚·Û›˙ÂÙ·È ÛÙËÓ ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘, ÙËÓ ËÏÈΛ·, ÙËÓ ÈÛÙÔ·ıÔÏÔÁ›· Î·È Û ÌÔÚÈ·ÎÔ‡˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜, fiˆ˜ Ë ÂÓ›Û¯˘ÛË ÙÔ˘ ÔÁÎÔÁÔÓȉ›Ô˘ N-myc. ™˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÂÙ·È ˆ˜ Ì¿˙· ηٿ Ì‹ÎÔ˜ Ù˘ Û˘Ì·ıËÙÈ΋˜ ·Ï˘Û›‰·˜. √È ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ÔÈΛÏÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ fiÁÎÔ˘ Î·È ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ÌÂÙ·ÛÙ·ÙÈ΋˜ ÓfiÛÔ˘. √ ÚˆÙÔ·ı‹˜ fiÁÎÔ˜ ÌÔÚ› Ó· ÂÓÙÔÈÛÙ› ÔÔ˘‰‹ÔÙ ÛÙÔ Û˘Ì·ıËÙÈÎfi Û‡ÛÙËÌ·, fiˆ˜ ÛÙ· ÂÈÓÂÊÚ›‰È·, ÛÙ· ÎÔÈÏȷο Û˘Ì·ıËÙÈο Á¿ÁÁÏÈ· ‹ ÛÙÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ. ∆· ‚Ú¤ÊË Ì Ó¢ÚÔ‚Ï¿Ûو̷ Û˘Ó‹ıˆ˜ ¤¯Ô˘Ó ÂÓÙÔÈṲ̂ÓË ÓfiÛÔ Î·Ï‹˜ ÚfiÁÓˆÛ˘, Ì ¢ÓÔ˚ÎÔ‡˜ ÌÔÚÈ·ÎÔ‡˜ ‰Â›ÎÙ˜ Û ·ÓÙ›ıÂÛË Ì ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙÔ˘ ¤ÙÔ˘˜. ∆Ô Î˘ÚÈfiÙÂÚÔ ·Ú·ÓÂÔÏ·ÛÌ·ÙÈÎfi Û‡Ó‰ÚÔÌÔ Û ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Â›Ó·È Ô Ô„ÔÌ˘fiÎÏoÓÔ˜-·Ù·Í›· Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 2-3% ÙˆÓ ·ÛıÂÓÒÓ. ™ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤¯Ô˘Ó ¯·ÌËÏfi ÛÙ¿‰ÈÔ ÓfiÛÔ˘ Î·È ¿ÚÈÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË. øÛÙfiÛÔ, ˆ˜ ÚÔ˜ ÙËÓ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË, Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÈ̤ÓÔ˘Û· ηı˘ÛÙ¤ÚËÛË. √È ˘¿Ú¯Ô˘Û˜ ıÂڷ¢ÙÈΤ˜ ÂÈÏÔÁ¤˜, fiˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ë ÂÓ‰ÔÊϤ‚È· Á-ÛÊ·ÈÚ›ÓË, Ë Ï·ÛÌ·Ê·›ÚÂÛË Î·È Ë ¯ËÌÂÈÔıÂڷ›·, ‰ÂÓ ¤¯Ô˘Ó ÚÔÛʤÚÂÈ Ù· ·Ó·ÌÂÓfiÌÂÓ·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ ËÏÈΛ·˜ 16 ÌËÓÒÓ Ì Ó¢ÚÔ‚Ï¿Ûو̷, Ô„ÔÌ˘fiÎÏoÓÔ-·Ù·Í›· Î·È „˘¯ÔÎÈÓËÙÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÂÓÒ ·Ó·ÛÎÔÂ›Ù·È Ë ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ ÚÔ˜ ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙË ıÂڷ›· Î·È ÙË Ó¢ÚÔÏÔÁÈ΋ ¤Î‚·ÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘.
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘ 2 ∆Ì‹Ì· ∞ÎÙÈÓԉȷÁÓˆÛÙÈ΋˜, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· ∫·ÏÌ·ÓÙ‹ pedhem@med.uoc.gr ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, µ’ ∫Ù‹ÚÈÔ ∆.∫. 711 10, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
§¤ÍÂȘ ÎÏÂȉȿ: N¢ÚÔ‚Ï¿Ûو̷, o„ÔÌ˘fiÎÏoÓÔ˜-·Ù·Í›·.
Opsoclonus-myoclonus-ataxia syndrome in a patient with neuroblastoma: Case report and review of the literature N. Katzilakis1, E. Mandadakis1, A. Savidou1, P. Vorgia1, M. Raissaki2, E. Steiakaki1, M. Kalmanti1 Abstract: Neuroblastoma represents 7-8% of all childhood malignancies and is responsible for 15% of cancer-related deaths in children. Staging is based on the age of the child, the extent of the disease and the histopathology and molecular prognostic markers, such as amplification of the N-myc oncogene. Neuroblastoma usually presents as a mass along the sympathetic chain, and its clinical manifestations are based on the site of the primary tumour and the presence or absence of metastatic disease. Infants with neuroblastoma usually have localized disease with favourable molecular markers (absence of N-myc amplification) in contrast to children >1 year of age. The most frequent paraneoplastic syndrome in neuroblastoma is opsomyoclonus-ataxia (OMA), which is seen in 2-3% of cases. Most of these patients have low-stage disease with a favourable prognosis regarding long-term survival, although their mental and motor development may be substantially delayed. The available therapeutic options such as corticosteroids, intravenous Á-globulin, exchange transfusion and chemotherapy do not offer the anticipated results in the development of these children. The case is presented of a 16 month-old boy with neuroblastoma, OMA and developmental retardation, along with a review of the literature of this paraneoplastic syndrome, with emphasis on its treatment and the neurological outcome of children with neuroblastoma and OMA.
1 Haematology-Oncology Paediatric Department, General University Hospital of Heraklion, Crete 2 Diagnostic Radiology Department, General University Hospital of Heraklion, Crete Correspondence: Maria Kalmanti pedhem@med.uoc.gr General University Hospital of Heraklion, 2nd Building 711 10, Heraklion, Crete
Key words: Neuroblastoma, opsoclonus-myoclonus-ataxia (OMA) syndrome.
∂ÈÛ·ÁˆÁ‹ ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ Â›Ó·È o ‰Â‡ÙÂÚÔ˜ ÛÂ Û˘¯ÓfiÙËÙ· Û˘Ì·Á‹˜ fiÁÎÔ˜ Ù˘ ·È‰È΋˜ ËÏÈ-
Λ·˜. ∏ ›وÛË Ù˘ ÓfiÛÔ˘ ÂÎÙÈÌ¿Ù·È Û 9-10 ÂÚÈÙÒÛÂȘ ·Ó¿ 1.000.000 ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 15 ÂÙÒÓ ÂÙËÛ›ˆ˜ Î·È Â›Ó·È Ï›ÁÔ ¶·È‰È·ÙÚÈ΋ 2007;70:227-231
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·228
228
¡. ∫·Ù˙ËÏ¿Î˘ Î·È Û˘Ó.
ÌÂÁ·Ï‡ÙÂÚË ÛÙ· ·ÁfiÚÈ· (·Ó·ÏÔÁ›· ·ÁÔÚÈÒÓ ÚÔ˜ ÎÔÚ›ÙÛÈ· 1,2:1). ∏ ̤ÛË ËÏÈΛ· ‰È¿ÁÓˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Â›Ó·È ÔÈ 23 Ì‹Ó˜ ÌÂ Û˘¯ÓfiÙÂÚÔ Â‡ÚÔ˜ Ù· 0-4 ¤ÙË. ™ÙË ‰È¿ÁÓˆÛË, ÙÔ 40% Â›Ó·È ‚Ú¤ÊË, ÂÓÒ ÔÛÔÛÙfi ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 5% ¤¯Ô˘Ó ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 10 ÂÙÒÓ (1). ∆Ô ÌÂÙ·ÛÙ·ÙÈÎfi Ó¢ÚÔ‚Ï¿Ûو̷ Û ·È‰È¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ̛· ·fi ÙȘ ¯ÂÈÚfiÙÂÚ˜ ÚÔÁÓÒÛÂȘ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î·ÎÔËıÂÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∞Ó Î·È ·Ú¯Èο ··ÓÙ¿ ÛÙË ¯ËÌÂÈÔıÂڷ›·, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ˘ÔÙÚÔÈ¿˙ÂÈ Î·È Î·Ù·Ï‹ÁÂÈ Ì ÚfiÔ‰Ô Ù˘ ÓfiÛÔ˘. √È Ó¢ÚÔÁÂÓ›˜ fiÁÎÔÈ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÚÔÁÔÓÈο-ÔÏ˘‰‡Ó·Ì· Û˘Ì·ıËÙÈο ·ÙÙ·Ú· Ù˘ Ó¢ÚÈ΋˜ ·ÎÚÔÏÔÊ›·˜ ‹ ¯ÚˆÌÈfiÊÈÏ· ·ÙÙ·Ú· ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ. πÛÙÔÏÔÁÈο ‰È·ÎÚ›ÓÔÓÙ·È Û Ó¢ÚÔ‚Ï¿Ûو̷, Á·ÁÁÏÈÔÓ¢ÚÔ‚Ï¿Ûو̷ (fiÁÎÔ˜ Ì ÒÚÈÌ· Á·ÁÁÏȷο ·ÙÙ·Ú· Î·È Ó¢ÚÔ‚Ï¿ÛÙ˜) Î·È Á·ÁÁÏÈÔÓ‡ڈ̷. √È ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÔÈΛÏÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ fiÁÎÔ˘ Î·È ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ÌÂÙ·ÛÙ·ÙÈ΋˜ ÓfiÛÔ˘. ¶ÂÚ›Ô˘ ÙÔ 70% ÙˆÓ ÚˆÙÔ·ıÒÓ fiÁÎˆÓ ÂÓÙÔ›˙ÂÙ·È ÛÙËÓ ÎÔÈÏÈ¿, 25% ÛÙÔÓ ÙÚ¿¯ËÏÔ ‹ ÛÙÔÓ ıÒڷη Î·È 5% ÛÙËÓ ‡ÂÏÔ. √È ÌÂÙ·ÛÙ¿ÛÂȘ ··ÓÙÒÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙÔÓ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, ÛÙ· ÔÛÙ¿ Î·È ÛÙÔ˘˜ ÏÂÌÊ·‰¤Ó˜. ∆Ô ‹·Ú Î·È ÙÔ ‰¤ÚÌ· ÚÔÛ‚¿ÏÏÔÓÙ·È Û˘¯ÓfiÙÂÚ· Û ‚Ú¤ÊË Ì ÓfiÛÔ ÛÙ·‰›Ô˘ IVS (1). √ Ô„ÔÌ˘fiÎÏoÓÔ˜ (Û‡Ó‰ÚÔÌÔ Kinsbourne) Â›Ó·È Û¿ÓÈÔ ·Ú·ÓÂÔÏ·ÛÌ·ÙÈÎfi ‹ ÌÂÙ·ÏÔÈÌ҉˜ Ó¢ÚÔÏÔÁÈÎfi Û‡Ó‰ÚÔÌÔ, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‚Ú·¯Â›Â˜ ·ӷϷ̂·ÓfiÌÂÓ˜ ÎÈÓ‹ÛÂȘ ÙˆÓ ÔÊı·ÏÌÒÓ, ÙÔ˘ ÎÔÚÌÔ‡ Î·È ÙˆÓ ¿ÎÚˆÓ Ô˘ Û˘¯Ó¿ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÚÂÁÎÂÊ·ÏȉÈ΋ ·Ù·Í›· (Û‡Ó‰ÚÔÌÔ Ô„ÔÌ˘fiÎÏoÓÔ˘-·Ù·Í›·˜, OMA) (2,3). ™Ù· ·È‰È¿, ÙÔ Û‡Ó‰ÚÔÌÔ OMA Û˘ÓËı¤ÛÙÂÚ· Û˘Ó‰¤ÂÙ·È Ì Ó¢ÚÔ‚Ï¿Ûو̷, ÙÔ˘ ÔÔ›Ô˘ ·ÔÙÂÏ› ÂΉ‹ÏˆÛË ÛÙÔ 2-3% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (4). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÙÔ Û‡Ó‰ÚÔÌÔ OMA ¤¯ÂÈ Û˘Ó‰Âı› Ì ÔÈΛϷ ÓÂÔÏ¿ÛÌ·Ù·, fiˆ˜ ηÚΛÓÔ Ì·ÛÙÒÓ, ˆÔıËÎÒÓ Î·È ÌÈÎÚÔ΢ÙÙ·ÚÈÎfi ηÚΛӈ̷ Ó‡ÌÔÓ· (5). ∆Ô ÌÂÙ·ÏÔÈÌ҉˜ Ó¢ÚÔÏÔÁÈÎfi Û‡Ó‰ÚÔÌÔ √ª∞ ¤¯ÂÈ Û˘Ó‰Âı› Ì Ïԛ̈ÍË ·fi ‰È¿ÊÔÚÔ˘˜ ÈÔ‡˜ (6).
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 16 ÌËÓÒÓ Ô˘ ·Ú·¤ÌÊıËΠÏfiÁˆ „˘¯ÔÎÈÓËÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, Ô„ÔÌ˘fiÎÏoÓÔ˘-·Ù·Í›·˜ Î·È ÙÚfiÌÔ˘ ÎÔÚÌÔ‡, ÎÂÊ·Ï‹˜ Î·È ¿ÎÚˆÓ ·fi 15Ë̤ÚÔ˘ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘. ∆Ô ·È‰› ÁÂÓÓ‹ıËΠ̠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÌÂÙ¿ ·fi ‰›‰˘ÌË Î‡ËÛË 37 ‚‰ÔÌ¿‰ˆÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËPaediatriki 2007;70:227-231
Û˘ 2030 g, ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ 32,5 cm Î·È Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ 46 cm. ∆Ô ÂÚÈÁÂÓÓËÙÈÎfi, Ì·È¢ÙÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ. ∆Ô ‚Ú¤ÊÔ˜ ›¯Â Ê˘ÛÈÔÏÔÁÈ΋ „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 15 ÌËÓÒÓ, ηıÒ˜ ÛÙ‹ÚÈÍ ÙÔ ÎÂÊ¿ÏÈ Û ËÏÈΛ· 3 ÌËÓÒÓ, οıÈÛ Û ËÏÈΛ· 6-7 ÌËÓÒÓ, ‚¿‰ÈÛ Û ËÏÈΛ· 13 ÌËÓÒÓ Î·È Â›Â Ï¤ÍÂȘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 14-15 ÌËÓÒÓ. ∞fi 15Ë̤ÚÔ˘ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜, ÙÔ ·È‰› ·ÚÔ˘Û›·Û ·Ù·Í›·, ÚÔԉ¢ÙÈο ÂȉÂÈÓÔ‡ÌÂÓË ·‰˘Ó·Ì›· ÛÙ‹ÚÈ͢ ÎÂÊ·Ï‹˜, ·Ú·ÌÔÓ‹˜ Û fiÚıÈ· Î·È Î·ıÈÛÙ‹ ı¤ÛË, Ô„ÔÌ˘fiÎÏoÓÔ, ÙÚfiÌÔ ÎÔÚÌÔ‡, ÎÂÊ·Ï‹˜ Î·È ¿ÎÚˆÓ Î·È ·ÏÈÓ‰ÚfiÌËÛË ÏfiÁÔ˘. ªÂÙ¿ ÙËÓ ÂͤٷÛË ·fi ·È‰›·ÙÚÔ Î·È ·È‰ÔÓ¢ÚÔÏfiÁÔ, ·Ú·¤ÌÊıËΠÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó ·‡ÚÂÙÔ, Ì ηϿ ˙ˆÙÈο ÛËÌ›·, ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ÛÙËÓ 25Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (∂£), ‡„Ô˜ ÛÒÌ·ÙÔ˜ ÛÙËÓ 3Ë-10Ë ∂£ Î·È ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ οو ·fi ÙËÓ 3Ë ∂£. ∏ ηٿ Û˘ÛÙ‹Ì·Ù· ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰ÂÓ ·Ó¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÂÓÒ Ó¢ÚÔÏÔÁÈο ›¯Â ·‰˘Ó·Ì›· ÛÙ‹ÚÈ͢ ÎÂÊ·Ï‹˜, ·‰˘Ó·Ì›· ÛÙ‹ÚÈ͢ Û fiÚıÈ· Î·È Î·ıÈÛÙ‹ ı¤ÛË, ·‰˘Ó·Ì›· ‚¿‰ÈÛ˘ Î·È Ô„ÔÌ˘fiÎÏoÓÔ-ÙÚfiÌÔ ÎÔÚÌÔ‡, ÎÂÊ·Ï‹˜ Î·È ¿ÎÚˆÓ. ∏ Ì˘˚΋ ÈÛ¯‡˜, Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ Î·È Ù· ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∏ ·ÍÈÔÏfiÁËÛË Î·Ù¿ Denver ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ËÏÈΛ· 6-7 ÌËÓÒÓ ÛÙËÓ ·‰Ú‹, ÏÂÙ‹ ÎÈÓËÙÈÎfiÙËÙ· Î·È ÔÌÈÏ›· Î·È 10 ÌËÓÒÓ ÛÙËÓ ÎÔÈÓˆÓÈÎfiÙËÙ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ë ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ‹Ù·Ó ·ÚÓËÙÈ΋, fiˆ˜ Î·È Ô ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ÙÔ ˘ÂÚ˯ÔÙÔÌÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È Ë ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Ì ÛÎÈ·ÁÚ·ÊÈÎfi ‰ÂÓ ¤‰ÂÈÍ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞ÓÙ›ıÂÙ·, Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Ì ÛÎÈ·ÁÚ·ÊÈÎfi ·Ó¤‰ÂÈÍ ·Ú·ÛÔÓ‰˘ÏÈ΋ ‚Ï¿‚Ë ÛÙÔ ‡„Ô˜ ÙÔ˘ £8-£9 ÛÔÓ‰‡ÏÔ˘ ‰ÂÍÈ¿ ˆ˜ ÙËÓ Î¿Ùˆ ÂÈÊ˘Ûȷ΋ Ͽη ÙÔ˘ £10, Ë ÔÔ›· ‰ÂÓ ÂÂÎÙÂÈÓfiÙ·Ó ÂÓÙfi˜ ÙÔ˘ ÛÔÓ‰˘ÏÈÎÔ‡ ۈϋӷ, Ì ̤ÁÈÛÙË ÚÔÛıÈÔ›ÛıÈ· ‰È¿ÌÂÙÚÔ 2,4 cm, ÂÁοÚÛÈ· 0,6 cm, Î·È ÎÂÊ·ÏÔ˘Ú·›· 2,3 cm ÛÙÔ Î·ÙÒÙÂÚÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ ·Ú¿ ÙË ‰ÂÍÈ¿ ¤Íˆ Ï¢ÚԉȷÊÚ·ÁÌ·ÙÈ΋ ÁˆÓ›· (∂ÈÎfiÓ˜ 1 Î·È 2). ªÂ Èı·Ó‹ ‰È¿ÁÓˆÛË Ó¢ÚÔ‚Ï¿Ûو̷, ÙÔ ·È‰› ÌÂٷʤÚıËΠÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜ ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì 123π MIBG ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈ΋ ÚfiÛÏË„Ë Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘, ÂÓÒ Ë ÊÂÚÚÈÙ›ÓË ÔÚÔ‡ Î·È ÙÔ ‚·Ó˘ÏÌ·Ó‰ÂÏÈÓÈÎfi Ô͇ ÙˆÓ Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆Ô Ì˘ÂÏfiÁÚ·ÌÌ· ‰ÂÓ ·Ó¤‰ÂÈÍ ·ÚÔ˘Û›· ÌÂÌÔÓˆÌ¤ÓˆÓ Ó¢ÚÔ‚Ï·ÛÙÒÓ ‹ ÚÔ˙ÂÙÒÓ. ∏
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·229
229
¡Â˘ÚÔ‚Ï¿Ûو̷ Î·È Û‡Ó‰ÚÔÌÔ Ô„ÔÌ˘fiÎÏoÓÔ˘-·Ù·Í›·˜
N-myc. H ÛÙ·‰ÈÔÔ›ËÛË Û‡Ìʈӷ Ì ÙÔ ‰ÈÂıÓ¤˜ Û‡ÛÙËÌ· ÛÙ·‰ÈÔÔ›ËÛ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÓfiÛÔ ÛÙ·‰›Ô˘ π. ø˜ ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ √ª∞ ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· Á-ÛÊ·ÈÚ›ÓË ÙÚȘ, ‹È· ¯ËÌÂÈÔıÂڷ›· Ì ‚ÈÓÎÚÈÛÙ›ÓË (0,05 mg/kg) Î·È Î·Ù·ÙÂÙÌË̤ÓË Î˘ÎÏÔʈÛÊ·Ì›‰Ë (5 mg/kg/ Ë̤ڷ ÂÓ‰ÔÊÏ‚›ˆ˜ ÁÈ· 5 Ë̤Ú˜, οı 21 Ë̤Ú˜) ÁÈ· 4 ·ÎÏÔ˘˜, ·ÏÏ¿ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·fi ÙÔ ÛÙfiÌ· Û ‰È·ÊÔÚÂÙÈο ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ™ÙÔ Ï·›ÛÈÔ Ù·ÎÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘, ÙÔ ·È‰› ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ √ª∞ ‰¤Î· Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË, ÂÓÒ ÙfiÛÔ Ë ÛˆÌ·ÙÈ΋ fiÛÔ Î·È Ë „˘¯ÔÎÈÓËÙÈ΋ ÙÔ˘ ÂͤÏÈÍË ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÛÙ·ÛÈÌfiÙËÙ·.
∂ÈÎfiÓ· 1. ¶·Ú·Ô‚ÂÏÈ·›· ÙÔÌ‹ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜, fiÔ˘ ‰È·ÎÚ›ÓÂÙ·È ·ÙÚ·ÎÙÔÂȉ‹˜ ÈÛÙfi˜ (‚¤ÏÔ˜) Û·ÊÒÓ ÔÚ›ˆÓ Î·È ·ıÔÏÔÁÈÎÔ‡ Û‹Ì·ÙÔ˜.
ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Ù˘ Ì¿˙·˜ Ô˘ ÂÍ·ÈÚ¤ıËΠ̠ıˆÚ·ÎÔÎÔÈÏȷ΋ ÚÔۤϷÛË ¤‰ÂÈÍ ÂÈÎfiÓ· Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ¢ÓÔ˚΋˜ ÈÛÙÔÏÔÁ›·˜ ηٿ Shimada. ∏ Ì¿˙· ·Ê·ÈÚ¤ıËΠ› ˘ÁÈÒÓ ÔÚ›ˆÓ, ÂÓÒ ÔÈ ÏÂÌÊ·‰¤Ó˜ ‹Ù·Ó ·ÚÓËÙÈÎÔ› ÁÈ· ÌÂÙ·ÛÙ·ÙÈ΋ ÓfiÛÔ. ªÂ ÙÔÓ ÌÔÚÈ·Îfi ¤ÏÂÁ¯Ô ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ fiÁÎÔ˘ Ì in situ ˘‚ÚȉÈÛÌfi ÊıÔÚÈÔ¯ÚÒÌ·ÙÔ˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠÂÓ›Û¯˘ÛË ÙÔ˘ ÔÁÎÔÁÔÓȉ›Ô˘
∂ÈÎfiÓ· 2. ∂ÁοÚÛÈ· ÙÔÌ‹ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜, fiÔ˘ ‰È·ÎÚ›ÓÂÙ·È Ë Ù˘È΋ ·Ú·ÛÔÓ‰˘ÏÈ΋ ı¤ÛË ÙÔ˘ ·ıÔÏÔÁÈÎÔ‡ ÈÛÙÔ‡ (‚¤ÏÔ˜).
™˘˙‹ÙËÛË ∆Ô Û‡Ó‰ÚÔÌÔ √ª∞ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Î·ÓfiÓÈÛÙ˜, Ù˘¯·›Â˜ ÎÈÓ‹ÛÂȘ ÔÊı·ÏÌÔ‡, Ì˘ÔÎÏÔÓÈΤ˜ ÎÈÓ‹ÛÂȘ ¿ÎÚˆÓ Î·È ÎÔÚÌÔ‡ Î·È ·Ù·Í›· (dancing eyes, dancing feet) (2-12). ∆Ô 62% ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ԄfiÎÏoÓÔ, Ì˘fiÎÏÔÓÔ Î·È ·Ù·Í›· Î·È ÙÔ 38% Ì ¤Ó· ‹ ‰‡Ô ·fi Ù· ·Ú·¿Óˆ Û˘ÌÙÒÌ·Ù· (8). ∏ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î˘Ì·›ÓÂÙ·È ·fi 11 ¤ˆ˜ 31 Ì‹Ó˜ (̤ÛË ËÏÈΛ·: 18 Ì‹Ó˜). ∏ ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ √ª∞ ÚÈÓ ·fi ÙË ‰È¿ÁÓˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ˘ÔÏÔÁ›˙ÂÙ·È Û 6 Ë̤Ú˜ ¤ˆ˜ 17 Ì‹Ó˜, Ì ̤ÛË ‰È¿ÚÎÂÈ· ÙȘ 6 ‚‰ÔÌ¿‰Â˜ (2). ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ ÙÔ Û‡Ó‰ÚÔÌÔ ¤¯ÂÈ ·ÓÔÛÔÏÔÁÈ΋ ‚¿ÛË (2,7,8). √È ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ù· ·È‰È¿ Ì √ª∞ ·Ó·Ù‡ÛÛÔ˘Ó IgG ‹ IgM ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· ηٿ ÙÔ˘ fiÁÎÔ˘, Ù· ÔÔ›· ÛÙÚ¤ÊÔÓÙ·È fï˜ Î·È Î·Ù¿ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏÂ›Ù·È ‚Ï¿‚Ë Î·È ÔÍ›· Ó¢ÚÔÏÔÁÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. √È ·ÛıÂÓ›˜ Ì ۇӉÚÔÌÔ √ª∞ ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ Ó¢ÚÔ‚Ï¿Ûو̷ ¯·ÌËÏÔ‡ ÛÙ·‰›Ô˘ π ‹ ππ Î·È Î·Ï‹˜ ÚfiÁÓˆÛ˘, Èı·ÓfiÓ ÏfiÁˆ ÂÚÈÔÚÈÛÌÔ‡ Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ fiÁÎÔ˘ ·fi Ù· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· (8,9). ∆Ô ÌÂÛÔıˆÚ¿ÎÈÔ Â›Ó·È Û˘¯Ó‹ ÚˆÙÔ·ı‹˜ ÂÓÙfiÈÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì √ª∞, Û ·ÓÙ›ıÂÛË Ì ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ ¯ˆÚ›˜ ÙÔ ·Ú·ÓÂÔÏ·ÛÌ·ÙÈÎfi Û‡Ó‰ÚÔÌÔ, fiÔ˘ Ë ÓfiÛÔ˜ ÂÓÙÔ›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· ÛÙËÓ ÎÔÈÏÈ¿. ∆Ô Û‡Ó‰ÚÔÌÔ Â›Ó·È Û¿ÓÈÔ Û ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙÔ˘ ¤ÙÔ˘˜, Èı·Ófiٷٷ ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ·Ú·ÁˆÁ‹˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜. ∞ÛıÂÓ›˜ Ì √ª∞ ¤¯Ô˘Ó Ó¢ÚÔ‚Ï¿Ûو̷ ¢ÓÔ˚΋˜ ÈÛÙÔ·ıÔÏÔÁ›·˜ Î·È ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÂÓ›Û¯˘ÛË ÙÔ˘ ÔÁÎÔÁÔÓ›‰ÈÔ˘ N-myc, ÁÂÁÔÓfi˜ Ô˘ ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘. ∏ ÏÂÈÔ„ËÊ›· ÙÔ˘˜ ÂÌÊ·Ó›˙ÂÙ·È Ì ÌË ¶·È‰È·ÙÚÈ΋ 2007;70:227-231
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¡. ∫·Ù˙ËÏ¿Î˘ Î·È Û˘Ó.
