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¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜ M¤ÏË ™. ∞Ó‰ÚÔÓ›ÎÔ˘ ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ∂. °·Ï·Ó¿Î˘ §. £ˆÌ·˝‰Ô˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ ™. K›ÙÛÈÔ˘-∆˙¤ÏË ∞. ¶··‰ÔÔ‡ÏÔ˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿ ÀÔ‚ÔÏ‹ ∂ÚÁ·ÛÈÒÓ e-mail: hps@ath.forthnet.gr √‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜: http://www.e-child.gr/Instructions_ to_Authors_GR.pdf
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21 ¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·: ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Ã. ∆۷ηϛ‰Ë˜, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, ¡. ¡ÈÎÔÏ·˝‰Ë˜
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29 ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜: Â›Ó·È ·ÎfiÌ· ‰Ò! Ã. ∆Ú¿·ÏË, ª. ¶··Ê˘Ï·ÎÙÔ‡, °. ¶··‰fiÔ˘ÏÔ˜
EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶ÈÂÚ›·˜ 1∞ 144 51 MÂÙ·ÌfiÚʈÛË TËÏ.: 210 87 78 810 Fax: 210 87 78 822 I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889
ISSN 0377-2551
µƒ∞µ∂Àª∂¡∏ ∂ƒ°∞™π∞ 38 ∫ÏÈÓÈ΋ Î·È ÌÔÚȷ΋ ÌÂϤÙË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2 Û ·È‰È¿ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË ÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ™. æÒÓË, J. Traeger-Synodinos, Ã. ™ÔÊÔÎÏ¤Ô˘˜, ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË, ∞. ª·‡ÚÔ˘, ∂. ∫·Ó·‚¿Î˘, Œ. ºÚ˘Û›Ú· ∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 48 ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ π. ∫·Ï¤ÁÈ·˜, µ. ƒÔ‡ÏË, ∞. ∫·Ú·Ù˙·Ê¤ÚË, ∫. ¢·ÎÔÚÒÓÈ·˜, ª. ¶··˚ˆ¿ÓÓÔ˘, £. ¢·Ó›‰Ë, √. ¢. ¶··ÁˆÚÁ›Ô˘, ∫. ¶·Ô˘ÙÛ‹, °. ∫ÚÔÎȉ¿˜, ¡. ¢È·Ì·ÓÙfiÔ˘ÏÔ˜
55 √È Û˘Ó¤ÂȘ Ù˘ Áڛ˘ ÛÙ· ·È‰È¿ ÛÙËÓ ÎÔÈÓfiÙËÙ· ª. ∆ÛÔÏÈ¿, π. §ÔÁÔı¤ÙË, ¡. ¶··‰fiÔ˘ÏÔ˜, ª. ª·˘Ú›ÎÔ˘, ¡. ™˘Ú›‰Ë˜, ¶. ¢ÚÔÛ¿ÙÔ˘, ¢. ∫·ÊÂÙ˙‹˜, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ Î·È Ë ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ Áڛ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· ¶ƒ∞∫∆π∫√ £∂ª∞ 62 ™˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË - ·ÓÙÈÌÂÙÒÈÛË ¢. π. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ ∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ 68 µÚ¤ÊÔ˜ Ì ˈÛÈÓÔÊÈÏÈ΋ ÂÓÙÂÚ›Ùȉ· Ã. ∫Ô˘ÙÛ·˘Ù›ÎË, ∂. ª¿ÓÙ˙ÈÔ˘, ¢. ÷Ù˙‹˜, ∫. ¶··ÓÙ˙›Ì·˜, ∫. ™ÙÂÊ·Ó¿ÎË, ¡. ª˘ÚÈÔÎÂÊ·ÏÈÙ¿Î˘, ∂. ƒÒÌ·-°È·ÓÓ›ÎÔ˘ 74 ƒ·‚‰ÔÌ˘fiÏ˘ÛË ÌÂÙ¿ ·fi Ïԛ̈ÍË ·fi influenza A √. ºÈÏ›Ô˘, ª. ¢ÔÏÈ·Ó›ÙË, ∫. ¢ÈÁ·Ï¿ÎË-£¤ÌÂÏË, ª. ∑‹‚·-¶ÂÙÚÔÔ‡ÏÔ˘, ™. ¶··‰¿ÎÔ˘-§·ÁÔÁÈ¿ÓÓË 79 ∫§π¡π∫√ ∫√Àπ∑ ∞. ™·‚‚›‰Ô˘, °. ªÚÈ·ÛÔ‡Ï˘, ª. ƒ·˚Û¿ÎË, Õ. ª. ™·Ó¿ÎË, ¡. º˘ÙÚÔÏ¿ÎË, ∂. °·Ï·Ó¿Î˘, ª. ∫·ÏÌ·ÓÙ‹ 80 ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ ∂ÏÏËÓÈ΋ ·È‰È·ÙÚÈ΋ ¤Ú¢ӷ Û ‰ÈÂıÓ‹ ÂÚÈÔ‰Èο, 2007 E. °·Ï·Ó¿Î˘ 83 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ Ã. ™Î¢¿ÎË
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Bimonthly Publication of the Greek Paediatric Society
Paediatriki
President A. Constantopoulos Editorial Board Editor-in-Chief C. Stefanidis Members S. Andronikou P. Augoustides-Savvopoulou A. Vazeou-Gerasimidi G. Varlamis ∂. Galanakis L. Thomaidou M. Kanariou ∂. Katsarou-Pectasides A. Kattamis S. Kitsiou-Tzeli ∞. Papadopoulou N. Papadopoulos A. Siamopoulou-Mavridou M. Tsolia Manuscript submission e-mail: hps@ath.forthnet.gr Instructions to authors: http://www.e-child.gr/paediatriki/ iae.pdf Manuscript Editing Greek Editing M. Natsoulidou English Editing S. Nakou Publisher K. Griveas Publishing Coordinator SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822 Owner Greek Paediatric Society© 92 Michalakopoulou St. 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
Volume 71 ñ Number 1 ñ January-February 2008
Contents EDITORIAL COMMENTARY xviii C. Stefanidis REVIEW ARTICLES 1 New Methods and Trends in Paediatric Education. Undergraduate Training K. Sostmann, J. Hoeffe, S. Mueller, H. Krude, G. Gaedicke 5 Children with frequent infections: criteria for specialized immunological investigations D. C. Cassimos, ª. Liatsis, ∞. Stogiannidou, ª. ∫·nariou 14 Primary ciliary dyskinesia ª. ªoustaki, ∞. Fretzayas 21 Necrotizing enterocolitis: recent evidence on the pathophysiology of the disease C. Tsakalidis, ∞. Tragiannidis, ¡. Nikolaidis 29 Rheumatic fever: it is still here! C. Trapali, ª. Papafylaktou, G. Papadopoulos AWARD-WINNING ARTICLE 38 Clinical studies and analysis of the MECP2 gene in children with mental retardation in the Greek population S. Psoni, J. Traeger-Synodinos, C. Sofokleous, S. Kitsiou-Tzeli, ∞. ªavrou, ∂. ∫anavakis, H. Fryssira ORIGINAL ARTICLES 48 Sleep problems in school-age children J. Kaleyias, V. Rouli, ∞. Karatzaferi, ∫. Dakoronias, ª. Papaioannou, T. Danidi, U. D. Papageorgiou, ∫. Papoutsi, G. ∫rokidas, ¡. Diamantopoulos
55 The impact of influenza in children on the community ª. ∆solia, π. Logotheti, ¡. Papadopoulos, ª. Mavrikou, ¡. Spyridis, P. Drossatou, D. Kafetzis, ∞. Konstantopoulos and the outpatient flu study group PRACTICAL ISSUES 62 Syncopal episodes in childhood and adolescence: diagnosis - management D. I. Georgakopoulos CASE REPORTS 68 An infant with eosinophilic enteritis C. ∫outsaftiki, ∂. Mantziou, D. Hatzis, ∫. Papantzimas, ∫. Stefanaki, ¡. ªyriokefalitakis, ∂. Roma-Giannikou 74 Rhabdomyolysis following influenza A infection √. Filippou, ª. Dolianiti, ∫. Digalaki-Themeli, ª. Ziva-Petropoulou, S. Papadakou-Lagogianni 79 CLINICAL QUIZ ∞. Savvidou, G. Briassoulis, ª. Raisaki, A. ª. Spanaki, ¡. Fytrolaki, ∂. Galanakis, ª. Kalmandi 80 PAEDIATRIC NEWS IN BRIEF Greek paediatric research in international journals, 2007 E. Galanakis 83 NEWS FROM THE INTERNET C. Skevaki
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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
Zheng-Yan Zhao, Hangzhou, China
Christer Holmberg, Helsinki, Finland
Johannes Zschocke, Heidelberg, Germany
v
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√¢∏°π∂™ ¶ƒ√™ ∆√À™ ™À°°ƒ∞º∂π™ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜). 2. ∞Ó·ÛÎÔ‹ÛÂȘ. 3. µÚ·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. 4. ∂Ú¢ÓËÙÈΤ˜ ÌÂϤÙ˜. 5. ∫ÏÈÓÈο ∫Ô˘›˙. 6. ∂ÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ. 7. ∂›Î·ÈÚ· ı¤Ì·Ù·. 8. £¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜. 9. ∂ӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. 10. ™‡ÓÙÔÌ· Ó¤·. 11. µÚ·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. 12. ∂ÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË. 13. ¶ÂÚÈÏ‹„ÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. 14. ∞Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘Ó‰ڛˆÓ Î·È ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 15. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ, ηıÒ˜ Î·È ¿ÚıÚ· Ì ›ηÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·ÛÙ› ÛÙÔ ÂÙ‹ÛÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ·ÚÔ˘ÛÈ¿ÛÂˆÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì ›ηÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ÌËÓ ¤¯Ô˘Ó ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi. ∂ÈϤÔÓ, ÛÙËÓ ÂÚÁ·Û›· ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜, Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. E›Û˘, Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚÈÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶·È‰È·ÙÚÈ΋” Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋
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·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.
µ. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡Ó “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÈÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals), ÔÈ Ôԛ˜ ÙÚÔÔÔÈ‹ıËÎ·Ó ÚfiÛÊ·Ù· Î·È ‰ËÌÔÛȇÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È Ù˘ˆÌ¤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (21x29,7 cm), Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È ÂÚÈıÒÚÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2,5 cm ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ηٿÏÔÁÔ˜ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘. H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ·: ñ ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 2000-3000 ϤÍÂȘ. ñ ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 1500-2500 ϤÍÂȘ Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ñ ÙȘ ÂÈÛÙÔϤ˜ Û 250-500 ϤÍÂȘ.
™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: ñ ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ), ηıÒ˜ Î·È ÙÔ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ. ñ ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋. ñ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤ·/ˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙÔ˘˜. ñ ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·.
¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ñ £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 200 ϤÍÂȘ, fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ñ ∏ ÂÚ›ÏË„Ë ÙˆÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ ÛÂ: ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο.
Pediatri Jan-Feb 08
15-02-08
11:00
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K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ.
K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜, ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ì ÏÂÙÔ̤ÚÂȘ ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË, Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜.
TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙȘ ‰È¢ı‡ÓÛÂȘ: http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf
™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜, ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ.
BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ, ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó: ñ ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ. ñ ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜. ñ ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ. ñ ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÙȘ ÂÈÛÙÔϤ˜. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù· ÙÚÔÔÔÈË̤Ó˜ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals, (http://www.icmje.org Î·È http://www.icmje.org/icmje.pdf). OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus [List of Journals Indexed in Index Medicus (http://www.nlm.nih.gov/bsd/uniform_requirements.html)].
¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶∂ƒπO¢π∫∞ AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ÂÓÒ ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ, ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”. T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279. Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [Abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [Letter]. Arch Dis Child 1996;75:355-356. II. µπµ§π∞ ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã. ∏ ıÂڷ›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. πππ. CD-ROM Anderson SC, Poulsen KB. Anderson’s electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002.
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IV. ™∆O ¢π∞¢π∫∆ÀO ÕÚıÚÔ Û ÂÚÈÔ‰ÈÎfi: Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am J Nurs [Internet]. 2002 Jun: Webpage: http://www.nursingworld.org/AJN/2002/june/Wawatch.htm ªÔÓÔÁÚ·Ê›·: Foley KM, Gelband H, editors. Improving palliative care for cancer [Monograph, Internet]. Washington: National Academy Press; 2001. Webpage: http://www.nap.edu/books/0309074029/html πÛÙÔÛÂÏ›‰Â˜: Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancerpain.org/
°. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ‰ÈÛΤٷ ‹ CD, ηıÒ˜ Î·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙË ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹, Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ ‹ CD Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word, ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏÌ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË, ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹, EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92, 115 28 Aı‹Ó·
¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô Î·È ‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (7,5 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (15,5 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, Î.Ï.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜ Î·È ı· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜, ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.
¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜, ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜, Ù˘ˆÌ¤Ó· Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜. 2. ¢ÈÛΤٷ ‹ CD Ì fiÏÔ ÙÔ ˘ÏÈÎfi Ù˘ ÂÚÁ·Û›·˜ (ΛÌÂÓÔ, ›Ó·Î˜, ÂÈÎfiÓ˜). 3. ∂ÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ Î·È ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜. 4. ™ÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂÚÈÏ·Ì‚¿ÓÂÈ: ·.Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ ‚.fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜) Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· ‰.fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·. 5. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·, ηıÒ˜ Î·È Ï¤ÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 6. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 7. ∫›ÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 8. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢). 9. µÈ‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 10. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó. 11. ∂ÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜, ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó. 12. ∆›ÙÏÔ˘˜ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
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™À¡∆√ª√°ƒ∞ºπ∂™ o
A cal cm cm2 cm3 o C g h IU kg l m mg min mm mol n NS ‹ ª™ osm p SD SE sec U
angstrom ıÂÚÌ›‰· ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢‚ÈÎfi ÂηÙÔÛÙfi ‚·ıÌfi˜ ∫ÂÏÛ›Ô˘ ÁÚ·ÌÌ¿ÚÈÔ ÒÚ· ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ¯ÈÏÈfiÁÚ·ÌÌÔ Ï›ÙÚÔ Ì¤ÙÚÔ ¯ÈÏÈfiÁÚ·ÌÌÔ ÏÂÙfi ¯ÈÏÈÔÛÙfiÌÂÙÚÔ ÁÚ·ÌÌÔÌfiÚÈÔ ·ÚÈıÌfi˜ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Èı·ÓfiÙËÙ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ‰Â˘ÙÂÚfiÏÂÙÔ ÌÔÓ¿‰·
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (109) mega- (106) kilo- (103) hector- (102) deca- (101) deci- (10-1) centi- (10-2) milli- (10-3) micro- (10-6) nano- (10-9) pico- (10-12) femto- (10-15) atto- (10-18)
ABBREVIATIONS
Combining prefixes T G M k h da d c m Ì n p f a
angstrom calorie centimeter square centimeter cubic centimeter degree Celsius gram hour international unit kilogram liter meter milligram minute millimeter mole number not significant osmole probability standard deviation standard error second unit
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INSTRUCTIONS TO AUTHORS A. General Information The Greek Paediatric Society is the owner of “Paediatriki”, its official scientific journal, which is distributed to its members. Its objectives are the publication of paediatric scientific work and the continuing education of paediatricians. For this purpose, it publishes a variety of articles, and in particular: 1. Editorials (upon invitation by the Editorial Board). 2. Review articles. 3. Award-winning articles. 4. Original articles. 5. Clinical Quiz. 6. Round tables. 7. Current issues. 8. Issues of healthcare management and education. 9. Case reports. 10. News. 11. Brief reports. 12. Letters to the editor. 13. Abstracts. 14. Future congresses and events. 15. Book reviews. The Editorial Board reserves the right to publish articles of special scientific interest and articles on current issues without observing submission order. In addition, it publishes upon decision original papers presented at the Annual Paediatric Conference, presentations of special interest - in whole or in part, and letters - in whole or in part - referring to scientific articles published in the journal. Regarding papers on current issues, the author’s request for immediate publication should be quoted on the first page. The Editorial Board reserves the right to accept such papers for immediate publication. All manuscripts should not have been published previously, in whole or in part, and not be under consideration by another publication. Manuscripts should acknowledge any funding, sponsorship or other financial support. All clinical research should have been conducted following informed consent of participants or of their legal representatives according to the Declarations of Helsinki and Tokyo. In addition, the US National Institute of Health guide for the care and use of laboratory animals (DHEW Publication, NIH, 80-23) should have been observed. Clinical trials should have been approved by the Ethics Committee of the Hospital. Authors’ opinions and conclusions expressed in the published papers do not necessarily reflect those of the journal. The Greek Paediatric Society, the Editorial Board and the Publisher of the journal do not necessarily approve the content of the advertisements appearing in the journal. The copyright of all published papers is held by “Paediatriki” and their reproduction in whole or in part is authorized only following written consent of the journal.
B. Manuscript Preparation “Paediatriki” suggests compliance with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals”, recently modified and published on the websites: http://www.icmje.org and http://www.icmje.org/icmje.pdf The entire paper (including figure legends and tables)
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should be typed on one side of blank paper format A4 (21x29.7 cm), double line spacing and minimum indent 2.5 cm on both sides. The paper should have the following structure: title page, short title, abstract in Greek and English, list of abbreviations, text, acknowledgements and quoting of grants, sponsorships or other financial support sources, references, tables, figures, figure legends. Each of these sections should be started on a new page. Pages should be numbered consecutively, beginning with the title page. Text length shall be: ñ review articles 2000-3000 words; ñ original articles 1500-2500 words and case reports 1000-1500 words; ñ brief reports 1000-1500 words; ñ letters 250-500 words. The title page should include: ñ the title (<14 words) and the short title (<5 words) of the article. No abbreviations are permitted in the title; ñ the name and surname of all authors; ñ the centre (institution, clinic, laboratory) of origin of the paper. If there is no affiliation with a specific centre, the status of the author(s) should be cited (e.g., private paediatrician) and home address; ñ the complete address, e-mail and telephone number of the author to whom correspondence should be addressed. Abstracts The abstract should summarize the objectives, methodology, main results and conclusions of the study. ñ It should contain at least 200 words, and not exceed 250 words. ñ It should consist of the following paragraphs: background, methods, results and conclusions. The English abstract should cite at the beginning the title of the paper and the authors’ names in English. The content of the text should consist of the following paragraphs: background, methods, results and conclusions. The abstract in English should not differ in content from the corresponding Greek abstract. Beneath the Greek and English abstracts, three to five key words in the respective language should be supplied, to be used in the thematic index. Text Original articles include: introduction, methods, results and discussion. The introduction includes the latest research data on the subject and the main references and the objectives of the paper. The description of the methods should be precise and detailed so as to enable reproduction by other researchers. In addition, the statistical methods of analysis and evaluation of the results should be described. Results should be presented clearly, together with the appropriate statistical analysis. Discussion should cover the results ensuing from the research, their significance and possible associations with the observations of other researchers. Case reports comprise a short introduction, case description and brief discussion, with emphasis on differential diagnosis. The structure of all other articles is free, according to the judgment of the authors. Thanks or acknowledgements (reference to grants, sponsorships or other sources of financial support) should be quoted at the end of the text, before references.
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Units of measures of laboratory analyses Laboratory analyses should be expressed in the Système International (SI) units and in the metric (Conventional) system in parentheses. See conversion tables on the websites: http://www.icmje.org and http://www.icmje.org/icmje.pdf Abbreviations All issues of the journal contain internationally established abbreviations. Complex or long terms often repeated in the text may be replaced by abbreviations explained by the authors in a list submitted with the paper. Abbreviations are reported in parentheses only in abstracts. References The reference section contains all references numbered in the order in which they appear in the text. In the text, references are to be indicated by Arabic numerals in parentheses. References should be no more than: ñ 70 in review articles; ñ 30 in original articles; ñ 12 in current issues and case reports; ñ 5 in brief reports and letters. In listing references follow the recently modified standards of the International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals, (http://www.icmje.org and http:// www.icmje.org/icmje.pdf). Abbreviated names of journals should conform to the Cumulated Index Medicus [List of Journals Indexed in Index Medicus (http://www.nlm.nih.gov/bsd/uniform_requirements.html)]. Examples of reference style I. JOURNALS All authors are cited if they are six or less; if they are 7 or more, the first six are cited, followed by “et al”. Regular edition: Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. Supplement issue: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. No author: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. Article type specification: Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [Abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [Letter]. Arch Dis Child 1996;75:355-356. II. BOOKS Chapter in book: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome.
In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. Book or monograph: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. Publication in a volume of proceedings: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500. Doctoral dissertation: Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. πππ. CD-ROM Anderson SC, Poulsen KB. Anderson’s electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002. IV. ON THE INTERNET Article in journal Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am J Nurs [Internet]. 2002 Jun: Webpage: http://www.nursingworld.org/ AJN/2002/june/Wawatch.htm Monograph Foley KM, Gelband H, editors. Improving palliative care for cancer [Monograph, Internet]. Washington: National Academy Press; 2001. Webpage: http://www.nap.edu/books/0309074029/html Websites Cancer-Pain.org [Webpage, Internet]. New York: Association of Cancer Online Resources, Inc.; 2002: http://www.cancerpain.org/ Tables and Figures Three copies should be submitted (original plus 2 copies). Their width should either be equal to the width of one column (7.5 cm) or to the width of the page (15.5 cm). Their maximum length, titles included, should not exceed 22 cm. Tables are numbered with Arabic numerals in the order in which they appear in the text. They should have a short title and abbreviations should be listed at the bottom. Vertical lines in tables should be avoided. All illustration material is considered as figures (graphs, pictures, etc.). They should be of excellent quality. Also, at the back of every picture, the number of the picture and the name of the first author should be noted in pencil, with an arrow showing the top of the picture. The identity of patients should not be recognizable from their pictures nor should their names be stated.
C. Manuscript Submission and Publication All manuscripts should be accompanied by a floppy disk or CD, as well as by a letter, signed by all the authors, in which it is stated that the paper has not been published in part or in whole, or is not under consideration by another journal and that the authors accept its publication in “Paediatriki”. Any funding, sponsorship or other financial support should be acknowledged.
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Once the manuscript has been accepted, the corrected version, rewritten according to the reviewers’ recommendations, should be submitted to the Editorial Board accompanied by a floppy disk or CD, containing the paper in Word format, along with a covering letter specifying in detail the modifications or objections to the reviewers’ suggestions. Delay in submission of the modified paper exceeding 30 days entails new submission. Authors will be charged film and reprint expenses, paid upon dispatch of the first proof directly to the printer. Manuscripts of papers, which have not been approved for publication, are not returned to the author. The accompanying figures and photographs can be returned upon request within six months. Manuscripts submitted for review and publication in “Paediatriki” should be sent in three copies to the following address: Editorial Board, Greek Paediatric Society 92, Michalakopoulou Street, 115 28 Athens, Greece Before submitting your paper, make sure it contains: 1. 3 copies of the text of the paper, printed according to instructions. 2. A floppy disk or CD with the entire material of the paper (text, tables, pictures).
3. A covering letter and a statement that the paper has not been previously published. 4. The title page (on a separate page), which includes: a. the title and short title of the paper; b. the name and surname (full name) of the author(s); c. the academic centre(s) of origin; d. the corresponding authors’ name, address and telephone number; 5. English and Greek abstracts, with the following structure: background, methods, results and conclusions (double space, separate page) and keywords. 6. List of abbreviations (double space, separate page). 7. Text (double space, separate page). 8. Acknowledgements and reference to funding, sponsorships or other financial sources. 9. References (double space, separate page). 10. Tables (one per page) in three copies. 11. Figures with an arrow at the back showing the top, numbered, in two copies. 12. Figure titles (double space - on separate pages) in three copies.
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∂¶π™∆√§∏ ∞¶√ ∆∏ ™À¡∆∞•∏
EDITORIAL
∞Á·ËÙÔ› Û˘Ó¿‰ÂÏÊÔÈ, ∂Π̤ÚÔ˘˜ Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ Ù˘ “¶·È‰È·ÙÚÈ΋˜” Û·˜ ‡¯ÔÌ·È Â˘Ù˘¯ÈṲ̂ÓÔ, ‰ËÌÈÔ˘ÚÁÈÎfi Î·È Ì ˘Á›· ÙÔ 2008. ªÂ ÙËÓ Â˘Î·ÈÚ›· ·˘Ù‹, ı· ı¤Ï·Ì ӷ ¢¯·ÚÈÛÙ‹ÛÔ˘Ì fiÛÔ˘˜ Û˘ÓÂÈÛ¤ÊÂÚ·Ó ÛÙËÓ ÂÈÙ˘¯›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∆ÔÓ ÙÂÏÂ˘Ù·›Ô ¯ÚfiÓÔ, Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÛÙËÓ “¶·È‰È·ÙÚÈ΋” ·˘Í‹ıËΠÛËÌ·ÓÙÈο Û ۯ¤ÛË Ì ٷ ÚÔËÁÔ‡ÌÂÓ· ¯ÚfiÓÈ·. ∞˘Ùfi Ì·˜ ¤‰ˆÛ ÙËÓ Â˘Î·ÈÚ›· Ó· ‚ÂÏÙÈÒÛÔ˘Ì ٷ ÔÈÔÙÈο ÎÚÈÙ‹ÚÈ· Î·È ÔÈ ‰ËÌÔÛȇÛÂȘ Ó· Â›Ó·È ‰ÈÂıÓÔ‡˜ ·ÚÔ˘˜. ∏ ËÏÂÎÙÚÔÓÈ΋ ˘Ô‚ÔÏ‹ Î·È Ë ÂΉÔÙÈ΋ ‰ÈÂÎÂÚ·›ˆÛË ÙˆÓ ÂÚÁ·ÛÈÒÓ Â›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÈÙ¿¯˘ÓÛË Ù˘ ÎÚ›Û˘ Î·È Ù˘ ‰ËÌÔÛ›Â˘Û‹˜ ÙÔ˘˜. §ÂÙÔ̤ÚÂȘ ÁÈ· ÙËÓ ËÏÂÎÙÚÔÓÈ΋ ˘Ô‚ÔÏ‹ ÂÚÁ·ÛÈÒÓ ı· ‚Ú›Ù ÛÙȘ “√‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜”. °È· Ó· ÂÍÔÈÎÔÓÔÌËı› ¯ÒÚÔ˜ ÛÙÔ ÂÚÈÔ‰ÈÎfi, ÔÈ Ô‰ËÁ›Â˜ ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÌfiÓÔ ÛÙÔ ÚÒÙÔ Ù‡¯Ô˜ οı ¯ÚfiÓÔ˘ Î·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ “¶·È‰È·ÙÚÈ΋˜”. ™·˜ ˘ÂÓı˘Ì›˙Ô˘Ì fiÙÈ ÌÔÚ›Ù ӷ ‚Ú›Ù ÙȘ ‰ËÌÔÛȇÛÂȘ Ù˘ “¶·È‰È·ÙÚÈ΋˜” ¯ˆÚ›˜ ¯Ú¤ˆÛË ÛÙËÓ ÈÛÙÔÛÂÏ›‰· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ (http://www.paediatriki.edu.gr). ™Ù· ÂfiÌÂÓ· Ù‡¯Ë ı· Û˘Ó¯›ÛÔ˘ÌÂ, ·Ú¿ÏÏËÏ· Ì ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚ¢ÓËÙÈÎÒÓ ÂÚÁ·ÛÈÒÓ, ÙË ‰ËÌÔÛ›Â˘ÛË ·Ó·ÛÎÔ‹ÛÂˆÓ Ì ÂÚˆÙ‹ÛÂȘ ÔÏÏ·ÏÒÓ ··ÓÙ‹ÛˆÓ, ÙˆÓ “™‡ÓÙÔÌˆÓ ·È‰È·ÙÚÈÎÒÓ Ó¤ˆÓ” Ì ۯÔÏÈ·ÛÌfi ÚfiÛÊ·ÙˆÓ ÂÚÁ·ÛÈÒÓ ∂ÏÏ‹ÓˆÓ ÂÚ¢ÓËÙÒÓ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ηıÒ˜ Î·È ÓÂfiÙÂÚˆÓ ·fi ·È‰È·ÙÚÈο Û˘Ó¤‰ÚÈ· Î·È ·fi ÙÔ ‰È·‰›ÎÙ˘Ô. ¶ÂÚÈ̤ÓÔ˘Ì ÂÚˆÙ‹Ì·Ù· Ô˘ Û·˜ ··Û¯ÔÏÔ‡Ó ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË. ∆· ÂÚˆÙ‹Ì·Ù· ·˘Ù¿ ı· ·ÔÙÂϤÛÔ˘Ó Ù· ı¤Ì·Ù· ÁÈ· ÙË Ó¤· ÛÂÈÚ¿ ¿ÚıÚˆÓ: “ƒˆÙ‹ÛÙ ÙÔÓ ÂȉÈÎfi”. ∆¤ÏÔ˜, Û·˜ ˘ÂÓı˘Ì›˙Ô˘Ì fiÙÈ ı· Ú¤ÂÈ Ó· ‰ËÏÒÓÂÙ·È ÛÙȘ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÂÙ οı Èı·Ófi ·ÓÙÈÎÚÔ˘fiÌÂÓÔ Û˘ÌʤÚÔÓ, fiˆ˜ ¤¯ÂÈ ‰ÈÂıÓÒ˜ ηıÈÂÚˆı›. ªÂ ıÂÚÌÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜,
∫ˆÓÛÙ·ÓÙ›ÓÔ˜ I. ™ÙÂÊ·Ó›‰Ë˜ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
Dear colleagues, On behalf of the Editorial Board of “Paediatriki”, I wish you a happy, creative and healthy 2008. On this occasion, we would like to thank all who have contributed to the success of the journal. Submissions to the journal increased significantly during the past year. This gave us the opportunity to further improve the quality standards to achieve a world-class level. The submission of papers by e-mail and the electronic handling of the editorial process contributed so as to shorten the time to access the important information our articles provide. Detailed information about the submission of articles is included in the “Instructions to authors” of this issue. To save space, you will find the “Instructions to authors” only in the first issue of each year and at the web page of the journal. In addition, we would like to remind you that you can find the past publications free of charge at the web page of the journal (http://www.paediatriki.edu.gr). In the next issues we will continue, additionally to the original research studies, the publication of Continuing Medical Education papers with multiple choice questions, the “Paediatric news in brief” with comments on recent pediatric articles of Greek researchers, as well as brief information on news from Congresses, Seminars and from the Internet. Also, we would like to invite you to send us questions that arise from your every day practice. These questions will become the topics of the new section: “Ask the expert”. Finally, we remind that authors are required to declare any possible conflict of interest. Warm greetings, Constantinos J. Stefanidis, M.D., Ph.D. Editor-in-Chief Paediatriki 2007;70:18-000
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New Methods and Trends in Paediatric Education. Undergraduate Training K. Sostmann, J. Hoeffe, S. Mueller, H. Krude, G. Gaedicke Abstract: According to the most recent amendment to medical training in Germany, lessons in the form of lectures have been reduced considerably in favour of practical instruction and bedside teaching in small groups. Because of these changes, it became necessary to develop a new concept for paediatric undergraduate training. The faculty introduced the learning management system Blackboard© as a platform for providing scripts, videos, slides, and podcasts of all paediatric lectures. The students use this material to prepare for their practical training. A blended learning scenario was chosen to support bedside teaching with E-learning-elements under the supervision of tutors. During their self-study time students are provided with paediatric virtual patients for learning about cases that cannot be shown during ward rounds. E-tutors are available at the disposal of the students. In addition, the students have the opportunity to attend regular lectures during which case studies derived from the most important clinical paediatric fields are discussed. An audience response system, Mobi-Ted©, is used, which allows students to input questions into an auditory monitor and to get back the individual answer electronically. The results are immediately evaluated and presented on the screen to the audience, and can thus be interpreted and discussed interactively. This makes learning easy and discussions more fruitful. Making European Higher Education a “world quality reference” is a very ambitious goal for the year 2010. The Bologna process is an exciting development for undergraduate medical training and the widespread use of modern computer-based technologies will become mandatory for academic teaching.
Charité-Universitaetsmedizin Berlin, Campus VirchowKlinikum Correspondence: Prof. Dr. Gerhard Gaedicke gerhard.gaedicke@charite.de Klinik für Allgemeine Paediatrie und Arbeitsbereich/Projekt ELWIS-MED Charité Universitaetsmedizin Berlin, Campus Virchow Augustenburgerplatz 1, 133 53 Berlin
Key words: Paediatric undergraduate training, blended learning, E-learning, trends in medical education, education technology, interactive learning.
Introduction “I hear - I forget I see - I remember I do - I understand” This 4000 year-old Chinese proverb has been translated into English but never into German. It contains information that has been demonstrated by recent studies. A lecture alone is not a very effective method for transferring knowledge. To learn effectively we need to open other channels for information transfer (ears, eyes, senses) as well. This is particularly necessary because modern medical curricula are no longer knowledge-based alone, but also demand development of the students’ competence and skills. At present the Charité, Medical Faculty of Berlin (Figure 1), is in a state of transition. It runs a conventional curriculum (600 students per year), which has recently been amended by law, and a reformed curriculum (63 students per year), which represents a field of experimentation and development of new methodologies in teaching, learning and assessment. Lectures: Past and present situations The process of teaching medicine by lectures has largely remained unchanged during the last hundred years. In clinical lectures for students,
the live demonstration of patients is still a key element. Although the methods of presenting data have been considerably refined by the introduction of computer programmes, it is easy to see that the mediation of knowledge in lectures follows the same pattern as if data and facts had been written on a blackboard. One advantage of lectures is the instruction of a large number of students by a single lecturer (Figure 2). Proponents of this method say this would make a lecture economically attractive. But is this really the case? Of course a skilled teacher can act as a role model for
Figure 1. Charité, Medical Faculty of Berlin. ¶·È‰È·ÙÚÈ΋ 2008;71:1-4
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Figure 3. Portable digital audio player (MP3-Player). Figure 2. A clinical lecture.
the students. These examples, however, are rare. We all have been taught by such leaders in their field, but find that most lecturers do not meet up our expectations (1). The popularity of clinical lectures has steadily decreased during the last two decades among students in Germany. They would describe this type of learning clinical medicine as being outdated. This fact is reflected by the very low attendance, with less than 10% of students in a class attending clinical lectures regularly. The reasons given for this phenomenon vary: 1. Lectures are unsuitable for teaching clinical skills and knowledge 2. Exercises, seminars and examinations require a significant time investment 3. Students must work to earn a living 4. Students have family obligations A description follows of the ways being introduced for dealing with the new requirements of teaching clinical medicine to undergraduate medical students.
Reinvention of lectures This mode of pedagogical practice seeks to bridge the gap between theory-based instruction on the one hand and practical application on the other. It requires the development of a new way of thinking for medical faculties. The expansion of the space of learning crosses traditional borders. Educators must accept that their role will change from that of providing owner-based knowledge to becoming knowledge managers who must stimulate students to acquire that knowledge and skills. The students need to achieve an understanding of the conceptual and propositional knowledge that educators would formerly have transferred in the classroom setting. Now students from different universities can visit online course modules and collect their own electronic portfolios from the material in the learning environments of the universities. Podcasts as a teaching tool There is already extensive experience in the use of audio and videorecordings of teaching sessions (2). Podcasts represent a new and easy way of producing digital recordings from teaching units, which comPaediatriki 2008;71:1-4
bine the spoken word with the visual slides in one data-package (Figure 3). Podcasts also represent a new way of storing and distributing these files through the Internet to different kinds of players (computers, MP3-players). The user can subscribe to the files and his/her computer will automatically receive new transmissions. Production and distribution of podcasts have become much easier through the widespread use of portable MP3-Players. Students are able to use the podcasts at their own pace. They can access the files whenever they wish and use them. Digital storage of their data allows students to search the content and to select and include their collected and preferred data in their lifelong-learning tracks. Teachers are able to provide life-data from their class sessions and combine these with additional teaching material for their students simply by uploading the files to a server. They can edit and delete the files at any time and secure entry to the site by passwords.
Bedside teaching with virtual patients (Case based teaching) Contextual learning plays an important role in the development of expert knowledge. During the current renewal of the paediatric curriculum at German universities in general and at the Charité in particular, the focus on face-to-face teaching has shifted from theoretical systematic learning to bedside teaching with real patients. Bedside teaching as a method focuses on the conveying of practical clinical skills to students in an authentic environment (3). It aims to foster clinical decision-making skills, which correlate with the development of clinical expertise. The new German licensing rules for doctors obligate teaching of a maximum of three students at the patient’s bedside (4). Clinical case presentations can be held with a maximum of six students. Therefore, by the predefinition of learning goals, clinical learning in paediatrics is placed in the context of typical paediatric patients and clinical cases. Students can start to integrate their theoretical knowledge and earlier understanding of basic clinical sciences with practical demands. The challenge consists in the case mix of a university hospital, where the typical cases cannot be provided as standard to all of the 1,000 students who rotate through the wards each year. The
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Table 1. Virtual paediatric cases Six common or severe paediatric problems as virtual learning patients Gastroenteritis Febrile seizure Intussusception Pseudocroup Meningococcal meningitis Osteomyelitis
Figure 4. E-learning module (CAMPUS© Case based teaching software).
duration of stay of the patients in the hospital is usually very short and the typical initial symptoms that led to the first diagnostic steps disappear very quickly. To resolve these problems, a blended learning scenario was chosen, where the traditional bedside teaching is supplemented (blended) with eLearning modules (Figure 4), on which the students are required to work before and after they visit the paediatric ward.
Didactics Blended learning represents a shift in instructional strategy. The most useful parts of each teaching method are combined to reach the maximum teaching effort. This system merges the advantages of technology-based teaching methods, e.g. e-Learning, with traditional teaching (face-to-face), and small-group teaching methods such as problem-based learning. Blended learning makes possible self-directed learning by shifting the choice of teaching methods and materials used from the teacher to the student. It helps students choose the learning materials that match their learning types and needs (5). The additional use of virtual communication tools stresses the learner-centred role of these scenarios. The introduction of new communication tools helps partners to access teaching from multiple perspectives. Blended learning is achieved through the following steps: Students rotate through ten paediatric subspecialities during their paediatric semester in the 5th clinical semester. They receive four hours of bedside teaching time. Every 14 days they visit a new paediatric specialty with a new teacher. In order to provide continuity for the students, the e-Tutor was introduced. E-Tutors are physicians on the hospital staff who are trained to operate the different communication tools offered by the Blackboard© learning management system. Their role is to moderate the online discussions students are required to participate in during the semester. Online discussions can be held asynchronously which allows students and physicians
to participate in accordance with their daily commitments and at a distance. Learning goals for each ward are predefined, to ensure that the students get standardized teaching from all the different 60 teachers in the departments. Casebased interactive learning software called CAMPUS (6) is used, which enables the authors to represent digitally complete clinical cases in the form of virtual patient, with all kinds of multimedia materials (video, audio, photographs, hyperlinks) that are useful from the didactic perspective, and to distribute them as CDs or through the Internet to their teaching and learning community. Learners approach the cases from a constructivist point of view, and they have to accomplish the same steps as they would in an outpatient department or on a clinical ward. As a constructivist learning intervention this provides learners with an opportunity to discover information and to make meaningful decisions collaboratively. The students are respected in this setting as unique individuals and the physicians act as facilitators rather than teachers. Thus the software offers the possibility of approaching the virtual patient from individual perspectives.
E-Learning Six learning cases, so called virtual patients, were provided for the students (Table 1). Students can reach the learning cases online through the learning management system Blackboard©. The cases were passed through a peer review process and were chosen to represent typical and common problems of paediatric patients. The cases were supplemented with videos and sound materials that reproduce the patients’ major problems and symptoms even at an acute stage of their illness. For example, one video shows a patient with severe dehydration with ketoacidosis and Kussmaul-breathing. This method generates a surplus of information for the students using the learning cases. It should be realized in this context that additional information will put an additional study load on the students (7), but the key advantages of eLearning are flexibility and the possibility for the students to work in any place ¶·È‰È·ÙÚÈ΋ 2008;71:1-4
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where an Internet connection is available. A further advantage is the fact that teachers can use the learning cases to present the acute clinical situations with symptoms not available at the moment of teaching. Patients themselves are relieved of stress because the students are better prepared when attending the bedside teaching sessions.
Assessment A variety of elements are considered in assessing the students: Recent studies have shown the advantages for student motivation and have proved positive learning effects from the use of formative tests during a clinical rotation (8). When completing study of the virtual cases, the students have to complete 12 formative tests (case-related multiple-choice tests with three to six questions, at the end of each case). After finishing the tests, the students receive direct online feedback and hints about how to complete their knowledge gaps. They can do the tests as often as they wish, and they do not have to pass them. These tests are provided to offer the students a tool of self-assessment, and as a preparation for the final multiple-choice test at the end of the rotation, which consists of 40 questions. Students are asked to complete case-related tasks, e.g., discuss the differential diagnoses or therapeutic options of the virtual cases online with their tutors and colleagues. During the interdisciplinary course on pain management students are faced with an objective structured clinical examination (OSCE) where they are tested in practical tasks. In the future, it could prove useful to expand the use of the OSCE to assess further aspects of the students’ practical competence. The introduction of different test methods aims at assessing not only cognitive but also contextual knowledge, and thus to test in a more reliable way the students’ development of clinical reasoning skills (9). New methods are being developed at present for assessing students’ clinical decision-making skills. Outlook Triggered by the recent advances in technical teaching infrastructure and by the introduction of new teaching methods, the structure of medical education has changed. These changes have to be adopted by both teachers and students. Blended learning can overcome some of the constraints caused by the compression of workflow in the wards for staff and the reduction of hospitalization for the patients. The emphasis on clinical bedside teaching means that more students meet fewer patients with acute illnesses and see more patients with chronic diseases. Blended learning can help Paediatriki 2008;71:1-4
to disburden the patients and allow questions to be answered, from the audiovisual point of view, which cannot be discussed at the bedside. Students are better prepared in this way for the clinical ward round. The adoption of the new didactic concepts is essential to develop a surplus of learning material by means of the eLearning environment for students and teaching staff. The learner-centred design of eLearning environments can help students to choose the right media for their learning types and the particular learning situations, but it demands more initial preparation time from the teacher. New distributional technologies, such as podcasts and audience response systems, can help to make traditional classroom sessions more attractive. By introducing the new technologies as extensions of the operating learning environment, curriculum integration should be assured. Finally, eLearning materials demand a higher effort in the area of technical support for teaching staff from their faculties. It must be taken into account that a higher learning load is an extra burden for the students, when new eLearning materials are integrated into a curriculum.
References 1. Brown G, Manogue M. AMEE Medical Education Guide No. 22: Refreshing lecturing: a guide for lecturers. Med Teach 2001;23:231-244. 2. Tomlinson DR. Independent learning packages (audio tape/pamphlet) for a course in cell excitation: evidence that they can be at least as effective as conventional lectures. Med Educ 1979;13:257-262. 3. Lacombe MA. On bedside teaching. Ann Intern Med 1997;126:217-220. 4. German licensing order for medical doctors: Approbationsordnung für Aerzte - Bundesministerium für Gesundheit. Gesetztestext: htpp://www.bmg.bund.de/cln_040/nn_ 603274/SharedDocs/Gesetzestexte/Gesundheitsberufe/ 5. Gordon DL, Issenberg SB, Gordon MS, LaCombe D, McGaghie WC, Petrusa ER. Stroke training of prehospital providers: an example of simulation-enhanced blended learning and evaluation. Med Teach 2005;27:114-121. 6. Garde S, Heid J, Haag M, Bauch M, Weires T, Leven FJ. Can design principles of traditional learning theories be fulfilled by computer-based training systems in medicine: the example of CAMPUS. Int J Med Inform 2007;76:124129. (doi:10.1016/j.ijmedinf.2006.07.009) 7. De Leng B, Dolmans D, van de Wiel M, Muijtjens A, van der Vleuten C. How video cases should be used as authentic stimuli in problem-based medical education. Med Educ 2007;41:181-188. 8. Lewis DJ, Sewell RD. Providing formative feedback from a summative computer-aided assessment. Am J Pharm Educ 2007;71:33. 9. Wass V, McGibbon D, Van der Vleuten C. Composite undergraduate clinical examinations: how should the components be combined to maximize reliability? Med Educ 2001;35:326-330.
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¶·È‰È¿ ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ: ÎÚÈÙ‹ÚÈ· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ ¢. X. ∫·Û›ÌÔ˜1, ª. §È¿ÙÛ˘2, ∞. ™ÙÔÁÈ·ÓÓ›‰Ô˘1, ª. ∫·Ó¿ÚÈÔ˘2 ¶ÂÚ›ÏË„Ë: ¶ÔÏÏ¿ ·È‰È¿ ÂÌÊ·Ó›˙Ô˘Ó Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ, ·ÏÏ¿ Ï›Á· Â›Ó·È ÂΛӷ Ô˘ ¤¯Ô˘Ó ‰È·Ù·Ú·¯‹ ÙˆÓ ·Ì˘ÓÙÈÎÒÓ ÙÔ˘˜ Ì˯·ÓÈÛÌÒÓ. ™˘¯Ó¤˜, ˘ÔÙÚÔÈ¿˙Ô˘Û˜, ›ÌÔÓ˜, ‚·ÚȤ˜ ‹ ·Û˘Ó‹ıÈÛÙ˜ ÏÔÈÌÒÍÂȘ ·Ó·Ù‡ÛÛÔÓÙ·È Û ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· ÙÔ˘ ·Ì˘ÓÙÈÎÔ‡ Î·È ÂȉÈÎfiÙÂÚ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô ÈÛÙÔÚÈÎfi Î·È Ë Ê˘ÛÈ΋ ÂͤٷÛË ı¤ÙÔ˘Ó ÙËÓ ˘Ô„›· οÔÈ·˜ ˘ÔΛÌÂÓ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜. ™Â ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ, Á›ÓÂÙ·È ‚·ÛÈÎfi˜, ÂÚÁ·ÛÙËÚÈ·Îfi˜, ·ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηÈ, ·Ó οÙÈ Â›Ó·È ·ıÔÏÔÁÈÎfi ‹ ÙÂı› ˘Ô„›· ÁÈ· οÔÈÔ ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, Á›ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ Ì ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ·ÓÔÛÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ÔÈÔÙÈΤ˜ Î·È ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ‰ÒÛÔ˘Ì ٷ ÂÊfi‰È· ÛÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi ÁÈ· ÙË ÌÂıÔ‰È΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ÔÏ˘Û‡ÓıÂÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Î·È ÙËÓ ÔÚıÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ¤Ó‰ÂÈÍË ˘ÔΛÌÂÓ˘ ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜.
§¤ÍÂȘ ÎÏÂȉȿ: ∞ÓÔÛÔ·Ó¿ÚÎÂÈ·, ·ÓÔÛ›·, ¤ÏÂÁ¯Ô˜, ÏÔÈÌÒÍÂȘ, ·È‰È¿, ·Ó·ÛÎfiËÛË.
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¢ËÌÔÎÚ›ÙÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £Ú¿Î˘ 2 ∆Ì‹Ì· ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· °. ∫·Ó¿ÚÈÔ˘ mkanariou@hol.gr ∆Ì‹Ì· ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È ¶··‰È·Ì·ÓÙÔÔ‡ÏÔ˘, ∆.∫. 115 27, °Ô˘‰‹, ∞ı‹Ó·
Children with frequent infections: criteria for specialized immunological investigations D. C. Cassimos1, M. Liatsis2, A. Stogiannidou1, M. Kanariou2 Abstract: Although many children develop frequent infections, only a few have an underlying immune disorder. Children with dysfunction of the defense mechanisms of the immune system develop not only frequent infections but also recurrent, persistent, severe and rare infections. The medical history and physical examination provide a hint and should give rise to suspicion of an immune disorder. The approach to these patients starts with a primary diagnostic work up which, in relation to the clinical picture and the initial findings, should be extended to include more specialized investigations (qualitative and functional). The aim of this review is to provide paediatricians with the tools for approaching this problem and to propose an optimal method for investigating children with possible immune dysfunction. Key words: Immunodeficiency, immunity, investigation, infections, children, review.
™˘ÓÙÔÌÔÁڷʛ˜ BMAA µ·ÚÈ¿ ªÈÎÙ‹ ∞ÓÔÛÔ·Ó¿ÚÎÂÈ· C Complement / ™˘Ìϋڈ̷ CD Cluster Differentiation / ¢Â›ÎÙ˘ ¢È·ÊÔÚÔÔ›ËÛ˘ CMV Cytomegalovirus / ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ DHR Dihydrorodamine / ¢È˘‰ÚÔÚÔ‰·Ì›ÓË HPV Human Papilloma Virus / πfi˜ ·ÓıÚˆ›ÓˆÓ ıËÏˆÌ¿ÙˆÓ Ig Immunoglobulin / ∞ÓÔÛÔÛÊ·ÈÚ›ÓË MHC Major Histocompatibility Complex / ªÂ›˙ÔÓ ™‡ÛÙËÌ· πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ NBT Nitro Blue Tetrazolium / ¢ÔÎÈÌ·Û›· ¯ÚÒÛ˘ ÙÔ˘ ΢·ÓÔ‡ ÙÔ˘ ÙÂÙÚ·˙ÔÏ›Ô˘ NK Natural Killer / º˘ÛÈο ∫˘ÙÙ·ÚÔÎÙfiÓ· ¶∞∞ ¶ÚˆÙÔ·ı›˜ ∞ÓÔÛÔ·Ó¿ÚÎÂȘ
∂ÈÛ·ÁˆÁ‹ µ·ÛÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È Ë ·Ó·ÁÓÒÚÈÛË Î·È ‰È¿ÎÚÈÛË ÙˆÓ ‰ÈÎÒÓ ÙÔ˘ ȉ›ˆÓ ÛÙÔȯ›ˆÓ ·fi Ù·
1 Department of Paediatrics, Democritus University of Thrace 2 Department of Immunology and Histocompatibility, “Aghia Sophia” Children’s Hospital, Athens, Greece Correspondence: Maria G. Kanariou mkanariou@hol.gr Department of Immunology and Histocompatibility, “Aghia Sofia” Children’s Hospital Thivon & Papadiamantopoulou St., 115 27, Goudi, Athens, Greece
ͤӷ, Ì ÛÎÔfi Ó· ·Ó¤¯ÂÙ·È Ù· ‰Èο ÙÔ˘ Î·È Ó· ÂÈÙ›ıÂÙ·È ‹ ·ÔÚÚ›ÙÂÈ Ù· ͤӷ, ÒÛÙ ӷ ÚÔÛٷهÂÈ ÙËÓ ÔÌÔÈÔÛÙ·Û›· Î·È ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∆· ÈÔ Û˘Ó‹ıË Í¤Ó·, ÂÈÙÈı¤ÌÂÓ· ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ÛÙÔȯ›· Â›Ó·È ÔÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜. √È ÏÔÈÌÒÍÂȘ Â›Ó·È ÓÔÛ‹Ì·Ù· Ô˘ Û˘Ó‰¤ÔÓÙ·È ÙfiÛÔ ÛÙÂÓ¿ Ì ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ·, ÒÛÙÂ Â›Ó·È ‰˘Ó·Ùfi Ì ‚¿ÛË ÙË Ïԛ̈ÍË Î·È ÙÔ˘˜ ÙÔÈÎÔ‡˜ ‹ Û˘ÛÙËÌ·ÙÈÎÔ‡˜, ÂȉÈÎÔ‡˜ ‹ ÌË ÂȉÈÎÔ‡˜ Î·È Î˘ÙÙ·ÚÈÎÔ‡˜ ‹ ¯˘ÌÈÎÔ‡˜ ·ÓÔÛÈ·ÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ó· ·Ó·ÁÓˆÚÈÛı› ÙÔ ¤ÏÏÂÈÌÌ· Î·È Ó· Ù·ÍÈÓÔÌËı› Ë Ù˘¯fiÓ ·Ó¿ÚÎÂÈ·. √ÔÈÔÛ‰‹ÔÙ ÏÔÈÌÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· Ó· ÂΉËÏÒÛÂÈ ÓfiÛÔ ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ÂÈÙ˘¯Ë̤ÓË ‰È¿Û·ÛË ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ ·Ì˘ÓÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ ÙÔ ÓÂÔÁÓfi ÂÁηٷÏ›ÂÈ ÙÔ ÛÙ›ÚÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘ Ì‹ÙÚ·˜ ·ÔÈΛ˙ÂÙ·È Ì ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∏ ÌÈÎÚԂȷ΋ ¯ÏˆÚ›‰· Ô˘ ¶·È‰È·ÙÚÈ΋ 2008;71:5-13
Pediatri Jan-Feb 08
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¢. X. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
ª˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ
√˘‰ÂÙÂÚfiÊÈÏÔ ¶ÔÏ˘‰‡Ó·ÌÔ ·Ú¯¤ÁÔÓÔ Î‡ÙÙ·ÚÔ
¡∫ ·ÙÙ·ÚÔ
∞Ú¯¤ÁÔÓÔ Ì˘ÂÏÔÂȉ¤˜
∞Ú¯¤ÁÔÓÔ ÏÂÌÊÔÂȉ¤˜ ¶ÚÔ ∆ ·ÙÙ·ÚÔ
ªÔÓÔ·ÙÙ·ÚÔ
¶ÚÔ µ ·ÙÙ·ÚÔ ∏ˆÛÈÓfiÊÈÏÔ ª˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ
£‡ÌÔ˜
µ·ÛÂfiÊÈÏÔ
flÚÈÌÔ ∆ ·ÙÙ·ÚÔ
flÚÈÌÔ µ ·ÙÙ·ÚÔ
¶Ï·ÛÌ·ÙÔ·ÙÙ·ÚÔ
∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ ∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜.
·Ó·Ù‡ÛÛÂÙ·È fi¯È ÌfiÓÔ ‰ÂÓ Â›Ó·È ·ıÔÁfiÓÔ˜, ·ÏÏ¿ ÏÂÈÙÔ˘ÚÁ› Û˘Ì‚ÈÔÙÈο ˆ˜ ·Û›‰· ÌË ÂÈÙÚ¤ÔÓÙ·˜ Û ͤÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ó· ·Ó·Ù˘¯ıÔ‡Ó. ŸÙ·Ó ÙÔ ·È‰› ÚˆÙÔÛ˘Ó·ÓÙ‹ÛÂÈ Î¿ÔÈÔ ·ıÔÁfiÓÔ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÓÔÛ‹ÛÂÈ. ªÂ ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ ·Ó·Ù‡ÛÛÔÓÙ·È ·Ú¿ÏÏËÏ· ·ÓÔÛÔÏÔÁÈÎÔ› ·Ì˘ÓÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘ ηıÈÛÙÔ‡Ó ÙÔ ¿ÙÔÌÔ ÈηÓfi Ó· ÂÈ˙‹ÛÂÈ Î·È Ó· ·ÔÎÙ‹ÛÂÈ ÌÓËÌÔÓÈ΋ ·ÓÔÛ›· ηٿ ÙÔ˘ ·ıÔÁfiÓÔ˘ ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ·. §ÔÈÌÒÍÂȘ ·fi Û˘ÁÎÂÎÚÈ̤ÓÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ Ë §ÈÛÙ¤ÚÈ· Ë ÌÔÓÔ΢ÙÙ·ÚÈ΋ (Listeria monocytogenes) Î·È Ë ¶Ó¢ÌÔ·ÛÙË jiroveci (carinii), ‰ÂÓ Û˘Ó·ÓÙÒÓÙ·È ·Ú¿ ÌfiÓÔ Û ¿ÙÔÌ· Ì ˘ÔΛÌÂÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, ÂÓÒ ÌÂÚÈÎÔ› ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ô ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ (CMV), ÚÔηÏÔ‡Ó ·ÓÔÛÔηٷÛÙÔÏ‹. ∆Ô Â›Â‰Ô ıÚ¤„˘ ÂËÚ¿˙ÂÈ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙËÓ ·Ì˘ÓÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡, ÂÓÒ ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÛÙÔ ÔÔ›Ô ÌÂÁ·ÏÒÓÂÈ Î·ıÔÚ›˙ÂÈ ÙÔ˘˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÎÙ›ıÂÙ·È. º˘ÛÈÔÏÔÁÈο, fiÏ· Ù· ·È‰È¿ ÂÌÊ·Ó›˙Ô˘Ó ÏÔÈÌÒPaediatriki 2008;71:5-13
ÍÂȘ. ∫·Ù¿ ÙË ÓËȷ΋ ËÏÈΛ· ÛÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¯ÚfiÓÔ˘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÌÊ·Ó›ÛÔ˘Ó 8-10 ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È 1-2 ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡. øÛÙfiÛÔ, ··ÈÙÂ›Ù·È Ë ¿ÚÔ‰Ô˜ ÔÏÏÒÓ ÂÙÒÓ ÁÈ· Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÈηÓÔÔÈËÙÈ΋ ·ÓÔÛȷ΋ ÌÓ‹ÌË Î·È Ó· ÌÂȈı› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒ͈Ó. √ ·ÚÈıÌfi˜ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÌÂÈÒÓÂÙ·È ÌÂÙ¿ Ù· ÙÚ›· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ÂÊfiÛÔÓ ÙÔ ·È‰› ‰ÂÓ ·Ú·ÎÔÏÔ˘ı› ·È‰ÈÎfi ÛÙ·ıÌfi Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÏÏÔ ·È‰› ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ Ô˘ Ó· ËÁ·›ÓÂÈ Û¯ÔÏÂ›Ô (1). ∆Ô ÂÚÒÙËÌ· Ô˘ ÚÔ·ÙÂÈ Â›Ó·È ÔÈfi˜ ·ÚÈıÌfi˜ ÏÔÈÌÒÍÂˆÓ ı· ıˆÚËı› ÛËÌ·ÓÙÈÎfi˜ Î·È Û ÔÈ¿ ·È‰È¿ ı· ˘ÔÙ¢ıԇ̠‰È·Ù·Ú·¯‹ Ù˘ ¿Ì˘Ó·˜ Î·È Û ÙÈ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ı· ÚÔ¯ˆÚ‹ÛÔ˘ÌÂ. °È· Ó· ··ÓÙ‹ÛÔ˘Ì ے ·˘Ù¿ Ù· ÂÚˆÙ‹Ì·Ù· ı· Ú¤ÂÈ Ó· ˘ÂÓı˘Ì›ÛÔ˘Ì ÙÔ˘˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ ·Ì˘ÓÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ∆Ô ‰¤ÚÌ·, ÔÈ ‚ÏÂÓÓÔÁfiÓÔÈ Î·È Ù· ÚÔ˚fiÓÙ· Ô˘ ·˘ÙÔ› ÂÎÎÚ›ÓÔ˘Ó Â›Ó·È ÔÈ ÚÒÙÔÈ ÊÚ·ÁÌÔ› ÛÙË Ïԛ̈ÍË.
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∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û ÏÔÈÌÒÍÂȘ
∞ÓÙÈÁfiÓÔ
∞ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎfi ·ÙÙ·ÚÔ (APC)
AÓ·ÁÓÒÚÈÛË, ÂÂÍÂÚÁ·Û›· ·ÚÔ˘Û›·ÛË ·ÓÙÈÁfiÓÔ˘
¶Úfi‰ÚÔÌÔ ·ÈÌÔÔÈËÙÈÎfi ·ÙÙ·ÚÔ
∫‡ÙÙ·ÚÔ ¡∫ TH (T4) CD4
µ ·ÙÙ·ÚÔ
Tc (T8) CD8 Ts (T8) CD8
flÚÈÌÔ µ ∫‡ÙÙ·ÚÔ
IgM, IgD, IgG, IgA, IgE ∂ÈÎfiÓ· 2. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ ·ÏÏËÏ›‰Ú·Û˘ ÙˆÓ ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎÒÓ, ∆, µ, Î·È NK ΢ÙÙ¿ÚˆÓ Ì ÎÂÓÙÚÈÎfi ÚfiÏÔ ÙÔ˘ ‚ÔËıËÙÈÎÔ‡ ∆ ΢ÙÙ¿ÚÔ˘ (CD4) ÛÙËÓ ·ÓÔÛȷ΋ ·¿ÓÙËÛË (ÙÚÔÔÔÈË̤ÓÔ ·fi Ã. ∫·Û›ÌÔ˜, °ÂÓÈ΋ ¶·È‰È·ÙÚÈ΋, 1995).
ŸÙ·Ó ÔÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ˘ÂÚÈÛ¯‡ÛÔ˘Ó Î·È ÂÈÛ¤ÏıÔ˘Ó ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, ÌË ÂȉÈÎÔ› Î·È ÂȉÈÎÔ› ·ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ì˯·ÓÈÛÌÔ› ÎÈÓËÙÔÔÈÔ‡ÓÙ·È ÁÈ· Ó· ÂÌÔ‰›ÛÔ˘Ó ÙËÓ ·Ó¿Ù˘Í‹ ÙÔ˘˜. ∞Ó Î·È Ô Î¿ı ·ÓÔÛÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¤¯ÂÈ Í¯ˆÚÈÛÙ¤˜ ÏÂÈÙÔ˘ÚÁ›Â˜, ˘¿Ú¯ÂÈ Î·È ·ÍÈfiÏÔÁË ·ÏÏËÏ›‰Ú·ÛË Î·È ·ÏÏËÏÂÍ¿ÚÙËÛË ÁÈ· Ó· ÙÂÏÂÛÊÔÚ‹ÛÂÈ Ë ¿Ì˘Ó· ÙÔ˘ ÍÂÓÈÛÙ‹. °È· ÏfiÁÔ˘˜ ÌÂϤÙ˘ Î·È Î·Ù·ÓfiËÛ˘, ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ‰È·ÈÚÂ›Ù·È ÛÙ· “Û˘ÛÙ·ÙÈο” ÙÔ˘ (∂ÈÎfiÓ· 1), ÙÔ ÏÂÌÊÈÎfi Û‡ÛÙËÌ·, ÙÔ Ê·ÁÔ΢ÙÙ·ÚÈÎfi Î·È ÙÔ Û‡ÛÙËÌ· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ (2,3,4).
∆Ô ∞ÓÔÛÔÔÈËÙÈÎfi ™‡ÛÙËÌ· §ÂÌÊÔ·ÙÙ·Ú·: ∆· ÏÂÌÊÔ·ÙÙ·Ú· ‰È·ÎÚ›ÓÔÓÙ·È Û ‰‡Ô ‚·ÛÈΤ˜ ÔÌ¿‰Â˜, Ù· ∆ Î·È Ù· µ, Ì ‚¿ÛË ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›· Î·È Ù· Ê·ÈÓÔÙ˘Èο ÙÔ˘˜ ¯·Ú·ÎÙËÚÈÛÙÈο. √ Ê·ÈÓfiÙ˘fi˜ ÙÔ˘˜ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÂȉÈÎÔ‡˜ ‰Â›ÎÙ˜ (ÁÏ˘ÎÔÚˆÙ½Ó˜) Ô˘ ÂÎÊÚ¿˙Ô˘Ó ÛÙËÓ ÂÈÊ¿ÓÂÈ¿ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿-
‰ÈÔ ˆÚ›Ì·ÓÛ˘ Î·È ‰È·ÊÔÚÔÔ›ËÛ‹˜ ÙÔ˘˜ Î·È Ô˘ ·ÓȯÓ‡ÔÓÙ·È Ì ٷ ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·. ∆· ∆ ÏÂÌÊÔ·ÙÙ·Ú· ÂÍÂÏ›ÛÛÔÓÙ·È ÛÙÔ ı‡ÌÔ Û ÒÚÈÌ· ∆ ÏÂÌÊÔ·ÙÙ·Ú·. ∞ÔÙÂÏÔ‡Ó ÙËÓ ÏÂÈÔ„ËÊ›· ÙÔ˘ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È Â›Ó·È ‰˘Ó·Ù‹ Ë ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ ÙÔ˘˜ ‰È¿ÎÚÈÛË ÛÙÔ˘˜ ˘ÔÏËı˘ÛÌÔ‡˜ ÙÔ˘˜. ∆Ô 70% ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ê¤ÚÂÈ ÛÙËÓ ÂÈÊ¿ÓÂÈ¿ ÙÔ˘ ÙË CD4 ÁÏ˘ÎÔÚˆÙ›ÓË Î·È Ë ÏÂÈÔ„ËÊ›· ÙÔ˘˜ ¤¯ÂÈ ‚ÔËıËÙÈ΋/·ÁˆÁÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∆Ô ˘fiÏÔÈÔ 30% Â›Ó·È CD8+ ·ÙÙ·Ú· Î·È ¤¯Ô˘Ó ηٷÛÙ·ÏÙÈ΋/΢ÙÙ·ÚÔÙÔÍÈ΋ ÏÂÈÙÔ˘ÚÁ›·. √ ∆ ‚ÔËıËÙÈÎfi˜ ÏËı˘ÛÌfi˜ ÌÂÙ¿ ÙÔÓ ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi ·Ú¿ÁÂÈ Û˘ÁÎÂÎÚÈ̤Ó˜ ‰È·Ï˘Ù¤˜ Ô˘Û›Â˜, ÙȘ ÏÂÌÊÔΛÓ˜. ∞˘Ù¤˜ ·ÊÂÓfi˜ ¿ÁÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÁÈ· ·Ú·ÁˆÁ‹ ÂȉÈÎÒÓ ·ÓÙÈۈ̿وÓ, ·ÊÂÙ¤ÚÔ˘ ¢ԉÒÓÔ˘Ó ÌË ÂȉÈÎÔ‡˜ ÁÈ· ÙÔ ·ÓÙÈÁfiÓÔ Ì˯·ÓÈÛÌÔ‡˜, ÂÓÂÚÁÔÔÈÒÓÙ·˜ Ù· Ì·ÎÚÔÊ¿Á·, Ù· ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· Î·È ¿ÏÏ· Ï¢ÎÔ·ÙÙ·Ú·. ∆Ô ∆ ‚ÔËıËÙÈÎfi ·ÙÙ·ÚÔ ¶·È‰È·ÙÚÈ΋ 2008;71:5-13
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8
¢. X. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 1. ™ÙÔȯ›· ·fi ÙÔ ÈÛÙÔÚÈÎfi Û ·È‰È¿ Ì Èı·Ó‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ∞ÙÔÌÈÎfi πÛÙÔÚÈÎfi §ÔÈÌÒÍÂȘ: ‚·ÚȤ˜ (.¯. ÌËÓÈÁÁ›Ùȉ·, ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·) ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ì ÔÏϷϤ˜ ÂÓÙÔ›ÛÂȘ Ì ÂÈÏÔΤ˜ Ì ·Ú·ÙÂٷ̤ÓË ‰È¿ÚÎÂÈ· Ì و¯‹ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· ·ÔÛÙ‹Ì·Ù· §ÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜: ¢ηÈÚÈ·ÎÔ› ∂Ì‚ÔÏÈ·ÛÌÔ›: Ì ÂÈÏÔ΋/Ïԛ̈ÍË ∞ÏÏÂÚÁ›·: ›ÌÔÓË µÚÔÁ¯ÈÎfi ¿ÛıÌ·: ‚·Ú‡, ·ÓıÂÎÙÈÎfi ‹ ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ Ã∞¶, ‚ÚÔÁ¯ÔÂÎٷۛ˜ ∞˘ÙÔ¿ÓÔÛ˜ ÂΉËÏÒÛÂȘ: ΢ÙÙ·ÚÔÂӛ˜, ·ÁÁÂÈ›Ùȉ· ∫·ı˘ÛÙÂÚË̤ÓË ·fiÙˆÛË ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘ ∫·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ ¢˘ÛÌÔÚÊ›·, ÌÈÎÚÔÎÂÊ·Ï›· ÃÚfiÓÈ· ‰È¿ÚÚÔÈ· √ÈÎÔÁÂÓÂÈ·Îfi πÛÙÔÚÈÎfi ¡ÂÔÁÓÈÎfi˜/µÚÂÊÈÎfi˜ ı¿Ó·ÙÔ˜ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ °ÓˆÛÙ‹/¶Èı·Ó‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ™˘ÁÁ¤ÓÂÈ· ÁÔÓ¤ˆÓ §ÔÈÌÒÍÂȘ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ (HIV)
η٤¯ÂÈ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙËÓ Â˘fi‰ˆÛË Î·È ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·ÓÔÛÔ·¿ÓÙËÛ˘. ™Â ·ÓÙ›ıÂÛË, Ô ∆ ηٷÛÙ·ÏÙÈÎfi˜ ˘ÔÏËı˘ÛÌfi˜ ¯·ÏÈÓ·ÁˆÁ› ÙËÓ ·ÓÔÛÔ·¿ÓÙËÛË. ∆ÔÓ CD4 ‰Â›ÎÙË ¤¯Ô˘Ó Î·È Ù· ∆ ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ ÂÈ‚Ú·‰˘ÓfiÌÂÓ˘ ˘ÂÚ¢·ÈÛıËÛ›·˜, ÂÓÒ ÙÔÓ CD8 ¤¯Ô˘Ó Ù· ∆ ·ÙÙ·Ú· Ô˘ ÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜, ÙËÓ “ÂÈÙ‹ÚËÛË” ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÔÏ˘ÛÌ¤ÓˆÓ ·fi ÙÔ˘˜ ÈÔ‡˜ ΢ÙÙ¿ÚˆÓ (5,6). ∆· µ ÏÂÌÊÔ·ÙÙ·Ú· Â›Ó·È Ô ¿ÏÏÔ˜ ÌÂÁ¿ÏÔ˜ ÏÂÌÊÔ¶›Ó·Î·˜ 2. ∫ÏÈÓÈο ÛËÌ›· ·È‰ÈÒÓ Ì Èı·Ó‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ¢˘ÛÙÚÔÊ›· ¢˘ÛÌÔÚÊ›· ÕÎÚ·: ÏËÎÙÚÔ‰·ÎÙ˘Ï›·, ˆ¯ÚfiÙ˘ ™ÙÔÌ·ÙÔÊ¿Ú˘ÁÁ·˜: Ô˘Ï›ÙȘ, ›ÌÔÓË Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·, ÂÚÈÔ‰ÔÓÙ›Ùȉ·, ηı˘ÛÙÂÚË̤ÓË ·fiÙˆÛË ÓÂÔÁÈÏÒÓ Ô‰fiÓÙˆÓ ∫·Ú‰È·ÁÁÂÈ·Îfi: Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ· ∞Ó·Ó¢ÛÙÈÎfi: ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ·, ‚ÚÔÁ¯ÂÎٷۛ˜, ÓÂ˘Ì·ÙÔ΋Ϙ °·ÛÙÚÂÓÙÂÚÈÎfi: Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· §ÂÌÊÈÎfi˜ ÈÛÙfi˜ (·Ì˘Á‰·Ï¤˜, ÏÂÌÊ·‰¤Ó˜, ı‡ÌÔ˜): ·Ô˘Û›· ‹ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ı‡ÌˆÌ· ¢¤ÚÌ·-ÙÚ›¯Â˜: ¤Î˙ÂÌ·, ÂÙ¤¯ÂȘ, Ô˘Ï¤˜, ÎÔÎÎÈÒÌ·Ù·, ·ÁÁÂÈÔÔ›‰ËÌ·, ·ÏÊÈÛÌfi˜, ·ÏˆÂΛ· √Êı·ÏÌÔ›: ·ÓˆÌ·Ï›Â˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, ÙËÏ·ÁÁÂÈÂÎٷۛ˜ ¡Â˘ÚÈÎfi Û‡ÛÙËÌ·: ·Ù·Í›·
Paediatriki 2008;71:5-13
΢ÙÙ·ÚÈÎfi˜ ÏËı˘ÛÌfi˜, Ô ÔÔ›Ô˜ ‰È·ÊÔÚÔÔÈÂ›Ù·È Î·È ˆÚÈÌ¿˙ÂÈ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ·fi ·˘Ù¿, ÌÂÙ¿ ·fi οÔÈÔ ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi, ÂÍÂÏ›ÛÛÔÓÙ·È Û ϷÛÌ·ÙÔ·ÙÙ·Ú·, Ù· ÔÔ›· Û˘Óı¤ÙÔ˘Ó Î·È ÂÎÎÚ›ÓÔ˘Ó ·ÓÔÛÔÛÊ·ÈÚ›Ó˜. ∫¿ı ¿ÙÔÌÔ ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· ·Ú¿ÁÂÈ ÂηÙÔÌ̇ÚÈ· µ ΢ÙÙ·ÚÈÎÒÓ ÎÏÒÓˆÓ, ηı¤Ó·˜ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Û˘Óı¤ÙÂÈ ¤Ó· ÂȉÈÎfi ·Óٛۈ̷. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ, ÙÔ ¿ÙÔÌÔ Â›Ó·È ¤ÙÔÈÌÔ Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙËÓ ÔÈÎÈÏ›· ÙˆÓ ·ÓÙÈÁÔÓÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ô˘ ı· Û˘Ó·ÓÙ‹ÛÂÈ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘. ªÂÚÈο ·fi Ù· ÂÓÂÚÁÔÔÈË̤ӷ µ ·ÙÙ·Ú· ‰ÂÓ ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È Û ϷÛÌ·ÙÔ·ÙÙ·Ú·, ·ÏÏ¿ ·Ú·Ì¤ÓÔ˘Ó ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ˆ˜ ÌÓËÌÔÓÈο ·ÙÙ·Ú·. ∂›Ó·È ·˘Ù¿ Ô˘ ı· ‰ÒÛÔ˘Ó ÙË ÁÚ‹ÁÔÚË ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ÂÚ›ÙˆÛË ·Ó·ÌfiÏ˘ÓÛ˘. Ÿˆ˜ Ù· ∆, ¤ÙÛÈ Î·È Ù· µ ·ÙÙ·Ú· ¤¯Ô˘Ó ÂÈÊ·ÓÂÈ·ÎÔ‡˜ ‰Â›ÎÙ˜, ‚¿ÛÂÈ ÙˆÓ ÔÔ›ˆÓ Ù·˘ÙÔÔÈÔ‡ÓÙ·È. √È ÏÂÌÊÔ΢ÙÙ·ÚÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ‰È·ÎÚ›ÓÔÓÙ·È ·‰Ú¿ Û ÂΛӘ ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ (΢ÙÙ·ÚÈΤ˜) Î·È Û ÂΛӘ ÙˆÓ µ (·ÓÙÈۈ̷ÙÈΤ˜), ·ÚfiÏÔ Ô˘ ˘¿Ú¯ÂÈ Î·È ÌÂÁ¿ÏË ·ÏÏËÏ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ (∂ÈÎfiÓ· 2). ™ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ·˘Ù‹ Ë ÂÈÎ¿Ï˘„Ë Î·È ·ÏÏËÏ›‰Ú·ÛË ‰ÂÓ Ú¤ÂÈ Ó· ˘ÔÙÈÌ¿Ù·È. ∂ÓÙÔ‡ÙÔȘ, ˆ˜ ÁÂÓÈÎfi ηÓfiÓ· ÌÔÚԇ̠ӷ ıˆڋÛÔ˘Ì fiÙÈ Ù· ∆ ·ÙÙ·Ú· Â›Ó·È ÈÔ ÛËÌ·ÓÙÈο ÛÙËÓ ¿Ì˘Ó· ¤Ó·ÓÙÈ ÙˆÓ ÈÒÓ, ÙˆÓ Ì˘Î‹ÙˆÓ, ÙˆÓ ·Ú·Û›ÙˆÓ, fiˆ˜ Î·È ¤Ó·ÓÙÈ ÙˆÓ fiÁÎˆÓ Î·È ÙˆÓ Í¤ÓˆÓ ÈÛÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÂÓÒ Ù· µ ·ÙÙ·Ú· ¤¯Ô˘Ó ηıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ¿Ì˘Ó· ηٿ ÙˆÓ ‚·ÎÙËÚȉ›ˆÓ. ∆¤ÏÔ˜, ÌÈ· ÙÚ›ÙË ÔÌ¿‰· ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Â›Ó·È Ù· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· (NK) ·ÙÙ·Ú·. ∆· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ÚÔ¤Ú¯ÔÓÙ·È ·fi Úfi‰ÚÔÌ· ·ÙÙ·Ú· ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, Ù· ÂÚÈÛÛfiÙÂÚ· ÙˆÓ ÔÔ›ˆÓ ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ÛÙÔÓ ÛÏ‹Ó· ‹ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È ·ÔÙÂÏÔ‡Ó ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (ÂÚ›Ô˘ 10%). ∆· ¡∫ ÏÂÌÊÔ·ÙÙ·Ú· ‰ÂÓ ¤¯Ô˘Ó ÂȉÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Î·È ÛÙÂÚÔ‡ÓÙ·È ·ÓÔÛÔÏÔÁÈ΋˜ ÂȉÈÎfiÙËÙ·˜ Î·È ÌÓ‹Ì˘. ∆· NK ·ÙÙ·Ú· Ï‡Ô˘Ó Ù· ÌÔÏ˘Ṳ̂ӷ Ì ÈÔ‡˜ Î·È Î·ÚÎÈÓÈο ·ÙÙ·Ú·. ¢ÂÓ ··ÈÙÂ›Ù·È ÚÔËÁÔ‡ÌÂÓË Â˘·ÈÛıËÙÔÔ›ËÛ‹ ÙÔ˘˜ Î·È ‰ÂÓ ÂÚÈÔÚ›˙ÔÓÙ·È ·fi Ù· ·ÓÙÈÁfiÓ· ÙÔ˘ MHC, ¤ÙÛÈ Ë ÎÈÓËÙÔÔ›ËÛË Î·È Ë ‰Ú¿ÛË ÙÔ˘˜ Â›Ó·È ¿ÌÂÛË. ∆Ô Ê·ÁÔ΢ÙÙ·ÚÈÎfi Û‡ÛÙËÌ·: ∆Ô Ê·ÁÔ΢ÙÙ·ÚÈÎfi ÛΤÏÔ˜ ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÔÈÎÈÏ›· ΢ÙÙ¿ÚˆÓ, Ô˘ ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ù˘ ÚfiÛÏ˄˘ Î·È Î·Ù·ÛÙÚÔÊ‹˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ. ∆¤ÙÔÈ· ·ÙÙ·Ú· Â›Ó·È Ù· ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, Ù· ˈÛÈÓfiÊÈÏ· Î·È Ù· ÌÔÓÔ·ÙÙ·Ú·, Ù· ÔÔ›·, ˘fi ÙËÓ Â›‰Ú·ÛË ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ÛÙÔ˘˜ ÈÛÙÔ‡˜. ∂Λ Ù· ÌÔÓÔ·ÙÙ·Ú· ÂÍÂÏ›ÛÛÔÓÙ·È ÛÂ
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·9
9
∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û ÏÔÈÌÒÍÂȘ
¶›Ó·Î·˜ 3. ™˘Ó‹ıË ·ıÔÁfiÓ· ˘Â‡ı˘Ó· ÁÈ· ÏÔÈÌÒÍÂȘ ·Ó¿ÏÔÁ· Ì ÙÔ ·ÓÔÛÈ·Îfi ¤ÏÏÂÈÌÌ· ∞ÓÔÛÈ·Îfi ŒÏÏÂÈÌÌ· ∞ÓÙÈۈ̷ÙÈ΋ ·Ó¿ÚÎÂÈ·
™˘Ó‹ıË ¶·ıÔÁfiÓ· µ·ÎÙËÚ›‰È·:
¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ·ÈÌfiÊÈÏÔ˜ ÈÓÊÏÔ˘¤ÓÙÛ· Ù‡Ô˘ b, ÛÙÚÂÙfiÎÔÎÎÔ˜ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜, echo
∂ÓÙÂÚÔÈÔ›: ∞Ó¿ÚÎÂÈ· ∆ ΢ÙÙ¿ÚˆÓ
ªÈÎÙ‹ ·Ó¿ÚÎÂÈ· ∆ & µ ΢ÙÙ¿ÚˆÓ (¯˘ÌÈ΋ & ΢ÙÙ·ÚÈ΋)
∂Ó‰Ô΢ÙÙ·ÚÈο ‚·ÎÙËÚ›‰È·:
Ì˘ÎÔ‚·ÎÙËÚ›‰È·, ÏÈÛÙ¤ÚÈ·
πÔ› ª‡ÎËÙ˜:
Candida, ·Û¤ÚÁÈÏÏÔ˜
µ·ÎÙËÚ›‰È· ª‡ÎËÙ˜ πÔ›: ¶·Ú¿ÛÈÙ·: ¶ÚˆÙfi˙ˆ·:
CMV, ¤Ú˘, ÈÏ·Ú¿˜ ÎÚ˘ÙfiÎÔÎÎÔ˜, ÎÚ˘ÙÔÛÔÚ›‰ÈÔ pneumocystis carinii
∞Ó¿ÚÎÂȘ Ê·ÁÔ΢ÙÙ¿ÚˆÓ
µ·ÎÙËÚ›‰È·: ª‡ÎËÙ˜: ÕÙ˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·
∞Ó¿ÚÎÂȘ Ê˘ÛÈ΋˜ ·ÓÔÛ›·˜
µ·ÎÙËÚ›‰È· (˘ÔÁfiÓ·) ª˘ÎÔ‚·ÎÙËÚ›‰È· πfi˜ ·ÓıÚˆ›ÓˆÓ ıËÏˆÌ¿ÙˆÓ (HPV)
∞Ó¿ÚÎÂȘ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜
µ·ÎÙËÚ›‰È·:
Ì·ÎÚÔÊ¿Á· ÁÓˆÛÙ¿ Î·È ˆ˜ ÈÛÙÈÔ·ÙÙ·Ú·. ∞ÚÎÂÙ¿ fiÚÁ·Ó· ¤¯Ô˘Ó ·Ó·Ù‡ÍÂÈ ÂȉÈÎÔ‡˜ ˘ÔÏËı˘ÛÌÔ‡˜ Ì·ÎÚÔÊ¿ÁˆÓ. ∆· ·ÙÙ·Ú· ÙÔ˘ Kupffer ÛÙÔ ‹·Ú, ÙÔ˘ Langerhans ÛÙÔ ‰¤ÚÌ·, Ù˘ ÌÈÎÚÔÁÏÔ›·˜ ÛÙÔÓ ÂÁΤʷÏÔ Î·È Ù· ÌÂÛ·ÁÁÂȷο ·ÙÙ·Ú· ÙˆÓ ÓÂÊÚÒÓ. ∆Ô ·Ú¯ÈÎfi ÁÂÁÔÓfi˜ Ù˘ Ê·ÁÔ΢ÙÙ¿ÚˆÛ˘ Â›Ó·È Ë ¯ËÌÂÈÔÙ·Í›·, ÏÂÈÙÔ˘ÚÁ›· Ì ÙËÓ ÔÔ›· ÚÔÛÂÏ·ÔÓÙ·È Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· ÛÙÔÓ ÙfiÔ Ù˘ ÊÏÂÁÌÔÓ‹˜. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ‰È¿ÊÔÚÔ˘˜ ¯ËÌÂÈÔÙ·ÎÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, Ì ΢ÚÈfiÙÂÚÔ ÙÔ ÎÏ¿ÛÌ· C5· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ∆· Ê·ÁÔ·ٷڷ ·Ó·ÁÓˆÚ›˙Ô˘Ó Î·È ÚÔÛÎÔÏÏÒÓÙ·È Û ÔÏÏÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ªÂ ÙËÓ Ô„ˆÓÈÓÔÔ›ËÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ, ÙË Û‡Ó‰ÂÛË ‰ËÏ·‰‹ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Ì ٷ ‹‰Ë Û¯ËÌ·ÙÈṲ̂ӷ ·ÓÙÈÛÒÌ·Ù· ‹/Î·È ÙÔ C3, Î·È Ì¤Ûˆ ·˘ÙÒÓ Î·È ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘˜ Ì ÙÔ Ê·ÁÔ·ÙÙ·ÚÔ, ·˘Í¿ÓÂÙ·È Ë ·Ó·ÁÓÒÚÈÛË Î·È Ë ÚÔÛÎfiÏÏËÛË ÙˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ ÛÙÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, ÒÛÙ ӷ Ê·ÁÔ΢ÙÙ·ÚˆıÔ‡Ó Î·È Ó· Á›ÓÂÈ Ë ‚·ÎÙËÚÈÔÎÙÔÓ›·. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ, ÙÔ Ê·ÁÔ΢ÙÙ·ÚÈÎfi Û‡ÛÙËÌ· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ¿Ì˘Ó·, ȉȷÈÙ¤Úˆ˜ ηٿ ‚·ÎÙËÚȉȷÎÒÓ ÏÔÈÌÒÍÂˆÓ (7,8). ∆Ô Û‡ÛÙËÌ· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜: ∆Ô Û‡ÛÙËÌ· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ Û˘ÌÌÂÙ¤¯ÂÈ Î·È ÂÓÈÛ¯‡ÂÈ ÙËÓ ÔÈÎÈÏ›· ÂȉÈÎÒÓ Î·È ÌË ÂȉÈÎÒÓ ·Ì˘ÓÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, fiˆ˜ Ë ¯ËÌÂÈÔÙ·Í›· Î·È Ë Ô„ˆÓÈÓÔÔ›ËÛË. ∞ÔÙÂÏÂ›Ù·È ·fi ÂÚÈÛÛfiÙÂÚ˜ ·fi 20 ÚˆÙ½Ó˜, Ô˘ ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛË, ·ÏÏËÏÂȉÚÔ‡Ó Ì ηıÔÚÈṲ̂ÓË ÛÂÈÚ¿ ÁÈ· Ó· ·Ú¿ÁÔ˘Ó ÂÓÂÚÁ¿ ÚÔ˚fiÓÙ·. ∆·
ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ¯Ú˘Û›˙ˆÓ, Gram (-) ·Û¤ÚÁÈÏÏÔ˜
Ó·˚ÛÛ¤ÚÈ· ÌËÓÈÁÁ›Ùȉ·˜
ÎÏ¿ÛÌ·Ù· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÂÓÂÚÁÔÔÈÔ‡Ó Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È Ù· Ì·ÎÚÔÊ¿Á·, Ù· ÔÔ›· Ï‡Ô˘Ó ·Â˘ı›·˜ Ù· ‚·ÎÙËÚ›‰È· Î·È Ù· ·ÙÙ·Ú· ÛÙfi¯Ô˘˜ Î·È ·˘Í¿ÓÔ˘Ó ÙË ‰È·‚·ÙfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ. ∏ ÂÓÂÚÁÔÔ›ËÛË Î·È ÙˆÓ ‰‡Ô Ô‰ÒÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, Ù˘ ÎÏ·ÛÈ΋˜ Î·È Ù˘ ÂÓ·ÏÏ·ÎÙÈ΋˜, Ô‰ËÁ› ÙÂÏÈο ÛÙË ‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙÔ˘ C3 Î·È ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ›‰ÈˆÓ ÂÓÂÚÁÒÓ ‚ÈÔÏÔÁÈÎÒÓ ÎÏ·ÛÌ¿ÙˆÓ. ™ÙÔÓ ¿ÓıÚˆÔ, ÔÈ ·Ó¿ÚÎÂȘ ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ Û˘Ó‰¤ÔÓÙ·È Ì ¯·Ú·ÎÙËÚÈÛÙÈο ÎÏÈÓÈο Û‡Ó‰ÚÔÌ·. ∞ÛıÂÓ›˜ Ì ·Ó¿ÚÎÂÈ· ÙÔ˘ C1, C4 ‹ C2 Û˘Ó‹ıˆ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ó‰ÚfiÌÔ˘ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ (ÂÍ¿ÓıËÌ· ·ÚÂÈÒÓ, ·ÚıÚ·ÏÁ›·, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, ˘ÚÂÙfi ‹ ¯ÚfiÓÈ· ·ÁÁÂÈ›Ùȉ·) Î·È Û·Ó›ˆ˜ Ì ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ˘ÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. ∞ÛıÂÓ›˜ Ì ·Ó¿ÚÎÂÈ· ÙÔ˘ C3 ˘ÔʤÚÔ˘Ó ·fi ‚·ÚȤ˜, ˘ÔÙÚÔÈ¿˙Ô˘Û˜, ˘ÔÁfiÓÔ˘˜ ÏÔÈÌÒÍÂȘ, ÂÓÒ ·Ú·ÙËÚÂ›Ù·È ÂÓÙ˘ˆÛȷ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ·Ó·ÚÎÂÈÒÓ ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ ÙÂÏÈÎÔ‡ ÛΤÏÔ˘˜ (C5, C6, C7, C8) Ì ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ·fi Ó·˚ÛÛ¤ÚȘ (ÁÔÓfiÎÎÔÎÔ, ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ) (3,8,9).
∞ÓÔÛÔ·Ó¿ÚÎÂȘ Î·È ÏÔÈÌÒÍÂȘ √ˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, fiÏ· Ù· ·È‰È¿ ¤¯Ô˘Ó ÙËÓ ÂÌÂÈÚ›· ÙˆÓ ÏÔÈÌÒ͈Ó. ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ô˘ ı· ·ÔÙÂϤÛÂÈ ÎÚÈÙ‹ÚÈÔ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÂϤÁ¯Ô˘ ÁÈ· ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Â›Ó·È Ë ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÛÙȘ ÏÔÈÌÒÍÂȘ. ∞˘Ùfi ÌÔÚ› Ó· ÛËÌ·›ÓÂÈ ·˘ÍË̤ÓË ¶·È‰È·ÙÚÈ΋ 2008;71:5-13
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·10
10
¢. X. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 4. ¢ÈÂÚ‡ÓËÛË ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ Û ·È‰È¿ ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ∞Ú¯ÈÎfi˜ ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ŒÏÂÁ¯Ô˜ °ÂÓÈ΋ ·›Ì·ÙÔ˜ ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÔÚÔ‡: IgG, IgA, IgM, IgE πÛÔ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›Ó˜ ™˘Ìϋڈ̷ C3, C4 ∂ȉÈÎfi˜ ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ŒÏÂÁ¯Ô˜ ÀÔÙ¿ÍÂȘ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ŒÏÂÁ¯Ô˜ Û˘ÌÏËÚÒÌ·ÙÔ˜ ŒÏÂÁ¯Ô˜ Ê·ÁÔ΢ÙÙ¿Úˆv ÀÔÏËı˘ÛÌÔ› ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ŒÏÂÁ¯Ô˜ ÁÈ· HIV
ÛÂ Û˘¯Ó¤˜ ‚·ÎÙËÚȉȷΤ˜ ÏÔÈÌÒÍÂȘ Û ‚·ÚȤ˜ ‚·ÎÙËÚȉȷΤ˜ ÏÔÈÌÒÍÂȘ, fiˆ˜ ·fi Ó·˚ÛÛ¤ÚÈ· ÌËÓÈÁÁ›Ùȉ·˜ Û ÏÔÈÌÒÍÂȘ ·fi ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ, Gram (-) ‚·ÎÙËÚ›‰È·, ̇ÎËÙ˜ Û ‚·ÚȤ˜ ÈÔÁÂÓ›˜ ‹ ¢ηÈÚȷΤ˜ ÏÔÈÌÒÍÂȘ Û ¢ηÈÚȷΤ˜ ÏÔÈÌÒÍÂȘ, TBC, ‚·ÚȤ˜ ÏÔÈÌÒÍÂȘ
∂ÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ŒÏÂÁ¯Ô˜ (‚Ϥ ¶›Ó·Î· 5)
Û˘¯ÓfiÙËÙ· (ÂÚÈÛÛfiÙÂÚ˜ ·fi 8-10 ·Ó¿ ¤ÙÔ˜), ·˘ÍË̤ÓË ÛÔ‚·ÚfiÙËÙ· ηÈ/‹ ·Ú·ÙÂٷ̤ÓË ‰È¿ÚÎÂÈ· ÙˆÓ ÏÔÈÌÒ͈Ó, ‚·ÚȤ˜ ÂÈÏÔΤ˜, ÏÔÈÌÒÍÂȘ ·fi ·Û˘Ó‹ıÂȘ ‹ ¢ηÈÚÈ·ÎÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ (¯ˆÚ›˜ Ï‹ÚË ·ÔηٿÛÙ·ÛË), Ì ·˘ÍË̤ÓË ÂÍ¿ÚÙËÛË ·fi Ù· ·ÓÙÈ‚ÈÔÙÈο Î·È Ù¤ÏÔ˜ Ì و¯‹ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ (10). ÀÔ„›· ·ıÔÏÔÁÈÎÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ˘ÔÛÙÚÒÌ·ÙÔ˜ Ù›ıÂÙ·È Â›Û˘ ÛÂ: ÔÚÈṲ̂Ó˜ ‰ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ (ÂÙ¤¯ÂȘ, ‚·Ú‡ ¤Î˙ÂÌ·, ηÓÙÈÓÙ›·ÛË), ¯ÚfiÓÈ· ‰È¿ÚÚÔÈ·, ÌÂȈ̤ÓË ·Ó¿Ù˘ÍË, ‡·ÚÍË Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜, ˘ÔÙÚÔÈ¿˙ÔÓÙ· ·ÔÛÙ‹Ì·Ù·, ˘ÔÙÚÔÈ¿˙Ô˘Û· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Î·È ‚·ÚÈ¿ ·ÏÏÂÚÁÈο ‹ ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·. ∞ÎfiÌË, ¤ÏÂÁ¯Ô˜ ··ÈÙÂ›Ù·È ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ (·Ù·Í›·, ÙËÏ·ÁÁÂÈÂÎÙ·Û›·, ıÚÔÌ‚ÔÂÓ›·, ¤Î˙ÂÌ·, ÙÂÙ·Ó›·), ÔÈ Ôԛ˜ Î·È Û˘Ó‰¤ÔÓÙ·È ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ Û‡Ó‰ÚÔÌ·. ¶·Ú¿ÏÏËÏ· Ì ÙÔ ÂÓ‰Âϯ¤˜ ÈÛÙÔÚÈÎfi, Î·È Ë ÚÔÛÂÎÙÈ΋ Ê˘ÛÈ΋ ÂͤٷÛË ‚ÔËı¿ÂÈ ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ªÂÁ¿ÏË ÛËÌ·Û›· ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘ ¤¯ÂÈ Ë Ù˘¯fiÓ ÛÔ‚·Ú‹ ·ÓÙ›‰Ú·ÛË ÛÙ· ÂÌ‚fiÏÈ·, ȉ›ˆ˜ Ì ˙ÒÓÙ˜ ÈÔ‡˜, Ë ‡·ÚÍË ı·Ó¿ÙÔ˘ Û ÓËȷ΋ ËÏÈΛ· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‹ Ë ‡·ÚÍË Û˘ÁÁÂÓÒÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ·ÏÏÂÚÁ›Â˜ ‹ ηÎÔ‹ıÂȘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ (¶›Ó·Î˜ 1 Î·È 2). ¡ÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· - ™˘¯ÓfiÙËÙ·: √È ·ÓÔÛÔ·Ó¿ÚÎÂȘ ‰È·ÎÚ›ÓÔÓÙ·È ·ÊÂÓfi˜ Û ڈÙÔ·ı›˜ ‹ ‰Â˘ÙÂÚÔ·ı›˜, ·ÊÂÙ¤ÚÔ˘ Û ·˘Ù¤˜ Ô˘ ÂÌϤÎÔÓÙ·È Ì˯·ÓÈÛÌÔ› Ù˘ ÂȉÈ΋˜ (¯˘ÌÈ΋˜, ΢ÙÙ·ÚÈ΋˜) ‹ ÌË ÂȉÈ΋˜ (.¯. Ê·ÁÔ·ÙÙ·Ú·, Û˘Ìϋڈ̷) ·ÓÔÛ›·˜. ™ÙËÓ ·È‰È΋ ËÏÈΛ· ΢ÚÈ·Ú¯Ô‡Ó ÔÈ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ (¶∞∞), ÂÓÒ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÔÈ ‰Â˘ÙÂÚÔ·ı›˜ (11). √È ¶∞∞ Â›Ó·È Û¿ÓÈ· ÓÔÛ‹Ì·Ù·. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È 1:10.000 ¿ÙÔÌ· ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ·Ó ÂÍ·ÈÚ¤ÛÂÈ Î·Ó›˜ ÙËÓ ·ÓÙÈۈ̷ÙÈ΋ ·Ó¿ÚÎÂÈ· Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ∞ (IgA), Ô˘ ¤¯ÂÈ ÂÚ›Ô˘ 20Ï¿ÛÈ· Û˘¯ÓfiÙËÙ·. À¿Ú¯ÂÈ ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ· ˆ˜ Paediatriki 2008;71:5-13
ÚÔ˜ ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Î·È ÙË ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÛfiÙÂÚ˜ ·fi 150 ¶∞∞ Ì ‰È·ÊÔÚÂÙÈÎfi Ë Î·ıÂÌ›· ·ÓÔÛÔÏÔÁÈÎfi ˘fiÛÙڈ̷, ·ÏÏ¿ Î·È Ì ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ÂΉËÏÒÛÂˆÓ (12-14).
∂ÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ∆Ô ·È‰› ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ÌÔÚ› Ó· ηٷٷ¯ı› Û ÂΛÓÔ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ï‹ÚË ·ÓÔÛÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË, ÂΛÓo Ô˘ ‰ÈηÈÔ‡Ù·È ‚·ÛÈÎfi ¤ÏÂÁ¯Ô Î·È ÛÙË ÌÂÁ¿ÏË ÏÂÈÔ„ËÊ›· ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÏÒ˜ ¯ÚÂÈ¿˙ÔÓÙ·È ·Ú·ÎÔÏÔ‡ıËÛË. ∏ ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ ¤¯ÂÈ ÛÔ‚·Úfiٷ٘ Û˘Ó¤ÂȘ ÁÈ· ÙÔÓ ·ÛıÂÓ‹, ÂÓÒ Ë ‰È¿ÁÓˆÛË ÛÙË ÌÈÎÚfiÙÂÚË ‰˘Ó·Ù‹ ËÏÈΛ· ‚ÔËı¿ ÛÙËÓ “·ÈÙÈÔÏÔÁÈ΋” ıÂڷ›· Î·È ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ, Ì ÙËÓ ¿ÌÂÛË Î·È ÛˆÛÙ‹ Û˘Ìو̷ÙÈ΋ ·ÁˆÁ‹. ∂ÈϤÔÓ, Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ Û ηϋ ηٿÛÙ·ÛË ı· ÂÈÙÚ¤„ÂÈ ÌÂÏÏÔÓÙÈο ÙËÓ ÂÊ·ÚÌÔÁ‹ Èı·ÓÒÓ ÚÈ˙ÈÎÒÓ ·ÈÙÈÔÏÔÁÈÎÒÓ ıÂÚ·ÂÈÒÓ. Œ¯ÔÓÙ·˜ ÁÓÒÛË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ÙÔ˘ ÙÚfiÔ˘ ¿Ì˘Ó·˜ ¤Ó·ÓÙÈ ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, ηÙ¢ı˘ÓfiÌ·ÛÙ ÛÙÔ˘˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÎÈÓ‰˘Ó‡ÂÈ Ô ¿ÚÚˆÛÙÔ˜ Ì ·ÓÔÛÔ·Ó¿ÚÎÂÈ· (¶›Ó·Î·˜ 3) (3,11). ∞ÎÔÏÔ˘ıÒÓÙ·˜ ·Ó¿ÏÔÁÔ ÙÚfiÔ ÛΤ„˘ Î·È ·ÓÙ›ÛÙÚÔÊË Ô‰fi, ÚÔÛ·Ó·ÙÔÏÈ˙fiÌ·ÛÙ ÛÙÔ Èı·Ófi, ¿Û¯ÔÓ, ·ÓÔÛÔÏÔÁÈÎfi ÛΤÏÔ˜. “¶˘Í›‰·” Â›Ó·È ÙÔ Â›‰Ô˜ Ù˘ Ïԛ̈͢ Î·È Ë ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ù˘. ∏ ÂÌÊ¿ÓÈÛË ·ÔÛÙËÌ¿ÙˆÓ Î·È “ÂÓ Ùˆ ‚¿ıÂÈ” ÏÔÈÌÒÍÂˆÓ ·fi ÛÙ·Ê˘ÏfiÎÔÎÎÔ, ÛÂÚÚ¿ÙÈ· ‹ ·Û¤ÚÁÈÏÏÔ Î·Ù¢ı‡ÓÔ˘Ó ÙË ÛΤ„Ë Ì·˜ Û ·Ó¿ÚÎÂÈ· ÙˆÓ ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ. √È ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ ·fi Ó·˚ÛÛ¤ÚÈ· (ÁÔÓfiÎÔÎÎÔ ‹ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ) ÂÌÊ·Ó›˙ÔÓÙ·È Û ¿ÙÔÌ· Ì ·Ó¿ÚÎÂÈ· ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ ÙÂÏÈÎÔ‡ ÛΤÏÔ˘˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ÂÓÒ Ù· ˘ÔÁfiÓ· ‚·ÎÙËÚ›‰È· (·ÈÌfiÊÈÏÔ˜, Ó¢ÌÔÓÈfiÎÔÎÎÔ˜, „¢‰ÔÌÔÓ¿‰·) ·Ó·Ù‡ÛÛÔ˘Ó ÓfiÛÔ Û ˘fiÛÙڈ̷ ·ÓÙÈۈ̷ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (1).
