ISSN 0377-2551
ANA™KO¶H™H
O ÌfiÏ˘‚‰Ô˜ Î·È ÔÈ ÂȉڿÛÂȘ ÙÔ˘ ÛÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡
¢‡ÛÎÔÏÔ ¿ÛıÌ· ÛÙ· ·È‰È¿
TOMO™ 64
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1Ô ¶∞¡∂§§∏¡πO ™À¡∂¢ƒπO À¶O∂π¢π∫O∆∏∆ø¡ ∆∏™ ¶∞π¢π∞∆ƒπ∫∏™ ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙÔ ·È‰ÈÎfi ¿ÛıÌ·
CONTINUING MEDICAL EDUCATION 329 330 336 342
347
351
355
361
¶AI¢IATPIKH
365
370
Language development and disorders in childhood E. Tzima - Tsitsika
376
∞. ¡ÈÎÔÏ¿Ô˘ - ¶··Ó·ÁÈÒÙÔ˘
™˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË
Brain development: Critical learning periods L. Thomaidou
∂. ∆˙›Ì· - ∆Û›ÙÛÈη
™‡Á¯ÚÔÓË ·ÓÙÈÌÂÙÒÈÛË ÓÔËÙÈÎÒÓ, ÁψÛÛÈÎÒÓ Î·È ÎÈÓËÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ·È‰È¿
Recurrent pneumonias in childhood J. N. Tsanakas
§. £ˆÌ·˝‰Ô˘
∞Ó¿Ù˘ÍË Î·È ‰È·Ù·Ú·¯¤˜ ÏfiÁÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·
The use of pulse oximetry by the pediatrician P. Panagiotopoulou - Gartagani
π. ¡. ∆۷ӿη˜
∞Ó·Ù˘Íȷ΋ ÂͤÏÈÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘: ∫Ú›ÛÈ̘ ËÏÈ˘ ÁÈ· Ì¿ıËÛË
Acute bronchiolitis: should we use bronchodilators or steroids? M. Anthracopoulos
¶. ¶·Ó·ÁȈÙÔÔ‡ÏÔ˘ - °·ÚÙ·Á¿ÓË
ÀÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜ ÛÙ· ·È‰È¿
Causes of failure in the treatment of asthma in children T. Tsiligiannis
ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
∏ ¯Ú‹ÛË ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ·fi ÙÔÓ ·È‰›·ÙÚÔ
The role of the long-acting ‚2-agonists in pediatric asthma treatment C. V. Katsardis
£. ∆ÛÈÏÈÁÈ¿ÓÓ˘
OÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·: Ó·È ‹ fi¯È ÛÙË ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Î·È ÛÙÂÚÔÂȉÒÓ;
Difficult asthma in children M. Eboriadou
Ã. B. ∫·ÙÛ·Ú‰‹˜
∞›ÙÈ· ·ÔÙ˘¯›·˜ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙ· ·È‰È¿
1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES New concepts in pediatric asthma M. K. Volonakis
ª. ∂ÌÔÚÈ¿‰Ô˘
O ÚfiÏÔ˜ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ‰Ú¿Û˘ ÛÙË ıÂڷ›· ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜
Lead and its effects on children's health E. Hatzidaki, C. Giannakopoulou
™À¡∂Ãπ∑Oª∂¡∏ ¶∞π¢π∞∆ƒπ∫∏ ∂∫¶∞π¢∂À™∏
ª. ∫. µÔÏÔÓ¿Î˘
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REVIEW ARTICLE 319
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
TEYXO™ 4
ETO™ 2001
πÔ‡ÏÈÔ˜ - ∞‡ÁÔ˘ÛÙÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 4
Contemporary rehabilitation of cognitive, linguistic and motor disorders in children A. Nikolaou - Papanagiotou
384
Emotional intelligence
π. ∆Û›ÎÔ˘Ï·˜
J. Tsikoulas
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
July - August 2001 . Volume 64 . No 4
IÔ‡ÏÈÔ˜ - ∞‡ÁÔ˘ÛÙÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 4
™˘Ó¤¯ÂÈ· ÂÚȯÔÌ¤ÓˆÓ ∏ Ó¢ÚÔ‚ÈÔÏÔÁÈ΋ ‚¿ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ì¿ıËÛ˘
Continuation of table of contents 387
A. Syrigou - Papavasiliou
∞. ™˘Ú›ÁÔ˘ - ¶··‚·ÛÈÏ›Ԣ
∏ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Ì·ıËÛÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ
391
395
400
406 410 417
420
424
430
436
Prevention and treatment of sports injuries in childhood and adolescence A. Tsiligiroglou - Fachantidou
Õ. ∆ÛÈÏÈÁÎÈÚfiÁÏÔ˘ - º·¯·ÓÙ›‰Ô˘
¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ ∞¤ÎÎÚÈÛË Ï¢ÎÔÙÚȤÓ˘ ∂4 Î·È ËˆÛÈÓÔÊÈÏÈ΋˜ ÚˆÙ½Ó˘ à ÛÙ· Ô‡Ú· ·È‰ÈÒÓ Ì ·ÙÔÈÎfi ¿ÛıÌ·
Sports and ergonomics in childhood and adolescence ¡. Skenteris
¡. ™ÎÂÓÙ¤Ú˘
¶ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜
Syncope and sudden cardiac death in children during exercise J. Papagiannis
π. ¶··ÁÈ¿ÓÓ˘
∞ıÏËÙÈÛÌfi˜ Î·È ÂÚÁÔÓÔÌ›· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·
Kawasaki disease and its consequences in the cardiovascular system G. S. Papadopoulos
°. ™. ¶··‰fiÔ˘ÏÔ˜
™˘ÁÎÔ‹ Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÛÙ· ·È‰È¿ ηٿ ÙËÓ ¿ıÏËÛË
Application of telemedicine link in the management of congenital heart defects A. Tsilimigaki - Christaki
∞. ∆ÛÈÏÈÌÈÁοÎË - ÃÚËÛÙ¿ÎË
NfiÛÔ˜ ∫awasaki Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·
Adolescents at-risk A. D. Askouni - Stroumpou
∞. ¢. ∞ÛÎÔ‡ÓË - ™ÙÚÔ‡ÌÔ˘
∏ ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÙËÏÂ˚·ÙÚÈ΋˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ
Growth disorders of height C. Kanaka - Gantenbein
Ã. ∫·Ó·Î¿ - Gantenbein
ŒÊË‚ÔÈ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘
Infections of the female lower genital tract during childhood E. Deligeoroglou
∂. ¢ÂÏËÁÂÒÚÔÁÏÔ˘
¢È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘ Û ‡„Ô˜
Congenital defects of the urinary and genital system that preoccupy the adolescent P. A. Androulakakis
º. ∞. ∞Ó‰ÚÔ˘Ï·Î¿Î˘
ºÏÂÁÌÔÓ¤˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ı‹ÏÂÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·
The role of the paediatrician in the management of learning difficulties S. Youroukos
™. °ÈÔ˘ÚÔ‡ÎÔ˜
™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ··Û¯ÔÏÔ‡Ó ÙÔÓ ¤ÊË‚Ô
The neurobiologic basis of learning disorders
328
LITERATURE ABSTRACTS Urinary excretion of leukotriene E4 and eosinophil protein X in children with atopic asthma
Severien C, Artlich A, Jonas S, Becher G ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
Severien C, Artlich A, Jonas S, Becher G Greek translation: M. Anthrakopoulos
™˘Ó¯›˙ÔÓÙ·È
Continued
July - August 2001 . Volume 64 . No 4
IÔ‡ÏÈÔ˜ - ∞‡ÁÔ˘ÛÙÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 4
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
ªÔÚ› Ó· ÌÂÙÚËı› Ì ·ÎÚ›‚ÂÈ· Ë Ì¤ÁÈÛÙË ÂÎÓ¢ÛÙÈ΋ ÚÔ‹ ηٿ ÙË ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ Ù˘ ‚›·È˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜;
Continuation of table of contents
335
Wensley D, Pickering D, Silverman M ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
∏ ¯ÔÚ‹ÁËÛË Ì›·˜ ÌfiÓÔ ÂÓ‰ÔÌ˘˚΋˜ ‰fiÛ˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ Â›Ó·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ú‰ÓÈ˙fiÓË ÛÙȘ ÎÚ›ÛÂȘ ¿ÛıÌ·ÙÔ˜ Û ·È‰È¿
Wensley D, Pickering D, Silverman M Greek translation: M. Anthrakopoulos 375
Gries DM, Moffitt DR, Pulos E, Carter ER ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∫. ÷Ù˙‹˜
KÏÈÓÈ΋ ÔÚ›· Î·È ÚfiÁÓˆÛË Û ·È‰È¿ Ì ÏÂÈÔ΢ÛÙÈÎÔ‡˜ ‰˘ÛÏ·ÛÙÈÎÔ‡˜ ÓÂÊÚÔ‡˜
386
399
405
Parvovirus B19 DNA in kidney tissue of patients with focal segmental glomerulosclerosis Tanawattanacharoen S, Falk RJ, Jennette JC, Kopp JB Greek translation: Z. Papadopoulou-Couloumbis
429
Levtchenko EN, Lahy C, Livy J, Ham HR, Piepsz A ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: Z. ¶··‰ÔÔ‡ÏÔ˘-KÔ˘ÏÔ˘Ì‹
H ·ÈÙÈÔÏÔÁ›· ÙˆÓ ÓÂÊÚÈÎÒÓ Ô˘ÏÒÓ Û ‚Ú¤ÊË Ì ˘ÂÏÔÓÂÊÚ›Ùȉ· Î·È Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË
Henoch-Schonlein purpura in Wiskott-Aldrich syndrome Duzova A, Topaloglu R, Sanal O, Kilic S, Mazza C, Besbas N, Bakkaloglu A Greek translation: Z. Papadopoulou-Couloumbis
Tanawattanacharoen S, Falk RJ, Jennette JC, Kopp JB ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: Z. ¶··‰ÔÔ‡ÏÔ˘-KÔ˘ÏÔ˘Ì‹
O ÚfiÏÔ˜ ÙÔ˘ Tc-99m DMSA ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ÓÂÊÚÒÓ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Ì ·ÚÓËÙÈ΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ
Clinical course and outcome for children with multicystic dysplastic kidneys Feldenberg LR, Siegel NJ Greek translation: K. D. KÔllios
Duzova A, Topaloglu R, Sanal O, Kilic S, Mazza C, Besbas N, Bakkaloglu A ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: Z. ¶··‰ÔÔ‡ÏÔ˘-KÔ˘ÏÔ˘Ì‹
DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË
A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children Gries DM, Moffitt DR, Pulos E, Carter ER Greek translation: K. Hatzis
Feldenberg LR, Siegel NJ ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: K. ¢. KÔÏÏÈfi˜
¶ÔÚʇڷ ÙÔ˘ Henoch-Schonlein Û ·ÛıÂÓ›˜ Ì ÙÔ Û‡Ó‰ÚÔÌÔ Wiskott-Aldrich
Can peak expiratory flow be measured accurately during a forced vital capacity manoeuvre?
Role of Tc-99m DMSA scintigraphy in the diagnosis of culture negative pyelonephritis Levtchenko EN, Lahy C, Livy J, Ham HR, Piepsz A Greek translation: Z. Papadopoulou-Couloumbis
440
Goldman M, Bistritzer T, Horne T, Zoareft I, Mordechay A ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: K. ¢. KÔÏÏÈfi˜
The etiology of renal scars in infants with pyelonephritis and vesicoureteral refux Goldman M, Bistritzer T, Horne T, Zoareft I, Mordechay A Greek translation: K. D. KÔllios
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xvii
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xxi
Abbreviations
July - August 2001 . Volume 64 . No 4
IÔ‡ÏÈÔ˜ - ∞‡ÁÔ˘ÛÙÔ˜ 2001
.
∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 4
¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜
Bimonthly Publication The Official Journal of the Hellenic Paediatric Society
EΉfiÙ˘ K. °ÚÈ‚¤·˜
Publisher K. Griveas
I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28
Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28
TËÏ:. (01) 7771 140 / 7771 663, Fax: 7758 354
Tel. (01) 7771 140 / 7771 663, Fax: 7758 354
EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∫. ª·Ï·Î¿ ¢È¢ı˘ÓÙ‹˜ : ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ M¤ÏË : ∂. ∞ÁÁÂÏ¿ÎË-°ÂˆÚÁ¿ÎË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ : °. µ·ÚÏ¿Ì˘ : ¶. ∫·ÊÚ›ÙÛ· : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ : £. ∆ÛÈÏÈÁÈ¿ÓÓ˘ : ∫. ∆ÛÔ˘Ì¿Î·˜ : ™. ºˆÙfiÔ˘ÏÔ˜ : A. ÷Ù˙‹˜
Scientific President Editor Members
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘
Manuscript Editing
∂È̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
English Editing Z. Papadopoulou-Couloumbis
∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: (01) 7771 140, Fax: 7758 354
Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: (01) 7771 140, Fax: 7758 354
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Editorial Board : K. Malaka : Z. Papadopoulou-Couloumbis : E. Agelaki-Georgaki : F. Athanassiadou-Piperopoulou : M. Anthrakopoulos : G. Varlamis : P. Kafritsa : A. Konstadopoulos : Th. Tsiligiannis : K. Tsoumakas : S. Fotopoulos : ∞. Hatzis
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July - August 2001
. Volume
64
. No
4
πSSN 0377-2551 i
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫◊” Â›Ó·È Ë Â›ÛËÌË ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ¤ÚÁÔ˘ ÛÙËÓ ∂ÏÏ¿‰· Î·È ÙË Û˘Ó¯‹ È·ÙÚÈ΋ ÂÓË̤ڈÛË Î·È ÂÈÌfiÚʈÛË ÙˆÓ EÏÏ‹ÓˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: ¿ÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜), ·Ó·ÛÎÔ‹ÛÂȘ, ›ηÈÚ· ı¤Ì·Ù·, ÂÍÂÏ›ÍÂȘ ÛÙËÓ π·ÙÚÈ΋ ∂ÈÛÙ‹ÌË, ÚˆÙfiÙ˘Â˜ ÂÚ¢ÓËÙÈΤ˜ ÌÂϤÙ˜ Ì ·È‰È·ÙÚÈÎfi ‹ È·ÙÚÔÎÔÈÓˆÓÈÎfi ÂÚȯfiÌÂÓÔ, ÁÂÓÈο ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÙËÓ ÔÚÁ¿ÓˆÛË Ù˘ È·ÙÚÈ΋˜ Âη›‰Â˘Û˘ Î·È ˘Á›·˜, ‚Ú·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜, ÂÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ, ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ, ‚È‚ÏÈÔÎÚÈۛ˜, ÂÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË, ÂÚÈÏ‹„ÂȘ Ù˘ ÂÏÏËÓÈ΋˜ Î·È Í¤Ó˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ·Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘ÌÔÛ›ˆÓ Î·È Û˘Ó‰ڛˆÓ Û ı¤Ì·Ù· Û¯ÂÙÈο Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È ·Ó·ÊÔÚ¤˜ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜ Î·È Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ‚Ú·‚¢ı› ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÂÙ‹ÛÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜, Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. µ. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫◊” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫◊”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫◊” Î·È Ë ÔÏÈ΋ ‹ ÌÂ-
ÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∏ ¶∞π¢π∞∆ƒπ∫∏ ÚÔÙ›ÓÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals) Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ JAMA 1997;277:927934, http://jama.ama-assn.org/info/auinst_req.html. OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word .doc ‹ MacWrite Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Exel ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 4 ÌËÓÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ÂÙ¿ (7) Ë̤Ú˜. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏ̘ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı›, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (22x28 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È Ê·Ú‰È¿ ÂÚÈıÒÚÈ· (2,5 cm) ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.
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H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ· ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 15-25, ÁÈ· ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 12-15 ÛÂÏ›‰Â˜, ÁÈ· Ù· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 3-5 ‰·ÎÙ˘ÏÔÁÚ·ÊË̤Ó˜ ÛÂÏ›‰Â˜, ÂÓÒ ÁÈ· ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000 ϤÍÂȘ Î·È ÁÈ· ÙȘ ÂÈÛÙÔϤ˜ Û 250-300 ϤÍÂȘ. ™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ) ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·. ¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ¢ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÂÏÏËÓÈÎfi. T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ. K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ∂ÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ªÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. T· ∞ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H ™˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ ηÈ
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‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜. TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ JAMA 1986;255:2329-2339. ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ. BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors / Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JAMA 1997;277:927-934), http://jama.amaassn.org/info/auinst_req.html. OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus (List of Journals Indexed in Index Medicus, http://www.nlm.nih.gov). ¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”. T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÏÂ͛Ԣ ¢, ª¿Ú· Ã, °È·ÓÓ·ÎÔÔ‡ÏÔ˘ Ã. ∂Ì‚fiÏÈ·, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1996;59:272-279.
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™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19.
¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, ÎÏ.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.
Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: ∫Ô˘Ú›‰Ë˜ Ã, ∫Ô˘Ú›‰Ë˜ °. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·ÈÌ›· Û ·È‰È¿ ‚ÔÚÂÈÔ‰˘ÙÈ΋˜ ∫‡ÚÔ˘ [¶ÂÚ›ÏË„Ë]. 36Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1998 5-7 πÔ˘Ó›Ô˘; ¶¿ÊÔ˜, ∫‡ÚÔ˜;1998. ÛÂÏ. 172. Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356. II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500.
¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ - ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜ - 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜ - ÛÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·): ÂÚÈÏ·Ì‚¿ÓÂÈ - Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ - fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· - fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›· - ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ηٿÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ΛÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ¢¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) - ‚È‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó - ÂÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó - Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¡ÙÔ˘ÓÙÔ˘Ï¿Î˘ π. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ÂÍ·ÚıÚ‹Ì·ÙÔ˜ ÙÔ˘ ÈÛ¯›Ô˘ Û ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the
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Paediatriki 2001;64:319-328
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O ÌfiÏ˘‚‰Ô˜ Î·È ÔÈ ÂȉڿÛÂȘ ÙÔ˘ ÛÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡ ∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
Lead and its effects on children's health E. Hatzidaki, C. Giannakopoulou
¶ÂÚ›ÏË„Ë: O ÌfiÏ˘‚‰Ô˜ Â›Ó·È ¤Ó· ̤ٷÏÏÔ ÁÓˆÛÙfi ÛÙÔÓ ¿ÓıÚˆÔ Â‰Ò Î·È 6000 ¯ÚfiÓÈ·. ∞Ú¯Èο, ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙËÓ Î·Ù·Û΢‹ Ì·ÁÂÈÚÈÎÒÓ Û΢ÒÓ, ‰›ÛÎˆÓ Î·È ÂȉÒÓ ‰È·ÎfiÛÌËÛ˘. ™ÙÔÓ ¿ÓıÚˆÔ ¤¯ÂÈ ÙÔÍÈΤ˜ ÂȉڿÛÂȘ Û ÔÏÏ¿ Û˘ÛÙ‹Ì·Ù·, ΢ڛˆ˜ ÛÙÔ ·ÈÌÔÔÈËÙÈÎfi, ÙÔ Ó¢ÚÈÎfi, ÙÔ Ô˘ÚÔÔÈËÙÈÎfi, ·ÎfiÌ· Î·È ÛÙÔ Û‡ÛÙËÌ· ·Ó··Ú·ÁˆÁ‹˜. ∫‡ÚȘ ËÁ¤˜ Ú‡·ÓÛ˘ ·ÔÙÂÏÔ‡Ó Ù· ¯ÚÒÌ·Ù·, ÙÔ ÓÂÚfi, ÙÔ Ê·ÁËÙfi, Ë ÛÎfiÓË, ÙÔ ¯ÒÌ·, Ù· Ì·ÁÂÈÚÈο ÛÎÂ‡Ë Î·È Ë ‚ÂÓ˙›ÓË Ô˘ ÂÚȤ¯ÂÈ ÌfiÏ˘‚‰Ô. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‰ËÏËÙËÚ›·Û˘ ÔÊ›ÏÔÓÙ·È Û ηٿÔÛË Î·È ·ÔÚÚfiÊËÛË ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Ë ¤ÎıÂÛË ÛÙÔ È¯ÓÔÛÙÔÈ¯Â›Ô Á›ÓÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜ ÙÔ˘˜. ∏ ‰ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô ÛÙ· ·È‰È¿ Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ÌÂٷ͇ 2Ô˘ Î·È 3Ô˘ ¤ÙÔ˘˜ ˙ˆ‹˜. ∏ ·ÚÈ· ËÁ‹ ¤ÎıÂÛ˘ ÁÈ· ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ Ù˘ ∞ÌÂÚÈ΋˜, Ê·›ÓÂÙ·È Ó· Â›Ó·È Ù· ¯ÚÒÌ·Ù· ·Ï·ÈÒÓ ÛÈÙÈÒÓ Î·È ·È¯ÓȉÈÒÓ. ™ÙËÓ ∂ÏÏ¿‰·, ÌÂÁ·Ï‡ÙÂÚÔ Úfi‚ÏËÌ· ·ÔÙÂÏ› Ë Ú‡·ÓÛË ÛÙÔ ¯ÒÌ·, ÙË ÛÎfiÓË Î·È Ù· Ê˘Ù¿ Á‡Úˆ ·fi Ù· ÂÚÁÔÛÙ¿ÛÈ· ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘, ηıÒ˜ Î·È Ë ¤ÎıÂÛË ÙˆÓ ·È‰ÈÒÓ ÏfiÁˆ ÙÔ˘ ·ÁÁ¤ÏÌ·ÙÔ˜ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜. ™ÙÔ ·ÚÂÏıfiÓ, ÛËÌ·ÓÙÈ΋ ËÁ‹ ·ÔÙÂÏÔ‡ÛÂ Î·È Ë ‚ÂÓ˙›ÓË. OÈ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÙÒÛÂȘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ™Â ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÚÔηÏ› ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ô˘ ÚÔ‚¿ÏÏÂÈ ÎÏÈÓÈο Ì ÎÂÊ·Ï·ÏÁ›·, ÓˆıÚfiÙËÙ·, Â̤ÙÔ˘˜, ¢ÂÚÂıÈÛÙfiÙËÙ·, Û·ÛÌÔ‡˜, ·Ù·Í›·, Ô›‰ËÌ· ÔÙÈÎÒÓ ıËÏÒÓ, ÎÒÌ· ‹ ·ÎfiÌ· Ô‰ËÁ› Î·È ÛÙÔ ı¿Ó·ÙÔ. ™Â ·È‰È¿ Ì ˘„ËÏ¿ ›‰· ÌÔχ‚‰Ô˘ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ·ÓÔÚÂÍ›·, ÂÚÈÔÚÈṲ̂ÓË ÈηÓfiÙËÙ· Î·È ‰È¿ıÂÛË ÁÈ· ·È¯Ó›‰È, Ì›ˆÛË Ù˘ ÈηÓfiÙËÙ·˜ ÚÔÛÔ¯‹˜,
Abstract: Lead is a metal known to humans for 6000 years. Early uses of lead included the manufacture of utensils, trays, and decorative articles. Lead is toxic to humans. It affects many systems especially the hemopoietic and nervous system, the urinary tract and the reproductive system. Main sources of lead exposure are paints, water, food, dust, soil, utensils, and gasoline containing lead. The majority of the cases of lead poisoning are due to oral ingestion and absorption from the gut. Lead poisoning in adults is due primarily to exposure in the workplace. Lead poisoning in children is a characteristic disease that occurs between the second and third year of life, resulting in United States of America mainly from ingestion of old house lead based paint chips and toys. In Greece, the main problem is found in areas surrounding factories which use lead in production, or in children of workers in such places. In the past lead containing gasoline was also a factor. The most serious complications involve the central nervous system manifested by symptoms of acute encephalopathy, such as persistent vomiting, ataxia, seizures, papilledema, impaired consciousness, coma, or even death. Hyperactivity, anorexia, decreased play activity, low intelligence quotient and poor school performance, can be seen in children with high lead levels. Symptoms from the hemopoietic system include microcytic, hypochromic anaemia with basophilic stipling of the erythrocytes. Lead crosses the placenta during pregnancy and has been associated with intrauterine death, prematurity, and low birth weight. In 1991, the Centers for Disease Control and Prevention in USA
¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
Department of Neonatology of University of Crete
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¶·È‰È·ÙÚÈ΋ 2001;64:319-328
Paediatriki 2001;64:319-328
Û˘ÁΤÓÙÚˆÛ˘ Î·È Ì¿ıËÛ˘, ÌÂȈ̤ÓË ·fi‰ÔÛË ÛÙÔ Û¯ÔÏ›Ô, ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ¯·ÌËÏfi ‰È·ÓÔËÙÈÎfi ËÏ›ÎÔ. ™ÙÔ ·ÈÌÔÔÈËÙÈÎfi Û‡ÛÙËÌ·, Ô ÌfiÏ˘‚‰Ô˜ ÚÔηÏ› ˘fi¯ÚˆÌË, ÌÈÎÚÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· Ì ‚·ÛÂfiÊÈÏË ÛÙ›ÍË ÙˆÓ ÂÚ˘ıÚÒÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, Ô ÌfiÏ˘‚‰Ô˜ ÂÚÓ¿ÂÈ ÙÔÓ Ï·ÎÔ‡ÓÙ· Î·È ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ ı·Ó¿ÙÔ˘˜, ÚÔˆÚfiÙËÙ· Î·È ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ∆Ô 1991, ÙÔ ∫¤ÓÙÚÔ ÂϤÁ¯Ô˘ ÓÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜ ηıfiÚÈÛÂ Û·Ó ˘„ËÏ¿ ›‰· ÌÔχ‚‰Ô˘ Ù· 10 Ìg/dL Î·È ÚfiÙÂÈÓ ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Û ›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 15 Ìg/dL.
redefined elevated blood lead levels as those ≥10 Ìg/dL and recommended a new set of guidelines for the treatment of lead levels ≥15 Ìg/dL.
§¤ÍÂȘ ÎÏÂȉȿ: ÌfiÏ˘‚‰Ô˜, ·È‰›, ‰ËÏËÙËÚ›·ÛË.
Key words: lead, child, poisoning.
O ÌfiÏ˘‚‰Ô˜ Â›Ó·È ¤Ó· ̤ٷÏÏÔ ÁÓˆÛÙfi ÛÙÔÓ ¿ÓıÚˆÔ Â‰Ò Î·È 6000 ¯ÚfiÓÈ· (1). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ Î›Ó‰˘ÓÔÈ Ô˘ ·ÔÚÚ¤Ô˘Ó ·fi ÙË ¯Ú‹ÛË ÙÔ˘ Â›Ó·È ÁÓˆÛÙÔ› ·fi ÙËÓ ·Ú¯·ÈfiÙËÙ·, Ë Â˘Ú›· ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÛÙȘ ̤Ú˜ Ì·˜ ÙÔÓ ¤¯ÂÈ Î·Ù·ÛÙ‹ÛÂÈ ¤Ó·Ó ·fi ÙÔ˘˜ ΢ÚÈfiÙÂÚÔ˘˜ Ú˘·ÓÙ¤˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. OÈ ÁÓÒÛÂȘ Ì·˜ ÁÈ· ÙËÓ ÙÔÍÈÎfiÙËÙ¿ ÙÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ ¤¯Ô˘Ó ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ∞Ú¯Èο, Ë ‰ËÏËÙËÚ›·ÛË Ì ÌfiÏ˘‚‰Ô ıˆڋıËΠ·ÁÁÂÏÌ·ÙÈÎfi ÓfiÛËÌ· Ô˘ ·ÊÔÚ¿ ΢ڛˆ˜ ÂÓ‹ÏÈΘ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ÌÂÙ·ÏÏ›· ‹ ÂÚÁÔÛÙ¿ÛÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô ÌfiÏ˘‚‰Ô˜. ∆· ÙÂÏÂ˘Ù·›·, fï˜, ¯ÚfiÓÈ· ¤ÁÈÓ ·ÓÙÈÏËÙfi fiÙÈ ·ÊÔÚ¿ Î·È ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi: ÂÓ‹ÏÈΘ Î·È ·È‰È¿ fiÏˆÓ ÙˆÓ ÎÔÈÓˆÓÈÎÒÓ Ù¿ÍÂˆÓ Ô˘ ÂÎÙ›ıÂÓÙ·È ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ È¯ÓÔÛÙÔÈ¯Â›Ô (1-4).
ÙÔ 16Ô ·ÈÒÓ· Ì.Ã. ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÁÈ· Ù˘ÔÁÚ·ÊÈο ÛÙÔȯ›·. ∏ Û˘Ó¯‹˜ ·Ó¿Ù˘ÍË Ù˘ Ù¯ÓÔÏÔÁ›·˜, Ë Û˘ÛÛÒÚ¢ÛË ÛÙ· ·ÛÙÈο ΤÓÙÚ· Î·È Ë Ú·Á‰·›· ·‡ÍËÛË ÙˆÓ Ì¤ÛˆÓ ÌÂÙ·ÊÔÚ¿˜, ÂÎÙfi˜ ·fi ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˙ˆ‹˜ ¤ÊÂÚ·Ó Î·È ÙËÓ ÚÔԉ¢ÙÈ΋ ·ÏÏÔ›ˆÛË ÙÔ˘ Ê˘ÛÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. µ·Ú¤· ̤ٷÏÏ·, fiˆ˜ Ô ÌfiÏ˘‚‰Ô˜, Ì‹Î·Ó Ì ÌÂÁ¿ÏË Â˘ÎÔÏ›· ÛÙË Ê·Ú¤ÙÚ· ÙˆÓ ˘ÏÈÎÒÓ Ù˘ Ó¤·˜ Ù¯ÓÔÏÔÁ›·˜ Û ٤ÙÔÈÔ ‚·ıÌfi, ÒÛÙ ӷ ıˆÚÔ‡ÓÙ·È “·ÓÙ·¯Ô‡ ·ÚfiÓÙ·” ÛÙÔ Û‡Á¯ÚÔÓÔ ÂÚÈ‚¿ÏÏÔÓ. ∞fi ÙÔ 1940 ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û·Ó ÚÔÛıÂÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙË ‚ÂÓ˙›ÓË, fiÙ·Ó ¤Ó·˜ ¯ËÌÈÎfi˜ Ì›·˜ ÔÏ˘ÂıÓÈ΋˜ ÂÙ·ÈÚ›·˜ ÂÙÚÂÏ·ÈÔÂȉÒÓ ·Ú·Ù‹ÚËÛ fiÙÈ Ë ÚÔÛı‹ÎË ÙÂÙÚ··Èı˘ÏÈÎÔ‡ ÌÔχ‚‰Ô˘ ÛÙË ‚ÂÓ˙›ÓË ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·fi‰ÔÛË Ù˘ Ì˯·Ó‹˜ Î·È ÂÚÈÔÚ›˙ÂÈ ÙÔ ıfiÚ˘‚Ô (9,10). ¶·Ú¿ÏÏËÏ·, ‚¤‚·È·, Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÂÌÊ·Ó›ÛÙËÎ·Ó Î·È ÔÈ ÚÒÙ˜ ÂӉ›ÍÂȘ ÙÔÍÈÎfiÙËÙ·˜. ∏ ÚÒÙË ·Ó·ÊÔÚ¿ ÎÔÏÈÎÔ‡ ÂÓÙ¤ÚÔ˘ Û ÂÚÁ¿ÙË ÌÂÙ·ÏÏ›Ԣ, ÙÔ 370 .Ã., ¤¯ÂÈ ·Ô‰Ôı› ÛÙÔÓ πÔÎÚ¿ÙË (5,6). O ¡›Î·Ó‰ÚÔ˜, ÙÔ 2Ô ·ÈÒÓ· .Ã., ·Ú·Ù‹ÚËÛ fiÙÈ Ô ÌfiÏ˘‚‰Ô˜ ÚÔηÏ› ÎÔÏÈÎÔ‡˜, ˆ¯ÚfiÙËÙ· Î·È Ì˘˚΋ ·‰˘Ó·Ì›· (11). ¢ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô Û ·È‰›, ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙÔ ™›‰Ó¸ Ù˘ ∞˘ÛÙÚ·Ï›·˜ ÙÔ 1892 (12). ™ÙÔÓ ¿ÓıÚˆÔ, Ô ÌfiÏ˘‚‰Ô˜ ÌÔÚ› Ó· ¤¯ÂÈ ÙÔÍÈΤ˜ ÂȉڿÛÂȘ Û ÔÏÏ¿ Û˘ÛÙ‹Ì·Ù·, ΢ڛˆ˜ ÛÙÔ ·ÈÌÔÔÈËÙÈÎfi, ÙÔ Ó¢ÚÈÎfi, ÙÔ Ô˘ÚÔÔÈËÙÈÎfi, ·ÎfiÌ· Î·È ÛÙÔ Û‡ÛÙËÌ· ·Ó··Ú·ÁˆÁ‹˜ (5,13,14). ∏ ÏËÚ¤ÛÙÂÚË Î·Ù·ÓfiËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜, ·ÏÏ¿ Î·È Ù˘ ¤ÎÙ·Û˘ ÙˆÓ ‚Ï·‚ÒÓ Ô˘ ÚÔηÏ›, Ô‰‹ÁËÛ ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ÙÔ ∫¤ÓÙÚÔ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ÛÙËÓ ·Ó·ÚÔÛ·ÚÌÔÁ‹ ÙˆÓ ·Ô‰ÂÎÙÒÓ Î·ÙÒÙÂÚˆÓ ÔÚ›ˆÓ ÙˆÓ ÙÈÌÒÓ ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì·, Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·. ª¤¯ÚÈ ÙÔ 1970, ÂÚÈÙÒÛÂȘ ‰ËÏËÙËÚ›·Û˘
πÛÙÔÚÈ΋ ·Ó·‰ÚÔÌ‹ ∞Ú¯Èο, Ô ÌfiÏ˘‚‰Ô˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ηٷÛ΢‹ Ì·ÁÂÈÚÈÎÒÓ Û΢ÒÓ, ‰›ÛÎˆÓ Î·È ÂȉÒÓ ‰È·ÎfiÛÌËÛ˘ (5,6). ¶ÔÏÏ¿ ¯ÚfiÓÈ· ÚÈÓ, ‰È¿ÊÔÚÔÈ Ï·Ô› ¿Ú¯ÈÛ·Ó Ó· ÙÔÓ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÁÈ· Ó· ÊÙÈ¿ÍÔ˘Ó ÌÔÁȤ˜ Î·È Î·ÏÏ˘ÓÙÈο. ™Â ›Ó·Î˜ ÊfiÚÔ˘ Ù˘ ÂÔ¯‹˜ ÙÔ˘ º·Ú·Ò Thumosis III (1500 .Ã.) Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙÔ ÌfiÏ˘‚‰Ô. ™ÙË ƒˆÌ·˚΋ ÂÚ›Ô‰Ô ¯ÚËÛÈÌÔÔÈ‹ıËΠÔχ ÛÙËÓ Î·Ù·Û΢‹ ‰Ô¯Â›ˆÓ ·Ú·Û΢‹˜ Î·È ·Ôı‹Î¢Û˘ ÔÙÒÓ, ÛˆÏ‹ÓˆÓ Î·È ‰ÂÍ·ÌÂÓÒÓ ‡‰Ú¢Û˘. ∏ “ȉȿ˙Ô˘Û· Û˘ÌÂÚÈÊÔÚ¿” ÔÏÏÒÓ ƒˆÌ·›ˆÓ ·˘ÙÔÎÚ·ÙfiÚˆÓ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ¯ÚfiÓÈ· ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ·fi ‰ËÏËÙËÚ›·ÛË Ì ÌfiÏ˘‚‰Ô (7). ∆Ô ÁÓˆÛÙfi ÛÙËÓ ·Ú¯·ÈfiÙËÙ· ÌÂÙ·ÏÏÂ›Ô ÙÔ˘ §·˘Ú›Ô˘, ÙÚÔÊÔ‰ÔÙÔ‡Û Ì ÌfiÏ˘‚‰Ô Î·È ·Û‹ÌÈ ÙËÓ ·Ú¯·›· ∞ı‹Ó·, ÛÙËÚ›˙ÔÓÙ·˜ Ô˘ÛÈ·ÛÙÈο ÙËÓ ÔÈÎÔÓÔÌÈ΋ Â˘ÚˆÛÙ›· Ù˘, ¯ˆÚ›˜ ‚¤‚·È· Ó· ·Ê‹ÓÂÈ ·Ó¤·ÊÔ ÙÔ ÂÚÈ‚¿ÏÏÔÓ (8). ªÂ ÙËÓ ÂʇÚÂÛË Ù˘ Ù˘ÔÁÚ·ÊÈ΋˜ Ì˯·Ó‹˜
320
¶·È‰È·ÙÚÈ΋ 2001;64:319-328
ıˆÚÔ‡ÓÙ·Ó ÂΛӘ Ô˘ Ù· ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚ· ·fi 60 Ìg/dL Î·È Â›¯·Ó Û˘Û¯ÂÙÈÛÙ› Ì Â̤ÙÔ˘˜, ¢ÂÚÂıÈÛÙfiÙËÙ·, ÎÔÈÏȷο ¿ÏÁË, Û·ÛÌÔ‡˜, ÎÒÌ· ‹ ·ÎfiÌ· Î·È ı¿Ó·ÙÔ. ∆Ô 1971, ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· ÌÂÁ·Ï‡ÙÂÚ· ·fi 40 Ìg/dL ıˆÚÔ‡ÓÙ·Ó ˘„ËÏ¿, ÁÈ· Ó· ·Ó·ıˆÚËıÔ‡Ó Û 30 Ìg/dL ÙÔ ¤ÙÔ˜ 1975 Î·È 25 Ìg/dL ÙÔ 1985 (2,13). ∆Ô 1991, ÙÔ ∫¤ÓÙÚÔ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜ ηıfiÚÈÛÂ Û·Ó ˘„ËÏ¿ ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· Ù· 10 Ìg/dL Î·È ÚfiÙÂÈÓ ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Û ›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 15 Ìg/dL (2). ¶·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ Ô˘ ¤ÁÈÓ·Ó ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¤ÎıÂÛ˘ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰‡Ô ‰ÂηÂٛ˜, 900.000 ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 6 ÂÙÒÓ ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ∞ÌÂÚÈ΋˜ ¤¯Ô˘Ó ÔÛfiÙËÙ˜ ÌÔχ‚‰Ô˘ Û ›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 10 Ìg/dL (15). ∆Ô 1977, Ë ∂˘Úˆ·˚΋ OÈÎÔÓÔÌÈ΋ ∫ÔÈÓfiÙËÙ· ı¤ÛÈÛ ÙËÓ Ô‰ËÁ›· 77/3122 Ì ı¤Ì· ÙËÓ ·Ó›¯Ó¢ÛË ÏËı˘ÛÌÒÓ Ì ¤ÎıÂÛË ÛÙÔ ÌfiÏ˘‚‰Ô ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ∆· ÂÈÙÚÂÙ¿ fiÚÈ· ÌÔχ‚‰Ô˘ ·›Ì·ÙÔ˜ Ô˘ Û˘ÓÈÛÙÔ‡ÛÂ Ë Ô‰ËÁ›·, ÁÈ· ÏËı˘ÛÌfi ¯ˆÚ›˜ ·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË Û ÌfiÏ˘‚‰Ô, ÔÚ›ÛÙËÎ·Ó Û <20 Ìg/dL ÁÈ· ÙÔ 50% ÙÔ˘ ÏËı˘ÛÌÔ‡, Û <30 Ìg/dL ÁÈ· ÙÔ 90% ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È Û <35 Ìg/dL ÁÈ· ÙÔ 98% ÙÔ˘ ÏËı˘ÛÌÔ‡. ¶·Ú¿ÏÏËÏ·, ÚfiÙÂÈÓ ÙË Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, fiˆ˜ ÙË Ì›ˆÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙË ‚ÂÓ˙›ÓË (16). ŸÙ·Ó ‰ËÌÔÛȇÙËÎÂ Ë Ô‰ËÁ›·, ·Ú’ fiÏÔ Ô˘ Ë ¯ÒÚ· Ì·˜ ‰ÂÓ ‹Ù·Ó ̤ÏÔ˜ Ù˘ ∂˘Úˆ·˚΋˜ ∫ÔÈÓfiÙËÙ·˜, ÚÔÁÚ·ÌÌ·Ù›ÛÙËΠÛÙ·‰È·Î‹ Ì›ˆÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙË ‚ÂÓ˙›ÓË. ∆Ô ª¿ÚÙÈÔ ÙÔ˘ 1980, ÌÂÈÒıËÎÂ Ô ÌfiÏ˘‚‰Ô˜ ÛÙË ‚ÂÓ˙›ÓË ·fi 0,80 g/l Û 0,40 g/l Î·È ÛÙË Û˘Ó¤¯ÂÈ·, ÙÔÓ πÔ‡ÓÈÔ ÙÔ˘ 1983, ÛÙË ‚ÂÓ˙›ÓË Ù‡Ô˘ “ÛÔ‡ÂÚ” ÛÙËÓ ÂÚÈÔ¯‹ ∞ÙÙÈ΋˜ ·fi 0,40 g/l Û 0,15 g/l, ÂÓÒ Û‹ÌÂÚ· ÚÔˆıÂ›Ù·È Ë ¯Ú‹ÛË ·ÌfiÏ˘‚‰Ë˜ ‚ÂÓ˙›Ó˘ (17). ∆Ô 1987, Ô ¶·ÁÎfiÛÌÈÔ˜ OÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ ηıfiÚÈÛÂ Û·Ó ÂÈÙÚÂÙ¿ fiÚÈ· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì·, ÙÈ̤˜ ÌÈÎÚfiÙÂÚ˜ ÙˆÓ 20 Ìg/dL ÁÈ· ÙÔ 98% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, Ì ̤ÛË ÂÈÙÚÂfiÌÂÓË ÙÈÌ‹ Ù· ~10 Ìg/dL (18). ∞ÔÚÚfiÊËÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ·fi ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ∏ ·ÔÚÚfiÊËÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔÓ ¿ÓıÚˆÔ Á›ÓÂÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·, ÏÈÁfiÙÂÚÔ ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ·fi ÙÔ ‰¤ÚÌ· (5,13). ∂›Û˘, Ô ÌfiÏ˘‚‰Ô˜ ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·, ÂÚÓ¿ ÛÙÔ ÂÌ‚Ú˘˚Îfi ·›Ì· Î·È ·ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· (19,20). ∞Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·: O ÌfiÏ˘‚‰Ô˜ ‚Ú›ÛÎÂÙ·È
Paediatriki 2001;64:319-328
ÛÙÔÓ ·¤Ú· Û ÌÔÚÊ‹ ۈ̷Ùȉ›ˆÓ. ∏ ·ÔÚÚfiÊËÛ‹ ÙÔ˘˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘ÁΤÓÙÚˆÛ‹ ÙÔ˘, ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÛˆÌ·Ùȉ›ˆÓ Î·È ÙÔ Ú˘ıÌfi Ù˘ ·Ó·ÓÔ‹˜. ∆· ÌÂÁ·Ï‡ÙÂÚ· ۈ̷ٛ‰È· ·Áȉ‡ÔÓÙ·È ÛÙË Ì‡ÙË, ·’ fiÔ˘ ¤Ó· ÔÛÔÛÙfi ηٷ›ÓÂÙ·È Î·È ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·. ∆· ÌÈÎÚfiÙÂÚ· Û ̤ÁÂıÔ˜ ÊÙ¿ÓÔ˘Ó ÛÙȘ ΢„ÂÏ›‰Â˜ Î·È Â›Ù ʷÁÔ΢ÙÙ·ÚÒÓÔÓÙ·È ·fi Ù· Ì·ÎÚÔÊ¿Á·, ›Ù ·ÔÚÚÔÊÒÓÙ·È Î·Ù¢ı›·Ó ·fi Ù· ÏÂÌÊ·ÁÁ›·. OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔÓ ·¤Ú· Â›Ó·È ÌÈÎÚfiÙÂÚ˜ ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, ÌÂÁ·Ï‡ÙÂÚ˜ ÛÙȘ ·ÛÙÈΤ˜ (fiÔ˘ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË Î˘ÎÏÔÊÔÚ›· ·˘ÙÔÎÈÓ‹ÙˆÓ) Î·È ˘„ËÏfiÙÂÚ˜ Û ÂÚÈÔ¯¤˜ ÌÂÙ·ÏÏÔ˘ÚÁ›ˆÓ (5). ¶ÂÙÈÎfi Û‡ÛÙËÌ·: ∞fi ÙÔ ÌfiÏ˘‚‰Ô Ô˘ ÂÚȤ¯ÂÙ·È ÛÙËÓ ÙÚÔÊ‹, Ô ÂÓ‹ÏÈη˜ ·ÔÚÚÔÊ¿ ÙÔ 10%, ÂÓÒ ÙÔ ·È‰› ÂÚ›Ô˘ ÙÔ 50%. ŸÙ·Ó Ô Û›‰ËÚÔ˜ Î·È ÙÔ ·Û‚¤ÛÙÈÔ ÏÂ›Ô˘Ó ·fi ÙȘ ÙÚÔʤ˜, Ë ·ÔÚÚfiÊËÛË ÙÔ˘ ÌÔχ‚‰Ô˘ Â›Ó·È ·˘ÍË̤ÓË. ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi Â›Ó·È Û˘¯Ófi Û ·È‰È¿ ÔÈÎÔÁÂÓÂÈÒÓ ¯·ÌËÏ‹˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋˜ ηٿÛÙ·Û˘. O ÌfiÏ˘‚‰Ô˜ Ô˘ ÚÔÛÏ·Ì‚¿ÓÂÙ·È Ì ÙËÓ ÙÚÔÊ‹ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË Ú‡·ÓÛË ÙˆÓ ÙÚÔÊ›ÌˆÓ Ê˘ÙÈ΋˜ ‹ ˙ˆÈ΋˜ ÚÔ¤Ï¢Û˘. ªÔÚ› ‰˘ÓËÙÈο Ó· ÚÔÛÙÂı› ÛÙËÓ ÙÚÔÊ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ·Ú·Û΢‹˜ ÙÔ˘ Á‡̷ÙÔ˜ ·fi ÎÔ˘ÙÈ¿ ÎÔÓÛÂÚ‚ÒÓ ‹ ÛÎÂ‡Ë Ì·ÁÂÈÚÈ΋˜, fiˆ˜ ›Û˘ Î·È ·fi ÙÔ ÓÂÚfi Ô˘ ‰ÈÔ¯ÂÙ‡ÂÙ·È ÛÙÔ ‰›ÎÙ˘Ô ‡‰Ú¢Û˘ ·fi ÌÔÏ˘‚‰ÔۈϋÓ˜. O ÌfiÏ˘‚‰Ô˜ Ô˘ ÂÚȤ¯ÂÙ·È ÛÙË ÛÎfiÓË ÌÔÚ› Ó· ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ·ÙÌfiÛÊ·ÈÚ·, ·fi ÙȘ ÌÔÁȤ˜ ÙÔ˘ ÛÈÙÈÔ‡, Â¿Ó Â›Ó·È ·Ï·È¿˜ ηٷÛ΢‹˜, ·ÏÏ¿ Î·È ·fi Ù· ÂÚÁ·ÙÈο ÚÔ‡¯· ÙˆÓ ÁÔÓ¤ˆÓ, fiÙ·Ó Ù· ʤÚÓÔ˘Ó ÛÙÔ Û›ÙÈ (5,21,22). ∂ȉËÌÈÔÏÔÁ›· ∫‡ÚȘ ËÁ¤˜ Ú‡·ÓÛ˘ Ì ÌfiÏ˘‚‰Ô ·ÔÙÂÏÔ‡Ó Ù· ¯ÚÒÌ·Ù·, ÙÔ ÓÂÚfi, ÙÔ Ê·ÁËÙfi, Ë ÛÎfiÓË, ÙÔ ¯ÒÌ·, Ù· Ì·ÁÂÈÚÈο ÛÎÂ‡Ë Î·ıÒ˜ Î·È Ë ‚ÂÓ˙›ÓË Ô˘ ÂÚȤ¯ÂÈ ÌfiÏ˘‚‰Ô. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‰ËÏËÙËÚ›·Û˘ ÔÊ›ÏÔÓÙ·È Û ηٿÔÛË Î·È ·ÔÚÚfiÊËÛË ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Ë ¤ÎıÂÛË ÛÙÔ È¯ÓÔÛÙÔÈ¯Â›Ô Á›ÓÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜ ÙÔ˘˜. ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÔÙÂÏÔ‡Ó ÂÚÁ·˙fiÌÂÓÔÈ Û ÂÚÁÔÛÙ¿ÛÈ· ·Ú·ÁˆÁ‹˜ Î·È ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘ (23). ∏ ·ÚÈ· ËÁ‹ ¤ÎıÂÛ˘ ÁÈ· ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ Ù˘ ∞ÌÂÚÈ΋˜ Ê·›ÓÂÙ·È Ó· Â›Ó·È Ù· ¯ÚÒÌ·Ù· ÛÈÙÈÒÓ Î·È ·È¯ÓȉÈÒÓ ·Ï·È¿˜ ηٷÛ΢‹˜ (5,13,24). ™ÙËÓ ∂ÏÏ¿‰·, ÌÂÁ·Ï‡ÙÂÚÔ Úfi‚ÏËÌ· ·ÔÙÂÏ› Ë Ú‡·ÓÛË ÛÙÔ ¯ÒÌ·, ÙË ÛÎfiÓË Î·È Ù· Ê˘Ù¿ Á‡Úˆ ·fi Ù· ÂÚÁÔÛÙ¿ÛÈ· ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘, ηıÒ˜ Î·È Ë ¤ÎıÂÛË ÙˆÓ
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·È‰ÈÒÓ ÏfiÁˆ ÙÔ˘ ·ÁÁ¤ÏÌ·ÙÔ˜ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜. ™ÙÔ ·ÚÂÏıfiÓ, ÛËÌ·ÓÙÈ΋ ËÁ‹ ÌfiÏ˘ÓÛ˘ ·ÔÙÂÏÔ‡ÛÂ Î·È Ë ‚ÂÓ˙›ÓË (6,8,17). ∆· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÏfiÁˆ Ù˘ ÁÓˆÛÙ‹˜ Û˘Ó‹ıÂÈ·˜ Ó· ʤÚÓÔ˘Ó Ù· ¯¤ÚÈ· ÙÔ˘˜ ÛÙÔ ÛÙfiÌ·, ÚÔÛÏ·Ì‚¿ÓÔ˘Ó ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ Ì ÙËÓ Î·Ù¿ÔÛË (5,13,24). ∏ ‰ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô ÛÙ· ·È‰È¿ Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ÌÂٷ͇ 2Ô˘ Î·È 3Ô˘ ¤ÙÔ˘˜ ˙ˆ‹˜. ∂ÓÙÔ‡ÙÔȘ, οÔȘ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (25,26). ∏ ¤ÎıÂÛË ÛÙÔ ÌfiÏ˘‚‰Ô ÌÔÚ› Ó· ·Ú¯›ÛÂÈ ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ˙ˆ‹, ·ÊÔ‡ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ· (19). ∂›Û˘, ·ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· Û ÌÈÎÚ¤˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Î·È ¤ÙÛÈ Ù· ‚Ú¤ÊË Ô˘ ıËÏ¿˙Ô˘Ó ÚÔÛÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÂÎÎÚÈÓfiÌÂÓË ÔÛfiÙËÙ· ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ Ì ÙÔ ıËÏ·ÛÌfi (20,27). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, Ù· ‚Ú¤ÊË ·˘Ù¿ ‚Ú›ÛÎÔÓÙ·È Û ÏÂÔÓÂÎÙÈÎfiÙÂÚË ı¤ÛË Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ‰È·ÙÚ¤ÊÔÓÙ·È Ì ÂÍ·ÓıÚˆÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜. O ΛӉ˘ÓÔ˜ ÁÈ· Ù· ‚Ú¤ÊË Ô˘ ‰È·ÙÚ¤ÊÔÓÙ·È Ì Ù¯ÓËÙ‹ ÙÚÔÊ‹ ÔÈΛÏÏÂÈ Î·È ÂÍ·ÚÙ¿Ù·È ·ÊÂÓfi˜ ÌÂÓ ·fi ÙËÓ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙÔ˘ ÓÂÚÔ‡ Û ÌfiÏ˘‚‰Ô Î·È ·ÊÂÙ¤ÚÔ˘ ·fi ÙÔ Â›‰Ô˜ ÙˆÓ Û΢ÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ú·Û΢‹ ÙÔ˘ Á¿Ï·ÙÔ˜ (25,26). ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Ì›· ·Û˘Ó‹ı˘ ÂÚ›ÙˆÛË ÌÔÏ˘‚‰›·Û˘ Û ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 5 ÌËÓÒÓ, ‰È·ÙÚÂÊfiÌÂÓÔ ·ÔÎÏÂÈÛÙÈο Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ∏ ÌËÙ¤Ú· ÙÔ˘ ÙÔÔıÂÙÔ‡Û ηχÙÚ˜ ηٷÛ΢·Ṳ̂Ó˜ ·fi ÌfiÏ˘‚‰Ô ÛÙË ıËÏ‹ ÙˆÓ Ì·ÛÙÒÓ Ù˘, ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi οı ıËÏ·ÛÌfi. ¶ÚfiÎÂÈÙ·È ÁÈ· ·Ú¿‰ÔÛË Ô˘ ¤¯ÂÈ ÙȘ Ú›˙˜ Ù˘ ÛÙË ªÈÎÚ¿ ∞Û›·, Ì ÛÎÔfi ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÛÙ‹ıÔ˘˜ ·fi ÙË ‰ËÌÈÔ˘ÚÁ›· Ú·Á¿‰ˆÓ (28). ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, ÔÈ ËÁ¤˜ ¤ÎıÂÛ˘ Â›Ó·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ‰È·ÊÔÚÂÙÈΤ˜ ·fi ·˘Ù¤˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙȘ ·Ó·Ù˘Á̤Ó˜. ™ÙËÓ ∞Û›· Î·È ÙË §·ÙÈÓÈ΋ ∞ÌÂÚÈ΋, ÔÈÎÔÁ¤ÓÂȘ ¯·ÌËÏÔ‡ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÌÂÚÈΤ˜ ÊÔÚ¤˜ ·Ú·‰ÔÛȷο ıÂڷ¢ÙÈο Û΢¿ÛÌ·Ù· Ì ‚¿ÛË ÙÔ ÌfiÏ˘‚‰Ô ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÎÔÏÈÎÒÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙ· ‚Ú¤ÊË, ÙËÓ Â›Û¢ÛË ·Ô‚ÔÏ‹˜ ÌËÎˆÓ›Ô˘ ÛÙ· ÓÂÔÁ¤ÓÓËÙ· ‹ Û·Ó ÚÒÙË ‡ÏË ÁÈ· ηÏÏ˘ÓÙÈο (29-31). ™ÙËÓ ∂ÏÏ¿‰·, ÂÎÙfi˜ ·fi ÙȘ ÙÚÔʤ˜, ·ÚÈ· ËÁ‹ ¤ÎıÂÛ˘ Û ÌfiÏ˘‚‰Ô ·ÔÙÂÏ› Ë Ú‡·ÓÛË ÙÔ˘ ‰¿ÊÔ˘˜ Î·È Ë ÛÎfiÓË ÙˆÓ ‰¤ÓÙÚˆÓ Î·È ÙˆÓ Ê˘ÙÒÓ. O ÌfiÏ˘‚‰Ô˜ ÛÙË ÛÎfiÓË ‚Ú¤ıËΠfiÙÈ ÚÔ¤Ú¯ÂÙ·È Î˘Ú›ˆ˜ ·fi ÂÚÁÔÛÙ¿ÛÈ· ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘, ·ÏÏ¿ Î·È ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÚÔ¯ÔÊfiÚˆÓ Ô˘ ηٷӷÏÒÓÔ˘Ó ‚ÂÓ˙›ÓË ÂÌÏÔ˘ÙÈṲ̂ÓË Ì ÙÂÙÚ··Èı˘ÏÈÎfi ÌfiÏ˘‚‰Ô (6,8,17). ™ÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÂÚÁÔÛÙ·Û›Ô˘ ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘ ÛÙÔ §·‡ÚÈÔ
322
Paediatriki 2001;64:319-328
∞ÙÙÈ΋˜, ‰Â›ÁÌ·Ù· ÙÔ˘ ‰¿ÊÔ˘˜ Î·È ÙˆÓ Ê‡ÏÏˆÓ ‚Ú¤ıËÎ·Ó Ó· ÂÚȤ¯Ô˘Ó ÌfiÏ˘‚‰Ô ÛÂ Û˘ÁÎÂÓÙÚÒÛÂȘ ̤¯ÚÈ Î·È 300 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÂÈÙÚÂÙ¤˜ (32). ™Â ÌÂϤÙË Ù˘ Î. ¡¿ÎÔ˘ Î·È ÙˆÓ Û˘ÓÂÚÁ·ÙÒÓ Ù˘, Ô˘ ‰ËÌÔÛȇÙËΠÙÔ 1989, ÂÍÂÙ¿ÛÙËÎ·Ó ·È‰È¿ Ô˘ ηÙÔÈÎÔ‡Û·Ó ÌfiÓÈÌ· ÛÙÔ §·‡ÚÈÔ ∞ÙÙÈ΋˜ Î·È ‚Ú¤ıËΠfiÙÈ ÙÔ 51% ›¯Â ›‰· ÌÔχ‚‰Ô˘ ·›Ì·ÙÔ˜ >35 Ìg/dL, ÂÓÒ ÙÔ 62% ›¯Â ›‰· ÌÔχ‚‰Ô˘ >30 Ìg/dL. ∞ÓÙ›ıÂÙ·, ÛÙËÓ ∞ÁÈ¿ £ÂÛÛ·Ï›·˜ - ÂÚÈÔ¯‹ Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÂÂÍÂÚÁ·Û›· ÌÔχ‚‰Ô˘ - ηӤӷ ·È‰› ‰ÂÓ Â›¯Â ›‰· ÌÔχ‚‰Ô˘ >30 Ìg/dL, ÂÓÒ ÙÔ ÌÔÓ·‰ÈÎfi ·È‰› Ô˘ ›¯Â >25 Ìg/dL ‰È¤ÌÂÓ ‰›Ï· ÛÙÔ Ú·Ù‹ÚÈÔ ‚ÂÓ˙›Ó˘ ÙÔ˘ ·Ù¤Ú· ÙÔ˘ (33). ∞fi ·Ó¿ÏÔÁË ÌÂϤÙË Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠÛÙË ¯ÒÚ· Ì·˜ Î·È ‰ËÌÔÛȇÙËΠÙÔ 1982, ‚Ú¤ıËΠfiÙÈ Ù· ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· Û ÓÂÔÁ¤ÓÓËÙ· Ô˘ ÔÈ ÌËÙ¤Ú˜ ÙÔ˘˜ ηÙÔÈÎÔ‡Û·Ó ÛÙÔ Î¤ÓÙÚÔ Ù˘ ∞ı‹Ó·˜ ‹Ù·Ó 17-49 Ìg/dL, Ì ̤ÛË ÙÈÌ‹ 31,03 Ìg/dL, ÛÙ· ÓÂÔÁ¤ÓÓËÙ· ·fi Ù· ÚÔ¿ÛÙÈ· 13-43 Ìg/dL, Ì ̤ÛË ÙÈÌ‹ 26,94 Ìg/dL, ÂÓÒ ÛÙ· ÓÂÔÁ¤ÓÓËÙ· ·fi ÙËÓ ‡·ÈıÚÔ 9-35 Ìg/dL, Ì ̤ÛË ÙÈÌ‹ 21,66 Ìg/dL. ∏ ÙÈÌ‹ ÙÔ˘ ÌÔχ‚‰Ô˘ Û ·È‰È¿ Ô˘ ηÙÔÈÎÔ‡Û·Ó ÛÙȘ ‚ÈÔÌ˯·ÓÈΤ˜ Û˘ÓÔÈ˘ ÙÔ˘ ¶ÂÈÚ·È¿ ‹Ù·Ó 5,6-63 Ìg/dL, Ì ̤ÛË ÙÈÌ‹ 32,30 Ìg/dL, ÂÓÒ ÛÙËÓ ‡·ÈıÚÔ 9-32 Ìg/dL, Ì ̤ÛË ÙÈÌ‹ 22,98 Ìg/dL. ™Â ÛÙÚ·ÙÈÒÙ˜ Ô˘ ηÙÔÈÎÔ‡Û·Ó ÛÙÔ Î¤ÓÙÚÔ Ù˘ ∞ı‹Ó·˜ Î·È Ù· ÚÔ¿ÛÙÈ·, Ë Ì¤ÛË ÙÈÌ‹ ‹Ù·Ó 27,03 Ìg/dL, ÂÓÒ ÛÙËÓ ‡·ÈıÚÔ ‹Ù·Ó 18,81 Ìg/dL. ™Ù· ·È‰È¿ ·fi ÙÔ §·‡ÚÈÔ, Û ÂÚÈÔ¯‹ Ì ÂÚÁÔÛÙ¿ÛÈÔ ÂÂÍÂÚÁ·Û›·˜ ÌÔχ‚‰Ô˘, Ë Ì¤ÛË ÙÈÌ‹ ‹Ù·Ó 77,71 Ìg/dL (8). ∆Ô 1981-1982, Û ‰Â›ÁÌ· ÏËı˘ÛÌÔ‡ ∞ı‹Ó·˜ Î·È ¶ÂÈÚ·È¿ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ù· ›‰· ÌÔχ‚‰Ô˘ ·›Ì·ÙÔ˜ Û 606 ÂÓ‹ÏÈΘ Î·È 206 ·È‰È¿ Î·È ‚Ú¤ıËÎ·Ó 3-35 Ìg/dL Ì ‰È¿ÌÂÛË ÙÈÌ‹ 13,5 Ìg/dL Î·È 6-36 Ìg/dL Ì ‰È¿ÌÂÛË ÙÈÌ‹ 12 Ìg/dL, ·ÓÙ›ÛÙÔȯ·. ∆· ˘„ËÏfiÙÂÚ· ›‰· ‚Ú¤ıËÎ·Ó ÛÙÔ˘˜ ηÙÔ›ÎÔ˘˜ Ù˘ ‚ÈÔÌ˯·ÓÈ΋˜ ˙ÒÓ˘ Î·È Ù· ¯·ÌËÏfiÙÂÚ· ÛÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ÙˆÓ ÚÔ·ÛÙ›ˆÓ Î·È ÛÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ÙÔ˘ ΤÓÙÚÔ˘ ÂӉȿÌÂÛ·. ™ÙË Û˘Ó¤¯ÂÈ·, ¤ÁÈÓ ·Ú·ÎÔÏÔ‡ıËÛË ÌÈÎÚÒÓ ˘ÔÔÌ¿‰ˆÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÙËÓ ÂÚ›Ô‰Ô 1984-1986 Î·È ‰È·ÈÛÙÒıËΠ̛· ÂÈϤÔÓ Ì›ˆÛË Î·Ù¿ 1-3,8 Ìg/dL ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ÌÔχ‚‰Ô˘ Ô˘ ›¯·Ó ‹‰Ë ÌÂȈı› Û ۯ¤ÛË Ì ÙȘ ÙÈ̤˜ ÙÔ˘ 1981-1982, ÁÂÁÔÓfi˜ Ô˘ ÂӉ¯Ô̤ӈ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙË Ì›ˆÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙË ‚ÂÓ˙›ÓË (17). ™ÙË ¯ÒÚ· Ì·˜, ›Û˘, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ ÌÔÏ˘‚‰›·Û˘ Û ·È‰È¿ ÁÔÓ¤ˆÓ Ô˘ ηٷÛ··˙·Ó Û˘ÛÛˆÚÂ˘Ù¤˜ ·fi ÌfiÏ˘‚‰Ô ‹ ¤‚·Ê·Ó ‹ÏÈÓ· ‰Ô¯Â›·, ÙˆÓ ÔÔ›ˆÓ Ù· ÂÚÁ·ÛÙ‹ÚÈ· ‚Ú›ÛÎÔÓÙ·Ó ÛÙÔ Û›ÙÈ ÙÔ˘˜ (34).
¶·È‰È·ÙÚÈ΋ 2001;64:319-328
∞¤ÎÎÚÈÛË ÌÔχ‚‰Ô˘ ·fi ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi O ÌfiÏ˘‚‰Ô˜ ‰ÂÓ ÌÂÙ·‚ÔÏ›˙ÂÙ·È ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi, ·ÏÏ¿ ·ÔıË·ÂÙ·È Î˘Ú›ˆ˜ ÛÙ· ÔÛÙ¿ Ì ÙË ÌÔÚÊ‹ ·‰È¿Ï˘ÙÔ˘ ÙÚÈÙÔÙ·ÁÔ‡˜ ʈÛÊÔÚÈÎÔ‡ ÌÔχ‚‰Ô˘. ∞ÂÎÎÚ›ÓÂÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi Î·È ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·, ηıÒ˜ Î·È ·fi ÙÔÓ È‰ÚÒÙ·, Ù· Ì·ÏÏÈ¿ Î·È Ù· Ó‡¯È·. OÈ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ ÛÙ· Ì·ÏÏÈ¿, Ù· ÎfiÚ·Ó·, Ù· Ó‡¯È· Î·È Ù· Ô‡Ú· ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û·Ó ‰Â›ÎÙ˜ ÌÔÏ˘‚‰›·Û˘ (5,35). ∫·Ù·ÓÔÌ‹ ÌÔχ‚‰Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ∏ Û˘ÛÛÒÚ¢ÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ·ÓıÚÒÈÓÔ ÛÒÌ· ·Ú¯›˙ÂÈ ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ÎÈfiÏ·˜ ˙ˆ‹ (19). ∏ Û˘ÛÛÒÚ¢ÛË ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi Â›Ó·È ÚÔԉ¢ÙÈ΋ Î·È ÛÙ·Ì·Ù¿ÂÈ Ì ÙÔ ı¿Ó·ÙÔ ÙÔ˘ ·ÙfiÌÔ˘. ªÂÙ¿ ÙËÓ ·ÔÚÚfiÊËÛ‹ ÙÔ˘ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ‹ ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÂÚÓ¿ÂÈ ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, ·' fiÔ˘ ¤Ó· ̤ÚÔ˜ ÙÔ˘ ·ÂÎÎÚ›ÓÂÙ·È, ÂÓÒ ÙÔ ˘fiÏÔÈÔ Î·Ù·Ó¤ÌÂÙ·È ÛÙÔ˘˜ ÈÛÙÔ‡˜. O ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÛÙÔ ·›Ì· Â›Ó·È ÂÚ›Ô˘ 30 Ë̤Ú˜. ∆Ô 99% ÂÚ›Ô˘ ÙÔ˘ ÌÔχ‚‰Ô˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÂÓÙÔ›˙ÂÙ·È ÛÙ· ÂÚ˘ıÚ¿ ·ÈÌÔÛÊ·›ÚÈ·, ÂÓÒ ÙÔ ˘fiÏÔÈÔ Î˘ÎÏÔÊÔÚ› ÛÙÔ Ï¿ÛÌ· Î·È Â›Ó·È Ô˘ÛÈ·ÛÙÈο ·˘Ùfi Ô˘ ÂÓ·ÔÙ›ıÂÙ·È ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ‰Ú· ÙÔÍÈο ÛÙ· ‰È¿ÊÔÚ· fiÚÁ·Ó· (36,37). ¶ÂÚ›Ô˘ ÙÔ 90-95% ·ÔıË·ÂÙ·È ÛÙ· ÔÛÙ¿. ∞˘ÍË̤ÓË ÎÈÓËÙÔÔ›ËÛË ÌÔχ‚‰Ô˘ ·fi Ù· ÔÛÙ¿ ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ Î·È Ù˘ Á·ÏÔ˘¯›·˜ (20,38,39)Ø Â›Û˘, Û ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· ÙˆÓ ÔÛÙÒÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ËÌÂÈÔıÂڷ›·˜, ÌÂÙÂÌÌËÓÔ·˘Ûȷ΋˜ ÔÛÙÂÔfiÚˆÛ˘ Î·È ˘ÂÚı˘ÚÂÔÂȉÈÛÌÔ‡ (40-42). Œ¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ ÙÔ ÔÛÔÛÙfi Ô˘ ÂÓÙÔ›˙ÂÙ·È ÛÙ· ÔÛÙ¿ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ÌÈÎÚfiÙÂÚÔ Û ۯ¤ÛË Ì ·˘Ùfi ÙˆÓ ÂÓËÏ›ÎˆÓ Î·È ÌÔÚ› Ó· ÎÈÓËÙÔÔÈËı› Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÚÔ˜ ÙËÓ Î˘ÎÏÔÊÔÚ›·, ΢ڛˆ˜ Û ÂÚ›ÙˆÛË Ïԛ̈͢ ‹ ÔͤˆÛ˘. O ÌfiÏ˘‚‰Ô˜ ÙˆÓ ÔÛÙÒÓ ·ÂÈÎÔÓ›˙ÂÙ·È ·ÎÙÈÓÔÏÔÁÈο Û·Ó ˘ÎÓ¤˜ ÁÚ·Ì̤˜ ÛÙȘ ÌÂٷʇÛÂȘ. ∂ÎÙfi˜ ·fi Ù· ÔÛÙ¿, Ì·ÎÚfi¯ÚÔÓË ·Ôı‹Î¢ÛË Á›ÓÂÙ·È Î·È ÛÙ· ‰fiÓÙÈ·. O ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÙÔ˘ ÌÔχ‚‰Ô˘ ÙˆÓ ÔÛÙÒÓ Â›Ó·È 30 ¯ÚfiÓÈ·, ÂÓÒ ÂΛÓÔ˘ ÙˆÓ ·ÚÂÁ¯˘Ì·ÙÈÎÒÓ ÔÚÁ¿ÓˆÓ 30 Ë̤Ú˜ (43,44). ∆ÔÍÈÎfiÙËÙ· ÙÔ˘ ÌÔχ‚‰Ô˘ O ÌfiÏ˘‚‰Ô˜ Û˘ÛÛˆÚ‡ÂÙ·È ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ÚÔηÏÒÓÙ·˜ ÙÔÍÈΤ˜ ÂȉڿÛÂȘ Û ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·, ΢ڛˆ˜ ÛÙÔ ·ÈÌÔÔÈËÙÈÎfi, ÙÔ Ó¢ÚÈÎfi, ÙÔ Ô˘ÚÔÔÈËÙÈÎfi, ·ÎfiÌ· Î·È ÛÙÔ Û‡ÛÙËÌ· ·Ó··Ú·ÁˆÁ‹˜. ∆· ›‰· ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· ıˆÚÔ‡ÓÙ·È Î·Ïfi˜ ‰Â›ÎÙ˘ ÚfiÛÊ·Ù˘ ¤ÎıÂÛ˘. ∏ ÙÔÍÈÎfiÙËÙ¿ ÙÔ˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ÈηÓfiÙËÙ¿
Paediatriki 2001;64:319-328
ÙÔ˘ Ó· ·ÓÙȉڿ Ì ÙȘ ÛÔ˘ÏÊȉÚÈΤ˜ ÔÌ¿‰Â˜ Û ‰È¿ÊÔÚ· ¤Ó˙˘Ì· Î·È Ó· Ù· ·‰Ú·ÓÔÔÈ› (13,43,44). ∞ÈÌÔÔÈËÙÈÎfi Û‡ÛÙËÌ·: O ÌfiÏ˘‚‰Ô˜ ·ÚÂÌÔ‰›˙ÂÈ ÙË ‚ÈÔÛ‡ÓıÂÛË Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·‰Ú·ÓÔÔÈÒÓÙ·˜ Ù· ¤Ó˙˘Ì· Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙË ÌÂÙ·‚ÔÏÈ΋ Ù˘ Ô‰fi Î·È ÚÔηÏ› ˘fi¯ÚˆÌË, ÌÈÎÚÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· Ì ‚·ÛÂfiÊÈÏË ÛÙ›ÍË ÙˆÓ ÂÚ˘ıÚÒÓ. ∏ ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË ·Ú¯›˙ÂÈ Ó· Á›ÓÂÙ·È ÂÌÊ·Ó‹˜, fiÙ·Ó Ù· ›‰· ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ ÊÙ¿ÛÔ˘Ó Ù· 20 Ìg/dL. ∂ӉȿÌÂÛÔÈ ÌÂÙ·‚Ôϛ٘, fiˆ˜ ‰-·ÌÈÓÔÏ‚ԢÏÈÓÈÎfi Ô͇ Î·È ÚˆÙÔÔÚÊ˘Ú›ÓË ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ·˘Í¿ÓÔÓÙ·È ÚÔԉ¢ÙÈο Î·È ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û·Ó ‰Â›ÎÙ˜ Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∏ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‰Â¸‰Ú·Ù¿ÛË ÙÔ˘ ·ÌÈÓÔÏ‚ԢÏÂÓÈÎÔ‡ ÔͤԘ ¤¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ ·Ú¯›˙ÂÈ Ó· ÂËÚ¿˙ÂÙ·È Û ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· 3-5 Ìg/dL. ∏ ÚˆÙÔÔÚÊ˘Ú›ÓË ÙˆÓ ÂÚ˘ıÚÒÓ ·˘Í¿ÓÂÙ·È Û ÂÚ›ÙˆÛË ‰ËÏËÙËÚ›·Û˘ Ì ÌfiÏ˘‚‰Ô (ÏfiÁˆ ·Ó·ÛÙÔÏ‹˜ Ù˘ Û˘ÓıÂÙ¿Û˘ Ù˘ ·›Ì˘), ·ÏÏ¿ Î·È Û ÛȉËÚÔÂÓ›·. ™Â ÂÚ›ÙˆÛË ÛȉËÚÔÂÓ›·˜, ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰¤ÛÌÂ˘Û‹ Ù˘ Ì ۛ‰ËÚÔ Î·È ‰ÂÛ̇ÂÙ·È Ì „¢‰¿ÚÁ˘ÚÔ, Û¯ËÌ·Ù›˙ÔÓÙ·˜ ÙËÓ ÚˆÙÔÔÚÊ˘Ú›ÓË ÙÔ˘ „¢‰·ÚÁ‡ÚÔ˘. ™ÙȘ ÌÔÏ˘‚‰È¿ÛÂȘ, ÙÔ 90% Ù˘ ÚˆÙÔÔÚÊ˘Ú›Ó˘ ÙˆÓ ÂÚ˘ıÚÒÓ Â›Ó·È Û ÌÔÚÊ‹ ÚˆÙÔÔÚÊ˘Ú›Ó˘ ÙÔ˘ „¢‰·ÚÁ‡ÚÔ˘ (14,40,44-46). ¡Â˘ÚÈÎfi Û‡ÛÙËÌ·: OÈ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÙÒÛÂȘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ™Â ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÚÔηÏ› ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ô˘ ÚÔ‚¿ÏÂÈ ÎÏÈÓÈο Ì ÎÂÊ·Ï·ÏÁ›·, ÓˆıÚfiÙËÙ·, Â̤ÙÔ˘˜, ¢ÂÚÂıÈÛÙfiÙËÙ·, Û·ÛÌÔ‡˜, ·Ù·Í›·, Ô›‰ËÌ· ÔÙÈÎÒÓ ıËÏÒÓ, ÎÒÌ· ‹ Ô‰ËÁ› ·ÎfiÌ· Î·È ÛÙÔ ı¿Ó·ÙÔ. ™˘Ìو̷ÙÔÏÔÁ›· ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Î·È Û ›‰· ÌÈÎÚfiÙÂÚ· ÙˆÓ 100 Ìg/dL. ÀÂÚÎÈÓËÙÈÎfiÙËÙ·, ·ÓÔÚÂÍ›·, ÂÚÈÔÚÈṲ̂ÓË ÈηÓfiÙËÙ· Î·È ‰È¿ıÂÛË ÁÈ· ·È¯Ó›‰È, Ì›ˆÛË Ù˘ ÈηÓfiÙËÙ·˜ ÚÔÛÔ¯‹˜, Û˘ÁΤÓÙÚˆÛ˘ Î·È Ì¿ıËÛ˘, ÌÂȈ̤ÓË ·fi‰ÔÛË ÛÙÔ Û¯ÔÏ›Ô, ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ¯·ÌËÏfi ‰È·ÓÔËÙÈÎfi ËÏ›ÎÔ, ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó Û ·È‰È¿ Ì ›‰· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· 35 Ìg/dL ‹ Î·È ¯·ÌËÏfiÙÂÚ· (14,45,47-52). ∏ ¤ÎıÂÛË ÛÙÔ ÌfiÏ˘‚‰Ô ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· Û¯ÂÙ›˙ÂÙ·È Ì ÂÁÎÂÊ·ÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ô˘ ÂÈ̤ÓÂÈ Ì¤¯ÚÈ Î·È 50 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË (53-55). O Needleman Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘, Û ÌÈ· Ôχ ÂӉȷʤÚÔ˘Û· ÌÂϤÙË ÙÔ˘˜, Û˘Û¯ÂÙ›˙Ô˘Ó ÙÔ ÌfiÏ˘‚‰Ô Ù˘ Ô‰ÔÓÙ›Ó˘ Ì ÙÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ·Û˘Ìو̷ÙÈÎÒÓ ·È‰ÈÒÓ. ∆· ·È‰È¿ Ì ÙȘ ˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ›¯·Ó ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ¯·ÌËÏfiÙÂÚÔ Î·Ù¿ Ù¤ÛÛÂÚȘ ‚·ıÌÔ‡˜, Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· Ì ÙȘ ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜. ∂›Û˘, Ù· ·È‰È¿ ·˘Ù¿ ˘ÛÙÂÚÔ‡Û·Ó Û ÏÂÈÙÔ˘ÚÁ›Â˜, fiˆ˜ Ë ÏÂÎÙÈ΋ ÈηÓfiÙËÙ· Î·È Ë ÚÔÛÔ¯‹ (56).
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∞Ó¿ÏÔÁË ÌÂϤÙË, Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ ·fi ÙÔÓ Î. ÷Ù˙¿ÎË Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘, ˘Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Û οı ·‡ÍËÛË Î·Ù¿ 10 Ìg/dL Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ Û ÌfiÏ˘‚‰Ô, ÙÔ ÓÔËÙÈÎfi ËÏ›ÎÔ ÂÌÊ·Ó›˙ÂÈ ÙÒÛË Î·Ù¿ 2,7 ÌÔÓ¿‰Â˜. ∏ ÌÂϤÙË ÙÔ˘˜ ÂÚȤϷ‚ 509 ·È‰È¿ Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ÌÔχ‚‰Ô˘ ÙÔ˘ ·›Ì·ÙÔ˜ ‹Ù·Ó 23,7 Ìg/dL. OÈ ÂȉڿÛÂȘ ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ÓÔËÙÈÎfi ËÏ›ÎÔ ‹Ù·Ó ÂÓÙÔÓfiÙÂÚ˜ Û ›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 25 Ìg/dL (57). ∞fi ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ ¤¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ Ô ÌfiÏ˘‚‰Ô˜ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Ó¢ÚÔÌÂÙ·‚È‚·ÛÙÒÓ, ÚÔηÏ› ·ÔÌ˘ÂϛӈÛË ÙˆÓ Ó¢ڷÍfiÓˆÓ, ÂÌÔ‰›˙ÂÈ ÙË ÌÂÙ·‚›‚·ÛË ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë Î·È ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ ÔÍ›· ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Â›Ó·È Ë ÛÔ‚·ÚfiÙÂÚË ÌÔÚÊ‹ ‰ËÏËÙËÚ›·Û˘ (56,58,59). ∏ ÂÚÈÊÂÚÈ΋ Ó¢ڛÙȉ· ··ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ· ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ¤¯ÂÈ ˘ÔÛÙËÚȯÙ› fiÙÈ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ ÛÙËÓ Ù·¯‡ÙËÙ· ·ÁˆÁ‹˜ ÙˆÓ Ó‡ڈÓ. ™Ù· ·È‰È¿ ··ÓÙ¿Ù·È Ôχ Û¿ÓÈ·, Â¿Ó ÂÍ·ÈÚ¤ÛÂÈ Î·Ó›˜ ·˘Ù¿ Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ. ∆˘Èο, ÚÔÛ‚¿ÏÏÂÈ ÙÔ˘˜ ÂÎÙ›ÓÔÓÙ˜ Ì˘˜, Ì ÌÈÎÚ‹ ·ÒÏÂÈ· Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜ (14, 45,60). O˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ·: ™Â ·È‰È¿ Ì ÌÔÏ˘‚‰›·ÛË ¤¯ÂÈ ·Ú·ÙËÚËı› Û‡Ó‰ÚÔÌÔ Fanconi, Ì ·ÌÈÓÔ͢Ԣڛ·, ÁÏ˘ÎÔ˙Ô˘Ú›·, ʈÛÊ·ÙÔ˘Ú›· Î·È ÌÂȈ̤ÓË ÛˆÏËÓ·Úȷ΋ ·ӷÚÚfiÊËÛË. ∞˘Ù‹ Ë ‰È·Ù·Ú·¯‹ ·Ó·Ê¤ÚÂÙ·È Î˘Ú›ˆ˜ Û ·È‰È¿ Î·È Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË. ™ÙÔ˘˜ ÂÓ‹ÏÈΘ ¤¯ÂÈ ÂÚÈÁÚ·Ê›, ΢ڛˆ˜, Ë ¯ÚfiÓÈ· ÌÔÚÊ‹, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È¿ÌÂÛË ›ÓˆÛË, ·˙ˆıÂÌ›· Î·È ÌÂȈ̤ÓË ÛÂÈÚ·Ì·ÙÈ΋ ‰È‹ıËÛË (14,45). O Loghman-Adham Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÂÎÙ›ÌËÛ·Ó ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û 134 ·È‰È¿ Î·È Ó¤Ô˘˜ ÂÓ‹ÏÈΘ 8 Ì 13 ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì ¯ËÏÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ·’ fiÔ˘ Î·È ‰È·ÈÛÙÒıËΠfiÙÈ Ë ‰È·Ù·Ú·¯‹ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· ÂÈ̤ÓÂÈ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 13 ¯ÚfiÓÈ·. ∏ ‚Ï¿‚Ë ÌÔÚ› Ó· ÂΉËψı› ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ÙËÓ ¤ÎıÂÛË ÛÙÔ ÌfiÏ˘‚‰Ô (61). ∏ ˘¤ÚÙ·ÛË Ô˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ì ·˘ÍË̤ÓÔ ÊÔÚÙ›Ô ÌÔχ‚‰Ô˘ ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ Û¯¤ÛË Ì ÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘. ∏ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ 1,25 ‰È¸‰ÚÔ͢‚ÈÙ·Ì›Ó˘ D ÛÙÔÓ ÔÚfi, Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ÛÙ· ·È‰È¿ Ì ·˘ÍË̤ӷ ›‰· ÌÔχ‚‰Ô˘, ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÙÔÍÈ΋ ›‰Ú·ÛË ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ ÛÙË ‚ÈÔÛ‡ÓıÂÛË Ù˘ ‚ÈÙ·Ì›Ó˘ ÛÙ· ÓÂÊÚÈο ·ÙÙ·Ú· (14,45,62). ÕÏÏ· Û˘ÛÙ‹Ì·Ù·: ∏ ‰ËÏËÙËÚ›·ÛË Ì ÌfiÏ˘‚‰Ô ÚÔηÏ› ÎÔÏÈÎÔ‡˜ ÂÓÙ¤ÚÔ˘ Î·È ‰˘ÛÎÔÈÏÈfiÙËÙ·
324
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(14). ÷ÌËÏÔ› Ú˘ıÌÔ› ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ (63), ÌÂȈ̤ÓÔ˜ ·ÚÈıÌfi˜ Î·È Î·Î‹ ÎÈÓËÙÈÎfiÙËÙ· ÛÂÚÌ·ÙÔ˙ˆ·Ú›ˆÓ Û ÂÓ‹ÏÈΘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓË ÔÛfiÙËÙ· ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· (14,64). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, Ô ÌfiÏ˘‚‰Ô˜ ÂÚÓ¿ÂÈ ÙÔÓ Ï·ÎÔ‡ÓÙ· Î·È ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÂÓ‰ÔÌ‹ÙÚÈÔ˘˜ ı·Ó¿ÙÔ˘˜, ÚÔˆÚfiÙËÙ· Î·È ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ Á·ÏÔ˘¯›·˜, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ·ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï·. ŒÙÛÈ, ÙÔ ÓÂÔÁÓfi Î·È ÙÔ ÌÈÎÚfi ‚Ú¤ÊÔ˜ ÌÔÚ› Ó· ·ÔÎÙ‹ÛÂÈ - ·fi ÙÔ Á¿Ï· Î·È ÌfiÓÔ - ÛËÌ·ÓÙÈο ›‰· ÌÔχ‚‰Ô˘, Û ̛· ÂÚ›Ô‰Ô Ô˘ ÔÈ ·Ó·Ù˘ÛÛfiÌÂÓÔÈ ÈÛÙÔ› Î·È È‰È·›ÙÂÚ· Ô ÂÁΤʷÏÔ˜ Â›Ó·È ·ÚÎÂÙ¿ ¢¿ÏˆÙÔÈ (39,45, 49,64,65). ∂ÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ∆· ›‰· ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· Â›Ó·È Ë ÂÚÈÛÛfiÙÂÚÔ ‰È·‰Â‰Ô̤ÓË ÂÚÁ·ÛÙËÚȷ΋ ̤ıÔ‰Ô˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙÔ˘. O ÌfiÏ˘‚‰Ô˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·ÔÙÂÏ› ÙÔ ÙÌ‹Ì· ÂΛÓÔ Ô˘ ηٷӤÌÂÙ·È ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÚÔηÏ› ÙȘ ÙÔÍÈΤ˜ ÂȉڿÛÂȘ ÛÙ· ‰È¿ÊÔÚ· fiÚÁ·Ó·-ÛÙfi¯Ô˘˜. µÚ›ÛÎÂÙ·È, fï˜, Û ÌÈÎÚ¿ ÔÛ¿ Î·È ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ‰‡ÛÎÔÏ·. ∏ ÚˆÙÔÔÚÊ˘Ú›ÓË ÙˆÓ ÂÚ˘ıÚÒÓ ·ÓÙ·Ó·ÎÏ¿ ÙË ‰È·Ù·Ú·¯‹ ÛÙË Û‡ÓıÂÛË Ù˘ ·›Ì˘. ∞˘ÍË̤ÓË ‚Ú›ÛÎÂÙ·È Î·È Û ÂÚÈÙÒÛÂȘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ Î·È ÛȉËÚÔÂÓ›·˜. ™ÙÔ ·ÚÂÏıfiÓ, ›¯Â ¯ÚËÛÈÌÔÔÈËı› Û·Ó ·Ú¯ÈÎfi˜ ·ÓȯÓ¢ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÊÔ‡ Â›Ó·È ÊıËÓfiÙÂÚË Î·È ÈÔ Â‡ÎÔÏ· ‰È·ı¤ÛÈÌË Ì¤ıÔ‰Ô˜. ªÂ ‰Â‰Ô̤ÓË ÙËÓ ·‰˘Ó·Ì›· Ù˘ Ó· ·ÓȯÓ‡ÛÂÈ Â›Â‰· ÌÔχ‚‰Ô˘ ÌÂٷ͇ 10 Î·È 25 Ìg/dL, Ù›ÓÂÈ Ó· ÂÁηٷÏÂÈÊı› Û·Ó Ì¤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ (13,14,46,66). OÈ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ ÛÙ· Ì·ÏÏÈ¿ Î·È Ù· Ó‡¯È· ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û·Ó ‰Â›ÎÙ˜ ÌÔÏ˘‚‰›·Û˘ (5,35). O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÛÙË ‰ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô, ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÎÙÈÓÔÁڷʛ˜ Ù˘ ÎÔÈÏȷ΋˜ ¯ÒÚ·˜ Î·È ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ. ™Ù· ÔÛÙ¿ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Â›Ó·È ÔÈ ÁÚ·ÌÌÒÛÂȘ ÛÙȘ ÂÈʇÛÂȘ, ÔÈ Ôԛ˜ ‚¤‚·È· ‰ÂÓ ·ÔÙÂÏÔ‡Ó Â˘·›ÛıËÙË Ì¤ıÔ‰Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ‰ËÏËÙËÚ›·Û˘ ·fi ÌfiÏ˘‚‰Ô. ÷ڷÎÙËÚÈÛÙÈΤ˜ ÛÙ· ÔÛÙ¿ Â›Ó·È ÔÈ ÁÚ·ÌÌÒÛÂȘ ÛÙȘ ÂÈʇÛÂȘ. ∞Ú¯Èο, ÔÈ ·ÏÏÔÈÒÛÂȘ ÂÓÙÔ›˙ÔÓÙ·È ÎÔÓÙ¿ ÛÙȘ ÂÈʇÛÂȘ. ªÂ ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, fï˜, ÌÂÙ·ÙÔ›˙ÔÓÙ·È ÚÔ˜ ÙË ‰È¿Ê˘ÛË ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ. ŸÛÔ ÎÂÓÙÚÈÎfiÙÂÚ·, ÏÔÈfiÓ, ÙȘ ‚Ú›ÛÎÔ˘ÌÂ, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ ‰È¿ÛÙËÌ· ¤¯ÂÈ ÂÚ¿ÛÂÈ ·fi ÙËÓ ¤ÎıÂÛË. ™ÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ· ÌÔÚ› Ó· ‰È·Ê·ÓÔ‡Ó ÁÚ·Ì̤˜ ÌÔχ‚‰Ô˘ ‹ ·ÎfiÌ· Î·È ÌÈÎÚ¿ ÙÂÌ¿¯È· Ô˘ ÂÚȤ¯Ô˘Ó ÌfiÏ˘‚‰Ô Ô˘ ÂӉ¯Ô̤ӈ˜ ¤¯Ô˘Ó ηٷÔı› (14,45,67).
¶·È‰È·ÙÚÈ΋ 2001;64:319-328
¶ÚfiÏË„Ë ¶ÚˆÙÔÁÂÓ‹˜ ÚfiÏË„Ë: ™ÙË Û‡Á¯ÚÔÓË ÎÔÈÓˆÓ›·, Ù· ·È‰È¿ Ù˘ ÚÔÛ¯ÔÏÈ΋˜ ·ÏÏ¿ Î·È Ù˘ ÚÒÙ˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ‰È¿ÁÔ˘Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ˙ˆ‹˜ ÙÔ˘˜ Û ÂÚÈ‚¿ÏÏÔÓ ÂÎÙfi˜ ÙÔ˘ ÛÈÙÈÔ‡. ¶·Ú·ÎÔÏÔ˘ıÔ‡Ó ÚÔÁÚ¿ÌÌ·Ù· ‚ÚÂÊÔÓËÈ·ÎÒÓ, ·È‰ÈÎÒÓ ÛÙ·ıÌÒÓ Î·È ÔÏÔ‹ÌÂÚˆÓ Û¯ÔÏ›ˆÓ. O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÛÙËÓ Âη›‰Â˘ÛË ÙfiÛÔ ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔ Î·È ÙˆÓ ¿ÏÏˆÓ ·ÙfiÌˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ·È‰› ÚÔÛ¯ÔÏÈ΋˜, ΢ڛˆ˜, ·ÏÏ¿ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ·È‰ÈÔ‡ ·fi ·˘ÙfiÓ ÙÔÓ - ¿ÁÓˆÛÙÔ Û ÔÏÏÔ‡˜ ¯ıÚfi. ™Ùfi¯Ô˜ ÙÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ÙfiÛÔ Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ¤ÎıÂÛ˘, fiÛÔ Î·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ·ÔÚÚfiÊËÛ˘. O ÚÒÙÔ˜ ÛÙfi¯Ô˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ÛˆÛÙ‹ ÏËÚÔÊfiÚËÛË Î·È ÙËÓ ÂÍÔÈΛˆÛË ÁÈ· ÙȘ ËÁ¤˜ ¤ÎıÂÛ˘, Ô˘ Â›Ó·È Î˘Ú›ˆ˜ Ë ÛÎfiÓË Î·È ÔÈ ÌÔÁȤ˜ ·Ï·ÈÒÓ ÛÈÙÈÒÓ Î·È ·È¯ÓȉÈÒÓ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÙÔ ÓÂÚfi Î·È ÙÔ ¯ÒÌ· (9,68). ∆Ô ¯ÒÌ· ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ËÁ‹ ¤ÎıÂÛ˘ Û ÔÚÈṲ̂Ó˜ ÂÚÈÔ¯¤˜ Ù˘ ∂ÏÏ¿‰·˜ (6,32,33). O ‰Â‡ÙÂÚÔ˜ ÛÙfi¯Ô˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙȘ Ô‰ËÁ›Â˜ ÁÈ· ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹, ÏÔ‡ÛÈ· Û ۛ‰ËÚÔ Î·È ·Û‚¤ÛÙÈÔ Î·È ÊÙˆ¯‹ Û ϛԘ, Ô˘ ÂÚÈÔÚ›˙ÂÈ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· (9,68). ¢Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë: ∏ ‰ËÏËÙËÚ›·ÛË Ì ÌfiÏ˘‚‰Ô Â›Ó·È Ì›· ÂÚÈ‚·ÏÏÔÓÙÈ΋ ·ÂÈÏ‹. ™Â ˘Ô„›· ‰ËÏËÙËÚ›·Û˘ Ì ÌfiÏ˘‚‰Ô, ·ÎÔÏÔ˘ı› Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÛÙÔ ·›Ì·. ∏ ÂÚÈ‚·ÏÏÔÓÙÈ΋ ‰ÈÂÚ‡ÓËÛË Î·È Ô ÂÓÙÔÈÛÌfi˜ Ù˘ ËÁ‹˜ ¤ÎıÂÛ˘ ÌÔÚ› ‰˘ÓËÙÈο Ó· ÚÔÛٷهÛÂÈ Ù· ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‹ Ù· ¿ÏÏ· ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÙÔ ›‰ÈÔ ËÌÂÚ‹ÛÈÔ ÚfiÁÚ·ÌÌ· (9,68). °È· ÙÔÓ ÂÏÏËÓÈÎfi ÏËı˘ÛÌfi, Ë ÚÔÛÙ·Û›· ÙˆÓ ·È‰ÈÒÓ ·fi ÙË ÌÂÙ·ÊÔÚ¿ ÌÔχ‚‰Ô˘ ÛÙÔ Û›ÙÈ Ì¤Ûˆ ÙˆÓ ÂÓ‰˘Ì¿ÙˆÓ Î·È ÙˆÓ Ì·ÏÏÈÒÓ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜, ÔÈ ÔÔ›ÔÈ ÂÎÙ›ıÂÓÙ·È ÁÈ· ·ÁÁÂÏÌ·ÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ÛÙÔ ÌfiÏ˘‚‰Ô, Â›Ó·È Ì›˙ÔÓÔ˜ ÛËÌ·Û›·˜ (6,33). ∆Ô 1997, ÙÔ ∫¤ÓÙÚÔ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ÚfiÙÂÈÓ ÙÔÓ ¤ÏÂÁ¯Ô fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‰˘ÓËÙÈο ÌÔÚ› Ó· ¤¯Ô˘Ó ÂÎÙÂı› ÛÙÔ ÌfiÏ˘‚‰Ô. À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ıˆÚÔ‡ÓÙ·È ÂÚÈÔ¯¤˜ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜ fiÔ˘ ≥27% ÙˆÓ ÎÙÈÚ›ˆÓ Â›Ó·È Î·Ù·Û΢·Ṳ̂ӷ ÚÈÓ ÙÔ 1950. ∂›Û˘, ÚÔÙ›ÓÂÈ ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÌÔχ‚‰Ô˘ Û οı ·È‰› Ì ·ÓÂÍ‹ÁËÙË ÓfiÛÔ, fiˆ˜ ÛÔ‚·Ú‹ ·Ó·ÈÌ›·, Û·ÛÌÔ‡˜, Ï‹ı·ÚÁÔ Î·È ÎÔÈÏȷο ¿ÏÁË (9,68). £Âڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ∏ ·fiÊ·ÛË ÁÈ· ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ‚·Û›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙ· ›‰· ÌÔχ‚‰Ô˘ ÙÔ˘ ·›Ì·ÙÔ˜.
Paediatriki 2001;64:319-328
∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ÚÔÙ›ÓÂÈ Ì›· ·ӷÏËÙÈ΋ ̤ÙÚËÛË Û ÊÏ‚ÈÎfi ·›Ì· Ì ÙȘ ηٿ ÙÔ ‰˘Ó·ÙfiÓ Î·Ï‡ÙÂÚ˜ Û˘Óı‹Î˜ Ï‹„˘, ÌÂÙ·ÊÔÚ¿˜ Î·È ·Ôı‹Î¢Û˘, ·ÔʇÁÔÓÙ·˜ ÂӉ¯fiÌÂÓË ÂÈÌfiÏ˘ÓÛË Î·È ÂÌÏÔ˘ÙÈÛÌfi ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜. ∞˘Ù‹ Ë Â·Ó·ÏËÙÈ΋ ̤ÙÚËÛË ÚÔÙ›ÓÂÙ·È Ó· Á›ÓÂÙ·È ¿ÌÂÛ· ÛÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ Ù· ›‰· ÌÔχ‚‰Ô˘ Â›Ó·È >70 Ìg/dL, Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 48 ˆÚÒÓ Â¿Ó Ù· ›‰· ÙÔ˘ ·›Ì·ÙÔ˜ Â›Ó·È ÌÂٷ͇ 45 Î·È 69 Ìg/dL, ÂÓÙfi˜ 7 ËÌÂÚÒÓ Â¿Ó Ù· ›‰· Â›Ó·È ÌÂٷ͇ 20 Î·È 44 Ìg/dL Î·È Ì¤Û· ÛÙÔÓ ÂfiÌÂÓÔ Ì‹Ó· Â¿Ó Ù· ›‰· ÙÔ˘ ·›Ì·ÙÔ˜ Â›Ó·È ÌÂٷ͇ 10 Î·È 19 Ìg/dL. ∂¿Ó Ù· ›‰· Â›Ó·È ÌÂٷ͇ 10 Î·È 14 Ìg/dL, ÚÔÙ›ÓÂÙ·È Ë Â·Ó¿ÏË„Ë Ù˘ ̤ÙÚËÛ˘ Û 3 Ì‹Ó˜. ™˘Ó‹ıˆ˜ ‰ÂÓ Â›Ó·È Â‡ÎÔÏÔ Ó· ÂÓÙÔ›ÛÂÈ Î·Ó›˜ ÙËÓ ËÁ‹ ¤ÎıÂÛ˘. °È· Ù· ·È‰È¿ ÂΛӷ Ô˘ Ù· ›‰· ÛÙÔ ·›Ì· ÙÔ˘˜ Â›Ó·È ÌÂٷ͇ 15 Î·È 19 Ìg/dL, Ë Û˘˙‹ÙËÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Ì ÙÔ˘˜ ÁÔÓ›˜ Î·È Ë Ï‹„Ë ÏÂÙÔÌÂÚÔ‡˜ ÈÛÙÔÚÈÎÔ‡ ıˆÚÂ›Ù·È Ì›˙ÔÓÔ˜ ÛËÌ·Û›·˜. ∞·Ú·›ÙËÙË ÎÚ›ÓÂÙ·È Ë Ï‹„Ë ÏËÚÔÊÔÚÈÒÓ, fiÛÔÓ ·ÊÔÚ¿ ÙȘ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÙËÓ ·Ï·ÈfiÙËÙ· Ù˘ ηÙÔÈΛ·˜ ÙÔ˘˜, ÙȘ ÚÔÛˆÈΤ˜ Î·È ÙȘ ÔÈÎÔÁÂÓÂȷΤ˜ Û˘Ó‹ıÂȘ, ÙËÓ ÂӉ¯fiÌÂÓË ¯Ú‹ÛË Ú·ÎÙÈÎÒÓ ·Ú·‰ÔÛÈ·ÎÒÓ ıÂڷ¢ÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ, ηıÒ˜ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· ÙˆÓ ¿ÏÏˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. OÈ ÁÔÓ›˜ ı· Ú¤ÂÈ Ó· ÂÓËÌÂÚÒÓÔÓÙ·È ÁÈ· ÙȘ ÂӉ¯fiÌÂÓ˜ ËÁ¤˜ ¤ÎıÂÛ˘, ·ÏÏ¿ Î·È ÁÈ· ÙÔ˘˜ ÙÚfiÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡ Ù˘ ·ÔÚÚfiÊËÛ˘ ÙÔ˘ ȯÓÔÛÙÔÈ¯Â›Ô˘. ¢È·ÙÚÔÊ‹ ÏÔ‡ÛÈ· Û ۛ‰ËÚÔ Î·È ·Û‚¤ÛÙÈÔ Î·È ÊÙˆ¯‹ Û ϛԘ, ÌÂ Û˘¯Ó‹ ¯Ú‹ÛË ÎÚ¤·ÙÔ˜ ÂÚÈÔÚ›˙ÂÈ ÛËÌ·ÓÙÈο ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ÌÔχ‚‰Ô˘ ·fi ÙÔ ÂÙÈÎfi. ∂·Ó·ÏËÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Û˘ÛÙ‹ÓÂÙ·È Û ‰È¿ÛÙËÌ· ‰‡Ô ÌËÓÒÓ. ™Â ›‰· ÌÔχ‚‰Ô˘ ÌÂٷ͇ 20 Î·È 44 Ìg/dL, Ë Û˘˙‹ÙËÛË Ì ÙÔ˘˜ ÁÔÓ›˜, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Î·È ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘ Î·È Ë Âη›‰Â˘ÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÂÚÈÔÚÈÛÌfi ÙfiÛÔ Ù˘ ¤ÎıÂÛ˘, fiÛÔ Î·È Ù˘ ·ÔÚÚfiÊËÛ˘, Â›Ó·È ÂÓÙ·ÙÈÎfiÙÂÚË. £Âڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì ¯Ú‹ÛË ¯ËÏÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Û˘Ó‹ıˆ˜ ÚÔÙ›ÓÂÙ·È ÁÈ· ›‰· ÌÔχ‚‰Ô˘ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 45 Ìg/dL. ∞˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ¯Ú‹ÛË ·Û‚ÂÛÙ›Ô˘-‰ÈÓ·ÙÚ›Ô˘-·Èı˘ÏÂÓ›Ô˘‰È·ÌÈÓÔÙÂÙÚ·ÔÍÂ˚ÎÔ‡ ÔͤԘ (EDTA), 1000 mg/m2/24ˆÚÔ ÂÓ‰ÔÊÏ‚›ˆ˜ Û 24ˆÚË ¤Á¯˘ÛË ‹ Û ‚Ú·¯‡¯ÚÔÓ˜ ÂÁ¯‡ÛÂȘ ÙˆÓ 20-30 ÏÂÙÒÓ ÁÈ· 5 Û˘Ó¯fiÌÂÓ˜ Ë̤Ú˜. ∂Ó·ÏÏ·ÎÙÈο ¯ÚËÛÈÌÔÔÈÂ›Ù·È 2,3 ‰ÈÌÂÚηÙÔ-ÛÔ˘ÍÈÓÈÎfi Ô͇ (DMS∞) Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·. ∆Ô ıÂڷ¢ÙÈÎfi ·˘Ùfi Û¯‹Ì· ·ӷϷ̂¿ÓÂÙ·È Ì¤¯ÚÈ Ù· ›‰· ÌÔχ‚‰Ô˘ Ó· Á›ÓÔ˘Ó ÌÈÎÚfiÙÂÚ· ÙˆÓ 20 Ìg/dL. ™˘Ìو̷ÙÈο ·È‰È¿ ÓÔÛËχÔÓÙ·È Î·È ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÛÙÔ
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ÓÔÛÔÎÔÌÂ›Ô ·ÓÂÍ¿ÚÙËÙ· ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙÔ ·›Ì· ÙÔ˘˜. ¶·È‰È¿ Ì ›‰· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 70 Ìg/dL ıˆÚÔ‡ÓÙ·È Â›ÁÔÓÙ· ÂÚÈÛÙ·ÙÈο Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ¿ÌÂÛË ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ıÂڷ›· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ 2,3 ‰ÈÌÂÚηÙÔÚÔ·ÓfiÏË (BAL) 75 mg/m2 οı 4 ÒÚ˜ Î·È EDTA 1500 mg/m2/24ˆÚÔ ÛÂ Û˘Ó¯‹ ¤Á¯˘ÛË ÁÈ· 5 Ë̤Ú˜. ∆Ô ıÂڷ¢ÙÈÎfi ·˘Ùfi Û¯‹Ì· ·ӷϷ̂¿ÓÂÙ·È Ì¤¯ÚÈ Ù· ›‰· ÌÔχ‚‰Ô˘ Ó· Á›ÓÔ˘Ó ÌÈÎÚfiÙÂÚ· ÙˆÓ 20 Ìg/dL (4,68,69). ™˘ÌÂÚ¿ÛÌ·Ù· ∞fi ÙË ‰È·ÊÔÚԉȷÁÓˆÛÙÈ΋ ÛΤ„Ë ÙÔ˘ ·È‰È¿ÙÚÔ˘ ‰ÂÓ Ú¤ÂÈ Ó· Ï›ÂÈ Ë ‰ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô, ȉȷ›ÙÂÚ· Û ·È‰È¿ Ì „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ‰È·Ù·Ú·¯¤˜ ÏfiÁÔ˘, Û˘ÌÂÚÈÊÔÚ¿˜ Î·È Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜. ∏ Û˘Ó¯‹˜ ·Ó¿Ù˘ÍË Ù˘ Ù¯ÓÔÏÔÁ›·˜, ÂÎÙfi˜ ·fi ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˙ˆ‹˜, ¤ÊÂÚÂ Î·È ÙËÓ ÚÔԉ¢ÙÈ΋ ·ÏÏÔ›ˆÛË ÙÔ˘ Ê˘ÛÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. O ÌfiÏ˘‚‰Ô˜ ıˆÚÂ›Ù·È “·ÓÙ·¯Ô‡ ·ÚÒÓ” ÛÙÔ Û‡Á¯ÚÔÓÔ ÂÚÈ‚¿ÏÏÔÓ. ∆Ô ·È‰›, ΢ڛˆ˜ ·˘Ùfi Ô˘ ηÙÔÈΛ Û ÂÚÈ‚¿ÏÏÔÓ ÊÔÚÙÈṲ̂ÓÔ Ì ÌfiÏ˘‚‰Ô, ·ÔÙÂÏ› ÙÔ ·ÎÔ‡ÛÈÔ ı‡Ì· Ù˘ ÎÔÈÓˆÓ›·˜ ÙˆÓ ÂÓËϛΈÓ. O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÛÙËÓ Âη›‰Â˘ÛË ÙfiÛÔ ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔ Î·È ÙˆÓ ¿ÏÏˆÓ ·ÙfiÌˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ·È‰› ÚÔÛ¯ÔÏÈ΋˜, ΢ڛˆ˜, ·ÏÏ¿ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ·È‰ÈÔ‡ ·fi ·˘ÙfiÓ ÙÔÓ - ¿ÁÓˆÛÙÔ Û ÔÏÏÔ‡˜ ¯ıÚfi. OÈ ÁÔÓ›˜ Î·È fiÛÔÈ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡ Ú¤ÂÈ Ó· ÈÂÚ·Ú¯Ô‡Ó ÙȘ ÚÔÛ¿ıÂȤ˜ ÙÔ˘˜ Ì ‚¿ÛË ÙË ÁÓÒÛË fiÙÈ “fiÛÔ ÏÈÁfiÙÂÚÔ˜ Ô ÌfiÏ˘‚‰Ô˜ ÁÈ· ÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ, ÙfiÛÔ Î·Ï‡ÙÂÚ·” (70). ∏ ÚÔÛ¿ıÂÈ· ÂÍ·Ê¿ÓÈÛ˘ ÙÔ˘ ÌÔχ‚‰Ô˘ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ¤ÏÂÁ¯Ô ÚÔ˘Ù›Ó·˜ ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÚÈÔ˘˜ ¿ÍÔÓ˜ ΛÓËÛ˘, Ì ÛÙfi¯Ô ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ Ù˘ ∞ÌÂÚÈ΋˜ Ó· ÂÍ·ÏÂÈÊı› Ë ‰ËÏËÙËÚ›·ÛË ·fi ÌfiÏ˘‚‰Ô ÙÔ 2011. ÀÁÈ‹ ·È‰È¿ ‰ÈηÈÔ‡ÓÙ·È Ó· ˙Ô˘Ó Û ¤Ó· ÂÚÈ‚¿ÏÏÔÓ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ “˘ÁȤ˜” Î·È ··ÏÏ·Á̤ÓÔ ·fi οı ·ÂÈÏ‹. µÈ‚ÏÈÔÁÚ·Ê›· 1. Tackett SL. Lead in the environment: Effects of human exposure. APCR 1987;17:14-19. 2. Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta, GA: US Dept of Health and Human Services; 1991. 3. Casey R, Wiley C, Rutstein R, Pinto-Martin J. Prevalence of
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-11-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-02-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37, 71305 ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∞¤ÎÎÚÈÛË Ï¢ÎÔÙÚȤÓ˘ ∂4 Î·È ËˆÛÈÓÔÊÈÏÈ΋˜ ÚˆÙ½Ó˘ à ÛÙ· Ô‡Ú· ·È‰ÈÒÓ Ì ·ÙÔÈÎfi ¿ÛıÌ·1 ∂ÈÛ·ÁˆÁ‹: ∏ ̤ÙÚËÛË Ù˘ Ï¢ÎÔÙÚȤÓ˘ ∂4 (LTE4) ÛÙ· Ô‡Ú· ·ÔÙÂÏ› Ì›· ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô ÂÎÙ›ÌËÛ˘ ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÙÔ˘ Ú˘ıÌÔ‡ ·Ú·ÁˆÁ‹˜ ÙˆÓ ÔÏÈÎÒÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∏ ˈÛÈÓÔÊÈÏÈ΋ ÚˆÙ½ÓË Ã (EPX) ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·. ™ÎÔfi˜ - ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰È·ÊÔÚÒÓ Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ LTE4 Î·È EPX ÌÂٷ͇ ·È‰ÈÒÓ Ì ڢıÌÈṲ̂ÓÔ ·ÙÔÈÎfi ¿ÛıÌ· Î·È ˘ÁÈÒÓ ·È‰ÈÒÓ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ Î·È Ë Û‡ÁÎÚÈÛË ÙˆÓ ÙÈÌÒÓ ÌÂٷ͇ ·È‰ÈÒÓ Ì ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ‚·Ú‡ÙËÙ· ¿ÛıÌ·ÙÔ˜. ∂ÈÚÔÛı¤Ùˆ˜, ÂÎÙÈÌ‹ıËÎÂ Ë Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ LTE4 Î·È EPX Î·È Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂›Û˘, Ë LTE4 ÚÔÛ‰ÈÔÚ›ÛÙËΠ(ÂÓ˙˘Ì·ÙÈÎfi˜ ·ÓÔÛÔÚÔÛ‰ÈÔÚÈÛÌfi˜) Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ EPX (Ú·‰ÈÔ-·ÓÔÛÔÚÔÛ‰ÈÔÚÈÛÌfi˜) ÛÙ· Ô‡Ú· Î·È ÌÂÙÚ‹ıËÎÂ Ë Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·È‰ÈÒÓ Ì ‹ÈÔ ¿ÛıÌ· (Ô˘ ‰ÂÓ Â›¯·Ó ¿ÚÂÈ ÔÙ¤ ÛÙÂÚÔÂȉ‹) (Ó=49), Ì ̤ÙÚÈÔ ÚÔ˜ ÛÔ‚·Úfi ¿ÛıÌ· (˘fi ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹) (Ó=31) Î·È ˘ÁÈÒÓ ·È‰ÈÒÓ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (Ó=28). ∞ÔÙÂϤÛÌ·Ù·: ∏ LTE4 ¢ڤıË ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÛÙ· Ô‡Ú· ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ·fi fiÙÈ ÂÎÂ›ÓˆÓ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (‰È¿ÌÂÛÔ˜ [‰È¿ÛÙËÌ· 25-75%] 238,5 [126,5-375,7] SD 191,8 ¤Ó·ÓÙÈ 189 [51-253,2] SD 131,7 pg/mg-1 ÎÚ·ÙÈÓ›Ó˘, p=0,021). H EPX ›Û˘ ¢ڤıË ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÛÙ· Ô‡Ú· ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Û ۯ¤ÛË Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ (85,5 [64-131,5] SD 76,2 ¤Ó·ÓÙÈ 48,5 [43,290] 112,1 Ìg/mmol-1 ÎÚ·ÙÈÓ›Ó˘, p=0,006). ¢ÂÓ Â˘Ú¤ıËÛ·Ó
328
‰È·ÊÔÚ¤˜ ÌÂٷ͇ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·È‰ÈÒÓ Ì ‹ÈÔ Î·È ÂΛӢ Ì ̤ÙÚÈÔ ÚÔ˜ ÛÔ‚·Úfi ¿ÛıÌ·. ∂˘Ú¤ıËÛ·Ó ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ Ù˘ LTE4 Î·È ÙÔ˘ ÂÓ‰ÔıˆÚ·ÎÈÎÔ‡ fiÁÎÔ˘ ·¤Ú· (ITGV), ÙÔ˘ ˘ÔÏÂÈfiÌÂÓÔ˘ fiÁÎÔ˘ (RV), ÙÔ˘ ‚›·ÈÔ˘ ÂÎÓ¢ÛÙÈÎÔ‡ fiÁÎÔ˘ ÛÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ (FEV1), Ù˘ ‚›·È˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (FVC) Î·È Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ ÛÙÔ 25% Ù˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (MEF25). ™˘ÌÂÚ¿ÛÌ·Ù·: H EPX ·ÚÔ˘Û›·ÛÂ Û˘Û¯¤ÙÈÛË ÌfiÓÔ Ì ÙË Ì¤ÁÈÛÙË ÂÎÓ¢ÛÙÈ΋ ÚÔ‹ ÛÙÔ 75% Ù˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (MEF75). ŒÙÛÈ, Ë ÙÈÌ‹ Ù˘ LTE4 ÌÔÚ› Ó· ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›· Û fi,ÙÈ ·ÊÔÚ¿ ÙÔ ‚·ıÌfi ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ. ∏ LTE4 Î·È Ë EPX ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ¯Ú‹ÛÈÌÔÈ ‰Â›ÎÙ˜ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ÌÔÚ› Ó· ·Ô‚Ô‡Ó ¯Ú‹ÛÈÌÔÈ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ¢ÂÓ Â˘Ú¤ıË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂȤ‰ˆÓ LTE4 Î·È EPX.
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1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES
∆Ô 1Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙËÓ ∞ı‹Ó· ÛÙȘ 1 & 2 ∞ÚÈÏ›Ô˘ 2000, ·ÔÙ¤ÏÂÛ ¤Ó· ·fi Ù· ÎÔÚ˘Ê·›· ÂÈÛÙËÌÔÓÈο ÁÂÁÔÓfiÙ· ÙÔ˘ ÎÏ¿‰Ô˘ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙË ¯ÒÚ· Ì·˜. ∏ ·Ó¿ÁÎË Ù˘ Û˘ÓÂÚÁ·Û›·˜ Î·È ·ÓÙ·ÏÏ·Á‹˜ ÂÈÛÙËÌÔÓÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ ÌÂٷ͇ ÙˆÓ ÁÂÓÈÎÒÓ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ·È‰È¿ÙÚˆÓ Û¯ÂÙÈο Ì ÙȘ ÚfiÛÊ·Ù˜ È·ÙÚÈΤ˜ ÂÍÂÏ›ÍÂȘ, Â›Ó·È ÂÈÙ·ÎÙÈ΋ Î·È ı· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÚ·ÈÙ¤Úˆ ÚfiÔ‰Ô Î·È ·Ó¿Ù˘ÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∂ÈÛÙ‹Ì˘. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ¢¯·ÚÈÛÙ› ıÂÚÌ¿ fiÛÔ˘˜ ·fi ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ÂȉÈÎÔ‡˜ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙȘ ÚfiÛÎÏËÛ‹ Ì·˜ Ó· ‰ËÌÔÛÈ¢ıÔ‡Ó ÔÈ ÂÈÛËÁ‹ÛÂȘ ÙÔ˘˜.
The 1st Panhellenic Meeting of the Pediatric Subspecialties which was held in Athens on April 1 & 2 2000, proved to be one of the most significant events in the field of Pediatrics in our country. The need for cooperation and for exchange of scientific information among pediatric professionals and experts in regards to the latest medical developments, is absolutely essential and will contribute to the overall progress in the development of Pediatrics. The Scientific Editorial Board wishes to thank those participants who kindly responded to our invitation to publish their presentations.
™ÙÔ Ù‡¯Ô˜ ·˘Ùfi Ù˘ “¶∞π¢π∞∆ƒπ∫∏™” ‰ËÌÔÛȇÔÓÙ·È ÔÈ ÙÂÏÂ˘Ù·›Â˜ ÂÈÛÙËÌÔÓÈΤ˜ ÂÈÛËÁ‹ÛÂȘ ÙˆÓ Î¿ÙˆıÈ ˘ÔÂȉÈÎfiÙËÙ˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜:
This issue of the Journal includes the last scientific presentations in the following Pediatric subspecialties:
1. 2. 3. 4. 5. 6. 7.
¶·È‰ÈÎfi ÕÛıÌ· ÛÙÔ ∫·ÙÒÊÏÈ ÙÔ˘ 2000 ¶Ó¢ÌÔÓÔÏÔÁ›· ∞Ó·Ù˘Íȷ΋ ¶·È‰È·ÙÚÈ΋ ¡Â˘ÚÔÏÔÁ›· ∂ÊË‚È΋ π·ÙÚÈ΋ ∫·Ú‰ÈÔÏÔÁ›· ∫ÔÈÓˆÓÈ΋ ¶·È‰È·ÙÚÈ΋
1. 2. 3. 4. 5. 6. 7.
Childhood Asthma in the New Millenium Pneumonology Developmental Pediatrics Neurology Adolescent Medicine Cardiology Social Pediatrics
329
¶·È‰È·ÙÚÈ΋ 2001;64:330-335
¶∞π¢π∫O ∞™£ª∞ ™∆O ∫∞∆øº§π ∆OÀ 2000
Paediatriki 2001;64:330-335
CHILDHOOD ASTHMA IN THE NEW MILLENIUM
™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙÔ ·È‰ÈÎfi ¿ÛıÌ· ª. ∫. µÔÏÔÓ¿Î˘
New concepts in pediatric asthma M. K. Volonakis
¶ÂÚ›ÏË„Ë: ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È Ê·›ÓÂÙ·È Ó· ˘ÂÚ‚·›ÓÂÈ ÙÔ 10% ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡. À¿Ú¯ÂÈ Â›Û˘ ·‡ÍËÛË ÛÙË Û˘¯ÓfiÙËÙ· Î·È ÛÙË ıÓËÙfiÙËÙ· Ù˘ ÓfiÛÔ˘. Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ Ì›· ˘Ô‰È¿ÁÓˆÛË Î·È ·ÙÂÏ‹˜ ıÂڷ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ô˘ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙË ÌÂÁ¿ÏË ÔÈÎÈÏ›· ÙˆÓ Û˘ÓÒÓ˘ÌˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ¢È·ÊÔÚÂÙÈÎÔ› Ê·ÈÓfiÙ˘ÔÈ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Û˘Ó˘¿Ú¯Ô˘Ó ‚¤‚·È· Û ‰È·ÊÔÚÂÙÈΤ˜ ·Ó·ÏÔÁ›Â˜ ÛÙȘ ‰È¿ÊÔÚ˜ ËÏÈ˘. ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ ¤Ó· ¿Ï˘ÙÔ Úfi‚ÏËÌ·. ∆Ô ¿ÛıÌ· Û‹ÌÂÚ· ıˆÚÂ›Ù·È Ì›· ¯ÚfiÓÈ· ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙˆÓ Î·ÙÒÙÂÚˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ. ∫˘ÙÙ·ÚÔΛÓ˜, ÌÂÛÔÏ·‚ËÙ¤˜ Î·È ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú· Â›Ó·È Ôχ ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ Î·È ÌÔÚ› Ó· Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÙË ‚ÚÔÁ¯È΋ ˘ÂÚ··ÓÙËÙÈÎfiÙËÙ· Î·È ÙË ‚Ï¿‚Ë Î·È ·Ó·Î·Ù·Û΢‹ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ÂÈıËÏ›Ô˘. ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÎÔ‡ÂÈ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜. ∂›Ó·È ÛËÌ·ÓÙÈ΋ Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÂȤ‰Ô˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÚÈÓ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜. ∏ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›Â‰Ô Ù˘ ‚·Ú‡ÙËÙ·˜ Î·È ·˘Í¿ÓÂÈ Â¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ·fiÎÚÈÛË. ∏ ·ÔÊ˘Á‹ ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ·ÏÏÂÚÁÈÔÁfiÓÔ˘ Î·È Ë ÂȉÈ΋ ·ÓÔÛÔıÂڷ›· ·ÔÙÂÏÔ‡Ó ÙË ÌfiÓË ÂȉÈ΋ ıÂڷ›· ÙÔ˘ ·ÏÏÂÚÁÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ∏ ·ÔÊ˘Á‹ ÙÔ˘ ·ÏÏÂÚÁÈÔÁfiÓÔ˘ Â›Ó·È ‰‡ÛÎÔÏË ‹ ·‰‡Ó·ÙË. ∂ÏÂÁ¯fiÌÂÓ˜ Ì placebo ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ·ÓÔÛÔıÂڷ›·
Abstract: Asthma affects more than 10% of children and its prevalence has increased considerably in the recent years. In addition, there has been also an increase in severity and mortality of the disease. Asthma remains often underdiagnosed and undertreated primarily because of the variety of synonyms that have been used to describe asthma in children. Different asthma phenotypes may coexist in different proportions at different ages. The pathogenesis of asthma is still an unsolved problem. Asthma is considered as a chronic multifactorial inflammatory disease. Cytokines, mediators and adhesion molecules from inflammatory cells are of key importance in this disease and may be responsible for bronchial hyperresponsiveness and airway remodeling. The management goals are to reduce symptoms and optimize life style. It is essential to evaluate asthma before initiating treatment, in order to determine the level of its severity. Treatment starts at a step appropriate to the severity of the patient’s asthma and steps up, if necessary. Allergen avoidance and specific immunotherapy represent the only specific treatment modality of allergic disease. Although avoidance of the offending allergens is the preferred treatment, this is very hard to achieve and in many cases impossible. Placebo controlled prospective studies have demonstrated that specific immunotherapy with appropriately selected allergenic extracts and safe administration of doses is effective in the treatment of allergic bronchial asthma.
¶·È‰›·ÙÚÔ˜ - ∞ÏÏÂÚÁÈÔÏfiÁÔ˜ ¢È¢ı˘ÓÙ‹˜ ∞ÏÏÂÚÁÈÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
Pediatric Allergiologist Director of Allergy Department “Agia Sophia” Children’s Hospital, Athens
330
¶·È‰È·ÙÚÈ΋ 2001;64:330-335
Paediatriki 2001;64:330-335
Ì ÂÈÏÂÁ̤ӷ Âί˘Ï›ÛÌ·Ù· ·ÏÏÂÚÁÈÔÁfiÓˆÓ Î·È ·ÛÊ·Ï‹ ¯ÔÚ‹ÁËÛË ÙˆÓ ‰fiÛÂˆÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÁÈ· ÙË ıÂڷ›· ÙÔ˘ ·ÏÏÂÚÁÈÎÔ‡ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. §¤ÍÂȘ ÎÏÂȉȿ: ¿ÛıÌ·, ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·, ·ÏÏÂÚÁÈÎfi ¿ÛıÌ·, ·È‰ÈÎfi ¿ÛıÌ·.
Key words: asthma, bronchial asthma, allergic asthma, pediatric asthma.
∂ȉËÌÈÔÏÔÁ›· ∆Ô ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ· (µ∞) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ¯ÚfiÓÈ· ¿ıËÛË Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ·, Ë ‚·Ú‡ÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· ÙÔ˘ µ∞ ·Ú¿ ÙȘ ÚÔfi‰Ô˘˜ Ô˘ ¤¯Ô˘Ó ÛËÌÂȈı› ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. H Û˘¯ÓfiÙËÙ· ÙÔ˘ µ∞ ÔÈΛÏÏÂÈ Â˘Ú¤ˆ˜ ÛÙȘ ‰È¿ÊÔÚ˜ ¯ÒÚ˜ Î·È ÂÚÈÔ¯¤˜ Î·È ÊÙ¿ÓÂÈ - ηٿ ̤ÛÔ fiÚÔ - ÙÔ 10% ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ (ÙÔ 9,9% ÙˆÓ ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, Û‡Ìʈӷ Ì ÚfiÛÊ·ÙË ÂÏÏËÓÈ΋ ÌÂϤÙË) (1). ™Â ÌÂϤÙ˜ ÛÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, ‚Ú¤ıËΠfiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ÚÈÓ›Ùȉ·˜ Î·È ÙÔ˘ µ∞ ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1964 Î·È 1994. ∂ȉÈÎfiÙÂÚ·, ‰Â›¯ıËΠfiÙÈ Ë “‰È¿ÁÓˆÛË ¿ÛıÌ·” ¤¯ÂÈ ·˘ÍËı› ·fi 4,1% ÙÔ 1964 Û 19,5% ÙÔ 1994 (2). ∞ӷʤÚÂÙ·È ÚÔÊ·ÓÒ˜ Ô fiÚÔ˜ “‰È¿ÁÓˆÛË ¿ÛıÌ·” ÁÈ·Ù› Ì ¿ÏϘ ÌÂϤÙ˜ ÛÙËÓ ∞ÁÁÏ›· ›¯Â ‰ÂȯÙ› ˘Ô‰È¿ÁÓˆÛË ÙÔ˘ µ∞ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ô˘ ÔÊÂÈÏfiÙ·Ó Î˘Ú›ˆ˜ ÛÙË ¯Ú‹ÛË fiÚˆÓ Ô˘ÛÈ·ÛÙÈο Û˘ÓÒÓ˘ÌˆÓ ÙÔ˘ µ∞, fiˆ˜ Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, ·ÛıÌ·ÙÈ΋ ‹ Û·ÛÙÈ΋ ‚ÚÔÁ¯›Ùȉ· (3).
ÁÓˆÛË ¿ÛıÌ·” Î·È ÛÙÔ 10% ÙˆÓ ·È‰ÈÒÓ Ì ¿ÏÏË ‰È¿ÁÓˆÛË, ÂÓÒ ÙÔ 1998 ›¯Â ¯ÔÚËÁËı› ÛÙÔ 78% Î·È 29% ÙˆÓ ·È‰ÈÒÓ ·ÓÙ›ÛÙÔȯ· (4,5). ∞fi ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜ Ê·›ÓÂÙ·È fiÙÈ, ·Ú¿ ÙË ‚ÂÏÙ›ˆÛË ÛÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞ Ô˘ ÛËÌÂÈÒıËΠÙÔ 1998, ÂÍ·ÎÔÏÔ˘ı› Ó· ˘¿Ú¯ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ Î¿ÔÈ· ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ ÛÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ fiÚÔ˘ µ∞ Î·È fiÙÈ ·˘Ùfi Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ› Û ·ÙÂÏ‹ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘. ∏ ‰È¿ÁÓˆÛË, fï˜, µ∞ Î·È Ë ÁÓˆÛÙÔÔ›ËÛ‹ Ù˘ ÛÙÔ˘˜ ÁÔÓ›˜ Ì ÏÂÙÔÌÂÚ‹ ÂÂÍ‹ÁËÛË Ù˘ ʇÛ˘ Î·È Ù˘ ÛËÌ·Û›·˜ Ù˘ ÓfiÛÔ˘, ı· ÌÔÚÔ‡Û ӷ ÙÔ˘˜ ÚÔ‚ÏËÌ·Ù›ÛÂÈ Î·È Ó· Û˘ÓÙÂϤÛÂÈ ÛÙËÓ ·Ô‰Ô¯‹ Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙÔ Â›ÌÔÓÔ µ∞.
ÀԉȿÁÓˆÛË Î·È ·ÙÂÏ‹˜ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞ ∏ Û‡Á¯˘ÛË Ô˘ ÚÔηÏ› Ë ¯Ú‹ÛË fiÚˆÓ Ô˘ÛÈ·ÛÙÈο Û˘ÓÒÓ˘ÌˆÓ ÙÔ˘ µ∞ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û η΋ ÂÎÙ›ÌËÛË Î·È ·ÙÂÏ‹ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞. ªÂ ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ı¤Ì·ÙÔ˜ ·˘ÙÔ‡ ÌÂÏÂÙ‹Û·Ì ÚfiÛÊ·Ù· 129 ·È‰È¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 4 ÂÙÒÓ Ô˘ ¤·Û¯·Ó ·fi µ∞ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó· ¯ÚfiÓÔ Î·È Û˘ÁÎÚ›Ó·Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Ì·˜ Ô˘ ¤ÁÈÓ ÚÈÓ ·fi 10 ¯ÚfiÓÈ·. µÚ¤ıËΠfiÙÈ ÌfiÓÔ ÛÙÔ 9% ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤·Û¯·Ó ·fi µ∞ ›¯Â ·Ó·ÊÂÚı› Ë ‰È¿ÁÓˆÛË ¿ÛıÌ· ÙÔ 1988 Î·È ÛÙÔ 22% ÙÔ 1998, ÂÓÒ ÛÙ· ˘fiÏÔÈ· ›¯Â ÙÂı› οÔÈ· ¿ÏÏË ‰È¿ÁÓˆÛË (·ÛıÌ·ÙÈ΋, Û·ÛÙÈ΋, ·ÏÏÂÚÁÈ΋ ‚ÚÔÁ¯›Ùȉ·). ¶·Ú·ÙËÚ‹ıËΠ·ÎfiÌË fiÙÈ Ì·ÎÚÔ¯ÚfiÓÈ· ·ÁˆÁ‹ Ì ÂÈÛÓÂfiÌÂÓ· ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ›ÌÔÓÔ˘ µ∞, ›¯Â ¯ÔÚËÁËı› ÙÔ 1988 ÛÙÔ 36% ÙˆÓ ·È‰ÈÒÓ Ì “‰È¿-
∂ÙÂÚÔÁ¤ÓÂÈ· ÙÔ˘ µ∞ À¿Ú¯ÂÈ ‚¤‚·È· Ì›· ÂÙÂÚÔÁ¤ÓÂÈ· ÛÙȘ Ê·ÈÓÔÙ˘ÈΤ˜ ÌÔÚʤ˜ ÙÔ˘ µ∞ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ‰È¿ÊÔÚ˜ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜. ◊‰Ë ·fi ÙËÓ ÚÒÙË ÔÌÔʈӛ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞ ÛÙ· ·È‰È¿ (Warner et al 1988), Ù· ‚Ú¤ÊË Ì ¿ÛıÌ· ‰È·ÎÚ›ÓÔÓÙ·È: ·) Û ÂΛӷ Ì ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, Ô˘ ‰ÂÓ Â›Ó·È ·ÙÔÈο Î·È Ô˘ Â›Ó·È ÂχıÂÚ· Û˘ÚÈÁÌÔ‡ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ‚) Û ÂΛӷ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó µ∞ Ô˘ ·Ú·Ì¤ÓÂÈ Î·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ· ‹ Î·È ·ÚÁfiÙÂÚ· (6). ™Â Ì›· Û¯ÂÙÈο ÚfiÛÊ·ÙË ¤Ú¢ӷ ÙˆÓ Martinez Î·È Û˘Ó (1995) ÌÂÏÂÙ‹ıËÎ·Ó ÚÔÔÙÈο 1200 ·È‰È¿ ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ ̤¯ÚÈ, ÔÏÏ¿ ·fi ·˘Ù¿, ÙËÓ ËÏÈΛ· ÙˆÓ 11 ÂÙÒÓ. ∆· ·È‰È¿ ‰È·ÎÚ›ıËÎ·Ó Û ÂΛӷ Ô˘: i) ÔÙ¤ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó Û˘ÚÈÁÌfi, ii) ·ÚÔ˘Û›·Û·Ó Û˘ÚÈÁÌfi ÛÙ· 3 ÚÒÙ· ¯ÚfiÓÈ·, Ô˘ ÛÙ·Ì¿ÙËÛ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ¯ÚfiÓˆÓ, iii) ‰ÂÓ ·ÚÔ˘Û›·Û·Ó Û˘ÚÈÁÌfi ̤¯ÚÈ Ù· 3 ¯ÚfiÓÈ·, ·ÏÏ¿ ·ÚÔ˘Û›·˙·Ó ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ¯ÚfiÓˆÓ, iv) ·ÚÔ˘Û›·˙·Ó ›ÌÔÓÔ Û˘ÚÈÁÌfi Ô˘ ¿Ú¯È˙ ÚÈÓ ·fi Ù· 3 ¤ÙË Î·È ÂÍ·ÎÔÏÔ˘ıÔ‡ÛÂ Î·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. µÚ¤ıËΠfiÙÈ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ¯ÚfiÓˆÓ: ·) ÙÔ 60% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì ÚÒÈÌÔ Û˘ÚÈÁÌfi
331
¶·È‰È·ÙÚÈ΋ 2001;64:330-335
‹Ù·Ó ÂχıÂÚÔ Û˘ÚÈÁÌÔ‡ ·ÏÏ¿ ·ÚÔ˘Û›·˙ Ì›ˆÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Ì¤¯ÚÈ Ù· 11 ¯ÚfiÓÈ·, ‚) Ù· ·È‰È¿ ÌÂ Û˘ÚÈÁÌfi ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ¯ÚfiÓˆÓ ·ÚÔ˘Û›·˙·Ó ·˘ÍË̤ÓË ËÌÂÚ‹ÛÈ· ‰È·Î‡Ì·ÓÛË Ù˘ PEF (Ô˘ ¤¯ÂÈ ‚ÚÂı› Ó· Û¯ÂÙ›˙ÂÙ·È Â˘ı¤ˆ˜ Ì ÙË ‚ÚÔÁ¯È΋ ˘ÂÚ··ÓÙËÙÈÎfiÙËÙ· Ô˘ ·ÔÙÂÏ› ·ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ µ∞), ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ó˘ÁÌÔ‡ Û ·ÏÏÂÚÁÈÔÁfiÓ· Î·È ··ÓÙÔ‡Û·Ó ¿Ù˘· Û ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, Á) ÙÔ 40% ÙˆÓ ·È‰ÈÒÓ Ì ›ÌÔÓÔ Û˘ÚÈÁÌfi ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘ÚÈÁÌfi, ‚ÚÔÁ¯È΋ ˘ÂÚ··ÓÙËÙÈÎfiÙËÙ·, ÂÏ¿ÙÙˆÛË Ó¢ÌÔÓÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Î·È ¿Ù˘Ë ·¿ÓÙËÛË Û ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (7). ŒÎ‚·ÛË ÙÔ˘ µ∞ ∏ ¿Ô„Ë fiÙÈ ÙÔ ·È‰ÈÎfi ¿ÛıÌ· Â›Ó·È Ì›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÓfiÛÔ˜ Ô˘ Ù›ÓÂÈ Ó· ‚ÂÏÙȈı› ‹ Î·È Ó· ˘Ô¯ˆÚ‹ÛÂÈ Ì¤¯ÚÈ Î·È ÙËÓ ÂÊ˂›·, Ê·›ÓÂÙ·È Ó· ·ÔÙÂÏ› Ì›· ·Ó·ÎÚÈ‚‹ ÁÂӛ΢ÛË. Œ¯ÂÈ ‚ÚÂı› fiÙÈ ÙÔ 40% ÙˆÓ ·È‰ÈÒÓ Ì µ∞ ÂÍ·ÎÔÏÔ˘ı› Ó· ¿Û¯ÂÈ ·fi ¿ÛıÌ· Î·È ÌÂÙ¿ ÙËÓ ÂÓËÏÈΛˆÛË Î·È fiÙÈ ¤Ó· ÔÛÔÛÙfi 50% ÙˆÓ ·È‰ÈÒÓ Ì µ∞ Ô˘ ‹Ù·Ó ÂχıÂÚ· Û˘ÌÙˆÌ¿ÙˆÓ Î·Ù¿ ÙËÓ ÂÊË‚È΋ ËÏÈΛ·, ·ÚÔ˘Û›·˙ ¿ÏÈ Û˘ÌÙÒÌ·Ù· ÛÙË Ó·ÓÈ΋ ËÏÈΛ· (8,9). Œ¯ÂÈ, ›Û˘, ·Ó·ÊÂÚı› fiÙÈ ÙÔ 60% ÙˆÓ ·Û˘Ìو̷ÙÈÎÒÓ Ó¤ˆÓ ÂÓËÏ›ÎˆÓ Ô˘ ¤·Û¯·Ó ·fi µ∞ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ·ÚÔ˘Û›·˙ ‚ÚÔÁ¯È΋ ˘ÂÚ··ÓÙËÙÈÎfiÙËÙ· Û ÚfiÎÏËÛË Ì ÈÛÙ·Ì›ÓË Î·È ¿ÛıÌ· ·fi ¿ÛÎËÛË (10). Œ¯ÂÈ ·ÎfiÌË ·Ó·ÊÂÚı› fiÙÈ ÙÔ ¯ÚfiÓÈÔ ÔÏÔÂÙ¤˜ ‚·Ú‡ µ∞ Û¿ÓÈ· ˘Ô¯ˆÚ› (11). ¶·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó ‚ÚÂı› Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ¤Î‚·ÛË ÙÔ˘ µ∞ Â›Ó·È Ë ·ÏÏÂÚÁ›·, ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜, Ë ‚·Ú‡ÙËÙ· ÙÔ˘ µ∞, ÙÔ Î¿ÓÈÛÌ· (Î·È ÙÔ ·ıËÙÈÎfi), Ë ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ÓfiÛÔ˘ Î·È Ë ıÂڷ¢ÙÈ΋ Ù˘ ·ÓÙÈÌÂÙÒÈÛË. ¶·ıÔÁ¤ÓÂÈ· ∏ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ µ∞ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ ¤Ó· ¿Ï˘ÙÔ, Û ÔÏÏ¿ ÛËÌ›·, Úfi‚ÏËÌ·. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÙÔ ¿ÛıÌ· ·Ó·Ê¤ÚÂÙ·È Û·Ó ¯ÚfiÓÈ· ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÓfiÛÔ˜ ÙˆÓ Î·ÙÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ¤¯ÂÈ Û·ÊÒ˜ ‰Âȯı› Ë ·ÂÏ¢ı¤ÚˆÛË ÂÓfi˜ Ï‹ıÔ˘˜ ΢ÙÙ·ÚÔÎÈÓÒÓ, ÌÂÛÔÏ·‚ËÙÒÓ Î·È Ó¢ÚÔÌÂÙ·‚È‚·ÛÙÒÓ ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú·. O ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÙÔ˘ µ∞ ÂÚÈÏ·Ì‚¿ÓÂÈ, ÛÂ Û˘ÓÙÔÌ›·, ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Ì·ÛÙÔ΢ÙÙ¿ÚÔ˘ (mast cell), ÂÓfi˜ ηْ ÂÍÔ¯‹Ó ÂÎÙÂÏÂÛÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘ Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘, ·fi ·ÏÏÂÚÁÈÔÁfiÓÔ (‹ ¿ÏÏÔ ÂÎÏ˘ÙÈÎfi ·Ú¿ÁÔÓÙ·), Ô˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ (ÈÛÙ·Ì›ÓË, ¤Ó˙˘Ì·) Î·È ÓÂÔÛ¯Ë-
332
Paediatriki 2001;64:330-335
Ì·ÙÈÛÌ¤ÓˆÓ (ÚÔÛÙ·ÁÏ·‰›Ó˜, Ï¢ÎÔÙÚȤÓÈ·) ÌÂÛÔÏ·‚ËÙÒÓ Ô˘ ‰ÚÔ˘Ó ¿ÌÂÛ· ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜ Î·È ÚÔηÏÔ‡Ó Û‡Û·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ (‚ÚÔÁ¯fiÛ·ÛÌÔ), ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÌÂÙ·ÙÚȯÔÂȉÈÎÒÓ ÊÏ‚ȉ›ˆÓ Î·È ‰›Ô‰Ô ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ˘ÁÚÔ‡ (Ô›‰ËÌ·), ·‡ÍËÛË ¤ÎÎÚÈÛ˘ ‚ϤÓÓ·˜ Î·È ÂÚÂıÈÛÌfi Ó¢ÚÈÎÒÓ ·ÔÏ‹ÍÂˆÓ (¿ÌÂÛË Ê¿ÛË). ¶ÔÏϤ˜ ÊÔÚ¤˜ ·ÎÔÏÔ˘ı› Î·È Ì›· ÂÈ‚Ú·‰˘ÓfiÌÂÓË Ê¿ÛË, ηٿ ÙËÓ ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û˘ÛÛÒÚ¢ÛË ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ, ΢ڛˆ˜ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ËˆÛÈÓÔʛψÓ, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ Â›‰Ú·ÛË ÌÂÛÔÏ·‚ËÙÒÓ Ì ¯ËÌÂÈÔÙ·ÎÙÈ΋ ‰Ú¿ÛË, Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ÂÓÂÚÁÔÔÈËı¤ÓÙ· Ì·ÛÙÔ·ÙÙ·Ú·. ∏ ‰Ú¿ÛË ÙˆÓ ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ÚÔηÏ› ›Û˘ ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ Î·È ¿ÏÏˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ. ªÂÙ·Ó¿ÛÙ¢ÛË Î·È ÂÓÂÚÁÔÔ›ËÛË ËˆÛÈÓÔÊ›ÏˆÓ Á›ÓÂÙ·È Î·È Ì ÙË ‰Ú¿ÛË ∆-΢ÙÙ·ÚÔÎÈÓÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ·fi Ù· ˈÛÈÓfiÊÈÏ· ÙÔÍÈÎÒÓ ÚˆÙÂ˚ÓÒÓ Î·È ÈÛ¯˘ÚÒÓ ÌÂÛÔÏ·‚ËÙÒÓ (ÚÔÛÙ·ÁÏ·‰›Ó˜, Ï¢ÎÔÙÚȤÓÈ· Î.¿.), ÙËÓ ÂÁηٿÛÙ·ÛË ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÙË ‚Ï¿‚Ë ÙˆÓ ÈÛÙÒÓ. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ πÙ·Ï›· ‚Ú¤ıËÎÂ Ë ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û˘ ÂÓfi˜ ÌÔÚ›Ô˘ ÚÔÛÎfiÏÏËÛ˘ Ù˘ ‚1 ˘ÔÔÌ¿‰·˜ ÙˆÓ ÈÓÙÂÁÎÚÈÓÒÓ ÙÔ˘ VLA4, ΢ڛˆ˜ ÛÙ· ˈÛÈÓfiÊÈÏ·, Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ µ∞ (12). ∂ÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ µ∞ ∏ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ µ∞ ¤¯ÂÈ Ú·ÎÙÈ΋ ÛËÌ·Û›·, ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÂÎÏÔÁ‹ ÙÔ˘ ÂȤ‰Ô˘ Ù˘ ·Ú¯È΋˜ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. ™ÙËÓ ÙÂÏÂ˘Ù·›· ÔÌÔʈӛ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞, fiˆ˜ ·˘Ù‹ Ù˘ ¢ÈÂıÓÔ‡˜ ™ÙÚ·ÙËÁÈ΋˜ ÁÈ· ÙËÓ ∞ÓÙÈÌÂÙÒÈÛË Î·È ¶ÚfiÏË„Ë ÙÔ˘ µ∞ (GINA), Ë ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ÛÙËÚ›˙ÂÙ·È ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙËÓ Ë̤ڷ Î·È ÙË Ó‡¯Ù·, ÛÙȘ ÙÈ̤˜ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÛÙËÓ ËÌÂÚ‹ÛÈ· ‰È·Î‡Ì·ÓÛË Ù˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ ÎÔÚ˘Ê‹˜ (PEF) (13). ™‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ÙÔ µ∞ ‰È·ÎÚ›ÓÂÙ·È Û ‹ÈÔ ‰È·Ï›ov, ›ÌÔÓÔ ‹ÈÔ, ›ÌÔÓÔ Ì¤Û˘ ‚·Ú‡ÙËÙ·˜ Î·È Â›ÌÔÓÔ ‚·Ú‡ ¿ÛıÌ· (›‰· ‹ ‚·ıÌ›‰Â˜ 1-4) (¶›Ó·Î·˜ 1). º·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∏ Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ µ∞ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›Â‰Ô Ù˘ ‚·Ú‡ÙËÙ¿˜ ÙÔ˘ Î·È Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2 ÁÈ· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 5 ÂÙÒÓ Î·È ÂÓ‹ÏÈΘ Î·È ÛÙÔÓ ¶›Ó·Î· 3 ÁÈ· ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ (13). ∂ÈÛËÌ·›ÓÔ˘Ì ‰‡Ô ÛËÌ›· ÛÙÔ˘˜ ›Ó·Î˜ ·˘ÙÔ‡˜: ∞) ÙËÓ ·ÓÙÈÌÂÙÒÈÛË
¶·È‰È·ÙÚÈ΋ 2001;64:330-335
Paediatriki 2001;64:330-335
¶›Ó·Î·˜ 1. µ·Ú‡ÙËÙ· ¿ÛıÌ·ÙÔ˜: ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÈÓ ÙË ıÂڷ›· ∂›Â‰Ô 4 µ·Ú‡ ∂›Â‰Ô 3 ª¤Û˘ ‚·Ú‡ÙËÙ·˜
™˘ÌÙÒÌ·Ù· ÙËÓ Ë̤ڷ
™˘ÌÙÒÌ·Ù· ÙË Ó‡¯Ù·
PEF ‹ FEV1
∏ÌÂÚ‹ÛÈ· ‰È·Î‡Ì·ÓÛË PEF
™˘Ó¯Ҙ
™˘¯Ó¿
≤60%
>30%
∫·ıËÌÂÚÈÓ¿
≥5 ÊÔÚ¤˜ / Ì‹Ó·
>60-80%
>30%
∂›Â‰Ô 2 ∂›ÌÔÓÔ ‹ÈÔ
3-6 ÊÔÚ¤˜ / ‚‰ÔÌ¿‰·
3-4 ÊÔÚ¤˜ / Ì‹Ó·
≥80%
20-30%
∂›Â‰Ô 1 ¢È·Ï›ÔÓ ‹ÈÔ
≤2 ÊÔÚ¤˜ / ‚‰ÔÌ¿‰·
≤2 ÊÔÚ¤˜ / Ì‹Ó·
≥80%
<20%
¶›Ó·Î·˜ 2. £Âڷ›· ¿ÛıÌ·ÙÔ˜ Û ·È‰È¿ >5 ÂÙÒÓ Î·È Û ÂÓ‹ÏÈΘ µ·Ú‡ÙËÙ· ¿ÛıÌ·ÙÔ˜
º·Ú̷΢ÙÈ΋ ·ÁˆÁ‹
∂›Â‰Ô 4 µ·Ú‡ ›ÌÔÓÔ
∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ˘„ËÏ‹ ‰fiÛË Î·È Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‚2-‰ÈÂÁ¤ÚÙ˘ ™ÙÂÚÔÂȉ¤˜ ·fi ÙÔ ÛÙfiÌ·
∂›Â‰Ô 3 ª¤ÙÚÈÔ Â›ÌÔÓÔ
∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ̤ÙÚÈ· ‰fiÛË ‹ ÂÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ ÌÈÎÚ‹/̤ÙÚÈ· ‰fiÛË + ÂÈÛÓÂfiÌÂÓÔ˜ ‚2-‰ÈÂÁ¤ÚÙ˘ Ì·ÎÚ¿˜ ‰Ú¿Û˘
∂›Â‰Ô 2 ◊ÈÔ Â›ÌÔÓÔ
∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ¯·ÌËÏ‹ ‰fiÛË ‹ Cromolyn ‹ Nedocromil £ÂÔÊ˘ÏÏ›ÓË ‚Ú·‰Â›·˜ ·Ô‰¤ÛÌ¢Û˘ Zafirlukast ‹ Zileuton ÁÈ· ·È‰È¿ ≥12 ÂÙÒÓ (;)
∂›Â‰Ô 1 ◊ÈÔ ‰È·Ï›ÔÓ
ªfiÓÔ ·ÓÙÈÌÂÙÒÈÛË Û˘Ìو̿وÓ
∂Í¿ÚÛÂȘ ¿ÛıÌ·ÙÔ˜ (fiÏÔÈ ÔÈ ·ÛıÂÓ›˜)
∂ÈÛÓÂfiÌÂÓÔ˜ ‚2-‰ÈÂÁ¤ÚÙ˘ ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ™ÙÂÚÔÂȉ¤˜ ·fi ÙÔ ÛÙfiÌ·
ÙˆÓ ÂÍ¿ÚÛÂˆÓ ÙÔ˘ µ∞ Ì ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ‚2 ‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ‹ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ· (fi¯È ÂÈÛÓÂfiÌÂÓˆÓ) Î·È µ) ÛÙÔ Ì¤ÙÚÈÔ Â›ÌÔÓÔ ¿ÛıÌ· ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 5 ÂÙÒÓ ·È‰È¿, ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓÔ˘ ÛÙÂÚÔÂȉԇ˜ Û ÌÈÎÚ‹ - ̤ÙÚÈ· ‰fiÛË Î·È ‚2 ‰ÈÂÁ¤ÚÙË Ì·ÎÚ¿˜ ‰Ú¿Û˘ Î·È ÛÙ· ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ, ÂÈÛÓÂfiÌÂÓÔ˘ ÛÙÂÚÔÂȉԇ˜ Û ÌÈÎÚ‹ - ̤ÙÚÈ· ‰fiÛË Î·È Ó‰o¯ÚˆÌ‡Ï˘, Ì ÛÎÔfi ÙËÓ ·ÔÊ˘Á‹ ·‡ÍËÛ˘ Ù˘ ‰fiÛ˘ ÙÔ˘ ÛÙÂÚÔÂȉԇ˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ µ∞ ‹ ÁÈ· Û˘ÓÙ‹ÚËÛË, fiÙ·Ó ¤¯ÂÈ ‹‰Ë ÂÈÙ¢¯ı› Ô ¤ÏÂÁ¯Ô˜. ªÂÙ·‚ÔÏ‹ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ ηٿ Ì›· ‚·ıÌ›‰· οو (.¯. ·fi ÙËÓ 3 ÛÙË 2) Ú·ÁÌ·ÙÔÔÈÂ›Ù·È fiÙ·Ó ÙÔ µ∞ ÂϤÁ¯ÂÙ·È Ï‹Úˆ˜ (+) ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 Ì‹Ó˜. ∞‡ÍËÛË Ù˘ ·ÁˆÁ‹˜ ÛÙËÓ ·ÓÒÙÂÚË ‚·ıÌ›‰· ·ÔÊ·Û›˙ÂÙ·È fiÙ·Ó Ô ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ¤Í·ÚÛË Û˘Ìو̿وÓ, Ó˘¯ÙÂÚÈÓ¿ Û˘ÌÙÒÌ·Ù· ‹ ·˘ÍË̤ÓË ·Ó¿ÁÎË Ï‹„˘ ‚2 ‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ (ÂÚÈÛÛfiÙÂÚÔ ·fi 2 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÁÈ· ÙË ‚·ıÌ›‰· 1, ÂÚÈÛÛfiÙÂÚÔ ·fi 2-3 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‹ Û ηıËÌÂÚÈÓ‹ ‚¿ÛË ÁÈ· Ì›· ‚‰ÔÌ¿‰· ÁÈ· ÙȘ ‚·ıÌ›‰Â˜ 2-3), ·ÊÔ‡ ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÏÂÁ¯ı› Ë Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜
ÛÙËÓ ·ÓÂÏÏÈ‹ Ï‹„Ë ÙˆÓ Ê·ÚÌ¿ÎˆÓ Û˘ÓÙ‹ÚËÛ˘, ÛÙË ÛˆÛÙ‹ ¯Ú‹ÛË ÙˆÓ Û˘Û΢ÒÓ Ï‹„˘ ÂÈÛÓÂfiÌÂÓˆÓ Ê·Ú̿ΈÓ, ÛÙËÓ ‡·ÚÍË Ó¤ˆÓ ÂÓ‰ÔÔÈÎÈ·ÎÒÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ, Î·È ·ÔÎÏÂÈÛÙ› Ë ‡·ÚÍË Ïԛ̈͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‹ ¿ÏÏË Û˘Ó˘¿Ú¯Ô˘Û· ÓfiÛÔ˜ (™¯‹Ì· 1). £Âڷ¢ÙÈ΋ ‰fiÛË ÂÈÛÓÂfiÌÂÓÔ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜ Â›Ó·È Ë ÌÈÎÚfiÙÂÚË ‰fiÛË Ì ÙËÓ ÔÔ›· ÂÈÙ˘Á¯¿ÓÂÙ·È Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ µ∞. ™˘ÁÎÚ›ÛÈ̘ ¯·ÌËϤ˜, ̤ÙÚȘ Î·È ˘„ËϤ˜ ËÌÂÚ‹ÛȘ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Expert Panel Report II (1997) Ù˘ GINA (13), Ì ÚÔÛ·ÚÌÔÁ‹ Û ·Î¤Ú·È· ÔÏÏ·Ï¿ÛÈ· ÙˆÓ ·Ú¯fiÌÂÓˆÓ ‰fiÛÂˆÓ ·fi ÙȘ ΢ÎÏÔÊÔÚÔ‡Û˜ ÛÙË ¯ÒÚ· Ì·˜ ‰ÔÛÔÌÂÙÚÈΤ˜ Û˘Û΢¤˜, ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∞ÓÔÛÔıÂڷ›· ∂ÎÙfi˜ ·fi ÙËÓ ·ÔÊ˘Á‹ ÙÔ˘ ·ÏÏÂÚÁÈÔÁfiÓÔ˘, Ë ÌfiÓË ÂȉÈ΋ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ BA ·Ú·Ì¤ÓÂÈ Ë ·ÓÔÛÔıÂڷ›· Û ·ÏÏÂÚÁÈÔÁfiÓ·. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÓÔÛÔıÂڷ›·˜ ¤¯ÂÈ ‰Âȯı› Ì ÔÏϤ˜ ‰ÈϤ˜ - Ì placebo ÂÏÂÁ¯fiÌÂÓ˜ - ÌÂϤÙ˜.