ÌÂÙ·ÛÙ·ÙÈ΋ ÓfiÛÔ, Û ·ÓÙ›ıÂÛË Ì ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ ËÏÈΛ·˜ ¿Óˆ ÙÔ˘ ¤ÙÔ˘˜ ¯ˆÚ›˜ √ª∞ Ô˘ Û˘¯Ó¿ ¿Û¯Ô˘Ó ·fi ÌÂÙ·ÛÙ·ÙÈ΋ ÓfiÛÔ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË. ∞ÎfiÌ· fï˜ Î·È ÁÈ· ÓfiÛÔ ÙÔ˘ ȉ›Ô˘ ÛÙ·‰›Ô˘, ÔÈ ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È √ª∞ ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË. ŒÙÛÈ, Ë ÙÚÈÂÙ‹˜ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ ËÏÈΛ·˜ ¿Óˆ ÙÔ˘ ¤ÙÔ˘˜ Ì ÌË ÌÂÙ·ÛÙ·ÙÈÎfi Ó¢ÚÔ‚Ï¿Ûو̷ ÛÙ·‰›ˆÓ π, ππ Î·È πππ Î·È √ª∞ Â›Ó·È 100% ¤Ó·ÓÙÈ 77% ·˘Ù‹˜ ·ÚfiÌÔÈˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ ¯ˆÚ›˜ √ª∞ (9). ¶·Ú’ fiÏÔ Ô˘ ÔÈ ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È Û‡Ó‰ÚÔÌÔ √ª∞ ¤¯Ô˘Ó ¿ÚÈÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË, Û˘¯Ó¿ ÂÌÊ·Ó›˙Ô˘Ó Â›ÌÔÓ· Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ¿Û¯Ô˘Ó ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ›ÌÔÓË ÎÈÓËÙÈ΋ (ÚÔ¤¯ÔÓ Û‡Ìو̷) Î·È ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ηı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘ Î·È ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ (2-4,9,10). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯ÂÙÈÛÌfi˜ ÌÂٷ͇ Ù˘ ‰È¿ÚÎÂÈ·˜ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ OM∞ ÚÈÓ ·fi ÙË ‰È¿ÁÓˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÂͤÏÈ͢ ÙˆÓ ·ÛıÂÓÒÓ (9). ™¯Â‰fiÓ fiÏ· Ù· ·È‰È¿ Ì √ª∞ ··ÈÙÔ‡Ó ·Ú·ÙÂٷ̤ÓË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ Î·È ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋ ıÂڷ›· ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂΉËÏÒÛÂˆÓ (2-4,8-12). ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ÎÔÚÙÈÎÔÙÚÔ›Ó˘ (ACTH), ÂÓ‰ÔÊϤ‚È·˜ Á-ÛÊ·ÈÚ›Ó˘, Ï·ÛÌ·Ê·›ÚÂÛË Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ¯ËÌÂÈÔıÂڷ›·. ªÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÌÔÚ› Ó· ·ÓÙ·ÔÎÚÈı› ÛÙËÓ ·Ú¯È΋ ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ‹ ACTH. ∏ ·Ú¯È΋, fï˜, ·¿ÓÙËÛË ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÏÈÁfiÙÂÚ· ·ÒÙÂÚ· Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· Î·È Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙ÂÈ ˘ÔÙÚÔ¤˜ ÛÙË Ê¿ÛË Ù˘ ÛÙ·‰È·Î‹˜ Ì›ˆÛ˘ Ùo˘ Ê·ÚÌ¿ÎÔ˘ (9). ¶Ôχ Û˘¯Ó‹ Â›Ó·È Î·È Ë ÂÌÊ¿ÓÈÛË ·ÚÂÁÎÂÊ·ÏȉÈ΋˜ ·ÙÚÔÊ›·˜ ¯ˆÚ›˜ ¿ÏÏ· ˘ÂÚÛÎËÓȉȷο ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Û ·ÛıÂÓ›˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ (4). ∏ ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÊϤ‚È·˜ Á-ÛÊ·ÈÚ›Ó˘ ‚ÂÏÙÈÒÓÂÈ Ù· Û˘ÌÙÒÌ·Ù·, Èı·ÓfiÓ ÏfiÁˆ Ì›ˆÛ˘ ·Ú·ÁˆÁ‹˜ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ·ÚÂÌfi‰ÈÛ˘ Ù˘ ‰Ú¿Û˘ ÙÔ˘˜. ∆· ·È‰È¿ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È √ª∞ Ô˘ ¤Ï·‚·Ó ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋ ¯ËÌÂÈÔıÂڷ›· Ê·›ÓÂÙ·È Â›Û˘ Ó· ¤¯Ô˘Ó ηχÙÂÚË Ó¢ÚÔÏÔÁÈ΋ ¤Î‚·ÛË ÏfiÁˆ Ù˘ Ì›ˆÛ˘ ·Ú·ÁˆÁ‹˜ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÚÔηÏ› Ë ¯ËÌÂÈÔıÂڷ›· (9). ∂Óı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ·Ó·Ê¤ÚÔÓÙ·È ÙÂÏÂ˘Ù·›· Ì ÙË ¯Ú‹ÛË ÙÔ˘ ·ÓÙÈ-CD20 ¯ÂÈÌÂÚÈÎÔ‡ ÌÔÓÔÎÏoÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ ÚÈÙÔ˘ÍÈÌ¿ÌË, ÙÔ ÔÔ›Ô ÛÙÚ¤ÊÂÙ·È Î·Ù¿ ÙˆÓ CD20+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (11,12). √È Pranzatelli Î·È Û˘ÓÂÚÁ¿Ù˜ ÌÂϤÙËÛ·Ó ÙȘ ·ÓÔÛÔÏÔPaediatriki 2007;70:227-231
ÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (∂¡À) 36 ·È‰ÈÒÓ Ì √ª∞ (16 ·Ú·ÓÂÔÏ·ÛÌ·ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Î·È 20 ÌË Û˘Û¯ÂÙÈ˙fiÌÂÓÔ Ì fiÁÎÔ˘˜) Î·È 18 Ì¿ÚÙ˘Ú˜ Ì ‰È¿ÊÔÚ· ÌÔÓÔÎÏoÓÈο ·ÓÙÈÛÒÌ·Ù· ηıÔÚÈÛÌÔ‡ ˘ÔÏËı˘ÛÌÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ¶·Ú’ fiÏÔ Ô˘ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÏÂÈÔ·ÙÙˆÛË ÛÙÔ ∂¡À, ‚Ú¤ıËΠ‰È·Ù·Ú·¯‹ ÛÙÔ˘˜ ˘ÔÏËı˘ÛÌÔ‡˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂ӉȷʤÚÔÓ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÂ Ù˘ÊÏ‹ - ˆ˜ ÚÔ˜ Ù· Â˘Ú‹Ì·Ù· ÙÔ˘ ∂¡À - ηٷÁÚ·Ê‹ ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ì ‚›ÓÙÂÔ, Ù· Â˘Ú‹Ì·Ù· ÙÔ˘ ∂¡À Û˘Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙȘ Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·ÛıÂÓÒÓ (12). ™˘ÌÂÚ·ÛÌ·ÙÈο, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È √ª∞: ·) Ë ÏÂÈÔ„ËÊ›· (62%) ·ÚÔ˘ÛÈ¿˙ÂÙ·È Î·È Ì ٷ 3 Û˘ÌÙÒÌ·Ù· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, ‚) ÔÈ ·ÛıÂÓ›˜ Â›Ó·È Û˘Ó‹ıˆ˜ ÛÙ·‰›Ô˘ π Î·È ππ, Á) ¤¯Ô˘Ó ¢ÓÔ˚΋ ÈÛÙÔ·ıÔÏÔÁ›·, ‰) Û¿ÓÈ· ¤¯Ô˘Ó ÂÓ›Û¯˘ÛË ÙÔ˘ ÔÁÎÔÁÔÓȉ›Ô˘ ¡-myc, Â) ÔÛÔÛÙfi 70-80% ¤¯ÂÈ Ì·ÎÚÔÚfiıÂÛÌ· Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Î·È ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ÛÙ) Ë ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ·ÓÙÈÌÂÙÒÈÛË Ì ·ÓÔÛÔηٷÛÙ·ÏÙÈΤ˜ ıÂڷ›˜ ‰ÂÓ Ô‰ËÁ› Û ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛˆÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Castleberry RP, Pritchard J, Ambros P, Berthold F, Brodeur GM, Castel V et al. The International Neuroblastoma Risk Groups (INRG): a preliminary report. Eur J Cancer 1997;33:2113-2116. 2. Mitchell WG, Davalos-Gonzalez Y, Brumm VL, Aller SK, Burger E, Turkel SB et al. Opsoclonus-ataxia caused by childhood neuroblastoma: developmental and neurologic sequelae. Pediatrics 2002;109:86-98. 3. Mitchell WG, Brumm VL, Azen CG, Patterson KE, Aller SK, Rodriguez J. Longitudinal neurodevelopmental evaluation of children with opsoclonus-ataxia. Pediatrics 2005;116:901-907. 4. Hayward K, Jeremy RJ, Jenkins S, Barkovich AJ, Gultekin SH, Kramer J et al. Long-term neurobehavioral outcomes in children with neuroblastoma and opsoclonus-myoclonus-ataxia syndrome: relationship to MRI findings and anti-neuronal antibodies. J Pediatr 2001;139:552-559. 5. Darnell RB, Posner JB. Paraneoplastic syndromes involving the nervous system. N Engl J Med 2003;349:1543-1554. 6. Araga S, Nakashima K. Neurologic signs and symptoms in viral infections - disease involving meninges, central nervous system or peripheral nerve system. Nippon Rinsho 1997;55:805-808. 7. ∞ntunes NL, Khakoo Y, Matthay KK, Seeger RC, Stram DO, Gerstner E et al. Antineuronal antibodies in patients with neuroblastoma and paraneoplastic opsoclonus-myoclonus. J Pediatr Hematol Oncol 2000;22:315-320. 8. Cooper R, Khakoo Y, Matthay KK, Lukens JN, Seeger RC, Stram DO et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: histopathologic features - a report from the Children’s Cancer Group. Med Pediatr Oncol 2001;36:623-629.
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9. Rudnick E, Khakoo Y, Antunes NL, Seeger RC, Brodeur GM, Shimada H et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: clinical outcome and antineuronal antibodies-a report from the Children’s Cancer Group Study. Med Pediatr Oncol 2001;36:612-622. 10. Tate ED, Allison TJ, Pranzatelli MR, Verhulst SJ. Neuroepidemiologic trends in 105 US cases of pediatric opsoclonus-myoclonus syndrome. J Pediatr Oncol Nurs 2005;22:8-19.
11. Pranzatelli MR, Tate ED, Travelstead AL, Barbosa J, Bergamini RA, Civitello L et al. Rituximab (anti-CD20) adjunctive therapy for opsoclonus-myoclonus syndrome. J Pediatr Hematol Oncol 2006;28:585-593. 12. Pranzatelli MR, Travelstead AL, Tate ED, Allison TJ, Moticka EJ, Franz DN et al. B- and T-cell markers in opsoclonus-myoclonus syndrome: immunophenotyping of CSF lymphocytes. Neurology 2004;62:1526-1532.
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CASE REPORT
µÚ¤ÊÔ˜ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· 1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. Î·È ∞. ∫˘ÚÈ·ÎÔ‡” 2 ∞ÈÌ·ÙÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. Î·È ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: ºˆÙÂÈÓ‹ ™ÙÚȤÏË stripeli@med.uoa.gr ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. Î·È ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
º. ™ÙÚȤÏË1, π. ¶. ¶·Ó·ÁÈÒÙÔ˘1, ∂. ¢ËÌËÙÚ›Ô˘1, ∂. ∫ÔÂÌÙ˙›‰Ô˘1, £. ∞Ó·ÛÙ·Û›Ô˘2, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜1 ¶ÂÚ›ÏË„Ë: ∏ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÌÔÚÊ‹ ¯ÚfiÓÈ·˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙ· ·È‰È¿. √Ê›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈۈ̿وÓ, Ù· ÔÔ›· ÛÙÚ¤ÊÔÓÙ·È Î·Ù¿ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ Û˘¯Ó¿ ‰È·Ê‡ÁÂÈ, ηıÒ˜ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ Â›Ó·È Û˘Ó‹ıˆ˜ ‹È·. ¶ÂÚÈÁÚ¿ÊÂÙ·È ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 9,5 ÌËÓÒÓ Ì ÈÛÙÔÚÈÎfi Û˘¯ÓÒÓ ÏÔÈÌÒÍÂˆÓ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ ÙÚÈÒÓ ÌËÓÒÓ, Ô˘ ·ÚÔ˘Û›·Û Â̇ÚÂÙË Û˘Ó‰ÚÔÌ‹, ¤ÏÎË ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ·Ú¯fiÌÂÓÔ ÂÚȉÚÈÎfi ·fiÛÙËÌ·. ¢È·ÁÓÒÛıËΠԢ‰ÂÙÂÚÔÂÓ›· ¯ˆÚ›˜ ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ÛÂ Â›Â‰Ô ¯˘ÌÈ΋˜ ‹ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜. ∏ ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Û ÂÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ¤ıÂÛ ÙË ‰È¿ÁÓˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜. ÃÔÚËÁ‹ıËΠ‰‡Ô ÊÔÚ¤˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. ∏ ÂÚ·ÈÙ¤Úˆ ÔÚ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ηϋ, ·Ú¿ ÙËÓ ÂÈ̤ÓÔ˘Û· Ô˘‰ÂÙÂÚÔÂÓ›·.
§¤ÍÂȘ ÎÏÂȉȿ: ∞˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·, ‚Ú¤ÊË, ‰È¿ÁÓˆÛË, ıÂڷ›·.
An infant with autoimmune neutropenia 1 2nd Paediatric Clinic, Kapodistrian University of Athens, “P and A. Kyriakou” Children’s Hospital 2 Haematology Laboratory, “P and A. Kyriakou” Children’s Hospital Correspondence: Fotini Stripeli stripeli@med.uoa.gr “P. and A. Kyriakou” Children’s Hospital Thivon & Levadias, 115 27 Athens
F. Stripeli 1, J. P. Panagiotou1, E. Dimitriou1, E. Koemzidou1, T. Anastasiou2, A. Constantopoulos1 Abstract: Autoimmune neutropenia of infancy, which is the most common cause of chronic neutropenia in childhood, is characterised by the presence of antineutrophil antibodies against specific neutrophil membrane antigens. The diagnosis of autoimmune neutropenia is often missed because the clinical findings are frequently mild. A case of a 9.5 month-old male infant with a history of recurrent infections is described, who presented with fever, mouth ulcers and perianal abscess. Initial laboratory evaluation revealed neutropenia with no evidence of humoral or cellular immunodeficiency. Detection of antineutrophil antibodies established the diagnosis of autoimmune neutropenia. The administration of granulocyte-colony stimulating factor was effective. The clinical course of the patient was uncomplicated, despite persisting neutropenia.
Key words: Immune neutropenia, infants, diagnosis, treatment.
∂ÈÛ·ÁˆÁ‹ ªÂ ÙÔÓ fiÚÔ Ô˘‰ÂÙÂÚÔÂÓ›· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ë Ì›ˆÛË ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ (∞∞√¶) οو ·fi Ù· 1500/ÌL, ÁÈ· ËÏÈ˘ ÌÂÁ·Ï‡ÙÂÚ˜ ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜. ™Ù· ‚Ú¤ÊË ˆ˜ ηÙÒÙÂÚË ÙÈÌ‹ ıˆÚÂ›Ù·È ·˘Ù‹ ÙˆÓ 1000/mL, ‰Â‰Ô̤ÓÔ Ô˘ Ú¤ÂÈ Ó· Â›Ó·È ÁÓˆÛÙfi ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔʇÁÂÙ·È Ë ˘ÂډȿÁÓˆÛË (1). ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› Û˘¯Ófi ·ÈÌ·ÙÔÏÔÁÈÎfi ‡ÚËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Î·È ¤¯ÂÈ ·ÚÔ‰ÈÎfi ¯·Ú·ÎÙ‹Ú·. ∞Ó¿ÏÔÁ· Ì ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· ‰È·ÎÚ›ÓÂÙ·È Û ÔÍ›· Î·È ¯ÚfiÓÈ·, ·Ó Ë ‰È¿ÁÓˆÛË ¤¯ÂÈ ÙÂı› Û ÌÈÎÚfiÙÂÚÔ ‹ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ¤ÍÈ Ì‹Ó˜. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ë ÓfiÛÔ˜ ‰È·ÚΛ ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi ¤ÍÈ Ì‹Ó˜ Ú¤ÂÈ Ó· ·Ó·˙ËÙËı› Ë ·ÈÙ›· Ô˘ ÙËÓ ÚÔοÏÂÛÂ. Paediatriki 2007;70:232-236
∏ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› Ù‡Ô ¯ÚfiÓÈ·˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜, Ë ÔÔ›· ‰È·ÎÚ›ÓÂÙ·È Û ‰‡Ô ˘ÔÔÌ¿‰Â˜: ·) ÛÙËÓ ÚˆÙÔ·ı‹, fiÔ˘ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› ÌÔÓ·‰È΋ ·ÈÌ·ÙÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ¯ˆÚ›˜ Ó· Û˘Ó˘¿Ú¯ÂÈ Ì ¿ÏÏÔ ÓfiÛËÌ· Î·È ‚) ÛÙË ‰Â˘ÙÂÚÔ·ı‹, fiÔ˘ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÂΉËÏÒÓÂÙ·È ÛÙÔ Ï·›ÛÈÔ Û˘ÛÙËÌ·ÙÈÎÔ‡ ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ‹ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎfi ÓfiÛËÌ· (2). ∏ ÚˆÙÔ·ı‹˜ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· Ù˘ ¯ÚfiÓÈ·˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜. √Ê›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (∞√∞), Ù· ÔÔ›· ÛÙÚ¤ÊÔÓÙ·È Î·Ù¿ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ (3-5). ∏ ‰È¿ÁÓˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, fï˜, Û˘¯Ó¿ ‰È·Ê‡ÁÂÈ ÁÈ·Ù› Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ Â›Ó·È ‹È· Î·È ÂÔ̤ӈ˜ ‰ÂÓ ·Ó·˙ËÙ›ٷÈ.
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·233
233
µÚ¤ÊÔ˜ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·
¶ÂÚÈÁÚ·Ê‹ ÂÚÈÛÙ·ÙÈÎÔ‡ ÕÚÚÂÓ ‚Ú¤ÊÔ˜ 9,5 ÌËÓÒÓ ÚÔÛ‹Ïı ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÏfiÁˆ Â̇ÚÂÙ˘ Û˘Ó‰ÚÔÌ‹˜ ‰È¿ÚÎÂÈ·˜ 4 ËÌÂÚÒÓ. ¢‡Ô Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ›¯Â ÂÌÊ·Ó›ÛÂÈ ¤ÏÎË ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ·Ú¯fiÌÂÓÔ ÂÚȉÚÈÎfi ·fiÛÙËÌ·. ™ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ·‰ÂÏÊ‹ Ì ÂÙÂÚÔ˙˘ÁˆÙÈÛÌfi ‚-ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. ∞fi ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ÛËÌÂÈÒÓÔÓÙ·È: ·) Û˘¯Ó¿ ÂÂÈÛfi‰È· ÛÙÔÌ·Ù›Ùȉ·˜ ·fi ÙË Á¤ÓÓËÛË, ‚) ·ÛÙ˜ ·Ó·ÙÔÏ‹˜, Á) ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜, ‰) ÚÔÛ‚ÔÏ‹ ·fi ÎÔηÙË Î·È ·ÓÂÌ¢ÏÔÁÈ¿ Û ËÏÈΛ· 3 Î·È 4 ÌËÓÒÓ ·ÓÙ›ÛÙÔȯ·. ∆ÔÓ›˙ÂÙ·È fiÙÈ ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÚÔËÁÔ‡ÌÂÓÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜. ∫·Ù¿ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ÂÌÊ¿ÓÈ˙ ˆ¯ÚfiÙËÙ· ‰¤ÚÌ·ÙÔ˜, ¿Êı˜ ÛÙË ÛÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ· Î·È ÂÚȉÚÈÎfi ·fiÛÙËÌ·. ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó ¿ÚÈÛÙË. ™ÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ‚Ú¤ıËΠ∞∞√¶ 265/mL Î·È ÙÔ ‚Ú¤ÊÔ˜ ÂÈÛ‹¯ıË ÚÔ˜ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô Î·È ıÂڷ›·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÛËÌÂÈÒÓÔÓÙ·È Ù· οوıÈ: 1) °ÂÓÈ΋ ·›Ì·ÙÔ˜: Hb=8,8 g/dl, Ht=27,7%, MCV=56,2 fl, RDW=21,7%, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·=5300/mL (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·: 5%, ÏÂÌÊÔ·ÙÙ·Ú·: 59%, ÌÔÓÔ·ÙÙ·Ú·: 35%), ·ÈÌÔÂÙ¿ÏÈ·= 278000/mL, ¢∂∫=0,85%. ™ÙÔ Â›¯ÚÈÛÌ· ·›Ì·ÙÔ˜ ‰È·ÈÛÙÒıËÎ·Ó ¤ÓÙÔÓ˜ ÌÔÚÊÔÏÔÁÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (·ÓÈÛÔ΢ÙÙ¿ÚˆÛË, ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË, ˘Ô¯ÚˆÌ›·, ÔÈÎÈÏÔ΢ÙÙ¿ÚˆÛË) Û˘Ì‚·Ù¤˜ Ì ÂÙÂÚÔ˙˘ÁˆÙÈÛÌfi ‚-ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. 2) ª˘ÂÏfiÁÚ·ÌÌ·: √ Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ ÂÌÊ¿ÓÈ˙ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ·Ó·ÛÙÔÏ‹ ˆÚ›Ì·ÓÛ˘ Ù˘ ÎÔÎÎÈÒ‰Ô˘˜ ÛÂÈÚ¿˜ ÛÙÔ Â›Â‰Ô ÙÔ˘ Ú·‚‰Ô‡ÚËÓÔ˘ (ÛÙÚÔÊ‹ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿). 3) µÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ë·ÙÈ΋˜ Î·È ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜: ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. 4) ŒÏÂÁ¯Ô˜ ‹Í˘: Ê˘ÛÈÔÏÔÁÈÎfi˜. 5) ∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜: √È ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ Ì·˙› Ì ÙȘ ˘ÔÔÌ¿‰Â˜ Ù˘ IgG, Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ Î·È Ë Î˘ÙÙ·ÚÈ΋ ·ÓÔÛ›· ‹Ù·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. 6) √ÚÔÏÔÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÁÈ· Ïԛ̈ÍË ·fi ÙÔ˘˜ ÈÔ‡˜ Epstein Barr (EBV), ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi (CMV), ÂÚ˘ıÚ¿˜, ¤ÚËÙ· 1, 2, 6, Coxsackie, Parvovirus B19, Ë·Ù›Ùȉ·˜ µ, Ë·Ù›Ùȉ·˜ C Î·È ·ÓıÚÒÈÓ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (HIV), ‹Ù·Ó ·ÚÓËÙÈΤ˜. ∞ÓÙ›ÛÙÔȯԘ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙÔ˘˜ ÈÔ‡˜ EBV, CMV, ÂÚËÙÔ˚Ô‡˜-1/2 Î·È Parvovirus B19 Ì ÙËÓ Ù¯ÓÈ΋ Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ Û ‰Â›ÁÌ· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ·¤‚Ë Â›Û˘ ·ÚÓËÙÈÎfi˜. ∆ËÓ 7Ë Ë̤ڷ Ù˘ ÓÔÛËÏ›·˜ ·ÂÛÙ¿ÏË ÔÚfi˜ Û ÂÍÂȉÈÎÂ˘Ì¤ÓÔ Î¤ÓÙÚÔ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ÁÈ· ÙËÓ ·Ó›-
¯Ó¢ÛË ÙˆÓ ∞√∞. ∆· ·ÓÙÈÛÒÌ·Ù· ÂϤÁ¯ıËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ (GIFT) Î·È Ì ÙË Ì¤ıÔ‰Ô Ù˘ Û˘ÁÎfiÏÏËÛ˘ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ (GAT). ªÂ ÙË Ì¤ıÔ‰Ô GIFT ·ÓȯÓ‡ÙËÎ·Ó ÛÙÔÓ ÔÚfi ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÓÙÈ-Ô˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ H¡∞1a ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ Î·È ¤ÙÛÈ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ‚ÚÂÊÈ΋˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜. ∞fi ÙËÓ ÚÒÙË Ë̤ڷ ÓÔÛËÏ›·˜ ¯ÔÚËÁ‹ıËΠÛÙÔ ‚Ú¤ÊÔ˜ ‰ÈÏ‹ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ (ÎÏÈÓ‰·Ì˘Î›ÓË Î·È ÓÂÙÈÏÌÈΛÓË). ∆ËÓ 5Ë Ë̤ڷ Ù˘ ÓÔÛËÏ›·˜, ¤ÁÈÓ ‰È¿ÓÔÈÍË Î·È ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ·ÔÛÙ‹Ì·ÙÔ˜ Î·È ¯ÔÚËÁ‹ıËΠ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ (G-CSF) Ì ‰fiÛË 3 Ìg/kg/24ˆÚÔ. ∆¤ÛÛÂÚȘ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ G-CSF, Ô ∞∞√¶ ¤Êı·Û ÙȘ 8900/mL Î·È ‰ÈÂÎfiË Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘. ªÂ ‚¿ÛË ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ‡Ô˘ (∂. coli, Proteus mirabilis Î·È Klebsiella pneumoniae ESBL) Î·È ÙÔ ·ÓÙÈ‚ÈfiÁÚ·ÌÌ· ¤ÁÈÓ ·ÓÙÈηٿÛÙ·ÛË Ù˘ ÎÏÈÓ‰·Ì˘Î›Ó˘ Ì ٷ˙ÔÌ·ÎÙ¿ÌË/ÈÂÚ·ÎÈÏÏ›ÓË. ∆Ô ‚Ú¤ÊÔ˜ ¤ÌÂÈÓ ÂχıÂÚÔ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔ ‰¤Î·ÙÔ 24ˆÚÔ Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘. ∫·Ù¿ ÙËÓ ¤ÍÔ‰Ô, ÙÔ‡ ¯ÔÚËÁ‹ıËΠ¯ËÌÂÈÔÚÔʇϷÍË Ì ÙÚÈÌÂıÔÚ›ÌË/ ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË Û ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· 2 mg/kg/‰fiÛË Î¿ı 12 ÒÚ˜ ÁÈ· ÙÚÂȘ Û˘Ó¯fiÌÂÓ˜ Ë̤Ú˜ Ù˘ ‚‰ÔÌ¿‰·˜. ∂›Û˘, Û˘ÓÂÛÙ‹ıË ¤ÏÂÁ¯Ô˜ ÙÔ˘ ∞∞√¶ Û οı Â̇ÚÂÙÔ ÂÂÈÛfi‰ÈÔ. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘ ·fi ÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÓÔÛËχÙËÎÂ Î·È ¿ÏÈ, ÏfiÁˆ Â̇ÚÂÙ˘ Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·˜ Ì ∞∞√¶ 535/mL. ¶·Ú·ÙËÚ‹ıËΠ›Û˘ ·˘ÍË̤ÓË C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË (189 mg/dl) Î·È Ù·¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ (82 mm/h). ÃÔÚËÁ‹ıËΠ‰ÈÏ‹ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ (ÎÏÈÓ‰·Ì˘Î›ÓË - ÓÂÙÈÏÌÈΛÓË) ÁÈ· ¤ÓÙ Ë̤Ú˜ Î·È G-CSF Û ‰fiÛË 3 Ìg/kg/24ˆÚÔ ÁÈ· ÙÚÂȘ Ë̤Ú˜ Î·È Ô ·ÛıÂÓ‹˜ ÂÍ‹Ïı Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË. ª¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· ÂÍ·ÎÔÏÔ˘ıÔ‡Û·Ó Ó· Â›Ó·È ¯·ÌËÏ¿, ÏÈÁfiÙÂÚ· ·fi 1000/ÌL, ¯ˆÚ›˜ fï˜ Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Ó¤Â˜ ÏÔÈÌÒÍÂȘ (∂ÈÎfiÓ· 1). ™˘˙‹ÙËÛË ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› Û¯ÂÙÈο Û˘¯Ófi ‡ÚËÌ· ÛÙ· ·È‰È¿. ∆· ÓÔÛ‹Ì·Ù· Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÙËÓ ÙÒÛË ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ Ù˘ ¯ÚfiÓÈ·˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È Ë ÚˆÙÔ·ı‹˜ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·. ∏ ÚÒÙË ·Ó·ÊÔÚ¿ ÛÙËÓ ÔÓÙfiÙËÙ· ·˘Ù‹ ¤ÁÈÓ ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’60 ·fi ÙÔ˘˜ Zuelzer Î·È Bajoghli (6), ÂÓÒ ·ÚÁfiÙÂÚ· ÔÈ Lalezari Î·È Û˘Ó. ÂȂ‚·›ˆÛ·Ó Ù· Â˘Ú‹Ì·Ù· Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÂÚ¢ÓËÙÈ΋˜ ÔÌ¿‰·˜ ·ÔÌÔÓÒÓÔÓÙ·˜ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù· Û 119 ·fi Ù· 121 ‚Ú¤ÊË Î·È ·È‰È¿ Ì ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· (7). ¶·È‰È·ÙÚÈ΋ 2007;70:232-236
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·234
234
∞fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈψÓ
º. ™ÙÚȤÏË Î·È Û˘Ó.
