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∞¡∞™∫O¶∏™∂π™ 350 Diagnosis and management of obstructive uropathy in infants A. M. Becker, M. Baum 361 ¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘ °. ¶·Ú‰·Ïfi˜ 370 ÕÙ˘Ë-·ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki: ¯ÚÂÈ·˙fiÌ·ÛÙ Ӥ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·; °. °ÚËÁÔÚÈ¿‰Ô˘ 374 ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi π. ¶·˘ÏÔÔ‡ÏÔ˘ 379 ∏ ‹È· Î·È Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ ª. £·ÓÔÔ‡ÏÔ˘. °. ∆ÛfiÏ·˜ µƒ∞µ∂Àª∂¡∂™ ∂ƒ°∞™π∂™
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
408 ¶·È‰È΋, Á˘Ó·ÈÎÔÏÔÁÈ΋ Î·È „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ì ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ ∂. ¢ÂÏËÁÂÒÚÔÁÏÔ˘, ∞. ¢ÂÏË‚ÂÏÈÒÙÔ˘, µ. §¿ÁÁ·ÚË, ¶. ∆̷ۛÚ˘, π. ∆ÛÈ¿ÓÙ˘, °. ∫Ú·ÙÛ¿˜ 413 Rare manifestations of coeliac disease – Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu
389 ªÂϤÙË ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405g/c VEGF Î·È ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ·È‰È¿ Ì ÓfiÛÔ Kawasaki §. ºÈ‰¿ÓË, ∞. °È·ÓÓfiÔ˘ÏÔ˜, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, °. ∆˙Ô˘‚ÂϤ΢, ∫. ∫·ÏÈÓ‰¤ÚË, ∞. ∫ÒÙÛ˘, π. ∫·‚·ÏÈÒÙ˘, º. ∞ı·Ó·ÛÈ¿‰Ô˘ ∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 395 ∂ȉËÌÈÔÏÔÁ›· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿ ÛÙËÓ ∂ÏÏ¿‰·: ªÂϤÙË Rotascore π. ∫·‚·ÏÈÒÙ˘, µ. ¶··Â˘·ÁÁ¤ÏÔ˘, ∂. ∫fiÎÎÔÚË, §. ª·ÓÙ·ÁÔ‡, °. ∆Ú›Ì˘, ∞. ∫ÔÓÙÔ‡, Ã. ª·ÛÈÔ‡ÚË, ¡. ¡ÈÎÔÏ·ÎÔÔ‡ÏÔ˘, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜, √Ì¿‰· ªÂϤÙ˘ ROTASCORE ∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ 402 º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ (·ʈÛË Pott) Û ÓËȷ΋ ËÏÈΛ· ¢. Ã. ∫·Û›ÌÔ˜, ¢. §·˙ÔÔ‡ÏÔ˘, Õ. ∆Û·ÏΛ‰Ë˜, ¢. µÂÚ¤ÙÙ·˜, Ÿ. §ÂˆÓ›‰Ô˘, ∞. √ÈÎÔÓfiÌÔ˘, ¡. §·˙ÔÔ‡ÏÔ˘, ª. £ÂÔ‰ˆÚ›‰Ô˘, ∞. ÷Ù˙ËÌȯ·‹Ï
¶ƒ∞∫∆π∫√ £∂ª∞ 416 ∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ º. ∫˘Ú‚·Û›Ï˘, ¡. ¶··‰fiÔ˘ÏÔ˜, π. ∆۷ӿη˜, º. ∫·Ó·ÎÔ‡‰Ë 420 ∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏ ∫. ™ÙÂÊ·Ó›‰Ë˜ 421 ∫§π¡π∫√ ∫√Àπ∑ ∞. ∑¤ÏÏÔ˘ 422 ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ - ¡fiÛÔ˜ Kawasaki Î·È ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ - ªËÓÈÁÁ›Ùȉ˜ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ· - ∏ ·ÓÂÚ¯fiÌÂÓË Kingella kingae - ∆· ÂÌ‚fiÏÈ· οÓÔ˘Ó Î·Ïfi Î·È ÛÙÔ˘˜ ÁÔÓ›˜ - ∏ ÂÔ¯‹ ÌÂÙ¿ ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ - ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÌÈ· ‰fiÛË ‰ÂÓ ÊÙ¿ÓÂÈ - º˘Ì·Ù›ˆÛË: ÓÂfiÙÂÚ· ÛÙË ‰È¿ÁÓˆÛË - ÃÂψӛÙÛ˜ Î·È ™·ÏÌÔÓ¤ÏϘ - ¶·Ú¤· Ì ˙Ò· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· - ∂ÎÊÔ‚ÈÛÌfi˜ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÌÂÙ¤ÂÈÙ·
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∂. °·Ï·Ó¿Î˘ 424 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ πÛÙÔÛÂÏ›‰Â˜ ÁÈ· Ù· ÊıÈÓÔˆÚÈÓ¿ ÎÚ˘ÔÏÔÁ‹Ì·Ù· ¡. ¶··‰fiÔ˘ÏÔ˜
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Paediatriki Bimonthly Publication of the Greek Paediatric Society
Volume 70 ñ Number 5 ñ September-October 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 A. Vasilopoulou English Editing S. Nakou
345 Classical and rare presentations of coeliac disease D. Branski, E. Lebenthal, E. Shteyer
402 Tuberculous spondylitis (Pott’s kyphosis) in a toddler D.H. Kasimos, D. Lazopoulou, A. Tsalkidis, D. Verettas, O. Leonidou, A. Oikonomou, N. Lazopoulou, M. Theodoridou, A. Hatzimihail
347 Rotavirus infection. How serious is it? I.T. Kavaliotis
CASE REPORTS
REVIEW ARTICLES 350 Diagnosis and management of obstructive uropathy in infants A. M. Becker, M. Baum 361 Kawasaki disease: Clinical heterogeneity and strategic management G. Pardalos
408 Paediatric gynaecological and psychological evaluation of a girl with a foreign body in the vagina: a case report E. Deligeoroglou, A. Deliveliotou, V. Laggari, P. Tsimaris, I. Tsiantis, G. Creatsas 413 Rare manifestations of coeliac disease – Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu
370 Atypical Kawasaki disease: criteria G. Grigoriadou
PRACTICAL ISSUE
374 Current concepts in prevention of rotavirus gastroenteritis I. D. Pavlopoulou
416 Influenza vaccination in children with asthma F. Kyrvassilis, N. Papadopoulos, I. Tsanakas, F. Kanakoudi
379 Mild-to-moderate hyperhomocysteinaemia as a risk factor for atherosclerosis and thromboembolic disease M. Thanopoulou, G. Tsolas
420 LETTER FROM THE EDITORS C. Stefanidis
Publisher K. Griveas
AWARD-WINNING ARTICLES
Publishing Coordinator
389 Study of VEGF 405VG C polymorphism and of relevant clinical and laboratory data in children with Kawasaki disease L. Fidani, A. Giannopoulos, A. Tragianidis, G. Tzouvelekis, K. Kalinderi, A. Kotsis, I. Kavaliotis, F. Athanassiadou
SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822
ORIGINAL ARTICLES 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
395 ROTASCORE Study: Epidemiological observational study of rotavirus acute gastroenteritis in children in Greece I. Kavaliotis, V. Papaevangelou, H. Kokori, L. Mantagou, G. Trimis, A. Kontou, C. Basiouri, N. Nikolakopoulou, A. Konstantopoulos, ROTASCORE Study Group
421 CLINICAL QUIZ A. Zellou 422 PAEDIATRIC NEWS IN BRIEF E. Galanakis 424 NEWS FROM THE INTERNET N. Papadopoulos
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™À¡∆∞∫∆π∫∏ E¶π∆ƒ√¶∏
EDITORIAL BOARD
¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
Editor-in-Chief
∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ∞ı‹Ó·
Constantinos Stefanidis, Athens
∂ȉÈÎÔ› ™˘ÓÙ¿ÎÙ˜
Section Editors
™Ù¤ÏÏ· ∞Ó‰ÚfiÓÈÎÔ˘, ¡ÂÔÁÓÔÏÔÁ›·, πˆ¿ÓÓÈÓ·
Stella Andronikou, Neonatology, Ioannina
¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, MÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, £ÂÛÛ·ÏÔÓ›ÎË
Persefoni Avgoustides-Savvopoulou, Metabolic Disorders, Thessaloniki
∞Ó‰ÚÈ·Ó‹ µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë, ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·, ∞ı‹Ó·
Andriani Vazaiou-Gerasimidi, Endocrinology, Athens
°ÂÒÚÁÈÔ˜ µ·ÚÏ¿Ì˘, ∫·Ú‰ÈÔÏÔÁ›·, £ÂÛÛ·ÏÔÓ›ÎË
George Varlamis, Cardiology, Thessaloniki
∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, ∏ıÈ΋ Î·È ¢ÂÔÓÙÔÏÔÁ›·, ∏Ú¿ÎÏÂÈÔ
Emmanouil Galanakis, Ethics and Deontology, Heraklion
§ˆÚ¤ÙÙ· £ˆÌ·˚‰Ô˘, ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, ∞ı‹Ó·
Loretta Thomaidou, Developmental Pediatrics, Athens
ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ÓÔÛÔÏÔÁ›·, ∞ı‹Ó·
Maria Kanariou, Immunology, Athens
∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ¡Â˘ÚÔÏÔÁ›·, ∞ı‹Ó·
Eustathia Katsarou-Pektasides, Neurology, Athens
∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·, ∞ı‹Ó·
Antonis Kattamis, Haematology - √ncology, Athens
™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË, °ÂÓÂÙÈ΋, ∞ı‹Ó·
Sophia Kitsiou-Tzeli, Genetics, Athens
∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ¢È·ÙÚÔÊ‹, ∞ı‹Ó·
Alexandra Papadopoulou, Gastroenterology - Nutrition, Athens
¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏÔÁ›· ¶Ó¢ÌÔÓÔÏÔÁ›·, ∞ı‹Ó·
Nicos Papadopoulos, Allergology - Pneumonology, Athens
∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, ƒÂ˘Ì·ÙÔÏÔÁ›·, πˆ¿ÓÓÈÓ·
Antigoni Siamopoulou-Mavridou, Rheumatology, Ioannina
ª·Ú›˙· ∆ÛÔÏÈ¿, §ÔÈ̈ÍÈÔÏÔÁ›·, ∞ı‹Ó·
Marisa Tsolia, Infectious Diseases, Athens
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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EDITORIAL COMMENTARY
∞ƒ£ƒ√ ™À¡∆∞•∏™
345
Classical and rare presentations of coeliac disease D. Branski, E. Lebenthal, E. Shteyer Coeliac disease (CD) is an autoimmune systemic disorder occurring in genetically susceptible subjects following exposure to gluten in the diet. It is a common disease, occurring in approximately 1% of the population of many geographical areas including Europe, USA, Northern Africa and the Middle East (1). The diagnosis of CD is based on the clinical presentation, the laboratory studies, mainly serological, the characteristic small bowel mucosal histopathology findings and the clinical response to a strict gluten-free diet (GFD). Although the small bowel biopsy is the “gold standard” for the ultimate diagnosis of CD, other disorders such as infections, infestations, food protein hypersensitivities, etc., may share the same histopathologic morphology of the small intestinal mucosa (1).
Classical presentations In recent decades the clinical presentation of CD has been changing, and the increased incidence of its diagnosis has become markedly apparent. In the past, most of the clinical features of CD presented early in life. The typical early presentations of CD included diarrhoea, steatorrhoea, malabsorption, failure to thrive and growth retardation. Some patients, mainly toddlers, manifested psychomotor delay, whereas adolescents showed delayed sexual development. Anorexia, apathy and irritability were common. Vomiting or constipation could be presenting symptoms; pseudo obstruction-like syndrome and intussusceptions were also, but less frequently, reported. However, recently, the bulk of new cases of CD are no longer identified from the classical presentation, but instead, many new subjects are being diagnosed as suffering from CD through screening programmes, monosymptomatic presentation, extraintestinal manifestations, symptoms related to the outcome of malabsorption and “atypical forms”. A current study (2) on CD revealed that only 36% of patients presented with diarrhoea, while 26% were diagnosed by targeted screening, and 16% had non-specific recurrent abdominal pain. Furthermore, it is apparent that most children with CD remain undiagnosed.
Coeliac crisis, as presented in the paper of Ugras and colleagues in this volume (3), is nowadays a very rare occurrence during the clinical course of CD. It is a common final pathway of severe malabsorption, and consequently severe malnutrition of major nutrients including carbohydrates, proteins and lipids, electrolytes, minerals, trace elements and vitamins. Hence, the patient may suffer from a combination of several important nutritional deficiencies, the most striking of which are hypoglycaemia, hypokalaemia, hypocalcaemia and hypomagnesaemia. Ascites due to hypoalbuminaemia, related to protein losing enteropathy accompanied by protein malabsorption is very significant in coeliac crisis. This is a life threatening situation and immediate supportive treatment can be life saving. In the past, CD patients were seldom observed with the very serious and ominous presentation of coeliac crisis. Very infrequently the admission of a patient with coeliac crisis constituted the presenting feature of CD. The main concern today is that even with the changing pattern of clinical presentation of CD a coeliac crisis can still happen. The second concern is how to explain the occurrence of coeliac crisis; is it due to secondary nutritional deficiencies or is it a primary occurrence? At present, mass screening of the whole population is not recommended, the aim being to screen the population at risk of developing CD, such as first-degree relatives of patients with CD, subjects with autoimmune disorders, such as insulin dependent diabetes mellitus, thyroiditis and other endocrinopathies (4,5). As an increased incidence of non-Hodgkin lymphoma is observed in active CD patients, 42.7 times higher than that expected in the normal population, the screening of patients with non-Hodgkin lymphoma for CD should be considered (6). Various autoimmune collagen diseases as well as several other disorders, mainly genetic syndromes, including Down syndrome (7), Turner syndrome and Beckwitt-Wiedemann syndrome, are associated with CD, and patients with these disorders should also be screened. Symptoms related to the outcome of malabsorption are not uncommon as presenting features of CD nowadays, such as iron deficiency anaemia or bone disorders, including osteoporosis.
Paediatric Gastroenterology Unit, Division of Paediatrics, Hebrew University, Hadassah Medical Centre, Jerusalem, Israel Correspondence: David Branski branski@hadassah.org.il Professor and Chairman Division of Paediatrics Hebrew University, Hadassah Medical Center Jerusalem, Israel
¶·È‰È·ÙÚÈ΋ 2007;70:345-346
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346
D. Branski et al.
Extraintestinal manifestations and “atypical forms” Growth retardation can be the only presenting symptom. Apart from endocrinopathies as mentioned earlier, endocrine abnormalities may occur in CD due to severe malabsorption. Secondary hypopituitarism, for example, probably caused by severe malnutrition, is found mainly in individuals with chronic disease on a gluten containing diet. Untreated female patients sometimes report hypomenorrhoea or amenorrhoea, or have recurrent abortions. Males may have hypogonadism, oligospermia and abnormal sperm motility and morphology. Mothers with active CD may have offspring of low birth weight in comparison to neonates born to mothers without CD (8). Peripheral neuropathy, patchy demyelinization of the spinal cord, cerebellar atrophy and capillary proliferation have been reported in CD. A triad of intractable epilepsy, parieto-occipital calcifications and CD has been described. Recently coeliac ataxia has been reported, with demonstration of tissue transglutaminase activity in the brain tissues (9). Chronic cryptogenic hepatitis and elevated liver transaminase levels are now recognized as isolated presenting symptoms of CD. Very rarely cardiac disorders and chronic lung diseases have been associated with CD. Monosymptomatic features, such as arthropathy and other associated disorders i.e., alopecia and enamel hypoplasia have been reported in CD. In addition, IgA deficiency is at least 3-6 times more common in people with CD than in the general population. Silent (asymptomatic) CD is being increasingly recognized, in which gastrointestinal symptoms are absent, but on small bowel biopsy, severe mucosal
Paediatriki 2007;70:345-346
damage consistent with CD is apparent. These patients are investigated during screening studies. In conclusion, at present more patients are being diagnosed as suffering from CD through the screening of at-risk populations and from extraintestinal manifestations and atypical presentation. The awareness of the physician, as well as the public, is the key issue to diagnosis of the disease at an early stage and subsequent timely commencement of strict GFD for life in order to avoid future complications, mainly iron deficiency anaemia, osteoporosis, infertility and non-Hodgkin lymphoma.
References 1. Lebenthal E, Branski D. Childhood celiac disease-a reappraisal. J Pediatr 1981;98:681-690. 2. Ravikumara M, Tuthill DP, Jenkins HR. The changing clinical presentation of coeliac disease. Arch Dis Child 2006;91:969-971. 3. Ugras M, Ertem D, Pehlivanoglu E. Rare manifestations of coeliac disease - Report of a case and review of the literature. Paediatriki 2007;70:422-424. 4. Fasano A, Catassi C. Coeliac disease in children. Best Pract Res Clin Gastroenterol 2005;19:467-478. 5. Branski D, Fasano A, Troncone R. Latest developments in the pathogenesis and treatment of celiac disease. J Pediatr 2006;149:295-300. 6. Holmes GK, Prior P, Lane MR, Pope D, Allan RN. Malignancy in coeliac disease-effect of a gluten free diet. Gut 1989;30:333-338. 7. Amil-Dias J, Walker-Smith J.A. Down's syndrome and coeliac disease. J Pediatr Gastroenterol Nutr 1990;10:41-43. 8. Ludvigsson JF, Montgomery SM, Ekbom A. Celiac disease and risk of adverse fetal outcome: a population-based cohort study. Gastroenterology 2005;129:454-463. 9. Hadjivassiliou M, Mäki M, Sanders DS, Williamson CA, Grünewald RA, Woodroofe NM, et al. Autoantibody targeting of brain and intestinal transglutaminase in gluten ataxia. Neurology 2006;66:373-377.
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ÊÔÚ¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ÂÓ›ÔÙ ÁÈ· >1 ÊÔÚ¿, ÂÓÒ 1:10 ·È‰È¿ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ¤ˆ˜ Î·È 5 ÓÔÛ‹ÛÂȘ. ¢ÈÂıÓÒ˜, 1:5 ·È‰È¿ ı· ÂÈÛÎÂÊı› ÁÈ·ÙÚfi ÏfiÁˆ Ïԛ̈͢ ·fi ÚÔÙ·˚fi, 1:50 ı· ÓÔÛËÏ¢ı› Î·È 1:285 ı· ηٷϋÍÂÈ. ∏ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi ¤¯ÂÈ ›‰È· Û˘¯ÓfiÙËÙ· ‰ÈÂıÓÒ˜ ·ÏÏ¿ ‰È·ÊÔÚÂÙÈ΋ ¤Î‚·ÛË, Ì ÙÔ 80% ÙˆÓ ı·Ó¿ÙˆÓ Ó· ·Ú·ÙËÚÂ›Ù·È Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜. ™˘ÓÂÒ˜, ÙÔ ÚÔÛˆÂ›Ô Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi Ì ‰È¿ÚÚÔÈ·-Â̤ÙÔ˘˜-·Ê˘‰¿ÙˆÛË-ηٷÏËÍ›·ı¿Ó·ÙÔ ÔÈΛÏÏÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ· (4,5,6). ™ÙËÓ ÂÚÈÔ¯‹ Ì·˜, Ì ‚¿ÛË Ù· ÛÙÔȯ›· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ Û ÌÂÁ¿ÏË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô (19842006) Ô˘ ·ÊÔÚÔ‡Ó 2264 ·ÛıÂÓ›˜ Ì ÔÍ›· ‰È¿ÚÚÔÈ· ·fi ÚÔÙ·˚fi (7), Î·È Ô˘ ÈÛÙ‡ԢÌ fiÙÈ Â›Ó·È ·ÓÙÈÚÔÛˆÂ˘ÙÈο fiÏ˘ Ù˘ ¯ÒÚ·˜, ÙÔ ÚÔÊ›Ï Ù˘ Ïԛ̈͢ ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ ÂÍ‹˜: ∏ ÂÙ‹ÛÈ· ηٷÓÔÌ‹ (∂ÈÎfiÓ· 2) ¤¯ÂÈ ‰È·Î˘Ì¿ÓÛÂȘ. øÛÙfiÛÔ, ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÈÂÙ›· ·Ú·ÙËÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ïԛ̈͢ Û ÔÛÔÛÙfi 220% (∂ÈÎfiÓ· 3). ∏ ÔÍ›· ‰È¿ÚÚÔÈ· ‹Ù·Ó Û˘¯ÓfiÙÂÚË Û ·È‰È¿ 300 ¶ÂÚÈÙÒÛÂȘ ¡Ô.
250 200 150 100 50 0
4 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06
∂Ó Û˘Ófiψ Ïԛ̈ÍË ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ÚÔÙ·˚fi˜ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ÛÙ· ‚Ú¤ÊË. √ Èfi˜ ·ÔÙÂÏÂ›Ù·È ·fi ‰ÈÏfi η„›‰ÈÔ, ¤¯ÂÈ 20‰ÚÈ΋ Û˘ÌÌÂÙÚ›·, ÔÚÔÔÌ¿‰Â˜ (∞, µ, C, D, E, F, G), ÔÚÔÙ‡Ô˘˜ (P Î·È G) Î·È ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ (·ÚȘ Â›Ó·È ÔÈ VP7, VP4, VP6). √È 5 ·ÚÈÔÈ oÚfiÙ˘ÔÈ, G1, G2, G3, G4 Î·È G9, ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó >98% Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi, Ô ÔÔ›Ô˜ ÌÂÙ·‰›‰ÂÙ·È Ì ÙËÓ ÂÓÙÂÚÔÛÙÔÌ·ÙÈ΋ Ô‰fi (¿ÙÔÌÔ-ÛÂ-¿ÙÔÌÔ), ÂÓÒ Â›Ó·È ‰˘Ó·Ù‹ Î·È Ë ·Ó·Ó¢ÛÙÈ΋ Ô‰fi˜ ÌÂÙ¿‰ÔÛ˘. °È· Ó· ·Ó·Ù˘¯ı› Ë Ïԛ̈ÍË, ··ÈÙÂ›Ù·È ÌÈÎÚ‹ ÏÔÈÌÔÁfiÓÔ˜ ‰fiÛË (10-100 pfu) ÙÔ˘ ÈÔ‡, Ô ÔÔ›Ô˜ ÂÈÔÏ¿˙ÂÈ Î˘Ú›ˆ˜ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ (∂ÈÎfiÓ· 1) (3). √ Èfi˜ ÌÔχÓÂÈ Ô˘ÛÈ·ÛÙÈο fiÏ· Ù· ·È‰È¿ ÁÈ· 1
500 450 400 350 300 250 200 150 100 50 0
19 8
¶ÚfiÛÊ·Ù· ÚÔÛÎÔÌ›ÛÙËΠÁÈ· ÂÁÎÂÊ·Ï›Ùȉ· ÛÙËÓ ÎÏÈÓÈ΋ Ó‹ÈÔ Ì Â̤ÙÔ˘˜, ‰È¿ÚÚÔȘ Î·È ˘ÚÂÙfi ·fi 3Ë̤ÚÔ˘. ¶ÚÔÛÙ¤ıËΠ˘ÓËÏ›·, ÓˆıÚfiÙËÙ·, Û˘Á¯˘ÙÈÎÔ‰ÈÂÁÂÚÙÈ΋ ηٿÛÙ·ÛË, ÔÈÛıfiÙÔÓÔ˜, ÛÙÚ·‚ÈÛÌfi˜, ÙÚÈÛÌfi˜ Ô‰fiÓÙˆÓ, ¿Ù·ÎÙ˜ ÎÈÓ‹ÛÂȘ Î·È fi¯È ηϋ ÂÈÎÔÈÓˆÓ›· Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ. √ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛıËΠˆ˜ ÂÁÎÂÊ·Ï›Ùȉ· Ì ·ÈÙÈÔÏÔÁÈ΋ (ÁÈ· Èı·Ófi HSV) Î·È Û˘Ìو̷ÙÈ΋ ·ÁˆÁ‹. ∏ 1Ë ªRI ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ Î·È Ë 2Ë (ÌÂÙ¿ 15 Ë̤Ú˜) ¤‰ÂÈÍ ·Ú¯fiÌÂÓË ·ÙÚÔÊ›· ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È ‹ÈÔ Ô›‰ËÌ· ÊÏÔÈÔ‡ ËÌÈÛÊ·ÈÚ›ˆÓ. ∞fi ÙÔÓ ÂÊÈÎÙfi Û ̷˜ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, ÌÔÓ·‰ÈÎfi ‡ÚËÌ· ‹Ù·Ó ÎfiÚ·Ó· ıÂÙÈο ÁÈ· ÚÔÙ·˚fi. ∞Ó Î·È Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÈÔ‡ ÌfiÓÔ ÛÙ· ÎfiÚ·Ó· ‰ÂÓ Â›Ó·È Ë Î·Ï‡ÙÂÚË ·fi‰ÂÈÍË ÁÈ· ÙË Û¯¤ÛË ÙÔ˘ ÚÔÙ·˚Ô‡ Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡, ˆÛÙfiÛÔ ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ·Ô‰›‰Ô˘Ó ·Ó¿ÏÔÁ˜ ÂÈÎfiÓ˜ ÛÙÔÓ ÚÔÙ·˚fi Ì ÌfiÓË ÂͤٷÛË ÙË ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· ÎÔÚ¿ÓˆÓ (1,2). TËÓ ›‰È· ÂÚ›Ô˘ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ‰Â¯ı‹Î·Ì ¤ÁÁÚ·ÊË ‰È·Ì·ÚÙ˘Ú›· ÁÔÓ¤· ÁÈ· ÌË Â˘Ú‹ Û˘ÌÂÚÈÊÔÚ¿ ÂȉÈ΢Ô̤ÓÔ˘. ∆Ô ·È‰› ÙÔ˘ ‰È·Ì·ÚÙ˘ÚfiÌÂÓÔ˘ ÁÔÓ¤· ¤·Û¯Â ·fi Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi Èfi ÚÔÙ·˚fi. £· ÌÔÚÔ‡Û ‚¤‚·È· Ó· ¿Û¯ÂÈ ·fi ÔÙȉ‹ÔÙ ¿ÏÏÔ. ∆· ‰‡Ô ·Ú·¿Óˆ ÁÂÁÔÓfiÙ·, ·ÓÂÍ¿ÚÙËÙ· ÌÂٷ͇ ÙÔ˘˜, ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙȘ ‰‡Ô fi„ÂȘ Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi: ÙËÓ ÂÓ Û˘Ófiψ Î·È ÙËÓ ÂÈ̤ÚÔ˘˜.
¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛÂˆÓ £ÂÛÛ·ÏÔӛ΢
∂ÈÎfiÓ· 2. ∂Ù‹ÛÈ· ηٷÓÔÌ‹ Ù˘ ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£. ¶·È‰È·ÙÚÈ΋ 2007;70:347-349
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π. £. ∫·‚·ÏÈÒÙ˘
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∂ÈÎfiÓ· 3. ™˘¯ÓfiÙËÙ· ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi ÙËÓ ÂÚ›Ô‰Ô ¡Ô¤Ì‚ÚÈÔ˜ ¤ˆ˜ ∞Ú›ÏÈÔ˜ (2005-2006/2006-2007). ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£.
ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ Î·È ÂȉÈÎfiÙÂÚ· Û ·È‰È¿ 6 ÌËÓÒÓ ¤ˆ˜ 2 ÂÙÒÓ. √ ÚÔÙ·˚fi˜ ›¯Â ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË (p<0,01) ÌÂ: - ™ËÌ›· ·Ê˘‰¿ÙˆÛ˘ - ∞ÏÏ·Á‹ Û˘ÌÂÚÈÊÔÚ¿˜ (¢ÂÚÂıÈÛÙfiÙËÙ·, ÎfiˆÛË, Ï‹ı·ÚÁÔ˜) - ∞ÚÈıÌfi ‰È·ÚÚÔÈÒÓ / Ë̤ڷ - ∂̤ÙÔ˘˜ (·ÚÈıÌfi ·Ó¿ Ë̤ڷ Î·È ‰È¿ÚÎÂÈ·) - ⁄·ÚÍË ˘ÚÂÙÔ‡ ≥38ÔC ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, 100 ·È‰È¿ ·ÚÔ˘Û›·Û·Ó ÂÈÏÔΤ˜ (¶›Ó·Î·˜ 1). √È ÂÈÏÔΤ˜ ‹Ù·Ó ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÂÏ·ÊÚ¤˜. Œ¯Ô˘Ì ÏÔÈfiÓ ÌÈ· ÓfiÛÔ Ì ‹È· ÔÚ›·, ¯ˆÚ›˜ ıÓËÙfiÙËÙ·, ·ÏÏ¿ Û˘¯Ó‹ Î·È Ì ÔÛÔÛÙfi ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Èı·ÓfiÓ ÍÂʇÁÔ˘Ó ÙÔ˘ ·˘ÛÙËÚÔ‡ ÔÚÈÛÌÔ‡, ·ÏÏ¿ ‰ÂÓ ·‡Ô˘Ó Ó· Â›Ó·È ÚÔ‚Ï‹Ì·Ù·.
∂È̤ÚÔ˘˜ Ïԛ̈ÍË ø˜ Ù¤ÙÔÈ· ÂÓÓÔԇ̠ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙË ÓÔÛËÚfiÙËÙ· ηÙÂÍÔ¯‹Ó Î·È ÛÙ· ·Ú¿Ï¢ڷ ÚÔ‚Ï‹Ì·Ù· Ô˘ ÚÔηÏ›. ™ËÌ·ÓÙÈ΋ Â›Ó·È Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÏÂ˘Ú¿ Ù˘ Ïԛ̈͢ (8,9). ∏ ›وÛË ÏÔÈfiÓ Ù˘ Ïԛ̈͢ ‰È·ÎÚ›ÓÂÙ·È ÛÂ: ÕÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜ - ™‡ÛÙËÌ· ÀÁ›·˜ - Ÿ¯È ÙfiÛÔ ÛÔ‚·Ú‹ ÓfiÛÔ˜ fiÛÔ ¿ÏϘ ÏÔÈÌÒÍÂȘ
¶›Ó·Î·˜ 1. ∂ÈÏÔΤ˜ ÔÍ›·˜ ‰È¿ÚÚÔÈ·˜ ·fi ÚÔÙ·˚fi Û ۇÓÔÏÔ 2264 ·ÛıÂÓÒÓ. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£ ™·ÛÌÔ› ¢˘Û·ÓÔ¯‹ ÛÙË Ï·ÎÙfi˙Ë ÀÔÓ·ÙÚÈ·ÈÌ›· ∞ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ∂ÁÎÂÊ·Ï›Ùȉ· ÕÛËÙË ÌËÓÈÁÁ›Ùȉ· √˘Ú·ÈÌÈÎfi ·ÈÌÔÏ˘ÙÈÎfi Û‡Ó‰ÚÔÌÔ £¿Ó·ÙÔ˜ Paediatriki 2007;70:347-349
100 89 51 10 11 3 2 1 1
ÕÌÂÛÔ ÌË È·ÙÚÈÎfi ÎfiÛÙÔ˜ - √ÈÎÔÁ¤ÓÂÈ· ·Û¯fiÓÙˆÓ - ORS ‰È·Ï‡Ì·Ù· - ¶¿Ó˜ - ªÂÙ·ÊÔÚÈο - ∆ÚÔÊ‹ ŒÌÌÂÛÔ ÎfiÛÙÔ˜ - √ÈÎÔÁÂÓÂÈ·Îfi˜ ÂÚ›Á˘ÚÔ˜ - ∫·ıÔÚ›˙ÂÙ·È ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ‰ÔÌ‹ οı ¯ÒÚ·˜ - ∞Ó Ë ÌËÙ¤Ú· ÂÚÁ¿˙ÂÙ·È, ÙÔ ÎfiÛÙÔ˜ ·˘Í¿ÓÂÈ Ôχ - ∞ÒÏÂÈ· ·Ú·ÁˆÁÈÎfiÙËÙ·˜ - ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ¯·Ì¤ÓˆÓ ËÌÂÚÒÓ ·fi ÙËÓ ÂÚÁ·Û›· ÙˆÓ ÁÔÓ¤ˆÓ ªÂ›ˆÛË ‰È·ıÂÛ›ÌˆÓ ÎÏÈÓÒÓ - ÃÂÈÌÂÚÈÓ‹ ÓfiÛÔ˜ - ∂Ô¯‹ Ì ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ¿ÏÏˆÓ ÏÔÈÌÒÍÂˆÓ - ¶ÂÚÈÔÚÈÛÌfi˜ ÎÏÈÓÒÓ. ∏ Î¿Ï˘„Ë ÙˆÓ ÎÏÈÓÒÓ ·fi ·ÛıÂÓ›˜ Ì ÔÍ›· ‰È¿ÚÚÔÈ· ÂÌÔ‰›˙ÂÈ ÙË ‰È¿ıÂÛË ÙˆÓ ÎÏÈÓÒÓ Û ·ÛıÂÓ›˜ Ì ¿ÏÏ· ÓÔÛ‹Ì·Ù· ÂÔ¯‹˜. - ∞˘Í¿ÓÂÈ Ô Û˘ÓˆÛÙÈÛÌfi˜ ·ÛıÂÓÒÓ Î·È Û˘ÓÔ‰ÒÓ Ì fiÏ· Ù· ·ÎfiÏÔ˘ı¿ ÙÔ˘. ∏ ÛËÌ·Û›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ·Ú·Ì¤ÙÚÔ˘ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 4, fiÔ˘ ÏfiÁˆ Ù˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ (·Ó·Ê¤ÚÔÓÙ·È ÔÈ ¯ÂÈÌÂÚÈÓÔ› Ì‹Ó˜ fiÔ˘ Â›Ó·È ÈÔ Û˘¯Ófi˜ Ô ÚÔÙ·˚fi˜), Â›Ó·È ÂÌÊ·Ó‹˜ Ë ·Ó¿ÁÎË ÂÍÔÈÎÔÓfiÌËÛ˘ ÎÏÈÓÒÓ.
¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ª¤¯ÚÈ Û‹ÌÂÚ· ÁÓˆÚ›˙·Ì fiÙÈ Ô ÚÔÙ·˚fi˜ ÚÔηÏ› ·ÓÙÈÁÔÓ·ÈÌ›·. ∆ÂÏÂ˘Ù·›·, ‰È·ÈÛÙÒıËΠfiÙÈ Û˘¯Ó‹ Â›Ó·È Î·È Ë È·ÈÌ›· Ô˘ Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·ÓÙÈÁÔÓ·ÈÌ›· Î·È Â›Ó·È ·ÓÂÍ¿ÚÙËÙË Ù˘ ·ÚÔ˘Û›·˜ ‰È¿ÚÚÔÈ·˜. ∞˘Ùfi ÛËÌ·›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Â͈ÂÓÙÂÚÈÎÒÓ ÂÓÙÔ›ÛˆÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ‰ÂÓ ÁÓˆÚ›˙Ô˘ÌÂ
¶ÂÚÈÙÒÛÂȘ ¡Ô.
¶ÂÚÈÙÒÛÂȘ ¡Ô.
- ¶Ôχ ÈÔ Û˘¯Ó‹ - ÕÚ· ˘„ËÏfi ÎfiÛÙÔ˜ ÁÈ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ - ¡ÔÛÔÎÔÌÂȷ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·. ÿÛˆ˜ Ë Î˘ÚÈfiÙÂÚË ·ÈÙ›· ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿ (1:5). ªÔÚ› Ó· ÂÈÌË·ÓÂÈ ÙË ÓÔÛËÏ›· ¤ˆ˜ Î·È 10 Ë̤Ú˜.
67
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2001
2002
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2007
∂ÈÎfiÓ· 4. ∂ÈÛ·ÁˆÁ¤˜ ÙÔ 1Ô ÙÂÙÚ¿ÌËÓÔ ÙÔ˘ ¤ÙÔ˘˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡∂¶£ (2000-2007).
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ÙËÓ Â›ÙˆÛË Ù˘ È·ÈÌ›·˜ ÛÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ‹ ÙËÓ ·ÎÚÈ‚‹ Û˘¯ÓfiÙËÙ· ÙˆÓ Â͈ÂÓÙÂÚÈÎÒÓ ÂΉËÏÒÛˆÓ. ∞˘Ùfi ‰ÂÓ ÌÂÈÒÓÂÈ, ‚¤‚·È·, ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ‰È·›ÛÙˆÛ˘ (10). ™Â Ôχ ÚfiÛÊ·ÙÔ ¿ÚıÚÔ (ª¿ÈÔ˜ 2007), ÔÈ Troncone R, Auricchio S (11) Û˘˙ËÙÔ‡Ó ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛË Ïԛ̈͢ ·fi ÚÔÙ·˚fi Î·È ÎÔÈÏÈÔο΢. ∆Ô ÂÓ ÏfiÁˆ ¿ÚıÚÔ Û‡ÓÙ·Í˘ ÛÙËÚ›¯ıËΠ۠‰‡Ô, ›Û˘ ÚfiÛÊ·Ù˜, ÌÂϤÙ˜ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì·. ∏ ÚÒÙË (12) Â›Ó·È ÚÔÔÙÈ΋ ¤Ú¢ӷ Ù˘ Ê˘ÛÈ΋˜ ÈÛÙÔÚ›·˜ Î·È ÙˆÓ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ÂÎÏ˘ÙÈÎÒÓ ·ÈÙ›ˆÓ ÁÈ· ÙÔÓ ‰È·‚‹ÙË Î·È ÙËÓ ÎÔÈÏÈÔοÎË Û ÁÂÓÂÙÈÎÒ˜ ÚԉȷÙÂıÂÈ̤ӷ ¿ÙÔÌ·, fiÔ˘ ÔÈ Û˘ÁÁÚ·Ê›˜ ‚Ú‹Î·Ó fiÙÈ ÔÈ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ·fi ÚÔÙ·˚fi ÂÈʤÚÔ˘Ó ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ÎÔÈÏÈÔοÎË. ∏ ‰Â‡ÙÂÚË (13) ·ÊÔÚ¿ ÙË ‰È¢ÎÚ›ÓËÛË ÙÔ˘ ÚfiÏÔ˘ ·ıÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÚfiÎÏËÛË ·˘ÙÔ¿ÓÔÛ˘ ·¿ÓÙËÛ˘ ÛÙËÓ ÎÔÈÏÈÔοÎË Î·È ÙËÓ ¤Ú¢ӷ ÂÙȉ›ˆÓ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ÎÔÈÏÈÔοÎË Ô˘ ›¯·Ó ÔÌÔÏÔÁ›· Ì ·ÓÙÈÁfiÓ· ÙÔ˘ ÚÔÙ·˚Ô‡. √È ‰‡Ô ·˘Ù¤˜ ÌÂϤÙ˜ ¤ÊÂÚ·Ó ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÔÚÈṲ̂ӷ ÛËÌ›· ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË ˆ˜ ·˘ÙÔ¿ÓÔÛ˘ ÓfiÛÔ˘ Ù˘ ÎÔÈÏÈÔο΢, ÙË Û˘¯Ó‹ Û˘Ó‡·ÚÍ‹ Ù˘ Ì ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÙÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË Ù˘ ÓfiÛÔ˘ Î·È ÙÔÓ Èı·Ófi ÚfiÏÔ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÛË. √ Ì˯·ÓÈÛÌfi˜ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È ÁÂÓÈο ¿ÁÓˆÛÙÔ˜. ∏ ÁÏÔ˘Ù¤ÓË Â›Ó·È Ô ÌÔÓ·‰ÈÎfi˜ ̤¯ÚÈ ÛÙÈÁÌ‹˜ Â͈ÁÂÓ‹˜ ÂÚÈ‚·ÏÏÔÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ˘ÂÈÛ¤Ú¯ÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘. √È ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÚÔ‚¿ÏÏÔ˘Ó ˆ˜ Ô ‰Â‡ÙÂÚÔ˜ Â͈ÁÂÓ‹˜ ·Ú¿ÁÔÓÙ·˜. ∫·È Â‰Ò ÂÌϤÎÂÙ·È Ô ÚÔÙ·˚fi˜, ÏfiÁˆ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ÏÔÈÌÒÍÂˆÓ Ô˘ ÚÔηÏ› ÛÙËÓ ÂÈΛӉ˘ÓË ÁÈ· ÎÔÈÏÈÔοÎË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ. ª¿ÏÈÛÙ·, Ë Û¯¤ÛË ÚÔÙ·˚Ô‡ Î·È ·Ó¿Ù˘Í˘ ·˘ÙÔ·ÓÔÛ›·˜ ˘ÔÏÔÁ›˙ÂÙ·È ˆ˜ 0 ÁÈ· ηıfiÏÔ˘ Ïԛ̈ÍË, 1,94 ÁÈ· 1 Ïԛ̈ÍË Î·È 3,76 ÁÈ· ¿Óˆ ·fi 2 ÏÔÈÌÒÍÂȘ. ∆Ô ÚÔÙÂÈÓfiÌÂÓÔ ÏÔÈfiÓ ÛÂÓ¿ÚÈÔ Â›Ó·È ÙÔ ÂÍ‹˜: ∏ ¯ÔÚ‹ÁËÛË ÁÏÔ˘Ù¤Ó˘ Û ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô, fiÔ˘ ˘¿Ú¯ÂÈ ÚÔ˚Ô‡Û· ÂÓÙÂÚÈ΋ Ïԛ̈ÍË, ‰È·Ù·Ú·¯‹ Ù˘ ‰È·‚·ÙfiÙËÙ·˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, Î·È ·Ú·ÁˆÁ‹ ÈÓÙÂÚÊÂÚÔÓÒÓ, ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÎÔÈÏÈÔο΢, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ·ÛıÂÓÒÓ. ∞Ó Ù· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· Ù˘ È·ÈÌ›·˜ Î·È Ù˘ ÂÌÏÔ΋˜ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÎÔÈÏÈÔο΢ ÂȂ‚·ÈˆıÔ‡Ó, ÙfiÙÂ, ÛÂ Û˘Ó‰˘·ÛÌfi Î·È Ì ÙȘ ¿ÏϘ ÂÈÙÒÛÂȘ Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi (Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·Ú·¿Óˆ), Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó ı· Ú¤ÂÈ Ó· ‰Ô‡Ì ·fi ¿ÏÏË Ï¤ÔÓ ÛÎÔÈ¿ ÙË Û˘ÓÔÏÈ΋ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi Î·È ÙȘ Û˘Ó¤ÂȤ˜ Ù˘. °È· ÙË Ì›ˆÛË Ù˘ Û˘ÓÔÏÈ΋˜ ›وÛ˘ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ÂÊ·ÚÌÔÛıÔ‡Ó 2 ̤ÙÚ·: 1. ∞˘ÛÙËÚ¿ ̤ÙÚ· ÂϤÁ¯Ô˘ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÓÔÛÔ-
ÎÔÌÂ›Ô Î·È ÛÙÔ˘˜ ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÛÙËÚ¿ ̤ÙÚ· ÚÔÛˆÈ΋˜ ˘ÁÈÂÈÓ‹˜. ∆¤ÙÔÈ· ̤ÙÚ· Ô˘‰¤ÔÙ ·¤‰ˆÛ·Ó, fiÔ˘ Î·È ·Ó ÂÊ·ÚÌfiÛıËηÓ. 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ ηٿ ÙÔ˘ ÚÔÙ·˚Ô‡. ∏ ‡·ÚÍË Û‹ÌÂÚ· ÂÌ‚ÔÏ›ˆÓ ηٿ ÙÔ˘ ·ıÔÁfiÓÔ˘ ·˘ÙÔ‡ ÚÔ‚¿ÏÏÂÈ ˆ˜ Ë Î·Ï‡ÙÂÚË Ï‡ÛË, ‰ÈfiÙÈ ¤¯ÂÈ ‰ÈÙÙfi ÛÙfi¯Ô: ÙËÓ ›‰È· ÙË Ïԛ̈ÍË ·fi ÙÔ ·ıÔÁfiÓÔ Î·È ÙËÓ Èı·Ó‹ ÚÔʇϷÍË ·fi ÙËÓ ÎÔÈÏÈÔοÎË, ÂÊfiÛÔÓ ÙÂÎÌËÚȈı› Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ‰‡Ô ηٷÛÙ¿ÛˆÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Lynch ª, Lee µ, Azimi P, Gentsch J, Glaser C, Gilliam S, et al. Rotavirus and central nervous system symptoms: cause or contaminant? Case reports and review. Clin Infect Dis 2001;33:932-938. 2. Minami K, Tamura A, Komori Y, Yanagawa T, Izumi G, Kioka N, et al. Acute encephalopathy and rhabdomyolysis following rotavirus gastroenteritis. J Paediatr Child Health 2007;43:90-91. 3. Santos N, Hoshino Y. Global distribution of rotavirus serotypes/genotypes and its implication for the development and implementation of an effective rotavirus vaccine. Rev Med Virol 2005;15:29-56. 4. Rivest P, Proulx M, Lonergan G, Lebel MH, Bédard L. Hospitalisations for gastroenteritis: the role of rotavirus. Vaccine 2004;22:2013-2017. 5. Glass RI, Parashar UD, Bresee JS, Turcios R, Fischer TK, Widdowson MA, et al. Rotavirus vaccines: current prospects and future challenges. Lancet 2006;368:323-332. 6. Soriano-Gabarro M, Mrukowicz J, Vesikari T, Verstraeten T. Burden of rotavirus disease in European Union countries. Pediatr Infect Dis J 2006;25(1 Suppl):S7-S11. 7. Tsiatsiou O, Papagiannopoulos O, Sarantopoulou E, Alexandratos Ch, Karabaxoglou D, Kavaliotis J. Clinical and epidemiological data of children hospitalized with rotavirus acute gastroenteritis in Northern Greece (Period 1984-2005). 44th Annual Meeting of IDSA, 1215/10/2006, Toronto, Canada. 8. Gleizes O, Desselberger U, Tatochenko V, Rodrigo C, Salman N, Mezner Z, et al. Nosocomial rotavirus infection in European countries: a review of the epidemiology, severity and economic burden of hospital-acquired rotavirus disease. Pediatr Infect Dis J 2006;25(1 Suppl):S12-S21. 9. Rheingans RD, Heylen J, Giaquinto C. Economics of rotavirus gastroenteritis and vaccination in Europe: what makes sense? Pediatr Infect Dis J 2006;25(1 Suppl):S48-S55. 10. Blutt SE, Matson DO, Crawford SE, Staat MA, Azimi P, Bennett BL, et al. Rotavirus antigenemia in children is associated with viremia. PLoS Med 2007;4:e121. 11. Troncone R, Auricchio S. Rotavirus and celiac disease: clues to the pathogenesis and perspectives on prevention. J Pediatr Gastroenterol Nutr 2007;44:527-528. 12. Stene LC, Honeyman MC, Hoffenberg EJ, Haas JE, Sokol RJ, Emery L, et al. Rotavirus infection frequency and risk of celiac disease autoimmunity in early childhood: a longitudinal study. Am J Gastroenterol 2006;101:2333-2340. 13. Zanoni G, Navone R, Lunardi C, Tridente G, Bason C, Sivori S, et al. In celiac disease, a subset of autoantibodies against transglutaminase binds toll-like receptor 4 and induces activation of monocytes. PLoS Med 2006;3:e358. ¶·È‰È·ÙÚÈ΋ 2007;70:347-349
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∞¡∞™∫√¶∏™∏
Diagnosis and management of obstructive uropathy in infants Department of Pediatrics1 and Internal Medicine2 University of Texas Southwestern Medical Center at Dallas Dallas, Texas, 75390-9063 Correspondence: Amy M. Becker Amy.Becker@UTSouthwester n.edu Department of Pediatrics U.T. Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, Texas 75390-9063
A. M. Becker1, M. Baum1,2 Abstract: The institution of routine prenatal ultrasound has led to an increase in the diagnosis of antenatal hydronephrosis. Studies have shown that the greater the prenatal renal anterior posterior diameter, the greater the likelihood of significant postnatal renal obstruction. Postnatal evaluation should include a renal ultrasound and a voiding cystourethrogram. Common etiologies for prenatal hydronephrosis include vesicoureteral reflux, ureteropelvic junction obstruction, posterior urethral valves, prune belly syndrome, ureterovesical junction obstruction, and ureterocele. Multicystic dysplastic kidneys appear to be the consequence of early obstruction of the developing ureter. There is a significant probability of contralateral renal abnormalities in patients with unilateral dysplasia or renal agenesis thereby necessitating routine postnatal evaluation. Electrolyte abnormalities are common in bilateral obstructive uropathy and result from distal tubular damage. Hyperkalemic metabolic acidosis along with sodium and water wasting should be assessed and treated appropriately. In addition to distal tubular damage, total nephron number is decreased in patients with significant obstructive uropathy. In patients with severe bilateral obstruction, chronic renal failure may result from the reduced nephron endowment and progressive renal damage from obstruction and infections. Severe obstructive uropathy may lead to end stage renal disease, but patients with obstructive uropathy can successfully receive a kidney transplant.
Key words: Antenatal hydronephrosis, obstructive uropathy, vesicoureteral reflux, neonates.
List of abbreviations: APD anterior-posterior diameter UPJ ureteropelvic junction VUR vesicoureteral reflux PUV posterior urethral valves PBS prune belly syndrome UVJ ureterovesical junction MCDK multicystic dysplastic kidney VCUG voiding cystourethrogram DMSA dimercaptosuccinic acid PD peritoneal dialysis HD hemodialysis Introduction Obstructive uropathy is a broad term that describes kidney damage resulting from urinary obstruction at any level of the urinary system. In the past, obstructive uropathy presented with pain, urinary tract infection, poor urinary stream, failure to thrive, neonatal sepsis, or respiratory distress. More recently, urinary obstruction is identified during routine prenatal ultrasound screening. There are multiple etiologies leading to urinary obstruction including ureteropelvic junction (UPJ) obstruction, vesicoureteral reflux (VUR), posterior urethral valves (PUV), prune belly syndrome (PBS), ureterovesical Paediatriki 2007;70:350-360
(UVJ) obstruction, urethral atresia or stricture, duplicated collecting system with ureterocele, and multicystic dysplastic kidney (MCDK).
Detection and evaluation of hydronephrosis Routine second trimester ultrasound screening has led to an increase in the diagnosis of antenatal hydronephrosis with an incidence estimated between 0.5 and 1% (1,2). The Society for Fetal Urology (SFU) grade and the anteriorposterior diameter (APD) are the two criteria used for grading antenatal hydronephrosis. The APD is most frequently reported, and most studies use the APD in their analyses. Despite this, there is no agreed upon measurement for a normal fetal APD. Most studies delineate an APD greater than or equal to 5 mm as abnormal (3-5). The probability of significant renal pathology is correlated with the severity of the hydronephrosis (3). ∞ meta-analysis of 17 studies calculated the risk of postnatal pathology stratified by degree of APD dilatation (as measured in the second trimester) (6). 88.3% of infants with severe antenatal hydronephrosis (APD ≥10 mm) had detectable pathology. Rates in infants with moderate (APD
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Table 1. Etiologies of obstructive uropathy and potential associated findings Diagnosis Vesicoureteral Reflux
Physical Exam Findings
Physiologic Disturbances
± Palpable abdominal mass if associated with large, hydronephrotic kidney
None, unless bilateral or in a solitary kidney
UPJ Obstruction
± Palpable abdominal mass
None, unless bilateral or in a solitary kidney
Posterior Urethral Valves
± Palpable bladder, poor urinary stream
± Hyponatremia, hyperkalemic metabolic acidosis, volume depletion, uremia
Prune Belly Syndrome
Absent abdominal musculature, bilateral undescended testicles
± Hyponatremia, hyperkalemic metabolic acidosis, volume depletion, uremia
± Palpable abdominal mass
None, unless bilateral or in a solitary kidney
± Palpable abdominal mass if associated with large, hydronephrotic kidney
None, unless bilateral or in a solitary kidney
Multicystic Dysplastic Kidney Ureterocele
7-10 mm) and mild (APD ≤7 mm) hydronephrosis were 45.1% and 11.9%, respectively. The likelihood of UPJ obstruction increased with increasing APD, but there was no correlation of VUR with APD (6). Initial evaluation of an infant with antenatal hydronephrosis should always begin with a physical examination (Table 1). UPJ obstruction and MCDK often present with a palpable abdominal mass. Prune belly syndrome is associated with absent abdominal wall musculature and bilateral undescended testicles. Infants with PUV will often have a palpable bladder (5). Immediate postnatal evaluation with a renal ultrasound and voiding cystourethrogram (VCUG) should be performed in infants with prenatal severe bilateral hydronephrosis or severe unilateral hydronephrosis in a single functioning kidney (3,5). Isolated antenatal hydronephrosis is defined as increased APD without identifiable urinary tract pathology (7). Systematic review of 25 studies on isolated antenatal hydronephrosis demonstrated spontaneous resolution of hydronephrosis and normal renal growth in infants with mild hydronephrosis (8). Meta-analysis of data from 7 of these studies showed improvement in 98% of infants with mild hydronephrosis (8). Transient and physiologic hydronephrosis represent the most common etiologies of isolated antenatal hydronephrosis. These may result from a large, unobstructed renal pelvis or an extrarenal pelvis (3). The dilatation may be exacerbated by the increased urine flow rate in the late gestation fetus, which is approximately 10 times higher, normalized for body weight, than the newborn (9). Some studies recommend that antenatal APD of 5 mm or greater warrants postnatal evaluation (10-
13), and prophylactic antibiotics should be initiated to prevent urinary tract infections and continued until obstructive uropathy is ruled out. The initial postnatal renal ultrasound should be delayed until after the first 24-48 hours of life as hydronephrosis may be missed due to the relative oliguria of infants immediately following birth (3,5). Routine postnatal screening with a VCUG for all infants with antenatal hydronephrosis is controversial. Some physicians recommend against routine VCUG in infants with two normal postnatal ultrasounds (14). Others suggest a VCUG be performed in all infants with prenatal detection of hydronephrosis, despite a normal postnatal ultrasound, as a significant proportion of these infants will have an abnormal VCUG (10-13). If VUR is detected, the current standard of care is to initiate prophylactic antibiotics. For infants with postnatal APD >10 mm and no evidence of VUR on VCUG, further evaluation with diuretic renography should be performed to detect UPJ obstruction (3,5,10) (Figure 1).
Etiologies of obstruction Vesicoureteral reflux Vesicoureteral reflux (VUR) occurs when urine flows upwards into the ureters during voiding. VUR is a common cause of antenatal hydronephrosis, occurring in up to 38% of infants (15), often despite a normal postnatal ultrasound (3). The International Reflux Study in Children classification system grades VUR from I to V. Grade I VUR is urinary reflux into a nondilated ureter, and grade II is reflux into the renal pelvis without dilatation. Grade III VUR is reflux into a dilated ureter up to the renal pelvis with possible blunting of the calyceal ¶·È‰È·ÙÚÈ΋ 2007;70:350-360
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Figure 1. Algorithm for systematic evaluation of antenatal hydronephrosis. APD = anterior-posterior diameter, US = ultrasound, VCUG = voiding cystourethrogram.
fornices. In grade IV VUR, the ureter is grossly dilated with moderate blunting of calyces, and grade V is characterized by massive ureteral dilatation and tortuosity with loss of the papillary impression (16) (Figure 2). VUR can lead to recurrent urinary tract infections (UTI) with parenchymal scarring resulting in hypertension and/or renal insufficiency
Figure 2. VCUG demonstrating bilateral grade V vesicoureteroreflux. Note the markedly dilated, tortuous ureters and massive hydronephrosis with calyceal blunting. Paediatriki 2007;70:350-360
(17). Spontaneous resolution of VUR occurs in 7890% of grades I-III reflux diagnosed after evaluation for antenatal hydronephrosis (18,19). Grades IV may spontaneously resolve, but Grade V rarely resolves and usually requires surgical intervention. Infants with VUR of grade IV or higher should be referred to a pediatric urologist. The presence of renal scarring identifies infants at greatest risk for long term renal sequelae (20). It is important to be flexible in the investigation of the child with VUR. One should choose imaging techniques of the urinary tract with the goal of identifying children at risk of developing acquired renal scarring (20,21). UPJ obstruction With an incidence of 1 in 1000 to 1500 newborns, UPJ obstruction is the most common cause of antenatal hydronephrosis (22,23). Bilateral obstruction is encountered in 20-25% of cases, and there is a male to female preponderance of 3:1 (3). The etiology of UPJ obstruction is unknown, and many potential etiologies have been postulated including embryologic, anatomic, functional, histologic, and molecular factors (22). UPJ obstruction can result from intrinsic stenosis, insertion anomaly of the ureters, peripelvic fibrosis, peristaltic abnormalities, and blood vessels crossing the ureter (22). Renal ultrasound demonstrates dilatation of the renal pelvis with normal ureters and
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bilateral UPJ obstruction or unilateral UPJ obstruction with decreased differential function should be referred to a pediatric urologist.
Figure 3. In UPJ obstruction, renal ultrasound demonstrates significant hydronephrosis without ureteral dilatation.
bladder (Figure 3). Diuretic renography is necessary to confirm the diagnosis and also provides an estimation of differential renal function. The differential renal function is useful in management decisions. Although controversy exists concerning the indications for surgical intervention, most experts recommend a conservative approach of observation if the obstruction is unilateral and associated with a well functioning kidney (differential function >35%) (5). Patients with
Figure 4. In posterior urethral valves, VCUG demonstrates a marked change in the caliber of the urethra at the level of the valves. Note the markedly dilated urethra above the site of obstruction. The arrow points to the site where the caliber change is seen.
Posterior urethral valves Occurring with an incidence of 1 in 5000 to 8000 live births, posterior urethral valves (PUV) are the most common cause of lower urinary tract obstruction in male infants. The “valves”, located in the posterior urethra, are actually a thin membrane of tissue causing obstruction of urinary flow out of the bladder (24). Detection of bilateral hydronephrosis and hydroureter with a distended, thick-walled bladder on prenatal ultrasound suggests a diagnosis of PUV. Antenatal detection of PUV prior to 24 weeks gestation carries a poorer prognosis; one study (with a mean follow-up of 4 years) reports a 50% chance of death or chronic renal failure in these patients (25). Moderate or severe hydronephrosis (with APD >10 mm), increased echogenicity on ultrasound, and cystic changes within the kidneys suggesting renal dysplasia also portend a poor prognosis (26,27). In addition to classical prenatal ultrasound changes, evaluation of poor urinary stream, UTI, enlarged bladder, or failure to thrive may lead to the diagnosis of PUV. Infants may present with sepsis, respiratory distress, hyponatremia, and hyperkalemic metabolic acidosis (27,28). Older children presenting with bedwetting, UTI, dribbling, hematuria, urinary retention, or poor urinary stream may have PUV with milder obstruction (29). An infant suspected of having PUV should have a thorough evaluation including renal ultrasound, VCUG, urinalysis, urine culture, and serum electrolytes, creatinine, and blood urea nitrogen. Bladder wall thickening, hydronephrosis, and posterior urethral dilatation are commonly seen on renal ultrasound, and renal dysplasia may also be detected. The gold standard for diagnosing PUV is a fluoroscopic VCUG demonstrating a linear filling defect in the column of radiocontrast in a markedly dilated posterior urethra (27) (Figure 4). The VCUG will also detect VUR which is seen in 25-50% of patients with PUV (28). Prenatal diagnosis of PUV provides an opportunity to intervene prior to the infant developing sepsis or metabolic complications. Despite this, the outcome of patients with PUV has not been significantly improved with prenatal diagnosis (30). Initial treatment of an infant with PUV begins with stabilization of the infant including respiratory support, fluid resuscitation (if volume depletion is suspected), correction of electrolyte abnormalities, ¶·È‰È·ÙÚÈ΋ 2007;70:350-360
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and initiation of antibiotics when clinically indicated (27,28). A urinary catheter should be inserted immediately to relieve the obstruction. Primary valve ablation with endoscopic incision of the PUV is the treatment of choice in a stabilized infant. Urinary diversion with a cutaneous vesicostomy may be necessary in infants whose urethras are too small for an 8F resectoscope (27). Persistent urethral dilatation after valve resection may also require urinary diversion (27-29,31). When possible, avoidance of urinary diversion is preferred. This helps to preserve bladder function and decreases the need for bladder augmentation later in life. Prophylactic antibiotics are indicated if concomitant VUR is present. Details of electrolyte and post-obstructive diuresis management are discussed later. Prune belly syndrome Prune belly syndrome (PBS) has an incidence of 1 in 29,000 to 40,000 male births (32), and is believed to be the result of early urethral obstruction leading to massive bladder distention and possible urinary ascites (27). Subsequently, the abdominal wall musculature degenerates and testicular descent is prevented (27). The membrane causing urethral obstruction ruptures before birth, and the postnatal urethra may or may not be stenotic (32). Ultrasound examination demonstrates increased bladder wall thickness and dilated, tortuous ureters with thickened walls. Hydronephrosis and renal dysplasia may be evident, and a patent urachus can also be seen. Multiple other anomalies are associated with PBS and include: gastrointestinal anomalies (malrotation, volvulus, gastroschisis, omphalocele, Hirschsprungâ&#x20AC;&#x2122;s, imperforate anus), pulmonary hypoplasia (secondary to oligohydramnios), cardiac anomalies (atrial septal defect, ventricular septal defect, tetralogy of Fallot),
Figure 5. Typical ultrasonographic appearance of a multicystic dysplastic kidney. Multiple cysts and no identifiable renal parenchyma are seen. The crosses mark the outer edges of the kidney. Paediatriki 2007;70:350-360
and orthopedic problems (developmental dislocation of the hip, scoliosis, pectus excavatum, talipes equinovarus, torticollis) (27). The initial evaluation of an infant suspected of having PBS should include a physical examination, renal ultrasound, VCUG, urinalysis, urine culture, and serum electrolytes, creatinine, and blood urea nitrogen. Because 85% of patients with PBS will have VUR, prophylactic antibiotics should be initiated immediately (33). Unfortunately, all patients with PBS will be sterile. Progressive azotemia or recurrent infections may be an indication for a vesicostomy. Orchiopexy is required, and a few children may need abdominoplasty and appendicovesicostomy placement (27). Multicystic dysplastic kidney Multicystic dysplastic kidney (MCDK) is the second most common cause for abdominal mass in a neonate with an incidence of 1 in 4300 live births (34). Failed coordination of the branching ureteric bud and the developing metanephros is postulated to be involved in the pathogenesis of MCDK (35). Ureteric obstruction may initiate the process. PAX2, BCL2, IGF-II, and IGF binding protein have been implicated in the development of cysts in MCDK. Tubules with high rates of cellular proliferation express PAX2 (9), and multifocal microcystic tubular dilatation is seen in mice that over express PAX2 in the kidney (36). Dysplastic kidney epithelial cells were shown to ectopically express BCL2, a protein that prevents apoptosis (9). Abnormal kidney tissue was shown to over express IGF-II with the epithelium of the cysts expressing IGF binding protein-3 (35). Many different histopathological changes can be seen in MCDK. The kidney grossly appears as a grapelike cluster of non-communicating cysts. Normal renal architecture and function are completely lost (37,38). Immature glomeruli, nests of metaplastic cartilage, primitive tubules surrounded by fibromuscular collars, and cysts derived from tubular and glomerular structures are seen on a microscopic level (35). Ultrasound appearance of MCDK includes non-communicating cysts, no identifiable renal parenchyma, and atretic proximal ureters (Figure 5). Classic ultrasound findings along with a non-functioning kidney on dimercaptosuccinic acid (DMSA) scan confirm the diagnosis of MCDK. Patients with MCDK have a 50% likelihood of a contralateral renal abnormality. The most commonly encountered abnormality is VUR, followed by UPJ obstruction (39). Since this represents a potential for renal damage in a solitary functioning kidney, postnatal evaluation should include a VCUG (and diuretic
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sports, however, may be safer than previously proposed.
Figure 6. Renal ultrasound showing hydroureteronephrosis characteristic of UVJ obstruction. The crosses mark the outer kidney edges, and the arrow points to the markedly dilated ureter.
renography when indicated) in all patients with an MCDK (39,40). Complications of MCDK rarely include urinary tract infection, hypertension, and malignant transformation. Traditionally, nephrectomy of the MCDK was the preferred treatment to prevent these potential complications (40). Observational studies have demonstrated that the natural course of MCDK is typically benign with a decrease in size or complete involution over time (37,40-42). Because of the benign natural course, current recommendation for treatment of MCDK is observation with serial ultrasounds. Rarely, malignancies can arise in a MCDK. Renal cell carcinoma, Wilm’s tumor, and mesothelioma have been reported in patients with MCDK (40,43). Morphologic changes concerning for malignancy and refractory hypertension are indications for nephrectomy (41). Compensatory hypertrophy of the contralateral kidney occurs in response to the non-functioning MCDK (36,42). This compensatory hypertrophy puts the functioning kidney at increased risk for traumatic injury as it is no longer protected in its entirety by the posterior ribcage (44). Many physicians recommend restricting participation in contact sports for patients with a solitary kidney. This recommendation is controversial. Studies of large trauma registries have shown that bicycle riding, snow sports (sledding, skiing), and rollerblading are associated with the highest risk of renal injury (45,46). In these analyses, team contact sports (excluding ice hockey) were not responsible for any high grade renal injury. The major limitation of both studies is that the number of patients with solitary kidneys is unknown (45,46). These studies highlight the importance of cautioning patients with a solitary kidney of the risks of recreational sporting activities; organized team
UVJ obstruction UVJ obstruction is more common on the left and is bilateral 25% of the time. It occurs 4 times as frequently in males. Ureteral dilatation (megaureter) and dilated renal pelvis are seen on ultrasound (Figure 6). An aperistaltic segment of the distal ureter, near the UVJ, leads to the UVJ obstruction. Some urologists advocate conservative management (47,48). Surgical intervention involves excision of the distal ureteric segment, and tapering and reimplantation of the ureter (49). Ureterocele Cystic dilatation of the intravesical ureter results in the formation of an ureterocele. With an incidence of 1 in 5000 infants, it is most often associated with a duplicated collecting system or ectopic ureteral insertion. It is bilateral in 20-50% of cases and 2.5-3 times more likely in females (50). On VCUG, ureterocele is seen as a round, smooth filling defect at the base of the bladder (Figure 7). A VCUG will also assess for concomitant VUR. Upper pole hydroureteronephrosis is most common in ureteroceles complicating a duplicated collecting system. Endoscopic incision of the ureterocele is the preferred treatment (51). Additionally, nuclear renography should be done to determine the function of the upper renal pole. Upper pole heminephro-ureterectomy may be indicated if the upper pole moiety is non-functioning.
Extrarenal manifestations of obstructive uropathy Since the kidneys produce 90% of the amniotic fluid after 20 weeks gestation, severe bilateral prenatal urinary obstruction often results in oligohydramnios (17). Normal lung and orthopedic/soft tissue development are dependent upon adequate amniotic fluid, and these systems are often compromised in prenatal urinary obstruction with oligohydramnios. The respiratory complications range from mild to severe lung hypoplasia (17,28). Neonatal mortality commonly results from respiratory insufficiency in infants with severe urinary tract obstruction (29). The timing of the onset of urinary obstruction and resultant oligohydramnios has a significant impact on respiratory development and infant survival. Severe obstruction beginning after 24 weeks gestation affords a better prognosis due to improved pulmonary development (52). Talipes equinovarus and limb ¶·È‰È·ÙÚÈ΋ 2007;70:350-360
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contractures are common orthopedic complications. Severe oligohydramnios may lead to Potter sequence manifested by a typical facies with low-set ears, wideset eyes, and micrognathia along with orthopedic complications.
Fetal intervention Prevention of neonatal respiratory insufficiency (often leading to death) and progressive renal damage has led to studies in fetal intervention for obstructive uropathy. Open fetal surgery, percutaneous vesico-amniotic shunt placement, and fetoscopic surgery with laser ablation of posterior urethral valves have all been attempted (52,53). Prenatal surgical intervention is reserved for male patients with severe bilateral hydronephrosis who develop oligohydramnios and have no evidence of renal damage. Normal fetal urine is hypotonic, and elevated urinary levels of sodium, chloride, and osmolality are suggestive of renal damage and possibly irreversible dysplasia. In order to remove the confounding variable of stagnant urine and establish a trend, serial measurements of urinary electrolytes at 48-72 hour intervals are commonly used for assessment of renal damage (54). Urinary values of sodium <100 meq/L, chloride <90 meq/L, and osmolality <210 mosm are associated with a more favorable prognosis (53,55). Some improvement in lung development has been reported with restoration of normal volumes of amniotic fluid, but fetal surgical intervention has not resulted in significant improvement in renal outcome (52). Fetal surgical intervention is associated with a fatality rate as high as 56%, and almost all surgical interventions result in premature labor (52,53). Multiple other complications exist including inadequate drainage or migration of the shunt, perforation of the fetal bowel or bladder, iatrogenic gastroschisis, hemorrhage, and chorioamnionitis. Currently, severe oligohydramnios without evidence of renal dysplasia is the only indication for fetal surgical intervention (52). Management Electrolyte derangements and fluid balance abnormalities represent challenging problems in the management of infants with obstructive uropathy (Table 1). Decreased sodium absorption in the cortical collecting tubules, partially resulting from decreased Na+/K+- ATPase activity, leads to sodium wasting (23). Impairment of distal tubular potassium and hydrogen ion secretion results in a type IV renal tubular acidosis (RTA) and associated hyperkalemic metabolic acidosis (23). Potential etiologies of the Paediatriki 2007;70:350-360
â&#x2C6;&#x17E;
B
Figure 7. A. Bilateral ureteroceles are seen as round filling defects in the bladder on this VCUG. B. On renal ultrasound, the bilateral ureteroceles are also detected as thin membranes within the bladder. Arrows point to the ureteroceles.
type IV RTA include unresponsiveness of the damaged distal tubule to aldosterone (56), impaired turnover of the Na+/K+- ATPase, and loss of H+ATPase on the apical surface of intercalated cells (57,58). Down regulation of aquaporins and distortion of the medullary architecture may lead to nephrogenic diabetes insipidus. (23). As a result, infants with obstructive uropathy commonly require significant fluid administration to prevent dehydration. Short stature and/or failure to thrive are often associated with obstructive uropathy and reduced renal function (26-29). In studies comparing surgical
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interventions for PUV, body growth was no different in children who underwent primary valve ablation compared to urinary diversion with temporary cutaneous vesicostomy. Unfortunately, growth was decreased in both groups compared to normal children (29,31). Obstruction of the developing kidney results in a decrease in nephron endowment (59). Patients with obstructive uropathy rarely require renal replacement therapy as infants, and of those requiring dialysis, some may be able to transition off dialysis. Because of the decreased nephron endowment, children may need dialysis later in life. The later decline in renal function commonly develops around the time of puberty when the body’s demands exceed the capacity of the remaining functioning nephrons. A combination of factors may contribute to the occurrence of end stage renal disease in late adolescence. These include persistent obstruction, renal dysplasia, hyperfiltration, recurrent infection, increasing muscle mass, and abnormal bladder function (60). Classical sequelae of chronic renal failure are encountered in patients with severe obstructive uropathy. Electrolytes abnormalities including hyperkalemia and hyperphosphatemia require diet modification and dietary phosphate binders. Because of the urinary concentrating defect associated with obstructive uropathy, patients typically do not experience problems with fluid overload as they continue to have large volumes of urine despite low glomerular filtration rates. Hypertension may be caused by renal scars resulting in high renin production (56). Anemia of chronic renal failure requires treatment with human recombinant erythropoietin coupled with iron supplementation. Secondary hyperparathyroidism develops due to hyperphosphatemia and decreased production of 1,25-dihydroxyvitamin D, necessitating supplementation with exogenous 1,25dihydroxyvitamin D. Poor nutrition, uremia, and resistance to growth hormone contribute to poor body growth, and children often benefit from nutritional supplementation and recombinant growth hormone (61). Options for renal replacement therapy in infants include peritoneal dialysis (PD) and hemodialysis (HD); however, PD is the preferred method. PD does not require maintenance of vascular access that is necessary for HD (62). PD uses the patient’s peritoneum as the dialysis membrane, and during PD dialysate is introduced into the peritoneal cavity through an indwelling
peritoneal catheter. Dextrose is used in the dialysate to create an osmotic gradient that drives the net removal of fluid. Clearance of solute is achieved through diffusion from the peritoneal capillaries into the dialysate. The most common complication of PD is infection. Repeated episodes of peritonitis result in damage to the peritoneal membrane and, with time, may render the membrane inadequate for dialysis (61). Transplantation is a viable option for children with end stage renal disease resulting from obstructive uropathy, and 16.3% of pediatric patients presenting for renal transplantation have a diagnosis of obstructive uropathy (63). Historically, concerns for bladder dysfunction were a deterrent to transplantation in this population. In spite of this concern, numerous studies have shown transplantation to be successful. Severe bladder dysfunction may require bladder augmentation or reconstruction prior to transplant to ensure success (60,63). Aggressive management of dysfunctional voiding is also important for successful transplantation (63).
