Pediatri Mar-Apr 08
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ISSN 0377-2551
™ÂÏ›‰·1
¶·È‰È·ÙÚÈ΋ ∆fiÌÔ˜ 71 ñ ∆‡¯Ô˜ 2 ñ ª¿ÚÙÈÔ˜-∞Ú›ÏÈÔ˜ 2008
¶ÂÚȯfiÌÂÓ· ∞¡∞™∫O¶∏™∂π™ 87 Paediatric liver transplantation: historical notes G. C. Sotiropoulos, S. Nadalin, A. Radtke, H. Lang 92 Childhood obesity – ∞ public health crisis across the European Union A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso 96 Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity M. Ponce-Rivera, D. Fuentes-Lugo
141 ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿: ÂÌÂÈÚ›· 15 ÂÙÒÓ Û ¤Ó· ΤÓÙÚÔ Ÿ. µÚ¿ÓË, ª. ¶·ÓÙÈΛ‰Ô˘, °. ÿÌ‚ÚÈÔ˜, π. •˘ÓÈ¿˜, µ. ¢ÂÌÂÚÙ˙›‰Ô˘, ∫. ∫¿ÓÙ˙ÈÔ˘, ∞. ª·˘ÚÔ˘‰‹, ¢. ∆·ÎÔ‡‰·˜, £. ¶··ÛÙ·‡ÚÔ˘, ∫. ™‡ÚÔÁÏÔ˘ 148 √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ µ. ∆ÛÈ¿ÓÙÔ˘, ∞. ∫·Úfi΢, ∂. ¶¿‚Ë, °. ∫˘ÚÈfiÔ˘ÏÔ˜ ¶ƒ∞∫∆π∫√ £∂ª∞ 157 ¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ÁÈ· ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ ∞. ∫·Ê¿ÙÔ˜
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162 Recurrent Respiratory Papillomatosis: case report and literature review D. A. Nunez
123 ∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ E. ∫Ô‡ÛÙ·, ∞. ¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘† ∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 128 ∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ ª. ¶··‰ÔÔ‡ÏÔ˘, ™. ¡ÙÔ˘Ì¿, ∫. ∫›ÙÛÈÔ˜, ¡. ∫·‰fiÁÏÔ˘, ∫. ∫ÒÛÙ·, π. ∆ÛÈÔ‡Ú˘ 135 ªÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi Èfi Epstein-Barr Î·È ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË, ∞. ºÏ¤‚·, µ. ∞ÓÙ¿ÚË, ∞. ¶·˘Ï›ÙÔ˘-∆ÛÈfiÓÙÛË, ª. ªÔÛÎÔÊ›‰Ë˜, °. µ·ÚÏ¿Ì˘
165 ∫§π¡π∫√ ∫√Àπ∑ ¶. ™ËÊÈ·ÓÔ‡, ∫. ºˆÙ›Ô˘, ∫. ™ÎÈ·‰¿˜, ∫. ¶··Á·ÚÔ˘Ê¿Ï˘ ∂¶I∫∞πƒ√ £Eª∞ 166 ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ 171 ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ 2008 E. °·Ï·Ó¿Î˘ ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ 173 ™‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ ‰È·‰›ÎÙ˘Ô ∫. ™ÙÂÊ·Ó›‰Ë˜
Pediatri Mar-Apr 08
08-04-08
11:51
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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 2 ñ March-April 2008
Contents REVIEW ARTICLES 87 Paediatric liver transplantation: historical notes G. C. Sotiropoulos, S. Nadalin, A. Radtke, H. Lang 92 Childhood obesity – ∞ public health crisis across the European Union A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso 96 Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity M. Ponce-Rivera, D. Fuentes-Lugo 105 Basic techniques of molecular biology and their applications in the diagnosis of childhood diseases S. Megremis, A. Pampanos 116 New aspects of infant nutrition C. Costalos 123 Indications for administering growth hormone to children and adolescents E. Kousta, A. Papathanassiou, C. Hadjiathanassiou† ORIGINAL ARTICLES 128 Final height of children with growth hormone deficiency who received replacement treatment M. Papadopoulou, S. Douma, ∫. ∫itsios, ¡. ∫adoglou, ∫. ∫osta, π. Tsiouris 135 Study of the immunophenotype of peripheral blood lymphocyte subsets in children with Epstein-Barr virus and cytomegalovirus infection: association with outcome ∂. Papadopoulou-Alataki, ∞. Fleva, V. Antari, ∞. Pavlitou-∆siontsi, ª. Moskofidis, G. Varlamis
141 Liver transplantation in children: 15 years experience in one center O. Vrani, ª. Pantikidou, G. Imvrios, π. Xinias, V. Demertzidou, ∫. ∫antziou, ∞. Mavroudi, D. Takoudas, T. Papastaurou, ∫. Spyroglou 148 Economic evaluation of new vaccines against varicella, serogroup C meningococcus and pneumococcus V. ∆siantou, ∞. ∫arokis, ∂. Pavi, G. ∫yriopoulos PRACTICAL ISSUE 157 Childhood and adolescent nutrition for promoting health and growth and preventing chronic diseases ∞. ∫afatos CASE REPORT 162 Recurrent Respiratory Papillomatosis: case report and literature review D. A. Nunez 165 CLINICAL QUIZ P. Sifianou, ∫. Fotiou, ∫. Skiadas, ∫. Papagaroufalis CURRENT ISSUE 166 National Immunization Programme PAEDIATRIC NEWS IN BRIEF 171 National Immunization Programme 2008 E. Galanakis NEWS FROM THE INTERNET 173 Paediatric news in brief at the internet C. Stefanidis
Pediatri Mar-Apr 08
07-04-08
16:22
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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
Nikolai Shabalov, St. Petersburg, Russia
Richard N. Fine, Stony Brook, USA
Alan Sinaiko, Minneapolis, USA
Margaret C. Fisher, Philadelphia, USA
Nick J. Spencer, Coventry, UK
Raif Geha, Boston, USA
Alfred Tenore, Udine, Italy
Adenike Grange, Lagos, Nigeria
Alkis Togias, Bethesda, USA
Judith G. Hall, Vancouver, Canada
Eva Tsalikian, Iowa City, USA
Patricia Hamilton, London, UK
Catherine Weil-Olivier, Paris, France
Enver Hasanoglu, Ankara, Turkey
Max Zach, Graz, Austria
Christer Holmberg, Helsinki, Finland
Zheng-Yan Zhao, Hangzhou, China
Lewis B. Holmes, Boston, USA
Johannes Zschocke, Heidelberg, Germany
v
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07-04-08
16:23
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∞¡∞™∫√¶∏™∏
REVIEW ARTICLE
87
Paediatric liver transplantation: historical notes G. C. Sotiropoulos1,2, S. Nadalin2, A. Radtke1,2, H. Lang1,2 Abstract: Liver transplantation (LT) is now a standard treatment for children with end-stage liver disease, with very good 1- and 5-year survival rates, which have been achieved through the constant improvement of surgical techniques and clinical management, and use of new immunosuppressive drugs. The indications for LT in infants and children include acute liver failure, chronic liver failure with pruritus, complications of cholestasis and failure to thrive. In young children the most common liver disease leading to transplantation is biliary atresia, which accounts for at least 50% of all LTs in children and is characterized by the failure of the bile ducts to develop normally and drain bile from the liver. Although the majority of transplanted children enjoy an excellent quality of life, there are still many possible complications, including short-term primary non-function, vascular and biliary problems, bowel perforation, severe rejection, infection, hypertension with long-term renal impairment, chronic rejection, de novo autoimmunity, lymphoproliferative disease and cancer, most of which are related to anti-rejection drug toxicity. This paper focuses on the historical development of surgical techniques in the era of paediatric LT. Key words: Liver transplantation, paediatric transplant programme, split liver, living donor liver
1 Department of General, Abdominal and Transplant Surgery, University Hospital, Johannes Gutenberg University Mainz, Germany 2 Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany Correspondence: Georgios C. Sotiropoulos sotiropoulos@ach.klinik. uni-mainz.de Klinik für Allgemein-, Abdominal- und Transplantationschirurgie, Klinikum der Johannes Gutenberg Universität Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
transplantation, split techniques, liver insufficiency, liver failure, biliary atresia.
Introduction Paediatric liver transplantation (LT) is an established method of treatment for patients with end-stage liver failure. Its mortality has decreased dramatically since its first description, thanks to new strategies for immunosuppression, new surgical techniques (1,2), and the improved overall condition of the patients prior to transplantation. The introduction of the splitliver (SL) techniques has dramatically improved the problem of organ shortage (3,4). Full-Size LT The first clinical attempt at liver replacement was made by Starzl on March 1st, 1963 on a 3 year-old child who had developed end-stage liver disease from biliary atresia, but “he bled to death as we worked desperately to stop the haemorrhage. The operation could not be completed” (5). This attempt was followed in 1963 by transplantation of livers into four adult patients, who all died from pulmonary embolism, after otherwise successful transplants. Starzl performed the next eight LTs in infants and children (6) all of whom survived surgery, but four died after 2-6 months from sepsis. This series of fatal complications was attributed to inadequate immunosuppression, followed by rejection. Between March 1963 and July 1976, 111 LTs were performed at the University of Colorado, but with a 1-year survival rate of only 28%. Such poor results were attributed to technical and medical problems (80%)
and acute rejection (20%) (7). From July 1976 to December 1977, following technical and diagnostic improvements the paediatric 1-year survival rate doubled from 34 to 62%. Based on these improved results, the development of other LT centres was undertaken. In Europe, the first attempt at LT was made on a 10 month-old child with biliary atresia on June 6th, 1968 in Cambridge, UK, by Sir Roy Calne. As with Starzl’s first attempt, the child died during surgery. The first successful LT in Europe was performed by Otte et al. on March 17th, 1971 on a 17 month-old boy with biliary atresia. The recovery was uneventful until the child developed acute rejection, which was reversed by steroids, but he died 7 weeks after transplantation from massive intrathoracic bleeding caused by a liver biopsy (8). Following this case, as in the USA, there was a long-term moratorium before the LT programme was finally resumed in 1984. The four children transplanted that year are still alive, including the first patient who received a reduced liver graft and who is currently, worldwide, the longest survivor with her original cut-down liver (9). All the early LT patients were treated with a drug regimen that had been developed for kidney grafts, namely azathioprine and steroids, sometimes with the addition of antilymphocyte globulins. Because of inadequate immunosuppression, long-term survival was observed in less than one third of patients. At the beginning of the 1980s, the introduction of cyclosporine led to a ¶·È‰È·ÙÚÈ΋ 2008;71:87-91
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Figure 1a. Adult split liver transplantation Right versus left liver split for an adult recipient, 3-dimensional reconstruction. Right graft segments 5-8 (green), left graft segments 1-4 (brown). RHV-right hepatic vein (blue), MHV-middle hepatic vein (yellow), LHV-left hepatic vein (red).
Figure 1b. Adult split liver transplantation Right versus left liver split for an adult recipient, 3-dimensional reconstruction of the hepatic veins. The line of division lies exactly over the MHV-middle hepatic vein (yellow). RHV-right hepatic vein (blue), LHV-left hepatic vein (red).
significant increase of graft and patient survival rates. In March 1980, the liver trials with cyclosporine A immunosuppression began in Denver. Twelve patients entered the study between March and September 1980, of whom 11 lived for one year or longer (10). In October 1986 representatives of the eight centres in Europe and the USA with experience of at least 20 paediatric LTs (i.e., Boston, Brussels, Cambridge, Dallas, Hannover, Minneapolis, Pittsburgh and Los Angeles) met for an update on the status of paediatric LT: long-term (>1 year) patient survival had reached 57-83%; all centres were using cyclosporine-based primary immunosuppression; the major indications biliary atresia being the most frequent - were already clearly delineated. Since the implementation of LT for end-stage liver disease there has been a strong disparity between organ demand and the cadaveric donor supply for children. This initially resulted in a pre-transplant mortality for
children on the waiting list for LT of around 25%, which was disproportionably high compared with that of adult patients (11). The problem of size mismatch and the different epidemiology of paediatric donorship and terminally diseased children were responsible for the disparity (12). This stimulated the development of technical innovations, based on the segmental anatomy of the liver, which facilitated transplanting parts of a large cadaveric donor liver into smaller recipients: i.e. reduced size LT, split LT and living donor LT.
Reduced size liver transplantation (RSLT) The first step in solving the size mismatch problem was the introduction of reduced-size techniques. With this approach, after harvesting the liver from a cadaver donor, liver resection is performed on the back table to tailor the size of the graft to that of one single recipient. The remaining resected liver tissue is discarded. In paediatric RSLT either the left lateral
Figure 1c. Adult split liver transplantation Left liver graft segments 1-4 for an adult recipient, 3-dimensional reconstruction. The right-sided border of the MHV-middle hepatic vein (yellow) can be seen exposed on the transection surface. All tributaries from segments 5 and 8 are exposed at their confluence with the MHV trunk. RHV-right hepatic vein (blue), LHV-left hepatic vein (red).
Figure 1d. Adult split liver transplantation Right liver graft segments 5-8 for an adult recipient, 3-dimensional reconstruction. The left-sided border of the MHV-middle hepatic vein (yellow) can be seen exposed on the transection surface. All tributaries from segments 4a and 4b are exposed at their confluence with the MHV trunk. RHV-right hepatic vein (blue), LHV-left hepatic vein (red).
Paediatriki 2008;71:87-91
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Paediatric liver transplantation
Figure 2a. Pediatric split liver transplantation Left lateral liver split for a child, 3-dimensional reconstruction of the hepatic vein anatomy. Graft segments 2-3 (brown), remnant segments 1,4-8 (green), RHV-right hepatic vein (blue), MHVmiddle hepatic vein (yellow), LHV-left hepatic vein (red).
segment (Couinaud's segments II-III) or the full left lobe (Couinaud's segments II-IV) is usually retained. The technique as originally described by Bismuth and Houssin (13) was validated in the late 1980s and later became standard practice worldwide with 1-year survival rates of about 80% (14-18). Although RSLT increases the number of paediatric donor organs, it does not increase the total number of organs available for LT, and indeed, it is actually disadvantageous to the adult recipient pool, which is continuously growing (19).
Split liver transplantation (SLT) The disadvantage of RSLT, namely, a discarded liver segment, was solved by the introduction of split liver techniques. SLT evolved from the RSLT and was first described by Pichlmayr (20). This technique allowed the preparation of two split grafts by dividing all vascular and biliary structures and parenchyma for the benefit of two recipients, one recipient receiving a right lobe graft, and the other receiving either a left lobe (segments 2-4, Figure 1) or left lateral segment
Figure 2c. Pediatric split liver transplantation Left lateral graft (segments 2-3) including LHV-left hepatic vein (red) for a child, 3-dimensional reconstruction. RHV-right hepatic vein (blue), MHV-middle hepatic vein (yellow) remained with the remnant liver.
Figure 2b. Pediatric split liver transplantation Left lateral liver split for a child, 3-dimensional reconstruction of the hepatic veins. The line of division lies exactly over the LHV-left hepatic vein (red). Main tributaries of the MHV-middle hepatic vein (yellow) draining segments IVa/IVb in the remnant liver are preserved. RHV-right hepatic vein (blue).
graft (segments 2-3, Figure 2). Usually the right lobe is transplanted into an adult and the left lobe or the left lateral segment into a child. In 1989, Pichlmayr and colleagues were the first to report the transplantation of one donor liver into two recipients (20,21). The first series was reported by Broelsch and co-workers at the University of Chicago (22) and in the early 1990s the technique was further validated (23-25). Technically, SLT is a complex procedure that can be performed in two ways, ex situ or in situ, both of which require precise knowledge of the liver anatomy and extensive experience with liver resection techniques and all the technical modalities of liver graft implantation. Unfortunately, the wider application of the split technique is still hindered by the lack of experience and unwillingness of some centres to split every suitable donor liver (26). Recent comprehensive studies confirm that SLTs generally lead to less favourable results for individual recipients, but they
Figure 2d. Pediatric split liver transplantation Remnant liver (segments 1,4-8) including RHV-right hepatic vein (blue) and MHV-middle hepatic vein (yellow) after retrieval of a left lateral liver graft (segments 2-3) including LHV-left hepatic vein (red) for a child, 3-dimensional reconstruction. ¶·È‰È·ÙÚÈ΋ 2008;71:87-91
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also result in more individuals deriving the benefit of LT. While initially holding great promise and being adopted as standard policy by many paediatric transplant centres, early experience demonstrated a higher incidence of technical complications and decreased graft and patient survival rates in recipients of right lobe grafts. Unfortunately, relevant extensive, detailed data on this issue are not yet available.
Living donor liver transplantation (LDLT) The development of LDLT in the USA and Europe has been driven by the shortage of donor organs in spite of the use of innovative techniques for cadaveric LT, such as RSLT and SLT (27). In Japan, where organ procurement from brain-dead donors was not legal until recently, LDLT was the only option. LDLT was first reported by Raia et al. in two patients in 1989 (28). Both recipients died shortly after the procedure of medical complications, but lived long enough for the technical feasibility of the procedure to be established. This was soon followed by a report from Strong et al. in Australia, where the first successful LT of a child using its mother's left lobe was performed in July 1989 (29). Even before the initial reports by Raia and Strong, an extensive ethical appraisal of the concept of LDLT was in progress at the University of Chicago, where clinical ethicists and transplant physicians convened a yearlong series of seminars and discussions open to the entire university community (30). The introduction of LDLT required a balance between the presumed benefits of an elective transplant for the recipient and the risk of morbidity or even mortality from LDLT for the donor. At the outset the main ethical problems the Chicago group had to deal with for the introduction of paediatric LDLT were the principle of equipoise and the principle of coercion (30,31). A proposal derived from these meetings was submitted to the institutional review board and a successful LDLT was performed in November 1989 by Dr. Broelsch, who subsequently initiated the systematic use of LDLT for children with end-stage liver disease (32). Between November 1989 and July 1996, 100 LDLTs were performed, with 1-year patient and graft survival rates of 88% and 72%, respectively. Similar results were reproduced worldwide, confirming the effectiveness of the procedure (33,34). LDLT has several advantages for the child and for the transplant population as a whole. First, it increases the number of organs directly available for the paediatric population. Second, most recipients receive their transplants on an elective basis and thus should incur lower morbidity and mortality rates and decreased overall cost. Third, the minimal cold ischaemia time Paediatriki 2008;71:87-91
and the use of healthy donors may contribute to the absence of primary non-function. The application of LDLT for children with end-stage liver disease had a profound impact on organ waiting list times and decreased waiting list mortality markedly (35). Paediatric LDLT is now accepted therapy for children throughout the world and frequently accounts for 50% or more of all paediatric LTs performed at regional referral centres (35). Despite the impressive results of LDLT, considerable debate persists concerning donor safety. The risks to the donor include those associated with invasive pre-surgical testing and with the surgical procedure. These risks are accepted by the potential donors in exchange for the knowledge that the child's life may be saved without the uncertainty of the cadaveric waiting list. The most recent donor outcomes from multiple centres have been excellent (36-38). The development of segmental hepatic grafts has expanded the supply of size-appropriate organs, allowing children who otherwise would have died on the waiting list the opportunity to undergo LT. Recently the association between graft type, recipient age and graft survival has been better defined: among children <3 years of age, LDLT provides superior graft survival compared to RLT and SLT. In older children it appears that cadaveric organs may offer a better outcome (39,40). While RLT and SLT grafts produce an overall inferior outcome in the national experience, they remain an important and necessary tool in paediatric centre armamentarium. They provide appropriately sized grafts for children with no suitable living donor and for those for whom no cadaveric paediatric donor is available, and they can yield an excellent outcome in experienced centres. It is apparent that the technical complexities and perioperative events surrounding these procedures have a significant impact on the outcome. This emphasizes the importance of experience, attention to continued technical refinement, and judicious selection of appropriate donors for specific recipients.
References 1. Kim JS, Grotelüschen R, Mueller T, Ganschow R, Bicak T, Wilms C, et al. Pediatric transplantation: the Hamburg experience. Transplantation 2005;79:1206-1209. 2. Burdelski MM, Rogiers X. What lessons have we learned in pediatric liver transplantation? J Hepatol 2005;42:28-33. 3. Rogiers X, Malagfi M, Gawad K, Jauch KW, Olausson M, Knoefel WT, et al. In situ splitting of cadaveric livers. The ultimate expansion of a limited donor pool. Ann Surg 1996;224:331-339. 4. Ringe B, Burdelski M, Rodeck B, Pichlmayr R. Experience with partial liver transplantation in Hannover. Clin Transpl 1990;4:135-144.
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5. Starzl TE. The Puzzle People: Memoirs of a Transplant Surgeon. Pittsburgh, Pennsylvania: University of Pittsburgh Press; 1992. 6. Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, et al. Orthotopic homotransplantation of the human liver. Ann Surg 1968;168:392-415. 7. Starzl TE, Koep LJ, Halgrimson CG, Hood J, Schroter GP, Porter KA, et al. Fifteen years of clinical liver transplantation. Gastroenterology 1979;77:375-388. 8. Otte JB. History of pediatric liver transplantation. Where are we coming from? Where do we stand? Pediatr Transplant 2002;6:378-387. 9. Otte JB, de Ville de Goyet J, Sokal E, Alberti D, Moulin D, de Hemptinne B, et al. Size reduction of the donor liver is a safe way to alleviate the shortage of size-matched organs in pediatric liver transplantation. Ann Surg 1990;211:146-157. 10. Starzl TE, Klintmalm GB, Porter KA, Iwatsuki S, Schröter GP. Liver transplantation with use of cyclosporin a and prednisone. N Engl J Med 1981;305:266-269. 11. Malagfi M, Rogiers X, Broelsch CE. Reduced-size hepatic allografts. Annu Rev Med 1995;46:507-512. 12. Emond JC, Whitington PF, Thistlethwaite JR, Alonso EM, Broelsch CE. Reduced-size orthotopic liver transplantation: use in the management of children with chronic liver disease. Hepatology 1989;10:867-872. 13. Bismuth H, Houssin D. Reduced-sized orthotopic liver graft in hepatic transplantation in children. Surgery 1984; 95:367-370. 14. Strong R, Ong TH, Pillay P, Wall D, Balderson G, Lynch S. A new method of segmental orthotopic liver transplantation in children. Surgery 1988;104:104-107. 15. Broelsch CE, Emond JC, Thistlethwaite JR, Whitington PF, Zucker AR, Baker AL, et al. Liver transplantation, including the concept of reduced-size liver transplants in children. Ann Surg 1988;208:410-420. 16. Broelsch CE, Emond JC, Thistlethwaite JR, Rouch DA, Whitington PF, Lichtor JL. Liver transplantation with reduced-size donor organs. Transplantation 1988;45:519-524. 17. Ringe B, Pichlmayr R, Burdelski M. A new technique of hepatic vein reconstruction in partial liver transplantation. Transpl Int 1988;1:30-35. 18. Ong TH, Lynch SV, Pillay SP, Balderson GA, Wall DR, Shepherd R, et al. Reduced-size orthotopic liver transplantation in children: an experience with seven cases. Transplant Proc 1989;21:2443-2444. 19. Busuttil RW, Goss JA. Split liver transplantation. Ann Surg 1999;229:313-321. 20. Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. [Transplantation of a donor liver to 2 recipients (splitting transplantation)--a new method in the further development of segmental liver transplantation]. Langenbecks Arch Chir 1988;373:127-130. 21. Pichlmayr R, Bretschneider HJ, Kirchner E, Ringe B, Lamesch P, Gubernatis G, et al. [Ex situ operation on the liver. A new possibility in liver surgery]. Langenbecks Arch Chir 1988;373:122-126. 22. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg 1990; 212: 368-375.
23. Bismuth H, Morino M, Castaing D, Gillon MC, Descorps Declere A, Saliba F, et al. Emergency orthotopic liver transplantation in two patients using one donor liver. Br J Surg 1989;76:722-724. 24. Otte JB, de Ville de Goyet J, Alberti D, Balladur P, de Hemptinne B. The concept and technique of the split liver in clinical transplantation. Surgery 1990;107:605-612. 25. Otte JB, de Ville de Goyet J, Reding R, Van Obbergh L, Veyckemans F, Carlier MA, et al. Pediatric liver transplantation: from the full-size liver graft to reduced, split, and living related liver transplantation. Pediatr Surg Int 1998; 13:308-318. 26. Colledan M, Segalin A, Spada M, Lucianetti A, Corno V, Gridelli B. Liberal policy of split liver for pediatric liver transplantation. A single centre experience. Transpl Int 2000;13:S131-133. 27. Trotter JF, Wachs M, Everson GT, Kam I. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002;346:1074-1082. 28. Raia S, Nery JR, Mies S. Liver transplantation from live donors. Lancet 1989;2:497. 29. Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y, Balderson GA. Successful liver transplantation from a living donor to her son. N Engl J Med 1990;322:1505-1507. 30. Singer PA, Siegler M, Whitington PF, Lantos JD, Emond JC, Thistlethwaite JR, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321:620-622. 31. Singer PA, Lantos JD, Whitington PF, Broelsch CE, Siegler M. Equipoise and the ethics of segmental liver transplantation. Clin Res 1988;36:539-545. 32. Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite JR, Stevens L, et al. Liver transplantation in children from living related donors. Surgical techniques and results. Ann Surg 1991;214:428-437. 33. Reding R, de Goyet Jde V, Delbeke I, Sokal E, Jamart J, Janssen M, et al. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts. J Pediatr 1999;134: 280-286. 34. Inomata Y, Tanaka K, Uemoto S, Asonuma K, Egawa H, Kiuchi T, et al. Living donor liver transplantation: an 8year experience with 379 consecutive cases. Transplant Proc 1999;31:381. 35. Emond JC, Heffron TG, Kortz EO, Gonzalez-Vallina R, Contis JC, Black DD, et al. Improved results of living-related liver transplantation with routine application in a pediatric program. Transplantation 1993;55:835-840. 36. Renz JF, Roberts JP. Long-term complications of living donor liver transplantation. Liver Transpl 2000;6:S73-76. 37. Lo CM. Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 2003;75:S12-15. 38. Nadalin S, Heuer M, Wallot M, Auth M, Schaffer R, Sotiropoulos GC, et al. Paediatric acute liver failure and transplantation: the University of Essen experience. Transpl Int. 2007;20:519-527. 39. Emond JC. Living donor liver transplantation in children: what to recommend? Am J Transplant 2004;4:293-294. 40. Abt PL, Rapaport-Kelz R, Desai NM, Frank A, Sonnad S, Rand E, et al. Survival among pediatric liver transplant recipients: impact of segmental grafts. Liver Transpl 2004;10: 1287-1293.
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REVIEW ARTICLE
Childhood obesity – A public health crisis across the European Union Primary / Secondary Care Group of the European Academy of Paediatrics
A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso
Correspondence: Alf Nicholson alf.nicholson@maile.hse.ie Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland
has become the primary paediatric health issue in the EU. It is known that some 10% of children are either overweight or obese, and that obesity worldwide, apart from in sub-Saharan Africa, has reached epidemic proportions, with a threefold or more rise in most European countries since the 1980s (1,2,14,18). The main causes of the obesity epidemic are clear - overeating, especially of foods rich in fats, extracted sugars or refined starches, and a progressive decline in physical activity. The management of this epidemic depends on the successful motivation of people to eat less, to eat healthier foods and to exercise more, all of which are difficult to achieve in societies where fruit and vegetables are less available than high-fat processed foods, and where exercise no longer plays a regular part in most people’s lives. Management of childhood obesity is time-consuming, frustrating, difficult and expensive (18). Adult obesity is the strongest predictor of childhood obesity; if both parents are obese, the chance of their child being obese increases tenfold. Breast feeding exerts a small protective effect against obesity. Television viewing is important, as it is known that for each additional hour of television watched at 5 years of age, the risk of adult obesity rises by 8% (7,8,18). Long-term increase or decrease in activity levels will influence whether a child becomes obese. Studies have implicated inactivity, with over 4 hours TV or computer use, and consumption of takeaway foods more than twice weekly and fizzy drinks in the rising rates of obesity. Prevention of obesity will occur only if there are fundamental changes in society, involving the production and availability of cheap healthy foods, urban planning to ensure that people exercise more, education about eating, beginning in schools, and a global code to promote only healthy food and drink to children and adolescents. The vast majority of obese children have primary obesity due to a disturbed energy balance. A very small percentage (5%) have a genetic cause for their obesity, and only very rarely are hormonal causes found.
Abstract: In the past, a fat child meant a healthy child, but in the last decade, excessive fatness or obesity
Key words: Childhood obesity, epidemiology, management, prevention.
The definition of childhood obesity The Body Mass Index (BMI) is the most practical measure of obesity and it is used in growth monitoring to assess fatness. The BMI charts for boys and girls (Tables 1 and 2) show the recommended International Obesity Task Force cut-off points for obesity and overweight in children. These correspond to the adult definitions of overweight (BMI >25) and obesity (BMI >30) at age 18 years. Rapid changes in BMI can occur during normal growth. The BMI is recommended as a practical estimate of overweight in children and adolescents, but it needs to be interpreted with caution as it is not a direct measure of adiposity. For epidemiological purposes overweight should be defined as BMI greater than or equal to the 85th centile of the 1990 reference data, and obesity as BMI greater than or equal to the 95th centile of the 1990 reference data. The international epidemic of childhood obesity The definitions of overweight and obesity in children differ between epidemiological studies, Paediatriki 2008;71:92-95
making comparisons of cross-sectional data difficult. The rates have increased threefold over 25 years in the USA and fourfold over 18 years in Egypt (see the international childhood obesity map) (1,2).
Consequences of childhood obesity Childhood obesity is a multisystem disease with potentially devastating consequences. It causes hypertension, dyslipidaemia, increased blood clotting tendency, endothelial dysfunction and hyperinsulinism. Type 2 diabetes mellitus, once virtually unknown in adolescence, is largely attributable to childhood obesity (4). A prediabetic state of glucose intolerance and insulin resistance appears to be highly prevalent among severely obese children irrespective of ethnic group. Type 2 diabetes is almost entirely attributable to the childhood obesity epidemic, although hereditary and life-style factors affect individual risk. Pulmonary complications include sleep-disordered breathing (sleep apnoea), asthma and exercise intolerance. The development of exercise intolerance in an obese child can limit physical activity and thus lead to further weight gain.
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Table 1. Complications of obesity
Table 2. Tests to be considered in obesity
Short-term
Long-term
Poor self-esteem/depression Asthma Sleep apnoea Type 2 diabetes mellitus Orthopaedic problems (e.g. slipped epiphysis) Hypertension/ high cholesterol Early puberty/ polycystic ovaries Gallstones
Persistence of obesity Social stigmatisation Sleep apnoea Type 2 diabetes mellitus Osteoarthritis Hypertension/ high cholesterol Menstrual irregularities/ hirsutism Gallstones
Childhood obesity, of course, has substantial psychosocial consequences, and overweight children can develop a negative self-image at as early as 5 years of age, while obese adolescents show diminishing degrees of self-esteem associated with sadness, loneliness and risk-taking behaviour (3,15).
Causes of childhood obesity Genetic causes In 1997, two massively obese Pakistani children of consanguineous parents were found to have a mutation in the gene encoding leptin and since then five genetic mutations causing obesity have been identified, all presenting in childhood (5,6). Prader-Willi syndrome (PWS) is a rare cause of obesity, with a deletion of chromosome 15 and features of a voracious appetite, poor linear growth, small hands and genitalia and dysmorphic features. Progress has been made in mapping the genetic loci of PWS but the molecular cause of this obesity syndrome has not yet been identified. Thus, single gene defects account for a very small fraction of human obesity and predisposition to obesity appears to be related to a complex interaction between at least 250 obesity-associated genes. Physical activity A lifestyle characterized by a lack of physical activity and excessive television viewing has been shown to be associated with childhood obesity. Among children from Mexico City, the risk of obesity decreased by 10% for each hour of moderate to vigorous physical activity and increased by 12% for each hour per day of television viewing. Television viewing Television viewing is thought to promote weight gain not only by displacing physical activity but also by increasing energy intake (7,8). Children tend to passively consume excessive amounts of energy-dense
Secondary causes of obesity are exceedingly rare; most obesity is what is termed simple obesity, and no investigations are required. - Short stature/hypertension/striae - morning and evening cortisol levels (to exclude Cushings disease) - Short stature/goitre/hip pain - thyroid function tests , hip X-ray to exclude slipped capital femoral epiphysis - Small hands and feet/voracious appetite - karyotype, FISH (Prader-Willi syndrome) - Excessive thirst/increased urine output - fasting + 2 hour blood sugar levels, glucose tolerance test (Diabetes) - Hirsutism/obesity/absence of periods - blood testosterone level, ultrasound scan of ovaries showing numerous cysts (polycystic ovary syndrome)
foods while watching television. Furthermore, television advertising could adversely influence dietary patterns at other times throughout the day. Screen time for children of over 2 years should be limited to no more than 1 to 2 hours per day (18). Diet Children who were bottle fed appear to be at greater risk of obesity later in childhood than those who were breast fed (9). Sugar-sweetened soft drinks have been the subject of several studies, which have shown that the total energy intake was 10% greater among children who consumed soft drinks than in those who did not (18). Increasing portion sizes are also a factor. Fast food typically incorporates potentially adverse dietary factors including saturated fat, a high glycaemic index, high energy density and, increasingly, large portion size. A large fast food meal could contain 2,200 kcal, which, at 85 kcal per mile, would require a full Marathon to burn off. Breakfast skipping, snacking and eating out (in particular at fast food establishments) are all associated with obesity (18). The ‘traffic light diet’, recommended for consumption by children in the age-group 6 to 12 years, consists of low energy, high nutrient foods such as fruit and vegetables (green), moderate energy foods (orange) and high energy foods (red). ‘Green’ foods may be eaten often, ‘orange’ foods in moderation and ‘red’ foods should be eaten sparingly (10,18). Family factors Parent-child interactions and the home environment can affect the risk of developing obesity. Traditional family meals tend to decrease television viewing and improve dietary quality; the child takes a diet with less saturated and trans fats, less fried foods, lower glycaemic load, more fibre, fewer soft drinks and more fruit and vegetables. ¶·È‰È·ÙÚÈ΋ 2008;71:92-95
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Prevention and treatment Prevention and treatment ultimately involves eating less and exercising more. Most efforts to reduce obesity in children have used family-based or schoolbased approaches and only in severe cases are pharmacological and surgical treatments considered. Following a review of randomised controlled trials, Ebstein et al. (10) concluded, somewhat soberly, that most interventions to treat childhood obesity are marked by only small changes in weight or BMI and very high rates of subsequent relapse. School-based interventions have been oriented towards prevention of obesity, targeting all children. The Pathways programme (12), for American Indian children at high risk of type 2 diabetes and cardiovascular disease, aimed to reduce dietary fat consumption and increase physical activity. This 3-year programme produced a significant decrease in fat consumption and a trend towards increased physical activity but the BMI did not differ between children in the intervention and the control schools at the end of the programme. The Planet Earth trial (11) focussed largely on changing the school environment over two school years to include reduced television viewing, increased physical activity, decreased fat intake, increased fruit and vegetable intake, altered class curricula and extensive education of families. In this trial there was a significant reduction in obesity in girls (absolute risk 0.47, CI 0.24-0.93), with trends in the same direction in boys, although not reaching statistical significance. The authors reported that the effect observed was largely attributable to observed reductions in television viewing. Most children managed in the community will have simple obesity with no underlying medical cause and without comorbidity. Treatment should be offered when the obese child and family are willing to make the necessary life-style changes. For children who are overweight and most children who are obese, weight maintenance is an acceptable goal (13). Weight maintenance can only be achieved by sustained behavioural changes, including healthier eating, an increase in physical activity to a minimum of 30 minutes per day and reduction of physical inactivity (e.g., watching television or playing computer games) to less than 2 hours per day. Particular attention should be given to methods for increasing physical activity in adolescents (18). Suggestions for parents Suggestions for increasing physical activity: - any increase in activity will help, - aim for simple changes at first, such as walking, cycling and using stairs rather than lifts, - develop an active life-style for the whole family, Paediatriki 2008;71:92-95
- encourage active play that is enjoyable and do all you can to keep exercise fun, - decrease TV viewing and other sedentary activities, - schedule unstructured free playtime on a daily basis. Dietary suggestions: - a balanced, varied diet for the whole family, - serve meals at regular times; avoid ‘grazing’ and TV snacks, - serve smaller portions, - avoid snacks as rewards or treats, - offer healthy snacks (e.g., fruit) as alternatives to sweets, chocolates, potato crisps, biscuits and cakes, - use less energy dense food (e.g., semi-skimmed milks and low fat spreads), - provide whole foods that take time to eat (e.g., fruits and wholemeal bread), - promote low calorie drinks (preferably water), - ensure at least five portions of fruit and vegetables per day, - grill, boil or bake foods rather than frying them, - “Eat to live, don’t live to eat”, - pare down the amount of ‘junk’ food in the house, - comfort with attention, listening and hugs instead of food.
The perfect meal plan Modern families may rarely sit down to a meal all together, and one major suggestion is to bring back the traditional family meal; the perfect meal plan entails: - firstly turn off the TV, - involve children in the cooking process, - switch mobile phones to silent, - make sure that everyone sits down together at the table, - serve the plates from a central location to ensure control over portion sizes, - the meal should last at least 20 minutes, - share the positive events of the day, - be mindful while eating of the colour, texture and smell of the food, - make dessert a continuation of the meal and not something too special, - substitute fruit for dessert at times, - parents, not children, should be responsible for food decision making, - limit soft drink consumption. Drug treatment for obesity Drug treatment is not recommended for children under 12 years, and in adolescence it is only
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recommended in situations where there are medical complications (orthopaedic complications or sleep apnoea) or severe psychological issues arising from the obesity. Medication used as part of a structured life-style modification produces an average weight loss of 5 to 10%, which typically reaches a plateau at 4 to 6 months of treatment, and weight regain is common after the drug is withdrawn (16,18). Prescribing should be made by a specialist multidisciplinary team. The drugs used are orlistat and sibutramine and they are generally used for a 6-12 month trial with regular reviews of effectiveness, adverse effects and adherence. Sibutramine is an appetite suppressant and orlistat works as a reversible lipase inhibitor (18). Drug treatment may be used to help the adolescent maintain weight loss as well as to continue to lose weight. Four experimental drugs have produced weight loss in small studies involving children with special conditions, specifically, metformin in obese adolescents with insulin resistance, octeotride for hypothalamic obesity, growth hormone in Prader-Willi syndrome and leptin for congenital leptin deficiency (17).
Bariatric surgery for obesity Surgery is generally not recommended for children and adolescents and constitutes, at best, a last resort for severely obese adolescents. Exceptional circumstances in which surgery might be considered are when the BMI is >40, or when in the case of a significant complication, such as hypertension or type 2 diabetes that could be improved by weight loss, all appropriate non-surgical measures have failed or when they are receiving intensive care. Key points to remember - Obesity is now the commonest chronic condition affecting children across the EU. - Obesity is due to an imbalance between energy consumption and energy expenditure. Obese children do not have low energy needs. - Family support is necessary for treatment to succeed. - Generally the aim of treatment is to help children and adolescents to maintain their weight. - In younger children the main impact of obesity is social and emotional rather than medical. - A medical cause for obesity is more likely in children who are both short and obese for age. - Most children are not obese because of an underlying medical problem, but rather as a result of their life-style. - Weight reduction or stabilization goals should always be kept reasonable. - The major calorie culprits are high-fat fast food, large portions and sugar-containing soft drinks.
- If a child is at risk of obesity due to family history, the earlier the modifications (e.g., reducing TV time) the better.
References 1. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 2001;286:2845-2848. 2. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360: 473-482. 3. Strauss RS. Childhood obesity and self-esteem. Paediatrics 2000;105:e15. 4. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Eng J Med 2002;346:802-810. 5. Montague CT, Farooqi IS, Whitehead JP, Soos MA, Rau H, Wareham NJ, et al. Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature 1997; 387:903-908. 6. Farooqi IS, O’Rahilly S. Recent advances in the genetics of severe childhood obesity. Arch Dis Child 2000;83:31-34. 7. Robinson TN. Does television cause childhood obesity? JAMA 1998;279: 959-960. 8. Robinson TN. Reducing children’s television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282:1561-1567. 9. Ludwig DS, Peterson KE, Gortmaker SL. Causes of obesity. Lancet 2001;357:1978-1979. 10. Epstein LH, Roemmich JN, Raynor HA. Behavioral therapy in the treatment of pediatric obesity. Pediatr Clin North Am 2001;48:981-993. 11. Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001;323: 1029-1032. 12. Lohman TG, Going S, Stewart D, et al. The effect of Pathways obesity prevention study on body composition in American children. FASEB J 2001;15:A1093. 13. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev 2003;(3):CD001872. 14. Wiegand S, Maikowski U, Blankenstein O, Biebermann H, Tarnow P, Grüters A. Type 2 diabetes and impaired glucose tolerance in European children and adolescents with obesity - a problem that is no longer restricted to minority groups. Eur J Endocrinol 2004;151:199-206. 15. Sabin MA, Ford AL, Holly JM, Hunt LP, Crowne EC, Shield JP. Characterisation of morbidity in a UK, hospital based, obesity clinic. Arch Dis Child 2006;91:126-130. 16. Glazer G. Long-term pharmacotherapy of obesity 2000: a review of efficacy and safety. Arch Intern Med 2001;161: 1814-1824. 17. Farooqi IS, Jebb SA, Langmack G, Lawrence E, Cheetham CH, Prentice AM, et al. Effects of recombinant leptin therapy in a child with congenital leptin deficiency. N Eng J Med 1999;341:879-884. 18. Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120:S254-S288. ¶·È‰È·ÙÚÈ΋ 2008;71:92-95
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Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity Facultad de Ciencias de la Salud, Universidad Autonoma del Carmen, Ciudad del Carmen, Campeche, Mexico Correspondence: Daniel Fuentes-Lugo daniel.fuentes@mac.com Facultad de Ciencias de la Salud, Universidad Autonoma del Carmen, Ciudad del Carmen, Mexico
M. Ponce-Rivera, D. Fuentes-Lugo Abstract: The prevalence of overweight and obesity in young children continues to rise in most parts of the world. Obese children have a significantly higher risk of becoming obese adults, which underlines the importance of adequate growth monitoring from early ages. Different international references for growth assessment are currently being used by paediatricians in most countries. This review examines the differences between the Centers for Disease Control (CDC) growth reference and the new World Health Organization (WHO) growth standards for children of less than five years when used as diagnostic tools for the detection of excess weight. It also includes preliminary results from a retrospective study conducted in a cohort of 300 healthy children from a paediatric clinic in Mexico evaluating differences in overweight prevalence depending on the growth reference employed. Results showed a higher prevalence of overweight and obesity with WHO standards than with the CDC reference in children from 1 through 5 years of age, independent of gender, in agreement with other studies. Use of the new WHO growth standards is emphatically encouraged for both routine clinical practice and epidemiological research, in order to avoid potential pitfalls and inaccuracies when monitoring child growth and to detect childhood overweight and obesity effectively. The new WHO standards provide a unique opportunity for redesigning child overweight surveillance and prevention programmes so that they become more useful for detection and decision making and less complicated for gathering epidemiological data. Key words: Childhood obesity, childhood overweight, growth reference, growth standard.
Childhood globesity: understanding the magnitude of the problem Overweight and obesity have achieved global acknowledgement during the past decade. Excess body weight is now considered one of the most important risk factors contributing to the overall burden of disease. Worldwide, around 1.2 billion adults are classified as being overweight, of which 312 million are considered obese (1). The prevalence of obesity has reached alarming levels, affecting both developed and developing countries and all socioeconomic groups, irrespective of age, sex or ethnicity. If effective preventive measures are not implemented soon, this public health problem will continue to expand to the extent that it will become out of control. For example, it is estimated that in the US by 2015, 75% of adults will be overweight, of which more than half will be obese (2). Concerning childhood obesity, around 10% of children in the world have some degree of overweight and over 22 million children under the age of 5 are already obese (3). The prevalence of overweight is dramatically higher in the economically developed regions, but it is also rising significantly in most other parts of the world. In developing nations, childhood obesity is most prevalent in the wealthier sections of the populaPaediatriki 2008;71:96-104
tion. However, it is also increasing among the urban poor in these countries, possibly due to their exposure to westernized diets. The prevalence of childhood overweight in America is currently above 20%, reaching up to 40% in the case of the US and Mexico. In Europe, the number of children who are overweight is expected to rise by 1.3 million children per year, with more than 300,000 of them becoming obese each year (4). By 2010 it is estimated that 26 million children in European countries will be overweight, including 6.4 million who will be obese (5). Such rapid changes in the numbers of obese children within a relatively stable population indicate that genetic factors are not the primary reason for change, although they play a role that is yet to be precisely determined. Childhood obesity is usually associated with complications that include diabetes types 1 and 2 (6,7), insulin resistance, atherosclerosis (8,9), hypertension, dyslipidaemia, polycystic ovary disease, kidney disease (10) and fatty liver among many others (11). Children with body mass index (BMI) and waist circumference exceeding the established normal values are at increased risk for metabolic syndrome when they reach adulthood (12,13). A higher BMI during
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childhood is also associated with an increased risk for coronary heart disease (CHD) in adulthood (14) and this association appears to be stronger in boys than in girls and to increase with age in both sexes (15). In addition, excess body weight appears to be an important risk factor for some cancers. A systematic review compared associations between 20 cancer types and BMI (16). Their results show that a higher BMI is associated with an increased risk of thyroid, renal and colon cancers, oesophageal adenocarcinoma, multiple myeloma, leukaemia and non-Hodgkin lymphoma in both sexes, rectal cancer and malignant melanoma in men, and gallbladder, pancreas, endometrial and postmenopausal breast cancers in women. Several theories have been formulated to account for the obesity epidemic. Clearly, the main causes are overeating and lack of physical activity. However, it is of paramount importance to identify all the risk factors that predispose an individual to become obese (17). There appears to be a direct causal relationship between childhood overweight and maternal pre-pregnancy body size, maternal smoking during pregnancy (18), early weaning (19), rapid growth (20) and children’s use of television and media, while breastfeeding appears to have a protective effect against overweight (21). Further studies are needed to elucidate the exact mechanisms by which these factors influence childhood adiposity, for example, its relationship with socioeconomic status (22). Some authors have claimed that, although clinically irrelevant, temperament may be slightly related to overweight and rapid early weight gain in infants (23). Others have proposed that a high early protein intake, particularly from dairy products, increases obesity risk (24,25). Some studies suggest that sleep deprivation may influence weight through effects on appetite, physical activity, and thermoregulation (26). Short sleep duration appears independently associated with weight gain in younger age groups (27). Unfortunately, to date, scientific evidence regarding risk factors for childhood obesity is still insufficient, with much of the literature being of limited quality, inconclusive and contradictory (28). There is strong evidence to suggest a direct relationship between weight status in childhood and eventual adult obesity, but many studies are based on cross-sectional data or have relatively long periods of time between measurements. It is now accepted that obesity in adolescence is highly predictive of obesity in adulthood. Therefore, an important next step will be to identify those young children at greatest risk of developing obesity in adolescence, and to intervene before chronic overweight is established during early childhood. Children who are found to be overweight
at least once at ages 24, 36 or 54 months during the preschool period are 5 times more likely to be overweight at age 12 years than those who are below the 85th percentile for BMI at all three of the preschool ages. The longer a child remains in the lower range of normal BMI, the less likelihood there is that the child will become overweight by early adolescence (29).
Adequate detection of overweight and obesity in childhood Not long ago, a fat child meant a healthy child, and the concept of “bigger is better” was widely accepted by parents, paediatricians and caregivers. Such a point of view belongs to the past, however (30), and at present, child obesity is one of the most evident, yet most neglected public health problems in the world. Although the problem is well recognized, most obesity prevention measures worldwide have been small, timid and ineffective to halt the epidemic (31). Arguably, ‘globesity’ might have been detectable earlier if a prescriptive reference had been available 20 years ago, and even now the first problem that needs to be addressed is agreement of a definition of true obesity. Some of the contradictory childhood obesity rates seen in the literature are a direct consequence of using different criteria to define overweight and obesity. The main purposes for defining overweight and obesity are to predict health risks and to provide comparisons between populations. For practical reasons, the definitions have usually been based on anthropometry, but regardless of which definition is used, the increasing rates have highlighted the relevance of the problem (32). Obesity is defined as an excess of body fat or adipose tissue. It is actually fat and not weight which is associated with all the comorbid conditions. Measuring fat is not as straightforward as measuring weight; therefore weight, rather than adiposity, is the usual clinical marker for identifying obesity. Although body weight tends to be associated with adiposity, weight alone is an insufficient measure of obesity by itself, because it is correlated with height (33). To avoid this limitation, a number of measures of weight in relation to height have been devised over the years. The simplest and most frequently used are weight-for-height and the BMI. BMI is a practical indirect measure of adiposity, although the relationship changes according to age, sex and ethnicity, but also degree of fatness. A child’s BMI can be compared with a reference data set and be converted into a Z-score. A BMI Z-score of 0 is equivalent to the median or 50th percentile value, a Z-score of +2.00 is approximately equivalent to the 98th percentile and a Z-score of +2.85 is >99th percentile. Some authors postulate that even though BMI Z-score ¶·È‰È·ÙÚÈ΋ 2008;71:96-104
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is optimal for assessing adiposity on a single occasion, it is not necessarily the best scale for measuring change in adiposity, as the within-child variability over time depends on the child’s level of adiposity (34). Use of BMI index charts during a paediatric health supervision visit increases physician recognition of overweight patients better than height-for-weight charts (35). Regrettably, BMI charts are not routinely used (36) and due to ineffective detection not all children with overweight receive either a formal diagnosis or treatment (37). A study conducted among public and private practice paediatricians in the US revealed that they identified overweight in only 27% of children with BMI at the 85th-94.9th percentile and up to 86% with a BMI at or above the 95th percentile (38). Rate recognition by physicians increased as the severity of obesity increased. US paediatricians may not use BMI charts because they recognize obesity empirically when they see it, at least when the BMI is above the 95th percentile. However, they may overlook excess weight in children with BMI at the 85th-94th percentile, perhaps because these children seem fairly normal. Adequate growth and weight gain should concern not only paediatricians and child caretakers but also parents (39). One study showed that parents of younger children were significantly more likely to underestimate overweight (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate weight, nor was accuracy associated with parental education or socieconomic status. Parental recognition of childhood overweight may be improved with BMI screening and feedback (40).
Growth references versus growth standards: which should be used? Growth references are a fundamental tool for the interpretation of anthropometric data. Classifying a child as overweight or obese assumes that such a child is comparable to the reference population, so choosing the right tool for proper detection is mandatory (41). In the US, reference growth charts based on nationally representative surveys have been produced since 1977. An expert committee recommended their use for children and adolescents, with the 95th BMI percentile for age and sex (or BMI 30 kg/m2) as the cutoff points for overweight and the 85th percentile as “at risk of overweight” for screening purposes. The fact that the committee decided not to use the term ‘obese’, which they associated with excess fat rather than weight, has lead to some confusion (42). In May 2000 the US Centers for Disease Control (CDC) released new growth charts to replace the 1977 NCHS reference. The CDC-2000 charts were based Paediatriki 2008;71:96-104
on five nationally representative surveys conducted between 1963 and 1994. This reference, currently used in about 100 countries, is based on data from several samples of children from a single country and suffers from a number of technical drawbacks that makes it inadequate for monitoring growth in early childhood. A survey reported that CDC-2000 is the growth reference most commonly used worldwide. Another interesting fact from this international study is that most paediatricians prefer using percentiles rather than Z-scores (43). The use of Z-scores offers advantages over the use of percentiles; for instance, when conducting epidemiological studies, Z-scores allow easier comparison between growth references. In the late 1990s, the International Obesity Task Force (IOTF) determined that although BMI was not ideal as a measure of adiposity, it could be used to define overweight and obesity in children and adolescents. IOTF recommended cutoff points based on age-specific values that project to the adult cutoff points of 25 kg/m2 for overweight and 30 kg/m2 for obesity. Using data collected between 1963 and 1993 from six different populations (Great Britain, Brazil, the Netherlands, Hong Kong, Singapore and USA) IOTF published their reference curves in 2000 (44). These are useful mainly for epidemiological research, since children and adolescents can only be categorized as non-overweight or overweight/obese. Since the adult cutoff points of BMI 25 and 30 may not be universally applicable, the IOTF curves are inappropriate for some child populations. A number of reports have shown that these cutoff points substantially underestimate the prevalence of childhood obesity in different settings (45). In short, the IOTF reference appears to be a less adequate tool for detecting overweight and obesity in clinical practice compared with methods based on percentiles or Z-scores.
WHO 2006 Child Growth Standards The WHO 2006 Child Growth Standards are the product of a long systematic process which started in the early 1990s. They are based for the first time on a prospective, prescriptive, international sample of infants selected to represent optimum growth (46). The WHO Multicenter Growth Reference Study (MGRS) was designed to provide data that describe how children should grow from birth to five years under optimal environmental conditions, rather than describing their growth in a particular time and place, and therefore, they can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding (47). The MGRS was carried out from July 1997 to
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Table 1. Body mass index (BMI) cutoff values for overweight from the IOTF, CDC-2000 and WHO-2006 growth standards in children aged 2 to 5 years
Age (years)
IOTF BMI 25 Kg/m2 Boys Girls
CDC 2000 +2 S.D. Boys Girls
WHO 2006 +2 S.D. Boys Girls
2 2.5 3 3.5 4 4.5 5
18.41 18.30 17.89 17.69 17.55 17.47 17.42
20.14 19.38 18.86 18.55 18.43 18.48 18.69
18.9 18.6 18.4 18.2 18.2 18.2 18.3
18.02 17.76 17.56 17.40 17.28 17.19 17.15
December 2003 as a population-based study covering the cities of Davis, California, USA; Muscat, Oman; Oslo, Norway; and Pelotas, Brazil, together with selected affluent neighborhoods of Accra, Ghana and South Delhi, India. The WHO combined a longitudinal follow-up from birth to 24 months with a crosssectional component of children aged 18-71 months. The study population lived under socioeconomic conditions favourable to growth. The individual inclusion criteria were: no known health or environmental constraints to growth, mothers willing to follow MGRS feeding recommendations (exclusive or predominant breast-feeding for at least 4 months, introduction of complementary foods by 6 months of age, and continued breast-feeding to at least 12 months of age), no maternal smoking before and after delivery, single term birth and absence of significant morbidity (48). Prior to their release, the standards were field-tested in four countries: Argentina, Italy, Maldives and Pakistan (49). One important feature of the WHO standards to bear in mind is that it makes breast-feeding the biological norm and establishes the breast-fed infant as the normative growth model (50). The previous references were based mostly on the growth pattern of artificially-fed children. The WHO-2006 standards demonstrate that healthy children from around the world who are raised in healthy environments and follow recommended feeding practices have similar patterns of growth. This indicates that the same potential for growth should be expected in any country. It also implies that deviations from this ideal growth pattern must be assumed to reflect adverse conditions that require correction (51). Since there are substantial differences in methodology, cutoff values and selected population between the various growth references, it is expected that significant changes would be found when one reference is compared to another, even if they are from the same country. For instance, the CDC-2000 reference under-
19.80 19.31 19.01 18.89 18.93 19.10 19.39
18.7 18.5 18.4 18.4 18.5 18.7 18.8
estimates the weight-for-height Z-scores of individual children compared to the 1977 NCHS reference, both of which are references derived from American children. A child classified as close to +3 Z-score using the 1977 NCHS reference will be just below +2 Z-score when the CDC 2000 reference is applied (52). Few studies have compared the 1977 NCHS criteria for defining overweight or obesity with the CDC2000 reference curves and the IOTF alternative set of cutoff points. In younger children, the IOTF curves gave significantly lower estimates for the prevalence of obesity. One study involving 258 Italian children (average age 4.8 years) found that the CDC -2000 reference led to a significantly higher prevalence of obesity in both males and females when compared to the growth charts of the IOTF (53). BMI cutoff points from the CDC and IOTF have relatively high specificity, but lower sensitivity, meaning that children with normal weight are unlikely to be wrongly labelled, but overweight and obese children may be missed. Detecting a child with overweight depends basically on which reference and which cutoff value is used, and this clearly represents a major problem (Tables 1 and 2). When CDC-2000 reference curves are compared with the new WHO-2006 standards, significant differences are found that vary by age group, growth Table 2. Body mass index (BMI) cutoff values for obesity from IOTF and WHO-2006 growth standards in children aged 2 to 5 years
Age (years)
IOTF BMI 25 Kg/m2 Boys Girls
WHO 2006 +3 S.D. Boys Girls
2 2.5 3 3.5 4 4.5 5
20.09 19.80 19.57 19.39 19.29 19.26 19.30
20.6 20.2 20.0 19.8 19.9 20.0 20.3
19.81 19.55 19.36 19.23 19.15 19.12 19.17
20.6 20.4 20.3 20.4 20.6 20.8 21.1
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Mean weight-for-age Z-scores 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 -0.8
NCHS CDC WHO
Table 3. Prevalence of overweight (including obesity) using weight-for-height Z-scores from the CDC-2000 growth reference and WHO-2006 growth standards during the first year of life
Birth 1 year 0
1
2
3
4
5 6 7 8 Age (months)
9
indicator and Z-score curve. The main differences in weight-for-age Z-score curves occur during infancy (Graph 1). Regarding weight-for-length Z-score curves for boys, estimates of overweight and obesity are higher when based on the WHO standards (54). The change in the shape of the curves is probably due to issues related to study design and the characteristics of the sample, as well as differences in the type of feeding. The CDC used samples of less than 100 infants per age group during the first six months; consequently, the CDC-2000 curves probably fail to capture the rapid and changing rate of weight gain in early infancy. The WHO-2006 standard is based on a much larger sample size (428 boys and 454 girls) and shorter measurement intervals. These design characteristics allowed the WHO curves to capture rapidly changing patterns of growth in early infancy. Comparison of weight-for-length and weight-forheight chart shows that CDC-2000 children were generally heavier than those included in the WHO2006 sample. The BMI-for-age curves are dramatically different, partly reflecting obesity in the US sample. This flaw makes the CDC-2000 weight-forheight curves inadequate for monitoring obesity from 100 cm onwards. In addition, the pattern of
0% 2.25%
0.59% 0%
3% 2.25%
z-BMI for girls (n=133) 1
1 WHO 2006
0.5
CDC 2000
0
WHO 2006
0.5 Z
CDC 2000
0 -0.5
-0.5 2
3
4
5
Age Graph 2. WHO Growth Standard versus CDC Growth Reference. Paediatriki 2008;71:96-104
0% 2.39%
lower centiles of the CDC weight-for-length chart below 53 cm may reflect peculiarities of the birth registry data used to design the CDC curves (55). In summary, the CDC-2000 charts provide a growth reference rather than a prescriptive standard, such as the WHO-2006. Based on this rationale, a retrospective study was conducted in a cohort of healthy children from a single paediatric clinic in Mexico City in order to assess differences between the CDC-2000 reference and the new WHO-2006 standards (56). Among the main outcomes examined were differences in estimated overweight/obesity prevalence. From the files with complete weight and height records from birth up to five years of age, 300 children (167 boys and 133 girls) were randomly selected. Children with a history of chronic disease were excluded. Weight-for-age, height-for-age, weight-for-height and BMI percentiles and Z-scores were obtained at 0, 12, 24, 36, 48 and 60 months of age (±2 months). To classify children with overweight or obesity, Z-score values of +2.00 S.D. and +3.00 S.D. respectively, were used. Anova regression analysis was performed to compare the curves from birth to five years of age derived from the two reference instruments. Using weight-for-height as an anthropometric marker, the results showed a relatively low prevalence of overweight in the complete cohort between the first and second years of age with both references, although the prevalence using the WHO-2006 standards was significantly different from that obtained
z-BMI for boys (n=167)
-1
Girls WHO CDC +2 S.D. +2 S.D.
10 11 12
Graph 1. WHO Growth Standard versus CDC-2000 and NCHS1977 Growth References (adapted from references 52 and 54).
Z
Boys WHO CDC +2 S.D. +2 S.D.
-1
2
3
4
5
Age Graph 3. WHO Growth Standard versus CDC Growth Reference.
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WHO 2006 CDC 2000
12 10
7 5
8
% 4
% 6
3
4
2
2
1
0
WHO 2006 CDC 2000
6
0 2
3 4 Age (years)
5
2
3 4 Age (years)
5
Graph 4. Prevalence of overweight/obesity in boys (BMI Zscore=/>2.0) (n=167).
Graph 5. Prevalence of overweight/obesity in girls (BMI Zscore=/>2.0) (n=133).
with the CDC-2000 reference (1.33% versus 0.66% overweight). The main differences in the weight-forheight Z-score were observed from 12 to 36 months of age. At 1 year of age, differences were found for the boys but not the girls (Table 3). The prevalence of overweight increased markedly at age 4-5, but with significant differences between CDC and WHO scores regardless of gender. It was not possible to compare Z-BMI curves between the two references during the first two years because such data is not included in the CDC-2000 growth curves. When BMI Z-score was used to identify overweight (+2.0) and obesity (+3.0), there were statistically significant differences between the two references (p<0.001) for both boys and girls from 2 to 5 years of age. Although the median values of the BMI Z-score were within the normal weight range with both references, the WHO-2006 curve pattern was always above the CDC curve pattern for both boys and girls from age 2 years to 5 years (Graphs 2 and 3). In addition, the prevalence of overweight and obesity using WHO standards was higher than the prevalence found when CDC growth references were used (Graphs 4 and 5). Furthermore, as pointed out elsewhere, the weight-for-height Z-score proved to be of lesser sensitivity in detecting overweight accurately when compared to the BMI Z-score, with both references (p<0.001).
Final comments The shift to the new WHO standards provides a unique opportunity not only to monitor linear growth, but also to redesign surveillance programmes so that they are more useful for problem detection and decision making, and less complicated for gathering epidemiological data (57). The WHO standards would set a markedly lower standard for weight gain beyond 4 months of age, and could thus support efforts to avoid future childhood obesity (58). However, there is evidence that they might not be appropriate for use across all populations, and specifically some populations in Asia (59) and Africa (60). One study conducted in refugee camps in Algeria, Kenya and Bangladesh showed important differences in the weight-for-height cutoff points used for defining acute malnutrition between those obtained from the WHO standards and those derived from the NCHS reference. The WHO standards apparently resulted in a higher measured prevalence of severe acute malnutrition. For such reasons, assessment of the new WHO growth standards in different populations and environments is recommended. Compared to previous international references they appear to be more accurate and easier to interpret. In addition, last year WHO published a second set of standards that include head circumference-for-age, arm circumference-for-age, triceps and subscapular skinfold-forage, and new international growth standards for the screening, surveillance and monitoring of school-age children and adolescents (61-63), all available at the WHO website. Prevention is perhaps the only effective way to stop this childhood obesity epidemic, and the first step for proper prevention, is proper detection. The WHO 2006 standards were created basically for that purpose. The authors agree with others who suggest that all the demographic surveys should now be derived using the
Table 4. Prevalence of overweight (including obesity) using body mass index (BMI) Z-scores from the CDC-2000 growth reference and WHO-2006 growth standards Age (years)
Boys WHO CDC
Girls WHO CDC
2 3 4 5
3.58% 7.77% 11.97% 11.36%
3% 6.76% 5.26% 6.76%
0% 4.18% 7.77% 8.97%
0.75% 4.50% 4.50% 3.75%
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WHO standards (64). Perhaps in the future technological advances will allow a more direct assessment of adiposity than BMI, and new charts will need to be created (65). Currently, there are few reports in the literature of studies assessing the level of body fat in childhood (66-68) and only one that has actually produced body fat reference curves for children aged older than five (69). There is a marked mismatch between the public health importance of childhood obesity and the number and quality of studies conducted so far to assess preventive interventions (70,71). There is an urgent need for well-designed intervention studies to demonstrate the long-term effectiveness of preventive strategies that would provide a basis for evidence-based recommendations (72,73). In Europe, a series of initiatives and actions have been launched in recent years, one of which is the creation of national centres for collecting country-specific data to back up concrete strategies for future policy building (74). In the US, the new National Children’s Study will seek information on enviromental risks and individual susceptibility factors for obesity, among other diseases. This will be conducted in a cohort of 100,000 US born children, which will be followed from conception to 21 years of age. Environmental exposures will be assessed repeatedly during pregnancy and throughout childhood in the children’s homes, schools and communities. Chemical assays will be performed by the CDC and banks of biological and genetic material and environmental samples will be collected. Recruitment started in 2007 at 7 sites and will be extended to 105 sites across the US (75). Unfortunately, it will be a long time before preliminary results are available. In the meantime, until all these studies start to answer some of the numerous questions regarding childhood obesity, it would be advisable to promote physical activity and healthy eating habits among children and to encourage adequate monitoring of growth and weight gain from early infancy.
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43. De Onis M, Wijnhoven TM, Onyango AW. Worldwide practices in child growth monitoring. J Pediatr 2004;144: 461-465. 44. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-1243. 45. Serra-Majem L, Ribas-Barba L, Pérez-Rodrigo C, Ngo J, Aranceta J. Methodological limitations in measuring childhood and adolescent obesity and overweight in epidemiological studies: does overweight fare better than obesity? Public Health Nutr 2007;10:1112-1120. 46. De Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J. The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food Nutr Bull 2004;25:S15-S26. 47. WHO Multicentre Growth Reference Study Group. Reliability of anthropometric measurements in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:38-46. 48. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl 2006;450:76-85. 49. Onyango AW, de Onis M, Caroli M, Shah U, Sguassero Y, Redondo N, et al. Field-testing the WHO child growth standards in four countries. J Nutr 2007;137:149-152. 50. WHO Multicentre Growth Reference Study Group. Breastfeeding in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:16-26. 51. Garza C. New growth standards for the 21st century: a prescriptive approach. Nutr Rev 2006;64:S55-S59. 52. De Onis M, Onyango AW. The Centers for Disease Control and Prevention 2000 growth charts and the growth of breastfed infants. Acta Paediatr 2003;92:413-419. 53. Vidal E, Carlin E, Driul D, Tomat M, Tenore A. A comparison study of the prevalence of overweight and obese Italian preschool children using different reference standards. Eur J Pediatr 2006;165:696-700. 54. De Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr 2007;137:144-148. 55. De Onis M, Onyango AW, Borghi E, Garza C, Yang H; WHO Multicentre Growth Reference Study Group. Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutr 2006;9:942-947. 56. Ponce M, Blanco A, Reyes H, Lfipez C, Fuentes D. Utilidad de las nueva curvas de crecimiento de la OMS para la de~os menores de cinteccifin del sobrepeso y obesidad en nin ~ co anos. Pediaãtrika 2007;27(4):48. 57. Garza C, de Onis M. Rationale for developing a new international growth reference. Food Nutr Bull 2004; 25:S5-S14. 58. Wright C, Lakshman R, Emmett P, Ong K. Implications of adopting the WHO 2006 Child Growth Standard in the UK: two prospective cohort studies. Arch Dis Child 2007 [Epub ahead of print]. 59. Hui LL, Schooling CM, Cowling BJ, Leung SS, Lam TH, Leung GM. Are universal standards for optimal infant growth appropriate? Evidence from a Hong Kong Chinese birth cohort. Arch Dis Child 2007 [Epub ahead of print]. 60. Seal A, Kerac M. Operational implications of using 2006 ¶·È‰È·ÙÚÈ΋ 2008;71:96-104
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Basic techniques of molecular biology and their applications in the diagnosis of childhood diseases S. Megremis, ∞. Pampanos Abstract: All the techniques applied in molecular biology focus on the characterization, isolation and manipulation of the molecular components of the cell. These components include DNA, which is the repository of genetic information, RNA and proteins. Genes are the functional units of the DNA, specifying the structure of proteins. There are about 24,000 protein-coding genes in the human genome as estimated by the Human Genome Project. Most of the molecular tests that are used in clinical diagnosis screen multiple genes for specific and/or non-specific mutations. Nowadays, a vast variety of genetic tests are available for use by clinicians in order to obtain diagnostic and prognostic information. Most of these tests are feasible because of the capability of the DNA double helix to denature and anneal or hybridize. In this review some of the basic molecular diagnostic techniques are presented, such as the polymerase chain reaction, DNA sequencing, DHPLC, and the southern and northern blotting techniques.
Key words: Genetics, molecular diagnostics, paediatrics.
™˘ÓÙÔÌÔÁڷʛ˜: PCR dNTP ddNTP QRT PCR RFLP VNTR STR DHPLC
Polymerase Chain Reaction diNucleotideTriPhosphatase didiNucleotideTriPhosphatase Quantitative Real Time PCR Restriction Fragment Length Polymorphism Variable Number Tandem Repeat Short Tandem Repeat Denaturant High Performance Liquid Chromatography
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Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital, Athens, Greece Correspondence: Andreas Pampanos apampanos@yahoo.com Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital Thivon & Levadias St., 115 27, Athens, Greece
ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ù˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Î·È Ù˘ ‚ÈÔÔÈÎÈÏfiÙËÙ·˜. √ fiÚÔ˜ ÁÂÓÂÙÈ΋ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ ÕÁÁÏÔ ÁÂÓÂÙÈÛÙ‹ Bateson ÙÔ 1905 (1). ∂›ÛËÌ·, ·Ù¤Ú·˜ Ù˘ ÁÂÓÂÙÈ΋˜ ıˆÚÂ›Ù·È Ô ªendel, Ô ÔÔ›Ô˜ ÙÔ 1865 ‰È·Ù‡ˆÛ ÙÔ˘˜ ÓfiÌÔ˘˜ Ô˘ ʤÚÔ˘Ó ÙÔ fiÓÔÌ¿ ÙÔ˘ (2). ∏ ·Ï‹ıÂÈ·, fï˜, Â›Ó·È fiÙÈ ÙÔ ˙‹ÙËÌ· Ù˘ ÌÂÙ·‚›‚·Û˘ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ·fi ÁÂÓÈ¿ Û ÁÂÓÈ¿ ¤¯ÂÈ ··Û¯ÔÏ‹ÛÂÈ ÙÔÓ ¿ÓıÚˆÔ ·fi ÙËÓ ·Ú¯·ÈfiÙËÙ·. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ·Ú¯·›ÔÈ µ·‚˘ÏÒÓÈÔÈ ÁÓÒÚÈ˙·Ó fiÙÈ ÁÈ· Ó· ·Ú·¯ı› ηÚfi˜ Û ÊÔÈÓÈÎfi‰ÂÓÙÚ· ¤Ú ӷ ÌÂÙ·ÊÂÚı› Á‡ÚË ·fi ¿ÚÚÂÓ· Ê˘Ù¿ ÛÙÔ˘˜ ‡ÂÚÔ˘˜ ÙˆÓ ıËÏ˘ÎÒÓ Ê˘ÙÒÓ (1). ™ÙËÓ ·Ú¯·›· ¶·È‰È·ÙÚÈ΋ 2008;71:105-115
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∂ÏÏ¿‰·, Ô ¶˘ı·ÁfiÚ·˜ ‰È·Ù‡ˆÛ ÙËÓ ˘fiıÂÛË fiÙÈ Ë ˙ˆ‹ ÍÂÎÈÓ¿ Ì ÙËÓ ·Ó¿ÌÂÈÍË ·ÚÛÂÓÈÎÒÓ Î·È ıËÏ˘ÎÒÓ ÛÂÚÌ¿ÙˆÓ (1). ∆ÔÓ 4o ·ÈÒÓ· .Ã., Ô ∞ÚÈÛÙÔÙ¤Ï˘ ˘ÔÛÙ‹ÚÈÍ fiÙÈ Ô Î¿ı ÁÔÓ¤·˜ Û˘Ì‚¿ÏÏÂÈ ÛÙË ÌÂÙ·ÊÔÚ¿ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ (1). ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 19Ô˘ ·ÈÒÓ·, Ô °¿ÏÏÔ˜ Ê˘ÛÈÔ‰›Ê˘ Lamarck ˘ÔÛÙ‹ÚÈÍ fiÙÈ Ù· ›ÎÙËÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÎÏËÚÔÓÔÌÔ‡ÓÙ·È (3), ÂÓÒ ÙÔ 1859 Ô Darwin ÙfiÓÈÛ ÙË ÛËÌ·Û›· ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ù˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÛÙË ÌÂϤÙË Ù˘ ÂͤÏÈ͢ ÙˆÓ ÂȉÒÓ (1). §›Á· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, ÙÔ 1865, Ô Mendel ‰ËÌÔÛȇÂÈ ÙȘ ıˆڛ˜ ÙÔ˘. ∆Ô 1903 ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ù· ¯ÚˆÌÔÛÒÌ·Ù· Â›Ó·È ÊÔÚ›˜ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ (1), ÂÓÒ ÙÔ 1910 Ô Morgan ÂÎÙÈÌ¿ fiÙÈ Ù· ÁÔÓ›‰È· ÂÓÙÔ›˙ÔÓÙ·È ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· (4). ∆Ô DNA ·Ú¯Èο ÔÓÔÌ¿ÛÙËΠÓÔ˘ÎϽÓË Î·È ·Ó·Î·Ï‡ÊıËΠ·fi ÙÔÓ Meischer ÙÔ 1867 (4), ·ÏÏ¿ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÁÂÁÔÓfi˜ Û˘ÓÙÂÏÂ›Ù·È ÙÔ 1953, fiÙ·Ó ÔÈ Watson Î·È Crick ÚÔÙ›ÓÔ˘Ó ÙÔ ÌÔÓÙ¤ÏÔ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ ÙÔ˘ DNA (4,5), ÂÓÒ ÙÔ 1956 ÔÈ Tjio Î·È Levan ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È 46 (1). ∞fi ÙfiÙÂ Ë ÂͤÏÈÍË Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È ÁÂÓÂÙÈ΋˜ Â›Ó·È Ù¤ÙÔÈ·, ÒÛÙ ӷ ıˆÚÂ›Ù·È Ï¤ÔÓ ‰Â‰Ô̤ÓË Ë ¯Ú‹ÛË ÙˆÓ ÌÂıfi‰ˆÓ ÙÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË. ∏ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙË ÌÔÚȷ΋ ‰È¿ÁÓˆÛË ÌÈ·˜ ÁÂÓÂÙÈ΋˜ ·Ûı¤ÓÂÈ·˜ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ Ì˯·ÓÈÛÌfi Ô˘ ÚÔηÏ› ÙËÓ ›‰È· ÙË ÓfiÛÔ. ™Ùfi¯Ô˜ ÙÔ˘ ¿ÚıÚÔ˘ Â›Ó·È Ë ·Ó·ÊÔÚ¿ ÛÙȘ ‚·ÛÈÎfiÙÂÚ˜ ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ ·Ó¿Ï˘Û˘ DNA, ÔÈ Ôԛ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ › ÙÔ Ï›ÛÙÔÓ ÛÙË ‰È¿ÁÓˆÛË ÁÂÓÂÙÈÎÒÓ ÓfiÛˆÓ Î·È ·Ó‹ÎÔ˘Ó Ï¤ÔÓ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ (¶›Ó·Î·˜ 1).