10.000 9.000 8.000 7.000 6.000 5.000 4.000 3.000 2.000 1.000 0
ÃÔÚ‹ÁËÛË G-CSF ŒÍÔ‰Ô˜ ·fi ÙÔ ÃÔÚ‹ÁËÛË G-CSF ÓÔÛÔÎÔÌÂ›Ô ∂·ÓÂÈÛ·ÁˆÁ‹ 0
30
60
90 120 150 180 210 240 270 ∏̤Ú˜ ·Ú·ÎÔÏÔ‡ıËÛ˘
∂ÈÎfiÓ· 1. ¶ÔÚ›· ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜
™ÙÔÓ ¶›Ó·Î· 2 ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ¤ÓÙ ÔÌ¿‰Â˜ ÙˆÓ ÂÙ¿ ÁÓˆÛÙÒÓ Ô˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈÁfiÓˆÓ (HNA = Human Neutrophil Alloantigens) Û‡Ìʈӷ Ì ÙËÓ Î·Ù¿Ù·ÍË Ù˘ ÔÌ¿‰·˜ ÂÚÁ·Û›·˜ Granulocyte Antigen Working Party of the International Society of Blood Transfusion (8). √ ‰È·¯ˆÚÈÛÌfi˜ ·˘Ùfi˜ ‚·Û›ÛıËΠÛÙË ı¤ÛË Ô˘ η٤¯Ô˘Ó Ù· ÂÓ ÏfiÁˆ ·ÓÙÈÁfiÓ· (·ÓÙÈÁÔÓÈΤ˜ ÚˆÙ½Ó˜) ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ÌÂÌ‚Ú¿ÓË ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈψÓ. √È ·ÓÔÛÔÁfiÓ˜ ÁÏ˘ÎÔÚˆÙ½Ó˜ Û˘Ì‚ÔÏ›˙ÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Î·È ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·fi ¤Ó· ÁÚ¿ÌÌ· ÙÔ˘ ·ÏÊ·‚‹ÙÔ˘ Ô˘ Û˘Ì‚ÔÏ›˙ÂÈ ÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÙˆÓ ÁÏ˘ÎÔÚˆÙÂ˚ÓÒÓ. ∆· ·ÓÙÈÁfiÓ· HNA-1a, HNA¶›Ó·Î·˜ 1. ∞›ÙÈ· Ô˘‰ÂÙÂÚÔÂÓ›·˜ √˘‰ÂÙÂÚÔÂÓ›· ·fi Â͈ÁÂÓ‹ ·›ÙÈ· ñ §ÔÈÌÒÍÂȘ ñ º¿Ú̷η ñ ∞˘ÙÔ¿ÓÔÛË (ÚˆÙÔ·ı‹˜ Î·È ‰Â˘ÙÂÚÔ·ı‹˜) ñ ∞ÏÏÔ¿ÓÔÛË ñ ∞ÓÙÈηٿÛÙ·ÛË ‹ ·Ï·Û›· ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (ηÎÔ‹ıÂȘ, ·Ï·Û›·) ñ ∞Ó·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì˘ÂÏÔÔ›ËÛË (.¯. ¤ÏÏÂÈ„Ë µ12 Î·È Ê˘ÏÏÈÎÔ‡) ñ ÀÂÚÛÏËÓÈÛÌfi˜ (¯ÚfiÓÈ· ·ÈÌfiÏ˘ÛË, ÂÏÔÓÔÛ›· Î.¿.) ñ ¡fiÛÔÈ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ (.¯. ™˘ÛÙËÌ·ÙÈÎfi˜ ∂Ú˘ıËÌ·Ù҉˘ §‡ÎÔ˜) √˘‰ÂÙÂÚÔÂÓ›· ·fi ÂÓ‰ÔÁÂÓ‹ ·›ÙÈ· ñ ÃÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· (.¯. ΢ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›·) ñ µ·ÚÈ¿ Û˘ÁÁÂÓ‹˜ Ô˘‰ÂÙÂÚÔÂÓ›· (Û‡Ó‰ÚÔÌÔ Kostmann) ñ √˘‰ÂÙÂÚÔÂÓ›· Ô˘ Û˘Ó‰˘¿˙ÂÙ·È Ì ·Á·Ì·ÛÊ·ÈÚÈÓ·ÈÌ›· ‹ Û‡Ó‰ÚÔÌÔ ˘ÂÚ-IgM ñ √˘‰ÂÙÂÚÔÂÓ›· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ۇӉÚÔÌ· (·ÔıË΢ÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘ Ù‡Ô˘ π‚, Û‡Ó‰ÚÔÌÔ Shwachman-Diamond, ηډÈÔÛÎÂÏÂÙÈ΋ Ì˘Ô¿ıÂÈ·, ÔÓ˘¯ÔÙÚȯԉ˘ÛÏ·Û›·) ñ ∞Ó·ÈÌ›· Fanconi ñ ª˘ÂÏÔ‰˘ÛÏ·Û›· ñ ™˘ÁÁÂÓ‹˜ ‰˘ÛÎÂÚ¿ÙˆÛË Paediatriki 2007;70:232-236
lb and HNA-1c, ·ÔÙÂÏÔ‡Ó ÙÚÂȘ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÔÏ˘ÌÔÚÊÈÎÔ‡˜ Ù‡Ô˘˜ ÙÔ˘ ›‰ÈÔ˘ Ô˘‰ÂÙÂÚfiÊÈÏÔ˘ ˘Ô‰Ô¯¤· FcÁIIIb (CD16). ∆Ô ·ÓÙÈÁfiÓÔ HNA-2a ·ÓÙÈÛÙÔȯ› ÛÙË ÁÏ˘ÎÔÚˆÙ½ÓË Gp50-64 (CD177). ∆Ô ·ÓÙÈÁfiÓÔ HNA-3a, ÂÓÙÔ›˙ÂÙ·È Û ̛· ÁÏ˘ÎÔÚˆÙ½ÓË Ì ÌÔÚÈ·Îfi ‚¿ÚÔ˜ 70-95 kDa. ∆· ·ÓÙÈÁfiÓ· HNA-4a Î·È HNA-5a, Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ÁÏ˘ÎÔÚˆÙ½Ó˜ CD11b Î·È CD11a. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÓÙÈÁÔÓÈÎÒÓ ÚˆÙÂ˚ÓÒÓ, ÙÔ˘˜ ÈÔ Û˘¯ÓÔ‡˜ “ÛÙfi¯Ô˘˜” ÙˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·ÔÙÂÏÔ‡Ó ÔÈ ÚˆÙ½Ó˜ D11b, CD16b Î·È CD177, ÂÓÒ ÌfiÓÔ ÙÔ 30% ÙˆÓ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÚ¤ÊÂÙ·È Î·Ù¿ Ù˘ ÚˆÙ½Ó˘ CD16b. √ ·ÎÚÈ‚‹˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ·Ó¿Ù˘Í˘ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ‰ÂÓ Â›Ó·È ·ÎfiÌË Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. Œ¯ÂÈ ·Ó·ÊÂÚı› Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ·ÓÙÈ-HNA-1a ·ÓÙÈÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ HLA-DR2, fï˜, Ë ÂΉ‹ÏˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Û ¤Ó·Ó ÌfiÓÔ ·fi ÙÔ˘˜ ‰‡Ô ÌÔÓÔ˙˘ÁˆÙÈÎÔ‡˜ ‰È‰‡ÌÔ˘˜ ·ÔÙÂÏ› ÈÛ¯˘Ú‹ ¤Ó‰ÂÈÍË fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ÎÏËÚÔÓÔÌÔ‡ÌÂÓÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ Ó· ·ÚÂÌ‚·›ÓÂÈ ÛÙÔ Ì›˙ÔÓ Û‡ÛÙËÌ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (9). ÕÏÏË ÔÌ¿‰· ÂÚ¢ÓËÙÒÓ ÂÓÙfiÈÛ ·ÓÙÈÛÒÌ·Ù· IgM ηٿ ÙÔ˘ ·Ú‚Ô˚Ô‡ µ19 Û 5 ·fi 11 ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· Î·È ıÂÒÚËÛ fiÙÈ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ·Ú‚Ô˚Ô‡ µ19 Î·È Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (10). ªÂÙ·ÁÂÓ¤ÛÙÂÚË fï˜ ÌÂϤÙË ÙˆÓ Bux Î·È Û˘Ó. ·Ó›¯Ó¢Û ÙÔ DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ Î·È Ù· IgG/IgM ·ÓÙÈÛÒÌ·Ù· ηٿ ÙÔ˘ ÈÔ‡ ÌfiÓÔ Û 36 ·fi ÙÔ˘˜ 110 ·ÛıÂÓ›˜ Î·È ˘ÔÛÙ‹ÚÈÍ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ ·Ú‚Ô˚fi µ19 Î·È Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (11). ŒÙÛÈ, ̤¯ÚÈ Û‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÔÏÏ¿ ·Ó·¿ÓÙËÙ· ÂÚˆÙ‹Ì·Ù· ÁÈ· ÙÔÓ ˘Â‡ı˘ÓÔ ·Ú¿ÁÔÓÙ· Î·È ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ·˘Ùfi˜ ‰Ú· ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ Ù· ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù·. ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÔ˘ÌÂ, ‰ÂÓ ÚԤ΢„ ‡ÚËÌ· ·fi ÙÔÓ ÂÎÙÂٷ̤ÓÔ ¤ÏÂÁ¯Ô Ô˘ Ó· ÌÔÚÔ‡Û ӷ ‰ÈηÈÔÏÔÁ‹ÛÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘. ∏ ̤ÛË ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 6 Î·È 12 ÌËÓÒÓ. ™ÙÔ ‰ÈÎfi Ì·˜ ÂÚÈÛÙ·ÙÈÎfi ÈÛÙ‡ԢÌ fiÙÈ ÙÔ Úfi‚ÏËÌ· ÂÌÊ·Ó›ÛÙËΠ۠ËÏÈΛ· 3 ÌËÓÒÓ ÂÚ›Ô˘, ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ηٿ ÙËÓ ÔÔ›· ÙÔ ‚Ú¤ÊÔ˜ ÂÌÊ¿ÓÈÛ ÙËÓ ÚÒÙË ÙÔ˘ ÛÔ‚·Ú‹ Ïԛ̈ÍË (ÎÔηÙË). øÛÙfiÛÔ ‰ÂÓ ˘¿Ú¯ÂÈ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ Ó· ÙÔ ÂȂ‚·ÈÒÓÂÈ. ∏ ‚·Ú‡ÙËÙ· ÙÔ˘ ∞∞√¶ Û˘¯Ó¿ Î˘Ì·›ÓÂÙ·È Û ÂӉȿÌÂÛ· ›‰· (500-1000/mL), ·ÏÏ¿ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÙ·ÙÈο Î·È Ì ÙÈ̤˜ οو ÙˆÓ 200/mL. ∆Ô Û˘¯ÓfiÙÂÚÔ Úfi‚ÏËÌ· ÙˆÓ ·ÛıÂÓÒÓ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È ÔÈ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ, ÔÈ Ôԛ˜ ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ›ӷÈ
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·235
235
µÚ¤ÊÔ˜ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·
¶›Ó·Î·˜ 2. ∞ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù· √Ì¿‰Â˜ ·ÓÙÈÁfiÓˆÓ
∞ÓÙÈÁfiÓ·
¶ÚÔËÁÔ‡ÌÂÓË ÔÓÔÌ·Û›·
°Ï˘ÎÔÚˆÙ½ÓË
HNA-1
HNA-1a HNA-1b HNA-1c HNA-2a HNA-3a HNA-4a HNA-5a
NA1 NA2 SH NB1 5b MART OND
FcÁπππb (CD16) FcÁπππb (CD16) FcÁπππb (CD16) CD177 (gp50-64) Gp70-95 CD11a CD11b
HNA-2 HNA-3 HNA-4 HNA-5
̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜. ŒÙÛÈ, Û˘¯Ó¿ ‰È·ÈÛÙÒÓÔÓÙ·È ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ·Ó·Ó¢ÛÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ˘Ô‰ÂÚÌ›·, ̤ÛË ˆÙ›Ùȉ· Î·È Á·ÛÙÚ›Ùȉ· (12). ∏ ÂÌÊ¿ÓÈÛË ÂÚȉÚÈÎÔ‡ ·ÔÛÙ‹Ì·ÙÔ˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È Â‰Ò, Â›Ó·È Û¿ÓÈ· ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ (13). ∂›Û˘ Û¿ÓÈ· Â›Ó·È Ë ÂÌÊ¿ÓÈÛË ÂÁÎÂÊ·ÏÈÎÒÓ ·ÔÛÙËÌ¿ÙˆÓ (12). ™ÙÔ Ì˘ÂÏfiÁÚ·ÌÌ·, Ô Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ ‰Â›¯ÓÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ‹ ·˘ÍË̤ÓË Î˘ÙÙ·ÚÔ‚Ú›ıÂÈ· ÙˆÓ Úfi‰ÚÔÌˆÓ Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ·ÏÏ¿ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ·Ú·ÙËÚÂ›Ù·È Û·Ê‹˜ Ì›ˆÛË ÙˆÓ ÒÚÈÌˆÓ Ô˘‰ÂÙÂÚfiÊÈψÓ. ∏ ÂͤٷÛË Ô˘ ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Â›Ó·È Ë ·Ó›¯Ó¢ÛË ÙˆÓ ÂȉÈÎÒÓ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ. √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì¤Ûˆ ‰È¿ÊÔÚˆÓ Ù¯ÓÈÎÒÓ, ‰‡Ô fï˜ Â›Ó·È ÔÈ ÂÈÎÚ·Ù¤ÛÙÂÚ˜: Ë Ì¤ıÔ‰Ô˜ Û˘ÁÎfiÏÏËÛ˘ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ (Granulocyte Agglutination Test GAT) Î·È Ë Ì¤ıÔ‰Ô˜ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ (Granulocyte Immunofluorescence Test - GIFT) (14). ¶·ÚfiÙÈ Ë Ì¤ıÔ‰Ô˜ GIFT Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Â˘·›ÛıËÙË (¢·ÈÛıËÛ›· 97%), Û ÔÛÔÛÙfi 3% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· ÌÔÚ› Ó· Â›Ó·È ıÂÙÈο ÌfiÓÔ ÛÙË Ì¤ıÔ‰Ô GAT. ªÂÈÔÓÂÎÙ‹Ì·Ù· ÂÌÊ·Ó›˙Ô˘Ó Î·È ÔÈ ‰‡Ô Ù¯ÓÈΤ˜. ∂Âȉ‹ Ô Ù›ÙÏÔ˜ ÙˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·ÚÎÂÙ¿ Û˘¯Ó¿ Â›Ó·È ÌË ·ÓȯÓ‡ÛÈÌÔ˜, Ë ÂͤٷÛË ¯ÚÂÈ¿˙ÂÙ·È Ó· ·ӷÏËÊı› ‰‡Ô Î·È ÙÚÂȘ ÊÔÚ¤˜ ÁÈ· ÙËÓ Â‰Ú·›ˆÛË ‹ ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ‰È¿ÁÓˆÛ˘. ∂›Û˘, Û ηٷÛÙ¿ÛÂȘ fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ˘ÂÚÁ·Ì·ÛÊ·ÈÚÈÓ·ÈÌ›·, .¯. ÔÏÏ·ÏÔ‡Ó Ì˘¤ÏˆÌ·, Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÔÈ ·Ú·¿Óˆ Ù¯ÓÈΤ˜ ‰›ÓÔ˘Ó „¢‰Ò˜ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· (15). ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘ÌÂ, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÈÙ‡¯ıËΠ̠ÙȘ ÌÂıfi‰Ô˘˜ GIFT Î·È GAT. ∏ ÔÚ›· Ù˘ ÓfiÛÔ˘ Â›Ó·È Î·Ï‹ Î·È ÙÔ 95% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙ÂÈ ·˘ÙfiÌ·ÙË ‡ÊÂÛË Û ̤ÁÈÛÙÔ ‰È¿ÛÙËÌ· 2 ÂÙÒÓ ·fi ÙË ‰È¿ÁÓˆÛË (11). ªÂ ‰Â‰Ô̤ÓË ÙËÓ Î·Ï‹ ÂͤÏÈÍË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÂȉÈ΋ ıÂڷ›·, ÂÎÙfi˜ ·fi ÙË Û˘Ìو̷ÙÈ΋ Î·È ·ÈÙÈÔÏÔÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒ͈Ó, fiÙ·Ó ·˘Ù¤˜
ÂÌÊ·ÓÈÛıÔ‡Ó. ∂ÈϤÔÓ, ÌÂϤÙ˜ ·¤‰ÂÈÍ·Ó fiÙÈ Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ÙÚÈÌÂıÔÚ›Ì˘ - ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏ˘ Ì›ˆÛ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÏÔÈÌÒ͈Ó, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿ÛÂÈ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ (16). ∞fiÏ˘ÙË ¤Ó‰ÂÈÍË ÚÔÊ˘Ï·ÎÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙ· ‚Ú¤ÊË ·ÔÙÂÏÔ‡Ó ÔÈ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÏÔÈÌÒÍÂȘ, ȉ›ˆ˜ ÛÂ Û˘¯Ó¿ ÂÂÈÛfi‰È· ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ̤ÛÔ˘ ˆÙfi˜. ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ¯ÔÚËÁ‹ıËΠÚÔÊ˘Ï·ÎÙÈο ÙÚÈÌÂıÔÚ›ÌË - ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË, ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ÏÔÈÌÒÍÂˆÓ Ô˘ ›¯Â ÂÌÊ·Ó›ÛÂÈ Î·Ù¿ ÙÔ˘˜ Ì‹Ó˜ Ô˘ ÚÔËÁ‹ıËÎ·Ó Ù˘ ‰È¿ÁÓˆÛ˘. ∂ÎÙfi˜ ·fi ÙËÓ ·ÈÙÈÔÏÔÁÈ΋ ıÂڷ›· ÙˆÓ ÏÔÈÌÒ͈Ó, ÌÂÏÂÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÔÛÔÂÓÈÛ¯˘ÙÈ΋˜ ˘ÔÛÙËÚÈÎÙÈ΋˜ ·ÁˆÁ‹˜ Û ÂÚÈÙÒÛÂȘ ÂÈΛӉ˘ÓˆÓ ÁÈ· ÙË ˙ˆ‹ ÙˆÓ ·ÛıÂÓÒÓ ÏÔÈÌÒ͈Ó. ¢ÔÎÈÌ¿ÛıËÎÂ Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ (IVIG), Ë ÔÔ›· Ô‰‹ÁËÛ Û ٷ¯Â›· ¿ÓÔ‰Ô ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈψÓ, Ô˘ ‰È‹ÚÎÂÛ fï˜, Ï›Á˜ Ë̤Ú˜. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ê·›ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ G-CSF, ·ÏÏ¿ Ë ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ‰ÂÓ Â›Ó·È Û˘Ó‹ıˆ˜ ··Ú·›ÙËÙË Î·È ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ Û ·ӷϷ̂·ÓfiÌÂÓ˜ / ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ (17) ‹ Û ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ··ÈÙÂ›Ù·È ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. ∏ ·ÓÙ·fiÎÚÈÛË ÛÙÔÓ G-CSF Â›Ó·È ¿ÌÂÛË Î·È ‰È·ÚΛ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Êı¿ÓÂÈ Ì¤¯ÚÈ Î·È ‰‡Ô Ì‹Ó˜. ™ÙÔ ‰ÈÎfi Ì·˜ ÂÚÈÛÙ·ÙÈÎfi ¯ÔÚËÁ‹ıËΠ‰‡Ô ÊÔÚ¤˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Î·È Ë ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ¿ÌÂÛË. £· Ú¤ÂÈ Ó· ‰È¢ÎÚÈÓÈÛÙ› fiÙÈ ÛÙË ‰Â‡ÙÂÚË ÓÔÛËÏ›· ÙÔ˘ ‚Ú¤ÊÔ˘˜, Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ G-CSF ‚·Û›ÛıËΠÛÙËÓ ˘Ô„›· ÁÈ· ÛÔ‚·Ú‹ ÌÈÎÚԂȷ΋ ÂÈÏÔ΋. ∆¤ÏÔ˜, ¤¯ÂÈ ‰ÔÎÈÌ·Ûı› Î·È Ë ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Ì ηϋ ·ÓÙ·fiÎÚÈÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ¿ÓÔ‰Ô ÙÔ˘ ∞∞√ (12). ∆Ô ÂÚÈÛÙ·ÙÈÎfi ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÁÈ·Ù›, ÂÓÒ Ë ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÙˆÓ ‚ÚÂÊÒÓ Î·È ·È‰ÈÒÓ ÌÈÎÚ‹˜ ËÏÈΛ·˜, ·ÔÙÂÏ› ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· ¿ÁÓˆÛÙË ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·È‰È¿ÙÚÔ˘˜. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ Ù›ıÂÙ·È Û˘Ó‹ıˆ˜ ÂÍ ·ÔÎÏÂÈÛÌÔ‡ ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Î·È ˘ÔÛÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·Ó‡ÚÂÛË ¶·È‰È·ÙÚÈ΋ 2007;70:232-236
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º. ™ÙÚȤÏË Î·È Û˘Ó.
·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈۈ̿وÓ. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ‚ÔËı¿ Î·È ÛÙËÓ ÈÔ ÔÚı‹ ·ÓÙÈÌÂÙÒÈÛË, Ì ·ÚÈÔ ÛÙÔÈ¯Â›Ô ÙË ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÙË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ÌfiÓÔ Â› ÂӉ›ÍˆÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Lakshman R, Finn A. Neutrophil disorders and their management. J Clin Pathol 2001;54:7-19. 2. Bux J, Mueller-Eckhardt C. Autoimmune neutropenia. Semin Hematol 1992;29:45-53. 3. Lalezari P, Khorshidi M, Petrosova M. Autoimmune neutropenia of infancy. J Pediatr 1986;109:764-769. 4. Boxer LA, Greenberg MS, Boxer GJ, Stossel TP. Autoimmune neutropenia. N Engl J Med 1975;293:748-753. 5. Bux J, Kissel K, Nowak K, Spengel U, Mueller-Eckhardt C. Autoimmune neutropenia: clinical and laboratory studies in 143 patients. Ann Hematol 1991; 63:249-252. 6. Zuelzer WW, Bajoghli M. Chronic granulocytopenia in childhood. Blood 1964;23:359-374. 7. Lalezari P, Jiang AF, Yegen L, Santorineou M. Chronic autoimmune neutropenia due to anti-NA2 antibody. N Engl J Med 1975;293: 744-747. 8. Bux J. Molecular nature of antigens implicated in immune neutropenias. Int J Hematol 2002;76 (Suppl 1):S399-S403. 9. Bux J, Mueller-Eckhardt G, Mueller-Eckhardt C. Autoimmunization against the neutrophil-specific NA1 antigen is associated with HLA-DR2. Hum Immunol 1991;30:18-21.