Animal models of obstruction Multiple animal models exist to investigate the pathogenesis and potential therapies for obstructive uropathy. The fetal sheep and the neonatal rat are the two most common models. The major benefit of fetal sheep is the ability to perform fetal surgery. Ureteral ligation and contralateral nephrectomy performed early in sheep gestation results in severe hydronephrosis and dysplasia of the remaining kidney (64,65). Simple hydronephrosis results when ureteral ligation is carried out late in gestation (64). Early decompression of surgically induced ureteral obstruction results in reversal of renal parenchymal damage. The previously obstructed kidney, however, has reduced postnatal function when compared to the contralateral kidney (66). The neonatal rat is a useful model for prenatal obstructive uropathy because only 10% of its nephrons are present at birth. During the initial 10 postnatal days, nephron formation is completed. In contrast, human kidney nephron development is completed by 34-36 weeks gestation (23). This difference in development allows for obstruction of the neonatal rat kidney to approximate human kidney obstruction during midtrimester nephrogenesis. Studies in neonatal rats demonstrate a significant reduction in nephron number that correlates with the duration of obstruction (59). Humoral and mechanical effects appear to play a ¶·È‰È·ÙÚÈ΋ 2007;70:350-360
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role in the obstructed rat kidney model. Impaired growth and maturation lead to a decrease in renal mass and DNA, a reduced number of nephrons, and immature glomeruli, tubules, renal vasculature, and interstitium (59,67,68). As distal tubular epithelial cells undergo mechanical stretching, tubular cells are stimulated to undergo apoptosis. This process may be mediated in part by increased expression of TGFâ&#x20AC;&#x161;1 (69). EGF expression is reduced during obstruction, and exogenous administration of EGF results in an 80% decrease in apoptosis (70). The interstitium is infiltrated by macrophages which enhances the production of ceramide. Both the macrophages and ceramide induce apoptosis (71,72). The renin-angiotensin system is activated during obstruction and mediates apoptosis via the AT2 receptor (23). Additionally, a reduction in renal blood flow and GFR is observed resulting from peritubular capillary compression and humoral effects (23,56).
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utero decompression prevents renal dysplasia. J Pediatr Surg 1984;19:649-657. 67. Chung KH, Chevalier RL. Arrested development of the neonatal kidney following chronic ureteral obstruction. J Urol 1996;155:1139-1144. 68. Chevalier RL, Kim A, Thornhill BA, Wolstenholme JT. Recovery following relief of unilateral ureteral obstruction in the neonatal rat. Kidney Int 1999;55:793-807. 69. Miyajima A, Chen J, Lawrence C, Ledbetter S, Soslow RA, Stern J, et al. Antibody to transforming growth factor-beta ameliorates tubular apoptosis in unilateral ureteral obstruction. Kidney Int 2000;58:2301-2313.
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70. Chevalier RL, Goyal S, Wolstenholme JT, Thornhill BA. Obstructive nephropathy in the neonatal rat is attenuated by epidermal growth factor. Kidney Int 1998;54:38-47. 71. Lange-Sperandio B, Cachat F, Thornhill BA, Chevalier RL. Selectins mediate macrophage infiltration in obstructive nephropathy in newborn mice. Kidney Int 2002;61:516-524. 72. Malik RK, Thornhill BA, Chang AY, Kiley SC, Chevalier RL. Renal apoptosis parallels ceramide content after prolonged ureteral obstruction in the neonatal rat. Am J Physiol Renal Physiol 2001;281:F56-F61.
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¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘ °. ¶·Ú‰·Ïfi˜ ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki (¡∫) Â›Ó·È ÌÈ· ÛÔ‚·Ú‹ ·ÁÁÂÈ›Ùȉ· ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ Ì ÚÔÙ›ÌËÛË ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜. ™‹ÌÂÚ·, ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›ÎÙËÙ˘ ηډÈÔ¿ıÂÈ·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, ·Ú¿ ÙÔ fiÙÈ ÌÂÈÒıËΠÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂڷ›·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ ÛÙËÚ›˙ÂÙ·È Û ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤ˆ˜ ÙÒÚ· ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ·ıÔÁÓˆÌÔÓÈ΋ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙËÓ ÙÂÎÌËÚÈÒÛÂÈ. ŸÙ·Ó Ë ¤ÎÊÚ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·˘ÙÒÓ Â›Ó·È Ï‹Ú˘, Ë ‰È¿ÁÓˆÛË Â›Ó·È Â‡ÎÔÏË. ™Â ·ÚÎÂÙÔ‡˜ fï˜ ·ÛıÂÓ›˜ ‰È·ÈÛÙÒÓÔÓÙ·È ÏÈÁfiÙÂÚ· ·fi Ù· ıÂÛÈÛı¤ÓÙ· ÎÚÈÙ‹ÚÈ· Î·È ·˘Ùfi ηıÈÛÙ¿ ÙË ‰È¿ÁÓˆÛË ‰˘Û¯ÂÚ‹. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ”·ÙÂÏ‹˜ ¡K”, Ë ‰È¿ÁÓˆÛË ·Ú·Ì¤ÓÂÈ ÂÈÙ·ÎÙÈ΋ ÁÈ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ˘„ËÏfi˜ Ì ·˘ÙfiÓ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘. ¶ÚfiÛÊ·Ù·, ·Ó·ÎÔÈÓÒıËÎ·Ó Ó¤Â˜ Û˘ÛÙ¿ÛÂȘ Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫. √È Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Î·È ÛÙË ÛÙÚ·ÙËÁÈ΋ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÒÛÙ ӷ ÚÔÏËÊı› Ô ·ÒÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘.
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, πÔÎÚ¿ÙÂÈÔ °¡ £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: °ÚËÁfiÚ˘ ¶·Ú‰·Ïfi˜ pargr@med.auth.gr §‡ÙÚ· 3 ∆.∫. 54 640, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: ∞ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki, ·ÁÁÂÈ›Ùȉ·, ·Ó‡ڢÛÌ·, ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘, ·ÛÈÚ›ÓË.
Kawasaki disease: Clinical heterogeneity and strategic management G. Pardalos Abstract: Kawasaki disease (KD) is a severe form of vasculitis of the middle-sized arteries with a predilection for the coronary arteries. It is the leading cause of paediatric acquired heart disease in developed countries, despite the significant decline in the incidence of coronary artery complications following the introduction of effective treatment. The diagnosis of KD is based on clinical criteria, in the absence of a specific diagnostic assay. The complete expression of these criteria makes the diagnosis simple, but some children may present with “incomplete KD” that displays some of the features without meeting the classic criteria. Diagnosis of KD in these children is often difficult, and the incidence of coronary artery complications in patients with the incomplete disease spectrum is at least as high as in those with typical Kawasaki disease. Recently, new guidelines have been published to aid in the diagnosis and management of KD. The aim of these guidelines is to sensitize paediatricians to the diagnostic evaluation and strategic management of patients with KD, and thereby to prevent the further risk of myocardial infarction.
First Department of Paediatrics, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece Correspondence: Grigoris Pardalos pargr@med.auth.gr 3, Lytra St. 54 640, Thessaloniki, Greece
Key words: Incomplete Kawasaki disease, vasculitis, aneurysm, intravenous gamma globulin, aspirin.
™˘ÓÙÔÌÔÁڷʛ˜ ¡∫ À∫ ∏∫° IVIG
¡fiÛÔ˜ Kawasaki ÀÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· ∏ÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ∂Ó‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘
∏ ÓfiÛÔ˜ Kawasaki (¡∫) Â›Ó·È ÌÈ· ÛÔ‚·Ú‹ ·ÁÁÂÈ›Ùȉ· ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ ÌÂ Û˘¯Ó‹ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ∏ Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂڷ›·˜ Ì Á-ÛÊ·ÈÚ›ÓË ¤Êı·Ó ÛÙÔ 20-40%, ÂÓÒ ÌÂÈÒıËΠ۠<5% ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÂÊ·ÚÌÔÁ‹˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·˘Ù‹˜ ·ÓÙÈÌÂÙÒÈÛ˘. ¶·ÚfiÏ· ·˘Ù¿,
Ë ¡∫ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›ÎÙËÙ˘ ηډÈÔ¿ıÂÈ·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ (1,2). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Î˘Ì·›ÓÂÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜ (∂˘ÚÒË ~5, ∞ÌÂÚÈ΋ ~10, ¡. ∫ÔÚ¤· ~50 Î·È π·ˆÓ›· >100 ÂÚÈÙÒÛÂȘ /100.000 ÏËı˘ÛÌÔ‡), Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ· (1,31,7:1) Î·È ·ÔÙÂÏ› ÓfiÛÔ Ù˘ ‚ÚÂÊÔÓËȷ΋˜ ΢ڛˆ˜ ËÏÈΛ·˜ (85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ≤ 5 ÂÙÒÓ) (1-4). ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Î·È Ë ·ıÔÁ¤ÓÂÈ¿ Ù˘ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ‰È¢ÎÚÈÓÈÛÙ›. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ¤Ó· ¿ÁÓˆÛÙÔ Ì¤¯ÚÈ Û‹ÌÂÚ· ·ÓÙÈÁfiÓÔ ¶·È‰È·ÙÚÈ΋ 2007;70:361-369
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(Èı·ÓÒ˜ ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜) ÚÔηÏ› ¤ÓÙÔÓË ‰È¤ÁÂÚÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ÂÎÊÚ¿˙ÂÙ·È Ì ÙȘ ÁÓˆÛÙ¤˜ ÊÏÂÁÌÔÓÒ‰ÂȘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÓÙȉڿÛÂȘ, Ì ΢ڛ·Ú¯Ô Û‡Ìو̷ ÙÔÓ ˘ÚÂÙfi. ŸÙ·Ó ÙÔ ·›ÙÈÔ ‰Ú· ¿Óˆ Û ¤Ó· ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ ˘fiÛÙڈ̷, ÙÔ ÔÔ›Ô Ì¤¯ÚÈ Û‹ÌÂÚ· ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ, Ô‰ËÁ› Û ÌÈ· ˘¤ÚÌÂÙÚË Î·È ·Ú·ÙÂٷ̤ÓË ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÂÓ·ÓÙ›ÔÓ ÙˆÓ Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÚÙËÚÈÒÓ Ì ÈÔ ÛËÌ·ÓÙÈ΋ ÚÔÛ‚ÔÏ‹ ·˘Ù‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∆ÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ‰ÈÂÚÁ·ÛÈÒÓ ·˘ÙÒÓ Â›Ó·È Ë Â›ÌÔÓË ÊÏÂÁÌÔÓ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Î·È Ë ÚfiÎÏËÛË ·Ó¢ڢÛÌ¿ÙˆÓ (1,5,6). ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ ÛÙËÚ›˙ÂÙ·È Û ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ÁÈ·Ù› ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ÌÈ· ·ıÔÁÓˆÌÔÓÈ΋ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙËÓ ÙÂÎÌËÚÈÒÛÂÈ. ŸÙ·Ó Ë ¤ÎÊÚ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·˘ÙÒÓ Â›Ó·È Ï‹Ú˘, Ë ‰È¿ÁÓˆÛË Â›Ó·È Â‡ÎÔÏË. ™Â ·ÚÎÂÙÔ‡˜ fï˜ ·ÛıÂÓ›˜, Ë ÓfiÛÔ˜ ÂÎÊÚ¿˙ÂÙ·È Ì ÏÈÁfiÙÂÚ· ·fi Ù· ıÂÛÈÛı¤ÓÙ· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Î·È ·˘Ùfi ηıÈÛÙ¿ ÙË ‰È¿ÁÓˆÛË ‰˘Û¯ÂÚ‹. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ “·ÙÂÏ‹˜ ¡∫”, Ë ‰È¿ÁÓˆÛË ·Ú·Ì¤ÓÂÈ ÂÈÙ·ÎÙÈ΋, ÁÈ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ˘„ËÏfi˜ Ì ·˘ÙfiÓ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘ (7). ¶ÚfiÛÊ·Ù·, Ë ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Âͤ‰ˆÛ Ӥ˜ Û˘ÛÙ¿ÛÂȘ Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫ (8). ™ÙÔ ¿ÚıÚÔ ·˘Ùfi, ı· ·Ó·Ù˘¯ıÔ‡Ó ÂÓ Û˘ÓÙÔÌ›· ÔÈ Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ Ì ÛÙfi¯Ô ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Î·È ÙË ÛÙÚ·ÙËÁÈ΋ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È fiÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÒÛÙ ӷ ÚÔÏËÊı› Ô ·ÒÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘.
∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ∏ ÎÏÈÓÈ΋ ÔÚ›· Ù˘ ¡∫, Û’ fiϘ ÙȘ ÌÔÚʤ˜ Ù˘, ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ Ê¿ÛÂȘ: π. √Í›· Ê¿ÛË (‰È¿ÚÎÂÈ·˜ 1-2 ‚‰ÔÌ¿‰ˆÓ), fiÔ˘ ÂÈÎÚ·ÙÔ‡Ó Ù· ¤ÓÙÔÓ· ÊÏÂÁÌÔÓÒ‰Ë Ê·ÈÓfiÌÂÓ· Ì ΢ڛ·Ú¯Ô ÙÔÓ ˘ÚÂÙfi. ππ. ÀÔÍ›· Ê¿ÛË (‰È¿ÚÎÂÈ·˜ 2-4 ‚‰ÔÌ¿‰ˆÓ). ÀÔ¯ˆÚ› Ô ˘ÚÂÙfi˜ ·ÏÏ¿ ÂÈ̤ÓÔ˘Ó Ë Î·ÎÔ˘¯›· Î·È Ë ·ÓÔÚÂÍ›·. ÷ڷÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ Ê¿Û˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚˆÓ Î·È Ë ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË, ·ÔÙÂÏ› ‰Â ÙË Ê¿ÛË Î·Ù¿ ÙËÓ ÔÔ›· ÂÈÛ˘Ì‚·›ÓÂÈ Ë ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Ì ·ÎfiÏÔ˘ıÔ ÙË ‰È¿Ù·Û‹ ÙÔ˘˜ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·Ó¢ڢÛÌ¿ÙˆÓ. πππ. º¿ÛË ·Ó¿ÚÚˆÛ˘. ∞Ú¯›˙ÂÈ 6-8 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Ì ÙËÓ Ï‹ÚË ˘Ô¯ÒÚËÛË fiÏˆÓ ÙˆÓ Î‡ÚÈˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ‰È·‰Èηۛ· Paediatriki 2007;70:361-369
˘ÔÛÙÚÔÊ‹˜ ‹ ÛÙ·ıÂÚÔÔ›ËÛ˘ ÙˆÓ ·Ó¢ڢÛÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ, Â¿Ó Ê˘ÛÈο ¤¯Ô˘Ó ÚÔ·„ÂÈ (1,2,5).
∆˘È΋ ÓfiÛÔ˜ Kawasaki ∆· ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ Ù˘È΋˜ ¡∫ Â›Ó·È ÎÏÈÓÈο Î·È Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. √ ˘ÚÂÙfi˜ ·ÔÙÂÏ› ÙÔ Î˘Ú›·Ú¯Ô Û‡Ìو̷, Â›Ó·È ˘„ËÏfi˜ (>39,5ÔC), ·ÓıÂÎÙÈÎfi˜ ÛÙ· ·ÓÙÈ˘ÚÂÙÈο Î·È Û˘Óԉ‡ÂÙ·È ·fi ·ÓÔÚÂÍ›·, ηٷ‚ÔÏ‹ ‰˘Ó¿ÌˆÓ, ·ÓËÛ˘¯›·, ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ˘ÓËÏ›·. ∏ ̤ÛË ‰È¿ÚÎÂÈ¿ ÙÔ˘ ¯ˆÚ›˜ ıÂڷ›· Â›Ó·È 11 Ë̤Ú˜, ·ÏÏ¿ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ÂÚÈÙÒÛÂȘ Ì ‰È¿ÚÎÂÈ· ÌÂÁ·Ï‡ÙÂÚË ·fi ¤Ó· Ì‹Ó·. ∏ ÂÈÂÊ˘Î›Ùȉ· Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚË, ÌË ˘Ò‰Ë˜ Î·È ·Û˘Ìو̷ÙÈ΋. ∆Ô ÁÂÁÔÓfi˜ ‰Â fiÙÈ ‰È·ÚΛ ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ì›· ¤ˆ˜ ‰‡Ô Ë̤Ú˜, οÓÂÈ ÙËÓ ·Ó›¯ÓÂ˘Û‹ Ù˘ ‰‡ÛÎÔÏË. √È ·ÏÏÔÈÒÛÂȘ ·fi ÙÔÓ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ÂÛÙÈ¿˙ÔÓÙ·È Î˘Ú›ˆ˜ ÛÙ· ÂÚ˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË Î·È ÙË ÌÔÚÔÂȉ‹ ÁÏÒÛÛ· (∂ÈÎfiÓ· 1). ™˘¯Ó¿, Û˘Ó˘¿Ú¯ÂÈ Î·È ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ·ÏÏ¿ ¯ˆÚ›˜ ÂÛÙȷΤ˜ ·ÏÏÔÈÒÛÂȘ, ¤ÏÎË ‹ ÂȯڛÛÌ·Ù·. ™ËÌÂÈÒÓÔÓÙ·È Â›Û˘ ·ÏÏÔÈÒÛÂȘ ·fi Ù· ÂÚÈÊÂÚÈο ¿ÎÚ·. ∆Ô ÂÚ‡ıËÌ· Î·È ÙÔ Ô›‰ËÌ· ·Ï·ÌÒÓ (∂ÈÎfiÓ· 2) Î·È ÂÏÌ¿ÙˆÓ ·Ó‹ÎÔ˘Ó ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÚÒÈÌ· Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ Î·È ··ÓÙÔ‡Ó Ôχ Û˘¯ÓfiÙÂÚ· ÛÙ· ‚Ú¤ÊË. ∞ÓÙ›ıÂÙ·, Ë ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË (∂ÈÎfiÓ· 4) ·ÔÙÂÏ› ÙÔ ÌÔÓ·‰ÈÎfi ·fi Ù· ÎÏ·ÛÈο Â˘Ú‹Ì·Ù· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Â‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ∆Ô ÂÍ¿ÓıËÌ· ÂÌÊ·Ó›˙ÂÙ·È ÙȘ ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ Ù˘ ÓfiÛÔ˘, Â›Ó·È ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ Î·È ÂÓÙÔ›˙ÂÙ·È ÈÔ ¤ÓÙÔÓ· ÛÙÔÓ ÎÔÚÌfi (∂ÈÎfiÓ· 3). ™·ÓÈfiÙÂÚ·, ÌÔÚ› Ó· ¿ÚÂÈ ÙË ÌÔÚÊ‹ ÙÔ˘ ÎÓȉˆÙÈÎÔ‡ ‹ ÙÔ˘ ÔÛÙÚ·ÎÈÒ‰Ô˘˜ Î·È Û¯Â‰fiÓ ÔÙ¤ ÙÔ˘ ÂÙ¯ÂÈÒ‰Ô˘˜ ‹ Ê˘Û·ÏÈ‰Ò‰Ô˘˜. ∆¤ÏÔ˜, Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Â›Ó·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ Ù˘ ÂÙÂÚfiÏ¢ÚË Î·È ˘ÔÏ›ÂÙ·È ÛÂ Û˘¯ÓfiÙËÙ· (25-50%) ÙˆÓ ÏÔÈÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ (>90%). √È ÏÂÌÊ·‰¤Ó˜ ¤¯Ô˘Ó ¶›Ó·Î·˜ 1. ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘ Kawasaki ¶˘ÚÂÙfi˜ ≥5 Ë̤Ú˜ Î·È 4 ·fi Ù· ·ÎfiÏÔ˘ı· 5 Â˘Ú‹Ì·Ù·: 1. ∞ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ· (ÌË ˘Ò‰Ë˜) 2. ™ÙÔÌ·ÙÔÊ·Ú˘ÁÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ - ÂÚ‡ıËÌ· Î·È Û¯¿ÛË ¯ÂÈϤˆÓ - ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ· - ‰È¿¯˘ÙÔ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎfi ÂÚ‡ıËÌ· 3. ∞ÏÏÔÈÒÛÂȘ ·fi Ù· ÂÚÈÊÂÚÈο ¿ÎÚ· - ÂÚ‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ - Ô›‰ËÌ· ¿ÎÚˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÈÒÓ - ·ÔϤÈÛË ‰·ÎÙ‡ÏˆÓ ¯ÂÈÚÒÓ Î·È Ô‰ÈÒÓ (ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË) 4. ∂Í¿ÓıËÌ· ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ ‹ ÈÏ·ÚÔÂȉ¤˜, ÌË Ê˘Û·Ïȉ҉˜ 5. ∂ÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ (≥1,5 cm)
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∂ÈÎfiÓ· 1. ∂Ú˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË Î·È ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ·. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).
∂ÈÎfiÓ· 3. ∂Í¿ÓıËÌ· ÎËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ ÛÙÔÓ ÎÔÚÌfi. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).
∂ÈÎfiÓ· 2. ∂Ú˘ıÚfiÙËÙ· Î·È Ô›‰ËÌ· ·Ï·ÌÒÓ. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23).
¶›Ó·Î·˜ 2. ÕÏϘ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ Kawasaki ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (ÂÎÙfi˜ ·fi Ù· ÎÏ·ÛÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·) ∫·Ú‰È·ÁÁÂÈ·Îfi - ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ (‰È¿Ù·ÛË, ·Ó¢ڇÛÌ·Ù·, Û·Ó›ˆ˜ ıÚfiÌ‚ˆÛË) - ·Ó¢ڇÛÌ·Ù· ÂÚÈÊÂÚÈÎÒÓ ·ÚÙËÚÈÒÓ - ‹È· ÂÚÈηډ›Ùȉ·, Ì˘Ôηډ›Ùȉ·, ·ÚÔ‰È΋ ·Ó¿ÚÎÂÈ· ‚·Ï‚›‰ˆÓ ∫¡™ - ¢ÂÚÂıÈÛÙfiÙËÙ·, ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· °·ÛÙÚÂÓÙÂÚÈÎfi - ‰È¿ÚÚÔÈ·, Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë·Ù›Ùȉ·, Û·Ó›ˆ˜ ‡‰Úˆ·˜ ¯ÔÏˉfi¯Ô˘ ∞Ó·Ó¢ÛÙÈÎfi - ‚‹¯·˜, ÚÈÓ›Ùȉ·, Û·Ó›ˆ˜ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ ª˘ÔÛÎÂÏÂÙÈÎfi - ·ÚıÚ·ÏÁ›Â˜, ·ÚıÚ›Ùȉ·, Û·Ó›ˆ˜ Ì˘ÔÛ›Ùȉ· √˘ÚÔÔÈËÙÈÎfi - ¿ÛËÙË ˘Ô˘Ú›·, Û·Ó›ˆ˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ‹/Î·È ·ÈÌ·ÙÔ˘Ú›·
‰È¿ÌÂÙÚÔ ÌÂÁ·Ï‡ÙÂÚË ·fi 1,5 cm Î·È Â›Ó·È Û˘Ó‹ıˆ˜ ÔÌÔÈÔÁÂÓ›˜ ¯ˆÚ›˜ ÎÏ˘‰·ÛÌfi (1,2,8-10). ∏ ÓfiÛÔ˜, fï˜, ÂÎÊÚ¿˙ÂÙ·È Î·È Ì ÌÈ· ÏÂÈ¿‰· ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (¶›Ó·Î·˜ 2). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ηıÈÛÙ¿ ··Ú·›ÙËÙË ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ·fi ·ı‹ÛÂȘ Ì ·ÚfiÌÔÈ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·, fiˆ˜ Â›Ó·È ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (ÈÏ·Ú¿, ∂-µV Ïԛ̈ÍË, ∏∏V-6, ·‰ÂÓÔ˚Ô›, ÂÓÙÂÚÔ˚Ô› Î.¿), ÔÈ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ (‚·ÎÙËÚȷ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, Ô˘ÚÔÏԛ̈ÍË, ÔÛÙÚ·ÎÈ¿, Û‡Ó‰ÚÔÌÔ ÛÙ·Ê˘ÏÔÎÔÎÎÈ΋˜ ·ÔÊÔÏȉˆÙÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜), ÙÔ Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜, ÙÔ Û‡Ó‰ÚÔÌÔ Stevens-Johnson, Ë ˘ÂÚ¢·ÈÛıËÛ›· Û ʿÚ̷η, Ë Û˘ÛÙËÌ·ÙÈ΋ Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· Î·È ¿ÏÏ· ÈÔ Û¿ÓÈ· ·›ÙÈ·. ÃÚÂÈ¿˙ÂÙ·È, ÏÔÈfiÓ, ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ÔÈ· ‰ËÏ·‰‹ ÎÏÈÓÈο
∂ÈÎfiÓ· 4. ¶ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋ ·ÔϤÈÛË. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ¿‰ÂÈ·˜ (23). ¶·È‰È·ÙÚÈ΋ 2007;70:361-369
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°. ¶·Ú‰·Ïfi˜
¶›Ó·Î·˜ 3. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ˘¤Ú Î·È ÂÓ·ÓÙ›ÔÓ ¡. Kawasaki ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο
À¤Ú ¡. Kawasaki
∫·Ù¿ ¡. Kawasaki
¶˘ÚÂÙfi˜
À„ËÏfi˜ (>39ÔC), Ô͇·È¯Ì· ·̷ٷ, ‰È·ÚΛ ≥ 5 Ë̤Ú˜ ªË ˘Ò‰Ë˜, ·ÌÊÔÙÂÚfiÏ¢ÚË ∂Ú˘ıÚ¿ Ì ۯ¿ÛÂȘ ¯Â›ÏË, ÌÔÚÔÂȉ‹˜ ÁÏÒÛÛ·, ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∂Ú‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ, Ô›‰ËÌ· ¿ÎÚˆÓ ¯ÂÈÚÒÓ-Ô‰ÈÒÓ, ·ÔϤÈÛË ‰·ÎÙ‡ÏˆÓ ÌÂÙ¿ ÙËÓ 1Ë ‚‰ÔÌ¿‰· ∫ËÏȉԂϷÙȉ҉˜ Û˘ÚÚ¤ÔÓ, ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ 5 ËÌÂÚÒÓ, ÌÔÈ¿˙ÂÈ Ì ÔÛÙÚ·ÎÈ҉˜ ‹ ÔχÌÔÚÊÔ, ÈÔ ¤ÓÙÔÓÔ ÂÚÈÚˆÎÙÈο-‰˘Ó·ÙfiÓ Î·È Ì ·ÔϤÈÛË ™˘Ó‹ıˆ˜ ÂÙÂÚfiÏ¢ÚË Î·È >1,5 cm ŒÓÙÔÓË Â˘ÂÚÂıÈÛÙfiÙËÙ·, ηډÈÔ·ÁÁÂȷΤ˜ ‰È·Ù·Ú·¯¤˜, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ‰È¿ÚÚÔÈ·, Ë·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹, ·ÚıÚ·ÏÁ›Â˜-·ÚıÚ›Ùȉ·, ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· ¿ÛËÙË ˘Ô˘Ú›·-Ô˘ÚËıÚ›Ùȉ·, ÈÚȉÔ΢ÎÏ›Ùȉ·
÷ÌËÏfi˜-̤ÙÚÈÔ˜ (<39ÔC), ˘Ô¯ˆÚ› Û ÏÈÁfiÙÂÚÔ ·fi 5 Ë̤Ú˜ ¶˘Ò‰Ë˜ ∂ͤڢıÚÔ˜ Ê¿Ú˘ÁÁ·˜ ÌfiÓÔ, fi¯È ÂÚ˘ıÚfiÙËÙ· ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ ∞ÔϤÈÛË ·Ï·ÌÒÓ-ÂÏÌ¿ÙˆÓ Û˘ÓÔÏÈο, fi¯È ÂȉÈο ÂÚÈÔÓ‡¯È· ‰·ÎÙ˘ÏÈ΋, ÛÙËÓ ·Ú¯‹ Ù˘ ÓfiÛÔ˘ ∂ÌÊ·Ó›˙ÂÙ·È ·ÚÁfiÙÂÚ· (> 5Ë Ì¤Ú· ÓfiÛÔ˘) Î·È ÌÂÙ¿ ÙËÓ ÙÒÛË ÙÔ˘ ˘ÚÂÙÔ‡
∂ÈÂÊ˘Î›Ùȉ· ∞ÏÏÔÈÒÛÂȘ ·fi ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∞ÏÏÔÈÒÛÂȘ ·fi ÂÚÈÊÂÚÈο ¿ÎÚ· ∂Í¿ÓıËÌ·
∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· ÕÏÏ· Â˘Ú‹Ì·Ù·
¯·Ú·ÎÙËÚÈÛÙÈο Â›Ó·È ÂÓ‰ÂÈÎÙÈο ÁÈ· ¡∫ Î·È ÔÈ· fi¯È (¶›Ó·Î·˜ 3). ∞·Ú·›ÙËÙË Â›Ó·È Â›Û˘ Î·È Ë Û˘Ó‰ÚÔÌ‹ ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ÔÈ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (1,2,8-10).
∞ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki ∏ ‰È¿ÁÓˆÛË Ù˘ ¡∫ Â›Ó·È Â‡ÎÔÏË fiÙ·Ó ÏËÚÔ‡ÓÙ·È Ù· Ù¤ÛÛÂÚ· ·fi Ù· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ¤ÓÙ ÎÚÈ-
°ÂÓÈÎÂ˘Ì¤ÓË ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ∫·Ï‹ ÁÂÓÈ΋ ηٿÛÙ·ÛË
Ù‹ÚÈ·, ·ÏÏ¿ ‰‡ÛÎÔÏË fiÙ·Ó ÏËÚÔ‡ÓÙ·È ÏÈÁfiÙÂÚ· (2 ‹ 3) (·ÙÂÏ‹˜ ¡. Kawasaki). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ··ÈÙ›, ÂÎÙfi˜ ·fi ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙˆÓ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ, ÙË ‚Ô‹ıÂÈ· Î·È ÙÔ˘ ·Ú·ÎÏÈÓÈÎÔ‡ ÂϤÁ¯Ô˘ (7). ∏ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Ì ÙË Û‡ÌʈÓË ÁÓÒÌË Î·È Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ Âͤ‰ˆÛÂ Û˘ÛÙ¿ÛÂȘ (guidelines) ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· Ô˘ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È Û ÂÚÈÙÒÛÂȘ “·ÙÂÏÔ‡˜ N. Kawasaki” (8).
¶˘ÚÂÙfi˜ ÁÈ· ≥5 ̤Ú˜ Î·È ≥2 ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ¡∫ µ‹Ì· 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË ªË Û˘Ì‚·Ù‹ Ì ¡∫ Î·È ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ∂·ÓÂÎÙ›ÌËÛË ¶ÏËÚÔ› Ù· ·ÚÈ· Î·È ≥3 Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” £Âڷ›· Î·È À∫
™˘Ì‚·Ù‹ Ì ¡∫ µ‹Ì· 2. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¶ÏËÚÔ› Ù· ·ÚÈ· Î·È <3 ¢ÂÓ ÏËÚÔ› Ù· ·ÚÈ· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·”
µ‹Ì· 3. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (À∫) µ‹Ì· 4. ∫·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË £ÂÙÈÎfi £Âڷ›·
∞ÚÓËÙÈÎfi √ ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ¡∞π
√Ãπ
√ ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ÁÈ· ≥2 ̤Ú˜ ¡∞π
√Ãπ
∞ÔϤÈÛË ∂·Ó¿ÏË„Ë ªË Èı·Ó‹ ∂·ÓÂÎÙ›ÌËÛË À∫ ‰È¿ÁÓˆÛË ÎÏÈÓÈ΋ Î·È Â·ÓÂÎÙ›ÌËÛË ¡∫ ÂÚÁ·ÛÙËÚȷ΋ ¡∞π √Ãπ ∂·Ó¿ÏË„Ë ¢È·ÎÔ‹ À∫ ·Ú·ÎÔÏÔ‡ıËÛ˘ ·ÓÂÎÙ›ÌËÛË ∂ÈÎfiÓ· 5. ∞ÏÁfiÚÈıÌÔ˜ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ·ÙÂÏÔ‡˜ ÓfiÛÔ˘ Kawasaki. Paediatriki 2007;70:361-369
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¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘
¶›Ó·Î·˜ 4. ∫‡ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ù˘ ·ÙÂÏÔ‡˜ ÓfiÛÔ˘ Kawasaki π. ∫‡ÚÈ· (2): - ∆∫∂: > 40 mm/h - CRP: > 3 mg/dL £ÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·: ≥ 1 “ÎÚÈÙ‹ÚÈÔ” ππ. ™˘ÌÏËڈ̷ÙÈο (6): - §Â˘ÎÔ΢ÙÙ¿ÚˆÛË: > 15 x 103/ÌL - ∞Ó·ÈÌ›· (ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘) - £ÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË: > 450 x 103/ÌL, ÌÂÙ¿ ÙËÓ 7Ë Ì¤Ú· ÓfiÛÔ˘ - ÀÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·: ≤ 3g/dL - ∞‡ÍËÛË ALT (SGPT) - ¶˘Ô˘Ú›·: > 10 ˘ÔÛÊ·›ÚÈ· ÎÔ £ÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·: ≥ 3 “ÎÚÈÙ‹ÚÈ·”
∏ ‰È·‰Èηۛ· ·˘Ù‹, ÁÈ· ¢ÎÔÏ›·, ÛÙ·‰ÈÔÔÈÂ›Ù·È Û ٤ÛÛÂÚ· ‚‹Ì·Ù· (∂ÈÎfiÓ· 5). ¢È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ·ÙÂÏÔ‡˜ ¡. Kawasaki µ‹Ì· 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË ∆Ô ÚˆÙ·Ú¯ÈÎfi Î·È Î‡ÚÈÔ ÂÚÒÙËÌ· Ô˘ Ù›ıÂÙ·È Â›Ó·È ·Ó Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÏËÚÔ› Ù· ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ “·ÙÂÏÔ‡˜ N. Kawasaki”, ‰ËÏ·‰‹ Â¿Ó ˘¿Ú¯ÂÈ ˘ÚÂÙfi˜ ≥5 Ë̤Ú˜ Î·È 2 ‹ 3 ·fi Ù· 5 ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·. ∞Ó Ë ·¿ÓÙËÛË Â›Ó·È ıÂÙÈ΋, ÚÔ¯ˆÚԇ̠ÛÙÔ ‰Â‡ÙÂÚÔ ‚‹Ì·. ∞Ó fï˜ Ë ÛËÌÂÈÔÏÔÁ›· ‰ÂÓ Â›Ó·È Û˘Ì‚·Ù‹ ÂÓÒ Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ, Ô ·ÛıÂÓ‹˜ ·ÓÂÎÙÈÌ¿Ù·È. µ‹Ì· 2. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ·ÚÈ· Î·È Ù· Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” (¶›Ó·Î·˜ 4) Î·È Ë ‰È·ÁÓˆÛÙÈ΋ ‰È·‰Èηۛ· ÂÍÂÏ›ÛÛÂÙ·È ·Ó·ÏfiÁˆ˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ. ŒÙÛÈ, fiÙ·Ó ÏËÚÔ‡ÓÙ·È Ù· ·ÚÈ· Î·È Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·”, ÙfiÙ ··ÈÙÂ›Ù·È Ë ¿ÌÂÛË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ·ÎÔÏÔ˘ı› Û ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (YK). ∞Ó fï˜ ÏËÚÔ‡ÓÙ·È ÌfiÓÔ Ù· ·ÚÈ· “ÎÚÈÙ‹ÚÈ·” Î·È ˘¿Ú¯Ô˘Ó <3 Û˘ÌÏËڈ̷ÙÈο, ÙfiÙ ÚÔ¯ˆÚԇ̠ÛÙÔ ÂfiÌÂÓÔ ‚‹Ì·. µ‹Ì· 3. ÀÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ŸÙ·Ó ÙÔ À∫ Â›Ó·È ıÂÙÈÎfi ÁÈ· ‰È¿Ù·ÛË ‹ ·Ó‡ڢÛÌ· ÛÙÂÊ·ÓÈ·›ˆÓ, ÚÔ¯ˆÚԇ̠۠ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∞Ó Â›Ó·È ·ÚÓËÙÈÎfi Î·È Ô ˘ÚÂÙfi˜ ¤¯ÂÈ ˘Ô¯ˆÚ‹ÛÂÈ, ÙfiÙÂ Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È Èı·Ó‹. ∞Ó fï˜ Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ, ÙfiÙÂ Û˘ÓÈÛÙ¿Ù·È Â·Ó¿ÏË„Ë ÙÔ˘ À∫ Î·È Â·ÓÂÎÙ›ÌËÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘, ÙfiÛÔ ÎÏÈÓÈ΋ fiÛÔ Î·È ÂÚÁ·ÛÙËÚȷ΋. ∆¤ÏÔ˜, ·Ó ‰ÂÓ ÏËÚÔ‡ÓÙ·È Ù· ·ÚÈ· ÂÚÁ·ÛÙËÚȷο ÎÚÈÙ‹ÚÈ· ÚÔ¯ˆÚԇ̠ÛÙÔ ÙÂÏÂ˘Ù·›Ô ‚‹Ì·. µ‹Ì· 4. ∫·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ŸÙ·Ó Ô ˘ÚÂÙfi˜ ÂÈ̤ÓÂÈ ÁÈ· >2 Ë̤Ú˜, ÙfiÙÂ Ô ·ÛıÂÓ‹˜ ˘Ô‚¿ÏÏÂÙ·È Û ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋
¶›Ó·Î·˜ 5. ∞Ú¯È΋ ıÂڷ›· ¡. Kawasaki 1. ∂Ó‰ÔÊϤ‚È· ¤Á¯˘ÛË Á- ÛÊ·ÈÚ›Ó˘ (IVIG) Û ‰fiÛË 2 g/kg Û ̛· Û˘Ó¯‹ ¤Á¯˘ÛË 2. ∞ÛÈÚ›ÓË: - ¤Ó·ÚÍË Ì ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ (˘„ËÏ‹ ‰fiÛË) ∏¶∞, π·ˆÓ›·: 80-100mg/kg Û 4 ›Û˜ ‰fiÛÂȘ per os ‹ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ: 30-50 mg/kg Û 3 ›Û˜ ‰fiÛÂȘ per os ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘: ·) ̤¯ÚÈ Î·È 2-3 ̤Ú˜ ÌÂÙ¿ ÙËÓ ÙÒÛË ˘ÚÂÙÔ‡ ‹/Î·È Ù˘ CRP ‹ ‚) ¤ˆ˜ Î·È ÙË 10Ë-14Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ - ·ÎÔÏÔ˘ı› Ë ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (¯·ÌËÏ‹ ‰fiÛË) 3-5 mg/kg ¿·Í ËÌÂÚËÛ›ˆ˜ ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ Î·È ¤ˆ˜ fiÙÔ˘ Á›ÓÂÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜
·ÓÂÎÙ›ÌËÛË. ∏ ÙÒÛË, ˆÛÙfiÛÔ, ÙÔ˘ ˘ÚÂÙÔ‡, ‰ÂÓ ‰ÈηÈÔÏÔÁ› ÂÊËÛ˘¯·ÛÌfi. ∞·Ú·›ÙËÙË, ÂÓ ÚÔÎÂÈ̤ӈ, Â›Ó·È Ë Î·ıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ÂÌÊ¿ÓÈÛ˘ ÂÚÈÔÓ‡¯È·˜ ‰·ÎÙ˘ÏÈ΋˜ ·ÔϤÈÛ˘. ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·ÔϤÈÛË, ÙfiÙ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ·Ú·ÎÔÏÔ‡ıËÛË. ∞Ó fï˜ ‰È·ÈÛÙˆı› ·ÔϤÈÛË, ÚÔ¯ˆÚԇ̠··Ú·Èًو˜ Û À∫ ÒÛÙ ӷ ηıÔÚ›ÛÔ˘ÌÂ, ·Ó·ÏfiÁˆ˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ, ÙËÓ ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ ··ÈÙÂ›Ù·È ÛÙ· ÌÈÎÚ¿ ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ ¤ÍÈ ÌËÓÒÓ, ÁÈ·Ù› fiÛÔ ÈÔ ÌÈÎÚ‹ Â›Ó·È Ë ËÏÈΛ· ÙfiÛÔ ÈÔ ·ÙÂÏ‹˜ Â›Ó·È Ë ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Î·È ÙfiÛÔ ÈÔ ˘„ËÏfi˜ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·Ó¢ڢÛÌ¿ÙˆÓ. ŒÙÛÈ, Û ÌÈÎÚ¿ ‚Ú¤ÊË Ì ˘ÚÂÙfi >6 Ë̤Ú˜ Î·È Û˘ÓÔ‰fi ·‡ÍËÛË ∆∫∂ ‹/Î·È CRP, ·ÎfiÌË Î·È ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· ·fi Ù· ‰È·ÁÓˆÛÙÈο ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ (0/5), ··Ú·›ÙËÙÔ ıˆÚÂ›Ù·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ¤¯Ô˘Ó ·ÔÎÏÂÈÛÙ› ¿ÏÏ· ·ıÔÏÔÁÈο ·›ÙÈ· Î·È Î˘Ú›ˆ˜ ÔÈ ÏÔÈÌÒÍÂȘ (11). ŸÙ·Ó ·ÎÔÏÔ˘ıÂ›Ù·È Ë ‰È·ÁÓˆÛÙÈ΋ ·˘Ù‹ ‰È·‰Èηۛ·, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÌË ‰È¿ÁÓˆÛ˘ ‹ Ù˘ ηı˘ÛÙ¤ÚËÛ˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ·ÔʇÁÔÓÙ·È Ù· ‰È·ÁÓˆÛÙÈο ÛÊ¿ÏÌ·Ù·. ∆· ÈÔ Û˘¯Ó¿ ÛÊ¿ÏÌ·Ù· Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È Â›Ó·È: ·) Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ ‚·ÎÙËÚȷ΋ Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ‚) Ë ˘Ô˘Ú›· Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ Ô˘ÚÔÏԛ̈ÍË Ì¤¯ÚÈ Ó· Á›ÓÂÈ ÁÓˆÛÙfi ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ηÏÏȤÚÁÂÈ·˜, Á) Ë Á·ÛÙÚÂÓÙÂÚÈ΋ ÛËÌÂÈÔÏÔÁ›· Ó· ıˆÚËı› ÔÍ›· ÎÔÈÏ›· Î·È Ó· ·ÓÙÈÌÂÙˆÈÛı› ·fi ·È‰Ô¯ÂÈÚÔ˘ÚÁÔ‡˜ Ì ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, fiÙ·Ó ·ÎÔÏÔ˘ı› Ë ¤Îı˘ÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜, ηıÒ˜ Î·È Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜, Ë fiÏË ÛËÌÂÈÔÏÔÁ›· ÂÎÏ·Ì‚¿ÓÂÙ·È ÂÛÊ·Ï̤ӷ ˆ˜ ·ÓÂÈı‡ÌËÙË ·ÓÙ›‰Ú·ÛË ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ∆¤ÏÔ˜, ‰) Ô ˘ÚÂÙfi˜, ÙÔ ÂÍ¿ÓıËÌ· Î·È Ë ¶·È‰È·ÙÚÈ΋ 2007;70:361-369
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°. ¶·Ú‰·Ïfi˜
ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË ÛÙÔ ∂¡À Ó· ÂÎÏ·Ì‚¿ÓÔÓÙ·È ÂÛÊ·Ï̤ӷ ˆ˜ ÈÔÁÂÓ‹˜ ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· Î·È fi¯È ˆ˜ Û˘ÓÔ‰¿ Â˘Ú‹Ì·Ù· Ù˘ ¡∫ (1,2,7-10).
£Âڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·Ú¯È΋ ıÂڷ›· Î·È ÙË ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∞Ú¯È΋ ıÂڷ›· ∏ ·Ú¯È΋ ıÂڷ›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ (IVIG) Î·È ·ÛÈÚ›Ó˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ (¶›Ó·Î·˜ 5) Î·È ÂÊ·ÚÌfi˙ÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∏ IVIG ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 2 g/kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Û ̛· Û˘Ó¯‹ ¤Á¯˘ÛË ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 10 ˆÚÒÓ. ∏ ıÂڷ›· Ì ·ÛÈÚ›ÓË ÍÂÎÈÓ¿ ·) Ì ÙËÓ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ (˘„ËÏ‹ ‰ÔÛÔÏÔÁ›·) Î·È Û˘Ó¯›˙ÂÙ·È ‚) Ì ÙËÓ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (¯·ÌËÏ‹ ‰ÔÛÔÏÔÁ›·) (5,8-10). ·) ∞ÓÙÈÊÏÂÁÌÔÓ҉˘ ‰fiÛË ·ÛÈÚ›Ó˘. ∞ÎÔÏÔ˘ıÔ‡ÓÙ·È ‰‡Ô ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù·: ÛÙȘ ∏¶∞ Î·È ÙËÓ π·ˆÓ›· ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙˆÓ 80-100 mg/kg/24ˆÚÔ Û 4 ›Û˜ ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ÂÓÒ ÛÙËÓ ∞ÁÁÏ›· Î·È ¿ÏϘ Â˘Úˆ·˚Τ˜ ΢ڛˆ˜ ¯ÒÚ˜ ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙˆÓ 30-50 mg/kg/24ˆÚÔ Û 3 ›Û˜ ‰fiÛÂȘ. ∆Ô Î¿ı ۯ‹Ì· ͯˆÚÈÛÙ¿ ¤¯ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· ·ÏÏ¿ ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Û‡ÁÎÚÈÛ˘ ÙˆÓ ‰‡Ô Û¯ËÌ¿ÙˆÓ Î·È ÙÔ Î¿ı ΤÓÙÚÔ ÂÊ·ÚÌfi˙ÂÈ ÙÔ ¤Ó· ‹ ÙÔ ¿ÏÏÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ (5,8-10). À¿Ú¯Ô˘Ó fï˜ Î·È ÌÂÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ Î›Ó‰˘ÓÔÈ ·fi ÙȘ ˘„ËϤ˜ ‰fiÛÂȘ ·ÛÈÚ›Ó˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔÈ ·fi Ù· ÔʤÏË Î·È ÚÔÙ›ÓÔ˘Ó ÙËÓ Î·Ù¿ÚÁËÛË Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ Î·È ÙËÓ ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ÙËÓ ÂÍ ·Ú¯‹˜ ¯ÔÚ‹ÁËÛË Ù˘ ¯·ÌËÏ‹˜ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ‰fiÛ˘ (12). ŸÌˆ˜, Û ̛· ÚfiÛÊ·ÙË ÌÂÙ··Ó¿Ï˘ÛË fiÏˆÓ ÙˆÓ ÂÚÁ·ÛÈÒÓ, ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ÚfiÏÔ Ù˘ ·ÛÈÚ›Ó˘ ÛÙË ¡∫, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ Â›Ó·È ÂÏÏÈ‹ Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ¤Ú¢Ó˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ıÔ‡Ó ÔÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ŒÙÛÈ, Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ÔÈ ÈÛ¯‡Ô˘Û˜ Û˘ÛÙ¿ÛÂȘ Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ Î·È ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ·ÁˆÁ‹˜ Ì ·ÛÈÚ›ÓË (¶›Ó·Î·˜ 5) (13). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÙËÓ ÂÊ·ÚÌfi˙Ô˘Ó Ì¤¯ÚÈ Î·È 2-3 ̤Ú˜ ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡, ·ÏÏ¿ ˘¿Ú¯Ô˘Ó ·ÎfiÌË Î¤ÓÙÚ·, ΢ڛˆ˜ ÛÙËÓ π·ˆÓ›·, Ô˘ ÂÊ·ÚÌfi˙Ô˘Ó ÙÔ ·Ï·ÈfiÙÂÚÔ Û¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ¤ˆ˜ Î·È 10-14 Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ (5,8-10). ‚) ∏ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË Ù˘ ·ÛÈÚ›Ó˘ ·Ú¯›˙ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ ¤Ú·˜ Ù˘ ·ÓÙÈPaediatriki 2007;70:361-369
ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ Û ‰fiÛË 3-5 mg/kg/24ˆÚÔ ÂÊ¿·Í Î·È Û˘Ó¯›˙ÂÙ·È ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ ̤¯ÚȘ fiÙÔ˘ Á›ÓÂÈ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ (5,8-10). ∏ ·Ú¯È΋ ıÂڷ›· Ì Á-ÛÊ·ÈÚ›ÓË Î·È ·ÛÈÚ›ÓË Â›Ó·È Ë ÌfiÓË ÂӉ‰ÂÈÁ̤ÓË Ì¤¯ÚÈ Û‹ÌÂÚ· Î·È Â›Ó·È ÂÈÙ˘¯‹˜ Û >85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (1,2,5,8-10). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› ÌÂϤÙ˜ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÂÍ ·Ú¯‹˜ ÚÔÛı‹ÎË ÎÔÚÙÈÎÔÂȉÒÓ (˘„ËϤ˜ ‰fiÛÂȘ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘) ÛÙÔ ˆ˜ ¿Óˆ Û¯‹Ì· ÌÂÈÒÓÂÈ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔͤˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Ê·ÈÓÔ̤ӈÓ, ÙË Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Î·È ÙÔ ÔÛÔÛÙfi ·ÔÙ˘¯›·˜ Ù˘ ıÂڷ›·˜ (14,15). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, fï˜, ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·fi ÌÈ· ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË, Ë ÔÔ›· ¤‰ÂÈÍ fiÙÈ ‰ÂÓ ˘‹Ú¯Â ηÌÈ¿ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· ‹ ·˘ÙÒÓ Ô˘ ‹Ú·Ó ÂÈϤÔÓ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (16). ÃÚÂÈ¿˙ÔÓÙ·È ÏÔÈfiÓ ÂÚÈÛÛfiÙÂÚ˜ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ ÒÛÙ ӷ ÂÍ·¯ıÔ‡Ó ÈÔ ·ÎÚÈ‚‹ Û˘ÌÂÚ¿ÛÌ·Ù· (17). ÕÏϘ, ÌÈÎÚfiÙÂÚ˜ Û ¤ÎÙ·ÛË ÌÂϤÙ˜ Ô˘ Î·È ·˘Ù¤˜ ¯Ú‹˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ ÂÓ‰Âϯԇ˜ ÌÂϤÙ˘, ›¯·Ó ·ÚfiÌÔÈ· ıÂÙÈο Â˘Ú‹Ì·Ù· fiÙ·Ó ÚÔÛ¤ıÂÛ·Ó ÂÍ ·Ú¯‹˜ ÛÙÔ ·Ú¯ÈÎfi Û¯‹Ì· ÙËÓ ÂÓÙÔÍ˘Ê˘ÏÏ›ÓË ‹ ÙËÓ Ô˘ÏÈÓ·ÛÙ·Ù›ÓË (Ë ÙÂÏÂ˘Ù·›· ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ ÛÙËÓ π·ˆÓ›·) (8-9). ÃÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜ ·Ú¯È΋˜ ıÂڷ›·˜ √ ¯ÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜ Ù˘ ·Ú¯È΋˜ ıÂڷ›·˜ Ì IVIG Î·È ·ÛÈÚ›ÓË ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ, ÁÈ·Ù› ‚Ú¤ıËΠfiÙÈ fiÛÔ ÓˆÚ›ÙÂÚ· ·Ú¯›˙ÂÈ Ë ·ÁˆÁ‹, ÙfiÛÔ ÌÈÎÚfiÙÂÚÔ˜ Â›Ó·È Ô Î›Ó‰˘ÓÔ˜ ÚfiÎÏËÛ˘ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ (5,8-10,18-19). ŒÙÛÈ, Û ¤ÁηÈÚË ‰È¿ÁÓˆÛË (5Ë-10Ë Ì¤Ú· ÓfiÛÔ˘) ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¿ÌÂÛ· Ô ·ÛıÂÓ‹˜. ™Â ÚÒÈÌË ‰È¿ÁÓˆÛË (<5Ë Ì¤Ú· ÓfiÛÔ˘), fiÏÔÈ Û˘ÌʈÓÔ‡Ó Ó· ·Ú¯›˙ÂÈ Ë ıÂڷ›· ·fi ÙËÓ 4Ë Ì¤Ú· ÓfiÛÔ˘ Î·È ÚÈÓ Û˘ÌÏËÚˆı› ÙÔ ıÂÛÈÛı¤Ó ÎÚÈÙ‹ÚÈÔ Ù˘ 5˘ Ë̤ڷ˜ ˘ÚÂÙÔ‡, ÂÓÒ ˘¿Ú¯Ô˘Ó Î·È Î¤ÓÙÚ·, ΢ڛˆ˜ ÛÙËÓ π·ˆÓ›·, Ô˘ ÍÂÎÈÓÔ‡Ó ÙË ıÂڷ›· Î·È ·fi ÙËÓ 3Ë Ì¤Ú· Ù˘ ÓfiÛÔ˘. ¶ÚÔ¸fiıÂÛË ÂÓ ÚÔÎÂÈ̤ӈ Â›Ó·È Ë ·ÚÔ˘Û›· ÙˆÓ 4/5 ÎÏÈÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Î·È Ô ·ÔÎÏÂÈÛÌfi˜ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ ·ÈÙ›ˆÓ. ™Â ηı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË (>10Ë Ì¤Ú· ÓfiÛÔ˘), ·Ó Î·È ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο Ô Î›Ó‰˘ÓÔ˜ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÓÂÍ·Úًو˜ ıÂڷ›·˜, Û˘ÓÈÛÙ¿Ù·È Ë ÂÊ·ÚÌÔÁ‹ Ù˘, ·Ó ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ‹/Î·È ˘¿Ú¯Ô˘Ó ·˘ÍË̤Ó˜ ÙÈ̤˜ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ ‹/Î·È ·Ó ˘¿Ú¯Ô˘Ó ‚Ï¿‚˜ ÛÙ· ÛÙÂÊ·ÓÈ·›·. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È Û ϋÚË ‡ÊÂÛË Î·È ·ÏÒ˜ ηı˘ÛÙ¤ÚËÛÂ Ë ‰È¿ÁÓˆÛË Î·È ÙÂÎÌËÚÈÒıËΠ̠ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·ÔϤÈÛ˘, ÙfiÙÂ Ô ¿ÚÚˆÛÙÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÌfiÓÔ Ì ¯ÔÚ‹ÁËÛË ÌÈÎÚ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜ (5,8-10). ∞¿ÓÙËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ ·Ú¯È΋ ıÂڷ›· ∏ ·Ú¯È΋ ıÂڷ›· Ì IVIG Î·È ·ÛÈÚ›ÓË Â›Ó·È ÂÈÙ˘¯‹˜ Û >85% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ
Paidiatriki 5 final
12-10-07
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¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘
ÌË ·¿ÓÙËÛ˘ ÛÙË ıÂڷ›·, ·Ó ‰ËÏ·‰‹ ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ¤ˆ˜ Î·È 36 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË IVIG (10-15%), ‹ Û ÂÚÈÙÒÛÂȘ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ (~1%), Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ‰Â‡ÙÂÚË ¤Á¯˘ÛË ›‰È·˜ ‰fiÛ˘ IVIG Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. √ÚÈṲ̂ÓÔÈ ÂÊ·ÚÌfi˙Ô˘Ó ÛÙË Ê¿ÛË ·˘Ù‹ Î·È ÙËÓ ÚÔÛı‹ÎË ÎÔÚÙÈÎÔÂȉÒÓ, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ‚Ï¿‚Ë ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È ·ÓıÂÎÙÈ΋ ·Ú¿ ÙË ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, ÙfiÙÂ Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ (pulse) ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘, 30 mg/kg (̤ÁÈÛÙË ‰fiÛË 1 g) ÛÂ Û˘Ó¯‹ ¤Á¯˘ÛË ó-1 ÒÚ·˜ ÂÊ¿·Í Î·È ÁÈ· ÙÚÂȘ Û˘Ó¯›˜ ̤Ú˜ (5,8-10). ∆¤ÏÔ˜, Û ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜ Î·È ·˘Ù‹˜ Ù˘ ·ÁˆÁ‹˜ ÂÊ·ÚÌfi˙ÂÙ·È Ë ÚÔÛı‹ÎË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ, fiˆ˜ Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë, Ë Î˘ÎÏÔÛÔÚ›ÓË Î·È, ÙÂÏÂ˘Ù·›ˆ˜, ÔÈ ·ÓÙÈ-∆¡F ·Ú¿ÁÔÓÙ˜ Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (5,8-10,19-20). ™ÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ∏ ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ¡∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÔ˘Û›· Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›·. ªÂ ‚¿ÛË ÙÔ ÎÚÈÙ‹ÚÈÔ ·˘Ùfi, Ë ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Ì ÙË Û‡ÌʈÓË ÁÓÒÌË Î·È Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ ηıfiÚÈÛ·Ó ¤ÓÙ “›‰· ÎÈÓ‰‡ÓÔ˘” ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Âͤ‰ˆÛ·Ó ‰Â Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜, ·Ó¿ÏÔÁ· Ì ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÛÙÔ ÔÔ›Ô ·Ó‹ÎÔ˘Ó (8). √È Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÂÛÙÈ¿˙ÔÓÙ·È, Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ÛÙËÓ ·Ó·ÁηÈfiÙËÙ· ‹ fi¯È ·) Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ì ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‹/Î·È ¿ÏÏË ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹, ‚) ÂÚÈÔÚÈÛÌÔ‡ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Á) Û˘¯Ó‹˜ ‹ fi¯È ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∂ȉÈÎfiÙÂÚ·, ÔÈ Û˘ÛÙ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î¿ı ¤Ó· ·fi Ù· “›‰· ÎÈÓ‰‡ÓÔ˘” ¤¯Ô˘Ó ˆ˜ ÂÍ‹˜ (8,9,21,22): ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ π. ∞Ô˘Û›· ‚Ï·‚ÒÓ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›·. ™Ù· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ·˘Ù‹˜, Ë ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÂÊ·ÚÌfi˙ÂÙ·È Ì¤¯ÚÈ ÙËÓ 6Ë ¤ˆ˜ 8Ë Â‚‰ÔÌ¿‰· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ¢ÂÓ ··ÈÙÂ›Ù·È Î·ÌÈ¿ ÂÚ·ÈÙ¤Úˆ ıÂڷ›·, Ô‡Ù ÂÚÈÔÚÈÛÌfi˜ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Û˘ÓÈÛÙ¿Ù·È Î·Ú‰ÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î¿ı 5 ¤ÙË. ™˘ÓÈÛٿٷÈ, ›Û˘, Û fiÏ· Ù· ·È‰È¿ Ì ÈÛÙÔÚÈÎfi ¡∫ Ë ·ÔÊ˘Á‹ ·Ú·ÁfiÓÙˆÓ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ·ıËÚÔÁ¤ÓÂÛË (·¯˘Û·ÚΛ·, οÓÈÛÌ·, Î.¿.) ÏfiÁˆ Èı·Ó‹˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ππ. ¶·ÚÔ‰ÈΤ˜ ‚Ï¿‚˜ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Ô˘ ˘Ô¯ˆÚÔ‡Ó ÚÈÓ ÙËÓ 8Ë Â‚‰ÔÌ¿‰·. πÛ¯‡Ô˘Ó Ù· ›‰È· Ì ÙÔ ÚÔËÁÔ‡ÌÂÓÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ Ì ÌfiÓË ‰È·ÊÔÚ¿ ÙË Û˘¯ÓfiÙÂÚË Î·Ú‰ÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, οı 3-5 ¯ÚfiÓÈ·.
∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ πππ. ªÈÎÚÔ‡ ‹ ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· (3-6 mm) Û ·ÚÈ· ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›·. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ¯·ÌËÏ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ Â›Ó·È ··Ú·›ÙËÙË Ì¤¯ÚÈ ÙËÓ ˘ÔÛÙÚÔÊ‹ ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ™ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ÌfiÓÔ ÂÙ‹ÛÈ· ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫° Î·È À∫. ªÂÙ¿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, ÂÚÈÔÚÈÛÌfi˜ ‹ fi¯È ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Ì ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘, Ë ÔÔ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î¿ı ‰‡Ô ¯ÚfiÓÈ·. ∫·ı’ fiÏË, fï˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Ì ·ÛÈÚ›ÓË Û˘ÓÈÛÙ¿Ù·È Ë ·ÔÊ˘Á‹ ·ıÏËÌ¿ÙˆÓ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ Î·È ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ۈ̷ÙÈ΋˜ ÚfiÛÎÚÔ˘Û˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ πV. ŒÓ· ‹ ÂÚÈÛÛfiÙÂÚ· ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· (>6mm) ‹ ÔÏÏ·Ï¿ ÌÈÎÚÔ‡-ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· ÛÙËÓ ›‰È· ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›·. ÃÔÚËÁÂ›Ù·È Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ Ì ·ÛÈÚ›ÓË Î·È Ù·˘Ùfi¯ÚÔÓ· ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ Ì ‚·ÚÊ·Ú›ÓË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‹ Ë·Ú›ÓË ÌÈÎÚÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ˘Ô‰ÔÚ›ˆ˜. ™ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ·ÏÏ¿ ÂÍ·ÌËÓÈ·›· ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫° Î·È À∫. ∂›Û˘, Û˘ÓÈÛÙ¿Ù·È ÂÎÏÂÎÙÈ΋ ÛÙÂÊ·ÓÈÔÁÚ·Ê›· Ì ηډȷÎfi ηıÂÙËÚÈ·ÛÌfi ¤ÍÈ Ì‹Ó˜ Ì ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ Î·È Â·Ó¿ÏË„‹ Ù˘ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ªÂÙ¿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È ÈÛ¯‡ÂÈ, ÁÈ· fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜, Ë ·ÔÊ˘Á‹ ·ıÏËÌ¿ÙˆÓ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ Î·È ÛˆÌ·ÙÈ΋˜ ÚfiÛÎÚÔ˘Û˘. ∂›Â‰Ô ÎÈÓ‰‡ÓÔ˘ V. £ÚfiÌ‚ˆÛË ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ∞ÎÔÏÔ˘ıÂ›Ù·È Ë ›‰È· Ù·ÎÙÈ΋ Ì ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ IV. ∂ÈϤÔÓ, ÂÎÙÈÌ¿Ù·È Ë ·Ó¿ÁÎË ÚÔÛı‹Î˘ ‚·ÔÎÏÂÈÛÙÒÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂȈı› Ë Î·Ù·Ó¿ÏˆÛË Ô͢ÁfiÓÔ˘ ·fi ÙÔ Ì˘ÔοډÈÔ. ∂›Û˘, ÂÈÛ‡‰ÂÙ·È Ô Î·Ú‰È·Îfi˜ ηıÂÙËÚÈ·ÛÌfi˜ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ıÚÔÌ‚ÔÏ˘ÙÈ΋˜ ·ÁˆÁ‹˜ ‹ ¿ÏÏ˘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘ ÛÙ· ÛÙÂÊ·ÓÈ·›· (.¯. bypass).∆ËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ·˘Ù‹˜ ÙËÓ ·Ó·Ï·Ì‚¿ÓÔ˘Ó ÔÈ ·È‰ÔηډÈÔÏfiÁÔÈ. √ ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì ¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ı›, Ó· Û˘ÓÂÚÁ¿˙ÂÙ·È ÛÙÂÓ¿ Ì ÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ Î·È Ó· ÂϤÁ¯ÂÈ ·Ó Ô ·ÛıÂÓ‹˜ ÂÊ·ÚÌfi˙ÂÈ ÛˆÛÙ¿ ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜, ÙˆÓ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Ù˘ Ù·ÎÙÈ΋˜ ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘ (8,9,21,22). ∫‡ÚÈÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ÁÈ· ÙÔÓ ·È‰›·ÙÚÔ √È ÈÔ Û˘¯ÓÔ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ÙˆÓ ·È‰È¿ÙÚˆÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ·È‰È¿ Ì ¡∫ ÂÛÙÈ¿˙ÔÓÙ·È ·) ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Reye ¶·È‰È·ÙÚÈ΋ 2007;70:361-369
Paidiatriki 5 final
12-10-07
16:28
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°. ¶·Ú‰·Ïfi˜
ÏfiÁˆ Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ Ï‹„˘ ·ÛÈÚ›Ó˘ Î·È ‚) ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ·) ∞ÛÈÚ›ÓË Î·È Û‡Ó‰ÚÔÌÔ Reye. ¢ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·Ó Ë ÌÈÎÚ‹ ‰fiÛË Ù˘ ·ÛÈÚ›Ó˘ ÌÔÚ› Ó· ÂÓÔ¯ÔÔÈËı› ÛÙËÓ ÚfiÎÏËÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘. ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ·Ó·ÊÂÚı› Ù¤ÙÔÈ· Û¯¤ÛË. ¶·ÚfiÏ· ·˘Ù¿ Û˘ÓÈÛÙ¿Ù·È Ô ÂÙ‹ÛÈÔ˜ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Î·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∆Ô ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, fiˆ˜ Î·È Î¿ı ¿ÏÏÔ ÂÌ‚fiÏÈÔ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Ù˘ Á-ÛÊ·ÈÚ›Ó˘. ∂È‚¿ÏÏÂÙ·È Â›Û˘ Ë ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Î·È Ë ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ (8). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi ı· Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› ˆ˜ Ë Û˘Á¯ÔÚ‹ÁËÛË È‚ÔÚÔ˘Ê¤Ó˘ Ì ·ÛÈÚ›ÓË Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, ÁÈ·Ù› ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÚÒÙË ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙËÓ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰Ú¿ÛË Ù˘ ‰Â‡ÙÂÚ˘. ™ÙËÓ ÂÚ›ÙˆÛË ÏÔÈfiÓ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ˘ÚÂÙÈÎÔ‡ ‹ ·Ó·ÏÁËÙÈÎÔ‡ ÛÙ· ·È‰È¿ Ì ¡∫, Ù· ÔÔ›· ·›ÚÓÔ˘Ó ÌÈÎÚ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ó· ÚÔÙÈÌ¿Ù·È Ë ·Ú·ÎÂÙ·ÌfiÏË (8). ‚) ∂Ì‚ÔÏÈ·ÛÌÔ› ·È‰ÈÒÓ Ì ¡∫. √È ÂÌ‚ÔÏÈ·ÛÌÔ› Ì ÂÌ‚fiÏÈ· ÂÚȤ¯ÔÓÙ· ÓÂÎÚÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ ‹ ·Ó·ÙÔ͛Ә, ηıÒ˜ Î·È fiÛ· ·Ú·Û΢¿˙ÔÓÙ·È Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA, Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Î·ÓÔÓÈο Î·È ¿ÊÔ‚·, Û‡Ìʈӷ Ì ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÙÔ˘ ·È‰ÈÔ‡, ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜. ºÚfiÓÈÌÔ fï˜ Â›Ó·È Ó· Á›ÓÔÓÙ·È 2 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘. ¶ÂÚÈÔÚÈÛÌfi˜ ˘¿Ú¯ÂÈ ÌfiÓÔ ÁÈ· Ù· ÂÌ‚fiÏÈ· Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, ÁÈ·Ù› ÔÈ ˘„ËϤ˜ ‰fiÛÂȘ Ù˘ ÂÓ‰ÔÊϤ‚È·˜ Á-ÛÊ·ÈÚ›Ó˘ ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏË Û˘ÁΤÓÙÚˆÛË ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÈÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηٷÛÙ¤ÏÏÂÙ·È Ë ·ÓÙÈÁÔÓÈÎfiÙËÙ·, ¿Ú· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ. ™˘ÓÈÛÙ¿Ù·È ÏÔÈfiÓ, Û‡Ìʈӷ Ì ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ªªR Î·È ·ÓÂÌ¢ÏÔÁÈ¿˜ Ó· Á›ÓÔÓÙ·È 11 Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ¤Á¯˘ÛË Ù˘ πVIG. ™ÙȘ ÂÚÈÙÒÛÂȘ, ηٿ ÙȘ Ôԛ˜, ÏfiÁˆ ÂȉËÌ›·˜, ¯ÚÂÈ¿˙ÂÙ·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÓˆÚ›ÙÂÚ·, ··ÈÙÂ›Ù·È Î·È ‰Â‡ÙÂÚË Â·Ó·ÏËÙÈ΋ ‰fiÛË ÛÙÔÓ ¯ÚfiÓÔ ·˘Ùfi (8).
™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫ ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, ÁÈ·Ù› fiÛÔ ÈÔ Û‡ÓÙÔÌ· ÂÊ·ÚÌÔÛÙ› Ë ıÂڷ›· Ì Á-ÛÊ·ÈÚ›ÓË Î·È ·ÛÈÚ›ÓË, ÙfiÛÔ ÌÈÎÚfiÙÂÚÔ˜ Â›Ó·È Ô Î›Ó‰˘ÓÔ˜ ÚfiÎÏËÛ˘ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ªÂ ÙË ‚Ô‹ıÂÈ· Î·È ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ Î‡ÚÈˆÓ Î·È Û˘ÌÏËڈ̷ÙÈÎÒÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ “ÎÚÈÙËÚ›ˆÓ”, ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ηډȿ˜ Î·È Ù˘ ηıËÌÂÚÈÓ‹˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ·ÚÚÒÛÙÔ˘, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÌË ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ ‹ Ù˘ Ï·Óı·Ṳ̂Ó˘ Paediatriki 2007;70:361-369
‰È¿ÁÓˆÛ˘ οÔÈ·˜ ¿ÏÏ˘ ÓfiÛÔ˘, ·Ú¯›˙ÂÈ ¤ÁηÈÚ· Ë ıÂڷ›· Î·È ·ÔÙÚ¤ÔÓÙ·È ÔÈ ·ÒÙÂÚ˜ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜. ∏ ·Ú¯È΋ ıÂڷ›· Ì IVIG Î·È ·ÛÈÚ›ÓË Â›Ó·È ÂÈÙ˘¯‹˜ Û ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 85% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ÌË ·¿ÓÙËÛ˘ ÛÙË ıÂڷ›·, ÔfiÙ ÂÈ̤ÓÂÈ Ô ˘ÚÂÙfi˜ ¤ˆ˜ Î·È 36 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË Ù˘ IVIG, Ë ÂӉ‰ÂÈÁ̤ÓË ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, Ì ÈηÓÔÔÈËÙÈο Û˘Ó‹ıˆ˜ ·ÔÙÂϤÛÌ·Ù·. ∞Ó fï˜ Ë ÓfiÛÔ˜ Â›Ó·È ·ÓıÂÎÙÈ΋ Î·È ÛÙË ‰Â‡ÙÂÚË ¤Á¯˘ÛË IVIG, ÙfiÙ ÂÓ‰¤¯ÂÙ·È Ó· ··ÈÙËı› Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ ηÈ, Û ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜ Î·È ·˘Ù‹˜ Ù˘ ·ÁˆÁ‹˜, Ë ÚÔÛı‹ÎË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (΢ÎÏÔʈÛÊ·Ì›‰Ë, ΢ÎÏÔÛÔÚ›ÓË, ·ÓÙÈ-TNF ·Ú¿ÁÔÓÙ˜ Î.¿.). ∏ ÛÙÚ·ÙËÁÈ΋ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ¡∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÔ˘Û›· Î·È ÙÔÓ ‚·ıÌfi ÙˆÓ ‚Ï·‚ÒÓ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ (›‰· ÎÈÓ‰‡ÓÔ˘). ∞Ó·ÏfiÁˆ˜ ÏÔÈfiÓ ÙÔ˘ ÂȤ‰Ô˘ ÎÈÓ‰‡ÓÔ˘, ÛÙÔ ÔÔ›Ô ·Ó‹ÎÂÈ Ô ·ÛıÂÓ‹˜, ηıÔÚ›˙ÂÙ·È Î·È Ë ·Ó·ÁηÈfiÙËÙ· ‹ fi¯È Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‹/Î·È ¿ÏÏË ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹), ÂÚÈÔÚÈÛÌÔ‡ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Î·È Û˘¯ÓfiÙËÙ·˜ ηډÈÔÏÔÁÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∆ËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ·˘Ù‹˜ ÙËÓ ·Ó·Ï·Ì‚¿ÓÔ˘Ó ÔÈ ·È‰ÔηډÈÔÏfiÁÔÈ. √ ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì ¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ı›, Ó· Û˘ÓÂÚÁ¿˙ÂÙ·È ÛÙÂÓ¿ Ì ÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ Î·È Ó· ÂϤÁ¯ÂÈ ·Ó Ô ·ÛıÂÓ‹˜ ÂÊ·ÚÌfi˙ÂÈ ÛˆÛÙ¿ Î·È Ù·ÎÙÈο ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ıÂڷ¢ÙÈ΋˜ ÙÔ˘ ·ÁˆÁ‹˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Burns JC, Glode MP. Kawasaki syndrome. Lancet 2004;364:533-544. 2. Falcini F. Kawasaki disease. Curr Opin Rheumatol 2006;18:33-38. 3. Huang GY, Ma XJ, Huang M, Chen SB, Huang MR, Gui YH, et al. Epidemiologic pictures of Kawasaki disease in Shanghai from 1998 through 2002. J Epidemiol 2006;16:9-14. 4. Yanagawa H, Nakamura Y, Yashiro M, Uehara R, Oki I, Kayaba K. Incidence of Kawasaki disease in Japan: the nationwide surveys of 1999-2002. Pediatr Int 2006;48:356-361. 5. Yeung RS. Pathogenesis and treatment of Kawasaki’s disease. Curr Opin Rheumatol 2005;17:617-623. 6. Wang CL, Wu YT, Lieu CA, Kuo HC, Yang KD. Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 2005;24:998-1004. 7. Baumer JH. Kawasaki disease: what to do with incomplete cases? Arch Dis Child Ed Pract 2005;90:102-104. 8. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment, and longterm management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics 2004;114:1708-1733. 9. Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health 2005;41:87-93.