333
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Paediatriki 2001;64:330-335
¶›Ó·Î·˜ 3. £Âڷ›· ¿ÛıÌ·ÙÔ˜ Û ‚Ú¤ÊË Î·È ·È‰È¿ ≤5 ÂÙÒÓ ∂›Â‰Ô 4 µ·Ú‡ ›ÌÔÓÔ
∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ˘„ËÏ‹ ‰fiÛË ™ÙÂÚÔÂȉ¤˜ ·fi ÙÔ ÛÙfiÌ·
∂›Â‰Ô 3 ª¤ÙÚÈÔ Â›ÌÔÓÔ
∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ̤ÙÚÈ· ‰fiÛË ‹ ÂÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ ¯·ÌËÏ‹/̤ÙÚÈ· ‰fiÛË + Nedocromyl ‹ ıÂÔÊ˘ÏÏ›ÓË
∂›Â‰Ô 2 ◊ÈÔ Â›ÌÔÓÔ
Cromolyn ‹ Nedocromyl ‹ ÂÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ - ¯·ÌËÏ‹ ‰fiÛË
∂›Â‰Ô 1 ◊ÈÔ ‰È·Ï›ÔÓ
ªfiÓÔ ·ÓÙÈÌÂÙÒÈÛË Û˘Ìو̿وÓ
∂Í¿ÚÛÂȘ ¿ÛıÌ·ÙÔ˜ (fiÏÔÈ ÔÈ ·ÛıÂÓ›˜)
∂ÈÛÓÂfiÌÂÓÔ˜ ‚2-‰ÈÂÁ¤ÚÙ˘ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ (ÓÂÊÂÏÔÔÈËÙ‹˜, ·ÂÚÔı¿Ï·ÌÔ˜ Ì ̿Ûη) ‚2-‰ÈÂÁ¤ÚÙ˘ ·fi ÙÔ ÛÙfiÌ· ¶Ú‰ÓÈ˙ÔÏfiÓË
¶›Ó·Î·˜ 4. ∂ÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ™˘ÁÎÚ›ÛÈ̘ ËÌÂÚ‹ÛȘ ‰fiÛÂȘ Û ·È‰È¿ (mcg) ∂ÈÛÓÂfiÌÂÓÔ ÛÙÂÚÔÂȉ¤˜ Beclomethasone Butesonide Flunisolide Fluticasone Triamcinolome
÷ÌËÏ‹ ‰fiÛË 100-350 100-200 500-750 100-200 400-800
(+)
E›Â‰Ô x+1
ª¤ÙÚÈ· ‰fiÛË 350-700 200-400 1000-1250 200-400 800-1200
(-)
>3 Ì‹Ó˜
E›Â‰Ô x
*
* ¶ÚÔËÁÂ›Ù·È ÂÎÙ›ÌËÛË: 1. ™˘ÌÌfiÚʈÛ˘ 2. ™ˆÛÙ‹˜ ¯Ú‹Û˘ Û˘Û΢‹˜ - ·ÂÚÔı·Ï¿ÌÔ˘ 3. ∞ÔÊ˘Á‹˜ ·ÏÏÂÚÁÈÔÁfiÓˆÓ Î·È ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ™¯‹Ì· 1. ŒÏÂÁ¯Ô˜ ¿ÛıÌ·ÙÔ˜
™Â 12 ÌÂϤÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË £¤ÛË ÁÈ· ÙËÓ ∞ÓÔÛÔıÂڷ›· Ù˘ ¶·ÁÎfiÛÌÈ·˜ OÚÁ¿ÓˆÛ˘ ÀÁ›·˜ Î·È Ô˘ ·ÊÔÚÔ‡Ó ·ÓÔÛÔıÂڷ›· Û ·Î¿Ú·, 8 ¤‰ÂÈÍ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Û˘ÌÙˆÌ¿ÙˆÓ ‹/Î·È Ì›ˆÛË Ù˘ ‚ÚÔÁ¯È΋˜ ··ÓÙËÙÈÎfiÙËÙ·˜ Û ·ÏÏÂÚÁÈÔÁfiÓ· ‹ ÌÂÙ·¯ÔÏ›ÓË (14). ªÂ ÔÏϤ˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰Âȯı› Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÓÔÛÔıÂڷ›·˜ Û Á‡ÚË, ȉȷ›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÌÔÓÔ¢·ÈÛıËÛ›· (Û ¤Ó· ›‰Ô˜ Á‡Ú˘), ÂÓÒ Ì ÌÈÎÚfiÙÂÚÔ ·ÚÈıÌfi ÌÂÏÂÙÒÓ ¤¯ÂÈ ‰Âȯı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ Û ÂÈı‹ÏÈ· ˙ÒˆÓ Î·È Ì‡ÎËÙ˜ (14). ∏ ·ÓÔÛÔıÂڷ›· Â›Ó·È Â›Û˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙÔ˘ µ∞ Û ·È‰È¿ Ì ·ÏÏÂÚÁÈ΋ ÚÈÓÔÂÈÂÊ˘Î›Ùȉ· (15), ÁÈ· ÙËÓ ÚfiÏË„Ë Â˘·È-
334
À„ËÏ‹ ‰fiÛË >700 >400 >1250 >450 >1200
ÛıËÙÔÔ›ËÛ˘ Û ¿ÏÏ· ·ÏÏÂÚÁÈÔÁfiÓ· Û ·ÛıÂÓ›˜ Ì ÌÔÓÔ¢·ÈÛıËÛ›· (16). OÈ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ·ÓÔÛÔıÂڷ›·˜ ÔÈΛÏÏÔ˘Ó, ·fi ÌÂÁ¿ÏË ÙÔÈ΋ ·ÓÙ›‰Ú·ÛË Ì¤¯ÚÈ Û˘ÛÙËÌ·ÙÈ΋ ·Ó·Ê˘Ï·Í›·. ∂›Ó·È Û˘¯ÓfiÙÂÚ˜ Î·È ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ‰˘ÛÎÔÏfiÙÂÚ· Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 5 ÂÙÒÓ, ÂÓÒ Û˘Ó·ÓÙÒÓÙ·È Û·ÓÈfiÙÂÚ·, Ì ηٿÏÏËÏË ¯ÔÚ‹ÁËÛË ÛÙ·ıÂÚÔÔÈËÌ¤ÓˆÓ Î·È ÙÈÙÏÔÔÈËÌ¤ÓˆÓ Âί˘ÏÈÛÌ¿ÙˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ. ¶ÚÔÔÙÈΤ˜ ∞fi fiÛ· ·Ó·Ê¤ÚıËÎ·Ó Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ÂÈÙ¢¯ı› ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ʇÛ˘ ÙÔ˘ µ∞ Î·È ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓfiÛÔ˘. ∏ ÚfiÎÏËÛË ÙÔ˘ ̤ÏÏÔÓÙÔ˜ ÛÙȘ ·Ú¯¤˜ ÙÔ˘ 21Ô˘ ·ÈÒÓ· Ô‰ËÁ› Û ¤Ú¢Ó˜ ΢ڛˆ˜ Û ΢ÙÙ·ÚÈÎfi Î·È ÌÔÚÈ·Îfi ›‰Ô, Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ıÂڷ›· ‹ ·ÎfiÌË Î·È Û ϋÚË ÚfiÏË„Ë Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ µ∞. µÈ‚ÏÈÔÁÚ·Ê›· 1. Katsardis CH, Gartziou CH, Rovina N, Lignos M, Tsakiris A, Dassiou M et al. The prevalence of asthma-like symptoms and allergic manifestations in Greek population during childhood. Eur Respir J 1999;14(Suppl 30):307S. 2. Omran M, Russel G. Continuing increase in respiratory symptoms and atopy in Abredeen schoolchildren. Evidence from two surveys 25 years apart. Br Med J 1992;304:873-875. 3. Speigh ANP, Lee DA, Hey EN. Underdiagnosis and
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A, Zhuo X, Grima P. The increased number of very late activation antigen -4- positive cells correlates with eosinophils and severity of disease in the induced sputum of asthmatic patients. J Allergy Clin Immunol 2000;105:65. National Heart, Lung and Blood Institute USA, 1977. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the diagnosis and management of asthma. NIH Publ no. 97-4051, Bethesda, USA. Bousquet J, Lookey RF, Malling HJ. Position Paper. Allergen Immunotherapy: therapeutic vaccines for allergic diseases. Allergy 1998;53(Suppl 44):1-42. Jacobsen L. The benefit of specific allergy treatment. In: Basomba A, Sastre J, editors. Proceedings of the XVI European Congress of Allergiology and Clinical Immunology, Bologna, Italy. Des Roches A, Paradis K, Menardo J et al. Immunotherapy with a standardized Dermatophagoides pteronyssinus extract. VI. Specific immunotherapy prevents the onset of new sensitizations in children. J Allergy Clin Immunol 1997;99:450-453.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÈ¯·‹Ï ∫. µÔÏÔÓ¿Î˘ ∞ı·Ó. ¢È¿ÎÔ˘ 9, ∫ËÊÈÛÈ¿, 145 61, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ªÔÚ› Ó· ÌÂÙÚËı› Ì ·ÎÚ›‚ÂÈ· Ë Ì¤ÁÈÛÙË ÂÎÓ¢ÛÙÈ΋ ÚÔ‹ ηٿ ÙË ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ Ù˘ ‚›·È˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜;1 ∂ÈÛ·ÁˆÁ‹: ∏ Ï‹Ú˘ ‰˘Ó·ÌÈ΋ ÛÈÚÔÌÂÙÚ›· Î·È Ë Ì¤ÙÚËÛË ·ÔÎÏÂÈÛÙÈο Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Û˘Ó‹ıˆ˜ Ì ‰È·ÊÔÚÂÙÈΤ˜ ÂÎÓ¢ÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Î·È ÂÎÙÂÏÔ‡ÓÙ·È Ì ‰È·ÊÔÚÂÙÈο fiÚÁ·Ó· ̤ÙÚËÛ˘. ™ÎÔfi˜: ∫·ıÒ˜ Ë ÛÈÚÔÌÂÙÚ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· ˘Á›·˜, ÔÈ Û˘ÁÁÚ·Ê›˜ ı¤ÏËÛ·Ó Ó· ÌÂÏÂÙ‹ÛÔ˘Ó Î·Ù¿ fiÛÔÓ ÚÔ·ÙÂÈ Î¿ÔÈ· Û˘ÛÙËÌ·ÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ (PEF) Ô˘ ÌÂÙÚ¿Ù·È Ì ÙË ‚Ú·¯Â›· ¤ÓÙÔÓË ÂÎÓÔ‹ (‰ÔÎÈÌ·Û›· PEF) Î·È ÂΛӢ Ô˘ ÌÂÙÚ¿Ù·È Î·Ù¿ ÙËÓ Ï‹ÚË ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ Ù˘ ‚›·È˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (FVC) ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ›‰ÈÔ ÛÈÚfiÌÂÙÚÔ (Microloop, Micro Medical, Kent, UK). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∑ËÙ‹ıËΠ·fi 80 ·È‰È¿ (38 Ì ÂÓÂÚÁfi ¿ÛıÌ·) ËÏÈΛ·˜ 7-16 ÂÙÒÓ Ó· ÂÎÙÂϤÛÔ˘Ó ‰È·‰Ô¯Èο, ÛÂ Ù˘¯·›· ·ÎÔÏÔ˘ı›·, ‰‡Ô ÔÏÔÎÏËڈ̤Ó˜ ‰ÔÎÈ̷ۛ˜ PEF Î·È FVC. ∞ÔÙÂϤÛÌ·Ù·: ∏ PEF Ô˘ ÂÂÙ‡¯ıË Ì ÙË ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ Ù˘ ̤ÁÈÛÙ˘ ÚÔ‹˜ (PEFPF) ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÂΛӢ Ô˘ ÂÂÙ‡¯ıË Ì ÙË ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ Ù˘
‚›·È˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ (PEFVC) ÙfiÛÔ ÛÙ· ˘ÁÈ‹ (̤ÛË ÙÈÌ‹ ‰È·ÊÔÚ¿˜ 20 L/min-1, p<0,001), fiÛÔ Î·È ÛÙ· ·ÛıÌ·ÙÈο ·È‰È¿ (̤ÛË ÙÈÌ‹ ‰È·ÊÔÚ¿˜ 9 L/min-1, p<0,004). ™˘ÌÂÚ¿ÛÌ·Ù·: ™ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, ̤ÛË ‰È·ÊÔÚ¿ PEF Ù˘ ٿ͈˜ ÙÔ˘ 3% Û ·È‰È¿ Ì ¿ÛıÌ· ‰ÂÓ Â›Ó·È ·ÍÈÔÏÔÁ‹ÛÈÌË Î·È ÂÔ̤ӈ˜ ÔÈ ÙÈ̤˜ Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ Ô˘ Ï·Ì‚¿ÓÔÓÙ·È Î·Ù¿ ÙË ÛÈÚÔÌÂÙÚ›· ÎÚ›ÓÔÓÙ·È ˆ˜ ¯Ú‹ÛÈ̘.
1 Wensley D, Pickering D, Silverman M Can peak expiratory flow be measured accurately during a forced vital capacity manoeuvre? Eur Respir J 2000;16:673-676
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CHILDHOOD ASTHMA IN THE NEW MILLENIUM
¢‡ÛÎÔÏÔ ¿ÛıÌ· ÛÙ· ·È‰È¿ ª. ∂ÌÔÚÈ¿‰Ô˘
Difficult asthma in children M. Eboriadou
¶ÂÚ›ÏË„Ë: ¢ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· Û¯ÂÙÈο Ì ÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜. ŒÓ·˜ ÚÔÙÂÈÓfiÌÂÓÔ˜ ÔÚÈÛÌfi˜ ÁÈ· ÙÔ ‰‡ÛÎÔÏÔ ¿ÛıÌ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ÌË ÂÏÂÁ¯fiÌÂÓÔ Ì ÙË Û˘Ó‹ıË ıÂڷ›·, ÙË ÊÙˆ¯‹ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙÔ ‚·Ú‡ Î·È ÙÔ ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ ‹ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi ¿ÛıÌ·. ªÔÚ› Ó· ÔÚÈÛÙ› Û·Ó ÙÔ ¿ÛıÌ· Ô˘ ‰ÂÓ ··ÓÙ¿ ÛÙȘ ˘„ËϤ˜ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Î·È ‚-‰ÈÂÁÂÚÙÒÓ. ∆Ô ‰‡ÛÎÔÏÔ ¿ÛıÌ· ÛÙ· ·È‰È¿ ηٷٿÛÛÂÙ·È Û 4 ηÙËÁÔڛ˜: ·˘Ùfi Ù˘ ÂÓ·ÏÏ·ÎÙÈ΋˜ ‰È¿ÁÓˆÛ˘, fiˆ˜ Ï·Ú˘ÁÁÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, Ù˘ ÊÙˆ¯‹˜ Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂڷ›·, ÙÔ ·ÏËı¤˜ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi ¿ÛıÌ· Î·È ÂΛÓÔ ÏfiÁˆ ˘ÂÚÂÎÙ›ÌËÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·fi ·È‰È¿ ‹ ÁÔÓ›˜. ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË ÛÙ· ÌÈÎÚ¿ ·È‰È¿ Â›Ó·È ‰‡ÛÎÔÏË. ¶Ú¤ÂÈ Ó· ·ÔÎÏ›ÔÓÙ·È Î·Ù·ÛÙ¿ÛÂȘ fiˆ˜ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, Û‡Ó‰ÚÔÌÔ Ì¤ÛÔ˘ ÏÔ‚Ô‡, ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· Î·È Î˘ÛÙÈ΋ ›ÓˆÛË. ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ Ù›ıÂÙ·È ÛÙ· ·È‰È¿ fiÙ·Ó, ·Ú¿ ÙË ÛˆÛÙ‹ ıÂڷ›·, ¤¯Ô˘Ó Û˘¯Ó¿ Û˘ÌÙÒÌ·Ù·, ¿ÛıÌ· ÌÂÙ¿ ·fi ¿ÛÎËÛË, ¯ÚÂÈ¿˙ÔÓÙ·È Û˘¯Ó¿ ‚2-‰ÈÂÁ¤ÚÙ˜ ηÈ/‹ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ·ÏÏ¿˙ÂÈ Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘˜ Î·È ÂȉÂÈÓÒÓÂÙ·È Ë Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ Á›ÓÂÙ·È Û ÙÚ›· ÛÙ¿‰È·. ∆Ô ·ÏËı¤˜ ÎÔÚÙÈÎÔ- ·ÓıÂÎÙÈÎfi ‹ ÎÔÚÙÈÎÔ- ÂÍ·ÚÙÒÌÂÓÔ ¿ÛıÌ· ¤¯ÂÈ Á›ÓÂÈ Û¿ÓÈÔ, ·ÊfiÙÔ˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹. ∆¤ÏÔ˜, ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ›· fiˆ˜ ÌÂıÔÙÚÂÍ¿ÙË, ΢ÎÏÔÛÔÚ›ÓË Î.¿., Û¿ÓÈ· ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› ÛÙ· ·È‰È¿ Ì ‰‡ÛÎÔÏÔ, ·ÓıÂÎÙÈÎfi ÛÙË ıÂڷ›· ¿ÛıÌ·.
Abstract: ∆here is no agreement regarding the definition of difficult asthma in children. One of the proposed definitions includes failure of response to conventional therapy, poor pulmonary function and the severe steroid dependent or resistant asthma. It can also be defined as asthma not responding to high doses of inhaled glucocorticoids and ‚2-agonists. Difficult asthma in children can be classified into four categories: that with alternative diagnosis such as laryngeal dysfunction and obliterative bronchiolitis, that with poor adherence to treatment, the true corticosteroid-unresponsive asthma and the asthma due to over-reporting of symptoms by either children or their parents. Accurate diagnosis in children can be difficult. Investigations to exclude diagnosis such as gastro-esophageal reflux, immunodeficiency, middle lobe lung syndrome, sinusitis and cystic fibrosis should be considered. The diagnosis of difficult asthma should be considered in those children who, despite an apparently optimal drug regimen, have frequent symptoms, develop exercise-induced asthma, demonstrate frequently the need for ‚2agonists and/or oral corticosteroids, poor quality of life and deterioration of pulmonary function. Management of difficult asthma in children may be seen as a three-step approach. Nowadays, truly steroid-resistant or steroid dependent asthma has become rare in children since the introduction of inhaled corticosteroids and the long-acting ‚2agonists. Finally, alternative therapy with methotrexate, cyclosporin, etc has rarely been tried in children with difficult asthma not responsive to treatment.
¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞
4th Pediatric Department, Aristotelion University of Thessaloniki, AHEPA Hospital, Thessaloniki
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Paediatriki 2001;64:336-341
§¤ÍÂȘ ÎÏÂȉȿ: ¿ÛıÌ·, ·ÓıÂÎÙÈÎfi ÛÙË ıÂڷ›· ¿ÛıÌ·, ‰‡ÛÎÔÏÔ ¿ÛıÌ·, ‚·Ú‡ ¿ÛıÌ·, ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ ¿ÛıÌ·.
Key words: asthma, asthma resistant to therapy, difficult asthma, severe asthma, steroid-dependent asthma.
O fiÚÔ˜ “‰‡ÛÎÔÏÔ ¿ÛıÌ·” ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚ›· ÛÙÔȯ›·: ·) ÙË ÓfiÛÔ Î·È ÙË ‚·Ú‡ÙËÙ¿ Ù˘, ‚) ÙÔÓ ¿ÚÚˆÛÙÔ Î·È Á) ÙËÓ ·ÓÙÈÌÂÙÒÈÛË. °ÂÓÈο, ‰ÂÓ ˘¿Ú¯ÂÈ ÔÌfiʈÓÔ˜ ÔÚÈÛÌfi˜ ÁÈ· ÙÔ “‰‡ÛÎÔÏÔ” ‹ ·ÓıÂÎÙÈÎfi ÛÙË ıÂڷ›· ¿ÛıÌ·. ∫·Ù¿ οÔÈÔÓ ÙÚfiÔ, Ô ÔÚÈÛÌfi˜ Â›Ó·È ·˘ı·›ÚÂÙÔ˜, ηıÒ˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙË Ê‡ÛË ÙˆÓ ÂÚˆÙ‹ÛÂˆÓ Ô˘ ·Â˘ı‡ÓÂÈ Î·Ó›˜. ∂¿Ó ˘ÈÔıÂÙËı› οÔÈ· ı¤ÛË, ÙfiÙ ÙÔ ‰‡ÛÎÔÏÔ ¿ÛıÌ· ı· ÂÚÈÏ·Ì‚¿ÓÂÈ: i) ÙÔ ÌË ÂÏÂÁ¯fiÌÂÓÔ ¿ÛıÌ· ÌÂÙ¿ Û˘Ó‹ıË ıÂڷ›·, ii) ÙÔ ¿ÛıÌ· Ì ÊÙˆ¯‹ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·, iii) ÙÔ ‚·Ú‡ ¿ÛıÌ·, iv) ÙÔ ÛÙÂÚÔÂȉÔÂÍ·ÚÙÒÌÂÓÔ ¿ÛıÌ· ·fi Ú‰ÓÈ˙ÔÏfiÓË Î·È v) ÙÔ ·ÓıÂÎÙÈÎfi ÛÙËÓ Ú‰ÓÈ˙ÔÏfiÓË ¿ÛıÌ· (1). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Û˘¯Ó¿ ÛÙËÚ›˙ÂÙ·È ÌfiÓÔ ÛÙ· ·Ó·ÊÂÚfiÌÂÓ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ˘˜ ÁÔÓ›˜, ¯ˆÚ›˜ η̛· ·ÓÙÈÎÂÈÌÂÓÈ΋ Ì·ÚÙ˘Ú›· ÓfiÛÔ˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ. ∏ ıÂڷ›· Ú˘ıÌ›˙ÂÙ·È Û‡Ìʈӷ Ì ٷ ·Ó·ÊÂÚfiÌÂÓ· Û˘ÌÙÒÌ·Ù·. ∞Ó Ù· Û˘ÌÙÒÌ·Ù· ˘ÂÚÂÎÙÈÌÒÓÙ·È ‹ ˘ÂÚÂÚÌËÓ‡ÔÓÙ·È, Ë ıÂڷ›· ÌÔÚ› Ó· ·˘ÍËı› Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Ó· ıˆÚÂ›Ù·È ‰‡ÛÎÔÏË (2). £· ‹Ù·Ó ›Ûˆ˜ ¯Ú‹ÛÈÌÔ, ÙfiÙÂ, Ó· ıˆڋÛÔ˘ÌÂ Û·Ó ‰‡ÛÎÔÏÔ ¿ÛıÌ· ›Ù ÙËÓ ˘ÔÙÚÔÈ¿˙Ô˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Ô˘ ··ÓÙ¿ ÊÙˆ¯¿ ÛÙË ıÂڷ›· Ì ԉËÁfi ÙË ÊÙˆ¯‹ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·, fiÔ˘ Â›Ó·È ‰˘Ó·Ù‹, ›Ù ٷ Û˘¯Ó¿ ·Ó·ÊÂÚfiÌÂÓ· Û˘ÌÙÒÌ·Ù· Û˘Ì‚·Ù¿ Ì ¿ÛıÌ·, ÂÌÊ·ÓÒ˜ Ì ÊÙˆ¯‹ ·¿ÓÙËÛË ÛÙË ıÂڷ›· (3). À¿Ú¯ÂÈ Ë ÂÓÙ‡ˆÛË fiÙÈ ·ÛıÌ·ÙÈο ·È‰È¿ Ô˘ Âı·›ÓÔ˘Ó, ›Ù ¤¯Ô˘Ó ‰‡ÛÎÔÏÔ ¿ÛıÌ· Î·È ‰ÂÓ ÂÈÙËÚÔ‡ÓÙ·È Ôχ, ‹ ¤¯Ô˘Ó ¤Ó· ·ÈÊÓ›‰ÈÔ ‚·Ú‡ ÙÂÏÈÎfi ÂÂÈÛfi‰ÈÔ Û ¤‰·ÊÔ˜ ÊÙˆ¯‹˜ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (4). ∆· ·Ú·Î¿Ùˆ Û˘ÓÈÛÙÔ‡Ó Ù¤ÛÛÂÚȘ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Ì “‰‡ÛÎÔÏÔ” ¿ÛıÌ·. 1. ∂È̤ÓÔ˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Û ‚Ú¤ÊË ªÂÚÈο ‚Ú¤ÊË Ì ÌÂÙ¿ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ÂÈ̤ÓÔ˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ (™∞), ˘ÔÙÚÔ¤˜ ™∞ Ì ÙȘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ‹ ÂÈ̤ÓÔ˘Û· ™∞, ¤¯Ô˘Ó ÌÈÎÚÔ‡˜ ‚ÚfiÁ¯Ô˘˜ (5) ηÈ, fiˆ˜ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ™™∞, ‰ÂÓ ¤¯Ô˘Ó ·ÙÔ›· (·Ó Î·È ÛÙ· ‚Ú¤ÊË Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ·˘Ùfi). ŸÌˆ˜, Ù· ‚Ú¤ÊË ··ÓÙÔ‡Ó ÊÙˆ¯¿ ÛÙË ıÂڷ›·. ™¯‹Ì·Ù· Ì ‚-‰ÈÂÁ¤ÚÙ˜ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (∫™), ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ Ú‰ÓÈ˙ÔÏfiÓ˘ ·fi ÙÔ ÛÙfiÌ·, ¤¯Ô˘Ó ‰ÒÛÂÈ ·ÌÊÈÏÂÁfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· (6-8). ¶Ôχ Ï›Á· ·fi ·˘Ù¿ Ù· ‚Ú¤ÊË ¯ÚÂÈ¿˙ÔÓÙ·È ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ÓÔÛËÏ›·, fi¯È ÏfiÁˆ ˘ÔÍ·ÈÌ›·˜ ·ÏÏ¿ ÏfiÁˆ ÙÔ˘ fiÙÈ ‰ÂÓ
··ÓÙÔ‡Ó ÛÙË Ê·Ú̷΢ÙÈ΋ ıÂڷ›· ÎÈ ¤ÙÛÈ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ‰‡ÛÎÔÏ·. 2. ∂È̤ÓÔ˘Û· Î·È ˘ÔÙÚÔÈ¿˙Ô˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ∆· ·Ú·¿Óˆ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ¿ÛıÌ· Î·È ÚÔÛ‚¿ÏÏÂÙ·È ÙÔ 30% ÙˆÓ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÙÔ 40% ·fi Ù· ÔÔ›· Â›Ó·È ·ÙÔÈο (4). ∏ Û˘Ó¯‹˜ ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ∫™ ‰ÂÓ ÚÔÏ·Ì‚¿ÓÂÈ Ù· Ôͤ· ÂÂÈÛfi‰È· ÛÙËÓ ÔÌ¿‰· ·˘Ù‹ (9) Î·È Û˘ÓÈÛÙ¿Ù·È ÁÈ· ·È‰È¿ ÌÂ Û˘ÌÙÒÌ·Ù· ηٿ ‰È·ÛÙ‹Ì·Ù·. ¢ÂÓ Â›Ó·È ÍÂηı·ÚÈṲ̂ÓÔ fiÛÔ Î·Ï¿ ··ÓÙÔ‡Ó ÛÙË ıÂڷ›· Ì ∫™ ·È‰È¿ ÌË ·ÙÔÈο ÌÂ Û˘ÌÙÒÌ·Ù· ηٿ ‰È·ÛÙ‹Ì·Ù·. ∞˘Ù¿ Ù· ·È‰È¿ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ¤¯Ô˘Ó ‰‡ÛÎÔÏÔ ¿ÛıÌ· Ô˘ ·˘Í¿ÓÂÙ·È Ë ıÂڷ›· ÙÔ˘˜ (fiˆ˜ ÙˆÓ ∫™ Ì ÓÂÊÂÏÔÔÈËÙ‹), ·ÏÏ¿ ¯ˆÚ›˜ Ó· ‚ÔËıÔ‡ÓÙ·È. 3. ∂›ÌÔÓÔ˜ ‚‹¯·˜ O ›ÌÔÓÔ˜ ‚‹¯·˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (10). ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi˜ Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ì ›ÌÔÓÔ ‚‹¯· Ô˘ ¤¯Ô˘Ó ·Ó·ÛÙÚ¤„ÈÌË ÓfiÛÔ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ. ¶ÚfiÛÊ·ÙË ÂÚÁ·Û›· ÂÈÛËÁÂ›Ù·È fiÙÈ ÌfiÓÔ Ï›Á· ·È‰È¿ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ¤¯Ô˘Ó ¿ÛıÌ· Ì ‰È·Î‡Ì·ÓÛË ÙÔ˘ ‚‹¯· (11,12). A˘Ùfi ıˆÚÂ›Ù·È ‰‡ÛÎÔÏÔ ¿ÛıÌ·, ‰ÈfiÙÈ Î·Ì›· ıÂڷ›· ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ηıÒ˜ Î·È ‰ÈfiÙÈ Ô ‚‹¯·˜ ·ÚÂÌ‚·›ÓÂÈ ÛÙÔÓ ‡ÓÔ (13). 4. ¢‡ÛÎÔÏÔ ¿ÛıÌ· ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ· ™Â ÚfiÛÊ·ÙË Û˘Ó¿ÓÙËÛË ÂȉÈÎÒÓ ·È‰È¿ÙÚˆÓ ÁÈ· ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù· ·Ó·Ê¤ÚÂÙ·È ˆ˜ Ô Î·ı¤Ó·˜ ÙÔ˘˜ ›¯Â ÏÈÁfiÙÂÚ· ·fi 30 ·È‰È¿ Ì ¯ÔÚ‹ÁËÛË ÌÂÎÏ·ÌÂı·˙fiÓ˘ >800 Ìg/Ë̤ڷ Î·È ˆ˜ ÌfiÓÔ ÌÂÚÈο ·fi ·˘Ù¿ ÎÚ›ıËÎ·Ó fiÙÈ ¤¯Ô˘Ó ‰‡ÛÎÔÏÔ ¿ÛıÌ· (4). O ÔÚÈÛÌfi˜ ÁÈ· ÙÔ ÊÙˆ¯fi ¤ÏÂÁ¯Ô ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‰fiıËΠˆ˜ ÂÍ‹˜: ·È‰È¿ Û ≥800 Ìg/Ë̤ڷ ÌÂÎÏÔÌÂı·˙fiÓ˘ ‹ ‚Ô˘‰Â˙ÔÓ›‰Ë˜ ‹ ≥400 Ìg ÊÏÔ˘ÙÈη˙fiÓ˘ ‹ >1 mg/Kg Ú‰ÓÈ˙ÔÏfiÓ˘ Û - ̤ڷ ·Ú¿ ̤ڷ - Û¯‹Ì·. ∂›Û˘, ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ (ÂÈϤÔÓ Ù˘ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ‚-‰ÈÂÁÂÚÙÒÓ Ô˘ ÌÔÚ› Ó· ¤·ÈÚÓ ‹‰Ë ÙÔ ·È‰›) ÁÈ· 3 Ë̤Ú˜ οı ‚‰ÔÌ¿‰·, ÏfiÁˆ Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜, Ì ۯÂÙÈο ÊÙˆ¯‹ ÛÈÚÔ̤ÙÚËÛË ÛÙÔ Û›ÙÈ <80% ÙÔ˘ ̤ÁÈÛÙÔ˘ ÂÎÓ¢ÛÙÈÎÔ‡ fiÁÎÔ˘ ·¤Ú· ÛÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ (FEV) Î·È ·Ó·ÛÙÚ„ÈÌfiÙËÙ· ‹ ¤Ó· ·Ô‰Â‰ÂÈÁ̤ÓÔ ÂÂÈÛfi‰ÈÔ Ì ÂÈϤÔÓ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Î¿ı ̋ӷ ‹ Û¯ÔÏÈ΋ ·Ô˘Û›· >5 ËÌÂÚÒÓ, ÏfiÁˆ ¿ÛıÌ·ÙÔ˜ (4).
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¶·È‰È·ÙÚÈ΋ 2001;64:336-341
∂Ô̤ӈ˜, Ù· ·È‰È¿ Ì ‰‡ÛÎÔÏÔ ¿ÛıÌ· Ê·›ÓÂÙ·È ˆ˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û ٤ÛÛÂÚȘ ÔÌ¿‰Â˜: ·) ÂΛӷ Ì ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î·È ÂÈ̤ÓÔÓÙ· ÌÂÌÔӈ̤ÓÔ ‚‹¯·, ‚) ÂΛӷ ÙˆÓ ÔÔ›ˆÓ Ë ıÂڷ›· Â›Ó·È ÂÏÏÈ‹˜, Á) ÂΛӷ Ì ÊÙˆ¯‹ ·¿ÓÙËÛË ÛÙË ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È ‰) ÂΛӷ Ô˘ ˘ÂÚ‚¿ÏÏÔ˘Ó Ù· Û˘ÌÙÒÌ·Ù·. ŸÏ· Ù· ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ ÙÔ ¿ÛıÌ· ‰ÂÓ ÂϤÁ¯ÂÙ·È Ì ≥800 Ìg ÌÂÎÏÔÌÂı·˙fiÓ˘ ‹ ÈÛÔ‰‡Ó·Ì· Û΢¿ÛÌ·Ù·, ı· Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÛÙÔÓ ÂȉÈÎfi (4). º·›ÓÂÙ·È ˆ˜ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ ·È‰ÈÒÓ Ì ‰‡ÛÎÔÏË ·¿ÓÙËÛË ÛÙË ıÂڷ›·. ¶·È‰È¿ Ì ¿ÏϘ ‰È·ÁÓÒÛÂȘ Ú¤ÂÈ Ó· ÂÓÙÔ›˙ÔÓÙ·È ¤ÁηÈÚ·. À¿Ú¯ÂÈ Î·È Ì›· ¿ÏÏË ÔÌ¿‰· ·ÙfiÌˆÓ Ì ‰‡ÛÎÔÏÔ ¿ÛıÌ· Ô˘ ¤¯Ô˘Ó Û¯ÂÙÈο ‹È· ηıËÌÂÚÈÓ¿ Û˘ÌÙÒÌ·Ù·, ·ÏÏ¿ ÎÈÓ‰˘ÓÂ‡Ô˘Ó ·fi ‚·ÚȤ˜ ·ÛıÌ·ÙÈΤ˜ ÎÚ›ÛÂȘ (brittle asthma) (14). ¶·È‰È·ÙÚÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· Â›Ó·È ‰‡ÛÎÔÏË Û ÌÈÎÚÔ‡˜ ·ÛıÂÓ›˜. ∏ ÂÎÙ›ÌËÛË, ¤Ú· ·fi ÙÔ ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ì›· ÂÚ›Ô‰Ô ÂϤÁ¯Ô˘ ÙˆÓ Û˘Ìو̿وÓ, ›ÛÎÂ„Ë ÛÙÔ Û›ÙÈ, ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È ·ÏÏÂÚÁÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∂ÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ·ÔÎÏÂÈÛÌfi ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙÔ ‰‡ÛÎÔÏÔ ¿ÛıÌ·, fiˆ˜ Á·ÛÙÚÔ-ÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, Û‡Ó‰ÚÔÌÔ Ì¤ÛÔ˘ ÏÔ‚Ô‡, ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· Î·È Î˘ÛÙÈ΋ ›ÓˆÛË, Â›Ó·È ··Ú·›ÙËÙÔ˜ (14) (¶›Ó·Î·˜ 1). O ¯ÚfiÓÔ˜ ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ÏËÚÔÊÔÚ›·. ∆Ô ·ÙÔÈÎfi ¿ÛıÌ· ÚˆÙÔ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÂ Û˘ÌÙÒÌ·Ù· ÛÙȘ ËÏÈ˘ ÌÂٷ͇ 2 Î·È 7 ÂÙÒÓ. ™˘ÌÙÒÌ·Ù· ÁÈ· ÚÒÙË ÊÔÚ¿ ¤Ú· ·fi ÙËÓ ËÏÈΛ· ·˘Ù‹ ÌÔÚ› Ó· Û˘Ì‚Ô‡Ó, ·Ï-
Paediatriki 2001;64:336-341
Ï¿ ¯ÚÂÈ¿˙ÂÙ·È ˘„ËÏfiÙÂÚË ˘Ô„›·. ∂›ÌÔÓ· Û˘ÌÙÒÌ·Ù· ÌÂÙ¿ ·fi Ì›· ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È Û ÌË ·Ó·ÛÙÚ¤„ÈÌË Ó¢ÌÔÓÈ΋ ‚Ï¿‚Ë, fiˆ˜ ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ÌÂÙ¿ ·fi Ïԛ̈ÍË Ì ·‰ÂÓÔ˚fi (14). ¢È·Ù·Ú·¯¤˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ µ-΢ÙÙ¿ÚˆÓ Â›Ó·È Û¯ÂÙÈο Û˘¯Ó¤˜ Î·È ÂÈϤÎÔÓÙ·È ‹ ÌÈÌÔ‡ÓÙ·È ¿ÛıÌ·. ∏ ·Ó¿ÚÎÂÈ· IgA Û˘Ó‰¤ÂÙ·È Ì ·ÏÏÂÚÁÈ΋ ÓfiÛÔ (15). ∆· Û˘¯Ó¿ ÂÂÈÛfi‰È· ‰Â˘ÙÂÚÔ·ıÔ‡˜ ÌÈÎÚԂȷ΋˜ Ïԛ̈͢ ÚÔηÏÔ‡ÌÂÓ˘ ·fi ·˘Ù‹ ÙËÓ Î·Ù¿ÛÙ·ÛË, ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ·ÓıÂÎÙÈο ·ÛıÌ·ÙÈο Û˘ÌÙÒÌ·Ù·. ∆Ë ‰˘ÛÎÈÓËÛ›· ÎÚÔÛÛˆÙÔ‡ ÂÈıËÏ›Ô˘ ı· Ú¤ÂÈ Ó· ÙË ÛΤÊÙÂÙ·È Î·Ó›˜ fiÙ·Ó Ù· Û˘ÌÙÒÌ·Ù· ·Ú¯›˙Ô˘Ó ·fi ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜ (16), Ì ¯ÚfiÓÈÔ ˘ÁÚfi ‚‹¯· Î·È ¯ÚfiÓÈ· ÂÎÎÚÈÙÈ΋ ˆÙ›Ùȉ·. ∏ ΢ÛÙÈ΋ ›ÓˆÛË, ›Û˘, Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚԉȿÁÓˆÛË, ÂÓÒ Û˘ÌÙÒÌ·Ù· ‰˘Û·ÔÚÚfiÊËÛ˘ Î·È Î·Î‹˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ÌÔÚ› Ó· ÌËÓ ˘¿Ú¯Ô˘Ó (14). ∏ ÂÎÙ›ÌËÛË ÙÔ˘ ÚfiÏÔ˘ Ù˘ Á·ÛÙÚÔ-ÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙÔ ‰‡ÛÎÔÏÔ ¿ÛıÌ· Â›Ó·È ÚÔ‚ÏËÌ·ÙÈ΋. ¢ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜ ¤‰ˆÛ·Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· (17,18). ∏ ÂÈÎÚ·Ù¤ÛÙÂÚË ¿Ô„Ë Â›Ó·È fiÙÈ ÙÔ ¿ÛıÌ· Â›Ó·È Èı·Ófiٷٷ ‰Â˘ÙÂÚÔ·ı¤˜ Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ Î·È fi¯È ÙÔ ·ÓÙ›ıÂÙÔ. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó fiÙÈ ı· Ú¤ÂÈ Ó· ˘Ô„È¿˙ÂÙ·È Î·Ó›˜ ÙËÓ ·ÏÈÓ‰ÚfiÌËÛË fiÙ·Ó ÙÔ ¿ÛıÌ· Â›Ó·È ·ÓıÂÎÙÈÎfi ηÈ/‹ ·ÓÂÍ‹ÁËÙÔ ÛÙ· Ï·›ÛÈ· ·ÏÏÂÚÁ›·˜ (19). §Ô‚҉˘ ·ÙÂÏÂÎÙ·Û›·, ÂȉÈο ÙÔ˘ ̤ÛÔ˘ ÏÔ‚Ô‡, ÂÚÈÁÚ¿ÊÂÙ·È Û ÔÛÔÛÙfi ̤¯ÚÈ 10% ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÁÈ· Ô͇ ¿ÛıÌ· (20,21). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, Ë ·ÙÂÏÂÎÙ·Û›· ·Ú·Ì¤ÓÂÈ Î·È ÌÔÚ› Ó· Â›Ó·È Û˘Ó¯‹˜ ·ÈÙ›· ‚‹¯· Î·È Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜, ·Ú’ fiÏË ÙËÓ ·‡ÍËÛË Ù˘ ·ÛıÌ·ÙÈ΋˜ ıÂڷ›·˜. ¢Â˘ÙÂÚÔ·ı‹˜ Ïԛ̈ÍË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ‚ÚÔÁ¯ÈÂÎÙ·Û›·.
¶›Ó·Î·˜ 1. ¢‡ÛÎÔÏÔ ¿ÛıÌ· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ãƒ∏™πªOπ ¢∂π∫∆∂™
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ÀÔÙÚÔÈ¿˙Ô˘Û· ÈÔÁÂÓ‹˜ Ïԛ̈ÍË ∫˘ÛÙÈ΋ ›ÓˆÛË °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÂÈÛÚfiÊËÛË ∫ÔÎ·Ù˘ §·Ú˘ÁÁÔ̷ϷΛ· (¯·Ï·Úfi˜ Ï¿Ú˘ÁÁ·˜ ‹ ¿ÏϘ ÛÙÂÓˆÙÈΤ˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜) ∞ÓÔÛÔ·Ó¿ÚÎÂÈ· ∫·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· ∞›ı·ÓÔ Ó· Â›Ó·È ¿ÛıÌ· ™˘ÁÁÂÓ‹˜ Ó¢ÌÔÓÔ¿ıÂÈ· ¶ÂÚÈÁÂÓÓËÙÈ΋ Ïԛ̈ÍË (¯Ï·Ì‡‰È·) ¢˘ÛÎÈÓËÛ›· ÎÚÔÛÛÒÓ ∫˘ÛÙÈ΋ ›ÓˆÛË ™˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Ì ÚÔˆÚfiÙËÙ·
¢È·Ï›ˆÓ, ·˘ÙÔ˚¿ÛÈÌÔ˜ ‚‹¯·˜ Î·È Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ ™Ù·ÛÈÌfiÙËÙ· ‚¿ÚÔ˘˜/˘ÁÚfi˜ ‚‹¯·˜/ÔÁÎÒ‰Ë ‰‡ÛÔÛÌ· ÎfiÚ·Ó· ¢˘ÛÎÔϛ˜ Û›ÙÈÛ˘/¤ÌÂÙÔ˜/Ó˘ÎÙÂÚÈÓfi˜ ‚‹¯·˜ ¶·ÚÔ͢ÛÌÈÎfi˜ ‚‹¯·˜ ¶ÂÚÈÛÛfiÙÂÚÔ˜ ÂÈÛÓ¢ÛÙÈÎfi˜ Û˘ÚÈÁÌfi˜ ·fi ÂÎÓ¢ÛÙÈÎfi
- ∂̇ÚÂÙÔ/ÛÔ‚·Ú‹ ˘ÔÙÚÔÈ¿˙Ô˘Û· Ïԛ̈ÍË - ¢‡ÛÓÔÈ· Î·È ÂÊ›‰ÚˆÛË ÛÙË Û›ÙÈÛË Ì ‹ ¯ˆÚ›˜ ʇÛËÌ· - ™˘ÌÙÒÌ·Ù· ·fi ÙË Á¤ÓÓËÛË
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¶·È‰È·ÙÚÈ΋ 2001;64:336-341
Paediatriki 2001;64:336-341
∏ ∂ÈÎfiÓ· 1 ‰Â›¯ÓÂÈ ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜. ª›· ÌÈÎÚ‹ ÔÌ¿‰· ·È‰ÈÒÓ ¤¯ÂÈ ÛÔ‚·Ú‹ Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ ÏfiÁˆ ·ÙÔÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Ô˘ ··ÓÙ¿ ÊÙˆ¯¿ ÛÙȘ ·˘ÍË̤Ó˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ. ªÂÚÈο ·fi ·˘Ù¿ Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓ·, ·ÏÏ¿ Û˘¯Ó¿ ¯ÚÂÈ¿˙ÔÓÙ·È ˘„ËϤ˜ ‰fiÛÂȘ Ô˘ Ô‰ËÁÔ‡Ó Û ·ÚÂÓ¤ÚÁÂȘ. ÕÏÏ· ¤¯Ô˘Ó ›ÌÔÓ· Û˘ÌÙÒÌ·Ù· ·Ú¿ ÙȘ ˘„ËϤ˜ ‰fiÛÂȘ ÛÙÂÚÔÂȉÒÓ Î·È ıˆÚÔ‡ÓÙ·È ·ÓıÂÎÙÈο. ŒÓ· ıÂڷ¢ÙÈÎfi Û¯‹Ì· ÌË ÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ· (1 mg/Kg/H, ̤ÁÈÛÙË 40 mg ÁÈ· 2 ‚‰ÔÌ¿‰Â˜) Û˘Ó‹ıˆ˜ ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ Ê¿ÛÌ·ÙÔ˜ ·‡ÍËÛ˘ ÙˆÓ ÛÙÂÚÔÂȉÒÓ Ô˘ ı· ˆÊÂÏ‹ÛÂÈ (14). O „˘¯ÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙfi fiÙÈ Â›Ó·È ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ·ÛıÌ·ÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ (22). ∂˘ÂÓ‰ÔÙfiÙËÙ·, ÊÙˆ¯‹ ÔÈÎÔÁÂÓÂȷ΋ ˘ÔÛÙ‹ÚÈÍË Î·È ¿ÚÓËÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ÛÔ˘‰·ÈfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔηÏÔ‡Ó ‰‡ÛÎÔÏÔ ¿ÛıÌ·. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ·ÏÏÂÚÁÈÎfi ¿ÛıÌ·, ‰ÂÓ Â›Ó·È ÍÂηı·ÚÈṲ̂ÓÔ Â¿Ó Ë ¤ÎıÂÛË Û ·ÏÏÂÚÁÈÔÁfiÓ· ÚÔηÏ› ¤Í·ÚÛË Û ÚÔ¸¿Ú¯ÔÓ ¿ÛıÌ· ‹ Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË ·ÈÙ›· Û˘ÌÙˆÌ¿ÙˆÓ (14). ∏ ‰È¿ÁÓˆÛË Î·È ÂÎÙ›ÌËÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ ¯ÚËÛÈÌfiÙËÙ· Ù˘ ̤ÙÚËÛ˘ Ù˘ ÔÏÈ΋˜ IgE ÂÈÓ·È ÂÚÈÔÚÈṲ̂ÓË, ·ÏÏ¿ ›Ûˆ˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë ÂÓÙfiÈÛË ÂÎÂ›ÓˆÓ Ì Ôχ ˘„ËÏ¿ ›‰·. ¶Ôχ ·ÏÏÂÚÁÈο ·È‰È¿ Ì IgE ¿Óˆ ·fi 2.000 kU/L ÌÔÚ› Ó· ‚ÂÏÙȈıÔ‡Ó Ì ·ÓÙ·ÁˆÓÈÛÙ¤˜ ∏1 Î·È ∏2 ˘Ô‰Ô¯¤ˆÓ, fiˆ˜ ÂÚÈ-
¶›Ó·Î·˜ 2. ŒÚ¢ӷ ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ÛÙË ıÂڷ›· ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿
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ŒÍˆ ·fi Û›ÙÈ
ÁÚ¿ÊÂÙ·È ÛÙË ıÂڷ›· ÙÔ˘ ˘¤Ú IgE (Job’s) Û˘Ó‰ÚfiÌÔ˘, ·Ó Î·È Â›Ó·È Èı·ÓfiÙÂÚË Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ Î·È Ù˘ ‰Â˘ÙÂÚÔ·ıÔ‡˜ Ïԛ̈͢, ·Ú¿ Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (Jo Warner, ÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›·) (14). ∏ ·ÏÏÂÚÁÈ΋ ‚ÚÔÁ¯ÔÓ¢ÌÔÓ›· Î·È ·ÛÂÚÁ›ÏψÛË Â›Ó·È Ì›· Ôχ Û¿ÓÈ· ÂÈÏÔ΋ ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ·ÏÏ¿ Ú¤ÂÈ Ó· ÙËÓ ˘Ô„È¿˙ÂÙ·È Î·Ó›˜ fiÙ·Ó Ë IgE Â›Ó·È Ôχ ˘„ËÏ‹ Î·È ·ÎÔÏÔ˘ı› ÂȂ‚·›ˆÛË Ì ٷ test ¢·ÈÛıËÛ›·˜ ÁÈ· ·Û¤ÚÁÈÏÏÔ. OÈ ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘ ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ Ï›Á· ÚÔÛʤÚÔ˘Ó. ∏ ÛÈÚÔ̤ÙÚËÛË Â›Ó·È Ôχ ¯Ú‹ÛÈÌË. ∏ ·¿ÓÙËÛË ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ú¤ÂÈ Ó· ÂÎÙÈÌ¿Ù·È, ÂȉÈο fiÙ·Ó Ô Ì¤ÁÈÛÙÔ˜ ÂÎÓ¢ÛÙÈÎfi˜ fiÁÎÔ˜ ·¤Ú· ÛÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ (FEV) Â›Ó·È Ôχ ÌÂȈ̤ÓÔ˜. ™ÙËÓ Ô‰fi ‰ÈÂÚ‡ÓËÛ˘ ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· Â›Ó·È Ë ¤Ú¢ӷ Î·È ıÂڷ›· Ù˘ Û˘Ó˘¿Ú¯Ô˘Û·˜ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜. ∏ ¯ÚfiÓÈ· ÈÁÌÔÚ›Ùȉ· ¤¯ÂÈ ÂÓÙÔÈÛÙ› Û·Ó ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ·ÓıÂÎÙÈÎfi ¿ÛıÌ· ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ·Ó Î·È ÔÈ Ì˯·ÓÈÛÌÔ› ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ·˘Ù‹ ‰ÂÓ Â›Ó·È ÍÂοı·ÚÔÈ (14). ™ÙËÓ ÔÚÁ¿ÓˆÛË Î·È ¯Ú‹ÛË ÈÔ Î·Ù¿ÏÏËÏ˘ ıÂڷ›·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ¤Ó·˜ ÌÈÎÚfi˜ ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Û˘Ó¯›˙ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÓÔÛËÚfiÙËÙ·. ∞˘Ù¿ Ù· ·È‰È¿ Ú¤ÂÈ Î·Ï‡ÙÂÚ· Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û ÂȉÈο ΤÓÙÚ· ·fi ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi. ¢˘ÛÙ˘¯Ò˜, ˘¿Ú¯Ô˘Ó ÂÚÈÔÚÈÛÌÔ› ÛÙÔ ÔÈ· ·ÛıÌ·ÙÈο ÓÔÛ‹Ì·Ù· ÌÔÚÔ‡Ó Ó· ÌÂȈıÔ‡Ó ‹ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ê·ÚÌ·ÎÔÏÔÁÈο.
ªÂÙ¿ ÙË Á¤ÓÓËÛË
¶ÚÈÓ ÙË Á¤ÓÓËÛË
∂ÈÎfiÓ· 1. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ·ÏÏËÏÂȉÚÔ‡Ó ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿.
∂ÈÏÔΤ˜/‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ∂ÍÂÙ¿ÛÂȘ ÚÒÙ˘ ÁÚ·ÌÌ‹˜ ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ™ÈÚÔ̤ÙÚËÛË Î·È Ì¤ÙÚËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋˜ ·¿ÓÙËÛ˘ °ÂÓÈ΋ ·›Ì·ÙÔ˜, IgA/IgG/IgM OÏÈ΋ IgE, Test ȉÚÒÙ· ∂ÍÂÙ¿ÛÂȘ ‰Â‡ÙÂÚ˘ ÁÚ·ÌÌ‹˜ ªantoux ŒÏÂÁ¯Ô˜ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ŒÏÂÁ¯Ô˜ ÎÈÓËÙÈÎfiÙËÙ·˜ ÎÚÔÛÛÒÓ/∏ª BÚÔÁ¯ÔÛÎfiËÛË (‡ηÌÙÔ) ∂ÎÙ›ÌËÛË ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ ¢ÂÚÌ·ÙÈο tests ·ÏÏÂÚÁ›·˜ ∫·ıËÌÂÚÈÓ‹ ηٷÁÚ·Ê‹/ÚÔÔ̤ÙÚËÛË ∂›ÛÎÂ„Ë ÛÙÔ Û›ÙÈ ¢ÔÎÈÌ·Û›· ÎfiˆÛ˘ ∞ÎÙÈÓÔÁÚ·Ê›· ÎfiÏˆÓ ÚÔÛÒÔ˘ æ˘¯ÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ig: ·ÓÔÛÔÛÊ·ÈÚ›ÓË, ∏ª: ∏ÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ, CT: ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·
339
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∞ÓÙÈÌÂÙÒÈÛË ÃÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ‰ÈϤ˜ Ù˘ÊϤ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂȉÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Û ÂȉÈÎÔ‡˜ ·ÚÚÒÛÙÔ˘˜ (23). ªÂÏÏÔÓÙÈΤ˜ ÌÂϤÙ˜ ÌÔÚ› Ó· ··ÓÙ‹ÛÔ˘Ó ÛÙÔ ÔÈ· Û˘ÌÙÒÌ·Ù· ÌÔÚÔ‡Ó Ó· ÂÏÂÁ¯ıÔ‡Ó Î·Ï‡ÙÂÚ· Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ „˘¯ÔÏÔÁÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, Ì ı¤Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ıÂڷ›·˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ÃÚÂÈ¿˙ÂÙ·È Â›Û˘ ηχÙÂÚË Î·Ù·ÓfiËÛË Û¯ÂÙÈο Ì ڷÎÙÈÎÔ‡˜ ηÓfiÓ˜ ·ÔÊ˘Á‹˜ ·ÏÏÂÚÁÈÔÁfiÓˆÓ. ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ¿ÛıÌ·ÙÔ˜ ı· Ú¤ÂÈ Ó· Ù›ıÂÙ·È ÛÙ· ·È‰È¿ Ô˘, ·Ú¿ ÙËÓ ÚÔÊ·Ó‹ ÛˆÛÙ‹ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ¤¯Ô˘Ó Û˘¯Ó¿ Û˘ÌÙÒÌ·Ù·, ¿ÛıÌ· ÌÂÙ¿ ·fi ¿ÛÎËÛË, ¯ÚÂÈ¿˙ÔÓÙ·È Û˘¯Ó¿ ‚2 ‰ÈÂÁ¤ÚÙ˜ ηÈ/‹ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (>100 Ìg ÙËÓ Ë̤ڷ), ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÏÏ·Á‹ ÛÙËÓ ÔÈfiÙËÙ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜ Î·È Âȉ›ӈÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (24,25). ∞ÎfiÌË Î·È ·È‰È¿ Ì ÈÔ ‚·Ú‡ ¿ÛıÌ· ÂϤÁ¯ÔÓÙ·È ÁÂÓÈο ηϿ Ì ۈÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË (ÁÈ· ·Ú¿‰ÂÈÁÌ· ÛˆÛÙ‹ Ù¯ÓÈ΋ ÂÈÛÓÔÒÓ, ¤ÏÂÁ¯Ô˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Î.¿.). ∂¿Ó, ·Ú¿ ÙË ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË, Ë ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Â›Ó·È Ôχ Û˘¯Ó‹, Ë Ì·ÎÚfi¯ÚÔÓË ¯Ú‹ÛË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÛÙÂÚÔÂȉÒÓ Û˘ÓÈÛٿٷÈ. ŸÌˆ˜, ÙÔ ·ÏËı¤˜ ÛÙÂÚȉÔ-·ÓıÂÎÙÈÎfi ‹ ÛÙÂÚȉÔ-ÂÍ·ÚÙÒÌÂÓÔ ¿ÛıÌ· ¤¯ÂÈ Á›ÓÂÈ Ôχ Û¿ÓÈÔ ÛÙ· ·È‰È¿, ÏfiÁˆ Ù˘ ¯Ú‹Û˘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ. ∆ÂÏÈο, ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂڷ›˜ (ÌÂıÔÙÚÂÍ¿ÙË, ΢ÎÏÔÛÔÚ›ÓË ∞) Û¿ÓÈ· ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ÛÙ· ·È‰È¿ Ì ‰‡ÛÎÔÏÔ ÛÙË ıÂڷ›·, ·ÓıÂÎÙÈÎfi ¿ÛıÌ· (24-26). ¶ÚÔÙ›ÓÔÓÙ·È ÙÚ›· ÛÙ¿‰È· ÚÔÛ¤ÁÁÈÛ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘, ·ÓıÂÎÙÈÎÔ‡ ÛÙË ıÂڷ›· ¿ÛıÌ·ÙÔ˜ (¢∞£∞) (¶›Ó·Î·˜ 3) (20,24). ™ÙÔ ÛÙ¿‰ÈÔ 1 ÚÔÙ›ÓÔÓÙ·È ˘„ËϤ˜ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Î·È ÂÈÛÓÂfiÌÂÓˆÓ ‚2-·ÁˆÓÈÛÙÒÓ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜. ∆·¯Â›· ¤Ó·ÚÍË Ì ‚2-‰ÈÂÁ¤ÚÙ˜
Paediatriki 2001;64:336-341
Î·È ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·fi ÙÔ ÛÙfiÌ· Û˘ÓÈÛÙ¿Ù·È Û ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘. ™ÙÔ ÛÙ¿‰ÈÔ 2 ÚÔÙ›ÓÔÓÙ·È ÛÙÂÚÔÂȉ‹ ·fi ÙÔ ÛÙfiÌ·, fiˆ˜ Ú‰ÓÈ˙ÔÏfiÓË 1-2 mg/Kg/∏ ÁÈ· 3-6 Ë̤Ú˜, ·ÏÏ¿ ÌÔÚ› Î·È Ì›· ‰fiÛË Û ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Ì›· ‹ ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ (27,28). °È· ÙÔ ÛÙ¿‰ÈÔ 3 ˘¿Ú¯Ô˘Ó Ï›Á˜ ·Ó·ÊÔÚ¤˜ ÁÈ· ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ›· Û ‚·ÚÈ¿ ·ÛıÌ·ÙÈο ·È‰È¿ (29-35). O Sole Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ (29) η٤‰ÂÈÍ·Ó Ì›ˆÛË ÛÙÂÚÔÂȉÒÓ ≥40% Ù˘ ·Ú¯È΋˜ ‰fiÛ˘, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÌÂıÔÙÚÂÍ¿ÙË Û 7 ·fi 8 ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÔÂÍ·ÚÙÒÌÂÓ· ·ÛıÌ·ÙÈο ·È‰È¿. À„ËϤ˜ ‰fiÛÂȘ ÂÓ‰ÔÊϤ‚È·˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ Û ÔÎÙÒ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÔÂÍ·ÚÙÒÌÂÓ· ·ÛıÌ·ÙÈο ·È‰È¿, Ô‰‹ÁËÛ·Ó Û 60% Ì›ˆÛË Ù˘ ‰fiÛ˘ Ú‰ÓÈ˙ÔÏfiÓ˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ Û ̤ڷ ·Ú¿ ̤ڷ Û¯‹Ì· (32), ÂÓÒ Û ‰‡Ô ¿ÏϘ ÌÂϤÙ˜ ‰ÂÓ ¤ÁÈÓ η̛· ‹ ¤ÁÈÓ ÂÏ·ÊÚ¿ Ì›ˆÛË (33,34). ¢ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ Û ‚·ÚÈ¿ ·ÛıÌ·ÙÈο ·È‰È¿. ÕÏϘ ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂڷ›˜, fiˆ˜ ¿Ï·Ù· ¯Ú˘ÛÔ‡ Î·È ‰·Û¿ÓË, ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› Û ·ÛıÌ·ÙÈο ·È‰È¿. ∆Ô ¢∞£∞ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ‰˘ÛÎÔÏÈÒÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÔÙ˘¯›·˜ ÛÙËÓ Âη›‰Â˘ÛË (Û˘ÌÌfiÚʈÛË Î·È Ù¯ÓÈ΋ ÂÈÛÓÔÒÓ) Î·È ÊÙˆ¯‹˜ ÂÎÙ›ÌËÛ˘ ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∞·ÈÙ› ÙËÓ Î·Ï‡ÙÂÚË ÂÎÙ›ÌËÛË ÙˆÓ Èı·ÓÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ì ÊÙˆ¯‹ ÚfiÁÓˆÛË (34). ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ì ÙËÓ Â›‰Ú·ÛË ÔÔÈ·Û‰‹ÔÙ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ Ô˘Û›·˜ ÛÙËÓ ÚfiÁÓˆÛË (35). ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙÒ ÙË Û˘Ó¿‰ÂÏÊÔ Î. ÃÚÈÛÙ›Ó· ª·ÁÓ‹Û·ÏË ÁÈ· ÙË ‚Ô‹ıÂÈ¿ Ù˘ ÛÙËÓ ÂÎfiÓËÛË ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Ind PW. Definition of difficult asthma. Eur Respir Rev
¶›Ó·Î·˜ 3. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ ÛÙË ıÂڷ›· ¿ÛıÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ™Ù¿‰ÈÔ 1: ∫·Ï‡ÙÂÚË ·ÛıÌ·ÙÈ΋ ıÂڷ›· Î·È Âη›‰Â˘ÛË ÙÔ˘ ·È‰ÈÔ‡ À„ËϤ˜ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ* + ‚2 ‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ‚2-‰ÈÂÁ¤ÚÙ˜ ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ + ÛÙÂÚÔÂȉ‹ Û˘ÛÙËÌ·ÙÈο (ÛÙfiÌ·) ÁÈ· Ï›Á˜ Ë̤Ú˜ Û ¤Í·ÚÛË ∫·Ï‹ Âη›‰Â˘ÛË Î·È Ù¯ÓÈ΋ ÂÈÛÓÔ‹˜ (ÂÚÈ‚¿ÏÏÔÓ, ÚÔÔ̤ÙÚËÛË, ·ÂÚÔı¿Ï·ÌÔÈ) - <3 ¯ÚfiÓˆÓ ·ÂÚÔı¿Ï·ÌÔ˜ - 3-5 ¯ÚfiÓˆÓ » - >5 ¯ÚfiÓˆÓ ÍËÚ¿ ÛÎfiÓË ™Ù¿‰ÈÔ 2: ™¯‹Ì· ¯ÔÚ‹ÁËÛ˘ ÛÙÂÚÔÂȉÒÓ Û˘ÛÙËÌ·ÙÈο (ÛÙfiÌ·) ¶Ú‰ÓÈ˙ÔÏfiÓË 1-2 mg/Kg/24ˆÚÔ ÁÈ· 3-6 Ë̤Ú˜, 1 ‹ 2 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, ‹ ¶Ú‰ÓÈ˙ÔÏfiÓË ÁÈ· Ì·ÎÚ‡ÙÂÚÔ ¯ÚfiÓÔ ÚÔÙÈÌ¿Ù·È Ë ÌÈÎÚfiÙÂÚË ‰fiÛË, ̤ڷ ·Ú¿ ̤ڷ ∞ÔÊ˘Á‹ ·ÏÏÂÚÁÈÔÁfiÓˆÓ ™Ù¿‰ÈÔ 3: ∂Ó·ÏÏ·ÎÙÈ΋ ıÂڷ›· ªÂıÔÙÚÂÍ¿ÙË ∞ÓÔÛÔÛÊ·ÈÚ›ÓË ÂÓ‰ÔÊϤ‚È· ÃÚ˘Ûfi˜ Î·È ‰·Û¿ÓË ˘fi ¤Ú¢ӷ
340
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¶∞π¢π∫O ∞™£ª∞ ™∆O ∫∞∆øº§π ∆OÀ 2000
Paediatriki 2001;64:342-346
CHILDHOOD ASTHMA IN THE NEW MILLENIUM
O ÚfiÏÔ˜ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ‰Ú¿Û˘ ÛÙË ıÂڷ›· ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Ã. B. ∫·ÙÛ·Ú‰‹˜
The role of the long-acting ‚2-agonists in pediatric asthma treatment Ch. V. Katsardis
¶ÂÚ›ÏË„Ë: OÈ ÂÈÛÓÂfiÌÂÓÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Â›Ó·È Ù· ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙËÓ ÈÔ ‰È·‰Â‰Ô̤ÓË ¯Ú‹ÛË ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ıÂڷ›·. ¶·Ú·‰ÔÛȷο, ¤¯Ô˘Ó ηٷٷ¯ı› Ì ‚¿ÛË ÙË ‰È¿ÚÎÂÈ· ¯ÚfiÓÔ˘ ‰Ú¿Û˘. OÈ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‚2-‰ÈÂÁ¤ÚÙ˜ Û·ÏÌÂÙÂÚfiÏË Î·È ÊÔÚÌÔÙÂÚfiÏË ·›˙Ô˘Ó ¤Ó· ÛÔ˘‰·›Ô ÚfiÏÔ ÛÙË ıÂڷ›· ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ Ì ̤ÙÚÈÔ ¤ˆ˜ ÛÔ‚·Úfi ¿ÛıÌ·. ¶·Ú’ fiÙÈ Ë Û·ÏÌÂÙÂÚfiÏË Î·È Ë ÊÔÚÌÔÙÂÚfiÏË ¤¯Ô˘Ó ·ÚfiÌÔÈ· ‰È¿ÚÎÂÈ· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ Î·È ÚÔÛÙ·Û›·˜ ·fi ÙÔ ‚ÚÔÁ¯fiÛ·ÛÌÔ, Ë ¤Ó·ÚÍË ‰Ú¿Û˘ Ù˘ ÊÔÚÌÔÙÂÚfiÏ˘ ÌÔÈ¿˙ÂÈ Ì ÂΛÓË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ (1,7 min), ÂÓÒ Ë Û·ÏÌÂÙÂÚfiÏË ¤¯ÂÈ Ôχ ‚Ú·‰‡ÙÂÚÔ ¯ÚfiÓÔ ¤Ó·Ú͢ (17,6 min). ™·Ó ·ÔÙ¤ÏÂÛÌ·, Ë ÊÔÚÌÔÙÂÚfiÏË ‰˘ÓËÙÈο Â›Ó·È Î·Ù¿ÏÏËÏË ÁÈ· ıÂڷ›· “ηْ ›ÎÏËÛË”, Ì ‚¿ÛË ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ Ù·¯Â›·˜ ¤Ó·Ú͢ Ù˘ ‰Ú¿Û˘ Ù˘, ÂÈÚfiÛıÂÙ· ·fi ÙÔÓ ·Ó·ÁÓˆÚÈṲ̂ÓÔ ÚfiÏÔ Ù˘ Û·Ó Ê¿ÚÌ·ÎÔ ÂϤÁ¯Ô˘ ÛÙÔ˘˜ ·ÛıÌ·ÙÈÎÔ‡˜ Ô˘ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ıÂڷ›· Ì ÙË ¯ÔÚ‹ÁËÛË ÌfiÓÔ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ. ∏ ÊÔÚÌÔÙÂÚfiÏË ‰ÂÛ̇ÂÈ Ï‹Úˆ˜ ÙÔ˘˜ ‚2-·‰ÚÂÓÂÚÁÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜. ™Â ·ÓÙ›ıÂÛË, Ë Û·ÏÌÂÙÂÚfiÏË ‰ÂÛ̇ÂÈ ÌÂÚÈÎÒ˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ‚2-·‰ÚÂÓÂÚÁÈÎÔ‡˜, Ì ·ÔÙ¤ÏÂÛÌ· ÌÂϤÙ˜ in vitro Ó· ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÂÌÔ‰›˙ÂÈ ¤ÙÛÈ ÙË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘. OÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Â›Ó·È ·ÛÊ·Ï›˜ Î·È Î·ÏÒ˜ ·ÓÂÎÙÔ› ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. À¿Ú¯ÂÈ ¤Ó‰ÂÈÍË fiÙÈ ÂÌÊ·Ó›˙ÂÙ·È ¤Ó·˜ ‚·ıÌfi˜ Ù·¯˘Ê‡Ï·Í˘, ÛÙËÓ ÚÔÛÙ·Û›· Ô˘ ·Ú¤¯Ô˘Ó ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘, ¤Ó·ÓÙÈ ‚ÚÔÁ¯ÔÛ˘Û·ÛÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ, ·ÏÏ¿ Ë ·Ú·Ì¤ÓÔ˘Û· ÚÔÛٷ٢ÙÈ΋ ÙÔ˘˜ ÈηÓfiÙËÙ· ·Ú·Ì¤ÓÂÈ ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋.
Abstract: Inhaled ‚2-agonists are the most effective bronchodilators and the most widely used drugs in asthma therapy. Traditionally these agents have been classified by their duration of action. The long-acting inhaled ‚2-agonists, salmeterol and formoterol, play a major role in asthma management in patients with moderate to severe asthma. Although salmeterol and formoterol have a similar duration of bronchodilation and bronchoprotection, the onset of action of formoterol is similar to short-acting ‚2agonists (1.7 min), whereas salmeterol has a much slower effect (17.6 min). As a result, formoterol is potentially suitable for “as needed” treatment, on the basis of its rapid onset of action, in addition to its established role as “control medication” in patients whose asthma does not adequately respond to inhaled steroids alone. Formoterol binds completely the ‚2-adrenergic receptors. By contrast, salmeterol binds only partially to a greater number of ‚2-adrenoceptors thus blocking, as demonstrated in vitro studies, the bronchodilation response of short-acting ‚2agonists. The long-acting ‚2-agonists are safe and well tolerated in pediatric patients. There is some evidence that a small degree of tachyphylaxis develops, in the protection provided by the longacting ‚2-agonists, against a number of bronchoconstrictor stimuli, but their main protective effect still remains clinically significant.
Ù. ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁ›·˜ ¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡, ¡ÔÛÔÎÔÌ›Ԣ ∞ıËÓÒÓ “∏ ∂Ï›˜”
former Assistant Professor of Pediatric Pneumonology Director of Pediatrics of “Elpis” Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:342-346
Paediatriki 2001;64:342-346
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ¿ÛıÌ·, ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘.
Key words: pediatric asthma, long-acting ‚2agonists.
∏ ·Ó·Î¿Ï˘„Ë Î·È ¯Ú‹ÛË ÙˆÓ Û˘Ì·ıÔÌÈÌËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙË ıÂڷ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ Ì·ÎÚ¿ ÈÛÙÔÚ›·. ∫·Ù¿ ¯ÚÔÓÔÏÔÁÈ΋ ÛÂÈÚ¿, ÙÔ 3000 .Ã. ÛÙËÓ ∫›Ó·, ·Ó·Î·Ï‡ÙÂÙ·È Ë Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË Ù˘ ÂʉڛÓ˘ Î·È ÛÙ· Ù¤ÏË ÙÔ˘ 19Ô˘ ·ÈÒÓ· Ì.Ã. Ù˘ ηÊ½Ó˘. ∆Ô 1903 οÓÂÈ ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘ Ë ·‰ÚÂÓ·Ï›ÓË Î·È ÙÔ 1930 Ë ÈÛÔÚÂÓ·Ï›ÓË. ™¯ÂÙÈÎÒ˜ ÚfiÛÊ·Ù·, ÙÔ 1960, Ë Û·Ï‚Ô˘Ù·ÌfiÏË Î·È Ë ÙÂÚÌÔ˘Ù·Ï›ÓË ‰›ÓÔ˘Ó Ó¤· ÒıËÛË ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ıÂڷ›·, ÂÓÒ ÙÔ 1986 ·Ó·Î·Ï‡ÙÔÓÙ·È ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘, Ë ÊÔÚÌÔÙÂÚfiÏË Î·È Ë Û·ÏÌÂÙÂÚfiÏË (Ë ‰Â‡ÙÂÚË ‰È·Ù¤ıËΠÛÙÔ ÂÌfiÚÈÔ ÚÒÙË, ·Ó Î·È ÚÔËÁ‹ıËÎÂ Ë ·Ó·Î¿Ï˘„Ë Ù˘ ÊÔÚÌÔÙÂÚfiÏ˘) (1). ∏ ‚¿ÛË Ù˘ ¯ËÌÈ΋˜ ‰ÔÌ‹˜ ÙˆÓ Û˘Ì·ıÔÌÈÌËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›Ó·È Ë ·‰ÚÂÓ·Ï›ÓË (ÂÈÓÂÊÚ›ÓË) Î·È fiϘ ÔÈ Ô˘Û›Â˜ ÂÚȤ¯Ô˘Ó 1 ‹ 2 ·Û‡ÌÌÂÙÚÔ˘˜ ηڂÔÓÈÎÔ‡˜ ‰·ÎÙ˘Ï›Ô˘˜ (2). ∞fi ÙËÓ ÙÚ·¯Â›· ̤¯ÚÈ Ù· ÙÂÏÈο ‚ÚÔÁ¯ÈfiÏÈ· ¢ڛÛÎÔÓÙ·È ‚-˘Ô‰Ô¯Â›˜. ™ÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ ÙÔ˘ ·ÓıÚÒÔ˘, ÙÔÓ Î‡ÚÈÔ ÚfiÏÔ ÏÂÈÙÔ˘ÚÁÈο ·›˙Ô˘Ó ÔÈ ‚2-˘Ô‰Ô¯Â›˜. OÈ ‚1-˘Ô‰Ô¯Â›˜ ‰ÂÓ ·Ó¢ڛÛÎÔÓÙ·È Û fiÏ· Ù· ›‰· ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ÂÓÒ Ë ‡·ÚÍË ‚3-˘Ô‰Ô¯¤ˆÓ ¤¯ÂÈ ·Ô‰Âȯı› ÌfiÓÔ Û ÂÈÚ·Ì·Ùfi˙ˆ·. OÈ ‚2-˘Ô‰Ô¯Â›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¤Ó· ÂÍˆÎ˘ÙÙ·ÚÈÎfi (ÙÂÏÈ΋ ·ÌÈÓÔÌ¿‰·), ¤Ó· ‰È·ÌÂÌ‚Ú·ÓÈÎfi Î·È ¤Ó· ÂÓ‰Ô΢ÙÙ·ÚÈÎfi (ÙÂÏÈÎfi ηڂÔ͇ÏÈÔ) ÙÌ‹Ì·. OÈ ÂÓ‰Ô΢ÙÙ·ÚÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘ ÌÂÛÔÏ·‚Ô‡Ó ÛÙË ¯¿Ï·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ‰È¤ÁÂÚÛË ÙˆÓ ‚-‰ÈÂÁÂÚÙÒÓ Ì¤Ûˆ ·‡ÍËÛ˘ Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ΢ÎÏÈ΋˜ 3’5’-ÌÔÓÔʈÛÊÔÚÈ΋˜ ·‰ÂÓÔÛ›Ó˘ (cAMP). ∏ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË Ù˘ ÙÂÏÂ˘Ù·›·˜ ÂÓÂÚÁÔÔÈ› ÙËÓ ÚˆÙÂ˚ÓÈ΋ ÎÈÓ¿ÛË ∞ (ƒ∫∞), Ë ÔÔ›· ʈÛÊÔÚ˘ÏÈÒÓÂÈ ·ÚÎÂÙ¤˜ ÚˆÙ½Ó˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙË ¯¿Ï·ÛË. H cAMP, ›Û˘, ÂÓÂÚÁÔÔÈ› Î·È ÙËÓ ÚˆÙÂ˚ÓÈ΋ ÎÈÓ¿ÛË G (PKG), Ô˘ ̤ۈ ʈÛÊÔÚ˘Ï›ˆÛ˘ ÚˆÙÂ˚ÓÒÓ “ÛÙfi¯ˆÓ” ÚÔηÏ› ¯¿Ï·ÛË. ∂ÈϤÔÓ, ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ ÚÔηÏÔ‡Ó ‰È¿ÓÔÈÍË ÙˆÓ ÌÂÁ¿ÏˆÓ ‰È·‡ÏˆÓ ÙÔ˘ Î·Ï›Ô˘ (maxi-K channels) ̤ۈ Ù˘ Ì›ˆÛ˘ Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘. OÈ ‰›·˘ÏÔÈ ÙÔ˘ Î·Ï›Ô˘ ÂÈÎÔÈÓˆÓÔ‡Ó ·Â˘ı›·˜ Ì ÙÔ˘˜ ‚2-˘Ô‰Ô¯Â›˜ Î·È ÌÔÚÔ‡Ó, ·Ó ‰ÈÂÁÂÚıÔ‡Ó, Ó· ÚÔηϤÛÔ˘Ó ¯¿Ï·ÛË, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ cAMP (3). OÈ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‚2-‰ÈÂÁ¤ÚÙ˜ ¤¯Ô˘Ó ÌÂÏÂÙËı› ·ÚÎÂÙ¿ Î·È Û˘ÓÔÙÈο ÔÈ È‰ÈfiÙËÙ¤˜ ÙÔ˘˜ Â›Ó·È ÔÈ ·Ú·Î¿Ùˆ: ·) Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ› ÛÙËÓ ·Ú·ÙÂٷ̤ÓË ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ (>10 h), ‚) ÂϤÁ¯Ô˘Ó Ù· Û˘ÌÙÒÌ·Ù· Î·È Î˘Ú›ˆ˜ Ù· Ó˘¯ÙÂÚÈÓ¿, Á) ‚ÂÏÙÈÒ-
ÓÔ˘Ó ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ Ó¢ÌfiÓˆÓ, ‰) ÌÂÈÒÓÔ˘Ó ÙËÓ ·Ó¿ÁÎË ¯Ú‹Û˘ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘, Â) ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔÓ ·ÛıÂÓ‹ ·fi ÔÈΛϷ ‚ÚÔÁ¯ÔÛ˘Û·ÛÙÈο ÂÚÂı›ÛÌ·Ù· (¿ÛÎËÛË, ÈÛÙ·Ì›ÓË, ÌÂÙ·¯ÔÏ›ÓË, ·ÏÏÂÚÁÈÔÁfiÓ· Î.Ï.) Î·È ÛÙ) ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ (4,5). ∏ Û¯¤ÛË Ù˘ ¤ÓÙ·Û˘ Ù˘ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ Ì ÙÔ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘ ÛÙÔ˘˜ Ù¤ÛÛÂÚȘ ·ÚÈÔ˘˜ ‚2‰ÈÂÁ¤ÚÙ˜ (‰‡Ô ‚Ú·¯Â›·˜ Î·È ‰‡Ô Ì·ÎÚ¿˜ ‰Ú¿Û˘) Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (6,7). ™¯ÔÏÈ¿˙ÔÓÙ·˜ ηÓ›˜ ÙÔÓ ¶›Ó·Î· 1 ı· ÌÔÚÔ‡Û ӷ ·Ú·ÙËÚ‹ÛÂÈ fiÙÈ: ·) ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘, fiˆ˜ ·Ó·Ì¤ÓÂÙ·È, ¤¯Ô˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÈÏ¿ÛÈ· ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ ·fi ÂΛÓÔ˘˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘, ‚) ÌÂÙ¿ Ì›· ÒÚ· ·fi ÙË ¯ÔÚ‹ÁËÛË ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‰ÂÓ ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÊÔÚÌÔÙÂÚfiÏ˘ Î·È Û·ÏÌÂÙÂÚfiÏ˘ Î·È Á) Ë ¤Ó·ÚÍË ‰Ú¿Û˘ Ù˘ ÊÔÚÌÔÙÂÚfiÏ˘ (1,7 min) Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛÓË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘. ∂Í·ÈÙ›·˜ Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰È·›ÛÙˆÛ˘, ÌÂÚÈÎÔ› ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ı· ÌÔÚÔ‡Û ӷ ¯ÚËÛÈÌÔÔÈËı› ·ÎfiÌ· Î·È ÛÙËÓ ÔÍ›· ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË (8,9), ÁÂÁÔÓfi˜ fï˜ Ô˘ ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙfi ·fi ÙË ¢ÈÂıÓ‹ ¶ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (GINA) (10). ∏ ÂÚÌËÓ›· Ù˘ Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ‰Ú¿Û˘ Ù˘ Û·ÏÌÂÙÂÚfiÏ˘ Î·È Ù˘ ÊÔÚÌÔÙÂÚfiÏ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È Û·Ê‹˜. ÿÛˆ˜ Â›Ó·È ¤ÓÙÔÓ· ÏÈÔÊÈÏÈΤ˜ Ô˘Û›Â˜ Ô˘ ·Óı›ÛÙ·ÓÙ·È (Ì ˘ÂÚ¤¯Ô˘Û· ÙË Û·ÏÌÂÙÂÚfiÏË) ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛ‹ ÙÔ˘˜ ·fi Ù· ÙÔȯÒÌ·Ù· ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È Èı·ÓÒ˜ Û˘Ó‰¤ÔÓÙ·È ÈÛ¯˘ÚfiÙÂÚ· Ì ÙÔ˘˜ ‚2-˘Ô‰Ô¯Â›˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ ‰ÈÂÁ¤ÚÙ˜ (2,6). ∏ ÂÎÏÂÎÙÈÎfiÙËÙ· ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ÂϤÁ¯ÂÙ·È Ì ۇÁÎÚÈÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ¯¿Ï·Û˘ ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (fiÔ˘ ‚Ú›ıÔ˘Ó ÔÈ ‚2˘Ô‰Ô¯Â›˜) Î·È Ù˘ ÚÔηÏÔ‡ÌÂÓ˘ ·‡ÍËÛ˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ ‰È¤ÁÂÚÛ˘ ÙÔ˘ Ì˘˚ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ηډȷÎÔ‡ ÎfiÏÔ˘ (fiÔ˘ ÂÈÎÚ·ÙÔ‡Ó ÔÈ ‚1˘Ô‰Ô¯Â›˜). ªÂ ÙËÓ ·Ú·¿Óˆ Ù¯ÓÈ΋ ·ÔηχÙÂÙ·È ˆ˜ ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Â›Ó·È ÈÔ ÂÎÏÂÎÙÈÎÔ› ·’ fiÙÈ ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ (11). ŒÙÛÈ, ‰ÂÓ ÚÔηÏ› ¤ÎÏËÍË ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ ÂÚÈÛÛfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ ·’ fiÙÈ ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ‚Ú·¯Â›·˜ ‰Ú¿Û˘. ª¿ÏÈÛÙ·, Ë Ì¤ÙÚËÛË ÙÔ˘ Î·Ï›Ô˘ ÙÔ˘ ÔÚÔ‡ Î·È ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT ÙÔ˘ ∏∫° Û ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤‰ÂÈÍ ·ÚfiÌÔȘ ÂȉڿÛÂȘ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ Î·È Ì·ÎÚ¿˜ ‰Ú¿Û˘ (12,13).
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¶·È‰È·ÙÚÈ΋ 2001;64:342-346
Paediatriki 2001;64:342-346
¶›Ó·Î·˜ 1. µÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ‚2-‰ÈÂÁ¤ÚÙ˜
ŒÓ·ÚÍË
∂ӉȿÌÂÛË ‰Ú¿ÛË
∂ÌÊ¿ÓÈÛË Ì¤ÁÈÛÙ˘
¢È¿ÚÎÂÈ·
∞ÓÙÈÛÙÔȯ›· ‰fiÛ˘
™·Ï‚Ô˘Ù·ÌfiÏË
0,8 min
5 min (75-80% max)
15 - 60 min
4-6h
100 Ìg
∆ÂÚÌÔ˘Ù·Ï›ÓË
1-3 min
5 min (75-80% max)
15 - 60 min
4-6h
250 Ìg
ºÔÚÌÔÙÂÚfiÏË
1,7 min
5-10 min (80-90% max)
2-3h
9 - ≥12 h
12 Ìg
™·ÏÌÂÙÂÚfiÏË
17,6 min
1 h (90% max)
2-4h
9 - ≥12 h
≤25 Ìg
∏ Û¯¤ÛË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Î·È Ù˘ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ Û˘ÓÔ„›˙ÂÙ·È ÛÙȘ ·Ú·Î¿Ùˆ ·Ú·ÙËÚ‹ÛÂȘ: ·) ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Â›Ó·È ÈÛ¯˘ÚÔ› Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ÏÂÈÙÔ˘ÚÁÈÎÔ› ·ÓÙ·ÁˆÓÈÛÙ¤˜ ¤Ó·ÓÙÈ ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ô˘ ÚÔηÏÔ‡Ó ‚ÚÔÁ¯fiÛ·ÛÌÔ, ›Ù ̤ۈ ·Â˘ı›·˜ ‰Ú¿Û˘ ÛÙȘ Ï›˜ Ì˘˚Τ˜ ›Ó˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (fiˆ˜ Ë ÈÛÙ·Ì›ÓË Î·È Ë ÌÂÙ·¯ÔÏ›ÓË), ›Ù ̤ۈ ·ÂÏ¢ı¤ÚˆÛ˘ ÌÂÛÔÏ·‚ËÙÒÓ (fiˆ˜ Ù· ·ÏÏÂÚÁÈÔÁfiÓ· Î·È Ë ¿ÛÎËÛË), ‚) Ë ·Ú·¿Óˆ ·ÓÙ·ÁˆÓÈÛÙÈ΋ ‰Ú¿ÛË ‰È·ÚΛ <4 h ÁÈ· ÙÔ˘˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Î·È 12≥24 h ÁÈ· ÙÔ˘˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ‰ÈÂÁ¤ÚÙ˜ Î·È Á) Ë ‰Ú¿ÛË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋ ÛÙËÓ fi„ÈÌË Ê¿ÛË Ù˘ ·ÓÙ›‰Ú·Û˘, ·ÎfiÌ· Î·È ·Ó ·ӷ¯ÔÚËÁËıÔ‡Ó Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹. ∞ÓÙ›ıÂÙ·, ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ¤¯Ô˘Ó Ôχ ηÏfi ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ fi„ÈÌË Ê¿ÛË Ù˘ ·ÓÙ›‰Ú·Û˘, ·Ú’ fiÙÈ ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÛÙ·ÏÙÈ΋ ›‰Ú·ÛË ÛÙÔ Â›Â‰Ô Ù˘ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ ÚÔ·ÙÂÈ ·fi Û¯ÂÙÈÎfi ¤ÏÂÁ¯Ô ÛÙÔ ·›Ì· Î·È ÛÙÔ Û›ÂÏÔ. ∏ ÂÚÌËÓ›· ÁÈ· ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙËÓ ·Ú·ÙÂٷ̤ÓË ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ Î·È ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ·ÓÙ·ÁˆÓÈÛÙÈÎfiÙËÙ·, ¯ˆÚ›˜ fï˜ Ó· ÙÂÎÌËÚÈÒÓÂÙ·È ·fiÏ˘Ù· (14). ¶ÔÏϤ˜ ÌÂϤÙ˜ Û ·ÛıÌ·ÙÈο ·È‰È¿ ‰Â›¯ÓÔ˘Ó ˆ˜ ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘, ÂÎÙfi˜ Ù˘ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜, ·Ú¤¯Ô˘Ó ÚÔÛÙ·Û›· ·fi ÙÔ ¿ÛıÌ· ¿ÛÎËÛ˘ ̤¯ÚÈ Î·È 12 ÒÚ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË, Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Ô˘ ηχÙÔ˘Ó Î˘Ú›ˆ˜ ÙȘ ÚÒÙ˜ 3-4 ÒÚ˜ (15,16). ∞Ó¿ÏÔÁË ÂÈÎfiÓ· ‰›ÓÂÈ Î·È Ë Û‡ÁÎÚÈÛË ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÚÔÎÏËÙ‹˜ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ (17,18). O Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Ì ÂÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÂȉ‹ Â›Ó·È ¤Ó· Ôχ ÛËÌ·ÓÙÈÎfi ÂÊfi‰ÈÔ ÛÙÔ ·ÓÙÈ·ÛıÌ·ÙÈÎfi ÔÏÔÛÙ¿ÛÈÔ, ÂÈÙÚ¤ÔÓÙ·˜ ÙfiÙ ÙËÓ ÔÓÔÌ·Û›· ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Û·Ó Ê¿Ú̷η ÂϤÁ¯Ô˘ (‹ Ú˘ıÌÈÛÙÈο) ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ∏ Û˘Á¯ÔÚ‹ÁËÛË ‚2‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Î·È ÌÈÎÚÒÓ (ÎÏ·ÛÈÎÒÓ) ‰fiÛÂˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜, ·ÔÙÂÏ› ÂÓ·ÏÏ·ÎÙÈ΋ Î·È ›Ûˆ˜ ηχÙÂÚË ·ÓÙÈÌÂÙÒÈÛË (Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ) Û ۇÁÎÚÈÛË Ì ÙË
344
¯ÔÚ‹ÁËÛË ÌfiÓÔ ˘„ËÏÒÓ ‰fiÛÂˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÛÙÔ Ì¤ÙÚÈÔ Î·È ÛÔ‚·Úfi ¿ÛıÌ·. ∏ ÚÔÛı‹ÎË ÊÔÚÌÔÙÂÚfiÏ˘ Û ¯·ÌËÏ‹ ‰fiÛË ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Â›Ó·È ÙÔ ›‰ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ÚfiÏË„Ë ‹ÈˆÓ ·ÚÔ͢ÛÌÒÓ (‰ËÏ·‰‹ Û ηٷÛÙ¿ÛÂȘ ·‡ÍËÛ˘ Ù˘ ¯Ú‹Û˘ ÙˆÓ ·Ó·ÎÔ˘ÊÈÛÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ Û˘Óԉ‡ÂÙ·È Î·È/‹ fi¯È Ì ÙÒÛË Ù˘ ̤ÁÈÛÙ˘ ·Ó·Ó¢ÛÙÈ΋˜ ÚÔ‹˜ (PEF), ‹ Î·È ·‡ÍËÛË ÙˆÓ Ó˘ÎÙÂÚÈÓÒÓ Û˘Ìو̿وÓ) Ì ÙË ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ·ÏÏ¿ ˘ÔÏ›ÂÙ·È Ù˘ ÚfiÏ˄˘ ÛÔ‚·ÚÒÓ ·ÚÔ͢ÛÌÒÓ (‰ËÏ·‰‹ Û ηٷÛÙ¿ÛÂȘ Ô˘ ‰È·ÈÛÙÒÓÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì¤ÙÚÈ· Ì›ˆÛË Ù˘ PEF ÌÂ Û˘Á¯ÔÚ‹ÁËÛË ‹ fi¯È ÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ·) (10,19,20). ™Â 3 ÔÌ¿‰Â˜ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ, Ë ¯ÔÚ‹ÁËÛË ÛÙËÓ ÚÒÙË ÁÈ· 1 ¯ÚfiÓÔ 400 Ìg ÌÂÎÏÔÌÂı·˙fiÓ˘, ÛÙË ‰Â‡ÙÂÚË Û˘Ó‰˘·ÛÌfi 400 Ìg ÌÂÎÏÔÌÂı·˙fiÓ˘ Î·È Û·ÏÌÂÙÂÚfiÏ˘ Î·È ÛÙËÓ ÙÚ›ÙË ÔÌ¿‰· 800 Ìg ÌÂÎÏÔÌÂı·˙fiÓ˘, ‰ÂÓ ÂÌÊ¿ÓÈÛ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ·Ó·ÊÔÚÈο Ì ٷ Û˘ÌÙÒÌ·Ù·, ÙȘ ÚÔ¤˜ Î·È ÙË ‚ÚÔÁ¯È΋ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·. ¶Èı·ÓÔÏÔÁÂ›Ù·È ›Ûˆ˜, fiÙÈ Ë ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÛÙ· ·È‰È¿ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·Ó·ÛÙÚ¤„ÈÌË ÏfiÁˆ ÌÈÎÚfiÙÂÚ˘ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜ ÂÁηٿÛÙ·Û˘ (19,21). ∆Ô ÂӉ¯fiÌÂÓÔ Ù˘ Ù·¯˘Ê‡Ï·Í˘ (·ÓÙÔ¯‹˜) ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÛÙË Û˘Ó¯‹ ¯Ú‹ÛË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ, ¤¯ÂÈ ··Û¯ÔÏ‹ÛÂÈ Â› Ì·ÎÚfiÓ ·ÚÎÂÙÔ‡˜ ÂÚ¢ÓËÙ¤˜, Ì ·ÎfiÏÔ˘ıÔ Ó· ÚÔ·ÙÔ˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ Î·È ÌÂϤÙ˜. º·›ÓÂÙ·È fiÙÈ Ë Î·ıËÌÂÚÈÓ‹ ¯Ú‹ÛË ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Û ÂÓ‹ÏÈΘ ·ÛıÌ·ÙÈÎÔ‡˜ ÚÔηÏ› Ù·¯˘Ê‡Ï·ÍË. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ Û ·È‰È¿. ∞ӷʤÚÂÙ·È Ù·¯˘Ê‡Ï·ÍË ÌÂÙ¿ ·fi ¯Ú‹ÛË ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ ÁÈ· 4 ‚‰ÔÌ¿‰Â˜ Û 14 ÂÊ‹‚Ô˘˜, ÒÛÙ ӷ ÚÔÛٷهÔÓÙ·È ·fi ¿ÛıÌ· ¿ÛÎËÛ˘, ηٿ ÙËÓ 28Ë Ì¤Ú· ¯ÔÚ‹ÁËÛ˘, ÌfiÓÔ ÙËÓ 1Ë ÒÚ· Î·È fi¯È Î·È ÙËÓ 9Ë ·fi ÙË ¯ÔÚ‹ÁËÛË, fiˆ˜ Û˘Ó¤‚·ÈÓ ÙËÓ 1Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (17,19,22). °È· ÙÔ˘˜ ‚2-‰ÈÂÁ¤ÚÙ˜ Ì·ÎÚ¿˜ ‰Ú¿Û˘, ÚfiÛÊ·ÙË ÌÂϤÙË Û ÂÓ‹ÏÈΘ ·ÛıÌ·ÙÈÎÔ‡˜ ‰Â›¯ÓÂÈ fiÙÈ, ·ÓÙ›ıÂÙ· Ì fi,ÙÈ ÈÛÙ‡ÂÙ·È, ‰ÂÓ ˘¿Ú¯ÂÈ Ù·¯˘Ê‡Ï·ÍË ÌÂÙ¿ ÌÔÓÔıÂڷ›· 24 ÌËÓÒÓ (23). ∏ Ù·¯˘Ê‡Ï·ÍË, fï˜, ·fi η̛· ÌÂϤÙË ‰ÂÓ
¶·È‰È·ÙÚÈ΋ 2001;64:342-346
ÚÔ·ÙÂÈ fiÙÈ Û˘Ó‰¤ÂÙ·È Ì Âȉ›ӈÛË Û˘Ìو̿وÓ. ∏ Û˘Ó¯‹˜ ¯ÔÚ‹ÁËÛË ‚2-‰ÈÂÁÂÚÙÒÓ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ › ÂÍ¿ÌËÓÔ ‰ÂÓ ÚÔοÏÂÛ Ì›ˆÛË Ù˘ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋˜ ÙÔ˘˜ ‰Ú¿Û˘, ·ÏÏ¿ ÂÏ¿ÙÙˆÛ ÙËÓ ÔÛfiÙËÙ· ÙˆÓ ‚2-˘Ô‰Ô¯¤ˆÓ ÛÙ· ÂÚÈÊÂÚÈο ÌÔÓÔ‡ÚËÓ·, Ô˘ ‰È·ÈÛÙÒÓÂÙ·È ‹‰Ë ·fi ÙËÓ ÙÚ›ÙË ¤ˆ˜ ÙËÓ ¤‚‰ÔÌË Ë̤ڷ Ù˘ ıÂڷ›·˜ (17). ªfiÓÔ Ë ¯ÔÚ‹ÁËÛË ·fi ÙÔ ÛÙfiÌ· ÛÙÂÚÔÂȉÒÓ ·˘Í¿ÓÂÈ ÙÔ˘˜ ‰È·ı¤ÛÈÌÔ˘˜ ‚2-˘Ô‰Ô¯Â›˜, fi¯È fï˜ Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹, Ô˘ ›Ûˆ˜ ‰ÚÔ˘Ó ÌfiÓÔ Ì¤Ûˆ ‰È·Ù‹ÚËÛ˘ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜, Èı·ÓÒ˜ Ì ·Ú¤Ì‚·ÛË ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÊÏÂÁÌÔÓ‹˜ Ô˘ ·Â˘·ÈÛıËÙÔÔÈÔ‡Ó ÙÔ˘˜ ˘Ô‰Ô¯Â›˜ (24,25). ∞fi ÙË Ê·Ú̷΢ÙÈ΋ ÂÙ·ÈÚ›· Novartis ÚÔ·ÙÂÈ ÌÂϤÙË (¡Ô 049), fiÔ˘ Û 518 ·È‰È¿ ËÏÈΛ·˜ 5-12 ¯ÚfiÓˆÓ, Ë Û˘Ó¯‹˜, › ÙÚ›ÌËÓÔ, ¯ÔÚ‹ÁËÛË ÊÔÚÌÔÙÂÚfiÏ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ıÂڷ›· ÛÙÔ ‹ÈÔ-̤ÙÚÈÔ ¿ÛıÌ·, ‰ÂÓ ÚÔηÏ› Ù·¯˘Ê‡Ï·ÍË. In vitro ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÊoÚÌÔÙÂÚfiÏË ‰ÂÛ̇ÂÈ ÂÓÙÂÏÒ˜ ÌÂÚÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜, ÂÓÒ Ë Û·ÏÌÂÙÂÚfiÏË, ÌÂÚÈÎÒ˜, ÂÚÈÛÛfiÙÂÚÔ˘˜ ˘Ô‰Ô¯Â›˜. ∂¿Ó ÙÔ Ê·ÈÓfiÌÂÓÔ ÂȂ‚·Èˆı› Î·È È‰›ˆ˜ in vivo, ÙfiÙ ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó Û·ÏÌÂÙÂÚfiÏË ÁÈ· ¯ÚfiÓÈ· ıÂڷ›·, Û ÂÚ›ÙˆÛË ÔÍ›·˜ ÎÚ›Û˘ Ó· ÌËÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙÔ› ‰È·ı¤ÛÈÌÔÈ ‚2-˘Ô‰Ô¯Â›˜ ÁÈ· Ó· ‰Ú¿ÛÔ˘Ó ÔÈ ‚2‰ÈÂÁ¤ÚÙ˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘. ∏ ·Ú·¿Óˆ ˘fiıÂÛË ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È ÂÔ̤ӈ˜ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ÁÈ· ÙÂÏÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ¶·Ú¿ ÙȘ ÌÂϤÙ˜ in vivo, fiÔ˘ Ê·›ÓÂÙ·È fiÙÈ Ë Û·ÏÌÂÙÂÚfiÏË ˘ÛÙÂÚ› Ù˘ ÊÔÚÌÔÙÂÚfiÏ˘ ÛÙË ‰Ú¿ÛË Ù˘ ÛÙÔ˘˜ ·ÓıÚÒÈÓÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜, Èı·ÓÒ˜ Ë ¯Ú‹ÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘, fiˆ˜ Ë Û·ÏÌÂÙÂÚfiÏË, Ô˘ ÌÂÚÈÎÒ˜ ‰ÂÛ̇ÂÈ ÙÔ˘˜ ˘Ô‰Ô¯Â›˜, ¤¯ÂÈ Î¿ÔÈ· ÎÏÈÓÈο ÏÂÔÓÂÎÙ‹Ì·Ù·. ¶·Ú·‰Â›ÁÌ·Ù· ·ÔÙÂÏÔ‡Ó ÔÈ ÏÈÁfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ Î·È Ô ÌÈÎÚfiÙÂÚÔ˜ ‚·ıÌfi˜ Ù·¯˘Ê‡Ï·Í˘. ∂ÓÒ ÁÈ· ÙÔ ÚÒÙÔ ·Ú¿‰ÂÈÁÌ· ˘¿Ú¯Ô˘Ó ÌÂÚÈΤ˜ ˘ÔÛÙËÚÈÎÙÈΤ˜ ÌÂϤÙ˜, ÁÈ· ÙÔ ‰Â‡ÙÂÚÔ ‰ÂÓ ˘¿Ú¯ÂÈ ÎÏÈÓÈ΋ ÂȂ‚·›ˆÛË (25,25·). °È· ÙÔÓ ÂӉ¯fiÌÂÓÔ Î›Ó‰˘ÓÔ Ù·¯˘Ê‡Ï·Í˘ ·fi ÙË Û˘Ó¯‹ ¯Ú‹ÛË ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘, ÌÂÚÈÎÔ› Û˘ÓÈÛÙÔ‡Ó, ÂÊ’ fiÛÔÓ ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi, ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ Î·È Î˘Ú›ˆ˜ ÙÔ ‚Ú¿‰˘ (26). ªÂ ·˘Ù‹ ÙË ı¤ÛË ‰È·ÊˆÓ› Ì›· Û¯ÂÙÈÎÒ˜ ÚfiÛÊ·ÙË ÌÂϤÙË (Am J Med 1998;104:431438), ÛÙËÓ ÔÔ›· fï˜ Ô ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÂÓ‹ÏÈÎˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÛıÂÓÒÓ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ·‰˘Ó·Ì›Â˜ ÛÙ‹ÚÈ͢ Î·È ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ·ÓÙ›ıÂÙ˘ ¿Ô„˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¯Ú‹ÛË ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Û˘ÓÈÛÙ¿Ù·È ÛÙ· ÛÙ¿‰È· 3 Î·È 4 ÙÔ˘ ¯ÚfiÓÈÔ˘ ¿ÛıÌ·ÙÔ˜ (10). ∏ ËÏÈΛ· ¤Ó·Ú͢ ¯ÔÚ‹ÁË-
Paediatriki 2001;64:342-346
Û˘ Â›Ó·È Ù· 4-6 ¯ÚfiÓÈ·, ¯ˆÚ›˜, Û ȉȷ›ÙÂÚ˜ ÂÚÈÙÒÛÂȘ, Ó· ··ÁÔÚ‡ÂÙ·È Ë ¯Ú‹ÛË ÙÔ˘˜ Î·È Ï›ÁÔ ÓˆÚ›ÙÂÚ·. ∂›Ó·È ›Ûˆ˜ ÚÔÙÈÌfiÙÂÚÔ Ó· Û˘Ó‰˘¿˙ÔÓÙ·È Ì ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ Ù·¯˘Ê‡Ï·Í˘ Î·È ·Ó Â›Ó·È ÂÊÈÎÙfi, Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ̛· ‚Ú·‰ÈÓ‹ ‰fiÛË ·Ó¿ 24ˆÚÔ. ∏ Û˘Á¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Ì ÌÈÎÚ¤˜ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Ú¤ÂÈ Ó· Â›Ó·È Ë ÚÒÙË ÂÈÏÔÁ‹ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ̤ÙÚÈÔ˘-ÛÔ‚·ÚÔ‡ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ, Ô˘ ÛÙÔ˘˜ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ ÙÔ ·È‰›, Â›Ó·È Èı·Ófi Ó· ¤¯ÂÈ Ì·ÎÚÔ¯ÚfiÓÈ· ‰˘Û¿ÚÂÛÙ· ·ÎfiÏÔ˘ı· (19,26). µÈ‚ÏÈÔÁÚ·Ê›· 1. Person C. On the history of sympathomimetics in asthma. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 1-18. 2. Nyberg L. Pharmacokinetics of beta2-adrenoceptorstimulating drugs. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 87-130. 3. Barnes P. Effect of beta-agonists on airway effector cells. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 35-66. 4. Verberne A, De Jongste C. The role of inhaled long-acting bronchodilator therapy. Rur Respir Rev 1996;6:199-203. 5. Bonner A. Salmeterol: long-term studies in children. Eur Respir J 1993;15(Suppl):318S. 6. Ullman A, Bergendal A, Linden A, Waldeck B, Skoogh BE, Lojdahl CG. Onset of action and duration of effect of formoterol and salmeterol compared to salbutamol in isolated guinea pig trachea with and without epithelium. Allergy 1992;47:384-387. 7. Derom E, Pauwels R. Bronchodilatation. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 161-178. 8. Schreurs A, Sinninghe-Damste H, De Graaff C, Greejhorst A. A dose-response study with formoterol Turbuhaler as maintenance therapy in asthmatic patients. Eur Respir J 1996;9:1678-1683. 9. Politiek M, Boorsma M, Aalbers R. Comparison of formoterol, salbutamol and salmeterol in metacholineinduced severe bronchoconstriction. Eur Respir J 1999;13:988-992. 10. Global strategy for asthma management and prevention. NHLBI/WHO Workshop Report. National Institutes of Health, National Heart, Lungand Blood Institute, Bethesda MD. ∂ÏÏËÓÈ΋ ÌÂÙ¿ÊÚ·ÛË, ÂÈ̤ÏÂÈ· Î·È ÚÔÛ·ÚÌÔÁ‹ (º. ™·ÍÒÓË-¶··ÁˆÚÁ›Ô˘ Î·È Ã. ∫·ÙÛ·Ú‰‹˜); ª¿ÚÙÈÔ˜ 2000. 11. Rabe K, Linden A. Mechanisms of duration of action of inhaled long-acting beta2-adrenoceptor agonists. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York:
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Marcel Dekker, Inc; 1997. p. 131-160. 12. Lotvall J, Persson G, Larsson P, Mardell C, Rosenborg J. Tolerability of inhaled high doses of formoterol and salbutamol in asthmatic patients maintained on twice daily formoterol 12 Ìg/9 Ìg delivered. [Abstract]. Eur Respir J 1997;10(Suppl 25):103S. 13. Totterman K, Huhti L, Sutinen E, Backman R, Pietinalho, Falck M et al. Tolerability to high doses of formoterol and terbutaline via turbuhaler for 3 days in stable asthmatic patients. Eur Respir J 1998;12:573-579. 14. Twentyman P, Finnerty J, Harris A, Palmer J, Holgate S. Protection against allergen-induced asthma by salmeterol. Lancet 1990;336:1338-1342. 15. Henriksen M, Agertoft L, Pedersen S. Protective effect and duration of action of inhaled formoterol and salbutamol on exercise-induced asthma in children. J Allergy Clin Immunol 1992;89:1176-1182. 16. Gronnerod T, Hamre H, Oepen G, Von Berg A. Protective effect of single doses of formoterol turbuhaler 4.5 Ìg and 9 Ìg in children with exercise-induced bronchoconstriction. [Abstract]. Am J Respir Crit Care Med 1999;159:A858. 17. Simons F. Clinical studies of beta2-adrenergic agonists in children. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 319-347. 18. Ramsdale H, Otis J, Klein P, Hargreave E, O’ Bryne M. The effect of long acting ‚2-adrenoceptor agonist, formoterol on metacholine airway responsiveness in asthmatic subjects. Am Rev Respir Dis 1991;143:998-1001. 19. Verberne A. Options for bronchodilation in children: can we rely on adult data? Allergy 1999;54(Suppl):51-54S. 20. Pauwels R, Lofdahl G, Postma S. Effect of inhaled formoterol and budesonide on exacerbations of asthma. N Engl J Med 1997;337:1405-1411.
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21. Verberne A, Frost C, Duiverman J, Grol H. Dutch Pediatric Asthma Study Group. Addition of salmeterol versus doubling the dose of beclomethasone in children with asthma. Am J Respir Crit Care Med 1998;158:213-219. 22. Yates H, Sussman H, Shaw M, Barnes P, Cheung K. Regural formoterol tratment in mild asthma: effect on bronchial responsiveness during and after treatment. Am J Respir Crit Care Med 1995;152:1170-1174. 23. Rosenthal R, Busse W, Kemp J, Baker J, Kelberg C, Emmett A et al. Effect of long-term salmeterol therapy compared with as-needed albuterol use on airway hyperresponsiveness. Chest 1999;116:595-602. 24. Lipworth B. Tolerance with beta2-agonists. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 349-365. 25. Nikunard N. Long acting beta2-agonists. Annual Congress of the Europ Respir Soc Madrid; 1999. 25a. Palmqvist M, Ibsen T, Mellen A, Lotvall J. Comparison of the relative efficacy of formoterol and salmeterol in asthmatic patients. Am J Respir Crit Care Med 1999;160:244-249. 26. Pedersen S. The role of beta2-agonists in the treatment of asthma in children. In: Pauwels R, O’ Byrne P, eds. Lung Biology in Health and Disease. Beta2-agonists in asthma treatment. New York: Marcel Dekker, Inc; 1997. p. 379-396.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÿÚ˘ ∫·ÙÛ·Ú‰‹˜ ∫·˝ÚË 21, ¡. ™Ì‡ÚÓË, 171 22, ∞ı‹Ó·
¶·È‰È·ÙÚÈ΋ 2001;64:347-350
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PNEUMONOLOGY
∞›ÙÈ· ·ÔÙ˘¯›·˜ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙ· ·È‰È¿ £. ∆ÛÈÏÈÁÈ¿ÓÓ˘
Causes of failure in the treatment of asthma in children T. Tsiligiannis
¶ÂÚ›ÏË„Ë: ∏ ÂÈÙ˘¯‹˜ ıÂڷ›· ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ·ÔÙ¤ÏÂÛÌ· ‰ÈÂıÓÒÓ ÔÌÔʈÓÈÒÓ Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÙ›·˜, ÂÍ·ÚÙ¿Ù·È ·fi Ì›· ÏÂÈ¿‰· ·Ú·ÁfiÓÙˆÓ, ÂÎÙfi˜ ·fi ÙË Û˘ÓÙ·ÁÔÁÚ¿ÊËÛË ÙˆÓ Î·Ù¿ÏÏËÏˆÓ Ê·Ú̿ΈÓ. OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ÛˆÛÙ‹ ‰È¿ÁÓˆÛË, ÙËÓ Â·Ú΋ ·ÁˆÁ‹ Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Û˘, ÙËÓ Î·Ù¿ÏÏËÏË ¯ÚfiÓÈ· ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË, ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÙË ÛˆÛÙ‹ ¯Ú‹ÛË ÙˆÓ ÔÈÎ›ÏˆÓ ÌÔÚÊÒÓ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙˆÓ Û˘Û΢ÒÓ ¯ÔÚ‹ÁËÛ˘.
Abstract: The successful treatment of childhood asthma, which has ensued from the development of international guidelines during the last decade, depends on a number of factors, in addition to the appropriate drug prescription. Included among these factors are, the establishment of correct diagnosis, adequate treatment of the asthmatic crisis, appropriate chronic antiinflammatory therapy, treatment of exercise induced asthma, avoidance of triggering factors and the appropriate use of the various forms of inhaled medications, devices, and spacers.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ¿ÛıÌ·, ıÂڷ›·, ·›ÙÈ· ·ÔÙ˘¯›·˜.
Key words: childhood asthma, treatment, causes of failure.
∂ÈÛ·ÁˆÁ‹ Œ¯Ô˘Ó ÂÚ¿ÛÂÈ ÂÚÈÛÛfiÙÂÚ· ·fi 10 ¯ÚfiÓÈ· ·fi ÙfiÙ Ԣ ÙÂÎÌËÚÈÒıËÎÂ Ë ¿Ô„Ë fiÙÈ ÙÔ ¿ÛıÌ· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÂȉÈ΋˜ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ‚ÚfiÁ¯ˆÓ Î·È fi¯È ·Ï¿ ‚ÚÔÁ¯fiÛ·ÛÌÔ˜ Ô˘ ˘Ô¯ˆÚ› Ì ÙË ıÂڷ›· Ù˘ ·ÛıÌ·ÙÈ΋˜ ¤Í·ÚÛ˘ ‹ Î·È ·˘ÙfiÌ·Ù·. ŒÙÛÈ, ηıÈÂÚÒıËÎÂ Ë ÛˆÛÙ‹ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ Û˘Ó‰˘·ÛÌfi ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Î·È ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ê·Ú̿ΈÓ, ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘. ∏ ·Ó¿ÁÎË ÁÈ· ÙËÓ ÔÌÔÈfiÌÔÚÊË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·ıȤڈÛË ÙˆÓ ÁÓˆÛÙÒÓ ÔÌÔʈÓÈÒÓ Û ÂıÓÈÎfi Â›Â‰Ô ÛÙȘ ∏¶∞, ÙËÓ ∞ÁÁÏ›· Î·È ¿ÏϘ ¯ÒÚ˜, ηıÒ˜ Î·È ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÔÌÔʈӛ· Û ·ÁÎfiÛÌÈÔ Â›Â‰Ô Ì ÙË Û˘ÌÌÂÙÔ¯‹ Ù˘ ¶·ÁÎfiÛÌÈ·˜ OÚÁ¿ÓˆÛ˘ ÀÁ›·˜ (Global Initiative for Asthma - GINA), Ë ÔÔ›· Ì·˙› Ì ÙË Û‡ÓÔ„‹ Ù˘, ÚfiÛÊ·Ù· ÌÂÙ·ÊÚ¿ÛÙËÎÂ Î·È ÙÚÔÔÔÈ‹ıËΠÁÈ· ÙȘ ·Ó¿ÁΘ Ù˘
¯ÒÚ·˜ Ì·˜ (1). ¶·Ú’ fiÏ· ·˘Ù¿, ÙÔ ¿ÛıÌ· ÂÍ·ÎÔÏÔ˘ı› Ó· ‰È·ÎÚ›ÓÂÙ·È ·fi ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ·fi Û˘¯Ó¤˜ ÂÈÛ·ÁˆÁ¤˜ ·È‰ÈÒÓ Û ÓÔÛÔÎÔÌ›·, ÂÓÒ ÔÏϤ˜ ÊÔÚ¤˜ Ë ·ÁˆÁ‹ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È Ê·›ÓÂÙ·È Ó· ÌËÓ ÂÈÙ˘Á¯¿ÓÂÈ ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ô˘ ¤¯Ô˘Ó ÙÂı› ·fi ÙȘ ÔÌÔʈӛ˜. ∞˘Ù¤˜ ÔÈ ÔÌÔʈӛ˜, ÂÍ¿ÏÏÔ˘, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÚÈṲ̂ӷ ·ÌÊÈÏÂÁfiÌÂÓ· ÛËÌ›·, Ù· ÔÔ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó ÙÔ˘˜ ıÂÚ¿ÔÓÙ˜ È·ÙÚÔ‡˜ - Ô˘ ηٿ ηÓfiÓ· Â›Ó·È ÁÂÓÈÎÔ› È·ÙÚÔ›, ·È‰›·ÙÚÔÈ ‹ ·ıÔÏfiÁÔÈ - Û ϷÓı·Ṳ̂Ó˜ ÂÎÙÈÌ‹ÛÂȘ ‹ Ï·Óı·Ṳ̂Ó˜ ıÂڷ¢ÙÈΤ˜ ÂÈÏÔÁ¤˜. ∂›Ó·È .¯. ÂÓÙ˘ˆÛÈ·Îfi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙȘ ÔÌÔʈӛ˜ ‰ÂÓ ÙÔÓ›˙ÂÙ·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ‰È·Ï›ÔÓ ‹ÈÔ ¿ÛıÌ· ÌÔÚ› Ó· ÂΉËÏÒÛÔ˘Ó Ôχ ‚·ÚȤ˜ (life threatening) ·ÛıÌ·ÙÈΤ˜ ÎÚ›ÛÂȘ, ÂÓÒ Û˘Ó‹ıˆ˜ Â›Ó·È ÂÎÏËÎÙÈο ˘ÁÈ›˜ Î·È ·ÓÙÂÏÒ˜ ÂχıÂÚÔÈ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· (2).
¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì· ¡·˘ÙÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ
Pediatric Division Athens Naval Hospital
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∆· ·›ÙÈ· Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ Â›Ó·È ÔÏÏ¿ Î·È Û˘Ó‹ıˆ˜ ÂÍ·ÙÔÌÈ·ÔÓÙ·È. ¶·Ú’ fiÏ· ·˘Ù¿, ÌÔÚ› ηÓ›˜ Ó· ‰È·ÎÚ›ÓÂÈ ÌÂÚÈΤ˜ ·fi ÙȘ ÈÔ Û˘¯Ó¤˜ ·Èٛ˜ ‹ ·Ú·Ï›„ÂȘ Ô˘ Ô‰ËÁÔ‡Ó ÛÙËÓ ·ÔÙ˘¯›·. ªË ·Ó·ÁÓÒÚÈÛË Ù˘ ÛˆÛÙ‹˜ ‰È¿ÁÓˆÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ¿ÛıÌ· ‰ÂÓ ¤¯ÂÈ ¿ÓÙÔÙ ÙËÓ ›‰È· ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜, ‹ ·ÎfiÌ· Î·È ÛÙÔÓ ›‰ÈÔ ·ÛıÂÓ‹ Û ‰È·ÊÔÚÂÙÈΤ˜ ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜. ™ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ ¿ÛıÌ· ·Ú·Ì¤ÓÂÈ Ì›· ‰È·ÏÂ›Ô˘Û· ÓfiÛÔ˜. ∂›Ó·È ›Û˘ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ì›· ·Ôχو˜ ÂͤٷÛË Ô˘ Ó· ÙÂÎÌËÚÈÒÓÂÈ ‹ Ó· ·ÔÎÏ›ÂÈ ·‰È·ÌÊÈÛ‚‹ÙËÙ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ë ÔÔ›· Ú¤ÂÈ Ó· ‚·Û›˙ÂÙ·È ÛÙÔ ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi, ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ Ê˘ÛÈ΋˜ ÂͤٷÛ˘, ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ·Ú·ÎÏÈÓÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·È ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓ‹ ÛÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹. OÈ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ Ì ÙȘ Ôԛ˜ ÌÔÚ› Ó· ÂΉËψı› ÙÔ ·È‰ÈÎfi ¿ÛıÌ· Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (3). π‰È·›ÙÂÚ· ·Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ôχ Û˘¯Ó¿ Á›ÓÂÙ·È Ï·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, fiÙ·Ó Ù· ·È‰È¿ ÂΉËÏÒÓÔ˘Ó ÙÔ ¿ÛıÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Ì ÙË ÌÔÚÊ‹ Ù˘ ˘ÂÚÚ¤ÎÚÈÛ˘ ÙˆÓ ‚ÚfiÁ¯ˆÓ Î·È ÙˆÓ ÛÙËıÔ·ÎÔ˘ÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·¯Â›˜ Î·È ÏÂÙÔ‡˜ ˘ÁÚÔ‡˜ ÚfiÁ¯Ô˘˜, ΢ڛˆ˜ ηٿ ÙËÓ ÂÈÛÓ¢ÛÙÈ΋ Ê¿ÛË. ŒÙÛÈ, Ì·›ÓÂÈ Ôχ Û˘¯Ó¿ Ë ‰È¿ÁÓˆÛË
Paediatriki 2001;64:347-350
Ù˘ ‚ÚÔÁ¯›Ùȉ·˜ Î·È Ù· ·È‰È¿ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÁˆÁ‹ Ì ·ÓÙÈ‚ÈÔÙÈο Î·È ·Ô¯ÚÂÌÙÈο Ê¿Ú̷η. ÕÏÏÔ Û˘¯Ófi ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› Ë ÂÚ›ÙˆÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ¿ÛıÌ· Ô˘ ÂΉËÏÒÓÂÙ·È ÌfiÓÔ ‹ ΢ڛˆ˜ Ì ‚‹¯·, ÂÓÒ Ë ·ÎÚfi·ÛË ÙÔ˘ ıÒڷη ÛÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋, fiˆ˜ Î·È Ë ÙÈÌ‹ Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜. §·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË ¿ÛıÌ·ÙÔ˜ Ÿˆ˜ οı ·È‰› Ì ¿ÛıÌ· ‰ÂÓ ¤¯ÂÈ ··Ú·›ÙËÙ· ‹ ¿ÓÙÔÙÂ Û˘ÚÚ›ÙÔ˘ÛÛ· ·Ó·ÓÔ‹ (wheezing), ¤ÙÛÈ Î·È Î¿ı ·È‰› ÌÂ Û˘ÚÚ›ÙÔ˘ÛÛ· ·Ó·ÓÔ‹ ‰ÂÓ ¤¯ÂÈ ÔˆÛ‰‹ÔÙ ¿ÛıÌ·. À¿Ú¯Ô˘Ó ÔÏϤ˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙÔ ¿ÛıÌ· ÛÙ· ·È‰È¿, fiˆ˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2, ÙȘ Ôԛ˜ Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ¤¯ÂÈ ˘’ fi„ÈÓ ÙÔ˘. π‰È·›ÙÂÚ· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ηٷÛÙ¿ÛÂȘ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙÔ ¿ÛıÌ· ÂΉËÏÒÓÔÓÙ·È Û ·È‰È¿ ÌÈÎÚ‹˜ ËÏÈΛ·˜, fiÙ·Ó Â›Ó·È ·‰‡Ó·ÙË Ë ‰ÈÂÓ¤ÚÁÂÈ· ÂȉÈÎÒÓ Ó¢ÌÔÓÔÏÔÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ. ∞ÓÂÈÙ˘¯‹˜ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Û˘ ™ÙËÓ ·È‰È΋ ËÏÈΛ·, ÔÈ ·ÛıÌ·ÙÈΤ˜ ÎÚ›ÛÂȘ Ô˘ ¢ı‡ÓÔÓÙ·È ÙfiÛÔ ÁÈ· ÙË ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ·, fiÛÔ Î·È ÁÈ· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÈÛ·ÁˆÁ¤˜ ÛÙ· ÓÔÛÔÎÔÌ›·, ¤¯Ô˘Ó Û·Ó ÂÎÏ˘ÙÈÎfi ·›ÙÈÔ ÙȘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∏ ÂÈÙ˘¯‹˜ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Ûˆ˜ ··ÈÙ› ÙÔ Û˘Ó‰˘·ÛÌfi Ù˘ Û˘¯Ó‹˜ ¯ÔÚ‹ÁËÛ˘ ÂÈÛÓÂfiÌÂÓˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Î·È Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (4). ŸÛÔ ÈÔ
¶›Ó·Î·˜ 1. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ 1. ∫Ï·ÛÈÎfi ÂÂÈÛԉȷÎfi ¿ÛıÌ· ™˘Ó‹ı˘ ÂΉ‹ÏˆÛË: ∆˘Èο ÂÂÈÛfi‰È· Ì ‚‹¯·, Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ (wheezing), ‰‡ÛÓÔÈ· Î·È ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù·. 2. ∂›ÌÔÓÔ ¿ÛıÌ· ™Ù·ıÂÚ¿, ηıËÌÂÚÈÓ¿ (‹ οı Ӈ¯Ù·) Û˘ÌÙÒÌ·Ù· Î·È ÂÈϤÔÓ ÔÍ›˜ ·ÛıÌ·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ (Û˘¯Ó¿ ‚·ÚȤ˜). 3. ÕÛıÌ· Ì ÌÔÓ·‰È΋ ÂΉ‹ÏˆÛË ÙÔ ‚‹¯· π‰È·›ÙÂÚ· ›ÌÔÓÔ˜, ÍËÚfi˜ Ó˘¯ÙÂÚÈÓfi˜ ‚‹¯·˜. 4. ÀÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ‚‹¯·/‚ÚÔÁ¯›Ùȉ·˜ “ÕÛıÌ· Ì ˘ÂÚ¤ÎÎÚÈÛË”: ¶·Ú·ÙÂٷ̤ӷ ÂÂÈÛfi‰È· ‚‹¯· ηÈ/‹ “˘ÁÚ¿ ·ÎÚÔ·ÛÙÈο Â˘Ú‹Ì·Ù·” ÛÙÔ ÛÙ‹ıÔ˜ ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. ™˘¯Ó‹ ÌÔÚÊ‹ ÂΉ‹ÏˆÛ˘ ÛÙ· ‚Ú¤ÊË Î·È Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. 5. ÀÔÙÚÔÈ¿˙Ô˘Û· “Ó¢ÌÔÓ›·” ∂›ÌÔÓË/˘ÔÙÚÔÈ¿˙Ô˘Û· ·ÙÂÏÂÎÙ·Û›· (ȉȷ›ÙÂÚ· ÛÙÔ ‰ÂÍÈfi ̤ÛÔ ÏÔ‚fi). ™˘¯Ó‹ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ªÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ÂÈÎ¿Ï˘„Ë Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ٤ٷÚÙ˘ ·Ú·ÁÚ¿ÊÔ˘. 6. ÕÛıÌ· ÌÂÙ¿ ·fi ¿ÛÎËÛË ™˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ (wheezing) ‹ ‚‹¯·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË ÌfiÓÔ, Ì ÂÏ¿¯ÈÛÙ· ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. 7. µ·Ú‡ ÂÂÈÛԉȷÎfi ¿ÛıÌ· ∞Ú·È¿ - ·ÏÏ¿ “ÂÎÚËÎÙÈÎÔ‡ Ù‡Ô˘” - ÂÂÈÛfi‰È· ·ÛıÌ·ÙÈÎÒÓ ÎÚ›ÛˆÓ, Û˘¯Ó¿ ȉȷ›ÙÂÚ· ‚·ÚÈ¿ Î·È ÂÈΛӉ˘Ó·, Ì ÂÎÏËÎÙÈο Ê˘ÛÈÔÏÔÁÈ΋ ÂÈÎfiÓ· ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÌÂٷ͇ ÙˆÓ ÎÚ›ÛˆÓ. 8. ∂›ÌÔÓË Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ ‚ÚÂÊÒÓ ™˘Ó‹ıˆ˜ ¯ˆÚ›˜ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ‹ ¿ÏÏ· ¤ÓÙÔÓ· Û˘ÌÙÒÌ·Ù·. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ, Â›Ó·È Èı·Ófi Ë Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ (wheezing) Ó· ÌËÓ ÔÊ›ÏÂÙ·È Û ¿ÛıÌ·.
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¶·È‰È·ÙÚÈ΋ 2001;64:347-350
¶›Ó·Î·˜ 2. ∫·Ù·ÛÙ¿ÛÂȘ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙÔ ¿ÛıÌ· ∞. ∞fiÊÚ·ÍË Î˘Ú›ˆ˜ ÙˆÓ ÌÈÎÚÒÓ ·ÂÚ·ÁˆÁÒÓ 1. ¶Â˘ÌÔÓÈ΋ ÂÈÛÚfiÊËÛË 2. µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· 3. OÍ›· ÈÔÁÂÓ‹˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· 4. ∫˘ÛÙÈ΋ ›ÓˆÛË µ. ∞fiÊÚ·ÍË Î˘Ú›ˆ˜ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÂÚ·ÁˆÁÒÓ 1. ∂ÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ 2. ™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Î·È ÙˆÓ Ó¢ÌfiÓˆÓ 3. ∫·Ú‰ÈÔ¿ıÂȘ 4. ∂Ó‰Ô‚ÚÔÁ¯ÈÎÔ› fiÁÎÔÈ 5. ∂͈ÙÔȯˆÌ·ÙÈο ·›ÙÈ· ‚ÚÔÁ¯È΋˜ ÛÙ¤ÓˆÛ˘ 6. ÀÂÚÁψÙÙȉÈ΋ ·fiÊÚ·ÍË ·ÂÚ·ÁˆÁÒÓ 7. ÀÛÙÂÚÈο Û˘ÌÙÒÌ·Ù· („˘¯ÔÁÂÓ‹˜ ‚‹¯·˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ʈÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ ÌÈÌÔ‡ÌÂÓË Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹, „˘¯ÔÁÂÓ‹˜ ˘¤ÚÓÔÈ·)
¤ÁηÈÚ· ÂÊ·ÚÌÔÛÙ› Ë Î·Ù¿ÏÏËÏË ·˘Ù‹ ·ÁˆÁ‹, ÙfiÛÔ Ù·¯‡ÙÂÚ· ‚ÂÏÙÈÒÓÂÙ·È Ë ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË Î·È ·ÔÌ·ÎÚ‡ÓÂÙ·È Ë Èı·ÓfiÙËÙ· ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∞˘Ùfi Ô˘ Û˘Ì‚·›ÓÂÈ Û˘¯Ó¿ Â›Ó·È Ó· ÌËÓ ¯ÔÚËÁÔ‡ÓÙ·È Î·ıfiÏÔ˘ Û˘ÛÙËÌ·ÙÈο ÛÙÂÚÔÂȉ‹ ÛÙËÓ ÔÍ›· ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË, ‹ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹, ÂÓÒ Ù· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ¯ÔÚËÁÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ Û ·Ú·È¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ∞Ó·Ú΋˜ Î¿Ï˘„Ë ÛÙÔ ¯ÚfiÓÈÔ ¿ÛıÌ· Ì ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ ∆· ·È‰È¿ Ì ¯ÚfiÓÈÔ Â›ÌÔÓÔ ¿ÛıÌ· ¤¯Ô˘Ó ·Ó¿ÁÎË ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ·ÁˆÁ‹ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏÂÁ¯ı› Ë ÓfiÛÔ˘˜ ÙÔ˘˜, Ó· ÚÔÏËÊıÔ‡Ó ÔÈ ÂÍ¿ÚÛÂȘ Î·È Ó· Û˘Ó¯ÈÛÙ› Ë Ê˘ÛÈÔÏÔÁÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ¶ÔÏϤ˜ ÊÔÚ¤˜ Û˘Ì‚·›ÓÂÈ Ó· ‰È·ÎfiÙÂÙ·È ¿Î·ÈÚ· Ë ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ ‹ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ê¿Ú̷η Ì ·ÛıÂÓ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ‰Ú¿ÛË, ‹ - ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ¯·ÌËϤ˜ ‰fiÛÂȘ Ô˘ ‰ÂÓ Î·Ï‡ÙÔ˘Ó ÙȘ ·Ó¿ÁΘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ·ÛıÂÓ‹, ÒÛÙ ·˘Ùfi˜ Ó· ·Ú·Ì¤ÓÂÈ ÂχıÂÚÔ˜ Û˘Ìو̿وÓ. ∞Ó·Ú΋˜ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË O ‚ÚÔÁ¯fiÛ·ÛÌÔ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË Â›Ó·È Û‡ÓËı˜ Ê·ÈÓfiÌÂÓÔ ÛÙ· ·È‰È¿ Û¯ÔÏÈ΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ Ì ¿ÛıÌ· Î·È ÔÏϤ˜ ÊÔÚ¤˜ ÂÌÔ‰›˙ÂÈ ÙË Ê˘ÛÈ΋ ÙÔ˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ·. O ·Ó·Ú΋˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·ÛıÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È Ë ·Ô˘Û›· Î¿Ï˘„˘ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ì ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ì·ÎÚ¿˜ ‰Ú¿Ûˆ˜ ‹ Ì ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ‚Ú·¯Â›·˜ ‰Ú¿Ûˆ˜ ÚÈÓ ·fi ÙËÓ ¿ÛÎËÛË, Â›Ó·È ¤Ó· ·fi Ù· ·›ÙÈ· Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜.
Paediatriki 2001;64:347-350
ÃÚ‹ÛË ÂÈÛÓÂfiÌÂÓˆÓ Ê·ÚÌ¿ÎˆÓ ¯ˆÚ›˜ ·ÂÚÔı¿Ï·ÌÔ ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ Ù· ÂÈÛÓÂfiÌÂÓ· Ê¿Ú̷η ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÏfiÁˆ Ù˘ ¿ÌÂÛ˘ ÂÓ·fiıÂÛ‹˜ ÙÔ˘˜ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜, Ù˘ Ù·¯Â›·˜ ‰Ú¿Û˘ Î·È Ù˘ ÌÈÎÚ‹˜ ··ÈÙÔ‡ÌÂÓ˘ ‰fiÛ˘, Ô˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙˆÓ Èı·ÓÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. ∏ ¯Ú‹ÛË, fï˜, ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ Ê·ÚÌ¿ÎˆÓ ·Â˘ı›·˜, ¯ˆÚ›˜ ÙË ¯Ú‹ÛË ·ÂÚÔı·Ï¿ÌÔ˘, ÚÔ¸Ôı¤ÙÂÈ ÙËÓ ÈηÓfiÙËÙ· Û˘Á¯ÚÔÓÈÛÌÔ‡ ÙÔ˘ ·ÛıÂÓ‹, οÙÈ Ô˘ Â›Ó·È Û¯Â‰fiÓ ¿ÓÙÔÙ ·Ó¤ÊÈÎÙÔ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ∞ÎfiÌË Î·È Ì ÙȘ Û˘Û΢¤˜ ÍËÚ¿˜ ÎfiÓˆ˜ (fiˆ˜ turbuhaler, discus Î.Ï.), Â›Ó·È ··Ú·›ÙËÙÔ˜ Ô Û˘Á¯ÚÔÓÈÛÌfi˜ Î·È Ë Â›Ù¢ÍË Ù˘ ·Ó·Áη›·˜ ÂÈÛÓ¢ÛÙÈ΋˜ ÚÔ‹˜ ÁÈ· ÙËÓ ÂÓ·fiıÂÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ (5). ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË, ÔÈ ÁÔÓ›˜ - ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·˜ ÙËÓ ¿ÚÓËÛË ÙˆÓ ÌÈÎÚÒÓ ·È‰ÒÓ ÛÙË ¯Ú‹ÛË ÙˆÓ ·ÂÚÔı·Ï¿ÌˆÓ Ì ‹ ¯ˆÚ›˜ Ì¿Ûη - ¯ÔÚËÁÔ‡Ó Ù· ÂÈÛÓÂfiÌÂÓ· Ê¿Ú̷η ηْ ¢ı›·Ó ·fi ÙÔ ÛÙfiÌ·, ÈÛÙ‡ÔÓÙ·˜ fiÙÈ ¤ÙÛÈ ÙÔ ·È‰› Û˘ÓÂÚÁ¿˙ÂÙ·È Î·Ï‡ÙÂÚ·, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Û˘ÓÔÏÈ΋ ۯ‰fiÓ ÂÓ·fiıÂÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ·. ∞ÔÙ˘¯›· ·ÂÚÔı·Ï¿ÌˆÓ ‹ Û˘Û΢ÒÓ ¯ÔÚ‹ÁËÛ˘ ÂÈÛÓÔÒÓ ŸÙ·Ó Ù· ÂÈÛÓÂfiÌÂÓ· Ê¿Ú̷η ¯ÔÚËÁÔ‡ÓÙ·È Ì ËÏÂÎÙÚÈ΋ Û˘Û΢‹ ÓÂÊÂÏÔÔ›ËÛ˘, Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ fiÙÈ Ì ÙË ÛˆÛÙ‹ ÂÊ·ÚÌÔÁ‹ Ù˘ Ì¿Ûη˜ ÛÙÔ ÚfiÛˆÔ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ÂÓ·fiıÂÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Û ÔÛÔÛÙfi 8-9%. ŒÓ· Û˘¯Ófi Ï¿ıÔ˜ Â›Ó·È Ë ·Ê·›ÚÂÛË Ù˘ Ì¿Ûη˜ Î·È Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ÛËÌ›Ԣ ÂÍfi‰Ô˘ ÙÔ˘ ÓÂÊÂÏÔÔÈË̤ÓÔ˘ Ê·ÚÌ¿ÎÔ˘ ÎÔÓÙ¿ ÛÙÔ ÚfiÛˆÔ ÙÔ˘ ·ÛıÂÓ‹, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ ÂÈÛÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ Ó· ·ÔÙÂÏÂ›Ù·È ·fi ·ÙÌÔÛÊ·ÈÚÈÎfi ·¤Ú· Î·È fi¯È ·fi ÙÔ ÓÂÊÂÏÔÔÈË̤ÓÔ Ì›ÁÌ·. ∂¿Ó ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ‰ÔÛÈÌÂÙÚÈΤ˜ Û˘Û΢¤˜, Ë ÂÓ·fiıÂÛË Î˘Ì·›ÓÂÙ·È Û ÔÛÔÛÙfi 3-60%. ∂¿Ó ‰ÂÓ ÚÔËÁËı› ·Ó·Î›ÓËÛË Ù˘ ‰ÔÛÈÌÂÙÚÈ΋˜ Û˘Û΢‹˜, Ë ÂÓ·fiıÂÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÌÂÈÒÓÂÙ·È Ì¤¯ÚÈ 52% (6). ™ÙËÓ Î˘ÚÈÔÏÂÍ›·, Ë Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÌÂÓË ‰fiÛË ‰ÂÓ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ‰fiÛË Ô˘ ηٷϋÁÂÈ ÛÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È ‰ÂÓ ÁÓˆÚ›˙Ô˘Ì ·ÎÚÈ‚Ò˜ ÔÈ¿ Â›Ó·È Ë È‰·ÓÈ΋ ‰fiÛË ÁÈ· ÙÔ˘˜ Ó‡ÌÔÓ˜. ™Ù· ·›ÙÈ· Ù˘ ·ÔÙ˘¯›·˜ ÙˆÓ Û˘Û΢ÒÓ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë Î·Î‹ Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÙȘ Ô‰ËÁ›Â˜ ¯Ú‹Û˘ ÙˆÓ Û˘Û΢ÒÓ Î·È Ë ¯Ú‹ÛË ·Î·Ù¿ÏÏËÏ˘ Û˘Û΢‹˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓ‹. ¶Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ fiÙÈ ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ÛÙȘ ·ÓÙÈÛÙ¿ÛÂȘ ÙˆÓ ‚·Ï‚›‰ˆÓ ÌÂٷ͇ ÙˆÓ
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·ÂÚÔı·Ï¿ÌˆÓ Ì ̿Ûη Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Ù˘ ÂÈÛÓ¢ÛÙÈ΋˜ ÚÔ‹˜ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙË ‰È¿ÓÔÈÍË Ù˘ ‚·Ï‚›‰·˜. ∂›Û˘, Û ·È‰È¿ Ô˘ ÌÔÚÔ‡Ó Ó· Û˘Á¯ÚÔÓÈÛÙÔ‡Ó ÌÂ Û˘Û΢¤˜ ÌÂÁ¿ÏÔ˘ fiÁÎÔ˘ (Volumatic, Fisonair Î.Ï.), ·˘Ù¤˜ Ú¤ÂÈ ÔˆÛ‰‹ÔÙ ӷ ÚÔÙÈÌÒÓÙ·È Î·È ÙÔ ·È‰› Ó· ·ÏÏ¿˙ÂÈ Û˘Û΢‹ fiÙ·Ó ÌÂÁ·ÏÒÛÂÈ. ∞ÔÙ˘¯›· Û˘Û΢ÒÓ ÍËÚ¿˜ ÎfiÓˆ˜ OÈ Û˘Û΢¤˜ ÍËÚ¿˜ ÎfiÓˆ˜ ÏÂÔÓÂÎÙÔ‡Ó ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÙÔ˘˜ fiÁÎÔ˘ Î·È Ù˘ ¢ÎÔÏ›·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙË ¯Ú‹ÛË. ¢ÂÓ ˘¿Ú¯ÂÈ ·ÛʷϤ˜ fiÚÈÔ ËÏÈΛ·˜ ÁÈ· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ÛˆÛÙ‹˜ ¯Ú‹Û˘ ÙÔ˘˜. ∏ ·ÔÙ˘¯›· ÔÊ›ÏÂÙ·È ÛÙË ÌË Â·Ú΋ ÂÈÛÓ¢ÛÙÈ΋ ÚÔ‹ Ô˘ Ú¤ÂÈ Ó· ÚÔηϤÛÂÈ Ô ·ÛıÂÓ‹˜ Î·È Ë ÔÔ›· ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ Â·Ú΋ ÂÓ·fiıÂÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ÏfiÁˆ ·Ó·ÚÎÔ‡˜ ÂÈÛÓ¢ÛÙÈ΋˜ ÚÔÛ¿ıÂÈ·˜ (ȉ›ˆ˜ fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û˘Û΢¤˜ ÍËÚ¿˜ ÎfiÓˆ˜ Û ÌÈÎÚ‹ ËÏÈΛ·) ‹ ÏfiÁˆ ·‰˘Ó·Ì›·˜ Ó· ÂÈÙ¢¯ı› Ë Î·Ù¿ÏÏËÏË ÂÈÛÓ¢ÛÙÈ΋ ÚÔ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¤ÓÙÔÓÔ˘ ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ Ô˘ ÂÈÛ˘Ì‚·›ÓÂÈ Û ̛· ÔÍ›· ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË. ŒÏÏÂÈ„Ë Â›‰ÂÈ͢ Ù˘ ¯Ú‹Û˘ ÙˆÓ Û˘Û΢ÒÓ ·fi ÙÔ ÁÈ·ÙÚfi ¶ÔÏϤ˜ ÊÔÚ¤˜ ıˆÚÂ›Ù·È ·˘ÙÔÓfiËÙÔ fiÙÈ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ηٷÓÔ‹ÛÂÈ ÙȘ Ô‰ËÁ›Â˜ ¯ÔÚ‹ÁËÛ˘ ÂÈÛÓÂfiÌÂÓˆÓ Ê·Ú̿ΈÓ, Ì ‹ ¯ˆÚ›˜ Û˘Û΢‹. ∂›Û˘, ·Ó·Ì¤ÓÂÙ·È fiÙÈ Ô Ê·ÚÌ·ÎÔÔÈfi˜ ı· Â›Ó·È ·˘Ùfi˜ Ô˘ ı· ÂÍËÁ‹ÛÂÈ ÛÙÔ˘˜ ÁÔÓ›˜ ÙË ¯Ú‹ÛË ÙˆÓ Û˘Û΢ÒÓ Î·È ÙˆÓ ·ÂÚÔı·Ï¿ÌˆÓ. ∂¿Ó ‰ÂÓ ÚÔËÁËı› ›‰ÂÈÍË ÙÔ˘ ÛˆÛÙÔ‡ ÙÚfiÔ˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ÂÈÛÓÂfiÌÂÓÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ·È‰› ·fi ÙÔ ÁÈ·ÙÚfi, Ë ·ÔÙ˘¯›· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ‰Â‰Ô̤ÓË. ∂›ÌÔÓË ¤ÎıÂÛË Û ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ¶·È‰È¿ Ô˘ ¤¯Ô˘Ó ȉȷ›ÙÂÚË Â˘·ÈÛıËÛ›· Û ÂÚÈ‚·ÏÏÔÓÙÈο ·ÏÏÂÚÁÈÔÁfiÓ·, ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù¿ÏÏËÏÔ ¤ÏÂÁ¯Ô ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛÙÔ ÔÔ›Ô ˙Ô˘Ó, fiˆ˜ ¤ÏÂÁ¯Ô ÙÔ˘ ˘ÓÔ‰ˆÌ·Ù›Ô˘ ÁÈ· ˘ÁÚ·Û›· Î·È Ì‡ÎËÙ˜, ·ÔÌ¿ÎÚ˘ÓÛË ÌÔÎÂÙÒÓ, ηÙÔÈΛ‰ÈˆÓ ˙ÒˆÓ Î·È ÙËÓÒÓ Î·È ·ÔÊ˘Á‹ ηӛÛÌ·ÙÔ˜. ÕÚÓËÛË ·Ô‰Ô¯‹˜ Ù˘ ÓfiÛÔ˘ ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂÈÙ˘¯›· Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ Ë ·Ô‰Ô¯‹ ·fi ̤ÚÔ˘˜ ÙˆÓ ÁÔÓ¤ˆÓ Ù˘ ‰È¿ÁÓˆÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÁÈ· ÙÔ ·È‰› ÙÔ˘˜, Ú¿ÁÌ· ÙÔ ÔÔ›Ô ÔÏϤ˜ ÊÔÚ¤˜ ·ÚÓÔ‡ÓÙ·È. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ÁÈ·Ù› ·ÎfiÌË Î·È Ë Ï¤ÍË ¿ÛıÌ· ·ÔÙÂÏ› ÛÙ›ÁÌ· ÁÈ· ÙÔ ·È‰› ‹ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÂÓÒ Ë ÓfiÛÔ˜ ¤¯ÂÈ Ù·˘ÙÈÛÙ› Ì ÙËÓ ÂÈÎfiÓ· ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙÔ˜ ¯ÚfiÓÈÔ˘ ·ÛıÂÓ‹ ‹ Ì ÙËÓ ·ÚÔ˘Û›· ·Ó·ËÚ›·˜ ‰È¿ ‚›Ô˘. ™Ù· ·Ú¯È-
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ο ÛÙ¿‰È· ‹ › ·ÌÊÈ‚ÔÏ›·˜ ÙˆÓ ıÂÚ·fiÓÙˆÓ È·ÙÚÒÓ ÁÈ· ÙËÓ ÔÚı‹ ‰È¿ÁÓˆÛË, ·ÓÙ› ÁÈ· ÙÔ ¿ÛıÌ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÔÏϤ˜ ÊÔÚ¤˜ ¿ÏÏÔÈ fiÚÔÈ, fiˆ˜ Û·ÛÙÈ΋ ‹ ·ÛıÌ·ÙÈ΋ ‚ÚÔÁ¯›Ùȉ· ‹ ·ÏÏÂÚÁÈÎfi˜ ‚‹¯·˜. ∞˘Ùfi, ÛÙË Û˘Ó¤¯ÂÈ·, Ô‰ËÁ› ÛÙËÓ ˘ÔıÂڷ›· ‹ Î·È ÛÙËÓ ¿ÚÓËÛË Û˘ÌÌfiÚʈÛ˘ Ì ÙȘ ˘Ô‰Â›ÍÂȘ, ȉȷ›ÙÂÚ· fiÙ·Ó ˘¿Ú¯ÂÈ ·Ó¿ÁÎË ÁÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹. ¶ÔχÏÔη ıÂڷ¢ÙÈο Û¯‹Ì·Ù· ™ÙÔ ¯ÚfiÓÈÔ Â›ÌÔÓÔ ¿ÛıÌ· ˘¿Ú¯ÂÈ ·Ó¿ÁÎË ÁÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó‹ıˆ˜ ÂÚÈÛÛfiÙÂÚ· ·fi ¤Ó· Ê¿Ú̷η, Ù· ÔÔ›· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ‰‡Ô ‹ Î·È ÙÚÂȘ ËÌÂÚ‹ÛȘ ‰fiÛÂȘ. ∆·˘Ùfi¯ÚÔÓ·, ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ¿ÚÂÈ ‰È·ÊÔÚÂÙÈΤ˜ Ô‰ËÁ›Â˜ ÁÈ· ÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ô˘ ı· ·ÎÔÏÔ˘ı‹ÛÔ˘Ó Û ÔÍ›· ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË ‹ Û ¤Í·ÚÛË ÙˆÓ Û˘Ìو̿وÓ. ∞fi ÔÏϤ˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÏÈÁfiÙÂÚÔ ·fi ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Û˘ÌÌÔÚÊÒÓÂÙ·È Ì ÙËÓ Î·ıËÌÂÚÈÓ‹ ¯ÔÚ‹ÁËÛË Ê·Ú̿ΈÓ, ȉ›ˆ˜ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ Ê·Ú̿ΈÓ, ÂÓÒ Â›Ó·È ‰‡ÛÎÔÏÔ ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi Ó· ÚԂϤ„ÂÈ ÔÈÔÈ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ÙÔ˘ ı· Û˘ÌÌÔÚʈıÔ‡Ó (7). µÈ‚ÏÈÔÁÚ·Ê›· 1. Global Initiative For Asthma. National institutes of Health. National Heart, Lung and Blood Institute, Publication Number 95-3659, January 1995. 2. Weinberger MM. What are the problems with the NIH Guidelines? What are the solutions? Proceedings of the Fourth International Congress on Pediatric Pulmonology; 2000 21-24 February; Nice. France. EDK Paris; 2000. p. 16. 3. Anderson SD, Mellis CM. Clinical Presentation and Ongoing Clinical and Physiologic Assessment of Asthma in Children. In: Taussig LM, Landau LI, eds. Pediatric Respiratory Medicine. St Louis: Mosby Inc; 1999. p. 938-960. 4. Guidelines for the diagnosis and management of asthma: Expert panel report 2: NIH publication no. 97-4051, April 1997. 5. Brain JD, Blanchard JD. Mechanisms of particle deposition and clearance. In: Moren F, Dolovich MB, Newhouse MT, Newman SP, eds. Aerosols in Medicine: Principles diagnosis and therapy. 2nd ed. Amsterdam, Netherlands: Elsevier; 1993. p. R117-R125. 6. Everard ML, Devadason SG, Le Souef PN. Factors affecting total and “respirable” dose delivered by a salbutamol metered dose inhaler. Thorax 1995;50:517-519. 7. Ley P. Communicating with patients: Improving communication, satisfaction and compliance. New York: Chapman and Hall; 1998. p. 61-63.