∆Ô ‰ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚Îfi Ô͇ (DNA) ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÎÏËÚÔÓÔÌÈΤ˜ ÏËÚÔÊÔڛ˜ ÌÂÙ·‚È‚¿˙ÔÓÙ·È ·fi οı ·ÙÙ·ÚÔ ÛÙ· ı˘Á·ÙÚÈο ÙÔ˘, ηٿ ÙËÓ Î˘ÙÙ·ÚÈ΋ ‰È·›ÚÂÛË, ‰È·Ì¤ÛÔ˘ ÙˆÓ ÁÔÓȉ›ˆÓ. ◊‰Ë, ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ ÂÈÎÔÛÙÔ‡ ·ÈÒÓ·, ÔÈ ÂÈÛÙ‹ÌÔÓ˜ ıˆÚÔ‡Û·Ó ‰Â‰Ô̤ÓÔ fiÙÈ Ù· ÁÔÓ›‰È· ‚Ú›ÛÎÔÓÙ·È ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù·, Ù· ÔÔ›· ÙfiÙ ‹Ù·Ó ÁÓˆÛÙ¿ ˆ˜ ÓËÌ·ÙÔÂȉ›˜ ‰Ô̤˜ ÙÔ˘ ˘Ú‹Ó· ÙˆÓ Â˘Î·Ú˘ˆÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Á›ÓÔÓÙ·È ÔÚ·Ù¿ fiÙ·Ó ÙÔ Î‡ÙÙ·ÚÔ ·Ú¯›˙ÂÈ Ó· ‰È·ÈÚ›ٷÈ. ªÂ ÙËÓ ¿ÚÔ‰Ô ‰Â ÙÔ˘ ¯ÚfiÓÔ˘ Î·È Ì ÙËÓ ÂͤÏÈÍË ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ó·Ï‡ÛÂˆÓ ÂȂ‚·ÈÒıËΠfiÙÈ Ù· ¯ÚˆÌÔÛÒÌ·Ù· ·ÔÙÂÏÔ‡ÓÙ·È ·fi DNA Î·È ÚˆÙ½Ó˜. ∞Ú¯Èο, ÔÈ ÂÈÛÙ‹ÌÔÓ˜ ‰˘ÛÎÔχÔÓÙ·Ó Ó· ‰Â¯ÙÔ‡Ó ÙÔ Ì·ÎÚ‡ ·˘Ùfi ÔÏ˘ÌÂÚ¤˜ ˘ÏÈÎfi Ô˘ ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 4 ÌfiÓÔ Â›‰Ë ˘ÔÔÌ¿‰ˆÓ, ˆ˜ ÁÂÓÂÙÈÎfi ˘ÏÈÎfi, ÏfiÁˆ Ù˘ Ê·ÈÓÔÌÂÓÈ΋˜ ·ÏfiÙËÙ·˜ Ù˘ ¯ËÌ›·˜ ÙÔ˘. ∆Ô 1953, fï˜, ÔÈ J. Watson & F. Crick Paediatriki 2008;71:105-115
¶›Ó·Î·˜ 1. ∂Ӊ›ÍÂȘ ·Ó¿Ï˘Û˘ DNA ÃÚfiÓÔ˜ DNA ·Ó¿Ï˘Û˘
∂Ӊ›ÍÂȘ (·Ú·‰Â›ÁÌ·Ù·)
¶ÚÔÁÂÓÓËÙÈο
ñ ¢È¿ÁÓˆÛË Î‡ËÛ˘ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (.¯. ÈÛÙÔÚÈÎfi Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ Duchenne) ¡ÂÔÁÓ¿ - µÚ¤ÊË ñ ∂Ȃ‚·›ˆÛË ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ (.¯. Ê·ÈÓfiÙ˘Ô˜ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ Ì ıÂÙÈÎfi ÙÂÛ٠ȉÚÒÙ·) ¶·È‰È¿ ñ ¢ÈÂÚ‡ÓËÛË ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ (.¯. ·ÔÎÏÂÈÛÌfi˜ Û˘Ó‰ÚfiÌÔ˘ ¢ıÚ·‡ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ Ã) ñ ∂Ȃ‚·›ˆÛË ‰È¿ÁÓˆÛ˘ ÓÔÛ‹Ì·ÙÔ˜ Ì ¤Ó·ÚÍË ÂΉËÏÒÛÂˆÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (.¯ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne) ∂Ó‹ÏÈΘ ñ ŒÏÂÁ¯Ô˜ ÊÔÚ¤ˆÓ (.¯. ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ΢ÛÙÈ΋˜ ›ÓˆÛ˘) ñ ¶ÚÔÛ˘Ìو̷ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ (ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ηÚΛÓÔ˘ Ì·ÛÙÔ‡/ˆÔıËÎÒÓ) ñ ∂Ȃ‚·›ˆÛË ‰È¿ÁÓˆÛ˘ ÓÔÛ‹Ì·ÙÔ˜ Ì ¤Ó·ÚÍË ÂΉËÏÒÛÂˆÓ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (.¯. ÓfiÛÔ˜ Huntington)
(4,5) ˘¤‚·Ï·Ó Û ·Ó¿Ï˘ÛË ÂÚ›ıÏ·Û˘ ·ÎÙ›ÓˆÓ Ã (Ù¯ÓÈ΋ ηıÔÚÈÛÌÔ‡ ÙÚÈۉȿÛÙ·Ù˘ ·ÙÔÌÈ΋˜ ‰ÔÌ‹˜ ÙˆÓ ÌÔÚ›ˆÓ) ÙÔ ‰ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚Îfi Ô͇ (DNA) ·Ô‰›‰ÔÓÙ¿˜ ÙÔ˘ ÙË ‰›ÎψÓË ÂÏÈÎÔÂȉ‹ ÌÔÚÊ‹, ‰›ÓÔÓÙ·˜ ¤ÙÛÈ ·¿ÓÙËÛË Û ÂÚˆÙ‹Ì·Ù· ÙÔ˘ Ù‡Ô˘: ‰˘Ó·ÙfiÙËÙ· ·ÎÚÈ‚Ô‡˜ ·ÓÙÈÁÚ·Ê‹˜ ÙˆÓ 2 ÎÏÒÓˆÓ Î·È ÌÂÙ·ÊÔÚ¿ ÏËÚÔÊÔÚÈÒÓ, ˘fi ¯ËÌÈ΋ ÌÔÚÊ‹, ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡. ∏ ¤Ó·ÚÍË Ù˘ Û‡ÓıÂÛ˘ ÙÔ˘ DNA, fiˆ˜ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ, Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÛÙȘ ÏÂÁfiÌÂÓ˜ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ (replication forks) ˘fi ÙËÓ ·ÚÔ˘Û›· ÂȉÈÎÒÓ ÂÓ·ÚÎÙ‹ÚÈˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ·Ó·ÁÓˆÚ›˙Ô˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ DNA ÛÙȘ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ·Ô‰È·Ù¿ÛÛÔ˘Ó ÙÔÈο ÙÔ˘˜ 2 ÎÏÒÓÔ˘˜ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜. √È ÚÔ·ÙÔÓÙ˜ ÂÎÙÂıÂÈ̤ÓÔÈ ÌÔÓÔ› ÎÏÒÓÔÈ ·Ú·Ì¤ÓÔ˘Ó ·Ó¤·ÊÔÈ Î·È ÏÂÈÙÔ˘ÚÁÔ‡Ó ˆ˜ ÂÎÌ·Á›· ÁÈ· ÙÔ Û¯ËÌ·ÙÈÛÌfi Û˘ÌÏËڈ̷ÙÈÎÒÓ ÎÏÒÓˆÓ DNA (∂ÈÎfiÓ˜ 1· Î·È 1‚) ˘fi ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ DNA ÔÏ˘ÌÂÚ¿ÛË Î·È ¿ÓÙÔÙ ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË 5ã→3ã. ∆· ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÙȘ ÁÂÓÂÙÈΤ˜ ÙÔ˘˜ Ô‰ËÁ›Â˜, Ù· ÁÔÓ›‰È¿ ÙÔ˘˜, ̤ۈ Ù˘ ÌÂÙ·ÁÚ·Ê‹˜ Î·È Ù˘ ÌÂÙ¿ÊÚ·Û˘, ¤ÙÛÈ ÒÛÙÂ Ë ÚÔ‹ ÙˆÓ ÁÂÓÂÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ Ó· Â›Ó·È ¿ÓÙ· Ë ÂÍ‹˜: DNA→RNA→¶ÚˆÙ½Ó˜. ∆Ô RNA ‰È·‰Ú·Ì·Ù›˙ÂÈ Î˘Ú›ˆ˜ ÙÔ ÚfiÏÔ ÂÓfi˜ ÌÂÛ¿˙ÔÓÙ· (∂ÈÎfiÓ· 2). ∫·Ù¿ Û˘Ó¤ÂÈ·, Ù· ÁÔÓ›‰È· ‰ÂÓ Â›Ó·È Ù›ÔÙ ¿ÏÏÔ ·fi ÙȘ ıÂÌÂÏÈÒ‰ÂȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ÌÔÓ¿‰Â˜ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ οı ˙ÒÓÙÔ˜ ÔÚÁ·ÓÈÛÌÔ‡ Ô˘ ηٷϷ̂¿ÓÔ˘Ó ¤Ó·Ó ÂȉÈÎfi ÙfiÔ-ı¤ÛË (locus) ¿Óˆ Û οı ¯ÚˆÌfiۈ̷. ∏ ‰ÔÌ‹ ÙÔ˘ οıÂ
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·107
107
ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË
∞ÊÂÙËÚ›· ·ÓÙÈÁÚ·Ê‹˜
∞ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜
1
5ã ¢›Îψӷ DNA 3ã
∫·Ù‡ı˘ÓÛË Ù˘ ‰È¯¿Ï·˜ 2
3ã 5㠢ȿÓÔÈÍË Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ Ì ÙË ‚Ô‹ıÂÈ· ÂÓ·ÚÎÙ‹ÚÈˆÓ ÂÎÌ·Á›ˆÓ
¢È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜
0,1 Ìm
5ã
3ã
3ã
5ã
0,1 Ìm
ªÔÓfiÎψӷ DNA ÂÎÌ·Á›·, ¤ÙÔÈÌ· ÁÈ· ÙË Û‡ÓıÂÛË DNA
3
∂ÈÎfiÓ· 1‚. ∞ÓÙÈÁÚ·Ê‹ DNA. ∂ȉÈΤ˜ ÂÓ·ÚÎÙ‹ÚȘ ÚˆÙ½Ó˜ ·Ó·ÁÓˆÚ›˙Ô˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ DNA ÛÙȘ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÙÔÈο ·Ô‰È·Ù¿ÛÛÔ˘Ó ÙÔ˘˜ 2 ÎÏÒÓÔ˘˜ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜. √È ÚÔ·ÙÔÓÙ˜ ÌÔÓÔ› ÎÏÒÓÔÈ ‰‡Ó·ÓÙ·È Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ ÂÎÌ·Á›· ·ÓÙÈÁÚ·Ê‹˜ ÙÔ˘ DNA.
∂ÈÎfiÓ· 1·. ™‡ÓıÂÛË DNA ÛÙȘ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ (replication forks). ∏ÏÂÎÙÚÔÓÈ΋ ÌÈÎÚÔʈÙÔÁÚ·Ê›· ¯ÚˆÌÔÛÒÌ·ÙÔ˜ ¢ηڢˆÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘, ÛÙÔ ÔÔ›Ô ÔÈ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ ÌÂÙ·ÎÈÓÔ‡ÓÙ·È ÚÔ˜ ·ÓÙ›ıÂÙ˜ ηÙ¢ı‡ÓÛÂȘ ÍÂÎÈÓÒÓÙ·˜ ·fi ÔÏϷϤ˜ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜.
ÁÔÓȉ›Ô˘ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ Î·È ·ÔÙÂÏÂ›Ù·È ·fi ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ·ÏÏËÏÔ˘¯›Â˜, ÁÓˆÛÙ¤˜ ˆ˜ ÂÛfiÓÈ· (introns), ÂÓ·ÏÏ·ÛÛfiÌÂÓ˜ Ì Έ‰ÈÎÔÔÈÔ‡Û˜ ·ÏÏËÏÔ˘¯›Â˜, Ù· ÂÍfiÓÈ· (exons). ™˘Ó‹ıˆ˜, Ù· ÂÍfiÓÈ· Â›Ó·È ‚Ú·¯‡ÙÂÚ· ·fi Ù· ÈÓÙÚfiÓÈ· Î·È Ë ÂÚÈÔ¯‹ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È Û˘¯Ó¿ ·ÓÙÈÚÔۈ‡ÂÈ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÙÔ˘ ÂοÛÙÔÙ ÁÔÓȉ›Ô˘ (∂ÈÎfiÓ· 3). ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰ÔÌ‹ Î·È Ê˘ÛÈο ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ οı ÁÔÓȉ›Ô˘ ¤¯Ô˘Ó ÔÈ ˘ÔÎÈÓËÙ¤˜ (promoters).
¶˘Ú‹Ó·˜
¶ÚfiÎÂÈÙ·È ÁÈ· ·ÏÏËÏÔ˘¯›Â˜ DNA ÛÙȘ Ôԛ˜ ÚÔÛ‰¤ÓÂÙ·È Ë RNA ÔÏ˘ÌÂÚ¿ÛË ÚÔÙÔ‡ ·Ú¯›ÛÂÈ ÙË ÌÂÙ·ÁÚ·Ê‹ ÙÔ˘ DNA Û RNA. ∆Ô ÁÔÓȉ›ˆÌ· ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡ Â›Ó·È fiϘ ÔÈ ÎÏËÚÔÓÔÌ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ Î·È Îˆ‰ÈÎÔÔÈÂ›Ù·È ÛÙÔ DNA. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÂÎÙÈÌ‹ÛÂȘ, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· ¤¯ÂÈ Ì¤ÁÂıÔ˜ ÂÚ›Ô˘ 3 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‚¿ÛÂȘ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ 20.000-25.000 ÁÔÓ›‰È· (6). ∏ ÁÔÓȉȷ΋ ˘ÎÓfiÙËÙ· ÂÓfi˜ ÁÔÓȉÈÒÌ·ÙÔ˜ Â›Ó·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÁÔÓȉ›ˆÓ ·Ó¿ ¤Ó· ÂηÙÔÌ̇ÚÈÔ ‚¿ÛÂȘ (megabase, Mb).
πÓÙÚfiÓÈ·
∂ÍfiÓÈ·
DNA
°ÔÓ›‰ÈÔ
MÂÙ·ÁÚ·Ê‹
¶ÚˆÙÔÁÂÓ¤˜ RNA ÌÂÙ¿ÁÚ·ÊÔ
¶ÚÔÛı‹ÎË 5' ηχÙÚ·˜ Î·È Ô˘Ú¿˜ ÔÏ˘ ∞
∫·Ï‡ÙÚ· RNA ∞∞∞∞ ™˘ÚÚ·Ê‹ RNA m RNA
∞∞∞∞ EÍ·ÁˆÁ‹
m RNA
∞∞∞∞ MÂÙ¿ÊÚ·ÛË
∫˘ÙÙ·ÚfiÏ·ÛÌ·
¶ÚˆÙ½ÓË
∂ÈÎfiÓ· 2. ∏ ÚÔ‹ ÁÂÓÂÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ ·fi DNA Û ڈÙ½ÓË. ™¯ËÌ·ÙÈ΋ ·Ó··Ú¿ÛÙ·ÛË ÙˆÓ ÛÙ·‰›ˆÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· Ó· ÂÎÊÚ·Ûı› Ë ÁÂÓÂÙÈ΋ ÏËÚÔÊÔÚ›·. ™Ù· ¢ηڢˆÙÈο ·ÙÙ·Ú· ÙÔ ·Ú¯ÈÎfi ÌfiÚÈÔ ÙÔ˘ RNA ÂÚȤ¯ÂÈ ÈÓÙÚfiÓÈ· Ù· ÔÔ›· ·Ê·ÈÚÔ‡ÓÙ·È Ì ÌÈ· ÂÓ˙˘ÌÈο Î·Ù·Ï˘fiÌÂÓË ·ÓÙ›‰Ú·ÛË Û˘ÚÚ·Ê‹˜. ∞fi ÙȘ ÌÂÙ·ÙÚÔ¤˜ ·˘Ù¤˜ ·Ú¿ÁÂÙ·È mRNA, ÙÔ ÔÔ›Ô ÌÂٷʤÚÂÙ·È ·fi ÙÔÓ ˘Ú‹Ó· ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·, fiÔ˘ Î·È ÌÂÙ·ÊÚ¿˙ÂÙ·È Û ڈÙ½ÓË. ¶·È‰È·ÙÚÈ΋ 2008;71:105-115
Pediatri Mar-Apr 08
10-04-08
12:42
™ÂÏ›‰·108
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™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜
™ËÌÂ›Ô ÂÎΛÓËÛ˘ ÌÂÙ·ÁÚ·Ê‹˜ Û RNA -1
πÓÙÚfiÓÈÔ
TGA-Έ‰ÈÎfiÓÈÔ ÙÂÚÌ·ÙÈÛÌÔ‡ ÌÂÙ¿ÊÚ·Û˘ tga
Ṳ̂ӷ Ì ٤ÙÔÈÔ ÙÚfiÔ, ÒÛÙ ӷ ·Ô‰›‰Ô˘Ó ÂÚ›Ô˘ 6 Ìg DNA ·fi 200 Ìl ÂÚÈÊÂÚÈÎÔ‡ ÔÏÈÎÔ‡ ·›Ì·ÙÔ˜ Ì ·ÓÙÈËÎÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ -fiˆ˜ EDTAÎ·È Ì¤¯ÚÈ 50 Ìg DNA ·fi Ù· ÂÈıËÏȷο ·ÙÙ·Ú· Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Ô˘ ÂÚȤ¯ÔÓÙ·È Û 200 Ìl ÛȤÏÔ˘ (13).
∂ÍfiÓÈÔ
∂ÈÎfiÓ· 3. ∆˘ÈÎfi ÁÔÓ›‰ÈÔ Â˘Î·Ú˘ˆÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘. ∫¿ı ÁÔÓ›‰ÈÔ ·ÔÙÂÏÂ›Ù·È ·fi Έ‰ÈÎÔÔÈÔ‡Û˜ (ÂÍÒÓÈ·) Î·È ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜ (ÂÛfiÓÈ· ‹ ÈÓÙÚfiÓÈ·).
H ÁÔÓȉȷ΋ ˘ÎÓfiÙËÙ· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ Â›Ó·È Û¯Â‰fiÓ 12-15 ÁÔÓ›‰È·/ÌÂÁ·‚¿ÛË (7). √È ‰ÈÂÚÁ·Û›Â˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÂȉÈfiÚıˆÛ˘ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ οı ΢ÙÙ¿ÚÔ˘ Û¿ÓÈ· ·ÔÙ˘Á¯¿ÓÔ˘Ó Î·È ¤ÙÛÈ ‰È·ÙËÚÂ›Ù·È Ë ÓÔ˘ÎÏÂÔÙȉÈ΋ ÙÔ˘ ·ÏÏËÏÔ˘¯›· ÛÙ·ıÂÚ‹. ∂Ó›ÔÙÂ, fï˜, ‰‡Ó·Ù·È Ó· ·Ú·ÙËÚËıÔ‡Ó ÓÔ˘ÎÏÂÔÙȉÈΤ˜ ·ÏÏ·Á¤˜, ÛËÌÂȷΤ˜ ‹ ÌË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ô‰ËÁԇ̷ÛÙ Û ۇÓıÂÛË ·ıÔÏÔÁÈÎÒÓ ÚˆÙÂ˚ÓÒÓ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÙË ÌË Ê˘ÛÈÔÏÔÁÈ΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ·Ú·ÁÒÁÔ˘ ÙÔ˘ ÁÔÓȉ›Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. √ÔÈ·‰‹ÔÙ ٤ÙÔÈ· ·ÏÏ·Á‹ ηÏÂ›Ù·È ÌÂÙ¿ÏÏ·ÍË. ∂ÓÙÔ‡ÙÔȘ, ÛËÌÂȷΤ˜ ·ÏÏ·Á¤˜ Û ÁÔÓ›‰ÈÔ, ÔÈ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ó ›وÛË ÛÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ Έ‰ÈÎÔÔÈÔ‡Û·˜ ÚˆÙ½Ó˘, ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ÔÏ˘ÌÔÚÊÈÛÌÔ› ‹ ÔÏ˘ÌÔÚÊÈΤ˜ ı¤ÛÂȘ. ªÂÙ·ÏÏ¿ÍÂȘ ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ ÛÙȘ Έ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜ ÙˆÓ ÁÔÓȉ›ˆÓ, ·ÏÏ¿ Î·È Û ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜, Ì ٷ ›‰È· ·ÔÙÂϤÛÌ·Ù· (8). OÈ Î˘ÚÈfiÙÂÚÔÈ Ù‡ÔÈ ÌÂÙ·ÏÏ¿ÍÂˆÓ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2.
∞ÔÌfiÓˆÛË DNA ∏ ÂͤٷÛË ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÚÔ¸Ôı¤ÙÂÈ Û ÚÒÙË Ê¿ÛË ÙËÓ ÂÍ·ÁˆÁ‹ Î·È ·ÔÌfiÓˆÛË ÙÔ˘ DNA (ÁÂÓˆÌÈÎÔ‡, ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ ‹ ÈÈÎÔ‡) ·fi ÂÚÈÊÂÚÈÎfi ·›Ì· ‹ ¿ÏÏÔ˘˜ ÈÛÙÔ‡˜, Ì ÛÎÔfi ÙÔ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ·fi Ù· ˘fiÏÔÈ· Û˘ÛÙ·ÙÈο ÙˆÓ Î˘ÙÙ¿ÚˆÓ (ÚˆÙ½Ó˜, ÏÈ›‰È·, RNA, Î.Ï.). √È ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË Ì˯·ÓÈ΋ ıÚ·‡ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ, ÒÛÙ ӷ ·ÓÔ›ÍÔ˘Ó Ì ÙË ¯Ú‹ÛË ‰È¿ÊÔÚˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ Î·È ÂÓ˙‡ÌˆÓ, Ì ÛÎÔfi ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (9-11). À¿Ú¯Ô˘Ó ‰‡Ô ̤ıÔ‰ÔÈ ·ÔÌfiÓˆÛ˘ DNA ·fi ÂÚÈÊÂÚÈÎfi ·›Ì· ‹ ·fi ‰È¿ÊÔÚÔ˘˜ ÈÛÙÔ‡˜, Ë Ì¤ıÔ‰Ô˜ ÙÔ˘ NaCl (10) Î·È Ë ¯Ú‹ÛË ÙˆÓ ÂÌÔÚÈο ‰È·ı¤ÛÈÌˆÓ ‘kits’, Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ï¤ÔÓ ÂÚÈÛÛfiÙÂÚÔ ÏfiÁˆ Ù˘ ˘ÂÚÔ¯‹˜ ÙÔ˘˜ Û ٷ¯‡ÙËÙ· (ÂÚ›Ô˘ 25 ÏÂÙ¿, ¤Ó·ÓÙÈ ‰‡Ô ËÌÂÚÒÓ ÛÙË Ì¤ıÔ‰Ô ÙÔ˘ NaCl) (12) Î·È Ù˘ ηı·ÚfiÙËÙ·˜ ÙÔ˘ ÂÍ·ÁfiÌÂÓÔ˘ DNA. ∆· ÂÌÔÚÈο ‰È·ı¤ÛÈÌ· kits Â›Ó·È Û¯Â‰È·Paediatriki 2008;71:105-115
AÓ¿Ï˘ÛË Î·È ÌÂϤÙË ÙÔ˘ DNA ∞Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ (Polymerase Chain Reaction, PCR) ∏ ̤ıÔ‰Ô˜ ·Ó·Î·Ï‡ÊıËΠÙÔ 1987 ·fi ÙÔÓ Mullis (14), Ô ÔÔ›Ô˜ ‚Ú·‚‡ÙËΠ̠Nobel ÙÔ 1995, Î·È ·ÔÛÎÔ› ÛÙÔÓ ÂÎıÂÙÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi ÌÈÎÚÒÓ ÙÌËÌ¿ÙˆÓ DNA Ì ÙË ¯Ú‹ÛË Û˘ÓıÂÙÈÎÒÓ ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉ›ˆÓ (ÂÎÎÈÓËÙ¤˜-primers) Î·È ıÂÚÌÔ·ÓıÂÎÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ (15-17). √ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ·ÊÔÚ¿ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÚÈÔ¯¤˜ DNA Ô˘ ÌÔÚ› Ó· ÂÚȤ¯Ô˘Ó ›Ù ¤Ó· ·Ïfi ÁÔÓ›‰ÈÔ ‹ ̤ÚÔ˜ ·˘ÙÔ‡ ‹ ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜, ÌÂÁ¤ıÔ˘˜ ̤¯ÚÈ 10.000 ‚¿ÛÂȘ (bp) (18-21). ∏ Ù¯ÓÈ΋ PCR ‚·Û›˙ÂÙ·È ÛÙËÓ ÂÓ˙˘Ì·ÙÈ΋ ÎψÓÔÔ›ËÛË ÙÔ˘ ÁÂÓˆÌÈÎÔ‡ ˘ÏÈÎÔ‡, ¯ˆÚ›˜ ÙË ¯Ú‹ÛË ˙ÒÓÙˆÓ ÔÚÁ·ÓÈÛÌÒÓ fiˆ˜ ∂. coli ‹ ̇ÎËÙ˜ (14-17). ∏ ̤ıÔ‰Ô˜ ÂÊ·ÚÌfi˙ÂÙ·È Â˘Ú‡Ù·Ù· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È ÙË ‚ÈÔÏÔÁÈ΋ ¤Ú¢ӷ ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚ› Ó· ÂÓÙÔ›ÛÂÈ ÌÈ· Û˘ÁÎÂÎÚÈ̤ÓË ·ÏÏËÏÔ˘¯›· DNA ‹ RNA Û ÔÔÈÔ‰‹ÔÙ ˘fi ÂͤٷÛË ÎÏÈÓÈÎfi ‰Â›ÁÌ· (22). ∫Ï·ÛÈο ·Ú·‰Â›ÁÌ·Ù· Â›Ó·È ÔÈ ÁÂÓÂÙÈΤ˜ ·ı‹ÛÂȘ ÁÓˆÛÙÒÓ ÌÔÓÔÁÔÓȉȷÎÒÓ ‹ ÔÏ˘ÁÔÓȉȷÎÒÓ ÓÔÛËÌ¿ÙˆÓ, fiÔ˘ Ì PCR ·ÓȯÓ‡ÂÙ·È Ë ÌÂÙ·‚ÔÏ‹ ¤ÛÙˆ Î·È ÌÈ·˜ ÌfiÓÔ ‚¿Ûˆ˜ Î·È ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÔÌfi˙˘Á˜ ‹ ÂÙÂÚfi˙˘Á˜ ηٷÛÙ¿ÛÂȘ, Î·Ù·Ï˘ÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÂÍÂÏÈÎÙÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ (¶›Ó·Î·˜ 3). ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi, ηı›ÛÙ·Ù·È ÂÊÈÎÙfi˜ Ô ÚÔÁÂÓÓËÙÈÎfi˜, ·fi ·ÌÓÈ·Îfi ˘ÁÚfi (23) ‹ ¯ÔÚȷΤ˜ Ï¿¯Ó˜ (24,25), ηıÒ˜ Î·È Ë ÚÔÂÌÊ˘Ù¢ÙÈ΋ ‰È¿ÁÓˆÛË ·fi ‚Ï·ÛÙÔ·ÛÙË (26) ‹ ÔÏÈÎfi ۈ̿ÙÈÔ (27). ¶›Ó·Î·˜ 2. ∆‡ÔÈ ÌÂÙ·ÏÏ¿ÍÂˆÓ 1. ∂ÏÏ›„ÂȘ ‹ ‰ÈÏ·ÛÈ·ÛÌÔ› ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÍÔÓ›ˆÓ ÂÓfi˜ ÁÔÓȉ›Ô˘. 2. ªÂÙ·ÏÏ¿ÍÂȘ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ˘ÔÎÈÓËÙ‹. 3. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ‰È·‰Èηۛ· ÙÔ˘ Ì·Ù›ÛÌ·ÙÔ˜. 4. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ·ÏÏ¿˙Ô˘Ó ÙÔ Ï·›ÛÈÔ ·Ó¿ÁÓˆÛ˘ (frameshifts). 5. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó Îˆ‰ÈÎfiÓÈÔ ÙÂÚÌ·ÙÈÛÌÔ‡ (nonsense mutation). 6. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ·ÏÏ¿˙Ô˘Ó ¤Ó· ·ÌÈÓÔ͇ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ Ì ¤Ó· ¿ÏÏÔ (missense mutation). 7. MÂÙ·ÏÏ¿ÍÂȘ Ô˘, ÂÓÒ ·ÏÏ¿˙Ô˘Ó ÙÔ Îˆ‰ÈÎfiÓÈÔ ÂÓfi˜ ·ÌÈÓÔͤԘ, ‰ÂÓ ·ÏÏ¿˙Ô˘Ó ÙÔ ·ÌÈÓÔ͇ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È (silent mutation).
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·109
109
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£¤ÚÌ·ÓÛË ÁÈ· ÙÔ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ÎÏÒÓˆÓ
À‚ÚȉÈÛÌfi˜ ÙˆÓ ÂÎÎÈÓËÙÒÓ
+DNA ÔÏ˘ÌÂÚ¿ÛË +dNTPs
¢›ÎψÓÔ DNA
™Ù¿‰ÈÔ 2
™Ù¿‰ÈÔ 1
™Ù¿‰ÈÔ 3
1Ô˜ ·ÎÏÔ˜ ∂ÈÎfiÓ· 4. ∏ ‚·ÛÈ΋ ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ Ù˘ PCR. ∏ ‚·ÛÈ΋ ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ PCR, fiˆ˜ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ·ÎÏÔ˘. √È ‰‡Ô ·Ï˘Û›‰Â˜ DNA ·Ô‰È·Ù¿ÛÛÔÓÙ·È (ÛÙ¿‰ÈÔ 1) Î·È Ô Î¿ı ÂÎÎÈÓËÙ‹˜ ÚÔÛÎÔÏÏ¿Ù·È ÛÙÔ Û˘ÌÏËڈ̷ÙÈÎfi ÙÔ˘ ÎÏÒÓÔ (ÛÙ¿‰ÈÔ 2). √È ÂÎÎÈÓËÙ¤˜ ÂÈÌË·ÓÔÓÙ·È Ì ÙË ‰Ú¿ÛË Ù˘ DNA ÔÏ˘ÌÂÚ¿Û˘ ·ÓÙÈÁÚ¿ÊÔÓÙ·˜ ÙËÓ ÂÚÈÔ¯‹ ÛÙfi¯Ô ÙÔ˘ DNA (ÛÙ¿‰ÈÔ 3).
∏ ¯Ú‹ÛË Ù˘ PCR ÂӉ›ÎÓ˘Ù·È Â›Û˘ ÛÙË ‰È¿ÁÓˆÛË ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ‰ÈfiÙÈ Ë Â˘·ÈÛıËÛ›· Ù˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·ÎfiÌ· Î·È ·fi ·˘Ù‹ ÙˆÓ ·ÓÔÛÔÂÓ˙˘Ìȶ›Ó·Î·˜ 3. ¶·Ú·‰Â›ÁÌ·Ù· ÎÏËÚÔÓÔÌÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ‰‡Ó·ÓÙ·È Ó· ‰È·ÁÓˆÛıÔ‡Ó Ì PCR ñ A˘ÙÔۈ̷ÙÈÎfi˜ EÈÎÚ·ÙËÙÈÎfi˜
∫ˆ‰ÈÎfi˜ PubMed
¶ÔÏ˘Î˘ÛÙÈ΋ ÓfiÛÔ˜ ÙˆÓ ÓÂÊÚÒÓ ¡fiÛÔ˜ ÙÔ˘ Huntington ª˘ÔÙÔÓÈ΋ ‰˘ÛÙÚÔÊ›· √˙҉˘ ÛÎÏ‹Ú˘ÓÛË ∫ÒʈÛË DFN∞5 ÀÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· ƒÂÙÈÓÔ‚Ï¿Ûو̷
OMIM 600666 OMIM 143100 OMIM 160900 OMIM 191100 OMIM 608798 √ªπª 44010 OMIM 180200
ñ ∞˘ÙÔۈ̷ÙÈÎfi˜ YÔÏÂÈfiÌÂÓÔ˜ ™˘ÁÁÂÓ¤˜ ÓÂÊÚˆÙÈÎfi Û‡Ó‰ÚÔÌÔ ∫˘ÛÙÈ΋ ›ÓˆÛË ¡Â˘ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· DFNB1 µ ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· º·ÈÓ˘ÏÔÎÂÙÔÓÔ˘Ú›· ™‡Ó‰ÚÔÌÔ Usher 1 ŒÏÏÂÈ„Ë 21-˘‰ÚÔÍ˘Ï¿Û˘ NfiÛÔ˜ Tay-Sachs ¡fiÛÔ˜ Gaucher ™‡Ó‰ÚÔÌÔ Bloom ¡ˆÙÈ·›· Ì˘˚΋ ·ÙÚÔÊ›· (SMA)
∫ˆ‰ÈÎfi˜ PubMed √ªπª 600995 √ªπª 219700 √ªπª 220290 √ªπª 141900 √ªπª 261600 OMIM 276900 OMIM 201910 OMIM 272800 OMIM 230800 OMIM 210900 OMIM 253300
ñ à º˘ÏÔÛ‡Ó‰ÂÙÔ˜ ∫ˆ‰ÈÎfi˜ PubMed ™‡Ó‰ÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à OMIM 300624 ¡ÂÊÚÔÏÈı›·ÛË OMIM 310468 ∞ÈÌÔÊÈÏ›· ∞/µ √ªπª 306700/ 306900 ª˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne √ªπª 310200 ª˘˚΋ ‰˘ÛÙÚÔÊ›· Becker √ªπª 300376 ∞¯ÚˆÌ·ÙÔ„›· ÂÚ˘ıÚÔ‡-Ú·Û›ÓÔ˘ (‰·ÏÙÔÓÈÛÌfi˜) √ªπª 303900 X Ê˘ÏÔÛ‡Ó‰ÂÙË È¯ı‡·ÛË √ªπª 607602 Ã Ê˘ÏÔÛ‡Ó‰ÂÙË ·Á·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· √ªπª 300300 ŒÏÏÂÈ„Ë ÁÏ˘Îfi˙˘ 6 ʈÛÊ·Ù¿Û˘ ·Ê˘‰ÚÔÁÔÓ¿Û˘ √ªπª 305900
ÎÒÓ ÌÂıfi‰ˆÓ (Elisa) (28) Î·È ··ÈÙÂ›Ù·È ÂÏ¿¯ÈÛÙÔ ÁÂÓÂÙÈÎfi ˘ÏÈÎfi ÙÔ˘ ·ıÔÁfiÓÔ˘ ·ÈÙ›Ô˘ (¤Ó· ÌfiÓÔ ·ÓÙ›ÁÚ·ÊÔ), ÒÛÙ ӷ ÌË ‚·Û›˙ÂÙ·È Ë ‰È¿ÁÓˆÛË ÛÙËÓ ‡·ÚÍË ‹ ÌË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘ (¶›Ó·Î·˜ 4). ∏ PCR ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â›Û˘ ÛÙËÓ ·Ó›¯Ó¢ÛË ·ÏÏËÏÔ˘¯ÈÒÓ ÁÔÓȉÈÒÌ·ÙÔ˜ ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Ì ηÎÔ‹ıÂȘ fiÁÎÔ˘˜ ‹ ÛÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ÔÁÎÔÁÔÓ›‰È· ‹/Î·È ÔÁÎÔηٷÛÙ·ÏÙÈο ÁÔÓ›‰È· (¶›Ó·Î·˜ 4). ∏ ·ÓÙ›‰Ú·ÛË Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÛÙÔ ıÂÚÌÈÎfi ΢ÎÏÔÔÈËÙ‹, Ô ÔÔ›Ô˜ ·˘ÍÔÌÂÈÒÓÂÈ ÙË ıÂÚÌÔÎÚ·Û›· Ù˘ ·ÓÙ›‰Ú·Û˘, Ì ÛÎÔfi ÙË ‰È·‰Ô¯È΋ ·Ô‰È¿Ù·ÍË Î·È ˘‚ÚȉÔÔ›ËÛË Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ DNA. H ·ÓÙ›‰Ú·ÛË PCR ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚ›· ÛÙ¿‰È· (∂ÈÎfiÓ˜ 4 Î·È 5): 1. AԉȿٷÍË ÙÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ (template denaturation) Û ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· (94ÔC-96ÔC) Ì ‰È¿ÚÎÂÈ· ÂÓfi˜ ÏÂÙÔ‡. 2. ™‡Ó‰ÂÛË (annealing) ÙˆÓ ÂÎÎÈÓËÙÒÓ Ì ÙȘ Û˘ÌÏËڈ̷ÙÈΤ˜ ÙÔ˘˜ ·ÏÏËÏÔ˘¯›Â˜ ÛÙÔ DNA Û ıÂÚÌÔÎÚ·Û›· ÌÂٷ͇ 37ÔC-70ÔC Û˘Ó‹ıˆ˜ ÁÈ· ¤Ó· ÏÂÙfi. 3. ∂ÈÌ‹Î˘ÓÛË ÙˆÓ ˘‚ÚȉÈÛÌ¤ÓˆÓ ÂÎÎÈÓËÙÒÓ (primer extension), Ë ÔÔ›· Á›ÓÂÙ·È Û ıÂÚÌÔÎÚ·Û›·
¶›Ó·Î·˜ 4. ¶·Ú·‰Â›ÁÌ·Ù· ›ÎÙËÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ‰‡Ó·ÓÙ·È Ó· ‰È·ÁÓˆÛıÔ‡Ó Ì PCR §ÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· ÕÚıÚÔ ∞Ó·ÊÔÚ¿˜ πfi˜ ÙÔ˘ Epstein-Barr (EBV) 49 ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ (CMV) 50 πfi˜ ·ÏÔ‡ ¤ÚËÙÔ˜ (HSV) 51 πfi˜ ÙˆÓ ·ÓıÚˆ›ÓˆÓ ıËÏˆÌ¿ÙˆÓ (HPV) 28 ª˘ÎÔ‚·ÎÙ‹ÚÈÔ Ê˘Ì·Ù›ˆÛ˘ 29 ¡ÂÔϷۛ˜ ∫ˆ‰ÈÎfi˜ PubMed √ÁÎÔηٷÛÙ·ÏÙÈο ÁÔÓ›‰È· BRCA1/ √ªπª 113705/ BRCA2 600185 P53 √ªπª 191170 MYC √ªπª 190080 RAS √ªπª 190020 ¶·È‰È·ÙÚÈ΋ 2008;71:105-115
Pediatri Mar-Apr 08
07-04-08
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™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜
¢È·¯ˆÚÈÛÌfi˜ ÙˆÓ ÎÏÒÓˆÓ ÙÔ˘ DNA Î·È ÚÔÛı‹ÎË ÂÎÎÈÓËÙÒÓ
¢È·¯ˆÚÈÛÌfi˜ ÙˆÓ ÎÏÒÓˆÓ ÙÔ˘ DNA Î·È ÚÔÛı‹ÎË ÂÎÎÈÓËÙÒÓ
™‡ÓıÂÛË DNA
™‡ÓıÂÛË DNA
DNA ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉÈÎÔ› ÂÎÎÈÓËÙ¤˜ ¢›ÎψÓÔ DNA
1Ô˜ ·ÎÏÔ˜ (·Ú¿ÁÂÈ 2 ‰›Îψӷ ÌfiÚÈ· DNA)
2Ô˜ ·ÎÏÔ˜ (·Ú¿ÁÂÈ 4 ‰›Îψӷ ÌfiÚÈ· DNA)
∂ÈÎfiÓ· 5. √ ÚÒÙÔ˜ Î·È ‰Â‡ÙÂÚÔ˜ ·ÎÏÔ˜ ÌÈ·˜ ·ÓÙ›‰Ú·Û˘ PCR. ∫·Ù¿ ÙÔÓ 1Ô Î‡ÎÏÔ Ù˘ ·ÓÙ›‰Ú·Û˘ ·Ú¿ÁÔÓÙ·È 2 ‰›Îψӷ ÌfiÚÈ· DNA, ηٿ ÙÔ 2Ô Î‡ÎÏÔ 4 ‰›Îψӷ ÌfiÚÈ· DNA, ηٿ ÙÔÓ 3Ô Î‡ÎÏÔ 16 Î.Ô.Î.
72ÔC ÁÈ· ¤Ó· ÂÚ›Ô˘ ÏÂÙfi. ∆· ÙÚ›· ·˘Ù¿ ÛÙ¿‰È· ·ÔÙÂÏÔ‡Ó ¤Ó·Ó ·ÎÏÔ Ù˘ ·ÓÙ›‰Ú·Û˘. ªÈ· Û˘ÓËıÈṲ̂ÓË PCR ·ÔÙÂÏÂ›Ù·È ·fi 25-30 ·ÎÏÔ˘˜. ™ÙÔ Ù¤ÏÔ˜ οı ·ÎÏÔ˘, ÙÔ ÚÔ˚fiÓ Ù˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ οı ÂÎÎÈÓËÙ‹ ı· ·ÔÙÂϤÛÂÈ -‡ÛÙÂÚ· ·fi ·Ô‰È¿Ù·ÍË- ÙÔ ˘fiÛÙڈ̷ ÙÔ˘ ¿ÏÏÔ˘ ÂÎÎÈÓËÙ‹. ∏ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÔÈÎÈÏ›· ·Ú·ÏÏ·ÁÒÓ, fiˆ˜ nested PCR, ARMS PCR, QRT-PCR Ì ÙË ıÂÌÂÏÈÒ‰Ë ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ Ó· ·Ú·Ì¤ÓÂÈ Ë ›‰È· (14,17,24). ∏ÏÂÎÙÚÔÊfiÚËÛË ÚÔ˚fiÓÙˆÓ PCR Û ‹Îو̷ ·Á·Úfi˙˘ ∏ ̤ıÔ‰Ô˜ Â›Ó·È Û˘ÌÏËڈ̷ÙÈ΋ Ù˘ PCR, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏÂÁ¯ı› Ë ÂÈÙ˘¯›· Ù˘ (29). ∆· ÚÔ˚fiÓÙ· Ù˘ ·ÓÙ›‰Ú·Û˘ PCR ËÏÂÎÙÚÔÊÔÚÔ‡ÓÙ·È Û ‹Îو̷ ·Á·Úfi˙˘ (∂ÈÎfiÓ· 6). ∏ ·Á·Úfi˙Ë Â›Ó·È ¤Ó· ÁÚ·ÌÌÈÎfi ÔÏ˘ÌÂÚ¤˜, Û˘ÛÙ·ÙÈÎfi ÙÔ˘ ¿Á·Ú, Ô˘ ¤¯ÂÈ ÙËÓ Ù¿ÛË Ó· Û¯ËÌ·Ù›˙ÂÈ ËÎÙÒÌ·Ù·, Ë ÂÚÈÂÎÙÈÎfiÙËÙ· ÙÔ˘ ÔÔ›Ô˘ ÂÈϤÁÂÙ·È Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ıÚ·˘ÛÌ¿ÙˆÓ DNA Ô˘ ı· ‰È·¯ˆÚÈÛıÔ‡Ó. ∆· ÚÔ˚fiÓÙ· Ù˘ PCR ËÏÂÎÙÚÔÊÔÚÔ‡ÓÙ·È ÛÙÔ ‹Îو̷ Ì·˙› Ì ÂȉÈ΋ ¯ÚˆÛÙÈ΋ (loading dye) Î·È Î·Ù¿ ÙÔ ‰È·¯ˆÚÈÛÌfi ‚¿ÊÔÓÙ·È Ì ‚ÚˆÌÈÔ‡¯Ô ·Èı›‰ÈÔ, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· ÚfiÛ‰ÂÛ˘ ÌÂٷ͇ ÙˆÓ ‚¿ÛÂˆÓ ÙÔ˘ DNA (29). ∆· ‰È·ÊÔÚÂÙÈο ıÚ·‡ÛÌ·Ù· DNA, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤¯Ô˘Ó ·ÚÓËÙÈÎfi ÊÔÚÙ›Ô, ηÙ¢ı‡ÓÔÓÙ·È ÚÔ˜ ÙÔ ıÂÙÈÎfi fiÏÔ Ì ٷ¯‡ÙËÙ· Ô˘ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙˆÓ ÏÔÁ·Ú›ıÌˆÓ ÙÔ˘ ÌÔÚÈ·ÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘, ÔÈ ˙ÒÓ˜ ÙÔ˘ DNA Á›ÓÔÓÙ·È ÔÚ·Ù¤˜ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· (∂ÈÎfiÓ· 6). Paediatriki 2008;71:105-115
°È· Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÚÔ˚fiÓÙÔ˜, ËÏÂÎÙÚÔÊÔÚÂ›Ù·È ·Ú·Ïϋψ˜ Î·È ¤Ó· Ì›ÁÌ· ıÚ·˘ÛÌ¿ÙˆÓ DNA ÁÓˆÛÙÔ‡ ÌÂÁ¤ıÔ˘˜. ªÂ ÙË Ì¤ıÔ‰Ô PCR ÌÔÚÔ‡Ó Â›Û˘ Ó· ·ÓȯÓ¢ıÔ‡Ó Î·È ÔÈ ÔÈΛÏÔ˘ ·ÚÈıÌÔ‡ ·ӷϷ̂·ÓfiÌÂÓ˜
M
· ‚
∂ÈÎfiÓ· 6. ∏ÏÂÎÙÚÔÊfiÚËÛË ARMS-PCR Û ‹Îو̷ ·Á·Úfi˙˘. ¢Â›ÁÌ·Ù· ˘fi ÂͤٷÛË Û˘ÁÎÚÈÓfiÌÂÓ· Ì ·ıÔÏÔÁÈÎfi ‰Â›ÁÌ·. ª¿ÚÙ˘Ú·˜ ÌÂÁ¤ıÔ˘˜ ·ÏÏËÏÔ˘¯ÈÒÓ: 100 bp ladder ·: ˙ÒÓË ÂϤÁ¯Ô˘ ÙˆÓ ˘fi ÂͤٷÛË ‰ÂÈÁÌ¿ÙˆÓ, ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÂÈÙ˘¯Ë̤Ó˘ ·ÓÙ›‰Ú·Û˘ (Û ÂÚ›ÙˆÛË ·Ô˘Û›·˜ Ù˘, Ë ·ÓÙ›‰Ú·ÛË ‰ÂÓ ‹Ù·Ó ÂÈÙ˘¯‹˜), ‚: ˙ÒÓË ·ıÔÏÔÁÈ΋˜ ·ÏÏËÏÔ˘¯›·˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ıÂÙÈÎfi ÎÔÓÙÚfiÏ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ËÏÂÎÙÚÔÊfiÚËÛË, Ë ·ÓÙ›‰Ú·ÛË Â›Ó·È ÂÈÙ˘¯‹˜ Î·È Î·Ó¤Ó· ‰Â›ÁÌ· ‰ÂÓ Ê¤ÚÂÈ ÌÂÙ¿ÏÏ·ÍË.
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ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË
·ÏÏËÏÔ˘¯›Â˜ (Variable Number of Tandem Repeats, VNTRs), Ì‹ÎÔ˘˜ 14-100 ‚¿ÛˆÓ. ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi ÌÈ· ÎÂÓÙÚÈ΋ ·ÏÏËÏÔ˘¯›· Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ¤Ó·Ó ·ÚÈıÌfi Ù·˘ÙfiÛËÌˆÓ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ·ÏÏËÏÔ˘¯ÈÒÓ, ÔÈ Ôԛ˜ ÔÚÁ·ÓÒÓÔÓÙ·È Û ÔÌ¿‰Â˜ (Ì ·ÚÈıÌfi ·ӿÏ˄˘ 4 ¤ˆ˜ 40 ÊÔÚ¤˜). ∞˘Ù¤˜ ÔÈ ÔÌ¿‰Â˜ ‚Ú›ÛÎÔÓÙ·È Û fiÏ· Ù· ¯ÚˆÌÔÛÒÌ·Ù· Î·È ÎÏËÚÔÓÔÌÔ‡ÓÙ·È Î·È ·fi ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜. OÈ VNTRs ¯ˆÚ›˙ÔÓÙ·È Û ‰‡Ô ηÙËÁÔڛ˜ Ì ‚¿ÛË ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜: 1) ÛÙȘ Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (minisatellites) Î·È 2) ÛÙȘ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (microsatellites). OÈ Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΘ ·ÏÏËÏÔ˘¯›Â˜ ·ÔÙÂÏÔ‡ÓÙ·È ·fi 10-100 bp Î·È ·Ó¢ڛÛÎÔÓÙ·È Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 1000 ÂÚÈÔ¯¤˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜. ™˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯ÚˆÌÔÛˆÌÈΤ˜ ÂÚÈÔ¯¤˜, ÔÈ Ôԛ˜ Â›Ó·È ÂÈÚÚ›˜ Û ıÚ˘ÌÌ·ÙÈÛÌÔ‡˜, fiˆ˜ ÙÂÏÔÌÂÚ›‰È·, ÂÓÒ ‚Ú›ÛÎÔÓÙ·È ÎÔÓÙ¿ Û ÛËÌ›· ÌÂÙ·ı¤ÛÂˆÓ (30). ∂ÈÚÔÛı¤Ùˆ˜, ÔÈ ÂÚÈÔ¯¤˜ Ô˘ ηχÙÔÓÙ·È ·fi Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ Â›Ó·È ÔÈ ÂÚÈÛÛfiÙÂÚÔ ·ÛÙ·ı›˜ ÛÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· (31). ∏ ¯·ÚÙÔÁÚ¿ÊËÛ‹ ÙÔ˘˜ ‚Ô‹ıËÛ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙË ÁÂÓÂÙÈ΋ Ù·˘ÙÔÔ›ËÛË (DNA fingerprint) Ô˘ Â›Ó·È ··Ú·›ÙËÙË ÛÙËÓ È·ÙÚÔ‰ÈηÛÙÈ΋ Î·È Â›Û˘ ÛÙË ‰È¿ÁÓˆÛË ÁÂÓÂÙÈÎÒÓ ·ı‹ÛÂˆÓ Ô˘ ÔÊ›ÏÔÓÙ·È Û ÌË Ê˘ÛÈÔÏÔÁÈÎfi ·Ó·‰ÈÏ·ÛÈ·ÛÌfi ÙÔ˘ DNA (ÔÏ˘ÌÔÚÊÈÛÌÔ› ·ÚÈıÌÔ‡ ·ÓÙÈÁÚ¿ÊˆÓ - copy number variation) (32). √È ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (microsatellite or Small Tandem Repeats, STRs) ·ÔÙÂÏÔ‡ÓÙ·È ·fi 100-200 ‚¿ÛÂȘ. ∂ÎÙÈÌ¿Ù·È fiÙÈ ÔÈ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ˘Â‡ı˘Ó˜ ÁÈ· ÙËÓ ÚfiÎÏËÛË ÓfiÛÔ˘, ·ÏÏ¿ ·ÔÙÂÏÔ‡Ó ÂÍ·ÈÚÂÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ Ù·˘ÙÔÔ›ËÛË ÂÓfi˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ ‹ ÌÈ·˜ ÁÂÓÂÙÈ΋˜ ı¤Û˘ Î·È ‚Ú›ÛÎÔ˘Ó ÂÊ·ÚÌÔÁ‹ ÛÙË ¯·ÚÙÔÁÚ¿ÊËÛË ÁÔÓȉ›ˆÓ Î·È ÛÙoÓ ¤ÏÂÁ¯Ô ·ÙÚfiÙËÙ·˜ (33) (∂ÈÎfiÓ· 7). ∞Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Ù˘ ÚˆÙÔÙ·ÁÔ‡˜ ‰ÔÌ‹˜ ÙÔ˘ DNA (Sequencing) ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· ÂÓfi˜ ÙÌ‹Ì·ÙÔ˜ DNA (.¯. ÁÔÓ›‰ÈÔ), ÂÈÙÚ¤ÔÓÙ·˜ ¤ÙÛÈ ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ (34,35). ∆Ô ÙÌ‹Ì· Ô˘ ·Ó·Ï‡ÂÙ·È ·Ô‰È·Ù¿ÛÛÂÙ·È Î·È ÏÂÈÙÔ˘ÚÁ› ˆ˜ Ì‹ÙÚ· ÛÙËÓ ÔÔ›· ˘‚Úȉ›˙ÂÙ·È ¤Ó·˜ ÂÎÎÈÓËÙ‹˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÍÂÎÈÓ‹ÛÂÈ Ë ÂÓ˙˘Ì·ÙÈ΋ ÂÈÌ‹Î˘ÓÛË Ù˘ ÂÚÈÔ¯‹˜-ÛÙfi¯Ô˘. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Â›Ó·È Ë Ú·ÁÌ·ÙÔÔ›ËÛË ·ÓÙ›‰Ú·Û˘, Û‡ÓıÂÛ˘ ·ÓÙÈÁÚ¿ÊˆÓ ÙÔ˘ ȉ›Ô˘ ÌÔÓfiÎψÓÔ˘ DNAÌ‹ÙÚ·, Ì ÙË ¯Ú‹ÛË 4 ddNTPs, ηı¤Ó· ·fi Ù· ÔÔ›· ʤÚÂÈ Û‹Ì·ÓÛË Ì ‰È·ÊÔÚÂÙÈ΋ ÊıÔÚ›˙Ô˘Û· ¯ÚˆÛÙÈ΋. ∆Ô ÚÔ˚fiÓ Ù˘ ·ÓÙ›‰Ú·Û˘ ‰È·¯ˆÚ›˙ÂÙ·È Ì οıÂÙË ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·ÎÚ˘Ï·Ì›‰Ë˜ ηÈ
M
C
F
Human paternity analysis using NICETM probe 33.6 ∂ÈÎfiÓ· 7. ŒÏÂÁ¯Ô˜ ·ÙÚfiÙËÙ·˜ Ì ¯Ú‹ÛË ÙˆÓ VNTRs. M=MËÙ¤Ú·, F= ¶·Ù¤Ú·˜, C= ¶·È‰›. ∫¿ı ˙ÒÓË ·ÓÙÈÚÔۈ‡ÂÈ ÌÈÎÚÔ-‰ÔÚ˘ÊÔÚÈΤ˜ ı¤ÛÂȘ (microsatellites). ™Â οı ı¤ÛË ·ÓÙÈÛÙÔÈ¯Ô‡Ó 2 ·ÏÏËÏfiÌÔÚÊ·. º·›ÓÔÓÙ·È ÔÈ ÌÈÎÚÔ-‰ÔÚ˘ÊÔÚÈΤ˜ ı¤ÛÂȘ Ô˘ ¤¯Ô˘Ó ÎÏËÚÔÓÔÌËı› ·fi ÙÔÓ Î¿ı ÁÔÓ¤· (ÎfiÎÎÈÓ· ‚¤ÏË-ı¤ÛÂȘ Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È ·fi ÙÔÓ ·Ù¤Ú·, ÌϤ ‚¤ÏË-ı¤ÛÂȘ Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È ·fi ÙË ÌËÙ¤Ú·).
‰‡Ó·Ù·È Ó· ·ÓȯÓ¢ı› Ì ‰¤ÛÌË ÊˆÙfi˜ laser (36-39). ∏ ·ÓÙ›‰Ú·ÛË Ï·Ì‚¿ÓÂÈ ¯ÒÚ· Û ıÂÚÌÈÎfi ΢ÎÏÔÔÈËÙ‹ (40). ∫·Ù¿ ̤ÛÔ fiÚÔ ··ÈÙÔ‡ÓÙ·È 30-35 ·ÎÏÔÈ, ¤ÙÛÈ ÒÛÙ ӷ ‰È·ÛÊ·ÏÈÛı› Ë ·Ú·ÁˆÁ‹ ·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ ·ÓÙÈÁÚ¿ÊˆÓ (∂ÈÎfiÓ· 8). ∏ ¢·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ Sequencing Â›Ó·È Ù¤ÙÔÈ· ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó›¯Ó¢ÛË ·ÏÏ·Á‹˜ ·ÎfiÌË Î·È ÌÈ·˜ ÌfiÓÔ ‚¿Û˘ ÛÙËÓ ˘fi ÌÂϤÙË ·ÏÏËÏÔ˘¯›·. ¶ÚfiÎÂÈÙ·È ‰ËÏ·‰‹ ÁÈ· ÌÈ· ÂÍ·ÈÚÂÙÈο ¯Ú‹ÛÈÌË Ù¯ÓÈ΋, Ë ÔÔ›· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ÔÔÈÔ‰‹ÔÙ ÁÂÓÂÙÈÎfi ÓfiÛËÌ·, ÂÊfiÛÔÓ ÁÓˆÚ›˙Ô˘Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· Ù˘ ÂÚÈÔ¯‹˜-ÛÙfi¯Ô˘.
A
C
A
T
C (g>a) A
T
C
C
C
∂ÈÎfiÓ· 8. ∞Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Ù˘ ÚˆÙÔÙ·ÁÔ‡˜ ‰ÔÌ‹˜ ÙÔ˘ DNA (Sequencing). ¶·Ú·ÙËÚÂ›Ù·È ·ÓÙÈηٿÛÙ·ÛË ÁÔ˘·Ó›Ó˘ ·fi ·‰ÂÓ›ÓË. ¶·È‰È·ÙÚÈ΋ 2008;71:105-115
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·112
112
™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜
6 5
8,248
7
4,612 4,412
mV 8
3,944
ªÂÚÈο ·fi Ù· ÂηÙÔÓÙ¿‰Â˜ ·Ú·‰Â›ÁÌ·Ù· ÁÂÓÂÙÈÎÒÓ ·ı‹ÛˆÓ, fiÔ˘ Ë Ù¯ÓÈ΋ ·˘Ù‹ ‚Ú›ÛÎÂÈ ÂÊ·ÚÌÔÁ‹ ÁÈ· ÙË ‰È¿ÁÓˆÛË, Â›Ó·È Ë Î˘ÛÙÈ΋ ›ÓˆÛË, Ë Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, ÙÔ Û‡Ó‰ÚÔÌÔ Rett, ÔÈ ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ, Ë Ô˙҉˘ ÛÎÏ‹Ú˘ÓÛË Î·È Ë ÓfiÛÔ˜ Wilson (41,42).
4
∞ԉȷٷÎÙÈ΋ ¯ÚˆÌ·ÙÔÁÚ·Ê›· ˘ÁÚ‹˜ Ê¿Û˘ (Denaturing High Performance Liquid Chromatography, DHPLC) ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÂÍ·ÈÚÂÙÈο ·ÍÈfiÈÛÙÔ Û‡ÛÙËÌ· ·Ó›¯Ó¢Û˘ ÌÂÙ·ÏÏ¿ÍÂˆÓ Î·È Û˘Á¯ÚfiÓˆ˜ ÁÚ‹ÁÔÚÔ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈ‹ÛÂÈ ÙÔÓ ¤ÏÂÁ¯Ô ÂÓfi˜ ‰Â›ÁÌ·ÙÔ˜ Û 6 ÏÂÙ¿. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÛÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ 24ÒÚÔ˘ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› Ô ¤ÏÂÁ¯Ô˜ ÂÚ›Ô˘ 240 ‰ÂÈÁÌ¿ÙˆÓ. ∏ Ù¯ÓÈ΋ DHPLC ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ DNA ‹ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏϿ͈Ó, fiˆ˜ ÂÓı¤ÛˆÓ, ÂÏÏ›„ˆÓ, ·ÓÙÈηٷÛÙ¿ÛˆÓ, ÛËÌÂÈ·ÎÒÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ (SNPs) Î·È ‰È·‰Ô¯ÈÎÒÓ Â·Ó·Ï‹„ÂˆÓ (∂ÈÎfiÓ· 9). √ ÂÓÙÔÈÛÌfi˜ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì¤Ûˆ Ù˘ ·Ó›¯Ó¢Û˘ ÂÙÂÚÔ‰ÈÌÂÚÒÓ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÏfiÁˆ ÌË Û˘ÌÏËڈ̷ÙÈÎÒÓ ‚¿ÛÂˆÓ ÛÙÔ ˘fi ÌÂϤÙË ÙÌ‹Ì· ÙÔ˘ DNA. ∂ÈÚÔÛı¤Ùˆ˜, ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› ‰È·¯ˆÚÈÛÌfi˜ Ì ‚¿ÛË ÙÔ Ì‹ÎÔ˜ (fragment analysis), ÙËÓ ·Ó¿Ï˘ÛË Î·È ÙÔÓ Î·ı·ÚÈÛÌfi ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉ›ˆÓ (Ôligonucleotide purification and analysis). ∏ ¢·ÈÛıËÛ›· Ù˘ ·Ó›¯Ó¢Û˘ ÌÂÙ·ÏÏ¿ÍÂˆÓ Î·È Ë ·ÎÚ›‚ÂÈ· ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ·ÁÁ›˙ÂÈ ÙÔ 100%, ÂÓÒ Ë ÂÏ¿¯ÈÛÙË ÔÛfiÙËÙ· ÙˆÓ ·ÓÙȉڷÛÙËÚ›ˆÓ Î·È ÙÔ ¯·ÌËÏfi ÎfiÛÙÔ˜ ÙÔ˘˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÔÊ˘Á‹ ¯Ú‹Û˘ ÂÈΛӉ˘ÓˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ, ηıÈÛÙÔ‡Ó ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÌÈ· ·fi ÙȘ ϤÔÓ ‰È·‰Â‰Ô̤Ó˜ Ù¯ÓÈΤ˜ ÌÔÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘. ÷ڷÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ DHPLC ·ÔÙÂÏ› Ë ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙ· 2 ÁÔÓ›‰È· Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙÔÓ Î·ÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ Î·È ÙˆÓ ˆÔıËÎÒÓ, BRCA1 Î·È BRCA2 (43,44). ª¤ıÔ‰ÔÈ ˘‚ÚȉÔÔ›ËÛ˘: Southern Blotting Î·È Northern Blotting ∆Ô Ê·ÈÓfiÌÂÓÔ Ù˘ ˘‚ÚȉÔÔ›ËÛ˘, ‰ËÏ·‰‹ Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ÂÓfi˜ ÌÔÓfiÎψÓÔ˘ ÌÔÚ›Ô˘ ÓÔ˘ÎÏÂ˚ÎÔ‡ ÔͤԘ Ó· Û¯ËÌ·Ù›˙ÂÈ ‰›ÎψÓË ¤ÏÈη Ì ¤Ó· ¿ÏÏÔ ÌÔÓfiÎψÓÔ ÌfiÚÈÔ, ·ÔÙÂÏ› ÙË ‚¿ÛË ÁÈ· ÔÏϤ˜ Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙfiÛÔ ÛÙË ÌÔÚȷ΋ ‰È¿ÁÓˆÛË, fiÛÔ Î·È ÛÙË ÁÂÓÂÙÈ΋ Ì˯·ÓÈ΋. ªÂٷ͇ ·˘ÙÒÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ Ù¯ÓÈΤ˜ Southern Î·È NÔrthern Blot. Southern Blotting ∏ ̤ıÔ‰Ô˜ ÙÔ˘ Southern Blotting ‹Ú ÙÔ fiÓÔÌ¿ Ù˘ ·fi ÙÔÓ Edwin Southern Î·È ÌÔÚ› Ó· ‰È·¯ˆÚ›Paediatriki 2008;71:105-115
3 2 1 0 -1 2
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7
min
∂ÈÎfiÓ· 9. ŒÏÂÁ¯Ô˜ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ì ÙË Ì¤ıÔ‰Ô DHPLC. DHPLC: ∞ԉȷٷÎÙÈ΋ Ãڈ̷ÙÔÁÚ·Ê›· ÀÁÚ‹˜ º¿Û˘. ™‡ÁÎÚÈÛË ‰Â›ÁÌ·ÙÔ˜ ˘fi ÂͤٷÛË (Ú¿ÛÈÓÔ) Ì ·ıÔÏÔÁÈÎfi ‰Â›ÁÌ· (ηʤ) ˆ˜ ÛËÌÂ›Ô ·Ó·ÊÔÚ¿˜. ∏ η̇ÏË Ô˘ ˘Ô‰ÂÈÎÓ‡ÂÙ·È ·Ô ÙÔ ‚¤ÏÔ˜ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ¤ÎÏÔ˘ÛË ÙˆÓ ÂÙÂÚÔ‰ËÌÂÚÒÓ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÏfiÁˆ Ù˘ ˘¿Ú¯Ô˘Û·˜ ÌÂÙ¿ÏÏ·Í˘.
ÛÂÈ, Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜, Û˘ÁÎÂÎÚÈ̤ӷ ÙÌ‹Ì·Ù· ÁÂÓˆÌÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ¤Ó· Ì›ÁÌ· ÔÏÏÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÙÌËÌ¿ÙˆÓ (45). ∆Ô ÚÔ˜ ·Ó¿Ï˘ÛË DNA (.¯. ÙÔ DNA ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡) ˆ¿˙ÂÙ·È Ì ÙË ¯Ú‹ÛË ÂÚÈÔÚÈÛÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘. °È· ¤Ó·Ó ÔÚÁ·ÓÈÛÌfi Ì ۇÓıÂÙÔ ÁÔÓȉ›ˆÌ·, ·˘Ù‹ Ë ¤„Ë ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÂηÙÔÌ̇ÚÈ· ‰È·ÊÔÚÂÙÈο ÚÔ˚fiÓÙ· ÎÔ‹˜ (ÎÏ¿ÛÌ·Ù· ÂÚÈÔÚÈÛÌÔ‡). ∆· ÚÔ˚fiÓÙ· Ù˘ ¤„˘ ‰È·¯ˆÚ›˙ÔÓÙ·È Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·Á·Úfi˙˘. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘ ÙÔ ‹Îو̷ ÂÎÙ›ıÂÙ·È Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÙÔ DNA ·ÂÈÎÔÓ›˙ÂÙ·È ˆ˜ Û˘Ó¯fiÌÂÓË Ù·ÈÓ›·. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÔ˘Ó ÂÌÊ·Ó‹ Ù· ‰È·ÊÔÚÂÙÈο ıÚ·‡ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ¤„Ë, ÌÂٷʤÚÔÓÙ·È Û ıÂÙÈο ÊÔÚÙÈṲ̂ÓË ÌÂÌ‚Ú¿ÓË Ó¿ÈÏÔÓ ‹ ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘. ¶ÚÈÓ Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, ÙÔ ‹Îو̷ ·Ú·Ì¤ÓÂÈ Û ·ÏηÏÈÎfi ‰È¿Ï˘Ì· ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ô‰È·Ù·¯ı› ÙÔ DNA Î·È Ó· Á›ÓÂÈ ÌÔÓfiÎψÓÔ. ∆Ô Ê›ÏÙÚÔ ÛÙË Û˘Ó¤¯ÂÈ· ˘‚Úȉ›˙ÂÙ·È Ì ÛËÌ·Ṳ̂ÓÔ˘˜ ·ÓȯÓÂ˘Ù¤˜ Ô˘ ʤÚÔ˘Ó ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ ˘fi ‰ÈÂÚ‡ÓËÛË ÁÔÓȉ›Ô˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ ÌÔÓfiÎψÓÔ DNA Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÁÔÓȉ›Ô˘ Ó· ÛËÌ·›ÓÂÙ·È Î·È ¿Ú· Ó· ·ÓȯÓ‡ÂÙ·È. ∆ÂÏÈο, Ë ÊˆÙÔÁÚ¿ÊËÛË Ì ÊÈÏÌ ·ÎÙ›ÓˆÓ Ã ·ÔηχÙÂÈ Ù· ÛËÌ·Ṳ̂ӷ ıÚ·‡ÛÌ·Ù· (45) (∂ÈÎfiÓ· 10). ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÌÔÚÔ‡Ó Ó· ·ÓȯÓ¢ıÔ‡Ó Î˘Ú›ˆ˜ ÌÔÚȷΤ˜ ‚Ï¿‚˜ Ô˘ ·ÏÏÔÈÒÓÔ˘Ó ÙÔ Ì‹ÎÔ˜ ÂÓfi˜ ÙÌ‹Ì·ÙÔ˜ DNA (.¯. ÂÏÏ›ÌÌ·Ù·, ‰ÈÏ·ÛÈ·ÛÌÔ›), ·ÏÏ¿ fi¯È ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ . ∆Ë ÌÂÁ·Ï‡ÙÂÚË ›Ûˆ˜ ·Í›· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›¯Â Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Southern Blotting ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ ÌÂÁ¤ıÔ˘˜ ÎÏ·ÛÌ¿ÙˆÓ ÂÚÈÔÚÈÛÌÔ‡ (RFLP: Ê˘ÛÈÔÏÔÁÈο ÎÏËÚÔÓÔÌÔ‡ÌÂÓ˜
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·113
113
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∏ÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·Á·Úfi˙˘
¶¤„Ë Ì ÂÚÈÔÚÈÛÙÈο ¤Ó˙˘Ì·
°ÂÓˆÌÈÎfi DNA £Ú·‡ÛÌ·Ù· DNA ∞ԉȿٷÍË µ¿ÚÔ˜ ∆˙¿ÌÈ
÷ÚÙÔÂÙÛ¤Ù˜
º‡ÏÏ· ¯·ÚÙÈÔ‡ Whartman 3MM ÂÌÔÙÈṲ̂ӷ Û ‰È¿Ï˘Ì· 2xSSC
ªÂÌ‚Ú¿ÓË ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘ ÷ÚÙ› Whartman 3MM ¢È¿Ï˘Ì· 20xSSC
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∂ÈÎfiÓ· 10. ∏ ̤ıÔ‰Ô˜ Southern Blotting. AÚ¯‹ Ù˘ ÌÂıfi‰Ô˘ ÌÂÙ·ÊÔÚ¿˜ ηٿ Southern ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘‚ÚȉÈÛÌfi Ì ȯÓËıÂÙË̤ÓÔ ·ÓȯÓÂ˘Ù‹.
ÔÈÎÈÏÔÌÔÚʛ˜ ÎÔÓÙ¿ ÛÙÔÓ ˘fi ÌÂϤÙË ÁÂÓÂÙÈÎfi ÙfiÔ, ÔÈ Ôԛ˜ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÂÓfi˜ ÓÔÛÔÁfiÓÔ˘ ÁÔÓȉ›Ô˘, ·ÎfiÌ· Î·È fiÙ·Ó ‰ÂÓ ÌÔÚ› Ó· ·ÓȯÓ¢ı› Ë Û˘ÁÎÂÎÚÈ̤ÓË ÌÔÚȷ΋ ‰È·Ù·Ú·¯‹) (46). ªÂ ÙËÓ ·Ó·Î¿Ï˘„Ë, fï˜, ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ÓÂfiÙÂÚˆÓ ÌÔÚÈ·ÎÒÓ Ù¯ÓÈÎÒÓ, ÙÔ Southern Blotting Û·Ó›ˆ˜ ϤÔÓ ¯ÚËÛÈÌÔÔÈ›ٷÈ, ÂÎÙfi˜ ·fi οÔȘ ÂÚÈÙÒÛÂȘ ∂˘ıÚ·‡ÛÙÔ˘ Ã. Northern Blotting ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ·Ó›¯Ó¢ÛË Û˘ÁÎÂÎÚÈ̤ÓÔ˘ RNA ·fi ¤Ó· Ì›ÁÌ· ‰È·ÊÔÚÂÙÈÎÒÓ RNAs. ∞Ú¯Èο ÏfiÁˆ ·Ó·ÏÔÁ›·˜ Î·È ÔÌÔÈfiÙËÙ·˜ Ù˘ ÌÂıfi‰Ô˘ Ì ÙÔ Southern µlotting Î·È Ì ¯ÈÔ˘ÌÔÚÈÛÙÈ΋ ‰È¿ıÂÛË Ù˘ ·Â‰fiıË ÙÔ fiÓÔÌ· Northern µlotting, ÌÈ· ÔÓÔÌ·Û›· Ô‡ ÙÂÏÈο ÂÈÎÚ¿ÙËÛ ‰ÈÂıÓÒ˜. ∆Ô ˘fi ÂͤٷÛË ‰Â›ÁÌ· RNA ˘Ê›ÛÙ·Ù·È ÂÂÍÂÚÁ·Û›· ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ¯ËÌÈΤ˜ Ô˘Û›Â˜ (.¯. ÊÔÚÌ·Ï‰Â˛‰Ë), ÂÈÙ˘Á¯¿ÓÔÓÙ·˜ ÙËÓ ·Ô‰È¿Ù·ÍË ÙˆÓ ‰Â˘ÙÂÚÔÙ·ÁÒÓ ‰ÔÌÒÓ ÙÔ˘. T· ‰È·ÊÔÚÂÙÈο ÌfiÚÈ· RNA ÙÔ˘ Ì›ÁÌ·ÙÔ˜, ‰È·¯ˆÚ›˙ÔÓÙ·È Ì ËÏÂÎÙÚÔÊfiÚËÛË Ì ‚¿ÛË ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ Î·È ÌÂٷʤÚÔÓÙ·È Û ʛÏÙÚÔ ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘. ™ÙË Û˘Ó¤¯ÂÈ·, ÙÔ Ê›ÏÙÚÔ ÂÎÙ›ıÂÙ·È Û ÛËÌ·Ṳ̂ÓÔ ÂÎÎÈÓËÙ‹ DNA (probe) Î·È ˘fiÎÂÈÙ·È Û ڷ‰ÈÔ·˘ÙÔÁÚ·Ê›·. ∏ Ù¯ÓÈ΋ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú‡Ù·Ù· ÁÈ· ÙË ÌÂϤÙË Ù˘ ¤ÎÊÚ·Û˘ ÂÓfi˜ ÏËı˘ÛÌÔ‡ mRNA Û ‰È·-
ÊÔÚÂÙÈο ÛÙ¿‰È· ·Ó¿Ù˘Í˘ ÙˆÓ ˘fi ÌÂϤÙË ÈÛÙÒÓ (.¯. mRNA ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ‚-ÛÊ·ÈÚ›Ó˘) (47,48).