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10. Brogan PA, Bose A, Burgner D, Shingadia D, Tulloh R, Michie C, et al. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002;86:286-290. 11. Chang FY, Hwang B, Chen SJ, Lee PC, Meng L, Lu JH. Characteristics of Kawasaki disease in infants younger than six months of age. Pediatr Infect Dis J 2006;25:241-244. 12. Hsieh KS, Weng KP, Lin CC, Huang TC, Lee CL, Huang SM. Treatment of acute Kawasaki disease: aspirin’s role in the febrile stage revisited. Pediatrics 2004;114:e689-693. 13. Baumer JH, Love SJ, Gupta A, Haines LC, Maconochie I, Dua JS. Salicylate for the treatment of Kawasaki disease in children. Cochrane Database Syst Rev 2006;18:CD004175. 14. Inoue Y, Okada Y, Shinohara M, Kobayashi T, Kobayashi T, Tomomasa T, et al. A multicenter prospective randomized trial of corticosteroids in primary therapy for Kawasaki disease: clinical course and coronary artery outcome. J Pediatr 2006;149:336-341. 15. Burns JC. Revisiting steroids in the primary treatment of acute Kawasaki disease. J Pediatr 2006;149:291-292. 16. Newburger JW, Sleeper LA, McCrindle BW, Minich LL,
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Gersony W, Vetter VL, et al. Randomized trial of pulsed corticosteroid therapy for primary treatment of Kawasaki disease. N Engl J Med 2007;356:663-675. Burns JC. The riddle of Kawasaki disease. N Engl J Med 2007;356:659-661. Wilder MS, Palinkas LA, Kao AS, Bastian JF, Turner CL, Burns JC. Delayed diagnosis by physicians contributes to the development of coronary artery aneurysms in children with Kawasaki syndrome. Pediatr Infect Dis J 2007;26:256-260. Yeung RS. Phenotype and coronary outcome in Kawasaki's disease. Lancet 2007;369:85-87. Weiss JE, Eberhard BA, Chowdhury D, Gottlieb BS. Infliximab as a novel therapy for refractory Kawasaki disease. J Rheumatol 2004;31:808-810. ¶··‰fiÔ˘ÏÔ˜ °™. ¡fiÛÔ˜ Kawasaki Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·. ¶·È‰È·ÙÚÈ΋ 2001;64:420-423. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ ¢, ¶··‰fiÔ˘ÏÔ˜ °. √‰ËÁ›Â˜ ÁÈ· ¿ÛÎËÛË Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ÌÂ Û˘ÁÁÂÓ›˜ ‹ ›ÎÙËÙ˜ ·ı‹ÛÂȘ ΢ÎÏÔÊÔÚÈÎÔ‡. ¶·È‰È·ÙÚÈ΋ 2006;69:468-477. Cohen µ∞, Lehmann CU. DermAtlas, Johns Hopkins University; 2000-2007: http://dermatlas.med.jhmi.edu
Quiz 1. ¶fiÙ ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÂÍ¿ÓıËÌ· ÛÙË ÓfiÛÔ Kawasaki; ·. ∆Ș ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ ‚. ªÂÙ¿ ÙȘ ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ Á. ªÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ÓfiÛÔ˘ ‰. ¢ÂÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ¯ÚÔÓÈÎfi fiÚÈÔ ÂÌÊ¿ÓÈÛ˘ 2. ™Â ÂÚÈÙÒÛÂȘ ·ÙÂÏÔ‡˜ ¡. Kawasaki, fiÛ· ·fi Ù· ·ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ú¤ÂÈ Ó· ÏËÚÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ú¯›ÛÂÈ ¤ÁηÈÚ· Ë ıÂڷ›·; ·. ŒÓ· ·fi Ù· ·ÚÈ· Î·È 2 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ‚. ¢‡Ô ·fi Ù· ·ÚÈ· Î·È ¤Ó· ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” Á. ŒÓ· ·fi Ù· ·ÚÈ· Î·È ≥3 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” ‰. ¢‡Ô ·fi Ù· ·ÚÈ· Î·È ≥2 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” 3. ∏ ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ì ¯·ÌËÏ‹, ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË ·ÛÈÚ›Ó˘ Û ·ÛıÂÓ›˜ Ì N. Kawasaki ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÛÙÂÊ·ÓÈ·›ˆÓ ›ӷÈ: ·. ¢‡Ô ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ‚. ∆ÚÂȘ ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Á. ŒÍÈ Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ‰. ∆¤ÛÛÂÚȘ Ì ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 4. ¶fiÙ ÂӉ›ÎÓ˘Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR ÛÙ· ·È‰È¿ Ì ¡. Kawasaki, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘; ·. ¢ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó·˜ ÂÚÈÔÚÈÛÌfi˜ ‚. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜ Á. ŒÓÙÂη Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜ ‰. ŒÍÈ Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 5. ™Â ·È‰È¿ Ì ¡. Kawasaki Ô˘ Ú¤ÂÈ Â› ÛÂÈÚ¿ ÂÙÒÓ Ó· ·›ÚÓÔ˘Ó ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ·. ∞ÓÙÂӉ›ÎÓ˘Ù·È ‚. ∂È‚¿ÏÏÂÙ·È ¯ˆÚ›˜ ηӤӷ ÂÚÈÔÚÈÛÌfi Á. ∂È‚¿ÏÏÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ‰. ∂›Ó·È ˘Ô¯ÚˆÙÈÎfi˜, ·ÏÏ¿ 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ¶·È‰È·ÙÚÈ΋ 2007;70:361-369
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REVIEW ARTICLE
ÕÙ˘Ë-·ÙÂÏ‹˜ ÓfiÛÔ˜ Kawasaki: ¯ÚÂÈ·˙fiÌ·ÛÙ Ӥ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·; ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ, “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: °ÂˆÚÁ›· °ÚËÁÔÚÈ¿‰Ô˘ grigeo9@yahoo.gr ∞Ó·ÙÔÏ‹˜ 87 ∆.∫. 155 62, ÃÔÏ·ÚÁfi˜
°. °ÚËÁÔÚÈ¿‰Ô˘ ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki ·ÔÙÂÏ› ÙË Û˘ÓËı¤ÛÙÂÚË Â›ÎÙËÙË Î·Ú‰ÈÔ¿ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. 20% ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÌÊ·Ó›ÛÔ˘Ó ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÍ›·˜ ·ÁÁÂÈ›Ùȉ·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù›ıÂÙ·È Ì ۷ʋ ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·, ˆÛÙfiÛÔ Ë ÂÌÂÈÚ›· ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ ‰ÂÓ Â›Ó·È Û¿ÓÈ· Ë ‰È·›ÛÙˆÛË ‚Ï·‚ÒÓ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜, ¯ˆÚ›˜ Ó· ¤¯Ô˘Ó ÚÔËÁËı› fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘. √È ·È‰›·ÙÚÔÈ Â›Ó·È ·Ó·Áη›Ô Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÛÙÔȯ›·, ÌË ÂȉÈο Ù˘ ÓfiÛÔ˘ ·ÏÏ¿ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ¤ÙÛÈ ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂڷ›·. ¶˘ÚÂÙfi˜ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 4 Ë̤Ú˜ Û ·È‰È¿ ¯ˆÚ›˜ Ù· ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ· ·ÔÙÂÏ› ˘„ËÏfi ‰Â›ÎÙË ˘Ô„›·˜ Ù˘ ÓfiÛÔ˘ Kawasaki. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·ÔÙÂÏ› ÛÔ˘‰·›Ô ÂÚÁ·ÏÂ›Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. §¤ÍÂȘ ÎÏÂȉȿ: ÕÙ˘Ë ÓfiÛÔ˜ Kawasaki, ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·, ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·.
Atypical Kawasaki disease: criteria Cardiology Department, “P. & A. Kyriakou”, Athens, Greece Correspondence: Georgia Grigoriadou grigeo9@yahoo.gr 87, Anatolis St. 155 62, Cholargos, Athens, Greece
G. Grigoriadou Abstract: Kawasaki disease (KD) is the leading cause of acquired heart disease in children in several parts of the world. Of children with KD, 20% will develop coronary artery abnormalities as a result of intense vasculitis. Atypical (incomplete) KD occurs when children develop coronary aneurysms without having met the criteria for full case definition. Clinicians use several additional clues, which are not specific for the disease but which occur in a large number of patients with KD, so that they can initiate early treatment. Paediatricians who are evaluating fever lasting more than 4 days in infants without classical forms of KD should have a “high index of suspicion” for the possibility of KD. Echocardiography is an important tool in the diagnosis of atypical KD.
Key words: Atypical Kawasaki disease, coronary aneurysm, diagnostic criteria.
∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ÔÍ›· ·ÁÁÂÈ›Ùȉ·, Ë ÔÔ›· ÚÔÛ‚¿ÏÏÂÈ ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ Î·È ·ÔÙÂÏ› ÙË Û˘ÓËı¤ÛÙÂÚË Â›ÎÙËÙË Î·Ú‰ÈÔ¿ıÂÈ· ÛÙȘ ÚÔËÁ̤Ó˜ ¯ÒÚ˜ (1). ∏ ÛÔ‚·ÚfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘ Kawasaki Â›Ó·È Ë ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 20% ÙˆÓ ÌË ıÂڷ¢ı¤ÓÙˆÓ ·ÛıÂÓÒÓ. ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎÙ·Û›·, ÌÈÎÚÔ‡ Î·È ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· (Ô˘ ˘Ô¯ˆÚÔ‡Ó ÂÓÙfi˜ 1-2 ÂÙÒÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘) Î·È ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· Ô˘ ··ÈÙÔ‡Ó ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ Î·È ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ì˘Ôηډȷ΋˜ ÈÛ¯·ÈÌ›·˜ Î·È Ì˘ÔηډȷÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘. ∏ ¤ÁηÈÚË ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÛÙÔ 3-8% Î·È ÌÂÈÒÓÂÈ ÙË ıÓËÛÈÌfiÙËÙ· ÛÙÔ 0,2% (2). ∏ ÓfiÛÔ˜ ·ÓÂÌÊ·Ó›˙ÂÙ·È ÌÂ Û˘¯ÓfiÙËÙ· <4% Û˘Ó‹ıˆ˜ ÂÓÙfi˜ ‰‡Ô ÂÙÒÓ ·fi ÙËÓ ·Ú¯È΋ ÚÔÛ‚ÔÏ‹. Paediatriki 2007;70:370-373
√È Ì·ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ¤˜, ·ÏÏ¿ ÎÏÈÓÈο ÛȈËÏ¿ ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ÌÔÚ› Ó· ·Ó·ÁÓˆÚÈÛÙÔ‡Ó ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ÏfiÁˆ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ‹ ı·Ó¿ÙÔ˘ (3).
ÕÙ˘Ô-·ÙÂϤ˜ Kawasaki: ÙÔ ‰›ÏËÌÌ· ÙÔ˘ ·È‰›·ÙÚÔ˘ ∫Ï·ÛÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏÔ‡Ó ·ıÚÔÈÛÙÈο Ë ÂÈÌÔÓ‹ ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 5 Ë̤Ú˜ Î·È Ô Û˘Ó‰˘·ÛÌfi˜ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ·ÎfiÏÔ˘ı· ¤ÓÙÂ Â˘Ú‹Ì·Ù·: ·) ·ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ·, ‚) ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏ·Á¤˜ ÛÙ· ¯Â›ÏË (ÂÚ‡ıËÌ·, ÍËÚfiÙËÙ·, ÚˆÁ̤˜, ·ÔϤÈÛË, ·ÈÌÔÚÚ·Á›·) Î·È ÙÔ ÛÙfiÌ· (‰È¿¯˘ÙÔ ÂÚ‡ıËÌ· ÛÙÔ ÛÙÔÌ·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î·È ÙÔÓ Ê¿Ú˘ÁÁ·), Á) ÁÂÓÈÎÂ˘Ì¤ÓÔ ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ·, ‰) ·ÌÊÔÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË Î·È ·ÔϤÈÛË ÛÙ· ¯¤ÚÈ· Î·È Ù· fi‰È· Î·È Â) ÙÚ·¯ËÏÈ΋
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ÕÙ˘Ë ÓfiÛÔ˜ Kawasaki: ÎÚÈÙ‹ÚÈ·
ÏÂÌÊ·‰ÂÓ›Ùȉ· Ì ¤Ó·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÏÂÌÊ·‰¤Ó· Ì ‰È¿ÌÂÙÚÔ ÌÂÁ·Ï‡ÙÂÚË ·fi 1,5 ÂηÙÔÛÙfi. ÕÙ˘Ë ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Kawasaki Û˘Ó·ÓÙ¿Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ, fiÔ˘ ·Ó·Ù‡ÛÛÔÓÙ·È ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· fiÏˆÓ ÙˆÓ ÎÚÈÙËÚ›ˆÓ (4). √ÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ Ì ¿Ù˘Ë ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Èı·ÓfiÓ Ó· ·Ó·Ù‡ÍÔ˘Ó Ù· Ù˘Èο Â˘Ú‹Ì·Ù· ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∫¿ÔÈÔÈ ¿ÏÏÔÈ ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Ù˘Èο Â˘Ú‹Ì·Ù· ÁÈ· Ì·ÎÚfi ‰È¿ÛÙËÌ·, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË Î·È Ù¤ÏÔ˜, ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ¿Ù˘· Â˘Ú‹Ì·Ù· ı· ‰È·Ê‡ÁÔ˘Ó ÙË ‰È¿ÁÓˆÛË, Ë ÔÔ›· Î·È ı· Á›ÓÂÈ ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÏfiÁˆ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ÂÂÈÛÔ‰›Ô˘. √ ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· ·ÛıÂÓ›˜ Ì ¿Ù˘Â˜ ÂΉËÏÒÛÂȘ. ¶ÔÛÔÛÙfi 28% ÙˆÓ ‚ÚÂÊÒÓ Î·È 7%-10% ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ Ì ÓfiÛÔ Kawasaki ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ¿Ù˘Â˜ ÂΉËÏÒÛÂȘ (5). ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ·Û˘Ó‹ı˘ Û ‚Ú¤ÊË ËÏÈΛ·˜ <3 ÌËÓÒÓ (ÛÙËÓ π·ˆÓ›· ÙÔ ÔÛÔÛÙfi ·Ó¤Ú¯ÂÙ·È ÛÙÔ 1,6%, ÂÓÒ ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ÙÔ ÔÛÔÛÙfi Â›Ó·È <1%). ∆· ‚Ú¤ÊË, ΢ڛˆ˜ ·˘Ù¿ οو ÙˆÓ 6 ÌËÓÒÓ, ¤¯Ô˘Ó ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÛÙ· ·È‰È¿ Ì ¿Ù˘Ë ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘, Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ‰È¿ÁÓˆÛ˘ Î·È ıÂڷ›·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki, fiˆ˜ ·Ó·Ê¤ÚıËΠÚÔËÁÔ˘Ì¤Óˆ˜, ‚·Û›˙ÂÙ·È ÛÙ· ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ‰‡ÛÎÔÏË Ë ·Ó·ÁÓÒÚÈÛ‹ Ù˘ Û ¿Ù˘Â˜ ÂÚÈÙÒÛÂȘ.
ÕÙ˘Ô Kawasaki: Â›Ó·È ·Ó·Áη›· Ù· Ó¤· ÎÚÈÙ‹ÚÈ·; √ ¯ÂÈÚÈÛÌfi˜ ÙˆÓ ¿Ù˘ˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ‰È¯ÔÁӈ̛·˜ ÌÂٷ͇ ÙˆÓ ·È‰È¿ÙÚˆÓ Î·È Ó¤Â˜ Ô‰ËÁ›Â˜ Â›Ó·È ·Ó·Áη›Â˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË. ¢ÂÓ Â›Ó·È ·Û‡ÓËı˜, ·È‰È¿ Ô˘ ‰ÂÓ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· Ó· ·Ó·Ù‡ÛÛÔ˘Ó ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·. Œ¯ÂÈ ‚ÚÂı› fiÙÈ ÂÚ›Ô˘ 30% ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ˘¿Ú¯ÂÈ ˘Ô„›· ÓfiÛÔ˘ Kawasaki Ï·Ì‚¿ÓÔ˘Ó Á-ÛÊ·ÈÚ›ÓË ÁÈ· ÙËÓ ÚfiÏË„Ë ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ, ÂÓÒ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ ÔÚÈṲ̂ÓÔÈ ·fi ·˘ÙÔ‡˜ ¿Û¯Ô˘Ó ·fi ¿ÏÏÔ ÓfiÛËÌ·. ∂›Ó·È ÂÔ̤ӈ˜ ·Ó·Áη›· Ë ¯ÚËÛÈÌÔÔ›ËÛË ÂÈÚfiÛıÂÙˆÓ ÛÙÔȯ›ˆÓ, Ù· ÔÔ›· ‰ÂÓ Â›Ó·È ÌÂÓ ÂȉÈο Ù˘ ÓfiÛÔ˘ Kawasaki, ·Ú·ÙËÚÔ‡ÓÙ·È fï˜ Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ Ì Kawasaki Î·È ÌÔÚÔ‡Ó Ó· ·˘Í‹ÛÔ˘Ó ÙËÓ ÈηÓfiÙËÙ· ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ (6). ∆· ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÛÙÔȯ›· ·ÊÔÚÔ‡Ó ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ‹ ÚÔÛ‚ÔÏ‹ ÔÚÁ¿ÓˆÓ. ¶·Ú·Ù›ıÂÙ·È Î·ÙˆÙ¤Úˆ ›Ó·Î·˜ Ì ٷ ÂÈÚfiÛıÂÙ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ⁄‰Úˆ„ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ÂΉËÏÒÓÂÙ·È Ì ¤ÓÙÔÓÔ fiÓÔ ÛÙÔ ‰ÂÍ› ¿Óˆ ÙÂÙ·ÚÙËÌfiÚÈÔ Ù˘ ÎÔÈÏ›·˜. ÕÛËÙË ÌËÓÈÁÁ›Ùȉ· Û˘Ì‚·›ÓÂÈ ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Û˘Ó‹ıˆ˜ Â›Ó·È ÎÏÈÓÈο ÛȈËÏ‹. ∏ ·ÚıÚ›Ùȉ· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ 10%-20% Î·È ÚÔÛ‚¿ÏÏÂÈ ÌÈÎÚ¤˜ ·ÚıÚÒÛÂȘ ÙˆÓ ‰·ÎÙ‡ÏˆÓ ÛÙ· ¯¤ÚÈ· Î·È Ù· fi‰È·. ŸÙ·Ó ÚÔÛ‚¿ÏÏÂÈ ÌÂÁ¿Ï˜ ·ÚıÚÒÛÂȘ, ÌÈÌÂ›Ù·È ÛËÙÈ΋ ·ÚıÚ›Ùȉ·. ∏ ¢ÂÚÂıÈÛÙfiÙËÙ·, ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, Ë ‰È¿ÚÚÔÈ·, Ô ÂÌÂÙfi˜ Î·È Ë ·ÚıÚ›Ùȉ· Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ¿Ù˘Â˜ ÂΉËÏÒÛÂȘ (7). ¢˘ÛÙ˘¯Ò˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ·ÍÈÔÏfiÁËÛ˘ Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜ ÙˆÓ ÂÈÚfiÛıÂÙˆÓ ·˘ÙÒÓ Â˘ÚËÌ¿ÙˆÓ.
¶›Ó·Î·˜ 1. ¶›Ó·Î·˜ ÂÈÚfiÛıÂÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ÓfiÛÔ˘ Kawasaki ∫ÏÈÓÈο Â˘Ú‹Ì·Ù·
∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·
∂˘Ú‹Ì·Ù· ·fi Ù· fiÚÁ·Ó·
∂˘ÂÚÂıÈÛÙfiÙËÙ·-¿ÛËÙË ÌËÓÈÁÁ›Ùȉ· ¶ÔÏ˘·ÚıÚ›Ùȉ· ∂Ú‡ıËÌ·/·ÔϤÈÛË ÙÔ˘ ÂÚÈÓ¤Ô˘, ∂Ú‡ıËÌ· ÛÙÔ ÛËÌÂ›Ô ¤ÓÂÛ˘ ÙÔ˘ BCG ∂Ï·Ùو̤Ó˜ ÂÚÈÊÂÚÈΤ˜ ÛʇÍÂȘ, ÈÛ¯·ÈÌ›· ¿ÎÚˆÓ, Á¿ÁÁÚ·ÈÓ· À¤ÚÙ·ÛË ∞‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ/ ÁÏÔ˘Ù·ÌÈÓÈ΋˜ ÙÚ·ÓÛÊÂÚ¿Û˘ ÕÛËÙË ˘Ô˘Ú›· ∞‡ÍËÛË ∆∫∂/ CRP ∞Ó·ÈÌ›· §Â˘ÎÔ΢ÙÙ¿ÚˆÛË £ÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË Ã·ÌËÏ¿ ›‰· Na ÷ÌËÏ¿ ›‰· ·Ï‚Ô˘Ì›Ó˘ ∞˘ÍË̤ӷ ÏÈ›‰È· Ï¿ÛÌ·ÙÔ˜ ∏ˆÛÈÓÔÊÈÏ›·/·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ IgE ⁄‰Úˆ„ Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ ƒ·ÁÔÂȉ›ÙȘ ¶·È‰È·ÙÚÈ΋ 2007;70:370-373
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°. °ÚËÁÔÚÈ¿‰Ô˘
∫·Ú‰›Ùȉ· οÔÈÔ˘ ‚·ıÌÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ Kawasaki. ∆Ô ÂÚÈοډÈÔ, ÙÔ Ì˘ÔοډÈÔ Î·È ÙÔ ÂÓ‰ÔοډÈÔ ÌÔÚÔ‡Ó Ó· ÂËÚ·ÛÙÔ‡Ó. ¶ÂÚÈηډ›Ùȉ· ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 20%-40% ÙˆÓ ÂÚÈÙÒÛˆÓ. ºÏÂÁÌÔÓ‹ Ù˘ ÌÈÙÚÔÂȉԇ˜ ‹ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜ Ô‰ËÁ› Û ·Ó¿ÚÎÂÈ· ÙˆÓ ‚·Ï‚›‰ˆÓ. ™˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·Ó¿ÚÎÂÈ· Û˘Ì‚·›ÓÂÈ ÛÙÔ 5% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∞Ó¢ڇÛÌ·Ù· ı· ÂÌÊ·ÓÈÛÙÔ‡Ó ÛÙÔ 20%-25% ÙˆÓ ·ÛıÂÓÒÓ, Û˘Ó‹ıˆ˜ ÌÂٷ͇ 2˘ Î·È 4˘ ‚‰ÔÌ¿‰·˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Î·È Û·ÓÈfiÙÂÚ· ÓˆÚ›ÙÂÚ·, ÂÓÙfi˜ 7 ËÌÂÚÒÓ. ¶·Ú¿ÁÔÓÙ˜, ÔÈ ÔÔ›ÔÈ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ·ÔÙÂÏÔ‡Ó ÙÔ Ê‡ÏÔ (Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ·), Ë ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ (οو ÙÔ˘ ¤ÙÔ˘˜), Ë ·Ú·ÌÔÓ‹ ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 16 ËÌÂÚÒÓ, Ë Î·Ú‰ÈÔÌÂÁ·Ï›·, Ë ·ÈÌÔÛÊ·ÈÚ›ÓË <·fi 10gr/dl, Ù· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· >30.000/mm3, Ë ∆∫∂ >·fi 100 mm/hr, Ë ıÂÙÈ΋ CRP, Ë ÔÔ›· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ ¿Óˆ ·fi 30 Ë̤Ú˜, Î·È ÔÈ ·ÚÚ˘ı̛˜. ™Â ·ÛıÂÓ›˜, fiÔ˘ ˘¿Ú¯ÂÈ ˘Ô„›· Ù˘ ÓfiÛÔ˘, ··ÈÙÂ›Ù·È Ë¯ÔηډÈÔÁÚ·ÊÈ΋ ÂÎÙ›ÌËÛË ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ ÂÙ¿ ËÌÂÚÒÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ∆· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· ·ÔÙÂÏÔ‡Ó ·ıÔÁÓˆÌÔÓÈÎfi ÛÙÔÈ¯Â›Ô Ù˘ ÓfiÛÔ˘. ∂› ÌË Â˘Ú¤Ûˆ˜ ıÂÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÂÙ·È Î·Ù¿ ÙËÓ 2Ë, 4Ë Î·È 8Ë Â‚‰ÔÌ¿‰·. ∏ ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È ˘„ËÏ‹˜ ‰fiÛ˘ ·ÛÈÚ›Ó˘ ·ÔÙÂÏÔ‡Ó ÙË ıÂڷ›· ÂÈÏÔÁ‹˜. ∂› ·ÔÙ˘¯›·˜ Ù˘ ·ÁˆÁ‹˜ (ÌË ÙÒÛ˘ ÙÔ˘ ˘ÚÂÙÔ‡ ‹ ·ÓÂÌÊ¿ÓÈÛ‹˜ ÙÔ˘ ÌÂÙ¿ ·fi 48 ÒÚ˜) ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË 2˘ ‰fiÛ˘ Á-ÛÊ·ÈÚ›Ó˘. ∂› ·ÔÙ˘¯›·˜ Î·È Ù˘ 2˘ ‰fiÛ˘ Á-ÛÊ·ÈÚ›Ó˘, ÚÔÙÈÌ¿Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ Infliximamb (ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ ηٿ ÙÔ˘ TNF-·) ·fi ÙËÓ ÎÔÚÙÈ˙fiÓË, Ì Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù·. ∏ ηډÈÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋˜ ·ÁˆÁ‹˜ ÂÍ·ÚÙÒÓÙ·È ·fi Ù· ηډÈÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √È ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ıÂڷ‡ÔÓÙ·È Ï‹Úˆ˜. ™ÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· Ì ‰È¿ÌÂÙÚÔ <8mm Û˘Ó‹ıˆ˜ ·Ôηı›ÛÙ·ÓÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜. ªÂÁ·Ï‡ÙÂÚ· ·Ó¢ڇÛÌ·Ù· Û¯ÂÙ›˙ÔÓÙ·È Ì ̷ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ Î·È ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Î·Ú‰È·ÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘ÍË̤Ó˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ (·ÁÒÓˆÓ). ∏ American Heart Association ηıfiÚÈÛ ÙË ‰È·ÛÙڈ̿وÛË ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ÓfiÛÔ Kawasaki Î·È ÚfiÙÂÈÓ ·Ó¿ÏÔÁË ıÂڷ›· Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ (8). √È ¿Ù˘Â˜ ÂΉËÏÒÛÂȘ Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ‚Ú¤ÊË. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î˘Ú›ˆ˜ ÛÙ· ‚Ú¤ÊË Paediatriki 2007;70:370-373
ÂÚÈÏ·Ì‚¿ÓÂÈ ÈÔÁÂÓ›˜ Î·È ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ, Ê·Ú̷΢ÙÈ΋ ·ÓÙ›‰Ú·ÛË Î·È ÓÔÛ‹Ì·Ù· ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÙÒÛÂȘ ‚ÚÂÊÒÓ 2,5 Î·È 3 ÌËÓÒÓ Ì ¿Ù˘Ë ÓfiÛÔ Kawasaki (9,10). ™Â ‚Ú¤ÊÔ˜ 7 ‚‰ÔÌ¿‰ˆÓ Ì ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù·, Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË 2 ‰fiÛÂˆÓ Á-ÛÊ·ÈÚ›Ó˘ Î·È ÎÔÚÙÈ˙fiÓ˘ ‹Ù·Ó ·Ó·Ú΋˜ Î·È ··ÈÙ‹ıËÎ·Ó 2 ‰fiÛÂȘ Infliximamb ÁÈ· ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ (11). ¶·È‰› 2 ÂÙÒÓ Ì ¿Ù˘Ô Kawasaki Î·È ıÚÔÌ‚ÔÂÓ›· ·Ó¤Ù˘Í ÙÚ›· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù·. ∞Ó·ÊÔÚ¤˜ Û 30 ÂÚÈÙÒÛÂȘ Ì ÓfiÛÔ Kawasaki Î·È ıÚÔÌ‚ÔÂÓ›· Û˘ÁÎÏ›ÓÔ˘Ó ÛÙÔ fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘˜ Â›Ó·È Û˘¯ÓfiÙÂÚÔ˜ Û ÎÔÚ›ÙÛÈ· ÌÈÎÚ‹˜ ËÏÈΛ·˜ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ Î·È Ì˘ÔηډȷÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘. π‰È·›ÙÂÚ· ÂӉȷʤÚÔ˘Û· Â›Ó·È Ë ÂÚ›ÙˆÛË Ó¤·˜ Á˘Ó·›Î·˜ 20 ÂÙÒÓ Ô˘ ·ÚÔ˘Û›·ÛÂ Ì˘ÔηډȷÎfi ¤ÌÊÚ·ÎÙÔ ·fi ıÚfiÌ‚ˆÛË ÁÈÁ·ÓÙÈ·›Ô˘ ·Ó¢ڇÛÌ·ÙÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ªÂÙ¿ ·fi ·ÔÎÏÂÈÛÌfi ·ÁÁÂȷ΋˜ ‹ Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘ ‰È·ÁÓÒÛıËΠ¿Ù˘Ë ÓfiÛÔ˜ Kawasaki (12). ¶·È‰È¿ (΢ڛˆ˜ ‚Ú¤ÊË) Ì ˘ÚÂÙfi ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 4 Ë̤Ú˜ Î·È Ì ÛÙÔȯ›· ÊÏÂÁÌÔÓ‹˜ ¯ˆÚ›˜ Û·Ê‹ ·ÈÙÈÔÏÔÁ›· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Ë¯ÔηډÈÔÁÚ·ÊÈο ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ÓfiÛÔ˘ Kawasaki (13). √ ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔÙÂÏ› ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ∏ ‰˘ÛÎÔÏ›· ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È Û˘Ó·ÎfiÏÔ˘ı· Ù˘ ¤ÁηÈÚ˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ È·ÙÚÈÎÔ‡ ÎfiÛÌÔ˘ Î·È ÙËÓ ·ÍÈÔÔ›ËÛË fiÏˆÓ ÙˆÓ ÂÈÚfiÛıÂÙˆÓ ÛÙÔȯ›ˆÓ Ô˘ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÁÈ· ÁÚ‹ÁÔÚË Î·È ·ÛÊ·Ï‹ ‰È¿ÁÓˆÛË ÂÓfi˜ ›ÎÙËÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ì ̷ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ, ÙˆÓ ÔÔ›ˆÓ ÙÔ ·ÎÚÈ‚¤˜ ̤ÁÂıÔ˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi ̤¯ÚÈ Û‹ÌÂÚ· (14).
µÈ‚ÏÈÔÁÚ·Ê›· 1. Burns JC, Glode MP. Kawasaki syndrome. Lancet 2004;364:533-544. 2. Fulton DR, Newburger JW. Long-term cardiac sequelae of Kawasaki disease. Curr Rheumatol Rep 2000;2:324-329. 3. Kato H. Cardiovascular complication in Kawasaki disease: coronary artery lumen and long-term consequences. Progress Pediatr Cardiol 2004;19:137-145. 4. Pfafferott C, Wirtzfeld A, Permanetter B. Atypical Kawasaki syndrome: how many symptoms have to be present? Heart 1997;78:619-621. 5. Rowley AH. Incomplete (atypical) Kawasaki disease. Pediatr Infect Dis J 2002;21:563-565. 6. Burns JC, Pannaraj PS, Turner CL, Bastian JF. Kawasaki disease: do we need a new case definition? Pediatr Res 2002;53:163.
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7. Uziel Y, Hashkes PJ, Kassem E, Gottesman G, Wolach B. “Unresolving pneumonia” as the main manifestation of atypical Kawasaki disease. Arch Dis Child 2003;88:940942. 8. Dajani AS, Taubert KA, Takahashi M, Bierman FZ, Freed MD, Ferrieri P, et al. Guidelines for long-term management of patients with Kawasaki disease. Report from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 1994;89:916-922. 9. Dahifar H, Ghorbani A. Atypical Kawasaki disease in two infants younger than 6 mÔnths. JRMS 2005;10:239-243. 10. Genizi J, Miron D, Spiegel R, Fink D, Horowitz Y. Kawasaki disease in very young infants: high prevalence of atypical presentation and coronary arteritis. Clin Pediatr (Phila) 2003;24:263-267.
11. O’ Connor MJ, Saulsbury FT. Incomplete and atypical Kawasaki disease in a young infant: severe, recalcitrant disease responsive to infliximamb. Clin Pediatr (Phila) 2007;46:345-348. 12. Nofech-Mozes Y, Garty BZ. Thrombocytopenia in Kawasaki disease: a risk factor for the development of coronary artery aneurysms. Pediatr Hematol Oncol 2003;20:597-601. 13. Hsiao JY, Chen MR, Huang FY, Kao HA, Sung TC. Clinical analysis of Kawasaki disease in infants below 6 months of age. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1998;29: 318-323. 14. Brogan PA, Bose A, Burgner D, Shingadia D, Tulloh R, Michie C, et al. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002;86:286-290.
“∂ͤÁÂÚÛË” Tarja Tiihonen 13 ÂÙÒÓ, ºÈÓÏ·Ó‰›· ∆˘ÊÏfi ·È‰› “∆· Ù˘ÊÏ¿ ·È‰È¿ ˙ˆÁÚ·Ê›˙Ô˘Ó”, ÕÓÓ· §·Ô˘Ù¿ÚË °ÎÚÈÙ˙¿Ï·, ∞ı‹Ó·, 2006 “A rousing”
Tarja Tiihonen 13 years old, Finland Blind child “Blind children paint”, Anna LaoutariGritzala, Athens 2006 ¶·È‰È·ÙÚÈ΋ 2007;70:370-373
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™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ, ∆Ì‹Ì· ¡ÔÛËÏ¢ÙÈ΋˜
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AÏÏËÏÔÁÚ·Ê›·: πˆ¿ÓÓ· ¶·˘ÏÔÔ‡ÏÔ˘ idpavlop@yahoo.gr ºÂȉ›Ô˘ 25, ∆.∫.:155 62, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë: √ ÚÔÙ·˚fi˜ Â›Ó·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ ·›ÙÈÔ ‰È¿ÚÚÔÈ·˜ Î·È ·Ê˘‰¿ÙˆÛ˘ ÛÙ· ÌÈÎÚ¿ ·È‰È¿ Î·È ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ ÙˆÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ÂÍ·ÈÙ›·˜ ÙÔ˘ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ Û˘¯Ó‹˜ ·Ó¿Á΢ ÁÈ· ÓÔÛËÏ›·. ∂Âȉ‹ Ë Ïԛ̈ÍË Â›Ó·È Û¯Â‰fiÓ ·Ó·fiÊ¢ÎÙË Î·È ÌÂÙ¿ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ê·›ÓÂÙ·È Ó· ‰ËÌÈÔ˘ÚÁ› οÔÈÔ˘ ‚·ıÌÔ‡ ·ÓÔÛ›·, Â›Ó·È Â˘ÓfiËÙÔ fiÙÈ Ï‡ÛË ÛÙÔ Úfi‚ÏËÌ· ı· ÌÔÚÔ‡Û ӷ ÚÔÛʤÚÂÈ Ë ÚfiÏË„Ë Ù˘ ÛÔ‚·Ú‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ì ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÚfiÛÊ·ÙË Î˘ÎÏÔÊÔÚ›· ‰‡Ô Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ· Î·È Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈο ¤Ó·ÓÙÈ Ù˘ ÛÔ‚·Ú‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi, ˘fiÛ¯ÂÙ·È Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘. ∂ÈϤÔÓ, Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ú·¿Óˆ ÂÌ‚ÔÏ›ˆÓ ÛÙȘ ÚÔηıÔÚÈṲ̂Ó˜ ËÏÈ˘ ‰ÂÓ ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ȉ›ˆ˜ ÂÁÎÔÏ·ÛÌfi. ∞·Ú·›ÙËÙË Â›Ó·È Ë Û˘Ó¯‹˜ ÂÈÙ‹ÚËÛË, ÁÈ· Ó· ··ÓÙËıÔ‡Ó ÂÚˆÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ¤Ó·ÓÙÈ ÓÂÔÂÌÊ·ÓÈ˙fiÌÂÓˆÓ ÔÚÔÙ‡ˆÓ ÈÔ‡ Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Û ¿ÏϘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜. ∂›Û˘, Ë Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ı· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ›‰Ú·Û‹˜ ÙÔ˘ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Î·È ÛÙË ‰È¢ÎÚ›ÓËÛË Ù˘ Û¯¤Û˘ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜. §¤ÍÂȘ ÎÏÂȉȿ: °·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÚÔÙ·˚fi˜, ÂÌ‚fiÏÈ·.
Current concepts in prevention of rotavirus gastroenteritis Athens University, Faculty of Nursing, Athens, Greece
Correspondence: Ioanna D. Pavlopoulou idpavlop@yahoo.gr 25, Fidiou St. 155 62, Athens, Greece
I. D. Pavlopoulou Abstract: Rotavirus is the most common cause of diarrhoea and dehydration in young children, with a significant impact upon healthcare systems in developed countries, at both in- and outpatient levels. Since rotavirus infection is difficult to prevent, but provides some natural immunity after the first infection, prevention of severe gastroenteritis by vaccination could represent a solution to the burden of this illness. Recent licensure of two new oral, live, attenuated vaccines that have proven efficacious against severe rotavirus gastroenteritis, offers a possibility of reducing the morbidity, mortality and economic burden of disease in nations able to afford the vaccines. Large scale efficacy and safety data have shown excellent efficacy of the above vaccines against severe rotavirus disease. In addition, their administration at the scheduled ages was not associated with serious adverse events, particularly intussusception. Ongoing surveillance is needed in order to answer questions regarding their coverage against new rotavirus serotypes and whether older children can also safely receive the vaccine. In addition, post-licensure data will be needed to assess the impact and cost-effectiveness of rotavirus vaccination. Key words: Gastroenteritis, rotavirus, vaccines.
™˘ÓÙÔÌÔÁڷʛ˜ °ƒ:
Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi
∂ÈÛ·ÁˆÁ‹ ∏ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Û ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ô ÚÔÙ·˚fi˜ Â›Ó·È ˘Â‡ı˘ÓÔ˜ ÁÈ· 600.000 ı·Ó¿ÙÔ˘˜ ÂÙËÛ›ˆ˜, ÂÓÒ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ÙÔ Î‡ÚÈÔ Úfi‚ÏËÌ· ·ÔÙÂÏÔ‡Ó Ë ˘„ËÏ‹ ÓÔÛËÚfiÙËÙ· Ô˘ Ô‰ËÁ› Û ·˘ÍË̤ÓÔ Paediatriki 2007;70:374-378
·ÚÈıÌfi È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ Î·È ÂÈÛ·ÁˆÁÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜ (1,2). ™‡Ìʈӷ Ì ÂÎÙÈÌ‹ÛÂȘ, fiÏ· Ù· ·È‰È¿ ı· ÌÔÏ˘ÓıÔ‡Ó ·Ô ÚÔÙ·˚fi ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ, Ë Û˘¯ÓfiÙËÙ· fï˜ ÚÔÛ‚ÔÏ‹˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ‚Ú¤ÊË 6 ¤ˆ˜ 24 ÌËÓÒÓ Ô˘ ÊÔÈÙÔ‡Ó Û ‚ÚÂÊÈÎÔ‡˜ ÛÙ·ıÌÔ‡˜ ‹ Û ÂΛӷ Ô˘ ÌÔχÓÔÓÙ·È ÂÓ‰ÔÓÔÛÔÎÔÌÂȷο, ÂÓÒ ÓÔÛËχÔÓÙ·È ÁÈ· ¿ÏÏË ·ÈÙ›· (3,4). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÔÈ ÂÚÈÙÒÛÂȘ ÓÔÛËÏ›·˜ ÏfiÁˆ °ƒ ÛÙȘ
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¶ÚfiÏË„Ë Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi
∏¶∞ Â›Ó·È 58.000-70.000 οı ¯ÚfiÓÔ, ÂÓÒ ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ ∞˘ÛÙÚ·Ï›· ηٷÁÚ¿ÊÔÓÙ·È 87.000 Î·È 10.000 ÂÚÈÙÒÛÂȘ ·ÓÙ›ÛÙÔȯ· (5-7). §ÈÁfiÙÂÚÔ Â˘ÎÚÈÓ‹˜ Â›Ó·È Ë ·ÂÈÎfiÓÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë, ηıÒ˜ Ù· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ô˘ ˘¿Ú¯Ô˘Ó Â›Ó·È ·Ó·Ú΋ (6). °ÂÁÔÓfi˜ ¿ÓÙˆ˜ Â›Ó·È fiÙÈ Ë Ú·ÁÌ·ÙÈ΋ ›وÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· ˘ÔÂÎÙÈÌ¿Ù·È, ·ÊÔ‡ ÔÏϤ˜ ÏÔÈÌÒÍÂȘ Â›Ó·È ‹È˜ Î·È ·˘ÙÔ˚ÒÓÙ·È ¯ˆÚ›˜ Ó· ¯ÚÂÈ·ÛÙÔ‡Ó È·ÙÚÈ΋ ÊÚÔÓÙ›‰·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È fiÙÈ fiÛÔ ‚·Ú‡ÙÂÚË Â›Ó·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û ̛· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÙfiÛÔ ·˘Í¿ÓÂÈ Ë Èı·ÓfiÙËÙ· ·˘Ù‹ Ó· ÔÊ›ÏÂÙ·È Û ÚÔÙ·˚fi (8). ¶ÂÚÈÔÚÈṲ̂ӷ ‰Â‰Ô̤ӷ ·ÂÈÎÔÓ›˙Ô˘Ó ÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÓÔÛËÏ›·˜ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì °ƒ, ηıÒ˜ Î·È Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ÌÂ Û˘ÁÁÂÓ›˜ ‹ ›ÎÙËÙ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ‹ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ (9-11). ∏ Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ Ù˘ °ƒ Â›Ó·È Ë ·Ê˘‰¿ÙˆÛË, ηıÒ˜ Ù· ¿Û¯ÔÓÙ· ‚Ú¤ÊË Î·È Ó‹È· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó 10-20 ÎÂÓÒÛÂȘ ËÌÂÚËÛ›ˆ˜ Î·È Â̤ÙÔ˘˜ ‰È¿ÚÎÂÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ‹ ›Û˘ ÙˆÓ 24 ˆÚÒÓ. √ ΛӉ˘ÓÔ˜ ·Ê˘‰¿ÙˆÛ˘ ·˘Í¿ÓÂÈ fiÙ·Ó Ë ËÏÈΛ· ÚÔÛ‚ÔÏ‹˜ Â›Ó·È ÌÈÎÚfiÙÂÚË (2). ∆· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ÔÈ ÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ °ƒ ·ÁÎÔÛÌ›ˆ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ȉÈfiÙËÙ˜ ÙÔ˘ ÚÔÙ·˚Ô‡ Î·È ÙËÓ ·Ô˘Û›· ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ·ÓÙÈ˚΋˜ ıÂڷ›·˜, Â›Ó·È ÔÈ Î‡ÚÈÔÈ ÏfiÁÔÈ Ô˘ Ô‰‹ÁËÛ·Ó ÛÙËÓ ·Ú·Û΢‹ ÂÌ‚ÔÏ›ˆÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÈÎÂÓÙÚÒÓÂÈ ÛÙȘ ÚfiÛÊ·Ù˜ ÂÍÂÏ›ÍÂȘ ÛÙÔ ¯ÒÚÔ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡.
ªÔÚÊÔÏÔÁ›· Î·È ·ÓÙÈÁÔÓÈΤ˜ ȉÈfiÙËÙ˜ ÙÔ˘ ÚÔÙ·˚Ô‡ √È ÚÔÙ·˚Ô› ÔÊ›ÏÔ˘Ó ÙÔ fiÓÔÌ¿ ÙÔ˘˜ ÛÙËÓ ÂÈÎfiÓ· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ Ô˘ ÌÔÈ¿˙ÂÈ Ì “ÙÚÔ¯fi” (Ï·ÙÈÓÈÎfi˜ fiÚÔ˜, rota). AÓ‹ÎÔ˘Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Reoviridae Î·È ·ÔÙÂÏÔ‡ÓÙ·È ·fi η„›‰ÈÔ Ì ‰‡Ô ÛÙÈ‚¿‰Â˜, ÔÈ Ôԛ˜ ÂÚÈÎÏÂ›Ô˘Ó 11 ÙÌ‹Ì·Ù· RNA Ì ‰ÈÏ‹ ¤ÏÈη. ∏ Â͈ÙÂÚÈ΋ ÛÙÈ‚¿‰· ÂÚȤ¯ÂÈ ‰‡Ô ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ ÙÔ˘ ÈÔ‡ (viral proteins, VP): ÙËÓ ÚˆÙ½ÓË VP4 (P-ÚˆÙ½ÓË, ÚÔÛÎÔÏÏË̤ÓË ÛÙËÓ ÚˆÙ¿ÛË) Î·È ÙË ÁÏ˘ÎÔÚˆÙ½ÓË VP7 (G-ÚˆÙ½ÓË). √È ÚˆÙ½Ó˜ ·˘Ù¤˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ÚÔÙ·˚ÒÓ Û P Î·È G ÔÚÔÙ‡Ô˘˜ Î·È Ù·˘Ùfi¯ÚÔÓ· ¤¯Ô˘Ó ηıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›ˆÓ, ·ÔÙÂÏÒÓÙ·˜ ÛÙfi¯Ô˘˜ ÁÈ· Ù· ÂÍÔ˘‰ÂÙÂÚˆÙÈο ·ÓÙÈÛÒÌ·Ù· (12). ∏ ÂÛˆÙÂÚÈ΋ ÛÙÈ‚¿‰· ÂÚȤ¯ÂÈ ÙÔ Ì›˙ÔÓ ·ÓÙÈÁfiÓÔ ÙÔ˘ ÈÔ‡, ÙËÓ ÚˆÙ½ÓË VP6, Ì ‚¿ÛË ÙËÓ ÔÔ›· Á›ÓÂÙ·È Ë Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘ Û ÔÌ¿‰Â˜ A-E (∂ÈÎfiÓ· 1). ∏ ÔÚÔÔÌ¿‰· ∞ Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ·
11 ÙÌ‹Ì·Ù· RNA ‰ÈÏ‹˜ ¤ÏÈη˜ ¶ÚˆÙ½ÓË VP6 (Ì›˙ÔÓ ·ÓÙÈÁfiÓÔ ÙÔ˘ ÈÔ‡)
G - ÚˆÙ½ÓË (VP7) ∞ÓÔÛ›· P - ÚˆÙ½ÓË (VP4)
∂ÈÎfiÓ· 1: ¢ÔÌ‹ ÙÔ˘ ÚÔÙ·˚Ô‡.
ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ. ∂ȉËÌÈΤ˜ ÂÍ¿ÚÛÂȘ °ƒ ·fi ÔÚÔÔÌ¿‰· µ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙËÓ ∫›Ó·, ÂÓÒ Ë ÔÌ¿‰· C ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ·Û˘Ìو̷ÙÈΤ˜ ÏÔÈÌÒÍÂȘ (12,13). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÙÔ˘Ï¿¯ÈÛÙÔÓ 15 ÔÚfiÙ˘ÔÈ G Î·È 23 ÔÚfiÙ˘ÔÈ P, ÔÛÔÛÙfi 90-95% ÙˆÓ ÛÙÂϯÒÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Î¿ı ¯ÚfiÓÔ Û ·È‰È¿ Ì ÓfiÛÔ ·Ó‹ÎÂÈ ÛÙÔ˘˜ G1P[8], G2P[4], G3P[8], G4P[8] Î·È Û·ÓÈfiÙÂÚ· ÛÙÔÓ G9P[8] (12,13). ¡ÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔÈ ÔÚfiÙ˘ÔÈ Â›Ó·È Ô G9 ÛÙȘ ∏¶∞, Û ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Î·È ÙËÓ π·ˆÓ›·, ÔÈ G5, G6, G8, G10 ΢ڛˆ˜ Û ¯ÒÚ˜ Ù˘ §·ÙÈÓÈ΋˜ ∞ÌÂÚÈ΋˜ Î·È Ô G12 ·Ú¯Èο ÛÙȘ ºÈÏțӘ Î·È ·ÚÁfiÙÂÚ· ÛÙËÓ ∫ÔÚ¤·, ÛÙȘ ∏¶∞ Î·È ÛÙËÓ ∂˘ÚÒË (13-16). ¢È·ÊÔÚÂÙÈο ÛÙÂϤ¯Ë ÙÔ˘ ÈÔ‡ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÔ˘Ó Î·È ˙Ò·, fiˆ˜ ‚ÔÔÂȉ‹ Î·È Èı‹ÎÔ˘˜, Ë ÌÂÙ¿‰ÔÛË fï˜ ·fi ˙ÒÔ Û ¿ÓıÚˆÔ Â›Ó·È ·Û˘Ó‹ı˘. º˘ÛÈ΋ Û‡˙¢ÍË ˙ˆ˚ÎÒÓ Ì ·ÓıÚÒÂÈ· ÛÙÂϤ¯Ë ¤¯ÂÈ ·Ú·ÙËÚËı› Û ·ÓıÚÒÔ˘˜ Î·È ¤¯ÂÈ ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜ ÁÈ· ·Ú·Û΢‹ ÂÌ‚ÔÏ›ˆÓ (13,17).
¡fiÛÔ˜ ·fi ÚÔÙ·˚fi Î·È ·ÓÔÛ›· √È ÚÔÙ·˚Ô› ÌÂÙ·‰›‰ÔÓÙ·È Ì ÙËÓ ÎÔÚ·ÓÔÛÙÔÌ·ÙÈ΋ Ô‰fi Ì ¿ÌÂÛË Â·Ê‹ ‹ ̤ۈ ·ÓÙÈÎÂÈ̤ӈÓ, ·ÏÏ¿ Èı·ÓfiÓ Î·È ·fi ÌÔÏ˘Ṳ̂ÓË ÙÚÔÊ‹ ‹ ÓÂÚfi ηıÒ˜ Î·È Ì ÛÙ·ÁÔÓ›‰È· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (18,19). √ Èfi˜ Â›Ó·È ·ÓıÂÎÙÈÎfi˜ ÛÙ· Û˘Ó‹ıË Ì¤ÙÚ· ˘ÁÈÂÈÓ‹˜, fiˆ˜ ÙÔ Ï‡ÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ, ·ÏÏ¿ Î·È Û ·ÓÙÈÛËÙÈο Ô˘ ¤¯Ô˘Ó ˆ˜ ‚¿ÛË ÙË ¯ÏˆÚÂÍȉ›ÓË, ÂÓÒ ·‰Ú·ÓÔÔÈÂ›Ù·È ÌÂÙ¿ ·fi ¯Ú‹ÛË ·ÏÎÔÔÏÔ‡¯ˆÓ ‹ ¯ÏˆÚÈÔ‡¯ˆÓ ‰È·Ï˘Ì¿ÙˆÓ (20). √ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ‰Ú· ÚÔÛٷ٢ÙÈο ÌfiÓÔ ˆ˜ ÚÔ˜ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (21). ŒÓ·˜ ÂÈÚfiÛıÂÙÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙË ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Â›Ó·È Ë ·Ô‚ÔÏ‹ ÙÔ˘ ·fi Ù· ÎfiÚ·Ó· Ï›ÁÔ ÚÈÓ Î·È Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ (22). ªÂÙ¿ ·fi ÂÒ·ÛË 1-3 ËÌÂÚÒÓ, Ë ÓfiÛÔ˜ ÍÂÎÈÓ¿ ·ÈÊÓ›‰È· Ì Â̤ÙÔ˘˜, ¶·È‰È·ÙÚÈ΋ 2007;70:374-378
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π. ¶·˘ÏÔÔ‡ÏÔ˘
ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÚÔÛÙ›ıÂÓÙ·È ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ, ÂÓÒ 25% ÙˆÓ ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ Î·È ˘ÚÂÙfi. ∆· Û˘ÌÙÒÌ·Ù· ‰È·ÚÎÔ‡Ó Û˘Ó‹ıˆ˜ 3-7 Ë̤Ú˜, ÌÔÚ› Ó· Â›Ó·È ‹È· ‹ ÛÔ‚·Ú¿ Î·È Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·Ê˘‰¿ÙˆÛË, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Î·Ù·ÏËÍ›· (12). ∏ Û˘Û¯¤ÙÈÛË Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Û ÚÔËÁËı›۷ Ïԛ̈ÍË ‹ ÓfiÛÔ, Ì ÙËÓ ÚÔÛÙ·Û›· ·fi Ó¤· ¤ÎıÂÛË ÛÙÔÓ ÚÔÙ·˚fi, ‰ÂÓ Â›Ó·È ·Ôχو˜ ηٷÓÔËÙ‹. ∏ ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ (IgG, IgA Î·È ÂÍÔ˘‰ÂÙÂÚˆÙÈÎÒÓ ·ÓÙÈۈ̿وÓ) ÛÙÔÓ ÔÚfi Î·È Û ÂÓÙÂÚÈΤ˜ ÂÎÎÚ›ÛÂȘ, ηıÒ˜ Î·È ·ÓÙÈÛˆÌ¿ÙˆÓ ÔÚÔ‡ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ VP4 Î·È VP7, ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Û ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ Ì ÚÔÛÙ·Û›· ÂÓÒ Û ¿ÏϘ fi¯È (23,24). º·›ÓÂÙ·È ¿ÓÙˆ˜ fiÙÈ Ù· ·Ú·¿Óˆ ·ÓÙÈÛÒÌ·Ù· ÌÔÚ› Ó· ‰Ú¿ÛÔ˘Ó ÚÔÛٷ٢ÙÈο ÙfiÛÔ ¤Ó·ÓÙÈ ÙÔ˘ ›‰ÈÔ˘ fiÛÔ Î·È ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ·, ¤Ó·ÓÙÈ ¿ÏÏˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÈÔ‡. ™˘Ó‹ıˆ˜, ÌÂÙ¿ ÙËÓ ÚÒÙË Ïԛ̈ÍË Ë ·ÓÔÛÔ·¿ÓÙËÛË ·ÊÔÚ¿ ÙÔ ›‰ÈÔ Û٤ϯԘ, ÂÓÒ Û ·ÎfiÏÔ˘ı˜ ÏÔÈÌÒÍÂȘ ·ÎfiÌ· Î·È Ì ÙÔÓ ›‰ÈÔ ÔÚfiÙ˘Ô, ‰ËÌÈÔ˘ÚÁÂ›Ù·È Â˘Ú‡ÙÂÚË, ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÚÔÛÙ·Û›· (25). ∆¤ÏÔ˜, Ô ÚfiÏÔ˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ·ÊÔÚ¿ ÙfiÛÔ ÙËÓ ·Ó¿ÚÚˆÛË ·fi ÙËÓ ÔÍ›· Ïԛ̈ÍË Î·È ÙË ‚Ú¿¯˘ÓÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ÈÔ‡, fiÛÔ Î·È ÙËÓ ÚÔÛÙ·Û›· ·fi ÂfiÌÂÓ˜ ÏÔÈÌÒÍÂȘ (26).
¶ÚfiÏË„Ë-∂Ì‚fiÏÈ· ∏ ·Ó¿ÁÎË Ù˘ ¯Ú‹Û˘ ÂÌ‚ÔÏ›Ô˘ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Ì ÛÎÔfi ÙËÓ ÚfiÏË„Ë Ù˘ °ƒ ÚԤ΢„ Ϸ̂¿ÓÔÓÙ·˜ ˘fi„Ë Ù· ·Ú·Î¿Ùˆ ‰Â‰Ô̤ӷ (12): 1. ∏ ÓÔÛËÚfiÙËÙ· ·Ô ÚÔÙ·˚fi ÌÂٷ͇ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ Î·È ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ‰ÂÓ ‰È·Ê¤ÚÂÈ, ÁÂÁÔÓfi˜ Ô˘ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ ·‰˘Ó·Ì›· ÚfiÏ˄˘ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤ÙÚˆÓ ˘ÁÈÂÈÓ‹˜. 2. ∏ ¯Ú‹ÛË ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ÂÓ˘‰¿ÙˆÛ˘ ·fi ÙÔ ÛÙfiÌ· Ì›ˆÛ ٷ ÔÛÔÛÙ¿ ÓÔÛËÏ›·˜ ÛÙȘ ∏¶∞ ÌfiÓÔ Î·Ù¿ 16%. 3. ∏ ·Ú¯È΋ Ïԛ̈ÍË Ê·›ÓÂÙ·È Ó· ÚÔÛٷهÂÈ ·fi ÂfiÌÂÓ· ÂÂÈÛfi‰È· ÛÔ‚·Ú‹˜ °ƒ. ¶·ÚfiÏ· ·˘Ù¿, ‹È· ‹ ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ. 4. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÓˆÚ›˜ ÛÙË ˙ˆ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜, ÌÈÌÔ‡ÌÂÓÔ˜ ÙË Ê˘ÛÈ΋ Ïԛ̈ÍË, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÏ¿‚ÂÈ Ù· ÛÔ‚·Ú¿ ÂÂÈÛfi‰È· °ƒ Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘˜, ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È Û ı¤ÛË Ó· ÚÔÛٷهÛÂÈ ·fi ‹È· ‹ ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË. ∆Ô ÚÒÙÔ ÂÌ‚fiÏÈÔ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ ÚfiÙ· Ô˘ ¤Ï·‚ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ 1998 ÛÙȘ ∏¶∞, ‹Ù·Ó ÙÔ ˙ˆÓ ÂÍ·ÛıÂÓË̤ÓÔ, ÙÂÙÚ·‰‡Ó·ÌÔ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ, Ì ÙËÓ ÔÓÔÌ·Û›· Rotashield, ÙÔ ÔÔ›Ô fï˜ Û‡ÓÙÔÌ· ·ÔÛ‡ÚıËΠÏfiÁˆ Ù˘ ¯ÚÔÓÈ΋˜ Û˘Û¯¤ÙÈÛ˘ Ì ÂÂÈÛfi‰È· ÂÁÎÔÏ·ÛÌÔ‡, 3-7 Ë̤Ú˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ 1˘ ‰fiÛ˘ (27), ·ÏÏ¿ Î·È Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ¿ÏÏˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Î·È ·ÈÌ·ÙËÚÒÓ ÎÂÓÒÛÂˆÓ (28). ∏ ÂÎ Ó¤Ô˘ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·Ó¤‰ÂÈÍ ˆ˜ ·Ú¿ÁÔÓÙ· ÎÈÓPaediatriki 2007;70:374-378
‰‡ÓÔ˘ ÁÈ· ÂÁÎÔÏ·ÛÌfi ÙËÓ ËÏÈΛ· ≥90 ËÌÂÚÒÓ Î·Ù¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ 1˘ ‰fiÛ˘ (29). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ Î·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ù˘ ¯Ú‹Û˘ ÙÔ˘ ·Ú·¿Óˆ ÂÌ‚ÔÏ›Ô˘ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÁÂÓÈÎfiÙÂÚË ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÂÁÎÔÏ·ÛÌÔ‡ (27,29). ∂ÈϤÔÓ, ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙÔ˘ Ê˘ÛÈÎÔ‡ ÈÔ‡ Ì ÂÁÎÔÏ·ÛÌfi Î·È Ë ·ıÔÁ¤ÓÂÈ¿ ÙÔ˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË (30). ∞ÎÔÏÔ‡ıËÛÂ Ë ·Ú·Û΢‹, Ô ÂÎÙÂٷ̤ÓÔ˜ ¤ÏÂÁ¯Ô˜ Ì ÌÂϤÙ˜ Ê¿Ûˆ˜ πππ Î·È Ë ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ 2006, ‰‡Ô Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ: ÙÔ˘ ÌÔÓÔ‰‡Ó·ÌÔ˘ Rotarix (GSK) Î·È ÙÔ˘ ÂÓÙ·‰‡Ó·ÌÔ˘ RotaTeq (Merck). ∆Ô Rotarix ÂÚȤ¯ÂÈ ˙ÒÓÙ· ÂÍ·ÛıÂÓË̤ÓÔ ·ÓıÚÒÂÈÔ Èfi (Û٤ϯԘ G1P1A[8]), ·Ú¤¯ÂÈ ÂÎÙfi˜ ÙÔ˘ G1 Î·È ÂÙÂÚÔÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙˆÓ ÔÚÔÙ‡ˆÓ G3, G4, G9 Î·È Û‡Ìʈӷ Ì ÚfiÛÊ·Ù· ÛÙÔȯ›· Î·È ¤Ó·ÓÙÈ ÙÔ˘ G2P[4] (31,32), ÂÓÒ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· Û 2 ‰fiÛÂȘ. ∆Ô RotaTeq Â›Ó·È ÂÓÙ·‰‡Ó·ÌÔ, ÂÍ·ÛıÂÓË̤ÓÔ, ÂÙÂÚÔÛ˘Ó‰˘·Ṳ̂ÓÔ ‚Ô›Ԣ/·ÓıÚˆÂ›Ô˘ Ù‡Ô˘, ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙˆÓ ÔÚÔÙ‡ˆÓ G1-4 Î·È G9 Î·È ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· Û 3 ‰fiÛÂȘ. ∆· ÂÌ‚fiÏÈ· ·˘Ù¿ ¤¯Ô˘Ó ‰ÔÎÈÌ·Ûı› Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·È‰ÈÒÓ Â›Ó·È ·ÛÊ·Ï‹, ·ÓÔÛÔÁfiÓ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÛÔ‚·ÚÒÓ ÂÂÈÛÔ‰›ˆÓ °ƒ Û ÔÛÔÛÙÔ 85-98%, ¯ˆÚ›˜ Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ȉ›ˆ˜ ÂÁÎÔÏ·ÛÌfi, fiÙ·Ó ¯ÔÚËÁ‹ıËÎ·Ó ÛÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ (31,33). ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÔÈ ÂӉ›ÍÂȘ Î·È ·ÓÙÂӉ›ÍÂȘ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2 (12). ∆Ô Rotarix ¤¯ÂÈ ¿ÚÂÈ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ Û ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜, Û ¯ÒÚ˜ Ù˘ §·ÙÈÓÈ΋˜ ∞ÌÂÚÈ΋˜, ÙËÓ ∞˘ÛÙÚ·Ï›· Î·È ÌÂÚÈΤ˜ ¯ÒÚ˜ Ù˘ ∞Û›·˜, ÂÓÒ ÙÔ RotaTeq ¤¯ÂÈ ¿‰ÂÈ· ΢ÎÏÔÊÔÚ›·˜ ÛÙȘ ∏¶∞ (fiÔ˘ ¤¯ÂÈ ÂÓÙ·¯ı› Î·È ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ), Û ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Î·È ÙËÓ ∞˘ÛÙÚ·Ï›·. ÕÌÂÛË Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹, ‰ÈfiÙÈ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ‰ÂÓ ¤ÁÈÓ·Ó Û ›‰ÈÔ˘˜ ÏËı˘ÛÌÔ‡˜, Ô‡Ù ¯ÚËÛÈÌÔÔ›ËÛ·Ó Ù· ›‰È· ÙÂÏÈο ÎÚÈÙ‹ÚÈ· ·ÍÈÔÏfiÁËÛ˘. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙÔ ÎfiÛÙÔ˜ Û˘ÁÎÚÈÙÈο Ì ÙÔ ÚÔÛ‰ÔÎÒÌÂÓÔ fiÊÂÏÔ˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, fiÔ˘ Ë ıÓËÙfiÙËÙ· ÂÍ·ÈÙ›·˜ °ƒ Â›Ó·È ¯·ÌËÏ‹ Î·È ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ˘„ËÏfi, Â›Ó·È ·Ó·Áη›· Ë Û˘ÏÏÔÁ‹ Î·È ·Ó¿Ï˘ÛË ÛÙÔȯ›ˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· Û˘Ó˘ÔÏÔÁÈÛıÔ‡Ó ÔÈ ¯·Ì¤Ó˜ ÂÚÁ·ÙÔÒÚ˜ ÙˆÓ ÁÔÓ¤ˆÓ, ÙÔ ÎfiÛÙÔ˜ Ù˘ ÓÔÛËÏ›·˜, ÙˆÓ È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ Î·È Ù˘ ÌË È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜ (ÂȉÈ΋ ‰È·ÙÚÔÊ‹, ¿Ó˜, ÂÓ˘‰·ÙÈο ‰È·Ï‡Ì·Ù·) (34). ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ¤ÁÈÓ·Ó ‰È·ı¤ÛÈÌ· ÚfiÛÊ·Ù· Î·È ÛÙË ¯ÒÚ· Ì·˜, ¯ˆÚ›˜ fï˜ ·ÎfiÌ· Ó· ¯ÔÚËÁÔ‡ÓÙ·È ·fi Ù· ·ÛÊ·ÏÈÛÙÈο Ù·Ì›·. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ù·˘Ùfi¯ÚÔÓË Ì ٷ ¿ÏÏ· ÂÌ‚fiÏÈ·, ¯ˆÚ›˜ Ó·
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¶ÚfiÏË„Ë Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi
ÂËÚ¿ÛÂÈ ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ·˘Ù¿. ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·, ÔÈ ÂӉ›ÍÂȘ Î·È ·ÓÙÂӉ›ÍÂȘ ÙˆÓ ‰‡Ô ÂÌ‚ÔÏ›ˆÓ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2 (12).
ªÂÏÏÔÓÙÈÎÔ› ÛÙfi¯ÔÈ ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÂÌ‚fiÏÈ· ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡ ¤¯Ô˘Ó ÌÂÏÂÙËı› ÛÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·È‰ÈÒÓ ÌÂÙ¿ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜, ÂÚˆÙËÌ·ÙÈο ·Ú·Ì¤ÓÔ˘Ó Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ÛÙËÓ ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ÓÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔ˘˜ ÔÚfiÙ˘Ô˘˜, ÙËÓ ·ÛÊ¿ÏÂÈ¿ ÙÔ˘˜ Â¿Ó ¯ÔÚËÁËıÔ‡Ó Û ‰È·ÊÔÚÂÙÈΤ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ ‹ Û ÏËı˘ÛÌÔ‡˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ÚfiˆÚ· ‹ ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· ‹ ·ÓÔÛÔηٷÛÙÔÏ‹. ∂˘ÓfiËÙË Â›Ó·È Ë ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ·ÚÔ¯‹˜ ÙÔ˘˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ Ë ıÓËÙfiÙËÙ· Â›Ó·È ÌÂÁ¿ÏË. ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ¤ÁÈÓ·Ó ‰È·ı¤ÛÈÌ· ÚfiÛÊ·Ù· Î·È ÛÙË ¯ÒÚ· Ì·˜, ¯ˆÚ›˜ fï˜ ·ÎfiÌ· Ó· ¤¯ÂÈ ·Ó·ÏËÊı› Ë Î¿Ï˘„Ë Ù˘ ‰·¿Ó˘ ·fi Ù· ·ÛÊ·ÏÈÛÙÈο Ù·Ì›·. ™¯ÂÙÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘˜, ÌÂϤÙ˜ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ ·Ô˘ÛÈ¿˙Ô˘Ó. ∂›Ó·È ¢ÓfiËÙÔ fiÙÈ ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ·fi ¿ÏϘ ¯ÒÚ˜ ‰ÂÓ ¤¯Ô˘Ó ·fiÏ˘ÙË ÂÊ·ÚÌÔÁ‹, ΢ڛˆ˜ ‰ÈfiÙÈ ÔÈ ‰·¿Ó˜ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ ÓÔÛËÏ›·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ (34). ™ËÌ·ÓÙÈο ¿ÓÙˆ˜ Â›Ó·È Ù· ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· Ô˘ ÚԤ΢„·Ó ·fi ÚfiÛÊ·ÙË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Û ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi Î·È ‰Â›¯ÓÔ˘Ó ÔÙÈ Ô ÚÔÙ·˚fi˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ ‹ÌÈÛ˘ ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ô˘ ÓÔÛËχÔÓÙ·È ‹ ÂÈÛΤÙÔÓÙ·È Ù· ·È‰È·ÙÚÈο ÙÌ‹Ì·Ù· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ Ù˘ ¯ÒÚ·˜ (35). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÂÊ·ÚÌÔÁ‹ ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ¤Ó·ÓÙÈ ÙÔ˘ ÚÔÙ·˚Ô‡, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ·, Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË ÓÔÛËÚfiÙËÙ· Î·È ÙȘ ÂÈÏÔΤ˜ ÛÙ· ÌÈÎÚ¿ ·È‰È¿, ηıÒ˜ Î·È ÙËÓ ÂÈ‚¿Ú˘ÓÛË ÛÙ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜ ÙˆÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ ÔÈ Ôԛ˜ ›¶›Ó·Î·˜ 1. ∂Ӊ›ÍÂȘ Î·È ÙÚfiÔ˜ ¯ÔÚ‹ÁËÛ˘ ÂÌ‚ÔÏ›Ô˘ ¤Ó·ÓÙÈ ÚÔÙ·˚Ô‡ ŸÏ· Ù· ‚Ú¤ÊË ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6-12 ‚‰ÔÌ¿‰ˆÓ - RotaTeq: 2, 4, 6 ÌËÓÒÓ (3 ‰fiÛÂȘ) - ÔÏÔÎÏ‹ÚˆÛË Û¯‹Ì·ÙÔ˜ Û ËÏÈΛ· ≤32 ‚‰ÔÌ¿‰ˆÓ - Rotarix: 2, 4 ÌËÓÒÓ (2 ‰fiÛÂȘ) - ÔÏÔÎÏ‹ÚˆÛË Û¯‹Ì·ÙÔ˜ Û ËÏÈΛ· ≤24 ‚‰ÔÌ¿‰ˆÓ ∏ 1Ë ‰fiÛË ‰ÂÓ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È Û ËÏÈΛ· >12 ‚‰ÔÌ¿‰ˆÓ ∂Ï¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ‰fiÛÂˆÓ 4 ‚‰ÔÌ¿‰Â˜ Ÿ¯È ÂÌ‚ÔÏÈ·ÛÌfi˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ ªÔÚ› Ó· Û˘Á¯ÔÚËÁËı› Ì ¿ÏÏ· ÂÌ‚fiÏÈ·
¶›Ó·Î·˜ 2. ¢∂¡ ·ÔÙÂÏÔ‡Ó ·ÓÙÂӉ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ◊ÈÔ Â̇ÚÂÙÔ ÓfiÛËÌ· ¶ÚÔËÁËı›۷ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi ∫‡ËÛË ÛÙÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ/ ıËÏ·ÛÌfi˜ ¶ÚÔˆÚfiÙËÙ· <37 ‚‰ÔÌ¿‰ˆÓ (ÂÊfiÛÔÓ ËÏÈΛ· 6 ‚‰ÔÌ¿‰ˆÓ, ÛÙ·ıÂÚ‹ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË) ÕÙÔÌÔ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ (χÛÈÌÔ ¯ÂÚÈÒÓ) ™Â ¤ÌÂÙÔ, ‰ÂÓ Â·Ó·¯ÔÚËÁÂ›Ù·È Ë ‰fiÛË ™Â ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ‹ ÚÔ˚fiÓÙˆÓ-ÌÂÛԉȿÛÙËÌ· 42 Ë̤Ú˜ A¡∆∂¡¢∂π•∂π™: ÈÛÙÔÚÈÎfi ÂÁÎÔÏ·ÛÌÔ‡, ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË Û ÚÔËÁÔ‡ÌÂÓË ‰fiÛË, ·ÓÔÛÔηٷÛÙÔÏ‹, ¯ÚfiÓÈ· ÓfiÛÔ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·
Ó·È Û ı¤ÛË Ó· ·ÓÙ·ÂͤÏıÔ˘Ó ÛÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘. ∂›Û˘, fiÙ·Ó Ù· Ó¤· ÂÌ‚fiÏÈ· ¯ÔÚËÁ‹ıËÎ·Ó Û ηıÔÚÈṲ̂ӷ ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Î·È ËÏÈ˘, ‰ÂÓ Û˘Ó‰˘¿ÛÙËÎ·Ó Ì ÛËÌ·ÓÙÈΤ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Î·È È‰È·›ÙÂÚ· ÂÁÎÔÏ·ÛÌfi. ¢È¢ÎÚ›ÓËÛË ¯ÚÂÈ¿˙ÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÚÔÙÂÈÓfiÌÂÓ˜ ËÏÈ˘ Ì ÙË Û˘Ó¯È˙fiÌÂÓË ÂÈÙ‹ÚËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÁÎÔÏ·ÛÌÔ‡ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜. ∂Í›ÛÔ˘ ÛËÌ·ÓÙÈ΋ Â›Ó·È Î·È Ë Û˘ÓÂÚÁ·Û›· ÁÈ· ÙËÓ ¿ÌÂÛË ‰È¿ıÂÛ‹ ÙÔ˘˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, fiÔ˘ ÙÔ ÚÔÛ‰ÔÎÒÌÂÓÔ fiÊÂÏÔ˜ Û fiÙÈ ·ÊÔÚ¿ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· Â›Ó·È ÙÔ Ì¤ÁÈÛÙÔ.
