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E§§HNIKH ¶AI¢IATPIKH ETAIPEIA AP£PO ™YNTA•H™ 353 ¶Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ·ÓıÂÎÙÈÎfi˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÛÙËÓ ∂ÏÏ¿‰·: ÙÔ Úfi‚ÏËÌ· Â›Ó·È Û·Ê¤˜ ÛÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡
TOMO™ 63 ●
¶AI¢IATPIKH
EN¢IAºEPOY™E™ ¶EPI¶Tø™EI™ 418 ™˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË πÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans - ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ª. ÷ڛÛË, ∞. ∑ÈÒÁ·, ∂. ∫ÚËÙÈÎÔ‡, ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
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ANA™KO¶H™H 356 N¤Â˜ Ù¿ÛÂȘ Î·È ÚÔÔÙÈΤ˜ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ·È‰ÈÒÓ Û ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ °. ªÚÈ·ÛÔ‡Ï˘
421 °Ï˘ÎÔÁÔÓ›·ÛË ∆‡Ô˘ ππ (ÓfiÛÔ˜ ÙÔ˘ Pompe): ¡¤· ÌÂÙ¿ÏÏ·ÍË Û ŒÏÏËÓ· ·ÛıÂÓ‹ Ì ÙË ‚ÚÂÊÈ΋ ÌÔÚÊ‹ ∂. ªÈ¯ÂϷοÎË, ∂. ª·˘Ú›‰Ô˘, M. Hermans, Ã. §¿ÛηÚË, ª. ∫Ô˘ÚÎÔ˘Ï‹, A. Reuser
426 ƒ·¯›Ùȉ·-ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D - ∆‡Ô˘ π
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∂¶π∫∞πƒ∞ £∂ª∞∆∞ 367 ∞ÓÙÈÏ¢ÎÔÙÚȤÓÈ·: ŒÓ· Ó¤Ô Â›‰Ô˜ Ê·ÚÌ¿ÎˆÓ ÛÙÔ ÔÔÏÔÛÙ¿ÛÈÔ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ Ã.µ. ∫·ÙÛ·Ú‰‹˜
¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, ¢. ∆ÛÈÏÈ‚¿ÎÔ˜, °. ∫·ÓÈ¿Ú˘, °. ∆ÛfiÏ·˜, Ã. ∫·Ú‹˜
430 ™˘ÁÁÂÓ‹˜ ‰È·Ù·Ú·¯‹ ÛÙËÓ ˆÛÌÔÚÚ‡ıÌÈÛË Ù˘ ‰›„·˜ Î·È Ù˘ ¤ÎÎÚÈÛ˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘ ∞. ¶··‰ËÌËÙÚ›Ô˘, ∫. ∫ËÔ˘ÚÔ‡+, Ã. ª·ÓÙ¿, °. ∆·¿ÎË, º. ºÈÏÈ›‰Ë˜
∂•∂§π•∂π™ ™∆∏¡ π∞∆ƒπ∫∏ 375 ∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË ª. ªÔ˘ÛÙ¿ÎË, ¶. °È¿ÏÏÔ˘ÚÔ˜
433 ™¿ÓÈ· ÌÔÚÊ‹ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶. ∑ÒÛË, ∏. °ÂˆÚÁÈ¿‰Ë˜, ¢. ∫·Ú·Î·˚‰fi˜, ¢. ∆ÛÈÏÈ‚¿ÎÔ˜, £. µÏ¿¯Ô˘, Ã. ¢Ú¿ÎÔ˘, ÃÚ›ÛÙÔ˜ ∫·Ú‹˜
EPEYNHTIKE™ EP°A™IE™ 382 ¶·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¶. ∫·Ï·Ì·Ï›Î˘, ª. ¡·ÚÏ›ÔÁÏÔ˘, ¡. ∑¿‚Ú·˜, ¢. ¶·Ú¿Û¯Ô˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜
391 ∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ ‚ÚÂÊÈ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ù˘ ∫Ú‹Ù˘ Ô˘ ÚԤ΢„·Ó ·fi ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜
437 ∞˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Û ÚfiˆÚ· ‰›‰˘Ì· ÓÂÔÁÓ¿ ™. °·Ú‰›Î˘, ∂. ÷Ù˙ˉ¿ÎË, X. °È·ÓÓ·ÎÔÔ‡ÏÔ˘, π. µÏ·¯¿Î˘, ™. µÏ·˙¿Î˘, °. ÷ڛÛ˘
440 ™˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË ÎÏÂȉfi˜: ¶ÂÚÈÁÚ·Ê‹ ÌÈ·˜ ÂÚ›ÙˆÛ˘ £. ªÂÛϛη˜, ∫. ¶··‚·ÛÈÏ›Ԣ, ¡. ¶¿ÓÔ˘, °. ¶··‰ËÌËÙÚ›Ô˘, µ. ¶··‚·ÛÈÏ›Ԣ
ª. §ÈÓ·Ú‰¿Î˘, π. ªÔÛ¯·Ó‰Ú¤·, ∞. ∫·Ê¿ÙÔ˜
408 ™›ÙÈÛË ÓÂÔÁÓÒÓ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ ∞. °Ô‡Ó·Ú˘, ¡. ∞ÏÂ͛Ԣ, Ã. ¶ÂÙÚÔÔ‡ÏÔ˘, ∂. ∫ˆÓÛÙ·ÓÙ¤ÏÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜
412 ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Ã. ¶·ÓÙÂÏÈ¿‰Ë˜, ∞. ª·Ï¿Ûη, ª. ∆˙ËÙËÚ›‰Ô˘, O. ∫ÔÙ˙·ÂÚ›‰Ô˘, ∂. ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘
PAEDIATRIKI
¶PAKTIKE™ O¢H°IE™ ™TOY™ °O¡∂π™ 444 OÈÎȷο ·Ù˘¯‹Ì·Ù·: O‰ËÁ›Â˜ ÚfiÏ˄˘ ∫. ∆ÛÔ˘Ì¿Î·˜
¶AI¢IATPIKH ENHMEPø™∏ 446 ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ ¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ· ™˘ÓÙÔÌÔÁڷʛ˜
Hellenic Paediatric Society
™∂¶∆∂ªµƒπO™-O∫∆øµƒπO™ 2000
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¶AI¢IATPIKH TfiÌÔ˜ 63, T‡¯Ô˜ 5Ô ™ÂÙ.-OÎÙ. 2000
HELLENIC PAEDIATRIC SOCIETY
¢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
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E§§HNIKH ¶AI¢IATPIKH ETAIPEIA
HELLENIC PAEDIATRIC SOCIETY
¶AI¢IATPIKH
PAEDIATRIKI
TfiÌÔ˜ 63, T‡¯Ô˜ 5Ô ™ÂÙ.-OÎÙ. 2000
Volume 63, No. 5, Sept-Oct 2000
¶EPIEÃOMENA
CONTENTS ™ÂÏ.
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜
vii
Page
Instructions for Authors
vii
AP£PO ™YNTA•H™
EDITORIAL
¶Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ·ÓıÂÎÙÈÎfi˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÛÙËÓ ∂ÏÏ¿‰·: ÙÔ Úfi‚ÏËÌ· Â›Ó·È Û·Ê¤˜ ÛÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ °.∞. ™˘ÚÔÁÈ·ÓÓfiÔ˘ÏÔ˜
Streptococcus pneumoniae resistant to antibiotics in Greece: the problem is real in respiratory infections G.A. Syrogiannopoulos
353
353
ANA™KO¶H™H
REVIEW ARTICLE
N¤Â˜ Ù¿ÛÂȘ Î·È ÚÔÔÙÈΤ˜ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ·È‰ÈÒÓ Û ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜
New trends and perspectives in the nutritional needs of critically ill children in intensive care
°. ªÚÈ·ÛÔ‡Ï˘
356
G. Briassoulis
356
∂¶π∫∞πƒ∞ £∂ª∞∆∞
CURRENT ISSUES
∞ÓÙÈÏ¢ÎÔÙÚȤÓÈ·: ŒÓ· Ó¤Ô Â›‰Ô˜ Ê·ÚÌ¿ÎˆÓ ÛÙÔ ÔÔÏÔÛÙ¿ÛÈÔ Ù˘ ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜
Antileukotrienes: A new class of drugs in the pediatric asthma treatment armamentarium
Ã.µ. ∫·ÙÛ·Ú‰‹˜
367
∂•∂§π•∂π™ ™∆∏¡ π∞∆ƒπ∫∏
C.V. Katsardis
367
MEDICAL PROGRESS
∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË ª. ªÔ˘ÛÙ¿ÎË, ¶. °È¿ÏÏÔ˘ÚÔ˜
The use of flexible bronchoscopy in children 375
M. Moustaki, P. Giallouros
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
ORIGINAL PAPERS
¶·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜
Monitoring and treatment of children with meningococcemia in a Paediatric Intensive Care Unit
¶. ∫·Ï·Ì·Ï›Î˘, ª. ¡·ÚÏ›ÔÁÏÔ˘, ¡. ∑¿‚Ú·˜, ¢. ¶·Ú¿Û¯Ô˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜
382
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ ‚ÚÂÊÈ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ù˘ ∫Ú‹Ù˘ Ô˘ ÚԤ΢„·Ó ·fi ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜ ª. §ÈÓ·Ú‰¿Î˘, π. ªÔÛ¯·Ó‰Ú¤·, ∞. ∫·Ê¿ÙÔ˜
375
P. Kalabalikis, M. Narlioglou, N. Zavras, D. Paraschou, G. Briassoulis, A. Hatzis
382
Growth curves of infants and preschool age children from Crete which resulted from longitudinal study M. Linardakis, I. Moschandrea, A. Kafatos
391
391
™›ÙÈÛË ÓÂÔÁÓÒÓ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ ∞. °Ô‡Ó·Ú˘, ¡. ∞ÏÂ͛Ԣ, Ã. ¶ÂÙÚÔÔ‡ÏÔ˘, ∂. ∫ˆÓÛÙ·ÓÙ¤ÏÏÔ˘, Ã. ∫ÒÛÙ·ÏÔ˜
Feeding of neonates with perinatal asphyxia and disturbances of gut hormone levels 408
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Ã. ¶·ÓÙÂÏÈ¿‰Ë˜, ∞. ª·Ï¿Ûη, ª. ∆˙ËÙËÚ›‰Ô˘, O. ∫ÔÙ˙·ÂÚ›‰Ô˘, ∂. ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘
A. Gounaris, N. Alexiou, C. Petropoulou, E. Constantellou, C. Costalos
Botulinum toxin-A in the treatment of cerebral palsy 412
C. Panteliadis, A. Balaska, M. Tzitiridou, O. Kotzaeridou, E. Karatza-Xifilidou
EN¢IAºEPOY™E™ ¶EPI¶Tø™EI™
CASE REPORTS
™˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË πÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans - ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜
Congenital self-healing Langerhans cell Histiocytosis. Case report and review of the literature
ª. ÷ڛÛË, ∞. ∑ÈÒÁ·, ∂. ∫ÚËÙÈÎÔ‡, ∞. ™È·ÌÔÔ‡ÏÔ˘ª·˘Ú›‰Ô˘, ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
408
418
™˘Ó¯›˙ÔÓÙ·È
412
M. Charisi, A. Zioga, E Kritikou, A. Siamopoulou-Mavridou, Z. Papadopoulou-Couloumbis 418
Continued
iii
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E§§HNIKH ¶AI¢IATPIKH ETAIPEIA
HELLENIC PAEDIATRIC SOCIETY
¶AI¢IATPIKH
PAEDIATRIKI
TfiÌÔ˜ 63, T‡¯Ô˜ 5Ô ™ÂÙ.-OÎÙ. 2000
Volume 63, No. 5, Sept-Oct 2000
™ÂÏ.
°Ï˘ÎÔÁÔÓ›·ÛË ∆‡Ô˘ ππ (ÓfiÛÔ˜ ÙÔ˘ Pompe): ¡¤· ÌÂÙ¿ÏÏ·ÍË Û ŒÏÏËÓ· ·ÛıÂÓ‹ Ì ÙË ‚ÚÂÊÈ΋ ÌÔÚÊ‹ ∂. ªÈ¯ÂϷοÎË, ∂. ª·˘Ú›‰Ô˘, M. Hermans, Ã. §¿ÛηÚË, ª. ∫Ô˘ÚÎÔ˘Ï‹, A. Reuser 421
ƒ·¯›Ùȉ·-ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D - ∆‡Ô˘ π ¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, ¢. ∆ÛÈÏÈ‚¿ÎÔ˜, °. ∫·ÓÈ¿Ú˘, °. ∆ÛfiÏ·˜, Ã. ∫·Ú‹˜
426
430
∞˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Û ÚfiˆÚ· ‰›‰˘Ì· ÓÂÔÁÓ¿
A. Papadimitriou, K. Kipourou+, C. Manta, G. Tapaki, P. Philippidis P. Zosi, H. Georgiadis, D. Karakaidos, D. Tsilivakos, T. Vlahou, C. Drakou, C. Karis
S. Gardikis, E. Hatzidaki, C. Giannakopoulou, J. Vlahakis, S. Vlazakis, G. Charissis
430
433
437
437
Congenital pseudarthrosis of the clavicle: A case report 440
¶PAKTIKE™ O¢H°IE™ ™TOY™ °O¡∂π™
T. Beslikas, K. Papavasiliou, N. Panou, G. Papadimitriou, V. Papavasiliou
440
PRACTICAL ADVICE TO PARENTS Household accidents: Preventive measures 444
¶∞π¢π∞∆ƒπ∫∏ E¡∏ª∂ƒø™∏ ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
426
Spontaneous gastric perforation in premature twins
™˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË ÎÏÂȉfi˜: ¶ÂÚÈÁÚ·Ê‹ ÌÈ·˜ ÂÚ›ÙˆÛ˘
OÈÎȷο ·Ù˘¯‹Ì·Ù·: O‰ËÁ›Â˜ ÚfiÏ˄˘ ∫. ∆ÛÔ˘Ì¿Î·˜
D. Karakaidos, P. Zosi, D. Tsilivakos, G. Kaniaris, G. Tsolas, C. Karis
A rare case of scleroderma in childhood. Case report
¶. ∑ÒÛË, ∏. °ÂˆÚÁÈ¿‰Ë˜, ¢. ∫·Ú·Î·˚‰fi˜, ¢. ∆ÛÈÏÈ‚¿ÎÔ˜, £. µÏ¿¯Ô˘, Ã. ¢Ú¿ÎÔ˘, ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ 433
£. ªÂÛϛη˜, ∫. ¶··‚·ÛÈÏ›Ԣ, ¡. ¶¿ÓÔ˘, °. ¶··‰ËÌËÙÚ›Ô˘, µ. ¶··‚·ÛÈÏ›Ԣ
421
Congenital defect in the osmoregulation of thirst and the secretion of antidiuretic hormone
™¿ÓÈ· ÌÔÚÊ‹ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘
™. °·Ú‰›Î˘, ∂. ÷Ù˙ˉ¿ÎË, X. °È·ÓÓ·ÎÔÔ‡ÏÔ˘, π. µÏ·¯¿Î˘, ™. µÏ·˙¿Î˘, °. ÷ڛÛ˘
H. Michelakakis, I. Mavridou, M. Hermans, H. Laskari, M. Kourkouli, A. Reusser
Vitamin D dependent Rickets - Type I
™˘ÁÁÂÓ‹˜ ‰È·Ù·Ú·¯‹ ÛÙËÓ ˆÛÌÔÚÚ‡ıÌÈÛË Ù˘ ‰›„·˜ Î·È Ù˘ ¤ÎÎÚÈÛ˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘ ∞. ¶··‰ËÌËÙÚ›Ô˘, ∫. ∫ËÔ˘ÚÔ‡+, Ã. ª·ÓÙ¿, °. ∆·¿ÎË, º. ºÈÏÈ›‰Ë˜
Page
Glycogen storage disease type II (Pompe's disease): New mutation in a Greek infant
K.T. Tsoumakas
444
PAEDIATRIC NEWS 446
Z. Papadopoulou-Couloumbis
446
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xi
Scheduled Medical Meetings
xi
™˘ÓÙÔÌÔÁڷʛ˜
xii
Abbreviations
xii
∞Á·ËÙÔ› ™˘Ó¿‰ÂÏÊÔÈ, OÈ Ô‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ¤¯Ô˘Ó ÙÚÔÔÔÈËı›. ¶·Ú·Î·Ï›Ûı ÛÙÔ ÂÍ‹˜ Ó· ‰È·ÌÔÚÊÒÓÂÙ ÙȘ ÂÚÁ·Û›Â˜ Ô˘ ÚfiÎÂÈÙ·È Ó· ·ÔÛÙ›ÏÂÙ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ Û‡Ìʈӷ Ì ÙȘ Ӥ˜ Ô‰ËÁ›Â˜. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹
iv
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·9
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. 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΋ ‹ ÌÂÚÈ΋ ·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 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˘. 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˜
vii
SEPT-OCT.2000
30-05-03
14:03
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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˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜.
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∂˘¯·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. Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.
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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. 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.
¶›Ó·Î˜ Î·È ÂÈÎfiÓ˜ 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. ¶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 elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995.
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:353-355
Aƒ£ƒO ™À¡∆∞•∏™
¶Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ·ÓıÂÎÙÈÎfi˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÛÙËÓ ∂ÏÏ¿‰·: ÙÔ Úfi‚ÏËÌ· Â›Ó·È Û·Ê¤˜ ÛÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ °ÂÒÚÁÈÔ˜ ∞. ™˘ÚÔÁÈ·ÓÓfiÔ˘ÏÔ˜
G.A. Syrogiannopoulos. Streptococcus pneumoniae resistant to antibiotics in Greece: the problem is real in respiratory infections. Paediatriki 2000;63:353-355. ● Abstract: Streptococcus pneumoniae in Greece is the most common etiologic factor for bacterial pneumonia, acute otitis media and sinusitis. Studies performed at our center during the period 1995-1999 revealed that, in 2,789 pre-school aged children examined, the carriage rate in the nasopharynx of antibiotic resistant Streptococcus pneumoniae was significantly increased. Similar findings have been reported by other investigators in Greece and abroad. Although Streptococcus pneumoniae is resistant to different groups of antibiotics, of particular interest, from the clinical point of view, is its resistance to penicillin and Erythromycin. From the epidemiologic and therapeutic aspect, the degree of resistance to Penicillin has been classified internationally to those species with intermediate MIC (defined as minimal inhibitory concentration of 0.0121Ìg/ml) and those with high MIC (minimal inhibitory concentration ≥2Ìg/ml). It should be emphasized that species with intermediate MIC to Penicillin are of significant clinical importance since they are difficult to eradicate and may cause persistence or even deterioration of the clinical symptoms. Furthermore,
™ÙË ¯ÒÚ· Ì·˜ Ô Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÌÈÎÚԂȷ΋˜ Ó¢ÌÔÓ›·˜, ̤Û˘ ˘Ò‰Ô˘˜ ˆÙ›Ùȉ·˜ Î·È ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜. ™Â ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ ·fi ÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ Î·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 19951999, ‰È·ÈÛÙÒÛ·Ì fiÙÈ Î·È ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ ˘¿Ú¯ÂÈ Ú·ÁÌ·ÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÛÔÚ¿ Ó¢ÌÔÓÈÔÎfiÎÎˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο (1-3). ∆· ÛÙÂϤ¯Ë Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ·ÔÌÔÓÒıËÎ·Ó ·fi ÙÔÓ ÚÈÓÔÊ¿-
species with intermediate MIC to Penicillin demonstrate equal resistance to Ampicillin and Amoxicillin, and even greater resistance to certain oral cephalosporins, particularly those that belong to the 3rd generation drugs. The problem of Streptococcus pneumoniae resistant to antibiotics is a real problem in respiratory tract infections in Greece as evidenced, among other factors, by the increasing difficulty in treating effectively acute pyogenic otitis media which often forces the pediatricians to double the regular dose of Amoxicillin. In Greece, the resistance to Penicillin in respiratory infections ranges between 17-29% while resistance to Erythromycin and other macrolides is around 1819%. It must be stressed that in systemic infections, such as septicemia and meningitis, the resistance to Penicillin is much lower ranging between 3-5,5%. The use of heptavalent pneumonococcal conjugate vaccine in children is quite promising in the prevention of respiratory as well as other invasive infections due to Streptococcus pneumoniae. In the meantime, the pediatrician should avoid the unnecessary prescription of drugs which usually leads to the development of resistant organisms. Key words: pneumonococcal resistance, antibiotics, respiratory infections.
Ú˘ÁÁ· 2.789 ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ (1-3). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ÛÙÂϤ¯Ë Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ÙÔÓ ÚÈÓÔÊ¿Ú˘ÁÁ· ¤¯Ô˘Ó ÔÌÔÈfiÙËÙ· Ì ÂΛӷ Ô˘ ÚÔηÏÔ‡Ó ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ȉȷ›ÙÂÚ· ̤ÛË ˘Ò‰Ë ˆÙ›Ùȉ· (4,5). ÕÏψÛÙÂ, Ë ·Ï‹ ÌÂٷΛÓËÛË ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ·fi ÙÔÓ ÚÈÓÔÊ¿Ú˘ÁÁ· Û ÛÙ›Ú˜ ÂÚÈÔ¯¤˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·ÔÙÂÏ› Î·È ÙÔ ‚·ÛÈÎfi Ì˯·ÓÈÛÌfi ·ıÔÁ¤ÓÂÛ˘ ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡.
353
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·354
¶∞π¢π∞∆ƒπ∫∏ 2000;63:353-355
¢‡Ô ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ÙËÓ ·Ú¯È΋ ÂÚÈÁÚ·Ê‹ Ù˘ ‰È·ÛÔÚ¿˜ Ó¢ÌÔÓÈÔÎfiÎÎˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ, ÙÔ Úfi‚ÏËÌ· ¤ÁÈÓ ۷ʤ˜ Î·È ·fi ¿ÏϘ ÌÂϤÙ˜ ·ÏÏ¿ ΢ڛˆ˜ ·fi ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ ÂÌÂÈÚ›·. O Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ¤¯ÂÈ ·ÓÙÔ¯‹ Û ÔÏϤ˜ ‰È·ÊÔÚÂÙÈΤ˜ ÔÌ¿‰Â˜ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. π‰È·›ÙÂÚË ÛËÌ·Û›· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ¤¯ÂÈ Ë ·ÓÙÔ¯‹ ÙÔ˘ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Î·È ÛÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Ù· ÛÙÂϤ¯Ë Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ÂӉȿÌÂÛË ·ÓÙÔ¯‹ Î·È Û ·˘Ù¿ Ì ˘„ËÏ‹. ø˜ ·ÓıÂÎÙÈο ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË ÛÙÂϤ¯Ë ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ÔÚ›˙ÔÓÙ·È ·˘Ù¿, Ù· ÔÔ›· ¤¯Ô˘Ó ÂÏ¿¯ÈÛÙË ·Ó·ÛÙ·ÏÙÈ΋ ˘ÎÓfiÙËÙ· (minimal inhibitory concentration, MIC) 0,012-1 Ìg/ml (ÂӉȿÌÂÛË ·ÓÙÔ¯‹) Î·È ·˘Ù¿ Ì ˘„ËÏ‹ ·ÓÙÔ¯‹ fiÙ·Ó Ë MIC Â›Ó·È ≥2 Ìg/ml. ∏ Ù·ÍÈÓfiÌËÛË ·˘Ù‹, ·ÁÎfiÛÌÈ· ·Ô‰ÂÎÙ‹, ¤¯ÂÈ Î·ıÈÂÚˆı› ÁÈ· ÂȉËÌÈÔÏÔÁÈÎÔ‡˜ Î·È ıÂڷ¢ÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ŒÓ· ÂÚˆÙËÌ·ÙÈÎfi Ô˘ Û˘¯Ó¿ Ù›ıÂÙ·È, Â›Ó·È Ì‹ˆ˜ Ù· ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Ì ÂӉȿÌÂÛË ·ÓÙÔ¯‹ Â›Ó·È ·Ï¿ ¤Ó· ‡ÚËÌ· Ì ÂÚÁ·ÛÙËÚÈ·Îfi ÂÚÈÛÛfiÙÂÚÔ ·Ú¿ Ì ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ. ∏ ·¿ÓÙËÛË Â›Ó·È ÍÂοı·ÚË: Ù· ÛÙÂϤ¯Ë Ì ÂӉȿÌÂÛË ·ÓÙÔ¯‹ ¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ÎÏÈÓÈ΋ ÛËÌ·Û›·. ∆Ô ÛÙÔÈ¯Â›Ô ·˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È Î˘Ú›ˆ˜ ·fi ηϿ ÙÂÎÌËÚȈ̤Ó˜ ÌÂϤÙ˜, ȉ›ˆ˜ Û ÔÍ›· ̤ÛË ˘Ò‰Ë ˆÙ›Ùȉ· (4-7). ∆· ÛÙÂϤ¯Ë Ì ÂӉȿÌÂÛË ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Û˘¯Ó¿ Û˘Ó‰¤ÔÓÙ·È Ì ·‰˘Ó·Ì›· ÂÎÚ›˙ˆÛ˘ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ·fi ÙÔ Ì¤ÛÔ ·˘Ù› Î·È ÂÈÌÔÓ‹ ‹ Î·È Âȉ›ӈÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ˆÙ›Ùȉ·˜ (5-7). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi ‰ÂÓ ı· Ú¤ÂÈ Ó· ·ÁÓÔ› ηÓ›˜ fiÙÈ Ù· ÛÙÂϤ¯Ë Ì ÂӉȿÌÂÛË ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË ¤¯Ô˘Ó ·Ó¿ÏÔÁÔ Â›Â‰Ô ·ÓÙÔ¯‹˜ ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË Î·È ÙËÓ ·ÌÔ͢ÎÈÏÏ›ÓË, ÂÓÒ Ë ·ÓÙÔ¯‹ Â›Ó·È Û·ÊÒ˜ ˘„ËÏfiÙÂÚË Û ÔÚÈṲ̂Ó˜ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ·fi ÙÔ ÛÙfiÌ·, ȉȷ›ÙÂÚ· Û ·˘Ù¤˜ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙËÓ ÙÚ›ÙË ÁÂÓÈ¿ (5,7). ªÂÙ¿ ·fi ÌÈ· ·Ú¯È΋ ÂÚ›Ô‰Ô ‰˘ÛÈÛÙ›·˜ Î·È ·ÌÊÈ‚ÔÏÈÒÓ, Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ Ó· ·ÚÓËı› ηÓ›˜ Û‹ÌÂÚ· fiÙÈ Ú¿ÁÌ·ÙÈ ¤¯ÂÈ ·˘ÍËı› Ë ‰È·ÛÔÚ¿ ·ÓıÂÎÙÈÎÒÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο Ó¢ÌÔÓÈÔÎfiÎÎˆÓ ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ. ∏ ‰È·ÛÔÚ¿ ·˘Ù‹ ·ÔÙÂÏ› Úfi‚ÏËÌ· ȉȷ›ÙÂÚ· ÁÈ· ÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô fiÙÈ ˘¿Ú¯ÂÈ Úfi‚ÏËÌ· Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ·ÓıÂÎÙÈÎÔ‡ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ÙÂÎÌËÚÈÒÓÂÙ·È Ì ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ ÙÔ˘ ı¤Ì·ÙÔ˜. ∏ Ì›· ÚÔÛ¤ÁÁÈÛË Â›Ó·È ÔÈ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙË ‰È·ÛÔÚ¿ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ (2,3,8,9). OˆÛ‰‹ÔÙ ˘¿Ú¯ÂÈ ‰È·Î‡Ì·ÓÛË ÛÙÔ ÔÛÔÛÙfi ·ÓÙÔ¯‹˜, ·Ó¿ÏÔÁ· Ì ٷ ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ô˘ ÌÂÏÂÙ‹ıËÎÂ: ·ÚÈıÌfi˜ Î·È ËÏÈΛ· ·È‰ÈÒÓ, ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡, ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô˜ Î·È ÂÚÈÔ¯‹ ·fi ÙËÓ ÔÔ›· ÚÔ¤Ú¯ÂÙ·È ÙÔ ‰Â›ÁÌ· (1-3,8,9).
354
°. ∞. ™˘ÚÔÁÈ·ÓÓfiÔ˘ÏÔ˜
∏ ¿ÏÏË ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ·ÓÙÔ¯‹˜ Â›Ó·È Ë Û·Ê‹˜ ÂÌÂÈÚ›· ÙˆÓ ·È‰È¿ÙÚˆÓ ·fi ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÈ ·È‰›·ÙÚÔÈ ¤¯Ô˘Ó ‰È·ÈÛÙÒÛÂÈ ÂÌÊ·Ó‹ ‰˘ÛÎÔÏ›· ÛÙË ıÂڷ›· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∏ ˆÙ›Ùȉ·, Ë Û˘¯ÓfiÙÂÚË Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ıÂڷ‡ÂÙ·È Û‹ÌÂÚ· Ì ÌÂÁ·Ï‡ÙÂÚË ‰˘ÛÎÔÏ›· ·fi fi,ÙÈ ÚÈÓ ·fi ÌÂÚÈο ¯ÚfiÓÈ·. ∂›Ó·È ‰‡ÛÎÔÏÔ Ó· ·ÚÓËı› ηÓ›˜ fiÙÈ Î·Ù¿ ÙÔ 1999 Ë ıÂڷ›· Ù˘ ̤Û˘ ˘Ò‰Ô˘˜ ˆÙ›Ùȉ·˜ ‹Ù·Ó Û·ÊÒ˜ ‰˘ÛÎÔÏfiÙÂÚË ·fi fi,ÙÈ ‹Ù·Ó ÚÔ 5 ‹ 10 ÂÙÒÓ. ÷ڷÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ·, Ë ·ÌÔ͢ÎÈÏÏ›ÓË, ÎÏ·ÛÛÈÎfi ·ÓÙÈ‚ÈÔÙÈÎfi ·’ ÂÎÏÔÁ‹˜ ÁÈ· ÙÔÓ Ó¢ÌÔÓÈfiÎÔÎÎÔ. ∏ ·Ú¯È΋ ¤Ó‰ÂÈÍË ‹Ù·Ó 30-50 mg/kg ËÌÂÚËÛ›ˆ˜. ™‹ÌÂÚ· Ô ŒÏÏËÓ·˜ ·È‰›·ÙÚÔ˜ ¤¯ÂÈ Î·Ù·ÓÔ‹ÛÂÈ fiÙÈ Û˘¯Ó¿ Ú¤ÂÈ Ó· ˘Âڂ› ÙËÓ ·ÓÒÙÂÚË ‰fiÛË Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Û ·Ï·ÈfiÙÂÚ·. Ÿˆ˜ Î·È ÛÙȘ ∏¶∞ Î·È ÛÂ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ Ì ·˘ÍË̤ÓË ‰È·ÛÔÚ¿ Ó¢ÌÔÓÈÔÎfiÎÎˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, Ë Û˘ÓÙ·ÁÔÁÚ¿ÊËÛË Ù˘ ·ÌÔ͢ÎÈÏÏ›Ó˘ ÎÈÓÂ›Ù·È Ï¤ÔÓ Û ·˘Ùfi Ô˘ ·Ï¿ ÔÓÔÌ¿˙ÂÙ·È "‰ÈÏ‹ ‰fiÛË ·ÌÔ͢ÎÈÏÏ›Ó˘". ∏ ËÌÂÚ‹ÛÈ· ‰fiÛË ·ÌÔ͢ÎÈÏÏ›Ó˘ 60-80 mg/kg, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Î·È 90 mg/kg ÙËÓ Ë̤ڷ, ·ÔÙÂÏ› Ú·ÎÙÈ΋ ÛÙËÓ ÔÔ›· Ô ·È‰›·ÙÚÔ˜ ·Ó·Áο˙ÂÙ·È Û˘¯Ó¿ Ó· ÚÔÛʇÁÂÈ. ∫·È Â›Ó·È ·Ó·ÌÊ›‚ÔÏÔ fiÙÈ Ë ‰ÈÏ‹ ‰fiÛË Ù˘ ·ÌÔ͢ÎÈÏÏ›Ó˘ ‰ÂÓ ÛÙԯ‡ÂÈ Ô‡Ù ÛÙÔÓ ·ÈÌfiÊÈÏÔ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜ Ô‡Ù ÛÙËÓ ÌÔڷͤÏÏ· ÙËÓ Î·Ù·ÚÚÔ˚΋. O ÛÙfi¯Ô˜ Â›Ó·È Û·Ê‹˜: Ô Ó¢ÌÔÓÈfiÎÔÎÎÔ˜. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÚfiÛÊ·Ù· ÛÙÔȯ›· ·fi ÙËÓ ∂ÏÏ¿‰· Ù· ÔÔ›· Ó· ‰Â›¯ÓÔ˘Ó ·‡ÍËÛË Ù˘ ‰È·ÛÔÚ¿˜ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ·ÈÌfiÊÈÏÔ˘ Î·È ÌÔڷͤÏÏ·˜, Ô˘ ·Ú¿ÁÔ˘Ó ‚-Ï·ÎÙ·Ì¿ÛË. ∏ ·ÓÙÔ¯‹ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Î·È Ù˘ ÌÔڷͤÏÏ·˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ıˆÚÂ›Ù·È fiÙÈ Î·Ù¿ ÙËÓ ÙÂÏÂ˘Ù·›· ÂÓÙ·ÂÙ›· ·Ú·Ì¤ÓÂÈ Û ÛÙ·ıÂÚ¿ ›‰·. ¶Èı·ÓfiÓ Ì¿ÏÈÛÙ· Ó· ˘¿Ú¯ÂÈ Î·È ÌÈÎÚ‹ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ô˘ ·Ú¿ÁÔ˘Ó ‚-Ï·ÎÙ·Ì¿ÛË. OˆÛ‰‹ÔÙÂ, Ë ·ÓÙÔ¯‹ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË ‰ÂÓ Êı¿ÓÂÈ Ù· ›‰· Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Û ¯ÒÚ˜ fiˆ˜ Ë °·ÏÏ›· Î·È Ë πÛ·Ó›·, fiÔ˘ Ë ·ÓÙÔ¯‹ ÚÔÛÂÁÁ›˙ÂÈ ‹ Î·È ÍÂÂÚÓ¿ ÙÔ 50% (4). ™ÙËÓ ∂ÏÏ¿‰· Ù· ÛÙÂϤ¯Ë Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ÂÚÈÔ¯¤˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, fiˆ˜ Â›Ó·È Ô ÚÈÓÔÊ¿Ú˘ÁÁ·˜ Î·È ÙÔ Ì¤ÛÔ ·˘Ù›, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÙÔ¯‹ ¤Ó·ÓÙÈ Ù˘ ÂÓÈÎÈÏÏ›Ó˘, ÙÔ ÔÔ›Ô ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Î˘Ì·›ÓÂÙ·È ·fi 17 ¤ˆ˜ 29% (1,2,8). ∆Ô ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·ÊÔÚ¿ ÛÙÂϤ¯Ë Ô˘ ¤¯Ô˘Ó ·ÔÌÔÓˆı› ·fi ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ·È‰ÈÎfi ÛÙ·ıÌfi ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ· (1). ∏ ÚfiÛÊ·ÙË ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ó· ·ÔÈÎÈÛÙ› ÙÔ ·È‰› Î·È Èı·ÓfiÓ Ó· ·Ó·Ù‡ÍÂÈ Ïԛ̈ÍË ·fi ·ÓıÂÎÙÈÎfi ÛÙ· ·ÓÙÈ‚ÈÔÙÈο
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·355
¶∞π¢π∞∆ƒπ∫∏ 2000;63:353-355
Û٤ϯԘ (5,9,10). ∏ ·ÓÙÔ¯‹ ÛÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË Î·È ÙȘ ¿ÏϘ Ì·ÎÚÔÏ›‰Â˜ ˘ÔÏÔÁ›˙ÂÙ·È Û˘Ó‹ıˆ˜ Û 1819% (1,3,8). ∏ ·ÓÙÔ¯‹ ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‰ÂÓ Ú¤ÂÈ Ó· Û˘ÁÎÚ›ÓÂÙ·È Ì ÙËÓ ·ÓÙÔ¯‹ Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÛÙÂϤ¯Ë ·fi Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ. OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ, fiˆ˜ Ë ÌÈÎÚÔ‚È·ÈÌ›· Î·È Ë ÌËÓÈÁÁ›Ùȉ·, ÔÊ›ÏÔÓÙ·È Û ÛÙÂϤ¯Ë Ô˘ Û˘¯Ó¿ ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÔÚfiÙ˘Ô˘˜ Ì ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ·ÓÙÔ¯‹˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο. ™ÙËÓ ∂ÏÏ¿‰·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÛÙÂϯÒÓ Ì ÌÂÚÈ΋ ‹ Ï‹ÚË ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ·ÛıÂÓ›˜ Ì ÌÈÎÚÔ‚È·ÈÌ›· ‹ ÌËÓÈÁÁÁ›Ùȉ· ıˆÚÂ›Ù·È fiÙÈ Î˘Ì·›ÓÂÙ·È ·fi 3 ¤ˆ˜ 5,5%. £· Ú¤ÂÈ ‚¤‚·È· Ó· ‰È·ÙËÚÂ›Ù·È Î¿ÔÈ· ÂÈʇϷÍË ÛÙÔ ÔÛÔÛÙfi ·˘Ùfi ‰ÈfiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ÛÙÂϯÒÓ ·fi Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ Â›Ó·È ÌÈÎÚfi˜. ∆Ô ÂÙ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘, ÙÔ ÔÔ›Ô Î·Ï‡ÙÂÈ 7 Û˘¯ÓÔ‡˜, Î·È Ì ÛËÌ·ÓÙÈ΋ ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, ÔÚfiÙ˘Ô˘˜ ˘fiÛ¯ÂÙ·È Ó· ÚÔÛʤÚÂÈ ÛËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ·. OÈ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó Ôχ ÌÂÁ¿ÏË ÂÏ¿ÙÙˆÛË ÙˆÓ ‰ÈÂÈÛ‰˘ÙÈÎÒÓ ÏÔÈÌÒ͈Ó, ÌÈÈÎÚÔ‚È·ÈÌ›·˜ Î·È ÌËÓÈÁÁ›Ùȉ·˜ ·ÏÏ¿ Î·È ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ Ó¢ÌÔÓ›·˜ Î·È Ù˘ ˆÙ›Ùȉ·˜ (11,12). ∫·Ù·ÓÔÒÓÙ·˜ ÙÔ Úfi‚ÏËÌ· Ù˘ ·ÓÙÔ¯‹˜ ÙÔ˘ Ó¢ÌÔÓÈÔÎfiÎÎÔ˘, Ô ·È‰›·ÙÚÔ˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÙÚÔÔÔÈ‹ÛÂÈ ¿ÌÂÛ· ÙË Û˘ÓÙ·ÁÔÁÚ¿ÊËÛË, ·ÔʇÁÔÓÙ·˜ ÙËÓ ¿ÛÎÔË ¯ÔÚ‹ÁËÛË ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÁˆÁ‹˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Syrogiannopoulos GA, Grivea IN, Beratis NG, Spiliopoulou AE, Fasola EL, Bajaksouzian S, et al. Resistance patterns of Streptococcus pneumoniae from carriers attending day-care centers in Southwestern Greece. Clin Infect Dis 1997;25:188-194. 2. Syrogiannopoulos GA, Grivea IN, Katopodis GD, Geslin P, Jacobs MR, Beratis NG. Carriage of antibiotic-resistant Streptococcus pneumoniae in Greek infants and toddlers. Eur J Clin Microbiol Infect Dis 2000;19:288-293. 3. Syrogiannopoulos GA, Grivea IN, Davies TA, Katopodis GD, Appelbaum PC, Beratis NG. Antimicrobial use and colonization with erythromycin-resistant Streptococcus pneumoniae in Greece during the first 2 years of life. Clin Infect Dis 2000. In press.
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4. Cohen R, Levy C, Boucherat M, Langue J, Autret E, Gehanno P, et al. Five vs. ten days of antibiotic therapy for acute otitis media in young children. Pediatr Infect Dis J 2000;19:458-463. 5. Dagan R, Leibovitz E, Leiberman A, Yagupsky P. Clinical significance of antibiotic resistance in acute otitis media and implication of antibiotic treatment on carriage and spread of resistant organisms. Pediatr Infect Dis J 2000;19:S57-65. 6. Dagan R, Johnson C, McLinn S, Abughalli N, Feris J, Leibovitz E, et al. Bacteriologic and clinical efficacy of amoxicillin/clavulanate vs. azithromycin in acute otitis media. Pediatr Infect Dis J 2000;19:95-104. 7. Dagan R, Leibovitz E, Fliss DM, Leiberman A, Jacobs MR, Craig W, et al. Bacteriological efficecies of oral azithromycin and oral cefaclor in treatment of acute otitis media in infants and young children. Antimicrobial Agents Chemother 2000; 44:43-50. 8. °Îڤη ¶, ∫·Ú·Ì¤ÙÔ˜ ∞, ¢·ÛηϿÎË ∂, ÷Ù˙ËÁˆÚÁ›Ô˘ ¢, •ËÚÔ˘¯¿ÎË ∂, ª·Ó‰·Ú¿Î· ∞ Î·È Û˘Ó. ∂ÈÔÏ·ÛÌfi˜ Ù˘ ·ÓÙÔ¯‹˜ ÙÔ˘ Streptococcus pneumoniae ηٿ ÙÔ 1998 ÛÙËÓ ∞ÙÙÈ΋ [¶ÂÚ›ÏË„Ë]. 25Ô ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; ª·˝Ô˘; ∞ı‹Ó·; 1999. 9. ∆ÛÔÏÈ¿ ª, ∫Ô˘¿ÚË °, ∑·ÊÂÈÚÔÔ‡ÏÔ˘ ∞, °·‚Ú›ÏË ™, ∆ÛÈÚ¤· ª, ∫·ÊÂÙ˙‹˜ ¢ Î·È Û˘Ó. ∞ÔÈÎÈÛÌfi˜ Ì Ó¢ÌÔÓÈfiÎÔÎÎÔ ·ÓıÂÎÙÈÎfi ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ˘ÁÈÒÓ ·È‰ÈÒÓ Û ·È‰ÈÎÔ‡˜ ÛÙ·ıÌÔ‡˜ Ù˘ ÂÚÈÔ¯‹˜ ÙˆÓ ∞ıËÓÒÓ. [¶ÂÚ›ÏË„Ë]. 37Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, £ÂÛÛ·ÏÔÓ›ÎË, 1999. 10. Guillemot D, Carbon C, Balkau B, Geslin P, Lecoeur H, Kervroëdan-Vauzelle F, et al. Low dosage and long treatment duration of ‚-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA 1998;279: 365-370. 11. Black S, Shinefield H, Fireman B, Lewis E, Ray P, Hansen JR, et al. Efficacy, safety and immunogenecity of heptavalent pneumococcal conjugate vaccine in children. Pediatr Infect Dis J 2000;19:187-195. 12. Eskola J, Kilpi T. Potential of bacterial vaccines in the prevention of acute otitis media. Pediatr Infect Dis J 2000; 19:S72-78.
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356
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
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total parenteral nutrition (TPN) which is associated with a greater risk of septic morbidity and mortality, danger of overfeeding and increased expense. Early enteral nutrition is effective in achieving increased nutrient intake, improved overall nutritional status and better outcome than TPN in most critically ill children. The development of enteral formulas with possible immunologic as well as nutritional properties is discussed. Future trends in nutritional support, including that of nutritional pharmacotherapy, are also considered. Key words: nutrition, malnutrition, enteral feeding, total parenteral nutrition, immunonutrtion, critical illness.