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·11
11
∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û ÏÔÈÌÒÍÂȘ
¶›Ó·Î·˜ 5. ∞ÏÁfiÚÈıÌÔ˜ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ ·È‰ÈÒÓ Ì ‚¿ÛË ÙȘ ÏÔÈÌÒÍÂȘ ¶·ıÔÁfiÓ·
µ·ÎÙËÚ›‰È·
™Ù·Ê˘ÏfiÎÔÎÎÔ˜
¡·˚ÛÛ¤ÚÈ· ÌËÓÈÁÁ›Ùȉ·˜
∂Ó‰Ô΢ÙÙ¿ÚÈ·: ª˘ÎÔ‚·ÎÙËÚ›‰È·, ÏÈÛÙ¤ÚÈ·, ÈÔ›, ÚˆÙfi˙ˆ·, ̇ÎËÙ˜
∫ÏÈÓÈ΋ ÂÈÎfiÓ·
ÀÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ .¯. ·Ó·Ó¢ÛÙÈÎÔ‡
ÀÔÙÚÔÈ¿˙Ô˘Û˜ ‹ ‚·ÚȤ˜ ÏÔÈÌÒÍÂȘ, ·ÔÛÙ‹Ì·Ù·
¶ÔÏϷϤ˜ ÌËÓÈÁÁ›Ùȉ˜
¶ÔÈΛÏÏÂÈ
¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ
∞Á·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·
∞Ó¿ÚÎÂÈ· Ô˘‰ÂÙÂÚÔʛψÓ
∞Ó¿ÚÎÂÈ· Û˘ÌÏËÚÒÌ·ÙÔ˜
¢È·Ù·Ú·¯‹ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜
¢È·Ù·Ú·¯‹ ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘
¢È·Ù·Ú·¯‹ ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘
™˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ·
ÀÂÚ IgM ∞Ó¿ÚÎÂÈ· ˘ÔÙ¿ÍÂˆÓ IgG ∞Ó¿ÚÎÂÈ· ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘
∞Ú¯ÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (¶›Ó·Î·˜ 4) ∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ∂ȉÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (¶›Ó·Î·˜ 4)
¶¿Û¯ÔÓ ·ÓÔÛÈ·Îfi ÛΤÏÔ˜
ŒÏÏÂÈÌÌ· ·ÓÙÈۈ̷ÙÈ΋˜ ·¿ÓÙËÛ˘
ŒÏÏÂÈÌÌ· Ô˘‰ÂÙÂÚÔʛψÓ
¢È·Ù·Ú·¯‹ Û˘ÌÏËÚÒÌ·ÙÔ˜
∞Ó¿ÚÎÂȘ ÙÔ˘ ∆ ΢ÙÙ¿ÚÔ˘ ªÈÎÙ¤˜ ·Ó¿ÚÎÂȘ
∂ÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ §ÂÈÙÔ˘ÚÁ›Â˜ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ·ÓÔÛÔ΢ÙÙ¿ÚˆÓ ÌÔÚÈ·Îfi˜ Î·È ÁÂÓÂÙÈÎfi˜ ¤ÏÂÁ¯Ô˜
¶·Ú·‰Â›ÁÌ·Ù· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÂϤÁ¯Ô˘
Btk ÛÂ Ê˘ÏÔÛ‡Ó‰ÂÙË ·-Á-ÛÊ·ÈÚÈÓ·ÈÌ›· CD40L Û ˘ÂÚ IgM I
πÛÔ¤Ó˙˘ÌÔ Î˘ÙÙÔ¯ÚÒÌ·ÙÔ˜ °ÔÓ›‰ÈÔ gp 91 phox
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ÃÚfiÓÈ· ÎÔÎÎȈ̷Ù҉˘ ÓfiÛÔ˜
∞Ó¿ÚÎÂÈ· ˘ÔÙ¿ÍÂˆÓ IgG ÀÂÚ πgM Û‡Ó‰ÚÔÌ·
∞Ó¿ÚÎÂÈ· ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ (LAD)
∂ȉÈÎfi ·ÓÙÈۈ̷ÙÈÎfi ¤ÏÏÂÈÌÌ· ∫ÔÈÓ‹ ÔÈΛÏË ·ÓÔÛÔ·Ó¿ÚÎÂÈ·
∞ÓÙ›ıÂÙ·, Ë ·Ó¿Ù˘ÍË ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ÔÚÁ·ÓÈÛÌÒÓ ÂÓÔ¯ÔÔÈ› ¤ÏÏÂÈÌÌ· ÛÙÔ Î˘ÙÙ·ÚÈÎfi ÛΤÏÔ˜ Ù˘ ·ÓÔÛ›·˜ Î·È È‰È·›ÙÂÚ· ÛÙ· ∆ ÏÂÌÊÔ·ÙÙ·Ú·. ¶ÔÈfiÓ ¤ÏÂÁ¯Ô ı· ·ÎÔÏÔ˘ı‹ÛÂÈ Ô ·È‰›·ÙÚÔ˜ ÛÙÔ ¿ÚÚˆÛÙÔ ·È‰› Ô˘ ı· ÙÂı› Ë ˘Ô„›· Ù˘ ·ÓÔÛÔ·ÓÂ-
Ác ·Ï˘Û›‰· ÁÈ· µª∞∞ ¶ÚˆÙ½ÓË/ÁÔÓ›‰ÈÔ Û˘Ó‰ÚfiÌÔ˘ Wiskott-Aldrich (WASP) ∞Ó¿ÚÎÂÈ· ·Ú·ÁfiÓÙˆÓ Û˘ÌÏËÚÒÌ·ÙÔ˜ (c)
ªÈÎÙ‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ¢È·Ù·Ú·¯‹ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ™‡Ó‰ÚÔÌÔ Di George ∞Ù·Í›· ÙËÏ·ÁÁÂÈÂÎÙ·Û›· ™‡Ó‰ÚÔÌÔ Wiskott-Aldrich AIDS
¿ÚÎÂÈ·˜ (9,11,15-17); √ ·Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ: ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÔÚÔ‡, Û˘Ìϋڈ̷ Î·È ÂȉÈÎfiÙÂÚ· ÛÙ· ‚Ú¤ÊË ÈÛÔ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›Ó˜ (¶›Ó·Î·˜ 4). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ Î·È ÙÔ˘ Ù‡Ô˘ ÙÔ˘˜ ·ÔÎÏ›ÂÈ ¶·È‰È·ÙÚÈ΋ 2008;71:5-13
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¢. X. ∫·Û›ÌÔ˜ Î·È Û˘Ó.
Ù˘¯fiÓ Ô˘‰ÂÙÂÚÔÂÓ›· ‹ ÏÂÌÊÔÂÓ›· Î·È Ë ÌÔÚÊÔÏÔÁ›· ÙÔ˘˜ ÌÔÚ› Ó· Ì·˜ ηÙ¢ı‡ÓÂÈ ÛÙË ‰È¿ÁÓˆÛË (.¯. Û‡Ó‰ÚÔÌÔ Chediak-Higashi). H ·ÈÌÔÛÊ·ÈÚ›ÓË, Ô ·ÈÌ·ÙÔÎÚ›Ù˘ Î·È Ë ÌÔÚÊÔÏÔÁ›· ÙˆÓ ÂÚ˘ıÚÒÓ Â›Ó·È Î·ÏÔ› ‰Â›ÎÙ˜ ÁÈ· ˘ÔΛÌÂÓÔ ¯ÚfiÓÈÔ ÓfiÛËÌ·. ∆· ·ÈÌÔÂÙ¿ÏÈ·, Ô˘ Â›Ó·È ¤Ó·˜ ·ÎfiÌË Î·Ïfi˜ ‰Â›ÎÙ˘ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ì˘ÂÏÔ‡, ÌÔÚ› Ó· Â›Ó·È ÌÂȈ̤ӷ Û ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· Î·È ÛÙÔ Û‡Ó‰ÚÔÌÔ WiskottAldrich. √ ‚·ÛÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ µ ΢ÙÙ¿ÚˆÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ. ∞Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙÔ˘˜ ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, Ô ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÂÎÙ›ÓÂÙ·È (¶›Ó·Î˜ 4 Î·È 5). °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÓÙÈۈ̷ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô ÈÔ ÂȉÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÚÔÛ‰ÈÔÚÈÛÌfi ÔÚÈṲ̂ӈÓ, Û˘ÁÎÂÎÚÈ̤ӈÓ, ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÂȤ‰ˆÓ ÙˆÓ ˘ÔÙ¿ÍÂˆÓ Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ G (IgG) Î·È Ù›ÙÏÔ˘ ÈÛÔ·ÈÌÔÛ˘ÁÎÔÏÏËÙÈÓÒÓ (·ÓÙÈ-∞, ·ÓÙÈ-µ) ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ª (IgM) (8,18). ∞Í›˙ÂÈ Ó· ˘ÂÓı˘Ì›ÛÔ˘Ì fiÙÈ Ù· ‚Ú¤ÊË ÙˆÓ 6-8 ÌËÓÒÓ Û˘¯Ó¿ ÂÌÊ·Ó›˙Ô˘Ó ÙË ÁÓˆÛÙ‹ ·ÚÔ‰È΋ ˘ÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· Î·È Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ‰ÂÓ ÂÚÈ̤ÓÔ˘Ì ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ÔÏ˘Û·Î¯·ÚȉÈο ·ÓÙÈÁfiÓ·, .¯. ·ÈÌfiÊÈÏÔ˜ Ù˘ influenza-b Û Ӌȷ οو ÙˆÓ 24 ÌËÓÒÓ (19). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÁÈ· Ù· Û˘ÁÎÂÎÚÈ̤ӷ ÓÔÛ‹Ì·Ù· Î·È ÁÈ’ ·˘Ù¤˜ ÙȘ ËÏÈ˘, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÂÌ‚fiÏÈ· Û˘Ó‰Â‰Â̤ӷ Ì ڈÙÂ˚ÓÈο ·ÓÙÈÁfiÓ·, Ù· ÔÔ›· ¢ԉÒÓÔ˘Ó ÈηÓÔÔÈËÙÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË (·-Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi, ·-·ÈÌÔÊ›ÏÔ˘, ·-ÌËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘) (20). ∏ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· ÂÎÙÈÌ¿Ù·È ·ÊÂÓfi˜ Ì ÙË Ì¤ÙÚËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙÔ˘˜, ·ÊÂÙ¤ÚÔ˘ Ì ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÂÈ‚Ú·‰˘ÓÔ̤Ó˘ ˘ÂÚ¢·ÈÛıËÛ›·˜ Û ÎÔÈÓ¿ ·ÓÙÈÁfiÓ·. ∆¤ÙÔÈ· ·ÓÙÈÁfiÓ· Â›Ó·È ·˘Ù¿ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ (ÙÂÙ¿ÓÔ˘ Î·È ‰ÈÊıÂÚ›Ùȉ·˜) Î·È Ù· ÎÔÈÓ¿ ·ÓÙÈÁfiÓ· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, fiˆ˜ ÙÚȯfiÊ˘Ù·, candida, ÚˆÙ¤·˜. °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηÙ' ·Ú¯‹Ó ·ÚΛ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Î·È Ù˘ ÌÔÚÊÔÏÔÁ›·˜ ÙÔ˘˜. °È· ÙÔÓ ÔÏÔÎÏËڈ̤ÓÔ ¤ÏÂÁ¯Ô ÙˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ, ‚ÔËı¿ÂÈ Ô ¤ÏÂÁ¯Ô˜ Ù˘ ÔÍÂȉˆÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ì ÙËÓ ÎÏ·ÛÈ΋ ‰ÔÎÈÌ·Û›· ¯ÚÒÛ˘ ÙÔ˘ ΢·ÓÔ‡ ÙÔ˘ ÙÂÙÚ·˙ÔÏ›Ô˘ (NBT) ‹ Ì ÙËÓ Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ (DHR), ηıÒ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ¯ËÌÂÈÔÙ·Í›·˜ Î·È Ù˘ Ê·ÁÔ΢ÙÙ¿ÚˆÛ˘. °È· ÙÔ Û˘ÓÔÏÈÎfi ¤ÏÂÁ¯Ô Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, Ë ÈÔ ÚÔÛÈÙ‹ ̤ıÔ‰Ô˜ Â›Ó·È Ë Ì¤ÙÚËÛË ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ C3, C4. ¶ÈÔ ¯Ú‹ÛÈÌÔ˜, ˆÛÙfiÛÔ, Â›Ó·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÔÏÈÎÔ‡ ·ÈÌÔÏ˘ÙÈÎÔ‡ Û˘ÌÏËÚÒÌ·ÙÔ˜ (CH50), ̤ıÔ‰Ô˜ Ô˘ ··ÈÙ› ÙËÓ ·ÚÔ˘Û›· fiÏˆÓ ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ∂¿Ó οÔÈ· ·fi ÙȘ ‚·ÛÈΤ˜ ‰ÔÎÈ̷ۛ˜ Â›Ó·È ·Paediatriki 2008;71:5-13
ıÔÏÔÁÈ΋, Ú¤ÂÈ Ó· ÚÔ¯ˆÚ‹ÛÔ˘Ì Û ÈÔ ÂȉÈÎfi ¤ÏÂÁ¯Ô. √È ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ̤ıÔ‰ÔÈ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ·ÓÔÛÔÊ·ÈÓÔÙ‡Ô˘ ÙˆÓ ∆ Î·È µ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ, ÙËÓ ÈηÓfiÙËÙ· ·ÓÙÈÁÔÓÈ΋˜ ‰È¤ÁÂÚÛ˘, ηÏÏȤÚÁÂȘ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÂȉÈÎfiÙÂÚ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· Ù· ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· Î·È Ì¤ÙÚËÛË fiÏˆÓ ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ™Â Ôχ ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÂÚÈÙÒÛÂȘ ··ÈÙÔ‡ÓÙ·È ÂȉÈΤ˜ ηÏÏȤÚÁÂȘ, ÂȉÈÎÔ› ÂÓ˙˘ÌÈÎÔ› ÚÔÛ‰ÈÔÚÈÛÌÔ›, ·Ó¿Ï˘ÛË ÙˆÓ ÁÏ˘ÎÔÚˆÙ½ÓÒÓ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Î·È ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜ Ì DNA ‹ RNA ·Ó·Ï‡ÛÂȘ. ∂¿Ó ˆ˜ ·ÈÙ›· ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Èı·ÓÔÏÔÁÂ›Ù·È ·ÏÏÂÚÁÈÎfi ÓfiÛËÌ·, ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ù· ›‰· Ù˘ ÔÏÈ΋˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ∂ (IgE) ÛÙÔÓ ÔÚfi Î·È ÙˆÓ ÂȉÈÎÒÓ IgE (RAST) ¤Ó·ÓÙÈ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ.
¶ÚfiÁÓˆÛË ∏ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ Ì ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Â›Ó·È Î·Ù¿ Ôχ ηχÙÂÚË ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÓÙ·ÂÙ›· Î·È Ë ÚfiÔ‰Ô˜ ·˘Ù‹ Â›Ó·È ‚¤‚·ÈÔ fiÙÈ ı· Û˘Ó¯ÈÛÙ›, ·ÊÔ‡ ÔÈ ÏÂÙÔ̤ÚÂȘ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È Ù˘ ÁÂÓÂÙÈ΋˜ ÙÔ˘˜ ‚¿Û˘ ηıËÌÂÚÈÓ¿ ‰È¢ÎÚÈÓ›˙ÔÓÙ·È Î·È ÚÔÔÙÈο Ë ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Á›ÓÂÙ·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋. øÛÙfiÛÔ, ηıÔÚÈÛÙÈ΋ ·Ú·Ì¤ÓÂÈ Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË ·˘ÙÒÓ ÙˆÓ ·ÚÚÒÛÙˆÓ Î·È Ë ¤ÁηÈÚË, ¿ÌÂÛË Î·È “ÂÈıÂÙÈ΋” ıÂڷ›· ¤Ó·ÓÙÈ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Ô˘ ı· ÂΉËψı› ÛÙÔ ·È‰› Ì ·ÓÔÛÔ·Ó·ÚÎÔ‡Ó ˘fiÛÙڈ̷. ™Ùfi¯Ô˜ Â›Ó·È Ó· ÌËÓ ÂÁηٷÛÙ·ıÔ‡Ó ÌfiÓÈ̘ ‚Ï¿‚˜ ‹ ·ÂÈÏËı› Ë ˙ˆ‹ ÙÔ˘, Û˘Ó‹ıˆ˜ ·fi οÔÈ· ÛÔ‚·Ú‹ Ïԛ̈ÍË. √È ¶∞∞ ·ÔÙÂÏÔ‡Ó ¤Ó· ÔÏ˘Û‡ÓıÂÙÔ ÎÏÈÓÈÎfi Úfi‚ÏËÌ· Ì ÔÈΛϘ ÂΉËÏÒÛÂȘ Î·È ÌÈ· ‰È·ÁÓˆÛÙÈ΋ ÚfiÎÏËÛË ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi. ∂›ÏÔÁÔ˜ ∏ ÌÂıÔ‰È΋, ·Ó·Ï˘ÙÈ΋ Î·È Û˘ÓıÂÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·È‰ÈÒÓ Ì Èı·Ó‹ ¶∞∞ ı· ‚ÔËı‹ÛÂÈ ÛÙË ÛˆÛÙ‹ ‰È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË, ·ÔÎÏ›ÔÓÙ·˜ ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Î·È ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÔÚı‹ ‰È¿ÁÓˆÛË, ÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ›· Î·È ·ÓÙÈÌÂÙÒÈÛË (21). ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙÔÓ ∫·ıËÁËÙ‹ ∆¿ÎË ¶·Ó·ÁȈÙfiÔ˘ÏÔ ÁÈ· ÙËÓ Î·ıÔÚÈÛÙÈ΋ Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙË Û˘ÁÁÚ·Ê‹ Ù˘ ÂÚÁ·Û›·˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Bird AG. Diagnosis of antibody deficiency states. In: Levinsky RJ, editor. IgG subclass deficiencies. London: Royal Society of Medicine Services; 1989. p. 3-12. 2. °ÂÚÌÂÓ‹˜ ∞. §ÂÈÙÔ˘ÚÁÈ΋ ‰ÔÌ‹ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙÔ: °ÂÚÌÂÓ‹˜ ∞, ÂΉfiÙ˘. π·ÙÚÈ΋ ∞ÓÔÛÔÏÔÁ›·. ∞ı‹Ó·: ∂ΉfiÛÂȘ ¶··˙‹ÛË; 2000. Û. 13-21.
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3. Chapel H, Haeney M, Misbah S and Snowden N. Basic Components: structure and function. In: Chapel H, Haeney M, Misbah S and Snowden N, editors. Essentials of Clinical Immunology. 5th ed. Oxford: Blackwell Publishing; 2006. p. 1-32. 4. ∫·Ó¿ÚÈÔ˘ M. ¢È·Ù·Ú·¯¤˜ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙÔ: ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ A., ÂΉfiÙ˘. ∫ÏÈÓÈ΋ ¶·È‰È·ÙÚÈ΋. Aı‹Ó·: ∂ΉfiÛÂȘ ∑‹Ù·; 2006-2007. Û. 199-211. 5. Report of a WHO scientific group. Primary immunodeficiency diseases. Clin Exp Immunol 1997;109 Suppl 1:1-28. 6. De Vries E, Noordzij JG, Kuijpers TW, van Dongen JJ. Flow cytometric immunophenotyping in the diagnosis and follow-up of immunodeficient children. Eur J Pediatr 2001; 160:583-591. 7. Golub ES. Immunity, infections and tumors. In: Golub ES, editor. Immunology: A Synthesis. Sunderland, Massachussets: Sinauer Associates, Inc.; 1987. p. 439-460. 8. Wood RA, Sampson HA. The child with frequent infections. Curr Probl Pediatr 1989;19:229-284. 9. Fleisher TA. Immune function. Pediatr Rev 1997;18:351-356. 10. Stiehm ER. Clinical and laboratory evaluation of the child with suspected immunodeficiency. Pediatr Rev 1985;7:53-61. 11. De Vries E; Clinical Working Party of the European Society for Immunodeficiencies (ESID). Patient-centred screening for primary immunodeficiency: a multi-stage diagnostic protocol designed for non-immunologists. Clin Exp Immunol 2006;145:204-214. 12. Bonilla FA, Geha RS. 12. Primary immunodeficiency diseases. J Allergy Clin Immunol 2003;111:S571-581. 13. Notarangelo L, Casanova JL, Conley ME, Chapel H, Fischer A, Puck J, et al. Primary immunodeficiency diseases: an update from the International Union of Immunological Societies Primary Immunodeficiency Diseases Classification Committee Meeting in Budapest, 2005. J Allergy Clin Immunol 2006;117:883-896.
14. Smith CIE, Ochs HD, Puck JM. Genetically determined immunodeficiency diseases: a perspective. In: Ochs HD, Smith CIE, Puck JM, editors. Primary Immunodeficiency Diseases: A Molecular and Genetic Approach. 2nd ed. Oxford: Oxford Universiry Press; 2007. p. 3-15. 15. Pacheco SE, Shearer WT. Laboratory aspects of immunology. Pediatr Clin North Am 1994;41:623-655. 16. Sewell WA, Khan S, Doré PC. Early indicators of immunodeficiency in adults and children: protocols for screening for primary immunological defects. Clin Exp Immunol 2006;145:201-203. 17. Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol 2005;94:S1-63. 18. Pachman LM, Lynch PA, Silver RK, Ozog DL, Poznanski AK. Primary immunodeficiency disease in children: an update. Curr Probl Pediatr 1989;19:1-64. 19. Umetsu DT, Ambrosino DM, Quinti I, Siber GR, Geha RS. Recurrent sinopulmonary infection and impaired antibody response to bacterial capsular polysaccharide antigen in children with selective IgG-subclass deficiency. N Engl J Med 1985;313:1247-1251. 20. Sorensen RU, Moore C. Immunology in the pediatrician’s office. Pediatr Clin North Am 1994;41:691-714. 21. Buckley RH. Primary immunodeficiency or not? Making the correct diagnosis. J Allergy Clin Immunol 2006;117:756-8.
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REVIEW ARTICLE
¶ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ 1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: ª·Ú›· ªÔ˘ÛÙ¿ÎË maria-m@otenet.gr µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ
ª. ªÔ˘ÛÙ¿ÎË1, ∞. ºÚÂÙ˙¿ÁÈ·˜2 ¶ÂÚ›ÏË„Ë: H ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ Â›Ó·È ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ÓfiÛÔ˜. ∂ΉËÏÒÓÂÙ·È ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÙȘ ·Ú·ÚÚ›ÓȘ ÎÔÈÏfiÙËÙ˜, fiÔ˘ ·Ú·ÙËÚÔ‡ÓÙ·È ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ·Ó·Ó¢ÛÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ‚ÚÔÁ¯ÂÎٷۛ˜ Î·È ÂÂÈÛfi‰È· ˆÙ›Ùȉ·˜ Î·È ÈÁÌÔÚ›Ùȉ·˜. ∞fi ÙÔ ÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· ·ÌÊÔÙ¤ÚˆÓ ÙˆÓ Ê‡ÏˆÓ ·Ú·ÙËÚÂ›Ù·È ˘ÔÁÔÓÈÌfiÙËÙ·. ∆Ô Û‡Ó‰ÚÔÌÔ Û˘Ó‰¤ÂÙ·È Û 50% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ·Ó·ÛÙÚÔÊ‹ ÙˆÓ ÛÏ¿Á¯ÓˆÓ (Û‡Ó‰ÚÔÌÔ Kartagener). ∏ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì ÌÈ· ÛÂÈÚ¿ ÌË ÂȉÈÎÒÓ ÂÍÂÙ¿ÛˆÓ, fiˆ˜ ‰ÔÎÈÌ·Û›· ۷ί·Ú›Ó˘, ̤ÙÚËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ Î·È ·ÂÈÎfiÓÈÛË Ù˘ ÌÔÚÊÔÏÔÁ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ Î·È ÙÔ˘ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ ÙÔ˘˜ Ì ÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ. ∞Ó Î·È Î¿ı ÂÚÁ·ÛÙ‹ÚÈÔ ¤¯ÂÈ ÙȘ ‰ÈΤ˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜, ÔÈ Î·Ù¿ ÚÔÛ¤ÁÁÈÛË Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÁÈ· ÙË Û˘¯ÓfiÙËÙ· ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ Â›Ó·È 11-16 Hz. ∆Ô ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÙÌ‹Ì· ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ. ÃÚÂÈ¿˙ÂÙ·È ÁÈ· ÙËÓ ·ÔÙ‡ˆÛË Ù˘ ‰ÔÌ‹˜ ÙˆÓ ÎÚÔÛÛÒÓ Î·È ÙÔ˘ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ ÙÔ˘˜. ∞ӈ̷ϛ˜ Û 10% ÙˆÓ ÎÚÔÛÛÒÓ ·Ú·ÙËÚÔ‡ÓÙ·È Î·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ‰Â›ÁÌ·Ù·. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ ÚÈÓÈÎfi ÂÎÓÂfiÌÂÓÔ ÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (¡√) Â›Ó·È ¯·ÌËÏfi Î·È ÌÔÚ› ÛÙÔ Ì¤ÏÏÔÓ Ó· ·ÔÙÂϤÛÂÈ ÂͤٷÛË ‰ÂÈÁÌ·ÙÔÏË„›·˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ ÚÔ˜ ÙÔ ·ÚfiÓ ‰ÂÓ ˘¿Ú¯ÂÈ Â›ÛËÌË Û‡ÛÙ·ÛË ÁÈ· ÙË ¯Ú‹ÛË ÙÔ˘. ¢ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ıÂڷ›· ·ÔηٿÛÙ·Û˘ Ù˘ ‰ÔÌ‹˜ ‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ. ÃÚËÛÈÌÔÔÈÂ›Ù·È ·Ó·Ó¢ÛÙÈ΋ Ê˘ÛÈÔıÂڷ›· Î·È Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ fiÙ·Ó ÂӉ›ÎÓ˘Ù·È.
§¤ÍÂȘ ÎÏÂȉȿ: ¢˘ÛÎÈÓËÛ›· ÎÚÔÛÛÒÓ, ·Ó·Ó¢ÛÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ˘ÔÁÔÓÈÌfiÙËÙ·, ·Ó·ÛÙÚÔÊ‹ ÛÏ¿Á¯ÓˆÓ.
Primary ciliary dyskinesia 1 2nd Paediatric Clinic, University of Athens 2 3rd Paediatric Clinic, University of Athens Correspondence: Maria Moustaki maria-m@otenet.gr 2nd Paediatric Clinic, University of Athens
M. Moustaki1, A. Fretzayas2 Abstract: Primary ciliary dyskinesia is a multisystem disease characterized by recurrent respiratory tract infections, bronchiectasis, otitis, sinusitis and subfertility in both sexes. It is associated in about 50% of patients with situs inversus (Kartagener syndrome). It is a genetic disorder characterized by abnormalities in ciliary structural function. Diagnosis is made by a series of investigations, starting with the saccharin test, ciliary beat frequency, and electron microscopy, in order to reveal ciliary morphology and orientation. Although it is recommended that each laboratory has its own normal range, the approximate normal range for beat frequency is 11-16 Hz. Electron microscopy is an essential part of diagnostic testing, necessary for the assessment of cilia structure and possible disorientation. Abnormalities in up to 10% of cilia may be seen in normal samples. Nasal nitric oxide (NO) is low and this measurement may be used in future as a screening tool but at present a definite clinical role for NO measurement in the diagnosis of primary ciliary dyskinesia is not recommended. There is no specific treatment. And the cornerstone of management is physiotherapy, with administration of systematic antibiotics when appropriate.
Key words: Ciliary dyskinesia, respiratory tract infections, subfertility, situs inversus.
∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ Ù˘ ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1904 ·fi ÙÔÓ Siewert Î·È ·ÚÁfiÙÂÚ· ÙÔ 1935 ·fi ÙÔÓ Kartagener ˆ˜ Ë ÙÚÈ¿‰· ·Ó·ÛÙÚÔÊ‹˜ ÙˆÓ ÛÏ¿Á¯ÓˆÓ, ÈÁÌÔÚ›Ùȉ·˜ Î·È ‚ÚÔÁ¯ÂÎÙ·Û›·˜ (1). ŒÎÙÔÙÂ, Ë ·ıÔÏÔÁ›· Ù˘ ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÏÂÙÔÌÂÚ¤ÛÙÂÚ· Î·È Û‹ÌÂÚ· Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·ÎfiÌË Î·È Â› ·Ô˘Û›·˜ ·Ó·ÛÙÚÔÊ‹˜ ÙˆÓ ÛÏ¿Á¯ÓˆÓ (1-3). ∏ ı¤ÛË ÙˆÓ ÛÏ¿Á¯ÓˆÓ ηٿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÌ‚Ú˘ÔÁ¤ÓÂÛ˘ ηıÔPaediatriki 2008;71:14-20
Ú›˙ÂÙ·È ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ΛÓËÛË ÙˆÓ ÎÚÔÛÛÒÓ Î·È Â› ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ ·fiÏÏ˘Ù·È Ô ¯ˆÚÔÙ·ÍÈÎfi˜ ÚÔÛ·Ó·ÙÔÏÈÛÌfi˜ Î·È ˘¿Ú¯ÂÈ Èı·ÓfiÙËÙ· 50% ·Ó·ÛÙÚÔÊ‹˜ ÙˆÓ ÛÏ¿Á¯ÓˆÓ (1,4,5). ∞Ó Î·È Û¿ÓÈ· ÁÂÓÂÙÈο ηıÔÚÈ˙fiÌÂÓË ÓfiÛÔ˜, Ë ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ ·ÔÙÂÏ› ¯ÚfiÓÈÔ ÛÔ‚·Úfi ÓfiÛËÌ·, ÂÓÒ Ô ·È‰›·ÙÚÔ˜ ¯ÚÂÈ¿˙ÂÙ·È Ó· Â›Ó·È ÂÍÔÈÎÂȈ̤ÓÔ˜ Ì ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·˘ÙÔ‡ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ë ·ÚÔ˘Û›·ÛË ÙˆÓ
Pediatri Jan-Feb 08
15-02-08
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¶ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ
ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÚˆÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, Ù· ÔÔ›· ¤¯Ô˘Ó ÂÌÏÔ˘ÙÈÛÙ› Ì ٷ ÛÙÔȯ›· Ù˘ ÚfiÛÊ·Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜.
∫ÚÔÛÛˆÙfi ÂÈı‹ÏÈÔ ∞fi ÎÚÔÛÛˆÙfi ÂÈı‹ÏÈÔ Î·Ï‡ÙÔÓÙ·È ÔÈ ‚ÏÂÓÓÔÁfiÓÔÈ ÙˆÓ ·Ú·ÚÚÈÓ›ˆÓ ÎfiψÓ, ÔÈ ·ÓÒÙÂÚÔÈ Î·È Î·ÙÒÙÂÚÔÈ ·ÂÚ·ÁˆÁÔ›, ÔÈ ÛÂÚÌ·ÙÈΤ˜ Ô‰Ô› Ì ٷ ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ·, ÔÈ Û¿ÏÈÁÁ˜ Î·È ÙÔ Â¤Ó‰˘Ì· ÙˆÓ ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (4,5). ∫¿ı ÎÚÔÛÛfi˜ ·ÔÙÂÏÂ›Ù·È ·fi ÙË Ú›˙·, ÙÔ ‚·ÛÈÎfi ۈ̿ÙÈÔ Î·È ÙÔ ÂχıÂÚÔ Û٤ϯԘ. ∆Ô Ì¤ÁÂıfi˜ ÙÔ˘˜ Â›Ó·È 5-15 nm Î·È Ë ‰È¿ÌÂÙÚfi˜ ÙÔ˘˜ 0,2 nm. ∆Ô Û٤ϯԘ ·ÔÙÂÏÂ›Ù·È ·fi 9 ÂÚÈÊÂÚÈο ˙‡ÁË ÌÈÎÚÔÛˆÏËÓ›ÛÎˆÓ Î·È ‰‡Ô ÎÂÓÙÚÈÎÔ‡˜ ÌÈÎÚÔÛˆÏËÓ›ÛÎÔ˘˜ (1) (∂ÈÎfiÓ˜ 1, 2, 3). ¢‡Ô ‚Ú·¯›ÔÓ˜ ·ÔÙÂÏÔ‡ÌÂÓÔÈ ·fi ÚˆÙ½ÓË (‰˘Ó½ÓË) ÂÎÙ›ÓÔÓÙ·È ·fi ÙÔÓ ∞ ÌÈÎÚÔÛˆÏËÓ›ÛÎÔ Î¿ı ÂÚÈÊÂÚÈÎÔ‡ ˙‡ÁÔ˘˜ ÚÔ˜ ÙÔ µ ÌÈÎÚÔÛˆÏËÓ›ÛÎÔ ÙÔ˘ ·Ú·Î›ÌÂÓÔ˘ ˙‡ÁÔ˘˜ (1,6). √ ¤Ó·˜ ‚Ú·¯›ÔÓ·˜ ÂÎÙ›ÓÂÙ·È ÂÛˆÙÂÚÈο Î·È Ô ¿ÏÏÔ˜ Â͈ÙÂÚÈο. ÕÏÏÔÈ, ·ÎÙÈÓÔÂȉҘ ÊÂÚfiÌÂÓÔÈ, ‚Ú·¯›ÔÓ˜ (·ÎÙÈÓÔÂȉ¤˜ ÓËÌ¿ÙÈÔ) ÂÂÎÙ›ÓÔÓÙ·È ·fi ÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÌÈÎÚÔÛˆÏËÓ›ÛÎÔ˘˜ ÚÔ˜ ÙÔ ÎÂÓÙÚÈÎfi ˙‡ÁÔ˜, ÂÓÒ Ô ‚Ú·¯›ÔÓ·˜ Ù˘ ÓÂ͛Ӣ ÂÓÒÓÂÈ ÌÂٷ͇ ÙÔ˘˜ Ù· ˙‡ÁË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ÌÈÎÚÔÛˆÏËÓ›ÛÎˆÓ (∂ÈÎfiÓ˜ 1, 2, 3). √È ÎÈÓ‹ÛÂȘ ÙˆÓ ÎÚÔÛÛÒÓ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ¤Ó· ·Ú¯Èο Ù·¯‡ ÎÙ‡ËÌ·, ηٿ ÙÔ ÔÔ›Ô ·Ú·Ì¤ÓÔ˘Ó ¿Î·ÌÙÔÈ, Î·È ·fi ·ÎfiÏÔ˘ıË ‚Ú·‰Â›· ¿ÓÔ‰Ô ÛÙË ı¤ÛË ÙÔ˘˜, fiÔ˘ fiÏÔ ÙÔ Û٤ϯԘ οÌÙÂÙ·È ¯·Ï·Úfi. √È ÎÈÓ‹ÛÂȘ ÙˆÓ ÎÚÔÛÛÒÓ ÛÙËÓ ÂÈıËÏȷ΋ ÂÈÊ¿ÓÂÈ· Â›Ó·È Û˘Á¯ÚÔÓÈṲ̂Ó˜, ÌÂÙ·ÎÈÓÒÓÙ·˜ ¤ÙÛÈ ÙË ‚ϤÓÓ· ·fi ÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ (1). ∂ȉËÌÈÔÏÔÁ›· ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈ· ÁÂÓÂÙÈ΋ ÓfiÛÔ ÌÂ Û˘¯ÓfiÙËÙ· 1:20.000 (1,2). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ·Ï‹˜ ·Ó·ÛÙÚÔÊ‹˜ ÙˆÓ ÛÏ¿Á¯ÓˆÓ Â›Ó·È 1:10.000 Î·È ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Kartagener 1:40.000 (1,2). ∂Âȉ‹ ·˘Ù‹ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ 1:20.000 ÛÙËÚ›˙ÂÙ·È ÛÙËÓ
∂ÈÎfiÓ· 2. º˘ÛÈÔÏÔÁÈÎfi˜ ÎÚÔÛÛfi˜ fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ.
˘fiıÂÛË fiÙÈ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ı· ·Ó·Ù‡ÍÔ˘Ó ‚ÚÔÁ¯ÂÎÙ·Û›·, Â›Ó·È Û·Ê¤˜ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ·˘Ù‹ ˘ÔÂÎÙÈÌ¿ ÙÔÓ Ú·ÁÌ·ÙÈÎfi ÂÈÔÏ·ÛÌfi Ù˘ ÓfiÛÔ˘. ªÂ ‚¿ÛË ·˘ÙÔ‡˜ ÙÔ˘˜ ˘ÔÏÔÁÈÛÌÔ‡˜, 3.000 ¿ÙÔÌ· ÛÙË ª. µÚÂÙ·Ó›· Ú¤ÂÈ Ó· ¿Û¯Ô˘Ó ·fi ÙÔ Û‡Ó‰ÚÔÌÔ. ™Â ÌÈ· ÔÌ¿‰·, fï˜, ÛÙ‹ÚÈ͢ ÙˆÓ ·ÛıÂÓÒÓ Ì ÙË ÓfiÛÔ Â›Ó·È ÂÁÁÂÁÚ·Ì̤ӷ 130-150 ¿ÙÔÌ· (1) ‰ËÏÒÓÔÓÙ·˜ ÙË ‰˘ÛÎÔÏ›· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË, ηıÒ˜ ÂÏ¿¯ÈÛÙ· ΤÓÙÚ· ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ı¤ÛÔ˘Ó ÙË ‰È¿ÁÓˆÛË Ì ÂÓ‰Âϯ‹ ¤ÏÂÁ¯Ô Ù˘ ·Ó·ÙÔÌ›·˜ Î·È Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ ÎÚÔÛÛÒÓ.
∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∏ ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ ‰ÂÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ηıÔÚÈÛÙÈο ÁÈ· ÙË ‰È¿ÁÓˆÛË Û˘ÌÙÒÌ·Ù·. ∞Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÚÔÂÍ¿Ú¯Ô˘Ó Î¿ÔÈ· Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· Ô˘ ı¤ÙÔ˘Ó ÙËÓ ˘Ô„›· Ù˘ ÓfiÛÔ˘, fiˆ˜ Â›Ó·È ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Ë Â›ÌÔÓË ÚÈÓ›Ùȉ· ·fi ÙËÓ ÚÒÙË Ë̤ڷ Ù˘ ˙ˆ‹˜ (711), ÙÔ Û‡Ó‰ÚÔÌÔ ·ÚÔ‰È΋˜ Ù·¯‡ÓÔÈ·˜ Û ·Ô˘Û›·
∞ÎÙÈÓˆÙ‹ Û‡Ó‰ÂÛË ∂͈ÙÂÚÈ΋ ‰˘Ó½ÓË ∂ÛˆÙÂÚÈ΋ ‰˘Ó½ÓË ™‡Ó‰ÂÛÌÔÈ ÓÂ͛Ӣ ™ˆÏËÓ¿ÚÈÔ ∞ ™ˆÏËÓ¿ÚÈÔ µ ∂ÈÎfiÓ· 1. ∂ÁοÚÛÈ· Û¯ËÌ·ÙÈ΋ ÙÔÌ‹ ÎÚÔÛÛÔ‡ fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ.
∂ÈÎfiÓ· 3. ∫ÚÔÛÛfi˜ ·fi ·ÛıÂÓ‹ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, fiÔ˘ ·Ô˘ÛÈ¿˙Ô˘Ó ÔÈ ÎÏ¿‰ÔÈ Ù˘ ‰˘Ó½Ó˘. ¶·È‰È·ÙÚÈ΋ 2008;71:14-20
Pediatri Jan-Feb 08
15-02-08
11:00
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16
ª. ªÔ˘ÛÙ¿ÎË, ∞. ºÚÂÙ˙¿ÁÈ·˜
ÚԉȷıÂÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (7,8) Î·È Ë ÓÂÔÁÓÈ΋ Ó¢ÌÔÓ›· (7,8) ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi ÓfiÛÔ˘ Ù˘ ÌËÙ¤Ú·˜ ‹ ·Ú·ÙÂٷ̤Ó˘ ڋ͢ ÙÔ˘ ı˘Ï·Î›Ô˘. ∏ ›ÌÔÓË ÚÈÓ›Ùȉ· ·fi ÙËÓ ÚÒÙË Ë̤ڷ Ù˘ ˙ˆ‹˜ ‰È·Ê¤ÚÂÈ ·fi ÙË ‰È·ÏÂ›Ô˘Û· ÚÈÓ›Ùȉ· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜ ÂÍ·ÈÙ›·˜ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ (10,11). ™Â ÌÈ· ÛÂÈÚ¿ 30 ·ÛıÂÓÒÓ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, ÔÈ 13 ÂÌÊ¿ÓÈÛ·Ó Û˘ÌÙÒÌ·Ù· ·fi ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (9). ¢ÂÍÈÔηډ›· ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 50% ÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ ÛÙÔ 23% ·˘ÙÒÓ Ì ‰ÂÍÈÔηډ›· ˘¿Ú¯ÂÈ Û‡Ó‰ÚÔÌÔ ‰˘ÛÎÈÓ‹ÙˆÓ ÎÚÔÛÛÒÓ (12). ™ÙË ‰ÂÍÈÔηډ›· Î·È ÛÙË Û˘ÓÔ‰fi ·Ó·ÛÙÚÔÊ‹ ÙˆÓ ÛÏ¿Á¯ÓˆÓ Ë Î·Ú‰È¿ ·Ó·ÙÔÌÈο Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. Œ¯Ô˘Ó ·Ú·ÙËÚËı› ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·, ·ÙÚËÛ›· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ‹ ÙˆÓ ¯ÔÏËÊfiÚˆÓ, ˘‰ÚÔΤʷÏÔ Î·È ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi (13-15). ™ÙËÓ ·È‰È΋ ËÏÈΛ·, ¤Ú· ·fi ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ‰ÂÍÈÔηډ›·˜, ·Ú·ÙËÚÔ‡ÓÙ·È ‚ÚÔÁ¯ÂÎٷۛ˜, ÂÈÎfiÓ· ÛÔ‚·ÚÔ‡ ‹ ¿Ù˘Ô˘ ¿ÛıÌ·ÙÔ˜ ÌË ·ÓÙ·ÔÎÚÈÓfiÌÂÓÔ˘ ÈηÓÔÔÈËÙÈο ÛÙËÓ ·ÁˆÁ‹, ˆÙ›Ùȉ· ÂÎÎÚÈÙÈ΋, ÈÁÌÔÚ›Ùȉ· Ì ‹ ¯ˆÚ›˜ Û˘ÓÔ‰Ô‡˜ Ôχԉ˜ (1,10). øÙ›Ùȉ· Ì ÔÏϷϤ˜ ÂÂÌ‚¿ÛÂȘ ·Ú·ÙËÚ‹ıËΠÛÙÔ 95% ÌÈ·˜ ÔÌ¿‰·˜ 110 ·ÛıÂÓÒÓ Ì ۇӉÚÔÌÔ ‰˘ÛÎÈÓ‹ÙˆÓ ÎÚÔÛÛÒÓ (16). ∏ ÂÌÊ¿ÓÈÛË ÙˆÓ ‚ÚÔÁ¯ÂÎÙ·ÛÈÒÓ ·˘Í¿ÓÂÈ Ì ÙËÓ ËÏÈΛ· ÏfiÁˆ Ù˘ ·ıÔÏÔÁ›·˜ ·fi ÙÔÓ Ó‡ÌÔÓ·. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ Ë Ì¤ÛË ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ ‚ÚÔÁ¯ÂÎÙ·ÛÈÒÓ ‹Ù·Ó 30±2,2 ¤ÙË Û ·ÓÙ›ıÂÛË ÙȘ ËÏÈ˘ 10±4,4 ¤ÙË (16), Ô˘ ‹Ù·Ó Ë Ì¤ÛË ËÏÈΛ· ηٿ ÙËÓ ÔÔ›· ‰ÂÓ Â›¯·Ó ·Ú·ÙËÚËı› ·ÎfiÌË ‚ÚÔÁ¯ÂÎٷۛ˜. ¶ÏËÎÙÚÔ‰·ÎÙ˘Ï›· ·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ (16). ∏ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ¯ˆÚ›˜ ‹ Ì ÌÂÚÈ΋ ·Ó·ÛÙÚ„ÈÌfiÙËÙ· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‚2 ‰ÈÂÁ¤ÚÙË. ™Â ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· ·Ú·ÙËÚÂ›Ù·È ˘ÔÍ›· Î·È ˘ÂÚηӛ·. ™ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÂÎÙfi˜ ·fi Ù· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ˘Ô„›· Ù˘ ÓfiÛÔ˘ Ù›ıÂÙ·È Û ÂÚÈÙÒÛÂȘ ·Ó‰ÚÈ΋˜ ÛÙÂÈÚfiÙËÙ·˜, fiÙ·Ó Ù· ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ· Â›Ó·È ·Î›ÓËÙ· ‹ ¤¯Ô˘Ó ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· (17), ¯ˆÚ›˜ Ë ÁÔÓÈÌfiÙËÙ· Ó· ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË ÛÙÔ˘˜ ¿ÚÚÂÓ˜. ∞Ó¿ÏÔÁ· ÈÛ¯‡Ô˘Ó ÁÈ· ÙË ÛÙÂÈÚfiÙËÙ· ÙˆÓ Á˘Ó·ÈÎÒÓ, fiÙ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ó·ÙÔÌÈÎÔ› ‹ ÔÚÌÔÓÈÎÔ› ÏfiÁÔÈ Ù˘ ˘ÔÁÔÓÈÌfiÙËÙ·˜ (4).
¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È ·fi ÙËÓ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ, ÙÔ ¿ÛıÌ·, ÙȘ ·ÓÔÛÔ·Ó¿ÚÎÂȘ Î·È ¿ÏϘ ¯ÚfiÓȘ Ó¢ÌÔÓÈΤ˜ ÓfiÛÔ˘˜. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë ÚÒÙË ÛÂÈÚ¿ ÂÍÂÙ¿ÛÂˆÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰ÔÎÈÌ·Û›· ȉÚÒÙ·, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜, Û˘ÌÂÚÈÏ·Ì‚·ÓfiÌÂÓ˘ Ù˘ IgE, ˘ÔÔÌ¿‰Â˜ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ÚÔÛ‰ÈÔÚÈÛÌfi ·ÓÙÈۈ̷ÙÈÎÒÓ ··ÓÙ‹ÛÂˆÓ Û ÚÔËÁËı¤Paediatriki 2008;71:14-20
ÓÙ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ‹ Ïԛ̈ÍË Ì ·‰ÂÓÔ˚fi ‹ Ì˘ÎfiÏ·ÛÌ·, ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Î·È Â›Â‰· ·1-·ÓÙÈıÚ˘„›Ó˘. ™Â ·È‰È¿ Ì ¿ÛıÌ· Ô˘ ‰ÂÓ ··ÓÙÔ‡Ó ÛÙËÓ Î·Ù¿ÏÏËÏË ·ÁˆÁ‹ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÂÍÂÙ¿ÛÂȘ Ô˘ ÂȂ‚·ÈÒÓÔ˘Ó ÙË ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰˘ÛÎÈÓ‹ÙˆÓ ÎÚÔÛÛÒÓ.
¢È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ¢ÔÎÈÌ·Û›· ۷ί·Ú›Ó˘ ™Â ·È‰È¿ Ô˘ ÌÔÚÔ‡Ó Ó· Û˘ÓÂÚÁ·ÛÙÔ‡Ó, ËÏÈΛ·˜ Û˘Ó‹ıˆ˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 12 ÂÙÒÓ, ÙÂÌ¿¯ÈÔ 12 mm ۷ί·Ú›Ó˘ Ù›ıÂÙ·È ÛÙÔ ÚfiÛıÈÔ ¿ÎÚÔ Ù˘ οو ÚÈÓÈ΋˜ ÎfiÁ¯Ë˜ (18,19). √ ·ÛıÂÓ‹˜ οıÂÙ·È ‹ÚÂÌÔ˜ Ì ÙÔ ÎÂÊ¿ÏÈ ÁÂṲ́ÓÔ ÚÔ˜ Ù· ÂÌÚfi˜ ¯ˆÚ›˜ Ó· ‚‹¯ÂÈ, Ó· ÙÚÒÂÈ ‹ Ó· ›ÓÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜. ∂¿Ó ÌÂÙ¿ ÙËÓ ¿ÚÔ‰Ô Ì›·˜ ÒÚ·˜ ‰ÂÓ ·ÈÛı·Óı› ÙË Á‡ÛË Ù˘ ۷ί·Ú›Ó˘ ÛËÌ·›ÓÂÈ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ·ıÔÏÔÁÈ΋ οı·ÚÛË Ù˘ ‚ϤÓÓ·˜ ·fi ÙÔ˘˜ ÎÚÔÛÛÔ‡˜. ™ÙÔÓ ·ÛıÂÓ‹ ÙÔÔıÂÙÂ›Ù·È Û·Î¯·Ú›ÓË Î·Ù¢ı›·Ó ÛÙË ÁÏÒÛÛ· ÁÈ· Ó· ÂȂ‚·Èˆı› fiÙÈ ÌÔÚ› Ó· ·ÈÛı·Óı› ÙË Á‡ÛË Ù˘. ª¤ÙÚËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ ∂¿Ó Ë ‰ÔÎÈÌ·Û›· ۷ί·Ú›Ó˘ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ (<Ì›· ÒÚ·), ÙfiÙ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÂͤٷÛË. ∞Ó fï˜ Â›Ó·È ·ıÔÏÔÁÈ΋, ··ÈÙÂ›Ù·È Ó· Á›ÓÂÈ Ì¤ÙÚËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ Î·È ·ÂÈÎfiÓÈÛË Ù˘ ÌÔÚÊÔÏÔÁ›·˜ Ù˘ ΛÓËÛ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ï·Ì‚¿ÓÂÙ·È ÂÈı‹ÏÈÔ ·fi ÙÔ ÚÈÓÔÊ¿Ú˘ÁÁ· Ì ΢ÙÙ·ÚÔÏÔÁÈ΋ ‚Ô‡ÚÙÛ· ·ÔÛÙÂÈڈ̤ÓË ‹ ÌÈ·˜ ¯Ú‹Ûˆ˜ (20). ∆Ô ‰Â›ÁÌ· Ô˘ Ï·Ì‚¿ÓÂÙ·È Ì ·˘Ùfi ÙÔÓ ÙÚfiÔ, ·ÎfiÌË Î·È fiÙ·Ó ÙÔ ·È‰› ‰ÂÓ Û˘ÓÂÚÁ¿˙ÂÙ·È, Â›Ó·È ÈηÓÔÔÈËÙÈÎfi ÛÙÔ 80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (21). ∂¿Ó Á›ÓÂÈ ‚ÚÔÁ¯ÔÛÎfiËÛË ÁÈ· ¿ÏÏÔ ÏfiÁÔ, ηÏfi Â›Ó·È Ó· ÏËÊı› Î·È ·fi ÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜ ‰Â›ÁÌ·, ÁÓˆÚ›˙ÔÓÙ·˜ fiÙÈ ·Ó·ÈÛıËÙÈο, fiˆ˜ Ë ·ÏÔı¿ÓË Î·È Ë ÏȉÔη˝ÓË, ÌÂÈÒÓÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ (22). ∆Ô ‰Â›ÁÌ· ηÓÔÓÈο Ú¤ÂÈ Ó· ÌÂÙ·ÊÂÚı› ÂÓÙfi˜ 2 ˆÚÒÓ ÛÙÔ Î¤ÓÙÚÔ Ô˘ ı· οÓÂÈ ÙË Ì¤ÙÚËÛË, ·ÏÏ¿ Î·È ‰Â›ÁÌ·Ù· ÌÂÙ·ÊÂÚfiÌÂÓ· ÂÓÙfi˜ 24 ˆÚÒÓ ÌÂÙÚÒÓÙ·È Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ Úfi‚ÏËÌ· (7). ¶ÔÏÏÔ› ÚÔÛı¤ÙÔ˘Ó ÛÙÔ ‰Â›ÁÌ· Ô˘ ÚfiÎÂÈÙ·È Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ¤Ú·Ó ÙˆÓ ‰‡Ô ˆÚÒÓ Î·È ÂÓÈÎÈÏÏ›ÓË ‹ ÛÙÚÂÙÔÌ˘Î›ÓË ÁÈ· Ó· ηٷȤÛÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÂÈıËÏ›Ô˘. ∫¿ı ΤÓÙÚÔ Ú¤ÂÈ Ó· ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙȘ ‰ÈΤ˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ‰ÈfiÙÈ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· Î·È ·fi ÙË Ì¤ıÔ‰Ô. √È Û˘Ó‹ıÂȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Â›Ó·È 11-16 Hz (7). ∂Âȉ‹ Ë Û˘¯ÓfiÙËÙ· Ù˘ ΛÓËÛ˘ ÂËÚ¿˙ÂÙ·È ·ÎfiÌË Î·È ·fi Û˘Ó‹ıÂȘ ÏÔÈÌÒÍÂȘ, ÙÔ ‰Â›ÁÌ· ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È 4-6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ·fi ·Ó¿ÏÔÁÔ ÂÂÈÛfi‰ÈÔ Ô˘ ÂÈÓ¤ÌÂÙ·È ÙÔ ·Ó·Ó¢ÛÙÈÎfi (1,23,24). °È· ÙË Ì¤ÙÚËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ¯ÚËÛÈÌÔÔÈ›ٷÈ
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·17
17
¶ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ
Û˘Ó‹ıˆ˜ Ë ÊˆÙÔ‰ÈÔ‰È΋ ̤ıÔ‰Ô˜, Ì ÙËÓ ÔÔ›· ‰ÂÓ ÂϤÁ¯ÂÙ·È Ô ÙÚfiÔ˜ Ù˘ ΛÓËÛ˘ ÙˆÓ ÎÚÔÛÛÒÓ. °È· ÙËÓ ·ÂÈÎfiÓÈÛË ÙÔ˘ ÙÚfiÔ˘ Ù˘ ΛÓËÛ˘, ··ÈÙÂ›Ù·È Ë ·Ó¿Ï˘ÛË Ì video ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ Î·È ˘„ËÏ‹˜ Ù·¯‡ÙËÙ·˜. ∏ ηٷÁÚ·Ê‹ ÙÔ˘ ÙÚfiÔ˘ ΛÓËÛ˘ Â›Ó·È ··Ú·›ÙËÙË, ÁÈ·Ù› ·Ó¿ÏÔÁ· Ì ÙÔ ‰ÔÌÈÎfi ÂÏ¿Ùو̷ ÌÔÚ› Ë Û˘¯ÓfiÙËÙ· ΛÓËÛ˘ Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋, ·ÏÏ¿ Ë ÌÔÚÊ‹ Ù˘ ΛÓËÛ˘ ·ıÔÏÔÁÈ΋ (1,4,7). √ ÙÂÏÂ˘Ù·›Ô˜ Û˘Ó‰˘·ÛÌfi˜ ·Ú·ÙËÚÂ›Ù·È Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÙfiÈÛË ÙˆÓ ÎÚÔÛÛÒÓ ‹ Ì ·ÁÂÓÂÛ›· ÙˆÓ ÎÂÓÙÚÈÎÒÓ ÌÈÎÚÔÛˆÏËÓ·Ú›ˆÓ. ™ÙȘ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ ‚Ï¿‚˘ Ù˘ Â͈ÙÂÚÈ΋˜ ‹ Ù˘ ÂÛˆÙÂÚÈ΋˜ ‰˘Ó½Ó˘ ‹ ÙÔ˘ ·ÎÙÈÓÔÂȉԇ˜ ÓËÌ·Ù›Ô˘ (radial spoke), ÂËÚ¿˙ÂÙ·È ¿ÓÙÔÙÂ Î·È Ë Û˘¯ÓfiÙËÙ·, ÂÓÒ Ë Î›ÓËÛË Î·Ù¿ ÙËÓ ·Ó¿Ï˘ÛË Ì video Â›Ó·È ·ıÔÏÔÁÈ΋. ∞Ó Ë Î›ÓËÛË Î·È Ë Û˘¯ÓfiÙËÙ· Â›Ó·È Ê˘ÛÈÔÏÔÁÈΤ˜, ‰ÂÓ ˘¿Ú¯ÂÈ ÓfiÛÔ˜ ‰˘ÛÎÈÓ‹ÙˆÓ ÎÚÔÛÛÒÓ Î·È Ë ‰ÈÂÚ‡ÓËÛË ÛÙ·Ì·Ù¿ ‰Ò. ∞Ó Â›Ó·È ·ıÔÏÔÁÈ΋ ÌÈ· ·fi ÙȘ ‰‡Ô ‹ ·Ó Ë Û˘¯ÓfiÙËÙ· Â›Ó·È ÌÂÓ Ê˘ÛÈÔÏÔÁÈ΋, ·ÏÏ¿ ¯ˆÚ›˜ Ó· ¤¯ÂÈ Á›ÓÂÈ Î·È ·Ó¿Ï˘ÛË Ù˘ ΛÓËÛ˘, Ë ÂͤٷÛË Û˘Ó¯›˙ÂÙ·È Ì ËÏÂÎÙÚÔÓÈ΋ ÌÈÎÚÔÛÎfiËÛË (∂ÈÎfiÓ· 4). ∏ÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ °È· ÙËÓ ÂͤٷÛË Ù˘ ‰ÔÌ‹˜ ÙˆÓ ÎÚÔÛÛÒÓ Ì ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ Â›Ó·È ÚÔÙÈÌËÙ¤· Ë Ï‹„Ë ‰Â›ÁÌ·ÙÔ˜ Ì ‚ÈÔ„›· ·fi ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈÔ¯¤˜, ÒÛÙ ӷ ·ÔÎÏÂÈÛÙ› Î·È Ë ÂÚ›ÙˆÛË ‰Â˘ÙÂÚÔÁÂÓÒÓ ‚Ï·‚ÒÓ ÂÍ·ÈÙ›·˜ Ïԛ̈͢ ‹ ÊÏÂÁÌÔÓ‹˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Ïԛ̈͢ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÎÚÔÛÛÔ› ÌÂÙ¿ ·fi ÂȉÈΤ˜ ηÏÏȤÚÁÂȘ ÛÂ Û˘Óı‹Î˜ ·ÂÚ›Ô˘-˘ÁÚ¿˜ Ê¿Ûˆ˜ (25), ·ÏÏ¿ ·˘Ù¤˜ ÔÈ Î·ÏÏȤÚÁÂȘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ΤÓÙÚˆÓ. ™˘ÓÔÏÈο, Ú¤ÂÈ Ó· ÌÂÏÂÙËıÔ‡Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 50 ÎÚÔÛÛÔ› (26). ∞ӈ̷ϛ˜ ÌÔÚ› Ó· ·Ú·ÙËıÔ‡Ó ÛÙÔ 10% Î·È ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÂÈı‹ÏÈÔ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ÔÈ ·ÓˆÌ·Ï›Â˜ Ú¤ÂÈ Ó· ÂÎÊÚ·ÛÙÔ‡Ó Î·È ÔÛÔÙÈο (26,27). √È Û˘¯ÓfiÙÂÚ˜ ‰È·Ù·Ú·¯¤˜ (28) Â›Ó·È Ë ‰˘ÛÌÔÚÊ›· ‹ ·Ô˘Û›· ÙˆÓ ÂÛˆÙÂÚÈÎÒÓ ‹ ÙˆÓ Â͈ÙÂÚÈÎÒÓ ‚Ú·¯ÈfiÓˆÓ Ù˘ ‰˘Ó½Ó˘ (80%), ÌÂÙ·ÙfiÈÛË ÙˆÓ ÎÂÓÙÚÈÎÒÓ ÌÈÎÚÔÛˆÏËÓ·Ú›ˆÓ (10%) Î·È ‚Ï¿‚Ë ÙÔ˘ ·ÎÙÈÓÔÂȉԇ˜ ÓËÌ·Ù›Ô˘ (6%). ÕÏϘ, ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Ë ·Ï·Û›· ÙˆÓ ÎÚÔÛÛÒÓ, ‰È·ÊÔÚÔÔÈ‹ÛÂȘ ÙÔ˘ ‚·ÛÈÎÔ‡ ÛˆÌ·Ù›Ô˘, ¤ÏÏÂÈ„Ë ÙÔ˘ ·ÍÔÓÈÎÔ‡ ÛˆÌ·Ù›Ô˘ ‹ ÎÚÔÛÛÔ› ÌÂÁ¿ÏÔ˘ Ì‹ÎÔ˘˜. √ÚÈṲ̂Ó˜ ·fi ÙȘ ‚Ï¿‚˜, fiˆ˜ Ë ÌÂÙ·ÙfiÈÛË ÙˆÓ ÎÂÓÙÚÈÎÒÓ ÌÈÎÚÔÛˆÏËÓ·Ú›ˆÓ, ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó ÌÂÙ¿ ·fi ‰Â˘ÙÂÚÔÁÂÓ›˜ ÌÂÙ·‚ÔϤ˜ ÏfiÁˆ Ïԛ̈͢ ‹ ÊÏÂÁÌÔÓ‹˜. ™ÙÔ 3% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ·ÓˆÌ·Ï›· (28), ÔfiÙÂ Ë ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÛÙÔȯÂÈÔıÂÙËı› ÌfiÓÔ Ì ÙËÓ ·ıÔÏÔÁÈ΋ ΛÓËÛË ÙˆÓ ÎÚÔÛÛÒÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó·
¢ÔÎÈÌ·Û›· ۷ί·Ú›Ó˘ ‹ ÚÈÓÈÎÔ‡ ¡√ (Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 12 Î·È 6 ÂÙÒÓ, ·ÓÙ›ÛÙÔȯ·)
º˘ÛÈÔÏÔÁÈ΋
¶·ıÔÏÔÁÈ΋
ª¤ÙÚËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È ·Ó¿Ï˘ÛË Î›ÓËÛ˘
º˘ÛÈÔÏÔÁÈ΋
¶·ıÔÏÔÁÈ΋
∏ÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ ∂ÈÎfiÓ· 4. ∞ÏÁfiÚÈıÌÔ˜ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ·ÛıÂÓÔ‡˜ Ì ˘Ô„›· ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ.
Á›ÓÂÙ·È Î·È ÌÂϤÙË ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ ÙˆÓ ÎÚÔÛÛÒÓ (29,30), ‰ÈfiÙÈ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÂÚÈÙÒÛÂȘ ÌÂ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ ·Ó·ÙÔÌÈο ÎÚÔÛÛÔ‡˜, ·ÏÏ¿ Ì ·ıÔÏÔÁÈÎfi ÚÔÛ·Ó·ÙÔÏÈÛÌfi ηٿ ÙËÓ Î›ÓËÛË, fiÔ˘ Ë Ì¤ÛË ·fiÎÏÈÛË ÙˆÓ Û¯ËÌ·ÙÈ˙fiÌÂÓˆÓ ÁˆÓÈÒÓ (7) Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 20Æ. ¢ÔÎÈÌ·Û›· ÚÈÓÈÎÔ‡ ÂÎÓÂfiÌÂÓÔ˘ ¡√ √È ÙÈ̤˜ ÙÔ˘ ÚÈÓÈÎÔ‡ ÂÎÓÂfiÌÂÓÔ˘ ¡√ Û ·ÛıÂÓ›˜ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ Â›Ó·È Ôχ ¯·ÌËϤ˜ (14,31) Î·È ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ËÏÈΛ·. ™Â ÌÈ· ÔÌ¿‰· 64 ·ÛıÂÓÒÓ Ì ÂȂ‚·ÈˆÌ¤ÓË ‰È¿ÁÓˆÛË ‹Ù·Ó 19±17 nl/minute Û ۯ¤ÛË Ì 376±124 nl/minute ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Î·È 184±109 nl/minute ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ (16). √È ÙÈ̤˜ ÙÔ˘ ¡√ Û ·ÛıÂÓ›˜ Ì ‚·Ú‡ ¿ÛıÌ· ‹ Ì ‚ÚÔÁ¯ÂÎٷۛ˜ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ Â›Ó·È ˘„ËϤ˜ (7,16,32)Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ¯·ÌËÏfi ¡√ Û ·ÛıÂÓ‹ Ì ¿ÛıÌ· Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙËÓ ·ÁˆÁ‹ ı¤ÙÂÈ ÙËÓ ˘Ô„›· Ù˘ ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ. ÷ÌËÏfi, ˆÛÙfiÛÔ, Â›Ó·È ÙÔ ¡√ Î·È Û ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ Î·È Û ·ÛıÂÓ›˜ Ì ÚÈÓÈÎÔ‡˜ Ôχԉ˜ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ (33). µ¤‚·È·, ÔÈ ÙÈ̤˜ Û ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ Â›Ó·È Ôχ ÈÔ ¯·ÌËϤ˜, ·ÏÏ¿ ˘¿Ú¯ÂÈ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ·ÏÏËÏÔÂÈÎ¿Ï˘„Ë Ì ÙËÓ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ (33). °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, ··ÈÙÂ›Ù·È Ô ·ÔÎÏÂÈÛÌfi˜ Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÈÓÔ΢ÛÙÈ΋˜ Û ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi ¡√. ¢ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› Û˘Û¯¤ÙÈÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ¡√ Ì ÙÔ Â›‰Ô˜ Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ‚Ï¿‚˘ Ô‡ÙÂ Â›Ó·È ÁÓˆÛÙfi˜ Ô ·ıÔÊ˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ÂÎÓÔ‹˜ ÙfiÛÔ ¯·ÌËÏÒÓ ÂȤ‰ˆÓ ¡√. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÔÈ ÙÈ̤˜ ÙˆÓ ˘Ô¯ÚˆÙÈÎÒÓ ÂÙÂÚÔ˙˘ÁˆÙÒÓ, ÁÔÓ¤ˆÓ ÙˆÓ ¶·È‰È·ÙÚÈ΋ 2008;71:14-20
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·18
18
ª. ªÔ˘ÛÙ¿ÎË, ∞. ºÚÂÙ˙¿ÁÈ·˜
·È‰ÈÒÓ Ì ÂȂ‚·ÈˆÌ¤ÓË ‰È¿ÁÓˆÛË, Â›Ó·È ÂӉȿÌÂÛ˜ 285±101 nl/minute, Ì ‡ÚÔ˜ 37-613 nl/minute, ˘Ô‰ËÏÒÓÔÓÙ·˜ fiÙÈ ˘¿Ú¯ÂÈ Î¿ÔÈ· Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ÂÙÂÚÔ˙˘ÁˆÙÒÓ Î·È Ù˘ ·Ú·ÁˆÁ‹˜ ¡√ (14). ∞Ó Î·È ‰ÂÓ ¤¯ÂÈ Â›ÛËÌ· ηıÈÂÚˆı› ˆ˜ ÂͤٷÛË ‰È·ÏÔÁ‹˜ ÁÈ· ·ÛıÂÓ›˜ Ì ˘Ô„›· ÁÈ· ÚˆÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, ÚÔÙ›ÓÂÙ·È ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ (34,35) ˆ˜ ¯Ú‹ÛÈÌÔ ÂÚÁ·ÏÂ›Ô ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·ÛıÂÓÒÓ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ. °ÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ Â›Ó·È ÁÂÓÂÙÈο ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ÓfiÛÔ˜ Ì ·˘ÙfiÛˆÌÔ ˘ÔÏÂÈfiÌÂÓÔ Ù‡Ô, ·Ó Î·È ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È Û¿ÓȘ ÂÚÈÙÒÛÂȘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙËÙÈÎfi ‹ Î·È ÌÂ Ê˘ÏÔÛ‡Ó‰ÂÙÔ (7,36,37). ∂Âȉ‹ ÔÈ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ Â›Ó·È ÔÈΛÏÔ˘ Ù‡Ô˘, ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ¤Ó·˜ ›ÙÔÔ˜ ÁÂÓÂÙÈο ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙË ÓfiÛÔ. ÕÏψÛÙÂ, Î·È Û ·ÛıÂÓ›˜ Ì ÙȘ ›‰È˜ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ·Ú·ÙËÚÂ›Ù·È ÁÂÓÂÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ·. ª¤¯ÚÈ Û‹ÌÂÚ·, ÔÈ Î˘ÚÈfiÙÂÚ˜ ÌÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó Ù·˘ÙÔÔÈËı› Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜. ªÂÙ¿ÏÏ·ÍË Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ ÚˆÙ½ÓË (4,38) DNAI1 (dynein axonemal intermediate chain 1) Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 9p13-21, ·˘Ù‹ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ ÚˆÙ½ÓË (4,37) DNAH5 (dynein axonemal heavy chain 5) Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 5p155p14 Î·È ·˘Ù‹ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ ÚˆÙ½ÓË (4,37) DNAH11 Ô˘ Έ‰ÈÎÔÔÈ› ›Û˘ ÙË ‚·Ú›· ¿Ï˘ÛÔ Ù˘ ‰˘Ó½Ó˘ Î·È ÂÓÙÔ›˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 17p21. ∏ ÙÂÏÂ˘Ù·›· ÌÂÙ¿ÏÏ·ÍË ¤¯ÂÈ Û˘Ó‰Âı› ΢ڛˆ˜ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·ÛÙÚÔÊ‹˜ ÙˆÓ ÛÏ¿Á¯ÓˆÓ. ∂›Û˘, ÌÂÙ¿ÏÏ·ÍË ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È ÁÈ· ÙË ‚·Ú›· ¿Ï˘ÛÔ Ù˘ ÂÛˆÙÂÚÈ΋˜ ‰˘Ó½Ó˘ (4,38) DNAH7 Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 2q32. ™Â ÌÂÌÔӈ̤ӷ ÂÚÈÛÙ·ÙÈο ¤¯ÂÈ ·Ú·ÙËÚËı› ÌÂÙ¿ÏÏ·ÍË Ù˘ ÚˆÙ½Ó˘ RPGR (37,39) Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ Ãp21 Î·È Ù˘ ÚˆÙ½Ó˘ √FD1 Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ Ãp22 (40). ¶ÂÚ·ÈÙ¤Úˆ ÁÂÓÂÙÈΤ˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÁÈ· Ó· ·Ô‰Âȯı› Â¿Ó Ë ·Ó·ÛÙÚÔÊ‹ ÙˆÓ ÛÏ¿Á¯ÓˆÓ Û˘ÓÙÂÏÂ›Ù·È Ù˘¯·›· ÛÙÔ˘˜ ÌÈÛÔ‡˜ ·ÛıÂÓ›˜ Ì ÙË ÓfiÛÔ ÏfiÁˆ ¤ÏÏÂȄ˘ ÙÔ˘ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ ÙˆÓ ÎÚÔÛÛÒÓ ‹ ÔÚÈṲ̂ӷ ÁÔÓ›‰È· Â›Ó·È ÈÔ ÛÙÂÓ¿ Û˘Ó‰Â‰Â̤ӷ Ì ÙËÓ ·Ó·ÛÙÚÔÊ‹ ÙˆÓ ÛÏ¿Á¯ÓˆÓ.
£Âڷ›· ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ, Ù· ÔÔ›· Û˘Ó¿ÁÂÙ·È Ë ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ, ÏfiÁˆ ¤ÏÏÂȄ˘ ÌÂÏÂÙÒÓ, Á›ÓÂÙ·È ·fi ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Î·È ·fi ÙËÓ ÂÌÂÈÚ›· Ô˘ ˘¿Ú¯ÂÈ Û ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ Î·È ‚ÚÔÁ¯ÂÎٷۛ˜ ¿ÏPaediatriki 2008;71:14-20
Ï˘ ·ÈÙÈÔÏÔÁ›·˜. ∏ ıÂڷ¢ÙÈ΋ ÙÔ˘˜ ·ÓÙÈÌÂÙÒÈÛË ÚÔÙ›ÓÂÙ·È Ó· Á›ÓÂÙ·È Û ÂȉÈο ΤÓÙÚ·, ÛÙ· ÔÔ›· ÙÔ ·È‰› ÌÔÚ› Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Û ٷÎÙ¿ ÌÂÛԉȷÛÙ‹Ì·Ù·, ÂÊfiÛÔÓ Ì¤ÓÂÈ Ì·ÎÚÈ¿, Î·È Ë ÂӉȿÌÂÛË ·Ú·ÎÔÏÔ‡ıËÛË Ó· Á›ÓÂÙ·È ÛÂ Û˘ÓÂÓÓfiËÛË Ì ÙÔ ıÂÚ¿ÔÓÙ· ·È‰›·ÙÚÔ (11). ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÛÙË ¯ÒÚ· Ì·˜ ˘¿Ú¯ÂÈ ·Ó¿ÁÎË ÔÚÁ·ÓˆÌ¤ÓˆÓ ΤÓÙÚˆÓ ‰È¿ÁÓˆÛ˘, ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ. ∏ ÚÒÙÈÛÙË ÊÚÔÓÙ›‰· ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÈηÓÔÔÈËÙÈ΋˜ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Â›Ó·È Ë ·Ó·Ó¢ÛÙÈ΋ Ê˘ÛÈÎÔıÂڷ›· (1,7). ¶Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ › ›ÎÔÛÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÏÂÙ¿. ∏ Ê˘ÛÈÎÔıÂڷ›· Ú¤ÂÈ Ó· Û˘Ó‰˘¿˙ÂÙ·È Ì ¯Ú‹ÛË ‚2 ‰ÈÂÁ¤ÚÙË, ÂÊfiÛÔÓ Â›Ó·È ıÂÙÈ΋ Ë ‰ÔÎÈÌ·Û›· ·ÓÙÈÛÙÚ„ÈÌfiÙËÙ·˜, ηıÒ˜ Î·È Ì ¿ÛÎËÛË. √ ‚‹¯·˜ ¯ÚÂÈ¿˙ÂÙ·È Ó· ÂÓı·ÚÚ‡ÓÂÙ·È Î·È fi¯È Ó· ηٷȤ˙ÂÙ·È, ‰ÈfiÙÈ ‚ÔËı¿ ÛÙË ‚ÏÂÓÓÒ‰Ë Î¿ı·ÚÛË. ™Â ÂÚ›ÙˆÛË ÏÔÈÌÒÍÂˆÓ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ·Ó¿ÏÔÁ· Ì ÙÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È. ¶ÚÔÏËÙÈο ¯ÔÚËÁÂ›Ù·È ÂÙËÛ›ˆ˜ ÙÔ ·ÓÙÈÁÚÈÈÎfi ÂÌ‚fiÏÈÔ Î·È Á›ÓÂÙ·È ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ÙfiÛÔ Ì ÙÔ Û˘ÓÂ˙¢Á̤ÓÔ 7‰‡Ó·ÌÔ fiÛÔ Î·È Ì ÙÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi 23‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ, ÒÛÙ ӷ ·Ú¤¯ÂÙ·È Î¿Ï˘„Ë ÁÈ· ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚ· ÛÙÂϤ¯Ë ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ (10). ∞ÓÙÈ‚›ˆÛË ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ïԛ̈͢ ‰›‰ÂÙ·È ·fi ÙÔ ÛÙfiÌ· ‹ ÂÓ‰ÔÊϤ‚È·. ∏ ·ÔÌfiÓˆÛË ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Á›ÓÂÙ·È Â›Ù Ì ηÏÏȤÚÁÂÈ· ÂÎÎÚ›ÛÂˆÓ ·fi ÙÔ ‚‹¯· ‹ Ì ηÏÏȤÚÁÂÈ· ÙÔ˘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. √È ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ Û˘Ó‹ıˆ˜ ·ÔÌÔÓÒÓÔÓÙ·È Â›Ó·È ·ÈÌfiÊÈÏÔ˜ Ù˘ Áڛ˘, ¯Ú˘Û›˙ÔÓÙ·˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Î·È Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ (41,42). 梉ÔÌÔÓ¿‰· ·ÂÚÈÔÁÂÓ‹˜ ·ÔÌÔÓÒÓÂÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ¯ˆÚ›˜ Ó· ·ÔÎÏ›ÂÙ·È Ë Î·ÏÏȤÚÁÂÈ¿ Ù˘ Î·È ÛÙËÓ ·È‰È΋ ‹ ÂÊË‚È΋ ËÏÈΛ· (14,41). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ ¤¯Ô˘Ó ·ÔÌÔÓˆı› ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·. ∞ÓÙÈ‚ÈÔÙÈο ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Û˘ Î·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜. ∏ Ì˘ÚÈÁÁÔÙÔÌ‹ Î·È Ë ÙÔÔı¤ÙËÛË ÛˆÏËÓ›ÛÎˆÓ ·ÂÚÈÛÌÔ‡ ·Ú·Ì¤ÓÂÈ ı¤Ì· ˘fi Û˘˙‹ÙËÛË, ÁÈ·Ù›, ·Ó Î·È ·ÔÙÂÏ› ̤ıÔ‰Ô ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ¯ÚfiÓÈ·˜ ̤Û˘ ˆÙ›Ùȉ·˜ Ì ˘ÁÚfi, ÌÔÚ› Ó· ·Ú·ÙËÚËı› ¯ÚfiÓÈ· ¤ÎÎÚÈÛË ‹ Î·È Ù˘Ì·ÓÔÛÎÏ‹Ú˘ÓÛË (4). ∂›Ó·È ·ÌÊ›‚ÔÏÔ Î·Ù¿ fiÛÔ Ë ¯Ú‹ÛË ÙÔ˘˜ ‚ÔËı¿ ÛÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÎÔ‹˜, Ë ÔÔ›· fiÙ·Ó ÂËÚ¿˙ÂÙ·È Ú¤ÂÈ Ó· ˘Ô‚ÔËıÂ›Ù·È Ì ·ÎÔ˘ÛÙÈο ‚·ÚËÎÔ˝·˜ (4). ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¯ÚÂÈ·ÛÙ› Ù˘Ì·ÓÔÏ·ÛÙÈ΋, fiÙ·Ó ÂӉ›ÎÓ˘Ù·È, ÌÔÚ› Ó· Û˘Ì‚Â›, ηıÒ˜ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· (43).
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¶ÚˆÙÔ·ı‹˜ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ
∏ ¯ÚfiÓÈ· ·Ú·ÚÈÓÔÎÔÏ›Ùȉ· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì χÛÂȘ ÙˆÓ ÎfiψÓ, ÚÈÓÈο ÛÙÂÚÔÂȉ‹ Î·È Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈο Ê¿Ú̷η ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‚ÚÔÁ¯ÂÎÙ·ÛÈÒÓ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÁÈ·Ù› Â›Ó·È ÂÓ ‰˘Ó¿ÌÂÈ ÁÂÓÈÎÂ˘Ì¤ÓÔ Úfi‚ÏËÌ· ÁÈ· ÙË ÓfiÛÔ Î·È Û˘˙ËÙÂ›Ù·È ÌfiÓÔ Û ÂÚÈÙÒÛÂȘ ÌÔÓ‹ÚÔ˘˜ ‚ÚÔÁ¯ÂÎÙ·Û›·˜ ÌË ·ÓÙÈÌÂÙˆÈ˙fiÌÂÓ˘ ÈηÓÔÔÈËÙÈο Û˘ÓÙËÚËÙÈο (44). ∂›Û˘, Û ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ· ¤¯ÂÈ Á›ÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜-Ó¢ÌfiÓˆÓ ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó¢ÌfiÓˆÓ (45). ∆Ô ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ·Ó¿ÏÔÁÔ Ì ·˘Ùfi ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ÁÈ· ¿ÏϘ ·Èٛ˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1.Meeks M, Bush A. Primary ciliary dyskinesia (PCD). Pediatr Pulmonol 2000;29:307-316. 2.Afzelius BA. Genetics and pulmonary medicine. 6. Immotile cilia syndrome: past, present, and prospects for the future. Thorax 1998;53:894-897. 3.De Iongh RU, Rutland J. Ciliary defects in healthy subjects, bronchiectasis, and primary ciliary dyskinesia. Am J Respir Crit Care Med 1995;151:1559-1567. 4.Ferkol T, Mitchison HM, O’Callaghan C, Leigh M, Carson J, Lie H, et al. Current issues in the basic mechanisms, pathophysiology, diagnosis and management of primary ciliary dyskinesia. Eur Respir Mon 2006;37:291-313. 5.Nonaka S, Tanaka Y, Okada Y, Takeda S, Harada A, Kanai Y, et al. Randomization of left-right asymmetry due to loss of nodal cilia generating leftward flow of extraembryonic fluid in mice lacking KIF3B motor protein. Cell 1998; 95:829-837. 6.Porter ME, Johnson KA. Dynein structure and function. Annu Rev Cell Biol 1989;5:119-151. 7.Bush A, Cole P, Hariri M, Mackay I, Phillips G, O’Callaghan C, et al. Primary ciliary dyskinesia: diagnosis and standards of care. Eur Respir J 1998;12:982-988. 8.Whitelaw A, Evans A, Corrin B. Immotile cilia syndrome: a new cause of neonatal respiratory distress. Arch Dis Child 1981;56:432-435. 9.Greenstone M, Rutman A, Dewar A, Mackay I, Cole PJ. Primary ciliary dyskinesia: cytological and clinical features. Q J Med 1988;67: 405-423. 10.∫˘Ú‚·Û›Ï˘ ºµ, ∆۷ӿη˜ π¡. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Î·È ·ÓÙÈÌÂÙÒÈÛË ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ. ªÔÓÔÁÚ·Ê›· ·È‰È·ÙÚÈ΋˜ Ó¢ÌÔÓÔÏÔÁ›·˜. ™ÙÔ: ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ª, ¶Ú›ÊÙ˘ ∫, ÂÈ̤ÏÂÈ· ¤Î‰ÔÛ˘. ™˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù· Ì Ó¢ÌÔÓÈ΋ Û˘ÌÌÂÙÔ¯‹ (ππ). ∞ı‹Ó·:2006. Û. 95-100. 11.µush ∞, Chodhari R, Collins N, Copeland F, Hall P, Harcourt J, et al. Primary ciliary dyskinesia: current state of the art. Arch Dis Child 2007;92:1136-1140. 12.Holzmann D, Ott PM, Felix H. Diagnostic approach to primary ciliary dyskinesia: a review. Eur J Pediatr 2000;159: 95-98. 13.Engesaeth VG, Warner JO, Bush A. New associations of primary ciliary dyskinesia syndrome. Pediatr Pulmonol 1993;16:9-12.
14.Gershoni-Baruch R, Gottfried E, Pery M, Sahin A, Etzioni A. Immotile cilia syndrome including polysplenia, situs inversus, and extrahepatic biliary atresia. Am J Med Genet 1989;33:390-393. 15.Greenstone MA, Jones RW, Dewar A, Neville BG, Cole PJ. Hydrocephalus and primary ciliary dyskinesia. Arch Dis Child 1984;59:481-482. 16.Noone PG, Leigh MW, Sannuti A, Minnix SL, Carson JL, Hazucha M, et al. Primary ciliary dyskinesia: diagnostic and phenotypic features. Am J Respir Crit Care Med 2004;169:459-467. 17.Munro NC, Currie DC, Lindsay KS, Ryder TA, Rutman A, Dewar A, et al. Fertility in men with primary ciliary dyskinesia presenting with respiratory infection. Thorax 1994;49:684-687. 18.Stanley P, MacWilliam L, Greenstone M, Mackay I, Cole P. Efficacy of a saccharin test for screening to detect abnormal mucociliary clearance. Br J Dis Chest 1984;78:62-65. 19.Greenstone M, Cole PJ. Ciliary function in health and disease. Br J Dis Chest 1985;79:9-26. 20.Rutland J, Griffin W, Cole P. Nasal brushing and measurement of ciliary beat frequency. An in vitro method for evaluating pharmacologic effects on human cilia. Chest 1981;80:865-867. 21.Stillwell PC, Abell-Aleff P, Scheithauer BW. Electron microscopy of cilia obtained by nasal brushing. Am Rev Respir Dis 1990;141:A626. 22.Gyi A, O’Callaghan C, Langton JA. Effect of halothane on cilia beat frequency of ciliated human respiratory epithelium in vitro. Br J Anaesth 1994;73:507-510. 23.Afzelius BA. Immotile cilia syndrome and ciliary abnormalities induced by infection and injury. Am Rev Respir Dis 1981;124:107-109. 24.Wilson R. Secondary ciliary dysfunction. Clin Sci (Lond) 1988;75:113-120. 25.Jorissen M, Willems T. Success rates of respiratory epithelial cell culture techniques with ciliogenesis for diagnosing primary ciliary dyskinesia. Acta Otorhinolaryngol Belg 2000;54:357-365. 26.Carlén B, Stenram U. Primary ciliary dyskinesia: a review. Ultrastruct Pathol 2005;29:217-220. 27.Rossman CM, Lee RM, Forrest JB, Newhouse MT. Nasal ciliary ultrastructure and function in patients with primary ciliary dyskinesia compared with that in normal subjects and in subjects with various respiratory diseases. Am Rev Respir Dis 1984;129:161-167. 28.Van’s Gravesande KS, Omran H. Primary ciliary dyskinesia: clinical presentation, diagnosis and genetics. Ann Med 2005;37:439-449. 29.Rutland J, de Iongh RU. Random ciliary orientation. A cause of respiratory tract disease. N Engl J Med 1990;323:1681-1684. 30.Rutman A, Cullinan P, Woodhead M, Cole PJ, Wilson R. Ciliary disorientation: a possible variant of primary ciliary dyskinesia. Thorax 1993;48:770-771. 31.Narang I, Ersu R, Wilson NM, Bush A. Nitric oxide in chronic airway inflammation in children: diagnostic use and pathophysiological significance. Thorax 2002;57:586-589. 32.Kharitonov SA, Yates D, Robbins RA, Logan-Sinclair R, Shinebourne EA, Barnes PJ. Increased nitric oxide in exhaled air of asthmatic patients. Lancet 1994;343:133-135. 33.Balfour-Lynn IM, Laverty A, Dinwiddie R. Reduced upper ¶·È‰È·ÙÚÈ΋ 2008;71:14-20
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airway nitric oxide in cystic fibrosis. Arch Dis Child 1996;75:319-322. 34.µ·Ú‚·Ú¤ÛÔ˘ ∞, °È¿ÏÔ˘ÚÔ˜ ¶. ¢È¿ÁÓˆÛË ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ. ªÔÓÔÁÚ·Ê›· ¶·È‰È·ÙÚÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁ›·˜. ™ÙÔ: ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ª, ¶Ú›ÊÙ˘ ∫, ÂÈ̤ÏÂÈ· ¤Î‰ÔÛ˘. ™˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù· Ì Ó¢ÌÔÓÈ΋ Û˘ÌÌÂÙÔ¯‹ (ππ). ∞ı‹Ó·:2006. Û. 88-94. 35.Corbelli R, Bringolf-Isler B, Amacher A, Sasse B, Spycher M, Hammer J. Nasal nitric oxide measurements to screen children for primary ciliary dyskinesia. Chest 2004;126: 1054-1059. 36.Perraudeau M, Scott J, Walport M, Oakley C, Bloom S, Brooks D. Late presentation of Kartagener’s syndrome. Consequences of ciliary dysfunction. BMJ 1994;308:519-521. 37.ªÈ¯·ËÏ›‰Ô˘ ∂, ¶·Û·Ï¿ÎË ¶. ∏ ‚·ÛÈ΋ ‰È·Ù·Ú·¯‹ ÛÙË ‚·ÛÈ΋ ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ. ªÔÓÔÁÚ·Ê›· ¶·È‰È·ÙÚÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁ›·˜. ™ÙÔ: ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ª, ¶Ú›ÊÙ˘ ∫, ÂÈ̤ÏÂÈ· ¤Î‰ÔÛ˘. ™˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù· Ì Ó¢ÌÔÓÈ΋ Û˘ÌÌÂÙÔ¯‹ (ππ). ∞ı‹Ó·:2006. Û. 77-87. 38.Geremek M, Witt M. Primary ciliary dyskinesia: genes, candidate genes and chromosomal regions. J Appl Genet. 2004;45:347-361. 39.Pedersen M, Stafanger G. Bronchopulmonary symptoms
Paediatriki 2008;71:14-20
in primary ciliary dyskinesia. A clinical study of 27 patients. Eur J Respir Dis Suppl 1983;127:118-128. 40.Moore A, Escudier E, Roger G, Tamalet A, Pelosse B, Marlin S, et al. RPGR is mutated in patients with a complex X linked phenotype combining primary ciliary dyskinesia and retinitis pigmentosa. J Med Genet 2006;43:326-333. 41.Budny B, Chen W, Omran H, Fliegauf M, Tzschach A, Wisniewska M, et al. A novel X-linked recessive mental retardation syndrome comprising macrocephaly and ciliary dysfunction is allelic to oral-facial-digital type I syndrome. Hum Genet 2006;120:171-178. 42.Schidlow DV. Primary ciliary dyskinesia (the immotile cilia syndrome). Ann Allergy 1994;73:457-468. 43.Denoyelle F, Roger G, Ducroz V, Escudier E, Fauroux B, Garabedian EN. Results of tympanoplasty in children with primary ciliary dyskinesia. Arch Otolaryngol Head Neck Surg 1998;124:177-179. 44.Smit HJ, Schreurs AJ, Van den Bosch JM, Westermann CJ. Is resection of bronchiectasis beneficial in patients with primary ciliary dyskinesia? Chest 1996;109:1541-1544. 45.Raã bago G, Copeland JG 3rd, Rosapepe F, Tsen AC, Arzouman DA, Arabia FA, et al. Heart-lung transplantation in situs inversus. Ann Thorac Surg 1996;62:296-298.
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¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·: ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Ã. ∆۷ηϛ‰Ë˜1, ∞. ∆Ú·ÁÈ·ÓÓ›‰Ë˜2, ¡. ¡ÈÎÔÏ·˝‰Ë˜1 ¶ÂÚ›ÏË„Ë: ∏ ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· (¡∂∫) ·ÔÙÂÏ› ÓfiÛÔ Î˘Ú›ˆ˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È Û˘¯Ó¿ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Î·È ˘„ËÏ‹ ıÓËÙfiÙËÙ·. ∞Ó Î·È ·ÚÎÂÙÔ› ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘, Ì ΢ÚÈfiÙÂÚÔ˘˜ ÙËÓ ÚÔˆÚfiÙËÙ·, ÙËÓ ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È ÙË Ïԛ̈ÍË, ÂÓÙÔ‡ÙÔȘ, ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ› Ë ·ıÔÁ¤ÓÂÛ‹ Ù˘. ∆· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·, ¤¯ÂÈ ÂÎÙÂÓÒ˜ ÌÂÏÂÙËı›, ΢ڛˆ˜ Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ, Ë Â›‰Ú·ÛË Ù˘ ˘ÔÍ›·˜ Î·È Ù˘ ÌÈÎÚԂȷ΋˜ ÚÔÛ‚ÔÏ‹˜ ÛÙËÓ ÚfiÎÏËÛË ‚Ï¿‚˘ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡. ∞˘Ù¤˜, Î·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ô˘Û›· ÚÔÛٷ٢ÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÛÙÔ ÌÈÎÚÔ·ÁÁÂÈ·Îfi ÂÓÙÂÚÈÎfi ÂÓ‰Ôı‹ÏÈÔ, fiˆ˜ ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (NO) Î·È Ë ·ÓˆÚÈÌfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡, ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯‹ Ù˘ ·Ì˘ÓÙÈ΋˜ ÈÛÔÚÚÔ›·˜ Î·È Û˘Ó·ÎfiÏÔ˘ıË ‚Ï¿‚Ë. ∂ÈϤÔÓ, Û‹ÌÂÚ· Â›Ó·È ÁÓˆÛÙ‹ Ë ‰Ú¿ÛË ÙˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ, fiˆ˜ Ô ·Ú¿ÁÔÓÙ·˜ ‰È¤ÁÂÚÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (platelet activating factor - PAF) Î·È ÔÈ Î˘ÙÔΛÓ˜, ÛÙËÓ ÚfiÎÏËÛË ÈÛ¯·ÈÌ›·˜ Î·È ·ÎÔÏÔ‡ıˆ˜ Ó¤ÎÚˆÛ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi, ·Ó·ÛÎÔÔ‡ÓÙ·È ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Î·È Ù· ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛ‹ Ù˘.
1 µ’ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ∞¶£, ¡ÔÛÔÎÔÌÂ›Ô ¶··ÁˆÚÁ›Ô˘, £ÂÛÛ·ÏÔÓ›ÎË 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ∞ı·Ó¿ÛÈÔ˜ ∆Ú·ÁÈ·ÓÓ›‰Ë˜ atragian@hotmail.com & atriagia@auth.gr µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: ¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ÚÔˆÚfiÙËÙ·, ·Ú¿ÁÔÓÙ·˜ ‰È¤ÁÂÚÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, ÂÓÙÂÚÈ΋ Û›ÙÈÛË, Ïԛ̈ÍË.
Necrotizing enterocolitis: recent evidence on the pathophysiology of the disease C. Tsakalidis1, A. Tragiannidis2, N. Nikolaidis1 Abstract: Necrotizing enterocolitis (NEC) is a disease affecting predominantly premature infants. It has a severe clinical presentation and many complications and is a leading cause of mortality in preterm neonates. Although many predisposing factors have been identified, such as prematurity, enteral feeding and infection, its pathogenesis is not fully understood. In the past 20 years, the role of hypoxia and infection in causing damage to the intestinal mucosa has been studied, mainly in animals. The lack of protective mechanisms in the vascular enteric endothelium, such as nitric oxide, and the immaturity of the intestinal epithelial barrier in premature infants affect the balance between protective and injurious mechanisms. It is now known that proinflammatory mediators play an important role in intestinal ischaemia and necrosis. This review focuses on the main contributing factors in NEC and recent data on its pathogenesis. Key words: Necrotizing enterocolitis, prematurity, platelet activating factor, enteral feeding, infection.
∂ÈÛ·ÁˆÁ‹ ∏ ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· (¡∂∫) Â›Ó·È ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ·ÓÒÚÈÌÔ˘ ÂÓÙ¤ÚÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ Î·È ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ıÓËÛÈÌfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ÙÔ˘˜ Û‡ÛÙËÌ·. ¶ÚÒÙÔ˜ Ô Paltauf ÂÚȤÁÚ·„ ÎÏÈÓÈΤ˜ ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Ì ¡∂∫ ÙÔ 1888, fï˜ Ô fiÚÔ˜ “ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·” ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Schmid Î·È Quaiser ÙÔ 1953 (1,2). ™ÙË Û˘Ó¤¯ÂÈ· ÔÈ Mizrahi Î·È Û˘Ó. ÂÚȤÁÚ·„·Ó ÙÔ 1965 ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· ˆ˜ “Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Â̤ÙÔ˘˜, ‰È¿Ù·ÛË ÎÔÈ-
1 2nd Department of Neonatology, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece 2 2nd Department of Paediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece Correspondence: Athanassios Tragiannidis atragian@hotmail.com & atriagia@auth.gr 2nd Department of Paediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
Ï›·˜, ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Î·È shock Û ÚfiˆÚ· ÓÂÔÁÓ¿” (3). ∆Ô ÚÔÂͤ¯ÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ¡∂∫ Â›Ó·È Ë ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Û˘Óԉ¢fiÌÂÓË ·fi Ó¤ÎÚˆÛË, Ô˘ Û˘¯Ó¿ Ô‰ËÁ› Û ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÂÈÏÔΤ˜, fiˆ˜ Ë ‰È¿ÙÚËÛË. ∏ ¡∂∫ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÓÂÔÁÓ¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ª∂¡¡ Î·È Ë Â›ÙˆÛ‹ Ù˘ ÔÈΛÏÏÂÈ Û‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÌÂÏÂÙÒÓ. ™˘ÁÎÂÎÚÈ̤ӷ, Ë Â›ÙˆÛ‹ Ù˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ·ÁÁ›˙ÂÈ ÙȘ 1-2,4 ÂÚÈÙÒÛÂȘ ÛÙ· 1.000 ˙ÒÓÙ· ÓÂÔÁÓ¿ (4,5). ¶ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÛÔÛÙfi 1-7,7% ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ¶·È‰È·ÙÚÈ΋ 2008;71:21-28
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Ã. ∆۷ηϛ‰Ë˜ Î·È Û˘Ó.