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∏ ‹È· Î·È Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ ª.£·ÓÔÔ‡ÏÔ˘1, °. ∆ÛfiÏ·˜2 ¶ÂÚ›ÏË„Ë: ∏ ÔÌÔ΢ÛÙ½ÓË ·ÔÙÂÏ› ÂӉȿÌÂÛÔ ÚÔ˚fiÓ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÌÂıÂÈÔÓ›Ó˘. ªÂϤÙ˜ ÙˆÓ ‰‡Ô ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ Û ÂÓ‹ÏÈΘ ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ‹È· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ˆ˜ ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ. ∆· ›‰· ·›Ì·ÙÔ˜ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (tHcy) ηıÔÚ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ Ê‡ÏÔ, ÙËÓ ËÏÈΛ·, Ù· ›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 ÛÙÔÓ ÔÚfi ηıÒ˜ Î·È ·fi ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ªÂÙ·ÏÏ¿ÍÂȘ ÙˆÓ ÂÓ˙‡ÌˆÓ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ·Ó¿ÚÎÂÈ· ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ µ6, µ12 Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ Ô˘ ‰ÚÔ˘Ó ˆ˜ Û˘Ì·Ú¿ÁÔÓÙ˜ ÙˆÓ ÂÓ˙‡ÌˆÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ӷ ›‰· ÔÌÔ΢ÛÙ½Ó˘. ∏ ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi 677C-T ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈ΋ Ú‰ԢÎÙ¿ÛË (ª∆HFR) ·ÔÙÂÏ› ÙÔÓ ÈÔ Û˘¯Ófi ÁÂÓÂÙÈÎfi ·Ú¿ÁÔÓÙ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Î·È Ë ‡·ÚÍ‹ Ù˘ ÚÔηÏ› ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ηٿ ÂÚ›Ô˘ 2,5 Ìmol/l. ¶·Ú¿ÏÏËÏ·, ¤¯ÂÈ Á›ÓÂÈ ÁÓˆÛÙfi fiÙÈ Ë ·ıËڈ̷ÙÈ΋ ‰ÈÂÚÁ·Û›· ·Ú¯›˙ÂÈ Î·È ÂÍÂÏ›ÛÛÂÙ·È ‹‰Ë ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·. ∆· ›‰· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÙˆÓ Ï¤ÔÓ ÛËÌ·ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ·˘Ù¿ ÙˆÓ ÏÈȉ›ˆÓ, ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏÔ‡Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· Ù· ·ÓÙ›ÛÙÔȯ· ›‰· ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙË ÌÂÙ·‚ÔÏÈ΋ Ô‰fi Ù˘ ÔÌÔ΢ÛÙ½Ó˘, ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· ›‰¿ Ù˘ ÛÙÔ ·›Ì·, ÛÙ· ·›ÙÈ· Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜, ÛÙË Û˘Û¯¤ÙÈÛ‹ Ù˘ Ì ÙËÓ ·ıËÚÔıÚÔÌ‚ˆÙÈ΋ ÓfiÛÔ, fiˆ˜ ·˘Ù‹ ÙÂÎÌËÚÈÒÓÂÙ·È ·fi ÌÂϤÙ˜ ÂÓËϛΈÓ, ηıÒ˜ Î·È ÛÙȘ ‰˘Ó·ÙfiÙËÙ˜ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘. ∆¤ÏÔ˜, ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙ· ÓÂfiÙÂÚ· ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ ÁÈ· ÙÔ˘˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Î·È ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ›Û˘ Î·È ÙȘ Û˘Ó‹ıÂȘ ˙ˆ‹˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙ· ·È‰È¿.
1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ∞ÙÙÈÎfi ¡ÔÛÔÎÔÌÂ›Ô 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶·Ó. & ∞ÁÏ·˝·˜ ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ geotsol@otenet.gr µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶·Ó. & ∞ÁÏ·˝·˜ ∫˘ÚÈ·ÎÔ‡”
§¤ÍÂȘ ÎÏÂȉȿ: √ÌÔ΢ÛÙ½ÓË, ·ıËڈ̿وÛË, ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜, ·È‰›.
Mild-tÔ-moderate hyperhomocysteinaemia as a risk factor for atherosclerosis and thromboembolic disease M. Thanopoulou1, G. Tsolas2 Abstract: Homocysteine is a metabolite of methionine. In the past two decades, there has been growing interest in mild to moderate degrees of hyperhomocysteinemia as an independent risk factor for atherosclerosis and thromboembolic disease. Total serum homocysteine (tHcy) levels may be associated with age, gender, with serum levels of folate and vitamin B6 and B12, and with renal function. Mutations in the enzymes involved in homocysteine metabolism and deficiencies of vitamins B6, B12 and folic acid (co-factors of these enzymes) are associated with hyperhomocysteinemia. Homozygosity for the methylenotetrahydrofolate reductase (MTHFR) 677C-T polymorphism is the most common genetic determinant, and individuals with the MTHFR 677TT genotype usually have tHcy levels approximately 2.5 Ìmol/l higher than the normal. It is well known that the atherosclerotic process begins and progresses during childhood and adolescence, and that some children display risk factors such as moderate to high levels of cholesterol, which may be predictive of adult levels. This article briefly summarizes the biochemical background of tHcy, the causes and diagnosis of hyperhomocysteinemia, and the role of high serum levels of homocysteine in atherosclerosis and thrombotic disease, through studies of adults, and its treatment. In addition, the article focuses on the physiologic, genetic and lifestyle determinants of homocysteine levels in children.
1 3rd Paediatric Department of the University of Athens, Attikon Hospital 2 2nd Paediatric Department of the University of Athens, “P. and A. Kyriakou” Children’s Hospital Correspondence: Georgios Tsolas geotsol@otenet.gr 2nd Paediatric Department of the University of Athens, “P. and A. Kyriakou” Children’s Hospital
Key words: Homocysteine, atherosclerosis, arterial and venous thrombosis, child.
∂ÈÛ·ÁˆÁ‹ √È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ·ıËڈ̿وÛ˘ Ê·›ÓÂÙ·È fiÙÈ ‰ÚÔ˘Ó ‹‰Ë ·fi ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ∞ıËڈ̷ÙÈΤ˜
·ÏÏÔÈÒÛÂȘ ÛÙ· ÙÔȯÒÌ·Ù· ÙˆÓ ·ÁÁ›ˆÓ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ÂÊ‹‚Ô˘˜ ·ÏÏ¿ Î·È Û ·È‰È¿ (13). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ηӛÛÌ·ÙÔ˜, Ù˘ ·¯˘Û·ÚΛ·˜, ¶·È‰È·ÙÚÈ΋ 2007;70:379-388
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Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ ππ Î·È ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ηıÈÛÙÔ‡Ó ÂÈÙ·ÎÙÈ΋ ÙËÓ ·Ó¿Ù˘ÍË ÌÂıfi‰ˆÓ ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘ Û ·˘Ù‹ ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· (4-5). ∏ ·Ó·˙‹ÙËÛË Ó¤ˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÂÚ¢ÓËÙÈÎfi ‰›Ô, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÂÚ›Ô˘ ÙÔ 25% ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÒÈÌË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ ÎÏ·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (6). ∞Ó¿ÌÂÛ· ÛÙÔ˘˜ Ó¤Ô˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÔÌÔ΢ÛÙ½ÓË, Ë ÔÔ›· ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ˆ˜ ÛËÌ·ÓÙÈÎfi˜ ‚ÈÔ¯ËÌÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ·ıËڈ̷ÙÈ΋˜ ‰ÈÂÚÁ·Û›·˜ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘. ∏ ‹È· Î·È Ë Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÌÔÚÔ‡Ó, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ, Ó· ·ÔηٷÛÙ·ıÔ‡Ó Â‡ÎÔÏ· Ì ·ÛÊ·Ï›˜ Î·È Û¯ÂÙÈο ÌÈÎÚÔ‡ ÎfiÛÙÔ˘˜ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ, fiˆ˜ ÙÔ ‰È·ÙÚÔÊÈÎfi Û˘Ìϋڈ̷ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ¿ÏÏˆÓ ‚ÈÙ·ÌÈÓÒÓ (713). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂÓ‰¤¯ÂÙ·È Ó· ÂËÚ¿ÛÂÈ ÙËÓ ÂȉËÌÈÔÏÔÁ›· Î·È Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘, ÁÈ’ ·˘Ùfi Î·È ·ÔÙÂÏ› ÙÔ ·ÓÙÈΛÌÂÓÔ ÔÏÏÒÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÂͤÏÈÍË.
√ ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ∏ ÔÌÔ΢ÛÙ½ÓË (Hcy) ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÌÂÙ·‚ÔÏÈ΋ Ô‰fi ÙÔ˘ ··Ú·›ÙËÙÔ˘ ·ÌÈÓÔͤԘ ÌÂıÂÈÔÓ›ÓË. À¿Ú¯ÂÈ ÙfiÛÔ Û ÂχıÂÚË (›¯ÓË ~2%) fiÛÔ Î·È ÛÂ Û˘˙¢Á̤ÓË Ì ڈÙ½Ó˜ ÌÔÚÊ‹. ™ÙÔ Ï¿ÛÌ·, ÔÍÂȉÒÓÂÙ·È ÛÙ· ‰ÈÛÔ˘ÏÊ›‰È· ÔÌÔ΢ÛÙ½ÓË-ÔÌÔ΢ÛÙ½ÓË (ÔÌÔ΢ÛÙ›ÓË) Î·È ÔÌÔ΢ÛÙ½ÓË-΢ÛÙ½ÓË (ÌÈÎÙfi ‰ÈÛÔ˘ÏÊ›‰ÈÔ). ∏ ÂχıÂÚË Î·È Ë Û˘Ó‰Â‰Â̤ÓË Ì ڈÙ½ÓË ÔÌÔ΢ÛÙ½ÓË, ηıÒ˜ Î·È Ù· ‰ÈÛÔ˘ÏÊ›‰È¿ Ù˘,
·Ó·Ê¤ÚÔÓÙ·È ‰ÈÂıÓÒ˜ ˆ˜ ÔÏÈ΋ ÔÌÔ΢ÛÙ½ÓË (tHcy) ‹ ·ÏÒ˜ ÔÌÔ΢ÛÙ½ÓË (14). À¿Ú¯Ô˘Ó ‰‡Ô Ô‰Ô› ·ӷÌÂı˘Ï›ˆÛ˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Û ÌÂıÂÈÔÓ›ÓË Î·È Ì›· Ô‰fi˜ ÌÂÙ·ÙÚÔ‹˜ Ù˘ Û ΢ÛÙ½ÓË (∂ÈÎfiÓ· 1). ™ÙÔ ÌÔÓÔ¿ÙÈ Ù˘ ·ӷÌÂı˘Ï›ˆÛ˘ Ô˘ ηٷχÂÙ·È ·fi ÙË Û˘ÓıÂÙ¿ÛË Ù˘ ÌÂıÂÈÔÓ›Ó˘, Ë ‚ÈÙ·Ì›ÓË µ12 (ÎÔ‚·Ï·Ì›ÓË) ÏÂÈÙÔ˘ÚÁ› ˆ˜ Û˘Ó¤Ó˙˘ÌÔ Î·È Ë ÌÂı˘ÏÔÌ¿‰· ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ 5-ÌÂı˘ÏÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi Ô͇, ÙËÓ Î‡ÚÈ· ÌÔÚÊ‹ ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔ Ï¿ÛÌ·, Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ 5,10 ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi Ô͇ Ì ÙË ‰Ú¿ÛË Ù˘ Ú‰ԢÎÙ¿Û˘ ÙÔ˘ ÌÂı˘ÏÂÓÔÙÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎÔ‡ ÔͤԘ (MTHFR). ™ÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ Ô‰fi ·ӷÌÂı˘Ï›ˆÛ˘, Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ ÛÙÔ ‹·Ú, Ë ‚ÂÙ·˝ÓË Â›Ó·È Ô ‰ˆÚËÙ‹˜ Ù˘ ÌÂı˘ÏÔÌ¿‰·˜ Î·È Ë ·ÓÙ›‰Ú·ÛË Î·Ù·Ï‡ÂÙ·È ·fi ÙË ÌÂı˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË Ù˘ ‚ÂÙ·˝Ó˘-ÔÌÔ΢ÛÙ½Ó˘. ∏ ÔÌÔ΢ÛÙ½ÓË ÌÂÙ·ÙÚ¤ÂÙ·È ·fi ÙË ‚-Û˘ÓıÂÙ¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ Û ΢ÛÙ·ıÂÈÔÓ›ÓË Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÙË ‰Ú¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ¿Û˘ Û ΢ÛÙ½ÓË. ∏ ʈÛÊÔÚÈ΋ ˘ÚȉÔÍ¿ÏË, ·Ú¿ÁˆÁÔ Ù˘ ‚ÈÙ·Ì›Ó˘ µ6, ÏÂÈÙÔ˘ÚÁ› ˆ˜ Û˘Ó¤Ó˙˘ÌÔ Î·È ÛÙȘ ‰‡Ô ÂÓ˙˘ÌÈΤ˜ ·ÓÙȉڿÛÂȘ (14) (∂ÈÎfiÓ· 1). ∏ ‚ÈÙ·Ì›ÓË µ6 Â›Ó·È Â›Û˘ ··Ú·›ÙËÙË ÁÈ· ÙË ÌÂÙ·ÙÚÔ‹ Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ Û ΢ÛÙ½ÓË Î·È ·-ÎÂÙÔ‚Ô˘Ù˘ÚÈÎfi Ô͇.
¶·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· ›‰· ÔÌÔ΢ÛÙ½Ó˘ ·›Ì·ÙÔ˜ º˘ÛÈÔÏÔÁÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ›Û˘ ÔÈ Û˘Ó‹ıÂȘ ˙ˆ‹˜, Ê·›ÓÂÙ·È fiÙÈ ·›˙Ô˘Ó ÚfiÏÔ ÛÙË ‰È·ÌfiÚʈÛË ÙˆÓ ÂȤ‰ˆÓ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ ·›Ì· ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÏÏ¿ Î·È ÙˆÓ ·È‰ÈÒÓ (15). ∏ ÔÌÔ΢ÛÙ½ÓË ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚÈÛı› ›Ù ÛÙÔÓ ÔÚfi
ª∂£∂π√¡π¡∏
º˘ÏÏÈÎfi Ô͇
∆ÂÙÚ·¸‰ÚÔÊ˘ÏÏÈÎfi ‹ THF Û˘ÓıÂÙ¿ÛË Ù˘ µ12 ÌÂıÂÈÔÓ›Ó˘ 5,10-ÌÂı˘ÏÂÓÔTHF 5-ÌÂı˘ÏÔTHF Ú‰ԢÎÙ¿ÛË ÙÔ˘ ÌÂı˘ÏÂÓÔTHF
S-·‰ÂÓÔÛ˘ÏÔÌÂıÂÈÔÓ›ÓË
‰ÈÌÂı˘ÏÔÁÏ˘Î›ÓË ÌÂı˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË Ù˘ ‚ÂÙ·˝Ó˘-ÔÌÔ΢ÛÙ½Ó˘ ‚ÂÙ·˝ÓË
√ª√∫À™∆∂´¡∏
‚-Û˘ÓıÂÙ¿ÛË Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘
S-·‰ÂÓÔÛ˘ÏÔÌÔ΢ÛÙ½ÓË
µ6
΢ÛÙ·ıÂÈÔÓ›ÓË Î˘ÛÙ·ıÂÈÔÓÈÓ¿ÛË
µ6
∫À™∆∂´¡∏ ∂ÈÎfiÓ· 1. ªÂÙ·‚ÔÏÈ΋ Ô‰fi˜ Ù˘ ÔÌÔ΢ÛÙ½Ó˘.
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ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜
›Ù ÛÙÔ Ï¿ÛÌ·. ∆· ‰Â›ÁÌ·Ù· Ï¿ÛÌ·ÙÔ˜ ÚÔÙÈÌÒÓÙ·È ÁÈ·Ù› ÌÔÚÔ‡Ó Ó· Ê˘ÁÔÎÂÓÙÚËıÔ‡Ó ·Ì¤Ûˆ˜ ‹ Ó· ÙÔÔıÂÙËıÔ‡Ó Û ¿ÁÔ Î·È Ó· ‰È·ÙËÚËıÔ‡Ó ÁÈ· 6 ÒÚ˜. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ ·ÔʇÁÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ·fi Ù· ÂÚ˘ıÚ¿ Î·È ÂÔ̤ӈ˜ Ë „¢‰‹˜ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘. ∏ ηٷӿψÛË Á‡̷ÙÔ˜ ÏÔ‡ÛÈÔ˘ Û ڈÙ½ÓË ÌÔÚ› Ó· ·˘Í‹ÛÂÈ Ù· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ̤¯ÚÈ Î·È 15% ÌÂÙ¿ ·fi ¿ÚÔ‰Ô 6-8 ˆÚÒÓ (14).
∂›Â‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ËÏÈΛ· ∆· ›‰· Ù˘ tHcy ÛÙÔ ·›Ì· ·˘Í¿ÓÔÓÙ·È Ì ÙËÓ ËÏÈΛ·. ∏ ̤ÛË Û˘ÁΤÓÙÚˆÛË Â›Ó·È 4-8 Ìmol/l ÛÙ· ·È‰È¿ ËÏÈΛ·˜ <15 ÂÙÒÓ, Ô˘ ·ÓÙÈÛÙÔȯ› ÂÚ›Ô˘ ÛÙÔ 60% ÙˆÓ ÙÈÌÒÓ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (16). ∫¿ÔȘ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ÛÙ· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·, ‰È·ÊÔÚ¿ Ë ÔÔ›· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ¤Î‰ËÏË Î·Ù¿ ÙËÓ ÂÊ˂›· Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ·˘Ù‹ (16-21). ∞ÎfiÌË, Â›Ó·È ¯·ÌËÏfiÙÂÚË ÛÙȘ Á˘Ó·›Î˜ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ ·fi fi,ÙÈ ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È ·˘Í¿ÓÂÙ·È ÌÂÙ¿ ÙËÓ ÂÌÌËÓfi·˘ÛË (22). ∂›Â‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ‚Èٷ̛Ә µ6, µ12 Î·È Ê˘ÏÏÈÎfi Ô͇ √È ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Ù· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Â›Ó·È Ë Â¿ÚÎÂÈ· ‚ÈÙ·ÌÈÓÒÓ µ6, µ12 Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ηıÒ˜ Î·È Ë Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (15). ∏ ›‰Ú·ÛË ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ µ ÛÙ· ›‰· ÔÌÔ΢ÛÙ½Ó˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ Ô˘ ¤¯Â› ηٷÁÚ·Ê› ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (23). ™Â ·È‰È¿ ËÏÈΛ·˜ >24 ÌËÓÒÓ, Ë Û˘ÁΤÓÙÚˆÛË tHcy ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ٷ ›‰· ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ÏÈÁfiÙÂÚÔ Ì ·˘Ù¿ Ù˘ ÎÔ‚·Ï·Ì›Ó˘ (9,16). ∏ ‚ÈÙ·Ì›ÓË µ6 ›¯Â ÙËÓ ·ÛıÂÓ¤ÛÙÂÚË ‹ Î·È Î·Ì›· ›‰Ú·ÛË (16-24). ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ÛÙ· ¿ÙÔÌ· Ô˘ Ï¿Ì‚·Ó·Ó ÔÏ˘‚ÈÙ·ÌÈÓÔ‡¯· Û˘ÌÏËÚÒÌ·Ù· ‰È·ÙÚÔÊ‹˜ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ‰ÂÓ Ï¿Ì‚·Ó·Ó (7). ∂Ô̤ӈ˜, ‰ÂÓ ÌÔÚ› Ó· Á›ÓÂÈ ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ·ÛıÂÓÒÓ Ì ÎÏÈÓÈ΋ ˘Ô„›· ‰È·Ù·Ú·¯ÒÓ, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·Ó Ô ·ÛıÂÓ‹˜ Ï·Ì‚¿ÓÂÈ Û˘ÌÏËÚÒÌ·Ù· ‚ÈÙ·ÌÈÓÒÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ µ. ∂›Â‰· ÔÌÔ΢ÛÙ½Ó˘ Î·È ·¯˘Û·ÚΛ· ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ÛÙ· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÔÛfiÙËÙ· Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÁÏ˘Îfi˙˘. ™Ù· ·¯‡Û·Úη ·È‰È¿, Ë ÙÈÌ‹ Ù˘ tHcy ·ÚÔ˘ÛÈ¿˙ÂÈ ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ÙÔÓ ÏÈÒ‰Ë ÈÛÙfi Î·È Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ (25). ∫·Ù·‰Â›¯ıËΠ›Û˘ Ë ‡·ÚÍË ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁ˘ Û¯¤Û˘ ·Ó¿ÌÂÛ·
ÛÙËÓ tHcy Î·È ÙË Û˘ÁΤÓÙÚˆÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ (26). √È ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Ô‰ËÁÔ‡Ó Û ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ÛÙ· ·¯‡Û·Úη ·È‰È¿: ÚÒÙÔÓ, ÙËÓ ·Ó·Ú΋ ÚfiÛÏË„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‰Â‡ÙÂÚÔÓ, ÙÔÓ ˘ÂÚÈÓÛÔ˘ÏÈÓÈÛÌfi Ô˘ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ ·ÓÔ¯‹ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ·ÊÔ‡ Ë ÈÓÛÔ˘Ï›ÓË ·fi ÌfiÓË Ù˘ ÌÂÈÒÓÂÈ ·ÓÙ› Ó· ·˘Í¿ÓÂÈ ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy (27). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·¯˘Û·ÚΛ·, fiˆ˜ Ë ·˘ÍË̤ÓË ‰È·ÛÙÔÏÈ΋ ›ÂÛË Î·È Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÔÌÔ΢ÛÙ½ÓË ÛÙ· ·È‰È¿, ÛÙÔÈ¯Â›Ô ÙÔ ÔÔ›Ô ‰ÂÓ Â›Ó·È Û‡ÌʈÓÔ Ì ٷ ·ÓÙ›ÛÙÔȯ· Â˘Ú‹Ì·Ù· ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (16,26,28). ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ·˘Í‹ıËΠ·ÓÙ› Ó· ÂÏ·ÙÙˆı› Û ·¯‡Û·Úη ·È‰È¿, Ù· ÔÔ›· Û˘ÌÌÂÙ›¯·Ó Û ÚfiÁÚ·ÌÌ· Ì›ˆÛ˘ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ (29). ∏ ·‡ÍËÛË ·˘Ù‹ ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ‰Â˘ÙÂÚÔÁÂÓ‹˜ ÏfiÁˆ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ÌÂıÂÈÔÓ›Ó˘ ·fi ÙÔÓ Î·Ù·‚ÔÏÈÛÌfi ÙˆÓ ÚˆÙÂ˚ÓÒÓ, ¯ˆÚ›˜ Ó· ÌÔÚ› Ó· ·ÁÓÔËı› Î·È Ë Èı·Ó‹ Û˘ÓÂÈÛÊÔÚ¿ Ù˘ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ (29).
ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó Ù· ›‰· ÔÌÔ΢ÛÙ½Ó˘ ÕÏÏÔÈ, ÏÈÁfiÙÂÚÔ Î·Ï¿ ÌÂÏÂÙË̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó Ù· ›‰· ÔÌÔ΢ÛÙ½Ó˘ Â›Ó·È ÙÔ Î¿ÓÈÛÌ·, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË Î·È Ë Î·Ù·Ó¿ÏˆÛË Î·Ê¤ Î·È ÔÈÓÔÓ‡̷ÙÔ˜ (15). Ÿˆ˜ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ¤ÙÛÈ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜, ÙÔ Î¿ÓÈÛÌ· Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ ›‰· tHcy, Ô˘ ÌÔÚ› ÂÓ Ì¤ÚÂÈ Ó· ·Ô‰Ôı› ÛÙËÓ ·Ó·Ú΋ ÚfiÛÏË„Ë ‚ÈÙ·ÌÈÓÒÓ Î·È ÛÙËÓ Î·Î‹ ‰È·ÙÚÔÊ‹ ÙˆÓ Î·ÓÈÛÙÒÓ (9,16). √È Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ tHcy ÔÈΛÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ÂıÓÈÎfiÙËÙ· Î·È Â›Ó·È ˘„ËÏfiÙÂÚ˜ ÛÙ· Ì·‡Ú· ·È‰È¿ ·fi fi,ÙÈ ÛÙ· ÏÂ˘Î¿ (15). OÈ ¶·Ô˘ÙÛ¿Î˘ Î·È Û˘Ó. ¤‰ÂÈÍ·Ó fiÙÈ Ô ÔÌfi˙˘ÁÔ˜ ∆∆ ÁÔÓfiÙ˘Ô˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ӷ ›‰· tHcy ÌfiÓÔ ÛÙ· ·È‰È¿ Ì ¯·ÌËÏ¿ ›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È È‰›ˆ˜ ÛÙ· ¿ÚÚÂÓ· ¿ÙÔÌ· (30). ∞Ó¿ÏÔÁ˜ ·Ó·ÎÔÈÓÒÛÂȘ Û ÓÂÔÁ¤ÓÓËÙ· ·Ó·Ê¤ÚÔ˘Ó ÙË ÌË Â›‰Ú·ÛË ÙˆÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ MTHFR 677 C-T Î·È 1298A-C ÛÙ· ›‰· Ù˘ tHcy Ï¿ÛÌ·ÙÔ˜ (31). ∞›ÙÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ∞) ∂ÎÛÂÛËÌ·Ṳ̂ÓË ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· (√ÌÔ΢ÛÙÈÓÔ˘Ú›·) ∏ Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÂÎÛÂÛËÌ·Ṳ̂Ó˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ (›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ Ï¿ÛÌ· >100 Ìmol/L) Â›Ó·È Ë Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ ‚-Û˘ÓıÂÙ¿Û˘ Ù˘ ΢ÛÙ·ıÂÈÔÓ›Ó˘ (CBS), Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ¶·È‰È·ÙÚÈ΋ 2007;70:379-388
Paidiatriki 5 final
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ÔÔ›·˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È ÂÚ›Ô˘ 1/335.000 Ì ¢Ú›· ‰È·Î‡Ì·ÓÛË, ·fi 1/65.000 (πÚÏ·Ó‰›·) ¤ˆ˜ 1/900.000 (π·ˆÓ›·) (32). ∆· ¿Û¯ÔÓÙ· ¿ÙÔÌ· ·Ó·Ù‡ÛÛÔ˘Ó ÙÔ ÎÏ·ÛÈÎfi Û‡Ó‰ÚÔÌÔ Ù˘ ÔÌÔ΢ÛÙÈÓÔ˘Ú›·˜, ÙÔ ÔÔ›Ô ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÎÙÔÔ˘˜ Ê·ÎÔ‡˜, ÛÎÂÏÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÚÒÈÌË ·ÁÁÂȷ΋ ÓfiÛÔ, ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· Î·È ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË (33). ¶ÂÚ›Ô˘ 5-10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÌÔ΢ÛÙÈÓÔ˘Ú›·˜ ·Ô‰›‰ÔÓÙ·È Û ÎÏËÚÔÓÔÌÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ Ô‰Ô‡ Ù˘ ·ӷÌÂı˘Ï›ˆÛ˘ (34). ∏ Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ ª∆∏FR (<10% ÙˆÓ ÙÈÌÒÓ ·Ó·ÊÔÚ¿˜ Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜) ·ÔÙÂÏ› Û˘¯Ó‹ ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ‰È·Ù·Ú·¯‹ Ù˘ Ô‰Ô‡ ·ӷÌÂı˘Ï›ˆÛ˘ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi „˘¯ÔÎÈÓËÙÈ΋ ˘ÛÙ¤ÚËÛË, Û·ÛÌÔ‡˜, ÂÚÈÊÂÚÈ΋ Ó¢ÚÔ¿ıÂÈ·, ÚÒÈÌË ·ÁÁÂȷ΋ ÓfiÛÔ Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· (35,36). µ) ◊È·-̤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· √È ÌÔÚʤ˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ‹È·˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ (›‰· Ó‹ÛÙÂÔ˜: 15-100 Ìmol/L) ·Ô‰›‰ÔÓÙ·È Û ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ›ÎÙËÙ˜ ηٷÛÙ¿ÛÂȘ ‹ Û˘¯ÓfiÙÂÚ· ÛÂ Û˘Ó‰˘·ÛÌfi ÙˆÓ ‰‡Ô. √È ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ Ô‰ËÁÔ‡Ó Û Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙˆÓ ÂÓ˙‡ÌˆÓ ηٿ 50%, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ÂÙÂÚfi˙˘Á˘ ¤ÏÏÂȄ˘ ÙˆÓ CBS ‹ MTHFR Ì ·ıÚÔÈÛÙÈÎfi ÂÈÔÏ·ÛÌfi ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi 0,4%-1,5% Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ‹È· Î·È ÙË Ì¤ÙÚÈ· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·. ÕÏÏË ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ηٿ 50% ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÌÈ·˜ ıÂÚÌÔ¢·›ÛıËÙ˘ ÌÂÙ¿ÏÏ·Í˘ Ù˘ MTHFR (37), Ë ÔÔ›· ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÓÙÈηٿÛÙ·ÛË Ù˘ ΢ÙÔÛ›Ó˘ ·fi ÙË ı˘Ì›ÓË ÛÙÔ ÓÔ˘ÎÏÂÔÙ›‰ÈÔ 677 ÙÔ˘ Έ‰ÈÎÔÔÈÔ‡ ÁÔÓȉ›Ô˘, ·ÓÙÈηıÈÛÙÒÓÙ·˜ ÛÙÔ ¤Ó˙˘ÌÔ ÙÔ Îˆ‰ÈÎfiÓÈÔ Ù˘ ·Ï·Ó›Ó˘ Ì ·˘Ùfi Ù˘ ‚·Ï›Ó˘. √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ÔÌÔ˙˘ÁˆÙ›·˜ ÁÈ· ÙË ÌÂÙ¿ÏÏ·ÍË C677T Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 5% Î·È 20% ÛÙÔ˘˜ ∫·˘Î¿ÛÈÔ˘˜ (37). √È Ì¤ÙÚȘ ·˘Í‹ÛÂȘ ÙˆÓ ÂȤ‰ˆÓ Ù˘ tHcy ‰ÂÓ ·Ó¢ڛÛÎÔÓÙ·È Û fiÏ· Ù· ¿ÙÔÌ· Ì ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ÚÔηÏÔ‡Ó ÂÏ¿ÙÙˆÛË Ù˘ ÂÓ˙˘ÌÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ηٿ 50%, ˘Ô‰ËÏÒÓÔÓÙ·˜ fiÙÈ Ë Ê·ÈÓÔÙ˘È΋ ÂΉ‹ÏˆÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ÂËÚ¿˙ÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘Ú›ˆ˜ ·fi ÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ (38). ™Ù· ·›ÙÈ· Ù˘ ›ÎÙËÙ˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ¤ÏÏÂÈ„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÎÔ‚·Ï·Ì›Ó˘ Î·È ˘ÚȉÔ͛Ӣ, ηıÒ˜ Î·È Ë ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (39,40). º¿Ú̷η Ô˘ ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ì›·˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi ÙȘ ·Ú·¿Óˆ ‚Èٷ̛Ә, fiˆ˜ Ë ÌÂıÔÙÚÂÍ¿ÙË, Ù· ·ÓÙÈÛ·Û̈‰Èο, ÙÔ ·Ó·ÈÛıËÙÈÎfi nitrous oxide Î·È Ë ıÂÔÊ˘ÏÏ›ÓË, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ‹È· ˘ÂÚÔÌÔPaediatriki 2007;70:379-388
¶›Ó·Î·˜ 1. ∂ηÙÔÛÙÈ·›· ηٷÓÔÌ‹ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (Ìmol/l) Û ·È‰È¿ ÂÏÏËÓÈ΋˜ ηٷÁˆÁ‹˜ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· (46) ∂ηÙÔÛÙÈ·›· ηٷÓÔÌ‹ 25 50 75 85 95
6-9 ÂÙÒÓ (N=111)
10-12 ÂÙÒÓ (N=143)
13-15 ÂÙÒÓ (N=266)
5,6 6,4 7,3 7,6 10,0
6,3 7,2 8,3 8,6 10,6
7,2 8,3 9,9 10,4 14,4
΢ÛÙÂ˚Ó·ÈÌ›·. ∞ÓÙÈı¤Ùˆ˜, Ù· ÔÈÛÙÚÔÁfiÓ·, Ë Ù·ÌÔÍÈʤÓË, Ë ÂÓÈÎÈÏÏ·Ì›ÓË Î·È Ë ·ÎÂÙ˘ÏÔ΢ÛÙ½ÓË ÂÏ·ÙÙÒÓÔ˘Ó Ù· ›‰· ÔÚÔ‡ Ù˘ tHcy (41-44).
¢È¿ÁÓˆÛË Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ø˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÔÚ›˙ÂÙ·È Ë ·‡ÍËÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ¿Óˆ ·fi ÙËÓ ÙÈÌ‹ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ 95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Ù˘ ηٷÓÔÌ‹˜ Ù˘ Û ˘ÁÈ‹ ¿ÙÔÌ· ·Ó·ÏfiÁÔ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘, Ë ÔÔ›· ηıÔÚ›˙ÂÙ·È ÂÚ›Ô˘ ÛÙËÓ ÙÈÌ‹ ÙˆÓ 15Ìmol/l. √È “Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜” ÔÈΛÏÔ˘Ó Â˘Ú¤ˆ˜ ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÏËı˘ÛÌÔ‡˜, ·ÊÔ‡ ÂËÚ¿˙ÔÓÙ·È ·fi ÙȘ Û˘Ó‹ıÂȘ ‰È·‚›ˆÛ˘. ™Â ÏËı˘ÛÌÔ‡˜ Ì ÚfiÛıÂÙË Ï‹„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÙÔ ·ÓÒÙÂÚÔ Ê˘ÛÈÔÏÔÁÈÎfi fiÚÈÔ ÌÔÚ› Ó· ÔÚÈÛı› ÛÙ· 12 Ìmol/l (45). ™ÙÔÓ ÂÏÏËÓÈÎfi ·È‰ÈÎfi ÏËı˘ÛÌfi, Ë ÂηÙÔÛÙÈ·›· ηٷÓÔÌ‹ Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ ÔÚÔ‡ ÌÂÏÂÙ‹ıËΠ·fi ÙÔ˘˜ ¶··Ó‰Ú¤Ô˘ ¢. Î·È Û˘Ó. (46) (¶›Ó·Î·˜ 1) Î·È ·fi ÙÔ˘˜ ¶·Ô˘ÙÛ¿ÎË Î·È Û˘Ó., Ô˘ ·Ó·Ê¤ÚÔ˘Ó ÙÈ̤˜ tHcy Ï¿ÛÌ·ÙÔ˜ 95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ Ù˘ ٿ͈˜ ÙÔ˘ 11,5 Ìmol/l, fiÛÔÓ ·ÊÔÚ¿ 186 ÂÏÏËÓfiÔ˘Ï· ËÏÈΛ·˜ 11-12 ÂÙÒÓ (47). ∆· ›‰· Ù˘ ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔÓ ÔÚfi ‹ ÛÙÔ Ï¿ÛÌ· ˘ÁÈÒÓ ·È‰ÈÒÓ Ì ‚¿ÛË ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· ·fi ÌÂϤÙ˜ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Î·È ·ıËÚÔıÚÔÌ‚ˆÙÈ΋ηډȷÁÁÂȷ΋ ÓfiÛÔ˜ ¶ÔÏϤ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ·ÎfiÌË Î·È Ë ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘ (49-61). ™Â ÌÂÙ·-·Ó¿Ï˘ÛË 27 ·Ó·‰ÚÔÌÈÎÒÓ ÌÂÏÂÙÒÓ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÚÈÓ ÙÔ 1994, ‰È·ÈÛÙÒıËΠfiÙÈ Ô Û˘ÓÔÏÈÎfi˜ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) Û ¿ÙÔÌ· Ì ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ‹Ù·Ó 1,7 (95% C.I., 1,5-1,9) ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, 2,5 (2,0-3,0) ÁÈ· ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È 6,8 (2,9-15,8) ÁÈ· ÂÚÈÊÂÚÈ΋ ·ÚÙËÚȷ΋ ÓfiÛÔ (50). °È· οı ·‡ÍËÛË Ù˘ Ù¿Í˘ ÙˆÓ 5Ìmol/L Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ˘‹Ú¯Â ·‡ÍËÛË ÂÚ›Ô˘ ηٿ 40% ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ. ∏ Û¯¤ÛË Ù˘
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ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜
¶›Ó·Î·˜ 2. ™˘ÁÎÂÓÙÚˆÙÈÎfi˜ ›Ó·Î·˜ ÙˆÓ Î˘ÚÈfiÙÂÚˆÓ ÌÂÏÂÙÒÓ ·Ó·ÊÔÚÈο Ì ٷ ›‰· ÔÏÈ΋˜ ÔÌÔ΢ÛÙ½Ó˘ (tHcy) ÔÚÔ‡ ‹ Ï¿ÛÌ·ÙÔ˜ ˘ÁÈÒÓ ·È‰ÈÒÓ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (∞: ·ÁfiÚÈ·, ∫: ÎÔÚ›ÙÛÈ·) µÈ‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿
ŒÙÔ˜
º‡ÏÔ
∏ÏÈΛ· (¤ÙË)
∞ÚÈıÌfi˜ ·È‰ÈÒÓ
tHcy (Ìmol/L)
Infante-Rivard et al (31) Tonstad et al (48) Delvin et al (39)
2002 1997 2000
<1 7-17 2-19
Rauh et al (21)
2001
A+K A+K A+K A ∫
438 155 127 120 137 62 108 138 142 60 60 105 59 31
5,1(4,9-5,2) 6,3 (3,3-33) 5,8 (2,6-24,3) 5,7+/-1,7 5,5+/-1,6 4,8 (2,2-8,1) 5,7 (2,7-10,6) 6,4 (3,5-11,8) 7,8 (3,9-14,3) 8,5+-2,8 9,3+-2,9 5,8 (3,3-8,3) 6,6 (4,7-10,3) 8,1 (4,7-11,3)
6-17
Bates et al (16)
2002
∞
4- 6 7-10 11-14 15-18
Reddy et al (19)
1997
A ∫
0,1-18
Vilaseca et al (20)
1997
A+K
0,6-10 11-15 16-18
˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Ì ÙËÓ ·ÁÁÂȷ΋ ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ ·Ú¤ÌÂÈÓ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Î·È ÌÂÙ¿ ÙÔÓ ¤ÏÂÁ¯Ô ÁÈ· ÙÔ˘˜ ÎÏ·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ fiˆ˜ Â›Ó·È ÙÔ Î¿ÓÈÛÌ·, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ÂȂ‚·ÈÒÓÔÓÙ·˜ fiÙÈ Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ·ÔÙÂÏ› ¤Ó·Ó ‰È·‚·ıÌÈ˙fiÌÂÓÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, ·Ó¿ÏÔÁÔ Î·È ·ÓÂÍ¿ÚÙËÙÔ ÙˆÓ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ªÈ· ÈÔ ÚfiÛÊ·ÙË ·Ó¿Ï˘ÛË Ù˘ ›‰È·˜ ÌÂϤÙ˘ ¤‰ÂÈÍ fiÙÈ ÂÈÚfiÛıÂÙÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Î¿Ùˆ ·fi ÙË 10Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Î·È Ù˘ ‚ÈÙ·Ì›Ó˘ µ6 οو ·fi ÙËÓ 20‹ ÂηÙÔÛÙÈ·›· ı¤ÛË (51). ¢‡Ô ÌÂϤÙ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙËÓ ÔÌÔ΢ÛÙ½ÓË Î·È ÙÔ ¿¯Ô˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ηڈٛ‰·˜ Ô˘ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ì ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Û ¿ÙÔÌ· ÂχıÂÚ· ÎÏÈÓÈο ¤Î‰ËÏ˘ ·ıËڈ̿وÛ˘. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Û¯ÂÙÈ˙fiÙ·Ó Ì ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ˘ÚȉÔ͛Ӣ Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ (52,53). ÕÏϘ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ÙËÓ ‡·ÚÍË Û˘Û¯¤ÙÈÛ˘ ·Ó¿ÌÂÛ· ÛÙ· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ıËڈ̷ÙÈ΋˜ ‚Ï¿‚˘ ÛÙËÓ ·ÔÚÙ‹, ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Î·È ÛÙȘ ÂÚÈÊÂÚÈΤ˜ ·ÚÙËڛ˜ (54-56). ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Û¯¤ÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ì ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ Û ¿ÙÔÌ· Ù· ÔÔ›· ‹Ù·Ó ˘ÁÈ‹ ÙË ÛÙÈÁÌ‹ Ù˘ ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙË ÌÂϤÙË, ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·Ó¿ÌÂÛ· ÛÙ· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È ÛÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ı·Ó·ÙËÊfiÚÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (57-6). ∏ ÌÔÓ·‰È΋ ÚÔÔÙÈ΋ ÌÂϤÙË ·ÛıÂÓÒÓ Ì ÎÏÈÓÈο ¤Î‰ËÏË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ¤‰ÂÈÍ ÌÈ· ÈÛ¯˘Ú‹ Î·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ tHcy Î·È Ù˘ Û˘ÓÔÏÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜, Ë ÔÔ›·
‹Ù·Ó ·ÓÂÍ¿ÚÙËÙË ·fi ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ˘ÔÔÌ¿‰ˆÓ ¤‰ÂÈÍ fiÙÈ Ë tHcy ·ÔÙÂÏÔ‡Û ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ı·Ó¿ÙÔ˘ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜, ʇÏÔ˘ Î·È ÏÔÈÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ (60). ∆· ÂÂÈÛfi‰È· ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈ·, ÂÚ›Ô˘ 2/100.000 ÂÙËÛ›ˆ˜. ™ÙÔ 30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (62). √ÚÈṲ̂Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÂÓÙ·ÂÙ›· ·Ó·Ê¤ÚÔ˘Ó ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ˆ˜ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Î·È ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (∞∂∂) Î·È ÛÙ· ·È‰È¿ (62-64). ∏ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy ÛÙ· ·È‰È¿ ‹ Û ӤԢ˜ ÂÓ‹ÏÈΘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ‡·ÚÍË ıÂÙÈÎÔ‡ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÁÈ· ÚÒÈÌË (<55 ÂÙÒÓ) ηډȷÁÁÂȷ΋ ÓfiÛÔ ÛÙÔ˘˜ ¿ÚÚÂÓ˜ Û˘ÁÁÂÓ›˜ ‹ ÁÔÓ›˜ Î·È ·ÓȯÓ‡ıËΠ۠·È‰È¿ Ì ÁÔÓ›˜ ‹ ·Ô‡‰Â˜ Ì ·ÔÊÚ·ÎÙÈ΋ ·ÚÙËÚȷ΋ ÓfiÛÔ (63,65-67). ™Ù· ·È‰È¿ Ì ÔÈÎÔÁÂÓ‹ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, Ë tHcy ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Û fiÛ· ›¯·Ó ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ (48,68). √È ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ô ÔÈÎÔÁÂÓ‹˜ ΛӉ˘ÓÔ˜ ÁÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ ÂÍËÁÂ›Ù·È ÌÂÚÈÎÒ˜ ·fi ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË tHcy. ¶Èı·ÓfiÙÂÚË Â›Ó·È Ë ÂΉԯ‹ Ù˘ ›‰Ú·Û˘ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ Î·È ¿ÏÏˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ‰È·‚›ˆÛ˘ ÙfiÛÔ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ fiÛÔ Î·È ÛÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘. ∂ÈÚÔÛı¤Ùˆ˜, ÛÙ· ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌÈο ·È‰È¿ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ··ÈÙÂ›Ù·È ÂÓÙÔÓfiÙÂÚË ÚÔÛ¿ıÂÈ· ÂϤÁ¯Ô˘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Î·È ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È ÙÔ ÂӉ¯fiÌÂÓÔ Ì›ˆÛ˘ ÙˆÓ ÂȤ‰ˆÓ Ù˘ tHcy Ì ÙË Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·ÌÈÓÒÓ (67). ¶·È‰È·ÙÚÈ΋ 2007;70:379-388
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ª.£·ÓÔÔ‡ÏÔ˘, °. ∆ÛfiÏ·˜
∏ ›‰Ú·ÛË ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ MTHFR 677CT ÛÙ· ›‰· tHcy Î·È Ê˘ÏÏÈÎÔ‡ ÔͤԘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÈ̤˜ ÔÌÔ΢ÛÙ½Ó˘ ˘„ËÏfiÙÂÚ˜ ηٿ 25% Î·È ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙ· ÔÌfi˙˘Á· ∆∆ ¿ÙÔÌ· Û ۯ¤ÛË Ì ٷ CC ¿ÙÔÌ·, ‰È·ÈÛÙÒıËÎÂ Î·È Û 92 ·È‰È¿ Ì ÔÈÎÔÁÂÓ‹ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· ËÏÈΛ·˜ 611 ÂÙÒÓ (69-70). ∂ÈÚfiÛıÂÙ·, Û 108 ·È‰È¿ ËÏÈΛ·˜ 4-18 ÂÙÒÓ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ·Ó¢ڤıËÛ·Ó 32 ·È‰È¿ Ì ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·fi Ù· ÔÔ›· 12 ‹Ù·Ó ÔÌÔ˙˘ÁÒÙ˜ ÁÈ· ÙÔÓ C677T ÔÏ˘ÌÔÚÊÈÛÌfi ÙÔ˘ MTHFR ÁÔÓȉ›Ô˘ Î·È 10 ÂÌÊ¿ÓÈ˙·Ó ·˘ÍË̤ӷ ›‰· ÔÌÔ΢ÛÙ½Ó˘ (71). ∏ tHcy ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› ÙfiÛÔ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ∞∂∂ (64,72,73), fiÛÔ Î·È Ì ÙËÓ ÂΉ‹ÏˆÛË ÊÏ‚È΋˜ ıÚfiÌ‚ˆÛ˘ (74) ÛÙ· ÓÂÔÁ¤ÓÓËÙ· Î·È ÛÙ· ·È‰È¿. §fiÁˆ Ù˘ Û·ÓÈfiÙËÙ·˜ ÙˆÓ Û˘Ì‚·Ì¿ÙˆÓ, ÔÈ ÏËı˘ÛÌÔ› Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› Â›Ó·È ÌÈÎÚÔ› (ÂÚ›¶·Ú·‰ÔÛÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ - ÀÂÚÏÈȉ·ÈÌ›· - ¶·¯˘Û·ÚΛ·/ ªÂȈ̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· - ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ - ∫¿ÓÈÛÌ· - À¤ÚÙ·ÛË
Ô˘ 400 ÂÚÈÙÒÛÂȘ ̤¯ÚÈ Û‹ÌÂÚ·), ·ÏÏ¿ Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙËÓ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Â›Ó·È ÂÍ·ÈÚÂÙÈο ÈÛ¯˘Ú‹, ·ÓÙÈÛÙÔȯÒÓÙ·˜ Û ۯÂÙÈÎfi ΛӉ˘ÓÔ >4 (73). ™Â ÌÂϤÙË Ô˘ ÂÚȤϷ‚ 118 ·È‰È¿, ÂΛӷ Ì ÔÌfi˙˘ÁÔ ÁÔÓfiÙ˘Ô MTHFR TT ›¯·Ó ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ tHcy Î·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ÂÓfi˜ ÚÒÙÔ˘ Î·È ·ÎÔÏÔ‡ıˆ˜ ·ÓÂÈÏËÌÌ¤ÓˆÓ ÂÂÈÛÔ‰›ˆÓ (75). √ÌÔ›ˆ˜, ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÂÚÈÛÛfiÙÂÚ· ·fi 140 ·È‰È¿ ¤‰ÂÈÍ fiÙÈ ÔÈ ÁÔÓfiÙ˘ÔÈ TT Î·È CT Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ∞∂∂ (74). ∆¤ÏÔ˜, ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÔÌÔ΢ÛÙ½Ó˘ Ï¿ÛÌ·ÙÔ˜ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ·È‰È¿ Ì ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ∞∂∂ Û ËÏÈΛ· <50 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÂÊ‹‚Ô˘˜ ÌÂ Û˘ÛÙÔÏÈ΋ ˘¤ÚÙ·ÛË (76). √È ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘ ·ıËڈ̷ÙÔÁfiÓÔ˘ ‰Ú¿Û˘ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ÍÂηı·ÚÈṲ̂ÓÔÈ. ¶Èı·ÓÔÏÔÁÂ›Ù·È ¿ÌÂÛË ‚Ï¿‚Ë
∂Ó‰ÔÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ - °ÂÓÂÙÈ΋ ÚԉȿıÂÛË - ¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ - ∞˘ÍË̤ÓË Â˘·ÈÛıËÛ›·
¡ÂÔÂÌÊ·ÓÈ˙fiÌÂÓÔÈ ·Ú¿ÁÔÓÙ˜ - ™˘ÛÙËÌ·ÙÈ΋ Ïԛ̈ÍË/ ÊÏÂÁÌÔÓ‹ - ∫˘ÙÙ·ÚÔΛÓ˜ - CRP - √ÌÔ΢ÛÙ½ÓË
¢À™§∂π∆√Àƒ°π∞ ∞°°∂π∞∫√À ∂¡¢√£∏§π√À
∞˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ
ªÂȈ̤ÓË ·Ú·ÁˆÁ‹/ ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙÔ˘ ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘
∞˘ÍË̤ÓË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË ÂÓ‰ÔıËÏ›Ô˘
™¯ËÌ·ÙÈÛÌfi˜ Î·È ÂͤÏÈÍË ·ıËڈ̷ÙÈ΋˜ ‚Ï¿‚˘ ∂ÓÂÚÁÔÔ›ËÛË/ ·fiÛ·ÛË ·ıËڈ̷ÙÈ΋˜ Ͽη˜ £ÚfiÌ‚ˆÛË/ ·ÁÁÂÈfiÛ·ÛÌÔ˜ ∂Ï·Ùو̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹
∫∞ƒ¢π∞°°∂π∞∫∏ ¡√™√™ ∂ÈÎfiÓ· 2. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÒÈÌË ·ıËڈ̿وÛË Î·È ‚Ï¿‚Ë ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÓ‰ÔıËÏ›Ô˘. Paediatriki 2007;70:379-388
ÀÂÚÏ·Û›· ÙÔ˘ ¤Ûˆ ¯ÈÙÒÓ· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È ‰È‹ıËÛË ÙˆÓ Ï›ˆÓ Ì˘ÈÎÒÓ ÈÓÒÓ ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú·
Paidiatriki 5 final
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ÀÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·, ·ıËڈ̿وÛË Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜
ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ì ÙËÓ ·Ú·ÁˆÁ‹ ÂÓÂÚÁÒÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ Ô˘ ÚÔηÏÔ‡Ó ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ì›ˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙÔ˘ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ¡√. ∞˘Ùfi Ô‰ËÁ› Û ÌÂȈ̤ÓË ‰È·Ù·ÛÈÌfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ, Û ¿ıÚÔÈÛË Î·È ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, Û ÚÔÛÎfiÏÏËÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È Û ۯËÌ·ÙÈÛÌfi ıÚfiÌ‚Ô˘, ηٷÛÙ¿ÛÂȘ ÔÈ Ôԛ˜ ÚÔ¿ÁÔ˘Ó ÙËÓ ·ıËڈ̷ÙÈ΋ ‰ÈÂÚÁ·Û›· (77-79) (∂ÈÎfiÓ· 2).
£Âڷ›· Ù˘ ‹È·˜ Î·È Ì¤ÙÚÈ·˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ √ ·ÚÈÔ˜ ıÂڷ¢ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ù˘ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ Â›Ó·È ÙÔ Ê˘ÏÏÈÎfi Ô͇, ÌfiÓÔ ÙÔ˘ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÎÔ‚·Ï·Ì›ÓË Î·È ÙË ‚ÈÙ·Ì›ÓË µ6 (7). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÙÚÂȘ ·˘ÙÔ› ·Ú¿ÁÔÓÙ˜ Û˘¯Ó¿ Û˘Á¯ÔÚËÁÔ‡ÓÙ·È, Ê·›ÓÂÙ·È fiÙÈ ÙÔ Ê˘ÏÏÈÎfi Ô͇ Â›Ó·È ÙÔ Ï¤ÔÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ·ÊÔ‡ Ô‰ËÁ› Û ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ fiÙ·Ó ¯ÔÚËÁÂ›Ù·È ˆ˜ ÌÔÓÔıÂڷ›· (8,9). ªÂÙ·-·Ó¿Ï˘ÛË ‰Ò‰Âη ÌÂÏÂÙÒÓ, ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ì ÙËÓ ÚÔÛı‹ÎË Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ 1114 ·ÙfïÓ, ›Ù ÌfiÓÔ˘ ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‚ÈÙ·Ì›ÓË µ6 ‹ ‚ÈÙ·Ì›ÓË µ12 ‹ Î·È ÙȘ ‰‡Ô ‚Èٷ̛Ә (10), ¤‰ÂÈÍ fiÙÈ Ë ·Ó·ÏÔÁÈ΋ Î·È ·fiÏ˘ÙË Ì›ˆÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Ô˘ ÚÔÎÏ‹ıËΠ·fi ÙË Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ ‹Ù·Ó ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË fiÛÔ ˘„ËÏfiÙÂÚË ‹Ù·Ó Ë ÙÈÌ‹ Ù˘ ÔÌÔ΢ÛÙ½Ó˘ Î·È fiÛÔ ¯·ÌËÏfiÙÂÚ· Ù· ›‰· Ê˘ÏÏÈÎÔ‡ ÔͤԘ ÛÙÔÓ ÔÚfi ÚÈÓ ÙË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË. ∏ ‚ÈÙ·Ì›ÓË µ12 Ô‰‹ÁËÛ Û ÂÈÚfiÛıÂÙË Ì¤ÛË ÂÏ¿ÙÙˆÛË Ù˘ ٿ͈˜ ÙÔ˘ 7% (3-10%), ÂÓÒ Ë ‚ÈÙ·Ì›ÓË µ6 ‰ÂÓ Â›¯Â ÛËÌ·ÓÙÈ΋ ÂÈÚfiÛıÂÙË ‰Ú¿ÛË (10). ¶·ÚfiÏ· ·˘Ù¿, Ë ‚ÈÙ·Ì›ÓË µ6 Ú¤ÂÈ Ó· Û˘Á¯ÔÚËÁÂ›Ù·È Ì ÙÔ Ê˘ÏÏÈÎfi Ô͇ Î·È ÙË ‚ÈÙ·Ì›ÓË µ12, ηıÒ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÌÂÈÒÓÂÈ Ù· ›‰· ÔÌÔ΢ÛÙ½Ó˘ ·›Ì·ÙÔ˜ ÌÂÙ¿ ·fi ÙË ÊfiÚÙÈÛË Ì ÌÂıÂÈÔÓ›ÓË (10). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ‚Èٷ̛Ә ÌÂÈÒÓÔ˘Ó Ù· ›‰· Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔ ·›Ì·, ‰ÂÓ ÁÓˆÚ›˙Ô˘Ì ·ÎfiÌË ·Ó Ù·˘Ùfi¯ÚÔÓ· ÂÈÙ˘Á¯¿ÓÔ˘Ó Î·È Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂΉ‹ÏˆÛ˘ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘. ªÂ ‚¿ÛË ÙË ‰È·‚·ıÌÈ˙fiÌÂÓË Â›‰Ú·ÛË Ù˘ ÔÌÔ΢ÛÙ½Ó˘ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ÌÈ· ÌÂÙ·-·Ó¿Ï˘ÛË ¤Ó‰Âη ÌÂÏÂÙÒÓ Ù˘ ›‰Ú·Û˘ Ù˘ ·˘ÍË̤Ó˘ ÚfiÛÏ˄˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ ˘ÔÏfiÁÈÛ fiÙÈ 13.500 ¤ˆ˜ 50.000 ı¿Ó·ÙÔÈ ÂÙËÛ›ˆ˜ ·fi ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÔÊ¢¯ıÔ‡Ó ÛÙȘ ∏.¶.∞. Ì ÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙˆÓ ÙÚÔÊ›ÌˆÓ ÛÂ Ê˘ÏÏÈÎfi Ô͇ (11). ∏ Ï‹„Ë 100 g ‰ËÌËÙÚÈ·ÎÒÓ ËÌÂÚËÛ›ˆ˜ Ô˘ ·Ú¤¯Ô˘Ó 127 Ìg Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÔÛfiÙËÙ· Ë ÔÔ›· ·ÓÙÈÛÙÔȯ› ÂÚ›Ô˘ ÛÙ· ›‰·
ÂÌÏÔ˘ÙÈÛÌÔ‡ ÌÂ Ê˘ÏÏÈÎfi Ô͇ Ô˘ Û˘ÓÈÛÙ¿ Ë ∂ÈÙÚÔ‹ ∆ÚÔÊ›ÌˆÓ Î·È º·ÚÌ¿ÎˆÓ ÙˆÓ ∏.¶.∞., F.D.A.Food and Drug Administration-(140 Ìg ÁÈ· οı 100 g ‰ËÌËÙÚÈ·ÎÒÓ), ÂÈÙ˘Á¯¿ÓÂÈ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ tHcy ÌfiÓÔ Î·Ù¿ 3,7%, fiˆ˜ Ê¿ÓËΠ·fi Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË, Ì›ˆÛË Èı·Ófiٷٷ ·Ó·Ú΋ ÁÈ· ÙËÓ ·ÔÙÚÔ‹ ηډȷÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ (12). ™ÙË ÌÂϤÙË “Nurses’ Health Study”, Ô˘ ·ÊÔÚÔ‡Û ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· 14 ¤ÙË 80.082 Á˘Ó·ÈÎÒÓ, ÛÙËÓ ÔÔ›· ˘ÔÏÔÁ›ÛıËÎÂ Ë Û˘Ó‹ı˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓË ‰fiÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·Ì›Ó˘ µ6 ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô Î·È ÁÈ· ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ‰È·ÈÛÙÒıËΠfiÙÈ Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·Ó¿ÌÂÛ· ÛÙ· ·ÎÚ·›· ÂÌÙËÌfiÚÈ· Ù˘ ËÌÂÚ‹ÛÈ·˜ ÚfiÛÏ˄˘ ‹Ù·Ó 0,69 (95% C.I. 0,53-0,87) fiÛÔÓ ·ÊÔÚ¿ ÙÔ Ê˘ÏÏÈÎfi Ô͇ (̤ÛË ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë 696 Ìg ¤Ó·ÓÙÈ 158 Ìg) Î·È 0,67 (95% C.I. 0,530,85) ÁÈ· ÙË ‚ÈÙ·Ì›ÓË µ6 (̤ÛË ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë 4,6 mg ¤Ó·ÓÙÈ 1,1 mg) (13). ™ÙËÓ ›‰È· ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÌÂÈÒıËΠ۠fiÛ˜ Á˘Ó·›Î˜ Ï¿Ì‚·Ó·Ó Û˘ÛÙËÌ·ÙÈο ÔÏ˘‚ÈÙ·ÌÈÓÔ‡¯· Û˘ÌÏËÚÒÌ·Ù· (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 0,76, 0,65-0,9) (13). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ Ë ÚfiÛÏË„Ë Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ‚ÈÙ·Ì›Ó˘ µ6 ÌÔÚ› Ó· ‰È·‰Ú·Ì·Ù›ÛÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÔÙÚÔ‹ Ù˘ ÚÒÈÌ˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘. ∏ ̤¯ÚÈ Û‹ÌÂÚ· Û˘ÓÈÛÙÒÌÂÓË ıÂڷ›· Ù˘ ‹È·˜ Î·È Ì¤ÙÚÈ·˜ ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË Ê˘ÏÏÈÎÔ‡ ÔͤԘ Û ‰fiÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ 0,5 mg ËÌÂÚËÛ›ˆ˜ Î·È ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 Ì ÛÎÔfi ÙË ‰È·ÛÊ¿ÏÈÛË Ù˘ Ï‹ÚÔ˘˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ Î·È ÙËÓ ·ÔÙÚÔ‹ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂΉ‹ÏˆÛ˘ Ó¢ÚÔ¿ıÂÈ·˜ ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘ ÎÔ‚·Ï·Ì›Ó˘, ÂÈÎfiÓ· ÙËÓ ÔÔ›· Û˘ÁηχÙÂÈ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ. √È ‰fiÛÂȘ ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ µ6 Î·È µ12 Ô˘ ı· Ú¤ÂÈ Ó· Û˘Á¯ÔÚËÁÔ‡ÓÙ·È Ì ÙÔ Ê˘ÏÏÈÎfi Ô͇ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË Î·ıÔÚÈÛı› (80). ¢ÈÂÍ¿ÁÔÓÙ·È ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ì ÛÎÔfi ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÂÈη˙fiÌÂÓ˘ ·ÓÙÈ·ıËڈ̷ÙÈ΋˜ Î·È ·ÓÙÈıÚÔÌ‚ˆÙÈ΋˜ ‰Ú¿Û˘ Ù˘ Û˘ÌÏËڈ̷ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ‚ÈÙ·ÌÈÓÒÓ.
™˘Ì¤Ú·ÛÌ· ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÏÂÙÒÓ Î·Ù·‰ÂÈÎÓ‡ÂÈ fiÙÈ ·ÎfiÌË Î·È Ë ‹È· ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÚÒÈÌ˘ ·ıËڈ̿وÛ˘ ηıÒ˜ Î·È ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ıÚfiÌ‚ˆÛ˘ Û ÂÓ‹ÏÈΘ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ηٷ‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË Ù˘ tHcy ·ÔÙÂÏ› ÈÛ¯˘Úfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÔÊÚ·ÎÙÈ΋ ·ÁÁÂȷ΋ ÓfiÛÔ Î·È ÛÙ· ·È‰È¿. ∞·ÈÙ›ٷÈ, ˆÛÙfiÛÔ, Ë ‰ÈÂÓ¤ÚÁÂÈ· Î·È ¿ÏÏˆÓ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙÂÎÌËÚȈı› ÏËÚ¤ÛÙÂÚ· ¶·È‰È·ÙÚÈ΋ 2007;70:379-388
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ªÂϤÙË ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405g/c VEFG Î·È ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ·È‰È¿ Ì ÓfiÛÔ Kawasaki §. ºÈ‰¿ÓË1, ∞. °È·ÓÓfiÔ˘ÏÔ˜1, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜1, °. ∆˙Ô˘‚ÂϤ΢1, ∫. ∫·ÏÈÓ‰¤ÚË2, ∞. ∫ÒÙÛ˘2, π. ∫·‚·ÏÈÒÙ˘3, º. ∞ı·Ó·ÛÈ¿‰Ô˘1 ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki (¡∫) ·ÔÙÂÏ› ÔÍ›· Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· Ù˘ ‚ÚÂÊÈ΋˜ Î·È ·È‰È΋˜ ËÏÈΛ·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ Î·È Û˘ÛÙËÌ¿ÙˆÓ. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÙÔ˘ ÁÔÓȉȷÎÔ‡ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ +405G/C ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÓ‰ÔıËÏÈ·ÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (VEGF) Ì ÙË ¡∫ Û ·È‰È¿ ·fi ÙË µfiÚÂÈ· ∂ÏÏ¿‰·. ∏ ÌÂϤÙË Ì·˜ ‰ÈÂÓÂÚÁ‹ıËΠ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 2004 ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ 2006. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‚·Û›ÛÙËΠÛÙ· ÎÚÈÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›·. °È· οı ·ÛıÂÓ‹ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ, ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘. ™Â 19 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ¤ÁÈÓ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Û˘ÁÎÚ›ıËÎ·Ó Ì ٷ ·ÓÙ›ÛÙÔȯ· 55 ˘ÁÈÒÓ Ì·ÚÙ‡ÚˆÓ È‰›Ô˘ ʇÏÔ˘. ∞fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘, 10 (50%) ÂÌÊ¿ÓÈ˙·Ó ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡Ìʈӷ Ì ٷ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο ÙÔ˘˜ Â˘Ú‹Ì·Ù·, ÂÎ ÙˆÓ ÔÔ›ˆÓ 8 (80%) ·ÁfiÚÈ· (p<0,05). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙËÓ ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ Î·È Ë ¯·ÌËÏ‹ ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ηٿ ÙË ‰È¿ÁÓˆÛË ·ÔÙ¤ÏÂÛ·Ó ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. TÔ ÔÛÔÛÙfi ÙˆÓ VEGF +405 CC ÔÌÔ˙˘ÁˆÙÒÓ ÂÌÊ·Ó›ÛÙËΠ·˘ÍË̤ÓÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ¿Û¯ÔÓÙ˜, ·Ó Î·È Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (26,3 ¤Ó·ÓÙÈ 14,5%, p =0,205). ∂ÈϤÔÓ, Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ηٷÁÚ¿ÊËΠ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜. ¶ÚÔ·ÙÂÈ Û˘ÓÂÒ˜, fiÙÈ Ë Â¤ÎÙ·ÛË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û ÌÂÁ·Ï‡ÙÂÚÔ ‰Â›ÁÌ· ·ÛıÂÓÒÓ ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÍ·ÁˆÁ‹ ·ÛʷϤÛÙÂÚˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ÛÙÔ Ì¤ÏÏÔÓ.
1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ £ÂÛÛ·ÏÔÓ›ÎË 2 ∂ÚÁ·ÛÙ‹ÚÈÔ °ÂÓÂÙÈ΋˜µÈÔÏÔÁ›·˜ ∞.¶.£, £ÂÛÛ·ÏÔÓ›ÎË 3 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛˆÓ, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: º. ∞ı·Ó·ÛÈ¿‰Ô˘¶ÈÂÚÔÔ‡ÏÔ˘ atriagia@auth.gr, atragian@hotmail.com ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ ™Ù. ∫˘ÚȷΛ‰Ë 1 ∆.∫. 54 636, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: ¡fiÛÔ˜ Kawasaki, ·ÁÁÂÈ·Îfi˜ ÂÓ‰ÔıËÏÈ·Îfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ÔÏ˘ÌÔÚÊÈÛÌfi˜, ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜.
Study of VEGF 405G C polymorphism and of relevant clinical and laboratory data in children with Kawasaki disease L. Fidani1, A. Giannopoulos1, A. Tragianidis1, G. Tzouvelekis1, K. Kalinderi2, A. Kotsis2, I. Kavaliotis3, F. Athanassiadou1 Abstract: Kawasaki disease (KD) represents an acute systemic vasculitis of infancy and childhood, characterized by fever and signs of mucocutaneous inflammation in many systems and organs with predilection of cardiovascular system. Aim of our study was to correlate clinical and laboratory data and to analyze the genetic polymorphisms of vascular endothelial growth factor (VEGF) with the development of KD in children from Northern Greece. We conducted a 3-year prospective study from January 2004 to December 2006. Diagnosis of KD was based on the American Heart Association criteria for KD. For each patient demographic, clinical and laboratory data were registered. VEGF 405G C polymorphism was typed in 19 patients and results were compared with those of 55 healthy sex paired controls. Of the 20 patients with KD, 10 (50%) had coronary artery abnormalities (dilatations, aneurisms) in echocardiograms. Of 10 patients that developed coronary abnormalities 8 (80%) were boys (p<0.05). Duration of fever before diagnosis and administration of intravenous gamma-globulin and low hemoglobin values at diagnosis were predictive risk factors for the development of coronary abnormalities. A higher percentage of VEGF 405 CC homozygotes was found in patients with KD compared to the healthy controls. However, this difference was not found statistically significant (26.3 ¤Ó·ÓÙÈ 14.5%, p =0.205). Moreover, the presence of the G allele was pronounced in the subgroup of patients with cardiovascular complications. We deduce that the study of a larger number of patients with KD in the Greek population may give valid conclusions in the future.
1 2nd Paediatric Clinic of Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece 2 Laboratory of Biogenetics of Aristotle University of Thessaloniki, Thessaloniki, Greece 3 Paediatric Clinic of the Special Disease Hospital, Thessaloniki, Greece Correspondence: F. AthanassiadouPiperopoulou atriagia@auth.gr, atragian@hotmail.com AHEPA Hospital 1, St. Kyriakidis St. 54 636, Thessaloniki, Greece
Key words: Kawasaki disease, vascular endothelial growth factor, polymorphisms, cardiovascular complications.
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§. ºÈ‰¿ÓË Î·È Û˘Ó.
∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki (¡∫) ·ÔÙÂÏ› ÌÈ· ÔÍ›·, ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· ·ÁÓÒÛÙÔ˘ ̤¯ÚÈ Û‹ÌÂÚ· ·ÈÙÈÔÏÔÁ›·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ Î·È Û˘ÛÙËÌ¿ÙˆÓ Ì ΢ÚÈfiÙÂÚÔ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi (1,2). ¶ÚÒÙÔ˜ Ô Tomisaku Kawasaki ‰ËÌÔÛ›Â˘Û ÙÔ 1967 ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· 50 Ӥ˜ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ¡∫ (3). §fiÁˆ Ù˘ ·Ô˘Û›·˜ ÂȉÈ΋˜ ‰È·ÁÓˆÛÙÈ΋˜ ÂÚÁ·ÛÙËÚȷ΋˜ ÂͤٷÛ˘, Ë ‰È¿ÁÓˆÛË Ù˘ ¡∫ Ù›ıÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ ‰È¿ÚÎÂÈ·˜ ≥5 ËÌÂÚÒÓ Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ¤ÓÙ ÎÏÈÓÈο ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙÔÓ Tomisaku Kawasaki Î·È ·Ó·ıˆÚËı› ·fi ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÔÌ¿‰Â˜ ÔÌÔʈӛ·˜ ÁÈ· ÙËÓ ¡∫ (1,2,4). √È Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ Ù˘ ¡∫, Ì ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÙȘ ÂÎٷۛ˜, ÙȘ ‰È·Ù¿ÛÂȘ Î·È Ù· ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, ·ÔÙÂÏÔ‡Ó ·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· ηٿ ÙË ‰È·‰ÚÔÌ‹ Â̇ÚÂÙ˘ ÓfiÛÔ˘ Ì ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ÂΛӷ Ù˘ ¡∫ (5-8). ∞Ó Î·È ¤¯ÂÈ ÂÎÙÂÓÒ˜ ÌÂÏÂÙËı› Ë Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ Ì ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ηıÒ˜ ›Û˘ Î·È Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Ô˘ ÂÎχÂÙ·È, ÂÓÙÔ‡ÙÔȘ ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ηٷÛÙ› ‰˘Ó·Ùfi Ó· ‰È¢ÎÚÈÓÈÛÙ› Ô ÚfiÏÔ˜ ÙÔ˘˜ ÛÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ (9-12). ∂ÈϤÔÓ, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ηٷÁÚ¿ÊÂÙ·È Ë ÓfiÛÔ˜ ÛÙË µÔÚÂÈÔ·Ó·ÙÔÏÈ΋ ∞Û›· Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (13,14). ™‹ÌÂÚ·, Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙfi fiÙÈ Ô VEGF ÚÔ¿ÁÂÈ ÙËÓ ·ÁÁÂÈÔÁ¤ÓÂÛË Î·È Û˘ÌÌÂÙ¤¯ÂÈ ÛÙË Ú‡ıÌÈÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ·ÁÁ›ˆÓ (15). ªÂÙ·‚ÔϤ˜ ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› ÛÙÔ ·ÚÂÏıfiÓ Ì ηډȷÁÁÂȷο Î·È ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (15). ∞˘ÍË̤ÓË ¤ÎÊÚ·Û‹ ÙÔ˘ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Û ·ÛıÂÓ›˜ Ì ¡∫ ÁÂÓÈÎfiÙÂÚ· Î·È Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂΉ‹ÏˆÛË ·Ó¢ڢÛÌ¿ÙˆÓ ÂȉÈÎfiÙÂÚ·, ÂÓÒ ÂÈϤÔÓ, Ë ·Ó‡ÚÂÛË ˘„ËÏÒÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ıˆÚÂ›Ù·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ (16-20). ŒÓ· ÔÛÔÛÙfi Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·Î‡Ì·ÓÛ˘ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ VEGF ÛÙÔÓ ÔÚfi Û ¤Ó·Ó ÏËı˘ÛÌfi, ÔÊ›ÏÂÙ·È ÛÙËÓ ‡·ÚÍË ÁÂÓÂÙÈÎÒÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ‹ ÙË ‰ÔÌÈ΋ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ŒÓ·˜ Ù¤ÙÔÈÔ˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ Â›Ó·È Ô VEGF 405G C: ÔÈ CC ÔÌÔ˙˘ÁÒÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙ· ›‰· ÙÔ˘ VEGF ÛÙÔ Ï¿ÛÌ· Û ۯ¤ÛË Ì ÙÔ˘˜ GG ÔÌÔ˙˘ÁÒÙ˜ (19,21) Î·È ÂÔ̤ӈ˜ Ô ÂÓ ÏfiÁˆ ÔÏ˘ÌÔÚÊÈÛÌfi˜ ı· ÌÔÚÔ‡Û ӷ Û˘Û¯ÂÙÈÛÙ› Ì ÙË ¡∫ ‹/Î·È ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ™ÎÔfi˜ ÂÔ̤ӈ˜ Ù˘ ÚÔÔÙÈ΋˜ Ì·˜ ÌÂϤÙ˘ Paediatriki 2007;70:389-394
‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ì ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Î·ıÒ˜ ›Û˘, Î·È Ë ‰ÈÂÓ¤ÚÁÂÈ· Û˘Û¯ÂÙÈÛÌÔ‡ ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ Ì ÙËÓ ¡∫ Û ·È‰È¿ ·fi ÙË µfiÚÂÈÔ ∂ÏÏ¿‰·.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÔÙ¤ÏÂÛ·Ó 20 ·È‰È¿ Ì ¡∫, Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙË µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£ Î·È ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∂ȉÈÎÒÓ ¶·ı‹ÛÂˆÓ £ÂÛÛ·ÏÔӛ΢. °È· ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ ÛÙË ÌÂϤÙË ÂÏ‹ÊıË ·fi ÙÔ˘˜ ÁÔÓ›˜ ÁÚ·Ù‹ Û˘ÁηٿıÂÛË. ∞fi Ù· 20 ·È‰È¿ Ù˘ ÌÂϤÙ˘, Ù· 12 (60%) ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· 8 (40%) ÎÔÚ›ÙÛÈ·. ∏ ̤ÛË ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 16,5 Î·È Ë ‰È¿ÌÂÛË 13 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· (‡ÚÔ˜: 3-84 Ì‹Ó˜). ∂ÈϤÔÓ, ·fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜ 12 (60%) ‹Ù·Ó ‚Ú¤ÊË. ø˜ ÔÌ¿‰· ÂϤÁ¯Ô˘ ÁÈ· ÙË ÌÂϤÙË ÙÔ˘ VEGF 405G C ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 55 ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜ ›‰ÈÔ˘ ʇÏÔ˘. ¢ÈÂÓÂÚÁ‹ıËΠÚÔÔÙÈ΋ ÌÂϤÙË ‰È¿ÚÎÂÈ·˜ 3 ÂÙÒÓ (·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 2004 ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ 2006). ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÛÙ· ÎÚÈÙ‹ÚÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ô˘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (2). ™ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ‰ÂÓ ÏËÚÔ‡Û·Ó Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, ÂÓÒ Û˘Á¯ÚfiÓˆ˜ ›¯·Ó ·ÔÎÏÂÈÛÙ› ¿ÏϘ Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË ·ÙÂÏÔ‡˜ ¡∫, Û‡Ìʈӷ Ì ÙȘ ·Ó·ıˆÚË̤Ó˜ Ô‰ËÁ›Â˜ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∫·Ú‰ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (2). °È· οı ·ÛıÂÓ‹ ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ‰ËÌÔÁÚ·ÊÈÎÒÓ (ʇÏÔ, ËÏÈΛ·), ÎÏÈÓÈÎÒÓ (Ë̤Ú˜ ˘ÚÂÙÔ‡ ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, Ù˘È΋/·ÙÂÏ‹˜ ¡∫) Î·È Î˘ÚÈfiÙÂÚˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ (∆∫∂, CRP, ·ÈÌÔÛÊ·ÈÚ›ÓË, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·, ·ÈÌÔÂÙ¿ÏÈ·) ηٿ ÙË ‰È¿ÁÓˆÛË (ÂÎÙfi˜ ·fi ÙËÓ ÙÈÌ‹ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÙË 10Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘). ∂ÈϤÔÓ, fiÛÔÓ ·ÊÔÚ¿ Ù· ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ÙˆÓ ·ÛıÂÓÒÓ Î·Ù·ÁÚ¿ÊËÎÂ Ë ·ÚÔ˘Û›· ‰È·Ù¿ÛˆÓ, ÂÎÙ·ÛÈÒÓ (ÌÈÎÚÔ‡ ‡ÚÔ˘˜ ‰È¿Ù·ÛË ÙÔ˘ ·ÁÁ›Ԣ) Î·È ·Ó¢ڢÛÌ¿ÙˆÓ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, Ù· ÔÔ›· ‚¿ÛÂÈ ÙˆÓ ‰È·ÛÙ¿ÛÂÒÓ ÙÔ˘˜ ‰È·ÎÚ›ÓÔÓÙ·È Û ÌÈÎÚÔ‡ (‰È¿ÌÂÙÚÔ˜ <5mm), ÌÂÛ·›Ô˘ (‰È¿ÌÂÙÚÔ˜ 5-8mm) Î·È ÁÈÁ·ÓÙÈ·›Ô˘ ÌÂÁ¤ıÔ˘˜ (‰È¿ÌÂÙÚÔ˜ >8mm). A. ∞ÔÌfiÓˆÛË DNA ·fi ÔÏÈÎfi ·›Ì· °È· ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ÁÔÓȉȈ̷ÙÈÎÔ‡ DNA ·fi ÔÏÈÎfi ·›Ì· ¯ÚËÛÈÌÔÔÈ‹ıËΠkit ÙÔ˘ ÂÌÔÚ›Ô˘ (“PUREGENEì DNA PURIFICATION SYSTEM”, Gentra Systems, Minneapolis, MN, USA). B. °ÔÓÔÙ˘ÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405G/C 1. ∂Ó›Û¯˘ÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF Ì ÙËÓ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). °È· ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF, ÙÔ ÔÔ›Ô ÂÚȤ¯ÂÈ ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi +405G/C, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÂȉÈÎÔ› ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉÈÎÔ› ÂÎÎÈÓËÙ¤˜: VEGF(F): 5’-ATTTATTTTTGCTTGCCATT-3’ VEGF(R): 5’-GTCTGTCTGTCTGTCCGTCA-3’ ∆Ô Ì›ÁÌ· Ù˘ οı ·ÓÙ›‰Ú·Û˘ ÂÚÈ›¯Â 20 mM Tris -HCl (pH 8,4), 50 mM KCl, 3 mM MgCl2, 0,1 mM ·fi οı ‰ÂÔ͢ÓÔ˘ÎÏÂÔÙ›‰ÈÔ (dATP, dGTP, dTTP, dCTP), 25 pmole ·fi οı ÂÎÎÈÓËÙ‹, 1 unit Taq DNA ÔÏ˘ÌÂÚ¿ÛË Î·È 100 - 200 ng DNA, Û ÙÂÏÈÎfi fiÁÎÔ 25 ÌL. √È Û˘Óı‹Î˜ Ù˘ PCR Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó: 5 ÏÂÙ¿ ÛÙÔ˘˜ 94oC, 15 ·ÎÏÔÈ ·fi 30’’ ÛÙÔ˘˜ 94oC/ 30’’
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°ÔÓȉȷÎfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ +405g/c VEFG Î·È ¡fiÛÔ˜ Kawasaki
ÛÙÔ˘˜ 61oC/ 45’’ ÛÙÔ˘˜ 72oC , 20 ·ÎÏÔÈ ·fi 30’’ ÛÙÔ˘˜ 94oC/ 30’’ ÛÙÔ˘˜ 55oC/ 45’’ ÛÙÔ˘˜ 72oC, Î·È 10 ÏÂÙ¿ ÛÙÔ˘˜ 72oC. ∆Ô ÙÌ‹Ì· ÙÔ˘ ÁÔÓȉ›Ô˘ VEGF Ô˘ ÂÓÈÛ¯‡ÂÙ·È Ì ·˘Ù¤˜ ÙȘ Û˘Óı‹Î˜ ¤¯ÂÈ Ì‹ÎÔ˜ 304 ˙‡ÁË ‚¿ÛÂˆÓ (bp). 2. ∂Ó˙˘ÌÈ΋ ˘‰ÚfiÏ˘ÛË ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA Ì ÙËÓ ÂÓ‰ÔÓÔ˘ÎÏ¿ÛË ÂÚÈÔÚÈÛÌÔ‡ BsmF1. 10 ÌL ·fi οı ·ÓÙ›‰Ú·ÛË ÂÓ›Û¯˘Û˘ ÙÔ˘ DNA Ì PCR ˆ¿ÛÙËÎ·Ó ÛÙÔ˘˜ 65oC, ÁÈ· 4 ÒÚ˜, Ì 5 units Ù˘ ÂÓ‰ÔÓÔ˘ÎÏ¿Û˘ ÂÚÈÔÚÈÛÌÔ‡ BsmF1, ·ÚÔ˘Û›· 50 mM Tris HCl (pH 8,0), 50 mM NaCl Î·È 10 mM MgCl2, Û ÙÂÏÈÎfi fiÁÎÔ 20 ÌL. 3. ∞Ó›¯Ó¢ÛË Î·È Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA. ∏ ·Ó›¯Ó¢ÛË Î·È Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ ÂÓÈÛ¯˘Ì¤ÓÔ˘ DNA ¤ÁÈÓ Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ËÎÙ‹ ·Á·Úfi˙˘ 2,5. ªÂÙ¿ ÙÔ ¤Ú·˜ Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘, Ë ËÎÙ‹ ÙÔÔıÂÙ‹ıËΠ¿ӈ Û ÙÚ¿Â˙· ÂÎÔÌ‹˜ ˘ÂÚÈÒ‰Ô˘˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ˙ˆÓÒÓ ÙÔ˘ DNA. ∏ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ Ù˘ ÂÓ˙˘ÌÈ΋˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ DNA Ì ÙÔ BsmF1 ¤ÁÈÓ Ì ۇÁÎÚÈÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ˙ˆÓÒÓ ÙÔ˘ DNA Ì ÚfiÙ˘Ë Îϛ̷η ÙÂÌ·¯›ˆÓ DNA ÁÓˆÛÙÔ‡ ÌÂÁ¤ıÔ˘˜, Ù· ÔÔ›· ‰È·¯ˆÚ›ÛÙËÎ·Ó Î·Ù¿ ÙËÓ ËÏÂÎÙÚÔÊfiÚËÛË ·Ú¿ÏÏËÏ· ÚÔ˜ Ù· ˘fi ÌÂϤÙË ‰Â›ÁÌ·Ù·. ∏ ·Ó›¯Ó¢ÛË ÌÈ·˜ ÌfiÓÔ ˙ÒÓ˘ DNA ÌÂÁ¤ıÔ˘˜ 304 bp ˘Ô‰ËÏÒÓÂÈ ÔÌÔ˙˘ÁˆÙ›· ÙÔ˘ ·ÏÏËÏÔÌfiÚÊÔ˘ VEGF +405 G, ÙÚÈÒÓ ˙ˆÓÒÓ 304, 193 Î·È 111 bp, ÂÙÂÚÔ˙˘ÁˆÙ›· ÁÈ· Ù· ·ÏÏËÏfiÌÔÚÊ· VEGF +405 G Î·È VEGF +405 C, ÂÓÒ ‰‡Ô ˙ˆÓÒÓ 190 Î·È 130 bp ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙÔ ·ÏÏËÏfiÌÔÚÊÔ VEGF +405 CC. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS (version 11.0). ∏ ̤ıÔ‰Ô˜ Ù˘ ÛÙ·ÙÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘ ÂÚÈÏ¿Ì‚·Ó ˘ÔÏÔÁÈÛÌfi ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ Ù˘ ̤Û˘ ÙÈÌ‹˜ (mean), Ù˘ ‰È·Ì¤ÛÔ˘ ÙÈÌ‹˜ (median), Ù˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ (standard deviation, SD) Î·È ÙÔ˘ ÛÙ·ıÂÚÔ‡ ÛÊ¿ÏÌ·ÙÔ˜ ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘ (standard error of the mean, SEM). °È· ÙÔÓ ¤ÏÂÁ¯Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÂÊ·ÚÌfiÛÙËÎ·Ó Ë ‰ÔÎÈÌ·Û›· Fisher (ÁÈ· ÙȘ ·Û˘Ó¯›˜ ÌÂÙ·‚ÏËÙ¤˜) Î·È Ë ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·ÓÂÍ¿ÚÙËÙ· ‰Â›ÁÌ·Ù· (unpaired samples t-test) (ÁÈ· ÙȘ Û˘Ó¯›˜ ÌÂÙ·‚ÏËÙ¤˜). ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.
∞ÔÙÂϤÛÌ·Ù· ™‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ¡∫ ·fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÚԤ΢„ fiÙÈ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ›¯·Ó ˘ÚÂÙfi ‰È¿ÚÎÂÈ·˜ ≥5 ËÌÂÚÒÓ (100%). ∞ÌÊÔÙÂÚfiÏ¢ÚË ÌË ˘Ò‰Ë˜ ÂÈÂÊ˘Î›Ùȉ· ηٷÁÚ¿ÊËΠ۠18 ·ÛıÂÓ›˜ (90%), ÛÙÔÌ·Ù›‰·/¯ÂÈÏ›Ùȉ· Û 16 (80%), Ô›‰ËÌ·/ÂÚ‡ıËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ Ô˘ Û˘Óԉ‡ÙËΠ·fi ·ÔϤÈÛË Û 15 (75%),
ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ· Û 16 (80%) Î·È Ù¤ÏÔ˜, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û 10 (50%). ø˜ ·ÙÂÏ‹˜ ‹ ¿Ù˘Ë ¯·Ú·ÎÙËÚ›ÛÙËÎÂ Ë ÓfiÛÔ˜ Û 8 ·ÛıÂÓ›˜ (40%). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Âԯȷ΋ ηٷÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫, ÚԤ΢„ fiÙÈ 6 (30%) ÂΉ‹ÏˆÛ·Ó ÙË ÓfiÛÔ ÙËÓ ¿ÓÔÈÍË, 2 (10%) ÙÔ Î·ÏÔη›ÚÈ, 8 (40%) ÙÔ ÊıÈÓfiˆÚÔ Î·È Ù¤ÏÔ˜, 4 (20%) ÙÔ ¯ÂÈÌÒÓ·. ∏ ̤ÛË ÙÈÌ‹, Ë ‰È¿ÌÂÛÔ˜ Î·È Ë ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜, 10 (50%) ÂÌÊ¿ÓÈ˙·Ó ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi (‰È¿Ù·ÛË, ÂÎٷۛ˜, ·Ó¢ڇÛÌ·Ù· ÛÙÂÊ·ÓÈ·›ˆÓ) Û‡Ìʈӷ Ì ٷ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈο ÙÔ˘˜ Â˘Ú‹Ì·Ù·. ∞fi ÙË Û˘Û¯¤ÙÈÛË ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ ÚԤ΢„ fiÙÈ Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ, Ù˘ CRP, Ù˘ ∆∫∂ Î·È ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ·È‰ÈÒÓ ÌÂ Î·È ¯ˆÚ›˜ ‚Ï¿‚˜ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi ·ÓÙ›ÛÙÔȯ·. ∏ ̤ÛË ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ‹Ù·Ó 9,89 g/dl (±1,23) Î·È 10,74 g/dl (±0,9) ÁÈ· Ù· ·È‰È¿ ÌÂ Î·È ‰›¯ˆ˜ ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ·ÓÙ›ÛÙÔȯ· Î·È ·ÔÙ¤ÏÂÛ ÙË ÌfiÓË ÂÚÁ·ÛÙËÚȷ΋ ·Ú¿ÌÂÙÚÔ Ù˘ ÌÂϤÙ˘ Ì·˜ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο (p<0,05). ∆¤ÏÔ˜, Ë ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ (9,9 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷΤ˜ ‚Ï¿‚˜ ¤Ó·ÓÙÈ 6,4 Ë̤Ú˜ ÁÈ· ÂΛÓÔ˘˜ ¯ˆÚ›˜ ‚Ï¿‚˜) (p<0,05) ·ÔÙ¤ÏÂÛ ÙË ÌfiÓË ÎÏÈÓÈ΋ ·Ú¿ÌÂÙÚÔ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο. ∞fi ÙË ÌÂϤÙË ÙˆÓ ÔÈÔÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ Ì·˜ ‰ÂÓ ÚԤ΢„ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ·fi ÙË Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ (Ù˘È΋/·ÙÂÏ‹˜) Î·È Ù˘ ËÏÈΛ·˜ ÙˆÓ ·ÛıÂÓÒÓ (‚Ú¤ÊË/Ó‹È·) Ì ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ¢È¤ÊÂÚÂ, fï˜, Ë ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Û ۯ¤ÛË Ì ÙÔ Ê‡ÏÔ ÙˆÓ ·ÛıÂÓÒÓ. ™˘ÁÎÂÎÚÈ̤ӷ, ·fi ÙÔ˘˜ 10 ·ÛıÂÓ›˜ Ô˘ ÂΉ‹ÏˆÛ·Ó ηډȷÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜, 8 (80%) ‹Ù·Ó ·ÁfiÚÈ·, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,05). TÔ ÔÛÔÛÙfi ÙˆÓ VEGF +405 CC ÔÌÔ˙˘ÁˆÙÒÓ ÂÌÊ·Ó›ÛÙËΠ·˘ÍË̤ÓÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ¿Û¯ÔÓÙ˜, ·Ó Î·È Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÛÙÔ ‰Â›ÁÌ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ (26,3% ¤Ó·ÓÙÈ 14,5%, p = 0,205) Î·È ÔÈ Î·Ù·ÓÔ̤˜ ÙˆÓ ÁÔÓÔÙ˘ÈÎÒÓ Û˘¯ÓÔÙ‹ÙˆÓ ÛÙÔ Û‡ÓÔÏfi
¶›Ó·Î·˜ 1. ª¤ÛË ÙÈÌ‹, ‰È¿ÌÂÛÔ˜ Î·È ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÌÂϤÙ˘ ¶·Ú¿ÌÂÙÚÔ˜ ∆∫∂ (mm 1Ë ÒÚ·) CRP (mg/dl) WBC (/mm3) Hb (g/dl) PLT (/mm3)
ª¤ÛË ÙÈÌ‹ (mean)
¢È¿ÌÂÛÔ˜ (median)
™Ù·ıÂÚ‹ ·fiÎÏÈÛË (standard deviation)
76 10,54 17130 10,3 732000
80 7,2 16000 10,4 669000
26,5 7,59 5940 1,1 233000
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Paidiatriki 5 final
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§. ºÈ‰¿ÓË Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405GC Û ·ÛıÂÓ›˜ Ì ¡∫ Î·È ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘
∞ÛıÂÓ›˜ Ì NK (n = 19) √Ì¿‰· ÂϤÁ¯Ô˘ (n = 55) ™Ù·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ·
GG
GC
GG+GC
CC
7 (36,8%) 18 (32,7%)
7 (36,8%) 29 (52,7%) P1 = 0,383
14 (73,7%) 47 (85,5%)
5 (26,3%) 8 (14,5%) P2 = 0,205
1 ™‡ÁÎÚÈÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÁÔÓÔÙ‡ˆÓ GG, GC, CC 2 ™‡ÁÎÚÈÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ Î·È ÙˆÓ CC ÔÌÔ˙˘ÁˆÙÒÓ (¢ÔÎÈÌ·Û›· Fisher ÚÔ˜ ÌÈ· ηÙ‡ı˘ÓÛË)
ÙÔ˘˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ (p = 0,383) (¶›Ó·Î·˜ 2, ∂ÈÎfiÓ· 1). √ ÏfiÁÔ˜ Ù˘ Èı·ÓfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ ¡∫ Û ¿ÙÔÌ· Ì ÁÔÓfiÙ˘Ô VEGF +405 CC ÚÔ˜ ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Èı·ÓfiÙËÙ· Û ¿ÙÔÌ· - ÊÔÚ›˜ ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ (odds ratio) ˘ÔÏÔÁ›ÛÙËΠ›ÛÔ˜ ÚÔ˜ 1,809 (95% CI = 0,674 - 4,860). ∂ÈϤÔÓ, Ë ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ‹Ù·Ó Û¯ÂÙÈο ÂÌÏÔ˘ÙÈṲ̂ÓË Û ÊÔÚ›˜ ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ (8/10 ¤Ó·ÓÙÈ 6/9), ·ÏÏ¿ Î·È Û’·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (ƒ = 0,444) (¶›Ó·Î·˜ 3). √ ÏfiÁÔ˜ ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·Ó¢ڇÛÌ·ÙÔ˜ Û ·ÛıÂÓ‹ Ì ¡∫, Û ۯ¤ÛË Ì ÙË ÊÔÚ›· ÙÔ˘ VEGF +405 G ·ÏÏËÏÔÌfiÚÊÔ˘ ˘ÔÏÔÁ›ÛÙËΠ›ÛÔ˜ ÚÔ˜ 1,2 (95% CI = 0,688 - 2,093).
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ %
™˘˙‹ÙËÛË ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ¡∫, Ë ÂÈÎÚ·Ù¤ÛÙÂÚË Û‹ÌÂÚ· ıˆڛ· ÂÓÔ¯ÔÔÈ› ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛ‹ Ù˘ οÔÈÔÓ ÏÔÈÌÒ‰Ë ·Ú¿ÁÔÓÙ· (9-11). ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÔÍ›· Â̇ÚÂÙË ÓfiÛÔ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Âԯȷ΋, ËÏÈÎȷ΋ Î·È ÂȉËÌÈ΋ ηٷÓÔÌ‹ Ù¿ÛÛÔÓÙ·È ˘¤Ú Ù˘ ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜, fï˜ ·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 30 ¯ÚfiÓˆÓ ‰ÂÓ Î·Ù¤ÛÙË ‰˘ÛÙ˘¯Ò˜ ‰˘Ó·ÙfiÓ Ó· ·ÔÌÔÓˆı› ‹ Ó· Û˘Û¯ÂÙÈÛÙ› οÔÈÔ˜ ÏÔÈÌ҉˘ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ì ÙËÓ ¡∫. ™‡Ìʈӷ Ì ̛· ¿ÏÏË ıˆڛ· Ë ¡∫ Û˘Û¯ÂÙ›˙ÂÙ·È 100 90 80 70 60 50 40 30 20 10 0
GG+GC CC
¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405GC Û ·ÛıÂÓ›˜ Ì ¡∫, Û ۯ¤ÛË Ì ÙË ·ÚÔ˘Û›· ‹ fi¯È ∫∂1 ∫∂
NK
ª¿ÚÙ˘Ú˜
∂ÈÎfiÓ· 1. °Ú·ÊÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ ηٷÓÔÌ‹˜ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ VEGF +405 GC ÛÙËÓ ÔÌ¿‰· ÌÂϤÙ˘ (¡∫) Î·È ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (Ì¿ÚÙ˘Ú˜). Paediatriki 2007;70:389-394
Ì ÙËÓ ÎÏËÚÔÓÔÌÈ΋ ÚԉȿıÂÛË, ·ÊÔ‡ fiˆ˜ Â›Ó·È ÁÓˆÛÙfi Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ˘„ËÏ‹ Û ∞ÛÈ¿Ù˜ Û˘ÁÎÚÈÙÈο Ì ¿ÙÔÌ· Ù˘ ∫·˘Î¿ÛÈ·˜ Ê˘Ï‹˜ (1,2,14). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙËÓ µÔÚÂÈÔ·Ó·ÙÔÏÈ΋ ∞Û›·, ΢ڛˆ˜ ÛÙËÓ ∫ÔÚ¤· Î·È ÛÙËÓ π·ˆÓ›·. ∂Í¿ÏÏÔ˘, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ù˘ ¡∫ ÛÙËÓ π·ˆÓ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘„ËÏ‹ ›وۋ Ù˘ Û π¿ˆÓ˜ 2˘ Î·È 3˘ ÁÂÓ¿˜ ÛÙȘ ∏¶∞ Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ (2,10). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ¡∫, fiˆ˜ ÚÔ·ÙÂÈ ·fi ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ·˘Í¿ÓÂÙ·È ·ÁÎÔÛÌ›ˆ˜. ™‡Ìʈӷ Ì ÛÙÔȯ›· È·ÒÓˆÓ ÂÚ¢ÓËÙÒÓ Î·Ù·ÁÚ¿ÊÔÓÙ·È ÂÚ›Ô˘ 5000-6000 Ӥ˜ ÂÚÈÙÒÛÂȘ ¡∫ ÂÙËÛ›ˆ˜ Î·È Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ·ÁÁ›˙ÂÈ ÙȘ 120150 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ·È‰È¿ Û ·ÓÙ›ıÂÛË Ì ÙȘ ∏¶∞, fiÔ˘ Ë ·ÓÙ›ÛÙÔÈ¯Ë Â›ÙˆÛË ·Ó¤Ú¯ÂÙ·È Û 5-15 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ·È‰È¿ (1,2,10). ∂ÈϤÔÓ, Ë ¡∫ Â›Ó·È 1,5 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙ· ·ÁfiÚÈ·, fiˆ˜ ÚÔ·ÙÂÈ Î·È ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, fiÔ˘ Ù· ·ÁfiÚÈ· ·ÔÙ¤ÏÂÛ·Ó ÙÔ 60% (22,23). ∞fi ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÛıÂÓÒÓ Ì ¡∫ ÚÔ·ÙÂÈ fiÙÈ Ë Ì¤ÛË ËÏÈΛ· Â›Ó·È <2 ÂÙÒÓ Î·È ÔÈ Î·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ‚Ú¤ÊË, ·Ú·Ù‹ÚËÛË Ô˘ ‰ÂÓ ÂȂ‚·ÈÒıËΠ·fi Ù· Â˘Ú‹Ì·Ù¿ Ì·˜ (5,8,22,24). ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ ¡∫ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 2-3% Î·È Â›Ó·È ˘„ËÏfiÙÂÚË Û ·È‰È¿ ËÏÈΛ·˜ <3 ÂÙÒÓ Î·È Û ÂΛӷ Ì ‰È¿Ù·ÛË ‹ ÂÎÙ·Û›· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ÛÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ (1,25). ∂ÈϤÔÓ, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Û ·‰¤ÚÊÈ· Â›Ó·È 10 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ۇÁÎÚÈÛË Ì ÙÔÓ ˘fiÏÔÈÔ ÏËı˘ÛÌfi, Û‡Ìʈӷ Ì ‰Â‰Ô̤ӷ ÌÂϤÙ˘ ÛÙËÓ π·ˆÓ›·, Î·È ÙÔ
¡·È Ÿ¯È ™Ù·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ·
GG+GC
CC
8 6
2 3 ƒ2=0,444
1 ∫·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ÂÎٷۛ˜, ‰È·Ù¿ÛÂȘ, ·Ó¢ڇÛÌ·Ù· ÛÙÂÊ·ÓÈ·›ˆÓ) 2 ¢ÔÎÈÌ·Û›· Fisher ÚÔ˜ ÌÈ· ηÙ‡ı˘ÓÛË
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°ÔÓȉȷÎfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ +405g/c VEFG Î·È ¡fiÛÔ˜ Kawasaki
50% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂΉËÏÒÓÔ˘Ó ÙË ÓfiÛÔ ÂÓÙfi˜ 10 ËÌÂÚÒÓ (26). ∆¤ÏÔ˜, Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ Û ‰›‰˘Ì· ·‰¤ÚÊÈ· Î·È Û ·È‰È¿, ÔÈ ÁÔÓ›˜ ÙˆÓ ÔÔ›ˆÓ ›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ¡∫ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘fiıÂÛË Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ (27,28). ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ Á›ÓÂÈ ÌÂÁ¿ÏË ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Û ·È‰È¿ Ì ¡∫. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÚÔ·ÙÂÈ fiÙÈ Ë Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, Ô ¯·ÌËÏfi˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ, Ë ˘„ËÏ‹ ÙÈÌ‹ Ù˘ CRP, Ë ¯·ÌËÏ‹ ÙÈÌ‹ ÙÔ˘ ·ÈÌ·ÙÔÎÚ›ÙË, Ë ÌÈÎÚ‹ ËÏÈΛ· Î·È ÙÔ ¿ÚÚÂÓ Ê‡ÏÔ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ·Ó¢ڢÛÌ¿ÙˆÓ (6). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Î·È Ë ¯·ÌËÏ‹ ÙÈÌ‹ ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È Ù˘ ·Ï‚Ô˘Ì›Ó˘ ÙÔ˘ ÔÚÔ‡ ·ÔÙÂÏÔ‡Ó ÂÈϤÔÓ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û‡Ìʈӷ Ì ¿ÏϘ ÌÂϤÙ˜ (29,30). ∞fi ÙË ÌÂϤÙË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÌfiÓÔ Ë ‰È¿ÚÎÂÈ· ÙÔ˘ ˘ÚÂÙÔ‡ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÎÔÈÓ‹˜ Á-ÛÊ·ÈÚ›Ó˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ ÌÂ Î·È ¯ˆÚ›˜ ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜, ·Ú·Ù‹ÚËÛË Ô˘ Û˘ÌʈÓ› Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ (6,29,30). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÚfiÛÊ·Ù˘ ÌÂϤÙ˘ ÙˆÓ Kim Î·È Û˘Ó. ÚԤ΢„ fiÙÈ Ë Ì¤ÛË ÙÈÌ‹ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È Ù˘ CRP ‹Ù·Ó ˘„ËÏfiÙÂÚË Î·È ‰È¤ÊÂÚ Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (·ÛıÂÓ›˜ ÌÂ Î·È ¯ˆÚ›˜ ‚Ï¿‚˜ ·ÓÙ›ÛÙÔȯ·) (6). ∞fi ÙË ÌÂϤÙË Ì·˜ ηٷÁÚ¿ÊËΠÌfiÓÔ ˘„ËÏfiÙÂÚË Ì¤ÛË ÙÈÌ‹ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜, Ë ÔÔ›· ‰ÂÓ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙÔÓ ÁÔÓȉȷÎfi ÔÏ˘ÌÔÚÊÈÛÌfi VEGF +405 GÆC, ÛÙË ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÁÔÓÔÙ‡ˆÓ ·Ó¿ÌÂÛ· ÛÙËÓ ÔÌ¿‰· ÌÂϤÙ˘ Î·È ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. ¶·ÚfiÏ· ·˘Ù¿, Ë ·˘ÍË̤ÓË ·Ó·ÏÔÁ›· ÙˆÓ CC ÔÌÔ˙˘ÁˆÙÒÓ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∫ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÌÈ·˜ Ù¿Û˘, Ô˘ fï˜ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÁÁ›ÍÂÈ ÙË ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜. ™ÙÔ ›‰ÈÔ Úfi‚ÏËÌ·, ·˘Ùfi Ù˘ ·Ó·ÚÎÔ‡˜ ÛÙ·ÙÈÛÙÈ΋˜ ÈÛ¯‡Ô˜, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Î·È Ë ·‰˘Ó·Ì›· ·Ó›¯Ó¢Û˘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ VEGF +405 GÆC Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¡∫, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™’ ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ‚¤‚·È·, Ë Û¯ÂÙÈο ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙˆÓ ÊÔÚ¤ˆÓ ÙÔ˘ G ·ÏÏËÏÔÌfiÚÊÔ˘ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ηډȷÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ìʈ-
Ó›· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Û ȷˆÓÈÎfi ÏËı˘ÛÌfi (31). ™‡Ìʈӷ Ì ·˘Ù‹ ÙËÓ ˘fiıÂÛË, Ô VEGF ÚÔηÏ› ‚Ï¿‚Ë ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÌÈÎÚÔ·ÁÁÂȷ΋ ‰È·ÂÚ·ÙfiÙËÙ· ·ÊÂÓfi˜ Î·È ÚÔηÏÒÓÙ·˜ ÂÚÈ·ÁÁÂÈ·Îfi Ô›‰ËÌ· ·ÊÂÙ¤ÚÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÙÔȯˆÌ¿ÙˆÓ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ Ô˘ ‰Â˘ÙÂÚÔ·ıÒ˜ Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ·Ó¢ڢÛÌ¿ÙˆÓ. ∂ÈϤÔÓ, Ô VEGF ÚÔ¿ÁÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Î·È ÙË ÌÂÙ·Ó·ÛÙ¢ÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (NO) Û˘Ì‚¿ÏÏÔÓÙ·˜ ÛÙËÓ ·Ó·Î·Ù·Û΢‹ Î·È ÙË ‰È·Ù·Ú·¯‹ Ù˘ ÌÈÎÚÔ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ·ÁÁ›ˆÓ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ (31). ∞fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÚÔ·ÙÂÈ Ë ·Ó¿ÁÎË ÁÈ· ¤ÎÙ·ÛË Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û ÌÂÁ·Ï‡ÙÂÚÔ ‰Â›ÁÌ· ·ÛıÂÓÒÓ Ì ¡∫, ¤ÙÛÈ ÒÛÙ ӷ ÂÍ·¯ıÔ‡Ó ·ÛʷϤÛÙÂÚ· Û˘ÌÂÚ¿ÛÌ·Ù·, ÙfiÛÔ Û ۯ¤ÛË Ì ٷ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· fiÛÔ Î·È ·Ó·ÊÔÚÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ VEGF +405 GÆC ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ¡∫ ·ÊÂÓfi˜ Î·È Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ·ÊÂÙ¤ÚÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ηٷϋÁÔ˘Ì fiÙÈ Ë ‰ÈÂÚ‡ÓËÛË Ó¤ˆÓ ÁÂÓÂÙÈÎÒÓ Î·È ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¡∫ ı· Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Î·È ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ÂÚÈÔÚ›˙ÔÓÙ·˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Japanese Circulation Society Joint Research Group. Guidelines for diagnosis and management of cardiovascular sequelae in Kawasaki disease. Pediatr Int 2005;47:711732. 2. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al. Diagnosis, treatment and longterm management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardioascular Disease in the Young, American Heart Association. Pediatrics 2004;114:1708-1733. 3. Kawasaki T. Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children. Arerugi 1967;16:178-222. 4. Freeman AF, Shulman ST. Kawasaki disease: summary of the American Heart Association guidelines. Am Fam Physician 2006;74:1141-1148. 5. Chuang CH, Hsiao MH, Chiu CH, Huang YC, Lin TY. Kawasaki disease in infants three months of age or younger. J Microbiol Immunol Infect 2006;39:387-391. 6. Kim T, Choi W, Woo CW, Choi B, Lee J, Lee K, et al. Predictive risk factors for coronary artery abnormalities in Kawasaki disease. Eur J Pediatr 2007;166:421-425. 7. Belay ED, Maddox RA, Holman RC, Curns AT, Ballah K, Schonberger LB. Kawasaki syndrome and risk factors for coronary artery abnormalities: United States, 1994-2003. Pediatr Infect Dis J 2006;25:245-249. ¶·È‰È·ÙÚÈ΋ 2007;70:389-394
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8. Chang FY, Hwang B, Chen SJ, Lee PC, Meng CC, Lu JH. Characteristics of Kawasaki disease in infants younger than six months of age. Pediatr Infect Dis J 2006;25:241-244. 9. Benseler SM, McCrindle BW, Silverman ED, Tyrrell PN, Wong J, Yeung RS. Infections and Kawasaki disease: implications for coronary artery outcome. Pediatrics 2005;116:760-766. 10. Wang CL, Wu YT, Liu CA, Kuo HC, Yang KD. Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 2005;24:998-1004. 11. Yeung RS. Pathogenesis and treatment of Kawasaki's disease. Curr Opin Rheumatol 2005;17:617-623. 12. Burgner D, Harnden A. Kawasaki disease: what is the epidemiology telling us about the etiology? Int J Infect Dis 2005;9:185-194. 13. Park YW, Han JW, Park IS, Kim CH, Yun YS, Cha SH, et al. Epidemiologic picture of Kawasaki disease in Korea, 2000-2002. Pediatr Int 2005;47:382-387. 14. Yanagawa H, Nakamura Y, Yashiro M, Uehara R, Oki I, Kayaba K. Incidence of Kawasaki disease in Japan: the nationwide surveys of 1999-2002. Pediatr Int 2006;48:356-361. 15. Ferrara N. Molecular and biological properties of vascular endothelial growth factor. J Mol Med 1999;77:527-543. 16. Hamamichi Y, Ichida F, Yu X, Hirono KI, Uese KI, Hashimoto I, et al. Neutrophils and mononuclear cells express vascular endothelial growth factor in acute Kawasaki disease: its possible role in progression of coronary artery lesions. Pediatr Res 2001;49:74-80. 17. Maeno N, Takei S, Masuda K, Akaike H, Matsuo K, Kitajima I, et al. Increased serum levels of vascular endothelial growth factor in Kawasaki disease. Pediatr Res 1998;44:596-599. 18. Ohno T, Igarashi H, Inoue K, Akazawa K, Joho K, Hara T. Serum vascular endothelial growth factor: a new predictive indicator for the occurrence of coronary artery lesions in Kawasaki disease. Eur J Pediatr 2000;159:424-429. 19. Watson CJ, Webb NJ, Bottomley MJ, Brenchley PE. Identification of polymorphisms within the vascular endothelial growth factor (VEGF) gene: correlation with variation in VEGF protein production. Cytokine 2000;12:1232-1235. 20. Stevens A, Soden J, Brenchley PE. et al. Haplotype analysis of the polymorphic human vascular endothelial growth factor gene promoter. Cancer Res 2003;63:812-816.
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21. Awata T, Inoue K, Kurihara S, Ohkubo T, Watanabe M, Inukai K. A common polymorphism in the 5’- untranslated region of the VEGF gene is associated with diabetic retinopathy in type 2 diabetes. Diabetes 2002;51:1635-1639. 22. Holman RC, Curns AT, Belay ED, Steiner CA, Schonberger LB. Kawasaki syndrome hospitalizations in the United States, 1997 and 2000. Pediatrics 2003;112:495-501. 23. Chang RK. The incidence of Kawasaki disease in the United States did not increase between 1988 and 1997. Pediatrics 2003;111:1124-1125. 24. Gandhi A, Wilson DG. Incomplete Kawasaki disease: not to be forgotten. Arch Dis Child 2006;91:276-277. 25. Yanagawa H, Nakamura Y, Yashiro M, Ojima T, Tanihara S, Oki I, et al. Results of the nationwide epidemiologic survey of Kawasaki disease in 1995 and 1996 in Japan. Pediatrics 1998;102:65. 26. Fujita Y, Nakamura Y, Sakata K, Hara N, Kobayashi M, Nagai M. Kawasaki disease in families. Pediatrics 1989;84: 666-669. 27. Newburger JW, Taubert KA, Shulman ST, Rowley AH, Gewitz MH, Takahashi M, et al. Summary and abstracts of the Seventh International Kawasaki Disease Symposium: December 4-7, 2001, Hakone, Japan. Pediatr Res 2003;53: 153-157. 28. Kaneko K, Obinata K, Katsumata K, Tawa T, Hosaka A, Yamashiro Y. Kawasaki disease in a father and daughter. Acta Paediatr 1999;88:791-792. 29. Honkanen VE, McCrindle BW, Laxer RM, Feldman BM, Schneider R, Silvermann ED. Clinical relevance of the risk factors for coronary artery infiammation in Kawasaki disease. Pediatr Cardiol 2003;24:122-126. 30. Nakamura Y, Yashiro M, Uehara R, Watanabe M, Tajimi M, Oki I, et al. Use of laboratory data to identify risk factors of giant coronary aneurysms due to Kawasaki disease. Pediatr Int 2004;46:33-38. 31. Kariyazono H, Ohno T, Khajoee V, Ihara K, Kusuhara K, Kinukawa N, et al. Association of vascular endothelial growth factor (VEGF) and VEGF receptor gene polymorphisms with coronary artery lesions of Kawasaki disease. Pediatr Res 2004;56:953-959.
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
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∂ȉËÌÈÔÏÔÁ›· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿ ÛÙËÓ ∂ÏÏ¿‰·: ªÂϤÙË ROTASCORE π. ∫·‚·ÏÈÒÙ˘1, µ. ¶··Â˘·ÁÁ¤ÏÔ˘2, ∂. ∫fiÎÎÔÚË3, §. ª·ÓÙ·ÁÔ‡4, °. ∆Ú›Ì˘5, ∞. ∫ÔÓÙÔ‡1, Ã. ª·ÛÈÔ‡ÚË3, ¡. ¡ÈÎÔÏ·ÎÔÔ‡ÏÔ˘4, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜2, √Ì¿‰· ªÂϤÙ˘ ROTASCORE* ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ Î·È ÛÔ‚·ÚfiÙÂÚÔ ·›ÙÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ ·ÁÎÔÛÌ›ˆ˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) Î·È Ë Û‡ÁÎÚÈÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Û ۯ¤ÛË Ì ÙË Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙ· ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ÙÂÛÛ¿ÚˆÓ ÌÂÁ¿ÏˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È Û 50 ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· ÌÂٷ͇ π·ÓÔ˘·Ú›Ô˘ Î·È ª·˝Ô˘ 2006. ªÂÏÂÙ‹ıËÎ·Ó ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·. ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó· ¤ÁÈÓ Ì ٷ¯Â›· ·ÓÔÛԯڈ̷ÙÔÁÚ·ÊÈ΋ ‰ÔÎÈÌ·Û›·. ∏ ‚·Ú‡ÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ ·ÍÈÔÏÔÁ‹ıËΠ̠ÙËÓ Îϛ̷η Clark. ∞ÔÙÂϤÛÌ·Ù·: ¶ÂÚÈÂÏ‹ÊıËÛ·Ó 706 ·È‰È¿ (385 ·ÁfiÚÈ·, ‰È¿ÌÂÛË ËÏÈΛ· 20 Ì‹Ó˜), ·fi Ù· ÔÔ›· ÙÔ 38,6% ÂÈÛΤÊıËΠٷ ∆∂¶ Î·È ÙÔ 61,4% Ù· ȉȈÙÈο È·ÙÚ›·. °ƒ ÂÌÊ¿ÓÈÛ ÙÔ 29,1% ÙˆÓ ·ÛıÂÓÒÓ, ÙÔ 18,3% ÙˆÓ ·È‰ÈÒÓ ·fi Ù· ȉȈÙÈο È·ÙÚ›·, ÙÔ 45,7%, ÙˆÓ ·ÛıÂÓÒÓ ·fi Ù· ∆∂¶ Î·È ÙÔ 49,1% ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ ·È‰ÈÒÓ. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ °ƒ (71,7%) ÂÌÊ·Ó›ÛıËΠ۠·È‰È¿ ËÏÈΛ·˜ 0,53 ÂÙÒÓ. ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ˘ÚÂÙfi˜ ≥38ÔC, ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ Î·È ¤ÌÂÙÔÈ ·Ú·ÙËÚ‹ıËÎ·Ó Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙËÓ ÔÌ¿‰· Ù˘ °ƒ (p<0,01), ηıÒ˜ ›Û˘ Î·È ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓfiÛÔ˘ ̤ÙÚÈ·˜ ‹ ÛÔ‚·Ú‹˜ ‚·Ú‡ÙËÙ·˜ (p=0,013 Î·È p=0,021 ·ÓÙÈÛÙÔ›¯ˆ˜), ·Ó¿Á΢ ÁÈ· ÓÔÛËÏ›· (p=0,011) Î·È ·Ú¿Ù·Û˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ (p=0,039). ™˘ÌÂÚ¿ÛÌ·Ù·: √ ÚÔÙ·˚fi˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ ‹ÌÈÛ˘ ۯ‰fiÓ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ ‹ ¯Ú‹˙Ô˘Ó ÓÔÛËÏ›·˜. ∏ ¯Ú‹ÛË Î·Ù¿ÏÏËÏÔ˘ ÂÌ‚ÔÏ›Ô˘ ı· ÌÔÚÔ‡Û ӷ Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÚfiÏË„Ë ·˘Ù‹˜ Ù˘ Û˘¯Ó‹˜ Î·È ÔÏϤ˜ ÊÔÚ¤˜ ÛÔ‚·Ú‹˜ ÓfiÛÔ˘.
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢ 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” 3 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ 4 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘ 5 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: °ÈÒÚÁÔ˜ ∆Ú›Ì˘ gtrim@otenet.gr ∫ËÊÈÛ›·˜ 32 T.K. 115 26 ∞ÌÂÏfiÎËÔÈ, ∞ı‹Ó·
§¤ÍÂȘ ÎÏÂȉȿ: ∂ȉËÌÈÔÏÔÁ›·, Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÚÔÙ·˚fi˜, ·È‰È¿.
ROTASCORE study: Epidemiological observational study of rotavirus acute gastroenteritis in children in Greece I. ∫avaliotis1, V. Papaevangelou2, H. ∫okori3, L. Mantagou4, G. Trimis5, A. Kontou1, C. Basiouri3, N. Nikolakopoulou4, A. Konstantopoulos2, ROTASCORE Study Group* Abstract Background: Rotavirus is the most frequent and serious cause of acute gastroenteritis (AGE) in children aged up to 5 years worldwide. The aim of this study was to determine the proportion of Paediatric Rotavirus Gastroenteritis (PRG) and compare its burden to that of AGE due to other pathogens. Methods: The study was conducted in four Hospital Emergency Units (HEU) and 50 private paediatric clinics between January and May 2006. Children aged up to 5 years with AGE were included. A rapid stool immunochromatographic test for rotavirus antigen detection was performed. The symptom severity score was evaluated using the Clark scale. Results: The study included 706 children (385 boys) of median age 20 months; 38.6% of the patients visited HEU and 61.4% private clinics. Rotavirus antigen was identified in 29.1% of the patients, and specifically in 18.3% of the children who were examined in private clinics, 45.7% of those in HEU and 49.1% of hospitalised children. Most children with PRG (71.7%) were aged between 0.5 and 3 years. Behavioural changes, signs of dehydration, weight loss, fever ≥38ÔC, diarrhoea and vomiting were all more prevalent in the PRG group (p<0.01). In addition, children with PRG presented higher rates of moderate or severe gastroenteritis (p=0.013 and p=0.021 respectively) and hospitalization (p=0.011), and had a longer hospitalization stay (p= 0.039). Conclusions: PRG is responsible for nearly half of the cases of children aged up to 5 years with AGE attending HEU or requiring hospitalization. Appropriate vaccination could help prevent this common and often severe disease.
1 Paediatric Department, Hospital of Infectious Diseases of Thessaloniki 2 2nd Paediatric Department, Athens University School of Medicine, “Aglaia Kyriakou” Children’s Hospital, Athens 3 2nd Paediatric Department, Venizelio Hospital of Heraklion 4 Paediatric Department, University Hospital of Rio, Patras 5 1st Paediatric Department, Athens University School of Medicine, ”Agia Sophia” Children’s Hospital, Athens Correspondence: Georgios Trimis gtrim@otenet.gr 32, Kifissias Avenue 115 26, Ambelokipoi Athens, Greece
Key words: Epidemiology, gastroenteritis, rotavirus, children. ¶·È‰È·ÙÚÈ΋ 2007;70:395-401
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π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.
™˘ÓÙÔÌÔÁڷʛ˜ ∆∂¶: ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ °ƒ: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi °∞: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ·
∂ÈÛ·ÁˆÁ‹ √ ÚÔÙ·˚fi˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ≤5 ÂÙÒÓ (1). ∏ Û˘¯ÓfiÙËÙ· Ù˘ Ïԛ̈͢ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È·ÊÔÚ¤˜ ·Ó¿ÏÔÁ· Ì ÙË ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÔÛÔÛÙfi ı·Ó¿ÙˆÓ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ÂÍ·ÈÙ›·˜ Û˘ÓıËÎÒÓ Î·Î‹˜ ‰È·ÙÚÔÊ‹˜ Î·È ·Ó·ÚÎÔ‡˜ È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜ (2). ™ÙËÓ Ú¿ÍË ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ fiÏ· Ù· ·È‰È¿ ı· ÌÔÏ˘ÓıÔ‡Ó ·fi ÚÔÙ·˚fi ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ÊÔÚ¿ ÛÙ· 23 ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Î·È Û˘¯ÓfiÙÂÚ· ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ (3-5). √È ÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) Â›Ó·È ÛËÌ·ÓÙÈΤ˜, ÏfiÁˆ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È Ù˘ ›‰Ú·Û‹˜ ÙÔ˘˜ ÛÙË ˙ˆ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™ÙËÓ ∂˘ÚÒË ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ Â›ÙˆÛË Ù˘ °ƒ. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û¿ÓÈ· Á›ÓÂÙ·È ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÚÔ˘Û›·˜ ÚÔÙ·˚Ô‡, ηıÒ˜ ·˘Ùfi ‰ÂÓ Û˘ÓÙÂÏ› Û ·ÏÏ·Á‹ ıÂڷ›·˜ ‹ ÛÙË Ï‹„Ë ÂȉÈÎÒÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ. ÕÏÏÔ˜ ÏfiÁÔ˜ Â›Ó·È fiÙÈ Ë °ƒ ‰ÂÓ ·Ó‹ÎÂÈ ÛÙ· ˘Ô¯ÚˆÙÈÎÒ˜ ‰ËÏÔ‡ÌÂÓ· ÓÔÛ‹Ì·Ù·. ∂ÈϤÔÓ, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ °ƒ ·fi ÙËÓ ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞) Â›Ó·È ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏË, ηıÒ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û˘ÁÎÂÎÚÈ̤ӷ Î·È Û·Ê‹ ÎÏÈÓÈο ‹ ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· (6). º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Ë Â›ÙˆÛ‹ Ù˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· ˘ÔÂÎÙÈÌ¿Ù·È. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙËÓ Âԯȷ΋ ηٷÓÔÌ‹ Ù˘ ÓfiÛÔ˘, ÌÂϤÙ˜ Û ¯ÒÚ˜ Ì ‡ÎÚ·ÙÔ Îϛ̷ ‰Â›¯ÓÔ˘Ó ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ, ΢ڛˆ˜ ηٿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ (7). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ë ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠηٿ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ∫‡ÚÈÔ˜ ÛÎÔfi˜ ‹Ù·Ó Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ≤5 ÂÙÒÓ Ì °ƒ Î·È Î·Ù¿ ‰Â‡ÙÂÚÔ ÏfiÁÔ, Ô Î·ıÔÚÈÛÌfi˜ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì °ƒ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, Ë Û‡ÁÎÚÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ ÙˆÓ ·È‰ÈÒÓ Ì ÚÔÙ·˚fi Û ۯ¤ÛË Ì ÙË °∞ ηÈ, Ù¤ÏÔ˜, Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ ÚÔÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ °ƒ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™¯Â‰È·ÛÌfi˜ ÌÂϤÙ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÔÏ˘ÎÂÓÙÚÈ΋, ÌË ·ÚÂÌ‚·ÙÈ΋, ÚÔÔÙÈ΋ ÌÂϤÙË ÂȉËÌÈÔÏÔÁÈ΋˜ ·Ú·Ù‹ÚËÛ˘, Ë ÔÔ›· ÂÁÎÚ›ıËΠ·fi ÙȘ ∂ÈÙÚÔ¤˜ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È ·Ú¿ÏÏËÏ· ÁÓˆÛÙÔÔÈ‹ıËΠÛÙÔÓ ∂ıÓÈÎfi √ÚÁ·ÓÈÛÌfi º·Ú̿ΈÓ. ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó Paediatriki 2007;70:395-401
·È‰È¿ ËÏÈΛ·˜ ¤ˆ˜ 5 ÂÙÒÓ Ô˘ ÂÍÂÙ¿ÛıËÎ·Ó ÛÙ· ∆Ì‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) Î·È Û ηıÔÚÈṲ̂ӷ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·, ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 15/1 ¤ˆ˜ 15/5/2006, ÌÂ Û˘ÌÙÒÌ·Ù· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜. ∏ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ °ƒ ÁÈÓfiÙ·Ó Ì ‰ÔÎÈÌ·Û›· ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó·. ∫ÚÈÙ‹ÚÈ· Û˘ÌÌÂÙÔ¯‹˜ Î·È ·ÔÎÏÂÈÛÌÔ‡ ∫ÚÈÙ‹ÚÈÔ Û˘ÌÌÂÙÔ¯‹˜ ‹Ù·Ó Ë Â›ÛÎÂ„Ë ·È‰ÈÔ‡ ÌÈÎÚfiÙÂÚÔ˘ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ Ì ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û οÔÈÔ ·fi Ù· ∆∂¶ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÎÏÈÓÈÎÒÓ ‹ Ù· ηıÔÚÈṲ̂ӷ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·. √ ÔÚÈÛÌfi˜ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ÂÚÈÏ¿Ì‚·Ó ÙËÓ ‡·ÚÍË ÙÚÈÒÓ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ˘‰·ÚÒÓ ÎÂÓÒÛÂˆÓ Ì ‹ ¯ˆÚ›˜ ¤ÌÂÙÔ Û ‰È¿ÛÙËÌ· 24 ˆÚÒÓ. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ‹Ù·Ó Ë ·ÚÔ˘Û›· ¯ÚfiÓÈ·˜ ‰È¿ÚÚÔÈ·˜ (‰È¿ÚÎÂÈ· >7 ̤Ú˜), ÓÔÛËÌ¿ÙˆÓ ÌË Û˘Ì‚·ÙÒÓ Ì ÙÔÓ ÔÚÈÛÌfi Ù˘ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ (.¯. ÎÔÈÏÈÔοÎË, ÓfiÛÔ˜ ÙÔ˘ Hirschprung, Î.Ï.), Ë ÚÔۤϢÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ È·ÙÚfi ÁÈ· ¿ÏÏÔÓ ÏfiÁÔ, Ë ÁÓˆÛÙ‹ ÙÚÔÊÈ΋ ‰ËÏËÙËÚ›·ÛË ‹ Ë È·ÙÚÔÁÂÓ‹˜ ‰È¿ÚÚÔÈ· (.¯. Ï‹„Ë ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ). ∂›Û˘, ·ÔÎÏ›ÛÙËÎ·Ó ·È‰È¿ Ì ·‰˘Ó·Ì›· ¯ÔÚ‹ÁËÛ˘ ‰Â›ÁÌ·ÙÔ˜ ÎÔÚ¿ÓˆÓ Î·È Ì ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ¤‰ˆÛ·Ó Û˘ÁηٿıÂÛË ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË. ∂ÈÏÔÁ‹ ÙˆÓ Î¤ÓÙÚˆÓ Ù˘ ÌÂϤÙ˘ ∏ ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ÌÂϤÙ˘ ¤ÁÈÓ ÛÙ· ∆∂¶ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÎÏÈÓÈÎÒÓ ÙÂÛÛ¿ÚˆÓ ÌÂÁ¿ÏˆÓ ÓÔÛÔÎÔÌ›ˆÓ (µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡”, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢, µã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ Î·È ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘) Î·È Û 50 ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· Û ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜. √ Û˘ÓÙÔÓÈÛÌfi˜ Î·È Ë Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ·Ó ·fi ÙË µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∏ ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹ ÙˆÓ Î¤ÓÙÚˆÓ ‹Ù·Ó ¢Ú›·, ÒÛÙ ӷ ˘¿Ú¯ÂÈ ·Ó·ÏÔÁÈ΋ Ì ÙÔÓ ÏËı˘ÛÌfi ·ÓÙÈÚÔÛÒ¢ÛË fiÏˆÓ ÙˆÓ ÂÚÈÔ¯ÒÓ. ™˘ÏÏÔÁ‹ ‰Â‰ÔÌ¤ÓˆÓ ∏ Û˘ÏÏÔÁ‹ ‰Â‰ÔÌ¤ÓˆÓ ÂÚÈÏ¿Ì‚·Ó ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙÔ˘ ·ÛıÂÓ‹ (ʇÏÔ, ËÏÈΛ·), ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ (Û˘ÌÙÒÌ·Ù·, Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ·Ó¿ Ë̤ڷ Î·È ‰È¿ÚÎÂÈ·) Î·È ÙÔ˘ ÙÚfiÔ˘ ‰È·‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ (·ÚÈıÌfi˜ ·‰ÂÚÊÒÓ, ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡, ıËÏ·ÛÌfi˜). ∏ ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ οı ÂÚÈÛÙ·ÙÈÎÔ‡ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ‚·ıÌÔÏÔÁ‹ıËΠۇÌʈӷ Ì ÙËÓ Îϛ̷η ÙÔ˘ Clark, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙËÓ ·ÚÔ˘Û›·, ÙËÓ ¤ÓÙ·ÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (8). ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÛÙ· ÎfiÚ·Ó· ÁÈÓfiÙ·Ó Ì ÙËÓ Ù·¯Â›· ·ÓÔÛԯڈ̷ÙÔÁÚ·ÊÈ΋ ‰ÔÎÈÌ·Û›· VIKIA (BioMerieux), ÂÓÒ ÙÔ ‰Â›ÁÌ· ÌÔÚÔ‡Û ӷ Ê˘Ï·¯ı› ÁÈ· 24-48 ÒÚ˜ Û ıÂÚÌÔÎÚ·Û›· „˘Á›Ԣ (2-8ÆC). ™ÙÔ Ù¤ÏÔ˜ Ù˘ ÂͤٷÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈÓfiÙ·Ó ·Ó¿ÁÓˆÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ù˘ ‰ÔÎÈÌ·Û›·˜ ÎÔÚ¿ÓˆÓ, ¤ÙÛÈ ÒÛÙ o È·ÙÚfi˜ Ó· ÌËÓ ÂËÚ·ÛÙ› ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘ ·ÁˆÁ‹˜. ™˘ÌÏËڈ̷ÙÈο ÛÙÔȯ›· ÁÈ· ÙË Û˘ÓÔÏÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ Ï·Ì‚¿ÓÔÓÙ·Ó ÌÂÙ¿ ·fi ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Ì ÙÔ˘˜ ÁÔÓ›˜, 6-10 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÂÚÈÂÏ¿Ì‚·Ó ۇÁÎÚÈÛË ÙˆÓ ·È‰ÈÒÓ ÛÙ· ÔÔ›· ‰È·ÁÓÒÛıËΠ°ƒ Ì ٷ ·È‰È¿ ÛÙ· ÔÔ›·
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∂ȉËÌÈÔÏÔÁ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿
‰È·ÁÓÒÛıËΠ°∞, ηıÒ˜ Î·È Û‡ÁÎÚÈÛÂȘ ÌÂٷ͇ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ t-test. °È· Ó· ÂÏÂÁ¯ı› Ë ÛËÌ·ÓÙÈÎfiÙËÙ· Ù˘ ›‰Ú·Û˘ ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ÚÔ˘Û›· °ƒ, ηıÒ˜ Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, ÂÊ·ÚÌfiÛÙËÎÂ Ô ¤ÏÂÁ¯Ô˜ χ2. ∆¤ÏÔ˜, ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ Û¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ (odds ratios) Ù˘ ÂÌÊ¿ÓÈÛ˘ ÔÚÈÛÌ¤ÓˆÓ ÌÂÙ·‚ÏËÙÒÓ ÛÙ· ·È‰È¿ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞. ∆Ô Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÔÚ›ÛÙËΠˆ˜ p<0,05. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Û‡ÛÙËÌ· SPSS (version 10.0, Chicago, USA).
ı› ·È‰› ıÂÙÈÎfi ÁÈ· ÚÔÙ·˚fi ·’ fi,ÙÈ ÛÙ· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· (p<0,01). ™˘ÁÎÂÎÚÈ̤ӷ, °ƒ ÂÌÊ¿ÓÈÛ·Ó 125/273 ·ÛıÂÓ›˜ ·fi Ù· ∆∂¶ (45,7%, CI 95%: 40-51,7%) Î·È 77/420 ·ÛıÂÓ›˜ ·fi Ù· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· (18,3%, CI 95%: 14,9-22,3%). ∏ Û˘¯ÓfiÙËÙ· Ù˘ °ƒ ·ÚÔ˘Û›·Û ‰È·Î˘Ì¿ÓÛÂȘ ·Ó¿ÏÔÁ· Ì ÙË ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹, fï˜, ·Ú¤ÌÂÓ ÛÙ·ıÂÚ¿ ˘„ËÏfiÙÂÚË ÛÙ· ∆∂¶, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ °ƒ ηٷÁÚ¿ÊËΠÛÙȘ ËÏÈ˘ 6 ÌËÓÒÓ - 3 ÂÙÒÓ (71%, ∂ÈÎfiÓ· 2). ∏ ‰È¿ÌÂÛË ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Ù˘ °ƒ ‹Ù·Ó 17 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 20±13 ÌËÓÒÓ) Î·È Ù˘ °∞ 22 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 26±12 ÌËÓÒÓ), p=0,042. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÛÙ· ∆∂¶ Ë ‰È¿ÌÂÛË ËÏÈΛ· Ù˘ ÂÌÊ¿ÓÈÛ˘ °ƒ ‹Ù·Ó 15 Ì‹Ó˜ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ °∞ 18 Ì‹Ó˜ (p>0,05), ÂÓÒ ÛÙ· ȉȈÙÈο È·ÙÚ›· ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ‹Ù·Ó 19 Î·È 26 Ì‹Ó˜ (p=0,035). ∆¤ÏÔ˜, Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ °ƒ ‹Ù·Ó ÛÙ·ıÂÚ‹ ηٿ ÙÔ˘˜ Ì‹Ó˜ π·ÓÔ˘¿ÚÈÔ ˆ˜ ∞Ú›ÏÈÔ (2831%), ÂÓÒ ÙÔÓ ª¿ÈÔ ‹Ù·Ó ¯·ÌËÏfiÙÂÚË (17,2%). ¢ÂÓ ÂÓÙÔ›ÛÙËÎ·Ó ·Ú¿ÁÔÓÙ˜ Ô˘ Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ °ƒ, ηıÒ˜ ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·‰ÂÚÊÒÓ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡. ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ (ÓˆıÚfiÙËÙ·, ¢ÂÚÂıÈÛÙfiÙËÙ·, ÎfiˆÛË, ˘ÔÙÔÓ›·, Ï‹ı·ÚÁÔ˜), ·ÚÔ˘Û›· ÛËÌ›ˆÓ ·Ê˘‰¿ÙˆÛ˘ Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‹Ù·Ó ÔÈ ÂΉËÏÒÛÂȘ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙË °ƒ Û˘ÁÎÚÈÙÈο Ì ÙË °∞ (p<0,01,
∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó Û˘ÓÔÏÈο 706 ·È‰È¿, (54,5% ·ÁfiÚÈ·), ÂÎ ÙˆÓ ÔÔ›ˆÓ ÛÙ· 6 ‰ÂÓ Î·Ù·ÁÚ¿ÊËΠÙÔ Ê‡ÏÔ. ∏ ‰È¿ÌÂÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 20 Ì‹Ó˜ (̤ÛË ËÏÈΛ· 24±12 Ì‹Ó˜), ÂÓÒ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ (63,0%) ·Ó‹Î ÛÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÙˆÓ 6 ÌËÓÒÓ ˆ˜ 3 ÂÙÒÓ. ™ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ‰ÂÓ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 9 ·ÛıÂÓ›˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ Â›¯·Ó Û˘ÌÏËÚˆı› Ù· ‰Â‰Ô̤ӷ Î·È 4 ·ÛıÂÓ›˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ·Ó·Ê¤ÚıËΠˆ˜ ·‰È¢ÎÚ›ÓÈÛÙÔ. ™˘ÓÂÒ˜, Ë ·Ó¿Ï˘ÛË ÂÚÈÏ¿Ì‚·Ó 693 ·ÛıÂÓ›˜ (98,2% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜), ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 273 (39%) ÂÈÛΤÊıËÎ·Ó Ù· ∆∂¶ Î·È ÔÈ 420 (61%) Ù· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·. ∞fi ÙÔ Û‡ÓÔÏÔ Ô˘ ÂÍÂÙ¿ÛıËΠ(¡=693), 202 ·È‰È¿ (29,1%, CI 95%: 25,9-32,6%) ‚Ú¤ıËÎ·Ó ıÂÙÈο ÁÈ· ÚÔÙ·˚fi. ™Ù· ·ÁfiÚÈ· ‰È·ÈÛÙÒıËΠ°ƒ Û ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·’ fi,ÙÈ ÛÙ· ÎÔÚ›ÙÛÈ· (p=0,038). ∂›Û˘, ÛÙ· ∆∂¶ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ‚ÚÂ-
µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ (¡=63)
56%
¡ÔÛÔÎÔÌÂ›Ô §ÔÈ̈‰ÒÓ £ÂÛÛ·ÏÔӛ΢ (¡=110)
45%
¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡ (¡=70)
41%
¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ƒ›Ô˘ (¡=30)
40%
π‰ÈˆÙÈο È·ÙÚ›· ∫Ú‹Ù˘ (¡=48)
23%
π‰ÈˆÙÈο È·ÙÚ›· πˆ·ÓÓ›ÓˆÓ (¡=28)
21%
π‰ÈˆÙÈο È·ÙÚ›· ∞ıËÓÒÓ (¡=205)
21%
π‰ÈˆÙÈο È·ÙÚ›· ¶¿ÙÚ·˜ (¡=34)
18%
π‰ÈˆÙÈο È·ÙÚ›· £ÂÛÛ·ÏÔӛ΢ (¡=68)
12%
π‰ÈˆÙÈο È·ÙÚ›· ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘(¡=20)
10%
π‰ÈˆÙÈο È·ÙÚ›· §¿ÚÈÛ·˜ (¡=17)
6% 0%
1000%
2000%
3000%
4000%
5000%
6000%
∂ÈÎfiÓ· 1. ™˘¯ÓfiÙËÙ· ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) ·Ó¿ ÂÚÈÔ¯‹.
¶·È‰È·ÙÚÈ΋ 2007;70:395-401
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π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.
3000%
30%
26%
2500%
2000%
1500%
15% 13%
1000% 9% 7% 500%
0% < 0,5
0,51 - 1
1,1 - 2
2,1 - 3
3,1 - 4
4,1 - 5
∏ÏÈΛ· (¤ÙË)
(N=202)
∂ÈÎfiÓ· 2. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) ·Ó¿ ËÏÈΛ·.
¶›Ó·Î·˜ 1). ∂ÈϤÔÓ, Ë ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi ÚÔÙ·˚fi ·ÚÔ˘Û›·Û ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ ≥38ÔC, ÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÙÔÓ ·ÚÈıÌfi ·Ó¿ Ë̤ڷ ‰È·ÚÚÔ˚ÎÒÓ ÎÂÓÒÛÂˆÓ Î·È Â̤وÓ, ηıÒ˜ Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÌ¤ÙˆÓ (p<0,01, ¶›Ó·Î·˜ 1).