AÏÏËÏ›‰Ú·ÛË ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘ - ıÚ¤„˘ Û ·È‰È¿ ™ÙËÓ ÔÍ›· Ê¿ÛË ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘, fiϘ ÔÈ ··ÈÙ‹ÛÂȘ Û ÂÓ¤ÚÁÂÈ· ÁÈ· ÙȘ ΢ÙÙ·ÚÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ ηχÙÔÓÙ·È ·fi ÙË ‰È¿Û·ÛË Û‡ÌÏÔÎˆÓ ÊˆÛÊÔÚÈÎÒÓ ÂÓÒÛÂˆÓ ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ·fi‰ÔÛ˘, ȉȷ›ÙÂÚ· Ù˘ ÙÚÈʈÛÊÔÚÈ΋˜ ·‰ÂÓÔÛ›Ó˘ (ATP). T· Û‡ÌÏÔη ·˘Ù¿ ‰È·ÛÒÓÙ·È Û ˘„ËÏfi ÔÛÔÛÙfi (·ÛÙ·ı‹) Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ·ÔıË·ÔÓÙ·È. ™Â οı ‰Â‰Ô̤ÓË ÛÙÈÁÌ‹ ÙÔ ·ÓıÚÒÈÓÔ ÛÒÌ· ÂÚȤ¯ÂÈ ATP ÈηÓfi Ó· ÚÔÛʤÚÂÈ ÂÓ¤ÚÁÂÈ· ÁÈ· οÔÈ· ÏÂÙ¿ ÌfiÓÔ, ··ÈÙÒÓÙ·˜ ÙË ‰È·Ú΋ Û‡ÓıÂÛË ATP ÒÛÙ ӷ ÌËÓ ˘¿ÚÍÂÈ ÂÓÂÚÁÂÈ·Îfi ¤ÏÏÂÈÌÌ· (1). TÚÂȘ Ù¿ÍÂȘ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ (˘‰·Ù¿ÓıڷΘ, ÚˆÙ½Ó˜, Ï›Ë) Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÔıË΢ıÔ‡Ó Î·È Ó· ÔÍÂȉˆıÔ‡Ó ÁÈ· ÙË Û˘Ó¯‹ Û‡ÓıÂÛË ATP. E¿Ó ÔÈ ··Ú·›ÙËÙ˜ ·˘Ù¤˜ ÂÓÂÚÁÂȷΤ˜ ËÁ¤˜ ‰ÂÓ ÚÔÛʤÚÔÓÙ·È ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ÛÙË ‰È¿ÚÎÂÈ· ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘, Ô ÔÚÁ·ÓÈÛÌfi˜ ·Ó·Áο˙ÂÙ·È Ó· ηٷӷÏÒÛÂÈ ÙȘ ıÚÂÙÈΤ˜ Ô˘Û›Â˜ Ô˘ ¤¯ÂÈ ·ÔıË·ÛÂÈ, ηٷ‚ÔÏ›˙ÔÓÙ·˜ ΢ڛˆ˜ ÙË ÛˆÌ·ÙÈ΋ ÚˆÙ½ÓË Î·È ÙÔ Ï›Ô˜, Êı¿ÓÔÓÙ·˜ ‰ËÏ·‰‹ ÛÙÔÓ ÏÂÁfiÌÂÓÔ ·˘ÙÔηÓÓÈ‚·ÏÈÛÌfi (2). TÔ ¿ÚÚˆÛÙÔ ·È‰› Â›Ó·È È‰È·›ÙÂÚ· ¢¿ÏˆÙÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÚˆÙÂ˚ÓÈ΋˜ ÂÓÂÚÁÂȷ΋˜ ˘ÔıÚ„›·˜ (¶EY). H ·ÔÛÙ¤ÚËÛË ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ·˘ÍË̤Ó˜ ··ÈÙ‹ÛÂȘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ô˘ ÚÔηÏ› ÙÔ stress Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔ ¿ÚÚˆÛÙÔ ·È‰›. K·È ·˘Ùfi ÁÈ·Ù› ÙÔ ·È‰› Â›Ó·È ·Ó·Ù˘ÛÛfiÌÂÓÔ˜ ÔÚÁ·ÓÈÛÌfi˜ Ì ÂÍ·ÈÚÂÙÈο ÌÂȈ̤ӷ ÂÓÂÚÁÂȷο ·Ôı¤Ì·Ù· Ô˘ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÙÔ˘ ÂÍ·ÛÊ·Ï›ÛÔ˘Ó ·ÓÙÈÚÚfiÈÛË Û ÂÚ›ÙˆÛË ÛÔ‚·Ú‹˜ ÓfiÛÔ˘, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. K·Ù¿ Û˘Ó¤ÂÈ· ÙÔ ·È‰› Â›Ó·È ÂÍ·ÚÙÒÌÂÓÔ Î·Ù¿ ¤Ó· ·fiÏ˘ÙÔ ÙÚfiÔ ·fi ÙËÓ ÚÔÛÊÔÚ¿ ÂÓ¤ÚÁÂÈ·˜ (3). ŒÙÛÈ ÂÍËÁÂ›Ù·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÌfiÓÔ ÙÔ 63% ÙˆÓ ‚·ÚÈ¿ ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ ‚Ú›ÛÎÔÓÙ·Ó ÂÎÙfi˜ ÎÈÓ‰‡ÓÔ˘ ˘ÔıÚ„›·˜ ηٿ ÙËÓ Â›ÛÔ‰Ô ÙÔ˘˜ ÛÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ME£) (Ù·ÍÈÓfiÌËÛË Î·Ù¿ Waterlow). ™ÙÔ˘˜ ›‰ÈÔ˘˜ ·ÛıÂÓ›˜ ÛÙÔ 53% ‚Ú¤ıËΠ̤ÙÚÈÔ ‹ ÛÔ‚·Úfi ¤ÏÏÂÈÌÌ· ۈ̷ÙÈ΋˜ ÚˆÙ½Ó˘ (¤ÏÏÂÈÌÌ· <80% ‹ <60%, ·ÓÙ›ÛÙÔȯ·, ηٿ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ۈ̷ÙÈ΋˜ ÚˆÙ½Ó˘ Û‡Ìʈӷ Ì ÙÔÓ ‰Â›ÎÙË ÎÚ·ÙÈÓ›Ó˘/‡„Ô˘˜) (4). I‰È·›ÙÂÚ·, ·È‰È¿ Ì ¯ÚfiÓÈÔ ÓfiÛËÌ· ¤Êı·Û·Ó Û ηٿÛÙ·ÛË ÚˆÙÂ˚ÓÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ̤۷ Û 3
™˘ÓÙÔÌÔÁڷʛ˜ ATP ¶EY ME£ ¶BM ¶KE VO2 VCO2 RQ O¶¢ OE¢ M¶¢ MCT LCT rGH IGF-1 NB OFR
TÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË ¶ÚˆÙÂ˚ÓÈ΋-ÂÓÂÚÁÂȷ΋ ˘ÔıÚ„›· MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¶ÚÔ‚ÏÂfiÌÂÓÔ˜ ‚·ÛÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ¶ÚÔ‚ÏÂfiÌÂÓË Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ K·Ù·Ó¿ÏˆÛË Ô͢ÁfiÓÔ˘ ¶·Ú·ÁˆÁ‹ ‰ÈÔÍÂȉ›Ô˘ ÙÔ˘ ¿ÓıÚ·ÎÔ˜ AÓ·Ó¢ÛÙÈÎfi (·ÓÙ·ÏÏ·ÛÛfiÌÂÓÔ) ËÏ›ÎÔ OÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ OÏÈ΋ ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ MÂÚÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ TÚÈÁÏ˘ÎÂÚ›‰È· ̤Û˘ ·Ï‡ÛÔ˘ TÚÈÁÏ˘ÎÂÚ›‰È· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ AÓ·Û˘Ó‰˘·Ṳ̂ÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË ¶·Ú¿ÁÔÓÙ·˜ ·‡ÍËÛ˘ Ù˘ ÈÓÛÔ˘Ï›Ó˘ IÛÔ˙‡ÁÈÔ ·˙ÒÙÔ˘ EχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘
Ë̤Ú˜ ·fi ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ stress, Î·È Û‡ÓÙÔÌ· Û ηٿÛÙ·ÛË ÛÔ‚·Ú‹˜ ·Ó¿ÚÎÂÈ·˜, ÂÊ fiÛÔÓ Ë Î·Ù¿ÛÙ·ÛË stress Û˘Ó¯È˙fiÙ·Ó (ÌË ·ÓÙÈÚÚfiÈÛË, ÓfiÛÔ˜ Û ÂͤÏÈÍË). E›Ó·È ÁÓˆÛÙfi ·fi ÔÏϤ˜ ÌÂϤÙ˜ fiÙÈ Ë ˘ÔıÚ„›· Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔ˘˜ ·ÛıÂÓ›˜ Û˘Ó‰¤ÂÙ·È Ì ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ·, ıÓËÛÈÌfiÙËÙ· Î·È ·ÓÔÛÔηٷÛÙÔÏ‹ (5). OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÛÙË Ê¿ÛË ÙÔ˘ stress ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ Â›‰Ú·ÛË ÙˆÓ ÂÓ‰ÔÁÂÓÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ÙÔ˘ stress (6). ŒÙÛÈ, Ë ÈÓÙÂÚÏ¢ΛÓË-6 ‰Ú· Û˘ÓÂÚÁÈο Ì ٷ ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉ‹, ‰ÈÂÁ›ÚÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘. (7). ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ¤ÎÏ˘ÛË ÙˆÓ Î·Ù·‚ÔÏÈÎÒÓ ÔÚÌÔÓÒÓ Ù˘ ¤ÓÙ·Û˘ (‹ ·ÓÙÈ-Ú˘ıÌÈÛÙÈÎÒÓ, counter-regularory), ‰ÈÂÁ›ÚÂÙ·È ÙÔ Û˘Ì·ıËÙÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·, Ì ÙÂÏÈ΋ Èı·Ó‹ Û˘ÓÈÛٷ̤ÓË ÌÈ· "˘ÂÚÌÂÙ·‚ÔÏÈ΋ ηٿÛÙ·ÛË". AÎfiÌË Î·È ·Ô˘Û›· ıÚÂÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, ηıÒ˜ Û ÔÏϤ˜ ÌÔÓ¿‰Â˜ ÔÈ ·ÛıÂÓ›˜ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË ˘ÔÛÙËÚ›˙ÔÓÙ·È ÌfiÓÔ Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ËÏÂÎÙÚÔχÙ˜ ˘‰·ÙÈο ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘, ‰ÔÌÈο ˘ÔÛÙÚÒÌ·Ù· ΢ÎÏÔÊÔÚÔ‡Ó Û ·˘ÍË̤ÓÔ˘˜ Ú˘ıÌÔ‡˜ (·˘ÙÔηÓÓÈ‚·ÏÈÛÌfi˜) ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ stress (8). EÈÚfiÛıÂÙ·, Ë ‰È·ÊÔÚÂÙÈ΋ ·ÏÏËÏ›‰Ú·ÛË ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÛÔÏ·‚ËÙÒÓ ÙÔ˘ stress ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Î·È Ë ·Ú¿ÏÏËÏË
357
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·358
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
¤ÎÊÚ·ÛË Ù˘ ȉȷ›ÙÂÚ˘ ηٿ ÂÚ›ÙˆÛË ÔÚÌÔÓÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘ (·ÓÙ·ÁˆÓÈÛÌfi˜ ·Ó·‚ÔÏÈÎÒ˜ ‰ÚÒÓÙˆÓ ÔÚÌÔÓÒÓ, fiˆ˜ Ë ÈÓÛÔ˘Ï›ÓË, Î·È Î·Ù·‚ÔÏÈÎÒ˜ ‰ÚÒÓÙˆÓ ÔÚÌÔÓÒÓ, fiˆ˜ Ë ÎÔÚÙÈ˙fiÓË Î·È ÔÈ Î·Ù¯ÔϷ̛Ә, ÂÍËÁÔ‡Ó Ù· ÔÈΛϷ ÌÂÙ·‚ÔÏÈο ÚfiÙ˘· Ô˘ ·ÔÙ˘ÒıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÛÔ‚·Ú‹˜ ηٿÛÙ·Û˘ stress ÛÙ· ·È‰È¿ Û ÚfiÛÊ·ÙË ÌÂϤÙË. ◊‰Ë ηٿ ÙËÓ ÚÒÙË Ë̤ڷ ÂΉ‹ÏˆÛ˘ ÙÔ˘ stress, 48,6% ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó ˘ÔÌÂÙ·‚ÔÏÈο, 40,5% ÓÔÚÌÔÌÂÙ·‚ÔÏÈο Î·È ÌfiÓÔ 10,8% ˘ÂÚÌÂÙ·‚ÔÏÈο (4). H ›‰È· Ë ÌÂÙ·‚ÔÏÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙÔ stress ÂÍ¿ÏÏÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ¤Ó‰ÂÈÍË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ (9). AÛıÂÓ›˜ Ì ˘ÔÌÂÙ·‚ÔÏÈÎfi (ÌÂÙÚËı›۷ ηٷӿψÛË ÂÓ¤ÚÁÂÈ·˜ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ¤ÌÌÂÛ˘ ıÂÚÌȉÔÌÂÙÚ›·˜ ÌÈÎÚfiÙÂÚË ÙÔ˘ 90% ÙÔ˘ ÚÔ‚ÏÂfiÌÂÓÔ˘ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (¶BM)) ‹ ˘ÂÚÌÂÙ·‚ÔÏÈÎfi (ÌÂÙÚËı›۷ ηٷӿψÛË ÂÓ¤ÚÁÂÈ·˜ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ¤ÌÌÂÛ˘ ıÂÚÌȉÔÌÂÙÚ›·˜ ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 110% ÙÔ˘ ¶BM) ÚfiÙ˘Ô Î·Ù¿ ÙËÓ ÚÒÙË Ë̤ڷ, ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ıÓËÛÈÌfiÙËÙ· Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÔÚÌÔÌÂÙ·‚ÔÏÈÛÌfi. I‰È·›ÙÂÚ·, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ıÓËÛÈÌfiÙËÙ·˜ ÁÈ· ÙÔ ˘ÔÌÂÙ·‚ÔÏÈÎfi ÚfiÙ˘Ô ‹Ù·Ó 6,27 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜. £ÂÚÌȉÈΤ˜ ·Ó¿ÁΘ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ OÈ Û˘ÓÈÛÙÒÌÂÓ˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ ÁÈ· ·Ó·Ï‹ÚˆÛË ıÂÚÌ›‰ˆÓ Û ·È‰È¿ ¤¯Ô˘Ó ‚·ÛÈÛı› Û ÂÎÙÂٷ̤Ó˜ ıÂÚÌȉÔÌÂÙÚÈΤ˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ fï˜ ¤ÁÈÓ·Ó Û ˘ÁÈ‹ ¿ÙÔÌ· ¯ˆÚ›˜ stress (10). ™Â ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÌÈ· ˘ÂÚÌÂÙ·‚ÔÏÈ΋ ·ÓÙ·fiÎÚÈÛË Û ÛÔ‚·Ú‹ ÓfiÛÔ ‹ ÙÚ·‡Ì· Ë ÔÔ›· Û·ÊÒ˜ ‰È·ÊÔÚÔÔÈÂ›Ù·È ·fi ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Û ‹ÚÂÌË, ¯ˆÚ›˜ stress, ηٿÛÙ·ÛË (11). H ¤ÎÙ·ÛË Î·Ù¿ ÙËÓ ÔÔ›· ·ÚfiÌÔȘ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ ÂËÚ¿˙Ô˘Ó ÙȘ Ú·ÁÌ·ÙÈΤ˜ ıÂÚÌȉÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ηıÔÚÈÛı›. °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜ Ë ··ÈÙÔ‡ÌÂÓË ÂÓ¤ÚÁÂÈ· Û ·È‰È¿ Û stress ¤¯ÂÈ ÚÔÛÂÁÁÈÛı› ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ù‡Ô˘˜ ÚÔ‚ÏÂfiÌÂÓ˘ ηٷӿψÛ˘ ÂÓ¤ÚÁÂÈ·˜ (¶KE), ‰ÈÔÚıˆÌ¤ÓÔ˘˜ ηٿ ÙÔÓ ÂÎÙÈÌËı¤ÓÙ· ‚·ıÌfi stress (12). EÓÙÔ‡ÙÔȘ, Ë ·ÎÚ›‚ÂÈ· ÙˆÓ ÂÍÈÛÒÛÂˆÓ Úfi‚Ï„˘ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ ·Ó·ÁÎÒÓ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ stress Â›Ó·È ·ÌÊ›‚ÔÏË, Î·È Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Â›Ó·È Èı·Ófi Ó· Ô‰ËÁ‹ÛÂÈ Û ϷÓı·Ṳ̂ӷ Û¯‹Ì·Ù· ıÚ¤„˘ ˘ÔÛÈÙÈÛÌÔ‡ ‹ ˘ÂÚÛÈÙÈÛÌÔ‡ (13). AÓ·Ú΋˜ ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË ÔÍ›·˜ ¶EY, Î·È ÁÂÓÈÎfiÙÂÚ· ·‡ÍËÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜. AÓÙ›ıÂÙ·, ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ıÂÚÌ›‰ˆÓ Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÂÈ Û ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ· ·ÛıÂÓ›˜ Ì ‰È·Ù·Ú·Á̤ÓË ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Ó· ÚÔηϤÛÂÈ ÚfiÛıÂÙ˜ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ (14).
358
°. MÚÈ·ÛÔ‡Ï˘
™Â ÚfiÛÊ·ÙË ÚÔÔÙÈ΋ ÎÏÈÓÈ΋ ÌÂϤÙË ·Ô‰Â›¯ıËΠfiÙÈ Ë ¯Ú‹ÛË Ù‡ˆÓ Úfi‚Ï„˘ ÂÓÂÚÁÂÈ·ÎÒÓ ·Ó·ÁÎÒÓ ·È‰ÈÒÓ Û stress, Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÂÈ Û ÌÂÁ¿Ï˜ ·ÔÎÏ›ÛÂȘ ·fi ÙȘ Ú·ÁÌ·ÙÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ·ÛıÂÓÒÓ, Ô‰ËÁÒÓÙ·˜ Û ˘ÂÚÛÈÙÈÛÌfi ‹ ˘ÔÛÈÙÈÛÌfi Ì ÛËÌ·ÓÙÈ΋ ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (15). AÎfiÌË Î·È ÙÚÔÔÔÈË̤Ó˜ ÁÈ· ηٷÛÙ¿ÛÂȘ stress ÂÍÈÛÒÛÂȘ, Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ˘ÂÚÛ›ÙÈÛË ¤ˆ˜ Î·È 100% ¤Ó·ÓÙÈ ÙˆÓ Ú·ÁÌ·ÙÈÎÒÓ ·Ó·ÁÎÒÓ ÙˆÓ ·ÛıÂÓÒÓ. ¶·Ú' fiÙÈ Ô ÚÔÛ·ÚÌÔṲ̂ÓÔ˜ ÛÙËÓ ËÏÈΛ· ‚·ÛÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ Ê·›ÓÂÙ·È Ó· ÚÔÛÂÁÁ›˙ÂÈ ÙË ÌÂÙÚËı›۷ ÂÓ¤ÚÁÂÈ· ηٿ 10%, ¿ÏϘ ÎÏÈÓÈÎÔ› ·Ú¿ÌÂÙÚÔÈ, ·ÓıÚˆÔÌÂÙÚÈΤ˜ ÌÂÙÚ‹ÛÂȘ, Î·È ‰Â›ÎÙ˜ ıÚ¤„˘, Ú¤ÂÈ Â›Û˘ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·Ù¿ ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ·Ó·ÁÎÒÓ ·È‰ÈÒÓ Û stress. °È· ÙË ÛˆÛÙ‹ ÂÔ̤ӈ˜, ıÂÚÌȉÈ΋ Î¿Ï˘„Ë ‚·ÚÈ¿ ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÔÓÙ·È Û ME£, ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË Ë Û˘ÛÙËÌ·ÙÈ΋ ̤ÙÚËÛË ÙˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ÙÔ˘˜ ·Ó·ÁÎÒÓ. ™‹ÌÂÚ·, ̤ۈ Ù˘ ̤ÙÚËÛ˘ Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ·ÓÙ·ÏÏ·Á‹˜ ÙˆÓ ·ÂÚ›ˆÓ ÛÙË ÌÔÓ¿‰· ÙÔ˘ ¯ÚfiÓÔ˘, VO2 Î·È VCO2, Â›Ó·È ‰˘Ó·Ù‹ Ë Ì¤ÙÚËÛË Ù˘ ηٷӿψÛ˘ ÂÓ¤ÚÁÂÈ·˜ Î·È ÙÔ˘ ›‰Ô˘˜ ÙˆÓ ÔÍÂȉԇÌÂÓˆÓ ˘ÔÛÙÚˆÌ¿ÙˆÓ (16). TÔ Î¿ı ıÚÂÙÈÎfi ˘fiÛÙڈ̷ ÔÍÂȉÒÓÂÙ·È Ì ÌÈ· ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·ÓÙ·ÏÏ·Á‹ CO2 ÁÈ· O2. A˘Ù‹ Ë ·ÓÙ·ÏÏ·Á‹ Â›Ó·È ÁÓˆÛÙ‹ Û·Ó ·Ó·Ó¢ÛÙÈÎfi ËÏ›ÎÔ (RQ). OÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ TȘ ȉȷ›ÙÂÚ˜ ıÂÚÌȉÈΤ˜ ··ÈÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û ηٿÛÙ·ÛË stress ‰ÂÓ Â›Ó·È Û ı¤ÛË Ó· ÙȘ ηχ„Ô˘Ó ·Ï¿ ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ. ŒÙÛÈ, ÂÓÒ ÂÌÏÔ˘ÙÈṲ̂ÓÔÈ ÔÚÔ› ˘‰·Ù·ÓıÚ¿ÎˆÓ ·ÔÙ˘Á¯¿ÓÔ˘Ó Ó· ·Ó·ÛÙÚ¤„Ô˘Ó ÙÔ˘˜ ÛËÌ·ÓÙÈÎÔ‡˜ Ú˘ıÌÔ‡˜ ÔÍ›‰ˆÛ˘ Ï›Ô˘˜ Î·È ÚˆÙÂ˚ÓÒÓ, Ë O¶¢ Î·È OE¢ ÂËÚ¿˙Ô˘Ó ıÂÙÈο ÙÔ˘˜ ÏfiÁÔ˘˜ ·Ó·ÏËÚˆı¤ÓÙÔ˜/ ÔÍÂȉˆı¤ÓÙÔ˜ ˘ÔÛÙÚÒÌ·ÙÔ˜, ÚÔÛʤÚÔÓÙ·˜ ÙÔ˘˜ ÌÔÓ·‰ÈÎÔ‡˜ ÙÚfiÔ˘˜ ıÚ¤„˘ ÙˆÓ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ. OÈ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÌÂıfi‰ˆÓ ıÚ¤„˘ Â›Ó·È ÛËÌ·ÓÙÈΤ˜ (¶›Ó·Î·˜ 1). M ‚¿ÛË ÙȘ ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ Ô˘ ¤¯Ô˘Ó ÂȂ‚·Èˆı› Û ÔÏϤ˜ ÌÂϤÙ˜, Ë O¶¢ Û‹ÌÂÚ· ¤¯ÂÈ ÙËÓ ¤ÓÓÔÈ· Ù˘ ·ÚÔ‰È΋˜ ıÚÂÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Û ·È‰È¿ Û stress, ÂΛ fiÔ˘ Â›Ó·È ·‰‡Ó·ÙË Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË (›ÌÔÓË ÌË ÂÏÂÁ¯fiÌÂÓË ‰È¿ÚÚÔÈ·, ÂÈÏÂfi˜, ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, ·ÈÌÔÚÚ·Á›· ·ÓÒÙÂÚÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓÔ shock). H O¶¢ ·È‰ÈÒÓ Û stress ÓÔÂ›Ù·È ¿ÓÙ· Ì ÙËÓ ¤ÓÓÔÈ· Ù˘ Ï‹ÚÔ˘˜ Î¿Ï˘„˘ ÙˆÓ Ú·ÁÌ·ÙÈÎÒÓ ‹ ¤ÛÙˆ ÚÔ‚ÏÂfiÌÂÓˆÓ ıÚÂÙÈÎÒÓ ·Ó·ÁÎÒÓ ÙÔ˘ ·ÛıÂÓÔ‡˜, Î·È ˆ˜ ÁÓˆÛÙfiÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË ˘‰·Ù·ÓıڿΈÓ, ÚˆÙÂ˚ÓÒÓ, Ï›Ô˘˜, ËÏÂÎÙÚÔÏ˘ÙÒÓ, ÌÂÙ¿ÏψÓ, ȯÓÔÛÙÔȯ›ˆÓ Î·È ‚ÈÙ·ÌÈÓÒÓ (¶›Ó·Î·˜ 2).
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·359
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Û ª∂£
¶›Ó·Î·˜ 1. ¢È·ÊÔÚ¤˜ ÌÂٷ͇ ÔÏÈ΋˜ ·ÚÂÓÙÂÚÈ΋˜ (O¶¢) Î·È ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜. E›‰Ú·ÛË O¶¢ EÓÙÂÚÈ΋ Û›ÙÈÛË ™Ï·¯ÓÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹
IÛ¯·ÈÌ›·
EÓ›Û¯˘ÛË ·ÈÌ¿ÙˆÛ˘
EÓÙÂÚÈÎfi˜ ‚ÏÂÓÓÔÁfiÓÔ˜
AÙÚÔÊ›·, ‰È·ÂÚ·ÙfiÙËÙ· Û ÌÈÎÚfi‚È·, ÂÓ‰ÔÙÔ͛Ә (66%)
AÓ¤·ÊÔ˜, ‚·ÎÙËÚȷ΋ ‰È·ÂÚ·ÙfiÙËÙ· 0-33%
K·ıÂÙ‹Ú˜ - ÏÔÈÌÒÍÂȘ
N·È
KfiÛÙÔ˜
A˘ÍË̤ÓÔ
MÂȈ̤ÓÔ
MÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜
™˘¯Ó¤˜
™¿ÓȘ
AÓÔÛÔηٷÛÙÔÏ‹
¶Èı·Ó‹ (¢E™, Ô˘‰ÂÙÂÚfiÊÈÏ·, T helper: T suppresor)
Ÿ¯È
H·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·
N·È
Ÿ¯È
XÔÏÔ΢ÛÙ›Ùȉ·
N·È
Ÿ¯È
M ÙËÓ ¤ÓÓÔÈ· ·˘Ù‹, Ë Ï‹Ú˘ O¶¢ ηχÙÂÈ ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ ÙÔ˘ ·ÛıÂÓÔ‡˜. T· ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÚÔÛʤÚÔ˘Ó ÌfiÓÔ ÙÔ 30% ¤ˆ˜ 50% ÙˆÓ ÔÏÈÎÒÓ ıÂÚÌ›‰ˆÓ. ™ÙË Ê¿ÛË ÙÔ˘ stress Ë ÁÏ˘Îfi˙Ë ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ Ù· 5-8 mg/kg/min ηıÒ˜ ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ˘‰·Ù·ÓıÚ¿ÎˆÓ ‰ËÌÈÔ˘ÚÁ› ¤Ó· ÛËÌ·ÓÙÈÎfi ÌÂÙ·‚ÔÏÈÎfi stress ¯ˆÚ›˜ Ó· ÚÔÛʤÚÂÈ ÂÈÚfiÛıÂÙË ‚Ô‹ıÂÈ·. T· Ú¿ÁÌ·Ù· Á›ÓÔÓÙ·È ·ÎfiÌË ÈÔ ÔχÏÔη ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, ηıÒ˜ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ (·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ Ï›Ô˘˜ Û ÛË„·ÈÌ›· ‹ ÛÂ Û˘ÛÙËÌ·ÙÈ΋ Ïԛ̈ÍË ·fi Candida, ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ Ï›Ô˘˜ ‹ ÚˆÙÂ˚ÓÒÓ Û ˷ÙÈ΋ ‹ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ù¯ÓÈÎÔ› ÏfiÁÔÈ), ÔÏϤ˜ ÊÔÚ¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·ÔÎÏÂÈÛÙÈο ÂÌÏÔ˘ÙÈṲ̂ӷ ‰È·Ï‡Ì·Ù· ÁÏ˘-
Ÿ¯È
Îfi˙˘ ÌfiÓ· ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰È·Ï‡Ì·Ù· ·ÌÈÓÔͤˆÓ Û ÌÂÚÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ (M¶¢). ™Â ÌÈ· Ù¤ÙÔÈ· ÂÚ›ÙˆÛË, ·˘Í¿ÓÂÙ·È ˘ÂÚ‚ÔÏÈο Ë VCO2 Î·È Û˘ÓÂÒ˜ Ë ıÂÚÌÔÁ¤ÓÂÛË, ÂÓÒ Ì¤ÚÔ˜ Ù˘ ÁÏ˘Îfi˙˘ ÌÂÙ·ÙÚ¤ÂÙ·È Û ϛԘ (ÏÈÔÁ¤ÓÂÛË). MfiÓË Ë ÁÏ˘Îfi˙Ë, ·ÎfiÌË Î·È Ì ÙËÓ ÚÔÛı‹ÎË ·ÌÈÓÔͤˆÓ, ‰ÂÓ ·Ó·ÛÙ¤ÏÏÂÈ ÙË ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛË (Û˘Ó¯‹˜ ηٷ‚ÔÏÈÛÌfi˜ Ì˘ÒÓ), ÂÓÒ Ë ¤ÎÏ˘ÛË ÈÓÛÔ˘Ï›Ó˘ ÂÚÈÔÚ›˙ÂÈ ÌÂÓ ÙËÓ ÚˆÙÂfiÏ˘ÛË ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ, ·˘Í¿ÓÂÈ fï˜ ÙÔÓ "ηÓÓÈ‚·ÏÈÛÌfi" ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÙÚÔÊ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘. ¶·Ú¿ÏÏËÏ·, Ë ÈÓÛÔ˘ÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË ‰ÂÓ ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰È¿Û·ÛË ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ (ηٷ‚ÔÏÈÛÌfi˜ ·ÔıËÎÒÓ Ï›Ô˘˜). °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜, ıˆÚÂ›Ù·È ··Ú·›ÙËÙË Ë ¯ÔÚ‹ÁËÛË ÚˆÙÂ˚ÓÒÓ Î·È Ï›Ô˘˜
¶›Ó·Î·˜ 2. AÏÔÔÈË̤ÓÔ Û¯‹Ì· O¶¢ ·È‰ÈÒÓ Û stress. ¶ÚˆÙ½ÓË 1,5-3,5 g/kg/Ë̤ڷ ñ ™¯¤ÛË ÌË ÚˆÙÂ˚ÓÈÎÒÓ ıÂÚÌ›‰ˆÓ: ·˙ÒÙÔ˘ = 80-150:1 ñ A‡ÍËÛË ·Ó·‚ÔÏÈÛÌÔ‡ ñ M›ˆÛË ÚˆÙÂ˚ÓÈ΋˜ ¯Ú‹Û˘ ÁÈ· ÂÓ¤ÚÁÂÈ· (ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛË) ñ K¿Ï˘„Ë ··Ú·›ÙËÙˆÓ ·ÌÈÓÔͤˆÓ (ÈÛÔÏ¢ΛÓË, Ï¢ΛÓË, Ï˘Û›ÓË, ÌÂıÂÈÔÓ›ÓË, Ê·ÈÓ˘Ï·Ï·Ó›ÓË, ıÚÂÔÓ›ÓË, ÙÚ˘ÙÔÊ¿ÓË, ‚·Ï›ÓË) ñ K¿Ï˘„Ë ÁÏÔ˘Ù·Ì›Ó˘, Ù·˘Ú›Ó˘ §›Ë (35-60%) 2-4 g/kg/ Ë̤ڷ ñ ¶˘ÎÓfi ÂÓÂÚÁÂÈ·Îfi ˘fiÛÙڈ̷ ñ K¿Ï˘„Ë ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ (Linoleic, linolenic) Y‰·Ù¿ÓıڷΘ (35-45%) ñ °Ï˘Îfi˙Ë 5-8 mg/kg/min HÏÂÎÙÚÔχÙ˜ M¤Ù·ÏÏ· - ȯÓÔÛÙÔȯ›· BÈٷ̛Ә
359
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·360
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
ÚÔÎÂÈ̤ÓÔ˘ Ó· Î·Ï˘ÊıÔ‡Ó ÔÈ ıÂÚÌȉÈΤ˜ Î·È ÚˆÙÂ˚ÓÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ·ÛıÂÓÒÓ, fiÙ·Ó Ê˘ÛÈο ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë Î¿Ï˘„Ë ·˘ÙÒÓ ÙˆÓ ·Ó·ÁÎÒÓ ‰È· Ù˘ ÂÓÙÂÚÈ΋˜ Ô‰Ô‡. E›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ‰È·Ù·Ú·Á̤ÓÔ˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ stress, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÓÙÔÓÔ Î·Ù·‚ÔÏÈÛÌfi Î·È ·˘ÍË̤ÓË ·¤ÎÎÚÈÛË ·˙ÒÙÔ˘. ¶·Ú¿ÏÏËÏ·, ÂËÚ¿˙ÂÙ·È Î·È Ë ÚˆÙÂ˚ÓÈ΋ Û‡ÓıÂÛË ÛÙÔ Î˘ÙÙ·ÚÈÎfi Â›Â‰Ô (17). I‰È·›ÙÂÚ·, ÔÈ Ú›˙˜ ¿Óıڷη ÙˆÓ ·ÌÈÓÔͤˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔÓ Î‡ÎÏÔ ÙÔ˘ ÙÚÈηڂÔ͢ÏÈÎÔ‡ ÔͤԘ, ÙË ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛË Î·È ÙË Û‡ÓıÂÛË ÚˆÙÂ˚ÓÒÓ ÔÍ›·˜ Ê¿Û˘. H ·˘ÍË̤ÓË ·˘Ù‹ ÚˆÙÂ˚ÓÈ΋ ·Ó·Î‡ÎψÛË Î·È ·Ó·Î·Ù·ÓÔÌ‹ Ù˘ ÚÔ‹˜ ·ÌÈÓÔͤˆÓ, ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ ˘ÔÛÙ‹ÚÈÍË ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Î·È ÂÓ›Û¯˘ÛË Ù˘ ·Ì˘ÓÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ŒÙÛÈ, ÔÈ ·Ó¿ÁΘ Û ڈÙ½Ó˜ ·˘Í¿ÓÔ˘Ó ÛËÌ·ÓÙÈο ¤ˆ˜ Î·È 300% ÛÙË Ê¿ÛË ÙÔ˘ stress. I‰È·›ÙÂÚ·, ·˘Í¿ÓÔÓÙ·È Î·Ù¿ Ôχ ÔÈ ·Ó¿ÁΘ ÁÈ· ÙË ÁÏÔ˘Ù·Ì›ÓË Î·È Û ÔÚÈṲ̂Ó˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ, fiˆ˜ Â›Ó·È Ù· ÚfiˆÚ· ÓÂÔÁÓ¿, ÁÈ· ¿ÏÏ· ·ÌÈÓÔͤ· fiˆ˜ Â›Ó·È Ë ÌÂıÂÈÔÓ›ÓË, Ù·˘Ú›ÓË, ΢ÛÙ›ÓË Î·È Ù˘ÚÔÛ›ÓË. °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜ Ë O¶¢ Ô˘ ÚÔÔÚ›˙ÂÙ·È ÁÈ· ME£ ·È‰ÈÒÓ ‹ ÓÂÔÁÓÒÓ ÂÌÏÔ˘Ù›˙ÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì ٷ ·ÌÈÓÔͤ· ÁÏÔ˘Ù·Ì›ÓË Î·È Ù·˘Ú›ÓË, ·ÓÙ›ÛÙÔȯ·. ŸÌˆ˜ Î·È Ë ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË M¶¢ ÁÈ· ·Ú·ÙÂٷ̤ӷ ‰È·ÛÙ‹Ì·Ù· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, ηıÒ˜ Û˘Óԉ‡ÂÙ·È ·fi Ë·ÙÈ΋ ÛÙ¿وÛË, ‰È¿Û·ÛË Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, Î·È Âȉ›ӈÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜, Ë·ÙÈ΋˜, Î·È Á·ÛÙÚÂÓÙÂÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·ÏÏ¿ Î·È Î·ı˘ÛÙ¤ÚËÛË ÂԇψÛ˘ ÙˆÓ ÙÚ·˘Ì¿ÙˆÓ. H ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÈÓÛÔ˘Ï›Ó˘ ÏfiÁˆ ˘„ËÏÒÓ ˘ÎÓÔÙ‹ÙˆÓ ÁÏ˘Îfi˙˘ ·˘Í¿ÓÂÈ ÙËÓ ÂÛÙÂÚÔÔ›ËÛË ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ÂÓ·fiıÂÛË Ï›Ô˘˜ ÛÙÔ ‹·Ú. H ÏÈÔÁ¤ÓÂÛË ·˘Ù‹ ÌÂÈÒÓÂÙ·È Ì Ì›ˆÛË Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ˘ÎÓfiÙËÙ·˜ ÁÏ˘Îfi˙˘ Î·È ÚÔÛı‹ÎË Ï›Ô˘˜. M ٷ ‚¿ÛË ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ·Ú·ÙËÚ‹ÛÂȘ Ô˘ ÛÙËÚ›˙ÔÓÙ·È Û ‚·ÛÈ΋ (‚ÈÔ¯ËÌÈ΋, ÂÈÚ·Ì·ÙÈ΋) Î·È ÎÏÈÓÈ΋ ¤Ú¢ӷ, Á›ÓÂÙ·È Ê·ÓÂÚfi fiÙÈ Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ë ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È Ï›Ô˜ (O¶¢). H ÂÈÏÔÁ‹ ·˘Ù‹ Ê˘ÛÈο, ‰ÂÓ ·Ó·ÈÚ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ›‰È· Ë O¶¢ ‰ÂÓ ·‡ÂÈ Ó· ·ÔÙÂÏ› ¤Ó· ÌË Ê˘ÛÈÔÏÔÁÈÎfi ÙÚfiÔ ‰È·ÙÚÔÊ‹˜, ·Ú·Î¿ÌÙÔÓÙ·˜ Ô˘ÛÈÒ‰ÂȘ ÁÈ· ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ıÚÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (¤ÎÎÚÈÛË ÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ, ¤„Ë, ‰È¿Û·ÛË, ÂÎÏÂÎÙÈ΋ ·ÔÚÚfiÊËÛË, ÌÂÙ·‚ÔÏÈÛÌfi˜ ÛÙÔ ‹·Ú). ŒÙÛÈ, fiˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ O¶¢, ȉȷ›ÙÂÚ· Ù˘ Ì·ÎÚfi¯ÚÔÓ˘, ¤¯Ô˘Ó ηٿ ηÈÚÔ‡˜ ηٷÁÚ·Ê› ‰È¿ÊÔÚ· ÌÂÙ·‚ÔÏÈο ÚÔ‚Ï‹Ì·Ù· Ì ÙË ¯ÔÚ‹ÁËÛË ÏÈȉ›ˆÓ. ™Â ÛËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Û˘¯Ó¿ ·˘Í¿ÓÔÓÙ·È Ù· ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ÏÈ·ÚÒÓ ÔͤˆÓ ÏfiÁˆ ÌÂȈ̤Ó˘
360
°. MÚÈ·ÛÔ‡Ï˘