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10. Cartron J, Bader-Meunier B, Deplanche M, et al. Human Parvovirus B19-associated childhood autoimmune neutropenia. Int J Pediatr Hematol Oncol 1995;2:471-473. 11. Bux J, Behrens G, Jaeger G, Welte K. Diagnosis and clinical course of autoimmune neutropenia in infancy: analysis of 240 cases. Blood 1998;91:181-186. 12. Lejkowski M, Maheshwari A, Calhoun DA, Christensen RD, Skoda-Smith S, Dabrow S. Persistent perianal abscess in early infancy as a presentation of autoimmune neutropenia. J Perinatol 2003;23:428-430. 13. Tokushima-Imayoshi M, Onoue T, Matsuo M, Yoshida N, Sato T, Kobayashi M, et al. Autoimmune neutropenia of infancy with multiple brain abscesses during the course of human herpesvirus-6 infection. Int J Hematol 2006;84: 151-153. 14. Bux J, Chapman J. Report on the Second International Granulocyte Serology Workshop. Transfusion 1997;37: 977-983. 15. Bux J, Sohn M, Hachmann R, Mueller-Eckhardt C. Quantitation of granulocyte antibodies in sera and determination of their binding sites. Br J Haematol 1992;82:20-25 16. Kobayashi M, Sato T, Kawaguchi H, Nakamura K, Kihara H, Hiraoka A, et al. Efficacy of prophylactic use of trimethoprim-sulfamethoxazole in autoimmune neutropenia in infancy. J Pediatr Hematol Oncol 2003;25:553-537. 17. Palmblad JE, von dem Borne AE. Idiopathic, immune, infectious and idiosyncratic neutropenias. Semin Hematol 2002;39:113-120.
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∫ÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ∞. ª¿Î˘, ¡. ÷ÏÈ¿ÛÔ˜ ¶ÂÚ›ÏË„Ë: √˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Ë ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â˘·ÈÛıËÛ›· Û ÏÔÈÌÒÍÂȘ ·fi ˘ÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· Â›Ó·È ÔÍ›· ‹ ¯ÚfiÓÈ·, ÎÏËÚÔÓÔÌÈ΋ ‹ ›ÎÙËÙË Î·È ÂÓ‰¤¯ÂÙ·È Ó· ÂÌÊ·ÓÈÛÙ› ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· (Û˘ÁÁÂÓ‹˜) ‹ ÛÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹. √È ÎÏËÚÔÓÔÌÈΤ˜ Ô˘‰ÂÙÂÚÔÂӛ˜ ÔÊ›ÏÔÓÙ·È Û ÂÓ‰ÔÁÂÓ›˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÂÓ‰¤¯ÂÙ·È Ó· Û˘Ó˘¿Ú¯Ô˘Ó Ê·ÈÓÔÙ˘ÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÂÓÒ ÔÈ Â›ÎÙËÙ˜ ÚÔ¤Ú¯ÔÓÙ·È Û˘Ó‹ıˆ˜ ·fi Â͈ÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂȉÚÔ‡Ó ÛÙÔ Ô˘‰ÂÙÂÚfiÊÈÏÔ. ∆· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ÛÙ· ·È‰È¿ Â›Ó·È Â›ÎÙËÙ· Î·È È‰È·›ÙÂÚ· ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Î·È Ù· Ê¿Ú̷η. √È ÏÔÈÌÒÍÂȘ ÛÙ· ·È‰È¿ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ÚÔηÏÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ¯ÏˆÚ›‰·˜. ∏ ¢·ÈÛıËÛ›· ÛÙȘ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ‚·ıÌfi Î·È ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, ·ÏÏ¿ Î·È ·fi ÙË Ê‡ÛË Ù˘ ˘ÔΛÌÂÓ˘ ·ÈÙÈÔÏÔÁ›·˜. ∏ ·Ú¯È΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ··ÈÙ› ȉȷ›ÙÂÚË ÚÔÛÔ¯‹, ȉȷ›ÙÂÚ· fiÙ·Ó ÂÌÊ·Ó›˙ÂÙ·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, fiÙ·Ó ‰È·ÚΛ ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ‹ fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ ‹ ۈ̷ÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ∆Ô ·Ó·Ï˘ÙÈÎfi ÈÛÙÔÚÈÎfi, Ë ÚÔÛÂÎÙÈ΋ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·È Ô Î·ıÔ‰ËÁÔ‡ÌÂÓÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô‰ËÁÔ‡Ó ÛÙËÓ ·Ó‡ÚÂÛË Ù˘ ˘ÔΛÌÂÓ˘ ·ÈÙÈÔÏÔÁ›·˜.
¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ AÏÏËÏÔÁÚ·Ê›·: ∞ϤͷӉÚÔ˜ ª¿Î˘ alexandros.makis@medai.gr √Ì‹ÚÔ˘, ∫·Ú‰·Ì›ÙÛÈ·, ∆.∫. 459 00, πˆ¿ÓÓÈÓ·
§¤ÍÂȘ ÎÏÂȉȿ: √˘‰ÂÙÂÚÔÂÓ›·, ·È‰È¿.
Clinical and laboratory investigation of children with neutropenia A. Makis, N. Chaliassos Abstract: Neutropenia is defined as a decrease in the absolute neutrophil count to below normal levels and is characterized by an increased risk of pyogenic infections. Neutropenia is classified as acute or chronic, inherited or acquired. Inherited neutropenias are caused by an intrinsic defect of proliferation and maturation of stem or myeloid cells. Most of the acquired neutropenias are secondary to extrinsic factors, postinfectious and drug-induced neutropenia being the commonest forms in children. Neutropenic patients usually become infected by organisms of their own endogenous flora; the resident bacteria of the mouth and oropharynx, gastrointestinal tract, and skin. The type of infection depends on the degree and chronicity of the neutropenia and on the nature of the associated diseases. The risk of severe infection does not increase until the neutrophil count falls below 0.5x109/L, but it rises rapidly when the count is below 0.2x109/L. The age of the child at presentation, the depth of the neutropenia, the severity of infections and the presence or absence of non-haematological signs and symptoms all guide the initial investigation of a child with neutropenia.
Paediatric Department of the University General Hospital of Ioannina Correspondence: Alexandros Makis alexandros.makis@medai.gr Omirou St., Kardamitsia, 459 00, Ioannina, Greece
Key words: Neutropenia, children.
∂ÈÛ·ÁˆÁ‹ ∆· Ô˘‰ÂÙÂÚfiÊÈÏ· Â›Ó·È Î‡ÙÙ·Ú· Ù· ÔÔ›· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÔÏ˘‰‡Ó·Ì· ·ÙÙ·Ú· Ù˘ ÎÔÎÎÈÒ‰Ô˘˜ Ì˘ÂÏÈ΋˜ ÛÂÈÚ¿˜, ÌÂÙ¿ ·fi ÙË ‰Ú¿ÛË ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ GM-CSF Î·È GCSF Î·È ÚÔÊ˘Ï¿ÛÛÔ˘Ó ÙÔÓ ÔÚÁ·ÓÈÛÌfi ·fi ÙÔ˘˜ ˘ÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. √˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Ë ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·. Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1, ÙÔ Î·ÙÒÙÂÚÔ Ê˘ÛÈÔÏÔÁÈÎfi fiÚÈÔ ÛÙ· ‚Ú¤ÊË Â›Ó·È 1,0x109/L. ªÂÙ¿ ÙË ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô, ̤¯ÚÈ
ÙËÓ ËÏÈΛ· ÙˆÓ ‰¤Î· ÂÙÒÓ Â›Ó·È 1,5x109/L, ÂÓÒ ÌÂÙ¤ÂÈÙ· ÙÔ fiÚÈÔ 1,8x109/L ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙÔÓ ÔÚÈÛÌfi Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (1). ∏ Ô˘‰ÂÙÂÚÔÂÓ›· Ù·ÍÈÓÔÌÂ›Ù·È ˆ˜ ‹È· (οو ·fi ÙÔ ¯·ÌËÏfiÙÂÚÔ fiÚÈÔ, ·ÏÏ¿ >1,0x109/L), ̤ÙÚÈ· (ÌÂٷ͇ 0,5 Î·È 1,0x109/L), ÛÔ‚·Ú‹ (ÌÂٷ͇ 0,2 Î·È 0,5x109/L) Î·È Ôχ ÛÔ‚·Ú‹ (<0,2x109/L). ∆· ηÙÒÙÂÚ· fiÚÈ· Â›Ó·È ¯Ú‹ÛÈÌ· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, ÂÂȉ‹ Ô Î›Ó‰˘ÓÔ˜ ÛÔ‚·ÚÒÓ ÏÔÈÌÒÍÂˆÓ ˘Ê›ÛÙ·Ù·È Â¿Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Â›Ó·È Î¿Ùˆ ·fi 0,5x109/L Î·È ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο fiÙ·Ó Â›Ó·È Î¿Ùˆ ·fi ¶·È‰È·ÙÚÈ΋ 2007;70:237-245
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·238
238
∞. ª¿Î˘, ¡. ÷ÏÈ¿ÛÔ˜
¶›Ó·Î·˜ 1. º˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹
°¤ÓÓËÛË 12 ÒÚ˜ 24 ÒÚ˜ 1Ë Â‚‰ÔÌ¿‰· 2Ë Â‚‰ÔÌ¿‰· 1Ô˜ Ì‹Ó·˜ 1Ô ¤ÙÔ˜ 6Ô ¤ÙÔ˜ 10Ô ¤ÙÔ˜ 16Ô ¤ÙÔ˜
ª¤ÛÔ˜ fiÚÔ˜ (x109/L)
∂‡ÚÔ˜ (x109/L)
¶ÔÛÔÛÙfi %
11,0 15,5 11,5 5,5 4,5 3,8 3,5 4,3 4,4 4,4
6,0-26,0 6,0-28,0 5,0-21,0 1,5-10,0 1,0-9,5 1,0-9,0 1,5-8,5 1,5-8,0 1,8-8,0 1,8-8,0
61 68 61 45 40 35 31 51 54 59
0,2x109/L (2). ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· Â›Ó·È ÎÏËÚÔÓÔÌÈ΋ ‹ ›ÎÙËÙË Î·È ÂÓ‰¤¯ÂÙ·È Ó· ÂÌÊ·ÓÈÛÙ› ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· (Û˘ÁÁÂÓ‹˜) ‹ ÛÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹. ∆· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· Â›Ó·È Ù· ›ÎÙËÙ· Î·È È‰È·›ÙÂÚ· ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. ∏ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› ÚfiÎÏËÛË ÁÈ· ÙÔÓ ÁÂÓÈÎfi ·È‰›·ÙÚÔ, ȉȷ›ÙÂÚ· fiÙ·Ó ÂÌÊ·Ó›˙ÂÙ·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, fiÙ·Ó ‰È·ÚΛ ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ‹ fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ ‹ ۈ̷ÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ∆Ô ·Ó·Ï˘ÙÈÎfi ÈÛÙÔÚÈÎfi, Ë ÚÔÛÂÎÙÈ΋ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·È Ô Î·ıÔ‰ËÁÔ‡ÌÂÓÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô‰ËÁÔ‡Ó ÛÙË ‰È·Ï‡ηÓÛË Ù˘ ˘ÔΛÌÂÓ˘ ·ÈÙÈÔÏÔÁ›·˜. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ ı· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, Ù· ·›ÙÈ· Ô˘ Ô‰ËÁÔ‡Ó Û Ԣ‰ÂÙÂÚÔÂÓ›· Î·È ı· ·Ó·Ï˘ı› Ô ·ÏÁfiÚÈıÌÔ˜ Ù˘ ÎÏÈÓÈ΋˜ Î·È ÂÚÁ·ÛÙËÚȷ΋˜ ÚÔÛ¤ÁÁÈÛ˘.
∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ √È ÏÔÈÌÒÍÂȘ ÛÙ· ·È‰È¿ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ÚÔηÏÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ¯ÏˆÚ›‰·˜, fiˆ˜ Â›Ó·È Ù· ÌÈÎÚfi‚È· Ô˘ ·ÔÈΛ˙Ô˘Ó ÙË ÛÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ·, ÙÔÓ Ê¿Ú˘ÁÁ·, ÙÔÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ Î·È ÙÔ ‰¤ÚÌ·. ∏ ¢·ÈÛıËÛ›· ÛÙȘ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ‚·ıÌfi Î·È ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜, ·ÏÏ¿ Î·È ·fi ÙË Ê‡ÛË Ù˘ ˘ÔΛÌÂÓ˘ ·ÈÙÈÔÏÔÁ›·˜ (3). ŸÙ·Ó Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÔÊ›ÏÂÙ·È Û ÂÏ·Ùو̤ÓË ·Ú·ÁˆÁ‹ ·fi ÙÔÓ Ì˘ÂÏfi, Ë ÛÔ‚·ÚfiÙËÙ· Î·È Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Î·È ÙÔ˘ ›‰Ô˘˜ Ù˘ ‚Ï¿‚˘. ªÂ Ô˘‰ÂÙÂÚfiÊÈÏ· <0,2x109/L ˘¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ÛË„·ÈÌ›· ·fi ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ Î·È ·ÚÓËÙÈο ηٿ gram ÌÈÎÚfi‚È· (Pseudomonas aeruginosa, Escherichia coli, Klebsiella spp). ŸÙ·Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Â›Ó·È >0,2x109/L, ÙfiÙ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Î˘Ú›ˆ˜ Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·, ÂÚÈÚˆÎÙÈÎfi ·fiÛÙËÌ· ‹ ΢ÙÙ·Ú›Ùȉ·, ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ˆÙ›Ùȉ˜ ‹ ÈÁÌÔÚ›Ùȉ˜. ∞ÔÛÙ‹Paediatriki 2007;70:237-245
Ì·Ù·, Ó¢ÌÔÓ›· ‹ ÛË„·ÈÌ›· ÌÔÚÔ‡Ó Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó, ·ÏÏ¿ Ì ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ·. ∞ÓÙÈı¤Ùˆ˜, Ù¤ÙÔÈ· ·Ó¿ÏÔÁË Û˘Û¯¤ÙÈÛË ‰ÂÓ ˘¿Ú¯ÂÈ fiÙ·Ó ÙÔ ·›ÙÈÔ Â›Ó·È Ë ·˘ÍË̤ÓË Î·Ù·ÛÙÚÔÊ‹, fiˆ˜ Â›Ó·È Ë ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ‹ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. ¶·È‰È¿ Ì ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÂÓ‰¤¯ÂÙ·È Ó· ¤¯Ô˘Ó Ô˘‰ÂÙÂÚfiÊÈÏ· <0,2x109/L ÁÈ· Ì‹Ó˜ ‹ ¯ÚfiÓÈ· ¯ˆÚ›˜ ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. ∆· ·È‰È¿ Ì ¯ÚfiÓÈ· ÛÔ‚·Ú‹ Ô˘‰ÂÙÂÚÔÂÓ›· ÏfiÁˆ ÂÏ·Ùو̤Ó˘ ·Ú·ÁˆÁ‹˜ ·fi ÙÔÓ Ì˘ÂÏfi, ÂÌÊ·Ó›˙Ô˘Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ‚·ÚȤ˜ ÏÔÈÌÒÍÂȘ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ¤¯Ô˘Ó Ô˘‰ÂÙÂÚÔÂÓ›· ÏfiÁˆ ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ‹ ¯ËÌÂÈÔıÂڷ›·˜. √ ÏfiÁÔ˜ Â›Ó·È fiÙÈ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ¯ÚfiÓÈ·˜ ÛÔ‚·Ú‹˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ Ì›· ÌÂÌÔӈ̤ÓË Î·È ÂÚÈÔÚÈṲ̂ÓË ‰È·Ù·Ú·¯‹ Ô˘ ·ÊÔÚ¿ ÌfiÓÔ ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ·, ÌÂ Û˘ÓÔ‰fi ·ÓÙÈÚÚÔÈÛÙÈ΋ ·‡ÍËÛË ÙˆÓ ÌÔÓÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ ËˆÛÈÓÔʛψÓ, Ô˘ Ì ÙË Ê·ÁÔ΢ÙÙ·ÚÈ΋ ÙÔ˘˜ ‰Ú¿ÛË ·Ó·ÏËÚÒÓÔ˘Ó ÌÂÚÈÎÒ˜ ÙÔ ¤ÏÏÂÈÌ· ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. ∞ÓÙ›ıÂÙ·, Ë ¯ËÌÂÈÔıÂڷ›· Âȉڿ ηٷÛÙÚÔÊÈο fi¯È ÌfiÓÔ ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ·, ·ÏÏ¿ Î·È Û ¿ÏÏÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ù˘ ¿Ì˘Ó·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÙÔ˘ ÊÚ·ÁÌÔ‡ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â›ÛÔ‰Ô ÛÙÔ ·›Ì· ÙˆÓ ÌÈÎÚÔ‚›ˆÓ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ¯ÏˆÚ›‰·˜ Î·È ÙËÓ Â·ÎfiÏÔ˘ıË ÌÈÎÚÔ‚È·ÈÌ›· ‹ ÛË„·ÈÌ›·.
∞›ÙÈ· Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙ· ·È‰È¿ ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ÛÙ· ·È‰È¿ ¤¯ÂÈ ÔÏÏ¿ ·›ÙÈ·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∆·ÍÈÓÔÌÂ›Ù·È Û ÎÏËÚÔÓÔÌÈ΋ Î·È Â›ÎÙËÙË, ÔÍ›· ‹ ¯ÚfiÓÈ·. ™˘ÁÁÂÓ‹˜ Â›Ó·È Ë Ô˘‰ÂÙÂÚÔÂÓ›· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Ï›ÁÔ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‹ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜. √È Û˘ÁÁÂÓ›˜ Ô˘‰ÂÙÂÚÔÂӛ˜ Â›Ó·È ˆ˜ › ÙÔ Ï›ÛÙÔÓ ÎÏËÚÔÓÔÌÈΤ˜ (.¯. ÓfiÛÔ˜ Kostmann, ΢ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›·), ·ÏÏ¿ ÌÔÚ› Ó· Â›Ó·È Î·È Â›ÎÙËÙ˜ (.¯. ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·). √È ÎÏËÚÔÓÔÌÈΤ˜
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·239
239
¢ÈÂÚ‡ÓËÛË Ô˘‰ÂÙÂÚoÂÓ›·˜ ÛÙ· ·È‰È¿
¶›Ó·Î·˜ 2. ∞›ÙÈ· Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙ· ·È‰È¿ ∫ÏËÚÔÓÔÌÈ΋
∂›ÎÙËÙË
™‡Ó‰ÚÔÌÔ Kostmann ∫˘ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›· ™‡Ó‰ÚÔÌÔ ShwachmanDiamond ™‡Ó‰ÚÔÌÔ Pearson °Ï˘ÎÔÁÔÓ›·ÛË Ù‡Ô˘ 1b ™‡Ó‰ÚÔÌ· ÚˆÙÔ·ıÒÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ ∞Ó·ÈÌ›· Fanconi ™˘ÁÁÂÓ‹˜ ‰˘ÛÎÂÚ¿ÙˆÛË
§Ô›ÌˆÍË º¿Ú̷η πÛÔ- Î·È ·˘ÙÔ-¿ÓÔÛË
ª˘ÂÏÔη¯ÂÍ›· ™‡Ó‰ÚÔÌÔ Barth
¢È‹ıËÛË Ì˘ÂÏÔ‡ ÀÂÚÛÏËÓÈÛÌfi˜ ∞Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ª˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ¶·ÚÔ͢ÛÌÈ΋ Ó˘¯ÙÂÚÈÓ‹ ·ÈÌÔÛÊ·ÈÚÈÓÔ˘Ú›· ∞Ó¿ÚÎÂÈ· µ12, Ê˘ÏÏÈÎÔ‡
Ô˘‰ÂÙÂÚÔÂӛ˜ ÔÊ›ÏÔÓÙ·È Û ÂÓ‰ÔÁÂÓ›˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÂÓÒ ÔÈ Â›ÎÙËÙ˜ ÚÔ¤Ú¯ÔÓÙ·È Û˘Ó‹ıˆ˜ ·fi Â͈ÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂȉÚÔ‡Ó ÛÙÔ Ô˘‰ÂÙÂÚfiÊÈÏÔ.