34,6% ◊È· ª¤ÙÚÈ· ™Ô‚·Ú‹
58,9% °∞ (N=491) 40,1%
1,1% ◊È· ª¤ÙÚÈ· ™Ô‚·Ú‹ 58,8%
∂ÈÎfiÓ· 3. ™‡ÁÎÚÈÛË ‰ÂÈÎÙÒÓ ÛÔ‚·ÚfiÙËÙ·˜ ÌÂٷ͇ ·È‰ÈÒÓ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi (°ƒ) Î·È ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞).* *µ·ıÌÔÏfiÁËÛË Ì ÙËÓ Îϛ̷η Clark Paediatriki 2007;70:395-401
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi (°ƒ) Î·È Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ¿ÏÏ· ·ıÔÁfiÓ· (°∞) ∫ÏÈÓÈ΋ ÂÈÎfiÓ·
°ƒ (N=202) 6,5%
™‡Ìʈӷ Ì ÙËÓ Îϛ̷η ÙÔ˘ Clark, Ë ÔÔ›· ‰È·¯ˆÚ›˙ÂÈ ÙË Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Û ‹È·, ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜, Ù· ·È‰È¿ Ì °ƒ ·ÚÔ˘Û›·Û·Ó Û˘¯ÓfiÙÂÚ·
∞Ê˘‰¿ÙˆÛË ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ¢È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ∫fiˆÛË-Ï‹ı·ÚÁÔ˜ ¶˘ÚÂÙfi˜ ≥38oC ¢È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ ≥8 ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ/Ë̤ڷ ∫ÂÓÒÛÂȘ Ì ÚfiÛÌÈÍË ‚ϤÓÓ˘ ŒÌÂÙÔÈ ≥7 ¤ÌÂÙÔÈ/Ë̤ڷ ≥3 Ë̤Ú˜ Ì Â̤ÙÔ˘˜ ≥5 Ë̤Ú˜ Ì ‰È¿ÚÚÔÈ· ≥3 Ë̤Ú˜ Ì ˘ÚÂÙfi ™·ÛÌÔ› √Í›· ̤ÛË ˆÙ›Ùȉ· ™À¡√§√
°ƒ (n, % )
°∞ (n, %)
p
93 (46,0) 87 (43,1) 143 (70,7)
92 (18,7) 125 (25,5) 269 (54,7)
0,01 0,01 0,01
74 (36,6) 154 (76,2) 201 (99,5) 31 (15,4)
66 (13,4) 248 (50,5) 441 (89,8) 24 (4,9)
0,01 0,01 0,01 0,01
151 (74,7)
233 (47,4)
0,01
141 (69,8) 13 (6,5) 29 (14,4) 15 (7,4) 39 (19,3) 2 (0,9) 13 (6,5) 202
197 (40,1) 4 (0,8) 36 (7,3) 33 (6,7) 75 (15,3) 4 (0,8) 33 (6,7) 491
0,01 0,01 0,01 NS NS NS NS
°ƒ: √Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ÚÔÙ·˚fi °∞:√Í›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ¿ÏÏ· ·ıÔÁfiÓ· ¡S: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi
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∂ȉËÌÈÔÏÔÁ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Û ·È‰È¿
̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ ÓfiÛÔ, (65,4 ¤Ó·ÓÙÈ 41,2%, p<0,01, ∂ÈÎfiÓ· 3). ∏ ̤ÛË ÙÈÌ‹ ‚·ıÌÔÏfiÁËÛ˘ Ù˘ ‚·Ú‡ÙËÙ·˜ ηٿ Clark ÁÈ· Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó 11,1±5,1, ÂÓÒ ÁÈ· Ù· ·È‰È¿ Ì °∞ ‹Ù·Ó 9,2±4,9. ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ Â‡ÚËÌ· ‹Ù·Ó fiÙÈ Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ÂÈÛ·¯ıÔ‡Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ¤Ó·ÓÙÈ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤·Û¯·Ó ·fi °∞ (104/202, 51,5%, ¤Ó·ÓÙÈ 108/491, 22%, p=0,011). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÚԤ΢„ ·fi ÙËÓ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ Ô˘ ›¯·Ó Ù· ·È‰È¿ Ì °ƒ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ȉȈÙÈο È·ÙÚ›· (42,8 ¤Ó·ÓÙÈ 6%, p<0,01), ηıÒ˜, ÛÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ∆∂¶, Ë Û˘¯ÓfiÙËÙ· ÂÈÛ·ÁˆÁÒÓ ‰ÂÓ ‰È¤ÊÂÚ ÌÂٷ͇ ·È‰ÈÒÓ Ì °ƒ Î·È ·È‰ÈÒÓ Ì °∞ (56,8 ¤Ó·ÓÙÈ 59%, p>0,05). ∆· ·È‰È¿ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ∆∂¶, ·ÓÂÍ·Úًو˜ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¿Û¯Ô˘Ó ·fi ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· (76,4 ¤Ó·ÓÙÈ 24,2%, p<0,01). ™Ù· ·È‰È¿ ÙˆÓ È‰ÈˆÙÈÎÒÓ È·ÙÚ›ˆÓ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) ÁÈ· ÂÌÊ¿ÓÈÛË Ì¤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ηٿ 5,3 ÊÔÚ¤˜ (5,32, CI 95%: 1,65-14,8, p<0,01) Î·È ÁÈ· ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·˘ÍË̤ÓÔ˜ ηٿ 7,1 ÊÔÚ¤˜ (7,12, CI 95%: 2,49-19,52, p<0,01). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÓÔÛËÏ›· ·ÓÂÍ·ÚÙ‹ÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ (¡=212), Ù· 104 ·È‰È¿ (49,1%, CI 95%: 42,3-55,7%) ¤·Û¯·Ó ·fi °ƒ. ∂›Û˘, Ù· ·È‰È¿ Ì °ƒ ›¯·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ ÓÔÛËÏ›·˜ (̤ÛË ‰È¿ÚÎÂÈ· 5,1±3,2 Ë̤Ú˜ ÁÈ· ÙËÓ °ƒ ¤Ó·ÓÙÈ 3,7±2,2 ËÌÂÚÒÓ ÁÈ· ÙËÓ °∞, p=0,039). √È ·Ó·ÊÂÚfiÌÂÓ˜ Ë̤Ú˜ ·Ô˘Û›·˜ ÁÔÓ¤ˆÓ ·fi ÙËÓ ÂÚÁ·Û›· ‹Ù·Ó ·ÚÎÂÙ¤˜ Û ÔÔÈ·Û‰‹ÔÙ ·ÈÙÈÔÏÔÁ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· (3,6±2,8 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·È‰ÈÒÓ Ì °ƒ Î·È 3,4±3,2 Ë̤Ú˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·È‰ÈÒÓ Ì °∞). ∞ÎfiÌ·, Ù· ·È‰È¿ Ì °ƒ ‹Ù·Ó Èı·ÓfiÙÂÚÔ Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ÎÏÈÓÈ΋ ·ÓÂÎÙ›ÌËÛË, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ¿ÏÏË ÔÌ¿‰· (73,8 ¤Ó·ÓÙÈ 46,4%, p=0,012). ™Ù· ·È‰È¿ Ì °ƒ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ì °∞, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (odds ratio) ÁÈ· ·Ú¿Ù·ÛË Ù˘ ÓÔÛËÏ›·˜ ¤Ú·Ó ÙˆÓ 3 ËÌÂÚÒÓ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ηٿ 2,1 ÊÔÚ¤˜ (2,13, CI 95%: 1,29-4,6, p<0,01) Î·È ÁÈ· ÎÏÈÓÈ΋ ·ÓÂÎÙ›ÌËÛË ·˘ÍË̤ÓÔ˜ ηٿ 1,6 ÊÔÚ¤˜ (1,59, CI 95%: 1,02-3,44, p=0,012). ∆¤ÏÔ˜, ·È‰È¿ ËÏÈΛ·˜ <2 ÂÙÒÓ Ì °ƒ ·ÚÔ˘Û›·˙·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ (73,9 ¤Ó·ÓÙÈ 46,9%, p=0,019) Î·È ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Û˘ÁÎÚÈÙÈο Ì ٷ ·ÓÙ›ÛÙÔȯ· ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ (56,5 ¤Ó·ÓÙÈ 40,6%, p=0,0431).
™˘˙‹ÙËÛË ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÔÙ‡ˆÛË Ù˘ ÂȉËÌÈÔÏÔÁ›·˜ Î·È ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘
Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi ÛÙË ¯ÒÚ· Ì·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÌÔÚʈı› ÛÙÚ·ÙËÁÈ΋ ÚfiÏ˄˘ Ù˘ ÓfiÛÔ˘, Ì ÙËÓ Â˘Î·ÈÚ›· Ù˘ ÂÈΛÌÂÓ˘ ΢ÎÏÔÊÔÚ›·˜ ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÂÌ‚ÔÏ›ˆÓ. ∂ÈϤÔÓ, Ù· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó Ì›· ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÌÂÙ·‚ÔÏÒÓ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›·, ÂÊfiÛÔÓ ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ ÚÔÙ·˚Ô‡ ÂÓÙ·¯ı› ÛÙÔ ∂ıÓÈÎfi ÃÚÔÓԉȿÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (9). ∆· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙËÓ ÎÏÈÓÈ΋ ÂÈ‚¿Ú˘ÓÛË Ô˘ ÚÔηÏ› Ë °ƒ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ ÛÙË ¯ÒÚ· Ì·˜ Î·È ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ë ÓfiÛÔ˜ Â›Ó·È Û˘¯Ó‹ ÛÙËÓ ∂ÏÏ¿‰·, ·ÊÔ‡ ۯ‰fiÓ ÛÙ· ÌÈÛ¿ ·È‰È¿ ËÏÈΛ·˜ <5 ÂÙÒÓ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ ‹ ÂÈÛ¿ÁÔÓÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜, ˘Â‡ı˘ÓÔ ·ıÔÁfiÓÔ Â›Ó·È Ô ÚÔÙ·˚fi˜. ∏ °ƒ ÂÌÊ·Ó›˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ· ·fi ÙË °∞, ÂÓÒ Ë ÛÔ‚·Ú‹ ÌÔÚÊ‹ Ù˘ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 2 ÂÙÒÓ. ¢ÂÓ ı· ‹Ù·Ó ˘ÂÚ‚ÔÏ‹ Ó· ÈÛ¯˘ÚÈÛÙԇ̠fiÙÈ Â›Ó·È Ì›· “·Ó·fiÊ¢ÎÙË” ÓfiÛÔ˜, ηıÒ˜ Ù· ÂӉ¯fiÌÂÓ· ÚÔÏËÙÈο ̤ÙÚ· (.¯. ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÌË ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡) ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙË Û˘¯ÓfiÙËÙ¿ Ù˘, Ô˘ ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚ¿ ˘„ËÏ‹ Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·, ŒÙÛÈ, Ì·˙› Ì ÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ¤Í·ÚÛË ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô, ÚÔηÏ› ›Û˘ ÛËÌ·ÓÙÈ΋ ÏÂÈÙÔ˘ÚÁÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙÔ ™‡ÛÙËÌ· ÀÁ›·˜. ªÂ ‚¿ÛË ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ Îϛ̷η Clark, Ë °ƒ ÂÌÊ·Ó›˙ÂÈ ·˘ÍË̤ÓË ‚·Ú‡ÙËÙ· Û˘ÁÎÚÈÙÈο Ì ÙË °∞ Î·È ·ÔÙÂÏ› ηٿ Û˘Ó¤ÂÈ· ·›ÙÈÔ ÌÂÁ·Ï‡ÙÂÚ˘ ٷϷȈڛ·˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÛËÌ›· ÂÓ‰ÂÈÎÙÈο ÛÔ‚·Ú‹˜ ·Ê˘‰¿ÙˆÛ˘ (·ÒÏÂÈ· ‚¿ÚÔ˘˜, ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜), Ì›·˜ ηٿÛÙ·Û˘ Ô˘ ÌÔÚ› Ó· ·Ô‰Âȯı› ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹, Â›Ó·È ÈÔ Û˘¯Ó¿ ÛÙË °ƒ. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙÔÓ Ì¤ÁÈÛÙÔ ·ÚÈıÌfi ÙˆÓ ˘ÔÏÔ›ˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·Ó¿ Ë̤ڷ Î·È ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘˜. ∂›Û˘, Û ËÏÈΛ· ˆ˜ 2 ÂÙÒÓ, Ë ‚·Ú‡ÙËÙ· Ù˘ °ƒ Î·È ÙÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁÒÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚ·. ™‡Ìʈӷ Î·È Ì ¿ÏϘ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È Ì›· ÚfiÛÊ·ÙË ÛÙËÓ πÛ·Ó›·, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ °ƒ ·ÊÔÚÔ‡Û ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÌÂٷ͇ 6 ÌËÓÒÓ Î·È 3 ÂÙÒÓ (3,9). ™˘ÓÂÒ˜, ¤Ó· ÂÌ‚fiÏÈÔ, ÙÔ Û¯‹Ì· ÙÔ˘ ÔÔ›Ô˘ ı· ÔÏÔÎÏËÚÒÓÂÙ·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Î·È ı· ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ¯ÚfiÓÈ·, ı· Â›Ó·È Î·Ù¿ÏÏËÏÔ ÁÈ· ÙÔÓ Ì·˙ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Î·È ÙËÓ ÚfiÏË„Ë Ù˘ Ïԛ̈͢ ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ô˘ ÎÈÓ‰˘Ó‡ÂÈ (10). ¶·È‰È·ÙÚÈ΋ 2007;70:395-401
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π. ∫·‚·ÏÈÒÙ˘ Î·È Û˘Ó.
∞fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ÚÔ·ÙÂÈ fiÙÈ Ë °ƒ Â›Ó·È 2,5 ÊÔÚ¤˜ Èı·ÓfiÙÂÚÔ Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·fi ÙË °∞. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÔÊ›ÏÂÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙˆÓ È‰ÈˆÙÈÎÒÓ È·ÙÚ›ˆÓ Ì °ƒ, ÙˆÓ ÔÔ›ˆÓ Ë ‰È¿ÌÂÛË ËÏÈΛ· ‹Ù·Ó ÌÈÎÚfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì °∞ (19 ¤Ó·ÓÙÈ 26 ÌËÓÒÓ), ÔÈ ÔÔ›ÔÈ ¯ÚÂÈ¿ÛıËÎ·Ó ÂÈÛ·ÁˆÁ‹ Û ÔÛÔÛÙfi 7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ (42,8 ¤Ó·ÓÙÈ 6%). ∞ÓÙÈı¤Ùˆ˜, Ù· ·È‰È¿ ÙˆÓ ∆∂¶ ÂÌÊ¿ÓÈÛ·Ó Û˘¯ÓfiÙÂÚ· ̤Û˘ ‹ ÛÔ‚·Ú‹˜ ‚·Ú‡ÙËÙ·˜ ÓfiÛÔ Î·È ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ (57-59%), ·ÓÂÍ·Úًو˜ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∆¤ÏÔ˜, Ù· ·È‰È¿ Ô˘ ÓfiÛËÛ·Ó ·fi °ƒ ÓÔÛËχıËÎ·Ó Î·Ù¿ ̤ÛÔÓ fiÚÔ 2 ·Ú·¿Óˆ Ë̤Ú˜, ÂÓÒ fiÛ· ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Â͈ÓÔÛÔÎÔÌÂȷο ¯ÚÂÈ¿ÛıËÎ·Ó Û˘¯ÓfiÙÂÚ· ÎÏÈÓÈ΋ ·ÓÂÎÙ›ÌËÛË. ŸÏ· Ù· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜ (11). ∏ °ƒ ¢ı‡ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚ· ¿ÌÂÛ· ¤ÍÔ‰· ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ·È‰ÈÒÓ ÏfiÁˆ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ Î·È ‰È¿ÚÎÂÈ·˜ Û˘Ìو̿وÓ, fiˆ˜ ÔÈ ¤ÌÂÙÔÈ Î·È ÔÈ ‰È¿ÚÚÔȘ (·ÁÔÚ¿ Á·Ï¿ÙˆÓ ÂχıÂÚˆÓ Ï·ÎÙfi˙˘, ηٷӿψÛË ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈıÌÔ‡ ·ÓÒÓ, ÂÚÈÛÛfiÙÂÚ˜ È·ÙÚÈΤ˜ ÂÈÛΤ„ÂȘ Î·È ¤ÍÔ‰· ÌÂٷΛÓËÛ˘). ŸÌˆ˜ Î·È ÁÈ· ÙÔ ™‡ÛÙËÌ· ¢ËÌfiÛÈ·˜ ÀÁ›·˜ Ë °ƒ ÎÔÛÙ›˙ÂÈ ÂÚÈÛÛfiÙÂÚÔ (ÂÚÈÛÛfiÙÂÚ˜ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂÚÈÛÛfiÙÂÚ˜ Ë̤Ú˜ ÓÔÛËÏ›·˜, ·Ó¿ÁÎË ıÂڷ›·˜ Ì ·ÚÂÓÙÂÚÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓ· ‰È·Ï‡Ì·Ù·, ÂÚÈÛÛfiÙÂÚ˜ È·ÙÚÈΤ˜ ÂÈÛΤ„ÂȘ) (12,13). ∆¤ÏÔ˜, Ë Ì¤ÛË ·ÒÏÂÈ· ËÌÂÚÒÓ ÂÚÁ·Û›·˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ (>3 Ë̤Ú˜). ∏ ÎÏÈÓÈ΋ ÂÈ‚¿Ú˘ÓÛË Ô˘ ÚÔηÏ› Ë °ƒ ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ Ô˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ¿ÏϘ ¯ÒÚ˜. ∏ Ïԛ̈ÍË ·fi ÚÔÙ·˚fi ·Ó·Ê¤ÚÂÙ·È ˆ˜ ÙÔ Û˘¯ÓfiÙÂÚÔ Î·È ÛÔ‚·ÚfiÙÂÚÔ ·›ÙÈÔ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 5 ÂÙÒÓ Û fiϘ ÙȘ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› ÛÙËÓ ∂˘ÚÒË, ·ÏÏ¿ Î·È Û ÂıÓÈΤ˜ ÌÂϤÙ˜ ÛÙË °ÂÚÌ·Ó›·, ÛÙË ¢·Ó›· Î·È ÛÙËÓ πÛ·Ó›· (3-6,9,14). ∏ Û˘¯ÓfiÙËÙ· Ù˘ °ƒ, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙÔ ÔÛÔÛÙfi ·Ó‡ÚÂÛ˘ ·ÓÙÈÁfiÓÔ˘ ÚÔÙ·˚Ô‡ Û ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 5 ÂÙÒÓ Ô˘ ÂÈÛΤÙÔÓÙ·È Ù· ∆∂¶ (45,7%) ‹ ÓÔÛËχÔÓÙ·È (49,1%) ÏfiÁˆ ÔÍ›·˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜, Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ ¿ÏÏˆÓ Â˘Úˆ·˚ÎÒÓ ÌÂÏÂÙÒÓ, fiÔ˘ Ù· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ Î˘Ì·›ÓÔÓÙ·È ·fi 45-60%. ∏ ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË Â›Ó·È Ë Û˘¯ÓfiÙËÙ· Ù˘ °ƒ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· (18%), ÙËÓ ÔÔ›· ÛÙË ¯ÒÚ· Ì·˜ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ¤¯Ô˘Ó ·Ó·Ï¿‚ÂÈ ÔÈ È‰ÈÒÙ˜ ·È‰›·ÙÚÔÈ, fiÔ˘ ÙÔ ÔÛÔÛÙfi Â›Ó·È ¯·ÌËÏfiÙÂÚÔ ·fi ÙÔÓ Ì¤ÛÔ Â˘Úˆ·˚Îfi fiÚÔ Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 25 ˆ˜ 40% (3,4,14). ∞˘Ùfi ÔÊ›ÏÂÙ·È Èı·ÓfiÓ, fiˆ˜ Ê¿ÓËÎÂ Î·È Ì ÙË ‚·ıÌÔÏfiÁËÛË Clark, ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ̤ÙÚÈ·˜ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, fiÔ˘ Ë °ƒ Â›Ó·È Û˘¯ÓfiÙÂÚË, ÚÔÛÎÔPaediatriki 2007;70:395-401
Ì›˙ÔÓÙ·È ·Â˘ı›·˜ ÛÙ· ∆∂¶ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ. µ¤‚·È·, Ë Û˘¯ÓfiÙËÙ· Ù˘ °ƒ, fiˆ˜ Î·È Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÈÔ‡, Î˘Ì·›ÓÂÙ·È ·fi ÂÔ¯‹ Û ÂÔ¯‹ Î·È ·fi ÂÚÈÔ¯‹ Û ÂÚÈÔ¯‹, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÂȉËÌÈÔÏÔÁÈ΋ ·Ú·Ù‹ÚËÛË Î·È Û ¿ÏϘ ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜, ȉ›ˆ˜ ¯ÂÈÌÂÚÈÓ¤˜, ÁÈ· Ó· ¤¯Ô˘Ì ·ÎÚÈ‚¤ÛÙÂÚË ÂÈÎfiÓ· Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ÛÙË ¯ÒÚ· Ì·˜ (5,15). ™ÙË ÌÂϤÙË ‰ÂÓ ‰ÈÂÚ¢ӋıËÎÂ Ë Û˘¯ÓfiÙËÙ· Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ °ƒ, Ë ÔÔ›· ¢ı‡ÓÂÙ·È ÁÈ· ¿Óˆ ·fi ÙÔ ‹ÌÈÛ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Û ·È‰È¿ ËÏÈΛ·˜ ˆ˜ 5 ÂÙÒÓ (16). ÕÏÏ· ÂÚÈÛÙ·ÙÈο Ô˘ ‰ÂÓ Û˘Ó˘ÔÏÔÁ›ÛÙËÎ·Ó ‹Ù·Ó fiÛ· ¤Ï·‚·Ó ÙËÏÂʈÓÈΤ˜ Ô‰ËÁ›Â˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ÌÂϤÙË ‰ÂÓ ÂÚȤϷ‚ fiÏÔ˘˜ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ ÌÔÚ› Ó· ˘ÔÙ›ÌËÛ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘. ∂ӉȷʤÚÔÓ ı· ›¯Â Ó· ÚÔÛ‰ÈÔÚÈÛıÔ‡Ó Î·È ÔÈ ÔÚfiÙ˘ÔÈ ÙÔ˘ ÚÔÙ·˚Ô‡. µ¤‚·È·, ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÁÈ· ÔÛÔÛÙ¿ ÌÂÁ·Ï‡ÙÂÚ· ÙÔ˘ 98% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â˘ı‡ÓÔÓÙ·È 5 ÔÚfiÙ˘ÔÈ ÚÔÙ·˚Ô‡ (G1P[8], G2P[4], G3P[8], G4P[8] Î·È G9P[8]), ÔfiÙÂ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ Ë ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÔÚÔÙ‡ˆÓ ÙÔ˘ ÚÔÙ·˚Ô‡ Ó· Â›Ó·È ·ÚfiÌÔÈ· Î·È ÛÙË ¯ÒÚ· Ì·˜ (14). ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÚÔÙ·˚fi Î·È ÛÙË ¯ÒÚ· Ì·˜, Î·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÂϤÙ˜ ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ ı· ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ·ÛÊ·ÏÔ‡˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘, ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Î·È Ù˘ ÎÔÈÓˆÓÈ΋˜ Î·È ÔÈÎÔÓÔÌÈ΋˜ ÂÈ‚¿Ú˘ÓÛ˘ Ô˘ ÚÔηÏ›.
∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙÔ˘˜ ·Ú·Î¿Ùˆ ·È‰È¿ÙÚÔ˘˜, ̤ÏË Ù˘ √Ì¿‰·˜ ªÂϤÙ˘ ROTASCORE*, ÁÈ· ÙË ÛËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙË ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ (ηٿ ·ÏÊ·‚ËÙÈ΋ ÛÂÈÚ¿): ∞ÁÁÂÏ¿ÎÔ˘ µ·ÛÈÏÈ΋, µ·ÛÈÏ¿ÎË-°·Ú˘Ê·Ï¿ÎË ∂ÈÚ‹ÓË, µÏ·¯¿ÎË °ÂˆÚÁ›·, µÚÂÙ¿ÎÔ˘ µÂÓÂÙ›·, °·Ù›‰Ë˜ ¡¤ÛÙÔÚ·˜, °ÂÚÔÁÈ¿ÓÓ˘ ÃÚ‹ÛÙÔ˜, °ÂˆÚÁ·ÎfiÔ˘ÏÔ˘ £Â·ÓÒ, °È·ÓӷΛ‰Ô˘-∫Ô˘ÊÔÁÈ¿ÓÓË ª·Ú›·, °È·ÓÓ·ÎfiÔ˘ÏÔ˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, °È·ÓÓ·ÎfiÔ˘ÏÔ˜ ¶·Ó·ÁÈÒÙ˘, °È‰¿Ú˘ ¢‹ÌÔ˜, °ÚÈ‚¿ÎË ª·Ú›·, ¢Â‰Ô‡ÎÔ˘ •·Óı‹, ¢Ú¿ÎÔ˘ ∞Ó·ÛÙ·Û›·, ∑·ÚÁ¿Ó˘ ¢È·ÁfiÚ·˜, ∑˘ÁÔÁÈÒÚÁÔ˜ ∞ÛÙ¤ÚÈÔ˜, £ˆÌ·˝‰Ô˘ ∞Á·ı‹, ∫·ÂÙ·Ó¿Î˘ °ÈÒÚÁÔ˜, ∫·Ú·ÓÙÈÓfi˜ °ÈÒÚÁÔ˜, ∫·Ú‡‰Ë˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∫Ï¿ÓıÔ˘˜ ¶fiÏ˘˜, ∫ÔÌÌ·Ù¿˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∫Ô˘ÙÛfi˜ ¶·Ó·ÁÈÒÙ˘, ∫ˆÛÙfiÔ˘ÏÔ˜ ∂ÌÌ·ÓÔ˘‹Ï, §˘ÁÂÚÔ‡ª·Ó›Î· ¢¤ÛÔÈÓ·, §ÒÏ˘ £ÂÔ¯¿Ú˘, ª·ÓÙ¿-∫·ÏÔÌÂÓÔÔ‡ÏÔ˘ ÃÚÈÛÙ›Ó·, ª·ÓÙ·Áfi˜ ™Ù¤Ê·ÓÔ˜, ª¿ÓÙ˙ÈÔ˘ £ÂÔ‰ÒÚ·, ª·Ú·ÁÎÔ˘‰¿ÎË ∂ϤÓË, ªÂÏ¿˜ °ÚËÁfiÚÈÔ˜, ªÂÓ¤ÎÔ˜ ¶¤ÙÚÔ˜, ª¤Û˘ ™ˆÙ‹ÚÈÔ˜, ªÔ˘ÛÌԇ΢ πˆ¿ÓÓ˘, ¡ÈÎÔÏ¿Ô˘-ƒ·ÌÔÙ¿ ª·Ú›·, ¡ÈÎÔÏÔ˘‰¿Î˘ ¡ÈÎfiÏ·Ô˜, ¡ÈˆÙ¿Î˘ °ÈÒÚÁÔ˜, √ÏÔÔÈ¿‰Ô˘ ¶fiË, √ÚÊ·ÓÔ‡ ª·Ú›·, ¶·Ó¿ÁÔ˜ ∞ÓÙÒÓÈÔ˜, ¶·ÓÙÂÏ‹-ÃÚÈÛÙÔÔ‡ÏÔ˘ §›ÏÈ·Ó, ¶··‰ÔÔ‡ÏÔ˘ µËıϤÌ, ¶··Ó‰Ú¿‰Ë-ª¤Ê· ™ÔÊ›·, ¶··ÛÙ·Ì·Ù›Ô˘ µ·Û›ÏÂÈÔ˜, ¶·Ú›Û˘ ¶·Ó·ÁÈÒÙ˘, ¶·ÙÚÒÓË ∞ıËÓ¿,
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¶ÂÚ‰ÈÎÔÁÈ¿ÓÓ˘ ªËÓ¿˜, ¶ËÚÔ˘Ó¿ÎË-¢·ÚÈ‚È·Ó¿ÎË ∂‡Ë, ¶ÈÙÛÈÏ›‰Ô˘ ∂ÈÚ‹ÓË, ¶Ïȿη˜ ¢ËÌ‹ÙÚÈÔ˜, ™È·Ê¿Î·˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∆˙¿ÏÏ·˜ ¢ËÌ‹ÙÚÈÔ˜, ∆Ú›Îη °ÈԇϷ, º¿ÎÔ˜ ¶·Ó·ÁÈÒÙ˘, º·Ú¿¯ ∆˙ÒÚÙ˙, ÷ڛÙÔ˘ ∞ÓÙˆÓ›·, æ·ı¿-ª·˙Ì¿ÓË ª·Ú›·. ∂›Û˘ ¢¯·ÚÈÛÙԇ̠ÙȘ º·Ú̷΢ÙÈΤ˜ ∂Ù·ÈÚ›˜ µπ∞¡∂• Î·È Sanofi Pasteur MSD ÁÈ· ÙË ‰ˆÚÂ¿Ó ¯ÔÚ‹ÁËÛË ÙˆÓ kit ·Ó›¯Ó¢Û˘ ÙÔ˘ ÚÔÙ·˚Ô‡ ÛÙ· ÎfiÚ·Ó·.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9:565-572. 2. Haffejee IE. The epidemiology of rotavirus infections: a global perspective. J Pediatr Gastroenterol Nutr 1995;20: 275-286. 3. The Pediatric ROTavirus European CommitTee (PROTECT). The paediatric burden of rotavirus disease in Europe. Epidemiol Infect 2006;134:908-916. 4. Soriano-Gabarro M, Mrukowicz J, Vesikari T, Verstraeten T. Burden of rotavirus disease in European Union countries. Pediatr Infect Dis J 2006;25:S7-S11. 5. Ehlken B, Laubereau B, Karmaus W, Petersen G, Rohwedder A, Forster J, RoMoD Study Group. Prospective population-based study on rotavirus disease in Germany. Acta Paediatr 2002; 91:769-775. 6. Fischer TK. Incidence of hospitalizations due to rotavirus gastroenteritis in Denmark. Acta Paediatr 2001;90:10731075. 7. Koopmans M, Brown D. Seasonality and diversity of group A rotaviruses in Europe. Acta Paediatr 1999;88 (Suppl): 14-19. 8. Clark HF, Bernstein DI, Dennehy PH, Offit P, Pichichero M, Treanor J, et al. Safety, efficacy and immunogenicity of a live, quadrivalent, human-bovine reassortant rotavirus vaccine in healthy infants. J Pediatr 2004;144:184-190.
9. Diez-Domingo J, Martin IO, Sanz AB, Lopez AG, Martinez CC, Boronat CP, et al. Rotavirus gastroenteritis among children under five years of age in Valencia, Spain. Pediatr Infect Dis J 2006;25:455-457. 10. Vesikari T, Matson DO, Dennehy P, Van Damme P, Santosham M, Rodriguez Z, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23-33. 11. Berner R, Schumacher RF, Hameister S, Forster J. Occurrence and impact of community-acquired and nosocomial rotavirus infections-a hospital-based study over 10 y. Acta Paediatr 1999;88 (Suppl):S48-S52. 12. Piednoir E, Bessaci K, Bureau-Chalot F, Sabouraud P, Brodard V, Andreoletti L, et al. Economic impact of healthcare-associated rotavirus infection in a paediatric hospital. J Hosp Infect 2003;55:190-195. 13. Harrington M, Butler K, Cafferkey M. Rotavirus infection in hospitalised children: incidence and impact on healthcare resources. Ir J Med Sci 2003;172:33-36. 14. Giaquinto C, Gothefors L, Huet F, Hulbe C, Paricio Talayero J, Tomas Vila M et al. Burden of paediatric rotavirus gastroenteritis at hospital and primary care levels in seven European countries: Results from REVEAL study [∞bstract]. Presented at 24th Annual Meeting of ESPID, Basel, May 3-5, 2006. 15. Rosenfeldt V, Vesikari T, Pang XL, Zeng SQ, Tvede M, Paerregaard A. Viral etiology and incidence of acute gastroenteritis in young children attending day-care centers. Pediatr Infect Dis J 2005;24:962-965. 16. Gleizes O, Desselberger U, Tatochenko V, Rodrigo C, Salman N, Mezner Z et al. Nosocomial rotavirus infection in European countries: a review of the epidemiology, severity and economic burden of hospital-acquired rotavirus disease. Pediatr Infect Dis J 2006;25:S12-S21.
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1 ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 2 √ÚıÔ‰È΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 3 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 4 ∞’ √ÚıÔ‰È΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 5 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”. AÏÏËÏÔÁÚ·Ê›·: ∞ı·Ó¿ÛÈÔ˜ ÷Ù˙ËÌȯ·‹Ï, dimalexpoli@yahoo.com ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ ¢‹ÌËÙÚ·˜ 19, ∆.∫. 68 100, ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏË
CASE REPORT
º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ (·ʈÛË Pott) Û ÓËȷ΋ ËÏÈΛ· ¢. Ã. ∫·Û›ÌÔ˜1, ¢. §·˙ÔÔ‡ÏÔ˘5, Õ. ∆Û·ÏΛ‰Ë˜1, ¢. µÂÚ¤ÙÙ·˜2, Ÿ. §ÂˆÓ›‰Ô˘4, ∞. √ÈÎÔÓfiÌÔ˘3, ¡. §·˙ÔÔ‡ÏÔ˘5, ª. £ÂÔ‰ˆÚ›‰Ô˘5, ∞. ÷Ù˙ËÌȯ·‹Ï1 ¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ ÙÔ˘ Pott ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ Ê˘Ì·Ù›ˆÛ˘ ÙˆÓ ÔÛÙÒÓ Î·È ÙˆÓ ·ÚıÚÒÛˆÓ. ∂ÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙË ıˆÚ·ÎÈ΋ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÛÙËÓ ÔÛÊ˘˚΋ Î·È ÙËÓ ·˘¯ÂÓÈ΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∂ΉËÏÒÓÂÙ·È Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘, fiÓÔ˘ Î·È Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. √ ˘ÚÂÙfi˜ ‰ÂÓ ·ÔÙÂÏ› Û˘¯Ófi Û‡Ìو̷ Ù˘ ÓfiÛÔ˘. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ı‹ÏÂÔ˜, ËÏÈΛ·˜ 2 ¯ÚfiÓˆÓ, ·ıÈÁÁ·ÓÈ΋˜ ηٷÁˆÁ‹˜, Ô˘ ÓÔÛËχÙËΠÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ ÁÈ· ‰ÈÂÚ‡ÓËÛË ‡‚Ô˘ ÛÙË ıˆÚ·ÎÈ΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. √ ‡‚Ô˜ ·ÚÔ˘ÛÈ¿ÛÙËΠ·ÈÊÓ›‰È· 10 Ë̤Ú˜ ÚÈÓ ·fi ÙËÓ ÚÔÛ¤ÏÂ˘Û‹ Ù˘ ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ¯ˆÚ›˜ Ó· ·Ó·Ê¤ÚÔÓÙ·È ¿ÏÏ· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. ∏ ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÛÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË Ì ·/· ıÒڷη, ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ÛÙË ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux. ™ÎÔfi˜ Ù˘ ·ÚÔ˘Û›·Û˘ Â›Ó·È Ó· ÙÔÓÈÛı› Ë Û¿ÓÈ· ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Û ÌÈÎÚ‹ ËÏÈΛ· Ì ·Ô˘Û›· Ó¢ÚÔÏÔÁÈÎÒÓ ‹ ¿ÏÏˆÓ ÚÒÈÌˆÓ ·ıÔÏÔÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ë Î·Ï‹ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ·fi ‰ÈÂÙ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ıÂڷ›·.
§¤ÍÂȘ ÎÏÂȉȿ: º˘Ì·Ù›ˆÛË ÔÛÙÒÓ, ÛÔÓ‰˘Ï›ÙȘ, ÊÏÂÁÌÔÓ‹ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ·ʈÛË Pott.
Tuberculous spondylitis (Pott’s kyphosis) in a toddler 1 University Paediatric Clinic of the Hospital of Alexandroupolis 2 Orthopedic Clinic of the Hospital of Alexandroupolis 3 Radiology Department of the Hospital of Alexandroupolis 4 First Orthopedics Clinic of the “Aghia Sophia” Children’s Hospital 5 First Paediatric Clinic of the University of Athens, “Aghia Sophia” Children’s Hospital Correspondence: Athanassios Hatzimihail, dimalexpoli@yahoo.com Paediatric Clinic of Peripheral General Hospital of Alexandroupolis 19, Dimitra St. 68 100, Alexandroupolis, Greece
D.H. Kasimos1, D. Lazopoulou5, A. Tsalkidis1, D. Verettas2, O. Leonidou4, A. Oikonomou3, N. Lazopoulou5, M. Theodoridou5, A. Hatzimihail1 Abstract: Pott’s disease is the most common form of bone and joint tuberculosis. It is usually localized in the thoracic region and less commonly in the lumbar and the cervical regions of the spine. The presenting symptoms are a hump, pain and neurological findings. Fever is not a common symptom of Pott’s disease. The case of a 2 year-old girl is described, who was hospitalized for a hump in the thoracic region of the spine that had appeared 10 days before admission, without neurological symptoms. The diagnosis was based on the clinical presentation, the findings on the chest X-ray, CT scan and MRI, and on the positive PPD tuberculin skin test. The favourable outcome after treatment is discussed. Key words: Bone tuberculosis, Pott’s disease, spondylitis, spinal infection.
™˘ÓÙÔÌÔÁڷʛ˜ ·/· ∞ª™™ £ª™™ √ª™™ ∆∫∂ ™™ ∆∂¶ £9-£10 C/T MRI ¢.¢. Ê.Ù.
∞Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ∞˘¯ÂÓÈ΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ £ˆÚ·ÎÈ΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ √ÛÊ˘˚΋ ÌÔ›Ú· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ∆·¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ™ÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ∆Ì‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ 9Ô˜ Î·È 10Ô˜ ıˆÚ·ÎÈÎfi˜ ÛfiÓ‰˘ÏÔ˜ ∞ÍÔÓÈ΋ ∆ÔÌÔÁÚ·Ê›· ª·ÁÓËÙÈ΋ ∆ÔÌÔÁÚ·Ê›· ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË º˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜
∂ÈÛ·ÁˆÁ‹ ∏ Ê˘Ì·Ù›ˆÛË ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ ÙÔ˘ Ï·Ó‹ÙË. ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· √ÚÁ¿ÓˆÛË ÀÁ›·˜ (¶.√.À.), ÙÔ 1/3 ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ ¤¯ÂÈ ÌÔÏ˘Óı› ·fi ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Paediatriki 2007;70:402-407
Ù›ˆÛ˘ Î·È Î¿ı ¯ÚfiÓÔ ÓÔÛÔ‡Ó 8-10 ÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ÏÔÈÌ҉˜ ·›ÙÈÔ ı·Ó¿ÙÔ˘ Û ӤԢ˜ ÂÓ‹ÏÈΘ Î·È ˘Â‡ı˘ÓÔ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 100.000 ı·Ó¿ÙÔ˘˜ ·È‰ÈÒÓ ·ÁÎÔÛÌ›ˆ˜ (1). ™ÙËÓ ∂ÏÏ¿‰·, Ë ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· Â›Ó·È 51/100.000 ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È Ë ·È‰È΋ ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· 11,6/100.000. ™ÙËÓ ÂÚÈʤÚÂÈ· Ù˘ £Ú¿Î˘, Ë ÂÙ‹ÛÈ· ÓÔÛËÚfiÙËÙ· Â›Ó·È 37,8/100.000. ¶·ÚfiÏÔ Ô˘ Û¯ÂÙÈο ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÛÙË µ. ∂ÏÏ¿‰· ¤‰ÂÈ¯Ó·Ó Ì›· Ù¿ÛË Ì›ˆÛ˘ ÙÔ˘ Ê˘Ì·ÙÈÓÈÎÔ‡ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ (2), Ë ·ÏÏ·Á‹ Ù˘ Û‡ÛÙ·Û˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÏfiÁˆ Ù˘ ÌÂÙ·Ó¿ÛÙ¢Û˘ ͷӷʤÚÓÂÈ ÙÔ Úfi‚ÏËÌ· ÛÙËÓ ÂÈÊ¿ÓÂÈ·. ª›· ·fi ÙȘ Û·ÓÈfiÙÂÚ˜ ÂÓÙÔ›ÛÂȘ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË. ™ÎÂÏÂÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û˘Ì‚·Ù¤˜ ÌÂ Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ· ¤¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› ÛÙËÓ ∞›Á˘ÙÔ Û ÌÔ‡ÌȘ
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º˘Ì·ÙÈ҉˘ ÛÔÓ‰˘Ï›ÙȘ
ËÏÈΛ·˜ 5000 ÂÙÒÓ Î·È Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È ·fi ÙÔÓ πÔÎÚ¿ÙË. ∏ ÓfiÛÔ˜ ÂÚÈÁÚ¿ÊËΠˆ˜ ͯˆÚÈÛÙ‹ ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· ÙÔ 1779 ·fi ÙÔÓ Percival Pott, Î·È ¤ÎÙÔÙ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙË Ê˘Ì·Ù›ˆÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∏ ‚Ï¿‚Ë ÂÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ £ª™™ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÛÙË √ª™™ ‹ ∞ª™™. ∏ ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘, fiÓÔ˘, „ËÏ·ÊËÙ‹˜ Ì¿˙·˜ Î·È Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·. √ ˘ÚÂÙfi˜ ‰ÂÓ ·ÔÙÂÏ› Û˘¯Ófi Û‡Ìو̷ Ù˘ ÓfiÛÔ˘. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux Â›Ó·È Û˘Ó‹ıˆ˜ ıÂÙÈ΋, ÂÓÒ Ë ∆∫∂ Â›Ó·È ˘„ËÏ‹ ÌfiÓÔ ÛÙÔ 35% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ ·ÔÌfiÓˆÛË ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ·fi ÙÔ˘˜ ÈÛÙÔ‡˜, Ù· Ù‡ÂÏ· Î·È ÙÔ Á·ÛÙÚÈÎfi ˘ÁÚfi (3). ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙ· ÌÂÁ¿Ï· ·È‰È¿ Î·È Û ӤԢ˜ ÂÊ‹‚Ô˘˜, ÂÓÒ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ Û ÂÓ‹ÏÈΘ. ™ÙËÓ ∂ÏÏ¿‰· ˘¿Ú¯Ô˘Ó Ï›Á˜ ·Ó·ÊÔÚ¤˜, ΢ڛˆ˜ ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ‰ÂηÂٛ˜, Ì ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ ÛÙË ™™.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ËÏÈΛ·˜ 2 ÂÙÒÓ, ÌÔ˘ÛÔ˘ÏÌ¿Ó· ·ıÈÁÁ·ÓÈ΋˜ ηٷÁˆÁ‹˜, ÚÔÛÎÔÌ›ÛıËΠÛÙ· ∆∂¶ ÏfiÁˆ ·ÈÊÓ›‰È·˜
∞
ÂÌÊ¿ÓÈÛ˘ ÁˆÓÈÒ‰Ô˘˜ ‡‚Ô˘ ÛÙË £ª™™ ·fi 10Ë̤ÚÔ˘. ∂›Ó·È ÙÔ ÙÚ›ÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi, ›¯Â ÔÌ·Ï‹ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË, ηϋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÂχıÂÚÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi. ™ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ‡‚Ô˜ ÛÙÔ ‡„Ô˜ ÙˆÓ £9-£10 Ù˘ ™™. ∞fi ÙËÓ ˘fiÏÔÈË ÂͤٷÛË ‰ÂÓ ˘‹Ú¯·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË Î·Ù¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÛıËÙÈÎfiÙËÙ·, ÎÈÓËÙÈÎfiÙËÙ· Î·È Ì˘˚΋ ÈÛ¯‡ ¿Ìʈ. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux, ÌÂÙ¿ 48 ÒÚ˜, ‹Ù·Ó ıÂÙÈ΋ Ì ÙÔÈ΋ ‰È‹ıËÛË 16mm. √ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (ÁÂÓÈ΋ ·›Ì·ÙÔ˜- ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜) ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ∆∫∂ ‹Ù·Ó 75 mm/1h Î·È Ë CRP 3,72mg/L (Ê.Ù.<1). Hb 10,5gr%, Ht 33,2%. §Â˘Î¿ 13.400/ÌL (¶62% §30% ª6%). ∞ÈÌÔÂÙ¿ÏÈ· 460.000/ÌL, ۿί·ÚÔ 80mg/dL, Ô˘Ú›· 27mg/dL, ÎÚ·ÙÈÓ›ÓË 0,7mg/dL, Na 138 mEq/L, K 40mEq/L, SGOT 29U/L (Ê.Ù. 15-48U/L), SGPT 45U/L (Ê.Ù. 15-48U/L), ÔÏÈο Ï¢ÎÒÌ·Ù· 7,6 g/L, ·Ï‚Ô˘Ì›ÓË 4,5 g/L. ™ÙËÓ ÔÈÛıÔÚfiÛıÈ· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη (∂ÈÎfiÓ· 1) ·Ú·ÙËÚ‹ıËΠÔÈÛıÔηډȷ΋ ÛΛ·ÛË Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÒıËÛË ÙˆÓ ·Ú·ÛÔÓ‰˘ÏÈÎÒÓ
B
∂ÈÎfiÓ· 1. √ÈÛıÔÚfiÛıÈ· (·) ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ·ÒıËÛË ÙˆÓ ·Ú·ÛÔÓ‰˘ÏÈÎÒÓ ÁÚ·ÌÌÒÓ ·fi ÙË Ì¤ÛË ÁÚ·ÌÌ‹ ¿Ìʈ ÛÙË ÌÂÛfiÙËÙ· Ù˘ ıˆÚ·ÎÈ΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ‰ÈfiÁΈÛË Ù˘ ‰ÂÍÈ¿˜ ·Ú·ÙÚ·¯Âȷ΋˜ ¯ÒÚ·˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ‡Ï˘ Î·È ·Û·Ê‹˜ ‡ÎÓˆÛË ÛÙÔÓ Ì¤ÛÔ ÏÔ‚fi. ¶Ï¿ÁÈ· (‚) ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ™ÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘. ¶·È‰È·ÙÚÈ΋ 2007;70:402-407
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¢. Ã. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
ÁÚ·ÌÌÒÓ ÚÔ˜ Ù· ¤Íˆ, ‰ÈfiÁΈÛË Ù˘ ‰ÂÍÈ¿˜ ·Ú·ÙÚ·¯Âȷ΋˜ ¯ÒÚ·˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ‡Ï˘ ÌÂ Û˘ÓÔ‰fi ‡ÎÓˆÛË ÛÙÔ ‰ÂÍÈfi ̤ÛÔ Ó¢ÌÔÓÈÎfi ‰›Ô. ∂ÈϤÔÓ, ÛÙËÓ Ï¿ÁÈ· ·ÎÙÈÓÔÁÚ·Ê›· ·ÂÈÎÔÓ›ÛÙËÎÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘. ∏ ηÏÏȤÚÁÂÈ· Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ‚¿ÎÈÏÏÔ Koch. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη (∂ÈÎfiÓ· 2) ·Ó·‰Â›¯ıËÎ·Ó ÂÎÛÂÛËÌ·Ṳ̂ÓË ‰ÂÍÈ¿ ·Ú·ÙÚ·¯Âȷ΋ Î·È ‰ÂÍÈ¿ ˘Ï·›· ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Ì ÔÏϷϤ˜ ·‰Ú¤˜ ·ۂÂÛÙÒÛÂȘ Î·È ‡ÎÓˆÛË ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡. ™ÙÔ Â›Â‰Ô ÙÔ˘ £10 ·Ú·ÙËÚ‹ıËΠ‰È¿‚ÚˆÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ Î·È ÌÂÚÈο ÂηÙÔÛÙ¿ ¯·ÌËÏfiÙÂÚ· ·fi ·˘ÙfiÓ ÙÔÓ ÛfiÓ‰˘ÏÔ ÚÔÛÔÓ‰˘ÏÈ΋ Î·È ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Ì ÛÙÈÎÙ¤˜ ·ۂÂÛÙÒÛÂȘ (·fiÛÙËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Û ÂÁοÚÛÈÔ Î·È Ô‚ÂÏÈ·›Ô Â›Â‰Ô Ì ÂÈÎfiÓ˜ ∆1 Î·È ∆2 ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ (∂ÈÎfiÓ· 3·) ·Ó¤‰ÂÈÍ ÙËÓ Î˘ÊˆÙÈ΋ ·Ú·ÌfiÚʈÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÏfiÁˆ ÛÊËÓÔÂȉԇ˜ ·Ú·-
∂ÈÎfiÓ· 2. ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη. ™ÙÔ Â›Â‰Ô ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡ ·Ó·‰ÂÈÎÓ‡ÂÙ·È ‡ÎÓˆÛË ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡ Ô˘ Û˘Ó¤¯ÂÙ·È Ì ÙË ‰ÂÍÈ¿ ‡ÏË Ì¤Û· ÛÙËÓ ÔÔ›· ·Ú·ÙËÚÔ‡ÓÙ·È Î·È ·‰Ú¤˜ ··Û‚ÂÛÙÒÛÂȘ. Paediatriki 2007;70:402-407
ÌfiÚʈÛ˘ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ Î·È ‹È· ·Û·ÊÔÔ›ËÛË ÙÔ˘ ˘ÂÚÎÂÈ̤ÓÔ˘ £9-£10 ÌÂÛÔÛÔÓ‰˘Ï›Ô˘ ‰›ÛÎÔ˘. ∞Ó·‰Â›¯ıËÎÂ, ›Û˘, Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ (˘„ËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì· Û ·ÎÔÏÔ˘ı›Â˜ ∆2 Î·È ¯·ÌËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì· Û ∆1 ·ÎÔÏÔ˘ı›Â˜ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡), Ë ÔÔ›· ÂÂÎÙÂÈÓfiÙ·Ó Î·È ÔÈÛı›ˆ˜ ÛÙÔÓ ÂÈÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ, Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙·-·fiÛÙËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ. ™ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ô ·Ù¤Ú·˜, ËÏÈΛ·˜ 31 ¯ÚfiÓˆÓ, ›¯Â ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË ÙˆÓ Ó¢ÌfiÓˆÓ Ì ηÏÏȤÚÁÂÈ· Ù˘¤ÏˆÓ ıÂÙÈ΋ ÁÈ· ‚.Koch Î·È ÂÙ¤ıË Û ÙÚÈÏ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ıÂڷ›·. ∏ ÌËÙ¤Ú·, ËÏÈΛ·˜ 25 ¯ÚfiÓˆÓ, ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· Ïԛ̈ÍË ·fi Ê˘Ì·Ù›ˆÛË. ∆· ‰‡Ô ·‰¤ÏÊÈ· Ù˘ ·ÛıÂÓÔ‡˜ (ËÏÈΛ·˜ 6 Î·È 4 ¯ÚfiÓˆÓ) ›¯·Ó ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux, ¯ˆÚ›˜ ·ÎÙÈÓÔÏÔÁÈο ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ¯ÔÚËÁ‹ıËΠÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ì ÈÛÔÓÈ·˙›‰Ë ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 9 ÌËÓÒÓ. ∞fi Ù· ÎÏÈÓÈο Î·È ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ ·È‰› Î·È ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙËÓ ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË ÙÔ˘ ·Ù¤Ú· ÂÙ¤ıË Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÙÔ˘ Pott. ∏ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛıËΠ̠ÙÚÈÏ‹ ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ (ÚÈÊ·ÌÈΛÓË, ÈÛÔÓÈ·˙›‰Ë Î·È ˘Ú·˙ÈÓ·Ì›‰Ë) ÁÈ· 6 Ì‹Ó˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰ÈÏ‹ (ÚÈÊ·ÌÈΛÓË Î·È ÈÛÔÓÈ·˙›‰Ë) ÁÈ· 18 Ì‹Ó˜. ∂ÈϤÔÓ, ÙÔÔıÂÙ‹ıËΠÂȉÈÎfi˜ Ó¿ÚıËη˜ ÛÙ‹ÚÈ͢ Ù˘ ıˆÚ·ÎÈ΋˜ ÌÔ›Ú·˜ Ù˘ ™™. ∆Ô ·È‰› ·Ú·¤ÌÊıËΠÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “∞Á›· ™ÔÊ›·” ÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÁÈ· ÂÈϤÔÓ Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙ›ÌËÛË, fiÔ˘ Û˘ÓÂÛÙ‹ıË Ë Û˘Ó¤¯ÈÛË Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜. ∫·Ù¿ ÙÔÓ Ù·ÎÙÈÎfi ·ӤÏÂÁ¯Ô ·fi ÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √ ·ӤÏÂÁ¯Ô˜ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ η٤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, ÂÓÒ ·Ú¤ÌÂÈÓÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ (∂ÈÎfiÓ· 3‚). ∏ ·Ú·ÌfiÚʈÛË Ù˘ ™™ Ì ۯËÌ·ÙÈÛÌfi ‡‚Ô˘ ·Ú¤ÌÂÈÓ ÛÙ·ıÂÚ‹ ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË Î·È ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ‹ ¿ÏϘ ÂÈÏÔΤ˜ (∂ÈÎfiÓ· 4). ∏ ‰È·ÎÔ‹ Ù˘ ·ÁˆÁ‹˜ Î·È Ë ·Ê·›ÚÂÛË ÙÔ˘ ÂȉÈÎÔ‡ Ó¿ÚıËη ¤ÁÈÓ ÌÂÙ¿ ·fi 2 ¯ÚfiÓÈ·, ÂÓÒ Ë ·ÛıÂÓ‹˜ Â›Ó·È Û Ôχ ηϋ ηٿÛÙ·ÛË Î·È Ì ÈηÓÔÔÈËÙÈ΋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË.
™˘˙‹ÙËÛË ∏ Ê˘Ì·Ù›ˆÛË ·Ú·Ì¤ÓÂÈ ¤Ó· ÛÔ‚·Úfi Úfi‚ÏËÌ· ˘Á›·˜ ÁÈ· ÙËÓ ¯ÒÚ· Ì·˜, ȉȷ›ÙÂÚ· ÁÈ· ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ Ì ηΤ˜ Û˘Óı‹Î˜ ˘ÁÈÂÈÓ‹˜, fiˆ˜ ÔÈ ÔÈÎÔÓÔÌÈÎÔ› ÌÂÙ·Ó¿ÛÙ˜ Î·È ¿ÏϘ ÎÔÈÓˆÓÈΤ˜ ÔÌ¿‰Â˜ Ù˘ ¯ÒÚ·˜ Ì·˜ Ì ¯·ÌËÏfi ‚ÈÔÙÈÎfi ›‰Ô.
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∂ÈÎfiÓ· 3. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ıˆÚ·ÎÔÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (™™) Û ԂÂÏÈ·›Ô Â›Â‰Ô Ì ÂÈÎfiÓ· ∆2 ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡. ¶·Ú·ÙËÚÂ›Ù·È ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË Î·È Î·ı›˙ËÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ £10 ÛÔÓ‰‡ÏÔ˘ Ì ›ÂÛË Â› ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Î·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·ʈÛË Ù˘ ™™, ηıÒ˜ Î·È ·ÚÔ˘Û›· ·ÏÏÔ›ˆÛ˘ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ ∆2 Û‹Ì·ÙÔ˜ ÚÔÛÔÓ‰˘ÏÈο („˘¯Úfi ·fiÛÙËÌ·) (·), Ë ÔÔ›· Û ·ӤÏÂÁ¯Ô 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ıÂڷ›·˜ ÂÏ·ÙÙÒıËΠÛËÌ·ÓÙÈο Û ̤ÁÂıÔ˜ (‚).
∏ ÓfiÛÔ˜ ÙÔ˘ Pott ÚÔηÏÂ›Ù·È ·fi ÙËÓ ·ÈÌ·ÙÔÁÂÓ‹ ‰È·ÛÔÚ¿ ÙˆÓ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ Ù˘ Ê˘Ì·Ù›ˆÛ˘, ΢ڛˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚˆÙÔ·ıÔ‡˜ Ïԛ̈͢. ™·ÓÈfiÙÂÚ·, ÌÔÚ› Ó· ÚÔÎÏËı› ÌÂÙ¿ ·fi Û˘ÁÁÂÓ‹ Ïԛ̈ÍË ‹ ÌÂÙ¿ ·fi Ï¢ڛÙȉ· Î·È ÏÂÌÊÔÁÂÓ‹ ‰È·ÛÔÚ¿. ™ÙË Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ·, Û˘Ó‹ıˆ˜, Ë ‚Ï¿‚Ë ÍÂÎÈÓ¿ÂÈ ÛÙÔ ÚfiÛıÈÔ ÙÌ‹Ì· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ ˘Ô¯ÔÓ‰Ú›ˆ˜ ÛÙËÓ ÂÈÊ˘Ûȷ΋ Ͽη, Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂÂÎÙ›ÓÂÙ·È Î¿Ùˆ ·fi ÙÔÓ ÚfiÛıÈÔ ÂÈÌ‹ÎË Û‡Ó‰ÂÛÌÔ ÛÙ· Á‡Úˆ ̷Ϸο ÌfiÚÈ·, ‰È·‚ÚÒÓÔÓÙ·˜ ÙËÓ ÚfiÛıÈ· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘. ∆Ë ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ·ÎÔÏÔ˘ı› Ë ·Ó¿Ù˘ÍË ÎÔÎÎȈ̷ÙÒ‰Ô˘˜ ÈÛÙÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰È¿‚ÚˆÛË Î·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·ÎÔÏÔ˘ı› ‚Ú·‰‡ÙÂÚË ÔÚ›· Û ۯ¤ÛË Ì ÙËÓ ˘ÔÁfiÓÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, ÏfiÁˆ ÌË ·Ú·ÁˆÁ‹˜ ÚˆÙÂÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ∏ ÊÏÂÁÌÔÓ‹ Û·ÓÈfiÙÂÚ· ÂÂÎÙ›ÓÂÙ·È Î·È ÛÙÔÓ ·Ú·Î›ÌÂÓÔ ÌÂÛÔÛÔÓ‰‡ÏÈÔ ‰›ÛÎÔ, ›Ù ‰È·Ì¤ÛÔ˘ ÙˆÓ ÂÈÌ‹ÎˆÓ Û˘Ó‰¤Û̈Ó, ›Ù ‰È·ÂÚÓÒÓÙ·˜ ÙËÓ ¯fiÓ‰ÚÈÓË ÂÈÊ˘Ûȷ΋ Ͽη. ¶ÈÔ Û¿ÓÈ·, Ë ‰È¿‚ÚˆÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘ ÚÔηÏ› Úfi-
ÙˆÛË Î·È ÂÈÓ¤ÌËÛË ÙÔ˘ ‰›ÛÎÔ˘. ∏ Ù·˘Ùfi¯ÚÔÓË Û˘ÌÌÂÙÔ¯‹ ÛÔÓ‰‡ÏÔ˘ Î·È ‰›ÛÎÔ˘ Â›Ó·È Û·ÓÈfiÙÂÚË ÛÙË Ê˘Ì·ÙÈÒ‰Ë ÛÔÓ‰˘Ï›Ùȉ· Û ۯ¤ÛË Ì ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ ˘ÔÁÂÓ‹ ÛÔÓ‰˘Ï›Ùȉ·, Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È Î·È Ù·¯‡ÙÂÚ· ÂÍÂÏÈÛÛfiÌÂÓË. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ô˘ Û˘ÓËÁÔÚÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ ˘¤Ú Ê˘Ì·ÙÈÒ‰Ô˘˜ ÛÔÓ‰˘Ï›Ùȉ·˜, ÂÎÙfi˜ ·fi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ‰›ÛÎÔ˘, Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë Â˘ÌÂÁ¤ı˘ Î·È Â·Û‚ÂÛو̤ÓË Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ (fiˆ˜ Î·È ÛÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË), Ë ·Ô˘Û›· ÛÎÏ‹Ú˘ÓÛ˘ ÙˆÓ ·ÚıÚÈÎÒÓ ÂÈÊ·ÓÂÈÒÓ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÔÏÏ·ÏÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ™™. ∞fi ÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒÓÂÙ·È Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ Î·È ·Ú·ÌfiÚʈÛË Ù˘ ™™. ªÂ ÙËÓ C/∆ Ù˘ ™™ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ηıÔÚÈÛÙ› Ë ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘. ∏ ‰È·›ÛÙˆÛË Â·Û‚ÂÛو̤Ó˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜ ıˆÚÂ›Ù·È ·ıÔÁÓˆÌÔÓÈ΋ Ù˘ ÓfiÛÔ˘ Î·È ‚ÔËı¿ ÛÙË ¢.¢. ·fi ÙËÓ ˘ÔÁfiÓÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·. ∏ ªRI ηٷ‰ÂÈÎÓ‡ÂÈ ÙËÓ ›ÂÛË ÙˆÓ ÓÂ‡ÚˆÓ ·fi ÙÔ˘˜ ÈÛÙÔ‡˜ (4-7). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Ì ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË Ì ·Ï¤˜ ¶·È‰È·ÙÚÈ΋ 2007;70:402-407
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¢. Ã. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
∂ÈÎfiÓ· 4. ∆Ô ·È‰› ÌÂÙ¿ ‰‡Ô ÂÙÒÓ ·ÓÙÈÊ˘Ì·ÙÈ΋˜ ıÂڷ›·˜, fiÔ˘ ·ÂÈÎÔÓ›˙ÂÙ·È ÂÚÈÔÚÈṲ̂ÓË ‚Ï¿‚Ë Ù˘ ™.™. (ÁˆÓÈ҉˘ ‡‚Ô˜ ÛÙÔ ‡„Ô˜ £9-£10).
·ÎÙÈÓÔÁڷʛ˜ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ™™, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∏ ÂȂ‚·›ˆÛË Ù˘ ÌfiÏ˘ÓÛ˘ ·fi ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Á›ÓÂÙ·È Ì ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·˘ÙÔ‡ Ì PCR ‹ ÙËÓ ·Ó‡ÚÂÛË ÎÔÎÎÈˆÌ¿ÙˆÓ Û ÈÛÙÔÏÔÁÈο ·Ú·Û΢¿ÛÌ·Ù· Î·È Ì ÙË ıÂÙÈ΋ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux. ∏ ıÂڷ›· Ù˘ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·Ù¿ÏÏËÏË ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹. ÃÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÚÈ˙ÈÎfi ¯ÂÈÚÔ˘ÚÁÈÎfi ηı·ÚÈÛÌfi ÙˆÓ ÓÂÎÚˆÌ¤ÓˆÓ ÈÛÙÒÓ Î·È ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ™™ Á›ÓÂÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ Ó¢ÚÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, ·ÛÙ¿ıÂÈ· ‹ ·Ú·ÌfiÚʈÛË Ù˘ ™™ ‹ ηٷÛÙÚÔÊ‹ >50% ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ (8-10). ∏ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ ÛÙË ™™ Â›Ó·È Û¿ÓÈ· ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È È‰È·›ÙÂÚ· Û ·È‰È¿ ÓËȷ΋˜ ËÏÈΛ·˜, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜. ∏ ȉȷÈÙÂÚfiÙËÙ· Ù˘ ÂÚ›ÙˆÛ‹˜ Ì·˜ Â›Ó·È fiÙÈ Ë ÓfiÛÔ˜ ÂΉËÏÒıËΠ·ÈÊÓ›‰È· Ì ÂÌÊ¿ÓÈÛË ‡‚Ô˘ ¯ˆÚ›˜ ˘ÚÂÙfi Î·È ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë Ì¤ÛË ‰È¿ÚÎÂÈ· Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ÛÙË ÓfiÛÔ ÙÔ˘ Pott ΢Paediatriki 2007;70:402-407
Ì·›ÓÂÙ·È ·fi ‚‰ÔÌ¿‰Â˜ ¤ˆ˜ Î·È ¯ÚfiÓÈ·, ÚÈÓ ÙÂı› Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (3,11), Î·È ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·˘Ù‹˜, fiˆ˜ ·Ú¿Ï˘ÛË, ·Ú·ÌfiÚʈÛË ‹ ÂÌÊ¿ÓÈÛË Û˘ÚÈÁÁÒ‰Ô˘˜ fiÚÔ˘ (12). ÿÛˆ˜ ·˘Ùfi Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ Î·È Û ÏËı˘ÛÌÔ‡˜ Ì ¯·ÌËÏfi ‚ÈÔÙÈÎfi ›‰Ô, fiÔ˘ ‰ÂÓ ‰›ÓÂÙ·È Ë ‰¤Ô˘Û· ÛËÌ·Û›· ÛÂ Û˘ÌÙÒÌ·Ù·, fiˆ˜ Ô fiÓÔ˜ ÛÙË Ú¿¯Ë ‹ ÛÙÔÓ ·˘¯¤Ó·. ∂Ӊ¯Ô̤ӈ˜, Ù¤ÙÔÈ· Û˘ÌÙÒÌ·Ù· Ó· ˘‹Ú¯·Ó Î·È ÛÙËÓ ·ÛıÂÓ‹ Ì·˜, ·ÏÏ¿ ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËηÓ. ™ÙËÓ ·ÛıÂÓ‹ Ì·˜, Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‚·Û›ÛıËΠÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ì ÙÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ıˆÚ·ÎÈÎfi ‡‚Ô, ÙË ıÂÙÈ΋ ªantoux Î·È Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·: ‡ÎÓˆÛË (¢∂) ̤ÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ‰›Ô˘, ‰ÈfiÁΈÛË ÏÂÌÊ·‰¤ÓˆÓ ÌÂÛÔıˆÚ·Î›Ô˘, ‰È¿‚ÚˆÛË ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ (£10-£11) Ì ‰ËÌÈÔ˘ÚÁ›· ·Ú·ÛÔÓ‰˘ÏÈο ÊÏÂÁÌÔÓÒ‰Ô˘˜ Ì¿˙·˜, ·ıÔÁÓˆÌÔÓÈ΋˜ Ù˘ Ê˘Ì·ÙÈÒ‰Ô˘˜ ÛÔÓ‰˘Ï›Ùȉ·˜ Î·È ÙËÓ ·Ó‡ÚÂÛË Ê˘Ì·Ù›ˆÛ˘ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡. √È ÂÈÏÔΤ˜ Ù˘ ÓfiÛÔ˘ Â›Ó·È ÔÛÙÈΤ˜ Î·È Ó¢ÚÔÏÔÁÈΤ˜ (9,10,13). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Ë Î·Ù¿ÏÏËÏË Ê·Ú̷΢ÙÈ΋ ıÂڷ›· Î·È ÔÚıÔ‰È΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÙÔÔı¤ÙËÛË Ó¿ÚıËη Û˘Ó¤‚·Ï ÙÂÏÈο ÛÙËÓ ÚfiÏË„Ë ÂÈÚfiÛıÂÙˆÓ ÔÛÙÈÎÒÓ ‚Ï·‚ÒÓ Î·È Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ Ì ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ™™ Î·È ¯ˆÚ›˜ ÙÂÏÈο ÙËÓ ÂÌÊ¿ÓÈÛË Î‡ÊˆÛ˘. ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ËÁ‹ ÌfiÏ˘ÓÛ˘ ÂÓÙÔ›ÛÙËΠÛÙÔ ÔÈÎÂ›Ô ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, ÛÙÔÓ ·Ù¤Ú· ÙÔ˘, Ô ÔÔ›Ô˜ ÛÙËÓ ·/· ıÒڷη ·ÚÔ˘Û›·˙ ÂÈÎfiÓ· ÛËÏ·›Ô˘. ∆· Û˘¯Ó¿ ÎÚÔ‡ÛÌ·Ù· Ù˘ ·È‰È΋˜ Ê˘Ì·Ù›ˆÛ˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Ó· ÂϤÁÍÂÈ ÙË ÌÂÙ¿‰ÔÛ‹ Ù˘. ∏ ¿ÌÂÛË Î·È ÈηÓÔÔÈËÙÈ΋ ÂÍ·ÎÚ›‚ˆÛË Ù˘ ËÁ‹˜ ÌfiÏ˘ÓÛ˘, ȉȷ›ÙÂÚ· ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÂȉÈÎÒÓ ÎÔÈÓˆÓÈÎÒÓ ÔÌ¿‰ˆÓ Î·È Ë ÂÊ·ÚÌÔÁ‹ ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ıÂڷ›·˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ Î·Ï‡ÙÂÚÔ ¤ÏÂÁ¯Ô Ù˘ ·È‰È΋˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ ·ÔÙÂÏ› ÚfiÎÏËÛË ÁÈ· ··ÓÙ‹ÛÂȘ Ô˘ ÂÎÎÚÂÌÔ‡Ó, ΢ڛˆ˜ Û ۯ¤ÛË Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙÔ˘ ·ÓÙÈÊ˘Ì·ÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ BCG. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È Ì¿ÏÈÛÙ· Û ÌÈÎÚ‹ ËÏÈΛ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÂӉ‰ÂÈÁ̤ÓË ÁÈ· ÂÚÈÔ¯¤˜ Î·È ÏËı˘ÛÌÔ‡˜ Ì ·˘ÍË̤ÓÔ ÂÈÔÏ·ÛÌfi Ù˘ ÓfiÛÔ˘.
µÈ‚ÏÈÔÁÚ·Ê›·: 1. American Academy of Pediatrics. Report of the Committee on Infectious Diseases. Red Book 2006; 595-613, 27th Ed. 2. ÷˚‰ÔÔ‡ÏÔ˘ ∫, ∂ÌÔÚÈ¿‰Ô˘ ª, £¿ÓÔ˘-∫‡ÚÙÛÔ˘ ¶, ∆ÛÈÏÈÁÁ›ÚË, ª, µ·ÚÏ¿Ì˘ °, ∫·Ú·Ì¤Ú˘ ™. ¢Â›ÎÙ˘ Ì˘-
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ÎÔ‚·ÎÙËÚȉȷ΋˜ ‰È·ÌfiÏ˘ÓÛ˘ Û ·È‰È¿ Ù˘ ∞ã¢ËÌÔÙÈÎÔ‡ ÛÙÔ ¡ÔÌfi £ÂÛÛ·ÏÔӛ΢ ÙË ‰ÂηÂÙ›· 1988-1997. ¶·È‰È·ÙÚÈ΋ µÔÚ. ∂ÏÏ¿‰Ô˜ 2001;13:55-59. Crofton J, Horne N, Miller F. Tuberculosis in children. In: Crofton J, Horne N, Miller F, editors. Clinical Tuberculosis. 2nd ed. London: Macmillan; 1999. p. 29-86. Resnick D, Kransdorf MJ. Osteomyelitis, septic arthritis and soft tissue infection: organisms. In: Resnick D, editor. Bone and Joint imaging. 3rd ed. Philadelphia: Elsevier Saunders; 2005. p. 758-761. Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondilitis on MRI. Am J Roentgenol 2004;182:1405-1410. Ng AW, Chu WC, Ng BK, Li AM. Extensive paraspinal abscess complicating tuberculous spondylitis in an adolescent with Pott kyphosis. Clin Imaging 2005;25:359-361. Chang MC, Wu HT, Lee CH, Chen TH. Tuberculous spondylitis and pyogenic spondylitis: comparative magnetic resonance imaging features. Spine 2006;31:782-788. MRC Working Party on Tuberculosis of the spine. Fiveyear assessment of controlled trials of short-course
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chemotherapy regimens of 6, 9 or 18 months’ duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery. Int Orthop 1999;23:73-81. Turgut M. Spinal tuberculosis (Pott’s disease): its clinical presentation, surgical management and outcome. A survey study of 694 patients. Neurosurg Rev 2001;24:8-13. Alici E, Akçali O, Tatari H, Günal I. Effect of preoperative chemotherapy on the outcome of surgical treatment of vertebral tuberculosis: retrospective analysis of 434 cases. Arch Orthop Trauma Surg 2001;121:65-66. Rezai AR, Lee M, Cooper PR, Errico TJ, Koslow M. Modern management of spinal tuberculosis. Neurosurgery 1995;36:87-97; discussion 97-98. Fitzerald D, Haars DW. Mycobacterium tuberculosis. In: Mandel GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia: Churchill Livingston; 2005.p: 2852-2908. Moghtaderi A, Alavi-Naini R, Rahimi-Movaghar V. Tuberculous myelopathy: current aspects of neurologic sequels in the southeast of Iran. Acta Neurol Scand 2006;113:267-272.
™ˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÙÔ˘ Quiz ÁÈ· ÙÔ ¿ÚıÚÔ “¡fiÛÔ˜ Kawasaki: ∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Î·È ÛÙÚ·ÙËÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ˘” 1. ¶fiÙ ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÂÍ¿ÓıËÌ· ÛÙË ÓfiÛÔ Kawasaki; ·. ∆Ș ÚÒÙ˜ ¤ÓÙ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡ 2. ™Â ÂÚÈÙÒÛÂȘ ·ÙÂÏÔ‡˜ ¡. Kawasaki, fiÛ· ·fi Ù· ·ÚÈ· Î·È Û˘ÌÏËڈ̷ÙÈο ÂÚÁ·ÛÙËÚȷο “ÎÚÈÙ‹ÚÈ·” Ú¤ÂÈ Ó· ÏËÚÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ú¯›ÛÂÈ ¤ÁηÈÚ· Ë ıÂڷ›·; Á. ŒÓ· ·fi Ù· ·ÚÈ· Î·È ≥3 ·fi Ù· Û˘ÌÏËڈ̷ÙÈο “ÎÚÈÙ‹ÚÈ·” 3. ∏ ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ì ¯·ÌËÏ‹, ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰fiÛË ·ÛÈÚ›Ó˘ Û ·ÛıÂÓ›˜ Ì N. Kawasaki ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÛÙÂÊ·ÓÈ·›ˆÓ ›ӷÈ: ‰. ∆¤ÛÛÂÚȘ Ì ¤ÍÈ Â‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ 4. ¶fiÙ ÂӉ›ÎÓ˘Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR ÛÙ· ·È‰È¿ Ì ¡. Kawasaki, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘; Á. ŒÓÙÂη Ì‹Ó˜ ÌÂÙ¿ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜ 5. ™Â ·È‰È¿ Ì ¡. Kawasaki Ô˘ Ú¤ÂÈ Â› ÛÂÈÚ¿ ÂÙÒÓ Ó· ·›ÚÓÔ˘Ó ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ‰. ∂›Ó·È ˘Ô¯ÚˆÙÈÎfi˜, ·ÏÏ¿ 11 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È Ì ÙËÓ ·Ú¿ÏÏËÏË ‰È·ÎÔ‹ Ù˘ ·ÛÈÚ›Ó˘ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ Ì ¿ÏÏË ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ·ÁˆÁ‹ ÁÈ· 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi
¶·È‰È·ÙÚÈ΋ 2007;70:402-407
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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
CASE REPORT
¶·È‰È·ÙÚÈ΋, Á˘Ó·ÈÎÔÏÔÁÈ΋ Î·È „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ì ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ 1 ∆Ì‹Ì· ¶·È‰È΋˜-∂ÊË‚È΋˜ °˘Ó·ÈÎÔÏÔÁ›·˜ Î·È ∂·ÓÔÚıˆÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜, µ’ ª·È¢ÙÈ΋ Î·È °˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ”∞ÚÂÙ·›ÂÈÔ” ¡ÔÛÔÎÔÌ›Ô, ∞ı‹Ó· 2 ¶·È‰Ô„˘¯È·ÙÚÈ΋ ∫ÏÈÓÈ΋ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ∂˘ı‡ÌÈÔ˜ ¢ÂÏËÁÂÒÚÔÁÏÔ˘ edeligeo@aretaieio.uoa.gr ª·Ú·ıÒÓÔ˜ 48, ∆∫ 152 35, µÚÈÏÏ‹ÛÈ·
E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘1, ∞. ¢ÂÏË‚ÂÏÈÒÙÔ˘1, µ. §¿ÁÁ·ÚË2, ¶. ∆̷ۛÚ˘1, π. ∆ÛÈ¿ÓÙ˘2, °. ∫Ú·ÙÛ¿˜1 ¶ÂÚ›ÏË„Ë: ∏ Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ Î·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚ›ÙˆÛË ÂÓfi˜ ÂÓÙ¿¯ÚÔÓÔ˘ ÎÔÚÈÙÛÈÔ‡ Ô˘ ÚÔÛ‹Ïı ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÈ̤ÓÔ˘Û·˜ ‰‡ÛÔÛÌ˘ ηÊÂÔÂȉԇ˜ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘, Û˘ÓÔ‰Â˘Ì¤Ó˘ ·fi ÎÓËÛÌfi, ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ ‰‡Ô ¯ÚfiÓˆÓ. ∫·Ù¿ ÙËÓ ·ÌÊ›¯ÂÈÚË Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË ·fi ÙÔ ÔÚıfi ·ÔηχÊıËΠÌÈ· „ËÏ·ÊËÙ‹ Ì¿˙·, ·ÓÒ‰˘ÓË, ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘ Î·È ÔÌ·Ï‹˜ ˘Ê‹˜, ÛÙÂÚ¿ ÚÔÛÎÔÏÏË̤ÓË ÛÙÔÓ Ô›ÛıÈÔ ÎÔÏÈÎfi ıfiÏÔ. ∆Ô ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·ÂÎ¿Ï˘„ ¤Ó· ÂÙÂÚÔÁÂÓ¤˜ ÌfiÚʈ̷ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘, ÂÓÒ Ì ÙËÓ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· ηٷ‰Â›¯ıËΠÛÙËÓ ›‰È· ı¤ÛË ÛÎÈ·ÁÚ·ÊÈÎfi ¤ÏÏÂÈÌÌ·, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∞ÎÔÏÔ‡ıËÛ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ‰È· ̤ۈ ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘. ∆Ô ·È‰› ·Ó¤ÊÂÚ fiÙÈ Â›¯Â ‚¿ÏÂÈ ÌfiÓÔ ÙÔ˘ ÙÔ Í¤ÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÔÔ›Ô ¤‚Á·Ï ·fi ÙÔ Á¤ÌÈÛÌ· ÌÈ·˜ ÎÔ‡ÎÏ·˜. ¢ÈÂÓÂÚÁ‹ıËΠ„˘¯ÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ·È‰ÈÔ‡, ̤ۈ Ù˘ ¯ÔÚ‹ÁËÛ˘ Ù˘ Îϛ̷η˜ “Child Behaviour Check List”(CBCL), Ë ÔÔ›· ¤‰ÂÈÍ ÙËÓ Èı·Ó‹ ‡·ÚÍË „˘¯ÔÏÔÁÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰ÂÍÈfiÙËÙ˜ Î·È ÙËÓ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ηıÒ˜ ›Û˘ Î·È ÙËÓ ÁÓˆÛÙÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·. °È· ÙËÓ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÎÔÚÈÙÛÈÒÓ Ì ˘Ô„›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ Â›Ó·È ··Ú·›ÙËÙË Ë Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔًوÓ. §¤ÍÂȘ ÎÏÂȉȿ: ∂Ó‰ÔÎÔÏÈÎfi ͤÓÔ ÛÒÌ·, ·È‰È΋ ËÏÈΛ·, ·È‰È·ÙÚÈ΋- Á˘Ó·ÈÎÔÏÔÁÈ΋- „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË.
Paediatric, gynaecological and psychological evaluation of a girl with a foreign body in the vagina: a case report 1 Division of PaediatricAdolescent Gynaecology and Reconstructive Surgery, 2nd Department of Obstetrics and Gynaecology, University of Athens Medical School, Aretaieion Hospital, Athens, Greece 2 Department of Child Psychiatry, University of Athens Medical School, Children’s Hospital “Aghia Sophia”, Athens, Greece Correspondence: Efthimios Deligeoroglou, edeligeo@aretaieio.uoa.gr 48, Marathonos St., 152 35, Vrilissia, Athens, Greece
E. Deligeoroglou1, A. Deliveliotou1, V. Laggari2, P. Tsimaris1, I. Tsiantis2, G. Creatsas1 Abstract: A five year-old girl was referred by a paediatrician for evaluation of persistent foul-smelling brown vaginal discharge with pruritus for over two years, not responding to antibiotic therapy. On bimanual abdomino-rectal examination, a solid mass was palpated, deeply embedded in the posterior vaginal fornix, without tenderness. Transabdominal ultrasound identified a heterogeneous mass securely fixed in the upper third of the vaginal wall. Vaginography revealed a filling defect in the upper part of the vagina, confirming the diagnosis of an intravaginal foreign body. The foreign body, partially visualized in the vaginal introitus, was grasped and removed by traction. It turned out to be a thin doubly wrapped piece of sponge. The girl recalled having herself inserted the material, which was derived from the stuffing of a doll. Psychological assessment of the girl included Ackenbach’s “Child Behaviour Check List” (CBCL), which indicated psychological disturbances relating to social competence, adaptiveness and cognitive functioning. The aim of this paper is to present the effective approach and successful management of a child with a retained intravaginal foreign body (in this case a piece of sponge) through the collaboration of different medical subspecialists. Key words: Intravaginal foreign body, childhood, paediatric- gynaecological- psychological evaluation.
∂ÈÛ·ÁˆÁ‹ ∏ ˘ÔÙÚÔÈ¿˙Ô˘Û· ‹ ÂÈ̤ÓÔ˘Û· ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË Û ¤Ó· ÎÔÚ›ÙÛÈ ·È‰È΋˜ ËÏÈΛ·˜ ÌÔÚ› Ó· Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÔÈÎ›ÏˆÓ ·ÈÙÈÒÓ, fiˆ˜ Ë ÚˆÙÔ·ı‹˜ ÌÈÎÚԂȷ΋ ÎÔÏ›Ùȉ·, Ë ‰ÂÚÌ·ÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ·È‰Ô›Ô˘, ηÎÔ‹ıÂȘ fiÁÎÔÈ ÙÔ˘ ÎfiÏÔ˘ ‹ ·ÎfiÌË Î·È ·ÔÙ¤ÏÂÛÌ· Èı·Ó‹˜ ÛÂÍÔ˘·ÏÈ΋˜ ηÎÔÔ›ËÛ˘ (1-3). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Paediatriki 2007;70:408-412
Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·. √ ÛÎÔfi˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ¿ÚıÚÔ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÈ· ÂӉȷʤÚÔ˘Û· ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ Ì ÂÈ̤ÓÔ˘Û· ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË Û·Ó ·ÔÙ¤ÏÂÛÌ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, ηıÒ˜ Î·È ¤Ó·Ó ·ÏÁfiÚÈıÌÔ ÁÈ· ÙËÓ ÛˆÛÙ‹ ÚÔÛ¤ÁÁÈÛË Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋
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∫ÔÚ›ÙÛÈ Ì ÛÒÌ· ÛÙÔÓ ÎfiÏÔ
·ÓÙÈÌÂÙÒÈÛË ·ÚfiÌÔÈˆÓ ÂÚÈÙÒÛˆÓ, Ì ÙËÓ Ô˘ÛÈ·ÛÙÈ΋ Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ È·ÙÚÈÎÒÓ ÂȉÈÎÔًوÓ.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ŒÓ· ÂÍ¿¯ÚÔÓÔ ÎÔÚ›ÙÛÈ ·Ï‚·ÓÈ΋˜ ηٷÁˆÁ‹˜, Û˘Óԉ¢fiÌÂÓÔ ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘, ·Ú·¤ÌÊıËΠÛÙÔ ∆Ì‹Ì· ¶·È‰È΋˜ Î·È ∂ÊË‚È΋˜ °˘Ó·ÈÎÔÏÔÁ›·˜ ÙÔ˘ “∞ÚÂÙ·›ÂÈÔ˘” ¡ÔÛÔÎÔÌ›Ԣ ·fi ·È‰›·ÙÚÔ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÈ̤ÓÔ˘Û·˜ ‰‡ÛÔÛÌ˘ ηÊÂÔÂȉԇ˜ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘ Û˘Óԉ¢Ô̤Ó˘ ·fi ÎÓËÛÌfi, ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 2 ¯ÚfiÓˆÓ. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÎÔÚ›ÙÛÈ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÁÈ· ÙËÓ ËÏÈΛ· Ù˘ ‡„Ô˜ Î·È ‚¿ÚÔ˜, Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi. ∆Ô ÎÔÚ›ÙÛÈ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â Ï¿‚ÂÈ Û˘ÓÔÏÈο 5 Û¯‹Ì·Ù· ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ÌÂÙ¿ ·fi ηÏÏȤÚÁÂÈ· ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡, ¯ˆÚ›˜ fï˜ ˘Ô¯ÒÚËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Û˘Ìو̿وÓ. TfiÛÔ Ë ›‰È·, fiÛÔ Î·È Ë ÌËÙ¤Ú·, ·¤ÎÏÂÈÛ·Ó ÙËÓ Èı·ÓfiÙËÙ· ÛÂÍÔ˘·ÏÈ΋˜ ηÎÔÔ›ËÛ˘. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙÔ ÎÔÚ›ÙÛÈ ‚Ú¤ıËΠӷ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈο ¤Íˆ ÁÂÓÓËÙÈο fiÚÁ·Ó· ı‹ÏÂÔ˜ Ì ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ· Î·È ÍËÚfiÙËÙ· ÛÙ· ÌÂÁ¿Ï· ¯Â›ÏË ÙÔ˘ ·È‰Ô›Ô˘ Û˘Óԉ¢Ô̤ÓË ·fi ÔÏϷϤ˜ ÂΉÔÚ¤˜ Û fiÏË ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÂÚÈÓ¤Ô˘. √ ·ÚıÂÓÈÎfi˜ ˘Ì¤Ó·˜ ‹Ù·Ó ¿ıÈÎÙÔ˜ Ì ηϿ Û¯ËÌ·ÙÈṲ̂ÓË ÎÂÓÙÚÈ΋ Ô‹. ∫·Ù¿ ÙËÓ ·ÌÊ›¯ÂÈÚË Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË ·fi ÙÔ ÔÚıfi ·ÔηχÊıËΠÌÈ· „ËÏ·ÊËÙ‹ Ì¿˙·, ·ÓÒ‰˘ÓË, ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘ Î·È ÔÌ·Ï‹˜ ˘Ê‹˜, ÛÙÂÚ¿ ÚÔÛÎÔÏÏË̤ÓË ÛÙÔÓ Ô›ÛıÈÔ ÎÔÏÈÎfi ıfiÏÔ. ™ÙË Û˘Ó¤¯ÂÈ· ÂÏ‹ÊıË ÎÔÏÈÎfi ˘ÁÚfi, ‰È·Ì¤ÛÔ˘ Ù˘ Ô‹˜ ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·, ÙÔ ÔÔ›Ô ÛÙ¿ÏıËΠÁÈ· ηÏÏȤÚÁÂÈ·. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ηÏÏȤÚÁÂÈ·˜ ·ÂÎ¿Ï˘„·Ó ÙËÓ ·ÚÔ˘Û›· Staphylococcus epidermidis Î·È Streptococcus faecallis. ™ÙË Ê¿ÛË ·˘Ù‹ ¤ÁÈÓ ¤ÎÏ˘ÛË ÙÔ˘ ÎfiÏÔ˘ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi, Ë ÔÔ›· fï˜ ‰ÂÓ ·oÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· οÔÈÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ ·ÎÔÏÔ‡ıËÛÂ, ÙÔ ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· η٤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÓfi˜ ·ÓÔÌÔÈÔÁÂÓÔ‡˜ ˯ԉÔÌ‹˜ ÌÔÚÊÒÌ·ÙÔ˜, Û ÛÙÂÓ‹ Û˘Ó¿ÊÂÈ· Ì ÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘, Ì ‰È·ÛÙ¿ÛÂȘ 16 cm x 8 cm x16 cm, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ Ì‹ÙÚ· Î·È ÔÈ ˆÔı‹Î˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÌÂÁ¤ıÔ˘˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘, ÂÓÒ Ô ÙÚ¿¯ËÏÔ˜ Î·È ÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ¿Óˆ ÙÚÈÙËÌÔÚ›Ô˘ ÙÔ˘ ÎfiÏÔ˘ ·ÚÔ˘Û›·˙·Ó ¤ÓÙÔÓË ˘ÂÚ·ÈÌ›·. ™ÙËÓ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· Ê¿ÓËΠ¤Ó· ¤ÏÏÂÈÌÌ· ÛÎÈ·ÁÚ¿ÊËÛ˘ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘ Ì ‰È·ÛÙ¿ÛÂȘ 2 cm Û ϿÙÔ˜ Î·È 3 cm Û ̋ÎÔ˜, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÂÓfi˜ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (∂ÈÎfiÓ· 2). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ‰ÂÓ Î·Ù¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÌÊ·ÓÔ‡˜ ·ıÔÏÔÁ›·˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÎfiÏÔ˘. ™Â ÌÈ· ‰Â‡ÙÂÚË ·È‰ÔÁ˘Ó·ÈÎÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË
∂ÈÎfiÓ· 1. ∆Ô ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ÂÓfi˜ ·ÓÔÌÔÈÔÁÂÓÔ‡˜ ˯ԉÔÌ‹˜ ÌÔÚÊÒÌ·ÙÔ˜, ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘.
ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ÌÂÙ¿ ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, ÙÔ Í¤ÓÔ ÛÒÌ· ‹Ù·Ó ÌÂÚÈÎÒ˜ ÂÌÊ·Ó¤˜ ›Ûˆ ·fi ÙÔÓ ·ÚıÂÓÈÎfi ˘Ì¤Ó·, Î·È Ì ÙË ‚Ô‹ıÂÈ· Ï·‚›‰·˜ Allis Û˘ÓÂÏ‹ÊıË Î·È ·Ê·ÈÚ¤ıËÎÂ. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘, ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ˘ÏÈÎfi Á¤ÌÈÛ˘ Ì›·˜ ÎÔ‡ÎÏ·˜ Ì ‰È·ÛÙ¿ÛÂȘ 2 cm. › 3 cm ηٿ ÙËÓ ÚÒÙË ÂÎÙ›ÌËÛË, ÙÔ ÔÔ›Ô fiÙ·Ó Í‰ÈÏÒıËΠ›¯Â ‰È·ÛÙ¿ÛÂȘ 5,5 cm › 3,5 cm (∂ÈÎfiÓ· 3). ŒÓ· ‰Â‡ÙÂÚÔ ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· η٤‰ÂÈÍ ÙËÓ ·Ô˘Û›· Èı·ÓÔ‡ ·Ú·Ì¤ÓÔÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜ ‹ Î·È ¿ÏÏÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ. ™ÙÔ ÎÔÚ›ÙÛÈ Û˘ÓÂÛÙ‹ıË ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Ì ·ÌÔÍ˘Î˘Ï›ÓË Î·È ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇ ÁÈ· 10 ̤Ú˜. ¢‡Ô ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ·, ÙfiÛÔ Ë ÌËÙ¤Ú· fiÛÔ Î·È ÙÔ ·È‰› ·Ó¤ÊÂÚ·Ó ‡ÊÂÛË Ù˘ ÎÔÏÈ΋˜ ˘ÂÚ¤ÎÎÚÈÛ˘ Î·È ÙÔ˘ ÎÓËÛÌÔ‡, ÂÓÒ Î·È Ë Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡ ‹Ù·Ó ÛÙ›ڷ ÌÈÎÚÔ‚›ˆÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Û˘ÓÔÌÈÏ›·˜ Ì ÙÔ ·È‰›, ·˘Ùfi ·Ó¤ÊÂÚ fiÙÈ Â›¯Â ‚¿ÏÂÈ ÌfiÓÔ ÙÔ˘ ÙÔ Í¤ÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÔÔ›Ô ¤‚Á·Ï ·fi ÙÔ Á¤ÌÈÛÌ· ÌÈ¿˜ ÎÔ‡ÎÏ·˜. ∆Ô ÎÔÚ›ÙÛÈ ·ÈÙÈÔÏfiÁËÛ ̿ÏÈÛÙ· ·˘Ù‹ ÙË Û˘ÌÂÚÈÊÔÚ¿ ϤÁÔÓÙ·˜ ¶·È‰È·ÙÚÈ΋ 2007;70:408-412
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E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘ Î·È Û˘Ó.
∂ÈÎfiÓ· 2. ∏ ·ÓÈÔ‡Û· ÎÔÏÔÁÚ·Ê›· ¤‰ÂÈÍ ¤Ó· ¤ÏÏÂÈÌÌ· ÛÎÈ·ÁÚ¿ÊËÛ˘ ÛÙÔ ¿Óˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÎfiÏÔ˘ Ì ‰È·ÛÙ¿ÛÂȘ 2ÂÎ Ã 3ÂÎ.
ˆ˜ ÙÔ ¤Î·ÓÂ Û·Ó ·ÓÙ›‰Ú·ÛË ÚÔ˜ ÙË ÌËÙ¤Ú· ÙÔ˘, Ë ÔÔ›· ÙÔ Â›¯Â ÙÈ̈ڋÛÂÈ, ÂÂȉ‹ ‰ÂÓ ÎÔÈÌfiÙ·Ó. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÙÔ ·È‰› Ì·˙› Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ ·Ú·¤ÌÊıËΠÁÈ· ÂÎÙ›ÌËÛË ÛÙËÓ ¶·È‰Ô„˘¯È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”.
∂ÈÎfiÓ· 3. ∆Ô Í¤ÓÔ ÛÒÌ· ‹Ù·Ó ¤Ó· ÏÂÙfi ‰Èψ̤ÓÔ ÎÔÌÌ¿ÙÈ ÛfiÁÁÔ˘, ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ˘ÏÈÎfi Á¤ÌÈÛ˘ Ì›·˜ ÎÔ‡ÎÏ·˜.
Paediatriki 2007;70:408-412
∞ÔÙÂϤÛÌ·Ù· „˘¯ÔÌÂÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘ ™ÎÔfi˜ Ù˘ ·Ú·ÔÌ‹˜ ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ Î·È Û˘ÌÂÚÈÊÔÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙȉڷÛÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡, Ô˘ ÚÔοÏÂÛ ÙÔ Á˘Ó·ÈÎÔÏÔÁÈÎfi Úfi‚ÏËÌ·. ∆Ô ·È‰› ηٿ ÙËÓ ÂÚ›Ô‰Ô ‰ÈÂÓ¤ÚÁÂÈ·˜ Ù˘ ÂÎÙ›ÌËÛ˘ ‹Ù·Ó 6 ÂÙÒÓ Î·È 2 ÌËÓÒÓ. ™Ù· Ï·›ÛÈ· Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ ¯ÔÚËÁ‹ıËΠÛÙË ÌËÙ¤Ú· Ë ÂÏÏËÓÈ΋ ÛÙ¿ıÌÈÛË Ù˘ ∫ϛ̷η˜ “Child Behaviour Check List” (CBCL) ÙÔ˘ Ackenbach, Ë ÔÔ›· ·ÔÙÂÏ› ¤Ó· ¢ڤˆ˜ Î·È ‰ÈÂıÓÒ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ·˘ÙÔ·Ó·ÊÔÚ¿˜, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÎÔÈÓˆÓÈ΋˜ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜-ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜, ηıÒ˜ Î·È ÚÔ‚ÏËÌ¿ÙˆÓ Û˘ÌÂÚÈÊÔÚ¿˜ Û ·È‰È¿ ËÏÈΛ·˜ 6-12 ÂÙÒÓ, Û‡Ìʈӷ Ì ÙËÓ ·Ó·ÊÔÚ¿ ÙˆÓ ÁÔÓÈÒÓ (4,5). ∆· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ CBCL ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î·, ÔÈ ‚·ıÌÔÏÔÁ›Â˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙȘ ˘ÔÎϛ̷Θ “∫ÔÈÓˆÓÈ΋ §ÂÈÙÔ˘ÚÁÈÎfiÙËÙ·”, “∫ÔÈÓˆÓÈο ¶ÚÔ‚Ï‹Ì·Ù·” Î·È “¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔÛÔ¯‹˜” ‚Ú›ÛÎÔÓÙ·È Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (2Ô Î·È 90fi ÂηÙÔÛÙËÌfiÚÈÔ ·ÓÙ›ÛÙÔȯ·), Û ۇÁÎÚÈÛË Ì ÙȘ ‚·ıÌÔÏÔÁ›Â˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ›‰ÈÔ˘ ʇÏÔ˘ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ù˘ ÂÏÏËÓÈ΋˜ ÛÙ¿ıÌÈÛ˘ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘. ™˘˙‹ÙËÛË ∏ ·Ó‡ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û˘Ì‚·›ÓÂÈ Û ÔÛÔÛÙfi 4% ÙˆÓ ÎÔÚÈÙÛÈÒÓ, ËÏÈΛ·˜ οو ÙˆÓ 13 ÂÙÒÓ, Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È ÛÙ· ¶›Ó·Î·˜ 1. ∆· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ CBCL, Ô˘ ·ÊÔÚÔ‡Ó ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜ ¶ÚÔ‚Ï‹Ì·Ù· ™˘ÌÂÚÈÊÔÚ¿˜
∞ÔÙÂϤÛÌ·Ù· CBCL
∞fiÛ˘ÚÛË ™ˆÌ·ÙÈο ∂Óԯϋ̷ٷ ÕÁ¯Ô˜/ ∫·Ù¿ıÏÈ„Ë ∫ÔÈÓˆÓÈο ¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔ‚Ï‹Ì·Ù· ™Î¤„˘ ¶ÚÔ‚Ï‹Ì·Ù· ¶ÚÔÛÔ¯‹˜ ∂͈ÙÂڛ΢ÛË ∂ÛˆÙÂڛ΢ÛË ¶·Ú·‚·ÙÈ΋ ™˘ÌÂÚÈÊÔÚ¿ ∂ÈıÂÙÈ΋ ™˘ÌÂÚÈÊÔÚ¿ ™‡ÓÔÏÔ ¶ÚÔ‚ÏËÌ¿ÙˆÓ ¶ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ¢Ú·ÛÙËÚÈfiÙËÙ˜ ∫ÔÈÓˆÓÈ΋ §ÂÈÙÔ˘ÚÁÈÎfiÙËÙ·
4 0 7 6* 1 8* 16 10 3 13 42 3 2**
* ÙÈ̤˜ ÛÙȘ ˘ÔÎϛ̷Θ Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (>90Ô‡ ÂηÙÔÛÙËÌÔÚ›Ô˘ ‹ >90% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘). ** ÙÈ̤˜ ÛÙȘ ˘ÔÎϛ̷Θ Û ÎÏÈÓÈο ÛËÌ·ÓÙÈÎfi Â›Â‰Ô (<2Ô˘ ÂηÙÔÛÙËÌÔÚ›Ô˘ ‹ <2% ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘).
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∫ÔÚ›ÙÛÈ Ì ÛÒÌ· ÛÙÔÓ ÎfiÏÔ
Â͈ÙÂÚÈο È·ÙÚ›· ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi ‹ ÙÔ ÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· (6). ™Â Ì›· ¿ÏÏË ÌÂϤÙË, Ô Capraro η٤ÏËÍ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ Û ÎÔÚ›ÙÛÈ· ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜, Ì ·Ó·ÊÂÚfiÌÂÓË ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ·, ‹Ù·Ó 10% (7). √È Stricker Î·È Û˘Ó. (8) ·Ó¤ÊÂÚ·Ó fiÙÈ ÂÚ›Ô˘ ÛÙ· ÌÈÛ¿ (49%) ·fi Ù· ÎÔÚ›ÙÛÈ· Ô˘ ÙÂÏÈο ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ͤÓÔ ÛÒÌ· ÛÙÔÓ ÎfiÏÔ, ÙÔ ÚÔÂÍ¿Ú¯ÔÓ Û‡Ìو̷ ‹Ù·Ó Ë ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ· ‹ Ë ·ÈÌ·ÙËÚ‹ ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË, ÂÓÒ ÛÙÔ 20 % ÙÔ Î‡ÚÈÔ Û‡Ìو̷ ‹Ù·Ó Ô ÎÔÈÏÈ·Îfi˜ fiÓÔ˜. °ÂÓÈο, Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ ¤Ó· ÌÈÎÚfi ·È‰› Ó· ÂÚÈÁÚ¿„ÂÈ ÂÓԯϋÛÂȘ ·fi ÙÔ ·È‰Ô›Ô Î·È ÙÔÓ ÎfiÏÔ. ∆· Û˘Ó‹ıË Û˘ÌÙÒÌ·Ù·, ÁÈ· Ù· ÔÔ›· ·Ú·ÔÓÔ‡ÓÙ·È Ù· ·È‰È¿ ÛÙË ÌËÙ¤Ú· ÙÔ˘˜, Â›Ó·È Ë Ê·ÁÔ‡Ú·, Ô fiÓÔ˜, Î·È ÙÔ ·›ÛıËÌ· η‡ÛÔ˘. ∏ ˘ÔÙÚÔÈ¿˙Ô˘Û· ‹ ÂÈ̤ÓÔ˘Û· ‰‡ÛÔÛÌË ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË ‹ Ë ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ· ·Ó·Î·Ï‡ÙÂÙ·È Û˘ÓËı¤ÛÙÂÚ· ·fi ÙÔ˘˜ ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ ¤ÓÙÔÓ· ıÔÚ˘‚Ë̤ÓÔÈ ·Â˘ı‡ÓÔÓÙ·È ·Ì¤Ûˆ˜ ÛÙÔÓ ·È‰›·ÙÚÔ. ŒÓ·˜ ˘„ËÏfi˜ ‚·ıÌfi˜ ˘Ô„›·˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ, Â›Ó·È ··Ú·›ÙËÙÔ˜, ÒÛÙ ӷ ·Ú·¤Ì„ÂÈ ¤ÁηÈÚ· ÙÔ ÎÔÚ›ÙÛÈ Û ¤Ó· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ Î¤ÓÙÚÔ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ Á˘Ó·ÈÎÔÏÔÁ›·˜. √ ·È‰ÔÁ˘Ó·ÈÎÔÏfiÁÔ˜ ÔÊ›ÏÂÈ Ì ÙË ÛÂÈÚ¿ ÙÔ˘ Ó· οÓÂÈ ÌÈ· ÚÔÛÂÎÙÈ΋ Á˘Ó·ÈÎÔÏÔÁÈ΋ ÂͤٷÛË, Ë ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙË Ï‹„Ë ÎÔÏÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ. ª›· ÚÒÙË ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÂÓfi˜ Èı·ÓÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÌÔÚ› Ó· Á›ÓÂÈ Ì ¤ÎÏ˘ÛË ÙÔ˘ ÎfiÏÔ˘ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ‹ Ì Ȉ‰ÈÔ‡¯Ô. ∏ ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰ÔÁ˘Ó·ÈÎÔÏfiÁÔ˘ Ì ¤Ó·Ó ·ÎÙÈÓÔÏfiÁÔ Ì ·ÓÙ›ÛÙÔÈ¯Ë ÂÌÂÈÚ›· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÔÚÈÙÛÈÒÓ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜, Â›Ó·È ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈ΋, ÒÛÙ ӷ ÂÈÙ¢¯ı› Ô Î·Ï‡ÙÂÚÔ˜ ‰˘Ó·Ùfi˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Ì ‰È·ÎÔÈÏÈ·Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ÎÔÏÔÁÚ·Ê›· Î·È MRI (9). ∆· ÂÚÈÛÛfiÙÂÚ· ͤӷ ÛÒÌ·Ù· ‰ÂÓ Â›Ó·È ·ÎÙÈÓÔÛÎÈÂÚ¿, ÔfiÙÂ Î·È ‰ÂÓ Ê·›ÓÔÓÙ·È ÛÙȘ ·Ï¤˜ ·ÎÙÈÓÔÁڷʛ˜. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ë MRI ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Ë ÈÔ ·ÍÈfiÈÛÙË ÁÈ· ÙËÓ ·ÂÈÎfiÓÈÛË ÂÓfi˜ ÂÓ‰ÔÎÔÏÈÎÔ‡ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (10). ŸÙ·Ó ÙÔ Í¤ÓÔ ÛÒÌ· Â›Ó·È ÔÚ·Ùfi ÛÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ÎfiÏÔ˘, Ë Û‡ÏÏË„Ë Ì Ϸ‚›‰· Allis Â›Ó·È Â‡ÎÔÏË Î·È Ô‰ËÁ› ÛÙËÓ ·Ê·›ÚÂÛ‹ ÙÔ˘. ∂›ıÈÛÙ·È fï˜, Ù· ͤӷ ÛÒÌ·Ù· Ó· ÂÓÛÊËÓÒÓÔÓÙ·È ‚·ıÈ¿ ÛÙÔ ÎÔÏÈÎfi ÙÔ›¯ˆÌ·, ÔfiÙ ÁÈ· ÙÔÓ Ï‹ÚË ¤ÏÂÁ¯Ô ÙÔ˘ ÎfiÏÔ˘ ηı›ÛÙ·Ù·È ··Ú·›ÙËÙË Ë ÂÎÙ¤ÏÂÛË ·ÚıÂÓÔÛÎfiËÛ˘ Ì ¯ÔÚ‹ÁËÛË ·Ó·ÈÛıËÛ›·˜. ∏ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ù›ıÂÙ·È Ì ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ¶·Ú·Ì¤ÓÂÈ ˆÛÙfiÛÔ ·ÌÊÈÏÂÁfiÌÂÓË
ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ë ·Í›· Ù˘ ÙÔÈ΋˜ ÂÊ·ÚÌÔÁ‹˜ ·ÏÔÈÊ‹˜ ÔÈÛÙÚÔÁfiÓˆÓ Î·È ÙˆÓ ÙÔÈÎÒÓ Ï‡ÛÂˆÓ Ì ¯·ÌÔÌ‹ÏÈ ‹ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ÌÂÙ¿ ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ (8). ∫¿ÓÔÓÙ·˜ ·Ó·‰ÚÔÌ‹ Û ·ÚÎÂÙ¿ ÌÂÌÔӈ̤ӷ ÂÚÈÛÙ·ÙÈο ÂÊ‹‚ˆÓ ·ÁÔÚÈÒÓ Ô˘ ›¯·Ó ÌfiÓ· ÙÔ˘˜ ÙÔÔıÂÙ‹ÛÂÈ Í¤Ó· ÛÒÌ·Ù· ÛÙÔ Ô˘ÚÔÁÂÓÓËÙÈÎfi ÙÔ˘˜ Û‡ÛÙËÌ·, Ô Kenney ·Ó·Ê¤ÚÂÈ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÌÈ· Û˘ÌÂÚÈÊÔÚ¿ ‰ÈÂÚ‡ÓËÛ˘, Ì ¿ÁÓˆÛÙË Û˘¯ÓfiÙËÙ·, Ë ÔÔ›· fï˜ ÌÔÚ› Ó· ·ӷϷ̂¿ÓÂÙ·È Ì ·ÓÙÈΛÌÂÓ· ‰˘ÓËÙÈο ÂÈΛӉ˘Ó·, ÂÓÒ ÙÔ „˘¯È·ÙÚÈÎfi ÚÔÊ›Ï ÙÔ˘˜ Ê·ÓÂÚÒÓÂÈ ¿ÙÔÌ· Ì οÔÈ· „˘¯ÔÏÔÁÈ΋ ÚԉȿıÂÛË (11). √ Wise, ÂÍ¿ÏÏÔ˘, Û˘ÓÔ„›˙ÔÓÙ·˜ ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ Û¯ÂÙÈο Ì ¿ÙÔÌ· Ì ͤӷ ÛÒÌ·Ù· ÛÙËÓ Ô˘Ú‹ıÚ· η٤ÏËÍ ˆ˜ Ë ‰˘Ó·ÌÈ΋ ηٷÓfiËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ·˘Ù‹˜ Û˘Ì‚·‰›˙ÂÈ Ì ÙËÓ ·Ó¿Ù˘ÍË Ù˘ „˘¯·Ó·Ï˘ÙÈ΋˜ ıˆڛ·˜ (12). ∏ ·ÚÔ‡Û· ÂÚ›ÙˆÛË ·ÔÙÂÏ› ÙËÓ ÚÒÙË ·Ó·ÊÔÚ¿ ÛÙËÓ ‚È‚ÏÈÔÁÚ·Ê›·, ÛÙËÓ ÔÔ›· ¤ÁÈÓ „˘¯ÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË ÂÓfi˜ ÎÔÚÈÙÛÈÔ‡ Ô˘ ‰È·ÁÓÒÛÙËΠ̠ÂÓ‰ÔÎÔÏÈÎfi ͤÓÔ ÛÒÌ·, ÙÔ ÔÔ›Ô Â›¯Â ÙÔÔıÂÙËı› ·fi ÙÔ ›‰ÈÔ. √ ÛÙfi¯Ô˜ Ù˘ ·Ú·ÔÌ‹˜ ÁÈ· „˘¯ÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË Èı·ÓÒÓ Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ Î·È Û˘ÌÂÚÈÊÔÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÛÙȘ Ôԛ˜ ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡, ηıÒ˜ ÂÓ ÙË ·Ô˘Û›· „˘¯Ô·ıÔÏÔÁÈÎÔ‡ Â˘Ú‹Ì·ÙÔ˜ ·˘Ù‹ ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Û ڿÍÂȘ ·˘ÙÔÂÚˆÙÈÛÌÔ‡ Î·È ÛˆÌ·ÙÈ΋˜ ÂÍÂÚ‡ÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡. ∏ Îϛ̷η “Child Behaviour Check List” (CBCL) ÙÔ˘ Ackenbach ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙ‹ ·ÁÎÔÛÌ›ˆ˜ ÙfiÛÔ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË fiÛÔ Î·È ÛÙËÓ ¤Ú¢ӷ, ˆ˜ ¤Ó· ¯Ú‹ÛÈÌÔ „˘¯ÔÌÂÙÚÈÎfi ÂÚÁ·ÏÂ›Ô ÁÈ· ÙË ÛÊ·ÈÚÈ΋ ÂÎÙ›ÌËÛË Ù˘ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·˜ Î·È Ù˘ „˘¯Ô·ıÔÏÔÁ›·˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ (4). ∂ÈϤÔÓ, Ë ‡·ÚÍË ˘ÔÏÔÁÈÛÌ¤ÓˆÓ cut-off ÙÈÌÒÓ ‚¿ÛÂÈ ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ÛÙ¿ıÌÈÛ˘ (5) ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ¯·Ú·ÎÙËÚÈÛÌÔ‡ Ù˘ ÂοÛÙÔÙ ‚·ıÌÔÏÔÁ›·˜ ˆ˜ ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋˜ ‹ ÌË. ∆· ÎÏÈÓÈο ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ˘ÔÎϛ̷Θ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ CBCL ˘Ô‰ËÏÒÓÔ˘Ó ÙËÓ ‡·ÚÍË „˘¯ÔÏÔÁÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰ÂÍÈfiÙËÙ˜ Î·È ÙËÓ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ· ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, ηıÒ˜ ›Û˘ Î·È ÙËÓ ÁÓˆÛÙÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·. ∂ȉÈÎfiÙÂÚ·, Ë „˘¯ÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË ¤‰ÂÈÍ fiÙÈ Ê·›ÓÂÙ·È Ó· ÚÔÂÍ¿Ú¯Ô˘Ó ÔÈ ‰˘ÛÎÔϛ˜ ÎÔÈÓˆÓÈ΋˜ ·ÏÏËÏ›‰Ú·Û˘ Î·È Ó· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÏÏÈ‹˜ ÎÔÈÓˆÓÈÎÔÔ›ËÛË Î·È ÊÙˆ¯¤˜ Û¯¤ÛÂȘ ÌÂ Û˘ÓÔÌ‹ÏÈη ·È‰È¿, ÂÓÒ ÛÙÔ ÁÓˆÛÙÈÎfi Â›Â‰Ô ÂÓÙÔ›˙ÂÙ·È ·‰˘Ó·Ì›· Û˘ÁΤÓÙÚˆÛ˘, ÔÓÂÈÚÔfiÏËÛË Î·È ·ÚÔÚÌËÙÈÎfiÙËÙ·. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË, Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ·Ú¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ¶·È‰È·ÙÚÈ΋ 2007;70:408-412
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E. ¢ÂÏËÁÂÒÚÔÁÏÔ˘ Î·È Û˘Ó.
ÏËÚÔÊÔڛ˜ Û ۯ¤ÛË Ì ÙËÓ „˘¯ÔÏÔÁÈ΋ Î·È ÎÔÈÓˆÓÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·, ηıÒ˜ Î·È ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡. ÕÏψÛÙÂ, ·ÔÙÂÏ› Û˘Ó‹ıË Î·È ÂÈÛÙËÌÔÓÈο ·Ô‰ÂÎÙ‹ Ú·ÎÙÈ΋ Ë ÂÚÈÁÚ·Ê‹ ÙÔ˘ „˘¯ÔÏÔÁÈÎÔ‡ ÚÔÊ›Ï ·ÛıÂÓÒÓ, ̤ۈ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÛÙ·ıÌÈÛÌ¤ÓˆÓ Î·È ¤ÁÎ˘ÚˆÓ „˘¯ÔÌÂÙÚÈÎÒÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ. µ¤‚·È·, ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ‰ÂÓ ·ÔÙÂÏ› ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô ÛÙÔ ÔÔ›Ô ı· ÌÔÚÔ‡Û ηÓ›˜ Ó· ‚·ÛÈÛÙ› ÁÈ· ÙË ‰È¿ÁÓˆÛË ÌÈ·˜ Û˘ÁÎÂÎÚÈ̤Ó˘ ÓÔÛÔÏÔÁÈ΋˜ ÔÓÙfiÙËÙ·˜ Î·È Û˘ÓÂÒ˜ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙËÓ ‰È·ÁÓˆÛÙÈ΋ ÎÏÈÓÈ΋ Û˘Ó¤ÓÙ¢ÍË Î·È ·ÍÈÔÏfiÁËÛË. ∂ÈϤÔÓ, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ „˘¯ÔÌÂÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘ ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· ·ÏËı¢ÙÔ‡Ó Î·È Ó· Û˘ÓÂÎÙÈÌËıÔ‡Ó Ì ÎÏÈÓÈο ÛÙÔȯ›· ηıÒ˜ ‰ÂÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÂÚ·ÈÙ¤Úˆ „˘¯ÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÏfiÁˆ ¿ÚÓËÛ˘ ÙˆÓ ÁÔÓÈÒÓ - ·Ú¿ ÙȘ Û˘ÛÙ¿ÛÂȘ ÙˆÓ ÂȉÈÎÒÓ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙËÓ ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ ÎÏÈÓÈ΋˜ ‰ÈÂÚ‡ÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ηıÒ˜ Î·È Û˘Ì‚Ô˘Ï¢ÙÈ΋˜ ÚÔ˜ ÙÔ˘˜ ›‰ÈÔ˘˜. ∂Ô̤ӈ˜, Â›Ó·È Û·Ê¤˜ fiÙÈ ¤Ú·Ó Ù˘ ÎÏÈÓÈ΋˜ Î·È ÂÚ¢ÓËÙÈ΋˜ ¯ÚËÛÈÌfiÙËÙ·˜ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘, Î·È ·Ú¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ô˘ Ì·˜ ·Ú¤¯ÂÈ ÁÈ· ÙÔ „˘¯ÔÏÔÁÈÎfi ÚÔÊ›Ï ·˘ÙÔ‡ ÙÔ˘ ÎÔÚÈÙÛÈÔ‡, Ë Î·Ù·ÓfiËÛË ÙˆÓ ÂÚÈÔÚÈÛÌÒÓ Î·È ÙˆÓ ÔÚ›ˆÓ ÛÙË ¯Ú‹ÛË ÙÔ˘ -fiˆ˜ ¿ÏψÛÙÂ Î·È fiÏˆÓ ÙˆÓ „˘¯ÔÌÂÙÚÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ- Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÍÈÔÔ›ËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙÔ˘ ηٿ ÙÔÓ ÔÚıfiÙÂÚÔ ÂÈÛÙËÌÔÓÈο Î·È ‰ÂÔÓÙÔÏÔÁÈο ÙÚfiÔ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÎÔÚÈÙÛÈÒÓ Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È Ì ÂÈ̤ÓÔ˘Û· ‰‡ÛÔÛÌË ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË, ı· Ú¤ÂÈ Ó· ‰ÈÂÚÂ˘Ó¿Ù·È Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ÂÓfi˜ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ. ªÈ· ηϿ ÔÚÁ·ÓˆÌ¤ÓË, ÛÊ·ÈÚÈ΋ Î·È ‰ÈÂÈÛÙËÌÔÓÈ΋ ÚÔÛ¤ÁÁÈÛË ··ÈÙ› ÚˆÙ·Ú¯Èο ÙËÓ Ô˘ÛÈ·ÛÙÈ΋ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰È¿ÙÚÔ˘, Ô ÔÔ›Ô˜ ÚÒÙÔ˜ ‚ϤÂÈ ÙÔ ·È‰›, Ì ÙÔÓ Á˘Ó·ÈÎÔÏfiÁÔ, Ô ÔÔ›Ô˜ Ú¤ÂÈ Ó· Â›Ó·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˜ Û ÚÔ‚Ï‹Ì·Ù· Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜. °ÓˆÚ›˙ÔÓÙ·˜, ÂÍ¿ÏÏÔ˘, fiÙÈ Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ ·fi ÙÔ ›‰ÈÔ ÙÔ ÎÔÚ›ÙÛÈ, ÌÔÚ› ‰˘ÓËÙÈο Ó· ·ÔÙÂÏ› ÚÒÈÌË ¤Ó‰ÂÈÍË „˘¯È΋˜ ‰È·Ù·Ú·¯‹˜ ‹ Û‡Ìو̷ ˘Ô‚fiÛÎÔ˘Û·˜ ‰È·Ù·Ú·¯‹˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ë ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÚÈÔÚ›˙ÂÙ·È ÛÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ·fi ÙÔÓ ÎfiÏÔ. ∫·ıÔ-
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ÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË fiÛÔ Î·È ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·ÓÂÌÊ¿ÓÈÛ˘ Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ÂÚÈÛÙ·ÙÈÎÒÓ, ıˆÚÂ›Ù·È Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ÂÌϤÎÔÓÙ·È Á‡Úˆ ·fi ı¤Ì·Ù· „˘¯È΋˜ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ, ηıÒ˜ Î·È Ë ‰˘Ó·ÙfiÙËÙ· ‰È·Û‡Ó‰ÂÛ˘ ÙˆÓ ˘ËÚÂÛÈÒÓ, Ì ÛÎÔfi ÙËÓ ·Ú·ÔÌ‹ Û ˘ËÚÂۛ˜ „˘¯È΋˜ ˘Á›·˜ ·È‰ÈÒÓ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Herman-Giddens ME. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc Med. 1994;148(2):195-200. 2. Striegel AM, Myers JB, Sorensen MD, Furness PD, Koyle MA. Vaginal discharge and bleeding in girls younger than 6 years. J Urol.2006;176(6 Pt 1):2632-2635. 3. Cuadros J, Mazon A, Martinez R, Gonzalez P, Gil-Setas A, Flores U, Orden B, Gomez-Herruz P, Millan R; Spanish Study Group for Primary Care Infection. The aetiology of paediatric inflammatory vulvovaginitis. Eur J Pediatr. 2004; 163(2):105-107. 4. MacDonald VM, Tsiantis J, Achenbach TM, Motti-Stefanidi F, Richardson SC. Competencies and problems reported by parents of Greek and American children, ages 611. Eur Child Adolesc Psychiatry 1995;4(1):1-13. 5. Roussos A, Karantanos G, Richardson C, Hartman C, Karajiannis D, Kyprianos S, Lazaratou H, Mahaira O, Tassi M, Zoubou V. Achenbach's Child Behaviour Checklist and Teacher's Report Form in a normative sample of Greek children 6-12 years old. Eur Child Adolesc Psychiatry 1999; 8:165-172. 6. Paradise JE, Willis ED. Probability of vaginal foreign body in girls with genital complaints. Am J Obstet Gynecol 1985; 139:472. 7. Capraro VJ. Vulvovaginitis and other local lesions of the vulva. Clin Obstet Gynecol 1974;1:533. 8. Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health. 2004;40(4):205-207. 9. Caspi B, Zalel Y, Katz Z, Appelman Z, Insler V. The role of sonography in the detection of vaginal foreign bodies in young girls: the bladder indentation sign. Pediatr Radiol. 1995;25 Suppl 1:S60-61. 10. Kihara M, Sato N, Kimura H, Kamiyama M, Sekiya S, Takano H. Magnetic resonance imaging in the evaluation of vaginal foreign bodies in a young girl. ArchGynecol Obstet 2001; 265(4):221-222. 11. Kenney RD. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required? Urology 1988;32:127. 12. Wise TN. Urethral manipulation: an unusual paraphilia. J Sex Marital Ther 1982;8:222.
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Rare manifestations of coeliac disease - Report of a case and review of the literature M. Ugras, D. Ertem, E. Pehlivanoglu Abstract: Coeliac disease (CD) is an immune-mediated enteropathy caused by the ingestion of gluten in genetically susceptible individuals. Classically, coeliac disease presents with anorexia, chronic diarrhoea, abdominal distension, muscle wasting and failure to thrive. However, atypical CD may present with iron deficiency anaemia resistant to therapy, leukopenia, thrombocytopenia, osteoporosis, arthritis, dental enamel defects, pubertal delay and recurrent abdominal pain. Coeliac crisis is a manifestation of the disease which was very frequent in the past. It is characterized by diarrhoea, electrolyte imbalance and metabolic acidosis. The case is reported here of a child presenting with coeliac crisis, with emphasis on the importance of this rare manifestation of CD. Key words: Coeliac disease, coeliac crisis, electrolyte imbalance, acidosis, child.
Introduction Coeliac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. The introduction of gluten into the diet leads to damage of the intestinal mucosa, which causes malabsorption. The classical presentation of CD is with anorexia, chronic or recurrent diarrhoea, abdominal distension, muscle wasting and failure to thrive. However, atypical CD has become a more common clinical presentation nowadays. It is manifested with iron deficiency anaemia resistant to therapy, prolonged prothrombin time (PT) and aPTT, osteoporosis, arthritis, dental enamel defects, pubertal delay, recurrent abdominal pain and hyperamilasaemia (1). The serological tests available for the diagnosis of CD include antigliadin antibodies and connective tissue antibodies: reticulin, endomysial and tissue transglutaminase antibodies (tTG). The current gold standard in coeliac serology remains the IgA endomysial antibody (EMA). Overall the sensitivity of the EMA and tTG is greater than 90% (2-4). The laboratory findings of CD include thrombocytosis, thrombocytopenia, leukopenia, and prolonged PT and APTT (5). Coeliac crisis is a manifestation of the disease which was frequent in past decades, but has now almost disappeared. A few cases of coeliac crisis are reported annually in the developing countries, and it should be kept in mind among the differential diagnoses of children having severe electrolyte imbalance, metabolic acidosis and a history of coeliac disease.
Marmara University, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey Correspondence: Meltem Ugras meltemkorkut@yahoo.com Marmara University, Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Tophanelioglu cad 13-15, Altunizade, Istanbul, Turkey
Case report A 13 year-old girl was admitted with carpopedal spasm, oedema and intermittent diarrhoea. During the previous few months she had been weak, had lost 5 kg and had arthralgia. There was no consanguinity between her parents; her prenatal and postnatal history was unremarkable. On physical examination her height and weight were below the 3rd percentile. She was pale and weak and had abdominal distension. There was pitting oedema over her tibia and she also had digital clubbing. Her liver was 2 cm palpable below the right costal margin. She was anaemic with a blood haemoglobin value of 8.1 g/dl, and on admission measurement of her serum electrolytes revealed hyponatraemia, hypokalaemia, hypocalcaemia and hypoproteinaemia (Na 127 meq/dl K 1.97 meq/dl, Ca 6.2 mg/dl, ionized calcium 0.6 mmol/L, albumin 1.5 g/dl) and acidosis (blood pH 7.24, HCO3 8.6). AST 46 IU/L, ALT 47 IU/L, PT 24.2 sec, INR 2.31. HBsAg, Anti HBs, HAV Ig G and M, Anti HCV were negative, and alpha-fetoprotein and alpha1-antitripsin levels were within the normal range. Abdominal ultrasonography showed an enlarged liver with normal parenchymal echogeneity, gall bladder, intrahepatic and extrahepatic biliary tract. Since the arterial blood gas analysis revealed metabolic acidosis, intravenous fluid, electrolyte and bicarbonate supplements were started immediately. During her hospital stay, she developed hyperaemic, papular, pruritic skin lesions on the buttocks, legs and arms (Figure 1). ¶·È‰È·ÙÚÈ΋ 2007;70:413-415
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Figure 1. Papular lesions on the legs and arms.
The electrolyte imbalance and mild degree of acidosis persisted, and it was not possible to discontinue intravenous fluid and albumin infusion. An upper gastrointestinal endoscopy was performed and the characteristic pathological findings on the duodenal biopsies (Figure 2), and high levels of antiendomysium and antigliadin IgA and IgG, revealed that the patient had gluten sensitive enteropathy. The girlâ&#x20AC;&#x2122;s condition was considered to be â&#x20AC;&#x153;coeliac crisisâ&#x20AC;? and methyprednisolone at a dose of 2 mg/kg/day was started consequently, in addition to gluten free diet (GFD). On the 8th day of steroid treatment, her serum electrolyte and acid-base status became stable, the pruritic skin lesions regressed, and it was possible to stop intravenous fluid and electrolyte support within a few days.
Discussion CD is common in European countries, with a wide spectrum of gastrointestinal and systemic signs and symptoms. The definitive diagnosis depends on the histopathological examination of the distal duodenal mucosa. The differential diagnosis of total or partial villous atrophy includes food allergy, immunodeficiency states, Rotavirus enteritis, Giardia lamblia infestations, tropical sprue and post-enteritis syndrome. The clinical presentation of CD in children is diverse. Classic CD is characterized by gastrointestinal manifestations starting between 6 and 24 months of age, after the introduction of gluten into the diet. Infants and young children typically present with impaired growth, chronic diarrhoea, abdominal distension, muscle wasting and hypotonia, poor appetite and unhappy behaviour. Within weeks to months of starting to ingest gluten, weight gain velocity decreases and finally weight loss can be observed. Despite a wide variation between countries, typical CD still represents a common presentation in the paediatric age group. Atypical presentation of CD usually tends to Paediatriki 2007;70:413-415
Figure 2. Histopathologic examination revealing villous atrophy, increased intraepithelial lymphocytes. (HEx200 magnification).
occur in older children, who present a picture of recurrent abdominal pain, nausea, vomiting, bloating, and constipation. Extra-intestinal manifestations such as short stature, pubertal delay, iron deficiency, dental enamel defects and abnormalities in liver function are common in atypical CD (1). Dermatitis herpetiformis (DH) is a chronic papulovesicular skin disease frequently associated with asymptomatic gluten-sensitive enteropathy. Dermatitis herpetiformis is at present regarded as a variant of CD rarely affecting the paediatric population. In general the treatment of DH consists of removal of gluten from the diet and use of pharmacological agents such as dapsone, dexamethasone and cyclophosphamide (6-9). There is strong evidence that DH is a skin manifestation of CD. Most patients with DH have concomitant intestinal mucosal changes of CD on duodenal biopsy, even in the absence of gastrointestinal symptoms. Both the rash and intestinal mucosal morphology improve on gluten free diet (9,10). The association of osteoporosis and CD has been reported in several clinical and epidemiological studies, but no conclusive data on the pathogenesis of bone involvement in CD are available. Bone changes were originally thought to be secondary to intestinal malabsorption of calcium and vitamin D, but recently, other causes of bone metabolism impairment have been cited, including the interaction between cytokines and local/systemic factors influencing bone formation and reabsorption. Further, there is now substantial evidence supporting the concept that lifelong GFD is the only effective measure to restore bone metabolism to normal. In the paediatric population, prompt introduction of GFD can even lead to satisfactory recovery
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of the bone mass. It has been shown that in children and adolescents the bone mineral content, bone area and bone mineral density were significantly lower in CD subjects than in controls, and that GFD causes complete recovery of bone density and body mass composition. Conversely, adults affected by osteoporosis secondary to CD do not experience spontaneous recovery, and there are no conclusive data on the efficacy of standard therapies for osteoporosis in reducing the fracture risk. This evidence stresses the need for timely diagnosis as a preventive intervention to avoid CD complications (1,11-13). Apart from the characteristic manifestations of the disease, CD can also present with unusual clinical features, which can lead to delayed diagnosis and treatment. A rare and life-threatening complication, usually affecting children under 2 years of age is the so called “coeliac crisis” (14). Clinically, this condition is characterized by severe diarrhoea, dehydration and electrolyte imbalance. Various precipitating factors have been identified for coeliac crisis, including severe malnutrition, infections, hypoproteinaemia, poor compliance to GFD, bacterial overgrowth in a setting of altered gastrointestinal motility and use of anticholinergic drugs (15). Early reports of CD described several patients suffering from severe and life-threatening malabsorption. In 1952, Andersen and Di Saint Agnese described the course of CD in 58 children (16). Although the majority suffered from growth retardation and hypoproteinaemia, 35 of them had episodes of sudden dehydration and acidosis, a condition called coeliac crisis. This kind of clinical presentation was confined to the children of under 2 years. There are some case reports of children presenting with coeliac crisis who were successfully treated with steroid and GFD (16). In the middle of the 19th century, severe malabsorption due to coeliac crisis was the leading presentation of CD. Recently, advances in serological testing have made the diagnosis of CD easier, with the result that the consequences of severe malabsorption are now rarely seen. In conclusion, CD is still a common diagnosis in current medical practice. Although the numbers of newly diagnosed CD patients are increasing, either because of the improved diagnostic techniques or the approach of the clinicians, fewer new coeliac crisis cases are being reported from the developing countries. However, this condition should be kept in mind
among children with severe electrolyte imbalance, metabolic acidosis, and severe malabsorption even in older children.
References 1. Fasano A, Catassi C. Celiac disease in children. Best Pract Res Clin Gastroenterol 2005;19:467-478. 2. NIH Consensus Development Conference on Celiac Disease [Statement]. 2004: Webpage: http://www.consensus.nih. gov/ cons/118/118cdc_intro. htm. [ Available from: http:// www.consensus.nih.gov/cons/118/118cdc_intro.htm] 3. Rossi TM, Kumar V, Lerner A, Heitlinger LA, Tucker N, Fisher J. Relationship of endomysial antibodies to jejunal mucosal pathology: specificity towards both symptomatic and asymptomatic celiacs. J Pediatr Gastroenterol Nutr 1988;7:858-863. 4. Chorzelski TP, Beutner EH, Sulej J, Tchorzewska H, Jablonska S, Kumar V, et al. IgA anti-endomysium antibody. A new immunological marker of dermatitis herpetiformis and coeliac disease. Br J Dermatol 1984;111:395-402. 5. Halfdanarson TR, Litzow MR, Murray JA. Hematologic manifestations of celiac disease. Blood. 2007;109:412-421. 6. Egan CA, Smith EP, Taylor TB, Meyer LJ, Samowitz WS, Zone JJ. Linear IgA bullous dermatosis responsive to a gluten-free diet. Am J Gastroenterol 2001;96:1927-1929. 7. Burks W. Skin manifestations of food allergy. Pediatrics 2003;111:1617-1624. 8. Sacchidanand S, Hiremath NC, Natraj HV, Revathi TN, Rani S, Pradeep, G, et al. Dexamethasone-cyclophosphamide pulse therapy for autoimmune-vesiculobullous disorders at Victoria hospital, Bangalore. Dermatol Online J 2003;9:2. 9. Andersson H, Mobacken H. Dietary treatment of dermatitis herpetiformis. Eur J Clin Nutr 1992;46:309-315. 10. Brow JR, Parker F, Weinstein WM, Rubin CE. The small intestinal mucosa in dermatitis herpetiformis. I. Severity and distribution of the small intestinal lesion and associated malabsorption. Gastroenterology 1971;60:355-361. 11. Mora S, Barera G, Beccio S, Menni L, Proverbio MC, Bianchi C, et al. A prospective, longitudinal study of the long-term effect of treatment on bone density in children with celiac disease. J Pediatr 2001;139:516-521. 12. Barera G, Mora S, Brambilla P, Ricotti A, Menni L, Beccio S, et al. Body composition in children with celiac disease and the effects of a gluten-free diet: a prospective casecontrol study. Am J Clin Nutr 2000;72:71-75. 13. Lunt H, Florkowski CM, Cook HB, Whitehead MR. Bone mineral density, type 1 diabetes, and celiac disease. Diabetes Care 2001;24:791-792. 14. Anderson M, Forbes D, Gracey M. Celiac disease. In: Gracey M, Burke V, editors. Pediatric Gastroenterology and Hepatology. 3rd ed. Boston: Blackwell Scientific Publications; 1993. p: 403-425. 15. Walia A, Thapa BR. Celiac crisis. Indian Pediatr 2005;42: 1169. 16. Andersen DH, Di Sant’ Agnese PA. Idiopathic celiac disease. I. Mode of onset and diagnosis. Pediatrics 1953;11: 207-222.
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º. ∫˘Ú‚·Û›Ï˘Å, ¡. ¶··‰fiÔ˘ÏÔ˜Ç, π. ∆۷ӿη˜Å, º. ∫·Ó·ÎÔ‡‰ËÑ ¶ÂÚ›ÏË„Ë: ∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ÛÙ· ·È‰È¿ ıˆÚÂ›Ù·È ˆ˜ ¤Ó·˜ ·fi ÙÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ÓfiÛËÛË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÚfiÛÊ·Ù· Û˘ÓÈÛÙ¿Ù·È Ô Î·ıÔÏÈÎfi˜ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ. ∞fi ÙËÓ ·Ó·ÛÎfiËÛË Ù˘ Û‡Á¯ÚÔÓ˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ∆· ‰Â‰Ô̤ӷ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ Ù˘¯·ÈÔÔÈË̤ÓË, ÚÔÔÙÈ΋ ÌÂϤÙË Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ‰Â›¯ÓÔ˘Ó fiÙÈ ‰ÂÓ ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ·fi ÙȘ ÂÍ¿ÚÛÂȘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·ÙfiÈÓ ÈÒÛˆÓ, ÂÓÒ ·Ú¿ÏÏËÏ· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ·fi ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÌÂÈÒıËÎ·Ó ÔÈ ÂÈÛ·ÁˆÁ¤˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ ¿ÛıÌ· ÛÙ· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›· Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË ·fi ÙËÓ ‹È· ˆ˜ ÙËÓ ‚·ÚÈ¿ ÌÔÚÊ‹ ÙÔ˘, Î·È fiÙÈ ÔÈ ÈÔ› Ô˘ ¢ı‡ÓÔÓÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÛÙ· ·È‰È¿, Â›Ó·È ÔÈ ÚÈÓÔ˚Ô› Î·È Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜, Û˘ÌÂÚ·›ÓÔ˘Ì fiÙÈ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· Ó· ·Ô‰Âȯı› Ë ·Ó·ÁηÈfiÙËÙ· ÙÔ˘ ηıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ì ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ. §¤ÍÂȘ ÎÏÂȉȿ: ÕÛıÌ·, ·È‰È¿, ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ, Èfi˜ Áڛ˘, ÚÈÓÔ˚Ô›.
Influenza vaccination in children with asthma 1 Unit of Paediatric Pneumonology, 3rd Paediatric Clinic, Aristotle University of Thessaloniki 2 Department of Allergology, 2nd Paediatric Clinic, University of Athens 3 1st Paediatric Clinic, Aristotle University of Thessaloniki Correspondence: Fotios Kirvassilis 47a, A. Ypsilantou St., 57013, Oraiokastro, Thessaloniki, Greece
F. KÈrvassilisÅ, N. PapadopoulosÇ, I. TsanakasÅ, F. KanakoudiÑ Abstract: Bronchial asthma is considered to be a risk factor for the occurrence of post influenza infection complications. For this reason influenza vaccination has recently been recommended for all children with asthma. However, review of the current literature on the application of influenza vaccination to children with asthma revealed conflicting results. Data from the randomized prospective study of its application in asthmatic children failed to demonstrate protection from post-viral bronchial asthma exacerbations. There are also no data from prospective studies to show that hospitalizations of children with asthma are reduced following influenza vaccination. Considering that bronchial asthma in children has a wide phenotypic occurrence ranging from mild to severe types, and that the rhinoviruses and respiratory syncytial virus are the viruses mainly responsible for asthma exacerbations in children it is concluded that more data is needed to confirm the necessity of influenza vaccination for all children with asthma. Key words: Asthma, children, influenza vaccination, influenza virus, rhinoviruses.
∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ¯ÚfiÓÈ· ¿ıËÛË ÛÙ· ·È‰È¿ Î·È ıˆÚÂ›Ù·È ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ·fi ÓfiÛËÛË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ (1). ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ÛÙ· ·È‰È¿ Â›Ó·È Ë Ïԛ̈ÍË ·fi ÈÔ‡˜ (2-5). ∆ËÓ ÎÏÈÓÈ΋ ·˘Ù‹ ÂÌÂÈÚ›· ÂȂ‚·ÈÒÓÂÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ. √È Jartti Î·È Û˘Ó. ‚Ú‹Î·Ó fiÙÈ ÛÙÔ 88% 293 ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó Ì Ô͇ ÂÎÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi Î·È ÌÂÏÂÙ‹ıËÎ·Ó ÚÔÔÙÈο, ·ÔÌÔÓÒıËΠÈfi˜ ˆ˜ ·›ÙÈÔ Ù˘ ¤Í·ÚÛ˘ (3). ™‡Ìʈӷ Ì ÌÂϤÙË ÙˆÓ Neuzil Î·È Û˘Ó. ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÔÈ ÂÈÛ·ÁˆÁ¤˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ Áڛ˘ Ô˘ ηٷÁÚ¿ÊËÎ·Ó Î·Ù¿ ÙËÓ ÂÈÎÔÛ·ÂÙ›· 1973-1993 Paediatriki 2007;70:416-419
‹Ù·Ó ÂÚ›Ô˘ ‰ÂηϿÛȘ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (500-1000/100.000 ÏËı˘ÛÌÔ‡) Û˘ÁÎÚÈÙÈο Ì ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ ̤¯ÚÈ ÙËÓ ÂÊ˂›·. √ ·ÚÈıÌfi˜ ÙˆÓ ·Ú·¿Óˆ ÂÈÛ·ÁˆÁÒÓ ‰ÈÏ·ÛÈ¿˙ÂÙ·È Û ·È‰È¿ Ì ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜ ·ı‹ÛÂȘ (4,5). ∆Ô Î¤ÓÙÚÔ ÂϤÁ¯Ô˘ ÏÔÈÌÒÍÂˆÓ ÙˆÓ ∏¶∞ ·Ó·Ê¤ÚÂÈ fiÙÈ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô 1990-1999 ηٷÁÚ¿ÊËÎ·Ó 36.000 ı¿Ó·ÙÔÈ ·fi ÁÚ›Ë ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 90% ·ÊÔÚÔ‡Û ¿ÙÔÌ· ËÏÈΛ·˜ >65 ÂÙÒÓ. √È ı¿Ó·ÙÔÈ ÔÊ›ÏÔÓÙ·Ó Î˘Ú›ˆ˜ Û Ó¢ÌÔÓ›·, ηډÈÔ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù· Î·È ¿ÏϘ ¯ÚfiÓȘ ·ı‹ÛÂȘ (1,6). ∫·Ù·‰ÂÈÎÓ‡ÂÙ·È ÏÔÈfiÓ Ë ÌÂÁ¿ÏË ÛËÌ·Û›· οı ÚÔÛ¿ıÂÈ·˜ ÚfiÏ˄˘ Ù˘ Áڛ˘, ȉȷ›ÙÂÚ· Ì¿ÏÈÛÙ· Â¿Ó ·Ó·ÏÔÁÈÛÙ› ηÓ›˜ ÙÔÓ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘
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∞ÛıÌ·ÙÈο ·È‰È¿ Î·È ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜
·Ó‰ËÌ›·˜ Ô˘ ÛÙÔ ·ÚÂÏıfiÓ ·ÔÙ¤ÏÂÛ ·ÈÙ›· ÔÏÏÒÓ ı·Ó¿ÙˆÓ (1). √ ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤¯ÂÈ Î·ıÈÂÚˆı› ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ ÌÂٷ͇ ÙˆÓ Ôo›ˆÓ Û˘ÁηٷϤÁÔÓÙ·È fiÏ· Ù· ¿ÙÔÌ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ Î·È ·È‰È¿ Ì ¯ÚfiÓȘ ·ı‹ÛÂȘ ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙËÓ ÂÙ‹ÛÈ· ¤ÎıÂÛ‹ Ù˘ ÁÈ· ÙÔ 2003, Ë ™˘Ì‚Ô˘Ï¢ÙÈ΋ ∂ÈÙÚÔ‹ ÙˆÓ ∂Ì‚ÔÏÈ·ÛÌÒÓ ÙˆÓ ∏¶∞ (Advisory Committee on Immunization Practices) (1) Û˘ÓÈÛÙ¿ ÂÌ‚ÔÏÈ·ÛÌfi fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ≥6 ÌËÓÒÓ Ì ¿ÛıÌ·, Ô‰ËÁ›· Ô˘ ·Ú·Ì¤ÓÂÈ ÛÙËÓ ÙÚÔÔÔ›ËÛË ÙˆÓ Ô‰ËÁÈÒÓ ·˘ÙÒÓ ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 2004-2005 Î·È Ì¤¯ÚÈ Û‹ÌÂÚ· (6). ¶·Ú¿ ÙËÓ ÈÛ¯‡Ô˘Û· Û‡ÛÙ·ÛË ÁÈ· ÙÔÓ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ Ì ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜ ·ı‹ÛÂȘ, ¤¯ÂÈ ‰ËÌÔÛÈ¢Ù› ÚfiÛÊ·Ù· fiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ô˘ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ·ÁÁ›˙ÂÈ ÌfiÓÔ ÙÔ 16% (7). ¶·Ú¿ÏÏËÏ·, ¿ÏÏË ÌÂϤÙË ·Ó·Ê¤ÚÂÈ fiÙÈ Ù· ·È‰È¿ Ì ¿ÛıÌ· Â›Ó·È ·˘Ù¿ Ì ÙÔ ¯·ÌËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ ˆ˜ ÚÔ˜ ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ Û ۇÁÎÚÈÛË Ì ÙȘ ˘fiÏÔȘ ÔÌ¿‰Â˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (8). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Ô‰‹ÁËÛ·Ó Û ÌÈ· ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ì ÛÎÔfi ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (9-11). ™ÙËÓ ÚÔÛ¿ıÂÈ· ·˘Ù‹ ÂÓÙ¿ÛÛÔÓÙ·È Î·È Ù· Â˘Ú‹Ì·Ù· ÙˆÓ Quach Î·È Û˘Ó., ·fi ÌÂϤÙË 182 ·ÛıÂÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËΠӷ ÓÔÛËÏ¢ÙÔ‡Ó ÏfiÁˆ Áڛ˘. ¢È·›ÛÙˆÛ·Ó fiÙÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÓÔÛËÏ›· ÏfiÁˆ Áڛ˘ ‹Ù·Ó ·) ËÏÈΛ· <12 ÌËÓÒÓ, ‚) ·Ê˘‰¿ÙˆÛË Î·È Á) ¯·ÌËÏfi˜ ÎÔÚÂÛÌfi˜ √2. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ 70% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó ‰ÂÓ ·Ó‹Î·Ó Û ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (11). ∂›Ó·È ‰Â ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ÙÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ Ì ̤ÙÚÈÔ-‚·Ú‡ ¿ÛıÌ· Êı¿ÓÂÈ ÙÔ 21-25% (1,7), ÂÓÒ ·˘Ùfi ÙˆÓ ·È‰ÈÒÓ Ì ΢ÛÙÈ΋ ›ÓˆÛË ÙÔ 79% (1). ∆Ô Ê·ÈÓfiÌÂÓÔ ÙÔ˘ ÌË Î·ıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÔÊ›ÏÂÙ·È Î¿ÔȘ ÊÔÚ¤˜ ÛÙËÓ ÂÈÊ˘Ï·ÎÙÈÎfiÙËÙ· ÔÚÈÛÌ¤ÓˆÓ ·ÛıÂÓÒÓ ˆ˜ ÚÔ˜ ÙÔÓ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (12). ∂ÈϤÔÓ, Ê·›ÓÂÙ·È fiÙÈ Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ Ô˘ ÚfiÎÂÈÙ·È Ó· ÂÌ‚ÔÏÈ¿ÛÂÈ ¤Ó· ·ÛıÌ·ÙÈÎfi ·È‰› Û˘Ó˘ÔÏÔÁ›˙ÂÈ fiÙÈ ÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ˆ˜ Ë ÈÔ Û˘¯Ó‹ ¯ÚfiÓÈ· ¿ıËÛË ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi, ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘Ú›· Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ “·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ” ÂÌÊ·Ó›˙Ô˘Ó ‰È·Ï›ÔÓ ‹ ‹ÈÔ ¿ÛıÌ· Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÂÈÛfi‰È· ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ ÌÂÙ¿ ·fi ÈÒÛÂȘ ÌÂÌÔӈ̤ÓÔ˘ ¯·Ú·ÎÙ‹Ú·, ¯ˆÚ›˜ Û˘ÌÙÒÌ·Ù· ÛÙÔ ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÂÍ¿ÚÛˆÓ. ∆· ÂÂÈÛfi‰È· ·˘Ù¿ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Â‡ÎÔÏ· Ì ıÂڷ›· ÛÙÔ Û›ÙÈ, ¯ˆÚ›˜ ·Ó¿ÁÎË ÓÔÛËÏ›·˜ ÛÙÔ ÓÔÛÔ-
ÎÔÌ›Ô, ÁÂÁÔÓfi˜ Ô˘ ÌÂÈÒÓÂÈ ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È Î·Ù’ ¤ÎÙ·ÛË, ÙËÓ ·Ó¿ÁÎË ÚfiÏ˄˘ Ù˘ Áڛ˘ Ì ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÏfiÁˆ ¿ÛıÌ·ÙÔ˜ Û ·È‰È·ÙÚÈΤ˜ ÎÏÈÓÈΤ˜ ÙÚÈÒÓ ÓÔÛÔÎÔÌ›ˆÓ Ù˘ µfiÚÂÈ·˜ ∂ÏÏ¿‰·˜ ηٿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰È·ÈÛÙÒıËΠ̠ÚfiÛÊ·ÙË ÌÂϤÙË (13), Ô˘ Û˘Ì‚·‰›˙ÂÈ Ì ٷ ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ (14). ™ÙË Ì›ˆÛË ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ¤¯ÂÈ Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο Ë ¯Ú‹ÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Û ¯·ÌËϤ˜ ‰fiÛÂȘ ÛÙ· ·È‰È¿ Ì ‹ÈÔ ¿ÛıÌ·, ·ÓÙÈÌÂÙÒÈÛË Ë ÔÔ›· ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ηχÙÂÚ˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È Ì›ˆÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÚÔ͢ÛÌÒÓ (15). ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·È‰È¿ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ™Â ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È Ì›ˆÛË ÙˆÓ Â̇ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÁÂÓÈο ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi (17) ηıÒ˜ ›Û˘ Î·È Ì›ˆÛË ÙˆÓ Â̇ÚÂÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ÌÂÙ¿ ÙËÓ Î·ıȤڈÛË ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ (18,19). ¢ÂÓ ˘¿Ú¯Ô˘Ó ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó ÙË Ì›ˆÛË ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ÁÂÁÔÓfi˜ Ô˘ ‰È·ÈÛÙÒıËΠ۠ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙË ™Ô˘Ë‰›· Û ¿ÙÔÌ· ËÏÈΛ·˜ ≥65 ÂÙÒÓ (16). °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜ ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÚÔÔÙÈΤ˜, ÂÏÂÁ¯fiÌÂÓ˜, Ù˘¯·ÈÔÔÈË̤Ó˜ Î·È Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜ ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂȂ‚·Èˆı› fiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÚÔÏ·Ì‚¿ÓÂÈ ÙȘ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙË ÁÚ›Ë ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜, Î·È ÌÂÈÒÓÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÂÈÛ·ÁˆÁÒÓ (20), ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ˘Â‡ı˘Ó· ÁÈ· Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ Áڛ˘ ÛÙÂϤ¯Ë οı ÂÔ¯‹˜. ™˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔı‹Î˘ Cohrane, ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÙfiÌˆÓ Û˘ÌÂÚ·›ÓÂÈ fiÙÈ Ù· ¤ˆ˜ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ÁÈ· Ù· ÔʤÏË Î·È ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙ· ·ÛıÌ·ÙÈο ¿ÙÔÌ· Â›Ó·È ·Ó·Ú΋ ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ (21). √È Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ·Ó·‰ÚÔÌÈο (18) ‹ ÙÔ˘ ÔÛÔÛÙÔ‡ ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘ ÛÙÔÓ Èfi Ù˘ Áڛ˘ Û ·ÛıÌ·ÙÈÎfi ÏËı˘ÛÌfi (20). ¶ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ‰ÈÂÚ‡ÓËÛ ÙȘ ÂÈÛΤ„ÂȘ ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Î·È ÙȘ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÌÂٷ͇ ‰‡Ô ÏËı˘ÛÌÒÓ 400 ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-19 ÂÙÒÓ, Ô˘ ¤Ï·‚·Ó ‹ fi¯È ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ, ¤‰ÂÈÍ fiÙÈ ÛÙ· ·È‰È¿ Ô˘ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ¶·È‰È·ÙÚÈ΋ 2007;70:416-419
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º. ∫˘Ú‚·Û›Ï˘ Î·È Û˘Ó.