ÂÈÛ¿ÁÔÓÙ·È Û ª∂¡¡ Î·È 10% ÂÎÂ›ÓˆÓ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (VLBW) ı· ÂΉËÏÒÛÔ˘Ó ¡∂∫ (4-6). ∂ÈϤÔÓ, fiÛÔÓ ·ÊÔÚ¿ Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 5-25ò Î·È Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È ÌÂٷ͇ Ù˘ 2˘ Î·È 3˘ Ë̤ڷ˜ ˙ˆ‹˜ Û ·ÓÙ›ıÂÛË Ì ٷ ÚfiˆÚ· ÛÙ· ÔÔ›· ·Ú¯›˙ÂÈ ÌÂٷ͇ Ù˘ 10˘ Î·È Ù˘ 15˘ Ë̤ڷ˜ ˙ˆ‹˜ (7). ¶ÔÏϤ˜ ÂÚ¢ÓËÙÈΤ˜ ÔÌ¿‰Â˜ ¤¯Ô˘Ó ÂÈÎÂÓÙÚÒÛÂÈ Û‹ÌÂÚ· ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›·, ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÙȘ ıÂڷ¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ Ù˘. ∞Ú¯Èο, Ë ¡∂∫ ›¯Â ·Ô‰Ôı› Û ÔÈÎÈÏ›· ·Ú·ÁfiÓÙˆÓ Ô˘ ÚÔηÏÔ‡Ó ÂÚÈÁÂÓÓËÙÈÎfi stress, ÂÓÒ ·ÚÎÂÙ¤˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó Û˘Û¯ÂÙ›ÛÂÈ ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ Ì Â͈ÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ô ¯ÚfiÓÔ˜ ηÈ/‹ Ë Ù·¯‡ÙËÙ· ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Á¿Ï·ÎÙÔ˜, Ô Ù‡Ô˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ (ÌËÙÚÈÎfi ¤Ó·ÓÙÈ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰·˜) (8-12). ™‹ÌÂÚ·, ·ÚfiÏÔ Ô˘ Ô ·ÎÚÈ‚‹˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ‹˜ Ù˘ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›, ¤¯ÂÈ ÔÌÔÊÒÓˆ˜ ηٷÛÙ› ·Ô‰ÂÎÙ‹ Ë Û˘Ó¤ÚÁÂÈ· Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ (13). ™ËÌ·ÓÙÈ΋ ı¤ÛË ÌÂٷ͇ ·˘ÙÒÓ Î·Ù¤¯Ô˘Ó Ë ÚÔˆÚfiÙËÙ·, Ë ÈÛ¯·ÈÌ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ô ·ÔÈÎÈÛÌfi˜ ÙÔ˘ Ì ·ıÔÁfiÓ· ÌÈÎÚfi‚È· Î·È Ë ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (14,15). ∆· ¯·Ú·ÎÙËÚÈÛÙÈο ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù· Ù˘ ¡∂∫ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÙËÓ ÈÛ¯·ÈÌÈ΋ Ó¤ÎÚˆÛË, ÙÔÓ ·ÔÈÎÈÛÌfi Î·È ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ‚·ÎÙËÚ›ˆÓ Î·È Ù¤ÏÔ˜, ÙËÓ ·Ó·‰fiÌËÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ Û˘Óԉ¢fiÌÂÓË Û˘Ó‹ıˆ˜ ·fi ›ÓˆÛË. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi ·Ó·ÛÎÔÔ‡ÓÙ·È Ô Èı·Ófi˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Î·È ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ÌÔÓÙ¤ÏÔ Û˘ÌÌÂÙÔ¯‹˜ Î·È ‰Ú¿Û˘ ÙˆÓ ·ÈÙÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¡∂∫.
ÎÔÈÏ›·˜ Î·È ¯ÔÏÒ‰Ë ˘fiÏÔÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (16). √È ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÔÙ¤ÏÂÛ·Ó ÙË ‚¿ÛË ÁÈ· ÙÔÓ ÔÚÈÛÌfi Ù˘ ¡∂∫, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÔÓ ·ÔÈÎÈÛÌfi Î·È ÔÏÏ·Ï·ÛÈ·ÛÌfi ÌÈÎÚÔ‚›ˆÓ, ÙËÓ ÈÛ¯·ÈÌ›· Î·È ÙËÓ ·ÚÔ˘Û›· ÚԉȷıÂÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (.¯. ¤Ó·ÚÍË ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘). ™‹ÌÂÚ·, ¯¿ÚË ÛÙËÓ ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ ÂÈÙ¢¯ı› ÛÙË ÓÂÔÁÓÔÏÔÁ›· ¤¯ÂÈ ·ÊÂÓfi˜ ÌÂȈı› Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÛÊ˘ÎÙÈÎÒÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È Ë ·Ú·ÌÔÓ‹ ÙÔ˘˜ Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Î·È ·ÊÂÙ¤ÚÔ˘ ÂÚÈÔÚÈÛÙ› Ë Ú·ÎÙÈ΋ ηıÂÙËÚÈ·ÛÌÔ‡ ÙˆÓ ÔÌÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ. ∂ÈϤÔÓ, Â›Ó·È Â˘Ú¤ˆ˜ ·Ô‰ÂÎÙfi fiÙÈ Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ ÂÎÙ›ıÂÓÙ·È ÔÏÔ¤Ó· Î·È ÏÈÁfiÙÂÚÔ Û ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔηÏÔ‡Ó ÂÚÈÁÂÓÓËÙÈÎfi stress, fiˆ˜ ˘fiÙ·ÛË, ˘ÔıÂÚÌ›·, ˘ÔÍ›· Î·È ·Ó·ÈÌ›·, ÔÈ ÔÔ›ÔÈ Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ∏ ¤Ú¢ӷ ¤¯ÂÈ, ÂÔ̤ӈ˜, ÂÈÎÂÓÙÚˆı› ÛÙÔ ÚfiÏÔ ÙÔ˘ ·ÓÒÚÈÌÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Ùˆ¯‹ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÛÙËÓ ÂÈÛ‚ÔÏ‹ ÂÓÙÂÚÈÎÒÓ ·ıÔÁfiÓˆÓ. ∞Ó Î·È Ë ÂÎÎÚÈÙÈ΋ ·ÓÔÛÔÛÊ·ÈÚ›ÓË ∞ (sIgA) ‰ÂÓ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙË ÊÏÂÁÌÔÓÒ‰Ë ‰ÈÂÚÁ·Û›·, Ë ¤ÏÏÂÈ„‹ Ù˘ ¢ÓÔ› ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË Î·È ÙÔÓ ·ÔÈÎÈÛÌfi ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ·fi ‚·ÎÙ‹ÚÈ·. ™˘ÁÎÂÎÚÈ̤ӷ, Ë sIgA ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ¿Ì˘Ó· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘, ·ÊÔ‡ Û˘Ó‰¤ÂÙ·È Ì ٷ ÂÈÊ·ÓÂȷο ·ÓÙÈÁfiÓ· ÙˆÓ ·ıÔÁfiÓˆÓ, ÚÔˆıÒÓÙ·˜ ÙËÓ ·ÔÚÚfiÊËÛ‹ ÙÔ˘˜ ·fi Ù· ÂÓÙÂÚÔ·ÙÙ·Ú· (17,18). ŒÓ·˜ ‰Â‡ÙÂÚÔ˜ Èı·ÓÔÏÔÁÔ‡ÌÂÓÔ˜ Ì˯·ÓÈÛÌfi˜ ÂÓÔ¯ÔÔÈ› ÙË ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÙËÓ ·‰˘Ó·Ì›· ·Ó·ÁÓÒÚÈÛ˘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ (17).
¶ÚÔˆÚfiÙËÙ· ∏ ÚÔˆÚfiÙËÙ· ·ÔÙÂÏ› ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂΉ‹ÏˆÛË ¡∂∫, ·Ó Î·È Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙfi fiÙÈ Ë Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· ÌÔÚ› Ó· ÂΉËψı› Î·È Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (4,6,7). ¶ÂÚ›Ô˘ 5-10% ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ <1.500g ı· ÂΉËÏÒÛÂÈ ¡∂∫ Î·È Ë Â›ÙˆÛË ·˘Í¿ÓÂÈ ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ·ËÛ˘ (4-6). ™ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’60, Ô Santulli ÂÚȤÁÚ·„ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ¯·ÌËÏ‹ ‚·ıÌÔÏfiÁËÛË Apgar ηٿ ÙË Á¤ÓÓËÛË Î·È ÓfiÛÔ Ù˘ ˘·ÏÔÂȉԇ˜ ÌÂÌ‚Ú¿Ó˘ (16). ™Ù· ÓÂÔÁÓ¿ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÂϤÙ˘ Û˘Ó˘‹Ú¯·Ó ÂÈϤÔÓ Ù· ÂÍ‹˜ ¯·Ú·ÎÙËÚÈÛÙÈο: ¯Ú‹ÛË Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ηıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ ÔÌÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ, ÂÌÊ¿ÓÈÛË ÛËÌ›ˆÓ Î·È Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, fiˆ˜ ÌÂÙˆÚÈÛÌfi˜
™›ÙÈÛË ∏ ¡∂∫ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ÙËÓ ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÂΉËÏÒÓÂÙ·È ÌÂÙ¿ ·fi ÚfiÛÊ·ÙË ·‡ÍËÛË ‹ ·ӤӷÚÍ‹ Ù˘ ÌÂÙ¿ ·fi ‰È·ÎÔ‹ (19-21). ∏ ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÂÏ·ÙÙÒÓÂÈ ÙËÓ Â›ÙˆÛ‹ Ù˘, ·ÏÏ¿ ‰ÂÓ ÚÔÏ·Ì‚¿ÓÂÈ ÂÓÙÂÏÒ˜ ÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘. ¶ÚÒÙÔ˜ Ô Barlow ‰ËÌÔÛ›Â˘Û ÙÔ 1974 ÌÂϤÙË ·Ó·‰ÂÈÎÓ‡ÔÓÙ·˜ ÙË ÛËÌ·Û›· ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÛÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂΉ‹ÏˆÛ˘ ¡∂∫ Î·È ÙÔÓ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ Ù˘ sIgA (8). ÕÏϘ ÌÂϤÙ˜ ÂÈÎÂÓÙÚÒıËÎ·Ó ÛÙËÓ Â›‰Ú·ÛË Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ÛÙËÓ ÚfiÎÏËÛË ‚Ï¿‚˘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘, ¯ˆÚ›˜ fï˜ Ó· ·ÏËı¢ÙÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜. ™‹ÌÂÚ·, ·Ó Î·È ˘¿Ú¯ÂÈ ‰È¯ÔÁӈ̛·, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ “·ÛÊ·Ï‹” ·‡ÍËÛË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÌÂÏÂÙËÙ¤˜ ÙËÓ ·Ô‰¤¯ÔÓÙ·È (22-24).
Paediatriki 2008;71:21-28
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·23
23
¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·
™˘ÁÎÂÎÚÈ̤ӷ, Ë ·‡ÍËÛË Î·Ù¿ 20 ml/kg/ËÌÂÚËÛ›ˆ˜ ·ÔÙÂÏ› ·ÛÊ·Ï‹ Ú·ÎÙÈ΋ ÛÙȘ ª∂¡¡ (22,31). ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› Ô ÛËÌ·ÓÙÈÎfi˜ ÚfiÏÔ˜ ÙfiÛÔ ÙˆÓ Úo‚ÈÔÙÈÎÒÓ fiÛÔ Î·È ÙˆÓ Ú‚ÈÔÙÈÎÒÓ ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ Ù˘ ¡∂∫ Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ, ·ÏÏ¿ Î·È Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜. ∆· ÚÔ‚ÈÔÙÈο ·ÔÙÂÏÔ‡Ó ÌÈ· ÂÙÂÚÔÁÂÓ‹ ηÙËÁÔÚ›· ‚·ÎÙËÚ›ˆÓ Î·È ÔÊ›ÏÔ˘Ó ÙËÓ ÔÓÔÌ·Û›· ÙÔ˘˜ ÛÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ ˆ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ÚÔ˚fiÓÙÔ˜ ˙‡ÌˆÛ˘. ™ËÌ·ÓÙÈ΋ ı¤ÛË ÌÂٷ͇ ·˘ÙÒÓ Î·Ù¤¯Ô˘Ó Ù· Bifidobacterium Î·È ÔÈ Lactobacillus Ô˘ ·ÔÙÂÏÔ‡Ó Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÙˆÓ ˘ÁÈÒÓ ÓÂÔÁÓÒÓ. ∆· Ú‚ÈÔÙÈο Â›Ó·È ÔÏÈÁÔ۷ί·Ú›Ù˜ Ô˘ ‰ÂÓ ¤ÙÔÓÙ·È Î·È Â˘ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÌÈÎÚԂȷ΋˜ ¯ÏˆÚ›‰·˜ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÙÔ˘ Bifidobacterium Î·È ÙÔ˘ Lactobacillus. ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ, Â›Ó·È Èı·Ófi Ó· ·›˙Ô˘Ó ÚfiÏÔ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘, ·ÊÔ‡ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ›وÛ˘, ·ÏÏ¿ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ‹‰Ë ÂÁηÙÂÛÙË̤Ó˘ ¡∂∫, ·Ó¿ÏÔÁ· ‚¤‚·È· Ì ÙÔ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ (27-31).
§Ô›ÌˆÍË ∂›Ó·È ¢ڤˆ˜ ÁÓˆÛÙ‹ Ë ÛËÌ·Û›· ÙÔ˘ ·Ú¿ÁÔÓÙ· Ïԛ̈ÍË ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¡∂∫ (14,15). ∏ ÌÈÎÚԂȷ΋ ‰È‹ıËÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ·ÔÙÂÏ› ·Ó·ÌÊ›‚ÔÏ· ‰Â˘ÙÂÚÔ·ı‹ ·Ú¿ÁÔÓÙ· ÛÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ·ÚÎÂÙÔ› ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÙËÓ ÚÒÙË ı¤ÛË Î·Ù¤¯Ô˘Ó Ù· Gram ·ÚÓËÙÈο ‚·ÎÙ‹ÚÈ· (΢ڛˆ˜ ÂÓÙÂÚÔ‚·ÎÙËÚÈÔÂȉ‹) Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ Gram ıÂÙÈÎÔ› ÎfiÎÎÔÈ, Ù· ·Ú¿ÛÈÙ· Î·È ÔÈ ÈÔ›. ¶ÔÈΛϷ ‚·ÎÙ‹ÚÈ· ¤¯Ô˘Ó ·ÔÌÔÓˆı› ·fi ηÏÏȤÚÁÂȘ ÎÔÚ¿ÓˆÓ ÓÂÔÁÓÒÓ Ì ¡∂∫ fiˆ˜: Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Salmonella, Clostridium difficile, Coagulase-negative staphylococci Î·È ¿ÏÏ·. ∆· ÂÚÈÛÙ·ÙÈο ÓÂÔÁÓÒÓ Ô˘ ÂΉËÏÒÓÔ˘Ó ¡∂∫ Â›Ó·È Û˘Ó‹ıˆ˜ ÛÔÚ·‰Èο, ÂÓÙÔ‡ÙÔȘ, ÔÏϤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ô ·ÔÈÎÈÛÌfi˜ ª∂¡¡ Ì ‚·ÎÙ‹ÚÈ· ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÌÈÎÚÔÂȉËÌÈÒÓ. ∞Ó Î·È ÌfiÓÔ ÛÙÔ 1/3 ÙˆÓ ÓÂÔÁÓÒÓ Ì ¡∂∫ ı· Û˘Ó˘¿Ú¯ÂÈ ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, Ë ÌÈÎÚÔ‚È·ÈÌ›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‚·Ú‡ÙÂÚË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÚÔ¯ˆÚË̤ÓË ÓfiÛÔ. πÛ¯·ÈÌ›· ∆Ô ˘ÔÍ·ÈÌÈÎfi-ÈÛ¯·ÈÌÈÎfi ÙÚ·‡Ì· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ¡∂∫ (32-34). ∞Ó Î·È ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÚfiˆÚ· ÓÂÔÁÓ¿, ÂÓÙÔ‡ÙÔȘ, Î·È Ù· ÙÂÏÂÈfiÌËÓ· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ¡∂∫, fiÙ·Ó Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ÚÔηÏÔ‡Ó ÈÛ¯·ÈÌ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, fiˆ˜ ÔÈ Î˘·ÓˆÙÈΤ˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ë ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·, Ë ˘fiÙ·ÛË Î·È Ë ¯ÔÚ‹-
ÁËÛË ÈÓ‰ÔÌÂı·Î›Ó˘ (10,12,34). ∆Ô ˘ÔÍ·ÈÌÈÎfiÈÛ¯·ÈÌÈÎfi stress Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÚÔηÏ› ‚Ï¿‚Ë ÙÔ˘ ÂÓÙ¤ÚÔ˘, ·ÏÏ¿ Ë ˘fiıÂÛË fiÙÈ ·˘Ùfi ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ Ô˘ “˘ÚÔ‰ÔÙ›” ÙËÓ ÚfiÎÏËÛË Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ ÂÓÙfiÓˆ˜ ·ÌÊÈÛ‚ËÙËı›. ™‹ÌÂÚ·, Ë ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘ ÂÓÔ¯ÔÔÈ› Û ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÙËÓ ÚÔˆÚfiÙËÙ·, ÙËÓ ÚÒÈÌË Î·È “ÂÈıÂÙÈ΋” ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È ÙË ÊÏÂÁÌÔÓÒ‰Ë ‰ÈÂÚÁ·Û›· Û ۯ¤ÛË Ì ÙËÓ ÈÛ¯·ÈÌ›·. ™˘ÁÎÂÎÚÈ̤ӷ, Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Ë ·ÓÒÚÈÌË Ú‡ıÌÈÛË Ù˘ ÂÓÙÂÚÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Ô‰ËÁ› Û ˘ÔÍ›·ÈÛ¯·ÈÌ›· ˆ˜ ·¿ÓÙËÛË ÛÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ‹ ÛÙÔÓ ·ÔÈÎÈÛÌfi Ì ·ıÔÁfiÓ· ‚·ÎÙ‹ÚÈ·. √ÚÈṲ̂Ó˜ ÌÂϤÙ˜ Û ·ÓÒÚÈÌ· ÂÈÚ·Ì·Ùfi˙ˆ· ‰Â›¯ÓÔ˘Ó Î¿ÔÈ· ‰È·Ù·Ú·¯‹ Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ÂÓÙÂÚÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ ÌÂÙ¿ ·fi ˘ÔÍ›· ‹ ÈÛ¯·ÈÌ›·, Â˘Ú‹Ì·Ù· Ô˘ ‰ÂÓ ÂȂ‚·ÈÒÓÔÓÙ·È ·fi ¿ÏϘ ÌÂϤÙ˜. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ÂÓÔ¯ÔÔÈÔ‡Ó ÙË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÓÈÙÚÈÎÔ‡ ÔÍÂȉ›Ô˘ (NO) ·fi ÙÔ ·ÁÁÂÈ·Îfi ÂÓ‰Ôı‹ÏÈÔ ˆ˜ ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÚfiÎÏËÛË ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ (32,35,36). ∆Ô NO ·ÔÙÂÏ› ÂχıÂÚË Ú›˙· Ô˘ ·Ú¿ÁÂÙ·È ·fi ÙÔ ·Î¤Ú·ÈÔ ÂÓ‰Ôı‹ÏÈÔ Î·È ÚÔ¿ÁÂÈ ÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹ (32). ∂Ô̤ӈ˜, ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, ΢Úȷگ› ÛÙÔ ÌÈÎÚÔ·ÁÁÂÈ·Îfi ÂÓ‰Ôı‹ÏÈÔ Ë ·ÁÁÂÈԉȷÛÙÔÏ‹. °ÂÁÔÓfiÙ· Ô˘ ‰È·Ù·Ú¿ÛÛÔ˘Ó ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÈÛÔÚÚÔ›·, fiˆ˜ Ë ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ‹ Ë ·Ú·ÙÂٷ̤ÓË ¯·ÌËÏ‹ ·ÈÌ·ÙÈ΋ ÚÔ‹ Û ÓÂÔÁÓ¿ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘, ¢ı‡ÓÔÓÙ·È ÁÈ· ÙË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÙÔ˘ ¡√, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È, ÂÔ̤ӈ˜, ÙË Ì›ˆÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Î·È Ù˘ ·ÚÔ¯‹˜ Ô͢ÁfiÓÔ˘. (35,36). ªÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙÔ ÚfiÏÔ ÙÔ˘ ¡√ ÛÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ÂÓÙÂÚÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, ̤ۈ ‰È·Ù·Ú·¯‹˜ Ù˘ ·Ú·ÁˆÁ‹˜ ÙÔ˘. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È, ÒÛÙ ӷ ‰È¢ÎÚÈÓÈÛÙ› Ô Â·ÎÚÈ‚‹˜ ÚfiÏÔ˜ Ù˘ ÈÛ¯·ÈÌ›·˜ ˆ˜ ÚÒÈÌÔ ‹ ·ÒÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ÂÓÙÂÚÈ΋˜ ΢ÎÏÔÊÔÚ›·˜.
ºÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ô ÚfiÏÔ˜ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜ Î·È Ù˘ ·Ó·ÚÎÔ‡˜ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘ ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ ¤¯Ô˘Ó ·ÔÙÂϤÛÂÈ ÛËÌ·ÓÙÈÎfi ‰›Ô ¤Ú¢ӷ˜ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ¡∂∫. ™Â ÔÏϤ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› ·‡ÍËÛË ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Î·È ¤¯ÂÈ Á›ÓÂÈ ÚÔÛ¿ıÂÈ· Û˘Û¯ÂÙÈÛÌÔ‡ ÙÔ˘˜ Ì ÙËÓ ÂΉ‹ÏˆÛË Î·È ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ (37-42). ∆· ÂÓÙÂÚÈο ÂÈıËÏȷο ·ÙÙ·Ú· ·Ú¿ÁÔ˘Ó ÔÏϤ˜ ΢ÙÙÔΛÓ˜ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙË Ïԛ̈ÍË Î·È ÙË ‚Ï¿‚Ë ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡. ªÂٷ͇ ·˘ÙÒÓ, ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ Ù˘ IL-6 ÛÙËÓ ·Ú·ÁˆÁ‹ ¶·È‰È·ÙÚÈ΋ 2008;71:21-28
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·24
24
Ã. ∆۷ηϛ‰Ë˜ Î·È Û˘Ó.
ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘, ÛÙËÓ ÚÔ·ÁˆÁ‹ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÛÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi Ù· µ ÏÂÌÊÔ·ÙÙ·Ú· (37). ∏ ·Ú·ÁˆÁ‹ ÙÔ˘ TNF-a ¿ÁÂÙ·È ·fi ÙÔ˘˜ ÌÈÎÚÔ‚È·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ¿ÏϘ ΢ÙÙÔΛÓ˜, ÂÓÒ Ì ÙË ÛÂÈÚ¿ ÙÔ˘ ÚÔ¿ÁÂÈ ÙËÓ Î˘ÙÙ·ÚÔÙÔÍÈ΋ ·¿ÓÙËÛË Î·È ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ Î˘ÙÙ·ÚÈÎfi ı¿Ó·ÙÔ (41). √ ·Ú¿ÁÔÓÙ·˜ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (platelet activating factor - PAF) ·ÔÙÂÏ› ¤Ó·Ó ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ Î·È ÂÚÈÛÛfiÙÂÚÔ ÌÂÏÂÙË̤ÓÔ˘˜ ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÊÏÂÁÌÔÓ‹˜ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ¡∂∫ (41,43). ∞ÔÙÂÏ› ¤Ó·Ó ʈÛÊÔÏÈȉÈÎfi ·Ú¿ÁÔÓÙ· Ô˘ ·Ú¿ÁÂÙ·È ·fi Ù· ÊÏÂÁÌÔÓÒ‰Ë, Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, Ù· ·ÈÌÔÂÙ¿ÏÈ· Î·È Ù· ‚·ÎÙ‹ÚÈ· Î·È ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘. ™˘ÓÙ›ıÂÙ·È ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛË Ù˘ ʈÛÊÔÏÈ¿Û˘ ∞2ππ (PLA2) Î·È ‰È·Û¿Ù·È ·fi ÙÔ ¤Ó˙˘ÌÔ PAF-·ÎÂÙ˘ÏÔ¸‰ÚÔÏ¿ÛË. Àԉԯ›˜ ÁÈ· ÙÔÓ PAF ˘¿Ú¯Ô˘Ó Û ÔÏÏ¿ ·ÙÙ·Ú· Î·È Ë ‰Ú¿ÛË ÙÔ˘ ·ÛÎÂ›Ù·È Ì¤Ûˆ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ˘Ô‰Ô¯¤· G-ÚˆÙ½ÓË-˙‡ÁÔ˜ PAF Ô˘ ‚Ú›ÛÎÂÙ·È Û ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ, ΢ڛˆ˜ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔÓ ÂÈÏÂfi, Ô˘ ·ÔÙÂÏ› Î·È ÙË Û˘¯ÓfiÙÂÚË ı¤ÛË ÚÔÛ‚ÔÏ‹˜ Ù˘ ¡∂∫. ∏ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ PAF ÚÔ¿ÁÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ¿ÏÏˆÓ Î˘ÙÙÔÎÈÓÒÓ Î·È ‰Â˘ÙÂÚ¢fiÓÙˆÓ ÌÂÛÔÏ·‚ËÙÒÓ, fiˆ˜ Ô TNF-a, Ë IL-6, Ë IL-8, Ë IL-1, ÙÔ ¡√ Î·È ÔÈ Ï¢ÎÔÙÚȤÓ˜. ∂ÈϤÔÓ, Û‡Ìʈӷ Ì ÌÂϤÙ˜, Ë ‰Ú¿ÛË ÙÔ˘ ·ÛÎÂ›Ù·È Î·È Ì¤Ûˆ Ù˘ ·fiÙˆÛ˘ ÙˆÓ ÂÓÙÂÚÈÎÒÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ªÂ ‚¿ÛË ÙËÓ ˘fiıÂÛË ·˘Ù‹, Ë ·fiÙˆÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÈıËÏ›Ô˘, ÙËÓ ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÙËÓ Â›ÛÔ‰Ô ÙˆÓ ‚·ÎÙËÚ›ˆÓ ÛÙÔ ÂÓÙÂÚÈÎfi ÙÔ›¯ˆÌ·. ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ô PAF ÚÔηÏ› ‚Ï¿‚Ë ÛÙ· ÙÚȯÔÂȉ‹, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÙˆÓ ÓÂÊÚÒÓ, Ô˘‰ÂÙÂÚÔÂÓ›·, ıÚÔÌ‚ÔÂÓ›· Î·È ˘fiÙ·ÛË (41,43). ∆Ô ¤Ó˙˘ÌÔ PAF-·ÎÂÙ˘ÏÔ¸‰ÚÔÏ¿ÛË, Ô˘ ÙÔÓ ·‰Ú·ÓÔÔÈ›, ‚Ú›ÛÎÂÙ·È Û ¯·ÌËÏ‹ Û˘ÁΤÓÙÚˆÛË ÛÙ· ÚfiˆÚ· ΢ڛˆ˜ ÓÂÔÁÓ¿ Î·È ÛÙÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Ì ÙÔ ÔÔ›Ô ÛÈÙ›˙ÔÓÙ·È, Û ·ÓÙ›ıÂÛË Ì ÙÔ ÌËÙÚÈÎfi, Ô˘ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÂÚȤ¯ÂÈ ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË (41,43). ∆¤ÏÔ˜, Û ÓÂÔÁÓ¿ Ô˘ ÂΉ‹ÏˆÛ·Ó ¡∂∫ ‰È·ÈÛÙÒıËÎ·Ó ·˘ÍË̤ӷ ›‰· ÙÔ˘ PAF ÛÙÔ Ï¿ÛÌ· Î·È Ù· ÎfiÚ·Ó·, Â˘Ú‹Ì·Ù· Ô˘ ÂÓÈÛ¯‡Ô˘Ó ¤ÌÌÂÛ· ÙÔ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÙÔ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÓfiÛÔ˘ (41).
Toll-like receptors (TLRs) √È TLRs ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ÂÈÊ¿ÓÂÈ· Î·È ‰ÚÔ˘Ó ˆ˜ ·ÈÛıËÙ‹Ú˜ Ù˘ ÌÈÎÚԂȷ΋˜ Ïԛ̈͢, ‰È·‰Ú·Ì·Ù›˙ÔÓÙ·˜ Û˘Á¯ÚfiÓˆ˜ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Paediatriki 2008;71:21-28
ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘. ∆· ÌÈÎÚfi‚È· ÂÎÎÚ›ÓÔ˘Ó ÌfiÚÈ· Ô˘ ‰ÚÔ˘Ó ˆ˜ ˘Ô‰Ô¯Â›˜ ÛÙÔ˘˜ TLRs, fiˆ˜ ÔÈ ÏÈÔÔÏ˘Û·Î¯·Ú›Ù˜ (LPS) Î·È ÙÔ ÏÈÔÙ¯Ô˚Îfi Ô͇ (LTA). ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ LPS ·ÓÙȉÚÔ‡Ó Ì ÙȘ TLR4 Î·È ÙÔ LTA Ì ÙȘ TLR2. ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ÙˆÓ RakoffNahoum Î·È Û˘Ó. ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ TLRs ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÂÓÙÂÚÈ΋ ÌÈÎÚԂȷ΋ ¯ÏˆÚ›‰· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘, ÂÓÒ Û˘Á¯ÚfiÓˆ˜ ÙÔ ÚÔÛٷهÂÈ ·fi ÙÔ ÙÚ·‡Ì· Î·È Î·Ù·Ï‹ÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÔÈ TLRs Â›Ó·È ··Ú·›ÙËÙÔÈ ÁÈ· ÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ ÌÂÙ¿ ·fi ‚Ï¿‚Ë ‹ ÙÚ·˘Ì·ÙÈÛÌfi (44). ∂ÈϤÔÓ, Û‡Ìʈӷ Ì ÌÈ· ¿ÏÏË ˘fiıÂÛË, Ë ˘ÂÚ¤ÎÊÚ·ÛË ÔÚÈÛÌ¤ÓˆÓ TLRs, fiˆ˜ ÔÈ TLR4, ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ÚÔÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘ ÛÙÔ ÂÓÙÂÚÈÎfi ÂÈı‹ÏÈÔ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, Ì ·Ô˘Û›· Ê˘ÛÈÔÏÔÁÈ΋˜ ÌÈÎÚԂȷ΋˜ ¯ÏˆÚ›‰·˜ (33).
∞ÓˆÚÈÌfiÙËÙ· ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ ∏ ·ÎÂÚ·ÈfiÙËÙ· Î·È ÌË ‰È·ÂÚ·ÙfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ ‰È·ÙËÚÂ›Ù·È Ì¤Ûˆ ÛÂÈÚ¿˜ Ì˯·ÓÈÎÒÓ Î·È ÌË ·Ú·ÁfiÓÙˆÓ, Ô˘ ‰ÚÔ˘Ó Û˘ÓÂÚÁÈο, Ì ·ÒÙÂÚÔ ÛÎÔfi ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ·fi ÙËÓ ÂÈÛ‚ÔÏ‹ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ (17,45,46). √È ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› ›ӷÈ: ·. ÔÈ ÛÙ·ıÂÚ¤˜ Û˘Ó‰¤ÛÂȘ, ‚. Ô ÂÚÈÛÙ·ÏÙÈÛÌfi˜ Î·È Á. Ù· Û˘ÛÙ·ÙÈο ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜ Ù˘ ‚ϤÓÓ·˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÂÎÎÚÈÙÈ΋˜ sIgA. ¶ÔÏÏÔ› ·fi ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ·˘ÙÔ‡˜ Â›Ó·È ·ÓÒÚÈÌÔÈ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ηıÈÛÙÒÓÙ·˜ Ù· ÂÚÈÛÛfiÙÂÚÔ Â˘¿ÏˆÙ· ÛÙËÓ ÂΉ‹ÏˆÛË ¡∂∫. ∏ ·ÓÒÚÈÌË ÂÓÙÂÚÈ΋ ÎÈÓËÙÈÎfiÙËÙ· Î·È ¤„Ë ·ÔÙÂÏÔ‡Ó ÂÈϤÔÓ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ¡∂∫ Û ÚfiˆÚ· ÓÂÔÁÓ¿. ªÂϤÙ˜ ÙfiÛÔ Û ÓÂÔÁÓ¿ fiÛÔ Î·È Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ¤¯Ô˘Ó ·Ô‰Â›ÍÂÈ fiÙÈ Ë ÂÓÙÂÚÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ·Ú¯›˙ÂÈ ÛÙÔ ‰Â‡ÙÂÚÔ Î·È ˆÚÈÌ¿˙ÂÈ ÛÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ (4749). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Û˘ÁÎÚÈÙÈÎÒÓ ÌÂÏÂÙÒÓ ÌÂٷ͇ ÚfiˆÚˆÓ Î·È ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ, ÚԤ΢„ fiÙÈ Ë ÂÓÙÂÚÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ÙˆÓ ÚfiˆÚˆÓ Â›Ó·È ·ÓÒÚÈÌË, fï˜ Ë ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ÚÔ¿ÁÂÈ ÙËÓ ˆÚ›Ì·ÓÛ‹ Ù˘ (50-53). ¶·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÓˆÚÈÌfiÙËÙ· Ù˘ ÂÓÙÂÚÈ΋˜ ÎÈÓËÙÈÎfiÙËÙ·˜, ÂÓÒ ‰Â‰Ô̤ӷ ÌÂÏÂÙÒÓ Û ·ÓıÚÒÔ˘˜ Î·È ˙Ò· ·¤‰ÂÈÍ·Ó fiÙÈ Ë ÂÌ‚Ú˘˚΋ ˘ÔÍ›· ‹ Ë ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ÂÏ·ÙÙÒÓÔ˘Ó ÙË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÓÙÂÚÈ΋ ÎÈÓËÙÈÎfiÙËÙ· (53,55). ∆¤ÏÔ˜, Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ ‰ÂÓ ¤¯Ô˘Ó ·Ó·Ù‡ÍÂÈ Ï‹Úˆ˜ ÙËÓ ÈηÓfiÙËÙ· ¤„˘ Î·È ·ÔÚÚfiÊËÛ˘ ÙˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜, Ì ·ÔÙ¤ÏÂÛÌ· ¿ÂÙ· ÌfiÚÈ¿ ÙÔ˘ Ó· ÚÔηÏÔ‡Ó ÙÚ·˘Ì·ÙÈÛÌfi ÛÙÔ ¤ÓÙÂÚÔ, Û˘Ì‚¿ÏÏÔÓÙ·˜ ÛÙËÓ ÚfiÎÏËÛË Ù˘ ¡∂∫ (56,57).
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·25
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¡ÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·
¶ÚÔ·ÙÂÈ, ÂÔ̤ӈ˜, fiÙÈ Ë ÂÏ·Ùو̤ÓË ¤„Ë/ ·ÔÚÚfiÊËÛË Î·È Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÌÔÓ‹˜ Ù˘ ÙÚÔÊ‹˜ ÛÙÔ ¤ÓÙÂÚÔ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÚfiÎÏËÛË ÙÚ·‡Ì·ÙÔ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÓÒÚÈÌË ¿Ì˘Ó· Î·È ÙÔ˘˜ ÌÂȈ̤ÓÔ˘˜ ÂÓÙÂÚÈÎÔ‡˜ ÊÚ·ÁÌÔ‡˜. ∞. Tight junctions (™Ù·ıÂÚ¤˜ Û˘Ó‰¤ÛÂȘ) ™ÎÔfi˜ ÙÔ˘˜ Â›Ó·È Ë ‰ËÌÈÔ˘ÚÁ›· ÊÚ·ÁÌÔ‡, ̤ۈ Û‡Ó‰ÂÛ˘ ÙˆÓ Ï·Á›ˆÓ ÂÈÊ·ÓÂÈÒÓ ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ. √È tight junctions ‹ ÛÙ·ıÂÚ¤˜ Û˘Ó‰¤ÛÂȘ ·ÔÙÂÏÔ‡ÓÙ·È ·fi ÔÏϷϤ˜ ÔÈÎÔÁ¤ÓÂȘ ÚˆÙÂ˚ÓÒÓ (‰È·ÌÂÌ‚Ú·ÓÈΤ˜ ÚˆÙ½Ó˜, fiˆ˜ Ë ÔÎÏÔ˘‰›ÓË, Ë ÎÏ·Ô˘‰›ÓË Î·È ÔÈ ÚˆÙ½Ó˜ ÚÔÛÎfiÏÏËÛ˘) (58). ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÈ ÛÙ·ıÂÚ¤˜ Û˘Ó‰¤ÛÂȘ ‰ÂÓ Â›Ó·È ÛÙ·ÙÈΤ˜ ‰Ô̤˜, ·ÏÏ¿ ÌÂÙ·‚¿ÏÏÔÓÙ·È Î·Ù¿ ÙË ‰È·‰ÚÔÌ‹ ‰È·ÊfiÚˆÓ ÎÏÈÓÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ (45). ∆fiÛÔ in vivo fiÛÔ Î·È in vitro ÌÂϤÙ˜ ¤¯Ô˘Ó ·Ô‰Â›ÍÂÈ fiÙÈ Ë ÂÓ‰ÔÙÔÍÈÓ·ÈÌ›· ÚÔηÏ› Ì›ˆÛË ÛÙËÓ ¤ÎÊÚ·ÛË ÚˆÙÂ˚ÓÒÓ ÙˆÓ ÛÙÂÚÂÒÓ ÂÓÒÛˆÓ, fiˆ˜ ÔÈ ZO-1, ZO-2, ZO-3 Î·È Ë ÔÎÏÔ˘‰›ÓË, ̤ۈ Ù˘ ‰Ú¿Û˘ ÙÔ˘ ¡√, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰È¿Û·ÛË Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ (56,58). µ. ∂ÓÙÂÚÈÎfi˜ ÂÚÈÛÙ·ÏÙÈÛÌfi˜ √ ÂÚÈÛÙ·ÏÙÈÛÌfi˜ Î·È ÔÈ ÎÈÓ‹ÛÂȘ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÚÔηÏÔ‡Ó ÌÂٷΛÓËÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÌÂ Î˘Ì·ÙÔÂȉ›˜ Û˘Û¿ÛÂȘ (59). ™ÎÔfi˜ ÙÔ˘˜ Â›Ó·È Ë ¤„Ë ÙˆÓ ÙÚÔÊÒÓ, ÂÓÒ, ÂÈϤÔÓ, ‰ÚÔ‡Ó Û˘ÓÂÚÁÈο ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ÂÈıËÏȷ΋˜ ·ÎÂÚ·ÈfiÙËÙ·˜. √ ÂÚÈÛÙ·ÏÙÈÛÌfi˜ ÌÂÈÒÓÂÈ Û˘Á¯ÚfiÓˆ˜ ÙÔ ¯ÚfiÓÔ Ì ÙÔÓ ÔÔ›Ô Ù· ·ÓÙÈÁfiÓ· ÙˆÓ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ‚Ú›ÛÎÔÓÙ·È Û ·ʋ Ì ÙÔ ÎÔÚ˘Ê·›Ô ÙÌ‹Ì· ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ, ÌË ÂÈÙÚ¤ÔÓÙ·˜ ÙËÓ ·ÓÙ›‰Ú·ÛË ·ÓÙÈÁfiÓÔ˘-·ÓÙÈÛÒÌ·ÙÔ˜ (59). ∆· ÚfiˆÚ· ÓÂÔÁÓ¿ ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ·Ó·Ù˘Á̤ÓÔ ÂÚÈÛÙ·ÏÙÈÛÌfi, ·ÊÔ‡ Ô Ì˯·ÓÈÛÌfi˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ‰ÂÓ ˆÚÈÌ¿˙ÂÈ ÚÈÓ ·fi ÙÔÓ 8Ô Ì‹Ó· Ù˘ ·ËÛ˘ (60). ∆¤ÏÔ˜, ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ÌÔÓÙ¤ÏÔ Û‹ÌÂÚ· ÂÓÔ¯ÔÔÈ› ÙËÓ ¤ÏÏÂÈ„Ë ÂÚÈÛÙ·ÏÙÈÛÌÔ‡ ÁÈ· ÙËÓ ÚfiÎÏËÛË stress ÛÙÔÓ ÂÓÙÂÚÈÎfi ÊÚ·ÁÌfi Î·È ‰Â˘ÙÂÚÔ·ı‹ ÌÈÎÚԂȷ΋ ÚÔÛ‚ÔÏ‹ Î·È ÊÏÂÁÌÔÓÒ‰Ë ·¿ÓÙËÛË. °. ™‡ÛÙ·ÛË ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜ ‚ϤÓÓ·˜ ∆Ô ÛÙÚÒÌ· Ù˘ ‚ϤÓÓ·˜ Ô˘ ÂÈηχÙÂÈ Ù· ÂÓÙÂÚÔ·ÙÙ·Ú· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÎÂÚ·ÈfiÙËÙ· Î·È ÚÔÛÙ·Û›· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ (61). √È ÂÈÊ¿ÓÂȘ ÙÔ˘ ÂÈıËÏ›Ô˘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ÙÔ˘ ·Ó··Ú·ÁˆÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ıËÏ·ÛÙÈÎÒÓ ·ÔÙÂÏÂ›Ù·È ·fi ÓÂÚfi, ‚ÏÂÓÓ›ÓË Î·È ÏÈ›‰È· (46). ∏ ‚ÏÂÓÓ›ÓË ·ÔÙÂÏ› ÁÏ˘ÎÔÚˆÙ½ÓË ˘„ËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ô˘ ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· Û¯ËÌ·Ù›˙ÂÈ ·¯‡ÚÚ¢ÛÙË Á¤ÏË ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ. √ ‚·ıÌfi˜ ÚÔÛÙ·-
Û›·˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·fi ÙȘ ‚ÏÂÓÓ›Ó˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ‚·ıÌfi ˆÚ›Ì·ÓÛ‹˜ ÙÔ˘˜, Ë ÔÔ›· ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ (62). ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ ˆÚÈÌfiÙÂÚ˜ Â›Ó·È ÈÔ ·¯‡ÚÚ¢ÛÙ˜, Ô͇ÙÂÚ˜ Î·È ÂÚÈÛÛfiÙÂÚÔ ·ÓıÂÎÙÈΤ˜ ÛÙË ‰Ú¿ÛË ÙˆÓ ‚·ÎÙËÚÈ·ÎÒÓ ÂÓ˙‡ÌˆÓ, Û ·ÓÙ›ıÂÛË Ì ÂΛӘ Ô˘ ··ÓÙÒÓÙ·È ÛÙ· ÚfiˆÚ· (63-65). ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ¤ÏÏÂÈ„Ë ‚ϤÓÓ˘ ‰È·‰Ú·Ì·Ù›˙ÂÈ ÚfiÏÔ Û ÓÔÛ‹Ì·Ù· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙË ¡∂∫, fiˆ˜ Ë ÌÂÙ·Ï·Û›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ë Á·ÛÙÚ›Ùȉ·, Ô˘ Ô‰ËÁ› Û ¤ÏÎÔ˜, Î·È ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔÈ ÙÔ˘ ÂÓÙ¤ÚÔ˘ (61-62). ∏ IgA ·ÔÙÂÏ› ÙËÓ ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ô˘ ·Ú¿ÁÂÙ·È Û ÌÂÁ·Ï‡ÙÂÚË ÔÛfiÙËÙ· ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi (66). ™ÙÔ ¤ÓÙÂÚÔ, Ë sIgA ‰Ú· ·ÊÂÓfi˜ ̤ۈ Ù˘ Û‡Ó‰ÂÛ‹˜ Ù˘ Ì ٷ ‚·ÎÙ‹ÚÈ· Î·È ·ÊÂÙ¤ÚÔ˘ ̤ۈ Ù˘ ÂÍÔ˘‰ÂÙ¤ÚˆÛ˘ ÙˆÓ ‚·ÎÙËÚÈ·ÎÒÓ ÂÓ‰ÔÙÔÍÈÓÒÓ, ÙˆÓ ÚÔÙ·˚ÒÓ Î·È ÙÔ˘ ÈÔ‡ Ù˘ Áڛ˘, Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ¡∂∫ (67). ¶·Ú¿ ÙÔÓ ·Ú¯ÈÎfi ÂÓıÔ˘ÛÈ·ÛÌfi ÁÈ· ÙËÓ Èı·Ó‹ ÚÔÛٷ٢ÙÈ΋ Ù˘ ‰Ú¿ÛË, ÚfiÛÊ·ÙË ÌÂÙ·Ó¿Ï˘ÛË 3 ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ì 2.095 ÂÓÙ·¯ı¤ÓÙ· ÓÂÔÁÓ¿ ‰ÂÓ ·¤‰ÂÈÍ Ì›ˆÛË Ù˘ ›وÛ˘ Ù˘ ¡∂∫ ÌÂÙ¿ ÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË Û˘Ó‰˘·ÛÌÔ‡ IgG/IgA ‹ ÌfiÓÔ IgG (68).
¶ÚfiÏË„Ë - ∞ÓÙÈÌÂÙÒÈÛË ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¡∂∫ ‚·Û›˙ÂÙ·È ÛÙË Û˘Ó¯‹ ·ÔÛ˘ÌÊfiÚËÛË ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ, ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ Î·È ‰È·Ù‹ÚËÛË ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ÙˆÓ ˘ÁÚÒÓ Î·È, Ù¤ÏÔ˜, ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ. ∏ Û‡Á¯ÚÔÓË ÛÙÚ·ÙËÁÈ΋ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ¤¯ÂÈ Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÚÒÈÌˆÓ Î·È ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ (¶Ãµ¡) Ì ¡∂∫. ∏ Û›ÙÈÛË Ì ÌËÙÚÈÎfi Á¿Ï·, ΢ڛˆ˜ ÛÙ· ÓÂÔÁÓ¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ (69-71). ¶·ÚfiÏ· ·˘Ù¿, ˘¿Ú¯ÂÈ ·ÎfiÌË ‰È¯ÔÁӈ̛· ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÚÔÛÙ·Û›· Ô˘ ÚÔÛʤÚÂÈ Ë ¯ÔÚ‹ÁËÛË Í¤ÓÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ (72). ∏ ÚÔÁÂÓÂÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË IgA, ·ÓıÚÒÈÓ˘ ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘ (rhEPO), ·ÚÁÈÓ›Ó˘ ηÈ, Ù¤ÏÔ˜, Ë ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ·ÓÙÈ‚ÈÔÙÈο ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË Ì›ˆÛË Ù˘ ›وۋ˜ Ù˘, ¯ˆÚ›˜ fï˜ Ó· ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ‰Ôı› Û·Ê›˜ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ Ú·ÎÙÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ (68,73-76). ∏ ¢ÂÚÁÂÙÈ΋ ‰Ú¿ÛË Ù˘ EPO ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ Ù˘ ¡∂∫ ¤¯ÂÈ ·Ô‰Âȯı› ÙfiÛÔ Û ÂÈÚ·Ì·ÙÈο fiÛÔ Î·È Û ÌË ÌÔÓ٤Ϸ (75,77). √ ÚfiÏÔ˜ Ù˘ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ¶·È‰È·ÙÚÈ΋ 2008;71:21-28
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·26
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Ã. ∆۷ηϛ‰Ë˜ Î·È Û˘Ó.
Û˘ÛÙ‹Ì·ÙÔ˜ ‚·Û›ÛÙËΠÛÙËÓ ·Ó‡ÚÂÛ‹ Ù˘ ÛÙÔ ·ÓıÚÒÈÓÔ Á¿Ï· Î·È ÛÙËÓ ¤ÎÊÚ·ÛË ˘Ô‰Ô¯¤ˆÓ Ù˘ ÛÙ· ÂÓÙÂÚÔ·ÙÙ·Ú·. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ÙÚÔÊ‹˜, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ·Ó ‰Ôı› ÚÒÈÌ· Û¯ÂÙ›˙ÂÙ·È Ì ˘„ËÏfiÙÂÚË ·ÓÔ¯‹, ηχÙÂÚË ·Ó¿Ù˘ÍË, ÌÈÎÚfiÙÂÚÔ ‰È¿ÛÙËÌ· ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ ÓÔÛËÏ›·˜ Î·È ÌÂȈ̤ÓÔ ÔÛÔÛÙfi ÛË„·ÈÌ›·˜ (78,79). ∂ÈϤÔÓ, Ë ÚÒÈÌË ¤Ó·ÚÍË Ù˘ Û›ÙÈÛ˘ ‰ÂÓ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ¡∂∫ (78,79). ∂ÓÙÔ‡ÙÔȘ, ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ï‹Úˆ˜ ·fi ÙȘ ÌÂϤÙ˜ Ë ÔÚı‹ ÛÙÚ·ÙËÁÈ΋ Û›ÙÈÛ˘ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ‚·ÎÙËÚÈ·Îfi˜ ·ÔÈÎÈÛÌfi˜ Ì ÚÔ‚ÈÔÙÈο Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÚfiÏË„Ë ÔÏÏÒÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È, ÂÔ̤ӈ˜, ·ÔÙÂÏÔ‡Ó ÌÈ· ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË ·Ú¤Ì‚·ÛË ÛÙËÓ ÚfiÏË„Ë Î·È ıÂڷ›· Ù˘ ÓfiÛÔ˘. √È ÌÂϤÙ˜ ¤¯Ô˘Ó ÂȂ‚·ÈÒÛÂÈ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÚÔ‚ÈÔÙÈÎÒÓ Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË Ù˘ ›وÛ˘ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ¡∂∫ (80,81). ∂Ó·ÏÏ·ÎÙÈΤ˜ ‹ Û˘ÌÏËڈ̷ÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ ÚfiÏ˄˘ ·ÔÙÂÏÔ‡Ó Ë ¯ÔÚ‹ÁËÛË ÙˆÓ Ú‚ÈÔÙÈÎÒÓ Ô˘, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÌÈÎÚԂȷ΋˜ ¯ÏˆÚ›‰·˜, ηıÒ˜ Î·È ÙˆÓ ÌÂÙ·‚ÈÔÙÈÎÒÓ (postbiotics), fiˆ˜ ÙÔ ‚Ô˘Ù˘ÚÈÎfi Ô͇ Ô˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ Ì ÙËÓ ·Ó¿Ù˘ÍË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÙËÓ Î·Ù·ÛÙÔÏ‹ Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜ Î·È ÙËÓ ·fiÙˆÛË (82-86). ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ¤¯ÂÈ ÌÂÏÂÙËı› Û ·È‰È¿ Ì ÊÏÂÁÌÔÓÒ‰Ë ÓÔÛ‹Ì·Ù· ÙÔ˘ ÂÓÙ¤ÚÔ˘, fï˜ ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ¯ÔÚËÁËı› Û ÓÂÔÁÓ¿ (87). ∆¤ÏÔ˜, fiÛÔÓ ·ÊÔÚ¿ Ù· ¶Ãµ¡ Ô˘ ÂÈ˙Ô‡Ó ·fi ¡∂∫, ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó¢ÚÔ·Ó·Ù˘ÍÈ·ÎÒÓ, ΢ڛˆ˜, ‰È·Ù·Ú·¯ÒÓ (88,89). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ÙˆÓ Stoll Î·È Û˘Ó., ÚԤ΢„ fiÙÈ Ù· ·È‰È¿ Ì ¡∂∫ ÂÌÊ¿ÓÈ˙·Ó Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘, ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÚÔ‚Ï‹Ì·Ù· fiÚ·Û˘ Î·È ·ÎÔ‹˜ (90). ™Â ÌÂϤÙË 3.000 ¶Ãµ¡ (<1.000g) ÂÎ ÙˆÓ ÔÔ›ˆÓ ¤˙ËÛ·Ó 245 ÌÂÙ¿ ·fi ¡∂∫, ‰È·ÈÛÙÒıËΠfiÙÈ fiÛ· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈο ÂÌÊ¿ÓÈ˙·Ó Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ηı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜ Û ۇÁÎÚÈÛË Ì ÂΛӷ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Û˘ÓÙËÚËÙÈο (91).
¶ÚfiÔ‰ÔÈ, ÂÚˆÙ‹Ì·Ù· Î·È ÌÂÏÏÔÓÙÈÎÔ› ÛÙfi¯ÔÈ ™‡Ìʈӷ Ì ٷ ÚÔ·Ó·ÊÂÚfiÌÂÓ·, ÚÔ·ÙÂÈ fiÙÈ Ë ÂΉ‹ÏˆÛË ¡∂∫ ·ÓÙ·Ó·ÎÏ¿ ÙÔ Û˘Ó‰˘·ÛÌfi Î·È ÙË Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Ô‰ËÁÔ‡Ó ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡, ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·Ì˘ÓÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘. Paediatriki 2008;71:21-28
∏ Ï‹Ú˘ ηٷÓfiËÛË ÙˆÓ ÌÔÚÈ·ÎÒÓ Ì˯·ÓÈÛÌÒÓ Ô˘ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙË ‚Ï¿‚Ë Î·È ÙËÓ ÈÛ¯·ÈÌ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÛÂ Û˘Ó‰˘·ÛÌfi Ì Ӥ˜ ıÂڷ¢ÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ ı· ¤¯Ô˘Ó ˆ˜ ÛÙfi¯Ô ÙËÓ ·ÔηٿÛÙ·Û‹ Ù˘, ı· Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂΉËÏÒÓÔ˘Ó ¡∂∫. ∆¤ÏÔ˜, Ë ÂÈΤÓÙÚˆÛË Ù˘ ÌÂÏÏÔÓÙÈ΋˜ ¤Ú¢ӷ˜ ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Èı·ÓÒ˜ Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÂΉ‹ÏˆÛ˘ ¡∂∫ ı· ÌÔÚÔ‡Û ӷ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÂÍ·ÙƠ̂΢ÛË Ù˘ ıÂڷ›·˜ Î·È ÛÙËÓ ÚÒÈÌË ÂÊ·ÚÌÔÁ‹ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ ÛÙ· ÓÂÔÁÓ¿ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ‹˜ Ù˘.
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REVIEW ARTICLE
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ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜: Â›Ó·È ·ÎfiÌ· ‰Ò! ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
Ã. ∆Ú¿·ÏË, ª. ¶··Ê˘Ï·ÎÙÔ‡, °. ¶··‰fiÔ˘ÏÔ˜ ¶ÂÚ›ÏË„Ë: √ ÚÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜ (ƒ¶), ·Ó Î·È Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÈÎÚԂȷ΋ Ïԛ̈ÍË, ·Ú·Ì¤ÓÂÈ ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· 2500 ¯ÚfiÓÈ· ·fi ÙËÓ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ·fi ÙÔÓ πÔÎÚ¿ÙË. ∆Ô Úfi‚ÏËÌ· ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙȘ ÂÈÏÔΤ˜ Ù˘ ÚÂ˘Ì·ÙÈ΋˜ ηډ›Ùȉ·˜ (ƒ∫) Ô˘ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ™Â οı ÏËı˘ÛÌfi ÂÎÙÈÌ¿Ù·È fiÙÈ ˘¿Ú¯Ô˘Ó ¿ÙÔÌ· ¢¿ÏˆÙ· Û ƒ¶. ∆· ÂÌ‚fiÏÈ· Â›Ó·È ·ÎfiÌ· Ì·ÎÚÈ¿ ·fi ÙÔ Ó· Ù‡¯Ô˘Ó ÂÊ·ÚÌÔÁ‹˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È Ë ıÂڷ›· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ Ê¿Ú˘ÁÁ· ·fi ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ ·Ú·Ì¤ÓÂÈ Ë ‚¿ÛË Ù˘ ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘. ∏ ‰È¿ÁÓˆÛË ÂÍ·ÎÔÏÔ˘ı› Ó· ‚·Û›˙ÂÙ·È ÛÙ· ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ· Jones Ì ÙÚÔÔÔÈ‹ÛÂȘ Î·È ÂÈÛËÌ¿ÓÛÂȘ. ∏ ıÂڷ›· ÙÔ˘ ÔͤԘ ƒ¶ ÂÍ·ÎÔÏÔ˘ı› Ó· ‚·Û›˙ÂÙ·È Û ÎÏ·ÛÈΤ˜ Ú·ÎÙÈΤ˜, ·Ú¿ Û ÙÂÎÌËÚȈ̤Ó˜ Ô‰ËÁ›Â˜ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÁ¿ÏˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÌÂÏÂÙÒÓ. ∏ ‰Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë Ì ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË Î·Ù¿ÏÏËÏ˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜ Â›Ó·È Ô ·ÎÚÔÁˆÓÈ·›Ô˜ Ï›ıÔ˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ƒ∫. ∫·ÈÓÔ‡ÚÁÈ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ, Èı·ÓÔ› ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Î·È ÓÂfiÙÂÚ· ÛÙÔȯ›· ÁÈ· ÙËÓ ÚfiÏË„Ë, ÙË ‰È¿ÁÓˆÛË Î·È ÙË ıÂڷ›· Ù˘ ÓfiÛÔ˘ Û˘ÓÔ„›˙ÔÓÙ·È, Ì ¤ÌÊ·ÛË ÛÙËÓ Èı·Ó‹ ÎÏÈÓÈ΋ ÙÔ˘˜ ·ÍÈÔÔ›ËÛË.
AÏÏËÏÔÁÚ·Ê›·: ÃÚÈÛÙ›Ó· ∆Ú¿·ÏË trapali_chr@yahoo.gr ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡»
§¤ÍÂȘ ÎÏÂȉȿ: ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜, ÚÂ˘Ì·ÙÈ΋ ηډ›Ùȉ·, ıÂڷ›·, ÚfiÏË„Ë.
Rheumatic fever: it is still here! C. Trapali, M. Papafylaktou, G. Papadopoulos Abstract: Acute rheumatic fever (RF), although related to infection, remains a major health problem 2500 years since it was first described by Hippocrates. Its main problem derives from the chronic sequelae of rheumatic heart disease, which causes considerable morbidity and mortality. It is estimated that in any population some individuals are more susceptible to RF. Vaccines are still far away from being available and the effective treatment of group A beta-haemolytic streptococcal pharyngitis remains the cornerstone of primary prevention. The Jones criteria modified and revised are still the main diagnostic tool for RF. The treatment of acute RF is still based more on traditional practice than on the use of optimal agents tested in randomized controlled trials. Secondary prevention of RF is essential and is focused on the long-term administration of the appropriate antibiotic agent. New epidemiological findings, pathogenetic mechanisms and current views on prevention, diagnosis and treatment of RF are reviewed, with special consideration given to their potential clinical application.
Cardiology Department, “P. & A. Kyriakou” Children’s Hospital, Athens, Greece Correspondence: Christina Trapali trapali_chr@yahoo.gr Cardiology Department, “P. & A. Kyriakou” Children’s Hospital, Athens, Greece
Key words: Rheumatic fever, rheumatic heart disease, treatment, prevention.
™˘ÓÙÔÌÔÁڷʛ˜ ƒ¶ ƒ∫ ∏Ã∫ ASTO ∆∫∂ CRP i.m. i.v. p.os µ™ ¶√À RF ª∫ ∂∫
ƒÂ˘Ì·ÙÈÎfi˜ ¶˘ÚÂÙfi˜ ƒÂ˘Ì·ÙÈ΋ ∫·Ú‰›Ùȉ· ∏¯ÔηډÈÔÁÚ¿ÊËÌ· ∆›ÙÏÔ˜ ∞ÓÙÈÛÙÚÂÙÔÏ˘Û›Ó˘ ∆·¯‡ÙËÙ· ∫·ı›˙ËÛ˘ ∂Ú˘ıÚÒÓ C-∞ÓÙȉÚÒÛ· ¶ÚˆÙ½ÓË ÂÓ‰ÔÌ˘Èο ÂÓ‰ÔÊϤ‚È· ·fi ÙÔ ÛÙfiÌ· µ¿ÚÔ˜ ™ÒÌ·ÙÔ˜ ¶·ÁÎfiÛÌÈÔ˜ √ÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ Rheumatic Fever ªÂ›˙ÔÓ· ∫ÚÈÙ‹ÚÈ· ∂Ï¿ÛÛÔÓ· ∫ÚÈÙ‹ÚÈ·
∂ÈÛ·ÁˆÁ‹ √ ƒ¶ ·Ú·Ì¤ÓÂÈ ÛÙÔ Â›ÎÂÓÙÚÔ ÙÔ˘ ÂӉȷʤÚÔÓÙÔ˜, ΢ڛˆ˜ ÏfiÁˆ ÙˆÓ Ì·ÎÚÔ¯ÚfiÓÈˆÓ ÂÈ-
ÙÒÛÂˆÓ Ù˘ ƒ∫. ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘ Î·È ˘ÁÈÂÈÓ‹˜, Ë ‰˘Ó·ÙfiÙËÙ· ÚfiÛ‚·Û˘ ÛÙȘ ˘ËÚÂۛ˜ ˘Á›·˜, ·ÏÏ¿ Î·È Ë ¯Ú‹ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û˘Ó¤‚·Ï·Ó ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ›وÛ˘ Ù˘ ÓfiÛÔ˘, Ô˘ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ÎÔÈӈӛ˜ ˘ÔÏÔÁ›˙ÂÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 0,05% (1). ∞ÓÙ›ıÂÙ·, Ô ƒ¶ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, ηıÒ˜ Î·È Û ÏËı˘ÛÌÔ‡˜ Èı·ÁÂÓÒÓ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ (.¯. ∞˘ÛÙÚ·Ï›·, ¡¤· ∑ËÏ·Ó‰›·). ÀÔÏÔÁ›˙ÂÙ·È, fiÙÈ ÂÚ›Ô˘ 3-6% οı ÏËı˘ÛÌÔ‡ Â›Ó·È ÂÈÚÚ¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË ƒ¶ (1). ™˘ÓÂÒ˜, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ô È·ÙÚÈÎfi˜ ÎfiÛÌÔ˜ Ó· ‰È·ÙËÚ› ÙËÓ ÂÙÔÈÌfiÙËÙ· ÙÔ˘ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ‰ËÌÔÛȇÙËΠÚfiÛÊ·Ù· ÛÙÔ Lancet Ë ¶·È‰È·ÙÚÈ΋ 2008;71:29-37
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Ã. ∆Ú¿·ÏË Î·È Û˘Ó.
ı·Ó·ÙËÊfiÚÔ˜ ηٿÏËÍË ÂÊÙ¿¯ÚÔÓ˘ Ì ƒ¶, ÛÙËÓ ÔÔ›· ÁÈ· ‰‡Ô ¯ÚfiÓÈ· ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (2). ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ·Ó·Ê¤ÚÔÓÙ·È ÓÂÒÙÂÚ· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘, Û‡Ìʈӷ Ì ÙȘ ˘¿Ú¯Ô˘Û˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜. ∂›Û˘, ÙÔÓ›˙ÔÓÙ·È Ù· ·ÌÊÈÏÂÁfiÌÂÓ· ‰›· Î·È ÔÈ ÌÂÏÏÔÓÙÈΤ˜ ÚÔÔÙÈΤ˜.
∂ȉËÌÈÔÏÔÁ›· √ ¶·ÁÎfiÛÌÈÔ˜ √ÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ (¶√À) ·Ó·Ê¤ÚÂÈ fiÙÈ ÙÔ 2004 ÂÚÈÛÛfiÙÂÚÔÈ ·fi 15,6 ÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ ¤·Û¯·Ó ·fi ƒ¶ Î·È ¿Óˆ ·fi 230.000 ¿ÓıÚˆÔÈ Î¿ı ¯ÚfiÓÔ Âı·›ÓÔ˘Ó ·fi ƒ¶. ∫¿ı ¯ÚfiÓÔ ˘ÔÏÔÁ›˙ÔÓÙ·È 500.000 Ӥ˜ ÂÚÈÙÒÛÂȘ ƒ¶ Î·È ÂÚ›Ô˘ ÔÈ 300.000 ηٷϋÁÔ˘Ó Û ƒ∫. ∏ ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Ù˘ ƒ∫ ·ÊÔÚ¿ ΢ڛˆ˜ ÙÔ˘˜ Ó¤Ô˘˜ ·ÓıÚÒÔ˘˜ Ì ÙÂÚ¿ÛÙȘ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ. ∏ ›وÛË Î·È ıÓËÙfiÙËÙ· ÙÔ˘ ƒ¶ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÂÚ¿ÛÙȘ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ·Ó·Ù˘ÁÌ¤ÓˆÓ Î·È ˘·Ó¿Ù˘ÎÙˆÓ ¯ˆÚÒÓ (1). ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, Ë Â›ÙˆÛË Û ·È‰È¿ ËÏÈΛ·˜ 514 ÂÙÒÓ ˘ÔÏÔÁ›˙ÂÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 0,5ò, ÂÓÒ ÛÙȘ ˘·Ó¿Ù˘ÎÙ˜ ¯ÒÚ˜ Â›Ó·È È‰È·›ÙÂÚ· ·˘ÍË̤ÓË, ÂÎÙÈÌÒÌÂÓË ÛÙÔ˘˜ ·˘Ùfi¯ıÔÓ˜ Ù˘ ∞˘ÛÙÚ·Ï›·˜ Û 5ò (1). ∆Ô ¯·ÌËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Î·È Ù· ·ÎfiÏÔ˘ı¿ ÙÔ˘ (ηΤ˜ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘, Û˘ÓˆÛÙÈÛÌfi˜, ˘ÔÛÈÙÈÛÌfi˜, ‰˘Û¯ÂÚ‹˜ ÚfiÛ‚·ÛË Û ˘ËÚÂۛ˜ ˘Á›·˜) ÔÏÏ·Ï·ÛÈ¿˙Ô˘Ó ÙËÓ Èı·ÓfiÙËÙ· ƒ¶, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ÓfiÛÔ˜ Â›Ó·È Û¯Â‰fiÓ ·Ó‡·ÚÎÙË ÚÈÓ ·fi ÙÔ 2Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜, ÂÓÒ ÌfiÓÔ ÙÔ 5% ÙÔ˘ ÚÒÙÔ˘ ÂÂÈÛÔ-
‰›Ô˘ ƒ¶ ·Ú·ÙËÚÂ›Ù·È Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ (3). ∏ ˘„ËÏfiÙÂÚË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È ÚÔ Ù˘ ÂÊ˂›·˜ Î·È ·ÎÔÏÔ˘ı› ÚÔԉ¢ÙÈ΋ Ì›ˆÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ. ∏ ÓfiÛÔ˜ Â›Ó·È Û¿ÓÈ· ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 35 ÂÙÒÓ (1). √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ƒ∫ ·˘Í¿ÓÂÈ Ì ÙËÓ ËÏÈΛ·, Êı¿ÓÔÓÙ·˜ ÛÙË Ì¤ÁÈÛÙË ÙÈÌ‹ Û ËÏÈΛ· 25-35 ÂÙÒÓ, ·ÓÙÈηÙÔÙÚ›˙ÔÓÙ·˜ ÙËÓ ÚÔÛ‚ÔÏ‹ ·fi ƒ¶ Û ÓÂfiÙÂÚË ËÏÈΛ·. ∞ÎfiÌ· ÎÈ ¤Ó· ÌÂÌÔӈ̤ÓÔ ÂÂÈÛfi‰ÈÔ ƒ¶ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ƒ∫ (4), ÂÓÙÔ‡ÙÔȘ, ηٿ ηÓfiÓ· ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È·. ™ÙÔ˘˜ Ó·ÚÔ‡˜ ·ÛıÂÓ›˜, Ë ·Ó¿ÚÎÂÈ· Ù˘ ÌÈÙÚÔÂȉԇ˜ ‚·Ï‚›‰·˜ Â›Ó·È Ë Û˘ÓËı¤ÛÙÂÚË ‚Ï¿‚Ë. ¶ÚÔ˚Ô‡Û˘ Ù˘ ËÏÈΛ·˜, Ë ‚Ï¿‚Ë Û˘Ó‹ıˆ˜ ÂÍÂÏ›ÛÛÂÙ·È ÚÔ˜ ÛÙ¤ÓˆÛË.
¶·ıÔÁ¤ÓÂÈ· √ ƒ¶ ıˆÚÂ›Ù·È ·ÔÙ¤ÏÂÛÌ· ηı˘ÛÙÂÚË̤Ó˘ ·ÓÔÛÔ·¿ÓÙËÛ˘ ÛÂ Ê·Ú˘ÁÁÈΤ˜ ÏÔÈÌÒÍÂȘ ·fi ‚·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞, ·Ó Î·È Ô ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜. √È ‚-·ÈÌÔÏ˘ÙÈÎÔ› ÛÙÚÂÙfiÎÔÎÎÔÈ ¯ˆÚ›˙ÔÓÙ·È Û ÔÌ¿‰Â˜ Ì ‚¿ÛË ÙÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi ·ÓÙÈÁfiÓÔ ÙÔ˘ ÙÔȯÒÌ·Ùfi˜ ÙÔ˘˜ Î·È ÔÈ ÛÙÚÂÙfiÎÔÎÎÔÈ Ù˘ ÔÌ¿‰·˜ ∞ Â›Ó·È ˘Â‡ı˘ÓÔÈ ÁÈ· ÙË Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ÛÙÚÂÙÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔÓ ¿ÓıÚˆÔ (5). ∞fi ÙËÓ ÏËıÒÚ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·˘ÙÒÓ, ÌfiÓÔ Ë Ê·Ú˘ÁÁ›Ùȉ· ¤¯ÂÈ Û˘Ó‰Âı› ·ÈÙÈÔ·ıÔÏÔÁÈο Ì ƒ¶ (6). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Î·È ÏÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·fi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ ›Ù ·Â˘ı›·˜ ›Ù ̤ۈ ÚfiÎÏËÛ˘ Ê·Ú˘ÁÁÈ΋˜ Ïԛ̈͢ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ƒ¶ (7). ∂›Ó·È Èı·Ófi Î·È ÔÈ ÛÙÚÂÙfiÎÔÎÎÔÈ ÙˆÓ ÔÌ¿‰ˆÓ C Î·È G Ó· ¤¯Ô˘Ó ·ıÔÁÂÓÂÙÈÎfi
¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∂·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ
∂·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ ∂˘·ı‹˜ ÔÚÁ·ÓÈÛÌfi˜ ∞¡√™√∞¶∞¡∆∏™∏
ƒÂ˘Ì·ÙÈ΋ ηډ›Ùȉ·
1Ô ÂÂÈÛfi‰ÈÔ ƒ¶ ∫·ÈÓÔ‡ÚÁÈ· ÂÂÈÛfi‰È· ƒ¶
ªÔÚȷ΋ ÔÌÔÈfiÙËÙ· ·ÓÙÈÁfiÓÔ˘ -ÈÛÙÒÓ ÍÂÓÈÛÙ‹
∂ÓÂÚÁÔÔ›ËÛË ·˘ÙÔ¿ÓÔÛÔ˘ Ì˯·ÓÈÛÌÔ‡ °ÂÓÂÙÈ΋ ÚԉȿıÂÛË
∂ÈÎfiÓ· 1. ¶·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÚÂ˘Ì·ÙÈÎÔ‡ ˘ÚÂÙÔ‡ Î·È ÚÂ˘Ì·ÙÈ΋˜ ηډ›Ùȉ·˜. Paediatriki 2008;71:29-37
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31
ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜
ÚfiÏÔ ÛÙÔ ƒ¶ (8), ηıÒ˜ Û˘¯Ó¿ ¤¯Ô˘Ó ·ÔÌÔÓˆı› Û ηÏÏȤÚÁÂȘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·fi ÏËı˘ÛÌÔ‡˜ Ì ˘„ËÏ‹ ›وÛË ƒ¶. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ÔÈ ÛÙÚÂÙfiÎÔÎÎÔÈ C Î·È G ·ÔÎÙÔ‡Ó ÏÔÈÌÔÁfiÓÔ ‰Ú¿ÛË (9,10). ™˘ÓÂÒ˜, Â›Ó·È ÛÎfiÈÌÔ Ó· ˘¿Ú¯ÂÈ ÂÁÚ‹ÁÔÚÛË Î·È ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ Ì ÈÛÙÔÚÈÎfi ‰ÂÚÌ·ÙÈ΋˜ Ïԛ̈͢ ‹ Ê·Ú˘ÁÁ›Ùȉ·˜ Ì ηÏÏȤÚÁÂÈ· ıÂÙÈ΋ ÁÈ· ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ C ‹ G. ™ÙËÓ EÈÎfiÓ· 1, Û˘ÓÔ„›˙ÂÙ·È Ô ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ƒ¶ Î·È ƒ∫. ¶Ú¤ÂÈ Ó· ÚÔËÁËıÔ‡Ó Â·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ ÚÈÓ ·fi ÌÈ· Ê·Ú˘ÁÁ›Ùȉ· ·fi ÛÙÚÂÙfiÎÎÔ ÔÌ¿‰·˜ ∞ Ô˘ ı· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ÙËÓ ·ÓÔÛÔ·¿ÓÙËÛË Û ¢·›ÛıËÙÔ ÍÂÓÈÛÙ‹, Ô‰ËÁÒÓÙ·˜ ÛÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ƒ¶ (11). ∏ ·ÈÙ›· Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ·ÓÔÛÔ·¿ÓÙËÛ˘ ·Ô‰›‰ÂÙ·È Û ‰ÔÌÈΤ˜ Î·È ·ÓÔÛÔÏÔÁÈΤ˜ ÔÌÔÈfiÙËÙ˜ ÌÂٷ͇ ·ÓıÚÒÈÓˆÓ ÈÛÙÒÓ Î·È Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÈÙfiˆÓ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ ÚˆÙ½Ó˘ ª. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ÔÌÔÈfiÙËÙ· Ù˘ ÚˆÙ½Ó˘ ª Ì ÙË Ì˘Ôηډȷ΋ Ì˘ÔÛ›ÓË ıˆÚÂ›Ù·È ˘Â‡ı˘ÓË ÁÈ· ·˘Ù‹ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË (12). ∂Ó·ÓÙ›ÔÓ ·˘Ù‹˜ Ù˘ ¿Ô„˘ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Î·Ú‰›Ùȉ· ÙÔ˘ ÔͤԘ ƒ¶ Â›Ó·È ‚·Ï‚ȉ›Ùȉ· ÎÈ fi¯È Ì˘Ôηډ›Ùȉ·. ∞Ó Ë Ì˘ÔÛ›ÓË ÂÌÏÂÎfiÙ·Ó ÛÙÔÓ Ì˯·ÓÈÛÌfi, ı· ·Ó·ÌÂÓfiÙ·Ó Ì˘Ôηډ›Ùȉ· Ì ·‡ÍËÛË ÙˆÓ ÂÓ˙‡ÌˆÓ Î·È fi¯È ‚·Ï‚ȉ›Ùȉ·, ·ÊÔ‡ ÔÈ ‚·Ï‚›‰Â˜ ‰ÂÓ ¤¯Ô˘Ó Ì˘ÔÛ›ÓË (13). ∞fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ ¤¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ Ë ·ÈÙ›· Ù˘ ‚·Ï‚ȉ›Ùȉ·˜ Â›Ó·È Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ¤Ó·ÓÙÈ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ ÚˆÙ½Ó˘ ª. ™Â Ì›· ÂfiÌÂÓË Ê¿ÛË ÚÔηÏÂ›Ù·È ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ·fi ÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ Ï·ÌÈÓ›Ó˘ ÙˆÓ ‚·Ï‚›‰ˆÓ ·fi Ù· ¢·ÈÛıËÙÔÔÈË̤ӷ ∆ ÏÂÌÊÔ·ÙÙ·Ú· (14). ∆¤ÏÔ˜,
˘¿Ú¯Ô˘Ó ÓÂÒÙÂÚ· ‰Â‰Ô̤ӷ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ¿Ô„Ë ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ Ì ÙË ¡·ÎÂÙ˘ÏÔÁÏ˘ÎÔ˙·Ì›ÓË (15). ŸÔÈÔ˜ ÎÈ ·Ó Â›Ó·È Ô ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂÓÂÚÁÔÔÈ› ÙËÓ ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË, ·˘Ùfi Ô˘ ¤¯ÂÈ È‰È·›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌ·Û›· Â›Ó·È Ë ÚfiÎÏËÛË ‚·Ï‚›Ùȉ·˜. ªÂÙ¿ ÙËÓ ·Ú¯È΋ Ú‹ÍË Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘, ÚÔηÏÂ›Ù·È ‚·Ï‚›Ùȉ· ·fi Ì›· ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ì ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‰È‹ıËÛË ·fi Ì·ÎÚÔÊ¿Á· Î·È ÓÂÔ·ÁÁ›ˆÛË (16,17).
¶ÚfiÏË„Ë ™ÙËÓ ∂ÈÎfiÓ· 2, ·ÂÈÎÔÓ›˙ÔÓÙ·È ÔÈ ıˆÚËÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ·Ú¤Ì‚·Û˘, Ì ÛÎÔfi ÙËÓ ÚfiÏË„Ë ÙÔ˘ ƒ¶. √È ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÙËÓ ÔÏÈÙ›·. ∏ ¯Ú‹ÛË ÙÔ˘ ·ÓÙÈÛÙÚÂÙÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÛÙÂÚÂ›Ù·È Ú·ÎÙÈ΋˜ ÛËÌ·Û›·˜, ·ÊÔ‡ ·Ú·Ì¤ÓÔ˘Ó ·Ó·¿ÓÙËÙ· ÔÏÏ¿ ÂÚˆÙ‹Ì·Ù· Û¯ÂÙÈο Ì ÙÔ Ì˯·ÓÈÛÌfi, ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ (18). ÕÏψÛÙÂ, ıˆÚÂ›Ù·È ·›ı·ÓÔ Ó· Â›Ó·È ‰È·ı¤ÛÈÌÔ ÚÈÓ ·fi ÙÔ 2015 (19). ∏ ÚˆÙÔÁÂÓ‹˜ ÚfiÏË„Ë ÂÛÙÈ¿˙ÂÙ·È ÛÙË ıÂڷ›· Ì ·ÓÙÈ‚ÈÔÙÈο Ù˘ Û˘Ìو̷ÙÈ΋˜ Ê·Ú˘ÁÁ›Ùȉ·˜ ·fi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞. ∆· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ƒ¶ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÏËÊıÔ‡Ó, fiÙ·Ó Ë ·ÁˆÁ‹ ‰Ôı› ÂÓÙfi˜ 9 ËÌÂÚÒÓ ·fi ÙËÓ ¤Ó·ÚÍË Û˘ÌÙˆÌ¿ÙˆÓ Ê·Ú˘ÁÁ›Ùȉ·˜ (20). ¶ÚÔÙ›ÓÂÙ·È Ë ‰ÈÂÓ¤ÚÁÂÈ· Ù·¯Â›·˜ ÂͤٷÛ˘ ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ηÈ, › ·ÌÊÈ‚ÔÏ›·˜, ηÏÏȤÚÁÂÈ· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌfiÓÔ ÙÔ 20% ÙˆÓ Ê·Ú˘ÁÁ›ÙȉˆÓ ÔÊ›ÏÂÙ·È ÛÂ
¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜
1 ∂·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ
∂·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ
3 3
∂˘·ı‹˜ ÔÚÁ·ÓÈÛÌfi˜ ∞¡√™√∞¶∞¡∆∏™∏
ƒÂ˘Ì·ÙÈ΋ ηډ›Ùȉ·
1Ô ÂÂÈÛfi‰ÈÔ ƒ¶ ∫·ÈÓÔ‡ÚÁÈ· ÂÂÈÛfi‰È· ƒ¶
2
4
6 ªÔÚȷ΋ ÔÌÔÈfiÙËÙ· ·ÓÙÈÁfiÓÔ˘ -ÈÛÙÒÓ ÍÂÓÈÛÙ‹
5
∂ÓÂÚÁÔÔ›ËÛË ·˘ÙÔ¿ÓÔÛÔ˘ Ì˯·ÓÈÛÌÔ‡
1) µÂÏÙ›ˆÛË Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘-ÂÚ›ı·Ï„˘ (ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ). 2) ∞ÓÔÛÔÔ›ËÛË-ÂÌ‚fiÏÈ·. 3) £Âڷ›· ÛÙÚÂÙÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Ì ·ÓÙÈ‚ÈÔÙÈο. 4) ª·ÎÚÔ¯ÚfiÓÈ· ‰Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë Ì ·ÓÙÈ‚ÈÔÙÈο. 5) °ÂÓÂÙÈ΋ ·Ú¤Ì‚·ÛË. 6) ∫·Ù·ÛÙÔÏ‹ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ·˘ÙÔ¿ÓÔÛÔ˘ Ì˯·ÓÈÛÌÔ‡.
°ÂÓÂÙÈ΋ ÚԉȿıÂÛË ∂ÈÎfiÓ· 2. £ÂˆÚËÙÈο ÛËÌ›· ·Ú¤Ì‚·Û˘ ÁÈ· ·ÔÙÚÔ‹ ÚÂ˘Ì·ÙÈÎÔ‡ ˘ÚÂÙÔ‡ Î·È ÚÂ˘Ì·ÙÈ΋˜ ηډ›Ùȉ·˜. ¶·È‰È·ÙÚÈ΋ 2008;71:29-37
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·32
32
Ã. ∆Ú¿·ÏË Î·È Û˘Ó.
¶›Ó·Î·˜ 1. ¶ÚˆÙÔÁÂÓ‹˜ ÚfiÏË„Ë ÚÂ˘Ì·ÙÈÎÔ‡ ˘ÚÂÙÔ‡: ÚÔÙÂÈÓfiÌÂÓË ıÂڷ›· ÁÈ· ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· (22) ∞ÓÙÈ‚ÈÔÙÈÎfi
ÃÔÚ‹ÁËÛË
¢ÔÛÔÏÔÁ›·
™¯fiÏÈ·
µÂÓ˙·ıÈÓÈ΋ ÂÓÈÎÈÏ›ÓË G
i.m. ÂÊ¿·Í
™˘ÓÈÛÙ¿Ù·È Û ·ÛıÂÓ›˜ Ì Èı·ÓfiÙËÙ· ÌË Û˘ÌÌfiÚʈÛ˘ ÛÙÔ 10‹ÌÂÚÔ Û¯‹Ì·
º·ÈÓÔ͢ÌÂı˘ÏÔ ÂÓÈÎÈÏ›ÓË (¶ÂÓÈÎÈÏ›ÓË V)
p.os ÁÈ· 10 ̤Ú˜
∞ÌÔ͢ÎÈÏÏ›ÓË
p.os ÁÈ· 10 ̤Ú˜
¶ÚÒÙ˘ ÁÂÓÈ¿˜ ÎÂÊ·ÏÔÛÔÚ›Ó˜* ∂Ú˘ıÚÔÌ˘Î›ÓË
p.os ÁÈ· 10 Ë̤Ú˜ p.os ÁÈ· 10 Ë̤Ú˜
1.200.000 IU 600.000 IU ÁÈ· µ™ < 27 kg ¶·È‰È¿: 250 mg 2-3 ÊÔÚ¤˜/24ˆÚÔ ∂Ó‹ÏÈΘ: 250 mg 3-4 ÊÔÚ¤˜/24ˆÚÔ ‹ 500 mg 2 ÊÔÚ¤˜/24ˆÚÔ 25-50mg/kg/24ˆÚÔ Û 3 ‰fiÛÂȘ (̤ÁÈÛÙË ‰fiÛË: 750-1500 mg/24ˆÚÔ) ¶ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙÔ Û··ÛÌ· ¶ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙÔ Û··ÛÌ·
¢ÂÓ ¤¯ÂÈ ·Ó·ÊÂÚı› ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏ›ÓË ·fi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞
∂Ó·ÏÏ·ÎÙÈο Ù˘ p.os ÂÓÈÎÈÏ›Ó˘, ÏfiÁˆ Á‡Û˘
∂Ó·ÏÏ·ÎÙÈο Ù˘ p.os ÂÓÈÎÈÏ›Ó˘** ∂Ó·ÏÏ·ÎÙÈο Û ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁ›· ÛÙËÓ ÂÓÈÎÈÏ›ÓË
*¢ÂÓ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ·ÛıÂÓ›˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ¿ÌÂÛÔ˘ Ù‡Ô˘ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙ· ‚-Ï·ÎÙ·ÌÈο ·ÓÙÈ‚ÈÔÙÈο **5% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÌÊ¿ÓÈÛ ¤ÛÙˆ Î·È ‹È· ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË ÛÙËÓ ÂÓÈÎÈÏ›ÓË, ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ Î·È ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜
ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ (21). √ ¤ÏÂÁ¯Ô˜ Ù›ÙÏÔ˘ ·ÓÙÈۈ̿وÓ, fiˆ˜ ASTO Î·È anti-DNase µ, ‰ÂÓ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ Ì¤ÁÈÛÙ˜ ÙÈ̤˜ ·Ú·ÙËÚÔ‡ÓÙ·È 3-4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË Ïԛ̈ÍË. ∆Ô Â›‰Ô˜, Ë ‰fiÛË, Ô ·ÚÈıÌfi˜ ‰fiÛÂˆÓ ÙÔ˘ ηٿÏÏËÏÔ˘ ÁÈ· ÙË ıÂڷ›· Ù˘ Ê·Ú˘ÁÁ›Ùȉ·˜ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ¤¯Ô˘Ó Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ ÌÂÏÂÙÒÓ. ™ÙÔÓ ¶›Ó·Î· 1 ηٷÁÚ¿ÊÂÙ·È Ë ÚfiÙ·ÛË ÙÔ˘ ¶√À (22). °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÔÍ›· Ê·Ú˘ÁÁ›Ùȉ· Î·È ÈÛÙÔÚÈÎfi ƒ¶ ÔÈ Ô‰ËÁ›Â˜ Â›Ó·È ›‰È˜. ŸÌˆ˜, ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, fiˆ˜ Î·È Â› ˘ÔÙÚÔ‹˜ Ù˘ Ê·Ú˘ÁÁ›Ùȉ·˜, Û˘ÛÙ‹ÓÂÙ·È Î·ÏÏȤÚÁÂÈ· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ Î·È ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ 10‹ÌÂÚ˘ ·ÁˆÁ‹˜ (22). ∂› ˘ÔÙÚÔ‹˜, ¯ÔÚËÁÔ‡ÓÙ·È 1.200.000 IU ‚ÂÓ˙·ıÈÓÈ΋˜ ‚ÂÓ˙˘ÏÔÂÓÈÎÈÏÏ›Ó˘ (i.m.) Û ÌÈ· ‰fiÛË Î·È, ·Ó ˘¿Ú¯Ô˘Ó ˘Ô„›Â˜ ÁÈ· ·Ú·ÁˆÁ‹ ÂÓÈÎÈÏÏÈÓ¿Û˘ ·fi ÙÔ ÛÙÚÂÙfiÎÔÎÎÔ, ÚÔÙ›ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÎÏÈÓ‰·Ì˘Î›Ó˘ ‹ ·ÌÔ͢ÎÈÏÏ›Ó˘-ÎÏ·‚Ô˘Ï·ÓÈÎÔ‡ ÔͤԘ (22). ø˜ ‰Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë ÔÚ›˙ÂÙ·È Ë Ù·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ƒ¶, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· Î·È ˘ÔÙÚÔ‹ ÂÂÈÛÔ‰›Ô˘ ÔͤԘ ƒ¶. ◊‰Ë ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ ã60 ‹Ù·Ó ÁÓˆÛÙfi fiÙÈ ÂÚ›Ô˘ ÙÔ 60% ÙˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ‚·Ï‚ȉÈÎÒÓ ‚Ï·‚ÒÓ ˘ÔÛÙÚ¤ÊÔÓÙ·È ÛÙË 10ÂÙ›·, ·Ó ‰ÂÓ ˘¿ÚÍÂÈ ˘ÔÙÚÔ‹ ƒ¶ (23). ¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ Ì ∏Ã∫ ‰Â›¯ÓÔ˘Ó ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ƒ¶ ·ÎfiÌ· Î·È ÛÙÔ 24% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ›¯·Ó ÛÔ‚·Ú‹ ηډ›Ùȉ· (24). ∏ ·ÔÊ˘Á‹, ÂÔ̤ӈ˜, Ó¤Ô˘ ÂÂÈÛÔ‰›Ô˘ ƒ¶ Â›Ó·È ÌÂPaediatriki 2008;71:29-37
Á¿Ï˘ ÛËÌ·Û›·˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ, ηٿ ηÓfiÓ·, Ë ¯ÚfiÓÈ· ƒ∫ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÏÒÓ ÂÂÈÛÔ‰›ˆÓ ƒ¶ (4). ∏ ÚfiÙ·ÛË ÙÔ˘ ¶√À (22) ÁÈ· ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Î·Ù·ÁÚ¿ÊÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ ¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘ ÂÓ‰ÔÌ˘˚ο ¤¯ÂÈ Ê·Ó› ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË Ù˘ ·ÁˆÁ‹˜ ·fi ÙÔ ÛÙfiÌ·, ÂÓÒ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË, ›Û˘, Â›Ó·È Î·È Ë ¯ÔÚ‹ÁËÛË Î¿ı 3 ‚‰ÔÌ¿‰Â˜ (25). ¶·Ú¿ Ù·‡Ù·, ÙÔ ·Ó¿ 3 ‚‰ÔÌ¿‰Â˜ Û¯‹Ì· ÚÔÙ›ÓÂÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ƒ∫, ÂÓÒ ÁÈ· ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÚÔÙÈÌ¿Ù·È Ë ¯ÔÚ‹ÁËÛË Î¿ı 4 ‚‰ÔÌ¿‰Â˜ (19). ∂›Ó·È ÛÎfiÈÌÔ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ÔÈ ·Ï¤˜ Ô‰ËÁ›Â˜ ÁÈ· Ì›ˆÛË ÙÔ˘ fiÓÔ˘, fiˆ˜ Ë ı¤ÚÌ·ÓÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ıÂÚÌÔÎÚ·Û›· ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ÙÔ ÛÙ¤Áӈ̷ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Î·È Ë ·ÚÁ‹ ¯ÔÚ‹ÁËÛË (ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 3 ÏÂÙ¿) (19). ∂›Û˘, ¤¯ÂÈ ÚÔÙ·ı› Û˘Á¯ÔÚ‹ÁËÛË Ì ÏȉÔη˝ÓË (26), ÂÓÒ Ê·›ÓÂÙ·È Ó· ‚ÔËı¿ Ë ÁÓˆÛÙ‹ ÛÙË ¯ÒÚ· Ì·˜ Ú·ÎÙÈ΋ Ì ÂÈı¤Ì·Ù· ÙÔÈÎÔ‡ ·Ó·ÈÛıËÙÈÎÔ‡, Ô˘ ÚÔËÁÂ›Ù·È Ù˘ ¯ÔÚ‹ÁËÛ˘. ¶Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› fiÙÈ Ë ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘ ‰ÂÓ ·ÔÙÚ¤ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ‚·ÎÙËÚȉȷ΋˜ ÂÓ‰Ôηډ›Ùȉ·˜, ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ÔÔ›·˜ ÈÛ¯‡Ô˘Ó Ù· ÁÓˆÛÙ¿ ÁÈ· Ô‰ÔÓÙÈ·ÙÚÈΤ˜ Î·È ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ.
¢È¿ÁÓˆÛË °È· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ƒ¶ ‰ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ÂͤٷÛË. ∆Ô 1944 ıÂÛ›ÛÙËÎ·Ó Ù· ÁÓˆÛÙ¿ ÎÚÈÙ‹ÚÈ· Jones (27), Ô˘ ¤ÎÙÔÙ ÙÚÔÔÔÈ‹ıËÎ·Ó ¤ÓÙ ÊÔÚ¤˜. √È ÙÂÏÂ˘Ù·›Â˜ ÙÚÔÔÔÈ‹ÛÂȘ ·fi ÙËÓ American
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·33
33
ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜
¶›Ó·Î·˜ 2. ¢Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë: Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ›· Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÚÂ˘Ì·ÙÈÎÔ‡ ˘ÚÂÙÔ‡ ‹ ÚÂ˘Ì·ÙÈ΋˜ ηډ›Ùȉ·˜ (22) ∞ÓÙÈ‚ÈÔÙÈÎfi
ÃÔÚ‹ÁËÛË ¢ÔÛÔÏÔÁ›·
™¯fiÏÈ·
µÂÓ˙·ıÈÓÈ΋ ÂÓÈÎÈÏ›ÓË G
i.m.
- ™Â ƒ¶ ¯ˆÚ›˜ ηډ›Ùȉ·: 5 ¯ÚfiÓÈ· ·fi ÙÂÏÂ˘Ù·›Ô ÂÂÈÛfi‰ÈÔ ƒ¶ ‹ ̤¯ÚÈ 18 ¯ÚÔÓÒÓ - ™Â ‹È· ‹ ıÂڷ¢ı›۷ ηډ›Ùȉ·: 10 ¯ÚfiÓÈ· ·fi ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÂÈÛfi‰ÈÔ ƒ¶ ‹ ̤¯ÚÈ 25 ¯ÚÔÓÒÓ** - ™Â ÈÔ ÛÔ‚·Ú‹ ηډ›Ùȉ· ‹ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ‚·Ï‚›‰·˜: ÂÊ' fiÚÔ˘ ˙ˆ‹˜
º·ÈÓÔ͢ÌÂı˘ÏÔ p.os ÂÓÈÎÈÏ›ÓË (¶ÂÓÈÎÈÏ›ÓË V) ∂Ú˘ıÚÔÌ˘Î›ÓË p.os
1-2 ÂηÙÔÌ̇ÚÈ· IU οı 3-4 ‚‰ÔÌ¿‰Â˜ 600.000 IU οı 3-4 ‚‰ÔÌ¿‰Â˜ ÁÈ· µ™ < 27 kg* 250 mg 2 ÊÔÚ¤˜/24ˆÚÔ 250 mg 2 ÊÔÚ¤˜/24ˆÚÔ
* º·ÚÌ·ÎÔÎÈÓËÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Èı·ÓÒ˜ Ë ‰fiÛË Â›Ó·È ·Ó·Ú΋˜ ÁÈ· οÔÈ· ·È‰È¿ Î·È ÚÔÙ›ÓÂÙ·È Ë ÌÈÎÚ‹ ‰fiÛË ÌfiÓÔ ·Ó ÙÔ µ™ <20 kg (19) ** ◊ fiÛÔ ˘¿Ú¯Ô˘Ó ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ (52)
Heart Association (AHA) ¤ÁÈÓ·Ó ÙÔ 1992 (28) Î·È ·fi ÙÔÓ ¶√À ÙÔ 2003, Ô˘ ‰È·ÊÔÚÔÔÈ› Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ 1992 ÌfiÓÔ ÁÈ· ˘ÔÙÚÔ‹ ƒ¶, ı¤ÙÔÓÙ·˜ ÏÈÁfiÙÂÚÔ “·˘ÛÙËÚ¿” ÎÚÈÙ‹ÚÈ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·˘Í¿ÓÔ˘Ó ÙËÓ Â˘·ÈÛıËÛ›· Û ‚¿ÚÔ˜ Ù˘ ÂȉÈÎfiÙËÙ·˜. ∆· ÎÚÈÙ‹ÚÈ· ‰È·ÎÚ›ÓÔÓÙ·È Û Ì›˙ÔÓ· (ª∫) Î·È ÂÏ¿ÛÛÔÓ· (∂∫) Î·È ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. °È· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÚÒÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· AHA Î·È ¶√À. ∞·ÈÙÔ‡ÓÙ·È 2 ª∫ ‹ 1 ª∫ Î·È 2 ∂∫ Î·È ÂÈÚfiÛıÂÙ· ·fi‰ÂÈÍË ÚÔËÁËı›۷˜ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ ∞ Ïԛ̈͢ (ÚfiÛÊ·ÙË ÔÛÙÚ·ÎÈ¿, ÙÂÎÌËÚȈ̤ÓË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ·, ˘„ËÏfi˜ Ù›ÙÏÔ˜ ·ÓÙÈÛÙÚÂÙÔÎÔÎÎÈÎÒÓ ·ÓÙÈۈ̿وÓ). ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ ÛÙÔ 20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÚÒÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ƒ¶ Î·È ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Ì ¯ÔÚ›· ·Ú·ÙËÚÂ›Ù·È ¯·ÌËÏfi˜ Ù›ÙÏÔ˜ ASTO. ∂È‚¿ÏÏÂÙ·È ÏÔÈfiÓ ¤ÏÂÁ¯Ô˜ Î·È ÙÔ˘ Ù›ÙÏÔ˘ antiDNase µ. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ¯ÔÚ›·˜ Î·È ˘ÔÎÏÈÓÈ΋˜ ηډ›Ùȉ·˜, Û‡Ìʈӷ Ì ÙËÓ ∞∏∞ (28) Î·È Ì ÙÔÓ ¶√À (22), ‰ÂÓ ··ÈÙ› ·fi‰ÂÈÍË ÚÔËÁËı›۷˜ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ïԛ̈͢ ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË ƒ¶. °È· ˘ÔÙÚÔ‹ ƒ¶, Ô ¶√À ·ÚÎÂ›Ù·È Û 2 ∂∫ ÎÚÈÙ‹ÚÈ· Î·È ÂÈÚfiÛıÂÙ· ·fi‰ÂÈÍË ÚÔËÁËı›۷˜ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ïԛ̈͢, ÂÓÒ Ë ∞∏∞ ··ÈÙ› ÂÚÈÛÛfiÙÂÚ· ∂∫ ÎÚÈÙ‹ÚÈ· (·‡ÍËÛË ÂȉÈÎfiÙËÙ·˜, Ì›ˆÛË Â˘·ÈÛıËÛ›·˜) (28). ∂Ӊ¯Ô̤ӈ˜, ·˘Ù‹ Ë Ú·ÎÙÈ΋ Ó· Â›Ó·È ÚÔÙÈÌfiÙÂÚË ÛÙË ¯ÒÚ· Ì·˜. ™ÎfiÈÌÔ Â›Ó·È Ó· ÂÈÛËÌ·Óı› fiÙÈ Ù· ÎÚÈÙ‹ÚÈ· Jones Â›Ó·È ‰È·ÁÓˆÛÙÈο ÂÚÁ·Ï›· ÎÈ fi¯È ·fiÏ˘ÙÔÈ Ô‰ËÁÔ› ÎÈ fiˆ˜ ۯ‰fiÓ Û οı ÂÚ›ÙˆÛË ÛÙËÓ È·ÙÚÈ΋ Û˘ÓÈÛÙ¿Ù·È ÂÍ·ÙƠ̂΢ÛË. √ ÔÚÈÛÌfi˜ Ù˘ ηډ›Ùȉ·˜ › ƒ¶ ·ÔÙÂÏ› ÛËÌÂ›Ô ÙÚÈ‚‹˜ ÛÙËÓ ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›·. ∂›ÛËÌ·, ··ÈÙÂ›Ù·È Ë ·ÚÔ˘Û›· Ê˘Û‹Ì·ÙÔ˜ ÁÈ· ÙÂÎÌËÚ›ˆÛË ‚·Ï‚ȉ›Ùȉ·˜ (22,28), ·ÏÏ¿ fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ∏Ã∫ÊÈ΋ ‰È·›ÛÙˆÛË ‚·Ï‚ȉ›-
Ùȉ·˜, ¤ÛÙˆ Î·È ¯ˆÚ›˜ ʇÛËÌ·, Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ·Ô‰ÂÈÎÙÈ΋ ηډ›Ùȉ·˜. ∆· ÛÙÔȯ›· Ô˘ ‚·Û›˙ÂÙ·È Ë ¿Ô„Ë ·˘Ù‹ ›ӷÈ: (1) ∞ÛıÂÓ›˜ Ì ƒ¶ ¯ˆÚ›˜ ηډ›Ùȉ· (¯ˆÚ›˜ ʇÛËÌ·) ·Ó¤Ù˘Í·Ó ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ƒ∫ (29,30), Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ Î·È Ì “¯Ú˘Û¿ ·˘ÙÈ¿” οÔȘ ‚·Ï‚ȉ›Ùȉ˜ ¯¿ÓÔÓÙ·È. (2) ¢È·ÈÛÙÒıËÎ·Ó ‚·Ï‚ȉÈΤ˜ ‚Ï¿‚˜ 6 Ì‹Ó˜ ˆ˜ 8 ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ˘ÔÎÏÈÓÈ΋ ƒ∫ (31-33). (3) ™Â 452 ·ÛıÂÓ›˜ Ì ƒ¶, ‰È·ÁÓˆṲ̂ÓÔ Ì ‚¿ÛË Ù· ›ÛËÌ· ÎÚÈÙ‹ÚÈ·, ‰È·ÈÛÙÒıËΠ̠∏Ã∫ fiÙÈ Û οÔÈÔ˘˜ ·ÛıÂÓ›˜ ÙÔ Ê‡ÛËÌ· Ô˘ ›¯Â ·Ô‰Ôı› Û ηډ›Ùȉ· ÔÊÂÈÏfiÙ·Ó Û ¿ÏÏË ·ÈÙ›· (.¯. ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·) Î·È ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ‰ÂÓ Â›¯·Ó ƒ¶. ¶·Ú¿ÏÏËÏ·, Û οÔÈÔ˘˜ ¿ÏÏÔ˘˜ ·ÛıÂÓ›˜, ¯ˆÚ›˜ ÎÏÈÓÈ΋ ¤Ó‰ÂÈÍË Î·Ú‰›Ùȉ·˜, Ì ∏Ã∫ ‰È·ÈÛÙÒıËΠ‚·Ï‚ȉ›Ùȉ·, ÁÂÁÔÓfi˜ Ô˘ ¿ÏÏ·Í ÙËÓ ÚÔÛ¤ÁÁÈÛ‹ ÙÔ˘˜ (34). Œ¯ÂÈ ‰È·Ù˘ˆı› Î·È Ô ·ÓÙ›ıÂÙÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜, Ì‹ˆ˜ ‰ËÏ·‰‹, ÏfiÁˆ Ù˘ Û˘¯Ó‹˜ ·Ó›¯Ó¢Û˘ ‹È·˜ ‰È·Ê˘Á‹˜ ÌÈÙÚÔÂȉԇ˜ ‚·Ï‚›‰·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÏËı˘ÛÌfi, Ë ı¤ÛÈÛË ÛÙ· ÎÚÈÙ‹ÚÈ· Ù˘ ∏Ã∫ÊÈ΋˜ ·Ó›¯Ó¢Û˘ ·Ó¿ÚÎÂÈ·˜ ı· Ô‰ËÁ‹ÛÂÈ Û ˘ÂډȿÁÓˆÛË ƒ¶. ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ ˘¿Ú¯Ô˘Ó ÈÛ¯˘Ú¿ ÎÚÈÙ‹ÚÈ· ∏Ã∫ ‰È·ÊÔÚÔÔ›ËÛ˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·fi ·ıÔÏÔÁÈ΋ “ÛȈËÏ‹” ·Ó¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜ ‚·Ï‚›‰·˜ (35), fï˜ ·˘Ùfi ‰ÂÓ Â›Ó·È Î·ıÔÏÈο ·Ô‰ÂÎÙfi. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛı› fiÙÈ fiÙ·Ó Ô ·È‰›·ÙÚÔ˜ ˘ÔÙ‡ÂÙ·È ƒ¶ Î·È ‰ÂÓ ·ÎÔ‡ÂÈ Ê‡ÛËÌ· Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌ‹ÛÂÈ Ù· ‰Â‰Ô̤ӷ Ì ÙÔÓ ·È‰ÔηډÈÔÏfiÁÔ. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÎÏÈÓÈ΋˜ ‚·Ï‚ȉ›Ùȉ·˜ ·Ú·Ì¤ÓÂÈ ÌÈ· ÚfiÎÏËÛË Î·È, fiˆ˜ ÚfiÛÊ·Ù· ‰ËÌÔÛȇıËÎÂ: “fiÔ˘ Ô Î›Ó‰˘ÓÔ˜ ƒ¶ Â›Ó·È ÌÂÁ¿ÏÔ˜, Ë ˘ÔÎÏÈÓÈ΋ ηډ›Ùȉ· ı· Ú¤ÂÈ Ó· ˘ÔÏÔÁ›˙ÂÙ·È Ì¤ÚÔ˜ ÙÔ˘ Ê¿ÛÌ·ÙÔ˜ ÙÔ˘ ƒ¶” (19). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ‚·Ï‚›‰ˆÓ, Ô˘ ·Ê·ÈÚ¤ıËÎ·Ó ·fi ¶·È‰È·ÙÚÈ΋ 2008;71:29-37
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·34
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Ã. ∆Ú¿·ÏË Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ∫ÚÈÙ‹ÚÈ· Jones ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÚÂ˘Ì·ÙÈÎÔ‡ ˘ÚÂÙÔ‡ (27) ªÂ›˙ÔÓ· ÎÚÈÙ‹ÚÈ· 1. ∫·Ú‰›Ùȉ· (ÚÔÊ·Ó‹˜ ÎÏÈÓÈο) 2. ¶ÔÏ˘·ÚıÚ›Ùȉ· 3. ÃÔÚ›· 4. ¶ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· 5. ÀÔ‰fiÚÈ· Ô˙›‰È· ∂Ï¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·: 1. ∫ÏÈÓÈο (˘ÚÂÙfi˜, ·ÚıÚ·ÏÁ›·) 2. ∂ÚÁ·ÛÙËÚȷο (Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, ·Ú¿Ù·ÛË ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ PR, ·˘ÍË̤ÓË ∆∫∂, ·˘ÍË̤ÓË CRP)
Ó·ÚÔ‡˜ ·ÛıÂÓ›˜ (ËÏÈΛ· <40 ÂÙÒÓ) ÏfiÁˆ ƒ¶, ›¯·Ó ·˘ÍË̤ÓÔ Ì˘ÍˆÌ·ÙÒ‰Ë ÈÛÙfi (36). √È Ì˘ÍˆÌ·ÙÒ‰ÂȘ ‚·Ï‚›‰Â˜ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ ˘·ÏÔ˘ÚÔÓÈÎfi. ™ÙÂϤ¯Ë ÛÙÚÂÙÔÎfiÎÎˆÓ ˘„ËÏ‹˜ ÏÔÈÌÔÁfiÓÔ˘ ‰‡Ó·Ì˘, ›Û˘, ¤¯Ô˘Ó ·˘ÍË̤ÓÔ ˘·ÏÔ˘ÚÔÓÈÎfi Î·È ·˘Ùfi Èı·Ó¿ Ô‰ËÁ› Û ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÓÙ›‰Ú·ÛË. ∫·Ù¿ Û˘Ó¤ÂÈ·, ı· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ Û ·È‰È¿ ÌÂ Ê·Ú˘ÁÁ›Ùȉ· Î·È ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜ (ÌÂ Ì˘ÍˆÌ·ÙÒ‰ÂȘ ‚·Ï‚›‰Â˜).