∂›ÏÔÁÔ˜ ™ÙȘ ̤Ú˜ Ì·˜ Ù· ÂÚÁ·ÛÙ‹ÚÈ· ªÔÚȷ΋˜ °ÂÓÂÙÈ΋˜ ÚÔÛʤÚÔ˘Ó ÌÈ· ÔÈÎÈÏ›· ‰È·ÁÓˆÛÙÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ·Ó¿Ï˘Û˘ DNA. ∏ ¿ÌÂÛË ·Ó¿Ï˘ÛË ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Â›Ó·È ‰È·ı¤ÛÈÌË ÁÈ· ÏËıÒÚ· ÁÂÓÂÙÈÎÒÓ ·ı‹ÛÂˆÓ Î·È Î·ıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ Û ¿Û¯ÔÓÙ˜, ÙËÓ ÚÔÛ˘Ìو̷ÙÈ΋ ‰È¿ÁÓˆÛË Û ¿ÙÔÌ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓÔ ÓfiÛËÌ·, ÙËÓ ·Ó›¯Ó¢ÛË ÊÔÚ¤ˆÓ Î·È ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‹ ÙËÓ ÚÔÂÌÊ˘Ù¢ÙÈ΋ ÁÂÓÂÙÈ΋ ‰È¿ÁÓˆÛË. °È· Ù· ÌÔÓÔÁÔÓȉȷο ÓÔÛ‹Ì·Ù·, fiÔ˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó›¯Ó¢ÛË ÌÂÙ·ÏϿ͈Ó, ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÂÓÂÙÈÎÔ› ‰Â›ÎÙ˜, ÒÛÙ ӷ ÚÔ‚ÏÂÊı› Ë ÎÏËÚÔÓÔÌÈ΋ ÌÂÙ·‚›‚·ÛË, ·Ú·‰Â›ÁÌ·ÙÔ˜ ¯¿ÚÈÓ ÛÙÔ Û‡Ó‰ÚÔÌÔ Marfan Î·È ÛÙË Ó¢ÚÔ˚ӈ̿وÛË Ù‡Ô˘ 1. ∂›Ó·È ›Û˘ ÛËÌ·ÓÙÈÎfi fiÙÈ ‰Â›ÁÌ·Ù· DNA ÌÔÚÔ‡Ó Ó· Û˘ÓÙËÚËıÔ‡Ó ÁÈ· ·ÂÚÈfiÚÈÛÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÌÂÏÏÔÓÙÈο ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. √È ÛËÌÂÚÈÓ¤˜ ‰˘Ó·ÙfiÙËÙ˜ ·ÍÈfiÈÛÙ˘ ·Ó¿Ï˘Û˘ ÙˆÓ ÁÔÓȉ›ˆÓ οı ·ÙfiÌÔ˘, ηıÒ˜ Î·È ÔÈ ·ÏÌ·ÙÒ‰ÂȘ ÚfiÔ‰ÔÈ Ù˘ ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û¯ÂÙÈο ÁÚ‹ÁÔÚ· Î·È Ì ÔÏÔ¤Ó· ÌÈÎÚfiÙÂÚÔ ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜, ‰ÈηÈÔÏÔÁÔ‡Ó ÙË ‰È‡ڢÓÛË Ù˘ ÌÔÚȷ΋˜ ‰È·ÁÓˆÛÙÈ΋˜. ŒÙÛÈ, Ô ·È‰›·ÙÚÔ˜ ηÙ¢ı‡ÓÂÈ ÙȘ ÔÈÎÔÁ¤ÓÂȘ ¶·È‰È·ÙÚÈ΋ 2008;71:105-115
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Ì ÙÔ ÁÂÓÂÙÈÎfi Úfi‚ÏËÌ· ÛÙȘ ηٿÏÏËϘ ˘ËÚÂۛ˜ ÎÏÈÓÈ΋˜ Î·È ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜, ÒÛÙ ÂÁη›Úˆ˜ Î·È ˘Â‡ı˘Ó· Ó· ÂÓËÌÂÚÒÓÔÓÙ·È ÁÈ· ÙȘ ‰˘Ó·ÙfiÙËÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÙÔ˘˜ ÚÔÛÊÂÚıÔ‡Ó ÛÙ· Ï·›ÛÈ· Ù˘ ÌÔÚȷ΋˜ ‰È¿ÁÓˆÛ˘.
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REVIEW ARTICLE
¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ “∞ÏÂÍ¿Ó‰Ú·” ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: Ã. ∫ÒÛÙ·ÏÔ˜ ccostalos@yahoo.gr ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·” ∞ıËÓÒÓ
Ã. ∫ÒÛÙ·ÏÔ˜ ¶ÂÚ›ÏË„Ë: ∏ ÚÔÛ¿ıÂÈ· Ì›ÌËÛ˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ô‰‹ÁËÛ Û ÛÔ‚·Ú¿ Ï¿ıË ÎÈ ·˘Ùfi ‰ÈfiÙÈ Ë Û‡ÛÙ·ÛË ÙÔ˘ ·ÓıÚˆ›ÓÔ˘ Á¿Ï·ÎÙÔ˜ ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ‹ Î·È ÂÍ¿ÏÏÔ˘ Ë ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ·’ fi,ÙÈ ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂȯÂÈÚ› Ó· Ú›ÍÂÈ ÌÈ· ÎÚÈÙÈ΋ Ì·ÙÈ¿ Û ÔÚÈṲ̂ӷ ÓÂfiÙÂÚ· Û˘ÛÙ·ÙÈο ÙÔ˘ ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï·, fiˆ˜ Â›Ó·È Ù· ÓÔ˘ÎÏÂÔÙ›‰È·, Ù· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, Ë ÁÏÔ˘Ù·Ì›ÓË, Ë ·ÚÁÈÓ›ÓË, Ë Î·ÚÓÈÙ›ÓË, Ô Û›‰ËÚÔ˜, Ù· Ú‚ÈÔÙÈο, Ù· ÚÔ‚ÈÔÙÈο Î·È Ù· Á¿Ï·Ù· ˘„ËÏ‹˜ ıÚÂÙÈ΋˜ ·Í›·˜. ∞fi ÙË Û˘˙‹ÙËÛË ÚÔ·ÙÂÈ fiÙÈ ÁÈ· ÔÚÈṲ̂Ó˜ Ô˘Û›Â˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· Ô˘ Ó· ‰ÈηÈÔÏÔÁÔ‡Ó ÙËÓ ÚÔÛı‹ÎË ÙÔ˘˜. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÔÔÈ·‰‹ÔÙ ÙÚÔÔÔ›ËÛË ˆ˜ ÚÔ˜ ÙË Û‡ÓıÂÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Á·Ï¿ÙˆÓ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ ¤ÂÈÙ· ·fi ÂÓ‰Âϯ›˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, Ì ÛÙfi¯Ô fi¯È ÌfiÓÔ Ù˘¯fiÓ ‚Ú·¯˘ÚfiıÂÛÌÔ fiÊÂÏÔ˜, ·ÏÏ¿ Î·È ÙËÓ Â˘ÓÔ˚΋ ›وÛË ÂÓfi˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÙÚÔÊÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙË ÓÔËÙÈ΋ ÂͤÏÈÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜, ηıÒ˜ Î·È Û ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ÂÓËÏ›ÎÔ˘ ˙ˆ‹˜. §¤ÍÂȘ ÎÏÂȉȿ: ¢È·ÙÚÔÊ‹ ‚Ú¤ÊÔ˘˜, ÓÔ˘ÎÏÂÔÙ›‰È·, ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, ÁÏÔ˘Ù·Ì›ÓË, ·ÚÁÈÓ›ÓË, ηÚÓÈÙ›ÓË, Û›‰ËÚÔ˜, Ú‚ÈÔÙÈο, ÚÔ‚ÈÔÙÈο, Á¿Ï·Ù· ˘„ËÏ‹˜ ‰È·ÙÚÔÊÈ΋˜ ·Í›·˜.
New aspects of infant nutrition Neonatal Unit, Alexandra Regional General Hospital, Athens, Greece Correspondence: C. Costalos ccostalos@yahoo.gr Neonatal Unit, Alexandra Regional General Hospital, Athens, Greece
C. Costalos Abstract: Efforts to imitate human milk for feeding the infant led to serious miscalculations of the levels of supplementation needed, with resultant dangers. As the exact content of human milk is difficult to estimate due to its wide fluctuations, only limited information can be deduced from measurement of the levels of specific components of human milk. In addition, there may be possible differences in bioavailability and substances other than components of human milk may be needed to achieve the desired effect. This article provides a critical review of these factors, which include nucleotides, polyunsaturated fatty acids, glutamine, arginine, carnitine, iron, prebiotics, probiotics and high energy formulae. Following discussion of these nutrients, it is concluded that for some of them there is insufficient data to justify their use and that there may even be potential dangers from their inclusion. Independent scientific bodies should evaluate any proposed modification of infant formulae beyond the established standards before permission is given for introduction of such products into the market. It is important that such research considers not only the short-term effects of the nutrients on growth, but also safety aspects and the possibility of evaluating long-term effects on neurodevelopmental achievement and the incidence of chronic diseases.
Key words: Infant nutrition, nucleotides, polyunsaturated fatty acids, glutamine, arginine, carnitine, iron, prebiotics, probiotics, high energy formulae.
∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Á›Ó·Ì ̿ÚÙ˘Ú˜ ÌÈ·˜ ÌÂÙ·ÛÙÚÔÊ‹˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜. EÓÒ ·Ï·ÈfiÙÂÚ· Ô Î‡ÚÈÔ˜ ÛÙfi¯Ô˜ ηٿ ÙËÓ ·Ú·Û΢‹ ÂÓfi˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‹Ù·Ó Ë ·ÚÔ¯‹ ÛˆÛÙ‹˜ ÔÛfiÙËÙ·˜ Î·È ·Ó·ÏÔÁ›·˜ ÌÂÁ·ÏÔÌÔÚÈ·ÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, Û‹ÌÂÚ· Ë ¤Ú¢ӷ ·Ô‚ϤÂÈ ÛÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙÔ˘ Á¿Ï·ÎÙÔ˜ Ì ÂȉÈο Û˘ÛÙ·ÙÈο Ù˘ ÙÚÔÊ‹˜, Ù· ÔÔ›· ·ÓȯÓ‡ÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ηÈ, ÂÎÙfi˜ ·fi ÙȘ ηı·Ú¿ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ ·Í›Â˜, ÂËÚ¿˙Ô˘Ó ÙË ÁÂÓÈÎfiÙÂÚË ˘Á›· ÙÔ˘ ·È‰ÈÔ‡. ŒÙÛÈ, Ë ‰È·›ÛÙˆÛË Ù˘ Paediatriki 2008;71:116-122
·ÚÔ˘Û›·˜ ÛÙÔ ·ÓıÚÒÈÓÔ Á¿Ï· ·Ú¯Èο Ù˘ Ù·˘Ú›Ó˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, ÙˆÓ Ú‚ÈÔÙÈÎÒÓ, ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, Ù˘ ÁÏÔ˘Ù·Ì›Ó˘, Ù˘ ·ÚÁÈÓ›Ó˘ Ô‰‹ÁËÛ ÛÙËÓ ÚÔÛı‹ÎË ÙˆÓ Ô˘ÛÈÒÓ ·˘ÙÒÓ ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ¶·Ú¿ ÙȘ ÊÈÏfiÙÈ̘ ÚÔÛ¿ıÂȘ, ηӤӷ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ÌÔÚ› Ó· ¤¯ÂÈ ÙȘ ȉÈfiÙËÙ˜ ÙÔ˘ ·ÓıÚˆ›ÓÔ˘, ÎÈ ·˘Ùfi ÁÈ·Ù› Ë Û‡ÓıÂÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ‹, ·ÏÏ¿ ÌÂÙ·‚¿ÏÏÂÙ·È Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. ŒÙÛÈ, Â›Ó·È ‰‡ÛÎÔÏÔ˜ Ô ·ÎÚÈ‚‹˜ ˘ÔÏÔÁÈÛÌfi˜
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·117
117
¢È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜
Ù˘ ··ÈÙÔ‡ÌÂÓ˘ ÔÛfiÙËÙ·˜ ÁÈ· οı ÛÙÔȯ›Ô. ∏ ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÂÍ¿ÏÏÔ˘ Î·È Ë Â›‰Ú·ÛË ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Ô˘ÛÈÒÓ ÌÔÚ› Ó· Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ·’ fi,ÙÈ ÛÙÔ Í¤ÓÔ Á¿Ï·. ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ï‹ıÔ˜ ÔÚÌÔÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚ› Ó· ¢ԉÒÓÔ˘Ó ‹ Ó· ÂÚÈÔÚ›˙Ô˘Ó ÙË ‰Ú¿ÛË ÌÈ·˜ Û˘ÁÎÂÎÚÈ̤Ó˘ Ô˘Û›·˜, ÁÂÁÔÓfi˜ Ô˘ ‰ÂÓ Û˘Ì‚·›ÓÂÈ Ì ÙÔ Í¤ÓÔ Á¿Ï·. ™ÙËÓ Ú¿ÍË ·Ô‰Â›¯ıËΠfiÙÈ Ù· ÔÏ˘‰È·ÊËÌÈ˙fiÌÂÓ· ÔʤÏË ÁÈ· ÔÏϤ˜ Ô˘Û›Â˜ Â›Ó·È ·Ó‡·ÚÎÙ· ‹ ÛÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ÙˆÛË ÔÚȷο, ÂÓÒ ˘¿Ú¯Ô˘Ó Î·È Î›Ó‰˘ÓÔÈ ·fi ÙËÓ ·ÓÂͤÏÂÁÎÙË ¯Ú‹ÛË ÙÔ˘˜. ™ÙË Û˘Ó¤¯ÂÈ· ı· ÚÔÛ·ı‹ÛÔ˘Ì ӷ οÓÔ˘Ì ÌÈ· ·ÓÙÈÎÂÈÌÂÓÈ΋ ·ÍÈÔÏfiÁËÛË Î¿ı ÌÈ·˜ ·fi ·˘Ù¤˜ ÙȘ Ô˘Û›Â˜.
¡Ô˘ÎÏÂÔÙ›‰È· (¡∫) ∞ÔÙÂÏÔ‡Ó Úfi‰ÚÔ̘ Ô˘Û›Â˜ ÙÔ˘ RNA Î·È ÙÔ˘ DNA. £ÂˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÛÙËÓ ·‡ÍËÛË Î·È ÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ÂÙÈÎÔ‡, ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜, ÛÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡, ÛÙË Ì›ˆÛË Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÁÂÓÈÎfiÙÂÚ·, ηıÒ˜ Î·È ÛÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË (1). ∞. ∂›‰Ú·ÛË ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÙÈÎÔ‡ £ÂÙÈ΋ ›‰Ú·ÛË ÙˆÓ ¡∫ ÛÙÔ ÂÙÈÎfi ‚Ú¤ıËΠ۠ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ÔÓÙ›ÎÈ· Ô˘ ¤Ï·‚·Ó 2 ÙÚÔʤ˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ë Ì›· ÂÚÈ›¯Â ¡∫ Î·È Ë ¿ÏÏË ‰ÂÓ ÂÚÈ›¯Â ηıfiÏÔ˘ ¡∫. ™ÙËÓ Ú¿ÍË, fï˜, ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· Á¿Ï· Ô˘ Ó· ÌËÓ ÂÚȤ¯ÂÈ Î·ıfiÏÔ˘ ¡∫. ∂›Û˘, ÂÓÒ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÔÓÙÈÎÒÓ Ô˘ ¤Ï·‚ Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ÓÔ˘ÎÏÂÔÙ›‰È· ·Ú·ÙËÚ‹ıËΠÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÓÙ¤ÚÔ˘, ÂÓÒ ·Ú·‰fi͈˜ Û ڈÙ½ÓË ‰ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ‰È·ÊÔÚ¿ ÛÙÔ Ì¤ÛÔ Î·È ÙÔ ÙÂÏÈÎfi ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ (2). ŒÙÛÈ, ¯ÚÂÈ¿˙ÔÓÙ·È ÂÈϤÔÓ ÌÂϤÙ˜ ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ ·Ú·¿Óˆ. µ. ∂ÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ∂˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ¡∫ ·Ó·Ê¤ÚÔÓÙ·È Û ÌÈ· ÌÂϤÙË, fiÔ˘ Û˘ÁÎÚ›ıËΠÌÈ· ÔÌ¿‰· ÓÂÔÁÓÒÓ Ô˘ ¤·ÈÚÓ Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ¡∫ Ì ¿ÏÏË Ô˘ ¤·ÈÚÓ Á¿Ï· ¯ˆÚ›˜ ¡∫. ∏ ÌÂϤÙË ÂÚÈ›¯Â ÌÈÎÚfi ·ÚÈıÌfi Û˘ÌÌÂÙ¯fiÓÙˆÓ ¯ˆÚ›˜ ÛˆÛÙ‹ Ù˘¯·ÈÔÔ›ËÛË. ¢ÂÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔÓ ·fiÏ˘ÙÔ ·ÚÈıÌfi ÙˆÓ ·ÔÈÎÈÒÓ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ÛÙ· ÎfiÚ·Ó·. ªfiÓÔ fiÙ·Ó ¤ÁÈÓ ۇÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÔÛÔÛÙÒÓ Î¿ı ÌÈÎÚÔ‚›Ô˘ ÛÙ· ÎfiÚ·Ó· ‚Ú¤ıËΠοÔÈ· ‰È·ÊÔÚ¿ (3). ™Ù· ›‰È· Û˘ÌÂÚ¿ÛÌ·Ù· ηٷϋÁÂÈ Î·È ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË (4).
°. ∂›‰Ú·ÛË ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi ∞Ó Î·È ·Ó·Ê¤ÚıËΠ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ Î˘ÙÙ¿ÚˆÓ (¡∫ cells) Î·È ˘„ËÏfiÙÂÚÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜ Î·È Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ÛÙÔ˘˜ 2 Ì‹Ó˜ ˙ˆ‹˜ Û ‚Ú¤ÊË Ô˘ ¤Ï·‚·Ó Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ¡∫, ‰ÂÓ ˘‹Ú¯Â η̛· ‰È·ÊÔÚ¿ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ÌËÓÒÓ (5) Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ›Û˘ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ‹ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ¢. ¢È¿ÚÚÔÈ·-ÏÔÈÌÒÍÂȘ ∞Ó Î·È ÔÈ ÚÒÙ˜ ÌÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó Î·Ï‡ÙÂÚË ÂԇψÛË ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÌÂÙ¿ ·fi ÚÔÎÏËÙ‹ ‚Ï¿‚Ë (2) ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ¡∫, ÎÏÈÓÈ΋ ÌÂϤÙË Û ·È‰È¿ ‰ÂÓ ¤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ‰È¿ÚÚÔÈ·˜ Î·È ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· οı ÂÂÈÛÔ‰›Ô˘. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ›Û˘ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ Î·È ÙÔ˘ ηو٤ÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ù˘ ·Ú·ÌÔÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (6). ∂. ∂›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË ªÈ· ÌÂϤÙË ¤‰ÂÈÍ ηχÙÂÚË ·ÓÙÈÚÚÔÈÛÙÈ΋ ·‡ÍËÛË Û ÙÂÏÂÈfiÌËÓ· Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ (7) ÌÂÙ¿ ÙË Ï‹„Ë ¡∫. ÕÏϘ ÌÂϤÙ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ·˘Ù‹ ÙËÓ ¿Ô„Ë (8,9). À„ËϤ˜ ‰fiÛÂȘ ¡∫ ‚Ú¤ıËΠfiÙÈ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (10). ¢È΋ Ì·˜ Ù˘¯·ÈÔÔÈË̤ÓË Ù˘ÊÏ‹ ÌÂϤÙË ‰ÂÓ ¤‰ÂÈÍ ›‰Ú·ÛË ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ ÛÙËÓ ·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ˘‰·Ù·ÓıÚ¿ÎˆÓ Ô‡ÙÂ Î·È Ì›ˆÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ ÛÙ· ÎfiÚ·Ó· (11). ªÈ· Èı·Ó‹ ÂÍ‹ÁËÛË Ù˘ ÌË ·Ó‡ÚÂÛ˘ ıÂÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ ›Ûˆ˜ Ó· Â›Ó·È fiÙÈ Ë ÌÂϤÙË ‰ÂÓ ÂÚÈÂÏ¿Ì‚·Ó ·Ú΋ ·ÚÈıÌfi ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘ÛÙÚÔÊ›·, Ù· ÔÔ›·, ηٿ ÙË ÁÓÒÌË Ì·˜, ı· ˆÊÂÏÔ‡ÓÙ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ ÚÔÛı‹ÎË ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ.
¶ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· (¶∞§√) ∞ÔÙÂÏÔ‡Ó Úfi‰ÚÔ̘ Ô˘Û›Â˜ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, ÚÔÛÙ·Î˘ÎÏ›Ó˘, ıÚÔÌ‚ÔÍ¿Ó˘, Ï¢ÎÔÙÚÈÂÓ›ˆÓ Î·È ıˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ù˘ ÔÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ¶·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÚÈÎÒÓ Û˘Ó¿„ÂˆÓ (12-14). ∂ȉÚÔ‡Ó, ›Û˘, ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi, ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË, ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÔÛÙÒÓ (15). ∞Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚÒÙÔ˘ ‰ÈÏÔ‡ ‰ÂÛÌÔ‡ ·fi ÙÔ ÌÂı˘ÏÈÎfi ¿ÎÚÔ ‰È·ÎÚ›ÓÔÓÙ·È Û ˆ-3 Î·È ˆ-6. ¶·È‰È·ÙÚÈ΋ 2008;71:116-122
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·118
118
Ã. ∫ÒÛÙ·ÏÔ˜
∆· ΢ÚÈfiÙÂÚ· Â›Ó·È ÙÔ ·Ú·¯È‰ÔÓÈÎfi Î·È ÙÔ 22-ÂÍ·ÓÔ˚Îfi Ô͇ (DHA). ∞ÔÙÂÏÔ‡Ó Û˘ÛÙ·ÙÈÎfi Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, Ë ÔÔ›· Â›Ó·È Â˘·ı‹˜ Û ÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘. ÀÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ¶∞§√ ·˘Í¿ÓÂÈ ÙËÓ ·ÈÌfiÏ˘ÛË ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÂÈÙ›ÓÂÈ ÙËÓ ˘ÂÚÔÍÈ΋ ‚Ï¿‚Ë ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ÙË ÊˆÙÔÙÔÍÈ΋ ‚Ï¿‚Ë ÙˆÓ Ú·‚‰›ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Úԉȷı¤ÙÔÓÙ·˜ ›Ûˆ˜ Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (ö), ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ (¡∂∫), ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ (∞¶) (16). ¶ÚfiˆÚ· Ô˘ ¤Ï·‚·Ó ȯı˘¤Ï·ÈÔ Â›¯·Ó ¯·ÌËÏfiÙÂÚË ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (17). ∞˘Ùfi ÔÊÂÈÏfiÙ·Ó Û ·ÚÂÌfi‰ÈÛË ·fi Ù· ˆ-3 ÏÈ›‰È· Ù˘ ÌÂÙ·ÙÚÔ‹˜ ÙÔ˘ ÏÈÓÔÏÂ˚ÎÔ‡ ÔͤԘ Û ·Ú·¯È‰ÔÓÈÎfi. ªÂ ‚¿ÛË ·˘Ù¿, Ë ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜ ÚÔÙ›ÓÂÈ Ë ÔÛfiÙËÙ· ÙÔ˘ DHA ÛÙÔ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· Ó· ÌËÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 0,5% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ Ï›Ô˘˜ Î·È Ë ÂÚÈÂÎÙÈÎfiÙËÙ· Û ∞∞ Ó· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ›ÛË Ì ·˘Ù‹ ÙÔ˘ DHA (18). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚ˜ ‚ÈÔÌ˯·Ó›Â˜ ·Ú·Û΢‹˜ ‚ÚÂÊÈÎÒÓ Á·Ï¿ÙˆÓ ÚÔÛı¤ÙÔ˘Ó ¶∞§√ ÛÙ· ÚÔ˚fiÓÙ· ÙÔ˘˜. Œ¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÌÂϤÙ˜ ÙfiÛÔ Û ÚfiˆÚ· fiÛÔ Î·È Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ ηٿ ÙË ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Â›Ó·È ·ÓÙÈÊ·ÙÈο. £· ÛÙ·¯˘ÔÏÔÁ‹ÛÔ˘Ì ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜.
ªÂϤÙ˜ Û ÚfiˆÚ· ÓÂÔÁÓ¿ ªÂÁ¿ÏË ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË Ô˘ Û˘ÌÂÚȤϷ‚ 11 ÌÂϤÙ˜ ¤‰ÂÈÍ fiÙÈ Ë ÚÔÛı‹ÎË ¶∞§√ Û ÚfiˆÚ· ‰ÂÓ Â›¯Â η̛· ıÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Î·È ÓÔËÙÈ΋ ÂͤÏÈÍ‹ ÙÔ˘˜ (19). √È ÌÂϤÙ˜ ‰ÂÓ ÂÚÈÂÏ¿Ì‚·Ó·Ó fï˜ ÓÂÔÁÓ¿ Ì ÂÍ·ÈÚÂÙÈο ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ÕÏÏË Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ë ÚÔÛı‹ÎË ¶∞§√ ÛÙË ‰È·ÙÚÔÊ‹ ÚÔÒÚˆÓ Ô‰‹ÁËÛ Û ηχÙÂÚË ·Ó¿Ù˘ÍË Û ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ÌËÓÒÓ. ∆· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘ ›¯·Ó ÛÙÔ˘˜ 18 Ì‹Ó˜ ˙ˆ‹˜ ˘„ËÏfiÙÂÚÔ ÓÔËÙÈÎfi ‰Â›ÎÙË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (20). ÕÏÏË ÌÂϤÙË ¤‰ÂÈÍ ¿ÏÈ fiÙÈ ÚfiˆÚ· Ô˘ ¤Ï·‚·Ó ¶∞§√ ›¯·Ó ÛÙË ‰ÈÔÚıˆÌ¤ÓË ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ ˘„ËÏfiÙÂÚÔ˘˜ ‰Â›ÎÙ˜ ÓÔËÌÔÛ‡Ó˘ Û‡Ìʈӷ Ì ÙËÓ Îϛ̷η Bayley (21). ªÂϤÙ˜ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ √È ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û ÙÂÏÂÈfiÌËÓ· ¤‰ÂÈÍ·Ó ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·. ªÂÁ¿ÏË ·Ó·ÛÎfiËÛË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó 10 ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÂÓ ¤‰ÂÈÍ ηӤӷ fiÊÂÏÔ˜ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ (22). ™Â ¿ÏPaediatriki 2008;71:116-122
ÏË ·Ó·ÛÎfiËÛË ¿ÏÈ ‚Ú¤ıËΠfiÙÈ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ Ì ¶∞§√ ›¯Â ıÂÙÈ΋ ‰Ú¿ÛË ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÓÂÔÁÓÒÓ ÛÙÔ 2Ô Ì‹Ó· ˙ˆ‹˜ (23). À¿Ú¯ÂÈ, fï˜, Î·È ÌÂϤÙË Ô˘ ‰Â›¯ÓÂÈ ¯ÂÈÚfiÙÂÚË ÓÔËÙÈ΋ ¤Î‚·ÛË ÛÙËÓ ËÏÈΛ· ÙˆÓ 39 ÌËÓÒÓ Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ (24). Ÿˆ˜ ·Ó·Ê¤ÚÂÈ Ë Fewtrell (25), ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ÏfiÁÔ˘˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ¿Óˆ ÛÙ· ¶∞§√ Â›Ó·È ·ÓÙÈÊ·ÙÈο, Â›Ó·È ÔÈ ÂÍ‹˜: ·) √È ÂÏ¿¯ÈÛÙ˜ ·Ó·Áη›Â˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ¤˜. ‚) ∏ Û¯¤ÛË 18:ˆ-3/18:ˆ6 ÛÙ· ¯ÔÚËÁÔ‡ÌÂÓ· ¶∞§√ Î·È Ë ÚÔ¤ÏÂ˘Û‹ ÙÔ˘˜ ÔÈΛÏÏÂÈ. Á) ∏ ¯ÔÚËÁÔ‡ÌÂÓË ÔÛfiÙËÙ·, ›Û˘, ÔÈΛÏÏÂÈ. ‰) ¢ÂÓ ˘¿Ú¯Ô˘Ó, Ù¤ÏÔ˜, Ì·ÎÚfi¯ÚÔÓ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙËÓ ¤Î‚·ÛË ÙˆÓ ˘fi ÌÂϤÙË ·È‰ÈÒÓ. ∞fi Ù· ·Ú·¿Óˆ Ê·›ÓÂÙ·È fiÙÈ ·˘Ù¿ Ô˘ ˆÊÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ Â›Ó·È Ù· Ôχ ÚfiˆÚ· ÓÂÔÁÓ¿, Ù· ÔÔ›· ¤¯Ô˘Ó Î·È Ù· ¯·ÌËÏfiÙÂÚ· ·Ôı¤Ì·Ù· ÙˆÓ ÏÈ·ÚÒÓ ·˘ÙÒÓ ÔͤˆÓ ηٿ ÙË Á¤ÓÓËÛË. ∏ ·Ó·ÁηÈfiÙËÙ· ¯ÚËÛÈÌÔÔ›ËÛ‹˜ ÙˆÓ ¶∞§√ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ̤ÓÂÈ Ó· ·Ô‰Âȯı›.
°ÏÔ˘Ù·Ì›ÓË ∞ÔÙÂÏ› ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· Ù· ÂÓÙÂÚÔ·ÙÙ·Ú· Î·È ·Ú¤¯ÂÈ ¿˙ˆÙÔ ÁÈ· ÙË Û‡ÓıÂÛË ·ÌÈÓÔͤˆÓ Ô˘ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ, ÙËÓ ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘, ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ (26). ¶ÚfiˆÚ· Û ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ô˘ ¤Ï·‚·Ó ÂÏ¿¯ÈÛÙË ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ô˘ ‹Ù·Ó ÂÌÏÔ˘ÙÈṲ̂ÓË Ì ÁÏÔ˘Ù·Ì›ÓË Â›¯·Ó ¯·ÌËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ÛË„·ÈÌ›·˜ Î·È ·˘ÍË̤ÓË ·ÓÔ¯‹ ÂÓÙÂÚÈ΋˜ ÙÚÔÊ‹˜ (27). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÁÏÔ˘Ù·Ì›Ó˘ ·ÌÊÈÛ‚ËÙÂ›Ù·È Û ·ı‹ÛÂȘ, fiˆ˜ Û‡Ó‰ÚÔÌÔ ÙÔ˘ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ÊÏÂÁÌÔÓÒ‰Ë ÂÓÙÂÚÔ¿ıÂÈ· Î·È ·ÎÙÈÓÈ΋ ‚Ï¿‚Ë ÙÔ˘ ÂÓÙ¤ÚÔ˘ (28), ÂÓÒ ÌÂϤÙ˜ Û ÓÂÔÁÓ¿ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯Ú‹ÛË Ù˘ ‰ÂÓ ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÏÔÈÌÒÍÂˆÓ Î·È ¡∂∫, ·ÏÏ¿ Ô‡ÙÂ Î·È Ô‰ËÁ› Û ηχÙÂÚË ·ÓÔ¯‹ ÂÓÙÂÚÈ΋˜ ÙÚÔÊ‹˜ (29,30). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È Î·È Èı·Ó‹ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ ÁÏÔ˘Ù·Ì›Ó˘ ‹ ÙÔ˘ ÁÏÔ˘Ù·ÌÈÎÔ‡, Ô˘ ·ÔÙÂÏ› ·Ú¿ÁˆÁfi Ù˘, ÛÙÔ ∫¡™. ∏ ÁÏÔ˘Ù·Ì›ÓË, Ù¤ÏÔ˜, ÌÔÚ› Ó· ·Ú¤Ì‚ÂÈ ·ÚÓËÙÈο ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ¿ÏÏˆÓ ·ÌÈÓÔͤˆÓ (31). ∞ÚÁÈÓ›ÓË ∂›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Û‡ÓıÂÛË ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘, ÙËÓ ÂÓÙÂÚÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹, ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡, ÙËÓ ·Ú·ÁˆÁ‹ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (32). ∏ ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ·ÛıÂÓ›˜ ÓÔÛËÏ¢fiÌÂÓÔ˘˜ Û ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰· ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË (33). ¶ÚfiˆÚ· Ô˘ ·Ó¤Ù˘Í·Ó ¡∂∫ ›¯·Ó ¯·ÌËÏfiÙÂÚ· ›‰· ·ÚÁÈÓ›Ó˘ ·›Ì·ÙÔ˜ (34) Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜. ∆Ô ·ÌÈÓÔ͇ ·˘Ùfi ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ù˘
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·119
119
¢È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜
ÁÏ˘Îfi˙˘, ¤¯ÂÈ ÈÛÙ·ÌÈÓÈ΋ ‰Ú¿ÛË (35), ÂÓÒ ·˘Í¿ÓÂÈ ÙË Û‡ÓıÂÛË ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·Ó·ÓfiÚıˆÙÔ ÛËÙÈÎfi ÛÔÎ (36).
∫·ÚÓÈÙ›ÓË ∂›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÔÍ›‰ˆÛË ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ÌÈÙÔ¯fiÓ‰ÚÈ· Î·È ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ·ÎÂÙ˘ÏÈˆÌ¤ÓˆÓ ÚÔ˚fiÓÙˆÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (37). ¡ÂfiÙÂÚ˜ ÌÂϤÙ˜ ·ÌÊÈÛ‚ËÙÔ‡Ó ÙË ¯ÚËÛÈÌfiÙËÙ¿ Ù˘ (38), ÂÓÒ ÔÚÈṲ̂ÓÔÈ ıˆÚÔ‡Ó fiÙÈ ÌÔÚ› Î·È Ó· ‚Ï¿ÙÂÈ ·Ó ¯ÔÚËÁËı› Û ·˘ÍË̤ÓË ‰fiÛË (39). ™›‰ËÚÔ˜ ∂ÌÔ‰›˙ÂÈ ÙËÓ ·ÔÚÚfiÊËÛË „¢‰·ÚÁ‡ÚÔ˘ Î·È ¯·ÏÎÔ‡ ·fi ÙÔ ÂÙÈÎfi. ∂›Ó·È ÈÛ¯˘Úfi ÔÍÂȉˆÙÈÎfi Î·È ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë. ™Â ÂÓ‹ÏÈΘ ˘¿Ú¯ÂÈ ¿ÌÂÛË Û¯¤ÛË ÌÂٷ͇ ·ÔıÂÌ¿ÙˆÓ Ûȉ‹ÚÔ˘ Î·È Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ (40). ™Â ÌÂϤÙË ·fi ÙË ™Ô˘Ë‰›· Û ‚Ú¤ÊË ËÏÈΛ·˜ 4-9 ÌËÓÒÓ Ì ·Ú΋ ·Ôı¤Ì·Ù· Ûȉ‹ÚÔ˘, Ë ¯ÔÚ‹ÁËÛË ÂÈϤÔÓ Ûȉ‹ÚÔ˘ ·fi ÙÔ ÛÙfiÌ· Ô‰‹ÁËÛ Û ÌÂȈ̤ÓË ·‡ÍËÛË ÂȘ Ì‹ÎÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ. ∂›Û˘, Ù· ‚Ú¤ÊË ÂÌÊ¿ÓÈÛ·Ó, Û˘ÁÎÚÈÙÈο Ì ̿ÚÙ˘Ú˜, ˘„ËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ‰È¿ÚÚÔÈ·˜ Î·È ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (41). ¶Ú‚ÈÔÙÈο ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÎÙfi˜ ·fi ÙȘ ¿ÏϘ ÙÔ˘ ȉÈfiÙËÙ˜ ÂÓÈÛ¯‡ÂÈ ÂÈϤÔÓ ÙËÓ ¿Ì˘Ó· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ̤ۈ Ù˘ ¢ÂÚÁÂÙÈ΋˜ ÙÔ˘ ‰Ú¿Û˘ ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ÙÔ˘ ÓÂÔÁÓÔ‡, ÂÓÒ ·Ú¿ÏÏËÏ· ÌÂÈÒÓÂÈ ÙËÓ ÂΉ‹ÏˆÛË ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (42). ª¤ÚÔ˜ Ù˘ ¢ÓÔ˚΋˜ ÙÔ˘ ‰Ú¿Û˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· Á·Ï·ÎÙÔ-ÔÏÈÁÔ۷ί·Úȉ›ˆÓ, Ù· ÔÔ›· ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ bifidobacteria Î·È Á·Ï·ÎÙÔ‚·Î›ÏÏˆÓ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ (43). ŒÙÛÈ, ηıÈÂÚÒıËÎÂ Ô fiÚÔ˜ «Ú‚ÈÔÙÈο», Ô˘ ˘Ô‰ËÏÒÓÂÈ ÔÚÈṲ̂ӷ ›‰Ë ˘‰·Ù·ÓıÚ¿ÎˆÓ Ê˘ÙÈ΋˜ ÚÔ¤Ï¢Û˘ Ô˘ ‰ÂÓ ‰È·ÛÒÓÙ·È ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, ·ÏÏ¿ Êı¿ÓÔ˘Ó ·Ó·ÏÏÔ›ˆÙ· ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, fiÔ˘ ÚÔ¿ÁÔ˘Ó ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜ Ì ¢ÓÔ˚Τ˜ Û˘Ó¤ÂȘ ÁÈ· ÙÔÓ ÍÂÓÈÛÙ‹ (44). À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ›‰Ë Ú‚ÈÔÙÈÎÒÓ, Ì ΢ÚÈfiÙÂÚ· Ù· ÊÚÔ˘ÎÙÔ-ÔÏÈÁÔ۷ί·Ú›‰È· (º√™), Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ê˘Ù¿ .¯. Ì·Ó¿Ó·, Ú·‰›ÎÈ·, ÛÈÙ¿ÚÈ, ÎÚÂÌ̇‰È·, Î·È Ù· Á·Ï·ÎÙÔ-ÔÏÈÁÔ۷ί·Ú›‰È· (°√™) Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ Á¿Ï· (45). √È ‚ÈÔÌ˯·Ó›Â˜ ·È‰ÈÎÒÓ ÙÚÔÊÒÓ ·Ú‹Á·Á·Ó ÚÔÛ·ÚÌÔṲ̂ӷ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÔÓÙ· Ì›ÁÌ· º√™ Î·È °√™ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙË ÌÔÚȷ΋ ‰ÔÌ‹ ÙˆÓ ÔÏÈÁÔ۷ί·Úȉ›ˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ (46). ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ Ì›ÁÌ·ÙÔ˜ ·˘ÙÔ‡ ÙfiÛÔ Û ÙÂÏÂÈfiÌËÓ· (47,48) fiÛÔ Î·È Û ÚfiˆÚ· ÓÂÔÁÓ¿ (49,50) ‹Ù·Ó ηϿ ·ÓÂÎÙ‹ Î·È Û˘Óԉ‡ÙËΠ·fi ·˘ÍË̤ÓË ·Ó¿Ù˘ÍË
bifidobacteria ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ì ηٷÛÙÔÏ‹ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ·ıÔÁfiÓˆÓ ÂÓÙÂÚÔ‚·ÎÙËÚȉ›ˆÓ. ¶·Ú¿ÏÏËÏ·, Ô ·ÚÈıÌfi˜ ÙˆÓ ÎÂÓÒÛÂˆÓ Î·È Ë Û‡ÛÙ·ÛË ÙˆÓ ÎÔÚ¿ÓˆÓ, fiˆ˜ Î·È ÙÔ pH, ·ÚÔÌÔ›·˙·Ó Ì ÂΛӷ ÓÂÔÁÓÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·. ¶ÚfiÛÊ·Ù·, ·Ó·Ê¤ÚıËÎÂ Î·È Â˘ÓÔ˚΋ ‰Ú¿ÛË ÙˆÓ Ú‚ÈÔÙÈÎÒÓ ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ (51). ∞Ó Î·È Ù· Ú‚ÈÔÙÈο ·ÎfiÌ· ‰ÂÓ ıˆÚÔ‡ÓÙ·È ·fiÏ˘Ù· ·ÛÊ·Ï‹, ı· Ú¤ÂÈ Ó· ‰›ÓÔÓÙ·È Ì ÚÔÛÔ¯‹ ÂȉÈο Û ÚfiˆÚ· ‹ ‰˘ÛÙÚÔÊÈο ÓÂÔÁÓ¿ ÁÈ·Ù› ÌÔÚ› Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ¤„Ë Î·È ÙËÓ ·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ˘‰·Ù·ÓıÚ¿ÎˆÓ ·fi ÙÔ ¤ÓÙÂÚÔ (52).
¶ÚÔ‚ÈÔÙÈο ∂›Ó·È ˙ÒÓÙ˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ¯ÔÚËÁÔ‡ÌÂÓÔÈ Û ·ÚΛ˜ ÔÛfiÙËÙ˜ ÚÔ¿ÁÔ˘Ó ÙËÓ ˘Á›· ÙÔ˘ ÍÂÓÈÛÙ‹. ∆· ÂÚÈÛÛfiÙÂÚÔ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Â›Ó·È Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Î·È bifidobacteria, Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈο Î·È ÛÙÔ ¤ÓÙÂÚÔ ‚ÚÂÊÒÓ Ô˘ ·›ÚÓÔ˘Ó ÌËÙÚÈÎfi Á¿Ï·. ∏ ·ÚÔ˘Û›· ÙÔ˘˜ ÛÙÔ ¤ÓÙÂÚÔ Î·Ù·ÛÙ¤ÏÏÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ·ıÔÁfiÓˆÓ ÌÈÎÚÔ‚›ˆÓ, ÌÂÈÒÓÂÈ ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÙËÓ ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Û ·ÏÏÂÚÁÈÔÁfiÓ· (53,54). ¶ÚÔ‚ÈÔÙÈο ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· Û Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ROTA Èfi (55), ÛÙË ‰È¿ÚÚÔÈ· ·fi ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ (56), ÛÙËÓ ÚfiÏË„Ë ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ (57) Î·È ÈÔ ÚfiÛÊ·Ù· ÛÙËÓ ÚfiÏË„Ë Ù˘ ¡∂∫ Û ÚfiˆÚ· ÓÂÔÁÓ¿ (58,59). °È· Ù· ÚÔ‚ÈÔÙÈο ··ÈÙÔ‡ÓÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜. ¶·ÚÂÓ¤ÚÁÂȘ ·Ó·Ê¤ÚÔÓÙ·È Ôχ Û¿ÓÈ· ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Á·Ï·ÎÙÔ‚¿ÎÈÏÏˆÓ Î·È ˙˘ÌÔ̇ÎËÙˆÓ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ÂȉÈο Û ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ¿ÙÔÌ·, ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË (Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Ô˘ ·Ú¿ÁÔ˘Ó Á·Ï·ÎÙÈÎfi Ô͇), ÌÂÙ·ÊÔÚ¿ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÚÔ˜ ¿ÏÏ· ÌÈÎÚfi‚È·, ÌÂ Û˘Ó¤ÂÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ (60,61). ™˘Ì‚ÈÔÙÈο ŒÓ· ÌÂÈÔÓ¤ÎÙËÌ· ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ Â›Ó·È fiÙÈ ¤¯Ô˘Ó ‚Ú·¯Â›· ‰Ú¿ÛË, ÌÂ Û˘Ó¤ÂÈ· Ó· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Î·ıËÌÂÚÈÓ¿ .∏ ÚÔÛı‹ÎË Ú‚ÈÔÙÈÎÒÓ ÛÙ· ÚÔ‚ÈÔÙÈο ·˘Í¿ÓÂÈ ÙÔ ¯ÚfiÓÔ ‰Ú¿Û˘ ÙÔ˘˜ ÎÈ ¤ÙÛÈ ‰ÂÓ ··ÈÙÂ›Ù·È Û˘¯Ó‹ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ (62). ∏ ¯Ú‹ÛË ÙÔ˘˜, fï˜, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ÙÂÎÌËÚȈı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. °¿Ï·Ù· ·˘ÍË̤Ó˘ ıÚÂÙÈ΋˜ ·Í›·˜ ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘ÛÙÚÔÊ›·, ·ÏÏ¿ Î·È Ë Î·Î‹ ıÚ¤„Ë Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ ÎÚ›ÛÈÌÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜, ÌÔÚ› Ó· ¤¯ÂÈ ÛÔ‚·Úfiٷ٘ Û˘Ó¤ÂȘ ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋ Î·È ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜ (63,64). H Û˘¯ÓfiÙËÙ· ÂÓ‰ÔÌ‹ÙÚÈ·˜ ‰˘ÛÙÚÔÊ›·˜ Û ¶·È‰È·ÙÚÈ΋ 2008;71:116-122
Pediatri Mar-Apr 08
07-04-08
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™ÂÏ›‰·120
120
Ã. ∫ÒÛÙ·ÏÔ˜
ÓÂÔÁÓ¿ Ì Ôχ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Êı¿ÓÂÈ Î·È ÙÔ 30%. ªÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘ÔÛÈÙ›˙ÔÓÙ·È Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÏfiÁˆ Ù˘ ÏËıÒÚ·˜ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·Ù¿ ÙË ÓÔÛËÏ›· ÙÔ˘˜ Û ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰·, ÌÂ Û˘Ó¤ÂÈ· Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ‰˘ÛÙÚÔÊÈο ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô (65). ŒÙÛÈ ÙÔ ‚¿ÚÔ˜ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ÛÙË ÛˆÛÙ‹ Û›ÙÈÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ∆· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Ù·¯Â›· ·Ó·ÏËڈ̷ÙÈ΋ ·‡ÍËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿ Ô‰ËÁ› Û ηχÙÂÚË ÓÔËÙÈ΋ ÂͤÏÈÍË (66,67). À¿Ú¯ÂÈ, fï˜, Î·È Ë ¿Ô„Ë fiÙÈ Ù·¯Â›· ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÌÔÚ› Ó· Úԉȷı¤ÛÂÈ Û ¯ÚfiÓÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ, ˘¤ÚÙ·ÛË, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2 Î·È ÔÛÙÂÔfiÚˆÛË ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (68). ªÈ· ÌÂÁ¿ÏË ·Ó·ÛÎfiËÛË ‰ÂÓ ¤‰ÂÈÍ ηӤӷ fiÊÂÏÔ˜ ˆ˜ ÚÔ˜ ÙË ÛˆÌ·ÙÈ΋ Î·È æ∫ ÂͤÏÈÍË (69). ∞fi Ù· ·Ú·¿Óˆ Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ÛÙÔ ı¤Ì· Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ··ÈÙÂ›Ù·È Û‡ÓÂÛË Î·È ÚÔÛÔ¯‹ ÛÙËÓ ˘ÈÔı¤ÙËÛË Ó¤ˆÓ ·Ú¯ÒÓ. Àfi ·˘Ùfi ÙÔ Ó‡̷, Ë ESPGHAN Âͤ‰ˆÛ ԉËÁ›Â˜ Ô˘ ÂÈÛËÌ·›ÓÔ˘Ó fiÙÈ “Ë ·Ï‹ ·ÚÔ˘Û›· ÌÈ·˜ Ô˘Û›·˜ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ‰ÈηÈÔÏÔÁ› ÙËÓ ·˘ÙfiÌ·ÙË ÚÔÛı‹ÎË Ù˘ ÛÙÔ Û˘ÓıÂÙÈÎfi Á¿Ï·, ¯ˆÚ›˜ ÚÔËÁÔ˘Ì¤Óˆ˜ Ó· ‰È·ÈÛÙˆı› fi¯È ÌfiÓÔ ÙÔ ‚Ú·¯˘ÚfiıÂÛÌÔ, ·ÏÏ¿ Î·È ÙÔ Ì·ÎÚÔÚfiıÂÛÌÔ fiÊÂÏÔ˜ Ô˘ ·ÔʤÚÂÈ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÔÚÁ·ÓÈÛÌfi” (70).
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∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ E. ∫Ô‡ÛÙ·, ∞. ¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘† ¶ÂÚ›ÏË„Ë: ª¤¯ÚÈ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980, Ë ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) ›¯Â ¯ÚËÛÈÌÔÔÈËı› ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙË ıÂڷ›· ·È‰ÈÒÓ Ì ÛÔ‚·Ú‹ ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÊÂÈÏfiÌÂÓË Û ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD). ∏ GHD ·ÊÔÚ¿ Û˘Ó‰˘·ÛÌfi ÎÏÈÓÈÎÒÓ, ·ÎÙÈÓÔÏÔÁÈÎÒÓ, ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÔÚÌÔÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. ∏ ÂÈÏÔÁ‹ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ, ÛÙ· ÔÔ›· ı· Á›ÓÔ˘Ó ‰È·ÁÓˆÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¤ÎÎÚÈÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ÚÔ¸Ôı¤ÙÂÈ ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È Î˘Ú›ˆ˜ ÙÔ˘ ‰È·ÁÚ¿ÌÌ·ÙÔ˜ ·‡ÍËÛ˘. ∏ ıÂڷ›· Ì G∏ ÛÙ· ·È‰È¿ Ì GHD Ô‰ËÁ› Û ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È Â›Ó·È ‰˘Ó·Ùfi Ó· ÊÙ¿ÛÔ˘Ó ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Â¿Ó Ë ıÂڷ›· ·Ú¯›ÛÂÈ ÂÁη›Úˆ˜. E›Û˘, ÂÎÙfi˜ ·fi ÙÔ ‡„Ô˜, Ë GH ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi, ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· Î·È ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ·ÚÂÓ¤ÚÁÂȘ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 20 ÂÙÒÓ, ÔÈ ÂӉ›ÍÂȘ ¤¯Ô˘Ó ÂÂÎÙ·ı› Î·È ¤¯ÂÈ ÂÁÎÚÈı› Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÛÙ· ÎÔÚ›ÙÛÈ· Ì ۇӉÚÔÌÔ Turner Î·È Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È Û‡Ó‰ÚÔÌÔ Prader-Willi. ™ÙȘ ∏¶∞ Î·È ÙȘ ¯ÒÚ˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ ¤¯ÂÈ ÂÁÎÚÈı› Ë ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Û ·È‰È¿ ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË GH Û ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ¤¯ÂÈ ÂÁÎÚÈı› ÌfiÓÔ ÛÙȘ ∏¶∞. ∏ ıÂڷ›· fï˜ ÛÙ· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ¤¯ÂÈ ÂÁÎÚÈı› ÛÙË ¯ÒÚ· Ì·˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ÂÂÎÙ·ı› Ë ¯Ú‹ÛË Ù˘ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ GHD. ∏ ıÂڷ›· Ì GH Â›Ó·È ÌÈ· ·ÎÚÈ‚‹ ıÂڷ›· Î·È ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·.
∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∂ϤÓË ∫Ô‡ÛÙ· lkousta@otenet.gr ™. ∞Ú‚·ÓÈÙ¿ÎË 6 ∆.∫. 491 00, ∫¤Ú΢ڷ
§¤ÍÂȘ ÎÏÂȉȿ: ∞˘ÍËÙÈ΋ ÔÚÌfiÓË, ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Û‡Ó‰ÚÔÌÔ ∆urner, Û‡Ó‰ÚÔÌÔ Prader-Willi, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·.
Indications for administering growth hormone to children and adolescents ∂. Kousta, A. Papathanassiou, C. Hadjiathanassiou† Abstract: Recombinant growth hormone (GH) was used exclusively for the treatment of children with severe growth retardation due to GH deficiency (GHD) up until the end of the 1980’s. GHD is characterized by a combination of clinical, radiological, metabolic and hormonal abnormalities. The selection of cases for whom there is a need to proceed to stimulation tests requires accurate auxological data and correct interpretation of the growth curve. GH treatment in children with GHD leads to acceleration of growth velocity and, if treatment is started early enough, to a final height within the normal range. Treatment with GH improves not only the height, but also body composition, by decreasing fat mass and increasing bone density, without significant side effects. During the last 20 years, the indications for treatment with GH have been expanded and its use has been approved for girls with Turner syndrome and for children with chronic renal failure and Prader-Willi syndrome. In the USA and some countries of the EU, GH treatment is approved for children born small for gestational age. Treatment for idiopathic short stature has been approved only in the USA. These indications have not been approved in Greece. Over the last few years its use has been extended to adolescents and adults with severe GH deficiency. GH treatment is an expensive therapy and regular monitoring of its use needs to be made in specialised centres.
Department of Endocrinology, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: Eleni Kousta lkousta@otenet.gr 6, Sp. ∞rvanitaki St., 491 00, Corfu, Greece
Key words: Growth hormone, growth hormone deficiency, Tyrner syndrome, Prader-Willi syndrome, chronic renal failure.
™˘ÓÙÔÌÔÁڷʛ˜ GH GHD IGFs ISS SGA
A˘ÍËÙÈ΋ ÔÚÌfiÓË AÓ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ A˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ I‰ÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ¶·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘
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ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·
EÈÛ·ÁˆÁ‹ ∏ GH ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÂÈÙ˘¯Ò˜ ÁÈ· ÙË ıÂڷ›· ·È‰ÈÒÓ Ì ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÁÈ· ۯ‰fiÓ 50 ¯ÚfiÓÈ·. ∞Ú¯Èο, ¯ÚËÛÈÌÔÔÈ‹ıËΠGH ¶·È‰È·ÙÚÈ΋ 2008;71:123-127
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E. ∫Ô‡ÛÙ· Î·È Û˘Ó.
ÚÔÂÚ¯fiÌÂÓË ·fi ·ÓıÚÒÈÓÔ ÈÛÙfi ˘fiÊ˘Û˘, Ë ¯Ú‹ÛË Ù˘ ÔÔ›·˜ fï˜ ‰È·ÎfiËΠÏfiÁˆ Ù˘ ·ÈÙÈÔÏÔÁÈ΋˜ Û˘Û¯¤ÙÈÛ‹˜ Ù˘ Ì ÙË ÓfiÛÔ Creutzfeldt-Jakob, ÌÈ· Û¿ÓÈ· ı·Ó·ÙËÊfiÚÔ, ÛÔÁÁÔÂȉ‹ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ∏ ·Ú·ÁˆÁ‹ ‚ÈÔÛ˘ÓıÂÙÈ΋˜ GH Ô‰‹ÁËÛ ÛÙËÓ Â˘Ú‡ÙÂÚË ¯Ú‹ÛË Ù˘ GH. M¤¯ÚÈ Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980, Ë GH ¯ÚËÛÈÌÔÔÈ‹ıËΠ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙË ıÂڷ›· ·È‰ÈÒÓ Ì ÛÔ‚·Ú‹ ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÊÂÈÏfiÌÂÓË Û GHD. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 20 ÂÙÒÓ, ÔÈ ÂӉ›ÍÂȘ ¤¯Ô˘Ó ÂÂÎÙ·ı› Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ Û‡Ó‰ÚÔÌÔ Turner (1), ÙË ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (2) Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Prader-Willi (3). H GH ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·ÎfiÌË Û ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ (Small for Gestational Age - SGA) (4). ∏ ¤Ó‰ÂÈÍË ·˘Ù‹ ¤¯ÂÈ ÂÁÎÚÈı› Û ∞ÌÂÚÈ΋ Î·È ∂˘ÚÒË Î·È ÛÙËÓ ∂ÏÏ¿‰· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔÓ ∂√º Î·È ÙÔ ∫∂™À Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ˘ÔÁÚ·Ê‹˜. ∞ÎfiÌ·, Ë GH ¤¯ÂÈ ¯ÔÚËÁËı› Û ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (Idiopathic Short Stature - ISS) (5). ™ÙȘ ∏¶∞ ¤¯ÂÈ ‰Ôı› ¤ÁÎÚÈÛË ÌfiÓÔ Û ¤Ó· Û··ÛÌ· Î·È ÚÔ˜ ÙÔ ·ÚfiÓ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÛÙ· ·È‰È¿ ·˘Ù¿ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ ÛÙ· Ï·›ÛÈ· ÂÚ¢ÓËÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ. ª¤¯ÚÈ ÚfiÛÊ·Ù·, ÛÙ· ·È‰È¿ Ì GHD ÁÈÓfiÙ·Ó ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ÂÚÈfi‰Ô˘ ·Ó¿Ù˘Í˘. ∆ÒÚ·, Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Â·Ó¤ÏÂÁ¯Ô˜ Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ GH ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ ηٿ ÙË Û‡ÁÎÏÂÈÛË ÙˆÓ ÂÈʇÛˆÓ, ȉȷÈÙ¤Úˆ˜ ÙˆÓ ·È‰ÈÒÓ Ì Ôχ ¯·ÌËϤ˜ ÙÈ̤˜ GH Î·È Ì ·ıÔÏÔÁÈ΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ˘fiÊ˘Û˘ (ÌÈÎÚfi ‡„Ô˜, ¤ÎÙÔË ˘fiÊ˘ÛË) ‹ ÈÛÙÔÚÈÎfi fiÁÎÔ˘ ‹ ·ÎÙÈÓÔ‚ÔÏ›·˜. ™Â fiÛÔ˘˜ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ¯·ÌËÏ‹˜ ¤ÎÎÚÈÛ˘ GH Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙˆÓ ÂÓËϛΈÓ, Û˘ÓÈÛÙ¿Ù·È Û˘Ó¤¯ÈÛË Ù˘ ıÂڷ›·˜ Ì ‰ÔÛÔÏÔÁ›· ÂÓËϛΈÓ, ÏfiÁˆ ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ÂÈÙÒÛÂˆÓ Ù˘ ÛÔ‚·Ú‹˜ ·Ó¿ÚÎÂÈ·˜ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ∫¿ÔÈÔÈ ÂÚ¢ÓËÙ¤˜ Û˘ÓÈÛÙÔ‡Ó ÙË Û˘Ó¤¯ÈÛË Ù˘ ıÂڷ›·˜ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ÁÈ· οÔÈÔ ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙË Û‡ÁÎÏÂÈÛË ÙˆÓ ÂÈʇÛˆÓ, ÏfiÁˆ Ù˘ ıÂÙÈ΋˜ ›‰Ú·Û˘ ÛÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (6). ∏ ıÂڷ›· Ì GH ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·. ∆Ô ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜ Â›Ó·È ÌÂÁ¿ÏÔ, ȉȷ›ÙÂÚ· ÛÙ· ·È‰È¿ Ì ۇӉÚÔÌÔ Turner, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È È‰ÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, Ù· ÔÔ›· ¯ÚÂÈ¿˙ÔÓÙ·È ÌÂÁ·Ï‡ÙÂÚË ‰fiÛË GH. ∂ÈϤÔÓ, ÚÈÓ ·ÔÊ·ÛÈÛÙ› Ë ıÂڷ›· Ì GH, Ú¤ÂÈ ¤Ú· ·fi ÙËÓ Â˘ÓÔ˚΋ ›‰Ú·ÛË Ù˘ ıÂڷ›·˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Ó· ÏËÊıÔ‡Ó ˘fi„Ë „˘¯ÔÎÔÈÓˆÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ë Ù˘¯fiÓ ·ÚÓËÙÈ΋ ›وÛË Ù˘ ıÂڷ›·˜ ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·fi ÙȘ ηıËÌÂÚÈÓ¤˜ ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ. ¶·ÚfiÏÔ Ô˘ ÙÔ ¯·Paediatriki 2008;71:123-127
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· GHD ñ ™ËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ηı˘ÛÙ¤ÚËÛË ‡„Ô˘˜ (<3 SD) ñ ⁄„Ô˜ <1,5 SD οو ·fi ÙÔ ‡„Ô˜-ÛÙfi¯Ô ñ ⁄„Ô˜ <-2 SD Î·È Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ <1 SD οو ·fi ÙÔ Ì¤ÛÔ fiÚÔ ÙÔÓ ÚÔËÁÔ‡ÌÂÓÔ ¯ÚfiÓÔ (‹ -0,5 SD ÁÈ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ) ñ ™Â ·È‰È¿ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡„Ô˘˜, ÙÒÛË Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ <1,5 SD › 2 ¯ÚfiÓÈ· ñ ™ËÌ›· ÂÓ‰ÔÎÚ·Óȷ΋˜ ‚Ï¿‚˘ ‹ ÔÏÏ·Ï‹˜ ˘ÔÊ˘Ûȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ñ ™˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· ¤ÏÏÂȄ˘ GH ÛÙÔ ÓÂÔÁÓfi (˘ÔÁÏ˘Î·ÈÌ›·, ÌÈÎÚfi ¤Ô˜)
ÌËÏfi ·Ó¿ÛÙËÌ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÌÔÚ› Ó· ÂÈ‚·Ú‡ÓÂÈ „˘¯ÔÏÔÁÈο οÔÈ· ·È‰È¿, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› Î·È ‰ÂÓ Â›Ó·È ·fi fiÏÔ˘˜ ·Ô‰ÂÎÙ‹ Ë Â˘ÓÔ˚΋ ›‰Ú·ÛË Ù˘ ıÂڷ›·˜ Ì GH ÛÙÔÓ „˘¯ÈÛÌfi ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ.
∞Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD) ∏ GHD ÛÙ· ·È‰È¿ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÔ Û˘Ó‰˘·ÛÌfi ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ù· ÔÔ›· ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Û ÌÈÎÚfi ‹ ÌÂÁ¿ÏÔ ‚·ıÌfi ·Ó¿ÏÔÁ· Ì ÙËÓ Ï‹ÚË ‹ ÌÂÚÈ΋ ·Ó¿ÚÎÂÈ· ‹ ÌË ¤ÎÎÚÈÛË ‰Ú·ÛÙÈ΋˜ GH ‹ ÂÏ¿ÙÙˆÛË ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (IGFs) (7). ∏ ‰È¿ÁÓˆÛË Ù˘ GHD ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ¤Ó· ‰‡ÛÎÔÏÔ ı¤Ì·, ‰ÈfiÙÈ Ë ¤ÎÎÚÈÛË Ù˘ GH ÛÙ· ·È‰È¿ ηχÙÂÈ ¤Ó· Û˘Ó¯¤˜ Ê¿ÛÌ·, ÙÔ ÔÔ›Ô ÂÎÙ›ÓÂÙ·È ·fi Ù· fiÚÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ¤ˆ˜ ÙË Ì¤ÙÚÈ· ·Ó¿ÚÎÂÈ· ¤ÎÎÚÈÛ˘ (ÌÂÌÔӈ̤ÓË GHD) ̤¯ÚÈ ÙË ÛÔ‚·Ú‹ ·Ó¿ÚÎÂÈ· (fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ÔÏÏ·Ï‹ ˘ÔÊ˘Ûȷ΋ ·Ó¿ÚÎÂÈ· ‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ˘Ôı·Ï·ÌÈÎÔ‡ ÂÎÏ˘ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·) ‹ Ï‹ÚË ¤ÏÏÂÈ„Ë (·¿ÏÂÈ„Ë ÁÔÓȉ›Ô˘ Ù˘ GH). ™˘Ó‹ıˆ˜, ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ ‘ÎÏ·ÛÈ΋˜’, Ï‹ÚÔ˘˜ GHD, fï˜ Ë ·Ó·ÁÓÒÚÈÛË Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·È‰ÈÒÓ, Ù· ÔÔ›·, ÂÓÒ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÚȷ΋ ‰È·Ù·Ú·¯‹ ÛÙËÓ ¤ÎÎÚÈÛË Ù˘ GH, ı· ˆÊÂÏËıÔ‡Ó ·fi ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘, ·Ú·Ì¤ÓÂÈ ÌÈ· ÚfiÎÏËÛË (8,9). ¶ÚfiÛÊ·Ù·, ηıÈÂÚÒıËÎ·Ó ÎÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ‰ÈÂıÓ‹ ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË GHD, Ù· ÔÔ›· ‚·Û›˙ÔÓÙ·È Û ·ÍÈÔÏfiÁËÛË Ù˘ ·‡ÍËÛ˘, ηıÒ˜ Î·È ÙÔ˘ ¿ÍÔÓ· GH-IGF. ∆· ÎÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· ¤ÏÏÂȄ˘ GH ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ GH ÂÎÎÚ›ÓÂÙ·È Î·Ù¿ ÒÛÂȘ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘. ∂Ô̤ӈ˜, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ GH ÛÙÔ Ï¿ÛÌ·, ¯ˆÚ›˜ Ó· ÚÔËÁËı› ‰È¤ÁÂÚÛË, ‰ÂÓ ¤¯ÂÈ ‰È·ÁÓˆÛÙÈ΋ ·Í›· Î·È ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈ›ٷÈ. °È· ÙË ‰È¿ÁÓˆÛË Ù˘ GHD ··ÈÙÂ›Ù·È Ì¤ÁÈÛÙË ·ÓÙ·fiÎÚÈÛË GH (peak) οو ·fi Ù· fiÚÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ (GH <10 ng/ml) Û ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘. ™ÎÔfi˜ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ Â›Ó·È Ó·
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∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘
Û˘ÌÏËÚÒÛÔ˘Ó ÙËÓ ÎÏÈÓÈ΋ ˘Ô„›· Ù˘ GHD Û ٤ÙÔÈÔ ‚·ıÌfi, ÒÛÙ ӷ ÌÂȈıÔ‡Ó ÛÙÔ ÂÏ¿¯ÈÛÙÔ „¢‰Ò˜ ıÂÙÈΤ˜ ‹ „¢‰Ò˜ ·ÚÓËÙÈΤ˜ ‰È·ÁÓÒÛÂȘ (10). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ IGF-1, Â¿Ó ¤¯Ô˘Ó ·ÔÎÏÂÈÛı› ¿ÏϘ ·Èٛ˜ (Ë·ÙÔ¿ıÂÈ·, ¯ÚfiÓÈ· ·Ó·ÈÌ›·, Î.Ï.), ‚ÔËı¿ ÛÙË ‰È¿ÁÓˆÛË Û ·È‰› Ì ÈÛÙÔÚÈÎfi Î·È Î·Ì‡ÏË ·Ó¿Ù˘Í˘ Ô˘ ı¤ÙÔ˘Ó ÙËÓ ˘Ô„›· GHD. ¶ÚÔËÁÔ˘Ì¤Óˆ˜, Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛıÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ, fiˆ˜ Ô ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, ¯ÚfiÓÈ· Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù·, ÙÔ Û‡Ó‰ÚÔÌÔ Turner Î·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ™ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ GHD ÛÙ· ·È‰È¿ ÌÔÚ› ›Û˘ Ó· ‚ÔËı‹ÛÂÈ Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ù˘ ˘fiÊ˘Û˘, Ì ÙËÓ ÔÔ›· ÌÔÚ› Ó· ‰È·ÁÓˆÛı› Ë ˘ÔÏ·Û›· ÙÔ˘ ÚÔÛı›Ô˘ ÏÔ‚Ô‡ Ù˘ ˘fiÊ˘Û˘, Ë ÂÎÙÔ›· ÙÔ˘ ÔÈÛı›Ô˘ ÏÔ‚Ô‡, Ë ·ÁÂÓÂÛ›· ÙÔ˘ Ì›Û¯Ô˘, ηıÒ˜ Î·È ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∏ ·ÍÈÔÈÛÙ›· ÙˆÓ Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ‰È¤ÁÂÚÛ˘ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ¤ÎÎÚÈÛ˘ GH ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ (11). ™ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ ÔÏ˘ÎÂÓÙÚÈÎÒÓ ÌÂÏÂÙÒÓ Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¯ÔÚËÁ‹ıËΠıÂڷ›· Ì GH, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ôχ Ï›Á˜ ·ÍÈfiÈÛÙ˜ ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ Î·È Ó· Á›ÓÂÈ ÚÔÛ¿ıÂÈ· Ó· ηıÔÚÈÛıÔ‡Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ËÏÈ˘ (12,13). H ÂÙ·ÈÚ›· ¤Ú¢ӷ˜ GH (Growth Hormone Research Society) ¤¯ÂÈ ÂΉÒÛÂÈ Î·Ù¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È ÙË ıÂڷ›· Ù˘ GHD ÛÙ· ·È‰È¿ (14). ŒÓ· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÔÂÓ‰ÔÎÚÈÓÔÏfiÁˆÓ ·ÎÔÏÔ˘ı› ·˘Ù¤˜ ÙȘ Ô‰ËÁ›Â˜, ·ÚfiÙÈ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ·ÔÎÏ›ÛÂȘ ÛÙȘ ‰È¿ÊÔÚ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ (15,16). ∏ ıÂڷ›· Ì G∏ Ô‰ËÁ› Û ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηÈ, Â¿Ó Ë ıÂڷ›· ·Ú¯›ÛÂÈ ÂÁη›Úˆ˜, Û ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ÃÚÂÈ¿˙ÂÙ·È ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË Ù˘ ‰fiÛ˘ Ì ÙËÓ ËÏÈΛ·, ÒÛÙ ÙÔ ·È‰› Ó· ‚Ú›ÛÎÂÙ·È ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· Ù˘ η̇Ï˘ ·‡ÍËÛ˘ Î·È Ó· ÂÈÙ‡¯ÂÈ ÙÔ ÁÂÓÂÙÈÎÒ˜ ·Ó·ÌÂÓfiÌÂÓÔ ·Ó¿ÛÙËÌ·. ∏ ıÂڷ›· Ì GH, ¤Ú· ·fi ÙÔ ‡„Ô˜, ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË (body composition), ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi, ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· Î·È ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·. Œ¯ÂÈ Â›Û˘ ¢ÂÚÁÂÙÈΤ˜ ÌÂÙ·‚ÔÏÈΤ˜ ÂȉڿÛÂȘ: ÌÂÈÒÓÂÈ ÙÔ ÏfiÁÔ Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÚÔ˜ ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË. ∏ ‰fiÛË Ù˘ ıÂڷ›·˜ Î˘Ì·›ÓÂÙ·È ·fi 0,15 ¤ˆ˜ 0,30 mg/Kg/‚‰ÔÌ¿‰·, Û ηıËÌÂÚÈÓ¤˜ ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ. ¶·ÚfiÏÔ Ô˘ Ë ıÂڷ›· Ì GH Ô‰ËÁ› Û ·‡ÍËÛË ÙÔ˘ IGF-1, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÌÈÙÔÁfiÓÔ ‰Ú¿ÛË, ‰ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ·Ó¿Ù˘ÍË Î·ÎÔ‹ıÂÈ·˜ ÛÙ· ·È‰È¿ Ô˘ ·›ÚÓÔ˘Ó ÙË ıÂÚ·-
›· (17). Œ¯Ô˘Ó ·Ó·ÊÂÚı› Û¿ÓÈ· ηÏÔ‹ı˘ ÂÓ‰ÔÎÚ·Óȷ΋ ˘¤ÚÙ·ÛË, ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·, ÂÈÊ˘ÛÈÔÏ›ÛıËÛË Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘, Âȉ›ӈÛË Ù˘ ÛÎÔÏ›ˆÛ˘ Î·È Á˘Ó·ÈÎÔÌ·ÛÙ›· (17).