‰Ú¿Û˘ Ù˘ ÏÈÔÚˆÙÂ˚ÓÈ΋˜ ÏÈ¿Û˘, Î·È ··ÈÙÂ›Ù·È Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ÔÚÔ‡ ÙˆÓ ·ÛıÂÓÒÓ. Œ¯Ô˘Ó ›Û˘ ·Ó·ÊÂÚı›, ÌÂȈ̤ÓË Ó¢ÌÔÓÈ΋ ‰È‹ıËÛË Û ۇӉÚÔÌ· ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÊÏÂÁÌÔÓˆ‰ÒÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, ıÚÔÌ‚ÔÂÓ›· Î·È ¤ÎÙÔË ÂÓ·fiıÂÛË ÏÈȉ›ˆÓ ÛÙÔ ‰ÈÎÙ˘ÔÂÓ‰ÔıËÏÈ·Îfi Û‡ÛÙËÌ·. ŸÌˆ˜, ÔÏÏ¿ ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ·˘Ù¿ ‰ÂÓ ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·fi ¿ÏϘ Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ Î·È Û˘Û¯ÂÙ›ÛıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ Ì ˘„ËϤ˜ ‰fiÛÂȘ ‹ ·Ú·ÙÂٷ̤ÓË ¯ÔÚ‹ÁËÛË, ȉ›ˆ˜ Û ¢·›ÛıËÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ (ÚÔˆÚfiÙËÙ·, ÛË„·ÈÌ›·). ™ÙËÓ ÂÚ›ÙˆÛË ¿ÓÙˆ˜ Ì·ÎÚfi¯ÚÔÓ˘ ¯ÔÚ‹ÁËÛ˘ O¶¢, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÚÈÔÚÈÛıÔ‡Ó Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ÚÔ‚Ï‹Ì·Ù·, ¤¯ÂÈ ÚÔÙ·ı› ÙÔ ÏÂÁfiÌÂÓÔ Î˘ÎÏÈÎfi Û¯‹Ì· O¶¢, ηٿ ÙÔ ÔÔ›Ô Ë O¶¢ ¯ÔÚËÁÂ›Ù·È ÁÈ· ‰È¿ÛÙËÌ· 16-20 ˆÚÒÓ ÙÔ 24ˆÚÔ, ·ÔʇÁÔÓÙ·˜ ÙËÓ ·‰È¿ÎÔË Û˘Ó¯‹ ÛÙ¿Á‰ËÓ ¯ÔÚ‹ÁËÛË ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ 24 ÒÚ˜ ÙÔ 24ˆÚÔ. M ÙÔÓ ÙÚfiÔ ·˘Ùfi ·ÔʇÁÂÙ·È Ë ÛÙ·ıÂÚ¿ ·˘ÍË̤ÓË Î˘ÎÏÔÊÔÚ›· ÁÏ˘Îfi˙˘ fiÏÔ ÙÔ 24ˆÚÔ Ô˘ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙË ¯ˆÚ›˜ ÂÚÈfi‰Ô˘˜ ·Ó¿·˘Û˘ Û˘Ó¯‹ ‰È¤ÁÂÚÛË ¤ÎÎÚÈÛ˘ ÈÓÛÔ˘Ï›Ó˘ Î·È ÙË Û˘Ó·ÁfiÌÂÓË ÌÂȈ̤ÓË ÔÍ›‰ˆÛË ÏÈȉ›ˆÓ, ÙËÓ ·‡ÍËÛË ÏÈȉȷ΋˜ ·Ôı‹Î¢Û˘, Î·È ÙËÓ Î·Ù·ÛÙÔÏ‹ ·ÂÏ¢ı¤ÚˆÛ˘ ÙˆÓ ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ. ŒÓ· ȉȷ›ÙÂÚÔ Úfi‚ÏËÌ· Ì ٷ ˘¿Ú¯ÔÓÙ· ‰È·Ï‡Ì·Ù· O¶¢, ÙÔ ÔÔ›Ô ¤¯ÂÈ Á›ÓÂÈ Î·È ·ÓÙÈΛÌÂÓÔ ÂÎÙÂٷ̤Ó˘ ¤Ú¢ӷ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ·ÚÂÓÙÂÚÈο ‰È·Ï‡Ì·Ù· ÏÈÒÓ Î·È ·ÌÈÓÔͤˆÓ Â›Ó·È ÏÈÁfiÙÂÚÔ Ï‹ÚË Î·È ÈÛÔÚÚÔË̤ӷ ·fi Ù· ·ÓÙ›ÛÙÔȯ· ÂÓÙÂÚÈο ‰È·Ï‡Ì·Ù·. ŸÌˆ˜, Ë ¤ÏÏÂÈ„Ë ÈÛÔÚÚÔ›·˜ Â›Ó·È Èı·Ófi Ó· ÂËÚ¿˙ÂÈ ÙËÓ ›‰È· ÙË Û‡ÓıÂÛË ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ¿ÏÏˆÓ ‰ÔÌÈÎÒÓ ÛÙÔȯ›ˆÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·Úfi‚ÏÂÙË ‹ Î·È ·ıÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ηٿ ÙËÓ ¤ÎıÂÛ‹ ÙÔ˘ ÛÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ Î·È ÙËÓ ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó¿Ù˘Í˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·Ó¿ÚÎÂÈ·˜. EȉÈÎfiÙÂÚ·, Ù· ÏÈȉȷο Á·Ï·ÎÙÒÌ·Ù· Ù˘ O¶¢ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÛÔÁȤϷÈÔ ÂÚȤ¯Ô˘Ó ·˘ÍË̤ӷ ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· ˆ-6, ȉ›ˆ˜ ÏÈÓÔÏÂ˚Îfi (C:18:2) Î·È ·Ó·ÚΛ˜ ÔÛfiÙËÙ˜ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ (·-ÙÔÎÔÊÂÚfiÏË). ø˜ ·ÎfiÏÔ˘ıÔ, Ù· ‰È·Ï‡Ì·Ù· ·˘Ù¿ ÚÔηÏÔ‡Ó ·ÓÈÛÔÚÚÔ›· ÙˆÓ Û˘ÓÙÂı¤ÌÂÓˆÓ ‰ÔÌÈÎÒÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ʈÛÊÔÏÈ›‰È· ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ (·˘ÍË̤ÓÔ ÏÈÓÔÏÂ˚Îfi, ˆ-6 ÔÏ˘·ÎfiÚÂÛÙ·, ·Ú·ÁˆÁ‹ ηٷ‚ÔÏÈÙÒÓ ˘ÂÚÔÍ›‰ˆÛ˘ Î·È ÌÂȈ̤ӷ ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ·), ηıÈÛÙÒÓÙ·˜ Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi ΢ÙÙ·ÚÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ ¢¿ÏˆÙÔ˘˜ Û ÔÍÂȉˆÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (.¯. OFR) ηٿ ÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ stress Î·È È‰È·›ÙÂÚ· ÙË Ê¿ÛË Ù˘ ÈÛÙÈ΋˜ ·ӷÈÌ¿ÙˆÛ˘ (reperfusion). °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜, Ë ¤Ú¢ӷ ϤÔÓ ÛÙÚ¤ÊÂÙ·È ÛÙËÓ ·Ú·Û΢‹
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·361
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Û ª∂£
¶›Ó·Î·˜ 3. ™‡Á¯ÚÔÓ˜ Ù¿ÛÂȘ ÛÙËÓ ˘ÔÛÙ‹ÚÈÍË ·È‰ÈÒÓ Û ME£ Ì O¶¢. 1. O¶¢ ÚÔÙÈÌfiÙÂÚË ·fi ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘ ‹ M¶¢ ÁÈ· ·ÔÊ˘Á‹: ñ ñ ñ ñ ñ
ŒÏÏÂȄ˘ Ô˘ÛÈ·ÛÙÈÎÒÓ ÏÈ·ÚÒÓ ÔͤˆÓ (ıÚÔÌ‚ÔÂÓ›·, ·ÏˆÂΛ·, ‰ÂÚÌ·Ù›Ùȉ·.) A˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ÈÓÛÔ˘Ï›Ó˘ ÏfiÁˆ ˘„ËÏÒÓ ˘ÎÓÔÙ‹ÙˆÓ ÁÏ˘Îfi˙˘ EÛÙÂÚÔÔ›ËÛ˘ ÏÈ·ÚÒÓ ÔͤˆÓ, ÂÓ·fiıÂÛ˘ Ï›Ô˘˜ ÛÙÔ ‹·Ú K·Ù·‚ÔÏÈÛÌÔ‡ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ (˘ÔıÚ„›·) K·Ù·‚ÔÏÈÛÌÔ‡ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ (·ÙÚÔÊ›· ÂÓÙ¤ÚÔ˘)
2. K˘ÎÏÈ΋ ¯ÔÚ‹ÁËÛË Ì·ÎÚfi¯ÚÔÓ˘ O¶¢ (‰È¿ÛÙËÌ· ËÚÂÌ›·˜) ÁÈ· ·ÔÊ˘Á‹: ñ MÂȈ̤Ó˘ Ó¢ÌÔÓÈ΋˜ ‰È‹ıËÛ˘, ·‡ÍËÛ˘ ÂȤ‰ˆÓ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ (ÚÔÛÙ·ÁÏ·Ó‰›Ó˜ = ·ÁÁÂÈÔÛ‡Û·ÛË Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ, ÏÈÒ‰Ë ÌÈÎÚԤ̂ÔÏ·) ñ A˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ PGE2, ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ‰Ú¿Û˘ ñ EÓ·fiıÂÛ˘ Û ¢E™, ‹ ¤ÎÙÔ· ÂÓ‰Ô΢ÙÙ¿ÚÈ· (ηÚÓÈÙ›ÓË) ñ £ÚÔÌ‚ÔÂÓ›·˜, ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›·˜ (ÌÂȈ̤ÓË ‰Ú¿ÛË ÏÈÔÚˆÙÂ˚ÓÈ΋˜ ÏÈ¿Û˘) 3. EÌÏÔ˘ÙÈÛÌfi˜ Ì ÁÏÔ˘Ù·Ì›ÓË ñ A·Ú·›ÙËÙÔ ÁÈ· ÏÂÙfi ¤ÓÙÂÚÔ Î·È ·ÓÔÛÔ·ÙÙ·Ú· Û ηٿÛÙ·ÛË stress 4. §Èȉȷο Á·Ï·ÎÙÒÌ·Ù· Ì MCT:LCT 50%-50% + ˆ-3 ÏÈ·Ú¿ Ôͤ· ñ MÂȈ̤ӷ ÂÈÎÔÛ·ÓÔÂȉ‹, ·˘ÍË̤ÓË ·ÓÙÈÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË, ·˘ÍË̤ÓË ·ÓÔÛ›· ñ T·¯Â›· ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙÔ Ï¿ÛÌ· 5. ŒÚ¢ӷ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ÈÛÔÚÚÔË̤ӷ ‰È·Ï‡Ì·Ù· ñ AÔÊ˘Á‹ ·ÓÈÛÔÚÚÔ›·˜ Ô˘ Â›Ó·È Èı·Ófi Ó· ÂËÚ¿˙ÂÈ ÙËÓ ¤Î‚·ÛË Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ ñ AÔÊ˘Á‹ ÚfiÎÏËÛ˘ ·ÓÈÛÔÚÚÔ›·˜ ÛÙ· ʈÛÊÔÏÈ›‰È· ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ (·˘ÍË̤ÓÔ ÏÈÓÔÏÂ˚Îfi, ˆ-6 ÔÏ˘·ÎfiÚÂÛÙ·, ·Ú·ÁˆÁ‹ ηٷ‚ÔÏÈÙÒÓ ˘ÂÚÔÍ›‰ˆÛ˘ Î·È ÌÂȈ̤ӷ ˆ-3). ÏÈȉȷÎÒÓ Á·Ï·ÎÙˆÌ¿ÙˆÓ Ô˘ Ó· ÂÚȤ¯Ô˘Ó ÈÛÔÚÚÔË̤ÓË ·Ó·ÏÔÁ›· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ̤Û˘ Î·È Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (MCT:LCT 50%:50%), Ô˘ Ì ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÚÔÛı‹ÎË ÙˆÓ ˆ-3 (ˆ-6:ˆ-3 2:1) ÏÈ·ÚÒÓ ÔͤˆÓ ı· ÚÔÛ‰›‰Ô˘Ó ÛÙ· ‰È·Ï‡Ì·Ù· ·˘ÍË̤ÓË ·ÓÙÈÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË Î·È ÂÓÈÛ¯˘Ì¤ÓË ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË (18). M ‚¿ÛË fiÏ· Ù· ·ÓˆÙ¤Úˆ, ÔÈ Û‡Á¯ÚÔÓ˜ Ù¿ÛÂȘ ÛÙËÓ O¶¢ ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È ÛËÌ·ÓÙÈο Û ۯ¤ÛË Ì ٷ ηıÈÂڈ̤ӷ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Û¯‹Ì·Ù· (¶›Ó·Î·˜ 3). OÏÈ΋ ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ º˘ÛÈο Ù· ÚÔ‚Ï‹Ì·Ù· ‰ÂÓ ÂÚÈÔÚ›˙ÔÓÙ·È ÌfiÓÔ ÛÙËÓ O¶¢ ·ÏÏ¿ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÂÂÎÙ›ÓÔÓÙ·È Î·È ÛÙË ¯ÔÚ‹ÁËÛË Ù˘ ÔÏÈ΋˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (OE¢) (ηı˘ÛÙ¤ÚËÛË Á·ÛÙÚÈ΋˜ ΤӈÛ˘, ‰È¿ÚÚÔÈ·, ÌÂÙ·ÙfiÈÛË Î·ıÂÙ‹Ú·, ÂÈÛÚfiÊËÛË, ÎfiÛÙÔ˜ ·ÓÙÏÈÒÓ Û˘Ó¯ԇ˜ ¤Á¯˘Û˘). T· ÔʤÏË ÂÓÙÔ‡ÙÔȘ, ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ OE¢ Â›Ó·È ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚ· ·fi ÙȘ Ù˘¯fiÓ ·ÚÂÓ¤ÚÁÂȤ˜ Ù˘ Î·È Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ÚÔÒıËÛ˘ Ù˘ ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ ¤Ó·ÓÙÈ Ù˘ O¶¢ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ (¶›Ó·Î·˜ 4). AÎfiÌË Î·È ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ì˘ÓÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·ÚÎÔ‡˜ ¤ÎÎÚÈÛ˘ Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ A, ··Ú·›ÙËÙË Â›Ó·È Ë ‰È¤ÁÂÚÛ‹ Ù˘ ̤ۈ Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (19). Ÿˆ˜ Â›Ó·È Â˘ÓfiËÙÔ, Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË Û‹ÌÂÚ· Ù›ÓÂÈ Ó· Á›ÓÂÈ Ë ‰È·ÙÚÔÊ‹ ÂÈ-
ÏÔÁ‹˜ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ (20). ¶ÚÔ·ÙÔ˘Ó ¤ÙÛÈ, ÂÚˆÙ‹Ì·Ù· ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜, ÙËÓ Î·Ù¿ÏÏËÏË ÔÛfiÙËÙ· ˘ÁÚ‹˜ ÙÚÔÊ‹˜, ÙÔÓ Î·Ù¿ÏÏËÏÔ ¯ÚfiÓÔ ¤Ó·Ú͢ Ù˘ Û›ÙÈÛ˘. EÈÏÔÁ‹ ÂÓÙÂÚÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ¶·Ú¿ ÙËÓ ‡·ÚÍË ÔÏÏÒÓ Û¯ËÌ¿ÙˆÓ Ï‹ÚÔ˘˜ ˘ÁÚ‹˜ ‰È·ÙÚÔÊ‹˜ ·fi ÙÔ ¤ÓÙÂÚÔ, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¶›Ó·Î·˜ 4. ¶ÏÂÔÓÂÎÙ‹Ì·Ù· ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ 1. £ÂÙÈ΋ Ê˘ÛÈÔÏÔÁÈ΋ ‰Ú¿ÛË ñ §ÂÈÙÔ˘ÚÁ›· ¤„˘ - ‰È¤ÁÂÚÛË ÚˆÙÂ˚ÓÈ΋˜ Û‡ÓıÂÛ˘ ñ P˘ıÌÈÛÙÈ΋ ÈηÓfiÙËÙ· ·ÔÚÚfiÊËÛ˘ ıÚÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ ñ AÏÏËÏ›‰Ú·ÛË ıÚÂÙÈÎÒÓ ˘ÔÛÙÚˆÌ¿ÙˆÓ ÔÚÌÔÓÒÓ (¤ÎÎÚÈÛË Á·ÛÙÚ›Ó˘, ÂÓÙÂÚÔÁÏ˘Î·ÁfiÓ˘, ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ÂȉÂÚÌÈÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·) ñ ¢È·Ù‹ÚËÛË ·ÎÂÚ·ÈfiÙËÙ·˜ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ 2. M›ˆÛË ÓÔÛËÚfiÙËÙ·˜ (ÏÔÈÌÒÍÂȘ, ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ·) 3. M›ˆÛË ËÌÂÚÒÓ ÓÔÛËÏ›·˜, ıÓËÛÈÌfiÙËÙ·˜ 4. ÕÓÂÛË, ·ÛÊ¿ÏÂÈ· 5. X·ÌËÏfi ÎfiÛÙÔ˜
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30-05-03
14:03
™ÂÏ›‰·362
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
ÂÚÈÙÒÛÂȘ ÚÔÙÈÌÔ‡ÓÙ·È ÔÈ ÔÏ˘ÌÂÚ›˜ ‰›·ÈÙ˜ Ô˘ ·ÔÙÂÏÔ‡ÓÙ·È ·fi ·Ó¤·Ê˜ ÚˆÙ½Ó˜, Û‡ÌÏÔÎÔ˘˜ ˘‰·Ù¿ÓıڷΘ, ÔÈΛϷ ÔÛ¿ Ï›Ô˘˜, ̤ٷÏÏ·, ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›· (21). TÔ ˘„ËÏfi ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ‰›ÓÂÈ ÛÙȘ ‰›·ÈÙ˜ ·˘Ù¤˜ ¯·ÌËÏ‹ ˆÛÌÔÙÈÎfiÙËÙ·. ™Â ·ÛıÂÓ›˜ Ì Ôχ ·˘ÍË̤ÓÔ Î·Ù·‚ÔÏÈÛÌfi (.¯. ÂÁη˘Ì·Ù›Â˜) ÚÔÙÈÌÔ‡ÓÙ·È ‰›·ÈÙ˜ ˘ÂÚÚˆÙÂ˚ÓÔ‡¯Â˜ Î·È ˘ÂÚıÂÚÌȉÈΤ˜ (1,5 kcal/ml). OÈ ÔÏÈÁÔÌÂÚ›˜ ‰›·ÈÙ˜ Â›Ó·È Â›Û˘ Ï‹ÚÂȘ ÙÚÔʤ˜, ÂÚȤ¯Ô˘Ó fï˜ ÔÏÈÁÔÂÙ›‰È· Î·È ¤ÙÛÈ Â›Ó·È ‰˘Ó·Ùfi Ó· ¯ÔÚËÁËıÔ‡Ó Û ·ÛıÂÓ›˜ Ì ÚÔ‚Ï‹Ì·Ù· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. OÈ ÌÔÓÔÌÂÚ›˜ ‹ ÛÙÔȯÂȷΤ˜ ‰›·ÈÙ˜ Â›Ó·È Î·Ù¿ ηÓfiÓ· ˘ÂÚÔÛ̈ÙÈΤ˜ ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ÙˆÓ ıÚÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ô˘ ÙËÓ ·ÔÙÂÏÔ‡Ó. A˘Ù¤˜ ··ÈÙÔ‡Ó ÂÏ¿¯ÈÛÙË ÂÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔÈ ÙÔ˘ ÂÓÙ¤ÚÔ˘) Î·È ·ÔÚÚÔÊÔ‡ÓÙ·È Â‡ÎÔÏ·, ·Ê‹ÓÔÓÙ·˜ ÂÏ¿¯ÈÛÙÔ ˘fiÏÂÈÌÌ·. ¶ËÁ¤˜ ˘‰·Ù·ÓıÚ¿ÎˆÓ ·ÔÙÂÏÔ‡Ó ÔÈ ÔÏÈÁÔ۷ί·Ú›‰Â˜, Ë ÛÔ˘ÎÚfi˙Ë Î·È Ë ÁÏ˘Îfi˙Ë. OÈ ÚˆÙ½Ó˜ Â›Ó·È ÚˆÙÔ·ı‹ ‚Ú·¯Â›·˜ ·Ï‡ÛÔ˘ ÂÙ›‰È· Î·È ·ÌÈÓÔͤ·. T· Ï›Ë Û˘Ó‹ıˆ˜ ·ÔÙÂÏÔ‡ÓÙ·È ·fi ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È ÌÈÎÚ¿ ÔÛ¿ ÏÈ·ÚÒÓ ÔͤˆÓ. T¤ÏÔ˜, ÂȉÈΤ˜ ‰›·ÈÙ˜ ¤¯Ô˘Ó ۯ‰ȷÛı› ÁÈ· Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ·ÛıÂÓ›˜ Ì ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜, Û‡Ó‰ÚÔÌ· ‰˘Û·ÔÚÚfiÊËÛ˘ Î·È ÔÚÁ·ÓÈΤ˜ ·Ó¿ÚÎÂȘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Û˘ÁÎÂÎÚÈ̤Ó˜ ·ı‹ÛÂȘ. EÓÙÔ‡ÙÔȘ, ÛÙȘ ME£ ÓÔÛËχÔÓÙ·È Û˘¯ÓfiÙÂÚ· ·ÛıÂÓ›˜ ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ stress, ηٷ‚ÔÏÈÎÔ›, Ì οÔÈÔ˘ ›‰Ô˘˜ ·ÓÔÛÔηٷÛÙÔÏ‹, ÛË„·ÈÌ›· ‹ ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ·. H ÌÂÙ·ÙÚÔ‹ Ù˘ ÛÙÔȯÂȷ΋˜ ‰›·ÈÙ·˜ Û ·ÓÔÛÔÂÓÈÛ¯˘ÙÈ΋ ¤¯ÂÈ ·ÓÔ›ÍÂÈ ÙÔ ‰ÚfiÌÔ ÛÙËÓ ÂÍÂȉÈÎÂ˘Ì¤ÓË Û›ÙÈÛË ÙˆÓ ·ÛıÂÓÒÓ ÙˆÓ ME£, Ì ‰ÈÏfi ÛÙfi¯Ô ÙËÓ ÈηÓÔÔÈËÙÈ΋ ıÚÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍ‹ ÙÔ˘˜ Î·È ÙËÓ Ù·˘Ùfi¯ÚÔÓË Ê·Ú̷΢ÙÈ΋ ·Ú¤Ì‚·ÛË ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ ̤ۈ Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (·ÓÔÛԉȷÙÚÔÊ‹) (22). A˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙˆÓ ÂÓÙÂÚÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ Ì ·˘ÍË̤ӷ ÔÛ¿ ·ÏÒÓ ıÚÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ (ÁÏÔ˘Ù·Ì›ÓË, ·ÚÁÈÓ›ÓË, ˆ-3 ÏÈ·Ú¿ Ôͤ·, ÓÔ˘ÎÏÂÔÙ›‰È·, ·ÓÙÈÔÍÂȉˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜) Ô˘ fï˜ Û ÌÂÁ¿Ï˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÌÂÙ·ÙÚ¤ÔÓÙ·È Û ʷÚ̷΢ÙÈΤ˜ ‰Ú·ÛÙÈΤ˜ Ô˘Û›Â˜. ŒÙÛÈ, Ë ÁÏÔ˘Ù·Ì›ÓË ÚÔ¿ÁÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ê·ÁÔ΢ÙÙ·ÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ, Ë ·ÚÁÈÓ›ÓË ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙˆÓ ·ÛıÂÓÒÓ, Î·È Ù· ˆ-3 ÏÈ·Ú¿ Ôͤ· ÌÂÈÒÓÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ÊÏÂÁÌÔÓˆ‰ÒÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ (23). ¶ÔÛfiÙËÙ· ˘ÁÚ‹˜ ÙÚÔÊ‹˜ ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÔÛfiÙËÙ· ıÂÚÌ›‰ˆÓ ÛÙË Ê¿ÛË ÙÔ˘ stress, ÚfiÛÊ·ÙË ÌÂϤÙË Ì ¤ÌÌÂÛË ıÂÚÌȉÔÌÂÙÚ›· Û ME£ ·È‰ÈÒÓ ¤‰ÂÈÍ fiÙÈ Ë ÌÂÙÚËı›˜ ÂÓ¤Ú-
362
°. MÚÈ·ÛÔ‡Ï˘
ÁÂÈ· ÛÙËÓ ÔÍ›· Ê¿ÛË ‚·ÚÈ¿˜ ÓfiÛÔ˘ ÚÔÛÂÁÁ›˙ÂÈ ÙÔÓ ¶BM ÙˆÓ ·ÛıÂÓÒÓ (15). ¢È·¯ÚÔÓÈο, Ô ˘ÔÌÂÙ·‚ÔÏÈÛÌfi˜ ¯·Ú·ÎÙ‹ÚÈÛ ÙÔ Î˘Ú›ˆ˜ ÌÂÙ·‚ÔÏÈÎfi ÚfiÙ˘Ô Ù˘ ÚÒÙ˘ Ë̤ڷ˜, ÂÓÒ Ô ˘ÂÚÌÂÙ·‚ÔÏÈÛÌfi˜ ·ÂÙ¤ÏÂÛ ¤Ó· ÂÚÈÛÛfiÙÂÚÔ fi„ÈÌÔ Û˘Ì‚¿Ó (5Ë-10Ë Ë̤ڷ). K·Ù¿ ÙË ‰È¿ÚÎÂÈ· fiÏˆÓ ÙˆÓ Ê¿ÛÂˆÓ ÙÔ˘ stress, ÔÈ ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi ·ÂÙ¤ÏÂÛ·Ó ¤ˆ˜ Î·È ÙÔ 40% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ù˘ ÌÂϤÙ˘. H ·Úfi‚ÏÂÙË ·˘Ù‹ ÔÈÎÈÏÔÌÔÚÊ›· ηıÈÛÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ˘ÔÏÔÁÈÛÌÔ‡ ÙˆÓ ıÂÚÌȉÈÎÒÓ ·Ó·ÁÎÒÓ Û ·ÛıÂÓ›˜ ME£ ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏË, Ì fiÏ· Ù· Û˘Ó·ÎfiÏÔ˘ı· ÚÔ‚Ï‹Ì·Ù· Ô˘ ¤¯Ô˘Ó ‹‰Ë ·Ó·ÊÂÚı› ·Ú·¿Óˆ. AÛÊ·ÏÒ˜, ÙËÓ È‰·ÓÈ΋ χÛË ·ÔÙÂÏ› Ë Ì¤ÙÚËÛË Ù˘ ηٷӷÏÈÛÎfiÌÂÓ˘ ÂÓ¤ÚÁÂÈ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ¤ÌÌÂÛ˘ ıÂÚÌȉÔÌÂÙÚ›·˜ Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ·Ó·Ï‹ÚˆÛ‹ Ù˘. ŒÓ·ÚÍË Û›ÙÈÛ˘ NÂfiÙÂÚ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÎÚ›ÛÈÌ· ÛÙËÓ ÂͤÏÈÍ‹ ÙÔ˘˜ ÓÔÛ‹Ì·Ù·, fiˆ˜ Ë ÛË„·ÈÌ›·, Ë ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ë ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË Ô˘ ··ÈÙÔ‡Ó Û˘ÛÙËÌ·ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Û ÔÏ˘‰‡Ó·Ì˜ ME£, ÂËÚ¿˙Ô˘Ó ·ÚÓËÙÈο ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ô‰ËÁÒÓÙ·˜ Û ·ÙÚÔÊ›· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, Î·È ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· Û ÌÈÎÚfi‚È· Î·È Ì·ÎÚÔÌfiÚÈ· fiˆ˜ ÔÈ ÂÓ‰ÔÙÔ͛Ә (24). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ë ÚÒÈÌË ÂÓÙÂÚÈ΋ Û›ÙÈÛË ‰Ú· ÚÔÛٷ٢ÙÈο ÛÙÔÓ ÂÓÙÂÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ÚÔÏ·Ì‚¿ÓÔÓÙ·˜ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ fiˆ˜ Ë ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ· (25). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÌÂ Î¿Ï˘„Ë ÙˆÓ ‚·ÛÈÎÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ Ì ÂȉÈ΋ Ï‹ÚË ˘ÁÚ‹ ÙÚÔÊ‹ Â›Ó·È ÂÊÈÎÙ‹, ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ME£ (26). H ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È Ë ¯Ú‹ÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ ‹ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ ‰ÚÔ˘Ó ·Ó·ÛÙ·ÏÙÈο ÛÙËÓ ÚÔÒıËÛË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘. AÓÙ›ıÂÙ·, Ë ÂÈÙ˘¯‹˜ ÂÊ·ÚÌÔÁ‹ Ù˘ ¤ÁηÈÚ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Û ·È‰È¿ Û stress Û˘Ó‰¤ÂÙ·È Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ì ıÂÙÈÎÔÔ›ËÛË ÙÔ˘ NB Î·È Î·Ï‹ ÙÂÏÈ΋ ¤Î‚·ÛË (27). M¤ıÔ‰ÔÈ ÂÓÈÛ¯˘ÙÈ΋˜ ıÂڷ›·˜ Ù˘ ıÚ¤„˘ H ·Ó¿ÁÎË ÁÈ· Ӥ˜ ıÂڷ¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÂÏÙȈı› Ë ÌÂÙ·‚ÔÏÈ΋ Î·È ÎÏÈÓÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÚÂÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ¤¯ÂÈ ÙÔÓÈÛı› ȉȷ›ÙÂÚ· ÙÂÏÂ˘Ù·›·. H ¯ÔÚ‹ÁËÛË ‚ÂÏÙȈÙÈ΋˜ ıÂڷ›·˜ ÌÂÏÂÙ‹ıËΠ΢ڛˆ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·ÏÏ¿ Î·È Û ÓÂfiÙÂÚ˜ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜. H ÚÔÛ¤ÁÁÈÛË Ù˘ ÂÓÈÛ¯˘ÙÈ΋˜ ·˘Ù‹˜ ıÂڷ›·˜ ÛÙË ıÚÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ‚·ÚÈ¿ ·Û¯fiÓÙˆÓ ˘Ô‚¿ÏÏÂÙ·È Û‹ÌÂÚ· Û ÂÎÙÂٷ̤ÓË Î·È ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÎÏÈÓÈ΋ ¤Ú¢ӷ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ: (¶›Ó·Î·˜ 5)
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·363
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
¶›Ó·Î·˜ 5. EÓÈÛ¯˘ÙÈΤ˜ ̤ıÔ‰ÔÈ ıÚÂÙÈ΋˜, ÌÂÙ·‚ÔÏÈ΋˜ Î·È ·ÓÔÛÔÏÔÁÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·ÛıÂÓÒÓ 1. XÔÚ‹ÁËÛË ·Ó·Û˘Ó‰˘·ÛÌ¤ÓˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÛÙÂÚÔÂȉÒÓ (rGH, oxandrolone) ñ ™˘ÓÔÏÈ΋ ·Ó·‚ÔÏÈ΋ ‰Ú¿ÛË ñ EȉÈΤ˜ - ÈÛÙÈΤ˜ ÙÚÔÊÈΤ˜ ‰Ú¿ÛÂȘ (¤ÓÙÂÚÔ, ̇˜, ÙÚ·‡Ì·Ù·) ñ Ÿ¯È ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· Û ·ÛıÂÓ›˜ ME£ (·ÓÙ›ıÂÙË ‰Ú¿ÛË ÎÔÚÙÈ˙fiÓ˘, ηÙ¯ÔÏ·ÌÈÓÒÓ, ΢ÙÔÎÈÓÒÓ;) ñ ¶·ÚÂÓ¤ÚÁÂȘ: YÂÚÁÏ˘Î·ÈÌ›·, ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· 2. XÔÚ‹ÁËÛË ‰˘ÓËÙÈο ··Ú·›ÙËÙˆÓ ·ÌÈÓÔͤˆÓ (·ÚÁÈÓ›ÓË, ÁÏÔ˘Ù·Ì›ÓË) ñ AÓ·‚ÔÏÈ΋ ‰Ú¿ÛË ñ AÓÔÛÔÚÚ‡ıÌÈÛË ñ AÓ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÂÓÙÂÚÈο ‰È·Ï‡Ì·Ù·; A˙ˆı·ÈÌ›·; 3. XÚ‹ÛË ÙÚÔÔÔÈËÌ¤ÓˆÓ Û˘Ó‰˘·ÛÌÒÓ ÏÈȉ›ˆÓ ÛÙË ‰È·ÙÚÔÊ‹ ·ÛıÂÓÒÓ ÛÙȘ ME£ (Ù¯ÓËÙ¿ Ï›Ë, ȯı˘¤Ï·È·: ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·) ñ AÓÔÛÔÂÓÈÛ¯˘ÙÈ΋ ‰Ú¿ÛË ñ AÓÙÈÊÏÂÁÌÔÓ҉˘ ‰Ú¿ÛË ñ ¶ÚÔ‚Ï‹Ì·Ù· Ì ·˘ÙÔÔÍ›‰ˆÛË, ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË 4. XÔÚ‹ÁËÛË ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ Ô˘ÛÈÒÓ (‚ÈÙ·Ì›ÓË A, C, E, ‚-ηÚÔÙ¤ÓÈ·, CSH) ñ IÛÙÈ΋ ·Ó·Û‡ÓıÂÛË, ΢ÙÙ·ÚÈ΋ ÚÔÛÙ·Û›· ñ MÂÌÔӈ̤Ó˜ ‰ÚÔ˘Ó ÚÔÔÍÂȉˆÙÈο! I‰ÂÒ‰ÂȘ Û˘Ó‰˘·ÛÌÔ›; 5. ™˘Ó‰˘·Ṳ̂Ó˜ ıÂڷ›˜ (rGH + ÁÏÔ˘Ù·Ì›ÓË + ‰›·ÈÙ·) ñ AÏÏËÏÔÛ˘ÌÏ‹ÚˆÛË Î·È ·Ó·›ÚÂÛË ÂÈÏÔÎÒÓ
1. AÓ·Û˘Ó‰˘·Ṳ̂ÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË H ¯ÔÚ‹ÁËÛË rGH Û ʷÚÌ·ÎÔÏÔÁÈΤ˜ ‰fiÛÂȘ (0,05-0,2 mg/kg/d) ‚ÂÏÙÈÒÓÂÈ ÙÔÓ ÚˆÙÂ˚ÓÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi Û ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ηٷÛÙ¿ÛÂȘ, ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ· Î·È AIDS. EȉÈÎfiÙÂÚ·, Ë ‰Ú¿ÛË Ù˘ ¤¯ÂÈ ÙÂÎÌËÚȈı› ÛÙËÓ ÂԇψÛË ÙÚ·˘Ì¿ÙˆÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰¤ÚÌ·ÙÔ˜. ™Â ·È‰È¿ Ì ÛÔ‚·Ú¿ ÂÁη‡Ì·Ù· ›Û˘, Ë ËÌÂÚ‹ÛÈ· ¯ÔÚ‹ÁËÛË rGH Û ‰fiÛË 0,2 mg/kg ‚ÂÏÙ›ˆÛ ÙÔ˘˜ Ú˘ıÌÔ‡˜ ÂԇψÛ˘ ÙˆÓ ÙÚ·˘Ì¿ÙˆÓ Î·È Ì›ˆÛ ÙÔÓ ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (28). EÓÙÔ‡ÙÔȘ, ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔÈ ·ÛıÂÓ›˜ Â›Ó·È ·ÓıÂÎÙÈÎÔ› ÛÙËÓ ·Ó·‚ÔÏÈ΋ ‰Ú¿ÛË Ù˘ rGH. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙ›ÛÙ·ÛË ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·È ÙË ‰Ú¿ÛË ÙˆÓ Ù·˘Ùfi¯ÚÔÓ· ·Ú·ÁfiÌÂÓˆÓ ÔÚÌÔÓÒÓ ÙÔ˘ stress (ÎÔÚÙÈ˙fiÓË, ηÙ¯ÔϷ̛Ә, ΢ÙÙÔΛÓ˜) (29). ø˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ÂÓÈÛ¯˘ÙÈ΋˜ ·˘Ù‹˜ ÌÂıfi‰Ô˘ ıÚÂÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢
¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Û ª∂£
ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·Ó·Ê¤ÚÔÓÙ·È: ˘ÔÁÏ˘Î·ÈÌ›· ·ÓıÂÎÙÈ΋ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·, ηٷÎÚ¿ÙËÛË Na, ÓÂÔÏ·ÛÌ·ÙÈ΋ ˘ÂÚÏ·Û›·. 2. ¶·Ú¿ÁÔÓÙ·˜ ·‡ÍËÛ˘ Ù˘ ÈÓÛÔ˘Ï›Ó˘ (IGF-1) E›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ Î·È Û˘¯Ó¿ ÚÔηÏ› ˘ÔÁÏ˘Î·ÈÌ›· (30). H ›‰È· Ë ÈÓÛÔ˘Ï›ÓË ¿ÏψÛÙÂ, ·ÛΛ ·Ó·‚ÔÏÈ΋ ›‰Ú·ÛË ÌfiÓÔ fï˜ ηٿ ÙË ıÂڷ›· Ù˘ ˘ÂÚÁÏ˘Î·ÈÌ›·˜. 3. AÓ·‚ÔÏÈΤ˜ ÛÙÂÚÔÂȉ›˜ ÔÚÌfiÓ˜ ™Â ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ ¤¯ÂÈ ÂÈÙ˘¯Ò˜ ‰ÔÎÈÌ·Ûı› Ë Oxandrolone (31). ¢ÂÓ ˘¿Ú¯ÂÈ fï˜ ·Ú΋˜ ÙÂÎÌËÚ›ˆÛË, ÂÓÒ ÂÏÏÈ‹˜ Â›Ó·È Ë ÏËÚÔÊfiÚËÛË ÁÈ· ÙȘ ·ÚÂÓ¤ÚÁÂȤ˜ Ù˘ ÛÙ· ·È‰È¿. 4. AÚÁÈÓ›ÓË TÔ ‰˘ÓËÙÈο ··Ú·›ÙËÙÔ Û ηٿÛÙ·ÛË stress ·ÌÈÓÔ͇ ·ÚÁÈÓ›ÓË, Â›Ó·È ËÌÈÛ˘ÓıÂÙÈÎfi, ÂӉȿÌÂÛÔ ÙÔ˘ ·ÎÏÔ˘ Ù˘ Ô˘Ú›·˜ Î·È ¤ÌÌÂÛ· Û˘Ó‰Â‰Â̤ÓÔ Ì ÙÔÓ Î‡ÎÏÔ ÎÈÙÚÈÎÔ‡, Û˘ÌÌÂÙ¤¯ÔÓÙ·˜ ÛÙËÓ ÔÍ›‰ˆÛË ÂÓÂÚÁÂÈ·ÎÒÓ ˘ÔÛÙڈ̿وÓ. ™ÙË Ê¿ÛË ÙÔ˘ stress ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ë ÂÓ‰ÔÁÂÓ‹˜ ·Ú·ÁˆÁ‹ ÙÔ˘, ÂËÚ¿˙ÔÓÙ·˜ ·ÚÓËÙÈο ÙËÓ ·ÓÔÛÔÚÚ‡ıÌÈÛË. H ·ÚÁÈÓ›ÓË ·˘Í¿ÓÂÈ ÙË ‰Ú·ÛÙÈÎfiÙËÙ· ÙˆÓ T-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‰ÈÂÁ›ÚÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2, Î·È ·˘Í¿ÓÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÙÚÔÊÈÎÒÓ ÔÚÌÔÓÒÓ (ÈÓÛÔ˘Ï›ÓË, ۈ̷ÙÔÛÙ·Ù›ÓË, ·˘ÍËÙÈ΋ ÔÚÌfiÓË). EÓÈÛ¯‡ÂÈ ÙËÓ ·ÓÔÛÔ΢ÙÙ·ÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË ÂÈÚ·Ì·Ùfi˙ˆˆÓ Û ÛËÙÈΤ˜ ηٷÛÙ¿ÛÂȘ, ÂÈÙ·¯‡ÓÂÈ ÙËÓ ÂԇψÛË Î·È ‰È¢ÎÔχÓÂÈ ÙËÓ ¤ÎÎÚÈÛË GH (32). Œ¯ÂÈ ÂÚÈÁÚ·Ê› ̤ÙÚÈ· ‚ÂÏÙ›ˆÛË ÙÔ˘ NB Û ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡˜ ·ÚÚÒÛÙÔ˘˜ Û ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ÂÌÏÔ˘ÙÈṲ̂ÓË Ì ·ÚÁÈÓ›ÓË. ¶Èı·Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ: ·˘ÍË̤ÓË ·¤ÎÎÚÈÛË Ï˘Û›Ó˘ (·ÎfiÌË Î·È ·Ó¿ÚÎÂÈ·), ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ·˙ˆı·ÈÌ›·. 5. °ÏÔ˘Ù·Ì›ÓË H ÁÏÔ˘Ù·Ì›ÓË Â›Ó·È ÙÔ ·ÊıÔÓfiÙÂÚÔ ·ÌÈÓÔ͇ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi, ·ÔÙÂÏÒÓÙ·˜ ÙÔ 60% ÙˆÓ ÂχıÂÚˆÓ ·ÌÈÓÔͤˆÓ ÛÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ Ì˘˜ Î·È ÙÔ 20% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ÂχıÂÚˆÓ ·ÌÈÓÔͤˆÓ. ™˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ÔÍÂÔ‚·ÛÈ΋ ÈÛÔÚÚÔ›·, ÛÙË ÁÏ˘ÎÔÓÂÔÁ¤ÓÂÛË Î·È ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ˘fiÛÙڈ̷ Ù·¯¤ˆ˜ ÔÏÏ·Ï·ÛÈ·˙fiÌÂÓˆÓ ÈÛÙÒÓ, fiˆ˜ Â›Ó·È ÙÔ ¤ÓÙÂÚÔ Î·È ÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ·. ¶ÂÚÈÛÙ·Ûȷο ÂÓÙÔ‡ÙÔȘ, Û ¤ÓÙÔÓ˜ ηٷ‚ÔÏÈΤ˜ ηٷÛÙ¿ÛÂȘ Î·È ÛËÌ·ÓÙÈ΋ ηٷӿψÛË (·˘ÍË̤Ó˜ ·Ó¿ÁΘ, ÌÂȈ̤ÓË ÂÓ‰ÔÁÂÓ‹ ·Ú·ÁˆÁ‹), Ë ÁÏÔ˘Ù·Ì›ÓË ÌÂÙ·ÙÚ¤ÂÙ·È Û ··Ú·›ÙËÙÔ ·ÌÈÓÔ͇. TÔ ·ÌÈÓÔ͇ ·˘Ùfi ÚÔ¿ÁÂÈ ÙË Ê·ÁÔ΢ÙÙ·ÚÈ΋ ÈηÓfiÙËÙ· ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ‰ÈÂÁ›ÚÂÈ ÙËÓ T-ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ·ÓÙ·fiÎÚÈÛË Î·È ÙÔÓ ÏfiÁÔ CD4/CD8 ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. A˘Í¿ÓÂÈ ÙÔ NB, ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙȘ ÏÔÈÌÒÍÂȘ, ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘
363
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·364
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ Î·È ÙËÓ ÂÈ‚›ˆÛË (33). ¶·Ú' fiÏ· ·˘Ù¿, ‰ÂÓ ‰È·ÈÛÙÒıËΠη̛· ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ·fi ÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË ÁÏÔ˘Ù·Ì›Ó˘ Û ·ÛıÂÓ›˜ ME£ ÂÓ‹ÏÈΘ Î·È ·È‰È¿ (‰ÈϤ˜ Ù˘ÊϤ˜ ÌÂϤÙ˜) (34). I‰È·›ÙÂÚ·, Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÂÌÏÔ˘ÙÈṲ̂ÓË Ì ÁÏÔ˘Ù·Ì›ÓË ‰ÂÓ ·‡ÍËÛ ٷ ›‰· ÁÏÔ˘Ù·Ì›Ó˘ ÛÙÔ ·›Ì· Û ‰È¿ÊÔÚ˜ ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ, Û ·ÓÙ›ıÂÛË Ì ÙËÓ O¶¢ fiÔ˘ ÛËÌÂÈÒıËΠ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ. H ·ÈÙ›· Â›Ó·È Èı·ÓÒ˜ Ë ·˘ÍË̤ÓË Î·Ù·Ó¿ÏˆÛË Ù˘ ÁÏÔ˘Ù·Ì›Ó˘ ·fi Ù· ·ÙÙ·Ú· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ηٿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË (35). E›Û˘, ··ÈÙÂ›Ù·È ÚÔÛÔ¯‹ Û ·ÛıÂÓ›˜ Ì ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ·, ÏfiÁˆ ÂÈ‚¿Ú˘ÓÛ˘ Ù˘ Ë·ÙÈ΋˜ Î·È ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·ÏÏ¿ Î·È Âȉ›ӈÛ˘ Èı·Ó‹˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (31). ¶ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔ˘˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Î·È Ó¤· ÚÔ˚fiÓÙ·, ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ‰È¿ÊÔÚÔ˘˜ Û˘Ó‰˘·ÛÌÔ‡˜ Î·È ÌÔÚʤ˜ ‰ÈÂÙȉ›ˆÓ ÁÏÔ˘Ù·Ì›Ó˘, ¢ڛÛÎÔÓÙ·È Û‹ÌÂÚ· ˘fi ¤Ú¢ӷ. 6. ÕÏÏ· ·ÌÈÓÔͤ· T· ÛËÌÂÚÈÓ¿ ÂÓ‰ÔÊϤ‚È· ‰È·Ï‡Ì·Ù· ·ÌÈÓÔͤˆÓ Â›Ó·È ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· "·ÓÈÛfiÚÚÔ·" ˆ˜ ÚÔ˜ ÙȘ Û¯ÂÙÈΤ˜ ·Ó·ÏÔÁ›Â˜ ·ÌÈÓÔͤˆÓ. ŒÙÛÈ, ÙÂÏÂ˘Ù·›· ‰È·ÈÛÙÒıËΠfiÙÈ ÔÏÏ¿ ·fi Ù· ‰È·Ï‡Ì·Ù· ·˘Ù¿ ¤¯Ô˘Ó ÌÂȈ̤ÓË ÂÚÈÂÎÙÈÎfiÙËÙ· Û ٷ˘Ú›ÓË, ΢ÛÙ½ÓË, Î·È ÁÏÔ˘Ù·Ì›ÓË, ÂÓÒ ·˘ÍË̤Ó˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Î·È ÔÈ ·Ó¿ÁΘ ÙˆÓ ·È‰ÈÒÓ Û ÈÛÙȉ›ÓË Î·È Ù˘ÚÔÛ›ÓË. OÈ ÚÔÛ¿ıÂȘ ÁÈ· ‰ËÌÈÔ˘ÚÁ›· ϤÔÓ ÈÛÔÚÚÔËÌ¤ÓˆÓ ÛÙ·ıÂÚÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÎÚ˘ÛÙ·ÏÏÈÎÒÓ ·ÌÈÓÔͤˆÓ ¢ڛÛÎÔÓÙ·È Û ÂÈÚ·Ì·ÙÈÎfi ÛÙ¿‰ÈÔ. 7. AÓÙÈÔÍÂȉˆÙÈο EχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘ (OFR) Ô˘ ·Ú¿ÁÔÓÙ·È Û ηٷÛÙ¿ÛÂȘ stress, ȉ›ˆ˜ ηٿ ÙË Ê¿ÛË Â·Ó·ÈÌ¿ÙˆÛ˘, ·ÛÎÔ‡Ó ‚Ï·ÙÈ΋ ›‰Ú·ÛË ÛÙÔ DNA, ÙȘ ÚˆÙ½Ó˜ Î·È Ù· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Î˘ÙÙ·ÚÈ΋ ‚Ï¿‚Ë Î·È ÙËÓ ·Ó¿Ù˘ÍË ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·Ó¿ÚÎÂÈ·˜. H ·ÓÙÈÔÍÂȉˆÙÈ΋ ÂÓ‰ÔÁÂÓ‹˜ ¿Ì˘Ó· ·ÔÛÎÔ› ΢ڛˆ˜, ÛÙËÓ ·Ó·ÛÙÚÔÊ‹ ÙˆÓ OFR Û ÛÙ·ıÂÚ¿ ÌÔÚȷο ÚÔ˚fiÓÙ· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ‚Èٷ̛Ә E, C, A, Ù· ‚-ηÚÔÙ¤ÓÈ·, Î·È ÙÔ Û‡ÌÏÂÁÌ· ÙˆÓ ·ÌÈÓÔͤˆÓ ΢ÛÙ½Ó˘, Ù·˘Ú›Ó˘ Î·È ÁÏ˘Ù·ıÂÈfiÓ˘, ÁÓˆÛÙfi ˆ˜ GSH. H ‰Ú¿ÛË ÙˆÓ ÂÓ‰ÔÁÂÓÒÓ ·˘ÙÒÓ Û˘ÛÙËÌ¿ÙˆÓ ÂÓÈÛ¯‡ÂÙ·È Î·È ·fi ÙËÓ Î·Ù·Ï˘ÙÈ΋ ›‰Ú·ÛË ¿ÏÏˆÓ ÛÙÔȯ›ˆÓ fiˆ˜ Ô ¯·ÏÎfi˜, Ô „¢‰¿ÚÁ˘ÚÔ˜, ÙÔ ÛÂÏ‹ÓÈÔ Î·È ÙÔ Ì·ÁÓ‹ÛÈÔ. ™Â ηٷÛÙ¿ÛÂȘ stress ·Ú·ÙËÚÔ‡ÓÙ·È ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ÂÏÏ›ÌÌ·Ù· ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ Ô˘ÛÈÒÓ, Ë ·Ó·Ï‹ÚˆÛË ÙˆÓ ÔÔ›ˆÓ ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÂÓ‰ÔÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ (36). ◊‰Ë ΢ÎÏÔÊÔÚÔ‡Ó ·ÚÎÂÙ¿ ‰È·Ï‡Ì·Ù· ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ ÁÈ· ‚·ÚÈ¿ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ·Ó¿ÏÔÁ˜ ·ÓÙÈÔÍÂȉˆÙÈΤ˜ Ô˘Û›Â˜ Î·È È¯ÓÔÛÙÔȯ›·. º˘ÛÈο, ··ÈÙÔ‡ÓÙ·È ÌÂϤÙ˜
364
°. MÚÈ·ÛÔ‡Ï˘
Û˘Ó‰˘·ÛÌÔ‡ ÙˆÓ Ô˘ÛÈÒÓ ·˘ÙÒÓ ÒÛÙ ӷ ¤¯Ô˘Ó ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·, ηıÒ˜ ÌfiÓ˜ Û ·˘ÍË̤Ó˜ ‰fiÛÂȘ (.¯. ‚ÈÙ·Ì›ÓË E ‹ C) ‰ÚÔ˘Ó ÚÔÔÍÂȉˆÙÈο, ·˘Í¿ÓÔÓÙ·˜ ÙȘ OFR. 8. N¤ÔÈ ÏÈȉȷÎÔ› Û˘Ó‰˘·ÛÌÔ› ÁÈ· ‰È·ÙÚÔÊ‹ ‚·ÚÈ¿ ·Û¯fiÓÙˆÓ ·ÛıÂÓÒÓ T· Ï›Ë Û ÂÓÙÂÚÈο ‰È·Ï‡Ì·Ù· Û›ÙÈÛ˘ Â›Ó·È Û˘Ó‹ıˆ˜ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (LCT 14-24 C) ‹ ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ ‰˘Û·ÔÚÚfiÊËÛ˘ ̤Û˘ (MCT 6-12 C) ‹ ‚Ú·¯Â›·˜ (2-4 C) ·Ï‡ÛÔ˘. ¶·Ú¤¯Ô˘Ó ΢ڛˆ˜ ˘„ËÏ‹ ıÂÚÌȉÈ΋ ˘ÎÓfiÙËÙ· ·ÏÏ¿ Î·È Ù· ··Ú·›ÙËÙ· Ï›Ë. ŸÌˆ˜, ˘¿Ú¯ÂÈ ˘fiÓÔÈ· fiÙÈ Ù· Ï›Ë ÛfiÁÈ·˜ ‹ ËÏȤϷȷ (ˆ-6 ÏÈ·Ú¿) ·ÛÎÔ‡Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË, ¢ÓÔÒÓÙ·˜ ÙÔÓ Û¯ËÌ·ÙÈÛÌfi ÛÙȘ ΢ÙÙ·ÚÈΤ˜ ÌÂÌ‚Ú¿Ó˜ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ (Ï¢ÎÔÙÚȤÓ˜, ıÚÔÌ‚ÔÍ¿Ó˜, ÚÔÛÙ·ÁÏ·Ó‰›Ó˜ E2), Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË ÏÔÈÌÒÍÂˆÓ (37). AÓÙ›ıÂÙ·, ‰È·ÈÙËÙÈο ˆ-3 ÏÈ·Ú¿ Ôͤ· (Ô˘ ΢ڛˆ˜ ·ÓÙÈÚÔۈ‡ÔÓÙ·È ·fi ȯı˘¤Ï·È·), ÂÓۈ̷ÙÒÓÔÓÙ·È Ù·¯¤ˆ˜ ÛÙȘ ΢ÙÙ·ÚÈΤ˜ ÌÂÌ‚Ú¿Ó˜, ¢ÓÔÔ‡Ó ÙËÓ ·Ú·ÁˆÁ‹ ÂÈÎÔÛ·ÓÔÂȉÒÓ Ì ÌÂȈ̤ÓË ÊÏÂÁÌÔÓÒ‰Ë ‰Ú¿ÛË (ÚÔÛÙ·ÁÏ·Ó‰›ÓË E3), ηٷÛÙ¤ÏÏÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ (ÈÓÙÂÚÏ¢ΛÓË 1) Î·È ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›·. EÂȉ‹ ·ÎÚÈ‚Ò˜ ÔÈ ËÁ¤˜ Ï›Ô˘˜ ÂËÚ¿˙Ô˘Ó ÙË ÏÈȉȷ΋ Û‡ÓıÂÛË ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ (‰È·ÂÚ·ÙfiÙËÙ·, ÌÂÙ·‚›‚·ÛË, ÎÏ), ÂÚ¢ÓÒÓÙ·È Û‹ÌÂÚ· ‰È¿ÊÔÚÔÈ Û˘Ó‰˘·ÛÌÔ› ÏÈȉȷÎÒÓ Á·Ï·Îو̿وÓ. ™˘ÁÎÂÎÚÈ̤ӷ, ÌÂÏÂÙÒÓÙ·È Û˘Ó‰˘·ÛÌÔ› MCT-LCT-ȯı˘ÂÏ·›ˆÓ Î·È ·Ú·ÁÒÁˆÓ ˆ3 ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, ηıÒ˜ Î·È ‰ÔÌÈÎÒÓ (Ù¯ÓËÙÒÓ) ÏÈÒÓ, fiÔ˘ ÂȯÂÈÚÂ›Ù·È Ë ·Ó·Û‡ÓıÂÛË ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Ì ÙË ÁÏ˘ÎÂÚfiÏË. ¶·ÚfiÌÔÈ· Á·Ï·ÎÙÒÌ·Ù· Û ÂÈÚ·Ì·Ùfi˙ˆ· ÚÔοÏÂÛ·Ó ·‡ÍËÛË ÙÔ˘ NB, Ì›ˆÛË ÙˆÓ ÏÔÈÌÒ͈Ó, Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘. ™Â ·ÓıÚÒÔ˘˜ Ë ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ‰Ú¿ÛË ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ (ÏÈÓÔÏÂÓÈÎfi) ÂϤÁ¯ıËΠ̠ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· Û ηÚÎÈÓÔ·ı›˜ ·ÛıÂÓ›˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο (38). EÓÙÔ‡ÙÔȘ, ·ÚÎÂÙ¿ ·ÎfiÌË ÂÚˆÙËÌ·ÙÈο ·Ú·Ì¤ÓÔ˘Ó ·Ó·¿ÓÙËÙ·. ¶·ÚÂÓ¤ÚÁÂȘ fiˆ˜ Ë ·˘ÍË̤ÓË ·˘ÙÔÔÍ›‰ˆÛË Î·È Î˘ÙÙ·ÚÈ΋ ‚Ï¿‚Ë, ·˘ÍË̤ÓË ·Ó¿ÁÎË Û ·ÓÙÈÔÍÂȉˆÙÈο, Î·È ·˘ÍË̤ÓË ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË (‰Ú¿ÛË ÛÂ Û˘ÁÎÔÏÏËÙÈÎfiÙËÙ· ·ÈÌÔÂÙ·Ï›ˆÓ) Ô˘ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ̤¯ÚÈ Û‹ÌÂÚ·, ÚÔ‚ÏËÌ·Ù›˙Ô˘Ó ÁÈ· ÙËÓ ·ÚfiÛÎÔÙË ¯Ú‹ÛË ÙÔ˘˜ Û ME£ (39). E›Ó·È ··Ú·›ÙËÙÔ ÂÔ̤ӈ˜, Ó· Á›ÓÔ˘Ó Î·Ï¿ ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ ÂϤÁ¯Ô˘ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿, ÚÈÓ ÂÚ¿ÛÂÈ Û ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ Ë ¯Ú‹ÛË Ù¤ÙÔÈˆÓ Û΢·ÛÌ¿ÙˆÓ, ȉ›ˆ˜ Û ‰È·Ï‡Ì·Ù· O¶¢. 9. ™˘Ó‰˘·ÛÌÔ› ÌÂıfi‰ˆÓ ÂÓÈÛ¯˘ÙÈ΋˜ ıÂڷ›·˜ Ù˘ ıÚ¤„˘ ™Â ÌÈ· ÚÔÛ¿ıÂÈ· ˘¤Ú‚·Û˘ ÙˆÓ ÂÈ̤ÚÔ˘˜ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·365
¶∞π¢π∞∆ƒπ∫∏ 2000;63:356-366
‰È·ÊfiÚˆÓ ÌÂıfi‰ˆÓ ÂÓÈÛ¯˘ÙÈÎÒÓ ıÂÚ·ÂÈÒÓ Ù˘ ıÚ¤„˘, ·ÏÏ¿ Î·È ·‡ÍËÛ˘ Ù˘ Èı·ÓfiÙËÙ·˜ Û˘ÓÂÚÁÈ΋˜ ‰Ú¿Û˘ ÙÔ˘˜, ¤¯Ô˘Ó ‰ÔÎÈÌ·Ûı› Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Û˘Ó‰˘·ÛÌÔ› ÙˆÓ ÌÂıfi‰ˆÓ ·ÓÔÛԉȷÙÚÔÊ‹˜. ™˘Ó‰˘·ÛÌÔ› rGH, ÁÏÔ˘Ù·Ì›Ó˘, Î·È ‰›·ÈÙ·˜ Û ۇӉÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ Ô‰‹ÁËÛ·Ó Û ·‡ÍËÛË ÙÔ˘ NB, ·Ó¿Ï·ÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ Î·È Ì›ˆÛË Ù˘ ÔÛfiÙËÙ·˜ Ù˘ O¶¢ (40). ¶ÂÈÚ·Ì·ÙÈ΋ ˘ÁÚ‹ ‰È·ÙÚÔÊ‹ (·˘ÍË̤ÓË ÚˆÙ½ÓË, ·ÚÁÈÓ›ÓË, RNA, ˆ-3 ȯı˘¤Ï·È·) ›¯Â ›Û˘ ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙȘ ›ÎÙËÙ˜ ÏÔÈÌÒÍÂȘ, ÌfiÓÔ fï˜ ÛÙËÓ ÔÌ¿‰· ÛËÙÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó Û ME£ (41). ™Â ÂÚÈÙÒÛÂȘ ηÚÎÈÓÔ·ıÒÓ ¯ÂÈÚÔ˘ÚÁËÌ¤ÓˆÓ ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ, ÂÌÏÔ˘ÙÈṲ̂ӷ Û¯‹Ì·Ù· (ˆ-3-ÏÈ·Ú¿ Ôͤ·, ·ÚÁÈÓ›ÓË, ÓÔ˘ÎÏÂÔÙ›‰È·) Û˘Óԉ‡ıËÎ·Ó ·fi ÏÈÁfiÙÂÚ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜, ‚Ú·¯‡ÙÂÚË ·Ú·ÌÔÓ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (42), Î·È ÌÈÎÚfiÙÂÚÔ ÙÂÏÈÎfi ÎfiÛÙÔ˜ (Ï·Ì‚·ÓfiÌÂÓÔ˘ ˘fi„Ë Î·È ÙÔ˘ ÎfiÛÙÔ˘˜ ÙˆÓ ÂÈÏÔÎÒÓ) (43). ŸÌˆ˜, ÔÈ ÏÔÈÌÒÍÂȘ ·Ú¤ÌÂÈÓ·Ó ÛÙ· ›‰È· ›‰·. EÈÚfiÛıÂÙ·, ÔÈ ÂÈÚ·Ì·ÙÈΤ˜ ‰›·ÈÙ˜ ÂÚÈ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË ÔÛfiÙËÙ· ÚˆÙÂ˚ÓÒÓ ·' fi,ÙÈ Ë ÔÌ¿‰· ÂϤÁ¯Ô˘ (15 ¤Ó·ÓÙÈ 9 g/Ë̤ڷ). ¢È·ÙÚÔÊÈ΋ Ê·ÚÌ·ÎÔıÂڷ›·: ÚÔ‚ÈÔÙÈο Î·È ÚÈ‚ÈÔÙÈο ¶ÚÔ‚ÈÔÙÈο (probiotics) (ÂȉÈΤ˜ ÌÈÎÚԂȷΤ˜ ÔÌ¿‰Â˜ Û˘Á¯ÔÚËÁÔ‡ÌÂÓ˜ Ì ÙËÓ ÙÚÔÊ‹ Ì ‰˘ÓËÙÈο ÔʤÏË ÁÈ· ÙÔÓ ·ÛıÂÓ‹), Î·È ÚÈ‚ÈÔÙÈο (prebiotics) (‰È·ÈÙËÙÈο ÛÙÔȯ›· fiˆ˜ Û‡ÌÏÔÎÔÈ ˘‰·Ù¿ÓıڷΘ ÈηÓÔ› Ó· ÌÂÙ·‚¿ÏÏÔ˘Ó ÙËÓ ÂÓÙÂÚÈ΋ ÌÈÎÚԯψڛ‰· Î·È Ó· ¢ÓÔ‹ÛÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÌË ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ ÛÙÂϯÒÓ) Â›Ó·È ÂÚÈÔ¯¤˜ ¤Ú¢ӷ˜ Ì ÛËÌ·ÓÙÈÎfi ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ (44). OÈ Ì¤ıÔ‰ÔÈ ·˘Ù¤˜ Â›Ó·È Ó· ‰˘Ó·Ùfi Ó· ÚÔÛʤÚÔ˘Ó ÂÓ·ÏÏ·ÎÙÈΤ˜ χÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰ÈÔÁÎÔ‡ÌÂÓÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ·Ó¿Ù˘Í˘ ÔÏ˘·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ Î·È ÂÈΛӉ˘ÓˆÓ ÂÓ‰ÔÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ Û ·ÛıÂÓ›˜ ÙˆÓ ME£, ÌÂÙ·ÌÔÚÊÒÓÔÓÙ·˜ ·ÏÒ˜ ÙËÓ ÂÌÏÔ˘ÙÈṲ̂ÓË ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÛÂ Û˘Á¯ÚÔÓÈṲ̂ÓË ıÚÂÙÈ΋ Î·È ÛËÌ·ÓÙÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ›Ûˆ˜ fi¯È ÛÙÔ Ôχ Ì·ÎÚÈÓfi ̤ÏÏÔÓ. ™˘ÌÂÚ¿ÛÌ·Ù· OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÚÔÙ¿ÛÂȘ Ô˘ ¤¯Ô˘Ó ·Ó·‰˘ı› ·fi ÙËÓ ÎÏÈÓÈ΋ ¤Ú¢ӷ Û ME£ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ‰›ÓÔ˘Ó È‰È·›ÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË, Î·È Î·Ù' ¤ÎÙ·ÛË ÂÓÙÂÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ™Ùfi¯Ô˜ Â›Ó·È Ó· ˘ÔÛÙËÚȯıÔ‡Ó Ë ÂÓÙÂÚÈ΋ ·ÔÚÚÔÊËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ë ÂÓÙÂÚÈ΋ ·Ì˘ÓÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· (·Ó¤·ÊÔ˜ ÂÓÙÂÚÈÎfi˜ ‚ÏÂÓÓÔÁfiÓÔ˜, ÊÚ·ÁÌfi˜ ÛÙË ‰È·ÂÚ·ÙfiÙËÙ· ÌÈÎÚÔ‚›ˆÓ Î·È ÂÓ‰ÔÙÔÍÈÓÒÓ), Ë ÂÓ›Û¯˘ÛË Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ë ÚfiÏË„Ë Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·Ó¿ÚÎÂÈ·˜, Î·È Ë Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜. H ÎÏÈÓÈ΋ ¤Ú¢ӷ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛԉȷÙÚÔÊ‹˜, ÙˆÓ ÌÂıfi‰ˆÓ ÂÓÈÛ¯˘ÙÈ΋˜ ıÂڷ›·˜ Ù˘
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ıÚ¤„˘, Î·È Ù˘ ‰È·ÙÚÔÊÈ΋˜ Ê·ÚÌ·ÎÔıÂڷ›·˜, ÚԉȷÁÚ¿ÊÔ˘Ó ÙȘ Ù¿ÛÂȘ Ù˘ ıÚÂÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÙˆÓ ·ÛıÂÓÒÓ ÙˆÓ ME£ Ù· ÂfiÌÂÓ· ¯ÚfiÓÈ·. BÈ‚ÏÈÔÁÚ·Ê›· 1. Koretz RL. Nutritional supplementation in the ICU. How critical is nutrition for the critically ill? Am J Respir Crit Care Med 1995;151:570-573. 2. Clague MB, Keir MJ, Wright PD, Johnston IDA. The effects of nutrition and trauma on whole-body protein metabolism in man. Clin Sci 1983;65:165-175. 3. Pollack MM, Wiley JS, Kanter R, Holbrook PR. Malnutrition in critically ill infants and children. JPEN 1982;6:20-24. 4. Briassoulis G, Shekhar Venkataraman S, Thompson A. Nutritional status, nitrogen balance and metabolic response to stress related to the severity of illness in children. Intens Care Med 1996;22(3 suppl)S347. 5. Seltzer MH, Fletcher HS, Slocum BA, Engler PE. Instant nutritional assessment in the intensive care unit. Nutrition 1981;5:70-72. 6. Pomposelli JJ, Flores EA, Bistrian BR. Role of biochemical mediators in clinical nutrition and surgical metabolism. JPEN J Parenter Enteral Nutr 1988;12:212-218. 7. Frayn KN. Hormonal control of metabolism in trauma and sepsis. Clin Endocrinol 1986;24:577-599. 8. Takala J. Nutrition and body composition in multiple organ failure. Nutrition 1995;11:769-770. 9. Steinhorn DM, Green TP. Severity of illness correlates with alterations in energy metabolism in the pediatric intensive care unit. Crit Care Med 1991;19:1503-1509. 10. Talbot FB. Basal metabolism standards for children. Amer J Dis Child 1938;55:455-459. 11. Mann S, Westenskow DR, Houtchens BA. Measured and predicted caloric expenditure in the acutely ill. Crit Care Med 1985;13:173-177. 12. Tilden SJ, Watkins S, Tong TK. Jeevanandam M. Measured energy expenditure in pediatric intensive care patients. AJDC 1989;143:490-492. 13. Chwals WJ, Lally KP, Woolley MM, Mahour GH. Measured energy expenditure in critically ill infants and young children. J Surg Research 1988;44:467-472. 14. Weissman C, Kemper M. Assessing hypermetabolism and hypometabolism in the postoperative critically ill patient. Chest 1992;102:1566-1571. 15. Briassoulis G, Shekhar Venkataraman S, Thompson A. Energy expenditure in critically ill children. Crit Care Med 2000;in press. 16. Firouzbakhsh S, Mathis RK, Dorchester WL, Oseas RS, Groncy PK, Grant KE, et al. Measured resting energy expenditure in children. J Ped Gastroenterol Nutr 1993;16:136-142. 17. Clague MB, Keir MJ, Wright PD, Johnston ID. The effects of nutrition and trauma on whole-body protein metabolism in man. Clin Sci 1983;65(2):165-175. 18. Siderova VS, Carpentier YA, Dahlan W, Richelle M. Intravascular metabolism of different fatty acids during lipid infusion in man. Clin Nutr 1993;12:329-344. 19. Alverdy J, Chi GS, Sheldon G. The effect of parenteral
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● ¶ÂÚ›ÏË„Ë: ∆· ΢ÛÙÂ˚ÓÈο Ï¢ÎÔÙÚȤÓÈ· LTC4, LTD4 Î·È LTE4 Ô˘ Û˘ÓÙ›ıÂÓÙ·È ·fi ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ ÛÙ· Ì·ÛÙÔ·ÙÙ·Ú·, ÛÙ· Ì·ÎÚÔÊ¿Á· Î·È ÛÙ· ˈÛÈÓfiÊÈÏ·, ·›˙Ô˘Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÚÔηÏÒÓÙ·˜ ‚ÚÔÁ¯fiÛ·ÛÌÔ, Ô›‰ËÌ· ÙˆÓ ÈÛÙÒÓ, ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘ Î·È ÂÓÔÚ¯ËÛÙÚÒÓÔ˘Ó ÙȘ ÂÈÙÒÛÂȘ Ù˘ ˈÛÈÓÔÊÈÏÈ΋˜ ÊÏÂÁÌÔÓ‹˜. ªÂ ‰Â‰Ô̤ÓÔ fiÙÈ ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë Û˘Ì‚ÔÏ‹ ÙˆÓ Î˘ÛÙÂ˚ÓÈÎÒÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ÛÙÔ ¿ÛıÌ·, Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ô ÂÎÏÂÎÙÈÎfi˜ ·ÓÙ·ÁˆÓÈÛÌfi˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ı· ÌÔÚÔ‡Û ӷ ·ÔÙÂÏ› ¤Ó·Ó Ó¤Ô ıÂڷ¢ÙÈÎfi ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÓfiÛÔ˘. ∆Ô Montelukast, ¤Ó·˜ ÈÛ¯˘Úfi˜ Î·È ÂÎÏÂÎÙÈÎfi˜ ·ÓÙ·ÁˆÓÈÛÙ‹˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ, ¤¯ÂÈ Ê·ÚÌ·ÎÔÏÔÁÈ΋ Û˘ÌÂÚÈÊÔÚ¿, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÓÙÈ·ÛıÌ·ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ‰˘Ó·ÙfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È ‰Ú¿ÛË ÌÂÁ¿Ï˘ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜. ÃÔÚËÁÔ‡ÌÂÓÔ ¿·Í ËÌÂÚËÛ›ˆ˜, Û ‰fiÛË 5 mg ÚÈÓ ÙË ‚Ú·‰ÈÓ‹ ηٿÎÏÈÛË, ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÚˆÈÓ‹˜ FEV1 Î·È PEFR, Ì›ˆÛË ÙˆÓ ËˆÛÈÓfiÊÈÏˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜, fiˆ˜ ÚÔ·ÙÂÈ ·fi Û¯ÂÙÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, Ô˘ Û˘ÌÏËÚÒıËΠ·fi ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∂ÈϤÔÓ ÙÔ Montelukast ¤¯ÂÈ ·Ô‰ÂȯÙ› ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ‚ÚÔÁ¯fiÛ·ÛÌÔ˘, Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ¿ÛÎËÛË. ∆Ô Ê¿ÚÌ·ÎÔ Ê·›ÓÂÙ·È ·ÍÈfiÈÛÙÔ, ·ÔÙÂÏÂÛÌ·ÙÈÎfi Î·È ¯ˆÚ›˜ ·ÚÂÓ¤ÚÁÂȘ. ∞·ÈÙÔ‡ÓÙ·È fï˜, ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ÙÂÏÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜, Ù˘ ·ÛÊ¿ÏÂÈ·˜ Î·È Ù˘ ı¤Û˘ ÙˆÓ ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ (∞§) ÛÙË ıÂڷ›· ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ¶·È‰È·ÙÚÈ΋ 2000;63:367-374. §¤ÍÂȘ ÎÏÂȉȿ: ¿ÛıÌ·, ·È‰›, ıÂڷ›·, ·ÓÙÈÏ¢ÎÔÙÚȤÓÈ·. C.V. Katsardis. Antileukotrienes: A new class of drugs in the pediatric asthma treatment armamentarium. Paediatriki 2000;63:367-374. ● Abstract: The cysteinyl leukotrienes LTC4, LTD4 and LTE4, are synthesized from arachidonic acid in mast cells, macrophages and eosinophils, and play a pivotal role in asthma pathophysiology by causing bronchoconstriction, enhanced vascular permeability and mucus production, and by orchestrating eosinophilmediated inflammatory events. Since the data supporting the involvement of the cysteinyl leukotrienes in asthma have been adequatly documented, it is evident that selective antagonists of the cysLTI receptors could provide a new therapeutic approach to the disease. Montelukast, a potent and selective antagonist of the cysLTI receptor, has a pharmacological profile characterized by high potency, oral bioavailability and long duration of action. Montelukast in a single daily dose of 5 mg, before night time sleep has resulted in improvement of the morning FEV1 and PEFR, reduction of peripheral blood eosinophils, and significant improvement in the qualityof-life scores by the use of an asthma-specific quality-of-life questionaire. Furthermore, it has been proven effective in the management of exercise induced bronchospasm. The drug appears to be reliable, efficient and without side-effects. Nevertheless, further studies are needed in order to further evaluate the effectiveness, safety and plase of the antileukotrienes in the pediatric asthma treatment armamentarium. Key words: asthma, child, treatment, antileukotrienes.
∂ÈÛ·ÁˆÁ‹ ∆· ÙÂÏÂ˘Ù·›· ÙÚÈ¿ÓÙ· ¯ÚfiÓÈ·, Ë Ê·Ú̷΢ÙÈ΋ ıÂڷ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (ÎÔÚÙÈÎÔÂȉ‹, ‚2-‰ÈÂÁ¤ÚÙ˜, ıÂÔÊ˘ÏÏ›ÓË) ¤¯ÂÈ ÌÂÚÈÎÒ˜ ÌfiÓÔ ÙÚÔÔÔÈËı› Ì ÙËÓ
ÚÔÛı‹ÎË ¯ÚˆÌÔÓÒÓ, ıÂÔÊ˘ÏÏ›Ó˘ ‚Ú·‰Â›·˜ ·ÂÏ¢ı¤ÚˆÛ˘, ‚2-‰ÈÂÁÂÚÙÒÓ Ì·ÎÚ¿˜ ‰Ú¿Û˘ Î·È ÙÔ˘ ÎÂÙÔÙÈʤÓÈÔ˘. ∂›Ó·È Ë ÚÒÙË ÊÔÚ¿ Ô˘ Á›ÓÂÙ·È Ó¤· ÚÔÛ¤ÁÁÈÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ì ٷ
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Ã. ∫·ÙÛ·Ú‰‹˜
·ÓÙÈÏ¢ÎÔÙÚȤÓÈ·, ÌÈ· ηÙËÁÔÚ›· ÌË ÛÙÂÚÔÂȉÒÓ Ê·Ú̿ΈÓ, Ô˘ ¤¯Ô˘Ó ˘‚Úȉȷ΋ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Î·È ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË. ∏ ÚÒÙË ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ÛÙË Î·Ù·ÓfiËÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ¤ÁÈÓ ÙÔ 1963, fiÙ·Ó Ô Samuelson ‰ËÌÔÛ›Â˘Û fiÙÈ Ë ÁÓˆÛÙ‹ ˆ˜ ÙfiÙ ‚Ú·‰¤ˆ˜ ·ÓÙȉÚÒÛ· Ô˘Û›· Ù˘ ·Ó·Ê˘Ï·Í›·˜ (Slowreacting substance of anaphylaxis), Â›Ó·È Ù·˘ÙfiÛËÌË Ì ٷ ΢ÛÙÂ˚ÓÈο Ï¢ÎÔÙÚȤÓÈ· LC4, LD4, Î·È LE4. ∆· Ï¢ÎÔÙÚȤÓÈ· Û˘ÓÙ›ıÂÓÙ·È ·fi ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇, ÙÔ ÔÔ›Ô ÂÏ¢ıÂÚÒÓÂÙ·È ·fi Ù· ʈÛÊÔÏÈ›‰È· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Ì ÙË ‰Ú¿ÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ ʈÛÊÔÏÈ¿ÛË ∞2. ™ÙË Û˘Ó¤¯ÂÈ·, ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ ·ÎÔÏÔ˘ı› ‰‡Ô ÌÂÙ·‚ÔÏÈÎÔ‡˜ ‰ÚfiÌÔ˘˜ ÎÈ ¤ÙÛÈ ÚÔ·ÙÔ˘Ó ‰È·ÊÔÚÂÙÈο ‚ÈÔÏÔÁÈο ·Ú¿ÁˆÁ· (ÂÈÎÔÛ·ÓÔÂȉ‹): (·) ªÂ ÙË ‰Ú¿ÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ ΢ÎÏÔ͢ÁÂÓ¿ÛË ÌÂÙ·ÙÚ¤ÂÙ·È Û ÚÔÛÙ·ÁÏ·‰›Ó˜ Î·È ıÚÔÌ‚ÔÍ¿Ó˜ Î·È (‚) Ì ÙË ‰Ú¿ÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ 5-ÏÈÔ͢ÁÂÓ¿ÛË Î·È ÌÈ·˜ ‰ÂÛÌÂ˘Ì¤Ó˘ ÛÙËÓ ˘ÚËÓÈ΋ ÌÂÌ‚Ú¿ÓË ÚˆÙ½Ó˘ Ô˘ ÂÓÂÚÁÔÔÈ› ÙËÓ 5-ÏÈÔ͢ÁÂÓ¿ÛË, ÁÓˆÛÙ‹˜ ˆ˜ FLAP (·fi Ù· ·Ú¯Èο Five Lipoxygenase Activating Protein), ÌÂÙ·ÙÚ¤ÂÙ·È Û Ï¢ÎÔÙÚȤÓÈ· (∂ÈÎfiÓ· 1). ∞fi Ù· Ï¢ÎÔÙÚȤÓÈ· (LTA4, LTB4, LTC4, LTD4, L∆∂4) Ù· C4, D4 Î·È ∂4 ÂÚȤ¯Ô˘Ó ÙÔ ·ÌÈÓÔ͇ ΢ÛÙ½ÓË Î·È ÁÈ’ ·˘Ùfi ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ΢ÛÙÂ˚ÓÈο Ï¢ÎÔÙÚȤÓÈ·. ∆· ∞4 Â›Ó·È ·ÛÙ·ı‹ Î·È ÌÂÙ·ÙÚ¤ÔÓÙ·È Û µ4 ‹ C4, ÂÓÒ Ù· C4 Î·È D4 ÁÚ‹ÁÔÚ· ÌÂÙ·‚¿ÏÏÔÓÙ·È
ºˆÛÊÔÏÈ›‰È· ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ºˆÛÊÔÏÈ¿ÛË ∞ ∞Ú·¯È‰ÔÓÈÎfi Ô͇ 5-ÏÈÔ͢ÁÂÓ¿ÛË/FLAP ΢ÎÏÔÔ͢ÁÂÓ¿ÛË ¶ÚÔÛÙ·ÁÏ·Ó‰›Ó˜, ıÚÔÌ‚·Í¿Ó˜ LTA4 ∞ÓÙ·ÁˆÓÈÛÙ¤˜ ÀÔ‰Ô¯¤· §Â˘ÎÔÙÚÈÂÓ›ˆÓ
µÚÔÁ¯fiÛ·ÛÌÔ˜ ŒÎÎÚÈÛË ‚ϤÓÓ˘ O›‰ËÌ· ÀÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ∏ˆÛÈÓÔÊÈÏ›·
LTC4
LTB4
LTD4
LTE4
∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ·Ú·ÁˆÁ‹˜ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ·fi Ù· ʈÛÊÔÏÈ›‰È· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘.