∞. ∫ÏËÚÔÓÔÌÈΤ˜ Ô˘‰ÂÙÂÚÔÂӛ˜ ¡fiÛÔ˜ Kostmann (ÛÔ‚·Ú‹ ‚ÚÂÊÈ΋ ·ÎÔÎÎÈÔ΢ÙÙ·Ú·ÈÌ›·) ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÓfiÛËÌ· Ô˘ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú·. ∆˘Èο, ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ÛÔ‚·Ú‹ ‹ Ôχ ÛÔ‚·Ú‹ Ô˘‰ÂÙÂÚÔÂÓ›· Î·È Û˘¯Ó¤˜ ÛÔ‚·Ú¤˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ, ÂÓÒ ÛÙÔ Ì˘ÂÏfiÁÚ·ÌÌ· ·Ó·‰ÂÈÎÓ‡ÂÙ·È ·Ó·ÛÙÔÏ‹ Ù˘ ˆÚ›Ì·ÓÛ˘ ÛÙË Ê¿ÛË ÙÔ˘ ÚÔÌ˘ÂÏÔ΢ÙÙ¿ÚÔ˘ / Ì˘ÂÏÔ΢ÙÙ¿ÚÔ˘ (4). ™˘¯Ó¿ ˘¿Ú¯ÂÈ ·ÓÙȉڷÛÙÈ΋ ÌÔÓÔ΢ÙÙ¿ÚˆÛË Î·È ‹È· ˈÛÈÓÔÊÈÏ›·. ™Â ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ, ÂÚ›Ô˘ 12%, ˘¿Ú¯ÂÈ ÂÍ·ÏÏ·Á‹ ÛÂ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ÔÍ›· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›· (5-7). ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ·ÎfiÌË ·‰È¢ÎÚ›ÓÈÛÙË. ¶ÚfiÛÊ·Ù·, ¤¯Ô˘Ó ‚ÚÂı› ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ ELA2 Ô˘ Â›Ó·È ˘Â‡ı˘ÓÔ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ÂÏ·ÛÙ¿Û˘ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (8,9). ªÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ ELA2 ›Ûˆ˜ Ó· Ô‰ËÁÔ‡Ó Û ·Ú·ÁˆÁ‹ ÙÚÔÔÔÈË̤Ó˘ ÂÏ·ÛÙ¿Û˘, Ë ÔÔ›· ·Ô‰ÂÛ̇ÂÙ·È Ì¤Û· ÛÙÔ ÚÔÌ˘ÂÏÔ·ÙÙ·ÚÔ Î·È ÙÔ Î·Ù·ÛÙÚ¤ÊÂÈ ‹ ¿ÁÂÈ ÙËÓ ·fiÙˆÛ‹ ÙÔ˘ (10). ∏ ıÂڷ›· Â›Ó·È Ë ¯ÔÚ‹ÁËÛË G-CSF Î·È Ë ÚÔÊ˘Ï·ÎÙÈ΋ Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ¢Â‰Ô̤ÓÔ˘ ÙÔ˘ ÛËÌ·ÓÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ηÎÔ‹ıÔ˘˜ ÂÍ·ÏÏ·Á‹˜, Û ·ÚÎÂÙ¿ ΤÓÙÚ· Á›ÓÂÙ·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, Â¿Ó ˘¿Ú¯ÂÈ Û˘Ì‚·Ùfi˜ ·‰ÂÚÊfi˜, ÚÈÓ ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÚˆÌÔÛˆÌÈ·ÎÒÓ ·ÓˆÌ·ÏÈÒÓ (11). ∫˘ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›· ∏ ΢ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›· ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú· Î·È Û ۯ¤ÛË
Ì ÙË ÓfiÛÔ ÙÔ˘ Kostmann ÂΉËÏÒÓÂÙ·È Ï›ÁÔ ·ÚÁfiÙÂÚ· ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Î·È Ì ÏÈÁfiÙÂÚÔ ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ, ÂÓÒ ‰ÂÓ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ Ï¢¯·ÈÌÔÁ¤ÓÂÛ˘ (12). ∆˘Èο ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚÈÔ‰È΋ Ô˘‰ÂÙÂÚÔÂÓ›· <0,2x109/L ÁÈ· 3-5 Ë̤Ú˜, οı ÂÚ›Ô˘ 21 Ë̤Ú˜ (Ì ‡ÚÔ˜ 13-35 Ë̤Ú˜), ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ‹ ۯ‰fiÓ Ê˘ÛÈÔÏÔÁÈÎfi ·ÚÈıÌfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù·. ™ÙÔ Ó·‰›Ú ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙÔÌ·ÙÈο ¤ÏÎË ·fi ·Ó·ÂÚfi‚È· ÌÎÚfi‚È· Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÁÂÓÈÎÂ˘Ì¤ÓË Ïԛ̈ÍË, ˘ÚÂÙfi˜, ˆÙ›Ùȉ·, ÏÔÈÌÒÍÂȘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Û·ÓÈfiÙÂÚ· ÂÚÈÚˆÎÙÈο ·ÔÛÙ‹Ì·Ù·. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ˘¿Ú¯ÂÈ Î·È ÂÚÈÔ‰È΋ ıÚÔÌ‚ÔÂÓ›· Î·È ÂÏ¿ÙÙˆÛË ÙˆÓ ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ. ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘ ·›˙Ô˘Ó ÔÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ ELA2 Ù˘ ÂÏ·ÛÙ¿Û˘ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, ηıÒ˜ ¤¯Ô˘Ó ‚ÚÂı› ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ (13). ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙÔ ÎÏËÚÔÓÔÌÈÎfi Î·È ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi Î·È ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ELA2. ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ÙÔ˘ ÌÔÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘, ÙfiÙ ڤÂÈ Ó· Á›ÓÂÙ·È ·ÈÌÔÏË„›· Î·È ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ÙÚÂȘ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÁÈ· ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ÁÈ· Ó· ·Ó·‰Âȯı› Ë Î˘ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›·. £Âڷ›· ·ÔÙÂÏÔ‡Ó Ë ¯ÔÚ‹ÁËÛË G-CSF Î·È Ë ÚÔÊ˘Ï·ÎÙÈ΋ Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ™‡Ó‰ÚÔÌÔ Shwachman-Diamond ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· Û¿ÓÈ· ÓfiÛÔ Ô˘ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ÙÚfiÔ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Â͈ÎÚÈÓ‹ ·ÁÎÚ·ÙÈ΋ ·Ó¿ÚÎÂÈ·, ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È Ô˘‰ÂÙÂÚÔÂÓ›· (14). ªÂÙ¿ ÙËÓ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ Â›Ó·È Ë ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ·ÈÙ›· Â͈ÎÚÈÓÔ‡˜ ·ÁÎÚ·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙ· ·È‰È¿. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ·Ó·Ú΋ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜, ‰˘Û·ÔÚÚfiÊËÛË Î·È Û˘¯Ó¤˜ Î·È ÛÔ‚·Ú¤˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ. ÕÏϘ ÂΉËÏÒÛÂȘ Â›Ó·È ÙÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, Ë ‰˘ÛÏ·Û›· ÂÈʇÛÂˆÓ Î·È ÌÂٷʇÛˆÓ, Ë Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ÔÈ ÓÂÊÚÔÛˆÏËÓ·ÚȷΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÂӉ¯Ô̤ӈ˜ Ë „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ™ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ë ·ÁÎÚ·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·Ôηı›ÛÙ·Ù·È ÛÙ·‰È·Î¿ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·. ∂Í·ÏÏ·Á‹ ÛÂ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ÔÍ›· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 15% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (15). £Âڷ¢ÙÈο ¯ÔÚËÁÔ‡ÓÙ·È ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· ηÈ, Â¿Ó Û˘Ì‚·›ÓÔ˘Ó ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ, ¯ÔÚËÁÂ›Ù·È Î·È G-CSF. ™‡Ó‰ÚÔÌÔ Pearson ∏ Û¿ÓÈ· ·˘Ù‹ ÓfiÛÔ˜ ‚Ú›ÛÎÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË fiÙ·Ó ‰ÈÂÚ¢Óԇ̠·È‰› Ì Èı·Ófi Û‡Ó‰ÚÔÌÔ Shwachman-Diamond, ·ÏÏ¿ ÙË ‰È¿ÁÓˆÛË ı¤ÙÂÈ Ë ¶·È‰È·ÙÚÈ΋ 2007;70:237-245
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·240
240
∞. ª¿Î˘, ¡. ÷ÏÈ¿ÛÔ˜
¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· ÙÔ˘ Ì˘ÂÏÔ‡. ¶ÚfiÎÂÈÙ·È Ô˘ÛÈ·ÛÙÈο ÁÈ· Ì›· Û˘ÛÙËÌ·ÙÈ΋ ÓfiÛÔ Ô˘ ÚÔ·ÙÂÈ ·fi ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ DNA Î·È ÂΉËÏÒÓÂÙ·È Û ÌÈÎÚ‹ ËÏÈΛ· Ì ·ÓıÂÎÙÈ΋ ÛȉËÚÔ‚Ï·ÛÙÈ΋ ·Ó·ÈÌ›·, Ì ÎÂÓÔÙfiÈ· ÛÙ· ¿ˆÚ· Ì˘ÂÏÈο ·ÙÙ·Ú·, Ô˘‰ÂÙÂÚÔÂÓ›·, ıÚÔÌ‚ÔÂÓ›·, Â͈ÎÚÈÓ‹ ·ÁÎÚ·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È Á·Ï·ÎÙÈ΋ ÔͤˆÛË (16,17). °Ï˘ÎÔÁÔÓ›·ÛË Ù‡Ô˘ 1b ∏ ÁÏ˘ÎÔÁÔÓ›·ÛË ·˘Ù‹ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ÙÚfiÔ Î·È ÚÔ·ÙÂÈ ·fi ÙËÓ ¤ÏÏÂÈ„Ë ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÁÏ˘ÎÔ˙Ô-6-ʈÛÊÔtranslocase Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·Ú΋ ·Ú·ÁˆÁ‹ ÁÏ˘Îfi˙˘ Ì ÙË ÁÏ˘ÎÔÓÂÔÁ¤ÓÂÛË ‹ ÙË ÁÏ˘ÎÔÁÔÓfiÏ˘ÛË. ∆· ·È‰È¿ ·˘Ù¿ ÂÌÊ·Ó›˙Ô˘Ó ˘ÔÁÏ˘Î·ÈÌ›·, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, Û·ÛÌÔ‡˜ Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÛÔ‚·Ú‹ Ô˘‰ÂÙÂÚÔÂÓ›· ÌÂ Û˘ÓÔ‰fi ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ì Ì˯·ÓÈÛÌfi Ô˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ˜ (18). ∂Ӊ¯fiÌÂÓˆ˜ Ó· ÂËÚ¿˙ÂÙ·È ¿ÌÂÛ· Ë Ì˘ÂÏÔÔ›ËÛË, ‰ÈfiÙÈ Û ÂÚÈÙÒÛÂȘ Ô˘ ¤ÁÈÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ‰ÂÓ ‰ÈÔÚıÒıËÎÂ Ë Ô˘‰ÂÙÂÚÔÂÓ›· (19). ™‡Ó‰ÚÔÌ· ÚˆÙÔ·ıÒÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ·ÔÙÂÏ› ÂΉ‹ÏˆÛË ·ÚÎÂÙÒÓ Û˘Ó‰ÚfiÌˆÓ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜, fiˆ˜ Â›Ó·È Ë Ê˘ÏÔÛ‡Ó‰ÂÙË ·Á·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· (ÓfiÛÔ˜ Bruton), ·Ó¿ÚÎÂÈ· CD40-ligand (Ê˘ÏÔÛ‡Ó‰ÂÙÔ ˘ÂÚ-IgM Û‡Ó‰ÚÔÌÔ), cartilage hair hypoplasia, ‰ÈÎÙ˘ˆÙ‹ ‰˘ÛÁÂÓÂÛ›· (reticular dysgenesis) Î.¿. ¶Èı·ÓfiÓ, Ô Ì˯·ÓÈÛÌfi˜ Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Ó· Â›Ó·È ·˘ÙÔ¿ÓÔÛÔ˜, fï˜ ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ·Ó¢ڛÛÎÔÓÙ·È Û ¤Ó· Û¯ÂÙÈο ÌÈÎÚfi ÔÛÔÛÙfi ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ (20). ¶ÚfiÛÊ·Ù· ·Ó·‰Â›¯ıËΠfiÙÈ Ô CD40 ligand ‰ÈÂÁ›ÚÂÈ Ù· ·ÙÙ·Ú· ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜ ÙÔ˘ Ì˘ÂÏÔ‡ ÁÈ· Ó· ·Ú¿ÁÔ˘Ó flt3-ligand Î·È ıÚÔÌ‚ÔÔÈËÙ›ÓË Ô˘ Â›Ó·È ··Ú·›ÙËÙÔÈ ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË Ì˘ÂÏÔÔ›ËÛË (21). ∆Ô Â‡ÚËÌ· ·˘Ùfi ›Ûˆ˜ Ó· ÂÍËÁ› ÙËÓ Ô˘‰ÂÙÂÚÔÂÓ›· ÛÙ· ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· CD40ligand. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙËÓ ·Ó¿ÚÎÂÈ· CD40-ligand, Ë ÂÈÎfiÓ· ÙÔ˘ Ì˘ÂÏÔ‡ Â›Ó·È ·ÚfiÌÔÈ· Ì ÙË ÓfiÛÔ Kostmann, ‰ËÏ·‰‹ Ì ·Ó·ÛÙÔÏ‹ Ù˘ ˆÚ›Ì·ÓÛ˘ ÛÙË Ê¿ÛË ÙÔ˘ ÚÔÌ˘ÂÏÔ΢ÙÙ¿ÚÔ˘-Ì˘ÂÏÔ΢ÙÙ¿ÚÔ˘. ∞˘Ùfi ·Ó·‰ÂÈÎÓ‡ÂÈ ÙË ÛËÌ·Û›· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ Û ·È‰È¿ Ô˘ ‰ÈÂÚ¢ÓÒÓÙ·È ÁÈ· ÛÔ‚·Ú‹ ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›·. ™‡Ó‰ÚÔÌÔ Chediak-Higashi: AÓ‹ÎÂÈ ÛÙ· Û‡Ó‰ÚÔÌ· ·ÏÊÈÛÌÔ‡ Î·È ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú·. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÌÂÚÈÎfi ÔÊı·ÏÌÔ‰ÂÚÌ·ÙÈÎfi ·ÏÊÈÛÌfi, ÂÚÈÊÂÚÈ΋ Ó¢ڛÙȉ·, Ô˘‰ÂÙÂÚÔÂÓ›· Ì ¯·Ú·ÎÙËÚÈÛÙÈο ÌÂÁ¿Ï· ¤ÁÎÏÂÈÛÙ· ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È ÔÈÔÙÈΤ˜ ‰È·Ù·Ú·Paediatriki 2007;70:237-245
¯¤˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (22). ™ÙËÓ ÂÈÙ·¯˘ÓfiÌÂÓË Ê¿ÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ˘¿Ú¯ÂÈ ·Ó΢ÙÙ·ÚÔÂÓ›·, ÁÂÓÈÎÂ˘Ì¤ÓË ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Î·È ÂÎÙÂٷ̤ÓË ‰È‹ıËÛË ÙˆÓ ÈÛÙÒÓ ·fi ÏÂÌÊÔÂȉ‹ ·ÙÙ·Ú·. ™‡Ó‰ÚÔÌÔ Wiskott Aldrich: ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ÂΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ ÌÂ: ·) ¤Î˙ÂÌ·, ‚) ·ÈÌÔÚÚ·Á›Â˜ ÏfiÁˆ ıÚÔÌ‚ÔÂÓ›·˜ (Ì Ôχ ÌÈÎÚ¿ ·ÈÌÔÂÙ¿ÏÈ·) Î·È ÔÈÔÙÈ΋˜ ‰È·Ù·Ú·¯‹˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Á) ÏÔÈÌÒÍÂȘ ÏfiÁˆ Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î·È Ù˘ ÌÈÎÙ‹˜ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (23). À¿Ú¯ÂÈ, ›Û˘, ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ÂÌÊ¿ÓÈÛË ÏÂÌÊˆÌ¿ÙˆÓ (24). ∂ÊfiÛÔÓ ˘¿Ú¯ÂÈ Û˘Ì‚·Ùfi˜ ·‰ÂÚÊfi˜, Ë ıÂڷ›· Â›Ó·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™Â ·ÓÙ›ıÂÙË ÂÚ›ÙˆÛË, Á›ÓÂÙ·È ÛÏËÓÂÎÙÔÌ‹, Ë ÔÔ›· fï˜ ‰ÈÔÚıÒÓÂÈ ÌfiÓÔ ÙË ıÚÔÌ‚ÔÂÓ›·. ∞Ó·ÈÌ›· Fanconi ∏ ·Ó·ÈÌ›· Fanconi Â›Ó·È Ì›· ÌÔÚÊ‹ ·Ï·ÛÙÈ΋˜ ·Ó·ÈÌ›·˜ Ô˘ ·Ó‹ÎÂÈ ÛÙ· ÎÏËÚÔÓÔÌÈο Û‡Ó‰ÚÔÌ· Ì˘ÂÏÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (25). ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ˘¿Ú¯ÂÈ ‚·ÛÈ΋ ·Ó¿ÚÎÂÈ· ÛÙËÓ ÂȉÈfiÚıˆÛË ÙˆÓ ‚Ï·‚ÒÓ ÙÔ˘ DNA. ∂ΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ Û ËÏÈΛ· 5-10 ÂÙÒÓ Î·È Û¿ÓÈ· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯Ô˘Ó ÔÏϷϤ˜ ·ÓˆÌ·Ï›Â˜, fiˆ˜ Â›Ó·È ÙÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÌÈÎÚÔÎÂÊ·Ï›·, café-au-lait ÎËÏ›‰Â˜, ·Ô¯ÚˆÌ·ÙÈÛÌfi˜ ‰¤ÚÌ·ÙÔ˜, ÔÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, ·Ó·ÙÔÌÈο ÚÔ‚Ï‹Ì·Ù· ·fi ÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi, Ù· ÒÙ· Î·È ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ Î·È ‰È·ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ™˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Ì ·Ó·ÈÌ›· Î·È ıÚÔÌ‚ÔÂÓ›· Î·È Û·ÓÈfiÙÂÚ· Ì ÌÂÌÔӈ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›·. ∏ ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙË ‰ÔÎÈÌ·Û›· ¢ıÚ·˘ÛÙfiÙËÙ·˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ Û ÌÈÙÔÁfiÓ˜ Ô˘Û›Â˜. ¢˘ÓËÙÈο ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ÁÈ· ÂÍ·ÏÏ·Á‹ ÛÂ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ÔÍ›· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, fiˆ˜ ›Û˘ Î·È ÁÈ· ÂÌÊ¿ÓÈÛË Î·ÚΛÓÔ˘ ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ· (26). ™˘ÁÁÂÓ‹˜ ‰˘ÛÎÂÚ¿ÙˆÛË ∞ÔÙÂÏ› ¤Ó· Û¿ÓÈÔ ÓfiÛËÌ· Ô˘ ·Ó‹ÎÂÈ Î·È ·˘Ùfi ÛÙ· ÎÏËÚÔÓÔÌÈο Û‡Ó‰ÚÔÌ· Ì˘ÂÏÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ÂΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· ‹ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ˘¤Ú¯ÚˆÛË ‰¤ÚÌ·ÙÔ˜, ‰˘ÛÙÚÔÊ›· ÔÓ‡¯ˆÓ, Ï¢ÎÔϷΛ· Î·È ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ÂÓ‰¤¯ÂÙ·È Ó· ÂÌÊ·ÓÈÛÙ› ·Ú¯Èο ÚÈÓ ÙËÓ ·Ï·Û›· Î·È ÙˆÓ ˘ÔÏÔ›ˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ ÛÂÈÚÒÓ. À¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· Ï¢¯·ÈÌÔÁ¤ÓÂÛË, ηıÒ˜ Î·È ÁÈ· ηÚΛÓÔ˘˜ ·fi ÂÈıËÏȷο ·ÙÙ·Ú· (27,28).
Pediatri May-Jun 07
24-05-07
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ª˘ÂÏÔη¯ÂÍ›· ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ÙÚfiÔ. À¿Ú¯ÂÈ Ì¤ÙÚÈ· ¤ˆ˜ ÛÔ‚·Ú‹ Ô˘‰ÂÙÂÚÔÂÓ›· Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÌÔÚÊÔÏÔÁ›· ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, Ù· ÔÔ›· ¤¯Ô˘Ó ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈο ÎÂÓÔÙfiÈ· Î·È ·ÓÒÌ·ÏÔ˘˜ ÔÏ˘Î·Ù¿ÙÌËÙÔ˘˜ ˘Ú‹Ó˜. º·›ÓÂÙ·È fiÙÈ Ô Ì˯·ÓÈÛÌfi˜ Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÏ·Ùو̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ bcl-x Î·È ÛÙËÓ Â·ÁˆÁ‹ Ù˘ ·fiÙˆÛ˘ ÙˆÓ Úfi‰ÚÔÌˆÓ Î˘ÙÙ¿ÚˆÓ (29). ™‡Ó‰ÚÔÌÔ Barth ∆Ô Û¿ÓÈÔ ·˘Ùfi Û‡Ó‰ÚÔÌÔ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÔÓ Û˘Ó‰˘·ÛÌfi Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î·È Î·Ú‰ÈÔÌ˘Ô¿ıÂÈ·˜. √È ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÏÔÈÌÒ͈Ó. ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ˘¿Ú¯Ô˘Ó ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Â›Ó·È ˘Â‡ı˘ÓÔ ÁÈ· ÙË Û‡ÓıÂÛË Ù˘ ηډÈÔÏÈ›Ó˘ (30).
µ. ∂›ÎÙËÙ˜ Ô˘‰ÂÙÂÚÔÂӛ˜ ªÂÙ·ÏÔÈÌ҉˘ Ô˘‰ÂÙÂÚÔÂÓ›· ª·˙› Ì ٷ Ê¿Ú̷η, ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË ÛÙ· ·È‰È¿. ∂ÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ·fi Ïԛ̈ÍË ·fi ÈÔ‡˜, ‚·ÎÙ‹ÚÈ·, ÚˆÙfi˙ˆ· ‹ ̇ÎËÙ˜. √È Ì˯·ÓÈÛÌÔ› Â›Ó·È Î˘Ú›ˆ˜ Ë ¿ÌÂÛË Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡, Ë Â›‰Ú·ÛË ÛÙËÓ ·Ó·Î·Ù·ÓÔÌ‹, ηıÒ˜ ›Û˘ Î·È Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. ∏ Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ÍÂÎÈÓ¿ÂÈ Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ Ïԛ̈͢ Î·È Ó· ‰È·ÚΛ ̤¯ÚÈ 4-6 ‚‰ÔÌ¿‰Â˜. ∂ÈÚfiÛıÂÙ·, ÔÚÈṲ̂ÓÔÈ ÈÔ› Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ¿ÁÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, ÌÂ Û˘Ó¤ÂÈ· Ë Ô˘‰ÂÙÂÚÔÂÓ›· Ó· ‰È·ÚΛ ÁÈ· Ì‹Ó˜. √È ÛÔ‚·Ú¤˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ ÌÂÙ·ÏÔÈÌÒ‰Ô˘˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (31). √È ÈÔ› Ô˘ ÚÔηÏÔ‡Ó Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Î˘Ú›ˆ˜ ÔÈ ÂÍ‹˜: EBV, CMV, RSV, Èfi˜ Ù˘ ÂÚ˘ıÚ¿˜, ÈÏ·Ú¿˜, ·ÓÂÌ¢ÏÔÁÈ¿˜, Áڛ˘, Ë·Ù›Ùȉ·˜ ∞, µ, C, Èfi˜ Parvo B19, HSV-6 Î·È HIV (32). √È ÏÔÈÌÒÍÂȘ ·fi ÛÙ·Ê˘ÏfiÎÔÎÎÔ, Ê˘Ì·Ù›ˆÛË, ‚ÚԢΤÏÏ· ‹ Û·ÏÌÔÓ¤ÏÏ· ÚÔηÏÔ‡Ó Ì¤ÙÚÈ· Ô˘‰ÂÙÂÚÔÂÓ›·, ÂÎÙfi˜ Â¿Ó ÚÔ¸¿Ú¯ÂÈ ÛË„·ÈÌ›·, ÔfiÙÂ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· Â›Ó·È Ôχ ÛÔ‚·Ú‹. √˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ›, ›Û˘, Ó· ÚÔηϤÛÂÈ Ë Ïԛ̈ÍË ·fi ÏÂ˚ÛÌ¿ÓÈ·, ÂÏÔÓÔÛ›· ‹ ÈÛÙÔÏ¿Û̈ÛË. º·Ú̷΢ÙÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›· ∆· Ê¿Ú̷η ·ÔÙÂÏÔ‡Ó Û˘¯Ó¿ ·›ÙÈÔ Ô˘‰ÂÙÂÚÔÂÓ›·˜, Ë ÔÔ›· ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ÌÔÚ› Ó· Â›Ó·È Ôχ ÛÔ‚·Ú‹. √È Ì˯·ÓÈÛÌÔ› Ô˘ Ô‰ËÁÔ‡Ó Û Ԣ‰Â-
ÙÂÚÔÂÓ›· Â›Ó·È Î˘Ú›ˆ˜ Ë ¿ÌÂÛË Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡, Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ Úfi‰ÚÔÌˆÓ Î˘ÙÙ¿ÚˆÓ Ì¤Ûˆ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ηıÒ˜ Î·È Ë ¿ÌÂÛË ÂÚÈÊÂÚÈ΋ ηٷÛÙÚÔÊ‹. ∆· Ê¿Ú̷η Ô˘ ÚÔηÏÔ‡Ó Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È ÔÏÏ¿. ∆· ΢ÚÈfiÙÂÚ· Â›Ó·È Ù· ¯ËÌÂÈÔıÂڷ¢ÙÈο, Ù· ·ÓÙÈ‚ÈÔÙÈο (.¯. ÎÂÊ·ÏÔÛÔÚ›Ó˜, ÙÚÈÌÂıÔÚ›ÌËÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË), Ù· ·ÓÙÈÂÈÏËÙÈο, Ù· ·ÓÙÈı˘ÚÂÔÂȉÈο, Ô ¯Ú˘Ûfi˜, Ë ‰ÂÊÂÚÈÚfiÓË Î·È Ù· ÌË-ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë (33,34). ∏ ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Ô‰ËÁ› Û˘Ó‹ıˆ˜ Û ÁÚ‹ÁÔÚË ·Ó¿Î·Ì„Ë ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ÂÚÈÙÒÛÂȘ Ô˘ Ë Û˘Ó¤¯ÈÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Â›Ó·È ·Ó·Áη›· ÁÈ· ÙÔ ·È‰›, fiˆ˜ Û˘Ì‚·›ÓÂÈ .¯. Ì ٷ ·ÓÙÈÂÈÏËÙÈο. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Â¿Ó Ô ·ÚÈıÌfi˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Â›Ó·È >0,5-0,7x109/L Î·È ‰ÂÓ Û˘Ì‚·›ÓÔ˘Ó ÏÔÈÌÒÍÂȘ, ÙfiÙ ÌÔÚ› Ó· Û˘Ó¯ÈÛÙ› Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ˘fi ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË. πÛÔ- Î·È ·˘ÙÔ-¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· √È ‰‡Ô ·˘Ù¤˜ ηٷÛÙ¿ÛÂȘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. ∏ ÓÂÔÁÓÈ΋ ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‹ ̤۷ ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ Î·È Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ Rhesus. À¿Ú¯ÂÈ, fï˜, Ì›· ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿: Ë ÓÂÔÁÓÈ΋ ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Î·È ÛÙÔ ÚÒÙÔ ·È‰›. ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈ· ηٿÛÙ·ÛË Î·È ÔÈ ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÂÈÏÔ΋, ·Ú¿ ÙȘ Ôχ ¯·ÌËϤ˜ ÙÈ̤˜ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (<0,2x109/L) (35). ∏ ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ˘ ·È‰ÈÔ‡ ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ô˘ ÎÏËÚÔÓfiÌËÛ ÙÔ ·È‰› ·fi ÙÔÓ ·Ù¤Ú·. ∆· ·ÓÙÈÛÒÌ·Ù· ·˘Ù¿ ‰È¤Ú¯ÔÓÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ· Î·È ÌÔÚ› Ó· ÚÔηÏÔ‡Ó Ô˘‰ÂÙÂÚÔÂÓ›· ÛÙÔ ‚Ú¤ÊÔ˜ ̤¯ÚÈ Ó· ÂÍ·Ê·ÓÈÛÙÔ‡Ó, Û˘Ó‹ıˆ˜ Û 3-28 ‚‰ÔÌ¿‰Â˜ (̤ÛÔ˜ fiÚÔ˜: 11 ‚‰ÔÌ¿‰Â˜). ¶·ÚfiÌÔÈ· ÂÈÎfiÓ· Ì ÙË ÓÂÔÁÓÈ΋ ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ë ·ıËÙÈ΋ ‰È¤Ï¢ÛË ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ· ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙË ÌËÙ¤Ú· Ô˘ ¿Û¯ÂÈ ·fi ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·. ∏ ÚˆÙÔ·ı‹˜ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È Ì›· Û¯ÂÙÈο ηÏÔ‹ı˘ ¿ıËÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ú·ÁˆÁ‹ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÌÂ Û˘¯Ó¿ ÛÔ‚·Ú‹ Ô˘‰ÂÙÂÚÔÂÓ›·, ¯ˆÚ›˜ fï˜ ‚·ÚȤ˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ. ∂ÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (5-15 ÌËÓÒÓ) Î·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (95%) ˘¿Ú¯ÂÈ ·˘ÙfiÌ·ÙË ·Ó¿Î·Ì„Ë ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ì¤¯ÚÈ ÙËÓ ¶·È‰È·ÙÚÈ΋ 2007;70:237-245
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·242
242
∞. ª¿Î˘, ¡. ÷ÏÈ¿ÛÔ˜
ËÏÈΛ· ÙˆÓ 3-4 ÂÙÒÓ (17 Ì‹Ó˜ ηٿ ̤ÛÔ fiÚÔ) (36,37). ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ G-CSF ‹ Î·È ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ ÛÙȘ Û¿ÓȘ ÂÚÈÙÒÛÂȘ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. ¢ÂÓ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ηÎÔ‹ıÔ˘˜ ÂÍ·ÏÏ·Á‹˜. ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ‚¿ÛË: ·) ÙÔ ÈÛÙÔÚÈÎfi, fiÔ˘ ‰ÂÓ ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ, ‚) ÙË ¯ˆÚ›˜ ȉȷ›ÙÂÚ· Â˘Ú‹Ì·Ù· ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, Á) ÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒÓÔÓÙ·È ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ‰) ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÂȉÈÎÒÓ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈۈ̿وÓ. ŸÙ·Ó Û˘Ó˘¿Ú¯Ô˘Ó Ù· ·ÓˆÙ¤Úˆ, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÙ·È Ì˘ÂÏfiÁÚ·ÌÌ· (38). ¢Â˘ÙÂÚÔ·ı‹˜ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÛÙÔ Ï·›ÛÈÔ ˘ÔΛÌÂÓÔ˘ ·˘ÙÔ·ÓfiÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜, fiˆ˜ Â›Ó·È Ô Û˘ÛÙËÌ·ÙÈÎfi˜ ÂÚ˘ıËÌ·Ù҉˘ χÎÔ˜ ‹ Ë Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ·. ∆Ô Û‡Ó‰ÚÔÌÔ Felty Â›Ó·È Ô Û˘Ó‰˘·ÛÌfi˜ ÛÏËÓÔÌÂÁ·Ï›·˜ Î·È Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ó·ÓÈ΋ ȉÈÔ·ı‹ ·ÚıÚ›Ùȉ·. ¢Â˘ÙÂÚÔ·ı‹˜ ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ÚÔ·„ÂÈ ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ‹ Ï‹„Ë Ê·ÚÌ¿ÎˆÓ (39). ¢È‹ıËÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ √˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ÚÔ¤ÏıÂÈ ·fi ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ·fi ηÎÔ‹ıË ‹ ÌË Î‡ÙÙ·Ú·, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·Ú΋ ·Ú·ÁˆÁ‹ Ô˘‰ÂÙÂÚÔʛψÓ. ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯ÂÈ ·Ó·ÈÌ›· ‹/Î·È ıÚÔÌ‚ÔÂÓ›·. ∆¤ÙÔȘ ·ı‹ÛÂȘ Â›Ó·È Ë ÔÍ›· Ï¢¯·ÈÌ›·, ÙÔ Ï¤Ì-
ʈ̷, ÌÂÙ·ÛÙ¿ÛÂȘ ·fi ÌË-·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ (.¯. Ó¢ÚÔ‚Ï¿Ûو̷, Ú·‚‰ÔÌ˘ÔÛ¿ÛÚΈ̷, ÔÛÙÂÔÛ¿ÚΈ̷), ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË, ÓfiÛÔ˜ Gaucher Î·È ÔÛÙÂÔ¤ÙÚˆÛË. ∏ ÔÛÙÂÔ¤ÙÚˆÛË ÚÔηÏ› ΢ÙÙ·ÚÔÂӛ˜ ÂÂȉ‹ Ô Ì˘ÂÏÈÎfi˜ ¯ÒÚÔ˜ ηٷϷ̂¿ÓÂÙ·È ·fi ÔÛÙ›ÙË ÈÛÙfi ÏfiÁˆ ·Ó¿ÚÎÂÈ·˜ ÙˆÓ ÔÛÙÂÔÎÏ·ÛÙÒÓ Ó· ÙÔÓ ·Ô‰ÔÌ‹ÛÔ˘Ó. ÕÏÏ· ·›ÙÈ· √˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Û ÂÚÈÙÒÛÂȘ ˘ÂÚÛÏËÓÈÛÌÔ‡ (.¯. ÛÙË ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·), ·Ï·ÛÙÈ΋˜ ·Ó·ÈÌ›·˜ (ȉÈÔ·ı‹˜, ›ÎÙËÙË), Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ·ÚÔ͢ÛÌÈ΋˜ Ó˘¯ÙÂÚÈÓ‹˜ ·ÈÌÔÛÊ·ÈÚÈÓÔ˘Ú›·˜ ‹ ·Ó¿ÚÎÂÈ·˜ µ12 ‹ Ê˘ÏÏÈÎÔ‡ ÔͤԘ. ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯Ô˘Ó ·Ó·ÈÌ›· ‹/Î·È ıÚÔÌ‚ÔÂÓ›·.