™‡Ó‰ÚÔÌÔ Turner ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È 1/2.500 1/3.000 ÁÂÓÓ‹ÛÂȘ ÎÔÚÈÙÛÈÒÓ (1). T· ÎÔÚ›ÙÛÈ· ·˘Ù¿, ·Ú¿ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÂÓ‰ÔÁÂÓ‹ ¤ÎÎÚÈÛË GH, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È Èı·ÓfiÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋. ¢È¿ÊÔÚÔÈ Ì˯·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›, fiˆ˜: ÂÏ·Ùو̤ÓË ‚ÈÔ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ GH, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ¿ÍÔÓ· IGF, ÌÔÓÔۈ̛· ÙÔ˘ Ã-¯ÚˆÌÔÛÒÌ·ÙÔ˜ (·Ô˘Û›· ÙÔ˘ ÁÔÓȉ›Ô˘ SHOX, Ô˘ ηıÔÚ›˙ÂÈ ÙÔ ·Ó¿ÛÙËÌ· Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ Ã) Î·È Èı·ÓfiÓ Î·È Ë Ï‹Ú˘ ·Ó¿ÚÎÂÈ· ÔÈÛÙÚÔÁfiÓˆÓ Î·Ù¿ ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· (1,18). ∂Âȉ‹ ‰ÂÓ ˘¿Ú¯ÂÈ GHD, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÔÈ ·ÛıÂÓ›˜ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË G∏. ∆Ô ‡„Ô˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ۇӉÚÔÌÔ Turner Ú¤ÂÈ Ó· ÚÔ‚¿ÏÏÂÙ·È ÛÙ· ÂȉÈο ‰È·ÁÚ¿ÌÌ·Ù· ·‡ÍËÛ˘ (19). ∏ ¯ÔÚ‹ÁËÛË GH Û ·È‰È¿ Ô˘ ¿Ú¯ÈÛ·Ó ÙË ıÂڷ›· ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-13 ÂÙÒÓ Ô‰ËÁ› Û ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ·fi 3 ¤ˆ˜ 12 cm (1,20,21). H ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· Ì GH, fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Â›Ó·È Î·Ï‡ÙÂÚË fiÛÔ ÓˆÚ›ÙÂÚ· ·Ú¯›˙ÂÈ Ë ıÂڷ›· (20,22). ∏ ıÂڷ›· Ì GH Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ Ôχ ηϿ ·ÓÂÎÙ‹, Ë Î·ÏÔ‹ı˘ ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË Î·È Ë ‹È· ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Ô˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Â›Ó·È ·Ó·ÛÙÚ¤„È̘, ·ÏÏ¿ Ë ÂÌÊ¿ÓÈÛË Ì¤Û˘ ˆÙ›Ùȉ·˜ Î·È Ë ·Ó¿ÁÎË ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘ (ÛÙ· ·˘ÙÈ¿, ÙË Ì‡ÙË Î·È ÙÔ Ï¿Ú˘ÁÁ·) ·Ó·Ê¤ÚÂÙ·È Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ Ô˘ ¤Ï·‚·Ó ıÂڷ›· Ì GH (1,20). √È Ì·ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ Ù˘ ıÂڷ›·˜ Ì G∏, fiÛÔÓ ·ÊÔÚ¿ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· Î·È ÙÔ ÌÂÙ¤ÂÈÙ· ΛӉ˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ‰È·‚‹ÙË Ù‡Ô˘ 2 Û ÎÔÚ›ÙÛÈ· Ì ۇӉÚÔÌÔ Turner, ‰ÂÓ Â›Ó·È ·ÎfiÌ· Ï‹Úˆ˜ ÁÓˆÛÙ¤˜ (1). ÃÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÔ˘Ó ÂÚÈÛÛfiÙÂÚ˜ Ì·ÎÚÔÚfiıÂÛ̘ ÌÂϤÙ˜, Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÁÈ· Ó· ÂÍ·¯ıÔ‡Ó ÔÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ∏ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Â›Ó·È Ó· ¯ÔÚËÁÂ›Ù·È G∏ Û οı ·È‰› Ì ۇӉÚÔÌÔ Turner (1). ∏ Û˘Ó‹ı˘ ‰fiÛË Â›Ó·È 0,30-0,35 mg/Kg/‚‰ÔÌ¿‰·. ∏ ıÂڷ›· Û˘Ó‰˘¿˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÔÈÛÙÚÔÁfiÓˆÓ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ. ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (á∞) ∆Ô ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ· ÛÙ· ·È‰È¿ Ì á∞. H ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È ·ÊÔÚ¿ ÙfiÛÔ ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ¿ÍÔÓ· GH-πGF-1, fiÛÔ Î·È ¶·È‰È·ÙÚÈ΋ 2008;71:123-127
Pediatri Mar-Apr 08
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E. ∫Ô‡ÛÙ· Î·È Û˘Ó.
ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ ıÚ¤„˘ (23,24). ∂Âȉ‹ ‰ÂÓ ˘¿Ú¯ÂÈ ·Ó¿ÚÎÂÈ·, ·ÏÏ¿ ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ GH, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÔÈ ·ÛıÂÓ›˜ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË G∏. ∏ ıÂڷ›· Ì GH, Â¿Ó ‰Ôı› ÓˆÚ›˜, ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ Î·È ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ (2,23,24). ∏ ıÂڷ›· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔ 1996 Î·È ¯ÔÚËÁÂ›Ù·È Û ·ÛıÂÓ›˜ Ì á∞ ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜ ÚÔÙÂÏÈÎÔ‡ Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ∏ ıÂڷ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û fiÛÔ ‰˘Ó·ÙfiÓ ÌÈÎÚfiÙÂÚË ËÏÈΛ·, ÂÊfiÛÔÓ Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÂÌÊ·Ó›˙ÂÈ ÙÒÛË, Ë ÔÔ›· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·Ó·Ú΋ ıÚ¤„Ë ‹ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ‰fiÛË Ù˘ GH ÛÙË Ã¡∞ Â›Ó·È 0,35 mg/Kg/‚‰ÔÌ¿‰·.
™‡Ó‰ÚÔÌÔ Prader-Willi ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈÔ ÁÂÓÂÙÈÎfi Û‡Ó‰ÚÔÌÔ (Û˘¯ÓfiÙËÙ· 1/10.000-15.000), ÙÔ ÔÔ›Ô ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÒÏÂÈ· Ù˘ ÁÔÓȉȷ΋˜ ¤ÎÊÚ·Û˘ Ù˘ ÂÚÈÔ¯‹˜ 15q11-q13 ÙÔ˘ ·ÙÚÈÎÔ‡ ·ÏÏËÏfiÌÔÚÊÔ˘ ·ÔÙ˘ˆÌ¤ÓÔ˘ ÁÔÓȉ›Ô˘ (imprinted gene) Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÂÚÊ·Á›·, ·¯˘Û·ÚΛ·, ˘ÔÁÔÓ·‰ÈÛÌfi, ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È GHD ÔÊÂÈÏfiÌÂÓË Û ˘Ôı·Ï·ÌÈ΋ ‰È·Ù·Ú·¯‹ (3,25). ∏ ıÂڷ›· Ì GH ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘, ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Î·È ¤¯ÂÈ È‰È·›ÙÂÚ· ¢ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi Î·È ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· (3,25). ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,25 mg/Kg/‚‰ÔÌ¿‰·. ¶ÚfiÛÊ·Ù· ·Ó·Ê¤ÚıËÎ·Ó ·ÈÊÓ›‰ÈÔÈ ı¿Ó·ÙÔÈ, ΢ڛˆ˜ ·fi ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ˘Ô·ÂÚÈÛÌfi Û ·È‰È¿ Ì ÙÔ Û‡Ó‰ÚÔÌÔ, Ù· ÔÔ›· ÂÏ¿Ì‚·Ó·Ó ıÂڷ›· Ì GHØ ·ÚfiÏÔ Ô˘ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› Ë Û˘Û¯¤ÙÈÛË Ù˘ ıÂڷ›·˜ Ì GH, ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÙ·È ÚÔÛÂÎÙÈÎfi˜ ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁÈÎfi˜ Î·È ·Ó·Ó¢ÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (26). ÕÏϘ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ¯ÔÚËÁÂ›Ù·È GH Û ·È‰È¿, ÔÈ Ôԛ˜ fï˜ ‰ÂÓ ¤¯Ô˘Ó ¿ÚÂÈ ¤ÁÎÚÈÛË ÛÙË ¯ÒÚ· Ì·˜ ¶·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ (Small for Gestational Age, SGA) ¶ÂÚ›Ô˘ 10% ÙˆÓ ·È‰ÈÒÓ Ì SGA (‚¿ÚÔ˜ ‹/Î·È Ì‹ÎÔ˜ <2 SD) ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 2 ÚÒÙˆÓ ÂÙÒÓ Ù˘ ˙ˆ‹˜, Ì ·ÔÙ¤ÏÂÛÌ· ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ¯·ÌËÏfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (ÂÚ›Ô˘ 1 SD οو ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘) (27). ™Â ·È‰È¿ 2-4 ÂÙÒÓ Ì SGA, Ù· ÔÔ›· ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È ¤¯Ô˘Ó ‡„Ô˜ <-2,5 SD (‹ Û ·È‰È¿ Ì SGA ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 4 ÂÙÒÓ Ì ‡„Ô˜ <-2 SD), Û˘ÓÈÛÙ¿Ù·È Ó· Ï·Ì‚¿ÓÔ˘Ó ıÂڷ›· Ì GH Paediatriki 2008;71:123-127
(27). ∏ ¯ÔÚ‹ÁËÛË GH ‚ÂÏÙÈÒÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ Î·È ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ (4). §fiÁˆ ÙˆÓ Â˘ÓÔ˚ÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂڷ›·˜, ·Ó Î·È Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ¤¯ÂÈ ‹‰Ë ÂÁÎÚÈı› Ë ıÂڷ›· Û ·˘Ù¿ Ù· ·È‰È¿ Û ∞ÌÂÚÈ΋ Î·È ∂˘ÚÒË Î·È ÛÙËÓ ∂ÏÏ¿‰· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔÓ ∂√º Î·È ÙÔ ∫∂™À Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ˘ÔÁÚ·Ê‹˜. √È Ì·ÎÚÔÚfiıÂÛ̘, fï˜, ÌÂÙ·‚ÔÏÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ıÂڷ›·˜ Ì GH, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ÙËÓ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· Û ·˘Ù¿ Ù· ·È‰È¿, Â›Ó·È ·ÎfiÌË ˘fi ÌÂϤÙË. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,25 mg/Kg/‚‰ÔÌ¿‰·. ¶·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (Idiopathic Short Stature, ISS) T· ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (<2,25 SD) Â›Ó·È ÌÈ· ÂÙÂÚÔÁÂÓ‹˜ ÔÌ¿‰·, Ù· ÂÚÈÛÛfiÙÂÚ· ·fi ·˘Ù¿ (·ÏÏ¿ fi¯È fiÏ·) ‰ÂÓ ÊÙ¿ÓÔ˘Ó ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ∏ ıÂڷ›· Ì GH ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘, Â¿Ó ‰Ôı› ÓˆÚ›˜, ȉ›ˆ˜ ÛÙËÓ ·Ú¯‹ Ù˘ ıÂڷ›·˜ Î·È ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ηٿ 4-7 cm, Û οÔȘ, ·ÏÏ¿ fi¯È Û fiϘ ÙȘ ÌÂϤÙ˜ (5). T· ̤¯ÚÈ Û‹ÌÂÚ· ·ÔÙÂϤÛÌ·Ù·, ·ÚfiÙÈ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ıÂڷ›· Ì GH Â›Ó·È ·ÛÊ·Ï‹˜ ÛÙ· ·È‰È¿ ·˘Ù¿, Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (5). ™ÙȘ ∏¶∞ ¤¯ÂÈ ‰Ôı› ¤ÁÎÚÈÛË ÌfiÓÔ Û ¤Ó· Û··ÛÌ·. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, Ë ¯ÔÚ‹ÁËÛË GH ÛÙ· ·È‰È¿ ·˘Ù¿ Â›Ó·È ˘fi ÌÂϤÙË Î·È ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛÙ· Ï·›ÛÈ· ÂÚ¢ÓËÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,30 mg/Kg/‚‰ÔÌ¿‰·. ÕÏϘ ÂÚÈÙÒÛÂȘ ¯ÔÚ‹ÁËÛ˘ GH H GH ¤¯ÂÈ Â›Û˘ ¯ÔÚËÁËı› Ì ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· Û ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ˘ÂÚÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ (28) Î·È Û ·È‰È¿ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ (29), Ë ¯Ú‹ÛË Ù˘, fï˜, Û ·˘Ù¿ Ù· ·È‰È¿ ·ÎfiÌË ÌÂÏÂٿٷÈ.
GHD Û ÂÓ‹ÏÈΘ ∞ÊÔÚ¿ ÂÚ›Ô˘ 200 ·ÛıÂÓ›˜ ·Ó¿ 1.000.000. ∏ ıÂڷ›· ¯ÔÚËÁÂ›Ù·È Û ·ÛıÂÓ›˜ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·Ó¿ÚÎÂÈ·, ‰ËÏ·‰‹ Ì ̤ÁÈÛÙË ·¿ÓÙËÛË GH ÛÙË ‰ÔÎÈÌ·Û›· ˘ÔÁÏ˘Î·ÈÌ›·˜, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÈÓÛÔ˘Ï›Ó˘ <3 ng/ml. ∏ ¤ÏÏÂÈ„Ë GH ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Ô‰ËÁ› Û ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ·, ÂÏ·Ùو̤ÓË ¿ÏÈÔ Ì¿˙· (lean body mass), ÂÏ·Ùو̤ÓË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, ·˘ÍË̤ÓË Î·Ú‰È·ÁÁÂȷ΋ ÓÔÛËÚfiÙËÙ· Î·È ÂËÚ·Ṳ̂ÓË ÔÈfiÙËÙ· ˙ˆ‹˜, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË GH ‚ÂÏÙÈÒÓÂÈ ÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ (30). ∏ ‰fiÛË Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Î˘Ì·›ÓÂÙ·È ·fi 0,15-0,3 mg/Ë̤ڷ, Ì ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË, Ô˘ ηıÔÚ›˙ÂÙ·È ·fi Ù· ›‰· ÙÔ˘ IGF-1 (30).
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16. Juul A, Bernasconi S, Clayton PE, Kiess W, DeMuinckKeizer Schrama S; Drugs and Therapeutics Committee of the European Society for Paediatric Endocrinology (ESPE). European audit of current practice in diagnosis and treatment of childhood growth hormone deficiency. Horm Res 2002;58:233-241. 17. Bowlby DA, Rapaport R. Safety and efficacy of growth hormone therapy in childhood. Pediatr Endocrinol Rev 2004;2 Suppl 1:68-77. 18. Rao E, Weiss B, Fukami M, Rump A, Niesler B, Mertz A, et al. Pseudoautosomal deletions encompassing a novel homeobox gene cause growth failure in idiopathic short stature and Turner syndrome. Nat Genet 1997;16:54-63. 19. Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child 1985;60:932-935. 20. Stephure DK; Canadian Growth Hormone Advisory Committee. Impact of growth hormone supplementation on adult height in turner syndrome: results of the Canadian randomized controlled trial. J Clin Endocrinol Metab 2005;90:3360-3366. 21. Baxter L, Bryant J, Cave CB, Milne R. Recombinant growth hormone for children and adolescents with Turner syndrome. Cochrane Database Syst Rev 2007;(1):CD003887. 22. Ranke MB, Lindberg A, Ferrãandez Long as ã A, Darendeliler F, Albertsson-Wikland K, Dunger D, et al. Major determinants of height development in Turner syndrome (TS) patients treated with GH: analysis of 987 patients from KIGS. Pediatr Res 2007;61:105-110. 23. Mahan JD, Warady BA; the Consensus Committee. Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement. Pediatr Nephrol 2006;21:917-930. 24. Stefanidis CJ, Klaus G. Growth of prepubertal children on dialysis. Pediatr Nephrol. 2007;22:1251-1259. 25. Goldstone AP. Prader-Willi syndrome: advances in genetics, pathophysiology and treatment. Trends Endocrinol Metab 2004;15:12-20. 26. Eiholzer U. Deaths in children with Prader-Willi syndrome. A contribution to the debate about the safety of growth hormone treatment in children with PWS. Horm Res 2005;63:33-39. 27. Clayton PE, Cianfarani S, Czernichow P, Johannsson G, Rapaport R, Rogol A. Management of the child born small for gestational age through to adulthood: a consensus statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society. J Clin Endocrinol Metab 2007;92:804-810. 28. Gallagher MP, Levine LS, Oberfield SE. A review of the effects of therapy on growth and bone mineralization in children with congenital adrenal hyperplasia. Growth Horm IGF Res 2005;15 Suppl A:S26-30. 29. Hardin DS, Ferkol T, Ahn C, Dreimane D, Dyson M, Morse M, et al. A retrospective study of growth hormone use in adolescents with cystic fibrosis. Clin Endocrinol (Oxf) 2005;62:560-566. 30. Drake WM, Howell SJ, Monson JP, Shalet SM. Optimizing gh therapy in adults and children. Endocr Rev 2001;22: 425-450.
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ORIGINAL ARTICLE
∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ 1. °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °¶¡£ 2. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎoÌÂ›Ô ∫ÈÏΛ˜ 3. ∞’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, πÔÎÚ¿ÙÂÈÔ °¶¡£ AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›Ó· ∫ÒÛÙ·, konstantinakosta@yahoo.gr °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °¶¡£
ª. ¶··‰ÔÔ‡ÏÔ˘1, ™. ¡ÙÔ˘Ì¿2, ∫. ∫›ÙÛÈÔ˜3, ¡. ∫·‰fiÁÏÔ˘3, ∫. ∫ÒÛÙ·1, π. ∆ÛÈÔ‡Ú˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Û ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GH) Ô˘ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì ·Ó·Û˘Ó‰˘·Ṳ̂ÓË GH Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 72 ·È‰È¿ (25 ÚÔÂÊË‚Èο) Ì ÌÂÌÔӈ̤ÓË (61/72) ‹ Û˘Ó‰˘·Ṳ̂ÓË (11/72) ·Ó¿ÚÎÂÈ· GH, Ô˘ ‰È·ÁÓÒÛÙËΠÌÂÙ¿ ·fi ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ GH Ì ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘. ∆· ·È‰È¿ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì GH sc, 3, 6 ‹ 7 ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜. ¶ÚÔÛ‰ÈÔÚ›ÛÙËΠÁÈ· οı ·È‰› ÙÔ ‡„Ô˜-ÛÙfi¯Ô˜. ∫·Ù·ÁÚ¿ÊËÎ·Ó Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Î·È ·ÎÔÏÔ‡ıˆ˜ ·Ó¿ ÂÍ¿ÌËÓÔ ÙÔ ‡„Ô˜ Û fiÚıÈ· ı¤ÛË, Ë ÔÛÙÈ΋ ËÏÈΛ·, Ô ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ·‡ÍËÛ˘ Î·È ÙÔ ÛÙ¿‰ÈÔ ÂÓ‹‚ˆÛ˘. ∞ÔÙÂϤÛÌ·Ù·: ∏ ‰È·ÊÔÚ¿ Ù˘ ̤Û˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜ Û ۯ¤ÛË Ì ٷ ÚÔ ·˘Ù‹˜ ›‰· ‹Ù·Ó 1,3. ™ÙÔ ‡„Ô˜-ÛÙfi¯Ô ¤ÊÙ·Û·Ó 23 ·È‰È¿ (32%). À‹Ú¯Â ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙÔ ·Ú¯ÈÎfi ‡„Ô˜, ÙÔ ‡„Ô˜-ÛÙfi¯Ô Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ ·Ó¿ ‚‰ÔÌ¿‰·, ÂÓÒ ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜, ÙÔ Ê‡ÏÔ Î·È ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ıÂڷ›·˜. ∆· ·È‰È¿ ÌÂ Û˘Ó‰˘·Ṳ̂ÓË ·Ó¿ÚÎÂÈ· ÔÚÌÔÓÒÓ Î¤Ú‰ÈÛ·Ó ÂÚÈÛÛfiÙÂÚÔ ‡„Ô˜ Ì ÙË ıÂڷ›· Û ۯ¤ÛË Ì ÂΛӷ Ì ÌÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· GH. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯ÔÚ‹ÁËÛË GH ·ÔÙÂÏ› ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ÁÈ· ·È‰È¿ Ì ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÔÊÂÈÏfiÌÂÓÔ Û ·Ó¿ÚÎÂÈ· ·˘Ù‹˜. ∆Ô ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÛÙ· ·È‰È¿ ·˘Ù¿ Ê·›ÓÂÙ·È ˆ˜ ηıÔÚ›˙ÂÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ ‡„Ô˜-ÛÙfi¯Ô Î·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ GH ·Ó¿ ‚‰ÔÌ¿‰·.
§¤ÍÂȘ ÎÏÂȉȿ: A˘ÍËÙÈ΋ ÔÚÌfiÓË, ‹‚Ë, Û˘Ó‰˘·Ṳ̂ÓË ·Ó¿ÚÎÂÈ· ÔÚÌÔÓÒÓ, ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ‡„Ô˜-ÛÙfi¯Ô˜.
Final height of children with growth hormone deficiency who received replacement treatment 1. 3rd Paediatric Department, Aristotle University of Thessaloniki, Hippokration General Hospital of Thessaloniki 2. Paediatric Department, General Hospital of Kilkis 3. 1st Department of Internal Medicine, Hippokration General Hospital of Thessaloniki Correspondence: ∫onstantina Kosta, konstantinakosta@yahoo.gr 3rd Paediatric Department, Aristotle University of Thessaloniki, Hippokration General Hospital of Thessaloniki
M. Papadopoulou1, S. Douma2, K. Kitsios3, N. Kadoglou3, K. Kosta1, I. Tsiouris1 Abstract Background: The aim of the study was the evaluation of the final height of children with Growth Hormone (GH) deficiency treated with recombinant GH, and of the factors related to their final height. Methods: Seventy two children (25 prepubertal) with isolated (61/72) or combined (11/72) GH deficiency, diagnosed after measurement of GH following stimulation tests with clonidin or insulin, were monitored. The children were treated with 3, 6 or 7 weekly subcutaneous injections of recombinant GH. The target height (TH) was calculated for each child. Height, bone age, growth velocity and pubertal stage were recorded at the beginning of treatment and every 6 months. Final height was defined as the height at the time of the complete fusion of the epiphyses observed in a plain X-ray of the hand and wrist. Results: The difference in the SDS of the mean final height before and after GH treatment was 1.3. Twenty three children (32%) reached the TH. The final height was associated statistically with the initial height, the TH and the number of weekly injections, while no relationship was observed with the age at the beginning of treatment, the duration of treatment, the growth velocity during the first year of treatment or the sex of the child. Children with combined hormone deficiency gained more height than those with isolated GH deficiency, but they also had a greater TH. Conclusions: GH replacement therapy is beneficial for children with small height due to deficiency of the hormone. The final height in these children appears to be highly predictable by the TH and the number of GH injections given weekly.
Key words: Growth hormone, puberty, combined hormone deficiency, final height, target height.
Paediatriki 2008;71:128-134
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·129
129
AÓ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘
∂ÈÛ·ÁˆÁ‹ ∏ ·ÓıÚÒÈÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) Â›Ó·È Ë Î‡ÚÈ· ‰Ú·ÛÙÈ΋ ÔÚÌfiÓË Ô˘ ÚÔ¿ÁÂÈ ÙËÓ ·‡ÍËÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ȉ›ˆ˜ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ (1). ∏ GH Â›Ó·È ·Ó·‚ÔÏÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔ¿ÁÂÈ ÙËÓ ·‡ÍËÛË fiÏˆÓ ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. √È ‰Ú¿ÛÂȘ Ù˘ Â›Ó·È ·) ¿ÌÂÛ˜ ÌÂÙ·‚ÔÏÈΤ˜ Ô˘ ‰È¢ÎÔχÓÔ˘Ó ÙËÓ ·‡ÍËÛË ÙˆÓ Ì˘ÒÓ Î·È ÙËÓ ÂÍÔÈÎÔÓfiÌËÛË Ù˘ ÁÏ˘Îfi˙˘ Î·È ‚) ·˘ÍËÙÈΤ˜ ÛÙÔ ÛÎÂÏÂÙfi. ∏ ·‡ÍËÛË ÙÔ˘ ÛÎÂÏÂÙÔ‡ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÛÙȘ ÂÈʇÛÂȘ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ Î·È Ë Â›‰Ú·ÛË ·˘Ù‹ ‰È·ÎfiÙÂÙ·È Ì ÙË Û‡ÁÎÏÈÛË ÙˆÓ ÂÈʇÛˆÓ. ∏ GH ‰Ú· ÛÙÔ Û˘˙¢ÎÙÈÎfi ¯fiÓ‰ÚÔ, fiÔ˘ ‰ÈÂÁ›ÚÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ¯ÔÓ‰ÚÔ΢ÙÙ¿ÚˆÓ ·ÊÂÓfi˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÈÓÛÔ˘ÏÈÓoÌfiÚÊˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁÔÓÙˆÓ (IGF). √ ÈÓÛÔ˘ÏÈÓfiÌÔÚÊÔ˜ ·Ú¿ÁÔÓÙ·˜ π (IGF-1) ‰ÈÂÁ›ÚÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Î·È ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ¯ÔÓ‰ÚÔ΢ÙÙ¿ÚˆÓ. ∏ ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÂΉËÏÒÓÂÙ·È ˆ˜: ·) ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (2,5 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ (SDS) οو ·fi ÙÔ Ì¤ÛÔ fiÚÔ ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ), ‚) ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÔÛÙÒÓ, Á) ¯·ÌËÏ‹ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ Î·È ‰) ¯·ÌËÏ‹ ¤ÎÎÚÈÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ‰È¤ÁÂÚÛ˘. ™Â ·È‰È¿ Ì ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ¯ÔÚËÁÂ›Ù·È ıÂڷ¢ÙÈο ‚ÈÔÛ˘ÓıÂÙÈ΋ GH Ô˘ ·Ú¿ÁÂÙ·È Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA. ∏ ¯ÔÚ‹ÁËÛË Á›ÓÂÙ·È Ì ÙË ÌÔÚÊ‹ ˘Ô‰ÔÚ›ˆÓ ÂÓ¤ÛˆÓ. ∏ ‚ÈÔÛ˘ÓıÂÙÈ΋ GH ·Ú·Û΢¿ÛÙËΠ·Ú¯Èο ÙÔ 1979, ·ÏÏ¿ ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ·fi ÙÔ 1985, ÔfiÙÂ Î·È ·ÓÙÈηٿÛÙËÛ ÙËÓ ÙˆÌ·ÙÈ΋ ·˘ÍËÙÈ΋ ÔÚÌfiÓË Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·fi ÙÔ 1957. ∏ ıÂڷ›· ·ÔÛÎÔ› ÛÙÔ Ó· ÂÈÙ¢¯ı› ÙÂÏÈÎfi ‡„Ô˜ ̤۷ ÛÙ· Ï·›ÛÈ· ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˘˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÛÙÔ Ê‡ÏÔ. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Û ·È‰È¿ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ùfi. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 72 ·È‰È¿, 43 ·ÁfiÚÈ· Î·È 29 ÎÔÚ›ÙÛÈ·, Ì ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Ô˘ ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) ¯ÔÚËÁÔ‡ÌÂÓË ˘Ô‰fiÚÈ·. ∆· 61 ›¯·Ó ÌÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È Ù· 11 Û˘Ó‰˘·Ṳ̂ÓË. ∂ȉÈÎfiÙÂÚ·: 6 ·È‰È¿, 4 ·ÁfiÚÈ· Î·È 2 ÎÔÚ›ÙÛÈ·, ›¯·Ó ·Ó¿ÚÎÂÈ· ı˘ÚÔ͛Ӣ (∆4), 1 ·ÁfiÚÈ Â›¯Â ·Ó¿ÚÎÂÈ· ∆4 Î·È ÙÂÛÙÔÛÙÂÚfiÓ˘, 1 ÎÔÚ›ÙÛÈ Â›¯Â ·Ó¿ÚÎÂÈ· ∆4 Î·È ÔÈÛÙÚÔÁfiÓˆÓ, 1 ·ÁfiÚÈ Â›¯Â ·Ó¿ÚÎÂÈ· ∆4 Î·È ¿ÔÈÔ ‰È·‚‹ÙË Î·È 2 ÎÔÚ›ÙÛÈ· ·Ó˘ÔÊ˘ÛÈÛÌfi ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁËı¤ÓÙ˜ ÂÁÎÂÊ·ÏÈÎÔ‡˜ fiÁÎÔ˘˜. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ‹Ù·Ó 11,6±2,9 ¤ÙË Î·È Î·Ù¿ ÙÔ ¤Ú·˜ ·˘Ù‹˜ 16,2±1,6. ∞ÓıÚˆÔÌÂÙÚÈΤ˜ ÌÂÙÚ‹ÛÂȘ Á›ÓÔÓÙ·Ó Ì ·Ó·ÛÙËÌfiÌÂÙÚÔ Harpenden
ÛÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Î·È ·Ó¿ ÂÍ¿ÌËÓÔ Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ¿ Ù˘. ∏ ̤ÙÚËÛË ÙÔ˘ ‡„Ô˘˜ οı ·È‰ÈÔ‡ ÁÈÓfiÙ·Ó Û fiÚıÈ· ı¤ÛË Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÛËÌÂȈÓfiÙ·Ó ÛÙȘ η̇Ϙ ·‡ÍËÛ˘ ÙˆÓ Tanner Î·È Whitehouse ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ (∂£). ¶ÚÔÛ‰ÈÔÚÈ˙fiÙ·Ó Ô ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ·‡ÍËÛ˘ (∂ƒ∞). √ ∂ƒ∞ ‹ height velocity Â›Ó·È Ë ‰È·ÊÔÚ¿ ÙÔ˘ ‡„Ô˘˜ Û ¤Ó· ¯ÚfiÓÔ. ¶ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ·fi ÙÔ ËÏ›ÎÔ Ù˘ ‰È·ÊÔÚ¿˜ ÙÔ˘ ‡„Ô˘˜ ·Ó¿ÌÂÛ· Û ‰‡Ô ÌÂÙÚ‹ÛÂȘ ‰È· ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ÌÂÛÔÏ¿‚ËÛÂ Î·È ÂÎÊÚ¿˙ÂÙ·È Û cm/¤ÙÔ˜. ∆Ô ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ˘ÔÏÔÁ›˙ÂÙ·È ·ÎÚÈ‚Ò˜ Ì ÙÔ ‰Âη‰ÈÎfi ËÌÂÚÔÏfiÁÈÔ. √È ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ‡„Ô˘˜ Î·È ÙÔ˘ ∂ƒ∞ ÙÔ˘ οı ·È‰ÈÔ‡ ÂÎÊÚ¿ÛÙËÎ·Ó Û ‰Â›ÎÙ˜ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ (Standard Deviation Score, SDS) Ì ‚¿ÛË ÙË ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ·. √ ‰Â›ÎÙ˘ ·˘Ùfi˜ ‰Â›¯ÓÂÈ fiÛ˜ ·ÎÚÈ‚Ò˜ ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ ·fi ÙÔ Ì¤ÛÔ fiÚÔ ‚Ú›ÛÎÂÙ·È ÙÔ ‡„Ô˜ ‹ ¿ÏÏË Ì¤ÙÚËÛË ÙÔ˘ ·È‰ÈÔ‡. √ ‰Â›ÎÙ˘ ·˘Ùfi˜ ˘ÔÏÔÁ›˙ÂÙ·È ·fi ÙÔÓ Ù‡Ô: SDS=(X-XÌÙ) / SD, fiÔ˘ Ã: ‡„Ô˜ (‹ ¿ÏÏË Ì¤ÙÚËÛË ÙÔ˘ ·È‰ÈÔ‡), ÃÌÙ: Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ‡„Ô˘˜ (·fi ›Ó·Î˜) Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÙÔ˘ ·È‰ÈÔ‡ Î·È SD: Ë ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË Ù˘ ›‰È·˜ ËÏÈΛ·˜ (2). ∂›Û˘, ˘ÔÏÔÁ›ÛÙËΠÙÔ ‡„Ô˜-ÛÙfi¯Ô˜ (target height, TH) ÁÈ· Ó· ÂÏÂÁ¯ı› ·Ó ÙÔ ÙÂÏÈÎfi ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ ‚Ú›ÛÎÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ‰˘Ó·ÌÈÎÔ‡ ÙÔ˘. ∆Ô TH ˘ÔÏÔÁ›˙ÂÙ·È ·Ó ÛÙÔ Ì¤ÛÔ ‡„Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ÚÔÛÙÂıÔ‡Ó 6,5 cm, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ·ÁfiÚÈ, ‹ ·Ê·ÈÚÂıÔ‡Ó 6,5 cm, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÎÔÚ›ÙÛÈ. °ÈÓfiÙ·Ó ˘ÔÏÔÁÈÛÌfi˜ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Î·È ·Ó¿ ¤ÙÔ˜, Û‡Ìʈӷ Ì ÙÔÓ ¿ÙÏ·ÓÙ· TWRUS. ∂›Û˘, ÁÈÓfiÙ·Ó ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ÂÊ˂›·˜ ηٿ Tanner ÛÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Î·È ·Ó¿ ÂÍ¿ÌËÓÔ. ¶ÚÔÂÊË‚ÈÎfi ıˆÚ›ÙÔ Î¿ı ÎÔÚ›ÙÛÈ ¯ˆÚ›˜ „ËÏ·ÊËÙfi Ì·˙ÈÎfi ·‰¤Ó· Î·È Î¿ı ·ÁfiÚÈ Ì fiÁÎÔ fiÚ¯ÂˆÓ <4 ml. ∆Ô Ì¤ÁÂıÔ˜ ÙˆÓ fiÚ¯ÂˆÓ ÂÎÙÈÌ‹ıËΠ̠ÔگȉfiÌÂÙÚÔ Prader. ø˜ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ıˆڋıËΠÙÔ ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ¯ÂÈÚÒÓ ‰È·ÈÛÙˆÓfiÙ·Ó Ï‹Ú˘ Û‡ÁÎÏÈÛË ÙˆÓ ÂÈʇÛÂˆÓ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ™Â οı ·È‰› ÂÎÙÈÌ‹ıËÎÂ Ë ¤ÎÎÚÈÛË GH ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ‰È¤ÁÂÚÛ˘ Ì ÎÏÔÓȉ›ÓË ‹ ‰È·Ï˘Ù‹ ÈÓÛÔ˘Ï›ÓË Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ GH Û ¯ÚfiÓÔ˘˜ 0, 15, 30, 45, 60, 90, 120 min. ¶·ıÔÏÔÁÈ΋ ıˆÚ›ÙÔ ÙÈÌ‹ GH <10 ng/ml Ô˘ ÂȂ‚·ÈˆÓfiÙ·Ó Û ‰Â‡ÙÂÚË ‰ÔÎÈÌ·Û›· ÂÓÙfi˜ ÂÓfi˜ ÌËÓfi˜. °È· ÙÔÓ ¤ÏÂÁ¯Ô ¤Ó·Ú͢ Ù˘ ÂÊ˂›·˜ ÁÈÓfiÙ·Ó ‰ÔÎÈÌ·Û›· LHRH Ì ÚÔÛ‰ÈÔÚÈÛÌfi ÙÈÌÒÓ LH, FSH Û ¯ÚfiÓÔ˘˜ 0, 30, 60 min. ŒÓ·ÚÍË Ù˘ ÂÊ˂›·˜ ıˆÚ›ÙÔ ÙÈÌ‹ LH >15 IU/L (3). ∂›Û˘, ÁÈÓfiÙ·Ó ‰ÔÎÈÌ·Û›· TRH ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ TSH (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ TSH: 0,4-4 ÌπU/ml) Û ¯ÚfiÓÔ˘˜ 0, 30, 60 min Î·È Ù˘ ∆4 Û ¯ÚfiÓÔ 0 (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ∆4: 5,6-12 Ìg/dl). ∞Ó¿ ÂÍ¿ÌËÓÔ ÁÈÓfiÙ·Ó ¤ÏÂÁ¯Ô˜ ÁÏ˘Îfi˙˘ ÔÚÔ‡, ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c%), ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (TSH, T3, T4), ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ÛÙ· ·È‰È¿ Ô˘ Ë ÂÊ˂›· ›¯Â ÍÂÎÈÓ‹ÛÂÈ. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË √È ÔÛÔÙÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ Û˘ÓÔ„›ÛÙËÎ·Ó ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ̤ÛÔ˘˜ fiÚÔ˘˜ Î·È Ù˘ÈΤ˜ ·ÔÎÏ›ÛÂȘ (standard deviation). °È· ÙË Û‡ÁÎÚÈÛË ‰‡Ô Ì¤ÛˆÓ fiÚˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· ηٿ Student’s t-test. ¶·Ú¿ÏÏËÏ· ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ Î·ÓÔÓÈÎfiÙËÙ· ÙˆÓ ÌÂÙ·‚ÏËÙÒÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙË ‰ÔÎÈÌ·Û›· ηٿ Shapiro-Wilk, fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·fiÎÏÈÛË ·fi ÙËÓ Î·ÓÔÓÈÎfiÙËÙ· Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ¶·È‰È·ÙÚÈ΋ 2008;71:128-134
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·130
130
ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 1. µ·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηٿ ÙËÓ ¤Ó·ÚÍË ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ ∞ÛıÂÓ›˜
ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)
º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ⁄„Ô˜-ÛÙfi¯Ô˜ (∆∏) (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)
72 (43 ¿ÚÚÂÓ·, 29 ı‹Ï·) 11,59±2,95 -2,5±0,84 9,49±3,02 -0,74±1,05 -0,77±0,74 -0,91±0,9 -0,66±0,91
ª¤ÁÈÛÙË ÙÈÌ‹
∂Ï¿¯ÈÛÙË ÙÈÌ‹
16,06 -0,51 14,10
3,23 -5,78 1,50
1,83 1,05 1,3 1,54
-4,73 -2,21 -3,36 -2,51
SDS: standard deviation score, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ
··ÈÙ‹ıËΠÔÔÈ·‰‹ÔÙ ÌÂÙ·ÙÚÔ‹ ÙˆÓ ÌÂÙ·‚ÏËÙÒÓ. ∞Ú¯Èο, Ë Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ Ì ÙȘ ¿ÏϘ ηÙËÁÔÚÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ ÂÍÂÙ¿ÛÙËΠ̠ÙÔ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson, ÂÓÒ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û¯¤Û˘ ʇÏÔ˘ Î·È ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ô Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman. ∂Ê·ÚÌfiÛÙËΠÔÏ˘·Ú·ÁÔÓÙÈ΋ ÁÚ·ÌÌÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ÁÈ· Ó· ÂÍÂÙ·ÛÙ› Ë Û˘ÓÔÏÈ΋ Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ Ì ¿ÏÏÔ˘˜ ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ™’ fiϘ ÙȘ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ, ÙÔ Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÔÚ›ÛÙËΠˆ˜ 0,05 Î·È ·ÌʛϢÚÔ. √È ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ ÂÊ·ÚÌfiÛÙËÎ·Ó Ì ٷ ÛÙ·ÙÈÛÙÈο ·Î¤Ù· SPSS 13.0 Î·È STATA.
∞ÔÙÂϤÛÌ·Ù· ∆· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂڷ›·˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο ÛÙÔÓ ¶›Ó·Î· 2. ¢È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÌÂ: ÙÔ ·Ú¯ÈÎfi ‡„Ô˜, ÙÔ ‡„Ô˜ÛÙfi¯Ô˜, ÙÔ ‡„Ô˜ Ù˘ ÌËÙ¤Ú·˜, ÙÔ ‡„Ô˜ ÙÔ˘ ·Ù¤Ú· Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ ·Ó¿ ‚‰ÔÌ¿‰· (¶›Ó·Î·˜ 3). ¢ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙÔ Ê‡ÏÔ, ÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Î·È ÙËÓ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ (height velocity) ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂڷ›·˜. ªÂ ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÁÚ·ÌÌÈ΋˜
·ÏÈÓ‰ÚfiÌËÛ˘, ÂÍÂÙ¿ÛÙËÎÂ Ë Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë Ù· ‚·ÛÈο ÙÔ˘˜ ¯·Ú·ÎÙËÚÈÛÙÈο. ∆ÂÏÈο, ‰È·ÌÔÚÊÒıËΠ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi ÌÔÓÙ¤ÏÔ ·Ó¿Ï˘Û˘, Ì ÙÔ ÔÔ›Ô ÌÔÚ› Ó· ÚÔ‚ÏÂÊı› ÙÔ 38,7% (R2adj= 0,387) ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜. ∞fi ÙËÓ ·Ú·¿Óˆ ·Ó¿Ï˘ÛË ÚÔ·ÙÂÈ fiÙÈ ÙÔ ‡„Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Ì GH, Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÓ¤ÛÂˆÓ Â‚‰ÔÌ·‰È·›ˆ˜, ÙÔ ‡„Ô˜ Ù˘ ÌËÙ¤Ú·˜ fiÛÔ Î·È ÙÔ˘ ·Ù¤Ú· ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÂÓfi˜ ·ÙfiÌÔ˘ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘. ™ÙË Û˘Ó¤¯ÂÈ· ÌÂÏÂÙ‹ıËÎ·Ó ˆ˜ ͯˆÚÈÛÙ‹ ˘ÔÔÌ¿‰· Ù· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ÙË ıÂڷ›· ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘. ∆· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο ÛÙÔ˘˜ ¶›Ó·Î˜ 4 Î·È 5. ∆Ô ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÛÙ· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ÚÈÓ ·fi ÙËÓ ‹‚Ë Â›Ó·È ÌÈÎÚfiÙÂÚÔ Û ۯ¤ÛË Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘ (p=0,037). ∆Ô ·ÔÙ¤ÏÂÛÌ· ·˘Ùfi, fï˜, Ê·›ÓÂÙ·È Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Î·È ÙÔ ·Ú¯ÈÎfi ‡„Ô˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ÚÈÓ ·fi ÙËÓ ‹‚Ë ‹Ù·Ó ÌÈÎÚfiÙÂÚÔ (p=0,016). ŸÙ·Ó Û˘ÁÎÚ›ıËÎÂ Ë ‰È·ÊÔÚ¿ Ù˘ ̤Û˘
¶›Ó·Î·˜ 2. ∞ÔÙÂϤÛÌ·Ù· ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ∞ÛıÂÓ›˜ (¡=72)
ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)
ª¤ÁÈÛÙË ÙÈÌ‹
∂Ï¿¯ÈÛÙË ÙÈÌ‹
∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂڷ›·˜ (Height Velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂڷ›·˜ (¤ÙË)
-1,23±1,02
1,22
-5,08
6,26±4,95 16,16±1,61 1,3±0,97 -0,47±0,91 0,47±0,11 6,57±1,23 4,64±2,75
19,00 19,27 4,46 1,75 0,80 7,00 14,81
-1,99 12,44 -0,88 -3,70 0,27 3,00 1,10
SDS: standard deviation score, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ, ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS) Paediatriki 2008;71:128-134
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·131
131
AÓ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘
¶›Ó·Î·˜ 3. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ¶·Ú¿ÁÔÓÙ˜ ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) TH (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)
∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· ™˘Û¯¤ÙÈÛË p r=0,474 r=0,265
<0,01 0,024
r=0,384 r=0,51 r=0,394 r=0,434
<0,01 <0,001 <0,01 <0,001
SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ
Ù˘È΋˜ ·fiÎÏÈÛ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜-·Ú¯ÈÎÔ‡ ‡„Ô˘˜ (¢ height SDS), ·˘Ù‹ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ 2 ˘ÔÔÌ¿‰Â˜ (p=0,9). ∆· ·ÓˆÙ¤Úˆ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ªÈ· ¿ÏÏË ˘ÔÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËΠͯˆÚÈÛÙ¿ ‹Ù·Ó Ù· ·È‰È¿ Ì ¤ÏÏÂÈ„Ë Î·È ¿ÏÏˆÓ ÔÚÌÔÓÒÓ ÏËÓ Ù˘ ·˘ÍËÙÈ΋˜. ∆Ô ¢ height ÛÙ· ·È‰È¿ ·˘Ù¿ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ›¯·Ó ÌÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (p=0,001), ·Ó Î·È ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ 2 ·˘Ù¤˜ ˘ÔÔÌ¿‰Â˜ (p=0,091). ∆· ·ÓˆÙ¤Úˆ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 7.
™˘˙‹ÙËÛË ∏ ̤ÛË Ù˘È΋ ·fiÎÏÈÛË ÙÔ˘ ‡„Ô˘˜ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (HtSDS) ‹Ù·Ó -2,5, ÂÓÒ Ë Ì¤ÛË Ù˘È΋ ·fiÎÏÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ (FHSDS) ‹Ù·Ó -1,22. ∏ ıÂڷ›· ˘ÔηٿÛÙ·Û˘ ‚ÂÏÙ›ˆÛ ۷ÊÒ˜ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ, ·Ó Î·È ÌfiÓÔ 23 ·È‰È¿ (32%) ¤ÊÙ·Û·Ó ÙÔ ‡„Ô˜-ÛÙfi¯Ô (TH). ¶·È‰È¿ Ì ȉÈÔ·ı‹ ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD) ‹ ˘ÔÊ˘ÛÈÛÌfi Ô˘ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ıÂڷ›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó FHSDS ÌÂٷ͇
-4 Î·È -6 (4). ™Â ÌÈ· ÛÂÈÚ¿ ·fi ·Ó¿ÏÔÁ˜ ÂÚÁ·Û›Â˜ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÌÂٷ͇ 1995 Î·È 2006, ÙÔ FHSDS ·Ó·Ê¤ÚÂÙ·È ÌÂٷ͇ -0,4 Î·È -2,0 (5-13). ™Â ÌÂϤÙ˜ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÌÂٷ͇ 1981 Î·È 1989, ÙÔ FHSDS ·Ó·Ê¤ÚÂÙ·È ÌÂٷ͇ -1,75 Î·È -3,0 (14-20). ∆· Ùˆ¯fiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ·Ï·ÈfiÙÂÚˆÓ ·˘ÙÒÓ ÌÂÏÂÙÒÓ ÔÊ›ÏÔÓÙ·È ÛÙË ¯Ú‹ÛË ÚÈÓ ·fi ÙÔ 1985 Ù˘ و̷ÙÈ΋˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηıÒ˜ Î·È ÛÙË ıÂڷ›· Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ì 3 ÌfiÓÔ ÂÓ¤ÛÂȘ GH ‚‰ÔÌ·‰È·›ˆ˜. ∏ ¿ÚÈÛÙË ‰fiÛË Ù˘ GH ¤¯ÂÈ ÔÚÈÛı› ÛÙȘ 0,3-0,6 πU/kg/‚‰ÔÌ¿‰· ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (21). ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜, Ë ¤ÎÎÚÈÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ·˘Í¿ÓÂÙ·È Î·È Û˘ÓÂÒ˜ ı· Ú¤ÂÈ Ë ‰fiÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ó· ·Ó·ÚÔÛ·ÚÌfi˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ (22). √È Ranke Î·È Butendandt (1989) (19) ηıÒ˜ Î·È Ë ÌÂϤÙË KIGS (20,23) ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ FHSDS Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ GH. ∞˘Ùfi ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÛÙËÓ ÔÔ›· 6 ·È‰È¿ ¤Î·Ó·Ó 3 ÌfiÓÔ ÂÓ¤ÛÂȘ ‚‰ÔÌ·‰È·›ˆ˜, ÂÓÒ 66 ·È‰È¿ ·ÎÔÏÔ‡ıËÛ·Ó Û¯‹Ì· 6 ‹ 7 ÂÓ¤ÛÂˆÓ Â‚‰ÔÌ·‰È·›ˆ˜. ∂ÓÙÔ‡ÙÔȘ, Û¯‹Ì·Ù· Ì ÂÚÈÛÛfiÙÂÚ˜ Ù˘ ÌÈ·˜ ¤ÓÂÛ˘ ËÌÂÚËÛ›ˆ˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÚÔÛʤÚÔ˘Ó ÌÂÁ·Ï‡ÙÂÚÔ fiÊÂÏÔ˜ (24). √ ·Ú¿ÁÔÓÙ·˜ Ô˘ ‚Ú¤ıËΠӷ ¤¯ÂÈ ÙËÓ ÈÛ¯˘ÚfiÙÂÚË Û˘Û¯¤ÙÈÛË Ì ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‹Ù·Ó ÛÙË ÌÂϤÙË Ì·˜ ÙÔ ‡„Ô˜-ÛÙfi¯Ô˜ (·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ) (T∏). ∏ Û˘Û¯¤ÙÈÛË ·˘Ù‹ ¤¯ÂÈ ·Ó·ÊÂÚı› Î·È Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (12,14,19,20,23,25). º·›ÓÂÙ·È ÙÂÏÈο ˆ˜ ÙÔ ÁÂÓÂÙÈÎfi ‰˘Ó·ÌÈÎfi Â›Ó·È ·˘Ùfi Ô˘ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ηıÔÚ›˙ÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ∂›Û˘, ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Û˘Û¯ÂÙ›ÛÙËΠÛÙË ÌÂϤÙË Ì·˜ Î·È Ì ÙÔ ‡„Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (12,26). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ Ù˘ ÌË ·Ó‡ÚÂÛ˘ ÛÙË ÌÂϤÙË Ì·˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Î·È ‰È¿ÚÎÂÈ·˜ ıÂڷ›·˜. ™ÙË ÌÂϤÙË KIGS (20,23) ˘‹ÚÍ ÔÚȷ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ‰˘Ô
¶›Ó·Î·˜ 4. µ·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ¤Ó·ÚÍË ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ ηٿ ÙËÓ ÚÔÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜
ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)
º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)
25 (11 ¿ÚÚÂÓ·, 14 ı‹Ï·) 8,4±2,39 -2,89±1,08 6,32±2,64 -0,855±1,45 -0,9±0,78 -1,06±1,05 -0,76±0,89
ª¤ÁÈÛÙË ÙÈÌ‹
∂Ï¿¯ÈÛÙË ÙÈÌ‹
10,99 -0,51 10,10
3,23 -5,78 1,50
1,83 1,01 1,11 1,51
-4,73 -2,21 -3,36 -2,21
SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height) ¶·È‰È·ÙÚÈ΋ 2008;71:128-134
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·132
132
ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 5. ∞ÔÙÂϤÛÌ·Ù· ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ¤Ó·ÚÍË ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ ηٿ ÙËÓ ÚÔÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜ (¡=25)
ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)
ª¤ÁÈÛÙË ÙÈÌ‹
∂Ï¿¯ÈÛÙË ÙÈÌ‹
∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂڷ›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-TH (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂڷ›·˜ (¤ÙË)
-1,56±1,3
1,22
-5,08
5,93±4,66 15,36±1,8 1,32±1,37 -0,66±1,2 0,54±0,13 6,08±1,68 6,97±3,13
17,97 18,1 4,46 1,75 0,80 7,00 14,81
-0,37 12,44 -0,88 -3,70 0,35 3,00 2,72
SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS)
·˘ÙÒÓ ·Ú·Ì¤ÙÚˆÓ (Ú=0,06) Î·È ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‰È·ÊÔÚ¿˜ ÙÂÏÈÎÔ‡-·Ú¯ÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ (¢ height) Î·È Ù˘ ‰È¿ÚÎÂÈ·˜ ıÂڷ›·˜ (p=0,001). ∂ȯÂÈÚÒÓÙ·˜ Û‡ÁÎÚÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘ Î·È ·˘ÙÒÓ Ô˘ ÍÂΛÓËÛ·Ó ÌÂÙ¿, ‰È·ÈÛÙÒıËΠˆ˜ ÙÔ ¢ height ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ ‰‡Ô ˘ÔÔÌ¿‰Â˜ (p=0,9). ∆· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ÚÔÂÊË‚Èο ›¯·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ·Ú¯ÈÎfi ‡„Ô˜ (p=0,016) Î·È ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ÙÂÏÈÎfi ‡„Ô˜ (p=0,037) Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ·ÁˆÁ‹ ηٿ ÙËÓ ÂÊ˂›·. ∆Ô fiÊÂÏÔ˜ ·fi ÙË ıÂڷ›·, fiˆ˜ ·ÓÙÈηÙÔÙÚ›˙ÂÙ·È ÛÙÔ ÎÂÚ‰Ëı¤Ó ·Ó¿ÛÙËÌ·, ‹Ù·Ó ÙÔ ›‰ÈÔ ÛÙȘ ‰‡Ô ·˘Ù¤˜ ˘ÔÔÌ¿‰Â˜. ∂ÓÙÔ‡ÙÔȘ, ÙÔ 54% ÙˆÓ ·È‰ÈÒÓ Ì ¤Ó·ÚÍË ıÂڷ›-
·˜ ÚÔÂÊË‚Èο Êı¿ÓÂÈ ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÁÈ· Ù· ·È‰È¿ Ì ¤Ó·ÚÍË ıÂڷ›·˜ ηٿ ÙËÓ ÂÊ˂›· Â›Ó·È ÌfiÏȘ 18,4% (13,27). £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, ˆÛÙfiÛÔ, fiÙÈ Ù· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÚÈÓ ·fi ÙËÓ ÂÊ˂›· ‹Ú·Ó ıÂڷ›· ÁÈ· ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Û ˘„ËÏfiÙÂÚË ‰fiÛË Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂڷ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜ (p<0,001 Î·È p=0,001). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ˆ˜ ÛÙÔ Û‡ÓÔÏÔ, ÌfiÓÔ Ù· 23 ·fi Ù· 72 ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó (32%) ¤ÊÙ·Û·Ó ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô (∆∏). ™Â 47 ·fi Ù· 72 ·È‰È¿, Ë ‹‚Ë Â›¯Â ‹‰Ë ÍÂÎÈÓ‹ÛÂÈ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ 80-85% Ù˘ ·‡ÍËÛ˘ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÚÈÓ ·fi ÙËÓ ‹‚Ë Î·È ¤ÙÛÈ Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ¤¯·Û·Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·,
¶›Ó·Î·˜ 6. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ›‰Ú·Û˘ Ù˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÛÙËÓ ÚÔÂÊË‚È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜ (¡=72)
¶ÚÔÂÊË‚È΋ ËÏÈΛ·
∂ÊË‚È΋ ËÏÈΛ·
p
AÚÈıÌfi˜ - º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂڷ›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜( SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂڷ›·˜ (¤ÙË)
25 (11 ¿ÚÚÂÓ·, 14 ı‹Ï·) 8,4±2,39 -2,89±1,08 6,32±2,64
47 (32 ¿ÚÚÂÓ·, 15 ı‹Ï·) 13,29±1,39 -2,29±0,59 11,18±1,43
-0,855±1,45 -0,9±0,78 -1,06±1,05 -0,76±0,89 -1,56±1,3
-0,67±0,76 -0,7±0,71 -0,83±0,82 -0,6±0,93 -1,04±0,79
0,56 0,29 0,30 0,48 0,037
5,93±4,66 15,36±1,8 1,32±1,37 -0,66±1,2 0,54±0,13 6,08±1,68 6,97±3,13
6,43±5,14 16,58±1,34 1,28±0,69 -0,36±0,71 0,43±0,09 6,83±0,82 3,4±1,42
0,69 0,005 0,9 0,26 0,001 0,044 <0,001
0,01 <0,001 0,016 <0,001
SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS) Paediatriki 2008;71:128-134
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·133
133
AÓ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘
¶›Ó·Î·˜ 7. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ›‰Ú·Û˘ Ù˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË Û ·È‰È¿ ÌÂ Û˘Ó‰˘·Ṳ̂ÓË Î·È ·È‰È¿ Ì ÌÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· GH ∞ÛıÂÓ›˜ (¡=72)
∞Ó¿ÚÎÂÈ· ÔÏÏ·ÏÒÓ ÔÚÌÔÓÒÓ
ªÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· GH
p
º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂڷ›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂڷ›·˜ (¤ÙË)
11 (6 ¿ÚÚÂÓ·, 5 ı‹Ï·) 10,26±3,38 -2,91±0,78 7,17±3,71
61 (37 ¿ÚÚÂÓ·, 24 ı‹Ï·) 11,83±2,82 -2,42±0,83 9,91±2,71
NS 0,1 0,075 0,005
-0,52±1,05 -0,183±1,02 -0,5±1,41 0,08±0,87 -0,75±1,18
-0,77±1,05 -0,88±0,63 -0,98±0,78 -0,79±0,86 -1,31±0,97
0,47 0,003 0,29 0,003 0,091
6,62±4,71 16,8±1,07 2,17±1,1 -0,56±1,01 0,52±0,14 6±1,73 6,55±3,2
6,19±5,03 16,04±1,67 1,14±0,87 -0,45±0,9 0,46±0,11 6,67±1,11 4,29±2,54
0,79 0,15 0,001 0,71 0,14 0,24 0,011
SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), NS: non significant, ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS)
ÏfiÁˆ ηı˘ÛÙ¤ÚËÛ˘ ÛÙËÓ ·Ó·˙‹ÙËÛË ÂÍÂȉÈÎÂ˘Ì¤Ó˘ ·Ú¤Ì‚·Û˘ (28-30). ªÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË, Ù· ·È‰È¿ ‚ÂÏÙÈÒÓÔ˘Ó ÙÔÓ ÂÙ‹ÛÈÔ Ú˘ıÌfi ·‡ÍËÛ˘ ηٿ 2 ÊÔÚ¤˜ Û ۯ¤ÛË Ì ÂΛÓÔÓ ÚÈÓ ·fi ÙË ıÂڷ›·. ŸÛÔ ÌÈÎÚfiÙÂÚÔ Â›Ó·È ÙÔ ·È‰›, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ÂÈÙ˘Á¯¿ÓÂÈ Ì ÙËÓ ¤ÁηÈÚË ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜. ∏ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ıÂڷ›·˜ Â›Ó·È Û˘Ó‹ıˆ˜ Î·È Ë Ì¤ÁÈÛÙË Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ GH (27). ∏ ÌË ·Ó‡ÚÂÛË ÛÙË ÌÂϤÙË Ì·˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙËÓ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ıÂڷ›·˜ ÔÊ›ÏÂÙ·È Èı·ÓÒ˜ ÛÙË ÌÂÁ¿ÏË Û¯ÂÙÈο ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜. ™˘ÁÎÚ›ÓÔÓÙ·˜ Ù· ·È‰È¿ Ì ÔÏÏ·Ï‹ ·Ó¿ÚÎÂÈ· ÔÚÌÔÓÒÓ Ì ÂΛӷ Ì ÌÂÌÔӈ̤ÓË ·Ó¿ÚÎÂÈ· GH, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÛÙȘ 2 ˘ÔÔÌ¿‰Â˜, fiˆ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È Û ¿ÏϘ ÌÂϤÙ˜ (12,31). ∆Ô 45,5% ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ¤ÊÙ·Û ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô. ∂ÓÙÔ‡ÙÔȘ, ÙÔ ¢ height ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ (p=0,001) ÛÙ· ·È‰È¿ Ì ÔÏÏ·Ï‹ ·Ó¿ÚÎÂÈ· ÔÚÌÔÓÒÓ, Ù· ÔÔ›· Ê·›ÓÂÙ·È Ó· ˆÊÂÏ‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ıÂڷ›· (13). £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, ˆÛÙfiÛÔ, fiÙÈ Ë ·ÚÔ‡Û· ÔÌ¿‰· ÙˆÓ 11 ·È‰ÈÒÓ Ì ·Ó¿ÚÎÂÈ· ÔÏÏÒÓ ÔÚÌÔÓÒÓ ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË SDS ÁÈ· ÙÔ TH Û ۯ¤ÛË ÌÂ
Ù· ·È‰È¿ Ì ÌÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηÈ, Û˘ÓÂÒ˜, ˘‹Ú¯Â ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ ·Ó¿ÛÙËÌ·. ∞·ÈÙ›ٷÈ, ÂÔ̤ӈ˜, ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ·ÛÊ·ÏÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ . ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, ηıÒ˜ Î·È ¿ÏÏˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÌÂÏÂÙÒÓ ‰ÈÂıÓÒ˜, ‰Â›¯ÓÔ˘Ó ÌÈ· Û·Ê‹ ‚ÂÏÙ›ˆÛË ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Ì ÙË ¯Ú‹ÛË Ù˘ ‚ÈÔÛ˘ÓıÂÙÈ΋˜ GH 6 ‹ 7 ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜, Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË 3 ‰fiÛÂˆÓ Ô˘ ·ÔÙÂÏÔ‡ÛÂ Û˘Ó‹ıË Ú·ÎÙÈ΋ ÛÙÔ ·ÚÂÏıfiÓ. ∂ÓÙÔ‡ÙÔȘ, ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÈηÓÔÔÈËÙÈÎfi ÁÈ· fiÏÔ˘˜ ÙÔ˘ ·ÛıÂÓ›˜ Î·È È‰›ˆ˜ ÁÈ· ÂΛÓÔ˘˜ Ô˘ ÍÂΛÓËÛ·Ó ÙËÓ ·ÁˆÁ‹ Û¯ÂÙÈο ·ÚÁ¿. ∏ ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηٿ ÙËÓ ÂÊ˂›· Ê·›ÓÂÙ·È Ó· ··ÈÙ› ÌÈ· ·‡ÍËÛË Î·Ù¿ 50% ÂÚ›Ô˘ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ‰fiÛ˘ ÚÈÓ ·fi ÙËÓ ‹‚Ë. ∆¤ÏÔ˜, ‰ÂÓ ı· Ú¤ÂÈ Ó· ·Ú·‚ϤÂÈ Î·Ó›˜ ÙÔ ÚfiÏÔ Ô˘ ·›˙ÂÈ ÙÔ ÁÂÓÂÙÈÎfi ‰˘Ó·ÌÈÎfi ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Hindmarsh PC, Dattani MT. Use of growth hormone in children. Nat Clin Pract Endocrinol Metab 2006;2:260-268. 2. ÃÈÒÙ˘ ¢, ∆ÛÈÊÙ‹˜ °, ÷Ù˙ËÛ˘ÌÂÒÓ ª, ª·ÓÈ¿ÙËÃÚËÛÙ›‰Ë ª, ∫Ú›ÎÔ˜ •, ¢¿ÎÔ˘-µÔ˘ÙÂÙ¿ÎË ∞. ∞Ó¿ÛÙËÌ· Î·È ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ÂÏÏËÓÔ·›‰ˆÓ ËÏÈΛ·˜ 0-18 ÂÙÒÓ (2001-2002): Û‡ÁÎÚÈÛË Ì ‰Â‰Ô̤ӷ ÌÂϤÙ˘ ÙÔ˘ 19781979. ¢ÂÏÙ›Ô ∞ã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋˜ 2003;50:136-156. 3. Cavallo A, Richards GE, Busey S, Michaels SE. A simplified ¶·È‰È·ÙÚÈ΋ 2008;71:128-134
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07-04-08
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™ÂÏ›‰·134
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ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.
gonadotrophin-releasing hormone test for precocious puberty. Clin Endocrinol (Oxf) 1995;42:641-646. 4. Wit JM, Kamp GA, Rikken B. Spontaneous growth and response to growth hormone treatment in children with growth hormone deficiency and idiopathic short stature. Pediatr Res 1996;39:295-302. 5. De Angelis R, di Natale B, Lukezic M, Bozzato N, Mora C, Pozzobon G, Vigano G, Chiumello G. Final height in idiopathic growth hormone deficient children after optimized rhGH treatment [abstract]. Horm Res 1997;48:149. 6. Barsanti S, Saggese G. Final height in children with growth hormone deficiency treated with recombinant growth hormone (abstract). Horm Res 1997;48:151. 7. Brämswig JH, Schlösser H, Kiese K. Final height in children with growth hormone deficiency. Horm Res 1995;43:126-128. 8. De Luca F, Maghnie M, Arrigo T, Lombardo F, Messina MF, Bernasconi S. Final height outcome of growth hormone-deficient patients treated since less than five years of age. Acta Paediatr 1996;85:1167-1171. 9. Coste J, Letrait M, Carel JC, Tresca JP, Chatelain P, Rochiccioli P, et al. Long-term results of growth hormone treatment in France in children of short stature: population, register based study. BMJ 1997;315:708-713. 10. Cacciari E, Cicognani A, Pirazzoli P, Zucchini S, Salardi S, Balsamo A, et al. Final height of patients treated for isolated GH deficiency: examination of 83 patients. Eur J Endocrinol 1997 Jul;137:53-60. 11. Thomas M, Massa G, Bourguignon JP, Craen M, De Schepper J, de Zegher F, et al. Final height in children with idiopathic growth hormone deficiency treated with recombinant growth hormone: the Belgian experience. Horm Res 2001;55:88-94. 12. Karavanaki K, Kontaxaki C, Maniati-Christidi M, Petrou V, Dacou-Voutetakis C. Growth response, pubertal growth and final height in Greek children with growth hormone (GH) deficiency on long-term GH therapy and factors affecting outcome. J Pediatr Endocrinol Metab 2001;14:397-405. 13. Reiter EO, Price DA, Wilton P, Albertsson-Wikland K, Ranke MB. Effect of growth hormone (GH) treatment on the near-final height of 1258 patients with idiopathic GH deficiency: analysis of a large international database. J Clin Endocrinol Metab 2006;91:2047-2054. 14. Burns EC, Tanner JM, Preece MA, Cameron N. Final height and pubertal development in 55 children with idiopathic growth hormone deficiency, treated for between 2 and 15 years with human growth hormone. Eur J Pediatr 1981;137:155-164. 15. Lenko HL, Leisti S, Perheentupa J. The efficacy of growth hormone in different types of growth failure. An analysis of 101 cases. Eur J Pediatr 1982;138:241-249. 16. Joss E, Zuppinger K, Schwarz HP, Roten H. Final height of patients with pituitary growth failure and changes in growth variables after long term hormonal therapy. Pediatr Res 1983;17:676-679. 17. Job JC, Joab N, Toublanc JE, Canlorbe P. Résultats à terme des traitments par l’hormone de croissance humaine. Arch Fr Pediatr 1984;41:477-482. 18. Hibi I, Tanaka T, Tanae A, Kagawa J, Hashimoto N,
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Yoshizawa A, et al. The influence of gonadal function and the effect of gonadal suppression treatment on final height in growth hormone (GH)-treated GH-deficient children. J Clin Endocrinol Metab 1989;69:221-226. 19. Ranke MB, Butenandt O. Idiopathic growth hormone deficiency: final height to treatment with growth hormone and effects of puberty and sex steroids. In: Frisch H, Zaron Z, editors. Induction of puberty in hypopituitarism. Serono Symposia Review No. 16. Rome: Ares-Serono Symposia; 1988. p. 84-89. 20. Ranke MB, Guilbaud O. Growth response in prepubertal children with idiopathic growth hormone deficiency during the first two years of treatment with human growth hormone. Analysis of the Kabi Pharmacia International Growth Stydy. Acta Paediatr Scand Suppl 1991;379:109115. 21. Radetti G, D’Addato G, Gatti D, Bozzola M, Adami S. Influence of two different GH dosage regimens on final height, bone geometry and bone strength in GH-deficient children. Eur J Endocrinol 2006;154:479-482. 22. Ranke MB, Price DA, Albertsson-Wikland K, Maes M, Lindberg A. Factors determining pubertal growth and final height in growth hormone treatment of idiopathic growth hormone deficiency. Analysis of 195 Patients of the Kabi Pharmacia International Growth Study. Horm Res 1997;48:62-71. 23. Ranke MB, Guilbaud O, Lindberg A, Cole T. Prediction of the growth response in children with various growth disorders treated with growth hormone: analyses of data from the Kabi Pharmacia International Growth Study. International Board of the Kabi Pharmacia International Growth Study. Acta Paediatr Suppl 1993;82 Suppl 391:82-88. 24. Hakeem V, Hindmarsh PC, Brook CG. Intermittent versus continuous administration of growth hormone treatment. Arch Dis Child 1993;68:783-784. 25. Hilczer M, Smyczy‹ska J, Lewi‹ski A. Parentally-adjusted deficit of height as a prognostic factor of the effectiveness of growth hormone (GH) therapy in children with GH deficiency. Neuro Endocrinol Lett 2006;27:149-152. 26. Chen YD, Shu SG, Chi CS. Growth response and final height in growth hormone-deficient patients treated with biosynthetic growth hormone. Acta Paediatr Taiwan 2001;42:291-296. 27. Bajpai A, Kabra M, Gupta AK, Menon PS. Growth pattern and skeletal maturation following growth hormone therapy in growth hormone deficiency: factors influencing outcome. Indian Pediatr 2006;43: 593-599. 28. Frisch H, Birnbacher R. Final height and pubertal development in children with growth hormone deficiency after long-term treatment. Horm Res 1995;43:132-134. 29. August GP, Julius JR, Blethen SL. Adult height in children with growth hormone deficiency who are treated with biosynthetic growth hormone: the National Cooperative Growth Study experience. Pediatrics 1998;102:512-516. 30. Saggese G, Federico G, Barsanti S. Growth Hormone Deficiency. In: Hindmarsh PC, editor. Current Indications for Growth Hormone Therapy. Endocr Dev. Basel, Karger, 1999, vol 1, pp 55-67. 31. Severi F. Final height in children with growth hormone deficiency. Horm Res 1995;43:138-140.
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
135
ªÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi Èfi Epstein-Barr Î·È ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË1, ∞. ºÏ¤‚·2, µ. ∞ÓÙ¿ÚË1, ∞. ¶·˘Ï›ÙÔ˘-∆ÛÈfiÓÙÛË2, ª. ªÔÛÎÔÊ›‰Ë˜3, °. µ·ÚÏ¿Ì˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ë ÌÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì ۇӉÚÔÌÔ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ (™§ª) ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ Ïԛ̈͢, ηıÒ˜ Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘ Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 26 ·È‰È¿ Ì ™§ª, Ì ̤ÛÔ fiÚÔ ËÏÈΛ·˜ 6,6±3,5 ¤ÙË. ¶·Ú·ÎÔÏÔ˘ı‹ıËÎÂ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÔÚ›· Î·È ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÛÏËÓfi˜, ̤ÙÚËÛË ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÚÔÛ‰ÈÔÚÈÛÌfi ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, Á-GT, ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgG, IgA, IgM) Î·È ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ, ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD3+, CD3+/CD4+, CD3+/CD8+), µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD19+) Î·È Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ (CD3-/CD16+56+) ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ·fi 3-6 Ì‹Ó˜. ∞ÔÙÂϤÛÌ·Ù·: ∆Ô 69% ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·˙ Ïԛ̈ÍË ·fi Èfi Epstein-Barr (EBV), ÂÓÒ ÙÔ 31% ·fi ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi (CMV). ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙˆÓ ÂȤ‰ˆÓ IgM Î·È ·‡ÍËÛË ÙˆÓ IgG ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ·Ú¿ÏÏËÏË ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË. ∏ ÛÏËÓÔÌÂÁ·Ï›·, Ë ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË Î·È Ë ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ˘Ô¯ÒÚËÛ·Ó ÛËÌ·ÓÙÈο. ∏ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ΢ڛˆ˜ Ù˘ IgM, ·ÔηٷÛÙ¿ıËÎÂ. ∫·Ù¿ ÙËÓ ÔÍ›· Ïԛ̈ÍË, Ù· CD3+/CD8+ ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË, Ì ÂÏ¿ÙÙˆÛË ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+, ÂÓÒ Ù· CD19+ Î·È Ù· CD3+/CD4+ ‹Ù·Ó ÂÏ·Ùو̤ӷ. ™ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, Ù· CD3+ Î·È CD3+/CD8+ ·ÚÔ˘Û›·˙·Ó ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË, ÂÓÒ Ù· CD3+/CD4+, Ù· CD19+ Î·È Ô ÏfiÁÔ˜ CD4+/CD8+ ·ÚÔ˘Û›·˙·Ó ·‡ÍËÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· CD3+/CD8+ ∆ ÏÂÌÊÔ·ÙÙ·Ú· ·ÔÙÂÏÔ‡Ó ÙËÓ Î˘ÙÙ·ÚÔÙÔÍÈ΋ ∆ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ·¿ÓÙËÛË ÛÙ· EBV Î·È CMV ·ÓÙÈÁfiÓ· Î·È Ë Ì›ˆÛ‹ ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ‡ÊÂÛË Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜. ∞fi ÙË ÌÂϤÙË ÚÔ·ÙÂÈ Ë ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì ™§ª Ô˘ ¯ÚÔÓ›˙ÂÈ.
1 ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË 3 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfiµÈÔ¯ËÌÈÎfi-πÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ∂˘ÊËÌ›· ¶··‰ÔÔ‡ÏÔ˘∞Ï·Ù¿ÎË efiala@otenet.gr °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, ¶ÂÚÈÊÂÚÂȷ΋ Ô‰fi˜ ¡. ∂˘Î·Ú›·, ∆.∫. 564 03, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: ∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜, EBV, CMV Ïԛ̈ÍË, ÎÏÈÓÈ΋ ¤Î‚·ÛË.
Study of the immunophenotype of peripheral blood lymphocyte subsets in children with Epstein-Barr virus and cytomegalovirus infection: association with outcome E. Papadopoulou-Alataki1, A. Fleva2, V. Antari1, A. Pavlitou-Tsiontsi2, M. Moskofidis3, G. Varlamis1 Abstract Background: The purpose of this study was to identify the immunophenotype of children with infectious mononucleosis during the acute phase of the disease and convalescence and to investigate its association with the disease outcome. Methods: A study was made of 26 children aged 6.6±3.5 years, affected by infectious mononucleosis. The clinical presentation, spleen size, peripheral blood count, anti-virus specific antibodies, levels of SGOT, SGPT, Á-GT, IgG, IgA and IgM, and immunophenotype of blood T, B and NK cells were studied during the acute phase and 3-6 months later. Results: Of the 26 children, 69% were infected by Epstein-Barr virus (EBV) and 31% by cytomegalovirus (CMV). At 3-6 month reevaluation a significant decrease in IgM and an increase in IgG antivirus antibodies were observed, and the splenomegaly, lymphocytosis and high initial levels of SGOT were restored to normal. At the time of onset of symptoms, the CD3+/CD8+ cells were considerably increased, CD19+ and CD3+/CD4+ percentages were low and a marked lowering of the CD4+/CD8+ ratio was observed. At reevaluation, CD3+ and CD3+/CD8+ were lower, while CD3+/CD4+, CD19+ cells and the CD4+/CD8+ ratio were significantly increased. Conclusions: The increase in CD3+/CD8+ cells represents the cytotoxic response to the proliferation of EBV and CMV antigens, and may be related with the remission of symptoms. Immunophenotyping of peripheral blood could be helpful in the follow-up of children with persistent infectious mononucleosis.
1 4th Department of Paediatrics, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki 2 ImmunologyHistocompatibility Laboratory, Papageorgiou General Hospital, Thessaloniki 3 MicrobiologicalBiochemical-Virological Department, Papageorgiou General Hospital, Thessaloniki Correspondence: Efimia Papadopoulou-Alataki efiala@otenet.gr Papageorgiou General Hospital, Ring road, 564 03, ¡. Efkarpia, Thessaloniki, Greece
Key words: Immunophenotype, EBV, CMV infection, clinical outcome. ¶·È‰È·ÙÚÈ΋ 2008;71:135-140
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∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.