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Paediatriki 2001;64:351-354
PNEUMONOLOGY
OÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·: Ó·È ‹ fi¯È ÛÙË ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Î·È ÛÙÂÚÔÂȉÒÓ; ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜
Acute bronchiolitis: should we use bronchodilators and steroids? M. Anthracopoulos
¶ÂÚ›ÏË„Ë: À¿Ú¯ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏ›· ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÓÔÛËÏ¢ÙÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ Û fi,ÙÈ ·ÊÔÚ¿ ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Î·È ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜. ¶oÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂȯÂÈÚ‹ÛÂÈ Ó· ··ÓÙ‹ÛÔ˘Ó ÛÙÔ Î·Ù¿ fiÛÔ Ë ·ÁˆÁ‹ Ì ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ‹/Î·È ÛÙÂÚÔÂȉ‹ ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÔÍ›· ÓfiÛÔ. ¶·Ú¿ Ù·‡Ù·, Ù· Û˘ÌÂÚ¿ÛÌ·Ù¿ ÙÔ˘˜ ·ÓÙÈÊ¿ÛÎÔ˘Ó. ™‡Ìʈӷ Ì ÌÂÙ·-·Ó¿Ï˘ÛË ÌÂÏÂÙÒÓ Ô˘ ‰ÈÂÚ‡ÓËÛ·Ó ÙÔ ÚfiÏÔ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ ÛÙË ÓfiÛÔ, Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÛÎfiÈÌË Ë ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓÔ˘ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ (.¯. Û·Ï‚Ô˘Ù·ÌfiÏ˘) Û ·ÛıÂÓ›˜ Ì ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È ÛÙÔ ∆Ì‹Ì· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ. øÛÙfiÛÔ, Â¿Ó ‰ÂÓ Â¤ÏıÂÈ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË Ì ÙËÓ ·ÁˆÁ‹ ‹ Â¿Ó ˘¿ÚÍÂÈ Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ‹ ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ, Ë ıÂڷ›· Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È. ™‡Ìʈӷ Ì ÛÂÈÚ¿ ÌÂÏÂÙÒÓ, Ë ÂÈÛÓÂfiÌÂÓË ·‰ÚÂÓ·Ï›ÓË ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ. ∆· ÛÙÂÚÔÂȉ‹, ¯ÔÚËÁÔ‡ÌÂÓ· Û˘ÛÙËÌ·ÙÈο ‹ Û ÂÈÛÓÔ¤˜, ‰ÂÓ ¤¯Ô˘Ó ı¤ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ‰ÂÓ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ‚·Û›˙ÂÙ·È ÛÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ ıÂڷ›· ÙÔ˘ ‚Ú¤ÊÔ˘˜, Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÍ·ÈÌ›·˜ Ì ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÚÚÈÓÈÎÔ‡ Ô͢ÁfiÓÔ˘ Î·È ÙË Ú‡ıÌÈÛË ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ‡‰·ÙÔ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ.
Abstract: To this day there is great variability in the use of bronchodilators and anti-inflammatory drugs in the management of acute bronchiolitis. Although a large number of studies has addressed this issue, the effectiveness of bronchodilators and/or steroids in the acute disease is still controversial. A meta-analysis of studies that investigated the use of bronchodilators in acute bronchiolitis showed that a trial of inhaled bronchodilators (i.e. salbutamol) might be beneficial in infants with acute disease upon arrival to the emergency room. Treatment, however, should be discontinued if there is no clinical improvement or if deterioration of signs and symptoms or of oxygen saturation occurs. Studies comparing different bronchodilators show that inhaled epinephrine is more effective than other drugs. Systemic or inhaled steroids have no place in the management of the disease in other-wise healthy infants. The management of acute bronchiolitis continues to rely primarily on supportive measures, i.e. the treatment of hypoxemia, preferably via nasal cannula, and the replacement of fluid and electrolyte deficits.
§¤ÍÂȘ ÎÏÂȉȿ: ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ‚Ú¤ÊÔ˜, ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο, ÛÙÂÚÔÂȉ‹.
Key words: bronchiolitis, infant, bronchodilators, steroids.
∂ÈÌÂÏËÙ‹˜, À‡ı˘ÓÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁÈ΋˜ ªÔÓ¿‰·˜ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
Registrar, Division of Pediatric Pneumonology Pediatric Clinic of University of Patras
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∂ÈÛ·ÁˆÁ‹ ∏ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Â›Ó·È ÓfiÛÔ˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ÂΉËÏÒÓÂÙ·È Ì ÎfiÚ˘˙· Î·È Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù·¯‡ÓÔÈ·, ÂÈÛÔÏΤ˜ ˘Ô¯ÔÓ‰Ú›ˆÓ, ÂÌʇÛËÌ· Î·È ÙÚ›˙ÔÓÙ˜ ‹/Î·È Û˘ÚÈÁÌfi. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙË µ. ∞ÌÂÚÈ΋ Ô Û˘ÚÈÁÌfi˜ ·ÔÙÂÏ› ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜, ÂÓÒ ÛÙË ª. µÚÂÙ·Ó›· Î·È ÙËÓ ∞˘ÛÙÚ·Ï›· ÔÈ ÙÚ›˙ÔÓÙ˜ ıˆÚÔ‡ÓÙ·È ÙÔ Î‡ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, ‚Ú¤ÊË Ô˘ ÛÙȘ ∏¶∞ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û·Ó ÂÚÈÙÒÛÂȘ Ì ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ÛÙË ª. µÚÂÙ·Ó›· ı· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ˆ˜ “·ÛıÌ·ÙÈ΋ ‚ÚÔÁ¯›Ùȉ·” (wheezy bronchitis), ÂÓÒ ·ÓÙÈı¤Ùˆ˜ ‚Ú¤ÊË Ô˘ Ë ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ ÛÙË ª. µÚÂÙ·Ó›· ı· ‹Ù·Ó ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, ÛÙȘ ∏¶∞ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ˆ˜ ÂÚÈÙÒÛÂȘ Ó¢ÌÔÓ›·˜. ¶ÚÔÊ·ÓÒ˜, ÔÈ ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ ÛÙÔÓ ÔÚÈÛÌfi Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÚÔ‚Ï‹Ì·Ù· ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ. ∏ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ÂΉËÏÒÓÂÙ·È ÛÙÔ˘˜ ÚÒÙÔ˘˜ 18-24 Ì‹Ó˜ Ù˘ ˙ˆ‹˜ Î·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ ·›ÙÈÔ Â›Ó·È Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜ (respiratory syncytial virus, RSV). O RSV Â›Ó·È ÂԯȷÎfi˜ Èfi˜ ÙˆÓ „˘¯ÚÒÓ Î·Ù’ ÂÍÔ¯‹Ó ÌËÓÒÓ, Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ·. ŒÙÛÈ, ÂÚ›Ô˘ ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ ÚÔÛ‚ÏËı› ÛÙ· 3 ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜, ÂÓÒ ÙÔ 1-4% ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ‚ÚÂÊÒÓ Î¿Ùˆ ÙˆÓ 6 ÌËÓÒÓ ··ÈÙ› ÓÔÛËÏ›·. ™ÙÔÓ ¶›Ó·Î· 1 Ê·›ÓÔÓÙ·È ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ RSV ÛÙ· 2 ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜: ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Î·È ÛÙÂÚÔÂȉ‹ ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ ÎfiÛÌÔ˘. ¶Ú¿ÁÌ·ÙÈ, ÂÓÒ ÁÈ· ÙË ıÂڷ›· Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ Û ∂˘Úˆ·˚Τ˜ ¯ÒÚ˜ Ù· ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È, ηٿ ‰‹ÏˆÛË ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡, ¿¶›Ó·Î·˜ 1. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ RSV ÛÙ· ‰‡Ô ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜ ñ ∞Û˘Ìو̷ÙÈ΋ ÚÔÛ‚ÔÏ‹ ñ ƒÈÓ›Ùȉ·, ‚‹¯·˜, Èı·ÓfiÓ ˘ÚÂÙfi˜ ñ OÍ›· ̤ÛË ˆÙ›Ùȉ· ñ Croup ñ µÚÔÁ¯ÈÔÏ›Ùȉ· ñ ¶Ó¢ÌÔÓ›· ñ ÕÓÔÈ· (≤2 ÌËÓÒÓ, ÚÔˆÚfiÙËÙ·, ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ·ÙÂÏÂÎÙ·Û›·˜)
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ÓÙÔÙ ÛÙÔ 61% Î·È Ù· ÛÙÂÚÔÂȉ‹ ÛÙÔ 11% ÙˆÓ ÂÚÈÙÒÛˆÓ, Ù· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ÛÙËÓ ∞˘ÛÙÚ·Ï›· Â›Ó·È ÌfiÓÔ 6% Î·È 1% (1,2). ∂›Û˘, ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ··ÓÙÒÓÙ·È Î·È ÌÂٷ͇ ‰È·ÊÔÚÂÙÈÎÒÓ ÓÔÛËÏ¢ÙÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ ÛÙËÓ ›‰È· ¯ÒÚ·. ŒÙÛÈ, Û ¤ÓÙ ·گ›Â˜ ÙÔ˘ ∫·Ó·‰¿ Ë Û˘¯ÓfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Û ‚Ú¤ÊË Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î˘Ì·ÈÓfiÙ·Ó ÛÙËÓ ·Ú¯‹ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 ÌÂٷ͇ 68% Î·È 93% Î·È ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÌÂٷ͇ 3% Î·È 18% (3). ∆· ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ÛÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ‚-‰ÈÂÁÂÚÙÒÓ Î·È ÙÔ˘ ‚ÚˆÌÈÔ‡¯Ô˘ ÈÚ·ÙÚÔ›Ô˘ ÛÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ¤¯ÂÈ Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ ‰ÈÂÚ‡ÓËÛ˘ Ï‹ıÔ˘˜ ÌÂÏÂÙÒÓ, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ηٷϋÍÂÈ Û ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ™Â ÌÂÙ·-·Ó¿Ï˘ÛË (4) Ô˘ ÂÚȤϷ‚ 15 ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ì 734 Û˘ÓÔÏÈο ·ÛıÂÓ›˜ ‚Ú¤ıËΠfiÙÈ ÂÓ Á¤ÓÂÈ Ù· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο (Û·Ï‚Ô˘Ù·ÌfiÏË, ÈÚ·ÙÚfiÈÔ, ·‰ÚÂÓ·Ï›ÓË) ÂÈʤÚÔ˘Ó ‚Ú·¯˘¯ÚfiÓÈ·, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘Ìو̿وÓ, fiÙ·Ó ·˘Ù¿ ÌÂÙÚÒÓÙ·È Ì ÙË ‚Ô‹ıÂÈ· ·˘ı·›ÚÂÙˆÓ ·ÏÏ¿ ¢ڤˆ˜ ‰È·‰Â‰ÔÌ¤ÓˆÓ ÎÏÈÌ¿ÎˆÓ ‚·ıÌÔÏfiÁËÛ˘ (ÎÏÈÓÈο scores). ¶Ú¿ÁÌ·ÙÈ, ‚Ú¤ıËΠfiÙÈ ÙÔ 54% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤Ï·‚·Ó ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ ·ÚÔ˘Û›·Û ‚ÂÏÙ›ˆÛË, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ ‹Ù·Ó 25%. ªÂ ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿, › ÙÂÛÛ¿ÚˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹, Ô ¤Ó·˜ ı· ˆÊÂÏËı› ·fi ÙË ıÂڷ›·. øÛÙfiÛÔ, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ·˘Ù‹ ‰ÂÓ ·Ó¤‰ÂÈÍ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ıÂڷ¢fiÌÂÓˆÓ ·ÛıÂÓÒÓ Î·È Ù˘ ÔÌ¿‰·˜ placebo Û fiÙÈ ·ÊÔÚ¿ ¿ÏÏÔ˘˜ ÛËÌ·ÓÙÈÎÔ‡˜ ÎÏÈÓÈÎÔ‡˜ ‰Â›ÎÙ˜, fiˆ˜ Ô ÎÔÚÂÛÌfi˜ Ô͢ÁfiÓÔ˘ (O2Sat) ‹ Ë ·Ó¿ÁÎË ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∆· ‰Â‰Ô̤ӷ Ù˘ ÌÂÙ·-·Ó¿Ï˘Û˘ ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ıÂڷ›·˜ Ì ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ¤Ú· ·fi ÙÔ ∆Ì‹Ì· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ (∆∂¶) ‹Û·Ó ·Ó·Ú΋. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Û ‰‡Ô ÌfiÓÔ ÌÂϤÙ˜ Ù˘ ·ÓˆÙ¤Úˆ ÌÂÙ·-·Ó¿Ï˘Û˘ ÂÏ‹ÊıË ˘’ fi„ÈÓ Ë Î·Ù¿ÛÙ·ÛË ÂÁÚ‹ÁÔÚÛ˘ ÙˆÓ ‚ÚÂÊÒÓ ÛÙË ÌÂÙ·‚ÔÏ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ (5,6). ∫·È ÛÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ Ë Û·Ï‚Ô˘Ù·ÌfiÏË ‰ÂÓ ·Ô‰Â›¯ıËΠ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ÙÔ˘ placebo. ∂›Û˘, Ë ÂÓ ÏfiÁˆ ÌÂÙ·-·Ó¿Ï˘ÛË ‰ÂÓ ÂÚȤϷ‚ ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ù˘ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ ¤ÁÈÓ Ì ̤ÙÚËÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚ÚÂÊÒÓ. ¶¿ÓÙˆ˜, ÙÔ Û˘Ì¤Ú·ÛÌ· Ù˘ Û˘ÁÎÂÓÙÚˆÙÈ΋˜ ·˘Ù‹˜
¶·È‰È·ÙÚÈ΋ 2001;64:351-354
ÌÂϤÙ˘ Â›Ó·È fiÙÈ Ë ‰ÔÎÈÌ·ÛÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ ı· ‹Ù·Ó ¯Ú‹ÛÈÌË ·Ú¯Èο - Èı·ÓfiÓ Î·Ù¿ ÙÔ ÚÒÙÔ 24ˆÚÔ - ÂÊfiÛÔÓ Û˘Óԉ‡ÂÙ·È ·fi ÚÔÛÂÎÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ·¿ÓÙËÛ˘ ÙÔ˘ ‚Ú¤ÊÔ˘˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ·ÛÈÛÙ› Ë Û˘Ó¤¯ÈÛË ‹ Ë ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜. ¶ÚfiÛÊ·ÙË Û¯ÂÙÈο ÌÂϤÙË ‰ÈÂÚ‡ÓËÛ ÙË ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ (Û·Ï‚Ô˘Ù·ÌfiÏ˘) Û ·È‰È¿ ≤2 ÂÙÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ÓÂÊÂÏÔÔ›ËÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘ ÛÙÔ ∆∂¶ (7). ∏ ηϿ ۯ‰ȷṲ̂ÓË ·˘Ù‹ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ë ÂÚ·ÈÙ¤Úˆ ¯ÔÚ‹ÁËÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‰ÂÓ Â›¯Â ηӤӷ ·ÔÙ¤ÏÂÛÌ· ÛÙÔ Ú˘ıÌfi ‚ÂÏÙ›ˆÛ˘ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÙÔ˘ O2Sat, Ù˘ ›Ù¢Í˘ ÚÔηıÔÚÈÛÌ¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ÂÍfi‰Ô˘ ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ù˘ Ú·ÁÌ·ÙÈ΋˜ ‰È¿ÚÎÂÈ·˜ ÓÔÛËÏ›·˜. ∂›Û˘, ·Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› Ë ¯ÚËÛÈÌfiÙËÙ· Ù˘ ÂÈÛÓÂfiÌÂÓ˘ ·‰ÚÂÓ·Ï›Ó˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜. ◊‰Ë ·fi ÙÔ 1978, ÔÈ Wohl Î·È Chernick (8) ·Ó¤ÊÂÚ·Ó fiÙÈ ›Ûˆ˜ Ë ·‰ÚÂÓ·Ï›ÓË ·ÔÙÂÏ› ÙÔ È‰·ÓÈÎfi ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎfi Ê¿ÚÌ·ÎÔ ÁÈ· ÙË ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ÏfiÁˆ Ù˘ ‰Ú¿Û˘ Ù˘, ÙfiÛÔ ÛÙÔ˘˜ ·- fiÛÔ Î·È ÛÙÔ˘˜ ‚- ·‰ÚÂÓÂÚÁÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜, ÌÂ Û˘Ó¤ÂÈ· - ÂÎÙfi˜ Ù˘ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋˜ - ·ÁÁÂÈÔÛ˘Û·ÛÙÈ΋ ‰Ú¿ÛË Ô˘ Ô‰ËÁ› Û ÂÏ¿ÙÙˆÛË ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÙˆÓ ‚ÚÔÁ¯ÈÔÏ›ˆÓ. ¶Ú¿ÁÌ·ÙÈ, ÌÂϤÙ˜ ÔÈ Ôԛ˜ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·‰ÚÂÓ·Ï›Ó˘ Ì ÂΛÓË Ù˘ Û·Ï‚Ô˘Ù·ÌfiÏ˘ ÛÙË ıÂڷ›· Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜, ¤‰ÂÈÍ·Ó fiÙÈ ˘ÂÚÙÂÚ› Ë ·‰ÚÂÓ·Ï›ÓË (9,10). ∆¤ÏÔ˜, ·fi ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ ‰ÈÂÚ¢ӋıËÎÂ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ì ̤ÙÚËÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚ÚÂÊÒÓ, ÚԤ΢„·Ó ›Û˘ ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·. ªÂÚÈÎÔ› ·ÛıÂÓ›˜ ‚ÂÏÙÈÒÓÔÓÙ·È (11-13), ·ÚÎÂÙÔ› ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙËÓ ·ÁˆÁ‹ (14,15), ÂÓÒ ÔÚÈṲ̂ÓÔÈ ÌÔÚ› Ó· ÂȉÂÈÓˆıÔ‡Ó (15,16). OÈ Hughes Î·È Û˘Ó (15) ÚÔÙ›ÓÔ˘Ó ˆ˜ Èı·ÓfiÙÂÚË ÂÚÌËÓ›· Ù˘ “·Ú¿‰Ô͢” Âȉ›ӈÛ˘ Ù˘ ÌÂÁ›ÛÙ˘ ÚÔ‹˜ ÌÂÙ¿ ·fi ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û·Ï‚Ô˘Ù·ÌfiÏË, Ì ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÙfiÓÔ˘ ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, ·ÔÛÙ·ıÂÚÔÔÈ› ÙÔ˘˜ ÌÈÎÚÔ‡˜ ·ÂÚ·ÁˆÁÔ‡˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Û‡ÁÎÏÈÛ‹ ÙÔ˘˜ ηٿ ÙË ‰˘Ó·ÌÈ΋ ÂÎÓÔ‹. ™ÙËÓ ›‰È· ÌÂϤÙË, Ë ÂÏ¿ÙÙˆÛË Ù˘ ¯ÚÔÓÈ΋˜ ÛÙ·ıÂÚ¿˜ (time constant, Ù) ÛÙËÓ ‹ÚÂÌË ·Ó·ÓÔ‹ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘, Ê·ÓÂÚÒÓÂÈ ÂÏ¿ÙÙˆÛË Ù˘ ¤‰ËÛ˘ ηٿ ÙËÓ ÂÎÓÔ‹, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô Èı·ÓfiÓ ¤¯ÂÈ ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙË ‰È·Ù‹ÚËÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ fiÁÎÔ˘.
Paediatriki 2001;64:351-354
∆· Û˘ÛÙËÌ·ÙÈο ÛÙÂÚÔÂȉ‹ ÛÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÛÙÂÚÔÂȉÒÓ ÛÙË ıÂڷ›· Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ¤¯ÂÈ, ›Û˘, ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ‰È·Ì¿¯Ë˜. ∏ ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜ ‚·Û›˙ÂÙ·È ÛÙËÓ ÈÛ¯˘Ú‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ‰Ú¿ÛË ÙÔ˘˜ Î·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÊÏÂÁÌÔÓˆ‰ÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙ· ‚ÚÔÁ¯ÈfiÏÈ· (17,18). ◊‰Ë ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ›¯·Ó ÚÔ·„ÂÈ ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Û fiÙÈ ·ÊÔÚ¿ ÙË ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ ÛÙÂÚÔÂȉÒÓ ÛÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ∆Ô 1983, ÔÈ Tal Î·È Û˘Ó (19) ÌÂϤÙËÛ·Ó 32 ‚Ú¤ÊË Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Î·È ¤‰ÂÈÍ·Ó fiÙÈ Ù· Û˘ÛÙËÌ·ÙÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓ· ÛÙÂÚÔÂȉ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÈÛÓÂfiÌÂÓ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η ·ÛÎÔ‡Ó Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË. øÛÙfiÛÔ, Ë ÌÂϤÙË ·˘Ù‹ ÂÚȤϷ‚Â Î·È ‚Ú¤ÊË Ì Ô͇ ÂÂÈÛfi‰ÈÔ Û˘ÚÈÁÌÔ‡, Ù· ÔÔ›· ›¯·Ó ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓˆÓ ÂÂÈÛÔ‰›ˆÓ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·˘Í¿ÓÂÙ·È Ë Èı·ÓfiÙËÙ· Û˘ÌÌÂÙÔ¯‹˜ ÛÙË ÌÂϤÙË ‚ÚÂÊÒÓ Ì ¿ÛıÌ·. ªÂÙ·ÁÂÓ¤ÛÙÂÚ˜, ηϿ ÙÂÎÌËÚȈ̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ (20-23). ∆¤ÏÔ˜, ÌÂϤÙË ·Ó·ÊÔÚ¿˜ ·ÔÙÂÏ› Ë ÌÂϤÙË ÙˆÓ Roosevelt Î·È Û˘Ó (24), Ë ÔÔ›· η٤‰ÂÈÍ fiÙÈ Ë ÂÓ‰ÔÌ˘˚΋ ‰ÂÍ·ÌÂı·˙fiÓË Û ˘„ËϤ˜ ‰fiÛÂȘ (1 mg/kg/Ë̤ڷ) ‰ÂÓ ÂÈÛ‡‰ÂÈ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ‰ÂÓ ÂÏ·ÙÙÒÓÂÈ ÙË ‰È¿ÚÎÂÈ· Ô͢ÁÔÓÔıÂڷ›·˜ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ÓÔÛËχÔÓÙ·È ÁÈ· ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ Û˘ÚÈÁÌÔ‡. ∂›Û˘, Ì ÙË ¯Ú‹ÛË Ù˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ‚-‰ÈÂÁÂÚÙÒÓ (‹ ·ÓÙÈ‚ÈÔÙÈÎÒÓ) ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ∏ ¯Ú‹ÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Ô˘ Û˘Óԉ‡ÂÈ Ù· ÓÔÛËÏ¢ı¤ÓÙ· ÁÈ· ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‚Ú¤ÊË (25). ¶ÚfiÛÊ·ÙË ÌÂϤÙË ‰ÂÓ ÂȂ‚·›ˆÛ ÙË ¯ÚËÛÈÌfiÙËÙ· Ù˘ Ú‰ÓÈ˙ÔÏfiÓ˘ per os ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ÌÂÙ·-‚ÚÔÁ¯ÈÔÏÈÙȉÈÎÔ‡ Û˘ÚÈÁÌÔ‡ (26). ∏ ·Ó·Ï˘ÙÈ΋ Û˘˙‹ÙËÛË ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ Î·È Û˘ÛÙËÌ·ÙÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ÌÂÙ·-‚ÚÔÁ¯ÈÔÏÈÙȉÈÎÔ‡ Û˘ÚÈÁÌÔ‡, ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙȘ ÚÔı¤ÛÂȘ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘. ™˘ÌÂÚ¿ÛÌ·Ù· ¢ÂÓ ˘¿Ú¯Ô˘Ó ·Ô‰Â›ÍÂȘ fiÙÈ ˘Ê›ÛÙ·Ù·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ (‹ ·ÓÙÈ-ÈÈ΋) ıÂڷ›· ¤Ó·ÓÙÈ Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜. ™Â ·ÛıÂÓ›˜ Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È ÛÙ· ∆∂¶ ÌÔÚ› Ó· ‰ÔÎÈÌ·ÛÙ›, ÚÔÛÂÎÙÈο, ıÂڷ›· ÌÂ Û·Ï‚Ô˘Ù·ÌfiÏË
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‹, ηٿ ÚÔÙ›ÌËÛË, Ì ·‰ÚÂÓ·Ï›ÓË Î·È Ó· ÂÎÙÈÌËı› Ë ÎÏÈÓÈ΋ ·¿ÓÙËÛË. ∂¿Ó ‰ÂÓ Â¤ÏıÂÈ ‚ÂÏÙ›ˆÛË ‹ Â¿Ó ˘¿ÚÍÂÈ Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ‹ ÙÔ˘ O2Sat, Ë ıÂڷ›· Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È. ∆· ÛÙÂÚÔÂȉ‹, ¯ÔÚËÁÔ‡ÌÂÓ· Û˘ÛÙËÌ·ÙÈÎÒ˜ ‹ Û ÂÈÛÓÔ¤˜, ‰ÂÓ ¤¯Ô˘Ó ı¤ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‚ÚÂÊÒÓ Ô˘ ‰ÂÓ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ¶Ú¤ÂÈ, fï˜, Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ıÂڷ›· Ì ÛÙÂÚÔÂȉ‹ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Û ‚Ú¤ÊË Ì ˘ÔΛÌÂÓË ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ, fiˆ˜ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·, ¿ÛıÌ· Î.Ï. ŸÛÔ Î·È ·Ó ·˘Ùfi ÚÔηÏ› ¤ÎÏËÍË, Ë ıÂڷ›· Ù˘ ÔÍ›·˜ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‰ÂÓ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ Ô˘ÛÈ·ÛÙÈο Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ·. ∏ ·Ú·Ù‹ÚËÛË ÙˆÓ Reynolds Î·È Cook fiÙÈ “Ë ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ÛÙË ‚ÚÔÁ¯ÈÔÏ›Ùȉ· Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜ Î·È ˘¿Ú¯Ô˘Ó ÂÏ¿¯ÈÛÙ˜ ·Ô‰Â›ÍÂȘ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÔÔÈ·Û‰‹ÔÙ ¿ÏÏ˘ ıÂڷ›·˜” (27) Â›Ó·È ·ÎfiÌË Â›Î·ÈÚË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Kimpen JL, Schaad UB. Treatment of respiratory syncytial virus bronchiolitis: 1995 poll of members of the European society for paediatric infectious diseases. Pediatr Infect Dis J 1997;16:479-481. 2. Barben JU, Robertson CF, Robinson PJ. Current management of acute bronchiolitis in Australia. Eur Respir J 1999;14:20s. 3. Law BJ, De Carvalho V, PICNIC. Respiratory syncytial virus infections in hospitalized Canadian children: regional differences in patient populations and management practices. Pediatr Infect Dis J 1993;12:659-663. 4. Kellner JD, Ohlsson A, Gadomski AM, Wang EEL. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med 1996;150:1166-1172. 5. Gadomski AM, Lichenstein R, Horton L, King J, Keane V, Permutt T. Efficacy of albuterol in the management of bronchiolitis. Pediatrics 1994;93:907-912. 6. Gadomski AM, Aref GH, El Din OB, El Sawy IH, Khallaf N, Black RE. Oral versus nebulized albuterol in the management of bronchiolitis in Egypt. J Pediatr 1994;124:131-138. 7. Dobson JV, Stephens-Goff SM, Mc Mahon SR, Stemmler MM, Brallier SL, Bay C. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics 1998;101:361-368. 8. Wohl ME, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis 1978;118:759-781. 9. Sanchez I, De Koster J, Powell RE, Wolstein R, Chernick V. Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis. J Pediatr 1993;122:145-151. 10. Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 1995;126:1004-1007. 11. Stokes GM, Milner AD, Hodges IGC, Henry RL, Elphik MC. Nebulised therapy in acute sever bronchiolitis in infancy.
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Arch Dis Child 1983;58:279-283. 12. Tepper RS, Rosenberg D, Eigen H, Reister T. Bronchodilator responsiveness in infants with bronchiolitis. Pediatr Pulmonol 1994;17:81-85. 13. Derish M, Hodge G, Dunn C, Ariagno R. Aerosolized albuterol improves airway reactivity in infants with acute respiratory failure from Respiratory Syncytial Virus. Pediatr Pulmonol 1998;26:12-20. 14. Sly PD, Lanteri CJ, Raven JM. Do wheezy infants recovering from bronchiolitis respond to inhaled salbutamol? Pediatr Pulmonol 1991;10:36-39. 15. Hughes DM, LeSouef PN, Landau LI. Effect of salbutamol on respiratory mechanics in bronchiolitis. Pediatr Res 1987;22:83-86. 16. Prendiville A, Green S, Silverman M. Paradoxical response to nebulised salbutamol in wheezy infants, assessed by partial expiratory flow-volume curves. Thorax 1987;42:88-91. 17. Darville T, Yamauchi T. Respiratory Syncytial Virus. Pediatr Rev 1998;19:55-61. 18. Abu-Harb M, Bell F, Finn A, Rao WH, Nixon L, Shale D et al. IL-8 and neutrophil elastase levels in the respiratory tract of infants with RSV bronchiolitis. Eur Respir J 1999;14:139-143. 19. Tal A, Bavilski C, Yohai D, Bearman JE, Gorodischer R, Moses SW. Dexamethasone and salbutamol in the treatment of acute wheezing in infants. Pediatrics 1983;71:13-18. 20. Springer C, Bar-Yishay E, Uwayyed K, Avital A, Vilozni D, Godfrey S. Corticosteroids do not affect the clinical or physiological status of infants with bronchiolitis. Pediatr Pulmonol 1990;9:181-185. 21. Klassen TP, Sutcliffe T, Watters LK, Wells GA, Allen UD, Li MM. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: A randomized, controlled trial. J Pediatr 1997;130:191-196. 22. De Boeck K, Van der Aa N, Van Lierde S, Corbeel L, Eeckels R. Respiratory Syncytial Virus bronchiolitis: A double-blind dexamethasone efficacy study. J Pediatr 1997;131:919-921. 23. Berger I, Agraman Z, Schwartz SB, Segal E, Kiderman A, Branski D et al. Efficacy of corticosteroids in acute bronchiolitis: Short-term and long-term follow-up. Pediatr Pulmonol 1998;26:162-166. 24. Roosevelt G, Sheehan K, Grupp-Phelan J, Tanz RR, Listernick R. Dexamethasone in bronchiolitis: a randomised controlled trial. Lancet 1996;348:292-295. 25. Wong JYW, Moon S, Beardsmore C, O’Callaghan C, Simpson H. No objective benefit from steroids inhaled via a spacer in infants recovering from bronchiolitis. Eur Respir J 2000;15:388-394. 26. van Woensel JBM, Kimpen JLL, Sprikkelman AB, Ouwehand A, van Aalderen WMC. Long-term effects of prednisolone in the acute phase of bronchiolitis caused by Respiratory Syncytial Virus. Pediatr Pulmonol 2000;30:92-96. 27. Reynolds EOR, Cook CD. The treatment of bronchiolitis. J Pediatr 1963;63:1205-1207.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ e-mail: manthra@otenet.gr
¶·È‰È·ÙÚÈ΋ 2001;64:355-360
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Paediatriki 2001;64:355-360
PNEUMONOLOGY
∏ ¯Ú‹ÛË ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ·fi ÙÔÓ ·È‰›·ÙÚÔ ¶. ¶·Ó·ÁȈÙÔÔ‡ÏÔ˘ - °·ÚÙ·Á¿ÓË
The use of pulse oximetry by the pediatrician P. Panagiotopoulou - Gartagani
¶ÂÚ›ÏË„Ë: ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ηıÈÂÚÒıËÎÂ Ë Ì¤ÙÚËÛË Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ÙÔ˘ ÔÛÔÛÙÔ‡ Ù˘ Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ, ÂÂȉ‹ Â›Ó·È Ì›· ̤ıÔ‰Ô˜ ·Ï‹, ·Ó·›Ì·ÎÙË, ·ÍÈfiÈÛÙË Î·È Ì ¯·ÌËÏfi ÎfiÛÙÔ˜. ∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ‚·Û›˙ÂÙ·È ÛÙË ÊˆÙÔËÏÂÎÙÚÈ΋ ÏËı˘ÛÌÔÁÚ·Ê›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ê·ÛÌ·ÙÔʈÙÔÌÂÙÚ›·. OÈ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ÂËÚ¿˙ÔÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· Â›Ó·È ·ÛÊ·Ï›˜ ‹ ÂÈΛӉ˘ÓÔÈ Î·Ù¿ ÂÚ›ÙˆÛË, ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ ÙÔ˘˜ (Ù¯ÓÈÎÔ›-Ê˘ÛÈÔÏÔÁÈÎÔ›). ∆Ô ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÔÍ·ÈÌ›·˜ ÎÏÈÓÈο Û ·ÛıÂÓ›˜ Ì ηډÈÔ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù·, ÓÔÛËÏ¢fiÌÂÓÔ˘˜ ΢ڛˆ˜ Û ÓÔÛÔÎÔÌ›Ô, ·ÏÏ¿ Î·È Û Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜. OÈ ·È‰›·ÙÚÔÈ, ÁÈ· Ó· ¤¯Ô˘Ó ·ÎÚȂ›˜ ÌÂÙÚ‹ÛÂȘ Ì ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, ÂÈ‚¿ÏÏÂÙ·È Ó· ÁÓˆÚ›˙Ô˘Ó ÙȘ ·Ú¯¤˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘, ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ ·ÈÛıËÙ‹Ú· Ô˘ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó, ÂÂȉ‹ ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ·ÈÛıËÙ‹ÚˆÓ, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜.
Abstract: During the last few years, the measurement of hemoglobin oxygen saturation by pulse oximeter has been established as an easy, non invasive, accurate and at low cost method for the estimation of blood oxygenation. The function of pulse oximeter is based on the differential absorption of two wavelengths of light by total haemoglobin and oxyhaemoglobin from pulsative arterial blood. Pulse oximetry is used for the clinical diagnosis of hypoxia caused by cardiorespiratory diseases, especially in hospitalized patients as well as in an outpatient setting. The pediatrician, in order to obtain accurate measurements by pulse oximetry, must have knowledge of the principles of the technique, the factors that may limit its efficacy and the use of the proper sensors depending on the age of the patient.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, Ô͢·ÈÌÔÛÊ·ÈÚ›ÓË, ÎÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û O2, ˘ÔÍ›·, η̇ÏË ·Ô‰¤ÛÌ¢Û˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û O2.
Key words: pulse oximetry, haemoglobin oxygen saturation, hypoxia, oxyhaemoglobin dissociation curve.
∂ÈÛ·ÁˆÁ‹ ∆Ô 1942, Ô Clen Millican ηıÈÂÚÒÓÂÈ ÙÔÓ fiÚÔ Ô͢ÌÂÙÚ›· Î·È ÂÍÂÏ›ÛÛÂÈ ÙÔ Ô͇ÌÂÙÚÔ Millikan. ∆Ô 1970, Ë Hewlett Packard ·Ú¿ÁÂÈ ÙÔ Ô͇ÌÂÙÚÔ ÏÔ‚Ô‡ ÙÔ˘ ·˘ÙÈÔ‡ 8 ÌËÎÒÓ Î‡Ì·ÙÔ˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Ù˘ Ô͢ÁfiÓˆÛ˘ ÙˆÓ
·ÛıÂÓÒÓ ·Ú¯›˙ÂÈ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ ’80. ∆Ô 1987, ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Î·ıÈÂÚÒÓÂÙ·È ·fi ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∞Ó·ÈÛıËÛÈÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Û·Ó ··Ú·›ÙËÙÔ fiÚÁ·ÓÔ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ·ÛıÂÓÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÁÂÓÈ΋ Ó¿ÚΈÛË. ∆· ÂfiÌÂÓ· ¯ÚfiÓÈ·, Ë Ì¤ÙÚËÛË ÙÔ˘
¶·È‰›·ÙÚÔ˜ - ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∂ÈÌÂÏ‹ÙÚÈ· ∞’ ∂.™.À. ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
Senior Registrar, Pediatric Pulmonologist 1st Pediatric Clinic of Athens University “Saint Sophia” Children’s Hospital, Athens
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Paediatriki 2001;64:355-360
ÔÛÔÛÙÔ‡ Ù˘ Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Î·ıÈÂÚÒÓÂÙ·È ÎÏÈÓÈο Û·Ó ÙÔ “5Ô ˙ˆÙÈÎfi ÛËÌ›Ԕ ÛÙËÓ ÂÎÙ›ÌËÛË ·ÛıÂÓÒÓ Ì ηډÈÔ·Ó·Ó¢ÛÙÈÎfi Úfi‚ÏËÌ·, ÂÂȉ‹ Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ Â›Ó·È ·Ó·›Ì·ÎÙË, ·ÍÈfiÈÛÙË, ‡ÎÔÏË Î·È Ì ¯·ÌËÏfi ÎfiÛÙÔ˜ (1). §ÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ‚·Û›˙ÂÙ·È ÛÙË ÊˆÙÔËÏÂÎÙÚÈ΋ ÏËı˘ÛÌÔÁÚ·Ê›· (ÓfiÌÔ˜ ÙÔ˘ Lambert-Beer) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ê·ÛÌ·ÙÔʈÙÔÌÂÙÚ›· (2,3). °È· Ó· ÌÂÙÚËı› Ë Ô͢·ÈÌÔÛÊ·ÈÚ›ÓË Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô ·ÈÛıËÙ‹Ú·˜ ÙÔ˘ ÔÚÁ¿ÓÔ˘ Ô˘ ¤¯ÂÈ ˆ˜ ʈÙÂÈÓ‹ ËÁ‹ ‰‡Ô ʈÙÔ‰Èfi‰Ô˘˜, ÔÈ Ôԛ˜ ÂΤÌÔ˘Ó Û ‰‡Ô ‰È·ÊÔÚÂÙÈο Ì‹ÎË Î‡Ì·ÙÔ˜, ÛÙ· 660 nm (ÂÚ˘ıÚfi ʈ˜) Î·È ÛÙ· 940 nm (˘¤Ú˘ıÚÔ Êˆ˜) Î·È ¤Ó· ʈÙÔ·ÓȯÓÂ˘Ù‹. OÈ ÊˆÙÔ‰›Ô‰ÔÈ Î·È Ô ÊˆÙÔ·ÓȯÓÂ˘Ù‹˜ ÙÔÔıÂÙÔ‡ÓÙ·È ÔÈ ÌÂÓ ·¤Ó·ÓÙÈ ·fi ÙÔÓ ‰Â Î·È ÌÂٷ͇ ÙÔ˘˜ ˘¿Ú¯Ô˘Ó ÔÈ ÈÛÙÔ› Î·È ÙÔ ·ÚÙËÚÈ·Îfi ϤÁÌ· ÙÔ˘ ‰·ÎÙ‡ÏÔ˘ (™¯‹Ì· 1). ∏ ʈÙÔËÏÂÎÙÚÈ΋ ÏËı˘ÛÌÔÁÚ·Ê›· Â›Ó·È Ì›· Ù¯ÓÈ΋ Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ÁÈ· Ó· ·ÓȯÓ‡ÛÂÈ ÛÙÈÁÌÈ·›Â˜ ·ÏÏ·Á¤˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔÓ fiÁÎÔ ·›Ì·ÙÔ˜ Û ̛· ÂÚÈÔ¯‹ ÙÔ˘ ‰·ÎÙ‡ÏÔ˘ ÙÔ˘ ¯ÂÚÈÔ‡ ‹ ÙÔ˘ Ô‰ÈÔ‡ fiÔ˘ ÙÔÔıÂÙÂ›Ù·È ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ. ∞˘Ù¤˜ ÔÈ ·ÏÏ·Á¤˜ fiÁÎÔ˘, fiˆ˜ Â›Ó·È Ê˘ÛÈÎfi, ÔÊ›ÏÔÓÙ·È ÛÙÔ ·ÏÌÈÎfi ·̷ ÙˆÓ ·ÚÙËÚÈÒÓ. ∫·Ù¿ ÙË Û˘ÛÙÔÏÈ΋ Ê¿ÛË ÙÔ˘ ηډȷÎÔ‡ ·ÎÏÔ˘, ·˘Í¿ÓÂÙ·È Ô fiÁÎÔ˜ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ (·ÏÌÈÎfi ·̷) Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ·ÔÚÚfiÊËÛ˘ ÙÔ˘ ʈ-
Ùfi˜ ·fi ·˘Ùfi. ¢ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÙfiÙ ‰‡Ô ÌÔÚʤ˜ ·ÔÚÚfiÊËÛ˘: Ë Ì›· ·fi ÙÔ ·ÏÌÈÎfi ·̷, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ·fi ÙÔ ·›Ì· ÙˆÓ ·ÚÙËÚÈÒÓ Î·È Ë ¿ÏÏË, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ·fi ÙÔ˘˜ ÈÛÙÔ‡˜ (‰¤ÚÌ·, Ì·Ï·ÎÔ› ÈÛÙÔ›, ÔÛÙ¿) Î·È ÙÔ ÊÏ‚ÈÎfi ·›Ì·. ∆Ô ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ˘ÔÏÔÁ›˙ÂÈ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ·fi ÙÔ˘˜ ÈÛÙÔ‡˜, ÙÔ ÊÏ‚ÈÎfi Î·È ÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· Î·È ÙÂÏÈο ÂÌÊ·Ó›˙ÂÈ ÌfiÓÔ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ·fi ÙÔ ·ÚÙËÚÈ·Îfi ·›Ì·. ∏ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ Ô˘ ÔÊ›ÏÂÙ·È Û ÈÛÙÔ‡˜ Â›Ó·È ÛÙ·ıÂÚ‹, ˘ÔÏÔÁ›˙ÂÙ·È Î·È ·Ê·ÈÚ›ٷÈ. ŒÙÛÈ ·ÔÌÔÓÒÓÂÙ·È ÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· ·’ fiÏ· Ù· ¿ÏÏ· ÛÙÔȯ›· Ô˘ ·ÚÂÌ‚¿ÏÏÔÓÙ·È ÌÂٷ͇ Ù˘ ËÁ‹˜ ÙÔ˘ ʈÙfi˜ Î·È ÙÔ˘ ·ÓȯÓÂ˘Ù‹. ∏ Ê·ÛÌ·ÙÔʈÙÔÌÂÙÚ›· Â›Ó·È Ë Ù¯ÓÈ΋ Ô˘ ·ÓȯÓ‡ÂÈ ÙË ‰È·ÊÔÚ¿ ÛÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ ·fi ÙËÓ Ô͢·ÈÌÔÛÊ·ÈÚ›ÓË Î·È ÙËÓ ·Ó·¯ı›۷ ·ÈÌÔÛÊ·ÈÚ›ÓË. ∆Ô Êˆ˜ ·˘Ùfi ÂΤÌÂÙ·È ·fi ÙË ÊˆÙÂÈÓ‹ ËÁ‹ ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ Û ‰‡Ô ‰È·ÊÔÚÂÙÈο Ì‹ÎË Î‡Ì·ÙÔ˜. ∏ ·ÔÚÚfiÊËÛË ÙÔ˘ ʈÙfi˜ Ì‹ÎÔ˘˜ ·̷ÙÔ˜ 660 nm (ÂÚ˘ıÚ¿ ÂÚÈÔ¯‹) Â›Ó·È ˘„ËÏ‹ ·fi ÙËÓ ·Ó·¯ı›۷ ·ÈÌÔÛÊ·ÈÚ›ÓË Î·È ¯·ÌËÏ‹ ·fi ÙËÓ Ô͢·ÈÌÔÛÊ·ÈÚ›ÓË. ∆Ô ·ÓÙ›ıÂÙÔ Û˘Ì‚·›ÓÂÈ Ì ÙÔ Êˆ˜ Ì‹ÎÔ˘˜ ·̷ÙÔ˜ 940 nm (˘¤Ú˘ıÚË ÂÚÈÔ¯‹). ∂Ô̤ӈ˜, Ë Û¯¤ÛË Ù˘ ·ÔÚÚfiÊËÛ˘ ÙÔ˘ ʈÙfi˜ Ì‹ÎÔ˘˜ ·̷ÙÔ˜ 660 nm ‹ 940 nm ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÔÛfi Ù˘ Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È Ù˘ ·Ó·¯ı›۷˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (™¯‹Ì· 2). ∆Ô ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÙˆÓ ·ÓˆÙ¤Úˆ Ù¯ÓÈÎÒÓ, ÌÂÙÚ¿ ÙÔÓ ÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ (SpO2) ηıÒ˜ Î·È ÙȘ
À¤Ú˘ıÚË (940nm) ‰›Ô‰Ô˜
∂Ú˘ıÚ‹ (660nm) ‰›Ô‰Ô˜ ∫·Ù·Û΢‹ ·ÔÎÏÂ›Ô˘Û· ›ÛÔ‰Ô ÊˆÙfi˜
ÕÎÚÔ (¢¿ÎÙ˘ÏÔ ¯ÂÚÈÔ‡ ‹ Ô‰ÈÔ‡) ∫·ÏÒ‰ÈÔ
ºˆÙÔ·ÓȯÓÂ˘Ù‹˜ SpO2 97% ™Ê‡ÍÂȘ
¶·ÏÌÈÎfi Ô͇ÌÂÙÚÔ
75/min
™¯‹Ì· 1. ™˘ÛÙ·ÙÈο ÙÔ˘ ·ÈÛıËÙ‹Ú· Î·È Ù˘ ÔıfiÓ˘ ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘.
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¶·È‰È·ÙÚÈ΋ 2001;64:355-360
Paediatriki 2001;64:355-360
Y¶∂ƒÀ£ƒO 940nm
∂Ï·Ùو̤ÓË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙ˘ Hb Ì O2
O͢·ÈÌÔÛÊ·ÈÚ›ÓË
∞Ó·¯ı›۷ ·ÈÌÔÛÊ·ÈÚ›ÓË
A˘ÍË̤ÓË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙ˘ Hb Ì O2
2,3 DPG
[H+] £ÂÚÌ. PCO2 P50 HbF
2,3 DPG [H+] ¶˘ÚÂÙfi˜ PCO2 P50
∞ÔÚÚfiÊËÛË
ªÂı·ÈÌÔÛÊ·ÈÚ›ÓË (Met-Hb)
SpO2 KÔÚÂÛÌfi˜ Hb(%)
∂ƒÀ£ƒO 660nm
P50 - 26,5 mmHg
600
700
800
900
1000
∆· Ì‹ÎË Î‡Ì·ÙÔ˜ ÙÔ˘ “ʈÙfi˜” (nm) ™¯‹Ì· 2. ∆· Ì‹ÎË Î‡Ì·ÙÔ˜ ÙÔ˘ ʈÙfi˜ Î·È Ë ·ÔÚÚfiÊËÛ‹ ÙÔ˘˜ ·fi ÙȘ ‰È¿ÊÔÚ˜ ·ÈÌÔÛÊ·ÈÚ›Ó˜.
ÛʇÍÂȘ. ∏ ÙÈÌ‹ ÙÔ˘ SpO2 Â›Ó·È ÙÔ ÔÛÔÛÙfi Ù˘ Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ Û ۇÁÎÚÈÛË Ì ÙÔ ¿ıÚÔÈÛÌ· Ù˘ Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È Ù˘ ·Ó·¯ı›۷˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ‰ËÏ·‰‹ Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÏÈ΋ ·ÈÌÔÛÊ·ÈÚ›ÓË Ô˘ Â›Ó·È ÈηӋ Ó· ÌÂٷʤÚÂÈ Ô͢ÁfiÓÔ (O2). °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, Ô SpO2 Ô˘ ÌÂÙÚ¿ ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ÔÓÔÌ¿˙ÂÙ·È ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÎÔÚÂÛÌfi˜ (4,5). (SpO2=OxyHb/OxyHb+·Ó·¯ı›۷ ·ÈÌÔÛÊ·ÈÚ›ÓË) ÕÏÏË Ì¤ıÔ‰Ô˜ ÂϤÁ¯Ô˘ Ù˘ Ô͢ÁfiÓˆÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Ë Ì¤ÙÚËÛË Ù˘ ÌÂÚÈ΋˜ ›ÂÛ˘ ÙÔ˘ Ô͢ÁfiÓÔ˘ ÛÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· (PaO2) ̤ۈ ·Ó¿Ï˘Û˘ ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ Â›Ó·È Ë Î·Ï‡ÙÂÚË, ·ÏÏ¿ Â›Ó·È ·ÈÌ·ÙËÚ‹ Î·È ÌÂÙÚ¿ÂÈ ÙËÓ PaO2 ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹. ∞ÓÙÈı¤Ùˆ˜, ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Ì ÙË Ì¤ÙÚËÛË ÙÔ˘ SpO2 ‰›ÓÂÈ Û˘Ó¯›˜ ÏËÚÔÊÔڛ˜ ˆ˜ ÚÔ˜ ÙËÓ Ô͢ÁfiÓˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÌÂÈÒÓÂÙ·È ¤ÙÛÈ ‰Ú·ÛÙÈο Ô ·ÚÈıÌfi˜ ÙˆÓ Ï·Ì‚·ÓfiÌÂÓˆÓ ‰ÂÈÁÌ¿ÙˆÓ ·›Ì·ÙÔ˜. ∏ Û¯¤ÛË ÙÔ˘ SpO2 Ì ÙËÓ PaO2 ÂÎÊÚ¿˙ÂÙ·È ·fi ÙË ÛÈÁÌÔÂȉԇ˜ Û¯‹Ì·ÙÔ˜ η̇ÏË ·Ô‰¤ÛÌ¢Û˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (Hb) Û O2 (6). ∏ ÚfiÛÏË„Ë Î·È Ë ·fi‰ÔÛË ÙÔ˘ O2 ‰È¢ÎÔχÓÂÙ·È ·fi ÙÔ Û¯‹Ì· Ù˘ η̇Ï˘ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÙÈÌ‹ Ù˘ PaO2 ÛÙËÓ Î·Ì‡ÏË Î·È ·fi ÙË ı¤ÛË Ù˘ η̇Ï˘ (™¯‹Ì· 3). ™ÙÔ ¿Óˆ Â›Â‰Ô ÙÌ‹Ì· Ù˘ η̇Ï˘, ÔÈ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ SpO2 ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚÎÂÙ‹ ¢·ÈÛıËÛ›· ÛÙÔ Ó· ·Ôηχ„Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ Ù˘ PaO2 Û ˘„ËÏ¿
PaO2 (mmHg) ™¯‹Ì· 3. ∫·Ì‡ÏË ·Ô‰¤ÛÌ¢Û˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û O2.
›‰· Ô͢ÁfiÓˆÛ˘ Ô˘ ¤¯Ô˘Ó ÎÏÈÓÈ΋ ÛËÌ·Û›· Û ÚfiˆÚ· ÓÂÔÁÓ¿. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÂÙ·ÎÈÓÔ‡Ó ÙËÓ Î·Ì‡ÏË ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿ Î·È ÂÏ·ÙÙÒÓÔ˘Ó ÙË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙËÙ· Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ì O2, Â›Ó·È Ë ·ÏοψÛË, Ë ˘ÔıÂÚÌ›·, Ë ˘Ôηӛ·, ÙÔ ÂÏ·Ùو̤ÓÔ 2,3 DPG, Ë HbF, Ë HbS, ÙÔ Ì˘Ío›‰ËÌ·, Ë Î·Ú‚Ô͢·ÈÌÔÛÊ·ÈÚ›ÓË Î·È ÙÔ ÂÏ·Ùو̤ÓÔ P50. ∞ÓÙÈı¤Ùˆ˜, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙË ‰ÂÛÌ¢ÙÈ΋ ÈηÓfiÙËÙ· Ù˘ Hb Ì O2 Î·È ÌÂÙ·ÎÈÓÔ‡Ó ÙËÓ Î·Ì‡ÏË ÚÔ˜ Ù· ‰ÂÍÈ¿, Â›Ó·È Ë ÔͤˆÛË, Ë ˘ÂÚηӛ·, Ô ˘ÚÂÙfi˜, ÙÔ ·˘ÍË̤ÓÔ 2,3 DPG Î·È ÙÔ ·˘ÍË̤ÓÔ P50 (7,8). (P50 Â›Ó·È Ì›· Û‡ÓÙÌËÛË ·fi ÙË ÌÂÚÈ΋ ›ÂÛË ÙÔ˘ Ô͢ÁfiÓÔ˘, ÛÙËÓ ÔÔ›· Ë ·ÈÌÔÛÊ·ÈÚ›ÓË Â›Ó·È 50% Ô͢ÁÔӈ̤ÓË Î·È Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· Ó· ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙȘ ÌÂÙ·ÎÈÓ‹ÛÂȘ ÛÙËÓ Î·Ì‡ÏË ·Ô‰¤ÛÌ¢Û˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û O2). ¢È¿ÊÔÚ˜ ¯Ú‹ÛÂȘ ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ∆Ô ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ÂÍ‹˜ ÂÚÈÙÒÛÂȘ: 1) °È· ÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÔÍ·ÈÌ›·˜ ÎÏÈÓÈο (9): ·) ∫·Ù¿ ÙËÓ ÚÔ·Ó·ÈÛıËÙÈ΋ ÂÚ›Ô‰Ô - ÚÔÓ¿ÚΈÛË. ‚) ∫·Ù¿ ÙË ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô. ™ÙËÓ ·È‰È·ÙÚÈ΋ ·Ó·ÈÛıËÛ›·, ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ÚÒÙÔ ‰È¤ÁÓˆÛ ÌÂÁ¿ÏË ˘ÔÍ·ÈÌ›· (SpO2 <85% ÁÈ· t >30 sec) ÛÙ· 41 ·fi Ù· 59 ÂÂÈÛfi‰È¿ Ù˘, ÂÓÒ Ô ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ‰È¤ÁÓˆÛ ٷ 13/59, Ô ‰Â ηÓÔÁÚ¿ÊÔ˜ ÌfiÓÔ Ù· 5/59.
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Á) ∫·Ù¿ ÙË ÌÂÙ·Ó·ÈÛıËÙÈ΋ ÂÚ›Ô‰Ô, ‰ÈfiÙÈ ÙfiÙ ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ˘ÔÍ·ÈÌ›·˜. ‰) ™Â Ô͇ Î·È ¯ÚfiÓÈÔ fiÓÔ, fiÙ·Ó ¯ÔÚËÁÂ›Ù·È ÌÔÚÊ›ÓË. Â) ™ÙËÓ ª∂£ ÁÈ· ÙË Ú‡ıÌÈÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ÂÈÛÓÂfiÌÂÓÔ˘ O2 ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ÛÙ) ™Â ›ÁÔ˘Û· È·ÙÚÈ΋, ηٿ ÙË ÌÂÙ·ÊÔÚ¿ ·ÛıÂÓÒÓ ÛÙË ª∂£. ˙) ™Â ÂÓ‰ÔÛÎÔ‹ÛÂȘ (Ë µÚÂÙÙ·ÓÈ΋ ŒÓˆÛË °·ÛÙÚÂÓÙÂÚÔÏfiÁˆÓ Û˘ÛÙ‹ÓÂÈ ÙË ¯Ú‹ÛË ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ Û fiϘ ÙȘ ÂÂÌ‚¿ÛÂȘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜). Ë) ™Â ‚ÚÔÁ¯ÔÛÎÔ‹ÛÂȘ, Ô‰ÔÓÙÈ·ÙÚÈ΋ Î.Ï. ı) ∫·Ù¿ ÙÔÓ ¤ÏÂÁ¯Ô ΢·ÓˆÙÈ΋˜ ηډÈÔ¿ıÂÈ·˜, ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, ηډÈÔ¿ıÂÈ·˜ Ì Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË. È) ∫·Ù¿ ÙÔÓ ¤ÏÂÁ¯Ô ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ·ÚÙËÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. È·) ∫·Ù¿ ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ·›Ì·ÙÔ˜ Û ÂÚÈÊÂÚÈΤ˜ ·ÁÁÂÈÔ¿ıÂȘ. 2) °È· ‰È¿ÊÔÚ˜ ¿ÏϘ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜, fiˆ˜: ·) ∆Ë ÌÂϤÙË ÂÂÈÛÔ‰›ˆÓ ¿ÓÔÈ·˜ ηٿ ÙÔÓ ‡ÓÔ, ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ‚·Ú‡ÙËÙ¿˜ ÙÔ˘˜ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Â¿Ó Â›Ó·È ÎÂÓÙÚÈÎÔ‡ ‹ ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘. O ‚·ıÌfi˜ Ù˘ ÙÒÛ˘ ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ÛÙËÓ ·ÔÊÚ·ÎÙÈ΋ ¿ÓÔÈ· Â›Ó·È ‰Â›ÎÙ˘ ·˘ÍË̤ÓÔ˘ ÂÁ¯ÂÈÚËÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ Ô˘ ı· ˘Ô‚ÏËıÔ‡Ó Û ·‰ÂÓÔÙÔÌ‹ - ·Ì˘Á‰·ÏÂÎÙÔÌ‹ (10). ‚) ∆ÔÓ ¤ÏÂÁ¯Ô Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÂÂÈÛÔ‰›ˆÓ ¿ÓÔÈ·˜ Î·È ‚Ú·‰˘Î·Ú‰›·˜ Û ·È‰È¿ Ì ·Ú’ ÔÏ›ÁÔ ı·Ó·ÙËÊfiÚ· ÂÂÈÛfi‰È· ¿ÓÔÈ·˜ ‹ Û ·‰¤ÏÊÈ· ·È‰ÈÒÓ Ô˘ ›¯·Ó ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ. Á) ∆Ë Ú‡ıÌÈÛË ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ Û ·È‰È¿ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Ì·ÎÚÔ¯ÚfiÓÈ· ·Ó·Ó¢ÛÙ‹Ú·. ‰) ∆Ș ÌÂϤÙ˜ Û ˘„ËÏfi ˘„fiÌÂÙÚÔ Î·Ù¿ ÙËÓ ÔÚÂÈ‚·Û›·, ÙËÓ ·ıÏËÙÈ·ÙÚÈ΋ Î.Ï. Â) ∆ËÓ ÚfiÏË„Ë ÔÈÛıÔÊ·ÎÈ΋˜ ÈÓÔÏ·Û›·˜ Û ÚfiˆÚ· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ÔÈ ÙÈ̤˜ ÙÔ˘ SpO2 Ú¤ÂÈ Ó· Î˘Ì·›ÓÔÓÙ·È ·fi 91-96%. °È· ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÔÍ›·˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, Ô SpO2 ·Ú¤¯ÂÈ ÌÂÁ¿ÏË ·ÛÊ¿ÏÂÈ·, ÂÓÒ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÂÚÔÍ›·˜ Â›Ó·È ··Ú·›ÙËÙË Î·È Ë Ì¤ÙÚËÛË ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ (6-8). ÛÙ) ∆ÔÓ ¤ÏÂÁ¯Ô Ô͢ÁÔÓÔıÂڷ›·˜ Û ·È‰È¿ Ì ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· ‹ Ì ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ· ÛÙÔ È·ÙÚÂ›Ô ‹ ÛÙÔ Û›ÙÈ. °È· ÙË Ú‡ıÌÈÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ Ú¤ÂÈ Ó· ÌÂÙÚ¿Ù·È Ô SpO2 ηٿ ÙËÓ ÂÁÚ‹ÁÔÚÛË, ÙÔÓ ‡ÓÔ Î·È ÙËÓ ¿ÛÎËÛË ÙˆÓ ·È‰ÈÒÓ (11). ˙) ∆ËÓ ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó Ó¢ÌÔ-
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Ó›· ‹ Ïԛ̈ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ıÂڷ›· Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ·ÏÁfiÚÈıÌÔ Ù˘ ¶·ÁÎfiÛÌÈ·˜ OÚÁ¿ÓˆÛ˘ ÀÁ›·˜ (12). [>50 ·Ó·ÓÔ¤˜/min ÁÈ· ·È‰È¿ 2-11 ÌËÓÒÓ, >60 ·Ó·ÓÔ¤˜/min ÁÈ· ·È‰È¿ 12-60 ÌËÓÒÓ, ÀÔÍ·ÈÌ›· (SpO2 <96,6% - 2SD)]. Ë) ∆ËÓ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ·ÛıÌ·ÙÈ΋˜ ÎÚ›Û˘ (13-16). i) ∆˘ ‹È·˜ (SpO2 >95%) Ì ٷ ·ÓÙ›ÛÙÔȯ· ·¤ÚÈ· ·›Ì·ÙÔ˜ PaO2 >80%, PaCO2 <35%. ii) ∆˘ ̤ÙÚÈ·˜ (SpO2 = 90-95%) Ì ٷ ·ÓÙ›ÛÙÔȯ· ·¤ÚÈ· ·›Ì·ÙÔ˜ PaO2 = 60-80%, PaCO2: Ê˘ÛÈÔÏÔÁÈÎfi ‹ ·˘ÍË̤ÓÔ <50%. iii) ∆˘ ÛÔ‚·Ú‹˜ (SpO2 <90%) Ì ٷ ·ÓÙ›ÛÙÔȯ· ·¤ÚÈ· ·›Ì·ÙÔ˜ PaO2 <60%, PaCO2 >50%. ı) ™˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì ٛÙÏÔ Uses of Pulse Oximetry in the Hospital Management of Acute Asthma in childhood ÙˆÓ G. Conett, W. Lenney. Peadiatr Pulmonol 1993;15:345-349. ¶·È‰È¿ Û ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË Ì SpO2 <91% ¯ÚÂÈ¿ÛÙËΠӷ ÂÈÛ·¯ıÔ‡Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ó· ÙÔ˘˜ ¯ÔÚËÁËı› Û·Ï‚Ô˘Ù·ÌfiÏË Û ÓÂÊÂÏÔÔÈËÙ‹ Ì ·ÚÔ¯‹ Ô͢ÁfiÓÔ˘. ™Â ·˘Ù¿ Ô˘ Ô SpO2 ·Ú¤ÌÂÈÓ <91%, ÂÎÙfi˜ ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹ ¯ÚÂÈ¿ÛÙËΠӷ ÙÔ˘˜ ¯ÔÚËÁËı› ·ÌÈÓÔÊ˘ÏÏ›ÓË ÂÓ‰ÔÊϤ‚È·. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ·fi ÙȘ ÌÂϤÙ˜ Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙȘ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ SpO2 Û·Ó ¤Ó· ·fi Ù· ÎÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·Ó ÂÓÙ·ÙÈ΋ ıÂڷ›· Î·È ÈÔ ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË. ∂ȉڿÛÂȘ ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙȘ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ∞. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ÒÛÙ ӷ ÌË ‰Â›¯ÓÂÈ ÙË ÛˆÛÙ‹ ÙÈÌ‹ ÙÔ˘ SpO2, ·ÏÏ¿ ·˘Ùfi˜ Ô˘ ÙÔ ¯ÚËÛÈÌÔÔÈ› Ó· ÌÔÚ› Ó· ÙÔ ·ÓÙÈÏËÊı› (·ÛÊ·Ï›˜), ›ӷÈ: ·) ∆¯ÓÈÎÔ›: i) Ù· Ì˯·ÓÈο ·Ú¿ÛÈÙ· (ÔÈ ÎÈÓ‹ÛÂȘ ÙˆÓ ¿ÎÚˆÓ ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÙȘ ÌÂÙÚ‹ÛÂȘ), ii) Ù· ËÏÂÎÙÚÔÌ·ÁÓËÙÈο ·Ú¿ÛÈÙ· (¯ÂÈÚÔ˘ÚÁÈΤ˜ ‰È·ıÂỨ˜ - ΢„ÂÏȉÈο ÙËϤʈӷ). OÈ Û‡Á¯ÚÔÓÔÈ ·ÈÛıËÙ‹Ú˜ ¤¯Ô˘Ó ·Û›‰· ÚÔÛÙ·Û›·˜, iii) Ô Ì·ÁÓËÙÈÎfi˜ ÙÔÌÔÁÚ¿ÊÔ˜. ‚) º˘ÛÈÔÏÔÁÈÎÔ›: i) ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÛÊ˘ÁÌfi, ÙÔÓ fiÁÎÔ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÙÔ Ú˘ıÌfi, ii) Ë ¯·ÌËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË, iii) Ë ·Ó·ÈÌ›· (Ë ·Ó·ÈÌ›· ‰›ÓÂÈ ÙËÓ „¢‰‹ ÂÈÎfiÓ· fiÙÈ Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ Â·Ú΋ Ô͢ÁfiÓˆÛË), Ë ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·, iv) Ë ¯ÔÏÂÚ˘ıÚ›ÓË >30 mg/dl, v) Ô È‰ÚÒÙ·˜ - Ù· „˘¯Ú¿ ¿ÎÚ· - ÙÔ Ô›‰ËÌ· (ÙÔ ‰¿ÎÙ˘ÏÔ Ú¤ÂÈ Ó· Â›Ó·È ÛÙÂÁÓfi Î·È ÛÂ Ê˘ÛÈÔÏÔÁÈ΋ ıÂÚÌÔÎÚ·Û›·).
¶·È‰È·ÙÚÈ΋ 2001;64:355-360
µ. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ÒÛÙ ӷ ‰Â›¯ÓÂÈ ÂÏ·Ùو̤ÓË ‹ ·˘ÍË̤ÓË ÙÈÌ‹ ÙÔ˘ SpO2, ·ÏÏ¿ Î·È Ó· Ê·›ÓÂÙ·È fiÙÈ ÏÂÈÙÔ˘ÚÁ› ÛˆÛÙ¿ (ÂÈΛӉ˘ÓÔÈ), ›ӷÈ: ·) ∆¯ÓÈÎÔ›: i) Ë Ú‡ıÌÈÛË = ‡ÚÔ˜ ÙÈÌÒÓ, ii) Ë Î·ı˘ÛÙ¤ÚËÛË (25ãã) ÁÈ· Ó· ‰Â›ÍÂÈ ÙËÓ ·fiÙÔÌË ˘ÔÍ›·, iii) ÔÈ Â͈ÙÂÚÈΤ˜ ʈÙÂÈÓ¤˜ ËÁ¤˜ (ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›·, Ͽ̘ ÊıÔÚ›Ô˘), Ô˘ ÌÔÚÔ‡Ó Ó· ·ÔÊ¢¯ıÔ‡Ó Â¿Ó Î·Ï˘Êı› Ô ·ÈÛıËÙ‹Ú·˜ ÙÔ˘ ÔÍ˘Ì¤ÙÚÔ˘ Ì ·‰È·Ê·Ó¤˜ ˘ÏÈÎfi. ‚) º˘ÛÈÔÏÔÁÈÎÔ›: i) ÔÈ ·ıÔÏÔÁÈΤ˜ ·ÈÌÔÛÊ·ÈÚ›Ó˜ (HbCO, MetHb, HbS). HbCO, MetHb ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙÔ ·›Ì· Û ›‰· <2% Î·È ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙȘ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ÔÍ˘Ì¤ÙÚÔ˘. OÈ HbCO, MetHb Î·È HbS Û ·˘ÍË̤ӷ ›‰· ÂËÚ¿˙Ô˘Ó ÙȘ ÙÈ̤˜ ÙÔ˘ SpO2 Î·È ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈÎfi Ô͇ÌÂÙÚÔ (CO oximeter) (17), ii) ÔÈ ‚·Ê¤˜ Ó˘¯ÈÒÓ (·‰È·Ê·Ó¤˜ ‚ÂÚÓ›ÎÈ), iii) ÔÈ ¯ÚˆÛÙÈΤ˜ Ô˘Û›Â˜ (ÙÔ Î˘·ÓÔ‡Ó ÙÔ˘ ÌÂı˘ÏÂÓ›Ô˘ ÁÈ· ÙË ıÂڷ›· Ù˘ ªÂı·ÈÌÔÛÊ·ÈÚÈÓ·ÈÌ›·˜, ÙÔ Ú¿ÛÈÓÔ ÈÓ‰ÔÎÈ·Ó›Ó˘), iv) Ù· Ê¿Ú̷η (ÛÔ˘ÏÊÔÓ·Ì›‰Ë, ÓÈÙÚÒ‰Ë, PAS), v) ÔÈ ÊϤ‚˜ Ô˘ Ûʇ˙Ô˘Ó ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÙÚ‹ÛˆÓ.
Paediatriki 2001;64:355-360
∂ÈÎfiÓ· 1. ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - Ì·ÓÙ·Ï¿ÎÈ.
¶ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ∆Ô ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ¤¯ÂÈ ·ÎÚ›‚ÂÈ· ±2% ÁÈ· ÎÔÚÂÛÌfi ·fi 70-100%, ¤¯ÂÈ ¯ÚfiÓÔ ·¿ÓÙËÛ˘ Û ·ÈÊÓ›‰È· Ì›ˆÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ 6 sec ÁÈ· ÙÔÓ ·ÈÛıËÙ‹Ú· ÙÔ˘ ·˘ÙÈÔ‡ Î·È 24 sec ÁÈ’ ·˘ÙfiÓ ÙÔ˘ ‰·ÎÙ‡ÏÔ˘ ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ. ¢È·ı¤ÙÂÈ ÔÈÎÈÏ›· ·ÈÛıËÙ‹ÚˆÓ (‰¿ÎÙ˘ÏÔ ¯ÂÚÈÔ‡ - Ô‰ÈÔ‡, ÏÔ‚fi ÙÔ˘ ·˘ÙÈÔ‡, Ú¿¯Ë Ù˘ ̇Ù˘). ∆·˘Ùfi¯ÚÔÓ·, ·Ú¤¯ÂÈ ÛÙËÓ ÔıfiÓË ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÛʇÍÂˆÓ Ì·˙› Ì ÙËÓ ÏËı˘ÛÌÔÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ ÛÊ˘ÁÌÔ‡. º¤ÚÂÈ Û˘Ó·ÁÂÚÌfi Û ڢıÌÈ˙fiÌÂÓ· ·ÓÒÙÂÚ· Î·È Î·ÙÒÙÂÚ· fiÚÈ·. °ÂÓÈο fiÚÈ· Û˘Ó·ÁÂÚÌÔ‡ ÁÈ· ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Â›Ó·È Ë ÙÈÌ‹ ÙÔ˘ SpO2 <90%, ÂÓÒ fiÚÈÔ ·ÂÈÏËÙÈÎfi ÁÈ· ÙË ˙ˆ‹ ıˆÚÂ›Ù·È Ô SpO2 <76%. ∂›Û˘, ÙÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ¤¯ÂÈ ÌÓ‹ÌË, ¤ÙÛÈ ÒÛÙ ӷ Â›Ó·È Û ı¤ÛË Ó· ·Ô‰ÒÛÂÈ ÙȘ ÌÂÙ·‚ÔϤ˜ ̤۷ Û ÔÚÈṲ̂ÓÔ ¯ÚfiÓÔ (1-12 ÒÚ˜). ∆‡ÔÈ ·ÈÛıËÙ‹ÚˆÓ ·ÏÌÈÎÔ‡ ÔÍ˘Ì¤ÙÚÔ˘ ∞) ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - Ì·ÓÙ·Ï¿ÎÈ (∂ÈÎfiÓ· 1). ∞¢ı‡ÓÂÙ·È Û ÂÓ‹ÏÈΘ (˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔȯԘ ÁÈ· ·È‰È¿ Ì µ™ >15 kg). ∆Ô ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÔÚ›˙ÂÙ·È: ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ >40 kg Î·È ÁÈ· Ù· ·È‰È¿ >15 kg. ∏ ÚÔÙÂÈÓfiÌÂÓË ı¤ÛË Â›Ó·È Ô ‰Â›ÎÙ˘ ¯ÂÚÈÔ‡, ·ÏÏ¿ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Î·È Û ¿ÏÏ· ‰¿ÎÙ˘Ï·. ¢ÂÓ Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÛÙÔÓ ·ÓÙ›¯ÂÈÚ· ‹ ÛÙÔ ÌÂÁ¿ÏÔ ‰¿ÎÙ˘ÏÔ ÙÔ˘ Ô‰ÈÔ‡. µ) ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - ÔÏÏ·ÏÒÓ ı¤ÛÂˆÓ (∂ÈÎfiÓ· 2). ∆Ô ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÔÚ›˙ÂÙ·È:
∂ÈÎfiÓ· 2. ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - ÔÏÏ·ÏÒÓ ı¤ÛˆÓ.
ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ >40 kg, ÁÈ· Ù· ·È‰È¿ 3-30 kg Î·È ÁÈ· Ù· ÓÂÔÁÓ¿ 1-3 kg. ªÂ Ì·ÓÙ·Ï¿ÎÈ ÁÈ· ÙÔ ·˘Ù› ÔÚ›˙ÂÙ·È Û >30 kg. ∏ ÚÔÙÂÈÓfiÌÂÓË ı¤ÛË Â›Ó·È - ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È Ù· ·È‰È¿ - Ô ‰Â›ÎÙ˘ ¯ÂÚÈÔ‡. ∂ÓÒ, ÁÈ· Ù· ÓÂÔÁÓ¿, ÙÔ ¤ÏÌ· ÙÔ˘ Ô‰ÈÔ‡ ‹ Ë ·Ï¿ÌË. ÕÏÏË ı¤ÛË ÛÙ· ·È‰È¿ ÌÔÚÔ‡Ó Ó· ·ÔÙÂϤÛÔ˘Ó fiÏ· Ù· ‰¿ÎÙ˘Ï· ÙˆÓ ¯ÂÚÈÒÓ Î·È ÙˆÓ Ô‰ÈÒÓ. °) ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - ÁÈ· ·È‰È¿ ‹ ‚Ú¤ÊË
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∂ÈÎfiÓ· 3. ∞ÈÛıËÙ‹Ú·˜ ÔÍ˘Ì¤ÙÚÔ˘ - ÁÈ· ·È‰È¿ ‹ ‚Ú¤ÊË.
(∂ÈÎfiÓ· 3). ∆Ô ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÔÚ›˙ÂÙ·È: ÁÈ· Ù· ·È‰È¿ 15-40 kg, ÁÈ· Ù· ‚Ú¤ÊË 3-15 kg. ∏ ÚÔÙÂÈÓfiÌÂÓË ı¤ÛË ÁÈ· Ù· ·È‰È¿ Â›Ó·È Ô ‰Â›ÎÙ˘ ÙÔ˘ ¯ÂÚÈÔ‡, ÂÓÒ ÁÈ· Ù· ‚Ú¤ÊË ÙÔ ÌÂÁ¿ÏÔ ‰¿ÎÙ˘ÏÔ ÙÔ˘ Ô‰ÈÔ‡. ÕÏϘ ı¤ÛÂȘ ÁÈ· Ù· ·È‰È¿ Â›Ó·È Ô ·ÓÙ›¯ÂÈÚ·˜ ‹ ¿ÏÏ· ÌÈÎÚ¿ ‰¿ÎÙ˘Ï·. ∂Ê·ÚÌfi˙ÂÙ·È Ì ·˘ÙÔÎfiÏÏËÙ˜ Ù·Èӛ˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Mower RW, Sachs C, Nicklin LE, Safa P, Baraff JL. Effect of routine emergency department. Triage pulse oximetry, screening on medical management. Chest 1995;108:1297-1302. 2. Moyle TJ. Uses and abuses of pulse oximetry. Arch Dis Child 1996;74:77-80. 3. ªÔ˘ÏÔ‡‰Ë ∂, ªÂÙ·Í¿ÚË ª, °ÂˆÚÁfiÔ˘ÏÔ˜ ¢. ∂ÏÏËÓÈ΋ π·ÙÚÈ΋ 1997;63(3 Suppl):371-379. 4. ∆ÛÈÏÈÁÈ¿ÓÓ˘ £. ∏ ·ÏÌÈ΋ Ô͢ÌÂÙÚ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1998;61:5-9.
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5. ¶·Ó·ÁȈÙÔÔ‡ÏÔ˘-°·ÚÙ·Á¿ÓË ¶. ÃÚËÛÈÌfiÙËÙ· Î·È ·ÍÈÔÏfiÁËÛË Ù˘ ÛÊ˘ÁÌÈ΋˜ Ô͢ÌÂÙÚ›·˜. ¶Ú·ÎÙÈο 5˘ ∏ÌÂÚ›‰·˜ ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛˆÓ. ª¿ÈÔ˜ 1996. ÛÂÏ. 64-73. 6. Gupta R, Yoxall WC, Suledhar N, Shaw JN. Individualised pulse oximetry limits in neonatal intensive care. Arch Dis Child Fetal Neonatal Ed 1999;81:F194-196. 7. Poets FC, Southal PD. Noninvasive monitoring of oxygenation in infants and children: Practical considerations and areas of concern. Pediatrics 1994;93:737-746. 8. Bhutani V, Taube J, Antunes M, Delivoria-Papadopoulos M. Adaptive control of inspired oxygen delivery to the neonate. Pediatr Pulm 1992;14:110-117. 9. Elchhorn J. Pulse oximetry as a standard practice in anesthesia. Anesthesiology 1993;78:423-428. 10. Rosen G, Muckle R, Mahowald M. Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: Can it be anticipated? Pediatrics 1994;93:784-788. 11. Abman SH, Grouthins IR. Pathophysiology and treatment of bronchopulmonary dysplasia. Pediatr Clin N Am 1994;41:227. 12. Madico G, Gilman R, Jabra A, Rojas L, Hernandez H, Fukuda J. The role of pulse oximetry. Arch Pediatr Adolesc Med 1995;149:1259-1263. 13. Bishop J, Nolan T. Pulse oximetry in acute asthma. Arch Dis Child 1991;66:724-725. 14. Gayle M, Kissoon N. Assessment of respiratory distress in the asthmatic child: When we should be concerned? Pediatr Ann 1996;25:128-135. 15. Connett G, Lenney M. Use of pulse oximetry in the hospital management of acute asthma in childhood. Pediatr Pulm 1993;15:345-349. 16. Needleman J, Setty B, Varlotta L, Dampier C, Allen J. Measurement of hemoglobin saturation by oxygen in children and adolescents with sickle cell disease. Pediatr Pulm 1999;28:423-428.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶. ¶·Ó·ÁȈÙÔÔ‡ÏÔ˘-°·ÚÙ·Á¿ÓË ∏Ï›· ∫ÔÎÎÒÓË 4, ¡. ™Ì‡ÚÓË, 171 24
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Paediatriki 2001;64:361-364
PNEUMONOLOGY
ÀÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜ ÛÙ· ·È‰È¿ π. ¡. ∆۷ӿη˜
Recurrent pneumonias in childhood J. N. Tsanakas
¶ÂÚ›ÏË„Ë: OÈ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜ ·ÔÙÂÏÔ‡Ó Û˘¯Ó¿ ‰È·ÁÓˆÛÙÈÎfi Úfi‚ÏËÌ·, Ë Ï‡ÛË ÙÔ˘ ÔÔ›Ô˘ ··ÈÙ› ÂȉÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ·ÚÎÂÙfi ¯ÚfiÓÔ. ∏ ·ÈÙÈÔÏÔÁ›· ÙÔ˘˜ ¤¯ÂÈ ÌÂÁ¿ÏÔ Ê¿ÛÌ·, ·fi ÏÔÈÌÒÍÂȘ ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, ̤¯ÚÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ó‡ÌÔÓ· ‹ Î·È Û˘ÛÙËÌ·ÙÈΤ˜ ÓfiÛÔ˘˜. ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ı· Ú¤ÂÈ Ó· Â›Ó·È ÌÂıÔ‰È΋ Î·È Ë ıÂڷ›· ·ÈÙÈÔÏÔÁÈ΋. ∏ ·Ê·›ÚÂÛË ÙÌ‹Ì·ÙÔ˜ ‹ ÔÏfiÎÏËÚÔ˘ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ Ó‡ÌÔÓ· ı· Ú¤ÂÈ Ó· Â›Ó·È Ï‡ÛË ÙÂÏÂ˘Ù·›·˜ ÂÈÏÔÁ‹˜.
Abstract: Recurrent pneumonias are usually a diagnostic problem for the practicing pediatrician. Special investigations and a lot of time are needed to identify the cause. The spectrum of differential diagnosis extends from resistant bacterial infections to congenital lung abnormalities or systemic diseases with pulmonary involvement. A methodical diagnostic approach and appropriate treatment based on etiology are necessary to resolve the problem. Segmental or whole lung resection should always be considered as the last choice of treatment.
§¤ÍÂȘ ÎÏÂȉȿ: ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔӛ˜, ÏÔÈÌÒÍÂȘ, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ó‡ÌÔÓ·, Ó¢ÌÔÓÂÎÙÔÌ‹.
Key words: recurrent pneumonias, infections, congenital lung abnormalities, pneumonectomy.
ªÂ ÙÔÓ fiÚÔ “˘ÔÙÚÔÈ¿˙Ô˘Û· Ó¢ÌÔÓ›·” (À¶) ÂÓÓÔԇ̠ÂÚÈÛÛfiÙÂÚ· ÙÔ˘ ÂÓfi˜ ÂÂÈÛfi‰È· Ó¢ÌÔÓ›·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘ ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚ›· ÂÂÈÛfi‰È· ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜. ªÂ ÙÔÓ fiÚÔ “Ó¢ÌÔÓ›·” ÂÓÓÔԇ̠ÙË ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Ô˘ ÂΉËÏÒÓÂÙ·È ÌÂ Û˘ÌÙÒÌ·Ù· (‚‹¯·, Ù·¯‡ÓÔÈ·, ˘ÁÚÔ‡˜ ÚfiÁ¯Ô˘˜) Î·È ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· (‡ÎÓˆÛË). ∏ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡, ·Ó Î·È Û˘¯Ó¿ Û˘Óԉ‡ÂÈ ÙËÓ Ó¢ÌÔÓ›·, ‰ÂÓ ·ÔÙÂÏ› ··Ú·›ÙËÙÔ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ. ŒÙÛÈ, ÔÈ À¶ ‰È·ÎÚ›ÓÔÓÙ·È Û ÙÚÂȘ ηÙËÁÔڛ˜ ·Ó¿ÏÔÁ· Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÎÏÈÓÈÎÒÓ Î·È ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ: ·) ™Â fiÛ˜ ˘¿Ú¯Ô˘Ó ÌfiÓÈÌ· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÌÙÒÌ·Ù· (.¯. ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· Î.Ï.). ‚) ™Â ÂΛӘ fiÔ˘
˘¿Ú¯Ô˘Ó ˘ÔÙÚÔÈ¿˙ÔÓÙ· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È Û˘ÌÙÒÌ·Ù· (.¯. ΢ÛÙÈ΋ ›ÓˆÛË, ·ÓÔÛÔ·Ó¿ÚÎÂȘ Î.Ï.). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Ù· ·ıÔÏÔÁÈο ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ‰ÂÓ ˘Ô¯ˆÚÔ‡Ó Ï‹Úˆ˜ ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù·. Á) ™Â ÂΛӘ fiÔ˘ Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ˘Ô¯ˆÚÔ‡Ó ÙÂÏ›ˆ˜ ·Ó¿ÌÂÛ· ÛÙȘ ÚÔÛ‚ÔϤ˜ (.¯. ÂÈÏÔΤ˜ ·ÙÂÏÂÎÙ·ÛÈÒÓ ·fi ÎÚ›ÛÂȘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈο Û˘Ú›ÁÁÈ· Î.Ï.). ∞˘Ù¤˜ ·ÔÙÂÏÔ‡Ó ÙȘ Û˘ÓËı¤ÛÙÂÚ˜ ÂÚÈÙÒÛÂȘ.
∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁ›·˜ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢
∞›ÙÈ· OÈ À¶ ηٷٿÛÛÔÓÙ·È ÛÙȘ ·ÎfiÏÔ˘ı˜ ηÙËÁÔڛ˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·›ÙÈÔ Ô˘ ÙȘ ÚÔοÏÂÛÂ: ·) Û‡Ó‰ÚÔÌ· ÂÈÛÚfiÊËÛ˘, ‚) Û˘ÁÁÂÓ›˜ ‰˘ÛϷۛ˜
Associate Professor of Paediatric Pulmonology Aristotelion University of Thessaloniki
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Ó‡ÌÔÓ·, Á) Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù·, ‰) ‰È¿ÊÔÚ· ¿ÏÏ· ÓÔÛ‹Ì·Ù· Î·È Â) Û‡Ó‰ÚÔÌÔ “È·ÙÚÔÁÂÓÔ‡˜ ˘ÂډȿÁÓˆÛ˘”. ™Ù· Û‡Ó‰ÚÔÌ· ÂÈÛÚfiÊËÛ˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·ı‹ÛÂȘ fiÔ˘ ˘¿Ú¯ÂÈ ‚Ï¿‚Ë ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ, ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ Î·È ·¯·Ï·Û›· ÔÈÛÔÊ¿ÁÔ˘. ™ÙȘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ó‡ÌÔÓ· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ˘ÔÏ·Û›· - ·Ï·Û›·, ÔÈ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÙÚ·¯ÂÈÔ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘, ÙÔ Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ· Î·È ÙÔ Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· (∂ÈÎfiÓ· 1). ∞fi Ù· Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù·, Ù· ΢ÚÈfiÙÂÚ· Â›Ó·È ÔÈ ·ÓÔÛÔ·Ó¿ÚÎÂȘ, ÔÈ ÓÂÔϷۛ˜ Î·È Ë Î˘ÛÙÈ΋ ›ÓˆÛË. ÕÏÏ· Û¿ÓÈ· ÓÔÛ‹Ì·Ù· Ô˘ Ú¤ÂÈ Ó· Ì·›ÓÔ˘Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ À¶, Â›Ó·È Ù· Û‡Ó‰ÚÔÌ· ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ, Ë ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· Î·È Ë Ó¢ÌÔÓÈ΋ ·ÈÌÔÛȉ‹ÚˆÛË. ∆Ô Û‡Ó‰ÚÔÌÔ Ù˘ È·ÙÚÔÁÂÓÔ‡˜ ˘ÂډȿÁÓˆÛ˘ Â›Ó·È Ôχ Û˘¯Ó‹ ·ÈÙ›· Ï·Óı·Ṳ̂Ó˘ ‰È¿ÁÓˆÛ˘ Ì›·˜ Ó¢ÌÔÓ›·˜ ˆ˜ “˘ÔÙÚÔÈ¿˙Ô˘Û·˜”. ∞˘Ùfi ÌÔÚ› Ó· Û˘Ì‚Â› ·fi ÙËÓ ÂÈfiÏ·È· ÂÎÙ›ÌËÛË ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓ‹, ηٿ ÙÔ ÛÙ¿‰ÈÔ ·Ô‰ÚÔÌ‹˜ Ù˘ Ó¢ÌÔÓ›·˜. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ·ÔηٿÛÙ·ÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ì›·˜ Ó¢ÌÔÓ›·˜, ··ÈÙ› ·Ú¤Ï¢ÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ ÔÎÙÒ ¤ˆ˜ ‰Ò‰Âη ‚‰ÔÌ¿‰ˆÓ. ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ÌÔÚ› Ô ·ÛıÂÓ‹˜ Ó· ÚÔÛ‚ÏËı› ·fi οÔÈ· ÈÔÁÂÓ‹ Ïԛ̈ÍË, ÔfiÙ Û ηÈÓÔ‡ÚÁÈÔ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ı· Ê·ÓÔ‡Ó ÔÈ ˘ÔÏÂÈÌÌ·ÙÈΤ˜ ‚Ï¿‚˜ Ù˘ ÚÔË-
Paediatriki 2001;64:361-364
ÁËı›۷˜ Ó¢ÌÔÓ›·˜, ÔÈ Ôԛ˜ ÌÔÚ› Ó· ıˆÚËıÔ‡Ó Û·Ó Ó¤· ˘ÔÙÚÔ‹ (™¯‹Ì· 1). ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ∆¤ÛÛÂÚ· Â›Ó·È Ù· ÂÚˆÙ‹Ì·Ù· Ô˘ Ú¤ÂÈ Ó· ··ÓÙËıÔ‡Ó ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ À¶: ·) ∂›Ó·È Ú¿ÁÌ·ÙÈ ˘ÔÙÚÔÈ¿˙Ô˘Û· Ó¢ÌÔÓ›· ‹ ÚfiÎÂÈÙ·È ÁÈ· ˘ÂډȿÁÓˆÛË; ‚) ∞ÊÔÚ¿ ¤Ó·Ó ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ÏÔ‚Ô‡˜; Á) OÊ›ÏÂÙ·È Û ÌÈÎÚÔ‚È·Îfi ·›ÙÈÔ ‹ fi¯È; ‰) ∆È ÂÍÂÙ¿ÛÂȘ ¯ÚÂÈ¿˙ÔÓÙ·È; ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙȘ À¶ ı· Á›ÓÂÈ Ì ‚¿ÛË ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÚÔÛ‚·ÏÏfiÌÂÓˆÓ ÏÔ‚ÒÓ (¶›Ó·Î·˜ 1). ™˘Ó‹ıˆ˜, ·Ó ˘¿Ú¯ÂÈ ÚÔÛ‚ÔÏ‹ ÌfiÓÔ ÂÓfi˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÏÔ‚Ô‡ ÛÙÔÓ ¤Ó· Ó‡ÌÔÓ·, Ë ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë ı· ÛÙÚ·Ê› ÚÔ˜ ÙÔ Í¤ÓÔ ÛÒÌ·, ÙËÓ Â͈‚ÚÔÁ¯È΋ ›ÂÛË ÙÔ˘ ÏÔ‚Ô‡, ÙË ÛÙ¤ÓˆÛË ÂÓfi˜ ‚ÚfiÁ¯Ô˘, ÙÔ Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì· ‹ οÔÈ· ÂÓÙÔÈṲ̂ÓË ‚ÚÔÁ¯ÈÂÎÙ·Û›·. ∞ÓÙ›ıÂÙ·, ·Ó Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Â›Ó·È ‰È¿Û·ÚÙ· Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ÏÔ‚Ô‡˜ Î·È ÛÙÔ˘˜ ‰‡Ô Ó‡ÌÔÓ˜, ÙfiÙ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ı· ÛÎÂÊÙԇ̠ÚÒÙ· Ù· Û‡Ó‰ÚÔÌ· ÂÈÛÚfiÊËÛ˘, ÙȘ ·ÓÔÛÔ·Ó¿ÚÎÂȘ, Ù· Û‡Ó‰ÚÔÌ· ‰˘ÛÎÈÓËÛ›·˜ ÙˆÓ ÎÚÔÛÛÒÓ, ÙËÓ Î˘ÛÙÈ΋ ›ÓˆÛË Î·È ÙȘ ÓÂÔϷۛ˜ (∂ÈÎfiÓ· 2). ∫·Ù¿ ÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ı· Ú¤ÂÈ Ó· ÂÚ¢ÓËı› Ë Èı·ÓfiÙËÙ· ÂÈÛÚfiÊËÛ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜, Ë Û˘Ó‡·ÚÍË Û˘¯ÓÒÓ ÚÔÛ‚ÔÏÒÓ ˆÙ›Ùȉ·˜ ‹ ÈÁÌÔÚ›Ùȉ·˜, Ë ‡·ÚÍË ¯ÚfiÓÈÔ˘ ‰È·ÚÚÔ˚ÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, Û˘¯ÓÒÓ ÂÌ¤ÙˆÓ ‹ ‰˘ÛÎÔÏ›·˜ ÛÙËÓ Î·Ù¿ÔÛË. ™ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË Â›Ó·È ··Ú·›ÙËÙË Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÂȤ‰Ô˘ ıÚ¤„˘ ÙÔ˘ ·ÛıÂÓ‹, Ë Î·Ï‹
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™¯‹Ì· 1. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ù˘ “È·ÙÚÔÁÂÓÔ‡˜ ˘ÂډȿÁÓˆÛ˘”. ∏ Û˘¯Ó‹ ·ӿÏË„Ë ÙˆÓ ·ÎÙÈÓÔÁÚ·ÊÈÒÓ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÛÙ·‰È·Î‹˜ ·ÎÙÈÓÔÏÔÁÈ΋˜ ·ÔηٿÛÙ·Û˘, ı¤ÙÂÈ ÙË Ï·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ Ó¢ÌÔÓ›·˜.
¶·È‰È·ÙÚÈ΋ 2001;64:361-364
Paediatriki 2001;64:361-364
¶›Ó·Î·˜ 1. ∞ÈÙÈÔÏÔÁÈ΋ ηٿٷÍË ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ Ó¢ÌÔÓ›·˜ Ì ‚¿ÛË ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÚÔÛ‚·ÏÏfiÌÂÓˆÓ ÏÔ‚ÒÓ. ¶ÚÔÛ‚ÔÏ‹ ¤ÓÔ˜ ÏÔ‚Ô‡
¶ÚÔÛ‚ÔÏ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÏÔ‚ÒÓ
∞. ∂Ó‰Ô‚ÚÔÁ¯È΋ ·fiÊÚ·ÍË ñ •¤ÓÔ ÛÒÌ· ñ µÚÔÁ¯ÈÎfi ·‰¤ÓˆÌ· ñ µÚÔÁ¯ÈÎfi Ï›ˆÌ·
∞. ™‡Ó‰ÚÔÌ· ÂÈÛÚfiÊËÛ˘ ñ °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ñ ∆Ú·¯ÂÈÔ-ÔÈÛÔÊ·ÁÈÎfi Û˘ÚÚ›ÁÁÈÔ ñ ¢È·Ù·Ú·¯¤˜ ηٿÔÛ˘
µ. ∂͈‚ÚÔÁ¯È΋ ·fiÊÚ·ÍË
µ. ∫Ú›ÛÂȘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜
°. ™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ñ ∆Ú·¯ÂÈ·Îfi˜ ‚ÚfiÁ¯Ô˜ ñ ™Ù¤ÓˆÛË - ·ÙÚËÛ›· ‚ÚfiÁ¯Ô˘ ñ µÚÔÁ¯ÈÂÎٷۛ˜ ñ ÀÔÏ·Û›· - ∞Ï·Û›· ÏÔ‚Ô‡ ñ ¶Ó¢ÌÔÓÈÎfi ·fiÏÏ˘Ì· ñ ™˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ·
°. ∞ÓÔÛÔ·Ó¿ÚÎÂȘ ñ ∂›ÎÙËÙ˜: ∞ÓÔÛÔηٷÛÙ·ÏÙÈο ñ ™˘ÁÁÂÓ›˜: ∫˘Ù·ÚÈΤ˜, ¯˘ÌÈΤ˜ ¢. ¢˘ÛÎÈÓËÛ›· ÎÚÔÛÛÒÓ ñ Kartagener (ÚˆÙÔ·ı‹˜) ñ K˘ÛÙÈ΋ ›ÓˆÛË (‰Â˘ÙÂÚÔ·ı‹˜) ∂. ™˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ· ™∆. ¶Ó¢ÌÔÓÈ΋ ·ÈÌÔÛȉ‹ÚˆÛË
∂ÈÎfiÓ· 2. ∂ÎÙÂÙ·Ì̤Ó˜ ‚ÚÔÁ¯ÈÂÎٷۛ˜ Û ·È‰› Ì ΢ÛÙÈ΋ ›ÓˆÛË. ∞Ó Î·È Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ ‰ÂÍÈ¿, ˘ÔÛËÌ·›ÓÔÓÙ·È Î·È ÛÙÔÓ ·ÚÈÛÙÂÚfi Ó‡ÌÔÓ·.
ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ Ì˘ÒÓ Ù˘ ηٿÔÛ˘, Ë ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ· Î·È Ë Ù˘¯fiÓ ‡·ÚÍË ·ıÔÏÔÁÈÎÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ (˘ÁÚÔ›/ÍËÚÔ› ÚfiÁ¯ÔÈ). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·Ú¯›˙ÂÈ Ì ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ∏ Ï·Á›· ·ÎÙÈÓÔÁÚ·Ê›· Â›Ó·È Û˘¯Ó¿ ·Ó·Áη›·, ȉ›ˆ˜ fiÙ·Ó ˘¿Ú¯ÂÈ ˘fiÓÔÈ· ÔÈÛıÔηډȷ΋˜ ‡ÎÓˆÛ˘. ™ÙË Û˘Ó¤¯ÂÈ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÚ›ÙˆÛË, ı· ÚÔ¯ˆÚ‹ÛÔ˘Ì Û ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ù˘¤ÏˆÓ, ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux, ÚÔÛ‰ÈÔÚÈÛÌfi ¯ÏˆÚÈÔ‡¯ˆÓ ÙÔ˘ ȉÚÒÙ·, ·Ó·˙‹ÙËÛË ÛȉËÚÔÊ¿ÁˆÓ ÛÙÔ Á·ÛÙÚÈÎfi ˘ÁÚfi, ¤ÏÂÁ¯Ô ÙÔ˘ ÎÚÔÛÛˆÙÔ‡ ÂÈıËÏ›Ô˘, ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ¯·ÌÂÙÚ›· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ‚·ÚÈÔ‡¯Ô Á‡̷, ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ϋ„Ë ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜, ÛÈÓıËÚÔÁÚ¿ÊËÌ· ·ÂÚÈÛÌÔ‡-·ÈÌ¿ÙˆÛ˘ (∂ÈÎfiÓ· 3) ‹ Î·È Û ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (΢ڛˆ˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ‚ÚÔÁ¯ÈÂÎÙ·-
∂ÈÎfiÓ· 3. ™ÈÓıËÚÔÁÚ¿ÊËÌ· ·ÈÌ·ÙÒÛˆ˜ Û ·È‰› ÌÂ Û˘ÁÁÂÓ¤˜ ÏԂ҉˜ ÂÌʇÛËÌ· ·ÚÈÛÙÂÚ¿. º·›ÓÂÙ·È Î·ı·Ú¿ Ë ·Ô˘Û›· ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ οو ÏÔ‚Ô‡.
ÛÈÒÓ ‹ ·Ó ˘¿Ú¯ÂÈ ˘fiÓÔÈ· ‡·Ú͢ fiÁÎÔ˘ ÛÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ). ∆¤ÏÔ˜, Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ηٷʇÁÔ˘Ì ÛÙËÓ ·ÓÔÈÎÙ‹ ‚ÈÔ„›· ÙÔ˘ Ó‡ÌÔÓ· (‰È¿ÌÂÛ˜ Ó¢ÌÔÓÔ¿ıÂȘ, ÂÓ‰ÔÓ¢ÌÔÓÈÎÔ› fiÁÎÔÈ). ∞ÓÙÈÌÂÙÒÈÛË ∏ ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙȘ À¶ Ú¤ÂÈ Ó· Â›Ó·È ¿ÓÙ· ·ÈÙÈÔÏÔÁÈ΋ Î·È Ó· ÌËÓ ÂÚÈÔÚ›˙ÂÙ·È ÛÙËÓ ÂÌÂÈÚÈ΋ ÂÓ·ÏÏ·Á‹ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ∞˘Ùfi ÈÛ¯‡ÂÈ È‰È·›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ, fiÔ˘ Ë ·Ó·˙‹ÙËÛË Û¿ÓÈˆÓ ·ıÔÁfiÓˆÓ (.¯. pneumocystis carinii, Aspergillus, Candida Î.¿.) ·ÔÙÂÏ› ÚÔ¸fiıÂÛË ÁÈ· ÙË ¯ÔÚ‹ÁËÛË Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜. ∂›Û˘, Ë Î·Ù¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘
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(Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·ÓÔÛÔ·Ó¿ÚÎÂÈ·, ΢ÛÙÈ΋ ›ÓˆÛË Î.¿.) ÂÚÈÔÚ›˙ÂÈ ÛËÌ·ÓÙÈο ÙÔÓ ·ÚÈıÌfi ÙˆÓ ˘ÔÙÚÔÒÓ. ™Â ¿ÏϘ ÂÚÈÙÒÛÂȘ, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Ù˘ ‚Ï¿‚˘ (Ó¢ÌÔÓÈÎfi ·fiÏ˘Ì·, ÂÎÙÂÙ·Ì̤Ó˜ ‚ÚÔÁ¯ÈÂÎٷۛ˜, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘ÚÚ›ÁÁÈÔ) χÓÂÈ ÙÔ Úfi‚ÏËÌ·. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ Ó¢ÌÔÓÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Â›Ó·È ¿ÓÙ· Ì›· ‰‡ÛÎÔÏË ·fiÊ·ÛË, Ô˘ ÁÈ· ÙË Ï‹„Ë Ù˘ ··ÈÙÂ›Ù·È ·ÍÈÔÏfiÁËÛË ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ. O “¯ÚfiÓÔ˜” Â›Ó·È Û˘Ó‹ıˆ˜ Ô Î·Ï‡ÙÂÚÔ˜ Û‡Ì‚Ô˘ÏÔ˜ ÁÈ· ÙË Ï‹„Ë Ì›·˜ Ù¤ÙÔÈ·˜ ·fiÊ·Û˘. OÈ À¶ ı· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÛÙËÓ ·Ú¯‹ Û˘ÓÙËÚËÙÈο, ÌÂ Û˘Ó‰˘·ÛÌfi Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ Î·È ¤ÓÙÔÓË Ê˘ÛÈÔıÂڷ›· ÁÈ· ·ÚÎÂÙfi ¯ÚfiÓÔ. ªÂ ÙËÓ Ù·ÎÙÈ΋ ·˘Ù‹, Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ, Ô ·ÛıÂÓ‹˜ ·Ó·Ù‡ÛÛÂÙ·È Ê˘ÛÈÔÏÔÁÈο Î·È ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÔÙÚÔ¤˜ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·. ∞ÓÙ›ıÂÙ·, ÛÙȘ ÂÚÈÙÒÛÂȘ Û˘¯ÓÒÓ ˘ÔÙÚÔÒÓ, Ì ÂÈ‚Ú¿‰˘ÓÛË ‹ ÛÙ·ÛÈÌfiÙËÙ· Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ÛÙ·‰È·Î‹ Âȉ›ӈÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜ ·ÔÙÂÏ› ÙË ÌfiÓË ÂӉ‰ÂÈÁ̤ÓË Ï‡ÛË.
Paediatriki 2001;64:361-364
3. April M, Marsh B. Recurrent or persistent pneumonias. In: Loughlin G, Eigen H, eds. Respiratory disease in children. Baltimore: Williams and Wilkins; 1994. p. 338-360. 4. Brown M, Lemen R. Bronchiectasis. In: Chernick V, Boat T, eds. Disorders of the respiratory tract in children. 6th ed. Philadelphia: Saunders Co; 1998. p. 538-552. 5. Swischuk LE, John SD. Differential diagnosis in paediatric radiology. 2nd ed. Baltimore: Williams and Wilkins; 1995. p. 157-163. 6. Malfroot A, Vandenplas Y, Verlinden M, Piepsz A, Dab I. Gastroesophageal reflux and unexplained chronic respiratory disease in infants and children. Pediatr Pulm1987;3:208-213. 7. Denning DW, Stevens DA. Antifungal and surgical treatment of invasive aspergillosis: review of 2121 published cases. Rev Infect Dis 1990;12:1147-1201. 8. Stigers KB, Woodring JH, Kanga JF. The clinical and imaging spectrum of findings in patients with congenital lobar emphysema. Pediatr Pulm 1992;14:160-170. 9. Gotz M, Ponhold W. Pneumonia in children. In: Torres A, Woodhead M, editors. Pneumonia. European Respiratory Monograph; 1997. p. 226-259.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Regelmann WE. Diagnosing the cause of recurrent and persistent pneumonia in children. Pediatr Ann 1993;22:561-568. 2. Wald ER. Recurrent pneumonia in children. Adv Pediatr Infect Dis 1990;5:183-203.
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DEVELOPMENTAL PEDIATRICS
∞Ó·Ù˘Íȷ΋ ÂͤÏÈÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘: ∫Ú›ÛÈ̘ ËÏÈ˘ ÁÈ· Ì¿ıËÛË §. £ˆÌ·˝‰Ô˘
Brain development: Critical learning periods L. Thomaidou
¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Û‡ÏÏË„Ë. ™ÙËÓ ËÏÈΛ· ÙˆÓ 3 ¯ÚfiÓˆÓ Ô ÂÁΤʷÏÔ˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÚȤ¯ÂÈ 100 ‰ÈÛÂηÙÔÌ̇ÚÈ· ·ÙÙ·Ú·, Ù· ÔÔ›· Û˘Ó‰¤ÔÓÙ·È ÌÂٷ͇ ÙÔ˘˜ Ì 1000 ÙÚÈÛÂηÙÔÌ̇ÚÈ· Û˘Ó¿„ÂȘ. ∏ ·Ú·‰ÔÛȷ΋ ¿Ô„Ë fiÙÈ Ë ‰È·ÌfiÚʈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÂÍ·ÚÙ¿Ù·È ·ÔÎÏÂÈÛÙÈο ·fi ÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ·Ú¯›˙ÂÈ Ó· ·ÌÊÈÛ‚ËÙÂ›Ù·È ·fi Û‡Á¯ÚÔÓ˜ ¤Ú¢Ó˜, Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ù· ÂÚÂı›ÛÌ·Ù· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 3 ÚÒÙˆÓ ¯ÚfiÓˆÓ Ù˘ ˙ˆ‹˜ Ú˘ıÌ›˙Ô˘Ó Û ΢ÙÙ·ÚÈÎfi Î·È ¯ËÌÈÎfi Â›Â‰Ô ÙË ‰ËÌÈÔ˘ÚÁ›· Ó¢ÚÈÎÒÓ Û˘Ó¿„ˆÓ. ∆· 3 ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Â›Ó·È ÎÚ›ÛÈÌ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ˆÚ›Ì·ÓÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ¶ÚÒÈÌË ÂÎ·È‰Â˘ÙÈ΋ ·Ú¤Ì‚·ÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘˜ Ê·›ÓÂÙ·È fiÙÈ ÚÔ¿ÁÂÈ ÛËÌ·ÓÙÈο ÙȘ ÁÓˆÛÙÈΤ˜, ÁψÛÛÈΤ˜ Î·È ÎÈÓËÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ȉȷ›ÙÂÚ· Û ·È‰È¿ Ì ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜.
Abstract: Brain development starts soon after conception and by the age of 3 years the brain is crisscrossed by more than 100 billion neurons, each of which connects to thousand others, so that it has more than 100 trillion connections. During the first three critical years of life the infant’s brain is a work in progress with trillions of neurons waiting to be wired into a mind. The traditional view that brain maturation is predetermined exclusively by genetic factors is now being challenged by new evidence indicating the crucial role of the environment in regulating, on a cellular and chemical basis, the development of neuronal synapses. The first three years of life are critical for the development and maturation of the brain. Intesive early education during the critical period of brain development enchances cognitive, language, social and motor skills, especially in children with developmental delay and disabilities.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô˜ Ì¿ıËÛ˘, ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜.
Key words: brain development, critical learning period, developmental disabilities.
∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ·ÎfiÌË Î·È Û‹ÌÂÚ·, ·Ú¿ ÙË Ú·Á‰·›· ÂͤÏÈÍË Ù˘ Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·˜, ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÚÈÛÙ¿ Ì›· ÔχÏÔÎË ‰È·‰Èηۛ· Ô˘ ·Ú·Ì¤ÓÂÈ Û ÔÏÏ¿ ÛËÌ›· ·ÓÂÍÂÚ‡ÓËÙË. ¶Ú¿ÁÌ·ÙÈ, ηıÒ˜ ·Ú¯›˙ÂÈ Ë Ó¤· ¯ÈÏÈÂÙ›·, ÙÔ ÂÚÒÙËÌ· Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÎÔÚ˘Ê‹ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ù˘ È·ÙÚÈ΋˜ ¤Ú¢ӷ˜ Â›Ó·È “Ì ÔÈÔ ÙÚfiÔ ‰ËÌÈÔ˘ÚÁÂ›Ù·È Ô ÂÁΤʷÏÔ˜ Î·È Ò˜ ·˘Ùfi ÙÔ fiÚÁ·ÓÔ ‰ËÌÈÔ˘ÚÁ› ÙÔ “ÓÔ˘”. O fiÚÔ˜ “ÓÔ˘˜” ÂÚÈÏ·Ì‚¿ÓÂÈ ÂΛÓÔ ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Û‡ÛÙËÌ· Ô˘ Ï·Ì‚¿ÓÂÈ, ·ÔıË·ÂÈ, ·Ó·Î·Ï›, ÌÂÙ·Û¯ËÌ·Ù›˙ÂÈ
Î·È ÌÂÙ·‰›‰ÂÈ ÏËÚÔÊÔڛ˜, ·ÏÏ¿ Î·È ‰ËÌÈÔ˘ÚÁ› Ӥ˜. º·›ÓÂÙ·È, ÁÈ· Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ì ۇÁ¯ÚÔÓÔ˘˜ fiÚÔ˘˜, fiÙÈ Ë Ù¯ÓÔÏÔÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÙfiÛÔ ÔχÏÔÎË ÎÈ ÂÍÂÏÈÁ̤ÓË ÒÛÙ ӷ ‰Â›¯ÓÂÈ Ì·ÁÈ΋. ∞˘Ù‹, fï˜, Ë Ì·ÁÈ΋ Ù¯ÓÔÏÔÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È Ù·˘Ùfi¯ÚÔÓ· Î·È È‰È·›ÙÂÚ· ¢¿ÏˆÙË Û ϋıÔ˜ ‚Ï·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚÔ‡Ó Ó· ‰È·Ù·Ú¿ÍÔ˘Ó ÙËÓ ·Ó¿Ù˘Í‹ Ù˘ Û ÔÔÈÔ‰‹ÔÙ ÛÙ¿‰ÈÔ ÂͤÏÈ͢. °È· ·Ú¿‰ÂÈÁÌ·, ¤Ó· ̈Úfi Ô˘ ÁÂÓÓÈ¤Ù·È Ì ‰È·Ù·Ú·¯‹ ÛÙË ‰ÔÌ‹, ÛÙ· ·ÙÙ·Ú· ‹ ÛÙȘ Û˘Ó‰¤ÛÂȘ
¶·È‰›·ÙÚÔ˜-∞Ó·Ù˘ÍÈÔÏfiÁÔ˜ À‡ı˘ÓË π·ÙÚ›Ԣ ∞Ó·Ù˘Íȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ
Pediatrician - Developmentalist Director of Developmental Pediatrics A’ Pediatric Clinic of the University of Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:365-369
ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘, ¤Ú¯ÂÙ·È ‰ËÏ·‰‹ ÛÙÔÓ ÎfiÛÌÔ Ì ÂÏ·Ùو̷ÙÈÎfi ÂÁÎÂÊ·ÏÈÎfi ÂÍÔÏÈÛÌfi, Â›Ó·È ¤Ó· ̈Úfi ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ó· ÂÌÊ·Ó›ÛÂÈ ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, ›Ù ÎÈÓËÙÈ΋, ›Ù ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ∂›Û˘, ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ̈Úfi Â›Ó·È Î·È ÂΛÓÔ Ô˘ ÂÓÒ ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÂÍÔÏÈÛÌfi, ÁÈ· οÔÈÔ ÏfiÁÔ ·ÓÂÎfiË Ë ·Ó·ÌÂÓfiÌÂÓË Ê˘ÛÈÔÏÔÁÈ΋ ÂͤÏÈÍ‹ ÙÔ˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÎÈÓ‰˘Ó‡ÂÈ Î·È ·˘Ùfi Ó· ÂÌÊ·Ó›ÛÂÈ ·ÚfiÌÔȘ ‹ ·ÎfiÌË ‚·Ú‡ÙÂÚ˜ ‰È·Ù·Ú·¯¤˜. ∏ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ı¤Ì·ÙÔ˜ Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ Ó¤ˆÓ ÁÓÒÛÂˆÓ ·fi ·˘ÙfiÓ, ı· Á›ÓÂÈ Ì ‚¿ÛË ÙȘ ‰È·‰Èηۛ˜ ÂΛӘ Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÙÚ¤„Ô˘Ó ÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ, Û ÂÁΤʷÏÔ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÁÓˆÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÁÂÓÂÙÈο ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË Î·È ÂÈÙÂÏÂ›Ù·È ÌÂ Û˘ÁÎÂÎÚÈ̤ÓÔ Ú˘ıÌfi Î·È Û ‰È·‰Ô¯Èο ÛÙ¿‰È·. ∏ ÌÂϤÙË ÙˆÓ ‰È·‰Ô¯ÈÎÒÓ ·˘ÙÒÓ ÛÙ·‰›ˆÓ Ì¿˜ ‚ÔËı¿ Ó· ηٷÓÔ‹ÛÔ˘Ì ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Î·È ·Ú¿ÏÏËÏ· Ó· ‚Úԇ̠ÙÚfiÔ˘˜ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘˜. ∞˜ ‰Ô‡ÌÂ, ÏÔÈfiÓ, Ò˜ ‰È·ÌÔÚÊÒÓÂÙ·È ÛÙ·‰È·Î¿ Ë Â͈ÙÂÚÈ΋ ‰ÔÌ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∆ËÓ 3Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë ¤¯ÂÈ ‹‰Ë Û¯ËÌ·ÙÈÛÙ› Ô Ó¢ÚÈÎfi˜ ۈϋӷ˜. §›ÁÔ ·ÚÁfiÙÂÚ·, ÙËÓ 4Ë Â‚‰ÔÌ¿‰·, Á‡Úˆ ·fi ·˘ÙfiÓ ·Ú¯›˙Ô˘Ó Ó· ·Ó·‰‡ÔÓÙ·È ˘fi ÌÔÚÊ‹ ΢ÎÏÔÙÂÚÒÓ Û¯ËÌ·ÙÈÛÌÒÓ Ù· ‰È¿ÊÔÚ· ÙÌ‹Ì·Ù· ÙÔ˘ ∫¡™ Î·È ÙËÓ 7Ë Â‚‰ÔÌ¿‰· ‰È·ÎÚ›ÓÂÙ·È Ô ÂÁÎÂÊ·ÏÈÎfi˜ Û¯ËÌ·ÙÈÛÌfi˜ Î·È Ë ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË. ∆Ë 10Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰·, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Â›Ó·È Ôχ ÌÈÎÚfi ·ÎfiÌË, ˙˘Á›˙ÂÈ 30 gr Î·È ¤¯ÂÈ Ì‹ÎÔ˜ 15 mm, Ô ÂÁΤʷÏfi˜ ÙÔ˘ ¤¯ÂÈ ‰ÔÌÈο ‰È·ÊÔÚÔÔÈËı› ÛÙ· ‚·ÛÈο ÙÌ‹Ì·Ù· Ô˘ ÙÔÓ ·ÔÙÂÏÔ‡Ó, ÂÓÒ ÙË 12Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰· ‰È·ÎÚ›ÓÔÓÙ·È Î·Ï¿ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· Î·È Ë ·ÚÂÁÎÂÊ·Ï›‰·. ∫¿ı ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÈÌÔ˘ ·˘ÙÔ‡ ÛÙ·‰›Ô˘ Ô˘ Û˘Ì›ÙÂÈ Ú·ÎÙÈο Ì ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, ›Ù ÚÔÎÏËı› ·fi ÁÂÓÂÙÈο, ›Ù Ì˯·ÓÈο ›Ù ÙÔÍÈο ·›ÙÈ·, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú¤˜ ·Ó·ÙÔÌÈΤ˜ ‰˘ÛϷۛ˜ ÛÙÔ ÌˆÚfi, fiˆ˜ ·ÓÂÁÎÂÊ·Ï›·, ‰˘ÛÚ·ÊÈÛÌfi, ‰Èۯȉ‹ Ú¿¯Ë. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 2Ô˘ ÙÚÈÌ‹ÓÔ˘ Ù˘ ·ËÛ˘, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ·˘Í¿ÓÂÈ Ì ÁÚ‹ÁÔÚÔ Ú˘ıÌfi. ∆Ô Î‡ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ·˘Ù‹˜ Ù˘ Ê¿Û˘ Â›Ó·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ËÌÈÛÊ·ÈÚ›ˆÓ, Ë Â͈ÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÔÔ›ˆÓ ·Ú·Ì¤ÓÂÈ ·ÎfiÌ· Ï›· Î·È Â›Â‰Ë, Û ·ÓÙ›ıÂÛË ÌÂ
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Paediatriki 2001;64:365-369
ÙÔ 3Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÏÈÎÒÛÂˆÓ ÛÙËÓ Â͈ÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∆ÒÚ· ‰È·ÌÔÚÊÒÓÂÙ·È Ë ÊÏÔÈ҉˘ ÌÔ›Ú·, Ô ÊÏÔÈfi˜, Ô˘ Â›Ó·È ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙȘ ·ÓÒÙÂÚ˜ ÓÂ˘Ì·ÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ·ÓıÚÒÔ˘. ∏ ÂÚ›Ù¯ÓË ‰È·ÌfiÚʈÛË ÙÔ˘ ÊÏÔÈÔ‡ Ì ÙȘ ÂÏÈÎÒÛÂȘ, ÙȘ ·‡Ï·Î˜ Î·È ÙȘ Û¯ÈṲ̂˜ Û˘ÓÙÂÏÂ›Ù·È ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 2 Ì‹Ó˜ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜. ¶ÈÔ ÔχÏÔΘ fï˜ Î·È ÂÓÙ˘ˆÛȷΤ˜ Â›Ó·È ÔÈ ‰ÈÂÚÁ·Û›Â˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô Û ΢ÙÙ·ÚÈÎfi ›‰Ô. ∞˜ ‰Ô‡Ì ÏÔÈfiÓ, ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙ· Ó¢ÚÈο ·ÙÙ·Ú· ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ·. ∆· ·ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Â›Ó·È Ô ÔÏÏ·Ï·ÛÈ·ÛÌfi˜, Ë ÌÂÙ·Ó¿ÛÙ¢ÛË, Ë ‰È·ÊÔÚÔÔ›ËÛË, Ë ·Ó¿Ù˘ÍË ‰ÂÓ‰ÚÈÙÈÎÒÓ Û˘Ó¿„ÂˆÓ Î·È Ë Ì˘ÂϛӈÛË. OÈ ‰ÈÂÚÁ·Û›Â˜ ·˘Ù¤˜ ηÙ¢ı‡ÓÔÓÙ·È ·fi ÂÓ‰ÔÁÂÓ›˜ Ì˯·ÓÈÛÌÔ‡˜ Î·È Â›Ó·È Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ÁÂÓÂÙÈο ηıÔÚÈṲ̂Ó˜. º·›ÓÂÙ·È fiÙÈ ·ÎÔÏÔ˘ıÔ‡Ó Û˘ÁÎÂÎÚÈ̤ÓË ÛÂÈÚ¿ Î·È Î¿ı ̛· ·fi ·˘Ù¤˜ ÂÌÊ·Ó›˙ÂÈ ÙË Ì¤ÁÈÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ¿ Ù˘ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô. ŒÙÛÈ, Ô ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÍÂÎÈÓ¿ÂÈ ·fi ÙËÓ ·Ú¯‹ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, Á›ÓÂÙ·È fï˜ ȉȷ›ÙÂÚ· ¤ÓÙÔÓÔ˜ ÌÂٷ͇ Ù˘ 6˘ Î·È 20˘ ÂÌ‚Ú˘˚΋˜ ‚‰ÔÌ¿‰·˜. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ÔÈ Ó¢ÚÒÓ˜ ·Ó·Ù‡ÛÛÔÓÙ·È Ì ڢıÌfi 250.000 ΢ÙÙ¿ÚˆÓ ·Ó¿ ÒÚ·. ∆· ÌÈÛ¿ ÂÚ›Ô˘ ·fi Ù· ·ÙÙ·Ú· Ô˘ ·Ú¿ÁÔÓÙ·È Âı·›ÓÔ˘Ó ÚÈÓ ·fi ÙË Á¤ÓÓËÛË. £ÂˆÚÂ›Ù·È fiÙÈ Ô ı¿Ó·ÙÔ˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ··ÏÏ¿ÛÛÂÈ ÙÔÓ ÂÁΤʷÏÔ ·fi ÂÏ·Ùو̷ÙÈο ·ÙÙ·Ú·. ªÂÙ¿ ÙËÓ 20Ë Â‚‰ÔÌ¿‰·, Ô ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÂÏ·ÙÙÒÓÂÙ·È ÁÈ· Ó· ÔÏÔÎÏËÚˆı› ÚÈÓ ·fi ÙË Á¤ÓÓËÛË. ∫·Ù¿ ÙË Á¤ÓÓËÛË, ¿ÓÙˆ˜, Ô ÂÁΤʷÏÔ˜ ÂÌÂÚȤ¯ÂÈ ÙÔ Û‡ÓÔÏÔ ÙˆÓ Ó¢ÚÒÓˆÓ Ô˘ ı· ÙÔÓ ·ÔÙÂÏÔ‡Ó. O ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ô˘ Â›Ó·È È‰È·›ÙÂÚ· ¤ÓÙÔÓË ÌÂٷ͇ Ù˘ 12˘ Î·È 24˘ ‚‰ÔÌ¿‰·˜ Ù˘ ÂÌ‚Ú˘˚΋˜ ˙ˆ‹˜. ∆· ÔÏÏ·Ï·ÛÈ·˙fiÌÂÓ·, ‰ËÏ·‰‹, ·ÙÙ·Ú· ·Ú¯›˙Ô˘Ó Î·Ù¿ ÔÌ¿‰Â˜ Ó· ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó Û ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ fiÔ˘ ı· ·Ó·Ï¿‚Ô˘Ó Î·È ‰È·ÊÔÚÂÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ë ·Ó¿Ù˘ÍË ‰ÂÓ‰ÚÈÙÈÎÒÓ Û˘Ó¿„ÂˆÓ Î·È Ë Ì˘ÂϛӈÛË Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó, Â›Ó·È È‰È·›ÙÂÚ· ¤ÓÙÔÓ˜ ·fi ÙËÓ 24Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰· ¤ˆ˜ ÙÔÓ 3Ô ¯ÚfiÓÔ Ù˘ Â͈̋ÙÚÈ·˜ ˙ˆ‹˜. ∏ ΢ÙÙ·ÚÈ΋ ÌÂÙ·Ó¿ÛÙ¢ÛË ·˘ÙÔÚ˘ıÌ›˙ÂÙ·È ·fi ÂÓ‰ÔÁÂÓ›˜ ÁÂÓÂÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ∆· ·ÙÙ·Ú· Ô˘ ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ·Ú¿ÁÔ˘Ó ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙÔ˘˜ ÂȉÈΤ˜ ÚˆÙ½Ó˜. OÈ ÚˆÙ½Ó˜ ·˘Ù¤˜ ÌÂٷʤÚÔ˘Ó ÁÂÓÂÙÈο ÌËӇ̷ٷ Ô˘ ηıÔ‰ËÁÔ‡Ó
¶·È‰È·ÙÚÈ΋ 2001;64:365-369
ÙË ÌÂٷΛÓËÛË Î·È ÂÁηٿÛÙ·ÛË ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙÔÓ ÙÂÏÈÎfi ÙÔ˘˜ ÚÔÔÚÈÛÌfi. ∆·˘Ùfi¯ÚÔÓ·, ÔÈ ÚˆÙ½Ó˜ ·˘Ù¤˜ Έ‰ÈÎÔÔÈÔ‡Ó ÁÂÓÂÙÈΤ˜ ÏËÚÔÊÔڛ˜ Ô˘ ηıÔÚ›˙Ô˘Ó Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· Ô˘ ı· ·Ó·Ï¿‚Ô˘Ó Ù· ÌÂÙ·Ó·ÛÙ‡ÔÓÙ· ·ÙÙ·Ú· ÛÙÔÓ ÚÔÔÚÈÛÌfi ÙÔ˘˜. ¶ÔÈ·, ‰ËÏ·‰‹, ·ÙÙ·Ú· ı· ‰È·ÊÔÚÔÔÈËıÔ‡Ó Û ÔÙÈο, ÔÈ· Û ·ÎÔ˘ÛÙÈο, ÔÈ· Û ÎÈÓËÙÈο Î.Ô.Î. OÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÌÂÙ·Ó¿ÛÙ¢Û˘ Î·È ‰È·ÊÔÚÔÔ›ËÛ˘ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÚÔηÏÔ‡Ó ÛÔ‚·Ú‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛÙÔÓ ÂÁΤʷÏÔ. ∂Âȉ‹, fï˜, Û˘Ì‚·›ÓÔ˘Ó Û ΢ÙÙ·ÚÈÎfi Â›Â‰Ô Î·È Û˘¯Ó¿ ·ÊÔÚÔ‡Ó ÌÈÎÚfi ·ÚÈıÌfi ΢ÙÙ¿ÚˆÓ, ‰ÂÓ Â›Ó·È ¿ÓÙ· ÔÚ·Ù¤˜ ÛÙÔ Û˘Ó‹ıË ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ì ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·. ŒÙÛÈ ÂÚÌËÓ‡ÂÙ·È Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, fiˆ˜ Û ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ‹ ‰È·Ù·Ú·¯‹ ÏfiÁÔ˘, ÂÓÒ ÎÏÈÓÈο ¤¯Ô˘Ì ÛÔ‚·Ú‹ ÌÂÈÔÓÂÍ›·, ‰ÂÓ ÌÔÚԇ̠ӷ ·ÂÈÎÔÓ›ÛÔ˘Ì ÙË ‚Ï¿‚Ë. ∏ ‚Ï¿‚Ë ˘¿Ú¯ÂÈ, ·ÏÏ¿ ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· ·ÙÙ·Ú· Î·È ‰ÂÓ ÌÂÙ·‚¿ÏÏÂÈ ÙË ‰ÔÌ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ŸÙ·Ó Ù· Ó¢ÚÈο ·ÙÙ·Ú· ÊÙ¿ÛÔ˘Ó ÛÙÔÓ ÙÂÏÈÎfi ÚÔÔÚÈÛÌfi ÙÔ˘˜, ·Ú¯›˙Ô˘Ó Ó· Â΂ϷÛÙ¿ÓÔ˘Ó Á‡Úˆ ·fi ÙÔ ÛÒÌ· ÙÔ˘˜ ÔÏϤ˜ ·ÔÊ˘¿‰Â˜, ÙÔ˘˜ ‰ÂÓ‰Ú›Ù˜, ̤ۈ ÙˆÓ ÔÔ›ˆÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë Û‡Ó‰ÂÛ‹ ÙÔ˘˜ Ì ¿ÏÏ· ·ÙÙ·Ú·. OÈ Û˘Ó‰¤ÛÂȘ ÌÂٷ͇ ÙÔ˘˜ Á›ÓÔÓÙ·È ÛÙ· Û˘Ó·ÙÈο ¿ÎÚ· ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ Î·È ÙˆÓ ·ÍfiÓˆÓ Ì ÙË ‚Ô‹ıÂÈ· ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ, ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ. O ·ÚÈıÌfi˜ ÙˆÓ Û˘Ó¿„ÂˆÓ Ô˘ ‰¤¯ÂÙ·È ÙÔ Î¿ı Ó¢ÚÈÎfi ·ÙÙ·ÚÔ ÔÈΛÏÏÂÈ. ŸÛÔ ÈÔ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÏÂÈÙÔ˘ÚÁ›· ÂÈÙÂÏ›, ÙfiÛÔ ÂÚÈÛÛfiÙÂÚ˜ Û˘Ó¿„ÂȘ ‰¤¯ÂÙ·È. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ Î¿ı ·ÙÙ·ÚÔ Pur kinje ‰¤¯ÂÙ·È 800 Û˘Ó¿„ÂȘ, οı ·ÙÙ·ÚÔ ÙÔ˘ ÔÙÈÎÔ‡ ÊÏÔÈÔ‡ 13.000 Û˘Ó¿„ÂȘ Î·È Î¿ı ·ÙÙ·ÚÔ ÙÔ˘ ÚÔÌÂوȷ›Ô˘ ÊÏÔÈÔ‡ ÌÔÚ› Ó· ‰Â¯ı› 24.000 Û˘Ó¿„ÂȘ. ™ÙËÓ ÙÂÏÈ΋ ÙÔ˘ ‰È·ÌfiÚʈÛË, Ô ·ÓıÚÒÈÓÔ˜ ÂÁΤʷÏÔ˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÚȤ¯ÂÈ 100 ‰ÈÛÂηÙÔÌ̇ÚÈ· ·ÙÙ·Ú·, ·fi Ù· ÔÔ›· ı· ¤¯Ô˘Ó Ê˘ÙÚÒÛÂÈ 1000 ÙÚÈÛÂηÙÔÌ̇ÚÈ· Û˘Ó¿„ÂȘ ̤¯ÚÈ ÙÔÓ 3Ô ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ Ô ÂÁΤʷÏÔ˜ ÂÓfi˜ ·È‰ÈÔ‡ 3 ÂÙÒÓ Î·Ù·Ó·ÏÒÓÂÈ ‰ÈÏ¿ÛÈ· ÂÓ¤ÚÁÂÈ· Û ۯ¤ÛË Ì ÂΛÓÔÓ ÙÔ˘ ÂÓ‹ÏÈη. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÙfiÛÔ Ë ‰ËÌÈÔ˘ÚÁ›· Û˘Ó¿„ÂˆÓ ÌÂٷ͇ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ fiÛÔ Î·È Ë Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ ·fi ÙÔÓ ÂÁΤʷÏÔ Â›Ó·È È‰È·›ÙÂÚ· ¤ÓÙÔÓ˜ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, Ô˘ ‰Èη›ˆ˜ ıˆÚÔ‡ÓÙ·È ÎÚ›ÛÈÌ· ¯ÚfiÓÈ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ ¿Ô„Ë ·˘Ù‹ ÂÓÈÛ¯‡ÂÙ·È Î·È ·fi ÚfiÛÊ·Ù˜ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ Û ˙Ò·, Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó
Paediatriki 2001;64:365-369
fiÙÈ Ô ÂÁΤʷÏÔ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·Ú¿ÁÂÈ Ôχ ÂÚÈÛÛfiÙÂÚ· Ó¢ÚÈο ·ÙÙ·Ú· ·fi ·˘Ù¿ Ô˘ ÙÂÏÈο ı· ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ Î·È ·ÎÔÏÔ‡ıˆ˜ ·‰Ú·ÓÔÔÈ› ‹ ηٷÛÙÚ¤ÊÂÈ Î¿ÔÈ· ·fi ·˘Ù¿. ∏ ‰È·‰Èηۛ· ·˘Ù‹ ÙÔ˘ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ı·Ó¿ÙÔ˘ Â›Ó·È ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓË Î·È Ï¤ÁÂÙ·È “·fiÙˆÛȘ”. ∆· Ó¢ÚÈο ·ÙÙ·Ú· Ô˘ ÂÈ‚ÈÒÓÔ˘Ó Â΂ϷÛÙ¿ÓÔ˘Ó ¿ÍÔÓ˜ Ô˘ Ù· Û˘Ó‰¤Ô˘Ó Ì ÁÂÈÙÔÓÈο ·ÙÙ·Ú·. ™ÙË Û˘Ó¤¯ÂÈ·, ÔÈ Û˘Ó‰¤ÛÂȘ ·˘Ù¤˜ ÂÓÈÛ¯‡ÔÓÙ·È Î·È ÛÙ·ıÂÚÔÔÈÔ‡ÓÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ Î·È ÙËÓ ¤ÓÙ·ÛË Ù˘ ‚ÈÔ¯ËÌÈ΋˜ ‰È¤ÁÂÚÛ˘ Ô˘ ı· ‰Â¯ıÔ‡Ó ·fi ÙÔ Î‡ÙÙ·ÚÔ. ∂¿Ó Ë ‰È¤ÁÂÚÛË Ô˘ ı· ‰Â¯ıÔ‡Ó Â›Ó·È ¤ÓÙÔÓË, ı· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ÔÏϤ˜ Ӥ˜ ‰È·Û˘Ó‰¤ÛÂȘ ÛÙ· ¿ÎÚ· ÙÔ˘˜, ÂÓÒ Â¿Ó Ë ‰È¤ÁÂÚÛË Â›Ó·È ÌÈÎÚ‹, ÔÈ ‰È·Û˘Ó‰¤ÛÂȘ ı· Â›Ó·È Ï›Á˜ Î·È Â›Ó·È Èı·Ófi Ó· ·ÙÚÔÊ‹ÛÔ˘Ó. ∆Ô ÂÚÒÙËÌ· Ô˘ Ù›ıÂÙ·È Â›Ó·È ·fi Ô‡ ÚÔ¤Ú¯ÂÙ·È Ë ‚ÈÔ¯ËÌÈ΋ ·˘Ù‹ ‰È¤ÁÂÚÛË Ô˘ ·˘Í¿ÓÂÈ ‹ ÌÂÈÒÓÂÈ ÙȘ Û˘Ó‰¤ÛÂȘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì·˜. ∞fi ÂÓ‰ÔÁÂÓ›˜ Ì˯·ÓÈÛÌÔ‡˜, ·fi Â͈ÙÂÚÈο ÂÚÂı›ÛÌ·Ù· ‹ Î·È ·fi Ù· ‰‡Ô; ∏ ·¿ÓÙËÛË Â›Ó·È ‰‡ÛÎÔÏË. °ÓˆÚ›˙Ô˘ÌÂ, fï˜, fiÙÈ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÂΉËÏÒÓÂÙ·È ÛÙÔÓ ÂÁΤʷÏÔ Ì›· ¤ÓÙÔÓË ‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙˆÓ ‰È·Û˘Ó‰¤ÛÂˆÓ ÌÂٷ͇ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ‰Ú·ÛÙËÚÈÔÔ›ËÛË ·˘Ù‹ Û˘Ì›ÙÂÈ Î·È Èı·Ófiٷٷ Û˘Ó‰¤ÂÙ·È ¿ÌÂÛ· Ì ÙÔ Ï‹ıÔ˜, ÙÔ ¯Â›Ì·ÚÚÔ ÙˆÓ ·ÈÛıËÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ô˘ ‚ÔÌ‚·Ú‰›˙Ô˘Ó ÙÔÓ ÂÁΤʷÏÔ ÌÂÙ¿ ÙË Á¤ÓÓËÛË. ∆· ÂÚÂı›ÛÌ·Ù· ·˘Ù¿ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ê·›ÓÂÙ·È fiÙÈ Ú˘ıÌ›˙Ô˘Ó Û ΢ÙÙ·ÚÈÎfi Î·È ¯ËÌÈÎfi Â›Â‰Ô ÙË ‰ÈÎÙ‡ˆÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ηıÔÚ›˙ÔÓÙ·˜ ÔȘ ‰È·Û˘Ó‰¤ÛÂȘ ı· ÂÓÈÛ¯˘ıÔ‡Ó ÙËÓ Î·Ù¿ÏÏËÏË ÛÙÈÁÌ‹ Î·È ÔȘ ı· ·ÙÚÔÊ‹ÛÔ˘Ó. O ÂÁΤʷÏÔ˜, ‰ËÏ·‰‹, ‰È·ÌÔÚÊÒÓÂÙ·È Î·È ‰ÔÌÈο ·fi ÙȘ ÚÒÙ˜ ·È‰ÈΤ˜ ÂÌÂÈڛ˜. £· ϤÁ·Ì ÌÂÙ·ÊÔÚÈο fiÙÈ Â¿Ó Ù· ÁÔÓ›‰È¿ Ì·˜ Â›Ó·È ÔÈ Ì˯·ÓÈÎÔ›, Ù· ÂÚÂı›ÛÌ·Ù· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Â›Ó·È ÔÈ ·Ú¯ÈÙ¤ÎÙÔÓ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì·˜. ∂¿Ó ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ ÙÔ˘ ·Ú¤¯ÂÈ Ù· ηٿÏÏËÏ· ÂÚÂı›ÛÌ·Ù· ÙËÓ Î·Ù¿ÏÏËÏË ÛÙÈÁÌ‹, ÔÈ Û˘Ó‰¤ÛÂȘ ·Ó¿ÌÂÛ· ÛÙ· Ó¢ÚÈο ·ÙÙ·Ú· ı· ÌÂȈıÔ‡Ó ‹ ı· ·ÙÚÔÊ‹ÛÔ˘Ó Î·È Ë ÂÁÎÂÊ·ÏÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁ›· ·ÛÊ·ÏÒ˜ ı· ˘ÔÏ›ÂÙ·È. OÈ ÂÁΤʷÏÔÈ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó Û ȉڇ̷ٷ fiÔ˘ ‰ÂÓ ÙÔ˘˜ ·Ú¤¯ÔÓÙ·È ÔÏÏ¿ ÂÚÂı›ÛÌ·Ù·, ·ÏÏ¿ ‰È·ÙÚ¤ÊÔÓÙ·È ÈηÓÔÔÈËÙÈο, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ¤¯Ô˘Ó ηٿ 30% ÌÈÎÚfiÙÂÚÔ fiÁÎÔ ·fi ÙÔ˘˜ ÂÁÎÂÊ¿ÏÔ˘˜ ·È‰ÈÒÓ Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó Ê˘ÛÈÔÏÔÁÈο. ¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ‰È·ÈÛÙÒıËÎ·Ó Î·È Û ÂÈÚ·Ì·Ùfi˙ˆ·. ¶ÔÓÙ›ÎÈ· Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó Û ÎÏÔ˘‚È¿ Ì ·È¯Ó›‰È· ‰Â›¯ÓÔ˘Ó ÔÏ˘ÏÔÎfiÙÂÚË Û˘ÌÂÚÈÊÔÚ¿ ·fi ÔÓÙ›ÎÈ· Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó Û ¿‰ÂÈ·
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¶·È‰È·ÙÚÈ΋ 2001;64:365-369
ÎÔ˘ÙÈ¿. ∏ ·Ó·ÙÔÌÈ΋ ÌÂϤÙË ÙˆÓ ÂÁÎÂÊ¿ÏˆÓ ÙÔ˘˜ Û ∏/ªÈÎÚÔÛÎfiÈÔ ‰Â›¯ÓÂÈ fiÙÈ Ù· ÚÒÙ· ¤¯Ô˘Ó 25% ÂÚÈÛÛfiÙÂÚ˜ Û˘Ó¿„ÂȘ ·Ó¿ Ó¢ÚÒÓ· Û ۯ¤ÛË Ì ٷ ‰Â‡ÙÂÚ·. ∏ ‰ËÌÈÔ˘ÚÁ›· Ó¤ˆÓ Û˘Ó‰¤ÛÂˆÓ Î·Ù¿ ÙËÓ Â͈̋ÙÚÈÔ ˙ˆ‹ ÚÔÛ‰›‰ÂÈ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ Â˘ÂÏÈÍ›· Î·È ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·. ∆· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Ô ÂÁΤʷÏÔ˜ Â›Ó·È ÙfiÛÔ Â‡Ï·ÛÙÔ˜, ÒÛÙ ‚Ú¤ÊË Ì ۷ʋ ÂÁÎÂÊ·ÏÈ΋ οΈÛË ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ÌÔÚ› Ó· ÂÍÂÏȯıÔ‡Ó Ê˘ÛÈÔÏÔÁÈο, Â¿Ó - Ì ٷ ηٿÏÏËÏ· ÂÚÂı›ÛÌ·Ù· ÂÚÈÔ¯¤˜ ÁÂÈÙÔÓÈΤ˜ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‰Ú·ÛÙËÚÈÔÔÈËıÔ‡Ó Î·È ·Ó·ÏËÚÒÛÔ˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÂÚÈÔ¯‹˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË. ∞Ó¿ÏÔÁË ·Ó·Ï‹ÚˆÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘Ì‚·›ÓÂÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. °È· οı ÂÁÎÂÊ·ÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· ˘¿Ú¯ÂÈ Ì›· ÎÚ›ÛÈÌË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô˜, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÔ›·˜ Ë Û˘ÁÎÂÎÚÈ̤ÓË ÏÂÈÙÔ˘ÚÁ›· Ì·ı·›ÓÂÙ·È ÁÚ‹ÁÔÚ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ÙÔÓ ÂÁΤʷÏÔ ‹ ·Ó·ÏËÚÒÓÂÙ·È ÈηÓÔÔÈËÙÈο Â¿Ó Â›Ó·È ÌÂÈÔÓÂÎÙÈ΋. ™Â οı ̛· ·fi ·˘Ù¤˜ ÙȘ ÎÚ›ÛÈ̘ ÂÚÈfi‰Ô˘˜ Ù· ·È‰È¿ ·ÔÎÙÔ‡Ó Ù·¯‡Ù·Ù· ÎÈÓËÙÈΤ˜, ÏÂÎÙÈΤ˜ Î·È ÓÔËÙÈΤ˜ ÂȉÂÍÈfiÙËÙ˜. OÈ ÎÚ›ÛÈ̘ ·˘Ù¤˜ ËÏÈ˘ Ì¿ıËÛ˘ ·ÚÈÛÙÔ‡Ó ·Ú¿ı˘Ú· ÁÓÒÛ˘ ÛÙÔ ¯ÚfiÓÔ Î·È ÛÙÔÓ ÂÁΤʷÏÔ Î·È Ú¤ÂÈ Ó· ·ÍÈÔÔÈÔ‡ÓÙ·È Ì ÙÔÓ Î·Ï‡ÙÂÚÔ ÙÚfiÔ. ∫Ú›ÛÈÌË ËÏÈΛ· ÁÈ· ÙËÓ Î›ÓËÛË Â›Ó·È Ë ÂÚ›Ô‰Ô˜ ·fi ÙËÓ 7Ë Â‚‰ÔÌ¿‰· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, fiÙ·Ó Û¯ËÌ·Ù›˙ÔÓÙ·È ÔÈ ÚÒÙ˜ Û˘Ó¿„ÂȘ ÙˆÓ ÎÈÓËÙÈÎÒÓ Ó¢ÚÒÓˆÓ, ¤ˆ˜ ÙÔÓ 5Ô ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, ÔfiÙ ¤¯ÂÈ Û¯Â‰fiÓ ÔÏÔÎÏËÚˆı› ÙÔ Û˘Ó·ÙÈÎfi ÎÈÓËÙÈÎfi ‰›ÎÙ˘Ô. ∂¿Ó ‰ÂÓ ‰ÔıÔ‡Ó Ù· ηٿÏÏËÏ· ÂÚÂı›ÛÌ·Ù· ÛÙÔ˘˜ Ó¢ÚÒÓ˜ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ¯ÚfiÓˆÓ (.¯. ÂÍ·ÈÙ›·˜ ¯ÚfiÓÈ·˜ ·ÎÈÓËÙÔÔ›ËÛ˘), ÙÔ ÎÂÓfi ‰ÂÓ ı· ÌÔÚ¤ÛÂÈ Ó· ·Ó·ÏËÚˆı›. ∆Ô ·È‰› ı· ÂÚ·Ù¿ÂÈ, ı· ÎÈÓ›ٷÈ, ·ÏÏ¿ ‰ÂÓ ı· ·ÔÎÙ‹ÛÂÈ ÙËÓ ·ÚÌÔÓÈ΋ ΛÓËÛË Î·È ÂȉÂÍÈfiÙËÙ· ÙˆÓ Û˘ÓÔÌËÏ›ÎˆÓ ÙÔ˘. ∫Ú›ÛÈÌË ËÏÈΛ· ÁÈ· ÙËÓ fiÚ·ÛË Â›Ó·È Ë ÂÚ›Ô‰Ô˜ ·fi ÙËÓ ·Ú¯‹ Ù˘ ˙ˆ‹˜ ̤¯ÚÈ ÙÔÓ 3Ô ¯ÚfiÓÔ Î·È ÁÈ· ÙË Û‡ÓıÂÙË ÔÙÈ΋ ·ÓÙ›ÏË„Ë Ì¤¯ÚÈ ÙÔÓ 8Ô ¯ÚfiÓÔ. °È· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘, Ë ÂÚ›Ô‰Ô˜ ·˘Ù‹ ÂÎÙ›ÓÂÙ·È ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙÔÓ 4Ô ¯ÚfiÓÔ Î·È ÁÈ· ÙËÓ ÂÎÌ¿ıËÛË ‰Â‡ÙÂÚ˘ ÁÏÒÛÛ·˜ ̤¯ÚÈ ÙÔ 10Ô ¯ÚfiÓÔ. °È· ÙË Ì·ıËÌ·ÙÈ΋/·ÊËÚË̤ÓË ÏÔÁÈ΋ ÛΤ„Ë Ì¤¯ÚÈ ÙÔÓ 5Ô ¯ÚfiÓÔ Î·È ÁÈ· ÙË ÌÔ˘ÛÈ΋ ̤¯ÚÈ ÙÔ 10Ô ¯ÚfiÓÔ. ∆· Ó¤· ·˘Ù¿ Â˘Ú‹Ì·Ù· ¤Ú¯ÔÓÙ·È Ó· ÂÓÈÛ¯‡ÛÔ˘Ó ÙË ÛËÌ·Û›· Ù˘ ÚÒÈÌ˘ ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Û ÌÈÎÚ‹˜ ËÏÈΛ·˜ ·È‰È¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ¯·ÌËϤ˜ ÁÓˆÛÙÈΤ˜ ÈηÓfiÙËÙ˜ ÂÍ·ÈÙ›·˜ ÔÚÁ·ÓÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ‹ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∞ÊÔ‡, fiˆ˜ ›‰·ÌÂ, ÔÈ Â͈ÙÂÚÈΤ˜ ÂÌÂÈڛ˜ ÛÙË ÌÈÎÚ‹ ËÏÈΛ· Â›Ó·È ÈηӤ˜ Ó· ‰ÈÂÁ›ÚÔ˘Ó ‚ÈÔ¯ËÌÈο Ù· Ó¢ÚÈο ·ÙÙ·Ú· Î·È Ó· ·Ú¿ÁÔ˘Ó ÁÓÒÛË,
368
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ÌÔÚԇ̠›Ûˆ˜ Ì ٷ ηٿÏÏËÏ· ÂÚÂı›ÛÌ·Ù· Ó· ‚ÔËı‹ÛÔ˘Ì ·È‰È¿ Ì ¯·ÌËϤ˜ ‰˘Ó·ÙfiÙËÙ˜ Ó· ·Ó·ÏËÚÒÛÔ˘Ó Î¿ÔÈ· ·fi Ù· ÁÓˆÛÙÈο ÙÔ˘˜ ÂÏÏ›ÌÌ·Ù·. ŒÙÛÈ, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ó·ÁÓˆÚ›˙ÂÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘, ‰ËÏ·‰‹ Ù˘ Âη›‰Â˘Û˘ ÛÙË ÌÈÎÚ‹ ËÏÈΛ· ·È‰ÈÒÓ Ì ·Ó·Ù˘ÍȷΤ˜ ÌÂÈÔÓÂ͛˜. ŒÓ· ·fi Ù· ÈÔ ÁÓˆÛÙ¿ ÚÔÁÚ¿ÌÌ·Ù· ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘ Â›Ó·È Î·È ÙÔ ÚfiÁÚ·ÌÌ· Portage, ÙÔ ÔÔ›Ô ÂÊ·ÚÌfi˙ÂÙ·È Û˘ÛÙËÌ·ÙÈο ÛÙÔ π·ÙÚÂ›Ô ∞Ó·Ù˘Íȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ Ù˘ ∞ ¶∫¶∞ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”. ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ ÏÔÁfiÙ˘Ô Â›Ó·È: “Ë ¤ÁηÈÚË ‚Ô‹ıÂÈ· οÓÂÈ ÙË ‰È·ÊÔÚ¿”, ·ÎÚÈ‚Ò˜ ÁÈ·Ù› ·Â˘ı‡ÓÂÙ·È Û ·È‰È¿ ÌÈÎÚ‹˜ ËÏÈΛ·˜ Ô˘ ¤¯Ô˘Ó ·ÎfiÌ· ·ÓÔÈÎÙ¿ Ù· ·Ú¿ı˘Ú· Ù˘ ÁÓÒÛ˘ ÙÔ˘˜. ∂ÎÌÂÙ·ÏχÂÙ·È, ‰ËÏ·‰‹, ÙȘ ÎÚ›ÛÈ̘ ËÏÈ˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∆Ô ÚfiÁÚ·ÌÌ· Portage ·ÔÙÂÏÂ›Ù·È ·fi Û˘ÁÎÂÎÚÈ̤ÓË ‡ÏË Ô˘ ‰È‰¿ÛÎÂÙ·È ÛÙÔ ·È‰› ÛÙ·‰È·Î¿ Ì ηıÔÚÈṲ̂ÓÔ Î·È ÂÏÂÁ¯fiÌÂÓÔ ÙÚfiÔ. £ÂÏ‹Û·Ì ӷ ‰È¢Ú¢ӋÛÔ˘Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘ ÂÊ·ÚÌfi˙ÔÓÙ¿˜ ÙÔ Û ·È‰È¿ ÌÈÎÚ‹˜ ËÏÈΛ·˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÛÔ‚·Ú¿ ·Ó·Ù˘Íȷο ÚÔ‚Ï‹Ì·Ù·. ∏ ÌÂϤÙË Ì·˜ ‰È‹ÚÎÂÛ 3 ¯ÚfiÓÈ· Î·È ı· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Î·ÙˆÙ¤Úˆ ÂÓ Û˘ÓÙÔÌ›· Ù· ‚·ÛÈο Ì·˜ Â˘Ú‹Ì·Ù·. ∆Ô ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÔÙ¤ÏÂÛ·Ó 24 ·È‰È¿ Ì ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË, ËÏÈΛ·˜ 11 ÌËÓÒÓ ¤ˆ˜ 5 ¯ÚÔÓÒÓ. ∆· ·›ÙÈ· Ù˘ ηı˘ÛÙ¤ÚËÛ‹˜ ÙÔ˘˜ ÌÂÙ¿ ·fi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ·Ô‰fiıËÎ·Ó Û ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë ‹ ‰˘ÛÏ·Û›· Û 16 ·È‰È¿, Û ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Û 4, ÛÂ Û˘ÁÁÂÓ‹ ÌÈÎÚÔÎÂÊ·Ï›· Û 2 Î·È Û ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË Û 2. ŸÏ· Ù· ·È‰È¿ ˘Ô‚Ï‹ıËÎ·Ó Û ÏÂÙÔÌÂÚ‹ ÂÎÙ›ÌËÛË ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ÈηÓÔÙ‹ÙˆÓ ÙÔ˘˜ Ì ÂȉÈ΋ ‰ÔÎÈÌ·Û›· Ô˘ ‚·ıÌÔÏÔÁ› ͯˆÚÈÛÙ¿ ÙÔ˘˜ 5 ‚·ÛÈÎÔ‡˜ ÙÔÌ›˜ Ù˘ ·Ó¿Ù˘Í˘ (·‰Ú‹ ÎÈÓËÙÈÎfiÙËÙ·, ÎÔÈÓˆÓÈÎfiÙËÙ·, ÁψÛÛÈ΋ ÈηÓfiÙËÙ·, ÏÂÙÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ Î·È Â›‰ÔÛË) Î·È ‰›ÓÂÈ ÁÂÓÈÎfi ·Ó·Ù˘ÍÈ·Îfi ËÏ›ÎÔ (GDQ) ηıÒ˜ Î·È ÂȉÈÎfi ËÏ›ÎÔ (DQ) ÁÈ· οı ÙÔ̤· ͯˆÚÈÛÙ¿. ™ÙË Û˘Ó¤¯ÂÈ·, Ù· 24 ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û 12 ˙‡ÁË Ù˘ ›‰È·˜ ËÏÈΛ·˜ Î·È ÙÔ˘ ›‰ÈÔ˘ ÔÚÁ·ÓÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Î·È Ù· ÌÈÛ¿ (1 ·fi οı ˙‡ÁÔ˜) ÂÓÙ¿¯ıËÎ·Ó ÌÂ Ù˘¯·›Ô ÙÚfiÔ ÛÙÔ ÚfiÁÚ·ÌÌ· Î·È ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· Portage, ÂÓÒ Ù· ˘fiÏÔÈ· 12 ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û ÚÒÈÌË ·Ú¤Ì‚·ÛË Î·È ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∫·Ù¿ ÙËÓ 1Ë ÂͤٷÛË Ô˘ ¤ÁÈÓ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘, ÙÔ Û˘ÓÔÏÈÎfi ·Ó·Ù˘ÍÈ·Îfi ËÏ›ÎÔ ‹Ù·Ó ·ÚfiÌÔÈÔ Î·È ÛÙȘ 2
¶·È‰È·ÙÚÈ΋ 2001;64:365-369
Paediatriki 2001;64:365-369
¶›Ó·Î·˜ 1. ∞Ó·Ù˘ÍÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË √ª∞¢∞
GDQ MT(SD)
Portage
¶ÚÈÓ 54 (16)
1Ô˜ ÃÚfiÓÔ˜ 70 (15)
2Ô˜ ÃÚfiÓÔ˜ 73 (15)
ª¿ÚÙ˘Ú˜
58 (14)
55 (14)
49 (13)
8 ª‹Ó˜ ªÂÙ¿ 74 (13) p<0,001 47 (14)
GDQ: General Developmental Quotient
ÔÌ¿‰Â˜. ◊Ù·Ó 54 ÌÔÓ¿‰Â˜ ÛÙËÓ ÔÌ¿‰· Portage Î·È 58 ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (˘ÂÓı˘Ì›˙ÂÙ·È fiÙÈ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ·Ó·Ù˘ÍÈ·Îfi ËÏ›ÎÔ Â›Ó·È 85 ¤ˆ˜ 120). ∆ÔÓ 1Ô ¯ÚfiÓÔ Ù˘ ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘, ÙÔ ËÏ›ÎÔ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Î·Ó·Ó ·Ú¤Ì‚·ÛË ·fi 54 ÌÔÓ¿‰Â˜ ¤ÁÈÓ 70, ·˘Í‹ıËΠ‰ËÏ·‰‹ ηٿ 16 ÌÔÓ¿‰Â˜, ÂÓÒ ÙÔ ËÏ›ÎÔ ÙˆÓ Ì·ÚÙ‡ÚˆÓ Ô˘ ‰ÂÓ ¤Î·Ó·Ó ·Ú¤Ì‚·ÛË ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ· ·Ú¤ÌÂÈÓ ¯·ÌËÏfi (55 ÌÔÓ¿‰Â˜). ∆Ô 2Ô ¯ÚfiÓÔ Ù˘ ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘, ÙÔ ËÏ›ÎÔ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ Portage Û˘Ó¤¯ÈÛ ӷ ·˘Í¿ÓÂÈ Ì ÌÈÎÚfiÙÂÚÔ fï˜ Ú˘ıÌfi (·fi 70 ÌÔÓ¿‰Â˜ ‹Á 73), ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô Ù˘ ÔÌ¿‰·˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÌÂÈÒıËΠ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ (·fi 55 ¤ÁÈÓ 49). ªÂÙ¿ Ù· 2 ¯ÚfiÓÈ· Û˘ÛÙËÌ·ÙÈ΋˜ ıÂڷ›·˜ ‰È·Îfi„·Ì ÙÔ ÚfiÁÚ·ÌÌ· Î·È Â·ÓÂÍÂÙ¿Û·Ì ٷ ·È‰È¿ 8 Ì‹Ó˜ ·ÚÁfiÙÂÚ· ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙÒÛÔ˘Ì ηٿ fiÛÔ Ù· ·Ó·Ù˘Íȷο ÔʤÏË Ù˘ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘ ‰È·ÙËÚÔ‡ÓÙ·È Î·È ÌÂÙ¿ ÙË Ï‹ÍË Ù˘. ŒÙÛÈ, 8 Ì‹Ó˜ ÌÂÙ¿ ÙË Ï‹ÍË Ù˘ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘, ÙÔ ËÏ›ÎÔ Ù˘ ÔÌ¿‰·˜ Portage ‰È·ÙËÚ‹ıËΠÛÙ·ıÂÚfi (·fi 73 ¤ÁÈÓ 74), ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÙˆÓ ·È‰ÈÒÓ ¯ˆÚ›˜ ·Ú¤Ì‚·ÛË ·Ú¤ÌÂÓ ¯·ÌËÏfi (47 ÌÔÓ¿‰Â˜) (¶›Ó·Î·˜ 1). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ¤Ú¯ÔÓÙ·È Ó· ÂȂ‚·ÈÒÛÔ˘Ó Î·È ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÙȘ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·‰Èηۛ˜ Ô˘ ÂÚÈÁÚ¿„·Ì ·Ú¯Èο, fiÙÈ ‰ËÏ·‰‹ ÔÈ Î·Ù¿ÏÏËϘ Â͈ÙÂÚÈΤ˜ ÂÌÂÈڛ˜ ÛÙËÓ Î·Ù¿ÏÏËÏË ËÏÈΛ· Â›Ó·È ÈηӤ˜ Ó· ‰ÈÂÁ›ÚÔ˘Ó Ì›· ÛÂÈÚ¿ ‚ÈÔ¯ËÌÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÛÙ· Ó¢ÚÈο ·ÙÙ·Ú· Î·È Ó· ·Ú¿ÁÔ˘Ó ÁÓÒÛË. ªÔÚԇ̠‰ËÏ·‰‹ Ì ٷ ηٿÏÏËÏ· ÂÚÂı›ÛÌ·Ù· ÛÙȘ ÎÚ›ÛÈ̘ ËÏÈ˘ Ì¿ıËÛ˘ Ó· ‚ÔËı‹ÛÔ˘Ì ·È‰È¿ Ì ÌÂÈÔÓÂ͛˜ Ó· ·Ó·ÏËÚÒÛÔ˘Ó Û οÔÈÔ ‚·ıÌfi Ù· ÁÓˆÛÙÈο ÙÔ˘˜ ÂÏÏ›ÌÌ·Ù·. ÿÛˆ˜ ‰ÂÓ ÌÔÚԇ̠ӷ οÓÔ˘Ì ÔÏÏ¿, ·ÎfiÌ· Î·È Û‹ÌÂÚ·, ÁÈ· Ó· ÌÂÙ·‚¿ÏÔ˘Ì fiÙÈ Â›Ó·È ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ Î·È Û˘Ì‚·›ÓÂÈ ÚÈÓ ·fi ÙË Á¤ÓÓËÛË.