ηٷÁÚ¿ÊËΠÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÂÈÛΤ„ÂˆÓ ÛÙ· È·ÙÚ›· ¿ÛıÌ·ÙÔ˜ Î·È ÛÙ· ÙÌ‹Ì·Ù· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (23). ∏ ÌÔÓ·‰È΋ Ù˘¯·ÈÔÔÈË̤ÓË ‰ÈÏ‹-Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ ÌÂϤÙË, ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ √ÏÏ·Ó‰›·, Î·È ‰ËÌÔÛȇÙËΠÙÔÓ ª¿ÚÙÈÔ ÙÔ˘ 2004 (24). ∞ÊÔÚ¿ ÛÙËÓ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ·‰Ú·ÓÔÔÈË̤ÓÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ Û 347 ·ÛıÌ·ÙÈο ·È‰È¿ Û ۇÁÎÚÈÛË Ì 349 ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ™ÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÁÈÓfiÙ·Ó Î·ıËÌÂÚÈÓ‹ ηٷÁÚ·Ê‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔ ·ÓÒÙÂÚÔ Î·È Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Î·È Ï‹„Ë Ê·Ú˘ÁÁÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ηٿ ÙȘ ÂÍ¿ÚÛÂȘ. ¢È·ÈÛÙÒıËΠfiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‰ÂÓ Î·Ù¤ÏËÍ Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡, Ù˘ ‚·Ú‡ÙËÙ·˜ ‹ Ù˘ ‰È¿ÚÎÂÈ·˜ ÙˆÓ ÂÍ¿ÚÛÂˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ô˘ ÚÔÎÏ‹ıËÎ·Ó ·fi ÁÚ›Ë. π‰È·›ÙÂÚ· ·ÍÈfiÏÔÁ˜ ÚÔÛ¿ıÂȘ Á›ÓÔÓÙ·È Û‹ÌÂÚ· ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ, fiˆ˜ ÙÔ ÂÓ‰ÔÚÚÈÓÈο ¯ÔÚËÁÔ‡ÌÂÓÔ ÂÌ‚fiÏÈÔ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜. ∆Ô ÂÌ‚fiÏÈÔ ·˘Ùfi ÚÔ˜ ÙÔ ·ÚfiÓ ·ÓÙÂӉ›ÎÓ˘Ù·È ÛÙ· ·È‰È¿ Ì ¿ÛıÌ· ÏfiÁˆ Âȉ›ӈÛ˘ Ô˘ Èı·ÓfiÓ Ó· ÚÔηϤÛÂÈ ÛÙË ÓfiÛÔ. ¶·Ú¿ÏÏËÏ·, ¤¯ÂÈ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ë ÙÔÈ΋ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ÂӉ¯Ô̤ӈ˜ Ó· ÂÓÈÛ¯‡ÂÈ ÙËÓ ÙÔÈ΋ IgA ·ÓÔÛ›· Ë ÔÔ›· ·ÔÙÂÏ› ÙËÓ ¿Ì˘Ó· ÚÒÙ˘ ÁÚ·ÌÌ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞ӷ̤ÓÔÓÙ·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜. ¶ÚÔÛ·ıÒÓÙ·˜ Ó· ÂÚÌËÓ‡ÛÔ˘Ì ٷ Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ ·Ú·¿Óˆ ÌÂÏÂÙÒÓ ·Í›˙ÂÈ Ó· ÂÈÛËÌ¿ÓÔ˘Ì fiÙÈ ·fi ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ηٷÁڷʤ˜ Û ·È‰È¿ Ì ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÔÈ Î˘Ú›ˆ˜ ¢ı˘ÓfiÌÂÓÔÈ ÈÔ› Â›Ó·È ·) ÁÈ· Ù· ‚Ú¤ÊË Ô RSV Û ÔÛÔÛÙfi 2070% Î·È ÔÈ ÚÈÓÔ˚Ô›-ÂÓÙÂÚÔ˚Ô› Û ÔÛÔÛÙfi 30-60%, ÂÓÒ ‚) ÁÈ· Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÔÈ ÚÈÓÔ˚Ô›-ÂÓÙÂÚÔ˚Ô› ÛÙÔ 65% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-2 ÂÙÒÓ Î·È ÛÙÔ 82% ÙˆÓ ·È‰ÈÒÓ ¿Óˆ ÙˆÓ 3 ÂÙÒÓ (3,25-27). º·›ÓÂÙ·È fiÙÈ ÔÈ ÚÈÓÔ˚Ô› ¤¯Ô˘Ó ÌÈ· ȉȷ›ÙÂÚË Û¯¤ÛË Ì ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ ÛÙ· ·È‰È¿ ·Ú·Ì¤ÓÔÓÙ·˜ ÛÙȘ ÚÈÓÈΤ˜ ÂÎÎÚ›ÛÂȘ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (26), ÂÓÒ ·fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ fiÙÈ ÂÎÙfi˜ ·fi ÙÔ ·ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηϤÛÔ˘Ó Î·È Ó¢ÌÔÓ›· Û ˘ÁÈ‹ ¿ÙÔÌ· (28,30,31). ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ë ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÛÙÔÓ ÚÈÓÔ˚fi fi¯È ÌfiÓÔ ‰ÂÓ Â›Ó·È ·ÔÎÏÂÈÛÙÈο Ù‡Ô˘ 1 (Th1) ·ÏÏ¿ fiÙÈ Û ·ÙÔÈÎÔ‡˜ ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È ÌÂȈ̤ÓË Û ۯ¤ÛË ÌÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ··ÓÙ‹ÛÂȘ Th2 Ù‡Ô˘ (29,30). º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ ÔÈ Û˘¯ÓfiÙÂÚ· ÂÓÔ¯ÔÔÈÔ‡ÌÂÓÔÈ ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ Â›Ó·È ÔÈ ÚÈÓÔ˚Ô› ÔÈ ÔÔ›ÔÈ Ì ÙËÓ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÛıÌ·ÙÈÎÔ‡ ·ÙfiÌÔ˘ ÎÈÓËÙÔÔÈÔ‡Ó Ì˯·ÓÈÛÌfi Paediatriki 2007;70:416-419
·ÓÔÛ›·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ Ù‡Ô˘ 2 ·ÓÙ›‰Ú·ÛË, ÂÓÒ ÔÈ ÈÔ› Ù˘ Áڛ˘ Ôχ Û·ÓÈfiÙÂÚ· ·ÔÌÔÓÒÓÔÓÙ·È ·fi ÙȘ ÚÈÓÈΤ˜ ÂÎÎÚ›ÛÂȘ ·ÙfiÌˆÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·ÛıÌ·ÙÈ΋ ¤Í·ÚÛË.
™˘ÌÂÚ¿ÛÌ·Ù· ·) §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· fiÙÈ Ô ·ÓÙÈÁÚÈÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ÂȂ‚ÏË̤ÓÔ˜ Û ·È‰È¿ Ì ‚·ÚȤ˜ ηډÈÔ¿ıÂȘ Î·È ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ, fiˆ˜ ‚·Ú‡ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·, ΢ÛÙÈ΋ ›ÓˆÛË, Û‡Ó‰ÚÔÌÔ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ, ‚ÚÔÁ¯ÂÎٷۛ˜ Î.Ï., fiÔ˘ ˘¿Ú¯ÂÈ ÌË ·Ó·ÛÙÚ¤„ÈÌË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÂÏÏÈ‹˜ ·Ó¿Ù˘ÍË Ù˘ ÙÔÈ΋˜ ·ÓÔÛ›·˜. ‚) À¿Ú¯Ô˘Ó ‰ËÌÔÛÈÂ˘Ì¤Ó· ÛÙÔȯ›· Ô˘ ÎÏÔÓ›˙Ô˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ˆ˜ ÚÔ˜ ÙË Ì›ˆÛË ÙˆÓ ÂÍ¿ÚÛÂˆÓ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿, ηıÒ˜ ÔÈ Î·ÙÂÍÔ¯‹Ó ¢ı˘ÓfiÌÂÓÔÈ ÈÔ› ÁÈ· ÙȘ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ Â›Ó·È Ô RSV Î·È ÔÈ ÚÈÓÔ˚Ô›. ŒÙÛÈ ıˆÚÂ›Ù·È ·ÌÊ›‚ÔÏË Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ηıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ‹ÈÔ ‹ ·ÎfiÌË Î·È Ì¤ÙÚÈÔ ¿ÛıÌ·, fiÔ˘ Ë ‚Ï¿‚Ë ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÈıËÏ›Ô˘ Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË. ¶ÚÔÔÙÈΤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ì ٷÍÈÓfiÌËÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Û‡Ìʈӷ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ı· ‰ÒÛÔ˘Ó ÔÚÈÛÙÈ΋ ·¿ÓÙËÛË ÛÙÔ ı¤Ì· ÙÔ˘ ηıÔÏÈÎÔ‡ ‹ ÂÈÏÂÎÙÈÎÔ‡ ·ÓÙÈÁÚÈÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. CDC. Prevention and control of illness: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza 2003/ 52 (RR08);1-36. 2. Johnston SL, Pattemore PK, Sanderson G, Smith S, Lampe F, Josephs L et al. Community study of the role of viral infections in exacerbations of asthma in 9-11 year old children. BMJ 1995;310:1225-1229. 3. Jartti T, Lehtinen P, Vuorinen T, Osterback R, van den Hoogen B, Osterhaus AD, Ruuskanen O. Respiratory picornaviruses and respiratory syncytial virus as causative agents of acute expiratory wheezing in children. Emerg Infect Dis 2004;10:1095-1101. 4. Neuzil KM, Mellen BG, Wright PF, Mitchel EF, Griffin MR. Effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children. New Engl J Med 2000;342:225-231. 5. Neuzil KM, Wright PF, Mitchel EF, Griffin MR. Burden of influenza illness in children with asthma and other chronic medical conditions. J Pediatr 2000;137:856-864. 6. CDC. Prevention and control of illness: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza 2004/ 53 (No. RR-6). 7. Gnanasekaran SK, Finkelstein JA, Lozano P, Farber HJ,
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19. Christenson B, Hedlund J, Lundbergh P, Ortqvist A. Additive preventive effect of influenza and pneumococcal vaccines in elderly persons. Eur Respir J 2004;23:363-368. 20. Neuzil KM. Influenza vaccine for children. Clin Infect Dis 2004;38:689-691. 21. Cates CJ, Jefferson TO, Bara AI, Rowe BH. Vaccines for preventing influenza in people with asthma. Cohrane Database Syst Rev 2004;(2):CD000364. 22. Ruben FL. Inactivated Influenza Virus Vaccines in Children. Clin Infec Dis 2004; 38:678-688. 23. Christy C, Aligne CA, Auinger P, Pulcino T, Weitzman M. Effectiveness of influenza vaccine for the prevention of asthma exacerbations. Arch Dis Child 2004;89:734-735. 24. Beuving HJ,Bernsen RMD, de Jongste JC, et al. Influenza vaccination in children with asthma.Randomized DoubleBlind Placebo-controlled Trial. Am J Respir Crit Care Med 2004;169:488-493. 25. Jartti T, Lehtinen P, Vuorinen T, Koskenvuo M, Ruuskanen O. Persistence of rhinovirus and enterovirus RNA after acute respiratory illness in children. J Med Virol. 2004;72:695-699. 26. van Benten I, Koopman L, Niesters B, Hop W, van Middelkoop B, de Waal L, et al. Predominance of rhinovirus in the nose of symptomatic and asymptomatic infants. Ped Allergy Immunol 2003;14:363-370. 27. Fleming DM, Pannell RS, Elliot AJ, Cross KW. Respiratory illness associated with influenza and respiratory syncytial virus infection. Arch Dis Child 2005; 90:741-746. 28. Papadopoulos NG. Do rhinoviruses cause pneumonia in children? Paediatr Respir Rev 2004;5 (Suppl A):S191S195. 29. Papadopoulos NG, Stanciou LA, Papi A, Holgate ST, Johnston SL. A defective type 1 response to rhinovirus in atopic asthma. Thorax 2002;57:328-332. 30. Papadopoulos NG, Papi A, Psarras S, Johnston SL Mechanisms of rhinovirus-induced asthma. Paediatr Respir Rev 2004;5:255-260. 31. Papadopoulos N, Bates PJ, Bardin PG, Papi A, Leir SH, Fraenkel DJ, et al. Rhinovirus infects the lower airways. J Infect Dis 2000:181:1875-1884.
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LETTER FROM THE EDITORS
¢ÈÏ‹ ÙÈÌËÙÈ΋ ‰È¿ÎÚÈÛË ÛÙÔ˘˜ ¤ÏÏËÓ˜ ·È‰›·ÙÚÔ˘˜ ∏ ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· (∂¶∂) ‰ÈÂÍ‹Á·Á ÛÙËÓ ∞ı‹Ó· ÙÔ 25Ô ¶·ÁÎfiÛÌÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ˘fi ÙËÓ ÚÔ‰ڛ· ÙÔ˘ ηıËÁËÙÔ‡ ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˘ ·fi 25-30 ∞˘ÁÔ‡ÛÙÔ˘, ÙÔ ÔÔ›Ô ÂÛÙ¤ÊıË ·fi ·fiÏ˘ÙË ÂÈÙ˘¯›· (ÔÚÁ·ÓˆÙÈο Î·È ÂÈÛÙËÌÔÓÈο). ∆Ô ·Ú·ÎÔÏÔ‡ıËÛ·Ó ÂÚ›Ô˘ 8.000 Û‡Ó‰ÚÔÈ ·fi 133 ¯ÒÚ˜. ™Ù· ÁÚ·Ê›· Ù˘ ∂¶∂ Êı¿ÓÔ˘Ó Î·ıËÌÂÚÈÓ¿ ‰Âο‰Â˜ ÂÈÛÙÔϤ˜ Î·È e-mails, ÛÙ· ÔÔ›· ÂÎÊÚ¿˙ÔÓÙ·È Ù· Û˘Á¯·ÚËÙ‹ÚÈ· ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ¶·Ú¿ÏÏËÏ·, Ë ÁÂÓÈ΋ Û˘Ó¤Ï¢ÛË Ù˘ ¶·ÓÂ˘Úˆ·˚΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜, ÛÙË Û˘Ó‰ڛ· Ù˘ 27 ∞˘ÁÔ‡ÛÙÔ˘, ÂͤÏÂÍ ·Ì„ËÊ› ÙÔÓ Î·ıËÁËÙ‹ Î. ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ ˆ˜ Úfi‰ÚÔ Ù˘ ¶·ÓÂ˘Úˆ·˚΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜. ŸÏ· ·˘Ù¿ ÂȂ‚·ÈÒÓÔ˘Ó ÙÔ ‡„Ô˜ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂ÈÛÙ‹Ì˘ ÛÙÔÓ ‰ÈÂıÓ‹ ÔÚ›˙ÔÓÙ·. ™˘Á¯·›ÚÔ˘Ì ÙÔÓ Î·ıËÁËÙ‹ Î. ∞Ó‰Ú¤· ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ ÁÈ· ÙËÓ ÂÎÏÔÁ‹ ÙÔ˘ ÛÙË ı¤ÛË ·˘Ù‹ Î·È ÙÔ˘ ¢¯fiÌ·ÛÙ ÂÈÙ˘¯›· ÛÙÔ Ó¤Ô ÙÔ˘ ¤ÚÁÔ, ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∂˘ÚÒ˘. °È· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
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¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ “ªËÙ¤Ú·”
∞. ∑¤ÏÏÔ˘
∞ÁfiÚÈ ËÏÈΛ·˜ 11 ÂÙÒÓ ·Ú·¤ÌÊıËΠÏfiÁˆ ‰È·Ï›ÔÓÙÔ˜ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ ÛÙÔ ‰ÂÍÈfi ˘Ô¯fiÓ‰ÚÈÔ. ¢ÂÓ ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ˘ÚÂÙÔ‡, ‰È¿ÚÚÔÈ·˜ ‹ Â̤وÓ. ™ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ÙÔ ·È‰› ‹Ù·Ó ·¯‡Û·ÚÎÔ Ì ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ >95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ Î·È Ì ̿˙· ÛÒÌ·ÙÔ˜ >95˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘. ∫·Ù¿ ÙËÓ „ËÏ¿ÊËÛË Ù˘ ÎÔÈÏÈ¿˜ ‰È·ÈÛÙÒıËΠ¢·ÈÛıËÛ›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ‰ÂÍÈÔ‡ ˘Ô¯fiÓ‰ÚÈÔ˘, Ì ·ÚÓËÙÈÎfi ˆÛÙfiÛÔ ÛËÌÂ›Ô Murphy. ™Â ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ·Ú·ÙËÚ‹ıËÎ·Ó ·˘ÍË̤ӷ Ë·ÙÈο ¤Ó˙˘Ì· ÛÙÔÓ ÔÚfi (SGPT= 120 IU/L, SGOT= 99 IU/L, GGT= 47 IU/L), Î·È ·˘ÍË̤ÓË ¯ÔÏËÛÙÂÚfiÏË Î·È ÙÚÈÁÏ˘ÎÂÚ›‰È· (ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË = 220 mg/dl, ÙÚÈÁÏ˘ÎÂÚ›‰È· = 334 mg/dl) ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·Ì˘Ï¿ÛË ÔÚÔ‡ (·Ì˘Ï¿ÛË = 34 IU/L). √È ÁÂÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ∏ ·1 ·ÓÙÈıÚ˘„›ÓË, ÛÂÚÔ˘ÏÔÏ·ÛÌ›ÓË, ¯·ÏÎfi˜ ÔÚÔ‡ Î·È Ë Û˘ÁΤÓÙÚˆÛË ¯·ÏÎÔ‡ ÛÂ Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆Ô ·È‰› ˘Ô‚Ï‹ıËΠ۠˘ÂÚ˯Ô-
ÁÚ¿ÊËÌ· ‹·ÙÔ˜, ÙÔ ÔÔ›Ô ·¤ÎÏÂÈÛ ÙËÓ ‡·ÚÍË ¯ÔÏÔÏÈı›·Û˘, Î·È Û ‰È·‰ÂÚÌ·ÙÈ΋ ‚ÈÔ„›· ‹·ÙÔ˜, Ë ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ù˘ ÔÔ›·˜ ·ÂÈÎÔÓ›˙ÂÙ·È ·Ú·Î¿Ùˆ.
AÏÏËÏÔÁÚ·Ê›·: ∞›ÁÏË ∑¤ÏÏÔ˘ azellos@jhmi.edu ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ “ªËÙ¤Ú·” §ÂˆÊ. ∫ËÊÈÛ›·˜ Î·È ∂Ú˘ıÚÔ‡ ™Ù·˘ÚÔ‡ 6, ∆.∫. 151 23, ª·ÚÔ‡ÛÈ, ∞ı‹Ó·
¶ÔÈ¿ Â›Ó·È Ë ‰È¿ÁÓˆÛË; 1. ÃÚfiÓÈ· Ë·Ù›Ùȉ· B ‹ C 2. ∞˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· 3. ¡fiÛÔ˜ Wilson 4. §È҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜
¶·È‰È·ÙÚÈ΋ 2007;70:421-421
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422
™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞
AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘
¡fiÛÔ˜ Kawasaki Î·È ‚Ï¿‚˜ ÛÙÂÊ·ÓÈ·›ˆÓ ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Kawasaki ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË, fiˆ˜ ·Ú·Ì¤ÓÂÈ ·Ó·¿ÓÙËÙÔ Î·È ÙÔ ÁÈ·Ù› Ù· ÛÙÂÊ·ÓÈ·›· ·Ó¢ڇÛÌ·Ù· ‰ÂÓ ÂÌÊ·Ó›˙ÔÓÙ·È Û fiÏ· Ù· ·È‰È¿. ∆Ô ÃˆÚ¤ÌÂÈÔ ¤·ıÏÔ 2007 ‰fiıËΠ۠ÌÂϤÙË ·fi ÙË £ÂÛÛ·ÏÔÓ›ÎË (‰ËÌÔÛȇÂÙ·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜) ÁÈ· ÙÔÓ ÔÏ˘ÌÔÚÊÈÛÌfi VEGF 405G/C ˆ˜ ÁÂÓÂÙÈÎfi ·Ú¿ÁÔÓÙ· ¢¿ıÂÈ·˜ ÛÙË ÓfiÛÔ Kawasaki. ªÂϤÙË ·fi ÙËÓ √ÏÏ·Ó‰›·, ˘fi ‰ËÌÔÛ›Â˘ÛË ÛÙÔ Clin Exp Immunol (ËÏÂÎÙÚÔÓÈ΋ ÚÔ‰ËÌÔÛ›Â˘ÛË 2 ∞˘Á 2007), Û˘Û¯ÂÙ›˙ÂÈ ÙÔ˘˜ ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ ¯ËÌÂÈÔÎÈÓÒÓ CCR3-CCR2-CCR5 Ì ÙËÓ Â˘¿ıÂÈ· ÛÙË ÓfiÛÔ Kawasaki Î·È ÌÂϤÙË ·fi ÙËÓ π·ˆÓ›· ÛÙÔ Ù‡¯Ô˜ ∞˘ÁÔ‡ÛÙÔ˘ ÙÔ˘ J Pediatr (2007;151:155-160) ηٷϋÁÂÈ fiÙÈ ÔÈ ÔÏ˘ÌÔÚÊÈÛÌÔ› ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ÈÛÙÈÎÔ‡ ·Ó·ÛÙÔϤ· Ù˘ ÌÂÙ·ÏÏÔÚˆÙÂ˚Ó¿Û˘ 2 ·ÔÙÂÏÔ‡Ó ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‚Ï·‚ÒÓ ÛÙ· ÛÙÂÊ·ÓÈ·›·. ªËÓÈÁÁ›Ùȉ˜ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ· ∏ ·fi ·ÏÈ¿ ÁÓˆÛÙ‹ ÏËÚÔÊÔÚ›· fiÙÈ Ë ‚·ÎÙËÚȉȷ΋ ÌËÓÈÁÁ›Ùȉ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ì·ÎÚÔ¯ÚfiÓÈ· ÚÔ‚Ï‹Ì·Ù· Ì¿ıËÛ˘ ÂȂ‚·ÈÒıËΠ̠ÚfiÛÊ·ÙË ‚ÚÂÙ·ÓÈ΋ ÌÂϤÙË (Arch Dis Child, ËÏÂÎÙÚÔÓÈ΋ ÚÔ‰ËÌÔÛ›Â˘ÛË ª·ÚÙ 2007) Û 461 Ó¤Ô˘˜ Ô˘ ›¯·Ó ÓÔÛ‹ÛÂÈ ˆ˜ ‚Ú¤ÊË ·fi ÌËÓÈÁÁ›Ùȉ· ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 Î·È 289 Ì¿ÚÙ˘Ú˜. ∏ ÔÌ¿‰· Ì ·Ó·ÌÓËÛÙÈÎfi ÌËÓÈÁÁ›Ùȉ·˜ ›¯Â ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÊÔ›ÙËÛ˘ Û ÂȉÈο Û¯ÔÏ›· (8% ¤Ó·ÓÙÈ 0%) Î·È ·ÔÙ˘¯›·˜ ÛÙȘ ÂÍÂÙ¿ÛÂȘ ÂıÓÈÎÔ‡ ÂȤ‰Ô˘. ∫·Ù¿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 ‹Ù·Ó Û˘¯Ó‹ Ë ÌËÓÈÁÁ›Ùȉ· ·fi ·ÈÌfiÊÈÏÔ Ù˘ Áڛ˘ Ù‡Ô˘ b, ·ıÔÁfiÓÔ ÁÓˆÛÙfi ÁÈ· Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ηٿÏÔÈ¿ ÙÔ˘, Î·È ÂӉ¯Ô̤ӈ˜ Ë ¤Î‚·ÛË ÙˆÓ ·È‰ÈÒÓ Ó· Â›Ó·È Î·Ï‡ÙÂÚË Û‹ÌÂÚ· Ô˘ Ô ·ÈÌfiÊÈÏÔ˜ Û·Ó›˙ÂÈ. ∞ÓÙ›ıÂÙ·, ÔÈ ÂΉfiÙ˜ ÙÔ˘ Pediatr Infect Dis J (ª¿ÈÔ˜ 2007; Newsletter) ·ÓËÛ˘¯Ô‡Ó Ì‹ˆ˜ Ë Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ ÌÂÙ¿ Ù· ÂÈÙ˘¯Ë̤ӷ ÂÌ‚fiÏÈ· Ô‰ËÁ‹ÛÂÈ Û ¯·Ï¿ÚˆÛË Ù˘ ·ÁÚ‡ÓËÛ˘, ηı˘ÛÙÂÚË̤ÓË ‰È¿ÁÓˆÛË Î·È ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË. Paediatriki 2007;70:422-423
∏ ·ÓÂÚ¯fiÌÂÓË Kingella kingae ∏ Kingella kingae ÁÂÓÈÎÒ˜ ıˆÚÂ›Ù·È ˆ˜ ·ıÔÁfiÓÔ ‰Â˘ÙÂÚÂ‡Ô˘Û·˜ ÛËÌ·Û›·˜ ÛÙȘ ÔÛÙÂÔ·ÚıÚÈΤ˜ ÏÔÈÌÒÍÂȘ, fiÔ˘ Ì¿ı·Ì ӷ ÂÈÎÚ·ÙÔ‡Ó Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, Ô ‚-·ÈÌÔÏ˘ÙÈÎfi˜ ÛÙÚÂÙfiÎÔÎÎÔ˜ Î·È Ô ·ÈÌfiÊÈÏÔ˜ Ù˘ Áڛ˘ Ù‡Ô˘ b. øÛÙfiÛÔ, ÌÂϤÙË ·fi ÙË §˘fiÓ Ù˘ °·ÏÏ›·˜ (Ped Infect Dis J 2007;26:377) Ì PCR ˘„ËÏ‹˜ ¢·ÈÛıËÛ›·˜ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙËÓ K. kingae ˆ˜ ÙÔ Û˘¯ÓfiÙÂÚÔ ·ıÔÁfiÓÔ ÔÛÙÂÔ·ÚıÚÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·È‰È¿ (39% ¤Ó·ÓÙÈ 25% ÙÔ˘ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘) Î·È Ì¿ÏÈÛÙ· ÛÙ· ÌÈÎÚfiÙÂÚ· (6 ÌËÓÒÓ ¤ˆ˜ 3 ÂÙÒÓ). ∆Ô Î·Ïfi Ì ÙËÓ K. kingae Â›Ó·È fiÙÈ ·Ú·Ì¤ÓÂÈ Â˘·›ÛıËÙË Û ÔÏÏ¿ ·ÓÙÈ‚ÈÔÙÈο, ÙÔ Î·Îfi Â›Ó·È fiÙÈ Ì ÙȘ Û˘ÓËıÈṲ̂Ó˜ ηÏÏȤÚÁÂȘ ˘Ô‰È·ÁÈÁÓÒÛÎÂÙ·È. ∆· ÂÌ‚fiÏÈ· οÓÔ˘Ó Î·Ïfi Î·È ÛÙÔ˘˜ ÁÔÓ›˜ To ÂÙ·‰‡Ó·ÌÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ÛÙ· ·È‰È¿ ÌÂÈÒÓÂÈ ÙȘ Ó¢ÌÔӛ˜ Î·È ÛÙÔ˘˜ ÁÔÓ›˜: ÛÙȘ ∏¶∞ (Lancet 2007;369:1179 Î·È 1144), ÔÈ Û˘ÓÔÏÈΤ˜ ÂÈÛ·ÁˆÁ¤˜ ÁÈ· Ó¢ÌÔÓ›· ÌÂÈÒıËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ηٿ 39% ÁÈ· Ù· ‚ÚÂÊÔÓ‹È· ·ÏÏ¿ Î·È Î·Ù¿ 26% ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ 18-39 ÂÙÒÓ. ∏ ÂÍ‹ÁËÛË Â›Ó·È Â‡ÏÔÁË: ÔÈ ÁÔÓ›˜ ·ı·›ÓÔ˘Ó ÏÈÁfiÙÂÚ˜ Ó¢ÌÔӛ˜ ÂÂȉ‹ Ù· ·È‰È¿ ʤÚÔ˘Ó ÏÈÁfiÙÂÚÔ˘˜ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘˜. ∏ ÂÔ¯‹ ÌÂÙ¿ ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ∆Ô Ù‡¯Ô˜ πÔ˘Ó›Ô˘ ÙÔ˘ Pediatr Infect Dis J ÊÈÏÔÍÂÓ› 4 ÌÂϤÙ˜ ÁÈ· ÙÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ (2007;26:461, 468, 473, 540). ™ÙÔ ∆¤Í·˜, ÔÈ ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ˘Ô‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ˆÛÙfiÛÔ ÔÈ ÔÚfiÙ˘ÔÈ Ô˘ ‰ÂÓ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ ·Ú·Ì¤ÓÔ˘Ó Úfi‚ÏËÌ·, ȉȷ›ÙÂÚ· Ô 19∞ Ô˘ ¤¯ÂÈ Î·È ·˘ÍË̤ÓË ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ∫·È ÛÙË ª·Û·¯Ô˘Û¤ÙË, Ô ÔÚfiÙ˘Ô˜ 19∞ Â›Ó·È ÙÔ Î‡ÚÈÔ ·ıÔÁfiÓÔ Î·È ÂÈϤÔÓ Ù·˘ÙÔÔÈ‹ıËΠÔÏ˘·ÓıÂÎÙÈÎfi˜ ÎÏÒÓÔ˜. ™ÙÔ µ·ÓÎÔ‡‚ÂÚ, ÔÈ ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ˘Ô¯ÒÚËÛ·Ó ı·̷ÙÈο ÌÂÙ¿ ÙÔ ÂÌ‚fiÏÈÔ, Ì ÙËÓ ÈÔ ÌÂÁ¿ÏË ÙÒÛË (85%) Ó· ·Ú·ÙËÚÂ›Ù·È ÛÙ· ‚ÚÂÊÔÓ‹È· 6-23 ÌËÓÒÓ.
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PAEDIATRIC NEWS IN BRIEF ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÌÈ· ‰fiÛË ‰ÂÓ ÊÙ¿ÓÂÈ √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì›ˆÛ ‰Ú·Ì·ÙÈο (85%) ÙËÓ Â›ÙˆÛË Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÛÙȘ ∏¶∞, ˆÛÙfiÛÔ 9,5% ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌ¤ÓˆÓ ·È‰ÈÒÓ ‰ÂÓ ·¤Ê˘Á·Ó ÙË ÓfiÛÔ ÎÈ fiÛÔ ÂÚÓÔ‡ÛÂ Ô Î·ÈÚfi˜ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, ÙfiÛÔ Û˘¯ÓfiÙÂÚ· Î·È ÛÔ‚·ÚfiÙÂÚ· ‹Ù·Ó Ù· ÎÚÔ‡ÛÌ·Ù· (N Engl J Med 2007;356:1121). ªÂ ÙËÓ ·Ú·Ù‹ÚËÛË ·˘Ù‹, ÔÈ Û˘ÛÙ¿ÛÂȘ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ™˘Ì‚Ô˘Ï¢ÙÈ΋˜ ∂ÈÙÚÔ‹˜ ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· Ì›· ÌfiÓÔ ‰fiÛË ÛÙ· ·È‰È¿ ¿ÏÏ·Í·Ó ÚfiÛÊ·Ù· (ACIP, 22 πÔ˘Ó›Ô˘ 2007 Î·È MMWR 2007; 56(RR04):1-40). ∆ÒÚ· Û˘ÓÈÛÙÒÓÙ·È 2 ‰fiÛÂȘ ÁÈ· fiÏ· Ù· ·È‰È¿, Ë ÚÒÙË ÛÙÔ˘˜ 12-15 Ì‹Ó˜ Î·È Ë ‰Â‡ÙÂÚË ÛÙ· 4-6 ¤ÙË ‹ Î·È ÓˆÚ›ÙÂÚ· (·ÏÏ¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÚÒÙË ‰fiÛË). ™Â ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ·Ó·ÌÓËÛÙÈÎfi 1 ÌfiÓÔ ‰fiÛ˘ Û˘ÓÈÛÙ¿Ù·È ¿ÏÏË 1. ∆Ô ÂÌ‚fiÏÈÔ Û˘ÓÈÛÙ¿Ù·È Î·È ÁÈ· ÙȘ 3-5 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË ·ÓÂÌ‚ÔÏ›·ÛÙÔ˘ Û ÎÚÔ‡ÛÌ·. ªÂÙ··Ó¿Ï˘ÛË ÛÙÔ Ù‡¯Ô˜ ∞˘ÁÔ‡ÛÙÔ˘ ÙÔ˘ Pediatr Infect Dis J (2007;26:572-576) ˘Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ·ÓÔÛÔÁÔÓÈÎfi˜ Î·È ÛÙȘ ÈÔ ÌÈÎÚ¤˜ ËÏÈ˘ ÙˆÓ 12-14 ÌËÓÒÓ. º˘Ì·Ù›ˆÛË: ÓÂfiÙÂÚ· ÛÙË ‰È¿ÁÓˆÛË ∏ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙ· ·È‰È¿ ‰˘Û¯ÂÚ·›ÓÂÙ·È ·fi ÙË ‰˘ÛÎÔÏ›· ·Ú·ÁˆÁ‹˜ Ù˘¤ÏˆÓ ÌÂÙ¿ ·fi¯ÚÂ̄˘ Î·È ÙËÓ ÂÓÔ¯ÏËÙÈ΋ ̤ıÔ‰Ô Ï‹„˘ Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡. ∏ ‰ÂÈÁÌ·ÙÔÏË„›· Ù˘¤ÏˆÓ ÌÂÙ¿ ·fi ÚfiÎÏËÛË Ì ÓÂÊÂÏÔÔÈË̤ÓÔ ˘¤ÚÙÔÓÔ ¯ÏˆÚÔÓ·ÙÚÈÔ‡¯Ô ‰È¿Ï˘Ì· ¤¯ÂÈ ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο. ™Â ÌÂϤÙË ÂÓËÏ›ÎˆÓ Ì Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË ·fi ÙÔ §ÔÓ‰›ÓÔ (Clin Inf Dis πÔ‡Ó 2007;44:1415-1420), Ë ÂͤٷÛË 3 ‰ÂÈÁÌ¿ÙˆÓ ÚÔÎÏËÙÒÓ Ù˘¤ÏˆÓ ‚Ú¤ıËΠÈÔ Â˘·›ÛıËÙË ·fi ÙˆÓ 3 Á·ÛÙÚÈÎÒÓ ÂÎÏ˘Ì¿ÙˆÓ (39% ¤Ó·ÓÙÈ 30%, p=0,03). ªÂϤÙË ·È‰ÈÒÓ Ì Ó¢ÌÔÓÈ΋ Ê˘Ì·Ù›ˆÛË ·fi ÙËÓ √˘ÁοÓÙ· (Arch Dis Child ∞‡Á 2007;92:693-696) ‰Â›¯ÓÂÈ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· Î·È Ì ÙËÓ ÂͤٷÛË ˘ÏÈÎÔ‡ ·fi ÚÈÓÔÊ·Ú˘ÁÁÈ΋ ·Ó·ÚÚfiÊËÛË (ıÂÙÈ΋ ¯ÚÒÛË 8,5% Î·È ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· 23,9%, ÂÚ›Ô˘ fiÛÔ Î·È Ì ٷ ÚÔÎÏËÙ¿ Ù‡ÂÏ·). H PCR ÚÈÓÔÊ·Ú˘ÁÁÈÎÔ‡ ›¯Â ¢·ÈÛıËÛ›· 62% Î·È ÂȉÈÎfiÙËÙ· 98%. ÃÂψӛÙÛ˜ Î·È ™·ÏÌÔÓ¤ÏϘ √È ÌÈÎÚ¤˜ (Î¤Ï˘ÊÔ˜ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 10 ÂηÙÔÛÙÒÓ) ¯ÂÏÒÓ˜ Û ÂÓ˘‰Ú›· ‹Ù·Ó ÚÔÛÊÈÏ›˜ ÛÙ· ·È‰È¿, ˆÛÙfiÛÔ Ë ÒÏËÛ‹ ÙÔ˘˜ ··ÁÔÚ‡ıËΠÛÙȘ ∏¶∞ ÌÂÙ¿ ÙË ‰È·›ÛÙˆÛË ÊÔÚ›·˜ Î·È ÎÚÔ˘ÛÌ¿ÙˆÓ Û·ÏÌÔÓ¤ÏψÛ˘ Î·È ÛÙȘ ¯ÂψӛÙÛ˜ Î·È ÛÙ· ·È‰È¿ Ô˘ ¤·È˙·Ó Ì·˙› ÙÔ˘˜. ™‡Ìʈӷ Ì ÙÔ˘˜ ÂΉfiÙ˜ ÙÔ˘ Pediatr Inf Dis J (Newsletter August 2007), ÔÈ ÌÔÏ˘Ṳ̂Ó˜ ¯ÂÏÒÓ˜ ÛÙȘ ∏¶∞ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙÔ ›‰ÈÔ ÂÎÙÚÔÊÂ›Ô ÛÙË §Ô˘È˙È¿Ó·. ªÂÙ¿ ·fi ›ÔÓ˜ ÚÔÛ¿ıÂȘ, ÔÈ ¯ÂÏÒÓ˜ Â›Ó·È ¿ÏÈ Î·ı·Ú¤˜ Î·È ÛÙÔ Ì¤ÏÏÔÓ ›Ûˆ˜ ͷӷοÓÔ˘Ó ·Ú¤· ÛÙ· ·È‰È¿. øÛÙfi-
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ÛÔ, ÚfiÛÊ·ÙË ·Ó·ÎÔ›ÓˆÛË ÙÔ˘ ·ÌÂÚÈηÓÈÎÔ‡ CDC (MMWR 6 πÔ˘Ï›Ô˘ 2007;56:649-652) ˘ÂÓı˘Ì›˙ÂÈ fiÙÈ ·Ó·ÊÔÚ¤˜ ÌÂÙ¿‰ÔÛ˘ Û·ÏÌÔÓÂÏÏÒÓ ·fi ¯ÂÏÒÓ˜ ÛÙÔÓ ¿ÓıÚˆÔ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘¿Ú¯Ô˘Ó, Ì ¤Ó· ÚfiÛÊ·ÙÔ Ì¿ÏÈÛÙ· ı·Ó¿ÛÈÌÔ ÎÚÔ‡ÛÌ· Û ‚Ú¤ÊÔ˜.
¶·Ú¤· Ì ˙Ò· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ªÂÁ¿ÏË ÁÂÚÌ·ÓÈ΋ ÌÂϤÙË (13 ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›·, 748 ·È‰È¿ Ì ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘, 1481 ·È‰È¿ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘) Û˘ÌÂÚ·›ÓÂÈ fiÙÈ Ë Û˘¯Ó‹ ·ʋ Ì ˙Ò· ·ÁÚÔÎÙ‹Ì·ÙÔ˜ (‚ÔÔÂȉ‹, ÁÔ˘ÚÔ‡ÓÈ·, ·ÈÁÔÚfi‚·Ù·) ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÓfiÛÔ˘ Crohn Î·È ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ ·ÚÁfiÙÂÚ· (Pediatrics 2007;120:354-361). ∂ÎÊÔ‚ÈÛÌfi˜ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÌÂÙ¤ÂÈÙ· „˘¯È΋ ˘Á›· ™ÙË ºÈÓÏ·Ó‰›·, 2540 ·ÁfiÚÈ· ÁÂÓÓË̤ӷ ÙÔ 1981 ÌÂÏÂÙ‹ıËÎ·Ó Û ËÏÈΛ· 8 ÂÙÒÓ ÁÈ· ÙÔ ·Ó ›¯·Ó ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ·¤Ó·ÓÙÈ ÛÙÔ˘˜ Û˘ÌÌ·ıËÙ¤˜ ÙÔ˘˜ ‹ ·Ó ˘‹ÚÍ·Ó ı‡Ì·Ù· ÂÈıÂÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ·fi Û˘ÌÌ·ıËÙ¤˜. ∆· ›‰È· ·È‰È¿ ÌÂÏÂÙ‹ıËÎ·Ó ·ÚÁfiÙÂÚ·, Û ËÏÈΛ· 18-23 ÂÙÒÓ ·fi Ù· ÛÙÚ·ÙÔÏÔÁÈο ˘ÁÂÈÔÓÔÌÈο ·Ú¯Â›·. ∆· ·È‰È¿ Ì ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ‹Ù·Ó ÈÔ Èı·Ófi Ó· ‚ÚÂıÔ‡Ó ·ÚÁfiÙÂÚ· Ì ·ÓÙÈÎÔÈÓˆÓÈ΋ ‰È·Ù·Ú·¯‹ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È Ù· ·È‰È¿-ı‡Ì·Ù· Ì ·Á¯Ò‰ÂȘ ‰È·Ù·Ú·¯¤˜. ∆· ·È‰È¿ Ô˘ ˘‹ÚÍ·Ó Î·È ÙÚ·ÌÔ‡ÎÔÈ Î·È ı‡Ì·Ù· ÂÎÊÔ‚ÈÛÌÔ‡ ‚ÚÈÛÎfiÙ·Ó ÈÔ Û˘¯Ó¿ Î·È Ì ·ÓÙÈÎÔÈÓˆÓÈ΋ ‰È·Ù·Ú·¯‹ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È Ì ·Á¯Ò‰ÂȘ ‰È·Ù·Ú·¯¤˜ (Pediatrics 2007;120:397-404). ∂ȉËÌ›· ÈÏ·Ú¿˜ Û ۯÔÏÂ›Ô ÛÙË °ÂÚÌ·Ó›· ™ÙÔ Duisburg (504.000 οÙÔÈÎÔÈ) Ù˘ °ÂÚÌ·Ó›·˜ ÛËÌÂÈÒıËΠÙËÓ ¿ÓÔÈÍË ÙÔ˘ 2006 ÌÂÁ¿ÏË ÂȉËÌ›· ÈÏ·Ú¿˜ Ì 614 ÎÚÔ‡ÛÌ·Ù·, 54% Û ¿ÙÔÌ· ËÏÈΛ·˜ 10 ÂÙÒÓ Î·È ¿Óˆ. ™ÙËÓ ›‰È· fiÏË Â›¯·Ó ηٷÁÚ·Ê› ÌfiÏȘ 4 ÎÚÔ‡ÛÌ·Ù· ÙËÓ ÚÔËÁÔ‡ÌÂÓË ÂÓÙ·ÂÙ›· 2001-2005. ∆Ô Úfi‚ÏËÌ· ¤Ï·‚ ÎÔÈÓˆÓÈΤ˜ ‰È·ÛÙ¿ÛÂȘ ηıÒ˜ Ì¿ÏÈÛÙ· ÛÙËÓ Â˘Ú‡ÙÂÚË ÂÚÈÔ¯‹ ¤ÁÈÓ·Ó 16 ·fi ÙÔ˘˜ 24 ·ÁÒÓ˜ ÙÔ˘ Ô‰ÔÛÊ·ÈÚÈÎÔ‡ World Cup Î·È ·ÚÎÂÙ¤˜ ¯ÒÚ˜ Âͤ‰ˆÛ·Ó Ù·ÍȉȈÙÈΤ˜ Ô‰ËÁ›Â˜ ÁÈ· ÙÔ˘˜ ÊÈÏ¿ıÏÔ˘˜. ªÂÏÂÙ‹ıËΠÙÔ ·Ó·ÌÓËÛÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ‰ËÌfiÛÈÔ Û¯ÔÏÂ›Ô Ì 1250 Ì·ıËÙ¤˜ ËÏÈΛ·˜ 10-21 ÂÙÒÓ Î·È 53 ÎÚÔ‡ÛÌ·Ù·. ∏ ÓÔÛËÚfiÙËÙ· ‹Ù·Ó 53% ÛÙÔ˘˜ ·ÓÂÌ‚ÔÏ›·ÛÙÔ˘˜ Ì·ıËÙ¤˜, 1% Û ÂΛÓÔ˘˜ Ì 1 ‰fiÛË Î·È 0,4% Û ÂΛÓÔ˘˜ Ì ‰˘Ô ‰fiÛÂȘ ·ÓıÈÏ·ÚÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘. ∆Ô ÂÌ‚fiÏÈÔ ·¤‰ÂÈÍ ÙËÓ ·Í›· ÙÔ˘ Û fiÛÔ˘˜ ÙÔ Â›¯·Ó οÓÂÈ, ˆÛÙfiÛÔ ÔÈ Û˘ÁÁÚ·Ê›˜ ηٷϋÁÔ˘Ó (Pediatr Infect Dis J ™ÂÙ 2007;26:782-786) fiÙÈ ÌfiÓÔ Ë Ôχ ¢Ú›· Î¿Ï˘„Ë ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ Ù¤ÙÔȘ ÂȉË̛˜, Û˘¯Ó¿ ÂÈÛ·ÁfiÌÂÓ˜- Ë Û˘ÁÎÂÎÚÈ̤ÓË ÂȉËÌ›· Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Â›¯Â ÚԤϢÛË ·fi ÙËÓ √˘ÎÚ·Ó›·. ¶·È‰È·ÙÚÈ΋ 2007;70:422-423
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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√
µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
AÏÏËÏÔÁÚ·Ê›·: ¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜ npg@allergy.gr
πÛÙÔÛÂÏ›‰Â˜ ÁÈ· Ù· ÊıÈÓÔˆÚÈÓ¿ ÎÚ˘ÔÏÔÁ‹Ì·Ù· ∆Ô ÊıÈÓfiˆÚÔ ‹ÚıÂ, Î·È Ï›ÁÔ Ôχ fiÏÔÈ Ì·˜ ͯ·Ṳ̂ÓÔÈ ÛÙȘ ·Ó·ÌÓ‹ÛÂȘ ÙÔ˘ ηÏÔηÈÚÈÔ‡ Î·È ÙˆÓ ˘„ËÏÒÓ ıÂÚÌÔÎÚ·ÛÈÒÓ Ô˘ ÙÔ Û˘Óԉ‡ԢÓ, ‡ÎÔÏ· ÁÈÓfiÌ·ÛÙ ٷ ÚÒÙ· ı‡Ì·Ù· ÂÓfi˜ ÊıÈÓÔˆÚÈÓÔ‡ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜. ∆Ô ‰È·‰›ÎÙ˘Ô ÚÔÛʤÚÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· fi¯È ÌfiÓÔ Ó· ÂÓËÌÂÚˆıԇ̠·ÏÏ¿ ·ÎfiÌË Î·È Ó· ÚÔÏ¿‚Ô˘ÌÂ Î·È Ó· ıÂڷ‡ÛÔ˘Ì ٤ÙÔÈÔ˘ ›‰Ô˘˜ ·ÓÂÈı‡ÌËÙ· Î·È ÂÓÔ¯ÏËÙÈο Û˘ÌÙÒÌ·Ù· Ô˘ ÚÔηÏÔ‡Ó Ù· ÎÚ˘ÔÏÔÁ‹Ì·Ù· Ù˘ ÂÔ¯‹˜.
¶ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ ÎÚ˘ÔÏfiÁËÌ· - www.commoncold.org ∆Ô ·Ó·Óˆ̤ÓÔ site ·Ú¤¯ÂÈ Ì ·Ïfi Î·È ÂÚÈÂÎÙÈÎfi ÙÚfiÔ fiϘ ÙȘ ··Ú·›ÙËÙ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ ÎÔÈÓfi ÎÚ˘ÔÏfiÁËÌ· Ô˘ ·ÊÔÚ¿ ÂÍ›ÛÔ˘ ÁÔÓ›˜ Î·È ·È‰È¿. ÈÚÈṲ̂ÓÔ Û 8 ˘ÔηÙËÁÔڛ˜, ‰›ÓÂÈ ··ÓÙ‹ÛÂȘ Û ÂÚˆÙ‹Ì·Ù· Ô˘, ·Ó Î·È ·ÎÔ‡ÁÔÓÙ·È Û˘¯Ó¿, ÂÏ¿¯ÈÛÙÔÈ ÁÓˆÚ›˙Ô˘Ó ÙËÓ ·¿ÓÙËÛ‹ ÙÔ˘˜. ªÂÚÈο ·fi ·˘Ù¿ ›ӷÈ: “∆È Â›Ó·È ÙÔ ÎÚ˘ÔÏfiÁËÌ·;”, “∆È ÚÔηÏ› Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜;”. ∆ÚfiÔÈ ÚfiÏ˄˘, ıÂڷ›·˜ ·ÏÏ¿ Î·È ÂÍ·ÈÚÂÙÈΤ˜ Û˘ÓÙ·Á¤˜ Ì·ÁÂÈÚÈ΋˜ Ì ‰È¿ÊÔÚ˜ Á‡ÛÂȘ ÁÈ· fiÏ· Ù· ÁÔ‡ÛÙ·, ¤Ú¯ÔÓÙ·È Ó· Ì·˜ ı˘Ì›ÛÔ˘Ó ÙȘ “ηϤ˜” Ï¢ڤ˜ ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜.
√‰ËÁfi˜ ÁÈ· (Ó¤Ô˘˜) ÁÔÓ›˜ - www.kidshealth.org “ÃÚ˘Ûfi √‰ËÁfi” Î·È ‰Ë ÁÈ· Ó¤Ô˘˜ ÁÔÓ›˜ ·ÔÙÂÏ› ÙÔ site ·˘Ùfi, ηıÒ˜ ÂÚȤ¯ÂÈ ·Ó·Ï˘ÙÈÎfiٷ٘ Û˘Ì‚Ô˘Ï¤˜ Î·È ÁÓÒÛÂȘ ÁÈ· fi,ÙÈ ÌÔÚ› Ó· ÙÔ˘˜ ··Û¯ÔÏ› Û¯ÂÙÈο Ì ÙÔ ·È‰› ÙÔ˘˜. ∫·Ï‡ÙÔÓÙ·˜ ÂÓ· ¢ڇ Ê¿ÛÌ· ıÂÌ·ÙÔÏÔÁ›·˜, fiˆ˜ ÔÈ ÚÒÙ˜ ‚Ô‹ıÂȘ, ˙ËÙ‹Ì·Ù· Á‡Úˆ ·fi ÙËÓ „˘¯ÔÏÔÁ›· ÙÔ˘ ·È‰ÈÔ‡ Î·È fiÏ· fiÛ· Ú¤ÂÈ Ó· ÁÓˆÚ›˙Ô˘Ì ÁÈ· ÙËÓ ˘Á›·, Û ¤Ó· ηϿ ‰ÔÌË̤ÓÔ site, ¯ˆÚÈṲ̂ÓÔ Û ÂÓfiÙËÙ˜, ÚÔÛʤÚÂÙ·È ÙfiÛÔ ÁÈ· ÏËÚÔÊfiÚËÛË fiÛÔ Î·È ÁÈ· Û˘Ì‚Ô˘Ï¤˜ Î·È ˘Ô‰Â›ÍÂȘ. ∏ Ì˯·Ó‹ ·Ó·˙‹ÙËÛ˘ Ô˘ ‰È·ı¤ÙÂÈ ‰›ÓÂÈ ÛÙÔÓ ÂÈÛΤÙË ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ı¤ÛÂÈ ÂÚˆÙ‹Ì·Ù· ‹ ϤÍÂȘ ÎÏÂȉȿ, Ï·Ì‚¿ÓÔÓÙ·˜ ··ÓÙ‹ÛÂȘ ·fi ÂȉÈÎÔ‡˜ ÂÈÛÙ‹ÌÔÓ˜. ™ÙËÓ Î·ÙËÁÔÚ›· pregnancy and newborns ‚Ú›ÛÎÂÈ Î·Ó›˜ ÛËÌ·ÓÙÈΤ˜ ËÚÔÊÔڛ˜ ÁÈ· ÙÔ˘˜ Ì‹Ó˜ Ù˘ ·ËÛ˘ ·ÏÏ¿ Î·È ÁÈ· ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ÂÓfi˜ ·È‰ÈÔ‡, Ôχ ¯Ú‹ÛÈ̘ ÁÈ· Ó¤Ô˘˜ ÁÔÓ›˜.
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∆· ¿ÓÙ· ÁÈ· ÙȘ ·ÏÏÂÚÁ›Â˜ - www.allergychannel.net ∆Ô allergy channel Â›Ó·È ¤Ó·˜ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ Ì ηÙËÁÔڛ˜ Ô˘ ηٷÚÙ›˙Ô˘Ó ÙÔÓ ÂÈÛΤÙË ÁÈ· ı¤Ì·Ù· Ô˘ ÙÔÓ ÚÔ‚ÏËÌ·Ù›˙Ô˘Ó Î·ıËÌÂÚÈÓ¿. £¤Ì·Ù· fiˆ˜ Ë ÂÍ¿ÚÙËÛË ·fi ÙÔ Î¿ÓÈÛÌ·, Ë ‰È·ÙÚÔÊ‹, Ë ·¯˘Û·Î›· Î·È ÙÔ ¿Á¯Ô˜ ‰È·ÊˆÙ›˙ÔÓÙ·È Ì ÙÚfiÔ ÏÈÙfi Î·È ÂÚÈÂÎÙÈÎfi, ·Ó¿ÏÔÁ· Ì ÙËÓ Î·ÙËÁÔÚ›· ÙÔ˘ ÎÔÈÓÔ‡ ÛÙËÓ ÔÔ›· ·Â˘ı‡ÓÔÓÙ·È. ŒÙÛÈ, ¿ÙÔÌ· fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ó· Ï¿‚Ô˘Ó ÌÈ· ÛÊ·ÈÚÈ΋ ÏËÚÔÊfiÚËÛË Î·È Ó· χÛÔ˘Ó ÙȘ ·Ôڛ˜ ÙÔ˘˜. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ÎÚ˘ÔÏfiÁËÌ·, Ë ÈÛÙÔÛÂÏ›‰· ¤¯ÂÈ ·ÊÈÂÚÒÛÂÈ Û ·˘Ùfi ¤Ó· ͯˆÚÈÛÙfi link, ÛÙÔ ÔÔ›Ô ·Ó·Ê¤ÚÔÓÙ·È fiÏ· Ù· Û˘ÌÙÒÌ·Ù· Î·È ·Ú¿ÏÏËÏ· ÚÔÙ›ÓÔÓÙ·È ıÂڷ¢ÙÈΤ˜ ̤ıÔ‰ÔÈ. ∆Ô site ¤¯ÂÈ ˙ˆÓÙ·Ó¿ ¯ÚÒÌ·Ù·, Î·È Â›Ó·È Ï‹Úˆ˜ ÂÓËÌÂڈ̤ÓÔ. ¢È·ı¤ÙÂÈ ÂÓËÌÂÚˆÙÈο video Î·È Ù· ÈÔ ÚfiÛÊ·Ù· Ó¤· ÁÈ· ÙËÓ ÂͤÏÈÍË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜. ∆¤ÏÔ˜, ÂÚȤ¯ÂÙ·È ÂÓÙ˘ˆÛȷ΋ ÔÛfiÙËÙ· Î·È ÔÈfiÙËÙ· ÏËÚÔÊÔÚÈÒÓ Á‡Úˆ ·fi ÙËÓ ·ÏÏÂÚÁ›·, ηıÒ˜ Î·È ÂȉÈο ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο È·ÙÚÔ‡˜.
™¯ÂÙÈο Ì ÙÔÓ Èfi Ù˘ Áڛ˘ - www.msnbc.msn.com ªÈ· ÂÓÙ˘ˆÛȷο ÂÓËÌÂڈ̤ÓË Î·È ÔÈÔÙÈο ‰ÔÌË̤ÓË ÈÛÙÔÛÂÏ›‰·, Ì ÏÂÙÔ̤ÚÂȘ ÁÈ· ÙÔ ÎÚ˘ÔÏfiÁËÌ· Î·È ÙÔÓ Èfi Ù˘ Áڛ˘. ∂ÈÛÙËÌÔÓÈΤ˜ ÌÂϤÙ˜, ¿ÚıÚ·, ·ÏÏ¿ Î·È ·Ôχو˜ ηٷÓÔËÙ¿ ‰ÔṲ̂Ó˜ ÏËÚÔÊÔڛ˜, ηıÈÛÙÔ‡Ó ÙËÓ ÈÛÙÔÛÂÏ›‰· ͯˆÚÈÛÙ‹. ∂ÌÏÔ˘ÙÈṲ̂ÓË Ì ÔÈΛÏÔ ıÂÌ·ÙÈÎfi ˘ÏÈÎfi, Û˘ÓÈÛÙ¿ ËÁ‹ ÁÓÒÛ˘ Ô˘ ·ÔÎÙ¿Ù·È Â‡ÎÔÏ· Î·È Â˘¯¿ÚÈÛÙ·, ηıÒ˜ ¤Ú¯ÂÙ·È Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ¯Ú‹ÛÈÌÔ Î·È Â‡¯ÚËÛÙÔ Ô‰ËÁfi fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘Á›· Ì·˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË. ∏ ÈÛÙÔÛÂÏ›‰· ¯ˆÚ›˙ÂÙ·È Û ‰‡Ô ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜, Û ·˘Ù‹ Ù˘ ˘Á›·˜ Î·È ÛÙËÓ Î·ÙËÁÔÚ›· ÙÔ˘ ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ÈÔ‡ Ù˘ Áڛ˘. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ‰›ÓÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ÌÈ·˜ ÁÂÓÈÎfiÙÂÚ˘ ÏËÚÔÊfiÚËÛ˘ ÁÈ· ÙËÓ ˘Á›·, ·ÏÏ¿ Î·È ‰ÈÂÍÔ‰È΋˜ ÁÓÒÛ˘ ÁÈ· ÙÔ ÎÚ‡ˆÌ· Î·È ÙË ÁÚ›Ë.
¶·È‰È·ÙÚÈ΋ 2007;70:424-425
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CLINICAL QUIZ
∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏
∏ ÛˆÛÙ‹ ·¿ÓÙËÛË Â›Ó·È “§È҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜”. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ˘ÂÚÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ÌÂ Û˘¯ÓfiÙËÙ· Ô˘ ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ Á‡Úˆ ÛÙÔ 7-10% ÙÔ˘ ÁÂÓÈÎÔ‡ ·È‰È·ÙÚÈÎÔ‡ ÏËı˘ÛÌÔ‡. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÓ·fiıÂÛË Ï›Ô˘˜ ÛÙÔ Ë·ÙÈÎfi ·Ú¤Á¯˘Ì· Î·È ÂÌÊ·Ó›˙ÂÙ·È Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ Ô˘ Î˘Ì·›ÓÔÓÙ·È ÌÂٷ͇ 10-80% ÛÙ· ·¯‡Û·Úη ·È‰È¿. ∏ ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÈÔ Û˘¯Ó¿ Û ·ÁfiÚÈ· Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ·ã fi,ÙÈ Û ÎÔÚ›ÙÛÈ· Î·È ·Ó·Î·Ï‡ÙÂÙ·È ·fi ÙÔÓ ·È‰›·ÙÚÔ ÛÂ Ù˘¯·›Ô ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË SGPT. ™Â ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‹·ÙÔ˜ ÂȂ‚·ÈÒÓÂÙ·È Ë ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜. ™Ù· ·È‰È¿ ·˘Ù¿ Û˘Ó˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ ·˘ÍË̤ÓË ¯ÔÏËÛÙÂÚfiÏË, ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È ÈÓÛÔ˘Ï›ÓË ÔÚÔ‡. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙË Û˘Ìو̷ÙÔÏÔÁ›·, Ù· ·È‰È¿ Â›Ó·È ·Ú¯Èο ·Û˘Ìو̷ÙÈο, ˆÛÙfiÛÔ ·ÚÁfiÙÂÚ· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜. ∆Ô ÏÈ҉˜ ‹·Ú ÌÔÚ› Ó· ÂÍÂÏȯı› Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ Û ÌË ·ÏÎÔÔÏÈ΋ ÛÙ·ÙÔË·Ù›Ùȉ· (nonalcoholic steatohepatitis), Ì›· ÓfiÛÔ Ô˘ Ï‹ÙÙÂÈ ÔÛÔÛÙfi 20% ÙˆÓ ·¯‡Û·ÚÎˆÓ ÂÊ‹‚ˆÓ ÛÙȘ ∏.¶.∞. √ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ·Ó¿Ù˘Í˘ ÌË ·ÏÎÔÔÏÈ΋˜ ÛÙ·ÙÔË·Ù›Ùȉ·˜ ·Ú·Ì¤-
Paediatriki 2007;70:426-426
ÓÂÈ ¿ÁÓˆÛÙÔ˜, ·ÏÏ¿ Èı·ÓÔÏÔÁÔ‡ÓÙ·È ‰È¿ÊÔÚ· ·›ÙÈ· fiˆ˜ ÙÔ ÔÍÂȉˆÙÈÎfi ÛÙÚ¤˜, Î·È Ë ‰Ú¿ÛË - ˆ˜ ‰È·ÌÂÛÔÏ·‚ËÙ¤˜ - ÙˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÙˆÓ ‚·ÎÙËÚȉȷÎÒÓ ÂÓ‰ÔÙÔÍÈÓÒÓ ·fi ÙÔ ¤ÓÙÂÚÔ Î.¿. ∏ ıÂڷ›· ÙÔ˘ ·È‰ÈÔ‡ Ì ÏÈÒ‰Ë ‰È‹ıËÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÚÔÛ¿ıÂÈ· ÁÈ· ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Ì ‰›·ÈÙ· ¯·ÌËÏ‹ Û ÏÈ·Ú¿ Î·È ˘‰·Ù¿ÓıڷΘ, ¿ÓÙ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÛÎËÛË. ∞ÓÙÈÔÍÂȉˆÙÈ΋ ıÂڷ›· Ì ‚ÈÙ·Ì›ÓË C, E, Ô˘ÚÛÔ‰ÂoÍÈÎÔÏÈÎfi Ô͇ Î·È ÌÂÙÊÔÚÌ›ÓË ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ¯ˆÚ›˜ ÌÂÁ¿ÏË ÂÈÙ˘¯›· Û ۯ¤ÛË Ì placebo. ™˘ÓÈÛÙ¿Ù·È ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ˷ÙÔÏÔÁÈÎfi ΤÓÙÚÔ ÁÈ· ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÁÈ·Ù› Ô ¤ÊË‚Ô˜ ·ÛıÂÓ‹˜ Ì ÌË ·ÏÎÔÔÏÈ΋ ÛÙ·ÙÔË·Ù›Ùȉ· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ Î›ÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Pall H. and Jonas MM. Acute and chronic hepatitis In: Wyllie R, Hyams JS, editors. Pediatric Gastrointestinal and Liver Disease. Philadephia, USA: Saunders-Elsevier; 2006. p. 925-949. 2. Schwimmer JB, Deutsch R, Lavine JE, Behling C et al. The population prevalence of fatty liver. J Pediatr Gastronterol Nutr 2005;41:513. 3. Schwimmer JB, Behling C, Newbury R, Deutsch R, Nievergelt C, Shork NJ, et al. Histopathology of pediatric nonalcoholic fatty liver disease. Hepatology 2005;42:641-649.
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¶ƒ√™∂Ã∏ ™À¡∂¢ƒπ∞ 4-6 √ÎÙˆ‚Ú›Ô˘ 2007
19Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ÛÂ Û˘Ó‰ÈÔÚÁ¿ÓˆÛË Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ∫·Ú‰›ÙÛ·˜ Ì ı¤Ì·: "¶·È‰› - √ÈÎÔÁ¤ÓÂÈ· ÛÙÔÓ 21Ô ·ÈÒÓ·" ∫ÙËÓÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·Ï›·˜, Contact: ª·Ú›· ∂ÏÏËÓÈÎÔ‡, ¶·Ó·ÁÈÒÙ˘ ∫Ï¿·˜ Tel.: 210-7462208, 7462253 e-mail: mellin@med.uoa.gr, e-mail: pklappas@med.uoa.gr Website: www.socped.gr
∫·Ú‰›ÙÛ·
6-7 √ÎÙˆ‚Ú›Ô˘ 2007
∂Ù‹ÛÈÔ ™˘Ó¤‰ÚÈÔ ∆Ô̤· ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ Website: http://users.uoi.gr/paediatr
πˆ¿ÓÓÈÓ·
2-6 √ÎÙˆ‚Ú›Ô˘ 2007
Child Neurology - 2007 Contact: Harvard Medical School CME Office Tel.: 617-384-8600 Fax: 617-384-8686 E-mail: hms-cme@hms.harvard.edu
Cambridge, MA, USA
3-6 √ÎÙˆ‚Ú›Ô˘ 2007
IV Congreso Iberoamericano de Neonatología XXI Congreso Nacional de Medicina Perinatal II Congreso de la SEMP Contact: Dr. Maria J. Castro Tel.: 58-212-472-77-87 Fax: 58-212-472-77-87 E-mail: chefacastro@gmail.com
Granada, Spain
6-8 √ÎÙˆ‚Ú›Ô˘ 2007
48th Annual Meeting of the European Society for Paediatric Research – ESPR Contact: ESPR Secretariat Tel.: 41-229-080-488 Fax: 41-227-322-852 E-mail: espr07@kenes.com
Prague, Czech Republic
12-13 √ÎÙˆ‚Ú›Ô˘ 2007 VI Simposio Internacional de Neonatologia Contact: Luis Alfonso Perez Vera Tel.: 64-33-335 Fax: 64-74-786 E-mail: ascon.santander@intercable.net.co
Bucaramanga, Colombia
13 √ÎÙˆ‚Ú›Ô˘ 2007
∞ı‹Ó·
∂ÈÛÙËÌÔÓÈ΋ ∏ÌÂÚ›‰·: ∂›Î·ÈÚ· £¤Ì·Ù· Î·È ∞ÓÙÈÁӈ̛˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ •ÂÓÔ‰Ô¯Â›Ô "King George" Contact: ∫∂°ª - Congress world - ª. ¶···Ó·ÁÈÒÙÔ˘ Tel: 210-7210001, 7210052 Fax: 210-7210051 E-mail: info@congressworld.gr Website:www.congressworld.gr
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17-20 √ÎÙˆ‚Ú›Ô˘ 2007 ESH-EHA Conference: Focus on Paediatric Haematology and Oncology Contact: Conference Secretariat: European School of Haematology (ESH), Centre Hayem, Hôpital Saint-Louis, 1, av. Claude Vellefaux Cedex 10, 75475 Paris Tel.: 33-142-066-540 Fax: 33-142-060-587 E-mail: ghyslaine_lebougault@at)paris7.jussieu.fr
Barcelona, Spain
18-22 √ÎÙˆ‚Ú›Ô˘ 2007 19th International Congress of Pediatrics Contact: Dr GhR Walizadeh, Dr A Habibolahi Tel.: 982 166 428 998 Fax: 982 166 923 054 E-mail: pedcong@tums.ac.ir
Tehran, Iran
24-27 √ÎÙˆ‚Ú›Ô˘ 2007 International Congres of Pediatric Hepatology, Gastroenterology and Nutrition Contact: Mortada El-Shabrawi Tel.: 20-123-133-705 Fax: 20-237-619-012 E-mail: mortada_elshabrawi@yahoo.com
Sharm El-Sheikh, Egypt
30 √ÎÙˆ‚Ú›Ô˘ 3 ¡ÔÂÌ‚Ú›Ô˘ 2007
SIOP 2007: 39th International Society of Paediatric Oncology Annual Meeting Contact: Conference Secretariat: SIOP 2007 Secretrariat, Varriance Conferences & Events, 37/900, Adarsh Nagar Century Bazaar, Worli, 400 03 Mumbai Tel.: 912-224-381-068 Fax: 912-224-385-021 E-mail: siop2007@varriance.com
Mumbai, India
1-4 ¡ÔÂÌ‚Ú›Ô˘ 2007
XI Congress of Pediatric Radiology-SLARP Contact: Silvia Moguillansky Tel.: 54 1-147-918-110 Fax: 541-147-918-110 E-mail: moguil@intramed.net.ar
Vina del Mar, Chile
8 ¢ÂÎÂÌ‚Ú›Ô˘ 2007
7Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, H·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜ ∞›ÁÏË ∑·Â›Ô˘, ∞ı‹Ó· Website: www.helspghan.org
∞ı‹Ó·
14-17 ¢ÂÎÂÌ‚Ú›Ô˘ 2007 7Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜ •ÂÓÔ‰Ô¯Â›Ô Makedonia Palace, £ÂÛÛ·ÏÔÓ›ÎË Website: http://www.mednet.gr/hsi/
£ÂÛÛ·ÏÔÓ›ÎË
16-19 √ÎÙˆ‚Ú›Ô˘ 2008 13th Meeting of the European Society for Immunodeficiencies (ESID) Theater aan de Parade 's-Hertogenbosch, Website: http://www.esid2008.org/
The Netherlands