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Û ∂4. ∆· Ï¢ÎÔÙÚȤÓÈ· ·Ú¿ÁÔÓÙ·È Î˘Ú›ˆ˜ ·fi ·ÙÙ·Ú· Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙÔ ¿ÛıÌ· fiˆ˜ Ì·ÛÙÔ·ÙÙ·Ú·, ˈÛÈÓfiÊÈÏ· Î·È Ì·ÎÚÔÊ¿Á·, Î·È ÂÎÙfi˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚ› Ó· ·Ó¢ÚÂıÔ‡Ó ÛÙË Ì‡ÙË, ÛÙÔ ‰¤ÚÌ·, ÛÙ· Ì¿ÙÈ·, ÛÙ· Ô‡Ú· Î·È ÙÔ˘˜ ÎfiÏÔ˘˜ ÙÔ˘ ÚÔÛÒÔ˘. ¢ÚÔ˘Ó Î˘Ú›ˆ˜ ÛÙÔ˘˜ ΢ÛÙÂ˚ÓÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Ù‡Ô˘ π (Cys LT1) Ô˘ ¢ڛÛÎÔÓÙ·È ÛÙÔ˘˜ Ï›Ԣ˜ ̇˜, ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ ·‰¤Ó˜, Ù· ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú· Î·È Â›Ó·È ‰È¿Û·ÚÙÔÈ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ. Œ¯Ô˘Ó ‚ÚÔÁ¯ÔÛ˘Û·ÛÙÈ΋ ‰Ú¿ÛË Ôχ ÈÛ¯˘ÚfiÙÂÚË (1000-5000 ÊÔÚ¤˜) Î·È ÈÔ ·Ú·ÙÂٷ̤ÓË ·fi ÙËÓ ÈÛÙ·Ì›ÓË, Ì Ì˯·ÓÈÛÌfi ‰Ú¿Û˘ fï˜ ÙÂÏ›ˆ˜ ‰È·ÊÔÚÂÙÈÎfi. ∂ÈϤÔÓ, ÚÔηÏÔ‡Ó Ô›‰ËÌ· ÙˆÓ ÈÛÙÒÓ, Ù·ÎÙÈÛÌfi ˈÛÈÓÔÊ›ÏˆÓ Î·È ·‡ÍËÛË ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ, ÂÈÎfiÓ· ·fiÏ˘Ù· Û˘Ì‚·Ù‹ Ì ÙÔ ¿ÛıÌ·. OÈ ˘Ô‰Ô¯Â›˜ Ù‡Ô˘ II (Cys LT2) ¢ڛÛÎÔÓÙ·È ÛÙȘ Ó¢ÌÔÓÈΤ˜ ÊϤ‚˜ Î·È ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ¿ÛıÌ·, (1-7). ∏ Û˘ÁΤÓÙÚˆÛË ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙÔ˘˜ ·ÛıÌ·ÙÈÎÔ‡˜, ·' fi,ÙÈ ÛÙÔ˘˜ ÌË ·ÛıÌ·ÙÈÎÔ‡˜ Î·È ·˘Í¿ÓÂÈ ÌÂÙ¿ ·fi ¿ÛÎËÛË, Ï‹„Ë ·ÛÈÚ›Ó˘ Î·È ÚfiÎÏËÛË Ì ·ÏÏÂÚÁÈÔÁfiÓ·. µÈÔ„›· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, ÚÔ Î·È ÌÂÙ¿ ÂÈÛÓÔ‹ Ï¢ÎÔÙÚÈÂÓ›ˆÓ, ‰Â›¯ÓÂÈ 25Ï¿ÛÈ· ·‡ÍËÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ Î·È ‰ÈÏ·ÛÈ·ÛÌfi ÙˆÓ Ô˘‰ÂÙÂÚÔʛψÓ, ÂÓÒ Û ÂÈÚ·Ì·Ùfi˙ˆ· ÌÂÙ¿ ÌÈ· Î·È ÌfiÓÔ ÂÈÛÓÔ‹ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ·Ú·ÙËÚÂ›Ù·È ËˆÛÈÓÔÊÈÏ›· ÁÈ· 30 ̤Ú˜ (6,7). ªÂ Ù· ‰Â‰Ô̤ӷ ·˘Ù¿, ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ fiÙÈ Ë Û‡ÓıÂÛË Ô˘ÛÈÒÓ, Ô˘ ı· ·Ó¤ÛÙÂÏÏ·Ó ÙÔÓ Û¯ËÌ·ÙÈÛÌfi ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ ‹ ı· ·ÚÂÌfi‰È˙·Ó ÙË Û‡Ó‰ÂÛ‹ ÙÔ˘˜ Ì ÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ˘Ô‰Ô¯Â›˜, Ó· ¤¯Ô˘Ó ÂÊ·ÚÌÔÁ‹ ÛÙËÓ ıÂڷ›· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ŒÙÛÈ ÛÙÔ ÔÏÔÛÙ¿ÛÈÔ ÙÔ˘ ıÂÚ¿ÔÓÙ· È·ÙÚÔ‡ ¢ڛÛÎÔÓÙ·È Û‹ÌÂÚ· ‰‡Ô ηÙËÁÔڛ˜ Ê·Ú̿ΈÓ. ∏ Ì›· ‰Ú· ˆ˜ ·Ó·ÛÙ·ÏÙÈÎfi Ù˘ ‚ÈÔÛ‡ÓıÂÛ˘ (̤ۈ ÙÔ˘ ÂÓ˙‡ÌÔ˘ 5-ÏÈÔ͢ÁÂÓ¿ÛË ‹ Ù˘ FLAƒ) Ì ÂÎÚfiÛˆÔ ÙÔ ∑afirlukast Î·È Ë ¿ÏÏË Î·ÙËÁÔÚ›· ˆ˜ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ, Ì ÂÎÚÔÛÒÔ˘˜ ÙÔ Montelukast, ÙÔ ∑afirlukast Î·È ÙÔ ƒranlukast.(1,5,7) º·ÚÌ·ÎÔÎÈÓËÙÈ΋ ™ÙË ¯ÒÚ· Ì·˜, ÁÈ· ¯Ú‹ÛË Û ·È‰È¿ 6-14 ¯ÚfiÓˆÓ, ΢ÎÏÔÊÔÚ› ÙÔ Ó·ÙÚÈÔ‡¯Ô Montelukast Û ̷ÛÒÌÂÓ· ‰ÈÛΛ· ÙˆÓ 5 mg. °È· ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ÙˆÓ 15 ¯ÚfiÓˆÓ Î˘ÎÏÔÊÔÚÔ‡Ó ‰ÈÛΛ· ÙˆÓ 10 mg. ∏ ˘„ËÏfiÙÂÚË Û˘ÁΤÓÙÚˆÛË ÛÙÔ Ï¿ÛÌ· ÂÈÙ˘Á¯¿ÓÂÙ·È 3 ÒÚ˜ ÂÚ›Ô˘ ÌÂÙ¿ ÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ï‹„Ë, Ô ¯ÚfiÓÔ˜ ËÌÈÛ›·˜ ˙ˆ‹˜ Â›Ó·È 5-6 ÒÚ˜ Î·È Ë ‚ÈԉȷıÂÛÈÌfiÙËÙ· 62%, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚÂ›Ù·È Ô˘ÛÈ·ÛÙÈ΋ Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ Ó¤ˆÓ Î·È ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ. ∏ ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙÔ˘ ∑afirlukast ÌÂÈÒÓÂÙ·È Î·Ù¿ 40%, fiÙ·Ó Ï·Ì‚¿ÓÂÙ·È Ì ÙËÓ ÙÚÔÊ‹. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·Ó¿ÏÔÁ· ‰Â‰Ô̤ӷ ÁÈ· ÙÔ Montelukast, ·ÏÏ¿
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™ÂÏ›‰·369
¶∞π¢π∞∆ƒπ∫∏ 2000;63:367-374
Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘, ÌÈ· ÊÔÚ¿ ÙËÓ Ë̤ڷ, ÌÈ· ÒÚ· ÚÔ ÙÔ˘ Ê·ÁËÙÔ‡ ‹ ‰‡Ô ÒÚ˜ ÌÂÙ¿.(3) ™ÙË Û˘Ó¤¯ÂÈ· ÌÂÙ¿ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘, ÙÔ Montelukast ÌÂÙ·‚ÔÏ›˙ÂÙ·È ÛÙ· ÌÈÎÚÔÛÒÌ·Ù· ÙˆÓ Ë·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·fi ÙÔ Î˘Ùfi¯ÚˆÌ· ƒ450, 3∞4, 2∞6 Î·È 2C9 (Û‡ÛÙËÌ· ÈÛÔÂÓ˙‡ÌˆÓ). ∞fi ÂΛ ÙÔ Montelukast Î·È ÔÈ ÌÂÙ·‚Ôϛ٘ ÙÔ˘ ÂÎÎÚ›ÓÔÓÙ·È Ì¤Ûˆ Ù˘ ¯ÔÏ‹˜ Î·È ·Ô‚¿ÏÏÔÓÙ·È ÛÙ· ÎfiÚ·Ó· Û ÔÛÔÛÙfi ÙÔ˘Ï¿¯ÈÛÙÔÓ 86%.(3,7) ™ÙȘ Ê·Ú̷΢ÙÈΤ˜ ‰fiÛÂȘ Ô˘ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· ÙÔ Montelukast ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÔÓÙ·È Ù· ›‰· ÙˆÓ Ê·ÚÌ¿ÎˆÓ ıÂÔÊ˘ÏÏ›ÓË, Ú‰ÓÈ˙ÔÏfiÓË, ‰ÈÁÔÍ›ÓË, ÙÂÚÊÂÓ·‰›ÓË, ÁÔ˘·ÚÊ·Ú›ÓË Î·È Ù· ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÓÙÈÛ˘ÏÏËÙÈο, Ô˘ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È ·fi ÙÔ ›‰ÈÔ Û‡ÛÙËÌ· ÂÓ˙‡ÌˆÓ. ∏ Û˘ÁΤÓÙÚˆÛË fï˜ ÙÔ˘ Montelukast ÌÔÚ› Ó· ÂÏ·ÙÙˆı› ÌÂ Û˘Á¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ Ô˘ ÚÔηÏÔ‡Ó ·Ó·ÁˆÁ‹, ÙÔ˘ ÈÛÔÂÓ˙‡ÌÔ˘ CÀƒ3 ∞4, fiˆ˜ Ë Ê·ÈÓ˘ÓÙÔ˝ÓË, Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È Ë ÚÈÊ·Ì˘Î›ÓË, ÔfiÙ ڤÂÈ Ó· Á›ÓÂÙ·È ·Ó¿ÏÔÁË ·Ú·ÎÔÏÔ‡ıËÛË.(3,7) ∫ÏÈÓÈο ‰Â‰Ô̤ӷ ÁÈ· ÙË ‰Ú¿ÛË ÙˆÓ ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ ∞fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ù· ·ÓÙÈÏ¢ÎÔÙÚȤÓÈ· (∞§) ÂÌÔ‰›˙Ô˘Ó ÙÔÓ ‚ÚÔÁ¯fiÛ·ÛÌÔ Ô˘ ÚÔηÏÂ›Ù·È ·fi ‰È¿ÊÔÚ· ÂÚÂı›ÛÌ·Ù· fiˆ˜ Ë ¿ÛÎËÛË, Ô ÎÚ‡Ô˜ ·¤Ú·˜, Ô ·Ú¿ÁÔÓÙ·˜ ÂÓÂÚÁÔÔ›ËÛ˘ ·ÈÌÔÂÙ·Ï›ˆÓ (ƒ∞F) Î·È ‰È¿ÊÔÚ· ·ÏÏÂÚÁÈÔÁfiÓ·. ™ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 50% ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ, ÂÍÔ˘‰ÂÙÂÚÒÓÔÓÙ·È ·fi Ù· ∞§. ∂ȉÈο ÁÈ· Ù· ·ÏÏÂÚÁÈÔÁfiÓ·, ÙÔ 70-80% Ù˘ ÚÒÈÌ˘ Î·È ÙÔ 50-60% Ù˘ fi„ÈÌ˘ ·ÓÙ›‰Ú·Û˘ ÂÌÔ‰›˙ÔÓÙ·È ·fi Ù· ∞§. ∆· ∞§ ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÙfiÛÔ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜, fiÛÔ Î·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·. ∂›Û˘, ÌÂÈÒÓÔ˘Ó Î·È ¿ÏÏ· ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, fiˆ˜ Ù· ∆-ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· Ì·ÛÙÔ·ÙÙ·Ú·. ∏ ›‰Ú·ÛË ÙÔ˘ ƒranlukast (΢ÎÏÔÊÔÚ› ÛÙËÓ π·ˆÓ›· (7)) ÛÙË Ì›ˆÛË Ù˘ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ ÌÂÙ¿ ·fi ÚfiÎÏËÛË Ì ÌÂÙ·¯ÔÏ›ÓË, ÈÛÙÔÔÈ‹ıËΠÌfiÓÔ Û ÌÈ· ÌÂϤÙË. ∆Ô ªontelukast ‚Ú¤ıËΠfiÙÈ ÌÂÈÒÓÂÈ ‰Ú·ÛÙÈο ÙÔÓ ‚ÚÔÁ¯fiÛ·ÛÌÔ ·fi ¿ÛÎËÛË, fi¯È fï˜ ÎÈ ÂΛÓÔÓ Ô˘ ÚÔηÏÂ›Ù·È ÌÂÙ¿ ¯ÔÚ‹ÁËÛË ÌÂÙ·¯ÔÏ›Ó˘.(3,6) ™Â ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË Û ·ÛıÂÓ›˜ ≥15 ¯ÚfiÓˆÓ, ªontelukast Û ‰fiÛË 10 mg ËÌÂÚËÛ›ˆ˜ ÚÈÓ ·fi ÙË Î·Ù¿ÎÏÈÛË, ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, fiˆ˜ ›Û˘ Î·È ‚ÂÏÙ›ˆÛË fiÏˆÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È ÂϤÁ¯Ô˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (8). ªÂϤÙ˜ Û ·È‰È¿ ∏ ›‰Ú·ÛË ÙÔ˘ ªontelukast ÌÂÏÂÙ‹ıËΠ۠336 ·È‰È¿ ËÏÈΛ·˜ 6-14 ¯ÚfiÓˆÓ Ì ηÏÒ˜ ÂÏÂÁ¯fiÌÂÓÔ,
AÓÙÈÏ¢ÎÔÙÚȤÓÈ· Î·È ¿ÛıÌ·
̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ¿ÛıÌ·. ªÂÙ¿ ıÂڷ›· 8 ‚‰ÔÌ¿‰ˆÓ, Ì 5 mg Ê·ÚÌ¿ÎÔ˘, Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· Ô˘ ¤·ÈÚÓ ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ (Ì¿ÚÙ˘Ú˜), ÔÈ ·ÛıÂÓ›˜ ÙÔ˘ ªontelukast ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ÚˆÈÓ‹˜ ÙÈÌ‹˜ Ù˘ F∂V1 ηٿ 8,23% (Û ۇÁÎÚÈÛË Ì 3,58% Ù˘ ÔÌ¿‰·˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ). ∂ÈϤÔÓ, Ë ÙÈÌ‹ Ù˘ ÚˆÈÓ‹˜ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ (ƒ∂FR) ‚ÂÏÙÈÒıËΠÛËÌ·ÓÙÈο ÛÙËÓ ÔÌ¿‰· ÌÂϤÙ˘, fiˆ˜ Î·È fiϘ ÔÈ ·Ú¿ÌÂÙÚÔÈ ÙÔ˘ ÂȉÈÎÔ‡ ÁÈ· ÙÔ ·È‰ÈÎfi ¿ÛıÌ· ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ÁÈ· ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜, ÂÏ·ÙÙÒıËΠÙÔ ÔÛÔÛÙfi ÙˆÓ ËÌÂÚÒÓ Î·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì Âȉ›ӈÛË. ∂›Û˘, ÌÂÈÒıËÎÂ Ë ËˆÛÈÓÔÊÈÏ›· ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·. ∏ ¤Ó·ÚÍË Ù˘ ‰Ú¿Û˘ ·Ú·ÙËÚ‹ıËΠ·fi ÙËÓ ÚÒÙË Ë̤ڷ, Ë ıÂڷ¢ÙÈ΋ Ù˘ ›‰Ú·ÛË ‰È·ÙËÚ‹ıËΠÛÙ·ıÂÚ‹, ¯ˆÚ›˜ ¤Ó‰ÂÈÍË Ù·¯˘Ê‡Ï·Í˘ Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜, ÂÓÒ ·Ú·Ïϋψ˜ Ì›ˆÛÂ Î·È ÙËÓ ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ‚2-‰ÈÂÁÂÚÙÒÓ. OÈ ÎÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ‹Ù·Ó Û¿ÓȘ, ‹È˜ Î·È ·ÚfiÌÔȘ Ì ·˘Ù¤˜ Ù˘ ÔÌ¿‰·˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ÔÈ Ôԛ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‹È· ÎÂÊ·Ï·ÏÁ›·, Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ÌÈÎÚ‹ ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ.(9) ™Â ¿ÏÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, ÛÙËÓ ÔÔ›· ‹Ú·Ó ̤ÚÔ˜ 27 ·È‰È¿ Ì ¯ÚfiÓÈÔ ÛÙ·ıÂÚfi ¿ÛıÌ· (F∂V1 ≥70% ·Ó·ÌÂÓfiÌÂÓ˘ ÙÈÌ‹˜), ·ÍÈÔÏÔÁ‹ıËÎÂ Ë ‰Ú¿ÛË ÙÔ˘ ªontelukast ÛÙÔÓ ‚ÚÔÁ¯fiÛ·ÛÌÔ ¿ÛÎËÛ˘. OÈ ·ÛıÂÓ›˜ ¤Ï·‚·Ó ›Ù 5 mg ªontelukast ›Ù ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ (placebo) ÚÈÓ ÙË Î·Ù¿ÎÏÈÛË, ÁÈ· 2 ̤Ú˜ Î·È ÙË ÙÚ›ÙË Ì¤Ú· (20-24 ÒÚ˜ ·fi ÙË ÙÂÏÂ˘Ù·›· ‰fiÛË) ˘Ô‚Ï‹ıËÎ·Ó Û ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘. ™ÙË ÌÂϤÙË ÂÎÙÈÌ‹ıËÎÂ Ë Ì¤ÁÈÛÙË ÂηÙÔÛÙÈ·›· ÌÂÙ·‚ÔÏ‹ Ô˘ ·ÚÔ˘Û›·ÛÂ Ë F∂V1 ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ¿ÛÎËÛË ¤ˆ˜ Î·È 90 ÏÂÙ¿ ÌÂÙ¿ ·fi ·˘Ù‹, Ë ÙÈÌ‹ Ù˘ F∂V1 ÛÙ· ÚÒÙ· 60 ÏÂÙ¿ Ù˘ ¿ÛÎËÛ˘, ηıÒ˜ Î·È Ô ¯ÚfiÓÔ˜ Ô˘ ··ÈÙ‹ıËΠÁÈ· ÙËÓ Â¿ÓÔ‰Ô Ù˘ F∂V1 ÛÙ· ÚÔ Ù˘ ¿ÛÎËÛ˘ ›‰·. ™ÙË Î·Ì‡ÏË ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ÌÂÙ·‚ÔÏÒÓ Ù˘ F∂V1 (οıÂÙÔ˜ ¿ÍÔÓ·˜) Û ۯ¤ÛË Ì ÙÔ ¯ÚfiÓÔ (ÔÚÈ˙fiÓÙÈÔ˜ ¿ÍÔÓ·˜) ·ÍÈÔÏÔÁ‹ıËΠÙÔ ÂÌ‚·‰fiÓ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÙÚ·Â˙›Ô˘ οو ·fi ÙËÓ Î·Ì‡ÏË (∞rea Under the Curve, ∞UC 0-60 min), Ë ÔÔ›· ‰›ÓÂÈ Û˘ÓÔÏÈο ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ¤ÓÙ·Û˘ ·ÏÏ¿ Î·È Ù˘ ‰È¿ÚÎÂÈ·˜ ÙÔ˘ ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ (∂ÈÎfiÓ˜ 2 Î·È 3). ∏ AUC 0-60 min ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË (59%) ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Montelukast ¤Ó·ÓÙÈ Ù˘ ÔÌ¿‰·˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ‰Â›¯ÓÂÈ ÙËÓ ÚÔÛٷ٢ÙÈ΋ ÙÔ˘ ‰Ú¿ÛË. ∏ ̤ÁÈÛÙË ÂηÙÔÛÙÈ·›· ÙÒÛË Ù˘ F∂V1, ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË fiÙ·Ó ÔÈ ·ÛıÂÓ›˜ ¤·ÈÚÓ·Ó Montelukast (18% ¤Ó·ÓÙÈ 26% ÙˆÓ Ì·ÚÙ‡ÚˆÓ). O ¯ÚfiÓÔ˜ ·Ó¿Ó˄˘ ·fi ÙÔÓ ‚ÚÔÁ¯fiÛ·ÛÌÔ Ù˘ ¿ÛÎËÛ˘ fï˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠӷ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ˜ (18 ¤Ó·ÓÙÈ 28 ÏÂÙÒÓ ÁÈ· ÙÔ˘˜ Ì¿ÚÙ˘Ú˜).(10)
369
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14:03
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Ã. ∫·ÙÛ·Ú‰‹˜
∂ÈÎfiÓ· 2. ∫ÚÈÙ‹ÚÈ· ·ÍÈÔÏfiÁËÛ˘ Ù˘ ¤ÓÙ·Û˘ Ù˘ ÌÂÙ·‚ÔÏ‹˜ Ù˘ FEV1 (οıÂÙÔ˜ ¿ÍÔÓ·˜) Û ۯ¤ÛË Ì ÙÔÓ ¯ÚfiÓÔ (ÔÚÈ˙fiÓÙÈÔ˜ ¿ÍÔÓ·˜) ÌÂÙ¿ Ê˘ÛÈ΋ ¿ÛÎËÛË. ∆Ô ÂÌ‚·‰fiÓ ÙÔ˘ ÙÚ·Â˙›Ô˘ οو ·fi ÙËÓ Î·Ì‡ÏË (Area Under the Curve, AVC 0-60 min) ‰›ÓÂÈ Û˘ÓÔÏÈο ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙËÓ ¤ÓÙ·ÛË ÙÔ˘ ‚ÚÔÁ¯fiÛ·ÛÌÔ˘. 5
Montelukast 0
Placebo
-5
FEV1% ÌÂÙ·‚ÔÏ‹ (ª¤ÛÔ˜ fiÚÔ˜ ±SE)
-10 -15 -20 -25 -30 0
5
10
15
30
45
60
ÃÚfiÓÔ˜ ÌÂÙ¿ ÙËÓ ¿ÛÎËÛË (min)
∂ÈÎfiÓ· 3. ª¤ÛË ÔÛÔÛÙÈ·›· ÌÂÙ·‚ÔÏ‹ Ù˘ ÙÈÌ‹˜ Ù˘ FEV1 Û ¯ÚÔÓÈο ÛËÌ›· 0 Î·È 60 ÏÂÙÒÓ ÌÂÙ¿ ÙËÓ ¿ÛÎËÛË, Û ۯ¤ÛË Ì ÙËÓ ÙÈÌ‹ Ù˘ FEV1 ÚÈÓ ÙËÓ ¿ÛÎËÛË (™‡ÁÎÚÈÛË ·ÓÙ›ÛÙÔȯˆÓ Î·Ì˘ÏÒÓ Montelukast Î·È placebo). ªÂϤÙ˜ Û ·ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 15 ¯ÚfiÓˆÓ Î·È Ë Û¯¤ÛË ÙˆÓ ∞§ Ì ¿ÏÏ· Û˘Ó·Ê‹ Ê¿Ú̷η ∆· ∞§ ‚ÂÏÙÈÒÓÔ˘Ó ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ Ó¢ÌfiÓˆÓ (Ë F∂V1 ·˘Í¿ÓÂÙ·È Î·Ù¿ 13,4%), ÌÂÈÒÓÔ˘Ó Ù· Û˘ÌÙÒÌ·Ù· ηٿ 37%, ÙË ¯Ú‹ÛË ÙˆÓ ‚2‰ÈÂÁÂÚÙÒÓ Î·Ù¿ 24% Î·È ÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ L∆∂4 ÛÙ· Ô‡Ú· Û ·ÛıÂÓ›˜ Ì ‹ÈÔ - ̤ÙÚÈÔ ¿ÛıÌ·.(5) ÃÔÚ‹ÁËÛË ∞§ ÚÔÏ·Ì‚¿ÓÂÈ ÙÔÓ ‚ÚÔÁ¯fiÛ·ÛÌÔ Ô˘ ÚÔηÏÂ›Ù·È Û ÌÂÚÈο ¿ÙÔÌ·, ÌÂÙ¿ ¯ÔÚ‹ÁËÛË ·ÛÈÚ›Ó˘ ‹ ¿ÏÏˆÓ ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ-
370
‰ÒÓ Ê·Ú̿ΈÓ. ø˜ ÁÓˆÛÙfi, Ë ·ÛÈÚ›ÓË ÂÎÙfi˜ ·fi ·ÓÙȉڿÛÂȘ ÛÙË Ì‡ÙË, ÛÙ· Ì¿ÙÈ·, ÛÙÔ ‰¤ÚÌ· Î·È ÛÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ ·ÎfiÌ· Î·È ·ÂÈÏËÙÈÎfi ÁÈ· ÙË ˙ˆ‹ ‚ÚÔÁ¯fiÛ·ÛÌÔ Û ÌÂÚÈÎÔ‡˜ ·ÛıÌ·ÙÈÎÔ‡˜. OÈ ÙÂÏÂ˘Ù·›ÔÈ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ·˘ÍË̤ÓË ‰Ú¿ÛË Ù˘ Û˘ÓıÂÙ¿Û˘ ·Ú·ÁˆÁ‹˜ ÙÔ˘ L∆C4, ÛÙ· ˈÛÈÓfiÊÈÏ· Î·È Ù· Ì·ÛÙÔ·ÙÙ·Ú·, Ô˘ Èı·ÓÒ˜ ÚÔ·ÙÂÈ ·fi ÌÂÙ¿ÏÏ·ÍË Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ ÚÔ¿ÁÂÈ ÙË Û˘ÓıÂÙ¿ÛË ÙÔ˘ LTC4.(2,3,11)
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™ÂÏ›‰·371
¶∞π¢π∞∆ƒπ∫∏ 2000;63:367-374
™Â ¿ÏÏË ÌÂϤÙË ÂȂ‚·ÈÒÓÂÙ·È Ë ÚÔÛٷ٢ÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË ÛÙËÓ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ÛÙËÓ ÌÂȈ̤ÓË ·Ó¿ÁÎË ¯Ú‹Û˘ ÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ· ÛÙÔ˘˜ ·ÚÔ͢ÛÌÔ‡˜.(12) ™Â ·ÛıÌ·ÙÈÎÔ‡˜ Ì ‹ÈÔ ¿ÛıÌ· ÙÔ Montelukast ¤‰ÂÈÍ fiÙÈ ÚÔÛٷهÂÈ ·fi ÙÔ ¿ÛıÌ· ¿ÛÎËÛ˘ ÁÈ· ÙËÓ ÂÚ›Ô‰Ô ÙˆÓ 12 ‚‰ÔÌ¿‰ˆÓ Ô˘ ¯ÔÚËÁ‹ıËÎÂ, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚËı› ·ÓÔ¯‹ ‹ ˘ÔÙÚÔ‹ Ì Âȉ›ӈÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ, ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘.(13) ™Â 191 ÂÓ‹ÏÈΘ ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ÔÌÔ›ˆ˜ Ì ‹ÈÔ ¿ÛıÌ·, Ë Û‡ÁÎÚÈÛË ÁÈ· 8 ‚‰ÔÌ¿‰Â˜ Ù˘ Û·ÏÌÂÙÂÚfiÏ˘ (50Ìg/12ˆÚÔ) Î·È ÙÔ˘ Montelukast (10mg/Ë̤ڷ Û ÌÈ· ‰fiÛË), ¤‰ÂÈÍ fiÙÈ ÙÔ Montelukast ·Ú¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÚÔÛÙ·Û›·˜ ·fi ‚ÚÔÁ¯fiÛ·ÛÌÔ ¿ÛÎËÛ˘, Ô˘ ·Ú·Ì¤ÓÂÈ ·Ó·ÏÏÔ›ˆÙÔ˜ ·fi ÙËÓ ·Ú¯‹ (60%) ¤ˆ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜ (57%), ÂÓÒ Ë Û·ÏÌÂÙÂÚfiÏË ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÓÔ¯‹ ηٿ ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô (41% ÛÙËÓ ·Ú¯‹ Î·È 17% ÛÙÔ Ù¤ÏÔ˜).(3) ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È Ë ÂÌÊ¿ÓÈÛË ·ÓÔ¯‹˜ ÌÂÙ¿ ·fi 1 ‚‰ÔÌ¿‰· ¯ÔÚ‹ÁËÛ˘ Û·Ï‚Ô˘Ù·ÌfiÏ˘.(14) ÕÏÏË ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ˘¿Ú¯ÂÈ Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË ÙˆÓ ∞§ Ì ÙÔ˘˜ ‚2-‰ÈÂÁ¤ÚÙ˜ ÛÙËÓ ÚfiÎÏËÛË ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜, Ë ÔÔ›· ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Â›Ó·È ÌÈÛ‹ ÂÚ›Ô˘ ·fi ÂΛÓË Ô˘ ÚÔηÏÔ‡Ó ÌfiÓÔÈ ÔÈ ‚2-‰ÈÂÁ¤ÚÙ˜ Î·È ÂΉËÏÒÓÂÙ·È Û 1-3 ÒÚ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË. ∏ ÂÈÚfiÛıÂÙË ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ Ô˘ ÚÔηÏÔ‡Ó Ù· ∞§ Èı·ÓÒ˜ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ ‰È·ÊÔÚÂÙÈÎfi Ì˯·ÓÈÛÌfi ‰Ú¿Û˘.(1,14) ∏ Û‡ÁÎÚÈÛË ÙˆÓ ∞§ Ì ÙË Ó·ÙÚÈÔ‡¯Ô ¯ÚˆÌÔÁÏ˘Î›ÓË (10mg/6ˆÚÔ), Û 18 ÂÊ‹‚Ô˘˜ ·ÛıÌ·ÙÈÎÔ‡˜, ÁÈ· ÂÚ›Ô‰Ô 2 ‚‰ÔÌ¿‰ˆÓ, ‰ÂÓ ¤‰ÂÈÍ ۷ʋ ˘ÂÚÔ¯‹ ÙˆÓ ∞§.(3) ∏ ¯Ú‹ÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Ê·›ÓÂÙ·È Ó· ˘ÂÚ¤¯ÂÈ Ù˘ ‰Ú¿Û˘ ÙˆÓ ∞§, Û ÌÂÚÈΤ˜ ‰Â ÌÂϤÙ˜ Ë ˘ÂÚÔ¯‹ ‹Ù·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋.(15) ŒÙÛÈ, ÂÓÒ Ë ‰Ú¿ÛË ÙÔ˘ Montelukast Î·È Ù˘ ÂÈÛÓÂfiÌÂÓ˘ ÌÂÎÏÔÌÂı·˙fiÓ˘ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ·fi ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ¯ÔÚ‹ÁËÛ˘ placebo ÛÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ F∂V1, Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È ÙË Ì›ˆÛË ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ Û˘Ìو̿وÓ, ÙˆÓ Ó˘ÎÙÂÚÈÓÒÓ ·Ê˘Ó›ÛÂˆÓ - ÂÓԯϋÛÂˆÓ Î·È ÙˆÓ ·ÚÔ͢ÛÌÒÓ, ˘‹Ú¯Â ›Û˘ Û·Ê‹˜ ˘ÂÚÔ¯‹ Ù˘ ‰Ú¿Û˘ Ù˘ ÌÂÎÏÔÌÂı·˙fiÓ˘ ¤Ó·ÓÙÈ ÙÔ˘ Montelukast, ˆ˜ ÚÔ˜ ÙȘ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚÔ˘˜. π‰È·›ÙÂÚ· ÂӉȷʤÚÔ˘Û· Â›Ó·È Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ë Î·Ù·ÓÔÌ‹ ·ÓÙ·fiÎÚÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙ· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ‹ ÛÙ· ∞§ ¤¯ÂÈ Îˆ‰ˆÓÔÂȉ¤˜ Û¯‹Ì· Î·È fiÙÈ ¿ÏÏÔÈ ·ÛıÂÓ›˜ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ÛÙÔ ¤Ó· Ê¿ÚÌ·ÎÔ Î·È ¿ÏÏÔÈ ÛÙÔ ¿ÏÏÔ, ÂÓÒ ·Ú¿ÏÏËÏ· ˘¿Ú¯ÂÈ ÌÂÁ¿ÏÔ˜ ‚·ıÌfi˜ ·ÏÏËÏÔÎ¿Ï˘„˘.(4,15) ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘Á¯ÔÚ‹ÁËÛË Montelukast Ô‰‹ÁËÛ Û Ì›ˆÛË Î·Ù¿ 46% Ù˘ ·Ó¿Á΢ ¯ÔÚ‹ÁËÛ˘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Î·È ÛÂ
AÓÙÈÏ¢ÎÔÙÚȤÓÈ· Î·È ¿ÛıÌ·
‰È·ÎÔ‹ ÛÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ.(1,7,14) ™Â ¿ÏÏË ÌÂϤÙË Ê¿ÓËΠfiÙÈ Ë ÚÔÛı‹ÎË ∞§ Â›Ó·È ÙÔ ›‰ÈÔ ·Ô‰ÔÙÈ΋ Ì ‰ÈÏ·ÛÈ·ÛÌfi Ù˘ ‰fiÛ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ.(6) ∏ Û‡ÁÎÚÈÛË Ù˘ ‰Ú¿Û˘ ÙˆÓ ∞§ Ì ÂΛÓË Ù˘ ıÂÔÊ˘ÏÏ›Ó˘, ÁÈ· ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ, ¤‰ÂÈÍ fiÙÈ Î·È Ù· ‰‡Ô Ê¿Ú̷η ÚÔηÏÔ‡Ó ·‡ÍËÛË Ù˘ F∂V1, ·ÏÏ¿ Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó ÈÔ ¤Î‰ËÏË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó ıÂÔÊ˘ÏÏ›ÓË.(1) ∏ Û˘Á¯ÔÚ‹ÁËÛË ∞§ Ì ÂÎÏÂÎÙÈÎfi ∏1-·ÓÙ·ÁˆÓÈÛÙ‹ Ù˘ ÈÛÙ·Ì›Ó˘ (ÏÔÚ·Ù·‰›ÓË) ÌÂÈÒÓÂÈ Î·Ù¿ 75% ÙfiÛÔ ÙËÓ ÚÒÈÌË fiÛÔ Î·È ÙËÓ fi„ÈÌË ·ÓÙ›‰Ú·ÛË, ÌÂÙ¿ ÚfiÎÏËÛË Ì ·ÏÏÂÚÁÈÔÁfiÓÔ. ∂ÈϤÔÓ, Ë Û˘Á¯ÔÚ‹ÁËÛË ÙˆÓ ·ÓˆÙ¤Úˆ Ê·ÚÌ¿ÎˆÓ ÚÔηÏ› Û ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ÈÔ ¤Î‰ËÏË ÚÈÓÈ΋ ·Ó·ÎÔ‡ÊÈÛË, ·fi ÂΛÓË Ô˘ ÚÔηÏÂ›Ù·È fiÙ·Ó Î¿ı ʿÚÌ·ÎÔ ¯ÔÚËÁÂ›Ù·È Í¯ˆÚÈÛÙ¿. ∂›Û˘, Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ∞§ ¤¯ÂÈ ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, Ì ÂΛӷ Ô˘ ÚÔηÏÔ‡Ó ·ÓÙÈÈÛÙ·ÌÈÓÈο ¯ÔÚËÁÔ‡ÌÂÓ· ·fi ÙÔ ÛÙfiÌ·.(2,3) £¤ÛË ÙˆÓ ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ ÛÙË ıÂڷ›· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ∆· ȉ·ÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓfi˜ ·ÓÙÈ·ÛıÌ·ÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ Ú¤ÂÈ Ó· Â›Ó·È Ù· ·Ú·Î¿Ùˆ(16): 1. ∂‡ÎÔÏÔ ÛÙË Ï‹„Ë, ÒÛÙ ӷ ˘¿Ú¯ÂÈ Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓ‹. ∂Âȉ‹ Ù· ∞§ ‰È·Ù›ıÂÓÙ·È Û ‰ÈÛΛ· Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÌÈ· (Montelukast) ‹ ‰‡Ô ÊÔÚ¤˜ (∑afirlukast, ƒranlukast) ÙËÓ Ë̤ڷ, Ì ÂÍ·›ÚÂÛË ÙÔ ∑ileuton Ô˘ ¯ÔÚËÁÂ›Ù·È Ù¤ÛÛÂÚȘ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÌʈÓÔ‡Ó fiÙÈ ˘ÂÚÙÂÚÔ‡Ó ÛÙË Û˘ÌÌfiÚʈÛË Û ۯ¤ÛË Ì ٷ ÂÈÛÓÂfiÌÂÓ· Ê¿Ú̷η. ªÂϤÙË Ô˘ ¤ÁÈÓ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜, ÌÂÙ¿ 4 ‚‰ÔÌ¿‰Â˜ ıÂڷ›·˜, ¤‰ÂÈÍ fiÙÈ ÙÔ 55% ÙˆÓ ·ÛıÂÓÒÓ ÚÔÙÈÌÔ‡Û·Ó ÙÔ ∑afirlukast Î·È ÌfiÓÔ ÙÔ 25% Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹.(1,6) ø˜ Û˘ÌÌfiÚʈÛË Ì ÙË ıÂڷ›·, ÌÔÚ› Ó· ÔÚÈÛı› ÙÔ ËÏ›ÎÔ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ‰fiÛÂˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, Ô˘ Ï·Ì‚¿ÓÔÓÙ·È ·fi ÙÔÓ ·ÛıÂÓ‹, ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‰fiÛÂˆÓ Ô˘ Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÓÙ·È ·fi ÙÔÓ È·ÙÚfi. ∏ Û˘ÌÌfiÚʈÛË Â›Ó·È ·Ó·ÌÊÈÛ‚‹ÙËÙË ÚÔ¸fiıÂÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ·ÛıÌ·ÙÈÎÔ‡ ·ÛıÂÓ‹, ·ÏÏ¿ ÌfiÓÔ ÙÔ 7-19%, ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ï·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ıÂÚ¿ÔÓÙ· È·ÙÚÔ‡, ÂÓÒ ÁÈ· ÙÔ 58% Ô ÙÚfiÔ˜ ¯Ú‹Û˘ ÎÚ›ÓÂÙ·È ··Ú¿‰ÂÎÙÔ˜ (17-19). ¶ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ ÂËÚ¿˙Ô˘Ó ÙË Û˘ÌÌfiÚʈÛË Î·È ÙËÓ ·ÁˆÁ‹ ÙfiÛÔ ÙˆÓ ÂÓËÏ›ÎˆÓ fiÛÔ Î·È ÙˆÓ ÌÈÎÚÒÓ ·ÛıÌ·ÙÈÎÒÓ ·ÛıÂÓÒÓ. ™Â ·˘ÙÔ‡˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·ÏfiÙËÙ· ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜, Ë Û˘ÓÂȉËÙÔÔ›ËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ηٿÛÙ·Û˘ ·fi ÙÔÓ ·ÛıÂÓ‹, Ë Â˘ÎÔÏ›· ¯ÔÚ‹ÁËÛ˘ Ù˘ ıÂڷ›·˜ (Ô‰fi˜ ¯ÔÚ‹ÁËÛ˘, ‡ÎÔÏË ¯Ú‹ÛË Û˘Û΢‹˜), Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· Ù˘ ıÂڷ›·˜, ηıÒ˜ Î·È Ë Û¯¤ÛË È·ÙÚÔ‡ -
371
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·372
¶∞π¢π∞∆ƒπ∫∏ 2000;63:367-374
·ÛıÂÓÔ‡˜. ∂›Û˘, ÛÙË Û˘ÌÌfiÚʈÛË ˘ÂÈÛ¤Ú¯ÔÓÙ·È ·Ú¿ÁÔÓÙ˜ ÎÔÈÓˆÓÈÎÔ›, „˘¯ÔÏÔÁÈÎÔ›, ÔÏÈÙÈÛÌÈÎÔ›, ‰È¿ÊÔÚ˜ ȉȷÈÙÂÚfiÙËÙ˜ (.¯. ¤ÊË‚ÔÈ) Î·È ÔÈ ÂÔÈı‹ÛÂȘ ÙÔ˘ ·ÛıÂÓÔ‡˜.(17) ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ··ÈÙ› ÁÓÒÛË, ÂÌÂÈÚ›· Î·È ¯ÚfiÓÔ. O ÙÂÏÂ˘Ù·›Ô˜ ıˆÚÂ›Ù·È ··Ú·›ÙËÙÔ˜ ÁÈ· ÙËÓ Âη›‰Â˘ÛË (ÂΛ ·Ó·Ê¤ÚÔÓÙ·È Ù· Û¯ÔÏ›· ¿ÛıÌ·ÙÔ˜) ÙˆÓ ·ÛıÂÓÒÓ. ÷ڷÎÙËÚÈÛÙÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÌÂÙ¿ ·fi 1 Ì‹Ó· Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓËÏ›ÎˆÓ ·ÛıÌ·ÙÈÎÒÓ, Ë Î·Î‹ Ù¯ÓÈ΋ Ï‹„˘ ÂÈÛÓÂfiÌÂÓˆÓ ÌÂÈÒıËΠ·fi 44% ÛÙËÓ ·Ú¯‹, Û 27% ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘.(6) ∏ ·Ó·Ú΋˜ Û˘ÌÌfiÚʈÛË ‰ÂÓ Â›Ó·È ¿ÓÙˆ˜ ›‰ÈÔ ÌfiÓÔ ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·ÛıÂÓÒÓ. ∫·È Û ¿ÏÏ· ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, fiˆ˜ ÛÙËÓ ÂÈÏË„›· Î·È ÛÙËÓ ˘¤ÚÙ·ÛË Ë Û˘ÌÌfiÚʈÛË Î˘Ì·›ÓÂÙ·È ·fi 40-50%.(20) 2. ªÂ›ˆÛË ÙˆÓ Û˘Ìو̿وÓ. ∆· ∞§ Ê·›ÓÂÙ·È ·fi ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ fiÙÈ ÌÂÈÒÓÔ˘Ó Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ¿ÛıÌ·ÙÔ˜.(1,3,5-14) ªÂ ‚¿ÛË ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ Ó¢ÌfiÓˆÓ, Ë ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË Â›Ó·È ÈÔ ‚·ıÌÈ·›· Î·È ÂÚ›Ô˘ ÛÙÔ ‹ÌÈÛ˘ Ù˘ ‰Ú¿Û˘ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ, ¯ˆÚ›˜ fï˜ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÔ¯‹, fiˆ˜ Û˘Ì‚·›ÓÂÈ Ì ÙÔ˘˜ ‚2-‰ÈÂÁ¤ÚÙ˜ ‚Ú·¯Â›·˜ Î·È Ì·ÎÚ¿˜ ‰Ú¿Û˘.(1,3,14) ∂›Û˘, Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ˘ÂÚ¤¯Ô˘Ó ÛÙË Ì›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ F∂V1, Û ۇÁÎÚÈÛË Ì ٷ ∞§. ∏ ‰Ú¿ÛË fï˜ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ Â›Ó·È Ôχ ÈÔ ÁÚ‹ÁÔÚË (¤Ó·ÚÍË Ù˘ ̤ÁÈÛÙ˘ ·fi‰ÔÛ˘ ۯ‰fiÓ Ì ÙËÓ ÚÒÙË ‰fiÛË), ÂÓÒ Ë ÌÂÎÏÔÌÂı·˙fiÓË ÌfiÓÔ ÌÂÙ¿ ·fi 7-10 ̤Ú˜ ·Ú¯›˙ÂÈ Ó· ˘ÂÚ¤¯ÂÈ ÙˆÓ ∞§ ÂÓÒ ÁÈ· ÙÔ Ì¤ÁÈÛÙÔ Ù˘ ‰Ú¿Û˘ Ù˘ ¯ÚÂÈ¿˙ÔÓÙ·È 6 ‚‰ÔÌ¿‰Â˜ ıÂڷ›·˜.(3,15) ∏ ‰Ú¿ÛË Ù˘ Ó·ÙÚÈÔ‡¯Ô˘ ¯ÚˆÌÔÁÏ˘Î›Ó˘, Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛӢ ÙˆÓ ∞§, Ì ÙË ‰È·ÊÔÚ¿ fiÙÈ Ë ¯ÚˆÌÔÁÏ˘Î›ÓË ··ÈÙ› 1-3 ‚‰ÔÌ¿‰Â˜ ıÂڷ›·˜, ÁÈ· Ó· Ê·Ó› Ë ıÂڷ¢ÙÈ΋ Ù˘ ›‰Ú·ÛË.(3,9) 3. ªÂ›ˆÛË ÙˆÓ ·ÚÔ͢ÛÌÒÓ. ∆· ∞§ ÌÂÈÒÓÔ˘Ó ÙÔ˘˜ ·ÚÔ͢ÛÌÔ‡˜ ηٿ ÔÛÔÛÙfi 60-80%. ª¿ÏÈÛÙ· Û ·ÛıÂÓ›˜ Ì ‚·Ú‡ ¿ÛıÌ· Ë Ì›ˆÛË ÙˆÓ ·ÚÔ͢ÛÌÒÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË.(4,21,22) ∏ Î¿Ï˘„Ë fï˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ÏËÚ¤ÛÙÂÚË.(16) ™Â ÌÂϤÙË Û˘Á¯ÔÚ‹ÁËÛ˘ ∞§ Î·È ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ‰È·ÈÛÙÒıËΠfiÙÈ Ë Ì›ˆÛË ÙˆÓ ·ÚÔ͢ÛÌÒÓ, Û ·ÛıÂÓ›˜ Ì ‚·Ú‡ ¿ÛıÌ·, Û˘Óԉ‡ÂÙ·È ·fi ÚfiÏË„Ë Ù˘ ·‡ÍËÛ˘ Ù˘ ˈÛÈÓÔÊÈÏÈ΋˜ ηÙÈÔÓÈ΋˜ ÚˆÙ½Ó˘ (∂Cƒ) Î·È ÙÔ˘ ¡O, Ô˘ Â›Ó·È ·ÍÈfiÈÛÙÔÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ÙÔ˘ placebo.(2,7) 4. µÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∆· ∞§ ¤¯Ô˘Ó Ô˘ÛÈ·ÛÙÈ΋ ·Ú¤Ì‚·ÛË ÛÙÔ ‚ÚÔÁ¯fiÛ·ÛÌÔ, Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÛÎËÛË. OÈ ·Ó·ÛÙÔÏ›˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ (Montelukast, Zafilukast, Pranlukast) ‰ÚÔ˘Ó ÙfiÛÔ ÛÙËÓ ÚÒÈÌË fiÛÔ Î·È ÛÙËÓ fi„ÈÌË ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË, Û ·ÓÙ›ıÂÛË ÌÂÙ¿ ÎÔÚÙÈÎÔÂȉ‹ Î·È ÙÔ˘˜
372
Ã. ∫·ÙÛ·Ú‰‹˜
·Ó·ÛÙÔÏ›˜ Ù˘ ‚ÈÔÛ‡ÓıÂÛ˘ ÙˆÓ Ï¢ÎÔÙÚÈÂÓ›ˆÓ (Zileuton), Ô˘ ·ÚÂÌ‚·›ÓÔ˘Ó ÌfiÓÔ ÛÙËÓ fi„ÈÌË.(5) ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙÔ˘ ·ÛıÌ·ÙÈÎÔ‡ ·ÛıÂÓ‹ Â›Ó·È ¤Î‰ËÏË ÌÂÙ¿ ÙË ¯Ú‹ÛË ∞§ ·ÏÏ¿ ÛËÌÂÈÒÓÂÙ·È Î·È ¿ÏÈ, fiÙÈ Ë ‰Ú¿ÛË ÙÔ˘˜ ˘ÔÏ›ÂÙ·È Û·ÊÒ˜ ÂΛӢ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ.(15) 5. ∫·ıÔÚÈÛÙÈÎfi ÛÙË ÌÂÏÏÔÓÙÈ΋ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ Ó· ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙËÓ Â›‰Ú·ÛË ÙˆÓ ∞§ ÛÙË ÌÂÏÏÔÓÙÈ΋ ¤Î‚·ÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜. À¿Ú¯Ô˘Ó fï˜ ‰ËÌÔÛȇÛÂȘ ·fi ÙȘ Ôԛ˜ ÚÔ·ÙÂÈ fiÙÈ Ù· ÛÙÂÚÔÂȉ‹ ·ÚÂÌ‚·›ÓÔ˘Ó Â˘ÂÚÁÂÙÈο ÛÙËÓ ÚfiÁÓˆÛË Î·È Ì¿ÏÈÛÙ· Â›Ó·È ÙfiÛÔ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο, fiÛÔ ÈÔ ¤ÁηÈÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È.(16) 6. ∂›Ó·È ·ÛÊ·Ï‹˜ Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘. ∆· ∞§ ÛÙÂÚÔ‡ÓÙ·È ‚·ÛÈÎÒ˜ ·ÚÂÓÂÚÁÂÈÒÓ Î·È ˘ÂÚÙÂÚÔ‡Ó ÛÙÔ ÙÔ̤· ·˘Ùfi ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ.(9) ∆Ô Ê·ÈÓfiÌÂÓÔ Churg - Strauss (ÂÎÛÂÛËÌ·Ṳ̂ÓË ËˆÛÈÓÔÊÈÏ›·, ηډȷ΋ ·Ó¿ÚÎÂÈ· Î·È ËˆÛÈÓÔÊÈÏÈ΋ ·ÁÁÂÈ›Ùȉ·) ·Ú·ÙËÚ‹ıËΠ۠ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Ô˘ ÂÎÙfi˜ ·fi ∞§, Ï¿Ì‚·Ó·Ó ˘„ËϤ˜ ‰fiÛÂȘ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ‹ Î·È ÎÔÚÙÈÎÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ·.(1,7) ™‹ÌÂÚ·, Ë Ì›· ·fi ÙȘ ‰‡Ô ·Ô‰ÂÎÙ¤˜ ·fi„ÂȘ ÁÈ· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È Ë ‡·ÚÍË ÙˆÓ ·Ú·Î¿Ùˆ ÙÚÈÒÓ ÎÚÈÙËÚ›ˆÓ: (·) ¿ÛıÌ·, (‚) ˈÛÈÓÔÊÈÏ›· (>1,5x109 ·ÙÙ·Ú·/L) Î·È (Á) ·ÁÁÂÈ›Ùȉ· Û ÂÚÈÛÛfiÙÂÚ· ·fi ‰‡Ô Â͈Ó¢ÌÔÓÈο fiÚÁ·Ó·. ∏ ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Û ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Î˘Ì·›ÓÂÙ·È ·fi 36-80/106, ÂÓÒ Û ·ÛıÂÓ›˜ ˘fi Û·ÏÌÂÙÂÚfiÏË Êı¿ÓÂÈ ÙÔ˘˜ 43/106, ˘fi Ó‰ÔÎÚÔÌ›ÏË Û 62/106 Î·È ˘fi ∞§ Û 44-118/106 ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜.(23) ∆Ô Û‡Ó‰ÚÔÌÔ Churg - Strauss ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÚ›· ÛÙ¿‰È·: 1Æ) ∂ȉ›ӈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ì ÔÏϷϤ˜ ·ÏÏÂÚÁÈΤ˜ ÂΉËÏÒÛÂȘ Î·È ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ˜. 2Æ) ∂ÎÛÂÛËÌ·Ṳ̂ÓË ËˆÛÈÓÔÊÈÏ›· Î·È ËˆÛÈÓÔÊÈÏÈΤ˜ ‰ÈËı‹ÛÂȘ ÙˆÓ Ó¢ÌfiÓˆÓ, ÔÈ Ôԛ˜ Â›Ó·È ÂÌÊ·Ó›˜ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. 3Æ) ∏ˆÛÈÓÔÊÈÏÈ΋ ·ÁÁÂÈ›Ùȉ· Ô˘ ηٷϷ̂¿ÓÂÈ fiÏ· Ù· fiÚÁ·Ó·, ·ÏÏ¿ ΢ڛˆ˜ ÙÔ ‰¤ÚÌ· Î·È ÙÔ Ì˘ÔοډÈÔ. ∆Ô Û‡Ó‰ÚÔÌÔ Û˘Ó‹ıˆ˜, ·ÚÔ˘ÛÈ¿˙ÂÈ ·˘ÙfiÌ·ÙË ‡ÊÂÛË ÚÈÓ ÙÔ ÙÚ›ÙÔ ÛÙ¿‰ÈÔ. OÌÔ›ˆ˜, Ë ¤ÁηÈÚË ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ·, ÛÙ· ‰‡Ô ÚÔËÁÔ‡ÌÂÓ· ÛÙ¿‰È·, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÂͤÏÈÍË ÚÔ˜ ÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ. ™‹ÌÂÚ· Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ Ê·ÈÓfiÌÂÓÔ˘ Churg - Strauss ·Ô‰›‰ÂÙ·È fi¯È ÛÙË ‰Ú¿ÛË ÙˆÓ ∞§, ·ÏÏ¿ ÛÙËÓ ÚÔÛ¿ıÂÈ· Ì›ˆÛ˘ ÙˆÓ ÛÙÂÚÔÂȉÒÓ, fiÙ·Ó ·Ú·ÙËÚÂ›Ù·È ‡ÊÂÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ÙË Û˘Á¯ÔÚ‹ÁËÛË ∞§. ∏ ‡ÊÂÛË fï˜ ·˘Ù‹ ‰ÂÓ Â›Ó·È Ù›ÔÙ ¿ÏÏÔ, ·Ú¿ Ë Ê˘ÛÈÔÏÔÁÈ΋ Ì›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÚÈÓ ÙÔ ÙÚ›ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ Ê·ÈÓfiÌÂÓÔ˘ Churg - Strauss ÙÔ ÔÔ›Ô
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·373
¶∞π¢π∞∆ƒπ∫∏ 2000;63:367-374
‚Ú›ÛÎÂÙ·È Û ÂͤÏÈÍË. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Û˘ÓÈÛÙ¿Ù·È Ë Ï‹„Ë ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒÚ·ÎÔ˜ Î·È Ì¤ÙÚËÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ ÁÈ· ·Ó›¯Ó¢ÛË Èı·ÓÔ‡ Û˘Ó‰ÚfiÌÔ˘ Churg - Strauss ÛÙÔ ‰Â‡ÙÂÚÔ ÛÙ¿‰ÈÔ, ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ Ì›ˆÛ˘ ÙˆÓ ÛÙÂÚÔÂȉÒÓ Û ·ÛıÂÓ‹, Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ‡ÊÂÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂ Û˘Á¯ÔÚ‹ÁËÛË ∞§.(24) O ¶›Ó·Î·˜ 1 Û˘ÓÔ„›˙ÂÈ ÙÔ˘˜ ÏfiÁÔ˘˜ Ô˘ Û˘ÓÙÚ¤¯Ô˘Ó ÁÈ· ¯Ú‹ÛË ÙˆÓ ∞§ ÛÙËÓ ·ÓÙÈ·ÛıÌ·ÙÈ΋ ıÂڷ›·. ¶›Ó·Î·˜ 1. §fiÁÔÈ ¯Ú‹Û˘ ÙˆÓ ·ÓÙÈÏ¢ÎÔÙÚÈÂÓ›ˆÓ ÛÙË ıÂڷ›· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. 1. ∞Ï‹ per os ıÂڷ›·, Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ. 2. Èڛ˜ Ô˘ÛÈ·ÛÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ. 3. ¶ÚÔηÏÔ‡Ó ÛÙ·ıÂÚ‹ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹. 4. ∞ÔÙÂÏÂÛÌ·ÙÈο ηٿ ÌÂÛÔÏ·‚ËÙ‹ Ô˘ ‰ÂÓ ÂϤÁ¯ÂÙ·È ·fi Ù· ÂÈÛÓÂfiÌÂÓ· ÎÔÚÙÈÎÔÂȉ‹. 5. ªÂÈÒÓÔ˘Ó ÙËÓ ËˆÛÈÓÔÊÏÈ΋ ÊÏÂÁÌÔÓ‹. 6. ªÂÈÒÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·ÚÔ͢ÛÌÒÓ. 7. µÂÏÙÈÒÓÔ˘Ó ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ¿ÛıÌ·ÙÔ˜. 8. ™˘Ó·ÁˆÓ›˙ÔÓÙ·È, ·Ó Î·È ˘ÔÏ›ÔÓÙ·È, ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ¯·ÌËÏ‹˜ ‰fiÛ˘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ. 9. ÀÔ‚ÔËıÔ‡Ó ÙË ‰Ú¿ÛË ÙfiÛÔ ÙˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ fiÛÔ Î·È ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ. 10. ∞ÔÙÂÏÂÛÌ·ÙÈο ÛÙÔ ¿ÛıÌ· ·fi ·ÛÈÚ›ÓË. 11. ∞ÛÊ·Ï‹˜ Î·È ÈηÓÔÔÈËÙÈ΋ ıÂڷ›· ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ ≥6 ¯ÚfiÓˆÓ (5 mg Montelukast ËÌÂÚËÛ›ˆ˜). 12. £Âڷ¢ÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, Ì ·Ó·ÎÔ‡ÊÈÛË ·ÓÒÙÂÚÔ˘ Î·È Î·ÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜.(3)
™˘ÌÂÚ·ÛÌ·ÙÈο, Ì ‚¿ÛË Ù· ÛËÌÂÚÈÓ¿ ‰Â‰Ô̤ӷ, Ë ı¤ÛË ÙˆÓ ∞§ ÛÙË ıÂڷ›· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Â›Ó·È Ë ÂÍ‹˜: 1. ◊ÈÔ ÂÈ̤ÓÔÓ ¿ÛıÌ·(20) (Û˘ÌÙÒÌ·Ù· ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜, fi¯È Û ηıËÌÂÚÈÓ‹ ‚¿ÛË, Ì Ӣ¯ÙÂÚÈÓ¤˜ ÂÓԯϋÛÂȘ - ·Ê˘Ó›ÛÂȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ‰‡Ô ÊÔÚ¤˜/Ì‹Ó·). ∫·Ù¿ ÙËÓ ·ÁÎfiÛÌÈ· ÛÙÚ·ÙËÁÈ΋ ÁÈ· ÙË ıÂڷ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (GI¡∞), ÌÔÚ› Ó· ˘ÔηٷÛÙ‹ÛÂÈ Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È Ó· ¯ÚËÛÈÌÔÔÈËı› ·ÎfiÌ· Î·È ˆ˜ ÌÔÓÔıÂڷ›·. ∂ÈÛËÌ·›ÓÂÙ·È fï˜ Ë ·Ó¿ÁÎË ÂÚÈÛÛfiÙÂÚˆÓ ÌÂÏÂÙÒÓ.(25) °È· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÔÓÔıÂڷ›·˜ ·fi ÌÂÚÈÎÔ‡˜ ÌÂÏÂÙËÙ¤˜ ÂÎÊÚ¿˙ÂÙ·È Î¿ÔÈ· ‰˘ÛÈÛÙ›·.(14) 2. ª¤ÙÚÈÔ ÂÈ̤ÓÔÓ ¿ÛıÌ·(20,25) (ηıËÌÂÚÈÓ¿ Û˘ÌÙÒÌ·Ù·, ¯Ú‹ÛË ‚2-‰ÈÂÁÂÚÙÒÓ Û ηıËÌÂÚÈÓ‹ ‚¿ÛË, Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, Ó˘¯ÙÂÚÈÓ¤˜ ·Ê˘Ó›ÛÂȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›·/‚‰ÔÌ¿‰·). ∫˘Ú›ˆ˜ ÙÔÓ›˙ÂÙ·È Ë ‚ÂÏÙ›ˆÛË Ù˘ Û˘ÌÌfiÚʈÛ˘ ÙÔ˘ ·ÛıÂÓ‹,
AÓÙÈÏ¢ÎÔÙÚȤÓÈ· Î·È ¿ÛıÌ·
Ë Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË Ì ٷ ¿ÏÏ· ·ÓÙÈ·ÛıÌ·ÙÈο Ê¿Ú̷η Î·È Ë ‰˘Ó·ÙfiÙËÙ· Ì›ˆÛ˘ Ù˘ ‰fiÛ˘ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÂȉÒÓ. 3. ¢È·Ï›ÔÓ ¿ÛıÌ·(20). À¿Ú¯Ô˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚÂȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì ·˘Ùfi ÙÔÓ Ù‡Ô ¿ÛıÌ·ÙÔ˜. ∞˘ÙÔ› Ô˘ ¤¯Ô˘Ó ¿ÛıÌ· ¿ÛÎËÛ˘, ·˘ÙÔ› Ô˘ ¤¯Ô˘Ó Ó˘¯ÙÂÚÈÓfi ¿ÛıÌ· Î·È ·˘ÙÔ› Ô˘ ÂÓ›ÔÙ ÂΉËÏÒÓÔ˘Ó ¿ÛıÌ· fiÙ·Ó ÂÎÙ›ıÂÓÙ·È Û ÂÚÂıÈÛÙÈÎfi ·Ú¿ÁÔÓÙ·. ™Â ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ∞§ ÌÔÚ› Ó· ıˆÚËı› ‰ÈηÈÔÏÔÁË̤ÓË. 4. ™Â ÔÔÈ·‰‹ÔÙ ¿ÏÏË ÂÚ›ÙˆÛË, fiÙ·Ó ˘¿Ú¯ÂÈ ÊÙˆ¯‹ Û˘ÌÌfiÚʈÛË Ì ٷ ÂÈÛÓÂfiÌÂÓ·(20), ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Ô ·ÛıÂÓ‹˜ ÛÙË ¯ÔÚËÁËı›۷ ıÂڷ›· (14), ‹ Ù¤ÏÔ˜ ·Ó ÂÈ‚¿ÏÂÙ·È Ë Ì›ˆÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ‚2-‰ÈÂÁÂÚÙÒÓ ‹ ÂÏ¿ÙÙˆÛË ˘„ËÏ‹˜ ‰fiÛ˘ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ ÏfiÁˆ ¿ÌÂÛˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ‹ Ù˘ ‡·Ú͢ ‚¿ÛÈÌ˘ Èı·ÓfiÙËÙ·˜ ÁÈ· ÂΉ‹ÏˆÛË ·ÒÙÂÚˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÛÙÔ Ì¤ÏÏÔÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Ù· ∞§ ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó ‰ÔÎÈÌ·ÛÙÈο Ì ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿˜ ÙÔ˘˜. ∂Ô̤ӈ˜, Ù· ∞§ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·Ó¿ÎÂÈ· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Î·È ‰ÂÓ Î·Ù·ÚÁÔ‡Ó ÙÔ Ì¤¯ÚÈ Û‹ÌÂÚ· ·ÓÙÈ·ÛıÌ·ÙÈÎfi ÔÏÔÛÙ¿ÛÈÔ. ¢›ÓÔ˘Ó fï˜, ·ÍÈfiÈÛÙ˜ ‰˘Ó·ÙfiÙËÙ˜ ÔÏÏ·ÏÒÓ ÂÈÏÔÁÒÓ Î·È Û˘Ó‰˘·ÛÌÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔÓ ıÂÚ¿ÔÓÙ· π·ÙÚfi. E˘¯·ÚÈÛٛ˜ ∏ Û˘ÁÁÚ·Ê‹ Ù˘ ·Ó·ÛÎfiËÛ˘ ¤ÁÈÓ Ì ·ÊÂÙËÚ›· ÙȘ ÂÈÛËÁ‹ÛÂȘ ÙˆÓ Î.Î. ¡. ªÂÚ¿ÙË, £. ∆ÛÈÏÈÁÈ¿ÓÓË, ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˘ Î·È ÙÔ˘ Û˘ÁÁڷʤ· ÛÙÔ ÛÙÚÔÁÁ˘Ïfi ÙÚ·¤˙È ÙÔ˘ 37Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ ÙÔ 1999 ÛÙË £ÂÛÛ·ÏÔÓ›ÎË, Ì ı¤Ì· Ù· ·ÓÙÈÏ¢ÎÔÙÚȤÓÈ·. ∂ÎÊÚ¿˙ÔÓÙ·È ÂÈÏÈÎÚÈÓ›˜ ¢¯·ÚÈÛٛ˜ ÛÙÔ˘˜ ·Ú·¿Óˆ Û˘Ó·‰¤ÏÊÔ˘˜ Î·È È‰È·ÈÙ¤Úˆ˜ ÛÙÔÓ Î·ıËÁËÙ‹ Î. ¡. ªÂÚ¿ÙË ÁÈ· Ù· ‡ÛÙÔ¯· Î·È ÂÔÈÎÔ‰ÔÌËÙÈο Û¯fiÏÈ¿ ÙÔ˘˜ ÚÈÓ ÙËÓ ÙÂÏÈ΋ ‰È·ÌfiÚʈÛË ÙÔ˘ ¿ÚıÚÔ˘.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Wood A. Treatment of asthma with drugs modifying the leukotriene pathway. N EngI J Med 1999;340:197-206. 2. Dahlen S. Lipid mediator pathways in the lung: leukotrienes as a new target for treatment of asthma. Clin Exp Allergy 1998;28 (SuppI):197-202. 3. Lipworth B. Leukotriene - receptor antagonists. Lancet 1999;353:57-62. 4. Holgate S. Concluding remarks. Eur Respir Rev 1998;8:1063-1064. 5. Leff J. Leucotriene modifiers as novel therapeutics in asthma. Clin Exp Allergy 1998;28(SuppI):116-122. 6. Sampson A. The pharmacology of leukotriene receptor antagonists. Eur Respir Rev 1998;8:1037-1041. 7. Fost D, Spahn J. The leukotriene modifiers: A new class of asthma medication. Contemp Pediatrics 1998;15:95-107. 8. Reiss T, Chervinsky P, Dokhorn R, Shingo S, Seidenberg
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 22-02-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÿÚ˘ ∫·ÙÛ·Ú‰‹˜ ∫·˝ÚË 21, ¡. ™Ì‡ÚÓË 17122
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17. Bousquet J. Factors affecting compliance in patients with mild astma. Eur Respir Rev 1997;7:318-320. 18. Cochrane M. Compliance in astma. Eur Respir Rev 1998;8:348-350. 19. £ÂÔ‰ˆÚ·ÎfiÔ˘ÏÔ˜ ¶, ∫·ÙÛ·Ú‰‹˜ Ã, ÷Ù˙ËÌȯ·‹Ï ∞, ∞Ú‚·ÓÈÙ›‰Ô˘ µ, ∆ÛÂÚÌÂÓ›‰Ë˜ π, ∞Ó‰ÚÔ˘Ï¿Î˘ π. ∏ ÛˆÛÙ‹ ¯Ú‹ÛË ÙˆÓ Aerosols ÛÙ· ·È‰È¿. [¶ÂÚ›ÏË„Ë]. 30Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1992 13-14 πÔ˘Ó›Ô˘; §ÂÌÂÛfi˜, ∫‡ÚÔ˜; 1992:69 µ∞. 20. Kemp J. The place of leukotriene receptor antagonists in adressing unmet needs including practical guidelines for prescribing physicians. Eur Respir Rev 1998;8:1059-1062. 21. O' Bryne M, Israel E, Drazen J. Antileukotrienes in the treatment of astma. Ann Intern Med 1997;127:472-480. 22. Horwitz J, McGill K, Busse W. The role of leukotriene modifiers in the treatment of asthma. Am J Respir Crit Care Med 1998;157:1363-1371. 23. Hart B. Replacing or reducing high dose oral corticosteroids with alternative asthma controller therapies: implications for leukotriene receptor antagonists. Eur Respir Rev 1998;8:1056-1058. 24. Barnes N. Replacing or reducing high - dose oral corticosteroids with alternative asthma contrloller therapies: implications for leukotriene receptor antagonists. Eur Respir Rev 1998;8:1054-1055. 25. Global Initiative for Asthma. NHLBI/ WHO Workshop report. National Institutes of Health, National Heart, Lung and Blood Institute, Publication NÆ 96 - 3659 B, November 1998.