™˘ÓÙÔÌÔÁڷʛ˜ EBV CMV ™§ª §ª SGOT SGPT Á-GT CD3+ CD3+/CD4+ CD3+/CD8+ CD19+ CD3-/16+56+
πfi˜ Epstein-Barr ªÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ ™‡Ó‰ÚÔÌÔ §ÔÈÌÒ‰Ô˘˜ ªÔÓÔ˘Ú‹ÓˆÛ˘ §ÔÈÌ҉˘ ªÔÓÔ˘Ú‹ÓˆÛË OÍ·ÏÔÍÈ΋ ÙÚ·ÓÛ·ÌÈÓ¿ÛË ¶˘ÚÔÛÙ·Ê˘ÏÈ΋ ÙÚ·ÓÛ·ÌÈÓ¿ÛË Á-ÁÏÔ˘Ù·Ì˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË flÚÈÌ· ∆ ÏÂÌÊÔ·ÙÙ·Ú· Ì TCR ˘Ô‰Ô¯¤· µÔËıËÙÈο ∆ ÏÂÌÊÔ·ÙÙ·Ú· ∫·Ù·ÛÙ·ÏÙÈο/΢ÙÙ·ÚÔÙÔÍÈο ∆ ÏÂÌÊÔ·ÙÙ·Ú· µ ÏÂÌÊÔ·ÙÙ·Ú· º˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· (NK)
∂ÈÛ·ÁˆÁ‹ ∏ §ÔÈÌ҉˘ ªÔÓÔ˘Ú‹ÓˆÛË (§ª) Â›Ó·È ¤Ó· ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi, Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· Î·È ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·. ∞Ó Î·È Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÊ›ÏÔÓÙ·È ÛÙÔÓ Èfi Epstein-Barr (EBV), ÏÔÈÌÒÍÂȘ ·fi ¿ÏÏ· ·›ÙÈ·, fiˆ˜ Ô ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô˜ (CMV), Ô ÂÚËÙÔ˚fi˜ 6 (HSV), Ô Èfi˜ Ù˘ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (HIV), ÔÈ ·‰ÂÓÔ˚Ô›, Ô Èfi˜ Ù˘ ÂÚ˘ıÚ¿˜, Ô Èfi˜ Parvo µ19, ÔÈ ÈÔ› Ù˘ Ë·Ù›Ùȉ·˜ ∞ Î·È µ, ÙÔ ÙÔÍfiÏ·ÛÌ·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚfiÌÔÈ· ÎÏÈÓÈ΋ Î·È ·ÈÌ·ÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Î·È ÚÔηÏÔ‡Ó ÙÔ Û‡Ó‰ÚÔÌÔ Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ (™§ª) (1-3). ∏ ‰È¿ÁÓˆÛË Ù˘ ÚfiÛÊ·Ù˘ Ïԛ̈͢ ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Ù¿Í˘ IgM. ∂ȉÈο ÁÈ· ÙÔÓ EBV, Ë ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙˆÓ Î·„ȉÈÎÒÓ, ÚÒÈÌˆÓ Î·È ˘ÚËÓÈÎÒÓ ·ÓÙÈÁfiÓˆÓ ˘Ô‚ÔËıÔ‡Ó ÙË ‰È¿ÁÓˆÛË. ∏ ·ÚÔ˘Û›· ·ÓÙÈη„ȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Ë ·Ô˘Û›· ·ÓÙÈ˘ÚËÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ÂÓ‰ÂÈÎÙÈΤ˜ Ù˘ ÔÍ›·˜ Ïԛ̈͢, ‰ÈfiÙÈ Ù· EBV ·ÓÙÈ˘ÚËÓÈο ·ÓÙÈÛÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿ÚÚˆÛ˘ (4,5). ∏ ÔÍ›· §ª Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÓfiÛÔ˜ (6). øÛÙfiÛÔ, Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ ηٷϋÁÂÈ Û ¯ÚfiÓÈ· ÂÓÂÚÁfi Ïԛ̈ÍË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÔÙÚÔ¤˜ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ùˆ¯‹ ÚfiÁÓˆÛË (7,8). ∞ÔÙÂÏ› ÌÈ· ÛÔ‚·Ú‹ ·Ûı¤ÓÂÈ· Ì ¿ÁÓˆÛÙË ·ıÔÁ¤ÓÂÈ· Ô˘ ÂÈ̤ÓÂÈ ¿Óˆ ·fi 3-6 Ì‹Ó˜ ¤ˆ˜ Î·È ¯ÚfiÓÈ·, ÂÓÒ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Î·È Û ¿ÙÔÌ· Ì ηϋ ·ÓÔÛÔÏÔÁÈ΋ ηٿÛÙ·ÛË (911). ∂ÈϤÔÓ, Û ·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ë EBV Ïԛ̈ÍË Ô‰ËÁ› Û˘¯Ó¿ Û ¯ÚfiÓÈ· ÂÓÂÚÁfi Ïԛ̈ÍË Ì Èı·Ó‹ ÂͤÏÈÍË Û ηÎÔ‹ıÂÈ· ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡. ™Â ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜, Ë §ª ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ÂÈıÂÙÈ΋ ÔÚ›· Ì ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ÂÈÏÔΤ˜ (7,12,13). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó·˙‹ÙËÛË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÏÔ›Paediatriki 2008;71:135-140
̈͢, ηıÒ˜ Î·È Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Û¯¤Û˘ ÙÔ˘˜ Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË Î·È ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓÔÛ›·˜.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 26 ·ÛıÂÓ›˜, 15 ·ÁfiÚÈ· Î·È 11 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 2-14 ÂÙÒÓ, Ì ̤ÛÔ fiÚÔ ËÏÈΛ·˜ 6,6±3,5 ¤ÙË. √È ·ÛıÂÓ›˜ ÓÔÛËχıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÙÒÓ 2005-2006 Î·È ÏËÚÔ‡Û·Ó Ù· ÂÍ‹˜ ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·: ·) ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚ›· ·fi Ù· ·Ú·Î¿Ùˆ: ˘ÚÂÙfi˜, Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÛÏËÓÔÌÂÁ·Ï›·, ÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›· Î·È ‚) ıÂÙÈο IgM ·ÓÙÈÛÒÌ·Ù· ˆ˜ ÚÔ˜ EBV ‹ CMV. √ ¤ÏÂÁ¯Ô˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ¿ÏÏˆÓ ·ÈÙ›ˆÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙÔ ™§ª (ÂÚËÙÔ˚Ô‡ 6, Parvo B19, ·‰ÂÓÔ˚Ô‡ Î·È ÙÔÍÔÏ¿ÛÌ·ÙÔ˜) ·¤‚Ë ·ÚÓËÙÈÎfi˜. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ‰ÂÓ Â›¯Â ÁÓˆÛÙ‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ· ‹ ·ÓÔÛÔηٷÛÙÔÏ‹. √ ÛÎÔfi˜ Ù˘ ÌÂϤÙ˘ ÂÍËÁ‹ıËΠÛÙÔ˘˜ ÁÔÓ›˜ Î·È fiÏÔÈ ÔÈ ÁÔÓ›˜ ¤‰ˆÛ·Ó ÁÚ·Ù‹ Û˘ÁηٿıÂÛË ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘. ™Â fiÏ· Ù· ·È‰È¿ ¤ÁÈÓ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ηıÒ˜ Î·È ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÛÏËÓfi˜. ∆· ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·›ÙÈÔ Ù˘ Ïԛ̈͢: Ë Ì›· ÔÌ¿‰· ÂÚÈÂÏ¿Ì‚·Ó 18 ·È‰È¿ Ô˘ ›¯·Ó ıÂÙÈο EBV IgM ·ÓÙÈÛÒÌ·Ù· Î·È Ë ¿ÏÏË ÂÚÈÂÏ¿Ì‚·Ó 8 ·È‰È¿ Ô˘ ›¯·Ó ıÂÙÈο CMV IgM ·ÓÙÈÛÒÌ·Ù·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·ÓÂ: ÁÂÓÈ΋ ·›Ì·ÙÔ˜, SGOT, SGPT, Á-GT, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ IgG, IgA, IgM Î·È ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô ∆, µ Î·È ¡∫ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆ÚÂȘ ¤ˆ˜ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿, ¤ÁÈÓ ÂÎÙ›ÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ÔÚ›·˜ Î·È Â·Ó¿ÏË„Ë ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘. ∏ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ IgG ¤Ó·ÓÙÈ ÙÔ˘ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô‡, ÙÔ˘ ·‰ÂÓÔ˚Ô‡ Î·È ÙÔ˘ ÙÔÍÔÏ¿ÛÌ·ÙÔ˜ (Toxoplasma gondii) ¤ÁÈÓ ÔÛÔÙÈο, Ë ‰Â ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ IgM ¤ÁÈÓ ÔÈÔÙÈο Ì ÙË ÌÈÎÚÔۈ̷Ùȉȷ΋ ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô (MEIA, Axsym, Abbott). ∏ ·Ó›¯Ó¢ÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ IgG Î·È IgM ¤Ó·ÓÙÈ ÙÔ˘ η„ȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ EBV (EBVVCA IgG/IgM, Virotech), ÙÔ˘ HSV (HSV-IgG/IgM, Virotech) Î·È ÙÔ˘ Parvo µ19 (Parvovirus B19 IgG/IgM, Focus) ¤ÁÈÓ·Ó Ì ÙËÓ ¤ÌÌÂÛË ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô (Elisa). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ (CD3+, CD3+/CD4+, CD3+/CD8+, CD19+, CD3-/CD16+56+, ÏfiÁÔ˘ CD4+/CD8+) ¤ÁÈÓ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Û ·Ó·Ï˘Ù‹ Epics Elite ESP, Coulter Î·È Ì ÙË ¯Ú‹ÛË ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ ÂÙ·ÈÚ›·˜ Beckman Coulter, Immunotech. ∏ ÔÛÔÙÈ΋ ̤ÙÚËÛË ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgG, IgA Î·È πgM) Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̠ÙË ÓÂÊÂÏÔÌÂÙÚÈ΋ ̤ıÔ‰Ô ÛÙÔÓ ·Ó·Ï˘Ù‹ Beckman Immage ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ·ÓÙȉڷÛÙ‹ÚÈ· Ù˘ ÂÙ·ÈÚ›·˜ Beckman Coulter. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÛÙ·ÙÈÛÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ SPSS 11.0. ∏ ‰È·‰Èηۛ· ÛÙ·ÙÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘ ÂÚÈÂÏ¿Ì‚·Ó ˘ÔÏÔÁÈÛÌfi ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ Ù˘ ̤Û˘ ÙÈÌ‹˜ (mean) Î·È Ù˘ Ù˘È΋˜ ·fiÎÏÈÛ˘ (SD). ∏ Û‡ÁÎÚÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ ·È‰ÈÒÓ ¤ÁÈÓ Ì t-test. √ Û¯ÂÙÈÎfi˜ Û˘ÓÙÂÏÂÛÙ‹˜ Pearson ˘ÔÏÔÁ›ÛıËΠÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘ÛË Ù˘ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ Î·È ÙˆÓ ¿ÏÏˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.
∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 26 ·È‰È¿ Ù˘ ÌÂϤÙ˘, Ù· 18 ›¯·Ó EBV Ïԛ̈ÍË, ÂÓÒ Ù· ˘fiÏÔÈ· ›¯·Ó CMV Ïԛ̈ÍË. √
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·137
137
∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ·È‰ÈÒÓ Ì EBV Î·È CMV Ïԛ̈ÍË
CD3+
72% 23%
CD3+/CD4+ CD3+/CD8+ CD19+ NK
26% 8%
82%
38% 49%
18%
9% 10%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% √Í›· Ïԛ̈ÍË ∂·Ó¤ÏÂÁ¯Ô˜ ∂ÈÎfiÓ· 1. ª¤Û˜ ÙÈ̤˜ ˘ÔÏËı˘ÛÌÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ÛÙËÓ ÔÍ›· Ïԛ̈ÍË Î·È ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô.
¯ÚfiÓÔ˜ ÓÔÛËÏ›·˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 3 ¤ˆ˜ Î·È 10 Ë̤Ú˜. √ ˘ÚÂÙfi˜ ‹Ù·Ó ÙÔ Û‡Ìو̷ Ô˘ ·ÚÔ˘Û›·˙·Ó fiÏ· Ù· ·È‰È¿ Î·È ·ÔÙ¤ÏÂÛ ÙËÓ Î‡ÚÈ· ·ÈÙ›· ÚÔÛ¤Ï¢Û˘. ∆ËÓ ÎÏ·ÛÈ΋ ÎÏÈÓÈ΋ ÙÚÈ¿‰· (˘ÚÂÙfi˜, ÏÂÌÊ·‰ÂÓ›Ùȉ· Î·È Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·) ·ÚÔ˘Û›·Û ÙÔ 65% ÙˆÓ ·È‰ÈÒÓ. √›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ ‰È·ÈÛÙÒıËΠÛÙÔ 23%, ·fiÊÚ·ÍË ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ 23%, ÂÍ¿ÓıËÌ· 11%, ÂÚÈηډ›Ùȉ· 11%, ÂÓÒ Ó¢ÌÔÓ›·, ·ÁÎÚ·ٛÙȉ· Î·È ·Ó΢ÙÙ·ÚÔÂÓ›· ·fi ¤Ó· ·È‰› ·ÓÙ›ÛÙÔȯ·. ŸÏ· Ù· ·È‰È¿ Ù˘ ÌÂϤÙ˘ ·ÚÔ˘Û›·Û·Ó ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ ¿Óˆ ·fi Ù· ·ÓÒÙÂÚ· fiÚÈ· ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘˜, Û‡Ìʈӷ Ì ÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô. ∆Ô Ì¤ÁÂıÔ˜ ÙÔ˘ ÛÏËÓfi˜ ‹Ù·Ó 11,5±1,9 cm ÛÙËÓ ÔÌ¿‰· EBV Î·È 9,8±1,8 cm ÛÙËÓ ÔÌ¿‰· CMV (p=0,04). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ‚Ú¤ıËΠfiÙÈ ÙÔ 77% ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ÔÛÔÛÙfi ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ >50% ÙˆÓ Û˘ÓÔÏÈÎÒÓ Ï¢ÎÒÓ Î·È ·fiÏ˘ÙÔ ·ÚÈıÌfi ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ >5000, ÂÓÒ ÛÙÔ 54% ‚Ú¤ıËÎ·Ó ¿Ù˘· ÏÂÌÊÔ·ÙÙ·Ú· Û ÔÛÔÛÙfi 4-29% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ™ÙÔ 81% ‰È·ÈÛÙÒıËΠ·‡ÍËÛË Ù˘ SGOT Î·È Ù˘ SGPT. √È Ì¤Û˜
ÙÈ̤˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ ¿Ù˘ˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ÀÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ̛· Ù¿ÍË ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ·ÚÔ˘Û›·Û ÙÔ 69% ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ IgM 53% Î·È ÛÙËÓ IgG 16%. ∞fi ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ ·Ó¿Ï˘ÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, ÚԤ΢„ fiÙÈ ÙÔ 58% ÙˆÓ ·È‰ÈÒÓ ÂÌÊ¿ÓÈ˙ ·‡ÍËÛË ÙˆÓ CD3+ (̤ÛÔ˜ fiÚÔ˜ >80%), ÙÔ 46% ÂÏ¿ÙÙˆÛË ÙˆÓ CD3+/CD4+ Î·È ÙÔ 58% ÂÏ¿ÙÙˆÛË ÙˆÓ CD19+ (ηÙÒÙÂÚË ÙÈÌ‹ 1,9%). ™Â fiÏ· Ù· ·È‰È¿ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ Ì ۇÁ¯ÚÔÓË ÂÏ¿ÙÙˆÛË ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Ô˘ Î˘Ì·ÈÓfiÙ·Ó ·fi 0,12 ¤ˆ˜ Î·È 1. ∫·Ó¤Ó· ·È‰› ‰ÂÓ Â›¯Â ·ıÔÏÔÁÈ΋ ÙÈÌ‹ ÙˆÓ CD3-/CD16+56+. ∞fi ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚˆÓ ‰ÂÓ ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ì EBV Ïԛ̈ÍË Î·È CMV Ïԛ̈ÍË Î·Ù¿ ÙËÓ ÔÍ›· Ê¿ÛË (¶›Ó·Î·˜ 2). ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, fiÏ· Ù· ·È‰È¿ ‹Ù·Ó ÂχıÂÚ· Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·ÚÔ˘Û›·˙·Ó Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ IgM Î·È ·‡ÍËÛË ÙˆÓ IgG ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÏËÓ Ì›·˜ ·ÛıÂÓÔ‡˜, Ù˘ ÔÔ›·˜ Ë ·Ó¿ÚÚˆÛË ‰È‹ÚÎÂÛ 8 Ì‹Ó˜. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ (8,7±1,4 cm) ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË (p<0,001), Û ۇÁÎÚÈÛË Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Ù˘ ÔÍ›·˜ Ïԛ̈͢. √È Ì¤Û˜ ÙÈ̤˜ Ù˘ ÂηÙÔÛÙÈ·›·˜ ·Ó·ÏÔÁ›·˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (47±10%), ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (3817±1136/Ìl), Ù˘ IgM (1±0,4 g/L) ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ¯·ÌËÏfiÙÂÚ˜ (p<0,001), ÂÓÒ ÔÈ Ì¤Û˜ ÙÈ̤˜ Ù˘ IgG (11,4±3,1 g/L) Î·È Ù˘ IgA (1,7±1 g/L) ‰ÂÓ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜. √È Ì¤Û˜ ÙÈ̤˜ ÙˆÓ CD3+ (72±5%), ÙˆÓ CD3/+CD8+ (26±6%) ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ (p<0,001), ÂÓÒ ÙˆÓ CD3+/CD4+ (38±7%) Î·È CD19+ (18,37±12,7%) ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤Ó˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ·ÍÈÔÛËÌ›ˆÙË ÌÂÙ·‚ÔÏ‹ ÛÙ· ¡∫ ·ÙÙ·Ú· (∂ÈÎfiÓ· 1). ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ (1,55±0,6) ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô Û ۇÁÎÚÈÛË Ì Ù˘ ÔÍ›·˜ Ïԛ̈͢ (p<0,001) (∂ÈÎfiÓ· 2). ∏ ‰ÔÎÈÌ·Û›· Pearson ¤‰ÂÈÍ fiÙÈ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ·ÈÌ·ÙÔÏÔÁÈÎÔ› Î·È Ë·ÙÈÎÔ› ‰Â›ÎÙ˜ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹
∞ÛıÂÓ›˜ ∏ÏÈΛ· (¤ÙË) ÃÚfiÓÔ˜ ÓÔÛËÏ›·˜ (Ë̤Ú˜) §Â˘Î¿ (Î/Ìl) §ÂÌÊÔ·ÙÙ·Ú· (%) ÕÙ˘· ÏÂÌÊÔ·ÙÙ·Ú· (%) SGPT (U/L) SGOT (U/L)
™‡ÓÔÏÔ
EBV Ïԛ̈ÍË
CMV Ïԛ̈ÍË
p
26 6,6±3,5 6,2±1,9 15.917±7.130 57,1±10,31 14,6±7,17 147±130 110±84,38
18 7±3,6 6,3±1,8 14.828±6.008 56,51±10,3 14,37±7,15 173±160 124±96
8 5,7±3,1 6±2,4 18.366±9.159 58,42±10,3 15,25±8,3 84±51 77,14±27,5
ª™ ª™ ª™ ª™ ª™ ª™ ª™
ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ¶·È‰È·ÙÚÈ΋ 2008;71:135-140
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·138
138
∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ Î·È ˘ÔÏËı˘ÛÌÔ› ∆ Î·È µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì ™§ª ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹
IgG (g/L) IgA (g/L) IgM (g/L) CD3+ (%) CD3+/CD4+ (%) CD3+/CD8+ (%) CD19+ (%) CD3-/CD16+56+ (%) CD4+/CD8+
™‡ÓÔÏÔ
EBV Ïԛ̈ÍË
CMV Ïԛ̈ÍË
p
13±3,9 2,1±1,3 2,2±0,9 82±9 22,9±10,6 48,5±15,5 7,7±4,9 9,4±3,7 0,4±0,3
13,5±4,1 2,1±1,1 2,2±0,9 78,6±10,2 22,3±10,1 47,8±14,3 7,8±4,3 9,3±3,2 0,5±0,3
12,1±3,3 2,2±1,7 2,15±1,04 81,1±6,5 24,2±12,5 49,9±17,5 7,4±6,2 9,4±4,9 0,4±0,2
ª™ ª™ ª™ ª™ ª™ ª™ ª™ ª™ ª™
ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi
ÙÔ˘ ™§ª ÛÙÔ 69% ÙˆÓ ·È‰ÈÒÓ, Û˘¯ÓfiÙËÙ· ¯·ÌËÏfiÙÂÚË ·fi ÙÔ 85-90% ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Û ÂÓ‹ÏÈΘ (3). ∏ ̤ÛË ËÏÈΛ· ÓfiÛËÛ˘ ‹Ù·Ó 6,6 ¤ÙË, 4
3
2 CD4+/CD8+
ÛÏËÓfi˜ ›¯Â ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ CD3+/CD8+ ÏÂÌÊÔ·ÙÙ·Ú· Î·È ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔ ÏfiÁÔ CD4+/CD8+. ªÂٷ͇ Ù˘ IgA Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ ‚Ú¤ıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË, ÂÓÒ ·ÚÓËÙÈ΋ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ IgA Î·È ÙˆÓ CD3+/CD4+ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Î·È ÈÛ¯˘Ú¿ ıÂÙÈ΋ Ì ٷ CD3+/CD8+. ∏ IgG ›¯Â ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ IgA Î·È Ù· CD3+/CD8+ (¶›Ó·Î·˜ 3). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÓÂϤÁ¯ıËηÓ, ÙÚ›· ·È‰È¿ (‰‡Ô ·ÁfiÚÈ· Î·È ¤Ó· ÎÔÚ›ÙÛÈ) ËÏÈΛ·˜ 9-11 ÂÙÒÓ, ·ÚÔ˘Û›·˙·Ó ηٷ‚ÔÏ‹ Î·È ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ·. ∆· ‰‡Ô ·fi ·˘Ù¿ ›¯·Ó Ïԛ̈ÍË ·fi EBV Î·È ·¤ÎÙËÛ·Ó ·ÓÔÛ›· 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË. ™ÙÔ ÙÚ›ÙÔ ·È‰›, ÎÔÚ›ÙÛÈ, Ì CMV Ïԛ̈ÍË, Ë ÂÁηٿÛÙ·ÛË ·ÓÔÛ›·˜ ηı˘ÛÙ¤ÚËÛÂ, Ì ÂÈÌÔÓ‹ ÙˆÓ ·ÓÙÈ-CMV IgM ·ÓÙÈÛˆÌ¿ÙˆÓ Â› 8 Ì‹Ó˜, ÙˆÓ ÔÔ›ˆÓ Ô Ù›ÙÏÔ˜ ÛÙ·‰È·Î¿ ÌˉÂÓ›ÛÙËÎÂ Î·È ·Ú·ÙËÚ‹ıËΠÂÈÎÚ¿ÙËÛË ÙˆÓ ·ÓÙÈ-CMV IgG ·ÓÙÈۈ̿وÓ. ∆ËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ÙÔ˘˜ ÂÈÎfiÓ· ¯·Ú·ÎÙ‹ÚÈ˙ ›ÌÔÓË ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË (>50%), ηıÒ˜ Î·È ·ÚÔ˘Û›· ¿Ù˘ˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Â› 3 Ì‹Ó˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ¤‰ÂÈÍ fiÙÈ ÛÙËÓ ÔÍ›· Ê¿ÛË Ù· ‰‡Ô ·È‰È¿ Ì EBV Ïԛ̈ÍË Î·È ÙÔ ¤Ó· ·È‰› Ì CMV Ïԛ̈ÍË Â›¯·Ó ˘„ËÏ¿ CD3+/CD8+: 40%, 70% Î·È 70% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ô ÏfiÁÔ˜ CD4+/CD8+ ‹Ù·Ó ¯·ÌËÏfi˜: 0,5, 0,15 Î·È 0,23 ·ÓÙ›ÛÙÔȯ·. ™ÙÔ ·È‰› Ì ÙË CMV Ïԛ̈ÍË, Ô ÏfiÁÔ˜ CD4+/CD8+ ·Ú¤ÌÂÈÓ <1 ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 8 ÌËÓÒÓ.
1
0
-1
™˘˙‹ÙËÛË ™ÙË ÌÂϤÙË Ì·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ì ÔÍ›· EBV Î·È CMV Ïԛ̈ÍË ·ÚÔ˘Û›·Û·Ó ·‡ÍËÛË ÙˆÓ CD8+ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ù· ÔÔ›· ÂÏ·ÙÙÒıËÎ·Ó ·Ú¿ÏÏËÏ· Ì ÙËÓ ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË. ∞Ó¿ÏÔÁ˜ ÌÂϤÙ˜, ·Ó·ÊÔÚÈο Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿ÚÚˆÛ˘, Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂Ó˜ Î·È ·ÊÔÚÔ‡Ó ÌfiÓÔ ÙÔÓ EBV (14,15). √ EBV ·ÔÙ¤ÏÂÛ ·›ÙÈÔ Paediatriki 2008;71:135-140
√Í›· Ïԛ̈ÍË
∂·Ó¤ÏÂÁ¯Ô˜
∂ÈÎfiÓ· 2. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ (ÔÚÈ˙fiÓÙÈ· ÁÚ·ÌÌ‹ ÂÓÙfi˜ ÙˆÓ ·Ú·ÏÏËÏÔÁÚ¿Ì̈Ó) ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ˘. TÔ 1o Î·È 3o ÙÂÙ·ÚÙËÌfiÚÈÔ (25% Î·È 75% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ÙËÓ ¿Óˆ Î·È Î¿Ùˆ ÏÂ˘Ú¿ ÙÔ˘ ·Ú·ÏÏËÏÔÁÚ¿ÌÌÔ˘. √È ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ÙÔ˘ ·Ú·ÏÏËÏÔÁÚ¿ÌÌÔ˘ ‰ËÏÒÓÔ˘Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+.
Pediatri Mar-Apr 08
07-04-08
16:23
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139
∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ·È‰ÈÒÓ Ì EBV Î·È CMV Ïԛ̈ÍË
ȉȷÈÙ¤Úˆ˜ ¯·ÌËÏ‹ Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ó·ÊÂÚfiÌÂÓË Û ¿ÏϘ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë Ïԛ̈ÍË Â›Ó·È Û˘¯ÓfiÙÂÚË Û ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ ˘„ËÏÒÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ ÔÌ¿‰ˆÓ (16), ηıÒ˜ Î·È Û ËÏÈ˘ 10-19 ÂÙÒÓ, ȉ›ˆ˜ Û ÎÏÂÈÛÙÔ‡˜ ÏËı˘ÛÌÔ‡˜ ÛÙÚ·ÙȈÙÈÎÒÓ Î·È ÊÔÈÙËÙÒÓ (17). ™Â ¿ÙÔÌ· ¯·ÌËÏÔ‡ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘ Î·È Û ÙÚÔÈΤ˜ Î·È ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë Ïԛ̈ÍË Â›Ó·È Û·ÓÈfiÙÂÚË Î·È ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ Û ÌÈÎÚ‹ ·È‰È΋ ËÏÈΛ· ˆ˜ ·Û˘Ìو̷ÙÈ΋ (9,18). √ CMV ˘‹ÚÍ ·ÍÈÔÛËÌ›ˆÙÔ ·›ÙÈÔ ™§ª, ηıÒ˜ ÚÔÛ¤‚·Ï 8 ·fi Ù· 26 ·È‰È¿ Ù˘ ÌÂϤÙ˘. ŸÌˆ˜, ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÍ·¯ıÔ‡Ó Û¯ÂÙÈο ·ÍÈfiÈÛÙ· Û˘ÌÂÚ¿ÛÌ·Ù· ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Ì CMV Î·È EBV Ïԛ̈ÍË, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ‰Â›ÁÌ·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ. ø˜ ÚÔ˜ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÔÈ ÂΉËÏÒÛÂȘ Â›Ó·È ÌÂÓ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜, ·ÏÏ¿ fi¯È ÂȉÈΤ˜, fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È Î·È ·ÏÏÔ‡ (19). ŸÏ· Ù· ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÚÔ˘Û›·Û·Ó ˘ÚÂÙfi Î·È ÛÏËÓÔÌÂÁ·Ï›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ïԛ̈͢. ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·fi Ù· ·ÓÙ›ÛÙÔȯ· (84% Î·È 64%) Û ·Ó¿ÏÔÁË ÌÂϤÙË (14). ŸÛÔÓ ·ÊÔÚ¿ ÙȘ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ÎÏÈÓÈΤ˜ ÂÈÏÔΤ˜, Ë ·fiÊÚ·ÍË ÙˆÓ ·ÓÒÙÂÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ ÂÌÊ·Ó›ÛÙËΠ۠Ôχ ÏÈÁfiÙÂÚ· ·È‰È¿ (23%) ÛÙË ÌÂϤÙË Ì·˜ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ (64%) Ù˘ ·ÓˆÙ¤Úˆ ÌÂϤÙ˘, ÂÓÒ ÙÔ Ô›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ ·Ú·ÙËÚ‹ıËΠÛÙÔ ›‰ÈÔ ÂÚ›Ô˘ ÔÛÔÛÙfi (23% Î·È 29% ·ÓÙ›ÛÙÔȯ·). ¶Ï‹Ú˘ ·Ó¿ÚÚˆÛË ·Ú·ÙËÚ‹ıËΠ۠¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 3-6 ÌËÓÒÓ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ, ÂÎÙfi˜ ·fi Ì›· ·ÛıÂÓ‹, ÁÂÁÔÓfi˜ Ô˘ ‰È·Ê¤ÚÂÈ ·fi ÙȘ ÌÂϤÙ˜ Û ÂÓ‹ÏÈΘ, fiÔ˘ Ë ‰È¿ÚÎÂÈ· ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi 6 Ì‹Ó˜ (19,20). ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi, ÔÈ ÂÓ‹ÏÈΘ Ì¿ÏÏÔÓ ·Ú·Ì¤ÓÔ˘Ó ÌÂÙ·‰ÔÙÈÎÔ›, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ ÂÈÌÔÓ‹ ÙÔ˘ ˘„ËÏÔ‡ ∂µV DNA ÊÔÚÙ›Ô˘ ÛÙÔ Û›ÂÏfi ÙÔ˘˜ (21). §ÂÌÊÔ΢ÙÙ¿ÚˆÛË ·Ú·ÙËÚ‹ıËΠÛÙÔ 77% ÙˆÓ ·È‰ÈÒÓ Û ۇÁÎÚÈÛË Ì ÙÔ 32% Î·È ÙÔ 85% ¿ÏÏˆÓ ÌÂÏÂÙÒÓ Û ÂÓ‹ÏÈΘ (3,22). ∞‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ‰È·ÈÛÙÒıËÎÂ Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ù˘ ‰È΋˜
Ì·˜ ÌÂϤÙ˘ (80%) Û ۇÁÎÚÈÛË Ì ÙÔ 59% ·Ó¿ÏÔÁ˘ ÌÂϤÙ˘ (14). ÀÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ΢ڛˆ˜ IgM Ù¿Í˘, ·Ú·ÙËÚ‹ıËΠÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì·˜. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ïԛ̈͢ ÚÔ·ÙÂÈ fiÙÈ Ù· CD3+ ‹Ù·Ó ·˘ÍË̤ӷ ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ, ‡ÚËÌ· Ô˘ Û˘ÌʈÓ› Ì ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (9,22). ∆Ô 50% ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·ÚÔ˘Û›·Û ȉȷ›ÙÂÚË Ì›ˆÛË ÙˆÓ CD3+/CD4+ Î·È ÙˆÓ CD19+, Û ·ÓÙ›ıÂÛË Ì ÌÂϤÙË ÂÓËϛΈÓ, fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·ÍÈÔÛËÌ›ˆÙË ÌÂÙ·‚ÔÏ‹ (22). ∫·Ó¤Ó· ·È‰› ‰ÂÓ ·ÚÔ˘Û›·Û ÌÂÙ·‚ÔÏ‹ ÛÙ· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ¡∫, fiˆ˜ ‰È·ÈÛÙÒıËÎÂ Î·È ·fi ÙÔ˘˜ Weisberger Î·È Û˘Ó. (23), ÂÓÒ ·ÓÙ›ıÂÙ· ÔÈ Williams Î·È Û˘Ó. (22) ·Ó¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ›‰· ¡∫ ΢ÙÙ¿ÚˆÓ Û ÂÓ‹ÏÈΘ Ì ÔÍ›· §ª. ™Â fiÏ· Ù· ·È‰È¿, ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙˆÓ CD3+/CD8+ (̤ÛË ÙÈÌ‹: 48,5%). ¶Èı·Ófiٷٷ, Ù· CD3+/CD8+ Û˘ÓÈÛÙÔ‡Ó Ù· ÂÓÂÚÁÔÔÈË̤ӷ ∆ ÏÂÌÊÔ·ÙÙÙ·Ú· Ô˘ ÌÔÚÊÔÏÔÁÈο ÔÚ›˙ÔÓÙ·È ˆ˜ ‘¿Ù˘·’ ÏÂÌÊÔ·ÙÙ·Ú· Î·È ·ÔÙÂÏÔ‡Ó ¤ˆ˜ Î·È ÙÔ 50% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ (20). ∏ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ ÛÙËÓ ÔÍ›· Ïԛ̈ÍË Û ÂÓ‹ÏÈΘ ÂÈÛËÌ·›ÓÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (20,22,24,25). ∆· CD3+/CD8+, ˆ˜ Ô Î˘Ú›·Ú¯Ô˜ ˘ÔÏËı˘ÛÌfi˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ·›˙Ô˘Ó ÚˆÙ·Ú¯ÈÎfi ÚfiÏÔ ÛÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡. ∞ÛÎÔ‡Ó Î˘ÙÙ·ÚÔÙÔÍÈ΋ ‰Ú¿ÛË ¤Ó·ÓÙÈ ÙˆÓ ÚÔÛ‚ÏËı¤ÓÙˆÓ ·fi ÙÔÓ Èfi µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‰ÈηÈÔÏÔÁÒÓÙ·˜ Èı·ÓÒ˜ ÙËÓ ÙÒÛË ÙˆÓ CD19+ Ô˘ ‰È·ÈÛÙÒıËΠÛÙË ÌÂϤÙË Ì·˜. ∏ ·Ú·ÙËÚÔ‡ÌÂÓË Î˘ÙÙ·ÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ CD3+/CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·Ú·ÙËÚÂ›Ù·È Î·È Û ¿ÏϘ ÏÔÈÌÒÍÂȘ, fiˆ˜ ÛÙËÓ ∏IV Î·È ÙËÓ HCV Ïԛ̈ÍË. øÛÙfiÛÔ, ÛÙË §ª Ù· CD3+/CD8+ ¤¯Ô˘Ó Ê·ÈÓfiÙ˘Ô CD45R0+/ CD45RA-, Û˘Ì‚·Ùfi Ì ∆ ÌÓËÌÔÓÈο ·ÙÙ·Ú· ·Ú¿ Ì ·Úı¤Ó· ∆ ÏÂÌÊÔ·ÙÙ·Ú· (20). ™Â fiÏ· Ù· ·È‰È¿, Ô ÏfiÁÔ˜ CD4+/CD8+ ‹Ù·Ó ÂÏ·Ùو̤ÓÔ˜ (0,12-1), ÁÂÁÔÓfi˜ ·Ó·ÌÂÓfiÌÂÓÔ ·fi ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‡ÚËÌ· Ô˘ Û˘ÌʈÓ› Ì ÙÔ˘˜ Weisberger Î·È Û˘Ó. (0,1-0,9) (23) Î·È Lima Î·È Û˘Ó. (0,11-1,23) (25).
¶›Ó·Î·˜ 3. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ∆, µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+, ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ Î·È ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ
ª¤ÁÂıÔ˜ ÛÏËÓfi˜ SGOT SGPT Á-GT IgG IgA IgM
CD3+
CD4+
CD8+
CD19+
NK
CD4/CD8
0,97 -0,08 0,03 -0,41* 0,22 0,18 -0,24
-0,44 -0,19 -0,24 -0,26 -0,06 -0,42* -0,31
0,52** 0,06 0,36 0,16 0,47* 0,50** 0,38
-0,75 -0,04 -0,11 0,23 -0,1 -0,2 0,03
0,18 -0,01 0,07 0,05 0,21 0,19 -0,26
-0,5** -0,08 -0,21 -0,19 -0,37 -0,48* -0,39*
IgA 0,32 0,48* 0,58* 0,51** 0,48* 0,21
∆· ‰Â‰Ô̤ӷ ‰›ÓÔÓÙ·È ˆ˜ Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ (r). T· p ·Ó·Ê¤ÚÔÓÙ·È fiÙ·Ó Â›Ó·È ÛËÌ·ÓÙÈο (*p<0,05, **p<0,001) ¶·È‰È·ÙÚÈ΋ 2008;71:135-140
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∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.
∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, Ë Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·Û ›·ÛË. ¶·Ú·ÙËÚ‹ıËΠÙÒÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ CD3+/CD8+ Î·È Â¿ÓÔ‰Ô˜ ÙˆÓ CD3+/CD4+, CD19+ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+. ∏ ÎÏÈÓÈ΋ ›·ÛË Û˘Ì‚¿‰È˙ Ì ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ. ¢È·ÈÛÙÒıËΠfiÙÈ Ù· CD3+/CD8+ ›¯·Ó ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ÛÏËÓÔÌÂÁ·Ï›·, ηıÒ˜ Î·È Ì ÙȘ IgG Î·È IgA. ™Â ÙÚ›· ·fi Ù· 26 ·È‰È¿, Ë ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË Î·ı˘ÛÙ¤ÚËÛ ¤ˆ˜ Î·È 8 Ì‹Ó˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔÔ›ˆÓ ÔÈ ÏfiÁÔÈ CD4+/CD8+ ·Ú¤ÌÂÓ·Ó ¯·ÌËÏÔ›. ∫·ı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿ÚÚˆÛ˘ ̤¯ÚÈ Î·È 18 Ì‹Ó˜, Ë ÔÔ›· ‰ÂÓ Û˘Ó‰¤ÂÙ·È fï˜ Ì ٷ ·˘ÍË̤ӷ ›‰· ÙˆÓ CD3+/CD8+, ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏÏË ÌÂϤÙË (15). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ·Ú¿Ù·ÛË Ù˘ Ïԛ̈͢ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙÔ ·˘ÍË̤ÓÔ ÈÈÎfi ÊÔÚÙ›Ô, ·ÏÏ¿ ÛÙËÓ ÂËÚ·Ṳ̂ÓË ·ÓÔÛȷ΋ ηٿÛÙ·ÛË ÙÔ˘ ÍÂÓÈÛÙ‹ (20). ™˘ÌÂÚ·ÛÌ·ÙÈο, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹Û·Ì ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ EBV Î·È Ù˘ CMV Ïԛ̈͢ ··ÓÙÔ‡Ó Ì ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ CD3+/CD8+. ∏ ‡ÊÂÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÔÍ›·˜ Ïԛ̈͢ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ¢Ú›·˜ ΢ÙÙ·ÚÔÙÔÍÈ΋˜ ∆ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ (CTL) ·¿ÓÙËÛ˘ ÛÙ· ·ÓÙÈÁfiÓ· ÙÔ˘ ÈÔ‡. ™˘ÓÂÒ˜, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Â›Ó·È ¯Ú‹ÛÈÌË ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì ¯ÚfiÓÈ· EBV ‹ CMV Ïԛ̈ÍË.
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17. 18.
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ORIGINAL ARTICLE
141
ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿: ÂÌÂÈÚ›· 15 ÂÙÒÓ Û ¤Ó· ΤÓÙÚÔ Ÿ. µÚ¿ÓË1, ª. ¶·ÓÙÈΛ‰Ô˘1, °. ÿÌ‚ÚÈÔ˜2, π. •˘ÓÈ¿˜1, µ. ¢ÂÌÂÚÙ˙›‰Ô˘1, ∫. ∫¿ÓÙ˙ÈÔ˘1, ∞. ª·˘ÚÔ˘‰‹1, ¢. ∆·ÎÔ‡‰·˜2, £. ¶··ÛÙ·‡ÚÔ˘1, ∫. ™‡ÚÔÁÏÔ˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏) ÛÙ· ·È‰È¿ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ıÂڷ›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌË ·Ó·ÛÙÚ¤„ÈÌ˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó·ÊÔÚ¿ Ù˘ ÂÌÂÈÚ›·˜ Ì·˜ ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∞fi ÙÔ 1990 ̤¯ÚÈ Û‹ÌÂÚ·, 16 ·ÛıÂÓ›˜ Ù˘ °’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜, ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 13 ÂÙÒÓ, ˘Ô‚Ï‹ıËÎ·Ó Û ª∏. ∞fi Ù· ·È‰È¿ ·˘Ù¿, 9 ›¯·Ó ·ÙÚËÛ›· Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, 2 ÔÍ›· Ë·ÙÈ΋ Ó¤ÎÚˆÛË ÌÂÙ¿ ÙË ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ, 1 Û‡Ó‰ÚÔÌÔ Alagille, 1 ÂÓ‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ÌË Û˘Ó‰ÚÔÌÈÎÔ‡ Ù‡Ô˘, 1 ÓfiÛÔ ÙÔ˘ Wilson, 1 ÚˆÙÔ·ı‹ ˘ÂÚÔÍ·ÏÔ˘Ú›· Î·È 1 Ë·ÙÔ‚Ï¿Ûو̷. ¢¤Î· ·È‰È¿ ˘Ô‚Ï‹ıËÎ·Ó Û ª∏ ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£ Î·È Ù· ˘fiÏÔÈ· Û ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ∆ÚÂȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ¤ÁÈÓ·Ó ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ‰fiÙË Î·È 13 ·fi و̷ÙÈÎfi ‰fiÙË. ŒÍÈ ·È‰È¿ ¤Ï·‚·Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ΢ÎÏÔÛÔÚ›ÓË, MMF Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È 7 ·È‰È¿ tacrolimus ·ÓÙ› ΢ÎÏÔÛÔÚ›Ó˘. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 16 ·È‰È¿ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË, 3 η٤ÏËÍ·Ó ÙÔÓ ÚÒÙÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi Ì‹Ó·. ∞fi Ù· ˘fiÏÔÈ· Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠¤ˆ˜ Û‹ÌÂÚ·, 3 ·ÚÔ˘Û›·Û·Ó ÔÍ›· Î·È 1 ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶¤ÓÙ ·È‰È¿ ÂÌÊ¿ÓÈÛ·Ó Ïԛ̈ÍË ·fi CMV, 5 ·fi EBV, 2 Ïԛ̈ÍË ·fi HSV, 2 ·fi Èfi Parvo µ19, 1 ·fi Èfi Coxsackie Î·È 1 ·fi Candida albicans. ∂›Û˘, ¤Ó· ·È‰› ·ÚÔ˘Û›·Û ·ÈÌÔÚÚ·Á›· ÙÔ˘ ·ÓÒÙÂÚÔ˘ °∂™ Î·È ¤Ó· ·ÚÔ˘Û›·Û ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∏ ¤Î‚·ÛË ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ηϋ, Ì ηϋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÂÎÙfi˜ ·fi ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ÙË ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ Ô˘ ¯ÚÂÈ¿ÛÙËΠӤ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÔÚ›· Î·È ¤Î‚·ÛË ·È‰ÈÒÓ Ì ˷ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Û¯ÂÙÈο ηϋ Ì ÙËÓ ÚÔ¸fiıÂÛË Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·.
1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 2 ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: ∫ÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘ klspirog@med.auth.gr °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 ∆.∫. 546 39, £ÂÛÛ·ÏÔÓ›ÎË
§¤ÍÂȘ ÎÏÂȉȿ: ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·È‰È¿.
Liver transplantation in children: 15 years experience in one center O. Vrani1, M. Pantikidou1, G. Imvrios2, I. Xinias1, V. Demertzidou1, K. Kantziou1, A. Mavroudi1, D. Takoudas2, T. Papastaurou1, K. Spyroglou1 Abstract Background: Liver transplantation (LT) is the only treatment for children with irreversible liver failure. This is a report of the follow-up of a series of 16 children who underwent LT. Methods: Since 1990, 16 patients of the 3rd Paediatric Clinic of the Hippocration General Hospital of Thessaloniki, aged 6 months to 13 years, underwent LT. Nine children presented initially with extrahepatic biliary atresia, 2 with acute liver failure following toxic mushroom ingestion, 1 with Alagille syndrome, 1 with non-syndromic intrahepatic biliary paucity, 1 with Wilson’s disease, 1 with primary hyperoxaluria and 1 with hepatoblastoma. Ten children underwent LT in the Organ Transplantation Unit of the Aristotle University of Thessaloniki and the others in various medical centers in other countries. Three transplants came from living-related donors and 13 from deceased donors. Six children went under immunosuppressive treatment with cyclosporine, MMF and corticosteroids and seven with tacrolimus, MMF and corticosteroids. Results: Three of the 16 children died within the first month after transplantation due to post-transplant complications, and eleven have survived. Three children presented with acute rejection and one with chronic organ rejection, which was successfully managed. Five children developed CMV infection, 5 EBV infection, 2 HSV infection, 2 Parvo B19 virus and 1 Candida Albicans infection. One child had upper GI haemorrhage and one presented with small biliary paucity. The outcome was satisfactory in most cases, with good graft function, except in the case of the patient with small biliary paucity, who required retransplantation. Conclusions: The long-term clinical course of children following LT is good, provided that they are monitored in specialized centres.
1. 3rd Department of Paediatrics, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece 2. Department of Surgery, Organ Transplantation Unit, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece Correspondence: ∫leomenis Spyroglou klspirog@med.auth.gr 3rd Department of Paediatrics, Aristotle University, Hippokration General Hospital of Thessaloniki 49 Konstantinoupoleos St., 546 39, Thessaloniki, Greece
Key words: Liver transplantation, children. ¶·È‰È·ÙÚÈ΋ 2008;71:141-147
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Ÿ. µÚ¿ÓË Î·È Û˘Ó.
∂ÈÛ·ÁˆÁ‹ ∏ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏) Ú·ÁÌ·ÙÔÔÈ‹ıËΠÙÔ 1963 ·fi ÙÔÓ Starzl (1) ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ ∫ÔÏÔÚ¿ÓÙÔ Û ·È‰› 3 ÂÙÒÓ Ô˘ ¤·Û¯Â ·fi ·ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. √ ·ÛıÂÓ‹˜ ·˘Ùfi˜ η٤ÏËÍ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤̂·Û˘ ÏfiÁˆ ·ıÚfi·˜ ·ÈÌÔÚÚ·Á›·˜. ∆¤ÛÛÂÚ· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·fi ÙÔÓ ›‰ÈÔ È·ÙÚfi Ë ÚÒÙË ÂÈÙ˘¯‹˜ ª∏ Û ¤Ó· Ó‹ÈÔ 18 ÌËÓÒÓ Ì ˷ÙÔ‚Ï¿Ûو̷, ÙÔ ÔÔ›Ô Â¤˙ËÛ ÁÈ· 400 Ë̤Ú˜ (2). ∆ËÓ ›‰È· ÂÚ›Ô‰Ô ¿Ú¯ÈÛÂ Ë ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ Ù˘ ª∏ Î·È ÛÙËÓ ∂˘ÚÒË Ì ˘„ËÏ¿, fï˜, ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜ ηٿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, Ô˘ ¤ÊÙ·Ó·Ó ÙÔ 60-70% (3,4). ŒÎÙÔÙÂ, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È Ë ·Ó¿Ù˘ÍË Ó¤ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ, ÙÔ ÔÔ›Ô Û‹ÌÂÚ·, ÛÙ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ·, ÍÂÂÚÓ¿ ÙÔ 90% ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙË ¯ÚfiÓÈ· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È ÙÔ 70% ÛÙËÓ ÔÍ›·, ÂÓÒ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË (10-15 ¤ÙË) ÍÂÂÚÓ¿ ÙÔ 80% (5-8). ª¿ÏÈÛÙ·, ÏfiÁˆ ÙˆÓ Ôχ ηÏÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÂÎÙ¿ıËÎ·Ó ÁÚ‹ÁÔÚ· Î·È ÔÈ ÂӉ›ÍÂȘ Ù˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÌÊ·ÓÈÛÙ› ¤Ó‰ÂÈ· ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ë ÔÔ›· ÂÚÈfiÚÈ˙ ÙËÓ ÔÚıÔÙÔÈ΋ ª∏ ÛÙ· ·È‰È¿. ™ËÌ·ÓÙÈ΋ ÒıËÛË ÛÙËÓ Â¤ÎÙ·ÛË ÙˆÓ ª∏, ȉ›ˆ˜ Û ‚Ú¤ÊË Î¿Ùˆ ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ Î·È ‚¿ÚÔ˘˜ οو ÙˆÓ 10 kg, ¤‰ˆÛ·Ó ÔÈ Ù¯ÓÈΤ˜ Ù˘ ÙÌËÌ·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (split liver) Î·È Ù˘ ÌÂıfi‰Ô˘ ÂÏ·ÙÙÒÛˆ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (reduced size), ηıÒ˜ ›Û˘ Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ‰fiÙË. ∏ ̤ıÔ‰Ô˜ ÂÏ·ÙÙÒÛˆ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1984 Û ·È‰› ·fi ÙÔ˘˜ Bismuth Î·È Houssin (9). ∆Ô 1989 ÔÈ Pichlmayr Î·È Û˘Ó. (10) ·Ó·ÎÔ›ÓˆÛ·Ó ÙËÓ ÚÒÙË ÂÈÙ˘¯Ë̤ÓË ÙÌËÌ·ÙÈ΋ ª∏, ÂÓÒ ÔÈ ÚÒÙ˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ˆÓÙ·Ófi ‰fiÙË ÂÚÈÁÚ¿ÊÔÓÙ·È ·fi ÙÔ˘˜ Broelsch Î·È Û˘Ó. (11). ™‹ÌÂÚ·, Ë ª∏ ÛÙ· ·È‰È¿ ·ÔÙÂÏ› ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ¤Ó‰ÂÈÍË -fiˆ˜ ηÎÔ‹ıÂÈ· ÂÎÙfi˜ ‹·ÙÔ˜, Û˘ÁÎÂÎÚÈ̤Ó˜ ÓÂÔϷۛ˜ ÙÔ˘ ‹·ÙÔ˜, fiˆ˜ ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷- ‹ ·ÎfiÌË Û˘Óı‹Î˜ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, Ô˘ Ó· ÌËÓ ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÙË Û˘ÌÌfiÚʈÛË Ì ٷ ÚˆÙfiÎÔÏÏ· Ù˘ ·ÁˆÁ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (12). ™ÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ Û ·È‰È¿ ·fi ÙÔ 1990, ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£, ÂÓÒ ·Ú¿ÏÏËÏ· ÙÔ ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ¤¯ÂÈ ·ÔÎÔÌ›ÛÂÈ ÛËÌ·ÓÙÈ΋ ÂÌÂÈÚ›· ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË 16 ·È‰ÈÒÓ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ë·Paediatriki 2008;71:141-147
¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È ·›ÙÈ· ª∏ ∏ÏÈΛ· ª¤ÛË 5 ¤ÙË (6 Ì‹Ó˜ - 13 ¤ÙË) <1 ¤ÙÔ˘˜ 3 1-6 ÂÙÒÓ 9 7-13 ÂÙÒÓ 4 º‡ÏÔ ∞ÁfiÚÈ· 8 ∫ÔÚ›ÙÛÈ· 8 ∞›ÙÈ· ∞ÙÚËÛ›· Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ 9 √Í›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÌÂÙ¿ ÙË ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ 2 ∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË (Û‡Ó‰ÚÔÌÔ Alagille, ÌË Û˘Ó‰ÚÔÌÈÎÔ‡ Ù‡Ô˘) 2 ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (ÓfiÛÔ˜ Wilson, ÚˆÙÔ·ı‹˜ ˘ÂÚÔÍ·ÏÔ˘Ú›·) 2 ŸÁÎÔÈ ‹·ÙÔ˜ (Ë·ÙÔ‚Ï¿Ûو̷) 1
ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ÛÙ· ÔÔ›· ÙÂÏÈÎÒ˜ Ù¤ıËΠ¤Ó‰ÂÈÍË ÁÈ· ª∏. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ٷ ·›ÙÈ· Ô˘ Ô‰‹ÁËÛ·Ó ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÙȘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÌÂıfi‰Ô˘˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, ÙËÓ ¤Î‚·Û‹ Ù˘, ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ÙË ª∏.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∞fi ÙÔ 1990 ̤¯ÚÈ Û‹ÌÂÚ·, 16 ·È‰È¿ (8 ·ÁfiÚÈ· Î·È 8 ÎÔÚ›ÙÛÈ·) ˘Ô‚Ï‹ıËÎ·Ó Û ª∏, 10 ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£ Î·È 6 Û ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ∆· ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È Ù· ·›ÙÈ· Ô˘ Ô‰‹ÁËÛ·Ó Û ª∏, ηıÒ˜ Î·È Ë ÔÛÔÛÙÈ·›· ·Ó·ÏÔÁ›· ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Î·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ ·ÔÙÂÏ› ÙÔ ÚÒÙÔ ÛÂ Û˘¯ÓfiÙËÙ· ·›ÙÈÔ. ∞ÎÔÏÔ˘ıÔ‡Ó Ë ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË (Û‡Ó‰ÚÔÌÔ Alagille, ÌË Û˘Ó‰ÚÔÌÈ΋ ˘ÔÏ·Û›· ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ), Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (ÓfiÛÔ˜ Wilson, ÚˆÙÔ·ı‹˜ ˘ÂÚÔÍ·ÏÔ˘Ú›·) ηÈ
ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· 13%
ŸÁÎÔÈ ‹·ÙÔ˜ 5%
∞ÙÚËÛ›· 56%
∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË 13%
√Í›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· 13% ∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙÈ·›· ·Ó·ÏÔÁ›· ÙˆÓ ·ÈÙÈÒÓ Ô˘ Ô‰‹ÁËÛ·Ó Û ª∏ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜.
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ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿
Ë ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÌÂÙ¿ ·fi ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ, ηÈ, Ù¤ÏÔ˜, ÔÈ fiÁÎÔÈ ÙÔ˘ ‹·ÙÔ˜. ∞fi Ù· 9 ·È‰È¿ Ì ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ, 3 ›¯·Ó ˘Ô‚ÏËı› Û ¤̂·ÛË Kasai (Ë·ÙÔ˘ÏÔÂÓÙÂÚÔ·Ó·ÛÙfïÛË) ÚÈÓ ·fi ÙË ª∏ Û ËÏÈΛ· 1, 2 Î·È 4 ÌËÓÒÓ. ™Â 2 ·È‰È¿ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ¤̂·ÛË Kasai Ù‡Ô˘ II, ηٿ ÙËÓ ÔÔ›· ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÂÓÙÂÚÔÛÙÔÌ›· ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ·Ú¤Ì‚·Û˘ ̤ۈ ·˘Ù‹˜ ÛÙË ¯ÔÏÔÂÙÈ΋ ·Ó·ÛÙfïÛË, Î·È Û ¤Ó· ·È‰› Kasai Ù‡Ô˘ I. ™Â fiÏ· Ù· ·È‰È¿, ÚÈÓ ·fi ÙË ª∏, Ù·ÍÈÓÔÌ‹ıËÎÂ Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· ηٿ Child-Pugh (9). ŒÓ· ·È‰› ‹Ù·Ó ÛÙ·‰›Ô˘ ∞, 7 ÛÙ·‰›Ô˘ µ, Î·È 8 ÛÙ·‰›Ô˘ C. ™Â 3 ·È‰È¿ ‰fiÙ˘ ‹Ù·Ó Ë ÌËÙ¤Ú·, ·fi ÙËÓ ÔÔ›· ÂÏ‹ÊıËÛ·Ó Ù· ÙÌ‹Ì·Ù· II & III ÙÔ˘ ‹·ÙÔ˜. ™Ù· ˘fiÏÔÈ· 13 ·È‰È¿ ÙÔ ÌfiÛ¯Â˘Ì· ÚÔÂÚ¯fiÙ·Ó ·fi و̷ÙÈÎfi ‰fiÙË. ™Â 7 ÂÚÈÙÒÛÂȘ Ô ‰fiÙ˘ ‹Ù·Ó ·È‰›, ÂÓÒ Û 6 ¯ÚËÛÈÌÔÔÈ‹ıËΠÌfiÛ¯Â˘Ì· ·fi ÂÓ‹ÏÈη ‰fiÙË. ∞fi ·˘Ù¤˜ ÙȘ 6 ÂÚÈÙÒÛÂȘ, ÛÙȘ 4 ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù¯ÓÈ΋ split liver, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ù· ÙÌ‹Ì·Ù· ππ & πππ ÙÔ˘ ‹·ÙÔ˜, ÂÓÒ Ô ‰ÂÍÈfi˜ ÏÔ‚fi˜ ÌÂÙ·ÌÔۯ‡ıËΠ۠ÂÓ‹ÏÈη Ï‹ÙË, Î·È ÛÙȘ ¿ÏϘ 2 ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Â›Û˘ Ù· ÙÌ‹Ì·Ù· ππ & πππ, ÁÈ· ÙÔ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ÔÔ›ˆÓ, fï˜, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù¯ÓÈ΋ reduced-size, ηٿ ÙËÓ ÔÔ›· ÙÔ ÂÓ·ÔÌÂ›Ó·Ó ÙÌ‹Ì· ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È ÌË ¯ÚËÛÈÌÔÔÈ‹ÛÈÌÔ. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÈ ·ÛıÂÓ›˜ ·Ú¤ÌÂÈÓ·Ó Û˘Ó‰Â‰Â̤ÓÔÈ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ÁÈ· 24 ¤ˆ˜ 48 ÒÚ˜ Î·È ‚Ú›ÛÎÔÓÙ·Ó ˘fi ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÔÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜, ÌÂÙ·‚ÔÏÈΤ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Î·È ÔÈ ÏÔÈÌÒÍÂȘ. ø˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁ‹ıËΠ·Ú¯ÈÎÒ˜ methylprednizolone (2 mg/kg IV) Î·È ·ÎÔÏÔ‡ıˆ˜ prednizolone (0,2 mg/kg, per os), ÛÂ Û˘Ó‰˘·ÛÌfi Ì mycophenolate mofetil/ MMF (CellCept) Î·È Î˘ÎÏÔÛÔÚ›ÓË (Neoral) Û 6 ·È‰È¿, ÂÓÒ Û 7 ·È‰È¿, ·ÓÙ› Ù˘ ΢ÎÏÔÛÔÚ›Ó˘, ¯ÔÚËÁ‹ıËΠFK506/ tacrolimus (Prograf).
∞ÔÙÂϤÛÌ·Ù· ∆Ú›· ·È‰È¿ η٤ÏËÍ·Ó ÙÔÓ ÚÒÙÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi Ì‹Ó· ·fi ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜: ¤Ó· ·fi ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, ¤Ó· ·fi ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ Î·È ¤Ó· ·fi ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·. ∞fi Ù· 13 ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠¤ˆ˜ Û‹ÌÂÚ·, 4 ÂÌÊ¿ÓÈÛ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ̤ÛÔ fiÚÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘˜ 25,7 Ì‹Ó˜ ÌÂÙ¿ ÙË ª∏. ™Ù· ‰‡Ô ·È‰È¿ Ù· ÂÂÈÛfi‰È· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÈÙ˘¯Ò˜ Ì ÒÛÂȘ ÎÔÚÙÈ˙fiÓ˘. ™Ù· ˘fiÏÔÈ· ‰‡Ô ··ÈÙ‹ıËΠ¯ÔÚ‹ÁËÛË ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈÎÔ‡ ÔÚÔ‡ (ATG), ÏfiÁˆ ·ÓıÂÎÙÈÎfiÙËÙ·˜ Ù˘ ·ÔÚÚÈÙÈ΋˜ ‰È·‰Èηۛ·˜ ÛÙ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ™ÙË Ì›· ÂÚ›ÙˆÛË Ë ·ÓÙ›ÛÙ·ÛË ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÔÊ›ÏÂÙÔ ÛÙÔ fiÙÈ Ô ‰fiÙ˘ ‹Ù·Ó Û˘Ì‚·Ù‹˜ Î·È fi¯È ›‰È·˜ ÔÌ¿‰·˜ ·›Ì·ÙÔ˜. √ ·ÛıÂÓ‹˜ ·˘Ùfi˜ ·ÚÔ˘Û›·Û ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ÔÔ›· fï˜ ÌÂÙÚÈ¿ÛÙËΠ̠·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ·fi ΢ÎÏÔÛÔÚ›ÓË Û tacrolimus. ∆ÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÎÚ›ıËΠ··Ú·›ÙËÙË Û 3 Û˘ÓÔÏÈο ·ÛıÂÓ›˜. ™ÙÔ˘˜
¶›Ó·Î·˜ 2. ∂ÈÏÔΤ˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ∂ÈÏÔ΋ §Ô›ÌˆÍË ñ CMV ñ EBV ñ Parvo B19 ñ HSV1,2 ñ Coxsackie ñ Candida albicans ∞fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜ ∞ÈÌÔÚÚ·Á›· ·ÓÒÙÂÚÔ˘ °∂™ ÀÂÚÔ˘Úȯ·ÈÌ›· ∂Í·Ê¿ÓÈÛË ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ
∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ 5 5 2 2 1 1 4 1 1 1
2 ¤ÁÈÓ ·ÏÏ·Á‹ ÙÔ˘ Û¯‹Ì·ÙÔ˜ ·fi cyclosporine Û tacrolimus, ÂÍ·ÈÙ›·˜ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ ÛÙË Ì›· ÂÚ›ÙˆÛË -Ë ÔÔ›· ‰ÈÂÁÓÒÛıË Ì ÎÏÂÈÛÙ‹ ‚ÈÔ„›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜-, Î·È ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÛÙËÓ ¿ÏÏË. ∏ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÂΉËÏÒıËΠ̠·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ Î·È ÂÏ¿ÙÙˆÛË ÙÔ˘ GFR ηٿ ÙË Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ÌÂϤÙË. ∆¤ÏÔ˜, Û ¤Ó· ·È‰› Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·ÏÏ·Á‹ ·fi tacrolimus Û ΢ÎÏÔÛÔÚ›ÓË, ÏfiÁˆ ·Ú¯fiÌÂÓ˘ ·ÁÎÚ·ٛÙȉ·˜. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙȘ ÏÔÈÌÒÍÂȘ (¶›Ó·Î·˜ 2), ·ÓȯÓ‡ıËÎ·Ó Î˘Ú›ˆ˜ ÔÈ ÈÔ› CMV, EBV Î·È Parvo µ19 Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). ∂›Û˘, 2 ·È‰È¿ ·ÚÔ˘Û›·Û·Ó Ïԛ̈ÍË ·fi HSV, 1 ·fi Coxsackie Î·È 1 ·fi Candida albicans. √È ÏÔÈÌÒÍÂȘ ·˘Ù¤˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÈÙ˘¯Ò˜ Ì ÂÏ¿ÙÙˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÙË ¯ÔÚ‹ÁËÛË gancyclovir, acyclovir ‹ amphotericin B. ªÈÎÚԂȷ΋ Ïԛ̈ÍË ‰ÂÓ ÂÌÊ¿ÓÈÛ ηӤӷ˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜. ÕÏϘ ÂÈÏÔΤ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, ‹Ù·Ó Á·ÛÙÚÔÚÚ·Á›· Î·È ˘ÂÚÔ˘Úȯ·ÈÌ›·. ∆¤ÏÔ˜, ¤Ó·˜ ·ÛıÂÓ‹˜ ÂÌÊ¿ÓÈÛ ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‡ÛÙÂÚ· ·fi ‰È·‰Ô¯ÈΤ˜ ÏÔÈÌÒÍÂȘ ·fi ÙÔ˘˜ ÈÔ‡˜ Parvo B19, CMV Î·È EBV ηٿ ÙËÓ ÚÒÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô, Ë ÔÔ›· Ô‰‹ÁËÛ Û ΛÚÚˆÛË Î·È ˘Ï·›· ˘¤ÚÙ·ÛË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¯ÚÂÈ·ÛÙ› ·ӷÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË, ¤ÍÈ ·È‰È¿ ¤¯Ô˘Ó Û‹ÌÂÚ· ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ¿Óˆ ·fi ÙËÓ 50‹ ÂηÙÔÛÙÈ·›· ı¤ÛË Ì ‚¿ÛË ÙȘ η̇Ϙ ·Ó¿Ù˘Í˘, 2 ÌÂٷ͇ 50‹˜ Î·È 25˘ ∂£ Î·È Ù· ˘fiÏÔÈ· οو ·fi ÙË 10Ë ∂£. ∆· ·È‰È¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È ¿Óˆ ·fi ÙËÓ 50‹ ∂£ ˘Ô‚Ï‹ıËÎ·Ó ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ËÏÈ˘ ·fi 3 ¤ˆ˜ 8 ÂÙÒÓ Î·È ‚Ú›ÛÎÔÓÙ·Ó ÛÙȘ ›‰È˜ ∂£ ÚÈÓ ·fi ÙË ª∏. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ‡„Ô˜, 7 ·È‰È¿ ‚Ú›ÛÎÔÓÙ·È Û‹ÌÂÚ· ¿Óˆ ·fi ÙË 50‹ ∂£, ÂÓÒ 6 ¤¯Ô˘Ó ‡„Ô˜ ›ÛÔ ‹ οو ·fi ÙËÓ 10Ë ∂£. ∆· ·È‰È¿ ¶·È‰È·ÙÚÈ΋ 2008;71:141-147
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·144
144
Ÿ. µÚ¿ÓË Î·È Û˘Ó.
Ô˘ Û‹ÌÂÚ· Â›Ó·È ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 10 ÂÙÒÓ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ›‰È· ∂£ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ÚÈÓ ·fi ÙË ª∏, ‰ËÏ·‰‹ Ë ·Ó¿Ù˘Í‹ ÙÔ˘˜ ‰ÂÓ ÂËÚ¿ÛÙËΠ·fi ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹. √ ÚÒÙÔ˜ ·ÛıÂÓ‹˜ Ô˘ ˘Ô‚Ï‹ıËΠ۠ª∏ Û ËÏÈΛ· 6 ÌËÓÒÓ, ÚÈÓ ·fi 15 ¯ÚfiÓÈ·, ÛÙÔ ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ ÙÔ˘ πÔÎÚ·Ù›Ԣ ÂÈ‚ÈÒÓÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ·, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ۈ̷ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË Î·È ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Î¿ı 6 Ì‹Ó˜ ÛÙËÓ °ã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋.
™˘˙‹ÙËÛË ∏ ª∏ ÛÙ· ·È‰È¿ ·ÔÙÂÏ› Û‹ÌÂÚ· ıÂڷ›· ÚÔ˘Ù›Ó·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ‰›ÓÔÓÙ·˜ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÈ‚›ˆÛ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ì ÓÔÛ‹Ì·Ù· Ô˘ ÚÔËÁÔ˘Ì¤Óˆ˜ ‹Ù·Ó ı·Ó·ÙËÊfiÚ·. ∆· ÓÔÛ‹Ì·Ù· Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ª∏ Î·È ÙÔ ÔÛÔÛÙfi Ô˘ ηٷϷ̂¿ÓÔ˘Ó ‰ÈÂıÓÒ˜ ·ÂÈÎÔÓ›˙ÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ™‡Ìʈӷ Ì ÙÔ ¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô ¢È¿ıÂÛ˘ √ÚÁ¿ÓˆÓ, Ë ·ÙÚËÛ›· ÙˆÓ Â͈˷ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›·, ÂÚ›Ô˘ 50%, ÛÙȘ ‰ËÌÔÛȇÛÂȘ fiÏˆÓ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ. ª¿ÏÈÛÙ·, ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÊÙ¿ÓÂÈ ÙÔ 76% ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ ∞ÌÂÚÈ΋ (8). ÕÏϘ ·ı‹ÛÂȘ ÔÈ Ôԛ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ˷ÙÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Â›Ó·È Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Î·È Ë ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË. ∞fi Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Û˘¯ÓfiÙÂÚ· Â›Ó·È Ë ÓfiÛÔ˜ ÙÔ˘ Wilson, Ë ·Ó¿ÚÎÂÈ· ·1·ÓÙÈıÚ˘„›Ó˘, Ë Ù˘ÚÔÛÈÓ·ÈÌ›· Î·È Ë ·ÈÌԯڈ̿وÛË. ¢ÈÂıÓÒ˜, ÔÛÔÛÙfi ÂÚ›Ô˘ 11% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, Ë ÔÔ›· Ô‰ËÁ› Û ª∏, ÂÍ·ÈÙ›·˜ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, Ê·ÚÌ¿ÎˆÓ ‹ ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ. √È ÌË ¯ÂÈÚÔ˘ÚÁÈο ÂÍ·ÈÚ¤ÛÈÌÔÈ fiÁÎÔÈ ÙÔ˘ ‹·ÙÔ˜ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ÁÈ· ª∏ Û ÔÛÔÛÙfi 2% (6,7,12,13). ∞fi Ù· ÂÚÈÛÙ·ÙÈο Ì·˜, ·Ó Î·È Ô ·ÚÈıÌfi˜ Â›Ó·È ÌÈÎÚfi˜, Ù· ·›ÙÈ· ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ‹‰Ë ‰ËÌÔÛÈ¢ı› ·fi ¿ÏÏ· ΤÓÙÚ·. ∏ ‰˘Û·ÔÚÚfiÊËÛË ÙÔ˘ Ï›Ô˘˜ Î·È ÙˆÓ ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·Ó·Ú΋ ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ Î·È ÂÔ̤ӈ˜ ‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘. •ÂÎÈÓÒÓÙ·˜ ¤ÁηÈÚ· ÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô, Ë ÔÌ¿‰· ÙˆÓ ÂȉÈÎÒÓ È·ÙÚÒÓ ÌÔÚ› Ó· ÂÈÎÂÓÙÚˆı› ·Ú¯Èο ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô˘ Â›Ó·È ÂËÚ·Ṳ̂ÓË ÏfiÁˆ Ù˘ ‰˘Û·ÔÚÚfiÊËÛ˘ (14). ∏ ‚ÂÏÙ›ˆÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ·ÛıÂÓÔ‡˜ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ ÂÈÙ˘¯›·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ηıÒ˜ Ë ‚ÂÏÙ›ˆÛË ·˘Ù‹ ÌÂÙ·ÊÚ¿˙ÂÙ·È Û Ì›ˆÛË ÙˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È Û˘ÓÔÏÈο Û ηχÙÂÚË ÂÈ‚›ˆÛË ÌÂÙ¿ Paediatriki 2008;71:141-147
∫˘ÛÙÈ΋ ›ÓˆÛË 2% ŸÁÎÔÈ 2% ∞˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· 2% ¡ÂÔÁÓÈ΋ Ë·Ù›Ùȉ· 3% ¶ÚˆÙÔ·ı‹˜ ¯ÔÏ·ÁÁÂÈ›Ùȉ· 5% ∂Ó‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· 6% ∫ÂÚ·˘ÓÔ‚fiÏÔ˜ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· 11%
ÕÏÏ· 12% ∞ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ 44%
ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· 13%
∂ÈÎfiÓ· 2. ∞›ÙÈ· ª∏ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ÈÂıÓÒ˜ (¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô ¢È¿ıÂÛ˘ √ÚÁ¿ÓˆÓ) (41).
ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (15). ª¿ÏÈÛÙ·, Û ÌÈ· ÛÂÈÚ¿ ·ÛıÂÓÒÓ Ì ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÂÂÈÁfiÓÙˆ˜ Û ª∏, ·ÚÓËÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ë ÌÈÎÚ‹ ËÏÈΛ·, Ë ÔÔ›· Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ (16). ™ÙË ‰È΋ Ì·˜ ÛÂÈÚ¿, 4 ·È‰È¿ ›¯·Ó ÛËÌ·ÓÙÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘ ηٿ ÙËÓ ·Ú·ÔÌ‹ ÙÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∆· ·È‰È¿ ·˘Ù¿ ˘Ô‚Ï‹ıËÎ·Ó ÛÙËÓ Î·Ù¿ÏÏËÏË ‰È·ÙÚÔÊÈ΋ ˘ÔÛÙ‹ÚÈÍË, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ë̤ڷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ Ó· ¤¯ÂÈ ·˘ÍËı› ηٿ 20-30%. ∏ ηϋ ۈ̷ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÛÙfi¯Ô ÁÈ· ÙÔ˘˜ È·ÙÚÔ‡˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ì ª∏. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ó·ÛÙÚ¤„ÂÈ ÙË ÛÙ·ÛÈÌfiÙËÙ· Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Ô˘ ÚÔ¸‹Ú¯Â ÏfiÁˆ Ù˘ ÓfiÛÔ˘, ÂÓÒ Ê˘ÛÈÔÏÔÁÈ΋ Â›Ó·È Î·È Ë ÓÂ˘Ì·ÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ (17,18). ∂ÓÙÔ‡ÙÔȘ, ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ˆ˜ ÌÔÚ› Ó· ˘¿Ú¯Ô˘Ó ÁÓˆÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ·ÏÏ¿ Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ÌÂÙ¿ ÙË ª∏ (19). ™ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È Û˘ÁηٷϤÁÔÓÙ·È Ë ÚÔÂÁ¯ÂÈÚËÙÈ΋ ηٿÛÙ·ÛË, Ë ·Ú·ÙÂٷ̤ÓË ÓÔÛËÏ›· Î·È Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹, ΢ڛˆ˜ Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∏ Ú·ÎÙÈ΋ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ‰ÈÂıÓÒ˜ -Î·È ·fi ÂÌ¿˜- Ì Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù·, Â›Ó·È Ë Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚË Ì›ˆÛË Î·È ‰È·ÎÔ‹ Ù˘ ÎÔÚÙÈ˙fiÓ˘ (20-24). ∆Ô ÌÂÁ¿ÏÔ Úfi‚ÏËÌ· ÛÙË ª∏ Â›Ó·È fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ˘Ô„‹ÊÈˆÓ ·È‰ÈÒÓ ˘ÂÚ‚·›ÓÂÈ Î·Ù¿ Ôχ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ·Ó¿ÁÎË
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·145
145
ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿
ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙËÓ ¤ÏÏÂÈ„Ë ÙˆÌ·ÙÈÎÒÓ ‰ÔÙÒÓ ÌÈÎÚ‹˜ ËÏÈΛ·˜ ÚÔοÏÂÛ ÙËÓ ·Ó·˙‹ÙËÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ËÁÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ¢‡Ô ÂÁ¯ÂÈÚËÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ÚÔÛʤÚÔ˘Ó ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·, Â›Ó·È Ë Ï‹„Ë ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰È·›ÚÂÛË Û ‰‡Ô ÏÂÈÙÔ˘ÚÁÈο ÙÌ‹Ì·Ù· ÙÔ˘ و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÓ‹ÏÈη ‰fiÙË, ÒÛÙ ӷ ÌÂÙ·ÌÔÛ¯Â˘ı› Û ‰‡Ô Ï‹Ù˜ (11,25). √È Ì¤ıÔ‰ÔÈ ·˘Ù¤˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ïfi ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ Ï‹ÙË Î·È ¤¯Ô˘Ó ϤÔÓ Î·ıÈÂÚˆı› ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ (26-30). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂȂ‚·ÈÒÓÂÈ ÌÈ· ÌÂÁ¿ÏË ÌÂÙ·-·Ó¿Ï˘ÛË, Ë ÔÔ›· ‰Â›¯ÓÂÈ fiÙÈ Ë ÂÈ‚›ˆÛË Â›Ó·È Î·Ï‡ÙÂÚË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ‡ÛÙÂÚ· ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Û˘ÁÎÚÈÙÈο Ì ·˘Ù‹ ·fi و̷ÙÈÎfi ‰fiÙË, ·ÊÂÓfi˜ ‰ÈfiÙÈ ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÂÈ‚·Ú‡ÓÔ˘Ó ÙË ÁÂÓÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË ·Ó·Ì¤ÓÔÓÙ·˜ و̷ÙÈÎfi ÌfiÛ¯Â˘Ì· Î·È ·ÊÂÙ¤ÚÔ˘ ÁÈ·Ù› ÔÈ ¯ÚfiÓÔÈ ıÂÚÌ‹˜ Î·È „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Â›Ó·È ÌÈÎÚfiÙÂÚÔÈ (31). ∂ÓÙÔ‡ÙÔȘ, ı· Ú¤ÂÈ Ó· ÂÈϤÁÔÓÙ·È Ôχ ÚÔÛÂÎÙÈο ÔÈ ˘Ô„‹ÊÈÔÈ ˙ÒÓÙ˜ ‰fiÙ˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÂÍ·ÈÙ›·˜ ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÛÙÔ ‰fiÙË ÌÂÙ¿ ÙËÓ Ë·ÙÂÎÙÔÌ‹ (.¯. ¯ÔÏfiÚÚÔÈ·, ıÚfiÌ‚ˆÛË ˘Ï·›·˜ ‹ Û‡ÛÙÔÈ¯Ë Ó¢ÌÔÓÈ΋ Û˘ÏÏÔÁ‹), ·ÏÏ¿ Î·È Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ·ÎfiÌË, Ë ÔÔ›·, fï˜, Â›Ó·È ÂÍ·ÈÚÂÙÈο ÌÈÎÚ‹ (0,01%). ªÂ ÙË Û˘Ó¯fiÌÂÓË ·‡ÍËÛË ÙˆÓ ˘Ô„ËÊ›ˆÓ ÁÈ· ª∏ -ηıÒ˜ Ì ÙËÓ ·‡ÍËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ‰È¢ڇÓıËÎ·Ó Î·È ÔÈ ÂӉ›ÍÂȘ Ù˘-, ÚԤ΢„ ¤Ó· ·ÎfiÌË ˙‹ÙËÌ·: Ë ÛˆÛÙ‹ ¯Ú‹ÛË ÙˆÓ ‰È·ÙÈı¤ÌÂÓˆÓ ÔÚÁ¿ÓˆÓ. ŸÙ·Ó ¿Ú¯ÈÛ ӷ ÂÊ·ÚÌfi˙ÂÙ·È Ë ª∏, Ë ‰È¿ıÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÁÈÓfiÙ·Ó Ì ‚¿ÛË ÙÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜. °Ú‹ÁÔÚ·, fï˜, ¤ÁÈÓ ·ÈÛıËÙ‹ Ë ·Ó¿ÁÎË ‡·Ú͢ ÂÓfi˜ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ı· ηıfiÚÈ˙ ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ. ∏ ·ÍÈÔÏfiÁËÛË ‚·Û›ÛÙËΠÛÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ηٿ Child-Turcotte-Pugh Î·È ÛÙȘ Ù˘¯fiÓ Û˘Ó˘¿Ú¯Ô˘Û˜ ÂÈÏÔΤ˜ Ù˘, fiˆ˜ ·ÛΛÙ˘, ÎÈÚÛÔÚÚ·Á›· ‹ Ë·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ (32). ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ ÛÙËÓ ∂˘ÚÒË -Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£- Î·È ÛÙËÓ ∞˘ÛÙÚ·Ï›·, Û˘Ó¯›˙Ô˘Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ·˘Ùfi ÙÔ Û‡ÛÙËÌ·. ™ÙȘ ∏¶∞ ÂÈÛ‹¯ıË ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ 2002 ¤Ó· Ó¤Ô Û‡ÛÙËÌ·, ÙÔ ÔÔ›Ô ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË ÌË ‰ÈÂÓ¤ÚÁÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÙÔ ÏÂÁfiÌÂÓÔ MELD (Model for End-Stage Liver Disease) ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È PELD (Pediatric End-Stage Liver Disease) ÁÈ· Ù· ·È‰È¿. ∆Ô ·Ó ·˘Ùfi ÙÔ Û‡ÛÙËÌ· Á›ÓÂÈ Î·ıÔÏÈο ·Ô‰ÂÎÙfi ·fi ÙË ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÎÔÈÓfiÙËÙ·, ̤ÓÂÈ Ó· ·Ô‰Âȯı› ÛÙÔ Ì¤ÏÏÔÓ (33,34). √È ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ ÛËÌ·ÓÙÈ΋ ÂÈ-
ÏÔ΋ Ù˘ ª∏ ÌÂÙ¿ ÙË ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È Î·Ù¿ ÙȘ ÚÒÙ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ Ë̤Ú˜. ∆ËÓ ÚÒÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Î˘ÚÈ·Ú¯Ô‡Ó ÔÈ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ, ÂÓÒ ÂÚ›Ô˘ 2 ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ·fi ̇ÎËÙ˜. ™ÙË Û˘Ó¤¯ÂÈ·, ÌÂÙ¿ ÙȘ 6 ‚‰ÔÌ¿‰Â˜ Î·È ÁÈ· fiÏË ÙË ‰È¿ÚÎÂÈ· ˙ˆ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÈÎÚ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÏÏÔ› ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó ¯ËÌÂÈÔÚÔʇϷÍË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∆· ·ÓÙÈ‚ÈÔÙÈο Î·È Ù· ·ÓÙÈÌ˘ÎËÙÈ·ÛÈο ‰È·ÎfiÙÔÓÙ·È ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â¿Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ Ïԛ̈͢, ÂÓÒ Ù· ·ÓÙÈ-ÈÈο ¤¯Ô˘Ó ı¤ÛË ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜. √È ÈÔ Û˘¯ÓÔ› ÈÔ› Â›Ó·È Ô CMV, o EBV, ÔÈ ·‰ÂÓÔ˚Ô› Î·È Ô RSV (35). √ EBV Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi˜ Èfi˜, ηıÒ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈ΋ ÓfiÛÔ (post transplant lymphoproliferative disease, PTLD) (36). ™‡Ìʈӷ Ì ٷ ÂÚÈÛÙ·ÙÈο Ì·˜, Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË ¤¯Ô˘Ó ÔÈ ÈÔ› EBV Î·È CMV Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ô Parvo B19, Ô HSV1,2, Ô Coxsackie Î·È Ë Candida albicans. ∂ÎÙfi˜ ·fi ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙË ÓÔÛËÚfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ÌÂÙ¿ ÙË ª∏ Â›Ó·È ÔÈ ÂÈÏÔΤ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, fiˆ˜ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (Neoral, Prograf), Ë Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, Ë ÔÛÙÂÔfiÚˆÛË Î·È Ë Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜ (37-39). ∏ ‰È·Ù‹ÚËÛË Î·Ï‹˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ï·Ì‚¿ÓÂÙ·È ÛÔ‚·Ú¿ ˘fi„Ë ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ∆· ÓÂfiÙÂÚ· Ê¿Ú̷η, mycophenolate mofetil (CellCept) Î·È Ù· ÈÔ ÚfiÛÊ·Ù· mycophenolate sodium (Myfortic) Î·È sirolimus (Rapamycin), Ù· ÔÔ›· ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ¤‰ˆÛ·Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÔÈ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ Û ÌÈÎÚfiÙÂÚ˜ ‰fiÛÂȘ, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ÙÔ˘˜ (40-43). ∞fi Ù· ÂÚÈÛÙ·ÙÈο Ì·˜, 1 ·È‰›, ÙÔ ÔÔ›Ô Ï¿Ì‚·Ó ΢ÎÏÔÛÔÚ›ÓË ÁÈ· ¤Ó· ¤ÙÔ˜, ·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ ÙÔ˘ ÔÚÔ‡ Î·È ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ∞ÓÙÈÌÂÙˆ›ÛÙËΠ·Ú¯ÈÎÒ˜ Ì Ì›ˆÛË Ù˘ ‰fiÛ˘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Û tacrolimus. ™Â ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÔÈ ÔÔ›ÔÈ Â›Ó·È Èı·Ófi Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ˘ÔÙÚÔ‹ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ª∏, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ÎÈÓ‰˘Ó‡ÂÈ ·fi ˘ÔÙÚÔ‹ Ù˘ ÚˆÙ·Ú¯È΋˜ ÓfiÛÔ˘. ∏ ·Ú·Ù‹ÚËÛË ·˘Ù‹ ÂȂ‚·ÈÒÓÂÙ·È Î·È ·fi Ù· ηχÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ (44). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ª∏ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË ÌfiÓË ‰È·ı¤ÛÈÌË ıÂڷ›· Û ·È‰È¿ Ì ÌË ·Ó·ÛÙÚ¤„ÈÌË ¶·È‰È·ÙÚÈ΋ 2008;71:141-147
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Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÏÂÈ¿‰· ÓÔÛËÌ¿ÙˆÓ, Ù· ÔÔ›· ÛÙÔ ·ÚÂÏıfiÓ ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÏÂÁ¯ıÔ‡Ó Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó. ∏ ηϋ Û˘ÓÂÚÁ·Û›· Ù˘ ÔÌ¿‰·˜ ÂȉÈÎÒÓ (¯ÂÈÚÔ˘ÚÁÒÓ, ·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏfiÁˆÓ, ·È‰Ô„˘¯È¿ÙÚˆÓ, ÓÔÛËÏ¢ÙÚÈÒÓ, ÎÔÈÓˆÓÈÎÒÓ ÏÂÈÙÔ˘ÚÁÒÓ) Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ıÂÌÂÏÈÒ‰Ô˘˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÔÌ·Ï‹ ÔÚ›· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. √È ÌÂÏÏÔÓÙÈΤ˜ ÂÍÂÏ›ÍÂȘ ÛÙË ¯Ú‹ÛË ÂÙÂÚÔÌÔÛ¯Â˘Ì¿ÙˆÓ ‹ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ηıÒ˜ Î·È ÔÈ È‰ÈfiÙËÙ˜ Ô˘ ‰È·Ê·›ÓÔÓÙ·È ÛÙ· ‚Ï·ÛÙÔ·ÙÙ·Ú·, ›Ûˆ˜ ÂÚÈÔÚ›ÛÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó·Ì¤ÓÔ˘Ó Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Starzl TE, Marchioro TL, Vonkaulla KN, Hermann G, Brittain RS, Waddell WR. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963;117:659-676. 2. Starzl TE. History of Liver and Other Splanchnic Organ Transplantation. In: Busutill RW, Klintmalm GB, editors. Transplantation of the Liver. Philadelphia, Pa: W.B. Saunders; 1996. p. 3-22. 3. Otte JB. History of pediatric liver transplantation. Where are we coming from? Where do we stand? Pediatr Transplant 2002;6:378-387. 4. Alagille D. History of pediatric liver transplantation in Europe. Acta Gastroenterol Belg 2004;67:172-175. 5. Schafer DF. Liver transplantation. Looking back, looking forward. In: Maddrey WC, Schiff ER, Sorrell MF, editors. Transplantation of the Liver. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2001. 6. Busuttil RW, Farmer DG, Yersiz H, Hiatt JR, McDiarmid SV, Goldstein LI, et al. Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience. Ann Surg 2005;241:905-916. 7. Lee WS, McKiernan P, Kelly DA. Etiology, outcome and prognostic indicator of childhood fulminant hepatic failure in the United Kingdom. J Pediatr Gastroenterol Nutr 2005;40:575-581. 8. Kelly DA. Current results and evolving indications for liver transplantation in children. J Pediatr Gastroenterol Nutr 1998;27:214-221. 9. Bismuth H, Houssin D. Reduced-size orthotopic liver graft in hepatic transplantation in children. Surgery 1984;95: 367-372. 10. Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. [Transplantation of a donor liver to 2 recipients (splitting transplantation) -- a new method in the further development of segmental liver transplantation]. Langenbecks Archiv Chir 1988;373:127-130. 11. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg 1990;212: 368-375. 12. Dhawan A, Cheeseman P, Mieli-Vergani G. Approaches to acute liver failure in children. Pediatr Transplant 2004;8: 584-588. 13. Kelly DA. Liver Transplantation. In: Walker WA et al, editors. Pediatric Gastrointestinal Disease. Philadelphia, Pa: BC Decker; 2000. p. 1272-1290. Paediatriki 2008;71:141-147
14. Tiao GM, Alonso M, Bezerra J, Yazigi N, Heubi J, Balisteri W, et al. Liver transplantation in children younger than 1 year - the Cincinnati experience. J Pediatr Surg 2005;40: 268-273. 15. Kelly DA. Nutritional factors affecting growth before and after liver transplantation. Ped Transplant 1997;1:80-84. 16. Nadalin S, Heuer M, Wallot M, Auth M, Schaffer R, Sotiropoulos GC, et al. Paediatric acute liver failure and transplantation: the University of Essen experience. Transpl Int 2007;20:519-527. 17. Holt RI, Broide E, Buchanan CR, Miell JP, Baker AJ, Mowat AP, et al. Orthotopic liver transplantation reverses the adverse nutritional changes of end-stage liver disease in children. Am J Clin Nutr 1997;65:534-542. 18. Burdelski M, Nolkemper D, Ganschow R, Sturm E, Malago M, Rogiers X, et al. Liver transplantation in children: long-term outcome and quality of life. Eur J Pediatr 1999; 158:S34-S42. 19. Van Mourik ID, Beath SV, Brook GA, Cash AJ, Mayer AD, Buckels JA, et al. Long term nutritional and neurodevelopmental outcome of liver transplantation in infants aged less than 12 months. J Pediatr Gastroenterol Nutr 2000;30: 269-275. 20. Bartosh SM, Thomas SE, Sutton MM, Brady LM, Whitington PF. Linear growth after pediatric liver transplantation. J Pediatr 1999;135: 624-631. 21. Melter M, Briscoe DM. Challenges after pediatric transplantation. Semin Nephrol 2000; 20:199-208. 22. Ramaccioni V, Soriano HE, Arumugam R, Klish WJ. Nutritional aspects of chronic liver disease and liver transplantation in children. J Pediatr Gastroenterol Nutr 2000; 30:361-367. 23. Viner RM, Forton JT, Cole TJ, Clark IH, Noble-Jamieson G, Barnes ND. Growth of long-term survivors of liver transplantation. Arch Dis Child 1999;80:235-240. 24. Reding R, Gras J, Sokal E, Otte JB, Davies HF. Steroid-free liver transplantation in children. Lancet 2003;362:2068-2070. 25. Magee JC, Bucuvalas JC, Farmer DG, Harmon WE, Hulbert-Shearon TE, Mendeloff EN. Pediatric transplantation. Am J Transplant 2004;4:54-71. 26. Lfipez-Santamaria M, de Vicente E, Gaãmez M, Murcia M, Leal N, Hernandez F, et al. Pediatric living donor liver transplantation. Transplant Proc 2003;35:1808-1809. 27. Takada Y, Tanaka K. Living related liver transplantation. Transplant Proc 2004;36:271-273. 28. Chen CL, Concejero A, Wang CC, Wang SH, Lin CC, Liu YW, et al. Living donor liver transplantation for biliary atresia: a single-center experience with first 100 cases. Am J Transplant 2006;6:2672-2679. 29. Hattori H, Higuchi Y, Tsuji M, Inomata Y, Uemoto S, Asonuma K, et al. Living-related liver transplantation and neurological outcome in children with fulminant hepatic failure. Transplantation 1998;65:686-692. 30. Yersiz H, Renz JF, Farmer DG, Hisatake GM, McDiarmid SV, Busuttil RW. One hundred in situ split-liver transplantations: a single-center experience. Ann Surg 2003;238:496-505. 31. Austin MT, Feuer ID, Chari RS, Gorden DL, Wright JK, Pinson CW. Survival after pediatric liver transplantation. Why does living donation offer an advantage? Arch Surg 2005;140:465-470. 32. Sundaram SS, Alonso EM, Whitington PF. Liver transplantation in neonates. Liver Transpl 2003;9:783-788.
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33. Graziadei I. Liver transplantation organ allocation between Child and MELD. Wien Med Wochenschr 2006;156: 410-415. 34. Evrard V, Otte JB, Sokal E, Rochet JS, Haccourt F, Gennari F, et al. Impact of surgical and immunological parameters in pediatric liver transplantation: a multivariate analysis in 500 consecutive recipients of primary grafts. Ann Surg 2004; 239:272-280. 35. Brown RS, Kumar KS, Russo MW, Kinkhabwala M, Rudow DL, Harren P, et al. Model for end-stage liver disease and Child-Turcotte-Pugh score as predictors of pretransplantation disease severity, posttransplantation outcome, and resource utilization in United Network for Organ Sharing status 2A patients. Liver Transpl 2002;8:278-284. 36. Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR. Fever in liver transplant recipients: changing spectrum of etiologic agents. Clin Infect Dis 1998;26:59-65. 37. Guthery SL, Heubi JE, Bucuvalas JC, Gross TG, Ryckman FC, Alonso MH, et al. Determination of risk factors for Epstein-Barr virus-associated posttransplant lymphoproliferative disorder in pediatric liver transplant recipients using objective case ascertainment. Transplantation 2003;75: 987-993. 38. Kling K, Lau H, Colombani P. Biliary complications of liv-
ing related pediatric liver transplant patients. Pediatr Transplant 2004;8:178-184. 39. Araz C, Pirat A, Torgay A, Zeyneloglu P, Arslan G. Early postoperative complications of pediatric liver transplantation: experience at one center. Transplant Proc 2004;36: 214-217. 40. Reding R. Tacrolimus in pediatric liver transplantation. Pediatr Transplant 2002;6:447-451. 41. Nobili V, Comparcola D, Sartorelli MR, Diciommo V, Marcellini M. Mycophenolate mofetil in pediatric liver transplant patients with renal dysfunction: preliminary data. Pediatr Transplant 2003;7:454-457. 42. Evans HM, McKiernan PJ, Kelly DA. Mycophenolate mofetil for renal dysfunction after pediatric liver transplantation. Transplantation 2005;79:1575-1580. 43. Mahadevan SBK, Beath SV, Davids P, Lloyd C, James C, van Mourik IDM, et al. Safety and efficacy of Sirolimus in children following chronic rejection and/or nephrotoxicity post intestinal transplant (Itx) and liver transplantation (LTx). J Pediatr Gastroenterol Nutr 2004;39:S152. 44. Bucuvalas JC, Ryckman FC. Long-term outcome after liver transplantation in children. Pediatr Transplant 2002;6:30-36. 45. United Network for Organ Sharing [Webpage, Internet]. http://www.unos.org/
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ORIGINAL ARTICLE
√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ 1 ∆Ô̤·˜ √ÈÎÔÓÔÌÈÎÒÓ Ù˘ ÀÁ›·˜, ∂ıÓÈ΋ ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ 2 ∂Ù·ÈÚÈΤ˜ ÀÔı¤ÛÂȘ, Wyeth Hellas A.E.B.E. AÏÏËÏÔÁÚ·Ê›·: µ·ÛÈÏÈ΋ ∆ÛÈ¿ÓÙÔ˘ vtsiantou@nsph.gr ∆Ô̤·˜ √ÈÎÔÓÔÌÈÎÒÓ Ù˘ ÀÁ›·˜, ∂ıÓÈ΋ ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ §ÂˆÊ. ∞ÏÂÍ¿Ó‰Ú·˜ 196 ∆.∫. 115 21, ∞ı‹Ó·
µ. ∆ÛÈ¿ÓÙÔ˘1, ∞. ∫·Úfi΢2, ∂. ¶¿‚Ë1, °. ∫˘ÚÈfiÔ˘ÏÔ˜1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∆· ÂÌ‚fiÏÈ· ·ÔÙÂÏÔ‡Ó ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÂÚÁ·Ï›· ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘. øÛÙfiÛÔ, ÔÈ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓ˜ ·Ó¿ÁΘ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ˘˜ ÂÚÈÔÚÈṲ̂ÓÔ˘˜ ÔÈÎÔÓÔÌÈÎÔ‡˜ fiÚÔ˘˜, ÂÈ‚¿ÏÏÔ˘Ó ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙȘ ·ÔÊ¿ÛÂȘ ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ·Ó·‰Â›ÍÂÈ ÙË Û˘Ì‚ÔÏ‹ Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÛÙÔÓ Â˘·›ÛıËÙÔ ÙÔ̤· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ Î·È ÂÌ‚ÔÏÈ·ÛÌÔ‡. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŒÁÈÓÂ Û˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË ÂÈÛÙËÌÔÓÈÎÒÓ ¿ÚıÚˆÓ Ô˘ ·ÊÔÚÔ‡Ó Û ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÌ‚ÔÏ›ˆÓ ηٿ ÙËÓ ÂÚ›Ô‰Ô 1999-2006. ø˜ ·Ú¯È΋ ËÁ‹ ‡ÚÂÛ˘ ¿ÚıÚˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ËÏÂÎÙÚÔÓÈ΋ ‚È‚ÏÈÔı‹ÎË PubMed. ∞ÔÙÂϤÛÌ·Ù·: ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ ‰ËÌÔÛȇÙËÎ·Ó ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÚÈÓ ·fi ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ‹ ÌË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ. ∫·Ù¿ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÙÔ˘˜ ÌÂÏÂÙ‹ıËÎ·Ó fiÏ· Ù· Èı·Ó¿ ÛÂÓ¿ÚÈ· Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ‰Â›ÎÙË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·fi ‰È¿ÊÔÚ˜ ·Ó·Ï˘ÙÈΤ˜ ÚÔÔÙÈΤ˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∞Ó Î·È ÔÏϤ˜ ·fi ÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ‰ÂÓ ‹Ù·Ó ¿ÓÙÔÙ ‹ ·Ôχو˜ ¢ÓÔ˚Τ˜ ÁÈ· ÙËÓ ¿ÌÂÛË ¤ÓÙ·ÍË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ, ÂÓ Î·ÈÚÒ, ÔÈ ¯ÒÚ˜ ÚÔ¤‚ËÎ·Ó ÛÙËÓ ¤ÓÙ·Í‹ ÙÔ˘˜, ·ÊÔ‡ ·ÍÈÔÏfiÁËÛ·Ó ·fi ÎÔÈÓÔ‡ ÙÔ˘˜ ‰Â›ÎÙ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜, ÙËÓ ·ÓËÛ˘¯›· ÙÔ˘ ÎÔÈÓÔ‡ Î·È ÙÔ ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi ÊÔÚÙ›Ô Ù˘ ÓfiÛÔ˘. √È ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Û˘Ó¤‚·Ï·Ó ÛÙËÓ ÙÂÎÌËÚȈ̤ÓË ·ÔÙ›ÌËÛË ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÛÙÚ·ÙËÁÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡.
§¤ÍÂȘ ÎÏÂȉȿ: √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË, ÂÌ‚fiÏÈ·, ·ÓÂÌ¢ÏÔÁÈ¿, ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˜ Ù‡Ô˘ C, Ó¢ÌÔÓÈfiÎÔÎÎÔ˜.
Economic evaluation of new vaccines against varicella, serogroup C meningococcus and pneumococcus 1 Department of Health Economics, National School of Public Health 2 Corporate Affairs, Wyeth Hellas S.A. Correspondence: Vasiliki Tsiantou vtsiantou@nsph.gr Health Economics Sector, National School of Public Health 196, Alexandras Avenue 115 21, Athens, Greece
V. Tsiantou1, A. Karokis2, E. Pavi1, G. Kyriopoulos1 Abstract Background: Vaccines are one of the most important tools for the primary prevention of infectious diseases. Decisions on the inclusion of new vaccines in the National Immunization Schedule need to address competing priorities, which stem from the lack of health care resources and the growing health care needs of the population. The objective of this study is to highlight the importance of economic evaluation in the sensitive field of immunization programs and vaccines. Methods: A systematic review of papers on the economic evaluation of new vaccines published in scientific journals between 1999 and 2006 was conducted through PubMed. Results: In the majority of the health care systems of developed countries, ex ante economic evaluations were published, which evaluated all the possible scenarios and factors influencing the cost-effectiveness ratio of the vaccines before their introduction. Conclusions: Economic evaluations were not always clearly in favour of the introduction of new vaccines into the vaccination schedules. However, countries usually adopted the vaccines for inclusion in the National Immunization Schedules after assessing additional parameters, such as the mortality and morbidity ratios, the economic and social burden of disease and the anxiety of the population regarding the risk of infection.
Key words: Economic evaluation, vaccines, varicella, serogroup meningococcus, pneumococcus vaccination.
∂ÈÛ·ÁˆÁ‹ ∆· ÂÌ‚fiÏÈ· ·ÔÙÂÏÔ‡Ó Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÂÚÁ·Ï›· ÁÈ· ÙËÓ ÚˆÙÔÁÂÓ‹ ÚfiÏË„Ë ÙˆÓ ÓÔPaediatriki 2008;71:148-156
ÛËÌ¿ÙˆÓ, Û˘ÓÂÈÛʤÚÔÓÙ·˜ ıÂÙÈο ÛÙË ‰ËÌfiÛÈ· ˘Á›· Î·È ÙËÓ ÔÈÎÔÓÔÌÈ΋ ˙ˆ‹. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Ô‰ËÁ› ÛÙË Ì›ˆÛË ‹ ·ÎfiÌ· Î·È ÛÙËÓ
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√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ
ÂÎÚ›˙ˆÛË ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÛÙËÓ ÂÍÔÈÎÔÓfiÌËÛË ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ˘ÁÂÈÔÓÔÌÈÎÒÓ ·Ó·ÁÎÒÓ (1). ∫·Ù¿ Û˘Ó¤ÂÈ·, ÂÎÙfi˜ ·fi ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ¿ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÙÔ˘˜ ·Ô‰ÔÙÈÎfiÙËÙ·. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘. ∏ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· Û‡ÓÔÏÔ Ù¯ÓÈÎÒÓ, ÙÔ ÔÔ›Ô ÂÎÙÈÌ¿ ÙË Û¯ÂÙÈ΋ ·Í›· ·˘ÙÒÓ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜, Û˘ÁÎÚ›ÓÔÓÙ·˜ ‰È·ÊÔÚÂÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È ÂΛÓË ÙÔ˘ ÌË ÂÌ‚ÔÏÈ·ÛÌÔ‡ (2,3). ∏ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Û˘Ì‚¿ÏÏÂÈ ÛÙË Ï‹„Ë ÌÈ·˜ ·fiÊ·Û˘, fiÙ·Ó Ú¤ÂÈ Ó· Á›ÓÂÈ ÈÂÚ¿Ú¯ËÛË ÚÔÙÂÚ·ÈÔÙ‹ÙˆÓ (3) Î·È ÂÓÈÛ¯‡ÂÈ ÙËÓ ÔÚıÔÏÔÁÈ΋ ηٷÓÔÌ‹ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ Û¿ÓÈˆÓ fiÚˆÓ. √È ÚÒÙ˜ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÂÌÊ·Ó›ÛÙËÎ·Ó ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 (4). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ô ·ÚÈıÌfi˜ ÙÔ˘˜ ·˘Í‹ıËÎÂ, Ë ÔÈfiÙËÙ¿ ÙÔ˘˜ ‚ÂÏÙÈÒıËÎÂ Î·È Ù· ÌÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì¤Ûˆ Ù˘ ¤Î‰ÔÛ˘ ηÙ¢ı˘ÓÙ‹ÚÈˆÓ Ô‰ËÁÈÒÓ (guidelines). ∆ÂÏÈο, Ë Ê·ÚÌ·ÎÔÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÂÓÙ¿¯ıËΠÛÙË ‰È·‰Èηۛ· Ï‹„˘ ·ÔÊ¿ÛÂˆÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜ ÔÏÏÒÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ. √ ÙÔ̤·˜ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Â›Ó·È È‰È·›ÙÂÚ· ¢·›ÛıËÙÔ˜ ‰ÈfiÙÈ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ Ù¤ÙÔÈ·˜ ·Ú¤Ì‚·Û˘ ‰ÂÓ Â›Ó·È ¿ÌÂÛ· ÔÚ·Ù¿. ∂ÈϤÔÓ, ÔÏÏ¿ ·fi Ù· Ó¤· ÂÌ‚fiÏÈ· ·ÊÔÚÔ‡Ó ·Ûı¤ÓÂȘ ÔÈ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ó ·˘ÍË̤ÓË ıÓËÙfiÙËÙ·, ·ÏÏ¿ ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙÔÓ ÏËı˘ÛÌfi, Ì ·ÔÙ¤ÏÂÛÌ· Ë ¯ÚËÛÈÌfiÙËÙ¿ ÙÔ˘˜ Î·È Ë Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Û˘¯Ó¿ Ó· ˘ÔÙÈÌ¿Ù·È ‹ Î·È Ó· ·ÌÊÈÛ‚ËÙÂ›Ù·È (4,5). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ·Ó·‰Â›ÍÂÈ ÙË ÛËÌ·Û›· Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÛÙÔÓ Â˘·›ÛıËÙÔ ÙÔ̤· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘, ÌÂÏÂÙÒÓÙ·˜ Ù· Ó¤· ÂÌ‚fiÏÈ· ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ÁÈ·Ù› ·˘Ù¿ ·ÂÈÎÔÓ›˙Ô˘Ó Î·Ï‡ÙÂÚ· ÙÔ ‰›ÏËÌÌ· Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÔÈ ˘Â‡ı˘ÓÔÈ Î·Ù¿ ÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÁÈ· ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ fiÚˆÓ. ∆· ÂÌ‚fiÏÈ· ·˘Ù¿ ÚfiÛÊ·Ù· ÂÓÙ¿¯ıËÎ·Ó ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ Ù˘ ∂ÏÏ¿‰·˜. ∏ ˘„ËÏ‹ ÙÈÌ‹ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó¿ÁÎË ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙÔ ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ¿ÛÎËÛË ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ ÔÏÈÙÈ΋˜ Â›Ó·È ÌÂÚÈο ·fi Ù· ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ÂÚÈϤÎÔ˘Ó ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÙË ‰È·‰Èηۛ· Ï‹„˘ ·ÔÊ¿ÛˆÓ.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÃÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ·Ó·ÛÎfiËÛ˘ ÂÈÛÙËÌÔÓÈÎÒÓ ¿ÚıÚˆÓ Ì ÙË ¯Ú‹ÛË Ù˘ Ì˯·Ó‹˜ ·Ó·˙‹ÙËÛ˘ Ù˘ ËÏÂÎÙÚÔÓÈ΋˜ ‚È‚ÏÈÔı‹Î˘ PubMed (www.pubmed.com). ø˜ ϤÍÂȘ ÎÏÂȉȿ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ fiÚÔÈ: economic evaluation, vaccines, pharmacoeconomic studies, cost-effectiveness of vaccines, varicella vaccine, meningococcal vaccine, pneumococcus vaccine Î·È Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ. ∂ÈϤ¯ÙËÎ·Ó Ù· ¿ÚıÚ· Ô˘ ·ÊÔÚÔ‡Û·Ó ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ÂÌ‚ÔÏ›ˆÓ. ∆· ¿ÚıÚ· Ô˘ ·ÓÙÏ‹ıËÎ·Ó ·ÊÔÚÔ‡Û·Ó ÙËÓ ÂÚ›Ô‰Ô 1999-2006 Î·È Ë ÁÏÒÛÛ· Û˘ÁÁÚ·Ê‹˜ ‹Ù·Ó Ë ·ÁÁÏÈ΋. ∂ÈϤÔÓ, Ú·ÁÌ·ÙÔÔÈ‹ıËΠ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·˙‹ÙËÛË ‰ËÌÔÛȇÛÂˆÓ ÛÙ· ÂÈÛÙËÌÔÓÈο ÂÚÈÔ‰Èο Ù· ÔÔ›· ηÙÂÍÔ¯‹Ó ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ı¤Ì· Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Î·È ÙˆÓ ÂÌ‚ÔÏ›ˆÓ, fiˆ˜ Ù·: Vaccines, The Lancet, Journal of Infectious Diseases, Health Economics, Pharmacoeconomics Î·È Pediatrics. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ªÂ ÙÔÓ fiÚÔ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË (economic evaluation) ÔÚ›˙ÂÙ·È Ë Û˘ÁÎÚÈÙÈ΋ ·ÔÙ›ÌËÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ıÂڷ¢ÙÈÎÒÓ ‹ ÚÔÏËÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ (6). ™ÎÔfi˜ Ù˘ Â›Ó·È Ó· ÂÓÙÔ›ÛÂÈ, Ó· ÌÂÙÚ‹ÛÂÈ Î·È Ó· ÂÎÙÈÌ‹ÛÂÈ ÙÔ ÎfiÛÙÔ˜ Î·È Ù· ÔʤÏË Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂοÛÙÔÙ ÚÔÁÚ¿ÌÌ·ÙÔ˜. ¢Â›¯ÓÂÈ, ¤ÙÛÈ, ÔÈÔ ÚfiÁÚ·ÌÌ· ÚÔÛʤÚÂÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‰˘Ó·Ùfi fiÊÂÏÔ˜ Ì ÙÔ ÌÈÎÚfiÙÂÚÔ ‰˘Ó·Ùfi ÎfiÛÙÔ˜. ∏ ∂ÈÎfiÓ· 1 ‰Â›¯ÓÂÈ Ù· Èı·Ó¿ ÛÂÓ¿ÚÈ· Ù˘ Û¯¤Û˘ ÎfiÛÙÔ˘˜-·ÔÙÂϤÛÌ·ÙÔ˜ Û ÌÈ· Ó¤· ·Ú¤Ì‚·ÛË ˘Á›·˜ Î·È ÙȘ ·ÓÙ›ÛÙÔȯ˜ ·ÔÊ¿ÛÂȘ. ∫·Ù¿ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ, ÙÔ ÎfiÛÙÔ˜ ‰È·ÎÚ›ÓÂÙ·È Û ÙÚÂȘ ηÙËÁÔڛ˜. ∆Ô ¿ÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜ ·ÊÔÚ¿ ‰·¿Ó˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ Ô˘ Â›Ó·È Û¯ÂÙÈΤ˜ Ì ÙËÓ ·Ûı¤ÓÂÈ· (Ê¿Ú̷η, ÂÍÂÙ¿ÛÂȘ, Î.Ù.Ï.) ‹ Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, fiˆ˜ Â›Ó·È Ë ÙÈÌ‹ ·ÁÔÚ¿˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ÔÈ ‰·¿Ó˜ ¯ÔÚ‹ÁËÛ˘ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Èı·ÓÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. ∆Ô ¿ÌÂÛÔ ÌË È·ÙÚÈÎfi ÎfiÛÙÔ˜ ·ÊÔÚ¿ ȉȈÙÈΤ˜ ÏËڈ̤˜ Î·È Ù· ¤ÍÔ‰· ÌÂٷΛÓËÛ˘ ÙÔ˘ ·ÛıÂÓ‹ ÚÔ˜ Î·È ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. √È ‰·¿Ó˜ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ·ÔÙÂÏÔ‡Ó ÎfiÛÙÔ˜ ÌfiÓÔ ÁÈ· ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹ Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. ∆Ô ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ·ÒÏÂÈ· ·Ú·ÁˆÁÈÎfiÙËÙ·˜ ÏfiÁˆ ·Ô˘Û›·˜ ‹ ÌÂȈ̤Ó˘ ÈηÓfiÙËÙ·˜ ÂÍ·ÈÙ›·˜ Ù˘ ·Ûı¤ÓÂÈ·˜ Î·È ÛÙËÓ ·ÒÏÂÈ·
¶ÂÚÈÔ¯‹ ∞ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÈÎÚfiÙÂÚÔ ÎfiÛÙÔ˜. °›ÓÂÙ·È ‰ÂÎÙ‹
∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ¯ÂÈÚfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÈÎÚfiÙÂÚÔ ÎfiÛÙÔ˜. ∏ ·fiÊ·ÛË ‰ÂÓ Â›Ó·È ÍÂοı·ÚË.
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∞¶√∆∂§∂™ª∞ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÂÁ·Ï‡ÙÂÚÔ ÎfiÛÙÔ˜. ∏ ·fiÊ·ÛË ‰ÂÓ Â›Ó·È + ÍÂοı·ÚË ∫√™∆√™ ¶ÂÚÈÔ¯‹ µ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ¯ÂÈÚfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÂÁ·Ï‡ÙÂÚÔ ÎfiÛÙÔ˜. ∞ÔÚÚ›ÙÂÙ·È
∂ÈÎfiÓ· 1. ™ÂÓ¿ÚÈ· ÎfiÛÙÔ˘˜-·ÔÙÂϤÛÌ·ÙÔ˜ ÌÈ·˜ Ó¤·˜ ·Ú¤Ì‚·Û˘ ˘Á›·˜ Î·È ÔÈ ·ÓÙ›ÛÙÔȯ˜ ·ÔÊ¿ÛÂȘ. ¶·È‰È·ÙÚÈ΋ 2008;71:148-156
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·150
150
µ. ∆ÛÈ¿ÓÙÔ˘ Î·È Û˘Ó.
·Ú·ÁˆÁÈÎfiÙËÙ·˜, ¯ÚfiÓÔ˘ Î·È ÂÈÛÔ‰‹Ì·ÙÔ˜ ÙˆÓ Û˘ÁÁÂÓÒÓ Î·È Ê›ÏˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÊÚÔÓÙ›ÛÔ˘Ó ÙÔÓ ·ÛıÂÓ‹ (2,3). ∆Ô ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ıˆÚÂ›Ù·È Î·È ÎÔÈÓˆÓÈÎfi ÎfiÛÙÔ˜, ηıÒ˜ ·Ó·Ê¤ÚÂÙ·È Û ÔÈÎÔÓÔÌÈΤ˜ ·ÒÏÂȘ Ù˘ ÎÔÈÓˆÓ›·˜. ∏ ÚÔÔÙÈ΋ Ù˘ ÌÂϤÙ˘ ηıÔÚ›˙ÂÈ ÔȘ ‰·¿Ó˜ ı· ÂÚÈÏËÊıÔ‡Ó Û ÌÈ· ÌÂϤÙË Î·È ı· ·Ó·Ï˘ıÔ‡Ó (2,6). ∏ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ ÂÚÈÏ·Ì‚¿ÓÂÈ fiϘ ÙȘ ηÙËÁÔڛ˜ ÎfiÛÙÔ˘˜ Î·È Û˘Ó˘ÔÏÔÁ›˙ÂÈ fiÏ· Ù· ÔʤÏË, ÂÓÒ ·Ú¿ÏÏËÏ· ıˆÚÂ›Ù·È Î·Ù·ÏÏËÏfiÙÂÚË ÁÈ· ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ ÏfiÁˆ Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜, Ë ÔÔ›· ¤¯ÂÈ ıÂÙÈΤ˜ ÂÈÙÒÛÂȘ Û fiÏÔ ÙÔÓ ÏËı˘ÛÌfi (7,8). √È Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜ (1-3,7-9): 1. ∞Ó¿Ï˘ÛË ÂÏ·¯ÈÛÙÔÔ›ËÛ˘ ÎfiÛÙÔ˘˜. √È ÂÓ·ÏÏ·ÎÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û˘ÁÎÚ›ÓÔÓÙ·È ÌfiÓÔ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, ÂÊfiÛÔÓ ¤¯Ô˘Ó ·Ô‰Â‰ÂÈÁ̤ӷ ›‰È· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÒÛÙ ӷ ÂÈÏÂÁ› Ë ÊıËÓfiÙÂÚË ·fi ·˘Ù¤˜. 2. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜. ∞ÔÙÈÌ¿ ÙfiÛÔ ÙÔ ÎfiÛÙÔ˜ fiÛÔ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ÓÔÌÈÛÌ·ÙÈΤ˜ ÌÔÓ¿‰Â˜ Î·È ·ÍÈÔÏÔÁ› ·Ó ÌÈ· ·Ú¤Ì‚·ÛË ˘Á›·˜ ·Í›˙ÂÈ Ó· ¯ÚËÌ·ÙÔ‰ÔÙËı›. 3. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜. ∂›Ó·È Ë Û˘¯ÓfiÙÂÚ· ÂÊ·ÚÌÔ˙fiÌÂÓË Ù¯ÓÈ΋, fiÔ˘ ÙÔ ÎfiÛÙÔ˜ ·ÔÙÈÌ¿Ù·È Û ÓÔÌÈÛÌ·ÙÈΤ˜ ÌÔÓ¿‰Â˜ Î·È Ù· ÔʤÏË ÛÂ Ê˘ÛÈΤ˜ ÌÔÓ¿‰Â˜ ·Ú·ÁfiÌÂÓÔ˘ ¤ÚÁÔ˘, fiˆ˜ ¤ÙË ˙ˆ‹˜ Ô˘ ÛÒ˙ÔÓÙ·È ‹ ÂÚÈÛÙ·ÙÈο Ô˘ ·ÔÙÚ¤ÔÓÙ·È. 4. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-¯ÚËÛÈÌfiÙËÙ·˜. ∂‰Ò ÙÔ fiÊÂÏÔ˜ ÌÂÙÚ¿Ù·È ˆ˜ Û˘Ó‰˘·ÛÌfi˜ ·Ú¿Ù·Û˘ Ù˘ ÂÈ‚›ˆÛ˘ Î·È ‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜. ∞˘Ù‹ Ë ÚÔÛ¤ÁÁÈÛË Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË ÁÈ· ÙȘ ·ÚÂÌ‚¿ÛÂȘ ˘Á›·˜ Ô˘ ·Ú¿ÁÔ˘Ó ÔʤÏË fi¯È ÌfiÓÔ fiÛÔÓ ·ÊÔÚ¿ ÙË ıÓËÛÈÌfiÙËÙ·, ·ÏÏ¿ Î·È ÙË ÓÔÛËÚfiÙËÙ·. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C ∏ ÌËÓÈÁÁ›Ùȉ· Â›Ó·È ÌÈ· ÊÏÂÁÌÔÓ‹ ÙˆÓ ÌËÓ›ÁÁˆÓ Ô˘ ÂÚÈÎÏÂ›Ô˘Ó ÙÔÓ ÂÁΤʷÏÔ Î·È ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÚÔηÏÂ›Ù·È ·fi ‚·ÎÙ‹ÚÈ· ‹ ÈÔ‡˜. ¶¤ÓÙ ÔÚfiÙ˘ÔÈ ÙÔ˘ ‚·ÎÙËÚ›Ô˘ Neisseria meningitidis (A, B, C, Y Î·È W-135) ÚÔηÏÔ‡Ó ÂÚÈÛÛfiÙÂÚ· ·fi ÙÔ 90% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌËÓÈÁÁ›Ùȉ·˜ ·ÁÎÔÛÌ›ˆ˜ (10). ™‡Ìʈӷ Ì ÙÔÓ ¶·ÁÎfiÛÌÈÔ √ÚÁ·ÓÈÛÌfi ÀÁ›·˜ (¶√À), ÔÈ Ù‡ÔÈ ∞ Î·È C Â›Ó·È ÔÈ Î‡ÚȘ ·Èٛ˜ Ù˘ ÂȉËÌÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜. Èڛ˜ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, ÂÚÈÛÛfiÙÂÚ· ·fi ÙÔ 50% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù·Ï‹ÁÔ˘Ó Û ı¿Ó·ÙÔ. ∞ÎfiÌ· fï˜ Î·È Ì ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Î·Ù¿ÏÏËÏË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, ÂÚ›Ô˘ 5-10% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù·Ï‹ÁÔ˘Ó Û ı¿Ó·ÙÔ, ÂÓÒ ÂÚ›Ô˘ ÙÔ 15-20% fiÛˆÓ ÂÈ‚ÈÒÓÔ˘Ó ˘ÔʤÚÔ˘Ó ·fi Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, fiˆ˜ ÎÒʈÛË Î·È ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ∆Ô Ó¤Ô Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C, ÚÔÛʤÚÂÈ ÚÔÛÙ·Û›· ÌfiÓÔ ¤Ó·ÓÙÈ ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ (11,12). ™ÙËÓ ∂ÏÏ¿‰·, Ë Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ÂÁÎÚ›ıËΠÙÔ ™Â٤̂ÚÈÔ ÙÔ˘ 2000, Ì ‰ÂÛ̇ÛÂȘ ÁÈ· ‰ÈÂÚ‡ÓËÛË Ù˘ ·Ó·ÁηÈfiÙËÙ·˜ ·Ó·ÌÓËÛÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÁÈ· Û˘ÛÙËÌ·ÙÈ΋ ˘Ô‚ÔÏ‹ ÛÙÔȯ›ˆÓ ·Ó·ÊÔÚÈο Ì ÙȘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (13). ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ‚·ÛÈο ÛÙÔȯ›· ÙˆÓ ÔÈÎÔÓÔÌÈÎÒÓ ·ÍÈÔÏÔÁ‹ÛÂˆÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘. ∏ Ù¯ÓÈ΋ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ΢ڛˆ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠ‹Ù·Ó Ë ·Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Ë ·Ó¿Ï˘ÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ˘fi ÙËÓ ÚÔÔÙÈ΋ Ù˘ ÎÔÈÓˆÓ›·˜ Î·È ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ. √È Û˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘ ‹Ù·Ó Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ›‰È˜ Û fiϘ Paediatriki 2008;71:148-156
ÙȘ ¯ÒÚ˜ Ô˘ ‰ÈÂÓ‹ÚÁËÛ·Ó Ù¤ÙÔȘ ÌÂϤÙ˜ Î·È ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜, ÂÓ·ÏÏ·ÎÙÈΤ˜ ÂÈÏÔÁ¤˜ Û¯ÂÙÈο Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ‰fiÛˆÓ. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ, ÂÓÒ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ë ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ô‰ËÁÔ‡Û Û ÂÈÏÔÁ¤˜ ÚÔÁÚ·ÌÌ¿ÙˆÓ Ì›·˜ ‰fiÛ˘, Ù· ÎÏÈÓÈο ‰Â‰Ô̤ӷ ¤‚·ÏÏ·Ó ÙËÓ ˘ÈÔı¤ÙËÛË ÛÙÚ·ÙËÁÈÎÒÓ 2 Û˘Ó 1 ‰fiÛÂˆÓ ÛÙ· ÂÚÈÛÛfiÙÂÚ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ªÂ ÙÔÓ fiÚÔ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ÔÚ›˙ÂÙ·È ÌÈ· ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙÔ ‚·ÎÙ‹ÚÈÔ Streptococcus pneumoniae. ™Ù· ÓÔÛ‹Ì·Ù· ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ‰ÈÂÈÛ‰˘ÙÈΤ˜ ÏÔÈÌÒÍÂȘ, fiˆ˜ ‚·ÎÙËÚÈ·ÈÌ›·, ÌËÓÈÁÁ›Ùȉ· Î·È ‚·ÎÙËÚÈ·ÈÌÈ΋ Ó¢ÌÔÓ›·. √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ÚÔηÏ› ›Û˘ ÌË ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ·Ûı¤ÓÂȘ, fiˆ˜ Ë Ì¤ÛË ˆÙ›Ùȉ· (10). √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ Â›Ó·È Î‡ÚÈ· ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·ÁÎÔÛÌ›ˆ˜ Î·È Â˘ı‡ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 1 ÂηÙÔÌ̇ÚÈÔ ı·Ó¿ÙÔ˘˜ Û ‚Ú¤ÊË Î·È ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ (18). ™ÙËÓ ∂ÏÏ¿‰·, Ë Â›ÙˆÛË Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ Û ·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ Â›Ó·È 43-100 ·Ó¿ 100.000 ·È‰È¿, ÔÛÔÛÙfi ˘„ËÏfiÙÂÚÔ ·fi ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜. ∆· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ·ÓÂÏÏ‹ÓÈ·˜ ÌÂϤÙ˘ ¤‰ÂÈÍ·Ó fiÙÈ ÛÙ· ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ, 88% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙÔ˘˜ ÔÚfiÙ˘Ô˘˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ∂ÓÒ ÁÈ· Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÌÂÈÒÓÂÙ·È ÛÙÔ 50% (19). ∂ÈϤÔÓ, ÙÔ ÂÌ‚fiÏÈÔ ÚÔÛٷهÂÈ ¤Ó·ÓÙÈ Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È Ù˘ Ó¢ÌÔÓ›·˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙÔ˘˜ ÔÚfiÙ˘Ô˘˜, ÔÈ ÔÔ›ÔÈ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ™ÙÔÓ ¶›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ‚·ÛÈο ÛÙÔȯ›· ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ∏ ·Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Ë ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ Ù˘ ·Ó¿Ï˘Û˘ Â›Ó·È Ù· ·ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ∏ ·ÓÂÌ¢ÏÔÁÈ¿ Â›Ó·È ¤Ó· ÓfiÛËÌ· Ì ÌÂÁ¿ÏË ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Î·È Â˘Ú‡ Ê¿ÛÌ· ÂÈÏÔÎÒÓ. ŸÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë ËÏÈΛ· ÓfiÛËÛ˘ ÙfiÛÔ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È. ∂›Û˘, ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·Ó ÌÈ· ¤ÁÎ˘Ô˜ ÓÔÛ‹ÛÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ‹ ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ÙÚÈÌ‹ÓÔ˘ ·ËÛ˘. ™‡Ìʈӷ Ì ¤Ú¢Ó˜ ÂÚ›Ô˘ ÙÔ 90% ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È Èı·Ófi Ó· ÚÔÛ‚ÏËı› ·fi ÙË ÓfiÛÔ (10). ∆Ô ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ ·ÓÔÛ›·˜ Ô˘ ÚÔÛʤÚÂÈ ÙÔ ÂÌ‚fiÏÈÔ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌ· ÂÍ·ÎÚÈ‚ˆı›, ·ÏÏ¿ Ë ÂÌÂÈÚ›· ·fi ¿ÏÏ· ÂÌ‚fiÏÈ· ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ‰Â›¯ÓÂÈ fiÙÈ Ë ·ÓÔÛ›· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ô‰ËÁ› Û ‹È˜ ·ÓÙȉڿÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î¿ÔÈ· ÂÍ·Óı‹Ì·Ù· ‹ ÂΉ‹ÏˆÛË ˘ÚÂÙÔ‡. ™·ÓÈfiÙÂÚ· ÂÌÊ·Ó›˙ÔÓÙ·È ÛÔ‚·ÚfiÙÂÚ˜ ·ÓÙȉڿÛÂȘ fiˆ˜ ÂÁÎÂÊ·Ï›Ùȉ˜, Ó¢ÌÔÓ›·, Û·ÛÌÔ› ·ÎfiÌË Î·È ı¿Ó·ÙÔ˜. ∆Ô Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÌ‚fiÏÈÔ ÂӉ›ÎÓ˘Ù·È ÁÈ· ÂÓÂÚÁËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÂÓ·ÓÙ›ÔÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Û ¿ÙÔÌ· Ô˘ Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘˜ ·fi ÙË ÓfiÛÔ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ (13,30). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÔÏϤ˜ ·Ó·Ï‡ÛÂȘ ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ¤Ó·ÓÙÈ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. √È ‚·ÛÈÎfiÙÂÚ˜ ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3.
Pediatri Mar-Apr 08
09-04-08
10:36
™ÂÏ›‰·151
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√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ
¶›Ó·Î·˜ 1. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜
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¢È¿ÊÔÚ˜ ÛÙÚ·ÙËÁÈΤ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ô˘ ‰È¤ÊÂÚ·Ó ÛÙÔÓ ÙÚfiÔ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘ Î·È ÛÙËÓ ËÏÈΛ· ¤Ó·Ú͢ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡
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1. ∂Ì‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘
√ÏÏ·Ó‰›· 2004 (16)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·
1. ∂Ì‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ 2 ‰fiÛÂˆÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘ 4. ∂Ì‚ÔÏÈ·ÛÌfi˜ ̤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜
Quebec ∫·Ó·‰¿˜ 2004 (17)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜
1. ∂Ì‚ÔÏÈ·ÛÌfi˜ ̤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 3. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘
1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ˘„ËÏ‹ 2. °È· ÙȘ ËÏÈ˘ 1-4 ÂÙÒÓ, Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Á›ÓÂÙ·È ·fi ÙÔ˘˜ ÁÂÓÈÎÔ‡˜ È·ÙÚÔ‡˜ 3. °È· ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (5-17 ÂÙÒÓ), Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Á›ÓÂÙ·È ÛÙ· Û¯ÔÏ›· 1. ÀÔı¤ÙÔÓÙ·˜ ÂÌ‚ÔÏÈ·ÛÙÈ΋ Î¿Ï˘„Ë 80% Î·È ·ÚÈıÌfi ÁÂÓÓ‹ÛÂˆÓ 80.000, Ë ¤ÓÙ·ÍË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ 2. ∏ ÛÙÚ·ÙËÁÈ΋ 3 ‰fiÛÂˆÓ ÂÈÙ˘Á¯¿ÓÂÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ fiÊÂÏÔ˜ ÁÈ· ÙËÓ ˘Á›· 1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ô˘ Á›ÓÂÙ·È Ì¤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜ Â›Ó·È Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ 2. ∞fi ÙȘ ÛÙÚ·ÙËÁÈΤ˜ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Ë ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Â›Ó·È ·˘Ù‹ Ù˘ Ì›·˜ ‰fiÛ˘, ·Ó Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ‹Ù·Ó Ï›ÁÔ ÂÚÈÔÚÈṲ̂ÓË Û ۯ¤ÛË Ì ÙȘ ˘fiÏÔȘ ÛÙÚ·ÙËÁÈΤ˜ 1. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ·ÓÔÛÔÔ›ËÛ˘ Â›Ó·È Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘ 2. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÎÏÈÓÈο Â›Ó·È Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ 3 ‰fiÛˆÓ
∞ÔÙÂϤÛÌ·Ù· √È ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C, ·ÏÏ¿ Î·È Ù· ‰È·ı¤ÛÈÌ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ¿Ô„˘ fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋. ∆Ô ÂÌ‚fiÏÈÔ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ηıÒ˜ ÚÔηÏ› ¿ÌÂÛË ÚÔÛÙ·Û›· ÛÙ· ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ·ÏÏ¿ Î·È ¤ÌÌÂÛË ÚÔÛÙ·Û›· ̤ۈ Ù˘ ÂÏ¿ÙÙˆÛ˘ Ù˘ ‰È·ÛÔÚ¿˜ ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ (36). ¢ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÚÂÓ¤ÚÁÂȘ, ÁÂÁÔÓfi˜ Ô˘ ı· ‰ËÌÈÔ˘ÚÁÔ‡Û ÌÂÁ·Ï‡ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ Î·È ÂÈϤÔÓ ÎfiÛÙÔ˜ ÁÈ· ÙË ÛÙÚ·ÙËÁÈ΋ ·ÓÔÛÔÔ›ËÛ˘. ª¿ÏÈÛÙ·, fiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘, ÙfiÛÔ Î·Ï‡ÙÂÚ· Ù· ·ÔÙÂϤÛÌ·Ù·, ηıÒ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì·ÎÚÔ¯ÚfiÓÈ· Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÏϤ˜ ¯ÒÚ˜ ·ÔÊ¿ÛÈÛ·Ó Ó· ÂÓÙ·¯ı› ÙÔ ÂÓ ÏfiÁˆ ÂÌ‚fiÏÈÔ ÛÙ· Ù·ÎÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÂÌ‚ÔÏÈ·ÛÌÔ‡. 1 2
√È ex ante ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘1 ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ·Ó Î·È ÙÔ ÂÌ‚fiÏÈÔ Â›Ó·È Ôχ ‰Ú·ÛÙÈÎfi Î·È ÌÂÈÒÓÂÈ ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘, ˆÛÙfiÛÔ, Ì ÙȘ ‰Â‰Ô̤Ó˜ ÙÈ̤˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Ë Â˘Ú›· ¯Ú‹ÛË ÙÔ˘ ‰ÂÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ¿ÓÙÔÙ ˆ˜ ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋. √È ex post2 ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ ¤‰ÂÈÍ·Ó fiÙÈ ·Ó ÏËÊı› ˘fi„Ë Ë Â›‰Ú·ÛË Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜, ÙfiÙÂ Ë ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ (36). øÛÙfiÛÔ, Ù· ¤ÌÌÂÛ· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÔÓÙ·È Ê·ÓÂÚ¿ Ì·ÎÚÔ¯ÚfiÓÈ· Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ÌÔÚÔ‡Ó Ó· Û˘Ó˘ÔÏÔÁÈÛÙÔ‡Ó ÛÙȘ ex ante ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ. ™ÙȘ ∏¶∞ ÙÔ ÂÙ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î˘ÎÏÔÊfiÚËÛ ÙÔ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 2000 Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ÔÈ ¤ÌÌÂÛ˜ ÂȉڿÛÂȘ ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó›˜. ™˘ÁÎÂÎÚÈ̤ӷ, ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÈÒıËÎ·Ó ÔÈ ÏÔÈÌÒÍÂȘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙÔ˘˜ ÔÚfiÙ˘Ô˘˜
ªÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÚÈÓ ·fi ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ˘ÏÔÔ›ËÛË Ù˘ ·Ú¤Ì‚·Û˘. ªÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÌÂÙ¿ ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ˘ÏÔÔ›ËÛË Ù˘ ·Ú¤Ì‚·Û˘.
¶·È‰È·ÙÚÈ΋ 2008;71:148-156
Pediatri Mar-Apr 08
09-04-08
10:37
™ÂÏ›‰·152
152
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¶›Ó·Î·˜ 2. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜
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¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜
™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜
∞ÔÙÂϤÛÌ·Ù·
2001 ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, Kaiser ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ™‡ÛÙËÌ· ÀÁ›·˜ Permanente, Oakland ∫·ÏÈÊfiÚÓÈ·, ∏¶∞ (20)
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ Û ‚Ú¤ÊË (2-15 ÌËÓÒÓ) Î·È ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì›·˜ ‰fiÛ˘ Û ·È‰È¿ 2-5 ÂÙÒÓ 2. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜
1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÌÔÚ› Ó· ÌÂÙ·‚¿ÏÂÈ ÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ 2. ∞ÎfiÌ· ÌÔÚ› Ó· ·Ô‰Âȯı› ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·Ó¿ÏÔÁ· Ì ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡
2003 ∫·Ó·‰¿˜ (21)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜
1. ∆·ÎÙÈÎfi˜ ∂Ì‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ 2. ŒÎÙ·ÎÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 3. ŒÎÙ·ÎÙÔ˜ 2 ‰fiÛÂˆÓ 4. ŒÎÙ·ÎÙÔ˜ 1 ‰fiÛ˘
1. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Â›Ó·È Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. øÛÙfiÛÔ, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ı· Â›Ó·È ÈÔ ·Ô‰ÔÙÈÎfi˜ ÁÈ· ÙËÓ ÎÔÈÓˆÓ›·, ·Ó Ë ÙÈÌ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÌÂȈı› ÛÙ· $30/‰fiÛË
2003 √ÏÏ·Ó‰›· (22)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜
1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜
1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ ÌÂÁ¿ÏÔ ·ÚÈıÌfi Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·È Ó· ÌÂÈÒÛÂÈ ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙË ÓÔÛËÚfiÙËÙ· 2. √ ‰Â›ÎÙ˘ ÎfiÛÙÔ˘˜- ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ‰ÂÓ Â›Ó·È Â˘ÓÔ˚Îfi˜ (83.226 – ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È), ÁÈ’ ·˘Ùfi ÚÔÙ›ÓÂÙ·È Ó· ÌËÓ ÂÓÙ·¯ı› ÙÔ ÂÌ‚fiÏÈÔ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi
2003 °ÂÚÌ·Ó›· (23)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∞ÛÊ·ÏÈÛÙÈο ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∆·Ì›·, ∫ÔÈÓˆÓ›·
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‚ÚÂÊÒÓ Î·È ·È‰ÈÒÓ ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ 2. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜
1. ∞fi ÙËÓ ÚÔÔÙÈ΋ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ ÙÔ ÂÌ‚fiÏÈÔ ÂÍÔÈÎÔÓÔÌ› 51,1% ÙˆÓ ‰··ÓÒÓ ÙÔ˘ 2. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋
2004 πÛ·Ó›· (24)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∫ÔÈÓˆÓ›·
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ‚ÚÂÊÒÓ ËÏÈΛ·˜ 6 ‚‰ÔÌ¿‰ˆÓ-7 ÌËÓÒÓ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ
1. ∏ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ı· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙË ÓÔÛËÚfiÙËÙ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË ÛÙ· ·È‰È¿ 2. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ <5 ÂÙÒÓ Â›Ó·È ·Ô‰ÔÙÈÎfi˜ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÛÎÔÈ¿ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙË ÛÎÔÈ¿ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜
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ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Ì›ˆÛË Ô˘ Î˘Ì·ÈÓfiÙ·Ó ÛÙÔ 80% ÂÚ›Ô˘ ÛÙ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ (20), ÂÓÒ ÂÈϤÔÓ, ηٷÁÚ¿ÊËΠÂÏ¿ÙÙˆÛË ÙˆÓ ‰ÈÂÈÛ‰˘ÙÈÎÒÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·Ù¿ 54% Û ¿ÙÔÌ· 2039 ÂÙÒÓ, ηٿ 25% Û ¿ÙÔÌ· 40-64 ÂÙÒÓ Î·È Î·Ù¿ 39% Û ¿ÙÔÌ· ¿Óˆ ÙˆÓ 65 ÂÙÒÓ (37). ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ‹Ù·Ó Ë Ì›ˆÛË Ù˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÓÙÔ¯‹˜, ηıÒ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ù· ÛÙÂϤ¯Ë Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Á›ÓÂÙ·È ‰‡ÛÎÔÏË Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ Î·È Ë Èı·ÓfiÙËÙ· ÂÈÏÔÎÒÓ Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË (20). ∆Ô 2006 ‰ËÌÔÛȇÙËΠÌÈ· ÌÂϤÙË ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘, Ë ÔÔ›· ‚·Û›ÛÙËΠ۠ÛÙÔȯ›· ·fi ÙËÓ ÂÓÙ·ÂÙ‹ ÂÌÂÈÚ›· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÛÙȘ ∏¶∞ (22). Paediatriki 2008;71:148-156
∏ ex ante ÌÂϤÙË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÂÎÙÈÌÔ‡Û fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ ı· ÎfiÛÙÈ˙ 176.000 ‰ÔÏ¿ÚÈ· ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È, fiÙ·Ó ˘ÔÏÔÁÈ˙fiÙ·Ó ÌfiÓÔ ÙÔ ¿ÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜, ÂÓÒ ·Ó Û˘Ó˘ÔÏÔÁÈ˙fiÙ·Ó ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È ÙÔ ÌË È·ÙÚÈÎfi ¿ÌÂÛÔ ÎfiÛÙÔ˜, ÙfiÙ ÙÔ ÂÌ‚fiÏÈÔ ı· ÎfiÛÙÈ˙ 80.000 ‰ÔÏ¿ÚÈ· ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È. ∆· ÛÙÔȯ›· Ô˘ ÚԤ΢„·Ó ·fi ÙËÓ ÂÓÙ·ÂÙ‹ ¯Ú‹ÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ Â¤‰Ú·ÛÂ Î·È ÛÙ· ÌË ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ÛÙ· ÔÔ›· ·ÚÔ˘ÛÈ¿ÛÙËΠ̛ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ Ô˘ ¤ÊÙ·Û ÙÔ 68%. µ¿ÛÂÈ ·˘ÙÒÓ ÙˆÓ ÛÙÔȯ›ˆÓ ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È ˘ÔÏÔÁ›ÛÙËΠÛÙ· 7.500 ‰ÔÏ¿ÚÈ·. ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Û¯ÂÙÈο Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ‰ÂÓ
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·153
153
√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ
¶›Ó·Î·˜ 2. (Û˘Ó¤¯ÂÈ·) ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜
ª¤ıÔ‰Ô˜
2004 ∞˘ÛÙÚ·Ï›· (25)
¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜
™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜
∞ÔÙÂϤÛÌ·Ù·
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜
1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Û 4 ‰fiÛÂȘ
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2005 ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ (26)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∂ıÓÈÎfi ™‡ÛÙËÌ· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÀÁ›·˜
∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ Û ·È‰È¿
™˘Ó˘ÔÏÔÁ›˙ÔÓÙ·˜ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜
2005 πÙ·Ï›· (27)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·
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2006 ¡ÔÚ‚ËÁ›· (28)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜™ÙÔÓ ˘ÔÏÔÁÈÛÌfi 1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÎfiÛÙÔ˘˜ 4 ‰fiÛÂˆÓ Î·È ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ - Û˘ÓÂÎÙÈÌ‹ıËÎ·Ó ÙÔ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÃÚËÛÈÌfiÙËÙ·˜ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È 3 ‰fiÛÂˆÓ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜
1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, Û‡Ìʈӷ Ì ÙȘ ÚÔ¸Ôı¤ÛÂȘ Ô˘ ı¤ÙÂÈ Ë ¡ÔÚ‚ËÁ›·, ·ÎfiÌ· ÎÈ ·Ó Û˘Ó˘ÔÏÔÁÈÛÙÔ‡Ó ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ 2. ∞Ó ÙÔ Û¯‹Ì· ÙˆÓ 3 ‰fiÛÂˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ‰Ú·ÛÙÈÎfi, fiˆ˜ ·˘Ùfi ÙˆÓ 4, ÙfiÙÂ Ë ÛÙÚ·ÙËÁÈ΋ Â›Ó·È ·Ô‰ÔÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ (cost saving) ·Ó Û˘Ó˘ÔÏÔÁÈÛÙ› Î·È ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜
2006 ∏¶∞ (29)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜
ªÂ ‰Â‰Ô̤ӷ Ù· ÛÙÔȯ›· Ù˘ ›‰Ú·Û˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙ· ÌË ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ¤ÂÈÙ· ·fi 5 ¯ÚfiÓÈ· ¯Ú‹Û˘, ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È $7.500 ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È. ∏ ·Ó·ÏÔÁ›· ·˘Ù‹ Â›Ó·È Î·Ù¿ Ôχ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ ·Ú¯È΋ Ô˘ ‹Ù·Ó $80.000 ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È
∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÌÈÎÚfiÙÂÚ· ÙˆÓ 23 ÌËÓÒÓ
Â›Ó·È È‰È·›ÙÂÚ· ÂÓı·ÚÚ˘ÓÙÈο Û¯ÂÙÈο Ì ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·Ô‰ÔÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Î·È ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙËÓ ÂÍÔÈÎÔÓfiÌËÛË fiÚˆÓ. ∂ȉÈÎfiÙÂÚ·, ÛÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›·, Ë ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ·ÓÔÛÔÔÈËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Û fiÏ· Ù· ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜, ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ÂıÓÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜, ‰ÂÓ Â›Ó·È Û η̛· ÂÚ›ÙˆÛË ÂˆÊÂÏ‹˜. ∞fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋, fiÔ˘ Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜, Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·Ô‰ÔÙÈο (38). øÛÙfiÛÔ Ë ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈηÓÔÔÈËÙÈ΋ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ı·Ó¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Î·È ¤ÌÌÂÛ· Ì ·˘Ù‹. ™˘ÁÎÂÎÚÈ̤ӷ,
ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙȘ ∏¶∞ ÌÂÙ¿ ·fi 4 ¯ÚfiÓÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ·ÁÔÚ¿, ¤‰ÂÈÍ fiÙÈ ÔÈ ı¿Ó·ÙÔÈ ÂÍ·ÈÙ›·˜ Ù˘ ÓfiÛÔ˘ ÌÂÈÒıËÎ·Ó ·fi 145 Û 66 ηْ ¤ÙÔ˜ (39). ∏ ·ÓÂÌ¢ÏÔÁÈ¿ Â›Ó·È ÌÈ· ÓfiÛÔ˜ Ô˘ ÂÈʤÚÂÈ ÌÂÁ¿ÏË ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙËÓ ÎÔÈÓˆÓ›·, ΢ڛˆ˜ ÏfiÁˆ ÙÔ˘ ¤ÌÌÂÛÔ˘ ÎfiÛÙÔ˘˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÈηÈÔÏÔÁ› ÂÓ Ì¤ÚÂÈ ÙËÓ ·fiÊ·ÛË ÔÏÏÒÓ ¯ˆÚÒÓ Ó· ÂÂÓ‰‡ÛÔ˘Ó ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∂ÈϤÔÓ, ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Â›Ó·È Î·È Ô Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Ô‰ËÁ› Û ÌË ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ ‹ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘ Â›Ó·È È‰È·›ÙÂÚ· ¢ÓÔ˚ο, ·Ó Ë ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ‰ÈÂÍ¿ÁÂÙ·È ˘fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ (40). ¶·È‰È·ÙÚÈ΋ 2008;71:148-156
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·154
154
µ. ∆ÛÈ¿ÓÙÔ˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÃÒÚ· Î·È ª¤ıÔ‰Ô˜ ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜
¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜
™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜
∞ÔÙÂϤÛÌ·Ù·
1999 ∞˘ÛÙÚ·Ï›· (31)
∞Ó¿Ï˘ÛË ∂ıÓÈÎfi ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ·ÓÂÌ¢ÏÔÁÈ¿ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· 3. ™˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ·Ú·¿Óˆ 4. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜
1. ∏ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 2. ¶ÈÔ ‰Ú·ÛÙÈ΋ ÛÙÚ·ÙËÁÈ΋ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ûı¤ÓÂÈ·˜ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ (ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ), ·ÏÏ¿ ‰ÂÓ ‹Ù·Ó ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋
2002 ∫·Ó·‰¿˜ (32)
∞Ó¿Ï˘ÛË ∫ÔÈÓˆÓ›·, ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜
1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ·ÓÂÌ¢ÏÔÁÈ¿ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· 4. ™˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ·Ú·¿Óˆ
1. ∆Ș ηχÙÂÚ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ›¯Â Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ ÌÈÎÙÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ·ÏÏ¿ ‰ÂÓ ‹Ù·Ó ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙË ÛÎÔÈ¿ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 2. ∞fi ÙËÓ ÔÙÈ΋ Ù˘ ÎÔÈÓˆÓ›·˜, Ë ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ËÏÈΛ· ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ 3. ∏ ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÌfiÓÔ ÙˆÓ ÂÊ‹‚ˆÓ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÌfiÓÔ ·fi ÙËÓ ÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜
2003 ∞ÁÁÏ›·√˘·Ï›· (33)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜
∫ÔÈÓˆÓ›·, ™‡ÛÙËÌ· ÀÁ›·˜
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‚ÚÂÊÒÓ 2. ŒÎÙ·ÎÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ 2-11 ÂÙÒÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ ¿Óˆ ÙˆÓ 11 ÂÙÒÓ
1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ÂÊ‹‚ˆÓ Â›Ó·È Ô ÈÔ ·ÛÊ·Ï‹˜ Î·È Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙËÓ ÚÔÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 2. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È ·›ı·ÓÔ Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜
2004 πÙ·Ï›· (34)
∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜√ʤÏÔ˘˜
∫ÔÈÓˆÓ›·, ™‡ÛÙËÌ· ÀÁ›·˜
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-2 ÂÙÒÓ (Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ‰È·ÊÔÚÂÙÈο ›‰· ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ (1-2 ÂÙÒÓ) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (ÙÔ ÔÔ›Ô ı· ‰È·ÚÎÔ‡Û ٷ 5 ÚÒÙ· ¤ÙË Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘) 3. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ (1-2 ÂÙÒÓ) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (ÙÔ ÔÔ›Ô ı· ‰È·ÚÎÔ‡Û ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘)
1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· ¤¯ÂÈ ıÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÓÔÛËÚfiÙËÙ· ÏfiÁˆ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∆· ÌÂÁ·Ï‡ÙÂÚ· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È fiÙ·Ó ÙÔ ÔÛÔÛÙfi Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ Â›Ó·È 90% 2. ∆Ô ÛÂÓ¿ÚÈÔ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ 90%, Â›Ó·È ·Ô‰ÔÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, ÙfiÛÔ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋, fiÛÔ Î·È ·fi ÙËÓ ÚÔÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 3. ŸÛÔ ÌÂÈÒÓÂÙ·È ÙÔ Â›Â‰Ô Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ ÙfiÛÔ ÏÈÁfiÙÂÚÔ ·Ô‰ÔÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Á›ÓÂÙ·È ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡. ¶·ÚfiÏ· ·˘Ù¿ ·ÎfiÌ· Î·È ÛÙÔ ¯ÂÈÚfiÙÂÚÔ ÛÂÓ¿ÚÈÔ ÙÔ ÂÌ‚fiÏÈÔ ·Ú·Ì¤ÓÂÈ ·ÔÙÂÏÂÛÌ·ÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜
2006 πÛ·Ó›· (35)
Dynamic model ∫ÔÈÓˆÓ›·, ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·
1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÁÈ· ·È‰È¿ 1-2 ÂÙÒÓ Î·È 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÌ‚ÔÏÈ·ÛÌfi ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (catch-up program)
1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤¯ÂÈ ıÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÓÔÛËÚfiÙËÙ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÓÂÌ¢ÏÔÁÈ¿. ª¿ÏÈÛÙ· ·fi ÎÔÈÓˆÓÈ΋ ÛÎÔÈ¿ Ë ÛÙÚ·ÙËÁÈ΋ ·˘Ù‹ ÂÌÊ·Ó›˙ÂÙ·È È‰È·›ÙÂÚ· ·Ô‰ÔÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ›Ù ÏËÊı› ˘fi„Ë ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ›Ù fi¯È 2. ∞fi ÙË ÛÎÔÈ¿ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ ÊÔÚ¤ˆÓ, Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ıˆÚÂ›Ù·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·Ó Î·È ·˘Í¿ÓÂÙ·È Ï›ÁÔ ÙÔ ÎfiÛÙÔ˜
Paediatriki 2008;71:148-156
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√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ
√ ¶√À Û˘ÓÈÛÙ¿ ÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ¯ÒÚ˜ fiÔ˘ Ë ·ÓÂÌ¢ÏÔÁÈ¿ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Î·È Ù˘ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋˜ ηٿÛÙ·Û˘ Ù˘ ¯ÒÚ·˜. ª¤¯ÚÈ ÙÔ 2004 ÙÔ ÂÌ‚fiÏÈÔ Î˘ÎÏÔÊÔÚÔ‡Û ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ Î·È ÔÚÈṲ̂Ó˜ ·fi ·˘Ù¤˜ ÙÔ Â›¯·Ó ÂÓÙ¿ÍÂÈ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (40).