º·›ÓÂÙ·È, fï˜, fiÙÈ ÌÔÚԇ̠ӷ ·ÏÏ¿˙Ô˘Ì ·ÚÎÂÙ¿ ·fi ·˘Ù¿ Ô˘ ı· Û˘Ì‚Ô‡Ó ÌÂÙ¿ ·fi ·˘Ù‹. µÈ‚ÏÈÔÁÚ·Ê›· 1. Piper M, Pless I. Early intervention for infants with Down’s syndrome: A controlled trial. Pediatrics 1980;65:463-468. 2. Simeonsson R, Cooper D, Scheiner A. A review and analysis of the effectiveness of early intervention programs. Pediatrics 1982;69:635-641. 3. Aronson M, Fallstrom K. Immediate and long term effects of developmental training in children with Down’s Syndrome. Dev Med Child Neurol 1977;19:489-494. 4. Clunies-Ross G. Accelerating the development of Down’s syndrome infants and young children. J Spec Educ 1979;13:19-177. 5. Macmilian D. Mental Retardation in School and Society. Boston: Little, Brown; 1982. 6. Hayden A, Haring N. Early intervention for high risk infants and young children. In: Tjossem TD, ed. Intervention Strategies for High Risk Infant and Young Children. Baltimore: University Park Press; 1976. 7. Goodman J, Cecil H, Barker W. Early intervention with retarded children: Some encouraging results. Dev Med Child Neurol 1984;26:47-55. 8. Shonkoff J, Hause-Cram P. Early intervention for disabled infants and their families: A quantitative analysis. Pediatrics 1987;80:650-658. 9. Farran D. Effects of intervention with disadvantaged and disabled children. In: Meisels S, Shonkoff J, eds. Handbook of Early Intervention. Cambridge: Cambridge University Press; 1990.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: §ˆÚ¤ÙÙ· £ˆÌ·˝‰Ô˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
369
¶·È‰È·ÙÚÈ΋ 2001;64:370-375
∞¡∞¶∆À•π∞∫∏ ¶∞π¢π∞∆ƒπ∫∏
Paediatriki 2001;64:1370-375
DEVELOPMENTAL PEDIATRICS
∞Ó¿Ù˘ÍË Î·È ‰È·Ù·Ú·¯¤˜ ÏfiÁÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∂. ∆˙›Ì· - ∆Û›ÙÛÈη
Language development and disorders in childhood E. Tzima - Tsitsika
¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘ ·ÔÙÂÏ› ¤Ó·Ó ·fi ÙÔ˘˜ ÛÔ˘‰·ÈfiÙÂÚÔ˘˜ ÙÔÌ›˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡. ∞ÔÙÂÏ› „˘¯Ô-Ê˘ÛÈÔÏÔÁÈÎfi Ê·ÈÓfiÌÂÓÔ Ô˘ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ·ÏÏËÏ›‰Ú·Û˘ ·ÊÂÓfi˜ ¤ÌÊ˘ÙˆÓ ÂÛˆÙÂÚÈÎÒÓ Ù¿ÛÂˆÓ ÁÂÓÂÙÈ΋˜ ÚÔ¤Ï¢Û˘ Î·È ·ÊÂÙ¤ÚÔ˘ Â͈ÙÂÚÈÎÒÓ ÂȉڿÛÂˆÓ Ì ÂÚÈ‚·ÏÏÔÓÙÈ΋ ÂÍ¿ÚÙËÛË. OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÏfiÁÔ˘ Î·È Ù˘ ÔÌÈÏ›·˜ ÚÔÛ‚¿ÏÏÔ˘Ó ÙÔ 5-10% ÙˆÓ ·È‰ÈÒÓ. ∏ ÂÎÙ›ÌËÛË Î·È Ë ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ ¤ÁηÈÚ· Î·È Ó· ÛÙÔ¯Â‡Ô˘Ó: 1) ÛÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ Â˘¿ÏˆÙˆÓ ÛËÌ›ˆÓ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘ ·ÏÏ¿ Î·È ÛÙË ÁÂÓÈÎfiÙÂÚË ·Ó¿Ù˘ÍË, 2) ÛÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ È·ÙÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, 3) ÛÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÂȉÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ù˘ ·ÓÈηÓfiÙËÙ·˜ Ì ÛÎÔfi ÙË ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋, 4) ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ηٿÏÏËÏ˘ ·Ú¤Ì‚·Û˘ (ÂÎ·È‰Â˘ÙÈ΋˜, È·ÙÚÈ΋˜, ·ÎÔÔÏÔÁÈ΋˜). °È· ÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ·È‰›, Ë ÁÏÒÛÛ· Î·È Ë ÔÌÈÏ›· (ÏÂÎÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÁÏÒÛÛ·˜) ˘ËÚÂÙÔ‡Ó ÙÚÂȘ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‚·ÛÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜: ·) ·ÔÙÂÏÔ‡Ó ÙÔ fi¯ËÌ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ‰ÂÛÌÔ‡, ‚) Â›Ó·È ÂÚÁ·ÏÂ›Ô ÂÈÎÔÈÓˆÓ›·˜, Á) Â›Ó·È fiÚÁ·ÓÔ ÁÓˆÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ÂÈÎÔÈÓˆÓ›· Û˘ÓÙÂÏÂ›Ù·È ‰È·Ì¤ÛÔ˘ ÙÚÈÒÓ ÌÂÁ¿ÏˆÓ Ô‰ÒÓ Ô˘ Â›Ó·È Ë ÂÎÊÚ·ÛÙÈ΋ (ÂÚȯfiÌÂÓÔ, ·ÓÙÈÏËÙÈÎfiÙËÙ·, ÚÔÛˆ‰›·, Ú·ÁÌ·ÙÔÏÔÁ›· Î·È ÚÔ‹ ÙÔ˘ ÏfiÁÔ˘), Ë ·ÎÔ˘ÛÙÈ΋ - ‰ÂÎÙÈ΋ (·ÎÔ˘ÛÙÈ΋ ·ÓÙ›ÏË„Ë - Û˘ÌÂÚÈÊÔÚ¿, ηٷÓfiËÛË ÂÓÙÔÏÒÓ) Î·È Ë ÔÙÈ΋ (·ÓÙ›ÏË„Ë, ¿Ù˘Â˜ Î·È Ù˘ÈΤ˜ ¯ÂÈÚÔÓƠ̂˜). ∏ ‰È¿ÁÓˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ‚·Û›˙ÂÙ·È ÛÙÔ ÈÛÙÔÚÈÎfi ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡, ÙÔ È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi Î·È ÙË Ê˘ÛÈ΋ ÂͤٷÛË. ŸÏ· Ù· ·È‰È¿ Ì ‰È·Ù·Ú·¯¤˜ ÛÙË ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË ı· Ú¤ÂÈ Ó· ˘Ô‚ÏËıÔ‡Ó Û ·ÎÔÔÏÔÁÈÎfi
Abstract: Language development is one of the most important aspects of early childhood development. It is a psycho-physiologic phenomenon that has to do with the interaction between innate drives of genetic origin and the external environmental influences. Language or speech disorders affect 5% to 10% of all children. The diagnosis must be established as soon as possible. Goals of evaluation include ascertain- ment of strengths and weaknesses in areas of language and non-language development, identification of associated medical disorders, determination of the specific etiology of the disability for genetic counseling purposes, and institution of appropriate intervention (educational, audiologic, medical). Language serves at least three functions for the developing child: a) a vehicle for social bonding, b) a communicative tool and c) an instrument for cognitive operation. Communication takes place in three major channels: expressive (content, intelligibility, prosody, pragmatics, fluency), auditory receptive (awareness, comprehension), and visual (awareness, informal and formal gestures). The diagnosis is based on developmental and medical history, physical examination and other diagnostic studies, if necessary, such as karyotype, electroencephalography, ophthalmologic evalu-ation and CT scanning. All speech-impaired children should undergo audiologic evaluation and developmental testing. Differential diagnosis will be referred to input central processing output schematic pathway. Hearing loss (permanent or not) mental retardation, autism, stuttering and voice disorders
¶·È‰›·ÙÚÔ˜ - ∞Ó·Ù˘ÍÈÔÏfiÁÔ˜ ¢È¢ı‡ÓÙÚÈ· ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡πª∆™
Developmental Pediatrics Director of Pediatric Division NIMTS, Athens
370
¶·È‰È·ÙÚÈ΋ 2001;64:370-375
Paediatriki 2001;64:1370-375
¤ÏÂÁ¯Ô Î·È ·Ó·Ù˘Íȷ΋ ÂÎÙ›ÌËÛË, ηıÒ˜ Î·È Û ¿ÏϘ ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ·Ó ÎÚÈı› ··Ú·›ÙËÙÔ, fiˆ˜ ηڢfiÙ˘Ô, ÔÊı·ÏÌÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· Î·È ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ¤¯ÂÈ Û¯¤ÛË Ì ÙË Û¯ËÌ·ÙÈ΋ Ô‰fi: ÚfiÛÏË„Ë ÂÚÂıÈÛÌ¿ÙˆÓ ÎÂÓÙÚÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ Ó¢ÚÈ΋ ·¿ÓÙËÛË Î·È Á›ÓÂÙ·È ÌÂٷ͇ Ù˘ ·ÒÏÂÈ·˜ ·ÎÔ‹˜ (·ÚÔ‰È΋˜ ‹ ÌfiÓÈÌ˘), Ù˘ ÓÔËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘, ÙÔ˘ ·˘ÙÈÛÌÔ‡, ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÊˆÓ‹˜, ÙÔ˘ ÙÚ·˘ÏÈÛÌÔ‡. ∞ӷʤÚÔÓÙ·È Ù· ·ÓËÛ˘¯ËÙÈο ÛËÌ›· ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘ Ù· ÔÔ›· ÂÈÛËÌ·›ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ‰È·Ù·Ú·¯‹˜.
must also be considered. The alerting signs indicating possible disorders in language development are presented.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ó¿Ù˘ÍË ÏfiÁÔ˘, ‰È·Ù·Ú·¯¤˜ ÏfiÁÔ˘, Ô‰Ô› ÁψÛÛÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜, ·ÒÏÂÈ· ·ÎÔ‹˜, ·ÓËÛ˘¯ËÙÈο ÛËÌ›· ·Ó¿Ù˘Í˘ ÏfiÁÔ˘.
Key words: language development, language disorders, communication channels, hearing loss, alerting signs in language development.
∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘ ·ÔÙÂÏ› ¤Ó·Ó ·fi ÙÔ˘˜ ÛÔ˘‰·ÈfiÙÂÚÔ˘˜ ÙÔÌ›˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡, fi¯È ÌfiÓÔ ÁÈ·Ù› Ë ·fiÎÙËÛË Ù˘ ÈηÓfiÙËÙ·˜ Ù˘ ÁψÛÛÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Â›Ó·È ¤Ó· ·fi Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ‰È·ÊÔÚÔÔÈ› ÙÔÓ ¿ÓıÚˆÔ ·fi Ù· ηÙÒÙÂÚ· fiÓÙ·, ·ÏÏ¿ Î·È ÁÈ·Ù› ·Ú·ÙËÚÂ›Ù·È ¿ÌÂÛË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÏfiÁÔ˘ Î·È ÓÔËÌÔÛ‡Ó˘. ∏ ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË ·ÔÙÂÏ› „˘¯Ô-Ê˘ÛÈÔÏÔÁÈÎfi Ê·ÈÓfiÌÂÓÔ Î·È Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÌÔÈ‚·›·˜ ›‰Ú·Û˘, ·ÊÂÓfi˜ ÌÂÓ ¤ÌÊ˘ÙˆÓ ÂÛˆÙÂÚÈÎÒÓ Ù¿ÛÂˆÓ Ô˘ ¤¯Ô˘Ó ÁÂÓÂÙÈ΋ ÚԤϢÛË Î·È ·ÊÂÙ¤ÚÔ˘ Â͈ÙÂÚÈÎÒÓ ÂȉڿÛÂˆÓ Ì ÂÚÈ‚·ÏÏÔÓÙÈ΋ ÂÍ¿ÚÙËÛË. ∏ ÂÚ›Ô‰Ô˜ Ù˘ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Â›Ó·È ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô˜ ÁÈ· ÙË ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË Î·È ÙÔ ·È‰› ËÏÈΛ·˜ 4-5 ÂÙÒÓ ÔÊ›ÏÂÈ Ó· ¤¯ÂÈ ·ÔÎÙ‹ÛÂÈ ÙË ‚·ÛÈ΋ ÁÏÒÛÛ·, Ì ÙÔÓ ··Ú·›ÙËÙÔ ÏÂÎÙÈÎfi ÏÔ‡ÙÔ, ÙË ÁÚ·ÌÌ·ÙÈ΋ ÏÔ΋ ÙˆÓ Ï¤ÍÂˆÓ Î·È ÙËÓ ·Ï‹ Û˘ÓÙ·ÎÙÈ΋ Û‡ÓıÂÛË. øÛÙfiÛÔ, ·˘Ùfi ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ¿ÓÙÔÙÂ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÁψÛÛÈ΋˜ ·Ó¿Ù˘Í˘ ÚÔÛ‚¿ÏÏÔ˘Ó ÙÔ 5-10% ÙˆÓ ·È‰ÈÒÓ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜. ∏ ÂÎÙ›ÌËÛË Î·È Ë ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ ¤ÁηÈÚ· Î·È Ó· ÛÙԯ‡ÂÈ: ·) ÛÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ ÈÛ¯˘ÚÒÓ ÎÈ ·‰‡Ó·ÙˆÓ ÛËÌ›ˆÓ Ù˘ ÁψÛÛÈ΋˜ Î·È ÌË ÁψÛÛÈ΋˜ ·Ó¿Ù˘Í˘, ‚) ÛÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ È·ÙÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, Á) ÛÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÂȉÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ù˘ ·ÓÈηÓfiÙËÙ·˜, Ì ÛÎÔfi ÙË ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋, ‰) ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ηٿÏÏËÏ˘ ·Ú¤Ì‚·Û˘ (ÂÎ·È‰Â˘ÙÈ΋˜, È·ÙÚÈ΋˜, ·ÎÔÔÏÔÁÈ΋˜). ∂Âȉ‹ Ô fiÚÔ˜ “ÏfiÁÔ˜” ¤¯ÂÈ Â˘Ú‡ÙÂÚË ÛËÌ·Û›·, Ë ÔÔ›· ‰ÂÓ Û˘Ì‚·‰›˙ÂÈ Ì ٷ ÚÒÈÌ· ÛÙ¿‰È·
Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡ Ô˘ ı· Ì·˜ ··Û¯ÔÏ‹ÛÔ˘Ó Û‹ÌÂÚ·, ı· ‹Ù·Ó ÔÚıfiÙÂÚÔ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó, ·ÓÙ› ·˘ÙÔ‡, ÔÈ fiÚÔÈ “ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË” Î·È “ÔÌÈÏ›·”. ∏ “ÁÏÒÛÛ·” ·Ó·Ê¤ÚÂÙ·È Û ÔÔÈÔ‰‹ÔÙ ۇÛÙËÌ· Û˘Ì‚fiÏˆÓ ÁÈ· ÙËÓ ·Ôı‹Î¢ÛË ÎÈ ·ÓÙ·ÏÏ·Á‹ ÏËÚÔÊÔÚÈÒÓ, Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ÚfiÛˆ·, ·ÓÙÈΛÌÂÓ·, ‰Ú·ÛÙËÚÈfiÙËÙ˜, ÁÓˆÛÙÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ Î·È Û˘Ó·ÈÛı‹Ì·Ù· (.¯. Û‹Ì·Ù· Morse, Û‡ÛÙËÌ· Braulle, ÁÏÒÛÛ· ÙˆÓ ÎˆÊÒÓ, ∞ÁÁÏÈ΋, ∂ÏÏËÓÈ΋, °ÂÚÌ·ÓÈ΋ ÁÏÒÛÛ·). ∏ “ÔÌÈÏ›·” Â›Ó·È Ë ÏÂÎÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÁÏÒÛÛ·˜, ·ÔÙÂÏ› ‰ËÏ·‰‹ Ì›· ηÙËÁÔÚ›· ÁψÛÛÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ¯ÚËÛÈÌÔÔÈ› Û˘ÛÙËÌ·ÙÔÔÈË̤ӷ ʈӋ̷ٷ ÁÈ· Ó· ÂÎÊÚ¿ÛÂÈ ÏÂÎÙÈΤ˜ ÌÔÓ¿‰Â˜ ‹ ϤÍÂȘ. ∏ ÁÏÒÛÛ· Î·È Ë ÔÌÈÏ›· ˘ËÚÂÙÔ‡Ó ÙÚÂȘ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‚·ÛÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÁÈ· ÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ·È‰›: 1. ∏ ÁÏÒÛÛ· ·ÔÙÂÏ› ÙÔ fi¯ËÌ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ‰ÂÛÌÔ‡ OÈ ÚÒÙ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ‰ÂÛÌÔ‡ ÌÂٷ͇ ÁÔÓ¤· - ‚Ú¤ÊÔ˘˜ Â›Ó·È ÔÈ ·ÌÔÈ‚·›Â˜ ʈÓÔÔÈ‹ÛÂȘ Î·È Ë ·ÌÔÈ‚·›· ‚ÏÂÌÌ·ÙÈ΋ ·ʋ. ∏ ‰È·ÎÔ‹ ·˘Ù‹˜ Ù˘ ‰ÈÂÚÁ·Û›·˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÁÂÓÈÎfiÙÂÚË - „˘¯ÔÎÔÈÓˆÓÈÎÔ‡ Ù‡Ô˘ ‰È·Ù·Ú·¯‹, fi¯È ÌfiÓÔ Ù˘ ÔÌÈÏ›·˜. 2. ∏ ÁÏÒÛÛ· Â›Ó·È ¤Ó· ÂÚÁ·ÏÂ›Ô ÂÈÎÔÈÓˆÓ›·˜ ŒÓ· ·È‰› 12 ÌËÓÒÓ, ÁÈ· ·Ú¿‰ÂÈÁÌ·, Ì·ı·›ÓÂÈ Ó· ˙ËÙ¿ Ù· ·ÓÙÈΛÌÂÓ· Ô˘ ÂÈı˘Ì›, ‰Â›¯ÓÔÓÙ·˜ Ì ÙÔ ‰Â›ÎÙË ‹ ·Ó·Ê¤ÚÔÓÙ¿˜ Ù· Ì ÙÔ fiÓÔÌ¿ ÙÔ˘˜. ∞˘Ùfi˜ Ô ÙÚfiÔ˜, Ì ÙÔÓ ÔÔ›Ô ÌÔÚ› Ó· ‰Â›ÍÂÈ ‹ Ó· ÂÎÊÚ¿ÛÂÈ ÙȘ ÂÈı˘Ì›Â˜ ÙÔ˘ ·ÓÙ› Ó· ··ÈÙ› ÎÏ·›ÁÔÓÙ·˜, ·ÔÙÂÏ› ÁψÛÛÈÎfi ÂÚÁ·Ï›Ô. §ÂÈÙÔ˘ÚÁ›Â˜
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fiˆ˜ Ó· ‰Â›¯ÓÂÈ, Ó· ÔÓÔÌ¿˙ÂÈ ·ÓÙÈΛÌÂÓ· ‹ Ó· ¯ÚËÛÈÌÔÔÈ› ÙÔ ÎÔ˘Ù¿ÏÈ, ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ›‰È· ËÏÈΛ· ÎÈ ·ÔÙÂÏÔ‡Ó ·Ú·‰Â›ÁÌ·Ù· Ù˘ ¯Ú‹Û˘ ÂÚÁ·Ï›Ԣ. 3. ∏ ÁÏÒÛÛ· Â›Ó·È ¤Ó· fiÚÁ·ÓÔ ÁÓˆÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ∆Ô ·È¯Ó›‰È Ê·ÓÙ·Û›·˜ ÂÓfi˜ 3¯ÚÔÓÔ˘ ·È‰ÈÔ‡ Â›Ó·È ·Ú¿‰ÂÈÁÌ· Ù˘ ÈηÓfiÙËÙ¿˜ ÙÔ˘ Ó· ÛΤÊÙÂÙ·È Ì ·ÊËÚË̤ÓÔ ÙÚfiÔ, ·ÏÏ¿ Î·È Ó· ·ӷÚÔÛ‰ÈÔÚ›˙ÂÈ ÙÔÓ ÎfiÛÌÔ ÙÔ˘. ∏ ÂÈÎÔÈÓˆÓ›· Û˘ÓÙÂÏÂ›Ù·È ‰È·Ì¤ÛÔ˘ 3 ÌÂÁ¿ÏˆÓ Ô‰ÒÓ, Ô˘ Â›Ó·È Ë ÂÎÊÚ·ÛÙÈ΋, Ë ·ÎÔ˘ÛÙÈ΋ - ‰ÂÎÙÈ΋ Î·È Ë ÔÙÈ΋ (¶›Ó·Î·˜ 1). ¢È¿ÁÓˆÛË ∆Ô ÈÛÙÔÚÈÎfi ·Ú·Ì¤ÓÂÈ ·ÎfiÌ· ÙÔ Î·Ï‡ÙÂÚÔ ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·ÏÂ›Ô Ô˘ ‰È·ı¤ÙÂÈ Ô ÎÏÈÓÈÎfi˜. πÛÙÔÚÈÎfi ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡: π‰È·›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ Ô ¯ÚfiÓÔ˜ Ô˘ ÔÈ ÁÔÓ›˜ ·ÓÙÈÏ‹ÊıËÎ·Ó ÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ Úfi‚ÏËÌ· ÛÙË ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡. ¢È·Ù·Ú·¯¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ ÎÈ ·ÒÏÂÈ· ·ÎÔ‹˜ Û˘¯Ó¿ ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ Úfi‚ÏËÌ· Û˘ÌÂÚÈÊÔÚ¿˜. OÈ ÁÔÓ›˜ ÌÔÚ› Ó· ÂÈ̤ÓÔ˘Ó fiÙÈ Ë ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ̤¯ÚÈ ÔÚÈṲ̂Ó˘ ËÏÈΛ·˜ Î·È ÌÂÙ¿ ÂÈ‚Ú·‰‡ÓıËΠ‹ ÛËÌ›ˆÛ ·ÏÈÓ‰ÚfiÌËÛË. ™˘¯Ó¿, ·˘Ùfi ÙÔ ÈÛÙÔÚÈÎfi ‰›‰ÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¿ÏÏÔ˘ ·È‰ÈÔ‡, ÙÔ˘ ÔÔ›Ô˘ Ë ·Ó¿Ù˘ÍË ÚÔÔÚ‡ÂÙ·È ·fi ·˘Ù‹ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ·È‰ÈÔ‡, ÁÂÁÔÓfi˜ Ô˘ ‰Â›¯ÓÂÈ fiÙÈ Ë ‰È·Ù·Ú·¯‹ ÚÔ¸‹Ú¯Â ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ∞ÎfiÌ·, Ë ‰È·Ù·Ú·¯‹ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› ÌfiÓÔ fiÙ·Ó ÙÔ ·È‰› ·Ú¯›ÛÂÈ Ó· ‚·‰›˙ÂÈ, ÔfiÙ ·ÔηχÙÂÙ·È fiÙÈ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙÔ ÏÂÎÙÈÎfi ¤ÏÂÁ¯Ô Î·È ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ Ô˘ ·Ú¯›˙Ô˘Ó Ó· ÂÈ‚¿ÏÔÓÙ·È (.¯. ÂÚÈÔÚÈÛÙÈο “ÌË”). ∏ ·Ó·ÛÙÔÏ‹ ‹ Ë ·ÏÈÓ‰ÚfiÌËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÔÌÈÏ›·˜ ‰Â›¯ÓÂÈ ÚÔԉ¢ÙÈο ÂÍÂÏÈÛÛfiÌÂÓ˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ ·ÒÏÂÈ· ·ÎÔ‹˜, ›ÎÙËÙË ÂÈÏËÙÈ΋ ·Ê·Û›· ‹ ÚÔԉ¢ÙÈ΋ ‰È·Ù·Ú·¯‹ ÙÔ˘ ∫.¡.™. ∆Ô ÈÛÙÔÚÈÎfi Ú¤ÂÈ Ó· ηχ„ÂÈ fiϘ ÙȘ ÂÚÈÔ¯¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ Ô˘ ‹‰Ë ¤¯Ô˘Ó ·Ó·ÊÂÚı›, ‰ËÏ·‰‹ ÙÔ ÂÎÊÚ·ÛÙÈÎfi ̤ÚÔ˜ (ÂÚȯfiÌÂÓÔ, ·ÓÙÈÏËÙÈÎfiÙËÙ·, ·ʋ Ì ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÚÔ‹ Î.Ï.), ÙÔ ·ÎÔ˘ÛÙÈÎfi - ‰ÂÎÙÈÎfi ̤ÚÔ˜, ηıÒ˜ Î·È ÙÔ ÔÙÈÎfi (ÔÙÈ΋ ÂÈÎÔÈÓˆÓ›·, ‚ÏÂÌÌ·ÙÈ΋ ·ʋ, Ó‡̷ٷ - ¯ÂÈÚÔÓƠ̂˜). ∂›Û˘, Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÏÂÁ¯ı› Ë ÌË ÁψÛÛÈ΋ ÂÚÈÔ¯‹ Ù˘ ·Ó¿Ù˘Í˘ (¯ÂÈÚÈÛÌÔ›, ·‰Ú‹ ÎÈÓËÙÈÎfiÙËÙ·, ÂÎÙ¤ÏÂÛË, ·È¯Ó›‰È, ÚÔÛˆÔÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË) Ì ÙË ¯Ú‹ÛË ‰ÔÎÈÌ·Û›·˜ (test) „˘¯ÔÎÈÓËÙÈ΋˜ ÂͤÏÈ͢. π·ÙÚÈÎfi ÈÛÙÔÚÈÎfi: ∞) ∫‡ËÛË: ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ¤Ó·ÚÍË Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÚÔ·ÙÂÈ fiÙ·Ó ·Ú·ÙËÚÂ›Ù·È ÊÙˆ¯‹ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚Ú‡Ô˘,
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¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο ÁψÛÛÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ÎÔÈÓ¿ ·›ÙÈ· ηı˘ÛÙ¤ÚËÛ˘ O¢Oÿ ∂¶π∫Oπ¡ø¡ÿ∞˜ π. ∂ÎÊÚ·ÛÙÈ΋ ¶ÂÚȯfiÌÂÓÔ ª¤ÁÂıÔ˜ ÏÂÍÈÏÔÁ›Ô˘ ™‡ÓıÂÛË ·Ï¤˜ ϤÍÂȘ ÊÚ¿ÛÂȘ ‰‡Ô ϤÍÂˆÓ ÙËÏÂÁÚ·ÊÈΤ˜ ÚÔÙ¿ÛÂȘ Ï‹ÚÂȘ ÚÔÙ¿ÛÂȘ ∞ÓÙÈÏËÙÈÎfiÙËÙ· ÕÚıÚˆÛË ∞Ó·Ù. ºˆÓ‹ ¶ÚÔÛˆ‰›· ∆fiÓÔ˜, ŸÁÎÔ˜ ¶Ú·ÁÌ·ÙÔÏÔÁ›· ∫ÔÈÓˆÓÈ΋ / ∂ÈÎÔÈÓˆÓȷ΋ §ÂÈÙÔ˘ÚÁ›· ƒÔ‹ ™˘¯ÓfiÙËÙ·, ƒ˘ıÌfi˜ ππ. ∞ÎÔ˘ÛÙÈ΋ - ¢ÂÎÙÈ΋ ∞ÎÔ˘ÛÙÈ΋ ·ÓÙ›ÏË„Ë-™˘ÌÂÚÈÊÔÚ¿ ∞ÎÔ˘ÛÙÈ΋ ηٷÓfiËÛË ÂÓÙÔÏÒÓ πππ. OÙÈ΋ OÙÈ΋ ·ÓÙ›ÏË„Ë ÕÙ˘Â˜ ¯ÂÈÚÔÓƠ̂˜ ∆˘ÈΤ˜ ¯ÂÈÚÔÓƠ̂˜
∞π∆π∞ ∫∞£À™∆Œƒ∏™∏˜
∞∞, ¡∫, ∞, ∞°∫ ∞∞, ¡∫, ∞, ∞°∫
∞∞, ∞°∫, ¢™, ¢™, ∞Ó·Ù. ∞ ∞
∆Ú·˘ÏÈÛÌfi˜ ∞∞, ∞°∫, ∞ ∞∞, ¡∫, ∞°∫, ∞ ∞ ∞ ¡∫, ∞
∞∞: ·ÒÏÂÈ· ·ÎÔ‹˜, ¡∫: ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ∞: ·˘ÙÈÛÌfi˜, ∞°∫: ·Ó·Ù˘Íȷ΋ ÁψÛÛÈ΋ ηı˘ÛÙ¤ÚËÛË, ¢™: ‰˘Û·ÚıÚ›·, ∞Ó·Ù.: ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· Ù˘ ʈÓËÙÈ΋˜ Ô‰Ô‡
Èۯȷ΋ ÚÔ‚ÔÏ‹, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ Î·È ÌÈÎÚÔÎÂÊ·Ï›· ηٿ ÙË Á¤ÓÓËÛË. ∂›Û˘, Ú¤ÂÈ Ó' ·Ó·˙ËÙËı› Ë ¤ÎıÂÛË Û ÙÂÚ·ÙÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ¯Ú‹ÛË Ê·Ú̿ΈÓ, Ó·ÚΈÙÈÎÒÓ Î·È ·ÏÎÔfiÏ. ø˜ ÚÔ˜ ÙÔ ÙÂÏÂ˘Ù·›Ô, ÔÈ ÂÚˆÙ‹ÛÂȘ Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÔÓÙ·È ÛÙÔ˘˜ Ì‹Ó˜ ÚÈÓ ·fi ÙËÓ ÂÁ΢ÌÔÛ‡ÓË, ‰ÈfiÙÈ ÙÔ ¤Ì‚Ú˘Ô Â›Ó·È È‰È·›ÙÂÚ· ¢¿ÏˆÙÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ Ù˘ ·ËÛ˘, fiÙ·Ó ÔÈ ÂÚÈÛÛfiÙÂÚ˜ Á˘Ó·›Î˜ ‰ÂÓ ÁÓˆÚ›˙Ô˘Ó ·ÎfiÌ· ÁÈ· ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ÙÔ˘˜. ∏ ¤ÎıÂÛË Û ÈÔÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ ÛÙÔ 1Ô ‹ 2Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, fiˆ˜ .¯. Ë ·Ó¿Ù˘ÍË ÓfiÛÔ˘ Ô˘ ˘Ô‰‡ÂÙ·È ÁÚÈÒ‰Ë Û˘Ó‰ÚÔÌ‹, ÌÔÚ› Ó· ˘Ô‰ËÏÒÓÂÈ Û˘ÁÁÂÓ‹ Ïԛ̈ÍË Ì ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi. ∂›Û˘, Ë ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË Ì ÙÔÓ Èfi Ù˘ ÂÚ˘ıÚ¿˜ ‹ ÙÔ˘ HIV, Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ ·Ó·Ù˘Íȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. µ) ¶ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi: ¶ÂÚÈÁÂÓÓËÙÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, Û·ÛÌÔ› Î·È ‰˘ÛˆÚÈÌfiÙËÙ·, ·ÔÙÂÏÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ¤Ó·ÚÍË Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜.
¶·È‰È·ÙÚÈ΋ 2001;64:370-375
°) OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi: Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÙÔ 25% ÙˆÓ Û˘ÁÁÂÓÒÓ ÚÒÙÔ˘ ‚·ıÌÔ‡ ÙÔ˘ ·È‰ÈÔ‡, ·ÚÔ˘ÛÈ¿˙ÂÈ ÁψÛÛÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ ‰È·Ù·Ú·¯¤˜ Ì¿ıËÛ˘. ∂›Û˘, Ú¤ÂÈ Ó· ÂÚ¢ÓËıÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ fiˆ˜ ·ÈÌÔÌÈÍ›·, Ì·ÎÚÔ¯ÚfiÓÈ· ÛÙ›ڈÛË ‹ ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹ Û ¿ÏÏ· ̤ÏË ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. º˘ÛÈ΋ ÂͤٷÛË: OÈ Î·Ì‡Ï˜ ·‡ÍËÛ˘ Î·È ÔÈ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ˆ˜ ÚÔ˜ ÙÔ ‚¿ÚÔ˜, Ì‹ÎÔ˜ Î·È ¶.∫., Ú¤ÂÈ Ó· ˘ÔÏÔÁ›˙ÔÓÙ·È ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ¶Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÔÓÙ·È ÔÔÈÂÛ‰‹ÔÙ ÌÈÎÚ¤˜ ۈ̷ÙÈΤ˜ ‰˘ÛÌÔÚʛ˜ - Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜. ∆ÚÂȘ ‹ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜, ‰Â›¯ÓÔ˘Ó È‰ÈÔÛ˘ÛÙ·Ûȷ΋ ‰È·Ù·Ú·¯‹, Ô˘ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÙÂÚ·ÙÔÁ¤ÓÂÛË, ¯ÚˆÌÔÛˆÌÈΤ˜ ηıÒ˜ Î·È ÔÏ˘ÁÔÓȉȷΤ˜ ‹ ÌÔÓÔÁÔÓȉȷΤ˜ ·ÓˆÌ·Ï›Â˜. ∂›Û˘, Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È Ô ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ·˜ ÔÙÈο Î·È ‰È¿ Ù˘ „ËÏ·Ê‹Ûˆ˜ (˘Ô‚ÏÂÓÓÔÁfiÓÈÔ Ï˘ÎfiÛÙÔÌ·) ÁÈ· ÙË ‰È·›ÛÙˆÛË ‰Èۯȉԇ˜ ÛÙ·Ê˘Ï‹˜ ‹ ‰Èۯȉԇ˜ ˘ÂÚÒ·˜. ∂ÈϤÔÓ, Ú¤ÂÈ Ó· ÈÛÙÔÔÈÔ‡ÓÙ·È ÔÈ Ó¢ÚÔ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜, ‰ÈfiÙÈ Â›Ó·È Û˘¯Ó¿ Ù· ÚÔ‚Ï‹Ì·Ù· ÏfiÁÔ˘ Î·È Ì¿ıËÛ˘ Û ·È‰È¿ Ì Ó¢ÚÔ˚ӈ̿وÛË. ∏ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô ÁÈ· ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ¿Óˆ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ·, ÙˆÓ ‚·ÛÈÎÒÓ Á·ÁÁÏ›ˆÓ Î·È Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ Ô˘ ÂΉËÏÒÓÔÓÙ·È Ì ۷ÛÙÈÎfiÙËÙ·, ‰˘Û·ÚıÚ›·, ·ı¤ÙˆÛË Î·È Ó˘ÛÙ·ÁÌfi. ∂›Û˘, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂϤÁ¯ÔÓÙ·È ÔÈ ÎÈÓËÙÈο Û˘Ó‰Â‰Â̤Ó˜ ÂÚÈÔ¯¤˜, ‰ËÏ·‰‹ Ë ÛÙÔÌ·ÙÔÎÈÓËÙÈ΋ ‹ Ë ‰˘ÛÚ·Í›· ÏÂÙÒÓ ¯ÂÈÚÈÛÌÒÓ Î·ıÒ˜ Î·È ÔÔÈ·‰‹ÔÙ Âȉ›ӈÛË Ù˘ ÎÈÓËÙÈ΋˜ ÌÔÓ¿‰·˜ Ô˘ ÂΉËÏÒÓÂÙ·È ÌÂ Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ·ÛıÂÓ‹ ¤ÎÏ˘ÛË ÙˆÓ ÙÂÓÔÓÙ›ˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ, .¯. Ë Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ˘˜ 1836 Ì‹Ó˜ ˆ˜ ‹È· ηı˘ÛÙ¤ÚËÛË Ù˘ ·‰Ú‹˜ ÎÈÓËÙÈÎfiÙËÙ·˜, ·‰ÂÍÈfiÙËÙ· Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ ÁψÛÛÈ΋˜ ·Ó¿Ù˘Í˘. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ∏ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ ‚·Û›˙ÂÙ·È ÛÙËÓ ÔÌ·Ï‹ ÚfiÛÏË„Ë ÙˆÓ Ó¢ÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ ·fi ÙÔ˘˜ Ó¢ÚÒÓ˜ (·ÎÔ‹, fiÚ·ÛË), ÛÙËÓ ·Î¤Ú·ÈË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ∫.¡.™. Î·È ÛÙËÓ ÔÌ·Ï‹ Ó¢ÚÈ΋ ·¿ÓÙËÛË Û ¤Ó· ·Î¤Ú·ÈÔ, ·fi ·Ó·ÙÔÌÈ΋ ¿Ô„Ë, ʈÓËÙÈÎfi Û‡ÛÙËÌ·. ∂Ô̤ӈ˜, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·Ó·Ê¤ÚÂÙ·È ÛÙȘ ÂÈ̤ÚÔ˘˜ ·˘Ù¤˜ ÏÂÈÙÔ˘ÚÁ›Â˜, fiˆ˜ Ê·›ÓÂÙ·È Î·È ÛÙË Û¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË: ¶ÚfiÛÏË„Ë Ó¢ÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ ÎÂÓÙÚÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ Ó¢ÚÈ΋ ·¿ÓÙËÛË. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂٷ͇ Ù˘ ·ÒÏÂÈ·˜ ·ÎÔ‹˜, ·ÚÔ‰È΋˜ ‹
Paediatriki 2001;64:1370-375
ÌfiÓÈÌ˘, Ù˘ ̤Û˘ ˆÙ›Ùȉ·˜, Ù˘ ÓÔËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘, ÙÔ˘ ·˘ÙÈÛÌÔ‡, ÙÔ˘ ÙÚ·˘ÏÈÛÌÔ‡ Î·È ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÊˆÓ‹˜. ™ÙË ÛËÌÂÚÈÓ‹ ·ÚÔ˘Û›·ÛË ı· ÂÚÈÔÚÈÛÙԇ̠ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ·ÒÏÂÈ·˜ ·ÎÔ‹˜, Ô˘ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË Î·ÙËÁÔÚ›·. ∞ÒÏÂÈ· ·ÎÔ‹˜ ∆Ô ·ÓıÚÒÈÓÔ ·˘Ù› ·ÓÙ·ÔÎÚ›ÓÂÙ·È Û ‹¯Ô˘˜ Û˘¯ÓfiÙËÙ·˜ 250 Î·È 16.000 ·ÎψÓ/sec (Hertz, Hz) Î·È ¤ÓÙ·Û˘ 0-120 decibels (dB). ∞ÒÏÂÈ· ·ÎÔ‹˜ ̤¯ÚÈ 30 dB ıˆÚÂ›Ù·È “Ê˘ÛÈÔÏÔÁÈ΋” ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ÂÈÙÚ¤ÔÓÙ·˜ οÔÈÔ˘ ‚·ıÌÔ‡ ·ÒÏÂÈ· Ì ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜. ™Ù· ·È‰È¿, ·ÒÏÂÈ· ·ÎÔ‹˜ ̤¯ÚÈ 25 dB ıˆÚÂ›Ù·È ÂÏ¿¯ÈÛÙË, ÛÙ· ‚Ú¤ÊË, fï˜, Ô˘ Â›Ó·È ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ, ·ÛΛ ȉȷ›ÙÂÚ· ·ÚÓËÙÈ΋ ›‰Ú·ÛË ˆ˜ ÚÔ˜ ÙË ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË. ∆· 25-40 dB ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ÌÈÎÚ‹ ·ÒÏÂÈ·, 40-55 dB ˆ˜ ̤ÙÚÈ· ·ÒÏÂÈ·, 55-70 dB ˆ˜ ÌÂÙÚ›ˆ˜ ‚·ÚÈ¿ ·ÒÏÂÈ·, 70-90 dB ˆ˜ ‚·ÚÈ¿ ·ÒÏÂÈ·, ÂÓÒ >90 dB ˆ˜ ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ·ÒÏÂÈ·. ∏ ·ÒÏÂÈ· Ù‡Ô˘ ·ÁˆÁÈÌfiÙËÙ·˜ Â›Ó·È Û˘Ó‹ıˆ˜ ÔÌÔÈfiÌÔÚÊË Û fiϘ ÙȘ Û˘¯ÓfiÙËÙ˜, ÂÓÒ Ë Ó¢ÚÔ·ÈÛıËÙËÚȷ΋ ·ÒÏÂÈ· ·ÊÔÚ¿ ÂÚÈÛÛfiÙÂÚÔ ÙȘ ˘„ËϤ˜ Û˘¯ÓfiÙËÙ˜. ∏ ÌÂÚÈ΋ ·ÒÏÂÈ· ·ÎÔ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·Ú¯Èο ˆ˜ ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÙÈÏËÙÈÎfiÙËÙ·˜ Ù˘ ÔÌÈÏ›·˜. ∆· Û˘ÚÚÈÛÙÈο Û‡Ìʈӷ (Û, Í, Ê) ·ÔÙÂÏÔ‡Ó ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜, ¯·ÌËÏ‹˜ ¤ÓÙ·Û˘ ÂÚÂı›ÛÌ·Ù· (4.000 Hz Î·È 30 dB) Î·È ‰ÂÓ Á›ÓÔÓÙ·È ·ÓÙÈÏËÙ¿ ·fi ÙÔ ·È‰› Ì ÌÈÎÚ‹ ÚÔ˜ ̤ÙÚÈ· ·ÒÏÂÈ· ·ÎÔ‹˜. µ·ÚÈ¿ ·ÒÏÂÈ· Û˘Ó‰¤ÂÙ·È Ì ÂÍ›ÛÔ˘ ‚·ÚÈ¿ ‰È·Ù·Ú·¯‹ Ù˘ ηٷÓfiËÛ˘ Î·È Ù˘ ·Ó¿Ù˘Í˘ Ù˘ ÔÌÈÏ›·˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ Û˘ÁÁÂÓÔ‡˜ ÎÒʈÛ˘, Ù· ʈӋ̷ٷ ÔÙ¤ ‰ÂÓ ·Ó·Ù‡ÛÛÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó· ÌË Â‰ÈÎfi ‚¿‚ÈÛÌ· „¤ÏÏÈÛÌ· Î·È ¯·Ú·ÎÙËÚÈÛÙÈο, ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6-9 ÌËÓÒÓ, ·Ú¯›˙ÂÈ Î·È Êı›ÓÂÈ Ë ÔÏÈ΋ ·Ú·ÁˆÁ‹ ʈÓËÌ¿ÙˆÓ, ÂÓÒ Ë ÔÙÈ΋ ÂÈÎÔÈÓˆÓ›· ·Ú·Ì¤ÓÂÈ ·Î¤Ú·ÈË. ¢È·ÎÚ›ÓÔÓÙ·È ‰‡Ô ηÙËÁÔڛ˜ ·ÒÏÂÈ·˜ ·ÎÔ‹˜: ·) Ë ·ÚÔ‰È΋, ÌÈÎÚ‹ ÚÔ˜ ̤ÙÚÈ· ·ÒÏÂÈ·, Ù‡Ô˘ ·ÁˆÁÈÌfiÙËÙ·˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÎÎÚÈÙÈ΋ ̤ÛË ˆÙ›Ùȉ· (∂ªø) Î·È ‚) Ë ÌfiÓÈÌË (·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙ›· Î·È ÙÔ Ì¤ÁÂıÔ˜) ·ÒÏÂÈ·, ΢ڛˆ˜ Ó¢ÚÔ·ÈÛıËÙËÚÈ·ÎÔ‡ Ù‡Ô˘. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÎÎÚÈÙÈ΋ ̤ÛË ˆÙ›Ùȉ· (∂ªø), fiÛÔ ÓˆÚ›ÙÂÚ· Á›ÓÂÈ Ë ·ÔÎ¿Ï˘„Ë Î·È Ë ‰È¿ÁÓˆÛË Ù˘ ‚·ÚËÎÔ˝·˜, ÙfiÛÔ ÈÔ ¤ÁηÈÚ· ı· ·ÓÙÈÌÂÙˆÈÛÙ›. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ¤¯ÂÈ ÙÂÚ¿ÛÙÈ· ÛËÌ·Û›·, ÙfiÛÔ ÁÈ· ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· Ù˘ ·ÎÔ‹˜, fiÛÔ Î·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜, ‰ÈfiÙÈ Ù· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÂÎÏÂÎÙÈ΋ ÂÚ›Ô‰Ô ‰ÂÎÙÈÎfiÙËÙ·˜ ÙˆÓ Ó¢ÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∂›Ó·È ‰ËÏ·‰‹ Ë “ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô˜” Ù˘ Ó¢ÚÈ΋˜
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¶·È‰È·ÙÚÈ΋ 2001;64:370-375
·Ó¿Ù˘Í˘, ηٿ ÙËÓ ÔÔ›· ·ÎfiÌ· Î·È Ë ·ÚÔ‰È΋ ·ÈÛıËÙËÚȷ΋ ·ÔÛÙ¤ÚËÛË ·Ú¿ÁÂÈ ÌË ·Ó·ÛÙÚ¤„È̘ ‚Ï¿‚˜ ÙÔ˘ ∫.¡.™. Î·È ÂÔ̤ӈ˜ ÌfiÓÈ̘ ‰È·Ù·Ú·¯¤˜ ÛÙË ÁψÛÛÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∞Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ Û ·È‰È¿ ÙÔ˘ ‰ËÌÔÙÈÎÔ‡ Û¯ÔÏ›Ԣ Ì ‰È·Ù·Ú·¯¤˜ ÛÙË ÁψÛÛÈ΋ ·Ó¿Ù˘ÍË, ¤‰ÂÈÍ·Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ̤Û˘ ˆÙ›Ùȉ·˜ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ∂›Û˘, ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ‚Ú¤ÊË Ì¤¯ÚÈ 2 ÂÙÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚ˜ ·fi 130 Ë̤Ú˜ ∂ªø, ˘ÔÏ›ÔÓÙ·Ó ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜, ¤Ó·ÓÙÈ ‚ÚÂÊÒÓ Ì ÏÈÁfiÙÂÚ˜ ·fi 30 Ë̤Ú˜ ∂ªø. O ·ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È ··Ú·›ÙËÙÔ˜, ‰ÈfiÙÈ ·ÒÏÂÈ· ·ÎÔ‹˜ ÌÂÁ¤ıÔ˘˜ 40-50 dB ÌÔÚ› Ó· ÌË Û˘Óԉ‡ÂÙ·È ·fi ·ÓÙ›ÛÙÔÈ¯Ë Û˘Ìو̷ÙÔÏÔÁ›· Ù˘ Ù˘Ì·ÓÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∞Ó Ô ·ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û ‚Ú¤ÊË ÌÈÎÚfiÙÂÚ· ÙˆÓ 24 ÌËÓÒÓ ·Ôηχ„ÂÈ Û˘Ó¯È˙fiÌÂÓË ·ÒÏÂÈ· ·ÎÔ‹˜ 45-50 dB, ÙfiÙÂ Û˘ÓÈÛÙ¿Ù·È Ë ÙÔÔı¤ÙËÛË ÛˆÏËÓ·Ú›ˆÓ ‹ Ë ¯Ú‹ÛË ·ÎÔ˘ÛÙÈÎÔ‡, ·ÓÂÍ¿ÚÙËÙ· ‚¤‚·È· ·fi ÙÔ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÂÂÈÛÔ‰›ˆÓ ∂ªø. ªfiÓÈÌË ·ÒÏÂÈ· ·ÎÔ‹˜ ∏ ̤ÛË ËÏÈΛ· ‰È¿ÁÓˆÛ˘ Ù˘ ‚·ÚÈ¿˜ Û˘ÁÁÂÓÔ‡˜ ÎÒʈÛ˘ Â›Ó·È 24 Ì‹Ó˜, ÂÓÒ Ë ÌÂÚÈ΋ ·ÒÏÂÈ· ·ÎÔ‹˜ (˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ‹ ÂÙÂÚfiÏ¢ÚË) Á›ÓÂÙ·È ·ÓÙÈÏËÙ‹ ÛÙ· 4-5 ¯ÚfiÓÈ·. §fiÁˆ Ù˘ ‰˘ÛÎÔÏ›·˜ Ù˘ ‰È¿ÁÓˆÛ˘, fiÏ· Ù· ·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙËÓ ÔÌ¿‰· “˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘” Ú¤ÂÈ Ó· ˘Ô‚ÏËıÔ‡Ó Û ·ÎÔÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ fiÛÔ ÈηÓÔÔÈËÙÈο Ê·›ÓÂÙ·È fiÙÈ ·ÎÔ‡ÓÂ Î·È ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ‡·ÚÍË ¿ÏÏ˘ ÂÚÌËÓ›·˜ ÁÈ· ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ÁψÛÛÈ΋˜ ·Ó¿Ù˘Í˘, fiˆ˜ .¯. ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË ‹ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∞˜ ÛËÌÂȈı› fiÙÈ Î·Ó¤Ó· ·È‰› ‰ÂÓ ıˆÚÂ›Ù·È Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜ ÁÈ· Ó· ÂÏÂÁ¯ı› ·ÎÔÔÏÔÁÈο (¶›Ó·Î·˜ 2). ∂ÈÛËÌ·›ÓÂÙ·È fiÙÈ ÙÔ ¤Ó· ÙÚ›ÙÔ ¤ˆ˜ ÙÔ ‹ÌÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ÌfiÓÈÌË ·ÒÏÂÈ· ·ÎÔ‹˜, ¤¯ÂÈ ÁÂÓÂÙÈ΋ ÂÈ‚¿Ú˘ÓÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ú¤ÂÈ Ó· ·Ú¤¯ÂÙ·È ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋.
Paediatriki 2001;64:1370-375
¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ŸÏ· Ù· ·È‰È¿ Ì ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ ı· Ú¤ÂÈ Ó· ˘Ô‚ÏËıÔ‡Ó Û ·ÎÔÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Î·È ·Ó·Ù˘Íȷ΋ ÂÎÙ›ÌËÛË. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ‰ÂÓ ÂӉ›ÎÓ˘Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ÂÎÙfi˜ ·Ó ˘¿Ú¯Ô˘Ó ÂÛÙȷΤ˜ Ó¢ÚÔÏÔÁÈΤ˜ ‚Ï¿‚˜ (Û·ÛÌÔ›, ËÌÈ¿ÚÂÛË) ‹ οÔÈÔ Û‡Ó‰ÚÔÌÔ Ì ÁÓˆÛÙ‹ ·ıÔÏÔÁ›· ·fi ÙÔ ∫.¡.™. ∆Ô ∂EG ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ·Í›· Î·È ÂӉ›ÎÓ˘Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ (.¯. Û ·ÎÔ˘ÛÙÈ΋ ·ÁÓˆÛ›·). ∏ ÔÊı·ÏÌÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Â›Ó·È Û˘¯Ó¿ ¯Ú‹ÛÈÌË ˆ˜ ‰È·ÁÓˆÛÙÈ΋ ÂͤٷÛË, ȉȷ›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘, ÛÙȘ Ôԛ˜ ÌÔÚ› Ó· ·Ôηχ„ÂÈ Î·Ù·ÚÚ¿ÎÙË, ¯ÔÚÈÔ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ·, ·ÙÚÔÊ›· ÔÙÈÎÔ‡ Ó‡ÚÔ˘ ‹ ÂÎʇÏÈÛË Ù˘ ÔÙÈ΋˜ ıËÏ‹˜. ∏ ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁÈ΋ ÂͤٷÛË ÂӉ›ÎÓ˘Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ (fiÙ·Ó ·Ú·ÙËÚÂ›Ù·È ‚Ú¿Á¯Ô˜ ʈӋ˜, Û˘ÚÈÁÌfi˜, ˘Ô‚ÏÂÓÓÔÁfiÓÈ· ‰Èۯȉ‹ ˘ÂÚÒ·). ™Â ·˘ÙÈÛÙÈο Î·È ÓÔËÙÈο ˘ÛÙÂÚË̤ӷ ·È‰È¿, Ì ˘Ô„›· ÔÚÁ·ÓÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î·Ú˘fiÙ˘Ô˜ Î·È ¤ÏÂÁ¯Ô˜ ÁÈ· ÙÔ Â‡ıÚ·˘ÛÙÔ Ã. ∫·Ù¿ ÙËÓ ·Ó·Ù˘Íȷ΋ ÂÎÙ›ÌËÛË Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÓÙÔÈÛÙÔ‡Ó Ù· ·ÎfiÏÔ˘ı· ·ÓËÛ˘¯ËÙÈο ÛËÌ›· ˆ˜ ÚÔ˜ ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ Î·È Ù· ÔÔ›· ÂÈÛËÌ·›ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ‰È·Ù·Ú·¯‹˜. ™˘ÁÎÂÎÚÈ̤ӷ, fiÙ·Ó ÙÔ ·È‰›: ·) Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ·ÎÔ‡ÂÈ ‹ ‰ÂÓ ÚÔÛ¤¯ÂÈ, ‚) ÛÙÔ˘˜ 12 Ì‹Ó˜ ‰ÂÓ ·ÓÙȉڿ ÛÙÔ fiÓÔÌ¿ ÙÔ˘, ‰ÂÓ Î·Ù·Ï·‚·›ÓÂÈ ÙÔ “ÌË”, ‰ÂÓ ·ÓÙȉڿ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ̛· ÁÓˆÛÙ‹ ϤÍË, Á) ÛÙÔ˘˜ 18 Ì‹Ó˜ ‰ÂÓ ·Ú¿ÁÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 1-2 ϤÍÂȘ, ‰) ÛÙÔ˘˜ 24 Ì‹Ó˜ ‰Â›¯ÓÂÈ Ó· ÌËÓ ·ÓÙÈÏ·Ì‚¿ÓÂÙ·È ÙË Û˘Ì‚ÔÏÈ΋ ·Ó··Ú¿ÛÙ·ÛË (.¯. Ó· ·›˙ÂÈ Ì ÙËÓ ÎÔ‡ÎÏ·, Ó· ¯ÚËÛÈÌÔÔÈ› ÎÔÈÓ‹˜ ¯Ú‹Û˘ ·ÓÙÈΛÌÂÓ· Û ÌÈÓÈ·ÙÔ‡Ú˜, fiˆ˜ ÎÔ˘Ù¿ÏÈ, ·ÂÏÏÔ, ÎÙ¤Ó·), Â) ÛÙ· 3 ¯ÚfiÓÈ· ‰Â›¯ÓÂÈ ·‰˘Ó·Ì›· Ó· ÚÔÛ¤¯ÂÈ Û ̛· ÈÛÙÔÚ›·, ‰ÂÓ ÂÎÙÂÏ› ÂÓÙÔϤ˜, ‰ÂÓ ·ÓÙÈÏ·Ì‚¿ÓÂÙ·È ÙÔÈΤ˜ ÚÔı¤ÛÂȘ (̤۷, ¤Íˆ, οو, ‰›Ï·) ηÈ
¶›Ó·Î·˜ 2. ∂Ӊ›ÍÂȘ ÁÈ· ·ÎÔÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ñ ªÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (ª∂¡¡) - µ° <2.500 g : ŸÏ˜ ÔÈ ÂÚÈÙÒÛÂȘ - µ° >2.500 g : ∞Ó ˘¿Ú¯Ô˘Ó ÂÈÏÔΤ˜ (·ÛÊ˘Í›·, Û·ÛÌÔ›, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ˆÙÔÙÔÍÈο Ê¿Ú̷η) ñ ∂Ó‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ñ µ·ÎÙËÚȉȷ΋ ÌËÓÈÁÁ›Ùȉ· ñ ∞ӈ̷ϛ˜ ÙÔ˘ 1Ô˘ ‹ 2Ô˘ ‚Ú·Á¯È·ÎÔ‡ ÙfiÍÔ˘ (ÌÈÎÚˆÙ›·, ‰˘ÛÏ·Û›· ˆÙfi˜, ÌÈÎÚÔÁÓ·ı›·) ñ ∞ӈ̷ϛ˜ ÂÎÙÔ‰¤ÚÌ·ÙÔ˜ (.¯. ÌÂÁ¿ÏË ·fiÛÙ·ÛË ÌÂٷ͇ ÙˆÓ ÔÊı·ÏÌÒÓ) ñ OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÎÒʈÛ˘ ñ ∞ÓËÛ˘¯›· ÙˆÓ ÁÔÓ¤ˆÓ ñ ∫·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÁÏÒÛÛ·˜ ‹ Ù˘ ÔÌÈÏ›·˜ ñ ÕÏϘ ·Ó·Ù˘ÍȷΤ˜ ·ÓˆÌ·Ï›Â˜ (ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ·˘ÙÈÛÌfi˜)
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‰ÂÓ ¯ÚËÛÈÌÔÔÈ› ÊÚ¿ÛÂȘ ·fi 2-3 ϤÍÂȘ Î·È ÛÙ) ÛÙ· 3 ¯ÚfiÓÈ·, ‹ Î·È ·ÚÁfiÙÂÚ·, ·Ú¿ÁÂÈ ÔÌÈÏ›· Ô˘ ‰ÂÓ ¤¯ÂÈ Û¯¤ÛË Ì ÙËÓ Î·Ù¿ÛÙ·ÛË Ô˘ ‚Ú›ÛÎÂÙ·È (˯ÔÏ·Ï›·). µÈ‚ÏÈÔÁÚ·Ê›· 1. Coplan J. Delayed language or speech. In: Stockman AJ, editor. Difficult Diagnosis in Pediatrics. W.B. Saunders comp; 1990. 2. Dunn LM, Dunn LM. PPVT. Peabody Picture Vocabulary Test. Revised. Circle Pines MN. American Guidance Service; 1981. 3. Holt SK. Developmental Paediatrics. Perspectives and Practice. London: Butterworths & Co Ltd; 1977. 4. O' Callaghan M, Williams MG, Andersen JM, Bor W, Najman MJ. Social and biological risk factors for mild and borderline impairment of language comprehension in a
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cohort of five-year-old children. Dev Med Child Neurol 1995;37:1051-1061. 5. Sheridan MD. Manual for the Stycar Language Test. Windsor, Berks: NFER Publishing Company; 1976. 6. ∆Û›ÙÛÈη ∂. ∏ ÂͤÏÈÍË Ù˘ ÔÌÈÏ›·˜ ÛÙÔ ·È‰›. ∂ÈÛ‹ÁËÛË ÛÙÔ ™ÂÌÈÓ¿ÚÈÔ: “∏ ÔÌÈÏ›· ÛÙ· ·È‰È¿ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘”. π·ÙÚÈ΋ 1976;29:175-196.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ∆˙›Ì·-∆Û›ÙÛÈη ¡ÔÛÔÎÔÌÂ›Ô ¡πªπ∆™ ªÔÓ‹˜ ¶ÂÙÚ¿ÎË 12, 115 21, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∏ ¯ÔÚ‹ÁËÛË Ì›·˜ ÌfiÓÔ ÂÓ‰ÔÌ˘˚΋˜ ‰fiÛ˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ Â›Ó·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ú‰ÓÈ˙fiÓË ÛÙȘ ÎÚ›ÛÂȘ ¿ÛıÌ·ÙÔ˜ Û ·È‰È¿1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ó· ÂÎÙÈÌËı› Â¿Ó Ì›· ÌfiÓÔ ÂÓ‰ÔÌ˘˚΋ ‰fiÛË ‰ÂÍ·ÌÂı·˙fiÓ˘ (IM Dex) Â›Ó·È ÂÍ›ÛÔ˘ ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙËÓ ÂÓı‹ÌÂÚË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙fiÓ˘ (p.os Pred) ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ‹È·˜ Î·È Ì¤Û˘ ÎÚ›Û˘ ¿ÛıÌ·ÙÔ˜ Û ·È‰È¿. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ÚÔÔÙÈ΋ Î·È Ù˘¯·ÈÔÔÈË̤ÓË ·˘Ù‹ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·fi ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ È·ÙÚÈÎfi ΤÓÙÚÔ ÙˆÓ ∏¶∞ Û ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 7 ÂÙÒÓ. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¯ÚÂÈ¿˙ÔÓÙ·Ó ÛÙÂÚÔÂȉ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÂÎÙfi˜ ÓÔÛÔÎÔÌ›Ԣ ‹ÈˆÓ Î·È Ì¤ÙÚÈˆÓ ÎÚ›ÛÂˆÓ ¿ÛıÌ·ÙÔ˜. OÈ ·ÛıÂÓ›˜ ‰È·¯ˆÚ›ÛÙËÎ·Ó Ù˘¯·›· Û ‰‡Ô ÔÌ¿‰Â˜: Û ·˘ÙÔ‡˜ Ô˘ ¤Ï·‚·Ó Ì›· ÌfiÓÔ ‰fiÛË IM Dex (ÂÚ›Ô˘ 1,7 mg/kg) Î·È Û ·˘ÙÔ‡˜ Ô˘ ¤Ï·‚·Ó p.os Pred (ÂÚ›Ô˘ 2 mg/kg/24h › 5 Ë̤Ú˜). ∂› 7 Ë̤Ú˜ ÁÈÓfiÙ·Ó ÎÏÈÓÈ΋ ‚·ıÌÔÏfiÁËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Î·Ù·ÁÚ·Ê‹ Ù˘ ·ÏÏ·Á‹˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·ÛıÂÓÒÓ, Ù˘ ¯Ú‹Û˘ ·ÏÌÔ˘ÙÂÚfiÏ˘ Î·È Ù˘ ·ÓÔ¯‹˜ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. ∞ÔÙÂϤÛÌ·Ù·: ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó Û˘ÓÔÏÈο 15 ·È‰È¿ (̤Û˘ ËÏÈΛ·˜ 37 ÌËÓÒÓ), ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠIM Dex Î·È 17 (̤Û˘ ËÏÈΛ·˜ 36 ÌËÓÒÓ), Ù· ÔÔ›· ¤Ï·‚·Ó p.os Ped. ™ËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛËÌÂÈÒıËΠηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 5 ËÌÂÚÒÓ Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚËı› ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ‚·ıÌfi ‚ÂÏÙ›ˆÛ˘ ÌÂٷ͇ ÙÔ˘˜.
™Â 3 ·È‰È¿ ·Ú·Ï›ÊıËÎÂ, ÏfiÁˆ ¿ÚÓËÛ‹˜ ÙÔ˘˜, ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 75% Ù˘ ‰fiÛ˘ Ú‰ÓÈ˙fiÓ˘, ÂÓÒ 4 ·ÎfiÌË ‰ÂÓ ¤Ï·‚·Ó ÙÔ 30-50% ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘˜. ∏ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÛË ‰ÂÍ·ÌÂı·˙fiÓ˘ ‰ÂÓ ÚÔοÏÂÛ ·ÚÂÓ¤ÚÁÂȘ. ∆Ô 75% ÙˆÓ ÁÔÓ¤ˆÓ Î·È ·fi ÙȘ 2 ÔÌ¿‰Â˜ ‰‹ÏˆÛ fiÙÈ ı· ÚÔÙÈÌÔ‡Û ÙËÓ IM Dex Û ÂfiÌÂÓË ÎÚ›ÛË ¿ÛıÌ·ÙÔ˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ™Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ê¿ÓËΠfiÙÈ Ë ¯ÔÚ‹ÁËÛË Ì›·˜ ÌfiÓÔ ÂÓ‰ÔÌ˘˚΋˜ ‰fiÛ˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ ‹Ù·Ó ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙËÓ ÂÓı‹ÌÂÚË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ú‰ÓÈ˙fiÓË ÛÙȘ ÎÚ›ÛÂȘ ‹ÈÔ˘ Î·È Ì¤ÛÔ˘ ‚·ıÌÔ‡ ¿ÛıÌ·ÙÔ˜.
1 Gries DM, Moffitt DR, Pulos E, Carter ER A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children J Pediatr 2000;136:298-303
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∞¡∞¶∆À•π∞∫∏ ¶∞π¢π∞∆ƒπ∫∏
Paediatriki 2001;64:376-383
DEVELOPMENTAL PEDIATRICS
™‡Á¯ÚÔÓË ·ÓÙÈÌÂÙÒÈÛË ÓÔËÙÈÎÒÓ, ÁψÛÛÈÎÒÓ Î·È ÎÈÓËÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ·È‰È¿ ∞. ¡ÈÎÔÏ¿Ô˘ - ¶··Ó·ÁÈÒÙÔ˘
Contemporary rehabilitation of cognitive, linguistic and motor disorders in children A. Nikolaou - Papanagiotou
¶ÂÚ›ÏË„Ë: ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÓÔËÙÈÎÒÓ, ÁψÛÛÈÎÒÓ, ÎÈÓËÙÈÎÒÓ ‹ ¿ÏÏˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ·È‰È¿, ‚·Û›˙ÂÙ·È ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ù˘Íȷ΋˜ ÙÔ˘˜ ηٿÛÙ·Û˘. ªÂ ÙË ‚Ô‹ıÂÈ· ÂȉÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ, fiˆ˜ .¯. Griffiths, M.F.E.D. Î.Ï., Û˘ÏϤÁÔ˘Ì ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ÂÈ̤ÚÔ˘˜ ‰˘Ó·ÙfiÙËÙ˜ ÙÔ˘ ·È‰ÈÔ‡ Û οı ÙÔ̤· ·Ó¿Ù˘Í˘ ¯ˆÚÈÛÙ¿, ‹ÙÔÈ ÙËÓ ·‰Ú¿ Î·È ÏÂÙ‹ ÎÈÓËÙÈÎfiÙËÙ·, ·ÓÙ›ÏË„Ë, ÔÌÈÏ›·, ·˘ÙÔÂ͢ËÚ¤ÙËÛË, ÎÔÈÓˆÓÈÎfiÙËÙ·-Û˘ÌÂÚÈÊÔÚ¿. ∂›Û˘, ·Ó·ÁÓˆÚ›˙Ô˘Ì ÙȘ ·ÏÏËÏÂȉڿÛÂȘ Î·È ÙȘ Û¯¤ÛÂȘ ÙÔ˘˜, ÂÓÙÔ›˙Ô˘Ì ٷ ‚·ÛÈο ÛËÌ›· ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Î·È ÔÈÎÔ‰ÔÌԇ̠ÙÔ ıÂڷ¢ÙÈÎfi ÚfiÁÚ·ÌÌ·. ∆Ô ıÂڷ¢ÙÈÎfi Û¯‹Ì· ÛÙԯ‡ÂÈ ÛÙË ÛÙ‹ÚÈÍË ÔÏfiÎÏËÚ˘ Ù˘ ·Ó¿Ù˘Í˘ Î·È fi¯È ÌfiÓÔ ÙÔ˘ ÂȉÈÎÔ‡ ·Ó·Ù˘ÍÈ·ÎÔ‡ ÂÏÏ›ÌÌ·ÙÔ˜. ™ÙËÓ ÂÚÁ·Û›· ·˘Ù‹ Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙȘ ϤÔÓ Û‡Á¯ÚÔÓ˜, ‰ÈÂıÓ›˜ ıÂڷ¢ÙÈΤ˜ ÌÂıfi‰Ô˘˜ ·ÓÙÈÌÂÙÒÈÛ˘ ·Ó¿ÏÔÁ· Ì ÙȘ ÂÓÙÔÈṲ̂Ó˜ ·fi ÙËÓ ·Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋ ‰È·Ù·Ú·¯¤˜, fiˆ˜ Ê˘ÛÈÎÔıÂڷ›·˜ (ÌÂı. Bobath, Vojta), ÂÚÁÔıÂڷ›·˜ (̤ı. Petö, ·ÈÛıËÙËÚȷ΋ ÂÓۈ̿وÛË Î·Ù¿ S. Ayres), ÎÈÓËÛÈÔıÂڷ›·˜ Î.Ï.
Abstract: The effective management of cognitive, language and motor difficulties in children is influenced by their stage of development. Developmental scales such as Griffiths and M.F.E.D. etc. help us to collect information about children’s performance on different domains (language, self-help skills, social behavior, perception, motor and fine control) and the relationship between them. The above scales enable us to identify the main characteristics of the disorder and plan the suitable therapeutic program. The therapeutic approach aims to improve not only the defective areas but also promote the child’s development as a whole. This paper presents the most internationally recognized and influential methods of rehabilitation such as physiotherapy (Bobath, Vojta), occupational therapy (Petö, sensory integration), motortherapy etc, which are appropriate for the management of the specific underlying disorder.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋, ̤ıÔ‰ÔÈ ·ÔηٿÛÙ·Û˘ ·È‰ÈÒÓ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ.
Key words: developmental assessment, methods of rehabilitation of children with special needs.
™Ù· Ï·›ÛÈ· Ù˘ ÚÔÛ¿ıÂÈ·˜ Ì›ˆÛ˘ ÙˆÓ ÓÔËÙÈÎÒÓ, ÎÈÓËÙÈÎÒÓ, ÁψÛÛÈÎÒÓ ‹ ¿ÏÏˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÎÂÚ‰›˙ÂÈ fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ¤‰·ÊÔ˜ Ë ÚÒÈÌË ‰È¿ÁÓˆÛË. ∞fi ‰È¿ÊÔÚ˜ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÁÓˆÚ›˙Ô˘ÌÂ
fiÙÈ ‹‰Ë ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È ‰˘Ó·ÙfiÓ, Ì ηٿÏÏËÏË ·Ú¤Ì‚·ÛË, Ó· ¤¯Ô˘Ì ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ·Ó¿Ù˘ÍË ÂÓfi˜ ·È‰ÈÔ‡ (1). ∆›ıÂÙ·È fï˜ ÙÔ ÂÚÒÙËÌ· ÔÈÔ˜ Â›Ó·È Ô ÛÙfi¯Ô˜ Ì›·˜ ÚÒÈÌ˘ ÚÔÒıËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÛÙ·
¶·È‰›·ÙÚÔ˜ - ∞Ó·Ù˘ÍÈÔÏfiÁÔ˜, π·ÙÚfi˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜ ∞Ó·ÏËÚÒÙÚÈ· ¢È¢ı‡ÓÙÚÈ· µ’ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ À‡ı˘ÓË π·ÙÚ›Ԣ ∞Ó·Ù˘Íȷ΋˜ - ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ÙÔ˘ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, Aı‹Ó·
Pediatrician - Social Medicine Doctor Associate Director of 2nd Pediatric Department Consultant of Developmental and Social Pediatrics Penteli Children’s Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:376-383
·È‰È¿ Ì ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜. ∫¿ı ÌÔÓÙ¤ÏÔ ‰È··È‰·ÁÒÁËÛ˘ ÚÔÛ·ı› Ó· ‚ÔËı‹ÛÂÈ ÙÔ ·È‰› Ó· ·ÍÈÔÔÈ‹ÛÂÈ fiϘ ÙȘ ‰˘Ó·ÙfiÙËÙ¤˜ ÙÔ˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÊÙ¿ÛÂÈ ÛÙÔ Î·Ï‡ÙÂÚÔ ÛËÌÂ›Ô ·Ó¿Ù˘Í‹˜ ÙÔ˘. ∆Ô ›‰ÈÔ Û˘Ì‚·›ÓÂÈ Î·È Û ·È‰È¿ Ì ·Ó·Ù˘Íȷο ÚÔ‚Ï‹Ì·Ù·, Ù· ÔÔ›· - Û ·ÓÙ›ıÂÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο - ¯ÚÂÈ¿˙ÔÓÙ·È ‚Ô‹ıÂÈ· Î·È ÂÚÈÛÛfiÙÂÚ· ÂÚÂı›ÛÌ·Ù· ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·ÓÙÏ‹ÛÔ˘Ó fiÏÔ ÙÔ ‰˘Ó·ÌÈÎfi ÙÔ˘˜, Ô˘ ÏfiÁˆ Ù˘ ·Ó·ËÚ›·˜ ¤¯ÂÈ ÛËÌ·ÓÙÈο ÂÚÈÔÚÈÛÙ›. ∞˘Ùfi ‰ÂÓ ÛËÌ·›ÓÂÈ fiÙÈ Û’ ¤Ó· Ù¤ÙÔÈÔ ·È‰› ı¤ÙÔ˘Ì ÙÔ˘˜ ›‰ÈÔ˘˜ ÛÙfi¯Ô˘˜ fiˆ˜ Û ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi, ·ÏÏ¿ ÂΛÓÔ Ô˘ ÂÚÈÛÛfiÙÂÚÔ ÂȉÈÒÎÔ˘ÌÂ Â›Ó·È Ó· ÙÔ ‚ÔËı‹ÛÔ˘Ì ӷ ·ÔÎÙ‹ÛÂÈ ÙËÓ ·˘ÙÔÂ͢ËÚ¤ÙËÛ‹ ÙÔ˘ ÁÈ· Ó· ÌÔÚ›, ¤ÙÛÈ, Ó· ÂÓۈ̷وı› ÛÙÔÓ ÎÔÈÓˆÓÈÎfi ÂÚ›Á˘ÚÔ. ∏ ÚÔÒıËÛË ÙˆÓ ÂÈ̤ÚÔ˘˜ ÈηÓÔÙ‹ÙˆÓ ÙÔ˘ ‰ÂÓ Â›Ó·È ·˘ÙÔÛÎÔfi˜, ·ÏÏ¿ Â͢ËÚÂÙ› ÛÙË ‰ËÌÈÔ˘ÚÁ›· Ì›·˜ ·ÓÂÍ¿ÚÙËÙ˘ ·˘ÙÔ‰‡Ó·Ì˘ ÚÔÛˆÈÎfiÙËÙ·˜. ∞˘Ùfi Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ¿ÓÙ· ÛÙË ÛΤ„Ë fiÏˆÓ fiÛˆÓ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ıÂڷ›· ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ, ÁÈ· Ó· Â›Ó·È Û ı¤ÛË Ó· ˙˘Á›˙Ô˘Ó Ì¤¯ÚÈ ÔÈÔ ÛËÌÂ›Ô ÌÔÚ› Ó· ÊÙ¿ÛÂÈ ÙÔ ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ¯ˆÚ›˜ Ó· ÂÍÔ˘ıÂÓÒÓÂÈ ÙÔ ·È‰› (2). ∆Ô Û‡ÓÔÏÔ Ù˘ ıÂڷ¢ÙÈ΋˜ ‰È·‰Èηۛ·˜, ‚‚·›ˆ˜, ÔÊ›ÏÂÈ Ó· Ï¿‚ÂÈ ˘’ fi„ÈÓ Ù˘ ÂÎÙfi˜ ·fi ÙÔ ·È‰› Î·È ÙË ˙ˆ‹ ÔÏfiÎÏËÚ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ¶Ú¤ÂÈ Ó· ·Ó·ÏÔÁÈ˙fiÌ·ÛÙ ÙÔ Î¤Ú‰Ô˜ Ù˘ ÚÔÒıËÛ˘ ÙÔ˘ ·È‰ÈÔ‡ Ì ÙËÓ ·Ó·Ù˘Íȷ΋ ‰È·Ù·Ú·¯‹, ¯ˆÚ›˜ ÙËÓ Ù·˘Ùfi¯ÚÔÓË ˙ËÌÈ¿ Ô˘ ÌÔÚ› Ó· ˘ÔÛÙ› ·fi ÙËÓ ÂÁηٿÏÂÈ„Ë ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· Ê˘ÛÈÔÏÔÁÈο ·‰¤ÚÊÈ·. ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ‚·Û›˙ÂÙ·È ÛÙËÓ ·Ó·Ù˘Íȷ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡. O ·È‰ÈÎfi˜ ÔÚÁ·ÓÈÛÌfi˜ ‰¤¯ÂÙ·È ¿ÂÈÚ· ÂÚÂı›ÛÌ·Ù· ·fi ÙÔ Â͈ÙÂÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ. ªÔÚ› fï˜ Ó· ÂÂÍÂÚÁ·ÛÙ› fiÛ· ÙÔ ·Ó·Ù˘ÍÈ·Îfi ÙÔ˘ ‰˘Ó·ÌÈÎfi ÙÔ‡ ÂÈÙÚ¤ÂÈ. °È· ·Ú¿‰ÂÈÁÌ·: ·) ª›· „˘¯ÔÓÔËÙÈ΋ ‰È·Ù·Ú·¯‹ ÂÚÈÔÚ›˙ÂÈ Î·Ù¿ ηÓfiÓ· ÙË ‰˘Ó·ÙfiÙËÙ· ·ÓÙ›Ï˄˘ ·˘ÙfiÌ·ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ‚) ∫ÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‰ÂÓ ÂÈÙÚ¤Ô˘Ó ÛÙÔ ·È‰› Ó· Û˘ÏÏ¿‚ÂÈ Â‡ÎÔÏ· Î·È Û˘ÓÂȉËÙ¿ ¤Ó· ·ÓÙÈΛÌÂÓÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌËÓ Â›Ó·È Û ı¤ÛË Ó· Û˘ÏϤÍÂÈ ÙȘ ··Ú·›ÙËÙ˜ ÂÌÂÈڛ˜ ̤۷ ·fi ÙË ‰È·‰Èηۛ· Ù˘ Û‡ÏÏ˄˘ Î·È Ù˘ ·Ê‹˜. Á) ∞ÈÛıËÙËÚȷΤ˜ ‰È·Ù·Ú·¯¤˜ ¯ÚÂÈ¿˙ÔÓÙ·È Â›Û˘ ÌÂÁ·Ï‡ÙÂÚË ‚Ô‹ıÂÈ·, ÁÈ· Ó· ·ÓÙÈÛÙ·ıÌÈÛÙÔ‡Ó Ù· ÂÏÏ›ÌÌ·Ù· Î.Ï. °ÂÓÈÎÒ˜, Û ÔÏϤ˜ ÂÁÎÂÊ·ÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Ë Û˘ÏÏÔÁ‹ Î·È Ë ÂÂÍÂÚÁ·Û›· ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∂›Ó·È, ÏÔÈfiÓ, ··Ú·›ÙËÙÔ Ó· ‰ÔÌÂ›Ù·È Ë ıÂڷ›· ÛÙË ‚¿ÛË Ù˘ ·Ó·Ù˘Íȷ΋˜ ‰È·ÁÓˆÛÙÈ΋˜.
Paediatriki 2001;64:376-383
£Âڷ›· ¯ˆÚ›˜ ·Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋ ÌÔÈ¿˙ÂÈ Ì ˙˘Áfi Ô˘ ·›˙ÂÈ ÌÂٷ͇ “ÌÂȈ̤Ó˘” Î·È “˘ÂÚ‚ÔÏÈ΋˜ ÚÔÒıËÛ˘”, ÌÂٷ͇ “„·Í›Ì·ÙÔ˜” Î·È “Ï¿ıÔ˘˜”. O ¯ÚfiÓÔ˜ Ô˘ ¯¿ÓÂÙ·È Ì¤Û· Û ·˘Ù‹ ÙË ‰È·‰Èηۛ· ÂÈʤÚÂÈ ·ÒÏÂÈ· ÛÙËÓ ·Ó·Ù˘Íȷ΋ ‰˘Ó·ÙfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡. ∞˘Ùfi ‰ÂÓ ÛËÌ·›ÓÂÈ ÌfiÓÔ ·ÒÏÂÈ· Ù˘ ÂÚ·ÈÙ¤Úˆ ÏÂÈÙÔ˘ÚÁÈ΋˜ ÙÔ˘ ·Ó¿Ù˘Í˘, ·ÏÏ¿ Î·È ‰¤ÛÌ¢ÛË Ôχ ÛËÌ·ÓÙÈÎfiÙÂÚˆÓ ‚·ÛÈÎÒÓ ÈηÓÔًوÓ, fiˆ˜ .¯. Ù˘ ‰È¿ıÂÛ˘ Û˘ÓÂÚÁ·Û›·˜, Ù˘ ‰È¿ÚÎÂÈ·˜ Î·È Ù˘ ¯·Ú¿˜ ÁÈ· ‰ËÌÈÔ˘ÚÁÈ΋ ··Û¯fiÏËÛË, Ù˘ ÂÙÔÈÌfiÙËÙ·˜ ÁÈ· ÂÚÈÛÛfiÙÂÚË ‰Ú·ÛÙËÚÈfiÙËÙ· Î.Ï. ªÂ ÙËÓ ·Ó·Ù˘Íȷ΋ ‰ÔÎÈÌ·Û›· ÌÔÚԇ̠ӷ Û˘ÏϤÍÔ˘Ì ÛÊ·ÈÚÈο ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ·Ó·Ù˘Íȷ΋ ηٿÛÙ·ÛË ÂÓfi˜ ·È‰ÈÔ‡. ªÔÚԇ̠̠ÙË ‚Ô‹ıÂÈ¿ Ù˘ Ó· ÏËÚÔÊÔÚËıԇ̠ÙȘ ÂÈ̤ÚÔ˘˜ ‰˘Ó·ÙfiÙËÙ¤˜ ÙÔ˘ ͯˆÚÈÛÙ¿ Û οı ÙÔ̤· Ù˘ ·Ó¿Ù˘Í˘, fiˆ˜ Â›Ó·È Ë ·‰Ú‹ Î·È ÏÂÙ‹ ÎÈÓËÙÈÎfiÙËÙ·, Ë ·ÓÙ›ÏË„Ë, Ë ÔÌÈÏ›· ˆ˜ ÚÔ˜ ÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ ÂÓÓÔÈÒÓ ·ÏÏ¿ Î·È ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ ÏfiÁÔ˘, Ë ·˘ÙÔÂ͢ËÚ¤ÙËÛË Î·È Ë Û˘ÌÂÚÈÊÔÚ¿-ÎÔÈÓˆÓÈÎfiÙËÙ· Î·È Ó· ÌÔÚ¤ÛÔ˘Ì ӷ ·Ó·ÁÓˆÚ›ÛÔ˘Ì ÙȘ ·ÏÏËÏÔÂȉڿÛÂȘ Î·È ÙȘ Û¯¤ÛÂȘ ÙÔ˘˜. ªÂ ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ·Ó·Ù˘ÍÈ·ÎÔ‡ ÚÔÊ›Ï, fiˆ˜ ·˘Ùfi ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ·Ó·Ù˘Íȷ΋ ‰ÔÎÈÌ·Û›· MFED (Muenchener Functionelle Entwicklungsdiagnostik), ›̷ÛÙ Û ı¤ÛË Ó· ‚Úԇ̠‡ÎÔÏ· Ù· ‚·ÛÈο ÛËÌ›· ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÛÙȘ ‰È¿ÊÔÚ˜ ·Ó·Ù˘ÍȷΤ˜ ÂÚÈÔ¯¤˜ Î·È Ó· οÓÔ˘Ì ÙȘ ηٿÏÏËϘ ‰È·ÊÔÚԉȷÁÓˆÛÙÈΤ˜ ˘Ôı¤ÛÂȘ, ¤ÙÛÈ ÒÛÙ ӷ Ô‰ËÁËıԇ̠·ÔÙÂÏÂÛÌ·ÙÈο - ̤ۈ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÎÏÈÓÈÎÔ-ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ - ÛÙË ÛˆÛÙ‹ ‰È¿ÁÓˆÛË, ·ÔʇÁÔÓÙ·˜ ÙȘ ¿ÛÎÔ˜ ÂÈϤÔÓ ‰ÈÂÚ¢ӋÛÂȘ. ∂Í¿ÏÏÔ˘, ·fi ÙÔ ·Ó·Ù˘ÍÈ·Îfi ÚÔÊ›Ï Ì¿˜ ‰›‰ÔÓÙ·È Î·È Ù· ‚·ÛÈο ÛÙÔȯ›· ÁÈ· ÙË ıÂڷ›· Ô˘ ı· ·ÎÔÏÔ˘ı‹ÛÔ˘Ì (™¯‹Ì· 1). °È· ·Ú¿‰ÂÈÁÌ·, Ì›· ıÂڷ›· ÏfiÁÔ˘ ı· Ú¤ÂÈ Ó· ÌÂıԉ¢Ù› ‰È·ÊÔÚÂÙÈο Û ¤Ó· ·È‰› Ì ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·’ fiÙÈ Û ¤Ó· ¿ÏÏÔ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ‚·Ú˘ÎÔ˝· ‹ „˘¯ÔÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ‹ Û‡Ó‰ÚÔÌÔ ÏfiÁˆ ÂÚÈ‚·ÏÏÔÓÙÈ΋˜ ·ÔÛÙ¤ÚËÛ˘. ∂›Û˘, ı· ÌÔÚԇ̠ӷ ηٷϿ‚Ô˘Ì ·Ó Ì›· ‰È·Ù·Ú·¯‹ Â›Ó·È ÚˆÙÔ·ı‹˜ ‹ ‰Â˘ÙÂÚÔ·ı‹˜ Î·È ÔȘ ·ÓÙÈÛÙ·ıÌÈÛÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ì ÁÈ· Ó· ‚ÂÏÙÈÒÛÔ˘ÌÂ Î·È ÙȘ ˘fiÏÔȘ (3). ™ÙËÓ ∂ÏÏ¿‰·, ÔÈ Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ Â›Ó·È ÔÈ: Griffiths, MFED, Baileys Î.Ï. ™ÙË ‚¿ÛË Ù˘ ·Ó·Ù˘Íȷ΋˜ ÂÈ̤ÚÔ˘˜ ‰È·ÁÓˆÛÙÈ΋˜ ¯Ù›˙ÂÙ·È ÙÔ ıÂڷ¢ÙÈÎfi ÚfiÁÚ·ÌÌ·, ÙÔ
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¶·È‰È·ÙÚÈ΋ 2001;64:376-383
Paediatriki 2001;64:376-383
∞Ó·Ù˘ÍÈ·Îfi PROFIL ÚÔ˜ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰È·ÊfiÚˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ÂÈ̤ÚÔ˘˜ ÙÔ̤ˆÓ
HÌÂÚÔÌ.
∏ÌÂÚ. Á¤ÓÓËÛ˘:
∏ÏÈΛ· (Ì‹Ó˜)
ŸÓÔÌ· ·È‰ÈÔ‡:
48. 47 46 45. 44 43 42. 41 40 39. 38 37 36. 35 34 33. 32 31 30. 29 28 27. 26 25 24. 23 22 21. 20 19 18. 17 16 15. 14 13 12. 11 10 9 . 8 7 6 .
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∫·Ù·ÓfiËÛË ÏfiÁÔ˘
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¶·Ú·ÙËÚ‹ÛÂȘ:
∂ÍÂÙ·ÛÙ‹˜
™¯‹Ì· 1. ∞Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋ ÙÔ˘ ªÔÓ¿¯Ô˘ ÁÈ· ÙÔ 2Ô Î·È 3Ô ¤ÙÔ˜.
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∞˘ÙÔÂ͢ËÚ¤ÙËÛË
¶·È‰È·ÙÚÈ΋ 2001;64:376-383
ÔÔ›Ô ÔÊ›ÏÂÈ Ó· Ï¿‚ÂÈ ˘’ fi„ÈÓ ÙÔ˘: ·) ÙËÓ ·Ó·Ù˘Íȷ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡, ‚) ÙȘ ÂȉÈΤ˜ ‰˘ÛÎÔϛ˜ ÙÔ˘ Î·È Á) ÙËÓ ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË (fi¯È ˘ÂÚ‚ÔϤ˜). ∞˘Ùfi ÈÛ¯‡ÂÈ, ȉȷ›ÙÂÚ·, fiÙ·Ó Û˘ÌÌÂÙ¤¯Ô˘Ó ıÂÚ·Â˘Ù¤˜ ‰È·ÊfiÚˆÓ ÂȉÈÎÔًوÓ. ∞˘Ùfi˜ Ô Û˘ÓÙÔÓÈÛÌfi˜ Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È ÛÙ· ¯¤ÚÈ· ·˘ÙÔ‡ Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÙËÓ ·Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋ ÙÔ˘ ·È‰ÈÔ‡ Î·È ·Ú·ÎÔÏÔ˘ı› ÙËÓ ÂͤÏÈÍ‹ ÙÔ˘, Ôχ ÂÚÈÛÛfiÙÂÚÔ fiÙ·Ó Ë ıÂڷ›· ‰È·ÚΛ ÁÈ· Ì·ÎÚfiÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÔfiÙ - fiˆ˜ Â›Ó·È ·˘ÙÔÓfiËÙÔ - Â›Ó·È ·Ó·Áη›Â˜ ÔÈ Â·ÓÂÍÂÙ¿ÛÂȘ Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· Ì ÛÎÔfi Ó· ‰È·ÈÛÙˆı› i) ·Ó ¤¯ÂÈ ·ÚÔ˘ÛÈ·ÛÙ› ÚfiÔ‰Ô˜ ÛÙËÓ ·Ó·Ù˘Íȷ΋ ÙÔ˘ ÂͤÏÈÍË, ii) ·Ó ÂÌÊ·Ó›ÛÙËÎ·Ó ‰˘ÛÎÔϛ˜ (Î·È ÔȘ), ÔÈ Ôԛ˜ ÂÈ‚Ú·‰‡ÓÔ˘Ó ÙÔ Ú˘ıÌfi, iii) ·Ó ÙÔ ıÂڷ¢ÙÈÎfi ÚfiÁÚ·ÌÌ· ‹Ù·Ó Ï¿ıÔ˜ Î·È ¯ÚÂÈ¿˙ÂÙ·È ·ÏÏ·Á‹ Î·È Ó¤Ô˜ Û˘ÓÙÔÓÈÛÌfi˜. ∆Ô Û¯‹Ì· Ù˘ ıÂڷ›·˜ ‰ÂÓ ÍÂÎÈÓ¿ ÌfiÓÔ ·fi ÙÔ ÂȉÈÎfi ·Ó·Ù˘ÍÈ·Îfi ¤ÏÏÂÈÌÌ· ÙÔ˘ ·È‰ÈÔ‡, ·ÏÏ¿ ÛÙԯ‡ÂÈ ÛÙË ÛÙ‹ÚÈÍË ÔÏfiÎÏËÚ˘ Ù˘ ·Ó¿Ù˘Í˘ Ô˘ ‚Ú›ÛÎÂÙ·È Û ΛӉ˘ÓÔ (2). OÈ Ï¤ÔÓ Û‡Á¯ÚÔÓ˜ Î·È Â˘Ú¤ˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ‰ÈÂıÓ›˜ ıÂڷ¢ÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ·Ó¿ÏÔÁ· Ì ÙȘ ÂÓÙÔÈṲ̂Ó˜ ·fi ÙËÓ ·Ó·Ù˘Íȷ΋ ‰È·ÁÓˆÛÙÈ΋ ‰È·Ù·Ú·¯¤˜ - ÎÈÓËÙÈΤ˜, ·ÓÙÈÏËÙÈΤ˜ (ÓÔËÙÈΤ˜), ÁψÛÛÈΤ˜ Î·È Û˘ÌÂÚÈÊÂÚÈÔÏÔÁÈΤ˜ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (5). ¶›Ó·Î·˜ 1. ™‡Á¯ÚÔÓ˜ ıÂڷ¢ÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ¢È·Ù·Ú·¯‹
£Âڷ›·
∞‰Ú‹˜ ÎÈÓËÙÈÎfiÙËÙ·˜
º˘ÛÈÎÔıÂڷ›· ÌÂ Û˘Ó¯Ҙ ÂÍÂÏÈÛÛfiÌÂÓ˜ ÌÔÚʤ˜ Bobath Vojta ∂ÚÁÔıÂڷ›· (SI)
§ÂÙ‹˜ ÎÈÓËÙÈÎfiÙËÙ·˜
∂ÚÁÔıÂڷ›· ∞ÈÛıËÙËÚȷ΋ ∂Óۈ̿وÛË ªÔÙÔıÂڷ›·
∞ÓÙ›Ï˄˘ ¢¤ÚÌ·, ∞ÚıÚÒÛÂȘ OÚÁ. πÛÔÚÚÔ›·˜ ∞ÎÔ‹ ŸÚ·ÛË
∂ÚÁÔıÂڷ›· ∞ÈÛıËÙËÚȷ΋ ∂Óۈ̿وÛË §ÔÁÔıÂڷ›· ∂η›‰Â˘ÛË ŸÚ·Û˘-∞ÎÔ‹˜
§fiÁÔ˘
§ÔÁÔıÂڷ›·
™˘ÌÂÚÈÊÔÚ¿˜ / ∫ÔÈÓˆÓÈÎÔÔ›ËÛ˘
£Âڷ›· ™˘ÌÂÚÈÊÔÚ¿˜ ¶·È¯ÓȉÔıÂڷ›· ªÔ˘ÛÈÎÔıÂڷ›· £Âڷ›· ̤ۈ ˙ˆÁÚ·ÊÈ΋˜ ∂ÚÁÔıÂڷ›·
G. Gschwend, 1998 (Neuroph. Grundlage der Hirnleistungsstoerungen)
Paediatriki 2001;64:376-383
º˘ÛÈÎÔıÂڷ›· ∏ Ê˘ÛÈÎÔıÂڷ›· ÂÊ·ÚÌfi˙ÂÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì Ó¢ÚÔÌ˘˚΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ·‰Ú‹ ÎÈÓËÙÈ΋ ÛÙ¤ÚËÛË, Ù· ÔÔ›· ÂËÚ¿˙Ô˘Ó ÙÔ ·È‰› Ó· ÎÈÓËı› ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ. ™ÎÔfi˜ Ù˘ Ê˘ÛÈÎÔıÂڷ›·˜ Â›Ó·È Ó· ·ÔηٷÛÙ‹ÛÂÈ ÙÔ ·È‰› ÙËÓ ÎÈÓËÙÈ΋ ·Î·Ì„›·, Ó· ‰ÈÔÚıÒÛÂÈ ÙȘ ·ıÔÏÔÁÈΤ˜ ÎÈÓ‹ÛÂȘ Î·È Ó· ÔÈÎÔ‰ÔÌ‹ÛÂÈ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ Ê˘ÛÈÔÏÔÁÈ΋ ΛÓËÛË, ÙËÓ ÔÔ›· ı· Ì¿ıÂÈ Û˘Ó¯Ҙ Ó· ‚ÂÏÙÈÒÓÂÈ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ˙ˆ‹ (4). OÈ Ï¤ÔÓ ÁÓˆÛÙ¤˜, ‰ÈÂıÓÒ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜, ̤ıÔ‰ÔÈ Â›Ó·È ÔÈ Bobath Î·È Vojta. OÈ Û˘Ó‹ıÂȘ ˘ÔÛÙËÚÈÎÙÈΤ˜ Ê˘ÛÈÎÔıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ÙÔ Ì·Û¿˙, Ë ˘‰ÚÔıÂڷ›·, Ë ËÏÂÎÙÚÔıÂڷ›·, Ë ¯Ú‹ÛË ıÂÚÌÒÓ ÂÈıÂÌ¿ÙˆÓ Î.Ï. º˘ÛÈÎÔıÂڷ›· ηٿ Bobath ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ·Ó·Ù‡¯ıËΠ·fi ÙÔ ˙‡ÁÔ˜ Bobath, ÙÔ ÔÔ›Ô ıÂÒÚËÛ ˆ˜ ‚·ÛÈÎfi Úfi‚ÏËÌ· ÙÔ˘ ÎÈÓËÙÈο ‰È·Ù·Ú·Á̤ÓÔ˘ ·È‰ÈÔ‡, ÙËÓ ·ıÔÏÔÁÈ΋ Û˘ÓÂÚÁ·Û›· Ì˘ÒÓ Û ̛· ΛÓËÛË (.¯. ÙËÓ ·‰˘Ó·Ì›· ·ÓÙ·ÁˆÓÈÛÙÒÓ Ì˘ÒÓ Ó· ‰Ú·ÛÙËÚÈÔÔÈËıÔ‡Ó ÛˆÛÙ¿ Û ̛· Û˘ÁÎÂÎÚÈ̤ÓË ı¤ÛË) (5). ™ÎÔfi˜ Ù˘ ıÂڷ›·˜ Â›Ó·È Ó· ‰Ôı› ¤Ó· Û¯¤‰ÈÔ Î›ÓËÛ˘ Ô˘ ·ÚÂÌÔ‰›˙ÂÈ ‹ ·‰Ú·ÓÔÔÈ› ÙËÓ ·ıÔÏÔÁÈ΋, ÂÓÒ ÎÙ›˙ÂÈ ÙË Ê˘ÛÈÔÏÔÁÈ΋, Ì ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ·È¯Ó›‰È Î·È Û ηıËÌÂÚÈÓ¤˜ ‰È·‰Èηۛ˜, fiˆ˜ ÓÙ‡ÛÈÌÔ Î.Ï. ∆Ô ‚·ÛÈÎfi ÛËÌÂ›Ô Ù˘ ıÂڷ›·˜ Bobath ‚Ú›ÛÎÂÙ·È, ηٿ ÙÔÓ ¤ÏÂÁ¯Ô ÎÂÊ·Ï‹˜-ÎÔÚÌÔ‡, ÛÙËÓ ÂÍ¿ÛÎËÛË ÈÛÔÚÚÔ›·˜, ÛÙ‹ÚÈ͢ ÙˆÓ ¿Óˆ ¿ÎÚˆÓ Î·È ÛÙÚÔÊ‹˜ ÙÔ˘ ÎÔÚÌÔ‡ (.¯. Û ·È‰› Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ‡ÙÈ· ı¤ÛË, Ë ‰˘Ó·ÙfiÙËÙ· ÛÙÚÔÊ‹˜ ÛÙËÓ ÚËÓ‹ ı¤ÛË ‹ Ë ‰˘Ó·ÙfiÙËÙ· ÛÙÚÔÊ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙËÓ Î·ıÈÛÙ‹ ı¤ÛË ÚÔ˜ ÙË Ì›· ÏÂ˘Ú¿) (6). ∞˘Ùfi ÙÔ Û¯¤‰ÈÔ Î›ÓËÛ˘ ‰ÂÓ ÂÍ·ÛÎÂ›Ù·È Ì¤Ûˆ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·Û΋ÛˆÓ, ·ÏÏ¿ Ì ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ·È¯Ó›‰È Î·È ÙȘ ηıËÌÂÚÈÓ¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ (∂ÈÎfiÓ· 1). º˘ÛÈÎÔıÂڷ›· ηٿ Vojta O ÂÌÓ¢ÛÙ‹˜ ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È Ô Î·ıËÁËÙ‹˜ Vaclav Vojta, ·È‰ÔÓ¢ÚÔÏfiÁÔ˜ ÛÙÔ ªfiÓ·¯Ô, Ô ÔÔ›Ô˜ ·Ú¯Èο ÙË ¯ÚËÛÈÌÔÔ›ËÛ Û ·È‰È¿ Ì ÎÂÓÙÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÂÓÒ Û‹ÌÂÚ· Ë Ì¤ıÔ‰Ô˜ ÂÊ·ÚÌfi˙ÂÙ·È Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ì ‰È¿ÊÔÚ˜ Ó¢ÚÔÏÔÁÈΤ˜ ‹ Ó¢ÚÔÌ˘˚Τ˜ ·ı‹ÛÂȘ, fiˆ˜ ÌËÓÈÁÁÔÌ˘ÂÏÔ΋ÏË, Û˘ÁÁÂÓ¤˜ ηْ ÈÛ¯‡ÔÓ ÂÍ¿ÚıÚËÌ·, Ì˘˚Îfi Î·È Ó¢ÚÔÁÂÓ¤˜ Ú·È‚fiÎÚ·ÓÔ, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, Ó·ÓÈΤ˜ ÛÎÔÏÈÒÛÂȘ, ·ÚıÚÔÁÚ‡ˆÛË Î.Ï. (6,7).
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¶·È‰È·ÙÚÈ΋ 2001;64:376-383
Paediatriki 2001;64:376-383
∂ÈÎfiÓ· 2. ¶·Ú¿‰ÂÈÁÌ· ıÂڷ›·˜ Vojta: ¶›ÂÛË ÛÙ· Û˘ÁÎÂÎÚÈ̤ӷ ÛËÌ›· (·ÓÙ·Ó·ÎÏ.). º¿ÛË ·ÓÙ·Ó·ÎÏ. ÛÙÚÔÊ‹˜. ∂ÈÎfiÓ· 1. ¶·Ú¿‰ÂÈÁÌ· ıÂڷ›·˜ Bobath: ∆Ô ·È‰› Ì·ı·›ÓÂÈ Ó· ÛÙËÚ›˙ÂÙ·È Î·È Ó· Û˘ÏÏ·Ì‚¿ÓÂÈ.
OÈ ‚·ÛÈΤ˜ ÛΤ„ÂȘ Ô˘ ¤Î·ÓÂ Ô Vojta Â›Ó·È fiÙÈ Û ̛· ÚÒÈÌË - ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· - ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹, Â›Ó·È ‰È·Ù·Ú·Á̤ÓË Ë Î·Ù‡ı˘ÓÛË Ù˘ ÛÙ¿Û˘-ı¤Û˘ ÙÔ˘ ÛÒÌ·ÙÔ˜. °È· Ó· ÍÂÂÚ·ÛÙ› ·˘Ù‹ Ë ‰È·Ù·Ú·¯‹ Ú¤ÂÈ Ó· ‰Ôı› ÛÙÔ ·È‰› ¤Ó· Û¯¤‰ÈÔ Î›ÓËÛ˘ Ô˘ Ó· ÌÔÚ› Ó· ÙÔ ÂËÚ¿ÛÂÈ. O Vojta ÈÛÙ‡ÂÈ fiÙÈ, ·fi ÔÏϤ˜ ÁÂÓ¤˜, ÛÙÔ ∫¡™ ¤¯ÂÈ Î·Ù·ÁÚ·Ê› ·˘Ùfi ÙÔ ÌÔÓÙ¤ÏÔ Î›ÓËÛ˘, ÙÔ ÔÔ›Ô ·ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ÙÌ‹Ì·Ù·: 1) ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÒıËÛ˘ Î·È 2) ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÛÙÚÔÊ‹˜. ª¤Ûˆ Ù˘ ‰Ú·ÛÙËÚÈÔÔ›ËÛ˘ ·˘ÙÒÓ ÙˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ ÌÔÚ› Ó· ·Ú·¯ı› ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi ·È¯Ó›‰È Ì˘ÒÓ, ÙÔ ÔÔ›Ô ·ÔηıÈÛÙ¿ ÙË ‰È·Ù·Ú·¯‹ Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ·ıÔÏÔÁ›·, ÙË ı¤ÛË Î·È ÙÔ Û˘ÓÙÔÓÈÛÌfi ÙˆÓ Ì˘ÒÓ. ∞˘Ùfi ÙÔ Û¯¤‰ÈÔ Î›ÓËÛ˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Ȥ˙ÔÓÙ·˜ ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ÛËÌ›· ÛÙÔ ÛÒÌ·. ∫·Ù¿ ÙË ıÂڷ›·, Ù· ·È‰È¿ Ì ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‰Â›¯ÓÔ˘Ó ·˘Ùfi ÙÔ Û¯¤‰ÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ΛÓËÛ˘ Ô˘ ·fi ÌfiÓ· ÙÔ˘˜ ‰ÂÓ ‹Ù·Ó Û ı¤ÛË Ó· ¤¯Ô˘Ó. ∞˘Ù¿ Ù· Û¯¤‰È· ΛÓËÛ˘ ·Ó‹ÎÔ˘Ó ÛÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÎÈÓ‹ÛÂȘ, ÙȘ Ôԛ˜ fï˜ ‚Ï¤Ô˘Ì ·ÚÁfiÙÂÚ· ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ (7). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ıÂڷ›·˜ Â›Ó·È Ó· ÂÍ·ÏÂÈÊı› ‹ Ó· ÌÂȈı› Ë ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹ (∂ÈÎfiÓ· 2). ∂ÚÁÔıÂڷ›· ∏ ÂÚÁÔıÂڷ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÏÂÙ‹ ÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË, ÙË ÓÔËÙÈ΋ Î·È ·ÈÛıËÙËÚȷ΋ ˆÚ›Ì·ÓÛË, ÙËÓ Î·Ù·ÓfiËÛË ÙÔ˘ ÏfiÁÔ˘, ÙË Û˘-
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ÌÂÚÈÊÔÚ¿ Î·È ÙËÓ „˘¯ÔÎÔÈÓˆÓÈ΋ ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘ ·È‰ÈÔ‡. ™ÎÔfi˜ Ù˘ ÂÚÁÔıÂڷ›·˜ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Î·È Ë ·Ó¿Ù˘ÍË ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÂÍÈÔÙ‹ÙˆÓ Ô˘ Â›Ó·È ¯Ú‹ÛÈ̘ ÁÈ· ÙÔ ·È¯Ó›‰È, ÙËÓ ·˘ÙÔÂ͢ËÚ¤ÙËÛË, ÙËÓ ÎÔÈÓˆÓÈÎÔÔ›ËÛË Î·È ÙËÓ Â›‰ÔÛË ÛÙÔ Û¯ÔÏÂ›Ô (4,5). ∆· ıÂڷ¢ÙÈο ̤۷ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÂÚÁÔıÂڷ›· ›ӷÈ: ˘ÏÈο ‰È·ÊfiÚˆÓ Î·Ù·Û΢ÒÓ Î·È ˙ˆÁÚ·ÊÈ΋˜ (¯·ÚÙÈ¿, ͇ÏÔ, Ï·ÛÙÂÏ›ÓË Î.¿.), fiÚÁ·Ó· Á˘ÌÓ·ÛÙÈ΋˜ (ÎÈÓËÙ¤˜ Ù¿‚Ϙ, ÎÚ‚¿ÙÈ·, ÎÚÂÌ·ÛÙ¿ ÛÙÚÒÌ·Ù· Î.Ï.), Ì·ÓÛ¤Ù˜ ‚¿ÚÔ˘˜, ÂÓÙ¿Ï (ÁÈ· Û˘ÓÙÔÓÈÛÌfi ÎÈÓ‹ÛˆÓ), ÔÚıˆÙÈÎÔ› ÎˉÂÌfiÓ˜, Ó¿ÚıËΘ Î.Ï. ø˜ ÔÈ Ï¤ÔÓ ÁÓˆÛÙ¤˜ ÂȉÈΤ˜ ̤ıÔ‰ÔÈ, ıˆÚÔ‡ÓÙ·È ‰ÈÂıÓÒ˜ Ë Î·Ù¿ Petö Î·È ÂΛÓË Ù˘ ∞ÈÛıËÙËÚȷ΋˜ ∂Óۈ̿وÛ˘ (ηٿ Jean Ayres, Bobath) (5,6). ª¤ıÔ‰Ô˜ ηٿ Petö ª›· ȉȷ›ÙÂÚ· ÂÓÙ·ÙÈ΋ ıÂڷ›· ÚÔ˜ ¢fi‰ˆÛË ÙˆÓ ÛÙfi¯ˆÓ Ù˘ ÂÚÁÔıÂڷ›·˜ ÂȉÈÒÎÂÙ·È Ì ÙË Ì¤ıÔ‰Ô Petö, ηٿ ÙËÓ ÔÔ›· Ù· ·È‰È¿ ÂÍ·ÛÎÔ‡ÓÙ·È Û ÌÈÎÚ¤˜ ÔÌÔÈÔÁÂÓ›˜ ÔÌ¿‰Â˜ Î·È Î·Ù¿ÏÏËÏ· ÚÔÂÙÔÈÌ·Ṳ̂ÓÔ ÂÚÈ‚¿ÏÏÔÓ. ªÂ ·˘ÙÔÌ·ÙÔÔÈË̤ÓË Ì¿ıËÛË Ì¤Û· ·fi ÙÔ ·È¯Ó›‰È, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· ÁÈ· ÚÔÒıËÛË Î·È ÂÍ¿ÛÎËÛË Ù˘ ·˘ÙÔÁÓˆÛ›·˜ Î·È Ù˘ ·˘ÙÔÂÔ›ıËÛ˘ ÙÔ˘ ·È‰ÈÔ‡. O O‡ÁÁÚÔ˜ ÁÈ·ÙÚfi˜ Andres Petö Ô˘ ·Ó¤Ù˘Í ·˘Ù‹ ÙË Ì¤ıÔ‰Ô ÂÈÛËÌ·›ÓÂÈ: “·Ê‹ÛÙ ÙÔ˘˜ ·Ú¿Ï˘ÙÔ˘˜ Ì˘˜ Î·È ·Û¯ÔÏËı›Ù Ì ÔÏfiÎÏËÚË ÙËÓ ÚÔÛˆÈÎfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡”. ∆· ·È‰È¿ - ΢ڛˆ˜ Ù˘ ÓËȷ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ - ÂÍ·ÛÎÔ‡ÓÙ·È Î·Ù¿ ÔÌ¿‰Â˜, ηı’ fiÙÈ Ë
¶·È‰È·ÙÚÈ΋ 2001;64:376-383
Û˘ÓÂÚÁ·Û›· ÛÙËÓ ÔÌ¿‰· ·›˙ÂÈ ¤Ó· ıÂÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ (6). ™ÙË Ì¤ıÔ‰Ô Petö ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÏ¿¯ÈÛÙ· ıÂڷ¢ÙÈο ̤۷, fiˆ˜ ÎÔ˘‰Ô˘Ó›ÛÙÚ˜, ÌÈÎÚÔ·ÓÙÈΛÌÂÓ· ÁÈ· ÙË Û‡ÏÏË„Ë Î·È ·ÚÁfiÙÂÚ· Ë ÂȉÈ΋ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ηڤÎÏ· Î·È ÙÔ ÎÚ‚¿ÙÈ, fiÔ˘ ÙÔ ·È‰› Â›Ó·È Û ı¤ÛË Ó· ÛÙËÚ›˙ÂÙ·È Î·È Ó· ÂÍ·ÛÎÂ›Ù·È ÎÈÓËÙÈο (∂ÈÎfiÓ· 3). ∞ÈÛıËÙËÚȷ΋ ÂÓۈ̿وÛË ∂Í·ÈÙ›·˜ Ù˘ ·ÈÛıËÙËÚȷ΋˜ ÂÓۈ̿وÛ˘ (S.I.), Ë Jean Ayres ·fi ÙËÓ ∫·ÏÈÊfiÚÓÈ· ÙˆÓ ∏.¶.∞. ·ÓÙÈÏ‹ÊıËΠfiÙÈ ÔÏϤ˜ ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, fiˆ˜ ÎÈÓËÙÈΤ˜, ÁψÛÛÈΤ˜, Û˘ÌÂÚÈÊÔÚÈÛÙÈΤ˜ Î.Ï., ÔÊ›ÏÔÓÙ·È Û ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÓÙ›Ï˄˘ (6,8). ∞˘Ù¤˜ ÔÈ ·ÓÙÈÏËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÂÂÎÙ›ÓÔÓÙ·È fi¯È ÌfiÓÔ ÛÙÔ Û¯‹Ì· ÙÔ˘ ÛÒÌ·ÙÔ˜ ·ÏÏ¿ Î·È ÙÔ˘ ¯ÒÚÔ˘. ∏ Jean Ayres ÚÔÒıËÛ ÙËÓ ÂÓۈ̿وÛË Ù˘ ·ÓÙ›Ï˄˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ì ÙËÓ ·ÓÙ›ÏË„Ë ÙÔ˘ ¯ÒÚÔ˘, ÁÈ· Ó· ÌÔÚ› ÙÔ ·È‰› Ì ÙÔ ÛÒÌ· ÙÔ˘ Ó· ÚÔÛ·ÚÌÔÛÙ› ÛÙÔ ¯ÒÚÔ (8). ¢È·ÈÛÙÒıËΠfiÙÈ Ë ÂÍ¿ÛÎËÛË ÈÛÔÚÚÔ›·˜ ÔÈÎÔ‰ÔÌ› ÙÔ Û¯‹Ì· ÛÒÌ·ÙÔ˜ Î·È ¯ÒÚÔ˘, ÒÛÙ ӷ ÚÔˆıÂ›Ù·È Ë ÂÓ·ÚÌfiÓÈÛË ·˘ÙÒÓ ÙˆÓ ‰‡Ô Û¯ËÌ¿ÙˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ë ·›ÛıËÛË ÈÛÔÚÚÔ›·˜ Ó· ÂÍ·ÛΛ ¤Ó· ÁÂÓÈÎfi ÚÔˆıËÙÈÎfi ÚfiÏÔ. ∂Âȉ‹ ‰Â, ÛÙ· Ï·›ÛÈ· ·˘Ù‹˜ Ù˘ ÔÏÈ΋˜ ÂÓۈ̿وÛ˘, ÙÔ ‚·ÛÈÎfi Û‡ÛÙËÌ· ‚Ú›ÛÎÂÙ·È Û ‰È·Ú΋ ÂÓ·ÏÏ·Á‹ ‰Ú¿Û˘ Ì ٷ 17 ÂÈ̤ÚÔ˘˜ Û˘ÛÙ‹Ì·Ù·, ÎÂÚ‰›˙Ô˘Ó ·fi ÙËÓ ÚÔÒıËÛË Ù˘ ÂÓۈ̿وÛ˘ fi¯È ÌfiÓÔ ÔÈ ÛÊ·ÈÚÈΤ˜ ÈηÓfiÙËÙ˜, Ì ÙȘ ‰ÈΤ˜ ÙÔ˘˜ ÓÔËÙÈΤ˜ ÂȉfiÛÂȘ, ·ÏÏ¿ Î·È fiϘ ÔÈ
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ÂÈ̤ÚÔ˘˜ ÈηÓfiÙËÙ˜. ∞˘Ù‹ ÏÔÈfiÓ Ë ÔÏÈ΋ ÚÔÒıËÛË ‚ÂÏÙÈÒÓÂÈ ÙËÓ Î›ÓËÛË, ÔÈ ‰ÂÓ‰Ú›Ù˜ Î·È Ó¢ڛÙ˜ ÙˆÓ Ó¢ÚÒÓˆÓ ‚Ï·ÛÙ¿ÓÔ˘Ó Î·È ·˘Í¿ÓÔÓÙ·È. ∂Âȉ‹ fiÏÔÈ ÔÈ Ó¢ÚÒÓ˜ ‰È·ı¤ÙÔ˘Ó ‰˘Ó·ÙfiÙËÙ· ÌÓ‹Ì˘, ‚ÂÏÙÈÒÓÂÙ·È Ì ÙËÓ ·ÈÛıËÙËÚȷ΋ ÂÓۈ̿وÛË Ë ÈηÓfiÙËÙ· Ì¿ıËÛ˘ ÙˆÓ Ó¢ÚÒÓˆÓ. ∏ ÚÔÒıËÛË Ù˘ ÈηÓfiÙËÙ·˜ Ì¿ıËÛ˘ ›ӷÈ, ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi, ÙÔ ·ÍÈÔı·‡Ì·ÛÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÈÛıËÙËÚȷ΋˜ ÂÓۈ̿وÛ˘ (6). ™ÙËÓ ∂ÈÎfiÓ· 4 Ê·›ÓÂÙ·È Ò˜ ÂÚÂı›˙ÂÙ·È ÔÏfiÎÏËÚÔ ÙÔ ÛÒÌ· ÙÔ˘ ·È‰ÈÔ‡ Ì ÙË ¯Ú‹ÛË Ù˘ ·ÈÒÚ·˜, ÎÈ ¤ÙÛÈ ÚÔˆıÂ›Ù·È Ë ·ÓÙ›ÏË„Ë Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, Ù˘ ÈÛÔÚÚÔ›·˜ Î·È Ù˘ ÂÓ Ùˆ ‚¿ıÂÈ ·ÈÛıËÙÈÎfiÙËÙ·˜. ∂ÓÒ, ÛÙËÓ ∂ÈÎfiÓ· 5 ·ÂÈÎÔÓ›˙ÂÙ·È ÙÔ ·È‰› Ô˘ ‚ÈÒÓÂÈ Ì ÔÏfiÎÏËÚÔ ÙÔ ÛÒÌ· ÙÔ˘ ÙË Û¯¤ÛË Ì ÙÔ ¯ÒÚÔ Î·È Ù· ÌÂÁ¿Ï· ·ÓÙÈΛÌÂÓ·, Ì ·ÔÙ¤ÏÂÛÌ·
∂ÈÎfiÓ· 4. ∞ÈÛıËÙËÚȷ΋ ∂Óۈ̿وÛË (S.I.) Ì ÙË ¯Ú‹ÛË ·ÈÒÚ·˜.
∂ÈÎfiÓ· 3. µÔËı‹Ì·Ù· ÛÙË Ì¤ıÔ‰Ô Petö: ∆Ô ·È‰› Ì·ı·›ÓÂÈ Ó· ÛÙËÚ›˙ÂÙ·È ÛÙËÓ Î·Ú¤ÎÏ· ÁÈ· Ó· ÛËΈı›.
∂ÈÎfiÓ· 5. ÃÚ‹ÛË ÌÂÁ¿ÏˆÓ ·ÓÙÈÎÂÈÌ¤ÓˆÓ ÛÙËÓ ∞ÈÛıËÙËÚȷ΋ ∂Óۈ̿وÛË (S.I.)
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ªÔÙԷȉ·ÁˆÁÈ΋ - ªÔÙÔıÂڷ›· (ÎÈÓËÛÈÔıÂڷ›·) ∞fi ÙËÓ ·Ú¯‹ Ù˘ ˙ˆ‹˜ ÙÔ˘, ÙÔ ·È‰› ·Ó·Î·Ï‡ÙÂÈ ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ̤۷ ·fi ÙËÓ Î›ÓËÛË. ∏ ΛÓËÛË Î·È Ë ·ÓÙ›ÏË„Ë ÂÓfi˜ ·È‰ÈÔ‡ ‰ÂÓ ‰È·¯ˆÚ›˙ÔÓÙ·È ·fi ÙȘ ÛΤ„ÂȘ Î·È Ù· Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘. ∂Âȉ‹ ·˘Ùfi ÈÛ¯‡ÂÈ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ªÔÙԷȉ·ÁˆÁÈ΋˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì›· ÛÙÂÓ‹ Û‡Ó‰ÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜, Ù˘ „˘¯‹˜, Ù˘ ΛÓËÛ˘ Î·È ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ªÔÙԷȉ·ÁˆÁÈ΋ ›ӷÈ, ηٿ Û˘Ó¤ÂÈ·, Ë Ì¿ıËÛË Î·È ·Ó¿Ù˘ÍË ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ·È‰ÈÔ‡ ̤۷ ·fi ÙËÓ Î›ÓËÛË, ÙÔ ·È¯Ó›‰È Î·È ÙË Û˘ÓÂÚÁ·Û›·. ™ÙË ªÔÙÔıÂڷ›· (ÎÈÓËÛÈÔıÂڷ›·) ÈÛ¯‡Ô˘Ó ÔÈ Î·ÓfiÓ˜ Ù˘ ÌÔÙԷȉ·ÁˆÁÈ΋˜, ÂÂÍÂÚÁ·Ṳ̂ÓÔÈ, fï˜, ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂÈÔÓÂÍ›· ÙÔ˘ ·È‰ÈÔ‡, ÚÔÛ·ÚÌÔṲ̂ÓÔÈ ÛÙȘ ‰˘Ó·ÙfiÙËÙ¤˜ ÙÔ˘ Î·È Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÔÏfiÎÏËÚË ÙËÓ ÚÔÛˆÈÎfiÙËÙ· Î·È ÙȘ ȉȷÈÙÂÚfiÙËÙ¤˜ ÙÔ˘ (5,6). ∏ ̤ıÔ‰Ô˜ ÂÊ·ÚÌfi˙ÂÙ·È Î˘Ú›ˆ˜ Û ÔÌ¿‰Â˜ ·È‰ÈÒÓ Î·È Û ¯ÒÚÔ˘˜ Á˘ÌÓ·ÛÙÈ΋˜ (Á˘ÌÓ·ÛÙ‹ÚÈ·). ™ÙËÓ ∂ÈÎfiÓ· 6 ·ÂÈÎÔÓ›˙ÂÙ·È ÙÔ ·È‰› Ô˘ Ì·ı·›ÓÂÈ ÙÔ ÛÒÌ· ÙÔ˘ Î·È Ô ÙÚfiÔ˜ Ô˘ Ú¤ÂÈ Ó· ÙÔ
ÌÂÙ·‚¿ÏÏÂÈ Ì¤Û· ·fi ÙËÓ Î›ÓËÛË. ™ÙËÓ ∂ÈÎfiÓ· 7 ÙÔ ·È‰› Ì·ı·›ÓÂÈ Ì ÙË ‚Ô‹ıÂÈ· Ù˘ ıÂڷ‡ÙÚÈ·˜ Ù· ·ÓÙÈΛÌÂÓ· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Î·È ÙÔÓ ÙÚfiÔ Ô˘ ı· Û˘ÏϤÁÂÈ ÏËÚÔÊÔڛ˜, ÂÓÒ ÛÙËÓ ∂ÈÎfiÓ· 8 Ê·›ÓÂÙ·È Ò˜ Ë ÔÌ¿‰· Û˘ÓÂÚÁ¿˙ÂÙ·È Î·È ÙÔ ·È‰› Ì ÙË ‚Ô‹ıÂÈ¿ Ù˘ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË Û˘ÓÂÚÁ·Û›· Î·È ÎÔÈÓˆÓÈÎÔÔÈ›ٷÈ. ™Â ·ÚfiÌÔÈ· ȉÂÔÏÔÁ›· ÛÙËÚ›˙ÂÙ·È Î·È Ë æ˘¯ÔÎÈÓËÙÈ΋ ıÂڷ›· (Ì ›ÎÂÓÙÚÔ ÙËÓ ∞ÈÛıËÙÈÎÔ-ÎÈÓËÙÈ΋). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Î¿ı ıÂڷ¢ÙÈ΋ ̤ıÔ‰Ô˜ ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÎÈÓÂ›Ù·È ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÂÊÈÎÙÔ‡. ∂›Ó·È ÂÔ̤ӈ˜ ‡ÏÔÁÔ, ȉȷ›ÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ‰È¿ÊÔÚ˜ ÂÈ̤ÚÔ˘˜ ‰È·Ù·Ú·¯¤˜, Ó· ·Ó·Ù‡ÛÛÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ηÈÓÔ‡ÚÁȘ ̤ıÔ‰ÔÈ, ÔÈ Ôԛ˜ ÚÔÛ·ıÔ‡Ó Ó· ηχ„Ô˘Ó ‹ Ó· ‚ÂÏÙÈÒÛÔ˘Ó Ù· ˘¿Ú¯ÔÓÙ· ÎÂÓ¿. ∆¤ÙÔȘ ̤ıÔ‰ÔÈ Â›Ó·È Ë ªÔ˘ÛÈÎÔıÂڷ›·, Ë ¶·È¯ÓȉÔıÂڷ›·, Ë £Âڷ›· ̤ۈ ˙ˆÁÚ·ÊÈ΋˜, ı¿ÙÚÔ˘ Î.Ï. ™ËÌ·ÓÙÈÎfi, ˆÛÙfiÛÔ, Â›Ó·È Ó· ÁÓˆÚ›˙Ô˘Ì fiÙÈ È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ Ì ÔÏϷϤ˜ ÌÂÈÔÓÂ͛˜ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ¤Ó· ÚfiÁÚ·ÌÌ· ·ÓÙÈÌÂÙÒÈÛ˘ Ì ‚¿ÛË ÙËÓ ÈÂÚ·Ú¯›· Ù˘ ‰È·Ù·Ú·¯‹˜, ÙÔ ÔÔ›Ô ı· ÂÊ·ÚÌfi˙ÂÙ·È ÌÂ Û˘Ó¯›˜ ·ӷϋ„ÂȘ. ¶Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë Ù·˘Ùfi¯ÚÔÓË ÂÊ·ÚÌÔÁ‹
∂ÈÎfiÓ· 6. ªÔÙԷȉ·ÁˆÁÈ΋ - ªÔÙÔıÂڷ›·: ∆Ô ·È‰› Ì·ı·›ÓÂÈ ÙÔ ÛÒÌ· ÙÔ˘ Î·È Ò˜ ı· ÙÔ ÌÂÙ·‚¿ÏÏÂÈ Ì¤Û· ·fi ÙËÓ Î›ÓËÛË.
∂ÈÎfiÓ· 7. ªÔÙԷȉ·ÁˆÁÈ΋ - ªÔÙÔıÂڷ›·: ∆Ô ·È‰› Ì·ı·›ÓÂÈ Ù· ·ÓÙÈΛÌÂÓ· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙfi˜ ÙÔ˘ Î·È Ò˜ Ó· Ù· ·ÓÙÈÏ·Ì‚¿ÓÂÙ·È Î·È Ó· Û˘ÏϤÁÂÈ ÏËÚÔÊÔڛ˜.
ÙËÓ Î·Ï‡ÙÂÚË ÂÓۈ̿وÛË Ù˘ ·ÓÙ›Ï˄˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ì ·˘Ù‹ ÙÔ˘ ¯ÒÚÔ˘.
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Ó¢ÚÒÓ˜, ÔÈ ÔÔ›ÔÈ Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ Ô‰ËÁÔ‡Ó Û ‰¤ÛÌ¢ÛË Ù˘ ÈηÓfiÙËÙ·˜ ÂȉfiÛÂˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (5). πÛ¯‡ÂÈ Î·È Â‰Ò Ë Ú‹ÛË “·Ó ̤ÙÚÔÓ ¿ÚÈÛÙÔÓ” ÙˆÓ ·Ú¯·›ˆÓ Ì·˜ ÚÔÁfiÓˆÓ. µÈ‚ÏÈÔÁÚ·Ê›·
∂ÈÎfiÓ· 8. ªÔÙԷȉ·ÁˆÁÈ΋ - ªÔÙÔıÂڷ›·: ∆Ô ·È‰› Ì·ı·›ÓÂÈ Ó· Û˘ÓÂÚÁ¿˙ÂÙ·È Î·È Ó· ÎÔÈÓˆÓÈÎÔÔÈ›ٷÈ.
ÔÏÏÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÌÂıfi‰ˆÓ, ÁÈ·Ù› ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ó· ÎÔ˘Ú¿˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ô ‹‰Ë ‰È·Ù·Ú·Á̤ÓÔ˜ ÂÁΤʷÏÔ˜. ∂Ô̤ӈ˜, ‰ÂÓ Ú¤ÂÈ Ó· ·ÁÓÔÔ‡ÓÙ·È ÔÈ ÁÓˆÛÙ¤˜ Û˘Ó¤ÂȘ Ù˘ “ÀÂÚıÂڷ›·˜”, Ë ÔÔ›· ˆ˜ ÁÓˆÛÙfiÓ ‰Ú·ÛÙËÚÈÔÔÈ› ÙÔ˘˜ ·Ó·ÛÙ·ÏÙÈÎÔ‡˜
1. Schamberger R. Effektivitaet der Fruehtherapie bei geistig behinderten kinder. Soz. Praeventivmed 1979;24:377-380. 2. Shamberger R, Heiss-Begemann E. Entwicklungstherapie auf der basis der Muenchener Functionellen Entwicklungs diagnostik. Kl.Soz.Paed. Springer Verlag; 1981. p. 240-246. 3. Koehler G, Egelkraut H, Hellbruegge T. Neufassung der Muenchener funktionellen Entwicklungsdiagnostik tuer das 2 und 3 Lebensjahr. Der kinderartzt 1983;14:1405-1407. 4. Kurtz L, Scull S. Rehabilitation of developmental disorders. Pediatr Clin 1993;33:841-860. 5. Gschwend G. Therapie moeglichkeiten. Neurophysiologische Grundlagen der Hirnleistungsstoerungen. Karger Verlag; 1998. p. 7-11. 6. Pflueger L, Bauer U et al. Unser kind braucht Hilfe. Fruehfoerderung behinderter kinder Trias-Thieme Verlag; 1993. p. 42-85. 7. Vojta V. Reflexbedingte Fortbewegung. Die zerebralen Bewegungsstoerungen im Saluglingsalter. Enke Verlag; 1988. p. 120-144. 8. Ayres AJ. Sensory Integration and the child. LA Western Psychological Services. 1980.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ¡ÈÎÔÏ¿Ô˘-¶··Ó·ÁÈÒÙÔ˘ ∂ıÓ. ∞ÓÙÈÛÙ¿Ûˆ˜ 50, 152 31, ÷ϿӉÚÈ
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¶·È‰È·ÙÚÈ΋ 2001;64:384-386
∞¡∞¶∆À•π∞∫∏ ¶∞π¢π∞∆ƒπ∫∏
Paediatriki 2001;64:384-386
DEVELOPMENTAL PEDIATRICS
™˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË π. ∆Û›ÎÔ˘Ï·˜
Emotional intelligence J. Tsikoulas
¶ÂÚ›ÏË„Ë: ∏ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË Â›Ó·È Ë ÈηÓfiÙËÙ· ÙÔ˘ ·ÙfiÌÔ˘ Ó· ÁÓˆÚ›˙ÂÈ Î·È Ó· ÂϤÁ¯ÂÈ Ù· Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘, Ó· ‚Ú›ÛÎÂÈ Î›ÓËÙÚ· ÁÈ· ÙÔÓ Â·˘Ùfi ÙÔ˘, Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ ¿ÏÏˆÓ Î·È Ó· ÌÔÚ› Ó· ¯ÂÈÚ›˙ÂÙ·È ÙȘ Û¯¤ÛÂȘ ÙÔ˘. ∏ ˘„ËÏ‹ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ıˆÚÂ›Ù·È ··Ú·›ÙËÙÔ ÛÙÔÈ¯Â›Ô ÁÈ· ÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ Î·È ÚÔÛˆÈ΋ ÂÈÙ˘¯›· ÙÔ˘ ·ÙfiÌÔ˘ Î·È ÌÔÚ› Ó· ·˘ÍËı› Ì ÙËÓ ÂÍ¿ÛÎËÛË.
Abstract: Emotional intelligence is a complex multifaceted quality representing such intangibles as self-awareness, empathy, persistence and social deftness. Emotional intelligence is considered to be a necessary element for the professional and personal success of the individual and can be developed through practice.
§¤ÍÂȘ ÎÏÂȉȿ: ÓÔËÌÔÛ‡ÓË, Û˘Ó·ÈÛı‹Ì·Ù·, ·˘ÙÔ›ÁÓˆÛË, ÂÓÛ˘Ó·›ÛıËÛË.
Key words: intelligence, awareness, empathy.