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∂•∂§π•∂π™ ™∆∏¡ π∞∆ƒπ∫∏
∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË ª·Ú›· ªÔ˘ÛÙ¿ÎË1, ¶·Ó·ÁÈÒÙ˘ °È¿ÏÏÔ˘ÚÔ˜2
● ¶ÂÚ›ÏË„Ë: ∏ ηٷÛ΢‹ ‡ηÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ·È‰È·ÙÚÈÎÔ‡ ÌÂÁ¤ıÔ˘˜ Ô‰‹ÁËÛ ÛÙË ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓË ¯Ú‹ÛË ÁÈ· ‚ÚÔÁ¯ÔÛÎfiËÛË Û ·È‰È¿ οı ËÏÈΛ·˜ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ Î·È ıÂڷ¢ÙÈÎÔ‡˜ ÛÎÔÔ‡˜. µÚÔÁ¯ÔÛÎfiËÛË Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÛÙ· ·È‰È¿, Û˘ÓÈÛÙ¿Ù·È ÛÂ Û˘ÁÁÂÓ‹ ‹ ›ÌÔÓÔ ÛÈÁÌfi, ›ÌÔÓË Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, ›ÌÔÓË ·ÙÂÏÂÎÙ·Û›·, ›ÌÔÓ˜ ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ, Ó¢ÌÔÓÈΤ˜ ‚Ï¿‚˜ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜, ¯ÚfiÓÈÔ ‚‹¯·, ·ÈÌfiÙ˘ÛË, ÂÎÏÂÎÙÈ΋ ‚ÚÔÁ¯ÔÁÚ·Ê›·, ·ÛıÂÓ‹ ˘Ô„›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜, ˘Ô„›· ‚Ï¿‚˘ ·ÂÚ·ÁˆÁÒÓ ÌÂÙ¿ ·fi ‰È·ÛˆÏ‹ÓˆÛË ‹ ÙÚ·¯ÂÈÔÛÙÔÌ›·, ˘Ô„›· ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÌÂÙ¿ ·fi ÂÈÛÓÔ‹ ‹ ÂÈÛÚfiÊËÛË ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ, Ï‹„Ë ÂÎÎÚ›ÛÂˆÓ ‹ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ ÁÈ· ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ‹ ΢ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË Î·È Ï‹„Ë Î˘ÙÙ¿ÚˆÓ ‹ ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜. £Âڷ¢ÙÈο ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·Ó·ÚÚfiÊËÛË ÂÎÎÚ›ÛˆÓ, ÁÈ· ıÂڷ¢ÙÈ΋ ‚ÚÔÁ¯Ô΢„ÂÏ˘‰È΋ ¤ÎÏ˘ÛË Î·È Û ‰‡ÛÎÔÏË ‰È·ÛˆÏ‹ÓˆÛË. µÚÔÁ¯ÔÛÎfiËÛË Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ Â›Ó·È ‰˘Ó·Ùfi Ó· Á›ÓÂÈ Ì ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ÂÈʤÚÔ˘Ó ‡ÓÔ ‹ ÂÓ·ÏÏ·ÎÙÈο ˘fi ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›·. ∂ÈÏÔΤ˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ Î·È Û˘ÓËı¤ÛÙÂÚ˜ Â›Ó·È Ë ˘ÔÍ›·, Ë Î·Ú‰È·Î‹ ·ÚÚ˘ıÌ›·, Ô Ï·Ú˘ÁÁfiÛ·ÛÌÔ˜ ‹ ‚ÚÔÁ¯fiÛ·ÛÌÔ˜, Ë ·ÈÌÔÚÚ·Á›· Î.¿. ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ·fi ÂÎ·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi Û ηٿÏÏËÏ· ÔÚÁ·ÓˆÌ¤ÓÔ ¯ÒÚÔ ·ÔÙÂÏ› ·ÛÊ·Ï‹ ‰È·ÁÓˆÛÙÈ΋ Î·È ÂÓ›ÔÙ ıÂڷ¢ÙÈ΋ ̤ıÔ‰Ô ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú·ÎÙÈ΋. ¶·È‰È·ÙÚÈ΋ 2000;63:375-381. §¤ÍÂȘ ÎÏÂȉȿ: ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ·È‰È·ÙÚÈ΋ ‚ÚÔÁ¯ÔÛÎfiËÛË, ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·, ‚ÚÔÁ¯È΋ ‚ÈÔ„›·. M. Moustaki, P. Giallouros. The use of flexible bronchoscopy in children. Paediatriki 2000;63:375-381. ● Abstract: The use of the flexible bronchoscope for diagnostic or therapeutic purposes in pediatrics has increased significantly since 1978 when the use of the flexible bronchoscope of appropriate size for paediatric applications was first described. The indications for flexible bronchoscopy are mainly diagnostic: stridor, persistent wheezing, persistent atelectasis, persistent or recurrent pulmonary infiltrates, lung lesions of unknown etiology, chronic cough, hemoptysis, selective bronchography, remote suspicion of trancheobronchial foreign body, assessment of airways for injury, to obtain biopsy samples, samples of secretions and/or cells. The flexible bronchoscope can also be used for therapeutic purposes such as removal of plugs or airway secretions, bronchoalveolar lavage and difficult intubations. Sedation is usually preferable to general anesthesia for pediatric flexible bronchoscopy. Complications, which are generally rare, include hypoxia, cardiac arrhythmia, laryngospasm, bronchospasm, hemorrhage etc. The flexible bronchoscope is a useful diagnostic and therapeutic tool in the hands of a skilled bronchoscopist supported by well trained personnel. Key words: flexible bronchoscope, pediatric bronchoscopy, bronchoalveolar lavage, bronchial biopsy.
∆· ÚÒÙ· ‡ηÌÙ· ‚ÚÔÁ¯ÔÛÎfiÈ·, ‰ÂÓ ‹Ù·Ó ηٿÏÏËÏ· ÁÈ· ÂÓ‰ÔÛÎfiËÛË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÙˆÓ ·È‰ÈÒÓ, ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ‰È·ÌÂÙÚ‹Ì·Ùfi˜ ÙÔ˘˜. ∏ ηٷÛ΢‹ fï˜, ÌÂÙ¿ ÙÔ 1978, ‡ηÌÙÔ˘ 1 2
‚ÚÔÁ¯ÔÛÎÔ›Ô˘(1) ·È‰È·ÙÚÈÎÔ‡ ÌÂÁ¤ıÔ˘˜, Ô‰‹ÁËÛ ÛÙË ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓË ¯Ú‹ÛË ÙÔ˘ Û ·È‰È¿ οı ËÏÈΛ·˜ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ Î·È ıÂڷ¢ÙÈÎÔ‡˜ ÛÎÔÔ‡˜.
µ' ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ "ª·Î¿ÚÈÔ˜ πππ" §Â˘ÎˆÛ›·˜
375
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·376
¶∞π¢π∞∆ƒπ∫∏ 2000;63:375-381
∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Ì Â͈ÙÂÚÈ΋ ‰È¿ÌÂÙÚÔ 2,2 mm ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË. ¢ÂÓ ‰È·ı¤ÙÂÈ ‰›·˘ÏÔ ÂÚÁ·Û›·˜ Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÈÙÚ¤ÂÈ ÙËÓ ÂÈÛÎfiËÛË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ fi¯È fï˜ Î·È ÙË Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ. ∆Ô ·È‰È·ÙÚÈÎfi ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ, Ì Â͈ÙÂÚÈ΋ ‰È¿ÌÂÙÚÔ 3,4-3,6 mm Â›Ó·È Î·Ù¿ÏÏËÏÔ ÁÈ· ÙË ‚ÚÔÁ¯ÔÛÎfiËÛË ‚ÚÂÊÒÓ Î·È ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ(2). ∆· ÙÂÏÂ˘Ù·›· 2 cm ÙÔ˘ ¿ˆ ¿ÎÚÔ˘ ÙÔ˘ ÈÓÔ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ·˘ÙÔ‡ Â›Ó·È Â‡Î·ÌÙ· Î·È Â›Ó·È Û ı¤ÛË Ó· Û¯ËÌ·Ù›ÛÔ˘Ó ÁˆÓ›· ̤¯ÚÈ 180o, ÚÔ˜ ÙË Ì›· ηÙ‡ı˘ÓÛË Î·È 130o ÚÔ˜ ÙËÓ ·ÓÙ›ıÂÙË. ¢È·ı¤ÙÂÈ ‰›·˘ÏÔ ÂÚÁ·Û›·˜ 1,2 mm, Ô ÔÔ›Ô˜ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó·ÚÚfiÊËÛË Î·È ÙËÓ ¤Á¯˘ÛË ˘ÁÚÒÓ, ÙË ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ Î·È ÙË Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ Ì ‚ÚÔÁ¯Ô΢„ÂÏ˘‰È΋ ¤ÎÏ˘ÛË, ·Ï‹ „‹ÎÙÚ· ‹ Ì Ϸ‚›‰· ‚ÈÔ„›·˜. °È· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 7 ÂÙÒÓ(3) ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Î·È ÙÔ ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÓËϛΈÓ, Ì Â͈ÙÂÚÈ΋ ‰È¿ÌÂÙÚÔ 4,9 mm Î·È Ì ‰›·˘ÏÔ ÂÚÁ·Û›·˜ 2,2 mm. ∆Ô ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÓËÏ›ÎˆÓ ¤¯ÂÈ ÔÏϤ˜ ÂÊ·ÚÌÔÁ¤˜ Î·È Â›Ó·È Î·Ù¿ÏÏËÏÔ ÁÈ· Ï‹„Ë ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ Î·È ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ Ì Ϸ‚›‰· ‹ Ì „‹ÎÙÚ·, ·Ï‹ ‹ ÚÔÛÙ·ÙÂ˘Ì¤ÓË. ∂Ӊ›ÍÂȘ ¯Ú‹Û˘ ÙÔ˘ ‡ηÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ÛÙ· ·È‰È¿ ¢È·ÁÓˆÛÙÈ΋ ‚ÚÔÁ¯ÔÛÎfiËÛË ªÂ ‚¿ÛË ÙȘ Ô‰ËÁ›Â˜ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜(4) (American Thoracic Society) ‰È·ÁÓˆÛÙÈ΋ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Û˘ÓÈÛÙ¿Ù·È ÛÙ· ·È‰È¿ fiÙ·Ó Ì ÙË ¯Ú‹ÛË ÙÔ˘ ·Ó·Ì¤ÓÂÙ·È fiÙÈ ı· ÚÔ·„Ô˘Ó ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÔÈ Ôԛ˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÔÎÙËıÔ‡Ó Ì ·ÏÔ‡ÛÙÂÚ˜ ÂÍÂÙ¿ÛÂȘ. ¢È·ÁÓˆÛÙÈ΋ ÈÓÔ‚ÚÔÁ¯ÔÛÎfiËÛË Û˘ÓÈÛÙ¿Ù·È ÛÂ(2,4,5): 1) Û˘ÁÁÂÓ‹ ‹ ›ÌÔÓÔ ÛÈÁÌfi, 2) ›ÌÔÓË Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ 3) ›ÌÔÓË ·ÙÂÏÂÎÙ·Û›·, 4) ›ÌÔÓ˜ ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ, 5) Ó¢ÌÔÓÈΤ˜ ‚Ï¿‚˜ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜, 6) ¯ÚfiÓÈÔ ‚‹¯·, 7) ·ÈÌfiÙ˘ÛË, 8) ÂÎÏÂÎÙÈ΋ ‚ÚÔÁ¯ÔÁÚ·Ê›·, 9) ·ÛıÂÓ‹ ˘Ô„›· ‡·Ú͢ ͤÓÔ˘ ÛÒÌ·ÙÔ˜, 10) ˘Ô„›· ‚Ï¿‚˘ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÌÂÙ¿ ·fi ‰È·ÛˆÏ‹ÓˆÛË ‹ ÙÚ·¯ÂÈÔÛÙÔÌ›·, 11) ˘Ô„›· ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÌÂÙ¿ ·fi ÂÈÛÓÔ‹ ‹ ÂÈÛÚfiÊËÛË ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ, 12) Ï‹„Ë ÂÎÎÚ›ÛÂˆÓ ‹ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ ÁÈ· ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ Î·È Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË Î·È 13) Ï‹„Ë Î˘ÙÙ¿ÚˆÓ Ì „‹ÎÙÚ· Î·È ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ Ì ‚ÚÔÁ¯È΋ ‹ ‰È·‚ÚÔÁ¯È΋ ‚ÈÔ„›·. ™ÈÁÌfi ÚÔηÏÔ‡Ó ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‹ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ Ï¿Ú˘ÁÁ·, fiˆ˜ ›Û˘ ·ÚÎÂÙ¤˜ ·ÓˆÌ·Ï›Â˜ Ù˘ ÙÚ·¯Â›·˜ Î·È ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ηıÒ˜ Î·È Ë ¿ÛÎËÛË ›ÂÛ˘ ÂÎ ÙˆÓ ¤Íˆ ÛÙÔÓ Ï¿Ú˘ÁÁ· ‹ ÙËÓ ÙÚ·¯Â›·(6).
376
ª. ªÔ˘ÛÙ¿ÎË, ¶. °È¿ÏÏÔ˘ÚÔ˜
∆ÔÓ›˙ÂÙ·È fiÙÈ Ë ·Ó‡ÚÂÛË ˘ÂÚÁψÙÙȉÈ΋˜ ·ÓˆÌ·Ï›·˜, Ë ÔÔ›· ı· ÌÔÚÔ‡Û ӷ ‰ÈηÈÔÏÔÁ‹ÛÂÈ ÙÔÓ ÛÈÁÌfi, ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË Û˘Ó‡·ÚÍË ˘ÔÁψÙÙȉÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ. °È· ÙÔÓ ÏfiÁÔ ·˘ÙfiÓ, Ë ‰ÈÂÚ‡ÓËÛË Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÙˆÓ ·È‰ÈÒÓ Ì ÛÈÁÌfi Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Ì ÂÈÛÎfiËÛË fi¯È ÌfiÓÔ ÙÔ˘ Ï¿Ú˘ÁÁ·, ·ÏÏ¿ fiÏÔ˘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘(7,8). O Wood ‰È·›ÛÙˆÛÂ Û˘ÓÔ‰fi ·ÓˆÌ·Ï›· ÛÙËÓ ÙÚ·¯Â›· ‹ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ Û 15% ÙˆÓ ·È‰ÈÒÓ Ì ÛÈÁÌfi(7). ∂Í¿ÏÏÔ˘, ÔÈ Nussbaum Î·È Û˘Ó.(8) ‚Ú‹Î·Ó Û˘ÓÔ‰¤˜ ·Ó·ÙÔÌÈΤ˜ ˘ÔÁψÙÙȉÈΤ˜ ·ÓˆÌ·Ï›Â˜ Û 18% ÙˆÓ ·È‰ÈÒÓ ÌÂ Ï·Ú˘ÁÁÔ̷ϷΛ·. OÈ ·ÓˆÌ·Ï›Â˜ ÛÙ· ·È‰È¿ Ô˘ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÛÈÁÌfi(6-8) Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ªÂ ÙÔ ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÔÈ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 ·ÔηχÙÔÓÙ·È Â‡ÎÔÏ· Ì ÂÍ·›ÚÂÛË ÙÔ Ï·Ú˘ÁÁÔÙÚ·¯ÂÈ·Îfi-ÔÈÛÔÊ·ÁÈÎfi ¤ÏÏÂÈÌÌ· Î·È ÙÔ ÙÚ·¯ÂÈÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ Ù‡Ô˘ ∏. ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ì ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂϤÁ¯ÂÙ·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏ· ÙÔ Ô›ÛıÈÔ ÙÌ‹Ì· ÙÔ˘ Ï¿Ú˘ÁÁ· Î·È ÙÔ˘ ¿Óˆ ÙÚÈÙËÌÔÚ›Ô˘ Ù˘ ÙÚ·¯Â›·˜. ŒÙÛÈ, Û ˘Ô„›· ‡·Ú͢ ÌÈ·˜ ·fi ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ·ÓˆÌ·Ï›Â˜, ÚÔÙÈÌ¿Ù·È Ë ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ(9,10). ∏ Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Ô˘ ÂÈ̤ÓÂÈ ‹ ˘ÔÙÚÔÈ¿˙ÂÈ Î·È ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ ·ÔÙÂÏ› ›Û˘ Û˘¯Ó‹ ·ÈÙ›· ‚ÚÔÁ¯ÔÛÎfiËÛ˘. ∞Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÛÂ Â˘Úˆ·˚ο ·È‰È·ÙÚÈο ΤÓÙÚ·(11) Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ¤‰ÂÈÍ fiÙÈ 15,5% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ‚ÚÔÁ¯ÔÛÎÔ‹ÛÂˆÓ ¤ÁÈÓ·Ó Ì ¤Ó‰ÂÈÍË ÙËÓ Â›ÌÔÓË ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË(12) ÛÙȘ ∏¶∞ Ë ÈÓÔ‚ÚÔÁ¯ÔÛÎfiËÛË ¤‰ÂÈÍ ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· Û 57% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ ̤¯ÚÈ 18 ÌËÓÒÓ Ì ˘ÔÙÚÔÈ¿˙Ô˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, Ë ÔÔ›· ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈο ÛÙË ıÂڷ›· Ì ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο Ê¿Ú̷η. ¶›Ó·Î·˜ 1. ∞Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Û ·È‰È¿ Ì ÛÈÁÌfi. §·Ú˘ÁÁÔ̷ϷΛ· ¶¿ÚÂÛË ÙˆÓ ÊˆÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ §·Ú˘ÁÁÈ΋ ‹ ÙÚ·¯Âȷ΋ ÌÂÌ‚Ú¿ÓË §·Ú˘ÁÁÈ΋ ‹ Î·È ÙÚ·¯Âȷ΋ ÛÙ¤ÓˆÛË §·Ú˘ÁÁÈ΋ ‹ ˘ÔÁψÙÙȉÈ΋ ·ÛÙË (Û·ÓÈfiÙÂÚ· fiÁÎÔ˜) §·Ú˘ÁÁÔÙÚ·¯ÂÈ·Îfi-ÔÈÛÔÊ·ÁÈÎfi ¤ÏÏÂÈÌÌ· ∆Ú·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ ÀÔÁψÙÙȉÈÎfi ·ÈÌ·ÁÁ›ˆÌ· ∆Ú·¯ÂÈÔ̷ϷΛ· ¶›ÂÛË Ù˘ ÙÚ·¯Â›·˜ ·fi ·ÁÁÂȷ΋ ‰˘ÛÏ·Û›· ÀÂÚÙÚÔÊ›· ·‰ÂÓÔÂȉÒÓ Â΂ϷÛÙ‹ÛˆÓ, ·Ì˘Á‰·ÏÒÓ
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·377
¶∞π¢π∞∆ƒπ∫∏ 2000;63:375-381
™ËÌÂÈÒÓÂÙ·È Ì¿ÏÈÛÙ·, fiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ ‚ÚÂÊÒÓ ËÏÈΛ·˜ ̤¯ÚÈ 6 ÌËÓÒÓ. ∏ ·Ó·ÏÔÁ›· ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ‚Ú¤ıËΠ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË(5) (87%) Û ·È‰È¿ Ì ›ÌÔÓË Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹. ÃÚÂÈ¿˙ÔÓÙ·È ÚfiÛıÂÙ˜ ÌÂϤÙ˜ ÁÈ· Ó· ÔÚÈÔıÂÙËıÔ‡Ó Â·ÎÚÈ‚Ò˜ Ù· ÎÚÈÙ‹ÚÈ· Ì ٷ ÔÔ›· ÂÈϤÁÔÓÙ·È ÁÈ· ‚ÚÔÁ¯ÔÛÎfiËÛË ÔÈ ·ÛıÂÓ›˜ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜. ¶·È‰È¿ Ì Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ Ô˘ ÂÈ̤ÓÔ˘Ó ‹ ˘ÔÙÚÔÈ¿˙Ô˘Ó ‹ ηٷϷ̂¿ÓÔ˘Ó ·Û˘Ó‹ıÈÛÙ· ÌÂÁ¿ÏË ¤ÎÙ·ÛË, Ú¤ÂÈ Ó· ‚ÚÔÁ¯ÔÛÎÔÔ‡ÓÙ·È ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi Ù˘¯fiÓ ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘, ΢ڛˆ˜ fï˜, ÁÈ· ÙË Ï‹„Ë ÂÎÎÚ›ÛÂˆÓ ‹ Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜(13) (ηÏÏȤÚÁÂÈ· Î·È Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË). O ¯ÚfiÓÈÔ˜ ‚‹¯·˜ ·ÔÙÂÏ› ›Û˘ ¤Ó‰ÂÈÍË ‚ÚÔÁ¯ÔÛÎfiËÛ˘ fiÙ·Ó ·fi ÙÔ ÈÛÙÔÚÈÎfi, ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› ÙÔ ÂӉ¯fiÌÂÓÔ Ó· ÔÊ›ÏÂÙ·È Û ¿ÛıÌ·, ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ, ÈÁÌÔÚ›Ùȉ·, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ‹ „˘¯ÔÁÂÓ‹ ·›ÙÈ·(2). ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ÌÔÚ› Ó· ‰ÈÂÚ¢ÓËı› ÙÔ ÂӉ¯fiÌÂÓÔ Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, Ë ·ÚÔ˘Û›· ÙÚ·¯ÂÈÔ̷ϷΛ·˜ ‹ ‚ÚÔÁ¯Ô̷ϷΛ·˜ ÔÈ Ôԛ˜ Û·Ó›ˆ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂΉËψıÔ‡Ó Ì ›ÌÔÓÔ ¯ÚfiÓÈÔ ‚‹¯·(2,14). ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Û ·È‰› Ì ÛÔ‚·Ú‹ ·ÈÌfiÙ˘ÛË, fiÙ·Ó Á›ÓÂÙ·È Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ··ÈÙ› ȉȷ›ÙÂÚË ÚÔÛÔ¯‹, ‰ÈfiÙÈ Ë ÌÈÎÚ‹ ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ ‰›·˘ÏÔ˘ ÂÚÁ·Û›·˜ ηıÈÛÙ¿ ‰‡ÛÎÔÏË ÙËÓ ·ÈÌfiÛÙ·ÛË. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Û ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·Á›· Ë ‚ÚÔÁ¯ÔÛÎfiËÛË ÚÔÙÈÌ¿Ù·È Ó· Á›ÓÂÙ·È Ì ÙÔ ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË ÂÛˆÙÂÚÈ΋ ‰È¿ÌÂÙÚÔ Î·È ÂÈÙÚ¤ÂÈ Î·Ï‡ÙÂÚË ·Ó·ÚÚfiÊËÛË Î·È ÂÊ·ÚÌÔÁ‹ ·ÈÌfiÛÙ·Û˘(2,5,9,10). ∏ ÂÓÂÚÁfi˜ fï˜ Ì·˙È΋ ·ÈÌfiÙ˘ÛË ·ÎfiÌË Î·È Û ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ‰ÂÓ ÂÈÙÚ¤ÂÈ Ó· ·ÔÎ·Ï˘Êı› Ë ÂÚÈÔ¯‹ ·fi ÙËÓ ÔÔ›· ÚÔ¤Ú¯ÂÙ·È Ë ·ÈÌÔÚÚ·Á›·. ªÂÙ¿ fï˜ ÙËÓ ‡ÊÂÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜, Â›Ó·È ‰˘Ó·Ù‹ Ë ·ÔÎ¿Ï˘„Ë Ù˘ ÂÛÙ›·˜ fiÙ·Ó Ë ‚Ï¿‚Ë Â›Ó·È ÂÓ‰Ô‚ÚÔÁ¯È΋ (.¯. ÂÈÔÏ‹˜ ÙÔȯˆÌ·ÙÈÎfi ·ÈÌ·ÁÁ›ˆÌ·) Î·È ‚Ú›ÛÎÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÔÙÈÎÔ‡ ‰›Ô˘ ÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘. ∞ÛıÂÓ›˜ Ì ̷ÎÚÔ¯ÚfiÓÈ· ÙÚ·¯ÂÈÔÛÙÔÌ›· Â›Ó·È ÛÎfiÈÌÔ Ó· ÂÓ‰ÔÛÎÔÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ÁÈ· Ó· ÂϤÁ¯ÂÙ·È ·Ó ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÛÙÔÌ›·˜ ¤¯ÂÈ ·Ó·Ù˘¯ı› ÎÔÎÎȈ̷Ù҉˘ ÈÛÙfi˜ ‹ ˘ÂÚÙÚÔÊ›· ÙÔ˘ ÙÚ·¯ÂÈ·ÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘(5,9). ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ô ¤ÏÂÁ¯Ô˜ fiÏÔ˘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘, ÁÈ·Ù› ‰ÂÓ Â›Ó·È Û¿ÓȘ ÔÈ ÂÚÈÙÒÛÂȘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ Î·È ÛÙ¤ÓˆÛ˘ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘ ·fi ÙȘ ·Ó·ÚÚÔÊ‹ÛÂȘ Ì ηıÂÙ‹Ú·. ∞Ó Ì¿ÏÈÛÙ· Ë ÙÚ·¯ÂÈÔÛÙÔÌ›· ¤ÁÈÓ ÁÈ·Ù› ˘‹Ú¯Â ·ÓˆÌ·Ï›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ï¿Ú˘ÁÁ·, Û˘ÓÈÛٿٷÈ
∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ
Ó· ÂϤÁ¯ÔÓÙ·È ÚÈÓ ·fi ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ Ë ·Ó·ÙÔÌ›· Î·È Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ Ï¿Ú˘ÁÁ·. ™Â ˘Ô„›· ͤÓÔ˘ ÛÒÌ·ÙÔ˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÌfiÓÔ fiÙ·Ó ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÈÛÙÔÚÈÎfi ÓÈÁÌÔÓ‹˜ ‹ ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏϘ ÈÛ¯˘Ú¤˜ ÎÏÈÓÈΤ˜ ‹ ·ÎÙÈÓÔÏÔÁÈΤ˜ ÂӉ›ÍÂȘ ÂÈÛÚfiÊËÛ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∂Ô̤ӈ˜, ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ‰ÈÂÚ‡ÓËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈÔ ‚‹¯·, ›ÌÔÓË Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ ‹ ›ÌÔÓË ·ÙÂÏÂÎÙ·Û›· ‹ Ó¢ÌÔÓ›·. ∆ÔÓ›˙ÂÙ·È fiÙÈ ÁÈ· ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ Û˘ÓÈÛÙ¿Ù·È Û¯Â‰fiÓ ·ÔÎÏÂÈÛÙÈο Ë ¯Ú‹ÛË ÙÔ˘ ¿Î·ÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘(9,15). ∏ ¯ÔÚ‹ÁËÛË Â·ÚÎÔ‡˜ ηٷÛÙÔÏ‹˜ Î·È ÙÔÈ΋˜ ·Ó·ÈÛıËÛ›·˜ ÚÈÓ ÙËÓ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ÌÂÈÒÓÂÈ ÙË ÌÈÎÚ‹ Û¯ÂÙÈο Èı·ÓfiÙËÙ· ÌÂٷΛÓËÛ˘ ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜ ÂÍ·ÈÙ›·˜ ÂÌÊ¿ÓÈÛ˘ ‚‹¯·. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ηٿ ÙËÓ ÂÓ‰ÔÛÎfiËÛË Ì ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ‚ÚÂı› ͤÓÔ ÛÒÌ·, Ú¤ÂÈ Ó· ÌËÓ ÂȉÈÒÎÂÙ·È Ë ·Ê·›ÚÂÛ‹ ÙÔ˘ ÁÈ· Ó· ·ÔʇÁÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÌÂٷΛÓËÛ‹˜ ÙÔ˘ ‚·ı‡ÙÂÚ· ÛÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ. ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÈÙÚ¤ÂÈ ÙË ‰›Ô‰Ô ‰È·Ì¤ÛÔ˘ ÙÔ˘ ۈϋӷ ÙˆÓ ··Ú·›ÙËÙˆÓ Ï·‚›‰ˆÓ ÁÈ· ÙËÓ ·ÛÊ·Ï‹ Û‡ÏÏË„Ë Î·È ·Ê·›ÚÂÛË ÙÔ˘ ͤÓÔ˘ ÛÒÌ·ÙÔ˜. ∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÈÙÚ¤ÂÈ ÙËÓ ÂÎÙ¤ÏÂÛË ÂÎÏÂÎÙÈ΋˜ ‚ÚÔÁ¯ÔÁÚ·Ê›·˜(2,16,17). ∏ ·ÎÙÈÓÔÛÎÈÂÚ‹ Ô˘Û›· ÂÁ¯¤ÂÙ·È ÛÙËÓ ÂÈı˘ÌËÙ‹ ÂÚÈÔ¯‹, ·ÊÔ‡ ÚÔËÁÔ˘Ì¤Óˆ˜ ¤¯ÂÈ ÂÈÛÎÔËı› ÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ Î·È ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ë ·ÚÔ˘Û›· ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ‹ ÌÂÁ¿Ï˘ ÔÛfiÙËÙ·˜ ‚ϤÓÓ·˜ Ô˘ ı· ¤‚·ÏÏ ÙËÓ ·Ó·‚ÔÏ‹ ‹ ÙË Ì·Ù·›ˆÛË Ù˘ ‚ÚÔÁ¯ÔÁÚ·Ê›·˜. ∂Âȉ‹ Ë ·ÎÙÈÓÔÛÎÈÂÚ‹ Ô˘Û›· ¤¯ÂÈ ˘„ËÏfi ÈÍ҉˜, ‰‡ÛÎÔÏ· ÂÁ¯¤ÂÙ·È Ì¤Û· ·fi ÙÔ ‰›·˘ÏÔ ÂÚÁ·Û›·˜ Î·È ‰‡ÛÎÔÏ· ·ÔÌ·ÎÚ‡ÓÂÙ·È ·fi ÙÔ fiÚÁ·ÓÔ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ÂͤٷÛ˘. ™˘ÓÔ„›˙ÔÓÙ·˜, Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ¯Ú‹Û˘ ÙÔ˘ ‡ηÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘, Ù· ÔÔ›· Û˘ÓÔÏÈο ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ÁÈ· 55-60% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÈÂÚ‡ÓËÛ˘ Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ, Ô˘ ÂÎÙÂÏÔ‡ÓÙ·È Û ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌÂȷο ΤÓÙÚ·(5,11), Â›Ó·È Ô Â›ÌÔÓÔ˜ ÛÈÁÌfi˜, Ë Â›ÌÔÓË ·ÙÂÏÂÎÙ·Û›·, ÔÈ Â›ÌÔÓ˜ ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ, Ë ˘ÔÙÚÔÈ¿˙Ô˘Û· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο. ∏ ‰È·ÁÓˆÛÙÈ΋ Û˘Ì‚ÔÏ‹ ÙÔ˘ ÈÓÔ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÈÙ›· ÁÈ· ÙËÓ ÔÔ›· Á›ÓÂÙ·È. ™Ù· Â˘Úˆ·˚ο ¶·È‰È·ÙÚÈο ¡ÔÛÔÎÔÌ›· Î˘Ì·›ÓÂÙ·È, fiˆ˜ ˘ÔÏÔÁ›ÛÙËΠ۠ÚfiÛÊ·ÙË ÌÂϤÙË(11), ·fi 4981%. ∞Ô‰ÔÙÈÎfiÙÂÚË Â›Ó·È fiÙ·Ó Á›ÓÂÙ·È Ì ¤Ó‰ÂÈÍË ÙÔÓ ÛÈÁÌfi. ∞Ó¿ÏÔÁË ÌÂϤÙË(18) ÛÙÔ πÛÚ·‹Ï, ¤‰ÂÈÍ fiÙÈ Ù· ÂÈÛÎÔÈο Â˘Ú‹Ì·Ù· Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Û˘Ó¤‚·Ï·Ó ÛËÌ·ÓÙÈο ÛÙËÓ
377
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·378
¶∞π¢π∞∆ƒπ∫∏ 2000;63:375-381
·ÓÙÈÌÂÙÒÈÛË 67,5% ÙˆÓ ·ÛıÂÓÒÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙ›· ÁÈ· ÙËÓ ÔÔ›· ¤ÁÈÓÂ Ë ÂÓ‰ÔÛÎfiËÛË. ∆· ÂÈÛÎÔÈο Â˘Ú‹Ì·Ù· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ Â˘Ú‹Ì·Ù· ·fi ÙËÓ Î˘ÙÙ·ÚÔÏÔÁÈ΋ Î·È ÙË ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ ·Ô‰Â›¯ıËΠfiÙÈ ¤¯Ô˘Ó ÎÏÈÓÈ΋ ÛËÌ·Û›· ÁÈ· 90% ÙˆÓ ·ÛıÂÓÒÓ(18) Ô˘ ÂÂϤÁËÛ·Ó Ì ÔÚıÔÏÔÁÈο ÎÚÈÙ‹ÚÈ·. £Âڷ¢ÙÈΤ˜ ÂÊ·ÚÌÔÁ¤˜ ÙÔ˘ ‡ηÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ™˘ÓÈÛÙ¿Ù·È ÁÈ·(2,17): ·) ·Ó·ÚÚfiÊËÛË ÂÎÎÚ›ÛÂˆÓ Î·È ‚˘ÛÌ¿ÙˆÓ ‚ϤÓÓ˘, ‚) ıÂڷ¢ÙÈ΋ ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË Î·È Á) ‰È·ÛˆÏ‹ÓˆÛË Ô˘ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ¿ÏÏÔ ÙÚfiÔ. ªÂ ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ê·›ÚÂÛË ÂÎÎÚ›ÛÂˆÓ Î·È ‚˘ÛÌ¿ÙˆÓ ‚ϤÓÓ˘ Ô˘ ÚÔηÏÔ‡Ó ·ÙÂÏÂÎÙ·Û›· ‹ ÂÈ‚·Ú‡ÓÔ˘Ó ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ȉȷ›ÙÂÚ· Û ‰È·ÛˆÏËӈ̤ӷ ·È‰È¿. ∏ ·Ê·›ÚÂÛË ÙˆÓ ÂÎÎÚ›ÛÂˆÓ Î·È ÙˆÓ ‚˘ÛÌ¿ÙˆÓ Ì ÙË ¯Ú‹ÛË Î·ıÂÙ‹ÚˆÓ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ÂÊÈÎÙ‹, ‰ÈfiÙÈ Èı·ÓfiÓ Ë ÂÚÈÔ¯‹ ÛÙËÓ ÔÔ›· ˘¿Ú¯ÂÈ ÙÔ ‚‡ÛÌ· Ó· ÌËÓ Â›Ó·È ÚÔÛÈÙ‹ ‹ Ë ‚ϤÓÓ· Ó· Â›Ó·È È‰È·›ÙÂÚ· ·¯‡ÚÚ¢ÛÙË ÒÛÙ ӷ ÌËÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó·ÚÚfiÊËÛ‹ Ù˘. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÁÈ· ÙËÓ ·Ê·›ÚÂÛË ·¯‡ÚÚ¢ÛÙˆÓ ÂÎÎÚ›ÛÂˆÓ ··ÈÙÂ›Ù·È ÚÔËÁÔ‡ÌÂÓË ¤Á¯˘ÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡. ∏ ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË Ì ·ÓÂÈÏËÌ̤Ó˜ ÂÁ¯‡ÛÂȘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ıÂڷ¢ÙÈο ÁÈ· ÙËÓ ·Ê·›ÚÂÛË Ôχ ·¯‡ÚÚ¢ÛÙˆÓ ÂÎÎÚ›ÛˆÓ. ∏ ¤ÎÏ˘ÛË, ÂÊfiÛÔÓ ÙÔ ÂÈÙÚ¤ÂÈ Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÔÏÔÎÏËÚÒÓÂÙ·È fiÙ·Ó ÙÔ ÂÚȯfiÌÂÓÔ Ù˘ ·Ó·ÚÚfiÊËÛ˘ Á›ÓÂÈ ‰È·˘Á¤˜. ∆Ô ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Û ÂÚÈÙÒÛÂȘ ‰‡ÛÎÔÏ˘ ‰È·ÛˆÏ‹ÓˆÛ˘(10,19,20) ‰ÈfiÙÈ ¤ÙÛÈ Á›ÓÂÙ·È ‰˘Ó·Ù‹ Ë ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ ˘fi ¿ÌÂÛË ÂÈÛÎfiËÛË. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ¤¯ÂÈ È‰È·›ÙÂÚË ÂÊ·ÚÌÔÁ‹ Û ·ÛıÂÓ›˜ Ì οΈÛË ‹ ·ÚıÚ›Ùȉ· Ù˘ ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜ (.¯. Û‡Ó‰ÚÔÌÔ Pierre Robin) ‹ Ì¿˙· ÛÙËÓ ÙÚ·¯ËÏÈ΋ ÂÚÈÔ¯‹ (.¯. ΢ÛÙÈÎfi ‡Áڈ̷). ∞ÓÙÂӉ›ÍÂȘ ¯Ú‹Û˘ ÙÔ˘ ‡ηÌÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ∞ÓÙÂӉ›ÍÂȘ ÁÈ· ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ(2) ·ÔÙÂÏÔ‡Ó: 1) Ë ·Ê·›ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, 2) Ë Ì·˙È΋ ·ÈÌfiÙ˘ÛË, 3) Ë ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË, 4) Ë ÛÔ‚·Ú‹ ˘ÔÍ›· ‹ Î·È ÛÔ‚·Ú‹ ·fiÊÚ·ÍË ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, 6) Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· Î·È 7) Ë Î·Ú‰È·Î‹ ·ÚÚ˘ıÌ›·. ªÂÚÈΤ˜ ·fi ÙȘ ·ÓÙÂӉ›ÍÂȘ ¯Ú‹Û˘ ÙÔ˘ ÈÓÔ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ·ÔÙÂÏÔ‡Ó ·fiÏ˘Ù˜ ÂӉ›ÍÂȘ ‚ÚÔÁ¯ÔÛÎfiËÛ˘ Ì ÙÔ ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ. ∞˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó(9,10,21): ·) ÙËÓ ·Ê·›ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ‚) ÙË Ì·˙È΋ ·ÈÌfiÙ˘ÛË, Á) ÙË ÛÔ‚·Ú‹
378
ª. ªÔ˘ÛÙ¿ÎË, ¶. °È¿ÏÏÔ˘ÚÔ˜
˘ÔÍ›· (Ì ÙÔ ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Ë ‰È·ı¤ÛÈÌË Ô‰fi˜ ÁÈ· ÙË ‰È·Î›ÓËÛË ÙÔ˘ ·¤Ú· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ˘ ‰È·Ì¤ÙÚÔ˘, ÁÈ·Ù› Ô ·ÛıÂÓ‹˜ ·Ó·Ó¤ÂÈ Ì¤Û· ·fi ÙÔ ÛˆÏ‹Ó· ÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ Î·È fi¯È Á‡Úˆ ·fi ÙÔ ÛˆÏ‹Ó· ÙÔ˘ ÈÓÔ‚ÚÔÁ¯ÔÛÎÔ›Ô˘) Î·È ‰) ÙËÓ ÂÈÛÎfiËÛË ÙÔ˘ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ Ï¿Ú˘ÁÁ· Î·È ÙÔ˘ ¿Óˆ ÙÚÈÙËÌÔÚ›Ô˘ Ù˘ ÙÚ·¯Â›·˜, ÁÈ· ·ÔÎÏÂÈÛÌfi Ï·Ú˘ÁÁÈÎÔ‡ ÂÏÏ›ÌÌ·ÙÔ˜ ‹ ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘ Ù‡Ô˘ ∏. ¶ÚÔÂÙÔÈÌ·Û›· - ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ‚ÚÔÁ¯ÔÛÎÔÂ›Ù·È ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ‡ηÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Á›ÓÂÈ Â›Ù Ì ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ÂÈʤÚÔ˘Ó ‡ÓÔ(2) ‹ ˘fi ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›·, ÂÓÒ Ë ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ··ÈÙ› ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›·. ¶ÚÔÙÈÌ¿Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ Î·È fi¯È Ë ÂÓ‰ÔÌ˘˚΋ ‹ Ë ÂÓÙÂÚÈ΋. ∞Ó·‰ÚÔÌÈ΋ ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÛÂ Â˘Úˆ·˚ο ÓÔÛÔÎÔÌ›· ÙÔ 1994, ¤‰ÂÈÍ fiÙÈ Ë Ìȉ·˙ÔÏ¿ÌË ÌfiÓË ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏ· Ê¿Ú̷η Â›Ó·È ÙÔ Ê¿ÚÌ·ÎÔ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯ÓfiÙÂÚ· ÁÈ· ηٷÛÙÔÏ‹(11). °È· ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ ÙÔ˘ ηٷÛÙ·Ï̤ÓÔ˘ ·ÛıÂÓÔ‡˜ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Î·Ù¿ÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi Î·È Î·Ù¿ ÚÔÙ›ÌËÛË ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜(22). °È· ÙÔÈ΋ ·Ó·ÈÛıËÛ›· ··ÈÙÂ›Ù·È ¤Á¯˘ÛË ÏȉÔη˝Ó˘ ÛÙË Ì‡ÙË, ÛÙȘ ʈÓËÙÈΤ˜ ¯ÔÚ‰¤˜ Î·È ÛÙÔ Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. ∏ ηٷÛÙÔÏ‹ ÏÂÔÓÂÎÙ› Ù˘ ÁÂÓÈ΋˜ ·Ó·ÈÛıËÛ›·˜, Ë ÔÔ›· ··ÈÙÂ›Ù·È ÁÈ· ÙË ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ¿Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ, ‰ÈfiÙÈ ÂÈÙÚ¤ÂÈ ÙËÓ ·ÔÎ¿Ï˘„Ë ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (ÙÚ·¯ÂÈÔ̷ϷΛ·, ‚ÚÔÁ¯Ô̷ϷΛ· Î.Ï.)(7), ÔÈ Ôԛ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Û˘ÁÎ·Ï˘ÊıÔ‡Ó fiÙ·Ó Ô ·˘ÙfiÌ·ÙÔ˜ ·ÂÚÈÛÌfi˜ Î·È Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ ηٷÛÙ·ÏÔ‡Ó ÛËÌ·ÓÙÈο. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ‚ÚÔÁ¯ÔÛÎÔÂ›Ù·È Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ηډȷÎÔ‡ Î·È ·Ó·Ó¢ÛÙÈÎÔ‡ Ú˘ıÌÔ‡, ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û O2 Î·È Ù˘ ÛˆÛÙ‹˜ ı¤Û˘ Ù˘ ÎÂÊ·Ï‹˜ Î·È ÂÔ̤ӈ˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ∆ÔÓ›˙ÂÙ·È Ì ¤ÌÊ·ÛË fiÙÈ Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È fi¯È ·fi ÙÔÓ È·ÙÚfi Ô˘ ‚ÚÔÁ¯ÔÛÎÔ›, ·ÏÏ¿ ·fi ¿ÏÏÔ Î·Ù¿ÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓÔ ¿ÙÔÌÔ(2,5). ¶ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ‚ÚÔÁ¯ÔÛÎfiËÛ˘ Ú¤ÂÈ Ó· ÂÍ·ÛÊ·Ï›˙ÔÓÙ·È Ô ··ÈÙÔ‡ÌÂÓÔ˜ ÂÍÔÏÈÛÌfi˜ Î·È Ù· ··Ú·›ÙËÙ· Ê¿Ú̷η ÁÈ· ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÓË„Ë. ªÂ ÂÍ·›ÚÂÛË ÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜, ÛÙËÓ ÔÔ›· Ë ‚ÚÔÁ¯ÔÛÎfiËÛË ÌÔÚ› Ó· Á›ÓÂÈ ÛÙËÓ ÎÏ›ÓË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÔÈ ı¿Ï·ÌÔÈ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ¯ÒÚÔ Î·Ù¿ÏÏËÏÔ ÁÈ· ‚ÚÔÁ¯ÔÛÎfiËÛË.