£Âڷ›· √È ÂÚÈÛÛfiÙÂÚ˜ ıÂڷ¢ÙÈΤ˜ Ú·ÎÙÈΤ˜ ÁÈ· ÙÔ ƒ¶ ‰ÂÓ ‚·Û›˙ÔÓÙ·È ÛÂ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, ·ÏÏ¿ Û ÎÔÈÓ‹ ÎÏÈÓÈ΋ ·›ÛıËÛË ÁÈ· ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· Ù˘ ·ÁˆÁ‹˜, Ì ·Ú¿ÏÏËÏË ‰È·Ù‹ÚËÛË ˘„ËÏÔ‡ ÂȤ‰Ô˘ ·ÛÊ¿ÏÂÈ·˜. ÷ڷÎÙËÚÈÛÙÈο ÙÔÓ›˙ÂÙ·È Û ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË ÛÙÔ British Medical Journal fiÙÈ “ÙfiÛ· ¯ÚfiÓÈ· ÎÈ ·ÎfiÌ· ‰ÂÓ Í¤ÚÔ˘ÌÂ, ·Ó Ú¤ÂÈ ÛÙÔ ƒ¶ Ó· ¯ÚËÛÈÌÔÔÈԇ̠ÛÙÂÚÔÂȉ‹” (37). ™Â ÌÂÙ··Ó·Ï‡ÛÂȘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ˘ÂÚÔ¯‹ οÔÈ·˜ ıÂڷ›·˜, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Â›ÙˆÛË ƒ∫ 1-10 ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ƒ¶ (23). ∂›Û˘, ‰ÂÓ ‰È·ÈÛÙÒıËΠ˘ÂÚÔ¯‹ Ù˘ ıÂڷ›·˜ Ì ·ÎÂÙ˘ÏÔÛ·ÏÈ΢ÏÈÎfi Û ۇÁÎÚÈÛË Ì ÙÔÓ ÎÏÈÓÔÛÙ·ÙÈÛÌfi (38-40), fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Â›ÙˆÛË ˘ÔÏÂÈfiÌÂÓ˘ ƒ∫, Ô‡Ù ‰È·ÈÛÙÒıËΠ˘ÂÚÔ¯‹ Ù˘ ·ÛÈÚ›Ó˘ ¤Ó·ÓÙÈ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Ô‡ÙÂ Î·È ÙÔ ·ÓÙ›ıÂÙÔ (41,42). ∆¤ÏÔ˜, Û ÚfiÛÊ·ÙË ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ÛÙË ‚·Ú‡ÙËÙ· ÙˆÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÔÍ›·˜ ‚·Ï‚ȉ›Ùȉ·˜ Ô‡Ù ÛÙËÓ Â›ÙˆÛË ¯ÚfiÓÈ·˜ ƒ∫ Û ·Ú·ÎÔÏÔ‡ıËÛË ÂÓfi˜ ¤ÙÔ˘˜ ÌÂÙ¿ ·fi ÙËÓ ÂÓ‰ÔÊϤ‚ÈÔ ¯ÔÚ‹ÁËÛË ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ¤Ó·ÓÙÈ placebo (43). ¶Ú¤ÂÈ Ó· Á›ÓÔ˘Ó ÌÂÁ¿Ï˜, ÔÏ˘ÎÂÓÙÚÈΤ˜, Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ÁÈ· Ó· ηٷ‰ÂȯıÔ‡Ó Ù· Èı·Ó¿ ÔʤÏË ÎÔÚÙÈÎÔÂȉÒÓ Î·È ÙˆÓ Î·ÈÓÔ‡ÚÁÈˆÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÔÍ›· Î·È ¯ÚfiÓÈ· ƒ∫ (19). ∏ ·ÏÈ¿ Ô‰ËÁ›· ÁÈ· ÎÏÈÓÔÛÙ·ÙÈÛÌfi “ʈٛ˙ÂÙ·È” ·fi Ó¤· ‰Â‰Ô̤ӷ, Û‡Ìʈӷ Ì ٷ ÔÔ›·, Ë ·Ú¯È΋ ‚Ï¿‚Ë ÛÙÔÓ ƒ¶ ·ÊÔÚ¿ ÙÔ ‰·ÎÙ‡ÏÈÔ Î·È ÙȘ ¯ÔÚ‰¤˜, Ë ‰Â Ù¿ÛË ÛÙȘ ¯ÔÚ‰¤˜ Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ›ÂÛ˘ ÛÙËÓ Paediatriki 2008;71:29-37
¶›Ó·Î·˜ 4. ∞ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ Ì Ô͇ ÚÂ˘Ì·ÙÈÎfi ˘ÚÂÙfi (22) 1. ∞ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ ‹ Û·ÏÈ΢ÏÈÎÒÓ Ì¤¯ÚÈ ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ƒ¶ 2. ∫ÏÈÓÔÛÙ·ÙÈÛÌfi˜, Ô˘ ·Ó ˘¿Ú¯ÂÈ Î·Ú‰›Ùȉ·, ·Ú·Ù›ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 4 ‚‰ÔÌ¿‰Â˜ 3. ∞ÓÙÈ‚›ˆÛË ÁÈ· ÂÎÚ›˙ˆÛË ÙÔ˘ ÛÙÚÂÙÔÎfiÎÎÔ˘ 4. ∞ÓÙÈÊÏÂÁÌÔÓÒ‰Ë: ·) ∞ÛÈÚ›ÓË 100 mg/kg/24ˆÚÔ Û 4-5 ‰fiÛÂȘ ÁÈ· 2 ‚‰ÔÌ¿‰Â˜, Ì›ˆÛË Û 60-70 mg/kg/24ˆÚÔ ÁÈ· ¿ÏϘ 3-6 ‚‰ÔÌ¿‰Â˜ ™ËÌ›ˆÛË: π. ™˘¯Ófi˜ ¤ÏÂÁ¯Ô˜ ÂȤ‰ˆÓ ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÔÓÙ·È ıÂڷ¢ÙÈο ›‰· Î·È Ó· ·ÔʇÁÂÙ·È Ë ÙÔÍÈÎfiÙËÙ· ππ. ∂› ·ÏÏÂÚÁ›·˜, Ó·ÚÔͤÓË 10-20 mg/kg/24ˆÚÔ ‚) ¶Ú‰ÓÈ˙fiÓË 1-2 mg/kg/24ˆÚÔ (̤ÁÈÛÙË: 80 mg) ÁÈ· 2-3 ‚‰ÔÌ¿‰Â˜, Ì›ˆÛË 20-25% οı ‚‰ÔÌ¿‰· ˘fi Û˘Á¯ÔÚ‹ÁËÛË ·ÛÈÚ›Ó˘ ™ËÌ›ˆÛË: ∏ Ú‰ÓÈ˙fiÓË ¤¯ÂÈ ¤Ó‰ÂÈÍË Û ÂÚÈÙÒÛÂȘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ‹ ÌË ·ÓÙ·fiÎÚÈÛ˘ ÛÙ· Û·ÏÈ΢ÏÈο Á) ªÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË ÂÓ‰ÔÊÏ‚›ˆ˜ ™ËÌ›ˆÛË: ∏ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË ÂӉ›ÎÓ˘Ù·È Û ηٷÛÙ¿ÛÂȘ ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹ 5. ÃÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Û ·ÛıÂÓ›˜ Ì ÂÌ̤ÓÔ˘Û· ÔÍ›· ηډ›Ùȉ· Ì ÛÔ‚·Ú‹ ηډȷ΋ ·Ó¿ÚÎÂÈ·
·ÚÈÛÙÂÚ‹ ÎÔÈÏ›· (44). ™˘ÓÂÒ˜, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙËÓ ›ÂÛË ›Ûˆ˜ ·ÏÏ¿˙ÂÈ Ë ÔÚ›· ÙÔ˘ ƒ¶ ÏfiÁˆ Ù˘ Û˘Ó·ÎfiÏÔ˘ı˘ ÂÏ¿ÙÙˆÛ˘ Ù˘ Ù¿Û˘ ÛÙȘ ¯ÔÚ‰¤˜. ∏ ÁÓˆÛÙ‹ Ì·˜ Ô‰ËÁ›· ÁÈ· ÎÏÈÓÔÛÙ·ÙÈÛÌfi › ƒ¶, ›Ûˆ˜ ‚ÔËı¿, ÁÈ·Ù› Ë ›ÂÛË Î·È Û˘ÓÂÒ˜ Î·È Ë Ù¿ÛË Â›Ó·È ¯·ÌËÏfiÙÂÚË Û ÎÏÈÓÔÛÙ·ÙÈÛÌfi ·’ fiÙÈ Û ‰Ú·ÛÙËÚÈfiÙËÙ·. ÀÂÓı˘Ì›˙ÂÙ·È, ›Û˘, fiÙÈ Ù· ·È‰È¿ Ì ƒ¶ Î·È ÛÔ‚·Ú‹ ·ÚıÚ›Ùȉ· ÛÙ·ÙÈÛÙÈο ¤¯Ô˘Ó ÏÈÁfiÙÂÚÔ ÛÔ‚·Ú‹ ηډ›Ùȉ·, ÂÂȉ‹, Èı·ÓfiÓ, ηıÒ˜ ÂÚÈÔÚ›˙ÂÙ·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ¿ ÙÔ˘˜, ÂÍ·ÈÙ›·˜ ÙÔ˘ ¿ÏÁÔ˘˜ Ù˘ ·ÚıÚ›Ùȉ·˜, ÂÏ·ÙÙÒÓÂÙ·È Ë ›ÂÛË ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›· Î·È ÙÂÏÈο Ë Ù¿ÛË ÛÙȘ ¯ÔÚ‰¤˜. ŸÏ· Ù· ·Ú·¿Óˆ Ô‰ËÁÔ‡Ó ÛÙÔ Ú·ÎÙÈÎfi ÂÚÒÙËÌ· Ì‹ˆ˜ ¯ÔÚËÁÒÓÙ·˜ Ê¿Ú̷η Ô˘ ÂÏ·ÙÙÒÓÔ˘Ó ÙÔ ÌÂÙ·ÊfiÚÙÈÔ, ¿Ú· ÙËÓ ›ÂÛË Î·È ÙÂÏÈο Î·È ÙËÓ Ù¿ÛË, ÙÚÔÔÔÈËı› Ë ÂͤÏÈÍË Ù˘ ‚·Ï‚ȉ›Ùȉ·˜. √È Û˘ÛÙ¿ÛÂȘ ÙÔ˘ ¶√À ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ô͇ ƒ¶ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ ÂÓ‰ÔÊÏ‚›ˆ˜ ÂӉ›ÎÓ˘Ù·È Û ÂÈΛӉ˘Ó˜ ηٷÛÙ¿ÛÂȘ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜, fï˜ Û ÚfiÛÊ·ÙË ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ‹Ù·Ó ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Û˘ÁÎÚÈÙÈο Ì ÙËÓ p.os ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙fiÓ˘ (45). ∆¤ÏÔ˜, Û ·ÛıÂÓ›˜ Ì ÂÌ̤ÓÔ˘Û· ÔÍ›· ηډ›Ùȉ· Ì ÛÔ‚·Ú‹ ηډȷ΋ ·Ó¿ÚÎÂÈ· Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ¯ÚfiÓÈ· ƒ∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÔÈ· ‹ ÔȘ ‚·Ï‚›‰Â˜ ¿Û¯Ô˘Ó (ÌÈÙÚÔÂȉ‹˜, ·ÔÚÙ‹ ‹ Î·È ÔÈ ‰‡Ô), ·fi ÙÔÓ Ù‡Ô Ù˘
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‚·Ï‚ȉԿıÂÈ·˜ (ÛÙ¤ÓˆÛË, ·Ó¿ÚÎÂÈ· ‹ ÌÈÎÙ‹ ÓfiÛÔ˜), ·fi ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ‚Ï¿‚˘ Î·È ÙȘ ÂÈÙÒÛÂȘ Ù˘ ÛÙË Ì˘Ôηډȷ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ·ÓÙÈÌÂÙÒÈÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·fi ·È‰ÔηډÈÔÏfiÁÔ.
ÃÔÚ›· ∞Ó·ÊÔÚÈο Ì ÙË ıÂڷ›· Ù˘ ¯ÔÚ›·˜, Ô ¶√À (22) ÙÔÓ›˙ÂÈ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ù· ÎÔÚÙÈÎÔÂȉ‹ ˆÊÂÏÔ‡Ó, ÂÓÒ Û ÌÈÎÚ¤˜ ÛÂÈÚ¤˜ ηٷÁÚ¿ÊÔÓÙ·È ‰Â‰Ô̤ӷ ÁÈ· ÙÔ ·ÓÙ›ıÂÙÔ (46). ∏ ¯ÔÚ‹ÁËÛË ‚·ÏÚÔ˚ÎÔ‡, ηڂ·Ì·˙›Ó˘, ·ÏÔÂÚȉfiÏ˘, ·ÔÙÂÏ› ›Û˘ ·ÓÙÈΛÌÂÓÔ ‰È·ÊˆÓÈÒÓ (47,48). ∂ÈϤÔÓ, ·ÌÊÈÛ‚ËÙÂ›Ù·È Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ (49,50). ∏ ÂÍ·ÛÊ¿ÏÈÛË ‹Û˘¯Ô˘ Î·È ‹ÚÂÌÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ıˆÚÂ›Ù·È fiÙÈ ‚ÔËı¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÙȘ ‹È˜ ÂÚÈÙÒÛÂȘ ¯ÔÚ›·˜ (19). ∞fi Ú·ÎÙÈ΋˜ ÏÂ˘Ú¿˜, Ì ‰Â‰Ô̤Ó˜ fiϘ ÙȘ ·Ú·¿Óˆ ·ÓÙÈÊ¿ÛÂȘ, Ë Û˘ÓÂÚÁ·Û›· Ó¢ÚÔÏfiÁÔ˘ Ì ÙÔÓ ·È‰›·ÙÚÔ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ıÂڷ¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ªÂÙ·ÛÙÚÂÙÔÎÔÎÎÈ΋ ·ÚıÚ›Ùȉ· (ª™∞) ∆· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ª™∞, Ô˘ ÙË ‰È·ÊÔÚÔÔÈÔ‡Ó ·fi ÙÔÓ ÎÏ·ÛÈÎfi ƒ¶, ›ӷÈ: Ë ·Ú·ÌÔÓ‹ Ù˘ ·ÚıÚ›Ùȉ·˜ ÁÈ· ÌÂÚÈÎÔ‡˜ Ì‹Ó˜, Ô ÌË ÌÂÙ·Ó·ÛÙ¢ÙÈÎfi˜ ¯·Ú·ÎÙ‹Ú·˜, Ë ÂÓȯڋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÌË ÛÙÂÚÈÓÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë, ηıÒ˜ Î·È Ë ˘ÂÚÔ¯‹ ÙÔ˘ Á˘Ó·ÈΛԢ ʇÏÔ˘ ÌÂٷ͇ ÙˆÓ ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ. ¢ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ΛӉ˘ÓÔ ÁÈ· ηډ›Ùȉ·, ·Ú¿ Ù·‡Ù·, ·Ó·Ê¤ÚÔÓÙ·È ·ÛıÂÓ›˜ Ô˘ ·ÚÔ˘Û›·Û·Ó ƒ∫ ηٿ ÙËÓ ÂÚ›Ô‰Ô ·Ú·ÎÔÏÔ‡ıËÛ˘. ¶ÚÔÊ·ÓÒ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ˘‹ÚÍ ‰È·ÁÓˆÛÙÈ΋ ·ÛÙÔ¯›· Î·È ÂÚfiÎÂÈÙÔ ÁÈ· ƒ¶ Î·È fi¯È ª™∞ (51). ¶ÚÔÙ›ÓÂÙ·È ÁÈ· ÙË ª™∞ ÚÔʇϷÍË Ì i.m ÂÓÈÎÈÏ›ÓË ÁÈ· ¤Ó· ¯ÚfiÓÔ Û ÏËı˘ÛÌÔ‡˜ Ì ¯·ÌËÏfi ΛӉ˘ÓÔ ÁÈ· ƒ¶ Î·È ÁÈ· ¤ÓÙ ¯ÚfiÓÈ· Û ÏËı˘ÛÌÔ‡˜ Ì ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ƒ¶ (19,22). ∫·Ù·Ï‹ÁÔÓÙ·˜, ÛËÌÂÈÒÓÔ˘Ì fiÙÈ, ·ÚfiÙÈ Û¯ÂÙÈ˙fiÌÂÓÔ˜ Ì ÌÈÎÚԂȷ΋ Ïԛ̈ÍË, Ô ƒ¶ 2.500 ¯ÚfiÓÈ· ·fi ÙËÓ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ·fi ÙÔÓ πÔÎÚ¿ÙË (53) ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÊÔÚ¿ ÙËÓ ·ÁÎfiÛÌÈ· ÎÔÈÓfiÙËÙ· Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ. ª¤¯ÚÈ Ó· ‰ÔıÔ‡Ó ÔÚÈÛÙÈÎfiÙÂÚ˜ χÛÂȘ ̤ۈ ÂÌ‚ÔÏÈ·ÛÌÒÓ ‹ ¿ÏÏ˘ ·Ú¤Ì‚·Û˘, ÂÈ‚¿ÏÏÂÙ·È Ë Â·ÁÚ‡ÓËÛË ÙˆÓ ÁÈ·ÙÚÒÓ, ÒÛÙÂ Ë ÓfiÛÔ˜ Ó· ·ÔʇÁÂÙ·È Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ‹ ¤ÛÙˆ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Î·È Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Î·Ù¿ ÙÔÓ ÚÔÛÊÔÚfiÙÂÚÔ ÙÚfiÔ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic fever in an endemic region: a guide to the susceptibility of the population? Epidemiol Infect 2000; 124:239-244.
2. Steer AC, Kado J, Colquhoun S, Noonan S, Babitu T. Awareness of rheumatic heart disease. Lancet 2006;367: 2118. 3. Tani LY, Veasy LG, Minich LL, Shaddy RE. Rheumatic fever in children younger than 5 years: is the presentation different? Pediatrics 2003;112:1065-1068. 4. Majeed HA, Batnager S, Yousof AM, Khuffash F, Yusuf AR. Acute rheumatic fever and the evolution of rheumatic heart disease: a prospective 12 year follow-up report. J Clin Epidemiol 1992;45:871-875. 5. Shulman ST. Streptococcal infections. In: Stevens D, Kaplan E, editors. Clinical aspects, microbiology and molecular pathogenesis. New York: Oxford University Press; 2000. p. 76-101. 6. Stollerman GH. Rheumatic fever in the 21st century. Clin Infect Dis 2001;33:806-14. 7. McDonald M, Currie BJ, Carapetis JR. Acute rheumatic fever: a chink in the chain that links the heart to the throat? Lancet Infect Dis 2004;4:240-245. 8. Haidan A, Talay SR, Rohde M, Sriprakash KS, Currie BJ, Chhatwal GS. Pharyngeal carriage of group C and group G streptococci and acute rheumatic fever in an Aboriginal population. Lancet 2000;356:1167-1169. 9. Kalia A, Bessen DE. Presence of streptococcal pyrogenic exotoxin A and C genes in human isolates of group G streptococci. FEMS Microbiol Lett 2003;219:291-295. 10. Kalia A, Enright MC, Spratt BG, Bessen DE. Directional gene movement from human-pathogenic to commensallike streptococci. Infect Immun 2001;69:4858-4869. 11. Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev 2000;13:470-511. 12. Lymbury RS, Olive C, Powell KA, Good MF, Hirst RG, LaBrooy JT, et al. Induction of autoimmune valvulitis in Lewis rats following immunization with peptides from the conserved region of group A streptococcal M protein. J Autoimmun 2003;20:211-217. 13. Kamblock J, Payot L, Iung B, Costes P, Gillet T, Le Goanvic C, et al. Does rheumatic myocarditis really exists? Systematic study with echocardiography and cardiac troponin I blood levels. Eur Heart J 2003;24:855-862. 14. Galvin JE, Hemric ME, Ward K, Cunningham MW. Cytotoxic mAb from rheumatic carditis recognizes heart valves and laminin. J Clin Invest 2000;106:217-224. 15. Cunningham MW. Autoimmunity and molecular mimicry in the pathogenesis of post-streptococcal heart disease. Front Biosci 2003;8:s533-543. 16. Roberts S, Kosanke S, Terrence Dunn S, Jankelow D, Duran CM, Cunningham MW. Pathogenic mechanisms in rheumatic carditis: focus on valvular endothelium. J Infect Dis 2001;183:507-511. 17. Guilherme L, Kalil J. Rheumatic fever: from sore throat to autoimmune heart lesions. Int Arch Allergy Immunol 2004;134:56-64. 18. Pichichero ME. Group A streptococcal vaccines. JAMA 2004;292:738-739. 19. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet 2005;366:155-168. 20. Robertson KA, Volmink JA, Mayosi BM. Antibiotics for the primary prevention of acute rheumatic fever: a metaanalysis. Eur Heart J 2004;25:527. 21. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group ¶·È‰È·ÙÚÈ΋ 2008;71:29-37
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Ã. ∆Ú¿·ÏË Î·È Û˘Ó.
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Quiz 1. ∏ ˘„ËÏfiÙÂÚË Â›ÙˆÛË ÙÔ˘ ƒ¶ ·Ú·ÙËÚ›ٷÈ: ·. ™Ù· ·È‰È¿ ÚÈÓ ·fi ÙËÓ ÂÊ˂›· ‚. ™Â ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Á. ™Â Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ 2. √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ƒ∫ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜: ·. ™Ù· ·È‰È¿ ‚. ™ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Á. ™ÙÔ˘˜ ÂÓ‹ÏÈΘ 3. ∏ ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁ›Ùȉ·˜ ›ӷÈ: ·. 10 Ë̤Ú˜ ‚. 1 ‚‰ÔÌ¿‰· Á. 2-3 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ 4. ŒÊË‚Ô˜ 17 ÂÙÒÓ Ì ‹È· ·Ó¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜, ÏfiÁˆ ÔͤԘ ƒ¶, ÂÊfiÛÔÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÂÈ ¿ÏÏÔ ÂÂÈÛfi‰ÈÔ, ı· Ú¤ÂÈ Ó· ¿ÚÂÈ ÚfiÏË„Ë: ·. °È· ÌÈ· 5ÂÙ›· ‚. °È· ÌÈ· 10ÂÙ›· Á. ø˜ ÙÔ 25Ô ¤ÙÔ˜ ‰. ∂Ê’ fiÚÔ˘ ˙ˆ‹˜ 5. ¶ÔÈfi˜ ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ¤¯ÂÈ ÙÂÎÌËÚȈ̤ÓÔ ƒ¶: ·. 9¯ÚÔÓÔ˜ Ì ÈÛÙÔÚÈÎfi ÔÛÙÚ·ÎÈ¿˜, Ô˘ ¤¯ÂÈ ¯ÔÚ›· Î·È Ì¤ÙÚÈ· ·Ó¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜ ‚. 9¯ÚÔÓÔ˜ Ì ¯ÔÚ›· Î·È ‹È· ·Ó¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜ Á. ∫·È ÔÈ ‰‡Ô ‰. ∫·Ó¤Ó·˜ 6. 10¯ÚÔÓÔ˜ Ì ˘ÚÂÙfi, ·ÚıÚ·ÏÁ›·, Û˘Ìو̷ÙÔÏÔÁ›· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È Û˘ÛÙÔÏÈÎfi ʇÛËÌ· 3/6 ÛÙËÓ ÎÔÚ˘Ê‹ Ì ¤ÎÙ·ÛË ÛÙË Ì·Û¯¿ÏË ¤¯ÂÈ ÙÂÎÌËÚȈ̤ӷ ƒ¶, ÂÊfiÛÔÓ Û˘Ó˘¿Ú¯ÂÈ: ·. ∞˘ÍË̤ÓË ∆∫∂ ‚. ™ÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· ÚÔ 2-3 ‚‰ÔÌ¿‰ˆÓ Á. ∞˘ÍË̤ÓË CRP ‰. ¶·Ú¿Ù·ÛË ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ PR ÛÙÔ ∏∫° √È ÛˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÛÙË ÛÂÏ›‰· 61
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∫ÏÈÓÈ΋ Î·È ÌÔÚȷ΋ ÌÂϤÙË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2 Û ·È‰È¿ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË ÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ∆Ì‹Ì· π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ™Ù·˘ÚԇϷ æÒÓË psonistavroula@gmail.com ∆Ì‹Ì· π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
™. æÒÓË, J. Traeger-Synodinos, Ã. ™ÔÊÔÎÏ¤Ô˘˜, ™. ∫›ÙÛÈÔ˘-∆˙¤ÏË, ∞. ª·‡ÚÔ˘, ∂. ∫·Ó·‚¿Î˘, Œ. ºÚ˘Û›Ú· ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ªÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ MECP2 ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ 60-95% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û˘Ó‰ÚfiÌÔ˘ Rett (RS), ÌÈ·˜ Ê˘ÏÔÛ‡Ó‰ÂÙ˘, ÂÈÎÚ·ÙËÙÈ΋˜, Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ‰È·Ù·Ú·¯‹˜ Ô˘ ÂËÚ¿˙ÂÈ Î˘Ú›ˆ˜ ÎÔÚ›ÙÛÈ·. ∆Ô ÎÏ·ÛÈÎfi RS ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ÚÒÈÌË ·Ó¿Ù˘ÍË, ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi „˘¯ÔÎÈÓËÙÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È ÛÙ·‰È·Î‹ ¤Ó·ÚÍË ÌÈÎÚÔÎÂÊ·Ï›·˜, ÂÓÒ ·Ú·ÙËÚÔ‡ÓÙ·È ·ÚÎÂÙ¤˜ ¿Ù˘Â˜ ÌÔÚʤ˜. ∆Ô MECP2 ÂÌϤÎÂÙ·È Â›Û˘ Û ÌÈ· ÔÈÎÈÏ›· Ê·ÈÓÔÙ‡ˆÓ Ì „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË (æ∫∫), fiˆ˜ Ê˘ÏÔÛ‡Ó‰ÂÙË ÔÈÎÔÁÂÓ‹ æ∫∫ Î·È ÂÈÎfiÓ˜ ÔÌÔÈ¿˙Ô˘Û˜ Ì ۇӉÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘-à (FXS) Î·È Û‡Ó‰ÚÔÌÔ Angelman (AS). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È ÙÔ˘ Ê¿ÛÌ·ÙÔ˜ ÙˆÓ MECP2 ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi Î·È Ë Û˘Û¯¤ÙÈÛË ÁÔÓÔÙ‡Ô˘-Ê·ÈÓÔÙ‡Ô˘. ª¤ıÔ‰ÔÈ: ∞ӷχıËÎ·Ó Ù· ÂÍfiÓÈ· 3 Î·È 4 Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ Ì ÎÏ›ÛË ·Ô‰È·Ù·ÎÙÈÎÔ‡ (DGGE - Denaturant Gradient Gel Electrophoresis), ¿ÌÂÛÔ ÚÔÛ‰ÈÔÚÈÛÌfi ·ÏÏËÏÔ˘¯›·˜ DNA Î·È GAPPCR ÛÂ: ∞. 124 ·È‰È¿ (102 ·ÁfiÚÈ·-22 ÎÔÚ›ÙÛÈ·) Î·È 41 ·È‰È¿ (14 ·ÁfiÚÈ·-27 ÎÔÚ›ÙÛÈ·) Ì ʷÈÓfiÙ˘Ô ·ÚfiÌÔÈÔ Ì FXS Î·È AS ·ÓÙ›ÛÙÔȯ·, ·ÏÏ¿ ·ÚÓËÙÈÎfi ÌÔÚÈ·Îfi ¤ÏÂÁ¯Ô, µ. 23 Î·È 25 ÎÔÚ›ÙÛÈ· Ì ÎÏ·ÛÈÎfi Î·È ¿Ù˘Ô RS, ·ÓÙ›ÛÙÔȯ· Î·È °. 11 ·ÁfiÚÈ· Ô˘ ÚÔÛ‹Ïı·Ó Ì Èı·Ófi RS. ŒÁÈÓ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÁÈ· Û˘Û¯¤ÙÈÛË ÙÔ˘ ÎÏÈÓÈÎÔ‡ score ‚·Ú‡ÙËÙ·˜ (Kerr, 2001) Ì ÙÔÓ Ù‡Ô ÙˆÓ MECP2 ÌÂÙ·ÏϿ͈Ó. ∞ÔÙÂϤÛÌ·Ù·: ªÂÙ·ÏÏ¿ÍÂȘ ·ÓȯÓ‡ıËÎ·Ó Û 78,3% Î·È 20% ÂÚÈÙÒÛÂȘ ÎÏ·ÛÈÎÔ‡ Î·È ¿Ù˘Ô˘ RS, ·ÓÙ›ÛÙÔȯ·. ŒÓ· ·ÁfiÚÈ ·ÚÔ˘Û›·Û ÙË ÌÂÙ¿ÏÏ·ÍË p.R106W Î·È ¤Ó· ¿ÏÏÔ ÌÂÁ¿ÏË ÁÔÓȉȷ΋ ·Ó·Î·Ù¿Ù·ÍË Ô˘ ··ÈÙ› ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. 7,3% Î·È 2,4% ÙˆÓ FXS Î·È AS ÔÌ¿‰ˆÓ, ·ÓÙ›ÛÙÔȯ·, ›¯·Ó ÌÂÙ·ÏÏ¿ÍÂȘ, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·˜ Î·È Ì›· ÂÚ›ÙˆÛË Ê˘ÏÔÛ‡Ó‰ÂÙ˘ ÔÈÎÔÁÂÓÔ‡˜ æ∫∫. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ·Ó¿Ï˘ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2 ·Ú¤¯ÂÈ ¤Ó· ηٿÏÏËÏÔ ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô ÁÈ· ÙÔ RS Î·È Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ ¤Ú¢ӷ Ù˘ ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘.
§¤ÍÂȘ ÎÏÂȉȿ: MECP2, Û‡Ó‰ÚÔÌÔ Rett, ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË.
Clinical studies and analysis of the MECP2 gene in children with mental retardation in the Greek population Medical Genetics, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital, Athens, Greece Correspondence: Stavroula Psoni psonistavroula@gmail.com Medical Genetics, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital Thivon & Levadias St., 115 27, Athens, Greece
S. Psoni, J. Traeger-Synodinos, C. Sofokleous, S. Kitsiou-Tzeli, A. Mavrou, E. Kanavakis, H. Fryssira Abstract Background: Mutations in the MECP2 gene (methyl-CpG-binding protein 2) are responsible for 70-95% of cases of Rett syndrome (RS), an X-linked dominant neurodevelopmental disorder, affecting mostly girls. Classical RS is characterized by normal early development, followed by psychomotor regression and gradual onset of microcephaly, although variable atypical forms are also observed. MECP2 has also been implicated in a variety of other mental retardation (MR) phenotypes, including X-linked Mental Retardation (XLMR), Fragile-X Syndrome (FXS) -like and Angelman Syndrome (AS) -like phenotypes. The aim of the study was: a) To evaluate the incidence and spectrum of MECP2 mutations in children with RS and atypical MR; b) ∆o make phenotype-genotype correlation. Methods: Exons 3 and 4 were analysed using Denaturant Gradient Gel Electrophoresis, sequencing and GAP-PCR in: A. 124 FXS-like children (102 males-22 females) and 41 AS-like children (14 males-27 females) negative for gene variation at FXS and AS loci, respectively; B. 23 classic and 25 atypical RS girls; C. 11 boys referred with possible RS. Statistical analysis included correlation of the RS clinical severity score (Kerr, 2001) with MECP2 mutations, and frequency of MECP2 mutations in the various patient categories. Results: Mutations were detected in 78.3% of classic and 20% of atypical RS cases respectively. One boy carried the p.R106W mutation, and another boy showed a large rearrangement requiring further characterization. Amongst AS- and FXS-like cases, 7.3% and 2.4% had MECP2 mutations respectively, including an XLMR case. Conclusions: MECP2 gene analysis provides an appropriate diagnostic tool for RS and contributes further information for research into MR.
Key words: MECP2, Rett syndrome, mental retardation. Paediatriki 2008;71:38-47
∞’ ÈڤÌÂÈÔ Œ·ıÏÔ, 45Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 25-27 ª·˝Ô˘ 2007, ÷ÏÎȉÈ΋
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¶›Ó·Î·˜ 1·. ∞Ó·Óˆ̤ӷ ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÙÔ ÎÏ·ÛÈÎfi RS (3)
™˘ÓÙÔÌÔÁڷʛ˜ RS ª∂CP2 Kb ªµP MBD TRD NLS æ∫∫ AS FXS PCR DGGE CDKL5 HDAC Ac æ∫∂ ¶∫ πVF EEG SMA II XLMR ··
Rett Syndrome ªethyl-CpG-Binding-Protein 2 Kilobases Methyl-Binding-Proteins Methyl-Binding-Domain Transcription-Repression-Domain Nuclear-Localization-Signal æ˘¯ÔÎÈÓËÙÈ΋ ∫·ı˘ÛÙ¤ÚËÛË Angelman Syndrome Fragile-X Syndrome Polymerase Chain Reaction Denaturant Gradient Gel Electrophoresis Cyclin Dependent Kinase-Like 5 Histone Deacetylase Acetyl æ˘¯ÔÎÈÓËÙÈ΋ ∂ͤÏÈÍË ¶ÂÚ›ÌÂÙÚÔ˜ ∫ÂÊ·Ï‹˜ In Vitro Fertilization ∂lectroencephalogram Spinal Muscular ∞trophy II X-Linked Mental Retardation ·ÌÈÓÔͤ·
∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ Rett (RS) Â›Ó·È Ê˘ÏÔÛ‡Ó‰ÂÙË, ÂÈÎÚ·ÙËÙÈ΋, ÎÏËÚÔÓÔÌÈ΋, Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹ Î·È ·ÔÙÂÏ› ÙË ‰Â‡ÙÂÚË ·ÈÙ›· ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ ÛÙ· ÎÔÚ›ÙÛÈ· ÌÂÙ¿ ÙÔ Û‡Ó‰ÚÔÌÔ Down (1). ∂ÌÊ·Ó›˙ÂÙ·È ÛÔÚ·‰Èο ÌÂ Û˘¯ÓfiÙËÙ· 1/10.00015.000 ÁÂÓÓ‹ÛÂȘ ·ÁÎÔÛÌ›ˆ˜ (2). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÔÌ·Ï‹ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË Ì¤¯ÚÈ ÙÔ˘˜ 6-12 Ì‹Ó˜ ˙ˆ‹˜, ÂÓ Û˘Ó¯›· ÛÙ·‰È·Î‹ ÌÈÎÚÔÎÂÊ·Ï›·, ·ÏÈÓ‰ÚfiÌËÛË ÙˆÓ ·ÔÎÙËıÂÈÛÒÓ ÁÓˆÛÙÈÎÒÓ Î·È ÎÈÓËÙÈÎÒÓ ÈηÓÔÙ‹ÙˆÓ Ì ÂÁηٿÛÙ·ÛË Ù˘ÈÎÒÓ ÛÙÂÚÂÔÙ˘ÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙˆÓ ¯ÂÚÈÒÓ, ·˘ÙÈÛÙÈÎÒÓ Ù¿ÛÂˆÓ Î·È ‰˘ÛÚ·Í›·˜ ‚¿‰ÈÛ˘. ªÂÙ¿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘, Û˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È ÂÚ›Ô‰Ô˜ ÛÙ·ÛÈÌfiÙËÙ·˜. ™˘ÓÔ‰¤˜ ÂΉËÏÒÛÂȘ Â›Ó·È ÂÂÈÛfi‰È· ¿ÓÔÈ·˜-˘¤ÚÓÔÈ·˜, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈΤ˜ ·ÓˆÌ·Ï›Â˜, Û·ÛÌÔ›, ˘ÂÚÙÔÓ›·-·ÙÚÔÊ›· ¿ÎÚˆÓ Î·È ÛÎÔÏ›ˆÛË (3) (¶›Ó·Î·˜ 1·). ∏ ÌÔÚȷ΋ ‚Ï¿‚Ë ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘
∫Ï·ÛÈÎfi RS ªÂ›˙ÔÓ· ∫ÚÈÙ‹ÚÈ· 1. º˘ÛÈÔÏÔÁÈ΋ ÚÔÁÂÓÓËÙÈ΋ Î·È ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ 2. º˘ÛÈÔÏÔÁÈ΋ æ∫∂ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ 3. º˘ÛÈÔÏÔÁÈ΋ ¶∫ ÛÙË Á¤ÓÓËÛË 4. ∂È‚Ú¿‰˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ Ù˘ ¶∫ 5. ∞ÒÏÂÈ· ÛÎfiÈÌˆÓ ÎÈÓ‹ÛÂˆÓ ¯ÂÚÈÒÓ ÌÂٷ͇ 6 ÌËÓÒÓ Î·È 2 1/2 ÂÙÒÓ 6. ™ÙÂÚÂÔÙ˘›Â˜ ¯ÂÚÈÒÓ 7. ∂ÍÂÏÈÛÛfiÌÂÓË ÎÈÓËÙÈ΋ ·fiÛ˘ÚÛË, ‰˘ÛÎÔÏ›· ÂÈÎÔÈÓˆÓ›·˜, ·ÒÏÂÈ· ·ÔÎÙËı¤ÓÙÔ˜ ÏfiÁÔ˘ Î·È ÁÓˆÛÙÈο ÂÏÏ›ÌÌ·Ù· ∂Ï¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ· 1. ¢È·Ù·Ú·¯‹ ·Ó·ÓÔ‹˜ ηٿ ÙËÓ ÂÁÚ‹ÁÔÚÛË 2. ∆ÚÈÛÌfi˜ Ô‰fiÓÙˆÓ 3. ∞ÓÒÌ·ÏÔ ÚfiÙ˘Ô ‡ÓÔ˘ ·fi ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô 4. ∞ÓÒÌ·ÏÔ˜ Ì˘˚Îfi˜ ÙfiÓÔ˜ Û˘Ó‰ÂfiÌÂÓÔ˜ Ì ·ÙÚÔÊ›· Î·È ‰˘ÛÙÔÓ›· 5. ¶ÂÚÈÊÂÚÈΤ˜ ·ÁÁÂÈÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ 6. ¶ÚÔԉ¢ÙÈ΋ ·ʈÛË-ÛÎÔÏ›ˆÛË 7. ∫·ı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ 8. ÀÔÙÚÔÊÈο ÌÈÎÚ¿ Î·È ÎÚ‡· ¿ÎÚ· ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ 1. ŒÓ‰ÂÈÍË ·ÔıËÛ·˘ÚÈÛÙÈ΋˜ ÓfiÛÔ˘ Î·È ÔÚÁ·ÓÔÌÂÁ·Ï›· 2. ∫·Ù·ÚÚ¿ÎÙ˘, ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· ‹ Î·È ·ÙÚÔÊ›· ÔÙÈÎÔ‡ Ó‡ÚÔ˘ 3. πÛÙÔÚÈÎfi ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘ ÚÔ- ‹ Î·È ÌÂÙ·ÁÂÓÓËÙÈο 4. ∂Ȃ‚·ÈˆÌ¤ÓË ÌÂÙ·‚ÔÏÈ΋ ‰È·Ù·Ú·¯‹ ‹ Ó¢ÚÔÂÎÊ˘ÏÈÛÙÈ΋ ÓfiÛÔ˜ 5. ∂›ÎÙËÙË Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ÏfiÁˆ ÂÁÎÂÊ·ÏÈÎÔ‡ ÙÚ·‡Ì·ÙÔ˜ ‹ Ïԛ̈͢ ∞·ÈÙÔ‡ÓÙ·È Î·È Ù· 6 Ì›˙ÔÓ· ÎÚÈÙ‹ÚÈ· ‹ 4/6 Ì›˙ÔÓ· Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ÂÏ¿ÛÛÔÓ·
ÁÔÓȉ›Ô˘ MECP2 (ªethyl-CpG-Binding-Protein 2), ÙÔ ÔÔ›Ô ¤¯ÂÈ ¯·ÚÙÔÁÚ·ÊËı› ÛÙÔ ÁÂÓÂÙÈÎfi ÙfiÔ Ãq28 (4). Œ¯ÂÈ Ì¤ÁÂıÔ˜ 76 kb Î·È ·ÔÙÂÏÂ›Ù·È ·fi 4 ÂÍfiÓÈ·, Ù· ÔÔ›· ˘fiÎÂÈÓÙ·È Û ÂÓ·ÏÏ·ÎÙÈÎfi Ì¿ÙÈÛÌ·, ‰›‰ÔÓÙ·˜ Á¤ÓÂÛË Û ‰‡Ô ÚˆÙÂ˚ÓÈΤ˜ ÈÛÔÌÔÚʤ˜ (ªeCP2∞-486 ··, ªeCP2B-449 ··) (∂ÈÎfiÓ· 1). ∏ ªeCP2B ΢Úȷگ› ÛÙÔ˘˜ ÂÁÎÂÊ·ÏÈÎÔ‡˜ ÈÛÙÔ‡˜ Î·È Â˘ı‡ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ÁÈ· ÙÔ Ê·ÈÓfiÙ˘Ô (5). ¡LS (·· 255-271)
ªBD TRD (·· 78-162) (·· 207-310)
5'
1
2
3
C-terminus (·· 311-486)
∂ÍfiÓÈÔ 4
3'
∂ÈÎfiÓ· 1. To ÁÔÓ›‰ÈÔ MECP2 Î·È ÔÈ ÏÂÈÙÔ˘ÚÁÈÎÔ› ÙÔÌ›˜ ÙÔ˘. MBD: ªethyl-Binding-Domain, TRD: Transcription-Repression-Domain, NLS: Nuclear-Localisation-Signal, C-Terminus: ηڂÔ͢ÙÂÏÈÎfi ¿ÎÚÔ, ··: ·ÌÈÓÔͤ·. ¶·È‰È·ÙÚÈ΋ 2008;71:38-47
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™. æÒÓË Î·È Û˘Ó.
∆Ô MECP2 ·Ó‹ÎÂÈ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ªBP (Methyl-Binding Proteins), Û˘Ó‰¤ÂÙ·È Û ÌÂı˘ÏȈ̤Ó˜ ·ÏÏËÏÔ˘¯›Â˜ DNA Î·È Î·Ù·ÛÙ¤ÏÏÂÈ ÙË ÁÔÓȉȷ΋ ÌÂÙ·ÁÚ·Ê‹ (6). ¶ÂÚȤ¯ÂÈ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁÈÎÔ‡˜ ÙÔÌ›˜ ªBD, ∆RD Î·È ¡LS (EÈÎfiÓ· 2). ∞Ú¯Èο ıˆڋıËΠÁÂÓÈÎfi˜ ÌÂÙ·ÁÚ·ÊÈÎfi˜ ηٷÛÙÔϤ·˜. øÛÙfiÛÔ, ÂÚ¢ÓËÙÈο ‰Â‰Ô̤ӷ ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Û˘Ó‰¤ÂÙ·È ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ÁÔÓ›‰È·-ÛÙfi¯Ô˘˜ ÛÙÔÓ ÂÁΤʷÏÔ, Ú˘ıÌ›˙ÔÓÙ·˜ ÙËÓ ¤ÎÊÚ·Û‹ ÙÔ˘˜ (7,8). ™Â ÎÏÈÓÈÎfi ›‰Ô, oÈ ÂΉËÏÒÛÂȘ ÙÔ˘ RS Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Û˘Ó·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ Î·È ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ Ó¢ÚÒÓˆÓ (9). ∞Ô̤ÓÂÈ Ó· ·Ô‰Âȯı› ÔÈ· Â›Ó·È ·ÎÚÈ‚Ò˜ Ù· ÁÔÓ›‰È·-ÛÙfi¯ÔÈ Î·È Ò˜ ηıÔÚ›˙Ô˘Ó ÙËÓ ·Ó¿Ù˘ÍË Î·È ‰È·Ù‹ÚËÛË ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ Û˘Ó¿„ˆÓ. ªÂÙ¿ÏÏ·ÍË ÙÔ˘ MECP2 ‰ÂÓ ÈÛÔ‰˘Ó·Ì› ¿ÓÙ· Ì ‰È¿ÁÓˆÛË RS. Œ¯Ô˘Ó ·Ó·ÁÓˆÚÈÛı› ·ÚÎÂÙ¤˜ ¿Ù˘Â˜ ÌÔÚʤ˜ RS: ·. ÓÂÔÁÓÈÎfi˜ Ù‡Ô˜ Ì ۷ÛÌÔ‡˜, ‚. Û˘ÁÁÂÓ‹˜ Ù‡Ô˜, Á. ÂÎÙÚˆÙÈ΋ ÌÔÚÊ‹, ‰. ‰È·Ù‹ÚËÛ˘ ÛÙÔȯ›ˆÓ ÏfiÁÔ˘ Î·È Â. fi„ÈÌ˘ ·ÏÈÓ‰ÚfiÌËÛ˘ (10) (¶›Ó·Î·˜ 1‚). ªÂÙ·ÏÏ¿ÍÂȘ ¤¯Ô˘Ó ·Ú·ÙËÚËı› Î·È Û ÏËıÒÚ· Ê·ÈÓÔÙ‡ˆÓ Ì „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË (æ∫∫) Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì RS, fiˆ˜ Û ·ÛıÂÓ›˜ Ì ÂÈÎfiÓ· Û˘Ó‰ÚfiÌÔ˘ Angelman (∞S), ÌË Û˘Ó‰ÚÔÌÈ΋ Ê˘ÏÔÛ‡Ó‰ÂÙË æ∫∫ Î·È ·˘ÙÈÛÙÈο ÛÙÔȯ›· (11-13). MECP2 ÌÂÙ·ÏÏ¿ÍÂȘ Û ·ÁfiÚÈ· ıˆÚÔ‡ÓÙ·Ó ¤ˆ˜ ÚfiÛÊ·Ù· ı·Ó·ÙËÊfiÚ˜. øÛÙfiÛÔ, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ ·ÁÔÚÈÒÓ ÌÂ: i) ÛÔ‚·-
Sin3A
¶›Ó·Î·˜ 1‚. ∞Ó·Óˆ̤ӷ ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÙÔ ¿Ù˘Ô RS (3) ÕÙ˘Ô RS ∫‡ÚÈ· ÎÚÈÙ‹ÚÈ· 1. ªÂ›ˆÛË ‹ ·ÒÏÂÈ· ÙˆÓ ÈηÓÔÙ‹ÙˆÓ ÙˆÓ ¯ÂÚÈÒÓ 2. ªÂ›ˆÛË ‹ ·ÒÏÂÈ· ÙˆÓ ÏÂÎÙÈÎÒÓ ÈηÓÔÙ‹ÙˆÓ 3. ™ÙÂÚÂÔÙ˘›Â˜ ¯ÂÚÈÒÓ 4. ªÂ›ˆÛË ‹ ·ÒÏÂÈ· ÙˆÓ ÈηÓÔÙ‹ÙˆÓ ÂÈÎÔÈÓˆÓ›·˜ 5. ∂È‚Ú¿‰˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ Ù˘ ¶∫ ·fi ÙËÓ ÚÒÈÌË ·È‰È΋ ËÏÈΛ· 6. ¶·ÏÈÓ‰ÚfiÌËÛË ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ÌÂÚÈ΋ ‚ÂÏÙ›ˆÛË ÀÔÛÙËÚÈÎÙÈο ÎÚÈÙ‹ÚÈ· 1. ∞ӈ̷ϛ˜ ·Ó·ÓÔ‹˜ 2. ªÂÙˆÚÈÛÌfi˜ ÎÔÈÏ›·˜ ‹ Î·È Î·Ù¿ÔÛË ·¤Ú· 3. ∆ÚÈÛÌfi˜ Ô‰fiÓÙˆÓ 4. ∞ÓÒÌ·ÏË ÎÈÓËÙÈÎfiÙËÙ· 5. ∫‡ÊˆÛË ‹ Î·È ÛÎÔÏ›ˆÛË 6. ∞ÙÚÔÊ›· οو ¿ÎÚˆÓ 7. ∫Ú‡·, ·Ô¯ÚˆÌ·ÙÈṲ̂ӷ Î·È Û˘Ó‹ıˆ˜ ˘ÔÙÚÔÊÈο fi‰È· 8. ¢È·Ù·Ú·¯¤˜ ‡ÓÔ˘ 9. ∞ÓÂÍ‹ÁËÙ· ÂÂÈÛfi‰È· ÎÚ·˘ÁÒÓ ‹ Á¤ÏˆÙÔ˜ 10. ∂ÌÊ·ÓÒ˜ ÌÂȈ̤ÓË Â˘·ÈÛıËÛ›· ÛÙÔÓ fiÓÔ 11. ŒÓÙÔÓË ‚ÏÂÌÌ·ÙÈ΋ ·ʋ ‹ Î·È ÚÔۋψÛË ∞·ÈÙÔ‡ÓÙ·È 3 ·fi Ù· 6 ·ÚÈ· Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 5 ˘ÔÛÙËÚÈÎÙÈο ÎÚÈÙ‹ÚÈ·
Ú‹ ÓÂÔÁÓÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ii) ÂÈÎfiÓ· ·ÚfiÌÔÈ· Ì RS, ÔÊÂÈÏfiÌÂÓË Û ̈۷˚ÎÈÛÌfi ‹ ˘ÂÚ¿ÚÈıÌÔ X ¯ÚˆÌfiۈ̷ Î·È iii) ÌË ÂȉÈ΋, ÌË ÂÍÂÏÈÛÛfiÌÂÓË æ∫∫ (14,15).
HDAC1 HDAC2
MeCP2 ∞c
¡ËÛ›‰Â˜ CpG
∞c ∞c ∞c
∞c
ÃÚˆÌfiۈ̷ Ã
HDAC1 Sin3A HDAC2 MeCP2
¡ËÛ›‰Â˜ CpG
ÃÚˆÌfiۈ̷ Ã
∂ÈÎfiÓ· 2. H MeCP2 Û˘Ó‰¤ÂÙ·È Ì¤Ûˆ ÙÔ˘ ÙÔ̤· MBD Û ÂȉÈΤ˜ ÌÂı˘ÏȈ̤Ó˜ ÓËÛ›‰Â˜ ÙÔ˘ DNA (CpG-ÓËÛ›‰Â˜), ÂÓÂÚÁÔÔÈÒÓÙ·˜ ¤Ó· ‚ÔËıËÙÈÎfi ηٷÛÙ·ÏÙÈÎfi ÌfiÚÈÔ, ÙÔ mSin3A, ÙÔ ÔÔ›Ô Û˘Ó‰¤ÂÙ·È Î·ÙfiÈÓ Ì ÙÔÓ ÙÔ̤· TRD. ∆Ô Û‡ÌÏÂÁÌ· ·˘Ùfi ÂÓÂÚÁÔÔÈ› ÙȘ ·Ô·ÎÂÙ˘Ï¿Û˜ ÙˆÓ ÈÛÙÔÓÒÓ 2 Î·È 2 (HDAC1, HDAC2), Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ô·ÎÂÙ˘Ï›ˆÛË ÙˆÓ ˘ÚËÓÈÎÒÓ ÈÛÙÔÓÒÓ Î·È ÙË Û˘Ì›ÂÛË ÙÔ˘ DNA Û ·ÓÂÓÂÚÁ‹ ÂÙÂÚԯڈ̷ٛÓË, ÌÂ Û˘Ó¤ÂÈ· ÙË ‰È·ÎÔ‹ Ù˘ ÌÂÙ·ÁÚ·Ê‹˜. Ac: ∞ÎÂÙ˘ÏÔÌ¿‰Â˜. Paediatriki 2008;71:38-47
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∫ÏÈÓÈ΋ Î·È ÌÔÚȷ΋ ÌÂϤÙË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2
¶›Ó·Î·˜ 2. ¶·Ú¿ÌÂÙÚÔÈ Ô˘ ÂÍÂÙ¿˙ÔÓÙ·È ÛÙËÓ Îϛ̷η ÎÏÈÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ RS 1. ¶ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ (¶∫) ηٿ ÙË Á¤ÓÓËÛË 2. ¶ÚÒÈÌË ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË (0-12 ÌËÓÒÓ) 3. ¶·ÚÔ‡Û· (¶∫) 4. µ¿ÚÔ˜ 5. ⁄„Ô˜ 6. ª˘˚Îfi˜ ÙfiÓÔ˜ 7. ∫·Ù¿ÛÙ·ÛË ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ 8. ™˘Áο̄ÂȘ ·ÚıÚÒÛÂˆÓ 9. ∞‰Ú‹ ÎÈÓËÙÈÎfiÙËÙ· - µ¿‰ÈÛË 10. ™ÙÂÚÂfiÙ˘Â˜ ÎÈÓ‹ÛÂȘ ¯ÂÚÈÒÓ 11. ÕÏϘ ·ÎÔ‡ÛȘ ÎÈÓ‹ÛÂȘ (ÙÚfiÌÔ˜, ‰˘ÛÙÔÓ›·, ¯ÔÚ›·, ·ı¤ÙˆÛË) 12. ∂ÎÔ‡ÛÈ· ¯Ú‹ÛË ÙˆÓ ¯ÂÚÈÒÓ 13. ¢˘ÛÎÔÏ›· ÛÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙˆÓ Ì˘ÒÓ Ù˘ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈ΋˜ ÂÚÈÔ¯‹˜ - ™›ÙÈÛË 14. ¢È·ÓÔËÙÈ΋ ÈηÓfiÙËÙ· - πηÓfiÙËÙ· Ì¿ıËÛ˘ 15. §fiÁÔ˜ 16. ∂ÈÏË„›· - ™·ÛÌÔ› 17. ¢È·Ù·Ú·Á̤ÓÔ˜ ·Ó·Ó¢ÛÙÈÎfi˜ Ú˘ıÌfi˜ (˘ÂÚ·ÂÚÈÛÌÔ›-¿ÓÔȘ) 18. ¶ÂÚÈÊÂÚÈ΋ ΢ÎÏÔÊÔÚ›· ¿ÎÚˆÓ 19. ¢È·Ù·Ú·¯¤˜ Û˘Ó·ÈÛı‹Ì·ÙÔ˜ (·Ó·›ÙÈ· Á¤ÏÈ·, ÎÚ·˘Á¤˜, ÎÏ¿Ì·Ù·) 20. ¢È·Ù·Ú·¯‹ ÚÔÙ‡Ô˘ ‡ÓÔ˘
ÓÔÙ‡Ô˘˜ Î·È ‰. ÌÂϤÙ˘ ÙˆÓ ·ÁÔÚÈÒÓ Ì ÌÂÙ·ÏÏ¿ÍÂȘ. ∏ ÛËÌ·Û›· Ù˘ ÌÂϤÙ˘ ¤ÁÎÂÈÙ·È, ›Û˘, ÛÙËÓ ÚÔÛ¿ıÂÈ· ÁÈ· ηٷÓfiËÛË Î¿ÔÈˆÓ ·fi Ù· ·›ÙÈ· Ù˘ ÎÏÈÓÈο ·‰È¢ÎÚ›ÓÈÛÙ˘ æ∫∫.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆Ô ˘ÏÈÎfi ·ÔÙ¤ÏÂÛ·Ó ‰‡Ô ÔÌ¿‰Â˜ ·È‰ÈÒÓ, ηÙfiÈÓ ¤ÁÁÚ·Ê˘ Û˘ÁηٿıÂÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜. ™ÙËÓ ÚÒÙË ÔÌ¿‰· ÂÈϤÁËÛ·Ó ·Ó·‰ÚÔÌÈο 180 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ·fi ·È‰È¿ Ô˘ ›¯·Ó ÂÏÂÁ¯ı› ÌÔÚȷο ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ÛÙÔ ∆Ì‹Ì· °ÂÓÂÙÈ΋˜ ÁÈ· Û‡Ó‰ÚÔÌÔ Fragile-X (FÃS) (n=137) Î·È AS (n=43) Ì ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù·. ∂ÎÙfi˜ ·fi ÙËÓ æ∫∫, ¤Ú ӷ ˘¿Ú¯ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ·fi Ù· ·Ú·Î¿Ùˆ ÎÚÈÙ‹ÚÈ·: ·. Ê·ÈÓfiÙ˘Ô˜ ·ÚfiÌÔÈÔ˜ Ì FÃS ‹ AS, ‚. Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ¯ˆÚ›˜ ‰ÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÂÁÎÂÊ¿ÏÔ˘ ÛÙÔ Ó¢ÚÔ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, Á. ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ì ‹ ¯ˆÚ›˜ Û·ÛÌÔ‡˜, ‰. ·Ô˘Û›· ÌÂÈ˙fiÓˆÓ ÌÔÚÊÔÏÔÁÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È Â. ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi æ∫∫. ªÔÚȷ΋ ·Ó¿Ï˘ÛË Î·Ù¤ÛÙË ‰˘Ó·Ù‹ Û 124 ·È‰È¿ (102 ·ÁfiÚÈ·-22 ÎÔÚ›ÙÛÈ·) Ù˘ FÃS-ÔÌ¿‰·˜. 16/124 ·È‰È¿ ›¯·Ó ·‰¤ÏÊÈ· Ì æ∫∫, Ù· ÔÔ›· ÂϤÁ¯ıËηÓ. ™ÙËÓ AS-ÔÌ¿‰· ÌÔÚȷ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Û 41 ·È‰È¿ (14 ·ÁfiÚÈ·-27 ÎÔÚ›ÙÛÈ·). ™˘ÓÔÏÈο, ÂϤÁ¯ıËÎ·Ó 165 ·ÛıÂÓ›˜, ËÏÈΛ·˜ 1-27 ÂÙÒÓ. ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰· ÂÍÂÙ¿ÛıËÎ·Ó ·È‰È¿ ÚÔÛÂÚ¯fiÌÂÓ· Ì ‰È¿ÁÓˆÛË RS ÙÔ ‰È¿ÛÙËÌ· 2000-2006 (n=69). §fiÁÔ˘˜
µ·ıÌÔÏÔÁ›·: 3 ‚·ıÌ›‰Â˜ ‚·Ú‡ÙËÙ·˜ (2, 1, 0) Score: 0-40
H ÂÎÙÂÓ‹˜ ·Ó¿Ï˘ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2 ·fi ÙÔ 1999 ¤ˆ˜ Û‹ÌÂÚ· ¤¯ÂÈ ·Ôηχ„ÂÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi 255 ÌÂÙ·ÏÏ¿ÍÂȘ (16). √È ÔÎÙÒ Û˘¯ÓfiÙÂÚ˜ ηχÙÔ˘Ó ÙÔ 65% fiÏˆÓ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ (17). 10% Â›Ó·È ÌÈÎÚ¿ ÂÏÏ›ÌÌ·Ù· (20-150 bp) ÛÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ¿ÎÚÔ, Û ÌÈ· ÂÚÈÔ¯‹ Ì ÔÏÏ¿ ·ӷÏËÙÈο ÛÙÔȯ›· ÌÂٷ͇ ÙˆÓ Îˆ‰ÈÎÔÓ›ˆÓ 1040-1200 Î·È ÂÈÚÚ¤ÂÈ· ÁÈ· ıÚ·‡ÛË ÙÔ˘ DNA (18). ªÔÚȷ΋ ‰È¿ÁÓˆÛË, Ì Ù¯ÓÈΤ˜ ‚·ÛÈṲ̂Ó˜ ÛÙËÓ PCR, ÚÔÛʤÚÂÙ·È ÛÙÔ 60-85% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ˘ ÎÏ·ÛÈÎÔ‡ Î·È ÛÙÔ 30-45% ÙÔ˘ ¿Ù˘Ô˘ RS (16). ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÓÂfiÙÂÚˆÓ ÌÂıfi‰ˆÓ ÁÈ· ·Ó›¯Ó¢ÛË ÌÂÁ¿ÏˆÓ ·Ó·Î·Ù·Ù¿ÍÂˆÓ ·Ó‚¿˙ÂÈ ÙÔ ÔÛÔÛÙfi ‰È¿ÁÓˆÛ˘ ÛÙÔ 95% (19). ∆Ô ÂÍfiÓÈÔ 1 ¤¯ÂÈ ·Ú¯›ÛÂÈ Ó· ÌÂÏÂÙ¿Ù·È ÚfiÛÊ·Ù· Î·È Ê·›ÓÂÙ·È Ó· Û˘Ì‚¿ÏÏÂÈ ÌfiÓÔ Î·Ù¿ 0,5%, ÂÓÒ ÛÙÔ ÂÍfiÓÈÔ 2 ‰ÂÓ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÌÂÙ·ÏÏ¿ÍÂȘ (16). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË ÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi ÙÔ˘ ›‰Ô˘˜ Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔ ÁÔÓ›‰ÈÔ MECP2, Û ·ÛıÂÓ›˜ Ì RS, ·ÏÏ¿ Î·È ¿ÏÏÔ˘˜ Ê·ÈÓÔÙ‡Ô˘˜. ŒÁÈÓ ÚÔÛ¿ıÂÈ·: ·. ηٷÁÚ·Ê‹˜ Ù˘ Û˘¯ÓfiÙËÙ·˜ Î·È Û‡ÁÎÚÈÛ˘ ÙÔ˘ ÚÔÙ‡Ô˘ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ۯ¤ÛË Ì ÙȘ ·Ó·ÊÔÚ¤˜ ·ÁÎÔÛÌ›ˆ˜, ‚. Û˘Û¯¤ÙÈÛ˘ ÁÔÓÔÙ‡Ô˘-Ê·ÈÓÔÙ‡Ô˘, Á. ‰ÈÂÚ‡ÓËÛ˘ Ù˘ ÛËÌ·Û›·˜ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ·È‰È¿ Ì ‰È¿ÊÔÚÔ˘˜ æ∫∫ Ê·È-
º˘ÛÈÔÏÔÁÈÎfi˜ ª·ÚÙ˘Ú·˜
¶·ıÔÏÔÁÈÎfi˜ ª·ÚÙ˘Ú·˜
∞ÛıÂÓ‹˜
ªËÙ¤Ú·
∂ÈÎfiÓ· 3·. DGGE ·Ó¿Ï˘ÛË. ∏ ̤ıÔ‰Ô˜ ‚·Û›˙ÂÙ·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÂÙÂÚÔ‰›ÎÏˆÓˆÓ ÙÌËÌ¿ÙˆÓ DNA, ÂÓfi˜ ÌÂÙ·ÏÏ·Á̤ÓÔ˘ Î·È ÂÓfi˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡, ηıÒ˜ ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ‰È·Ì¤ÛÔ˘ ÂÓfi˜ οıÂÙÔ˘ ËÎÙÒÌ·ÙÔ˜ ÔÏ˘·ÎÚ˘Ï·Ìȉ›Ô˘ Ì ·˘Í·ÓfiÌÂÓË ¯ËÌÈ΋ ÎÏ›ÛË ÂÓfi˜ ·Ô‰È·Ù·ÎÙÈÎÔ‡. ∫·ıÒ˜ ÙÔ ÙÌ‹Ì· ÙÔ˘ DNA ÂÈÛ¤Ú¯ÂÙ·È ÛÙË Û˘ÁΤÓÙÚˆÛË ÂΛÓË ÙÔ˘ ·Ô‰È·Ù·ÎÙÈÎÔ‡ ̤ÛÔ˘, fiÔ˘ Ë ÂÚÈÔ¯‹ ÙÔ˘ Ì ÙÔ ¯·ÌËÏfiÙÂÚÔ ÛËÌÂ›Ô Ù‹Í˘ ·Ú¯›˙ÂÈ Ó· ·Ô‰È·Ù¿ÛÛÂÙ·È, ÙÔ ÙÌ‹Ì· “·ÓÔ›ÁÂÈ” ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ¤Ó· ÌfiÚÈÔ DNA Ì ‰È·ÎÏ·‰ÈṲ̂ÓË ‰ÔÌ‹. ∆Ô ‰È·ÎÏ·‰ÈṲ̂ÓÔ ·˘Ùfi DNA ¤¯ÂÈ ÂÍ·ÈÚÂÙÈο ηı˘ÛÙÂÚË̤ÓË ÎÈÓËÙÈÎfiÙËÙ· ÛÙÔ ÛÙÚÒÌ· ÙÔ˘ ËÎÙÒÌ·ÙÔ˜. ∞Ó ¤Ó· ‰Â›ÁÌ· DNA ÂÚȤ¯ÂÈ ÌÈ· ÛËÌÂȷ΋ ÌÂÙ¿ÏÏ·ÍË ÛÙËÓ ÂÚÈÔ¯‹ ·˘Ù‹, ÙÔ ÛËÌÂ›Ô Ù‹Í˘ Ù˘ ÂÚÈÔ¯‹˜ ı· Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi, ÔfiÙ ÙÔ ÌÂÙ·ÏÏ·Á̤ÓÔ ÌfiÚÈÔ ÙÔ˘ DNA ı· ˘ÔÛÙ› Ù‹ÍË Û ÂÏ·ÊÚ¿ ‰È·ÊÔÚÂÙÈ΋ ıÂÚÌÔÎÚ·Û›· Î·È Û˘ÓÂÒ˜ ı· ¤¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ÛÙÔ ‹Îو̷ Û˘ÁÎÚÈÙÈο Ì ÙÔ DNA ÂϤÁ¯Ô˘. °È· ÙÔ Û¯Â‰È·ÛÌfi ÙˆÓ ÂÈÚ·Ì·ÙÈÎÒÓ Û˘ÓıËÎÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÚfiÁÚ·ÌÌ· Meltmap (21). ¶·È‰È·ÙÚÈ΋ 2008;71:38-47
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·42
42
™. æÒÓË Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ™˘Óı‹Î˜ PCR Î·È DGGE ·Ó¿Ï˘Û˘ ÁÈ· ÙÔ ÂÍfiÓÈÔ 4 ÙÔ˘ MECP2 ÁÔÓȉ›Ô˘ ∆Ì‹Ì·
∞ÏÏËÏÔ˘¯›· ÂÎÎÈÓËÙÒÓ
ª‹ÎÔ˜ (bp) £. ·Ó·‰È¿Ù·Í˘ ∫Ï›ÛË ™˘ÁΤÓÙÚˆÛË £. Ú˘ıÌÈÛÙÈÎÔ‡ Û˘ÁΤÓÙÚˆÛ˘ ·ÎÚ˘Ï·Ì›‰Ë˜ ‰È·Ï‡Ì·ÙÔ˜ DNA (oC) ·Ô‰È·Ù·ÎÙÈÎÔ‡ (%) Û˘Û΢‹˜ (%) DGGE (oC)
4.1
4.1F: 5ã-GC45-TGA CAT TGC TAT GGA GAG CC-3ã 4.1R:5ã-CGT TTG ATC ACC ATG ACC TG-3ã 4.2F:5ã-GC57-AGG GGG CAA GGC TGA GGG GG-3ã 4.2R:5ã-GGT GCT CCT TCT TGG GGG GT-3ã 4.3F:5ã-AGG ACT GAA GAC CTG TAA GAG C-3ã 4.3R: 5ã-GC45-CCC TTT GCT TTG CAA TCC GCT CC-3ã
430
60
20-60
6-12
60
410
60
20-80
6
60
488
56
40-70
6
63
4.2
4.3
*XÚfiÓÔ˜ ËÏÂÎÙÚÔÊfiÚËÛ˘: 18 ÒÚ˜, ∆¿ÛË: 65 Volts
·ÔÎÏÂÈÛÌÔ‡ Û˘ÓÔÏÈο 10 ·È‰ÈÒÓ ·ÔÙ¤ÏÂÛ·Ó: ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÂÁÎÂÊ¿ÏÔ˘, ·ıÔÏÔÁÈÎfi˜ ηڢfiÙ˘Ô˜, ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ∞S Î·È ¤ÏÏÂÈ„Ë ÎÏÈÓÈÎÒÓ ÛÙÔȯ›ˆÓ. ∆· ˘fiÏÔÈ· 59 ·È‰È¿ ηÙËÁÔÚÈÔÔÈ‹ıËÎ·Ó ˆ˜ ÂÍ‹˜: ·. ÎÏ·ÛÈÎfi RS (n1=23 ÎÔÚ›ÙÛÈ·), ‚. ¿Ù˘Ô RS (n2=25 ÎÔÚ›ÙÛÈ·) Î·È Á. ·ÁfiÚÈ· Ì Èı·Ó¤˜ MECP2 ÌÂÙ·ÏÏ¿ÍÂȘ (n3=11). ∏ Ù·ÍÈÓfiÌËÛË Û ÎÏ·ÛÈÎfi ‹ ¿Ù˘Ô RS ¤ÁÈÓ ‚¿ÛÂÈ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ (¶›Ó·Î˜ 1·, 1‚) (3). ™ÙȘ ÔÌ¿‰Â˜ ·-‚ Û˘ÌÏËÚÒıËΠÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÎÏÈÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ (¶›Ó·Î·˜ 2) (20). √È ··ÓÙ‹ÛÂȘ ‚·ıÌÔÏÔÁ‹ıËÎ·Ó Ì 2-1-0. ™ÙËÓ ÔÌ¿‰· ÙˆÓ ·ÁÔÚÈÒÓ ‰ÂÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠۇÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘, ÏfiÁˆ Ù˘ ÌË Î·Ï¿ ÙÂÎÌËÚȈ̤Ó˘ Ê·ÈÓÔÙ˘È΋˜ ÂÈÎfiÓ·˜ Î·È Û·ÓÈfiÙËÙ·˜ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ. ∞fi ÙÔ˘˜ ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Î·Ù¿ ÂÚ›ÙˆÛË ·fi ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘˜, ÌÂÏÂÙ‹ıËΠ‰Â›ÁÌ· DNA ·fi ÂÚÈÊÂÚÈο ÏÂÌÊÔ·ÙÙ·Ú· ·›Ì·ÙÔ˜. ™ÙË Û˘Ó¤¯ÂÈ·, Ù· ÂÍfiÓÈ· 3 Î·È 4 Î·È ÔÈ ·Ú¿Ï¢Ú˜ Û˘Ó‰ÂÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÍÔÓ›ˆÓ-ÂÓ‰ÔÓ›ˆÓ ÂÓÈÛ¯‡ıËÎ·Ó Ì PCR, Ì ¯ÚËÛÈÌÔÔ›ËÛË ÂȉÈο ۯ‰ȷ-
R106W (397C>T)
ÛÌ¤ÓˆÓ ÂÎÎÈÓËÙÒÓ (¶›Ó·Î·˜ 3). ∆· ÚÔ˚fiÓÙ· ÂÓ›Û¯˘Û˘ ÙÔ˘ ÂÍÔÓ›Ô˘ 4 ˘Ô‚Ï‹ıËÎ·Ó Û ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ Ì ÎÏ›ÛË ·Ô‰È·Ù·ÎÙÈÎÔ‡ (DGGE - Denaturant Gradient Gel Electrophoresis), Ë ÔÔ›· Â›Ó·È ÈÛ¯˘Ú‹ ̤ıÔ‰Ô˜ ‰È·ÏÔÁ‹˜, ηıÒ˜ ÂÈÙÚ¤ÂÈ ÙËÓ ÂͤٷÛË ÔÏÏÒÓ ‰ÂÈÁÌ¿ÙˆÓ Ù·˘Ùfi¯ÚÔÓ· Î·È ·ÓȯÓ‡ÂÈ ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 100% (∂ÈÎfiÓ· 3·) (21). ∆Ô ÂÍfiÓÈÔ 3 ‰ÂÓ ·Ó·Ï‡ıËΠ̠DGGE, ÏfiÁˆ Ù¯ÓÈÎÒÓ È‰ÈÔÌÔÚÊÈÒÓ (˘„ËÏ¿ ÛËÌ›· Ù‹Í˘), ηıÈÛÙÒÓÙ·˜ ‰‡ÛÎÔÏÔ ÙÔ Û¯Â‰È·ÛÌfi ÙˆÓ ÂÈÚ·Ì·ÙÈÎÒÓ Û˘ÓıËÎÒÓ. ™Â fiÛ· ÚÔ˚fiÓÙ· ·ÚÔ˘ÛÈ¿ÛıËΠ·ÓÒÌ·ÏÔ ÚfiÙ˘Ô ÌÂÙ·Ó¿ÛÙ¢Û˘ ÛÙË DGGE ·Ó¿Ï˘ÛË, ηıÒ˜ Î·È ÛÙ· ÚÔ˚fiÓÙ· PCR ÙÔ˘ ÂÍÔÓ›Ô˘ 3, ¤ÁÈÓ ¿ÌÂÛÔ˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ·ÏÏËÏÔ˘¯›·˜ DNA (∂ÈÎfiÓ· 3‚). ™Ù· ·ÚÓËÙÈο ‰Â›ÁÌ·Ù· ÙˆÓ RS ·È‰ÈÒÓ (ÎÔÚ›ÙÛÈ· Ì ÎÏ·ÛÈÎfi ‹ ¿Ù˘Ô RS, ·ÁfiÚÈ·) ÂÊ·ÚÌfiÛıËÎÂ Ë Ì¤ıÔ‰Ô˜ GAP-PCR, ˆ˜ ÚÒÙË ÚÔÛ¿ıÂÈ· ·ÔÎ¿Ï˘„˘ ÌÂÁ¿ÏˆÓ ÁÔÓȉȷÎÒÓ ·Ó·Î·Ù·Ù¿ÍˆÓ, Ì ¯ÚËÛÈÌÔÔ›ËÛË 6 ˙¢ÁÒÓ ·ÏÏËÏÔÂÈÎ·Ï˘ÙfiÌÂÓˆÓ ÂÎÎÈÓËÙÒÓ ÁÈ· Ù· ÂÍfiÓÈ· 3-4.
R306C (916C>T)
del 806G (G269fs)
∂ÈÎfiÓ· 3‚. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ·ÏÏËÏÔ˘¯›·˜ DNA (sequencing). ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÂȉÈο ÛÂÛËÌ·Ṳ̂ÓÔÈ Ì ÊıÔÚ›˙Ô˘Û· ¯ÚˆÛÙÈ΋ M13 ÂÎÎÈÓËÙ¤˜ (forward Cy5.0: 5ã-GTAAAACGACGGCCAGT-3ã; reverse Cy5.5: 5ã-CAGGAAACAGCTATGAC-3ã) Î·È ÙÔ kit Ù˘ Visible Genetics. ∏ ·Ó¿Ï˘ÛË ¤ÁÈÓ ÛÙÔ ·˘ÙfiÌ·Ùo Û‡ÛÙËÌ· sequencing Opengeneì (Visible Genetics, Ontario, Canada). Paediatriki 2008;71:38-47
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·43
43
∫ÏÈÓÈ΋ Î·È ÌÔÚȷ΋ ÌÂϤÙË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2
¶›Ó·Î·˜ 4. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÁÔÚÈÒÓ Ì Èı·Ó¤˜ ÌÂÙ·ÏÏ¿ÍÂȘ MECP2 (n=11) ∞ÛıÂÓ‹˜
∏ÏÈΛ·
∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ
ªÂÙ¿ÏÏ·ÍË
1 2
R11 R18
11 ÂÙÒÓ 13 ÌËÓÒÓ
R106W -
3
R23
9 ÌËÓÒÓ
4 5
R29 R39
6 ÂÙÒÓ 14 ÌËÓÒÓ
æ∫∫ ·fi 18 ÌËÓÒÓ, ·˘ÙÈÛÙÈο ÛÙÔȯ›·, ÌÂÁ¿Ï˜ ۈ̷ÙÔÌÂÙÚÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ¡ÂÔÁÓÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (ηÏfi ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi, ‚·ÚËÎÔ˝·, ˘ÂÚÙÔÓ›· ¿ÎÚˆÓ, ·‡ÚÂÙÔÈ Û·ÛÌÔ› ·fi 8,5 ÌËÓÒÓ, æ∫∫, ›ÎÙËÙË ÌÈÎÚÔÎÂÊ·Ï›·) ¡ÂÔÁÓÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (IVF, ‰›‰˘ÌÔ, ÌÈÎÚÔÎÂÊ·Ï›·, ˘ÂÚÙÔÓ›· ¿ÎÚˆÓ˘ÔÙÔÓ›· ÎÔÚÌÔ‡, ÛÙÂÚÂÔÙ˘ÈΤ˜ ÎÈÓ‹ÛÂȘ ÛÙÔÓ ‡ÓÔ, ¤ÓÙÔÓË æ∫∫) ÀÔÙÔÓ›·, æ∫∫, ÛÙÂÚÂfiÙ˘Â˜ ÎÈÓ‹ÛÂȘ ¯ÂÚÈÒÓ ÚÔ˜ ÙÔ ÛÙfiÌ· ªÈÎÚÔÎÂÊ·Ï›·, ˘ÔÙÔÓ›· ÎÔÚÌÔ‡, ÛÙÂÚÂÔÙ˘›Â˜, ÎÈÓËÙÈ΋ ·ÓˆÚÈÌfiÙËÙ· ÛÙ· ¯¤ÚÈ·
6 7 8 9 10
R41 R53 R54 R56 R59
14 ÌËÓÒÓ 5 ÂÙÒÓ 4 ÂÙÒÓ
™‡Ó‰ÚÔÌÔ West, ÛÙÂÚÂÔÙ˘›Â˜, æ∫∫, ÙÚfiÌÔ˜ ÎÔÚÌÔ‡ æ∫∫, Û·ÛÌÔ›, ÌÈÎÚÔÎÂÊ·Ï›· æ∫∫, ∂∂G (+) ¯ˆÚ›˜ Û·ÛÌÔ‡˜, ÛÈÙÈÛÙÈο ÚÔ‚Ï‹Ì·Ù· ˆ˜ ÓÂÔÁÓfi-‚Ú¤ÊÔ˜ æ∫∫, ·˘ÙÈÛÙÈο ÛÙÔȯ›·
11
R65
14 ÌËÓÒÓ
∫Ú›ÛÂȘ ‘∂’, ÛÙÂÚÂÔÙ˘›Â˜, ·Ù·Í›·, æ∫∫, ·˘ÙÈÛÙÈο ÛÙÔȯ›·
ªÂÁ¿ÏË ÁÔÓȉȷ΋ ·Ó·Î·Ù¿Ù·ÍË ÛÙ· ÂÍfiÓÈ· 3, 4 -
∞ÔÙÂϤÛÌ·Ù· ∆· ·ÔÙÂϤÛÌ·Ù· Û˘ÁÎÚ›ıËÎ·Ó Ì ÙËÓ InterRett ËÏÂÎÙÚÔÓÈ΋ ‚¿ÛË MECP2 ÌÂÙ·ÏÏ¿ÍÂˆÓ (http:// mecp2.chw.edu.au/). ªÔÚȷ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓÂ Û˘ÓÔÏÈο Û ¤ÓÙ ÔÌ¿‰Â˜ (n=221): 1. ∫Ï·ÛÈÎfi RS: µÚ¤ıËÎ·Ó ·ÏÏ·Á¤˜ Û 18/23 ÎÔÚ›ÙÛÈ· (78,3%). ™˘ÓÔÏÈο, fï˜, ‚Ú¤ıËÎ·Ó 19 ·ÏÏ·Á¤˜, ηıÒ˜ Ë ·ÛıÂÓ‹˜ R22 ¤ÊÂÚ ÙË ÌÂÙ¿ÏÏ·ÍË p.R168X Î·È ÙÔ ÛȈËÏfi ÔÏ˘ÌÔÚÊÈÛÌfi p.F142F. 12/19 ·ÏÏ·Á¤˜ ‹Ù·Ó ·ÚÂÚÌËÓ‡ÛÈ̘ (missense) (66,7%), 3 ·ÓÂÚÌËÓ‡ÛÈ̘ (nonsense) (16,7%) Î·È 3 Ï·ÈÛÈÔÙÚÔÔÔÈËÙÈΤ˜ (frameshift) (16,7%). ™ÙȘ missense ·ÏÏ·Á¤˜ ÂÚÈÏ‹ÊıËÎ·Ó 10 ÌÂÙ·ÏÏ¿ÍÂȘ Î·È 3 ÚÔ·Ó·ÊÂÚı¤ÓÙ˜ ηÏÔ‹ıÂȘ ÔÏ˘ÌÔÚÊÈÛÌÔ› Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·È Û ·Û˘Ìو̷ÙÈο ̤ÏË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ. O ÔÏ˘ÌÔÚÊÈÛÌfi˜ p.T197M ·Ú·ÙËÚ‹ıËΠÛÙËÓ ·ÛıÂÓ‹ R67, Ô p.L328L ÛÙËÓ R58 Î·È Ô p.F142F ÛÙËÓ R22. E›Û˘, ÛÙËÓ ·ÛıÂÓ‹ R13 Ô˘ ¤·Û¯Â ·fi ‰È·ÁÓˆṲ̂ÓË ÎÏÈÓÈο Î·È ÙÂÎÌËÚȈ̤ÓË ÌÔÚȷο NˆÙÈ·›· ª˘˚΋ ∞ÙÚÔÊ›·, ·ÓȯÓ‡ıËÎÂ Ë p.R306C (22). 2. ÕÙ˘Ô RS: ™ÙËÓ ÔÌ¿‰· ·˘Ù‹ ÂÍÂÙ¿ÛıËÎ·Ó 25 ÎÔÚ›ÙÛÈ·. ∞ÏÏ·Á¤˜ ÛÙË ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· ‚Ú¤ıËÎ·Ó ÛÙÔ 20% (5/25). ¢‡Ô ·ÏÏ·Á¤˜ ·Ó‹Î·Ó ÛÙȘ 8 ÈÔ Û˘¯Ó¤˜ ·ıÔÁfiÓ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÁÈ· ÙÔ ÎÏ·ÛÈÎfi RS (p.R106W, p.R306C). ∏ ÙÚ›ÙË ·ÏÏ·Á‹ ‹Ù·Ó Ô ÛȈËÏfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ p.T299T ÛÙËÓ ·ÛıÂÓ‹ R46 Î·È ÙÔÓ ·Ù¤Ú· Ù˘. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, Ë ÌÂÙ·‚ÔÏ‹ ÛÙË ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· ‰ÂÓ Î·Ù¤ÏËÍ Û ÌÂÙ·‚ÔÏ‹ ÛÙËÓ ·Ï˘Û›‰· ÙˆÓ ·ÌÈÓÔͤˆÓ. ∏ ٤ٷÚÙË ·ÏÏ·Á‹ (R61) ‹Ù·Ó ÌÈ· Ó¤· Û‡ÓıÂÙË ÌÂÙ¿ÏÏ·ÍË (del318insA), ηٿ ÙËÓ ÔÔ›· ·Ú·ÙËÚ‹ıËΠٷ˘Ùfi¯ÚÔÓ· ¤ÏÏÂÈÌÌ· Î·È ¤ÓıÂÛË ‚¿ÛˆÓ. ∏ ·ÛıÂÓ‹˜ ·˘-
-
Ù‹ ·ÚÔ˘Û›·˙ ›Û˘ ÙË ¯ÚˆÌÔÛˆÌÈ΋ ·ÓˆÌ·Ï›· 46,ÃXdel(13)(q11→pter), ÙËÓ ÔÔ›· ›¯Â ÎÏËÚÔÓÔÌ‹ÛÂÈ ·fi ÙÔÓ ·Ù¤Ú· Ù˘. ∏ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË (R64) ÂÌÊ¿ÓÈÛ ·ıÔÏÔÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ GAPPCR, ·Ú¤¯ÔÓÙ·˜ ÂӉ›ÍÂȘ ÁÈ· ÌÂÁ¿ÏË ·Ó·Î·Ù¿Ù·ÍË ÛÙ· ÂÍfiÓÈ· 3-4. ™‡Ìʈӷ Ì ÙËÓ ÔÛÔÙÈ΋ ·˘Ù‹ ̤ıÔ‰Ô ÔÏÏ·Ï·ÛÈ¿˙ÔÓÙ·È Î·È Û˘ÁÎÚ›ÓÔÓÙ·È ÌÂÁ¿Ï· ·ÏÏËÏÔÂÈÎ·Ï˘ÙfiÌÂÓ· ÙÌ‹Ì·Ù· ÙÔ˘ ÁÔÓȉ›Ô˘, ÔfiÙ ·ÔηχÙÔÓÙ·È ÂÏÏ›ÌÌ·Ù· Î·È ÂÓı¤ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ·ÎfiÌË Î·È ÔÏfiÎÏËÚ· ÂÍfiÓÈ·. 3. ∞ÁfiÚÈ· Ì Èı·Ó¤˜ MECP2 ÌÂÙ·ÏÏ¿ÍÂȘ: ™ÙËÓ ÔÌ¿‰· ÙˆÓ ·ÁÔÚÈÒÓ ‚Ú¤ıËÎ·Ó ‰‡Ô ·ÏÏ·Á¤˜ (2/11, 18,1%). ∏ ÚÒÙË ·ÊÔÚÔ‡Û ·ÛıÂÓ‹ 11 ÂÙÒÓ (R11) Î·È ‹Ù·Ó Ù˘È΋ RS ÌÂÙ¿ÏÏ·ÍË (p.R106W). ∆Ô ‰Â‡ÙÂÚÔ ·ÁfiÚÈ (R59), ËÏÈΛ·˜ 4 ÂÙÒÓ, ·ÚÔ˘Û›·Û ·ıÔÏÔÁÈÎfi GAP-PCR (¶›Ó·Î·˜ 4). 4. AS-·ÚÓËÙÈο ‰Â›ÁÌ·Ù·: ∞fi Ù· 41 ‰Â›ÁÌ·Ù·, Â˘Ú‹Ì·Ù· ˘‹ÚÍ·Ó Û ÙÚ›· ÎÔÚ›ÙÛÈ· (7,3%). √È ‰‡Ô ÚÒÙ˜ (RA1, RA28) ›¯·Ó ÙȘ Ù˘ÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ p.R306C Î·È p.R133C, ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ë RA35 ÂÌÊ¿ÓÈÛ de novo ¤ÏÏÂÈÌÌ· 6 ‚¿ÛÂˆÓ ÛÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ¿ÎÚÔ (c.1159del6). 5. FXS-·ÚÓËÙÈο ‰Â›ÁÌ·Ù·: ™Â 3/124 ‰Â›ÁÌ·Ù· (2,4%) ÛËÌÂÈÒıËÎ·Ó ·ÏÏ·Á¤˜. H ÚÒÙË ·ÊÔÚÔ‡Û ÔÈÎÔÁÂÓ‹ ÂÚ›ÙˆÛË æ∫∫. ™˘ÁÎÂÎÚÈ̤ӷ, ÂÚfiÎÂÈÙÔ ÁÈ· ‰‡Ô ·‰¤ÏÊÈ· (FR108), (·ÁfiÚÈ· 5 Î·È 3 ÂÙÒÓ, ·ÓÙ›ÛÙÔȯ·) Ì æ∫∫ Î·È Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÙËÓ ·Û˘Ìو̷ÙÈ΋ ÌËÙ¤Ú· ÙÔ˘˜. ŸÏÔÈ ÂÌÊ¿ÓÈÛ·Ó de novo ¤ÏÏÂÈÌÌ· ÛÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ¿ÎÚÔ (c.1140del86). ∏ ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ¤Ó· ·ÁfiÚÈ (FR120), Ì ÙËÓ p.∆203ª ·ÏÏ·Á‹, Ë ÔÔ›· ıˆÚÂ›Ù·È Î·ÏÔ‹ı˘ ÔÏ˘ÌÔÚÊÈÛÌfi˜. ∏ ÌËÙ¤Ú· ÙÔ˘, fï˜, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∏ ÙÚ›ÙË ÌÂÙ¿ÏÏ·ÍË ¶·È‰È·ÙÚÈ΋ 2008;71:38-47
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·44
44
™. æÒÓË Î·È Û˘Ó.
¶›Ó·Î·˜ 5. ™˘ÁÎÂÓÙÚˆÙÈο ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ªÂÙ·ÏÏ¿ÍÂȘ Î·È ·ÏÏ·Á¤˜ ·ÏÏËÏÔ˘¯›·˜ ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ ∞ÛıÂÓ›˜
∆‡Ô˜ ÌÂÙ¿ÏÏ·Í˘
To̤·˜
∂ÍfiÓÈÔ
¡Ô˘ÎÏÂÔÙȉÈ΋ ·ÏÏ·Á‹
∞ÏÏ·Á‹ ··
∫ÏÈÓÈο ÛÙÔȯ›· - ¶·Ú·ÙËÚ‹ÛÂȘ
R4 R5 R9 R11 R8 R12 R35 RA28 R21 R28 R36 R66 R2 R13
missense missense missense missense missense missense missense missense missense missense missense missense missense missense
MBD MBD MBD MBD MBD MBD MBD MBD MBD MBD MBD MBD TRD TRD
3 3 3 3 4 4 4 4 4 4 4 4 4 4
c.316C>T c.316C>T c.316C>T c.316C>T c.397C>T c.397C>T c.397C>T c.397C>T c.473C>T c.473C>T c.473C>T c.473C>T c.916C>T c.916C>T
R106W R106W R106W R106W R133C R133C R133C R133C T158M T158M T158M T158M R306C R306C
RA1
missense
TRD
4
c.916C>T
R306C
ÕÙ˘Ô RS, 21 ÌËÓÒÓ, ∫Ï·ÛÈÎfi RS, 7,5 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 18 ÌËÓÒÓ, , 11 ÂÙÒÓ, ·˘ÙÈÛÙÈο ÛÙÔȯ›·, æ∫∫ ∫Ï·ÛÈÎfi RS, 3 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 14 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 3 ÂÙÒÓ, AS Ê·ÈÓfiÙ˘Ô˜, 2 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 2,5 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 11 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 3 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 11 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 3 ÂÙÒÓ, ∫Ï·ÛÈÎfi RS, 8,5 ÂÙÒÓ, , ¿Û¯ÂÈ Î·È ·fi SMA II AS Ê·ÈÓfiÙ˘Ô˜, 2 ÂÙÒÓ,
R7
nonsense
4
c.502C>T
R168X
∫Ï·ÛÈÎfi RS, 7 ÂÙÒÓ,
R22
nonsense
4
c.502C>T
R168X
∫Ï·ÛÈÎfi RS, 19 ÌËÓÒÓ,
R1
nonsense
ªÂٷ͇ MBD-TRD ªÂٷ͇ MBD-TRD TRD
4
c.880C>T
R294X
∫Ï·ÛÈÎfi RS, 2 ÂÙÒÓ,
R61
frameshift
MBD
3
c.del318insA
R47 R3 R62
frameshift frameshift frameshift
TRD-NLS C-term. C-term.
4 4 4
RA35 FR36
frameshift frameshift
C-term. C-term.
4 4
c.806delG c.1117del87 c.1159insAGGGG TGGdel41 c.1159del6 c.1163del44
FR108 ·+‚
frameshift
C-term.
4
c.1140del86
R59 R64
ÕÙ˘Ô RS + ¯ÚˆÌÔÛˆÌÈ΋ ·ÓˆÌ·Ï›· ÎÏËÚÔÓÔÌË̤ÓË ·fi ÙÔÓ ·Ù¤Ú·, 4 ÂÙÒÓ, , Ó¤· ÌÂÙ¿ÏÏ·ÍË G269fs P387fs P387fs P388fs
ªÂÁ¿ÏË ÁÔÓȉȷ΋ ·Ó·Î·Ù¿Ù·ÍË ªÂÁ¿ÏË ÁÔÓȉȷ΋ ·Ó·Î·Ù¿Ù·ÍË
∫Ï·ÛÈÎfi RS, 19 ÌËÓÒÓ, ∫Ï·ÛÈÎfi RS, 22 ÌËÓÒÓ, , Ó¤· ÌÂÙ¿ÏÏ·ÍË ∫Ï·ÛÈÎfi RS, 16 ÂÙÒÓ, , ‚·Ú‡Ù·ÙË ÛÎÔÏ›ˆÛË, Ó¤· ÌÂÙ¿ÏÏ·ÍË ∞S Ê·ÈÓfiÙ˘Ô˜, 2 ÂÙÒÓ, , Ó¤· ÌÂÙ¿ÏÏ·ÍË FXS Ê·ÈÓfiÙ˘Ô˜, 5 ÂÙÒÓ, ÙÂÏÈÎfi˜ ÙÚfiÌÔ˜ ¿Óˆ ¿ÎÚˆÓ, , Ó¤· ÌÂÙ¿ÏÏ·ÍË XLMR, ·‰¤ÏÊÈ· , 5 Î·È 3 ÂÙÒÓ, ÌËÙ¤Ú· ·Û˘Ìو̷ÙÈ΋ ÊÔÚ¤·˜ æ∫∫, ·˘ÙÈÛÙÈο ÛÙÔȯ›· ∞Ù˘Ô RS, 2 ÂÙÒÓ,
R67
ÔÏ˘ÌÔÚÊÈÛÌfi˜
ªÂٷ͇ MBD-TRD
4
c.590C>T
T197M
∫Ï·ÛÈÎfi RS, 22 ÌËÓÒÓ, , ·Ù¤Ú·˜ ·Û˘Ìو̷ÙÈÎfi˜ ÊÔÚ¤·˜
FR120
ÔÏ˘ÌÔÚÊÈÛÌfi˜
ªÂٷ͇ MBD-TRD
4
c.608C>T
∆203ª
FXS Ê·ÈÓfiÙ˘Ô˜ (æ∫∫, ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜, Ì·ÎÚ‡ ÚfiÛˆÔ, ÚÔ¤¯ÔÓÙ· ·˘ÙÈ¿), 16 ÂÙÒÓ, , Ë ÌËÙ¤Ú· ‰ÂÓ Ê¤ÚÂÈ ÙËÓ ·ÏÏ·Á‹
R22
™ÈˆËÏfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ ™ÈˆËÏfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜ ™ÈˆËÏfi˜ ÔÏ˘ÌÔÚÊÈÛÌfi˜
ªµD
4
c.426C>T
F142F
KÏ·ÛÈÎfi RS ÌÂ ÌÂÙ¿ÏÏ·ÍË R168X
TRD
4
c.897C>T
∆299∆
C-term.