™˘˙‹ÙËÛË ∆· ÚÔÁÚ¿ÌÌ·Ù· ·ÓÔÛÔÔ›ËÛ˘ Â›Ó·È ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË ÁÈ· ÙË Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜, Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ÙÔ˘ ÎfiÛÙÔ˘˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ٷ ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·. ∏ ·fiÊ·ÛË ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÂÓfi˜ ÂÌ‚ÔÏ›Ô˘ ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÌÈ·˜ ¯ÒÚ·˜ Ï·Ì‚¿ÓÂÙ·È ‚¿ÛÂÈ ÂȉËÌÈÔÏÔÁÈÎÒÓ, ÔÈÎÔÓÔÌÈÎÒÓ, ÔÏÈÙÈÎÒÓ Î·È ÎÔÈÓˆÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ. ∏ Ù¯ÓÈ΋ Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘, ·Ó Î·È ·ÊÔÚ¿ Ì›· ÌfiÓÔ ÏÂ˘Ú¿ ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜, Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ÏfiÁˆ ·ÊÂÓfi˜ Ù˘ Û·ÓÈfiÙËÙ·˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ Î·È ·ÊÂÙ¤ÚÔ˘ ÙˆÓ ·˘Í·ÓfiÌÂÓˆÓ ˘ÁÂÈÔÓÔÌÈÎÒÓ ·Ó·ÁÎÒÓ. øÛÙfiÛÔ, ÔÈ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÙÔ ÌÔÓ·‰ÈÎfi ÎÚÈÙ‹ÚÈÔ Ï‹„˘ ·ÔÊ¿ÛˆÓ. ∞˘Ùfi Á›ÓÂÙ·È ÈÔ Î·Ù·ÓÔËÙfi ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ. ∞Ó Î·È ·fi ÔÈÎÔÓÔÌÈ΋˜ ÏÂ˘Ú¿˜ ÔÈ Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÚÂÌ‚¿ÛÂȘ ‰ÂÓ ‹Ù·Ó ¿ÓÙÔÙ ÔÈ Ï¤ÔÓ ·Ô‰ÔÙÈΤ˜, ·fi È·ÙÚÈ΋˜ ·fi„ˆ˜ ‹Ù·Ó ȉȷ›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È ¤ÙÛÈ, ÌÔÚÔ‡Û·Ó Ó· ηıËÛ˘¯¿ÛÔ˘Ó ¤Ó· ÌÂÁ¿ÏÔ ÙÌ‹Ì· ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ·ÓËÛ˘¯Ô‡Û ÁÈ· ·˘Ù¿ Ù· ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·. µÂ‚·›ˆ˜, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÈÎÔÓÔÌÈÎÒÓ ·ÍÈÔÏÔÁ‹ÛÂˆÓ ‰ÂÓ Ì¤ÓÔ˘Ó ·ÓÂÎÌÂÙ¿ÏÏÂ˘Ù·. ∞ÓÙ›ıÂÙ· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ ·Ô‰ÔÙÈÎfiÙÂÚ˘ ÛÙÚ·ÙËÁÈ΋˜ ·ÓÔÛÔÔ›ËÛ˘ Î·È ÛÙÔÓ Û¯Â‰È·ÛÌfi ÙˆÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ·ÚÂÌ‚¿ÛˆÓ. ∆· ‚·ÛÈο ÂÚˆÙ‹Ì·Ù· ÛÙ· ÔÔ›· ÔÈ ‰È·ÌÔÚʈ٤˜ Ù˘ ÔÏÈÙÈ΋˜ ˘Á›·˜ ηÏÔ‡ÓÙ·È Ó· ··ÓÙ‹ÛÔ˘Ó ÚÈÓ Ï¿‚Ô˘Ó ÔÔÈ·‰‹ÔÙ ·fiÊ·ÛË Â›Ó·È (41): 1. √È ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘ ı· ÌÂÈÒÛÔ˘Ó ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘; 2. ¶ÔÈÔ Â›Ó·È ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ fiÊÂÏÔ˜ ÁÈ· ÙËÓ ˘Á›·; 3. ™Â fiÛÔ ¯ÚfiÓÔ ı· Á›ÓÔ˘Ó ÂÌÊ·Ó‹ ·˘Ù¿ Ù· ÔʤÏË; 4. ¶fiÛÔ ÎÔÛÙ›˙ÂÈ Ë ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÔÈÔ ÙÔ ÎfiÛÙÔ˜ Ô˘ ·ÔÙÚ¤ÂÙ·È; 5. ∆· ·ÔÙÂϤÛÌ·Ù· ·Ú·Ì¤ÓÔ˘Ó ›‰È·, ·Ó ·ÏÏ¿ÍÔ˘Ó Î¿ÔȘ ·fi ÙȘ ·Ú·Ì¤ÙÚÔ˘˜; 6. ¶ÔÈÔ˜ Â›Ó·È Ô ·Ô‰ÂÎÙfi˜ ‰Â›ÎÙ˘ ÎfiÛÙÔ˘˜·ÔÙÂϤÛÌ·ÙÔ˜ ÁÈ· Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÌ‚ÔÏÈ·ÛÌÔ‡; √˘ÛÈ·ÛÙÈο ÔÈ ˘Â‡ı˘ÓÔÈ Ï‹„˘ ·ÔÊ¿ÛˆÓ
Ú¤ÂÈ Ó· ÛÙ·ıÌ›ÛÔ˘Ó Î·È Ó· Û˘Ì‚È‚¿ÛÔ˘Ó ÙÔ˘˜ ÂȉËÌÈÔÏÔÁÈÎÔ‡˜, ÔÈÎÔÓÔÌÈÎÔ‡˜, ÎÔÈÓˆÓÈÎÔ‡˜ Î·È ÔÏÈÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÒÛÙ ӷ Ï¿‚Ô˘Ó ÙËÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·Ô‰ÔÙÈ΋ Î·È ÎÔÈÓˆÓÈο ·Ô‰ÂÎÙ‹ ·fiÊ·ÛË.
∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠Ôχ ÁÈ· ÙËÓ ÔχÙÈÌË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙËÓ ·Ó·˙‹ÙËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ -ÂȉÈο fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜- ÙÔÓ Î. ∫ˆÙÛfiÔ˘ÏÔ ¡›ÎÔ, Health Economics Manager ÛÙËÓ ÂÙ·ÈÚ›· GlaxoSmithCline.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Jefferson T. Do vaccines make best use of available resources? (in other words are they cost-effective?). Vaccine 1999;17:S69-S73. 2. Van Damme P, Beutels P. Economic evaluation of vaccination. Pharmacoeconomics 1996;9:8-15. 3. Ess SM, Szucs TD. Economic evaluation of immunization strategies. Clin Infect Dis 2002;35:294-297. 4. Spier R, Jefferson TO, Demicheli V. An editorial policy statement: Submission of economic evaluation of vaccines. [Editorial]. Vaccine 2002;20:1693-1695. 5. Kimman TG, Boot HJ, Berbers GA, Vermeer-de Bondt PE, Ardine de Wit G, de Melker HE. Developing a vaccination evaluation model to support evidence-based decision making on national immunization programs. Vaccine 2006;24: 4769-4778. 6. Drummond MF, O’ Brien BJ, Stoddart GL, Torrance G. ª¤ıÔ‰ÔÈ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ˘Á›·˜. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∫ÚÈÙÈ΋. 2002. 7. Szucs TD. Health economic research on vaccinations and immunisation practices - an introductory primer. Vaccine 2005;23:2095-2103. 8. Chabot I, Goetghebeur MM, Gregoire JP. The societal value of universal childhood vaccination. Vaccine 2004;22: 1992-2005. 9. Szucs ∆. Cost-benefits of vaccination programmes. Vaccine 2000;18:S49-S51. 10. ¶···Ó·ÁÈÒÙÔ˘ π, ∫˘ÚÈ·˙ÔÔ‡ÏÔ˘-¢·Ï·˝Ó· µ. π·ÙÚÈ΋ ÌÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ÈÔÏÔÁ›·. £ÂÛÛ·ÏÔÓ›ÎË: ∂ΉfiÛÂȘ University Studio Press. 2001. 11. Wyeth Hellas [Webpage, Internet]. £Âڷ¢ÙÈ΋ ÂÓfiÙËÙ·: ªËÓÈÁÁ›Ùȉ·. http://www.wyeth.gr/th_areas/th_area_main. asp?th_ar_id=32 12. World Health Organization [Webpage, Internet]. Meningitis. http://www.who.int/topics/meningitis/en 13. ∂ıÓÈÎfi˜ √ÚÁ·ÓÈÛÌfi˜ º·Ú̿ΈÓ, ∂√º [Webpage, Internet]. http://www.eof.gr 14. Trotter CL, Edmunds WJ. Modelling cost-effectiveness of meningococcal serogroup C conjugate vaccination campaign in England and Wales. BMJ 2002;324:809. 15. Ruedin HJ, Ess S, Zimmermann HP, Szucks T. Invasive meningococcal and pneumococcal disease in Switzerland: cost-utility analysis of different vaccine strategies. Vaccine 2003;21:4145-4152. 16. Welte R, Van den Dobbelsteen G, Bos JM, de Melker H, van Alphen L, Spanjaard L, et al, Economic evaluation of meningococcal serogroup C conjugate vaccination programmes in The Netherlands and its impact on decisionmaking. Vaccine 2004;23:470-479. ¶·È‰È·ÙÚÈ΋ 2008;71:148-156
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17. De Wals P, Nguyen VH, Erickson LJ, Guay M, Drapeau J, St-Laurent J. Cost-effectiveness of immunization strategies for the control of serogroup C meningococcal disease. Vaccine 2004;22:1233-1240. 18. Beutels P, Thiry N, Van Damme P. Convincing or confusing? Economic evaluations of childhood pneumococcal conjugate vaccination - a review (2002-2006). Vaccine 2007; 25:1355-1367. 19. Zissis NP, Syriopoulou V, Kafetzis D, Daikos GL, Tsilimingaki A, Galanakis E, et al. Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae causing invasive infections and acute otitis media in children. Eur J Pediatr 2004;163:364-368. 20. Black S, Lieu TA, Ray GT, Capra A, Shinefield HR. Assessing costs and cost effectiveness of pneumococcal disease and vaccination within Kaiser Permanente. Vaccine 2000; 19:S83-S86. 21. De Wals P, Petit G, Erickson LJ, Guay M, Tam T, Law B, et al. Benefits and costs of immunization of children with pneumococcal conjugate vaccine in Canada. Vaccine 2003;21:3757-3764. 22. Bos JM, Rumke H, Welte R, Postma MJ. Epidemiologic impact and cost-effectiveness of universal infant vaccination with a 7-valent conjugated pneumococcal vaccine in the Netherlands. Clin Ther 2003;25:2614-2630. 23. Claes C, Schulenburg JM Graf von der. Cost effectiveness of pneumococcal vaccination for infants and children with the conjugate vaccine PnC-7 in Germany. Pharmacoeconomics 2003;21:587-600. 24. Asensi F, De Jose M, Lorente M, Moraga F, Ciuryla V, Arikian S, et al. A pharmacoeconomic evaluation of sevenvalent pneumococcal conjugate vaccine in Spain. Value Health 2004;7:36-51. 25. Butler JR, McIntyre P, MacIntyre CR, Gilmour R, Howarth AL, Sander B. The Cost- Effectiveness of pneumococcal conjugate vaccination in Australia. Vaccine 2004;22:1138-1149. 26. McIntosh ED, Conway P, Willingham J, Hollingsworth R, Lloyd A. Pneumococcal pneumonia in the UK - how herd immunity affects the cost-effectiveness of 7-valent pneumococcal conjugate vaccine (PCV). Vaccine 2005;23:1739-1745. 27. Marchetti M, Colombo GL. Cost-effectiveness of universal pneumococcal vaccination for infants in Italy. Vaccine 2005;23:4565-4576. 28. Wisloff T, Abrahamsen T, Bergsaker MA, Lovoll O, Moller P, Pedersen MK, et al. Cost effectiveness of adding 7-valent pneumococcal conjugate (PCV-7) vaccine to the Norwegian childhood vaccination program. Vaccine 2006;24: 5690-5699.
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29. Ray GT, Whitney CG, Fireman BH, Ciuryla V, Black SB. Cost-effectiveness of pneumococcal conjugate vaccine: evidence from the first 5 years of use in the United States incorporating herd effects. Pediatr Infect Dis J 2006;25:494-501. 30. GlaxoSmithCline [Webpage, Internet]. Varilrix http://emc. medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=9453 31. Scuffham PA, Lowin AV, Burgess MA. The cost-effectiveness of varicella vaccine programs for Australia. Vaccine 1999;18:407-415. 32. Brisson M, Edmunds WJ. The cost-effectiveness of varicella vaccination in Canada. Vaccine 2002;20:1113-1125. 33. Brisson M, Edmunds WJ. Varicella vaccination in England and Wales: cost-utility analysis. Arch Dis Child 2003;88: 862-869. 34. Coudeville L, Paree F, Lebrun T, Sailly J. The value of varicella vaccination in healthy children: cost-benefit analysis of the situation in France. Vaccine 1999;17:142-151. 35. Lenne X, Diez Domingo J, Gil A, Ridao M, Lluch J, Dervaux B. Economic evaluation of varicella vaccination in Spain: results from a dynamic model. Vaccine 2006;24: 6980-6989. 36. Trotter CL, Edmunds WJ. Reassessing the cost-effectiveness of meningococcal serogroup C conjugate (MCC) vaccines using a transmission dynamic model. Med Decis Making 2006;26:38-47. 37. McIntosh ED, Conway P, Willingham J, Hollingsworth R, Lloyd A. Pneumococcal pneumonia in the UK - how herd immunity affects the cost-effectiveness of 7-valent pneumococcal conjugate vaccine (PCV). Vaccine 2005;23: 1739-1745. 38. Diez Domingo J, Ridao M, Latour J, Ballester A, Morant A. A cost benefit analysis of routine varicella vaccination in Spain. Vaccine 1999;17:1306-1311. 39. Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med 2005;352:450-458. 40. Rentier B, Gershon AA; European Working Group on Varicella. Consensus: varicella vaccination of healthy children - a challenge for Europe. Pediatr Infect Dis J 2004;23: 379-389. 41. Welte R, Trotter CL, Edmunds WJ, Postma MJ, Beutels P. The role of economic evaluation in vaccine decision making: focus on meningococcal group C conjugate vaccine. Pharmacoeconomics 2005;23:855-874.
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¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ÁÈ· ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ ∞. ∫·Ê¿ÙÔ˜ ¶ÂÚ›ÏË„Ë: ∏ ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 ̤¯ÚÈ Û‹ÌÂÚ· ηıÈÛÙ¿ ·Ó·Áη›· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Î·È ÙˆÓ ÁÔÓÈÒÓ ÁÈ· ÙË ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ. ∏ ÂÓË̤ڈÛË ·˘Ù‹ ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ ·ÔÊ˘Á‹ ÙÚÔÊ›ÌˆÓ ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜, ÁÈ· ·Ú¿‰ÂÈÁÌ· ·Ù¿Ù˜ ÙÛȘ Ì 530 kcal/100 ÁÚ·Ì., ÌÈÛÎfiÙ· Ì ÛÔÎÔÏ¿Ù· Ì 524 kcal/100 ÁÚ·Ì. Î·È ¯·ÌËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο. ∆· ÙÚfiÊÈÌ· ·˘Ù¿ ÚÔÛʤÚÔ˘Ó ÂÏ¿¯ÈÛÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Ô˘ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜. ∆· ··Ú·›ÙËÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο ÂÍ·ÛÊ·Ï›˙ÔÓÙ·È fiÙ·Ó Ï·Ì‚¿ÓÔÓÙ·È ÔÈ Û˘ÓÈÛÙÒÌÂÓ˜ ÌÂÚ›‰Â˜ ·fi ηıÂÌÈ¿ ·fi ÙȘ 5 ηÙËÁÔڛ˜ ÙÚÔÊ›ÌˆÓ Î·È Î·Ù·Ó¤ÌÔÓÙ·È Û 3 ·ÚÈ· Î·È 2 ÌÈÎÚfiÙÂÚ· ÂӉȿÌÂÛ· Á‡̷ٷ. ∞·ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÚÔÛ¿ıÂÈ· ÂΠ̤ÚÔ˘˜ ÙˆÓ ÁÔÓÈÒÓ, ÒÛÙ ӷ ¤¯Ô˘Ó Ù· ·È‰È¿ 2-3 Á‡̷ٷ ÙËÓ Â‚‰ÔÌ¿‰· Ì ÌÈÎÚ¿ ÏÈ·Ú¿ „¿ÚÈ·, 2-8 ÌÂÚ›‰Â˜ Ï·¯·ÓÈÎÒÓ ËÌÂÚËÛ›ˆ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, 2-5 ÊÚÔ‡Ù· ÙËÓ Ë̤ڷ, 2-3 ÌÂÚ›‰Â˜ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ, ÂÏ¿¯ÈÛÙÔ ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È Î·ıfiÏÔ˘ ÂÂÍÂÚÁ·Ṳ̂ÓÔ ÎÚ¤·˜ (.¯. ˙·ÌfiÓ). ∆Ô ·Ú¿‰ÂÈÁÌ· ÙˆÓ ÁÔÓÈÒÓ ¯ˆÚ›˜ ÏfiÁÈ· Â›Ó·È Ô Î·Ï‡ÙÂÚÔ˜ ÙÚfiÔ˜ ‰È‰·Ûηϛ·˜ (ÛÙËÓ ¿ÛÎËÛË Î·È ÛÙÔ Ê·ÁËÙfi). ∏ ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ, ‚·ÛÈṲ̂ÓË ÛÙÔÓ ·Ú·‰ÔÛÈ·Îfi ÙÚfiÔ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ∂ÏÏ‹ÓˆÓ Ì·˙› Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ 2-3 ÒÚ˜ ¤ÓÙÔÓ˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ηıËÌÂÚÈÓ¿, ı· ÂÍ·ÛÊ·Ï›ÛÂÈ ¿ÚÈÛÙË ·Ó¿Ù˘ÍË Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ.
∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ∞ÓÙÒÓ˘ ∫·Ê¿ÙÔ˜ kafatos@med.uoc.gr ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘
§¤ÍÂȘ ÎÏÂȉȿ: ¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ, ·Ó¿Ù˘ÍË, ·¯˘Û·ÚΛ·, ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, ıÚÂÙÈο Û˘ÛÙ·ÙÈο, ۈ̷ÙÈ΋ ¿ÛÎËÛË.
Childhood and adolescent nutrition for promoting health and growth and preventing chronic diseases A. Kafatos Abstract: Paediatric obesity has been increasing since the 1980s in an epidemic mode. Due to this fact, it has become necessary to provide information for paediatricians and parents about the diet appropriate for growth and avoidance of obesity of children. The primary target should be the elimination of foods of high energy density and low nutrient content (e.g., chips, chocolate biscuits) from the diet of children, with emphasis on the traditional Greek diet. The intake of essential nutrients is ensured when children consume the recommended portions from each of the 5 categories of foods, and when these portions are distributed between 3 main and 2 smaller intermediate meals on a daily basis. Particular effort is required on the part of the parents to ensure that children consume 2-3 portions of small oily fish per week, 2-8 portions of vegetables daily, depending on age, and 2-5 portions of fruits and 2-3 portions of dairy products on a daily basis. The best way of teaching children about diet and physical activity is for parents to set an example by practising these habits themselves at home. The adoption of the traditional Greek diet, low in saturated fat and high in olive oil, vegetables, fruit and legumes, with at least 2-3 hours of daily intense physical activity will ensure excellent growth and development of the children and help in the prevention of chronic diseases.
Division of Preventive Medicine and Nutrition, Faculty of Medicine, University of Crete Correspondence: Antonis Kafatos kafatos@med.uoc.gr Division of Preventive Medicine and Nutrition, Faculty of Medicine, University of Crete
Key words: Childhood nutrition, growth, obesity, chronic diseases, nutrients, physical activity.
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·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡. °È’ ·˘Ùfi, οı ·È‰È·ÙÚÈ΋ ÂͤٷÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎÙ›ÌËÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·È‰ÈÔ‡. ∏ ÂÎÙ›ÌËÛË ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÈ (1): 1. ÎÏÈÓÈ΋ ÂͤٷÛË ÁÈ· ÛËÌ›· ·Ó·ÚÎÔ‡˜ ıÚ¤„˘ ‹ ÙÔÍÈ΋ ›‰Ú·ÛË ·fi ˘ÂÚ‚ÔÏÈ΋ Ï‹„Ë ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, 2. ۈ̷ÙÔÌÂÙÚÈΤ˜ ÌÂÙÚ‹ÛÂȘ (‚¿ÚÔ˜, Ì‹ÎÔ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:157-161
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∞. ∫·Ê¿ÙÔ˜
‹ ·Ó¿ÛÙËÌ·, ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜, ÂÚ›ÌÂÙÚÔ˜ ̤Û˘, ÏÂοÓË Î·È ‚Ú·¯›ÔÓ· Î·È ÔÚÈṲ̂Ó˜ ‰ÂÚÌ·ÙÈΤ˜ Ù˘¯¤˜) Î·È Û‡ÁÎÚÈÛË Ì ηٿÏÏËϘ η̇Ϙ ·Ó¿Ù˘Í˘, 3. ‰È·ÈÙËÙÈÎfi ÈÛÙÔÚÈÎfi Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Ï‹„˘ ÙÚÔÊ›ÌˆÓ ·fi οı ηÙËÁÔÚ›· ̤۷ Û ÌÈ· ‚‰ÔÌ¿‰· (¤ÓÙ ηÙËÁÔڛ˜ ÙÚÔʛ̈Ó, ηıÒ˜ Î·È ·Ó·„˘ÎÙÈο, ÁÏ˘Î¿, snacks, Ê·ÁËÙ¿ ·fi Ù·¯˘ÂÛÙÈ·ÙfiÚÈ·), ȉȷÈÙÂÚfiÙËÙ˜ ÛÙË ‰È·ÙÚÔÊ‹, .¯. Ê˘ÙÔÊ·Á›· ‹ ·fiÏ˘ÙË Ê˘ÙÔÊ·Á›·. ∆Ô ‰È·ÈÙÔÏfiÁÈÔ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÂÈÎÔÛÈÙÂÙÚ·ÒÚÔ˘ ‰›ÓÂÈ ÙȘ ÔÛfiÙËÙ˜ Ê·ÁËÙÔ‡ Î·È ÌÔÚ› Ó· ·Ó·Ï˘ı› Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û‡Ìʈӷ Ì ËÏÂÎÙÚÔÓÈ΋ ‚¿ÛË ÙÚÔʛ̈Ó, 4. ÂÎÙ›ÌËÛË Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ (›‰Ô˜, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ‹ ·‰Ú¿ÓÂÈ·˜, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ηıÈÛÙÈ΋˜ ÂÚÁ·Û›·˜ ÛÙÔ˘˜ ˘ÔÏÔÁÈÛÙ¤˜ ‹ ÙËÏÂfiÚ·ÛË, Î.Ù.Ï.), ‰È¿ÚÎÂÈ· ‡ÓÔ˘, ηıÒ˜ Î·È Ì¤ÙÚËÛË Ù˘ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÙÔ¯‹˜, 5. ‚ÈÔ¯ËÌÈ΋ ÂÎÙ›ÌËÛË ıÚ¤„˘ ÁÈ· ÎÏÈÓÈΤ˜ Î·È ˘ÔÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ·Ó·ÚÎÔ‡˜ ıÚ¤„˘ (.¯. ·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÈÌÔÛÊ·ÈÚÈÓÈÎÔ› ‰Â›ÎÙ˜, ÊÂÚÚÈÙ›ÓË, Ê˘ÏÏÈÎfi Ô͇ Î·È µ12, ηıÒ˜ Î·È ¿ÏϘ ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›· ÛÙÔ ·›Ì·), 6. ·ÓÔÛÔ‚ÈÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ù˘ ¯˘ÌÈ΋˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È ÛÙÂÓ¿ Ì ÙË ıÚ¤„Ë ÙÔ˘, 7. ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Ë ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ÙÔ DEXA, ηıÔÚ›˙Ô˘Ó Ì ·ÎÚ›‚ÂÈ· ÙË Û‡ÓıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÛÂ Ì˘˚΋ Ì¿˙·, ÔÏÈÎfi ϛԘ Î·È ÔÛÙÈ΋ Ì¿˙·. ¶Ï¤ÔÓ Â‡¯ÚËÛÙË Î·È ÏÈÁfiÙÂÚÔ ‰··ÓËÚ‹ Â›Ó·È Ë ‚ÈÔËÏÂÎÙÚÈ΋ ·ÁˆÁÈÌfiÙËÙ· ÁÈ· ÙË Û‡ÓıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ ı· ÂÚÈÔÚÈÛÙԇ̠ÛÙȘ Û˘ÛÙ¿ÛÂȘ Û ÙÚfiÊÈÌ· Î·È ıÚÂÙÈο Û˘ÛÙ·ÙÈο, ÒÛÙ ӷ ÂÈÙ‡¯ÂÈ ÙÔ ·È‰› ¿ÚÈÛÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË. √ ¶›Ó·Î·˜ 1 ‰›ÓÂÈ ÙȘ ÂÓÂÚÁÂȷΤ˜ ·Ó¿ÁΘ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ËÏÈΛ· Î·È Ê‡ÏÔ, ηıÒ˜ Î·È ÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÔÛfiÙËÙ˜ ÙˆÓ ‚·ÛÈÎÒÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ (2-5). °È· ¤Ó· ·È‰› 5 ÂÙÒÓ, ÙÔ 50% ÂÚ›Ô˘ Ù˘ ÂÓ¤ÚÁÂÈ·˜ Ô˘ Ï·Ì‚¿ÓÂÙ·È Î·ıËÌÂÚÈÓ¿ ηχÙÂÈ ÙȘ ·Ó¿ÁΘ ÙÔ˘ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ÙÔ 5% Íԉ‡ÂÙ·È ÛÙËÓ ÂȉÈ΋ ‰˘Ó·ÌÈ΋ ÂÓ¤ÚÁÂÈ· Ù˘ ·ÔÚÚfiÊËÛ˘, ȉȷ›ÙÂÚ· ÙˆÓ ÚˆÙÂ˚ÓÒÓ, Î·È ÙȘ ·Ó¿ÁΘ ÁÈ· ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘˜. ∆Ô 25% ÂÚ›Ô˘ Ù˘ ÂÓ¤ÚÁÂÈ·˜ Íԉ‡ÂÙ·È ÁÈ· ̤ÙÚÈ· Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙÔ 12% ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ÈÛÙÒÓ Î·È ÂÚ›Ô˘ 7% ¯¿ÓÂÙ·È ÛÙ· ÎfiÚ·Ó· (6). °È· ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡ ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË Â›Ó·È Ë ¤ÁÎ˘Ô˜ Paediatriki 2008;71:157-161
Ó· ¤¯ÂÈ ¿ÚÈÛÙË ‰È·ÙÚÔÊ‹ Ì ·ÔÊ˘Á‹ ÙˆÓ ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ, fiˆ˜ ÙÔ ¿ÌÂÛÔ Î·È ¤ÌÌÂÛÔ Î¿ÓÈÛÌ·, Î·È ÙˆÓ ÔÈÓÔÓÂ˘Ì·Ùˆ‰ÒÓ ÔÙÒÓ (7). ™ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, Ë ¤ÁÎ˘Ô˜ Ú¤ÂÈ Ó· ÚÔÂÙÔÈÌ·Ûı› ÁÈ· ÂÈÙ˘¯‹ ıËÏ·ÛÌfi. ∂ÈÙ˘¯‹˜ ıËÏ·ÛÌfi˜ ÛËÌ·›ÓÂÈ ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÁÈ· 6 Ì‹Ó˜ Î·È Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ̤¯ÚÈ ÙÔ 12Ô Ì‹Ó· Ì ÚÔԉ¢ÙÈ΋ ÚÔÛı‹ÎË ¿ÏÏˆÓ ÙÚÔÊÒÓ. ∆Ô ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Î·È ÔÈ ÁÈ·ÙÚÔ› ÛÙ· Ì·ÈÂ˘Ù‹ÚÈ· ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÈÙÚ¤Ô˘Ó ÛÙÔ˘˜ ·ÓÙÈÚÔÛÒÔ˘˜ ÙˆÓ ·È‰ÈÎÒÓ ÙÚÔÊÒÓ Ó· ‰›ÓÔ˘Ó ‰ÒÚ· ÛÙȘ ÌËÙ¤Ú˜ Ô‡Ù ӷ ‰Ôı› ͤÓÔ Á¿Ï· Ì ÌÈÌÂÚfi ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. ∏ ¯ÔÚ‹ÁËÛË ÌÈÌÂÚÔ‡ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ıËÏ·ÛÌÔ‡ ·ÔÎÏ›ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ıËÏ·ÛÌÔ‡. √ ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ¤¯ÂÈ ÔÏÏ¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÁÂÏ·‰ÈÓÔ‡ Á¿Ï·ÙÔ˜, ·ÏÏ¿ ΢ڛˆ˜ ÂÏ·ÙÙÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÌÂÏÏÔÓÙÈ΋˜ ·¯˘Û·ÚΛ·˜ Î·È fiÏˆÓ ÙˆÓ Û˘ÓÔ‰ÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ (˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜, ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 2 Î·È ·˘ÍË̤ÓÔ˘ ΛӉ˘ÓÔ˘ Û ÔÚÈṲ̂ÓÔ˘˜ ηÚΛÓÔ˘˜, Î.¿.). ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ú¤ÂÈ Ó· ·Ú¯›ÛÂÈ ÚÔԉ¢ÙÈ΋ ÂÈÛ·ÁˆÁ‹ fiÏˆÓ ÙˆÓ ÙÚÔÊÒÓ ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ Î·È Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ̤¯ÚÈ ÙÔ 12Ô Ì‹Ó·. ∏ ηıËÌÂÚÈÓ‹ ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ ıˆÚÂ›Ù·È ¿ÚÈÛÙË fiÙ·Ó ÂÚȤ¯ÂÈ ÙÚfiÊÈÌ· Î·È ·fi ÙȘ 5 ηÙËÁÔڛ˜ ÙˆÓ ÙÚÔÊ›ÌˆÓ Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (8). √È ··Ú·›ÙËÙ˜ ÌÂÚ›‰Â˜ Î·È ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ·˘Ùfi ÙÔÓ ›Ó·Î·. ∏ ÂÈÏÔÁ‹ ÙˆÓ ··Ú·›ÙËÙˆÓ ÌÂÚ›‰ˆÓ ÁÈ· οı ËÏÈΛ· ·fi fiϘ ÙȘ ηÙËÁÔڛ˜ ÙÚÔÊ›ÌˆÓ Î·ıËÌÂÚÈÓ¿ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙË Ï‹„Ë fiÏˆÓ ÙˆÓ ··Ú·›ÙËÙˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÛÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÔÛfiÙËÙ˜. ∆· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ¿ÚÈÛÙ˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÂÊ‹‚Ô˘ Â›Ó·È Ù· ·ÎfiÏÔ˘ı· (9): 1. ¶ÔÈÎÈÏ›· ÛÙË ‰È·ÙÚÔÊ‹ Ì ÂÈÏÔÁ‹ ÙÚÔÊ›ÌˆÓ Î·ıËÌÂÚÈÓ¿ ·’ fiϘ ÙȘ 5 ηÙËÁÔڛ˜ Ô˘ ı· ηٷӤÌÔÓÙ·È Û ÙÚ›· ·ÚÈ· Á‡̷ٷ Î·È 2-3 ÌÈÎÚfiÙÂÚ· ÂӉȿÌÂÛ·, .¯. Ï›ÁÔ „ˆÌ›, Ù˘Ú›, ÊÚÔ‡ÙÔ, ÁÈ·Ô‡ÚÙÈ, ¤Ó· ηÚfiÙÔ, ÌÈ· ÓÙÔÌ¿Ù·, Î.¿. (¶›Ó·Î·˜ 2). 2. ¡· ÌËÓ ÚÔÛÙ›ıÂÙ·È Î·ıfiÏÔ˘ ·Ï¿ÙÈ Î·È ˙¿¯·ÚË Ô‡Ù ηٿ ÙÔ Ì·Á›ÚÂÌ· Ô‡Ù ηٿ ÙÔ ÛÂÚ‚›ÚÈÛÌ·. 3. ¡· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·ÔÎÏÂÈÛÙÈο ·ÁÓfi ·Úı¤ÓÔ ÂÏ·ÈfiÏ·‰Ô ηٿ ÚÔÙ›ÌËÛË ˆÌfi Î·È Î·ıfiÏÔ˘ Ì·ÚÁ·Ú›Ó˜, ÛÔڤϷÈÔ, ‚Ô‡Ù˘ÚÔ ‹ ¿ÏÏ· ˙ˆÈο Î·È Ê˘ÙÈο Ï›Ë. 4. ¡· ÌËÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÂÍÂÚÁ·Ṳ̂ӷ ÙÚfiÊÈÌ· Ì ϋıÔ˜ ÚfiÛıÂÙˆÓ Ô˘ÛÈÒÓ, fiˆ˜ ÂÂÍÂÚÁ·Ṳ̂ӷ ÎÚ¤·Ù· (·ÏÏ·ÓÙÈο, ˙·ÌfiÓ, ÏÔ˘Î¿ÓÈη, Î.¿.), ÌÈÛÎfiÙ·, ÛÔÎÔÏ¿Ù˜, ¤ÙÔÈ̘ ·È‰ÈΤ˜ ÙÚÔʤ˜, ·Ù·Ù¿ÎÈ·, Á·Úȉ¿ÎÈ·, ÎÚÔ˘·Û¿Ó, Î.¿. ¡· ·ÔʇÁÔÓÙ·È Ù· Ù·¯˘ÂÛÙÈ·ÙfiÚÈ· ÁÈ·Ù› Ù· Ê·ÁËÙ¿ ÙÔ˘˜ Â›Ó·È ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È ¤¯Ô˘Ó
Pediatri Mar-Apr 08
07-04-08
16:23
™ÂÏ›‰·159
159
¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ
¶›Ó·Î·˜ 1. §ÈÔ‰È·Ï˘Ù¤˜ µÈٷ̛Ә
µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
∏ÏÈΛ· (¤ÙË)
∂Ó¤ÚÁÂÈ· (kcal)
¶ÚˆÙ½ÓË (g)
µÈÙ·Ì›ÓË ∞ (Ìg RE)
µÈÙ·Ì›ÓË D (Ìg)
µÈÙ·Ì›ÓË ∂ (mg ·-TE)
0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18
650 850 1300 1800 2500 3000 2200 2200
13 14 16 24 45 59 46 44
400 500 300 400 600 900 600 700
5 5 5 5 5 5 5 5
4 5 6 7 11 15 11 15
∏ÏÈΛ· (¤ÙË)
µÈÙ·Ì›ÓË C (mg)
0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18
40 50 40 45 45 75 50 65
0,2 0,3 0,5 0,6 0,9 1,2 0,9 1,0
∏ÏÈΛ· (¤ÙË)
∞Û‚¤ÛÙÈÔ (mg)
ºÒÛÊÔÚÔ˜ (mg)
0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18
210 270 500 800 1300 1300 1300 1300
µÈÙ·Ì›ÓË ∫ (Ìg) 2 2,5 30 55 60 75 60 75
À‰ÚÔ‰È·Ï˘Ù¤˜ µÈٷ̛Ә £ÂÈ·Ì›ÓË ƒÈ‚ÔÊÏ·‚›ÓË ¡È·Û›ÓË µÈÙ·Ì›ÓË µ6 º˘ÏÏÈÎfi µÈÙ·Ì›ÓË µ12 (mg) (mg) (mgNE) (mg) √͇ (Ìg) (Ìg)
100 275 460 500 1250 1250 1250 1250
0,3 0,4 0,5 0,6 0,9 1,3 0,9 1,0
2 4 6 8 12 16 12 14
0,1 0,3 0,5 0,6 1,0 1,3 1,0 1,2
π¯ÓÔÛÙÔȯ›· ª·ÁÓ‹ÛÈÔ ™›‰ËÚÔ˜ 梉¿ÚÁ˘ÚÔ˜ (mg) (mg) (mg) 30 75 80 130 240 410 240 360
0,27 11 7 10 8 11 8 15
2 3 3 5 8 11 8 9
65 80 150 200 300 400 400 400
0,4 0,5 0,9 1,2 1,8 2,4 1,8 2,4
πÒ‰ÈÔ (Ìg)
™ÂÏ‹ÓÈÔ (Ìg)
110 130 90 90 120 150 120 150
15 20 20 30 40 55 40 55
¶ËÁ¤˜: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997). Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998). Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001).
ÌÂÁ¿ÏË ÔÛfiÙËÙ· ÏÈÒÓ Î·È È‰È·›ÙÂÚ· ÎÔÚÂṲ̂ÓÔ˘ Ï›Ô˘˜, ηıÒ˜ Î·È Ôχ ·Ï¿ÙÈ Î·È ÔÏÏ‹ ˙¿¯·ÚË. 5. ¡· ·ÔʇÁÔÓÙ·È ·Ó·„˘ÎÙÈο Ô˘ ÂÚȤ¯Ô˘Ó ÌfiÓÔ ˙¿¯·ÚË (˘„ËÏfi ÁÏ˘Î·ÈÌÈÎfi ÊÔÚÙ›Ô), ηıÒ˜ Î·È ¯˘ÌÔ› ÊÚÔ‡ÙˆÓ Ì ·ÌÊ›‚ÔÏË ÂÚÈÂÎÙÈÎfiÙËÙ· Ê˘ÛÈÎÔ‡ ¯˘ÌÔ‡. ¶ÚÔÙÂÚ·ÈfiÙËÙ· Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ù· ÊÚÔ‡Ù· Î·È ÌÂÙ¿ Ô ÊÚ¤ÛÎÔ˜ ¯˘Ìfi˜ ÊÚÔ‡ÙˆÓ (Ù· ÊÚÔ‡Ù· ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚÔ ÁÏ˘Î·ÈÌÈÎfi ÊÔÚÙ›Ô ·fi ÙÔ˘˜ ÊÚ¤ÛÎÔ˘˜ ¯˘ÌÔ‡˜ ÊÚÔ‡ÙˆÓ). 6. ¡· ÚÔÙÈÌÒÓÙ·È ÈÛÙÔÔÈË̤ӷ ‚ÈÔÏÔÁÈο ÚÔ˚fiÓÙ·. 7. ¡· ‰›ÓÂÙ·È ÚÔÙÂÚ·ÈfiÙËÙ· Û „¿ÚÈ Î·È ı·Ï·ÛÛÈÓ¿ Ì 3-4 Á‡̷ٷ ÙËÓ Â‚‰ÔÌ¿‰·, ΢ڛˆ˜ ÌÈÎÚ¿ ÏÈ·Ú¿ „¿ÚÈ·, ÒÛÙ ӷ Ï·Ì‚¿ÓÔÓÙ·È Ù· ··Ú·›ÙËÙ· ˆ-3 ÏÈ·Ú¿ Ôͤ· Î·È Ë ‚ÈÙ·Ì›ÓË D. ∞ÎÔÏÔ˘ıÔ‡Ó Ù·
Ô˘ÏÂÚÈο Î·È Û·ÓÈfiÙÂÚ· ÙÔ ÎfiÎÎÈÓÔ ÎÚ¤·˜ (ÌÔÛ¯¿ÚÈ, ηÙÛ›ÎÈ, ·ÚÓ›, ¯ÔÈÚÈÓfi). ∆· fiÛÚÈ· Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯Ó¿. 8. ¡· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯Ó¿ ·Ó¿Ï·ÙÔÈ ÍËÚÔ› ηÚÔ›, ΢ڛˆ˜ ηڇ‰È·, 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. 9. ∏ ¿ÚÈÛÙË ‰È·ÙÚÔÊ‹ Ú¤ÂÈ Ó· Û˘Ó‰˘¿˙ÂÙ·È Ì ηıËÌÂÚÈÓ‹ ̤ÙÚÈ· ÚÔ˜ ¤ÓÙÔÓË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ÁÈ· 2 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÒÚ˜. ∞ÎfiÌË Î·È Ô ıËÏ·ÛÌfi˜ ÚÔÛʤÚÂÈ ÂÚÈÛÛfiÙÂÚË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ÛÙÔ ‚Ú¤ÊÔ˜, ÁÈ·Ù› Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ¿ÚÂÈ ÙÔ Á¿Ï· ·fi ÙË ÌËÙ¤Ú· Û ·ÓÙ›ıÂÛË Ì ÙÔ ÌÈÌÂÚfi Ô˘ ·‰ÂÈ¿˙ÂÈ Ôχ ÁÚ‹ÁÔÚ· Î·È Â‡ÎÔÏ·. 10. ¡· ÂÎÙ›ıÂÙ·È ÙÔ ‚Ú¤ÊÔ˜ Î·È ÙÔ ·È‰› ÛÙÔÓ ‹ÏÈÔ Ì Á˘ÌÓ¿ ¯¤ÚÈ· Î·È fi‰È· ÁÈ· 10-30 ÏÂÙ¿ ηıËÌÂÚÈÓ¿. ªÂ ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ‹ÏÈÔ˘ ·Ú¿ÁÂÙ·È Ë ¶·È‰È·ÙÚÈ΋ 2008;71:157-161
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∞. ∫·Ê¿ÙÔ˜
¶›Ó·Î·˜ 2. ∫·ıËÌÂÚÈÓ¤˜ ·Ó¿ÁΘ Û ÌÂÚ›‰Â˜ ·fi οı ÔÌ¿‰· ÙÚÔÊ›ÌˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Â›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜* √Ì¿‰Â˜ ÙÚÔʛ̈Ó
¶ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· 2-6 ¤ÙË
™¯ÔÏÈ΋ ËÏÈΛ· 7-12 ¤ÙË
∂ÊË‚È΋ ËÏÈΛ· 13-18 ¤ÙË
°·Ï·ÎÙÔÎÔÌÈο °¿Ï· °È·Ô‡ÚÙÈ ∆˘Ú›
2-3
2-3
3
ñ Õ·¯Ô ‹ ¯·ÌËÏfi Û ÏÈ·Ú¿ Á¿Ï· ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ. ñ ∞ÔÊ˘Á‹ Ù˘ ˘ÂÚηٷӿψÛ˘ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ.
¢ËÌËÙÚȷο æˆÌ› ¢ËÌËÙÚȷο ª·Î·ÚfiÓÈ·, Ú‡˙È ∞ڷο˜, ·Ù¿Ù˜, ηϷÌfiÎÈ
3-6
5-9
6-10
ñ ∆Ô Ì·‡ÚÔ „ˆÌ› Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ ·fi ÙÔ Ï¢Îfi. ñ ∆· ÈÙ˘ÚÔ‡¯· ‹ ÔÏÈ΋˜ ·Ï¤Ûˆ˜ ‰ËÌËÙÚȷο, ηÛÙ·Ófi Ú‡˙È Î·È Ì·Î·ÚfiÓÈ· ÔÏÈ΋˜ ·Ï¤Ûˆ˜ Â›Ó·È ÚÔÙÈÌfiÙÂÚ·.
§·¯·ÓÈο øÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ Ê˘ÏÏÒ‰Ë Ï·¯·ÓÈο (Ú·‰›ÎÈ·, Ì·ÚÔ‡ÏÈ, Û·Ó¿ÎÈ Î.Ï.) ∫›ÙÚÈÓ· Ï·¯·ÓÈο (ηÚfiÙÔ, ÎÔ˘ÓÔ˘›‰È, ÓÙÔÌ¿Ù· Î.¿.) º·ÛÔÏ¿ÎÈ· Ú¿ÛÈÓ·, Ì¿ÌȘ, ÌÂÏÈÙ˙¿Ó˜ Î.¿.
2-5
4-7
5-8
ñ ∆· Ï·¯·ÓÈο Ó· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·È Î›ÙÚÈÓ· Î·È Ú¿ÛÈÓ·, ˆÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ.
ºÚÔ‡Ù· ª‹ÏÔ, Ì·Ó¿Ó·, ÔÚÙÔοÏÈ, ·¯Ï¿‰È Î.Ï. ºÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÊÚÔ‡Ù· Ì·ÁÂÈÚÂ̤ӷ ‹ ÊÚÔ‡Ù· ÎÔÓÛ¤Ú‚·˜ Ã˘Ìfi˜ ÊÚÔ‡ÙˆÓ
2-3
3-4
3-5
ñ ™Ù· ÊÚÔ‡Ù· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ÊÚ¤ÛÎÔÈ ¯˘ÌÔ›, ·ÏÏ¿ Â›Ó·È ÚÔÙÈÌfiÙÂÚ· Ù· ÊÚ¤Ûη ÊÚÔ‡Ù·. ñ Ã˘ÌÔ› ÊÚÔ‡ÙˆÓ ¯ˆÚ›˜ ÚÔÛÙÈı¤ÌÂÓË ˙¿¯·ÚË.
1
1-2
2
∫Ú¤·˜-∞˘Á¿-æ¿ÚÈ-∫ÔÙfiÔ˘ÏÔŸÛÚÈ·-•ËÚÔ› ηÚÔ› ∫Ú¤·˜ æ¿ÚÈ £·Ï·ÛÛÈÓ¿ ∫ÔÙfiÔ˘ÏÔ ŸÛÚÈ· ∞˘Áfi •ËÚÔ› ηÚÔ›
ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜
ñ ∫ÔÙfiÔ˘ÏÔ: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ æ¿ÚÈ-ı·Ï·ÛÛÈÓ¿: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ŸÛÚÈ·: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ∫fiÎÎÈÓÔ ÎÚ¤·˜: 1-2 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ¡· ·Ê·ÈÚÂ›Ù·È ÙÔ ÔÚ·Ùfi ϛԘ ·fi Ù· Ô˘ÏÂÚÈο Î·È ÙÔ ÎÚ¤·˜. ñ ó ÌÂÚ›‰· Û˘ÎÒÙÈ (40 ÁÚ.) 1 ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ∞˘Áfi ۯ‰fiÓ Î¿ı ̤ڷ. ñ •ËÚÔ› ηÚÔ›: .¯. 2-3 ηڇ‰È· οı ‰Â‡ÙÂÚË Ì¤Ú· (ÙÚÈÌ̤ӷ ¿Óˆ ·fi ÌÈ· ÊÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÌÈ· Îڤ̷ ÁÈ· Ù· ÌÈÎÚ¿ ·È‰È¿).
√Ì¿‰Â˜ ÙÚÔÊ›ÌˆÓ & ̤ÁÂıÔ˜ ÌÂÚ›‰·˜ °·Ï·ÎÙÔÎÔÌÈο
1 ÌÂÚ›‰· = 1 ÊÏÈÙ˙. Á¿Ï·, 40 ÁÚ. Ù˘Ú›, 1 ÊÏÈÙ˙. ÁÈ·Ô‡ÚÙÈ
∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 12 ıÚÂÙÈο Û˘ÛÙ·ÙÈο.
¢ËÌËÙÚȷο
1 ÌÂÚ›‰· = 1 ʤٷ „ˆÌ›, 1 ÊÏÈÙ˙. ‰ËÌËÙÚȷο (ÎÔÚÓ ÊϤÈΘ), ó ÊÏÈÙ˙. ̷ηÚfiÓÈ·, ÈÏ¿ÊÈ, Ì·ÁÂÈÚÂ̤ӷ, ó ÊÏÈÙ˙. ·Ù¿Ù˜ Ì·ÁÂÈÚÂ̤Ó˜
∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 14 ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ ÈÓÒÓ.
§·¯·ÓÈο
1 ÌÂÚ›‰· = 1 ÊÏÈÙ˙. Ê˘ÏÏÒ‰Ë, ˆÌ¿ Ï·¯·ÓÈο (Ú·‰›ÎÈ·, Ì·ÚÔ‡ÏÈ, ∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 27 ıÚÂÙÈο Û˘ÛÙ·ÙÈο. Û·Ó¿ÎÈ Î.Ï.), ó ÊÏÈÙ˙. ˆÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ Ï·¯·ÓÈο (Ê·ÛÔÏ¿ÎÈ· Ú¿ÛÈÓ·, ηÚfiÙ·, Ì¿ÌȘ, ÓÙÔÌ¿Ù·, ·Ú·Î¿˜, ηϷÌfiÎÈ, ÎÔÏÔ·ıÈ Î.¿.), 3/4 ÊÏÈÙ˙. ·ÏÂṲ̂ӷ Ï·¯·ÓÈο Û ÛÔ‡· ‹ ¯˘Ìfi˜ Ï·¯·ÓÈÎÒÓ
ºÚÔ‡Ù·
1 ÌÂÚ›‰· = 1 ÌÂÙÚ›Ô˘ ÌÂÁ¤ıÔ˘˜ Ì‹ÏÔ, Ì·Ó¿Ó·, ÔÚÙÔοÏÈ, ·¯Ï¿‰È Î.Ï., ó ÊÏÈÙ˙. ÊÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÊÚÔ‡Ù· Ì·ÁÂÈÚÂ̤ӷ ‹ ÊÚÔ‡Ù· ÎÔÓÛ¤Ú‚·˜, 3/4 ÊÏÈÙ˙. ¯˘Ìfi˜ ÊÚÔ‡ÙˆÓ, 3/4 ÊÏÈÙ˙. ÍËÚ¿ ÊÚÔ‡Ù·
∫Ú¤·˜-∞˘Á¿-æ¿ÚÈ- 1 ÌÂÚ›‰· = 85 ÁÚ. ÎÚ¤·˜, ÎÔÙfiÔ˘ÏÔ, 85 ÁÚ. „¿ÚÈ, ı·Ï·ÛÛÈÓ¿, ∫ÔÙfiÔ˘ÏÔ-ŸÛÚÈ·ó ÊÏÈÙ˙. fiÛÚÈ·, 1/3 ÊÏÈÙ˙. ÍËÚÔ› ηÚÔ›, •ËÚÔ› ηÚÔ› 2 ÎÔ˘Ù·ÏȤ˜ Ù˘ ÛÔ‡·˜ ÛfiÚÔÈ (.¯. ËÏÈfiÛÔÚÔÈ), 1 ·˘Áfi *∆Ô ÊÏÈÙ˙¿ÓÈ Â›Ó·È ¯ˆÚËÙÈÎfiÙËÙ·˜ 240 ml
Paediatriki 2008;71:157-161
∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 27 ıÚÂÙÈο Û˘ÛÙ·ÙÈο.
™˘¯ÓfiÙÂÚË Î·Ù·Ó¿ÏˆÛË ÌÈÎÚÒÓ ÏÈ·ÚÒÓ „·ÚÈÒÓ, ÔÛÚ›ˆÓ Î·È ·Ó¿Ï·ÙˆÓ ÍËÚÒÓ Î·ÚÒÓ.
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¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ
··Ú·›ÙËÙË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‚ÈÙ·Ì›ÓË D. ∞fi Ù· ÏÈ·Ú¿ „¿ÚÈ· ÙÔ ·È‰› ·›ÚÓÂÈ ÙfiÛÔ ÙË ‚ÈÙ·Ì›ÓË D fiÛÔ Î·È Ù· ··Ú·›ÙËÙ· ˆ-3 ÏÈ·Ú¿ Ôͤ·. ¢Â‰Ô̤Ó˘ Ù˘ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ù˘ ¯ÒÚ·˜ Ì·˜, ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÙÚfiÊÈÌ· ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È Ó· ÚÔÙÈÌÒÓÙ·È ÙÚfiÊÈÌ· ˘„ËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›·. °È’ ·˘Ùfi Ë ÂÓ¤ÚÁÂÈ· ·fi ÏÈ·Ú¿ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙÔ 35% Ù˘ Û˘ÓÔÏÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ËÌÂÚËÛ›ˆ˜. ∆Ô ˘fiÏÔÈÔ ı· Â›Ó·È 55-65% ·fi Û‡ÓıÂÙÔ˘˜, ΢ڛˆ˜, ˘‰·Ù¿ÓıڷΘ, ÂÓÒ ÙÔ 10-20% Ó· ÚÔ¤Ú¯ÂÙ·È ·fi ÚˆÙ½Ó˜. ∆· ÏÈ·Ú¿ ı· Ú¤ÂÈ Û¯Â‰fiÓ ÂÍ’ ÔÏÔÎÏ‹ÚÔ˘ Ó· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÏ·ÈfiÏ·‰Ô, ÂÓÒ ¤Ó· ÌÈÎÚfi ̤ÚÔ˜, 1-2 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ, ·fi ˆ-3 ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÛÔ˘ („¿ÚÈ·) ‹ 5-6 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ ·fi ·-ÏÈÓÔÓÂÏÈÎfi Ô͇ (ηڇ‰È·, ¿ÁÚÈ· ¯fiÚÙ·, fiÛÚÈ·, Î.¿.). ∆· ˆ-6 ÏÈ·Ú¿ Ôͤ· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÛÔڤϷȷ, ÍËÚÔ‡˜ ηÚÔ‡˜, fiÛÚÈ· Î·È ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó Ù· 6-10 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ. ∞˘Ùfi Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈÙ¢¯ı›, fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·ıfiÏÔ˘ ÛÔڤϷȷ (8). ∆Ô ÎÔÚÂṲ̂ÓÔ Ï›Ô˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ Ù· 15-20 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ. √ ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È ÙÔ˘ ›‰Ԣ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ηıÒ˜ Î·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ ··ÈÙÔ‡ÌÂÓˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ·Ó·ÁÎÒÓ ı· ‰ÔıÔ‡Ó Û ¿ÏÏÔ ¿ÚıÚÔ, ηıÒ˜ ›Û˘ Î·È Ô ÙÚfi-
Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∫·Ê¿ÙÔ˜ ∞°, §·Ì·‰¿ÚÈÔ˜ ¢. ∆ÂÏÂ˘Ù·›Â˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ÎÏÈÓÈ΋ ‰È·ÙÚÔÊ‹ Î·È ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ‰È·ÙÚÔÊ‹˜. ∆Ì‹Ì· π·ÙÚÈ΋˜, ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘. ∏Ú¿ÎÏÂÈÔ: 1990. 2. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academy of Sciences; 1997. 3. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington DC: Food and Nutrition Board, Institute of Medicine, National Academy Press; 1998. 4. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. National Academy of Sciences; 2000. 5. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc National Academy of Sciences; 2001. 6. Williams SR. Nutrition and Diet Therapy. 8th ed. St Louis: Mosby Publishing Co.; 1997. 7. ¢È·ÙÚÔÊ‹ ÁÈ· ¶ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ·ÛıÂÓÂÈÒÓ. ∏Ú¿ÎÏÂÈÔ: ∆À¶√∫ƒ∂∆∞ ∞µ∂; πÔ‡ÏÈÔ˜ 2007. 8. Kafatos A, Codrington CA. Nutrition and diet for healthy lifestyles in Europe: the ‘Eurodiet’ Project. Public Health Nutr.1999;2:327-328. 9. ∫·Ê¿ÙÔ˜ ∞°. ÀÁ›·, ‰È·ÙÚÔÊ‹ Î·È ·Ó¿Ù˘ÍË ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∫Ú‹ÙË: ¡Ô̷گȷ΋ ∞˘ÙÔ‰ÈÔ›ÎËÛË Ã·Ó›ˆÓ; 2004.
¶·È‰È·ÙÚÈ΋ 2008;71:157-161
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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
CASE REPORT
Recurrent Respiratory Papillomatosis: case report and literature review Academic Unit of Otolaryngology, North Bristol NHS Trust, Southmead Hospital, Correspondence: D. A. Nunez d.a.nunez@bristol.ac.uk Academic Unit of Otolaryngology, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, United Kingdom
D. A. Nunez Abstract: Juvenile onset recurrent respiratory papillomatosis (RRP) is a rare but potentially life threatening disease caused by Human papilloma virus (HPV) infection, primarily HPV types 6 and 11. It typically presents in children with an onset at 3-4 years. The incidence estimates vary widely, but in Europe a rate of approximately 3.5 cases per million is reported. The vocal folds are the commonest site of involvement. Dysphonia and/or stridor are the main clinical features of respiratory papillomatosis. A typical case in a 3 year-old boy is presented. Laryngoscopy to visualise the larynx is required to arrive at the diagnosis. The mainstay of treatment is surgical resection using the CO2 laser or the laryngeal microshaver (microdebrider) under micro-laryngoscopic control. It is not unusual for a typical case to require 3 surgical interventions a year over a period of several years. In more aggressive cases adjuvant treatment is indicated, which includes systemic interferon and intra-lesional Cidofovir. Fatality is associated with loss of the airway, distal spread into the lungs or malignant transformation. An overview of the clinical condition and current treatment is presented.
Key words: Larynx, papilloma, Human papilloma virus 6, Human papilloma virus 11, voice disorders.
Case Report A 3 year-old boy presented to his paediatrician with a 4-month history of a persistent hoarse voice, with no history of preceding upper respiratory tract infection or trauma. He had no dysphagia or dyspnoea. His single mother reported that he was her first child, delivered normally at full term when she was 19 years old, after an uncomplicated pregnancy and delivery. On examination he was apyrexial and not distressed, and he was not jaundiced. He weighed 15 kg and was 105 cm tall. There was no stridor or cyanosis, his respiratory rate was 24 per minute, the trachea was central and the chest clear on auscultation. There were no abnormal heart sounds. Anterior rhinoscopy and oral cavity examination were normal. He was referred to an otolaryngologist who undertook a micro-laryngoscopic examination. The laryngoscopic appearance is as illustrated in the clinical photograph (Figure 1). Discussion Figure 1 shows a larynx of grossly abnormal appearance, in stark contrast to the appearance of the normal larynx, Figure 2. The mucosa of the vocal folds and vestibular folds is oedematous and polypoid in keeping with the typical appearance of widespread laryngeal papillomatosis. This pattern of presentation is to be distinguished from the single solitary often pedunculated upper aeroPaediatriki 2008;71:162-164
digestive tract papilloma. The latter is more common and often presents in the oropharynx arising from the soft palate, uvula or palatopharyngeal arches. Excision is usually curative. The laryngeal papilloma is the commonest benign neoplasm of the larynx (1). Laryngeal involvement when widespread, as demonstrated in this case, is not easily cured and the condition is known as recurrent laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP). The term RRP is to be preferred because while the larynx at the level of the vocal cords (glottis) is the site predominantly affected, the papillomata may extend above and below this level into the trachea and bronchi. RRP is an uncommon condition with a bimodal peak age incidence of 3-5 years in children and in the third decade in adults (2). The distribution of age of onset has lead to the condition being sub-classified as juvenile onset RRP or adult onset RRP. RRP can be life threatening because of airway compromise, especially in children, or due to malignant degeneration (3). The reported prevalence of juvenile onset laryngeal papillomatosis is lower in Europe (approximately 3.5 per million) than in the US (4.3 per 100,000) (4,5). The presenting features are hoarseness and stridor (2). Males and females are equally affected in childhood but in the adult onset disease males are more commonly affected in the ratio of 2-4 to 1 (6,7). The Human papilloma (wart) virus (HPV) is
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Figure 1.
Figure 2.
the causative agent for RRP, and specifically HPV subtypes 6 and 11 (8). There are reports that HPV 11 laryngeal disease is more aggressive, with a greater predilection for relapse and malignant degeneration (9). Malignant degeneration is usually associated with other cofactors such as tobacco use (10), or irradiation, which was an early therapy for RRP, however some cases undergo malignant change in the absence of any known cofactors (11). HPV subtypes 6 and 11 are not associated with a high risk of malignant change, in contrast to other subtypes such as 16 and 18, which have been established as causative agents of cancer of the uterine cervix (12,13). In the head and neck region high risk types of HPV have been isolated, predominantly from cancers of the oral cavity and oropharynx but also from the larynx. The degree of positivity, depending on the identification method, varies between 0% and 75% (14). This is in contrast to uterine cervical invasive squamous cell carcinoma, where the level of positivity is 86-94% (15). It would therefore seem that HPV has a causative role only in certain anatomical sites in the head and neck or in particular subgroups of patients. The mechanism of HPV transmission is uncertain but vertical materno-fetal transmission is the most favoured route. This is supported by the 231-fold increase in risk of juvenile onset recurrent respiratory papillomatosis in children born to mothers with cervical condoylomata (16). The birth canal is not the only route of transmission, as Armbruster-Moraes and colleagues demonstrated that HPV DNA can be isolated in amniotic fluid aspirates from women who had clinical and slot hybridisation evidence of cervical papilloma, providing evidence of in-utero transmission (17). This can explain the failure of Caesarean section to abolish the development of juvenile onset laryngeal papilloma disease (18,19).
The presence of HPV6 and/or 11 is not in itself sufficient to cause the development of laryngeal papillomatosis, as up to 25% of histologically normal larynges are positive for HPV6 and 11 DNA (20). Restricted host immune response is believed to play a role. The mainstay of treatment is surgery. Microlaryngoscopy provides the opportunity not only for tissue diagnosis by biopsy but also for excision of the papillomata. The surgeon must exercise caution in the pursuit of disease eradication in order to avoid damage to the laryngeal structure and thus irreversible impairment of laryngeal function. Stenosis and webbing of the anterior glottis can leave the patient with the same symptoms that the therapy is intended to treat, namely a restricted airway and a life-long hoarse voice. A CO2 laser beam controlled by a micromanipulator gives the surgeon microscopic guided accuracy in the control of papilloma excision. The 10,600 nm wavelength CO2 provides the advantage of haemostasis and this is the technique most widely used for treatment of laryngeal papillomata in the UK (21). A number of other laser types are also used, including the potassium titanyl phosphate laser delivered by a flexible fibre that facilitates treatment of papillomata in the tracheobronchial tree (1). A recent survey of members of American Society of Paediatric Otolaryngologists demonstrated the popularity of the laryngeal shaver (microdebrider) (22). This is a sleeved rotating blade with continuous saline irrigation and suction allowing for almost bloodless removal of laryngeal papillomata. RRP is a difficult condition to treat in many patients and in some patients it follows a relentless course requiring multiple surgeries with only short intervals between treatment schedules when the patient is clinically free of disease. This is due to the difficulty ¶·È‰È·ÙÚÈ΋ 2008;71:162-164
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of eradicating the papilloma virus, which is present even in normal appearing laryngeal tissue of the affected patients (19). For this reason a number of adjuvant treatments have been tried and put into use with the aim of reducing the relapse rate. Alpha interferon and indole-3-carbinol are two popular adjuvant therapies but they are not always effective (1,22). Intra-lesional Cidofovir is gaining in popularity because of the good early results obtained with this antimetabolite by some clinicians in controlling the disease (23). Photodynamic therapy is also under investigation (24). The launch of a highly efficacious HPV vaccine that targets HPV 6 and 11 in addition to 16 and 18 (25) offers the potential to eradicate this disease for future generations.
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with a history of multiple laryngeal papillomas: the significance of irradiation. Clin Otolaryngol Allied Sci 1991;16: 149-151. 12. Zur Hausen H. Human papillomaviruses in the pathogenesis of anogenital cancer. Virology 1991;184:9-13. 13. Zur Hausen H. Papillomaviruses in human cancer. Appl Pathol 1987;5:19-24. 14. McKaig RG, Baric RS, Olshan AF. Human papillomavirus and head and neck cancer: epidemiology and molecular biology. Head Neck 1998;20:250-265. 15. Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a metaanalysis update. Int J Cancer. 2007 Aug 1;121(3):621-632. 16. Silverberg MJ, Thorsen P, Lindeberg H, Grant LA, Shah KV. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet Gynecol 2003;101:645-652. 17. Armbruster-Moraes E, Ioshimoto LM, Lea~o E, Zugaib M. Presence of human papillomavirus DNA in amniotic fluids of pregnant women with cervical lesions. Gynecol Oncol 1994;54:152-158. 18. Shah K, Kashima H, Polk BF, Shah F, Abbey H, Abramson A. Rarity of cesarean delivery in cases of juvenile-onset respiratory papillomatosis. Obstet Gynecol 1986;68:795-799. 19. Abramson AL, Steinberg BM, Winkler B. Laryngeal papillomatosis: clinical, histopathologic and molecular studies. Laryngoscope 1987;97:678-685. 20. Nunez DA, Astley SM, Lewis FA, Wells M. Human papilloma viruses: a study of their prevalence in the normal larynx. J Laryngol Otol 1994;108:319-320. 21. Tasca RA, McCormick M, Clarke RW. British Association of Paediatric Otorhinolaryngology members experience with recurrent respiratory papillomatosis. Int J Pediatr Otorhinolaryngol 2006;70:1183-1187. 22. Schraff S, Derkay CS, Burke B, Lawson L. American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy. Arch Otolaryngol Head Neck Surg 2004;130:10391042. 23. Naiman AN, Ayari S, Nicollas R, Landry G, Colombeau B, Froehlich P. Intermediate-term and long-term results after treatment by cidofovir and excision in juvenile laryngeal papillomatosis. Ann Otol Rhinol Laryngol 2006;115:667-672. 24. Shikowitz MJ, Abramson AL, Freeman K, Steinberg BM, Nouri M. Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results. Laryngoscope 1998;108:962-967. 25. Ault KA; Future II Study Group. Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. Lancet. 2007;369:1861-1868.
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∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ
“¡¤Ô ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (2008)” ™ÙȘ 4/12/2007 Û˘Ó‹Ïı ÛÙËÓ ∞ı‹Ó· (¢È‡ı˘ÓÛË ¢ËÌfiÛÈ·˜ ÀÁ›·˜) Ë ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ (∂∂∂) ÁÈ· Ó· ·Ó·ıˆڋÛÂÈ ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (∂¶∂) Î·È Ó· ÚÔÙ›ÓÂÈ ÔÚÈṲ̂Ó˜ ·ÏÏ·Á¤˜ Û‡Ìʈӷ Ì ÙȘ ÙÚ¤¯Ô˘Û˜ ÂȉËÌÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ Ù˘ ¯ÒÚ·˜, ÙȘ ‰ÈÂıÓ›˜ Ù¿ÛÂȘ Î·È ÙËÓ Î˘ÎÏÔÊÔÚ›· Ó¤ˆÓ, Ôχ ÛËÌ·ÓÙÈÎÒÓ ÁÈ· ÙË ¢ËÌfiÛÈ· ÀÁ›· ∂Ì‚ÔÏ›ˆÓ. ªÂÙ¿ ·fi ÂÈÛٷ̤ÓË ÌÂϤÙË ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Î·È ÂÎÙÂÓ‹ Û˘˙‹ÙËÛË ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ù˘ ∂ÈÙÚÔ‹˜ › ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·˘ÙÒÓ ‰È·ÌÔÚÊÒıËΠÙÔ Ó¤Ô ∂¶∂, ÙÔ ÔÔ›Ô ¤ÁÈÓ ·Ô‰ÂÎÙfi ·fi ÙËÓ ÔÏÈÙÈ΋ ËÁÂÛ›· ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜, fiˆ˜ ·ÎÚÈ‚Ò˜ ÚÔÙ¿ıËÎÂ. √È ·ÏÏ·Á¤˜ Ô˘ ¤ÁÈÓ·Ó ÛÙÔ ∂¶∂ Û˘ÓÔ„›˙ÔÓÙ·È ˆ˜ ÂÍ‹˜: 1. ∂Ì‚fiÏÈÔ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÂÙ¿ÓÔ˘, ÎÔηÙË (DTaP). ¶ÚÔÛÙ›ıÂÙ·È Ì›· ÂÈϤÔÓ ‰fiÛË ÛÙËÓ ËÏÈΛ· 11-12 ÂÙÒÓ Ì ÙÔ Û··ÛÌ· TdaP (‚Ϥ ÂÂÍ‹ÁËÛË 2·, 2‚). 2. ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜ (Var). ¶ÚÔÛÙ›ıÂÙ·È 2Ë ‰fiÛË ÛÙËÓ ËÏÈΛ· 4-6 ÂÙÒÓ. 3. ∂Ì‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚÒÈÓˆÓ ıËÏˆÌ¿ÙˆÓ (Human Papilloma Virus ‹ HPV). ¶ÚÔÛÙ›ıÂÙ·È Ó¤Ô ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ HPV Ô˘ Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ ‹ ̤¯ÚÈ 26 ÂÙÒÓ, ÂÊfiÛÔÓ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (‚Ϥ ÂÂÍ‹ÁËÛË 9 Î·È ÙË Û¯ÂÙÈ΋ ÂÁ·ÎÏÈÔ Ô˘ ¶›Ó·Î·˜ 1. ÕÙÔÌ· Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÛÔ‚·Ú¤˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ñ ªÈÎÚ¿ ·È‰È¿ ¿Óˆ ÙˆÓ 2 ÂÙÒÓ Î·È ÂÓ‹ÏÈΘ >60 ÂÙÒÓ. ñ ÕÙÔÌ· ÌÂ Û˘ÁÁÂÓ›˜ ·ÓÙÈۈ̷ÙÈΤ˜ ·Ó¿ÚÎÂȘ (΢ڛˆ˜ ¤ÏÏÂÈ„Ë Ù˘ IgG2). ñ ÕÙÔÌ· Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ Èfi HIV. ñ ÕÙÔÌ· Ì ›ÎÙËÙË ·ÓÔÛÔηٷÛÙÔÏ‹, ÂÍ·ÈÙ›·˜ ÓÔÛ‹Ì·ÙÔ˜ ‹ ıÂڷ›·˜ ‹ ¿ÏÏ˘ (ÂÎÙfi˜ ÙÔ˘ HIV) ÈÔÁÂÓÔ‡˜ Ïԛ̈͢. ñ ÕÙÔÌ· Ì ÌÂÈÔÓÂÎÙÈ΋ ÛÏËÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‹ ·ÛÏËÓ›· .¯. Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ, Ì ˘ÂÚÛÏËÓÈÛÌfi, Ì ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙÔ˘ ÛÏ‹Ó·. ñ ÕÙÔÌ· Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ñ ÕÙÔÌ· Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ñ ÕÙÔÌ· Ì ¯ÚfiÓÈ· Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·Ó¿ÚÎÂÈ·. ñ ÕÙÔÌ· Ì ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ. ñ ÕÙÔÌ· Ì ‰È·Ê˘Á‹ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ ·fi Û˘ÁÁÂÓ›˜ ‹ ›ÎÙËÙ˜ ·Èٛ˜. Paediatriki 2008;71:166-170
¶›Ó·Î·˜ 2. ¶·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ê˘Ì·ÙÈ΋ ÌfiÏ˘ÓÛË/Ê˘Ì·Ù›ˆÛË ñ ªÂÙ·Ó¿ÛÙ˜ ·fi ¯ÒÚ˜ Ì ˘„ËÏfi ‹ ̤ÛÔ ‰Â›ÎÙË ÂÓ‰ËÌÈÎfiÙËÙ·˜. ñ ∫·Ù·˘ÏÈÛÌÔ› ·ıÈÁÁ¿ÓˆÓ Î·È ¿ÏÏˆÓ ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ô˘ ˙Ô˘Ó ÛÂ Û˘Óı‹Î˜ ÔÌ·‰È΋˜ ‰È·‚›ˆÛ˘. ñ ¶·È‰È¿ Ì Mantoux (-) ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ÔÔ›ˆÓ ˘¿Ú¯ÂÈ ¿ÙÔÌÔ ÌÂ Ê˘Ì·Ù›ˆÛË (ıÂÙÈο Ù‡ÂÏ·). ñ ¡ÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ Èfi HIV (fi¯È ‚Ú¤ÊË Û˘Ìو̷ÙÈο ÁÈ· AIDS). ñ ¡ÂÔÁÓ¿, ÛÙÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ ÙˆÓ ÔÔ›ˆÓ ˘¿Ú¯ÂÈ ¿ÙÔÌÔ ÌÂ Ê˘Ì·Ù›ˆÛË (ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Î·Ù¿ ÙË Á¤ÓÓËÛË).