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·379
¶∞π¢π∞∆ƒπ∫∏ 2000;63:375-381
∂ÈÏÔΤ˜ Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ¢È·ÎÚ›ÓÔÓÙ·È Û ·˘Ù¤˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ ηٿ ÙË ‚ÚÔÁ¯ÔÛÎfiËÛË, Î·È ÛÙ· Ê¿Ú̷η Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÚÈÓ Î·È Î·Ù¿ ÙË ‚ÚÔÁ¯ÔÛÎfiËÛË(2,5). OÈ ÂÈÏÔΤ˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ›‰È· ÙËÓ ÈÓÔ‚ÚÔÁ¯ÔÛÎfiËÛË ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ: 1) §ÂÈÙÔ˘ÚÁÈΤ˜ ·) ÀÔÍ›·. ¢ÂÓ Â›Ó·È ·Û˘Ó‹ı˘ ÂÈÏÔ΋ Î·È ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ‰È· ̤ÛÔ˘ Ì¿Ûη˜ ÚÔÛÒÔ˘(23), ÚÈÓÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ ‹ ÙÔ˘ ‰È·‡ÏÔ˘ ·Ó·ÚÚfiÊËÛ˘. ‚) ÀÂÚηӛ·. Á) ∫·Ú‰È·Î‹ ·ÚÚ˘ıÌ›·. ∏ ‰È¤ÁÂÚÛË ÙÔ˘ Ó¢ÌÔÓÔÁ·ÛÙÚÈÎÔ‡, Ë ˘ÔÍ›·, Ë ·Ó·Ú΋˜ ·Ó·ÈÛıËÛ›· ·ÔÙÂÏÔ‡Ó ·›ÙÈ· ÂÌÊ¿ÓÈÛ˘ ·ÚÚ˘ıÌ›·˜. ‰) §·Ú˘ÁÁfiÛ·ÛÌÔ˜, ‚ÚÔÁ¯fiÛ·ÛÌÔ˜. ∞ÛıÂÓ›˜ Ì ¿ÛıÌ· Ú¤ÂÈ Ó· ÚÔÂÙÔÈÌ¿˙ÔÓÙ·È Î·Ù¿ÏÏËÏ· Ì ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ ‹/Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Î·È ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÓfiÛÔ˘. 2) ªË¯·ÓÈΤ˜ ·) ∂›ÛÙ·ÍË ·fi ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ ÚÈÓÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ¶ÚfiÎÂÈÙ·È ÁÈ· ‹È· ÂÈÏÔ΋, Ô˘ ‰ÂÓ ··ÈÙ› ȉȷ›ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË. ‚) §·Ú˘ÁÁÈÎfi ÙÚ·‡Ì· ‹ Ô›‰ËÌ· ÌÔÚ› Ó· ÚÔÎÏËı› ·Ó ÙÔ ¿ÎÚÔ ÙÔ˘ ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ ·ÁÁ›˙ÂÈ ÙË ÁψÙÙ›‰·, ÂÓÒ Ô ·ÛıÂÓ‹˜ ‚‹¯ÂÈ. Á) ÀÔÁψÙÙȉÈÎfi Ô›‰ËÌ·. ∂›Ó·È Û¿ÓÈ· ÂÈÏÔ΋ ·Ó ‰ÂÓ ÚÔ¸¿Ú¯ÂÈ ˘ÔÁψÙÙȉÈÎfi Ô›‰ËÌ· ‹ ÛÙ¤ÓˆÛË. ‰) O›‰ËÌ· ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. Â) ∞ÈÌÔÚÚ·Á›·. ™ËÌ·ÓÙÈ΋ ·ÈÌÔÚÚ·Á›· Î·È ·ÈÌfiÙ˘ÛË ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·fi ‚ÚÔÁ¯È΋ ‹ ‰È·‚ÚÔÁ¯È΋ ‚ÈÔ„›·, ÔÈ Ôԛ˜ Û¿ÓÈ· ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ÛÙ· ·È‰È¿. ÛÙ) ¶Ó¢ÌÔıÒڷη˜. ∞ÔÙÂÏ› Èı·Ó‹ ÂÈÏÔ΋ Ù˘ ‰È·‚ÚÔÁ¯È΋˜ ‚ÈÔ„›·˜. 3) §ÔÈÌÒÍÂȘ ∏ ‚ÚÔÁ¯ÔÛÎfiËÛË Â›Ó·È ·Û‡ÓËı˜ Ó· ¢ı‡ÓÂÙ·È ÁÈ· Ïԛ̈ÍË, ÂÊfiÛÔÓ ÙËÚÔ‡ÓÙ·È fiÏÔÈ ÔÈ Î·ÓfiÓ˜ ·Ôχ̷ÓÛ˘ ÙÔ˘ ÈÓÔ‚ÚÔÁ¯ÔÛÎÔ›Ô˘ Î·È ÙˆÓ ÂÍ·ÚÙËÌ¿ÙˆÓ ÙÔ˘. ∂Âȉ‹ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛÙ› Ë ÌÂÙ·ÊÔÚ¿ ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ· ·fi ÙËÓ ¿Û¯Ô˘Û· ÂÚÈÔ¯‹ ÙÔ˘ Ó‡ÌÔÓ· ÛÙËÓ ˘ÁÈ‹, Û˘ÓÈÛÙ¿Ù·È Ë ÂÈÛÎfiËÛË Ó· ·Ú¯›˙ÂÈ, Ì ‚¿ÛË Ù· ÎÏÈÓÈο Î·È ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ·fi ÙËÓ ˘ÁÈ‹ ÂÚÈÔ¯‹. À¿Ú¯Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·Ó¿ÁÎË ÚÔÊ˘Ï·ÎÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚›ˆÛ˘ Û ¿ÙÔÌ· ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·(24,25). º·›ÓÂÙ·È Ó· Â›Ó·È ÛÎfiÈÌË Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ(26) Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜. ªÂÙ¿ ·fi ÙË ‚ÚÔÁ¯ÔÛÎfiËÛË ÌÔÚ› Ó· ·Ú·ÙËÚËı› ˘ÚÂÙfi˜, ȉȷ›ÙÂÚ· ·Ó ¤¯ÂÈ ÚÔËÁËı› ‚ÚÔÁ¯Ô-
∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ
΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË(27) ‰È·ÈÛÙÒıËΠfiÙÈ 17% ÙˆÓ ·È‰ÈÒÓ ÛÙ· ÔÔ›· ¤ÁÈÓ ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË ·ÚÔ˘Û›·Û·Ó ˘„ËÏfi ˘ÚÂÙfi (>39ÆC) 4-12 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÂÓ‰ÔÛÎfiËÛË. ∂ÈÏÔΤ˜ Û¯ÂÙÈΤ˜ Ì ÙË ¯Ú‹ÛË Ê·ÚÌ¿ÎˆÓ ∞Ó·Ú΋˜ ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô‰ËÁ› Û fiÓÔ Î·È stress. ∞ÓÙ›ıÂÙ·, Ë ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ÙÔ˘˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·Ù·ÛÙÔÏ‹ Ù˘ ·Ó·ÓÔ‹˜ Ì ·ÔÙ¤ÏÂÛÌ· ˘ÔÍ›· ‹ Î·È ˘ÂÚηӛ·. ∂ÏÏÈ‹˜ ÙÔÈ΋ ·Ó·ÈÛıËÛ›· ÚÔηÏ› ‰È¤ÁÂÚÛË ÙÔ˘ Ó¢ÌÔÓÔÁ·ÛÙÚÈÎÔ‡ Ì ÙȘ ÁÓˆÛÙ¤˜ Û˘Ó¤ÂȘ. ∂ÈÛËÌ·›ÓÂÙ·È fiÙÈ Ë ÏȉÔη˝ÓË ·ÔÚÚÔÊ¿Ù·È Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ·fi ÙÔÓ ‚ÏÂÓÓÔÁfiÓÔ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Ì ÂӉ¯fiÌÂÓË ÂΉ‹ÏˆÛË ÙÔÍÈ΋˜ ‰Ú¿Û˘ fiˆ˜ ‰È¤ÁÂÚÛ˘ ÙÔ˘ ∫¡™ (·ÓËÛ˘¯›· ‹ Û·ÛÌÔ›). ∞Ó¿ÏÔÁ· Ì ٷ ηٷÛÙ·ÏÙÈο Ê¿Ú̷η Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó, Ù· ÙÔÍÈο Ê·ÈÓfiÌÂÓ· Ô˘ ÂӉ¯fiÌÂÓ· ı· ÂÌÊ·ÓÈÛÙÔ‡Ó ÌÔÚ› Ó· ‰È·Ê¤ÚÔ˘Ó. ™Ù· ÂÚÈÛÛfiÙÂÚ· Â˘Úˆ·˚ο ÂÓ‰ÔÛÎÔÈο ΤÓÙÚ·(11) ÔÈ ·Ú·¿Óˆ ÂÈÏÔΤ˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 5% ÙˆÓ ·ÛıÂÓÒÓ. ∆¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙË ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ µÈÔ„›· ∏ Ï‹„Ë Ì ÙÔ ·È‰È·ÙÚÈÎfi ‚ÚÔÁ¯ÔÛÎfiÈÔ (3,5 mm) ˘ÏÈÎÔ‡ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‚ÚÔÁ¯È΋˜ Î·È ‰È·‚ÚÔÁ¯È΋˜ ‚ÈÔ„›·˜ Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏË, ÂÓÒ Â›Ó·È Â˘¯ÂÚ‹˜ Ì ÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ÙˆÓ ÂÓËÏ›ÎˆÓ (4,9 mm) Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ™ÙË ‚ÚÔÁ¯È΋ ‚ÈÔ„›· Ë Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ·fi ÔÚ·Ù‹ ‚Ï¿‚Ë ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ∏ ‰È·‚ÚÔÁ¯È΋ ‚ÈÔ„›· ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È¿ÁÓˆÛË ‰È¿¯˘Ù˘ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (.¯. Û·ÚÎÔ›‰ˆÛË, Ó¢ÌÔÓ›· ÔÊÂÈÏfiÌÂÓË Û Pneumocystis carinii, ΢„ÂÏȉÈ΋ ÚˆÙÂ˝ÓˆÛË). §‹„Ë ‰Â›ÁÌ·ÙÔ˜ Ì „‹ÎÙÚ· ∏ ¯Ú‹ÛË „‹ÎÙÚ·˜ ÂÈÙÚ¤ÂÈ ÙË Ï‹„Ë Î˘ÙÙ¿ÚˆÓ ·fi ÌÂÁ·Ï‡ÙÂÚË ¤ÎÙ·ÛË Û ۯ¤ÛË Ì ÙË ‚ÈÔ„›·. ÃÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ ΢ڛˆ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÓÂÔÏ·Û›·˜ (·Ó‡ÚÂÛË Î·ÎÔËıÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙÔ ‰Â›ÁÌ·). ∏ „‹ÎÙÚ· ÛÙ· ·È‰È¿ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ˘Ô„›· ÓÂÔÏ·Û›·˜, Û˘Ó‰ÚfiÌÔ˘ ·ÎÈÓ‹ÙˆÓ ÎÚÔÛÛÒÓ ‹ Û ·ÚÔ˘Û›· ¿ÏÏˆÓ Ì·ÎÚÔÛÎÔÈÎÒÓ ‚Ï·‚ÒÓ (.¯. ÎÔÎÎȈ̷Ù҉˘ ÈÛÙfi˜). ∏ ¯Ú‹ÛË ÚÔÛÙ·ÙÂ˘Ì¤Ó˘ „‹ÎÙÚ·˜ Â›Ó·È ÂÊÈÎÙ‹ ÌfiÓÔ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÈÓÔ‚ÚÔÁ¯ÔÛÎfiÈÔ ÂÓËÏ›ÎÔ˘ Î·È ·ÔÛÎÔ› ÛÙËÓ ·ÔÎ¿Ï˘„Ë ÙÔ˘ ÂÌÏÂÎfiÌÂÓÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡, Û Ó¢ÌÔӛ˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙË ıÂڷ›· ‹ ·Ó·Ù‡ÛÛÔÓÙ·È Û ¤‰·ÊÔ˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜. µÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· °È· ÙË Ï‹„Ë ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ ÛÙ· ·È‰È¿ Û˘ÓÈÛÙ¿Ù·È ¤Á¯˘ÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ ÛÂ
379
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·380
¶∞π¢π∞∆ƒπ∫∏ 2000;63:375-381
ÙÌËÌ·ÙÈÎfi ‹ ˘ÔÙÌËÌ·ÙÈÎfi ‚ÚfiÁ¯Ô Î·È Ù·¯Â›· ·Ó·ÚÚfiÊËÛË ÙÔ˘ ÂÎχ̷ÙÔ˜ ÌÂÙ¿ ·fi οı ¤Á¯˘ÛË. ∞ÎÔÏÔ˘ıÒÓÙ·˜ ÙË ‰È·‰Èηۛ· ·˘Ù‹, ÙÔ ˘ÏÈÎfi Ô˘ ·Ó·ÚÚÔÊ¿Ù·È ÚÔ¤Ú¯ÂÙ·È ·fi ÙȘ ΢„ÂÏ›‰Â˜ Î·È fi¯È ·fi ÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜ fiˆ˜ Û˘Ì‚·›ÓÂÈ Ì ÙËÓ ·Ï‹ ·Ó·ÚÚfiÊËÛË ÂÎÎÚ›ÛÂˆÓ Ì ‹ ¯ˆÚ›˜ ¤Á¯˘ÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡. Œ¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ ÁÈ· ÙÔÓ ˘ÔÏÔÁÈÛÌfi Ù˘ ÔÛfiÙËÙ·˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ Ô˘ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈËı›(28,29). ∆· ÈÔ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 3 ÂÙÒÓ Ë ¯ÔÚ‹ÁËÛË 1ml/kg ‚¿ÚÔ˘˜ Û ÙÚÂȘ ‰È·‰Ô¯ÈΤ˜ ÂÁ¯‡ÛÂȘ ÂÈÙÚ¤ÂÈ ÙËÓ ÂÍ·ÁˆÁ‹ ·ÍÈfiÈÛÙˆÓ Î·È Û˘ÁÎÚ›ÛÈÌˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ Î·È ÙË Ì¤ÙÚËÛË ÌË Î˘ÙÙ·ÚÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ ‚ÚÔÁ¯Ô΢„ÂÏ˘‰ÈÎÔ‡ ÂÎχ̷ÙÔ˜. ∆Ô ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÌÂϤÙË Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ÁÈ· ηÏÏȤÚÁÂÈ·. ∏ ·Ó¿Ù˘ÍË fï˜, ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘ ÂÓfi˜ ·ıÔÁfiÓˆÓ, ¯ˆÚ›˜ ·Ú¿ÏÏËÏ· Ó· ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË ·Ó·ÏÔÁ›· Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÂÎχ̷ÙÔ˜, ˘Ô‰ËÏÒÓÂÈ ÂÈÌfiÏ˘ÓÛË(8). ™Ù· ˘ÁÈ‹ ·È‰È¿, Ô Î˘ÙÙ·ÚÈÎfi˜ ÏËı˘ÛÌfi˜ ÙÔ˘ ÂÎχ̷ÙÔ˜ ·ÔÙÂÏ›ٷÈ(30-32) ·fi Ì·ÎÚÔÊ¿Á· (87-91%), ÏÂÌÊÔ·ÙÙ·Ú· (4-12%), Ô˘‰ÂÙÂÚfiÊÈÏ· (14%) Î·È ÂÈıËÏȷο ·ÙÙ·Ú· (1-2%). ∏ ·Ó‡ÚÂÛË ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ·Ó·ÏÔÁ›· Ô˘ ˘ÂÚ‚·›ÓÂÈ ÙÔ 5% Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÚfiÛÌÂÈ͢ ÙÔ˘ ΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ Ì ·ÙÙ·Ú· ·fi ÙÔÓ ‚ÚÔÁ¯ÈÎfi ‚ÏÂÓÓÔÁfiÓÔ(33), ·Ó Î·È ·˘ÍË̤ÓË ·Ó·ÏÔÁ›· ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È Û ·ÛıÂÓ›˜ Ì ¿ÛıÌ·(34). ∏ ·Ó‡ÚÂÛË ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ Ì·ÎÚÔÊ¿ÁˆÓ, Ù· ÔÔ›· ÂÚȤ¯Ô˘Ó ϛԘ ‹ ·ÈÌÔÛȉËÚ›ÓË, ı¤ÙÔ˘Ó ·ÓÙ›ÛÙÔȯ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÂÈÛÚfiÊËÛ˘(35,36) Î·È Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÈÌÔÛȉ‹ÚˆÛ˘(37). O ·ÚÈıÌfi˜ ÙˆÓ ‰ËÌÔÛȇÛÂˆÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ˘˜ ΢ÙÙ·ÚÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ ÙÔ˘ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎχ̷ÙÔ˜ Û ÔÈΛϘ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ ÛÙ· ·È‰È¿(38-40) (¿ÛıÌ·, ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ˜, ›ÌÔÓË Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, ¯ÚfiÓÈÔ˜ ‚‹¯·˜) ·˘Í¿ÓÂÙ·È Û˘Ó¯Ҙ Î·È Â›Ó·È ÂӉ¯fiÌÂÓÔ Ë Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÂÎχ̷ÙÔ˜ ÌÂÏÏÔÓÙÈο, Ó· ‚ÔËı¿ Ô˘ÛÈ·ÛÙÈο ÛÙË ‰È¿ÁÓˆÛË ‹ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ ÓÔÛÔÏÔÁÈÎÒÓ ·˘ÙÒÓ ÔÓÙÔًوÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ‚ÚÔÁ¯ÔÛÎfiËÛË Ì ÙÔ Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ ·ÔÙÂÏ› ·ÛÊ·Ï‹ ‰È·ÁÓˆÛÙÈ΋ Î·È ÂÓ›ÔÙ ıÂڷ¢ÙÈ΋ ̤ıÔ‰Ô ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú·ÎÙÈ΋. OÈ ‰È·ÁÓˆÛÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ı· ·˘ÍËıÔ‡Ó ÛÙÔ Ì¤ÏÏÔÓ Ì ÙËÓ ·ÍÈÔÔ›ËÛË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Ô˘ ·Ú¤¯ÔÓÙ·È ·fi Ù· ‰Â›ÁÌ·Ù·, Ù· ÔÔ›· Ï·Ì‚¿ÓÔÓÙ·È Ì „‹ÎÙÚ· Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ·ÛÊ·Ï‹ ÂÎÙ¤ÏÂÛ‹ Ù˘ Â›Ó·È Ë ‡·ÚÍË ÔÚÁ·ÓˆÌ¤ÓÔ˘ ¯ÒÚÔ˘ Î·È ÂÎ·È‰Â˘Ì¤ÓÔ˘ ÚÔÛˆÈÎÔ‡.
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ª. ªÔ˘ÛÙ¿ÎË, ¶. °È¿ÏÏÔ˘ÚÔ˜
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∆Ô Â‡Î·ÌÙÔ ‚ÚÔÁ¯ÔÛÎfiÈÔ
33. Klech H, Pohl W. Technical recommendations and guidelines for broncho-alveolar lavage (BAL). Eur Respir J 1989;2:561-585. 34. Beasly R, Roche WR, Roberts JA, Holgate ST. Celllular events in the bronchi in mild asthma and after bronchial provocation. Am Rev Respir Dis 1989;139:806-817. 35. Ahrens P, Noll C, Kitz R, Willigens P, Zielen S, Hofmann D. Lipid-laden macrophages (LLAM): a useful marker of silent aspiration in children. Pediatr Pulmonol 1999;28:83-88. 36. Knauer-Fischer S, Ratjen F. Lipid-laden macrophages in bronchoalveolar lavage fluid as a marker for pulmonary aspiration. Pediatr Pulmonol 1999;27:419-422. 37. Ahrens P, Kitz R, Weimer B, Hofmann D. Reference values of hemosiderin-laden alveolar macrophages in bronchoalveolar lavage in children. Pneumologie 1999;53:262-265. 38. Marguet C, Jouen Boedes F, Dean TP, Warner JO. Bronchoalveolar cell profiles in children with asthma, infantile wheeze, chronic cough, or cystic fibrosis. Am Respir Crit Care Med 1999;159:1533-1540. 39. Armstrong DS, Grimwood K, Carlin JB, Carzino R, Olinsky A, Phelan PD. Bronchoalveolar lavage or oropharyngeal cultures to identify lower respiratory pathogens in infants with cystic fibrosis. Pediatr Pulmonol 1996;21:267-275. 40. Ennis M, Turner G, Schock BC, Stevenson EC, Brown V, Fitch PS et al. Inflammatory mediators in bronchoalveolar lavage samples from children with and without asthma. Clin Exp Allergy 1999;29:362-366.
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¶·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¶·Ó·ÁÈÒÙ˘ ∫·Ï·Ì·Ï›Î˘, ª·Ú›· ¡·ÚÏ›ÔÁÏÔ˘, ¡ÈÎfiÏ·Ô˜ ∑¿‚Ú·˜, ¢‹ÌËÙÚ· ¶·Ú¿Û¯Ô˘, °ÂÒÚÁÈÔ˜ ªÚÈ·ÛÔ‡Ï˘, ∞Ó·ÛÙ¿ÛÈÔ˜ ÷Ù˙‹˜ ● ¶ÂÚ›ÏË„Ë: ªÂÏÂÙ‹ıËÎ·Ó 90 ·È‰È¿ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· (ª™), ËÏÈΛ·˜ 29 ËÌÂÚÒÓ ¤ˆ˜ 16 ÂÙÒÓ (ª∏: 6,2 ¤ÙË), Ô˘ ÓÔÛËχıËÎ·Ó ÛÙË ª∂£ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ "∏ ∞Á›· ™ÔÊ›·" ηٿ ÙË ‰È¿ÚÎÂÈ· 3 ÂÙÒÓ. ¶ÂÓ‹ÓÙ· ¤ÍÈ ·È‰È¿ (62,2%) ÂÈÛ‹¯ıËÛ·Ó ·fi Ù· ∂͈ÙÂÚÈο π·ÙÚ›· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì·˜, ÂÓÒ 34 (37,8%) ‰È·ÎÔÌ›ÛÙËÎ·Ó ÛÙÔ ÙÌ‹Ì· Ì·˜ ·fi ¿ÏÏ· ÓÔÛÔÎÔÌ›·. ™Â 55 ·ÛıÂÓ›˜ Ë ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒıËΠÂÚÁ·ÛÙËÚȷο, ÂÓÒ ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÂÙ¤ıË Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ·. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, 45 ·ÛıÂÓ›˜ (50%) ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηٷÏËÍ›·˜, ÂÓÒ 9 ·fi Ù· ·È‰È¿ Ô˘ ‹Ù·Ó ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙ·ıÂÚ¿ ·ÈÌÔ‰˘Ó·ÌÈο ÂÌÊ¿ÓÈÛ·Ó ÙȘ ÂfiÌÂÓ˜ ÒÚ˜ ÛËÌ›· ηٷÏËÍ›·˜. ™Â 54 ·ÛıÂÓ›˜ Û˘Ó˘‹Ú¯Â ÌËÓÈÁÁ›Ùȉ·, ÂÓÒ Û 12 (13,3%) ‰ÂÓ ¤ÁÈÓ O¡¶ ÏfiÁˆ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ηٿÛÙ·Û‹˜ ÙÔ˘˜. ∞fi Ù· ÛÙÂϤ¯Ë ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ô˘ Ù·˘ÙÔÔÈ‹ıËÎ·Ó 45,2% ·Ó‹Î·Ó ÛÙËÓ ÔÚÔÔÌ¿‰· µ Î·È 54,8% ÛÙËÓ ÔÚÔÔÌ¿‰· C. ™Ù· ·È‰È¿ Ì ÛËÌ›· ηٷÏËÍ›·˜ ÂÎÙÈÌ‹ıËÎÂ Ë Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Ì ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· Î·È Û 27 ·fi ·˘Ù¿ ¤ÁÈÓ ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ›Ù Ì ηıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (9 ·ÛıÂÓ›˜), ›Ù Ì ۇÛÙËÌ· ̤ÙÚËÛ˘ Û˘Ó¯ԇ˜ ηډȷ΋˜ ·ÚÔ¯‹˜ (PiCCO) (18 ·ÛıÂÓ›˜). ∏ ·ÁˆÁ‹ ÂÚÈÂÏ¿Ì‚·Ó ·ÓÙÈ‚›ˆÛË (ÎÂÊ·ÏÔÛÔÚ›ÓË 3˘ ÁÂÓ¿˜ ‹ Û˘Ó‰˘·ÛÌfi ÂÓÈÎÈÏÏ›Ó˘-¯ÏˆÚ·ÌÊÂÓÈÎfiÏ˘), ‰ÂÍ·ÌÂı·˙fiÓË ÛÙȘ ÂÚÈÙÒÛÂȘ ÌËÓÈÁÁ›Ùȉ·˜, ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË Û 20 ÂÚÈÙÒÛÂȘ Ì ηٷÏËÍ›· Î·È ÂÎÙÂٷ̤ÓÔ ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·, fiˆ˜ ›Û˘ ÊÔÚÙ›ÛÂȘ ˘ÁÚÒÓ Î·È ¯ÔÚ‹ÁËÛË ÈÓÔÙÚfiˆÓ Û ‰fiÛÂȘ ÂÍ·ÚÙÒÌÂÓ˜ ·fi ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٷÏËÍ›·˜. ∆ÚÈ¿ÓÙ· Ù¤ÛÛÂÚȘ ·ÛıÂÓ›˜ (37,8%) ¯ÚÂÈ¿ÛıËÎ·Ó Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜. ∂›ÎÔÛÈ ‰‡Ô (24,4%) ·ÚÔ˘Û›·Û·Ó Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÂÈÏÔΤ˜ ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙË ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË (17,8%), Ô˘ ·ÓÙÈÌÂÙˆ›ÛıËΠ̠¯ÔÚ‹ÁËÛË Ï¿ÛÌ·ÙÔ˜ Î·È ·Ú·ÁfiÓÙˆÓ ‹Í˘ ηıÒ˜ Î·È ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (6,7%), Ô˘ ·ÓÙÈÌÂÙˆ›ÛıËΠ̠·ÈÌԉȋıËÛË. ∫·Ù¤ÏËÍ·Ó 13 ·È‰È¿ (14,4%), ·fi Ù· ÔÔ›· Ù· 9 (69,2%) ·Â‚›ˆÛ·Ó ÙÔ 1Ô 24ˆÚÔ ÓÔÛËÏ›·˜. ¶·È‰È·ÙÚÈ΋ 2000;63:382-390. §¤ÍÂȘ ÎÏÂȉȿ: ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·, ¡·˚ÛÛ¤ÚÈ· ÌËÓÈÁÁ›Ùȉ·˜, ÌËÓÈÁÁ›Ùȉ·, ηٷÏËÍ›·. P. Kalabalikis, M. Narlioglou, N. Zavras, D. Paraschou, G. Briasoulis, A. Hatzis. Monitoring and treatment of children with meningococcemia in a Paediatric Intensive Care Unit. Paediatriki 2000;63:382-390. ● Abstract: We studied 90 children aged 29 days to 16 years (mean: 6.2 years) with meningococcemia admitted to the PICU of "Agia Sophia" Children’s Hospital during a 3 year period. Fifty six patients were admitted from the outpatient Department of our hospital (62.2%), and 34 (37.8%) were transferred from other hospitals. In fifty five children the diagnosis of meningococcemia, was verified by the appropriate laboratory examinations, while in the remainder 35 patients the diagnosis was based on clinical criteria. On admission 45 patients (50%) had clinical signs of shock, while 9 of those who initially were hemodynamically stable, developed signs of shock during the next few hours. In 54 patients meningitis coexisted, while in 12 patients (13.3%) lumbar puncture was not performed because of their unstable condition. The meningococcal isolates were serogroup B: 45.2%, and C: 54.8%. Echocardiographic assessment was performed on each child with signs of shock; in 27 of them hemodynamic monitoring was performed by using either pulmonary artery catheter (9 patients) or Pulse Contour Cardiac Output (PiCCO) (18 patients). Treatment included antibiotics (3rd generation cephalosporins, or penicillinchloramphenicol combination), dexamethasone in patients with meningitis, methylprednisolone in 20 cases with shock and extensive hemorrhagic lesions, as well as fluid resuscitation and inotropes in doses according to the severity of shock. Thirty four patients (37.8%) required mechanical ventilation. Twenty two patients (24.7%)
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜, ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ "∏ ∞Á›· ™ÔÊ›·"
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experienced 1 or more complications which included disseminated intravascular coagulation (17.8%) that was treated with FFP and coagulation factors, and renal failure (6.7%) that was treated with hemofiltration. Thirteen children died (14.4%), 9 of whom (69.2%) died within the first 24 hours. Key words: meningococcemia, Neisseria meningitidis, meningitis, shock.