4
c.984C>T
L328L
∞Ù˘Ô RS, 7 ÂÙÒÓ, , ·Ù¤Ú·˜ ·Û˘Ìو̷ÙÈÎfi˜ ÊÔÚ¤·˜ ∫Ï·ÛÈÎfi RS, , ÔÈ ÁÔÓ›˜ ‰ÂÓ ¤¯Ô˘Ó ÂÏÂÁ¯ı›
R46 R58
·Ú·ÙËÚ‹ıËΠ۠ÎÔÚ›ÙÛÈ (FR36) Î·È ‹Ù·Ó Î·È ·˘Ù‹ de novo ηڂÔ͢ÙÂÏÈÎfi ¤ÏÏÂÈÌÌ· (c.1163del44). ™˘ÓÔÏÈο, ÔÈ ·ÏÏ·Á¤˜ ÛÙÔ ÁÔÓ›‰ÈÔ MECP2 ‹Ù·Ó 32 (27 ÌÂÙ·ÏÏ¿ÍÂȘ, 5 ÔÏ˘ÌÔÚÊÈÛÌÔ›). 14/32 Paediatriki 2008;71:38-47
(43,75%) ·ÏÏ·Á¤˜ ÂÓÙÔ›˙ÔÓÙ·Ó ÂÓÙfi˜ ÙÔ˘ MBD, 5/32 (15,625%) ÂÓÙfi˜ ÙÔ˘ TRD, 4/32 (12,5%) ÛÙË MBD-TRD ÂÚÈÔ¯‹, 1/32 (3,125%) ÛÙË NLS, 6/32 (18,75%) ÛÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ¿ÎÚÔ Î·È 2/32 (6,25%)
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·45
45
∫ÏÈÓÈ΋ Î·È ÌÔÚȷ΋ ÌÂϤÙË ÙÔ˘ ÁÔÓȉ›Ô˘ MECP2
·ÔÙÂÏÔ‡Û·Ó ÌÂÁ¿Ï˜ ·Ó·Î·Ù·Ù¿ÍÂȘ. 18/32 ·ÏÏ·Á¤˜ (56,25%) ·Ó‹Î·Ó ÛÙȘ ÔÎÙÒ Ù˘ÈÎfiÙÂÚ˜ ÌÂ Û˘¯ÓfiÙËÙ˜: p.T158M, p.R106W Î·È p.R133C (4/18, 22,2%), ·ÎÔÏÔ˘ıÔ‡ÌÂÓ˜ ·fi ÙȘ p.R168X Î·È p.R294X Ì ÔÛÔÛÙ¿ 13,7% Î·È 5,5%, ·ÓÙ›ÛÙÔȯ·. ∏ Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ·Ú·ÙËÚ‹ıËΠÛÙÔ ÂÍfiÓÈÔ 4 (27/32, 84,375%) Î·È ÌfiÓÔ 5/32 (15,625%) ÛÙÔ ÂÍfiÓÈÔ 3 (¶›Ó·Î·˜ 5). ŒÁÈÓ ÚÔÛ¿ıÂÈ· ÁÈ· ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ÒÛÙ ӷ ÂÍ·¯ıÔ‡Ó Û˘ÌÂÚ¿ÛÌ·Ù· ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ÁÔÓÔÙ‡Ô˘-Ê·ÈÓÔÙ‡Ô˘. ™ÙËÓ ·Ó¿Ï˘ÛË ÂÚÈÏ‹ÊıËÎ·Ó ÌfiÓÔ ÎÔÚ›ÙÛÈ· fiÏˆÓ ÙˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ ÔÌ¿‰ˆÓ. ¢ËÌÈÔ˘ÚÁ‹ıËÎ·Ó 2 ÔÌ¿‰Â˜, Ë ÚÒÙË Ì ÎÔÚ›ÙÛÈ· Ì ÌÂÙ¿ÏÏ·ÍË (n=24) Î·È Ë ‰Â‡ÙÂÚË Ì ÎÔÚ›ÙÛÈ· Ì ÔÏ˘ÌÔÚÊÈÛÌÔ‡˜ ‹ ·ÚÓËÙÈÎfi ÌÔÚÈ·Îfi ¤ÏÂÁ¯Ô (n=28). √È ÔÌ¿‰Â˜ Û˘ÁÎÚ›ıËÎ·Ó ÌÂٷ͇ ÙÔ˘˜ ·) ˆ˜ ÚÔ˜ ÙËÓ Ù˘ÈÎfiÙËÙ· ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘, Ë ÔÔ›· ÂÎÊÚ¿˙ÂÙ·È Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÌÂÈ˙fiÓˆÓ ÎÚÈÙËÚ›ˆÓ Ô˘ ÏËÚÔ‡ÓÙ·È (0 ¤ˆ˜ 6) Î·È ‚) ˆ˜ ÚÔ˜ ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘, fiˆ˜ ÂÎÊÚ¿˙ÂÙ·È ·fi ÙË ‚·ıÌÔÏÔÁ›· (0 ¤ˆ˜ 40) ÛÙËÓ Îϛ̷η ·ÍÈÔÏfiÁËÛ˘. ∏ ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·ÓÂÍ¿ÚÙËÙ· ‰Â›ÁÌ·Ù· ¤‰ˆÛÂ Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙÔ Â›Â‰Ô ÙÔ˘ 1% (ta=3,54, dfa=50, Pa=0,000438 Î·È tb=4,94, dfb=50, P<0,0001, ·ÓÙ›ÛÙÔȯ·). ™ÙË Û˘Ó¤¯ÂÈ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ÛÔ‚·ÚfiÙËÙ·, Ù· ıÂÙÈο ÎÔÚ›ÙÛÈ· (n=24) Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ¤¯Ô˘Û˜ ̤ÙÚÈ·˜ (score 0-19) Î·È ÌÂÁ¿Ï˘ ‚·Ú‡ÙËÙ·˜ Ê·ÈÓfiÙ˘Ô (score 20-40), ·ÓÙ›ÛÙÔȯ·. √È ÌÂÙ·ÏÏ¿ÍÂȘ ¯ˆÚ›ÛıËÎ·Ó Û ÙÚÂȘ ÔÌ¿‰Â˜: ∞. missense, µ. ÚÒÈÌ· ‰È·ÎfiÙÔ˘Û˜ ÙËÓ ÚˆÙ½ÓË (earlytruncating), ÂÓÙÔÈ˙fiÌÂÓ˜ ¤ˆ˜ Î·È ÙËÓ ÂÚÈÔ¯‹ TRD-NLS Î·È °. late-truncating, οوıÂÓ ÙÔ˘ TRD. ¢ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ Ù‡Ô˘ Ù˘ ÌÂÙ¿ÏÏ·Í˘ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘, Û‡Ìʈӷ Ì ÙË ‰ÔÎÈÌ·Û›· Fisher-ExactTest ÁÈ· ÌÈÎÚfi ·ÚÈıÌfi ‰ÂÈÁÌ¿ÙˆÓ (Pa=0,3535, Pb=0,304). ∂›Û˘, Ë Û‡ÁÎÚÈÛË ÙˆÓ scores ÌÂٷ͇ ÙˆÓ missense Î·È ÙˆÓ nonsense-frameshift ÌÂÙ·ÏϿ͈Ó, Ì ÙË ‰ÔÎÈÌ·Û›· Wilcoxon-Mann-Whitney, ‰ÂÓ ¤‰ˆÛ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (U=31,5 Ì fiÚÈ· 15-53 ÛÙÔ Â›Â‰Ô ÙÔ˘ 5%). °È· ÙȘ ‰ÔÎÈ̷ۛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÏÔÁÈÛÌÈÎfi VassarStats (http:// faculty.vassar.edu/lowry/VassarStats.html).
™˘˙‹ÙËÛË ™ÙÔ ÎÏ·ÛÈÎfi RS, ÙÔ ÔÛÔÛÙfi ÌÂÙ·ÏÏ¿ÍÂˆÓ Î˘Ì·›ÓÂÙ·È ·fi 60 ¤ˆ˜ 95%. ∏ ‰È·Î‡Ì·ÓÛË ·˘Ù‹ ÔÊ›ÏÂÙ·È ÛÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ÂÈÏÔÁ‹˜ ÙˆÓ ÂÍÂÙ·˙ÔÌ¤ÓˆÓ Î·È ÛÙȘ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ÌÔÚȷΤ˜ ÌÂıfi‰Ô˘˜. ¢È¿ÁÓˆÛË ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ 95% Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÔÛÔÙÈ΋˜ ÌÂıfi‰Ô˘ ÁÈ· ·Ó›¯Ó¢ÛË ÌÂÁ¿ÏˆÓ ·Ó·Î·Ù·-
Ù¿ÍÂˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÔÏfiÎÏËÚ· ÂÍfiÓÈ· ‹ Î·È ÙÌ‹Ì·Ù· ·Ú·Î›ÌÂÓˆÓ ÁÔÓȉ›ˆÓ Î·È ÂͤٷÛË ÂÈϤÔÓ Î·È ÙÔ˘ ÂÍÔÓ›Ô˘ 1 (16,19). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ÔÛÔÛÙfi 78,3% Â›Ó·È ÛÙ· Ï·›ÛÈ· ÙÔ˘ Û˘Ó‹ıÔ˘˜ Ê¿ÛÌ·ÙÔ˜ (60-85%) (17). ™ÙÔ ¿Ù˘Ô RS, ÙÔ ÔÛÔÛÙfi ‹Ù·Ó ·ÚÎÂÙ¿ ¯·ÌËÏfi (20%) Û ۯ¤ÛË Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›· (30-45%) (23), ÁÂÁÔÓfi˜ Ô˘ ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÎÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Î·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Î·È ¿ÏÏ· ÁÔÓ›‰È· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ RS, fiˆ˜ ÙÔ CDKL5, Û‡Ìʈӷ Ì ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ (24). ∞Ó ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ¿Ù˘Ô˘ RS ÚÔÛÙ›ıÂÓÙÔ Î·È ÔÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÙˆÓ ÎÔÚÈÙÛÈÒÓ ÙˆÓ ÔÌ¿‰ˆÓ AS-FXS, ÙÔ ÔÛÔÛÙfi ı· ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 31% (9/29). ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÂÓÙÔ›ÛıËΠÛÙÔ ÂÍfiÓÈÔ 4, Û˘ÓÂÒ˜ ı· Ú¤ÂÈ Ó· ÌÂÏÂÙ¿Ù·È ÚÒÙÔ. ∆˘ÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ‚Ú¤ıËÎ·Ó ÛÙÔ 56,25%, ÔÛÔÛÙfi Ô˘ ÚÔÛÂÁÁ›˙ÂÈ ˘¿Ú¯Ô˘Û˜ ÌÂϤÙ˜ (58-72%) (17). ∂ÓÙo‡ÙÔȘ, ‰ÂÓ ÂÎÚÔÛˆ‹ıËÎ·Ó Î·ıfiÏÔ˘ ÔÈ p.R255X Î·È p.R270X (NLS). ∞ÓÙ›ıÂÙ·, ·Ú·ÙËÚ‹ıËÎ·Ó ÔÏϤ˜ MBD ÌÂÙ·ÏÏ¿ÍÂȘ, ¯ˆÚ›˜ οÔÈ· Ó· ÚÔÂÍ¿Ú¯ÂÈ. ™Â ÌÂÁ¿Ï˜ ÏËı˘ÛÌȷΤ˜ ÌÂϤÙ˜ Û˘¯ÓfiÙÂÚ· ·Ó¢ڛÛÎÂÙ·È Ë p.R168X Î·È Ë p.∆158ª. 6/32 (18,75%) ÙˆÓ ·ÏÏ·ÁÒÓ ‹Ù·Ó de novo, fiˆ˜ Ë del318insA ÛÙÔ ÂÍfiÓÈÔ 3 Î·È Ù· ¤ÓÙ ηڂÔ͢ÙÂÏÈο ÂÏÏ›ÌÌ·Ù·, ÙˆÓ ÔÔ›ˆÓ Ë Û˘¯ÓfiÙËÙ· (5/32, 15,625%) Û˘Ì‚¿‰È˙ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›· (10-15%) (16,17). ∏ ÚÔÛ¿ıÂÈ· Û˘Û¯¤ÙÈÛ˘ ÁÔÓÔÙ‡Ô˘-Ê·ÈÓÔÙ‡Ô˘ ·ÚÔ˘Û›·Û ‰˘ÛÎÔϛ˜, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ‰Â›ÁÌ·ÙÔ˜. ¶Ú¿ÁÌ·ÙÈ, ÔÏϤ˜ ÌÂϤÙ˜ Ì ÌÈÎÚ¤˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ ¤¯Ô˘Ó Ô‰ËÁËı› Û ·ÓÙÈÎÚÔ˘fiÌÂÓ· Û˘ÌÂÚ¿ÛÌ·Ù· Î·È ÌË ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù·. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈÎÒ˜ ÈÛ¯˘Ú¿ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ Ù˘ÈÎfiÙËÙ·˜ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘ Ì ÙËÓ Èı·ÓfiÙËÙ· ÌÂÙ¿ÏÏ·Í˘. ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÛıÂÓÒÓ ‚¿ÛÂÈ ÎÚÈÙËÚ›ˆÓ, ÚÔÙÔ‡ ·Ú·ÂÌÊıÔ‡Ó ÁÈ· DNA ·Ó¿Ï˘ÛË, ÒÛÙ ӷ ·˘Í¿ÓÔÓÙ·È ÔÈ Èı·ÓfiÙËÙ˜ ·Ó‡ÚÂÛ˘ ÌÂÙ¿ÏÏ·Í˘. ∏ Û‡ÁÎÚÈÛË ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÌÂٷ͇ ÙÔ˘˜ Î·È Û ۯ¤ÛË Ì ÙÔ ‚·ıÌfi Ê·ÈÓÔÙ˘È΋˜ ‚·Ú‡ÙËÙ·˜ ‰ÂÓ ¤‰ˆÛ ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ·ÔÙÂϤÛÌ·Ù·. ÕÏÏÔÈ ÙÚÔÔÔÈËÙ¤˜ Ù˘ ÁÔÓÔÙ˘È΋˜-Ê·ÈÓÔÙ˘È΋˜ Û˘Û¯¤ÙÈÛ˘ ›ӷÈ: 1. Ô ‚·ıÌfi˜ ·‰Ú·ÓÔÔ›ËÛ˘ ÙÔ˘ X ¯ÚˆÌÔÛÒÌ·ÙÔ˜, Ô ÔÔ›Ô˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ù˘¯·›Ô˜ Ì ·ÔÙ¤ÏÂÛÌ· ÎÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ·, 2. Ë ËÏÈΛ· ÂͤٷÛ˘, ηıÒ˜ Ô Ï‹Ú˘ Ê·ÈÓfiÙ˘Ô˜ ·ÔηχÙÂÙ·È ÌÂÙ¿ Ù· 3-4 ¤ÙË, 3. Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ÂÈϤÁÔÓÙ·È ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ Ê·ÈÓÔÙ˘ÈÎÒÓ scores, 4. Ô ‚·ıÌfi˜ Ù˘ÈÎfiÙËÙ·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘ Î·È 5. ¿ÁÓˆÛÙÔÈ ÂÈÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (25). øÛÙfiÛÔ, ÓÂfiÙÂÚ˜ ÌÂϤÙ˜ ηٷϋÁÔ˘Ó fiÙÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÚÈÓ Î·È ÂÓÙfi˜ Ù˘ NLS ÂÚÈÔ¯‹˜, Ô‰ËÁÔ‡Ó Û ÛÔ‚·Úfi Ê·ÈÓfiÙ˘Ô, ‰ÈfiÙÈ ÂȉÚÔ‡Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ 2008;71:38-47
Pediatri Jan-Feb 08
15-02-08
11:00
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™. æÒÓË Î·È Û˘Ó.
ÈηÓfiÙËÙ· Ù˘ ÚˆÙ½Ó˘ Ó· ÂÈÛ·¯ı› ÛÙÔÓ ˘Ú‹Ó· Î·È Ó· ÚÔÛ‰Âı› ÛÙÔ ÌÂı˘ÏȈ̤ÓÔ DNA (25,26). √È ÌÂÙ·ÏÏ¿ÍÂȘ ¤Ú· ·fi ÙÔ NLS Î·È Ù· ηڂÔ͢ÙÂÏÈο ÂÏÏ›ÌÌ·Ù· ¤¯Ô˘Ó ‹È·, ¿Ù˘Ë ¤ÎÊÚ·ÛË, ηıÒ˜ Ë ÚˆÙ½ÓË ·ÏÒ˜ ¯¿ÓÂÈ Î¿ÔÈ· ÈηÓfiÙËÙ· ÌÂÙ·ÁÚ·ÊÈ΋˜ ηٷÛÙÔÏ‹˜ (26). ∞fi ÙȘ ÎÏ·ÛÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ë p.R133C Î·È Ë p.R306C. ∏ ÚÒÙË Û¯ÂÙ›˙ÂÙ·È Ì ÌÈÎÚ‹ ‚·Ú‡ÙËÙ·, ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ¤Ó·Ú͢ ·ÏÈÓ‰ÚfiÌËÛ˘ Î·È ÎÏÈÓÈ΋ ÔÈÎÈÏÔÌÔÚÊ›· (25,26). ™Â Â›Â‰Ô ÚˆÙÂ˚ÓÈ΋˜ ¤ÎÊÚ·Û˘, ÌÈ· ÌÂϤÙË ¤‰ÂÈÍ in vitro ·ÚfiÌÔÈ· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ R133C Ì ÙË wild-type ÚˆÙ½ÓË (27). ∏ ‰Â‡ÙÂÚË ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ TRD, ofiÙ ‰ÂÓ ·Ú·‚Ï¿ÙÂÈ ÛËÌ·ÓÙÈο ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁÈÎÔ‡˜ ÙÔÌ›˜ Î·È ıˆÚÂ›Ù·È ‹È· (27). ™ÙË ÌÂϤÙË, Ë p.R133C Û˘ÁΤÓÙÚˆÛ ·Ú·‰fi͈˜ ˘„ËÏfi score ‚·Ú‡ÙËÙ·˜ (mean=23,55, SD=1,2714), ·ÏÏ¿ fiˆ˜ Î·È Ë p.R306C ·Ú·ÙËÚ‹ıËÎ·Ó Î·È ÛÙËÓ ¿Ù˘Ë AS-ÔÌ¿‰·. ∆· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ¤Ú¢ӷ ÙÔ˘ MECP2 Û ¿ÏÏÔ˘˜ æ∫∫ Ê·ÈÓÔÙ‡Ô˘˜ ‹Ù·Ó ÂÓı·ÚÚ˘ÓÙÈο, ·Ó Î·È ‰ÂÓ ÂÈÙÚ¤Ô˘Ó ÙË Ì·˙È΋ ÂÊ·ÚÌÔÁ‹ ÂϤÁ¯Ô˘ Û fiÏ· Ù· ·È‰È¿ Ì æ∫∫. ∂›Ó·È ›Ûˆ˜ ÛÎfiÈÌÔ Ó· ÂϤÁ¯ÔÓÙ·È AS-·ÚÓËÙÈο ·È‰È¿, ÏfiÁˆ ÂÈÎ¿Ï˘„˘ Ì ÙÔ RS, fiˆ˜ Ê¿ÓËΠ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ AS-ÔÌ¿‰·˜. ™ÙËÓ FÃS-oÌ¿‰· ÂӉȷʤÚÔÓ ÚÔηÏ› Ë ÔÈÎÔÁÂÓÂȷ΋ ÂÚ›ÙˆÛË. Œ¯Ô˘Ó ‹‰Ë ·Ó·ÊÂÚı› ÂÚÈÛÙ·ÙÈο Ì ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ÌÂÙ¿ÏÏ·ÍË ·fi ·Û˘Ìو̷ÙÈΤ˜ ÌËÙ¤Ú˜-ÊÔÚ›˜ Ì ÌÂÁ¿ÏÔ ‚·ıÌfi X ·‰Ú·ÓÔÔ›ËÛ˘ (28). ø˜ ÚÔ˜ ÙË ÛËÌ·Û›· Ù˘ ÌÂÙ·ÏÏ·Á‹˜ p.T203ª (·ÁfiÚÈ FR120 Ì ·ÚÓËÙÈ΋ ÌËÙ¤Ú·), ÌÂϤÙË Ì ÙÔ ÏÔÁÈÛÌÈÎfi PolyPhen (http://genetics. bwh.harvard.edu/pph/) ‰ÂÓ ÚÔ¤‚Ï„ ηÎÔ‹ıË Â›‰Ú·ÛË ÛÙËÓ ÚˆÙ½ÓË, ˆÛÙfiÛÔ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛı› Ë Â›‰Ú·ÛË ÛÙÔ Ê·ÈÓfiÙ˘Ô. ªÂϤÙ˜ Ì FÃS-·ÚÓËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰›ÓÔ˘Ó ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· Û 0,5-2%, ÔÛÔÛÙ¿ Û˘ÁÎÚ›ÛÈÌ· Ì ÙË ÌÂϤÙË Ì·˜ (12,29). ∞fi ÙËÓ ÔÌ¿‰· ÙˆÓ 11 ·ÁÔÚÈÒÓ, Ô R11 (p.R106W) ›Ûˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛˆÌ·ÙÈÎfi ̈۷˚ÎÈÛÌfi, ˘fiıÂÛË Û˘Ì‚·Ù‹ Ì ÙË Ê·ÈÓÔÙ˘È΋ ÙÔ˘ ÂÈÎfiÓ·, ηıÒ˜ ·Ó ¤ÊÂÚ ÙË ÌÂÙ¿ÏÏ·ÍË Û ϋÚË ÌÔÚÊ‹ ı· ÂÌÊ¿ÓÈ˙ Èı·Ófiٷٷ ÓÂÔÁÓÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Î·È ‰ÂÓ ı· ÂÈ‚›ˆÓÂ. ∏ ÌËÙ¤Ú· ‰ÂÓ ‹Ù·Ó ‰È·ı¤ÛÈÌË ÁÈ· ÂͤٷÛË. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ¤¯ÂÈ ·Ó·ÊÂÚı› Ì›· ·ÎfiÌË ·ÚfiÌÔÈ· ÂÚ›ÙˆÛË (30). ∏ ÂÚ›ÙˆÛË Ì ÙÔ ÌÂÁ¿ÏÔ ¤ÏÏÂÈÌÌ· (R59) ¯Ú‹˙ÂÈ ‰ÈÂÚ‡ÓËÛ˘ Ì ÔÛÔÙÈ΋ ̤ıÔ‰Ô. ∞Ó·ÎÂÊ·Ï·ÈÒÓÔÓÙ·˜, ÙÔ RS ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹ Ô˘ ÁÈ· ÚÒÙË ÊÔÚ¿ ÌÂÏÂÙ‹ıËΠÛÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi. ∏ ‰È¿ÎÚÈÛË Û ÎÏ·ÛÈ΋ Î·È ¿Ù˘Ë ÌÔÚÊ‹ Á›ÓÂÙ·È ‚¿ÛÂÈ ÎÚÈÙËÚ›ˆÓ ÂÈÙÚ¤ÔÓÙ·˜ ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi. øÛÙfiÛÔ, Ë ÌË ÂÎÏ‹ÚˆÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ Paediatriki 2008;71:38-47
ÌÔÚ› Ó· ÂÁ›ÚÂÈ ˘Ô„›· RS, ÏfiÁˆ Ù˘ ÂÌÏÔ΋˜ ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ÁÔÓȉ›Ô˘ Û ÏËıÒÚ· Ê·ÈÓÔÙ‡ˆÓ. ¶ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ‰Ôı› ÛÙ· ·È‰È¿ Ì AS Ê·ÈÓfiÙ˘Ô Î·È ÛÙ· ·È‰È¿ Ì ·‰È¢ÎÚ›ÓÈÛÙË æ∫∫, Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ¯ˆÚ›˜ ‰ÔÌÈΤ˜ ÂÁÎÂÊ·ÏÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È ·Ô˘Û›· ‰˘ÛÌÔÚÊÈÎÒÓ ÛÙÔȯ›ˆÓ. ∂ȉÈÎÔ› Ê·ÈÓfiÙ˘ÔÈ ·ÁÔÚÈÒÓ Ô˘ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Â›Ó·È ‚Ú¤ÊË Ì ÛÔ‚·Ú‹ ÓÂÔÁÓÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ·ÁfiÚÈ· Ì ÛËÌ›· RS, ÌË-ÂȉÈ΋, ÌË-ÂÍÂÏÈÛÛfiÌÂÓË æ∫∫, Û˘Óԉ¢fiÌÂÓË ·fi Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÛÙ· Ï·›ÛÈ· ÔÈÎÔÁÂÓÔ‡˜ Ê˘ÏÔÛ‡Ó‰ÂÙ˘ æ∫∫. ∏ ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ Â›Ó·È ÔχÏÔÎË, ηıÒ˜ 99% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ¤¯ÂÈ de novo ÌÂÙ·ÏÏ¿ÍÂȘ ÏfiÁˆ ̈۷˚ÎÈÛÌÔ‡ ÙˆÓ ÁÔÓ¿‰ˆÓ ÙÔ˘ ·Ù¤Ú· Î·È ÌfiÓÔ 1% Â›Ó·È ÔÈÎÔÁÂÓ›˜ ÂÚÈÙÒÛÂȘ. ™ÙȘ ÂÚÈÙÒÛÂȘ ıÂÙÈÎÒÓ ·ÁÔÚÈÒÓ, Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Î·È Ë ÌËÙ¤Ú·, ‰ÈfiÙÈ Û˘Ó‹ıˆ˜ Â›Ó·È ·Û˘Ìو̷ÙÈÎfi˜ ÊÔÚ¤·˜. °È· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ¿Û¯ÔÓ Ì¤ÏÔ˜, Û˘ÓÈÛÙ¿Ù·È ¤ÏÂÁ¯Ô˜ Ù˘ ÌËÙ¤Ú·˜ Î·È ÚÔÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û ÌÂÏÏÔÓÙÈ΋ ·ËÛË. ∏ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ RS Î·È ÙˆÓ ¿Ù˘ˆÓ ÌÔÚÊÒÓ Î·È Ë ¤Ú¢ӷ Û ÁÔÓȉȷÎfi Â›Â‰Ô Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ÌÔÚÊÒÓ Ù˘ ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi Î·È ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ.
µÈ‚ÏÈÔÁÚ·Ê›·: 1. Kim IJ, Kim YJ, Son BH, Nam SO, Kang HC, Kim HD, et al. Diagnostic mutational analysis of MECP2 in Korean patients with Rett syndrome. Exp Mol Med 2006;38:119-125. 2. Hagberg B, Hagberg G. Rett syndrome: epidemiology and geographical variability. Eur Child Adolesc Psychiatry 1997;6 Suppl 1:5-7. 3. Hagberg B, Hanefeld F, Percy A, Skjeldal O. An update on clinically applicable diagnostic criteria in Rett syndrome. Comments to Rett Syndrome Clinical Criteria Consensus Panel Satellite to European Paediatric Neurology Society Meeting, Baden Baden, Germany, 11 September 2001. Eur J Paediatr Neurol 2002;6:293-297. 4. Amir RE, Van den Veyver IB, Wan M, Tran CQ, Francke U, Zoghbi HY. Rett syndrome is caused by mutations in Xlinked MECP2, encoding methyl-CpG-binding protein 2. Nat Genet 1999;23:185-188. 5. Mnatzakanian GN, Lohi H, Munteanu I, Alfred SE, Yamada T, MacLeod PJ, et al. A previously unidentified MECP2 open reading frame defines a new protein isoform relevant to Rett syndrome. Nat Genet 2004;36:339-341. 6. Van den Veyver IB, Zoghbi HY. Methyl-CpG-binding protein 2 mutations in Rett syndrome. Curr Opin Genet Dev 2000;10:275-279. 7. Horike S, Cai S, Miyano M, Cheng JF, Kohwi-Shigematsu T. Loss of silent-chromatin looping and impaired imprinting of DLX5 in Rett syndrome. Nat Genet 2005;37:31-40. 8. Martinowich K, Hattori D, Wu H, Fouse S, He F, Hu Y, et al. DNA methylation-related chromatin remodeling in activity-dependent BDNF gene regulation. Science 2003;302: 890-893. 9. Shahbazian MD, Antalffy B, Armstrong DL, Zoghbi HY. Insight into Rett syndrome: M∂CP2 levels display tissue-
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and cell-specific differences and correlate with neuronal maturation. Hum Mol Genet 2002;11:115-124. 10. Hagberg BA, Skjeldal OH. Rett variants: a suggested model for inclusion criteria. Pediatr Neurol 1994;11:5-11. 11. Hitchins MP, Rickard S, Dhalla F, Fairbrother UL, de Vries BB, Winter R, et al. Investigation of UBE3A and MECP2 in Angelman syndrome (AS) and patients with features of AS. Am J Med Genet A 2004;125:167-172. 12. Gomot M, Gendrot C, Verloes A, Raynaud M, David A, Yntema HG, et al. MECP2 gene mutations in non-syndromic X-linked mental retardation: phenotype-genotype correlation. Am J Med Genet A 2003;123:129-139. 13. Erlandson A, Hagberg B. MECP2 abnormality phenotypes: clinicopathologic area with broad variability. J Child Neurol 2005;20:727-732. 14. Moog U, Smeets EE, van Roozendaal KE, Schoenmakers S, Herbergs J, Schoonbrood-Lenssen AM, et al. Neurodevelopmental disorders in males related to the gene causing Rett syndrome in females (MECP2). Eur J Paediatr Neurol 2003;7:5-12. 15. Orrico A, Lam C, Galli L, Dotti MT, Hayek G, Tong SF, et al. MECP2 mutation in male patients with non-specific Xlinked mental retardation. FEBS Lett 2000;481:285-288. 16. Philippe C, Villard L, De Roux N, Raynaud M, Bonnefond JP, Pasquier L, et al. Spectrum and distribution of MECP2 mutations in 424 Rett syndrome patients: a molecular update. Eur J Med Genet 2006;49:9-18. 17. Miltenberger-Miltenyi G, Laccone F. Mutations and polymorphisms in the human methyl CpG-binding protein MECP2. Human Mutat 2003;22:107-115. 18. Lee SS, Wan M, Francke U. Spectrum of MECP2 mutations in Rett syndrome. Brain Dev 2001;23 Suppl 1:S138S143. 19. Laccone F, Jünemann I, Whatley S, Morgan R, Butler R, Huppke P, et al. Large deletions of the MECP2 gene detected by gene dosage analysis in patients with Rett syndrome. Hum Mutat 2004;23:234-244. 20. Kerr AM, Nomura Y, Armstrong D, Anvret M, Belichenko PV, Budden S, et al. Guidelines for reporting clinical features in cases with MECP2 mutations. Brain Dev 2001;23: 208-211.
21. Myers RM, Maniatis T, Lerman LS. Detection and localization of single base changes by denaturing gradient gel electrophoresis. Methods Enzymol 1987;155:501-527. 22. Voutoufianakis S, Psoni S, Vorgia P, Tsekoura F, Kekou K, Traeger-Synodinos J, et al. Coinheritance of mutated SMN1 and MECP2 genes in a child with phenotypic features of spinal muscular atrophy (SMA) type II and Rett syndrome. Eur J Paediatr Neurol 2007;11:235-239. 23. Schanen C, Houwink EJ, Dorrani N, Lane J, Everett R, Feng A, et al. Phenotypic manifestations of MECP2 mutations in classical and atypical Rett syndrome. Am J Med Genet A 2004;126:129-140. 24. Mari F, Azimonti S, Bertani I, Bolognese F, Colombo E, Caselli R, et al. CDKL5 belongs to the same molecular pathway of MECP2 and it is responsible for the early-onset seizure variant of Rett syndrome. Hum Mol Genet, 2005;14:1935-1946. 25. Charman T, Neilson TC, Mash V, Archer H, Gardiner MT, Knudsen GP, et al. Dimensional phenotypic analysis and functional categorisation of mutations reveal novel genotype-phenotype associations in Rett syndrome. Eur J Hum Genet 2005;13:1121-1130. 26. Ham AL, Kumar A, Deeter R, Schanen NC. Does genotype predict phenotype in Rett syndrome? J Child Neurol 2005;20:768-778. 27. Yusufzai TM, Wolffe AP. Functional consequences of Rett syndrome mutations on human MECP2. Nucleic Acids Res 2000;28:4172-4179. 28. Dayer AG, Bottani A, Bouchardy I, Fluss J, Antonarakis SE, Haenggeli CA, et al. MECP2 mutant allele in a boy with Rett syndrome and his unaffected heterozygous mother. Brain Dev 2007;29:47-50. 29. Couvert P, Bienvenu T, Aquaviva C, Poirier K, Moraine C, Gendrot C, et al. MECP2 is highly mutated in X-linked mental retardation. Hum Mol Genet 2001;10:941-946. 30. Masuyama T, Matsuo M, Jing JJ, Tabara Y, Kitsuki K, Yamagata H, et al. Classic Rett syndrome in a boy with R133C mutation of MECP2. Brain Dev 2005;27:439-442.
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ORIGINAL ARTICLE
¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ 1 ¶·È‰ÔÓ¢ÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶¿ÙÚ·˜ “∫·Ú·Ì·Ó‰¿ÓÂÈÔ” 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶¿ÙÚ·˜ “∫·Ú·Ì·Ó‰¿ÓÂÈÔ” 3 ∂ȉÈ΋ ¶·ıÔÏfiÁÔ˜ AÏÏËÏÔÁÚ·Ê›·: ¢Ú. πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ Kaleyias@hotmail.com ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶¿ÙÚ·˜ “∫·Ú·Ì·Ó‰¿ÓÂÈÔ” ∂Ú˘ıÚÔ‡ ™Ù·˘ÚÔ‡ 40, ∆.∫. 263 31, ¶¿ÙÚ·
π. ∫·Ï¤ÁÈ·˜1, µ. ƒÔ‡ÏË2, ∞. ∫·Ú·Ù˙·Ê¤ÚË3, ∫. ¢·ÎÔÚÒÓÈ·˜2, ª. ¶··˚ˆ¿ÓÓÔ˘2, £. ¢·Ó›‰Ë1, √. ¢. ¶··ÁˆÚÁ›Ô˘2, ∫. ¶·Ô˘ÙÛ‹2, °. ∫ÚÔÎȉ¿˜2, ¡. ¢È·Ì·ÓÙfiÔ˘ÏÔ˜1 ¶ÂÚ›ÏË„Ë ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ ›وÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È Ë Èı·Ó‹ Û˘Û¯¤ÙÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·˘ÙÒÓ Ì ÔÈΛÏÔ˘˜ ÎÔÈÓˆÓÈÎÔ‡˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ÃÔÚËÁ‹ıËÎÂ Ù˘ÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û 166 ÁÔÓ›˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 6-12 ÂÙÒÓ Ô˘ ÂÈÛΤÊıËÎ·Ó ÙÔ ¡ÔÛÔÎÔÌ›Ô. ∞ÔÙÂϤÛÌ·Ù·: ∂·Ú΋˜ ‡ÓÔ˜ (≥10 ÒÚ˜) ÙȘ ηıËÌÂÚÈÓ¤˜ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ 39% ÙˆÓ ·È‰ÈÒÓ 6-9 ÂÙÒÓ Î·È ÛÙÔ 9% ÙˆÓ ·È‰ÈÒÓ 10-12 ÂÙÒÓ (p=0,0001), ÂÓÒ Ù· ™·‚‚·ÙÔ·Úȷη ÛÙÔ 74% Î·È 57%, ·ÓÙ›ÛÙÔȯ· (p=0,025). ∆Ô 24,7% ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·˙·Ó Û˘ÓÔÏÈο ÙȘ ÂÍ‹˜ ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘: I. ¢˘Û˘ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ (dysomnias): ·ÓÙ›ÛÙ·ÛË Ó· ¿ÂÈ ÛÙÔ ÎÚ‚¿ÙÈ (31%), ·Ó¿ÁÎË ÁÈ· Û˘Óԉ›· ÁÈ· ‡ÓÔ (26%), ËÌÂÚ‹ÛÈ· ˘ÓËÏ›· (14%), Ó˘¯ÙÂÚÈÓ‹ ·Ê‡ÓÈÛË (9,6%), ‡ÓÔ ÛÙÔ ÎÚ‚¿ÙÈ ÙˆÓ ÁÔÓÈÒÓ (9%), ÚÔ¯·ÏËÙfi (7,2%) Î·È ‰˘ÛÎÔÏ›· Ó· ·ÔÎÔÈÌËı› (6,6%). ππ. ¶·Ú·¸ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ (parasomnia): ·Ú·ÌÈÏËÙfi (11,4%), ÙÚÈÛÌfi˜ ‰ÔÓÙÈÒÓ (10,2%), Û˘Á¯˘ÙÈΤ˜ ·Ê˘Ó›ÛÂȘ (7,2%), ÂÊÈ¿ÏÙ˜ (5%), Ú˘ıÌÈΤ˜ ÎÈÓ‹ÛÂȘ (3%), Ó˘¯ÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË (2,4%), Ó˘¯ÙÂÚÈÓfi˜ ÙÚfiÌÔ˜ (1,8%) Î·È ˘ÓÔ‚·Û›· (1,8%). ªfiÓÔ ÙÔ 10% ÙˆÓ ÁÔÓ¤ˆÓ ·Ó·ÁÓˆÚ›˙Ô˘Ó ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯‹˜ ‡ÓÔ˘, ÂÓÒ ÌfiÏȘ ÔÈ ÌÈÛÔ› ·fi ·˘ÙÔ‡˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ ·˘Ùfi ¤¯ÂÈ ‰˘ÛÌÂÓ‹ ›‰Ú·ÛË ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ηıÒ˜ Î·È ÛÙË Û¯ÔÏÈ΋ ·fi‰ÔÛË ÙÔ˘ ·È‰ÈÔ‡. ™˘ÌÂÚ¿ÛÌ·Ù·: ™ÙËÓ ·ÚÔ‡Û· ÛÂÈÚ¿ ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ ‹Ù·Ó Û˘¯Ó¤˜ (25%). ŸÌˆ˜, ÌfiÓÔ ÙÔ 10% ÙˆÓ ÁÔÓ¤ˆÓ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ·È‰È¿ ÙÔ˘˜ ¤¯Ô˘Ó οÔÈÔ Úfi‚ÏËÌ· ÛÙÔÓ ‡ÓÔ. ŒÙÛÈ, Ë ¯Ú‹ÛË Ù˘ÔÔÈË̤ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ı· ÌÔÚÔ‡Û ӷ ‰È¢ÎÔχÓÂÈ ÛÙÔÓ ÂÓÙÔÈÛÌfi ·È‰ÈÒÓ Ì ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ‡ÓÔ Î·È ÙËÓ ·Ú·ÔÌ‹ ÙÔ˘˜ ÁÈ· ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË.
§¤ÍÂȘ ÎÏÂȉȿ: ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘, ·È‰È¿, ÁÔÓ›˜, ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ.
Sleep problems in school-age children 1 Paediatric Neurology Department, “Karamandanion” Children’s Hospital of Patras, Patras, Greece 2 Paediatric Department, “Karamandanion” Children’s Hospital of Patras, Patras, Greece 3 Internist Correspondence: J. Kaleyias Kaleyias@hotmail.com “Karamandanion” Children’s Hospital of Patras 40, Erythrou Stavrou St., 263 31, Patras, Greece
J. Kaleyias1, V. Rouli2, A. Karatzaferi3, K. Dakoronias2, M. Papaioannou2, T. Danidi2, U. D. Papageorgiou2, K. Papoutsi2, G. Krokidas2, N. Diamantopoulos1 Abstract Objectives: To survey the prevalence of sleep problems in school-age children and to explore the association between sleep disorders and various social and environmental factors. Methods: Sleep questionnaires were administrated to the parents of 166 children aged between 6 and 12 years. Results: Sufficient sleep (≥10 hours) was reported during the week for 39% of children aged 6-9 years and 9% of those aged 10-12 years (p=0.0001), while at the weekends the corresponding percentages were 74% and 57% respectively (p=0.025). The overall prevalence of sleep problems was 24.7%, and specifically: I. Dysomnia-related sleep-wake behaviour: bedtime resistance (31%), needing to be accompanied by someone (26%), daytime sleepiness (14%), night waking (9.6%), coming to parents’ bed (9%), snoring (7.2%), and difficulty in falling asleep (6.6%). II. Parasomnia-related sleep behaviour: talking in the sleep (11.4%), teeth grinding (10.2%), confused arousals (7.2%), nightmares (5%), rhythmical movements (3%), bed wetting (2.4%), night terrors (1.8%), and sleepwalking (1.8%). Ten percent of parents admitted that their child had a sleep problem, of which only 50% considered that this was a burden for the family. Conclusions: Sleep problems are common among school-age children, with an overall incidence of 25%, although only 10% of the parents reported that their children might have a sleep problem. The sleep questionnaire could help for the identification of children with sleep problems.
Key words: Sleep problems, children, parents, questionnaire.
Paediatriki 2008;71:48-54
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·49
49
¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘
∂ÈÛ·ÁˆÁ‹ √ ‡ÓÔ˜ Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Â˘ÂÍ›· ÙˆÓ ·È‰ÈÒÓ Î·È ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ‰Â›ÎÙË “ηϋ˜ ˘Á›·˜”, fiˆ˜ ›¯Â ‰È·Ù˘ÒÛÂÈ Î·È Ô πÔÎÚ¿Ù˘ (1). ∆· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘ÓÔÏÈο 10-11 ÒÚ˜ ‡ÓÔ ÙËÓ Ë̤ڷ (2). ∞Ó·Ú΋˜ Û ‰È¿ÚÎÂÈ· ‡ÓÔ˜ Û˘Û¯ÂÙÈ˙fiÌÂÓÔ˜ Ì ˘ÓËÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ (daytime sleepiness) ·ÔÙÂÏ› ¤Ó· Û˘¯Ófi ‡ÚËÌ· Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ ÛÙȘ ÓÔËÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜, ÙË Ê˘ÛÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ˘Á›·, ηıÒ˜ ›Û˘ Ì ÚÔ‚Ï‹Ì·Ù· ÂÈÎÔÈÓˆÓ›·˜ Î·È Î·Ù¿¯ÚËÛË Ô˘ÛÈÒÓ (1,3). √È ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ‡ÓÔ Â›Ó·È Û˘¯Ó¤˜ ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜, ·Ó Î·È Ë Â›ÙˆÛË ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ‰È·Ù·Ú·¯ÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· (1). °È· ·Ú¿‰ÂÈÁÌ·, Ù· ·È‰È¿ ÓËȷ΋˜ ËÏÈΛ·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯Ó¿ ·ÓÙ›ÛÙ·ÛË ÁÈ· Ó· ¿Ó ÛÙÔ ÎÚ‚¿ÙÈ ÙÔ˘˜ ÙËÓ ÒÚ· ÙÔ˘ ‡ÓÔ˘, ÂÓÒ Ù· ·È‰È¿ Ù˘ ÚÔÂÊË‚È΋˜ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ¤¯Ô˘Ó Û˘¯ÓfiÙÂÚ· ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘, fiˆ˜ ˘ÓÔ‚·Û›·, ÂÊÈ¿ÏÙ˜ Î·È ÙÚÈÛÌfi ÙˆÓ ‰ÔÓÙÈÒÓ (4). √È ¤ÊË‚ÔÈ Î·È ÔÈ ÂÓ‹ÏÈΘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ·¸Ó›· Î·È ˘ÓËÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ (5). √È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ‰›Ô ÌÂϤÙ˘, ·ÊÔ‡ Ù· ˘¿Ú¯ÔÓÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Â›Ó·È ·Ó·Ú΋. ∆· ·È‰È¿, Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, Û¿ÓÈ· ·ÈÙÈÒÓÙ·È ÁÈ· ÚÔ‚Ï‹Ì·Ù· ÛÙÔÓ ‡ÓÔ Î·È ÔÈ ÁÔÓ›˜, Ô˘ Â›Ó·È Î·È ÔÈ ÌÔÓ·‰ÈÎÔ› “·Ú·ÙËÚËÙ¤˜” ÙÔ˘ ‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ, Â›Ó·È ÔÈ ÌfiÓÔÈ Ô˘ ÌÔÚÔ‡Ó Ó· ‰ÒÛÔ˘Ó ÈηÓÔÔÈËÙÈΤ˜ ÏËÚÔÊÔڛ˜ (6). ∆· ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ‡ÓÔ˘ ÌÔÚ› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÛËÌ·ÓÙÈÎÒÓ È·ÙÚÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ, fiˆ˜ ÂÈÏË„›·, ‰È¿¯˘ÙË ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹, ¿ÓÔÈ·, Ï‹„Ë Ê·ÚÌ¿ÎˆÓ (5). ¶ÚfiÛÊ·Ù·, ÔÈ ∫·Ï¤ÁÈ·˜ Î·È Û˘Ó. (7) ¤‰ÂÈÍ·Ó fiÙÈ Ë ·¸Ó›· ÌÔÚ› Ó· Â›Ó·È ÂΉ‹ÏˆÛË ‰È¿¯˘ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Û ÌÈ· ÛÂÈÚ¿ 48 ·ÛıÂÓÒÓ ËÏÈΛ·˜ 1,5-18 ÂÙÒÓ Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÏfiÁˆ Û˘ÌÙˆÌ¿ÙˆÓ ·¸Ó›·˜ Û ·È‰È·ÙÚÈÎfi ΤÓÙÚÔ ‡ÓÔ˘ ÛÙȘ ∏¶∞, ÔÈ 9 (19%) ›¯·Ó ·˘ÙÈÛÌfi Ô˘ ‰È¤Ï·ı Ù˘ ‰È¿ÁÓˆÛ˘. ∞‰È·ÌÊÈÛ‚‹ÙËÙ·, Ù· ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ‡ÓÔ˘ ¿ÁÔÓÙ·È ‹ ÂËÚ¿˙ÔÓÙ·È ·fi ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ·Ô˘Û›· ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÌË ÂÊ·ÚÌÔÁ‹ ÙˆÓ Î·ÓfiÓˆÓ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ‡ÓÔ˘. ªÈ· Û˘¯Ó‹ Ù·ÍÈÓfiÌËÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Â›Ó·È Û ‰˘Û˘ÓÈΤ˜ (dysomnias) Î·È ·Ú·¸ÓÈΤ˜ (parainsomnias) (8). ¢˘Û˘ÓÈΤ˜ ÔÓÔÌ¿˙ÔÓÙ·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·ÓÂÈÙ˘¯‹, ·Ó·Ú΋, ‹ ˘ÂÚ‚ÔÏÈ΋˜ ‰È¿ÚÎÂÈ·˜ ‡ÓÔ, fiˆ˜ Ë ·¸Ó›· (‰˘ÛÎÔÏ›· ÛÙËÓ Â¤Ï¢ÛË ÙÔ˘
‡ÓÔ˘) ‹/Î·È Ë Ó˘¯ÙÂÚÈÓ‹ ·Ê‡ÓÈÛË (·¸Ó›·insomnia) (9). √È ·Ú·¸ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ¯ÒÚ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ Â›Ó·È ÔÈ Ó˘¯ÙÂÚÈÓÔ› ÂÊÈ¿ÏÙ˜, Ô Ó˘¯ÙÂÚÈÓfi˜ ÙÚfiÌÔ˜, Ë Ó˘¯ÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË, Î.¿. ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ηٷ‰Â›ÍÂÈ fiÙÈ ÙfiÛÔ ÔÈ ‰˘Û˘ÓÈΤ˜, fiÛÔ Î·È ÔÈ ·Ú·¸ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜, Â›Ó·È Û˘¯Ó¤˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (8,10,11). H ̤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ (gold standard) ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Â›Ó·È Ë ÔÏ˘¸ÓÔÁÚ·ÊÈ΋ ÌÂϤÙË (overnight polysomnography PSG) (12). ∏ ÌÂϤÙË ‡ÓÔ˘ ·ÓÙÈÎÂÈÌÂÓÔÔÈ› Ù· Â˘Ú‹Ì·Ù·, ··ÈÙ› fï˜ ¤Ó· ¿ÚÙÈ· ÔÚÁ·ÓˆÌ¤ÓÔ Î¤ÓÙÚÔ ·È‰È·ÙÚÈ΋˜ ÎÏÈÓÈ΋˜ ‡ÓÔ˘. √ ·ÚÈÔ˜ ÏfiÁÔ˜, ÁÈ· ÙÔÓ ÔÔ›Ô Ë ÔÏ˘¸ÓÔÁÚ·ÊÈ΋ ÌÂϤÙË ‰ÂÓ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙËÓ Ú¿ÍË ‹ ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ·¸Ó›·˜ ÙˆÓ ·È‰ÈÒÓ, Â›Ó·È ÁÈ·Ù› ··ÈÙ› Û˘Óı‹Î˜ ÓÔÛÔÎÔÌ›Ԣ Î·È Û‡Ó‰ÂÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ÔÏÏ·Ï¿ ËÏÂÎÙÚfi‰È·. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ˘¿Ú¯ÂÈ ·‰˘Ó·Ì›· ›Ù¢Í˘ ȉ·ÓÈÎÒÓ Û˘ÓıËÎÒÓ ÁÈ· ÙË ÌÂϤÙË Ù˘ ·¸Ó›·˜ (12) Î·È ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ Û ÂÚÈÙÒÛÂȘ, fiÔ˘ ˘Ô„È·˙fiÌ·ÛÙ ·ÔÊÚ·ÎÙÈΤ˜ ¿ÓÔȘ (Obstructive Sleep Apnea Syndrome - OSAS), ÂÚÈÔ‰ÈΤ˜ ÎÈÓ‹ÛÂȘ ÛÙÔÓ ‡ÓÔ (periodic leg movements - PLMs), ‰È·Ù·Ú·¯¤˜ Ù˘ Ê¿Û˘ REM, ·Ó Ë ‰È¿ÁÓˆÛË Ù˘ ·¸Ó›·˜ ·ÌÊÈÛ‚ËÙÂ›Ù·È ‹ ·Ó Ë ıÂڷ›· ·ÔÙ‡¯ÂÈ (13). ∂›Û˘, ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÂÚ¢ÓËÙÈÎfi ÂÚÁ·ÏÂ›Ô ÛÙË ÌÂϤÙË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘, fiˆ˜ ÚfiÛÊ·Ù· ¤‰ÂÈÍ·Ó ÔÈ ∫·Ï¤ÁÈ·˜ Î·È Û˘Ó. (14), fiÙ·Ó ‰ÈÂÚ‡ÓËÛ·Ó ÙȘ Ó˘¯ÙÂÚÈÓ¤˜ ·Ê˘Ó›ÛÂȘ Û ·È‰È¿, Ì ÙË ¯Ú‹ÛË ÂÈÚfiÛıÂÙˆÓ ÌÂوȷ›ˆÓ ËÏÂÎÙÚÔ‰›ˆÓ ÂÎÙfi˜ ÙˆÓ Û˘Ì‚·ÙÈÎÒÓ ÎÂÓÙÚÈÎÒÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È¢ÎÚÈÓÈÛıÔ‡Ó ÔÈ Ì˯·ÓÈÛÌÔ› Ù˘ ·Ê‡ÓÈÛ˘ Û ·È‰È¿ Ì ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ‡ÓÔ. √È ÁÔÓ›˜, ˆ˜ ·ÚÈÔÈ Ì¿ÚÙ˘Ú˜ ÙÔ˘ ·È‰ÈÎÔ‡ ‡ÓÔ˘, ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙË ÌÂϤÙË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ ÛÙ· ·È‰È¿ ̤ۈ Ù˘ÔÔÈË̤ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘, Ì ÛËÌ·ÓÙÈÎÔ‡˜ fï˜ ÂÚÈÔÚÈÛÌÔ‡˜, ·ÊÔ‡ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ˘ÔÎÂÈÌÂÓÈÎfiÙËÙ¿ ÙÔ˘˜ (6,15). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Û ˘ÁÈ‹ ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ (6-12 ÂÙÒÓ) Ì ÙË ¯ÔÚ‹ÁËÛË Ù˘ÔÔÈË̤ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ÛÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜ Î·È Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·˘ÙÒÓ Ì ÔÈΛÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ (ÎÔÈÓˆÓÈÎÔ‡˜, Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘ Î·È Û˘Ó‹ıÂȘ) Ô˘ ·ÏÏ¿˙Ô˘Ó ÛËÌ·ÓÙÈο Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÛÙËÓ ÂÏÏËÓÈ΋ ÎÔÈÓˆÓ›· Î·È ÂËÚ¿˙Ô˘Ó ÙÔÓ ‡ÓÔ ÙˆÓ ·È‰ÈÒÓ ÛÙË ¯ÒÚ· Ì·˜ ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ·Ú΋ ·Ó¿ÏÔÁ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ (16). ∂›Û˘, Û˘Û¯ÂÙ›Û·Ì ÙȘ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ Ì ÙË ÛÊ·ÈÚÈ΋ ¿Ô„Ë ÙˆÓ ÁÔÓ¤ˆÓ Û¯ÂÙÈο Ì ÙËÓ ‡·ÚÍË ÚÔ‚Ï‹Ì·ÙÔ˜ ‡ÓÔ˘ ÛÙ· ·È‰È¿ ÙÔ˘˜. ¶·È‰È·ÙÚÈ΋ 2008;71:48-54
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·50
50
π. ∫·Ï¤ÁÈ·˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο ·È‰ÈÒÓ Ã·Ú·ÎÙËÚÈÛÙÈο º‡ÏÔ ∏ÏÈΛ· ¶ÚfiˆÚ· (<37 ‚‰ÔÌ¿‰ˆÓ) BMI ¶·¯˘Û·ÚΛ· (>95Ë ∂£) ∆Ô ·È‰› ¤¯ÂÈ ‰ÈÎfi ÙÔ˘ ˘ÓÔ‰ˆÌ¿ÙÈÔ ªÔÓÔηÙÔÈΛ· ¢È·ÌÔÓ‹ Û ÚÔ¿ÛÙÈÔ £fiÚ˘‚Ô˜ ÙË Ó‡¯Ù· ªÔÚʈÙÈÎfi Â›Â‰Ô ÌËÙ¤Ú·˜
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ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ π. ÀÏÈÎfi ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 166 ·È‰È¿. ∫ÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ‹Ù·Ó: 1. ∏ÏÈΛ· 6-12 ÂÙÒÓ. 2. ∂ÏÏËÓÈ΋ ηٷÁˆÁ‹. ∂ÓÒ ÎÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ‹Ù·Ó: 1. ∏ ‡·ÚÍË ÛÔ‚·ÚÔ‡ Ó¢ÚÔÏÔÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ (ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ‰È¿¯˘ÙË ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹, ‰È¿Û·ÛË ÚÔÛÔ¯‹˜-˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ÂÈÏË„›· ˘fi ·ÁˆÁ‹). 2. ∏ Ï‹„Ë ÔÔÈ·Û‰‹ÔÙ ̷ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ ‰ÈÂÓÂÚÁ‹ıËΠÛÙ· Ù·ÎÙÈο Â͈ÙÂÚÈο È·ÙÚ›· Ù˘ ∫ÏÈÓÈ΋˜. ππ. ∂ÚˆÙËÌ·ÙÔÏfiÁÈÔ ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ·˘Ùfi ›¯Â ¯ÔÚËÁËı› ÛÙÔ ·ÚÂÏıfiÓ ·fi ÙÔ˘˜ Smedje et al. (15) Û ·È‰È¿ ËÏÈΛ·˜ 5-7 ÂÙÒÓ ÛÙË ™Ô˘Ë‰›·. ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Â›¯Â 4 ̤ÚË: 1. ™ÙÔ ÚÒÙÔ Ì¤ÚÔ˜ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÏËÚÔÊÔڛ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó ÙÔ ·È‰› (ʇÏÔ, ËÏÈΛ·, ÚÔˆÚfiÙËÙ·, ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ·¯˘Û·ÚΛ·), ÙȘ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘ (fiÛ· ¿ÙÔÌ· ̤ÓÔ˘Ó ÛÙÔ ›‰ÈÔ Û›ÙÈ, ·Ó ÙÔ ·È‰› ¤¯ÂÈ ‰ÈÎfi ÙÔ˘ ˘ÓÔ‰ˆÌ¿ÙÈÔ, ·Ó fi¯È Ì fiÛ· ¿ÙÔÌ· ÙÔ ÌÔÈÚ¿˙ÂÙ·È, ·Ó ̤ÓÔ˘Ó Û ÌÔÓÔηÙÔÈΛ· ‹ ÔÏ˘Î·ÙÔÈΛ·, ·Ó Â›Ó·È Û ΤÓÙÚÔ ‹ Û ÚÔ¿ÛÙÈÔ, ·Ó ˘¿Ú¯ÂÈ Ê·Û·Ú›· ÙË Ó‡¯Ù· ‹ fi¯È), ÙÔ˘˜ ÁÔÓ›˜ (ÌÔÚʈÙÈÎfi ›‰Ô, ¿ÁÁÂÏÌ·) Î·È ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ÙÔ˘ ·È‰ÈÔ‡. 2. ™ÙÔ ‰Â‡ÙÂÚÔ Ì¤ÚÔ˜ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÁÂÓÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔÓ ‡ÓÔ ÙÔ˘ ·È‰ÈÔ‡ (ÙÈ ÒÚ· ËÁ·›ÓÂÈ ÁÈ· ‡ÓÔ ÙȘ ηıËÌÂÚÈÓ¤˜ Î·È Ù· ™·‚‚·ÙÔ·Úȷη, ÙÈ ÒÚ· Í˘Ó¿ÂÈ ÙȘ ηıËÌÂÚÈÓ¤˜ Î·È Ù· ™·‚‚·ÙÔ·Úȷη, fiÛ˜ ÒÚ˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÎÔÈÌ¿Ù·È Û˘ÓÔÏÈο ÙȘ ηıËÌÂÚÈÓ¤˜ Î·È Ù· ™·‚‚·ÙÔ·Úȷη, ·Ó ËÁ·›ÓÂÈ ÁÈ· ‡ÓÔ ÌÂÙ¿ ÙȘ 11 ÙÔ ‚Ú¿‰˘, ·Ó ¤¯ÂÈ ÙËÏÂfiÚ·ÛË ÛÙÔ ‰ˆÌ¿ÙÈÔ ÙÔ˘, ·Ó ÎÔÈÌ¿Ù·È ÙÔ ÌÂÛË̤ÚÈ). 3. ™ÙÔ ÙÚ›ÙÔ Ì¤ÚÔ˜ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 21 ÂÚˆÙ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Û·Ó ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ ˆ˜ ÚÔ˜ ÙËÓ ÂÁÚ‹Paediatriki 2008;71:48-54
∞ÁfiÚÈ· ¡ (%) ∫ÔÚ›ÙÛÈ· ¡ (%) ª¤ÛË ÙÈÌ‹ ± SD (¤ÙË) (min-max) ¡ (%) (̤ÛË ± SD) (25Ë-75Ë ∂£) ¡ (%) ¡ (%) ¡ (%) ¡ (%) ¡ (%) π ππ πππ π ππ πππ
74 (44,5%) 92 (55,5%) 9±2 (6-12) 9 (5,4%) 19,1±3,8 (16-22) 23 (13,9%) 92 (55,4%) 110 (66%) 115 (69%) 21 (17,5%) 24 (14,5%) 83 (50%) 59 (35,5%) 22 (13,3%) 82 (49,4%) 62 (37,3%)
ÁÔÚÛË Î·È ÙÔÓ ‡ÓÔ. √È ÂÚˆÙ‹ÛÂȘ ·˘Ù¤˜ ·ÓȯÓÂ‡Ô˘Ó ‰˘Û˘ÓÈΤ˜ (∂1-∂12) Î·È ·Ú·¸ÓÈΤ˜ (∂13-∂21) ‰È·Ù·Ú·¯¤˜ Î·È ‚·ıÌÔÏÔÁÔ‡ÓÙ·È ·fi 1 ¤ˆ˜ Î·È 5 (ÔÙ¤, ÂÚÈÛÙ·Ûȷο, 1-2 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·, 3-4 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·, ÂÚÈÛÛfiÙÂÚÔ ·fi ¤ÓÙ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·). ∏ οı ÂÚÒÙËÛË ‚·ıÌÔÏÔÁ‹ıËΠͯˆÚÈÛÙ¿ Î·È ÙÔ ·È‰› ‚·ıÌÔÏÔÁ‹ıËΠ̠‚¿ÛË fiϘ ÙȘ ··ÓÙ‹ÛÂȘ (score: 21-105). 4. ∆Ô Ù¤Ù·ÚÙÔ Ì¤ÚÔ˜ ·ÔÙÂÏ›ÙÔ ·fi 4 ÂÚˆÙ‹ÛÂȘ Ì ÛÎÔfi ÙËÓ ·ÔÙ‡ˆÛË Ù˘ ÛÊ·ÈÚÈ΋˜ ¿Ô„˘ (global aspect) ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ‡·ÚÍË ‹ fi¯È ÔÔÈÔ˘‰‹ÔÙ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔÓ ‡ÓÔ. ∏ ÚÒÙË ‹Ù·Ó ÛÊ·ÈÚÈ΋ ÂÚÒÙËÛË Û¯ÂÙÈο Ì ÙÔ ·Ó ÈÛÙÂ‡Ô˘Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ¤¯ÂÈ ‰È·Ù·Ú·¯‹ ÛÙÔÓ ‡ÓÔ ‹ fi¯È. ŸÙ·Ó ··ÓÙÔ‡Û·Ó Î·Ù·Ê·ÙÈο, Û˘Ó¤¯È˙·Ó ÛÙȘ ¿ÏϘ ÙÚÂȘ ÂÚˆÙ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Û·Ó ÙËÓ Â›ÙˆÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·˘ÙÔ‡ ÛÙÔ ›‰ÈÔ ÙÔ ·È‰›, ÛÙË Û¯ÔÏÈ΋ ÙÔ˘ ·fi‰ÔÛË Î·È Ù¤ÏÔ˜ ÛÙËÓ ›‰È· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ∏ Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠ·fi ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ÛÙË ÌÂϤÙË È·ÙÚÔ‡˜ Ì ‚¿ÛË ÙȘ ··ÓÙ‹ÛÂȘ Ô˘ ¤‰ÈÓ·Ó ÔÈ ÁÔÓ›˜. πππ. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∆· ÔÈÔÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÂÎÊÚ¿ÛÙËÎ·Ó Û ·fiÏ˘ÙÔ ·ÚÈıÌfi (¡) Î·È ÂηÙÔÛÙÈ·›Ô ÔÛÔÛÙfi (%), ÂÓÒ Ù· ÔÛÔÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο Û ̤ÛË ÙÈÌ‹ (SD). ¢ÈÂÓÂÚÁ‹ıËΠÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË (‰ÔÎÈÌ·Û›· χ2 Î·È student t-test). ÃÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS (version 12).
∞ÔÙÂϤÛÌ·Ù· π. ÷ڷÎÙËÚÈÛÙÈο ÙˆÓ ·È‰ÈÒÓ (¶›Ó·Î·˜ 1) ™˘ÌÏËÚÒıËÎ·Ó Ù· 166 (92%) ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·fi Ù· 180 Ô˘ ¯ÔÚËÁ‹ıËηÓ. ππ. ™˘Ó‹ıÂȘ ÂÁÚ‹ÁÔÚÛ˘-‡ÓÔ˘ ∆Ô Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ÙȘ ηıËÌÂÚÈÓ¤˜ ÎÔÈÌ¿Ù·È ÓˆÚ›ÙÂÚ· (10±0,8) Û ۯ¤ÛË Ì ٷ ™·‚‚·ÙÔ·Úȷη (11±0,8) (p=0,01). ªÂÙ¿ ÙȘ 11:00 Ì.Ì. ÙȘ ηıËÌÂÚÈÓ¤˜ ÎÔÈÌ¿Ù·È ÙÔ 24% ÙˆÓ ·È‰ÈÒÓ Î·È Ù· ™·‚‚·ÙÔ·Úȷη ÙÔ 68%.
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·51
51
¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘
¶›Ó·Î·˜ 2. ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ ™‡ÓÔÏÔ ¡=186
6-9 ÂÙÒÓ ¡=80
10-12 ÂÙÒÓ ¡=86
p-value
¢˘Û˘ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ¢˘ÛÎÔÏ›· Ó· ·ÔÎÔÈÌËı› ¡˘¯ÙÂÚÈÓ‹ ·Ê‡ÓÈÛË ∞Ó‹Û˘¯Ô Î·È ÎÔ˘ÓÈ¤Ù·È ÛÙÔÓ ‡ÓÔ ÙÔ˘ ¶fiÓÔÈ ÛÙ· fi‰È· ‹ Ù· ÎÔ˘Ó¿ÂÈ Î·È Í˘Ó¿ÂÈ ƒÔ¯·Ï›˙ÂÈ ¢˘ÛÎÔÏ›· ÛÙËÓ ·Ó·ÓÔ‹ ÙÔ˘ ¡˘ÛÙ¿˙ÂÈ ÙËÓ Ë̤ڷ ∞ÓÙ›ÛÙ·ÛË Ó· ¿ÂÈ ÛÙÔ ÎÚ‚¿ÙÈ ÙÔ˘ ÙËÓ ÒÚ· ÙÔ˘ ‡ÓÔ˘ ¡Â˘ÚÈÎfi ‹ ·Ó‹Û˘¯Ô ÙËÓ ÒÚ· ÙÔ˘ ‡ÓÔ˘ ™˘Óԉ‡ÂÙ·È ·fi οÔÈÔÓ ÁÈ· Ó· ¿ÂÈ ÛÙÔ ÎÚ‚¿ÙÈ ∫ÔÈÌ¿Ù·È Ì¤ÚÔ˜ ÙÔ˘ ‡ÓÔ˘ Ì ÙÔ˘˜ ÁÔÓ›˜ ÃÚÂÈ¿˙ÂÙ·È ÊÒÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ó‡¯Ù·˜
6,6% 9,6% 17,4% 3% 7,3% 4,2% 14% 31% 15,6% 26,5% 9% 36%
10% 15% 24% 5% 10% 6,2% 15% 34% 25% 36,2% 16,2% 49%
3,5% 4,6% 11,6% 0,1% 4,7% 2,3% 12,7% 29% 7% 17,4% 2,3% 24%
0,04 0,024 0,039 0,19 0,18 0,26 0,67 0,51 0,002 0,006 0,002 0,01
¶·Ú·¸ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ƒ˘ıÌÈΤ˜ ÎÈÓ‹ÛÂȘ ¡˘¯ÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË ∆ÚÈÛÌfi˜ ‰ÔÓÙÈÒÓ ªÈÏ¿ÂÈ ÛÙÔÓ ‡ÓÔ ÙÔ˘ ÀÓÔ‚·Û›· ™˘Á¯˘ÙÈΤ˜ ·Ê˘Ó›ÛÂȘ ¡˘¯ÙÂÚÈÓfi˜ ÙÚfiÌÔ˜ ∂ÊÈ¿ÏÙ˜
3% 2,4% 10,2% 11,4% 1,8% 7,2% 1,8% 5%
2,5% 3,7% 11,2% 12,5% 1,2% 10% 2,5% 7,5%
3,5% 1,2% 9,3% 10,5% 2,3% 4,6% 1,2% 2,3%
0,72 0,48 0,67 0,69 0,85 0,04 0,86 0,15
∆· ·È‰È¿ ËÏÈΛ·˜ 6-9 ÂÙÒÓ ÎÔÈÌÔ‡ÓÙ·È ÌÂÙ¿ ÙȘ 11:00 Ì.Ì. ÙȘ ηıËÌÂÚÈÓ¤˜ ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û ۯ¤ÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· (11% Î·È 36% ·ÓÙ›ÛÙÔȯ·, p<0,0001). ¶·ÚfiÌÔÈ·, Ù· ™·‚‚·ÙÔ·Úȷη ÎÔÈÌ¿Ù·È ÌÂÙ¿ ÙȘ 11:00 Ì.Ì. ÙÔ 53% Î·È 81% ÙˆÓ ·È‰ÈÒÓ ·ÓÙ›ÛÙÔȯ· (p<0,0001). ∆Ô 75% ÙˆÓ ·È‰ÈÒÓ ÎÔÈÌ¿Ù·È Û˘ÓÔÏÈο ÏÈÁfiÙÂÚÔ ·fi 10 ÒÚ˜ ηıËÌÂÚÈÓ¿, ÂÓÒ Ù· ™·‚‚·ÙÔ·Úȷη ÙÔ 33% ÎÔÈÌ¿Ù·È ÏÈÁfiÙÂÚÔ ·fi 10 ÒÚ˜. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÁ¿ÏˆÓ ·È‰ÈÒÓ ‰ÂÓ ÎÔÈÌ¿Ù·È ÂÚÈÛÛfiÙÂÚÔ ·fi 10 ÒÚ˜ (90%) ÙȘ ηıËÌÂÚÈÓ¤˜, ÂÓÒ ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ 6-9 ÂÙÒÓ ÎÔÈÌÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ ·fi 10 ÒÚ˜ ÙȘ ηıËÌÂÚÈÓ¤˜ (p<0,0001). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÂÍ·ÎÔÏÔ˘ı› Ó· ˘Ê›ÛÙ·Ù·È Ù· ™·‚‚·ÙÔ·Úȷη, ·ÏÏ¿ Â›Ó·È ·ÛıÂÓ¤ÛÙÂÚË (25% 6-9 ÂÙÒÓ Î·È 42% 10-12 ÂÙÒÓ, p=0,02). ªÔÓÔ·Ú·ÁÔÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ̤Û˘ ‰È¿ÚÎÂÈ·˜ ‡ÓÔ˘, ÙfiÛÔ ÙȘ ηıËÌÂÚÈÓ¤˜ fiÛÔ Î·È Ù· ™·‚‚·ÙÔ·Úȷη, ‰ÂÓ ·Ó¤‰ÂÈÍÂ Û˘Û¯¤ÙÈÛË Ì ÙÔ Ê‡ÏÔ (p=0,55), ÙËÓ ÚÔˆÚfiÙËÙ· (p=0,89),ÙËÓ ‡·ÚÍË ‰ÈÎÔ‡ ÙÔ˘ ‰ˆÌ·Ù›Ô˘ (p=0,96), ÙË ‰È·ÌÔÓ‹ ÛÙÔ Î¤ÓÙÚÔ (p=0,48), ÙËÓ ·Ó·ÊÔÚ¿ ıÔÚ‡‚Ô˘ ÛÙË Î·ÙÔÈΛ· (p=0,56), ÙËÓ ‡·ÚÍË ÙËÏÂfiÚ·Û˘ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ (p=0,84) Î·È ÙË ÌfiÚʈÛË Ù˘ ÌËÙ¤Ú·˜ (p=0,19) Î·È ÙÔ˘ ·Ù¤Ú· (p=0,13). ∆· ·¯‡Û·Úη ·È‰È¿ ÎÔÈÌfiÓÙÔ˘Û·Ó ÏÈÁfiÙÂÚÔ ·fi Ù· ÌË-·¯‡Û·Úη, ¯ˆÚ›˜ fï˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p=0,09, Ù¿ÛË).
πππ. ∂ȉÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘ ∏ ›وÛË ÙˆÓ ÂÈ̤ÚÔ˘˜ ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ Ì ‚¿ÛË ÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ηٷÁÚ¿ÊÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. πV. ∫ϛ̷η ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ (¶›Ó·Î·˜ 3) ∏ ̤ÛË ÙÈÌ‹ (± SD) Ù˘ Îϛ̷η˜ ‹Ù·Ó 31,1 (±8,8) [25Ë ∂£ 27% Î·È 75Ë ∂£ 37%]. ¢ÈÂÓÂÚÁ‹ıËÎÂ Û˘Û¯¤ÙÈÛË (ÌÔÓÔ·Ú·ÁÔÓÙÈ΋) Ù˘ Îϛ̷η˜ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Ì ‰È¿ÊÔÚ˜ ÌÂÙ·‚ÏËÙ¤˜. ¢È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ·Ó·ÊÔÚ¿ ıÔÚ‡‚Ô˘ ÙË Ó‡¯Ù· ÛÙÔ Û›ÙÈ (p=0,018), ÙËÓ ·ÚÔ˘Û›· ÙËÏÂfiÚ·Û˘ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ ÙÔ˘ ·È‰ÈÔ‡ (p=0,001) Î·È ÙËÓ ËÏÈΛ· (p=0,001). ¢ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË Ì ÙÔ Ê‡ÏÔ, ÙËÓ ÚÔˆÚfiÙËÙ·, ÙËÓ ·¯˘Û·ÚΛ·, ÙË ‰È·ÌÔÓ‹, ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô ÌËÙ¤Ú·˜ Î·È ·Ù¤Ú· ‹ Ì ÙÔ ·Ó ÙÔ ·È‰› ›¯Â ‰ÈÎfi ÙÔ˘ ˘ÓÔ‰ˆÌ¿ÙÈÔ. V. ™Ê·ÈÚÈ΋ ¿Ô„Ë ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ ™ÙËÓ ÂÚÒÙËÛË “ÈÛÙ‡ÂÙ fiÙÈ ÙÔ ·È‰› Û·˜ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 6 Ì‹Ó˜ ·ÚÔ˘ÛÈ¿˙ÂÈ Î¿ÔÈ· ‰È·Ù·Ú·¯‹ ÛÙÔÓ ‡ÓÔ” ÙÔ 10% ÙˆÓ ÁÔÓ¤ˆÓ ·¿ÓÙËÛ ηٷʷÙÈο. ∏ ̤ÛË ‚·ıÌÔÏÔÁ›· ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ, ÔÈ ÁÔÓ›˜ ÙˆÓ ÔÔ›ˆÓ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ¤¯Ô˘Ó Úfi‚ÏËÌ·, Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Û ۯ¤ÛË Ì ·˘Ù‹ ÙˆÓ ·È‰ÈÒÓ, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÁÔÓ›˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ ‰ÂÓ ¤¯Ô˘Ó Úfi‚ÏËÌ· (45±11 ¤Ó·ÓÙÈ 31,7±7,4, p<0,0001). ¶·È‰È·ÙÚÈ΋ 2008;71:48-54
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·52
52
π. ∫·Ï¤ÁÈ·˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ªÔÓÔ·Ú·ÁÔÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ‚·ıÌÔÏÔÁ›·˜ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Ì ÔÈΛÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ¶·Ú¿ÁÔÓÙ˜
µ·ıÌÔÏÔÁ›· (score) (̤ÛË ÙÈÌ‹ ± SD)
p-value
º‡ÏÔ
∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ¡·È Ÿ¯È ¡·È Ÿ¯È ∫¤ÓÙÚÔ ¶ÚÔ¿ÛÙÈÔ ¡·È Ÿ¯È ∫·ÙÒÙÂÚÔ/̤ÛÔ ∞ÓÒÙÂÚÔ ∫·ÙÒÙÂÚÔ/̤ÛÔ ∞ÓÒÙÂÚÔ ¡·È Ÿ¯È ¡·È Ÿ¯È 6-9 ÂÙÒÓ 10-12 ÂÙÒÓ ¡·È Ÿ¯È
0,61
¶ÚÔˆÚfiÙËÙ· ¶·¯˘Û·ÚΛ· ¢È·ÌÔÓ‹ £fiÚ˘‚Ô˜ ªÔÚʈÙÈÎfi Â›Â‰Ô ÌËÙ¤Ú·˜ ªÔÚʈÙÈÎfi Â›Â‰Ô ·Ù¤Ú· ∆Ô ·È‰› ¤¯ÂÈ ‰ÈÎfi ÙÔ˘ ˘ÓÔ‰ˆÌ¿ÙÈÔ ¶·ÚÔ˘Û›· ÙËÏÂfiÚ·Û˘ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ ∏ÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ ™Ê·ÈÚÈ΋ ¿Ô„Ë ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ
∆Ô 41% ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ¤¯ÂÈ ‰È·Ù·Ú·¯‹ ‡ÓÔ˘ ıˆÚ› fiÙÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ÂËÚ¿˙ÂÈ ‰˘ÛÌÂÓÒ˜ ÙÔ ·È‰›, ÙÔ 53% fiÙÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ÂËÚ¿˙ÂÈ ÙËÓ Î·ıËÌÂÚÈÓ‹ ÙÔ˘ ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÙÔ 53% fiÙÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ÂËÚ¿˙ÂÈ fiÏË ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·.
™˘˙‹ÙËÛË ∏ ·ÚÔ‡Û· ÌÂϤÙË Û˘Ì‚¿ÏÏÂÈ ÛÙË ÁÓÒÛË Ì·˜ ÁÈ· ÙËÓ ¿Ô„Ë ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙȘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏ ÛÊ·ÈÚÈ΋ ¿Ô„Ë ÙˆÓ ÁÔÓ¤ˆÓ Ô˘ ·¿ÓÙËÛ·Ó ÛÙË ÌÂϤÙË ·˘Ù‹ ÁÈ· ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ ÛÙÔÓ ‡ÓÔ ÛÙ· ·È‰È¿ ÙÔ˘˜ ‰Â›¯ÓÂÈ fiÙÈ ÙÔ 10% ÈÛÙ‡ÂÈ fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙ÂÈ Î¿ÔÈ· ‰È·Ù·Ú·¯‹ ÛÙÔÓ ‡ÓÔ. ¶ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ ¤Ó· ¤ÌÙÔ ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ·ÚÔ‡Û· ÛÂÈÚ¿ Ê·›ÓÂÙ·È Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ Î¿ÔÈ· ‰È·Ù·Ú·¯‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰·, Ô˘ ÂÌ›ÙÂÈ Î˘Ú›ˆ˜ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ‰˘Û˘ÓÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (fiˆ˜ ·ÓÙ›ÛÙ·ÛË ÙËÓ ÒÚ· ÙÔ˘ ‡ÓÔ˘ Î·È ·¸Ó›·) Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û ÂΛÓË ÙˆÓ ·Ú·¸ÓÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ∂ÈÚfiÛıÂÙ·, Ë ·ÚÔ‡Û· ÌÂϤÙË ·Ó·‰ÂÈÎÓ‡ÂÈ ÙË ÛËÌ·ÓÙÈ΋ ÛÙ¤ÚËÛË ÙˆÓ ·È‰ÈÒÓ Ù˘ ¯ÒÚ·˜ Ì·˜, ËÏÈΛ·˜ ΢ڛˆ˜ 10-12 ÂÙÒÓ, Û ·Ú΋ ‡ÓÔ, ΢ڛˆ˜ ÙȘ ηıËÌÂÚÈÓ¤˜, Î·È ÙÔ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÓËÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ Ì ÙȘ ÁÓˆÛÙ¤˜ ÂÈÙÒÛÂȘ ÛÙË Û¯ÔÏÈ΋ ·fi‰ÔÛË. √È Owens Î·È Û˘Ó. (17) ¤‰ÂÈÍ·Ó fiÙÈ ÙfiÛÔ ÎÔÈÓˆÓÈPaediatriki 2008;71:48-54
33,5±7,9 32,8±9,4 32,6±11 33,2±8,7 33,5±8,5 33,3±8,8 34,7±8,8 32,3±8,7 36,6±9,3 32,4±8,5 32,5±8,8 34,2±8,6 32,6±9,1 34±8,2 33,3±8,8 32,9±7,8 39±7,8 33,5±9,2 35,4±9,6 31±7,5 45±11 31,7±7,4
0,86 0,91 0,086 0,018 0,23 0,33 0,73 0,001 0,001 <0,0001
ÎÔ› ·Ú¿ÁÔÓÙ˜ (ÊÔÚو̤ÓÔ ÚfiÁÚ·ÌÌ· ÙˆÓ ·È‰ÈÒÓ, ÙËÏÂı¤·ÛË, stress Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜), fiÛÔ Î·È È·ÙÚÈÎÔ› ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ (¿ÛıÌ·, ÏÔÈÌÒÍÂȘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡) ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÔÛÙ¤ÚËÛË ‡ÓÔ˘, ·ÏÏ¿ Î·È Û ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ê·›ÓÂÙ·È fiÙÈ Ù· ·È‰È¿ ËÏÈΛ·˜ 10-12 ÂÙÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈ΋ ÛÙ¤ÚËÛË ‡ÓÔ˘ ÙȘ ηıËÌÂÚÈÓ¤˜. ∂›Û˘, Ë ·ÚÔ˘Û›· ÙËÏÂfiÚ·Û˘ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ Û˘Û¯ÂÙ›ÛÙËΠ̠ÙËÓ ·˘ÍË̤ÓË Îϛ̷η ‰È·Ù·Ú·¯ÒÓ ÛÙÔÓ ‡ÓÔ. √È Ú·ÎÙÈΤ˜ ÛÙÔÓ ‡ÓÔ, fiˆ˜ ÎÔÈÓfi ˘ÓÔ‰ˆÌ¿ÙÈÔ, ı· ÌÔÚÔ‡Û·Ó Ó· ÂËÚ¿ÛÔ˘Ó Ù· ÚÔ‚Ï‹Ì·Ù· ‡ÓÔ˘, fï˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ÚԤ΢„Â Û˘Û¯¤ÙÈÛË ÎÔÈÓÔ‡ ˘ÓÔ‰ˆÌ·Ù›Ô˘ Î·È ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ Â‡ÚËÌ· fiÙÈ ÔÈ ‰˘Û˘ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ê·›ÓÂÙ·È Ó· ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· Û ·ÓÙ›ıÂÛË Ì ÙȘ ·Ú·¸ÓÈΤ˜. ™Â ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· η٤ÏËÍ·Ó ÔÈ Owens Î·È Û˘Ó. (17), ÔÈ ÔÔ›ÔÈ ÌÂϤÙËÛ·Ó ÙȘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ª›· ‡ÏÔÁË ÂÍ‹ÁËÛË ÌÔÚ› Ó· Â›Ó·È fiÙÈ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÌÈÎÚÒÓ ·È‰ÈÒÓ (16% Û ۯ¤ÛË Ì 2%) ÎÔÈÌÔ‡ÓÙ·È Ì·˙› Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ÁÂÁÔÓfi˜ Ô˘ οÓÂÈ ÙȘ ‰˘Û˘ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÈÔ Â‡ÎÔÏ· ·ÓȯÓ‡ÛÈ̘. ∏ ·¸Ó›· (insomnia) ·ÔÙÂÏ› ¤Ó· ·fi Ù· ϤÔÓ ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· ‡ÓÔ˘ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, Ë ÔÔ›· fï˜ ¤¯ÂÈ ÏËÌÌÂÏÒ˜ ÌÂÏÂÙËı› ÛÙËÓ ·È‰È΋ ËÏÈΛ· (18). √È ÂÈÙÒÛÂȘ Ù˘ ·¸Ó›·˜ ÌÔÚ›
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Ó· Â›Ó·È ‰Ú·Ì·ÙÈΤ˜ ÁÈ· ÙËÓ ·fi‰ÔÛË ÙÔ˘ ·È‰ÈÔ‡. ∂ÈÚfiÛıÂÙ·, ‰È·›ÛÙˆÛË ·¸Ó›·˜ Û ·È‰È¿ ÌÔÚ› Ó· ÂÈ‚¿ÏÏÂÈ ¤ÏÂÁ¯Ô ¿ÏÏˆÓ ‰È·Ù·Ú·¯ÒÓ, fiˆ˜ Û˘Ó‰ÚfiÌÔ˘ ‰È¿Û·Û˘ ÚÔÛÔ¯‹˜-˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ ‹ ‰È¿¯˘ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ (7). ¶ÚfiÛÊ·Ù·, ÔÈ Ivanenko Î·È Û˘Ó. (19) ÌÂϤÙËÛ·Ó ÙÔ „˘¯È·ÙÚÈÎfi ˘fiÛÙڈ̷ Î·È Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο 46 ·È‰ÈÒÓ Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó Û ·È‰È·ÙÚÈÎfi ΤÓÙÚÔ ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ Ì ·ÚÈ· ‰È·Ù·Ú·¯‹ ÙËÓ ·¸Ó›·, Ë ÔÔ›· ÔÚ›˙ÂÙ·È ˆ˜ ‰˘ÛÎÔÏ›· Ó· ·ÔÎÔÈÌËı› ÙÔ ·È‰› ‹/Î·È Ó· ‰È·ÙËÚ‹ÛÂÈ ÙÔÓ ‡ÓÔ ÙÔ˘. ™˘ÓÔÏÈο, ÙÔ 50% ÙˆÓ ·È‰ÈÒÓ Â›¯·Ó Û˘ÁÎÂÎÚÈ̤ÓÔ ˘fiÛÙڈ̷. ∞Ó¿ÌÂÛ· Û ·˘Ù¿, ÙÔ 61% ›¯Â Û‡Ó‰ÚÔÌÔ ‰È¿Û·Û˘ ÚÔÛÔ¯‹˜ Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ‹/Î·È „˘¯È·ÙÚÈÎfi ˘fiÛÙڈ̷, fiˆ˜ ηٿıÏÈ„Ë (30%) Î·È ·Á¯Ò‰Ë ‰È·Ù·Ú·¯‹ (65%). ∂Ô̤ӈ˜, Ë ¯ÚfiÓÈ· ·¸Ó›· ÌÔÚ› Ó· ·ÔÙÂÏ› ÂΉ‹ÏˆÛË ˘ÔΛÌÂÓ˘ „˘¯È·ÙÚÈ΋˜ ‰È·Ù·Ú·¯‹˜ (18). π‰È·›ÙÂÚË ·ÍÈÔÏfiÁËÛË ¯ÚÂÈ¿˙ÂÙ·È ÙÔ ·È‰› Ô˘ ·ÚÁ› Ó· ·ÔÎÔÈÌËı›, ·ÊÔ‡ Û ·˘Ùfi ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÔ˘Ó ·Ú¿ÁÔÓÙ˜ Â͈ÁÂÓ›˜, fiˆ˜ ·Ô˘Û›· ¯ÚÔÓÈÎÒÓ ÔÚ›ˆÓ, ÂÚÈ‚·ÏÏÔÓÙÈο ·›ÙÈ·, Û˘Ó‹ıÂȘ ‡ÓÔ˘, „˘¯ÔÏÔÁÈο ·›ÙÈ· ‹ ·ÎfiÌ· Î·È ¯ÚfiÓȘ ‹ ÔÍ›˜ È·ÙÚÈΤ˜ ηٷÛÙ¿ÛÂȘ ‹ Î·È Ê¿Ú̷η. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ 7% ÙˆÓ ·È‰ÈÒÓ ÚÔ¯·Ï›˙ÂÈ Î·È ÙÔ 14% Ó˘ÛÙ¿˙ÂÈ ÙËÓ Ë̤ڷ. ∆Ô ÚÔ¯·ÏËÙfi Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ËÌÂÚ‹ÛÈ· ˘ÓËÏ›·, Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÔÊÚ·ÎÙÈ΋ ¿ÓÔÈ· ÛÙÔÓ ‡ÓÔ Î·È Û˘¯Ó¿ ÔÊ›ÏÂÙ·È Û ˘ÂÚÙÔÊ›· ÙˆÓ ·‰ÂÓÔÂȉÒÓ Â΂ϷÛÙ‹ÛˆÓ. ŸÙ·Ó ÙÔ ·È‰› ÚÔ¯·Ï›˙ÂÈ, ··ÈÙÂ›Ù·È ·ÍÈÔÏfiÁËÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙ› ÙÔ ÚˆÙÔ·ı¤˜ ÚÔ¯·ÏËÙfi (primary snoring) ·fi ÙÔ Û‡Ó‰ÚÔÌÔ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÛÙÔÓ ‡ÓÔ (obstructive sleep apnea syndrome). ∞Ó ‰È·ÁÓˆÛÙ› ÙÔ Û‡Ó‰ÚÔÌÔ Ù˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÛÙÔÓ ‡ÓÔ, ÙfiÙÂ Ë ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÔ‡ (CPAP ‹ ·‰ÂÓÔÂȉÂÎÙÔÌ‹) ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ËÌÂÚ‹ÛÈ·˜ ÂÁÚ‹ÁÔÚÛ˘ ÙÔ˘ ·È‰ÈÔ‡ (20). ∏ ·ÚÔ‡Û· ÌÂϤÙË ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÚÈÔÚÈÛÌÔ‡˜ Ô˘ Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘fi„Ë Î·Ù¿ ÙËÓ ÂÚÌËÓ›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ŸÛÔÓ ·ÊÔÚ¿ ÙÔÓ ·ÚÈıÌfi ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, Ù· ·ÔÙÂϤÛÌ·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ·, ˆÛÙfiÛÔ ··ÈÙÂ›Ù·È ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ. ∂ÈϤÔÓ, Û˘ÌÌÂÙÔ¯‹ ·È‰ÈÒÓ ·fi ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Ì·˜ ı· ÌÔÚÔ‡Û ӷ Û˘Ì‚¿ÏÏÂÈ Û ÛÊ·ÈÚÈÎfiÙÂÚË ·ÍÈÔÏfiÁËÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ‡ÓÔ˘. ∞Í›˙ÂÈ, fï˜, Ó· ÛËÌÂȈı› fiÙÈ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Â‰›Ô ˘¿Ú¯ÂÈ ·Ô˘Û›· ‰Â‰ÔÌ¤ÓˆÓ Î·È ¤ÙÛÈ, Ë ·ÚÔ‡Û· ÌÂϤÙË ı· ÌÔÚÔ‡Û ӷ ÂÎÏËÊı› ˆ˜ ÌÈ· ÚÒÙË ÚÔÛ¿ıÂÈ· ‰ÈÂÚ‡ÓËÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. √ ‰Â‡ÙÂÚÔ˜ ÂÚÈÔÚÈÛÌfi˜ ÚÔ·ÙÂÈ ·fi ÙË ÌÂ-
ıÔ‰ÔÏÔÁ›· Ù˘ ÌÂϤÙ˘. ∏ ¯Ú‹ÛË ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ Ô˘ ·Â˘ı‡ÓÂÙ·È Û ÁÔÓ›˜ ·ÔÙÂÏ› ˘ÔÎÂÈÌÂÓÈ΋ ̤ıÔ‰Ô Ô˘ ¤¯ÂÈ fï˜ ¯ÚËÛÈÌÔÔÈËı› ¢ڤˆ˜ Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (15,16). ∫·Ù¿ Û˘Ó¤ÂÈ·, Ë ·ÚÔ‡Û· ÌÂϤÙË Ú¤ÂÈ Ó· ÂÎÏËÊı› ˆ˜ ·ÍÈÔÏfiÁËÛË Ù˘ ·ÓÙ›Ï˄˘ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· Ù· ÚÔ‚Ï‹Ì·Ù· ‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜, ·Ú¿ ˆ˜ ·ÓÙÈÎÂÈÌÂÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘. ¶·ÚfiÏ· Ù·‡Ù·, ÔÈ ·Ó·ÊÔÚ¤˜ ÙˆÓ ÁÔÓ¤ˆÓ ÌÔÚ› Ó· ÂÎÏËÊıÔ‡Ó ˆ˜ ·ÍÈÔÔÈ‹ÛÈ̘, ·ÊÔ‡ ÔÈ ÁÔÓ›˜ Â›Ó·È ÔÈ ÌfiÓÔÈ Ì¿ÚÙ˘Ú˜ ÙÔ˘ ‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ Î·È È‰È·›ÙÂÚ· ÛÙË ¯ÒÚ· Ì·˜, fiÔ˘ ·Ô˘ÛÈ¿˙Ô˘Ó Î¤ÓÙÚ· ·È‰È·ÙÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ‡ÓÔ˘ Ì ‰˘Ó·ÙfiÙËÙ˜ ÔÏ˘¸ÓÔÁÚ·ÊÈÎÒÓ ÌÂÏÂÙÒÓ. ∫·Ù·Ï‹ÁÔÓÙ·˜, Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ı· ı¤Ï·Ì ӷ ÙÔÓ›ÛÔ˘Ì ÌÂÚÈÎÔ‡˜ ÛËÌ·ÓÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ô ·È‰›·ÙÚÔ˜ ÔÊ›ÏÂÈ Ó· ÚˆÙ‹ÛÂÈ ÁÈ· ÙÔÓ ‡ÓÔ ÙˆÓ ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∞Ó¿ÌÂÛ· Û ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜ Â›Ó·È Ë ÛËÌ·ÓÙÈ΋ ›وÛË ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘ Û ·˘Ùfi ÙÔ ËÏÈÎÈ·Îfi Ê¿ÛÌ·, Ë Èı·ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ıÂڷ‡ÛÈÌÔ˘ ·ÈÙ›Ô˘, fiˆ˜ ¿ÓÔÈ·˜ ‹ ÂÓÔ‡ÚËÛ˘, Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÚÔ‚Ï‹Ì·Ù· ‡ÓÔ˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È ÈÛ¯˘Ú¿ Ì ¿ÏÏ· „˘¯ÔÏÔÁÈο Î·È È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ Ù˘ ηٿıÏȄ˘, ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È¿Û·Û˘ Ù˘ ÚÔÛÔ¯‹˜ Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ Î·È Ù˘ ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ (21-28). ŒÙÛÈ, ·Ó·˙ËÙÒÓÙ·˜ Ù˘¯fiÓ ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ‡ÓÔ, ÌÔÚ› Ó· ·Ó·‰ÂȯıÔ‡Ó ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ Û˘ÌÂÚÈÊÔÚ¿˜ (ÌË Û˘ÌÌfiÚʈÛ˘), Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ Î·È „˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ (ÊÔ‚›Â˜, ηٿıÏÈ„Ë, ·˘ÙÈÛÌfi˜) ‹ È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù· (¿ÛıÌ·) Ô˘ Û˘Ó˘¿Ú¯Ô˘Ó Ì ·˘Ù¤˜. §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÏ¿¯ÈÛÙÔÈ ·fi ÙÔ˘˜ ÁÔÓ›˜ Ô˘ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ ¤¯ÂÈ Î¿ÔÈ· ‰È·Ù·Ú·¯‹ ÛÙÔÓ ‡ÓÔ Û˘˙ËÙÔ‡Ó ÙÔ ı¤Ì· ·˘Ùfi Ì ÙÔÓ ·È‰›·ÙÚÔ, ·Ó·‰ÂÈÎÓ‡ÂÙ·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ Ë ÂÈÙ·ÎÙÈ΋ ·Ó¿ÁÎË ÁÈ· ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ıÂÚ¿ÔÓÙ· È·ÙÚÔ‡ ¿Óˆ Û ·˘Ù¿ Ù· ÚÔ‚Ï‹Ì·Ù·. ∏ Û˘˙‹ÙËÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ‡ÓÔ˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ Ì ÙÔ˘˜ ÁÔÓ›˜, ·ÏÏ¿ Î·È Ì ÙÔ ·È‰›, ÌÔÚ› Ó· Ì·˜ ‰ÒÛÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ηٷÓÔ‹ÛÔ˘Ì ηχÙÂÚ· ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, Ó· ·ÍÈÔÏÔÁ‹ÛÔ˘Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ Î·È Ó· Âηȉ‡ÛÔ˘Ì ÙÔ˘˜ ÁÔÓ›˜ Û ٷÎÙÈΤ˜ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ‡ÓÔ˘, Ì ·ÒÙÂÚÔ ÛÙfi¯Ô ÙËÓ ÚfiÏË„Ë ÛËÌ·ÓÙÈÎfiÙÂÚˆÓ ‹/Î·È ¯ÚfiÓÈˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡ÓÔ˘.
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16. Ottaviano S, Giannotti F, Cortesi F, Bruno O, Ottaviano C. Sleep characteristics in healthy children from birth to 6 years of age in the urban area of Rome. Sleep 1996;19:1-3. 17. Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep disturbance in elementary school-aged children. J Dev Behav Pediatr 2000;21:27-36. 18. The National Institutes of Health Consensus Development Program. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. Available at http://consensus.nih.gov/ 2005/ 2005InsomniaSOS026html.htm. 19. Ivanenko A, Barnes ME, Crabtree VM, Gozal D. Psychiatric symptoms in children with insomnia referred to a pediatric sleep medicine center. Sleep Med 2004;5:253-259. 20. Stradling JR, Thomas G, Warley AR, Williams P, Freeland A. Effects of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet 1990;335:249-253. 21. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989;262:1479-1484. 22. Kaplan BJ, McNicol J, Conte RA, Moghadam HK. Sleep disturbance in preschool-aged hyperactive and nonhyperactive children. Pediatrics 1987;80:839-844. 23. Stores G. Sleep studies in children with a mental handicap. J Child Psychol Psychiatry 1992;33:1303-1317. 24. Sadeh A, McGuire JP, Sachs H, Seifer R, Tremblay A, Civita R, et al. Sleep and psychological characteristics of children on a psychiatric inpatient unit. J Am Acad Child Adolesc Psychiatry 1995;34:813-819. 25. Johnson CR. Sleep problems in children with mental retardation and autism. Child Adolesc Psychiatr Clin North Am 1996;5:673-683. 26. Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006;15:210-215. 27. Abad VC, Guilleminault C. Sleep and psychiatry. Dialogues Clin Neurosci 2005;7:291-303. 28. Malow BA, McGrew SG, Harvey M, Henderson LM, Stone WL. Impact of treating sleep apnea in a child with autism spectrum disorder. Pediatr Neurol 2006;34: 325-328.