∞fi Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990, ÛÙÔ ¯ÒÚÔ Ù˘ „˘¯ÔÏÔÁ›·˜ Î·È Ù˘ ∞Ó·Ù˘Íȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ¤ÓÓÔÈ· Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘ (Emotional Intelligence) Î·È Â‰Ú·ÈÒıËΠÙÔ 1995 Ì ÙË Û˘ÁÁÚ·Ê‹ ÙÔ˘ ‚È‚Ï›Ô˘ ÙÔ˘ ηıËÁËÙ‹ Ù˘ „˘¯ÔÏÔÁ›·˜ Daniel Goleman ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ÙÔ˘ Harvard, Ô˘ ¤¯ÂÈ Ù›ÙÏÔ “™˘Ó·ÈÛıËÌ·ÙÈ΋ ¡ÔËÌÔÛ‡ÓË. °È·Ù› ÙÔ EQ Â›Ó·È ÈÔ ÛËÌ·ÓÙÈÎfi ·fi ÙÔ IQ”. ŒÙÛÈ, Û‹ÌÂÚ· ÈÛÙ‡ÂÙ·È fiÙÈ ÁÈ· ÙËÓ Úfi‚ÏÂ„Ë Ù˘ ÂÈÙ˘¯›·˜ ÂÓfi˜ ·ÙfiÌÔ˘ ·ÏÏ¿ Î·È ÙËÓ ÚÔÛˆÈ΋ ÙÔ˘ Â˘Ù˘¯›· Ë ‰‡Ó·ÌË ÙÔ˘ Ì˘·ÏÔ‡ ÙÔ˘ (Ë ÓÔËÌÔÛ‡ÓË), fiˆ˜ ÂÎÙÈÌ¿Ù·È Ì ٷ ÙÂÛÙ ÓÔËÌÔÛ‡Ó˘, ¤¯ÂÈ Ôχ ÌÈÎÚfiÙÂÚË ÛËÌ·Û›· ·fi ÙȘ ȉÈfiÙËÙ˜ Ô˘ ·ÔηÏԇ̠¯·Ú·ÎÙ‹Ú· ‹ ÓÔËÌÔÛ‡ÓË Ù˘ ηډȿ˜ (Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË), ÙȘ Ôԛ˜ ̤¯ÚÈ ÚfiÛÊ·Ù· Ë ÂÈÛÙ‹ÌË ¿ÊËÓ ÌfiÓÔ ÁÈ· ÙÔ˘˜ ÔÈËÙ¤˜. ∏ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ‰ÂÓ ·ÓÙÈÙ›ıÂÙ·È ÛÙËÓ ÎÏ·ÛÈ΋ ÓÔËÌÔÛ‡ÓË. ¢ÂÓ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ÈηÓfiÙËÙ˜, ·ÏÏ¿ ͯˆÚÈÛÙ¤˜ Î·È ·ÏÏËÏÔÛ˘-
ÌÏËÚÔ‡ÌÂÓ˜. ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯Ô˘Ó Û ·ÚfiÌÔÈÔ ‚·ıÌfi ÛÙÔ ›‰ÈÔ ¿ÙÔÌÔ, ·ÏÏ¿ fi¯È ¿ÓÙ·. £ÂˆÚÂ›Ù·È fiÙÈ ÙÔ 20% Ù˘ ÂÈÙ˘¯›·˜ Î·È Ù˘ Â˘Ù˘¯›·˜ ÂÓfi˜ ·ÙfiÌÔ˘ ÔÊ›ÏÂÙ·È ÛÙË ÓÔËÌÔÛ‡ÓË Î·È ÙÔ 80% ÛÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË, ηıÒ˜ Î·È Û ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ (Ù‡¯Ë, ÎÔÈÓˆÓÈÎfi Â›Â‰Ô Î.Ï.). Œ‰Ú· Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘ Â›Ó·È ÙÔ ÏÈÌÈÎfi ‹ ÌÂٷȯÌÈ·Îfi Û‡ÛÙËÌ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÂÓÒ Ù˘ ÓÔËÌÔÛ‡Ó˘ Â›Ó·È Ô ÊÏÔÈfi˜. Ÿˆ˜ Ë ÂÎÙ›ÌËÛË Ù˘ ÓÔËÌÔÛ‡Ó˘ Á›ÓÂÙ·È Ì ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ¢Â›ÎÙË ¡ÔËÌÔÛ‡Ó˘ [Intelligence Quotient (IQ)], ¤ÙÛÈ Î·È Ë Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ÂÎÙÈÌ¿Ù·È Ì ÙÔ ™˘Ó·ÈÛıËÌ·ÙÈÎfi ¢Â›ÎÙË [Emotional Quotient (EQ)]. ∂›Ó·È ϤÔÓ ·Ú·‰ÂÎÙfi fiÙÈ ÙÔ E.Q. Â›Ó·È ÈÔ ÛËÌ·ÓÙÈÎfi ·fi ÙÔ I.Q.! OÈ ‚·ÛÈÎÔ› ÙÔÌ›˜ Ô˘ Û˘ÓÈÛÙÔ‡Ó ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË Â›Ó·È ÔÈ ÂÍ‹˜: 1. °ÓÒÛË ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ Ì·˜. ∏ ·˘ÙÔ›ÁÓˆÛË ÂÓfi˜ Û˘Ó·ÈÛı‹Ì·ÙÔ˜ ÙËÓ ÒÚ· Ô˘
∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢
Associate Professor Aristotelion University of Thessaloniki
384
emotions,
self-
¶·È‰È·ÙÚÈ΋ 2001;64:384-386
‰ËÌÈÔ˘ÚÁÂ›Ù·È Â›Ó·È Ô ·ÎÚÔÁˆÓÈ·›Ô˜ Ï›ıÔ˜ Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘. ∏ ÈηÓfiÙËÙ· Ó· ·ÓÙÈÏ·Ì‚·ÓfiÌ·ÛÙÂ Î·È Ó· ·Ó·ÁÓˆÚ›˙Ô˘Ì οı ÛÙÈÁÌ‹ Ù· Û˘Ó·ÈÛı‹Ì·Ù· Â›Ó·È Î·›ÚÈ· ÁÈ· ÙËÓ „˘¯ÔÏÔÁÈ΋ ÂÓfiÚ·ÛË Î·È ·˘ÙÔηٷÓfiËÛË. ∏ Ù˘¯fiÓ ·ÓÈηÓfiÙËÙ¿ Ì·˜ Ó· ·Ú·ÙËÚ‹ÛÔ˘Ì ٷ Ú·ÁÌ·ÙÈο Ì·˜ ·ÈÛı‹Ì·Ù·, Ì¿˜ ·Ê‹ÓÂÈ ÛÙÔ ¤ÏÂfi˜ ÙÔ˘˜. ÕÓıÚˆÔÈ Ô˘ ÓÈÒıÔ˘Ó ÈÔ Û›ÁÔ˘ÚÔÈ Ì ٷ Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘˜ ‰È¢ı‡ÓÔ˘Ó Î·Ï‡ÙÂÚ· ÙË ˙ˆ‹ ÙÔ˘˜ Î·È ·ÔÎÙÔ‡Ó Ì›· ÈÔ ÚÔÛÁÂȈ̤ÓË ·›ÛıËÛË Î·È Â›ÁÓˆÛË ÙˆÓ ·ÔÊ¿ÛÂˆÓ Ô˘ ·›ÚÓÔ˘Ó ÁÈ· ÙÔÓ Â·˘Ùfi ÙÔ˘˜ (·fi ÙÔ ÔÈÔÓ ı· ‰È·Ï¤ÍÔ˘Ó ÁÈ· Û‡ÓÙÚÔÊfi ÙÔ˘˜, ̤¯ÚÈ ÔÈÔ Â¿ÁÁÂÏÌ· ı· ·Û΋ÛÔ˘Ó). 2. ŒÏÂÁ¯Ô˜ ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ Ì·˜. ∏ ÈηÓfiÙËÙ· Ó· ¯ÂÈÚ·ÁˆÁÔ‡ÌÂ Î·È Ó· ÂϤÁ¯Ô˘Ì ٷ Û˘Ó·ÈÛı‹Ì·Ù¿ Ì·˜ Ì ÙÚfiÔ ÒÛÙ ӷ Â›Ó·È Ù· ηٿÏÏËÏ· ·Ó¿ ¿Û· ÛÙÈÁÌ‹, ÔÈÎÔ‰ÔÌÂ›Ù·È ¿Óˆ ÛÙËÓ ·˘ÙÔ›ÁÓˆÛË. ∂›Ó·È Ë ÈηÓfiÙËÙ· ÙÔ˘ ·ÙfiÌÔ˘ Ó· ËÚÂÌ›, Ó· ··ÏÏ¿ÛÛÂÙ·È ·fi ÙÔ ·ÓÂͤÏÂÁÎÙÔ ¿Á¯Ô˜, ÙËÓ Î·Ù‹ÊÂÈ· ‹ ÙÔÓ Â‡ÎÔÏÔ ı˘Ìfi. ÕÙÔÌ· Ô˘ ÛÙÂÚÔ‡ÓÙ·È ·˘Ù‹˜ Ù˘ ÈηÓfiÙËÙ·˜, Ì¿¯ÔÓÙ·È ¿ÓÙ· Ù· ·ÈÛı‹Ì·Ù· Ù˘ ηٿıÏȄ˘, ÂÓÒ fiÛÔÈ ‰È·ÎÚ›ÓÔÓÙ·È ÁÈ· ·˘Ù‹, ÌÔÚÔ‡Ó Ôχ ÈÔ ÁÚ‹ÁÔÚ· Ó· ÍÂÂÚ¿ÛÔ˘Ó Ù· ÈÛˆÁ˘Ú›ÛÌ·Ù· Î·È ÙȘ ·ÔÁÔËÙ‡ÛÂȘ Ù˘ ˙ˆ‹˜. 3. ∂͇ÚÂÛË ÎÈÓ‹ÙÚˆÓ ÁÈ· ÙÔÓ Â·˘Ùfi Ì·˜. O ¤ÏÂÁ¯Ô˜ ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ Ô˘ ·ÔÛÎÔ› ÛÙËÓ Â͢ËÚ¤ÙËÛË ÂÓfi˜ ÛÙfi¯Ô˘ Â›Ó·È Ô˘ÛÈ·ÛÙÈÎfi˜ ÛÙËÓ ÚÔۋψÛË Ù˘ ÚÔÛÔ¯‹˜, ÙËÓ Â͇ÚÂÛË ÎÈÓ‹ÙÚˆÓ, ÙËÓ ·˘ÙÔ΢ÚÈ·Ú¯›· Î·È ÙË ‰ËÌÈÔ˘ÚÁÈÎfiÙËÙ·. O Û˘Ó·ÈÛıËÌ·ÙÈÎfi˜ ·˘ÙÔ¤ÏÂÁ¯Ô˜ - Ë Î·ı˘fiÙ·ÍË Ù˘ ·Ó˘ÔÌÔÓËÛ›·˜ Ì·˜ Î·È Ë ¯·ÏÈÓ·ÁÒÁËÛË Ù˘ ·ÚÔÚÌËÙÈÎfiÙËÙ·˜ - ‚Ú›ÛÎÂÙ·È ›Ûˆ ·fi οı ›‰Ô˘˜ ›Ù¢ÁÌ·. ∏ ÈηÓfiÙËÙ· ÙÔ˘ ·ÙfiÌÔ˘ Ó· Ì·›ÓÂÈ Û ·˘Ù‹ ÙËÓ “ηٿÛÙ·ÛË ÚÔ‹˜” ÂÈÙÚ¤ÂÈ ÂÎÏËÎÙÈΤ˜ ÂȉfiÛÂȘ Û fiÏÔ˘˜ ÙÔ˘˜ ÙÔÌ›˜. OÈ ¿ÓıÚˆÔÈ Ô˘ ¤¯Ô˘Ó ·˘Ù‹ ÙËÓ ÈηÓfiÙËÙ· Ù›ÓÔ˘Ó Ó· Â›Ó·È Ôχ ÂÚÈÛÛfiÙÂÚÔ ·Ú·ÁˆÁÈÎÔ› Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ› Û ÔÔÈ·‰‹ÔÙ ‰Ú·ÛÙËÚÈfiÙËÙ·. 4. ∞Ó·ÁÓÒÚÈÛË ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ ÙˆÓ ¿ÏψÓ. ∏ ÂÓÛ˘Ó·›ÛıËÛË, Ì›· ¿ÏÏË ÈηÓfiÙËÙ· Ô˘ ¤¯ÂÈ ÙË ‚¿ÛË Ù˘ ÛÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·˘ÙÔ›ÁÓˆÛË, Â›Ó·È Ë ıÂÌÂÏÈ҉˘ ·ÓıÚÒÈÓË ‰ÂÍÈfiÙËÙ·. ∆· “ÂÓÛ˘Ó·ÈÛıËÙÈο” ¿ÙÔÌ· Â›Ó·È ÈÔ ‰ÂÎÙÈο ÛÙ· ÛȈËÏ¿ ÎÔÈÓˆÓÈο Û‹Ì·Ù· Ô˘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÙÈ ı¤ÏÔ˘Ó ‹ ÙÈ ¤¯Ô˘Ó ·Ó¿ÁÎË ÔÈ ¿ÏÏÔÈ. ∞˘Ùfi ÙÔ˘˜ οÓÂÈ Î·Ï‡ÙÂÚÔ˘˜ Û ·ÁÁ¤ÏÌ·Ù· Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ÎÔÈÓˆÓÈ΋ ÚÔÛÊÔÚ¿, ‰È‰·Ûηϛ·, ˆÏ‹ÛÂȘ Î·È ‰ÈÔ›ÎËÛË. 5. ÃÂÈÚÈÛÌfi˜ ÙˆÓ Û¯¤ÛˆÓ. ∏ Ù¤¯ÓË ÙˆÓ ‰È·ÚÔÛˆÈÎÒÓ Û¯¤ÛÂˆÓ ·ÓÙÈÚÔۈ‡ÂÈ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙË ‰ÂÍÈfiÙËÙ· ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ ÙˆÓ ¿ÏψÓ. ∂›Ó·È Ë ÈηÓfiÙËÙ· Ô˘ ‚Ú›ÛÎÂÙ·È
Paediatriki 2001;64:384-386
›Ûˆ ·fi ÙË ‰ËÌÔÙÈÎfiÙËÙ·, ÙËÓ ËÁÂÙÈ΋ ‰ÂÈÓfiÙËÙ· Î·È ÙË ‰È·ÚÔÛˆÈ΋ ÂÈÙ˘¯›·. ÕÙÔÌ· Ô˘ ‰È·ı¤ÙÔ˘Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·˘Ù¤˜ ÙȘ ÈηÓfiÙËÙ˜ ‰È·Ú¤Ô˘Ó Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ÔÌ·Ï‹ ·ÏÏËÏ›‰Ú·Û‹ ÙÔ˘˜ Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ Î·È Ï¿ÌÔ˘Ó ¿ÓÙ· ÛÙÔ ÎÔÈÓˆÓÈÎfi ÛÙÂÚ¤ˆÌ·. OÈ ¿ÓıÚˆÔÈ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙȘ ÈηÓfiÙËÙ¤˜ ÙÔ˘˜ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÓˆÙ¤Úˆ ÙÔÌ›˜. ªÂÚÈÎÔ› .¯. ÌÔÚ› Ó· Â›Ó·È Ôχ Âȉ¤ÍÈÔÈ ÛÙÔ ¯ÂÈÚÈÛÌfi ÙÔ˘ ¿Á¯Ô˘˜, ·ÏÏ¿ Û˘ÁÎÚÈÙÈο ·Ó›‰ÂÎÙÔÈ ÛÙÔÓ Î·Ù¢ӷÛÌfi Ù˘ ‰˘ÛÙ˘¯›·˜ ÙÔ˘ ¿ÏÏÔ˘. O ÂÁΤʷÏÔ˜, fï˜, Â›Ó·È ÂÓÙ˘ˆÛȷο ‡ϷÛÙÔ˜ Î·È Ì·ı·›ÓÂÈ ·Î·Ù¿·˘ÛÙ·. ¶ÔÏÏ¿ ÎÂÓ¿ ÛÙȘ Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ‰ÂÍÈfiÙËÙ˜ ÌÔÚÔ‡Ó Ó· Î·Ï˘ÊıÔ‡Ó. ∫·ı¤Ó·˜ ·fi ÙÔ˘˜ ·ÓˆÙ¤Úˆ ÙÔÌ›˜ ·ÓÙÈÚÔۈ‡ÂÈ ¤Ó· Û‡ÓÔÏÔ Û˘ÌÂÚÈÊÔÚÒÓ Î·È ·ÓÙȉڿÛˆÓ, Ô˘ Ì ÙË ÛˆÛÙ‹ ÚÔÛ¿ıÂÈ· ÌÔÚÔ‡Ó Ó· ‚ÂÏÙÈÒÓÔÓÙ·È ·‰È¿ÎÔ·. ◊‰Ë ÛÙËÓ ∞ÌÂÚÈ΋ ¤¯Ô˘Ó ·Ú¯›ÛÂÈ ÚÔÁÚ¿ÌÌ·Ù· “Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÌfiÚʈÛ˘” ·fi ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, Ì ÛÎÔfi ÙËÓ ·Ó¿Ù˘ÍË Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘, ηı’ fiÛÔÓ ·Ô‰Â›¯ıËΠfiÙÈ Ë Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ‰ÂÓ ¤¯ÂÈ ÁÂÓÂÙÈ΋ ‚¿ÛË, ·ÏÏ¿ ‰È·ÌÔÚÊÒÓÂÙ·È Ì ÙȘ ÂÌÂÈڛ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ¯·ÌËÏ‹ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ¤¯Ô˘Ó ÔÈ ¿ÓıÚˆÔÈ Ô˘: ·) ‰ÂÓ ÌÔÚÔ‡Ó Ó· ηٷϿ‚Ô˘Ó ÙÈ Û˘Ó·ÈÛı‹Ì·Ù· ÓÈÒıÔ˘Ó Î·È ÁÈ·Ù›, ‚) ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÂϤÁÍÔ˘Ó Ù· Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘˜ (Ô ∞ÚÈÛÙÔÙ¤Ï˘ ¤ÏÂÁ fiÙÈ Â›Ó·È Ú¿ÁÌ·ÙÈ ‰‡ÛÎÔÏÔ Ó· ı˘ÌÒÛÂÈ Î·Ó›˜ Ì ÙÔ ÛˆÛÙfi ¿ÙÔÌÔ, ÛÙÔ ÛˆÛÙfi ‚·ıÌfi Î·È ÛÙË ÛˆÛÙ‹ ÛÙÈÁÌ‹, ÁÈ· ÙË ÛˆÛÙ‹ ·ÈÙ›· Î·È ÙÔ ÛˆÛÙfi ÙÚfiÔ), Á) ηÙËÁÔÚÔ‡Ó ÙÔ˘˜ ¿ÏÏÔ˘˜ ÁÈ· Ù· ‰Èο ÙÔ˘˜ Û˘Ó·ÈÛı‹Ì·Ù·, ‰) Â›Ó·È ·Ó·ÛÊ·Ï›˜ Î·È ‰ÂÓ ÂÎÙÈÌÔ‡Ó ÙÔÓ Â·˘Ùfi ÙÔ˘˜, Â) ÓÈÒıÔ˘Ó ·ÔÁÔ‹Ù¢ÛË Î·È ÈÎÚ›·, Â›Ó·È Ù· “·ÈÒÓÈ· ı‡Ì·Ù·”, ÛÙ) ÎÚ›ÓÔ˘Ó ‰È·ÚÎÒ˜ Î·È Ì ·˘ÛÙËÚfiÙËÙ· ÙÔ˘˜ ¿ÏÏÔ˘˜ Î·È ÙÔ˘˜ ÂÓÔ¯ÔÔÈÔ‡Ó, Û˘¯Ó¿ ¯ˆÚ›˜ Ó· ÚÔÛ·ıÔ‡Ó Ó· ηٷÓÔÔ‡Ó Ù· ΛÓËÙÚ¿ ÙÔ˘˜, ˙) ‰È·ÎfiÙÔ˘Ó ÙÔ˘˜ ¿ÏÏÔ˘˜ fiÙ·Ó ÌÈÏÔ‡Ó Î·È ‰ÂÓ Î·Ù·ÓÔÔ‡Ó Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ Û˘Ó·ÓıÚÒˆÓ ÙÔ˘˜. À„ËÏ‹ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÓÔËÌÔÛ‡ÓË ¤¯Ô˘Ó ÔÈ ¿ÓıÚˆÔÈ Ô˘: ·) ¤¯ÔÓÙ·˜ ÁÓÒÛË Î·È ¤ÏÂÁ¯Ô ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ ÙÔ˘˜, ‰ÂÓ ÊÔ‚Ô‡ÓÙ·È Ó· Ù· ÂÎÊÚ¿ÛÔ˘Ó Ì ۷ʋÓÂÈ· Î·È ·ÎÚ›‚ÂÈ· Î·È Ù· ·Ê‹ÓÔ˘Ó Ó· ÙÔ˘˜ ηıÔ‰ËÁÔ‡Ó ÛÙË ˙ˆ‹ (·ÎÔ‡Ó Î·È Û¤‚ÔÓÙ·È Ù· Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘˜), ‚) ‰ÂÓ Â›Ó·È ‰¤ÛÌÈÔÈ ·ÚÓËÙÈÎÒÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ fiˆ˜ Ô Êfi‚Ô˜, Ë ÂÓÔ¯‹, Ë ÓÙÚÔ‹, Ë ‰˘Û·Ú¤ÛÎÂÈ·, Ë ·‰˘Ó·Ì›·, Ë ÂÍ¿ÚÙËÛË, Á) ÈÛÔÚÚÔÔ‡Ó Ù· Û˘Ó·ÈÛı‹Ì·Ù¿ ÙÔ˘˜ Ì ÙË ÏÔÁÈ΋ Î·È ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ‰) ¤¯Ô˘Ó ˘„ËÏ‹ ·˘ÙÔÂÎÙ›ÌËÛË, Â) ‰ÂÓ ÂËÚ¿˙ÔÓÙ·È ÛÔ‚·Ú¿ ·fi ÙË ‰‡Ó·ÌË, ÙÔÓ ÏÔ‡ÙÔ Î·È ÙË Ê‹ÌË, ÛÙ) ÌÔÚÔ‡Ó Ó· ÂÚÌËÓ‡ÛÔ˘Ó Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ ¿ÏÏˆÓ ¯ˆÚ›˜ Ó·
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˙‹ÛÔ˘Ó ÈÔ Â˘Ù˘¯ÈṲ̂ÓÔÈ. ∞˘Ùfi ·ÔÙÂÏ› ÙÔ ÌÂÁ¿ÏÔ ÎÂÊ¿Ï·ÈÔ Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘!
¯ÚÂÈ¿˙ÔÓÙ·È ÏfiÁÈ·, ˙) ÂӉȷʤÚÔÓÙ·È ÁÈ· Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙˆÓ ¿ÏψÓ. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ›, Ù¤ÏÔ˜, fiÙÈ Ë ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ÚÔÛʤÚÂÙ·È È‰È·›ÙÂÚ· ÁÈ· ÙË ‰È‰·Ûηϛ· ÙÚfiˆÓ ·Ó¿Ù˘Í˘ Ù˘ Û˘Ó·ÈÛıËÌ·ÙÈ΋˜ ÓÔËÌÔÛ‡Ó˘. ¶·Ú’ fiÏ· ·˘Ù¿, fiÏÔÈ ÔÈ ¿ÓıÚˆÔÈ, ·ÓÂÍ·Úًو˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘˜, ÌÔÚÔ‡Ó Ì ÙËÓ ÂÍ¿ÛÎËÛË Ó· ·Ó·Ù‡ÍÔ˘Ó ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÔ˘˜ ÓÔËÌÔÛ‡ÓË ÎÈ ¤ÙÛÈ Ó· ÂÈÙ‡¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ· Î·È Ó·
µÈ‚ÏÈÔÁÚ·Ê›· 1. Daniel Goleman. Emotional Intelligence. Bantam Books; 1995. ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: π. ∆Û›ÎÔ˘Ï·˜ ªËÙÚÔfiψ˜ 119, 546 22, £ÂÛÛ·ÏÔÓ›ÎË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· KÏÈÓÈ΋ ÔÚ›· Î·È ÚfiÁÓˆÛË Û ·È‰È¿ Ì ÏÂÈÔ΢ÛÙÈÎÔ‡˜ ‰˘ÛÏ·ÛÙÈÎÔ‡˜ ÓÂÊÚÔ‡˜1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› Ë ÎÏÈÓÈ΋ ÔÚ›· Î·È Ë ÚfiÁÓˆÛË ·È‰ÈÒÓ Ì ÏÂÈÔ΢ÛÙÈÎfi ‰˘ÛÏ·ÛÙÈÎfi ÓÂÊÚfi (¶K¢N) (multicystic dysplastic kidney) Î·È Ó· ÚÔ‚ÏÂÊı› ÔÈÔÈ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰È·ÙÚ¤¯Ô˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó Ô˘ÚÔÏÔÈÌÒÍÂȘ Î·È ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: OÈ ·ÛıÂÓ›˜ Ù·ÍÈÓÔÌ‹ıËηÓ, Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· Ù˘ ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ÂͤٷÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È Ù· Â˘Ú‹Ì·Ù· ÙˆÓ ˘ÂÚ‹¯ˆÓ (U/S) ÓÂÊÚÒÓ, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÚÔ˘Û›· ·ÏÔ‡ ‹ Û‡ÓıÂÙÔ˘ ÔÏ˘Î˘ÛÙÈÎÔ‡ ‰˘ÛÏ·ÛÙÈÎÔ‡ ÓÂÊÚÔ‡. ø˜ ·Ïfi˜ ¶K¢N ÔÚ›ÛÙËÎÂ Ë ·ÚÔ˘Û›· ÌÔÓfiÏ¢Ú˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏ·Û›·˜ ¯ˆÚ›˜ Ó· Û˘Ó˘¿Ú¯Ô˘Ó ¿ÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙÔ˘˜ Û‡ÓıÂÙÔ˘˜ ¶K¢N ÂÚÈÂÏ‹ÊıËÛ·Ó ÔÈ ·ÛıÂÓ›˜ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· ‹ ÌÔÓfiÏ¢ÚË ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· ÌÂ Û˘Ó‡·ÚÍË ¿ÏÏˆÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡. ™ÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ·ÏÔ‡ ‹ Û‡ÓıÂÙÔ˘ ¶K¢N ‰ÂÓ ÂÚÈÂÏ‹ÊıËÎÂ Ë ·ÚÔ˘Û›· ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ηıÒ˜ ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û ΢ÛÙÂÔÔ˘ÚËıÔÁÚ·Ê›·. H ÌÂϤÙË ·ÊÔÚÔ‡Û 35 ·È‰È¿ Ì ¶K¢N Ì ̤ÛË ËÏÈΛ·, ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜, Ù· 6,5 ¤ÙË, Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÛÙÔ TÌ‹Ì· ¶·È‰È·ÙÚÈ΋˜ NÂÊÚÔÏÔÁ›·˜ Ù˘ I·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ÙÔ˘ Yale, Û ‰È¿ÛÙËÌ· Ì›·˜ ÙÂÙÚ·ÂÙ›·˜ (1994-1999). K·Ù·ÁÚ¿ÊËÎÂ Ë ÂÌÊ¿ÓÈÛË Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Î·È Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ÂͤٷÛË Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜. 21/35 ·È‰È¿ (60%) ›¯·Ó ·Ïfi ¶K¢N Î·È 14/21 ·È‰È¿ (40%) ›¯·Ó Û‡ÓıÂÙÔ˘˜ ¶K¢N. Afi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 35 ·È‰ÈÒÓ, ÌÔÓfiÏ¢ÚÔ ¶KN ›¯·Ó Ù· 28 (80%) Î·È Ù· ˘fiÏÔÈ· 7 ›¯·Ó ·ÌÊÔÙÂÚfiÏ¢ÚÔ˘˜ ¶K¢N.
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AÔÙÂϤÛÌ·Ù·: H ÙÂÏÈ΋ ÚfiÁÓˆÛË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·Ïfi ¶K¢N ‹Ù·Ó Ôχ ηϋ, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ·ÓÙÈÚÚÔÈÛÙÈ΋ ˘ÂÙÚÔÊ›· ÙÔ˘ ˘ÁÈÔ‡˜ ÓÂÊÚÔ‡ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ. AÓ Î·È ÔÈ ·ÛıÂÓ›˜ Ì ·Ïfi ¶K¢N ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ‹ ‰ÂÓ ‹Ú·Ó ÚÔʇϷÍË Ì ·ÓÙÈ‚ÈÔÙÈο, Ë ÂÌÊ¿ÓÈÛË Ô˘ÚÔÏԛ̈͢ ‹Ù·Ó ·Û˘Ó‹ı˘, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ‚Ï¿‚Ë ÛÙÔÓ ¿ÏÏÔ ÓÂÊÚfi Î·È Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‰È·ÙËÚ‹ıËΠÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·. AÓÙ›ıÂÙ·, ÔÈ ·ÛıÂÓ›˜ Ì ۇÓıÂÙÔ˘˜ ¶K¢N ›¯·Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· Ô˘ÚÔÏԛ̈͢ (28%), ÂÓÒ 7/14 (50%) ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ·Ó¤Ù˘Í·Ó ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ™˘ÌÂÚ¿ÛÌ·Ù·: O ÏÂÈÔ΢ÛÙÈÎfi˜ ‰˘ÛÏ·ÛÙÈÎfi˜ ÓÂÊÚfi˜ fiÙ·Ó Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚÔ˜ ‹ fiÙ·Ó Û˘Óԉ‡ÂÙ·È ·Ô ¿ÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ (Û‡ÓıÂÙÔ˜ ¶K¢N) ·ÚÔ˘ÛÈ¿˙ÂÈ, Û ۇÁÎÚÈÛË Ì ÙÔÓ ·Ïfi ¶K¢N, Û˘¯ÓfiÙÂÚ· ÂÂÈÛfi‰È· Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Î·È ÂÍÂÏ›ÛÛÂÙ·È Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ (50%) Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·.
1
Feldenberg LR, Siegel NJ Clinical course and outcome for children with multicystic dysplastic kidneys Pediatr Nephrol 2000;14:1098-1101
KˆÓ/ÓÔ˜ ¢. KÔÏÏÈfi˜ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ KÏÈÓÈ΋ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ
¶·È‰È·ÙÚÈ΋ 2001;64:387-390
¡∂ÀƒO§O°π∞
Paediatriki 2001;64:387-390
¡EUROLOGY
∏ Ó¢ÚÔ‚ÈÔÏÔÁÈ΋ ‚¿ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ì¿ıËÛ˘ ∞. ™˘Ú›ÁÔ˘ - ¶··‚·ÛÈÏ›Ԣ
The neurobiologic basis of learning disorders A. Syrigou - Papavasiliou
¶ÂÚ›ÏË„Ë: OÈ Ì˯·ÓÈÛÌÔ› Ù˘ Ì¿ıËÛ˘ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘˜ ¤¯Ô˘Ó ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ ÙˆÓ Ó¢ÚÔÂÈÛÙËÌÒÓ Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ·. ™¯ÂÙÈο Ó¤· ‰Â‰Ô̤ӷ ·fi ÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·, ÙË Ó¢ÚÔ·Ó·ÙÔÌ›·, ÙË ‚ÈÔÏÔÁ›·, ÙË Ó¢ÚÔ„˘¯ÔÏÔÁ›· Î·È ÙË Ó¢ÚÔ·ÂÈÎfiÓÈÛË ¤Ú¯ÔÓÙ·È Ó· ÂȂ‚·ÈÒÛÔ˘Ó ·˘Ùfi Ô˘ Ô πÔÎÚ¿Ù˘ ‰ÈÂÙ‡ˆÛ ·Ú¯Èο, fiÙÈ ‰ËÏ·‰‹ Ë ÌÂϤÙË ÙˆÓ ÓÔËÙÈÎÒÓ ‰ÈÂÚÁ·ÛÈÒÓ ÍÂÎÈÓ¿ ·fi ÙË ÌÂϤÙË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi Á›ÓÂÙ·È Ì›· Û‡ÓÙÔÌË Î·È ÂÚÈÔÚÈṲ̂ÓË ·Ó·ÊÔÚ¿ ÛÙ· Â˘Ú‹Ì·Ù· Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ÙË Ó¢ÚÔ‚ÈÔÏÔÁÈ΋ ‚¿ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ Ì¿ıËÛ˘.
Abstract: The mechanisms of learning and its disorders have been studied by the neuroscientists for many years. Astute clinical observations along with relatively new data from neurophysiology, neuroanatomy, biology, neuropsychology and neuroimaging have reconfirmed what Hippocrates initially stated, that, the study of the mental processes starts with the study of the brain. In this article a brief and limited review is attempted on the findings that lend support to the neurobiological basis of learning disorders.
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·Ù·Ú·¯¤˜ Ì¿ıËÛ˘, ‰˘ÛÏÂÍ›·, Ó¢ÚÔ·Ó·ÙÔÌ›·, Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·, Ó¢ÚÔ·ÂÈÎfiÓÈÛË, Ó¢ÚÔ‚ÈÔÏÔÁ›·.
Key words: learning disorders, dyslexia, neuroanatomy, neurophysiology, neuroimaging, neurobiology.
ª¿ıËÛË Â›Ó·È Ë ·fiÎÙËÛË ÁÓÒÛÂˆÓ Û¯ÂÙÈο Ì ÙÔÓ ÎfiÛÌÔ. ªÓ‹ÌË Â›Ó·È Ë Î·Ù·ÎÚ¿ÙËÛË ‹ ·Ôı‹Î¢ÛË ·˘ÙÒÓ ÙˆÓ ÁÓÒÛˆÓ. ªÂ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÔ‡˜ fiÚÔ˘˜ “Ì¿ıËÛË Â›Ó·È Ë Û¯ÂÙÈο ÌfiÓÈÌË ·‡ÍËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡ Û ¤Ó· ÂÚ¤ıÈÛÌ·, Ë ÔÔ›· ÂÍ·ÚÙ¿Ù·È ·fi ÚÔËÁËı›۷ ÂÓ›Û¯˘ÛË ÛÙËÓ ·ÚÔ˘Û›·ÛË ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜”. ∆Ô ·È‰› Ô˘ ‰ÂÓ Ù· ηٷʤÚÓÂÈ ÛÙÔ Û¯ÔÏ›Ô, ÌÔÏÔÓfiÙÈ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ÓÔËÌÔÛ‡ÓË, ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜ Â‰Ò Î·È ·ÚÎÂÙ¤˜ ‰ÂηÂٛ˜. ∞Ú¯Èο, Ë È‰¤· fiÙÈ ¤Ó· ·È‰› ·fi ÌÂÛ·›· ‹ ·ÓÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË Ô˘ Ê·ÈÓfiÙ·Ó ¤Í˘ÓÔ Î·È Â›¯Â ÛˆÛÙ‹ Âη›‰Â˘ÛË ‰ÂÓ ÌÔÚÔ‡Û ӷ Ì¿ıÂÈ, ‹Ù·Ó ÙÂÏ›ˆ˜ ·Î·Ù·ÓfiËÙË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ·ÈÙ›· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ıˆÚÔ‡ÓÙ·Ó Ë ¤ÏÏÂÈ„Ë ÎÈÓ‹-
ÙÚˆÓ ‹ „˘¯ÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∆fiÙ ÍÂÎÈÓÔ‡Û „˘¯ÔÏÔÁÈ΋ ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Û fiÛÔ˘˜ ›¯·Ó Ù¤ÙÔȘ ‰˘Ó·ÙfiÙËÙ˜, ÂÓÒ ÁÈ· ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ Ë Ï‡ÛË ‹Ù·Ó Ó· Ì›ÓÔ˘Ó ÂÎÙfi˜ Âη›‰Â˘Û˘. ∏ ÛΤ„Ë fiÙÈ Ë Ì·ıËÛȷ΋ ‰È·Ù·Ú·¯‹ ¤¯ÂÈ Èı·ÓfiÓ ÔÚÁ·ÓÈ΋ ‚¿ÛË ÍÂΛÓËÛ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1930 Î·È ¤ÁÈÓ ¢ڇÙÂÚ· ·Ô‰ÂÎÙ‹ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960. ∆fiÙ ÂÈÛ‹¯ıË Î·È Ë ¤ÓÓÔÈ· Ù˘ ÂÏ¿¯ÈÛÙ˘ ÂÁÎÂÊ·ÏÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, Ë ÔÔ›· Û ÌÂÁ¿ÏÔ ‚·ıÌfi ¤¯ÂÈ ÂÁηٷÏÂÈÊı› Û‹ÌÂÚ·, ‰ÈfiÙÈ ÙÂÏÈο ÚÔοÏÂÛ ̿ÏÏÔÓ Û‡Á¯˘ÛË ·Ú¿ ¤Ï˘Û ÚÔ‚Ï‹Ì·Ù·. ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ ÂÈÛ‹¯ıË Ë È‰¤· Ù˘ ÔÚÁ·ÓÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÛÙȘ Ì·ıËÛȷΤ˜ ‰È·Ù·Ú·¯¤˜, ÔÈ ÂÚ¢ÓËÙ¤˜ ÍÂΛÓËÛ·Ó Ó· „¿¯ÓÔ˘Ó ÁÈ· Ó¢ÚÔ‚ÈÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜. ∏ ÛΤ„Ë
¢È¢ı‡ÓÙÚÈ· ¡Â˘ÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘
Director, Department of Pediatric Neurology Penteli Children’s Hospital
387
¶·È‰È·ÙÚÈ΋ 2001;64:387-390
‹Ù·Ó fiÙÈ Ë ·Ó‡ÚÂÛË ÂÓfi˜ Ó¢ÚÔ·Ó·ÙÔÌÈÎÔ‡, Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÔ‡ ‹ Ó¢ÚÔ¯ËÌÈÎÔ‡ ·Ú¿ÁÔÓÙ· ı· ¤‰ÈÓ ‰È·ÁÓˆÛÙÈ΋ ‚‚·ÈfiÙËÙ·, ·ÏÏ¿ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ηٿٷ͢ ÙˆÓ ·ÛıÂÓÒÓ. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÂÚ›Ô˘ ÙÔ 15% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÊÔÈÙÔ‡Ó ÛÙÔ Û¯ÔÏÂ›Ô ¤¯Ô˘Ó ‰˘ÛÎÔϛ˜ ÛÙË Ì¿ıËÛË Î·È ÂÌÊ·Ó›˙Ô˘Ó ÌÂȈ̤ÓË ·fi‰ÔÛË Û ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ Û¯ÔÏÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜, fiˆ˜ ÛÙËÓ ·Ó¿ÁÓˆÛË, ÙË ÁÚ·Ê‹ ‹ ÙËÓ ·ÚÈıÌËÙÈ΋. À¿Ú¯Ô˘Ó ÔÏÏ¿ ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ Ì·ıËÛȷΤ˜ ‰È·Ù·Ú·¯¤˜ Û ¤Ó· ˘„ËÏfi ÔÛÔÛÙfi ¤¯Ô˘Ó Ó¢ÚÔÏÔÁÈÎfi ˘fiÛÙڈ̷, ‰ËÏ·‰‹ fiÙÈ ˘fiÎÂÈÙ·È Ù˘ ‰È·Ù·Ú·¯‹˜ οÔÈÔ Úfi‚ÏËÌ· ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ÔÚÁ¿ÓˆÛË. °È· ·Ú¿‰ÂÈÁÌ· ı· ·Ó·Ê¤ÚÔ˘Ì fiÙÈ Ë ‰˘ÛÏÂÍ›·, Ì ÙËÓ Ô˘ÛÈ·ÛÙÈ΋ ¤ÓÓÔÈ· ÙÔ˘ fiÚÔ˘, Ô ÔÔ›Ô˜ ÛËÌ·›ÓÂÈ ·Ó·ÁÓˆÛÙÈ΋ ‰È·Ù·Ú·¯‹, ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·ıÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÊÏÔÈÔ‡ Û ÂÚÈÔ¯¤˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈÛÊ·ÈÚ›Ô˘ Ô˘ ¤¯Ô˘Ó Ó· οÓÔ˘Ó Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÏfiÁÔ˘. ∂›Ó·È, ›Û˘, ÁÓˆÛÙfi fiÙÈ Û˘¯Ó¿ ÂÌÊ·Ó›˙ÂÙ·È Û ·È‰È¿ Ô˘ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· ›¯·Ó ÂÌÊ·Ó›ÛÂÈ Î·ı˘ÛÙ¤ÚËÛË ‹ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘. ∏ ‰˘Û·ÚÈıÌËÛ›· ‹ ‰˘ÛηÏÎÔ˘Ï›·, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ Í¤ÓË ‚È‚ÏÈÔÁÚ·Ê›·, ÛËÌ·›ÓÂÈ ‰È·Ù·Ú·¯‹ ÛÙËÓ ÈηÓfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡ Ó· ¯ÂÈÚÈÛÙ› Ì·ıËÌ·ÙÈΤ˜ ¤ÓÓÔȘ Î·È ·ÚÈıÌËÙÈΤ˜ Ú¿ÍÂȘ, οÙÈ Ô˘ ÌÔÚ› Ó· ÚÔ¤Ú¯ÂÙ·È ·fi ·ıÔÏÔÁÈ΋ ÔÚÁ¿ÓˆÛË ÂÚÈÔ¯ÒÓ ÙÔ˘ ‰ÂÍÈÔ‡ ‹ ·ÚÈÛÙÂÚÔ‡ ËÌÈÛÊ·ÈÚ›Ô˘. ∆¤ÏÔ˜, Ë ‰˘ÛÁÚ·Ê›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÎÈÓËÙÈÎÔ‡ Û˘ÓÙÔÓÈÛÌÔ‡ ‹ Ù˘ ÔÙÈÎÔÎÈÓËÙÈ΋˜ ·ÓÙÈÏËÙÈ΋˜ ÈηÓfiÙËÙ·˜. À¿Ú¯Ô˘Ó ÔÏÏ¿ ÛÙÔȯ›· Ù· ÔÔ›· ˘ÔÛÙËÚ›˙Ô˘Ó Ù· ·ÓˆÙ¤Úˆ Î·È Ù· ÔÔ›· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ·Ó·ÙÔÌÈ΋ ÌÂϤÙË ÂÁÎÂÊ¿ÏˆÓ ‰˘ÛÏÂÎÙÈÎÒÓ ·ÙfiÌˆÓ Ô˘ Û·ÊÒ˜ ˘Ô‰ÂÈÎÓ‡Ô˘Ó Ê·ÈÓfiÌÂÓ· ‰˘ÛÁÂÓÂÛ›·˜, fiˆ˜ Î·È ·fi Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ (ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·, ÂÁÎÂÊ·ÏÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο), fiˆ˜ Î·È ·fi ÙË ÌÂϤÙË ÙˆÓ ÁÓˆÛÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ù˘ ÂȉËÌÈÔÏÔÁ›·˜ Î.Ï. £· ·Ó·ÊÂÚıԇ̠ÛÙ· ÈÔ ÛËÌ·ÓÙÈο ·fi ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù· ÛÙË Û˘Ó¤¯ÂÈ·. ∆· ÛÙÔȯ›· ·˘Ù¿ ‰ÈηÈÔÏÔÁÔ‡Ó Ï‹Úˆ˜ ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÁÈ· Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ·È‰ÈÒÓ Ì ̷ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜, ¤ÙÛÈ ÒÛÙ ӷ ÂÓÙÔÈÛÙÔ‡Ó ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ÔÚÁ¿ÓˆÛË Î·È Ù· ÔÔ›· Ú¤ÂÈ Ó· Ù‡¯Ô˘Ó ÔÚÈÛÌ¤ÓˆÓ ¯ÂÈÚÈÛÌÒÓ ÂÓÙfi˜ Î·È ÂÎÙfi˜ ÙÔ˘ Û¯ÔÏ›Ԣ, Ì ÛÙfi¯Ô Ó· Á›ÓÂÈ ‰˘Ó·Ù‹ Ë Ï‹Ú˘ ¤ÓÙ·Í‹ ÙÔ˘˜ ̤۷ ÛÙË Û¯ÔÏÈ΋ ÎÔÈÓfiÙËÙ· Î·È ·ÚÁfiÙÂÚ· ÛÙËÓ ÎÔÈÓˆÓ›·.
388
Paediatriki 2001;64:387-390
¡Â˘ÚÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ‰Â‰Ô̤ӷ OÈ ÂÚÈÙÒÛÂȘ ‰˘ÛÏÂÍ›·˜ Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› Â›Ó·È Û¯ÂÙÈο Ï›Á˜. À¿Ú¯Ô˘Ó fï˜ ÛÙÔȯ›· Ô˘ ‰Â›¯ÓÔ˘Ó ‰È·Ù·Ú·¯‹ ÛÙËÓ ÂϛΈÛË ÙÔ˘ ÊÏÔÈÔ‡, ‰˘ÛÏ·ÛÙÈÎÔ‡ Ù‡Ô˘ Â˘Ú‹Ì·Ù· ÛÙÔ ÌÂÛÔÏfi‚ÈÔ Î·ıÒ˜ Î·È ¤ÎÙÔÔ˘˜ Ó¢ÚÒÓ˜. ™Â ÈÔ Î·Ï¿ ÌÂÏÂÙË̤Ó˜ ÂÚÈÙÒÛÂȘ ‰˘ÛÏÂÍ›·˜ ¤¯Ô˘Ó ·Ú·ÙËÚËı› Â˘Ú‹Ì·Ù· fiˆ˜ Ù· ηو٤ڈ: - ¶ÂÚÈÔ¯¤˜ ÊÏÔÈÒ‰Ô˘˜ ‰˘ÛÏ·Û›·˜ ÌfiÓÔ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈÛÊ·›ÚÈÔ Î·È ÂȉÈÎfiÙÂÚ· ÛÙÔ ÌÂٷȯÌÈ·Îfi Û‡ÛÙËÌ· ηıÒ˜ Î·È Û ¿ÏϘ ÂÚÈÔ¯¤˜ ÙÔ˘ ÊÏÔÈÔ‡, Ì ÛÔ‚·ÚfiÙÂÚË ÚÔÛ‚ÔÏ‹ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÏfiÁÔ˘. - ¶ÔÏ˘ÌÈÎÚÔÁ˘Ú›· Û ÂÚÈÔ¯¤˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡ ıˆÚÂ›Ù·È fiÙÈ Û¯ÂÙ›˙ÂÙ·È Ì ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÓÙ›ÏË„Ë Î·È ÂÎÊÔÚ¿ ÙÔ˘ ÏfiÁÔ˘. - ∞ÓÙÈÛÙÚÔÊ‹ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Û˘ÌÌÂÙÚ›·˜ ÙˆÓ 2 ËÌÈÛÊ·ÈÚ›ˆÓ ÛÙÔ Â›Â‰Ô ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ‰›Ô˘ (“planum temporale”). °È· Ó· ÂÍËÁ‹ÛÔ˘Ì ÙË ÛËÌ·Û›· ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ·˘ÙÔ‡ Â˘Ú‹Ì·ÙÔ˜ Â›Ó·È ·Ó·Áη›Ô Ó· ·Ó·ÙÚ¤ÍÔ˘Ì Û ÌÂÚÈο Ó¢ÚÔ·Ó·ÙÔÌÈο Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÔÚÁ¿ÓˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÏfiÁÔ˘. ™¯Â‰fiÓ Û fiÏÔ˘˜ ÙÔ˘˜ ‰ÂÍÈfi¯ÂÈÚ˜ Î·È ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÚÈÛÙÂÚfi¯ÂÈÚ˜, ÙÔ ·ÚÈÛÙÂÚfi ËÌÈÛÊ·›ÚÈÔ ‰È·ÙËÚ› ÙÔÓ ÂÈÎÚ·Ù¤ÛÙÂÚÔ ÚfiÏÔ ÛÙÔÓ ÙÔ̤· ÙÔ˘ ÏfiÁÔ˘. ∏ Ó¢ÚÔ·Ó·ÙÔÌÈ΋ ‚¿ÛË ÁÈ’ ·˘Ùfi Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ¤¯ÂÈ Û¯¤ÛË Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÓÒÙÂÚË ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡ Ô˘ ÔÓÔÌ¿˙ÂÙ·È “ÎÚÔÙ·ÊÈÎfi ‰›Ô”, Â›Ó·È Â˘Ú‡ÙÂÚË ÛÙÔ ·ÚÈÛÙÂÚfi ·Ú¿ ÛÙÔ ‰ÂÍÈfi ËÌÈÛÊ·›ÚÈÔ. ∞˘Ù‹ Ë ·Û˘ÌÌÂÙÚ›·, ‰ËÏ·‰‹ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈÛÊ·ÈÚ›Ô˘, Èı·Ófi Ó· ·ÔÙÂÏ› ÙÔ ·Ó·ÙÔÌÈÎfi ˘fiÛÙڈ̷ ÁÈ· ÙËÓ ÂÈÎÚ¿ÙËÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈÛÊ·ÈÚ›Ô˘ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘. À¿Ú¯ÂÈ ‰Â, ‹‰Ë ÛÙÔ ¤Ì‚Ú˘Ô Î·È ÛÙÔ ÓÂÔÁÓfi Î·È ÌÔÚ› Ó· ÚԉȷÁÚ¿ÊÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈÛÊ·›ÚÈÔ. ¡Â˘ÚÔÊ˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ 1. ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°) °ÂÓÈο ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ∏∂° ·ÓˆÌ·Ï›Â˜ Û ‰˘ÛÏÂÎÙÈο ·È‰È¿ ·’ fiÙÈ Û ̿ÚÙ˘Ú˜. ¶ÔÏÏ¿ Â˘Ú‹Ì·Ù· Â›Ó·È ·Ï¿ ÔÚȷο ‹ ¯ˆÚ›˜ ȉȷ›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌ·Û›·, ·Ó Î·È ÂÎʇÁÔ˘Ó ÙˆÓ Û˘Ó‹ıˆÓ. ∞ÎfiÌË Î·È ÂÈÏËÙfiÌÔÚÊ· Ê·ÈÓfiÌÂÓ· ¤¯Ô˘Ó ·Ó·ÊÂÚı› ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi Û·ÛÌÒÓ. ∏ ÛËÌ·Û›· ÙˆÓ ·ÓˆÙ¤Úˆ ¢ÚËÌ¿ÙˆÓ, fï˜, ‰ÂÓ Â›Ó·È ÚÔÊ·Ó‹˜ Î·È ÁÂÓÈο ‰ÂÓ ÙÔ˘˜ ·Ô‰›‰ÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙȘ ÌÂϤÙ˜ ˘¿Ú¯Ô˘Ó ÌÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ηÎfi˜ ÔÚÈÛÌfi˜ ÙˆÓ ÌÂÏÂÙÔ‡ÌÂÓˆÓ ÔÌ¿‰ˆÓ, ·Ô˘Û›· Ì·ÚÙ‡ÚˆÓ, ‰È¿ÊÔÚ˜ Ù¯ÓÈΤ˜ ηٷÁÚ·Ê‹˜,
¶·È‰È·ÙÚÈ΋ 2001;64:387-390
ÂÚÌËÓÂ˘Ù¤˜ Ô˘ ÁÓˆÚ›˙Ô˘Ó ÙÔÓ ÏËı˘ÛÌfi Î.¿. ™Â ÓÂfiÙÂÚ˜ ÌÂϤÙ˜, ÛÙȘ Ôԛ˜ ¤¯ÂÈ ‰Ôı› ÚÔÛÔ¯‹ Û fiÏÔ˘˜ ·˘ÙÔ‡˜ ÙÔ˘˜ ÌÂıÔ‰ÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‚Ú¤ıËÎ·Ó Î¿ÔȘ ‰È·ÊÔÚ¤˜ ÛÙË ‚ÈÔËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ·Ó¿ÌÂÛ· ÛÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ıËÛÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ŸÙ·Ó ¤ÁÈÓ ÔÛÔÙÈ΋ ·Ó¿Ï˘ÛË ÙÔ˘ ∏∂° ‚Ú¤ıËηÓ, ›Û˘, οÔȘ ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· Û ‰˘ÛÏÂÎÙÈÎÔ‡˜ Î·È Ì¿ÚÙ˘Ú˜, ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È ·fiÏ˘Ù· ÚÔÊ·Ó¤˜ ÔÈ· ·ÎÚÈ‚Ò˜ ÛËÌ·Û›· Ú¤ÂÈ Ó· ·Ô‰Ôı› ÛÙ· ÂοÛÙÔÙÂ Â˘Ú‹Ì·Ù·. 2. ∂ÁÎÂÊ·ÏÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ∞Ú¯Èο, ÌÂÚÈΤ˜ ÌÂϤÙ˜ ›¯·Ó ‰Â›ÍÂÈ ·ÓˆÌ·Ï›Â˜ ÛÙ· ÔÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Ì ‚Ú·¯‡ Ï·Óı¿ÓÔÓÙ· ¯ÚfiÓÔ, ÔÈ Ôԛ˜ ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÚÌËÓ¢ÙÔ‡Ó. ªÂÁ·Ï‡ÙÂÚË ÛËÌ·Û›· ıˆڋıËΠfiÙÈ ¤¯Ô˘Ó Ù· fi„ÈÌ· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Ì ̷ÎÚfi Ï·Óı¿ÓÔÓÙ· ¯ÚfiÓÔ, fiÔ˘ Ú¿ÁÌ·ÙÈ ‚Ú¤ıËÎ·Ó ‰È·Ù·Ú·¯¤˜. ŒÓ· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· Û ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ Â›Ó·È ·Ó ÔÈ ‰È·ÊÔÚ¤˜ ÔÊ›ÏÔÓÙ·È Û ‰È¿Û·ÛË ÚÔÛÔ¯‹˜, Ô˘ Û˘¯Ó¿ Û˘Ó˘¿Ú¯ÂÈ Ì ÙË Ì·ıËÛȷ΋ ‰È·Ù·Ú·¯‹ Î·È Ë ÔÔ›· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÚÔÔÔÈ› ÛËÌ·ÓÙÈο Ù· fi„ÈÌ· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο. ∫·ıÒ˜ Ë Ù¯ÓÔÏÔÁ›· ÚÔfi‰Â˘Û ÛËÌ·ÓÙÈο, ˘‹ÚÍ·Ó ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ·fi ÙË ÌÂϤÙË ÙˆÓ ÔÙÈÎÒÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ Ô˘ ¤‰ÂÈÍ·Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ÔÙÈ΋˜ ·ÓÙ›Ï˄˘ Û ¿ÙÔÌ· Ì ‰˘Û·Ó·ÁÓˆÛ›·. ∂ȉÈÎfiÙÂÚ·, ÔÈ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÔÙÈÎÒÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ Û ̛· ÔÌ¿‰· ‰˘ÛÏÂÎÙÈÎÒÓ ·È‰ÈÒÓ ˘Ô‰ÂÈÎÓ‡Ô˘Ó ·ÔÙ˘¯›· Û˘Á¯ÚÔÓÈÛÌÔ‡ ÙˆÓ ÔÙÈÎÒÓ Ô‰ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ô˘ ¿ÁÔ˘Ó ‰È·ÊÔÚÂÙÈÎfi Ù‡Ô ÂÚÂıÈÛÌ¿ÙˆÓ, ¤ÙÛÈ ÒÛÙÂ Ë ¿ÊÈÍË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Ô˘ Êı¿ÓÔ˘Ó ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÂӉȿÌÂÛÔ˘˜ ÛÙ·ıÌÔ‡˜ Î·È ÙÂÏÈÎÒ˜ ÛÙÔÓ ÔÙÈÎfi ÊÏÔÈfi Ó· Â›Ó·È ÂÙÂÚÔ¯ÚÔÓÈṲ̂ÓË. ªÂ Ôχ ÚÔËÁ̤Ó˜ Ù¯ÓÔÏÔÁÈο ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ ÂÓÙÔ›ÛÙËΠÙÔ Úfi‚ÏËÌ· ÛÙ· “ÌÂÁ¿Ï·” ·ÙÙ·Ú· ÙÔ˘ ¤Íˆ ÁÔÓ·ÙÒ‰Ô˘˜ ÛÒÌ·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ·ÌÈÁ‹ ‰˘Û·Ó·ÁÓˆÛ›·. ø˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ‰ÈÂÎÂÚ·›ˆÛ˘ Ù˘ ÔÙÈ΋˜ ÏËÚÔÊÔÚ›·˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ٷ “ÌÂÁ¿Ï·” ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ·˘ÙÔ‡ ˘Ú‹Ó·, ÔÈ Ï¤ÍÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È ıÔϤ˜ ÛÙÔÓ ·Ó·ÁÓÒÛÙË, Ë Ì›· Ó· ¤ÊÙÂÈ ¿Óˆ ÛÙËÓ ¿ÏÏË ‹ Û·Ó Ó· Ë‰Ô‡Ó ¿Óˆ ·fi ÙË ÛÂÏ›‰·. ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó¿ÁÓˆÛË, Ô˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ¤¯ÂÈ Ó· οÓÂÈ ·ÌÈÁÒ˜ Ì ‰È·Ù·Ú·¯‹ ÛÙË ‰ÈÂÎÂÚ·›ˆÛË ÙˆÓ ÔÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Î·È fi¯È Ì Úfi‚ÏËÌ· Û ÁÓˆÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·.
Paediatriki 2001;64:387-390
¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ¤¯Ô˘Ó ·Ú·ÙËÚËı› Î·È fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰ÈÂÎÂÚ·›ˆÛË ·ÎÔ˘ÛÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ÔÈ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Ì ٷ ÂÁÎÂÊ·ÏÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ¤¯Ô˘Ó Û˘ÛÙËÌ·ÙÈο ‰Â›ÍÂÈ ‰È·Ù·Ú·¯¤˜ ÛÙË ‰ÈÂÎÂÚ·›ˆÛË ÏËÚÔÊÔÚÈÒÓ Û ‰È¿ÊÔÚÔ˘˜ ·ÈÛıËÙÈÎÔ‡˜ ‰È·‡ÏÔ˘˜. ∂Ô̤ӈ˜, ÔÈ ·ÛıÂÓ›˜ Ì ‰˘ÛÏÂÍ›· ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó fiÏÔÈ Ù· ›‰È· Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÁÂÁÔÓfi˜ ·fiÏ˘Ù· ·Ó·ÌÂÓfiÌÂÓÔ, ·ÊÔ‡ ÛÙËÓ ÔÌ¿‰· Ù˘ ‰˘ÛÏÂÍ›·˜ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ· Ô˘ ¤¯ÂÈ Ó· οÓÂÈ Ì ÙÔ ÔÈ· ÂÚÈÔ¯‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ› ÛÙËÓ ÂοÛÙÔÙ ˘Ô-ÔÌ¿‰· Ô˘ ‚Ú›ÛÎÂÙ·È ˘fi ÌÂϤÙË. 3. “Neurometrics” ™‡ÓıÂÙË Ì¤ıÔ‰Ô˜ Ô˘ Ì ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹ ·Ó·Ï‡ÂÈ ÙÔ ∏∂° Î·È Ù· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Î·È ÚÔÛ·ı› ¤ÙÛÈ Ó· ÂÓÙÔ›ÛÂÈ ÙËÓ ÂÁÎÂÊ·ÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ∆· ‰Â‰Ô̤ӷ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ·Ó¿Ï˘ÛË ÂÓfi˜ ÚÒÙÔ˘ ÏÂÙÔ‡ (1’) ∏∂° Ì ٷ Ì¿ÙÈ· ÎÏÂÈÛÙ¿ Î·È 1’ Ì ٷ Ì¿ÙÈ· ·ÓÔÈÎÙ¿. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤‰ˆÛ ÂÓÙ˘ˆÛȷο ·ÔÙÂϤÛÌ·Ù·, ·ÏÏ¿ ˘¿Ú¯ÂÈ ÛÔ‚·Úfi˜ ÛÎÂÙÈÎÈÛÌfi˜ ÛÙËÓ ·Ô‰Ô¯‹ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ·Ó¿Ï˘ÛË ÂÓfi˜ ‹ ‰‡Ô ÏÂÙÒÓ ∏∂°. ∂›Ó·È ··Ú·›ÙËÙÔ Ó· ÛËÌÂȈı› fiÙÈ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ˘ÔÛÙËÚ›˙ÂÙ·È Ë ·ÓÙÈηٿÛÙ·ÛË Ù˘ Û˘ÓÔÏÈ΋˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ ‰˘ÛÏÂÎÙÈÎÔ‡ ·ÙfiÌÔ˘, Ô˘ ··Ú·›ÙËÙ· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙËÓ „˘¯ÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË, ·fi ÙË ‰ÔÎÈÌ·Û›· ·˘Ù‹ ‹ ·fi ¿ÏϘ ÌÂÌÔӈ̤Ó˜ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ. 4. ÷ÚÙÔÁÚ¿ÊËÛË ∏ Ù¯ÓÈ΋ ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ› ∏∂° Î·È ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ·fi ÔÏÏ¿ ËÏÂÎÙÚfi‰È· ÁÈ· Ó· ÊÙÈ¿ÍÂÈ ¤Ó· ¯¿ÚÙË Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹. µÚ¤ıËÎ·Ó ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙ· ‰˘ÛÏÂÎÙÈο ·È‰È¿ Î·È ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Î·È ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó ¯¿ÚÙ˜ Ô˘ ¤‰ÂÈÍ·Ó ÂÛÙȷ΋ ‹ ÔÏ˘ÂÛÙȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ŒÁÈÓ ÚÔÛ¿ıÂÈ· Ó· ηıÔÚÈÛÙÔ‡Ó ·ÎÚȂ›˜ Î·È ÔÌÔÈÔÁÂÓ›˜ ÔÌ¿‰Â˜, Ë ÔÔ›· ‹Ù·Ó Ôχ ÛËÌ·ÓÙÈ΋. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› Î·È ¿ÏÈ fiÙÈ ·˘Ù¤˜ ÔÈ Ì¤ıÔ‰ÔÈ ‰ÂÓ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Û˘ÏÏ‹‚‰ËÓ ÁÈ· ÙË ÌÂϤÙË fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Î·È ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ˘ÔηٷÛÙ‹ÛÔ˘Ó ÙË Û˘ÓÔÏÈ΋ ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·È‰ÈÒÓ Ì ̷ıËÛȷΤ˜ ‰È·Ù·Ú·¯¤˜. ¡Â˘ÚÔ¯ËÌÈο ‰Â‰Ô̤ӷ ∆· ‰Â‰Ô̤ӷ ·ÊÔÚÔ‡Ó Î·Ù’ ÂÍÔ¯‹Ó ˘ÂÚÎÈÓËÙÈο ·È‰È¿ Ì ‰È¿Û·ÛË ÚÔÛÔ¯‹˜, ·Ú¿ ·È‰È¿ Ì ̷ıËÛȷΤ˜ ‰È·Ù·Ú·¯¤˜. ∞ÊÔÚÔ‡Ó Î·Ù’ ÂÍÔ¯‹Ó ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ, ηıÒ˜ Î·È Î¿ÔȘ Ê·ÚÌ·ÎÔÏÔÁÈΤ˜ ÌÂϤÙ˜.
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¡Â˘ÚÔ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· OÚÈṲ̂ӷ ·fi Ù· ·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù· Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ÛÙȘ Ó¢ÚÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ÌÂϤÙ˜ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÓÙÔÈÛÙÔ‡Ó, ÙfiÛÔ ÛÙËÓ ·ÍÔÓÈ΋ fiÛÔ Î·È ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·. π‰È·›ÙÂÚ· ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·ÂÈÎÔÓ›˙ÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË Â˘ÎÔÏ›· ÙÔ Û˘ÌÌÂÙÚÈÎfi ̤ÁÂıÔ˜ ÙÔ˘ “ÎÚÔÙ·ÊÈÎÔ‡ ‰›Ô˘” (‹ ‰È·ÊÔÚÂÙÈο, Ë Î·Ù¿ÚÁËÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Û˘ÌÌÂÙÚ›·˜ ˘¤Ú ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈÛÊ·ÈÚ›Ô˘), Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÈ Ì›· ÔÌ¿‰· ‰˘ÛÏÂÎÙÈÎÒÓ ·ÙfïÓ. ∏ ·Û˘ÌÌÂÙÚ›· ·˘Ù‹ Ê˘ÛÈÔÏÔÁÈο ·Ó·‰ÂÈÎÓ‡ÂÙ·È ·ÎfiÌË Î·È Û ÚfiˆÚ· ÓÂÔÁÓ¿ ËÏÈΛ·˜ ΢‹Ûˆ˜ 29 Î·È Ï¤ÔÓ Â‚‰ÔÌ¿‰ˆÓ. ™Â Ì›· ÌÂϤÙË ÂϤÁ¯Ô˘ ‰˘ÛÏÂÎÙÈÎÒÓ ·ÙfïÓ, Ë Î·Ù¿ÚÁËÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Û˘ÌÌÂÙÚ›·˜ ÙÔ˘ “ÎÚÔÙ·ÊÈÎÔ‡ ‰›Ô˘” ‚Ú¤ıËΠÛÙÔ 70% ÙˆÓ ·ÙfiÌˆÓ Ì ‰˘Û·Ó·ÁÓˆÛ›·, ¤Ó·ÓÙÈ 30% ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ™ÙË ‰Â ˘ÔÔÌ¿‰· Ì ‰˘Û·Ó·ÁÓˆÛ›· ÏfiÁˆ ʈÓÔÏÔÁÈÎÔ‡ ÂÏÏ›ÌÌ·ÙÔ˜, ‚Ú¤ıËΠ۠ÔÛÔÛÙfi 100%. ™ËÌ·ÓÙÈ΋, ›Û˘, Â›Ó·È Ë ÚÔÛÊÔÚ¿ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÌÂıfi‰ˆÓ Ó¢ÚÔ·ÂÈÎfiÓÈÛ˘, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ÚÔÛʤÚÔ˘Ó ·Ó·ÙÔÌÈΤ˜ Î·È Ù·˘Ùfi¯ÚÔÓ· ÏÂÈÙÔ˘ÚÁÈΤ˜ ÏËÚÔÊÔڛ˜, ‰ËÏ·‰‹ ‰Â›¯ÓÔ˘Ó ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÛËÌ¿ÙˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÎÙ¤ÏÂÛ˘ ‰È·ÊfiÚˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. ∏ ÏÂÈÙÔ˘ÚÁÈ΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (fMRI) ¤‰ÂÈÍ fiÙÈ Î·Ù¿ ÙËÓ ÂÎÙ¤ÏÂÛË Ì›·˜ ʈÓÔÏÔÁÈ΋˜ ‰ÔÎÈÌ·Û›·˜, Ë ÂÁÎÂÊ·ÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Ô˘ ÛÙËÓ fMRI Ê·›ÓÂÙ·È ˆ˜ ·‡ÍËÛË Ù˘ ÂÚÈÔ¯È΋˜ ·ÈÌ·ÙÈ΋˜ ÂÁÎÂÊ·ÏÈ΋˜ ÚÔ‹˜, Ï·ÁÈÒÓÂÙ·È ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈÛÊ·›ÚÈÔ ÛÙÔ˘˜ ¿ÚÚÂÓ˜, ÂÓÒ ÛËÌÂÈÒÓÂÙ·È ·ÌÊÔÙÂÚfiÏ¢ڷ ÛÙ· ı‹Ï·. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ʇϷ ÌÔÚ› Ó· ¤¯ÂÈ ÛËÌ·Û›· ÁÈ· ÙȘ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ Ê‡ÏˆÓ ÛÙËÓ Â›ÙˆÛË Ù˘ ‰˘ÛÏÂÍ›·˜ (ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÛÙÔ˘˜ ¿ÚÚÂÓ˜). ∞ÎfiÌË Î·È ÛÙÔ PET scan (Positron Emission Tomography) ¤¯Ô˘Ó ‚ÚÂı› ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ‰˘ÛÏÂÎÙÈÎÒÓ Î·È Ê˘ÛÈÔÏÔÁÈÎÒÓ ·ÙfïÓ. °ÂÓÂÙÈΤ˜ ÌÂϤÙ˜ ∆· ¿ÊıÔÓ· ‰Â‰Ô̤ӷ ·fi ÙÔ ¯ÒÚÔ Ù˘ ÁÂÓÂÙÈ΋˜ Ô˘ ·ÊÔÚÔ‡Ó ÙfiÛÔ ÙË ‰˘ÛÏÂÍ›· fiÛÔ Î·È ÙÔ ™‡Ó‰ÚÔÌÔ ∂ÏÏÂÈÌÌ·ÙÈ΋˜ ¶ÚÔÛÔ¯‹˜ Î·È ÀÂÚÎÈÓËÙÈÎfiÙËÙ·˜, ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ·ÚÔ˘Û›· ‚ÈÔÏÔÁÈ΋˜ ‚¿Û˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·˘ÙÒÓ. ∂ȉÈο ÁÈ· ÙË ‰˘Û·Ó·ÁÓˆÛ›·, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ·È‰È¿ ‰˘ÛÏÂÎÙÈÎÒÓ ·ÙfiÌˆÓ ¤¯Ô˘Ó 5-7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÙÔ Úfi‚ÏËÌ· ·˘Ùfi Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∂ÈÚfiÛıÂÙ·, ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ ‰È‰‡ÌˆÓ ÌÔÓÔ˙˘ÁˆÙÈ-
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ÎÒÓ Î·È ‰È˙˘ÁˆÌ·ÙÈÎÒÓ, ÔÈ Ôԛ˜ ÂÚ·ÈÙ¤Úˆ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ‡·ÚÍË ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÛÙȘ ‰È·Ù·Ú·¯¤˜ Ì¿ıËÛ˘. ∏ ·ÏÏËÏ›‰Ú·ÛË ÁÂÓÂÙÈÎÒÓ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·ıÔÚ›˙ÂÈ, ÙÂÏÈο, ÙÔ Â›Â‰Ô Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ·ÓıÚÒˆÓ, ·ÏÏ¿ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ‰È·Ù·Ú·¯ÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù· ∞ӷʤڷÌ ÌÂÚÈο ÌfiÓÔ ·fi Ù· ÛÙÔȯ›· Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙË Ó¢ÚÔ‚ÈÔÏÔÁÈ΋ ‚¿ÛË ÙˆÓ Ì·ıËÛÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ∆· ‰Â‰Ô̤ӷ Â›Ó·È ¿Ú· ÔÏÏ¿ Î·È ·˘Í¿ÓÔ˘Ó ‰È·ÚÎÒ˜. ∏ ÔÈÎÈÏ›· ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ‰˘ÛÏÂÈÙÔ˘ÚÁÈÒÓ Ô˘ ¤¯ÂÈ ‚ÚÂı› ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ Î·È Î·Ï¿ ηıÔÚÈṲ̂Ó˜ ÔÌ¿‰Â˜ Ì·ıËÛÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ, fiˆ˜ .¯. ÛÙË ‰˘Û·Ó·ÁÓˆÛ›·, ·Ô‰ÂÈÎÓ‡ÂÈ ÙË ÌÂÁ¿ÏË ÎÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ. ø˜ ·ÔÙ¤ÏÂÛÌ·, ¤Ó·˜ ÙÚfiÔ˜ ÌÂϤÙ˘ ‹ ¤Ó·˜ ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÚÔÊ·ÓÒ˜ ‰ÂÓ Â·ÚΛ ÁÈ· ÙÔÓ Î¿ı ·ÛıÂÓ‹, ·ÎfiÌË ÎÈ ·Ó ·˘Ùfi˜ ·Ó‹ÎÂÈ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ˘Ô-ÔÌ¿‰·. °È’ ·˘ÙfiÓ ÙÔ ÏfiÁÔ, ÙÔ Î¿ı ·È‰› Ú¤ÂÈ Ó· ÌÂÏÂÙ¿Ù·È ‰ÈÂÍÔ‰Èο ·fi ÔÌ¿‰· ÂȉÈÎÒÓ Ô˘ ÂÈϤÁÔÓÙ·È Î·Ù¿ ÂÚ›ÙˆÛË (·È‰ÔÓ¢ÚÔÏfiÁÔ˜, ·Ó·Ù˘ÍÈÔÏfiÁÔ˜, ·È‰Ô„˘¯›·ÙÚÔ˜, ÎÏÈÓÈÎfi˜ „˘¯ÔÏfiÁÔ˜, ÏÔÁÔ·ıÔÏfiÁÔ˜, ÂÚÁÔıÂÚ·Â˘Ù‹˜, ÂȉÈÎfi˜ ·È‰·ÁˆÁfi˜ Î.¿.), ÔÈ ÔÔ›ÔÈ ı· ÂÈÎÔÈÓˆÓÔ‡Ó Î·È ı· ÂÓËÌÂÚÒÓÔ˘Ó ÙÔÓ ·È‰›·ÙÚÔ. ∆ËÓ ÔÌ¿‰· Ú¤ÂÈ Ó· Û˘ÓÙÔÓ›˙ÂÈ ÂΛÓÔ˜ Ô˘ ÁÓˆÚ›˙ÂÈ ÙÔ ·ÓÙÈΛÌÂÓÔ. ∏ ‰È·ÁÓˆÛÙÈ΋ ‰ÈÂÚ‡ÓËÛË Î·È Ë ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÔÓÙ·È, ‰ÈfiÙÈ ¤ÙÛÈ ı· Â͢ËÚÂÙËıÔ‡Ó Î·Ï‡ÙÂÚ· Ù· Û˘ÌʤÚÔÓÙ· ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Developmental Neuropsychiatry. Vol. 1. In: Harris JG, ed. Oxford Univ Press; 1995. 2. Developmental Neuropsychiatry. Vol. 2. In: Harris JG, ed. Oxford Univ Press; 1995. 3. Reading and Dyslexia. Visual and attentional processes. In: Everatt J, ed. Routledge; 1999. 4. Interventions for ADHD. Treatment in Developmental Context. In: Teefer PA, ed. The Guilford Press; 1998. 5. ADHD in Adolescents. Diagnosis and Treatment. In: Robin AL, ed. The Guildorf Press; 1998.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ ¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ ¶. ¶ÂÓÙ¤ÏË, 152 36
¶·È‰È·ÙÚÈ΋ 2001;64:391-394
¡∂ÀƒO§O°π∞
Paediatriki 2001;64:391-394
¡EUROLOGY
∏ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Ì·ıËÛÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ ™. °ÈÔ˘ÚÔ‡ÎÔ˜
The role of the paediatrician in the management of learning difficulties S. Youroukos
¶ÂÚ›ÏË„Ë: ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Ì·ıËÛÈ·ÎÒÓ ‰˘ÛÎÔÏÈÒÓ ÂÌÊ·Ó›˙ÂÈ ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù·. ¢È¿ÊÔÚ˜ ÂȉÈÎfiÙËÙ˜ ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ‚Ô‹ıÂÈ·, ·ÏÏ¿ fiˆ˜ Â›Ó·È Ê˘ÛÈÎfi, ÙÔÓ Î‡ÚÈÔ ÏfiÁÔ ¤¯Ô˘Ó ÔÈ ÂÎ·È‰Â˘ÙÈÎÔ›. O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ˜, ·ÏÏ¿ fi¯È ·Ó‡·ÚÎÙÔ˜. ÕÏψÛÙÂ, Â›Ó·È ÂΛÓÔ˜ ÛÙÔÓ ÔÔ›Ô Û˘Ó‹ıˆ˜ ·Â˘ı‡ÓÔÓÙ·È ÔÈ ÁÔÓ›˜. ∞·ÈÙÂ›Ù·È Ó· ¤¯ÂÈ ÁÓÒÛË ÙˆÓ ‰È·ÊfiÚˆÓ ıÂڷ¢ÙÈÎÒÓ ÚÔÛÂÁÁ›ÛÂˆÓ Î·È ÙˆÓ ÂÚÈÔÚÈÛÌÒÓ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó, ηıÒ˜ Â›Ó·È Û·Ê¤˜ fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚÈ˙ÈΤ˜ ıÂڷ›˜. O ·È‰›·ÙÚÔ˜ ¤¯ÂÈ ˘Ô¯Ú¤ˆÛË fi¯È ÌfiÓÔ Ó· ηÙ¢ı‡ÓÂÈ, ·ÏÏ¿ Î·È Ó· ÚÔÊ˘Ï¿ÛÛÂÈ ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘ ·fi ˘ÂÚ‚ÔϤ˜.
Abstract: The management of learning difficulties is not easy. Several specialists can provide help, but the key figure in the management is the school teacher. The role of the paediatrician is limited but undoubtedly he has a role. As a matter of fact he is, in most cases, the first person that will be asked for help. He should have full knowledge of the therapeutic possibilities and their limitations, since it is well established that no radical treatment exists. The paediatrician should not only provide guidance but should also protect the child and the family from treatments of doubtful results.
§¤ÍÂȘ ÎÏÂȉȿ: Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ‰˘ÛÏÂÍ›·, ·‰ÂÍÈfiÙËÙ·, Û‡Ó‰ÚÔÌÔ ÂÏÏÂÈÌÌ·ÙÈ΋˜ ÚÔÛÔ¯‹˜.
Key words: learning difficulties, hyperactivity, dyslexia, clumsiness, attention deficit disorder.
∂ÈÛ·ÁˆÁ‹ ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÔÏϤ˜ ‰˘ÛÎÔϛ˜. ∆· ·È‰È¿ ı· ‚ÔËıËıÔ‡Ó ·fi ÔÏϤ˜ Î·È ‰È·ÊÔÚÂÙÈΤ˜ ÂȉÈÎfiÙËÙ˜, οı ̛· ·fi ÙȘ Ôԛ˜ ‚ϤÂÈ ÙÔ Úfi‚ÏËÌ· ·fi ÙË ‰È΋ Ù˘ ÔÙÈ΋ ÁˆÓ›· Î·È Û˘¯Ó¿ ·ÁÓÔÒÓÙ·˜ fiϘ ÙȘ ¿ÏϘ. Ÿˆ˜ Â›Ó·È Ê˘ÛÈÎfi, ÙÔÓ ÚÒÙÔ ÏfiÁÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÔÈ ÂÎ·È‰Â˘ÙÈÎÔ›. O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÏÏ¿ fi¯È ·Ó‡·ÚÎÙÔ˜. ¢ÂÓ Ú¤ÂÈ Ó· ͯӿÌ fiÙÈ Û˘¯Ó¿ Â›Ó·È Ô ÚÒÙÔ˜ ·fi ÙÔÓ ÔÔ›Ô ı· ˙ËÙ‹ÛÔ˘Ó ‚Ô‹ıÂÈ· ÔÈ ÁÔÓ›˜. °È· ÏfiÁÔ˘˜ Ú·ÎÙÈÎÔ‡˜, Ë ÂÈÛ‹ÁËÛË ·˘Ù‹ ·ÔÙÂÏÂ›Ù·È ·fi ÙÚ›· ̤ÚË: ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·‰ÂÍÈfiÙËÙ·˜, Ù˘ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ Î·È Ù˘ ‰˘ÛÏÂÍ›·˜.
∫ÈÓËÙÈ΋ ‰˘ÛÚ·Í›· - ·‰ÂÍÈfiÙËÙ· ªÂÁ¿ÏË ÛËÌ·Û›· ¤¯ÂÈ Ë ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·fi ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Î·È ÙÔ Û¯ÔÏÂ›Ô (1). ¶Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚÈÛÙ› fiÙÈ ‰ÂÓ ÚfiÎÂÈÙ·È ÁÈ· “ÙÂÌÂÏÈ¿” Î·È fiÙÈ ÙÔ ·È‰› ¯ÚÂÈ¿˙ÂÙ·È ˘ÔÛÙ‹ÚÈÍË Î·È ‚Ô‹ıÂÈ·, fi¯È ›ÏËÍË. ™˘Ó‹ıˆ˜ ÙÔ ·È‰› ‰ÂÓ ¤¯ÂÈ ·˘ÙÔÂÔ›ıËÛË ÂÍ·ÈÙ›·˜ ÙˆÓ ÎÈÓËÙÈÎÒÓ ÙÔ˘ ‰˘ÛÎÔÏÈÒÓ. ∏ ÂÍ¿ÛÎËÛË ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ, fï˜ ÙÔ ·È‰› ÙËÓ ·ÔʇÁÂÈ ‰ÈfiÙÈ ‰ÂÓ Ù· ηٷʤÚÓÂÈ Î·Ï¿ Î·È Ô Ê·‡ÏÔ˜ ·ÎÏÔ˜ Û˘Ó¯›˙ÂÙ·È. OÈ ËÏÈ˘ ·fiÎÙËÛ˘ ‚·ÛÈÎÒÓ ÈηÓÔÙ‹ÙˆÓ ÎÈÓËÙÈÎÒÓ ‰ÂÍÈÔÙ‹ÙˆÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞Û΋ÛÂȘ Ê˘ÛÈÔıÂڷ›·˜ ÌÔÚÔ‡Ó Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ÈÛÔÚÚÔ›·, ÙȘ ÏÂÙ¤˜ ÎÈÓ‹ÛÂȘ ηıÒ˜ Î·È ÙÔ Û˘ÓÙÔÓÈÛÌfi fiÏˆÓ ÙˆÓ ÎÈÓ‹ÛˆÓ. O ¯ÔÚfi˜,
ÕÌÈÛıÔ˜ ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ™‡Ì‚Ô˘ÏÔ˜ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
Assistant Professor of Pediatrics A’ Pediatric Clinic, University of Athens
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›Û˘, ··ÈÙ› ηϋ ¿ÛÎËÛË ÛˆÌ·ÙÔÁÓˆÛ›·˜ Î·È ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ıÂڷ¢ÙÈο (1,2). O ÚfiÏÔ˜ ÙÔ˘ ÂÚÁÔıÂÚ·Â˘Ù‹ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ Ì ÙËÓ ÔÚÁ¿ÓˆÛË Î·Ù¿ÏÏËÏÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ (¶›Ó·Î·˜ 2). ∆Ô Û¯ÔÏÂ›Ô Ú¤ÂÈ Ó· ÂÓËÌÂÚˆı› ÒÛÙ ӷ ·Ú¤¯ÂÈ ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ÛÙȘ ÁÚ·Ù¤˜ ÂÍÂÙ¿ÛÂȘ Î·È Ó· ¤¯ÂÈ ÌÂȈ̤Ó˜ ··ÈÙ‹ÛÂȘ ηٿ ÙȘ Á˘ÌÓ·ÛÙÈΤ˜ ·Û΋ÛÂȘ. ™˘Ó‹ıˆ˜ ÙÔ ·‰¤ÍÈÔ ·È‰› ‰ÂÓ Ù· ηٷʤÚÓÂÈ Û ÔÌ·‰Èο ·È¯Ó›‰È· Ì ̿Ϸ, Û ·Û΋ÛÂȘ Ì ÂÊ·ÏÙ‹ÚÈ· Î.Ï. O ÚfiÏÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜. ¶Ú¤ÂÈ Ó· ·Ú¤¯ÔÓÙ·È ‰È¿ÊÔÚ˜ ‰È¢ÎÔχÓÛÂȘ Î·È ·Ú¿Ù·ÛË ¯ÚfiÓÔ˘, ·ÏÏ¿ Î·È Ó· ÂÓı·ÚÚ‡ÓÔÓÙ·È ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙȘ Ôԛ˜ ÙÔ ·È‰› Ù· ηٷʤÚÓÂÈ (¶›Ó·Î·˜ 3). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ‰ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ë ÂÈ‚Ú¿‚Â˘Û‹ ÙÔ˘. ™ÙÔÓ ¶›Ó·Î· 4 ·Ó·ÁÚ¿ÊÔÓÙ·È ÌÂÚÈο ·ıÏ‹Ì·Ù· fiÔ˘ ÙÔ ·‰¤ÍÈÔ ·È‰› ÌÔÚ› Ó· ‰È·ÎÚÈı› Î·È ¿ÏÏ·, ÛÙ· ÔÔ›· Ë ·ÔÙ˘¯›· Â›Ó·È Ôχ Èı·Ó‹. ªÂ ÙËÓ ÚfiÔ‰Ô Ù˘ ËÏÈΛ·˜ ÙÔ ·‰¤ÍÈÔ ·È‰› ‚ÂÏÙÈÒÓÂÙ·È ·˘ÙfiÌ·Ù· (2). ∂ÈϤÔÓ, Â›Ó·È Û ı¤ÛË Ó· ÎÚ‡„ÂÈ ÙËÓ ·‰ÂÍÈfiÙËÙ¿ ÙÔ˘ ·ÔʇÁÔÓÙ·˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙȘ Ôԛ˜ ÁÓˆÚ›˙ÂÈ fiÙÈ ‰ÂÓ Ù· ηٷʤÚÓÂÈ. ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ Ë Ê˘ÛÈÔıÂڷ›· Î·È Ë ÂÚÁÔıÂڷ›· ‚ÔËıÔ‡Ó. ¶Ú¤ÂÈ, fï˜, Ó· ÌË Á›ÓÔÓÙ·È Û ‚¿ÚÔ˜ ¿ÏÏˆÓ ÂÎ·È‰Â˘ÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔًوÓ, ηıÒ˜ Û˘¯Ó¿ Ù· ·‰¤ÍÈ· ·È‰È¿ ¤¯Ô˘Ó Î·È ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·. ∂ÏÏÂÈÌÌ·ÙÈ΋ ÚÔÛÔ¯‹ - ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ∆Ô ·È‰› Ì ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Î‹ Û¯ÔÏÈ΋ ›‰ÔÛË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰¤¯ÂÙ·È ·ÚÓËÙÈ΋ ÎÚÈÙÈ΋ ·fi ÙÔ Û›ÙÈ Î·È ÙÔ Û¯ÔÏÂ›Ô (3). ∞˘Ùfi ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤ÓË ·˘ÙÔÂÎÙ›ÌËÛË Î·È ·fiÚÚÈ„Ë ÙÔ˘ Û¯ÔÏ›Ԣ, ·ÏÏ¿ Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ (ÂÈıÂÙÈÎfiÙËÙ·, ·ÓÙÈÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Î.Ï.) (4). OÈ Î‡ÚÈÔÈ ÙÚfiÔÈ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ˘ÂÚÎÈÓËÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 5. O ÚfiÏÔ˜ ÙˆÓ ÁÔÓ¤ˆÓ Â›Ó·È ‰‡ÛÎÔÏÔ˜, ·ÏÏ¿ Î·È Ô˘ÛÈ·ÛÙÈÎfi˜. §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙȘ Ô‰ËÁ›Â˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ˘ÂÚ‚ÔÏÈ΋ ۈ̷ÙÈ΋ ÎfiˆÛË ¤¯ÂÈ Û˘Ó‹ıˆ˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË ÎÈÓËÙÈÎfiÙËÙ·. ∏ ·ÙÔÌÈ΋ ÂÈÙ‹ÚËÛË, Ì¿ÏÏÔÓ “·ÛÙ˘ÓfiÌ¢ÛË”, ηٿ ÙËÓ ÒÚ· Ù˘ ÌÂϤÙ˘ Û˘Ó‹ıˆ˜ ·Ô‰›‰ÂÈ Î·È ›Ûˆ˜ Â›Ó·È Î·Ï‡ÙÂÚ· Ó· ÌË Á›ÓÂÙ·È ·fi ÙÔ˘˜ ÁÔÓ›˜. H ÙÂÏÂ˘Ù·›· Ô‰ËÁ›· ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ·Ó¿ÁÎË Ô˘ ¤¯Ô˘Ó ÔÈ ÁÔÓ›˜ Ó· ʇÁÔ˘Ó, ¤ÛÙˆ ÁÈ· 1-2 Ë̤Ú˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÚÔ˘Ó ÙË ‰‡Ó·ÌË Ó· Û˘Ó¯›ÛÔ˘Ó (3,4). ∆· „˘¯Ô‰ÈÂÁÂÚÙÈο Ê¿Ú̷η Ô˘ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ˘ÂÚÎÈÓËÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 7. ∆Ô ÈÔ ÌÂÏÂÙË̤ÓÔ Î·È ÁÓˆÛÙfi Â›Ó·È Ë ÌÂı˘ÏÊ·ÈÓȉ¿ÙË
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¶›Ó·Î·˜ 1. ∏ÏÈΛ· ·fiÎÙËÛ˘ ÎÈÓËÙÈÎÒÓ ‰ÂÍÈÔÙ‹ÙˆÓ πηÓfiÙËÙ· ∫Ô˘ÌÈ¿ ¶fi‰È· ÂÓ·ÏÏ¿Í ÛÙË ÛοϷ ¶Ô‰‹Ï·ÙÔ Ì ‚ÔËıËÙÈΤ˜ æ·Ï›‰È (Îfi‚ÂÈ ¯·ÚÙ›) æ·Ï›‰È (ηٿ Ì‹ÎÔ˜ ¢ı. ÁÚ·ÌÌ‹˜) ∫ÔÚ‰fiÓÈ· ¶Ë‰¿ ·fi ÌÂÚÈο ÛηÏÈ¿ ¶Ô‰‹Ï·ÙÔ ∞ÏÒÓÂÈ ‚Ô‡Ù˘ÚÔ Ì ̷¯·›ÚÈ
ª¤ÛË ∏ÏÈΛ· 4 4 4,5 4,5 5,5 5,5 5,5 6 6 (Blondis 1999)
¶›Ó·Î·˜ 2. ™Ùfi¯ÔÈ ÂÚÁÔıÂڷ›·˜ ñ ¢ÂÍÈfiÙËÙ˜ ¯ÂÚÈÒÓ (ÎÔÚ‰fiÓÈ·, „·Ï›‰È Î.Ï.) ñ ŒÏÂÁ¯Ô˜ ‚ϤÌÌ·ÙÔ˜ ñ ∑ˆÁÚ·ÊÈ΋, ηٷÛ΢¤˜ ñ ∞ÓÙ›ÏË„Ë ÛÙÔ ¯ÒÚÔ ñ £¤ÛË ÌÂÏÒÓ ÛÒÌ·ÙÔ˜ ñ ¡Ù‡ÛÈÌÔ (ÎÔ˘ÌÈ¿, ·Ô‡ÙÛÈ· Î.Ï.) ñ º·ÁËÙfi
¶›Ó·Î·˜ 3. O ÚfiÏÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ª·ÎÚfiÙÂÚÔ˜ ¯ÚfiÓÔ˜: ͇ÓËÌ· ÓˆÚ›ÙÂÚ· ·Ú¿Ù·ÛË ‰È¿ÚÎÂÈ·˜ ÁÂ˘Ì¿ÙˆÓ ƒÔ‡¯·:
·Ô‡ÙÛÈ· “·ÓÙÔÊϤ”, Velcro
¢Ú·ÛÙËÚÈfiÙËÙ˜:
Ì·ÁÂÈÚÈ΋, ʈÙÔÁÚ·Ê›·, ÎËÔ˘ÚÈ΋, ÌÔ˘ÛÈ΋, ·ıÏ‹Ì·Ù·
¶›Ó·Î·˜ 4. ∞‰¤ÍÈÔ ·È‰› Î·È ·ıÏ‹Ì·Ù· ¡·È ∫ÔχÌÈ, ÈÛÙÈÔÏÔ˝· ∆Ú¤ÍÈÌÔ ¶Â˙ÔÔÚ›·, ÔÚÂÈ‚·Û›·, ¯ÈÔÓÔ‰ÚÔÌ›· π·Û›·
Ÿ¯È ¶Ô‰fiÛÊ·ÈÚÔ Volley Basket Tennis
¶›Ó·Î·˜ 5. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ˘ÂÚÎÈÓËÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ 1. ∂Î·È‰Â˘ÙÈÎfi ÚfiÁÚ·ÌÌ· - ·ÙÔÌÈ΋ Âη›‰Â˘ÛË 2. ∆ÚÔÔÔ›ËÛË Û˘ÌÂÚÈÊÔÚ¿˜ (ÁÓˆÛȷ΋ - Û˘ÌÂÚÈÊÔÚȷ΋ „˘¯ÔıÂڷ›·) 3. º¿Ú̷η
¶›Ó·Î·˜ 6. O‰ËÁ›Â˜ ÛÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ ˘ÂÚÎÈÓËÙÈÎÔ‡ ·È‰ÈÔ‡ ñ ¡·È ÛÙËÓ ¿ıÏËÛË, fi¯È ˘ÂÚ‚ÔϤ˜ ñ ∆‹ÚËÛË ˆÚ·Ú›Ô˘ (Ê·ÁËÙfi, ÌÂϤÙË, „˘¯·ÁˆÁ›·) ñ Ÿ¯È ÎÔÈÓˆÓÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘ ··ÈÙÔ‡Ó ·ÎÈÓËÛ›· ñ Ÿ¯È ۈ̷ÙÈ΋ ‚›· ñ ∫›ÓËÙÚ· ÁÈ· ÛÙ·‰È·Î‹ ·‡ÍËÛË Û˘ÁΤÓÙÚˆÛ˘ ñ ∞ÔÊ˘Á‹ ÔÏÏÒÓ ·È¯ÓȉÈÒÓ ÛÙÔÓ ›‰ÈÔ ¯ÒÚÔ ñ ∂ÈÙ‹ÚËÛË Î·Ù¿ ÙËÓ ÒÚ· Ù˘ ÌÂϤÙ˘ ñ ¶ÚÔʇϷÍË ·È‰ÈÒÓ ·fi ¯ıÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ ñ ÀÔÌÔÓ‹, ‰˘Ó·ÙfiÙËÙ· ·ÔÌ¿ÎÚ˘ÓÛ˘ ÁÔÓ¤ˆÓ
¶·È‰È·ÙÚÈ΋ 2001;64:391-394
¶›Ó·Î·˜ 7. æ˘¯Ô‰ÈÂÁÂÚÙÈο Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙ· ˘ÂÚÎÈÓËÙÈο ·È‰È¿ 1. ¢ÂÍÙÚÔ·ÌÊÂÙ·Ì›ÓË (Dexedrine) 2. ªÂı˘ÏÊ·ÈÓȉ¿ÙË (Ritalin) 3. ∞ÌÊÂÙ·Ì›ÓË / ¢ÂÍÙÚÔ·ÌÊÂÙ·Ì›ÓË (Adderall) 4. ¶ÂÌÔÏ›ÓË (Cylert)
(Ritalin). °È· ÔÏÏ¿ ¯ÚfiÓÈ· ÙÔ Ê¿ÚÌ·ÎÔ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·Ó Â˘Ú‡Ù·Ù· (̤¯ÚÈ ˘ÂÚ‚ÔÏ‹˜) ÛÙȘ ∏¶∞, ∫·Ó·‰¿ Î·È ∞˘ÛÙÚ·Ï›·, ÂÓÒ ·ÓÙ›ıÂÙ· Û Ôχ ÂÚÈÔÚÈṲ̂ÓË Îϛ̷η ÛÙËÓ ∂˘ÚÒË (2,4,5). ™ÙȘ ∏¶∞, ηٿ ÙËÓ ÂÓÙ·ÂÙ›· 1991-1995, ÙÚÈÏ·ÛÈ¿ÛÙËÎÂ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙȘ ËÏÈ˘ 2-4 ¯ÚfiÓˆÓ (!), Êı¿ÓÔÓÙ·˜ ÙÔ ÔÛÔÛÙfi 1,1% ÙˆÓ ·È‰ÈÒÓ. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ Ê¿ÚÌ·ÎÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì ·˘Í·ÓfiÌÂÓË Û˘¯ÓfiÙËÙ· Î·È ÛÙȘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ (2,4). ∫·Ó¤Ó· ·fi Ù· Ê¿Ú̷η ÙÔ˘ ¶›Ó·Î· 7 ‰ÂÓ ÂÈÛ¿ÁÂÙ·È ·fi Ê·Ú̷΢ÙÈ΋ ÂÙ·ÈÚ›· ÛÙËÓ ∂ÏÏ¿‰·, fï˜ Ë ÚÔÌ‹ıÂÈ· Ù˘ ÌÂı˘ÏÊ·ÈÓ˘‰¿Ù˘ Â›Ó·È ‰˘Ó·Ù‹ (ÂÈÛ¿ÁÂÙ·È ·fi ÙÔ πº∂∆) Ì ÙË ¯Ú‹ÛË ÂȉÈ΋˜ Û˘ÓÙ·Á‹˜ “Ó·ÚΈÙÈÎÒÓ”. ∞fi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ‰fiıËΠÚfiÛÊ·Ù· ÛÙ· ̤ÏË Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰ÔÓ¢ÚÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ ÚԤ΢„ fiÙÈ ÙÔ 57% ÙˆÓ ¶·È‰ÔÓ¢ÚÔÏfiÁˆÓ ‰ÂÓ Â›¯Â ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ ÙÔ Ê¿ÚÌ·ÎÔ ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÍ¿ÌËÓÔ. ∆· ·ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÌÂı˘ÏÊ·ÈÓ˘‰¿Ù˘ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 8 Î·È 9. ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ¤Ó· ÔÛÔÛÙfi 75% ÙˆÓ ·È‰ÈÒÓ ÂÌÊ·Ó›˙ÂÈ Ô˘ÛÈ·ÛÙÈ΋ ‚ÂÏÙ›ˆÛË Ì ÙÔ Ê¿ÚÌ·ÎÔ (5,6). ∞fi ÔÏÏÔ‡˜ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ¯Ú‹ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Ú¤ÂÈ Ó· ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÌfiÓÔ Û ÂΛӷ Ô˘ Ë ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ‰È·Ù·Ú¿ÛÛÂÈ ÛÔ‚·Ú¿ ÙË Ì·ıËÛȷ΋ ÙÔ˘˜ ÈηÓfiÙËÙ· (2). ™˘Ó‹ıˆ˜ Á›ÓÂÙ·È ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Ù· Û·‚‚·ÙÔ·Úȷη Î·È Û ÂÚÈfi‰Ô˘˜ ‰È·ÎÔÒÓ. ™Â ·È‰È¿ Ì ηı’ ¤ÍÈÓ ÎÈÓ‹ÛÂȘ ‹ Û‡Ó‰ÚÔÌÔ Tourette Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∞ÓËÛ˘¯›·, fï˜, ÚÔηÏ› ÙÔ ÂӉ¯fiÌÂÓÔ ·‡ÍËÛ˘ ÙˆÓ Èı·ÓÔÙ‹ÙˆÓ ÁÈ· ¯Ú‹ÛË ÂıÈÛÙÈÎÒÓ Ô˘ÛÈÒÓ ÛÙÔ Ì¤ÏÏÔÓ ÏfiÁˆ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¿ÓÙˆ˜, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ¿Ô„Ë ·˘Ù‹ (7). ™ÙÔÓ ¶›Ó·Î· 10 ·Ó·ÁÚ¿ÊÔÓÙ·È ¿ÏÏ· Ê¿Ú̷η Ô˘ ¤¯Ô˘Ó ÂÓ›ÔÙ ¯ÚËÛÈÌÔÔÈËı› ÛÙÔ ˘ÂÚÎÈÓËÙÈÎfi Û‡Ó‰ÚÔÌÔ. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ηٿ ηÈÚÔ‡˜ ‰È¿ÊÔÚ˜ “ÂÓ·ÏÏ·ÎÙÈΤ˜” ıÂڷ›˜. ™Â ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ‰›·ÈÙ· Feingold (‰›·ÈÙ· ¯ˆÚ›˜ Û˘ÓÙËÚËÙÈο Î·È ¯ÚÒÌ·Ù·), “˘Ô·ÏÏÂÚÁÈΤ˜” ‹ ¯ˆÚ›˜ ˙¿¯·ÚË ‰›·ÈÙ˜, ‚Èٷ̛Ә, ÈÚ·ÎÂÙ¿ÌË, ‚ÈÔ·Ó¿‰Ú·ÛË Î.Ï. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ ÔÈ ıÂڷ›˜ ·˘Ù¤˜ ¤¯Ô˘Ó Ô˘ÛÈ·ÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ· (4,6). ∏ ¤Î‚·ÛË ÙÔ˘ ·È‰ÈÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Ù˘
Paediatriki 2001;64:391-394
¶›Ó·Î·˜ 8. ªÂı˘ÏÊ·ÈÓȉ¿ÙË (Ritalin) ñ Tabl ñ ∂Ê¿·Í ‰fiÛË ñ ∏ÌÂÚ‹ÛÈ· ‰fiÛË ñ ∞Ú¯È΋ ‰fiÛË ñ M¤ÁÈÛÙË ÙÈÌ‹ ÛÙÔ Ï¿ÛÌ· ñ ∆/2 ñ ª¤ÁÈÛÙË ‰Ú¿ÛË ñ ¢È¿ÚÎÂÈ· ‰Ú¿Û˘
5, 10 mg 0,3 - 0,7 mg/kg 10 - 40 mg 5 mg + 5 mg 2 ÒÚ˜ 2-3 ÒÚ˜ 1-3 ÒÚ˜ 3-5 ÒÚ˜
¶›Ó·Î·˜ 9. ¶·ÚÂÓ¤ÚÁÂȘ ÌÂı˘ÏÊ·ÈÓȉ¿Ù˘ ñ ∞ÓÔÚÂÍ›· ñ ∞¸Ó›· ñ ÕÁ¯Ô˜ ñ ∂˘ÂÚÂıÈÛÙfiÙËÙ· ñ ™˘Ó·ÈÛıËÌ·ÙÈ΋ ·ÛÙ¿ıÂÈ· ñ ∆·¯˘Î·Ú‰›·, ˘¤ÚÙ·ÛË ñ ∫·ı’ ¤ÍÈÓ ÎÈÓ‹ÛÂȘ (1%) ñ ¶ÂÚÈÔÚÈÛÌfi˜ ‚¿ÚÔ˘˜, Ì‹ÎÔ˘˜ ñ ÃÚ‹ÛË Ó·ÚΈÙÈÎˆÓ ÛÙÔ Ì¤ÏÏÔÓ (?)
¶›Ó·Î·˜ 10. ÕÏÏ· Ê¿Ú̷η ÁÈ· ÙËÓ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· 1. ∏ÌÈÚ·Ì›ÓË (∆ofranil) 2. ∞ÌÈÙÚÈÙ˘Ï›ÓË (Saroten) 3. ∫ÏÔÓȉ›ÓË (Catapresan) 4. µÂÓÏ·Ê·Í›ÓË (Efexor)
20 - 40 20 - 50 0,1 - 0,3 60
mg/24 h mg/24 h mg/24 h mg/24 h
ÔÈÎÔÁ¤ÓÂÈ·˜, ÁÔÓ›˜ ÌÂ Ù˘¯fiÓ „˘¯Ô·ıÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, Û˘Ó‡·ÚÍË Î·È ¿ÏÏˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ (.¯. ‰˘ÛÏÂÍ›·˜) Î·È ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË. O ϤÔÓ ÛËÌ·ÓÙÈÎfi˜, fï˜, ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Ë ÓÔËÌÔÛ‡ÓË ÙÔ˘ ·È‰ÈÔ‡. ¶·È‰È¿ Ì ˘„ËÏ‹ ÓÔËÌÔÛ‡ÓË ¤¯Ô˘Ó ηٿ ηÓfiÓ· Ôχ ηχÙÂÚË ÚfiÁÓˆÛË. ¢˘ÛÏÂÍ›· ∏ ‰˘ÛÏÂÍ›· ·ÔÙÂÏ› ‰È·Ù·Ú·¯‹ ÛÙË ¯Ú‹ÛË ÙÔ˘ ÁÚ·ÙÔ‡ ÏfiÁÔ˘, Ô ÔÔ›Ô˜ ·ÔÙÂÏ› Ì›· ·fi ÙȘ “ÚfiÛÊ·Ù˜” ηٷÎÙ‹ÛÂȘ ÙÔ˘ ·ÓıÚÒÔ˘ Ì ËÏÈΛ· ÂÚ›Ô˘ 5.000 ¯ÚfiÓˆÓ (Ô ÚÔÊÔÚÈÎfi˜ ÏfiÁÔ˜ ¤¯ÂÈ ËÏÈΛ· 100.000 ¯ÚfiÓˆÓ). ∏ ‰˘ÛÏÂÍ›· ÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ Morgan ÛÙÔ British Medical Journal ÙÔ 1896 Î·È ·ÔÙÂÏÂ›Ù·È ·fi Ì›· ·ÓÔÌÔÈÔÁÂÓ‹ ÔÌ¿‰· ‰È·Ù·Ú·¯ÒÓ Ì ‚·Ú‡ÙËÙ· Ô˘ ÔÈΛÏÏÂÈ ÛËÌ·ÓÙÈο (8,9). ∂˘Ù˘¯Ò˜, Û ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ‰˘ÛÏÂÎÙÈÎÒÓ ·È‰ÈÒÓ ÔÈ ‰È·Ù·Ú·¯¤˜ Â›Ó·È ‹È˜. ∏ ‰˘ÛÏÂÍ›· Â›Ó·È Ì›· ÌfiÓÈÌË Î·È fi¯È ÚfiÛηÈÚË “·Ó·Ù˘Íȷ΋” ‰È·Ù·Ú·¯‹ Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÚÔÔÙÈ΋ ÔÏfiÎÏËÚ˘ ˙ˆ‹˜, ηıÒ˜ ¤Ó· ‰˘ÛÏÂÎÙÈÎfi ·È‰› ı· Á›ÓÂÈ ¤Ó·˜ ‰˘ÛÏÂÎÙÈÎfi˜ ÂÓ‹ÏÈÎÔ˜ (2,8). ∏ ‚Ô‹ıÂÈ· ÁÈ· ÙÔ ‰˘ÛÏÂÎÙÈÎfi ·È‰› Â›Ó·È Î˘Ú›ˆ˜
393
¶·È‰È·ÙÚÈ΋ 2001;64:391-394
ÂÎ·È‰Â˘ÙÈ΋. ™ÙÔÓ ¶›Ó·Î· 11 ·Ó·ÁÚ¿ÊÔÓÙ·È ÂȉÈΤ˜ ÂÎ·È‰Â˘ÙÈΤ˜ ·Û΋ÛÂȘ ÁÈ· Ù· ·È‰È¿ Ì Úfi‚ÏËÌ·, Ô˘ ÊÔÈÙÔ‡Ó ÛÙȘ ÚÒÙ˜ Ù¿ÍÂȘ ÙÔ˘ ‰ËÌÔÙÈÎÔ‡ Û¯ÔÏ›Ԣ. ¢˘ÛÙ˘¯Ò˜, Ù· ÂÚÈÛÛfiÙÂÚ· ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· Ì ÙË ¯Ú‹ÛË ˘ÔÏÔÁÈÛÙÒÓ Â›Ó·È ÛÙËÓ ·ÁÁÏÈ΋ ÁÏÒÛÛ· (8,10). ∆· ÌÂÁ¿Ï· ·È‰È¿ (‰Â˘ÙÂÚÔ‚¿ıÌÈ· Î·È ÙÚÈÙÔ‚¿ıÌÈ· Âη›‰Â˘ÛË) ¤¯Ô˘Ó ‰˘Ó·ÙfiÙËÙ· ·Ó¿ÁÓˆÛ˘ Ô˘ Â›Ó·È ‚Ú·‰‡ÙÂÚË, ÏÈÁfiÙÂÚÔ ·˘ÙÔÌ·ÙÔÔÈË̤ÓË Î·È ··ÈÙ› ÂÚÈÛÛfiÙÂÚË ÚÔÛ¿ıÂÈ·. ™ÙȘ ËÏÈ˘ ·˘Ù¤˜, Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂͤٷÛ˘, ÙÔ Ì·ÁÓËÙfiʈÓÔ Î·È Ô ËÏÂÎÙÚÔÓÈÎfi˜ ˘ÔÏÔÁÈÛÙ‹˜ ‚ÔËıÔ‡Ó ÛËÌ·ÓÙÈο (¶›Ó·Î·˜ 12). ∂Ï›˙ÂÙ·È fiÙÈ, ÛÙÔ ÎÔÓÙÈÓfi ̤ÏÏÔÓ, Ë ·Ó¿Ù˘ÍË ÏÔÁÈÛÌÈÎÔ‡ ÁÈ· ÙË ÊˆÓËÙÈ΋ ÂÈÎÔÈÓˆÓ›· Ì ÙÔÓ ËÏÂÎÙÚÔÓÈÎfi ˘ÔÏÔÁÈÛÙ‹ ı· ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο ÙÔ˘˜ ‰˘ÛÏÂÎÙÈÎÔ‡˜. °È· Ì›· ‰È·Ù·Ú·¯‹, ÁÈ· ÙËÓ ÔÔ›· ‰ÂÓ ˘¿Ú¯ÂÈ Û·Ê‹˜ Î·È ÚÈ˙È΋ ıÂڷ›·, Â›Ó·È ·˘ÙÔÓfiËÙÔ fiÙÈ ˘¿Ú¯Ô˘Ó ÌÂÁ¿Ï· ÂÚÈıÒÚÈ· ÁÈ· ÙË ‰È¿‰ÔÛË ÌË Û˘Ì‚·ÙÈÎÒÓ ıÂÚ·ÂÈÒÓ. ∆Ô Úfi‚ÏËÌ· Â›Ó·È ‰ÈÂıÓ¤˜. ™Â ÔÏϤ˜ ¯ÒÚ˜ ˘¿Ú¯Ô˘Ó ÚfiÛˆ· Ô˘ ÚÔÛʤÚÔ˘Ó - ¤Ó·ÓÙÈ ·‰Ú‹˜ ·ÌÔÈ‚‹˜ - “ıÂڷ¢ÙÈο” ÚÔÁÚ¿ÌÌ·Ù· ÁÈ· ÙË ‰˘ÛÏÂÍ›·, Ù· ÔÔ›· fï˜ ‰ÂÓ ¤¯Ô˘Ó ÂÈÛÙËÌÔÓÈ΋ ÙÂÎÌËÚ›ˆÛË (2,8). ÷ڷÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· ÛÙËÓ ∂ÏÏ¿‰· ·ÔÙÂÏ› ıÂÚ·Â˘Ù‹˜ (ÌË È·ÙÚfi˜) Ô˘ ˙ËÙ¿ Ó· Á›ÓÂÈ ÛÙÔ ·È‰› ÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· Ì “¯·ÚÙÔÁÚ¿ÊËÛË”. ∏ ÂÈÛÙËÌÔÓÈ΋ ·Í›· Ì›·˜ Ù¤ÙÔÈ·˜ ¯·ÚÙÔÁÚ¿ÊËÛ˘ Â›Ó·È È‰È·›ÙÂÚ· ·ÌÊÈÛ‚ËÙ‹ÛÈÌË. ™ÙÔ˘˜ ÁÔÓ›˜ ÂȉÂÈÎÓ‡ÔÓÙ·È Ù· ‰È¿ÊÔÚ· ¯ÚÒÌ·Ù· Ù˘ ¯·ÚÙÔÁÚ¿ÊËÛ˘ Û·Ó ÂȂ‚·›ˆÛË Ù˘ ˘ÔÙÈıÂ̤Ó˘ ‰È¿ÁÓˆÛ˘ Ù˘ ‰˘ÛÏÂÍ›·˜ Î·È ÚÔÙ›ÓÂÙ·È Ë ·Ó¿ÏÔÁË ‰··ÓËÚfiÙ·ÙË “ıÂڷ›·”. ∏ ÚfiÁÓˆÛË ÂËÚ¿˙ÂÙ·È ·fi ÙÔ ‰È·ÓÔËÙÈÎfi ËÏ›ÎÔ ÙÔ˘ ·È‰ÈÔ‡. ∏ ÔÈÎÔÁ¤ÓÂÈ· Ú¤ÂÈ Ó· ÚÔÛʤÚÂÈ ÛÙ‹ÚÈÍË Î·È Û˘ÌÏËڈ̷ÙÈ΋ ηْ Ô›ÎÔÓ Âη›‰Â˘ÛË. ∞fi ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ Û¯ÔÏ›Ԣ Ú¤ÂÈ Ó· ÚÔ¶›Ó·Î·˜ 11. ∂ȉÈΤ˜ ·Û΋ÛÂȘ ÁÈ· ‰˘ÛÏÂÍ›· Û ÌÈÎÚ¿ ·È‰È¿ ñ ∞Ó¿Ï˘ÛË Ï¤ÍÂˆÓ Û ʈӋ̷ٷ ñ OÙÈ΋ Î·È ·ÎÔ˘ÛÙÈ΋ ·Ó·ÁÓÒÚÈÛË ÊˆÓËÌ¿ÙˆÓ ñ ™‡ÓıÂÛË ÊˆÓËÌ¿ÙˆÓ Î·È Û¯ËÌ·ÙÈÛÌfi˜ ϤÍÂˆÓ ñ ∂ÓÙfiÈÛË ÔÌÔÈÔηٿÏËÎÙˆÓ ˙¢ÁÒÓ Ï¤ÍÂˆÓ ñ ∞Ó¿ÁÓˆÛË fi¯È Ì˯·ÓÈ΋, ·ÏÏ¿ Ì ¤ÌÊ·ÛË ÛÙÔ ÂÚȯfiÌÂÓÔ ñ Computer games ϤÍÂˆÓ ñ ∂Î·È‰Â˘ÙÈο CD-ROM
¶›Ó·Î·˜ 12. µÔ‹ıÂÈ· Û ÌÂÁ¿Ï· ·È‰È¿ Ì ‰˘ÛÏÂÍ›· ñ ¶·Ú¿Ù·ÛË ¯ÚfiÓÔ˘ ÂͤٷÛ˘ ñ ¶ÚÔÊÔÚÈ΋ ÂͤٷÛË ñ ÀÔÏÔÁÈÛÙ‹˜ ñ ª·ÁÓËÙfiʈÓÔ ÛÙËÓ Ù¿ÍË ñ ª·ÁÓËÙÔʈÓË̤ӷ ‚È‚Ï›· ñ ∂ÚˆÙËÌ·ÙÔÏfiÁÈ· ÔÏÏ·ÏÒÓ ÂÈÏÔÁÒÓ: fi¯È !
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ÛʤÚÂÙ·È ÛÙ‹ÚÈÍË, ‰È¢ÎfiÏ˘ÓÛË Î·È fi¯È ÂÚÈıˆÚÈÔÔ›ËÛË. ¢˘ÛÙ˘¯Ò˜, ‰ÈÂıÓÒ˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È fiÙÈ ÔÈ ‰È‰¿ÛηÏÔÈ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ·ÚÎÒ˜ ÂÎ·È‰Â˘Ì¤ÓÔÈ ÁÈ· Ó· ‰È‰¿ÍÔ˘Ó ÁÚ·Ê‹ Î·È ·Ó¿ÁÓˆÛË Û ·È‰È¿ Ì ‰˘ÛÎÔϛ˜. ¶ÚfiÛÊ·Ù·, ¿Ú¯ÈÛ·Ó Ó· ‰ÔÎÈÌ¿˙ÔÓÙ·È ÛÙȘ ∏¶∞, Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ÂȉÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ·È‰ÈÒÓ Ô˘ ı· ÂΉËÏÒÛÔ˘Ó ·ÚÁfiÙÂÚ· ‰˘ÛÏÂÍ›·, Ì ÛÙfi¯Ô ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘. ∆· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· Ì›·˜ Ù¤ÙÔÈ·˜ ÚÒÈÌ˘ ·Ú¤Ì‚·Û˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÙÂÎÌËÚȈ̤ӷ (8,10). ™˘ÌÂÚ¿ÛÌ·Ù· O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ Â›Ó·È Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˜. Œ¯ÂÈ, fï˜, ÙÔÓ ÚÒÙÔ ÏfiÁÔ ÛÙË ‰È·Ê‡Ï·ÍË Ù˘ ۈ̷ÙÈ΋˜ Î·È „˘¯È΋˜ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ë ÁÓÒÌË ÙÔ˘ ¤¯ÂÈ ‚·Ú‡ÙËÙ·. ∂›Ó·È ۷ʤ˜ fiÙÈ ÛÙȘ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚÈ˙ÈΤ˜ ıÂڷ›˜. ∞·ÈÙÂ›Ù·È Û˘ÓÂÚÁ·Û›· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ì ÙÔ˘˜ ÂÎ·È‰Â˘ÙÈÎÔ‡˜ › Ì·ÎÚfiÓ Î·È ÂӉ¯Ô̤ӈ˜ ‚Ô‹ıÂÈ· ·fi ‰È¿ÊÔÚÔ˘˜ ÂȉÈÎÔ‡˜. O ·È‰›·ÙÚÔ˜ ¤¯ÂÈ ˘Ô¯Ú¤ˆÛË fi¯È ÌfiÓÔ Ó· ηÙ¢ı‡ÓÂÈ, ·ÏÏ¿ Î·È Ó· ÚÔÊ˘Ï¿ÛÛÂÈ ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘ ·fi ˘ÂÚ‚ÔϤ˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Blondis TA. Motor disorders and attention-deficit / hyperactivity disorder. Ped Clin N Amer 1999;46:899-914. 2. Gordon NS. Specific learning disorders: motor skills, language and behaviour. In: Brett E, editor. Paediatric Neurology. London: Churchill Livingstone; 1997. p. 455. 3. Morgan A. Diagnosis of attention-deficit / hyperactivity Disorder. Ped Clin N Amer 1999;46:871-884. 4. ∞ccardo P, Blondis T, Whitman B, Stein M. Attention deficits and hyperactivity in children and adults. New York: M. Dekker; 1999. 5. Bennet FC, Brown RT, Craver J, Anderson D. Stimulant medication for the child with attention-deficit / hyperactivity disorder. Ped Clin N Amer 1999;46:929-944. 6. Birchard K. Progress made in ADH. Lancet 1999;353:1073. 7. Biedderman J, Wilens T, Mick E, Spenser T, Faraone S. Pharmacotherapy of ADHD reduces risk for substance use disorder. Pediatrics 1999;104:e20. 8. Shaywitz S. Dyslexia. N Engl J Med 1998;338:307-312. 9. Nicolson R, Fawcett A, Berry E, Jenkins H, Dean P, Brooks D. Association of abnormal cerebellar activation with motor learning difficulties in dyslexic adults. Lancet 1999;353:1662-1667. 10. Tallal P, Miller S, Bedi G, Byma G et al. Language comprehension in language-learning impaired children improved with acoustically modified speech. Science 1996;271:81-84.
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™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ··Û¯ÔÏÔ‡Ó ÙÔÓ ¤ÊË‚Ô º. ∞. ∞Ó‰ÚÔ˘Ï·Î¿Î˘
Congenital defects of the urinary and genital system that preoccupy the adolescent P. A. Androulakakis
¶ÂÚ›ÏË„Ë: OÈ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ‰˘Ó·ÙfiÓ, ÛÙË ÌÂÁ¿ÏË ÏÂÈÔ„ËÊ›· ÙÔ˘˜, Ó· ‰ÈÔÚıˆıÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈο. ∆Ô‡ÙÔ ÈÛ¯‡ÂÈ Î·Ù’ ÂÍÔ¯‹Ó Û ·ÓˆÌ·Ï›Â˜ Ù˘ ·ÓÒÙÂÚ˘ Ô˘ÚÔÊfiÚÔ˘ Ô‰Ô‡, Ï.¯. ÛÙ¤ÓˆÛË ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ ‹ Ô˘ÚËÙËÚÔ΢ÛÙÈ΋˜ Û˘Ì‚ÔÏ‹˜. À¿Ú¯Ô˘Ó, ˆÛÙfiÛÔ, ÔÚÈṲ̂Ó˜ ‰È·Ì·Úٛ˜ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È Ù˘ Ô˘Ú‹ıÚ·˜, fiÔ˘ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ‰ÂÓ ÂÍ·ÛÊ·Ï›˙ÂÈ Ï‹ÚË ‹ Ô˘ÛÈ·ÛÙÈ΋ ·ÔηٿÛÙ·ÛË, Ì ·ÔÙ¤ÏÂÛÌ· ÔÈ ÂÈÙÒÛÂȘ ÙÔ˘˜ Ó· ÌÂٷʤÚÔÓÙ·È ÛÙËÓ ÂÊË‚È΋ ‹ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹. OÈ ·ÓˆÌ·Ï›Â˜ ·˘Ù¤˜, Ô˘ ÔÈ ÂÈÙÒÛÂȘ ÙÔ˘˜ ı›ÁÔÓÙ·È ÛÙÔ ¿ÚıÚÔ ·˘Ùfi, Â›Ó·È Ë ÂÎÛÙÚÔÊ‹ Ù˘ ·ÛÙˆ˜, Ë Ó¢ÚÔÁÂÓ‹˜ ·ÛÙË (¡∫), ÔÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ (µOO) Î·È Ô ˘ÔÛ·‰›·˜. ∏ ÂÎÛÙÚÔÊÈ΋ ·ÛÙË ÌÂÙ¿ ÙË Û‡ÁÎÏÂÈÛ‹ Ù˘ ÛÙË ÓÂÔÁÓÈ΋ ‹ ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô, ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÓÙ·ÔÎÚÈı› ÛÙȘ ‰‡Ô ·ÚȘ ÏÂÈÙÔ˘ÚÁ›Â˜ Ù˘, ÙËÓ ÂÁÎÚ·Ù‹ Û˘ÁÎÚ¿ÙËÛË ÙˆÓ Ô‡ÚˆÓ Î·È ÙËÓ Ï‹ÚË - ÂÚÈÔ‰Èο - Τӈۋ Ù˘. OÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ χÛÂȘ Ô˘ ÂÈϤÁÔÓÙ·È ÚÔ˜ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ ÛÙËÚ›˙ÔÓÙ·È ÛÙËÓ ÚÔÛı‹ÎË ÙÌËÌ¿ÙˆÓ ÂÓÙ¤ÚÔ˘ ÚÔ˜ ·‡ÍËÛË Ù˘ ¯ˆÚËÙÈÎfiÙËÙ¿˜ Ù˘ (‰È‡ڢÓÛË) ‹ ÔÚÈÛÙÈ΋ ÂÎÙÚÔ‹ ÙˆÓ Ô‡ÚˆÓ ‰È’ ÂÌÊ˘Ù‡Ûˆ˜ ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ ÛÙÔ ÛÈÁÌÔÂȉ¤˜ (Ô˘ÚËÙËÚÔÛÈÁÌÔÂȉÔÛÙÔÌ›·). ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙË ¡∫. ∞Ó·fiÊ¢ÎÙ·, ÔÈ Ù¯ÓÈΤ˜ ·˘Ù¤˜ Û˘Ó‰¤ÔÓÙ·È Ì ÂÂÈÛfi‰È· ÏÔÈÌÒ͈Ó, ·ÔÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‹ ÌÂÙ·‚ÔÏÈ΋˜ ÈÛÔÚÚÔ›·˜ ηÈ, ÂӉ¯Ô̤ӈ˜, ·Ó¿Ù˘ÍË ÂÓÙÂÚÈÎÒÓ ÓÂÔÏ·ÛÈÒÓ. ¢È·Ù·Ú·Á̤ÓË ÏÂÈÙÔ˘ÚÁÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Ë Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË Â› µOO ÌÂÙ¿ ÙËÓ ¿ÚÛË ÙÔ˘ ˘Ô΢ÛÙÈÎÔ‡ Έχ̷ÙÔ˜ Û ÔÛÔÛÙfi 70-80% (‚·Ï‚ȉÈ΋ ·ÛÙË). ∆Ô‡ÙÔ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ
Abstract: Congenital defects of the urinary and genital system may be corrected surgically in their great majority. This is especially true for upper urinary tract anomalies, i.e. obstruction of pelvoureteral or ureterovesical junction. There exist, however, some defects of the urinary bladder and urethra, in which surgical reconstruction succeeds only partialy or temporarily, hence their subsequent sequelae may cause problems during adolescence or adulthood. Such anomalies, whose sequelae are briefly depicted in this article, are bladder exstrophy, neurogenic bladder (NB), posterior urethral valves (PUV) and hypospadias. The exstrophic bladder, following early closure during the neonatal period or infancy, cannot fulfill its two principal functions i.e. continent storage of urine and complete periodic emptying. Surgical options for its management include bladder enhancement with detubularised intestinal segments (cystoplasty) or permanent urinary diversion by ureterosigmoidostomy. The same applies for NB. These techniques are inevitably linked to frequent episodes of urinary tract infection, destabilization of kidney function and metabolic homeostasis, and probably development of intestinal neoplasms. Following ablation procedure for infravesical obstruction, the urinary bladder becomes dysfunctional in 70-80% of PUV cases (valve bladder). This may lead to progressive loss of kidney function, especially when intravesical pressures are high (low-compliance bladders). Finally, there will be some cases of hypospadias in which either the cometic or functional outcome will be unsatisfactory to the patients, affecting adversely
∞Ì. ∂. ∫·ıËÁËÙ‹˜ O˘ÚÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¢È¢ı˘ÓÙ‹˜ O˘ÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”
Assoc. Professor in Urology, Athens University Medical School Head, Dept of Pediatric Urology “Aghia Sophia” Children’s Hospital, Athens
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Paediatriki 2001;64:395-399
·ÔÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÚÔ˚fiÓÙÔ˜ ÙÔ˘ ¯ÚfiÓÔ˘, ȉȷ›ÙÂÚ· fiÙ·Ó ·Ó·Ù‡ÛÛÔÓÙ·È ˘„ËϤ˜ ÂÓ‰Ô΢ÛÙÈΤ˜ ȤÛÂȘ. ∆¤ÏÔ˜, ı· ˘¿ÚÍÔ˘Ó ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ˘ÔÛ·‰›·, fiÔ˘ ÙÔ ÎÔÛÌËÙÈÎfi ·ÏÏ¿ Î·È ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ı· ÈηÓÔÔÈ› ÙÔÓ ¤ÊË‚Ô, Ì ·ÓÙ›ÎÙ˘Ô ÛÙË ÛÂÍÔ˘·ÏÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘. ™Ù· ·Ú·¿Óˆ, Â˘Ù˘¯Ò˜ fi¯È Û˘¯Ó¿, ÚÔ‚Ï‹Ì·Ù·, Ë Û˘ÓÂÚÁ·Û›· ·È‰È¿ÙÚÔ˘ Î·È ·È‰ÔÔ˘ÚÔÏfiÁÔ˘ ÛÙËÓ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·Û¯fiÓÙˆÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜ ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÔÌ·Ï‹, ηٿ ÙÔ ‰˘Ó·ÙfiÓ, ÌÂÙ¿‚·ÛË ÙˆÓ ·ÙfiÌˆÓ ·˘ÙÒÓ ·fi ÙËÓ ÂÊ˂›· ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ Î·È ¤ÓÙ·ÍË ÛÙÔ ÎÔÈÓˆÓÈÎfi Û‡ÓÔÏÔ.
their sexual behaviour. In the above disorders, which are fortunately not too common, the close cooperation between pediatricians and pediatric urologists in approaching the patients and their family will help in ensuring their smooth transition from puberty to adulthood and their social well being.
§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡, ÂÎÛÙÚÔÊ‹ ·ÛÙˆ˜, Ó¢ÚÔÁÂÓ‹˜ ·ÛÙË, ‚·Ï‚›‰Â˜ Ô˘Ú‹ıÚ·˜, ˘ÔÛ·‰›·˜, ÂÊ˂›·.
Key words: congenital urogenital defects, bladder exstrophy, neurogenic bladder, posterior urethral valves, hypospadias, puberty.
∏ ¶·È‰ÔÔ˘ÚÔÏÔÁ›·, ˆ˜ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ O˘ÚÔÏÔÁ›·˜, ·ÔÙÂÏ› ηْ ÂÍÔ¯‹Ó ÎÏ¿‰Ô Ì ·ÓÔÚıˆÙÈÎfi ¯ÂÈÚÔ˘ÚÁÈÎfi ÂÚȯfiÌÂÓÔ. ™Ùfi¯Ô˜ ÙÔ˘ ·È‰ÔÔ˘ÚÔÏfiÁÔ˘, fiÔ˘ ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi, Â›Ó·È Ë ·ÔηٿÛÙ·ÛË Ù˘ ·Ó·ÙÔÌ›·˜ Î·È Ë ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ÂÎÂ›ÓˆÓ Ô˘ Ë Ê‡ÛË ‰ÂÓ ‰È¤Ï·Û ÔÚı¿. OÈ ·ÓˆÌ·Ï›Â˜ Ô˘ ηÏÂ›Ù·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Ô Ô˘ÚÔÏfiÁÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÛÙË ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜, ·Ôηı›ÛÙ·ÓÙ·È Û ‚·ıÌfi Ù¤ÙÔÈÔ ÒÛÙ ӷ ÌËÓ ÚÔηÏÔ‡Ó ÚÔ‚Ï‹Ì·Ù· ηٿ ÙËÓ ÂÊ˂›· ‹ ÙË ÌÂÙ¤ÂÈÙ· ÂÓ‹ÏÈÎË ˙ˆ‹. π‰È·›ÙÂÚ· ÈÛ¯‡ÂÈ ·˘Ùfi ÁÈ· ÙËÓ ·ÓÒÙÂÚË ·Ô¯ÂÙ¢ÙÈ΋ Ô˘ÚÔÊfiÚÔ Ô‰fi. ∆· ÔÛÔÛÙ¿ ÂÈÙ˘¯Ô‡˜ ‰ÈÔÚıÒÛˆ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, ÙÔ˘ ·ÔÊÚ·ÎÙÈÎÔ‡ ÌÂÁ·Ô˘ÚËÙ‹Ú· Î·È Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 90%, Ì ıÂÙÈΤ˜ Ê˘ÛÈο Û˘Ó¤ÂȘ fiÛÔÓ ·ÊÔÚ¿ Î·È ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (1). ŸÌˆ˜, Ë ›‰È· ·ÈÛÈfi‰ÔÍË ÚfiÁÓˆÛË ‰ÂÓ ÈÛ¯‡ÂÈ ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi ÁÈ· ÙȘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È ÙˆÓ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ. ªÔÈÚ·›·, ı· ˘¿ÚÍÔ˘Ó ÔÚÈṲ̂Ó˜ ‰È·Ì·Úٛ˜, fiÔ˘, ÏfiÁˆ Ù˘ ʇÛˆ˜ Î·È Ù˘ ‚·Ú‡ÙËÙ¿˜ ÙÔ˘˜, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË (‹ ·ÚÂÌ‚¿ÛÂȘ) ·‰˘Ó·Ù› Ó· ÂÍ·ÛÊ·Ï›ÛÂÈ ÙËÓ Ï‹ÚË ·ÔηٿÛÙ·ÛË (¶›Ó·Î·˜ 1). ™Â ·˘Ù¤˜ ÙȘ ‰È·Ì·Úٛ˜ Î·È Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Ó¿ÁÔÓÙ·È ÁÈ· ÙÔÓ/ÙËÓ ¤ÊË‚Ô/Ë, ÂÈÎÂÓÙÚÒÓÂÙ·È Ë ·ÚÔ‡Û· ÂÈÛ‹ÁËÛË.
‚ÔÏ‹ ÙÔ˘˜ ·Ó¿ 3-4 ÒÚ˜. ∏ Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi: ·) ¿ÛËÙÔ ÂÚÈ‚¿ÏÏÔÓ, ‚) ·Ôı‹Î¢ÛË ÙˆÓ Ô‡ÚˆÓ Ì ¯·ÌËϤ˜ ˘‰ÚÔÛÙ·ÙÈΤ˜ ȤÛÂȘ, ‰ËÏ. <30 cm H2O Î·È Ì ·fiÏ˘ÙË ÂÁÎÚ¿ÙÂÈ· Î·È Á) Ï‹ÚË Î¤ÓˆÛ‹ Ù˘, ÔÛ¿ÎȘ ÙÔ ·›ÛıËÌ· ÚÔ˜ ¤ÂÈÍË ÙÔ ··ÈÙ›. ∫¿ı ‰È·Ù·Ú·¯‹ ‹ ·ÒÏÂÈ· ÙˆÓ ·ÓˆÙ¤Úˆ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ¤¯ÂÈ ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ Î·È ·ÓÙ›ÎÙ˘Ô, ›Ù ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ›Ù ÛÙËÓ ÎÔÈÓˆÓÈο ·Ô‰ÂÎÙ‹ Ô‡ÚËÛË ÙÔ˘ ·ÙfiÌÔ˘. ∏ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÎÈÓ‰˘Ó‡ÂÈ, ÔÛ¿ÎȘ ·Ó·Ù‡ÛÛÔÓÙ·È ˘„ËϤ˜ ˘‰ÚÔÛÙ·ÙÈΤ˜ ȤÛÂȘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË, ‰ÈfiÙÈ ·˘Ù¤˜ ÌÂÙ·‰›‰ÔÓÙ·È ¿ÌÂÛ· ÛÙÔ ·ÓÒÙÂÚÔ Ô˘ÚÔÔÈËÙÈÎfi ηÈ, ÙÂÏÈο, ÛÙÔ˘˜ ÓÂÊÚÒÓ˜, Ì ηٿÏËÍË ÙËÓ ·ÙÚÔÊ›· ÂΠȤÛˆ˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ (1). ∏ ηٷÎÚ¿ÙËÛË (ÛÙ¿ÛË) ¢ÓÔ› ÙËÓ ÂÈÌfiÏ˘ÓÛ‹ ÙÔ˘˜ Î·È Ô‰ËÁ› Û ·ÓÈÔ‡Û· Ô˘ÚÔÏԛ̈ÍË, Ô˘ Â¿Ó ÂΉËψı› ˆ˜ ÔÍ›· ˘ÂÏÔÓÂÊÚ›ÙȘ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÏÂÈ ÂÈÚfiÛıÂÙ· ÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì·. ¶·Ú¿ÏÏËÏ·, Ë ·‰˘Ó·Ì›· Û˘ÁÎÚ¿ÙËÛ˘ ÙˆÓ Ô‡ÚˆÓ (·ÎÚ¿ÙÂÈ·) ı›ÁÂÈ Î·›ÚÈ· ÙËÓ ÎÔÈÓˆÓÈ΋ ·ÍÈÔÚ¤ÂÈ· ÙÔ˘ ·ÙfiÌÔ˘ Î·È ÙÔ Ô‰ËÁ› ÛÂ
¢È·Ì·Úٛ˜ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ∏ Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË ·ÔÙÂÏ› ÙÔ fiÚÁ·ÓÔ Ô˘ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ ·Ôı‹Î¢ÛË ÙˆÓ ·Ú·ÁfiÌÂÓˆÓ Ô‡ÚˆÓ Î·È ÙËÓ ÂÚÈÔ‰È΋ (‰È¿ Ù˘ Ô˘Ú‹ıÚ·˜) ·Ô-
396
¶›Ó·Î·˜ 1. ∫˘ÚÈfiÙÂÚ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ÂÊ˂›· O˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ - ¡Â˘ÚÔÁÂÓ‹˜ ·ÛÙË (Ì˘ÂÏÔÌËÓÈÁÁÔ΋ÏË, ηıËψ̤ÓÔ˜ ÙÂÏÈÎfi˜ ÎÒÓÔ˜ Î.Ï.) - ∂ÎÛÙÚÔÊ‹ - ÂÈÛ·‰›·˜ - ∫‡ÛÙË Â› ‚·Ï‚›‰ˆÓ Ô˘Ú‹ıÚ·˜ (‚·Ï‚ȉÈ΋ ·ÛÙË) ŒÍˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ - ÀÔÛ·‰›·˜ - ªÈÎÚÔÊ·ÏÏ›· - ∞ÓÔÚ¯›·
¶·È‰È·ÙÚÈ΋ 2001;64:395-399
Paediatriki 2001;64:395-399
·Ó·ÛÊ¿ÏÂÈ·, ·ÔÌfiÓˆÛË Î·È ·fiÚÚÈ„Ë ÂΠ̤ÚÔ˘˜ ÙˆÓ Û˘ÓÔÌËÏ›ÎˆÓ ÙÔ˘ (¶›Ó·Î·˜ 2). OÈ ·ÓˆÌ·Ï›Â˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ٷ ·Ú·¿Óˆ ‰ÂÓ Â›Ó·È Â˘Ù˘¯Ò˜ Û˘¯Ó¤˜, fï˜ Ù· ÚÔ‚Ï‹Ì·Ù¿ ÙÔ˘˜ ··Û¯ÔÏÔ‡Ó Ì·ÎÚÔÚfiıÂÛÌ· ÙÔÓ Ô˘ÚÔÏfiÁÔ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÂÓÒ ÔÏÏ¿ ·fi ·˘Ù¿ ı· ÌÂÙ·ÊÂÚıÔ‡Ó ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹. ∏ ÂÎÛÙÚÔÊ‹ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÈÛ·‰›·, ¤¯ÂÈ Û˘¯ÓfiÙËÙ· 1:30.00050.000. ∞˘Ùfi Ô˘ Ù‡ÔȘ ηÏÂ›Ù·È “·ÛÙË” Â›Ó·È ÛÙËÓ Ô˘Û›· Ì›· ·ÓÔÈÎÙ‹ Ì˘ÔÂÈıËÏȷ΋ Ͽη, ÛÙËÓ ÔÔ›· ÙÔ Ì˘˚Îfi fiÛÔ Î·È ÙÔ ÂÈıËÏÈ·Îfi ÛÙÔÈ¯Â›Ô Â›Ó·È ÂΠηٷÛ΢‹˜ ÌÂÈÔÓÂÎÙÈο Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ¤ÏÏÂÈ„Ë Ê˘ÛÈÔÏÔÁÈ΋˜ ÈηÓfiÙËÙ·˜ ÚÔ˜ ‰È¿Ù·ÛË Î·È Û‡Û·ÛË. ∞˘Ù‹ Ë ÂÁÁÂÓ‹˜ ÌÂÈÔÓÂÎÙÈÎfiÙËÙ· ÊÙ¿ÓÂÈ ÙÔ 90% Î·È Ï¤ÔÓ (2). ∏ ¿ÌÂÛË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÎÛÙÚÔÊ‹˜ Û˘Ó›ÛÙ·Ù·È ÛÙË Û‡ÁÎÏÂÈÛË Ù˘ ÂÎÛÙÚÔÊÈ΋˜ Ͽη˜ Î·È ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ¯¿ÛÌ·ÙÔ˜ ÙˆÓ ÎÔÈÏÈ·ÎÒÓ ÙÔȯˆÌ¿ÙˆÓ Ì ηٿÏÏËÏË ·Ú·Û΢‹ Î·È ÎÈÓËÙÔÔ›ËÛË Ì˘Ô‰ÂÚÌ·ÙÈÎÒÓ ÎÚËÌÓÒÓ (3). ∞˘Ùfi ÂÚÈÔÚ›˙ÂÈ ÛËÌ·ÓÙÈο ÙËÓ ·Ú¯È΋ ‰˘ÛÌÔÚÊ›· Î·È Ê˘ÛÈο ·Ó·ÎÔ˘Ê›˙ÂÈ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘. ∆Ë Û‡ÓÙÔÌË ÂÚ›Ô‰Ô Ù˘ Û˘ÁÎÚ·ÙË̤Ó˘ ·˘Ù‹˜ ·Ó·ÎÔ‡ÊÈÛ˘, ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3-4 ÂÙÒÓ, ‰È·‰¤¯ÂÙ·È ¤ÓÙÔÓÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ.
∞fi ÙË ÌÈ· ÏÂ˘Ú¿, ˘Ê›ÛÙ·Ù·È Ë ¿Ô„Ë (Î·È Ë Û¯ÔÏ‹) Ù˘ ‰È·ÙËÚ‹Ûˆ˜ Ù˘, ¤ÛÙˆ ÚÔ‚ÏËÌ·ÙÈ΋˜ ·ÏÏ¿ “Ê˘ÛÈ΋˜”, Ô˘ÚÔÊfiÚÔ˘ Ô‰Ô‡, Ì ÂÈÚfiÛıÂÙ˜ ‰ÈÔÚıˆÙÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ˘ÔÛÙËÚ›˙ÂÙ·È Ë ¿Ô„Ë Ù˘ ÂÁηٿÏÂȄ˘ Ù˘ ÚÔ‚ÏËÌ·ÙÈ΋˜ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È Ù˘ ÂÎÙÚÔ‹˜ ÙˆÓ Ô‡ÚˆÓ Ì ·Ó·ÛÙfïÛË ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ ÛÙÔ ¤ÓÙÂÚÔ. ∆· ÂȯÂÈÚ‹Ì·Ù· ·fi ÙÔ˘˜ ˘ÔÛÙËÚÈÎÙ¤˜ Ù˘ Ì›·˜ ‹ Ù˘ ¿ÏÏ˘ Û¯ÔÏ‹˜ Â›Ó·È ÔÏÏ¿ Î·È ÔÈ ·ÓÙÈ·Ú·ı¤ÛÂȘ ¿ÓÙÔÙ ηÏfiÈÛÙ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙfi¯Ô˜ Â›Ó·È ¿ÓÙÔÙÂ Ë ·Ó·ÎÔ‡ÊÈÛË ÙˆÓ ·ÛıÂÓÒÓ. ¶·ÚfiÌÔÈ· Â›Ó·È Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·È ÔÈ ·ÛıÂÓ›˜ Ì Ó¢ÚÔÌ˘˚Τ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ (Ó¢ÚÔÁÂÓ‹ ·ÛÙË) ÂÍ·ÈÙ›·˜ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÔÚÊÒÓ ‰˘ÛÚ·ÊÈÛÌÔ‡. ∏ ‰È·ÊÔÚ¿ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·Î·‰ËÌ·˚΋ ·Ú¿ Ô˘ÛÈ·ÛÙÈ΋, ‰ÈfiÙÈ ÙÂÏÈο ÔÈ Ï‡ÛÂȘ Ô˘ ‰›‰ÔÓÙ·È Î·È ÛÙË Ì›· Î·È ÛÙËÓ ¿ÏÏË ÂÚ›ÙˆÛË ‰ÂÓ ÂÈÏ‡Ô˘Ó Ù· ÚÔ‚Ï‹Ì·Ù·, ·ÏÒ˜ Ù· ·Ó·ÎÔ˘Ê›˙Ô˘Ó, ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ fï˜ Î·È ·˘Ù¤˜ Ó¤· ÚÔ‚Ï‹Ì·Ù· Ô˘ ΢ÚÈÔÏÂÎÙÈο ÛËÌ·‰Â‡Ô˘Ó ÙË ˙ˆ‹ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ (4,5) (¶›Ó·Î·˜ 3). ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË ÚÔÂÚ¯fiÌÂÓË ·fi ÙÚÈÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌÂ›Ô Ù˘ ™Ô˘Ë‰›·˜, Ô˘ ·ÊÔÚ¿ ·ÛıÂÓ›˜ Ì ÂÎÛÙÚÔÊ‹, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ Ì¤¯ÚÈ ÙËÓ ÂÓËÏÈΛˆÛ‹ ÙÔ˘˜ ‹Ù·Ó 6-19/·ÛıÂÓ‹,
¶›Ó·Î·˜ 2. §ÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È ÔÈ Û˘Ó¤ÂȤ˜ ÙÔ˘˜ ∞ÈÙÈÔÏÔÁ›· - ¡Â˘ÚÔÁÂÓ‹˜ ·ÛÙË - ∂ÎÛÙÚÔÊ‹ - ÂÈÛ·‰›·˜ - µ·Ï‚ȉÈ΋ ·ÛÙË
}
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∞‰˘Ó·Ì›· ÎÂÓÒÛˆ˜ Ô‡ÚˆÓ
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À„ËϤ˜ ȤÛÂȘ Û ÌÈÎÚfi fiÁÎÔ Ô‡ÚˆÓ
À‰ÚÔÓ¤ÊÚˆÛË, ·ÏÈÓ‰ÚfiÌËÛË, ÓÂÊÚÈ΋ ‚Ï¿‚Ë (·ÙÚÔÊ›· ·ÚÂÁ¯‡Ì·ÙÔ˜)
¶›Ó·Î·˜ 3. ∂ÈÏÔÁ¤˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ¶Úfi‚ÏËÌ·
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ñ ∞‰˘Ó·Ì›· ·ÔıË·ۈ˜
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- ∞Ó¿ÁÎË ‰È·ÏÂÈfiÓÙˆÓ Î·ıÂÙËÚÈ·ÛÌÒÓ - ™¯ËÌ·ÙÈÛÌfi˜ Ï›ıˆÓ - ∫›Ó‰˘ÓÔ˜ Ô˘ÚÔÂÓÙÂÚÈ΋˜ ÓÂÔÏ·Û›·˜
ñ ∞‰˘Ó·Ì›· ÎÂÓÒÛˆ˜
- ¢È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ› - ∂ÌʇÙ¢ÛË Ô˘ÚËÙ‹ÚˆÓ ÛÙÔ ¤ÓÙÂÚÔ
- ªÈÎÚÔ‚ÈÔ˘Ú›· - ªÂÙ·‚ÔÏÈ΋ ÔͤˆÛË - ∫›Ó‰˘ÓÔ˜ Ô˘ÚÔÂÓÙÂÚÈ΋˜ ÓÂÔÏ·Û›·˜
ñ À„ËϤ˜ ȤÛÂȘ Û ÌÈÎÚÔ‡˜ fiÁÎÔ˘˜ Ô‡ÚˆÓ
- ∞‡ÍËÛË ¯ˆÚËÙÈÎfiÙËÙ·˜ Ì ԢÚËÙ‹Ú· ‹ ÙÌ‹Ì· ÂÓÙ¤ÚÔ˘
- ∞Ó¿ÁÎË ‰È·ÏÂÈfiÓÙˆÓ Î·ıÂÙËÚÈ·ÛÌÒÓ - ™¯ËÌ·ÙÈÛÌfi˜ Ï›ıˆÓ - ∫›Ó‰˘ÓÔ˜ Ô˘ÚÔÂÓÙÂÚÈ΋˜ ÓÂÔÏ·Û›·˜
397
¶·È‰È·ÙÚÈ΋ 2001;64:395-399
ÙˆÓ ‰Â ÂÈÛ·ÁˆÁÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô 6-26/·ÛıÂÓ‹ ÛÙÔ ›‰ÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (6), ÂÓÒ Û ¿ÏÏË ÚfiÛÊ·ÙË ËÏÂÎÙÚÔÓÈ΋ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ̤ۈ ÙÔ˘ MEDLINE, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ÔÛÔÛÙfi ‰ÈÔÚıˆÙÈÎÒÓ Â·ÓÂÁ¯ÂÈÚ‹ÛÂˆÓ ÁÈ· ·ÛıÂÓ›˜ Ì Ó¢ÚÔÁÂÓ‹ ·ÛÙË, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÎÚ¿ÙÂÈ·˜ Ô‡ÚˆÓ, ‹Ù·Ó 12-61% (7). OÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ ¤¯Ô˘Ó Û˘¯ÓfiÙËÙ· 1:10.000-15.000 ÛÙÔÓ ¿ÚÚÂÓ· ÏËı˘ÛÌfi. OÈ ÚÔηÏÔ‡ÌÂÓ˜ ‚Ï¿‚˜ ÛÙËÓ ·Ô¯ÂÙ¢ÙÈ΋ Ô˘ÚÔÊfiÚÔ Ô‰fi Î·È ÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì· ·fi ÙȘ ÏÂÙ¤˜ (˘ÌÂÓÒ‰ÂȘ) ·˘Ù¤˜ Ù˘¯¤˜ Â›Ó·È Ú¿ÁÌ·ÙÈ ÂÓÙ˘ˆÛȷΤ˜. °ÓˆÚ›˙Ô˘Ì ۋÌÂÚ· ηÏÒ˜ fiÙÈ ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Î·Ù¿ ÙËÓ ÚÒÙË ÓÔÛËÏ›· ÙÔ˘˜ Ì ÂÈÙ˘¯‹ ‰ÈÔ˘ÚËıÚÈ΋ ‰È·ÙÔÌ‹ ÙˆÓ ‚·Ï‚›‰ˆÓ, ÔÛÔÛÙfi 2030% ı· ÂÌÊ·Ó›ÛÂÈ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ∆Ô‡ÙÔ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë Ô˘ ˘Ê›ÛÙ·Ù·È Ô ‰È·Ï·ÛÛfiÌÂÓÔ˜ (ÂÌ‚Ú˘˚Îfi˜) ÓÂÊÚfi˜ ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ‹‰Ë ·fiÊÚ·ÍË. ŸÌˆ˜, ¤Ó·˜ ÂÈÚfiÛıÂÙÔ˜ ·Ú¿ÁˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙË ÌÂÙ¤ÂÈÙ· ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Â›Ó·È Î·È Ë ·ıÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. O fiÚÔ˜ “‚·Ï‚ȉÈ΋ ·ÛÙË” (valve bladder) ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ô‰›‰ÂÈ ÙȘ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜, Ô˘ ÛÙËÓ Ô˘Û›· Û˘ÓÈÛÙÔ‡Ó Û˘ÌÂÚÈÊÔÚ¿ Ó¢ÚÔÁÂÓÔ‡˜ ·ÛÙˆ˜. ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ ∫ÏÈÓÈ΋ Ì·˜, Ô˘ ·ÊÔÚÔ‡Û ·ÛıÂÓ›˜ Ì ‚·Ï‚›‰Â˜ ·ÓÙÈÌÂÙˆÈÛı›Û˜ ÂÈÙ˘¯Ò˜ 10 ¯ÚfiÓÈ· ÓˆÚ›ÙÂÚ·, ‰È·ÈÛÙÒıËΠ̠ԢÚÔ‰˘Ó·ÌÈ΋ ̤ÙÚËÛË fiÙÈ ÌfiÓÔ 3/10 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ Ô‡ÚËÛË Î·È Ê˘ÛÈÔÏÔÁÈο ΢ÛÙÂÔÌ·ÓÔÌÂÙÚÈο Â˘Ú‹Ì·Ù· (8). ∏ ÂÚ›Ô‰Ô˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Â›Ó·È Ë ÂÊ˂›·, ηıÒ˜ Ë ÌÂÁ¿ÏË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË (growth spurt) Î·È Ë Û˘Ó·ÎfiÏÔ˘ıË ·‡ÍËÛË Ù˘ Ì˘˚΋˜ ÙÔ˘˜ Ì¿˙·˜ ‰ËÌÈÔ˘ÚÁ› Û˘Óı‹Î˜ ÂÈ‚¿Ú˘ÓÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÂÍ¿ÓÙÏËÛ˘ ÙˆÓ (ÌÈÎÚÒÓ) ÂʉÚÂÈÒÓ Ù˘. ¢È·Ì·Úٛ˜ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ∏ ¤ÏÏÂÈ„Ë Ù˘ ÂÚÈÊÂÚÈ΋˜ ÌÔ›Ú·˜ Ù˘ Ô˘Ú‹ıÚ·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙÔÓ ˘ÔÛ·‰›· Â›Ó·È Â·ÓÔÚıÒÛÈÌË Û ÔÛÔÛÙfi Ô˘ ÏËÛÈ¿˙ÂÈ ÙÔ 80-90% Ì ÙȘ ˘¿Ú¯Ô˘Û˜, ÂÓ ¯Ú‹ÛÂÈ, Ù¯ÓÈΤ˜ (9). ™‡Ìʈӷ Ì ٷ ˘ÊÈÛÙ¿ÌÂÓ· ¯ÂÈÚÔ˘ÚÁÈο ÎÚÈÙ‹ÚÈ·, ÂÈÙ˘¯‹˜ ıˆÚÂ›Ù·È Ë ·ÔηٿÛÙ·ÛË fiÙ·Ó ÂÈÙ¢¯ı› Ë ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ¤Íˆ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙË ‚¿Ï·ÓÔ, Ô Â˘ıÂÈ·ÛÌfi˜ ÙÔ˘ Ê·ÏÏÔ‡ Î·È Ë Û˘ÓÔÏÈ΋ ·ÈÛıËÙÈ΋ ‚ÂÏÙ›ˆÛ‹ ÙÔ˘ Ì ÙË Û˘ÌÌÂÙÚÈ΋ ‰È·ÌfiÚʈÛË Ù˘ fiÛı˘ Ô˘ ηχÙÂÈ ÙË Ú·¯È·›· Î·È ÙËÓ ÎÔÈÏȷ΋ ÂÈÊ¿ÓÂÈ· ÙÔ˘ Ê·ÏÏÔ‡. ŸÌˆ˜,
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·˘Ùfi Ô˘ ıˆÚÂ›Ù·È “·ÓÙÈÎÂÈÌÂÓÈο” ÂÈÙ˘¯¤˜ ‰ÂÓ Ù·ÈÚÈ¿˙ÂÈ ¿ÓÙÔÙ Ì ÙËÓ ˘ÔÎÂÈÌÂÓÈ΋ ·ÓÙ›ÏË„Ë ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô˘ ÔÏϤ˜ ÊÔÚ¤˜ ÚÔÛ·ı› Ó· ·ÔÛȈ‹ÛÂÈ ÙËÓ “·Ù¤ÏÂÈ¿” ÙÔ˘ fiˆ˜ ÂΛÓÔ˜ ÙË ‚ÈÒÓÂÈ. ∏ ÛȈ‹ ·˘Ù‹ ÌÔÚ› Ó· ÌÂÙ·Ùڷ› ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ Û ·ÔÌfiÓˆÛË Î·È ¿ÚÓËÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÛÂÍÔ˘·ÏÈÎÒÓ Û¯¤ÛˆÓ. OÈ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÂÊ‹‚Ô˘˜ ‹ Ó¤Ô˘˜ ÂÓ‹ÏÈΘ ¿Ó‰Ú˜ Ô˘ ¤¯Ô˘Ó ¯ÂÈÚÔ˘ÚÁËı› ÁÈ· ˘ÔÛ·‰›· Î·È ‰ÈÂÚ¢ÓÔ‡Ó ÙÔ Â˘·›ÛıËÙÔ ·˘Ùfi ÛËÌÂ›Ô Û·Ó›˙Ô˘Ó. ™Â Ì›· ÌÂϤÙË Ô˘ ·Ó·ÎÔÈÓÒıËΠÙÔ 1999 ÛÙÔ ∂˘Úˆ·˚Îfi O˘ÚÔÏÔÁÈÎfi ™˘Ó¤‰ÚÈÔ, Ô˘ ·ÊÔÚÔ‡Û 18 ¿Ó‰Ú˜ ËÏÈΛ·˜ >18 ÂÙÒÓ Ô˘ ›¯·Ó ¯ÂÈÚÔ˘ÚÁËı› ÁÈ· ˘ÔÛ·‰›·, ÂÓÒ ÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ·ÓÙÈÎÂÈÌÂÓÈο ÎÚ›ıËΠÂÈÙ˘¯¤˜ ÛÙÔ˘˜ 15/18, fiÙ·Ó ÚˆÙ‹ıËÎ·Ó ÔÈ ›‰ÈÔÈ ÔÈ ¯ÂÈÚÔ˘ÚÁËı¤ÓÙ˜ Â’ ·˘ÙÔ‡, Ë ·¿ÓÙËÛË ‹Ù·Ó ıÂÙÈ΋ ÌfiÓÔ ÛÙÔ˘˜ 3/18. ∂›Ó·È ۷ʤ˜ fiÙÈ Ë ·fiÎÏÈÛË ÌÂٷ͇ ·ÓÙÈÎÂÈÌÂÓÈ΋˜ Î·È ˘ÔÎÂÈÌÂÓÈ΋˜ ÂÈÙ˘¯›·˜ Â›Ó·È ÌÂÁ¿ÏË Î·È ·Ó·ÌÊÈÛ‚‹ÙËÙ· ÁÈ· ÙÔÓ ¿Û¯ÔÓÙ· ‚·Ú‡ÓÔ˘Û· ÛËÌ·Û›· ¤¯ÂÈ Ë ÚÔÛˆÈ΋ ·›ÛıËÛ‹ ÙÔ˘ ÁÈ· ÙÔ ÙÈ Â›Ó·È ÂÈÙ˘¯¤˜ Î·È ¿Ú· ·Ô‰ÂÎÙfi. £· ˘¿ÚÍÂÈ ·ÎfiÌË ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ô˘ ı· ÊÙ¿ÛÔ˘Ó ÛÙËÓ ÂÊ˂›· ¯ˆÚ›˜ Ô ˘ÔÛ·‰›·˜ ÙÔ˘˜ Ó· ¤¯ÂÈ ‰ÈÔÚıˆı›, ÂȘ ›ÛÌ· ·ÓÂÈÏËÌÌ¤ÓˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ·ÚÂÌ‚¿ÛˆÓ. OÈ ¤ÊË‚ÔÈ ·˘ÙÔ› ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÈϤÔÓ ÙˆÓ „˘¯ÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·È ÙȘ ÂÈÏÔΤ˜ Ù˘ ·ÔÙ˘¯Ë̤Ó˘ Ô˘ÚËıÚÔÏ·ÛÙÈ΋˜, ÂÓÒ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ÂÚ·ÈÙ¤Úˆ ÚÔÛ¿ıÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‰ÈfiÚıˆÛ˘ ÌÂ Û˘¯Ó¿ ›ÔÓ˜ Î·È ÔχÏÔΘ Ù¯ÓÈΤ˜ (¶›Ó·Î·˜ 4). ™˘ÌÂÚ¿ÛÌ·Ù· ∆Ô Ì‹Ó˘Ì· ·fi ÙËÓ ·ÚÔ‡Û· ÂÈÛ‹ÁËÛË ‰ÂÓ Ú¤ÂÈ Ó· ıˆÚËı› ··ÈÛÈfi‰ÔÍÔ. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Û˘ÁÁÂÓ›˜ Ô˘ÚÔÏÔÁÈΤ˜ Î·È ÁÂÓÓËÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ ¤¯ÂÈ, Â˘Ù˘¯Ò˜, ·Á·ı‹ ÚfiÁÓˆÛË Î·È ÔÌ·Ï‹ ÂͤÏÈÍË. ∆· ÚÔ‚Ï‹Ì·Ù· Ô˘ ı›ÁÔÓÙ·È Â‰Ò ·ÊÔÚÔ‡Ó ÌÈ· ÂÚÈÔÚÈṲ̂ÓË ·ÚÈıÌËÙÈο ÔÌ¿‰· ·ÛıÂÓÒÓ, fï˜ ÏfiÁˆ Ù˘ ȉÈÔÌÔÚÊ›·˜ ÙÔ˘˜ ¯ÚÂÈ¿˙ÔÓÙ·È ÚÔ‚ÏËÌ·ÙÈÛÌfi, ÂÚ›Û΄Ë, ˘ÔÌÔÓ‹ Î·È Û‡ÓÂÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜, Ë ‚Ô‹ıÂÈ· ÂΠ̤ÚÔ˘˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ı· Â›Ó·È ÔχÙÈÌË, ηıÒ˜ Ô ¶›Ó·Î·˜ 4. ™˘Ó¤ÂȘ ÂÈÂÏÂÁ̤ÓÔ˘ ˘ÔÛ·‰›· -
™˘Ú›ÁÁÈÔ Ô˘Ú‹ıÚ·˜ ∫¿Ì„Ë Ê·ÏÏÔ‡ (¯ÔÚ‰‹) ∞Û‡ÌÌÂÙÚË - ·Î·Ï·›ÛıËÙË Î·Ù·ÓÔÌ‹ fiÛı˘ ™Ù¤ÓˆÌ· Ô˘Ú‹ıÚ·˜ ∂ÎÎfiψ̷ Ô˘Ú‹ıÚ·˜ ∞Ó¿Ù˘ÍË ÙÚȯÒÓ Ì¤Û· ÛÙËÓ Ô˘Ú‹ıÚ·
¶·È‰È·ÙÚÈ΋ 2001;64:395-399
›‰ÈÔ˜, ¤¯ÔÓÙ·˜ Ì·ÎÚÔ¯ÚfiÓÈ· ·ʋ Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘˜, ÌÔÚ›, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ, Ó· Û˘˙ËÙ‹ÛÂÈ ¿ÌÂÛ· ÙÔ Úfi‚ÏËÌ·, Ó· ‰ÒÛÂÈ ‰È¤ÍÔ‰Ô ÛÙÔ ¿Á¯Ô˜ Ô˘ Û›ÁÔ˘Ú· ˘¿Ú¯ÂÈ Î·È Ó· ÚÔÂÙÔÈÌ¿ÛÂÈ ÙÔ ¤‰·ÊÔ˜ ÛÙÔ ÔÔ›Ô ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ı· ÚÔÛÁÂȈıÔ‡Ó Ì ·ÛÊ¿ÏÂÈ·, ·ÊÔ‡ ÂÚ¿ÛÔ˘Ó Ì¤Û· ·fi ÙË ÌÂÁ¿ÏË Î·Ù·ÈÁ›‰· Ô˘ ϤÁÂÙ·È ∂Ê˂›· (10).