¶ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›· ™ÙËÓ ∂ÈÎfiÓ· 1 ·ÚÔ˘ÛÈ¿˙ÂÙ·È ¤Ó·˜ ÚÔÙÂÈÓfiÌÂÓÔ˜ ·ÏÁfiÚÈıÌÔ˜ Ù˘ ÎÏÈÓÈ΋˜ Î·È ÂÚÁ·ÛÙËÚȷ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›·: 1) ∏ ÚÔÛ¤ÁÁÈÛË ·Ú¯›˙ÂÈ Ì ÙËÓ ÂȂ‚·›ˆÛË Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ Û‡Ìʈӷ Ì ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. 2) ∆Ô ÈÛÙÔÚÈÎfi Î·È Ë ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¢ı‡ÓÔ˘Ó ÙËÓ ÚÔÛ¤ÁÁÈÛË. ∆Ô ÈÛÙÔÚÈÎfi ‚ÔËı¿ ÛÙË ‰È¿ÎÚÈÛË Ù˘ ÔÍ›·˜ ·fi ÙË ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›·. ªÂ ÙÔ ÈÛÙÔÚÈÎfi Û˘ÏϤÁÔÓÙ·È ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜, fiˆ˜: ÂÂÈÛfi‰È· ÏÔÈÌÒÍÂˆÓ ÛÙÔ ·ÚÂÏıfiÓ (Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·, ÂÚÈÚˆÎÙÈο ·ÔÛÙ‹Ì·Ù·,
1 2 3 πÛÙÔÚÈÎfi, ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, ÁÂÓÈ΋ ·›Ì·ÙÔ˜
4 √Í›· ÓfiÛÔ˜
5 º¿Ú̷η
6 ™Ô‚·Ú‹ Â̇ÚÂÙË Ïԛ̈ÍË
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7
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ÃÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· ‹ ÏÔÈÌÒÍÂȘ ‹/Î·È Ô˘‰ÂÙÂÚfiÊÈÏ· <0,5 Û 3 ÌÂÙÚ‹ÛÂȘ
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πÔÁÂÓ‹˜ ¶ÂÚÈÔ‰ÈÎfiÙËÙ· ∞ÓÙÈÛÒÌ·Ù· ∫·Î‹ Ïԛ̈ÍË ∫ÏËÚÔÓÔÌÈÎfi ¤Ó·ÓÙÈ ‰È·ÙÚÔÊ‹ πÛÙÔÚÈÎfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ¢È¿ÚÚÔȘ °ÔÓ›‰ÈÔ ELA2 ∞Ó·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜
12 º·ÈÓÔÙ˘ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ªÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ ∫·Ú‰ÈÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·
13 ™˘¯Ó¤˜ ¿Ù˘Â˜ ÏÔÈÌÒÍÂȘ
14 ª˘ÂÏfiÁÚ·ÌÌ· ∫˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ √ÛÙÂÔÌ˘ÂÏÈ΋ ‚ÈÔ„›· ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋
¢È·ÎÔ‹ µ·ÎÙ‹ÚÈ· 4-6 ‚‰. ∫˘ÎÏÈ΋ πÛÔ¿ÓÔÛË µ12 Fanconi’s HIV ¢È‹ıËÛË Ì˘ÂÏÔ‡ MDS Ê·ÚÌ¿ÎÔ˘ ¶ÚˆÙfi˙ˆ· ¤ˆ˜ Ô˘‰ÂÙÂÚÔÂÓ›· ‹ º˘ÏÏÈÎfi ™˘ÁÁ. ‰˘ÛÎÂÚ¿ÙˆÛË ™˘ÁÁÂÓ›˜ Kostmann’s ∞‡ÍËÛË ª‡ÎËÙ˜ 6-17 Ì‹Ó˜ ·˘ÙÔ¿ÓÔÛË SDS Chediak-Higashi ·ÓÔÛÔ·Ó¿ÚÎÂȘ ∞Ï·ÛÙÈ΋ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ 3-4 ‚‰. Ô˘‰ÂÙÂÚÔÂÓ›· Pearson’s ªÂÙ·‚ÔÏÈο ·Ó·ÈÌ›· ÓÔÛ‹Ì·Ù· PNH Barth’s
∂ÈÎfiÓ· 1. ∞ÏÁfiÚÈıÌÔ˜ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ·È‰ÈÔ‡ Ì Ԣ‰ÂÙÂÚÔÂÓ›·. ∆ÚÔÔÔÈË̤ÓÔ˜ ·ÏÁfiÚÈıÌÔ˜ ·fi ÙÔ ‚È‚Ï›Ô: Practical Algorithms in Pediatric Hematology and Oncology. R.H. Stills, editor. S. Karger AG; 2003. Paediatriki 2007;70:237-245
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΢ÙÙ·Ú›Ùȉ·, Ó¢ÌÔÓ›·, ˆÙ›Ùȉ˜, Ë Û˘¯ÓfiÙËÙ· Î·È Ë ÛÔ‚·ÚfiÙËÙ¿ ÙÔ˘˜, ηıÒ˜ Î·È Ë ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›·), ·Ó·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ‹ ‰È¿ÚÚÔȘ, Ï‹„Ë Ê·ÚÌ¿ÎˆÓ ‹ ÂÌÊ¿ÓÈÛË Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î·È ÏÔÈÌÒÍÂˆÓ Û ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÂÙ·È ÛÙËÓ Èı·Ó‹ ·Ó‡ÚÂÛË ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·˜, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜, ˆ¯ÚfiÙËÙ·˜, ·ÈÌÔÚÚ·ÁÈÎÒÓ ÂΉËÏÒÛˆÓ, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‹ Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·˜. ™ËÌ·ÓÙÈÎfi Â›Ó·È Ó· ·Ó·˙ËÙÔ‡ÓÙ·È ÌË-·ÈÌ·ÙÔÏÔÁÈο ÛËÌ›· Ô˘ ηÙ¢ı‡ÓÔ˘Ó Û ÎÏËÚÔÓÔÌÈΤ˜ Ô˘‰ÂÙÂÚÔÂӛ˜. ∆¤ÙÔÈ· ÛËÌ›· Â›Ó·È ÙÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÔÈ ÔÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Ë ÌÈÎÚÔÎÂÊ·Ï›·, Ë ‰˘ÛÙÚÔÊ›· ÔÓ‡¯ˆÓ, Ë Ï¢ÎÔϷΛ·, Ô ·ÏÊÈÛÌfi˜ ‹ ÙÔ ¤Î˙ÂÌ·. ∏ ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ‚·ıÌfi Ù˘ Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌ·. ∂ÌÊ¿ÓÈÛË Ô˘‰ÂÙÂÚÔÂÓ›·˜ Î·È ÛÔ‚·ÚÒÓ ‚·ÎÙËÚÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜ ηÙ¢ı‡ÓÔ˘Ó ÙË ‰ÈÂÚ‡ÓËÛË Î˘Ú›ˆ˜ ÚÔ˜ ÙË ÓfiÛÔ Kostmann, ΢ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›· ‹ ÓÂÔÁÓÈ΋ ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·, ÂÊfiÛÔÓ ÛÙÔ Ì˘ÂÏfiÁÚ·ÌÌ· ‰ÂÓ ·Ó·Ê·›ÓÂÙ·È Î·ÎÔ‹ıÂÈ·. ãAÙ˘Â˜ Î·È ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó Û˘ÁÁÂÓ‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ‹ Ïԛ̈ÍË ·fi HIV. 3) ∏ ÂÎÙ›ÌËÛË Ù˘ ÁÂÓÈ΋˜ ·›Ì·ÙÔ˜ Î·È Ë ÌÈÎÚÔÛÎÔÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Â›Ó·È ·Ôχو˜ ··Ú·›ÙËÙ·. ∏ Û˘Ó‡·ÚÍË ·Ó·ÈÌ›·˜ ‹/Î·È ıÚÔÌ‚ÔÂÓ›·˜ ηÙ¢ı‡ÓÂÈ ÙË ‰ÈÂÚ‡ÓËÛË ÚÔ˜ Û˘ÁÎÂÎÚÈ̤Ó˜ ·Èٛ˜, ΢ڛˆ˜ ηÎÔ‹ıÂȘ Î·È ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›·. ™ÙÔ ÌÈÎÚÔÛÎfiÈÔ Ú¤ÂÈ ÔˆÛ‰‹ÔÙ ӷ Á›ÓÂÈ ·Ó·˙‹ÙËÛË ÁÈ· ‚Ï¿ÛÙ˜ (Ï¢¯·ÈÌ›·), Â̇ÚËÓ· ÂÚ˘ıÚ¿ (‰È‹ıËÛË, ·ÓÙÈηٿÛÙ·ÛË Ì˘ÂÏÔ‡), ÔÏ˘Î·Ù¿ÙÌËÙ· Ô˘‰ÂÙÂÚfiÊÈÏ· (·Ó¿ÚÎÂÈ· µ12, Ê˘ÏÏÈÎÔ‡), ·ÓÒÌ·ÏÔ˘˜ ˘Ú‹Ó˜ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (Ì˘ÂÏÔη¯ÂÍ›·), ·ÓÒÌ·Ï· ÌÂÁ¿Ï· ÎÔÎΛ· ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ· (Û‡Ó‰ÚÔÌÔ Chediak-Higashi), ÌÈÎÚÔıÚÔÌ‚ÔÂÓ›· (Û‡Ó‰ÚÔÌÔ Wiskott Aldrich) ‹ Ì·ÎÚÔ΢ÙÙ¿ÚˆÛË (·Ó·ÈÌ›· Fanconi). 4) ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· Â›Ó·È <1,0x109/L Î·È Ê·›ÓÂÙ·È fiÙÈ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÂÌÊ·Ó›ÛÙËΠÔͤˆ˜, ÙfiÙÂ Ë ‰ÈÂÚ‡ÓËÛË Ú¤ÂÈ Ó· Á›ÓÂÈ ˆ˜ ÂÍ‹˜: 5) ¶Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó Èı·Ó¿ Ê·Ú̷΢ÙÈο ·›ÙÈ·. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË Ë ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ı· Ô‰ËÁ‹ÛÂÈ Û ¿ÓÔ‰Ô ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Î·È ı· ı¤ÛÂÈ ÙË ‰È¿ÁÓˆÛË. 6) ∂¿Ó ÙÔ ·È‰› ¤¯ÂÈ ÛÔ‚·Ú‹ Â̇ÚÂÙË ÓfiÛÔ Î·È ‰Â›ÎÙ˜ Ô˘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÌÈÎÚԂȷ΋ Ïԛ̈ÍË, ÙfiÙ Èı·ÓÒ˜ Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÔÊ›ÏÂÙ·È ÛÙÔÓ ÌÈÎÚÔ‚È·Îfi ·Ú¿ÁÔÓÙ·. ∂¿Ó Ë Ô˘‰ÂÙÂÚÔÂÓ›· ‰ÂÓ ·Ôηı›ÛÙ·Ù·È Û 3-4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË Ïԛ̈ÍË, ÙfiÙ ڤÂÈ Ó· ˘ÔÏÔÁÈÛÙ› ÙÔ ÂӉ¯fiÌÂÓÔ Ó· ˘¿Ú¯ÂÈ ˘ÔΛÌÂÓË ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· Î·È Ë ·ÚÂÏıÔ‡Û· Ïԛ̈ÍË Ó· ÔÊ›ÏÂÙ·È Û ·˘Ù‹.
7) ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÙÔ ·È‰› ¤¯ÂÈ ÂÚ¿ÛÂÈ Ì›· ‹È· ÓfiÛÔ Ì ¯·Ú·ÎÙ‹Ú˜ Î·È ‰Â›ÎÙ˜ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢, ÙfiÙÂ Ë ÙÂÏÂ˘Ù·›· Â›Ó·È Ì¿ÏÏÔÓ Ë ·ÈÙ›· Ù˘ Ô˘‰ÂÙÂÚÔÂÓ›·˜. ∏ ‰È¿ÁÓˆÛË ı· ÂȂ‚·Èˆı›, Â¿Ó Û ·ӿÏË„Ë Ù˘ ÁÂÓÈ΋˜ ·›Ì·ÙÔ˜ Û 4-6 ‚‰ÔÌ¿‰Â˜ ¤¯ÂÈ ·ÔηٷÛÙ·ı› Ô ·ÚÈıÌfi˜ ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ¿ÁÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ·ÔÙ¤ÏÂÛÌ· Ë Ô˘‰ÂÙÂÚÔÂÓ›· Ó· ‰È·ÚΛ ÂÚÈÛÛfiÙÂÚÔ Î·È Ó· ¯ÚÂÈ¿˙ÂÙ·È, ÙfiÙÂ, Ó· Á›ÓÂÙ·È ÂÚÁ·ÛÙËÚȷ΋ ·Ó›¯Ó¢ÛË ÙˆÓ ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· ηıÔÚÈÛÌfi Ù˘ ‰È¿ÁÓˆÛ˘. 8) ∂¿Ó ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ¯ÚfiÓÈ·˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ‹ ÏÔÈÌÒÍÂˆÓ ‹/Î·È Ô˘‰ÂÙÂÚfiÊÈÏ· <0,5x109/L Û ÙÚÂȘ ÌÂÙÚ‹ÛÂȘ, Ë ‰ÈÂÚ‡ÓËÛË Ú¤ÂÈ Ó· Á›ÓÂÈ ˆ˜ ÂÍ‹˜: 9) ŸÙ·Ó ˘¿Ú¯ÂÈ ÂÚÈÔ‰ÈÎfiÙËÙ· ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‹ Ù˘ Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ıÂÙÈÎfi ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi Î·È ·Ó‡ÚÂÛ˘ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔ ÁÔÓ›‰ÈÔ ELA2, Ù›ıÂÙ·È Ë ‰È¿ÁÓˆÛË Ù˘ ΢ÎÏÈ΋˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜. ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ÙÔ˘ ÌÔÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘, ÙfiÙ ڤÂÈ Ó· Á›ÓÂÙ·È ·ÈÌÔÏË„›· Î·È ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ÙÚÂȘ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÁÈ· ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ÁÈ· Ó· ·Ó·‰Âȯı› Ë Î˘ÎÏÈ΋ Ô˘‰ÂÙÂÚÔÂÓ›·. 10) ∏ ÂÌÊ¿ÓÈÛË Ô˘‰ÂÙÂÚÔÂÓ›·˜ ¯ˆÚ›˜ ȉȷ›ÙÂÚ· Û˘¯Ó¤˜ ÛÔ‚·Ú¤˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ ÛÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜ ηÙ¢ı‡ÓÂÈ ÙË ‰ÈÂÚ‡ÓËÛË Î˘Ú›ˆ˜ ÚÔ˜ ÙË ÓÂÔÁÓÈ΋ ÈÛÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›·, ÂÊfiÛÔÓ ·ÓȯÓ¢ÙÔ‡Ó Î·È Ù· ÂȉÈο ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù· ÛÙÔÓ ÔÚfi Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ˘ ·È‰ÈÔ‡. ™Â ·È‰È¿ ËÏÈΛ·˜ >6 ÌËÓÒÓ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÈÛÙÔÚÈÎfi ÛÔ‚·ÚÒÓ ÏÔÈÌÒ͈Ó, Û˘Ó‹ıˆ˜ Ë ‰È¿ÁÓˆÛË Â›Ó·È ·˘ÙÔ¿ÓÔÛË Ô˘‰ÂÙÂÚÔÂÓ›· Î·È ÂÊfiÛÔÓ ·ÓȯÓ‡ÔÓÙ·È ·ÓÙÈÔ˘‰ÂÙÂÚÔÊÈÏÈο ·ÓÙÈÛÒÌ·Ù·, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ Ì˘ÂÏfiÁÚ·ÌÌ·. 11) ŸÙ·Ó ˘¿Ú¯ÂÈ Î·Î‹ ‰È·ÙÚÔÊ‹ ‹ ÛËÌ›· ‰˘Û·ÔÚÚfiÊËÛ˘ ÂÓ‰ÂÈÎÙÈο Â͈ÎÚÈÓÔ‡˜ ·ÁÎÚ·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (.¯. ÛÙ·ÙfiÚÚÔÈ·, ·Ó·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜), ÙfiÙ ڤÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ó¿ÚÎÂÈ· µ12/Ê˘ÏÏÈÎÔ‡ Î·È ‰ÈÂÚ‡ÓËÛË ÁÈ· Ù· Û‡Ó‰ÚÔÌ· Shwachman-Diamond (SDS) Î·È Pearson. 12) ™Ù· ·È‰È¿ Ì ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· Ô˘ Û˘Ó˘¿Ú¯Ô˘Ó Ê·ÈÓÔÙ˘ÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ ηډÈÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ó·ÈÌ›· Fanconi, Û˘ÁÁÂÓ‹ ‰˘ÛÎÂÚ¿ÙˆÛË, Û‡Ó‰ÚÔÌÔ Chediak-Higashi, ÁÏ˘ÎÔÁÔÓ›·ÛË Ù‡Ô˘ 1b Î·È Û‡Ó‰ÚÔÌÔ Barth, ·ÓÙ›ÛÙÔȯ·. 13) ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Û˘¯Ó¤˜ Î·È ÛÔ‚·Ú¤˜ ¿Ù˘Â˜ ÏÔÈÌÒÍÂȘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏϘ ‰È·Ù·Ú·¯¤˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‰ÈÂÚ‡ÓËÛË ÁÈ· Û˘ÁÁÂÓ›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ ‹ Ïԛ̈ÍË ·fi HIV. ¶·È‰È·ÙÚÈ΋ 2007;70:237-245
Pediatri May-Jun 07
24-05-07
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14) ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È ·ÓËÛ˘¯ËÙÈο ÛËÌ›· ÛÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË (.¯. ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·), fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ·Ó·ÈÌ›· ‹ ıÚÔÌ‚ÔÂÓ›· ‹ fiÙ·Ó ·Ó¢ڛÛÎÔÓÙ·È ‚Ï¿ÛÙ˜ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, ηıÒ˜ ›Û˘ fiÙ·Ó Ë ·Ú¯È΋ ‰ÈÂÚ‡ÓËÛË ‰ÂÓ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ·ÈÙ›· Î·È ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ÛÔ‚·ÚÒÓ ÏÔÈÌÒ͈Ó, Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì˘ÂÏfiÁÚ·ÌÌ·, ‚ÈÔ„›· ÔÛÙÔ‡ Î·È ·ÓÔÛÔÊ·ÈÓÔÙ˘ÈÎfi˜ Î·È Î˘ÙÙ·ÚÔÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜. ∏ ·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ Ì˘ÂÏÔ‡ ·fi ηÎÔ‹ıË Î‡ÙÙ·Ú· (Ï¢¯·ÈÌ›·, ϤÌʈ̷, ÌÂÙ·ÛÙ·ÙÈÎÔ› Û˘Ì·Á›˜ fiÁÎÔÈ) ÚÔηÏ› Û˘Ó‹ıˆ˜ ·Ó΢ÙÙ·ÚÔÂÓ›·, ·Ú¿ ÌÂÌÔӈ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›·. ™Â ÂÚ›ÙˆÛË ÓfiÛÔ˘ Kostmann ı· Ê·Ó› ·Ó·ÛÙÔÏ‹ ÛÙË Ê¿ÛË ÙÔ˘ ÚÔÌ˘ÂÏÔ΢ÙÙ¿ÚÔ˘/Ì˘ÂÏÔ΢ÙÙ¿ÚÔ˘. ∏ ÂÈÎfiÓ· ‰˘ÛÏ·Û›·˜ ÙÔ˘ Ì˘ÂÏÔ‡ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÓÒÌ·Ï· ΢ÙÙ·ÚÔÁÂÓÂÙÈο Â˘Ú‹Ì·Ù· Ô‰ËÁ› ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (MDS). ∏ ‚ÈÔ„›· ÔÛÙÔ‡ ‚ÔËı¿ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ·Ï·ÛÙÈ΋˜ ·Ó·ÈÌ›·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ·ÚÔ͢ÛÌÈ΋˜ Ó˘¯ÙÂÚÈÓ‹˜ ·ÈÌÔÛÊ·ÈÚÈÓÔ˘Ú›·˜ (PNH) Ù›ıÂÙ·È Ì ÙËÓ Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜.
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35. Levine DH, Madyastha PR. Isoimmune neonatal neutropenia. Am J Perinatol 1986;3:231-233. 36. Bussel JB, Abboud MR. Autoimmune neutropenia of childhood. Crit Rev Oncol Hematol 1987;7:37-51. 37. Bux J, Behrens G, Jaeger G, Welte K. Diagnosis and clinical course of autoimmune neutropenia in infancy: analysis of 240 cases. Blood 1998;91:181-186. 38. Ancliff PJ. Congenital neutropenia. Blood Rev 2003;17: 209-216. 39. Starkebaum G. Chronic neutropenia associated with autoimmune disease. Semin Hematol 2002;39:121-127.
“¶fiÏË Ù˘ º·ÓÙ·Û›·˜” Markovic Predrag, 14 ¯ÚÔÓÒÓ, ™ÂÚ‚›· & ª·˘ÚÔ‚Ô‡ÓÈÔ ¶·È‰› Ì ÌÂÚÈ΋ fiÚ·ÛË “∆· Ù˘ÊÏ¿ ·È‰È¿ ˙ˆÁÚ·Ê›˙Ô˘Ó”, ÕÓÓ· §·Ô˘Ù¿ÚË°ÎÚÈÙ˙¿Ï·, ∞ı‹Ó· 2006
“City of Fantasy”, Markovic Predrag, 14 years old, Serbia & Montenegro Partially blind child “Blind children paint”, Anna Laoutari-Gritzala, Athens 2006
¶·È‰È·ÙÚÈ΋ 2007;70:237-245
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∞ÁfiÚÈ ËÏÈΛ·˜ 13 ÂÙÒÓ ·Ú·¤ÌÂÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÏfiÁˆ ·ÓÒ‰˘Ó˘, ˘fiÛÎÏËÚ˘ ‰ÈfiÁΈÛ˘ ÏÂÌÊ·‰¤ÓˆÓ Ì ÂÓÙfiÈÛË ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ‰ÂÍÈ¿˜ ·ÚÂÈ¿˜ Î·È ÛÙÔÓ Û‡ÛÙÔÈ¯Ô ˘ÔÁÓ¿ıÈÔ ¯ÒÚÔ, ‰È·ÛÙ¿ÛÂˆÓ 5x6 cm ·fi 5Ë̤ÚÔ˘. √ ·ÛıÂÓ‹˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó ·‡ÚÂÙÔ˜, ·Ó¤ÊÂÚÂ Ì˘·ÏÁ›Â˜, ηٷ‚ÔÏ‹ Î·È ·ÓÔÚÂÍ›· ·fi 10Ë̤ÚÔ˘, ÂÓÒ ·fi 5Ë̤ÚÔ˘ ›¯Â Ï¿‚ÂÈ ·ÁˆÁ‹ Ì ·ÌÔ͢ÎÈÏÏ›ÓË/ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ¯ˆÚ›˜ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË. ∆· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ·ÈÌ·ÙÔÏÔÁÈÎÔ‡ Î·È ‚ÈÔ¯ËÌÈÎÔ‡ ÂϤÁ¯Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÔÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ Î·È Ë Mantoux ·ÚÓËÙÈÎÔ›. ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠ̠˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È CT Ù˘ ÂÚÈÔ¯‹˜ ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ¢ÌÂÁ¤ıÔ˘˜ ÏÂÌÊ·‰¤Ó· ‰È·ÛÙ¿ÛÂˆÓ 4,8x2,5x2,8 cm ˘ÔÁÓ¿ıÈ· ‰ÂÍÈ¿, Ì ÈÂÛÙÈο Ê·ÈÓfiÌÂÓ· ÛÙȘ ÁÂÈÙÔÓÈΤ˜ ‰Ô̤˜, ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ÌÈÎÚfiÙÂÚˆÓ ÏÂÌÊ·‰¤ÓˆÓ ÛÙÔ Ô›ÛıÈÔ ÙÚ›ÁˆÓÔ, ¿¯˘ÓÛË ÙÔ˘ ‰ÂÍÈÔ‡ Ï¿ÁÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ Ê¿Ú˘ÁÁ· Ì ÚÔ‚ÔÏ‹ ‚Ï¿‚˘ Ì·Ï·ÎÔ‡ ÈÛÙÔ‡ Î·È ÏÂÌÊÈ΋ ÛÙ¿ÛË Û‡ÛÙÔȯ·. √ ·ÛıÂÓ‹˜ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ Ù¤ıËΠ۠·ÁˆÁ‹ Ì ·ÌÔ͢ÎÈÏÏ›ÓË/ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇ Î·È ÙÂ˚ÎÔÏ·Ó›ÓË. ∆Ô ¤ÎÙÔ 24ˆÚÔ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ·ÚÔ˘Û›·Û ˘„ËÏfi ˘ÚÂÙfi ˆ˜ 40ÔC Ô˘ Û˘Óԉ‡ıËΠ·fi Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ηٿÛÙ·Û˘ Ì ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ÂÌÊ¿ÓÈÛË ÂÙ¯ÂÈÒ‰Ô˘˜ ÂÍ·Óı‹Ì·ÙÔ˜, Ì˘·ÏÁ›Â˜, ηٷ‚ÔÏ‹ Î·È Â̤ÙÔ˘˜. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠÌË ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ÏÂÌÊ·‰ÂÓÈ΋˜ Ì¿˙·˜ Î·È ·fi ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ï¢ÎÔÂÓ›· (WBC:
1200/mm3) Î·È ıÚÔÌ‚ÔÂÓ›· (PLT: 22000/mm3), ÂÓÒ ÔÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ ‹Ù·Ó ÂÎ Ó¤Ô˘ ·ÚÓËÙÈÎÔ›. √È Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Ô˘ ÂÏ‹ÊıËÛ·Ó ‹Ù·Ó ·ÚÓËÙÈΤ˜. §fiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ˘ÚÂÙÔ‡, ÙÔ˘ ÂÙ¯ÂÈÒ‰Ô˘˜ ÂÍ·Óı‹Ì·ÙÔ˜ Î·È Ù˘ ÌË ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ·Ú¯È΋ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂڷ›· Ô ·ÛıÂÓ‹˜ Ù¤ıËΠ۠·ÁˆÁ‹ Ì ÈÌÈÂÓ¤ÌË/ÛÈÏ·ÛÙ·Ù›ÓË, ·ÌÈηۛÓË Î·È ‚·ÓÎÔÌ˘Î›ÓË. ∆· ·ÓÙÈÛÒÌ·Ù· ÛÙÔÓ ÔÚfi ÁÈ· Toxoplasma, Bartonella henselae, Mycoplasma, Coxsackie B1-5, Salmonella, Shigella, Û‡ÊÈÏË, ÏÂ˚ÛÌ¿ÓÈ· ‹Ù·Ó ·ÚÓËÙÈο, ÂÓÒ Û fi,ÙÈ ·ÊÔÚ¿ ÛÙ· ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ CMV Î·È EBV ‰È·ÈÛÙÒıËΠ·ÓÔÛ›·. √ ·ÛıÂÓ‹˜ ˘Ô‚Ï‹ıËΠÛÂ Ì˘ÂÏfiÁÚ·ÌÌ· Î·È ÔÛÙÂÔÌ˘ÂÏÈ΋ ‚ÈÔ„›·, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÔ›ˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ ·Ú¿ÏÏËÏ·, o ¤ÏÂÁ¯Ô˜ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ¤‰ÂÈÍÂ: ANA+ (1/80), p-ANCA+ (6,31 U/ml) Î·È ‰ÈÂÓÂÚÁ‹ıËΠ·Ê·›ÚÂÛË Ù˘ ÏÂÌÊ·‰ÂÓÈ΋˜ ‰ÈfiÁΈÛ˘, Ë ÔÔ›· ÙÂÎÌËÚ›ˆÛ ÙË ‰È¿ÁÓˆÛË Ï›Á˜ Ë̤Ú˜ ·ÚÁfiÙÂÚ·. ªÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË Ù˘ Ì¿˙·˜, ¤ÁÈÓ ‰È·ÎÔ‹ Ù˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜ Î·È ‰‡Ô 24ˆÚ· ·ÚÁfiÙÂÚ·, Ô ·ÛıÂÓ‹˜ ·˘Ú¤ÙËÛÂ.
¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ: 1. NfiÛÔ˜ Kawasaki 2. §Ô›ÌˆÍË ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· 3. ¡fiÛÔ˜ Kikuchi-Fujimoto 4. ¡fiÛÔ˜ ·fi ·Ì˘¯‹ Á·Ï‹˜ 5. ƒ·‚‰ÔÌ˘ÔÛ¿ÚΈ̷
∏ ·¿ÓÙËÛË ·ÎÔÏÔ˘ı› ÛÙË ÛÂÏ›‰· 252 Paediatriki 2007;70:246,252
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∏ ηχÙÂÚË ‚ÈÔ˚·ÙÚÈ΋ ÌÂϤÙË Ù˘ ¯ÚÔÓÈ¿˜ ∆Ô 2006 ‹Ù·Ó ÌÈ· ηϋ ÂÚ¢ÓËÙÈ΋ ¯ÚÔÓÈ¿: ÂÚ›Ô˘ 700.000 ¿ÚıÚ· ηٷ¯ˆÚ‹ıËÎ·Ó ÛÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ PubMed. ∏ ‰ÈÂıÓ‹˜ ÂΉÔÙÈ΋ ÔÌ¿‰· ÙÔ˘ Lancet, ÙËÚÒÓÙ·˜ ·Ú¿‰ÔÛË ÂÙÒÓ, ͯÒÚÈÛ 23 ÂÍ ·˘ÙÒÓ Î·È Ù· ÚfiÙÂÈÓ ÛÙÔ˘˜ 13 ÂΉfiÙ˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ªÂÙ¿ ·fi Û˘˙‹ÙËÛË, ÔÈ ÂΉfiÙ˜ ¤ÏÂÍ·Ó (Lancet 2007;369:91) ˆ˜ ηχÙÂÚË ‚ÈÔ˚·ÙÚÈ΋ ÌÂϤÙË ÙÔ˘ 2006 ‰‡Ô Û˘Ó¯fiÌÂÓ· ¿ÚıÚ· ÛÙÔ New England Journal of Medicine (2006;354:11 Î·È 354:23) Ô˘ ·ÊÔÚÔ‡Û·Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ ÙÔ˘ ÈÔ‡ ÚfiÙ· (rotavirus). √È ÌÂϤÙ˜ ›¯·Ó ‰È·Í·¯ı› ·fi ÙȘ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÔÌ¿‰Â˜ ÙˆÓ Gulielmo Ruiz-Palacios (™·ÓÙÈ¿ÁÔ, ÃÈÏ‹) Î·È Timo Vesikari (∆¿ÌÂÚÂ, ºÈÓÏ·Ó‰›·). ∆Ô “·ÚÁ˘Úfi ÌÂÙ¿ÏÏÈÔ” ·ÔÓÂÌ‹ıËΠ›Û˘ Û ÌÂϤÙË ÁÈ· ÂÌ‚fiÏÈÔ, ÂΛÓÔ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚÒÈÓˆÓ ıËÏˆÌ¿ÙˆÓ HPV (Diane Harper, Darmouth/¡∏, ∏¶∞, Lancet 2006;367:1247). ÕÏϘ ÌÂϤÙ˜ Ô˘ ‰È·ÎÚ›ıËÎ·Ó ·ÊÔÚÔ‡Û·Ó ÙËÓ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÔÛÒÔ˘ (Lancet 2006;368:203) Î·È ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÂÁÎÂÊ¿ÏˆÓ ÙÔ˘ ·ÓıÚÒÔ˘ Î·È ÙÔ˘ ¯ÈÌ·ÓÙ˙‹ (Nature 2006;443:167). ∆· ηϿ ÙÔ˘ ıËÏ·ÛÌÔ‡ ∆· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ıËÏ·ÛÌÔ‡ Â›Ó·È ·ÛÈÊ·Ó‹ ÎÈ Â›Ó·È ·ÔÚ›·˜ ¿ÍÈÔ Ò˜ ÊÙ¿Û·Ì ÛÙÔ ÛËÌÂ›Ô Ù· ̈ڿ Ô˘ ıËÏ¿˙Ô˘Ó Ó· ·ÔÙÂÏÔ‡Ó ÂÍ·›ÚÂÛË. √ ıËÏ·ÛÌfi˜ ÚÔÛٷهÂÈ, ÌÂٷ͇ ¿ÏψÓ, ·fi ÏÔÈÌÒÍÂȘ Î·È ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi ÂȂ‚·ÈÒÓÂÈ ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ Ô˘ Û˘ÌÂÚȤϷ‚ 15.890 ˘ÁÈ‹ ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (Pediatrics 2007;119:e837). ∆· ‚Ú¤ÊË Ô˘ ıËÏ¿˙Ô˘Ó ÓÔÛËχÔÓÙ·È ÁÈ· ÏÈÁfiÙÂÚÔ ¯ÚfiÓÔ ÁÈ· ‰È¿ÚÚÔÈ· Î·È ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ÀÔÏÔÁ›ÛÙËΠfiÙÈ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ı· Ì›ˆÓ ÙÔÓ ¯ÚfiÓÔ ÓÔÛËÏ›·˜ ÁÈ· ‰È¿ÚÚÔÈ· ηٿ 53% Î·È ÁÈ· Ïԛ̈ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ηٿ 27% ÛÙÔ˘˜ ÚÒÙÔ˘˜ 8 Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ÙÔ˘ ·ÙfiÌÔ˘. ∆· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ÁÈ· ÙÔ ÌÂÚÈÎfi ıËÏ·ÛÌfi ı· ‹Ù·Ó 31% Î·È 25%. ∏ ¶·ÁÎfiÛÌÈ· √ÚÁ¿ÓˆÛË ÀÁ›·˜ ¤¯ÂÈ ÚÔ ÔÏÏÔ‡ Û˘ÛÙ‹ÛÂÈ ·ÔÎÏÂÈÛÙÈÎfi ıËÏ·-
AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
ÛÌfi ¤ˆ˜ ÙÔ˘˜ 6 Ì‹Ó˜ ÁÈ· ÙÔ 100% ÙˆÓ ‚ÚÂÊÒÓ. ™ÙËÓ ∫Ú‹ÙË ÌfiÓÔ 10% ÙˆÓ ‚ÚÂÊÒÓ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο ÛÙÔ˘˜ 6 Ì‹Ó˜ Î·È ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (J Pediatr Gastroenterol Nutr 2006;43:379 Î·È ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 2006;18:347) ÂȂ‚·ÈÒÓÔ˘Ó ¯·ÌËÏ¿ ÔÛÔÛÙ¿ Î·È ÛÙËÓ ∞ı‹Ó· (12%) Î·È ÙË µÔÚÂÈÔ‰˘ÙÈ΋ ∂ÏÏ¿‰· (9%).
ÃÚÂÈ¿˙ÂÙ·È Â·Ó¿ÏË„Ë Ù˘ ηÏÏȤÚÁÂÈ·˜ Ô‡ÚˆÓ ÛÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ù˘ Ô˘ÚÔÏԛ̈͢; ™Â 328 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ô˘ ÓÔÛËχıËÎ·Ó ÁÈ· Ô˘ÚÔÏԛ̈ÍË Û ÓÔÛÔÎÔÌÂ›Ô Ù˘ ¡¤·˜ ÀfiÚ΢ ¤ÁÈÓ ·ӿÏË„Ë Ù˘ ηÏÏȤÚÁÂÈ·˜ Ô‡ÚˆÓ ‰‡Ô Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÌÂÈÚÈ΋˜ ·ÓÙÈ‚›ˆÛ˘ (Pediatrics 2007;119:e325). ªfiÓÔ Û ¤Ó· ·È‰› (0,3%, 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ 0%-1,7%) ‰ÂÓ Â›¯·Ó ·ÔÛÙÂÈÚˆı› Ù· Ô‡Ú·. ∂ÚfiÎÂÈÙÔ ÁÈ· ‚Ú¤ÊÔ˜ 7 ÌËÓÒÓ Ô˘ ›¯Â ÂÈÛ·¯ı› ÁÈ· Ô˘ÚÔÏԛ̈ÍË Î·È ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ›¯Â Ï¿‚ÂÈ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË (ÏfiÁˆ ·ÏÏÂÚÁ›·˜ ÛÙËÓ ·ÌÔ͢ÎÈÏÏ›ÓË) Î·È ÛÙËÓ Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ ·Ó¤Ù˘Í Escherichia coli ·ÓıÂÎÙÈÎfi ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË. ∆Ô Â‡ÏÔÁÔ Û˘Ì¤Ú·ÛÌ·-ÂÚÒÙËÌ· Ù˘ ÌÂϤÙ˘ Â›Ó·È ·Ó ·Í›˙ÂÈ Ë ÂÈÌÔÓ‹ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ ˘fi ·ÓÙÈ‚›ˆÛË. ∏ ·ÓÙÔ¯‹ ÙˆÓ Ô˘ÚÔ·ıÔÁfiÓˆÓ, Û˘ÓÂÒ˜ Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÂÌÂÈÚÈ΋˜ ·ÁˆÁ‹˜, ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ· - ¿Ú·Á fiÛÔ Û˘¯Ó¿ ‚Ï¤Ô˘Ì ÛÙËÓ ∂ÏÏ¿‰· ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ Ô‡ÚˆÓ 2 ‹ 3 24ˆÚ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜;
øÙ›Ùȉ˜ Î·È ÛˆÏËÓ¿ÎÈ· ∏ ¯Ú‹ÛË ÛˆÏËÓ›ÛÎˆÓ ·ÂÚÈÛÌÔ‡ ÁÈ· ÙË ¯ÚfiÓÈ· ˆÙ›Ùȉ· ÛÙËÚ›¯ıËΠ۠·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ÙˆÓ ‰ÂηÂÙÈÒÓ 1950-1970 Ô˘ ›¯·Ó Û˘Û¯ÂÙ›ÛÂÈ ÙË ¯ÚfiÓÈ· Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ Ì ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË. ∆· ÛˆÏËÓ¿ÎÈ· ¤ÁÈÓ·Ó ÁÚ‹ÁÔÚ· ‰ËÌÔÊÈÏ‹ Î·È ¤ÊÙ·Û·Ó Ó· Â›Ó·È Ë ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ÛÙȘ ∏¶∞ (ÌÂÙ¿ ÙËÓ ÂÚÈÙÔÌ‹). ∏ ÚÔÛ¤ÁÁÈÛË ·˘Ù‹ ÎÚ›ÓÂÙ·È ÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ Ì¿ÏÏÔÓ ÂÈıÂÙÈ΋. ™ÙÔ Pittsburg ÙˆÓ ∏¶∞ Ë ÔÌ¿‰· ÙÔ˘ John Paradise, ÁÓˆÛÙ‹ ÁÈ· ¶·È‰È·ÙÚÈ΋ 2007;70:247-248
Pediatri May-Jun 07
248
24-05-07
17:58
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PAEDIATRIC NEWS IN BRIEF ÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜ Î·È ÊÙˆ¯¤˜ ¯ÒÚ˜. øÛÙfiÛÔ, Ë ÓÔÛËÚfiÙËÙ· ‰ÂÓ Â›Ó·È ·ÌÂÏËÙ¤· Î·È ÛÙȘ ÈÔ ÏÔ‡ÛȘ ¯ÒÚ˜, Ì ÂÍ¿ÚÛÂȘ Û ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜ Î·È ÈÛ›Ó˜ Î·È Ì ÙÔÈΤ˜ ÂȉË̛˜, fiˆ˜ ·˘Ù‹ ÛÙÔ Galway. ∆Ô ÎÚ˘ÙÔÛÔÚ›‰ÈÔ ÌÂÙ·‰›‰ÂÙ·È Î˘Ú›ˆ˜ ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ (Û˘Ó‹ıˆ˜ ̤ۈ Ï˘Ì¿ÙˆÓ Ô˘ ηٷϋÁÔ˘Ó ÛÙÔ ‰›ÎÙ˘Ô ‡‰Ú¢Û˘, fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙÔ Galway Û‡Ìʈӷ Ì ٷ ‰È·ı¤ÛÈÌ· ÛÙÔȯ›·) Î·È ·ÓÙ¤¯ÂÈ Â› Ì·ÎÚfiÓ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ Î·È ÛÙË ¯ÏˆÚ›ˆÛË.
ÙËÓ ¤ÚÂ˘Ó¿ Ù˘ Û¯ÂÙÈο Ì ÙË Ì¤ÛË ˆÙ›Ùȉ·, ·Ú·ÎÔÏÔ‡ıËÛ 6.350 ÓÂÔÁÓ¿ ·fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990. ™Â 429 ‚ÚÂÊÔÓ‹È· Ì ¯ÚfiÓÈ· ·ÚÔ˘Û›· ˘ÁÚÔ‡ ÛÙÔ Ì¤ÛÔ Ô˘˜, ÙÔÔıÂÙ‹ıËηÓ, ÌÂ Ù˘¯·›· ηٷÓÔÌ‹, ÛˆÏËÓ¿ÎÈ· ·Ì¤Ûˆ˜ ‹ ÌÂÙ¿ ·fi 9 Ì‹Ó˜ (·Ó ¤ÌÂÓÂ Ë Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡). 391 ·È‰È¿ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· 9-11 ¤ÙË (·ÍÈÔı·‡Ì·ÛÙË ÂÈÙ˘¯›· ÁÈ· Ù¤ÙÔȘ ÌÂϤÙ˜). ∞ÔÙÂϤÛÌ·Ù·: Ù· ÛˆÏËÓ¿ÎÈ· ‰ÂÓ ‚ÂÏÙÈÒÓÔ˘Ó ·Ó·Ù˘ÍȷΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, fiˆ˜ Ë ÔÌÈÏ›·, Ë ÁÏÒÛÛ·, Ë ÁÓˆÛÙÈ΋ Î·È Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ÂͤÏÈÍË (N Engl J Med 2007;356:248). ™‡Ìʈӷ Ì Ùo Û˘Óԉ¢ÙÈÎfi Û¯fiÏÈÔ ·fi ÙË Û‡ÓÙ·ÍË (N Engl J Med 2007;356:300), Ù· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÛËÌ·ÙÔ‰ÔÙÔ‡Ó ÙÔ Ù¤ÏÔ˜ Ù˘ ÂÈıÂÙÈ΋˜ ¯Ú‹Û˘ ÛˆÏËÓ›ÛÎˆÓ ·ÂÚÈÛÌÔ‡, ¿Ô„Ë Ô˘ Û˘ÌÌÂÚ›˙ÔÓÙ·È Î·È ÔÈ ÂΉfiÙ˜ ÙÔ˘ Pediatric Infections Disease Journal (Newsletter ∞ÚÈÏ›Ô˘ 2007). √È ·ÏȤ˜ Ô‰ËÁ›Â˜ ‹ıÂÏ·Ó ÛˆÏËÓ¿ÎÈ· ÌÂÙ¿ ·fi 3 Ì‹Ó˜ ÂÈÌÔÓ‹˜ ÙÔ˘ ˘ÁÚÔ‡, ÙÒÚ· fï˜ ÔÈ ∞ÌÂÚÈηÓÈΤ˜ ∂Ù·ÈÚ›˜ ¶·È‰È·ÙÚÈ΋˜, √ÈÎÔÁÂÓÂȷ΋˜ π·ÙÚÈ΋˜ Î·È øÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁ›·˜ Ù· Û˘ÓÈÛÙÔ‡Ó ÌfiÓÔ Û ÂÚ›ÙˆÛË ÛÔ‚·Ú‹˜ ·ÎÔ˘ÛÙÈ΋˜ ¤ÎÙˆÛ˘ (40 decibels ÙÔ˘Ï¿¯ÈÛÙÔÓ), ηı˘ÛÙ¤ÚËÛ˘ ÏfiÁÔ˘ ‹ ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ. ∂ÎÙfi˜ ·fi ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ·ÌÊÈÛ‚ËÙÂ›Ù·È Î·È Ë ·ÛÊ¿ÏÂÈ¿ ÙÔ˘˜: ÛÙÔ Ù‡¯Ô˜ ª·˝Ô˘ 2007 ÙÔ˘ European Journal of Pediatrics (2007;166:385), ·Ó·ÛÎfiËÛË ·fi ÂÏÏËÓÈ΋ ÔÌ¿‰· ·Ó·‰ÂÈÎÓ‡ÂÈ Ï‹ıÔ˜ ÂÈÏÔÎÒÓ Ù˘ ÙÔÔı¤ÙËÛ˘ ÛˆÏËÓ›ÛÎˆÓ ·ÂÚÈÛÌÔ‡, ·fi ˘Ò‰Ë ˆÙfiÚÚÔÈ· (1026%) ¤ˆ˜ Ô˘Ï¤˜ Î·È ÎÔÎÎÈÒÌ·Ù·. ∏ ÔÏÈ΋ Û˘¯ÓfiÙËÙ· ÂÈÏÔÎÒÓ ÌÔÚ› Ó· ÊÙ¿ÛÂÈ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 80% ÙˆÓ ¯ÂÈÚÔ˘ÚÁËÌ¤ÓˆÓ ·˘ÙÈÒÓ.
¶ÔÈÔ˜ ÌÂÙ·‰›‰ÂÈ ÙÔÓ ÎÔηÙË ÛÙ· ‚Ú¤ÊË; √È ÁÔÓ›˜ (55%), Ù· ·‰¤ÏÊÈ· (16%), ı›ÔÈ-ı›˜ Î·È ·Ô‡‰Â˜-ÁÈ·ÁÈ¿‰Â˜ (16%), ¿ÏÏÔÈ Û˘ÁÁÂÓ›˜ Î·È Ê›ÏÔÈ (10%), ¿ÏÏÔÈ ÁÂÓÈÎÒ˜ 3%. ∆· ·ÔÙÂϤÛÌ·Ù· ÚÔ¤Ú¯ÔÓÙ·È ·fi ·ÌÂÚÈηÓÔ-Á·ÏÏÔ-ηӷ‰È΋ ÌÂϤÙË Û ‚Ú¤ÊË ËÏÈΛ·˜ οو ÙˆÓ 6 ÌËÓÒÓ Ô˘ ‰ËÌÔÛȇıËΠÛÙÔ Ù‡¯Ô˜ ∞ÚÈÏ›Ô˘ ÙÔ˘ Pediatric Infections Disease Journal (2007;26:293). ŸÛÔ ‰ÂÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÔÈ ¤ÊË‚ÔÈ Î·È ÔÈ ÂÓ‹ÏÈΘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÙfiÛÔ Ù· ‚Ú¤ÊË ı· ÎÈÓ‰˘ÓÂ‡Ô˘Ó ·fi ÎÔηÙË. ™ÙÔ ›‰ÈÔ Ù‡¯Ô˜ (PIDJ 2007;26:316), ÊÈÓÏ·Ó‰È΋ ÌÂϤÙË Î·Ù·Ï‹ÁÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ 8% ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ÓÔÛËχÔÓÙ·È Ì ÂȂ‚·ÈˆÌ¤ÓË Ïԛ̈ÍË ·fi Èfi ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÁÎ˘Ù›Ô˘ (RSV) ¿Û¯Ô˘Ó Î·È ·fi ÎÔηÙË. ∞Ï‹ıÂÈ·, ÎÔÎ·Ù˘ fiˆ˜ ÙÔÓ Í¤Ú·Ì ‹ ÎÔΛÙ˘ fiˆ˜ ÂÈ̤ÓÔ˘Ó ÔÈ ·˘ÙfiÌ·ÙÔÈ ÔÚıÔÁÚ¿ÊÔÈ ÛÙȘ ÔıfiÓ˜ Ì·˜; ∫Ôη˙ˆ ÛËÌ·›ÓÂÈ (·fi ÙÔÓ Î·ÈÚfi ÙÔ˘ ∏Û›Ô‰Ô˘ ÙÔ˘Ï¿¯ÈÛÙÔÓ) ÎÚ¿˙ˆ (ÁÈ· ÎÔ‡ÎÔ˘˜, ÎfiڷΘ Î·È ÂÙÂÈÓÔ‡˜). ∆Ô ÎÔÎ·Ù˘ ·Ú·¤ÌÂÈ ÛÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÎÔÎÎÔÚfi‚˯·, ÂÓÒ ÙÔ ÎÔΛÙ˘ ·Ú·¤ÌÂÈ ÛÙËÓ ÔÚıÔÁÚ·ÊÈ΋ Ì·˜ ¿ÓÂÛË.
∫Ú˘ÙÔÛÔÚ›‰ÈÔ ÛÙÔ ‰›ÎÙ˘Ô ‡‰Ú¢Û˘ ªÂ›˙ÔÓ Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ Ì ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ÚÔÂÎÙ¿ÛÂȘ ÚԤ΢„ ÛÙÔ Galway Ù˘ πÚÏ·Ó‰›·˜ (BBC News, 29 ª·ÚÙ›Ô˘ Î·È 6 ∞ÚÈÏ›Ô˘ 2007) fiÙ·Ó ÙÔ ‰›ÎÙ˘Ô ‡‰Ú¢Û˘ ÌÔχÓıËΠ·fi ÙÔ ÚˆÙfi˙ˆÔ Cryptosporidium parvum ÛÂ Û˘ÁÎÂÓÙÚÒÛÂȘ ÂÍËÎÔÓÙ·Ï¿ÛȘ ÙÔ˘ ÔÚ›Ô˘ ·ÛÊ·Ï›·˜. ∆· ·È‰È¿ ‹Ù·Ó ÌÂٷ͇ ÙˆÓ ÈÔ Â˘¿ÏˆÙˆÓ ÔÌ¿‰ˆÓ. ∆Ô Galway Â›Ó·È Ë ÙÚ›ÙË Û ̤ÁÂıÔ˜ fiÏË Ù˘ πÚÏ·Ó‰›·˜ Ì 700.000 ÂÚ›Ô˘ ηÙÔ›ÎÔ˘˜. ∆Ô Úfi‚ÏËÌ· ˘ÔÏÔÁ›˙ÂÙ·È Ó· ‰È·ÚΤÛÂÈ Ì‹Ó˜ Î·È ·Ó·Ì¤ÓÂÙ·È Ó· ¤¯ÂÈ ÂÈÙÒÛÂȘ ÛÙËÓ ÙÔ˘ÚÈÛÙÈ΋ ÂÚ›Ô‰Ô - ‹‰Ë Ù· ÍÂÓԉԯ›· ÂÁηıÈÛÙÔ‡Ó Î·Ù¿ÏÏËÏ· Ê›ÏÙÚ·. ™ÙÔ˘˜ ηÙÔ›ÎÔ˘˜ Û˘ÛÙ‹ıËΠӷ ·ÔʇÁÔ˘Ó ÙÔ ÓÂÚfi ÙÔ˘ ‰ÈÎÙ‡Ô˘ ÁÈ· fiÛË, χÛÈÌÔ ÙÚÔʛ̈Ó, χÛÈÌÔ ‰ÔÓÙÈÒÓ Î·È ·Á¿ÎÈ·. ∫·ıÒ˜ Ì¿ÏÈÛÙ· Ë ÌfiÏ˘ÓÛË Û˘Ó¤ÂÛ Ì ÙÔ ¶¿Û¯·, fiÙ·Ó ÔÈ Î·ıÔÏÈÎÔ› Ù˘ ÂÚÈÔ¯‹˜ Ú·›ÓÔÓÙ·È Ì ·ÁÈ·ÛÌfi (Î·È ÂÓ›ÔÙ ÙÔÓ ›ÓÔ˘Ó), Ë ÙÔÈ΋ ∂ÎÎÏËÛ›· ÊÚfiÓÙÈÛ ӷ ÂÍ·ÛÊ·Ï›ÛÂÈ ÁÈ· ÙÔÓ ·ÁÈ·ÛÌfi ¯ÈÏÈ¿‰Â˜ ÊȿϘ ÓÂÚÔ‡ ηÙ¢ı›·Ó ·fi ËÁ¤˜. Œ¯Ô˘ÌÂ Û˘Ó‰¤ÛÂÈ ÙÔ ÎÚ˘ÙÔÛÔÚ›‰ÈÔ Ì ÏÔÈÌÒ-
º˘Ì·Ù›ˆÛË: ÂÌ›˜ ı· ı¤Ï·Ì ӷ ÙËÓ Í¯¿ÛÔ˘ÌÂ, ·ÏÏ¿ ÂΛÓË fi¯È ∏ ÚfiÛÊ·ÙË ·ÁÎfiÛÌÈ· ·Ó·˙ˆ‡ÚˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ·fi ÙÔ M. tuberculosis Ì¿˜ ‚Ú‹Î οˆ˜ ·ÚÔÂÙԛ̷ÛÙÔ˘˜. ∞fi ÙËÓ ¿ÏÏË, Ë Ê˘Ì·Ù›ˆÛË ·fi M. bovis, Ë ÔÔ›· ÂÌÊ·ÓÈ˙fiÙ·Ó ·ÚÎÂÙ¿ Û˘¯Ó¿ ÚÈÓ Î¿ÔȘ ‰ÂηÂٛ˜, ›¯Â ۯ‰fiÓ ÂÍ·ÏÂÈÊı› ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ·ÛÙÂÚ›ˆÛ˘ ÙÔ˘ ·ÁÂÏ·‰ÈÓÔ‡ Á¿Ï·ÎÙÔ˜. øÛÙfiÛÔ, Î·È ÙÔ M. bovis ͤÚÂÈ Ó· ·ÈÊÓȉȿ˙ÂÈ: ÛÙÔ Lancet ÙÔ˘ ∞ÚÈÏ›Ô˘ 2007 (369:1270) ÂÚÈÁÚ¿ÊÂÙ·È Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ M. bovis ÛÙËÓ ∞ÁÁÏ›· Û 6 Ó¤Ô˘˜ ÂÓ‹ÏÈΘ- ÔÈ 5 ‹Ù·Ó ÂÌ‚ÔÏÈ·Ṳ̂ÓÔÈ Ì BCG Î·È Ô ¤Ó·˜ η٤ÏËÍ ÌÂ Ê˘Ì·ÙÈÒ‰Ë ÌËÓÈÁÁ›Ùȉ·. ª¤Ûˆ ÌÔÚȷ΋˜ ÂȉËÌÈÔÏÔÁ›·˜ ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ ÌÂÙ·‰fiıËΠ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ Î·È Ì¿ÏÈÛÙ· ·fi Û˘Á¯ÚˆÙÈÛÌfi Û ̷Ú. •¤Ú·Ì fiÙÈ ÙÔ M. bovis ÌÂÙ·‰›‰ÂÙ·È Ì¤Ûˆ ÙÔ˘ ··ÛÙÂÚ›ˆÙÔ˘ ‚fiÂÈÔ˘ Á¿Ï·ÎÙÔ˜ Î·È fi¯È ÛÙ· ÔÙԈϛ·, ·ÏÏ¿ Ë Ê˘Ì·Ù›ˆÛË ÎÚ‡‚ÂÈ ÂÎÏ‹ÍÂȘ, Î·È fiˆ˜ ˘ÔÁÚ·ÌÌ›˙ÂÙ·È ÛÙÔ Û¯fiÏÈÔ Ù˘ Û‡ÓÙ·Í˘ (Lancet;2007;369:1236), ÙË Ê˘Ì·Ù›ˆÛË ·fi M. bovis ÙËÓ Í¯¿Û·ÌÂ, ·ÏÏ¿ ÂΛÓË ·Ú·Ì¤ÓÂÈ.