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™ÂÏ›‰·55
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
55
√È Û˘Ó¤ÂȘ Ù˘ Áڛ˘ ÛÙ· ·È‰È¿ ÛÙËÓ ÎÔÈÓfiÙËÙ· ª. ∆ÛÔÏÈ¿1, π. §ÔÁÔı¤ÙË1, N. ¶··‰fiÔ˘ÏÔ˜1, M. ª·˘Ú›ÎÔ˘2, N. ™˘Ú›‰Ë˜1, ¶. ¢ÚÔÛ¿ÙÔ˘3, ¢. ∫·ÊÂÙ˙‹˜1, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜1 Î·È Ë ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ Áڛ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ·* ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ Î·Ù¿ Ù˘ Áڛ˘ ÚÔ¸Ôı¤ÙÂÈ ÙÔÓ ·ÎÚÈ‚‹ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÓÔÛËÚfiÙËÙ·˜. ∏ ÚÔÔÙÈ΋ ·˘Ù‹ ÌÂϤÙË ¤¯ÂÈ ÛÙfi¯Ô ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÚÁ·ÛÙËÚȷο ÂȂ‚·ÈˆÌ¤Ó˘ Áڛ˘ Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Û ˘ÁÈ‹ ·È‰È¿ ÛÙËÓ ÎÔÈÓfiÙËÙ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 1.462 ·È‰È¿ ËÏÈΛ·˜ ≥6 ÌËÓÒÓ ¤ˆ˜ <14 ÂÙÒÓ Ô˘ ÂÍÂÙ¿ÛıËÎ·Ó ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ‹ Û ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·, ÏfiÁˆ ˘ÚÂÙÔ‡ Î·È Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ηٿ ÙËÓ ÂÔ¯‹ Ù˘ ÂÙ‹ÛÈ·˜ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ Áڛ˘ ÁÈ· ‰‡Ô ¯ÚfiÓÈ·. ∞ÔÙÂϤÛÌ·Ù·: ∏ ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ Áڛ˘ ‰È‹ÚÎÂÛ οı ¯ÚfiÓÔ 13-14 ‚‰ÔÌ¿‰Â˜. §Ô›ÌˆÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ‰È·ÈÛÙÒıËΠÛÙÔ˘˜ 573/1.462 (39%) ÙˆÓ ÂÍÂÙ·Ûı¤ÓÙˆÓ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙÔ 13,5% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÈÛΤÊıËÎ·Ó Ù· ·È‰È·ÙÚÈο È·ÙÚ›· ηٿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹. ∏ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· ‹Ù·Ó Ë ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ (18,5%). ∞ÓÙÈ‚ÈÔÙÈο Û˘ÓÙ·ÁÔÁÚ·Ê‹ıËÎ·Ó ÛÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë. √Í›· ̤ÛË ˆÙ›Ùȉ· Î·È Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÒÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚ˜ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ Ô˘ ·ÔÙÂÏÔ‡Û·Ó ÙÔ 58% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÌÂϤÙ˘. °È· οı ¿ÚÚˆÛÙÔ ·È‰›, ÔÈ ÁÔÓ›˜ ¤¯·Û·Ó 1,34 Ë̤Ú˜ ÂÚÁ·Û›·˜. ™ÙȘ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ·È‰ÈÒÓ Ì ÁÚ›Ë Î·Ù·ÁÚ¿ÊËΠÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Î·È ‰Â‡ÙÂÚÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ ·Ó·Ó¢ÛÙÈ΋˜ Ïԛ̈͢, ÂÈÛΤ„ÂˆÓ Û ȷÙÚfi Î·È ¯Ú‹Û˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù·: H ÁÚ›Ë ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙ· ·È‰È¿ ÛÙËÓ ÎÔÈÓfiÙËÙ·. √È Û˘Ó¤ÂȤ˜ Ù˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂÚÈÔÚÈÛıÔ‡Ó Ì ÙÔÓ Î·ıÔÏÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ <5 ÂÙÒÓ.
1 µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ 2 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 3 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: πˆ¿ÓÓ· §ÔÁÔı¤ÙË giannalogotheti@yahoo.gr µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
§¤ÍÂȘ ÎÏÂȉȿ: °Ú›Ë, ·È‰È¿, Â͈ÙÂÚÈÎÔ› ·ÛıÂÓ›˜, ÎÔÈÓfiÙËÙ·.
The impact of influenza in children on the community M. Tsolia1, I. Logotheti1, N. Papadopoulos1, M. Mavrikou2, N. Spyridis1, P. Drossatou3, D. Kafetzis1, A. Konstantopoulos1 and the outpatient flu study group* Abstract Background: Decisions regarding the introduction of influenza immunization of healthy children require an accurate evaluation of the influenza disease burden not only in the inpatient but also in the outpatient setting. Methods: A prospective study was made of the impact of virologically confirmed influenza on 1,462 outpatient children (≥6 months to <14 years) and on their families, during two consecutive influenza seasons. Results: Influenza was documented in 573/1,462 (39%) outpatients with febrile respiratory illness and it accounted for 13.5% of all outpatient visits during the 14 weeks of each season. Acute otitis media (AOM) was the most common complication (18.5%) and about 40% of influenza positive patients received antibiotics. AOM and antibiotic use were more common in children aged younger than 5 years, who accounted for 58% of all patients in the study. For each sick child with influenza, a mean of 1.34 workdays were lost by the parents. Family members of influenza positive children were more likely to develop a secondary respiratory illness and to require medical consultations and antibiotic prescription. Conclusions: Influenza is associated with a heavy burden of morbidity in the community that could be reduced considerably with the implementation of influenza immunization of children in the under 5 years age group.
1 2nd Department of Paediatrics, School of Medicine, University of Athens 2 1st Department of Paediatrics, “P. & A. Kyriakou” Children’s Hospital, Athens 3 2nd Department of Paediatrics, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: Ioanna Logotheti giannalogotheti@yahoo.gr 2nd Department of Paediatrics, School of Medicine, University of Athens, “P. & A. Kyriakou” Children’s Hospital Thivon & Levadias St., 115 27, Athens, Greece
Key words: Influenza, children, outpatients, community.
*√Ì¿‰· ÌÂϤÙ˘ Ù˘ Áڛ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· º. ™ÙÚȤÏË, °. ∆ÛfiÏ·˜, ª. ¶ÂÙÚ¿ÎË, ¶. ™˘Ú›‰Ë˜, ¢. ÃÔϤ‚·˜, Ã. ¶ÂÙÚÔÁÈ·ÓÓÔÔ‡ÏÔ˘, ∫. ™È·Î·‚¤Ï·˜, ¡. ª˘ÚÈÔÎÂÊ·ÏÈÙ¿Î˘ *Outpatient flu study group F. Stripeli, G. Tsolas, M. Petraki, P. Spyridis, D. Cholevas, C. Petroyannopoulou, K. Siakavellas, N. Myriokefalitakis ¶·È‰È·ÙÚÈ΋ 2008;71:55-61
Pediatri Jan-Feb 08
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™ÂÏ›‰·56
56
ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.
™˘ÓÙÔÌÔÁڷʛ˜ RSV ∆∂¶ ™∞
Respiratory Syncytial Virus ∆Ì‹Ì· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ ™Ù·ıÂÚ‹ ∞fiÎÏÈÛË
∂ÈÛ·ÁˆÁ‹ ¶ÚfiÛÊ·Ù˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÏfiÁˆ Áڛ˘ ÙˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ ÌÈÎÚ‹˜ ËÏÈΛ·˜, Â›Ó·È Û˘ÁÎÚ›ÛÈÌË Ì ·˘Ù‹ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (1,2). øÛÙfiÛÔ, Ë ·ÎÚÈ‚‹˜ ·ÍÈÔÏfiÁËÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ·˘ÙÒÓ ÂËÚ¿˙ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Î·Ù¿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ Ë ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ Áڛ˘ Û˘Ì›ÙÂÈ Ì ·˘Ù‹Ó Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÏÏÔ˘˜ ÈÔ‡˜, fiˆ˜ Â›Ó·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜ (respiratory syncytial virus - RSV). ÕÏϘ ÌÂϤÙ˜, ‚·ÛÈṲ̂Ó˜ Û ÂȉËÌÈÔÏÔÁÈ΋ ÂÈÙ‹ÚËÛË, Âȯ›ÚËÛ·Ó Ó· ‰È·¯ˆÚ›ÛÔ˘Ó ÙËÓ Â›‰Ú·ÛË ÙÔ˘ RSV Î·È ÙÔ˘ ÈÔ‡ Ù˘ Áڛ˘ ÛÙË Û˘¯ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ ÙˆÓ ˘ÁÈÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (3,4). ∆· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ÂȂ‚·›ˆÛ·Ó fiÙÈ Ù· ˘ÁÈ‹ ·È‰È¿ <2 ÂÙÒÓ, Î·È Èı·ÓfiÓ Î·È ÂΛӷ ÌÂٷ͇ 2 Î·È 4 ÂÙÒÓ, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÓÔÛËÏ¢ıÔ‡Ó ÏfiÁˆ Ù˘ Áڛ˘, Û ۇÁÎÚÈÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ¶ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ô˘ ‚·Û›ÛÙËÎ·Ó Û ηÏÏȤÚÁÂȘ ÙÔ˘ ÈÔ‡ ÂȂ‚·›ˆÛ·Ó ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÙˆÓ ·È‰ÈÒÓ ÌÈÎÚ‹˜ ËÏÈΛ·˜ (5). µ¿ÛÂÈ ·˘ÙÒÓ ÙˆÓ ÛÙÔȯ›ˆÓ Û˘ÛÙ‹ÓÂÙ·È ÛÙȘ ∏¶∞ ·fi ÙÔ 2003 Ô Î·ıÔÏÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ Áڛ˘ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 6-23 ÌËÓÒÓ (6). ¶·ÚfiÏÔ Ô˘ ÔÈ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÂÌ‚ÔÏÈ·ÛÌfi ‚·Û›ÛÙËÎ·Ó ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÙˆÓ ÌÈÎÚfiÙÂÚˆÓ ·È‰ÈÒÓ, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙ· ·È‰È¿ Î·È ÙËÓ ÎÔÈÓfiÙËÙ· (3). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÚ›Ô˘ ÙÔ 30-40% ÙˆÓ ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÓÔÛÔ‡Ó ·fi ÁÚ›Ë Î¿ı ¯ÚfiÓÔ Î·È ·ÔÙÂÏÔ‡Ó ÙËÓ Î‡ÚÈ· ËÁ‹ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ Û ÂÓËÏ›ÎÔ˘˜, ·È‰È¿ Î·È ¿ÙÔÌ· Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (7-12). ∞fi Ù· ·È‰È¿ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË, ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÓÔÛËχÂÙ·È, Ì ·ÔÙ¤ÏÂÛÌ· Ë ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Ó· ·ÓÙÈÚÔۈ‡ÂÈ ¤Ó· ÌÈÎÚfi ̤ÚÔ˜ Ù˘ Û˘ÓÔÏÈ΋˜ ÓÔÛËÚfiÙËÙ·˜ Ù˘ Áڛ˘ (13,14). ∏ ÙÂÏÈ΋ ·fiÊ·ÛË ÁÈ· ÙË Û‡ÛÙ·ÛË ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ˘ÁÈ‹ ·È‰È¿ ··ÈÙ› ÚÔÛÂÎÙÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘ Áڛ˘ ÙfiÛÔ ÛÙÔ˘˜ ÓÔÛËÏ¢fiÌÂÓÔ˘˜ fiÛÔ Î·È ÛÙÔ˘˜ Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜, ηıÒ˜ ›Û˘ Î·È ÙˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ Û˘ÓÂÂÈÒÓ Ù˘ Ïԛ̈͢ ÛÙËÓ ÎÔÈÓfiÙËÙ·. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙˆÓ Û˘ÓÂÂÈÒÓ Ù˘ ÂÚÁ·ÛÙËPaediatriki 2008;71:55-61
Úȷο ÂȂ‚·ÈˆÌ¤Ó˘ Áڛ˘ Û ˘ÁÈ‹ ·È‰È¿ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜ ÛÙËÓ ÎÔÈÓfiÙËÙ·.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¶ÚfiÎÂÈÙ·È ÁÈ· ÚÔÔÙÈ΋ ÌÂϤÙË Ô˘ ¤Ï·‚ ¯ÒÚ· ηٿ ÙË ‰È¿ÚÎÂÈ· ‰‡Ô Û˘Ó¯fiÌÂÓˆÓ ÂÙÒÓ 2003-2004 Î·È 2004-2005. ø˜ ÂÚ›Ô‰Ô˜ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Áڛ˘ ÔÚ›ÛÙËΠοı ¯ÚfiÓÔ ·˘Ù‹ Ô˘ ÔÚÈÔıÂÙÔ‡ÓÙ·Ó ·fi ÙÔ ÚÒÙÔ ¤ˆ˜ Î·È ÙÔ ÙÂÏÂ˘Ù·›Ô ıÂÙÈÎfi ‰Â›ÁÌ· ÁÈ· ÙÔÓ Èfi Ù˘ Áڛ˘, Ô˘ ηٷÁÚ¿ÊËΠÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÈÙ‹ÚËÛ˘. ∏ ÂÈÙ‹ÚËÛË ‰ÈÂÍ‹¯ıË ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ·fi ÙËÓ 1Ë ¢ÂÎÂÌ‚Ú›Ô˘ οı ¯ÚfiÓÔ˘ Î·È Û˘Ó¯›ÛÙËΠ̤¯ÚÈ ÙËÓ Î·Ù·ÁÚ·Ê‹ ·ÚÓËÙÈÎÒÓ ÌfiÓÔ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÁÈ· ‰‡Ô Û˘Ó¯fiÌÂÓ˜ ‚‰ÔÌ¿‰Â˜. ∆Ô ‰Â‡ÙÂÚÔ ¤ÙÔ˜ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË Î·È ·ÛıÂÓ›˜ Ô˘ ÂÍÂÙ¿˙ÔÓÙ·Ó Û ÂÙ¿ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·. ∆Ô ÚˆÙfiÎÔÏÏÔ Ù˘ ÌÂϤÙ˘ ÂÁÎÚ›ıËΠ·fi ÙËÓ ∂ÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. √È ÁÔÓ›˜ ÂÓËÌÂÚÒÓÔÓÙ·Ó ÚÔÊÔÚÈο Î·È ¤‰ÈÓ·Ó ÙË Û˘ÁηٿıÂÛ‹ ÙÔ˘˜ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ ÛÙË ÌÂϤÙË. ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 14 ÂÙÒÓ Ì ˘ÚÂÙfi (ıÂÚÌÔÎÚ·Û›· Ì·Û¯¿Ï˘ ≥37,8oC) Î·È ÂÓfi˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û˘ÌÙÒÌ·ÙÔ˜ ‹ ÛËÌ›Ԣ Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂Í·ÈÚ¤ıËÎ·Ó ·fi ÙË ÌÂϤÙË ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· ηıÒ˜ Î·È ‚Ú¤ÊË <1 ¤ÙÔ˘˜ Ì ÈÛÙÔÚÈÎfi ÚÔˆÚfiÙËÙ·˜. °È· οı ·ÛıÂÓ‹ Û˘ÌÏËÚÒıËΠÂȉÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ÂÚÈ›¯Â ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›·, Û‡ÓÙÔÌÔ ÈÛÙÔÚÈÎfi, Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· ·fi ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ·ÔÙÂϤÛÌ·Ù· ·fi ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ (Â¿Ó ¤ÁÈÓ·Ó), ÙÂÏÈ΋ ‰È¿ÁÓˆÛË, Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ÂÈÏÔΤ˜ Î·È ¤Î‚·ÛË. ∂›Û˘, Û˘ÏϤ¯ıËÎ·Ó ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Û·Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·‰ÂÏÊÒÓ, ÙËÓ ¤ÎıÂÛË Û οÓÈÛÌ·, ÙË Û˘ÌÌÂÙÔ¯‹ ‹ fi¯È Û ·È‰ÈÎfi ÛÙ·ıÌfi, ÙËÓ ÂÚÁ·Ûȷ΋ ηٿÛÙ·ÛË ÙˆÓ ÁÔÓÈÒÓ Î·È ÙË ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ¢‡Ô ¤ˆ˜ ÙÚÂȘ ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ÂͤٷÛË, ηÙfiÈÓ ÙËÏÂʈÓÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Ì ÙÔ˘˜ ÁÔÓ›˜, ηٷÁÚ¿ÊÔÓÙ·Ó ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Û·Ó ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘Ìو̿وÓ, ÙÔ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ È·ÙÚÈÎÒÓ ÂÈÛΤ„ˆÓ, ÙËÓ ÙÂÏÈ΋ ‰È¿ÁÓˆÛË (Â¿Ó ‹Ù·Ó ‰È·ÊÔÚÂÙÈ΋ ·fi ÙËÓ ·Ú¯È΋), ÙË ÏËÊı›۷ ıÂڷ›·, ÙËÓ Èı·Ó‹ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ÙË ‰È¿ÚÎÂÈ· ·Ô˘Û›·˜ ·fi ÙÔ Û¯ÔÏÂ›Ô ‹ ÙÔÓ ·È‰ÈÎfi ÛÙ·ıÌfi. ∂›Û˘, ηٷÁÚ¿ÊÔÓÙ·Ó Ë ÂΉ‹ÏˆÛË Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ë ·Ó·ÁηÈfiÙËÙ· È·ÙÚÈ΋˜ ÂͤٷÛ˘ ÁÈ’ ·˘Ù¿, Ë ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ, Ë ·Ô˘Û›· ·fi ÙËÓ ÂÚÁ·Û›· ÙÔ˘˜ Î·È Ë Ù˘¯fiÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∏ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓ›·˜ ‚·Û›ÛÙËΠ۠·ÂÈÎÔÓÈÛÙÈ΋ ÂȂ‚·›ˆÛË. ∏ ‰È¿ÁÓˆÛË Ïԛ̈͢ ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ¤ÁÈÓ Ì ·Ó›¯ÓÂ˘Û‹ ÙÔ˘ Û ÚÈÓÈÎfi ›¯ÚÈÛÌ· Ô˘ ÂÏ‹ÊıË ·fi οı ·ÛıÂÓ‹. °È· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ ¯ÚËÛÈÌÔÔÈ‹ıËΠ‰ÔÎÈÌ·Û›· Ù·¯Â›·˜ ·Ó›¯Ó¢Û˘ ·ÓÙÈÁfiÓÔ˘ [QuickVue Influenza Test (Quidel, San Diego, Ca)]. ªÂ ·˘Ù‹ ÙË ‰ÔÎÈÌ·Û›· ·Ó›¯Ó¢Û˘ ÙÔ˘ ÈÔ‡ Ù˘ Áڛ˘, ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ùfi˜ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ˘ÔÙ‡ˆÓ Áڛ˘. ŒÁÈÓ·Ó Û˘ÁÎÚ›ÛÂȘ ÌÂٷ͇ ıÂÙÈÎÒÓ Î·È ·ÚÓËÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ. √È ıÂÙÈÎÔ› ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜ ‰È·¯ˆÚ›ÛÙËÎ·Ó Î·È Û˘ÁÎÚ›ıËÎ·Ó Î·È Î·Ù¿ ËÏÈΛ· (≥6 ÌËÓÒÓ ¤ˆ˜ <2 ÂÙÒÓ, ≥2 ¤ˆ˜ <5 ÂÙÒÓ Î·È ≥5 ¤ˆ˜ <14 ÂÙÒÓ), ηٿ ÂÍÂÙ·ÛÙÈÎfi ΤÓÙÚÔ (∆∂¶ ‹ ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·) Î·È ¤ÙÔ˜ ¤ÓÙ·Í˘ ÛÙË ÌÂϤÙË. ∆Ô χ2 ‹ ÙÔ 2-tailed Fisher’s ÙÂÛÙ Î·È ÙÔ one-way ANOVA ÙÂÛÙ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙË Û‡ÁÎÚÈÛË
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·57
57
√È Û˘Ó¤ÂȘ Ù˘ Áڛ˘
ÙˆÓ Î·ÙËÁÔÚÈÎÒÓ Î·È Û˘Ó¯ÒÓ ÌÂÙ·‚ÏËÙÒÓ, ·ÓÙ›ÛÙÔȯ·. ø˜ Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ηıÔÚ›ÛÙËΠÙÔ ·=5%. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ÚfiÁÚ·ÌÌ· SPSS 11.5.
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ ¢ËÌÔÁÚ·ÊÈο ÛÙÔȯ›·
°Ú›Ë (+) °Ú›Ë (-) N=573 N=888
∞ÔÙÂϤÛÌ·Ù· ∏ ‰È¿ÚÎÂÈ· Ù˘ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ Áڛ˘ ‹Ù·Ó 13 Î·È 14 ‚‰ÔÌ¿‰Â˜, ·ÓÙ›ÛÙÔȯ·, ÁÈ· Ù· ‰‡Ô Û˘Ó¯fiÌÂÓ· ¤ÙË. ∆ÔÓ ÚÒÙÔ ¯ÚfiÓÔ, Ë ÂÔ¯‹ Ù˘ Áڛ˘ ¿Ú¯ÈÛ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· ÙÔ˘ ºÂ‚ÚÔ˘·Ú›Ô˘ ÂÓÒ ÙÔ ‰Â‡ÙÂÚÔ ·Ú¯¤˜ ¢ÂÎÂÌ‚Ú›Ô˘. ∞fi 1.462 ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ-14 ÂÙÒÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Ì ˘ÚÂÙfi Î·È Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, 573 (39,2%) ‹Ù·Ó ıÂÙÈο ÁÈ· ÁÚ›Ë. ∆ËÓ ÂÚ›Ô‰Ô ·È¯Ì‹˜, Ô˘ Î·È ÙȘ ‰‡Ô ¯ÚÔÓȤ˜ ‰È‹ÚÎÂÛ ÂÚ›Ô˘ Ù¤ÛÛÂÚȘ ‚‰ÔÌ¿‰Â˜, >50% ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ıÂÙÈÎÔ› (∂ÈÎfiÓ· 1). ∆ÔÓ ÚÒÙÔ ¯ÚfiÓÔ (2002-2003) Î·È ÙÔ ‰Â‡ÙÂÚÔ (2003-2004) ÂÍÂÙ¿ÛÙËÎ·Ó Ì Ô͇ Úfi‚ÏËÌ· 2.553 ·È‰È¿ Î·È 2.359, ·ÓÙ›ÛÙÔȯ·, Î·È ·fi ·˘Ù¿ 759 (29,7%) Î·È 946 (40%), ·ÓÙ›ÛÙÔȯ·, ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ¤ÓÙ·Í˘ ÛÙË ÌÂϤÙË. ¢ÔÎÈÌ·Û›· ÁÈ· ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ Ù˘ Áڛ˘ ¤ÁÈÓ Û 608 (80%) Î·È 854 (90%) Î·È ·fi ·˘ÙÔ‡˜ 254/608 (41,8%) Î·È 319/854 (37,3%), ·ÓÙ›ÛÙÔȯ·, ‹Ù·Ó ıÂÙÈÎÔ›. ¢ÂÓ ˘‹ÚÍ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ ÔÛÔÛÙfi Ïԛ̈͢ Ù· ‰‡Ô Û˘Ó¯fiÌÂÓ· ¤ÙË (p=0,088). ∆Ô 13,5% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÚÔÛ‹Ïı·Ó ÛÙ· ∆∂¶ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ηٿ Ù· ‰‡Ô ¯ÚfiÓÈ· Ô˘ ‰È‹ÚÎÂÛÂ Ë ÌÂϤÙË Î·È ÙÔ 16,1% ·˘ÙÒÓ Ô˘ ÂÈÛΤÊÙËÎ·Ó ÙÔ˘˜ ȉÈÒÙ˜ ·È‰È¿ÙÚÔ˘˜ Ô˘ Û˘ÌÌÂÙ›¯·Ó ›¯Â Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘. ∏ Û˘¯ÓfiÙËÙ· Ïԛ̈͢ ·fi ÁÚ›Ë ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ÛÙ· ·È‰È¿ <2 ÂÙÒÓ (30,9%) Û˘ÁÎÚÈÓfiÌÂÓË Ì ·˘Ù¿ ËÏÈΛ·˜ ≥2 Î·È ≤5 (42%) Î·È ÂΛӷ ≥5 ÂÙÒÓ (41,5%) (p=0,004). ∆· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Î·È ¯ˆÚ›˜ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›-
∏ÏÈΛ·, ̤ÛË ± ™∞ (Ì‹Ó˜) ∞ÁfiÚÈ·/∫ÔÚ›ÙÛÈ· πÛÙÔÚÈÎfi ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ¶·ıËÙÈÎfi οÓÈÛÌ· ™¯ÔÏ›Ô/·È‰ÈÎfi˜ ÛÙ·ıÌfi˜ ¶·È‰ÈÎfi˜ ÛÙ·ıÌfi˜ ¶·Ú·ÌÔÓ‹ ÛÙÔ Û›ÙÈ ™¯ÔÏÂ›Ô ª¤ÁÂıÔ˜ ÔÈÎÔÁ¤ÓÂÈ·˜, ̤ÛË ± ™∞ ∞‰¤ÏÊÈ·, ̤ÛË ± ™∞
62±43 1,4
55,8±43,6 0,008 1,2 0,411
97 (17)· 261 (46) 355 (61,5) 180 (31,5) 217 (38) 175 (30,5)
162 (18) 439 (50) 482 (55) 245 (28) 402 (45) 237 (27)
0,514 0,138 0,004 0,116 0,005 0,110
3,7±0,77 0,7±0,83
3,7±0,76 0,7±0,76
0,530 0,619
P
·
√È ·ÚÈıÌÔ› ÛÙËÓ ·Ú¤ÓıÂÛË ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ÔÛÔÛÙ¿ % ™∞ ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË
ӷη 1. ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ·È‰ÈÎfi ÛÙ·ıÌfi ‹ Û¯ÔÏ›Ô. ¶ÂÚ›Ô˘ ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ Ì ÁÚ›Ë ‹Ù·Ó οو ÙˆÓ 5 ÂÙÒÓ. ∏ ËÏÈÎȷ΋ ηٷÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ∏ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· ‹Ù·Ó Ë ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋. ∫·Ù·ÁÚ¿ÊËΠÛÙÔ 15% ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ·Ú¯È΋ ÂͤٷÛË Î·È ÛÙÔ 18,5% ÛÙÔ follow-up (∂ÈÎfiÓ· 3). µÚÔÁ¯ÈÔÏ›Ùȉ·, ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· Î·È Ó¢ÌÔÓ›· ‹Ù·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ ÛÙÔ˘˜ ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∞Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ‚¿ÛË ÙËÓ ËÏÈÎȷ΋ ηٷÓÔÌ‹ ÙˆÓ ıÂÙÈÎÒÓ ·ÛıÂÓÒÓ ¤‰ÂÈÍ fiÙÈ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· ‰È·ÁÓÒÛÙËΠÙÂÏÈο ÈÔ Û˘¯Ó¿ ÛÙ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ Î·È Û ·˘Ù¿ ËÏÈΛ·˜ ≥2 ¤ˆ˜ <5 ÂÙÒÓ Û ۇÁÎÚÈÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· ≥5 ¤ˆ˜
90 ∆∂¶
80
π‰ÈˆÙÈο π·ÙÚ›·
£ÂÙÈÎÔ› ·ÛıÂÓ›˜ %
70 60 50 40 30 20 10 11
9
7
5
3
1
51
20
18
16
14
12
10
8
6
0 2003 ∂‚‰ÔÌ¿‰Â˜ 2004 ∂ÈÎfiÓ· 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Áڛ˘ Û ·È‰È¿ Ì Â̇ÚÂÙË Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· Â͈ÙÂÚÈο ·È‰È·ÙÚÈο È·ÙÚ›· ‹ Û ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÂȉËÌÈÒÓ Áڛ˘ Ù˘ ÌÂϤÙ˘ (2002-2004). ¶·È‰È·ÙÚÈ΋ 2008;71:55-61
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·58
58
ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ¶·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ Ì ÁÚ›Ë
80
÷ڷÎÙËÚÈÛÙÈο
60 40
13-<14
12-<13
11-<12
9-<10
10-<11
8-<9
7-<8
6-<7
5-<6
4-<5
3-<4
2-<3
0
1-<2
20 0,5-<1
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ
100
∏ÏÈΛ· (¤ÙË) ∂ÈÎfiÓ· 2. ∏ÏÈÎȷ΋ ηٷÓÔÌ‹ ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ.
<14 ÂÙÒÓ (p=0,001) (¶›Ó·Î·˜ 3). §·Ú˘ÁÁ›Ùȉ· (croup) ÛÙȘ ·Ú·¿Óˆ ÔÌ¿‰Â˜ ÂΉËÏÒıËÎÂ Û˘¯ÓfiÙÂÚ· ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ (p=0,002) (¶›Ó·Î·˜ 3). ∞Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ‚¿ÛË ÙÔÓ ÙfiÔ ÂͤٷÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ¤‰ÂÈÍ fiÙÈ ÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· ‹Ù·Ó Û˘¯ÓfiÙÂÚÔ ÛÙÔ˘˜ ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· (14/90, 15,5%), Û ۇÁÎÚÈÛË Ì ٷ ∆∂¶ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ (32/483, 6,6%) (p=0,004). ¢ÂÓ ˘‹ÚÍ·Ó ¿ÏϘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·Ù¿ ËÏÈΛ·, ¤ÙÔ˜ Î·È ÙfiÔ ÂͤٷÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ ̤ÛË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë ‹Ù·Ó 8,4 Ë̤Ú˜ Î·È ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÙˆÓ ·ÚÓËÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ. ¢ÂÓ ˘‹ÚÍ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË Ì¤ÛË ‰È¿ÚÎÂÈ· ·Ô˘Û›·˜ ·fi ÙÔ Û¯ÔÏÂ›Ô Î·È ÙÔÓ ·È‰ÈÎfi ÛÙ·ıÌfi ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ. √È ıÂÙÈÎÔ› ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜ ÂÈÛΤÊÙËÎ·Ó ÙÔÓ È·ÙÚfi 1,36 ÊÔÚ¤˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ûı¤ÓÂÈ¿˜ ÙÔ˘˜. ∂ÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹Ù·Ó ··Ú·›ÙËÙË ÁÈ· ÙÔ 5,4% ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë Î·È ÁÈ· ÙÔ 7,7% ÙˆÓ ·ÛıÂÓÒÓ Ì ¿ÏϘ ÏÔÈÌÒÍÂȘ (p=0,165) (¶›Ó·Î·˜ 2). ∫·Ù¿ ÙËÓ ·Ú¯È΋ ÂͤٷÛË ÙˆÓ ·ÛıÂÓÒÓ, ·ÓÙÈ‚ÈÔÙÈο ¯ÔÚËÁ‹-
µÚÔÁ¯ÔÏ›Ùȉ·
(P=0,005)
∞Ì˘Á‰·Ï›Ùȉ·
(P=0,002)
ª˘ÔÛ›Ùȉ·
∞ÚÓËÙÈÎÔ› £ÂÙÈÎÔ›
(P=0,13)
¶·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·
(P=0,579)
Croup
(P=0,203)
¶Ó¢ÌÔÓ›·
(P=0,002) (P=0,001)
µÚÔÁ¯ÈÎfi ¿ÛıÌ·
(P=0,005)
√ªø 0
5
10
15
20
25
30
∂ÈÎfiÓ· 3. ∂ÈÏÔΤ˜ Û ıÂÙÈÎÔ‡˜ Î·È ·ÚÓËÙÈÎÔ‡˜ ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜. Paediatriki 2008;71:55-61
¢È¿ÚÎÂÈ· Û˘Ìو̿وÓ, ̤ÛË ± ™∞, Ë̤Ú˜ ∞Ô˘Û›· ·fi Û¯ÔÏ›Ô, ̤ÛË ± ™∞, Ë̤Ú˜ ∞Ô˘Û›· ·fi ·È‰ÈÎfi ÛÙ·ıÌfi, ̤ÛË ± ™∞, Ë̤Ú˜ ¡Ô È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ ∂ÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ∞ÓÙÈ‚ÈÔÙÈο µÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ∂ÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹ ™˘ÛÙËÌ·ÙÈο ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹ ∞ÓÙȂ˯Èο
°Ú›Ë (+) °Ú›Ë (-) N=392 N=452
P
8,4±5,7
7,3±4,4
0,002
5,2±5,5
5,9±5,1
0,302
9,2±8,19 1,4±0,96 21 (5,4)· 153 (39,5) 52 (13,3)
7,6±6,2 1,3±0,52 35 (7,7) 260 (57,6) 120 (26,5)
0,069 0,078 0,165 <0,0001 <0,0001
21 (5,4)
68 (15)
<0,0001
8 (2) 8 (1,8) 0,772 216 (55,4) 295 (65,3) 0,003
·
√È ·ÚÈıÌÔ› ÛÙËÓ ·Ú¤ÓıÂÛË ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ÔÛÔÛÙ¿ % ™∞ ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË
ıËÎ·Ó ÛÙÔ 18,5% ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ, ΢ڛˆ˜ ÏfiÁˆ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜. ∫·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ‰È·ÈÛÙÒıËΠfiÙÈ ·ÓÙÈ‚ÈÔÙÈο ¤Ï·‚ ÙÂÏÈο ÂÚ›Ô˘ ÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ. ∞ÓÙÈ‚ÈÔÙÈο, ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È ÂÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹ ¤Ï·‚·Ó Û˘¯ÓfiÙÂÚ· ÔÈ ·ÚÓËÙÈÎÔ› ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜ (¶›Ó·Î·˜ 2). ∞Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ‚¿ÛË ÙËÓ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ¤‰ÂÈÍ fiÙÈ ·ÓÙÈ‚ÈÔÙÈο Û˘ÓÙ·ÁÔÁÚ·Ê‹ıËÎ·Ó Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ Ì ÁÚ›Ë, Û ۇÁÎÚÈÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (p=0,027) (¶›Ó·Î·˜ 3). ∞ÓÙȂ˯Èο ÛÈÚfiÈ· ‰fiıËÎ·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ Û ۇÁÎÚÈÛË Ì ÂΛӷ ËÏÈΛ·˜ ≥2 ¤ˆ˜ <5 ÂÙÒÓ Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· (p=0,017) (¶›Ó·Î·˜ 3). µÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο, ÂÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹ Î·È ·ÓÙȂ˯Èο Ê¿Ú̷η Û˘ÓÙ·ÁÔÁÚ·Ê‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ˘˜ ȉÈÒÙ˜ ·È‰È¿ÙÚÔ˘˜. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ 90 ıÂÙÈÎÔ‡˜ ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›· ‰ÂÓ ÂÈÛ‹¯ıË ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂÓÒ 21/302 (6,8%) Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ›ÁÔÓÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÂÈÛ‹¯ıËÛ·Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô. √È ÁÔÓ›˜ ¤¯·Û·Ó ηٿ ̤ÛÔ fiÚÔ 1,34 ÂÚÁ¿ÛÈ̘ Ë̤Ú˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÙÔ˘ οı ¿ÚÚˆÛÙÔ˘ ·È‰ÈÔ‡. ∏ ‰È¿ÚÎÂÈ· ·Ô˘Û›·˜ ·fi ÙËÓ ÂÚÁ·Û›· ‹Ù·Ó ›‰È· ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ÙˆÓ ıÂÙÈÎÒÓ Î·È ÙˆÓ ·ÚÓËÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ. ¢Â˘ÙÂÚÔÁÂÓ‹˜ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙ· ̤ÏË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·ÛıÂÓÒÓ (58,2% ¤Ó·ÓÙÈ 40%, p<0,001). √È ‰È·ÊÔÚ¤˜ ‹Ù·Ó ÛËÌ·ÓÙÈΤ˜ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ (·Ù¤Ú·˜ 21,9% ¤Ó·ÓÙÈ 11,8%, p<0,001, ÌËÙ¤Ú· 27,2% ¤Ó·ÓÙÈ 14,4, p<0,001) ¿ÏÏ· fi¯È ÁÈ· Ù·
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·59
59
√È Û˘Ó¤ÂȘ Ù˘ Áڛ˘
¶›Ó·Î·˜ 3. ™˘ÁÎÚÈÙÈο ·ÔÙÂϤÛÌ·Ù· ÌÂٷ͇ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ·È‰ÈÒÓ
>6-23 ÌËÓÒÓ 24-59 ÌËÓÒÓ >59 ÌËÓÒÓ P
√Í›· ̤ÛË ˆÙ›Ùȉ·
§·Ú˘ÁÁ›Ùȉ·
∞ÓÙÈ‚ÈÔÙÈο
∞ÓÙȂ˯Èο
20 (27,8%) 35 (22,6%) 3. 17 (10,5%) 0,001
6 (8,3%) 3 (1,9%) 1 (0,6%) 0,002
35 (48,6%) 66 (42,9%) 52 (32,5%) 0,027
22 (30,6%) 69 (44,5%) 83 (51,2%) 0,017
·‰¤ÏÊÈ· (35,3% ¤Ó·ÓÙÈ 34%, p=0,734). ™ÙȘ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó ıÂÙÈÎÔ› ÁÈ· ÁÚ›Ë, Ë ·Ó¿ÁÎË È·ÙÚÈ΋˜ ›Û΄˘ Î·È ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚË. ∂›Û˘, Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂÌÊ¿ÓÈÛ·Ó Û˘¯ÓfiÙÂÚ· Ù· ·‰¤ÏÊÈ· ÙˆÓ ıÂÙÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó ÌÈÎÚfiÙÂÚ· ·fi 5 ÂÙÒÓ (44/141 ·‰¤ÏÊÈ·, 31,2%) Û ۇÁÎÚÈÛË Ì ٷ ÌÂÁ·Ï‡ÙÂÚ· (24/128, 18,8%) (p=0,003).
™˘˙‹ÙËÛË ™ÙËÓ ÚÔÔÙÈ΋ ·˘Ù‹ ÌÂϤÙË, Ô˘ ‚·Û›ÛÙËΠÛÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ÂȂ‚·›ˆÛË Ù˘ Áڛ˘, ·ÂÈÎÔÓ›˙ÂÙ·È Ë Â›‰Ú·ÛË Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ÛÙ· ·È‰È¿ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜ ÛÙËÓ ÎÔÈÓfiÙËÙ·, ηıÒ˜ Î·È Ë ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ ·fi ·˘Ù‹. ™ÙËÓ ¤Ú¢ӷ ·˘Ù‹ ¤Ï·‚ ̤ÚÔ˜ ¤Ó·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ, ÔÈ ÔÔ›ÔÈ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙ· ›ÁÔÓÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ‹ Û ȉȈÙÈο ·È‰È·ÙÚÈο È·ÙÚ›·, Î·È Ë ÌÂϤÙË Û˘Ó¯›ÛÙËΠÁÈ· ‰‡Ô ‰È·‰Ô¯Èο ¤ÙË. ¢È·ÈÛÙÒıËΠfiÙÈ Ë ÁÚ›Ë ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙ· ·È‰È¿ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜ ÛÙËÓ ÎÔÈÓfiÙËÙ· οı ¯ÚfiÓÔ. ∏ ‰È¿ÚÎÂÈ· Ù˘ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ Áڛ˘ ‹Ù·Ó 13-14 ‚‰ÔÌ¿‰Â˜ Î·È fi¯È 4-6 ‚‰ÔÌ¿‰Â˜, fiˆ˜ ‹Ù·Ó ÁÓˆÛÙfi ̤¯ÚÈ ÚfiÛÊ·Ù·. ∫·Ù¿ ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi, Ë ÓfiÛÔ˜ ÚÔοÏÂÛ ÙÔ 40% ÙˆÓ ÂÈÛΤ„ÂˆÓ ÁÈ· Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ˘ÚÂÙfi Î·È ÙÔ 13,5% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÈÛΤ„ÂˆÓ ÛÙ· ›ÁÔÓÙ· ·È‰È·ÙÚÈο È·ÙÚ›· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 14 ÂÙÒÓ. ∆Ô Ì‹Ó· ̤ÁÈÛÙ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, Ô Èfi˜ Ù˘ Áڛ˘ ¢ı˘ÓfiÙ·Ó ÁÈ· ÔÛÔÛÙfi >50% fiÏˆÓ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ˘ÚÂÙfi, ηıÒ˜ Î·È ÁÈ· ÙÔ 25% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÈÛΤ„ÂˆÓ ÛÙ· ·È‰È·ÙÚÈο È·ÙÚ›· ÙÔ˘ ∆∂¶. ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ‚·ÛÈṲ̂ÓË Û ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ, ÙÔ ÔÛÔÛÙfi Áڛ˘ Û ·È‰È¿ οو ÙˆÓ 3 ÂÙÒÓ ‹Ù·Ó Ù˘ ٿ͈˜ ÙÔ˘ 24% ¤ˆ˜ 35% ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ· (3). ∞ÎfiÌË Î·È ·Ó ¿ÏÏÔÈ ÈÔ› ΢ÎÏÔÊÔÚÔ‡Ó Ù·˘Ùfi¯ÚÔÓ· ηٿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜, Ê·›ÓÂÙ·È fiÙÈ Ë ÁÚ›Ë ˘ÂÚ¤¯ÂÈ Î·È Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙȘ Ù¤ÛÛÂÚȘ ‚‰ÔÌ¿‰Â˜ Ù˘ ·È¯Ì‹˜ Ù˘ ÓfiÛÔ˘. ªfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi (5%) ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÙÂÏÈ-
ο ÓÔÛËχÙËÎ·Ó Î·È ·˘Ùfi ˘ÔÁÚ·ÌÌ›˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ Ù˘ ÓÔÛËÚfiÙËÙ·˜ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË ÓfiÛÔ ·ÊÔÚ¿ ÙÔ˘˜ Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ Ú·ÁÌ·ÙÈ΋ ›‰Ú·ÛË Ù˘ Áڛ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· Èı·ÓÒ˜ Ó· ¤¯ÂÈ ˘ÔÂÎÙÈÌËı› Û ·˘Ù‹ ÙË ÌÂϤÙË. ™ÙË ÌÂϤÙË, Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÌfiÓÔ ·ÛıÂÓ›˜ Ì Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ˘ÚÂÙfi (14). ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˘ ÌÂıfi‰Ô˘ (15,16). ∞ÎfiÌË, Ô Èfi˜ ÙË Áڛ˘ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ·ÓȯÓ‡ÛÈÌÔ˜ ÛÙÔÓ ÚÈÓÔÊ¿Ú˘ÁÁ·, Â¿Ó ¤¯Ô˘Ó ÂÚ¿ÛÂÈ ·ÚÎÂÙ¤˜ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ô ·ÛıÂÓ‹˜ ÚÔÛ¤Ú¯ÂÙ·È Ì ÂÈÏÔΤ˜ Ù˘ ÓfiÛÔ˘ (17). ∆¤ÏÔ˜, Èı·Ófiٷٷ Ó· ›¯·Ì ¤Ó· ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÂÙÈÎÒÓ ÁÈ· ÁÚ›Ë ‰ÂÈÁÌ¿ÙˆÓ, Â¿Ó ·ÓÙ› ÁÈ· ÚÈÓÈÎfi ›¯ÚÈÛÌ· ›¯Â ¯ÚËÛÈÌÔÔÈËı› ÚÈÓÔÊ·Ú˘ÁÁÈÎfi ¤ÎÏ˘Ì· Î·È ·Ó ›¯Â ÂÊ·ÚÌÔÛı› ̤ıÔ‰Ô˜ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). √È ·ÛıÂÓ›˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ÁÚ›Ë ‹Ù·Ó ËÏÈÎȷο ÌÂÁ·Ï‡ÙÂÚÔÈ ·fi ·˘ÙÔ‡˜ Ô˘ ‹Ù·Ó ·ÚÓËÙÈÎÔ› Î·È ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Û˘¯ÓfiÙÂÚ· ·È‰ÈÎfi ÛÙ·ıÌfi ‹ Û¯ÔÏ›Ô, ÏfiÁˆ Û˘Á¯ÚˆÙÈÛÌÔ‡. ¶ÔÛÔÛÙfi ÂÚ›Ô˘ 60% ÙˆÓ ·ÛıÂÓÒÓ Ì ÁÚ›Ë ‹Ù·Ó οو ÙˆÓ 5 ÂÙÒÓ. ∏ ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ Áڛ˘ ‹Ù·Ó Ë ÔÍ›· ̤ÛË ˆÙ›Ùȉ· Î·È ÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·. ∆· ÛÙÔȯ›· ·˘Ù¿ Û˘ÌʈÓÔ‡Ó Ì ÂΛӷ ÚfiÛÊ·ÙˆÓ ÌÂÏÂÙÒÓ (13,14). ™ËÌÂÈÒÓÂÙ·È, ›Û˘, fiÙÈ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î·È Ó¢ÌÔÓ›· ‹Ù·Ó ÈÔ Û˘¯Ó¤˜ ÛÙÔ˘˜ ·ÚÓËÙÈÎÔ‡˜ ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜. ¶·ÚfiÏ· ·˘Ù¿, ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÁÚ›Ë ÚÔηÏ› ÙÔ 33% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜, ÙÔ 40% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ï·Ú˘ÁÁÔÙÚ·¯ÂÈÔ‚ÚÔÁ¯›Ùȉ·˜, ÙÔ 25% ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Î·È ÙÔ 17% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ó¢ÌÔÓ›·˜ ÛÙÔ˘˜ Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 13-14 ‚‰ÔÌ¿‰ˆÓ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ Áڛ˘ ÁÈ· ‰‡Ô Û˘Ó¯fiÌÂÓ· ¤ÙË. ™Â Û˘Ìʈӛ· Ì ٷ ˆ˜ ¿Óˆ Â˘Ú‹Ì·Ù· Â›Ó·È Î·È ·˘Ù¿ ÚÔËÁÔ‡ÌÂÓˆÓ ÌÂÏÂÙÒÓ, ÛÙȘ Ôԛ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ Áڛ˘ Ë Û˘¯ÓfiÙËÙ· Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ÌÂÈÒÓÂÙ·È Î·Ù¿ 30%-36% (18,19,20). ∆· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ (76%) Î·È 9/10 ÂÚÈÙÒÛÂȘ Ï·Ú˘ÁÁÔÙÚ·¯ÂÈÔ‚ÚÔÁ¯›Ùȉ·˜ ÂÌÊ·Ó›ÛÙËÎ·Ó Û ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ. ¶·È‰È·ÙÚÈ΋ 2008;71:55-61
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ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.
∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ Û˘Ó‰¤ÂÙ·È Ì ·ÏfiÁÈÛÙË ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ¢È·ÈÛÙÒıËΠfiÙÈ ÂÚ›Ô˘ 40% ÙˆÓ ·ÛıÂÓÒÓ ¤Ï·‚ ·ÓÙÈ‚ÈÔÙÈο ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ ÌÂ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. ∞˘Ù¿ Ù· ÛÙÔȯ›· Û˘ÌʈÓÔ‡Ó Ì ÛÙÔȯ›· ·fi ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (3,13,14). ¶Èı·Ófiٷٷ, Ë ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ó· ‹Ù·Ó ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË, Â¿Ó ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰ÔÎÈÌ·Û›·˜ Ù·¯Â›·˜ ‰È¿ÁÓˆÛ˘ ‰ÂÓ ÁÈÓfiÙ·Ó ÁÓˆÛÙfi (21). ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ›وÛË Î·È ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ·ÛıÂÓÒÓ. ∆Ô ÔÛÔÛÙfi ‰Â‡ÙÂÚÔ˘ ÂÂÈÛÔ‰›Ô˘ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, Ô˘ ÂÎÙÈÌ¿Ù·È Û 17%, Â›Ó·È Û‡ÌʈÓÔ Ì ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (11,22,23) Î·È Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÚÓËÙÈÎÔ‡˜ ÁÈ· ÁÚ›Ë ·ÛıÂÓ›˜. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ˘Ô‰ËÏÒÓÔ˘Ó ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÓ‰ÔÔÈÎÔÁÂÓÂȷ΋˜ ÌÂÙ¿‰ÔÛ˘ Ù˘ Áڛ˘, Û ۇÁÎÚÈÛË Ì ¿ÏϘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. °È· οı ·ÛıÂÓ‹ Ì ÁÚ›Ë, ¯¿ıËΠ·fi ÙÔ˘˜ ÁÔÓ›˜ ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ·fi ÙËÓ ÂÚÁ·Û›· ÙÔ˘˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ ·ÏÏ¿ Î·È ÏfiÁˆ ·Ûı¤ÓÂÈ·˜ ÙˆÓ ›‰ÈˆÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· Â̇ÚÂÙ˘ Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ ÛÙËÓ ÎÔÈÓfiÙËÙ·, ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ·È¯Ì‹˜ Ù˘ ÂÙ‹ÛÈ·˜ ÂȉËÌ›·˜ Áڛ˘ Î·È Â›Ó·È ¿ÌÂÛ· Û˘Ó‰Â‰Â̤ÓË Ì ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ˘ÂÚ‚ÔÏÈ΋, ÔÏϤ˜ ÊÔÚ¤˜ ·ÏfiÁÈÛÙË, ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ªfiÓÔ ÌÈÎÚfi ÔÛÔÛÙfi ·È‰ÈÒÓ Ì ÁÚ›Ë ÓÔÛËχÂÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ·˘Ùfi Ô‰ËÁ› ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÊÔÚÙ›Ô Ù˘ ÓfiÛÔ˘ ·ÊÔÚ¿ ÙÔ˘˜ Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ Ïԛ̈ÍË ·fi ÙË ÁÚ›Ë ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË Î·È ÛÙ· ¿ÏÏ· ̤ÏË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔÛ‚¿ÏÏÔÓÙ·È ÚÔηÏÒÓÙ·˜ ÓfiÛÔ, È·ÙÚÈΤ˜ ÂÈÛΤ„ÂȘ, ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È ·ÒÏÂÈ· ˆÚÒÓ ÂÚÁ·Û›·˜. ∆Ô 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Áڛ˘ Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÂÈÏÔÎÒÓ ·ÊÔÚ¿ ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, ÂÔ̤ӈ˜, Ë ÂÊ·ÚÌÔÁ‹ ηıÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ûã ·˘Ù‹Ó ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ı· ÌÔÚÔ‡Û ӷ ÌÂÈÒÛÂÈ ÙËÓ Â›ÙˆÛË Ù˘ Áڛ˘ ÛÙËÓ ÎÔÈÓfiÙËÙ· Î·È ÙȘ Û˘Ó¤ÂȤ˜ Ù˘ ÛÙÔ Û‡ÛÙËÌ· ˘Á›·˜.
∂˘¯·ÚÈÛٛ˜ £ÂṲ́˜ ¢¯·ÚÈÛٛ˜ ÛÙËÓ Î˘Ú›· ŒÏÂÓ· ∫ÚÈÙÛ¤ÏË ÁÈ· ÙË ‚Ô‹ıÂÈ¿ Ù˘ ÛÙË ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ‰ÈÔÚıÒÛÂˆÓ ÙÔ˘ ÎÂÈ̤ÓÔ˘.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Mullooly JP, Barker WH. Impact of type A influenza on children: a retrospective study. Am J Public Health 1982;72:1008-1016. 2. Glezen WP, Decker M, Joseph SW, Mercready RG Jr. Acute respiratory disease associated with influenza epiPaediatriki 2008;71:55-61
demics in Houston, 1981-1983. J Infect Dis 1987;155:11191126. 3. Neuzil KM, Mellen BG, Wright PF, Mitchel EF Jr, Griffin M. The effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children. N Engl J Med 2000;342:225-231. 4. Izurieta HS, Thompson WW, Kramarz P, Shay DK, Davis RL, DeStefano F, et al. Influenza and the rates of hospitalization for respiratory disease among infants and young children. N Engl J Med 2000;342:232-239. 5. Neuzil KM, Zhu Y, Griffin MR, Edwards KM, Thompson JM, Tollefson SJ, et al. Burden of interpandemic influenza in children younger than 5 years: a 25-year prospective study. J Infect Dis 2002;185:147-152. 6. Bridges CB, Harper SA, Fukuda K, Uyeki TM, Cox NJ, Singleton JA; Advisory Committee on Immunization Practices. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2003;52(RR-8):1-34. 7. Glezen WP, Taber LH, Frank AL, Gruber WC, Piedra PA. Influenza virus infections in infants. Pediatr Infect Dis J 1997;16:1065-1068. 8. Hurwitz ES, Haber M, Chang A, Shope T, Teo ST, Giesick JS, et al. Studies of the 1996-1997 inactivated influenza vaccine among children attending day care: immunologic response, protection against infection, and clinical effectiveness. J Infect Dis 2000;182:1218-1221. 9. Hurwitz ES, Haber M, Chang A, Shope T, Teo S, Ginsberg M, et al. Effectiveness of influenza vaccination of day care children in reducing influenza-related morbidity among household contacts. JAMA 2000;284:1677-1682. 10. Longini IM Jr, Koopman JS, Monto AS, Fox JP. Estimating household and community transmission parameters for influenza. Am J Epidemiol 1982;115:736-751. 11. Frank AL, Taber LH, Glezen WP, Geyer EA, McIlwain S, Paredes A. Influenza B virus infections in the community and the family. The epidemics of 1976-1977 and 1979-1980 in Houston, Texas. Am J Epidemiol 1983;118:313-325. 12. Reichert TA, Sugaya N, Fedson DS, Glezen WP, Simonsen L, Tashiro M. The Japanese experience with vaccinating schoolchildren against influenza. N Engl J Med 2001;344: 889-896. 13. Heikkinen T, Silvennoinen H, Peltola V, Ziegler T, Vainionpaa R, Vuorinen T, et al. Burden of influenza in children in the community. J Infect Dis 2004;190:1369-1373. 14. Principi N, Esposito S, Gasparini R, Marchisio P, Crovari P; Flu-Flu Study Group. Burden of influenza in healthy children and their households. Arch Dis Child 2004;89:1002-1007. 15. Uyeki TM. Influenza diagnosis and treatment in children: a review of studies on clinically useful tests and antiviral treatment for influenza. Pediatr Infect Dis J 2003;22:164177. 16. Zambon M, Hays J, Webster A, Newman R, Keene O. Diagnosis of influenza in the community: relationship of clinical diagnosis to confirmed virological, serologic, or molecular detection of influenza. Arch Intern Med 2001;161:2116-2122. 17. Neuzil KM, Zhu Y, Griffin MR, Edwards KM, Thompson JM, Tollefson SJ, et al. Burden of interpandemic influenza in children younger than 5 years: a 25-year prospective study. J Infect Dis 2002;185:147-152.
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√È Û˘Ó¤ÂȘ Ù˘ Áڛ˘
18. Heikkinen T, Ruuskanen O, Waris M, Ziegler T, Arola M, Halonen P. Influenza vaccination in the prevention of acute otitis media in children. Am J Dis Child 1991;145: 445-448. 19. Clements DA, Langdon L, Bland C, Walter E. Influenza A vaccine decreases the incidence of otitis media in 6- to 30month-old children in day care. Arch Pediatr Adolesc Med 1995;149:1113-1117. 20. Belshe RB, Mendelman PM, Treanor J, King J, Gruber WC, Piedra P, et al. The efficacy of live attenuated, cold-adapted, trivalent, intranasal influenzavirus vaccine in children. N Engl J Med 1998;338:1405-1412.
21. Noyola DE, Demmler GJ. Effect of rapid diagnosis on management of influenza A infections. Pediatr Infect Dis J 2000;19:303-307. 22. Hayden FG, Belshe RB, Clover RD, Hay AJ, Oakes MG, Soo W. Emergence and apparent transmission of rimantadine-resistant influenza A virus in families. N Engl J Med 1989;321:1696-1702. 23. White T, Lavoie S, Nettleman MD. Potential cost savings attributable to influenza vaccination of school-aged children. Pediatrics 1999;103:e73.
™ˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÙÔ˘ Quiz ÁÈ· ÙÔ ¿ÚıÚÔ “ƒÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜: Â›Ó·È ·ÎfiÌ· ‰Ò!” 1. ∏ ˘„ËÏfiÙÂÚË Â›ÙˆÛË ÙÔ˘ ƒ¶ ·Ú·ÙËÚ›ٷÈ: ·. ™Ù· ·È‰È¿ ÚÈÓ ·fi ÙËÓ ÂÊ˂›· 2. √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ƒ∫ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜: Á. ™ÙÔ˘˜ ÂÓ‹ÏÈΘ 3. ∏ ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁ›Ùȉ·˜ ›ӷÈ: ·. 10 Ë̤Ú˜ 4. ŒÊË‚Ô˜ 17 ÂÙÒÓ Ì ‹È· ·Ó¿ÚÎÂÈ· ÌÈÙÚÔÂȉԇ˜, ÏfiÁˆ ÔͤԘ ƒ¶, ÂÊfiÛÔÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÂÈ ¿ÏÏÔ ÂÂÈÛfi‰ÈÔ, ı· Ú¤ÂÈ Ó· ¿ÚÂÈ ÚfiÏË„Ë: Á. ø˜ ÙÔ 25Ô ¤ÙÔ˜ 5. ¶ÔÈÔ˜ ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ¤¯ÂÈ ÙÂÎÌËÚȈ̤ÓÔ ƒ¶: Á. ∫·È ÔÈ ‰‡Ô 6. 10¯ÚÔÓÔ˜ Ì ˘ÚÂÙfi, ·ÚıÚ·ÏÁ›·, Û˘Ìو̷ÙÔÏÔÁ›· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È Û˘ÛÙÔÏÈÎfi ʇÛËÌ· 3/6 ÛÙËÓ ÎÔÚ˘Ê‹ Ì ¤ÎÙ·ÛË ÛÙË Ì·Û¯¿ÏË ¤¯ÂÈ ÙÂÎÌËÚȈ̤ӷ ƒ¶, ÂÊfiÛÔÓ Û˘Ó˘¿Ú¯ÂÈ: ‚. ™ÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· ÚÔ 2-3 ‚‰ÔÌ¿‰ˆÓ
¶·È‰È·ÙÚÈ΋ 2008;71:55-61
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™˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË - ·ÓÙÈÌÂÙÒÈÛË ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
¢. π. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜
AÏÏËÏÔÁÚ·Ê›·: ¢ËÌ‹ÙÚÈÔ˜ π. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜ geodim4@hotmail.com ∫·Ú‰ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
ÙÂÚÔ ·›ÙÈÔ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Â›Ó·È Ë Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹, Ë ÔÔ›· Â›Ó·È ÌÈ· ηÏÔ‹ı˘ ηٿÛÙ·ÛË, Ì Ôχ ηϋ ÚfiÁÓˆÛË ÛÙË ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ ‚·Û›˙ÂÙ·È ÛÙÔ ÏÂÙÔÌÂÚ¤˜ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi Î·È ÛÙËÓ ÚÔÛÂÎÙÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË. ∞fi ÙÔ ÈÛÙÔÚÈÎfi ·Ó·˙ËÙ¿Ù·È È‰È·›ÙÂÚ· Ë ‡·ÚÍË ÂÂÈÛÔ‰›Ô˘ ·ÈÊÓȉ›Ô˘ ı·Ó¿ÙÔ˘ ÛÂ Û˘ÁÁÂÓÈÎfi ¿ÙÔÌÔ Ó·ڋ˜ ËÏÈΛ·˜, Ë ·ÚÔ˘Û›· ÛÙÔÓ ·ÛıÂÓ‹ ÁÓˆÛÙ‹˜ ηډȷ΋˜ ÓfiÛÔ˘, ÂÓÒ ‰ÈÂÚ¢ÓÒÓÙ·È Î·È ÔÈ ·ÎÚȂ›˜ Û˘Óı‹Î˜ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ Î·È Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi Î·È ÛÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ·Ó·˙ËÙÒÓÙ·˜ ÛËÌ›· ηډȷ΋˜ ‹ Ó¢ÚÔÏÔÁÈ΋˜ ·ı‹Ûˆ˜. ∞fi ÙȘ ·Ú·ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ··Ú·›ÙËÙÔ ÎÚ›ÓÂÙ·È ÙÔ ∏∫°, ÂÓÒ ÔÈ ˘fiÏÔȘ ·ÔÊ·Û›˙ÔÓÙ·È Ì ‚¿ÛË Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ ¯ÚÂÈ¿˙ÂÙ·È ÛÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ Û¿ÓÈˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ú‰ÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜ Î·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·fi Ù· ÂÂÈÛfi‰È· Û·ÛÌÒÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ó¢ÚÔηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ Ì ÂÊ·ÚÌÔÁ‹ ·ÏÒÓ Ì¤ÙÚˆÓ ÚfiÏ˄˘. ∫·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Ô Î·ıËÛ˘¯·ÛÌfi˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ë Âη›‰Â˘Û‹ ÙÔ˘ ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ.
¶ÂÚ›ÏË„Ë: ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Â›Ó·È Ôχ Û˘¯Ó¿ ηٿ ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ∆Ô Û˘¯Ófi-
§¤ÍÂȘ ÎÏÂȉȿ: ™˘ÁÎÔ‹, ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘, Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹.
Syncopal episodes in childhood and adolescence: diagnosis - management Cardiology Department, “P. & A. Kyriakou” Children’s Hospital, Athens, Greece Correspondence: Dimitrios π. Georgakopoulos geodim4@hotmail.com Cardiology Department, “P. & A. Kyriakou” Children’s Hospital Thivon & Levadias St., 115 27, Athens, Greece
D. π. Georgakopoulos Abstract: Syncopal episodes are very frequent during childhood and adolescence. The most frequent form is the common faint or neurocardiogenic syncope, which is a benign situation with excellent prognosis in the majority of cases. The diagnosis of neurocardiogenic syncope is based on the history and the physical examination. From the history, it is elicited, among other information, whether there has ever been a sudden death in a family member at a young age and whether the patient suffers from a known heart disease. An effort is made to elucidate the exact circumstances of the episode and the condition of the patient during and immediately after the syncope. Physical examination is concentrated on the circulatory and nervous systems, to detect possible signs of a cardiac or neurological disease. An ECG is considered necessary in all cases, with other laboratory examinations according to the clinical findings. Special care must be given to the detection of the rare but potentially dangerous episodes of cardiogenic syncope. The vast majority of patients are treated with simple measures aimed at avoidance of potential triggers. The patients must be reassured and taught how to recognize the premonitory signs and what to do to avoid evolution to full syncope.
Key words: Syncope, loss of consciousness, cardiogenic syncope.
∂ÈÛ·ÁˆÁ‹ ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û˘¯Ó¿ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜. ø˜ Û˘ÁÎÔ‹ ÔÚ›˙ÂÙ·È Ë ·ÈÊÓ›‰È· Î·È ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘ Î·È ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Ô˘ ÔÊ›ÏÂÙ·È Û ·Ó·Ú΋ ·ÚÔ¯‹ ·›Ì·ÙÔ˜ ÛÙÔÓ ÂÁΤʷÏÔ, Ù˘ ÔÔ›·˜ Û˘Ó‹ıˆ˜ ÚÔËÁÔ‡ÓÙ·È Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· Ôχ Û‡ÓÙÔÌ˘ ‰È¿ÚÎÂÈ·˜ Î·È Ù˘ ÔÔ›·˜ ¤ÂÙ·È ·˘ÙfiÌ·ÙË, Ù·¯Â›· Î·È Ï‹Ú˘ ·ÔηٿÛÙ·ÛË (1). ™ÙÔ ¿ÚıÚÔ Paediatriki 2008;71:62-67
·Ó·Ê¤ÚÂÙ·È Ë ÂȉËÌÈÔÏÔÁ›·, Ë ·ıÔÊ˘ÛÈÔÏÔÁ›·, Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ ·ÈÙ›ˆÓ, Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜.
∂ȉËÌÈÔÏÔÁ›· ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Â›Ó·È Û˘¯Ó¿ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·, Ì ÙËÓ Â›ÙˆÛ‹ ÙÔ˘˜ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ Ì›· ·È¯Ì‹ ÂÚ› ÙËÓ ËÏÈΛ· ÙˆÓ 15 ÂÙÒÓ Î·È Ó· Â›Ó·È ‰‡Ô ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ· Û ۯ¤ÛË Ì ٷ
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ñ ¡Â˘ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ñ ∫·Ú‰ÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ñ ∫Ú¿ÙËÌ· ·Ó·ÓÔ‹˜ ñ æ˘¯ÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ñ √ÚıÔÛÙ·ÙÈ΋ ˘fiÙ·ÛË ñ ™‡Ó‰ÚÔÌÔ ÔÚıÔÛÙ·ÙÈ΋˜ Ù·¯˘Î·Ú‰›·˜ ñ ∞ÓÙ·Ó·ÎÏ·ÛÙÈ΋ Û˘ÁÎÔ‹ (‚‹¯·˜, Ô‡ÚËÛË, ·Êfi‰Â˘ÛË) ñ ∞Ó·ÈÌ›· ñ §‹„Ë Ô˘ÛÈÒÓ
ñ ∆·¯˘·ÚÚ˘ı̛˜ ñ µÚ·‰˘·ÚÚ˘ı̛˜ ñ ™Ù¤ÓˆÛË ·ÔÚÙ‹˜ ñ ÀÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ñ ∆ÂÙÚ·ÏÔÁ›· Fallot ñ ™Ù¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ ñ ¶Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ñ ™ÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ (Kawasaki, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ·ÚÙËÚÈÒÓ) ñ ¢È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ñ ª˘Ôηډ›Ùȉ·
·ÁfiÚÈ·. ∏ ›وۋ Ù˘ ÛÙÔ ÁÂÓÈÎfi ·È‰È·ÙÚÈÎfi Î·È ÂÊË‚ÈÎfi ÏËı˘ÛÌfi ÂÎÙÈÌ¿Ù·È ÛÙÔ 0,05% ¤ˆ˜ 0,3% (2), ·Ó ÏËÊıÔ‡Ó ˘fi„Ë Ù· ÂÂÈÛfi‰È·, Ù· ÔÔ›· ηٷϋÁÔ˘Ó ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ. ™ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· fï˜, Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È Ôχ ÌÂÁ·Ï‡ÙÂÚË ·Ó Û˘Ó˘ÔÏÔÁÈÛıÔ‡Ó Ù· ÂÂÈÛfi‰È· ÂΛӷ, Ù· ÔÔ›· ‰ÂÓ Êı¿ÓÔ˘Ó Ì¤¯ÚÈ ÙÔ˘ ÛËÌ›Ԣ Ó· ·Ó·˙ËÙ‹ÛÔ˘Ó È·ÙÚÈ΋ ‚Ô‹ıÂÈ·. Ÿˆ˜ Ê·›ÓÂÙ·È ·fi ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ÊÔÈÙËÙ¤˜ ËÏÈΛ·˜ 20 ÂÙÒÓ, ÙÔ 20% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 50% ÙˆÓ Á˘Ó·ÈÎÒÓ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ¤¯Ô˘Ó ÙËÓ ÂÌÂÈÚ›· ÂÓfi˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û˘ÁÎÔÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (3). ™˘ÁÎÚÈÙÈο, Ó· ÛËÌÂȈı› fiÙÈ Ë Â›ÙˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û·ÛÌÒÓ Û ·ÚfiÌÔȘ ËÏÈ˘ Î˘Ì·›ÓÂÙ·È ÂÚ› ÙÔ 0,5% (4). ∞Ó Î·È Ù· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È Î·ÏÔ‹ıË Î·È ·Î›Ó‰˘Ó·, ¯ÚÂÈ¿˙ÂÙ·È Ó· ‰Ôı› ȉȷ›ÙÂÚË ÚÔÛÔ¯‹, ÒÛÙ ӷ ÌËÓ ‰È·Ê‡ÁÔ˘Ó ÔÈ Û¿ÓȘ, ·ÏÏ¿ ‰˘ÓËÙÈο ÂÈΛӉ˘Ó˜, ÂÚÈÙÒÛÂȘ, Ô˘ ÔÊ›ÏÔÓÙ·È Û ηډȷο ·›ÙÈ·.
∞ÈÙÈÔÏÔÁ›· - ¶·ıÔÊ˘ÛÈÔÏÔÁ›· ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ·ÔÙÂÏÔ‡Ó Ì¤ÚÔ˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÒÏÂÈ·˜ Ù˘ Û˘Ó›‰ËÛ˘. TÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Û˘ÁÎÔ‹˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, Î·È Ì¿ÏÈÛÙ· Ì ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ ·fi Ù· ˘fiÏÔÈ·, Â›Ó·È Ë Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ (¡∫™), ÁÓˆÛÙ‹ Î·È ˆ˜ ÎÔÈÓ‹ ÏÈÔı˘Ì›· (5). ÕÏÏ· ·›ÙÈ· Â›Ó·È Ë Î·Ú‰ÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹, ÙÔ ÎÚ¿ÙËÌ· Ù˘ ·Ó·ÓÔ‹˜, Ë „˘¯ÔÁÂÓ‹˜ Û˘ÁÎÔ‹, Ë ÔÚıÔÛÙ·ÙÈ΋ ˘fiÙ·ÛË Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ÔÚıÔÛÙ·ÙÈ΋˜ Ù·¯˘Î·Ú‰›·˜ (¶›Ó·Î·˜ 1). ∆· ·›ÙÈ· Ù˘ ηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜, Ù· ÔÔ›·, ·Ó Î·È Û¿ÓÈ· ÛÙ· ·È‰È¿, ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ÂÈΛӉ˘Ó·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ¡∫™ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ·ÔÛ·ÊËÓÈÛı›. °ÂÓÈο, Ê˘ÛÈÔÏÔÁÈÎfi Â›Â‰Ô Û˘Ó›‰ËÛ˘ ‰È·ÙËÚÂ›Ù·È fiÙ·Ó ÂÍ·ÛÊ·Ï›˙ÂÙ·È ¤Ó· ··Ú·›ÙËÙÔ Â›Â‰Ô Ì¤Û˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì¤Ûˆ ·˘Ù‹˜ ΢ڛˆ˜ ÂϤÁ¯ÂÙ·È Ë ÂÁÎÂÊ·ÏÈ΋ ÚÔ‹ ·›Ì·ÙÔ˜ (1). ∏ Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Î·È Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÚÔ¯‹˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ·fi ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ̤ۈ ÂÓfi˜ ÔχÏÔÎÔ˘ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ·ÓÙ·-
Ó·ÎÏ·ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô Û‡ÛÙËÌ· ·˘Ùfi ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘˜ Ù·ÛÂԸԉԯ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔ ÙÔ›¯ˆÌ· ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ (Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·, ·ÓÈÔ‡Û· ·ÔÚÙ‹, ¤Ûˆ ηڈٛ‰Â˜) Î·È ÙÔ˘˜ Ì˯·ÓԸԉԯ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ÎÔÈÏÈÒÓ Ù˘ ηډȿ˜. ∏ ÈÔ ·Ô‰ÂÎÙ‹ ıˆڛ· Â›Ó·È fiÙÈ Ë ¡∫™ ¤¯ÂÈ ˆ˜ ·ÊÂÙËÚ›· ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÁÎÔ˘ ·›Ì·ÙÔ˜ Ô˘ ÂÈÛÙÚ¤ÊÂÈ ÛÙË ‰ÂÍÈ¿ Î·È ÙËÓ ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›·. ∏ ÂÏ¿ÙÙˆÛË ·˘Ù‹ ÙÔ˘ fiÁÎÔ˘ ·›Ì·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È ·fiÙÔÎÔ˜ ·Ê˘‰¿ÙˆÛ˘ ‹ ÌÂÙ·‚ÔÏÒÓ Ù˘ ı¤Ûˆ˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ (.¯. ·fi ηıÈÛÙ‹ Û fiÚıÈ· ı¤ÛË). ∏ ηډȿ ·ÓÙȉڿ ·˘Í¿ÓÔÓÙ·˜ ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ¿ Ù˘ Î·È ·ÔÛÙ¤ÏÏÔÓÙ·˜ ̤ۈ ÙˆÓ Ì˯·ÓÔ¸Ô‰Ô¯¤ˆÓ Î·È ÙˆÓ ÚÔÛ·ÁˆÁÒÓ ÈÓÒÓ C ÌËӇ̷ٷ ÛÙÔÓ ÂÁΤʷÏÔ, Ô ÔÔ›Ô˜ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Ì ÙË ÛÂÈÚ¿ ÙÔ˘ Î·È ÛÙ¤ÏÓÂÈ ··ÁˆÁ¿ ÂÚÂı›ÛÌ·Ù· ÛÙËÓ Î·Ú‰È¿ Î·È ÛÙ· ·ÁÁ›· ̤ۈ ÙÔ˘ ·˘ÙfiÓÔÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆· ÂÚÂı›ÛÌ·Ù· ·˘Ù¿ ÂÏ·ÙÙÒÓÔ˘Ó ÙÔÓ ÙfiÓÔ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Î·È ·˘Í¿ÓÔ˘Ó ÙÔÓ ÙfiÓÔ ÙÔ˘ ·Ú·Û˘Ì·ıËÙÈÎÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ˘fiÙ·ÛË Î·È ÙË ‚Ú·‰˘Î·Ú‰›·. ŸÙ·Ó Ë ·¿ÓÙËÛË ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ Â›Ó·È ˘¤ÚÌÂÙÚË Î·È ˘Âڂ› οÔÈÔ fiÚÈÔ, ÙfiÙ ÂΉËÏÒÓÂÙ·È Û˘ÁÎÔÙÈÎfi ÂÂÈÛfi‰ÈÔ. ™ÙË Û˘Ó¤¯ÂÈ·, ÌfiÏȘ Ô ·ÛıÂÓ‹˜ ¤ÛÂÈ ÛÙÔ ¤‰·ÊÔ˜, ·˘Í¿ÓÂÙ·È Ë ÊÏ‚È΋ ÂÈÛÙÚÔÊ‹ ÛÙËÓ Î·Ú‰È¿, Ô ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ‰È·ÎfiÙÂÙ·È Î·È ÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ ·Ôηı›ÛٷٷÈ.
∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ó¢ÚÔηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜ ∏ Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹, fiˆ˜ ÚԷӷʤÚıËÎÂ, Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÂȉÈο ÛÙ· ÎÔÚ›ÙÛÈ·. ™˘Ó‹ıË ÂÚÂı›ÛÌ·Ù· Â›Ó·È Ë ·fiÙÔÌË ·ÏÏ·Á‹ ı¤Ûˆ˜ (·fi ηıÈÛÙ‹ ‹ ͷψ̤ÓË Û fiÚıÈ·), Ë ·Ú·ÙÂٷ̤ÓË ÔÚıÔÛÙ·Û›· Î·È Î·Ù·ÛÙ¿ÛÂȘ Ô˘ ÚÔηÏÔ‡Ó ¤ÓÙÔÓÔ Êfi‚Ô ‹ fiÓÔ (.¯. ·ÈÌÔÏË„›·, ı¤· ·›Ì·ÙÔ˜). ™˘¯Ó¿, ÛÙÔ ›‰ÈÔ ¿ÙÔÌÔ, Ù· ÂÂÈÛfi‰È· ÚÔηÏÔ‡ÓÙ·È ¿ÏÏÔÙ Ì ÙÔ ¤Ó· Î·È ¿ÏÏÔÙ Ì ÙÔ ¿ÏÏÔ ÂÚ¤ıÈÛÌ·. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Â›Ó·È Ë ·Ê˘‰¿ÙˆÛË, Ë ¶·È‰È·ÙÚÈ΋ 2008;71:62-67
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·64
64
¢. π. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜
˙¤ÛÙË, Ô Û˘ÓˆÛÙÈÛÌfi˜, ÙÔ ¿Á¯Ô˜, Ë ·‰È·ıÂÛ›· Î·È Ë ·Ó·ÈÌ›·. ∆· ÂÂÈÛfi‰È· Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ì‚Ô‡Ó Î·È ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ·ÓȯÓ‡ÛÈÌÔ˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹ Î·È Ì ÙÔÓ ·ÛıÂÓ‹ Û ηıÈÛÙ‹ ı¤ÛË. ∂ÂÈÛfi‰È· ·ÒÏÂÈ·˜ Ù˘ Û˘Ó›‰ËÛ˘ Ô˘ ¤گÔÓÙ·È Û ηٷÎÂÎÏÈÌ̤ÓË ı¤ÛË Î·È ¯ˆÚ›˜ Ó· ¤¯ÂÈ ÚÔËÁËı› οÔÈÔ Û˘Ó·ÈÛıËÌ·ÙÈÎfi ÂÚ¤ıÈÛÌ· Â›Ó·È ·›ı·ÓÔ Ó· ÔÊ›ÏÔÓÙ·È Û ¡∫™. ™˘Ó‹ıˆ˜ ‰È·ÎÚ›ÓÔÓÙ·È ÙÚ›· ÛÙ¿‰È·: ·) ¶ÚÔÛ˘ÁÎÔÙÈ΋ Ê¿ÛË. ∏ ¤Ó·ÚÍË Â›Ó·È ·fiÙÔÌË. √ ·ÛıÂÓ‹˜ ÂÓ‰¤¯ÂÙ·È Ó· ·ÈÛı·Óı› ·‰˘Ó·Ì›·, ˙¿ÏË, ‰È·Ù·Ú·¯¤˜ Ù˘ ÔÚ¿Ûˆ˜, ÎÂÊ·Ï·ÏÁ›·, ÛÈÂÏfiÚÚÔÈ· Î·È Ó·˘Ù›·, Ô˘ ÌÔÚ› Ó· ηٷϋÍÂÈ Î·È Û ÂÌÂÙfi. ∂›Û˘ ·Ú·ÙËÚÔ‡ÓÙ·È ˆ¯ÚfiÙËÙ·, ÂÊ›‰ÚˆÛË, ˘ÂÚ·ÂÚÈÛÌfi˜, ·Ó·ÛÙÂÓ·ÁÌÔ›, ¯·ÛÌÔ˘ÚËÙ¿, ‚Ú·‰˘Î·Ú‰›· Î·È ˘fiÙ·ÛË. ∏ ‰È¿ÚÎÂÈ· Ù˘ ÂÚÈfi‰Ô˘ ·˘Ù‹˜ Â›Ó·È Û‡ÓÙÔÌË, Û˘Ó‹ıˆ˜ ·fi 10 ̤¯ÚÈ 20 ‰Â˘ÙÂÚfiÏÂÙ·. ‚) ™˘ÁÎÔ‹. √ ·ÛıÂÓ‹˜ ÎÂ›Ù·È ·Ó·›ÛıËÙÔ˜, ¯·Ï·Úfi˜, ˆ¯Úfi˜, Ì ÙȘ ÎfiÚ˜ Û ‰È·ÛÙÔÏ‹. ∆Ô ‰¤ÚÌ· Â›Ó·È ÎÚ‡Ô Î·È Î¿ıȉÚÔ, ÂÓÒ Ô ÛÊ˘ÁÌfi˜ Â›Ó·È ‚Ú·‰‡˜ Î·È ·ÛıÂÓÈÎfi˜. ™¿ÓÈ· ÂÓ‰¤¯ÂÙ·È Ó· ·Ú·ÙËÚËıÔ‡Ó ·ÒÏÂÈ· Ô‡ÚˆÓ Î·È ÙÔÓÈΤ˜-ÎÏÔÓÈΤ˜ ÎÈÓ‹ÛÂȘ ÙˆÓ ¿ÎÚˆÓ. ¢È·ÚΛ ÙÔ Ôχ Ï›Á· ÏÂÙ¿. Á) ªÂÙ·Û˘ÁÎÔÙÈ΋ Ê¿ÛË. √ ·ÛıÂÓ‹˜ ÓÔÈÒıÂÈ ·‰‡Ó·ÌÔ˜, ˙·ÏÈṲ̂ÓÔ˜, Ì ٿÛË ÁÈ· ÂÌÂÙfi Î·È ÂÏ·ÊÚÈ¿ ÎÂÊ·Ï·ÏÁ›·. ∏ Ï‹Ú˘ ·ӷÊÔÚ¿ Â›Ó·È ÁÚ‹ÁÔÚË, Û˘Ó‹ıˆ˜ ̤۷ Û ÌÈÛ‹ ÒÚ·.
¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ¡∫™ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·fi Ù· ˘fiÏÔÈ· ·›ÙÈ· ÙˆÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÒÏÂÈ·˜ Ù˘ Û˘Ó›‰ËÛ˘, Û˘¯ÓfiÙÂÚÔ ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ÔÈ Û·ÛÌÔ›. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ‰›‰ÂÙ·È ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ·ıÔÏÔÁÈÎÒÓ Î·Ú‰ÈÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ, (ηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹), ÔÈ Ôԛ˜ ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ·ÂÈÏËÙÈΤ˜ ·ÎfiÌ· Î·È ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∫·Ú‰ÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ∏ ηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ¤گÂÙ·È fiÙ·Ó Ë Î·Ú‰È¿, ÁÈ· ÔÈΛÏÔ˘˜ ÏfiÁÔ˘˜, ·‰˘Ó·Ù› Ó· ηχ„ÂÈ ÙȘ ··ÈÙ‹ÛÂȘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Û √2, ÂȉÈο ηٿ ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË. ŸÏ˜ ÔÈ Î·Ú‰È·Î¤˜ ·ı‹ÛÂȘ Â›Ó·È ‰˘Ó·Ùfi οو ·fi ÔÚÈṲ̂Ó˜ Û˘Óı‹Î˜ Ó· ÚÔηϤÛÔ˘Ó Û˘ÁÎÔÙÈÎfi ÂÂÈÛfi‰ÈÔ, Û˘¯ÓfiÙÂÚ· fï˜ ·˘Ùfi ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ú˘ıÌÔ‡, ·ÔÊÚ·ÎÙÈΤ˜ ·ı‹ÛÂȘ ÙÔ˘ ¯ÒÚÔ˘ ÂÍfi‰Ô˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·-Ì˘Ôηډ›Ùȉ·, Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË. ™ÙÔȯ›·, Ù· ÔÔ›· ı· ÛÙÚ¤„Ô˘Ó ÙËÓ ÚÔÛÔ¯‹ Ì·˜ ÚÔ˜ ÙÔ Î˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ·, Â›Ó·È Ë ‡·ÚÍË ÁÓˆÛÙÔ‡ ηډȷÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô ·ÈÊÓ›‰ÈÔ˜ Î·È ·ÓÂÍ‹ÁËÙÔ˜ ı¿Ó·ÙÔ˜ Ó·ÚÔ‡ Û˘ÁÁÂÓÈÎÔ‡ ÚÔPaediatriki 2008;71:62-67
¶›Ó·Î·˜ 3. ∂Ӊ›ÍÂȘ ηډȷ΋˜ ÚÔ¤Ï¢Û˘ Û˘ÁÎÔÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ñ √ÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÈÊÓȉ›Ô˘ ı·Ó¿ÙÔ˘ (<40 ÂÙÒÓ) ñ ⁄·ÚÍË ÁÓˆÛÙÔ‡ ηډȷÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ñ ¶·ÚÔ˘Û›· ÔÚÁ·ÓÈÎÔ‡ Ê˘Û‹Ì·ÙÔ˜ ñ ∞Ô˘Û›· Úfi‰ÚÔÌˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ñ ∞›ÛıËÌ· ÚÔÎ¿Ú‰ÈˆÓ ·ÏÌÒÓ ÚÈÓ ·fi ÙÔ ÂÂÈÛfi‰ÈÔ ñ ∂Ή‹ÏˆÛË Î·Ù¿ ÙËÓ ¿ÛÎËÛË ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿
ÛÒÔ˘ (<40 ÂÙÒÓ), Ë ‡·ÚÍË ÔÚÁ·ÓÈÎÔ‡ Ê˘Û‹Ì·ÙÔ˜ ÛÙËÓ ·ÎÚfi·ÛË Ù˘ ηډȿ˜, Ë ·›ÛıËÛË ÚÔÎ¿Ú‰ÈˆÓ ·ÏÌÒÓ ÚÈÓ ·fi ÙÔ ÂÂÈÛfi‰ÈÔ, Ë Ôχ ÌÈÎÚ‹ ‰È¿ÚÎÂÈ· (<5 ‰Â˘ÙÂÚfiÏÂÙ·) ‹ Î·È Ï‹Ú˘ ·Ô˘Û›· Ù˘ Úfi‰ÚÔÌ˘ Ê¿Û˘ Î·È Ê˘ÛÈο Ë Â¤Ï¢ÛË ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ ηٿ ÙËÓ ¿ÛÎËÛË ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿ (¶›Ó·Î·˜ 3). ∫Ú¿ÙËÌ· ·Ó·ÓÔ‹˜ ∆· ÂÂÈÛfi‰È· ÎÚ·Ù‹Ì·ÙÔ˜ ·Ó·ÓÔ‹˜ (breathholding spells) Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¿ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ 2-3 ÂÙÒÓ (6,7). ∏ ¤Ó·ÚÍË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ Û ËÏÈΛ· ÌÂٷ͇ 6 ÌËÓÒÓ Î·È 2 ÂÙÒÓ Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ÛÙ·Ì·ÙÔ‡Ó ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ. ¢È·ÎÚ›ÓÔÓÙ·È ‰‡Ô ÌÔÚʤ˜ Ù˘, Ë Î˘·ÓˆÙÈ΋ Î·È Ë ˆ¯Ú¿, Ô˘ Î·È ÔÈ ‰‡Ô ıˆÚÂ›Ù·È fiÙÈ ·Ó‹ÎÔ˘Ó ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·Ú·Û˘Ì·ıËÙÈÎÒÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ∏ ΢·ÓˆÙÈ΋ ÌÔÚÊ‹ Â›Ó·È Ë ÈÔ Û˘¯Ó‹, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÂÈÛfi‰ÈÔ ¤ÓÙÔÓÔ˘ ÎÏ¿Ì·ÙÔ˜, ÙÔ ÔÔ›Ô ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ¿ÓÔÈ·, ΢¿ÓˆÛË Î·È Û‡ÓÙÔÌË ÂÚ›Ô‰Ô ·ÒÏÂÈ·˜ Ù˘ Û˘Ó›‰ËÛ˘ Î·È ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÙÂٷ̤ÓË ÂÎÓÔ‹ Ì ÎÏÂÈÛÙ‹ ÙË ÁψÙÙ›‰·. ∏ ˆ¯Ú¿ ÌÔÚÊ‹ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ‡·ÚÍË ÂÓfi˜ ·Ú¯ÈÎÔ‡ Û˘Ì‚¿Ì·ÙÔ˜, fiˆ˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ‹ ¤ÓÙÔÓÔ˘ Î·È Í·ÊÓÈÎÔ‡ Êfi‚Ô˘, Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·Û˘ÛÙÔÏ›· Î·È ·fiÙÔÌË ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘, Ë ÔÔ›· Û˘Óԉ‡ÂÙ·È ·fi ˆ¯ÚfiÙËÙ·. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ë ÌÔÚÊ‹ ·˘Ù‹ ÎÚ·Ù‹Ì·ÙÔ˜ Ù˘ ·Ó·ÓÔ‹˜ ÔÊ›ÏÂÙ·È Û ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·˘ÙfiÓÔÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È fiÙÈ Ù· ·È‰È¿ ·˘Ù¿ ¤¯Ô˘Ó ·˘ÍË̤Ó˜ Èı·ÓfiÙËÙ˜ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ·ÚÁfiÙÂÚ· ηٿ ÙËÓ ÂÊ˂›· ÂÂÈÛfi‰È· Ó¢ÚÔηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜. æ˘¯ÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ∆· „˘¯ÔÁÂÓ‹ ÂÂÈÛfi‰È· ‰È·ÎÚ›ÓÔÓÙ·È ÛÙȘ ÎÚ›ÛÂȘ ·ÓÈÎÔ‡ Î·È ÛÙȘ ˘ÛÙÂÚÈΤ˜ ÎÚ›ÛÂȘ. ™ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË ·Ú·ÙËÚ›ٷÈ, ÏfiÁˆ οÔÈÔ˘ Â͈ÙÂÚÈÎÔ‡ ÁÂÁÔÓfiÙÔ˜, ¤ÓÙÔÓÔ˜ ·ÓÈÎfi˜ Ì ˘ÂÚ·ÂÚÈÛÌfi Î·È ·›ÛıËÌ· ‚¿ÚÔ˘˜ Î·È ›ÂÛ˘ ÛÙÔ ÛÙ‹ıÔ˜. ∏ ˘ÛÙÂÚÈ΋ ÎÚ›ÛË ·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ Û ÂÊ‹‚Ô˘˜, ¿ÓÙ· ·ÚÔ˘Û›· ¿ÏÏˆÓ ÚÔÛÒˆÓ, ‰ÂÓ Û˘Ó‰˘¿˙ÂÙ·È Ì ˆ¯ÚfiÙËÙ· ‹ ‚Ú·‰˘Î·Ú‰›·, Ù· ÂÂÈÛfi‰È· Â›Ó·È Ôχ Û˘¯Ó¿ (̤¯ÚÈ Î·È ÔÏϤ˜ ÊÔÚ¤˜ ÙÔ ›‰ÈÔ 24ˆÚÔ) Î·È Ë ‰È¿ÚÎÂÈ¿ Ù˘ Â›Ó·È ·ÚÎÂÙ¿ ÌÂÁ¿ÏË. ÷ڷÎÙËÚÈÛÙÈÎfi
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·65
65
™˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙ· ·È‰È¿
¶›Ó·Î·˜ 4. ¢È¿ÎÚÈÛË Û˘ÁÎÔ‹˜ ·fi ÂÂÈÛfi‰È· Û·ÛÌÒÓ ™˘ÁÎÔ‹
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ñ ∞Ú¯›˙ÂÈ ÌÂÙ¿ ÙËÓ ÙÒÛË ñ ™˘Ó‹ıˆ˜ ˆ¯ÚfiÙ˘ ñ ªÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ (1-2 ÏÂÙ¿) ñ ∞ÒÏÂÈ· Ô‡ÚˆÓ: Û¿ÓÈ· ñ Ÿ¯È ‰¿ÁΈ̷ ÁÏÒÛÛ·˜ ñ ◊È· ÌÂÙ·Û˘ÁÎÔÙÈ΋ Û˘Á¯˘ÙÈ΋ Ê¿ÛË
ñ ∞Ú¯›˙Ô˘Ó ·fi ÙËÓ fiÚıÈ· ı¤ÛË ñ ¶Èı·Ó‹ ΢¿ÓˆÛË ñ ªÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ (>5 ÏÂÙ¿) ñ ∞ÒÏÂÈ· Ô‡ÚˆÓ: Û˘¯Ó‹ ñ ¢¿ÁΈ̷ ÁÏÒÛÛ·˜: 25% ñ ŒÓÙÔÓË Î·È ·Ú·ÙÂٷ̤ÓË Û˘Á¯˘ÙÈ΋ Ê¿ÛË ÌÂÙ¿ ÙÔ ÂÂÈÛfi‰ÈÔ
ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·˘ÙÒÓ Â›Ó·È fiÙÈ Ô ·ÛıÂÓ‹˜ ¤ÊÙÂÈ ¿ÓÙ· Ì οÔÈ· ¯¿ÚË Î·È ı·ÙÚÈÎfiÙËÙ· Î·È ˘¿Ú¯ÂÈ ÚfiÓÔÈ· ·ÔÊ˘Á‹˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∂›Û˘, fiÙ·Ó ÂÚÈÁÚ¿ÊÂÈ ÙÔ ÂÂÈÛfi‰ÈÔ Â›Ó·È ÂÍ·ÈÚÂÙÈο ‹ÚÂÌÔ˜ Î·È „‡¯Ú·ÈÌÔ˜. ∞Ú¯È΋ ÔÚıÔÛÙ·ÙÈ΋ ˘fiÙ·ÛË ™˘ÁÎÔ‹ ‹ Û˘¯ÓfiÙÂÚ· ÂÓԯϋ̷ٷ Ù˘ ÚÔÛ˘ÁÎÔÙÈ΋˜ Ê¿Û˘ Â›Ó·È Ôχ Û˘¯Ó¿ ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ¤ÁÂÚÛ˘ ÛÙËÓ fiÚıÈ· ı¤ÛË, ÂȉÈο ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· (8). ™¯Â‰fiÓ fiÏÔÈ ÔÈ ¤ÊË‚ÔÈ ·Ó·Ê¤ÚÔ˘Ó ÂÂÈÛfi‰È· ˙¿Ï˘ ηٿ ÙËÓ ·fiÙÔÌË ¤ÁÂÚÛË, ÂȉÈο ÌÂÙ¿ ·fi ·Ú·ÙÂٷ̤ÓË Î·Ù¿ÎÏÈÛË. ∆· ÂÓԯϋ̷ٷ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÓÙfi˜ ‰Â˘ÙÂÚÔÏ¤ÙˆÓ ·fi ÙËÓ ¤ÁÂÚÛË Î·È ‰È·ÚÎÔ‡Ó Ï›ÁÔ (30 ‰Â˘ÙÂÚfiÏÂÙ·). ™‡Ó‰ÚÔÌÔ ÔÚıÔÛÙ·ÙÈ΋˜ Ù·¯˘Î·Ú‰›·˜ (postural orthostatic tachycardia syndrome) ÷ڷÎÙËÚ›˙ÂÙ·È ·fi Û˘ÌÙÒÌ·Ù· ·Ó·ÚÎÔ‡˜ ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ (˙¿ÏË, ·›ÛıËÌ· ÎfiˆÛ˘, ·‰˘Ó·Ì›·, ıfiψÛË Ù˘ ÔÚ¿Ûˆ˜) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÍË̤ÓË Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· ÛÙËÓ fiÚıÈ· ı¤ÛË, ÂÓÒ Ë ·ÚÙËÚȷ΋ ›ÂÛË ·Ú·Ì¤ÓÂÈ ÛÙ· ηÙÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (9). ª›· ·‡ÍËÛË Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ηٿ 35% ‹ ηډȷ΋ Û˘¯ÓfiÙËÙ· ¿Óˆ ÙˆÓ 120/ÏÂÙfi ÌÂÙ¿ ·fi ‰‡Ô ÏÂÙ¿ ÔÚıÔÛÙ·Û›·˜ ıˆÚÂ›Ù·È ·ıÔÏÔÁÈ΋. ∆Ô Û‡Ó‰ÚÔÌÔ Â›Ó·È Û·ÊÒ˜ Û˘¯ÓfiÙÂÚÔ ÛÙ· ÎÔÚ›ÙÛÈ· (4:1), ·Ó Î·È Ë ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛ‹ ÙÔ˘ ··ÈÙ› Û˘Ó‹ıˆ˜ ÙË ‚Ô‹ıÂÈ· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ΤÓÙÚÔ˘. ∂ÂÈÛfi‰È· Û·ÛÌÒÓ ∏ ‰È¿ÎÚÈÛË ·fi Ù· ÂÂÈÛfi‰È· Û·ÛÌÒÓ ‰ÂÓ Â›Ó·È ¿ÓÙ· ‡ÎÔÏË (10). ™ÙÔȯ›· Ô˘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û·ÛÌÒÓ Â›Ó·È Ë ·ÚÔ˘Û›· ·ÊÚÒÓ ÛÙÔ ÛÙfiÌ·, ÙÔ ‰¿ÁΈ̷ Ù˘ ÁÏÒÛÛ·˜, Ë ÛÙÚÔÊ‹ Ù˘ ÎÂÊ·Ï‹˜, Ë ·ÒÏÂÈ· ÎÔÚ¿ÓˆÓ, Ë ‰È¿ÚÎÂÈ· ¿Óˆ ÙˆÓ ¤ÓÙ ÏÂÙÒÓ, Ë ·Ú·ÙÂٷ̤ÓË Î·È ¿Ù˘Ë ÌÂÙ·Û˘ÁÎÔÙÈ΋ Ê¿ÛË Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·ÒÏÂÈ· ÙÔ˘ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, ÛÔ‚·Ú‹ ÎÂÊ·Ï·ÏÁ›· Î·È ·ÒÏÂÈ· Ù˘ ÌÓ‹Ì˘ Î·È Ë ‡·ÚÍË ÂÛÙÈ·ÎÒÓ Ó¢ÚÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ (¶›Ó·Î·˜ 4). ∆· ˘fiÏÔÈ· ·›ÙÈ· ÂÂÈÛÔ‰›ˆÓ ·ÒÏÂÈ·˜ Ù˘
Û˘Ó›‰ËÛ˘, fiˆ˜ Ë ·Ó·ÈÌ›·, Ë ˘ÔÁÏ˘Î·ÈÌ›·, Ë Ô‡ÚËÛË, Ô ‚‹¯·˜ Î·È Ë ·Êfi‰Â˘ÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙ· ·È‰È¿. ∂ΛÓÔ, ÙÔ ÔÔ›Ô Â›Ó·È ÌÂÓ ·ÎfiÌ· Û¿ÓÈÔ, ·ÏÏ¿ ÚÔԉ¢ÙÈο ·˘Í¿ÓÂÙ·È Î·È Ú¤ÂÈ Ó· Û˘Óԉ¢Ù› Î·È ·fi ·Ó¿ÏÔÁË ·‡ÍËÛË ÙÔ˘ ‚·ıÌÔ‡ ÂÁÚ‹ÁÔÚÛ‹˜ Ì·˜, Â›Ó·È Ë ¯Ú‹ÛË „˘¯ÔÙÚfiˆÓ Ô˘ÛÈÒÓ.