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µÈ‚ÏÈÔÁÚ·Ê›· 1. ∞Ó‰ÚÔ˘Ï·Î¿Î˘ º∞. ™˘Ó‹ıË ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ·ÓÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ¢ÂÏÙ ∞’ ¶·È‰È·ÙÚ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1998;45:172-179. 2. Yerkes EB, Rink RC, Pope JC, Brock JW, Adams MC. How well do exstrophy patients actually void? [abstract]. J Urol 2000;163:618. 3. Williams DI. Epispadias and exstrophy. In: Eckstein HB, Hohenfellner R, Williams, eds. Surgical Pediatric Urology. Stuttgart: Thieme Verlag; 1977. p. 298-312. 4. ∞Ó‰ÚÔ˘Ï·Î¿Î˘ º∞. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙËÓ ¶·È‰ÔÔ˘ÚÔÏÔÁ›·. ∂ηÙfi ¯ÚfiÓÈ· ÌÂÙ¿. ∞گ›· ∂ÏÏËÓ π·ÙÚÈ΋˜ 1997;14:38-46. 5. °È·ÓÓ·ÎfiÔ˘ÏÔ˜ ™, °ÎÈ¿Ï·˜ π, ™ÎÔ‡ÏԢη˜ ª, ™ÙÂÊ·Ó›‰Ë˜
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∞, ªÈ¯·‹Ï µ, ∞Ó‰ÚÔ˘Ï·Î¿Î˘ º∞. ¢È‡ڢÓÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ Ì ԢÚËÙ‹Ú·. OÈ ÚÒÙ˜ ÂÌÂÈڛ˜. ∂ÏÏËÓ O˘ÚÔÏÔÁ›· 1997;9:375-379. Stjernqvist K, Kockum-Clementson C. Bladder exstrophy: psychological impact during childhood. J Urol 1999;162:2125-2129. Kryger JV, Gonsalez R, Barthold JS. Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol 2000;163:256-263. ™ÙÂÊ·Ó›‰Ë˜ ∞, ∫ÔÚÈÙÛÈ¿‰Ë˜ ™, ªÈ¯·‹Ï µ, ∞Ó‰ÚÔ˘Ï·Î¿Î˘ º∞. O˘ÚÔ‰˘Ó·ÌÈο Â˘Ú‹Ì·Ù· Û ·ÛıÂÓ›˜ Ì ·ÏȤ˜ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜. ∞گ›· ∂ÏÏËÓ π·ÙÚÈ΋˜ 1998;15:448-455. ∞Ó‰ÚÔ˘Ï·Î¿Î˘ º∞. ∂ÍÂÏ›ÍÂȘ ÛÙËÓ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ˘ÔÛ·‰›·. ∆È ÔÊ›ÏÂÈ Ó· ÁÓˆÚ›˙ÂÈ Ô ·È‰›·ÙÚÔ˜; ¢ÂÏÙ ∞’ ¶·È‰È·ÙÚ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1999;46:158-164. Woodhouse CRJ. Adolescent Urology. [editorial]. BJU Internat 1999;83(Suppl 3):iv.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: º›ÏÈÔ˜ ∞. ∞Ó‰ÚÔ˘Ï·Î¿Î˘ πˆ¿ÓÓÔ˘ °ÂÓÓ·‰›Ô˘ 14∞, 115 21, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¶ÔÚʇڷ ÙÔ˘ Henoch-Schonlein Û ·ÛıÂÓ›˜ Ì ÙÔ Û‡Ó‰ÚÔÌÔ Wiskott-Aldrich1 ∂ÈÛ·ÁˆÁ‹: To Û‡Ó‰ÚÔÌÔ Wiskott-Aldrich (WAS) Â›Ó·È Ì›· Û¿ÓÈ· ÓfiÛÔ˜ ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ·Ó·ÛÔ·Ó¿ÚÎÂÈ·˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÏÏÈ‹ ÁÏ˘ÎÔ˙ËÏ›ˆÛË Ù˘ ÛÈ·ÏÔÊÔÚ›Ó˘ (CD 43). AÓ Î·È Ë ÓÂÊÚÈ΋ ÚÔÛ‚ÔÏ‹ ‰ÂÓ Â›Ó·È Û˘¯Ó‹, ÂÓÙÔ‡ÙÔȘ ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÊÚÔ¿ıÂÈ·˜ Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È ·˘Ù‹˜ Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜. H ·ÓˆÌ·Ï›· Ù˘ ÁÏ˘ÎÔ˙ËÏ›ˆÛ˘ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ IgA ÓÂÊÚÔ¿ıÂÈ·˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 8 ÂÙÒÓ Ì ۇӉÚÔÌÔ Wiskott-Aldrich Ô˘ ÂÌÊ¿ÓÈ˙ ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ÔÚʇڷ˜ ÙÔ˘ Henoch-Schonlein Ì ÓÂÊÚÈ΋ Û˘ÌÌÂÙÔ¯‹, ÌÂÙ¿ ·fi ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÂȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™˘ÌÂÚ¿ÛÌ·Ù·: AÓ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÁÏ˘ÎÔ˙ËÏ›ˆÛ˘ ·Ú·ÙËÚÔ‡ÓÙ·È Î·È ÛÙ· ‰‡Ô ÓÔÛ‹Ì·Ù·, ·Ú' fiÏ· ·˘Ù¿ ı· Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ (ÁÂ-
ÓÂÙÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÈÎÔ›) Ô˘ Èı·ÓÒ˜ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙË Û¿ÓÈ· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ÓfiÛˆÓ (WAS Î·È ÔÚʇڷ ÙˆÓ Henoch-Schonlein).
1 Duzova A, Topaloglu R, Sanal O, Kilic S, Mazza C, Besbas N, Bakkaloglu A Henoch-Schonlein purpura in Wiskott-Aldrich syndrome Pediatr Nephrol 2001;16:500-502
Z. ¶··‰ÔÔ‡ÏÔ˘-KÔ˘ÏÔ˘Ì‹
399
¶·È‰È·ÙÚÈ΋ 2001;64:400-405
∂º∏µπ∫∏ π∞∆ƒπ∫∏
Paediatriki 2001;64:400-405
ADOLESCENT MEDICINE
ºÏÂÁÌÔÓ¤˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ı‹ÏÂÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∂. ¢ÂÏËÁÂÒÚÔÁÏÔ˘
Infections of the female lower genital tract during childhood E. Deligeoroglou
¶ÂÚ›ÏË„Ë: OÈ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ı‹ÏÂÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜ Î·È ÌÂÏÂÙÒÓÙ·È Ì ÙÔÓ fiÚÔ ·È‰ÔÈÔÎÔÏ›Ùȉ˜. ∞ÊÔÚÔ‡Ó ÙÔ 87% ÂÚ›Ô˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·fi Ù· Á˘Ó·ÈÎÔÏÔÁÈο fiÚÁ·Ó· Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ ËÏÈΛ· ÌÂٷ͇ 2 Î·È 7 ¯ÚfiÓˆÓ, ¤¯ÔÓÙ·˜ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ¤ÌÌËÓÔ Ú‡ÛË. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ Â›Ó·È Ë ·Ô˘Û›· ÔÈÛÙÚÔÁfiÓˆÓ, ÙÔ ÏÂÙfi ·ÙÚÔÊÈÎfi ÂÈı‹ÏÈÔ ÙÔ˘ ÎfiÏÔ˘ Ì Ԣ‰¤ÙÂÚÔ pH, Ë ·Ô˘Û›· ÙÚȯÒÛˆ˜ ÛÙÔ ÂÊ‹‚·ÈÔ Î·È Ë ÛÙÂÓ‹ ·Ó·ÙÔÌÈ΋ Û¯¤ÛË ÎfiÏÔ˘, ·È‰Ô›Ô˘ Î·È ÚˆÎÙÔ‡. ªÂÁ¿ÏË ÛËÌ·Û›· ¤¯ÂÈ Ë ÙÔÈ΋ ηı·ÚÈfiÙËÙ· Ù˘ ÂÚÈÔ¯‹˜ Î·È ÁÂÓÈο Ë Ù‹ÚËÛË ÙˆÓ Î·ÓfiÓˆÓ ˘ÁÈÂÈÓ‹˜ Ô˘ Û˘Ó‰˘¿˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ‰È¿ÎÚÈÛË ÙˆÓ ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ Û ÌË ÌÔÏ˘ÛÌ·ÙÈ΋˜ Î·È ÌÔÏ˘ÛÌ·ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÙÚfiÔ˘ Î·È ÙÔ˘ ›‰Ô˘˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∏ Û˘Ìو̷ÙÔÏÔÁ›· Ô˘ Û˘Óԉ‡ÂÈ ÙË ÊÏÂÁÌÔÓÒ‰Ë ‰ÈÂÚÁ·Û›· ÛÙÔ ·È‰Ô›Ô Î·È ÙÔÓ ÎfiÏÔ Â›Ó·È ¿ÏÏÔÙ ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË ÔÈΛÏÔ˘ ‚·ıÌÔ‡, ‰‡ÛÔÛÌË ‹ fi¯È, ÂÚ‡ıËÌ·, η‡ÛÔ˜, ‰˘ÛÔ˘Ú›·, ¿ÏÁÔ˜ Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÎÔÏÈ΋ ·ÈÌfiÚÚÔÈ·. ∏ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ÈÛÙÔÚÈÎfi, ÎÏÈÓÈ΋ ÂͤٷÛË, ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô (ηÏÏȤÚÁÂÈ· ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡, ·Ó›¯Ó¢ÛË ¯Ï·Ì˘‰›ˆÓ, Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜), ·ÚıÂÓÔÛÎfiËÛË Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜. ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ Â›Ó·È ·ÈÙÈÔÏÔÁÈ΋ Î·È ‚¿ÛÂÈ ÚÔËÁËı¤ÓÙÔ˜ ·ÓÙÈ‚ÈÔÁÚ¿ÌÌ·ÙÔ˜, ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ηÈ
Abstract: Infection of the female lower genital tract is a common disease during childhood. It has been estimated that this condition is found in 85% of all gynecologic problems seen in this period of life. It is observed more frequently in patients between 2 and 7 years of age. The vulva and vagina of the child are sensitive because of the absence of estrogenic activity, the close anatomical relationship between the vagina, the vulva and the rectum and other physiologic factors. Infection in the vulva during childhood is primary with secondary localization in the vagina. Clinical features of patients with this type of infection are: vaginal discharge, erythema, pruritus, dysuria, pain, edema, adhesion of labia minora and vaginal spotting. The diagnostic approach includes: medical history, physical examination, laboratory tests, vaginoscopy and imaging diagnostic procedures. Management of vulvovaginitis in the newborn and in childhood presents several problems. Administration of antibiotics must be justified and given only after isolation and identification of the offending pathogen, according to the sensitivity test. Correct and effective treatment is necessary to ensure that the disease will not relapse. Reassuring the patient and her parents, and informing them of preventive measures are very important.
ª·ÈÂ˘Ù‹Ú - °˘Ó·ÈÎÔÏfiÁÔ˜ - ∂ȉÈÎfi˜ ¶·È‰ÔÁ˘Ó·ÈÎÔÏfiÁÔ˜ §¤ÎÙˆÚ ª·È¢ÙÈ΋˜ - °˘Ó·ÈÎÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ µ’ ª·È¢ÙÈ΋ - °˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ∆Ì‹Ì· ¶·È‰È΋˜-∂ÊË‚È΋˜ °˘Ó·ÈÎÔÏÔÁ›·˜ Î·È ∂·ÓÔÚıˆÙÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜, “∞ÚÂÙ·›ÂÈÔ” ¡ÔÛÔÎÔÌ›Ô, ∞ı‹Ó·
Special Pediatric Gynecologist 2nd Department of Obstetrics and Gynecology Division of Pediatric - Adolescent Gynecology and Reconstructive Surgery of the University of Athens “Aretaieio” Hospital, Athens
400
¶·È‰È·ÙÚÈ΋ 2001;64:400-405
Paediatriki 2001;64:400-405
ÎÔÏÈ΋ ¯ÔÚ‹ÁËÛË Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ. ™ËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙË ıÂڷ›· Î·È ÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ Â›Ó·È Ë ÈÛÙ‹ Ù‹ÚËÛË ÙˆÓ Î·ÓfiÓˆÓ ˘ÁÈÂÈÓ‹˜ ·fi ÙÔ ·È‰› Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘. ªÂ ÛˆÛÙ‹ ÂÓË̤ڈÛË Î·È ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂڷ›· ·ÔʇÁÂÙ·È Ë ·ÓÈÔ‡Û· ¯ÚfiÓÈ· Ïԛ̈ÍË ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ì ·ÒÙÂÚÔ ÛÎÔfi ÙÔ ÛËÌÂÚÈÓfi ·È‰› Ó· ¤¯ÂÈ ¤Ó· ¿ÚÈÛÙÔ ·Ó··Ú·ÁˆÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙË ÌÂÙ¤ÂÈÙ· ÂÓ‹ÏÈÎË ˙ˆ‹ ÙÔ˘. §¤ÍÂȘ ÎÏÂȉȿ: ÔÈÛÙÚÔÁfiÓ·, ÊÏÂÁÌÔÓ¤˜, ÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ·, ·È‰È΋ ËÏÈΛ·, ıÂڷ›·, ·Ó··Ú·ÁˆÁ‹.
Key words: estrogens, infections, genital tract, childhood, treatment, reproduction.
∂ÈÛ·ÁˆÁ‹ OÈ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙË Ó·ڋ ËÏÈΛ· ÂÓÙÔ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ÛÙÔ ·È‰Ô›Ô, ÛÙÔÓ ÎfiÏÔ Î·È Û Ôχ ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ÛÙȘ Û¿ÏÈÁÁ˜. ∂Í·ÚÙÒÓÙ·È ·fi Ù· ›‰· ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ, ÙËÓ ‡·ÚÍË ‹ fi¯È ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ Î·È Ù¤ÏÔ˜ ·fi ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÛÂÍÔ˘·ÏÈÎÒÓ Â·ÊÒÓ fiÙ·Ó ˘¿Ú¯Ô˘Ó, ÂÓÒ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ·›˙Ô˘Ó ÔÈ ·ÓÙÈÛ˘ÏÏËÙÈΤ˜ ̤ıÔ‰ÔÈ. π‰È·›ÙÂÚË ÛËÌ·Û›· ‰›‰ÂÙ·È ÛÙȘ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ·È‰Ô›Ô˘ Î·È ÙÔ˘ ÎfiÏÔ˘ ÛÙÔ Ó·Úfi ÎÔÚ›ÙÛÈ ÛÙËÓ ËÏÈΛ· ÚÈÓ ÙËÓ ÂÌÌËÓ·Ú¯‹, ÔÈ Ôԛ˜ ÌÂÏÂÙÒÓÙ·È Ì ÙÔÓ fiÚÔ ·È‰ÔÈÔÎÔÏ›Ùȉ˜ Î·È ·Ó·Ï‡ÔÓÙ·È ÛÙË Û˘Ó¤¯ÂÈ·. ∏ ÁÓÒÛË Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ Î·È Ù˘ ·Ó·ÙÔÌ›·˜ ÙÔ˘ ÎfiÏÔ˘ ÛÙÔ ÎÔÚ›ÙÛÈ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ ÛÙËÓ ËÏÈΛ· ·˘Ù‹. O ÎfiÏÔ˜ (ÂÈı‹ÏÈÔ) ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÎÔÚÈÙÛÈÔ‡ Â›Ó·È ·¯‡˜, ÏfiÁˆ Ù˘ ›‰Ú·Û˘ ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Î·È ‰È·Ê¤ÚÂÈ ·fi ÂΛÓÔÓ ÙˆÓ ÂÓËÏ›ÎˆÓ ÌfiÓÔ ÛÙÔ fiÙÈ ‰ÂÓ ¤¯ÂÈ ÂÈÔÏ‹˜ ÛÙÈ‚¿‰·. ∆Ô ·È‰Ô›Ô ÙÔ˘ ÓÂÔÁÓÔ‡ Â›Ó·È ·Ó·Ù˘Á̤ÓÔ Î·È ÁÂÓÈο ÙÔ ‰¤ÚÌ· ÙÔ˘ Â›Ó·È ·¯‡ Î·È ÂÏ·ÛÙÈÎfi, ÏfiÁˆ ›Û˘, Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ‰Ú¿Û˘ ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ. ∆Ô pH ÙÔ˘ ÎfiÏÔ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Â›Ó·È 5,7 ÙËÓ ÚÒÙË Ë̤ڷ, 5,6 ÙË ‰Â‡ÙÂÚË, 4,9 ÙËÓ ÙÚ›ÙË Î·È 4,8 ÙËÓ Ù¤Ù·ÚÙË Ë̤ڷ. ªÂ ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ Á›ÓÂÙ·È ·ÏηÏÈÎfi Î·È Û 2-6 ‚‰ÔÌ¿‰Â˜ ÛÙ·ıÂÚÔÔÈÂ›Ù·È ÛÙÔ 7,0-7,5 ¤ˆ˜ Î·È 8,0, ÂÓÒ ·Ú·Ì¤ÓÂÈ ÛÙ· ›‰· ·˘Ù¿ ̤¯ÚÈ ÙËÓ ‹‚Ë. ∫·Ù¿ ÙËÓ ‹‚Ë, Ì ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜, ÙÔ pH ÂÏ·ÙÙÒÓÂÙ·È Û Ôχ ¯·ÌËÏ¿ ›‰· (3,5-4,5). ™ÙË Û˘Ó¤¯ÂÈ·, Ë ÙÈÌ‹ Î˘Ì·›ÓÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ (1-4). ∫·ÏÏȤÚÁÂȘ ÙÔ˘ ÎÔÏÈÎÔ‡ ˘ÁÚÔ‡ ÛÙÔ ÓÂÔÁÓfi ¤‰ÂÈÍ·Ó fiÙÈ ÛÙȘ 12 ÚÒÙ˜ ÒÚ˜ ÙÔ ÎÔÏÈÎfi ˘ÁÚfi Â›Ó·È ÛÙ›ÚÔ ÌÈÎÚÔ‚›ˆÓ. ªÂÙ¿ ÙËÓ ¿ÚÔ‰Ô 24
ˆÚÒÓ, ·Ó¿ÏÔÁ˜ ηÏÏȤÚÁÂȘ ¤‰ÂÈÍ·Ó ÙËÓ ·ÚÔ˘Û›· ÔÚÈÛÌ¤ÓˆÓ ÌÈÎÚÔ‚›ˆÓ Î·È ÌÂÙ¿ ·fi 48 ÒÚ˜ ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ‚·Î›ÏˆÓ Doderlein. OÈ Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Doderlein ÚÔηÏÔ‡Ó ÙËÓ Ô͇ÙËÙ· ÛÙÔÓ ÎfiÏÔ. ™ÙȘ ÚÒÙ˜ 48 ÒÚ˜, Ë Ô͇ÙËÙ· ÙÔ˘ pH ÙÔ˘ ÎfiÏÔ˘ ÔÊ›ÏÂÙ·È Â›Û˘ Î·È ÛÙÔ ¤Ó˙˘ÌÔ ÁÏ˘ÎÔÁÂÓ¿ÛË, ÙÔ ÔÔ›Ô ÌÂÙ·ÙÚ¤ÂÈ ÙÔ ÁÏ˘ÎÔÁfiÓÔ Û ÁÏ˘Îfi˙Ë. ∏ ·ÚÔ˘Û›· ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ‰È·ÈÛÙÒıËΠÛÙÔ ÎÔÏÈÎfi ˘ÁÚfi Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, Û ‰È¿ÊÔÚË ˘ÎÓfiÙËÙ· Î·È ·ÚÈıÌfi (4-6). ∫¿ı ÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÛÙË Ê˘ÛÈÔÏÔÁ›· ÙÔ˘ ÎfiÏÔ˘ Úԉȷı¤ÙÂÈ ÛÂ Û˘Ìو̷ÙÈ΋ ·‡ÍËÛË Ù˘ ÎÔÏÈ΋˜ ÂÎÎÚ›Ûˆ˜, Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ÌÂÙ·‚ÔÏ‹˜ Ù˘ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÎfiÏÔ˘. OÈ Fraenkel Î·È Papanicolaou (1937) ‹Ù·Ó ÔÈ ÚÒÙÔÈ Ô˘ ÂÂÛ‹Ì·Ó·Ó ÙȘ ·ÏÏ·Á¤˜ ÛÙ· ·ÔÊÔÏȉˆÌ¤Ó· ·ÙÙ·Ú· ÙÔ˘ ÎfiÏÔ˘ ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÎÔÚÈÙÛÈÔ‡ Î·È ÛÙËÓ ÂÌÌËÓfi·˘ÛË. OÈ Û˘ÁÁÚ·Ê›˜ ·Ú·Ù‹ÚËÛ·Ó fiÙÈ ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰·, Ù· ·ÔÊÔÏȉˆÌ¤Ó· ·ÙÙ·Ú· ‹Ù·Ó Û˘Ì·Á‹ ÛÙÚÔÁÁ˘Ï¿ ‹ ˆÔÂȉ‹ Î·È ¤ÌÔÈ·˙·Ó Ì ·˘Ù¿ Ù˘ ÎÏÈÌ·ÎÙËÚ›Ô˘, Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ ·Ú¯‹ ·ÙÚÔÊ›·˜ ÙÔ˘ ÎfiÏÔ˘. ªÂÙ¿ ·fi 15 Ë̤Ú˜ ‚Ú‹Î·Ó ¿Ù˘· ‹ ÌÂÙ·‚·ÙÈο ·ÙÙ·Ú· ÙÔ˘ ÎÔÏÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È fiÙÈ Ë ·Ú·‚·ÛÈ΋ ÛÙÈ‚¿‰· ‹Ù·Ó ÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙˆÓ ÌÈÛÒÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ÂÍ¤Ù·Û·Ó (3,6,7). ∏ ·ÚÔ˘Û›· ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘ ÛÙÔÓ ÎfiÏÔ ‰È·Ê¤ÚÂÈ ÛÙË ÓÂÔÁÓÈ΋, ÚÔÂÊË‚È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ∏ ·ÚÔ˘Û›· ‹ fi¯È ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘ ÛÙÔÓ ÎfiÏÔ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙȘ ·ÏÏ·Á¤˜ ÙÔ˘ ÎÔÏÈÎÔ‡ pH. ∆Ô ÁÏ˘ÎÔÁfiÓÔ Â˘Ú›ÛÎÂÙ·È ÛÙ· ÎÔÏÈο ·ÙÙ·Ú· Î·È ·ÂÏ¢ıÂÚÒÓÂÙ·È Î·Ù¿ ÙËÓ ·fiÙˆÛ‹ ÙÔ˘˜. ∂Âȉ‹ Ë ·fiÙˆÛË ÙˆÓ ÎÔÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÂËÚ¿˙ÂÙ·È ·fi ÙȘ ‰È·Î˘Ì¿ÓÛÂȘ Ù˘ ¤ÎÎÚÈÛ˘ ÔÈÛÙÚÔÁfiÓˆÓ, ·ÓÙ›ÛÙÔȯ˜ ‰È·Î˘Ì¿ÓÛÂȘ ˘Ê›ÛÙ·Ù·È Î·È Ë ˘ÎÓfiÙËÙ· ÙÔ˘ ÎÔÏÈÎÔ‡ ÁÏ˘ÎÔÁfiÓÔ˘. ™˘ÁÎÂÎÚÈ̤ӷ, Â›Ó·È ÛËÌ·ÓÙÈ΋ ηٿ ÙË Á¤ÓÓËÛË, ̤ÁÈÛÙË
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¶·È‰È·ÙÚÈ΋ 2001;64:400-405
ηٿ ÙËÓ ˆÔı˘Ï·ÎÈÔÚÚËÍ›· Î·È ÂÏ¿¯ÈÛÙË Î·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ηıÒ˜ Î·È ÌÂÙ¿ ÙËÓ ÂÌÌËÓfi·˘ÛË (5,8,9). À¿Ú¯Ô˘Ó ÔÏÏÔ› ÔÚÁ·ÓÈÛÌÔ› Ô˘ ÂÓ‰ËÌÔ‡Ó ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÙÔ˘ ÎfiÏÔ˘, fiˆ˜ Staphylococcus epidermidis, diphtheroids, ÔÈ Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Î·È ·Ó·ÂÚfi‚ÈÔÈ, fiˆ˜ Ù· Bacteroides. OÈ Ì‡ÎËÙ˜ ÙÔ˘ Á¤ÓÔ˘˜ candida Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Ïԛ̈͢ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· Î·È ÁÂÓÈο ÛÙȘ Á˘Ó·›Î˜. OÈ Ì‡ÎËÙ˜ candida albicans Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ Â›‰Ô˜ Ì˘Î‹ÙˆÓ, Ô˘ Û˘Ì‚ÈÒÓÂÈ Ì ÙÔÓ ¿ÓıÚˆÔ, Û˘¯Ó¿ Ì¿ÏÈÛÙ· ·ÔÌÔÓÒÓÂÙ·È ·fi ÙÔ ÛÙfiÌ· Î·È ÙÔ ·¯‡ ¤ÓÙÂÚÔ ˘ÁÈÒÓ ·ÙfiÌˆÓ (10-13). ∏ gardnerella vaginalis ÂÓ‰ËÌ› Û˘Ó‹ıˆ˜ ÛÙÔÓ ÎfiÏÔ Î·È Û¿ÓÈ· ÚÔηÏ› ·È‰ÔÈÔÎÔÏ›Ùȉ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·, fiˆ˜ ÚÔηÏ› Ôχ Û˘¯Ó¿ ÛÙȘ ÂÓ‹ÏÈΘ. ∂˘Ú›ÛÎÂÙ·È Û˘¯Ó¿ ÛÙȘ Á˘Ó·›Î˜ Ì ÌÂÁ¿ÏË ÛÂÍÔ˘·ÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Û Á˘Ó·›Î˜ Ì ÔÏÏÔ‡˜ Û˘ÓÙÚfiÊÔ˘˜, Û Á˘Ó·›Î˜ Ì ¿ÏÏ· ÛÂÍÔ˘·ÏÈο ÌÂÙ·‰È‰fiÌÂÓ· ÓÔÛ‹Ì·Ù· Î·È ÛÙȘ ¯·ÌËϤ˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ Ù¿ÍÂȘ. ∞fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· Ê·›ÓÂÙ·È fiÙÈ Ë gardnerella vaginalis Â›Ó·È ‰˘ÓËÙÈο ·ıÔÁfiÓÔ ÌÈÎÚfi‚ÈÔ, ÁÈ·Ù› ¤¯ÂÈ ‚ÚÂı› Î·È ÛÙ· ·È‰ÔÈÔÎÔÏÈο ÂȯڛÛÌ·Ù· ˘ÁÈÒÓ ·È‰ÈÒÓ, ËÏÈΛ·˜ 2 ÌËÓÒÓ ¤ˆ˜ 15 ¯ÚfiÓˆÓ, ¯ˆÚ›˜ Û˘ÌÙÒÌ·Ù· ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ (7,14-16). ∏ ÙÚȯÔÌÔÓ¿‰ˆÛË Â›Ó·È Î·È ·˘Ù‹ Û¯ÂÙÈο Û¿ÓÈ· Û ÎÔÚ›ÙÛÈ· ÚÈÓ ·fi ÙËÓ ‹‚Ë. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÙÚȯÔÌÔÓ·‰È΋˜ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ÛÙ· ÌÈÎÚ¿ ÎÔÚ›ÙÛÈ· ˘ÔÏÔÁ›˙ÂÙ·È Û 3% ÂÚ›Ô˘ Î·È ·˘Í¿ÓÂÙ·È ·Ú¿ÏÏËÏ· Ì ÙËÓ ·‡ÍËÛË Ù˘ ¤ÎÎÚÈÛ˘ ÔÈÛÙÚÔÁfiÓˆÓ. ∆· ÎÔÚ›ÙÛÈ· ÙˆÓ ÌËÙ¤ÚˆÓ Ì ÙÚȯÔÌÔÓ¿‰Â˜ ·ÔÈΛ˙ÔÓÙ·È Û ÔÛÔÛÙfi 2,5-5,0%. ∏ ÙÚȯÔÌÔÓ¿‰·, ÁÂÓÈο, ÚÔÙÈÌ¿ ÙÔÓ ÎfiÏÔ Ì ÔÈÛÙÚÔÁÔÓÈ΋ ›‰Ú·ÛË. ™˘Ó‹ıˆ˜ ÌÂÙ·‰›‰ÂÙ·È Ì ÙË ÛÂÍÔ˘·ÏÈ΋ ·ʋ Î·È Û¿ÓÈ· Ì ¿ÌÂÛË Â·Ê‹ (ÈÛ›Ó˜, Î.Ï.). O ¯ÚfiÓÔ˜ ˆ¿Ûˆ˜ Â›Ó·È 4-30 Ë̤Ú˜. ∏ trichomonas vaginalis ÂÓ‰ËÌ› Û˘¯Ó¿ ÛÙÔÓ ÎfiÏÔ, ÂÓÒ Ë trichomonas hominis ÛÙÔ ¤ÓÙÂÚÔ. ∏ chlamydia trachomatis ‰ÂÓ ·ÔÙÂÏ› Û˘¯Ófi ·›ÙÈÔ ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ ·È‰È΋˜, ÚÔÂÊË‚È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜. ∆· ÓÂÔÁÓ¿ Û˘Ó‹ıˆ˜ ÌÔχÓÔÓÙ·È ·fi ÙȘ ÌËÙ¤Ú˜ ÙÔ˘˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÎÔÏÈÎÔ‡ ÙÔÎÂÙÔ‡. ¶ÔÏÏÔ› ‰ÂÓ ‰¤¯ÔÓÙ·È fiÙÈ Ë chlamydia trachomatis ÚÔηÏ› ÎÔÏ›Ùȉ· Û ·ÙÚÔÊÈÎfi ÎÔÏÈÎfi ÂÈı‹ÏÈÔ (17,18). ∆Ô Ì˘ÎfiÏ·ÛÌ· ‰ÂÓ ·ÔÙÂÏ› Û¿ÓÈÔ ·›ÙÈÔ ·È‰ÔÈÔÎÔÏ›ÙȉˆÓ ÛÙËÓ ·È‰È΋ Î·È ÚÔÂÊË‚È΋ ËÏÈΛ·, ÔÚÈṲ̂ÓÔÈ ‰Â ÙÔ Û˘Ó‰˘¿˙Ô˘Ó Ì ÙË ÛÂÍÔ˘·ÏÈ΋ ηÎÔÔ›ËÛË ÙˆÓ ·È‰ÈÒÓ. ∆Ô Í¤ÓÔ ÛÒÌ· ·Ó¢ڛÛÎÂÙ·È ÛÂ Û˘¯ÓfiÙËÙ· ÂÚ›Ô˘ 25% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·È‰È΋˜ ËÏÈΛ·˜ Ì ·È‰ÔÈÔÎÔÏ›Ùȉ· Î·È Û˘Ó‹ıˆ˜ ÚfiÎÂÈÙ·È ÁÈ· ÙÂÌ¿¯È· ¯·ÚÙÈÔ‡
402
Paediatriki 2001;64:400-405
‹ ˘Ê¿ÛÌ·ÙÔ˜. ∏ ·ÚÔ˘Û›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔÓ ÎfiÏÔ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ Ì ‰‡ÛÔÛÌË ÎÔÏÈ΋ ˘ÂÚ¤ÎÎÚÈÛË Î·È ÛÙ·ÁÔÓÔÂȉ‹ ·ÈÌfiÚÚÔÈ·. ÷ڷÎÙËÚÈÛÙÈÎfi Ù˘ ˘ÂÚÂÎÎÚ›Ûˆ˜ Â›Ó·È fiÙÈ ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi ·ÚÎÂÙfi ηÈÚfi Î·È ‰ÂÓ ˘Ô¯ˆÚ› Ì ٷ ·ÓÙÈ‚ÈÔÙÈο. O haemophilus influenzae ÌÔÚ› Ó· ‚ÚÂı› Ê˘ÛÈÔÏÔÁÈο ÛÙÔ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi Û‡ÛÙËÌ· Ù˘ Á˘Ó·›Î·˜. OÈ ÊÏÂÁÌÔÓ¤˜ ·fi haemophilus influenzae Â›Ó·È ·Û˘Ó‹ıÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Û¿ÓÈ· Ô Èfi˜ ÚÔηÏ› ÎÔÏ›Ùȉ· (12,13,16,19,20). ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ, Ù¤ÏÔ˜, ÔÈ ·È‰ÔÈÔÎÔÏ›Ùȉ˜ Û˘Ó˘¿Ú¯Ô˘Ó ‹ Â›Ó·È Â·ÎfiÏÔ˘ı· Ì›·˜ ¿ÏÏ˘ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ Ë ˆÙ›Ùȉ·, ‚ÚÔÁ¯›Ùȉ· Î·È ·‰ÂÓ›Ùȉ·. ∏ ·È‰ÔÈ›Ùȉ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ Û‡ÌÌ˘ÛË ÙˆÓ ÌÈÎÚÒÓ ¯ÂÈϤˆÓ ÙÔ˘ ·È‰Ô›Ô˘. ∏ Û‡ÌÌ˘ÛË ÌÈÎÚÒÓ ¯ÂÈϤˆÓ Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙËÓ ËÏÈΛ· ÙˆÓ 2-6 ÂÙÒÓ Î·È Ú¤ÂÈ Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙ› ·fi ÙËÓ ·Ï·Û›· ‹ ·ÁÂÓÂÛ›· ÙÔ˘ ÎfiÏÔ˘ Î·È ÙËÓ ·ÙÚËÛ›· ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·. ™˘Ìو̷ÙÔÏÔÁ›· ∏ ÌÔÚÊ‹ Ì ÙËÓ ÔÔ›· ÂÌÊ·Ó›˙ÔÓÙ·È ÔÈ ·È‰ÔÈÔÎÔÏ›Ùȉ˜, ÔÍ›· ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û·, ¤¯ÂÈ ¿ÌÂÛË Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ™ÙÔ ÚˆÙfiÎÔÏÏÔ ‰È¿ÁÓˆÛ˘ Ù˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë Ï‹„Ë ÈÛÙÔÚÈÎÔ‡, Ë Ê˘ÛÈ΋ ÂͤٷÛË, Ô ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, Ë ·ÚıÂÓÔÛÎfiËÛË Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ̤ıÔ‰ÔÈ. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÊ·ÚÌfi˙ÂÙ·È ·Ó·ÏfiÁˆ˜ Ù˘ ÂÚ›ÙˆÛ˘ Î·È Û˘Ó›ÛÙ·Ù·È ÛÙË Ï‹„Ë ˘ÏÈÎÔ‡ ÁÈ· ηÏÏȤÚÁÂÈ· ·ÂÚfi‚ÈˆÓ Î·È ·Ó·ÂÚfi‚ÈˆÓ ·ıÔÁfiÓˆÓ ÌÈÎÚÔ‚›ˆÓ, ·Ó›¯Ó¢ÛË Ì˘ÎÔÏ·ÛÌ¿ÙˆÓ-¯Ï·Ì˘‰›ˆÓ Î·È Û ¤ÏÂÁ¯Ô ·Ì¤ÛÔ˘ ·Ú·Û΢¿ÛÌ·ÙÔ˜ ÁÈ· ÙÚȯÔÌÔÓ¿‰ˆÛË. ∞ÎÔÏÔ˘ı› ÁÂÓÈ΋ Ô‡ÚˆÓ, ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, ·Ú·ÛÈÙÔÏÔÁÈ΋ Î·È Î·ÏÏȤÚÁÂÈ· ÎÔÚ¿ÓˆÓ, ηıÒ˜ Î·È Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÎfiÏÔ˘ ηٿ ¶··ÓÈÎÔÏ¿Ô˘. ∏ Ï‹„Ë ˘ÏÈÎÔ‡ ÁÈ· ¶›Ó·Î·˜ 1. ∫ÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ∫ÔÏÈ΋ ÀÂÚ¤ÎÎÚÈÛË ·) OÚ҉˘ ‚) µÏÂÓÓ҉˘ Á) OÚÔ·ÈÌ·ÙËÚ‹ ∂Ú‡ıËÌ· ∫ÓËÛÌfi˜ ¢˘ÛÔ˘Ú›· ∂˘·ÈÛıËÛ›· ÎfiÏÔ˘ ÕÏÁÔ˜ O›‰ËÌ· ™‡ÌÌ˘ÛË ÌÈÎÚÒÓ ¯ÂÈϤˆÓ ∫ÔÏÈ΋ ·ÈÌfiÚÚÔÈ·
¶·È‰È·ÙÚÈ΋ 2001;64:400-405
ηÏÏȤÚÁÂÈ· ·fi ÙÔÓ ÎfiÏÔ Á›ÓÂÙ·È Ì ÂÈÛ·ÁˆÁ‹, ̤ۈ Ù˘ Ô‹˜ ÙÔ˘ ·ÚıÂÓÈÎÔ‡ ˘Ì¤Ó·, ÂÓfi˜ ·ÔÛÙÂÈڈ̤ÓÔ˘ ‚·Ì‚·ÎÔÊfiÚÔ˘ ÛÙ˘ÏÂÔ‡ ÌÈÎÚÔ‡ ‰È·ÌÂÙÚ‹Ì·ÙÔ˜. O ÛÙ˘ÏÂfi˜ Ú¤ÂÈ Ó· ·Ú·Ì›ÓÂÈ ÛÙÔÓ ÎfiÏÔ ÁÈ· ‚Ú·¯‡ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÒÛÙ ӷ ÂÌÔÙÈÛÙ› ·fi Ù· ˘ÁÚ¿ Ô˘ ˘¿Ú¯Ô˘Ó Û ·˘ÙfiÓ. ∏ ·ÚıÂÓÔÛÎfiËÛË ÂÎÙÂÏÂ›Ù·È Â› ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ ‹ ›ÌÔÓ˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜, ÎÔÏÈ΋˜ ·ÈÌfiÚÚÔÈ·˜ Î·È ˘Ô„›·˜ ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜, ÓÂÔÏ¿ÛÌ·ÙÔ˜ ‹ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜. ∏ ·ÚıÂÓÔÛÎfiËÛË ÚÔÛʤÚÂÈ ÏËÚ¤ÛÙÂÚÔ ¤ÏÂÁ¯Ô ÙÔ˘ ÎfiÏÔ˘ Î·È ÙÔ˘ ÙÚ·¯‹ÏÔ˘. ª¤Ûˆ Ù˘ Ô‹˜ ÙÔ˘ ÂÍÂÙ·ÛÙÈÎÔ‡ ۈϋӷ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÈÛ·¯ı› Ï·‚›‰· ‚ÈÔ„›·˜ ‹ ·Ê·›ÚÂÛ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜, ηıÒ˜ Î·È ‚·Ì‚·ÎÔÊfiÚÔ˜ ÛÙ˘ÏÂfi˜ ÁÈ· Ï‹„Ë ˘ÏÈÎÔ‡ ÁÈ· ηÏÏȤÚÁÂÈ· Î·È Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË. £Âڷ›· OÈ ·Ï¤˜ ÌÔÚʤ˜ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÌfiÓÔ Ì χÛÂȘ Ì ¯ÏÈ·Úfi ¯·ÌÔÌ‹ÏÈ. ∂ÈϤÔÓ, ÙËÚÔ‡ÓÙ·È ÔÈ Î·ÓfiÓ˜ ˘ÁÈÂÈÓ‹˜ Î·È ÂϤÁ¯ÂÙ·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ οÔÈ·˜ ÌfiÏ˘ÓÛ˘. ™ÙȘ ÛÔ‚·Ú¤˜ ÎÔÏ›Ùȉ˜, ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÂÈÙ˘Á¯¿ÓÔÓÙ·È fiÙ·Ó ·Ú¿ÏÏËÏ· Ì ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Á›ÓÂÙ·È Î·È ÙÔÈ΋ ıÂڷ›· Ì ÙÔ ›‰ÈÔ ·ÓÙÈ‚ÈÔÙÈÎfi. ∏ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Á›ÓÂÙ·È Ì ÂÓ‰ÔÎÔÏÈ΋ ¤Á¯˘ÛË, Ë ÔÔ›· Á›ÓÂÙ·È Ì ÂȉÈο Ú‡Á¯Ë ‹ Ì ÌÈ· ·Ï‹, ¯ˆÚ›˜ ‚ÂÏfiÓ·, Û‡ÚÈÁÁ·. ∏ ÂÓ‰ÔÎÔÏÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Á›ÓÂÙ·È ÁÈ· ‚Ú·¯‡ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÁÈ· ·ÔÊ˘Á‹ Èı·Ó‹˜ ηٷÛÙÚÔÊ‹˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÎfiÏÔ˘ (6). ∏ Ì˘ÎËÙÈ·ÛÈ΋ ÎÔÏ›Ùȉ· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙËÓ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÏÔÈÊ‹˜, Ë ÔÔ›· ÙÔÔıÂÙÂ›Ù·È Ì ÂȉÈÎfi Ú‡Á¯Ô˜ ̤۷ ÛÙÔÓ ÎfiÏÔ. ∂ÈϤÔÓ, ·Ó ‚ÚÂı› οÔÈÔ ÌÈÎÚfi‚ÈÔ ÛÙ· Ô‡Ú· ‹ ÛÙ· ÎfiÚ·Ó·, ¯ÔÚËÁÂ›Ù·È ÙÔ Î·Ù¿ÏÏËÏÔ, Ì ‚¿ÛË ÙËÓ Â˘·ÈÛıËÛ›·, ·ÓÙÈ‚ÈÔÙÈÎfi. ∆· ·Ú¿ÛÈÙ· Ô˘ Ù˘¯fiÓ Â˘Ú›ÛÎÔÓÙ·È ÛÙÔ ¤ÓÙÂÚÔ, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì Ì‚ÂÓ‰·˙fiÏË. ∏ Û‡ÌÌ˘ÛË ÙˆÓ ÌÈÎÚÒÓ ¯ÂÈϤˆÓ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙËÓ ··ÁˆÁ‹ ÙˆÓ ‰‡Ô ¯ÂÈϤˆÓ ÌÂٷ͇ ÙÔ˘˜, Ì ÙË ‚Ô‹ıÂÈ· ÙˆÓ ‰·ÎÙ‡ÏˆÓ ‹ ‰‡Ô ‚·Ì‚·ÎÔÊfiÚˆÓ ÛÙ˘ÏÂÒÓ. ªÂÙ¿ ÙËÓ Â¿ÓÔ‰Ô ÙÔ˘ ·È‰Ô›Ô˘ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ηٿÛÙ·ÛË, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· 5-7 Ë̤Ú˜ ‚·˙ÂÏÈÓÔ‡¯Ô˜ ‹ ·ÏÔÈÊ‹ ÔÈÛÙÚÔÁfiÓˆÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Â·Ó·Û˘ÁÎfiÏÏËÛ˘ ÙˆÓ ¯ÂÈϤˆÓ. °›ÓÂÙ·È ÛˆÛÙ‹ ÂÓË̤ڈÛË ÁÈ· ÙÔ˘˜ ηÓfiÓ˜ ÚfiÏ˄˘, fiˆ˜ Ë Ù‹ÚËÛË ÙˆÓ Î·ÓfiÓˆÓ ˘ÁÈÂÈÓ‹˜, Ë ·ÔÊ˘Á‹ ¯ÚËÛÈÌÔÔ›ËÛ˘ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ, Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÁÈ· ËÁ¤˜ ÌfiÏ˘ÓÛ˘, Ë ¯ÚËÛÈÌÔÔ›ËÛË ‚·Ì‚·ÎÂÚÒÓ ÂÛˆÚÔ‡¯ˆÓ, Ë ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ¿ÏÏˆÓ ÏÔÈÌÒÍÂˆÓ (·Ó·Ó¢ÛÙÈÎÔ‡ / Ô˘ÚÔÔÈËÙÈÎÔ‡).
Paediatriki 2001;64:400-405
™˘˙‹ÙËÛË OÈ ·È‰ÔÈÔÎÔÏ›Ùȉ˜ ·ÔÙÂÏÔ‡Ó Û˘¯Ófi Úfi‚ÏËÌ· ÙˆÓ ÎÔÚÈÙÛÈÒÓ, ΢ڛˆ˜ Ù˘ ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜ Î·È ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ·ÊÔÚÔ‡Ó ÙÔ 87% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙËÓ ËÏÈΛ· ·˘Ù‹. ¶·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· Û ÎÔÚ›ÙÛÈ· ÌÂٷ͇ 2 Î·È 7 ¯ÚfiÓˆÓ. OÈ ·È‰ÔÈÔÎÔÏ›Ùȉ˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ ‰È·Ê¤ÚÔ˘Ó Û˘Ó‹ıˆ˜ Û fiÙÈ ·ÊÔÚ¿ ÙËÓ ·ÈÙÈÔÏÔÁ›·, ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË, ÂÓÒ ·ÓÙ›ıÂÙ·, ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÌÌËÓÔÚÚ˘Û›·˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·ÊÔÚ¤˜ ·fi ÙȘ ·Ó¿ÏÔÁ˜ ÏÔÈÌÒÍÂȘ ÙˆÓ ÂÓËÏ›ÎˆÓ Á˘Ó·ÈÎÒÓ. ∆· Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· Ù˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ· Ù˘ Á˘Ó·›Î·˜, ·ÏÏ¿ Ë ‰È·ÊÔÚÂÙÈ΋ ·ıÔÏÔÁ›·, „˘¯ÔÏÔÁ›·, ÂÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ ÛÙËÓ ·È‰È΋ Î·È ÚÔÂÊË‚È΋ ËÏÈΛ·, οÓÔ˘Ó ÙËÓ ·È‰È΋ ·È‰ÔÈÔÎÔÏ›Ùȉ· Ì›· ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ·. ¶·Ú·‰ÔÛȷο, Ë ÈÔ Û˘¯Ó‹ ¿ıËÛË ÛÙËÓ ÂÊ˂›· ‹Ù·Ó ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜. ™‹ÌÂÚ·, Ô˘ ÔÈ ÛÂÍÔ˘·ÏÈΤ˜ ·ʤ˜ ·Ú¯›˙Ô˘Ó Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· Î·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È ·˘ÍË̤ÓË, ÔÈ ÂÈÏÔΤ˜ Ù˘ ·ËÛ˘, Ù· ÛÂÍÔ˘·ÏÈÎÒ˜ ÌÂÙ·‰È‰fiÌÂÓ· ÓÔÛ‹Ì·Ù· Î·È Ë ·È‰ÔÈÔÎÔÏ›Ùȉ· ·ÔÙÂÏÔ‡Ó Û˘¯Ó¿ ÚÔ‚Ï‹Ì·Ù·. ™¯Â‰fiÓ Î¿ı ÎÔÚ›ÙÛÈ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÌÊ·Ó›ÛÂÈ Î¿ÔÈ· ÛÙÈÁÌ‹ ·È‰ÔÈÔÎÔÏ›Ùȉ·. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ì›· ÌÂÁ¿ÏË ÔÈÎÈÏ›· ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÌÈÎÚԂȷΤ˜ ÌÔχÓÛÂȘ, ÌË ÂȉÈΤ˜ ‰ÂÚÌ·ÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜, ÙÚ·˘Ì·ÙÈÛÌÔ‡˜, ͤӷ ÛÒÌ·Ù·, ÓÂÔÏ¿ÛÌ·Ù·, Ô˘ÚÔÏÔÁÈο Û˘Ì‚¿Ì·Ù·, ÔÚÌÔÓÈÎÔ‡˜ ÏfiÁÔ˘˜, ·Ú¿ÛÈÙ· ÂÓÙ¤ÚÔ˘ Î.Ï. ∆Ô ÔÛÔÛÙfi ÚÔÛ‚ÔÏ‹˜ ÌÂٷ͇ ÙˆÓ ÂÊ‹‚ˆÓ Â›Ó·È ·˘ÍË̤ÓÔ, ÁÈ·Ù› Ù· ÎÔÚ›ÙÛÈ· ›Ù ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ¤Ó·Ó ÛÂÍÔ˘·ÏÈÎÔ‡˜ Û˘ÓÙÚfiÊÔ˘˜, ›ÙÂ Â›Ó·È ÈÔ Â˘·›ÛıËÙ· ÛÙËÓ ·Ó¿Ù˘ÍË ÊÏÂÁÌÔÓ‹˜, Û ۯ¤ÛË Ì ÙȘ ÈÔ ÌÂÁ¿Ï˜ Á˘Ó·›Î˜, Ô˘ Ê·›ÓÂÙ·È fiÙÈ ·Ó·Ù‡ÛÛÔ˘Ó ·ÓÔÛ›· ÛÙÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ™ÙÔÓ ÎfiÏÔ ˘¿Ú¯ÂÈ ÌÈ· ÏÂÙ‹ ÈÛÔÚÚÔ›·, Ë ÔÔ›· ÌÔÚ› Ó· ‰È·Ù·Ú·¯ı› ‡ÎÔÏ· ·fi Ì›· ÔÈÎÈÏ›· ·Ú·ÁfiÓÙˆÓ Î·È ¤ÙÛÈ Ó· ‰Ôı› Ë ‰˘Ó·ÙfiÙËÙ· Ó· ·Ó·Ù˘¯ıÔ‡Ó ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›. ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë Ïԛ̈ÍË Û˘Ó‹ıˆ˜ Â›Ó·È ÚˆÙÔ·ı‹˜ ÛÙÔ ·È‰Ô›Ô Ì ‰Â˘ÙÂÚÔ·ı‹ ÂÓÙfiÈÛË ÛÙÔÓ ÎfiÏÔ, ÂÓÒ Ë Û¯¤ÛË ·˘Ù‹ ·ÓÙÈÛÙÚ¤ÊÂÙ·È ÛÙËÓ ‹‚Ë Î·È ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ÛÂÍÔ˘·ÏÈÎÒÓ Â·ÊÒÓ, ÔfiÙÂ Ë ·È‰ÔÈ›Ùȉ· Á›ÓÂÙ·È Û¯Â‰fiÓ ·ÔÎÏÂÈÛÙÈο ‰Â˘ÙÂÚÔ·ı‹˜. ∆Ô ·È‰Ô›Ô Î·È Ô ÎfiÏÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È Â˘·›ÛıËÙ· ÏfiÁˆ Ù˘ ·Ô˘Û›·˜ ÔÈÛÙÚÔÁÔÓÈ΋˜ ‰Ú¿Û˘ Î·È Ù˘ ·Ó·ÙÔÌÈ΋˜ ηٷÛ΢‹˜ ÙÔ˘˜, ·ÏÏ¿ Î·È ÏfiÁˆ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ÊÏÂÁÌÔÓ‹ ÙÔ˘ ·È‰Ô›Ô˘ (·È‰ÔÈ›Ùȉ·)
403
¶·È‰È·ÙÚÈ΋ 2001;64:400-405
ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ: ÙÔÈΤ˜ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ·È‰Ô›Ô˘, ÊÏÂÁÌÔÓ¤˜ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔÓ ÎfiÏÔ ‹ ·fi ¿ÏÏÔ ÛËÌÂ›Ô ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔÈΤ˜ ÂΉËÏÒÛÂȘ ‰ÂÚÌ·ÙÔÏÔÁÈÎÒÓ ‹ ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ·ı‹ÛˆÓ. OÈ ÂȉÈΤ˜ ·È‰ÔÈÔÎÔÏ›Ùȉ˜ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·fi ÙȘ ·Ó¿ÏÔÁ˜ ÌË ÂȉÈΤ˜ (1,6,21). ∏ ÂÚÈÔ¯‹ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ÁÂÈÙÔÓ‡ÂÈ Ì ÙÔ ÔÚıfi. ™˘ÌÌÂÙÔ¯‹ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ¤¯Ô˘Ó ·ÎfiÌË Î·È ÔÈ Î·ÎÔ› ηÓfiÓ˜ ˘ÁÈÂÈÓ‹˜, fiˆ˜ Ô Î·ı·ÚÈÛÌfi˜ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ·fi ›Ûˆ ÚÔ˜ Ù· ÂÌÚfi˜, Ë Â·Ê‹ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ Ì ÙËÓ ÙÔ˘·Ï¤Ù·, ÙÔ ·È¯Ó›‰È ÛÙËÓ ¿ÌÌÔ, ÙÔ Í‡ÛÈÌÔ Ì ‚ÚÒÌÈη Ó‡¯È·, Ô È‰ÚÒÙ·˜, Ë ·˘ÍË̤ÓË ıÂÚÌÔÎÚ·Û›· Î·È ¿ÏÏÔÈ ÙÔÈÎÔ› ·Ú¿ÁÔÓÙ˜. ™ÙËÓ ÂÊ˂›·, Ë ·Ú·ÁˆÁ‹ ÔÈÛÙÚÔÁfiÓˆÓ ·fi ÙȘ ˆÔı‹Î˜ ·ÏÏ¿˙ÂÈ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰Ô›Ô˘ Î·È ÙÔ˘ ÎfiÏÔ˘. ∞Ó·Ù‡ÛÛÂÙ·È ÙÔ ÎÔÏÈÎfi ÂÈı‹ÏÈÔ, ÂÏ·ÙÙÒÓÂÙ·È ÙÔ pH, ·˘Í¿ÓÂÙ·È ÙÔ ÁÏ˘ÎÔÁfiÓÔ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·Ù‡ÛÛÂÙ·È Ë Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÙÔ˘ ÎfiÏÔ˘. ∂›Û˘, ·Ó·Ù‡ÛÛÔÓÙ·È Ù· ÌÂÁ¿Ï· ¯Â›ÏË, Ë ÙÚ›¯ˆÛË ÙÔ˘ ÂÊË‚·›Ô˘, ÙÔ ‰¤ÚÌ· Ù˘ ÂÚÈÔ¯‹˜ Á›ÓÂÙ·È ÈÔ ·ÓıÂÎÙÈÎfi Î·È ÏÂÈÙÔ˘ÚÁÔ‡Ó ÔÈ ÛÌËÁÌ·ÙÔÁfiÓÔÈ ·‰¤Ó˜. ¶·Ú¿ÏÏËÏ· Ì ·˘Ù¤˜ ÙȘ ·ÏÏ·Á¤˜, Ë ·È‰ÔÈÔÎÔÏ›Ùȉ· ‰›ÓÂÈ ÛÙ·‰È·Î¿ ÙË ı¤ÛË Ù˘, fiÛÔÓ ·ÊÔÚ¿ ÙË Û˘¯ÓfiÙËÙ·, ÛÙËÓ ÎÔÏ›Ùȉ·, ÙÚ·¯ËÏ›Ùȉ· Î·È Û·ÏÈÁÁ›Ùȉ·. ∆· ͤӷ ÛÒÌ·Ù· ·ÔÙÂÏÔ‡Ó Û˘¯Ó‹ ·ÈÙ›· ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ÎfiÏÔ˘ ÛÙ· ÎÔÚ›ÙÛÈ· ÚÈÓ ·fi ÙËÓ ‹‚Ë. ÷ÚÙÈ¿, ‚·Ì‚¿ÎÈ, ÎÔÌÌ¿ÙÈ· ͇ÏÔ˘ Î·È ¿ÏÏ· ·ÓÙÈΛÌÂÓ· ÌÔÚ› Ó· ÂÈÛ¯ˆÚ‹ÛÔ˘Ó ÛÙÔÓ ÎfiÏÔ ÂÎÔ‡ÛÈ· ‹ Ù˘¯·›· Î·È Ó· ÚÔηϤÛÔ˘Ó ÊÏÂÁÌÔÓ‹ (3-6). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·È‰ÔÈÔÎÔÏ›Ùȉ·˜ ÛÙË ÓÂÔÁÓÈ΋ Î·È ·È‰È΋ ËÏÈΛ· ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÚÎÂÙ¿ ÚÔ‚Ï‹Ì·Ù·. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Ú¤ÂÈ Ó· Â›Ó·È ‰ÈηÈÔÏÔÁË̤ÓË Î·È Ó· Á›ÓÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ·ÔÌfiÓˆÛË ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ·ıÔÁfiÓÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ Î·È Û‡Ìʈӷ Ì ÙË ‰ÔÎÈÌ·Û›· Ù˘ ¢·ÈÛıËÛ›·˜. ∆Ô Û‡ÓËı˜ ÂÚÒÙËÌ· ·ÚÎÂÙÒÓ ·È‰È¿ÙÚˆÓ Î·È Á˘Ó·ÈÎÔÏfiÁˆÓ Â›Ó·È Î·Ù¿ fiÛÔ ÙÔ ·ÓÙÈ‚ÈÔÙÈÎfi Û˘ÁÎÂÓÙÚÒÓÂÙ·È Û ÈηÓÔÔÈËÙÈ΋ ÛÙ¿ıÌË ÛÙÔÓ ÎfiÏÔ, Ô ÔÔ›Ô˜ ÂÈϤÔÓ ÛÙÂÚÂ›Ù·È Î·È ·‰¤ÓˆÓ. ¶ÔÏÏÔ› ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‹ Ë ·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÒÛˆ˜ ‰ÂÓ ‰›ÓÂÈ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. ∏ ·È‰ÔÈÔÎÔÏ›Ùȉ· Â›Ó·È Ì›· Û˘¯Ó‹ ¿ıËÛË Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜. ∏ ÛˆÛÙ‹ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ·ÔÙÂÏ› ÚÔ¸fiıÂÛË ÌË ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘. ∏ ηıËÛ‡¯·ÛË Î·È ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÚÔÏËÙÈο ̤ÙÚ· ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›·. ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ Ë ·È‰ÔÈÔÎÔÏ›ÙÈ-
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‰· ‰ÂÓ Â›Ó·È ÌÂÙ·‰ÔÙÈ΋ ÓfiÛÔ˜ Î·È ÙÔ ·È‰› ÌÔÚ› Ó· Û˘Ó¯›˙ÂÈ Î·ÓÔÓÈο ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘ (Û¯ÔÏ›Ô, ¿ıÏËÛË). µÈ‚ÏÈÔÁÚ·Ê›· 1. Pierce AM, Heart CA. Vulvovaginitis: causes and management. Arch Dis Child 1992;67:509-512. 2. Joyce CL, Strokosch GR. Urine leukocyte esterase as a screening tool for sexually transmissible diseases and vulvovaginitis in adolescent females. Adolesc Pediatr Gynecol 1993;6:15-19. 3. ∫Ú·ÙÛ¿˜ °, ÷ڷϷ̛‰Ë˜ µ, ∑·ÁÎÔÙ˙›‰Ô˘ ∂, ∞ÓıÔÔ‡ÏÔ˘ ∂, ªÈ¯·ËÏ›‰Ë˜ ¢, §Ô˘ÙÚ¿‰Ë˜ ¢ Î·È Û˘Ó. ∏ ÈÙÚ·ÎÔÓ·˙fiÏË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ÎÔÏÈ΋˜ ηÓÙÈÓÙ›·Û˘. ∂ÈÙ˘¯‹˜ ÌÔÓÔ‹ÌÂÚË ıÂڷ›·. ∂ÊË‚ °˘Ó ∞Ó· ∂ÌÌËÓ 1991;3:218-223. 4. Almeida Santos L, Beceiro J, Hernandez R. Congenital cutaneous candidiasis: report of four cases and review of the literature. Eur J Pediatr 1991;150:336-338. 5. McKay M. Vulvitis and vulvovaginitis: cutaneous considerations. Am J Obstet Gynecol 1991;165:1176-1182. 6. ∫Ú·ÙÛ¿˜ °. ¡ÂÔÁÓÈ΋, ¶·È‰È΋ Î·È ∂ÊË‚È΋ °˘Ó·ÈÎÔÏÔÁ›·. ∂ΉfiÛÂȘ “∂ÓÙÔ›·”; 1987. ÛÂÏ. 76-95. 7. Sandstrom I, Kallings I, Melen B. Neonatal chlamydial conjunctivitis. Acta Pediatr Scand 1988;7:207-208. 8. Ingram DL, White ST, Occuhiuti AR, Lyna PR. Childhood vaginal infections: association of Chlamydia trachomatis with sexual contact. Pediatr Infect Dis 1986;5:226-227. 9. Hammerschiag MR, Cummings M, Roraiswamny B. Nonspecific vaginitis following sexual abuse in children. Pediatrics 1985;75:1028-1029. 10. Schachter J, Dattel B. Sexually transmitted diseases in victims of sexual assault. N Eng J Med 1987;316:1023-1025. 11. Ingram DL, White ST, Durfee MF, Pearson AW. Sexual contact in children with gonorrhoeae. Am J Dis Child 1982;136:994-996. 12. Wallace RJ Jr, Baker CJ, Quinones FJ. Nontypable Haemophilus influenzae (Biotype IV) as a neonatal, maternal and genital pathogen. Rev Infect Dis 1983;5:123-125. 13. Dietrich MC, Watson DC, Kumar ML. Corynebacterium group JK infections in children. Pediatr Intect Dis J 1989;8:223-225. 14. Schachter J et al. Prospective study of perinatal transmission of chlamydia trachomatis. JAMA 1986;255:3374-3377. 15. Mcfarlane DE, Sharma DP. Haemophilus influenzae and genital tract infections in children. Act Pediatr Scand 1987;76:363-364. 16. Quentin R, Musser J, Mellouet M. Typing of urogenital, maternal and neonatal of Haemophilus influenzae and Haemophilus parainfluenzae in correlation with clinical source of isolation and evidence for genital specificity of Haemophilus influenzae biotype IV. J Clin Microbiol 1989;27:2286-2288. 17. Fuster CD, Neinstein LS. Vaginal Chlamidia trachomatis prevalence in sexually abused prepubertal girls. Pediatrics 1987;79-2: 235-236. 18. Bupm RC. Chlamydia trachomatis as a cause of
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prepubertal vagintitis. Obstet Gynecol 1985;65:384-385. 19. Hall GD, Washington JA II. Haemophilus influenzae in genitÔurinary tract infections. Diagn Microbiol Infect Dis 1983;1:65-67. 20. Albritton WL, Brunton JL, Meier M. Haemophilus influenzae: comparison of respiratory tract isolates with genitourinary tract isolates. J Clin Microbiol 1982;16:826-829.
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21. Gray LA, ∫otcher E. Vaginitis in childhood. Am J Obstet Gynecol 1961;82:530-532.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂˘ı‡ÌÈÔ˜ ¢ÂÏËÁÂÒÚÔÁÏÔ˘ §¤ÎÙˆÚ ª·È¢ÙÈ΋˜-°˘Ó·ÈÎÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ª·Ú·ıÒÓÔ˜ 48, 152 35, µÚÈÏ‹ÛÛÈ·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË1 ∂ÈÛ·ÁˆÁ‹: H ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË (FSGS) Â›Ó·È ¤Ó· ÎÏÈÓÈÎÔ·ıÔÏÔÁÈÎfi Û‡Ó‰ÚÔÌÔ Ì ÔÈΛÏË ·ÈÙÈÔÏÔÁ›·. ™ÎÔfi˜: EÚÂ˘Ó‹Û·Ì ÙËÓ ˘fiıÂÛË Â¿Ó ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ù˘ ÓfiÛÔ˘ Û¯ÂÙ›˙ÔÓÙ·È Ì Ïԛ̈ÍË ·fi ÙÔÓ ·Ú‚Ô˚fi B19. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: EÍÂÙ¿Û·Ì ÙÔ ÓÂÊÚÈÎfi ÈÛÙfi Ô˘ ÂÏ‹ÊıË ÌÂÙ¿ ·fi ÓÂÊÚÈ΋ ‚ÈÔ„›· Û 40 ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ FSGS, Ì FSGS Û˘Ó‰˘·Ṳ̂ÓË Ì ηٿÚÚ¢ÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ, ÌÂÌ‚Ú·ÓÒ‰Ë ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· (Î·È Ì ÙË ÓfiÛÔ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ (MCNS), ηıÒ˜ Î·È Û 4 ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÓÂÊÚÈÎfi ÈÛÙfi Ô˘ ·Ê·ÈÚ¤ıËΠÌÂÙ¿ ·fi ÓÂÊÚÂÎÙÔÌ‹. TÔ DNA ·ÔÛ¿ÛıËΠ·fi Ù· ηÙ„˘Á̤ӷ ÙÂÌ¿¯È· ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ÂÓÈÛ¯‡ıËΠ̠ÙË Ì¤ıÔ‰Ô PCR. ∞ÔÙÂϤÛÌ·Ù·: TÔ DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ·Ó¢ڤıËΠ۠8/10 ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ FSGS, Û 9/10 ·ÛıÂÓ›˜ Ì FSGS Î·È Î·Ù¿ÚÚ¢ÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ, Û 6/10 ·ÛıÂÓ›˜ Ì ÌÂÌ‚Ú·ÓÒ‰Ë ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, Û 5/10 Ì MCNS Î·È Û 2/4 ‰Â›ÁÌ·Ù· ηÚÎÈÓÔ·ıÒÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ÓÂÊÚÂÎÙÔÌ‹. H Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ÙÔ˘ DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B16 ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ FSGS Î·È FSGS Ì ηٿÚÚ¢ÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Û ۯ¤ÛË Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ ·ÛıÂÓ›˜ (P=0,05). EȉÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÓÔ˘ÎÏÂ˚ÎÔ‡ Ôͤˆ˜ ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi ‹Ù·Ó ·ÚÓËÙÈΤ˜.
™˘ÌÂÚ¿ÛÌ·Ù·: T· ·ÔÙÂϤÛÌ·Ù· ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ ÙÔ DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ·Ó¢ڛÛÎÂÙ·È Û˘¯Ó¿ ÛÙÔÓ ÓÂÊÚÈÎfi ÈÛÙfi ·ÛıÂÓÒÓ Ì ÔÈΛϷ ÓÂÊÚÈο ÓÔÛ‹Ì·Ù· Î·È Èı·ÓÒ˜ ·ÓÙÈÚÔۈ‡ÂÈ Ï·Óı¿ÓÔÓÙ· DNA ·fi ·Ï·ÈfiÙÂÚË Ïԛ̈ÍË. H ÌË ÂÓÙfiÈÛË ÙÔ˘ ÓÔ˘ÎÏÂ˚ÎÔ‡ Ôͤˆ˜ ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 ÛÙÔÓ ÓÂÊÚÈÎfi ÈÛÙfi ·ÔÎÏ›ÂÈ ÙËÓ Èı·ÓfiÙËÙ· Û˘Ó¯È˙fiÌÂÓ˘, ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÔÏÏ·Ï·ÛÈ·ÌÔ‡ ÙÔ˘ ÈÔ‡. ¶·Ú’ fiÏ· ·˘Ù¿, Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ÙÔ˘ DNA ÙÔ˘ ·Ú‚Ô˚Ô‡ B19 Û ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ FSGS ηıÒ˜ Î·È Ì FSGS Î·È Î·Ù¿ÚÚ¢ÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ, Â›Ó·È Èı·ÓÒ˜ ¤Ó‰ÂÈÍË ÙÔ˘ ·ıÔÁÂÓÂÙÈÎÔ‡ ÚfiÏÔ˘ ÙÔ˘ ÈÔ‡ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜.
1 Tanawattanacharoen S, Falk RJ, Jennette JC, Kopp JB Parvovirus B19 DNA in kidney tissue of patients with focal segmental glomerulosclerosis Am J Kidney Dis 2000;35:1166-1174
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Growth disorders of height C. Kanaka - Gantenbein
¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË Û ‡„Ô˜ ·ÔÙÂÏ› ·ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ··Û¯ÔÏÔ‡Ó Û˘¯Ó¿ ÙÔÓ ·È‰›·ÙÚÔ. °ÂÓÈÎfiÙÂÚ·, ÌÈÏ¿Ì ÁÈ· ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘ Û ‡„Ô˜, fiÙ·Ó ·˘Ùfi ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi ÙËÓ 3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (ÎÔÓÙfi ·Ó¿ÛÙËÌ·) ‹ ¿Óˆ ·fi ÙËÓ 97Ë ÂηÙÔÛÙÈ·›· ı¤ÛË („ËÏfi ·Ó¿ÛÙËÌ·) ÙˆÓ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂıÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È Ê‡ÏÔ˘, ‹ fiÙ·Ó Ë Ù·¯‡ÙËÙ· ·Ó¿Ù˘Í‹˜ ÙÔ˘ Â›Ó·È ·ıÔÏÔÁÈο ·ÚÁ‹ ‹ ¤ÓÙÔÓ· ·˘ÍË̤ÓË, ‹ ·ÎfiÌË ÙÔ ‡„Ô˜ ÙÔ˘ ÛÙȘ η̇Ϙ ·Ó¿Ù˘Í˘ ˘ÔÏ›ÂÙ·È ÛËÌ·ÓÙÈο Ù˘ η̇Ï˘ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙÔ Ì¤ÛÔ ÁÔÓÂ˚Îfi ‡„Ô˜. OÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘ Û ‡„Ô˜ ÔÊ›ÏÔÓÙ·È Û ‰È¿ÊÔÚ· ·›ÙÈ·, Ù· ÔÔ›· ÌÔÚ› Ó· ·ÔÙÂÏÔ‡Ó ·ÏÒ˜ Ì›· ·Ú·ÏÏ·Á‹ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ó¿Ù˘Í˘ ‹ Ó· ˘ÔÎÚ‡ÙÔ˘Ó ¤Ó· ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi Úfi‚ÏËÌ·, Ì›· ÛÎÂÏÂÙÈ΋ ·ÓˆÌ·Ï›· ‹ Ì›· ¯ÚfiÓÈ· ÓfiÛÔ. ∂ÈϤÔÓ, ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ· Û˘Û¯ÂÙ›˙ÔÓÙ·È ÙfiÛÔ Ì ÎÔÓÙfi fiÛÔ Î·È Ì „ËÏfi ·Ó¿ÛÙËÌ·. ™˘˙ËÙÒÓÙ·È Ù· ‰È¿ÊÔÚ· ·›ÙÈ·, ÙfiÛÔ ÙÔ˘ ÎÔÓÙÔ‡ fiÛÔ Î·È ÙÔ˘ „ËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Î·È ·Ó·Ï‡ÔÓÙ·È Ù· ‰È·ÁÓˆÛÙÈο Î·È ıÂڷ¢ÙÈο ‚‹Ì·Ù· Ô˘ ı· Ô‰ËÁ‹ÛÔ˘Ó Û οı ÂÚ›ÙˆÛË ÛÙË ÛˆÛÙ‹ ‰È¿ÁÓˆÛË Î·È ıÂڷ›·.
Abstract: Growth in height is one of the main characteristics of childhood and adolescence and its disorders preoccupy quite often the pediatrician. Growth disorders include the two ends of the normal growth spectrum, i.e. short stature, when a child’s height is below the 3rd centile for his race and sex, and tall stature, when the child’s stature is above the 97th centile for his race and sex. Furthermore, growth disorders include children whose growth velocity is abnormally slow or abnormally accelerated. Finally, investigations should be undertaken when a child’s growth curve falls far below the growth curve corresponding to his mid-parental height. Growth disorders may be due to various causes, many of which may be a normal variation, while others may be the expression of an endocrine disorder or a skelettal disease or even a chronic illness. Furthermore, genetic syndromes may be associated with either short or tall stature. The different etiologies are discussed and the diagnostic and therapeutic steps that have to be undertaken are analysed.
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·Ù·Ú·¯¤˜ ·Ó¿Ù˘Í˘, ‡„Ô˜, Ù·¯‡ÙËÙ· ·Ó¿Ù˘Í˘, ÎÔÓÙfi ·Ó¿ÛÙËÌ·, „ËÏfi ·Ó¿ÛÙËÌ·, ·˘ÍËÙÈ΋ ÔÚÌfiÓË.
Key words: growth disorders, growth, height, height velocity, short stature, tall stature, growth hormone.
OÚÈÛÌfi˜ ¢È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘ Û ‡„Ô˜ ·Ó·Ê¤ÚÔÓÙ·È fiÙ·Ó ÙÔ ‡„Ô˜ ÂÓfi˜ ·È‰ÈÔ‡ ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi ÙËÓ 3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË (∂£) (ÎÔÓÙfi ·Ó¿ÛÙË-
Ì·) ‹ ¿Óˆ ·fi ÙËÓ 97Ë ÂηÙÔÛÙÈ·›· ı¤ÛË („ËÏfi ·Ó¿ÛÙËÌ·) ÙˆÓ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂıÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È Ê‡ÏÔ˘. ∞Ó·Ú΋˜ ·Ó¿Ù˘ÍË, ›Û˘, ·Ó·Ê¤ÚÂÙ·È
¶·È‰›·ÙÚÔ˜ - ¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏfiÁÔ˜ Ù. §¤ÎÙÔÚ·˜ ¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
Pediatric Endocrinologist Former Instructor of Pediatric Endocrinology of University of Crete Scientific Collaborator of “Saint Sophia” Children’s Hospital, Athens
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fiÙ·Ó Ë Ù·¯‡ÙËÙ· ·Ó¿Ù˘Í˘ ÂÓfi˜ ·È‰ÈÔ‡ ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi ÙËÓ 25Ë ∂£ Ù˘ Ù·¯‡ÙËÙ·˜ ·Ó¿Ù˘Í˘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÏËı˘ÛÌÔ‡ Î·È Ê‡ÏÔ˘ ‹ ÙÔ ‡„Ô˜ ÙÔ˘ ¤ÊÙÂÈ ÛÙË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Û ¯·ÌËÏfiÙÂÚ˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ. ∫·Ù’ ·Ó·ÏÔÁ›·, ¤Ó· ·È‰› Ô˘ ÂÈÙ·¯‡ÓÂÈ ·fiÙÔÌ· ÙÔ Ú˘ıÌfi ·Ó¿Ù˘Í‹˜ ÙÔ˘ ¯Ú‹˙ÂÈ, ›Û˘, ‰ÈÂÚ‡ÓËÛ˘. ∂ÈϤÔÓ, ¤Ó· ·È‰› ¯ÚÂÈ¿˙ÂÙ·È ¤ÏÂÁ¯Ô Î·È ‰ÈÂÚ‡ÓËÛË fiÙ·Ó ÙÔ ‡„Ô˜ ÙÔ˘ ÛÙȘ η̇Ϙ ·Ó¿Ù˘Í˘ ˘ÔÏ›ÂÙ·È ÛËÌ·ÓÙÈο Ù˘ η̇Ï˘ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙÔ Ì¤ÛÔ ÁÔÓÂ˚Îfi ‡„Ô˜. ∫O¡∆O ∞¡Õ™∆∏ª∞ ∆Ô ÎÔÓÙfi ·Ó¿ÛÙËÌ· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÔÈΛϷ ·›ÙÈ· Î·È Ó· ·ÔÙÂÏ› ÂΉ‹ÏˆÛË Ì›·˜ ·Ú·ÏÏ·Á‹˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ó¿Ù˘Í˘ ‹ Ó· ·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙËÓ ‡·ÚÍË ÂÓfi˜ ÔÚÁ·ÓÈÎÔ‡ ‹ „˘¯Ôۈ̷ÙÈÎÔ‡ ·ÈÙ›Ô˘. ™˘ÁÎÂÎÚÈ̤ӷ, Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ··ÓÙÒÓÙ·È ·Ú·ÏÏ·Á¤˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ó¿Ù˘Í˘ Û ‡„Ô˜, ÂÓÒ Û·ÓÈfiÙÂÚ· ¢ı‡ÓÔÓÙ·È ÂÓ‰ÔÎÚÈÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ Î·È Û˘ÛÙËÌ·ÙÈΤ˜ ÓfiÛÔÈ ÁÈ· ÙËÓ ·Ó·Ú΋ ·Ó¿Ù˘ÍË. ŒÙÛÈ, Ë Ù·ÍÈÓfiÌËÛË Ù˘ ·ÈÙÈÔÏÔÁ›·˜ ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Û¯ËÌ·ÙÈο ·Ó·ÁÚ¿ÊÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Î·È ·Ó·Ï‡ÂÙ·È ÛÙË Û˘Ó¤¯ÂÈ·. ∞ÈÙÈÔÏÔÁ›· Î·È Ù·ÍÈÓfiÌËÛË ¶·Ú·ÏÏ·Á¤˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡: 1) OÈÎÔÁÂÓ¤˜ ÎÔÓÙfi ·Ó¿ÛÙËÌ·: ¶Ôχ Û˘¯Ó¿ Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È Ë ‡·ÚÍË ÁÔÓ¤ˆ˜ Ì ›Û˘ ÎÔÓÙfi ·Ó¿ÛÙËÌ·. ∆· ·È‰È¿ ·˘Ù¿ Û˘Ó‹ıˆ˜ ¤¯Ô˘Ó Ì›· Ù·¯‡ÙËÙ· ·Ó¿Ù˘Í˘ ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ·, ÂÌÊ·Ó›˙Ô˘Ó ¤Ó·ÚÍË ÂÊ˂›·˜ Û ηÓÔÓÈ΋ ËÏÈΛ· Î·È Î·Ù·Ï‹ÁÔ˘Ó Û¯ÂÙÈο ÎÔÓÙÔ› ÂÓ‹ÏÈΘ. 2) π‰ÈÔÛ˘ÛÙ·Ûȷ΋ ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ Î·È ÂÊ˂›·˜: ™ÙË ÌÂÁ¿ÏË ·˘Ù‹ ÔÌ¿‰· ˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ηı˘ÛÙ¤ÚËÛ˘ ÂÊ˂›·˜ ÛÙÔÓ ¤Ó· ·fi ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜. ∆Ô ·È‰› ı· ·ÚÁ‹ÛÂÈ Ó· ÂÌÊ·Ó›ÛÂÈ ÂÊ˂›· Î·È Î·Ù·Ï‹ÁÂÈ Û ¤Ó· ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ·. ¡ÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜: I. ªÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ۈ̷ÙÈΤ˜ ·Ó·ÏÔÁ›Â˜: A) ∂Ó‰ÔÎÚÈÓÈο ·›ÙÈ·: ªÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ÔÏÏ·Ï‹ ˘ÔÊ˘Ûȷ΋ ·Ó¿ÚÎÂÈ·, ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, ˘ÂÚÎÔÚÙÈ˙ÔÏÈÛÌfi˜ (˘ÂÚ¤ÎÎÚÈÛË ‹ ˘ÂÚ‚ÔÏÈ΋ ‰fiÛË Â͈ÁÂÓÔ‡˜ ÎÔÚÙÈ˙fiÏ˘). µ) ªË ÂÓ‰ÔÎÚÈÓÈο ·›ÙÈ·: 1. ÃÚfiÓÈ· ÓÔÛ‹Ì·Ù· (˘ÔÛÈÙÈÛÌfi˜, Û‡Ó‰ÚÔÌ· ‰˘Û·ÔÚÚfiÊËÛ˘ .¯. ÎÔÈÏÈÔοÎË, ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÃÚfiÓÈ· Ë·ÙÔ¿ıÂÈ·, ÃÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ·, ™˘ÛÙËÌ·ÙÈΤ˜ ÓfiÛÔÈ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘), 2. °ÂÓÂÙÈο ™‡Ó‰ÚÔÌ· (Û‡Ó‰ÚÔÌÔ Turner, Û‡Ó‰ÚÔÌÔ Down Î.Ï.), 3. ªÂÙ·‚ÔÏÈΤ˜ ÓfiÛÔÈ (‚ÏÂÓÓÔÔÏ˘Û·Î¯·ÚÈ-
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‰ÒÛÂȘ, ‚ÏÂÓÓÔÏÈȉÒÛÂȘ Î.Ï.), 4. ∂Ó‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ (Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ TORSCH, ·ı‹ÛÂȘ Ù˘ ÌËÙ¤Ú·˜ - ۷ί. ‰È·‚‹Ù˘, ˘¤ÚÙ·ÛË, ÂÓ‰ÔÌ‹ÙÚÈ· ¤ÎıÂÛË ÛÂ Ô˘Û›Â˜ - ·ÏÎÔfiÏ, Ó·ÚΈÙÈο, ÓÈÎÔÙ›ÓË, ·ÓÙÈÂÈÏËÙÈο Î.Ï., Û‡Ó‰ÚÔÌ· Silver-Russel, 3M, Î.Ï.), 5. æ˘¯ÔÎÔÈÓˆÓÈ΋ ·ÔÛÙ¤ÚËÛË. II. ªÂ ‰˘Û·Ó·ÏÔÁ›· ÎÔÚÌÔ‡ ¿ÎÚˆÓ: ™ÎÂÏÂÙÈΤ˜ ‰˘ÛϷۛ˜ (·¯ÔÓ‰ÚÔÏ·Û›·, ˘Ô¯ÔÓ‰ÚÔÏ·Û›· Î.Ï.). ¶Ò˜ ı· ÙÂı› Ë ‰È¿ÁÓˆÛË °È· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ú¤ÂÈ Ô ·È‰›·ÙÚÔ˜ Ó· ‰ÒÛÂÈ È‰È·›ÙÂÚË ÚÔÛÔ¯‹: ·) ÛÙË ÛËÌ·Û›· Ù˘ ÛˆÛÙ‹˜ ̤ÙÚËÛ˘: ™ÙË ‚ÚÂÊÈ΋ Î·È ÚÒÙË ÓËȷ΋ ËÏÈΛ· Ï·Ì‚¿ÓÂÙ·È ÙÔ ¶›Ó·Î·˜ 1. ∞ÈÙÈÔÏÔÁ›· ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ¶·Ú·ÏÏ·Á¤˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ 1. OÈÎÔÁÂÓ¤˜ ÎÔÓÙfi ·Ó¿ÛÙËÌ· 2. π‰ÈÔÛ˘ÛÙ·Ûȷ΋ ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ Î·È ÂÊ˂›·˜ ¡ÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ I. ªÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ۈ̷ÙÈΤ˜ ·Ó·ÏÔÁ›Â˜ A. ∂Ó‰ÔÎÚÈÓÈο ·›ÙÈ· - ªÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ∞˘ÍËÙÈ΋˜ OÚÌfiÓ˘ - ¶ÔÏÏ·Ï‹ ˘ÔÊ˘Ûȷ΋ ·Ó¿ÚÎÂÈ· - ™‡Ó‰ÚÔÌÔ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ∞˘ÍËÙÈ΋ OÚÌfiÓË - ÀÔı˘ÚÂÔÂȉÈÛÌfi˜ - ÀÂÚÎÔÚÙÈ˙ÔÏÈÛÌfi˜ (˘ÂÚ¤ÎÎÚÈÛË ‹ ˘ÂÚ‚ÔÏÈ΋ ‰fiÛË Â͈ÁÂÓÔ‡˜ ÎÔÚÙÈ˙fiÏ˘) B. ªË ÂÓ‰ÔÎÚÈÓÈο ·›ÙÈ· 1. ÃÚfiÓÈ· ÓÔÛ‹Ì·Ù· - ÀÔÛÈÙÈÛÌfi˜ - ™‡Ó‰ÚÔÌ· ‰˘Û·ÔÚÚfiÊËÛ˘ .¯. ÎÔÈÏÈÔοÎË, ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ - ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· - ÃÚfiÓÈ· Ë·ÙÔ¿ıÂÈ· - ÃÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ· - ™˘ÛÙËÌ·ÙÈΤ˜ ÓfiÛÔÈ ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ 2. °ÂÓÂÙÈο ™‡Ó‰ÚÔÌ· - ™‡Ó‰ÚÔÌÔ Turner - ™‡Ó‰ÚÔÌÔ Down Î.Ï. 3. ªÂÙ·‚ÔÏÈΤ˜ ÓfiÛÔÈ - µÏÂÓÓÔÔÏ˘Û·Î¯·ÚȉÒÛÂȘ - µÏÂÓÓÔÏÈȉÒÛÂȘ Î.Ï. 4. ∂Ó‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ - ™˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (TORSCH) - ¶·ı‹ÛÂȘ Ù˘ ÌËÙ¤Ú·˜ (۷ί. ‰È·‚‹Ù˘, ˘¤ÚÙ·ÛË) - ∂Ó‰ÔÌ‹ÙÚÈ· ¤ÎıÂÛË ÛÂ Ô˘Û›Â˜ (·ÏÎÔfiÏ, Ó·ÚΈÙÈο, ÓÈÎÔÙ›ÓË, ·ÓÙÈÂÈÏËÙÈο Î.Ï.) - ™‡Ó‰ÚÔÌ· (Silver-Russel, 3M, Î.Ï.) 5. æ˘¯ÔÎÔÈÓˆÓÈ΋ ·ÔÛÙ¤ÚËÛË II. ªÂ ‰˘Û·Ó·ÏÔÁ›· ÎÔÚÌÔ‡ ¿ÎÚˆÓ ™ÎÂÏÂÙÈΤ˜ ‰˘ÛϷۛ˜ (·¯ÔÓ‰ÚÔÏ·Û›·, ˘Ô¯ÔÓ‰ÚÔÏ·Û›· Î.Ï.)
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¶·È‰È·ÙÚÈ΋ 2001;64:406-409
Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ Û ‡ÙÈ· ı¤ÛË. ŸÙ·Ó ÙÔ ·È‰› Â›Ó·È ÈηÓfi Ó· ÛÙ·ı› ¢ı˘ÙÂÓ¤˜, Ï·Ì‚¿ÓÂÙ·È ÙÔ ‡„Ô˜ Û fiÚıÈ· ı¤ÛË, ‚) ÛÙËÓ ÙÔÔı¤ÙËÛË Û η̇Ϙ ·Ó¿Ù˘Í˘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂıÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È Ê‡ÏÔ˘, Á) ÛÙË ÛËÌ·Û›· Ù˘ Ù·¯‡ÙËÙ·˜ ·Ó¿Ù˘Í˘: ∏ Ù·¯‡ÙËÙ· ·Ó¿Ù˘Í˘ ηıÔÚ›˙ÂÙ·È ·fi Ù· ÂηÙÔÛÙ¿ Ô˘ ΤډÈÛ Û ‡„Ô˜ ¤Ó· ·È‰› ÛÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¯ÚfiÓÔ˘. OÈ ÌÂÙÚ‹ÛÂȘ, ÔÈ Ôԛ˜ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔÓ ˘ÔÏÔÁÈÛÌfi Ù˘ Ù·¯‡ÙËÙ·˜ ·Ó¿Ù˘Í˘, ı· Ú¤ÂÈ Ó· ·¤¯Ô˘Ó ¯ÚÔÓÈο ÌÂٷ͇ ÙÔ˘˜ ÙÔ ÏÈÁfiÙÂÚÔ 6 Ì‹Ó˜, ‰) ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô Î·È ÙȘ ·ÚÂÎÎÏ›ÛÂȘ. ∆Ô ‡„Ô˜-ÛÙfi¯Ô˜ (À™) ηıÔÚ›˙ÂÙ·È ·fi ÙËÓ Â͛ۈÛË: À™=(‡„Ô˜ ·Ù¤Ú·+‡„Ô˜ ÌËÙ¤Ú·˜±13 ÂηÙÔÛÙ¿):2. ™ÙËÓ ·Ú·¿Óˆ Â͛ۈÛË, Ù· 13 cm ÚÔÛÙ›ıÂÓÙ·È ÁÈ· ÙÔ ·ÁfiÚÈ Î·È ·Ê·ÈÚÔ‡ÓÙ·È ÁÈ· ÙÔ ÎÔÚ›ÙÛÈ. Ÿˆ˜ ÚԷӷʤÚıËΠÛÙÔÓ ÔÚÈÛÌfi, ÙÔ ‡„Ô˜ ÂÓfi˜ ·È‰ÈÔ‡ ¯Ú‹˙ÂÈ ‰ÈÂÚ‡ÓËÛ˘, Â¿Ó Ë Î·Ì‡ÏË ·Ó¿Ù˘Í‹˜ ÙÔ˘ ˘ÔÏ›ÂÙ·È ÛËÌ·ÓÙÈο Ù˘ η̇Ï˘ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô ÙÔ˘. ¢È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË ªÂÁ¿ÏË ÛËÌ·Û›· ¤¯Ô˘Ó Ù· ÂÍ‹˜ ‚‹Ì·Ù·: 1) OÈÎÔÁÂÓÂÈ·Îfi ·Ó·ÌÓËÛÙÈÎfi (ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ ÁÔÓ¤ˆÓ, ÎÔÓÙ¿ ·Ó·ÛÙ‹Ì·Ù· ÛÙËÓ Â˘Ú‡ÙÂÚË ÔÈÎÔÁ¤ÓÂÈ·, ·Ó¿Ù˘ÍË Î·È ËÏÈΛ· ÂÓ‹‚ˆÛ˘ ÙˆÓ ÁÔÓ¤ˆÓ Î.Ï.), 2) ∞ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi: ·) ∂Ó‰ÔÌ‹ÙÚÈ· ·Ó¿Ù˘ÍË, ‚) ™˘Óı‹Î˜ ÙÔÎÂÙÔ‡, Èۯȷ΋ ÚÔ‚ÔÏ‹, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, Î.Ï, Á) ÃÚfiÓȘ ÓfiÛÔÈ, ‰) ÃÚfiÓÈ· Ï‹„Ë Ê·Ú̿ΈÓ, Â) ™˘Ìو̷ÙÔÏÔÁ›· (.¯. ÔÓÔΤʷÏÔÈ, ÔÏ˘Ô˘Ú›·, ‰È·Ù·Ú·¯¤˜ fiÚ·Û˘, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Î.Ï.), 3) ∫ÏÈÓÈ΋ ÂͤٷÛË: ·)⁄„Ô˜, ‚¿ÚÔ˜, ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜, ‚) ™Ù›ÁÌ·Ù· (.¯. Û›ÏÔÈ, ‚Ï·ÈÛÔ› ·ÁÎÒÓ˜, ÎÏÈÓÔ‰·ÎÙ˘Ï›·, ·Û˘ÌÌÂÙڛ˜ Î.Ï. Ô˘ ı· ı¤ÛÔ˘Ó ÙËÓ ˘fiÓÔÈ· ÁÈ· οÔÈÔ Û‡Ó‰ÚÔÌÔ, .¯. Turner, Noonan, Silver Russel, Cornelia de Lange Î.Ï.), Á) ™˘ÌÌÂÙÚ›· ÎÔÚÌÔ‡, ·Ó·ÏÔÁ›· ÎÔÚÌÔ‡/¿ÎÚˆÓ (.¯.ÛÎÂÏÂÙÈΤ˜ ‰˘ÛϷۛ˜), ·Û˘ÌÌÂÙڛ˜ ¿ÎÚˆÓ (.¯. Û‡Ó‰ÚÔÌÔ Silver Russel), ‰) ¢¤ÚÌ·: ˘Ô- ‹ ˘ÂÚÌÂÏ¿Á¯ÚˆÛË, café au lait ÎËÏ›‰Â˜ (.¯. Ó¢ÚÔ˚ӈ̿وÛË), white spots, striae (.¯. Û‡Ó‰ÚÔÌÔ Cushing), Â) ÀÔ‰fiÚÈÔ Ï›Ô˜ (·˘ÍË̤ÓÔ Û ∞Ó¿ÚÎÂÈ· ∞˘ÍËÙÈ΋˜, ˘ÔÏ›ÂÙ·È Û ˘ÔÛÈÙÈÛÌfi, Û‡Ó‰ÚÔÌ· ‰˘Û·ÔÚÚfiÊËÛ˘ Î.Ï.), ÛÙ) ∫˘ÎÏÔÊÔÚÈÎfi: Ê˘Û‹Ì·Ù·, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ (Û‡Ó‰ÚÔÌ· Turner, Noonan), ˘¤ÚÙ·ÛË (Û. Cushing), ˙) O˘ÚÔÔÈËÙÈÎfi: Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ, ·ÓˆÌ·Ï›Â˜ (Û. Turner), Ë) ¶ÂÙÈÎfi: ÔÚÁ·ÓÔÌÂÁ·Ï›· (ıËÛ·˘ÚÈÛÌÒÛÂȘ), ÌÂÙˆÚÈÛÌfi˜, ÚÔ¤ÙÂÈ· (πÓÔ΢ÛÙÈ΋ ÓfiÛÔ˜, ÎÔÈÏÈÔοÎË Î.Ï.), ı) ™ÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ· (- ηı˘ÛÙ¤ÚËÛË Ô‰ÔÓÙÔÊ˘›·˜, Ë ÔÔ›· Û¯ÂÙ›˙ÂÙ·È Û˘Ó‹ıˆ˜ Î·È Ì ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ Û ‡„Ô˜, - ÌÔÓ‹Ú˘ ̤ÛÔ˜ ÙÔ̤·˜ (‰È·Ù·Ú·-
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¯¤˜ ̤Û˘ ÁÚ·ÌÌ‹˜), - Ì·ÎÚÔÁψÛÛ›· (˘Ôı˘ÚÂÔÂȉÈÛÌfi˜), È) OÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË (‚˘ıÔÛÎfiËÛË, Ë ÔÔ›· ÌÔÚ› Ó· Â›Ó·È ‰È·ÁÓˆÛÙÈ΋ Û ÂÓ‰ÔÌ‹ÙÚȘ ÏÔÈÌÒÍÂȘ, ıËÛ·˘ÚÈÛÌÒÛÂȘ Î.Ï.). ∂ÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ∞Ó¿ÏÔÁ· Ì ÙËÓ ˘fiÓÔÈ· Ô˘ ı· ı¤ÛÂÈ ÙÔ ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È Ë ÎÏÈÓÈ΋ ÂͤٷÛË, ı· ·ÎÔÏÔ˘ı‹ÛÂÈ Ô ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÁÂÓÈ΋ ·›Ì·ÙÔ˜, Û›‰ËÚÔ ÔÚÔ‡, ÊÂÚÚÈÙ›ÓË, ÁÂÓÈ΋ Ô‡ÚˆÓ, Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË, ÙÚ·ÓÛ·ÌÈÓ¿Û˜, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÁGT, ËÏÂÎÙÚÔχÙ˜, ·¤ÚÈ· ·›Ì·ÙÔ˜, ‰ÔÎÈÌ·Û›· ͢Ïfi˙˘, ·ÓÙÈÁÏÔÈ·‰ÈÓÈο ·ÓÙÈÛÒÌ·Ù·. ∆·˘Ùfi¯ÚÔÓ·, ‰ÈÂÓÂÚÁÔ‡ÓÙ·È Î·È Î¿ÔȘ ÂȉÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ı˘ÚÔÍ›ÓË (∆4), ÙÚÈ-Ȉ‰Ôı˘ÚÔÓ›ÓË (∆3), ı˘ÚÂÔÂȉÔÙÚfiÔ ÔÚÌfiÓË (∆SH), ¶ÚÔÏ·ÎÙ›ÓË, IGF I (™ˆÌ·ÙỔ›ÓË C) Î·È IGFBP3, Ë ÔÔ›· Â›Ó·È Ë Î˘ÚÈfiÙÂÚË ‰ÂÛÌ¢ÙÈ΋ ÚˆÙ½ÓË Ù˘ IGF I, ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ ∞˘ÍËÙÈ΋˜ OÚÌfiÓ˘. ™Â ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÍÂÙ¿˙ÂÙ·È Ô ‚ÈÔÚ˘ıÌfi˜ ÎÔÚÙÈ˙fiÏ˘. ™Â ˘fiÓÔÈ· ÔÏÏ·Ï‹˜ ˘ÔÊ˘Ûȷ΋˜ ·Ó¿ÚÎÂÈ·˜, Á›ÓÂÙ·È ÂÈϤÔÓ ¤ÏÂÁ¯Ô˜ ÁÔÓ·‰ÔÙÚÔÈÓÒÓ Î.Ï. ÂÓÒ ·Ó ˘¿Ú¯ÂÈ ˘fiÓÔÈ· ÁÂÓÂÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ÂϤÁ¯ÂÙ·È Ô Î·Ú˘fiÙ˘Ô˜. ¢ÈÂÓÂÚÁÂ›Ù·È ∞/· ηÚÔ‡ Î·È ¿ÎÚ·˜ ¯ÂÈÚfi˜ ·ÚÈÛÙÂÚ¿ face ÁÈ· ÚÔÛ‰ÈÔÚÈÛÌfi ÔÛÙÈ΋˜ ËÏÈΛ·˜ Î·È ∞/· ÙÔ˘ÚÎÈÎÔ‡ ÂÊÈ›Ô˘. ∂ÈϤÔÓ, Â¿Ó ˘¿Ú¯ÂÈ ·Ó¿ÏÔÁË ˘fiÓÔÈ· (‰È·Ù·Ú·¯¤˜ ̤Û˘ ÁÚ·ÌÌ‹˜, ˘fiÓÔÈ· ¯ˆÚÔηٷÎÙËÙÈ΋˜ ÂÂÍÂÚÁ·Û›·˜, ÔÏÏ·Ï‹˜ ˘ÔÊ˘Ûȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Î.Ï.), Á›ÓÂÙ·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ˘Ôı·Ï¿ÌÔ˘/˘fiÊ˘Û˘. £Âڷ›· ∏ ıÂڷ›· ηıÔÚ›˙ÂÙ·È ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË ·fi ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ. OÈ Û˘Ó‹ıÂȘ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¤Ú·Ó Ù˘ ·ÈÙÈÔÏÔÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Î·È ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹. ∆· ·È‰È¿ Î·È ÔÈ ÁÔÓ›˜ ÙÔ˘˜ Ú¤ÂÈ Ó· ÂÓËÌÂÚˆıÔ‡Ó ÁÈ· ÙËÓ ·Í›· Ù˘ ÏÔ‡ÛÈ·˜ Û Á·Ï·ÎÙÔÎÔÌÈο ÚÔ˚fiÓÙ·, ÊÚÔ‡Ù· Î·È Ï·¯·ÓÈο ‰È·ÙÚÔÊ‹˜ Î·È ÁÈ· ÙËÓ ·Ó¿ÁÎË ·ÔÊ˘Á‹˜ ÙˆÓ ÔÏÏÒÓ ÏÈ·ÚÒÓ ÁÂ˘Ì¿ÙˆÓ Î·È Ù˘ÔÔÈËÌ¤ÓˆÓ ÚÔ˚fiÓÙˆÓ (Á·Úȉ¿ÎÈ·, ÙÛȘ, croissants, Î.Ï.). ∫·›ÚÈ· Â›Ó·È Ë ·ÈÙÈÔÏÔÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË (·ÓÙÈÌÂÙÒÈÛË ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘, .¯. Û ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, Û ۇӉÚÔÌ· ‰˘Û·ÔÚÚfiÊËÛ˘, Û ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î.Ï.). ™Ù· Ï·›ÛÈ· Ù˘ ıÂڷ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÁÈ· ÙËÓ ÔÔ›· ı· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› ÛÙÔ˘˜ ÁÔÓ›˜ fiÙÈ ‰ÂÓ ‰›ÓÂÙ·È ·ÏÒ˜ Ì ‚¿ÛË ÙËÓ ÂÈı˘Ì›· Ó· Êı¿ÛÔ˘Ó Ù· ·È‰È¿ ¤Ó· “·ÍÈÔı·‡Ì·ÛÙÔ” ‡„Ô˜. ÃÔÚËÁÂ›Ù·È Û ÂȉÈΤ˜ ÌfiÓÔ ÂӉ›ÍÂȘ (·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Û‡Ó‰ÚÔÌÔ Turner, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·), ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ‰fiÛÂȘ Î·È Ì ٷÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó· ·È‰ÔÂÓ‰ÔÎÚÈÓÔÏÔÁÈο ΤÓÙÚ·.
¶·È‰È·ÙÚÈ΋ 2001;64:406-409
¶ÔÚ›· Î·È ÚfiÁÓˆÛË ∞Ó¿ÏÔÁ· Ì ÙËÓ ˘ÔΛÌÂÓË ·ÈÙÈÔÏÔÁ›·, Û ÔÈÎÔÁÂÓ¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ¯ˆÚ›˜ ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜, ·Ú·ÙËÚÂ›Ù·È ÎÔÓÙfi, fi¯È fï˜ ÛËÌ·ÓÙÈο, ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ™Â ȉÈÔÛ˘ÛÙ·Ûȷ΋ ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ Î·È ÂÓ‹‚ˆÛ˘, ˘¿Ú¯ÂÈ ÈηÓÔÔÈËÙÈÎfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ™Â ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÌÂÙ¿ ıÂڷ›· ˘ÔηٿÛÙ·Û˘, ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Â›Ó·È ÈηÓÔÔÈËÙÈÎfi, Û˘Ó‹ıˆ˜ ̤۷ ÛÙ· Ï·›ÛÈ· ÙÔ˘ ‡„Ô˘˜-ÛÙfi¯Ô˘. ™ÙȘ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ, Ë ÂͤÏÈÍË Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÂοÛÙÔÙ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘. æ∏§O ∞¡∞™∆∏ª∞ ∆Ô „ËÏfi ·Ó¿ÛÙËÌ·, fiˆ˜ Î·È ÙÔ ÎÔÓÙfi, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÔÈΛϷ ·›ÙÈ· Î·È Ó· Â›Ó·È Â›Ù ·ÚÔ‰ÈÎfi ›Ù ÌfiÓÈÌÔ. ∏ ·ÈÙÈÔÏÔÁ›· ·Ó·ÁÚ¿ÊÂÙ·È Û¯ËÌ·ÙÈο ÛÙÔÓ ¶›Ó·Î· 2 Î·È ·Ó·Ï‡ÂÙ·È ÛÙË Û˘Ó¤¯ÂÈ·. AÈÙÈÔÏÔÁ›· Î·È Ù·ÍÈÓfiÌËÛË ∞) ªfiÓÈÌÔ „ËÏfi ·Ó¿ÛÙËÌ·: ·) OÈÎÔÁÂÓ¤˜ „ËÏfi ·Ó¿ÛÙËÌ·, ‚) ™‡Ó‰ÚÔÌ· (Û‡Ó‰ÚÔÌÔ Sotos, Û‡Ó‰ÚÔÌÔ Marfan) Á) ÃÚˆÌÔÛˆÌȷΤ˜/ÁÂÓÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (Û‡Ó‰ÚÔÌÔ Klinefelter - 47,XXY, OÌÔ΢ÛÙÈÓÔ˘Ú›·) ‰) ÀÔÊ˘ÛÈ·Îfi˜ ÁÈÁ·ÓÙÈÛÌfi˜. µ) ¶·ÚÔ‰ÈÎfi „ËÏfi ·Ó¿ÛÙËÌ·: ·) ¶·¯˘Û·ÚΛ·, ‚) ™˘ÁÁÂÓ‹˜ ˘ÂÚÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ, Á) ¶ÚÒÈÌË ‹‚Ë. ∆· ‰È·ÁÓˆÛÙÈο ‚‹Ì·Ù· Î·È Ë ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ÛÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ „ËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ·Ó¿ÏÔÁ· ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, ‰ËÏ. ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ·Ó·ÌÓËÛÙÈÎÔ‡ Î·È Ù˘ ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ÂͤٷÛ˘, ÛËÌ·Û›· ÛÙÈÁÌ¿ÙˆÓ Î·È ÚÔ‚ÏËÌ¿ÙˆÓ ·fi ¿ÏÏ· Û˘ÛÙ‹Ì·Ù·, .¯. ΢ÎÏÔÊÔÚÈÎÔ‡ Û ۇӉÚÔÌÔ Marfan, ÔÊı·ÏÌÔÏÔÁÈÎfi Úfi‚ÏËÌ·, .¯. Û ÔÌÔ΢ÛÙÈÓÔ˘Ú›· Î·È Û‡Ó‰ÚÔÌÔ Marfan, Úfi‚ÏËÌ· ÂÓ‹‚ˆÛ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ Klinefelter Î.Ï. ∞Í›˙ÂÈ Ó· ÙÔÓÈÛÙ›, ¿ÓÙˆ˜, fiÙÈ Î·È ÛÙÔ „ËÏfi ·Ó¿ÛÙËÌ· ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË. ∞˘Ùfi Û˘Ì‚·›¶›Ó·Î·˜ 2. ∞ÈÙÈÔÏÔÁ›· „ËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ∞) ªfiÓÈÌÔ „ËÏfi ·Ó¿ÛÙËÌ· ñ OÈÎÔÁÂÓ¤˜ „ËÏfi ·Ó¿ÛÙËÌ· ñ ™‡Ó‰ÚÔÌ· - ™‡Ó‰ÚÔÌÔ Sotos - ™‡Ó‰ÚÔÌÔ Marfan ñ ÃÚˆÌÔÛˆÌȷΤ˜ / ÁÂÓÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ - ™‡Ó‰ÚÔÌÔ Klinefelter (47,XXY) - OÌÔ΢ÛÙÈÓÔ˘Ú›· ñ ÀÔÊ˘ÛÈ·Îfi˜ ÁÈÁ·ÓÙÈÛÌfi˜ µ) ¶·ÚÔ‰ÈÎfi „ËÏfi ·Ó¿ÛÙËÌ· ñ ¶·¯˘Û·ÚΛ· ñ ™˘ÁÁÂÓ‹˜ ˘ÂÚÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ ñ ¶ÚÒÈÌË ‹‚Ë
Paediatriki 2001;64:406-409
ÓÂÈ, ΢ڛˆ˜ ÁÈ·Ù› ÛÙÔ ·ÚÔ‰ÈÎfi „ËÏfi ·Ó¿ÛÙËÌ· ÙÔ ·È‰› ı· ηٷϋÍÂÈ ÎÔÓÙfi˜ ÂÓ‹ÏÈÎÔ˜, Â¿Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Van den Brande JL, Rappaport R. Normal and abnormal growth. πn: Bertrand J, Rappaport R, Sizonenko PC, eds. Pediatric Endocrinology: Physiology, Pathophysiology and Clinical aspects. 2nd ed. Baltimore: Williams and Wilkins; 1993. p. 185-207. 2. Hintz RL, Ritzen M. Short Stature. In: Hochberg Z, ed. Practical Algorithms in Pediatric Endocrinology. Basel: Karger Verlag; 1999. p. 4-5. 3. Hintz RL, Bourguignon JP. Growth hormone treatment. In: Hochberg Z, editor. Practical Algorithms in Pediatric Endocrinology. Basel: Karger Verlag; 1999. p. 6-7. 4. Hochberg Z, Ritzen M. Tall Stature. In: Hochberg Z, editor. Practical Algorithms in Pediatric Endocrinology. Basel: Karger Verlag; 1999. p. 8-9. 5. Parkin JM. The short child. In: Brook CGD, editor. Clinical paediatric Endocrinology. 2nd ed. Oxford: Blackwell Scientific Publications; 1989. p. 96-117. 6. Brook CGD, Hindmarsh PC, Smith PJ. The management of short stature. In: Brook CGD, editor. Clinical paediatric Endocrinology. 2nd ed. Oxford: Blackwell Scientific Publications; 1989. p. 118-127. 7. Hindmarsh PC, Brook CGD. Tall stature. In: Brook CGD, editor. Clinical paediatric Endocrinology. 2nd ed. Oxford: Blackwell Scientific Publications; 1989. p. 128-142. 8. Rogol AD, Clark PA, Roemmich JN. Growth and pubertal development in children and adolescents: effects of diet and physical activity. Am J Clin Nutr 2000;72(2 Suppl):521S-528S. 9. Betts P. Which children should receive growth hormone treatment. Long term side effects possible with high doses. Arch Dis Child 2000;83:176-178. 10. Kanaka C. Final Height in girls with Turner Syndrome and children with idiopathic short stature who have been treated with Growth hormone. ¶Ú·ÎÙÈο 3Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ™˘Ó‰ڛԢ Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ŒÚ¢ӷ˜ ∂Ê·ÚÌÔÁÒÓ ∞˘ÍËÙÈ΋˜ OÚÌfiÓ˘; 1998, 12 ¢ÂÎÂÌ‚Ú›Ô˘; ∞ı‹Ó·. 11. ¢È·Ù·Ú·¯¤˜ Ù˘ ∞‡ÍËÛ˘. ™ÙÔ: ¶ÂÙÚ›‰Ô˘ ∂, ∫·Ú¿ıÈÔ˜ £, ∆ÚȯfiÔ˘ÏÔ˜ ¢, ÂΉ. ¶ÚÔÛ˘Ìو̷ÙÈÎfi˜ ŒÏÂÁ¯Ô˜ ¶·È‰ÈÒÓ Î·È ∂Ê‹‚ˆÓ: ¢˘Ó·ÙfiÙËÙ˜, ¶ÂÚÈÔÚÈÛÌÔ› Î·È ¶ÚÔ‚ÏËÌ·ÙÈÛÌÔ›. ∞ı‹Ó·: ∑∏∆∞ π·ÙÚÈΤ˜ ∂ΉfiÛÂȘ; 1999. ÛÂÏ. 42-47. 12. Chanarin I. Causes of impaired fetal growth. JR Soc Med 2000;93:159. 13. Davis PB, Kercsamar CM. Growth in children with chronic lung disease. N Engl J Med 2000;342: 851-859. 14. Lanes R. Growth hormone treatment in patients with intrauterine growth retardation. J Clin Endocr Metab 2000;85:1345-1346.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· ∫·Ó·Î¿-Gantenbein ∆˘ÌÊÚËÛÙÔ‡ 52, 152 34, ÷ϿӉÚÈ e-mail: ganten@hol.gr
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¶·È‰È·ÙÚÈ΋ 2001;64:410-416
∂º∏µπ∫∏ π∞∆ƒπ∫∏
Paediatriki 2001;64:410-416
ADOLESCENT MEDICINE
ŒÊË‚ÔÈ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ∞. ¢. ∞ÛÎÔ‡ÓË - ™ÙÚÔ‡ÌÔ˘
Adolescents at-risk A. D. Askouni - Stroumpou
¶ÂÚ›ÏË„Ë: OÈ Û˘ÌÂÚÈÊÔÚ¤˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ¤¯Ô˘Ó Ì›· ηı·Ú¿ ·Ó·Ù˘Íȷ΋ ‚¿ÛË Î·È Â·˘Í¿ÓÔÓÙ·È ·fi Û˘Ó‰˘·ÛÌÔ‡˜ ÎÔÈÓˆÓÈÎÒÓ Î·È ÔÏÈÙÈÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ‰˘ÙÈÎÔ‡ ÔÏÈÙÈÛÌÔ‡. ªÂ ·˘Ù‹ ÙËÓ ¤ÓÓÔÈ·, fiÏÔÈ ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ ÌÔÚ› Ó· ‰È·ÎÈÓ‰˘ÓÂ‡Ô˘Ó Û οÔÈÔ ‚·ıÌfi ÁÈ· Ó· ÔÏÔÎÏËÚÒÛÔ˘Ó ÙËÓ ·Ó·Ù˘Íȷ΋ ÙÔ˘˜ ÔÚ›· ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· ÚÔ˜ ÙË ÓÂfiÙËÙ·, Ó· Á›ÓÔ˘Ó ·˘ÙfiÓÔÌÔÈ Î·È ÈηÓÔ› Ó· ÛÙ·ıÔ‡Ó ÛÙ· fi‰È· ÙÔ˘˜. ªÂÚÈÎÔ› ¤ÊË‚ÔÈ ÂÎÙ›ıÂÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Û ۯ¤ÛË Ì ¿ÏÏÔ˘˜, ÏfiÁˆ ȉÈÔÛ˘ÁÎÚ·Û›·˜, Û˘ÓıËÎÒÓ ˙ˆ‹˜ ηÈ/‹ ˘ÔΛÌÂÓ˘ „˘¯ÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ÂÓÒ ÔÈ Î›Ó‰˘ÓÔÈ ¿ÓÙ· ˘¿Ú¯Ô˘Ó. OÈ Â·ÁÁÂÏ̷ٛ˜ ˘Á›·˜ ¤¯Ô˘Ó ÌÂÁ¿ÏË ˘Â˘ı˘ÓfiÙËÙ· ÛÙÔ Ó· ÂÓÙÔ›˙Ô˘Ó ÙȘ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ ÛÙÔ˘˜ ¤ÊË‚Ô˘˜ ·ÛıÂÓ›˜ Î·È Ó· οÓÔ˘Ó Ù· ηٿÏÏËÏ· ‚‹Ì·Ù· ÁÈ· Ó· ÙÔ˘˜ ÚÔÛٷ٤„Ô˘Ó ·fi ÙȘ ·ÓÂÈı‡ÌËÙ˜ Û˘Ó¤ÂȘ. ∫·Ù¿ ÙËÓ ÂÎÙ›ÌËÛË ˘Á›·˜ ÙÔ˘ ÂÊ‹‚Ô˘, Ë ÂÁηٿÛÙ·ÛË Û¯¤Û˘ ÂÌÈÛÙÔÛ‡Ó˘ Î·È Ë ÂÓۈ̿وÛË ÛÙËÓ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Ù˘ ÂÈΛӉ˘Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÁÈ· ÙËÓ ˘Á›·, ηıÒ˜ Î·È Ë Î·ıÔ‰‹ÁËÛË ÁÈ· ÙË Ï‹„Ë ·fi ÙÔÓ ¤ÊË‚Ô ·fiÊ·Û˘, Â›Ó·È ·Ó·Áη›Â˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜, Â¿Ó ÚÔÙ›ıÂÓÙ·È Ó· ·Ú¤¯Ô˘Ó ÊÚÔÓÙ›‰· Û ÂÊ‹‚Ô˘˜.
Abstract: Risk-taking behavior in adolescents has a clear developmental basis and is augmented by a combination of social and cultural factors characteristic of contemporary western civilization. Within this context, all normal adolescents must be risk-takers to some degree in order to complete the contemporary child-rearing goals that enable our youngsters to be autonomous and capable of standing on their own two feet. Some adolescents are at a greater risk than others because of temperament, situational factors and/or underlying psychological disturbances, but the risk is always there. The health professional has no greater responsibility than identifying risk-taking behaviors in adolescent patients and taking appropriate steps to protect them against adverse consequences. Establishing a trust relationship and incorporating into the health assessment of adolescents the health-risk behavior together with prevention guidance and guided decision making are essential functions of all primary care physicians if they intend to provide care to adolescents.
§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÌÂÚÈÊÔÚ¿ ÂÈΛӉ˘ÓË ÁÈ· ÙËÓ ˘Á›·, ÛÂÍÔ˘·ÏÈ΋ Û˘ÌÂÚÈÊÔÚ¿, ηٿ¯ÚËÛË Ô˘ÛÈÒÓ, ‚Ï¿‚˜ ·fi ·Ù˘¯‹Ì·Ù·, ÂÎÙfi˜ ÂϤÁ¯Ô˘ Û˘ÌÂÚÈÊÔÚ¿, ÂÁÎÏËÌ·ÙÈÎfiÙËÙ·, Û¯¤ÛË ÂÌÈÛÙÔÛ‡Ó˘ Ì ÙÔÓ ¤ÊË‚Ô, „˘¯ÔÎÔÈÓˆÓÈ΋ ‰ÈÂÚ‡ÓËÛË, ÚÔÏËÙÈ΋ ·ÁˆÁ‹, ηıÔ‰ËÁÔ‡ÌÂÓË Ï‹„Ë ·fiÊ·Û˘, ÂÓ‰˘Ó¿ÌˆÛË.
Key words: health risk behavior, sexual behavior, substance abuse, accidental injury, out of control behavior, delinquency, relationship of trust with the adolescent, psychosocial exploration, prevention guidance, guided decision making, reinforcement.
¶·È‰›·ÙÚÔ˜, ¢È¢ı‡ÓÙÚÈ· ÀËÚÂÛÈÒÓ ªËÙÚfiÙËÙ·˜ - ¶·È‰ÈÔ‡ ÙÔ˘ ¶π∫¶∞, ∞ı‹Ó·
Pediatrician, Director of Maternal - Child Services PIKPA, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:410-416
∂ÈÛ·ÁˆÁ‹ T· ¯ÚfiÓÈ· Ù˘ ÂÊ˂›·˜ ·ÔÙÂÏÔ‡Ó ÂÍ ÔÚÈÛÌÔ‡ ¯ÚfiÓÈ· ÂÈÚ·Ì·ÙÈÛÌÔ‡ Î·È ÂÍÂÚ‡ÓËÛ˘. OÈ ¤ÊË‚ÔÈ ÁÈ· Ó· ·˘ÙÔÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ·ÔÎÙÔ‡Ó ¤Ó· ¢ڇ Ê¿ÛÌ· Û˘ÌÂÚÈÊÔÚÒÓ. ¶ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ - ÁÓˆÛÈ·ÎÔ›, „˘¯ÔÏÔÁÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› - Û˘Ì‚¿ÏÏÔ˘Ó ÒÛÙÂ Ë ÂÊ˂›· Ó· Â›Ó·È ÛÙÂÓ¿ Û˘Ó˘Ê·Ṳ̂ÓË Ì ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ô˘ ÂÓ¤¯Ô˘Ó ÎÈÓ‰‡ÓÔ˘˜ (¶›Ó·Î·˜ 1). ∆Ô ÂÁˆÎÂÓÙÚÈÎfi ·›ÛıËÌ· ·ÓÙÔ‰˘Ó·Ì›·˜ Î·È ÈÛ¯˘ÚÔ› ·ÚÓËÙÈÎÔ› Ì˯·ÓÈÛÌÔ› οÓÔ˘Ó Ù· Ó·ڿ ¿ÙÔÌ· Ó· ·ÈÛı¿ÓÔÓÙ·È ÚÔÛÙ·ÙÂ˘Ì¤Ó· ·fi ÙȘ ÔÔÈÂÛ‰‹ÔÙ ·ÚÓËÙÈΤ˜ Û˘Ó¤ÂȘ ÙˆÓ Û˘ÌÂÚÈÊÔÚÒÓ ÙÔ˘˜ (1-4). ∏ ·Ó·Ù˘Íȷ΋ ÔÚ›· Ù˘ ÂÊ˂›·˜ Û˘ÓÔÙÈο ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÂÈڷʤÙËÛË Î·È ÙÔÓ ·Ô¯ˆÚÈÛÌfi ·fi Ù· ‰ÂÛÌ¿ Ù˘ ·È‰È΋˜ ÂÍ¿ÚÙËÛ˘, ÙË ‰È·ÌfiÚʈÛË Ù˘ ·ÙÔÌÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ·˘ÙÔ‡, ÙÔÓ ¤ÏÂÁ¯Ô ÛÙÔÓ Â·˘Ùfi Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ Î·È ÙËÓ ·fiÎÙËÛË Ù˘ ÈηÓfiÙËÙ·˜ ÁÈ· ÛÂÍÔ˘·ÏÈΤ˜ Î·È ·ÌÔÈ‚·›Â˜ ‰È·ÚÔÛˆÈΤ˜ Û¯¤ÛÂȘ. ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ÂÊ‹‚Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ӥ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÔÎÈÌ¿ÛÂÈ Ù· fiÚÈ¿ ÙÔ˘ Î·È Ó· ÂÍÂÚ¢ӋÛÂÈ ÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘ ÁÈ· ·ÓÂÍ¿ÚÙËÙË ÏÂÈÙÔ˘ÚÁ›·. °È· ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ·˘Ù¤˜ Ô ¤ÊË‚Ô˜ ¤¯ÂÈ Ï›ÁË ÚÔËÁÔ‡ÌÂÓË ÂÌÂÈÚ›·, ÌË ·ÓÙÈÎÂÈÌÂÓÈ΋ ÏËÚÔÊfiÚËÛË, ¿ÁÓÔÈ· Î·È ·˘ıÔÚÌËÙÈÛÌfi. ªÂÚÈΤ˜ ÊÔÚ¤˜ Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ Â›Ó·È ·ÛÊ·Ï‹˜ Ë ÌÂÙ¿‚·ÛË ÙˆÓ Ó·ÚÒÓ ·ÙfiÌˆÓ Ì¤Û· ·fi ÙËÓ
Paediatriki 2001;64:410-416
ÔÈÎÈÏ›· ÙˆÓ ÂÈΛӉ˘ÓˆÓ Û˘ÌÂÚÈÊÔÚÒÓ. ∏ ÁÓˆÛȷ΋ ·ÓˆÚÈÌfiÙËÙ· Î·È Ë ·ÓÈηÓfiÙËÙ· Ó· ηٷÓÔ‹ÛÂÈ ÙȘ ·ÒÙÂÚ˜ Û˘Ó¤ÂȘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Èı·ÓfiÙËÙ· ηٷÛÙÚÔÊÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ (5). OÈ Û˘ÌÂÚÈÊÔÚ¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Á›· ·ÔÎÙÒÓÙ·È Û˘Ó‹ıˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜ Î·È ¤¯Ô˘Ó ÔÚÈṲ̂ӷ ¯·Ú·ÎÙËÚÈÛÙÈο (¶›Ó·Î·˜ 2). ∏ ηٷÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ù˘ „˘¯ÔÎÔÈÓˆÓÈ΋˜ Î·È ÁÓˆÛȷ΋˜ ·Ó¿Ù˘Í˘ Â›Ó·È ‚·ÛÈ΋ ÁÈ· ÙÔ ¯ÂÈÚÈÛÌfi ÙˆÓ ÂÈΛӉ˘ÓˆÓ Û˘ÌÂÚÈÊÔÚÒÓ. ∞Ï‹, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ‰È¿ÏÂÍË ÁÈ· ÙÔ˘˜ ‰˘Ó·ÙÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ‰ÂÓ ÚfiÎÂÈÙ·È Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜. ™ÙÔ Û‡ÓÔÏÔ Ù˘ ‰È·‰Èηۛ·˜ Ú¤ÂÈ Ó· ¤¯ÂÈ ÂÓÂÚÁfi ÚfiÏÔ Ô ¤ÊË‚Ô˜ ̤۷ ·fi ·Ó¿Ï˘ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ. O ¤Ê‹‚Ô˜ Ú¤ÂÈ Ó· ·ÔÊ·Û›ÛÂÈ ÙË ‰Ú¿ÛË Ô˘ ı· ÂÈϤÍÂÈ. ∂ȉÈÎfiÙÂÚ· ÛÙËÓ ÚÒÈÌË Î·È Ì¤ÛË ÂÊ˂›·, Ë ÛΤ„Ë ÚÔÛ·Ó·ÙÔÏ›˙ÂÙ·È ÛÙÔ “Â‰Ò Î·È ÙÒÚ·”. ¶Èı·Ó¤˜ ÌÂÏÏÔÓÙÈΤ˜ Û˘Ó¤ÂȘ ‰ÂÓ Á›ÓÔÓÙ·È Ï‹Úˆ˜ ηٷÓÔËÙ¤˜. ∏ ÚÔÙÂÈÓfiÌÂÓË ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ı· Ú¤ÂÈ Ó· ¤¯ÂÈ ¿ÌÂÛ· ÔʤÏË ÁÈ· ÙËÓ ÚÔÛˆÈ΋ ˙ˆ‹ ÙÔ˘. ™ÙËÓ fi„ÈÌË (ÌÂÙ¿ Ù· 16 ¯ÚfiÓÈ·) ÂÊ˂›·, Ë ÁÓˆÛȷ΋ ˆÚ›Ì·ÓÛË ÂÈÙÚ¤ÂÈ ÛÙÔ ¿ÙÔÌÔ Ó· ÂÎÙÈÌ‹ÛÂÈ ·ÊËÚË̤Ó˜ ¤ÓÓÔȘ Î·È È‰¤Â˜ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ Ì¤ÏÏÔÓ. ™ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ Ó¤ˆÓ Ô˘ Â›Ó·È ÈÔ Èı·Ófi Ó· ˘ÈÔıÂÙ‹ÛÔ˘Ó ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜, ÂȉÚÔ‡Ó ÛËÌ·ÓÙÈο ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ ÈÛÙÔÚÈÎÔ›, ÔÏÈÙÈÛÌÈÎÔ› Î·È ‚ÈÔ„˘¯ÔÎÔÈÓˆÓÈÎÔ› (6).
¶›Ó·Î·˜ 1. ™˘ÌÂÚÈÊÔÚ¤˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÔÈ Û˘Ó¤ÂȤ˜ ÙÔ˘˜ 1. ™ÂÍÔ˘·ÏÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ÂÊ‹‚ˆÓ ñ æ˘¯ÔÎÔÈÓˆÓÈΤ˜ ÂȉڿÛÂȘ ñ ™ÂÍÔ˘·ÏÈο ÌÂÙ·‰È‰fiÌÂÓ· ÓÔÛ‹Ì·Ù· ñ ∂Á΢ÌÔÛ‡ÓË 2. ∫·Ù¿¯ÚËÛË Ô˘ÛÈÒÓ (οÓÈÛÌ·, ÔÈÓfiÓÂ˘Ì·, ·Ú¿ÓÔÌ· Ê¿Ú̷η) ñ ∞Ù˘¯‹Ì·Ù· ÔÊÂÈÏfiÌÂÓ· Û ˘ÂÚ‚ÔÏÈ΋ ¯Ú‹ÛË ñ ™˘Ó‹ıÂÈ· Î·È ÂıÈÛÌfi˜ ñ º˘ÛÈ΋ ‚Ï¿‚Ë ñ æ˘¯ÔÎÔÈÓˆÓÈ΋ ‚Ï¿‚Ë (Û˘Ó·ÈÛıËÌ·ÙÈ΋, ÂÎ·È‰Â˘ÙÈ΋, ‰È·ÚÔÛˆÈ΋) ñ ¶ÚÔ‚Ï‹Ì·Ù· Ì ÙÔ ÓfiÌÔ ñ ∏ ¯Ú‹ÛË ÙˆÓ Ì·Ï·ÎÒÓ Ô˘ÛÈÒÓ ·ÔÙÂÏ› ÙË ı‡Ú· ÂÈÛfi‰Ô˘ ÛÙË ¯Ú‹ÛË ÛÎÏËÚÒÓ Ô˘ÛÈÒÓ ñ £¿Ó·ÙÔ˜ ·fi ˘ÂÚ‚ÔÏÈ΋ ‰fiÛË 3. ÀÂÚ‚ÔÏÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Û ·Ô‰ÂÎÙ¤˜ Ú¿ÍÂȘ (ÂÈΛӉ˘ÓË Ô‰‹ÁËÛË, ¿ÏϘ ÂÈΛӉ˘Ó˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜) ñ ∞Ù˘¯‹Ì·Ù·, ı¿Ó·ÙÔ˜, ηٷÛÙÚÔÊ‹ ÂÚÈÔ˘Û›·˜ 4. ™˘ÌÂÚÈÊÔÚ¤˜ ÂÎÙfi˜ ÂϤÁ¯Ô˘ (·ÏËÙ›·, ·Ú·ÙÒÌ·Ù·, Ê˘Á‹ ·fi ÙÔ Û›ÙÈ, ·fiÂÈÚ· ·˘ÙÔÎÙÔÓ›·˜, ÔÚÓ›·, ‚›·) ñ ¶ÚÔ‚Ï‹Ì·Ù· Ì ÙÔ ÓfiÌÔ ñ æ˘¯ÔÎÔÈÓˆÓÈ΋ ‚Ï¿‚Ë ñ º˘ÛÈ΋ ‚Ï¿‚Ë, ı¿Ó·ÙÔ˜ 5. ∂ÁÎÏËÌ·ÙÈÎfiÙËÙ· (ÎÏÔ¤˜, ÚÔÒıËÛË Ô˘ÛÈÒÓ, ÂÈı¤ÛÂȘ, ·ÓıÚˆÔÎÙÔӛ˜ Î.Ï.) ñ ¶ÚÔ‚Ï‹Ì·Ù· Ì ÙÔ ÓfiÌÔ ñ æ˘¯ÔÎÔÈÓˆÓÈ΋ ‚Ï¿‚Ë ñ º˘ÛÈ΋ ‚Ï¿‚Ë, ı¿Ó·ÙÔ˜ (ı‡Ì· ‚›·˜)
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¶·È‰È·ÙÚÈ΋ 2001;64:410-416
OÈ ¤ÊË‚ÔÈ Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó ÛÙȘ ‰˘ÙÈΤ˜ ÎÔÈӈӛ˜ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Â˘¿ÏˆÙÔÈ ·fi ÙÔ˘˜ Ó¤Ô˘˜ Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó Û ·Ú·‰ÔÛȷΤ˜ ÎÔÈӈӛ˜. ™ÙȘ ‰˘ÙÈΤ˜ ÎÔÈӈӛ˜, Ë Ì·ÎÚ¿ ÂÎ·È‰Â˘ÙÈ΋ ‰È·‰Èηۛ· ·ÔÌ·ÎÚ‡ÓÂÈ ÙÔ˘˜ Ó¤Ô˘˜ ·fi ÙÔ ÎÔÈÓˆÓÈÎfi Ú‡̷ Î·È ÙÔ˘˜ Ô‰ËÁ› ÔÏϤ˜ ÊÔÚ¤˜ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ÔÌ¿‰·˜ ÂÊ‹‚ˆÓ-Û˘ÓÙÚfiÊˆÓ Ì ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜. ™ÙÔ˘˜ ÔÈΛÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙȘ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜, Û˘ÁηٷϤÁÂÙ·È Î·È Ô ¯ÚfiÓÔ˜ Ù˘ ÂÓ‹‚ˆÛ˘. ¶ÚÒÈÌÔ˜ ÛÙ· ÎÔÚ›ÙÛÈ· Î·È fi„ÈÌÔ˜ ÛÙ· ·ÁfiÚÈ·, Úԉȷı¤ÙÂÈ Û ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ (¶›Ó·Î˜ 3,4). ¢È·‰Èηۛ· ÂϤÁ¯Ô˘ Î·È Î·ıÔ‰‹ÁËÛ˘ ∏ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È Ô ¯ÂÈÚÈÛÌfi˜ ÙˆÓ ÂÈΛӉ˘ÓˆÓ Û˘ÌÂÚÈÊÔÚÒÓ ÁÈ· ÙËÓ ˘Á›· Â›Ó·È Ô˘ÛÈ·ÛÙÈο Ù· ›‰È· Ì ·˘Ù¿ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÔÈÔ˘‰‹ÔÙ „˘¯ÔÎÔÈÓˆÓÈÎÔ‡ ı¤Ì·ÙÔ˜ ·˘Ù‹˜ Ù˘ ËÏÈÎȷ΋˜ ÔÌ¿‰·˜ Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÙË ‰È·‰Èηۛ· ÙÔ˘ GAPS, ‰ËÏ. ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜ ÙˆÓ ÂÊ‹‚ˆÓ Ù˘ American Academy of Pediatrics. ·) ∆Ô ÚÒÙÔ - Ôχ ÛËÌ·ÓÙÈÎfi - ‚‹Ì· Â›Ó·È Ë ¶›Ó·Î·˜ 2. ÷ڷÎÙËÚÈÛÙÈο Û˘ÌÂÚÈÊÔÚÒÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Á›· 1. ™Ù· ¯ÚfiÓÈ· Ù˘ ÂÊ˂›·˜ ·ÔÎÙÒÓÙ·È ÔÏϤ˜ Û˘ÌÂÚÈÊÔÚ¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Á›· ÙÔ˘ ·ÙfiÌÔ˘ ıÂÙÈο ‹ ·ÚÓËÙÈο ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘ 2. OÈ Î›Ó‰˘ÓÔÈ Â›Ó·È ¿ÌÂÛÔÈ ‹ ·ÔÌ·ÎÚ˘Ṳ̂ÓÔÈ. ÕÌÂÛÔÈ Î›Ó‰˘ÓÔÈ: ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·ÏÏ·Á‹˜ ̤ۈ Ù˘ ·Ú¤Ì‚·Û˘ 3. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ Û˘ÌÂÚÈÊÔÚ¤˜ ÙȘ Û¯ÂÙÈΤ˜ Ì ÙËÓ ˘Á›·, Â›Ó·È Â›ÎÙËÙÔÈ ‹ ÛÙ·ıÂÚÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÂÊ˂›· 4. OÈ ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ Û˘ÌÂÚÈÊÔÚ¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘Á›· ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ˆ˜ Û˘ÌϤÁÌ·Ù· 5. ™Â οı ·Ó·Ù˘Íȷ΋ ÂÚ›Ô‰Ô ÂΉËÏÒÓÔÓÙ·È Û˘ÌϤÁÌ·Ù· Û˘ÌÂÚÈÊÔÚÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ·ÊÔÚÔ‡Ó ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô, ·ÏÏ¿ Î·È ÚÔÁÂÓ¤ÛÙÂÚ˜.
Paediatriki 2001;64:410-416
ÂÁηٿÛÙ·ÛË ÌÈ·˜ Û¯¤Û˘ ÂÌÈÛÙÔÛ‡Ó˘ ÌÂٷ͇ ÂÊ‹‚Ô˘ Î·È ÏÂÈÙÔ˘ÚÁÔ‡ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜. ‚) ∆Ô ‰Â‡ÙÂÚÔ Â›Ó·È Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ‰ÈÂÚ‡ÓËÛË ÌÂ Û˘ÏÏÔÁ‹ ÏËÚÔÊÔÚÈÒÓ (Gather information) ÙˆÓ Û˘Ó·ÈÛıËÌ¿ÙˆÓ ÙÔ˘ ÂÊ‹‚Ô˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ì ηıÔÚÈṲ̂ÓÔ ÙÚfiÔ. Á) ∆Ô ÙÚ›ÙÔ ‚‹Ì· ÌÂÙÚ¿ Ù· Û˘Ó·ÈÛı‹Ì·Ù· Î·È ÙȘ Û˘ÌÂÚÈÊÔÚ¤˜ Û ۇÁÎÚÈÛË Ì ·˘Ù¿ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÊ‹‚ˆÓ (Assess - ÂÎÙ›ÌËÛË ÎÈÓ‰‡ÓÔ˘). ‰) ∆Ô Ù¤Ù·ÚÙÔ ‚‹Ì· ηıÔÚ›˙ÂÈ ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ‚ÈÔÏÔÁÈÎÔ‡ Î·È „˘¯ÔÎÔÈÓˆÓÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Problem identification). Â) ™ÙÔ ¤ÌÙÔ ‚‹Ì·, Ô ÎÏÈÓÈÎfi˜ ı· Ú¤ÂÈ Ó· ¤¯ÂÈ Ì›· ÍÂοı·ÚË ÂÈÎfiÓ· ÙˆÓ ÂȉÈÎÒÓ ÎÈÓ‰‡ÓˆÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ Ô ¤ÊË‚Ô˜ Î·È Ó· ‰È·¯ˆÚ›˙ÂÈ ·Ó Ë Û˘Ì‚Ô˘Ï¢ÙÈ΋ Â›Ó·È ·ÚÎÂÙ‹ ‹ ··ÈÙÂ›Ù·È ÈÔ ÂÎÙÂٷ̤ÓË ‰ÈÂÚ‡ÓËÛË Î·È ·Ú·ÔÌ‹ (Solutions) (7-9). O ÚfiÏÔ˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ Ù˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ O ÚfiÏÔ˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ Ù˘ ¶.º. Â›Ó·È ÎÚ›ÛÈÌÔ˜ ÛÙËÓ ÔÚ›· Ù˘ ÂÎÙ›ÌËÛ˘ Î·È Ù˘ ·Ú¤Ì‚·Û˘. ¶Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÂȉÈÎfi˜ ÂΛÓÔ˜ ·fi ÙÔÓ ÔÔ›Ô ˙ËÙÂ›Ù·È Ë Û˘Ì‚Ô˘Ï‹. ¶Ú¤ÂÈ Ó· ›ӷÈ, ÂÈϤÔÓ, ÁÔÓÂ˚Îfi˜ Ê›ÏÔ˜ Î·È Û ÚfiÏÔ ÚÔÙ‡Ô˘ ÂÓ‹ÏÈη. ∞˘Ùfi ·ÓÙ·Ó·ÎÏ¿ Ì›· ıÂÌÂÏȷ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ Ù˘ Ú·ÎÙÈ΋˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Î·È Ù˘ ∂ÊË‚È΋˜ π·ÙÚÈ΋˜. ∆Ô ‚·ÛÈÎfi ÛÙËÓ ¶·È‰È·ÙÚÈ΋ Â›Ó·È Ë ·Ó¿Ù˘ÍË Ì›·˜ Û¯¤Û˘ Ì ÙÔ ÁÔÓ¤·, ÂÓÒ ÛÙËÓ ∂ÊË‚È΋ π·ÙÚÈ΋ Ô ÁÈ·ÙÚfi˜ ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÈ Ó· Â›Ó·È Û‡ÌÌ·¯Ô˜ ÙÔ˘ ÁÔÓ¤· ‹ ¤Ó· ˘ÔηٿÛÙ·ÙÔ. °È·Ù› ·Ó Ô ¤ÊË‚Ô˜ ÚÔÛ·ı› Ó· ·ÔÌ·ÎÚ˘Óı› ·fi ÙȘ ÂÍ·ÚÙ‹ÛÂȘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‹ ‰ÂÓ ÂÌÈÛÙ‡ÂÙ·È ÙÔ˘˜ ÁÔÓ›˜, ÔÈ ÁÈ·ÙÚÔ›, ÔÈ ÔÔ›ÔÈ ·ÓÙÈÁÚ¿ÊÔ˘Ó ÙȘ ÁÔÓÂ˚Τ˜ ÊÈÁÔ‡Ú˜, ‰Â ı· ÎÂÚ‰›ÛÔ˘Ó ÙËÓ ÂÌÈÛÙÔÛ‡ÓË ÙÔ˘ ÂÊ‹‚Ô˘ (10,11). ∞Ú¯¤˜ Ù˘ ÎÏÈÓÈ΋˜ ›Û΄˘ OÈ ¤ÊË‚ÔÈ Â›Ó·È Û˘Ó‹ıˆ˜ Ôχ ¢·›ÛıËÙÔÈ ÛÙ· ‚·ı‡ÙÂÚ· ÌËӇ̷ٷ Ô˘ ÂÚÓÔ‡Ó ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ.
¶›Ó·Î·˜ 3. µÈÔ„˘¯ÔÎÔÈÓˆÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÓ¯fiÌÂÓÔÈ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1. 2. 3. 4. 5. 6. 7. 8.