Paediatriki 2007;70:247-248
Pediatri May-Jun 07
24-05-07
17:58
™ÂÏ›‰·249
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ª·Ú›· ∫·Ó¿ÚÈÔ˘ πÛÙÔÛÂÏ›‰Â˜ ÁÈ· ÙȘ ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ √È ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ (¶∞∞) Â›Ó·È ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù· Î·È Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ·Ô˘Û›·˜ ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ì›·˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·ÓÔÛÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ∏ Û˘ÓËı¤ÛÙÂÚË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ, ÛÙȘ Ôԛ˜ ÔÈ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›·. øÛÙfiÛÔ, ‰ÂÓ Â›Ó·È Û¿ÓȘ ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÔÈ ¶∞∞ ÚÔ‚¿ÏÏÔ˘Ó ˆ˜ ·˘ÙÔ¿ÓÔÛ· ‹ ·ÏÏÂÚÁÈο ÓÔÛ‹Ì·Ù· ‹ ÏÂÌÊÔ¸ÂÚϷۛ˜. ¶ÔÏϤ˜ ÊÔÚ¤˜ Ë ·Ó¿ÚÎÂÈ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ó·ÁÓˆÚÈÛÙ› Î·È ·Ú·Ì¤ÓÂÈ ·‰È¿ÁÓˆÛÙË, ÌÂ Û˘Ó¤ÂÈ· ÔÈ ·ÛıÂÓ›˜ Ó· ÌË ÁÓˆÚ›˙Ô˘Ó ÙËÓ ·ÈÙ›· ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ÙÔ˘˜ ÂΉËÏÒÛˆÓ, ηÈ, fi¯È Û¿ÓÈ·, Ó· Ï·Ì‚¿ÓÔ˘Ó Ï·Óı·Ṳ̂ÓË ıÂڷ›· Î·È ÊÚÔÓÙ›‰·. ∏ ¿Ù˘Ë ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ì·ÎÚfi¯ÚÔÓË Ù·Ï·ÈˆÚ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÓÔÛËÏ›˜ Î·È Èı·ÓÒ˜, Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘.
∆Ì‹Ì· ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· ∫·Ó¿ÚÈÔ˘ mkanariou@hol.gr
∂˘Úˆ·˚Τ˜ ™˘ÛÙ¿ÛÂȘ ÁÈ· ÙȘ ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ ÛÙÔ ¢È·‰›ÎÙ˘Ô http://www.eupidconference.com √È ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ Â›Ó·È Ôχ Û˘¯ÓfiÙÂÚ˜ ·’ fiÛÔ Î·Ù·ÁÚ¿ÊÂÙ·È. ∏ ÌË ·Ó·ÁÓˆÚÈÛÈÌfiÙËÙ¿ ÙÔ˘˜, ÙÔ ·ÚÓËÙÈÎfi ÎfiÛÙÔ˜, Ë ÌÂÁ¿ÏË Â›ÙˆÛË ÛÙË ‰ËÌfiÛÈ· ˘Á›·, ηıÈÛÙÔ‡Ó ·Ó·Áη›· ÙËÓ ÂÊ·ÚÌÔÁ‹ Û˘ÛÙ¿ÛÂˆÓ ÁÈ· ÙȘ ÂÓ¤ÚÁÂȘ Ô˘ ··ÈÙÔ‡ÓÙ·È ÂΠ̤ÚÔ˘˜ ÙˆÓ ÂıÓÈÎÒÓ Î˘‚ÂÚÓ‹ÛÂˆÓ ÙˆÓ ¯ˆÚÒÓ ÌÂÏÒÓ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘, ÒÛÙ ӷ ·Ú¯›ÛÂÈ Ë ‰È·‰Èηۛ· ·Ó·ÁÓÒÚÈÛ˘ ·˘ÙÔ‡ ÙÔ˘ “ÎÚ˘ÊÔ‡” ı¤Ì·ÙÔ˜ ‰ËÌfiÛÈ·˜ ˘Á›·˜. √ÏÔÎÏËڈ̤Ó˜ Î·È Û·Ê›˜ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙȘ ¶∞∞, ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, ÙËÓ ÚfiÁÓˆÛË Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂڷ›· ÚÔÛʤÚÂÈ Ë ÈÛÙÔÛÂÏ›‰· ·fi ÙÔ ∂˘Úˆ·˚Îfi Consensus Conference 2006.
∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ÁÈ· ÙȘ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ - http://www.esid.org ∏ ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ÁÈ· ÙȘ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ (ESID) ÛÙԯ‡ÂÈ ÛÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ ·ÓÙ·ÏÏ·Á‹˜ ȉÂÒÓ Î·È ÏËÚÔÊÔÚÈÒÓ ·Ó¿ÌÂÛ· Û ȷÙÚÔ‡˜, ÓÔÛËÏÂ˘Ù¤˜, ÂÚ¢ÓËÙ¤˜, ·ÛıÂÓ›˜ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ô˘ ÂӉȷʤÚÔÓÙ·È ‹ ÂËÚ¿˙ÔÓÙ·È ·fi ÙȘ ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ. ∂ÓÈÛ¯‡ÂÈ ÙËÓ ¤Ú¢ӷ ÁÈ· ÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ ·ÈÙÈÔ·ıÔÁÂÓÂÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ÙËÓ ÚÔÒıËÛË ıÂÚ·ÂÈÒÓ ÁÈ· Ù· Û˘ÁÎÂÎÚÈ̤ӷ ÓÔÛ‹Ì·Ù·. ∏ ÈÛÙÔÛÂÏ›‰· Ù˘ ∂Ù·ÈÚ›·˜ ·Ú¤¯ÂÈ, ÌÂٷ͇ ¿ÏψÓ, ÏËÚÔÊÔڛ˜ ÁÈ· Ù· ÂÈÛÙËÌÔÓÈο ‰ÚÒÌÂÓ·, Ù· ÛÙ·ÙÈÛÙÈο ÛÙÔȯ›·, Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, ÙȘ ÂÈÛÙËÌÔÓÈΤ˜ ÂÍÂÏ›ÍÂȘ Î·È Ù· Ó¤· ıÂڷ¢ÙÈο ̤۷, Û ·˘ÙfiÓ ÙÔÓ Û˘Ó¯Ҙ ÂÍÂÏÈÛÛfiÌÂÓÔ ÙÔ̤· Ù˘ µ·ÛÈ΋˜ Î·È ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜.
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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ International Nursing Group for Immunodeficiencies - http://www.ingid.org πÛÙÔÛÂÏ›‰· Ù˘ ¢ÈÂıÓÔ‡˜ √Ì¿‰·˜ ¡ÔÛËÏ¢ÙÒÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Ì ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ì ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ. ∞Ó·Ù‡ÛÛÔ˘Ó Î·È ÂÂÎÙ›ÓÔ˘Ó ÙËÓ ÔÈfiÙËÙ· Ù˘ ÊÚÔÓÙ›‰·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ¶∞∞ Î·È ÂȉÈÒÎÔ˘Ó ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙˆÓ È‰È·ÈÙÂÚÔÙ‹ÙˆÓ ÙˆÓ ·Û¯fiÓÙˆÓ ·fi ·˘Ù¿. Ÿ¯È ÌfiÓÔ ÔÈ ÓÔÛËÏÂ˘Ù¤˜ Ô˘ ÂӉȷʤÚÔÓÙ·È ÁÈ· ÙȘ ¶∞∞, ·ÏÏ¿ Î·È ÂΛÓÔÈ Ô˘ ÂÚÁ¿˙ÔÓÙ·È ÁÂÓÈÎfiÙÂÚ· Ì ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜, ı· ‚ÚÔ˘Ó ÛÙËÓ ÈÛÙÔÛÂÏ›‰· ÔÏϤ˜ Î·È ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ÙˆÓ ˘ËÚÂÛÈÒÓ ÙÔ˘˜.
International Patient Organisation for Primary Immunodeficiencies http://www.ipopi.org ªÈ· ·ÁÎfiÛÌÈ· ÔÚÁ¿ÓˆÛË Ô˘ ÂÚÁ¿˙ÂÙ·È ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂȤ‰Ô˘ ˙ˆ‹˜ ÙˆÓ ·ÓıÚÒˆÓ Ì ¶∞∞, ÂȯÂÈÚ› Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ÙËÓ È‰·ÓÈÎfiÙÂÚË ıÂڷ›· Î·È ÊÚÔÓÙ›‰· ÙˆÓ ·ÛıÂÓÒÓ. ¶·Ú¿ÏÏËÏ·, ÂÓÈÛ¯‡ÂÈ ÙȘ ÂıÓÈΤ˜ ÔÚÁ·ÓÒÛÂȘ ÙˆÓ ·Û¯fiÓÙˆÓ Ó· ÛÙËÓ ÚÔÛ¿ıÂÈ¿ ÙÔ˘˜ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÓfi˜ ηχÙÂÚÔ˘ ÎfiÛÌÔ˘ ÁÈ· ÙÔ˘˜ ·ÓıÚÒÔ˘˜ Ì ¶∞∞.
Immune Deficiency Foundation - http://www.primaryimmune.org ªÈ· ÈÛÙÔÛÂÏ›‰· Ì ÔÏϷϤ˜ ÏËÚÔÊÔڛ˜ Î·È ÁÈ· Ù· È·ÙÚÈο, ÂÈÛÙËÌÔÓÈο-ÂÚ¢ÓËÙÈο, ÎÔÈÓˆÓÈο ı¤Ì·Ù· Ô˘ ··Û¯ÔÏÔ‡Ó ÙfiÛÔ ÙÔ˘˜ ÂÚÁ·˙fiÌÂÓÔ˘˜ ‹ ÙÔ˘˜ ¤¯ÔÓÙ˜ ÂӉȷʤÚÔÓ ÛÙÔÓ ÙÔ̤· ÙˆÓ ¶∞∞, fiÛÔ Î·È ÙÔ˘˜ ›‰ÈÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜. ™ËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ ·ÔÙÂÏ› Ë ‰ËÌÔÛ›Â˘ÛË ÙˆÓ Ô‰ËÁÈÒÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ ¶∞∞ Î·È ÙË ÊÚÔÓÙ›‰· ÙˆÓ ·ÛıÂÓÒÓ.
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Institute of Medical Technology - Bioinformatics Group - http://bioinf.uta.fi ñ Immunodeficiency Resource ñ ID diagnostics ñ ID bases √È ÈÛÙÔÛÂÏ›‰Â˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ÙÔ˘ Tampere Ù˘ ºÈÓÏ·Ó‰›·˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚¿ÛÂȘ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ÛÙÔ¯Â‡Ô˘Ó ÛÙË Û˘ÏÏÔÁ‹, ÙËÓ Ù·˘ÙÔÔ›ËÛË, ÙËÓ ÂÚÈÁÚ·Ê‹ Î·È ÙË ÁÓˆÛÙÔÔ›ËÛË ÙˆÓ ˘ËÚÂÛÈÒÓ Ô˘ ÚÔÛʤÚÔÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ ·ÓÔÛÔ·Ó·ÚÎÂÈÒÓ.
The Jeffrey Modell Foundation - http://www.jmfworld.com πÛÙÔÛÂÏ›‰· Ô˘ ÔÚÁ·ÓÒıËÎÂ Î·È ÛÙËÚ›˙ÂÙ·È ·fi ÎÏËÚÔ‰fiÙËÌ· ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘ Jeffrey Modell, ·ÊÈÂڈ̤ÓÔ ÛÙË ÌÓ‹ÌË ÙÔ˘. ™ÎÔfi ¤¯ÂÈ Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È Ó· ÂÍ·ÛÊ·Ï›ÛÂÈ ÚfiÛ‚·Û‹ ÙÔ˘˜ ÛÙ· ÂȉÈο ΤÓÙÚ· ÁÈ· ÙȘ ¶∞∞ Î·È ÛÙȘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚ˜ Û‡Á¯ÚÔÓ˜ ıÂڷ›˜. ¶ÚÔˆı› ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Ô˘ ı· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙˆÓ ¶∞∞ Î·È ÛÙËÓ Â›Ù¢ÍË ·ÚÔ¯‹˜ ˘ËÚÂÛÈÒÓ ˘„ËÏ‹˜ ÔÈfiÙËÙ·˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜.
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CLINICAL QUIZ
∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏
¡fiÛÔ˜ Kikuchi-Fujimoto ∏ ÓfiÛÔ˜ Kikuchi-Fujimoto ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1972 ÛÙËÓ π·ˆÓ›· ·fi ÙÔ˘˜ Kikuchi Î·È Fujimoto Î·È ÚÔÛ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ·, ¿ÙÔÌ· Ó·ڋ˜ ËÏÈΛ·˜ (̤ÛË ËÏÈΛ· 30 ¤ÙË). ∂›Ó·È Û˘¯ÓfiÙÂÚË ÛÙȘ Á˘Ó·›Î˜ Î·È ÛÙÔ˘˜ ∞ÛÈ¿Ù˜, ÂÓÒ ·Ó·Ê¤ÚÂÙ·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· (1). ¶ÚfiÎÂÈÙ·È ÁÈ· ·˘ÙÔ˚¿ÛÈÌË, ηÏÔ‹ıË ÓfiÛÔ ¿ÁÓˆÛÙ˘ ̤¯ÚÈ Û‹ÌÂÚ· ·ÈÙÈÔÏÔÁ›·˜, ‰È¿ÚÎÂÈ·˜ ·fi 2 ‚‰ÔÌ¿‰Â˜ ˆ˜ 4 Ì‹Ó˜. ∏ ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ÎÏÈÓÈο ·fi ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ (‰È¿ÚÎÂÈ·˜ 1 ‚‰ÔÌ¿‰·˜-1 Ì‹Ó·) Î·È ÙË ‰ÈfiÁΈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (‰È·Ì¤ÙÚÔ˘ 1-2 cm, ˘fiÛÎÏËÚˆÓ, ¢ΛÓËÙˆÓ ÌÂ Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË ÛÙÔÓ ÙÚ¿¯ËÏÔ). ø˜ Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù· ·Ó·Ê¤ÚÔÓÙ·È Ù· ·ÎfiÏÔ˘ı·: Ó·˘Ù›·, ¤ÌÂÙÔÈ, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ·ÚıÚ·ÏÁ›Â˜, Ì˘·ÏÁ›Â˜, Ó˘¯ÙÂÚÈÓÔ› ȉÚÒÙ˜ Î·È ÛÙÔÌ·ÙÈο ¤ÏÎË (1,2). ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒÓÂÙ·È Û˘Ó‹ıˆ˜ Ï¢ÎÔÂÓ›·, ıÚÔÌ‚ÔÂÓ›·, ·Á΢ÙÙ·ÚÔÂÓ›· Î·È Ì¤ÙÚÈ· ·‡ÍËÛË Ù˘ ∆∫∂ (1). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÙÂÎÌËÚÈÒÓÂÙ·È ·fi Ù· ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù· Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÂÚÈÔ¯ÒÓ Ó¤ÎÚˆÛ˘ fiÔ˘ ·Ó¢ڛÛÎÔÓÙ·È Û˘¯ÓfiÙÂÚ· ˈÛÈÓfiÊÈÏ·, ÌÂ Û˘ÓÔ‰fi Ï‹ÚË ·Ô˘Û›· ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ Î·È ·ıÚÔ›ÛÌ·Ù· (clusters) ÌÔÓÔ΢ÙÙ¿ÚˆÓ, ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î˘Ú›ˆ˜ ∆-ÚÔ¤Ï¢Û˘ (1). ∏ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË Ì¤¯ÚÈ Û‹ÌÂÚ·, ÂÓÒ ¤¯ÂÈ ÚÔÙ·ı› Ë ‰È¤ÁÂÚÛË ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ˆ˜ ·¿ÓÙËÛË Û ›‰Ú·ÛË ÏÔÈÌÒ‰Ô˘˜ ·Ú¿ÁÔÓÙ·. ∫·Ù¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ë ÓfiÛÔ˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙÔÓ Û˘ÛÙËÌ·ÙÈÎfi ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ (™∂§)
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Î·È ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÓfiÛÔ˜ Kikuchi-Fujimoto Â›Ó·È Èı·ÓfiÓ Ó· ·ÔÙÂÏ› ¤Ó·Ó Ù‡Ô ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓÔ˘ ™∂§ (3,4). À¤Ú Ù˘ Û˘Û¯¤ÙÈÛ˘ ÙˆÓ ‰‡Ô ÓÔÛËÌ¿ÙˆÓ Î·È ÙÔ˘ ·˘ÙÔ¿ÓÔÛÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ Ù˘ ÓfiÛÔ˘ Û˘ÓËÁÔÚ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÚÎÂÙÔ› ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ıÂÙÈο ·˘ÙÔ·ÓÙÈÛÒÌ·Ù·, ηıÒ˜ Î·È Ë ·Ú·Ù‹ÚËÛË fiÙÈ ÔÚÈṲ̂ÓÔÈ ÂΉËÏÒÓÔ˘Ó ™∂§ ·ÎfiÌË Î·È 10 ˆ˜ 20 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Kikuchi-Fujimoto (1,3). ∆¤ÏÔ˜, Û‡Ìʈӷ Ì ÚfiÛÊ·ÙË ÌÂÙ·Ó¿Ï˘ÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ıÂÙÈο ANA ÂÌÊ¿ÓÈ˙ ÙÔ 15% Î·È ™∂§ ÂΉ‹ÏˆÛ ÙÔ 23% ∞ÛÈ·ÙÒÓ Ì ÓfiÛÔ Kikuchi-Fujimoto (5).
µÈ‚ÏÈÔÁÚ·Ê›· 1. Lazzareschi I, Barone G, Ruggiero A, Liotti L, Maurizi P, Larocca LM, et al. Paediatric Kikuchi-Fujimoto disease: A benign cause of fever and lymphadenopathy. Pediatr Blood Cancer 2006 [Epub ahead of print]. 2. Scagni P, Peisino MG, Bianchi M, Morello M, Sardi N, Linari A, et al. Kikuchi-Fujimoto disease is a rare cause of lymphadenopathy and fever of unknown origin in children: report of two cases and review of the literature. J Pediatr Hematol Oncol 2005;27:337-340. 3. Rao GS, Vohra D, Kuruvilla M. Is Kikuchi-Fujimoto disease a manifestation of systemic lupus erythematosus? Int J Dermatol 2006;45:454-456. 4. Hedia G, Jamel A, Maher A, Hanadi A, Agnes H, Nidhameddine K. Kikuchi-Fujimoto disease associated with systemic lupus erythematosus. J Clin Rheumatol 2005;11:341-342. 5. Kucukardali Y, Solmazgul E, Kunter E, Oncul O, Yildirim S, Kaplan M. Kikuchi-Fujimoto Disease: analysis of 244 cases. Clin Rheumatol 2007;26:50-54.
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8-10 πÔ˘Ó›Ô˘ 2007
5Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¶·È‰Ô„˘¯È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ∂ÏÏ¿‰Ô˜ ª¤Á·ÚÔ ªÔ˘ÛÈ΋˜ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: AC&C International ∆ËÏ.: 210 68 89 100 Fax: 210 68 44 777 E-mail: hscaconinfo@acnc.gr Website: www.hscapcongress2007.com
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24-28 πÔ˘Ó›Ô˘ 2007
5th World Congress on Pediatric Critical Care Geneva Palexpo Website: www.pcc2007.com
Geneva, Switzerland
27-30 πÔ˘Ó›Ô˘ 2007
46th European Society for Pediatric Endocrinology Meeting Contact: Pauline Bertrand, ESPE Secretariat, BioScientifica, Euro House, 22 Apex Court. Woodlands, Bristol, BS32 4JT, UK Tel.: 44-0-01-454-642-208 Fax: 44-0-1-454-642-222 Website: www.espe2007.org
Helsinki, Finland
29 πÔ˘Ó›Ô˘-3 πÔ˘Ï›Ô˘ 2007
GA2LEN Allergy Summer School 2007 Pantheon Palace ¢ÈÔÚÁ¿ÓˆÛË: ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì· µ’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂπÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: Everest travel, Î. ¢Ú·ÎÔÔ‡ÏÔ˘ ∆ËÏ.: 210 3249242 Website: www.allergy.gr
ÃÂÚÛfiÓËÛÔ˜, ∫Ú‹ÙË
5-7 πÔ˘Ï›Ô˘ 2007
17th Annual Meeting of the European Childhood Obesity Group (ECOG) Athenaeum Intercontinental ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress S.A 15, Mesogion Avenue. 115 26 Athens, Greece ∆ËÏ.: 210 7499 372 / 304 / 300 Fax: 210 7713 795 E-mail: congress@triaenatours.gr Website: www.ecog2007.gr
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25-30 ∞˘ÁÔ‡ÛÙÔ˘ 2007
25th International Congress of Pediatrics ª¤Á·ÚÔ ªÔ˘ÛÈ΋˜ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: ∞C&C International Tel.: 210 68 89 100 Fax: 210 68 44 777 E-mail: icp2007@acnc.gr Website: www.icp2007.gr
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31 ∞˘ÁÔ‡ÛÙÔ˘ 4 ™ÂÙÂÌ‚Ú›Ô˘ 2007
14th Congress of the International Pediatric Nephrology Association Blaguss Congress Bureau Tel.: +36 1 374 7030, Fax: +36 1 312 1582 E-mail: info@blaguss-congress.hu Website: www.blaguss-congress.hu
µÔ˘‰·¤ÛÙË, √˘ÁÁ·Ú›·
Pediatri May-Jun 07
24-05-07
17:58
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5-6 ™ÂÙÂÌ‚Ú›Ô˘ 2007
3rd International Multi-disciplinary symposium on Congenital Malformations in Fetus and Child Contact: Dr Liana Beni-Adani Tel.: 972-524-262-057 Fax: 972-36-973-451 E-mail: lianabenia@gmail.com
Jerusalem, Israel
9-13 ™ÂÙÂÌ‚Ú›Ô˘ 2007
8th World Congress of Perinatal Medicine Contact: MCA Events - Roberto Caflisch Tel.: 39-0-234-934-404 Fax: 39-0-234-934-397 E-mail: caflisch@mcaevents.org
Florence, Italy
14-16 ™ÂÙÂÌ‚Ú›Ô˘ 2007
European Society for Paediatric Haematology & Immunology 2007 Athens Hilton ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress S.A 15, Mesogion Avenue, 115 26 Athens, Greece ∆ËÏ.: 210 74 99 372 / 304 / 300 Fax: 210 77 13 795 E-mail: congress@triaenatours.gr Website: www.esphi2007-athens.gr
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13-14 ™ÂÙÂÌ‚Ú›Ô˘ 2007
European Society for Social Pediatrics and Child Health Annual Meeting Contact: Dr. Stella Tsitoura Dept of Social Pediatrics Aglaia Kyriakou Children's Hospital 18, Mesogeion Avenue Athens, Greece E-mail: socmed@otenet.gr Website: www.essop.org
Trieste, Italy
17-20 ™ÂÙÂÌ‚Ú›Ô˘ 2007
II World Congress of the World Federation of Associations of Pediatric Surgeons, WOFAPS General Secretariat: Uniline Exhibitions S.A. Av. Cfirdoba 632, 11th floor (C1054AAS) E-mail: pedsurg2007@uniline.com.ar Website: www.pedsurg2007.org.ar
Buenos Aires, Argentina
21 - 23 ™ÂÙÂÌ‚Ú›Ô˘ 2007
™ÂÌÈÓ¿ÚÈÔ ∂ÍÂȉÈÎÂ˘Ì¤Ó˘ ÀÔÛÙ‹ÚÈ͢ Ù˘ ∑ˆ‹˜ ÛÙ· ¶·È‰È¿ (APLS) ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ ¶ÏËÚÔÊÔڛ˜: ª.∂.£.¶. ¶·.°.¡.∏. ∆ËÏ.: 2810 392447 Fax: 2810 392652 ∂-mail: julietaperezg@hotmail.com
∏Ú¿ÎÏÂÈÔ, ∫Ú‹Ù˘
21-23 ™ÂÙÂÌ‚Ú›Ô˘ 2007
2Ë ∂ÈÛÙËÌÔÓÈ΋ ™˘Ó¿ÓÙËÛË ∂ÏÏËÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ Aldemar Olympian Village Resort ¶ÏËÚÔÊÔڛ˜: FIRSTEVENT ∆ËÏ.: 210 8228950 Fax: 210 8228901 E-mail: info@firstevent.gr
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