¢È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË ∏ ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ÔÊ›ÏÂÙ·È Û ηÏÔ‹ıË ·›ÙÈ· Î·È Ë ÚfiÁÓˆÛ‹ ÙÔ˘˜ Â›Ó·È Ôχ ηϋ. ∏ ·ÎÚÈ‚‹˜ fï˜ ‰È¿ÁÓˆÛË Ù˘ ·ÈÙÈÔÏÔÁ›·˜ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›·, ·ÊÂÓfi˜ ÌÂÓ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙˆÓ Û¿ÓÈˆÓ ·ÏÏ¿ ÂÈΛӉ˘ÓˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ú‰ÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜, ·ÊÂÙ¤ÚÔ˘ ‰Â ÏfiÁˆ ÙˆÓ ÛÔ‚·ÚÒÓ ÂÈÙÒÛÂˆÓ Ô˘ ¤¯Ô˘Ó Ù· ÂÂÈÛfi‰È· ·˘Ù¿ ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ÙËÓ ÎÔÈÓˆÓÈ΋ ˙ˆ‹ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜ (11). ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÛÙÔÈ¯Â›Ô Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ‰È·‰Èηۛ·˜ Â›Ó·È ·Ó·ÌÊ›‚ÔÏ· ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ÎÏÈÓÈ΋ ÂͤٷÛË. ∞fi ÙÔ ÈÛÙÔÚÈÎfi ‰ÈÂÚ¢ÓÒÓÙ·È ·Ú¯Èο ÔÈ Û˘Óı‹Î˜ οو ·fi ÙȘ Ôԛ˜ ¤ÁÈÓ ÙÔ ÂÂÈÛfi‰ÈÔ. √ ·ÛıÂÓ‹˜ ‹Ù·Ó ͷψ̤ÓÔ˜; ¶ÚÔËÁ‹ıËΠοÔÈÔ ¤ÓÙÔÓÔ Û˘ÁÎÈÓËÛÈ·Îfi ÂÚ¤ıÈÛÌ·; ™ËÎÒıËΠ·fiÙÔÌ· ·fi ÙËÓ Î·ıÈÛÙ‹ ÛÙËÓ fiÚıÈ· ı¤ÛË; ◊Ù·Ó ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· fiÚıÈÔ˜ Î·È Ì¿ÏÈÛÙ· Û ÎÏÂÈÛÙfi, ˙ÂÛÙfi ¯ÒÚÔ, Ì ÌÂÁ¿ÏÔ Û˘ÓˆÛÙÈÛÌfi; ∆Ô ÂÂÈÛfi‰ÈÔ Û˘Ó¤‚Ë Î·Ù¿ ÙËÓ ¿ÛÎËÛË ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿; ™ÙË Û˘Ó¤¯ÂÈ·, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ‰È¢ÎÚÈÓÈÛı› ÔÈ· ‹Ù·Ó Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙÔ ÂÂÈÛfi‰ÈÔ. ¶ÚÔËÁ‹ıËÎ·Ó Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù·; À‹ÚÍ ·›ÛıËÌ· ÚÔηډ›ˆÓ ·ÏÌÒÓ; À‹ÚÍ ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘ ‹ ÙÔ ÂÂÈÛfi‰ÈÔ ÂÚÈÔÚ›ÛıËΠÌfiÓÔ ÛÙ· Úfi‰ÚÔÌ· ÛËÌ›·; À‹ÚÍ·Ó Û·ÛÌÔ›; √ ·ÛıÂÓ‹˜ ‹Ù·Ó ˆ¯Úfi˜ Î·È ¯·Ï·Úfi˜ ‹ Û ۇ۷ÛË; À‹ÚÍ ·ÒÏÂÈ· Ô‡ÚˆÓ ‹ Î·È ÎÔÚ¿ÓˆÓ; À‹ÚÍ ÙÚ·˘Ì·ÙÈÛÌfi˜ ·fi ÙËÓ ÙÒÛË; ¶fiÛË ÒÚ· ‰È‹ÚÎÂÛ ÙÔ ÂÂÈÛfi‰ÈÔ; ªÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘, Ô ·ÛıÂÓ‹˜ ‹Ù·Ó Û˘Á¯˘ÙÈÎfi˜ Î·È ÁÈ· fiÛÔ ‰È¿ÛÙËÌ·; ∂Âȉ‹ ÔÏϤ˜ ÊÔÚ¤˜ Ô ·ÛıÂÓ‹˜ ‰ÂÓ Â›Ó·È Û ı¤ÛË Ó· Ì·˜ ‰ÒÛÂÈ ÈηÓÔÔÈËÙÈΤ˜ ÏËÚÔÊÔڛ˜, Ë Û˘Ó‰ÚÔÌ‹ ÙˆÓ ·ÚÈÛÙ·Ì¤ÓˆÓ ÛÙÔ ÂÂÈÛfi‰ÈÔ Â›Ó·È ÔχÙÈÌË. ∞fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ¤¯ÂÈ ·Í›· Ë ‡·ÚÍË ¶·È‰È·ÙÚÈ΋ 2008;71:62-67
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·66
66
¢. π. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜
·ÈÊÓȉ›Ô˘ ı·Ó¿ÙÔ˘, ·‰È¢ÎÚ›ÓÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, ÛÂ Û˘ÁÁÂÓÈÎfi ÚfiÛˆÔ ËÏÈΛ·˜ οو ÙˆÓ 40 ÂÙÒÓ. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·ÍÈÔÏÔÁÂ›Ù·È Ë ·ÚÔ˘Û›· ÁÓˆÛÙ‹˜ ηډÈÔ¿ıÂÈ·˜ ‹ ¿ÏÏ˘ ·ıÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ (.¯. Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹), ηıÒ˜ ›Û˘ Î·È Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ÂÚÈÏ·Ì‚¿ÓÂÈ Ê˘ÛÈο fiÏ· Ù· Û˘ÛÙ‹Ì·Ù·, ÂÈÎÂÓÙÚÒÓÂÙ·È fï˜ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi Î·È ÙÔ Ó¢ÚÔÏÔÁÈÎfi. ∞fi ÙÔ Î˘ÎÏÔÊÔÚÈÎfi Á›ÓÂÙ·È ÚÔÛÂÎÙÈ΋ ·ÎÚfi·ÛË ÙÔ˘ ÚÔηډ›Ô˘ Û ηٷÎÂÎÏÈÌ̤ÓË Î·È fiÚıÈ· ı¤ÛË, „ËÏ¿ÊËÛË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ Ûʇ͈Ó, ̤ÙÚËÛË Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ Î·È Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û ηٷÎÂÎÏÈÌ̤ÓË Î·È Û fiÚıÈ· ı¤ÛË, ‰‡Ô ÏÂÙ¿ ÌÂÙ¿ ÙËÓ ¤ÁÂÚÛË. ∞fi ÙÔ Ó¢ÚÔÏÔÁÈÎfi Á›ÓÂÙ·È ÌÈ· ·‰Ú‹ ÂÎÙ›ÌËÛË ·Ó·˙ËÙÒÓÙ·˜ ÂÛÙȷ΋ ÛËÌÂÈÔÏÔÁ›·. ∞fi ÙȘ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ, Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ∏∫° Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÚÔ˜ ·ÔÎÏÂÈÛÌfi ÔÚÈÛÌ¤ÓˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ ‹ ·ı‹ÛˆÓ, fiˆ˜ Ë ˘ÂÚÙÚÔÊ›· ÙˆÓ ÎÔÈÏÈÒÓ, Ô ÎÔÏÔÎÔÈÏÈ·Îfi˜ ·ÔÎÏÂÈÛÌfi˜, ÙÔ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT, ÙÔ Û‡Ó‰ÚÔÌÔ Wolff-Parkinson-White ‹ ÙÔ Û‡Ó‰ÚÔÌÔ Brugada. ∂›Û˘, ÙÔ ∏∫° ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÂÚÙÚÔÊÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ Î·È Ù˘ ·ÚÚ˘ıÌÈÔÁfiÓÔ˘ ‰˘ÛÏ·Û›·˜ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. ŸÙ·Ó ·fi ÙÔ ÈÛÙÔÚÈÎfi ‹ ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ÎÏÈÓÈ΋˜ ÂͤٷÛ˘ Î·È ÙÔ˘ ∏∫° ÚÔ·ÙÔ˘Ó ÛÙÔȯ›· ÁÈ· Èı·Ó‹ ηډȷ΋ ÚԤϢÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ, ÙfiÙÂ Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·Ú·¤ÌÂÙ·È Û ηډÈÔÏfiÁÔ ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. °ÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Á›ÓÔÓÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ˘Ô„›· ÁÈ· ·Ó·ÈÌ›· ‹ ˘ÔÁÏ˘Î·ÈÌ›·. ∂›Û˘, ÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· Á›ÓÂÙ·È ÌÂÙ¿ ·fi ÂÎÙ›ÌËÛË ·fi Ó¢ÚÔÏfiÁÔ, fiÙ·Ó ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ÁÈ· Ó¢ÚÔÏÔÁÈ΋ ÚԤϢÛË ÙÔ˘ ÂÂÈÛÔ‰›Ô˘. ∏ ‰ÔÎÈÌ·Û›· ·Ó·ÎÏÈÓÒÌÂÓ˘ ÙÚ·¤˙˘ (tilt test) ‰ÂÓ ¤¯ÂÈ ¤Ó‰ÂÈÍË ÌÂÙ¿ ·fi ¤Ó· Ù˘ÈÎfi, ÌÂÌÔӈ̤ÓÔ ÂÂÈÛfi‰ÈÔ. À¿Ú¯Ô˘Ó ÔÏÏ¿ ÚˆÙfiÎÔÏÏ· Ú·ÁÌ·ÙÔÔ›ËÛ˘ Ù˘ ‰ÔÎÈÌ·Û›·˜, fiÏ· fï˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÌÈ· ·Ú¯È΋ Ê¿ÛË Î·Ù¿ÎÏÈÛ˘ Û ÔÚÈ˙fiÓÙÈ· ı¤ÛË ÁÈ· 20-30 ÏÂÙ¿ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ¤ÁÂÚÛË ÛÙËÓ fiÚıÈ· ı¤ÛË ‹ Û ÎÏ›ÛË 60-70 ÌÔÈÚÒÓ Î·È ·Ú·ÌÔÓ‹ ÛÙË ı¤ÛË ·˘Ù‹ ÁÈ· 15-20 ÏÂÙ¿ ‹ ̤¯ÚÈ ÚÔÎÏ‹Ûˆ˜ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘. ™Â ÔÚÈṲ̂ӷ ÚˆÙfiÎÔÏÏ·, ·Ó Ë ·Ú¯È΋ ·˘Ù‹ Ê¿ÛË Â›Ó·È ·ÚÓËÙÈ΋, ÙfiÙ ·ÎÔÏÔ˘ı› Ì›· ‰Â‡ÙÂÚË, Ì Ӥ· ηٿÎÏÈÛË ÁÈ· 20-30 ÏÂÙ¿ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ¤ÁÂÚÛË Ì ٷ˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÈÛÔÚÔÙÂÚÂÓfiÏ˘. ¢È·ÎÚ›ÓÔ˘Ì ÙÚÂȘ ‰È·ÊÔÚÂÙÈÎÔ‡˜ Ù‡Ô˘˜ ·¿ÓÙËÛ˘ Û ÂÚ›ÙˆÛË ıÂÙÈ΋˜ ‰ÔÎÈÌ·Û›·˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó ΢Úȷگ› Ë ‚Ú·‰˘Î·Ú‰›· (ηډÈÔ·Ó·ÛÙ·ÏÙÈ΋), Ë ˘fiÙ·ÛË (·ÁÁÂÈÔηٷÛÙ·ÏÙÈ΋) ‹ Î·È Ù· ‰‡Ô (ÌÈÎÙ‹), Ô˘ Â›Ó·È Î·È Ô Û˘¯ÓfiÙÂÚÔ˜. ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ‰ÔÎÈÌ·Û›·˜ Â›Ó·È ÙÔ Ôχ ˘„ËÏfi ÔÛÔÛÙfi „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ ··ÓÙ‹Paediatriki 2008;71:62-67
ÛÂˆÓ (12), Ô˘ ÌÔÚ› Ó· Êı¿ÛÂÈ ÙÔ 50% Û‡Ìʈӷ Ì ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ (13). ∂›Û˘, Ë ıÂÙÈ΋ ·¿ÓÙËÛË ÛÙË ‰ÔÎÈÌ·Û›· ‰ÂÓ ·ÔÙÂÏ› ηÏfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ˘ÔÙÚÔÒÓ (14). ª¿ÏÈÛÙ·, fiˆ˜ Ê¿ÓËΠ·fi ÙËÓ ›‰È· ÌÂϤÙË, Ô Î·Ï‡ÙÂÚÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ô ·ÚÈıÌfi˜ ÙˆÓ ÚÔËÁËı¤ÓÙˆÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ªÂ ‚¿ÛË Ù· ·ÓˆÙ¤Úˆ, Ë ‰ÔÎÈÌ·Û›· ·Ó·ÎÏÈÓÒÌÂÓ˘ ÙÚ·¤˙˘ ‰ÂÓ ·ÔÙÂÏ› ÙÔ Î·Ï‡ÙÂÚÔ ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô ÁÈ· ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË ÙˆÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ªÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Û ·ÛıÂÓ›˜ ÌÂ Û˘¯Ó¿, ÌË Ù˘Èο ÂÂÈÛfi‰È·, Ù· ÔÔ›· ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙ· ÚÔÏËÙÈο ̤ÙÚ· Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ·Ú·Î¿Ùˆ, ηıÒ˜ ›Û˘ Î·È fiÙ·Ó Â›Ó·È ÂÈı˘ÌËÙfi Ó· ηıËÛ˘¯¿ÛÔ˘Ì ÙÔÓ ·ÛıÂÓ‹ Î·È Ó· ÙÔÓ Âηȉ‡ÛÔ˘ÌÂ, ÒÛÙ ӷ ·Ó·ÁÓˆÚ›˙ÂÈ Ù· Úfi‰ÚÔÌ· ÛËÌ›· Î·È Ó· ÌÔÚ› Ó· Ù· ÚÔÏ·Ì‚¿ÓÂÈ (15).
∞ÓÙÈÌÂÙÒÈÛË ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Â›Ó·È ·ÈÙÈÔÏÔÁÈ΋. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ ı· ·Ó·ÊÂÚıԇ̠ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¡∫™, Ô˘ Â›Ó·È Î·È Ë Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ ÙÔ˘˜. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ·ÈÙ›ˆÓ Û˘ÁÎÔ‹˜ Î·È ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Û·ÛÌÒÓ ÍÂʇÁÂÈ ·fi ÙÔ Ï·›ÛÈÔ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘. ∏ ÚfiÏË„Ë Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ó¢ÚÔηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜ Û˘Ó‹ıˆ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ‰È¿ÊÔÚ· ·ÓÒ‰˘Ó· Î·È Â‡ÎÔÏ· ÂÊ·ÚÌfiÛÈÌ· ̤ÙÚ· Î·È ÌfiÓÔ Û·Ó›ˆ˜ ··ÈÙÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ıÂڷ›·. ∂ΛÓÔ, ÙÔ ÔÔ›Ô ··ÈÙ›ٷÈ, Â›Ó·È Ó· ηıËÛ˘¯·Ûı› Ô ·ÛıÂÓ‹˜ Î·È ÔÈ ÁÔÓ›˜ ÙÔ˘, Ó· ÂÍËÁËı› Ô Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘, Ó· Ì¿ıÂÈ Ô ·ÛıÂÓ‹˜ Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Ù· Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù· Î·È Ó· ÂÎ·È‰Â˘ı› ÛÙÔ˘˜ ÙÚfiÔ˘˜ ·ÓÙ›‰Ú·Û˘, ÒÛÙ ӷ ·Ó·ÛÙ›ÏÂÈ ÙËÓ ÂͤÏÈÍË ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ Î·È Ó· ·ÔʇÁÂÈ ÙËÓ ·ÒÏÂÈ· Ù˘ Û˘Ó›‰ËÛ˘. ∆· ÚÔÏËÙÈο ̤ÙÚ·, Ù· ÔÔ›· ÚÔÙ›ÓÔÓÙ·È ÁÈ· ·ÔÊ˘Á‹ ˘ÔÙÚÔ‹˜ ÙÔ˘ ÂÂÈÛÔ‰›Ô˘, Â›Ó·È Ù· ÂÍ‹˜: 1. ·ÔÊ˘Á‹ ·Ê˘‰¿ÙˆÛ˘, ÂȉÈο ÙÔ˘˜ ηÏÔηÈÚÈÓÔ‡˜ Ì‹Ó˜, Ì ÙË Ï‹„Ë ÙÔ˘Ï¿¯ÈÛÙÔÓ 6-8 ÔÙËÚÈÒÓ ÓÂÚÔ‡ ËÌÂÚËÛ›ˆ˜ (Ù· Ô‡Ú· Ú¤ÂÈ Ó· Â›Ó·È ·ÓÔȯÙfi¯ÚˆÌ· Î·È Ë Û˘¯ÓfiÙËÙ· Ô‡ÚËÛ˘ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ÊÔÚ¤˜ ÙÔ Úˆ› Î·È ‰‡Ô ÙÔ ·fiÁÂ˘Ì·). ¡· ·ÔʇÁÔÓÙ·È ÔÈ ¯˘ÌÔ›, ÂȉÈο ÔÈ ÂÌÊȷψ̤ÓÔÈ, ‰ÈfiÙÈ ÚÔηÏÔ‡Ó ÔÛ̈ÙÈ΋ ‰ÈÔ‡ÚËÛË, 2. ·ÔÊ˘Á‹ Ï‹„˘ ηʤ, 3. ¯Ú‹ÛË ÚfiÛıÂÙÔ˘ ·Ï·ÙÈÔ‡ ÛÙÔ Ê·ÁËÙfi, 4. ·ÔÊ˘Á‹ ¯ÒÚˆÓ ÌÂ Û˘ÓˆÛÙÈÛÌfi Î·È ˙¤ÛÙË, 5. ·ÔÊ˘Á‹ ·fiÙÔÌ˘ ¤ÁÂÚÛ˘ (Ó· ÚÔËÁÔ‡ÓÙ·È ÎÈÓ‹ÛÂȘ ÙˆÓ Ô‰ÈÒÓ ÚÈÓ ·fi ÙËÓ ¤ÁÂÚÛË, Ó· οıÂÙ·È ÁÈ· Ï›ÁÔ Î·ıÈÛÙfi˜ ÛÙËÓ ¿ÎÚË ÙÔ˘ ÎÚ‚·ÙÈÔ‡), 6. ·ÔÊ˘Á‹ ·Ú·ÙÂٷ̤Ó˘ ÔÚıÔÛÙ·Û›·˜, ÂȉÈο Û ˙ÂÛÙÔ‡˜ ¯ÒÚÔ˘˜ ÌÂ Û˘ÓˆÛÙÈÛÌfi ηÈ, fiÙ·Ó ·˘Ùfi
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·67
67
™˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙ· ·È‰È¿
Â›Ó·È ·Ó·fiÊ¢ÎÙÔ, Ó· Á›ÓÔÓÙ·È Û˘Ó¯›˜ ÎÈÓ‹ÛÂȘ ÙˆÓ Ô‰ÈÒÓ ÂÈÙfiÔ˘. ŸÙ·Ó, ·ÚfiÏ· ·˘Ù¿, ÂΉËψıÔ‡Ó Ù· Úfi‰ÚÔÌ· Û˘ÌÙÒÌ·Ù·, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·ÓÙȉڿÛÂÈ „‡¯Ú·ÈÌ· Î·È ¤ÁηÈÚ· οÓÔÓÙ·˜ ¤Ó· ·fi Ù· ·Ú·Î¿Ùˆ: Ó· Í·ÏÒÛÂÈ ·Ó ·˘Ùfi Â›Ó·È ‰˘Ó·Ùfi, Ó· ηı›ÛÂÈ ÔÎÏ·‰fiÓ, Ó· Û˘Û¿ÛÂÈ ÙÔ˘˜ ÎÔÈÏÈ·ÎÔ‡˜ ̇˜ ‹ Ó· ‚¿ÏÂÈ ÙÔ ¤Ó· fi‰È ¿Óˆ Û οÔÈ· ηڤÎÏ· ‹ ÛηÏÔ¿ÙÈ. √È ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ηϋ ·ÓÙ·fiÎÚÈÛË Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ·Ú·¿Óˆ ̤ÙÚˆÓ, ·Ó Î·È ÙÔ ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ ·Ú·Ì¤ÓÂÈ ˘„ËÏfi (ÂÚ›Ô˘ 32%), ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ·ÍÈfiÈÛÙÔ˜ ÚÔ‚ÏÂÙÈÎfi˜ ‰Â›ÎÙ˘. ŸÙ·Ó Ù· ÂÂÈÛfi‰È· ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿, Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛʇÁÔ˘Ì ÛÙË ¯Ú‹ÛË Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ, fiˆ˜ Ë ÊÏÔ˘ÔÚÔÎÔÚÙÈ˙fiÓË (‰Ú· ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ ÂÓ‰Ô·ÁÁÂÈ·Îfi fiÁÎÔ), ÔÈ ‚-·Ó·ÛÙÔÏ›˜ (ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ¤ÓÙ·ÛË Ù˘ ηډȷ΋˜ Û˘ÛÙÔÏ‹˜ Î·È ÂӉ¯Ô̤ӈ˜ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈ΋ Ô‰fi Ô˘ ηٷϋÁÂÈ ÛÙË ‰È¤ÁÂÚÛË ÙÔ˘ ·Ú·Û˘Ì·ıËÙÈÎÔ‡) Î·È Ë „¢‰ÔÂʉڛÓË (·-‰ÈÂÁ¤ÚÙ˘, ÚÔηÏ› ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË, ·ÏÏ¿ ¤¯ÂÈ ÔÏϤ˜ ·ÚÂÓ¤ÚÁÂȘ). ∆Ô Úfi‚ÏËÌ· Ì ÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Â›Ó·È fiÙÈ ·ÊÂÓfi˜ ÌÂÓ Ê·›ÓÂÙ·È Ó· ÌËÓ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔÒÓ (14), ·ÊÂÙ¤ÚÔ˘ ‰Â ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙÔ ÁÈ· fiÛÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ú¤ÂÈ Ó· ¯ÔÚËÁ›ٷÈ. ∏ ÙÔÔı¤ÙËÛË ÌfiÓÈÌÔ˘ ‚ËÌ·ÙÔ‰fiÙË ÂȉÈο ÛÙ· ·È‰È¿ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÔÏÏ‹ ÊÂÈ‰Ò Î·È ÂÚ›Û΄Ë. ª¤¯ÚÈ Û‹ÌÂÚ· (16), ¤¯ÂÈ Á›ÓÂÈ Û ÂÏ¿¯ÈÛÙ˜ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ·ӷϷ̂·ÓfiÌÂÓ·, ÛÔ‚·Ú¿ ÂÂÈÛfi‰È·, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔÔ›ˆÓ ›¯Â ÙÂÎÌËÚȈı› Ë ‡·ÚÍË ·Ú·ÙÂٷ̤Ó˘ ηډȷ΋˜ ·‡Ï·˜ (>4 ‰Â˘ÙÂÚfiÏÂÙ·). Ÿˆ˜ Ê¿ÓËÎÂ Î·È ·fi ÙË ÌÂϤÙË VPSII (17), Ë ÌfiÓÈÌË ‚ËÌ·ÙÔ‰fiÙËÛË ‰ÂÓ ÚÔÛʤÚÂÈ Î¿ÔÈÔ Û˘ÁÎÚÈÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÛÙË ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ¤ÓÙÔÓË ·Û˘ÛÙÔÏ›· ηٿ Ù· ÂÂÈÛfi‰È· Ó¢ÚÔηډÈÔÁÂÓÔ‡˜ Û˘ÁÎÔ‹˜.
™˘ÌÂÚ¿ÛÌ·Ù· ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ÔÊ›ÏÔÓÙ·È Û˘Ó‹ıˆ˜ Û ηÏÔ‹ıÂȘ ηٷÛÙ¿ÛÂȘ, ÂÎ ÙˆÓ ÔÔ›ˆÓ Û˘¯ÓfiÙÂÚË Â›Ó·È Ë Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹. ∏ ÚfiÏË„Ë Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ·Ï¿ ̤ÙÚ· Î·È Û·Ó›ˆ˜ ··ÈÙÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ‹ ¿ÏÏË ·ÁˆÁ‹. ∏ ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ ‚·Û›˙ÂÙ·È ÛÙÔ ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È ÙËÓ ÂÓ‰Âϯ‹ ÎÏÈÓÈ΋ ÂͤٷÛË, ÒÛÙ ӷ ÌË ‰È·Ê‡ÁÔ˘Ó Ù· Û¿ÓÈ· ·ÏÏ¿ ÂÈΛӉ˘Ó· ·›ÙÈ· ηډȷ΋˜ ÚÔ¤Ï¢Û˘. ∆Ô ∏∫°, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÙÔ˘, ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙÔ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ‰ÈfiÙÈ ÌÔÚ› Ó· ·Ôηχ„ÂÈ ‰˘ÓËÙÈο ÂÈΛӉ˘Ó˜ ηٷÛÙ¿ÛÂȘ (Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT, Û‡Ó‰ÚÔÌÔ Wolff-
Parkinson-White, ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÁˆÁÈÌfiÙËÙ·˜). √ ˘fiÏÔÈÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, ·ÈÌ·ÙÔÏÔÁÈÎfi˜, ηډÈÔÏÔÁÈÎfi˜ ‹ Ó¢ÚÔÏÔÁÈÎfi˜, ÚÔÁÚ·ÌÌ·Ù›˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ٷ ÎÏÈÓÈο Â˘Ú‹Ì·Ù·.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Johnsrude CL. Current approach to pediatric syncope. Pediatr Cardiol 2000;21:522-531. 2. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol 1997;29:10391045. 3. Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W. Prevalence and triggers of syncope in medical students. Am J Cardiol 2003;91:1006-1008. 4. Wallace H, Shorvon S, Tallis R. Age-specific incidence and prevalence rates of treated epilepsy in an unselected population of 2,052,922 and age-specific fertility rates of women with epilepsy. Lancet 1998;352:1970-1973. 5. Sapin SO. Autonomic syncope in pediatrics: a practice-oriented approach to classification, pathophysiology, diagnosis and management. Clin Pediatr (Phila) 2004;43:17-23. 6. Lombroso CT, Lerman P. Breathholding spells (cyanotic and pallid infantile syncope). Pediatrics 1967;39:563-581. 7. Saul JP. Syncope: etiology, management, and when to refer. J S C Med Assoc 1999;95:385-387. 8. Tanaka H, Yamaguchi H, Matushima R, Tamai H. Instantaneous orthostatic hypotension in children and adolescents: a new entity of orthostatic intolerance. Pediatr Res 1999;46:691-696. 9. Low PA, Sandroni P, Singer W, et al. Postural tachycardia syndrome - an update. Clin Autonom Res 2002;12:107-109. 10. Hoefnagels WA, Padberg GW, Overweg J, van der Velde EA, Roos RA. Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol 1991;238:39-43. 11. Linzer M, Pontinen M, Gold DT, Divine GW, Felder A, Brooks WB. Impairment of physical and psychosocial function in recurrent syncope. J Clin Epidemiol 1991;44: 1037-1043. 12. Levine MM. Neurally mediated syncope in children: results of tilt testing, treatment, and long-term follow-up. Pediatr Cardiol 1999;20:331-335. 13. De Jong-de Vos Steenwijk CC, Wieling W, Johannes JM, Harms MP, Kuis W, Wesseling KH. Incidence and hemodynamic characteristics of near-fainting in healthy 6- to 16year old subjects. J Am Coll Cardiol 1995;25:1615-1621. 14. Kouakam C, Vaksmann G, Pachy E, Lacroix D, Rey C, Kacet S. Long-term follow-up of children and adolescents with syncope; predictor of syncope recurrence. Eur Heart J 2001;22:1618-1625. 15. Kenny RA, O’Shea D, Parry SW. The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders. Heart 2000;83:564-569. 16. McLeod KA, Wilson N, Hewitt J, Norrie J, Stephenson JB. Cardiac pacing for severe childhood neurally mediated syncope with reflex anoxic seizures. Heart 1999;82:721-725. 17. Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, et al. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA. 2003;289:2224-2229. ¶·È‰È·ÙÚÈ΋ 2008;71:62-67
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CASE REPORT
µÚ¤ÊÔ˜ Ì ˈÛÈÓÔÊÈÏÈ΋ ÂÓÙÂÚ›Ùȉ· 1 ∞’ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ 2 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 3 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ÃÚ˘Û‹ ∫Ô˘ÙÛ·˘Ù›ÎË kochrysa@yahoo.com ∞’ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ ∆.∫. 152 36, ¶. ¶ÂÓÙ¤ÏË
Ã. ∫Ô˘ÙÛ·˘Ù›ÎË1, ∂. ª¿ÓÙ˙ÈÔ˘1, ¢. ÷Ù˙‹˜2, ∫. ¶··ÓÙ˙›Ì·˜1, ∫. ™ÙÂÊ·Ó¿ÎË3, ¡. ª˘ÚÈÔÎÂÊ·ÏÈÙ¿Î˘1, ∂. ƒÒÌ·-°È·ÓÓ›ÎÔ˘2 ¶ÂÚ›ÏË„Ë: ∏ ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Â›Ó·È Û¿ÓÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·, Ë ÔÔ›· ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1937 ·fi ÙÔÓ Kaijser. ∂›Ó·È ΢ڛˆ˜ ÓfiÛÔ˜ ÙˆÓ ÂÓËϛΈÓ, ·ÊÔ‡ ··ÓÙ¿Ù·È Û ¿ÙÔÌ· ËÏÈΛ·˜ ÌÂٷ͇ ‰Â‡ÙÂÚ˘ Î·È ¤ÎÙ˘ ‰ÂηÂÙ›·˜ Ù˘ ˙ˆ‹˜, Ì ÌÈÎÚ‹ ˘ÂÚÔ¯‹ ÛÙÔ˘˜ ¿Ó‰Ú˜, ÂÓÒ ÙÂÏÂ˘Ù·›· ÏËı·›ÓÔ˘Ó ÔÈ ·Ó·ÊÔÚ¤˜ Û ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Î·È ·ÎfiÌË Û·ÓÈfiÙÂÚ· ‚ÚÂÊÒÓ. ∞·Ú·›ÙËÙ· ÛÙÔȯ›· ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ›ӷÈ: 1) ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·, fiˆ˜ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ¤ÌÂÙÔÈ, Á·ÛÙÚÂÓÙÂÚÈ΋ ÚˆÙÂ˚ÓfiÚÚÔÈ· Î.Ù.Ï. 2) ¢È‹ıËÛË ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ (°∂™) ·fi ˈÛÈÓfiÊÈÏ· >20 ∏PF Û ˘ÏÈÎfi ‚ÈÔ„›·˜ ‰È·ÊfiÚˆÓ ÙÌËÌ¿ÙˆÓ ÙÔ˘, Û˘Ó‹ıˆ˜ ÛÙÔÌ¿¯Ô˘ Î·È ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘. ™Ù· ‚Ú¤ÊË Â›Ó·È Û˘¯Ó‹ Ë ‰È‹ıËÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ (ˈÛÈÓÔÊÈÏÈ΋ ÔÈÛÔÊ·Á›Ùȉ·). 3) √ ·ÔÎÏÂÈÛÌfi˜ ¿ÏÏ˘ ·ÈÙ›·˜ ˈÛÈÓÔÊÈÏ›·˜ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ >80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌÊ·Ó›˙Ô˘Ó ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ˈÛÈÓÔÊÈÏ›· ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜. 4) ∏ ·ÓÙ·fiÎÚÈÛË Î·È Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ÙË ıÂڷ›·. ∏ ˈÛÈÓÔÊÈÏÈ΋ ÔÈÛÔÊ·Á›Ùȉ· ÔÌÔÈ¿˙ÂÈ ·ÚÎÂÙ¿ Ì ÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°√¶) Î·È ı· Ú¤ÂÈ Ó· Èı·ÓÔÏÔÁÂ›Ù·È ˆ˜ ‰È¿ÁÓˆÛË Î·È Ó· Á›ÓÂÙ·È ÂÓ‰ÔÛÎfiËÛË ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙË Û˘Ó‹ıË ıÂڷ›·. ∞Ó¿ÏÔÁ· Ì ÙÔ ÙÌ‹Ì· ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Ô˘ ¤¯ÂÈ ˘ÔÛÙ› ÙËÓ ËˆÛÈÓÔÊÈÏÈ΋ ‰È‹ıËÛË (‚ÏÂÓÓÔÁfiÓÔ˜, Ì˘˚Îfi˜ ¯ÈÙÒÓ·˜, ÔÚÔÁfiÓÔ˜, fiÏÔ ÙÔ ÙÔ›¯ˆÌ·) ‰È·ÎÚ›ÓÂÙ·È Û 4 ÈÛÙÔÏÔÁÈÎÔ‡˜ Ù‡Ô˘˜ ‰›ÓÔÓÙ·˜ Î·È ·ÓÙ›ÛÙÔÈ¯Ë Û˘Ìو̷ÙÔÏÔÁ›·. ø˜ ̤ÙÚÔ ·ÓÙÈÌÂÙÒÈÛ˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·Ú¯Èο ˘Ô·ÏÏÂÚÁÈ΋-ÛÙÔȯÂȷ΋ ‰›·ÈÙ· ηÈ, › ·ÔÙ˘¯›·˜ ·˘Ù‹˜, ¯ÔÚËÁÔ‡ÓÙ·È Î˘Ú›ˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È ‰Â˘ÙÂÚ¢fiÓÙˆ˜ Ë ÌÔÓÙÂÏÔ˘Î¿ÛÙË, ÙÔ ¯ÚˆÌÔÁÏ˘ÎÈÎfi Ó¿ÙÚÈÔ Î·È ¿ÏÏ·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ Ì ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Ô˘ ‰ÈÂÚ¢ӋıËΠÏfiÁˆ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜, ÂÌ¤ÙˆÓ Î·È ÂÎÛÂÛËÌ·Ṳ̂Ó˘ ˈÛÈÓÔÊÈÏ›·˜ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜. §¤ÍÂȘ ÎÏÂȉȿ: ∏ˆÛÈÓÔÊÈÏÈ΋ ÂÓÙÂÚ›Ùȉ·, ˈÛÈÓÔÊÈÏ›·, ¤ÌÂÙÔÈ, ‚Ú¤ÊÔ˜.
An infant with eosinophilic enteritis 1 1st Paediatric Department, General Children’s Hospital of Penteli 2 1st Paediatric Clinic, University of Athens, Children’s Hospital “Aghia Sophia” 3 Pathology Department, Children’s Hospital “Aghia Sophia” Correspondence: Chrysie Koutsaftiki kochrysa@yahoo.com 1st Paediatric Department, General Children’s Hospital of Penteli 152 36, P. Penteli, Greece
C. Koutsaftiki1, E. Mantziou1, D. Hatzis2, K. Papantzimas1, ∫. Stefanaki3, N. Myriokefalitakis1, E. Roma-Giannikou2 Abstract: Eosinophilic gastroenteritis is a rare disease, which was first described by Kaijser in 1937. It is a disease mainly of adults, encountered in people between the second and sixth decades of life, predominantly men, but recently there has been an increase in case reports of children, and more rarely of infants, with eosinophilic gastroenteritis. The diagnostic criteria are: 1) Gastrointestinal system symptoms, such as abdominal pain, vomiting, protein loss, etc. 2) Infiltration of the gastrointestinal tract by eosinophils (>20 HPF in biopsies), mainly found in the stomach and small intestine. In infants the oesophagus is most often infiltrated (eosinophilic oesophagitis). 3) Exclusion of other causes of eosinophilia, since in >80% of cases pronounced eosinophilia is reported. 4) Relief or improvement of the symptoms after initiation of treatment. The symptoms of eosinophilic oesophagitis resemble those of gastrooesophageal reflux, so it should be considered as possible diagnosis and biopsy must be taken in those cases where there is no improvement with the usual treatment. According to the layer of the enteric wall that is infiltrated (mucosa, muscle layer, serosa, the whole enteric wall), 4 histological types are described, with related symptoms in each type. To treat the disease, an elimination-hypoallergenic diet is introduced, and if that fails, oral corticosteroids are the main treatment, and in some cases montelucast, sodium cromoglycate or other drugs have been proposed. The case is described of an infant that was investigated due to weight loss, vomiting and marked eosinophilia, and found to have eosinophilic gastroenteritis.
Key words: Eosinophilic enteritis, eosinophilia, vomiting, infant.
Paediatriki 2008;71:68-73
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69
µÚ¤ÊÔ˜ Ì ˈÛÈÓÔÊÈÏÈ΋ ÂÓÙÂÚ›Ùȉ·
∂ÈÛ·ÁˆÁ‹ ∏ ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ıˆÚÂ›Ù·È Û¯ÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜, ·Ó Î·È ÂÚÈÁÚ¿ÊÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÛÛfiÙÂÚÔ ·fi 30 ¯ÚfiÓÈ· (1). ∂›Ó·È ÓfiÛÔ˜ ȉÈÔ·ı‹˜, Ô˘ ÚÔ‚¿ÏÏÂÈ Ì ¢ڇ Ê¿ÛÌ· Û˘ÌÙˆÌ¿ÙˆÓ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· (¶›Ó·Î·˜ 1). ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ·›˙ÂÈ Ë ‡·ÚÍË ·ÙÔ›·˜ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi-·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi. ¢È·ÎÚ›ÓÂÙ·È Û 4 Ù‡Ô˘˜, Ì ‚¿ÛË ÙËÓ ËˆÛÈÓÔÊÈÏÈ΋ ‰È‹ıËÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘: 1) ¶ÚÔÛ‚ÔÏ‹ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ (Û˘ÓËı¤ÛÙÂÚÔ˜ Ù‡Ô˜), ÌÂ Û˘ÌÙÒÌ·Ù· fiˆ˜ ¤ÌÂÙÔÈ, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ (ÌÈÌÂ›Ù·È ÔÍ›· ÎÔÈÏ›·), ‰È¿ÚÚÔȘ, ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ÛÙ· ÎfiÚ·Ó·, ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·, ‰˘Û·ÔÚÚfiÊËÛË, ÚˆÙÂ˚ÓfiÚÚÔÈ·, ·Ó·ÛÙÔÏ‹ ·‡ÍËÛ˘ Î.¿. 2) ¶ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ì˘˚ÎÔ‡ ¯ÈÙÒÓ·, fiÔ˘ ·¯‡ÓÂÙ·È ÙÔ ÂÓÙÂÚÈÎfi ÙÔ›¯ˆÌ· Î·È ÚÔÂÍ¿Ú¯Ô˘Ó Î·Ù¿ Û˘Ó¤ÂÈ· ·ÔÊÚ·ÎÙÈο Û˘ÌÙÒÌ·Ù· (ÌÈÌÂ›Ù·È ˘ÏˆÚÈ΋ ÛÙ¤ÓˆÛË). 3) ¶ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÔÚÔÁfiÓÔ˘ (Û·ÓÈfiÙÂÚÔ˜ Ù‡Ô˜), Ì ·ÚÈÔ Û‡Ìو̷ ÙÔÓ ·ÛΛÙË (¤¯ÂÈ ÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ˈÛÈÓÔÊ›ÏˆÓ ÛÙËÓ ÂÚÈʤÚÂÈ·). 4) ¶ÚÔÛ‚ÔÏ‹ fiÏÔ˘ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜, Ì ÔÈΛÏË Û˘Ìو̷ÙÔÏÔÁ›· (1-4). ∆· ıÂڷ¢ÙÈο ̤ÙÚ·, Ô˘ ηٿ ·ÚÈÔ ÏfiÁÔ ÂÊ·ÚÌfi˙ÔÓÙ·È, Â›Ó·È Ë ÛÙÔȯÂȷ΋ ‰›·ÈÙ·, ·Ú¯Èο, ȉȷ›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ fiÔ˘ ˘¿Ú¯ÂÈ Û·Ê‹˜ Û˘Û¯¤ÙÈÛË Ì ÙÚÔʤ˜ (ÛÙÔȯ›· ·fi ÈÛÙÔÚÈÎfi, prick tests, patch tests, RAST tests) Î·È Â› ·ÔÙ˘¯›·˜ Ë ¯ÔÚ‹ÁËÛË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (Ú‰ÓÈ˙fiÓË) Û ‰fiÛË 0,5-2mg/kg/ 24ˆÚÔ, Ì ÛÙfi¯Ô ÙË Ì›ˆÛ‹ ÙÔ˘˜ ‹ Î·È ÙËÓ Ï‹ÚË ‰È·ÎÔ‹ ÙÔ˘˜ Û fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Û˘ÓÙÔÌfiÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ™Â ÂÈÚ·Ì·ÙÈÎfi ÛÙ¿‰ÈÔ ‚Ú›ÛÎÂÙ·È Ë ¯ÔÚ‹ÁËÛË Î·È ¿ÏÏˆÓ Ô˘ÛÈÒÓ, fiˆ˜ ÙÔ ¯ÚˆÌÔÁÏ˘ÎÈÎfi Ó¿ÙÚÈÔ, Ë ÌÔÓÙÂÏÔ˘Î¿ÛÙË, Ë ÎÂÙÔÙÈÊ·›ÓË Î·È, Û ȉȷ›ÙÂÚ· ·ÓıÂÎÙÈΤ˜ ÛÙË ıÂڷ›· ÌÔÚʤ˜, Ë Î˘ÎÏÔÛÔÚ›ÓË ‹ ¿ÏÏ· ·ÓÔÛÔÙÚÔÔÔÈËÙÈο Ê¿Ú̷η, Ì ¿ÏÏÔÙ ¿ÏÏ· ·ÔÙÂϤÛÌ·Ù· (2-5,11). ¢˘ÛÙ˘¯Ò˜, ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔȯ›· ·fi ÛˆÛÙ¿ ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙËÓ ÂȉËÌÈÔÏÔÁ›·, ·ÏÏ¿ ÌÂÌÔӈ̤Ó˜ ·ÚÔ˘ÛÈ¿ÛÂȘ ÂÚÈÛÙ·ÙÈÎÒÓ, Ù· ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÔÔ›· ·ÊÔÚÔ‡Ó ÂÓËÏ›ÎÔ˘˜. ¶·Ú¿ Ù·‡Ù·, ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ˈÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· Ô˘ ÂΉËÏÒıËΠ·fi ÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Î·È Ì¿ÏÈÛÙ· Ì ·Û˘Ó‹ıÂȘ ÂÈÏÔΤ˜, fiˆ˜ ‰È¿ÙÚËÛË ÛÙÔÌ¿¯Ô˘ Î·È ÂÁÎÔÏ·ÛÌfi˜ (12). ÿÛˆ˜, ÙÂÏÈο, Ë ÓfiÛÔ˜ ·˘Ù‹ Ó· ÌËÓ Â›Ó·È ÙfiÛÔ Û¿ÓÈ· (3). ∞Ó Î·È ‰ÂÓ Â›Ó·È Ï›Á˜ ÔÈ ·Ó·ÊÔÚ¤˜ ÂÚÈÙÒÛÂˆÓ Ì ȉȷ›ÙÂÚ· ıÔÚ˘‚Ò‰Ë Û˘Ìو̷ÙÔÏÔÁ›· ηÈ, ÔÏϤ˜ ÊÔÚ¤˜, Ì ÌÔÈÚ·›· ηٿÏËÍË, Ë ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ ıˆÚÂ›Ù·È ÁÂÓÈο ηϋ. ¶·Ú·ÙËÚÔ‡ÓÙ·È ˘Ê¤ÛÂȘ Î·È ÂÍ¿ÚÛÂȘ, Ì ÚÔÛ‚ÔÏ‹ Û˘¯Ó¿ ‰È·ÊÔÚÂÙÈÎÒÓ ÙÌËÌ¿ÙˆÓ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡.
¶›Ó·Î·˜ 1. ™˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· Ù˘ ˈÛÈÓÔÊÈÏÈ΋˜ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ ·fi ÙÔ ÂÙÈÎfi (4) ™˘ÌÙÒÌ·Ù·
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∫ÔÈÏÈ·Îfi ¿ÏÁÔ˜ ∞ÓÔÚÂÍ›· ªÂÙˆÚÈÛÌfi˜ ¢È¿ÚÚÔÈ· ¢˘ÛÊ·Á›· ªÂȈ̤ÓË ·Ó¿Ù˘ÍË ª¤Ï·ÈÓ˜ ÎÂÓÒÛÂȘ ŒÌÂÙÔÈ ∞ÒÏÂÈ· ‚¿ÚÔ˘˜
∞ÛΛÙ˘ ∫ÔÏ›Ùȉ· °·ÛÙÚÂÓÙÂÚÈ΋ ÚˆÙÂ˚ÓfiÚÚÔÈ· √›‰ËÌ· √ÈÛÔÊ·Á›Ùȉ· ™˘Ú›ÁÁÈÔ ÂÓÙ¤ÚÔ˘ ¶ÂÙÈÎfi ¤ÏÎÔ˜ ÀÔÚˆÙÂ˚Ó·ÈÌ›· ∂ÈϽÙȉ· ¢˘Û·ÔÚÚfiÊËÛË ∞fiÊÚ·ÍË ÂÓÙ¤ÚÔ˘ ¢È¿ÙÚËÛË ÂÓÙ¤ÚÔ˘ £¿Ó·ÙÔ˜
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ µÚ¤ÊÔ˜ ¿ÚÚÂÓ ËÏÈΛ·˜ 7 1/2 ÌËÓÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋, ÏfiÁˆ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜ ·fi ‰ÈÌ‹ÓÔ˘ Î·È ¤ÓÙÔÓÔ Úfi‚ÏËÌ· ÂÌ¤ÙˆÓ ·fi ÓÂÔÁÓÈ΋˜ ËÏÈΛ·˜, Û˘Ó‹ıˆ˜ ÌÈÛ‹ ÒÚ· ‹ Î·È ·ÚÁfiÙÂÚ· ÌÂÙ¿ ÙË Û›ÙÈÛË, Ô˘ ÂȉÂÈÓÒıËΠȉȷ›ÙÂÚ· Ì ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ‰È·ÈÙÔÏfiÁÈfi ÙÔ˘ ÛÙÂÚÂÒÓ ÙÚÔÊÒÓ Û ËÏÈΛ· 5 ÌËÓÒÓ. ∆Ô ·È‰› ·ÓÙÈÌÂÙˆÈ˙fiÙ·Ó Ì ۛÙÈÛË Ì ·ÓÙÈ·Ó·ÁˆÁÈο Á¿Ï·Ù·, ˆ˜ ̤ÙÚÔ ¤Ó·ÓÙÈ Èı·Ó‹˜ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎÒ˜ fï˜. ◊Ù·Ó ÙÔ ÚÒÙÔ Î·È ÌÔÓ·‰ÈÎfi ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ηÏÔ‡ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘, Ì ¤ÓÙÔÓË ·ÙÔÈ΋ ÚԉȿıÂÛË. √ ·Ù¤Ú·˜ ¿Û¯ÂÈ ·fi ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· Î·È Â·ÚÈÓ‹ ÚÈÓÔÂÈÂÊ˘Î›Ùȉ· Î·È Ë ÌËÙ¤Ú· ·fi ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·. ∆Ô ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi ÙÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó ÂχıÂÚÔ, ÂÓÒ ·fi ËÏÈΛ·˜ 5 ÌËÓÒÓ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· Ù˘
∂ÈÎfiÓ· 1. ¢È‹ıËÛË ÙÔ˘ ¯ÔÚ›Ô˘, ÙˆÓ ÎÚ˘ÙÒÓ Î·È ÂÛÙ›· ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ÂÈıËÏ›Ô˘ ÙÂÌ·¯›Ô˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ ·fi ˈÛÈÓfiÊÈÏ· (·ÈÌ·ÙÔÍ˘Ï›ÓË-ˈۛÓË x200). ¶·È‰È·ÙÚÈ΋ 2008;71:68-73
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·70
70
Ã. ∫Ô˘ÙÛ·˘Ù›ÎË Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ŒÏÂÁ¯Ô˜ ∞Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜ °ÂÓÈ΋ ·›Ì·ÙÔ˜ §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 26.800 K/ÌL (¶=6%, §=42%, ª=2%, ∏=50% ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜: 13.400) ∞ÈÌÔÛÊ·ÈÚ›ÓË = 11,1 g/dl ∞ÈÌ·ÙÔÎÚ›Ù˘ = 33,6% ∞ÈÌÔÂÙ¿ÏÈ· = 530.000 K/ÌL ∆∫∂ = 14 mmHg/1Ë ÒÚ· CRP = (-) √ÏÈο Ï¢ÎÒÌ·Ù· = 5,2 g/dl §Â˘ÎˆÌ·Ù›Ó˜ = 3,2 g/dl ™Ê·ÈÚ›Ó˜ = 2 g/dl §ÔÈfi˜ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜: º˘ÛÈÔÏÔÁÈÎfi˜ ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜: IgG=206 mg/dl ↓ IgM=26 mg/dl ↓ IgA=11,8 mg/dl IgG1=85 mg/dl ↓ IgG2=84 mg/dl IgG3=5 mg/dl ↓ IgE=130 iu/ml ↑ IgG4=43 mg/dl RAST: °¿Ï· = ∆¿ÍË 1 ∞˘Áfi-™ÈÙËÚ¿-¶ÔÚÙÔοÏÈ = 0 ∫˘ÙÙ·ÚÈ΋ ·ÓÔÛ›·: º˘ÛÈÔÏÔÁÈÎÔ› ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ÏËı˘ÛÌÔ› ÁÈ· ÙËÓ ËÏÈΛ·. º˘ÛÈÔÏÔÁÈ΋ ÔÍÂȉˆÙÈ΋ ·Ó·Ó¢ÛÙÈ΋ ÈηÓfiÙËÙ· ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ. ∫·Ú‰ÈÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË: º˘ÛÈÔÏÔÁÈ΋ ‰ÔÌ‹ Î·È ÏÂÈÙÔ˘ÚÁ›· Ù˘ ηډȿ˜. RÖ ıÒÚ·ÎÔ˜: º˘ÛÈÔÏÔÁÈ΋ U/S ÎÔÈÏ›·˜: ◊·Ú-ÛÏËÓ Ê˘ÛÈÔÏÔÁÈο. ¢ÂÓ ·Ú·ÙËÚÂ›Ù·È Û·Ê‹˜ ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ ÂÓÙÂÚÈÎÒÓ ÂϛΈÓ. ¶·Ú·ÛÈÙÔÏÔÁÈ΋ ÎÔÚ¿ÓˆÓ: ∞ÚÓËÙÈ΋ ∫·ÏÏȤÚÁÂȘ ÎÔÚ¿ÓˆÓ: º˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· Mayer ÎÔÚ¿ÓˆÓ: £ÂÙÈ΋ ∞ÔÙÂϤÛÌ·Ù· ÂÓ‰ÔÛÎfiËÛ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡: ∞Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ŒÏÂÁ¯Ô˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ Ú‰ÓÈ˙fiÓ˘ °ÂÓÈ΋ ·›Ì·ÙÔ˜ §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 10.600 K/ÌL (¶=18%, §=72%, ª=10%, ∏=2% ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜:212) ∞ÈÌÔÛÊ·ÈÚ›ÓË = 14 g/dl ∞ÈÌ·ÙÔÎÚ›Ù˘ = 43,2% ∞ÈÌÔÂÙ¿ÏÈ· = 362.000 K/ÌL ∆∫∂ = 5 mmHg/1Ë ÒÚ· CRP = (-) √ÏÈο Ï¢ÎÒÌ·Ù· = 5,9 g/dl §Â˘ÎˆÌ·Ù›Ó˜ = 4,2 g/dl ™Ê·ÈÚ›Ó˜ = 1,7 g/dl ↓ §ÔÈfi˜ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜: º˘ÛÈÔÏÔÁÈÎfi˜ ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜: IgG=231 mg/dl ↓ IgM=60,4 mg/dl IgA=19,1 mg/dl Mayer ÎÔÚ¿ÓˆÓ: ∞ÚÓËÙÈΤ˜
ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â›¯Â ÓÔÛ‹ÛÂÈ ÂÚÈÛÛfiÙÂÚÔ ·fi ‰‡Ô ÊÔÚ¤˜ Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î·È ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. ¢ÂÓ ·Ó·ÊÂÚfiÙ·Ó ¯Ú‹ÛË Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ ¤Ú·Ó Ù˘ ·ÌÈÎÈÏÏ›Ó˘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Ù˘ ˆÙ›Ùȉ·˜ Î·È Ù˘ Û·Ï‚Ô˘Ù·ÌfiÏ˘
∂ÈÎfiÓ· 2. ∫Ú˘ÙÈ΋ ‰È‹ıËÛË ÙÂÌ·¯È‰›Ô˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ ·fi ˈÛÈÓfiÊÈÏ· x400. Paediatriki 2008;71:68-73
IgE=<5,0 iu/ml
Î·È Ù˘ ÊÏÔ˘ÙÈη˙fiÓ˘ Ì ÙË ÌÔÚÊ‹ ÂÈÛÓÔÒÓ, ÁÈ· ‰È¿ÛÙËÌ· 15 ËÌÂÚÒÓ Û˘ÓÔÏÈο . ∆Ô ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó ÌÂٷ͇ 3˘-10˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ (∂£), ÂÓÒ Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Î·È ÙÔ Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ ¿Óˆ ·fi ÙËÓ 50Ë ∂£. ™ÙËÓ Î·Ì‡ÏË ·Ó¿Ù˘Í˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ·È‰ÈÔ‡, ·Ú·ÙËÚÔ‡ÓÙ·Ó ÙÒÛË ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÌËÓÒÓ. ∂›¯Â ÂÈÎfiÓ· ‹È·˜ Ïԛ̈͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ¯ˆÚ›˜ ¿ÏÏ· Â˘Ú‹Ì·Ù· ·fi Ù· ÏÔÈ¿ Û˘ÛÙ‹Ì·Ù·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, Ô˘ ·Ú¯Èο ‹Ù·Ó 4.680/mm3 ηٿ ·fiÏ˘ÙÔ ·ÚÈıÌfi, ÂÓÒ ÙËÓ ÙÚ›ÙË Ì¤Ú· ÓÔÛËÏ›·˜ ͤڷÛ ÙȘ 13.400/mm3 (50% ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ) (¶›Ó·Î·˜ 2). ¢ÂÓ ·ÚÔ˘Û›·˙ ·Ó·ÈÌ›· ‹ ·ıÔÏÔÁÈÎfi ·ÚÈıÌfi ·ÈÌÔÂÙ·Ï›ˆÓ. ¶·ıÔÏÔÁÈ΋ ‹Ù·Ó ·ÎfiÌË Ë ÙÈÌ‹ ÙˆÓ ÏÂ˘ÎˆÌ¿ÙˆÓ Î·È ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÛÊ·ÈÚÈÓÒÓ Î·È ·ÚÁfiÙÂÚ· Î·È Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘. √ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÎÔÚ¿ÓˆÓ ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ‡·ÚÍË ·Ú·Û›ÙˆÓ ‹ ÌÈÎÚÔ‚›ˆÓ, ·ÏÏ¿ ıÂÙÈÎfi˜ ÁÈ· ·ÚÔ˘Û›· ·›Ì·ÙÔ˜ Û ÔÏÏ·Ï¿ ‰Â›ÁÌ·Ù·, ¯ˆÚ›˜ Ì·ÎÚÔÛÎÔÈ΋ ÂȂ‚·›ˆÛË. √ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ·Ú¯Èο
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·71
71
µÚ¤ÊÔ˜ Ì ˈÛÈÓÔÊÈÏÈ΋ ÂÓÙÂÚ›Ùȉ·
¶›Ó·Î·˜ 3. ¢ÈÂÚ‡ÓËÛË ËˆÛÈÓÔÊÈÏ›·˜ (7) ∞ÏÏÂÚÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ∞ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ÕÛıÌ· √Í›· ÎÓ›‰ˆÛË ∞ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Û ʿÚ̷η §ÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ ∂ÏÌÈÓıÈ¿ÛÂȘ ∆Úȯ›ÓˆÛË ∆ÔÍÔηڛ·ÛË ™ÙÚÔÁÁ˘ÏÔ›‰ˆÛË ∞Ûηڛ·ÛË ºÈÏ·Ú›·ÛË ™¯ÈÛÙÔۈ̛·ÛË ∂¯ÈÓÔÎÔÎΛˆÛË ¶Ó¢ÌÔÓÔ·ÛÙË carinii ∆ÔÍÔÏ¿Û̈ÛË ∞ÌÔÈ‚¿‰ˆÛË ∂ÏÔÓÔÛ›· µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ·ÛÂÚÁ›ÏψÛË ∫ÔÎÎȉÈÔÂȉÔ̇ΈÛË
∫·ÎÔ‹ıÂȘ ŸÁÎÔÈ ÂÁÎÂÊ¿ÏÔ˘ ¡fiÛÔ˜ Hodgkin - §ÂÌÊÒÌ·Ù· ∆ √Í›· Ì˘ÂÏÔÁÂÓ‹˜ Ï¢¯·ÈÌ›· °·ÛÙÚÂÓÙÂÚÈΤ˜ ·ı‹ÛÂȘ ºÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ∏ˆÛÈÓÔÊÈÏÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ∞ÓÔÛÔ·Ó¿ÚÎÂȘ ™‡Ó‰ÚÔÌÔ ˘ÂÚ IgE ™‡Ó‰ÚÔÌÔ Wiskott-Aldrich ∞ÓÙ›‰Ú·ÛË Î·Ù¿ ÌÔۯ‡̷ÙÔ˜ ¶Ó¢ÌÔÓÈΤ˜ ·ı‹ÛÂȘ ™‡Ó‰ÚÔÌÔ Löffler ∏ˆÛÈÓÔÊÈÏÈ΋ Ï¢¯·ÈÌ›· ¶Ó¢ÌÔӛ˜ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÕÏϘ ηٷÛÙ¿ÛÂȘ £ÚÔÌ‚Ô΢ÙÙ·ÚÔÂÓ›· Ì ·Ô˘Û›· ÎÂÚΛ‰·˜ ∞ÁÁÂÈ›Ùȉ· ªÂÙ¿ ·ÎÙÈÓÔ‚ÔÏ›· ÎÔÈÏȷ΋˜ ¯ÒÚ·˜ πÛÙÈÔ΢ÙÙ¿ÚˆÛË ÌÂ Û˘ÌÌÂÙÔ¯‹ ·fi ÙÔ ‰¤ÚÌ·
·Ó¤‰ÂÈÍ ·˘ÍË̤ÓË ÙÈÌ‹ Ù˘ πgE, ·ÏÏ¿ ÌÂȈ̤ÓË Ù˘ IgG Î·È Î¿ÔȘ ·fi ÙȘ ˘ÔÙ¿ÍÂȘ Ù˘, ηıÒ˜ Î·È ÂÏ·Ùو̤ÓË Ù˘ IgM. √ ¤ÏÂÁ¯Ô˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ¤‰ÂÈÍ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ ÂÓÙfi˜ ÙˆÓ ÚÔ‚ÏÂfiÌÂÓˆÓ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ÔÚ›ˆÓ. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ‰ÂÓ ·Ó¤‰ÂÈÍ ÂÓÂÚÁfi Ó¢ÌÔÓÈ΋ ·ÏÏÔ›ˆÛË Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ Î·È Î¿Ùˆ ÎÔÈÏ›·˜ ‹Ù·Ó ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë Î·Ù¢ı‡ÓıËΠ۠ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, fiˆ˜ Ë ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ÔÈ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ ÁÂÓÈÎfiÙÂÚ·, Ë ·ÏÏÂÚÁÈ΋ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔÈ ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÔÈ ·Ú·ÛÈÙÒÛÂȘ-ÏÔÈÌÒÍÂȘ, Ù· ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· Î.¿., ·ı‹ÛÂȘ Ô˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÁÓˆÛıÔ‡Ó ¯ÚÂÈ¿˙ÔÓÙ·È ÂÓ‰ÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô (¶›Ó·Î·˜ 3). ªÂ ‚¿ÛË ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ÙË ÌÈÎÚ‹
ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜, ıˆڋıËΠˆ˜ Èı·ÓfiÙÂÚÔ˜ ·ÈÙÈÔ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ οÔÈ· ·ÏÏÂÚÁÈ΋ ηٿÛÙ·ÛË Î·È ÂÊ·ÚÌfiÛÙËΠ‰›·ÈÙ· Ì ÛÙÔȯÂÈ·Îfi Á¿Ï·, Ï‹Ú˘ ·Ô¯‹ ·fi ÚÔ˚fiÓÙ· ·ÁÂÏ¿‰·˜ Î·È ·fi ¿ÏϘ ‰˘ÓËÙÈο ·ÏÏÂÚÁÈÔÁfiÓ˜ ÙÚÔʤ˜. ∏ ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ ‚ÂÏÙÈÒıËÎÂ, ÛÙ·Ì¿ÙËÛ·Ó ÔÈ ¤ÌÂÙÔÈ Î·È ¿Ú¯ÈÛ ӷ ÚÔÛÏ·Ì‚¿ÓÂÈ ‚¿ÚÔ˜ ÈηÓÔÔÈËÙÈο. ŸÌˆ˜, ·Ú¿ ÙËÓ Î¿ÔÈÔ˘ ‚·ıÌÔ‡ ÂÏ¿ÙÙˆÛË ÙˆÓ ËˆÛÈÓÔʛψÓ, ‰È·ÈÛÙÒıËΠÂÈϤÔÓ ÙÒÛË ÙˆÓ ÏÂ˘ÎˆÌ·ÙÈÓÒÓ Î·È ÙˆÓ ÛÊ·ÈÚÈÓÒÓ (ȉ›ˆ˜ Ù˘ IgG) Î·È Û˘Ó¯‹˜ ·Ó›¯Ó¢ÛË ·ÈÌÔÛÊ·ÈÚ›Ó˘ ÛÙ· ÎfiÚ·Ó·. ∆Ô ‚Ú¤ÊÔ˜ ˘Ô‚Ï‹ıËΠ۠ÂÓ‰ÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ ÂÙÈÎÔ‡, Ô˘ ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙÔ ·ÓÒÙÂÚÔ ÂÙÈÎfi Î·È ÏÂ˘Îˆfi ›¯ÚÈÛÌ· ÛÙÔ ÔÚıfi Î·È ÙÔ ÛÈÁÌÔÂȉ¤˜. ªÂ ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ‹È· ¯ÚfiÓÈ· ÔÈÛÔÊ·Á›Ùȉ· Î·È ‹È· ÌË ÂȉÈ΋ Á·ÛÙÚ›Ùȉ·, Ì ·ÚÎÂÙ¿ ˈÛÈÓfiÊÈÏ·, 4-13 HPF. √ ‚ÏÂÓÓÔÁfiÓÔ˜ ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ ›¯Â Ê˘ÛÈÔÏÔÁÈΤ˜ Ï¿¯Ó˜, ̤ÙÚÈ· ¯ÚfiÓÈ· 12Ï›Ùȉ· Î·È Û·ÊÒ˜ ·˘ÍË̤ӷ ˈÛÈÓfiÊÈÏ·, 20-39 HPF, Ì ʷÈÓfiÌÂÓ· ·ÔÎÔÎΛˆÛ˘ Î·È ÛÙÔȯ›· ÂÓ‰ÔÂÈıËÏȷ΋˜ ÌÂÙ·Ó·ÛÙ‡Ûˆ˜. ™ÙÔ ÔÚıÔÛÈÁÌÔÂȉ¤˜ ‰È·ÈÛÙÒıËΠÌÈÎÚÔ‡ ‚·ıÌÔ‡ ‰È·Ù·Ú·¯‹ Ù˘ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ·‰ÂÓÈÎÒÓ ÛÙÔȯ›ˆÓ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘, ·‡ÍËÛË ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Ï·ÛÌ·ÙÔ΢ÙÙ¿ÚˆÓ, ÂÓÒ Ù· ˈÛÈÓfiÊÈÏ· ‹Ù·Ó ÌÂÙÚ›ˆ˜ ·˘ÍË̤ӷ, 12-20 HPF, Ì ¤ÓÙÔÓ· Ê·ÈÓfiÌÂÓ· ·ÔÎÔÎΛˆÛ˘. √ ¤ÏÂÁ¯Ô˜ ÁÈ· ∏. pylori Î·È Ï¿Ì‚ÏȘ ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ·ÏÏÂÚÁÈ΋ ÂÍÂÚÁ·Û›· ÛÙÔ ·ÓÒÙÂÚÔ ÂÙÈÎfi Î·È ‹È· ˆ˜ ̤ÙÚÈ· ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, Ì ̤ÙÚÈ· ˈÛÈÓÔÊÈÏ›· ÛÙÔ Î·ÙÒÙÂÚÔ ÂÙÈÎfi.
∂ÈÎfiÓ· 3. ∆ÂÌ·¯›‰ÈÔ ‚ÏÂÓÓÔÁfiÓÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ Ì ·˘ÍË̤ӷ ˈÛÈÓfiÊÈÏ· Ì ÂÓ Ùˆ ‚¿ıÂÈ Î·Ù·ÓÔÌ‹ Î·È ÎÚ˘ÙÈ΋ ‰È‹ıËÛË x400.
¶·È‰È·ÙÚÈ΋ 2008;71:68-73
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·72
72
Ã. ∫Ô˘ÙÛ·˘Ù›ÎË Î·È Û˘Ó.
∏ ÙÂÏÈ΋ ‰È¿ÁÓˆÛË ‹Ù·Ó ÂΛÓË Ù˘ ˈÛÈÓÔÊÈÏÈ΋˜ ÂÓÙÂÚ›Ùȉ·˜. ∂Âȉ‹ οÔÈ· ·fi Ù· Û˘ÌÙÒÌ·Ù·, fiˆ˜ Ë ÚˆÙÂ˚ÓfiÚÚÔÈ· Î·È ÔÈ ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ, ¤ÌÂÓ·Ó, ·Ú¿ ÙË ‰›·ÈÙ· Ô˘ ¤ÁÈÓ ·ÎfiÌ· ÈÔ Û˘ÁÎÂÎÚÈ̤ÓË ‡ÛÙÂÚ· ·fi ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ (patch tests), ·ÔÊ·Û›ÛÙËÎÂ Ë ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙fiÓ˘ ·fi ÙÔ ÛÙfiÌ·, ·Ú¯Èο Û ‰fiÛË 1,5 mg/kg/ 24ˆÚÔ. √ ÚÒÙÔ˜ ·ӤÏÂÁ¯Ô˜, 7 ̤Ú˜ ÌÂÙ¿, ·Ó¤‰ÂÈÍ ·ÚÈıÌfi ˈÛÈÓÔÊ›ÏˆÓ <800/mm3, Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ πgE, Mayer ÎÔÚ¿ÓˆÓ ·ÚÓËÙÈ΋, ·ÏÏ¿ ¯·ÌËϤ˜ ÙÈ̤˜ ÏÂ˘ÎˆÌ·Ù›Ó˘ Î·È IgG, ÂÓÒ ÔÈ ÙÈ̤˜ ÙˆÓ IgM Î·È IgA ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ŒÎÙÔÙÂ, ÙÔ ·È‰› ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ù·ÎÙÈο ·fi ÔÌ¿‰· ÁÈ·ÙÚÒÓ (ÂȉÈÎfi Á·ÛÙÚÂÓÙÂÚÔÏfiÁÔ, ·ÏÏÂÚÁÈÔÏfiÁÔ Î·È ·È‰›·ÙÚÔ). ∏ Ú‰ÓÈ˙fiÓË ‰È·ÎfiÙÂÙ·È ÛÙ·‰È·Î¿, ¯ˆÚ›˜ ˘ÔÙÚÔ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 7 Ì‹Ó˜). ∏ ·Ó¿Ù˘Í‹ ÙÔ˘ Î·È Ë ÁÂÓÈ΋ ÙÔ˘ ‰È¿ıÂÛË Â›Ó·È ¿ÚÈÛÙË, Ë ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ÈηÓÔÔÈËÙÈ΋ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‚Ú›ÛÎÂÙ·È Û‹ÌÂÚ· ÌÂٷ͇ 25˘-50˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘.
™˘˙‹ÙËÛË ∏ ÂÈÛ·ÁˆÁ‹ ‚ÚÂÊÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜, Ô˘ Û˘¯Ó¿ Û˘Óԉ‡ÂÙ·È Î·È ·fi ¿ÏÏ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·, Â›Ó·È Û¯ÂÙÈο Û˘ÓËıÈṲ̂ÓË Î·Ù¿ÛÙ·ÛË. ∏ ‡·ÚÍË, fï˜, ˈÛÈÓÔÊÈÏ›·˜ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È Ì¿ÏÈÛÙ· ȉȷ›ÙÂÚ· ÛÔ‚·Ú‹˜ Â›Ó·È ·Û˘Ó‹ıÈÛÙË Î·È ÚÔ‚ÏËÌ·Ù›˙ÂÈ È‰È·›ÙÂÚ· ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi. ∏ ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ Î·È ÁÂÓÈÎfiÙÂÚ· ÛÙȘ ÙÚÔʤ˜ ÌÔÚ› Ó· ÚÔ‚¿ÏÏÂÈ ˆ˜ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, Û˘Ìو̷ÙÔÏÔÁ›· Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ Î·È ÂÓ›ÔÙÂ Û˘Óԉ‡ÂÙ·È ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î·È Û˘¯Ó¿ ÂÂÈÛfi‰È· ˆÙ›Ùȉ·˜. ™ÙÔ˘˜ ·ıÔÁÂÓÂÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ï·Ì‚¿ÓÂÈ Ì¤ÚÔ˜ Ë πgE (πgE-mediated), ·ÏÏ¿ Î·È ¿ÏÏÔÈ Ì˯·ÓÈÛÌÔ› (non IgE-mediated). ™ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ¤ˆ˜ Î·È Ï¢¯·ÈÌÔÂȉ‹˜ ·ÓÙ›‰Ú·ÛË ÛÙ· ˈÛÈÓfiÊÈÏ· ·ÙÙ·Ú·, Ì ·ÚÈıÌfi Ô˘ ÌÔÚ› Ó· Â›Ó·È >20.000/mm3, ·ÏÏ¿ Û ʿÛË ¯ÚÔÓÈfiÙËÙ·˜ Û¿ÓÈ· ÍÂÂÚÓ¿ Ù· 2.000/mm3 (6). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ·ÛıÂÓ‹ ‰ÂÓ ÂÚfiÎÂÈÙÔ ÁÈ· ÔÍ›· ηٿÛÙ·ÛË, ¿Ú· ‰ÂÓ Â˘ÛÙ·ı› ˆ˜ Èı·Ó‹ Ë ‰È¿ÁÓˆÛË ·˘Ù‹. √È ·Ú·ÛÈÙÈΤ˜ ÓfiÛÔÈ Î·È ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÁÂÓÈÎfiÙÂÚ· (∆oxocara canis, Strongyloides sp, H. pylori, Echinococcus, Î.¿.) ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÂÎÛÂÛËÌ·Ṳ̂ÓË ËˆÛÈÓÔÊÈÏ›·, ÙfiÛÔ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, fiÛÔ Î·È ÙÔÈο ÛÙÔ˘˜ ÈÛÙÔ‡˜. ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ÎÔÚ¿ÓˆÓ ‹Ù·Ó ¿ÓÙ· ·ÚÓËÙÈÎfi˜, fiˆ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ÈÛÙÔÙÂÌ·¯›ˆÓ ÙÔ˘ ÂÙÈÎÔ‡ (6,7). ∂Í¿ÏÏÔ˘, Ë ÌÈÎÚ‹ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔ Paediatriki 2008;71:68-73
ηÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·ıÈÛÙÔ‡Û·Ó Ï›ÁÔ ·›ı·ÓË ÙËÓ Â·Ê‹ ÙÔ˘ Ì οÔÈÔÓ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜. ∏ ȉÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Î·È È‰È·›ÙÂÚ· Ë ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Crohn, Ôχ Û¿ÓÈ· ÌÔÚ› Ó· ÚÔÛ‚¿ÏÏÂÈ Ù· ‚Ú¤ÊË ÌÈÎÚ‹˜ ËÏÈΛ·˜ Î·È Ì¿ÏÈÛÙ· Ì ÌfiÓÔ Û‡Ìو̷ ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ˘ÔıÚ„›·. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜, ›Û˘, fiÙÈ ÚÔηÏÔ‡Ó Î¿ÔÈÔ˘ ‚·ıÌÔ‡ ˈÛÈÓÔÊÈÏ›· ·›Ì·ÙÔ˜ Î·È ÙˆÓ ÈÛÙÒÓ ÙÔ˘ °∂™, ÔÙ¤ ·˘Ù‹ ‰ÂÓ Â›Ó·È ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ (·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ˈÛÈÓÔÊ›ÏˆÓ ·›Ì·ÙÔ˜ <1.500/mm3 Î·È ÈÛÙÒÓ <20 HPF ÛÙË ‚ÈÔ„›·) (3,6,8). ∆· ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· Î·È ÁÂÓÈÎfiÙÂÚ· ÔÈ Î·ÎÔ‹ıÂȘ (ˈÛÈÓÔÊÈÏÈ΋ Ï¢¯·ÈÌ›·, ÏÂÌÊÒÌ·Ù· ÌË Hodgkin, Î.¿.), Û˘Ó‹ıˆ˜ ·ÊÔÚÔ‡Ó ·È‰È¿ ËÏÈΛ·˜ >2 ÂÙÒÓ, ÂÓÒ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏÏ· Â˘Ú‹Ì·Ù· ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (.¯. ıÚÔÌ‚Ô΢ÙÙ·ÚÔÂÓ›·) (6,9). ∏ Èı·ÓfiÙËÙ· ÙÔ˘ ˘ÂÚˈÛÈÓÔÊÈÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ·ÔÎÏ›ÛÙËÎÂ, ηıÒ˜ ‰ÂÓ ÏËÚÔ‡Û ηӤӷ ·fi Ù· 3 ··Ú·›ÙËÙ· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛ‹ ÙÔ˘: ·) ∏ˆÛÈÓÔÊÈÏ›· ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ >1.500/mm3 ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 6 Ì‹Ó˜. ‚) ªË ·Ó‡ÚÂÛË ¿ÏÏÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· ˈÛÈÓÔÊÈÏ›·˜. Á) ⁄·ÚÍË Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ ÛÔ‚·Ú‹˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ (Ó¢ÌfiÓˆÓ, ÎÂÓÙÚÈÎÔ‡ Î·È ÂÚÈÊÂÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ηډȿ˜, ÔÊı·ÏÌÒÓ, ‰¤ÚÌ·ÙÔ˜) (6). ∆¤ÏÔ˜, Ë ‰È¿ÁÓˆÛË Ù˘ ÔÈÎÔÁÂÓÔ‡˜ ˈÛÈÓÔÊÈÏ›·˜ Ù›ıÂÙ·È Î·ÙfiÈÓ ·ÔÎÏÂÈÛÌÔ‡ ¿ÏÏˆÓ ·ı‹ÛÂˆÓ Î·È ÂÊfiÛÔÓ ˘¿Ú¯ÂÈ ÛÙÔ ¿ÌÂÛÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ¿ÏÏÔ ¿ÙÔÌÔ Ì ·Û˘Ìو̷ÙÈ΋ ˈÛÈÓÔÊÈÏ›· (10). √ ·ÛıÂÓ‹˜ Ì·˜ ÏËÚÔ‡Û fiÏ· Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ù˘ ˈÛÈÓÔÊÈÏÈ΋˜ ÂÓÙÂÚ›Ùȉ·˜ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ·˘Ù‹ Ë ‰È¿ÁÓˆÛË ‹Ù·Ó Î·È Ë ÙÂÏÈ΋. Œ¯ÂÈ ·ÓÙÈÌÂÙˆÈÛÙ› Ì ÂÈÙ˘¯›· ˆ˜ ÙÒÚ· Ì ‰È·ÈÙËÙÈο ̤ÙÚ· Î·È ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙fiÓ˘, ÂÓÒ 7 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË, Ë ‰fiÛË Û˘ÓÙ‹ÚËÛ˘ ÙÔ˘ ÛÙÂÚÔÂȉԇ˜ Â›Ó·È ÂÏ¿¯ÈÛÙË Î·È ¤¯ÂÈ ·Ú¯›ÛÂÈ Ë ÂÈÙ˘¯‹˜ ÛÙ·‰È·Î‹ ÂÈÛ·ÁˆÁ‹ ÙÚÔÊÒÓ ÛÙË ‰È·ÙÚÔÊ‹ ÙÔ˘. ¶ÚÔ‚ÏËÌ·Ù›˙ÂÈ Ë Â›ÌÔÓ· ¯·ÌËÏ‹ ÙÈÌ‹ Ù˘ IgG, Ë ÔÔ›· ·˘Í¿ÓÂÙ·È ·ÚÁ¿, ÂÓÒ ÔÈ ÙÈ̤˜ ÙˆÓ ˘fiÏÔÈˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈΤ˜. ∆Ô ÙÂÏÂ˘Ù·›Ô, ηıÒ˜ Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ·È‰› ‰ÂÓ ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ ÏÔÈÌÒÍÂȘ, οÓÂÈ Èı·Ó‹ ÙËÓ ·ÚÔ‰È΋ ˘ÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· Ù˘ ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜. ∆Ô ·È‰› ı· ·ӢԂÏËı› Û ÂÓ‰ÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏÂÁ¯ı› Î·È ÈÛÙÔÏÔÁÈο Ë ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ·È‰È¿ Î·È È‰È·›ÙÂÚ· ÛÙ· ‚Ú¤ÊË, ÔÈ ÂÂÌ‚·ÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, fiˆ˜ Ë ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ÂÙÈÎÔ‡, Á›ÓÔÓÙ·È Ì ÊÂȉÒ. £· Ú¤ÂÈ Ó· ·ÔÊ·Û›˙ÂÙ·È fï˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙˆı›
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Ë ËˆÛÈÓÔÊÈÏÈ΋ ‰È‹ıËÛË ÙÔ˘ °∂™ ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ˘¿Ú¯ÂÈ Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ÂÙÈÎfi Ô˘ ÔÈ Û˘Ó‹ıÂȘ ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ (°√¶, ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜, ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·) Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ ‰ÂÓ ÂÚÌËÓÂ‡Ô˘Ó Â·ÚÎÒ˜ (¶›Ó·Î·˜ 1). ¢ÂÓ Ú¤ÂÈ Ó· ÏËÛÌÔÓÂ›Ù·È fiÙÈ Ë ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÂÚÈÊÂÚÈ΋ ˈÛÈÓÔÊÈÏ›· Ô˘ ηÙ¢ı‡ÓÂÈ ÛÙË ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ·Ô˘ÛÈ¿˙ÂÈ ÛÙÔ 20% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÙÔ˘Ï¿¯ÈÛÙÔÓ (4). ¶Èı·ÓÒ˜, ÛÙÔ Ì¤ÏÏÔÓ Ó· ÌÂÏÂÙËı› ÏËÚ¤ÛÙÂÚ· Ë Û¿ÓÈ· ·˘Ù‹ ÔÓÙfiÙËÙ·, Ó· ηٷÁÚ·Ê› Ë ·ÎÚÈ‚‹˜ Û˘¯ÓfiÙËÙ¿ Ù˘ Î·È Ó· Á›ÓÔ˘Ó Î·Ù·ÓÔËÙÔ› ÔÈ ·ÈÙÈÔ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ÂÈÙ˘¯›·.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH. Eosinophilic gastroenteritis. Medicine (Baltimore) 1970; 49:299-319. 2. Khan S, Orenstein SR. Eosinophilic gastroenteritis: epidemiology, diagnosis and management. Paediatr Drugs 2002;4:563-570. 3. Kelly KJ. Eosinophilic gastroenteritis. J Pediatr Gastroenterol Nutr 2000;30 Suppl:S28-35. 4. Liacouras CA. Eosinophilic esophagitis in children and adults. J Pediatr Gastroenterol Nutr 2003;37 Suppl 1:S23-28. 5. Quack I, Sellin L, Buchner NJ, Theegarten D, Rump LC, Henning BF. Eosinophilic gastroenteritis in a young girl-long term remission under Montelucast. BMC Gastroenterol 2005;5:24.
6. Boxer LA. Eosinophils: diseases associated with eosinophilia. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics. 17th ed. Saunders; 2004. p. 709-710. 7. Brigden ML. A practical workup for eosinophilia. You can investigate the most likely causes right in your office. Postgrad Med 1999;105:193-194, 199-202, 207-210. 8. Bischoff SC. Mucosal allergy: role of mast cells and eosinophil granulocytes in the gut. Baillieres Clin Gastroenterol 1996;10:443-459. 9. Gotlib J, Cools J, Malone JM 3rd, Schrier SL, Gilliland DG, Coutré SE. The FIP1L1-PDGFRalpha fusion tyrosine kinase in hypereosinophilic syndrome and chronic eosinophilic leukemia: implications for diagnosis, classification, and management. Blood 2004;103:2879-2891. 10. Curnutte JT. Disorder of granulocyte function and granulopoiesis. In: Nathan DG, Oski FA, editors. Hematology of infancy and childhood. 4th ed. Philadelphia: WB Saunders Co; 1993. p. 953-957. 11. Daikh BE, Ryan CK, Schwartz RH. Montelukast reduces peripheral blood eosinophilia but not tissue eosinophilia or symptoms in a patient with eosinophilic gastroenteritis and esophageal stricture. Ann Allergy Asthma Immunol 2003;90:23-27. 12. Siahanidou T, Mandyla H, Salavoura K, Dimitriadis D, Van-Vliet C, Anagnostakis D. Eosinophilic gastroenteritis in a neonate. Paediatriki 2000;63:534-537.
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CASE REPORT
ƒ·‚‰ÔÌ˘fiÏ˘ÛË ÌÂÙ¿ ·fi Ïԛ̈ÍË ·fi influenza ∞ ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÛÎÏËÈÂ›Ô µÔ‡Ï·˜” AÏÏËÏÔÁÚ·Ê›·: ŸÏÁ· ºÈÏ›Ô˘ filiolga@hotmail.com ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÛÎÏËÈÂ›Ô µÔ‡Ï·˜”
O. ºÈÏ›Ô˘, M. ¢ÔÏÈ·Ó›ÙË, K. ¢ÈÁ·Ï¿ÎË-£¤ÌÂÏË, M. ∑‹‚·-¶ÂÙÚÔÔ‡ÏÔ˘, ™. ¶··‰¿ÎÔ˘-§·ÁÔÁÈ¿ÓÓË ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ 9 ¯ÚÔÓÒÓ Ì ڷ‚‰ÔÌ˘fiÏ˘ÛË. √ ·ÛıÂÓ‹˜ ÚÔÛ‹Ïı ÏfiÁˆ ·‰˘Ó·Ì›·˜ ‚¿‰ÈÛ˘ Î·È ¿ÏÁÔ˘˜ ÛÙȘ Á·ÛÙÚÔÎÓË̛˜ ·fi ˆÚÒÓ, ÂÓÒ ·fi ÂÓıË̤ÚÔ˘ ·ÚÔ˘Û›·˙Â Û˘ÌÙÒÌ·Ù· ÈÔÁÂÓÔ‡˜ Û˘Ó‰ÚÔÌ‹˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠfiÙÈ Ô Èfi˜ Ù˘ Áڛ˘ Ù‡Ô˘ A ‹Ù·Ó Ô ÏÔÈÌ҉˘ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔοÏÂÛ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·ÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Ù˘ Ú·‚‰ÔÌ˘fiÏ˘Û˘. ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ Ïԛ̈͢ ·fi influenza A, ·ÊÔ‡ ÌfiÓÔ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ̤¯ÚÈ Û‹ÌÂÚ· ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· ·È‰È¿. √ ·ÛıÂÓ‹˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ ‰ÂÓ ·ÚÔ˘Û›·Û ÂÈÏÔΤ˜ Î·È ·ÓÙ·ÔÎÚ›ıËΠÈηÓÔÔÈËÙÈο ÛÙËÓ Î·Ù¿ÏÏËÏË ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹. §fiÁˆ Ù˘ ¿Ù˘Ë˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ··ÈÙÂ›Ù·È ˘„ËÏÔ‡ ‚·ıÌÔ‡ ˘Ô„›· ÁÈ· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË.
§¤ÍÂȘ ÎÏÂȉȿ: ƒ·‚‰ÔÌ˘fiÏ˘ÛË, Ì˘·ÏÁ›Â˜, influenza A.
Rhabdomyolysis following influenza A infection Microbiological Department, Paediatric Clinic, “Asklipieio Voulas” General Hospital Correspondence: Olga Filippou filiolga@hotmail.com Paediatric Clinic, “Asklipieio Voulas” General Hospital
√. Filippou, ª. Dolianiti, ∫. Digalaki-Themeli, ª. Ziva-Petropoulou, S. Papadakou-Lagogianni Abstract: The case of a 9 year-old boy with rhabdomyolysis is described. The patient presented muscular weakness and myalgia of the calves following an upper respiratory tract infection of 5 days duration. The laboratory findings showed that influenza A was the viral agent responsible for the development of rhabdomyolysis. This is a remarkably rare complication of influenza A infection, since only occasional cases have been reported. This patient had a good response to supportive therapy and an uneventful recovery. A high index of suspicion is required in order to make this diagnosis, because of the subtle clinical presentation. Key words: Rhabdomyolysis, myalgia, influenza A.
™˘ÓÙÔÌÔÁڷʛ˜ IFA DAF £.™. ∞.¶.
Immunofluorescence Assay Direct Assay Fluorescence £ÂÚÌÔÎÚ·Û›· ™ÒÌ·ÙÔ˜ ∞ÚÙËÚȷ΋ ¶›ÂÛË
∂ÈÛ·ÁˆÁ‹ ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ (Ù‡ÔÈ ∞, µ Î·È C) ·ÊÔÚ¿ fiϘ ÙȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜ Î·È ÂΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ ˆ˜ ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ˜ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¤ÙÔ˘˜. ∞fi ÙÔ˘˜ ÙÚÂȘ Ù‡Ô˘˜, ÔÈ ∞ Î·È µ Â›Ó·È ÔÈ Î˘Ú›ˆ˜ ·ıÔÁfiÓÔÈ, ÂÓÒ Ô C ·ÔÙÂÏ› ÛÔÚ·‰ÈÎfi ·›ÙÈÔ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. √ Èfi˜ ÌÔÚ› Ó· ÂÓÙÔ›˙ÂÙ·È ÛÙÔ ·ÓÒÙÂÚÔ ‹ ηÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi ÚÔηÏÒÓÙ·˜ Â̇ÚÂÙË ÓfiÛÔ ÙˆÓ ·ÓÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ, Ï·Ú˘ÁÁ›Ùȉ·, ÙÚ·¯ÂÈÔ‚ÚÔÁ¯›Ùȉ·, ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ‹ Ó¢ÌÔÓ›·. ∏ Ïԛ̈ÍË ·fi ÈÓÊÏÔ˘¤ÓÙ˙· ÚÔηÏ› ÔÈÎÈÏ›· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ì ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙ· ·È‰È¿, ÂÓÒ ÔÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È Â›Ó·È Ë ÔÍÂÈ¿ ̤ÛË ˆÙ›Ùȉ· Î·È Ë ‚·ÎÙËÚȷ΋ Ó¢ÌÔÓ›·. øÛÙfiÛÔ, ¤¯Ô˘Ó ·Ó·ÊÂÚPaediatriki 2008;71:74-78
ı› Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜, fiˆ˜ Ë Ì˘Ôηډ›Ùȉ·, Ë ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ·, ÙÔ Û‡Ó‰ÚÔÌÔ Reye, Ë Ì˘ÔÛ›Ùȉ· Î·È Ë Ú·‚‰ÔÌ˘fiÏ˘ÛË. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ·ÁÔÚÈÔ‡ Ô˘ ÂΉ‹ÏˆÛ ڷ‚‰ÔÌ˘fiÏ˘ÛË ÛÙËÓ ÔÚ›· Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·fi influenza A. ∞ÎfiÌË, Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Î·È ·Ó·Ê¤ÚÔÓÙ·È ÔÈ Û‡Á¯ÚÔÓ˜ ·fi„ÂȘ ·Ó·ÊÔÚÈο Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙËÓ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 9 ¯ÚÔÓÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ Ì ˘ÚÂÙfi ¤ˆ˜ 39ÆC ÌÂ Û˘ÓÔ‰fi Ê·Ú˘ÁÁ·ÏÁ›· Î·È ÚÈÓÈ΋ ηٷÚÚÔ‹ ·fi ÂÓıË̤ÚÔ˘ Î·È ¿ÏÁÔ˜ ÛÙȘ Á·ÛÙÚÔÎÓË̛˜ ·fi 48ÒÚÔ˘, Ô˘ ÂȉÂÈÓÒıËΠÌÂÙ¿ ·fi ¯·ÌËÏ‹˜ ¤ÓÙ·Û˘ ¿ÛÎËÛË. ∆Ô ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÔÓÙ·È ÂχıÂÚ·. √ ·ÛıÂÓ‹˜ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ·fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÚԤ΢„·Ó Ù· ·ÎfiÏÔ˘ı·: ıÂÚÌÔÎÚ·Û›·: 37,6ÆC, ∞.¶.: 85/46 mmHg, ÛʇÍÂȘ: 90/min, ·ÚÈıÌfi˜ ·Ó·ÓÔÒÓ: 23/min,
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·75
75
ƒ·‚‰ÔÌ˘fiÏ˘ÛË ÌÂÙ¿ ·fi influenza ∞
·Ú›ÛıÌÈ· ÂÓÙfiÓˆ˜ ÂͤڢıÚ· Î·È Ú›Ó· Û˘ÌÊÔÚË̤ÓË. ∞fi ÙËÓ ·ÎÚfi·ÛË ÙÔ˘ ıÒڷη ‰È·ÈÛÙÒıËÎ·Ó ·¯Â›˜ ˘ÁÚÔ› ÚfiÁ¯ÔÈ ‰È¿Û·ÚÙÔÈ Î·È ÛÙ· ‰‡Ô Ó¢ÌÔÓÈο ‰›·, ÂÓÒ Î·Ù¿ ÙËÓ ÂͤٷÛË Ù˘ ÎÔÈÏ›·˜ ÙÔ ‹·Ú ‹Ù·Ó „ËÏ·ÊËÙfi ÂÚ›Ô˘ 3 cm, ¯ˆÚ›˜ ¢·ÈÛıËÛ›·, Ì ÔÌ·Ïfi ¯Â›ÏÔ˜ Î·È Ì·Ï·Î‹ Û‡ÛÙ·ÛË Î·È ‰ÂÓ ‹Ù·Ó „ËÏ·ÊËÙfi˜ Ô ÛÏ‹Ó·˜. √ ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·˙ ·‰˘Ó·Ì›· ‚¿‰ÈÛ˘, ¢·ÈÛıËÛ›· ηٿ ÙËÓ „ËÏ¿ÊËÛË ÛÙȘ Á·ÛÙÚÔÎÓË̛˜ ¿Ìʈ Î·È ÌÂȈ̤ÓÔ Ì˘˚Îfi ÙfiÓÔ ÛÙ· οو ¿ÎÚ·. ∆· ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο Î·È Ë ·ÈÛıËÙÈÎfiÙËÙ· (ÂÈÔÏ‹˜ Î·È ÂÓ Ùˆ ‚¿ıÂÈ) ÂϤÁ¯ıËÎ·Ó Ê˘ÛÈÔÏÔÁÈο. ∞fi Ù· ˘fiÏÔÈ· Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ‚Ú¤ıËÎ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÈÛfi‰Ô˘ ¤‰ÂÈÍÂ: ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 1.800/mm3, (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·: 37% ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜: 666, ÏÂÌÊÔ·ÙÙ·Ú·: 48%, ÌÔÓÔ·ÙÙ·Ú·: 8%, ˈÛÈÓfiÊÈÏ·: 2%), Hb: 11,8 g/dl, Ht: 38,6%, ·ÈÌÔÂÙ¿ÏÈ·: 173.000/mm3, ∆∫∂: 9 mm/1Ë ÒÚ·, CRP<3,13 mg/dl, SGOT: 203 U/L, SGPT: 61 U/L, LDH: 942 U/L, ÔÏÈο Ï¢ÎÒÌ·Ù·: 7 g/dl, ÏÂ˘ÎˆÌ·Ù›ÓË: 4 g/dl, ÔÏÈ΋/¿ÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË: 0,3/0,1 mg/dl, ÁGT: 9 U/L, ALP: 200 U/L, CPK: 4.767 U/L (º∆: 15-105 U/L ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘), CPK-MB: 2 U/L <5% Ù˘ ÔÏÈ΋˜ CPK, Glu: 98 mg/dl, Ô˘Ú›·: 23 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,6 mg/dl, Na+: 137 mEq/L, K+: 3,8 mEq/L, Ca++: 8,5 mg/dl, P: 4,7 mg/dl, ÁÂÓÈ΋ Ô‡ÚˆÓ: ÎÊ. ∏ ·/· ıÒڷη ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ Î·È Ë ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË ªantoux ·ÚÓËÙÈ΋. ™ÙÔÓ ·ÛıÂÓ‹ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ Ú·‚‰ÔÌ˘fiÏ˘Û˘, ÌÂ Û˘ÓÔ‰¿ Â˘Ú‹Ì·Ù·, Ï¢ÎÔÂÓ›· Î·È Ô˘‰ÂÙÂÚÔÂÓ›·, Û ¤‰·ÊÔ˜ Èı·Ó‹˜ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢, Î·È Ô ¤ÏÂÁ¯Ô˜ Û˘ÌÏËÚÒıËΠ̠·Ï‰ÔÏ¿ÛË ÔÚÔ‡: 7 U/L (º∆: 1,2-8,8 U/L ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘), Ì˘ÔÛÊ·ÈÚ›ÓË ÔÚÔ‡: 54 Ìg/L (º∆: 0-70 Ìg/L), Ì˘ÔÛÊ·ÈÚ›ÓË Ô‡ÚˆÓ: 154 Ìg/L (º∆: 0 Ìg/L), Ô˘ÚÈÎfi Ô͇: 7 mg/dl, ·¤ÚÈ· ·›Ì·ÙÔ˜: ÎÊ, PT: 11 sec, APTT: 31 sec, INR: 1, ÈÓˆ‰ÔÁfiÓÔ: 2,75 mg/dl. EÏ‹ÊıËÛ·Ó Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, ÔÈ Ôԛ˜ ‹Ù·Ó ÛÙ›Ú˜, Î·È ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ÈÒÓ influenza A-B, parainfluenza 12-3, EBV, CMV, adenovirus, coxsackie, echo fiˆ˜ ›Û˘ Î·È ÁÈ· mycoplasma. ∞fi ÙÔÓ ÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ·ÓÙÈÁfiÓ· ÁÈ· influenza A ıÂÙÈο ÛÙÔ ÚÈÓÔÊ·Ú˘ÁÁÈÎfi ›¯ÚÈÛÌ·, Ù· ÔÔ›· ·Ó·˙ËÙ‹ıËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô DAF, Î·È ·ÓÙÈÛÒÌ·Ù· Ù¿Í˘ IgM ıÂÙÈο Û ٛÙÏÔ 1/160 ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ Ù˘ influenza A Ô˘ ·ÓȯÓ‡ÙËÎ·Ó ÙËÓ 3Ë Ì¤Ú· ÓfiÛÔ˘. ªÂÙ¿ ·fi ‰‡Ô ‚‰ÔÌ¿‰Â˜ (17Ë Ì¤Ú· ÓfiÛÔ˘), ·ÓȯÓ‡ÙËÎ·Ó ·ÓÙÈÛÒÌ·Ù· Ù¿Í˘ IgG ıÂÙÈο Û ٛÙÏÔ 1/160 ¤Ó·ÓÙÈ ÙÔ˘ ›‰ÈÔ˘ ÈÔ‡ (ÔÚÔÌÂÙ·ÛÙÚÔÊ‹) Ì ÙË Ì¤ıÔ‰Ô πFA. √ ·ÓÙ›ÛÙÔȯԘ ¤ÏÂÁ¯Ô˜ ÁÈ· influenza B ‹Ù·Ó ·ÚÓËÙÈÎfi˜. √ ·ÛıÂÓ‹˜ Ù¤ıËΠ۠·˘ÍË̤ÓË ÂÓ˘‰¿ÙˆÛË
¶›Ó·Î·˜ 1. ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ·ÛıÂÓÔ‡˜ 24ˆÚÔ ÓfiÛÔ˘
1Ô
2Ô
§Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·/ÌL 1.800 1.800 ¶ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 37% 18% (666) (288) CPK (U/L) 4.767 2.247 SGOT (U/L) 203 187 SGPT (U/L) 61 70 LDH (U/L) 942 333 ª˘ÔÛÊ·ÈÚ›ÓË Ô‡ÚˆÓ 154 60 (Ìg/L)
3Ô
5Ô
8Ô
2.700 34% (618) 1.085 98 74 323 7,8
4.050 47% (1.900) 275 70 65
5.550 37% (2.035) 100 40 35 290
(¤Ï·‚ ˘ÁÚ¿ 1,5 ÊÔÚ¿ ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·Ó¿ÁΘ) Î·È ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÊϤ‚È·˜ ÊÔ˘ÚÔÛÂÌ›‰Ë˜ (‰fiÛË = 1 mg/kg/24ˆÚÔ) › ÙÚÈË̤ÚÔ˘. °ÈÓfiÙ·Ó Î·Ù·ÁÚ·Ê‹ ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ (·Ó¿ 1 ÒÚ· ÙÔ 1Ô 24ˆÚÔ ÓÔÛËÏ›·˜ Î·È ·Ó¿ 4 ÒÚ˜ Ù· ÂfiÌÂÓ· 24ˆÚ·), Ù˘ ˆÚÈ·›·˜ ‰ÈÔ‡ÚËÛ˘ Î·È ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ÚÔÛÏ·Ì‚·ÓÔ̤ӈÓ-·Ô‚·ÏÏÔÌ¤ÓˆÓ ˘ÁÚÒÓ. ¶Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·Ó Î·ıËÌÂÚÈÓfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÌÂ: ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ·¤ÚÈ· ·›Ì·ÙÔ˜, Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË, Ì˘ÔÛÊ·ÈÚ›ÓË ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ, ·Ï‰ÔÏ¿ÛË, CPK, LDH, SGOT, SGPT, Ô˘ÚÈÎfi Ô͇, Na+, K+, Ca++, P Î·È ÁÂÓÈ΋ Ô‡ÚˆÓ (¶›Ó·Î·˜ 1). ∆Ô ·È‰› ·Ú¤ÌÂÈÓ ηٷÎÂÎÏÈ̤ÓÔ Î·È Û ·ÔÌfiÓˆÛË. √ ·ÛıÂÓ‹˜ ‹Ù·Ó ·‡ÚÂÙÔ˜ Î·È Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·ıfiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓı‹ÌÂÚ˘ ÓÔÛËÏ›·˜ ÙÔ˘. ¶·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ Ì˘˚΋˜ ÈÛ¯‡Ô˜ Î·È ‡ÊÂÛË ÙÔ˘ ¿ÏÁÔ˘˜ Ì ϋÚË ˘Ô¯ÒÚËÛË Ì¤¯ÚÈ ÙËÓ ¤ÍÔ‰Ô. ¢ÂÓ ÂÌÊ¿ÓÈÛ ‰È·Ù·Ú·¯‹ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ Î·È Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÂÓÒ ·Ú·ÙËÚ‹ıËΠÚÔԉ¢ÙÈ΋ ·ÔηٿÛÙ·ÛË ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi fiÏˆÓ ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ.