OÈ ·ÏÏ·Á¤˜ ÛÙËÓ ÂÊ˂›· Á›ÓÔÓÙ·È ÁÚ‹ÁÔÚ· - ªÂÁ¿ÏË ›ÂÛË ÁÈ· ÚÔÛ·ÚÌÔÁ‹ ¢È·ÊÔÚÂÙÈΤ˜ ·ÓÙÈÏ‹„ÂȘ ÁÈ· ÙËÓ ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ ÂÊ‹‚ˆÓ Î·È ÂÓËÏ›ÎˆÓ ¶ÚÒÈÌË ¤Ó·ÚÍË ÂÊ˂›·˜, ·ÏÏ·Á‹ ·ÓÙÈÏ‹„ÂˆÓ ÁÈ· ÙȘ ÚÔÁ·ÌÈ·›Â˜ Û¯¤ÛÂȘ ª·ÎÚ¿ ÂÎ·È‰Â˘ÙÈ΋ ‰È·‰Èηۛ· - ªÂÁ¿Ï˜ ··ÈÙ‹ÛÂȘ ÁÈ· ·Î·‰ËÌ·˚ο ÂÈÙ‡ÁÌ·Ù· ∆·¯Â›· ·ÛÙÈÎÔÔ›ËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ - ªÂȈ̤Ó˜ ÚÔÔÙÈΤ˜ ÁÈ· ÂÚÁ·Û›· - ∞ÓÂÚÁ›· ™˘¯Ó‹ ÎÈÓËÙÈÎfiÙËÙ· ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ - ∞ÏÏ·Á‹ ÂÚÈÔ¯‹˜ ηÙÔÈΛ·˜ - ∂·Ó·ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÎÔÈÓˆÓÈÎÒÓ Û¯¤ÛÂˆÓ ¢È¿Û·ÛË Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ - ƒfiÏÔ˜ ÙˆÓ ª.ª.∂. ∏ ÎÔÈÓˆÓ›· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÙÔ˘˜ Ó¤Ô˘˜ Û·Ó ÔÈÎÔÓÔÌÈÎfi ·ıËÙÈÎfi Î·È fi¯È Û·Ó ÙÔ ÈÔ ÛËÌ·ÓÙÈÎfi ÂÓÂÚÁËÙÈÎfi ‰˘Ó·ÌÈÎfi Ô˘ ‰È·ı¤ÙÂÈ 9. O ‰˘ÙÈÎfi˜ ÔÏÈÙÈÛÌfi˜ Ù›ÓÂÈ Ó· ÂÎı¤ÙÂÈ Ì¿ÏÏÔÓ, ·Ú¿ Ó· ÚÔÛٷهÂÈ ÙÔ˘˜ Ó¤Ô˘˜ ·fi ÙȘ ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂȉڿÛÂȘ (ÔÈÓÔÓÂ˘Ì·ÙÒ‰Ë, Ê¿Ú̷η, ·˘ÙÔΛÓËÙ·, ‚›·ÈË Û˘ÌÂÚÈÊÔÚ¿)
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¶·È‰È·ÙÚÈ΋ 2001;64:410-416
¶›Ó·Î·˜ 4. OÌ¿‰Â˜ ÂÊ‹‚ˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ 1. ¡¤ÔÈ Ô˘ ¤¯Ô˘Ó ÌÂÁ·ÏÒÛÂÈ Û ÔÈÎÔÁ¤ÓÂȘ ·ıÔÏÔÁÈο ‰˘ÛÏÂÈÙÔ˘ÚÁÈΤ˜, ÊÙˆ¯È¤˜ ‹ ÏÔ‡ÛȘ 2. ¡¤ÔÈ Ô˘ ¤¯Ô˘Ó ÌÂÁ·ÏÒÛÂÈ ÛÙË ÊÙÒ¯ÂÈ· 3. ¡¤ÔÈ Ì ¯ÚfiÓÈ· ÓfiÛÔ 4. ¡¤ÔÈ Ô˘ ¤¯Ô˘Ó ηÎÔÔÈËı› ˆ˜ ·È‰È¿ 5. ¡¤ÔÈ Ì ̷ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ 6. ¡¤ÔÈ Ì ‰È·Ù·Ú·¯¤˜ Ù·˘ÙfiÙËÙ·˜ ÙÔ˘ ʇÏÔ˘
°È· Ó· ‰ڷȈı›, ÂÔ̤ӈ˜, Îϛ̷ ÂÌÈÛÙÔÛ‡Ó˘, Ù· ÌËӇ̷ٷ ·˘Ù¿ Ú¤ÂÈ Ó· Â›Ó·È ıÂÙÈο ÚÔ˜ ÙÔÓ ¤ÊË‚Ô. ∏ ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ ηٿÏÏËÏÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î¿ÔÈ· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο: i) ∏ ·›ıÔ˘Û· ·Ó·ÌÔÓ‹˜ Ú¤ÂÈ Ó· ÚÔηÏ› ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘ ÂÊ‹‚Ô˘. ii) ∆Ô ÚÔÛˆÈÎfi ÙÔ˘ È·ÙÚ›Ԣ Ú¤ÂÈ Ó· Â›Ó·È ¿ÓÂÙÔ Ì ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Ó· ÂÈÎÔÈÓˆÓ› Ì·˙› ÙÔ˘˜ Ì ¿ÌÂÛÔ, ·ÓÔÈÎÙfi Î·È ÊÈÏÈÎfi ÙÚfiÔ. iii) ∆Ô ÂÍÂÙ·ÛÙÈÎfi ÙÚ·¤˙È Ú¤ÂÈ Ó· Â›Ó·È Û ‰È·ÛÙ¿ÛÂȘ ÂÓ‹ÏÈη. iv) ∏ ·Ú¯È΋ ·ʋ Ì ÙÔÓ ¤ÊË‚Ô Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÓÒ ÂΛÓÔ˜ Â›Ó·È Ï‹Úˆ˜ ÓÙ˘Ì¤ÓÔ˜. v) ∞Ó Ô ¤ÊË‚Ô˜ ·Ú›ÛÙ·Ù·È Ì ÙÔ ÁÔÓ¤·, Ô ¯·ÈÚÂÙÈÛÌfi˜ Ú¤ÂÈ Ó· ·Â˘ı‡ÓÂÙ·È ÚÒÙ· ÛÙÔÓ ¤ÊË‚Ô. vi) ∆Ô Û‡ÓÔÏÔ ‹ ̤ÚÔ˜ Ù˘ Û˘Ó¤ÓÙ¢Í˘ Ú¤ÂÈ Ó· Â›Ó·È ·ÔÎÏÂÈÛÙÈο Ì ÙÔÓ ¤ÊË‚Ô, Ô ÔÔ›Ô˜ ı· Ú¤ÂÈ Ó· ‰È·‚‚·Èˆı› ˆ˜ ÚÔ˜ ÙÔ ı¤Ì· Ù˘ ÂÌÈÛÙ¢ÙÈÎfiÙËÙ·˜. vii) ∆Ô ÈÛÙÔÚÈÎfi Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ¿ÌÂÛ· ·fi ÙÔ Ó¤Ô Î·È fi¯È ·fi ÙÔ˘˜ ÁÔÓ›˜. viii) ∏ ÚÔÛ¤ÁÁÈÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÌË ÎÚÈÙÈÎfi ÙÚfiÔ, Ì ·Ô‰Ô¯‹ ÙˆÓ ·fi„ÂˆÓ ÙÔ˘ ÂÊ‹‚Ô˘ Î·È Ó· ·Ú¤¯ÂÙ·È ·ÓÙÈÎÂÈÌÂÓÈ΋ ÏËÚÔÊfiÚËÛË ¯ˆÚ›˜ Û¯fiÏÈ· (“ηÏfi” ‹ “ηÎfi”). æ˘¯ÔÎÔÈÓˆÓÈ΋ ‰ÈÂÚ‡ÓËÛË ªÂÙ¿ ÙËÓ ÚÒÙË Â·Ê‹ Î·È ÂÊfiÛÔÓ ¤¯ÂÈ ÂÁηٷÛÙ·ı› ¤Ó·˜ ‚·ıÌfi˜ ÂÌÈÛÙÔÛ‡Ó˘, ·Ú¯›˙ÂÈ Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ‰ÈÂÚ‡ÓËÛË. ∞˘Ù‹ ·ÊÔÚ¿ ÙÔ˘˜ ÁÔÓ›˜ Î·È ÙÔÓ ¤ÊË‚Ô, ·ÏÏ¿ ·ÓÂÍ¿ÚÙËÙ· ‹ ۠ͯˆÚÈÛÙ¤˜ ÂÈÛΤ„ÂȘ. ∏ ÂÎÙ›ÌËÛË Î·Ï‡ÙÂÈ ÙË Û˘ÌÂÚÈÊÔÚ¿ Û 3 ›‰·: ÛÙÔ Û›ÙÈ, ÙÔ Û¯ÔÏ›Ô, ÙÔ˘˜ Û˘ÓÙÚfiÊÔ˘˜. π‰È·›ÙÂÚË ¤ÌÊ·ÛË Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Û˘ÓÙÚfiʈÓ, ηıÒ˜ ÂΛ Â›Ó·È Ë ·Ú¤Ó· ÛÙËÓ ÔÔ›· Ï·Ì‚¿ÓÔ˘Ó ¯ÒÚ· ÔÈ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ (¶›Ó·Î·˜ 5). ™ÙÔ Û¯ÔÏ›Ô, ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ ÚÔÛ·ÚÌfi˙ÔÓÙ·È ÈηÓÔÔÈËÙÈο. ∆Ô Â›Â‰Ô Â›‰ÔÛ‹˜ ÙÔ˘˜ ·ÔÙÂÏ› Û˘Ó¤¯ÂÈ· ÙÔ˘ ÚÔËÁÔ‡ÌÂÓÔ˘. ∞Ó ˘¿Ú¯ÂÈ ·fiÎÏÈÛË, ·˘Ùfi ·ÔÙÂÏ› ÛËÌÂ›Ô ·ÓËÛ˘¯›·˜. ™ÙÔ Û›ÙÈ, ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙Ô˘Ó ¤Ó· ‚·ıÌfi ‰ÈÂÓ¤ÍÂˆÓ Ì ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ηıËÌÂÚÈÓ¿ ı¤Ì·Ù· (‰Ô˘ÏÂȤ˜ ÙÔ˘ ÛÈÙÈÔ‡, Ù·ÎÙÔ-
Paediatriki 2001;64:410-416
¶›Ó·Î·˜ 5. æ˘¯ÔÎÔÈÓˆÓÈ΋ ‰ÈÂÚ‡ÓËÛË 1. ™›ÙÈ ñ ∂›Â‰Ô ÂÈÎÔÈÓˆÓ›·˜, ‚·ıÌfi˜ ÂÌÈÛÙÔÛ‡Ó˘ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ñ ¶ÂÚÈÔ¯¤˜ ˘ÔÛÙ‹ÚÈ͢ / Û˘ÁÎÚÔ‡ÛÂˆÓ ñ ∞ÌÔÈ‚·›· Û˘Ó·ÈÛı‹Ì·Ù· ñ ¢˘Ó¿ÌÂȘ Î·È ·‰˘Ó·Ì›Â˜ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ 2. ™¯ÔÏÂ›Ô ñ ¶ÚÔÛ·ÚÌÔÁ‹ - ÔÔÈ·‰‹ÔÙ ·ÏÏ·Á‹ ñ °ÓÒÌË ÙÔ˘ ÂÊ‹‚Ô˘ ÁÈ· ÙÔ Û¯ÔÏÂ›Ô ñ ™¯¤ÛÂȘ ÌÂ Û˘ÌÌ·ıËÙ¤˜, ‰·ÛοÏÔ˘˜ ñ ™¯¤‰È· ÂÎ·È‰Â˘ÙÈο ‹ ·ÁÁÂÏÌ·ÙÈο 3. ™‡ÓÙÚÔÊÔ˜ ñ Œ¯ÂÈ Ê›ÏÔ˘˜; Œ¯ÂÈ ÛÙÂÓfi Ê›ÏÔ; ñ ¶ÚÔÙÈÌ¿ Ó· Â›Ó·È Ì ÙÔ˘˜ Ê›ÏÔ˘˜ ‹ ÌfiÓÔ˜; ñ ∫‡ÚÈ· ÂӉȷʤÚÔÓÙ· Î·È ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ì ÙËÓ ÔÌ¿‰· ÙˆÓ Ê›ÏˆÓ 4. ™¯¤ÛÂȘ Ì ÙÔ ¿ÏÏÔ Ê‡ÏÔ ñ ¶fiÙ ¿Ú¯ÈÛ·Ó - ÚÔËÁÔ‡ÌÂÓÔÈ Î·È ÙˆÚÈÓÔ› Û‡ÓÙÚÔÊÔÈ ñ º‡ÛË Ù˘ ÙˆÚÈÓ‹˜ Û¯¤Û˘, ÌÂÏÏÔÓÙÈο Û¯¤‰È· ñ ™˘ÌÂÚÈÊÔÚ¿: ªÂ ÔÈÔ ¿ÏÏÔ ˙¢Á¿ÚÈ ‚Á·›ÓÔ˘Ó Ì·˙›, Ô‡ ËÁ·›ÓÔ˘Ó; ñ ∂ÓÂÚÁ‹ Û¯¤ÛË, ÚÈÓ ‹ ÙÒÚ· ñ ∂Á΢ÌÔÛ‡ÓË ‹ ™ª¡ ñ ÃÚ‹ÛË ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ ñ °ÓÒÛË ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ ÛÂÍÔ˘·ÏÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ñ ∞ÓÙ›ÏË„Ë ÙÔ˘ ÂȤ‰Ô˘ ¢¿ıÂÈ·˜ ÛÙÔÓ Î›Ó‰˘ÓÔ 5. ÃÚ‹ÛË Ô˘ÛÈÒÓ ñ ∆ÛÈÁ¿Ú·, ÔÈÓfiÓÂ˘Ì·, Ì·ÚÈ¯Ô˘¿Ó·, ¿ÏÏ· Ê¿Ú̷η (ÏËÚÔÊÔڛ˜) ñ °ÓÒÛË ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ ¯Ú‹Û˘ Ô˘ÛÈÒÓ ñ ∂›Â‰Ô ¢¿ıÂÈ·˜ ÛÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ñ ÃÚ‹ÛË ÔÈÓÔÓ‡̷ÙÔ˜ ‹ ¿ÏÏˆÓ Ê·ÚÌ¿ÎˆÓ Î·Ù¿ ÙËÓ Ô‰‹ÁËÛË ñ ∂Ó·ÏÏ·ÎÙÈ΋ ÌÂÙ·ÊÔÚ¿, ·Ó Ô Ô‰ËÁfi˜ Â›Ó·È ˘fi ÙËÓ Â‹ÚÂÈ· Ô˘ÛÈÒÓ 6. ∞ÓÙÈÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ (ÛÙÔÓ ¤ÊË‚Ô ‹ ÙÔ˘˜ Û˘ÓÙÚfiÊÔ˘˜) ñ ∞ÏËÙ›·, ‰È·Î›ÓËÛË Ô˘ÛÈÒÓ, ÎÏÔ¤˜, ̤ÏÔ˜ Û˘ÌÌÔÚ›·˜ ñ ¶ÚÔ‚Ï‹Ì·Ù· Ì ÙÔ ÓfiÌÔ
Ô›ËÛË, ÓÙ‡ÛÈÌÔ, Ì·ÏÏÈ¿, ··ÁÔÚÂ˘Ì¤Ó˜ ÒÚ˜ Î.Ï.). ∂›Û˘, Û˘˙ËÙÔ‡Ó Ì ÙÔ˘˜ ÁÔÓ›˜ Ôχ ÛÔ‚·Ú¿ ı¤Ì·Ù· Î·È ÁÂÁÔÓfiÙ·, Ù· ÔÔ›· ‰ÂÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙȘ ÁÔÓÂ˚Τ˜ ··ÁÔÚÂ˘Ì¤Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜. ™ËÌ›· ‰È¿ÛÙ·Û˘ ¤Ú· ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ·Ú·ÙËÚÔ‡ÓÙ·È fiÙ·Ó ÔÈ Û˘ÁÎÚÔ‡ÛÂȘ ÂÂÎÙ›ÓÔÓÙ·È ¤Ú· ·fi ÙȘ ·Ú·‰ÔÛȷΤ˜ ÂÚÈÔ¯¤˜ Î·È Ô Ó¤Ô˜ ‚Ú›ÛÎÂÙ·È Û ÛÙ·ıÂÚ‹ Û‡ÁÎÚÔ˘ÛË, Â›Ó·È ÈÔ Ì˘ÛÙÈÎÔ·ı‹˜, Ï›ÂÈ ÙÔÓ ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ·fi ÙÔ Û›ÙÈ ¯ˆÚ›˜ ÂÍ‹ÁËÛË, ηÙËÁÔÚ› Î·È ·Â˘ı‡ÓÂÙ·È ÛÙÔ˘˜ ÁÔÓ›˜ Ì ı˘ÌˆÌ¤Ó· ÏfiÁÈ·, Ê·›ÓÂÙ·È Ó· ÙÔ˘˜ ÌÈÛ›, ¤¯ÂÈ ·ÔÌ·ÎÚ˘Óı› ‹ Â›Ó·È Î·Ù·ıÏÈÙÈÎfi˜. ™ÙȘ ·Ú¤Â˜, ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ, ÁÂÓÈο, ÚÔÙÈÌÔ‡Ó Ó· Â›Ó·È Ì ¿ÙÔÌ· Ù˘ ËÏÈΛ·˜ ÙÔ˘˜ ηÈ
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¤¯Ô˘Ó ¤Ó·Ó ‹ ‰‡Ô ÛÙÂÓÔ‡˜ Ê›ÏÔ˘˜ Ô˘ ÂÌÈÛÙ‡ÔÓÙ·È. ∏ ÔÌ¿‰· ÙˆÓ Û˘ÓÙÚfiÊˆÓ Â›Ó·È Ô ÌÂÁ¿ÏÔ˜ Ú˘ıÌÈÛÙ‹˜ Ù˘ ·Ô‰ÂÎÙ‹˜ - ‹ ÌË - Û˘ÌÂÚÈÊÔÚ¿˜. ∞Ó Ë ÔÌ¿‰· ÙˆÓ Û˘ÓÙÚfiÊˆÓ ÂÓ¤¯ÂÙ·È Û ÎÔÈÓˆÓÈο ·Ô‰ÂÎÙ¤˜ Û˘ÌÂÚÈÊÔÚ¤˜, Â›Ó·È Û¯Â‰fiÓ ‚¤‚·ÈÔ fiÙÈ Ô ¤ÊË‚Ô˜ ı· οÓÂÈ ÙÔ ›‰ÈÔ. ∆Ô ·ÓÙ›ÛÙÔÈ¯Ô ı· Û˘Ì‚Â› ·Ó Ë ÔÌ¿‰· ÙˆÓ Û˘ÓÙÚfiÊˆÓ ÂÓ¤¯ÂÙ·È Û ·ÚÓËÙÈΤ˜ Û˘ÌÂÚÈÊÔÚ¤˜. ™ÙË Ì¤ÛË ÂÊË‚È΋ ËÏÈΛ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ ÂӉȷʤÚÔÓÙ·È ÁÈ· ÙÔ ·ÓÙ›ıÂÙÔ Ê‡ÏÔ Î·È Ë ÛÂÍÔ˘·ÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÌÂٷ͇ ÙˆÓ ÂÊ‹‚ˆÓ Â›Ó·È Û˘¯Ó‹ Î·È ‰ÂÓ ·ÔÙÂÏ› ϤÔÓ ·ÔÎÏ›ÓÔ˘Û· Û˘ÌÂÚÈÊÔÚ¿. ¶ÔÏÏÔ› Ê˘ÛÈÔÏÔÁÈÎÔ› ¤ÊË‚ÔÈ ÌÔÚ› Ó· ÂÌÏ·ÎÔ‡Ó Û ¿ÏϘ ÂÈÚ·Ì·ÙÈΤ˜ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜, fiˆ˜ ·ÏÎÔfiÏ, ÙÛÈÁ¿Ú·, Ì·ÚÈ¯Ô˘¿Ó·. ∞Ó Î·È ÔÈ ÂÈÚ·Ì·ÙÈÛÌÔ› ·˘ÙÔ› ‰ÂÓ ˘Ô‰ËÏÒÓÔ˘Ó ¤Ó· ‰È·Ù·Ú·Á̤ÓÔ Ó¤Ô, οı ̛· ·fi ÙȘ Û˘ÌÂÚÈÊÔÚ¤˜ ·˘Ù¤˜ ÌÔÚ› Ó· ˘Ô‰ÂÈÎÓ‡ÂÈ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ˘Á›· Î·È ··ÈÙ› ·Ú¤Ì‚·ÛË. ∂ÎÙfi˜ ·fi ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙËÓ ·Ú¤· Ô˘ ·ÓËÛ˘¯Ô‡Ó ÙÔ˘˜ ÁÔÓ›˜, ÔÈ ÌÔÓ·¯ÈÎÔ› Î·È ¯ˆÚ›˜ ÛÙÂÓÔ‡˜ Ê›ÏÔ˘˜ ¤ÊË‚ÔÈ ‹ ÂΛÓÔÈ ¯ˆÚ›˜ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ·ÓÙ›ıÂÙÔ Ê‡ÏÔ ·ÔÙÂÏÔ‡Ó Â›Û˘ Ì›· ·ÈÙ›· ·ÓËÛ˘¯›·˜ (12-14). ∂ÎÙ›ÌËÛË O ÎÏÈÓÈÎfi˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Û ı¤ÛË Ó· ηıÔÚ›ÛÂÈ ÙÔ ‚·ıÌfi Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ÂÈΛӉ˘Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÙËÓ ·Ó¿ÁÎË ÁÈ· ·Ú¤Ì‚·ÛË. OÈ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û ̛· ·fi ÙȘ ·ÎfiÏÔ˘ı˜ ηÙËÁÔڛ˜ (¶›Ó·Î·˜ 6): ∞) O‡ÙÂ Ô ¤ÊË‚Ô˜, Ô‡Ù ÔÈ Û‡ÓÙÚÔÊÔ› ÙÔ˘ ÂÌϤÎÔÓÙ·È Û ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜: ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚԉȷıÂÛÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Á›ÓÂÙ·È Ì¤Ûˆ ÚÔÏËÙÈ΋˜ ·ÁˆÁ‹˜. µ) O Ó¤Ô˜ ‰ÂÓ ÂÌϤÎÂÙ·È ·ÎfiÌ· Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ ‹ Â›Ó·È Û ΛӉ˘ÓÔ ÁÈ·Ù› Ô Û‡ÓÙÚÔÊfi˜ ÙÔ˘ ÂÌϤÎÂÙ·È ‹ ˘¿Ú¯Ô˘Ó ·Ú¿ÁÔÓÙ˜ Ô˘ ÙÔÓ Î·ıÈÛÙÔ‡Ó Â˘¿ÏˆÙÔ: ·) ÚÔÏËÙÈ΋ ·ÁˆÁ‹, ‚) ÚÒÈÌË Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·Ú¤Ì‚·ÛË, Á) ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·, ·Ó ¯ÚÂÈ·ÛÙ›. °) O Ó¤Ô˜ ¤¯ÂÈ ÂÌϷΛ Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ Û ÂÈÚ·Ì·ÙÈÎfi ›‰Ô: ·) Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·Ú¤Ì‚·ÛË, ‚) ÚÔÛÂÎÙÈ΋ ηıÔ‰‹ÁËÛË ÚÔ˜ Ï‹„Ë ·fiÊ·Û˘ ÁÈ· ·ÏÏ·Á‹, Á) ÂÚÈÔ‰È΋ ÂÓ‰˘Ó¿ÌˆÛË, ‰) ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·, ·Ó Â›Ó·È Û ˘„ËÏfi ΛӉ˘ÓÔ. ¢) O Ó¤Ô˜ ¤¯ÂÈ ÂÌϷΛ Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ Û ‚·ıÌfi ÂÚÈÛÛfiÙÂÚÔ ·fi ÂÈÚ·Ì·ÙÈÎfi: ·) ·Ú·ÔÌ‹ Û ÚfiÁÚ·ÌÌ· „˘¯È΋˜ ˘Á›·˜, ‚) ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·, Á) ·Ú·ÎÔÏÔ‡ıËÛË, ‰) Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·fi ÙÔÓ ÎÏÈÓÈÎfi, ·Ó ¤¯ÂÈ ÌÂÁ¿ÏË ÂÌÂÈÚ›·.
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¶›Ó·Î·˜ 6. ∂ÎÙ›ÌËÛË ÙˆÓ Û˘ÌÂÚÈÊÔÚÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1. O‡ÙÂ Ô ¤ÊË‚Ô˜, Ô‡Ù ÔÈ Û‡ÓÙÚÔÊÔ› ÙÔ˘ ÂÌϤÎÔÓÙ·È Û ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚԉȷıÂÛÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ ñ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ 2. O Ó¤Ô˜ ‰ÂÓ ÂÌϤÎÂÙ·È Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿. ∂›Ó·È Û ΛӉ˘ÓÔ, ÁÈ·Ù› Ô Û‡ÓÙÚÔÊfi˜ ÙÔ˘ ÂÌϤÎÂÙ·È ‹ ˘¿Ú¯Ô˘Ó ·Ú¿ÁÔÓÙ˜ Ô˘ ÙÔÓ Î·ıÈÛÙÔ‡Ó Â˘¿ÏˆÙÔ ñ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ ñ ÚÒÈÌË Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·Ú¤Ì‚·ÛË ñ ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·, ·Ó ¯ÚÂÈ·ÛÙ› 3. ¶ÂÈÚ·Ì·ÙÈ΋ ÂÌÏÔ΋ Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ ñ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì ÚÔÛÂÎÙÈ΋ ηıÔ‰‹ÁËÛË ÁÈ· Ï‹„Ë ·fiÊ·Û˘ ÁÈ· ·ÏÏ·Á‹ ñ ÂÚÈÔ‰È΋ ÂÓ‰˘Ó¿ÌˆÛË ñ ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·, ·Ó Â›Ó·È Û ˘„ËÏfi ΛӉ˘ÓÔ 4. O Ó¤Ô˜ ¤¯ÂÈ ÂÌϷΛ Û ÂÈΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿ Û ‚·ıÌfi ÂÚÈÛÛfiÙÂÚÔ ·fi ÂÈÚ·Ì·ÙÈÎfi ñ ·Ú·ÔÌ‹ Û ÚfiÁÚ·ÌÌ· „˘¯È΋˜ ˘Á›·˜ ‹ ÂȉÈÎfi ÚfiÁÚ·ÌÌ· ñ ·Ú·ÎÔÏÔ‡ıËÛË ñ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·fi ÙÔÓ ÎÏÈÓÈÎfi, ·Ó ¤¯ÂÈ ÌÂÁ¿ÏË ÂÌÂÈÚ›·
∞ÓÙÈÌÂÙÒÈÛË ∫·Ù·ÛÙÚÒÓÂÙ·È ÛÙÚ·ÙËÁÈÎfi Û¯¤‰ÈÔ ·fi ÙÔÓ ÎÏÈÓÈÎfi Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÚÔÎÏËÙÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜ Î·È ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ ·¿ÓÙËÛ˘ ÙÔ˘ ÂÊ‹‚Ô˘ Û ·˘Ùfi ÙÔ ÂÚ¤ıÈÛÌ·. OÈ ÛÙÚ·ÙËÁÈΤ˜ ·˘Ù¤˜ ··ÈÙÔ‡Ó ·fi ÙÔÓ ÎÏÈÓÈÎfi ‰ËÌÈÔ˘ÚÁÈÎfiÙËÙ·, ÂÊ¢ÚÂÙÈÎfiÙËÙ· Î·È Ê·ÓÙ·Û›·. ∆· ‰‡Ô ·ÚÈ· ıÂڷ¢ÙÈο ÛÙËÚ›ÁÌ·Ù· ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi Â›Ó·È Ë ÚÔÏËÙÈ΋ ·ÁˆÁ‹ Î·È Ë ·ÚÂÌ‚·ÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ÛÙ· Ï·›ÛÈ· Ù˘ Û¯¤Û˘ ÂÌÈÛÙÔÛ‡Ó˘. ∆· ‚‹Ì·Ù· Î·È ÁÈ· ÙȘ ‰‡Ô Ù¯ÓÈΤ˜ Â›Ó·È Ù· ›‰È·, ·Ó Î·È ÙÔ ·ÓÙÈΛÌÂÓÔ Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi. ∞Ô‚Ï¤Ô˘Ó ÛÙËÓ ÔÚ›· Ù˘ ηıÔ‰ËÁÔ‡ÌÂÓ˘ ·fiÊ·Û˘ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ¤ÊË‚Ô. ∏ ÚÒÙË ‚ÔËı¿ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÂÈΛӉ˘Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È Ë ‰Â‡ÙÂÚË Î·Ù¢ı‡ÓÂÙ·È ÛÙËÓ ÙÚÔÔÔ›ËÛË Ù¤ÙÔÈˆÓ Û˘ÌÂÚÈÊÔÚÒÓ, fiÙ·Ó Û˘Ì‚Ô‡Ó. ∏ ÚÔÛ¤ÁÁÈÛË Â›Ó·È ÌË ÎÚÈÙÈ΋ Î·È ·Ú¤¯ÂÈ Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔȯ›· Ì ¢ı‡ ÙÚfiÔ. ŸÏ˜ ÔÈ ÂΉԯ¤˜, ηϤ˜ Î·È Î·Î¤˜, Û˘˙ËÙÔ‡ÓÙ·È. ªÔÚ› Ó· ÂÎÊÚ·ÛÙ› Ë ÁÓÒÌË ÙÔ˘ ÂÓ‹ÏÈη, ·ÏÏ¿ η̛· ÂÈÏÔÁ‹ ‰ÂÓ Ú¤ÂÈ Ó· ÂÈ‚¿ÏÏÂÙ·È Î·È Ô Ó¤Ô˜ Ú¤ÂÈ Ó· ·›ÚÓÂÈ ÙÔ Î·ı·Úfi Ì‹Ó˘Ì· fiÙÈ Ë ÂÈÏÔÁ‹ Â›Ó·È ‰È΋ ÙÔ˘. ∞Ó ‰Ôı› ÛÙÔÓ ¤ÊË‚Ô ¤Ó· ‡ÚÔ˜ ÂÈÏÔÁÒÓ Ì·˙› Ì ÏËÚÔÊfiÚËÛË ÁÈ· Ù· ·ÎfiÏÔ˘ı·, ˘¿Ú¯ÂÈ Èı·ÓfiÙËÙ· 80% Ô Ó¤Ô˜ Ó· οÓÂÈ ÛˆÛÙ¤˜ ÂÈÏÔÁ¤˜. ∏ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ ¤¯ÂÈ ÛÎÔfi Ó· ‚ÔËı‹ÛÂÈ ÙÔ Ó¤Ô Ó· ·ÔʇÁÂÈ ÂÍ·Ú¯‹˜ Ì›· Û˘ÌÂÚÈÊÔÚ¿. ŸÙ·Ó Á›ÓÔÓÙ·È ·˘Ù¤˜ ÔÈ Û˘ÛÙ¿ÛÂȘ, Â›Ó·È ÈÔ Ú·ÏÈÛÙÈÎfi Ó· Û˘ÛÙ‹ÓÔ˘Ì ÛÙÔ 13¯ÚÔÓÔ ¤ÊË‚Ô Ó·
¶·È‰È·ÙÚÈ΋ 2001;64:410-416
·Ó·‚¿ÏÂÈ Î¿ÔȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ (ÛÂÍ, ·ÏÎÔfiÏ) ÁÈ· ÌÂÚÈο ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, fiÙ·Ó ı· ¤¯ÂÈ ·˘ÍËı› Ë ÁÓˆÛȷ΋ ÙÔ˘ ˆÚÈÌfiÙËÙ· Î·È ı· ÌÔÚ› Ó· ¯ÂÈÚÈÛÙ› Û‡ÓıÂÙ˜ ηٷÛÙ¿ÛÂȘ Ì ÂÚÈÛÛfiÙÂÚË ÚÔÓÔËÙÈÎfiÙËÙ·. ∏ ·ÚÂÌ‚·ÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ÚÔÛ·ı› Ó· ηıÔ‰ËÁ‹ÛÂÈ ÙÔ Ó¤Ô Ô˘ ÂÌϤÎÂÙ·È ÛÂ Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘ÌÂÚÈÊÔÚ¤˜ ÂÊ‹‚ˆÓ Ì ÏÈÁfiÙÂÚÔ ÂÈΛӉ˘ÓÔ ÙÚfiÔ, ‰›ÓÔÓÙ·˜ ÂÓ·ÏÏ·ÎÙÈΤ˜ ÚÔÙ¿ÛÂȘ (¯Ú‹ÛË ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ, ÛÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ Ó· ηıÔÚ›˙ÂÙ·È ¤Ó· ¿ÙÔÌÔ Ô˘ ‰Â ı· ›ÓÂÈ ÁÈ· Ó· Ô‰ËÁ‹ÛÂÈ ÙÔ˘˜ ¿ÏÏÔ˘˜ ÛÙÔ Û›ÙÈ Î.Ï.). ∏ ‰È·ÎÔ‹ Ì›·˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÌÔÚ› Ó· Â›Ó·È ÂÈı˘ÌËÙ‹, ·ÏÏ¿ fi¯È ¿ÓÙ· Ú·ÏÈÛÙÈ΋. ∂Í·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ Ó¤Ô˘. °È· ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ Ú¤ÂÈ Ó· ˙ËÙÔ‡ÓÙ·È ÌÈÎÚ¤˜ ·ÏÏ·Á¤˜ ÛÙ·‰È·Î¿ Î·È ÚÔÛı‹ÎË Ó¤ˆÓ ˘ÁÈÒÓ Û˘ÌÂÚÈÊÔÚÒÓ, ·Ú¿ Ë ·fiÙÔÌË ‰È·ÎÔ‹ Ì›·˜ ·ÁȈ̤Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ (5,10). ∫·Ù‡ı˘ÓÛË ÁÈ· ÙË Ï‹„Ë ·fiÊ·Û˘ OÈ ¤ÊË‚ÔÈ ‰ÂÓ ¤¯Ô˘Ó ·Ú΋ ÏËÚÔÊfiÚËÛË ÁÈ· Ù· ·ÎfiÏÔ˘ı· ÙˆÓ ÂÈΛӉ˘ÓˆÓ Û˘ÌÂÚÈÊÔÚÒÓ. O ÚfiÏÔ˜ ÙÔ˘ ÁÈ·ÙÚÔ‡ Â›Ó·È Ó· ‰ÒÛÂÈ ÛÙÔÓ ¤ÊË‚Ô ÚfiÛıÂÙ˜ ÏËÚÔÊÔڛ˜ Î·È Ì›· ¿Ô„Ë ÙˆÓ ÌÂÏÏÔÓÙÈÎÒÓ Û˘ÓÂÂÈÒÓ ÁÈ· Ó· Û˘ÌÏËÚÒÛÂÈ Î·È Ó· ÂÓ‰˘Ó·ÌÒÛÂÈ ÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘ ÁÈ· Ï‹„Ë Ù˘ ‰È΋˜ ÙÔ˘ ·fiÊ·Û˘. O ÁÈ·ÙÚfi˜ ı· ‰È·ÁÚ¿„ÂÈ ÙËÓ ÔÚ›· Î·È Ô Ó¤Ô˜ ı· ·ÔÊ·Û›ÛÂÈ. ∏ ÔÚ›· ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜ ·ÎÔÏÔ˘ı› Ì›· ÏÔÁÈ΋ Û˘Ó¤¯ÂÈ· (¶›Ó·Î·˜ 7): ·) ∫·ıÔÚÈÛÌfi˜ ÚÔ‚Ï‹Ì·ÙÔ˜: ∂ȉÈÎfiÙÂÚ·, ηıÔÚ›˙ÂÙ·È ÔÈÔ Â›Ó·È ÙÔ Úfi‚ÏËÌ· Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, ÔÈÔÈ Â›Ó·È ÔÈ Î›Ó‰˘ÓÔÈ Î·È ÙÈ Ú¤ÂÈ Ó· ·ÏÏ¿ÍÂÈ, ÔȘ Â›Ó·È ÔÈ Ú›˙˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·fi ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ Ó¤Ô˘, ÙÔ˘ ÁÔÓ¤·, ÙÔ˘ ÎÏÈÓÈÎÔ‡. ™ÙÔ Ù¤ÏÔ˜ ·˘Ù‹˜ Ù˘ Ê¿Û˘ ı· Ú¤ÂÈ Ó· ˘¿ÚÍÂÈ Û˘Ìʈӛ· ÁÈ· ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÁÈ· ÙÔ ÔÈ· ÚÔÏËÙÈο ‚‹Ì·Ù· ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÔ˘Ó Î·È ÔÈ· ı¤Ì·Ù· Ú¤ÂÈ Ó· Ï˘ıÔ‡Ó. ‚) §‡ÛÂȘ Î·È ÚÔÔÙÈΤ˜ ÂÈÏÔÁÒÓ: ŸÏ˜ ÔÈ ÂÈÏÔÁ¤˜ ÙÔ˘ ÂÊ‹‚Ô˘ ı· Ú¤ÂÈ Ó· Û˘˙ËÙËıÔ‡Ó (˘¤Ú Î·È Î·Ù¿). O Ó¤Ô˜ ı· Ú¤ÂÈ Ó· ηٷÓÔ‹ÛÂÈ Ï‹Úˆ˜ ÙȘ ‰È¿ÊÔÚ˜ ÂÈÏÔÁ¤˜ Î·È Ù· Èı·Ó¿ ·ÎfiÏÔ˘ı· Ù˘ ηıÂÌÈ¿˜. Á) ∂ÈÏÔÁ‹ Î·È Û˘Ìʈӛ·: O ÎÏÈÓÈÎfi˜ ÌÔÚ› Ó· ηÙ¢ı‡ÓÂÈ ÙËÓ ÂÈÏÔÁ‹, ·ÏÏ¿ fi¯È Ó· ÙËÓ ÂÈ‚¿ÏÂÈ. £· Ú¤ÂÈ Ó· ÙËÓ ·Ô‰Â¯ı› ·ÎfiÌË Î·È ·Ó ‰ÂÓ Â›Ó·È Û˘ÓÂÙ‹, ÒÛÙ ӷ ̤ÓÂÈ ·ÓÔÈÎÙfi˜ ÁÈ· Ì›· ÌÂÏÏÔÓÙÈ΋ ηχÙÂÚË ÂÈÏÔÁ‹. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô Ó¤Ô˜ οÓÂÈ Ì›· ÂÈÏÔÁ‹ ÌË ·ÓÙÈÎÂÈÌÂÓÈο Ú·ÁÌ·ÙÔÔÈ‹ÛÈÌË, ı· Ú¤ÂÈ Ó· Á˘Ú›ÛÂÈ ›Ûˆ Î·È Ó· ÂÈϤÍÂÈ Ì›· ¿ÏÏË.
Paediatriki 2001;64:410-416
‰) ∂‰Ú·›ˆÛË Ù˘ ÂÈÏÔÁ‹˜: ∂ÊfiÛÔÓ ¤¯ÂÈ Î·ıÔÚÈÛÙ› Ë ÂÈÏÔÁ‹, ı· Ú¤ÂÈ Ó· Á›ÓÂÈ Û¯Â‰È·ÛÌfi˜ ÁÈ· ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛ‹ Ù˘. ∞˘Ùfi ··ÈÙ› ·ÙÔÌÈ΋ Î·È ÔÈÎÔÁÂÓÂȷ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·fi ÙÔ ÁÈ·ÙÚfi Ù˘ ¶.º. ‹ ·Ú·ÔÌ‹ Û ÂȉÈÎfi ÚfiÁÚ·ÌÌ·. ™Â ·˘Ùfi ÙÔ ÛÙ¿‰ÈÔ, Ë Û˘Ì‚Ô˘Ï¢ÙÈ΋ ·fi ÙÔÓ ÎÏÈÓÈÎfi Ú¤ÂÈ Ó· Â›Ó·È Ôχ Ú·ÎÙÈ΋ Î·È Ó· ˘Ô‰ÂÈÎÓ‡ÂÈ ÙÚfiÔ˘˜ ÁÈ· ·ÏÏ·Á‹ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ (·ÓÙ›ÛÙ·ÛË ÛÙËÓ ›ÂÛË ÙˆÓ Û˘ÓÙÚfiʈÓ, ·ÔÊ˘Á‹ ÙˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ÚÔ¿ÁÔ˘Ó ÙȘ ÂÈΛӉ˘Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜, ÙÈ ı· Ú¤ÂÈ Ó· ϤÂÈ Ô ¤ÊË‚Ô˜ Û ηٷÛÙ¿ÛÂȘ ›ÂÛ˘ Î.Ï.). £· Ú¤ÂÈ, ›Û˘, Ó· Á›ÓÂÈ Û˘Ìʈӛ·, ÒÛÙ Û ÂÚ›ÙˆÛË ·ÔÙ˘¯›·˜, Ô Ó¤Ô˜ Ó· ¤ÚıÂÈ Û ·ʋ Ì ÙÔ ÁÈ·ÙÚfi. ªÔÚ›, ›Û˘, Ô ÁÈ·ÙÚfi˜ Ó· ˘Ô‰Â›ÍÂÈ ‰È¿ÊÔÚ· ÙÔÈο ÚÔÁÚ¿ÌÌ·Ù· („˘¯È΋˜ ˘Á›·˜, ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÚÔÁÚ·ÌÌ·ÙÈÛÌÔ‡, ÚÔÁÚ¿ÌÌ·Ù· ÂχıÂÚÔ˘ ¯ÚfiÓÔ˘, ·ÂÍ¿ÚÙËÛ˘) Ì ٷ ÔÔ›· Â›Ó·È ÔÈΛԘ Î·È ¤¯ÂÈ ÚÔÛˆÈ΋ ·ʋ. Â) ∂Ó‰˘Ó¿ÌˆÛË: ∏ Û˘Ó¯‹˜ ˘ÔÛÙ‹ÚÈÍË ·fi ÙÔ ÁÈ·ÙÚfi Â›Ó·È ·Ó·Áη›·, ·ÎfiÌ· Î·È fiÙ·Ó Ô ¤ÊË‚Ô˜ ·Ú·ÂÌÊı› Û ¿ÏÏÔ ÚfiÁÚ·ÌÌ·. °È’ ·˘ÙfiÓ ÙÔ ÏfiÁÔ, ı· Ú¤ÂÈ Ó· ηıÔÚÈÛÙ› Û¯‹Ì· ›Û΄˘ ÁÈ· ·ÓÂÎÙ›ÌËÛË Î·È ÂÓ‰˘Ó¿ÌˆÛË (11). ™˘ÌÂÚ¿ÛÌ·Ù· OÈ Û˘ÌÂÚÈÊÔÚ¤˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ¤¯Ô˘Ó ηı·Ú¿ ·Ó·Ù˘Íȷ΋ ‚¿ÛË Î·È ·˘Í¿ÓÔÓÙ·È ·fi ÙÔ Û˘Ó‰˘·ÛÌfi ÎÔÈÓˆÓÈÎÒÓ Î·È ÔÏÈÙÈÛÌÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ‰˘ÙÈÎÔ‡ ÔÏÈÙÈÛÌÔ‡. ŸÏÔÈ ÔÈ ¤ÊË‚ÔÈ, Û οÔÈÔ ‚·ıÌfi, Â›Ó·È Û ΛӉ˘ÓÔ Ì¤¯ÚÈ Ó· ÔÏÔÎÏËÚÒÛÔ˘Ó ÙËÓ ·˘ÙÔÓÔÌ›· ÙÔ˘˜. ªÂÚÈÎÔ› ¤ÊË‚ÔÈ Â›Ó·È Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÏfiÁˆ ÙÔ˘ ¯·Ú·ÎÙ‹Ú· ÙÔ˘˜, ÙˆÓ Û˘ÓıËÎÒÓ ˙ˆ‹˜ ‹ ˘ÔΛÌÂÓ˘ „˘¯ÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ (15). OÈ ÏÂÈÙÔ˘ÚÁÔ› ˘Á›·˜ ¤¯Ô˘Ó ÙËÓ ˘Â˘ı˘ÓfiÙËÙ· ¶›Ó·Î·˜ 7. ∞ÓÙÈÌÂÙÒÈÛË Û˘ÌÂÚÈÊÔÚÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ñ∂Ï¿ÙÙˆÛË ÙÔ˘ ÚÔÎÏËÙÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜ ñ ∆ÚÔÔÔ›ËÛË Ù˘ ·¿ÓÙËÛ˘ ÙÔ˘ ÂÊ‹‚Ô˘
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∫·ıÔÚÈÛÌfi˜ ÚÔ‚Ï‹Ì·ÙÔ˜ - §‡ÛÂȘ - ¶ÚÔÔÙÈΤ˜ ÂÈÏÔÁÒÓ - ∂ÈÏÔÁ‹ - ™˘Ìʈӛ· - ∂‰Ú·›ˆÛË Ù˘ ÂÈÏÔÁ‹˜ - ∂Ó‰˘Ó¿ÌˆÛË ÙÔ˘ Ó¤Ô˘
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¶·È‰È·ÙÚÈ΋ 2001;64:410-416
Ó· ÂÓÙÔ›˙Ô˘Ó ÙȘ Û˘ÌÂÚÈÊÔÚ¤˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Ó· οÓÔ˘Ó Ù· ηٿÏÏËÏ· ‚‹Ì·Ù· ÁÈ· Ó· ÙÔ˘˜ ÚÔÛٷهÛÔ˘Ó. µ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Û ·˘Ù‹ ÙËÓ ÚÔÛ¿ıÂÈ· Â›Ó·È Ë ÂÁηٿÛÙ·ÛË Û¯¤Û˘ ÂÌÈÛÙÔÛ‡Ó˘ Ì ÙÔÓ ¤ÊË‚Ô, Ë ÚÔÏËÙÈ΋ ·ÁˆÁ‹ ˘Á›·˜, Ë ‰ÈÂÚ‡ÓËÛË Ù˘ ÂÈΛӉ˘Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ë ‰È·‰Èηۛ· Ù˘ ηıÔ‰ËÁÔ‡ÌÂÓ˘ ·fiÊ·Û˘ ·fi ÙÔÓ ¤ÊË‚Ô. ∏ ÂÊ˂›· Â›Ó·È ¯ÚfiÓÔ˜ ÂÈÚ·Ì·ÙÈÛÌÔ‡ ÁÈ· Ӥ˜ Û˘ÌÂÚÈÊÔÚ¤˜. ∏ ÚfiÎÏËÛË ÁÈ· οı ¤ÊË‚Ô Â›Ó·È Ó· οÓÂÈ ˘ÁÈ›˜ ÂÈÏÔÁ¤˜, ÂÓÒ Ë ÚfiÎÏËÛË ÁÈ· ÙËÓ ÎÔÈÓˆÓ›· Â›Ó·È Ó· ÂÏ·ÙÙÒÛÂÈ ÙÔ˘˜ ‚Ï·ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ˘ÁȤ˜ ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙÔ˘˜ ÂÊ‹‚Ô˘˜. °È· ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁÔ‡˜ ¶.º.À., ÚfiÎÏËÛË Â›Ó·È Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ó· οÓÔ˘Ó ˘ÁÈ›˜ ÂÈÏÔÁ¤˜, ÒÛÙÂ Ë ÌÂÙ¿‚·Û‹ ÙÔ˘˜ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ Ó· Á›ÓÂÈ Ì ÙÔ ÌÈÎÚfiÙÂÚÔ ‰˘Ó·Ùfi ÎfiÛÙÔ˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Kay P, Heights R. Experience with Risk-Taking Adolescents. J Am Acad Child Adolesc Psychiat 1996;35:1423-1424. 2. Levenberg PB, Gans JE. Help for the adolescent health crisis. Contemp Adol Gynecol 1995;24-28. 3. Neinstein LS, Mackenzie R. High risk and out-of-control behavior. In: Adolescent Health Care. Baltimore: Williams and Williams; 1996. p. 1094. 4. Friedman SB, Sarles RM. Out of Control Behavior in Adolescents. Pediatr Clin N Amer 1980;27:97-107. 5. Hofman AE. Clinical assessment and management of health risk behaviors in adolescents. In: Adolescent Medicine. Vol. I. Philadelphia: Hanley & Belfus, Inc; 1990.
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6. ∆ÛÈ¿ÓÙ˘ π, ÃÚÈÛÙÈ·ÓfiÔ˘ÏÔ˜ ∫, ∞Ó·ÛÙ·ÛfiÔ˘ÏÔ˜ ¢, §È·ÎÔÔ‡ÏÔ˘-÷ÓÙ˙¿Ú· µ. ∂º∏µ∂π∞: ŒÓ· ÌÂÙ·‚·ÙÈÎfi ÛÙ¿‰ÈÔ Û’ ¤Ó· ÌÂÙ·‚·ÏÏfiÌÂÓÔ ÎfiÛÌÔ. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∫·ÛÙ·ÓÈÒÙË; 1994. 7. Gans Epner JE, Levenber PB, Schoney, MS. Provider responsiveness to adolescent health risk behaviors. Arch Pediatr Adol Med 1998;152:774-780. 8. Elster AB. Comparison of recommendations for adolescent clinical preventive services developed by national organizations. Arch Pediatr Adol Med 1988;193-198. 9. ª·Ú·ÁÎfi˜ °¢. ∂ÊË‚È΋ π·ÙÚÈ΋ - µ·ÛÈο £¤Ì·Ù· Î·È ·Ú¯¤˜. ∞ı‹Ó·: π·ÙÚÈΤ˜ ∂ΉfiÛÂȘ §›ÙÛ·˜; 1997. 10. Elster AB. The American Medical Association guidelines for Adolescent Preventive Services. [letter]. Arch Pediatr Adol Med 1997;151:958-959. 11. Levenberg B, Elster AB. Guidelines for Adolescent Preventive Services (GAPS). AMA, Dept of Adolescent Health. Chicago Illinois: 1995. 1 2. Smith J, Berthelsent Connor IO. Child adjustment in high conflict families care. Health and Development 1997;23:113-133. 13. Mc Intire M. Violence in the U.S.A. Role of children and youth. World Pediatr Child Care 1996;6:40-43. 14. Alexander DE, Gwyther RE. Alcoholism in adolescents and their families. Pediatr Clin N Amer 1995;42:217-234. 15. Strasburger VC, Greydanus DE. At Risk Adolescents: An update for the New Century. Adolesc Med 2000;11:1.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ¢. ∞ÛÎÔ‡ÓË - ™ÙÚÔ‡ÌÔ˘ ¶·ÙÚÈ¿Ú¯Ô˘ πÂÚÂÌ›Ô˘ 48, 114 75, ∞ı‹Ó·
¶·È‰È·ÙÚÈ΋ 2001;64:417-419
∫∞ƒ¢πO§O°π∞
Paediatriki 2001;64:417-419
CARDIOLOGY
∏ ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÙËÏÂ˚·ÙÚÈ΋˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ ∞. ∆ÛÈÏÈÌÈÁοÎË - ÃÚËÛÙ¿ÎË
Application of telemedicine link in the management of congenital heart defects A. Tsilimigaki - Christaki
¶ÂÚ›ÏË„Ë: ∆ËÏÂ˚·ÙÚÈ΋ Â›Ó·È Ë ¿ÛÎËÛË Ù˘ È·ÙÚÈ΋˜ ·fi ·fiÛÙ·ÛË. ∏ Ù·¯Â›· ·Ó¿Ù˘Í‹ Ù˘ ¤¯ÂÈ ‹‰Ë ‚ÚÂÈ ÂÊ·ÚÌÔÁ¤˜ Û ‰È¿ÊÔÚ˜ ÂȉÈÎfiÙËÙ˜ Ù˘ È·ÙÚÈ΋˜. ∏ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ µÂÓÈ˙¤ÏÂÈÔ˘ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ Û˘ÌÌÂÙ›¯Â Û ¤Ó· ÚfiÁÚ·ÌÌ· ÙËÏÂ˚·ÙÚÈ΋˜ Ì ÙËÓ ÂˆÓ˘Ì›· “TELE-REMEDY”, ‰È¿ÁÓˆÛË, ·ÓÙÈÌÂÙÒÈÛË Î·È Âη›‰Â˘ÛË ·fi ·fiÛÙ·ÛË ÛÙȘ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. ∞˘Ùfi ¤ÙÚ ÙËÓ ÂÈÎÔÈÓˆÓ›· ÙˆÓ ·È‰È¿ÙÚˆÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ÛÙËÓ ∞ı‹Ó·, ÙÔ Royal Brompton ÛÙÔ §ÔÓ‰›ÓÔ, ÙÔ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ¶·ÙÚÒÓ Î·È ÙÔ Santa Cruz ÛÙËÓ ¶ÔÚÙÔÁ·Ï›·. ∆Ô ÚfiÁÚ·ÌÌ· ›¯Â ‰È¿ÚÎÂÈ· 18 ÌËÓÒÓ (·fi 1/7/1998 ¤ˆ˜ 31/12/1999) Î·È Ë Û‡Ó‰ÂÛË ÙˆÓ 5 ÓÔÛÔÎÔÌ›ˆÓ ¤ÁÈÓ Ì ÁÚ·Ì̤˜ ISDN Ô˘ ·Ú›¯Â Ô O∆∂. ŒÁÈÓ·Ó 39 ÙËωȷÛΤ„ÂȘ Î·È ÂÎÙÈÌ‹ıËÎ·Ó 93 ·È‰È¿ ÌÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. ∞fi ·˘Ù¿, 17 ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Û·Ó ·È‰È¿ Ì ÛÔ‚·Ú¤˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ù· ÔÔ›· ¯ÚÂÈ¿ÛÙËÎ·Ó ÌÂÙ·ÊÔÚ¿ - ›ÁÔ˘Û· ‹ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË - ÌÂÙ¿ ·fi ÛÙ·ıÂÚÔÔ›ËÛË. ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ Û˘Ó¤‚·Ï ÛÙËÓ Î·Ï‡ÙÂÚË ÂÈÎÔÈÓˆÓ›· Ì ÙÚÈÙÔ‚¿ıÌÈ· ΤÓÙÚ· Î·È ÛÙËÓ ·ÚÔ¯‹ ¤ÁηÈÚ˘ ‰È·ÁÓˆÛÙÈ΋˜ Î·È ıÂڷ¢ÙÈ΋˜ ‚Ô‹ıÂÈ·˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ¿ÛÎÔ˘ ÌÂٷΛÓËÛ˘ ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜.
Abstract: Telemedicine can be defined as the practice of medicine through data transmission from remote areas, in order to improve clinical care and facilitate diagnosis. Telemedicine has already been applied in numerous fields of medicine. Since July 1998 a telemedicine link was established between Venizelio General Hospital in Crete and “Aghia Sophia” Children’s Hospital in Athens, Royal Brompton in London, University Hospital in Patras and Santa Cruz in Portugal. This telemedicine link, based on ISDN technology, was part of the “TELE-REMEDY” project for remote diagnosis management and education in congenital heart disease. Over a period of 18 months, from July 1998 to December 1999, a total of 39 teleconsultations were carried out and data of 93 cases were transmitted. In 17 cases (18%) the diagnosis was that of a major cardiac disease which required transportation of the patient, either urgently or after the necessary initial measures for stabilization of the patient’s condition. The telemedicine link brought a number of benefits such as better access to the tertiary care center, timely diagnostic and therapeutic assistance and the avoidance of unnecessary transportation of the patient and his family.
§¤ÍÂȘ ÎÏÂȉȿ: ÙËÏÂ˚·ÙÚÈ΋, Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ.
Key words: disease.
∏ ÙËÏÂ˚·ÙÚÈ΋ Â›Ó·È ¤Ó· ÔχÙÈÌÔ ÂÚÁ·ÏÂ›Ô Ô˘ ÚÔÛʤÚÂÈ Ë Ù¯ÓÔÏÔÁ›· ÛÙ· ¯¤ÚÈ· ÙÔ˘ ÁÈ·ÙÚÔ‡ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ∏ ÂÈÛ‹ÁËÛË ·˘Ù‹ ·Ó·Ê¤ÚÂÙ·È
ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ÛÙÔ µÂÓÈ˙¤ÏÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ Î·È ÛÙ· ¯Ú‹ÛÈÌ· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚԤ΢„·Ó ·fi ·˘Ù‹.
¢È¢ı‡ÓÙÚÈ· µ’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ µÂÓÈ˙¤ÏÂÈÔ˘ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘
Director of B’ Pediatric Clinic Venizelio General Hospital, Heraklion, Crete
telemedicine,
congenital
heart
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∆ËÏÂ˚·ÙÚÈ΋, Ì ÙËÓ Â˘Ú›· ¤ÓÓÔÈ·, Â›Ó·È Ë ¿ÛÎËÛË Ù˘ È·ÙÚÈ΋˜ ·fi ·fiÛÙ·ÛË. ¶ÈÔ ·Ó·Ï˘ÙÈο, Â›Ó·È Ë ‰˘Ó·ÌÈ΋ Û ڷÁÌ·ÙÈÎfi ¯ÚfiÓÔ ÙËωȿÛÎÂ„Ë ÁÈ·ÙÚÒÓ Ô˘ Â›Ó·È ÁˆÁÚ·ÊÈο ·ÔÌ·ÎÚ˘Ṳ̂ÓÔÈ, Ì ‰˘Ó·ÙfiÙËÙ· Ù·˘Ùfi¯ÚÔÓ˘ ¯Ú‹Û˘ ÂÈÎfiÓˆÓ, ‹¯Ô˘ Î·È ÏËÚÔÊÔÚÈÒÓ ÁÈ· È·ÙÚÈÎÔ‡˜ Î·È ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÛÎÔÔ‡˜. ∏ ÙËÏÂ˚·ÙÚÈ΋ ‚·Û›˙ÂÙ·È ÛÙË Û‡Á¯ÚÔÓË Ù¯ÓÔÏÔÁ›· ÙÔ˘ ÙËÏÂÈÎÔÈÓˆÓÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘, ÛÙËÓ ÏËÚÔÊÔÚÈ΋ Î·È ÛÙÔ˘˜ ËÏÂÎÙÚÔÓÈÎÔ‡˜ ˘ÔÏÔÁÈÛÙ¤˜. ŒÙÛÈ, ÌÔÚÔ‡Ó Ó· ÌÂٷʤÚÔÓÙ·È - ·fi Ì›· È·ÙÚÈ΋ ÌÔÓ¿‰· Û ̛· ¿ÏÏË - ÛÙÔȯ›· ··Ú·›ÙËÙ· ÁÈ· ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔۤϷÛË ÂÓfi˜ ·ÛıÂÓÔ‡˜, fiˆ˜ ∏∫°, ·ÎÙÈÓÔÁڷʛ˜, ˯ÔηډÈÔÁÚ¿ÊËÌ·, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Î.¿. ∏ Ù·¯Â›· ·Ó¿Ù˘ÍË Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ¤¯ÂÈ ‹‰Ë ‚ÚÂÈ ÂÊ·ÚÌÔÁ¤˜ Û ‰È¿ÊÔÚ˜ ÂȉÈÎfiÙËÙ˜ Ù˘ È·ÙÚÈ΋˜, fiˆ˜ Ë ·ÎÙÈÓÔÏÔÁ›· (1-3), Ë „˘¯È·ÙÚÈ΋ (4), Ë ‰ÂÚÌ·ÙÔÏÔÁ›· (5,6), Ë Á˘Ó·ÈÎÔÏÔÁ›· (7), Ë Î·Ú‰ÈÔÏÔÁ›· (8), Ë ·È‰ÔηډÈÔÏÔÁ›· (9,10). ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯ÂÈ ÏËıÒÚ· ‰ËÌÔÛȇÛÂˆÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙȘ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ·fi ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ (9,11,12), ÙˆÓ ∏¶∞ (10,13), Ù˘ ∞Û›·˜ (14), Ù˘ ƒˆÛ›·˜ (15) Î·È ÙÔ˘ ∫·Ó·‰¿ (16). À¿Ú¯Ô˘Ó È·ÙÚÈο ÂÚÈÔ‰Èο Ì ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο ÙËÓ ÙËÏÂ˚·ÙÚÈ΋. OÈ ÚÒÙ˜ ÂÊ·ÚÌÔÁ¤˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙËÓ Î·Ú‰ÈÔÏÔÁ›· ¿Ú¯ÈÛ·Ó ÙÔ 1970 Ì ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ËÏÂÎÙÚÔηډÈÔÁÚ·Ê‹Ì·ÙÔ˜ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ Ô˘ ¤ÊÂÚ·Ó ÂÌÊ˘ÙÂ˘Ì¤ÓÔ ‚ËÌ·ÙÔ‰fiÙË (17). ™ÙËÓ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ·È‰ÔηډÈÔÏÔÁ›·˜ Ì ·ÚÈÔ ·ÓÙÈΛÌÂÓÔ ÙȘ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, fiÔ˘ Ë ÂÈÎfiÓ· ∏∫°, ·/· ÙËÏÂ. ηډ›·˜, ˯ÔηډÈÔÁÚ¿ÊËÌ· Î.¿. Î·È Ë ÂÚÌËÓ›· ÙÔ˘˜ ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎfi ̤ÛÔ ÛÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ÂÊ·ÚÌÔÁ‹ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ¤¯ÂÈ ÛËÌ·ÓÙÈο ÎÏÈÓÈο ÔʤÏË. OÈ ÛÙfi¯ÔÈ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ Ù¤ÙÔÈÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ›ӷÈ: ·) ™Â ›ÁÔ˘Û˜ ÂÚÈÙÒÛÂȘ, Ë ·ÚÔ¯‹ ¤Á΢Ú˘ Î·È ¤ÁηÈÚ˘ ‰È·ÁÓˆÛÙÈ΋˜ ‚Ô‹ıÂÈ·˜ ·fi ÂȉÈÎÔ‡˜ ÌÔÚ› Ó· ÌÂÙ·‚¿ÏÏÂÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ì ÙËÓ ·ÔÊ˘Á‹ Ù˘ ¿ÛÎÔ˘ ÌÂٷΛÓËÛ‹˜ ÙÔ˘ ‹ ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÂÂÈÁfiÓÙˆ˜ Û ÙÚÈÙÔ‚¿ıÌÈÔ Î¤ÓÙÚÔ ÁÈ· ıÂڷ›·. ‚) ™Â ÌË Â›ÁÔ˘Û˜ ÂÚÈÙÒÛÂȘ, Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì¤Û· ·fi Ù·ÎÙÈΤ˜ ÙËωȷÛΤ„ÂȘ ·ÔÛÎÔ› ÛÙË Ú‡ıÌÈÛ‹ ÙÔ˘˜, ¯ˆÚ›˜ Ó· ¯ÚÂÈ¿˙ÂÙ·È Ó· Ù·ÍÈ‰Â‡Ô˘Ó Ì·ÎÚÈ¿ ·fi ÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜ ÙÔ˘˜. Á) ∏ Û˘Ì‚ÔÏ‹ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ÛÙÔÓ ÙÔ̤· Ù˘ Âη›‰Â˘Û˘ Î·È Ù˘ ÂÈÌfiÚʈÛ˘ Ì ÙËÓ Ù·¯‡ÙÂÚË ÌÂÙ¿‰ÔÛË Ù˘ ÁÓÒÛ˘ Î·È Ù˘ ÏËÚÔÊÔÚ›·˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ·ÔÛÙ¿ÛÂȘ, ÌÂÈÒÓÂÈ ÙÔ ·›ÛıËÌ·
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·ÔÌfiÓˆÛ˘ Î·È ·˘Í¿ÓÂÈ ÙȘ ÁÓÒÛÂȘ Î·È ÙȘ ÈηÓfiÙËÙ˜ ÙÔ˘ È·ÙÚÈÎÔ‡ Î·È ÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡. ‰) ŸÏ· Ù· ·ÓˆÙ¤Úˆ ·Ó·ÊÂÚfiÌÂÓ· ÛÙÔȯ›· Û˘Ó¿ÁÔÓÙ·È Ì›ˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ ÛÙÔÓ ÙÔ̤· Ù˘ ˘Á›·˜. ∏ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ µÂÓÈ˙¤ÏÂÈÔ˘ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ Û˘ÌÌÂÙ›¯Â Û ¤Ó· ÚfiÁÚ·ÌÌ· ÙËÏÂ˚·ÙÚÈ΋˜ Ì ÙËÓ ÂˆÓ˘Ì›· “TELEREMEDY” - ‰È¿ÁÓˆÛË, ·ÓÙÈÌÂÙÒÈÛË Î·È Âη›‰Â˘ÛË ·fi ·fiÛÙ·ÛË ÛÙȘ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. ∞˘Ùfi ¤ÙÚ ÙËÓ ÂÈÎÔÈÓˆÓ›· ÙˆÓ ·È‰È¿ÙÚˆÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì ÙËÓ ¶·È‰ÔηډÈÔÏÔÁÈ΋ Î·È ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÎÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ÛÙËÓ ∞ı‹Ó·, ÙÔ Royal Brompton ÛÙÔ §ÔÓ‰›ÓÔ, ÙÔ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ¶·ÙÚÒÓ Î·È ÙÔ Santa Cruz ÛÙËÓ ¶ÔÚÙÔÁ·Ï›·. ∆Ô ÚfiÁÚ·ÌÌ· ÂȉÔÙ‹ıËΠ·fi ÙËÓ ∂˘Úˆ·˚΋ ŒÓˆÛË, ›¯Â ‰È¿ÚÎÂÈ· 18 ÌËÓÒÓ (1/7/1998 ¤ˆ˜ 31/12/1999) Î·È Ë Û‡Ó‰ÂÛË ÙˆÓ 5 ÓÔÛÔÎÔÌ›ˆÓ ¤ÁÈÓ Ì ÁÚ·Ì̤˜ ISDN Ô˘ ·Ú›¯Â Ô O∆∂. OÈ ÁÚ·Ì̤˜ ISDN Â›Ó·È „ËÊȷΤ˜ ÁÚ·Ì̤˜ ÙËÏÂÊÒÓÔ˘ Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂٷʤÚÔ˘Ó Ù·¯‡ÙÂÚ· ÂÚÈÛÛfiÙÂÚ˜ ÏËÚÔÊÔڛ˜, Û ۯ¤ÛË Ì ÙȘ ÎÏ·ÛÈΤ˜ ÙËÏÂʈÓÈΤ˜. ∏ οı ÁÚ·ÌÌ‹ ISDN ¤¯ÂÈ Ù·¯‡ÙËÙ· ÌÂÙ·ÊÔÚ¿˜ ‰Â‰ÔÌ¤ÓˆÓ 128 ∫bits/s (18). ŒÙÛÈ, Á›ÓÂÙ·È ‰˘Ó·Ù‹ Ë ¿ÌÂÛË ÌÂÙ·ÊÔÚ¿ ÂÈÎfiÓ·˜ Î·È ‹¯Ô˘ Û ڷÁÌ·ÙÈÎfi ¯ÚfiÓÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ÂÊÈÎÙ‹ Ë ÙËωȿÛÎÂ„Ë ÛÙ· Û˘Ó‰Â‰Â̤ӷ ÓÔÛÔÎÔÌ›·. ™ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ¤ÁÈÓ·Ó 39 ÙËωȷÛΤ„ÂȘ, ·fi ÙȘ Ôԛ˜ ÔÈ 4 ‹Ù·Ó ÂÎ·È‰Â˘ÙÈÎÔ‡ ¯·Ú·ÎÙ‹Ú· Ì ÙÔ ¡ÔÛÔÎÔÌÂ›Ô Royal Brompton, ÔÈ 33 ¤ÁÈÓ·Ó Ì ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” Î·È ·ÊÔÚÔ‡Û·Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ ÌÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ - Û˘ÓÙËÚËÙÈ΋, ÂÂÌ‚·ÙÈ΋ ‹ ¯ÂÈÚÔ˘ÚÁÈ΋. ∆¤ÏÔ˜, ÔÈ 2 ¤ÁÈÓ·Ó Ì ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·ÙÚÒÓ Î·È ·ÊÔÚÔ‡Û·Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ·ÚÚ˘ıÌÈÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·. ∂ÎÙÈÌ‹ıËÎ·Ó 93 ·È‰È¿ Ì ηډȷΤ˜ ·ı‹ÛÂȘ, ·fi Ù· ÔÔ›· ÌfiÓÔ 3 (3,2%) ¯ÚÂÈ¿ÛÙËÎ·Ó Â›ÁÔ˘Û· ÌÂÙ·ÊÔÚ¿, 46 (49,5%) ÌÂٷʤÚıËÎ·Ó ÚÔÁÚ·ÌÌ·ÙÈṲ̂ӷ ÁÈ· ηıÂÙËÚÈ·ÛÌfi ηډ›·˜, ÂÂÌ‚·ÙÈ΋ ‹ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Û ÙÚÈÙÔ‚¿ıÌÈ· ΤÓÙÚ· Î·È 44 (47,3%) ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÛÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜ ÙÔ˘˜. ∞fi ·˘Ù¿, ÛÔ‚·Ú¤˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ›¯·Ó 17 ·È‰È¿ (18%), 7 ›¯·Ó ÙÂÙÚ·ÏÔÁ›· Fallot, 5 ›¯·Ó Ï‹ÚË ÌÂÙ¿ıÂÛË ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, 1 ›¯Â ÔÏÈ΋ ·ÓÒÌ·ÏË Â΂ÔÏ‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ, 1 ·ÙÚËÛ›· ÙÚÈÁÏÒ¯ÈÓÔ˜, 1 ˘ÂÚ‚·Ï‚ȉÈ΋ ·ÔÚÙÈ΋ ÛÙ¤ÓˆÛË, 2 ˘Ô‚·Ï‚ȉÈ΋ ·ÔÚÙ‹ ÛÙ¤ÓˆÛË, Ù· ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÔÔ›· ¯ÚÂÈ¿ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ÕÏϘ ηډȷΤ˜ ·ı‹ÛÂȘ ‹Ù·Ó Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Û 16 ·È‰È¿ (17,2%), ·ı‹ÛÂȘ Ù˘ ·ÔÚÙ‹˜
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Û 9 (9,7%), ·ÚÚ˘ı̛˜ Û 9 (9,7%), Û‡ÌÏÔΘ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Û 9 (9,7%), ÌÂÛÔÎÔÏÈ΋ ÂÈÎÔÈÓˆÓ›· Û 8 (8,6%), ÛÙ¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ ‚·Ï‚›‰·˜ Û 4 (4,3%), ÂÏÏ›ÌÌ·Ù· ÂÓ‰ÔηډȷÎÒÓ ÚÔÛÎÂÊ·Ï·›ˆÓ Û 3 (3,2%), ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜ ‚·Ï‚›‰·˜ Î·È ·Ó¿ÚÎÂÈ· Û 3 (3,2%), ‰ÂÍÈÔηډ›· Û 2 (2,2%), ÛÙ¤ÓˆÛË ÙˆÓ ÎÏ¿‰ˆÓ Ù˘ Ó¢ÌÔÓÈ΋˜ Û 2 (2,2%), ·ÓÔÈÎÙfi˜ ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ Û 2 (2,2%), ÂÚÈηډ›ÙȘ Û 2 (2,2%), ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜ Û 1 (1,1%), ·Ó¿ÚÎÂÈ· ÙÚÈÁÏÒ¯ÈÓÔ˜ Û 1 (1,1%), Û‡Ó‰ÚÔÌÔ Marfan Ì ‰È¿Ù·ÛË Ù˘ Ú›˙·˜ Ù˘ ·ÔÚÙ‹˜ Û 1 (1,1%), ÂÓÒ 4 ·È‰È¿ (4,3%) ‰ÂÓ Â›¯·Ó ηډȷ΋ ¿ıËÛË. ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÙËÏÂ˚·ÙÚÈ΋˜ ·ÓÔ›ÁÂÈ Ó¤Ô˘˜ ÔÚ›˙ÔÓÙ˜ ÛÙÔÓ ÙÔ̤· Ù˘ ˘Á›·˜, ·Ú·Î¿ÌÙÂÈ ÁˆÁÚ·ÊÈÎÔ‡˜ Î·È ¯ÚÔÓÈÎÔ‡˜ ÂÚÈÔÚÈÛÌÔ‡˜ Î·È ‰ËÌÈÔ˘ÚÁ› ‰˘Ó·ÙfiÙËÙ˜ ÁÈ· ¢ڇÙÂÚ˜ Û˘ÓÂÚÁ·Û›Â˜ Ì ÛÙfi¯Ô ÙËÓ ·ÚÔ¯‹ ˘„ËÏÔ‡ ÂȤ‰Ô˘ È·ÙÚÈÎÒÓ ˘ËÚÂÛÈÒÓ.
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CARDIOLOGY
NfiÛÔ˜ ∫awasaki Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· °. ™. ¶··‰fiÔ˘ÏÔ˜
Kawasaki disease and its consequences in the cardiovascular system G. S. Papadopoulos
¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ Kawasaki, ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜, ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ Û ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 8 ÂÙÒÓ. ∫·Ù¿ ÙËÓ ˘ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È Û¯ËÌ·ÙÈÛÌfi˜ ·Ó¢ڢÛÌ¿ÙˆÓ ÛÙ· ÂÈηډȷο ·ÁÁ›· Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (25%) ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ıÂڷ›·, ÂÓÒ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ¤ÁηÈÚ· Û ıÂڷ›· ÙÔ ÔÛÔÛÙfi ·˘Ùfi ·Ó¤Ú¯ÂÙ·È ÛÙÔ 5%. ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ ·˘ÙÒÓ ˘Ô¯ˆÚ› Û ¤Ó· Ì ‰‡Ô ¤ÙË, ÂÓÒ ÌÈÎÚfi ÔÛÔÛÙfi ÂÍÂÏ›ÛÛÂÙ·È Û ÛÙ¤ÓˆÛË ‹ Û ·fiÊÚ·ÍË (¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘, 1%). §fiÁˆ Ù˘ ʇÛˆ˜ Ù˘ ·ÁÁÂÈ›Ùȉ·˜, Ë ÓfiÛÔ˜ Kawasaki ıˆÚÂ›Ù·È ÚԉȷıÂÛÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·ıËڈ̿وÛ˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Î·È ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘.
Abstract: Kawasaki disease, an entity of unknown etiology, associated with systemic angiitis, usually affects children aged up to 8 years. During the subacute phase of the disease, coronary artery aneurysms are developed in 25% of patients not receiving appropriate therapy, whereas in the group of patients under proper therapy the percentage of aneurysms is reduced (5%). The majority of coronary aneurysms usually disappear in one or two years, whereas a small percentage of cases will develop progressive stenosis or total obstruction of the artery (myocardial infarction, 1%). Due to the nature of angiitis, Kawasaki disease is considered to be a predisposing factor for the development of coronary artery disease.
§¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ Kawasaki, ·Ó¢ڇÛÌ·Ù· ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜.
Key words: Kawasaki disease, aneurysm of coronary artery, coronary disease.
∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ Î·È ÂΉËÏÒÓÂÙ·È ˆ˜ ÁÂÓÈÎÂ˘Ì¤ÓË ·ÁÁÂÈ›Ùȉ· Û ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 8 ÂÙÒÓ. ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ÌÈÎÚfiÙÂÚÔ ÙˆÓ 5 ÂÙÒÓ. ™·ÓÈfiÙÂÚ·, ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 3 ÌËÓÒÓ ‹ Û ÂÓ‹ÏÈΘ. ∏ ÓfiÛÔ˜ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1967 ·fi ÙÔÓ Dr. Tomisaku Kawasaki, o oÔ›Ô˜ ·ÚÔ˘Û›·Û 50 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ ÛÙËÓ π·ˆÓ›·. ∏ ÎÏÈÓÈ΋ ÙÔ˘˜ ÂÈÎfiÓ· ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi ˘ÚÂÙfi, ‰ÂÚÌ·ÙÈÎfi ÂÍ¿ÓıËÌ·, ÊÏÂÁÌÔÓ‹ ÙˆÓ ÂÈÂÊ˘ÎfiÙˆÓ, ÂÓ¿ÓıËÌ·, ÂÚ˘ıÚfiÙËÙ· Î·È Ô›‰ËÌ· ÙˆÓ ¯ÂÚÈÒÓ Î·È Ô‰ÈÒÓ Î·È ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·. ∏ ÂÙ‹ÛÈ· ›وÛË Ù˘ ÓfiÛÔ˘ ÛÙȘ ∏¶∞ ›ӷÈ
10/100.000 ·È‰È¿, ÂÓÒ ÛÙËÓ π·ˆÓ›· Â›Ó·È Ôχ ÌÂÁ·Ï‡ÙÂÚË 95/100.000 ·È‰È¿. ∏ Û˘¯ÓfiÙÂÚË ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ Â›Ó·È ÔÈ 18 ¤ˆ˜ 24 Ì‹Ó˜ ÛÙȘ ∏¶∞ Î·È ÔÈ 6 ¤ˆ˜ 12 Ì‹Ó˜ ÛÙËÓ π·ˆÓ›·. ∞Ô˘Û›· ÂȉÈ΋˜ ‰È·ÁÓˆÛÙÈ΋˜ ÂͤٷÛ˘, Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ˘ÚÂÙÔ‡ ÙÔ˘Ï¿¯ÈÛÙÔÓ 5 ËÌÂÚÒÓ Î·È ÙÂÛÛ¿ÚˆÓ ·fi Ù· ¤ÓÙ ÂÍ‹˜ ÎÚÈÙ‹ÚÈ·: ·) ∞ÌÊÔÙÂÚfiÏ¢ÚË ÌË ÂÎÎÚÈÙÈ΋ ÂÈÂÊ˘Î›Ùȉ·, ‚) ÃÂÈÏ›Ùȉ· - ÛÙÔÌ·Ù›Ùȉ·, Á) O›‰ËÌ·, ÂÚ‡ıËÌ·, ·ÔϤÈÛË ÙˆÓ ·Ï·ÌÒÓ Î·È ÙˆÓ ÂÏÌ¿ÙˆÓ, ‰) ¶ÔχÌÔÚÊÔ ÂÍ¿ÓıËÌ· ÙÔ˘ ÎÔÚÌÔ‡ Î·È Â) ∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ,
∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∫·Ú‰ÈÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
Division of Pediatric Cardiology “St. Sophia” Children’s Hospital, Athens
420
¶·È‰È·ÙÚÈ΋ 2001;64:420-423
·‡ÍËÛË Ù˘ ∆∫∂, ıÂÙÈ΋ CRP, ·‡ÍËÛË Ù˘ ·1 ·ÓÙÈıÚ˘„›Ó˘, ·Ó·ÈÌ›·, ÌÂÁ¿ÏË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË) Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰·, ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Î·È Î˘ÙÔÎÈÓÒÓ Î·È ÂÌÊ¿ÓÈÛË ¿ÛËÙ˘ ˘Ô˘Ú›·˜. ∂ÎÙfi˜ ·fi Ù· ·Ú·¿Óˆ Û˘ÌÙÒÌ·Ù·, ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ï‹ı·ÚÁÔ, ¿ÛËÙË ÌËÓÈÁÁ›Ùȉ·, ·ÚıÚ›Ùȉ·, Ô˘ÚËıÚ›Ùȉ·, Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ‡‰Úˆ· Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜, ‰È¿ÚÚÔÈ·, ÂÌÂÙÔ‡˜, Ó¢ÌÔÓ›Ùȉ· Î·È Ì¤ÛË ˆÙ›Ùȉ·. ÷ڷÎÙËÚÈÛÙÈ΋ Î·È Ô˘ÛÈ·ÛÙÈ΋ ›ӷÈ, ›Û˘, Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ì˘Ôηډ›Ùȉ·˜, ÂÚÈηډ›Ùȉ·˜, ÚÔÛ‚ÔÏ‹˜ ÙˆÓ Î·Ú‰È·ÎÒÓ ‚·Ï‚›‰ˆÓ Î·È ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ·fi ÈÏ·Ú¿, ÔÛÙÚ·ÎÈ¿, ÛÙ·Ê˘ÏÔÎÔÎÎÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ÙÔÍÈÎfi shock, Ó·ÓÈ΋ ÚÂ˘Ì·ÙÔÂȉ‹ ·ÚıÚ›Ùȉ·, ÙË ÓfiÛÔ Stevens-Johnson, Ô˙Ò‰Ë ÔÏ˘·ÚÙËÚ›Ùȉ· Î·È ‰È¿ÊÔÚ˜ Ê·Ú̷΢ÙÈΤ˜ ·ÓÙȉڿÛÂȘ. ÕÙ˘Â˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ˘ÚÂÙfi Î·È ÙÚ›· ·fi Ù· ¤ÓÙ ÎÚÈÙ‹ÚÈ· Ô˘ ÚԷӷʤÚıËηÓ. ∂Ó›ÔÙ ÛÙ· ‚Ú¤ÊË, Ë ÓfiÛÔ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÌfiÓÔ ˆ˜ ·Ú·ÙÂÈÓfiÌÂÓÔ Â̇ÚÂÙÔ Î·È Ë ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Â›Ó·È fiˆ˜ ·˘Ù¿ Ù˘ Ù˘È΋˜ ÓfiÛÔ˘. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Kawasaki ·Ú·Ì¤ÓÂÈ ·Û·Ê‹˜. OÚÈṲ̂Ó˜ ·ÓÔÛÔÏÔÁÈΤ˜ Î·È ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Û˘ÓËÁÔÚÔ‡Ó fiÙÈ ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ·Ú·ÁˆÁ‹ ÙÔ͛Ӣ (˘ÂÚ·ÓÙÈÁfiÓÔ) ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ (Û˘Ó‹ıˆ˜ Staph. Aureus coagulase positive), oÈ ÔÔ›ÔÈ ·ÔÈΛ˙Ô˘Ó ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ· ‹ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÂÙÈÎÔ‡ “ÁÂÓÂÙÈο ÚÔηıÔÚÈṲ̂ӈӔ ·ÙfïÓ. ∏ ÙÔÍ›ÓË, ·ÔÚÚÔÊÔ‡ÌÂÓË, ‰ÈÂÁ›ÚÂÈ ÂÎÏÂÎÙÈο Ù· ÌÔÓÔ‡ÚËÓ· Ô˘ ÂÎÎÚ›ÓÔ˘Ó ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜ (IL-1, TNF-a, IFN-Á). OÈ ·˘ÍË̤Ó˜ ΢ÙÔΛÓ˜ ÚÔηÏÔ‡Ó ˘ÚÂÙfi Î·È ·˘Í¿ÓÔ˘Ó Ù· ›‰· ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘, ÂÓÒ ·Ú¿ÏÏËÏ· ÚÔ¿ÁÔ˘Ó ÙËÓ ¤ÎÊÚ·ÛË Ó¤ˆÓ ·ÓÙÈÁfiÓˆÓ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∆Ô ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ·ÁÁ›ˆÓ Á›ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ıÚÔÌ‚ÔÁfiÓÔ Î·È Â˘·›ÛıËÙÔ ÛÙË Ï‡ÛË ·fi Ù· ‰ËÌÈÔ˘ÚÁÔ‡ÌÂÓ· ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù·. ∞ÔÙ¤ÏÂÛÌ· fiÏˆÓ ÙˆÓ ·ÓˆÙ¤Úˆ ‰ÈÂÚÁ·ÛÈÒÓ Â›Ó·È Ë ÂÌÊ¿ÓÈÛË Ì›·˜ ÁÂÓÈÎÂ˘Ì¤Ó˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·ÁÁÂÈ›Ùȉ·˜. ™ÙË ÓfiÛÔ Kawasaki ·Ú·ÙËÚÔ‡ÓÙ·È ÙÚÂȘ Ê¿ÛÂȘ. ∏ ÔÍ›· Â̇ÚÂÙÔ˜ Ê¿ÛË Â›Ó·È ‰È¿ÚÎÂÈ·˜ 1
Paediatriki 2001;64:420-423
¤ˆ˜ 2 ‚‰ÔÌ¿‰ˆÓ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi, ÂÈÂÊ˘Î›Ùȉ·, ÂÚ‡ıËÌ· Î·È Ô›‰ËÌ· ¯ÂÚÈÒÓ Î·È Ô‰ÈÒÓ, ‰ÂÚÌ·ÙÈÎfi ÂÍ¿ÓıËÌ· Î·È ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·. ∞fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ÂÌÊ·Ó›˙ÂÙ·È Ì˘Ôηډ›Ùȉ·, ÂÚÈηډ›Ùȉ· Î·È ÚÔÛ‚ÔÏ‹ ÙˆÓ Î·Ú‰È·ÎÒÓ ‚·Ï‚›‰ˆÓ. ∏ ˘ÔÍ›· Ê¿ÛË ·ÎÔÏÔ˘ı› Î·È ‰È·ÚΛ ¤ˆ˜ 4 ‚‰ÔÌ¿‰Â˜. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ¤ÓÙÔÓË ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË Î·È ·ÔϤÈÛË ÙˆÓ ‰·ÎهψÓ. ™ÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ·Ó¢ڇÛÌ·Ù· Û ÔÛÔÛÙfi 25%, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ıÂڷ›·. ∏ Ê¿ÛË Ù˘ ·Ó¿ÚÚˆÛ˘, ‰È¿ÚÎÂÈ·˜ ¤ˆ˜ 6-8 ‚‰ÔÌ¿‰ˆÓ, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÍ·Ê¿ÓÈÛË ÙˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ Î·È Û˘Ó¯›˙ÂÈ Ì¤¯ÚÈ Â·Ófi‰Ô˘ Ù˘ ∆∫∂ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·. ∫·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ÛÙË ÓfiÛÔ Kawasaki H ÓfiÛÔ˜ Kawasaki ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·, ÔÈ Ôԛ˜ ¯ÚÂÈ¿˙ÔÓÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ Î·È ÌÂϤÙË. ™ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ì˘Ôηډ›Ô˘ Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 50%). ™˘ÏÏÔÁ‹ ÂÚÈηډȷÎÔ‡ ˘ÁÚÔ‡ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 25%. ∏ ÚÔÛ‚ÔÏ‹ Ù˘ ÌÈÙÚÔÂȉԇ˜ ΢ڛˆ˜, ·ÏÏ¿ Î·È Ù˘ ·ÔÚÙÈ΋˜ ‚·Ï‚›‰·˜, Â›Ó·È Û¿ÓÈ· (1%). ∏ ÂÌÊ¿ÓÈÛË ·Ó¢ڢÛÌ¿ÙˆÓ ÛÙȘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÚÙËڛ˜ Â›Ó·È Û¯ÂÙÈο Û¿ÓÈ· (2%), ·ÏÏ¿ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜ Â›Ó·È ·˘ÍË̤ÓË Êı¿ÓÔÓÙ·˜ ÛÙÔ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙÔ˘ 25%. ∏ ÚfiÎÏËÛË ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ÏfiÁˆ ·fiÊڷ͢ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜ Â›Ó·È Û¯ÂÙÈο Û¿ÓÈ· (1-2%), ·ÏÏ¿ Ôχ ÛÔ‚·Ú‹ ÂÈÏÔ΋. ∆Ô ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· Â›Ó·È Ì›· ÛËÌ·ÓÙÈ΋, ·Ó·›Ì·ÎÙË Ù¯ÓÈ΋ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ·ÓˆÙ¤Úˆ ÂÈÏÔÎÒÓ. ªÂ ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· ÂϤÁ¯ÔÓÙ·È ÔÈ ‰È·ÛÙ¿ÛÂȘ Î·È Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜. ∂›Û˘, ÂϤÁ¯ÂÙ·È Ë ‡·ÚÍË ÂÚÈηډȷÎÔ‡ ˘ÁÚÔ‡ Î·È Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ Î·Ú‰È·ÎÒÓ ‚·Ï‚›‰ˆÓ. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ‰È·›ÛÙˆÛË ‡·Ú͢ ·Ó¢ڢÛÌ¿ÙˆÓ ÛÙËÓ ·Ú¯È΋ ÌÔ›Ú· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ˯ÔηډÈÔÁÚ·Ê‹Ì·ÙÔ˜ ‰‡Ô ‰È·ÛÙ¿ÛˆÓ. £Âڷ›· ŸÙ·Ó ÙÂı› Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, ̤۷ ÛÙȘ 10 ÚÒÙ˜ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡, ¯ÔÚËÁÂ›Ù·È ·ÛÈÚ›ÓË (100 mg/kg/24h Û 4 ‰fiÛÂȘ), ÏfiÁˆ Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰Ú¿Û˘ Ù˘. ∞·Ú·›ÙËÙË Â›Ó·È ‚¤‚·È· Ë Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ Û·Ï˘ÎÈÏÈÎÒÓ ÛÙÔ ·›Ì·. ∏ ¯ÔÚ‹ÁËÛË Ù˘ ·ÛÈÚ›Ó˘ Û˘Ó¯›˙ÂÙ·È 2-3 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÙÒÛË ÙÔ˘ ˘ÚÂÙÔ‡. ™ÙË Û˘Ó¤¯ÂÈ·, Ë ‰fiÛË ÂÏ·ÙÙÒÓÂÙ·È Û 3-5
421
¶·È‰È·ÙÚÈ΋ 2001;64:420-423
mg/kg/24h ÂÊ¿·Í ÁÈ· ÙËÓ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ Ù˘ ‰Ú¿ÛË ÁÈ· 6-8 ‚‰ÔÌ¿‰Â˜, fiÛÔ ‰ËÏ·‰‹ ‰È·ÚΛ Ë ¤ÓÙÔÓË ıÚÔÌ‚ÔÂÓ›· Ù˘ ÓfiÛÔ˘. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯Ô˘Ó ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, Ë ¯ÔÚ‹ÁËÛË Ù˘ ·ÛÈÚ›Ó˘ Û˘Ó¯›˙ÂÙ·È Ì¤¯ÚÈ Ó· ÂÍ·ÏÂÈÊıÔ‡Ó. ™˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ Ù˘ ·ÛÈÚ›Ó˘, ‰›‰ÂÙ·È ÂÓ‰ÔÊÏ‚›ˆ˜ Á-ÛÊ·ÈÚ›ÓË Û ‰fiÛË 2 g/kg ̤۷ Û 12 ÒÚ˜. ªÂ ‚¿ÛË ÙȘ ÌÂϤÙ˜, Ë ÂÌÊ¿ÓÈÛË ·Ó¢ڢÛÌ¿ÙˆÓ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· ÂÏ·ÙÙÒıËΠ·fi 25% ÛÙ· 5-6% ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘ Î·È ·ÛÈÚ›Ó˘ ÙȘ ÚÒÙ˜ 10 Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ˘ÚÂÙÔ‡. O ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ Ù˘ Á-ÛÊ·ÈÚ›Ó˘ ÛÙË ÓfiÛÔ Kawasaki ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Ë Á-ÛÊ·ÈÚ›ÓË ÂÚȤ¯ÂÈ ·ÓÙÈÙÔÍÈÓÈο ·ÓÙÈÛÒÌ·Ù· Ù· ÔÔ›· ÂÍÔ˘‰ÂÙÂÚÒÓÔ˘Ó Ù· “˘ÂÚ·ÓÙÈÁfiÓ·”, ÌÂÈÒÓÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Î·È ÙË ‰Ú¿ÛË ÙˆÓ Î˘ÙÔÎÈÓÒÓ, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ·fi ÙȘ ΢ÙÔΛÓ˜ Î·È ÂÚȤ¯ÂÈ ·ÓÙÈȉÈÔÙ˘Èο ·ÓÙÈÛÒÌ·Ù·, Ù· ÔÔ›· ÂÍÔ˘‰ÂÙÂÚÒÓÔ˘Ó Ù· ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈ-ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù·. ™˘ÓÔÏÈο, ÈÛÙ‡ÂÙ·È fiÙÈ Ë Á-ÛÊ·ÈÚ›ÓË ·ÛΛ ÔÏÏ·Ï‹ ·ÓÔÛÔÙÚÔÔÔÈËÙÈ΋ ‰Ú¿ÛË ÛÙÔÓ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi Ô˘ ÎÈÓËÙÔÔÈÂ›Ù·È Î·È Ô ÔÔ›Ô˜ ıˆÚÂ›Ù·È ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ì ˘ÔÙÚÔ¤˜ Ù˘ ÓfiÛÔ˘, ¯ÔÚËÁÔ‡ÓÙ·È ÎÔÚÙÈÎÔÂȉ‹ (ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË) Ì ηϿ ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ·fi ÔÚÈṲ̂ÓÔ˘˜ Û˘ÁÁÚ·Ê›˜, ·Ó Î·È ·˘Í¿ÓÔ˘Ó ÙËÓ ‹‰Ë ·˘ÍË̤ÓË ıÚÔÌ‚ÔÁfiÓÔ Ù¿ÛË Ù˘ ÓfiÛÔ˘. ∞Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ÛÙË ÓfiÛÔ Kawasaki T· ·Ó¢ڇÛÌ·Ù· ÛÙË ÓfiÛÔ Kawasaki ‰È·ÎÚ›ÓÔÓÙ·È Û ÌÈÎÚ¿ (‰È·Ì¤ÙÚÔ˘ <5 mm), ÌÂÛ·›· (‰È·Ì¤ÙÚÔ˘ 5-8 mm) Î·È ÁÈÁ·ÓÙÈ·›· (‰È·Ì¤ÙÚÔ˘ >8 mm). ∞Ó¿ÏÔÁ· Ì ÙÔ Û¯‹Ì·, ‰È·ÎÚ›ÓÔÓÙ·È Û ۷ÎÎÔÂȉ‹ Î·È ·ÙÚ·ÎÙÔÂȉ‹. ™Â ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¤Ï·‚·Ó ıÂڷ›·, ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È ÂÚ›Ô˘ 25%. ¶·ÚÔ‰ÈΤ˜ ‹È˜ ‰È·Ù¿ÛÂȘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Û˘Ì‚·›ÓÔ˘Ó Û ÔÛÔÛÙfi 40% ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘, ÔÈ Ôԛ˜ ˘Ô¯ˆÚÔ‡Ó ÓˆÚ›˜. °ÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· ·Ó¢ڛÛÎÔÓÙ·È Û ÔÛÔÛÙfi 5% ÂÚ›Ô˘. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¯ÔÚËÁ‹ıËΠ¤ÁηÈÚ· Ë Î·Ù¿ÏÏËÏË ıÂڷ›·, Ë ÂÌÊ¿ÓÈÛË ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ ÂÏÏ·ÙÒıËΠÛÙÔ 5% ÂÚ›Ô˘ Î·È ÛÙÔ 1% ÙˆÓ ÁÈÁ·ÓÙÈ·›ˆÓ. ∏ ÂͤÏÈÍË Î·È ÔÚ›· ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜. ∆· ÌÈÎÚ¿ Î·È ÌÂÛ·›· ·Ó¢ڇÛÌ·Ù· ˘ÔÛÙÚ¤ÊÔ˘Ó Î·Ù¿ ÙÔ ‹ÌÈÛ‡
422
Paediatriki 2001;64:420-423
ÙÔ˘˜ Û 1-2 ¤ÙË. ∞fi Ù· ·Ú·Ì¤ÓÔÓÙ·, ¤Ó· ÔÛÔÛÙfi ÂÍÂÏ›ÛÛÂÙ·È Û ÛÙ¤ÓˆÛË Ù˘ ·ÚÙËÚ›·˜ ‹ Î·È Û ϋÚË ·fiÊÚ·ÍË Î·È ¤ÌÊÚ·ÁÌ·. ∆· ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù· ۯ‰fiÓ ÔÙ¤ ‰ÂÓ ˘ÔÛÙÚ¤ÊÔ˘Ó Î·È Û ÔÛÔÛÙfi 50% Ô‰ËÁÔ‡Ó Û ÛÙ¤ÓˆÛË. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ì ÓfiÛÔ Kawasaki, ÙÔ 1-2% ÂÌÊ·Ó›˙ÂÈ Ô͇ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ∞fi ·˘ÙÔ‡˜, ÙÔ 70% ¤¯ÂÈ ÁÈÁ·ÓÙÈ·›· ·Ó¢ڇÛÌ·Ù·. ø˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·Ó¢ڢÛÌ¿ÙˆÓ ·Ó·Ê¤ÚÔÓÙ·È: ˘ÚÂÙfi˜ ‰È¿ÚÎÂÈ·˜ ¿Óˆ ÙˆÓ 16 ËÌÂÚÒÓ, ˘ÔÙÚÔ‹ ÙÔ˘ ˘ÚÂÙÔ‡ ÌÂÙ¿ ·˘ÚÂÍ›· 48 ˆÚÒÓ, ·ÚÚ˘ı̛˜, ËÏÈΛ· (<1 ¤ÙÔ˘˜), ÙÔ Ê‡ÏÔ (·ÁfiÚÈ·), Ë ·Ó·ÈÌ›·, Ë ıÚÔÌ‚ÔÂÓ›· Î·È Ë ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·. ŒÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ ÛÙË ÓfiÛÔ Kawasaki TÔ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ ÛÙË ÓfiÛÔ Kawasaki ÚÔηÏÂ›Ù·È ÏfiÁˆ ·fiÊڷ͢ Ì›·˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ‹ Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ıÚfiÌ‚Ô˘ ̤۷ ÛÙÔ Û¯ËÌ·ÙÈ˙fiÌÂÓÔ ·Ó‡ڢÛÌ·, ‹ ·ÚÁfiÙÂÚ·, ÏfiÁˆ ÌÂÁ¿Ï˘ ÛÙ¤ÓˆÛ˘ Î·È Ï‹ÚÔ˘˜ ·fiÊڷ͢ ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ·ÁÁ›Ԣ ·fi οÔÈÔ ıÚfiÌ‚Ô. ∫ÏÈÓÈο, ÙÔ ·È‰› ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÓËÛ˘¯›·, Û˘Ó¯¤˜ ÎÏ¿Ì·, Â̤ÙÔ˘˜, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÚÔοډÈÔ ¿ÏÁÔ˜ (Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿) ‹ ηډÈÔÁÂÓ¤˜ Shock. ™Â ÔÛÔÛÙfi 37% ÌÔÚ› ÙÔ ·È‰› Ó· Â›Ó·È ·Û˘Ìو̷ÙÈÎfi. ™ÙÔ ∏∫° ·Ó¢ڛÛÎÂÙ·È ·Ó¿Û·ÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ST ‹ ÂÌÊ¿ÓÈÛË Î‡Ì·ÙÔ˜ q. ∏ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È ıÂÙÈ΋ Ì ·‡ÍËÛË ÙˆÓ ÂÓ˙‡ÌˆÓ SGOT, SGPT, LDH, CPK-MB, Troponin. ™ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· ·Ú·ÙËÚÂ›Ù·È ˘ÔÎÈÓËÛ›·, ·ÎÈÓËÛ›· ‹ ‰˘ÛÎÈÓËÛ›· ÙÌ‹Ì·ÙÔ˜ ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜. H ıÂڷ›· ÛÙÔ Ô͇ ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ Û˘Ó›ÛÙ·Ù·È Û ·ÎÈÓËÛ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ (Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿) Î·È ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÊÏ‚›ˆ˜ ıÚÔÌ‚ÔÏ˘ÙÈÎÔ‡ (ÛÙÚÂÙÔÎÈÓ¿ÛË, rt-PA). ∏ ‰fiÛË ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ıÚÔÌ‚ÔÏ˘ÙÈÎÒÓ ÛÙ· ·È‰È¿ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË Ù·˘ÙÔÔÈËı›, ÏfiÁˆ ÌË Â·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ ÂÚÈÛÙ·ÙÈÎÒÓ. ªÂÙ¿ ÙË ‰È·ÎÔ‹ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ıÚÔÌ‚ÔÏ˘ÙÈÎÔ‡, ¯ÔÚËÁÂ›Ù·È Ë·Ú›ÓË ÂÓ‰ÔÊÏ‚›ˆ˜ ÁÈ· ·ÚÎÂÙ¤˜ Ë̤Ú˜. ∞ÁÁÂÈÔÏ·ÛÙÈ΋ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ÌÔÚ› Ó· Á›ÓÂÈ, ¯ˆÚ›˜ fï˜ ηϿ ·ÔÙÂϤÛÌ·Ù·. ∏ ·ÔÚÙÔ-ÛÙÂÊ·ÓÈ·›· ·Ú¿Î·Ì„Ë (By-pass) ¤¯ÂÈ ·ÚÎÂÙ¤˜ Ù¯ÓÈΤ˜ ‰˘ÛÎÔϛ˜, ΢ڛˆ˜ Û ·È‰È¿ <5 ÂÙÒÓ. ª·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ì ÓfiÛÔ Kawasaki ™‡Ìʈӷ Ì ٷ ÔÚ›ÛÌ·Ù· Ù˘ ÂÈÙÚÔ‹˜ ÁÈ· ÙË ÓfiÛÔ Kawasaki Ù˘ American Heart Association, ÔÈ ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È ÛÙȘ οوıÈ ÔÌ¿‰Â˜: ·) ∞ÛıÂÓ›˜ ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ™Ù· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È Î¿ÔÈ·
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ıÂڷ›· ÌÂÙ¿ ÙȘ 6-8 ‚‰ÔÌ¿‰Â˜, ‰ÂÓ ··ÈÙÂ›Ù·È ÂÚÈÔÚÈÛÌfi˜ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ¿˜ ÙÔ˘˜ Î·È ‰ÂÓ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ¤Ú·Ó ÙÔ˘ ¤ÙÔ˘˜. ‚) ∞ÛıÂÓ›˜ Ì ·ÚÔ‰È΋ ‰È¿Ù·ÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. πÛ¯‡Ô˘Ó Ù· ›‰È· Ì ÙËÓ ÚÔËÁÔ‡ÌÂÓË Î·ÙËÁÔÚ›·. Á) AÛıÂÓ›˜ Ì ÌÈÎÚÔ‡ - ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ¯ÔÚËÁÂ›Ù·È ·ÛÈÚ›ÓË (3-5 mg/kg/24h) ̤¯ÚÈ ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ™ÙËÓ 1Ë ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ÌfiÓÔ ÂÙ‹ÛÈ· ÂͤٷÛË Ì ∏∫° Î·È Echo ηډ›·˜. ªÂÙ¿ ÙËÓ 1Ë ‰ÂηÂÙ›·, ÂÚÈÔÚÈÛÌfi˜ ‹ fi¯È ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘. ‰) ∞ÛıÂÓ›˜ Ì ÁÈÁ·ÓÙÈ·›· ‹ ÔÏÏ·Ï¿ ÌÈÎÚÔ‡ ÌÂÛ·›Ô˘ ÌÂÁ¤ıÔ˘˜ ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ÃÔÚËÁÂ›Ù·È ·ÛÈÚ›ÓË (3-5 mg/kg/ 24ˆÚÔ) ηÈ, ·fi ÔÏÏÔ‡˜, Ù·˘Ùfi¯ÚÔÓ· ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ (INR=2,0-3,0). ™ÙËÓ 1Ë ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ·, ·ÏÏ¿ ¤ÏÂÁ¯Ô˜ Ì ∏∫° οı 6ÌËÓÔ Î·È Ì Echo ηډ›·˜ οı ¤ÙÔ˜. ∞Ó ÛÙÔ ∏∫° ·Ú·ÙËÚÔ‡ÓÙ·È ÈÛ¯·ÈÌÈÎÔ‡ Ù‡Ô˘ ·ÏÏÔÈÒÛÂȘ, Û˘ÓÈÛÙ¿Ù·È Ê·Ú̷΢ÙÈ΋ ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘. ªÂÙ¿ ÙËÓ 1Ë ‰ÂηÂÙ›·, Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ηıÔÚ›˙ÂÙ·È Ì ‚¿ÛË ÙË ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘. ŸÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÈÛ¯·ÈÌ›·˜, Û˘ÓÈÛÙ¿Ù·È ÂÎÏÂÎÙÈ΋ ÛÙÂÊ·ÓÈÔÁÚ·Ê›·. OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜, Û‡Ìʈӷ Ì ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ, Û˘ÓÈÛÙÔ‡Ó Û ·È‰È¿ Ì ÓfiÛÔ Kawasaki ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘˜ Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·Ó¿ ·Ú·È¿ ‰È·ÛÙ‹Ì·Ù· (3-5 ¤ÙË) Î·È Ó· ÊÚÔÓÙ›˙Ô˘Ó Ó· ·ÔʇÁÔ˘Ó ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Úԉȷı¤ÙÔ˘Ó Û ·ıËÚÔÁ¤ÓÂÛË (οÓÈÛÌ·, ·¯˘Û·ÚΛ·, ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È ˘¤ÚÙ·ÛË). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÓfiÛÔ˜ Kawasaki, Û ¤Ó· Û¯ÂÙÈο ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ, ÚÔηÏ› ÛËÌ·ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜ Ì ÌÂÏÏÔÓÙÈ΋
Paediatriki 2001;64:420-423
ÂÌÊ¿ÓÈÛË ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Ì ٷ ·ÎfiÏÔ˘ı¿ Ù˘. ∆· ·È‰È¿ ·˘Ù¿ Ô˘ÛÈ·ÛÙÈο ¤¯Ô˘Ó ¤Ó·Ó ÂÈϤÔÓ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ıËÚÔÁ¤ÓÂÛË ÏfiÁˆ Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘, ΢ڛˆ˜ ÛÙË ı¤ÛË ÙˆÓ ˘ÔÛÙڷʤÓÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ. ªÂ ÙËÓ ¤ÁηÈÚË fï˜ ‰È¿ÁÓˆÛË Î·È ıÂڷ›· Ù˘ ÓfiÛÔ˘, ÙÔ ÔÛÔÛÙfi ÂÌÊ·Ó›Û˘ ·Ó¢ڢÛÌ¿ÙˆÓ ÂÏÏ·ÙÒÓÂÙ·È ÛËÌ·ÓÙÈο. ¶Ôχ ÛËÌ·ÓÙÈ΋ ›ӷÈ, ›Û˘, Ë ÛˆÛÙ‹ Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì ·ÏÏÔÈÒÛÂȘ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Û ÂȉÈο ·È‰ÔηډÈÔÏÔÁÈο ΤÓÙÚ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Dajani AS, Taubert KA, Takahashi M, Bierman FZ, Freed MD, Ferrieri P et al. Guidelines for long-term management of patients with Kawasaki Disease. Circulation 1994;89:916-922. 2. Kato H, Sugimura T, Akagi T, Sato N, Hashino K, Maeno Y et al. Long-term consequences of Kawasaki Disease. A 10to 21-year follow-up study of 594 patients. Circulation 1996;94:1379-1385. 3. Leung DYM. Kawasaki syndrome: immunomodulatory benefit and potential toxin neutralization by intravenous immune globulin. Clin Exp Immunol 1996;104(Suppl 1):4954. 4. Melish ME. Kawasaki Syndrome. Pediatrics in Review 1996;17:153-162. 5. Shinohara M et al. Corticosteroids in the treatment of the acute phase of Kawasaki disease. J Pediatr 1999;135:465469. 6. Taubert KA, Shulman ST. Kawasaki Disease. Am Fam Physician 1999;59:3093-3102, 3107-3108. 7. Nelson - Textbook of Pediatrics. Kawasaki Disease; London: WB Saunders Co. 2000. p. 725-727.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °. ™. ¶··‰fiÔ˘ÏÔ˜ ∫ÂÊ·ÏÏËÓ›·˜ 18, 151 25, ª·ÚÔ‡ÛÈ
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Paediatriki 2001;64:424-429
CARDIOLOGY
™˘ÁÎÔ‹ Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÛÙ· ·È‰È¿ ηٿ ÙËÓ ¿ıÏËÛË π. ¶··ÁÈ¿ÓÓ˘
Syncope and sudden cardiac death in children during exercise J. Papagiannis
¶ÂÚ›ÏË„Ë: ∏ Û˘ÁÎÔ‹ Î·È Ô ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ηٿ ÙËÓ ¿ÛÎËÛË ·ÔÙÂÏÔ‡Ó ‰Ú·Ì·ÙÈο ÁÂÁÔÓfiÙ· Ô˘ ··ÈÙÔ‡Ó ¿ÌÂÛË Î·È ÂÓ‰Âϯ‹ ‰ÈÂÚ‡ÓËÛË ÁÈ· Ó· ÚÔÏËÊı› Ù˘¯fiÓ ˘ÔÙÚÔ‹ Î·È ÔÈ Û˘Ó¤ÂȤ˜ ÙÔ˘˜. ∆· Û˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· Û˘ÁÎÔ‹˜/·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û Ó·ÚÔ‡˜ ·ıÏËÙ¤˜ ÛÙËÓ ¿ÛÎËÛË Â›Ó·È: Ë ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ¿ÏϘ Ì˘ÔηډÈÔ¿ıÂȘ (.¯. ·ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰˘ÛÏ·Û›· ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·), ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ÙÔ Û‡Ó‰ÚÔÌÔ ÎÔÈÏȷ΋˜ ÚԉȤÁÂÚÛ˘ (Wolff-ParkinsonWhite), ÙÔ Û‡Ó‰ÚÔÌÔ Long QT, ‰È¿ÊÔÚ˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, fiˆ˜ Ë ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜ Î·È Ë ÙÂÙÚ·ÏÔÁ›· Fallot, ÙÔ Û‡Ó‰ÚÔÌÔ Marfan Î.¿. H Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹, Ì›· Û˘¯Ó‹ Î·È ÁÂÓÈο ηÏÔ‹ı˘ ηٿÛÙ·ÛË, Û˘Ó‹ıˆ˜ ‰ÂÓ Û˘Ì‚·›ÓÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÛÎËÛ˘ (ÂÎÙfi˜ Û·Ó›ˆÓ ÂÍ·ÈÚ¤ÛˆÓ), ·ÏÏ¿ Û‡ÓÙÔÌ· ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘. °È· ÙËÓ ÔÚı‹ ‰È¿ÁÓˆÛË fiÏˆÓ ·˘ÙÒÓ ÙˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Î·È ÙË ıÂڷ›· ÙÔ˘˜, ··ÈÙÂ›Ù·È ÏÂÙÔÌÂÚ‹˜ ¤ÏÂÁ¯Ô˜ Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ÂÚÈÁÚ¿ÊÔÓÙ·È ÂÚÈÏËÙÈο Ù· ‰È·ÁÓˆÛÙÈο Î·È ıÂڷ¢ÙÈο ‚‹Ì·Ù· Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· οı ̛· ·fi ÙȘ ·Ú·¿Óˆ ηٷÛÙ¿ÛÂȘ.
Abstract: Syncope and sudden death during exercise are dramatic events that require immediate and complete evaluation in order to prevent their recurrence and their consequences. The most common causes of syncope/sudden death during exercise in young athletes are: hypertrophic cardiomyopathy, other cardiomyopathies (such as arrhythmogenic right ventricular dysplasia, dilated cardiomyopathy), congenital coronary artery anomalies, ventricular preexcitation (Wolff-Parkinson-White syndrome), Long QT syndrome, various congenital heart defects such as aortic stenosis and tetralogy of Fallot, and Marfan syndrome. Neurocardiogenic syncope, a common and generally benign condition, usually does not occur during exercise (with rare exceptions), but soon after its discontinuation. The appropriate diagnosis and treatment of all these conditions requires detailed evaluation that can only be performed in specialized centers. In this review we briefly describe the diagnostic and therapeutic steps that are essential for each one of the above conditions.
§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÎÔ‹, ·ÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜, Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, Ì˘ÔηډÈÔ¿ıÂȘ, Û‡Ó‰ÚÔÌÔ ÚԉȤÁÂÚÛ˘, Û‡Ó‰ÚÔÌÔ Long QT, Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹, Û‡Ó‰ÚÔÌÔ Marfan.
Key words: syncope, sudden cardiac death, congenital heart disease, cardiomyopathy, preexcitation syndrome, Long QT syndrome, neurocardiogenic syncope, Marfan syndrome.
∂ÈÛ·ÁˆÁ‹ O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÂÓfi˜ ·ıÏËÙ‹ ηٿ ÙËÓ ¿ÛÎËÛË, ȉȷ›ÙÂÚ· Û Ó·ڋ ËÏÈΛ·, Â›Ó·È ¿ÓÙ· ¤Ó· ÙÚ·ÁÈÎfi ÁÂÁÔÓfi˜, ηıÒ˜ Ù· ¿ÙÔÌ· ·˘Ù¿ ıˆÚÔ‡ÓÙ·È Ù· ˘ÁȤÛÙÂÚ· Ù˘ ÎÔÈÓˆÓ›·˜ Ì·˜. ∂˘Ù˘-
¯Ò˜, Ë Û˘¯ÓfiÙËÙ· ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Â›Ó·È Ôχ ¯·ÌËÏ‹ (ÂÚ›Ô˘ 1:100.000) ÛÙ· ·ÁfiÚÈ· Î·È Ôχ ¯·ÌËÏfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ· (1), Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ¿ÏϘ ·Èٛ˜ (.¯. ·Ù˘¯‹Ì·Ù·, Ó·ÚΈÙÈο).
ÀԉȢı˘ÓÙ‹˜ ¶·È‰ÔηډÈÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ øÓ¿ÛÂÈÔ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ
Associate Director of Pediatric Cardiology Onassis Cardiac Surgery Center, Athens
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¶·È‰È·ÙÚÈ΋ 2001;64:424-429
∞Ó Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ÂÚÈÛÙ·ÙÈο ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ÔÊ›ÏÔÓÙ·È Û ηډȷο ·›ÙÈ·, ÂÚ›Ô˘ ÙÔ 15% Û¯ÂÙ›˙ÂÙ·È Ì ¿ÏÏ· ·›ÙÈ·, fiˆ˜ ÙÔ ¿ÛıÌ·. O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ¿ıÏËÛ˘. ∆· ·ıÏ‹Ì·Ù· Ô˘ Û˘Ó‹ıˆ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ Â›Ó·È Ë Î·Ï·ıÔÛÊ·›ÚÈÛË Î·È ÙÔ Ô‰fiÛÊ·ÈÚÔ. ™˘¯Ó¿, Ô ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂΉ‹ÏˆÛË Î·Ú‰È·ÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ (2), ·Ó Î·È ÔÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÙÔ 45% ÙˆÓ Ó·ÚÒÓ ·ıÏËÙÒÓ Ô˘ ¤ı·Ó·Ó ·ÈÊÓȉ›ˆ˜ ·Ó¤ÊÂÚ ÚÔËÁÔ‡ÌÂÓ· Û˘ÌÙÒÌ·Ù· (3). ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÈÊÓȉ›ˆÓ ı·Ó¿ÙˆÓ Û Ó·ÚÔ‡˜ ·ıÏËÙ¤˜ ÔÊ›ÏÂÙ·È Û ÔÚÁ·ÓÈ΋ ηډȷ΋ ÓfiÛÔ Ô˘ ›¯Â ‰È·Ê‡ÁÂÈ ÙË ‰È¿ÁÓˆÛË. ∆· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ı·Ó¿ÙÔ˘ Û Ó·ڿ ¿ÙÔÌ· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Î·È ·Ó·Ï‡ÔÓÙ·È ÛÙË Û˘Ó¤¯ÂÈ·, ΢ڛˆ˜ ˆ˜ ÚÔ˜ ÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ÀÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ∏ ˘ÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· (Àª) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û Ó·ÚÔ‡˜ ·ıÏËÙ¤˜ ηٿ ÙËÓ ¿ÛÎËÛË, Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 30-50% (4). ∏ Àª ÔÊ›ÏÂÙ·È Û ÁÂÓÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ ÙȘ ‚·ÚȤ˜ ·Ï‡ÛÔ˘˜ Ù˘ Ì˘ÔÛ›Ó˘, ·ÏÏ¿ Î·È ¿ÏϘ ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È ÂÚ›Ô˘ 1:500 (5). ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ¿˜ ΢ڛˆ˜ ÎÔÈÏ›·˜, Â›Ó·È Û˘Ó‹ıˆ˜ ·Û‡ÌÌÂÙÚË Ì ÂÈÎÚ¿ÙËÛË ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È Ì ·fiÊÚ·ÍË ÙÔ˘ ¯ÒÚÔ˘ ÂÍfi‰Ô˘ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ Û ¤Ó· ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ·ÛıÂÓÒÓ. πÛÙÔÏÔÁÈο ·Ú·ÙËÚÂ›Ù·È ·ÓˆÌ·Ï›· ÛÙËÓ ·Ú¯ÈÙÂÎÙÔÓÈ΋ ÙˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ (myocardial fiber disarray) Î·È ˘ÂÚÙÚÔÊ›· ÙˆÓ ¯ÈÙÒÓˆÓ ÙˆÓ ÂÓ‰ÔηډȷÎÒÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. ∫ÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ·ÎÔ˘ÛÙfi Û˘ÛÙÔÏÈÎfi ʇÛËÌ· (Û ¿ÙÔÌ· Ì ·fiÊÚ·ÍË ÙÔ˘ ¯ÒÚÔ˘ ÂÎÚÔ‹˜ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜), ÌÂ Û˘ÌÙÒÌ·Ù· ‰‡ÛÓÔÈ·˜ Î·È Â‡ÎÔÏ˘ ÎfiˆÛ˘ Ô˘ ÔÊ›ÏÔÓÙ·È Û ‰È·ÛÙÔÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔȶ›Ó·Î·˜ 1. ∫·Ú‰ÈÔ-·ÁÁÂȷο ·›ÙÈ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û Ó·ÚÔ‡˜ ·ıÏËÙ¤˜ 1. 2. 3. 4. 5. 6. 7. 8. 9.
ÀÂÚÙÚÔÊÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ∞ÓÒÌ·ÏË ¤ÎÊ˘ÛË ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ª˘Ôηډ›ÙȘ - ¢È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ∞ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰˘ÛÏ·Û›· ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ™‡Ó‰ÚÔÌÔ Wolff-Parkinson-White ™‡Ó‰ÚÔÌÔ Long QT π‰ÈÔ·ı‹˜ ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹ - ™‡Ó‰ÚÔÌÔ Brugada ™˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ™‡Ó‰ÚÔÌÔ Marfan
Paediatriki 2001;64:424-429
Ï›·˜, ÂÓ›ÔÙ Ì ÛÙËı·Á¯ÈÎfi ¿ÏÁÔ˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙȘ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÂÓ‰ÔÌ˘ÔηډȷÎÒÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Î·È Ì ÂÂÈÛfi‰È· ·ÈÛı‹Ì·ÙÔ˜ ·ÏÌÒÓ Î·È Û˘ÁÎÔ‹˜/·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Ô˘ ·Ô‰›‰ÔÓÙ·È Û ÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›·-Ì·ÚÌ·Ú˘Á‹. O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÌÔÚ› Ó· ·ÔÙÂÏ› Î·È ÙËÓ ÚÒÙË ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ∏ ıÓËÙfiÙËÙ· Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙ· ·È‰È¿ (4-6% ·Ó¿ ¤ÙÔ˜) Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ (6). ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi, ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙÔ ∏∫° Î·È Î˘Ú›ˆ˜ ·fi ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·, ÙÔ ÔÔ›Ô ı· Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÂÙ·È ÛÙËÓ ÂÊ˂›· ·Ó Â›Ó·È ·ÚÓËÙÈÎfi ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ÁÈ·Ù› ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜ ÂΉËÏÒÓÔÓÙ·È ·ÚÁfiÙÂÚ·. Œ¯Ô˘Ó ·ÔÌÔÓˆı› 5 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÔÓ›‰È· Ì ‰È¿ÊÔÚ˜ ·Ú·ÏÏ·Á¤˜ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙ· ¯ÚˆÌ·ÙÔÛÒÌ·Ù· 1, 11, 14, 15 Î·È 19. ∏ ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ˘„ËϤ˜ ‰fiÛÂȘ ‚-·Ó·ÛÙÔϤˆÓ, ·Ó·ÛÙÔÏ›˜ ÙÔ˘ Ca++, DDD-‚ËÌ·ÙÔ‰fiÙËÛË Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, Ì˘ÂÎÙÔÌ‹ Î·È Û ȉȷ›ÙÂÚ· ηÎÔ‹ıÂȘ ÌÔÚʤ˜ ÂÌÊ˘Ù‡ÛÈÌÔ ·ÈÓȉˆÙ‹. ™Â fiϘ ÙȘ ÌÔÚʤ˜ - ·ÔÊÚ·ÎÙÈΤ˜ Î·È ÌË - ··ÁÔÚ‡ÂÙ·È Ë ¿ıÏËÛË, Ì ÂÍ·›ÚÂÛË Ôχ ÂÏ·ÊÚ¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜. ™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ OÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ·ÔÙÂÏÔ‡Ó ÙË ‰Â‡ÙÂÚË - ηٿ ÛÂÈÚ¿ - ·ÈÙ›· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û ·ıÏËÙ¤˜, ÌÂ Û˘¯ÓfiÙËÙ· 19%. ∏ Û˘¯ÓfiÙÂÚË ·ÓˆÌ·Ï›· Â›Ó·È Ë ¤ÎÊ˘ÛË Ù˘ ·ÚÈÛÙÂÚ¿˜ ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜ ·fi ÙÔ ‰ÂÍÈfi ÎfiÏÔ ÙÔ˘ Valsalva (7). ∏ Û˘¯ÓfiÙËÙ· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ·fi ÙËÓ ·ÓˆÌ·Ï›· ·˘Ù‹ Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏ‹ (Û ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ÛÂÈÚ¤˜, ÙÔ 57% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¤ı·Ó Ì ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ) Î·È Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ηٿ ÙËÓ ¿ÛÎËÛË. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ÔÍ›· ÁˆÓ›· Ù˘ ¤ÎÊ˘Û˘ ÙÔ˘ ·ÁÁ›Ԣ Î·È ÛÙÔ Û¯ÈÛÌÔÂȉ¤˜ ÛÙfiÌÈÔ, ÙÔ ÔÔ›Ô Û˘ÌȤ˙ÂÙ·È ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ Î·Ù¿ ÙËÓ ¿ÛÎËÛË, ÏfiÁˆ Ù˘ ‰È¿Ù·Û˘ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ. ∏ ¿ıËÛË Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ Ó· ‰È·ÁÓˆÛÙ› ÚÈÓ ·fi ÙËÓ ÚÒÙË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË, Ô˘ ÌÔÚ› Ó· Â›Ó·È Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜. ∏ ‰ÔÎÈÌ·Û›· ÎÔÒÛˆ˜ Î·È ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Â›Ó·È Û˘Ó‹ıˆ˜ ÌË ‰È·ÁÓˆÛÙÈο, ÂÓÒ Î·È ÙÔ ∏∫° ËÚÂÌ›·˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi. ∏ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ Ì ÂÎÏÂÎÙÈ΋ ÛÙÂÊ·ÓÈÔÁÚ·Ê›· Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÌÂÙ¿ ·fi ¤Ó· ·ÈÊÓ›‰ÈÔ Û˘Ì‚¿Ó ηٿ ÙËÓ ¿ÛÎËÛË (Û˘ÁÎÔ‹, ÛÙËı¿Á¯Ë). ∞ӷʤÚÂÙ·È Î·È ‰È¿ÁÓˆÛË Ì ‰ÈÔÈÛÔÊ¿ÁÂÈÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Ô˘ ÌÔÚ› Ó· ·ÂÈÎÔÓ›ÛÂÈ Ôχ ηϿ ÙȘ ÂÎʇÛÂȘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∏ ıÂڷ›· Â›Ó·È Ë ·ÔÚÙÔÛÙÂÊ·ÓÈ·›· ·Ú¿Î·Ì„Ë ‹ Ë ÌÂÁ¤ı˘ÓÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ì ÙËÓ ·Ê·›ÚÂÛË
425
¶·È‰È·ÙÚÈ΋ 2001;64:424-429
ÙÔ˘ ÎÔÈÓÔ‡ ÙÔȯÒÌ·ÙÔ˜ ÌÂٷ͇ ·ÔÚÙ‹˜ Î·È ÛÙÂÊ·ÓÈ·›·˜ ·ÚÙËÚ›·˜ (8). ª˘Ôηډ›Ùȉ˜ - Ì˘ÔηډÈÔ¿ıÂȘ ∏ ÈÔÁÂÓ‹˜ Ì˘Ôηډ›ÙȘ ·Ó·Ê¤ÚÂÙ·È Û¯ÂÙÈο Û¿ÓÈ· Û·Ó ·ÈÙ›· ı·Ó¿ÙÔ˘ Û Ó·ÚÔ‡˜ ·ıÏËÙ¤˜. O Û˘ÓËı¤ÛÙÂÚÔ˜ Èfi˜ Â›Ó·È Ù‡Ô˘ Coxsackie B. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÔÍ›·˜ Ì˘Ôηډ›Ùȉ·˜, Ô Î›Ó‰˘ÓÔ˜ ÂΉ‹ÏˆÛ˘ ηÎÔ‹ıˆÓ ·ÚÚ˘ıÌÈÒÓ Â›Ó·È ˘„ËÏfiÙÂÚÔ˜ Î·È ÁÈ’ ·˘ÙfiÓ ÙÔ ÏfiÁÔ Û˘ÓÈÛÙ¿Ù·È Ë ·ÔÊ˘Á‹ ¤ÓÙÔÓ˘ ·Û΋Û˘ ÁÈ· ÌÂÚÈΤ˜ Ë̤Ú˜ ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. ∂¿Ó ‰È·ÁÓˆÛÙ› ÔÍ›· Ì˘Ôηډ›ÙȘ, Û˘ÓÈÛÙ¿Ù·È ·ÔÊ˘Á‹ ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ ÁÈ· 6 Ì‹Ó˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ. ∂ÈÙÚ¤ÂÙ·È Ë ÂÈÛÙÚÔÊ‹ Û ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÌfiÓÔ ÂÊ’ fiÛÔÓ ÂȂ‚·Èˆı› Ë Ï‹Ú˘ ·Ó¿ÚÚˆÛË ÎÏÈÓÈο, ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο Î·È Ë¯ÔηډÈÔÁÚ·ÊÈο. ª›· Û¯ÂÙÈο Û¿ÓÈ· ·ÏÏ¿ Ôχ ÂӉȷʤÚÔ˘Û· ÌÔÚÊ‹ Ì˘ÔηډÈÔ¿ıÂÈ·˜ Ô˘ ÌÔÚ› Ó· ÂΉËψı› ÌÂ Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Î·È ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ, Â›Ó·È Ë ·ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰˘ÛÏ·Û›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ (arrhythmogenic right ventricular dysplasiaARVD). ∏ ARVD ÂÚÈÁÚ¿ÊËΠۯÂÙÈο ÚfiÛÊ·Ù· (9). ∆Ô ·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· Â›Ó·È Ë ÌÂÚÈ΋ ‹ ÔÏÈ΋ ۯ‰fiÓ ·ÓÙÈηٿÛÙ·ÛË ÂÓfi˜ ÌÂÁ¿ÏÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂχıÂÚÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ·fi ÏÈÒ‰Ë ÈÛÙfi. ∏ ‰ÂÍÈ¿ ÎÔÈÏ›· Â›Ó·È ‰È·ÙÂٷ̤ÓË, ÌÂ Ï¤Ù˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ Î·È ÂÎÎÔÏÒÌ·Ù·. ™·ÓÈfiÙÂÚ· ÚÔÛ‚¿ÏÏÂÙ·È Î·È Ë ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›·. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ Ì ARVD ÂÌÊ·Ó›˙Ô˘Ó ·ÏÏÔÈÒÛÂȘ ÛÙÔ ∏∫° Ì ·Ú¿Ù·ÛË ÙÔ˘ QRS, ·Ó·ÛÙÚÔÊ‹ ÙÔ˘ ∆ ÛÙȘ ‰ÂÍȤ˜ ÚÔοډȘ ··ÁˆÁ¤˜ ηÈ, Û¿ÓÈ·, ¤Ó· ¯·ÌËÏfi ‰˘Ó·ÌÈÎfi ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ QRS, Ô˘ ÔÓÔÌ¿˙ÂÙ·È Î‡Ì· Â. ∆Ô Ë¯ÔηډÈÔÁÚ¿ÊËÌ· Î·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È Ôχ ‚ÔËıËÙÈο, ÂÓÒ Ë ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ‰ÂÍÈ¿ ÎÔÈÏÈÔÁÚ·Ê›· Î·È ‚ÈÔ„›· ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ ARVD ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi Ó·ÚÒÓ ·ÙfiÌˆÓ Î¿Ùˆ ÙˆÓ 35 ÂÙÒÓ Ô˘ ¤ı·Ó·Ó ·ÈÊÓ›‰È· ÛÙËÓ ÂÚÈÔ¯‹ Veneto Ù˘ ‚fiÚÂÈ·˜ πÙ·Ï›·˜, ÌÂ Ù˘Èο Â˘Ú‹Ì·Ù· ÛÙËÓ ·˘ÙÔ„›· (10). ª›· ȉȷ›ÙÂÚË ÌÔÚÊ‹ Ù˘ ·ÚÔ˘ÛÈ¿˙ÂÈ È‰È·›ÙÂÚË ÂÓÙfiÈÛË ÛÙË ¡¿ÍÔ (Naxos disease), ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ·fi ȉÈfiÌÔÚÊ· Í·Óı¿ ÛÁÔ˘Ú¿ Ì·ÏÏÈ¿, ˘ÂÚÎÂÚ¿ÙˆÛË ÂÏÌ¿ÙˆÓ Î·È ·Ï·ÌÒÓ Î·È ÚÔÛ‚ÔÏ‹ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. ∏ ¿ıËÛË ÌÔÚ› Ó· ÂΉËψı› ÁÈ· ÚÒÙË ÊÔÚ¿ Ì ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ Î·Ù¿ ÙËÓ ¿ÛÎËÛË ‹ Ì ·›ÛıËÌ· ·ÏÌÒÓ Î·È ÏÈÔı˘ÌÈο ÂÂÈÛfi‰È·. ∏ ÓÂfiÙÂÚË ËÏÈΛ· Ô˘ ¤¯ÂÈ ÂΉËψı› Ë ÓfiÛÔ˜ Â›Ó·È Ù· 7 ¤ÙË. ™Â ·ÛıÂÓ›˜ Ì ÙÂÎÌËÚȈ̤ÓË ‰È¿ÁÓˆÛË ··ÁÔÚ‡ÂÙ·È Ë ¿ÛÎËÛË, ·ÎfiÌË Î·È fiÙ·Ó Â›Ó·È ·Û˘Ìو̷ÙÈÎÔ›. ™Â ·ÛıÂÓ›˜ Ì ÎÔÈÏȷΤ˜ ·ÚÚ˘ı̛˜
426
Paediatriki 2001;64:424-429
Û˘ÓÈÛÙ¿Ù·È ·ÓÙÈ·ÚÚ˘ıÌÈ΋ ·ÁˆÁ‹ Ì ‚-·Ó·ÛÙÔÏ›˜, ÛÔÙ·ÏfiÏË ‹ ¿ÏÏ· ·ÓÙÈ·ÚÚ˘ıÌÈο. ™Â ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ‹ ÌË Î·Ù·ÛÙÂÏÏfiÌÂÓ˜ ·ÚÚ˘ı̛˜, Û˘ÓÈÛÙ¿Ù·È ÂÌʇÙ¢ÛË ·ÈÓȉˆÙ‹. ™‡Ó‰ÚÔÌÔ Long QT ∞ÔÙÂÏ› Û¯ÂÙÈο Û¿ÓÈ· ·ÈÙ›· ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘, ·ÏÏ¿ Ë Û˘¯ÓfiÙËÙ· ÌÔÚ› Ó· ˘ÔÂÎÙÈÌ¿Ù·È ÁÈ·Ù› ‰ÂÓ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋˜ ‰È¿ÁÓˆÛ˘. ¶Ôχ ÚfiÛÊ·Ù· ¤¯ÂÈ ·Ó·ÊÂÚı› ÁÔÓȉȷ΋ ·Ó¿Ï˘ÛË ÌÂÙ¿ ı¿Ó·ÙÔÓ. Œ¯Ô˘Ó ÂÚÈÁÚ·Ê› 3 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÔÓȉȷΤ˜ ÌÔÚʤ˜ ÔÈ Ôԛ˜ ‰ڿ˙ÔÓÙ·È ÛÙ· ¯ÚˆÌ·ÙÔÛÒÌ·Ù· 11 (LQTS-1), 7 (LQTS-2) Î·È 3 (LQTS-3). OÈ ‰‡Ô ÚÒÙ˜ ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯‹ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‰È·‡ÏˆÓ ÙÔ˘ ∫·Ï›Ô˘, ÂÓÒ Ë ÙÚ›ÙË ÂËÚ¿˙ÂÈ ÙÔ˘˜ ‰È·‡ÏÔ˘˜ ÙÔ˘ ¡·ÙÚ›Ô˘. ∂ӉȷʤÚÔ˘Û· Â›Ó·È Ë Û˘Û¯¤ÙÈÛË ÙÔ˘ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ÎÔχ̂ËÛË, ȉȷ›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì LQTS-1 (12). ∏ÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο, Ë ‰È¿ÁÓˆÛË ÙÔ˘ LQTS ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ú¿Ù·ÛË ÙÔ˘ ‰ÈÔÚıˆÌ¤ÓÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT (QTc=QT/ΟRR), Ì ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜ >460 msec ÛÙȘ Á˘Ó·›Î˜ Î·È >450 msec ÛÙÔ˘˜ ¿Ó‰Ú˜, Ô˘ ‰ÂÓ ÔÊ›ÏÔÓÙ·È Û ʿÚ̷η, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ Ì˘ÔηډÈÔ¿ıÂÈ·. ÕÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· Â›Ó·È Ë ÂÚ›ÂÚÁË ÌÔÚÊÔÏÔÁ›· ÙÔ˘ ·̷ÙÔ˜ ∆ (‰ÈÎfiÚ˘ÊÔ, ·Ú·ÙÂٷ̤ÓÔ, Ì ÂÓ·ÏÏ·ÛÛfiÌÂÓË ÔÏÈÎfiÙËÙ· Î.¿.). ™ËÌ·ÓÙÈο, ÂÈϤÔÓ, ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Â›Ó·È ÙÔ ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Û Ó·ڋ ËÏÈΛ· Î·È ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. O ı¿Ó·ÙÔ˜ ¤گÂÙ·È ÏfiÁˆ ÔχÌÔÚÊ˘ ÎÔÈÏȷ΋˜ Ù·¯˘Î·Ú‰›·˜ Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÌÔÚÊÔÏÔÁ›·, Ô˘ ·ÔηÏÂ›Ù·È ÚÈȉÈÔÂȉ‹˜ Ù·¯˘Î·Ú‰›· (‰ÈÂıÓÒ˜ ¤¯ÂÈ Î·ıÈÂÚˆı› Ô Á·ÏÏÈÎfi˜ fiÚÔ˜ torsade des pointes=Û˘ÛÙÚÔÊ‹ ÙˆÓ ÛËÌ›ˆÓ) Î·È ÌÔÚ› ‹ Ó· ‰È·ÎÔ› ·˘ÙÔÌ¿Ùˆ˜ ‹ Ó· ÂÎÊ˘ÏÈÛÙ› Û ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹. ∏ ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË ‚·Ó·ÛÙÔϤˆÓ, ÙËÓ ÂÌʇÙ¢ÛË ‚ËÌ·ÙÔ‰fiÙË Î·È, › ηÎÔ‹ıÔ˘˜ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ Î·È ·ÙÔÌÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡, ÂÌʇÙ¢ÛË ·ÈÓȉˆÙ‹. ∂›Û˘, ¤¯ÂÈ ·Ó·ÊÂÚı› Û·Ó ıÂڷ¢ÙÈÎfi ̤ÙÚÔ Ë ÂÎÙÔÌ‹ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ Û˘Ì·ıËÙÈÎÔ‡ Á·ÁÁÏ›Ô˘, Ë ÔÔ›· Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û¯ÂÙÈο Û¿ÓÈ·. ™Â ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, fiˆ˜ ÛÙÔ LQT3, ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Î·È ·Ó·ÛÙÔÏ›˜ ÙˆÓ ‰È·‡ÏˆÓ ÙÔ˘ Na++ (.¯. ªÂÍÈÏÂÙ›ÓË, ¶ÚÔ·ÊÂÓfiÓË). ™‡Ó‰ÚÔÌÔ Wolff-Parkinson-White ∆Ô Û‡Ó‰ÚÔÌÔ WPW Û˘Ó·ÓÙ¿Ù·È Û ÔÛÔÛÙfi 0,10,3% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È
¶·È‰È·ÙÚÈ΋ 2001;64:424-429
ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο ·fi ‚Ú·¯‡ ‰È¿ÛÙËÌ· PR, ¤Ó· ¯·Ú·ÎÙËÚÈÛÙÈÎfi ·̷ ‰ ÛÙËÓ ·Ú¯‹ ÙÔ˘ QRS Î·È ·fi ·ÚÔ͢ÛÌÈΤ˜ ˘ÂÚÎÔÈÏȷΤ˜ Ù·¯˘Î·Ú‰›Â˜ (13). ∆Ô ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ˘fi‚·ıÚÔ Â›Ó·È ¤Ó· ·Ú·ÏËڈ̷ÙÈÎfi Ì˘˚Îfi ‰ÂÌ¿ÙÈÔ Ô˘ ‰ËÌÈÔ˘ÚÁ› Ì›· ¤ÎÙÔË Û‡Ó‰ÂÛË ÌÂٷ͇ ÎÔÏÈÎÔ‡ Î·È ÎÔÈÏÈ·ÎÔ‡ Ì˘Ôηډ›Ô˘. OÈ ·ÛıÂÓ›˜ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È Ì ·ÚÔ͢ÛÌÈΤ˜ ˘ÂÚÎÔÈÏȷΤ˜ Ù·¯˘Î·Ú‰›Â˜, ·ÏÏ¿ Û¿ÓÈ· Â›Ó·È ÂÓÙÂÏÒ˜ ·Û˘Ìو̷ÙÈÎÔ› ̤¯ÚÈ ÙËÓ ÚÒÙË ÂΉ‹ÏˆÛË Ô˘ ÌÔÚ› Ó· Â›Ó·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ô ÙÂÎÌËÚȈ̤ÓÔ˜ ΛӉ˘ÓÔ˜ Â›Ó·È 1:1000 ·Ó¿ ¤ÙÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘, ·ÏÏ¿ ÌÔÚ› Ó· ˘¿Ú¯Ô˘Ó Î·È ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÔÙ¤, ÏfiÁˆ ÙˆÓ ÌÈÎÚÔÛÎÔÈÎÒÓ ‰È·ÛÙ¿ÛÂˆÓ ÙÔ˘ ‰ÂÌ·Ù›Ô˘, Ô˘ ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È Â‡ÎÔÏ· ÛÙËÓ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË. ∆Ô ·›ÙÈÔ ÙÔ˘ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Â›Ó·È ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹, Ë ÔÔ›· Â›Ó·È Û˘ÓËı¤ÛÙÂÚË Û ·ÛıÂÓ›˜ Ì ·Ú·ÏËڈ̷ÙÈÎfi ‰ÂÌ¿ÙÈÔ. §fiÁˆ Ù˘ ‡·Ú͢ ÙÔ˘ ‰ÂÌ·Ù›Ô˘ ˘¿Ú¯ÂÈ Ù·¯Â›· ·ÁˆÁ‹ ÙˆÓ ÎÔÏÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ ÛÙȘ ÎÔÈϛ˜, Ì ·ÔÙ¤ÏÂÛÌ· ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹ Î·È ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ (14). OÈ ·ÛıÂÓ›˜ ÌÂ Û˘¯Ó¿ ÂÂÈÛfi‰È· Ù·¯˘Î·Ú‰›·˜ ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Â›Ù ʷÚ̷΢ÙÈο Ì ·ÓÙÈ·ÚÚ˘ıÌÈο Ê¿Ú̷η (··ÁÔÚ‡ÂÙ·È Ë ‚ÂÚ··Ì›ÏË Î·È Ë ‰ÈÁÔÍ›ÓË, ÁÈ·Ù› ÌÔÚ› Ó· ·˘Í‹ÛÔ˘Ó ÙËÓ ·ÁˆÁ‹ ̤ۈ ÙÔ˘ ‰ÂÌ·Ù›Ô˘), ›Ù ÚÈ˙Èο ÌÂ Î·Ù¿Ï˘ÛË ÙÔ˘ ·Ú·ÏËڈ̷ÙÈÎÔ‡ ‰ÂÌ·Ù›Ô˘ Ì Ú‡̷ Ú·‰ÈÔÛ˘¯ÓfiÙËÙ·˜ Ì Ôχ ˘„ËÏfi ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ (15). ∞ÛıÂÓ›˜ Ì ¯·Ú·ÎÙËÚÈÛÙÈο ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (14) ‹ ¿ÙÔÌ· Ô˘ ¤¯Ô˘Ó ·Ó·˙ˆÔÁÔÓËı› ·fi Û˘ÁÎÔÙÈÎfi ÂÂÈÛfi‰ÈÔ, Ú¤ÂÈ Ó· ˘Ô‚¿ÏÔÓÙ·È ÛÂ Î·Ù¿Ï˘ÛË ÙÔ˘ ‰ÂÌ·Ù›Ô˘, ÚÈÓ Â·Ó¤ÏıÔ˘Ó Û ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜. ™˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ OÈ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó Û˘ÁÎÔ‹ Î·È ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ Â›Ó·È ÔÈ ·ÚÈÛÙÂÚfiÏ¢Ú˜ ·ÔÊÚ·ÎÙÈΤ˜ ‚Ï¿‚˜ (‚·Ï‚ȉÈ΋, ˘Ô‚·Ï‚ȉÈ΋ Î·È ˘ÂÚ‚·Ï‚ȉÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜, ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜), ÔÈ ¯ÂÈÚÔ˘ÚÁË̤Ó˜ ΢·ÓˆÙÈΤ˜ ηډÈÔ¿ıÂȘ (ÙÂÙÚ·ÏÔÁ›· Fallot, ‰ÈÏÔ¤ÍÔ‰Ô˜ ‰ÂÍÈ¿ ÎÔÈÏ›·, ÌÂÙ¿ıÂÛË ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, ÌÔÓ‹Ú˘ ÎÔÈÏ›· Î.¿.), ηıÒ˜ Î·È ÔÈ ÌË ¯ÂÈÚÔ˘ÚÁË̤Ó˜ ΢·ÓˆÙÈΤ˜ ·ı‹ÛÂȘ. ™ÙȘ ·ÚÈÛÙÂÚfiÏ¢Ú˜ ·ÔÊÚ·ÎÙÈΤ˜ ·ı‹ÛÂȘ, Ô Î›Ó‰˘ÓÔ˜ Â›Ó·È ÂÚ›Ô˘ 5% (16) Î·È ·Ô‰›‰ÂÙ·È ÛÙËÓ ·‡ÍËÛË ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÙËÓ ·Ó·Ú΋ ·ÈÌ¿ÙˆÛË Î·Ù¿ ÙËÓ ¿ÛÎËÛË. ™ÙËÓ ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË Ù˘ ·ÔÚÙ‹˜ ÌÔÚ›
Paediatriki 2001;64:424-429
Ó· Û˘Ó˘¿Ú¯Ô˘Ó Î·È ÂÁÎÂÊ·ÏÈο ·Ó¢ڇÛÌ·Ù· ÛÙÔÓ Î‡ÎÏÔ ÙÔ˘ Willis, Ù· ÔÔ›· ÌÔÚÔ‡Ó Ó· Ú·ÁÔ‡Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÛÎËÛ˘ ÏfiÁˆ ÌÂÁ¿Ï˘ ·‡ÍËÛ˘ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ™Â fiϘ ÙȘ ·ÚÈÛÙÂÚfiÏ¢Ú˜ ·ÔÊÚ·ÎÙÈΤ˜ ·ı‹ÛÂȘ ˘¿Ú¯ÂÈ ÙÔ ˘fi‚·ıÚÔ ·Ó¿Ù˘Í˘ ηÎÔ‹ıˆÓ ÎÔÈÏÈ·ÎÒÓ ·ÚÚ˘ıÌÈÒÓ, ÏfiÁˆ Ù˘ ·Ó¿Ù˘Í˘ ˘ÂÚÙÚÔÊ›·˜ Î·È ›ÓˆÛ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜. ∏ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË (ÙÚ·¯‡ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· Â͈ı‹Ûˆ˜, ‰È·ÊÔÚ¿ ȤÛˆ˜ ÌÂٷ͇ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚˆÓ ÛÙËÓ ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË), ÙÔ ∏∫° Î·È ÙÔ Ë¯ÔηډÈÔÁÚ¿ÊËÌ·. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ̤ÙÚÈ· ‹ ÛÔ‚·Ú‹ ÛÙ¤ÓˆÛË ··ÁÔÚ‡ÂÙ·È Ë ¿ÛÎËÛË, ̤¯ÚÈ Ó· ˘Ô‚ÏËıÔ‡Ó Â›Ù Û ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË, ›Ù Û ‚·Ï‚ȉÔÏ·ÛÙÈ΋ ‹ ·ÁÁÂÈÔÏ·ÛÙÈ΋ Ì ̷ÏfiÓÈ. ∏ ÙÂÙÚ·ÏÔÁ›· Fallot (TOF) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË Î·È ÈÔ ÌÂÏÂÙË̤ÓË Î˘·ÓˆÙÈ΋ ηډÈÔ¿ıÂÈ·. OÈ ·ÛıÂÓ›˜ Ì TOF ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ¯ÂÈÚÔ˘ÚÁËı› ÚÈÓ ÊÙ¿ÛÔ˘Ó Û ËÏÈΛ· Ô˘ ÂÈÙÚ¤ÂÈ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ Û ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜. ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ (ÂÚ›Ô˘ 80%) Â›Ó·È Û ηϋ ÏÂÈÙÔ˘ÚÁÈ΋ ηٿÛÙ·ÛË Î·È ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù·, Ì ÌÈÎÚ‹ ‹ ÙÔ Ôχ ̤ÙÚÈ· ·Ó¿ÚÎÂÈ· Ó¢ÌÔÓÈ΋˜. ∆· ¿ÙÔÌ· ·˘Ù¿ ÌÔÚÔ‡Ó Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó Û ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÂÏ·ÊÚ¿˜ ‹ ̤ÙÚÈ·˜ ¤ÓÙ·Û˘, ·Ó Î·È ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë Û˘ÌÌÂÙÔ¯‹ Û ·ÓÙ·ÁˆÓÈÛÙÈο ·ıÏ‹Ì·Ù·. ŒÓ· ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì TOF ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈο ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ: ÛÔ‚·Ú‹ ·Ó¿ÚÎÂÈ· Ó¢ÌÔÓÈ΋˜ Ì ‰È¿Ù·ÛË Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ˘ÔÏÂÈfiÌÂÓË ·fiÊÚ·ÍË ÙÔ˘ ¯ÒÚÔ˘ ÂÎÚÔ‹˜ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ‡·ÚÍË ˘„ËÏÔ‡ ‚·ıÌÔ‡ ¤ÎÙÔ˘ ÎÔÈÏȷ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Û Holter 24ÒÚÔ˘ ‹ ÎÔÈÏȷ΋˜ Ù·¯˘Î·Ú‰›·˜ ‹, Ù¤ÏÔ˜, ÎÔÏÈÎÔ‡ ÙÂÚ˘ÁÈÛÌÔ‡. °ÂÓÈο ÛÙË ¯ÂÈÚÔ˘ÚÁËı›۷ TOF, Ô Î›Ó‰˘ÓÔ˜ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ Î˘Ì·›ÓÂÙ·È ·fi 1-5% (17). O ΛӉ˘ÓÔ˜ Ê·›ÓÂÙ·È fiÙÈ ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο, ·Ó Ë ‰ÈfiÚıˆÛË Á›ÓÂÈ Û ÌÂÁ¿ÏË ËÏÈΛ·. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ··ÁÔÚ‡ÂÙ·È Ë ¿ÛÎËÛË, ÂÓÒ Ë ıÂڷ›· ηÙ¢ı‡ÓÂÙ·È ·Ó¿ÏÔÁ· Ì ÙȘ ˘ÔÏÂÈfiÌÂÓ˜ ·Ó·ÙÔÌÈΤ˜ ‹ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. OÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ ‚ÂÏÙÈÒÓÔÓÙ·È ÛËÌ·ÓÙÈο Ì ·ÓÙÈηٿÛÙ·ÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ‚·Ï‚›‰·˜. ∞ÛıÂÓ›˜ Ì ÛÔ‚·Ú¤˜ ·ÚÚ˘ı̛˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·ÓÙÈ·ÚÚ˘ıÌÈο Ê¿Ú̷η (΢ڛˆ˜ ÎÏ¿Û˘ πππ-ÛÔÙ·ÏfiÏË, ·ÌÈÔ‰·ÚfiÓË), Î·Ù¿Ï˘ÛË Ì Ú‡̷ Ú·‰ÈÔÛ˘¯ÓfiÙËÙ·˜ Î·È Û ·ÓıÂÎÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÎÔÈÏȷ΋˜ Ù·¯˘Î·Ú‰›·˜ Ì ÂÌʇÙ¢ÛË ·ÈÓȉˆÙ‹. ∞Ó¿ÏÔÁË Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂ
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¶·È‰È·ÙÚÈ΋ 2001;64:424-429
¿ÏϘ ΢·ÓˆÙÈΤ˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. π‰È·›ÙÂÚ· ˘„ËÏfi ΛӉ˘ÓÔ ‰È·ÙÚ¤¯Ô˘Ó ÔÈ ·ÛıÂÓ›˜ Ì ڈÙÔ·ı‹ ‹ ‰Â˘ÙÂÚÔ·ı‹ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ··ÁÔÚ‡ÂÙ·È ÔÔÈ·‰‹ÔÙ ÌÔÚÊ‹ ¿ÛÎËÛ˘. ∆¤ÏÔ˜, Ì›· ¿ÏÏË ¿ıËÛË ÛÙËÓ ÔÔ›· ˘¿Ú¯ÂÈ ˘„ËÏfi˜ ΛӉ˘ÓÔ˜ ηٿ ÙËÓ ¿ÛÎËÛË, Â›Ó·È ÔÈ ·ÛıÂÓ›˜ Ì ۇӉÚÔÌÔ Marfan Î·È ÛÔ‚·Ú‹ ‰È¿Ù·ÛË Ù˘ ·ÔÚÙÈ΋˜ Ú›˙·˜. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î˘ÛÙÈ΋ Ó¤ÎÚˆÛË ÙÔ˘ ̤ÛÔ˘ ¯ÈÙÒÓ· Ù˘ ·ÔÚÙ‹˜. ¶ÂÚ›Ô˘ 20% ÙˆÓ ı·Ó¿ÙˆÓ Û ·ÛıÂÓ›˜ Ì ۇӉÚÔÌÔ Marfan ÔÊ›ÏÔÓÙ·È Û ڋÍË Ù˘ ·ÔÚÙ‹˜ ‹ ‰È·¯ˆÚÈÛÙÈÎfi ·Ó‡ڢÛÌ· (18). ™˘ÓÈÛÙ¿Ù·È ·ÔÊ˘Á‹ Ù˘ ¿ÛÎËÛ˘, ¯ÔÚ‹ÁËÛË ‚-·Ó·ÛÙÔϤˆÓ ÁÈ· ¤ÏÂÁ¯Ô Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÂÓÒ fiÙ·Ó Ë ‰È¿ÌÂÙÚÔ˜ Ù˘ ·ÔÚÙÈ΋˜ Ú›˙·˜ ˘ÂÚ‚·›ÓÂÈ Ù· 5 cm, Û˘ÓÈÛÙ¿Ù·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË (·ÓÙÈηٿÛÙ·ÛË ·ÔÚÙÈ΋˜ Ú›˙·˜, ÂÁ¯Â›ÚËÛË Bentall). ¡Â˘ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Û˘ÁÎÔ‹˜ Û Ó·ڿ ¿ÙÔÌ· Â›Ó·È Ë Ó¢ÚÔηډÈÔÁÂÓ‹˜ Û˘ÁÎÔ‹ (¡∫™), Ë ÚfiÁÓˆÛË Ù˘ ÔÔ›·˜ Â›Ó·È Î·ÏÔ‹ı˘. ∆· Û˘ÁÎÔÙÈο ÂÂÈÛfi‰È· Û˘Ó‹ıˆ˜ ‰ÂÓ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÛÎËÛ˘, ·ÏÏ¿ Û˘Ó‹ıˆ˜ 1-10 min ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘, fiÙ·Ó ·ÔÛ‡ÚÂÙ·È ÙÔ Û˘Ì·ıËÙÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Î·È ˘ÂÚÈÛ¯‡ÂÈ ÙÔ ·Ú·Û˘Ì·ıËÙÈÎfi. ∆· ÂÂÈÛfi‰È· ÌÔÚ› Ó· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·ÈÊÓ›‰È· ‚Ú·‰˘Î·Ú‰›· ‹ ·ÎfiÌ· Î·È ·Û˘ÛÙÔÏ›· ÁÈ· Ï›Á· ‰Â˘ÙÂÚfiÏÂÙ·. ªÔÚ› fï˜ Ó· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·Ï¿ ·fi ÔÚıÔÛÙ·ÙÈ΋ ˘fiÙ·ÛË. Œ¯Ô˘Ó Û¿ÓÈ· ·Ó·ÊÂÚı› Î·È ÂÂÈÛfi‰È· ¡∫™ Ù· ÔÔ›· Û˘Ó¤‚ËÛ·Ó Î·Ù¿ ÙËÓ ¿ÛÎËÛË (19-21). ∂Âȉ‹ ˘¿Ú¯ÂÈ ÏËıÒÚ· ¿ÏÏˆÓ ·ı‹ÛÂˆÓ Ô˘ ÂΉËÏÒÓÔÓÙ·È ÌÂ Û˘ÁÎÔ‹ Î·È ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ Î·Ù¿ ÙËÓ ¿ÛÎËÛË (‚Ï. ·ÓˆÙ¤Úˆ), ÔÈ Ôԛ˜ ¤¯Ô˘Ó Ôχ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÙÒÛÂȘ ·Ó ‰ÂÓ ‰È·ÁÓˆÛÙÔ‡Ó Î·È ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¤ÁηÈÚ·, Ë ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ÛÙÚ¤ÊÂÙ·È ÚÒÙ· ÛÙȘ ·ı‹ÛÂȘ ·˘Ù¤˜ Î·È Ë ‰È¿ÁÓˆÛË Ù˘ ¡∫™ Ó· Á›ÓÂÙ·È ÂÍ ·ÔÎÏÂÈÛÌÔ‡. ™ÙË ‰È¿ÁÓˆÛË Ù˘ ¡∫™ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ Ë ÚÔÛÊÔÚ¿ Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÎÏÈÓfiÌÂÓ˘ ÙÚ·¤˙˘ (tilt-table test) (22). ∏ ıÂڷ›· Û ÂÚÈÙÒÛÂȘ ·Ô‰Â‰ÂÈÁ̤Ó˘ ¡∫™ ÌÂ Û˘¯Ó¿ ÂÂÈÛfi‰È· ‹ Ì ÈÛÙÔÚÈÎfi ÙÚ·˘Ì·ÙÈÛÌÔ‡ ηٿ ÙË Û˘ÁÎÔ‹, ÂÚÈÏ·Ì‚¿ÓÂÈ ·˘ÍË̤ÓË ÔÛfiÙËÙ· ˘ÁÚÒÓ Î·È ¿Ï·ÙÔ˜, ¯ÔÚ‹ÁËÛË ·Ú·ÁfiÓÙˆÓ fiˆ˜ ÊıÔÚÈÔ¸‰ÚÔÎÔÚÙÈ˙fiÓË (Florinef), ÌȉԉڛÓË, ‚-·Ó·ÛÙÔÏ›˜, ÂÎÏÂÎÙÈÎÔ‡˜ ·Ó·ÛÙÔÏ›˜ Ù˘ ·ӷÚfiÛÏ˄˘ Ù˘ ÛÂÚÔÙÔÓ›Ó˘ (ÊÏÔ˘ÔÍÂÙ›ÓË Î.¿.). OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ˘Ô‚¿ÏÔÓÙ·È Û ÂÚÈÔÚÈÛÌfi Ù˘ ¿ÛÎËÛ˘, ÂÎÙfi˜ Â¿Ó ¤¯Ô˘Ó ȉȷ›ÙÂÚ· Û˘¯Ó¿ ÂÂÈÛfi‰È· ‹ ¤¯Ô˘Ó ÙÚ·˘Ì·ÙÈÛÙ› ÛÔ‚·Ú¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Û˘ÁÎÔÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ.