·ÊÔÚ¿ ÙÔ ÂÌ‚fiÏÈÔ ·˘Ùfi ÛÙË ÛÙ‹ÏË Ù˘ ¢ËÌfiÛÈ·˜ ÀÁ›·˜). 4. ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ Ë·Ù›Ùȉ·˜ ∞ (Hep A). ¶ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙ· ··Ú·›ÙËÙ· ϤÔÓ ÂÌ‚fiÏÈ· ÙÔ˘ ∂¶∂ ·fi ÙÔ 12Ô Ì‹Ó· Î·È ÌÂÙ¿ (‚Ϥ ÂÂÍ‹ÁËÛË 10) Î·È Û˘Ó¯›˙ÂÈ Ó· Á›ÓÂÙ·È ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 3). °È· ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ, Ô˘ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂¶∂ ËÏÈΛ·, ˘¿Ú¯Ô˘Ó ÂȉÈο ¯ÚÔÓԉȿÁÚ·ÌÌ·Ù· (¶›Ó·Î˜ 5 Î·È 6) Ì ÙȘ Û¯ÂÙÈΤ˜ ÂÂÍËÁ‹ÛÂȘ. ∆Ô Ó¤Ô ∂¶∂, fiˆ˜ ‰È·ÌÔÚÊÒıËΠÁÈ· ÙÔ 2008, Û˘ÓÔ„›˙ÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1 Î·È ÛÙÔ˘˜ ¶›Ó·Î˜ 5 Î·È 6. ∏ ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ √ ¶Úfi‰ÚÔ˜: ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞Ó‰Ú¤·˜ ∆· ̤ÏË: µÈÔÏ¿ÎË ª., £ÂÔ‰ˆÚ›‰Ô˘ ª., ∫·Ó·ÎÔ‡‰Ë-∆۷ηϛ‰Ô˘ º., ∫·ÊÂÙ˙‹˜ ¢., ∫¯·ÁÈ·‰¿Î˘ °., ∫‡ÚÏÂÛË ∞., ™¿Ï· °., ™ÙÚ·ÙËÁ¿Î˘ ª., ™˘ÚÈÔÔ‡ÏÔ˘ µ., ÃÚÔ‡ÛÔ˜ °. ∏ °Ú·ÌÌ·Ù¤·˜: ™ˆÙ‹Ú¯Ô˘ ∞. ¶›Ó·Î·˜ 3. ∂Ӊ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ ∏·Ù›Ùȉ·˜ ∞ Û ¯ÒÚ˜ Ì ¯·ÌËÏ‹ Î·È Ì¤ÛË ÂÓ‰ËÌÈÎfiÙËÙ· ñ ∆·ÍȉÈÒÙ˜. ñ ∂·ÁÁÂÏ̷ٛ˜ ˘Á›·˜. ñ ∂·ÁÁÂÏ̷ٛ˜ ‰È·Î›ÓËÛ˘ ÙÚÔʛ̈Ó. ñ ¶ÚÔÛˆÈÎfi È‰Ú˘Ì¿ÙˆÓ. ñ ¶ÚÔÛˆÈÎfi ηı·ÚÈfiÙËÙ·˜ ‰ËÌfiÛÈˆÓ Î·È È‰ÈˆÙÈÎÒÓ ÂÎ·È‰Â˘ÙÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ. ñ ∫ÏÂÈÛÙÔ› ÏËı˘ÛÌÔ›*. ñ √ÌÔÊ˘ÏfiÊÈÏÔÈ - ∆ÔÍÈÎÔÌ·Ó›˜. ñ ÕÙÔÌ· Ì ¯ÚfiÓÈ· Ïԛ̈ÍË Ì ÙÔÓ Èfi Ù˘ ∏µ. * ‚Ϥ ˘ÔÛËÌ›ˆÛË ¶›Ó·Î· 4
Pediatri Mar-Apr 08
07-04-08
17:43
™ÂÏ›‰·167
167
∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ
∂£¡π∫√ ¶ƒ√°ƒ∞ªª∞ ∂ªµ√§π∞™ªø¡ - ÃÚÔÓԉȿÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· ¶·È‰È¿ Î·È ∂Ê‹‚Ô˘˜
°¤ÓÓËÛË
∏ÏÈΛ· ∂Ì‚fiÏÈÔ
Hep B1·
1 ÌËÓfi˜
2 ÌËÓÒÓ
4 ÌËÓÒÓ
6 ÌËÓÒÓ
Hep B1‚ (1-2 ‰fiÛÂȘ)
12 ÌËÓÒÓ
15 ÌËÓÒÓ
18 ÌËÓÒÓ
24 ÌËÓÒÓ
4-6 ÂÙÒÓ
11-12 ÂÙÒÓ
13-18 ÂÙÒÓ
Hep B
∏·Ù›Ùȉ·˜ µ (∏ep µ)1
¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘,
Hep B1Á
Hep B
DTaP
DTaP
Hep B DTaP
Hep B (fiϘ ÔÈ ‰fiÛÂȘ) DTaP
D∆aP2·,2‚
DTaP
2
∫ÔηÙË (D∆aP)
¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV(IPV)3
IPV
IPV
AÈÌfiÊÈÏÔ˘ Ù‡Ô˘ µ4
Hib
Hib
MËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ C (MCC)5
MCC
MCC
¶Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ (PCV)6
PCV
PCV
IPV Hib
IPV
Hib MCC
PCV
PCV (PPV)6·
PCV
πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR)7
MMR
MMR
AÓÂÌ¢ÏÔÁÈ¿˜ (Var)8
Var
Var HPV ÎÔÚ›ÙÛÈ· 12-15 ÂÙ. 3 ‰fiÛÂȘ
πfi˜ ∞ÓıÚÒÈÓˆÓ £ËÏˆÌ¿ÙˆÓ (∏PV)9 ∏·Ù›Ùȉ·˜ A (Hep A)10 º˘Ì·Ù›ˆÛ˘ (BCG)11 °Ú›Ë˜ (πNFL)12
Hep A (2 ‰fiÛÂȘ) Mantoux11·
Mantoux
BCG
Mantoux11‚
π¡FL (ÂÙËÛ›ˆ˜)
∂ÈÎfiÓ· 1. ÃÚÔÓԉȿÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜. ------ ∆· ÂÌ‚fiÏÈ· οو ·fi ÙË ‰È·ÎÂÎÔÌ̤ÓË ÁÚ·ÌÌ‹ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· ÂÈÏÂÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (‚Ϥ ÂÂÍËÁ‹ÛÂȘ Ù˘ ∂ÈÎfiÓ·˜ 1). ∂‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ™ÙËÓ ·Ú¤ÓıÂÛË ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ‰fiÛÂȘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ô˘ Á›ÓÔÓÙ·È Û’ ·˘Ùfi ÙÔ Â‡ÚÔ˜ ËÏÈÎÈÒÓ, fiÙ·Ó Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›·. ∆Ô Â‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÔÓÔ‰‡Ó·Ì· ‹ ÔÏ˘‰‡Ó·Ì· (Û˘Ó‰˘·Ṳ̂ӷ) ÂÌ‚fiÏÈ· ‹/Î·È Û˘Ó‰˘·ÛÌfi˜ ÌÔÓÔ‰‡Ó·ÌˆÓ-Û˘Ó‰˘·Ṳ̂ӈÓ. ∂‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÙ·Ó ·˘Ùfi˜ ‰ÂÓ ¤¯ÂÈ ÚÔËÁËı› ηٿ ÙÔ Û˘ÓÈÛÙÒÌÂÓÔ Û¯‹Ì· ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙȘ ‰fiÛÂȘ (‚Ϥ ÂÂÍËÁ‹ÛÂȘ ¶ÈÓ¿ÎˆÓ 5 Î·È 6).
∂ÂÍËÁ‹ÛÂȘ ∂ÈÎfiÓ·˜ 1 1. HepB = ∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ∏·Ù›Ùȉ·˜ µ. 1·. ∏ 1Ë ‰fiÛË ÙÔ˘ HepB ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÌfiÓÔÓ fiÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ÊÔÚ¤·˜ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ (HBsAg) ‹ fiÙ·Ó Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ÊÔÚ¤·˜ ‹ fi¯È. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ·Ó·ÁηÛÙÈο Ë 1Ë ‰fiÛË ÙÔ˘ HepB ¯ÔÚËÁÂ›Ù·È ˆ˜ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ. 1‚. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ë 1Ë ‰fiÛË ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘ÓÔÏÈο 4 ‰fiÛÂȘ ·ÓÙ› ÁÈ· 3 ‰fiÛÂȘ (Ë 2Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó· Î·È Ë 3Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2Ô˘ Ì‹Ó·). ∆Ô ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ 1˘ Î·È 2˘ ηıÒ˜ Î·È 2˘ Î·È 3˘ ‰fiÛ˘ Â›Ó·È 4 ‚‰ÔÌ¿‰Â˜. ∆Ô ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ ÚÔÙÂÏÂ˘Ù·›·˜ (3˘) Î·È ÙÂÏÂ˘Ù·›·˜ (4˘) ‰fiÛ˘ ÙÔ˘ ‚·ÛÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È 8-16 ‚‰ÔÌ¿‰Â˜ Î·È ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÓˆÚ›ÙÂÚ· ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 24 ‚‰ÔÌ¿‰ˆÓ (6 ÌËÓÒÓ). ¶ƒ√™√Ã∏! ™Â ÂÚ›ÙˆÛË Ô˘ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ ¯ÔÚËÁËı› ˆ˜ Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ, Ô ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ fiÙÈ Ù· Û˘Ó‰˘·Ṳ̂ӷ ÂÌ‚fiÏÈ· ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ 6Ë Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜. ∂Ô̤ӈ˜, ÙÔ ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· Ô˘ ÌÂÛÔÏ·‚› ·fi ÙË Á¤ÓÓËÛË, Ô˘ ¯ÔÚËÁÂ›Ù·È ÙÔ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ, Â›Ó·È 6 ‚‰ÔÌ¿‰Â˜ ·ÓÙ› 1 Ì‹Ó·˜. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ 1Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Û’ fiÏ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ, ÊÔÚ¤ˆÓ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘, Î·È Ì¤Û· ÛÙȘ ÚÒÙ˜ 12 ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¯ÔÚËÁÔ‡ÓÙ·È 0,5 ml ˘ÂÚ¿ÓÔÛ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÁÈ· ∏·Ù›Ùȉ· µ. ∏ ¤ÓÂÛË Á›ÓÂÙ·È Û ‰È·ÊÔÚÂÙÈÎfi ̤ÚÔ˜ ·’ ·˘Ùfi Ô˘ ¤ÁÈÓ (‹ ı· Á›ÓÂÈ) ÙÔ ÂÌ‚fiÏÈÔ. ŸÏ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi ÌËÙ¤Ú˜ ÊÔÚ›˜ Î·È ‹Ú·Ó ÙÔ ÂÌ‚fiÏÈÔ Î·È ÙËÓ ˘ÂÚ¿ÓÔÛË ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ (HBsAg) Î·È ·ÓÙÈÛÒÌ·Ù· (·ÓÙÈ-HBs) ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ¤ˆ˜ 15 ÌËÓÒÓ. ŸÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Â›Ó·È ‹ fi¯È ÊÔÚ¤·˜ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ηٿ ÙÔÓ ÙÔÎÂÙfi Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·Ô‰ÂȯÙ› fiÙÈ ‰ÂÓ Â›Ó·È, ·fi ÙË 2Ë ‰fiÛË Î·È ¤ÂÈÙ· ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ô˘ ÈÛ¯‡ÂÈ ÁÈ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ô˘ ‰ÂÓ Â›Ó·È ÊÔÚ›˜ ÙÔ˘ HbsAg, ‰ËÏ·‰‹ ·ÁÓÔÂ›Ù·È Ë 1Ë ‰fiÛË. 1Á. ŸÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ·ÚÓËÙÈ΋ ÁÈ· ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ, Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ (‰‡Ô ·Ú¯ÈΤ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:166-170
Pediatri Mar-Apr 08
07-04-08
168
17:43
™ÂÏ›‰·168
∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ
Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰ˆÓ Î·È ÌÈ· ÙÚ›ÙË Û ËÏÈΛ· 6-18 ÌËÓÒÓ Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ·fi ÙË 2Ë ‰fiÛË 8-16 ‚‰ÔÌ¿‰Â˜ Î·È fi¯È ÓˆÚ›ÙÂÚ· ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ). 2. DTaP = ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÔ˘ ÙÂÙ¿ÓÔ˘, ÙÔ˘ ÎÔηÙË Ô˘ ÂÚȤ¯ÂÈ Ù· ÙÔÍÔÂȉ‹ (‹ ·ÙÔ͛Ә) ÙÔ˘ ÎÔÚ˘ÓÔ‚·ÎÙËÚȉ›Ô˘ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ Î·È ÙÔ˘ ÎψÛÙËÚȉ›Ô˘ ÙÔ˘ ÙÂÙ¿ÓÔ˘ Î·È ÌfiÓÔ ·ÓÙÈÁfiÓ· Ù˘ µ. pertussis (fi¯È ÔÏfiÎÏËÚÔ ÙÔ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi ÓÂÎÚfi, fiˆ˜ Ù· ·Ï·ÈfiÙÂÚ· “ÔÏÔ΢ÙÙ·ÚÈο” ÂÌ‚fiÏÈ·), ÁÈ’ ·˘Ùfi Î·È Î·ÏÂ›Ù·È “·Î˘ÙÙ·ÚÈÎfi” ηٿ ÙÔ˘ ÎÔηÙË (acellular pertussis ‹ ·P) ÂÌ‚fiÏÈÔ. 2·. TdaP = ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÔ˘ ÙÂÙ¿ÓÔ˘, ÙÔ˘ ÎÔηÙË, Ì ÌÈÎÚfiÙÂÚË ‰fiÛË ‰ÈÊıÂÚÈÙÈ΋˜ ·ÙÔ͛Ӣ. ™ÙË ¯ÒÚ· Ì·˜ ÂÚȤ¯ÂÈ Î·È IPV Î·È ‰‡Ó·Ù·È Ó· ¯ÔÚËÁËı› ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ. ∆Ô TdaP Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÁÈ· ·ӷÏËÙÈ΋ ‰fiÛË ÛÙËÓ ËÏÈΛ· ÙˆÓ 11-12 ÂÙÒÓ ‹ Î·È ·ÚÁfiÙÂÚ· (̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 64 ÂÙÒÓ) ηٿ ÚÔÙ›ÌËÛË fiÙ·Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ·ÔÎÙ¿Ù·È ÓÂÔÁ¤ÓÓËÙÔ. ™˘ÓÈÛÙ¿Ù·È Ó· ·¤¯ÂÈ 5 ¯ÚfiÓÈ· ·fi ÙÔ DTaP ‹ ÙÔ ∆d ÁÈ· ÏÈÁfiÙÂÚ˜ ÙÔÈΤ˜ ·ÓÙȉڿÛÂȘ, ÌÔÚ› fï˜ Ó· ¯ÔÚËÁËı› Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· Î·È ‰‡Ô ÂÙÒÓ. ∂¿Ó ‰ÂÓ Î˘ÎÏÔÊÔÚ› ÙÔ TdaP ÌfiÓÔ ÙÔ˘ (¯ˆÚ›˜ IPV) ¯ÔÚËÁÂ›Ù·È ÙÔ Td ÂÓËϛΈÓ. √È ˘fiÏÔȘ ‰fiÛÂȘ ı· Â›Ó·È Î¿ı 10 ¯ÚfiÓÈ· Ì Td ÂÓËϛΈÓ. 2‚. Td = ∂Ì‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÙÂÙ¿ÓÔ˘ Î·È Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ Ì ÌÈÎÚfiÙÂÚË ‰fiÛË ‰ÈÊıÂÚÈÙÈ΋˜ ·ÙÔ͛Ӣ. ™˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Î¿ı 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ TdaP ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ·. ∆Ô ÂÌ‚fiÏÈÔ ÙÔ˘ ÙÂÙ¿ÓÔ˘ ÌÔÚ› Ó· Á›ÓÂÙ·È ‰È· ‚›Ô˘ Ì ·ÛÊ¿ÏÂÈ·. 3. IPV = ∂Ó¤ÛÈÌÔ ÂÓÈÛ¯˘Ì¤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜. 4. Hib = ™˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù‡Ô˘ ‚. ∂¿Ó Ë ÚˆÙ½ÓË Û‡˙¢Í˘ Â›Ó·È Ë PRP-OMP (ÚˆÙÂ˚ÓÈÎfi Û‡ÌÏÂÁÌ· Ù˘ Â͈ÙÂÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘), ÙfiÙÂ Ë 3Ë ·fi ÙȘ 3 ·Ú¯ÈΤ˜ ‰fiÛÂȘ ÌÔÚ› Ó· ·Ú·ÏËÊı› Î·È ÙÔ Û¯‹Ì· Ó· Â›Ó·È (2Ô˜, 4Ô˜ Î·È 12Ô˜-15Ô˜ Ì‹Ó·˜). 5. MCC = ™˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÚÔÔÌ¿‰·˜ C. ™˘ÓÈÛÙ¿Ù·È Ë ¤Ó·ÚÍË ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ËÏÈΛ· 2 ÌËÓÒÓ Î·È ·ÎÔÏÔ˘ıÂ›Ù·È Û¯‹Ì· 3 ‰fiÛÂˆÓ - ÔÈ 2 ÚÒÙ˜ ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 2 ÌËÓÒÓ Î·È Â·Ó·ÏËÙÈ΋ ‰fiÛË Û ËÏÈΛ· 15-18 ÌËÓÒÓ. ™Â ÂÚ›ÙˆÛË ¤Ó·Ú͢ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ËÏÈΛ· >12 ÌËÓÒÓ, ·ÎÔÏÔ˘ıÂ›Ù·È Û¯‹Ì· 1 ‰fiÛ˘. 6. PCV = ¡ÂÎÚfi, Û˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi, ÂÙ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ Ù˘ Ó¢ÌÔÓ›·˜ (Ó¢ÌÔÓÈfiÎÔÎÎÔ˘). ™˘ÓÈÛÙ¿Ù·È Û’ fiÏ· Ù· ·È‰È¿ ËÏÈΛ·˜ 2-23 ÌËÓÒÓ. ∏ ÙÂÏÂ˘Ù·›· ‰fiÛË (4Ë) Á›ÓÂÙ·È Û ËÏÈΛ· ≥12 ÌËÓÒÓ. ∆Ô ÂÌ‚fiÏÈÔ ÌÔÚ› Ó· Á›ÓÂÈ Î·È Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Î·È È‰È·›ÙÂÚ· Û ¿ÙÔÌ· Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (‚Ϥ ˘ÔÛËÌÂÈÒÛÂȘ 6,7 ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ¶›Ó·Î˜ 5 Î·È 6). ™ÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË, ÔÈ Â·Ó·ÏËÙÈΤ˜ ‰fiÛÂȘ ÌÔÚ› Ó· Á›ÓÔÓÙ·È Î·È Ì ÙÔ 23‰‡Ó·ÌÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi ÌË Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ (PPV). 6·. PPV = ªË Û˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ (23‰‡Ó·ÌÔ) ηٿ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ Ù˘ Ó¢ÌÔÓ›·˜ (Ó¢ÌÔÓÈÔÎfiÎÎÔ˘). ™˘ÓÈÛÙ¿Ù·È ÁÈ· ·ӷÏËÙÈΤ˜ ‰fiÛÂȘ Û ·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÔ‚·Ú‹ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË (¶›Ó·Î·˜ 1), ÂÎÙfi˜ ·fi ˘ÁÈ‹ ‚Ú¤ÊË Î·È ·È‰È¿ ËÏÈΛ·˜ 2-23 ÌËÓÒÓ. 7. MMR = ∂Ì‚fiÏÈÔ Ô˘ ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Ù˘ ÈÏ·Ú¿˜, ·ÚˆÙ›Ùȉ·˜ Î·È ÂÚ˘ıÚ¿˜. ÃÔÚËÁÂ›Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-15 ÌËÓÒÓ. ™˘ÓÈÛÙ¿Ù·È 2Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ·, ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. √ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÈ ·Ó ¤ÁÈÓ ‹ fi¯È Ë 2Ë ‰fiÛË Î·È ·Ó fi¯È ¯ÔÚËÁÂ›Ù·È Ë 2Ë ‰fiÛË Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·. 8. Var = ∂Ì‚fiÏÈÔ Ô˘ ÂÚȤ¯ÂÈ ˙ÒÓÙ· ÂÍ·ÛıÂÓË̤ÓÔ Èfi Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ÃÔÚËÁÂ›Ù·È Û’ fiÏ· Ù· ·È‰È¿ ÛÙËÓ ËÏÈΛ· ÙˆÓ 1218 ÌËÓÒÓ (ηٿ ÚÔÙ›ÌËÛË ÌÂÙ¿ ÙÔ 15Ô Ì‹Ó·), ·ÏÏ¿ Î·È Û’ ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ·, ÂÊfiÛÔÓ ÙÔ ¿ÙÔÌÔ ‰ÂÓ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ. ™˘ÓÈÛÙ¿Ù·È 2Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ· ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. √ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÈ ·Ó ¤ÁÈÓ ‹ fi¯È Ë 2Ë ‰fiÛË Î·È ·Ó fi¯È ¯ÔÚËÁÂ›Ù·È Ë 2Ë ‰fiÛË Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·. 9. HPV = ∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚÒÈÓˆÓ ıËψ̿وÓ. ™‡Ìʈӷ Ì ٷ ̤¯ÚÈ ÛÙÈÁÌ‹˜ ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ, ÌÔÚ› Ó· ¯ÔÚËÁËı› ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 9-26 ÂÙÒÓ. ™ÙË ¯ÒÚ· Ì·˜ Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-26 ÂÙÒÓ, Â¿Ó ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (¯ˆÚ›˜ Ó· ‰È·ÛÊ·Ï›˙ÂÙ·È Ë ÚÔʇϷ͋ ÙÔ˘˜, Â¿Ó ‹‰Ë ¤¯Ô˘Ó ÌÔÏ˘Óı› ·fi Ù‡Ô ÙÔ˘ ÈÔ‡ Ô˘ ÂÚȤ¯ÂÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ, ȉȷ›ÙÂÚ· ·Ó ¤¯Ô˘Ó ·ÏÏ¿ÍÂÈ 3-4 ÛÂÍÔ˘·ÏÈÎÔ‡˜ Û˘ÓÙÚfiÊÔ˘˜). ™ÙË ¯ÒÚ· Ì·˜ ΢ÎÏÔÊÔÚÔ‡Ó ‰‡Ô ÂÌ‚fiÏÈ·. ∆Ô ¤Ó· Â›Ó·È ‰È‰‡Ó·ÌÔ Î·È ÙÔ ¿ÏÏÔ ÙÂÙÚ·‰‡Ó·ÌÔ. ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ÂÚȤ¯Ô˘Ó Ù· ÔÁÎÔÁfiÓ· ÛÙÂϤ¯Ë 16 Î·È 18. ∆Ô ÙÂÙÚ·‰‡Ó·ÌÔ ÂÚȤ¯ÂÈ ÂÈϤÔÓ ‰‡Ô ·ÎfiÌ· Ù‡Ô˘˜ ÈÒÓ (6 Î·È 11), Ô˘ ·ÛÎÔ‡Ó ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË Î·Ù¿ ÙˆÓ ıËÏˆÌ¿ÙˆÓ (ÎÔÓ‰˘ÏˆÌ¿ÙˆÓ). ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Î·È ÁÈ· Ù· ‰‡Ô ÂÌ‚fiÏÈ· ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ. °È· ÌÂÓ ÙÔ ‰È‰‡Ó·ÌÔ, ÔÈ ‰fiÛÂȘ Â›Ó·È 0-1-6 Ì‹Ó˜, ÂÓÒ ÁÈ· ÙÔ ÙÂÙÚ·‰‡Ó·ÌÔ Â›Ó·È 0-2-6 Ì‹Ó˜. ™Â ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ÙËÚËı› ÙÔ ·ÎÚÈ‚¤˜ ¯ÚÔÓԉȿÁÚ·ÌÌ·, Ô ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· Û˘Ó¯›ÛÂÈ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, ¯ˆÚ›˜ Ó· ¯¿ÓÔÓÙ·È ÔÈ ÚÔËÁÔ‡ÌÂÓ˜ ‰fiÛÂȘ. ∆¤ÏÔ˜, Ë Û˘Á¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ì ¿ÏÏ· ÂÌ‚fiÏÈ· ¤¯ÂÈ ·Ô‰Âȯı› ̤¯ÚÈ ÛÙÈÁÌ‹˜ ·ÛÊ·Ï‹˜ ÌfiÓÔ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ. 10. Hep A = ∞‰Ú·ÓÔÔÈË̤ÓÔ ÔÏÔ΢ÙÙ·ÚÈÎfi ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ∏·Ù›Ùȉ·˜ ∞. ÃÔÚËÁÂ›Ù·È Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ· ¿Óˆ ÙÔ˘ ÂÓfi˜ (1) ¤ÙÔ˘˜ Û 2 ‰fiÛÂȘ, Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 6 ÌËÓÒÓ, ηıÒ˜ Î·È Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∏·Ù›Ùȉ· ∞ (¶›Ó·Î·˜ 3). 11. BCG = ∑ˆÓ ÂÍ·ÛıÂÓË̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ Ê˘Ì·Ù›ˆÛ˘. ™‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù˜ Ô‰ËÁ›Â˜ Ù˘ ¢ÈÂıÓÔ‡˜ ŒÓˆÛ˘ ηٿ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Î·È Ù˘ ¶·ÁÎfiÛÌÈ·˜ √ÚÁ¿ÓˆÛ˘ ÀÁ›·˜, Ë ¯ÒÚ· Ì·˜ ‰ÂÓ ÏËÚÔ› ÙȘ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙË ‰È·ÎÔ‹ ÙÔ˘ ·ÓÙÈÊ˘Ì·ÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Ô ÔÔ›Ô˜ ÂÍ·ÎÔÏÔ˘ı› Ó· Á›ÓÂÙ·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. π‰È·›ÙÂÚË ¤ÌÊ·ÛË Ú¤ÂÈ Ó· ‰Ôı› ΢ڛˆ˜ ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 2). ¶·Ú¿ÏÏËÏ·, Û˘ÓÈÛÙ¿Ù·È Ì·˙ÈÎfi˜ ÚÔÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ÛÙȘ ËÏÈ˘ 1, 4-6 ÂÙÒÓ (ÚÈÓ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ì BCG, 11·) Î·È ÛÙ· ·ÓÂÌ‚ÔÏ›·ÛÙ· ·È‰È¿, ÛÙËÓ ËÏÈΛ· 11-12 ÂÙÒÓ (fiÙ·Ó Á›ÓÂÙ·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ ÙÔ˘˜ Î¿Ï˘„˘, 11‚). 12. INFL = ∞‰Ú·ÓÔÔÈË̤ÓÔ ÔÏÔ΢ÙÙ·ÚÈÎfi ‹ ·Î˘ÙÙ·ÚÈÎfi (ÙÌËÌ·ÙÈÎfi) ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ Áڛ˘ Ô˘ Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÂÙËÛ›ˆ˜, Û 1 ‰fiÛË Î·È Û ËÏÈΛ· ¿Óˆ ·fi 6 ÌËÓÒÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ ÁÈ· ·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ Ó· ÓÔÛ‹ÛÔ˘Ó ÛÔ‚·Ú¿ ·fi ÁÚ›Ë (¶›Ó·Î·˜ 4). ¶·È‰È¿ οو ÙˆÓ 8 ÂÙÒÓ Ô˘ ı· ÂÌ‚ÔÏÈ·ÛıÔ‡Ó ÁÈ· ÚÒÙË ÊÔÚ¿ ı· ¿ÚÔ˘Ó 2 ‰fiÛÂȘ ÂÌ‚ÔÏ›Ô˘ (0,25 ml <3 ÂÙÒÓ Î·È 0,5 ml ≥3 ÂÙÒÓ) Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 4 ‚‰ÔÌ¿‰ˆÓ. Paediatriki 2008;71:166-170
Pediatri Mar-Apr 08
07-04-08
17:43
™ÂÏ›‰·169
169
∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ
¶›Ó·Î·˜ 4. ∂Ӊ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ Áڛ˘ ¶·ÚÔ˘Û›· ÂÓfi˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‹ ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·: ñ ÕÛıÌ· ‹ ¿ÏϘ ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ. ñ ∫·Ú‰È·Î‹ ÓfiÛÔ˜ Ì ÛÔ‚·Ú¤˜ ηډÈÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜. ñ ∞ÓÔÛÔηٷÛÙÔÏ‹ (ÂÍ·ÈÙ›·˜ ÓÔÛ‹Ì·ÙÔ˜ ‹ ıÂڷ›·˜). ñ ¢Ú·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ˜ (Î·È ¿ÏϘ ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ). ñ ¶·È‰È¿ Ô˘ ·›ÚÓÔ˘Ó ·ÛÈÚ›ÓË Ì·ÎÚÔ¯ÚfiÓÈ· (.¯. ÓfiÛÔ˜ Kawasaki) ÁÈ· Ó· ÂÏ·ÙÙˆı› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Û˘Ó‰ÚfiÌÔ˘ Reye ÌÂÙ¿ ·fi ÁÚ›Ë. ñ ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ‹ ¿ÏÏÔ ¯ÚfiÓÈÔ ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ·. ñ ÃÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ·. ñ ∫ÏÂÈÛÙÔ› ÏËı˘ÛÌÔ›*. ñ ∂·ÁÁÂÏ̷ٛ˜ ˘Á›·˜. ñ ∂·ÁÁÂÏ̷ٛ˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ԢÏÂÚÈο**. ñ ÕÙÔÌ· ËÏÈΛ·˜ 60 ÂÙÒÓ Î·È ¿Óˆ. * ¶ÚÔÛˆÈÎfi Î·È ÂÛˆÙÂÚÈÎÔ› ÛÔ˘‰·ÛÙ¤˜ Á˘ÌÓ·Û›ˆÓ-Ï˘Î›ˆÓ, ÛÙÚ·ÙȈÙÈÎÒÓ Î·È ·ÛÙ˘ÓÔÌÈÎÒÓ Û¯ÔÏÒÓ, ÂȉÈÎÒÓ Û¯ÔÏ›ˆÓ ‹ Û¯ÔÏÒÓ, ÙÚfiÊÈÌÔÈ Î·È ÚÔÛˆÈÎfi È‰Ú˘Ì¿ÙˆÓ Î.¿. ** √ Èfi˜ Ù˘ Áڛ˘ ÙˆÓ Ô˘ÏÂÚÈÎÒÓ Î·ÓÔÓÈο ‰ÂÓ ÚÔηÏ› ÓfiÛËÛË ÛÙÔÓ ¿ÓıÚˆÔ. ∂›Ó·È ‰˘Ó·ÙfiÓ fï˜, Û ÂÚ›ÙˆÛË Û˘ÏÏԛ̈͢ Ì ÙÔÓ Èfi Ù˘ Áڛ˘ ÙˆÓ ·ÓıÚÒˆÓ, Ó· ÚÔ·„ÂÈ ÌÂÙ·ÏÏ·Á̤ÓÔ˜ Èfi˜ Ô˘ Ó· ÚÔÛ‚¿ÏÏÂÈ Î·È ÙÔÓ ¿ÓıÚˆÔ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Û˘ÓÈÛÙ¿Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ·ÙfiÌˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ԢÏÂÚÈο.
∂›Û˘, Û˘ÓÈÛÙ¿Ù·È ÂÙ‹ÛÈÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ˘ÁÈÒÓ ·ÙfiÌˆÓ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ Î·È ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜. ™Â ÂÚ›ÙˆÛË ·ÏÏ·Á‹˜ ÙˆÓ ÂȉËÌÈÔÏÔÁÈÎÒÓ Û˘ÓıËÎÒÓ (.¯. ÂȉËÌ›·, ·Ó‰ËÌ›·) ÔÈ Û˘ÛÙ¿ÛÂȘ ·ÏÏ¿˙Ô˘Ó. ŸÏ· Ù· ·È‰È¿ Ú¤ÂÈ Ó· ÂÈÛΤÙÔÓÙ·È ÙÔ ÁÈ·ÙÚfi ÙÔ˘˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 11-12 ÂÙÒÓ (Ù¤ÏÔ˜ ‰ËÌÔÙÈÎÔ‡, ¤Ó·ÚÍË ÊÔ›ÙËÛ˘ ÛÙÔ Á˘ÌÓ¿ÛÈÔ), ÒÛÙ ӷ Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ Ù˘ ÂÌ‚Ô-
ÏÈ·ÛÙÈ΋˜ ÙÔ˘˜ Î¿Ï˘„˘ Î·È Î·Ù·ÁÚ·Ê‹ Ù˘ ÛÙËÓ ÂȉÈ΋ ÛÂÏ›‰· ÙÔ˘ ·ÙÔÌÈÎÔ‡ ‚È‚ÏÈ·Ú›Ô˘ ˘Á›·˜. ∫¿ı ÛÔ‚·Ú‹ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ô˘ ÂÈÛËÌ·›ÓÂÈ Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È ÛÙÔÓ ∂√º (Ó· Û˘ÌÏËÚÒÓÂÙ·È Ë Î›ÙÚÈÓË Î¿ÚÙ·). ™ÙÔ˘˜ ¶›Ó·Î˜ 5 Î·È 6 Û˘ÓÔ„›˙ÂÙ·È ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· Ù· ·È‰È¿ Ô˘ ηı˘ÛÙ¤ÚËÛ·Ó Ó· ÂÌ‚ÔÏÈ·ÛÙÔ‡Ó.
¶›Ó·Î·˜ 5. ¶ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 6 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ËÏÈΛ· ∂Ì‚fiÏÈÔ
∏·Ù›Ùȉ·˜ µ (Hep B) ¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘, ∫ÔηÙË (D∆aP)Ç ¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV3 ∞ÈÌfiÊÈÏÔ˘ Ù‡Ô˘ ‚ (Hib)4 ªËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C (MCC)5 ¶Ó¢ÌÔÓÈoÎfiÎÎÔ˘ (7‰‡Ó·ÌÔ) (PCV)6 πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR)7 ∞ÓÂÌ¢ÏÔÁÈ¿˜ (Var)8 ∏·Ù›Ùȉ·˜ ∞ (Hep ∞)9 º˘Ì·Ù›ˆÛ˘ (BCG)10 º˘Ì·ÙÈÓ·ÓÙ›‰Ú·ÛË11 (Mantoux) °Ú›Ë˜ (INFL)12
1Ë ‰fiÛË ËÌ/Ó›·
2Ë ‰fiÛË 1Ë-2Ë ËÌ/Ó›· ‰fiÛË1
3Ë ‰fiÛË 2Ë-3Ë ËÌ/Ó›· ‰fiÛË1
4Ë ‰fiÛË 3Ë-4Ë ËÌ/Ó›· ‰fiÛË1
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4 ‚‰. 4 ‚‰. 4 ‚‰. 4 ‚‰.
4 ‚‰. 4 ‚‰. 4 ‚‰. 4 ‚‰.
6 ÌËÓ. 4 ‚‰. 8 ‚‰. 8 ‚‰.
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4 ‚‰.
8 ‚‰.
5Ë ‰fiÛË 4Ë-5Ë ËÌ/Ó›· ‰fiÛË1
3-4 ¯ÚfiÓÈ·
4 ‚‰. 8 ‚‰. 6 ÌËÓ.
4 ‚‰.
¶·È‰È·ÙÚÈ΋ 2008;71:166-170
Pediatri Mar-Apr 08
07-04-08
17:43
™ÂÏ›‰·170
170
∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ
¶›Ó·Î·˜ 6. ¶ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ ËÏÈΛ·˜ 7-18 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ËÏÈΛ· ∂Ì‚fiÏÈÔ
∏·Ù›Ùȉ·˜ µ (Hep B) ¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘ (Td) Tdap ¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV ªËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C (MCC) πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR) ∞ÓÂÌ¢ÏÔÁÈ¿˜ (Var) πfi˜ ∞ÓıÚÒÈÓˆÓ £ËÏˆÌ¿ÙˆÓ (HPV)13 ∏·Ù›Ùȉ·˜ ∞ (Hep ∞) °Ú›Ë˜ (INFL)
1Ë ‰fiÛË ËÌ/Ó›·
2Ë ‰fiÛË 1Ë-2Ë ËÌ/Ó›· ‰fiÛË1
3Ë ‰fiÛË 2Ë-3Ë ËÌ/Ó›· ‰fiÛË1
4 ‚‰. 4 ‚‰.
3 ÌËÓ. 6 ÌËÓ.
4 ‚‰.
4 ‚‰.
4 ‚‰. 8 ‚‰. 4-8 ‚‰. 6 ÌËÓ.
4Ë ‰fiÛË 3Ë-4Ë ËÌ/Ó›· ‰fiÛË1 6 ÌËÓ. 5 ¯ÚfiÓÈ· 6 ÌËÓ.
4-5 ÌËÓ.
ÀÔÛËÌÂÈÒÛÂȘ/ÂÂÍËÁ‹ÛÂȘ ÙˆÓ ¶ÈÓ¿ÎˆÓ 5 Î·È 6 1. ÃÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙËÓ ÚÔËÁÔ‡ÌÂÓË ‰fiÛË. 2. ∏ 5Ë ‰fiÛË ÌÔÚ› Ó· ·Ú·ÏËÊı› fiÙ·Ó Ë 4Ë Á›ÓÂÈ ÌÂÙ¿ ÙÔ 4Ô ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Û˘Ó¯›˙ÂÙ·È Ì Td. To TdaP Á›ÓÂÙ·È Û ̛· ‰fiÛË ÛÙËÓ ÂÊ˂›·, ηٿ ÚÔÙ›ÌËÛË Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 5 ÂÙÒÓ ·fi ÙÔ Td. (µÏ¤Â ÂÂÍËÁ‹ÛÂȘ 2·, 2‚ ÛÙËÓ ∂ÈÎfiÓ· 1). 3. ÃÔÚËÁÔ‡ÓÙ·È 4 ‰fiÛÂȘ IPV. 4. °›ÓÂÙ·È Û 2 ‰fiÛÂȘ Û ¿ÙÔÌ· ≤12 ÌËÓÒÓ ‹ Û 1 ‰fiÛË ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∂¿Ó Á›ÓÂÈ Î¿Ï˘„Ë ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ì 2 ‰fiÛÂȘ Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 12 ÌËÓÒÓ, ÙfiÙ Á›ÓÂÙ·È , ÌÂÙ¿ ÙÔ 1Ô ¤ÙÔ˜, Î·È Ì›· ·ӷÏËÙÈ΋ ‰fiÛË. ¢ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘, Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 5 ÂÙÒÓ, Ì ÂÍ·›ÚÂÛË ¿ÙÔÌ· Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ¿ÙÔÌ· Ì ÛÏËÓÂÎÙÔÌ‹ ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ·ÛÏËÓ›·. 5. ∂¿Ó Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Û ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 12 ÌËÓÒÓ, ¯ÔÚËÁÂ›Ù·È Ì›· ÌfiÓÔ ‰fiÛË MCC. ∂¿Ó ÔÈ ÚÒÙ˜ 2 ‰fiÛÂȘ ¤ÁÈÓ·Ó Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 12 ÌËÓÒÓ Á›ÓÂÙ·È Ì›· 3Ë ‰fiÛË. 6. ∂¿Ó Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 7 ÌËÓÒÓ, ¯ÔÚËÁÔ‡ÓÙ·È 4 ‰fiÛÂȘ ÙÔ˘ PCV ηٿ ÙÔ Û¯‹Ì· Ô˘ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1 (Ë 4Ë ‰fiÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ). ∂¿Ó Ë ¤Ó·ÚÍË Á›ÓÂÈ ÌÂٷ͇ 12Ô˘ Î·È 23Ô˘ Ì‹Ó·, ¯ÔÚËÁÔ‡ÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰Â˜. ∂¿Ó Ë ¤Ó·ÚÍË Á›ÓÂÈ ·fi ÙÔÓ 24Ô Ì‹Ó· Î·È ÌÂÙ¿, ÛÙ· ˘ÁÈ‹ ·È‰È¿ ¯ÔÚËÁÂ›Ù·È Ì›· ÌfiÓÔ ‰fiÛË. ™Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ Î·È Û’ ·˘Ù¿ Ô˘ ·Ó‹ÎÔ˘Ó ÁÂÓÈο ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ (¶›Ó·Î·˜ 1) ¯ÔÚËÁÔ‡ÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰Â˜. 7. ∏ 2Ë ‰fiÛË ÙÔ˘ MMR Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ. ∂¿Ó fï˜ Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Û’ ·˘Ù‹ ÙËÓ ËÏÈΛ·, Ë 2Ë ‰fiÛË ÌÔÚ› Ó· Á›ÓÂÈ Û‡ÓÙÔÌ· Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 8 ‚‰ÔÌ¿‰Â˜. 8. ŸÙ·Ó Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Á›ÓÂÈ Û ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 12 ÂÙÒÓ Û˘ÓÈÛÙÒÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 2 ÌËÓÒÓ. 9. µÏ¤Â ÂÂÍ‹ÁËÛË 10 ÛÙËÓ ∂ÈÎfiÓ· 1. 10,11. µÏ¤Â ÂÂÍ‹ÁËÛË 11 (11·, 11‚) ÛÙËÓ ∂ÈÎfiÓ· 1. 12. µÏ¤Â ÂÂÍ‹ÁËÛË 12 ÛÙËÓ ∂ÈÎfiÓ· 1. 13. ªfiÓÔ ÁÈ· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-26 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (‚Ϥ ÂÂÍ‹ÁËÛË 9 ÛÙËÓ ∂ÈÎfiÓ· 1).
Paediatriki 2008;71:166-170
Pediatri Mar-Apr 08
08-04-08
12:26
™ÂÏ›‰·171
™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞
171
∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ 2008 ∂. °·Ï·Ó¿Î˘
¶ÚÈÓ ·fi Ï›Á˜ ‚‰ÔÌ¿‰Â˜ ·Ó·ÎÔÈÓÒıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜ ÙÔ “¡¤Ô ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ” (À1.°.¶.158238, 23 π·Ó. 2008) Ì ÙȘ Û¯ÂÙÈΤ˜ ÁÓˆÌÔ‰ÔÙ‹ÛÂȘ Ù˘ ∂ıÓÈ΋˜ ∂ÈÙÚÔ‹˜ ∂Ì‚ÔÏÈ·ÛÌÒÓ. ∏ ·fiÊ·ÛË Û˘Óԉ‡ÂÙ·È ·fi ¶›Ó·Î˜ Ì ¯ÚÔÓԉȷÁÚ¿ÌÌ·Ù· ‚·ÛÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÂÌ‚ÔÏÈ·ÛÌÔ‡ ·È‰ÈÒÓ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ·. ∞Ó·Ï˘ÙÈΤ˜ √‰ËÁ›Â˜ Â›Ó·È ‰È·ı¤ÛÈ̘ ÛÙËÓ ˘Ô˘ÚÁÈ΋ ·fiÊ·ÛË ÙÔ˘ ÀÀÎ∫∞ Î·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰· ÙÔ˘ (www.mohaw.gr → ÛÙÔ ·‡ÚÈÔ → ·Ó·ÎÔÈÓÒÛÂȘ-ÂÁ·ÎÏÈÔÈ) ηıÒ˜ Î·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘ ¶∞π¢π∞∆ƒπ∫∏™. ™ÙÔ Ó¤Ô ÂıÓÈÎfi ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ¤¯Ô˘Ó Á›ÓÂÈ ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙ·: ∂Ì‚fiÏÈÔ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚˆ›ÓˆÓ ıËψ̿وÓ. ¡¤Ô, ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ. ™˘ÓÈÛÙ¿Ù·È Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ Î·È Û ÎÔÚ›ÙÛÈ· Î·È Á˘Ó·›Î˜ 15-26 ÂÙÒÓ, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı›. ™ÙËÓ ∂ÏÏ¿‰· ΢ÎÏÔÊÔÚÔ‡Ó ¤Ó· ‰È‰‡Ó·ÌÔ (3 ‰fiÛÂȘ, 0-1-6 Ì‹Ó˜) Î·È ¤Ó· ÙÂÙÚ·‰‡Ó·ÌÔ (3 ‰fiÛÂȘ, 0-2-6 Ì‹Ó˜). ∂Ì‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÚÔÛı‹ÎË ‰Â‡ÙÂÚ˘ ‰fiÛ˘. ∏ 1Ë ‰fiÛË ¯ÔÚËÁÂ›Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-18 ÌËÓÒÓ (ηٿ ÚÔÙ›ÌËÛË ÌÂÙ¿ ÙÔ 15Ô Ì‹Ó·), ·ÏÏ¿ Î·È Û οı ¿ÏÏË ËÏÈΛ·, ÂÊfiÛÔÓ ÙÔ ¿ÙÔÌÔ ‰ÂÓ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ. ∏ 2Ë ‰fiÛË Û˘ÓÈÛÙ¿Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û οı ¿ÏÏË ËÏÈΛ·, ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. ∂Ì‚fiÏÈÔ Ù˘ Ë·Ù›Ùȉ·˜ ∞. ™˘ÓÈÛÙ¿Ù·È ÁÈ· fiÏ· Ù· ·È‰È¿ ¿Óˆ ÙÔ˘ 1 ¤ÙÔ˘˜. ÃÔÚËÁÂ›Ù·È ÛÂ
AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
ÔÔÈ·‰‹ÔÙ ËÏÈΛ· ¿Óˆ ÙÔ˘ 1 ¤ÙÔ˘˜ Û 2 ‰fiÛÂȘ Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 6 ÌËÓÒÓ. ∂Ì‚fiÏÈÔ ‰ÈÊıÂÚ›Ùȉ·˜-ÙÂÙ¿ÓÔ˘-ÎÔηÙË ÁÈ· ÂÊ‹‚Ô˘˜. ∂ÈÛ·ÁˆÁ‹ ÙÔ˘ ∆daP ÁÈ· Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ ¿Óˆ ÙˆÓ 11 ÂÙÒÓ. ∆Ô TdaP ÂÚȤ¯ÂÈ ÌÈÎÚfiÙÂÚË ‰fiÛË ÙÔÍÔÂȉԇ˜ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ ·fi ÙÔ DTaP. ∆· ÂÌ‚fiÏÈ· TdaP Ô˘ ‰È·Ù›ıÂÓÙ·È ÛÙËÓ ∂ÏÏ¿‰· ÂÚȤ¯Ô˘Ó Î·È IPV Î·È ¯ÔÚËÁÂ›Ù·È ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ. ™˘ÓÈÛÙ¿Ù·È 1 ·ӷÏËÙÈ΋ ‰fiÛË TdaP ÛÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ ‹ Î·È ·ÚÁfiÙÂÚ· (¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 64 ÂÙÒÓ), ηٿ ÚÔÙ›ÌËÛË fiÙ·Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ˘¿Ú¯ÂÈ ÓÂÔÁ¤ÓÓËÙÔ. ™˘ÓÈÛÙ¿Ù·È ÌÂÛԉȿÛÙËÌ· 5 ÂÙÒÓ ·fi ÙÔ DTaP ‹ ÙÔ Td ÁÈ· ÏÈÁfiÙÂÚ˜ ÙÔÈΤ˜ ·ÓÙȉڿÛÂȘ, ÌÔÚ› fï˜ Ó· ¯ÔÚËÁËı› Î·È Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 2 ÂÙÒÓ. ∂¿Ó ‰ÂÓ ‰È·Ù›ıÂÙ·È ÙÔ TdaP ÌfiÓÔ ÙÔ˘ (¯ˆÚ›˜ IPV) ¯ÔÚËÁÂ›Ù·È ÙÔ Td ÂÓËϛΈÓ. √È ˘fiÏÔȘ ‰fiÛÂȘ Á›ÓÔÓÙ·È Ì Ì Td ÂÓËÏ›ÎˆÓ ·Ó¿ 10ÂÙ›·. ∂Ì‚fiÏÈÔ Ù˘ Ë·Ù›Ùȉ·˜ µ. ªËÙ¤Ú· HBsAg(+), ‰ËÏ·‰‹ ÊÔÚ¤·˜ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ ‹ ÌËÙ¤Ú· Ì ¿ÁÓˆÛÙË Î·Ù¿ÛÙ·ÛË HBsAg: Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 4 ‰fiÛÂȘ: Ë 1Ë Á›ÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË (ˆ˜ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ, ÔÏ˘‰‡Ó·Ì· ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ 6Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜) Ë 2Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó·, Ë 3Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2Ô˘ Ì‹Ó· Î·È Ë 4Ë ÛÙÔ˘˜ 6-18 Ì‹Ó˜ ˙ˆ‹˜ (ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ 1˘-2˘ Î·È 2˘-3˘ ‰fiÛ˘: 4 ‚‰ÔÌ¿‰Â˜ Î·È ÌÂٷ͇ 3˘4˘ ‰fiÛ˘: 8 ‚‰ÔÌ¿‰Â˜). ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ HBsAg(+) ¯ÔÚËÁ›ٷÈ, ·Ú¿ÏÏËÏ· Ì ÙËÓ 1Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ˘ÂÚ¿ÓÔÛË ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ë·Ù›Ùȉ·˜ µ (0,5 ml, ÛÙȘ 12 ÚÒÙ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:171-172
Pediatri Mar-Apr 08
08-04-08
172
11:52
™ÂÏ›‰·172
PAEDIATRIC NEWS IN BRIEF ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û ‰È·ÊÔÚÂÙÈÎfi ÛËÌÂ›Ô ·fi ÙÔ ÂÌ‚fiÏÈÔ). ∆· ·È‰È¿ ·˘Ù¿ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· HBsAg Î·È ·ÓÙÈ-HBs ÛÙËÓ ËÏÈΛ· ÙˆÓ 9-15 ÌËÓÒÓ. ∞Ó Î·Ù¿ ÙÔÓ ÙÔÎÂÙfi Ë ÌËÙ¤Ú· Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Â›Ó·È ‹ fi¯È ÊÔÚ¤·˜ HBsAg Î·È ·ÎÔÏÔ‡ıˆ˜ ·Ô‰Âȯı› fiÙÈ ‰ÂÓ Â›Ó·È, ÙfiÙ ÙÔ ÓÂÔÁÓfi ·ÎÔÏÔ˘ı› ÙÔ Û¯‹Ì· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÁÈ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ HBsAg(-), ‰ËÏ·‰‹ ·ÁÓÔÂ›Ù·È Ë 1Ë ‰fiÛË. ªËÙ¤Ú· HBsAg(-): o ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ (ÌÂÛԉȿÛÙËÌ· 6-8
Paediatriki 2008;71:171-172
‚‰ÔÌ¿‰ˆÓ ÌÂٷ͇ 1˘ Î·È 2˘ ‰fiÛ˘ Î·È Ë 3Ë ÛÙÔ˘˜ 6-18 Ì‹Ó˜, Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 8 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË 2Ë ‰fiÛË). ∂Ì‚fiÏÈÔ ÁÈ· ÙË ÁÚ›Ë. ∂Í·ÎÔÏÔ˘ı› Ó· Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ Û ÔÌ¿‰Â˜ ÏËı˘ÛÌÔ‡ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, Û 1 ‰fiÛË ÂÙËÛ›ˆ˜. ™Â ·È‰È¿ οو ÙˆÓ 8 ÂÙÒÓ Ô˘ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿ Á›ÓÔÓÙ·È 2 ‰fiÛÂȘ ÂÌ‚ÔÏ›Ô˘ (<3 ÂÙÒÓ: 0,25 ml, ≥3 ÂÙÒÓ: 0,5 ml) Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 4 ‚‰ÔÌ¿‰ˆÓ.
Pediatri Mar-Apr 08
07-04-08
17:43
™ÂÏ›‰·173
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™‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ ‰È·‰›ÎÙ˘Ô ∫. ™ÙÂÊ·Ó›‰Ë˜ ™ÙȘ ̤Ú˜ Ì·˜, ¤Ó·˜ ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ‰ËÌÔÛȇÛÂˆÓ Ì·˜ ηٷÎχ˙ÂÈ. ∫¿ÔȘ ·fi ·˘Ù¤˜ ÌÔÚ› Ó· ¤¯Ô˘Ó ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ì·˜ Ú¿ÍË. ªÂÚÈΤ˜ ÌÔÚ› Ó· Ì·˜ ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ۿÓÈ· ÚÔ‚Ï‹Ì·Ù·. ŸÌˆ˜ Ë ÚfiÛ‚·ÛË Û ·˘Ù¤˜ ÙȘ Ӥ˜ ÏËÚÔÊÔڛ˜ ÌÔÚ› Ó· Â›Ó·È ‰˘Û¯ÂÚ‹˜ Î·È Ô ¯ÚfiÓÔ˜ Ì·˜ ÁÈ· ÏÂÙÔÌÂÚ‹ ÂÓË̤ڈÛË ÂÚÈÔÚÈṲ̂ÓÔ˜. ŒÙÛÈ, ÚfiÛÊ·Ù· ¤ÁÈÓ ȉȷ›ÙÂÚ· ‰ËÌÔÊÈÏ‹˜ Ë Û˘ÓÔÙÈ΋ ·ÚÔ˘Û›·ÛË ÙˆÓ ‚·ÛÈÎÒÓ ÛÙÔȯ›ˆÓ ÚfiÛÊ·ÙˆÓ ‰ËÌÔÛȇۈÓ. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÛÙ‹ÏË ÙˆÓ “™‡ÓÙÔÌˆÓ ¶·È‰È·ÙÚÈÎÒÓ ¡¤ˆÓ” ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ·Ú·Ì¤ÓÂÈ Ë ÚÒÙË ÚÔÙ›ÌËÛË ÙˆÓ ·Ó·ÁÓˆÛÙÒÓ. ∞ÚÎÂÙ¤˜ ÈÛÙÔÛÂÏ›‰Â˜ ÛÙÔ ‰È·‰›ÎÙ˘Ô ÂÚȤ¯Ô˘Ó ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ·fi ÚfiÛÊ·Ù· ¿ÚıÚ·. ª¿ÏÈÛÙ· ÔÏϤ˜ ÊÔÚ¤˜ ÛÙ¤ÏÓÔÓÙ·È Î·È Ì ËÏÂÎÙÚÔÓÈο ÌËӇ̷ٷ Ù· Û‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜, Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË. ŒÁÈÓ ÂÈÏÔÁ‹ ÙÂÛÛ¿ÚˆÓ ÈÛÙÔÛÂÏ›‰ˆÓ, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ÂÈÛΤ„ÂˆÓ Î·È ÂÚȤ¯Ô˘Ó ÏËÚÔÊÔڛ˜ Ô˘ ÂÏ›˙ˆ fiÙÈ ı· Û·˜ ÂӉȷʤÚÔ˘Ó.
AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ stefanid@hol.gr ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
∏ ÈÛÙÔÛÂÏ›‰· “Pediatric News” - http://www.pediatricnews.com/issues ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ÌËÓÈ·›Â˜ ‰ËÌÔÛȇÛÂȘ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙ¿ ÂÙÒÓ. ªÈ· ÏËıÒÚ· ·fi ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ·Ú¤¯ÔÓÙ·È ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜. ∂›Û˘, ˘¿Ú¯Ô˘Ó ȉȷ›ÙÂÚ· ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·, ÂÌ‚ÔÏÈ·ÛÌÔ‡˜, ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÂÊ‹‚Ô˘ Ì ·¯˘Û·ÚΛ· Î·È ÁÈ· ¿ÏÏ· Û˘Ó‹ıË ÚÔ‚Ï‹Ì·Ù·. π‰È·›ÙÂÚË ·Ó·ÊÔÚ¿ Á›ÓÂÙ·È ÛÙÔ ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ, Ô˘ ÚÈÓ ·fi 10 ¯ÚfiÓÈ· ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·È‰›·ÙÚÔÈ ‰ÂÓ ›ÛÙ¢·Ó fiÙÈ Â›Ó·È Úfi‚ÏËÌ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ™‹ÌÂÚ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ 2-9% ÙˆÓ ÂÊ‹‚ˆÓ, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÔÚÈÛÌfi Ô˘ ¯ÚËÛÈÌÔÔÈ›ٷÈ. ∆Ô 8% ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ÙÔ 44% ÙˆÓ ·¯‡Û·ÚÎˆÓ ÂÊ‹‚ˆÓ ·ÚÔ˘ÛÈ¿ÛÂÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi. ∆· ÛÙÔȯ›· ·˘Ù¿ Â›Ó·È ·ÓËÛ˘¯ËÙÈο, ÂÂȉ‹ Ë ·¯˘Û·ÚΛ· ÛÙȘ ̤Ú˜ Ì·˜ ¤¯ÂÈ ¿ÚÂÈ ÂȉËÌÈ΋ ‰È¿ÛÙ·ÛË. ∂›Û˘, ÙÔÓ›˙ÂÙ·È Ë ÛËÌ·Û›· Ù˘ ̤ÙÚËÛ˘ Ù˘ ÂÚÈ̤ÙÚÔ˘ Ù˘ ÎÔÈÏÈ¿˜. ™Â ÚfiÛÊ·ÙË ÈÙ·ÏÈ΋ ÌÂϤÙË (Maffeis C. Î·È Û˘Ó., J Pediatr 2008;152:207-213) ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ·¯‡Û·Úη ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Â›¯·Ó 13 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¤¯Ô˘Ó ‰‡Ô ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ. ∆· ˘¤Ú‚·Ú· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Â›¯·Ó 7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ. ∆¤ÏÔ˜, Ù· ˘¤Ú‚·Ú· ·È‰È¿ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ.
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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ ∏ ÈÛÙÔÛÂÏ›‰· “Medscape Pediatrics” - http://www.medscape.com/pediatrics ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û¯ÔÏÈ·Ṳ̂Ó˜ ÂÚÈÏ‹„ÂȘ ÚfiÛÊ·ÙˆÓ ‰ËÌÔÛȇۈÓ, ·fi„ÂȘ ÂȉÈÎÒÓ, ÂÓËÌÂÚˆÙÈο ¿ÚıÚ· Ì ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛ‹ Û·˜. ∞ÚÎÂÙ¿ ÂӉȷʤÚÔÓ Â›Ó·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁ›· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÈÓÔÌ˘·ÏÁ›·˜ ÛÙ· ·È‰È¿. ∂ÓÒ ·Ï·ÈfiÙÂÚ· ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi Ì˘ÔÛÎÂÏÂÙÈÎÔ‡˜ fiÓÔ˘˜, ·Ó¿ÏÔÁÔ˘˜ ¿ÏÏˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ·ı‹ÛˆÓ, Û‹ÌÂÚ· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ÈÓÔÌ˘·ÏÁ›· ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚÔ Ô˘‰fi fiÓÔ˘ Û ۯ¤ÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·. ∞˘Ùfi ÔÊ›ÏÂÙ·È Û ·ıÔÏÔÁÈ΋ ÂÂÍÂÚÁ·Û›· ÙÔ˘ fiÓÔ˘ ÛÙÔÓ ÂÁΤʷÏÔ Î·È ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi (Clauw DJ, J Clin Rheumatol 2007;13:102-109). ŒÙÛÈ ÂÍËÁÂ›Ù·È Î·È Ë ıÂڷ¢ÙÈ΋ ·ÔÙ˘¯›· ÙˆÓ ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ. ª¿ÏÈÛÙ· ÚfiÛÊ·Ù· ·Ó·Ê¤ÚÔÓÙ·È ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· Ì ÙË ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ӷÚfiÛÏ˄˘ (dual receptor reuptake inhibitors) (Rooks DS, Curr Opin Rheumat 2007;19:111-117). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ·È‰È¿ Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÙÚÔ¤˜ ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ì ·È‰È¿ Ì ıÂڷ›· Û˘ÓÙ‹ÚËÛ˘ Ì Ú‰ÓÈ˙ÔÏfiÓË Û ‰fiÛË ÌÈÎÚfiÙÂÚË ·fi 0.6 mg/kg/48ˆÚÔ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ô˘ Ì ٷ ÚÒÙ· Û˘ÌÙÒÌ·Ù· Ù˘ ›ˆÛ˘ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠηıËÌÂÚÈÓ¿ 5 mg Ú‰ÓÈ˙ÔÏfiÓ˘ ÁÈ· 7 ̤Ú˜ ·ÚÔ˘Û›·Û·Ó Û·ÓÈfiÙÂÚ· (18% Û ۯ¤ÛË Ì 48%) ˘ÔÙÚÔ¤˜ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ‹Ú·Ó ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ (Abeyagunawardena AS, Trompeter RS, Arch Dis Child 2008;93:226-228).
∏ ÈÛÙÔÛÂÏ›‰· “Pediatrics Jwatch” - http://pediatrics.jwatch.org/ ∏ ÂΉÔÙÈ΋ ÔÌ¿‰· ÙˆÓ ‰¤Î· ÁÓˆÛÙÒÓ ∞ÌÂÚÈηÓÒÓ Î·ıËÁËÙÒÓ ·È‰È·ÙÚÈ΋˜ ÂÈϤÁÂÈ Î·È Û¯ÔÏÈ¿˙ÂÈ ÂӉȷʤÚÔÓÙ· ¿ÚıÚ·, Ô˘ ÛÙ¤ÏÓÔÓÙ·È Î·ıËÌÂÚÈÓ¿ Ì ËÏÂÎÙÚÔÓÈο ÌËӇ̷ٷ ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜. H ÂÈÏÔÁ‹ ÙˆÓ ¿ÚıÚˆÓ Â›Ó·È ÂÍ·ÈÚÂÙÈ΋ Î·È Ù· ı¤Ì·Ù· ÂӉȷʤÚÔÓÙ·. ™Â ÂÓÙ·ÂÙ‹ Û˘Á¯ÚÔÓÈ΋ ÌÂϤÙË 2.216 ÂÊ‹‚ˆÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ¤ÊË‚ÔÈ Ô˘ ¤ÙÚˆÁ·Ó ηıËÌÂÚÈÓ¿ ÚˆÈÓfi ›¯·Ó ¯·ÌËÏfiÙÂÚÔ˘˜ ‰Â›ÎÙ˜ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ Û ۯ¤ÛË Ì ÂΛÓÔ˘˜ Ô˘ ÛÔÚ·‰Èο ›¯·Ó ÚfiÁÂ˘Ì· (Timlin MT Î·È Û˘Ó., Pediatrics 2008;121: e638). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ·Ú¿ÏË„Ë ÙÔ˘ ÚˆÈÓÔ‡ Û˘Û¯ÂÙ›˙ÂÙ·È Paediatriki 2008;71:173-175
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Ì ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ÂÊ‹‚ˆÓ, οÙÈ Ô˘ ·fi ·ÏÈ¿ ‹Ù·Ó ÁÓˆÛÙfi, fï˜ ÔÙ¤ ‰ÂÓ Â›¯Â ÂÈÛÙËÌÔÓÈο ÙÂÎÌËÚȈı›. ∂ӉȷʤÚÔÓ Â›¯Â Î·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙË ÛËÌ·Û›· Ù˘ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ‹Í˘ Û ÂÊ‹‚Ô˘˜ Ì ·ıÔÏÔÁÈ΋ ÌËÓÔÚÚ·Á›· (Kulp JL Î·È Û˘Ó., J Pediatr Adolesc Gynecol 2008;21:27), fiˆ˜ Î·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‚ÚÂÊÒÓ Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ¯ˆÚ›˜ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ê¿Ú̷η Ô˘ ÂÏ·ÙÙÒÓÔ˘Ó ÙË Á·ÛÙÚÈ΋ Ô͇ÙËÙ· (Hassall E, J Pediatr 2008;152:301).
∏ ÈÛÙÔÛÂÏ›‰· “Pediatric Linx” - http://www.mdlinx.com/pediatriclinx/ ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ì›· ηıËÌÂÚÈÓ‹ ÂÓÙ¿ÏÂÙË Â›Û΄‹ Ù˘ ·ÚΛ ÁÈ· ÙËÓ ÂÓË̤ڈۋ Û·˜. ™Â ·˘Ù¿ Ù· ¤ÓÙ ÏÂÙ¿ ÂÓÙÔ›ÛÙËÎ·Ó ÂӉȷʤÚÔÓÙ· ÛÙÔȯ›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ¤ÊË‚ÔÈ ÙËÓ ·¯˘Û·ÚΛ·, ÁÈ· ÙËÓ Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÁÈ· ÙËÓ Â›‰Ú·ÛË Ù˘ ÌÔ˘ÛÈ΋˜ ÛÙÔ ¿Á¯Ô˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÂÂÌ‚¿ÛÂȘ. √È ÏËÚÔÊÔڛ˜ ·˘Ù¤˜ ‹Ù·Ó ·ÚÎÂÙ¿ Û˘ÓÔÙÈΤ˜ Î·È ‹Ù·Ó ··Ú·›ÙËÙË Ë ·Ó¿ÁÓˆÛË ÙˆÓ ¿ÚıÚˆÓ. ŒÙÛÈ Ù· ¤ÓÙ ÏÂÙ¿ ¤ÊÙ·Ó·Ó ÌfiÓÔ ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÂӉȷÊÂÚfiÓÙˆÓ ıÂÌ¿ÙˆÓ Î·È ¯ÚÂÈ¿ÛÙËΠÂÚÈÛÛfiÙÂÚË ÒÚ· ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘˜.
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∫§π¡π∫√ ∫√Àπ∑
∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ √ ‰È·ÁÓˆÛÙÈÎfi˜ ¯ÂÈÚÈÛÌfi˜ ÂÚÈÏ¿Ì‚·Ó ÙËÓ ·Ê‡ÓÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ÂÂÈÛÔ‰›Ô˘ Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·ÎÔ‹ ÙÔ˘. ∞˘Ùfi Â›Ó·È ÙÔ Î‡ÚÈÔ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙȘ ηÏÔ‹ıÂȘ Ì˘ÔÎÏÔӛ˜ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (∫ªÀ¡), ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ô˘ ·ÔÙÂÏ› ÙË ‰È¿ÁÓˆÛË ÛÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË. √È ∫ªÀ¡ ÂÚÈÁÚ¿ÊËÎ·Ó ·fi ÙÔ˘˜ Coulter Î·È Allen ÙÔ 1982 (1). ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi Ì˘ÔÎÏÔÓÈο ÙÈÓ¿ÁÌ·Ù· (jerks) Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ·fi ÙȘ ÚÒÙ˜ ̤Ú˜ Ù˘ ˙ˆ‹˜ (1Ë ˆ˜ Î·È 16Ë Ì¤Ú·) (2), Û˘Ì‚·›ÓÔ˘Ó ÌfiÓÔ Î·Ù¿ ÙÔÓ ‡ÓÔ Î·È ÛÙ·Ì·ÙÔ‡Ó Ì ÙËÓ ·Ê‡ÓÈÛË. √È Ì˘ÔÎÏÔӛ˜ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢Ú˜ Î·È ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ Ù· ¿Óˆ, ·ÏÏ¿ Î·È Ù· οو ¿ÎÚ·. ¢È·ÚÎÔ‡Ó Ï›Á· ‰Â˘ÙÂÚfiÏÂÙ· ˆ˜ Î·È 20 ÏÂÙ¿ Î·È ÌÔÚ› Ó· ·ӷϷ̂¿ÓÔÓÙ·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÙÔ 24ˆÚÔ. ∂ÌÊ·Ó‹˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ, ¤Ú·Ó ÙÔ˘ ‡ÓÔ˘, ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜, ˆÛÙfiÛÔ, Û ϛÁ˜ ÂÚÈÙÒÛÂȘ ¤¯ÂÈ ·Ó·ÊÂÚı› Ë ÚfiÎÏËÛË ÂÂÈÛÔ‰›ˆÓ Ì ÙÔ ıfiÚ˘‚Ô ‹ Ì ÙÔ Ê¿ÛÎȈ̷ ‹ Ì ÙÔ ÎÔ‡ÓËÌ· ÙÔ˘ ÓÂÔÁÓÔ‡. ∆· ÂÂÈÛfi‰È· ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ÛÔÚ·‰ÈÎfi ¯·Ú·ÎÙ‹Ú·, ˘¿Ú¯Ô˘Ó fï˜ ‰ËÌÔÛȇÛÂȘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘˜ ÂÓfi˜ ÂÚÈÛÙ·ÙÈÎÒÓ ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· (3). ∏ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ ‚¿ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Â›Ó·È ·Û·Ê‹˜. ∞˘Ùfi Ô˘ ¤¯ÂÈ Á›ÓÂÈ ÁÓˆÛÙfi, Ì ÙË ‚Ô‹ıÂÈ· ÔÏ˘ÁÚ·Ê‹Ì·ÙÔ˜ ‡ÓÔ˘, Â›Ó·È fiÙÈ Ù· ÂÂÈÛfi‰È· Û˘Ì‚·›ÓÔ˘Ó ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‹ÚÂÌÔ˘ ‡ÓÔ˘ (quiet sleep) ÙˆÓ ÓÂÔÁÓÒÓ (4), Ô˘ ·ÔÙÂÏ› ÙÔ ÈÛÔ‰‡Ó·ÌÔ ÙÔ˘ NREM (Non Rapid Eye Movement) ‡ÓÔ˘ ÙˆÓ ÂÓËϛΈÓ. ∞fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ù· ÂÂÈÛfi‰È· ·Ú·Ì¤ÓÔ˘Ó ˆ˜ ÙÔ˘˜ 3 Ì‹Ó˜ ˙ˆ‹˜ Î·È ˘Ô¯ˆÚÔ‡Ó ÛÙË Û˘Ó¤¯ÂÈ·. √ ¯ÚfiÓÔ˜ ·˘Ùfi˜ Û˘Ì›ÙÂÈ Ì ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÛÙ·‰›ˆÓ ÙÔ˘ ‡ÓÔ˘ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Î·È ÙË ÛÙ·‰È·Î‹ ÂÌÊ¿ÓÈÛË ÙˆÓ Ê¿ÛÂˆÓ ‡ÓÔ˘ REM (Rapid Eye Movement) Î·È NREM, Û ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ Ê¿ÛÂˆÓ ÙÔ˘ ÂÓÂÚÁÔ‡ (active) Î·È ‹ÚÂÌÔ˘ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (5). ∆Ô Â‡ÚËÌ· ·˘Ùfi
Paediatriki 2008;71:165,176
·Ô‰›‰ÂÙ·È Û ÚÔÛˆÚÈÓ‹ ·ÓˆÚÈÌfiÙËÙ· Ù˘ ÔÚÁ¿ÓˆÛ˘ ÙÔ˘ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ·Ó·Ê¤ÚÔ˘Ó Û ÔÚÈṲ̂ӷ ‚Ú¤ÊË ÂÈÌÔÓ‹ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ̤¯ÚÈ Î·È ÙËÓ ËÏÈΛ· ÙˆÓ 10 ÌËÓÒÓ, ¯ˆÚ›˜ fï˜ ÂÈÙÒÛÂȘ ÛÙË „˘¯ÔÎÈÓËÙÈ΋ ÙÔ˘˜ ÂͤÏÈÍË. √È ∫ªÀ¡ Û˘Á¯¤ÔÓÙ·È Û˘¯Ó¿ Ì ۷ÛÌÔ‡˜, ·ÎfiÌ· Î·È Ì status epilepticus, ÌÔÏÔÓfiÙÈ ‰ÂÓ ÚfiÎÂÈÙ·È ÁÈ· ÂÈÏËÙÈÎfi Ê·ÈÓfiÌÂÓÔ (6). ∏ ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘˜ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ·Ó·›ÙÈ·˜ ·ÓËÛ˘¯›·˜ ÙˆÓ ÁÔÓ¤ˆÓ, Ù˘ ·‰ÈηÈÔÏfiÁËÙ˘ Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÂÍÂÙ¿ÛˆÓ, ·ÏÏ¿ ΢ڛˆ˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·Ú̿ΈÓ, Ù· ÔÔ›· ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ˘ÚÔ‰fiÙËÛË Ó¤ˆÓ ÂÂÈÛÔ‰›ˆÓ (6). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó Ì ‚‚·ÈfiÙËÙ· ∫ªÀ¡ ÔÈ Ì˘ÔÎÏÔӛ˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ÚÒÈÌË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ Î·Ù¿ ÙÔÓ ‡ÓÔ, ˘Ô¯ˆÚÔ‡Ó Ì ÙËÓ ·Ê‡ÓÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÂÈÏËÙÈÎÒÓ ÂÎÊÔÚÙ›ÛˆÓ. ∂ÊfiÛÔÓ ÏËÚÔ‡ÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ‰ÂÓ Ú¤ÂÈ Ó· ‰Ôı› Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÛÙÔ ÓÂÔÁÓfi Ô‡Ù ¯ÚÂÈ¿˙ÂÙ·È Ó· ˘Ô‚ÏËı› Û ÂÚ·ÈÙ¤Úˆ ‰È·ÁÓˆÛÙÈÎfi ¤ÏÂÁ¯Ô.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Coulter DL, Allen RJ. Benign neonatal sleep myoclonus. Arch Neurol 1982;39:191-192. 2. ParÔ-Panjan D, Neubauer D. Benign neonatal sleep myoclonus: experience from the study of 38 infants. Eur J Paediatr Neurol 2008;12:14-18. 3. Cohen R, Shuper A, Straussberg R. Familial benign neonatal sleep myoclonus. Pediatr Neurol 2007;36: 334-337. 4. Di Capua M, Fusco L, Ricci S, Vigevano F. Benign neonatal sleep myoclonus: clinical features and videopolygraphic recordings. Mov Disord 1993;8:191-194. 5. °ÈˆÛ·Ê¿Ù ª, ™ËÊÈ·ÓÔ‡ ¶. º˘ÛÈÔÏÔÁ›· Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ ÛÙ· ·È‰È¿. π·ÙÚÈ΋ 1984;46:4-15. 6. Egger J, Grossmann G, Auchterlonie IA. Benign sleep myoclonus in infancy mistaken for epilepsy. BMJ 2003;326:975-976.
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xiii
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
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5 ∞ÚÈÏ›Ô˘ 2008
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•ÂÓÔ‰Ô¯Â›Ô “Royal Olympic”, ∞ı‹Ó·
30 ∞ÚÈÏ›Ô˘1 ª·˝Ô˘ 2008
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Syracusa, Italy
3-6 ª·˝Ô˘ 2008
Pediatric Academic Societies' 2008 Annual Meeting Contact: Meeting Organiser Tel.: 281-419-0052 Fax: 281-419-0082 E-mail: info@pas-meeting.org
Honolulu, HI, United States
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
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10 ª·˝Ô˘ 2008
7Ë ∏ÌÂÚ›‰· ∞Ó¿Ó˄˘ «∏ ∞Ó¿ÓË„Ë ÛÙ· ·È‰È¿» ¢ÈÔÚÁ¿ÓˆÛË: ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ∞ıËÓÒÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡» ∂ÈÎÔÈÓˆÓ›·: ¶·ÙÚ›ÙÛÈ· ªfiÓÔ˘ ∆ËÏ.: 210-7798033 & 2132009443
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15-17 ª·˝Ô˘ 2008
9th Congress of the European Society for •ÂÓÔ‰Ô¯Â›Ô Pediatric Dermatology “Hilton”, ∞ı‹Ó· ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ & ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: Erasmus - ¶ËÓÂÏfiË ªËÙÚÔÁÈ¿ÓÓË Tel.: 0030-210-7257693 Fax: 0030-210-7257532 E-mail: info@espd2008.com
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
19-21 πÔ˘Ó›Ô˘ 2008
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Cernobbio, Italy
11-14 √ÎÙˆ‚Ú›Ô˘ 2008
2008 National Conference & Exhibition of the American Academy of Pediatrics Contact: PediaLink Customer Service Tel.: 866-843-2271 E-mail: csc@aap.org / kidsdocs@aap.org
Boston, MA, United States
23-26 √ÎÙˆ‚Ú›Ô˘ 2008
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Tunis, Tunisia
24-28 √ÎÙˆ‚Ú›Ô˘ 2008
2nd Congress of the European Academy of Paediatrics - EAP Contact: KENES International Tel: +41 22 908 0488 Fax: +41 22 732 2850 Email: paediatrics@kenes.com Website: www.kenes.com/paediatrics
Nice, France