™˘˙‹ÙËÛË ∏ Ú·‚‰ÔÌ˘fiÏ˘ÛË ·ÔÙÂÏ› ¤Ó· Û¯ÂÙÈο Û¿ÓÈÔ ÓfiÛËÌ· ÛÙ· ·È‰È¿ Î·È ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ Ô˘ ˘¿Ú¯Ô˘Ó Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·Îfi Û‡Ó‰ÚÔÌÔ Ô˘ ÂΉËÏÒÓÂÙ·È ÌÂÙ¿ ·fi ηٷÛÙÚÔÊ‹ ÙˆÓ ÁÚ·Ì̈ÙÒÓ Ì˘ÒÓ Î·È ·ÂÏ¢ı¤ÚˆÛË ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔÍÈÎÒÓ Î˘ÙÙ·ÚÈÎÒÓ ÚÔ˚fiÓÙˆÓ. ∆Ô ÎÂÓÙÚÈÎfi ÁÂÁÔÓfi˜ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È Ë ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ca++, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ÙÚ·˘Ì·ÙÈÛÌfi Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ Ì˘˚ÎÔ‡ ΢ÙÙ¿ÚÔ˘, ‹/Î·È Û ÂÍ¿ÓÙÏËÛË ÙˆÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ·ÔıÂÌ¿ÙˆÓ ∞∆ƒ. √ ηٷÚÚ¿ÎÙ˘ ÙˆÓ ÁÂÁÔÓfiÙˆÓ Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ú·ÁˆÁ‹ ÚˆÙÂÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ, Ô˘ ÚÔ¿ÁÔ˘Ó ÙË Û˘Ó¯È˙fiÌÂÓË Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ Ì˘ÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∆· ·›ÙÈ· Ù˘ Ú·‚‰ÔÌ˘fiÏ˘Û˘ ‰È·ÎÚ›ÓÔÓÙ·È ·‰Ú¿ ÛÂ Û˘ÁÁÂÓ‹ Î·È Â›ÎÙËÙ· (¶›Ó·Î·˜ 2) (1-3). ∞fi Ù· ¶·È‰È·ÙÚÈ΋ 2008;71:74-78
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·76
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O. ºÈÏ›Ô˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∞›ÙÈ· Ú·‚‰ÔÌ˘fiÏ˘Û˘ ™˘ÁÁÂÓ‹ ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·: ·. ∞Ó¿ÚÎÂȘ ÁÏ˘ÎÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ‚. ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÏÈȉ›ˆÓ ª˘˚Τ˜ ‰˘ÛÙÚÔʛ˜ ÕÏÏ· (ηÎÔ‹ı˘ ˘ÂÚıÂÚÌ›·) ∂›ÎÙËÙ· 1. §ÔÈÌÒÍÂȘ πÔ›: Influenza A-B, Parainfluenza 1-2-3, HIV, Coxsackie, ECHO, EBV, CMV, VZV, HSV µ·ÎÙËÚ›‰È·: Staphylococcus, Streptococcus, E.coli, Shigella, Salmonella spp, Mycoplasma, Legionella, Brucella ª‡ÎËÙ˜: Candida, Aspergillus 2. ∞˘ÍË̤ÓË Ì˘˚΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (¿ıÏËÛË, status epilepticus, Î.¿.) 3. ∞˘ÍË̤ÓË Ì˘˚΋ ηٷÛÙÚÔÊ‹ (ÂÁη‡Ì·Ù·, crush syndrome) 4. ªÂÙ·‚ÔÏÈΤ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ 5. ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘, ÌË ÎÂÙˆÙÈÎfi ˘ÂÚˆÛ̈ÙÈÎfi ÎÒÌ·, Ì˘ÍÔ›‰ËÌ·, ˘ÔÓ·ÙÚÈ·ÈÌ›·, ˘ÔηÏÈ·ÈÌ›·, ˘ÔʈÛÊ·Ù·ÈÌ›· 6. º¿Ú̷η, ÙÔÍÈΤ˜ Î·È Ó·ÚΈÙÈΤ˜ Ô˘Û›Â˜ (·ÓÙÈÈÛÙ·ÌÈÓÈο, ·Ó·ÈÛıËÙÈο, ·ÏÎÔfiÏ, ‰‹ÁÌ·Ù· ÊȉÈÒÓ, ËÚˆ›ÓË, ·ÌÊÂٷ̛Ә) 7. πÛ¯·ÈÌ›· Ì˘˚ÎÒÓ Î˘ÙÙ¿ÚˆÓ (ıÚÔÌ‚ÒÛÂȘ, ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ÎÚ›ÛË) 8. ºÏÂÁÌÔÓÒ‰ÂȘ Ì˘Ô¿ıÂȘ (ÔÏ˘ÔÌ˘ÔÛ›Ùȉ·, ‰ÂÚÌ·ÙÔÌ˘ÔÛ›Ùȉ·)
Û˘ÁÁÂÓ‹ ·›ÙÈ· Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· Â›Ó·È Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Î·È Ë Î·ÎÔ‹ı˘ ˘ÂÚıÂÚÌ›·. ∞fi Ù· ›ÎÙËÙ·, ÙË ÛÔ˘‰·ÈfiÙÂÚË ı¤ÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ· η٤¯Ô˘Ó ÔÈ ÏÔÈÌÒÍÂȘ Î·È ·ÎÔÏÔ˘ıÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ ·˘ÍË̤Ó˘ Ì˘˚΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Ì˘˚΋˜ ηٷÛÙÚÔÊ‹˜, Ù· ÂÁη‡Ì·Ù·, ÌÂÙ·‚ÔÏÈΤ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë ¯Ú‹ÛË ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ Î·È Ê·ÚÌ¿ÎˆÓ Î·È ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ Ì˘Ô¿ıÂȘ. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, ¤Ó· Ï‹ıÔ˜ ÈÔÁÂÓÒÓ, ÌÈÎÚÔ‚È·ÎÒÓ Î·È Ì˘ÎËÙÈ·ÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÌÔÚÔ‡Ó Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ ·ÈÙÈÔÏÔÁÈÎfi ˘fiÛÙڈ̷, Ì ÙȘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Ó· ·ÔÙÂÏÔ‡Ó ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ (¶›Ó·Î·˜ 2) (1,2,4,5,8). ™ÙË ÌÂÁ·Ï‡ÙÂÚË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ¤¯ÂÈ ‰ËÌÔÛÈ¢Ù› ̤¯ÚÈ Û‹ÌÂÚ·, ‰È·ÈÛÙÒıËΠfiÙÈ ˘¿Ú¯ÂÈ ‰ÈÎfiÚ˘ÊË Î·Ù·ÓÔÌ‹ ÙˆÓ ·ÈÙ›ˆÓ Ú·‚‰ÔÌ˘fiÏ˘Û˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (3). ∂ȉÈÎfiÙÂÚ·, ÔÈ ÈÔ› ·ÔÙÂÏÔ‡Ó ÙÔ ÚˆÙ·Ú¯ÈÎfi ·›ÙÈÔ ÛÙȘ ËÏÈ˘ 0-9 ¯ÚÔÓÒÓ, ÂÓÒ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ù· ÙÚ·‡Ì·Ù· Î·È Ë ¯Ú‹ÛË ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ Â›Ó·È Ù· Û˘ÓËı¤ÛÙÂÚ· ·›ÙÈ·. ∆· ‰Â‰Ô̤ӷ Ô˘ ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο Ì ÙË Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ Ú·‚‰ÔÌ˘fiÏ˘Û˘ ÛÙËÓ ÔÚ›· Ïԛ̈͢ ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ ÛÙ· ·È‰È¿ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ. ∞ӷʤÚÂÙ·È fiÙÈ ÙÔ 42% ÙˆÓ ÈÔÁÂÓÒÓ ·ÈÙ›ˆÓ Ú·‚‰ÔÌ˘fiÏ˘Û˘ Û ÂÓ‹ÏÈΘ ÔÊ›ÏÂÙ·È ÛÙÔÓ Èfi Paediatriki 2008;71:74-78
Ù˘ Áڛ˘, ÂÓÒ Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ·ÔÙÂÏ› ÙÔÓ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ· ÌfiÓÔ ÛÙÔ 8% (2,3). ™Â ÂÚÁ·Û›· ÙˆÓ Agyeman Î·È Û˘Ó., Ô˘ ·ÊÔÚÔ‡Û 311 ·È‰È¿ ÌÂ Ì˘ÔÛ›Ùȉ· ·fi ÙÔÓ Èfi Ù˘ Áڛ˘, ‰È·ÈÛÙÒıËΠfiÙÈ ÌfiÏȘ ÙÔ 3% ÂΉ‹ÏˆÛ ڷ‚‰ÔÌ˘fiÏ˘ÛË (6). º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÛÙ· ·È‰È¿ Ë ÂÌÊ¿ÓÈÛË Ú·‚‰ÔÌ˘fiÏ˘Û˘ ÛÙ· Ï·›ÛÈ· ÁÚÈÒ‰Ô˘˜ Û˘Ó‰ÚÔÌ‹˜ Â›Ó·È Û·ÓÈfiÙÂÚË Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÂÓÒ ÛÙËÓ ÎÏÈÓÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ Û˘Ì‚¿ÏÏÂÈ Î·È Ë Ê‡ÛË ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ÈÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÂȉËÌ›·˜. √ Ù‡Ô˜ ∞ ÙÔ˘ ÈÔ‡ ÚÔηÏ› Û˘¯ÓfiÙÂÚ· Ú·‚‰ÔÌ˘fiÏ˘ÛË, ÂÓÒ Ô Ù‡Ô˜ µ Ì˘ÔÛ›Ùȉ· (6,7). ∏ Ú·‚‰ÔÌ˘fiÏ˘ÛË ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÌÔÚ› Ó· ÂΉËψı› Ì ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ Áڛ˘, ÛÙËÓ ÔÚ›· Ù˘ ‹ ·ÎfiÌË Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ (8). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ô ·ÛıÂÓ‹˜ ÓfiÛËÛ ÛÙË Ì¤ÛË ÙÔ˘ ¯ÂÈÌÒÓ·, ÂÔ¯‹ Ô˘ ‹‰Ë ›¯Â ·Ú¯›ÛÂÈ Ë ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÚÔ˘Û›·ÛÂ Ì˘·ÏÁ›Â˜ ÙËÓ ÙÚ›ÙË Ë̤ڷ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÁÚÈÒ‰Ô˘˜ Û˘Ó‰ÚÔÌ‹˜. ¶ÚÔÛ‚¿ÏÏÔÓÙ·È Ôχ Û˘¯Ó¿ ÔÈ Á·ÛÙÚÔÎÓ‹ÌÈÔÈ Ì‡Â˜ (70%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ Ì‡Â˜ Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Î·È ÙˆÓ ¿Óˆ ¿ÎÚˆÓ (20%) Î·È ÔÈ ÔÛÊ˘˚ÎÔ› (5%) (6). ∂ÎÙfi˜ ·fi ÙÔÓ Èfi Ù˘ Áڛ˘ Ô˘ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÌÂÙ·ÏÔÈÌÒ‰Ô˘˜ Ú·‚‰ÔÌ˘fiÏ˘Û˘ ÛÙ· ·È‰È¿, ˘¿Ú¯ÂÈ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÛÔÚ·‰È΋ ηٷÁÚ·Ê‹ ÂÚÈÛÙ·ÙÈÎÒÓ Ú·‚‰ÔÌ˘fiÏ˘Û˘ Î·È ·fi ¿ÏÏ· ÏÔÈÌÒ‰Ë ·›ÙÈ· (¶›Ó·Î·˜ 2). ™˘¯ÓfiÙÂÚ· ·Ó·Ê¤ÚÔÓÙ·È Ô Èfi˜ Ù˘ ·Ú·Áڛ˘, Ô Coxsackie B, Ô VZV, Ô HIV, o EBV, Ô Èfi˜ ROTA Î·È ÙÔ Ì˘ÎfiÏ·ÛÌ·. ∞ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ·›ÙÈÔ Ô˘ ÙËÓ ÚÔοÏÂÛÂ, Ë Ú·‚‰ÔÌ˘fiÏ˘ÛË ÌÔÚ› Ó· ÂΉËψı› ÎÏÈÓÈο ›Ù Ì ÙËÓ “ÎÏ·ÛÈ΋ ÙÚÈ¿‰·” Û˘ÌÙˆÌ¿ÙˆÓ (Ì˘·ÏÁ›Â˜, Ì˘˚΋ ·‰˘Ó·Ì›·, ίڈṲ̂ӷ Ô‡Ú·), Ô˘ fï˜ Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ‹˜ Ù˘ Â›Ó·È Ôχ ÌÈÎÚ‹ (ÌfiÏȘ 0,5%), ›Ù Ì ¿Ù˘Ë Î·È ·Ì‚Ï˯ڋ Û˘Ìو̷ÙÔÏÔÁ›·. ∂ȉÈÎfiÙÂÚ·, Ë ÓfiÛÔ˜ ÌÔÚ› Ó· ÚÔ‚¿ÏÏÂÈ ÙfiÛÔ Ì ÙÔÈο Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›·, fiˆ˜ Ì˘˚Τ˜ Û˘Û¿ÛÂȘ, ÌÂȈ̤ӷ ‹ ηٷÚÁË̤ӷ ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο, fiÛÔ Î·È ÌÂ Û˘ÛÙËÌ·ÙÈο, fiˆ˜ ˘ÚÂÙfi, ηÎÔ˘¯›·, Ó·˘Ù›·, Â̤ÙÔ˘˜. √È ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ì˘·ÏÁ›Â˜ ÂÌÊ·Ó›˙ÂÈ ÂÚ›Ô˘ ÙÔ 45% ÙˆÓ ·ÛıÂÓÒÓ, Ì˘˚΋ ·‰˘Ó·Ì›· ÙÔ 38%, ÂÓÒ ˘¤Ú¯ÚÔ· Ô‡Ú· ‰È·ÈÛÙÒÓÔÓÙ·È ÌfiÏȘ ÛÙÔ 3,6% (3). ∂Ô̤ӈ˜, ··ÈÙÂ›Ù·È ˘„ËÏÔ‡ ‚·ıÌÔ‡ ˘Ô„›· ÁÈ· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË. ∂ÚÁ·ÛÙËÚȷο, Ë Ú·‚‰ÔÌ˘fiÏ˘ÛË ÔÚ›˙ÂÙ·È ˆ˜ ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ CPK (ÎÚ·ÙÈÓÔʈÛÊÔÎÈÓ¿ÛË) ¿Óˆ ·fi ÙÔ 5Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙÈÌ‹˜, ÂÓÒ ÙÔ ÎÏ¿ÛÌ· CPK-MB Ú¤ÂÈ Ó· Â›Ó·È <5% Ù˘ ÔÏÈ΋˜ ÙÈÌ‹˜. ∞˘ÍË̤Ó˜,
Pediatri Jan-Feb 08
15-02-08
11:00
™ÂÏ›‰·77
77
ƒ·‚‰ÔÌ˘fiÏ˘ÛË ÌÂÙ¿ ·fi influenza ∞
·ÏÏ¿ ηÙÒÙÂÚ˜ ·fi ÙÔ ÚÔ·Ó·ÊÂÚı¤Ó fiÚÈÔ, ÙÈ̤˜, Ì ›‰È· ‹ ·ÚfiÌÔÈ· ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Û˘ÓÈÛÙÔ‡Ó Ì˘ÔÛ›Ùȉ· (3,14). ∏ CPK ·ÔÙÂÏ› ¤Ó· ÁÚ‹ÁÔÚÔ Î·È ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË ÙfiÛÔ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ (¢·ÈÛıËÛ›· 100%), fiÛÔ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ Ù˘. ™˘Ó‹ıˆ˜, ÊÙ¿ÓÂÈ ÙË Ì¤ÁÈÛÙË ÙÈÌ‹ Ù˘ ÛÙÔ ÚÒÙÔ 24ˆÚÔ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÌÂÈÒÓÂÙ·È Î·ıËÌÂÚÈÓ¿ ηٿ 40% ÂÚ›Ô˘. ¢È·Ù‹ÚËÛË ‹ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÛÙÔÓ ÔÚfi ‰ËÏÒÓÂÈ Û˘Ó¯È˙fiÌÂÓË Ì˘˚΋ ηٷÛÙÚÔÊ‹ ‹ Û‡Ó‰ÚÔÌÔ ‰È·ÌÂÚÈÛÌ·ÙÔÔ›ËÛ˘ (ÌÂÈÒÓÂÙ·È Ë ›ÂÛË ¿Ú‰Â˘Û˘ ÙˆÓ Ì˘ÈÎÒÓ ÈÓÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ˘ÔÍ·ÈÌ›· Î·È ÈÛÙÈ΋ Ó¤ÎÚˆÛË). ∆· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù· Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È ·ÊÔÚÔ‡Ó: Ì˘ÔÛÊ·ÈÚÈÓÔ˘Ú›· Î·È Ì˘ÔÛÊ·ÈÚÈÓ·ÈÌ›·, ·‡ÍËÛË Ù˘ ·Ï‰ÔÏ¿Û˘, Ù˘ LDH Î·È ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, ˘ÂÚÔ˘Úȯ·ÈÌ›·, ˘ÂÚηÏÈ·ÈÌ›· Î·È ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘. ∞ÎfiÌË, ÌÔÚ› Ó· ÚÔÎÏËıÔ‡Ó ˘·Û‚ÂÛÙÈ·ÈÌ›· Î·È ˘ÂÚʈÛÊ·Ù·ÈÌ›·, ÔÈ Ôԛ˜ ‰ÂÓ ¯Ú‹˙Ô˘Ó ‰ÈfiÚıˆÛ˘, ·Ú¿ ÌfiÓÔ Â› Û˘Ìو̿وÓ. ™ÙË ÁÂÓÈ΋ Ô‡ÚˆÓ ·ÓȯÓ‡ÂÙ·È ·ÈÌÔÛÊ·ÈÚ›ÓË ¯ˆÚ›˜ ÂÚ˘ıÚ¿ ·ÈÌÔÛÊ·›ÚÈ·, ÂÓÒ ÔÏϤ˜ ÊÔÚ¤˜ ÛÙÔ ›˙ËÌ· ÙˆÓ Ô‡ÚˆÓ ÂÚȤ¯ÔÓÙ·È ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈÎÔ› ηʤ Ï·ÛÒ‰ÂȘ ·ÏÈÓ‰ÚÔÈ (muddy brown casts). ∏ ÔÚ›· Ù˘ ÌÂÙ·ÏÔÈÌÒ‰Ô˘˜ Ú·‚‰ÔÌ˘fiÏ˘Û˘ Â›Ó·È Û˘Ó‹ıˆ˜ ηÏÔ‹ı˘, Â¿Ó ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ· Î·È ÂÈıÂÙÈο, Î·È Ë ·ÔηٿÛÙ·ÛË ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÌÔÚ› Ó· Á›ÓÂÈ ÂÓÙfi˜ ÔÏ›ÁˆÓ ËÌÂÚÒÓ, fiˆ˜ Û˘Ó¤‚Ë ÛÙÔÓ ·ÛıÂÓ‹ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ·ÏÏ¿ ÌÔÚ› Ó· ÎÚ·Ù‹ÛÂÈ Î·È ¤ˆ˜ 6 ‚‰ÔÌ¿‰Â˜ (8). ™ÙȘ ÂÈÏÔΤ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, Ô˘ Â›Ó·È Ë ÛÔ‚·ÚfiÙÂÚË Î·È ÈÔ ÂÈΛӉ˘ÓË, Ë ˘ÔÔÁηÈÌ›·, Ë ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ÔÈ ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Ë ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ‰È·ÌÂÚÈÛÌ·ÙÔÔ›ËÛ˘. ∏ Ú·‚‰ÔÌ˘fiÏ˘ÛË Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔÓ Èfi Ù˘ Áڛ˘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈϷΛ ·fi ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ·fi 2,2% ¤ˆ˜ 80% (6). ŸÌˆ˜, Ë ÂÈÏÔ΋ ·˘Ù‹ ۯ‰fiÓ ÔÙ¤ ‰ÂÓ ÌÂÙ·›ÙÂÈ Û ¯ÚÔÓÈfiÙËÙ· (11,12). ∏ ‰È·Ù·Ú·¯‹ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û˘Ì‚·›ÓÂÈ Î˘Ú›ˆ˜ Û ·ÛıÂÓ›˜ Ô˘ ÛÙËÓ ÔÚ›· Ù˘ Ïԛ̈͢ ÂΉËÏÒÓÔ˘Ó Û‹„Ë ‹ Û‡Ó‰ÚÔÌÔ ¤ÎÙˆÛ˘ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ·Â˘ı›·˜ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ΢ÙÙ¿ÚÔ˘ ·fi ÙÔÓ Èfi (11). ∏ ıÂڷ›· Ù˘ Ú·‚‰ÔÌ˘fiÏ˘Û˘, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘, ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÂÈıÂÙÈ΋ ÂÓ˘‰¿ÙˆÛË ˘fi Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ Î·È ÛÙËÓ ·˘ÍË̤ÓË ‰ÈÔ‡ÚËÛË, Ì ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÈηÓÔÔÈËÙÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ÃÔÚËÁÔ‡ÓÙ·È ÈÛfiÙÔÓ· ‰È·Ï‡Ì·Ù· ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ Û ÔÛfiÙËÙ· ‰ÈÏ¿ÛÈ· ‹/Î·È ÙÚÈÏ¿ÛÈ· ÙˆÓ
ËÌÂÚ‹ÛÈˆÓ ·Ó·ÁÎÒÓ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÒÛÙ ӷ ÂÈÙ¢¯ı› ÈηÓÔÔÈËÙÈ΋ ¤ÎÙ˘ÍË ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ¯ÒÚÔ˘. ∞·Ú·›ÙËÙË Â›Ó·È, ›Û˘, Ë Ù·ÎÙÈ΋ (·Ó¿ 2 ÒÚ˜) ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ, ÙÔ˘ pH Î·È ÙˆÓ ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ ÙÔ˘ ·›Ì·ÙÔ˜, ηıÒ˜ Î·È ÙÔ˘ pH ÙˆÓ Ô‡ÚˆÓ, fiˆ˜ Î·È Ë ÙÔÔı¤ÙËÛË Ô˘ÚÔηıÂÙ‹Ú·, Ì ÛÙfi¯Ô ÙËÓ Î·Ù·ÁÚ·Ê‹ Ù˘ ˆÚÈ·›·˜ ‰ÈÔ‡ÚËÛ˘. ™Â Û˘Ó˘¿Ú¯Ô˘Û· ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ¯ÔÚËÁÔ‡ÓÙ·È Ì ÚÔÛÔ¯‹ i.v. ‰ÈÙÙ·ÓıÚ·ÎÈο, ÂÓÒ ÚÔÙ›ÓÂÙ·È Î·È ·ÏηÏÔÔ›ËÛË ÙˆÓ Ô‡ÚˆÓ (ÛÙfi¯Ô˜ pH Ô‡ÚˆÓ >6,5), ÂÓÒ Â› ÔÏÈÁÔ˘Ú›·˜, ¯ÔÚËÁÂ›Ù·È ÊÔ˘ÚÔÛÂÌ›‰Ë. ™Â ÂÚ›ÙˆÛË ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ‰ÈÔ˘ÚËÙÈο, ›ÌÔÓ˘ ˘ÂÚηÏÈ·ÈÌ›·˜ ‹/Î·È ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘, Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ‹ Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, Ô ·ÛıÂÓ‹˜ ˘Ô‚¿ÏÏÂÙ·È Û ıÂڷ›· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Ì ‰È¿ÊÔÚ˜ ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙËÓ ÎÏÈÓÈ΋ ÙÔ˘ ÂÈÎfiÓ· (ÂÚÈÙÔÓ·˚΋ οı·ÚÛË, Û˘Ó¯‹ ·ÈÌԉȋıËÛË, ·ÈÌÔοı·ÚÛË) (9,13). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ú·‚‰ÔÌ˘fiÏ˘ÛË Â›Ó·È ÌÈ· Û¯ÂÙÈο Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Èfi Ù˘ Áڛ˘, Ë ÔÔ›· fï˜ ··ÈÙ› ˘„ËÏÔ‡ ‚·ıÌÔ‡ ˘Ô„›· ÏfiÁˆ Ù˘ ¿Ù˘Ë˜ ÎÏÈÓÈ΋˜ ÚÔ‚ÔÏ‹˜. ∏ ÓfiÛÔ˜ ¤¯ÂÈ Û˘Ó‹ıˆ˜ ηÏÔ‹ıË ÔÚ›· ÛÙ· ·È‰È¿, ·ÏÏ¿ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú¤˜ Î·È Û οÔȘ ÂÚÈÙÒÛÂȘ ı·Ó·ÙËÊfiÚ˜ ÂÈÏÔΤ˜, fiˆ˜ ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Poels PJ, Gabreëls FJ. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg 1993;95:175-192. 2. Singh U, Scheld WM. Infectious etiologies of rhabdomyolysis: three case reports and review. Clin Infect Dis 1996;22:642-649. 3. Mannix R, Tan ML, Wright R, Baskin M. Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics 2006;118:2119-2125. 4. Watemberg N, Leshner RL, Armstrong BA, Lerman-Sagie T. Acute pediatric rhabdomyolysis. J Child Neurol 2000;15:222-227. 5. Hue V, Martinot A, Fourier C, Cremer R, Leteurtre S, Leclerc F. Acute rhabdomyolysis in the child. Arch Pediatr 1998;5:887-895. 6. Agyeman P, Duppenthaler A, Heininger U, Aebi C. Influenza-associated myositis in children. Infection 2004;32:199-203. 7. Hu JJ, Kao CL, Lee PI, Chen CM, Lee CY, Lu CY, Huang LM. Clinical features of influenza A and B in children and association with myositis. J Microbiol Immunol Infect 2004;37:95-98. 8. Mackay MT, Kornberg AJ, Shield LK, Dennett X. Benign acute childhood myositis: laboratory and clinical features. Neurology 1999;53:2127-2131. 9. Berger RP, Wadowksy RM. Rhabdomyolysis associated with infection by Mycoplasma pneumoniae: a case report. Pediatrics 2000;105:433-436. ¶·È‰È·ÙÚÈ΋ 2008;71:74-78
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O. ºÈÏ›Ô˘ Î·È Û˘Ó.
10. Watanabe T. Rhabdomyolysis and acute renal failure in children. Pediatr Nephrol 2001;16:1072-1075. 11. Watanabe T, Yoshikawa H, Abe Y, Yamazaki S, Uehara Y, Abe T. Renal involvement in children with influenza A virus infection. Pediatr Nephrol 2003;18:541-544. 12. ∞be M, Higuchi T, Okada K, Kaizu K, Matsumoto K. Clinical study of influenza-associated rhabdomyolysis with acute renal failure. Clin Nephrol 2006;66:166-170.
Dariusz Tulik, 15 ÂÙÒÓ, ¶Ôψӛ· ¶·È‰› Ì ÌÂÚÈ΋ fiÚ·ÛË “∆· Ù˘ÊÏ¿ ·È‰È¿ ˙ˆÁÚ·Ê›˙Ô˘Ó”, ÕÓÓ· §·Ô˘Ù¿ÚË°ÎÚÈÙ˙¿Ï·, ∞ı‹Ó· 2006
Dariusz Tulik, 15 years old, Poland Partially blind child “Blind children paint”, Anna Laoutari-Gritzala, Athens 2006
Paediatriki 2008;71:74-78
13. Wakabayashi Y, Nakano T, Kikuno T, Ohwada T, Kikawada R. Massive rhabdomyolysis associated with influenza A infection. Internal Med 1994;33:450-453. 14. Muscal E, de Guzman MM, Wilson R, Shah BR. Rhabdomyolysis. eMedicine [Internet]. 2007 Apr: Webpage: http://www.emedicine.com/ped/topic2003.htm.
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∞. ™·‚‚›‰Ô˘1, °. ªÚÈ·ÛÔ‡Ï˘2, ª. ƒ·˚Û¿ÎË3, Õ. ª. ™·Ó¿ÎË2, ¡. º˘ÙÚÔÏ¿ÎË2, ∂. °·Ï·Ó¿Î˘1, ª. ∫·ÏÌ·ÓÙ‹1 ∞ÁfiÚÈ 7 ÂÙÒÓ ‰È·ÎÔÌ›ÛıËΠÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ Ì ˘ÚÂÙfi, ÎÂÊ·Ï·ÏÁ›· Î·È Â̤ÙÔ˘˜ ·fi 12ÒÚÔ˘. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÂÈÛfi‰Ô˘, ÙÔ ·È‰› ‹Ù·Ó ÏËı·ÚÁÈÎfi, Ì Îϛ̷η °Ï·ÛÎ҂˘ 9/15 Î·È Ì ·˘¯ÂÓÈ΋ ‰˘Ûη̄›·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÈÛfi‰Ô˘ ¤‰ÂÈÍ ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 23.000/Ìl Ì 92% ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, ·ÈÌÔÛÊ·ÈÚ›ÓË 13,3 gr/dl, ·ÈÌÔÂÙ¿ÏÈ· 154.000/Ìl, C ·ÓÙȉÚÒÛ· ÚˆÙÂ˚ÓË 18 mg/dl, ¯ˆÚ›˜ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ¯ˆÚ›˜ ‰È·Ù·Ú·¯¤˜ ·fi ÙË ÓÂÊÚÈ΋ Î·È Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ¤‰ÂÈÍ 900 ·ÙÙ·Ú·/Ìl (51% Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È 15% ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· ˘fiÏÔÈ· ‹Ù·Ó ÌÔÓÔ‡ÚËÓ· ‹ ÌË ·Ó·ÁÓˆÚ›ÛÈÌ·), ÚˆÙ½ÓË 128 mg/dl Î·È ÁÏ˘Îfi˙Ë 67 mg/dl. √ ·ÛıÂÓ‹˜ ‰È·ÛˆÏËÓÒıËÎÂ
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Î·È Ù¤ıËΠ۠ÂÌÂÈÚÈ΋ ·ÁˆÁ‹ Ì ÎÂÊÙÚÈ·ÍfiÓË, ‚·ÓÎÔÌ˘Î›ÓË, ·Î˘ÎÏÔ‚›ÚË Î·È ‰ÂÍ·ÌÂı·˙fiÓË. ŒÁÈÓ ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ì ·ÎÔÏÔ˘ı›Â˜ ‰È¿¯˘Û˘ (∂ÈÎfiÓ˜ 1∞, 1µ, 1°) Î·È Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù¿ Ù˘ ·ÎÔÏÔ‡ıËÛÂ Î·È Ì·ÁÓËÙÈ΋ ÊÏ‚ÔÁÚ·Ê›· (∂ÈÎfiÓ· 2).
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ 2 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¶·›‰ˆÓ 3 ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ ∞ÂÈÎfiÓÈÛ˘, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ AÏÏËÏÔÁÚ·Ê›·: ∂. °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ
¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ: 1. ∂ÚËÙÈ΋ ÂÁÎÂÊ·Ï›Ùȉ· 2. ∞ÁÁÂÈ›Ùȉ· ·fi Û˘ÛÙËÌ·ÙÈÎfi ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ 3. µ·ÎÙËÚȷ΋ ÌËÓÈÁÁ›Ùȉ· Ì ıÚfiÌ‚ˆÛË ÂÁηÚÛ›Ô˘ ÎfiÏÔ˘ 4. ªËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ Ì ‰È¿¯˘ÙË ÂÓ‰Ô·ÁÁÂȷ΋ ‹ÍË 5. ∂ÁÎÂÊ·Ï›Ùȉ· ·fi ÚÈΤÙÛÈ·
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∂ÈÎfiÓ· 1. ∞. ∞ÎÔÏÔ˘ı›· ‰È¿¯˘Û˘: ÔÏϷϤ˜ ÌÈÎÚ¤˜ ÂÚÈÔ¯¤˜ Ì ÂÚÈÔÚÈṲ̂ÓË ‰È¿¯˘ÛË (‚¤ÏË) ÛÙËÓ ˘ÔÊÏÔÈÒ‰Ë Ï¢΋ Ô˘Û›· ÙˆÓ ‚ÚÂÁÌ·ÙÈÎÒÓ ÏÔ‚ÒÓ. µ. ∞ÎÔÏÔ˘ı›· ADC ¯¿ÚÙÔ˘ ÛÙÔ ›‰ÈÔ Â›Â‰Ô: ÔÈ ‚Ï¿‚˜ ·Ô‰›‰Ô˘Ó ¯·ÌËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì· (‚¤ÏË), ‡ÚËÌ· ÂÓ‰ÂÈÎÙÈÎfi ÈÛ¯·ÈÌÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Û ÔÍ›· Ê¿ÛË. °. ™ÙË Û˘Ì‚·ÙÈ΋ ·ÎÔÏÔ˘ı›· ∆2 ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, ÔÈ ‚Ï¿‚˜ Â›Ó·È ÌfiÏȘ ˘ÔÛËÌ·ÈÓfiÌÂÓ˜.
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∂ÈÎfiÓ· 2. ª·ÁÓËÙÈ΋ ÊÏ‚ÔÁÚ·Ê›·: ÂÏ·Ùو̤ÓË ¤ˆ˜ ·Ô‡Û· ÚÔ‹ ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì‹ÎÔ˜ ÙÔ˘ ‰ÂÍÈÔ‡ ÂÁηÚÛ›Ô˘ ÎfiÏÔ˘ (‚¤ÏË). ¶·È‰È·ÙÚÈ΋ 2008;71:79,86
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∂ÏÏËÓÈ΋ ·È‰È·ÙÚÈ΋ ¤Ú¢ӷ Û ‰ÈÂıÓ‹ ÂÚÈÔ‰Èο, 2007 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
∂. °·Ï·Ó¿Î˘ ∆Ô 2007, ηٷ¯ˆÚ‹ıËÎ·Ó 483 ÂÚÁ·Û›Â˜ ·fi ÙËÓ ∂ÏÏ¿‰· ÁÈ· ÙÔ ·È‰› Û 284 ‰ÈÂıÓ‹ ÂÚÈÔ‰Èο (·Ó·˙‹ÙËÛË ÛÙË ‚¿ÛË ISI, 31 ¢ÂÎÂÌ‚Ú›Ô˘ 2007, ϤÍÂȘ-ÎÏÂȉȿ: “child*” ÁÈ· ÙÔ ·ÓÙÈΛÌÂÓÔ Î·È “Greece” ÁÈ· ÙÔ Î¤ÓÙÚÔ ÚÔ¤Ï¢Û˘). ∏ ‰ËÌÔÛÈÂ˘Ì¤ÓË ¤Ú¢ӷ Î¿Ï˘Ù fiÏ· Ù· ‰›·, ·fi ÙÔ ÂÚÁ·ÛÙËÚÈ·Îfi ˆ˜ ÙÔ ÎÏÈÓÈÎfi Î·È ÙÔ ÎÔÈÓˆÓÈÎfi, Î·È fiϘ ÙȘ ËÏÈ˘, ·fi ÙÔ ÓÂÔÁÓfi Î·È ÙÔ ‚Ú¤ÊÔ˜ ˆ˜ ÙÔ ·È‰› Î·È ÙÔÓ ¤ÊË‚Ô. ∞ÎÔÏÔ˘ıÔ‡Ó, Ôχ ÂÈÁÚ·ÌÌ·ÙÈο, ·ÔÙÂϤÛÌ·Ù· ¢ڇÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Ï›ÁˆÓ ·fi ·˘Ù¤˜ ÙȘ ÂÚÁ·Û›Â˜.
Greek paediatric research in international journals, 2007 Department of Paediatrics, University of Crete
E. Galanakis
Correspondence: Emmanouil Galanakis egalanak@med.uoc.gr Department of Paediatrics, University of Crete
In 2007, 483 studies from Greece focusing on child health were recorded in 284 international journals (search in the ISI; December 31, 2007; terms “child*” for topic and “Greece” for address). The reported studies extended from laboratory to clinical and social fields and from the neonatal age through infancy and childhood to adolescence. A handful of the results of these studies that are of general interest are presented here in brief.
√È ÂÚÁ·˙fiÌÂÓ˜ ÌËÙ¤Ú˜ ıËÏ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ. ∞fi 3.734 ÌËÙ¤Ú˜ Ô˘ Á¤ÓÓËÛ·Ó ÙÔ 2000 Î·È ·ÓÙ·ÔÎÚ›ıËÎ·Ó (77%) Û ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ 8-12 Ì‹Ó˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi: ÛÙÔ˘˜ ÚÒÙÔ˘˜ 3 Î·È 6 Ì‹Ó˜ ı‹Ï·˙·Ó 52% Î·È 24% (·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ 37% Î·È 17%, ·ÓÙ›ÛÙÔȯ·). ¶ÂÚÈÛÛfiÙÂÚÔ ı‹Ï·Û·Ó ÔÈ ÂÚÁ·˙fiÌÂÓ˜ ÌËÙ¤Ú˜, fiˆ˜ Î·È fiÛ˜ ›¯·Ó Í·Ó·ıËÏ¿ÛÂÈ (Bakoula C, et al. Acta Pediatr 2007;96: 510-515). ∏ ¯ÔÚ‹ÁËÛË ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉÒÓ ÛÙËÓ ¤ÁÎ˘Ô ÂËÚ¿˙ÂÈ ÙËÓ ÂÌ‚Ú˘È΋ ÔÛÙÂÔÁ¤ÓÂÛË (¯·ÌËÏ¿ ›‰· ÚÔÂÙȉ›Ô˘ ÙÔ˘ ÚÔÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ π ÛÙÔ ÓÂÔÁÓfi), ˆÛÙfiÛÔ, ·˘Ù‹ Ë Â›ÙˆÛË ¤¯ÂÈ ÚÔÛˆÚÈÓfi Î·È ·Ó·ÛÙÚ¤„ÈÌÔ ¯·Ú·ÎÙ‹Ú· ‹‰Ë ÛÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ (Korakaki E, et al. J Bone Miner Metab 2007;25:172-178). Paediatriki 2008;71:80-82
¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. 15ÂÙ‹˜ (1989-2003) ÌÂϤÙË fiÏˆÓ ÙˆÓ ÓÂÔÁÓÒÓ Ì ÓÔÛËÏ›· ÛÙË ª∂¡¡ πˆ·ÓÓ›ÓˆÓ Î·È ÌÂÙ¤ÂÈÙ· ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·Ù¤ÏËÍ fiÙÈ ÔÈ Î‡ÚÈÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ‹Û·Ó, ÁÈ· ÌÂÓ Ù· ÓÂÔÁÓ¿ <34 ‚‰ÔÌ¿‰ˆÓ ËÏÈΛ·˜ ·ËÛ˘ Ë ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ·, Ë ·Ú·ÙÂٷ̤ÓË Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘ÈÎÒÓ ˘Ì¤ÓˆÓ Î·È Ë ·Ú·ÌÔÓ‹ ·ÓÔÈÎÙÔ‡ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘, ÁÈ· ‰Â Ù· ÓÂÔÁÓ¿ >34 ‚‰ÔÌ¿‰ˆÓ ÙÔ ÌÈÎÚfi ‚¿ÚÔ˜ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘, Ë ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ë ÛË„·ÈÌ›·-ÌËÓÈÁÁ›Ùȉ· (Drougia A, et al. Early Hum Dev 2007;83:541-547). ∞ÓÙÔ¯‹ Ô˘ÚÔ·ıÔÁfiÓˆÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÚÒÙ˘ ÁÚ·ÌÌ‹˜. ªÂϤÙË ÂÓÙ·ÂÙ›·˜ (20002004) ÙˆÓ Ô˘ÚÔ·ıÔÁfiÓˆÓ Û 262 ·È‰È¿ Ì ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Ô˘ÚÔÏԛ̈͢ ÛÙËÓ ∫Ú‹ÙË ¤‰ÂÈÍ ·ÓÙÔ¯‹ Û ·ÌÈÎÈÏÏ›ÓË, ÙÚÈÌÂıÔÚ›ÌË-
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PAEDIATRIC NEWS IN BRIEF ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË Î·È ÎÂÊ·ÎÏfiÚË Û 61%, 28%, Î·È 27%, ·ÓÙ›ÛÙÔȯ· (Anatoliotaki M, et al. Scand J Infect Dis 2007;39:671-675). ªËÓÈÁÁ›Ùȉ·: Ì·ÎÚÔ¯ÚfiÓȘ Ù¿ÛÂȘ. ∞Ó·ÛÎfiËÛË 2.477 ÎÚÔ˘ÛÌ¿ÙˆÓ ‚·ÎÙËÚȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ (32 ¤ÙË, 1974-2005) ÛÙÔ “∞Á›· ™ÔÊ›·”: Ô ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˜ ‹Ù·Ó ÛÙ·ıÂÚ¿ ÙÔ ÚÒÙÔ ·›ÙÈÔ ÁÈ· fiϘ ÙȘ ËÏÈ˘, Ì 10ÂÙ‹ ΢ÎÏÈÎfiÙËÙ·. √ ·ÈÌfiÊÈÏÔ˜ ‹Ù·Ó ·Ú¯Èο ‰Â‡ÙÂÚÔ ·›ÙÈÔ, ·ÏÏ¿ Ë Â›ÙˆÛ‹ ÙÔ˘ ˘ÔÂÍ·Ï·ÛÈ¿ÛÙËΠÌÂÙ¿ ÙÔ ÂÌ‚fiÏÈÔ. √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ›¯Â ÌÈ· ÛÙ·ıÂÚ‹ ·ÚÔ˘Û›·. ∏ ÁÂÓÈ΋ ıÓËÙfiÙËÙ· ‹Ù·Ó 3,8% (Theodoridou MN, et al. BMC Infect Dis 2007;7:101). ™¯‹Ì· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÁÈ· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ. ∞fi 348 ·È‰›·ÙÚÔ˘˜ ·fi fiÏË ÙË ¯ÒÚ·, 72% ÚÔÙÈÌÔ‡Ó Û¯‹Ì· ÌÈ·˜ ÌfiÓÔ ‰fiÛ˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ C ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ. ∏ Î¿Ï˘„Ë Ì ÌÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰fiÛË Â›Ó·È Û¯Â‰fiÓ 100% ÁÈ· Ù· ·È‰È¿ ¤ˆ˜ 2 ÂÙÒÓ Î·È 51% ÁÈ· ÙÔ Û‡ÓÔÏÔ ≤15 ÂÙÒÓ. ∏ ΢ÎÏÔÊÔÚ›· (2001) ÙÔ˘ Û˘ÓÂ˙¢Á̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘ Û˘Óԉ‡ıËΠ·fi ‰Ú·Ì·ÙÈ΋ Ì›ˆÛË Ù˘ ›وÛ˘ Ù˘ ÔÚÔÔÌ¿‰·˜ C (Kafetzis DA, et al. Clin Microbiol Infect 2007;13:550-552). ∞ÓÙÔ¯‹ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘. ¶·ÓÂÏÏ‹ÓÈ· ÌÂϤÙË 780 ÛÙÂϯÒÓ S. pneumoniae ·fi ÙÔ ÚÈÓÔÊ¿Ú˘ÁÁ· ·È‰ÈÒÓ ·fi ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜ ÛÙÔ ‰È¿ÛÙËÌ· 2004-6 ¤‰ÂÈÍ ÌË-¢·ÈÛıËÛ›· Û ÂÓÈÎÈÏÏ›ÓË, ÎÂÊÔ˘ÚÔÍ›ÌË, ÎÂÊÙÚÈ·ÍfiÓË, ÂÚ˘ıÚÔÌ˘Î›ÓË, ÙÂÙڷ΢ÎÏ›ÓË Î·È ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË ÛÙÔ 35%, 25%, 1%, 34%, 26% Î·È 44%. ∆Ô 7‰‡Ó·ÌÔ Û˘ÓÂ˙¢Á̤ÓÔ Ó¢ÌÔÓÈÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ ı· ÂÎ¿Ï˘Ù ÙÔ 72% ÙˆÓ ÛÙÂϯÒÓ (Poulakou G, et al. Int J Antimicrob Agents 2007;30:87-92). º˘Ì·Ù›ˆÛË: ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈÊ˘Ì·ÙÈο. ∞fi 77 ÛÙÂϤ¯Ë M. tuberculosis ·fi ÈÛ¿ÚÈıÌ· ·È‰È¿ (42% ËÏÈΛ·˜ <2 ÂÙÒÓ, 87% ∂ÏÏËÓfiÔ˘Ï·), 1994-2004, 21% ‹Û·Ó ·ÓıÂÎÙÈο Û 1 ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÓÙÈÊ˘Ì·ÙÈÎfi Î·È 4% ÔÏ˘·ÓıÂÎÙÈο (ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ÈÛÔÓÈ·˙›‰Ë Î·È ÚÈÊ·ÌÈΛÓË). ∏ ·ÓÙÔ¯‹ ÛÙË ÛÙÚÂÙÔÌ˘Î›ÓË ‹Ù·Ó ÈÔ Û˘¯Ó‹ ÛÙ· ·È‰È¿ ·Ú¿ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (p<0,001). ∆· ÛÙÂϤ¯Ë ·ÔÌÔÓÒıËÎ·Ó Î·Ù¿ 87% ·fi Á·ÛÙÚÈÎfi ˘ÁÚfi (Kanavaki S, et al. Int J Tuberc Lung Dis 2007;11:424-428). º˘Ì·Ù›ˆÛË: ‚Ú·¯‡ÙÂÚ· Û¯‹Ì·Ù·. ∂Ó‰ÂηÂÙ‹˜ ÌÂϤÙË (1995-2005) Û 926 ·È‰È¿ Ì ϷÓı¿ÓÔ˘Û· Ê˘Ì·Ù›ˆÛË Û˘Ó¤ÎÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÈÛÔÓÈ·˙›‰Ë˜ › 9 Ì‹Ó˜ Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÈÛÔÓÈ·˙›‰Ë˜ Î·È ÚÈÊ·ÌÈΛÓ˘ › 3 ‹ 4 Ì‹Ó˜. ∏ Û˘ÌÌfiÚʈÛË ‹Ù·Ó ηχÙÂÚË ÛÙ· ‚Ú·¯¤· Û¯‹Ì·Ù·. ™ÙËÓ 3ÂÙ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ·-
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Ú·ÎÔÏÔ‡ıËÛË, ηӤӷ ·È‰› ‰ÂÓ ·Ó¤Ù˘Í ÎÏÈÓÈ΋ ÓfiÛÔ Î·È Ó¤· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÂÓÂÚÁÔ‡ ÓfiÛÔ˘ ‹Ù·Ó Û·ÓÈfiÙÂÚ· ÛÙ· ·È‰È¿ Ì ٷ ‚Ú·¯¤· Û¯‹Ì·Ù· (Spyridis NP, et al. Clin Infect Dis 2007;45:715-722). °·ÛÙÚÂÓÙÂÚ›Ùȉ· Î·È Èfi˜ ÚfiÙ·. ªÂϤÙË ·fi Ù· ÓÔÛÔÎÔÌ›· 4 fiÏÂˆÓ Î·È 50 ·È‰È¿ÙÚÔ˘˜ Û fiÏË ÙË ¯ÒÚ·, π·ÓÔ˘¿ÚÈÔ˜-∞Ú›ÏÈÔ˜ 2006: ·fi 706 ·È‰È¿ Ì ÔÍ›· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, 29% ›¯·Ó Ïԛ̈ÍË ·fi Èfi ÚfiÙ·, ÎÈ ·fi ·˘Ù¿ Ù· 72% ›¯·Ó ËÏÈΛ· 6 ÌËÓÒÓ-3 ÂÙÒÓ. √ Èfi˜ ÚfiÙ· Û˘Ó‰˘¿ÛıËΠ̠‚·Ú‡ÙÂÚË ÎÏÈÓÈ΋ ÂÈÎfiÓ· (p<0,01), ÂÚÈÛÛfiÙÂÚ˜ ÂÈÛ·ÁˆÁ¤˜ (p<0,01) Î·È Ì·ÎÚ‡ÙÂÚÔ ¯ÚfiÓÔ ÓÔÛËÏ›·˜ (p<0,05) ·fi Ù· ¿ÏÏ· ·›ÙÈ· (Kavaliotis I, et al. Eur J Pediatr 2007;Epub ahead of print). ∏ ‚ÚԢΤÏψÛË ÂÈ̤ÓÂÈ. ∞Ó·‰ÚÔÌÈ΋ 14ÂÙ‹˜ ÌÂϤÙË ·fi ÙË §·ÎˆÓ›· Ì 144 ÎÚÔ‡ÛÌ·Ù· ‚ÚԢΤÏψÛ˘ (·È‰È¿ Î·È ÂÓ‹ÏÈΘ): ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ‹Û·Ó ıÂÙÈΤ˜ ÛÙÔ 82% Î·È Ë ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· (ÛÙÚÂÙÔÌ˘Î›ÓË Î·È ‰Ô͢΢ÎÏ›ÓË) 97%. √È 4 ˘ÔÙÚÔ¤˜ ·ÊÔÚÔ‡Û·Ó ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Â›¯·Ó Û˘ÌÌÔÚʈı› ÛÙËÓ ·ÁˆÁ‹ (Andriopoulos P, et al. Int J Infect Dis 2007;11:52-57). °ÂÓÂÙÈ΋ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ªÂϤÙË ·fi Ù· πˆ¿ÓÓÈÓ· Ì 275 ·È‰È¿ ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ô˘ÚÔÔÈËÙÈÎÔ‡ ‰ÂÓ ÂȂ‚·›ˆÛÂ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ∞-1332G ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ˘Ô‰Ô¯¤· Ù‡Ô˘ 2 Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ ÌÂ Û˘ÁÁÂÓ›˜ Ô˘ÚÔ¿ıÂȘ (Siomou E, et al. Pediatr Res 2007;62:83-87). ∂›Â‰· ¯·ÏÎÔ‡ Î·È „¢‰·ÚÁ‡ÚÔ˘ Û ˘ÁÈ‹ ·È‰È¿. ™Â ÌÈ· ÚÒÙË ÁÈ· ÙËÓ ∂ÏÏ¿‰· ÌÂϤÙË, ÚÔÛ‰ÈÔÚ›ÛıËÎ·Ó ¯·ÏÎfi˜ Î·È „¢‰¿ÚÁ˘ÚÔ˜ ÛÙÔÓ ÔÚfi 105 ˘ÁÈÒÓ ·È‰ÈÒÓ ÛÙË £Ú¿ÎË Î·È ‰È·ÈÛÙÒıËÎ·Ó Û˘Û¯ÂÙ›ÛÂȘ Ì ËÏÈΛ·, ‡„Ô˜, ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ Î·È ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ (Arvanitidou V, et al. Biol Trace Elem Res 2007;115:1-12). ¶·¯˘Û·ÚΛ· Î·È ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘. ªÂϤÙË ·fi ÙË §¿ÚÈÛ· Û ·È‰È¿ Ì ÚÔ¯·ÏËÙfi η٤ÏËÍ fiÙÈ Ë ·¯˘Û·ÚΛ· ‰ÂÓ ·ÔÙÂÏ› ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙˆÓ ·ÔÊÚ·ÎÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ·Ó·ÓÔ‹˜ ηٿ ÙÔÓ ‡ÓÔ ÛÙ· ÌÈÎÚ¿ ·È‰È¿, ·Ó Î·È ÂӉ¯Ô̤ӈ˜ Ó· ¤¯ÂÈ ÈÔ ÛËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ ÛÙȘ ‰È·Ù·Ú·¯¤˜ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (Kaditis AG, et al. Sleep Breath 2007; [Epub ahead of print]). ¶·¯˘Û·ÚΛ· ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ. ™Â ‰Â›ÁÌ· 6.448 Ì·ıËÙÒÓ ËÏÈΛ·˜ 6-17 ÂÙÒÓ, ·fi fiÏË ÙËÓ ¶·È‰È·ÙÚÈ΋ 2008;71:80-82
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™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ ∂ÏÏ¿‰· (1990-1991), 17% ÙˆÓ ·ÁÔÚÈÒÓ Î·È 18% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ‹Û·Ó ˘¤Ú‚·Ú·, Î·È 3,8% ÙˆÓ ·ÁÔÚÈÒÓ Î·È 3,3% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ‹Û·Ó ·¯‡Û·Úη. ∆· ÔÛÔÛÙ¿ ·˘Ù¿ ‹Ù·Ó ·Ó¿ÏÔÁ· ¿ÏÏˆÓ ∂˘Úˆ·˚ÎÒÓ ¯ˆÚÒÓ (Georgiadis G, et al. Eur J Clin Nutr 2007;61:1072-1074). ∂Ê˂›· Î·È ¿Á¯Ô˜. ™‡Ìʈӷ Ì fiÛ· ·¿ÓÙËÛ·Ó 3.373 ŒÏÏËÓ˜ ¤ÊË‚ÔÈ ËÏÈΛ·˜ 18 ÂÙÒÓ Î·È 7.039 ºÈÓÏ·Ó‰Ô› ¤ÊË‚ÔÈ ËÏÈΛ·˜ 15-16 ÂÙÒÓ, ÔÈ ¤ÊË‚ÔÈ ÛÙËÓ ∂ÏÏ¿‰· ›¯·Ó ÈÔ Û˘¯Ó¿ ¿Á¯Ô˜ Î·È Î·Ù¿ıÏÈ„Ë (Kapi A, et al. Acta Paediatr 2007;96:1174-1179). ∂Ê˂›· Î·È ·ÏÎÔfiÏ. ™Â ÌÂϤÙË 1.185 ÂÊ‹‚ˆÓ ·fi 15 Û¯ÔÏ›· Ù˘ £ÂÛÛ·ÏÔӛ΢, 57% ÙˆÓ ·ÁÔÚÈÒÓ Î·È 48% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·Ó¤ÊÂÚ·Ó Î·Ù·Ó¿ÏˆÛË ·ÏÎÔfiÏ, Ì ¤Ó·ÚÍË ÛÙ· 13 ÂÚ›Ô˘ ¤ÙË. ¶ÂÚÈÛÛfiÙÂÚÔ ¤ÈÓ·Ó ÔÈ ¤ÊË‚ÔÈ Ì ÁÔÓ›˜ ¯·ÌËÏÔ‡ ÌÔÚʈÙÈÎÔ‡ ÂȤ‰Ô˘, ¤ÏÏÂÈ„Ë ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘ Î·È Û˘¯Ó‹ ¯Ú‹ÛË Î·Ê¤ Î·È Î·ÓÔ‡. ∏ ¯Ú‹ÛË ·ÏÎÔfiÏ Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÙ·È, ˆÛÙfiÛÔ, ·Ú·Ì¤ÓÂÈ ·Ó¿ÌÂÛ· ÛÙȘ ˘„ËÏfiÙÂÚ˜ Â˘Úˆ·˚Τ˜ (Arvanitidou M, et al. Am J Drug Alcohol Abuse 2007;33:411-417). ∂Ê˂›· Î·È Î¿ÓÈÛÌ·. ∞fi ·ÓÂÏÏ‹ÓÈÔ ‰Â›ÁÌ· ÂÊ‹‚ˆÓ ËÏÈΛ·˜ 13-15 ÂÙÒÓ, 32% ›¯·Ó ‰ÔÎÈÌ¿ÛÂÈ ÙÛÈÁ¿ÚÔ Î·È 16% οÓÈ˙·Ó ηٿ ÙÔÓ ¯ÚfiÓÔ Ù˘ ÌÂϤÙ˘. ŒÓ·˜ ÛÙÔ˘˜ 4 Ì ·Ó·ÌÓËÛÙÈÎfi ηӛÛÌ·ÙÔ˜ ¿Ú¯ÈÛ ÚÈÓ ·fi Ù· 10 ¤ÙË. 90% ÙˆÓ ÂÊ‹‚ˆÓ ›¯·Ó ¤ÎıÂÛË Û ηÓfi ÛÙÔ Û›ÙÈ Î·È 95% ·Ó¤ÊÂÚ·Ó fiÙÈ ÌÔÚÔ‡Û·Ó Ó· ·ÁÔÚ¿ÛÔ˘Ó fiÛ· ÙÛÈÁ¿Ú· ‹ıÂÏ·Ó Ì ‰Èο ÙÔ˘˜ ¯Ú‹Ì·Ù· (Kyrlesi A, et al. BMC Public Health 2007;7:3). ¶·ıËÙÈÎfi οÓÈÛÌ· ÓË›ˆÓ. ∞fi 2.809 ÁÔÓ›˜ Ì ·È‰› Û ‚ÚÂÊÔÓËÈ·Îfi ÛÙ·ıÌfi ÛÙË ¢˘ÙÈ΋ ∫Ú‹ÙË (2004-2005), 52% ÙˆÓ ·Ù¤ÚˆÓ Î·È 36% ÙˆÓ ÌËÙ¤ÚˆÓ Î¿ÓÈ˙·Ó, ÛÙÔ 63% ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Î¿ÓÈ˙ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ô ¤Ó·˜ Î·È ÛÙÔ 26% οÓÈ˙·Ó Î·È ÔÈ ‰˘Ô ÁÔÓ›˜ (Vardavas CI, et al. BMC Public Health 2007;7:112). ÕÛıÌ·: Ì·ÎÚÔ¯ÚfiÓȘ Ù¿ÛÂȘ. √ ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜/‚ÚÔÁ¯fiÛ·ÛÌÔ˘ Û 11.221
Paediatriki 2008;71:80-82
·È‰È¿ ËÏÈΛ·˜ 8-10 ÂÙÒÓ ÛÙËÓ ¶¿ÙÚ· ÌÂÏÂÙ‹ıËΠ̠ÛÙ·ıÂÚ‹ ÌÂıÔ‰ÔÏÔÁ›· ÛÙË ‰È·‰ÚÔÌ‹ ÌÈ·˜ 25ÂÙ›·˜ (1978, 1991, 1998 Î·È 2003) Î·È ‚Ú¤ıËΠ1,5%, 4,6%, 6% Î·È 6,9%, ·ÓÙ›ÛÙÔȯ·, Ì ÛÙ·ıÂÚ‹ ‰ËÏ·‰‹ ·‡ÍËÛË, ·Ó Î·È Ì ٿÛË ÂȤ‰ˆÛ˘ ÛÙ· ÙÂÏÂ˘Ù·›· ¤ÙË (Anthracopoulos MB, et al. Arch Dis Child 2007; 92: 209-212). ¢ˆÚ¿ ÔÚÁ¿ÓˆÓ ·fi ·È‰È¿. ∞Ó·ÛÎfiËÛË ÙˆÓ ‚ÈˆÌ¿ÙˆÓ 22 ÁÔÓ¤ˆÓ 14 ·È‰ÈÒÓ Ì ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Û 2 ·È‰È·ÙÚÈΤ˜ ª∂£ ÛÙËÓ ∞ı‹Ó· Î·È Ù˘ ·fiÊ·Û‹˜ ÙÔ˘˜ Ó· ‰ˆÚËıÔ‡Ó fiÚÁ·Ó· Î·È ÈÛÙÔ› ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ (Bellali T, et al. Soc Sci Med 2007;64:439-450). ŒÎıÂÛË ÛÙÔÓ ‹ÏÈÔ Î·È ÏÂÌÊÒÌ·Ù·. ªÂÏÂÙ‹ıËÎ·Ó ÔÈ Û˘Ó‹ıÂȘ ¤ÎıÂÛ˘ ÛÙÔÓ ‹ÏÈÔ 71 ·È‰ÈÒÓ Ì ϤÌʈ̷ Hodgin, 87 Ì ϤÌʈ̷ ÌË Hodgin Î·È 164 ·È‰ÈÒÓ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. ∏ ·˘ÍË̤ÓË ¤ÎıÂÛË ÛÙÔÓ ‹ÏÈÔ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È Ì ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ϤÌʈ̷ ÌË Hodgin (Petridou ET, et al. Cancer Causes Control 2007;18:1031-1037). ªÂÛÔÁÂȷ΋ ‰›·ÈÙ·. ªÂϤÙË 690 ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ËÏÈΛ·˜ 7-18 ÂÙÒÓ ÛÙËÓ ·ÁÚÔÙÈ΋ ∫Ú‹ÙË ¤‰ÂÈÍ fiÙÈ Ë ‰È·ÙÚÔÊ‹ Ì ÛٷʇÏÈ·, ÔÚÙÔοÏÈ·, Ì‹Ï· Î·È ÓÙÔÌ¿Ù˜ ÚÔÛٷهÂÈ ·fi ‚ÚÔÁ¯fiÛ·ÛÌÔ Î·È ÚÈÓ›Ùȉ· Î·È Ë ÌÂÁ¿ÏË Î·Ù·Ó¿ÏˆÛË ÍËÚÒÓ Î·ÚÒÓ ·fi ‚ÚÔÁ¯fiÛ·ÛÌÔ. ∏ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‹Ù·Ó ÈÔ Û˘¯Ó‹ Ì ÙËÓ Î·Ù·Ó¿ÏˆÛË Ì·ÚÁ·Ú›Ó˘ (fiˆ˜ Î·È Ô ‚ÚÔÁ¯fiÛ·ÛÌÔ˜) Î·È ÈÔ Û¿ÓÈ· Ì ÙË ÌÂÛÔÁÂȷ΋ ‰›·ÈÙ· (Chatzi L, et al. Thorax 2007;62:677-683). ¢ÔÛÔÏÔÁ›· ÎÏ·ÚÈıÚÔÌ˘Î›Ó˘. ∞fi 343 ·È‰È¿ Ì Ïԛ̈ÍË ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ·ÁˆÁ‹ ·fi 29 ·È‰È¿ÙÚÔ˘˜ Ù˘ ∞ı‹Ó·˜, 78% ‹Ú·Ó ËÌÂÚ‹ÛÈ· ‰fiÛË ÌÂÁ·Ï‡ÙÂÚË Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘ (15 mg/kg) Î·È 26% ËÌÂÚ‹ÛÈ· ‰fiÛË ≥30 mg/kg. ∫·Î‹ ·ÓÔ¯‹ ·Ó·Ê¤ÚıËΠÛÙÔ 4% Î·È ·ÚÂÓ¤ÚÁÂȘ (΢ڛˆ˜ Á·ÛÙÚÂÓÙÂÚÈΤ˜) ÛÙÔ 18%. ∏ ·˘ÍË̤ÓË ‰fiÛË ‰ÂÓ Û˘Û¯ÂÙ›ÛıËΠ̠ÙËÓ ·ÓÔ¯‹ ‹ ÙȘ ·ÚÂÓ¤ÚÁÂȘ (Kafetzis DA, et al. Eur J Clin Microbiol Infect Dis 2007;26:99-103).
Pediatri Jan-Feb 08
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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√
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πÛÙÔÛÂÏ›‰Â˜ ÁÈ· ÙËÓ ∞ÏÏÂÚÁÈÔÏÔÁ›· ÃÚ˘Û¿ÓıË ™Î¢¿ÎË
µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡»
πÛÙÔÛÂÏ›‰· Ù˘ ∂˘Úˆ·˚΋˜ ∞η‰ËÌ›·˜ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜ http://www.eaaci.net
AÏÏËÏÔÁÚ·Ê›·: ÃÚ˘Û¿ÓıË ™Î¢¿ÎË cskevaki@allergy.gr
H ÈÛÙÔÛÂÏ›‰· www.eaaci.net ·ÔÙÂÏ› ÙÔÓ Â›ÛËÌÔ ‰È·‰ÈÎÙ˘·Îfi ÙfiÔ Ù˘ ∂˘Úˆ·˚΋˜ ∞η‰ËÌ›·˜ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ∫ÏÈÓÈ΋˜ ∞ÓÔÛÔÏÔÁ›·˜, Ë ÔÔ›· ȉڇıËΠÙÔ 1956 ÛÙË ºÏˆÚÂÓÙ›· Î·È ·ÚÈıÌ› ̤¯ÚÈ Û‹ÌÂÚ· 40 ∂˘Úˆ·˚Τ˜ ∂ıÓÈΤ˜ ∂ÓÒÛÂȘ (National Societies) Î·È ÂÚÈÛÛfiÙÂÚ· ·fi 5.500 ̤ÏË, ÚÔÂÚ¯fiÌÂÓ· ·fi ÙËÓ ·Î·‰ËÌ·˚΋ Î·È ÂÚ¢ÓËÙÈ΋ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ·. ™Ùfi¯Ô˜ Ù˘ ∞η‰ËÌ›·˜ Â›Ó·È Ë ÚÔÒıËÛË Ù˘ ‚·ÛÈ΋˜ Î·È ÎÏÈÓÈ΋˜ ¤Ú¢ӷ˜ ÛÙÔ Â‰›Ô Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ÎÏÈÓÈ΋˜ ·ÓÔÛÔÏÔÁ›·˜, Ë Û˘ÏÏÔÁ‹, ηٷÁÚ·Ê‹, ·ÍÈÔÏfiÁËÛË Î·È ‰È¿‰ÔÛË Ù˘ ÂÈÛÙËÌÔÓÈ΋˜ ÏËÚÔÊfiÚËÛ˘, Ë ÏÂÈÙÔ˘ÚÁ›· ˆ˜ ΤÓÙÚÔ˘ ·Ó·ÊÔÚ¿˜ ÁÈ· ÂÈÛÙËÌÔÓÈο fiÚÁ·Ó· Î·È ÔÏÈÙÈΤ˜ ‰Ô̤˜ ÁÈ· ÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ Û ·ÓÂ˘Úˆ·˚Îfi ›‰Ô, Ë ÂÓı¿ÚÚ˘ÓÛË Î·È ÚÔÛÊÔÚ¿ Û˘Ó¯È˙fiÌÂÓ˘ È·ÙÚÈ΋˜ Âη›‰Â˘Û˘ Î·È Ë ÚÔÛÊÔÚ¿ ˘ËÚÂÛÈÒÓ ÂÓË̤ڈÛ˘ Û ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁ›Â˜ Î·È ¿ÛıÌ·. ™ÙȘ ‰Ú¿ÛÂȘ Ù˘ ∞η‰ËÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û˘ÓÂÚÁ·Û›Â˜ Ì ·ÓÙ›ÛÙÔȯ˜ ·ÁÎfiÛÌȘ ÔÚÁ·ÓÒÛÂȘ, Û˘ÌÌÂÙÔ¯‹ Û ÂÚ¢ÓËÙÈο ÚÔÁÚ¿ÌÌ·Ù· Î·È ‰ÈÂıÓ›˜ Û˘Ó·ÓÙ‹ÛÂȘ, Ì ·ÔÎÔڇʈ̷ ÙÔ ÂÙ‹ÛÈÔ ‰ÈÂıÓ¤˜ Û˘Ó¤‰ÚÈÔ ·ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ÎÏÈÓÈ΋˜ ·ÓÔÛÔÏÔÁ›·˜. ™ÙËÓ Î·ÙËÁÔÚ›· ¡¤· ˘¿Ú¯ÂÈ ÏËÚÔÊfiÚËÛË ÂÈÛÙËÌÔÓÈÎÔ‡ Î·È ÂȉËÛÂÔÁÚ·ÊÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ Û¯ÂÙÈο Ì ÙȘ ·ÏÏÂÚÁ›Â˜ Î·È ÙÔ ¿ÛıÌ·. ∂ÈϤÔÓ, ÛÙËÓ ˘ÔηÙËÁÔÚ›· ¶ÚÔÊ›Ï, Á›ÓÂÙ·È ·ÚÔ˘Û›·ÛË ÂÈÏÂÁÌ¤ÓˆÓ ÚÔÛˆÈÎÔÙ‹ÙˆÓ Ì¤Û· ·fi ÙËÓ ∞η‰ËÌ›·, Ì ¤ÓÙÔÓË ‰Ú¿ÛË Î·È ÂÈÛÙËÌÔÓÈÎfi ÚÔÊ›Ï. ∆¤ÏÔ˜, ÛÙËÓ ÂÓfiÙËÙ· ·˘Ù‹ Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ Î·È Û Ӥ˜ ÂΉfiÛÂȘ Î·È ‚È‚Ï›· ·fi ÙÔ ¯ÒÚÔ Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜. ™ÙËÓ Î·ÙËÁÔÚ›· ¢Ú·ÛÙËÚÈfiÙËÙ˜, ÂÎÙfi˜ ·fi ÙËÓ Ù·ÎÙÈ΋ ÂÙ‹ÛÈ· Û˘Ó¿ÓÙËÛË Ù˘ ∞η‰ËÌ›·˜, ˘¿Ú¯Ô˘Ó ÏËÚÔÊÔڛ˜ ÁÈ· Ù· ıÂÚÈÓ¿ Î·È ¯ÂÈÌÂÚÈÓ¿ Û¯ÔÏ›· Ì ÂÎ·È‰Â˘ÙÈÎfi ¯·Ú·ÎÙ‹Ú·, ÂÈÛÙËÌÔÓÈΤ˜ Û˘Ó·ÓÙ‹ÛÂȘ, ·ÏÏ¿ Î·È ÁÂÓÈÎfiÙÂÚË ÏËÚÔÊfiÚËÛË ÁÈ· ·ÚÂÌÊÂÚÔ‡˜ ¯·Ú·ÎÙ‹Ú· ÁÂÁÔÓfiÙ· Û ·ÁÎfiÛÌÈÔ Â›Â‰Ô. ∆· ÂÈ̤ÚÔ˘˜ ÂÚ¢ÓËÙÈο Î·È ÂÈÛÙËÌÔÓÈο ‰›· ÛÙÔ ¯ÒÚÔ Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ÎÏÈÓÈ΋˜ ·ÓÔÛÔÏÔÁ›·˜ ÂÚÈÁÚ¿ÊÔÓÙ·È ·Ó·Ï˘ÙÈο ÛÙËÓ Î·ÙËÁÔÚ›· ∂ÓfiÙËÙ˜/√Ì¿‰Â˜ ∂ӉȷʤÚÔÓÙÔ˜, ÂÓÒ ÁÈ· Ù· Ó·ڿ ̤ÏË Ù˘ ∞η‰ËÌ›·˜ (¤ˆ˜ 35 ÂÙÒÓ) ˘¿Ú¯ÂÈ Í¯ˆÚÈÛÙ‹ ηÙËÁÔÚ›· Ì ÏËÚÔÊÔڛ˜ Î·È Ó¤· Ô˘ ·Â˘ı‡ÓÔÓÙ·È ÛÙÔ˘˜ Ó¤Ô˘˜ ÂÈÛÙ‹ÌÔÓ˜ ÙÔ˘ ¯ÒÚÔ˘. ¶·Ú¿ÏÏËÏ·, ˘¿Ú¯ÂÈ Î·È Ë ÂȉÈ΋ ÂÓfiÙËÙ· °È· Ù· ª¤ÏË ªfiÓÔ, ÛÙËÓ ÔÔ›· ÂÈÙÚ¤ÂÙ·È Ë ÚfiÛ‚·ÛË ‚¿ÛÂÈ Îˆ‰ÈÎÔ‡ ηıÒ˜ ÚÔÛʤÚÂÈ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ÏËÚÔÊfiÚËÛË. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÂÓfiÙËÙ· ¶ËÁ¤˜, Ô˘ ÚÔÛʤÚÂÈ ÂÚÁ·Ï›· ËÏÂÎÙÚÔÓÈ΋˜ Âη›‰Â˘Û˘ (e-learning) Ì ‰È·‰Ú·ÛÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¯Ú‹ÛÙË (webcasts), ·‰ËÌÔÛ›Â˘Ù˜ ÂÈÛÙËÌÔÓÈΤ˜ ¤Ú¢Ó˜ Î·È case-studies, ÏÔ‡ÛÈÔ ÊˆÙÔÁÚ·ÊÈÎfi ˘ÏÈÎfi Î·È ÏËÚÔÊfiÚËÛË ÁÈ· ı¤ÛÂȘ ¤Ú¢ӷ˜ Î·È ÂÚÁ·Û›·˜. ∆¤ÏÔ˜, Ë ÈÛÙÔÛÂÏ›‰· ÙÔ˘ www.eaaci.net ÚÔÛʤÚÂÈ ÚfiÛ‚·ÛË ÛÙȘ ›ÛË̘ ÂΉfiÛÂȘ Ù˘ ∞η‰ËÌ›·˜ (Allergy, Pediatric Allergy and Immunology, Newsletter) ηıÒ˜ Î·È ËÏÂÎÙÚÔÓÈΤ˜ Û˘Ó‰¤ÛÂȘ Ì ·ÁÎfiÛÌȘ ÂÈÛÙËÌÔÓÈΤ˜ Î·È È·ÙÚÈΤ˜ ÔÚÁ·ÓÒÛÂȘ.
¶·È‰È·ÙÚÈ΋ 2008;71:83-85
Pediatri Jan-Feb 08
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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ πÛÙÔÛÂÏ›‰· ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ √ÚÁ·ÓÈÛÌÔ‡ ∞ÏÏÂÚÁ›·˜ http://www.worldallergy. org/index.php ∏ ·Ó·Óˆ̤ÓË ÈÛÙÔÛÂÏ›‰· www.worldallergy.org ·ÔÙÂÏ› ÙÔÓ Â›ÛËÌÔ ‰È·‰ÈÎÙ˘·Îfi ÙfiÔ ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ √ÚÁ·ÓÈÛÌÔ‡ ∞ÏÏÂÚÁ›·˜ (WAO), Ô ÔÔ›Ô˜ ·ÓÙÈÚÔۈ‡ÂÈ ¤Ó· ‰ÈÂıÓ¤˜ ‰›ÎÙ˘Ô ·fi 74 ÂıÓÈΤ˜ Î·È ÂÚÈÊÂÚÂȷΤ˜ ÂÙ·ÈÚ›˜ ·ÏÏÂÚÁÈÔÏÔÁ›·˜ Î·È ÎÏÈÓÈ΋˜ ·ÓÔÛÔÏÔÁ›·˜ ·fi fiÏÔ ÙÔÓ ÎfiÛÌÔ. ™Ùfi¯Ô˜ ÙÔ˘ WAO Â›Ó·È Ó· ·ÔÙÂϤÛÂÈ ¤Ó· ·ÁÎfiÛÌÈÔ Î¤ÓÙÚÔ ÂÈÛÙËÌÔÓÈ΋˜ ÏËÚÔÊfiÚËÛ˘ ÁÈ· ÙËÓ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋, ÙËÓ ¤Ú¢ӷ, ÙËÓ Âη›‰Â˘ÛË Î·È ÙË ‰È· ‚›Ô˘ ηٿÚÙÈÛË, ̤۷ ·fi ‰ÈÔÚÁ·ÓÒÛÂȘ, ÂÈÛÙËÌÔÓÈο Û˘ÌfiÛÈ·, ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· Î·È ÂÎ·È‰Â˘ÙÈÎfi ˘ÏÈÎfi, Ì ¤ÌÊ·ÛË ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ΢ڛˆ˜ ¯ÒÚ˜. √ ¶·ÁÎfiÛÌÈÔ˜ √ÚÁ·ÓÈÛÌfi˜ ∞ÏÏÂÚÁ›·˜ ȉڇıËΠÙÔ 1951 Û˘ÓÂÓÒÓÔÓÙ·˜ ÙËÓ ÂÚ¢ÓËÙÈ΋, ·Î·‰ËÌ·˚΋ Î·È È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ· ·fi ÙÔ ¯ÒÚÔ Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜, ÂÓÒ Û˘ÓÂÚÁ¿˙ÂÙ·È Â›Û˘ ÛÙÂÓ¿ Î·È Ì ÙÔÓ ¶·ÁÎfiÛÌÈÔ √ÚÁ·ÓÈÛÌfi ÀÁ›·˜ (WHO). H ÈÛÙÔÛÂÏ›‰· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, Ì ÚfiÛÊ·ÙÔ, ·Ó·Óˆ̤ÓÔ ÚÔÊ›Ï, ¤¯ÂÈ ÌÔÓÙ¤ÚÓÔ Û¯Â‰È·ÛÌfi Î·È Â‡ÎÔÏË ÏÔ‹ÁËÛË. ∏ ηÙËÁÔÚ›· ∂η›‰Â˘ÛË ÛÙËÓ ∞ÏÏÂÚÁ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· Ù· ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÛÂÌÈÓ¿ÚÈ· Î·È ˘ÔÙÚÔʛ˜. ∏ ηÙËÁÔÚ›· ŒÚ¢ӷ ÛÙËÓ ∞ÏÏÂÚÁ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÂÚ¢ÓËÙÈο ÚÔÁÚ¿ÌÌ·Ù·, ÂÈÛÙËÌÔÓÈΤ˜ Û˘Ó·ÓÙ‹ÛÂȘ, Ì·ı‹Ì·Ù· Î·È ÈÛÙÔÔÈËÙÈο ÁÓÒÛ˘ Á‡Úˆ ·fi ÙËÓ ·ÏÏÂÚÁ›· Î·È ÙËÓ ÎÏÈÓÈ΋ ·ÓÔÛÔÏÔÁ›·. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÂÓfiÙËÙ· ∫ÚÈÙÈΤ˜, fiÔ˘ ·Ó·Ê¤ÚÂÙ·È Û ÎÚÈÙÈΤ˜ ‚È‚Ï›ˆÓ, ÂÚÈÔ‰ÈÎÒÓ Î·È ¿ÏÏˆÓ ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉfiÛÂˆÓ Ì ·ÓÙÈΛÌÂÓÔ ÙËÓ ·ÏÏÂÚÁ›·. ∏ ÈÛÙÔÛÂÏ›‰· ÏÂÈÙÔ˘ÚÁ›, ›Û˘, ˆ˜ ̤ÛÔ ÂÈÎÔÈÓˆÓ›·˜ Ì ٷ ̤ÏË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ̤۷ ·fi Ì›· ͯˆÚÈÛÙ‹ ηÙËÁÔÚ›· (°È· Ù· ª¤ÏË ªfiÓÔ), Ë ÔÔ›· ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ˘Ô‚ÔÏ‹˜ ÂÚˆÙËÌ¿ÙˆÓ Û ÂȉÈÎÔ‡˜ ·fi ÙÔ ¯ÒÚÔ Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜. ∆¤ÏÔ˜, Ë ÈÛÙÔÛÂÏ›‰· ÚÔÛʤÚÂÈ ÏËÚÔÊfiÚËÛË ÁÈ· Ù· ÂÂÚ¯fiÌÂÓ· Û˘Ó¤‰ÚÈ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ηıÒ˜ Î·È ËÏÂÎÙÚÔÓÈΤ˜ Û˘Ó‰¤ÛÂȘ Ì ·ÚÂÌÊÂÚ›˜ ÔÚÁ·ÓÈÛÌÔ‡˜ Î·È ÂÓÒÛÂȘ.
πÛÙÔÛÂÏ›‰· Ù˘ ∂˘Úˆ·˚΋˜ √ÌÔÛÔÓ‰›·˜ ÁÈ· ÙȘ ∂ÓÒÛÂȘ ∞ÛıÂÓÒÓ Ì ∞ÏÏÂÚÁ›· Î·È ¶·ı‹ÛÂȘ ÙÔ˘ ∞Ó·Ó¢ÛÙÈÎÔ‡ (EFA) - http://www.efanet.org/ ∏ ÈÛÙÔÛÂÏ›‰· www.efanet.org ·ÔÙÂÏ› ÙÔÓ Â›ÛËÌÔ ‰È·‰ÈÎÙ˘·Îfi ÙfiÔ Ù˘ ∂˘Úˆ·˚΋˜ √ÌÔÛÔÓ‰›·˜ ÁÈ· ÙȘ ∂ÓÒÛÂȘ ∞ÛıÂÓÒÓ Ì ∞ÏÏÂÚÁ›· Î·È ¶·ı‹ÛÂȘ ÙÔ˘ ∞Ó·Ó¢ÛÙÈÎÔ‡, EFA, Ë ÔÔ›· ȉڇıËΠÙÔ 1991 ÛÙË ™Ô˘Ë‰›·. ™Ùfi¯Ô˜ ‹Ù·Ó Ó· Û˘ÓÂÓÒÛÂÈ fiϘ ÙȘ ÂÓÒÛÂȘ ·ÛıÂÓÒÓ Ì ·ÏÏÂÚÁ›Â˜ Î·È ¿ÛıÌ· ÛÙËÓ ∂˘ÚÒË ÁÈ· Ó· ÈηÓÔÔÈ‹ÛÂÈ ÙȘ ·Ó¿ÁΘ ÙÔ˘˜ Î·È Ó· ÚÔ·Û›ÛÂÈ Ù· ‰ÈηÈÒÌ·Ù¿ ÙÔ˘˜, ·ÔÛÎÔÒÓÙ·˜ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘Á›·˜ ÙÔ˘˜ Î·È ÂÓ Á¤ÓÂÈ Ù˘ ÔÈfiÙËÙ·˜ Ù˘ ˙ˆ‹˜ ÙÔ˘˜. ™ÙÔ Ï·›ÛÈÔ ·˘Ùfi, ÚÔÛʤÚÂÈ ˘ËÚÂۛ˜ ÂȉËÛÂÔÁÚ·ÊÈ΋˜ ÂÓË̤ڈÛ˘ Î·È ÂÌÂÚÈÛٷو̤Ó˘ ÂÈÛÙËÌÔÓÈ΋˜ ÏËÚÔÊfiÚËÛ˘, ηıÒ˜ Î·È Û˘Ó·Ê¤˜ ÂÎ·È‰Â˘ÙÈÎfi ˘ÏÈÎfi. ª¤¯ÚÈ Û‹ÌÂÚ·, ÙÔ ‰›ÎÙ˘Ô Ù˘ EFA ÂÚÈÏ·Ì‚¿ÓÂÈ 14 ÂıÓÈΤ˜ ÂÓÒÛÂȘ Ì ۇÓÔÏÔ ÌÂÏÒÓ ¿Óˆ ÙˆÓ 400.000 Û fiÏË ÙËÓ ∂˘ÚÒË. ∏ ηÙËÁÔÚ›· ¢Ú·ÛÙËÚÈfiÙËÙ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ Ù·ÎÙÈΤ˜ Î·È ¤ÎÙ·ÎÙ˜ ÂΉfiÛÂȘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÁÂÁÔÓfiÙ· Î·È ÂΉËÏÒÛÂȘ, ‰Ú¿ÛÂȘ Î·È ÚˆÙÔ‚Ô˘Ï›Â˜ Ù˘ ∂∂ Î·È ÂÎ·È‰Â˘ÙÈο Î·È ÂÚ¢ÓËÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÛÂ Û˘ÓÂÚÁ·Û›· Ì ·ÚÂÌÊÂÚ›˜ Â˘Úˆ·˚ÎÔ‡˜ ÊÔÚ›˜. ∂ÈϤÔÓ, ˘¿Ú¯ÂÈ ÂÎÙÂٷ̤ÓË ·Ó·ÊÔÚ¿ Û ¤ÁÁÚ·Ê· ÔÏÈÙÈ΋˜, fiˆ˜ Â˘Úˆ·˚Τ˜ Û˘Óı‹Î˜ Î·È Û˘ÛÙ¿ÛÂȘ, ı¤Ì·Ù·
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ηٷӷψÙÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜ Î·È ˘ÁÂÈÔÓÔÌÈ΋˜ ÂÚ›ı·Ï„˘, ÂÚÈ‚·ÏÏÔÓÙÔÏÔÁÈο ı¤Ì·Ù·, Û˘Ó‰ÂfiÌÂÓ· Ì ÙȘ ·ÏÏÂÚÁ›Â˜ Î·È ÙȘ ·ı‹ÛÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ˙ËÙ‹Ì·Ù· ‰È·ÙÚÔÊ‹˜ Î·È Û‹Ì·ÓÛ˘ ÙˆÓ ÙÚÔÊÒÓ, ηıÒ˜ Î·È ˙ËÙ‹Ì·Ù· È·ÙÚÔÊ·Ú̷΢ÙÈ΋˜ ÂÚ›ı·Ï„˘. ∏ ηÙËÁÔÚ›· ¡¤· ·fi ÙËÓ EFA ÂÚÈÏ·Ì‚¿ÓÂÈ Âȉ‹ÛÂȘ ·fi ÙÔÓ ∆‡Ô Û¯ÂÙÈο Ì ÙȘ ·ÏÏÂÚÁ›Â˜ Î·È ÙÔ ¿ÛıÌ·, ÙËÓ ËÏÂÎÙÚÔÓÈ΋ ¤Î‰ÔÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ηıÒ˜ Î·È Âȉ‹ÛÂȘ ·fi ÙÔ ‰È·‰›ÎÙ˘Ô. ∂ÎÙfi˜ ·fi ÙȘ ͯˆÚÈÛÙ¤˜ ηÙËÁÔڛ˜ ÂÓË̤ڈÛ˘ ∞ÏÏÂÚÁ›· Î·È ÕÛıÌ·, Ô˘ ÂÚȤ¯Ô˘Ó ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙË Ê‡ÛË, ÙËÓ ÔÚÔÏÔÁ›·, ÙË ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ÂͤÏÈÍË ÙˆÓ ·ı‹ÛÂˆÓ ·˘ÙÒÓ, Ë ÈÛÙÔÛÂÏ›‰· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÂȉÈ΋ ηÙËÁÔÚ›· ÁÈ· ÙË ÃÚfiÓÈ· ∞ÔÊÚ·ÎÙÈ΋ ¶Ó¢ÌÔÓÔ¿ıÂÈ·. ™ÙËÓ ÂÓ ÏfiÁˆ ηÙËÁÔÚ›·, ÚÔÛʤÚÂÙ·È ÏËÚÔÊfiÚËÛË Û¯ÂÙÈο Ì ÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ¿ıËÛ˘, Ù· ̤ÙÚ· ÚfiÏ˄˘, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜. ∆¤ÏÔ˜, ÛÙËÓ Î·ÙËÁÔÚ›· ÃÚ‹ÛÈ̘ ™˘Ó‰¤ÛÂȘ, Ë ÈÛÙÔÛÂÏ›‰· ÚÔÛʤÚÂÈ ÏËıÒÚ· ËÁÒÓ Î·È Û˘Ó‰¤ÛÌˆÓ Ì ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ÊÔÚ›˜ Î·È ÔÚÁ·ÓÒÛÂȘ ·fi ÙÔ ¯ÒÚÔ Ù˘ ˘Á›·˜ Î·È Ù˘ ¤Ú¢ӷ˜.
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∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ ∏ ‰È¿ÁÓˆÛË ‹Ù·Ó ‚·ÎÙËÚȷ΋ ÌËÓÈÁÁ›Ùȉ· Ì ıÚfiÌ‚ˆÛË ÂÁηÚÛ›Ô˘ ÎfiÏÔ˘. ∏ PCR ÙÔ˘ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ ‹Ù·Ó ıÂÙÈ΋ ÁÈ· ÙÔÓ ÔÚfiÙ˘Ô 6 ÙÔ˘ S. pneumoniae. ∏ ÂÈÎfiÓ· ıÚfiÌ‚ˆÛ˘ ÙÔ˘ ‰ÂÍÈÔ‡ ÂÁοÚÛÈÔ˘ ÎfiÏÔ˘ Î·È ÔÈ ÔÏϷϤ˜ ÌÈÎÚ¤˜ ‚Ï¿‚˜ ÛÙË Ï¢΋ Ô˘Û›· ÙˆÓ ‚ÚÂÁÌ·ÙÈÎÒÓ ÏÔ‚ÒÓ ı· ÌÔÚÔ‡Û·Ó Ó· ·Ô‰ÔıÔ‡Ó Û ÌÈÎÚ¤˜ ÂÚÈÔ¯¤˜ ÈÛ¯·ÈÌ›·˜, ·fiÚÚÔÈ· Ù˘ ıÚfiÌ‚ˆÛ˘ ÙˆÓ ÊÏ‚ˆ‰ÒÓ ÎfiÏˆÓ ‹/Î·È ·fiÚÚÔÈ· ·ÁÁÂÈ›Ùȉ·˜ ÛÙ· Ï·›ÛÈ· ÂÁÎÂÊ·Ï›Ùȉ·˜. ∆Ô ·È‰› Ù¤ıËΠ۠˘Ô‰fiÚÈ· ¯ÔÚ‹ÁËÛË ÂÓÔÍ··Ú›Ó˘ Î·È ·Ú¤ÌÂÈÓ ‰È·ÛˆÏËӈ̤ÓÔ ÁÈ· 6 24ˆÚ·. ∆Ë 2Ë Â‚‰ÔÌ¿‰· Ù˘ ÓfiÛÔ˘, ¤ÁÈÓ ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ô˘ ¤‰ÂÈÍ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ıÚfiÌ‚ˆÛ˘. √È ‚Ï¿‚˜ Ù˘ Ï¢΋˜ Ô˘Û›·˜ ¤ÁÈÓ·Ó ÂÌÊ·Ó¤ÛÙÂÚ˜ ÛÙȘ Û˘Ì‚·ÙÈΤ˜ ·ÎÔÏÔ˘ı›Â˜, ‰ÂÓ ÂÌÊ¿ÓÈ˙·Ó ÂÚÈÔÚÈÛÌfi Ù˘ ‰È¿¯˘Û˘ ÛÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi Î·È ÂÌÏÔ˘Ù›˙ÔÓÙ·Ó Ì ÛÎÈ·ÁÚ·ÊÈ΋ Ô˘Û›·, Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÈÛ¯·ÈÌÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Û ˘ÔÍ›· Ê¿ÛË ·ÈÌ¿ÙˆÛ˘. ™ÙËÓ Â·ÓÂͤٷÛË ÌÂÙ¿ ·fi 1 Ì‹Ó·, Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ó¤‰ÂÈÍ ˘ÊÔÏÈ΋ χÛË Ù˘ ıÚfiÌ‚ˆÛ˘ ÙÔ˘ ÂÁηÚÛ›Ô˘ ÊÏÂ‚Ò‰Ô˘˜ ÎfiÏÔ˘ Î·È ˘ÔÏÂÈÌÌ·ÙÈΤ˜ ÌÈÎÚÔ·ÏÏÔÈÒÛÂȘ ÁÏÔ›ˆÛ˘ Ï¢΋˜ Ô˘Û›·˜. √ ¤ÏÂÁ¯Ô˜ ËÎÙÈÎfiÙËÙ·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ (ÔÌÔ΢ÛÙ½ÓË, ·Ú¿ÁÔÓÙ·˜ Leyden, ÚˆÙ½ÓË S, ÚˆÙ½ÓË C, ·ÓÙÈıÚÔÌ‚›ÓË πππ, ·ÓÙÈʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù·). √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ Â›Ó·È ÎÔÈÓfi ·›ÙÈÔ ‚·ÎÙËÚȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜, ‰Â‡ÙÂÚÔ ÛÂ Û˘¯ÓfiÙËÙ·, ÌÂÙ¿ ÙÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ, Û ·È‰ÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ Ô˘ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı› ÁÈ· ·ÈÌfiÊÈÏÔ Ù˘ Áڛ˘ Ù‡Ô˘ b (1). H ıÓËÙfiÙËÙ· Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ ‰ÂÓ Â›Ó·È ·ÌÂÏËÙ¤· Î·È ÔÈ Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜. ∏ ÚfiÛÊ·ÙË ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤¯ÂÈ ÔˆÛ‰‹ÔÙÂ Û˘Ì‚¿ÏÏÂÈ ÛÙË Ì¿¯Ë ηٿ Ù˘ Ófi-
Paediatriki 2008;71:79,86
ÛÔ˘, ·fi ÙËÓ ¿ÏÏË fï˜ Ë ·Ó¿‰˘ÛË ÛÙÂϯÒÓ ·ÓıÂÎÙÈÎÒÓ ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Áã ÁÂÓ¿˜ ¤¯ÂÈ ÂÈ‚¿ÏÏÂÈ ÙËÓ ÚÔÛı‹ÎË Ù˘ ‚·ÓÎÔÌ˘Î›Ó˘ ÛÙÔ ÂÌÂÈÚÈÎfi ·ÓÙÈ‚ÈÔÙÈÎfi Û¯‹Ì· Ù˘ ÎÂÊ·ÏÔÛÔÚ›Ó˘ Áã ÁÂÓ¿˜ (2,3). ∏ ‰ÂÍ·ÌÂı·˙fiÓË ÚÔÛÙ›ıÂÙ·È Û˘¯Ó¿ ÛÙË ıÂڷ›·, ·Ó Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ Â›Ó·È Û˘˙ËÙ‹ÛÈÌË. ∏ ıÚfiÌ‚ˆÛË ÊÏ‚ˆ‰ÒÓ ÎfiÏˆÓ ÌÂÙ¿ ·fi Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ ÌËÓÈÁÁ›Ùȉ· ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÂÍ·ÈÚÂÙÈο Û¿ÓȘ ÂÚÈÙÒÛÂȘ (4,5). ¶ÚԉȷıÂÛÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ıÚfiÌ‚ˆÛË ÊÏ‚ˆ‰ÒÓ ÎfiÏˆÓ ·ÔÙÂÏ› Ë ·Ê˘‰¿ÙˆÛË, Ë ÔÔ›· Èı·ÓfiÓ, ÏfiÁˆ ÚÔËÁËı¤ÓÙˆÓ Â̤وÓ, Ó· Û˘ÓÙ¤ÏÂÛ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ıÚfiÌ‚ˆÛ˘ ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Theodoridou MN, Vasilopoulou VA, Atsali EE, Pangalis AM, Mostrou GJ, Syriopoulou VP, et al. Meningitis registry of hospitalized cases in children: epidemiological patterns of acute bacterial meningitis throughout a 32-year period. BMC Infect Dis 2007;7:101. 2. Poulakou G, Katsarolis I, Matthaiopoulou I, Tsiodras S, Kanavaki S, et al; Hellenic Study Group for the Susceptibility of Streptococcus pneumoniae. Nationwide surveillance of Streptococcus pneumoniae in Greece: patterns of resistance and serotype epidemiology. Int J Antimicrob Agents 2007;30:87-92. 3. Levidiotou S, Vrioni G, Tzanakaki G, Pappa C, Gesouli H, Gartzonika C, et al. Serotype distribution of Streptococcus pneumoniae in north-western Greece and implications for a vaccination programme. FEMS Immunol Med Microbiol 2006;48:179-182. 4. Jorens PG, Parizel PM, Wojciechowski M, Laridon A, De Weerdt A, Mertens G, et al. Streptococcus pneumoniae meningoencephalitis with unusual and widespread white matter lesions. Eur J Paediatr Neurol 2007 [Epub ahead of print]. 5. Chatterjee T, Gowardman JR, Goh TD. Pneumococcal meningitis masquerading as subarachnoid haemorrhage. Med J Aust 2003;178:505-507.
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15-16 ºÂ‚ÚÔ˘·Ú›Ô˘ 2008 ∂ÓÙ·ÙÈ΋ ∂η›‰Â˘ÛË: 11Ô˜ ∫‡ÎÏÔ˜ “¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏÔÁ›·” ¶ÏËÚÔÊÔڛ˜: ∂ÏÏËÓÈ΋ ∂Ó‰ÔÎÚÈÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ¶·ÓÂÏÏ‹ÓÈ· ŒÓˆÛË ∂Ó‰ÔÎÚÈÓÔÏfiÁˆÓ TËÏ.: 0030-210-7774370, 7474046 Fax: 0030-210-7701552 E-mail: info@endo.gr Website: www.endo.gr
∞ı‹Ó·
15-16 ºÂ‚ÚÔ˘·Ú›Ô˘ 2008 Primer Simposio Internacional de Nutricion Neonatal Contact: Meeting Organiser Tel.: 57-63-354-923 E-mail: theobeltran@yahoo.com
Bogota, Colombia
23-24 ºÂ‚ÚÔ˘·Ú›Ô˘ 2008 Caribean ASCLEPIOS - IXth Congress about Mother & Child Health Contact: Kamel Bargaoui Tel.: 33-607-686-118 Fax: 33-143-839-985 E-mail: Kamel@medicom-international.com
Cancun, Mexico
28 ºÂ‚ÚÔ˘·Ú›Ô˘ 2008
Child Protect: Current Issues in Child Abuse and Neglect II Contact: Dr Desaline Joseph Simon Tel./Fax: 44-0-8-700-416-215 E-mail: info@medupdate.co.ul
Leicester, United Kingdom
1 ª·ÚÙ›Ô˘ 2008
17Ô ∂ÓËÌÂÚˆÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ “∂›Î·ÈÚ· ¶·È‰È·ÙÚÈο £¤Ì·Ù·” ¢ÈÔÚÁ¿ÓˆÛË: ¢ã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ °¡£ “°. ¶··ÁˆÚÁ›Ô˘” ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress TËÏ.: 0030-2310-256194/5 Fax: 0030-2310-256196 E-mail: salonica@triaenatours.gr Website: www.triaenatours.gr
∞›ıÔ˘Û· ∆ÂÏÂÙÒÓ ∞.¶.£., £ÂÛÛ·ÏÔÓ›ÎË
8-9 ª·ÚÙ›Ô˘ 2008
5Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ ¶·È‰È·ÙÚÈ΋˜ •ÂÓÔ‰Ô¯Â›Ô ¶ÏËÚÔÊÔڛ˜: AC&C International “Hilton”, ∞ı‹Ó· TËÏ.: 0030-210-6889130 Fax: 0030-210-6844777 E-mail: ped-subspec@acnc.gr Website: www.ped-subspec.gr
10-14 ª·ÚÙ›Ô˘ 2008
Gynaecology, Neonatology, Paediatrics: Deepening and Comparing Contact: Tivigest Sagl Tel.: 41-818-375-830 Fax: 41-818-375-831 E-mail: info@neonatologia.net
St. Moritz, Switzerland
27-30 ª·ÚÙ›Ô˘ 2008
PCICS Europe 2008 - European Symposium of the Pediatric Cardiac Intensive Care Society Contact: Secretariat Tel.: 41-229-080-488 ext 275 Fax: 41-227-322-850 E-mail: pcics@kenes.com
Monte Carlo, Monaco
Pediatri Jan-Feb 08
15-02-08
11:00
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4-6 ∞ÚÈÏ›Ô˘ 2008
2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¡ÂÔÁÓÔÏÔÁ›·˜ ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Î·È ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶ÂÚÈÁÂÓÓËÙÈ΋˜ π·ÙÚÈ΋˜ ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress ∆ËÏ.: 0030-210-7499300 Fax: 0030-210-7705752 E-mail: info@neonatology2008.gr Website: http://www.neonatology2008.gr
∞›ÁÏË ∑·Â›Ô˘, ∞ı‹Ó·
5 ∞ÚÈÏ›Ô˘ 2008
ªÂÙÂÎ·È‰Â˘ÙÈ΋ ∏ÌÂÚ›‰· ¶·È‰È·ÙÚÈο ∂›ÁÔÓÙ· & µ·ÛÈ΋ YÔÛÙ‹ÚÈÍË ∑ˆ‹˜ ¢ÈÔÚÁ¿ÓˆÛË: π·ÙÚÈÎfi˜ ™‡ÏÏÔÁÔ˜ ∞ıËÓÒÓ Î·È ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ¶ÏËÚÔÊÔڛ˜: ∞Ó·ÛÙ¿ÛÈÔ˜ ¢. ÷Ù˙‹˜ ∆ËÏ.: 0030-210-7488686 Website: www.isathens.gr
∞›ıÔ˘Û· ∂ΉËÏÒÛÂˆÓ π·ÙÚÈÎÔ‡ ™˘ÏÏfiÁÔ˘ ∞ıËÓÒÓ, ∞ı‹Ó·
19 ∞ÚÈÏ›Ô˘ 2008
6Ë ∂ÈÛÙËÌÔÓÈ΋ ∏ÌÂÚ›‰· ∂˘ÚˆÎÏÈÓÈ΋˜ ¶·›‰ˆÓ “™‡Á¯ÚÔÓ· ¶·È‰È·ÙÚÈο £¤Ì·Ù·” ¶ÏËÚÔÊÔڛ˜: Firstevent TËÏ.: 0030-210-8228950 Fax: 0030-210-8228901 E-mail: info@firstevent.gr
•ÂÓÔ‰Ô¯Â›Ô “Royal Olympic”, ∞ı‹Ó·
5-11 ª·˝Ô˘ 2008
XXIth European Society of Pediatric Neurosurgery (ESPN) Meeting Contact: Meeting Organiser E-mail: info@espn2008.org
Montreux, Switzerland
9-11 ª·˝Ô˘ 2008
13Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘ÌfiÛÈÔ √ÚıԷȉÈ΋˜ ¶·›‰ˆÓ ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ÃÂÈÚÔ˘ÚÁÈ΋˜ √ÚıԷȉÈ΋˜ & ∆Ú·˘Ì·ÙÔÏÔÁ›·˜ ∆Ì‹Ì· √ÚıԷȉÈ΋˜ ·›‰ˆÓ ¶ÏËÚÔÊÔڛ˜: ∫∂°ª ∆Ô˘ÚÈÛÙÈΤ˜ & ™˘Ó‰ÚȷΤ˜ ∂ȯÂÈÚ‹ÛÂȘ ∞∂ - Congress World - ª. ¶···Ó·ÁÈÒÙÔ˘ TËÏ.: 0030-210-7210052, 7210001 Fax: 0030-210-7210051 E-mail: info@congress@goldair.gr
•ÂÓÔ‰Ô¯Â›Ô “Olympian Village Aldemar”, ™Î·Êȉȿ
15-17 ª·˝Ô˘ 2008
9th Congress of the European Society for Pediatric Dermatology ¶ÏËÚÔÊÔڛ˜: Erasmus, η ¶ËÓÂÏfiË ªËÙÚÔÁÈ¿ÓÓË Tel.: 0030-210-7257693 Fax: 0030-210-7257532 E-mail: info@espd2008.com
∞ı‹Ó·
2-4 πÔ˘Ó›Ô˘ 2008
Perinatal Medicine 2008 Contact: Kate Melton Tel.: 02-0-89-798-300 Fax: 02-0-89-796-700 E-mail: kmelton@hamptonmedical.com
Harrogate, England, United Kingdom
13-15 πÔ˘Ó›Ô˘ 2008
46Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: AC&C International ∆ËÏ.: 0030-210-6889130 Fax: 0030-210-6844777 E-mail: pedcongress@acnc.gr Website:www.pediatric-congress.gr
COREXPO ∂ÎıÂÛÈ·Îfi ∫¤ÓÙÚÔ ∫¤Ú΢ڷ˜, ∫¤Ú΢ڷ