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™˘ÌÂÚ¿ÛÌ·Ù· ∏ Û˘ÁÎÔ‹ Î·È Ô ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ ÛÙ· ·È‰È¿ ηٿ ÙËÓ ¿ıÏËÛË ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È Û ̛· ÏÂÈ¿‰· ·ÈÙ›ˆÓ, Ù· ÔÔ›· ÌÔÚÔ‡Ó Ó· ‰È·ÁÓˆÛÙÔ‡Ó Ì ÙȘ ηٿÏÏËϘ ÂÍÂÙ¿ÛÂȘ. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ‰˘Ó·Ù‹ Ë Ì›ˆÛË ‹ Ë ÂÍ¿ÏÂÈ„Ë ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜ Ì ÙËÓ Î·Ù¿ÏÏËÏË Ê·Ú̷΢ÙÈ΋, ÂÂÌ‚·ÙÈ΋ ‹ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Epstein SE, Maron BJ. Sudden death in the competitive athlete. Perspectives on the preparticipation screening studies. J Am Coll Cardiol 1986;7:220-230. 2. Maron BJ, Shirani J, Poliac LC et al. Sudden death in the young competitive athletes: Clinical, demographic and pathological profiles. JAMA 1996;276:199-204. 3. Corrado D, Thiene G, Nava A et al. Sudden death in the young competitive athletes: Clinicopathologic correlations in 22 cases. Am J Med 1990;89:588-596. 4. Liberthson RR. Sudden death from cardiac causes in children and young adults. N Engl J Med 1996; 334:1039-1044. 5. Maron BJ, Gardin JM, Flack JM et al. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Circulation 1995;92:785-789. 6. Wigle ED, Rakowski H, Kimball BP et al. Hypertrophic cardiomyopathy: Clinical spectrum and treatment. Circulation 1995;92:1680-1692. 7. Cheitlin MD, De Castro CM, McAlister HA. Sudden death as a complication of anomalous left coronary artery origin from the anterior sinus of Valsalva: A not so minor anomaly. Circulation 1974;50:780-787. 8. Liberthson RR, Dinsmore RE, Fallon JT. Aberrant coronary artery origin from the aorta. Report of 18 patients, review of the literature and delineation of natural history and management. Circulation 1979;59:748-754. 9. Marcus FI, Fontaine GH, Guiraudon G et al. Right ventricular dysplasia: A report of 24 adult cases. Circulation 1982;65:384-398. 10. Thiene G, Nava A, Corrado D et al. Right ventricular cardiomyopathy and sudden death in young people. N Engl J Med 1988;318:129-133. 11. Moss AJ, Schwartz PJ, Crampton RS et al. The long QT syndrome: A prospective international study. Circulation 1985;71:17-21. 12. Roden DM, Lazzara R, Rosen M et al. Multiple mechanisms in the long QT syndrome: Current knowledge, gaps and future directions. Circulation 1996;94:1996-2012. 13. Wolff L, Parkinson J, White PD. Bundle branch block with short PR interval in healthy young people prone to paroxysmal tachycardia. Am Heart J 1930;5:685-704. 14. Klein GJ, Bashore TM, Sellers TD et al. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med 1979;301:1080-1085. 15. Kugler JD, Danford DA, Deal BJ et al. Radiofrequency catheter ablation for tachyarrhythmias in children and adolescents. The Pediatric Electrophysiology Society. N Engl J Med 1994;330:1481-1487.
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16. Wolfe RR, Driscoll DJ, Gersony WM et al. Arrhythmia's in patients with valvar aortic stenosis, valvar pulmonary stenosis and ventricular septal defect. Circulation 1993;87(Suppl):I-89-101. 17. Chandar JS, Wolff GS, Garson JR et al. Ventricular arrhythmia's in postoperative tetralogy of Fallot. Am J Cardiol 1990;65:655-661. 18. Silverman DI, Burton KJ, Gray J et al. Life expectancy in the Marfan syndrome. Am J Cardiol 1995;75:157-160. 19. Sneddon JF, Scalia G, Ward DE. Exercise induced vasodepressor syncope. Br Heart J 1994;71:554-557. 20. Sakaguchi S, Shultz JJ, Remole SC et al. Syncope associated with exercise, a manifestation of neurally mediated syncope. Am J Cardiol 1995;75:476-481.
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21. Calkins H, Siefert M, Morady F. Clinical presentation and long-term follow-up of athletes with exercise-induced vasodepressor syncope. Am Heart J 1995;129:1159-1164. 22. Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R. Methodology of head-up tilt table testing in patients with unexplained syncope. J Am Coll Cardiol 1991;17:125-130.
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¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· O ÚfiÏÔ˜ ÙÔ˘ Tc-99m DMSA ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ÓÂÊÚÒÓ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Ì ·ÚÓËÙÈ΋ ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› ÚÔÔÙÈο Ë ·Ó·ÏÔÁ›· ÙˆÓ ·È‰ÈÒÓ Ì ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÔÍ›·˜ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ (O¶N), ·ıÔÏÔÁÈÎfi ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (Tc-99m DMSA) Î·È ·ÚÓËÙÈΤ˜ ‹ ·ÌÊ›‚ÔϘ ηÏÏȤÚÁÂȘ Ô‡ÚˆÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ËÏÈΛ·˜ 6 ‚‰ÔÌ¿‰ˆÓ ¤ˆ˜ 15 ÂÙÒÓ Ì ˘Ô„›· ÔÍ›·˜ ¶N, ÂÈÛ‹¯ıËÛ·Ó ÛÙÔ ¶·È‰È·ÙÚÈÎfi ÙÌ‹Ì· Î·È ˘Ô‚Ï‹ıËÎ·Ó Û ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (DMSA) Û ‰È¿ÛÙËÌ· 3 ËÌÂÚÒÓ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ηıÒ˜ Î·È ÌÂÙ¿ ·fi 6 Ì‹Ó˜. Afi ÙÔ˘˜ 166 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘, ÔÈ 15 (9%) ›¯·Ó ·ÚÓËÙÈΤ˜ ηÏÏȤÚÁÂȘ Ô‡ÚˆÓ ·Ú¿ Ù· ·Ô‰ÂÈÎÙÈο ÛÙÔȯ›· ·fi ÙËÓ ÎÏÈÓÈ΋ Î·È ÛÈÓıËÚÔÁÚ·ÊÈ΋ ÂͤٷÛË ÁÈ· ÙËÓ ·ÚÔ˘Û›· O¶N. Afi Ù· ·Ú·¿Óˆ 15 ·È‰È¿, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· KO¶ Û 9 ·ÛıÂÓ›˜, ÂÓÒ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi ÛÙ· ˘fiÏÔÈ· 7 ·È‰È¿. TÔ Â·Ó·ÏËÙÈÎfi DMSA ÓÂÊÚÒÓ ¤ÍÈ Ì‹Ó˜ ·ÚÁfiÙÂÚ· ¤‰ÂÈÍ ÙËÓ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ‚Ï·‚ÒÓ Û 8 ·È‰È¿ Î·È ÌÂÚÈ΋ ‚ÂÏÙ›ˆÛË Û 4 ·È‰È¿. ™ÙËÓ ·ÚÔ‡Û· ÚÔÔÙÈ΋
ÌÂϤÙË Ë ‰È¿ÁÓˆÛË Ù˘ O¶N ı· ‰È¤Ê¢Á Û ÔÛÔÛÙfi 9% ÙˆÓ ·È‰ÈÒÓ Ì ‚¿ÛË ÙȘ ·ÚÓËÙÈΤ˜ ‹ ·ÌÊ›‚ÔϘ ηÏÏȤÚÁÂȘ Ô‡ÚˆÓ. ™˘ÌÂÚ¿ÛÌ·Ù·: ¶ÚÔÙ›ÓÂÙ·È Ë ‰ÈÂÍ·ÁˆÁ‹ DMSA ÛÈÓıËÚÔÁÚ·Ê‹Ì·ÙÔ˜ ÓÂÊÚÒÓ Û ·È‰È¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÛÔ‚·Ú‹ Ïԛ̈ÍË ¯ˆÚ›˜ ÂÌÊ·Ó‹ ·ÈÙÈÔÏÔÁ›· Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ Ì ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙË ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ.
1 Levtchenko EN, Lahy C, Livy J, Ham HR, Piepsz A Role of Tc-99m DMSA scintigraphy in the diagnosis of culture negative pyelonephritis Pediatr Nephrol 2001;16:503-506
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SOCIAL PEDIATRICS
∞ıÏËÙÈÛÌfi˜ Î·È ÂÚÁÔÓÔÌ›· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ¡. ™ÎÂÓÙ¤Ú˘
Sports and ergonomics in childhood and adolescence ¡. Skenteris
¶ÂÚ›ÏË„Ë: ∏ ∂ÚÁÔÓÔÌ›· ÌÂÏÂÙ¿ ÙÔÓ ¿ÓıÚˆÔ ‹ Ì›· ÔÌ¿‰· ·ÓıÚÒˆÓ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘˜. ™˘ÓÒÓ˘ÌÔ˜ fiÚÔ˜ Â›Ó·È Ë µÈÔÌ˯·ÓÈ΋, Ì ÙȘ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ÔÔ›·˜ ÛÙÔÓ ∞ıÏËÙÈÛÌfi ·Û¯ÔÏÂ›Ù·È Ë ∞ıÏËÙÈ΋ µÈÔÌ˯·ÓÈ΋. ∆Ô Â‡ÚÔ˜ Ó¤ˆÓ ÂÊ·ÚÌÔÁÒÓ Ù˘ ÛÙÔÓ ∞ıÏËÙÈÛÌfi ∂ȉfiÛˆÓ, ÛÙÔ ª·˙ÈÎfi ∞ıÏËÙÈÛÌfi Î·È ÛÙË ™¯ÔÏÈ΋ º˘ÛÈ΋ ∞ÁˆÁ‹, ηıÒ˜ Î·È Û Ӥ˜ Ù¯ÓÈΤ˜ ÚԉȷÁڷʤ˜ ·ıÏËÙÈÎÔ‡ ÂÍÔÏÈÛÌÔ‡ Î·È ÂÁηٷÛÙ¿ÛÂˆÓ (ηٿÏÏËÏ· ÚÔ‡¯·, ·ıÏËÙÈο ·Ô‡ÙÛÈ·, ÎÚ¿ÓÔ˜, Ì¿Ûη, Ù¯ÓËÙ¤˜ ÂÈÊ¿ÓÂȘ Î.¿.) Â›Ó·È ÌÂÁ¿ÏÔ. ªÂÁ¿ÏË Â›Ó·È Î·È Ë Û˘Ì‚ÔÏ‹ Ù˘ ÛÙËÓ ·ÔÊ˘Á‹ ηÎÒÛÂˆÓ Î·È ÓfiÛˆÓ Î·Ù¿ ÙËÓ ¿ÛÎËÛË ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ, ·ÏÏ¿ Î·È ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÙÔ˘˜ ˙ˆ‹ (·ÔÊ˘Á‹ ·Ú·ÌfiÚʈÛ˘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ‰ÈfiÚıˆÛË Ù˘ η΋˜ ı¤Û˘ ÙˆÓ Ô‰ÈÒÓ ÛÙË ‚¿‰ÈÛË Î.¿.). ÕÏÏ· ̤ÙÚ· Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÔÊ˘Á‹ ηÎÒÛÂˆÓ Î·È ÓfiÛˆÓ Â›Ó·È: 1) Ë ÚÔ·ıÏËÙÈ΋ È·ÙÚÈ΋ ÂͤٷÛË, 2) Ë ·Ô¯‹ ·fi ÙËÓ ¿ıÏËÛË ‹ Û˘ÁÎÂÎÚÈ̤ӷ ›‰Ë ·ıÏËÌ¿ÙˆÓ Û ÔÚÈṲ̂Ó˜ ηٷÛÙ¿ÛÂȘ, 3) Ë ¤Ó·ÚÍË ·ıÏËÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ ÛÙËÓ Î·Ù¿ÏÏËÏË, ÁÈ· οı ¿ıÏËÌ·, ËÏÈΛ·, 4) Ë ÁÓÒÛË ÙˆÓ È‰È·ÈÙÂÚÔÙ‹ÙˆÓ ‰È·ÊfiÚˆÓ ·ıÏËÌ¿ÙˆÓ (¿ÚÛ˘ ‚·ÚÒÓ, ‰ÚfiÌÔ˘ ÌÂÁ¿ÏˆÓ ·ÔÛÙ¿ÛˆÓ, ÌÔÍ, Ô‰ÔÛÊ·›ÚÔ˘ Î.¿.) Î·È ·ıÏËÙÈÎÔ‡ Ù‡Ô˘ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ (·Û΋ÛÂˆÓ ‰‡Ó·Ì˘, ÙÚÔ¯Ô¤‰ÈÏˆÓ Î.Ï.), 5) Ë ·ÔÊ˘Á‹ η΋˜ ÚÔÔÓËÙÈ΋˜ Ù·ÎÙÈ΋˜, 6) Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÛÙÚ˜ ÙˆÓ Ó¤ˆÓ ·ıÏËÙÒÓ, ηıÒ˜ ›Û˘ Ù˘ ÂÈıÂÙÈÎfiÙËÙ·˜ Î·È ‚›·˜, fiˆ˜ ·˘Ù‹ ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ˘˜ ·ıÏËÙÈÎÔ‡˜ ¯ÒÚÔ˘˜, 7) Ë ÚÔÒıËÛË ˘ÁÈÒÓ Û˘ÌÂÚÈÊÔÚÒÓ (·ÔÊ˘Á‹ ηӛÛÌ·ÙÔ˜, ·ÏÎÔfiÏ Î·È Ê·Ú̿ΈÓ, ˘ÈÔı¤ÙËÛË ˘ÁÈÂÈÓ‹˜ ‰È·ÙÚÔÊ‹˜ Î·È Ù¯ÓÈÎÒÓ
Abstract: Ergonomics studies a person or a group of persons in their work environment. Synonymous term is Biomechanics which, when reffered to sports, is Sport Biomechanics. The extent of application of Sport Biomechanics in High Performance Sports, Mass Sports and School Physical Education is extensive and includes, among others, new technical prescriptions for athletic equipment and installations (proper clothing, shoes, helmets, masks, artificial surfaces). Sport Biomechanics contributes significantly to avoiding injuries and illnesses in children and adolescents during exercise as well as during their everyday life (avoidance of spinal deformities, correction of wrong placement of feet during walking e.t.c.). Additional measures towards avoiding injuries and illnesses include: 1) preparticipation health examination, 2) abstinence from sports or group of sports under certain circumstances, 3) commencing participation at the proper age for each sport, 4) expertise in handling specific issues of certain sports like weight lifting, long distance running, box, football e.t.c, or athletic activities like strength exercises, skate running e.t.c, 5) avoidance of wrong training programs, 6) management of athletes’ stress, aggressiveness and violence in sport areas, 7) promotion of healthy behaviors (avoidance of smoking, alcohol and drug abuse, adoption of healthy diet and methods of insuring normal weight), 8) correct management of the use of ergogenic aids in sports, e.t.c. All of the above constitute aspects of the pediatrician’s role in dealing with and caring for the special needs
∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·Ï›·˜ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·Ï›·˜ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô §¿ÚÈÛ·˜
Assistant Professor of Pediatrics University of Thessaly University Hospital of Larisa
430
¶·È‰È·ÙÚÈ΋ 2001;64:430-435
Paediatriki 2001;64:430-435
ÂÍ·ÛÊ¿ÏÈÛ˘ ˘ÁÈÔ‡˜ ‚¿ÚÔ˘˜), 8) Ë ı¤ÛË ÙˆÓ ÂÚÁÔÁÂÓÒÓ ‚ÔËıËÌ¿ÙˆÓ ÛÙÔÓ ·ıÏËÙÈÛÌfi Î.¿. ∞˘Ù¿ ·ÔÙÂÏÔ‡Ó ÙÔ Ï·›ÛÈÔ ÙÔ˘ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡ Î·È Ù˘ ÛÙ¿Û˘ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙȘ ȉȷ›ÙÂÚ˜ ·Ó¿ÁΘ Ô˘ ¤¯ÂÈ ÙÔ ·È‰› Î·È Ô ¤ÊË‚Ô˜ Ô˘ ·ıÏÂ›Ù·È Î·È ÛÙËÓ È‰È·›ÙÂÚË ÊÚÔÓÙ›‰· Ô˘ ¯ÚÂÈ¿˙ÂÙ·È.
of children and adolescents participating in athletic activities.
§¤ÍÂȘ ÎÏÂȉȿ: ·ıÏËÙÈÛÌfi˜, ÂÚÁÔÓÔÌ›·, ·È‰È΋ ËÏÈΛ·, ÂÊË‚È΋ ËÏÈΛ·.
Key words: sports, ergonomics, childhood, adolescence.
∂ÈÛ·ÁˆÁ‹ ∏ ∂ÚÁÔÓÔÌ›· Â›Ó·È ÂÈÛÙËÌÔÓÈÎfi˜ ÎÏ¿‰Ô˜ Ô˘ ÌÂÏÂÙ¿ ÙÔÓ ¿ÓıÚˆÔ ‹ ÔÌ¿‰· ·ÓıÚÒˆÓ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘˜ (1). ™Ùfi¯Ô Ù˘ ¤¯ÂÈ Ó· ÂÓ·ÚÌÔÓ›ÛÂÈ ÙÔ ÂÚÁ·ÛÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ ÂÚÁ·˙fiÌÂÓÔ˘ ·ÓıÚÒÔ˘, ÙÔ ÔÔ›Ô Û˘Ó¿ÁÂÙ·È ÛˆÌ·ÙÈ΋ Î·È „˘¯È΋ ¢ÂÍ›· ÎÈ ÂÔ̤ӈ˜ ÌÂÁ·Ï‡ÙÂÚË ·Ô‰ÔÙÈÎfiÙËÙ·. ™˘ÓÒÓ˘ÌÔÈ, ۯ‰fiÓ, fiÚÔÈ Ù˘ ÂÚÁÔÓÔÌ›·˜ ›ӷÈ: ·) ªË¯·ÓÈ΋ ÙˆÓ ·ÓıÚÒÈÓˆÓ ·Ú·ÁfiÓÙˆÓ (human factors engineering), fiˆ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ∏¶∞ Î·È ‚) µÈÔÌ˯·ÓÈ΋, ÔÈ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ÔÔ›·˜ ÛÙÔÓ ·ıÏËÙÈÛÌfi Â›Ó·È ÁÓˆÛÙ¤˜ ˆ˜ ∞ıÏËÙÈ΋ µÈÔÌ˯·ÓÈ΋ (2,3). ∞˘Ù‹ ÌÂÏÂÙ¿ ÙȘ ·ÓıÚÒÈÓ˜ ÎÈÓ‹ÛÂȘ ÛÙÔ Ï·›ÛÔ ÙˆÓ Ê˘ÛÈÎÒÓ Î·È ·ıÏËÙÈÎÒÓ ·Û΋ÛˆÓ. ŒÙÛÈ Û˘Ì‚¿ÏÏÂÈ ÙfiÛÔ ÛÙÔÓ ∞ıÏËÙÈÛÌfi À„ËÏÔ‡ ∂Ȥ‰Ô˘ (∂ȉfiÛˆÓ) (4) fiÛÔ Î·È ÛÙÔ ª·˙ÈÎfi ∞ıÏËÙÈÛÌfi, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ™¯ÔÏÈ΋˜ º˘ÛÈ΋˜ ∞ÁˆÁ‹˜. ™˘Ì‚¿ÏÏÂÈ, ›Û˘, ÛÙËÓ ÂÂÍÂÚÁ·Û›· Ó¤ˆÓ Ù¯ÓÈÎÒÓ ÚԉȷÁÚ·ÊÒÓ ÁÈ· ·ıÏËÙÈÎfi ÂÍÔÏÈÛÌfi Î·È ·ıÏËÙÈΤ˜ ÂÁηٷÛÙ¿ÛÂȘ (·ıÏËÙÈο ·Ô‡ÙÛÈ·, ÛÙÔϤ˜, Ù¯ÓËÙ¤˜ ÂÈÊ¿ÓÂȘ Î.¿.), ÁÈ· Ó· ÂÏ·¯ÈÛÙÔÔÈËıÔ‡Ó ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Î·È Ó· ÌÂÁÈÛÙÔÔÈËıÔ‡Ó ÔÈ ÂȉfiÛÂȘ. H Úfi‚ÏÂ„Ë ÁÈ· ÙÔ Ù˙fiÁÎÈÓÁÎ fiÙÈ “Ù· ·Ô‡ÙÛÈ· ÙÔ˘ ̤ÏÏÔÓÙÔ˜ ı· ÂÊ·ÚÌfi˙Ô˘Ó ¿Óˆ Û ÌÈÎÚ¿ ÛÙÚÒÌ·Ù· ·¤Ú·” ¤ÁÈÓ ‹‰Ë Ú·ÁÌ·ÙÈÎfiÙËÙ·. ∏ ·Ó·˙‹ÙËÛË ‚È‚ÏÈÔÁÚ·Ê›·˜ ÛÙÔ ¢È·‰›ÎÙ˘Ô, ÛÙ· Ï‹Ì·Ù· “∂ÚÁÔÓÔÌ›·”, “∞ÓıÚÒÈÓÔÈ ¶·Ú¿ÁÔÓÙ˜”, “µÈÔÌ˯·ÓÈ΋” Î.Ô.Î., ‰ÂÓ ·¤‰ˆÛ ٷ ·Ó·ÌÂÓfiÌÂÓ· ÁÈ· ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·, ÙÔÓ ·ıÏËÙÈÛÌfi Î·È Ù· ÂӉȷʤÚÔÓÙ· ÂÓfi˜ ·È‰È¿ÙÚÔ˘, ·Ó Î·È Â›Ó·È ÁÂÓÈο ÏÔ‡ÛÈ· (5-11).
ÎÔ‡Ú·ÛË). ∂›Û˘, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂÈϤÁÔÓÙ·È ¯ÒÚÔÈ ¯ˆÚ›˜ ‚›· Î·È ¯ˆÚ›˜ ¤ÎıÂÛË Û ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ (.¯. ηÓfi˜ ·fi ·ÔÙ¤ÊÚˆÛË ‹ ·fi Ì˯·Ó¤˜). OÈ ¯ÒÚÔÈ Î·È Ô ÂÍÔÏÈÛÌfi˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Ù·ÎÙÈο Î·È ÔÈ ÂÈΛӉ˘Ó˜ ηٷÛÙ¿ÛÂȘ Ó· ‰ÈÔÚıÒÓÔÓÙ·È ·Ì¤Ûˆ˜. ∫·È ‚¤‚·È·, ··Ú·›ÙËÙË Â›Ó·È Ë Î·Ù¿ÏÏËÏË ÁÔÓÂ˚΋ ÂÈÙ‹ÚËÛË, Ë Û˘ÌÌfiÚʈÛË Ì ÙÔ˘˜ ηÓÔÓÈÛÌÔ‡˜ ·ÛÊ¿ÏÂÈ·˜ Î·È Ë ¯Ú‹ÛË ÚÔÛٷ٢ÙÈÎÒÓ Ì¤ÛˆÓ Î·È ÂÍÔÏÈÛÌÔ‡, ηıÒ˜ Î·È Ë ·ÔÊ˘Á‹ ·ÎÚ·›ˆÓ ηÈÚÈÎÒÓ Û˘ÓıËÎÒÓ. π‰È·›ÙÂÚË ÊÚÔÓÙ›‰· ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· ÙËÓ Â‡ÎÔÏË Î·È ·ÛÊ·Ï‹ ÚfiÛ‚·ÛË Î·È Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·È‰ÈÒÓ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ. ™Ù· ηٿÏÏËÏ· ÚÔ‡¯· Î·È ÂÍÔÏÈÛÌfi ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) ηٿÏÏËϘ ÁÈ· οı ÂȉÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· οÏÙÛ˜, ‚) ÎÚ¿ÓË ÁÈ· ÙÔ Ô‰‹Ï·ÙÔ (˘¿Ú¯Ô˘Ó Û ‰È¿ÊÔÚ· ÌÂÁ¤ıË), Á) ÎÚ¿ÓÔ˜, Ì¿Ûη ÚÔÛÒÔ˘, ÚÔÛٷ٢ÙÈο ÛÙfiÌ·ÙÔ˜ Î·È ÚÔÛΤʷϷ (pads) ÁÈ· ÙÔ Ô‰fiÛÊ·ÈÚÔ. ∏ ¯Ú‹ÛË ÚÔÛٷ٢ÙÈ΋˜ Ì¿Ûη˜ ÁÈ· Ù· Ì¿ÙÈ· Û˘ÓÈÛÙ¿Ù·È Û fiÏ· Ù· ·ıÏ‹Ì·Ù· Î·È ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ÁÈ’ ·˘Ù¿ Ì’ ¤Ó· ÏÂÈÙÔ˘ÚÁÈÎfi Ì¿ÙÈ (ÔÈ Ê·ÎÔ› ·ʋ˜ ‰ÂÓ ÚÔÛٷهԢÓ) Î·È ‰) ηٿÏÏËÏÔ ÓÙ‡ÛÈÌÔ ÁÈ· ‚¿‰ÈÛÌ· Î·È ÙÚ¤ÍÈÌÔ. ∆· ÚÔÛٷ٢ÙÈο ÂÓ‰‡Ì·Ù· Î·È Ô ·ıÏËÙÈÎfi˜ ÂÍÔÏÈÛÌfi˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Û˘¯Ó¿ Î·È Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·Ó Â›Ó·È ˙ÂÛÙ¿, ¤¯Ô˘Ó ˘ÔÛÙ› ‚Ï¿‚Ë ‹ ¤¯ÂÈ Ï‹ÍÂÈ Ë ËÌÂÚÔÌËÓ›· ¯Ú‹Û˘ ÙÔ˘˜. ∆Ô ÚÒÙÔ ÂÚÒÙËÌ· Ô˘ Ú¤ÂÈ Ó· ··ÓÙËı› Û¯ÂÙÈο Ì ÙËÓ ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Â›Ó·È “fiÙÂ Û˘ÛÙ‹ÓÂÙ·È ·Ô¯‹ ·fi ·˘Ù‹Ó” (¶›Ó·Î·˜ 2). ∞ÎÔÏÔ˘ı› Ë ÂÚÒÙËÛË “ÔÈ· ·ıÏ‹Ì·Ù· Â›Ó·È Î·Ù¿ÏÏËÏ· ÁÈ· οı ËÏÈΛ·”, Ë ÔÔ›· ı· ¤Ú ӷ ·ӷ‰È·Ù˘ˆı› ˆ˜ ÂÍ‹˜: “ÔÈ· ·ıÏ‹Ì·Ù· Â›Ó·È Î·Ù¿ÏÏËÏ· ÁÈ· οı ·Ó·Ù˘Íȷ΋ (Î·È fi¯È ¯ÚÔÓÔÏÔÁÈ΋) ËÏÈΛ·”. ∫·È ¿ÏÈ, Ë ·Ï‹ıÂÈ· Â›Ó·È fiÙÈ ÙÔ Î¿ı ·È‰› Î·È Ô Î¿ı ¤ÊË‚Ô˜ Â›Ó·È Ì›· ÌÔÓ·‰È΋, ·fi ‚ÈÔÌ˯·ÓÈ΋ ¿Ô„Ë, ÂÚ›ÙˆÛË. ŒÙÛÈ ÚÔÁÚ¿ÌÌ·Ù· ¿ÛÎËÛ˘ ÙˆÓ ‚ÚÂÊÒÓ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙ· (‰ÂÓ ‚ÂÏÙÈÒÓÔ˘Ó ÙË Ê˘ÛÈ΋ ηٿÛÙ·ÛË) (14). µ¤‚·È·, ÔÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ (15) ϤÓ fiÙÈ ÔÈ ·Û΋ÛÂȘ Ú¤ÂÈ Ó· ·Ú¯›ÛÔ˘Ó Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ·fi ÙȘ ÚÒÙ˜ ·ÎfiÌË Ë̤Ú˜ Ù˘ ˙ˆ‹˜
ª¤ÙÚ· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ηÎÒÛÂˆÓ Î·È ÓfiÛˆÓ °È· ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ‰È¿ ‚›Ô˘ Ê˘ÛÈ΋˜ ¿ÛÎËÛ˘ Û ӤԢ˜, Â›Ó·È ··Ú·›ÙËÙË, ÌÂٷ͇ ¿ÏÏˆÓ (12), Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ηÎÒÛÂˆÓ Î·È ÓfiÛˆÓ (¶›Ó·Î·˜ 1) (13). ™˘ÁÎÂÎÚÈ̤ӷ, Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÔÈ ÚԉȷÁڷʤ˜ (standards) ·ÛÊ¿ÏÂÈ·˜ ÛÙÔ Û¯Â‰È·ÛÌfi, ÙËÓ ÂÁηٿÛÙ·ÛË Î·È ÙË Û˘ÓÙ‹ÚËÛË (.¯. Û ·ÁˆÓÈÛÙÈÎÔ‡˜ ¯ÒÚÔ˘˜ Ó· ˘¿Ú¯ÂÈ ÎÚ‡Ô ÓÂÚfi Î·È ›ÛÎÈÔ˜ ÁÈ· ·ÈÁÓ›‰È Î·È ÍÂ-
431
¶·È‰È·ÙÚÈ΋ 2001;64:430-435
Paediatriki 2001;64:430-435
¶›Ó·Î·˜ 1. ª¤ÙÚ· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ηÎÒÛÂˆÓ Î·È ÓfiÛˆÓ ÛÙË Ê˘ÛÈ΋ ¿ÛÎËÛË ÙˆÓ Ó¤ˆÓ
¶›Ó·Î·˜ 2. ™˘ÛÙ¿ÛÂȘ ÁÈ· ·ÚÔ‰È΋ ‹ ÌfiÓÈÌË ·Ô¯‹ ·fi ÙËÓ ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹
1. ∞ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÚÈÓ ·fi ÙËÓ ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹ 2. ∫·Ù¿ÏÏËϘ ÁÈ· οı ·Ó·Ù˘Íȷ΋ ËÏÈΛ· ‰Ú·ÛÙËÚÈfiÙËÙ˜ 3. ∂Ȃ‚·›ˆÛË Ù˘ ηϋ˜ Ê˘ÛÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ Ó¤Ô˘ 4. O‰ËÁ›Â˜ ÁÈ· ÙË ‚ÈÔÌ˯·ÓÈ΋ ‹ ÁÈ· ÂȉÈΤ˜ ÎÈÓËÙÈΤ˜ ‰ÂÍÈfiÙËÙ˜ 5. ∫·Ù¿ÏÏËÏË ÔÌ·‰ÔÔ›ËÛË (·Ó¿ÏÔÁ· Ì ÙÔ ‡„Ô˜ Î·È ÙȘ ‰˘Ó·ÙfiÙËÙ˜) 6. ¶ÚÔÛ·ÚÌÔÁ‹ ÙˆÓ Î·ÓÔÓÈÛÌÒÓ ÛÙÔ Â›Â‰Ô ÂÌÂÈÚ›·˜ ÙˆÓ Ó¤ˆÓ Î·È ÛÙÔ ‰È·ı¤ÛÈÌÔ ÚÔÛٷ٢ÙÈÎfi ÂÍÔÏÈÛÌfi 7. ∞ÔÊ˘Á‹ ˘ÂÚ‚ÔÏÒÓ ÛÙËÓ ÚÔfiÓËÛË 8. ∆ÚÔÔÔ›ËÛË ÙˆÓ Î·ÓÔÓÈÛÌÒÓ ÁÈ· ÂÍ¿ÏÂÈ„Ë ÌË ·ÛÊ·ÏÒÓ Ú·ÎÙÈÎÒÓ 9. ∂Ȃ‚·›ˆÛË fiÙÈ ÔÈ Î·ÎÒÛÂȘ ıÂڷ‡ÙËηÓ, ÚÈÓ Û˘Ó¯ÈÛÙ› Ë ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹
∞. ¶·ÚÔ‰È΋ ·Ô¯‹ ·fi ·ıÏ‹Ì·Ù· ÌÂ Î·È ¯ˆÚ›˜ Û‡ÁÎÚÔ˘ÛË Î·È Â·Ê‹ Û˘ÛÙ‹ÓÂÙ·È ÛÂ: ñ ÂÓÂÚÁfi Ïԛ̈ÍË (·Ó·Ó¢ÛÙÈÎÔ‡, Ô˘ÚÔÔÈËÙÈÎÔ‡, ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË, Ë·Ù›Ùȉ·, ÚÂ˘Ì·ÙÈÎfi ˘ÚÂÙfi, ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË Î.¿.) ñ ÊÏÂÁÌÔÓ‹ ¿ÚıÚˆÛ˘ ·fi Ïԛ̈ÍË ‹ ÚfiÛÊ·ÙË Î¿ÎˆÛË ¶·ÚÔ‰È΋ ·Ô¯‹ ·fi ·ıÏ‹Ì·Ù· Ì ۇÁÎÚÔ˘ÛË Î·È Â·Ê‹ Û˘ÛÙ‹ÓÂÙ·È Î·È Û ÂÓÂÚÁfi ‰ÂÚÌ·ÙÔ¿ıÂÈ· (‰ÔıÈ‹Ó·, ÌÔÏ˘ÛÌ·ÙÈÎfi ÎËÚ›Ô, ¤ÚËÙ·).
ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÎÈ fiÙÈ Ô È‰·ÓÈÎfi˜ ÙÚfiÔ˜ Â›Ó·È Ó· Á›ÓÔÓÙ·È 3 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, ·ÏÏ¿ fi¯È ·Ì¤Ûˆ˜ ÌfiÏȘ ͢ӋÛÂÈ ‹ ÚÈÓ ÎÔÈÌËı› ÙÔ ·È‰›. ∏ Û˘ÌÌÂÙÔ¯‹ Û ÔÌ·‰Èο ·ıÏ‹Ì·Ù· (16) ηÏfi Â›Ó·È Ó· ·Ú¯›˙ÂÈ ÌÂÙ¿ Ù· 6 ¯ÚfiÓÈ·, ÁÈ·Ù› ̤¯ÚÈ ÙfiÙ ٷ ·È‰È¿ ‰ÂÓ Î·Ù·ÓÔÔ‡Ó ÙË ‰Ô˘ÏÂÈ¿ Û ÔÌ¿‰·. ª¤¯ÚÈ Ù· 6 ¯ÚfiÓÈ· Û˘ÛÙ‹ÓÂÙ·È ÂχıÂÚÔ ·ÈÁÓ›‰È ‹ ·ıÏ‹Ì·Ù· fiˆ˜ ÎÔχ̂ËÛË (·fi ÙËÓ ËÏÈΛ· ÙˆÓ 3 ¯ÚfiÓˆÓ) Î.¿. ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ οو ÙˆÓ 7 ¯ÚfiÓˆÓ ‰ÂÓ Â›Ó·È ¤ÙÔÈÌ· ÁÈ· ÛÙÂÓ‹ ·ʋ (fiˆ˜ ÛÙ· ÔÌ·‰Èο ·ıÏ‹Ì·Ù· ·ʋ˜ ‚fiϸ, Ì¿ÛÎÂÙ, Ô‰fiÛÊ·ÈÚÔ) Î·È ‰ÂÓ ˘Ê›ÛÙ·Ù·È ÌfiÓÔ Ô Î›Ó‰˘ÓÔ˜ Ê˘ÛÈ΋˜ οΈÛ˘, ·ÏÏ¿ Î·È ÔÈ Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ Û˘Ó¤ÂȘ (ÙÔ Ó· ¯¿ÓÔ˘Ó ÌÔÚ› Ó· Â›Ó·È Ôχ ÛÎÏËÚfi, fiˆ˜ Û˘Ì‚·›ÓÂÈ ·ÎfiÌ· Î·È Û ÂÓ‹ÏÈΘ). ∫·Ù¿ÏÏËÏË ËÏÈΛ· ÁÈ· Û˘Ó·ÁˆÓÈÛÌfi, ÙfiÛÔ ÛÙ· ·ÙÔÌÈο fiÛÔ Î·È ÛÙ· ÔÌ·‰Èο ·ıÏ‹Ì·Ù·, Â›Ó·È Ë ËÏÈΛ· ÙˆÓ 8-12 ¯ÚfiÓˆÓ. ∫·Ï‡ÙÂÚ·, fï˜, Â›Ó·È Ó· ·Ú¯›˙ÂÈ ÛÙËÓ ËÏÈΛ· ÙˆÓ 13 ¯ÚfiÓˆÓ. ∏ ¿ÚÛË ‚·ÚÒÓ ÂÈÙÚ¤ÂÙ·È ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ÂÊ˂›·˜ (ÛÙ¿‰ÈÔ V ηٿ Tanner). O ‰ÚfiÌÔ˜ ÌÂÁ¿Ï˘ ·fiÛÙ·Û˘ Ú¤ÂÈ Ó· ·Ó·‚¿ÏÏÂÙ·È ÁÈ· ÙËÓ ÂÊ˂›· (·ÎfiÌË Î·È ÙfiÙÂ, ÁÈ· ̤Û˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ·È‰È¿, ÂÚÈÔÚ›˙ÂÙ·È Û 800-1200 ̤ÙÚ· οı ÊÔÚ¿). ∆Ô ÌÔÍ ··ÁÔÚ‡ÂÙ·È ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚfiÎÏËÛË ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘. ∞Û΋ÛÂȘ ‰‡Ó·Ì˘ ÁÈ· ·‡ÍËÛË Ù˘ Ì˘˚΋˜ ‰‡Ó·Ì˘ Î·È ÚÔÂÙÔÈÌ·Û›· ÁÈ· ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ÂÈÙÚ¤ÔÓÙ·È Û ·È‰È¿ ÚÔÂÊË‚È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ ÌfiÓÔ ˘fi ÙËÓ Î·ıÔ‰‹ÁËÛË Î·Ù¿ÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓˆÓ ÂÓËÏ›ÎˆÓ (˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ηٷÁÌ¿ÙˆÓ ÂÈʇÛÂˆÓ ‹ ÌÂÛÔÛÔÓ‰‡ÏÈˆÓ ‰›ÛΈÓ). ∫ÈÓ‰‡ÓÔ˘˜ ηÎÒÛÂˆÓ ÂÁ΢ÌÔÓÔ‡Ó, Û ÌÈÎÚfiÙÂÚÔ ‹ ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi, fiÏ· Ù· ·ıÏ‹Ì·Ù·, ÂÈÎÂÊ·Ï‹˜ fï˜ Â›Ó·È ÙÔ Ô‰fiÛÊ·ÈÚÔ (ηÎÒÛÂȘ ÛÙÔ ÎÂÊ¿ÏÈ Î·È Ù· ÁfiÓ·Ù·). OÈ Î›Ó‰˘ÓÔÈ ·˘Í¿ÓÔÓÙ·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ·ʋ˜. ŒÙÛÈ, ·ÎÔÏÔ˘ı› Ë ¿ÏË, Ë Á˘ÌÓ·ÛÙÈ΋, ÙÔ Ì¿ÛÎÂÙ, Ô ‰ÚfiÌÔ˜. OÈ Î·ÎÒÛÂȘ
432
µ. ªfiÓÈÌË ·Ô¯‹ Û˘ÛÙ‹ÓÂÙ·È ÛÂ: ñ ¯ÚfiÓÈÔ ÓfiÛËÌ·, fiˆ˜ ÛÂ: - ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË (·ÈÌÔÚÔÊÈÏ›·) - ·ÚÚ‡ıÌÈÛÙÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË - ÛÔ‚·Ú‹ ¯ÚfiÓÈ· ·ÔÊÚ·ÎÙÈ΋ Ó¢ÌÔÓÔ¿ıÂÈ· - ηډȷ΋ ‚·Ï‚ȉԿıÂÈ· (ÛÙÂÓÒÛÂȘ ÌÈÙÚÔÂȉԇ˜, ·ÔÚÙ‹˜) - ÚÔËÁËı›۷ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË (ÂÓ›ÔÙÂ) - ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË ÁÓˆÛÙ‹˜ ·ÈÙÈÔÏÔÁ›·˜, fiˆ˜ ÛÂ: ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ·, ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜, fiÁÎÔ˘˜ ÂÈÓÂÊÚȉ›ˆÓ, Û˘ÁÁÂÓ‹ ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË ™Â ȉÈÔ·ı‹ ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Ô˘ ÂϤÁ¯ÂÙ·È Ì ʿÚ̷η ÂÈÙÚ¤ÂÙ·È Ë ¿ÛÎËÛË ‰‡Ó·Ì˘. ™Â ‹È˜ ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ ÂÈÙÚ¤ÂÙ·È ¿ÛÎËÛË ¯ˆÚ›˜ ·ʋ Î·È Û‡ÁÎÚÔ˘ÛË, Ì ȷÙÚÈ΋ ›‚ÏÂ„Ë Î·È Û˘¯Ófi ·ӤÏÂÁ¯Ô. ªfiÓÈÌË ·Ô¯‹ ·fi ·ıÏ‹Ì·Ù· Ì ۇÁÎÚÔ˘ÛË Î·È Â·Ê‹ Û˘ÛÙ‹ÓÂÙ·È Î·È ÛÙȘ ·ÎfiÏÔ˘ı˜ ηٷÛÙ¿ÛÂȘ: ñ ΋ÏË (ÂÊfiÛÔÓ ‰ÂÓ ¤¯ÂÈ ¯ÂÈÚÔ˘ÚÁËı›) ñ Û˘ÁÁÂÓ›˜ Ì˘ÔÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (·ÙÂÏ‹˜ ÔÛÙÂÔÁ¤ÓÂÛË Î.¿.) ñ ·ÒÏÂÈ· ‹ Ù˘ÊÏfiÙËÙ· ÂÓfi˜ Ì·ÙÈÔ‡ ñ ·ÓÂÈÏËÌ̤Ó˜ ηÎÒÛÂȘ ÎÂÊ·ÏÈÔ‡ ‹ ‰È·Û›ÛÂȘ, Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÒÏÂÈ· Û˘Ó›‰ËÛ˘ ñ ÌË ÂÏÂÁ¯fiÌÂÓË - Ê·Ú̷΢ÙÈο - ÂÈÏË„›· ‹ Û·ÛÌÔ› ñ ÚÔËÁËı›۷ ÎÚ·ÓÈÔ- ‹ Ó¢ÚÔ- ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ñ ·Ô˘Û›· ÂÓfi˜ ÓÂÊÚÔ‡ ñ ·Ô˘Û›· ÂÓfi˜ fiÚ¯ÂÔ˜
ÛÙ· ÁfiÓ·Ù· Â›Ó·È ÔÈ ÈÔ ÛÔ‚·Ú¤˜, Ù· 2/3 fï˜ Û˘Ì‚·›ÓÔ˘Ó ÛÙ· ̷Ϸο ÌfiÚÈ· Î·È ÌfiÓÔ ÙÔ 5% Â›Ó·È Î·Ù¿ÁÌ·Ù·. °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙÔ Ô‰fiÛÊ·ÈÚÔ ÂÈ‚¿ÏÏÂÙ·È Ë Î·Ï‹ ÛÙÂÚ¤ˆÛË ÙˆÓ ‰ÔÎÒÓ, Ë ÚÔÛٷ٢ÙÈ΋ Ì¿Ûη Ì·ÙÈÒÓ Î·È ÛÙfiÌ·ÙÔ˜, Ë ·Ôı¿ÚÚ˘ÓÛË ¯Ù˘‹Ì·ÙÔ˜ Ù˘ Ì¿Ï·˜ Ì ÙÔ ÎÂÊ¿ÏÈ Î·È Ë ··ÁfiÚ¢ÛË ÂÈıÂÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜. ∆· ÙÚÔ¯Ô¤‰ÈÏ· (skates) ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ÙÒÛË ÏfiÁˆ ·ÒÏÂÈ·˜ Ù˘ ÈÛÔÚÚÔ›·˜, ÂÏ·ÙÙÒÌ·ÙÔ˜ ÙÔ˘ Ô‰ÔÛÙÚÒÌ·ÙÔ˜, ÚfiÛÎÚÔ˘Û˘ Û ·ÓÙÈΛÌÂÓÔ, ˘ÂÚ‚ÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜, ·‰˘Ó·Ì›·˜ ÊÚÂÓ·Ú›ÛÌ·ÙÔ˜ ‹ ÂÎÙ¤ÏÂÛ˘ ÊÈÁÔ‡Ú·˜, Ì ·ÎfiÏÔ˘ıÔ ÙÚ·˘Ì·ÙÈÛÌfi. ™ÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÈ Î·ÎÒÛÂȘ ÂÓÙÔ›˙ÔÓÙ·È ÛÙÔÓ Î·Úfi (ÛÙ· 2/3 Â›Ó·È Î·Ù¿ÁÌ·Ù·). ∂È‚¿ÏÏÂÙ·È ¯Ú‹ÛË ÎÚ¿ÓÔ˘˜ Î·È ÚÔÛٷ٢ÙÈÎÒÓ Ì¤ÛˆÓ ÙˆÓ Î·ÚÒÓ, ÙˆÓ
¶·È‰È·ÙÚÈ΋ 2001;64:430-435
·ÁÎÒÓˆÓ Î·È ÙˆÓ ÁÔÓ¿ÙˆÓ. ∫·Ù¿ÏÏËÏË ËÏÈΛ· ¤Ó·Ú͢ Â›Ó·È Ù· 7-8 ¯ÚfiÓÈ·, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ Î·È ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙÔ˘ ·È‰ÈÔ‡. ∏ ¯Ú‹ÛË Ù·¯‡ÏÔÔ˘ (watercraft) ÛÙË ı¿Ï·ÛÛ· ÂÓ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÓÈÁÌÔ‡ ‹ ÙÚ·˘Ì·ÙÈÛÌÔ‡ / ı·Ó¿ÙÔ˘ ·fi Û‡ÁÎÚÔ˘ÛË Ì ¿ÏÏÔ ÛοÊÔ˜. ¢ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 16 ¯ÚfiÓˆÓ. ∂›Ó·È ··Ú·›ÙËÙË Ë ¯Ú‹ÛË ÂȉÈÎÔ‡ ÛˆÛÈ‚›Ô˘, ÂÓÒ ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌÂÙ¿ ÙË ‰‡ÛË ÙÔ˘ ‹ÏÈÔ˘. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ·ÁfiÚÈ· ÛÙËÓ ÂÊ˂›· ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚË Ì˘˚΋ Ì¿˙·, ÁÈ’ ·˘Ùfi Â›Ó·È ÈÔ ‰˘Ó·Ù¿. ª¤¯ÚÈ ÙËÓ ÂÊ˂›·, ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· ÌÔÚÔ‡Ó Ó' ·ÁˆÓ›˙ÔÓÙ·È Ì·˙›, ÁÈ·Ù› ¤¯Ô˘Ó ÙÔ ›‰ÈÔ ‚¿ÚÔ˜ Î·È ‡„Ô˜. ∆· ÎÔÚ›ÙÛÈ· Ì·›ÓÔ˘Ó ÛÙËÓ ÂÊ˂›· ÛÙËÓ ËÏÈΛ· ÙˆÓ 10-12 ¯ÚÔÓÒÓ (2 ¯ÚfiÓÈ· ÚÈÓ ·fi Ù· ·ÁfiÚÈ·). ™Â ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ Á˘Ó·ÈΛ· ÔÌ¿‰·, ÌÔÚÔ‡Ó Ó· ÂÓÙ·¯ıÔ‡Ó Û ·Ó‰ÚÈ΋. ∏ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È ÂÍ›ÛÔ˘ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, fiˆ˜ Ë ËÏÈΛ·, ÙÔ ‚¿ÚÔ˜, ÙÔ ‡„Ô˜ Î·È ÙÔ Ê‡ÏÔ. ∆Ô Ó· Ì¿ıÂÈ Î·Ó›˜ Ó' ·ÓÙÈÌÂÙˆ›˙ÂÈ ÙÔ ÛÙÚ˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘. ∫‡ÚÈ· ËÁ‹ ÛÙÚ˜ ÛÙÔ˘˜ Ó¤Ô˘˜ ·ıÏËÙ¤˜ Â›Ó·È Ë ›ÂÛË Ó· ÎÂÚ‰›ÛÔ˘Ó. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÛÙÚ˜ ÌÔÚ› Ó· Á›ÓÂÈ Ì ·Ï¿ ‚‹Ì·Ù·: ·) ÙÔÔı¤ÙËÛË ÙÔ˘ ·È‰ÈÔ‡ Û ÔÌ¿‰· ÌÈÎÚfiÙÂÚˆÓ ËÏÈÎÈÒÓ Î·È ÂÌÂÈÚ›·˜ (ÛÙ· ·ıÏ‹Ì·Ù· ·ʋ˜ ·ÓÙ›·ÏÔÈ ÌÔÚ› Ó· Â›Ó·È ÌfiÓÔ ·ıÏËÙ¤˜ ›‰ÈÔ˘ ‡„Ô˘˜, ‚¿ÚÔ˘˜, ÈηÓfiÙËÙ·˜ Î·È ˆÚÈÌfiÙËÙ·˜), ‚) ÔÈ Î·ÓÔÓÈÛÌÔ› ÂÓfi˜ ·ıÏ‹Ì·ÙÔ˜ ÌÔÚ› Ó' ·ÏÏ¿ÍÔ˘Ó ÁÈ· Ó· ÌÔÚÔ‡Ó Ó· ·›ÍÔ˘Ó fiÏÔÈ (.¯. ÌÈ· ÔÌ¿‰· Ì¿ÛÎÂÙ Ó· ¯·ÌËÏÒÛÂÈ Û ‡„Ô˜ ‹ ¤Ó·˜ ·ÁÒÓ·˜ ‰ÚfiÌÔ˘ Ó· ‚Ú·¯˘Óı› Û ‰È¿ÚÎÂÈ·). ∆· ·È‰È¿ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÌÙÒÌ·Ù· ÛÙÚ˜ ·fi ¿ÏϘ ·Èٛ˜ (ÔÈÎÔÁÂÓÂȷο ÚÔ‚Ï‹Ì·Ù·, Û˘ÁÎÚÔ‡ÛÂȘ ÌÂ Û˘ÓÔÌ‹ÏÈÎÔ˘˜, Û¯ÔÏÈ΋ ›ÂÛË Î·È ·ÏÏ·Á¤˜ ηÙÔÈΛ·˜) (17). ∆Ô ÛÙÚ˜ ·fi ÙËÓ ¿ıÏËÛË Û˘¯Ó¿ Â›Ó·È ÏÈÁfiÙÂÚÔ, Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ÙÔ ÛÙÚ˜ ·fi ÙȘ ¿ÏϘ ·Èٛ˜. ∆· ·ıÏ‹Ì·Ù· ÌÔÚÔ‡Ó Ó· ‰È‰¿ÍÔ˘Ó Ù· ‚‹Ì·Ù· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÛÙÚ˜ ·fi οÔÈÔ Úfi‚ÏËÌ·. ∞˘Ùfi˜ Â›Ó·È ¤Ó·˜ ÏfiÁÔ˜ Ô˘ ÔÈ ·È‰›·ÙÚÔÈ Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÔ˘Ó ÙË Û˘ÌÌÂÙÔ¯‹ ÛÙËÓ ¿ıÏËÛË. °È· ÙËÓ ÚÔ·ÁˆÁ‹ Î·È ·Ô‰Ô¯‹ Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ¿ÛÎËÛ˘ ·fi ÙÔ ·È‰› Î·È ÙÔÓ ¤ÊË‚Ô, Â›Ó·È ··Ú·›ÙËÙÔ Ó· ·Ôı·ÚÚ‡ÓÂÙ·È Ë ¯ÚËÛÈÌÔÔ›ËÛË ‹ Ì·Ù·›ˆÛË Ù˘ ¿ÛÎËÛ˘ ˆ˜ ÙÈ̈ڛ·, ÁÈ·Ù› Á›ÓÔÓÙ·È ·ÚÓËÙÈΤ˜ Û˘Ó‰¤ÛÂȘ ÛÙÔ Ì˘·Ïfi ÙˆÓ ·È‰ÈÒÓ. OÈ ÁÓˆÛÙ¤˜, ÛÙÔ˘˜ ·È‰›·ÙÚÔ˘˜, ÂÊ·ÚÌÔÁ¤˜ Ù˘ ∂ÚÁÔÓÔÌ›·˜ (‹ µÈÔÌ˯·ÓÈ΋˜) ·Ó·Ê¤ÚÔÓÙ·È ÛÙȘ ·Èٛ˜ Ô˘ ·Ú·ÌÔÚÊÒÓÔ˘Ó ÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË (18). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È Ë ·‰˘Ó·Ì›· ‰È·Ù‹ÚËÛ˘ Ì›·˜ ÛˆÛÙ‹˜ ÛÙ¿Û˘ Ïfi-
Paediatriki 2001;64:430-435
Áˆ ÚfiˆÚ˘ ÎfiˆÛ˘. ∞Èٛ˜ ÚfiˆÚ˘ ÎfiˆÛ˘ Â›Ó·È Ë ÂÏÏÈ‹˜ ÂÍ¿ÛÎËÛË ÙÔ˘ Ì˘˚ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÏfiÁˆ ÎÈÓËÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ÙÔ ÔχˆÚÔ Î¿ıÈÛÌ·, Ë fiÚıÈ· ÛÙ¿ÛË ¯ˆÚ›˜ ‰È·Ï›ÌÌ·Ù· (ÛÙÔ Û¯ÔÏ›Ô, ηٿ ÙË ÌÂϤÙË Î.Ù.Ï.), Ë ˘ÂÚÊfiÚÙˆÛË ÏfiÁˆ ÌÂÁ¿ÏÔ˘ ‚¿ÚÔ˘˜ ‹ Ì·ÎÚfi¯ÚÔÓÔ˘, ÌÔÓfiÏ¢ÚÔ˘ ÎÚ·Ù‹Ì·ÙÔ˜ ‚¿ÚÔ˘˜ (.¯. Û¯ÔÏÈ΋˜ ÙÛ¿ÓÙ·˜). ∏ ›وÛË Â›Ó·È Ë ·Ú·ÌfiÚʈÛË Ù˘ ÛÙ¿Û˘, ‰ËÏ·‰‹ ÙÔ ·È‰› ‰ÂÓ ÌÔÚ› Ó· ¿ÚÂÈ ÙËÓ ·Ú¯È΋ ı¤ÛË (‰ÔÎÈÌ·Û›· Matthias), ÏfiÁˆ ‰È·Ù·Ú·¯‹˜ Ù˘ Û˘Ó¤ÚÁÂÈ·˜ ÙˆÓ Ì˘ÒÓ. OÈ Û˘Ó¤ÂȘ Â›Ó·È ÁÓˆÛÙ¤˜: ÌÂÏÏÔÓÙÈο ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ì˘˚ÎÔ‡˜ Û·ÛÌÔ‡˜, ȉ›ˆ˜ ÛÙÔ˘˜ ÒÌÔ˘˜ Î·È ÛÙÔÓ ·˘¯¤Ó·, ÔÓÔΤʷÏÔ Î·È ÔÛÊ˘·ÏÁ›·, ·ÏÏ¿ Î·È ‰˘ÛÎÔÈÏÈfiÙËÙ· Î·È ÂÈfiÏ·È· ·Ó·ÓÔ‹, ÏfiÁˆ Ù˘ ÚÔÛ¤ÁÁÈÛ˘ ıÒڷη Î·È ÏÂοÓ˘ Î·È ÂÚÈÔÚÈÛÌÔ‡ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ Î·È ÎÔÈÏÈ·ÎÔ‡ ¯ÒÚÔ˘. ª·ÎÚÔÚfiıÂÛÌ· ÌÂÈÒÓÂÙ·È Î·È Ë ÛÙ·ıÂÚfiÙËÙ· ÙˆÓ ÌÂÛÔÛÔÓ‰‡ÏÈˆÓ ‰›ÛΈÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÈۯȷÏÁ›· ‹ ·Ú¤ÛÂȘ. °È· ÙËÓ ·fiÎÙËÛË Î·Ï‹˜ ۈ̷ÙÈ΋˜ ÛÙ¿Û˘ ˘¿Ú¯Ô˘Ó ηٿÏÏËϘ ·Û΋ÛÂȘ ÂÓ‰˘Ó¿ÌˆÛ˘ ÙˆÓ Ì˘ÒÓ Ù˘ Ú¿¯Ë˜ (ÔÚıÔÛˆÌÈΤ˜), ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ Û˘ÓÂÂÈÒÓ ÙÔ˘ ÔχˆÚÔ˘ ηı›ÛÌ·ÙÔ˜ ÛÙÔ Û¯ÔÏÂ›Ô ‹ ÁÈ· ÌÂϤÙË ÛÙÔ Û›ÙÈ. ÃÚ‹ÛÈÌË ÁÈ· ÙÔ˘˜ ·È‰›·ÙÚÔ˘˜ Â›Ó·È Î·È Ë ÚfiÏË„Ë Ì ηٿÏÏËϘ ·Û΋ÛÂȘ ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙȘ ·ÚıÚÒÛÂȘ ·fi ÙËÓ Î·Î‹ ı¤ÛË ÙˆÓ Ô‰ÈÒÓ ÛÙË ‚¿‰ÈÛË (19) (ÛÙËÓ ·Ú¯‹ Ì ηıËÌÂÚÈÓ¤˜ 15ÏÂÙ˜ ·Û΋ÛÂȘ Ô˘ ı· ·ÔÙÂϤÛÔ˘Ó, ÛÙË Û˘Ó¤¯ÂÈ·, ·Ó·fiÛ·ÛÙÔ Ì¤ÚÔ˜ Ù˘ ηıËÌÂÚÈÓ‹˜ ·ÁˆÁ‹˜ ÙÔ˘ ÛÒÌ·ÙÔ˜). ∆Ô Úfi‚ÏËÌ· ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÁÈ·Ù› ÙfiÛÔ Ù· ·È‰È¿ fiÛÔ Î·È ÔÈ ÂÓ‹ÏÈÎÔÈ ‰ÂÓ ÂÚ·ÙÔ‡Ó Í˘fiÏËÙÔÈ ÛÂ Ê˘ÛÈÎfi ¤‰·ÊÔ˜ Ì ÙȘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘, ·ÏÏ¿ Û Ù¯ÓËÙ¤˜, Ï›˜ Î·È ÛÎÏËÚ¤˜ ÂÈÊ¿ÓÂȘ Ì οÏÙÛ˜ Î·È ·Ô‡ÙÛÈ·. ∫·ı‹ÎÔÓ fiÏˆÓ Ì·˜ Â›Ó·È Ó· ÂÍ·ÛÊ·Ï›ÛÔ˘Ì ÛÙ· ·È‰È¿ Ì·˜ ¤Ó· Ê˘ÛÈÎfi Î·È ÎÔÈÓˆÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ Ô˘ ÂÓı·ÚÚ‡ÓÂÈ Î·È ÂÓ‰˘Ó·ÌÒÓÂÈ ÙËÓ ·ÛÊ·Ï‹ Î·È Â˘¯¿ÚÈÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÛÙËÓ ÎÔÈÓfiÙËÙ· (ÛÙÔ Û¯ÔÏ›Ô: ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ÌÂÙ¿ ÙË Û¯ÔÏÈ΋ Ë̤ڷ, ηıÒ˜ ›Û˘ Ù· ™·‚‚·ÙÔ·Úȷη, ÙÔ Î·ÏÔη›ÚÈ Î·È ÛÙȘ ‰È·ÎÔ¤˜, ÂÓÒ ÛÙËÓ ÎÔÈÓfiÙËÙ·: Ì Â˙ÔÔÚ›·, Ô‰ËÏ·Û›·, ›ÛÎÂ„Ë ‰ËÌfiÛÈˆÓ ÎÔÏ˘Ì‚ËÙËÚ›ˆÓ, ¿ÚÎˆÓ Î·È ¯ÒÚˆÓ ·Ó·„˘¯‹˜). ∆È Ú¤ÂÈ Ó· ÚÔÛ¤ÍÔ˘Ó ÔÈ ÁÔÓ›˜ ÛÙÔ ÚfiÁÚ·ÌÌ· Ê˘ÛÈ΋˜ ¿ÛÎËÛ˘ ÛÙÔ Û¯ÔÏÂ›Ô ∫¿ÔȘ ÂÏ¿¯ÈÛÙ˜ ··ÈÙ‹ÛÂȘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ≥45 min Û˘Ó¯ԇ˜ ¿ÛÎËÛ˘ (Î·È Ì ‰È·Ù¿ÛÂȘ) 3 ÊÔÚ¤˜/‚‰ÔÌ¿‰·, ≥30 min (·fi Ù· 45 min) ηډȷÁÁÂȷ΋˜ ‹ ·ÂÚfi‚È·˜ ¿ÛÎËÛ˘ Î·È Î·Ù¿ÏÏËÏÔ˘˜ Á˘ÌÓ·ÛÙ¤˜.
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¶·È‰È·ÙÚÈ΋ 2001;64:430-435
∞Ó ÙÔ ·È‰› ‰ÂÓ ı¤ÏÂÈ Ó· ÂÍ·ÎÔÏÔ˘ı‹ÛÂÈ Ó· Û˘ÌÌÂÙ¤¯ÂÈ Û’ ¤Ó· ÚfiÁÚ·ÌÌ· ¿ÛÎËÛ˘ Û˘˙ËÙ›ÛÙ ̷˙› ÙÔ˘! ªÔÚ› Ë ·ÈÙ›· Ó· Â›Ó·È Ôχ ·Ï‹ (fiˆ˜ Ó· ÌË Ì¤ÓÂÈ ÌfiÓÔ Ì ÙÔÓ ÚÔÔÓËÙ‹ ‹ Ó· ÓÈÒıÂÈ fiÙÈ Â›Ó·È ·Ú·ÁΈÓÈṲ̂ÓÔ, ·Ó ‰ÂÓ Û˘ÌÌÂÙ¤¯ÂÈ Û ·ÈÁÓ›‰È·). ∏ ·Ú·Ù‹ÚËÛË ÙÔ˘ ·È‰ÈÔ‡ ÌÔÚ› Ó· Ê·ÓÂÚÒÛÂÈ ÛËÌ›· ÛÙÚ˜ ·fi ÙËÓ ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹ (ÂÌÂÙÔ›, ·ÓÔÚÂÍ›·, ÔÓÔΤʷÏÔ˜), ÛËÌ¿‰È· ηٷ›ÂÛ˘ (ÎÔÈÌ¿Ù·È ÈÔ Û˘¯Ó¿ ·' fiÙÈ Û˘Ó‹ıˆ˜, Â›Ó·È ÏËı·ÚÁÈÎfi ‹ ·ÔÛ˘Ṳ́ÓÔ), ÁÈ’ ·˘Ùfi Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋. ∆· ·È‰È¿ Ú¤ÂÈ Ó· Ì¿ıÔ˘Ó Ó· ÌË ‰È·ÎfiÙÔ˘Ó ÙËÓ ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹. °È’ ·˘Ùfi ¯ÚÂÈ¿˙ÂÙ·È Ë Û˘ÓÂÚÁ·Û›· ÙÔ˘ ÁÔÓ¤· Ì ÙÔÓ ·È‰›·ÙÚÔ ‹ ÙÔÓ ÚÔÔÓËÙ‹ ÁÈ· Ó· Ï˘ı› ÙÔ Úfi‚ÏËÌ·. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙËÓ ¿ÛÎËÛË ÏfiÁˆ ¯·ÌËÏ‹˜ ‚·ıÌÔÏÔÁ›·˜, ‰ÂÓ ˘¿Ú¯ÂÈ ·Ï‹ ·¿ÓÙËÛË. ŒÓ· ·È‰› Ô˘ ¤¯ÂÈ Úfi‚ÏËÌ· ÛÙËÓ Ù¿ÍË ÂÍ·ÎÔÏÔ˘ı› Ó· ¯ÚÂÈ¿˙ÂÙ·È Ù· ÔʤÏË Ù˘ ¿ÛÎËÛ˘, ÙÔ˘ Û˘Ó·ÁˆÓÈÛÌÔ‡ Î·È ÙËÓ ·›ÛıËÛË ÂÓfi˜ ÂÈϤÔÓ ÚÔÛfiÓÙÔ˜. ∆· ·ıÏ‹Ì·Ù· ÌÔÚ› Ó· Â›Ó·È Ë ÌfiÓË ÏˆÊfiÚÔ˜ ÂÈÙ˘¯›·˜ ÛÙË ˙ˆ‹ ÂÓfi˜ ·È‰ÈÔ‡ Î·È ÌÔÚ› Ó· Â›Ó·È ÂÈ˙‹ÌÈ· Ë ·ÔÌ¿ÎÚ˘ÓÛ‹ ÙÔ˘ ·fi ·˘Ù¿. OÈ ÁÔÓ›˜ Ú¤ÂÈ Ó· „¿ÍÔ˘Ó ÁÈ' ¿ÏϘ ·Èٛ˜ η΋˜ Û¯ÔÏÈ΋˜ ›‰ÔÛ˘ (.¯. Û˘ÁÎÚÔ‡ÛÂȘ ÁÈ· οÙÈ, ÔχˆÚË ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› ÙÔ ·È‰› Ó· ÌË ÌÂÏÂÙ¿ ·ÚÎÂÙ¿. ∆fiÙÂ, ı· Ú¤ÂÈ Ó· ÂÍ·ÚÙËı› Ë ·ıÏËÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ·fi ÙËÓ Â›Ù¢ÍË Î·Ï‡ÙÂÚˆÓ ‚·ıÌÒÓ Î·È Ó· ÂÚˆÙËı› ÙÔ ·È‰› ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ ‚Ô‹ıÂÈ·˜ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È. ∂ÈıÂÙÈÎfiÙËÙ· Î·È ‚›· ∏ ÂÈıÂÙÈÎfiÙËÙ· Î·È Ë ‚›· Â›Ó·È ¤Ó· ÎÔÈÓˆÓÈÎfi Ê·ÈÓfiÌÂÓÔ Ì ÂӉȷʤÚÔ˘Û˜ ÂΉËÏÒÛÂȘ ÛÙÔ˘˜ ¯ÒÚÔ˘˜ fiÔ˘ ·ıÏÔ‡ÓÙ·È Ù· ·È‰È¿. ÕÏÏ· ·È‰È¿ Ì·ı·›ÓÔ˘Ó “·Ú¿ÓÔÌ·” ›‰Ë Ú·ÎÙÈ΋˜ Ô˘ ‚Ï¤Ô˘Ó ÛÙ· ·ÈÁÓ›‰È· ÙˆÓ Â·ÁÁÂÏÌ·ÙÈÎÒÓ ÔÌ¿‰ˆÓ, ÂÓÒ Û ¿ÏÏ· ·ÚÈÔÈ ˘ÔÎÈÓËÙ¤˜ Ù˘ ‚›·È˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙ· ·ıÏ‹Ì·Ù· Â›Ó·È ÔÈ Ê›ÏÔÈ. ∆· ˘ÂÚ‚ÔÏÈο ÂÈıÂÙÈο ·È‰È¿ Ê·›ÓÂÙ·È fiÙÈ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÁÔÓ›˜ Ô˘ Ù· ¤¯Ô˘Ó ·ÔÚÚ›„ÂÈ Î·È Ô˘ Û˘Ó‹ıˆ˜ Ì·ÏÒÓÔ˘Ó ÌÂٷ͇ ÙÔ˘˜. ∂›Û˘, Ù· ·È‰È¿ Ô˘ ÂÎÙ›ıÂÓÙ·È ÛÙËÓ ¿ÌÂÛË ÂÈıÂÙÈÎfiÙËÙ· ÙˆÓ ÁÔÓ¤ˆÓ ‹ Ô˘ Ë ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘˜ ÚÔ˜ ¿ÏÏÔ˘˜ ÂÓı·ÚÚ‡ÓÂÙ·È ·' ÙÔ˘˜ ÁÔÓ›˜ Á›ÓÔÓÙ·È ÈÔ ÂÈıÂÙÈÎÔ› ¤ÊË‚ÔÈ Î·È ÂÓ‹ÏÈΘ. ∏ ¤ÓÙÔÓË ¤ÎıÂÛË ÙˆÓ ·È‰ÈÒÓ ÛÙ· ·ÁˆÓÈÛÙÈο ·ıÏ‹Ì·Ù·, ȉ›ˆ˜ Ì ¤Ó·Ó ·ÓÙ›·ÏÔ, ›Ûˆ˜ ÂËÚ¿˙ÂÈ ÙȘ ÂÈıÂÙÈΤ˜ ÙÔ˘˜ Ù¿ÛÂȘ. ŸÌˆ˜, ·Ó ÙÔ ÌÂÙ·-·ÁˆÓÈÛÙÈÎfi Îϛ̷ ÔÚÁ·Óˆı› ÚÔÛÂÎÙÈο, ÒÛÙ ӷ ÚÔÛʤÚÂÈ Â˘Î·Èڛ˜ ÁÈ· Û˘ÓÂÚÁ·Û›·, ÙfiÙ ÔÈ ‰È·ÚÔÛˆÈΤ˜ Î·È ÔÈ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ¯ıÚfiÙËÙ˜ ‰È·Ï‡ÔÓÙ·È. ∆¤ÏÔ˜, ·È‰È¿ 8-9 ¯ÚfiÓˆÓ ÂËÚ¿-
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˙ÔÓÙ·È ÂÍ·ÈÚÂÙÈο ·fi ÙȘ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ÙÈ̈ڛ·˜, ·ıÏËÙ¤˜ 10-12 ¯ÚfiÓˆÓ Â›Ó·È È‰È·›ÙÂÚ· ¢·›ÛıËÙÔÈ ÛÙËÓ ÂÓı¿ÚÚ˘ÓÛË ÙˆÓ ÚÔÔÓËÙÒÓ ÙÔ˘˜, ÂÓÒ ÛÙËÓ ËÏÈΛ· ÙˆÓ 13-15 ¯ÚfiÓˆÓ ‰Â›¯ÓÔ˘Ó ˘ÂÚ‚ÔÏÈο ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ÛÙËÓ ÙÈ̈ڛ· Î·È ÙËÓ ÂÓı¿ÚÚ˘ÓÛË, ·ÏÏ¿ ‰›ÓÔ˘Ó ¤ÌÊ·ÛË Î·È ÛÙÔ ·Ó Ë ·ÚÓËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘˜ ·Ú¤¯ÂÈ Ô‰ËÁ›Â˜ ÁÈ· ‚ÂÏÙ›ˆÛË. ¶ÚÔÒıËÛË ˘ÁÈÒÓ Û˘ÌÂÚÈÊÔÚÒÓ ¶·Ú¿ÏÏËÏ·, ÔÈ ÂÎ·È‰Â˘ÙÈÎÔ›, ÔÈ ÁÔÓ›˜, ÔÈ ÚÔÔÓËÙ¤˜, ÔÈ ·ıÏËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ÔÈ ÏÂÈÙÔ˘ÚÁÔ› ˘Á›·˜ Ú¤ÂÈ Ó· ÚÔˆıÔ‡Ó ¤Ó· Ê¿ÛÌ· ˘ÁÈÒÓ Û˘ÌÂÚÈÊÔÚÒÓ, fiˆ˜ ·ÔÊ˘Á‹ ηӛÛÌ·ÙÔ˜, ·ÏÎÔfiÏ Î·È Ê·ÚÌ¿ÎˆÓ Î·È ˘ÈÔı¤ÙËÛË ˘ÁÈÂÈÓ‹˜ ‰È·ÙÚÔÊ‹˜ Î·È Ù¯ÓÈÎÒÓ ÂÍ·ÛÊ¿ÏÈÛ˘ ˘ÁÈÔ‡˜ ‚¿ÚÔ˘˜. ¶ÂÚÈÙÙ‡ÂÈ Ë ·Ó·ÊÔÚ¿ ÛÙËÓ ·Í›· ÙÔ˘ ÚÔÛˆÈÎÔ‡ ·Ú·‰Â›ÁÌ·ÙÔ˜ ÙˆÓ ·˘ıÂÓÙÈÒÓ, Ô˘ ·ÔÙÂÏԇ̠ÂÌ›˜ ÔÈ ÂÓ‹ÏÈΘ. ∂ÚÁÔÁÂÓ‹ ‚ÔËı‹Ì·Ù· ÛÙÔÓ ·ıÏËÙÈÛÌfi (20) Â›Ó·È ·˘Ù¿ Ô˘ ¯ÚËÛÈÌÔÔÈ› Ë ÂÈÛÙ‹ÌË Ù˘ ∂ÚÁÔÓÔÌ›·˜ ÁÈ· Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ·ıÏËÙÈ΋ ›‰ÔÛË ¿Óˆ Î·È ¤Ú· ·fi Ù· fiÚÈ· Ô˘ ηıÔÚ›˙ÔÓÙ·È ·fi ÙȘ Ê˘ÛÈΤ˜ ÈηÓfiÙËÙ˜ Î·È ÙËÓ ÚÔfiÓËÛË. £· ÌÔÚÔ‡Û·Ì ӷ Ù· ‰È·ÎÚ›ÓÔ˘Ì Û 5 ηÙËÁÔڛ˜: ·) ‰È·ÙÚÔÊ‹˜ (Û˘ÌÏËÚÒÌ·Ù· ·ÌÈÓÔͤˆÓ, ˘‰·Ù¿ÓıڷΘ, ÓÂÚfi), ‚) Ê˘ÛÈÔÏÔÁÈο (·ÏηÏÈο ¿Ï·Ù·, ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜, Ô͢ÁfiÓÔ), Á) Ê·Ú̷΢ÙÈο (·ÌÊÂٷ̛Ә, ·Ó·‚ÔÏÈο ÛÙÂÚÔÂȉ‹, ηʽÓË), ‰) „˘¯ÔÏÔÁÈο (‡ÓˆÛË, Ê·ÓÙ·ÛÈÒÛÂȘ, ¤ÏÂÁ¯Ô˜ ÙÔ˘ ¿Á¯Ô˘˜) Î·È Â) Ì˯·ÓÈο / ‚ÈÔÌ˯·ÓÈο (Û‡ÛÙ·ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜, ÂÓ‰˘Ì·Û›·, ÂÍÔÏÈÛÌfi˜). ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚ¢ÓÒÓ ‰ÂÓ Î·Ù·Ï‹ÁÔ˘Ó Û ÔÌÔʈӛ· Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂÚÁÔÁÂÓÒÓ ‚ÔËıËÌ¿ÙˆÓ. OÈ ¤Ú¢Ó˜ ¤¯Ô˘Ó ·Ô‰Â›ÍÂÈ fiÙÈ ÔÚÈṲ̂ӷ ÂÚÁÔÁÂÓ‹ ‚ÔËı‹Ì·Ù·, fiˆ˜ Ë ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ‹ Ë ¯ÚËÛÈÌÔÔ›ËÛË Ô͢ÁfiÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÛÎËÛ˘, ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ·fi‰ÔÛË Û ·ıÏ‹Ì·Ù· ·ÓÙÔ¯‹˜. °È· Ù· ·ÏηÏÈο Î·È Ù· ʈÛÊÔÚÈο ¿Ï·Ù·, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜ Â›Ó·È Û˘Áί˘Ì¤Ó·. ∆¤ÏÔ˜, ¿ÏÏ· ÂÚÁÔÁÂÓ‹ ‚ÔËı‹Ì·Ù·, fiˆ˜ Ë ‚ÈÙ·Ì›ÓË µ12 Î·È Ô ‚·ÛÈÏÈÎfi˜ ÔÏÙfi˜, ‰ÂÓ ÂÈʤÚÔ˘Ó Î·Ì›· ·Ôχو˜ ‚ÂÏÙ›ˆÛË ÛÙË Ê˘ÛÈ΋ ·fi‰ÔÛË. ∞ÎfiÌË, Û˘ÁÎÂÎÚÈ̤Ó˜ ÔÛfiÙËÙ˜ ηÊ½Ó˘ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ·fi ¿ÏϘ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ·fi‰ÔÛ˘. ∆¤ÏÔ˜, ˘¿Ú¯Ô˘Ó ÓfiÌÈÌ· Î·È ·Ú¿ÓÔÌ· ÂÚÁÔÁÂÓ‹ ‚ÔËı‹Ì·Ù·, ÂÓÒ Ù· ÂÚÈÛÛfiÙÂÚ· Â›Ó·È ·Ú¿ÓÔÌ· Î·È ··ÁÔÚ‡ÂÙ·È ·fi ÙË ¢ÈÂıÓ‹ OÏ˘Ìȷ΋ ∂ÈÙÚÔ‹ Ë ¯Ú‹ÛË ÙÔ˘˜ ·fi ÙÔ˘˜ ·ıÏËÙ¤˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó Û ·ÁÒÓ˜. ÿÛˆ˜, Ë °ÂÓÂÙÈ΋ Ó· Â›Ó·È ÙÔ ·ÒÙÂÚÔ ÂÚÁÔÁÂÓ¤˜ ‚Ô‹ıËÌ·, fiÛÔ ·Û‡ÏÏËÙÔ ÎÈ ·Ó Ê·›ÓÂÙ·È Î¿ÙÈ Ù¤ÙÔÈÔ Û‹ÌÂÚ·.
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∂˘¯·ÚÈÛٛ˜ OÊ›ψ Ó· ÂÎÊÚ¿Ûˆ ÙȘ ıÂṲ́˜ ÌÔ˘ ¢¯·ÚÈÛٛ˜ ÛÙËÓ ·È‰›·ÙÚÔ ª·Ú›· ªÔ˘ÛÙ¿ÎË ÁÈ· ÙË ÛËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ Ù˘ ÛÙËÓ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ÛÙËÓ ÔÔ›· ‚·Û›ÛÙËÎÂ Ë ·ÚÔ‡Û· ÂÚÁ·Û›·.
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SOCIAL PEDIATRICS
¶ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Õ. ∆ÛÈÏÈÁÎÈÚfiÁÏÔ˘ - º·¯·ÓÙ›‰Ô˘
Prevention and treatment of sports injuries in childhood and adolescence A. Tsiligiroglou - Fachantidou
¶ÂÚ›ÏË„Ë: ∏ ÚfiÏË„Ë ÙˆÓ ·ıÏËÙÈÎÒÓ Î·ÎÒÛˆÓ, Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ ÏfiÁˆ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÛÎÂÏÂÙÔ‡, Â›Ó·È ÂÈÙ·ÎÙÈ΋. OÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ - ·ÙÔÌÈÎÔ› ‹ Â͈ÙÂÚÈÎÔ› - ¤¯Ô˘Ó ÔÏϤ˜ ÊÔÚ¤˜ Û¯¤ÛË Ì ÙËÓ ˘¤Ú¯ÚËÛË, Ù· ÛÊ¿ÏÌ·Ù· ÚÔfiÓËÛ˘ Î·È Ù¯ÓÈ΋˜, ÙÔÓ ·Î·Ù¿ÏÏËÏÔ ·ıÏËÙÈÎfi ¯ÒÚÔ Î·È ‰È¿ÊÔÚ˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ‹ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, „˘¯ÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‹ ·ÎfiÌË Î·È Ì ÙÔÓ ·Î·Ù¿ÏÏËÏÔ ÁÈ· ÙÔ ¿ıÏËÌ· ۈ̷ÙfiÙ˘Ô Î.Ï. ∏ Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙ· ·È‰È¿ ·ÊÔÚ¿ ÙÔ Ì˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ· Î·È È‰È·›ÙÂÚ· Ù· ÔÛÙ¿ Ô˘ ‰È·Ê¤ÚÔ˘Ó ·fi ¿Ô„Ë ˘Ê‹˜. ™˘Ó‹ıÂȘ ηÎÒÛÂȘ ·fi ˘¤Ú¯ÚËÛË Â›Ó·È Ë ÙÂÓÔÓÙ›Ùȉ·, Ë ÂÈÎÔÓ‰˘Ï›Ùȉ·, Ë ·ÔÊ˘Û›Ùȉ·, Ë ÔÛÙÂÔ¯ÔÓ‰Ú›Ùȉ·, Ù· Ôͤ· ηٿÁÌ·Ù· Î·È Ë ÙÂÓÔÓÙÔÂÏ˘ÙÚ›Ùȉ·. OÈ Û˘Ó‹ıÂȘ ÙÚ·˘Ì·ÙÈΤ˜ ηÎÒÛÂȘ Â›Ó·È ÔÈ Ú‹ÍÂȘ Ì˘ÒÓ, Û˘Ó‰¤Û̈Ó, ÙÂÓfiÓÙˆÓ, Ó‡ڈÓ, ÂÍ·ÚıÚ‹Ì·Ù· Î·È Ôͤ· ηٿÁÌ·Ù·. OÈ Î·ÎÒÛÂȘ ÌÔÚ› Ó· ·ÊÔÚÔ‡Ó ÙÔ˘˜ Û˘Ó‰¤ÛÌÔ˘˜, ÙÔ˘˜ Ì˘˜, ÙÔ˘˜ Ù¤ÓÔÓÙ˜ Î·È ÙȘ ·ÚıÚÒÛÂȘ Î·È Â›Ó·È ‰È·ÊfiÚˆÓ ‚·ıÌÒÓ. ∆· Û˘Ó‹ıË ·›ÙÈ· Â›Ó·È ÙÚ·‡Ì·Ù·, ˘¤Ú¯ÚËÛË ‹ ˘ÂÚÚÔfiÓËÛË. π‰È·›ÙÂÚÔÈ Ù‡ÔÈ ÙˆÓ Î·ÎÒÛÂˆÓ Â›Ó·È ÔÈ ÂÈÊ˘ÛÈÔχÛÂȘ, Ô ÂÒ‰˘ÓÔ˜ ÚËÓÈÛÌfi˜, Ë ÓfiÛÔ˜ Legg Calvè Perthes. ™ÙÔÓ ·ıÏËÙÈÛÌfi, Û˘¯Ó¿ Â›Ó·È Ù· ·ÔÛ·ÛÌ·ÙÈο ηٿÁÌ·Ù· Î·È Ù· ηٿÁÌ·Ù· ÎfiˆÛ˘, ÂÓÒ ÈÔ Û¿ÓÈ· Â›Ó·È Ù· ·˘ÙfiÌ·Ù· ·ıÔÏÔÁÈο ηٿÁÌ·Ù·. ∏ ÚfiÏË„Ë Â›Ó·È ·Ó·Áη›· ηıÒ˜, Û‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜, οı Á˘ÌÓ·ÛÙ‹˜ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¿Óˆ ·fi ¤Ó· ÛÔ‚·Úfi ÂÚÈÛÙ·ÙÈÎfi ÂÙËÛ›ˆ˜. ∏ ÚfiÏË„Ë ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ Î·Ù¿ÏÏËÏÔ ˘ÏÈÎÔÙ¯ÓÈÎfi ÂÍÔÏÈÛÌfi, ÙË ÛˆÛÙ‹ ÚÔfiÓËÛË, ÙÔ Î·Ù¿ÏÏËÏÔ Îϛ̷, ¤Ó· ÏÂÙÔÌÂÚ‹ È·ÙÚÈÎfi ¤ÏÂÁ¯Ô. ∏ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ Ù‡Ô˘ Ù˘ οΈÛ˘ Î·È ÙÔ˘ ‚·ıÌÔ‡. ¶ÔÏϤ˜ ÊÔÚ¤˜
Abstract: Prevention of sports injuries in children and adolescents during development of the skeletal system is of great importance. Epidemiologic studies have identified several intrinsic and extrinsic risk factors relevant to overuse, heavy training and technique errors, inappropriate facility standards such as hard playing surface, anatomical malalignment, associated disease state or pathological and physiological factors including improper footwear or gear etc. The overwhelming majority of injuries in childhood and adolescence involve the musculoskeletal system and particularly bones of different types. Common injuries from overuse are tendonitis, epicondylitis, tenosynovitis, osteochondritis, acute fractures and tendon sheath injuries. Most frequent traumatic injuries involve muscles, tendons and ligament tears, tendon sheaths, dislocations and acute fractures. Injuries can involve ligaments, muscles, tendons and joints in varying severity, and are usually caused by trauma, overuse and overtraining. Special types of injuries include epiphyseal tears, painful pronation and Legg Calvè Pethes disease. In sports the most common injuries are the fragmentary fractures as well as stress fractures, while the automatic pathological fractures are rare. Recent research shows that every physical education instructor faces at least one serious injury incident annually. Prevention includes proper facility standards and exercise equipment, good climatic conditions and thorough medical screening. Treatment depends on the type and the degree of injury. Most often a simple manipulation and reduction is needed. Physical therapy is optional in children. Prevention
∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ¢È·ÙÚÔÊ‹˜ ∞ıÏÔ˘Ì¤ÓˆÓ ∆∂º∞∞, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢
Laboratory of Hygiene and Nutrition of Athletes TEFAA, Aristotelion University of Thessaloniki
436
¶·È‰È·ÙÚÈ΋ 2001;64:436-440
Paediatriki 2001;64:436-440
¯ÚÂÈ¿˙ÂÙ·È ·Ïfi˜ ¯ÂÈÚÈÛÌfi˜ Î·È ·Ó¿Ù·ÍË. ∏ Ê˘ÛÈÔıÂڷ›· ‰ÂÓ Â›Ó·È Û˘Ó‹ıˆ˜ ··Ú·›ÙËÙË ÛÙ· ·È‰È¿. ∏ ÚfiÏË„Ë Î·È Ë ¤ÁηÈÚË Î·È ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÛÙ· ·È‰È¿ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙÔ Ì¤ÏÏÔÓ ÙÔ˘ ·ıÏËÙÈÛÌÔ‡.
and early treatment of childhood injuries can ensure the future of athletics.
§¤ÍÂȘ ÎÏÂȉȿ: ÙÚ·˘Ì·ÙÈÛÌÔ›, ·È‰È΋ ËÏÈΛ·, ÂÊ˂›·, ˘¤Ú¯ÚËÛË, ·ÓÙÈÌÂÙÒÈÛË.
Key words: injuries, children, adolescents, overuse, prevention.
OÈ ·ıÏËÙÈΤ˜ ηÎÒÛÂȘ Â›Ó·È Û˘¯Ófi Ê·ÈÓfiÌÂÓÔ ÁÈ· fiÛÔ˘˜ ·Û¯ÔÏÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο Ì ÙÔÓ ·ıÏËÙÈÛÌfi. Œ¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ·fi‰ÔÛË ÙˆÓ ·ıÏËÙÒÓ ÁÈ· ÔÚÈṲ̂ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È ÔÏϤ˜ ÊÔÚ¤˜ ÙËÓ ¿ÌÂÛË ‰È·ÎÔ‹ Ù˘ ·ıÏËÙÈ΋˜ ÂͤÏÈÍ‹˜ ÙÔ˘˜. O Hemle ¤ÏÂÁ fiÙÈ Ë Î›ÓËÛË/¿ÛÎËÛË Â›Ó·È Î¿ÙÈ Û·Ó Ê¿ÚÌ·Îo Ô˘ Ú¤ÂÈ Ó· ÚÔÛ¤ÍÔ˘Ì ÙË ‰fiÛË ÙÔ˘ ÁÈ· Ó· ÌËÓ ¤¯Ô˘Ì ·ÚÂÓ¤ÚÁÂȘ. ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ Ë ÚÔÛÔ¯‹, fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ıÏËÙ¤˜ ÂÊ‹‚Ô˘˜ ‹ ·È‰È¿, Ú¤ÂÈ Ó· Â›Ó·È È‰È·›ÙÂÚË ÁÈ·Ù› Ô ÛÎÂÏÂÙfi˜ ÙÔ˘˜ Â›Ó·È ·Ó·Ù˘ÛÛfiÌÂÓÔ˜. OÈ ·Ú¿ÁÔÓÙ˜ ηÎÒÛÂˆÓ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ Â›‰Ô˜ ÙÔ˘ ·ıÏ‹Ì·ÙÔ˜, ÙÔ “ÔÛfi” Ù˘ ÚÔfiÓËÛ˘, ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· (1). ∂È‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Û¯¤ÛË Ì ÙËÓ ˘¤Ú¯ÚËÛË Î·È ¿ÏÏ· ·›ÙÈ· ÛÙÔ˘˜ Ó·ÚÔ‡˜ ·ıÏËÙ¤˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ıˆÚÔ‡ÓÙ·È ÂÈ‚·Ú˘ÓÙÈÎÔ› Â›Ó·È (1): ·) Ë Û˘ÌÌÂÙÔ¯‹ Û ¿ıÏËÌ· ·Î·Ù¿ÏÏËÏÔ ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ Î·È ÙÔ ÛˆÌ·ÙfiÙ˘Ô ÙÔ˘ ·È‰ÈÔ‡ Ô˘ ÂÈ‚·Ú‡ÓÂÈ ÙÔ ÛÎÂÏÂÙfi, ‚) Ë ÂÛ¢Ṳ̂ÓË Â¿ÓÔ‰Ô˜ ÛÙËÓ ¿ıÏËÛË ÌÂÙ¿ ·fi ÙÚ·˘Ì·ÙÈÛÌfi Î·È Á) ÔÈ Î·Î¤˜ ÌÂÙˆÚÔÏÔÁÈΤ˜ Û˘Óı‹Î˜. ∏ ÊÚÔÓÙ›‰· ÁÈ· ÚfiÏË„Ë ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ ÛÙ· ·È‰È¿ Â›Ó·È Ì›· ÚfiÎÏËÛË Û˘Ó¯ԇ˜ ÂӉȷʤÚÔÓÙÔ˜. OÈ ÙÚ·˘Ì·ÙÈÛÌÔ›, ÔÏϤ˜ ÊÔÚ¤˜, ¤¯Ô˘Ó ‰‡ÛÎÔÏË ‰È¿ÁÓˆÛË. ∞Ó fï˜ Á›ÓÂÈ ¤ÁηÈÚ·, Ë ·ÓÙÈÌÂÙÒÈÛË Î·È ·ÔηٿÛÙ·ÛË Â›Ó·È Û¯ÂÙÈο ‡ÎÔÏË Ì ٤ÏÂÈ· ·ÔÙÂϤÛÌ·Ù·, ·ÎfiÌË ÎÈ ·Ó ·ÊÔÚ¿ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÛÎÂÏÂÙfi.
∏ Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙ· ·È‰È¿ ·ÊÔÚ¿ ÙÔ Ì˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ·. ∆· ÔÛÙ¿ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ÈÔ ÔÚÒ‰Ë Î·È ÏÈÁfiÙÂÚÔ ˘ÎÓ¿. ∆· ÛˆÏËÓ¿ÚÈ· Havers Â›Ó·È ÈÔ Ê·Ú‰È¿ Î·È Î·Ù·Ï·Ì‚¿ÓÔ˘Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙˆÓ ÔÛÙÒÓ. ∏ ÂÓ·fiıÂÛË ·Ï¿ÙˆÓ Ca ÛÙË ÌÂÛÔ΢ÙÙ¿ÚÈ· Ô˘Û›· ·˘Í¿ÓÂÈ ÙËÓ ˘ÎÓfiÙËÙ· ÙÔ˘ ÔÛÙÔ‡ Û˘Ó¯Ҙ ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙËÓ Ï‹ÚË ÛÎÂÏÂÙÈ΋ ˆÚ›Ì·ÓÛË. ∏ ·˘ÍË̤ÓË ˘ÎÓfiÙËÙ· ÛËÌ·›ÓÂÈ fï˜ Î·È ÌÂÁ·Ï‡ÙÂÚË Â˘ıÚ·˘ÛÙfiÙËÙ· ÙÔ˘ ÔÛÙÔ‡ (2). ∆Ô ÂÚÈfiÛÙÂÔ Â›Ó·È ·¯‡ÙÂÚÔ ÛÙ· ·È‰È¿ Ì ¿ÊıÔÓË ·ÈÌ¿ÙˆÛË Î·È Â›Ó·È ¯·Ï·Ú¿ Û˘Ó‰Â‰Â̤ÓÔ Ì ÙË ‰È¿Ê˘ÛË. ™¯›˙ÂÙ·È ‰‡ÛÎÔÏ· ÛÙ· ηٿÁÌ·Ù·, ·ÏÏ¿ ·ÔÎÔÏÏ¿Ù·È Â‡ÎÔÏ· Û ·ÚÎÂÙ‹ ¤ÎÙ·ÛË Î·È ÙfiÙÂ Û˘ÌÂÚÈʤÚÂÙ·È Û·Ó ¤Ó· ›‰Ô˜ “ÌÂÓÙÂÛ¤” Ô˘ ‚ÔËı¿ÂÈ ÙËÓ ·Ó¿Ù·ÍË Î·È ÂÌÔ‰›˙ÂÈ ÙË ÌÂÁ¿ÏË ·ÚÂÎÙfiÈÛË ÙˆÓ ÔÛÙÒÓ. ∆Ô ·È‰ÈÎfi ‹ ÂÊË‚ÈÎfi ÔÛÙÔ‡Ó ·Ú¿ÁÂÈ ÒÚÔ Û ÌÂÁ·Ï‡ÙÂÚË ÔÛfiÙËÙ· ·fi ÙÔÓ ÂÓ‹ÏÈÎÔ. ∆· ȉȷ›ÙÂÚ· ÛÙÔȯ›· Ô˘ Û˘Ó·ÓÙ¿Ì ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÛÎÂÏÂÙfi Â›Ó·È Ô Û˘˙¢ÎÙÈÎfi˜ ¯fiÓ‰ÚÔ˜ Î·È ÔÈ ÂÈÊ˘ÛÈ·ÎÔ› ˘Ú‹Ó˜ (3). O Û˘˙¢ÎÙÈÎfi˜ ¯fiÓ‰ÚÔ˜ ¤¯ÂÈ ÂÏ·ÛÙÈÎfiÙËÙ· Ô˘ ÂÈÙÚ¤ÂÈ Ôχ ÌÈÎÚ‹ ΛÓËÛË Ù˘ Â›Ê˘Û˘ ÚÔ˜ ÙË ÌÂÙ¿Ê˘ÛË. ªÈÎÚfi˜ ÂÚÂıÈÛÌfi˜ ÙÔ˘ Û˘˙¢ÎÙÈÎÔ‡ ¯fiÓ‰ÚÔ˘ ÚÔηÏ› ·‡ÍËÛË Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ÔÛÙÔ‡, ÂÓÒ Ë Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÚÔηÏ› ÚÒÈÌË Û‡ÁÎÏÈÛË Ù˘ Â›Ê˘Û˘ Î·È ·Ó·ÛÙÔÏ‹ Ù˘ ·Ó¿Ù˘Í˘. ŒÓ·˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ú‹ÍË Û˘Ó‰¤ÛÌÔ˘ ÛÙÔÓ ÂÓ‹ÏÈÎÔ, ÛÙÔ ·È‰› ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÈÊ˘ÛÈfiÏ˘ÛË, ÁÈ·Ù› Ô Û˘˙¢ÎÙÈÎfi˜ ¯fiÓ‰ÚÔ˜ Â›Ó·È Ô ÈÔ ·‰‡Ó·ÌÔ˜. ∏ ÂÈÊ˘ÛÈfiÏ˘ÛË Û˘Ì‚·›ÓÂÈ ÌÂٷ͇ Ù˘ ÛÙÈ‚¿‰·˜ ÙˆÓ ˘ÂÚÙÚÔÊÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ ˙ˆÓÒÓ ÔÛÙ¤ˆÛ˘, ·ÏÏ¿ ·Ôηı›ÛÙ·Ù·È ÈÔ ÁÚ‹ÁÔÚ· ·fi ¤Ó· οٷÁÌ·. ∏ ÂÈÊ˘ÛÈfiÏ˘ÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· Î·È ÙËÓ Î·Ù‡ı˘ÓÛË Ô˘ ‰Ú· Ë ‚›·.
¶›Ó·Î·˜ 1. ¶·Ú¿ÁÔÓÙ˜ ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ ∞ÙÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜ - ™Ù¿‰ÈÔ ·Ó¿Ù˘Í˘ - ∞Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ - ŒÏÏÂÈ„Ë ÈÛÔÚÚÔ›·˜ Ì˘ÒÓ, ÙÂÓfiÓÙˆÓ - æ˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, ·ÚÔÛÂÍ›· - ¶·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ
∂͈ÙÂÚÈÎÔ› ·Ú¿ÁÔÓÙ˜ - ™Ê¿ÏÌ·Ù· ÚÔfiÓËÛ˘ ‹ Ù¯ÓÈ΋˜ - ∞ηٿÏÏËÏÔ˜ ‹ ÂÈΛӉ˘ÓÔ˜ ·ıÏËÙÈÎfi˜ ¯ÒÚÔ˜ - ™Ê¿ÏÌ·Ù· ‰È·ÙÚÔÊ‹˜, ¤ÏÏÂÈ„Ë Ca - ¶ÔÏÈÙÈÛÙÈÎÔ›, ÎÔÈÓˆÓÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜
∫·ÎÒÛÂȘ ∫¿ÎˆÛË ÔÓÔÌ¿˙ÂÙ·È Ë ‚Ï¿‚Ë ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÌÂÛË ‹ ¤ÌÌÂÛË ‚›·. OÈ Î·ÎÒÛÂȘ, ·Ó¿ÏÔÁ· Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÈÎÔÈÓˆÓ›·˜ ÙˆÓ ÈÛÙÒÓ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ, ‰È·ÎÚ›ÓÔÓÙ·È Û ÎÏÂÈÛÙ¤˜ Î·È ·ÓÔÈÎÙ¤˜ ·Ó¿ÏÔÁ· Ì ÙË ‰È¿ÚÎÂÈ·
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¶·È‰È·ÙÚÈ΋ 2001;64:436-440
ÂÊ·ÚÌÔÁ‹˜ Ù˘ ¤ÓÙ·Û˘ Ù˘ ‚›·˜ (3). ∏ οΈÛË ·fi ˘¤Ú¯ÚËÛË (overuse) ÔÊ›ÏÂÙ·È Û ̷ÎÚÔ¯ÚfiÓÈ· ¿ÛÎËÛË Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓË ÌÈÎÚ‹˜ ¤ÓÙ·Û˘ ‚›· Ô˘ ηٷÔÓ› ÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÚÔηÏ› ‚Ï¿‚˜ ÛÙÔ ÛÎÂÏÂÙfi ‹ Ù· ̷Ϸο ÌfiÚÈ· (¶›Ó·Î·˜ 2). ∏ ÙÚ·˘Ì·ÙÈ΋ οΈÛË ÔÊ›ÏÂÙ·È Û ÛÙÈÁÌÈ·›· ÂÊ·ÚÌÔÁ‹ ‚›·˜ ÛÙ· ̷Ϸο ÌfiÚÈ· Î·È ÛÙÔ ÛÎÂÏÂÙfi (¶›Ó·Î·˜ 3). ∫·ÎÒÛÂȘ ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÓÙfiÈÛË (4) ∞) ™˘Ó‰ÂÛÌÈΤ˜ ηÎÒÛÂȘ: ™˘Ó‹ıË ·›ÙÈ· Â›Ó·È Ù· ÙÚ·‡Ì·Ù·, Ë ˘¤Ú¯ÚËÛË, Ë ˘ÂÚÚÔfiÓËÛË. ¢È·ÎÚ›ÓÔÓÙ·È Û 1Ô˘ ‚·ıÌÔ‡ (‰È¿Ù·ÍË ‹ Ú‹ÍË ÂÏ¿¯ÈÛÙˆÓ ÈÓÒÓ), 2Ô˘ ‚·ıÌÔ‡ (ÌÂÚÈ΋ Ú‹ÍË ÙˆÓ Û˘Ó‰¤Û̈Ó) Î·È 3Ô˘ ‚·ıÌÔ‡ (Ï‹Ú˘ Ú‹ÍË ÙˆÓ Û˘Ó‰¤Û̈Ó). µ) ª˘˚Τ˜ ηÎÒÛÂȘ: ∫·Ï‡ÙÔ˘Ó ÙÔ 10-30% ÙˆÓ ·ıÏËÙÈÎÒÓ Î·ÎÒÛˆÓ. ¶ÔÏϤ˜ ÊÔÚ¤˜ Â›Ó·È ÂÈΛӉ˘Ó˜, Û˘Ó‹ıˆ˜, fï˜, ÂÈÙÚ¤Ô˘Ó ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ·ıÏËÙÒÓ. °) ∫·ÎÒÛÂȘ ÙÂÓfiÓÙˆÓ: ™˘Ó‹ıË ·›ÙÈ· Â›Ó·È Ë ˘¤Ú¯ÚËÛË Î·È Ù· ÙÚ·‡Ì·Ù·. ¢È·ÎÚ›ÓÔÓÙ·È ÛÂ: ·) ÙÂÓÔÓÙ›Ùȉ· Î·È ÙÂÓÔÓÙÔÂÏ˘ÙÚ›Ùȉ·, ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ù¤ÓÔÓÙ· Î·È ÙÔ˘ ÔÚÔÁfiÓÔ˘ ÂχÙÚÔ˘, ·ÓÙ›ÛÙÔȯ· Î·È ‚) Ú‹ÍÂȘ ÙÂÓfiÓÙˆÓ (ÌÂÚÈ΋ ‹ Ï‹Ú˘ Ú‹ÍË ÙÂÓfiÓÙÈˆÓ ÈÓÒÓ). ¢) ¢È¿ÛÙÚÂÌÌ·: ∂›Ó·È Ë ‚›·ÈË ‰È¿Ù·ÛË Û˘Ó‰¤ÛÌˆÓ Î·È ı‡Ï·Î· Ù˘ ¿ÚıÚˆÛ˘ Ô˘ Û˘Óԉ‡ÂÙ·È Û˘¯Ó¿ ·fi Ú‹ÍÂȘ ‰È¿ÊÔÚÂÙÈ΋˜ ¤ÎÙ·Û˘ Î·È ‚·Ú‡ÙËÙ·˜. ¢È·ÎÚ›ÓÂÙ·È Û 1Ô˘ ‚·ıÌÔ‡ (ÂÏ·ÊÚ‡ ‰È¿ÛÙÚÂÌÌ· Ì ÂÏ¿¯ÈÛÙË Ú‹ÍË Û˘Ó‰¤ÛÌˆÓ ÈÓÒÓ), 2Ô˘ ‚·ıÌÔ‡ (̤Û˘ ‚·Ú‡ÙËÙ·˜, ÌÂÚÈ΋ Ú‹ÍË ÙˆÓ Û˘Ó‰¤ÛÌˆÓ Î·È ÙÔ˘ ı‡Ï·Î· Ù˘ ¿ÚıÚˆÛ˘) Î·È 3Ô˘ ‚·ıÌÔ‡ (‚·Ú‡ ‰È¿ÛÙÚÂÌÌ·, Ï‹Ú˘ Ú‹ÍË ÙˆÓ Û˘Ó‰¤ÛÌˆÓ Î·È ÙÔ˘ ı‡Ï·Î· Ù˘ ¿ÚıÚˆÛ˘). ∂) ∂Í¿ÚıÚËÌ·: ∂›Ó·È Ë Ï‹Ú˘ Î·È ÌfiÓÈÌË ·ÚÂÎÙfiÈÛË ÙˆÓ ·ÚıÚÈÎÒÓ ÂÈÊ·ÓÂÈÒÓ. ¢È·ÎÚ›ÓÂÙ·È ÛÂ: ·) ηı’ ¤ÍÈÓ ÂÍ¿ÚıÚËÌ· - ·ӷϷ̂·ÓfiÌÂÓÔ ÂÍ¿ÚıÚËÌ· Î·È ‚) ˘ÂÍ¿ÚıÚËÌ· Ì ÌÂÚÈ΋ Î·È ÌfiÓÈÌË ·ÚÂÎÙfiÈÛË ÙˆÓ ·ÚıÚÈÎÒÓ ÂÈÊ·ÓÂÈÒÓ. ∫·ÎÒÛÂȘ ÔÛÙÒÓ (3) ∞) ∞ÔÊ˘Û›Ùȉ· (ÊÏÂÁÌÔÓ‹ ÛÙ· ÛËÌ›· ÚfiÛÊ˘Û˘ ÙˆÓ Ì˘ÒÓ Î·È ÛÙÔ˘˜ ÂÈÊ˘ÛÈ·ÎÔ‡˜ ˘Ú‹Ó˜ ÔÛÙÒÓ). µ) ∫·Ù¿ÁÌ·Ù· (·ÔÙÂÏÔ‡Ó Ì¤¯ÚÈ Î·È ÙÔ 82% ÙˆÓ Î·ÎÒÛÂˆÓ ÙˆÓ ÔÛÙÒÓ ÛÙ· ·È‰È¿). ¶›Ó·Î·˜ 2. ™˘Ó‹ıÂȘ ηÎÒÛÂȘ (·fi ˘ÂÚ¯ÚËÛ›·-overuse) (4) 1. 2. 3. 4. 5. 6. 7.
∆ÂÓÔÓÙ›Ùȉ· ∂ÈÎÔÓ‰˘Ï›Ùȉ· ÃÔÓ‰ÚÔÌ·Ï¿Î˘ÓÛË ∆ÂÓÔÓÙÔÂÏ˘ÙÚ›Ùȉ· ∞ÔÊ˘Û›Ùȉ· Oͤ· ηٿÁÌ·Ù· OÛÙÂÔ¯ÔÓ‰Ú›Ùȉ·
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¶›Ó·Î·˜ 3. ∆Ú·˘Ì·ÙÈΤ˜ ηÎÒÛÂȘ (4) 1. ƒ‹ÍÂȘ Ì˘ÒÓ 2. ƒ‹ÍÂȘ Û˘Ó‰¤ÛÌˆÓ 3. ƒ‹ÍÂȘ ÙÂÓfiÓÙˆÓ 4. ƒ‹ÍÂȘ ÓÂ‡ÚˆÓ 5. ∂Í·ÚıÚ‹Ì·Ù· 6. Oͤ· ηٿÁÌ·Ù·
∆·ÍÈÓÔÌÔ‡ÓÙ·È, ·Ó¿ÏÔÁ· Ì ÙËÓ Î·Ù‡ı˘ÓÛË, Û ÂÁοÚÛÈ·, ÏÔÍ¿, ÛÂÈÚÔÂȉ‹ Î·È ÙÔÍÔÂȉ‹ (bend), Û˘ÓÙÚÈÙÈο (Â›Ó·È Û¿ÓÈ· ÛÙ· ·È‰È¿ ÁÈ·Ù› ̤ÚÔ˜ Ù˘ ‰‡Ó·Ì˘ Íԉ‡ÂÙ·È ÛÙËÓ Î¿Ì„Ë ÙˆÓ ÔÛÙÒÓ), Ù‡Ô˘ ¯ÏˆÚÔ‡ ͇ÏÔ˘ Ì ÁˆÓ›ˆÛË Ì¤¯ÚÈ 45o Î·È Û¿ÛÈÌÔ ÙÔ˘ ÂÓfi˜ ÊÏÔÈÔ‡. ∞Ó¿ÏÔÁˆ˜ Ù˘ ÂÈÎÔÈÓˆÓ›·˜ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ ‰È·¯ˆÚ›˙ÔÓÙ·È Û ÎÏÂÈÛÙ¿ Î·È ·ÓÔȯٿ, ÂÓÒ ·Ó¿ÏÔÁ· Ì ÙËÓ Â¤ÎÙ·ÛË ÚÔ˜ ÙËÓ ¿ÚıÚˆÛË ‰È·ÎÚ›ÓÔÓÙ·È Û Â͈·ÚıÚÈο Î·È ÂÓ‰Ô·ÚıÚÈο. ∆¤ÏÔ˜, Ë Ù·ÍÈÓfiÌËÛË Û ·ÔÛ·ÛÙÈο Î·È Û˘ÌÈÂÛÙÈο (.¯. Ì ه¯ˆÛË ÊÏÔÈÔ‡ ÚÔ˜ Ù· ¤Íˆ Î·È Û‡ÓıÏÈ„Ë ÛÔÁÁÒ‰Ô˘˜, Ôχ Û˘¯Ófi ÛÙËÓ ¿Óˆ ÌÂÙ¿Ê˘ÛË ÙÔ˘ ‚Ú·¯ÈfiÓÈÔ˘ ‹ οو ÌÂÙ¿Ê˘ÛË ÎÂÚΛ‰·˜) Á›ÓÂÙ·È Ì ‚¿ÛË ÙË ‰‡Ó·ÌË ÂÏ΢ÛÌÔ‡ ‹ Û˘Ì›ÂÛ˘. π‰È·›ÙÂÚÔÈ Ù‡ÔÈ Î·ÎÒÛÂˆÓ ÛÙ· ·È‰È¿ (3) ∞) ∂ÈÊ˘ÛÈÔχÛÂȘ: ∞ÊÔÚÔ‡Ó ÙËÓ Â›Ê˘ÛË Î·È ÙÔ Û˘˙¢ÎÙÈÎfi ¯fiÓ‰ÚÔ. ™Â ÂÚ›ÙˆÛË ÂÈÊ˘ÛÈfiÏ˘Û˘ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È Ù· ÂÈÊ˘Ûȷο ·ÁÁ›· Î·È ¤¯Ô˘Ì ¿ÛËÙË Ó¤ÎÚˆÛË ÙÔ˘ Û˘˙¢ÎÙÈÎÔ‡ ¯fiÓ‰ÚÔ˘ Î·È Ù˘ Â›Ê˘Û˘. ∞ÔÙÂÏÔ‡Ó ÙÔ 15% ÙˆÓ Î·ÎÒÛÂˆÓ ÙˆÓ ÔÛÙÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. µ) ∂Ò‰˘ÓÔ˜ ÚËÓÈÛÌfi˜: ∂›Ó·È Û˘¯Ófi˜ Û ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ ÌÂÙ¿ ·fi ‚›·ÈÔ ÙÚ¿‚ËÁÌ· ÙˆÓ ¯ÂÚÈÒÓ, ÙË ÛÙÈÁÌ‹ Ô˘ Ô ·ÁÎÒÓ·˜ Â›Ó·È Û ¤ÎÙ·ÛË Î·È ÙÔ ·ÓÙÈ‚Ú¿¯ÈÔ Û ÚËÓÈÛÌfi. ∞˘Ùfi Ô˘ ÚÔηÏ› Û˘Ó‹ıˆ˜ Â›Ó·È ÙÔ ˘ÂÚÂÍ¿ÚıÚËÌ· Ù˘ ÎÂÊ·Ï‹˜ Ù˘ ÎÂÚΛ‰·˜. ™˘Ó‹ı˘ ·ÈÙ›· ›ӷÈ, ÁÈ· ·Ú¿‰ÂÈÁÌ·, Ë ÂÚ›ÙˆÛË ÙÔ˘ ·È‰ÈÔ‡ Ô˘ ÎÚ·ÙÈ¤Ù·È Ì ÙÂٷ̤ÓÔ ¯¤ÚÈ ·fi ÙÔ Û˘ÓÔ‰fi ÙÔ˘ Î·È ÛÎÔÓÙ¿ÊÙÂÈ. °) ¡fiÛÔ˜ Legg Calvè Perthes (3): H ÓfiÛÔ˜ ·˘Ù‹ ÛËÌ·›ÓÂÈ Ó¤ÎÚˆÛË ÙÔ˘ ÌËÚÈ·›Ô˘. ∏ ÚfiÏË„Ë Á›ÓÂÙ·È Ì ·ÔÊ˘Á‹ ·Ó‡„ˆÛ˘ ‚¿ÚÔ˘˜ Î·È ·¯˘Û·ÚΛ·˜, Û˘¯Ó‹ Û ·ÁfiÚÈ· - ·ıÏËÙ¤˜ Î·È ÌË ·ıÏËÙ¤˜ - Û˘Ó‹ıˆ˜ ¯·ÌËÏÔ‡ ÎÔÈÓˆÓÈÎÔ‡ ÂȤ‰Ô˘. ∏ ·fiÙÔÌË Û‡Û·ÛË ÙÔ˘ Ì˘fi˜, Ô˘ ÌÔÚ› .¯. Ó· Á›ÓÂÈ ÛÙÔ spaggato (ÁÓˆÛÙfi ›‰Ô˜ ¿ÛÎËÛ˘ ÛÙË Ú˘ıÌÈ΋ Î·È ÂÓfiÚÁ·ÓË Á˘ÌÓ·ÛÙÈ΋), ÌÔÚ› Ó· ÂÈʤÚÂÈ ÙËÓ ·fiÛ·ÛË Ù˘ Â›Ê˘Û˘, fiˆ˜ .¯. ÛÙÔ ÎÓËÌÈ·›Ô ·Úو̷ Î·È ÛÙÔ Ì›˙ÔÓ· ÙÚÔ¯·ÓÙ‹Ú·. ∞ÔÛ·ÛÙÈο ηٿÁÌ·Ù· ∏ ·fiÙÔÌË Û‡Û·ÛË ÙÔ˘ Ì˘fi˜, Ô˘ ÌÔÚ› Ó· Á›ÓÂÈ .¯. ÛÙÔ spaggato ÙˆÓ ·ıÏËÙÚÈÒÓ ¯ÔÚÔ‡, Ú˘ıÌÈ΋˜ Î·È ÂÓfiÚÁ·Ó˘, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÔÛ·ÛÙÈÎfi οٷÁÌ·. ∏ Û˘Ó‹ı˘ ÂÓÙfiÈÛË Â›Ó·È
¶·È‰È·ÙÚÈ΋ 2001;64:436-440
ÛÙÔ ÎÓËÌÈ·›Ô ·Úو̷ Î·È Ì›˙ÔÓ· ÙÚÔ¯·ÓÙ‹Ú· Î.Ï. ∫·Ù¿ÁÌ·Ù· ÎfiˆÛ˘ ∆· ηٿÁÌ·Ù· ÎfiˆÛ˘ ¤¯Ô˘Ó ‰È¿ÊÔÚ· Û˘ÌÙÒÌ·Ù·, fiˆ˜ .¯. fiÓÔ ÛÙÔ ÌÂÁ¿ÏÔ ‰¿ÎÙ˘ÏÔ Î·È ·‰˘Ó·Ì›· ÛÙ‹ÚÈ͢ ÛÙÔ ¿ÎÚÔ fi‰È. ™Â ·ıÏ‹ÙÚÈ· ̷ϤÙÔ˘ ÌÔÚ› Ó· ÛËÌ·›ÓÂÈ Î¿Ù·ÁÌ· ÛËÛ·ÌÔÂȉԇ˜ ÔÛÙÔ‡ Ù˘ ¿ÚıÚˆÛ˘. ∞ÈÙ›· Â›Ó·È Ë ˘ÂÚ¯ÚËÛ›· Î·È Ë Î·Ù·fiÓËÛË. ∆· ηٿÁÌ·Ù· ÎfiˆÛ˘ Û˘Ó‹ıˆ˜ Û˘Ì‚·›ÓÔ˘Ó ÙËÓ ¿ÓÔÈÍË, ÌÂÙ¿ ·fi ÙËÓ ·‰Ú¿ÓÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ· Î·È ÙËÓ Â·Ó·‰Ú·ÛÙËÚÈÔÔ›ËÛË. ™˘Ó‹ı˘ ÂÓÙfiÈÛË Â›Ó·È ÛÙÔ ¿Óˆ ÙÚÈÙ‹ÌÔÚÈÔ ÎÓ‹Ì˘, ÛÙÔ Î¿Ùˆ ÙÚÈÙËÌfiÚÈÔ ÂÚfiÓ˘, ÛÙ· ÌÂٷٿÚÛÈ·, ÛÙÔÓ ·˘¯¤Ó· ÌËÚÈ·›Ô˘ Î.Ï. ¶·ıÔÏÔÁÈο ηٿÁÌ·Ù· (3) ∞›ÙÈ· ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÁÌ¿ÙˆÓ ÌÔÚ› Ó· Â›Ó·È ÙÔ ›ÓˆÌ·, Ë ÌÔÓ‹Ú˘ ·ÛÙË, Ë ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ‹ ·ÙÂÏ‹˜ ÔÛÙÂÔÁ¤ÓÂÛË. ¶ÚfiÏË„Ë ∏ ÚfiÏË„Ë ÙˆÓ Î·ÎÒÛÂˆÓ Î·È Î˘Ú›ˆ˜ ÙˆÓ ·ıÏËÙÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ Á‹Â‰Ô ‹ ÛÙÔ Û¯ÔÏÂ›Ô Â›Ó·È ·Ó·Áη›·. ™Â ÚfiÛÊ·ÙË ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÛÙÔ Ì¿ıËÌ· Ù˘ Á˘ÌÓ·ÛÙÈ΋˜ ÛÙË Ì¤ÛË Âη›‰Â˘ÛË Î·È ÂÚÈÂÏ¿Ì‚·Ó 122 Á˘ÌÓ·ÛÙ¤˜ Î·È ¤Ó· Û‡ÓÔÏÔ 274 ÂÚÈÛÙ·ÙÈÎÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ Î¿ı Á˘ÌÓ·ÛÙ‹˜ ¤¯ÂÈ 1,12 ·Ù˘¯‹Ì·Ù· ÂÙËÛ›ˆ˜ ηٿ ̤ÛÔ fiÚÔ. ∆· ÔÚıÔ‰Èο ‹Ù·Ó Ù· Û˘¯ÓfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ηٿ 75%. ∆· ·›ÙÈ· ‹Ù·Ó Ë ·ÚÔÛÂÍ›· Û ÔÛÔÛÙfi 25%, ÙÔ ÛÚÒÍÈÌÔ Û ÔÛÔÛÙfi 22% Î·È Ô ·Î·Ù¿ÏÏËÏÔ˜ ¯ÒÚÔ˜ Á‡ÌÓ·Û˘ Û ÔÛÔÛÙfi 35% (5). ∏ ÚfiÏË„Ë Á›ÓÂÙ·È Î˘Ú›ˆ˜: ∞) Û ÂÚÈÙÒÛÂȘ ÙÚ·˘Ì¿ÙˆÓ ÏfiÁˆ ηÎÒÓ ÌÂÙˆÚÔÏÔÁÈÎÒÓ Û˘ÓıËÎÒÓ, ηÎÔ‡ ʈÙÈÛÌÔ‡, ÌÂÁ¿ÏÔ˘ Û˘Á¯ÚˆÙÈÛÌÔ‡, ÂÎÙ˘ÊψÙÈÎÔ‡ ‹ÏÈÔ˘, ·Ó·ÚÎÔ‡˜ ÂÍ·ÂÚÈÛÌÔ‡, ˘ÁÚ·Û›·˜ (¤ˆ˜ 90%), ‰˘Ó·ÙÔ‡ ·¤Ú· Î·È ‚ÚÔ¯‹˜. µ) Û ÙÚ·‡Ì·Ù· ÏfiÁˆ ηÎÔ‡ ˘ÏÈÎÔÙ¯ÓÈÎÔ‡ ÂÍÔÏÈÛÌÔ‡ Î·È Î˘Ú›ˆ˜ ·Î·Ù¿ÏÏËÏˆÓ ˘Ô‰ËÌ¿ÙˆÓ. ∆Ô ·ıÏËÙÈÎfi ·Ô‡ÙÛÈ Ú¤ÂÈ Ó· ¤¯ÂÈ Ì·Ï·Îfi ÂÛˆÙÂÚÈÎfi, ¯·Ï·Ú¿ ÎÔÚ‰fiÓÈ· Î·È Î˘Ú›ˆ˜ ÛÎÏËÚfi ÙÔ ›Ûˆ ̤ÚÔ˜ ÁÈ· Ó· ÚÔÛٷهÂÙ·È Ë ÊÙ¤ÚÓ·. °) Ì ¯Ú‹ÛË ·ÙÔÌÈÎÒÓ Ì¤ÙÚˆÓ ÚÔÛÙ·Û›·˜ (4), fiˆ˜ ÎÚ¿ÓË (Ì˯·ÓÔΛÓËÙÔ˜ ·ıÏËÙÈÛÌfi˜, TAE KWO DO, ¯fiθ, ÛÎÈ), Ì ÚÔÛÙ·Û›· ÚÔÛÒÔ˘, ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ (Ô‰fiÛÊ·ÈÚÔ, Ú¿ÁÌ˘, ¯fiθ) Î·È ·ÚıÚÒÛÂˆÓ Ì ÂȉÈΤ˜ Ù·Èӛ˜ Î·È ÂÚȯÂÈÚ›‰Â˜, Ì ÔÚıˆÙÈο Û˘ÛÙ‹Ì·Ù· Î·È ÂȉÈΤ˜ ÌfiÙ˜ Ì ›‰ÂÛË Ù˘ Ô‰ÔÎÓËÌÈ΋˜. ¢) Ì ȷÙÚÈÎfi ¤ÏÂÁ¯Ô (ÎÏÈÓÈÎfi˜, ÂÚÁ·ÛÙËÚÈ·Îfi˜ Î·È ÂÎÙ›ÌËÛË ÙÔ˘ ÛÙ·‰›Ô˘ ·Ó¿Ù˘Í˘). ∂) Ì ÚÔı¤ÚÌ·ÓÛË Î·È ÛˆÛÙ‹ ÚÔfiÓËÛË.
Paediatriki 2001;64:436-440
∞ÓÙÈÌÂÙÒÈÛË °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË, ÁÂÓÈο, ¯ÚÂÈ¿˙ÂÙ·È ÌÂÁ¿ÏË ÂÌÂÈÚ›· ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡ Î·È Î·Ù·ÁÚ·Ê‹ ·Ù˘¯ËÌ¿ÙˆÓ Î·ÎÒÛÂˆÓ Ì ÙË ‚Ô‹ıÂÈ· Ù˘ ÛÙ·ÙÈÛÙÈ΋˜ (ˆ˜ ·Ú¿‰ÂÈÁÌ· ı· ·Ó·Ê¤ÚÔ˘Ì ¤Ó· ÔÌ·‰ÈÎfi Î·È ¤Ó· ·ÙÔÌÈÎfi ¿ıÏËÌ·): ∫·Ï·ıÔÛÊ·›ÚÈÛË: ™Â ¤Ú¢ӷ Ô˘ ¤ÁÈÓ Û 243 Ó·ڤ˜ ·ıÏ‹ÙÚȘ ηϷıÔÛÊ·›ÚÈÛ˘ ÙÔ 1990, ηٷÁÚ¿ÊËÎÂ Ë ÂÍ‹˜ ÛÂÈÚ¿ ÙˆÓ Î·ÎÒÛˆÓ: ‰È¿ÛÙÚÂÌÌ· 78%, ÂÍ¿ÚıÚËÌ· 10%, ηٿÁÌ·Ù· 6,5%, ıÏ¿ÛË Ì˘ÒÓ 4%. ∏ ÂÓÙfiÈÛË ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ‚Ï·‚ÒÓ ‹Ù·Ó ÛÙËÓ Ô‰ÔÎÓËÌÈ΋ Û ÔÛÔÛÙfi 60% (5). ƒ˘ıÌÈ΋ Á˘ÌÓ·ÛÙÈ΋: ™Â 39 ·ıÏ‹ÙÚȘ ÙÔ˘ ¿ıÏËÌ·ÙÔ˜ ·˘ÙÔ‡, ›¯·Ì ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ηÎÒÛÂȘ ÛÙ· ¿ÏÌ·Ù· Ì ÔÛÔÛÙfi 44%, ÛÙÔ spaggato 74%, ˘ÂÚÂÎÙ¿ÛÂȘ 16%, ÚÂÏ‚¤ 15% (7). ∫ÔÈÓfi ÛËÌÂ›Ô ·Ù˘¯ËÌ¿ÙˆÓ Û fiÏ· Ù· ·ıÏ‹Ì·Ù· Â›Ó·È Ë ·Ó·Ú΋˜ ÚÔı¤ÚÌ·ÓÛË, ÂÓÒ Ë ËÏÈΛ· Ì ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ıˆÚÂ›Ù·È ÙÔ ÂÓ‰¤Î·ÙÔ ‹ ‰¤Î·ÙÔ ÙÚ›ÙÔ ¤ÙÔ˜. ∂ȉÈÎfiÙÂÚ·, Ú¤ÂÈ Ó· ‰›ÓÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙ· ·ÎfiÏÔ˘ı· ÛËÌ›· (8): ·) ∏ ·ÓÙÈÌÂÙÒÈÛË ÛÙ· ηٿÁÌ·Ù· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÁηÈÚ· ÚÈÓ Û¯ËÌ·ÙÈÛÙ› ÒÚÔ˜ ηÈ, fiÙ·Ó ¯ÚÂÈ·ÛÙ›, Ó· ÂÊ·ÚÌÔÛÙ› Ô Î·Ù¿ÏÏËÏÔ˜ Á‡„ÈÓÔ˜ ›‰ÂÛÌÔ˜ (8). ‚) ™Ù· ηٿÁÌ·Ù· Ù‡Ô˘ ¯ÏˆÚÔ‡ ͇ÏÔ˘, Û¿˙Ô˘ÌÂ Î·È ÙÔÓ ¿ÏÏÔ ÊÏÔÈfi ÁÈ· Ó· Ù· οÓÔ˘Ì ٤ÏÂÈ· ηٿÁÌ·Ù· Î·È ÌÂÙ¿ Ó· Ù· ¢ı˘ÁÚ·ÌÌ›ÛÔ˘Ì (3). Á) OÈ ÂÈÊ˘ÛÈÔχÛÂȘ ·Ó·Ù¿ÛÛÔÓÙ·È Î·Ù’ ·Ú¯¿˜ Û˘ÓÙËÚËÙÈο Î·È ¤ÁηÈÚ· Ì ‹ÈÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, ÁÈ· Ó· ÌË Á›ÓÂÈ Û‡˙¢ÍË ÙÔ˘ Û˘˙¢ÎÙÈÎÔ‡ ¯fiÓ‰ÚÔ˘. ∂Á¯ÂÈÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ··ÈÙÂ›Ù·È ÌfiÓÔ Û ÂÚ›ÙˆÛË ·Ó¿Á΢. ∏ ÚÒÈÌË ÎÈÓËÙÔÔ›ËÛË ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÛÙ· ·È‰È¿, ÁÈ·Ù› Ú¤ÂÈ Ó· ıÂڷ¢ÙÔ‡Ó ÚÒÙ· Ù· ̷Ϸο ÌfiÚÈ·. ∏ Ê˘ÛÈÔıÂڷ›· ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË ÛÙ· ·È‰È¿ (3). ∞·ÈÙÂ›Ù·È ·Ó¿ÚÚÔË ı¤ÛË ÙÔ˘ ̤ÏÔ˘˜ ÁÈ· Ó· ʇÁÂÈ ÙÔ Ô›‰ËÌ· Î·È Â›Û˘ Ù·ÎÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ÙÔ Î¿Ù·ÁÌ·. ¶ÚÔÙÚ¤Ô˘Ì ÙÔ ·È‰› Ó· ÎÔ˘Ó¿ Ù· ‰¿ÎÙ˘Ï· Û˘¯Ó¿. ¶ÚÒÙË ¤Ó‰ÂÈÍË ÈÛ¯·ÈÌ›·˜ Â›Ó·È ÔÈ ÂÒ‰˘Ó˜, Û ÌÂÁ¿ÏÔ ‚·ıÌfi, ·ıËÙÈΤ˜ ÂÎÙ¿ÛÂȘ ‰·ÎÙ‡ÏˆÓ Ô˘ ··ÈÙÔ‡Ó ¿ÌÂÛË ‰È¿ÓÔÈÍË ÙÔ˘ Á‡„ÈÓÔ˘ Âȉ¤ÛÌÔ˘. O fiÓÔ˜ ÛÙÔ ·È‰› Á›ÓÂÙ·È Ô‰ËÁfi˜ ÛÙȘ ÎÈÓ‹ÛÂȘ ÙÔ˘ Î·È ÛÙË ÛÙ·‰È·Î‹ ·ÔηٿÛÙ·ÛË Ù˘ οΈÛ˘. ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÚfiÏË„Ë Â›Ó·È ··Ú·›ÙËÙË ·ÏÏ¿ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ıÏËÙÈÎÒÓ Î·ÎÒÛÂˆÓ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ú¤ÂÈ Ó· Â›Ó·È ¤ÁηÈÚË Î·È Ó· Á›ÓÂÙ·È ÌfiÓÔ ·fi ÂȉÈÎfi, ηıÒ˜ ÙÔ Ì¤ÏÏÔÓ Ù˘ ÎÔÈÓˆÓ›·˜ Î·È ÙÔ˘ ·ıÏËÙÈÛÌÔ‡ ·Ó‹ÎÂÈ Û ·˘Ù‹ ÙËÓ ËÏÈΛ·.
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µÈ‚ÏÈÔÁÚ·Ê›· 1. Saderi G, McCann P, Bruno P. Sports Medicine. In: Principles of Primary care. St Louis Missouri: Mosby; 1997. p. 413-446. 2. ∆ÛÈÏÈÁÎÈÚfiÁÏÔ˘-º·¯·ÓÙ›‰Ô˘ ∞. AÓ·ÙÔÌ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÛÒÌ·ÙÔ˜. £ÂÛÛ·ÏÔÓ›ÎË: University Press; 1989. 3. ¡ÂÓÔÔ‡ÏÔ˘ ™. ∫·ÎÒÛÂȘ ÔÛÙÒÓ Î·È ·ÚıÚÒÛÂˆÓ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÛÎÂÏÂÙfi. £ÂÛÛ·ÏÔÓ›ÎË: University Press; 1985. 4. M·ÛΛÚÔÊ. ∞ıÏËÙÈ΋ ÙÚ·˘Ì·ÙÈÔÏÔÁ›·. ∂ΉfiÛÂȘ SALTO; 1990. 5. TÛÈÏÈÁÎÈÚfiÁÏÔ˘-º·¯·ÓÙ›‰Ô˘ ∞, °¿ÏÏÔ˜ °, ¶··‰ÔÔ‡ÏÔ˘ ™, ¶·ÈÔÓ›‰Ë˜ ∞. ∆41Ô˜ ∆2Ô˜ 1999:214-220. 6. Tsoyknika E, Abatzidis G, Galitzanos S, Fachantidou A, Deligiannis A. Instituto di Medicina delo Sport Universita di Thessalonik Proceedings. Treviso, πtaly; 1990.
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7. ª·ÏÏÈ·ÚfiÔ˘ÏÔ˜ ¡, ª·ÛÙÚ·ÓÙÒÓË ∞, ª·ÁÈ¿Ù˘ ∫, ∫Ô˘ÁÈÔ˘ÌÙ˙›‰Ë˜ Ã, ∆ÛÈÏÈÁÎÈÚfiÁÏÔ˘-º·¯·ÓÙ›‰Ô˘ ∞, ¢ÂÏËÁÈ¿ÓÓ˘ ∞. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ηÎÒÛÂˆÓ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ·ıÏ‹ÙÚȘ ̷ϤÙÔ˘ Î·È Ú˘ıÌÈ΋˜ Á˘ÌÓ·ÛÙÈ΋˜. ¶Ú·ÎÙÈο ÙÔ˘ 6Ô˘ µÔÚÂÈÔÂÏÏ·‰ÈÎÔ‡ π·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 1991. 8. ∞Ó‰ÚÔ˘Ï¿Î˘ °, ¢ËÌËÙÚÈ¿‰Ë˜ ¢. ™‡Á¯ÚÔÓÔ˜ Ô‰ËÁfi˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∑‹Ù·; 1996.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÕÓÓ· ∆ÛÈÏÈÁÎÈÚfiÁÏÔ˘-º·¯·ÓÙ›‰Ô˘ ¶. ¶. °ÂÚÌ·ÓÔ‡ 14, 546 22, £ÂÛÛ·ÏÔÓ›ÎË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· H ·ÈÙÈÔÏÔÁ›· ÙˆÓ ÓÂÊÚÈÎÒÓ Ô˘ÏÒÓ Û ‚Ú¤ÊË Ì ˘ÂÏÔÓÂÊÚ›Ùȉ· Î·È Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË1 ™ÎÔfi˜: EÍÂÙ¿ÛÙËΠ·Ó ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (KO¶) Ì ÙËÓ ·ÚÔ˘Û›· ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘ Û ‚Ú¤ÊË ÌÂÙ¿ ·fi ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·. H ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë ÂÎÙÈÌ‹ıËΠ̠ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Ì ¢ÈÌÂÚηÙÔÛÔ˘ÎÈÓÈÎfi Ô͇ (DMSA). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó 74 ‚Ú¤ÊË Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ·, 44 ÎÔÚ›ÙÛÈ· Î·È 30 ·ÁfiÚÈ· (̤ÛË ËÏÈΛ· ηٿ ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ 4.12 Ì‹Ó˜, ‰È¿ÌÂÛË ËÏÈΛ· 3 Ì‹Ó˜). K˘ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ˘¤Ú˯ÔÈ ÓÂÊÚÒÓ (U/S) ¤ÁÈÓ·Ó ÂÓÙfi˜ 6 ‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙËÓ Ô˘ÚÔÏԛ̈ÍË. TÔ DMSA ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ¤ÁÈÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ 4 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ Ô˘ÚÔÏԛ̈ÍË. H ‚Ï¿‚Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÔÚ›ÛÙËΠfiÙ·Ó ˘‹Ú¯·Ó ÂÛÙȷΤ˜ ‹ ÔÏ˘ÂÛÙȷΤ˜ ÂÚÈÔ¯¤˜ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ‹ fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÓfi˜ ÓÂÊÚÔ‡ ÛÙË Û˘ÓÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‹Ù·Ó ÌÈÎÚfiÙÂÚË ·fi 45%. AÔÙÂϤÛÌ·Ù·: TÔ DMSA ÛÈÓıËÚÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ·ÚÔ˘Û›· ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ ÛÙÔ 19% (14/74) ÙˆÓ ·È‰ÈÒÓ. OÈ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ‚Ï¿‚˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÌfiÓÔ fiÙ·Ó Û˘Ó˘‹Ú¯Â KO¶ Î·È fiÙ·Ó Ô ‚·ıÌfi˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ 3Ô˘. ¢ÂÓ ‰È·ÈÛÙÒıËÎ·Ó Â˘Ú‹Ì·Ù· ·fi ÙÔ ·Ú¤Á¯˘Ì· Û 51 ÓÂÊÚÈΤ˜ ÌÔÓ¿‰Â˜ ¯ˆÚ›˜ KO¶, Û 9 Ì KO¶ 1Ô˘ ‚·ıÌÔ‡ Î·È Û 54 Ì KO¶ 2Ô˘ ‚·ıÌÔ‡. BÏ¿‚˜ ÛÙÔ ·Ú¤Á¯˘Ì· ‰È·ÈÛÙÒıËÎ·Ó Û 9/24 ÓÂÊÚÈΤ˜ ÌÔÓ¿‰Â˜ Ì KO¶ 3Ô˘ ‚·ıÌÔ‡, 3/8 Ì KO¶ 4Ô˘ ‚·ıÌÔ‡ Î·È 2/2 Ì KO¶ 5Ô˘ ‚·ıÌÔ‡. ¢ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂÏÏÂÈÌÌ¿ÙˆÓ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì·
440
Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜, ηıÒ˜ Î·È ÙÔ˘ Ù‡Ô˘ ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡, Ù˘ ·ÚÔ˘Û›·˜ ‚·ÎÙËÚÈ·ÈÌ›·˜ ‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ˘ÔÙÚÔÈ·˙Ô˘ÛÒÓ Ô˘ÚÔÏÔÈÌÒ͈Ó. ™˘ÌÂÚ¿ÛÌ·Ù·: ™Â ‚Ú¤ÊË Ì ÔÍ›· ˘ÂÏÔÓÂÊÚ›Ùȉ· Ô˘ ıÂڷ‡ÔÓÙ·È Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÁˆÁ‹, Ë ÓÂÊÚÈ΋ ‚Ï¿‚Ë Èı·ÓfiÓ Ó· ÌËÓ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÊÏÂÁÌÔÓ‹˜, ·ÏÏ¿ Ó· ÔÊ›ÏÂÙ·È Û ̛· ÚÔ¸¿Ú¯Ô˘Û· Û˘ÁÁÂÓ‹ ·ıÔÏÔÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· KO¶. M ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· ·˘Ù¿, ÚÔÙ›ÓÂÙ·È Ó· ÌËÓ Á›ÓÂÙ·È DMSA Û οı ‚Ú¤ÊÔ˜ Ì ԢÚÔÏԛ̈ÍË, ·ÏÏ¿ Ë ¯Ú‹ÛË ÙÔ˘ Ó· ÂÚÈÔÚ›˙ÂÙ·È Û ·È‰È¿ Ì KO¶ 3Ô˘ ‹ ÌÂÁ·Ï‡ÙÂÚÔ˘ ‚·ıÌÔ‡.
1 Goldman M, Bistritzer T, Horne T, Zoareft I, Mordechay A The etiology of renal scars in infants with pyelonephritis and vesicoureteral refux Pediatr Nephrol 2000;14:385-388
KˆÓ/ÓÔ˜ ¢. KÔÏÏÈfi˜ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ KÏÈÓÈ΋ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ
¶PO™EXH ™YNE¢PIA 5-8 ∞˘ÁÔ‡ÛÙÔ˘
European Society for Pediatric Research Congreszon Ltd/ESPR Itälahdenkatu 22A 00210 Helsinki, Finland Fax: +358 9 5840 9555
∂ÏÛ›ÓÎÈ, ºÈÏ·Ó‰›·
2-4 ™ÂÙÂÌ‚Ú›Ô˘
The fetus as a patient: International course ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∫· ¶¤ÓË Ã·Ù˙ËÁˆÚÁ›Ô˘ ∆ËÏ.: 01 7499 312 ¤ˆ˜ 317 Fax: 01 7705 752
πˆ¿ÓÓÈÓ·
9-12 ™ÂÙÂÌ‚Ú›Ô˘
European Asthma Congress Congress Secretariat Dr. T. Slavyanskaya 16/10 Miklukho-Maklaya street Moscow, 117997 Russia Tel.: (++7 -095) 336-5000 & 429-9620 Fax: (++7 -095) 336-5000 E-mail: acicis@ibch.ru Web site: http://www.isir.ru
ªfiÛ¯·, ƒˆÛ›·
9-14 ™ÂÙÂÌ‚Ú›Ô˘
11th International Clinical Genetics Seminar "The Genetics of Diabetes Mellitus" ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∆ËÏ.: 01 7499 300 Fax: 01 7713 795 E-mail: congress@triaenatours.gr
∏Ú¿ÎÏÂÈÔ
9-14 ™ÂÙÂÌ‚Ú›Ô˘
23rd International Congress of Pediatrics ¶ÏËÚÔÊÔڛ˜: Chinese Medical Association 42 Dongsi Xidajie, Beijing 100710, China ∆ËÏ.: 86-10-6527 8804 / 6527 8803 Fax: 86-10-65-123-754 E-mail: 231CP@chinamed.com.cn.
Beijing, ∫›Ó·
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¶PO™EXH ™YNE¢PIA 23-27 ™ÂÙÂÌ‚Ú›Ô˘
World Congress of Perinatal Medicine ¶ÏËÚÔÊÔڛ˜: Santiago Dexeus Font Foundation Paeso Bonanova 67, 08017 Barcelona ∆ËÏ.: +34 (93) 227 4709 Fax: +34 (93) 418 78 32 E-mail: Fundacio@indexus.uab.es
µ·ÚÎÂÏÒÓË, πÛ·Ó›·
2-6 OÎÙˆ‚Ú›Ô˘
IXth Congress of European Society for the study and prevention of infant death ESPID, Prenatal Health Care and Postnatal Development Organizing Secretariat: Figure Congress Organization Ayazmaderesi Cad. Karadut Sk. No: 780888 Dikilitas, Istanbul, Turkey Tel.: +90 212 258 60 20 Fax: +90 212 258 60 78 E-mail: espid@figur.net
∫ˆÓ/ÔÏË, ∆Ô˘ÚΛ·
6-7 OÎÙˆ‚Ú›Ô˘
11Ë ∂ÈÛÙËÌÔÓÈ΋ ∂Ή‹ÏˆÛË ¶·È‰È·ÙÚÈ΋˜ ∆Ô̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ •ÂÓÔ‰Ô¯Â›Ô Du Lac °Ú·ÌÌ·Ù›·: ∆ËÏ.: (0651) 97 546 & 97 544 Fax: (0651) 97 032 Web site: http://www.uoi.gr/conf_sem/
πˆ¿ÓÓÈÓ·
xviii
™YNTOMO°PAºIE™
ABBREVIATIONS
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
AIDS
Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜
AMP, ADP, ATP
ÌÔÓÔ-, ‰È-, ÙÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË
ATPase cal CSF ‹ ENY CNS ‹ ∫¡™ cm CoA cmÑ cm2 cAMP ÆC CRP DNA ECG ‹ ∏∫° EEG ‹ ∏∂° ELISA ESR ‹ ∆∫∂ EDTA g Hct Hb HLA
ÙÚÈʈÛÊ·Ù¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ ıÂÚÌ›‰· ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂηÙÔÛÙfi Û˘Ó¤Ó˙˘ÌÔ ∞ ΢‚ÈÎfi ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢ÎÏÈÎfi AMP ‚·ıÌfi˜ KÂÏÛ›Ô˘ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‰ÂÔ͢ÚÈ‚Ô˙ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤Ó˙˘ÌÔ-Û˘Ó‰¤Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù·¯‡ÙËÙ· ηıÈ˙‹Ûˆ˜ ÂÚ˘ıÚÒÓ Âı˘ÏÂÓԉȷÌÈÓÔÙÂÙÚ·ÔÍÂ˚Îfi Ô͇ ÁÚ·ÌÌ¿ÚÈo ·ÈÌ·ÙÔÎÚ›Ù˘ ·ÈÌÔÛÊ·ÈÚ›ÓË ·ÓÙÈÁfiÓÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜
Ig ICU ‹ ª∂£ IU i.m. ‹ ∂.ª. i.p. ‹ ∂.¶. i.v. ‹ ∂.º. L log mol ªW ‹ MB MCH MCV mRNA m min n N NS ‹ ª™ Ôsm % PCR pH PCO2 PO2 p
·ÓÔÛÔÛÊ·ÈÚ›ÓË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚ο ÂÓ‰ÔÊϤ‚È· Ï›ÙÚÔ(·) ÏÔÁ¿ÚÈıÌÔ˜ ÁÚ·ÌÌÔÌfiÚÈÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ̤ÛË ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÚ˘ıÚÒÓ Ì¤ÛÔ˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ ·ÁÁÂÏÈÔÊfiÚÔ˜ RNA ̤ÙÚÔ ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÙÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·
acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability
xxi
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·
by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9
6
3
2
1
-1
-2
-3
-6
-9
-12
-15
-18
xxii
Combining prefixes T G M k h da d c m Ì n p f a
™˘ÓÙ·ÁÔÁÚ·ÊÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ¢È·ÊËÌÈ˙fiÌÂÓˆÓ ¶ÚÔ˚fiÓÙˆÓ
CECLOR: ¶∂ƒπ§∏æ∏ Ã∞ƒ∞∫∆∏ƒπ™∆π∫ø¡ ¶ƒO´O¡∆O™ ∂N¢EI•EI™: ∆Ô CECLOR® ÂӉ›ÎÓ˘Ù·È ÛÙË ıÂڷ›· ÙˆÓ ·ÎfiÏÔ˘ıˆÓ ÏÔÈÌÒ͈Ó, fiÙ·Ó ·˘Ù¤˜ ÚÔηÏÔ‡ÓÙ·È ·fi Ù· ·Ó·ÊÂÚfiÌÂÓ· ηو٤ڈ ÛÙÂϤ¯Ë ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÂÊfiÛÔÓ ·˘Ù¿ Â›Ó·È Â˘·›ÛıËÙ· Û ·˘Ùfi: §ÔÈÌÒÍÂȘ ÙˆÓ ·ÓˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ. ª¤ÛË ˘Ò‰Ë˜ ˆÙ›Ùȉ·: ÚÔηÏÔ‡ÌÂÓË ·fi S. pneumoniae, H. influenzae, Staphylococci (ÂÍ·ÈÚÔ˘Ì¤ÓˆÓ ÙˆÓ ÛÙÂϯÒÓ Ô˘ Â›Ó·È ·ÓıÂÎÙÈο ÛÙË ÌÂıÈÎÈÏÏ›ÓË), ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ Î·È ª. catarrhalis. º·Ú˘ÁÁ›Ùȉ· Î·È ·Ì˘Á‰·Ï›Ùȉ·, ·fi ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞.¶·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· ·fi ¢·›ÛıËÙ· ÛÙÂϤ¯Ë H. influenzae ( ‚-Ï·ÎÙ·Ì¿ÛË ±), ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞, S. pneumoniae, M. catarrhalis Î·È S. aureus ( ‚-Ï·ÎÙ·Ì¿Û˘ ±). ™ÙË ¯ÚfiÓÈ· ÌÔÚÊ‹ ··ÈÙÂ›Ù·È Û˘Ó‹ıˆ˜ ÚÔÛı‹ÎË Î·È ÂÓfi˜ ¿ÏÏÔ˘ ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ‡ ·Ú¿ÁÔÓÙ·, ‰Ú·ÛÙÈÎÔ‡ ÛÙÔ˘˜ ·Ó·ÂÚfi‚ÈÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜. §ÔÈÌÒÍÂȘ ÙˆÓ Î·ÙˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ: √Í›· ‚ÚÔÁ¯›Ùȉ·, Î·È ÔÍ›˜ ÂÍ¿ÚÛÂȘ ¯ÚfiÓÈ·˜ ‚ÚÔÁ¯›Ùȉ·˜ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿ÛË ±), H. parainfluenzae, M. catarrhalis (‚-Ï·ÎÙ·Ì¿ÛË ±), S. aureus. ¶Ó¢ÌÔÓ›· Û ·ÛıÂÓ›˜ Ù˘ ÎÔÈÓfiÙËÙ·˜ Ô˘ ÚÔηÏÂ›Ù·È ·Ô S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿Û˱) Î·È M. catarrhalis(‚-Ï·ÎÙ·Ì¿Û˱). ªË ÂÈÂÏÂÁ̤Ó˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È Î˘ÛÙ›Ùȉ·˜, (Ì ٷ˘Ùfi¯ÚÔÓË Î¿Ï˘„Ë ÁÈ· Ù· ·Ó·ÂÚfi‚È· ) Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ∂. coli, P. mirabilis, Klebsiella spp. §ÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi Staphylococcus aureus (‚-Ï·ÎÙ·Ì¿Û˱) Î·È ‚-·ÈÌÔÏ˘ÙÈÎÒÓ ÛÙÚÂÙÔÎfiÎÎˆÓ ÔÌ¿‰·˜ ∞. ANTEN¢EI•EI™: °ÓˆÛÙ‹ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙË ÎÂÊ·ÎÏfiÚË Î·È ¿ÏϘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ηıÒ˜ Î·È ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙȘ ÂÓÈÎÈÏϛӘ. ∞¡∂¶π£Àª∏∆∂™ ∂¡∂ƒ°∂π∂™: ∞ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ (‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÏÏÂÚÁ›· Ì ÙȘ ÂÓÈÎÈÏϛӘ10%). ¡·˘Ù›·,¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ÂÈÁ·ÛÙÚÈÎfi˜ ÊfiÚÙÔ˜. ∞§§∏§∂¶π¢ƒ∞™∂π™: ∏ Û‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÚÔ‚ÂÓÂÛ›‰Ë˜ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ CECLOR® ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È Ì ¿ÏÏ· ·ÓÙÈ‚ÈÔÙÈο. ™‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË Ì ÙÂÙڷ΢ÎϛӘ ‹ ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË, ¤¯ÂÈ ·ÓÙ·ÁˆÓÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ŸÙ·Ó ¯ÔÚËÁÂ›Ù·È Û ÌÂÁ¿Ï˜ ‰fiÛÂȘ Ì·˙› Ì ¿ÏÏ· ÓÂÊÚÔÙÔÍÈο Ê¿Ú̷η, fiˆ˜ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ¢√™√§√°π∞: XÔÚËÁÂ›Ù·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, Ì ‹ ¯ˆÚ›˜ Ê·ÁËÙfi. ∂Ó‹ÏÈΘ: 250 mg οı 8 ÒÚ˜, ‰ÈÏ·ÛÈ·˙fiÌÂÓË Û ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. M¤ÁÈÛÙË ‰fiÛË ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ 4 gr ËÌÂÚËÛ›ˆ˜ ¶·È‰È¿: 20-40 mg/kg ËÌÂÚËÛ›ˆ˜ ‰È·ÈÚÂ̤ÓË Û ÙÚÂȘ ›Û˜ ‰fiÛÂȘ. ™ÙË ıÂڷ›· Ù˘ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È Ê·Ú˘ÁÁ›Ùȉ·˜, Ë Û˘ÓÔÏÈ΋ ËÌÂÚ‹ÛÈ· ‰fiÛË ÌÔÚ› Ó· ‰È·ÈÚÂı› Î·È Ó· ¯ÔÚËÁËı› ·Ó¿ 12ˆÚÔ. ª¤ÁÈÛÙË Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÛÙ· ·È‰È¿ Â›Ó·È 1 gr ËÌÂÚËÛ›ˆ˜. ªOƒº∂™: Susp 125mg/5ml, 60ml, Susp 250mg/5ml, 60ml, Susp 375mg/5ml, 60ml, Caps 500mg Û ÎÔ˘Ù› ÙˆÓ 12. ¶ÔÛÔÛÙfi ÂȯÔÚ‹ÁËÛ˘ ·fi Ù· Ù·Ì›·: 75 %