∂ÈÛ·ÁˆÁ‹ ∏ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ‚Ú¤ÊË Î·È ·È‰È¿ Î·È ÔÊ›ÏÂÙ·È ÛÙË Neisseria meningitidis. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ‰˘ÓËÙÈο ·ıÔÁfiÓ· ÛÙÂϤ¯Ë ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ÙÔ ÚÈÓÔÊ¿Ú˘ÁÁ· Û ÔÛÔÛÙfi 2-10% ˘ÁÈÒÓ, ·Û˘Ìو̷ÙÈÎÒÓ ÊÔÚ¤ˆÓ. À‡ı˘Ó˜ ÁÈ· ÏÔÈÌÒÍÂȘ Â›Ó·È Î˘Ú›ˆ˜ ÔÈ ÔÚÔÔÌ¿‰Â˜ A, B, C, W-135 Î·È Y (1,2). ¶·Ú¿ ÙȘ ÁÓÒÛÂȘ Ô˘ ¤¯Ô˘Ì ·ÔÎÔÌ›ÛÂÈ Û fi,ÙÈ ·ÊÔÚ¿ ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ‰Ú¿Û˘ Î·È ·ÓÔÛÔÏÔÁ›·˜ ÙÔ˘ ÌËÓÈÁÁÈÙȉÈÎfiÎÎÔ˘, Ë ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ Ïԛ̈ÍË ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ‰ÈÂıÓÒ˜ ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ (3). ∏ ÓfiÛÔ˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·Ûı› Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÙfiÌˆÓ ¯ˆÚ›˜ ηӤӷ Úfi‰ÚÔÌÔ ‹ Û˘ÓÔ‰fi Û‡Ìو̷ Î·È Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Ô‰ËÁ‹ÛÂÈ Û ·Ï‹ ‚·ÎÙËÚÈ·ÈÌ›· Ô˘ ·˘ÙÔÂÚÈÔÚ›˙ÂÙ·È ‹ Û ÎÂÚ·˘ÓÔ‚fiÏÔ ÛË„·ÈÌ›· (3,4). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÛË„·ÈÌ›·˜ (ª™) Ë ·ÂÏ¢ı¤ÚˆÛË ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÔÈÎ›ÏˆÓ ÌÂÙ·‚È‚·ÛÙÒÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηϤÛÂÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜, ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË, ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ó· Ô‰ËÁ‹ÛÂÈ Û ı¿Ó·ÙÔ Ï›Á˜ ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (5,6). ∞Ó Î·È Ë fiÏË ‰È·‰Èηۛ· Â›Ó·È È‰È·›ÙÂÚ· ÔχÏÔÎË, ÙÚÂȘ Â›Ó·È Î˘Ú›ˆ˜ ÔÈ ‰È·Ù·Ú·¯¤˜ Ô˘ Û˘Óı¤ÙÔ˘Ó ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ Î·È Î·ıÔÚ›˙Ô˘Ó ÙË ‚·Ú‡ÙËÙ¿ Ù˘. 1. ∆Ô Î·ÏÔ‡ÌÂÓÔ "Û‡Ó‰ÚÔÌÔ ÙÚȯÔÂȉÈ΋˜ ‰È·Ê˘Á‹˜" (capillary leak syndrome) (7) Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ Î·È Â˘ı‡ÓÂÙ·È ÁÈ· ÙËÓ ˘ÔÔÁηÈÌ›· Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙË ª™. 2. ∏ Ì›ˆÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È Ë ‰È·Ù·Ú·¯‹ Ù˘ Ú‡ıÌÈÛ˘ ÙÔ˘ ÙfiÓÔ˘ ÙˆÓ ·ÁÁ›ˆÓ, Ù· ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘ÔÔÁηÈÌ›· ÚÔηÏÔ‡Ó ÙȘ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ÓfiÛÔ˘ (5). 3. OÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÌfiÛÙ·Û˘, Ô˘ ÔÊ›ÏÔÓÙ·È Û ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÚÔÛÙ·Î˘ÎÏ›Ó˘, Û ÂÏ¿ÙÙˆÛË Ù˘ ·ÓÙÈıÚÔÌ‚›Ó˘ πππ Î·È ÙˆÓ ÚˆÙÂ˚ÓÒÓ C Î·È S Î·È Û ηٷӿψÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ (8). OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ÚÔηÏÔ‡Ó ·Ê' ÂÓfi˜ ÌÈÎÚÔıÚÔÌ‚ÒÛÂȘ ·ÁÁ›ˆÓ Ô˘ Ô‰ËÁÔ‡Ó Û ÈÛ¯·ÈÌ›· ÔÚÁ¿ÓˆÓ Î·È ÓÂÎÚÒÛÂȘ, Î·È ·Ê’ ÂÙ¤ÚÔ˘ Û ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË. OÈ È‰È·ÈÙÂÚfiÙËÙ˜ Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ Ïԛ̈-
͢ Î·È Ë Û˘¯Ó¿ Ú·Á‰·›· ÂͤÏÈÍ‹ Ù˘ ηıÈÛÙÔ‡Ó ·Ó·Áη›· ÙËÓ ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ÙÌ‹Ì·Ù· (9). ¶·Ú¿ ÙȘ ÚÔfi‰Ô˘˜ fï˜ Ô˘ ¤¯Ô˘Ó ÛËÌÂȈı›, fiÛÔÓ ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ª™, Ê·›ÓÂÙ·È fiÙÈ Ë ıÓËÙfiÙËÙ· Ù˘ ÓfiÛÔ˘ ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ‰ÂÓ ¤¯ÂÈ ÌÂÙ·‚ÏËı› ·ÍÈfiÏÔÁ· (10,11). ™ÙË ÌÂϤÙË ·˘Ù‹ ηٷÁÚ¿ÊÂÙ·È Ë ÂÌÂÈÚ›· Ì·˜ ·fi ÙË ÓÔÛËÏ›· ·È‰ÈÒÓ Ì ª™ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£) ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜. M¤ıÔ‰ÔÈ ™ÙËÓ ·Ó·‰ÚÔÌÈ΋ ·˘Ù‹ ÌÂϤÙË ¤ÁÈÓ ·Ó·ÛÎfiËÛË ÙˆÓ ÈÛÙÔÚÈÎÒÓ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Ì "·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Î·È ˘ÚÂÙfi" Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙË ª∂£ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ "∏ ∞Á›· ™ÔÊ›·" Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 3 ÂÙÒÓ. ∆· ·È‰È¿ ›¯·Ó ÂÈÛ·¯ı› ÛÙË ª∂£, ·ÓÂÍ¿ÚÙËÙ· ‚·Ú‡ÙËÙ·˜, Ì ÙËÓ Èı·Ó‹ ‰È¿ÁÓˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÛË„·ÈÌ›·˜, Ì ÛÎÔfi ÙËÓ Î·Ï‡ÙÂÚË ·Ú·ÎÔÏÔ‡ıËÛË Î·Ù¿ ÙÔ ÚÒÙÔ 24ˆÚÔ, ηٿ ÙÔ ÔÔ›Ô Ë ÓfiÛÔ˜ ¤¯ÂÈ Û˘¯Ó¿ Ú·Á‰·›· ÂͤÏÈÍË. ™˘ÏϤ¯ıËÎ·Ó ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ ÈÛÙÔÚÈÎfi, ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÂÈÛfi‰Ô˘, ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, ÙËÓ ·ÓÙÈÌÂÙÒÈÛË, ÙȘ ÂÈÏÔΤ˜ Î·È ÙËÓ ¤Î‚·ÛË ÙˆÓ ·È‰ÈÒÓ. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ÂÍÂÙ¿ÛÂȘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ (ÔÚÔÏÔÁÈΤ˜, ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜, PCR), ·ÈÌ·ÙÔÏÔÁÈÎfi, ·ÈÌÔÚÚ·ÁÈÎfi, Ï‹ÚË ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô, C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË, ·¤ÚÈ· ·›Ì·ÙÔ˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ Ïԛ̈͢ Ù¤ıËΠ̠¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ·ÎfiÏÔ˘ı· ÎÚÈÙ‹ÚÈ·: 1. ∞ÔÌfiÓˆÛË N. meningitidis Û ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, ∂¡À ‹ ‰ÂÚÌ·ÙÈ΋˜ ‚Ï¿‚˘. 2. ¶·ÚÔ˘Û›· Gram (-) ‰ÈÏfiÎÎÔÎˆÓ Û Gram ¯ÚÒÛË ÛÙÔ ∂¡À ‹ Û ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë. 3. £ÂÙÈ΋ PCR ÁÈ· N. meningitidis ÛÙÔ ·›Ì· ‹ ÙÔ ∂¡À. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ÂÊ·ÚÌfiÛıËΠηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 3Ô˘ ¯ÚfiÓÔ˘ Ù˘ ÌÂϤÙ˘. 4. £ÂÙÈο ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈο ·ÓÙÈÁfiÓ· ÛÙÔ ∂¡À. ™ÙË ÌÂϤÙË ÂÚÈÏ‹ÊıËÎ·Ó Â›Û˘ ·È‰È¿ Ì "·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Î·È ˘ÚÂÙfi", ÛÙ· ÔÔ›· Ë ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· ıˆڋıËΠˆ˜ "‡ÔÙË". ∆· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ÏËÚÔ‡Û·Ó Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·, ·ÏÏ¿ ·ÚÔ˘Û›·˙·Ó fiÏ· Ù· ·ÎfiÏÔ˘ı· ÛËÌ›· ÌÈÎÚԂȷ΋˜ Ïԛ̈͢:
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¶. ∫·Ï·Ì·Ï›Î˘ Î·È Û˘Ó.
1. ∂ËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË. 2. §Â˘ÎÔ΢ÙÙ¿ÚˆÛË Ì ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÛË. (§Â˘Î¿>10.000/mm3, ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·>80%). 3. À„ËÏ‹ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË. ∏ ‰È¿ÁÓˆÛË Ù˘ ÌËÓÈÁÁ›Ùȉ·˜ Ù¤ıËΠ۠fiÛÔ˘˜ ›¯·Ó ηٿ ÙÔÓ Î˘ÙÙ·ÚÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô ∂¡À: ·ÚÈıÌfi Ï¢ÎÔ΢ÙÙ¿ÚˆÓ>5/mm3, χΈ̷>50mg/dl Î·È ÁÏ˘Îfi˙Ë<45 mg/dl. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ ıˆڋıËΠfiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ›· ηٷÏËÍ›·˜, fiÛÔÈ ÂÌÊ¿ÓÈ˙·Ó 1 ‹ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ·Ú·Î¿Ùˆ Û˘ÌÙÒÌ·Ù·. 1. ÷ÌËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË (<5Ë ∂£ ÁÈ· ÙËÓ ËÏÈΛ·).
2. ∫·Î‹ ÂÚÈÊÂÚÈ΋ ΢ÎÏÔÊÔÚ›·. 3. ™ËÌ·ÓÙÈ΋ Ù·¯˘Î·Ú‰›· (>180ÛÊ/min). 4. ªÂȈ̤ÓË ‰ÈÔ‡ÚËÛË (<1ml/Kg/h). ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ·Ú¤ÌÂÈÓ·Ó ÛÙË ª∂£ ÁÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ Â› 24 ÒÚ˜ (∂ÈÎfiÓ· 1). ŸÛÔÈ ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηٷÏËÍ›·˜ ˘Ô‚Ï‹ıËÎ·Ó Û ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·, Ì ÙÔ ÔÔ›Ô ÁÈÓfiÙ·Ó Ì¤ÙÚËÛË ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÂÍÒıËÛ˘ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ (Left Ventricular Ejection Fraction, LVEF) ηٿ ÙÔÓ ÂÈÌ‹ÎË ‹ ‚Ú·¯‡ ¿ÍÔÓ· Ù˘ ηډȿ˜. ∂¿Ó LVEF>65%, ·ÎÔÏÔ˘ıÔ‡Û·Ó ÊÔÚÙ›ÛÂȘ Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ (Ê˘ÛÈÔÏÔÁÈÎfi˜ ÔÚfi˜, Ringer's Lactate) ‹ ÎÔÏ-
¶∞ƒ∞∫O§OÀ£∏™∏ ∑ø∆π∫ø¡ ™∏ª∂πø¡ 1) 2) 3) 4)
∞ÚÙËÚȷ΋ ›ÂÛË (º˘ÛÈÔÏÔÁÈ΋ ÁÈ· ÙËÓ ËÏÈΛ·) ¶ÂÚÈÊÂÚÈ΋ ΢ÎÏÔÊÔÚ›· (º˘ÛÈÔÏÔÁÈ΋) ™Ê‡ÍÂȘ (<180/min) ¢ÈÔ‡ÚËÛË (>1ml/Kg/h)
º˘ÛÈÔÏÔÁÈο
1 ‹ ÂÚÈÛÛfiÙÂÚ· ·ıÔÏÔÁÈο
ŒÍÔ‰Ô˜ ·fi ÙË ª∂£ ÌÂÙ¿ 24ˆÚÔ
ÀÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·
LVEF>65%
ºÔÚÙ›ÛÂȘ Ì ÎÚ˘ÛÙ·ÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· ̤¯ÚÈ ·ÔηٿÛÙ·Û˘ ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ
LVEF<65%
2 ºÔÚÙ›ÛÂȘ + Dopamine
¡¤Ô ÀÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·
LVEF>65%
LVEF<65%
¶·Ú·ÎÔÏÔ‡ıËÛË ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ Î·È ÂӉ¯Ô̤ӈ˜ ∫º¶
º˘ÛÈÔÏÔÁÈο
™˘Ó¯‹˜ ̤ÙÚËÛË CO ∂Ӊ¯Ô̤ӈ˜ ª∞
¶·ıÔÏÔÁÈο
ÃÔÚ‹ÁËÛË ˘ÁÚÒÓ & ÈÓÔÙÚfiˆÓ ‚¿ÛÂÈ ÙˆÓ ÌÂÙÚ‹ÛˆÓ
∂·Ó¿ÏË„Ë ÊÔÚÙ›ÛÂˆÓ Ì¤¯ÚÈ ·ÔηٿÛÙ·Û˘ ∂ÈÎfiÓ· 1. ¶·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· ÛÙË ª∂£ LVEF: ∫Ï¿ÛÌ· ÂÍÒıËÛ˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ (Left Ventricular Ejection Fraction), ∫º¶: ∫ÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË, CO: ∫·Ú‰È·Î‹ ·ÚÔ¯‹ (Cardiac Output), MA: ªË¯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:382-390
ªËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·
ÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· (HAES 6%, HAES 10%) ̤¯ÚÈ ·ÔηٿÛÙ·Û˘ ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ. ∂¿Ó LVEF<65%, ¯ÔÚËÁÔ‡ÓÙ·Ó 1-2 ÊÔÚÙ›ÛÂȘ Ì ٷ˘Ùfi¯ÚÔÓË ¤Ó·ÚÍË ÂÓfi˜ ÈÓÔÙÚfiÔ˘ (ÓÙÔ·Ì›ÓË) Î·È ·ÎÔÏÔ˘ıÔ‡ÛÂ Ó¤Ô ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·. ∂¿Ó ÛÙÔ ‰Â‡ÙÂÚÔ ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· ÙÔ LVEF>65%, ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó Ù· ˙ˆÙÈο ÛËÌ›· ÙÔ˘ ·ÛıÂÓÔ‡˜, Î·È ÂÊfiÛÔÓ ·Ú¤ÌÂÓ·Ó ·ıÔÏÔÁÈο ÙÔÔıÂÙ›ÙÔ Î·ıÂÙ‹Ú·˜ ̤ÙÚËÛ˘ ÎÂÓÙÚÈ΋˜ ÊÏ‚È΋˜ ›ÂÛ˘ Î·È Â·Ó·Ï·Ì‚¿ÓÔÓÙ·Ó ÔÈ ÊÔÚÙ›ÛÂȘ ̤¯ÚÈ ·ÔηٿÛÙ·Û˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∂¿Ó LVEF<65%, ÁÈÓfiÙ·Ó ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ (̤ÙÚËÛË Î·Ú‰È·Î‹˜ ·ÚÔ¯‹˜ Î·È ‰ÂÈÎÙÒÓ ÚÔÊÔÚÙ›Ô˘-ÌÂÙ·ÊÔÚÙ›Ô˘) ›Ù Ì ηıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (Swan-Ganz), ›Ù Ì ۇÛÙËÌ· ̤ÙÚËÛ˘ Û˘Ó¯ԇ˜ ηډȷ΋˜ ·ÚÔ¯‹˜ (Pulse Contour Cardiac Output, PiCCO) Î·È ¯ÔÚËÁÔ‡ÓÙ·Ó ˘ÁÚ¿ Î·È ÈÓfiÙÚÔ· ‚¿ÛÂÈ ÙˆÓ ÌÂÙÚ‹ÛˆÓ. ™Â ÂÚÈÙÒÛÂȘ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÁÈÓfiÙ·Ó ÂÈϤÔÓ Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜. °È· ÙË Û‡ÁÎÚÈÛË ÌÂٷ͇ ÔÌ¿‰ˆÓ ·ÛıÂÓÒÓ, fiÛÔÓ ·ÊÔÚ¿ ÙȘ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ Î·È ÙȘ ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜, ÂÊ·ÚÌfiÛÙËÎÂ Ë ‰ÔÎÈÌ·Û›· ¯2. ∞ÔÙÂϤÛÌ·Ù· ∫·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi OÎÙÒ‚ÚÈÔ 1996 ¤ˆ˜ OÎÙÒ‚ÚÈÔ 1999 ÓÔÛËχıËÎ·Ó ÛÙË ª∂£ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ "∏ ∞Á›· ™ÔÊ›·" 94 ·È‰È¿ Ì "·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Î·È ˘ÚÂÙfi". ∞fi ÙÔ Û‡ÓÔÏÔ ·˘Ùfi ÙˆÓ ·ÛıÂÓÒÓ ·ÔÎÏ›ÛıËÎ·Ó 4 ·È‰È¿, Ù· ÔÔ›· ‰ÂÓ ÏËÚÔ‡Û·Ó Ù· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ÎÚÈÙ‹ÚÈ·. ™Â ÙÚ›· ·fi ·˘Ù¿ ÙÔ ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Ì ˘ÚÂÙfi ·Ô‰fiıËΠ۠ÈÔÁÂÓ‹ Ïԛ̈ÍË, ÂÓÒ Û 1 ‰È·ÁÓÒÛıËΠȉÈÔ·ı‹˜ ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ, Ë ÔÔ›· ›¯Â ÂÈϷΛ Ì Ïԛ̈ÍË. ∞fi Ù· 90 ·È‰È¿ Ô˘ ÙÂÏÈο ÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË Ù· 48 ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· 42 ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 29 ËÌÂÚÒÓ ¤ˆ˜ 16 ÂÙÒÓ (ª∏: 6,2 ¤ÙË). ∏ ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î˘Ì¿ÓıËΠ·fi 1 ÒÚ· ¤ˆ˜ 35 Ë̤Ú˜ (̤ÛË
‰È¿ÚÎÂÈ·: 4,1 Ë̤Ú˜). (¶›Ó·Î·˜ 1). O ·ÚÈıÌfi˜ ·˘Ùfi˜ ÙˆÓ ·ÛıÂÓÒÓ ·ÓÙÈÛÙÔȯ› ÂÚ›Ô˘ ÛÙÔ 9% ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÛÙË ª∂£ ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (90/970). ¶ÂÓ‹ÓÙ· ¤ÍÈ ·È‰È¿ (62,2%) ÂÈÛ‹¯ıËÛ·Ó ÛÙË ª∂£ ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô Ì·˜ Î·È 34 (37,8%) ‰È·ÎÔÌ›ÛÙËÎ·Ó ÛÙÔ ÙÌ‹Ì· Ì·˜ ·fi ¿ÏÏ· ¡ÔÛÔÎÔÌ›·. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙË ª∂£ 45 ·È‰È¿ (50%) ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηٷÏËÍ›·˜, ÂÓÒ 9 ·fi Ù· ·È‰È¿ (20%), Ô˘ ‹Ù·Ó ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙ·ıÂÚ¿ ·ÈÌÔ‰˘Ó·ÌÈο, ÂÌÊ¿ÓÈÛ·Ó ÙȘ ÂfiÌÂÓ˜ ÒÚ˜ ÛËÌ›· ηٷÏËÍ›·˜. ™Â 78 (86,7%) ÂÚÈÙÒÛÂȘ ¤ÁÈÓ ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË (O¡¶), ÛÙȘ ‰Â ˘fiÏÔȘ 12 ‰ÂÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠO¡¶ ÏfiÁˆ Ù˘ ‚·ÚÈ¿˜ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙˆÓ ·È‰ÈÒÓ. ™Â 54 ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰È·ÁÓÒÛÙËΠÌËÓÈÁÁ›Ùȉ·. ªËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ Ïԛ̈ÍË ‰È·ÈÛÙÒıËΠ۠55 ·ÛıÂÓ›˜: ™Â 10 ·ÔÌÔÓÒıËΠN. meningitidis ·fi ÙÔ ·›Ì· Î·È ÙÔ ∂¡À, Û 10 ÌfiÓÔ ·fi ÙÔ ·›Ì· Û 18 ÌfiÓÔ ·fi ÙÔ ∂¡À Î·È Û 2 ÌfiÓÔ ·fi ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë. ™Â 9 ÂÚÈÙÒÛÂȘ, Ô˘ ÔÈ Î·ÏÏȤÚÁÂȘ ›¯·Ó ·Ô‚› ·ÚÓËÙÈΤ˜, ·ÓȯÓ‡ıËΠÙÔ DNA ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ Ì PCR (Û 1 ÂÚ›ÙˆÛË ÛÙÔ ·›Ì· Î·È ∂¡À, Û 6 ÌfiÓÔ ÛÙÔ ·›Ì·, Û 2 ÌfiÓÔ ÛÙÔ ∂¡À). ∆¤ÏÔ˜, Û 6 ·ÛıÂÓ›˜ ·ÓȯÓ‡ıËΠÌfiÓÔ ·ÓÙÈÁfiÓÔ ¤Ó·ÓÙÈ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙÔ ∂¡À. ∞fi Ù· ÛÙÂϤ¯Ë ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ô˘ ·ÔÌÔÓÒıËÎ·Ó 45,2% ·Ó‹Î·Ó ÛÙËÓ ÔÚÔÔÌ¿‰· µ Î·È 54,8% ÛÙËÓ ÔÚÔÔÌ¿‰· C. H ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÂÈÎfiÓ· 1. ™Ù· 54 Û˘ÓÔÏÈο ·È‰È¿ Ô˘ ·ÚÔ˘Û›·Û·Ó ÛËÌ›· ηٷÏËÍ›·˜ ÂÎÙÈÌ‹ıËÎÂ Ë Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Ì ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·, ÂÓÒ Û 27 ·fi ·˘Ù¿ (50%) ¤ÁÈÓ ÂÈϤÔÓ ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (9 ·ÛıÂÓ›˜), ‹ Ì ۇÛÙËÌ· ̤ÙÚËÛ˘ Û˘Ó¯ԇ˜ ηډȷ΋˜ ·ÚÔ¯‹˜ (18 ·ÛıÂÓ›˜). O ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÈÛfi‰Ô˘ ·ÚÔ˘Û›·˙ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ı·ÓfiÓÙˆÓ Î·È ·˘ÙÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó. OÈ ·Ú¿ÌÂÙÚÔÈ Ô˘ ·ÚÔ˘Û›·˙·Ó ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ª∂£ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜. ∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ ∞fi ∂.π. ¡ÔÛÔÎÔÌ›Ԣ Ì·˜ ∞fi ¿ÏÏ· ¡ÔÛÔÎÔÌ›· ‹ ∫.À. ∏ÏÈΛ· ªËÓÈÁÁ›Ùȉ·* ™ËÌ›· ηٷÏËÍ›·˜ ªË¯. ∞ÂÚÈÛÌfi˜ ¢È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ŒÎ‚·ÛË (£¿Ó·ÙÔ˜)
90 56 34 29 ËÌ.-16 ¯Ú. 54 54 34 1ÒÚ·-35 ËÌ. 13
(48 ·ÁfiÚÈ·, 42 ÎÔÚ›ÙÛÈ·)
(ª¤ÛË: 6,2 ¤ÙË)
(¢È¿ÚÎÂÈ· 1 ÒÚ· - 18 Ë̤Ú˜) (ª¤ÛË: 4,2 Ë̤Ú˜)
*™Â 12 ·ÛıÂÓ›˜ ‰ÂÓ ¤ÁÈÓ ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË
385
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·386
¶∞π¢π∞∆ƒπ∫∏ 2000;63:382-390
¶. ∫·Ï·Ì·Ï›Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ∞ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·È‰ÈÒÓ Ì ηٷÏËÍ›· ÏfiÁˆ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÛË„·ÈÌ›·˜ (̤Û˜ ÙÈ̤˜ + SEM). ¶·Ú¿ÌÂÙÚÔ˜ HR MAP LVEF CI
∂¤˙ËÛ·Ó 152 ± 1,46 69,9 ± 0,95 60,8 ± 0,6 4,07 ± 0,08
∫·Ù¤ÏËÍ·Ó 165 ± 4,18 55,8 ± 1,1 40,8 ± 1,4 2,71 ± 0,08
p =0,005 <0,001 <0,001 <0,001
CVP PAP PCWP SVRI
8,9 18,4 13 1339,4
± ± ± ±
0,3 1,5 0,5 24,2
9,8 14,4 10,5 1488,2
± ± ± ±
0,4 1,3 0,5 48
=0,05 <0,02 <0,01 <0,05
PVRI LVSWI RVSWI ITBVI
130 37 6,8 634
± ± ± ±
10,5 0,8 0,3 10,8
223 17,2 5,6 677
± ± ± ±
14,5 2,3 0,4 11,3
<0,005 <0,001 <0,001 <0,05
GEDVI EVLWI
522 ± 16,7 8,8 ± 0,32
592 ± 17,9 10,3 ± 0,42
<0,05 <0,05
HR: ∫·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ·, ª∞ƒ: ª¤ÛË ·ÚÙËÚȷ΋ ›ÂÛË, LVEF: ∫Ï¿ÛÌ· ÂÍÒıËÛ˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜, CI: ∫·Ú‰È·Îfi˜ ‰Â›ÎÙ˘, CVP: ∫ÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË, PAP: ¶›ÂÛË Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜, PCWP: ¶›ÂÛË ÂÓÛÊ‹ÓˆÛ˘ Ó¢ÌÔÓÈÎÒÓ ÙÚȯÔÂȉÒÓ, SVRI: ¢Â›ÎÙ˘ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛˆÓ, PVRI: ¢Â›ÎÙ˘ Ó¢ÌÔÓÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛˆÓ, LVSWI: ¢Â›ÎÙ˘ ¤ÚÁÔ˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ ·Ó¿ ·ÏÌfi, RVSWI: ¢Â›ÎÙ˘ ¤ÚÁÔ˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ·Ó¿ ·ÏÌfi, ITBV: ¢Â›ÎÙ˘ ÂÓ‰ÔıˆÚ·ÎÈÎÔ‡ fiÁÎÔ˘ ·›Ì·ÙÔ˜, GEDVI: ¢Â›ÎÙ˘ ÔÏÈÎÔ‡ ÙÂÏԉȷÛÙÔÏÈÎÔ‡ fiÁÎÔ˘ ηډ›·˜, EVLWI: ¢Â›ÎÙ˘ Â͈·ÁÁÂÈ·ÎÔ‡ Ó¢ÌÔÓÈÎÔ‡ ‡‰·ÙÔ˜.
2 ·˘ÙÒÓ ÔÌ¿‰ˆÓ ‹Ù·Ó ÙÔ LVEF, Ô Î·Ú‰È·Îfi˜ ‰Â›ÎÙ˘ (Cardiac Index, CI), Ô ‰Â›ÎÙ˘ ¤ÚÁÔ˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ ·Ó¿ ·ÏÌfi (Left Ventricular Stroke Work Index, LVSWI), Ô ‰Â›ÎÙ˘ ¤ÚÁÔ˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ·Ó¿ ·ÏÌfi (Right Ventricular Stroke Work Index, RVSWI) (¶›Ó·Î·˜ 2). ∏ ·ÁˆÁ‹, ÂÎÙfi˜ Ù˘ ·ÓÙÈ‚›ˆÛ˘ (ÎÂÊ·ÏÔÛÔÚ›ÓË 3˘ ÁÂÓ¿˜ ‹ Û˘Ó‰˘·ÛÌfi˜ ÂÓÈÎÈÏÏ›Ó˘ - ¯ÏˆÚ·ÌÊÂÓÈÎfiÏ˘) Î·È Ù˘ ¯ÔÚ‹ÁËÛ˘ ‰ÂÍ·ÌÂı·˙fiÓ˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ÌËÓÈÁÁ›Ùȉ·˜ (0,15mg/Kg/6ˆÚÔ Â› 4 Ë̤Ú˜), ÂÚÈÂÏ¿Ì‚·Ó ›Û˘, ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (30 mg/Kg/6ˆÚÔ) Û 20 ÂÚÈÙÒÛÂȘ Ì ηٷÏËÍ›· Î·È ÂÎÙÂٷ̤ÓÔ ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·. ¢¤Î· ÂÓÓ¤· (35,2%) ·fi ÙÔ˘˜ ·ÛıÂÓ›˜, Ô˘ ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηٷÏËÍ›·˜, ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÌfiÓÔ Ì ÊÔÚÙ›ÛÂȘ ˘ÁÚÒÓ (Ê˘ÛÈÔÏÔÁÈÎfi˜ ÔÚfi˜ ‹ HAES), ÂÓÒ Û 35 ·È‰È¿ (64,8%) ¯ÚÂÈ¿ÛÙËÎÂ, ÂÈϤÔÓ ÙˆÓ ÊÔÚÙ›ÛˆÓ, ¯ÔÚ‹ÁËÛË ÈÓÔÙÚfiˆÓ (ÓÙÔ·Ì›ÓË: 5-30Ìg/Kg/min, ÓÙÔÌÈÔ˘Ù·Ì›ÓË: 530Ìg/kg/min, ÓÔÚ·‰ÚÂÓ·Ï›ÓË: 0,25-2Ìg/kg/min) Ì ‰fiÛÂȘ ÂÍ·ÚÙÒÌÂÓ˜ ·fi ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٷÏËÍ›·˜. ∆¤ÏÔ˜, Û 34 (37,8% ÙÔ˘ Û˘ÓfiÏÔ˘) ··ÈÙ‹ıËΠÌ˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Ì ‰È¿ÚÎÂÈ· Ô˘ Î˘Ì¿ÓıËΠ·fi 1 ÒÚ· ¤ˆ˜ 18 Ë̤Ú˜ (̤ÛË ‰È¿ÚÎÂÈ·: 6,2 Ë̤Ú˜) (¶›Ó·Î·˜ 3). ∂›ÎÔÛÈ ‰‡Ô ·ÛıÂÓ›˜ (24,4%) ·ÚÔ˘Û›·Û·Ó Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ ηٿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙË ª∂£ (¶›Ó·Î·˜ 4).
386
™˘¯ÓfiÙÂÚË ÂÈÏÔ΋ ‹Ù·Ó Ë ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË (¢∂¶), ÙËÓ ÔÔ›· ·ÚÔ˘Û›·Û·Ó 16 ·ÛıÂÓ›˜ (17,8%) Î·È ÌÂÙ·ÁÁ›ÛÙËÎ·Ó Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ì ÊÚ¤ÛÎÔ Î·Ù„˘Á̤ÓÔ Ï¿ÛÌ·. ∂ÈϤÔÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ¯ÔÚËÁ‹ıËΠ۠6 ·È‰È¿ ÂÓÂÚÁÔÔÈËÙ‹˜ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (Actilyse), Û 5 ·ÓÙÈıÚÔÌ‚›ÓË πππ, Û 3 ·Ú¿ÁˆÓ VII Î·È Û 2 ÚˆÙ½ÓË C. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÈÛ‹¯ıËÛ·Ó Î·Ù¿ Ù· ÙÂÏÂ˘Ù·›· 2 ¯ÚfiÓÈ· Ù˘ ÌÂϤÙ˘ (59 ·È‰È¿) ¤ÁÈÓ ϋÚ˘ ·ÈÌÔÚÚ·ÁÈÎfi˜ ¤ÏÂÁ¯Ô˜. Ÿˆ˜ Ê·›ÓÂÙ·È ¶›Ó·Î·˜ 3. ∞ÓÙÈÌÂÙÒÈÛË 90 ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·. ∞ÁˆÁ‹
∞ÛıÂÓ›˜ (n)
∞ÓÙÈ‚›ˆÛË ºÔÚÙ›ÛÂȘ ˘ÁÚÒÓ πÓfiÙÚÔ· ¢ÂÍ·ÌÂı·˙fiÓË ªÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË ¶Ï¿ÛÌ· ∂ÓÂÚÁÔÔÈËÙ‹˜ Ï·ÛÌÈÓÔÁfiÓÔ˘ ∞ÓÙÈıÚÔÌ‚›ÓË πππ ¶·Ú¿ÁˆÓ VII ¶ÚˆÙ½ÓË C ªË¯. ∞ÂÚÈÛÌfi˜ ∞ÈÌԉȋıËÛË / ∞ÈÌÔοı·ÚÛË
90 54 35 47 20 16 6 5 37 2 34 4
(%) 100 60 38,9 52,2 22,2 17,8 6,7 5,6 3,3 2,3 37,8 4,4
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·387
¶∞π¢π∞∆ƒπ∫∏ 2000;63:382-390
ªËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·
¶›Ó·Î·˜ 4. ∂ÈÏÔΤ˜ ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜ ÛÙË ª∂£. ∂ÈÏÔ΋
∞ÛıÂÓ›˜ (n)
(%)
22 16 6 1 6 4 1
24,4 17,8 6,7 1,1 6,7 4,4 1,1
∞ÚÈı. ·ÛıÂÓÒÓ Ì ≥1 ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ ¢∂¶ ¡ÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ∏·ÙÈ΋ ·Ó¿ÚÎÂÈ· ¡ÂÎÚÒÛÂȘ ‰¤ÚÌ·ÙÔ˜ ∞ÚıÚ›Ùȉ· πÛ¯·ÈÌ›· Ì˘Ôηډ›Ô˘ ¢∂¶: ¢È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË
¶›Ó·Î·˜ 5. ∞ÈÌÔÚÚ·ÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ 59 ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·. ¶·Ú¿ÁÔÓÙ·˜ ∞Ú. ·ÛıÂÓÒÓ Ì ÂËÚ·Ṳ̂ÓÔ˘˜ ≥1 ·Ú¿ÁÔÓÙ˜ πÓˆ‰ÔÁfiÓÔ >400 πÓˆ‰ÔÁfiÓÔ <100 ¶·Ú¿ÁÔÓÙ·˜ VII<50% FDP>0,5 TAT>5 PAP>500 ∞ÓÙÈıÚÔÌ‚›ÓË πππ<80% ¶ÚˆÙ½ÓË C <60% ¶ÚˆÙ½ÓË S <60%
∞ÛıÂÓ›˜ (n)
(%)
50 35 9 46 24 29 22 24 35 9
84,7 59,3 15,2 77,9 49,1 37,2 40,6 59,3 15,2
FDP: ¶ÚÔ˚fiÓÙ· ·Ô‰fiÌËÛ˘ ÈÓÒ‰Ô˘˜ (Fibrin Degradation Products) TAT: ™‡ÌÏÂÁÌ· ıÚÔÌ‚›Ó˘-·ÓÙÈıÚÔÌ‚›Ó˘ (Thrombin-Antithrombin complex) PAP: ™‡ÌÏÂÁÌ· Ï·ÛÌ›Ó˘-·ÓÙÈÏ·ÛÌ›Ó˘ (Plasmin-Antiplasmin complex)
¶›Ó·Î·˜ 6. ¢˘ÛÌÂÓ›˜ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ª∂£. ¶·Ú¿ÁˆÓ
∂¤˙ËÛ·Ó ∫·Ù¤ÏËÍ·Ó P (n=77)
™˘ÛÙ. ∞¶<70mmHg 15 PH<7,35 4 §Â˘Î¿<5000/mm3 6 ∞ÈÌÔÂÙ¿ÏÈ·<100.000/mm3 8 ∆·¯Â›· ¤Îı˘ÛË ÂÍ·Óı‹Ì·ÙÔ˜ 2 ÃÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘>25’’ 7
(n=13) 9 6 8 10 6 10
<0,01 <0,001 <0,001 <0,001 <0,001 <0,001
ÛÙÔÓ ›Ó·Î· 5, Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂÌÊ¿ÓÈ˙ ‰È·Ù·Ú·¯¤˜ Û 1 ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘. ŒÍÈ ·È‰È¿ ·ÚÔ˘Û›·Û·Ó ·ÓÔ˘Ú›·, ÏfiÁˆ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜, Ô˘ ·ÓÙÈÌÂÙˆ›ÛıËΠÌÂ Û˘Ó¯‹ ·ÚÙËÚÈÔÊÏ‚È΋ ·ÈÌԉȋıËÛË. ŒÓ· ·fi ·˘Ù¿ ¯ÚÂÈ¿ÛÙËΠÂÈϤÔÓ Û˘Ó‰ڛ˜ ·ÈÌÔοı·ÚÛ˘. ™Ù· 2 ·È‰È¿ Ô˘ ÂÈ‚›ˆÛ·Ó Ë ·ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‹Ù·Ó Ï‹Ú˘. ∏ ÔÏÈÁÔ˘Ú›· ‰È‹ÚÎÂÛ ̤¯ÚÈ 19 Ë̤Ú˜ Î·È ÔÈ ÙÈ̤˜ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ ·ӋÏı·Ó ÛÂ Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ̤۷ Û 27 Ë̤Ú˜. ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ¤Ó·˜ ·ÛıÂÓ‹˜ ÂÌÊ¿ÓÈÛ ÈÛ¯·ÈÌ›· Ì˘Ôηډ›Ô˘ ÌÂ Û˘Ì‚·Ù¤˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ∏∫°, ·ÏÏ¿ Î·È Ì ·‡ÍËÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ÂÓ˙‡ÌˆÓ (ÙÚÔÔÓ›ÓË, CPK-MB). ∆fiÛÔ ÙÔ ¿ÌÂÛÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ, fiÛÔ Î·È Ô ›‰ÈÔ˜ Ô ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·˙·Ó ÛËÌ·ÓÙÈ΋ ˘ÂÚ¯ÔÏËÛÙÂÚÈÓ·ÈÌ›·. OÈ ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ·ÏÏÔÈÒÛÂȘ Î·È Ù· ηډȷο ¤Ó˙˘Ì· ·ÔηٷÛÙ¿ıËÎ·Ó ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜ Ì ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓfiÛÔ˘, ¯ˆÚ›˜ Ó· ··ÈÙËı› ȉȷ›ÙÂÚË ·ÁˆÁ‹. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ·Â‚›ˆÛ·Ó 13 (ıÓËÙfiÙËÙ· 14,4%). ∞fi ·˘Ù¿, Ù· 9 (69,2%) η٤ÏËÍ·Ó Ì¤Û· ÛÙÔ 1Ô 24ˆÚÔ ÓÔÛËÏ›·˜. O ̤ÛÔ˜ fiÚÔ˜ ¤Ï¢Û˘ ı·Ó¿ÙÔ˘ ÛÙ· ·È‰È¿ Ô˘ ·Â‚›ˆÛ·Ó ‹Ù·Ó 36 ÒÚ˜ ·fi Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘˜ ÛÙË ª∂£ (1 ¤ˆ˜ 160 ÒÚ˜). ∂ÈϤÔÓ, 4 ·È‰È¿ Ì ÂÎÙÂٷ̤ÓÔ ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· ÚÔÛÎÔÌ›ÛÙËÎ·Ó ÛÙ· ∂͈ÙÂÚÈο π·ÙÚ›· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜ ÓÂÎÚ¿. ∆fiÛÔ Ë ‚·Ú‡ÙËÙ· fiÛÔ Î·È Ë ıÓËÙfiÙËÙ· Ù˘ ÓfiÛÔ˘ ‰ÂÓ Ê¿ÓËΠӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹ ÌÂ Û˘ÁÎÂÎÚÈ̤ÓË ÔÚÔÔÌ¿‰· ÙÔ˘ ÌÈÎÚÔ‚›Ô˘. ø˜ ‰˘ÛÌÂÓ›˜ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ηٿ ÙËÓ Â›ÛÔ‰Ô ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó: Ë Ù·¯Â›· ¤Îı˘ÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜, Ë ¯·ÌËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË (Û˘ÛÙÔÏÈ΋ ∞¶<70mm Hg), PH<7,35, ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·ÛÊ·ÈÚ›ˆÓ <5.000/mm3, Ï›ˆÓ<100.000/mm3 Î·È Ô ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ (¶›Ó·Î·˜ 6). ™˘˙‹ÙËÛË ™ÙËÓ ÂÚÁ·Û›· Ì·˜ ÌÂÏÂÙ‹ıËÎ·Ó 90 ·È‰È¿ Ì ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Î·È ˘ÚÂÙfi Ô˘ ·Ô‰fiıËΠ۠ª™. ™Â 55 ·fi Ù· ·È‰È¿ ·˘Ù¿ Ë ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ Ïԛ̈ÍË ‰È·ÈÛÙÒıËΠ›Ù Ì ηÏÏȤÚÁÂȘ, ›Ù Ì PCR ¤Ó·ÓÙÈ ÙÔ˘ DNA ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ›Ù Ì ·Ó›¯Ó¢ÛË ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘, ÂÓÒ ÛÙ· ˘fiÏÔÈ· Ë ª™ ıˆڋıËΠˆ˜ "‡ÔÙË". ŸÏ· Ù· ·È‰È¿ Ì "‡ÔÙË" ª™ ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ÌÈÎÚԂȷ΋˜ Ïԛ̈͢ (ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ˘„ËÏ‹ CRP), ÁÂÁÔÓfi˜ Ô˘ ıˆÚËÙÈο fï˜, ‰ÂÓ ·ÔÎÏ›ÂÈ ÙÔ ÂӉ¯fiÌÂÓÔ ÛË„·ÈÌ›·˜ ·fi Ó¢ÌÔÓÈfiÎÔÎÎÔ ‹ ·ÈÌfiÊÈÏÔ ÈÓÊÏÔ˘¤ÓÙÛ·˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ù· ÌÈÎÚfi‚È· ·˘Ù¿ ›ӷÈ
387
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·388
¶∞π¢π∞∆ƒπ∫∏ 2000;63:382-390
‰˘Ó·ÙfiÓ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· Î·È ·ÚfiÌÔȘ ÂΉËÏÒÛÂȘ Ì ÙÔÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ (12). ∞Ó Ï¿‚Ô˘Ì ˘fi„Ë ÙËÓ ËÏÈΛ· ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÛıÂÓÒÓ, ·˘ÙÔ‡˜ Ô˘ ›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ¤Ó·ÓÙÈ ÙÔ˘ Hib Î·È ÙË Û·ÓÈfiÙËÙ· ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÌÈÎÚÔ‚›ˆÓ Ó· ÚÔηÏÔ‡Ó ÛË„·ÈÌ›· Û˘Óԉ¢fiÌÂÓË ·fi ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·, ı· Ú¤ÂÈ Ë Èı·ÓfiÙËÙ· ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ ÛË„·ÈÌ›·˜, ÏËÓ Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜, Ó· ıˆÚÂ›Ù·È Ôχ ÌÈÎÚ‹, ÒÛÙ ӷ ÌËÓ ÂËÚ¿˙ÂÈ Ù· ÙÂÏÈο ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜. ∆Ô Û¯ÂÙÈο ÌÈÎÚfi ÔÛÔÛÙfi ·ÔÌfiÓˆÛ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚›ˆÛ˘ ÚÈÓ ·fi ÙË Ï‹„Ë ÙˆÓ Î·ÏÏÈÂÚÁÂÈÒÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Â›¯Â ÌÂÙ·ÊÂÚı› ·fi ¿ÏÏ· ÓÔÛÔÎÔÌ›· ÛÙÔ ÙÌ‹Ì· Ì·˜, ·ÊÔ‡ ›¯·Ó ‹‰Ë Ï¿‚ÂÈ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ·ÓÙÈ‚›ˆÛË, Ô ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi˜ ·ÔÌÔÓÒÓÂÙ·È ÛÙÔ 35-50% ÙˆÓ ·ÛıÂÓÒÓ, ·ÎfiÌË Î·È ·Ó ·˘ÙÔ› ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ· ‹ ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ (13). OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ª™ ·ÔÙÂÏÔ‡Ó ÙËÓ Î˘ÚÈfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ÔÊ›ÏÔÓÙ·È Û ÙÚȯÔÂȉÈ΋ ‰È·Ê˘Á‹ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Û ˘ÔÔÁηÈÌ›·, Û ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È Û Ì›ˆÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ (14). ∆Ô 50% ÙˆÓ ·È‰ÈÒÓ Ì ª™ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙÔ ÙÌ‹Ì· Ì·˜ ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηٷÏËÍ›·˜, ÂÓÒ ¤Ó· ·ÍÈfiÏÔÁÔ ÔÛÔÛÙfi (20%) ·fi ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û ÙȘ ÂfiÌÂÓ˜ ÒÚ˜ ÂÏ·ÊÚ¤˜ ‹ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∂›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi fiÙÈ ÙÔ 35,2% ÙˆÓ ·È‰ÈÒÓ Ì ÛËÌ›· ηٷÏËÍ›·˜ ÛÙ·ıÂÚÔÔÈ‹ıËΠ·ÈÌÔ‰˘Ó·ÌÈο ÌfiÓÔ Ì ÊÔÚÙ›ÛÂȘ ˘ÁÚÒÓ, Ì ÙȘ Ôԛ˜ ÂÈÙ‡¯ıËΠ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ ÙÔ˘˜ fiÁÎÔ˘, ÂÓÒ ÙÔ ˘fiÏÔÈÔ 64,8% ÙˆÓ ·ÛıÂÓÒÓ Ì ηٷÏËÍ›· ·ÚÔ˘Û›·˙ ÂÈϤÔÓ ÌÂȈ̤ÓË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· Ì˘Ôηډ›Ô˘ (LVEF<65%). O ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÌÂϤÙ˘ Ì·˜ ¤‰ÂÈÍ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ı·ÓfiÓÙˆÓ Î·È ÂÈ˙ÒÓÙˆÓ ÙfiÛÔ ˆ˜ ÚÔ˜ ÙÔ˘˜ ‰Â›ÎÙ˜ ÚÔÊÔÚÙ›Ô˘ (ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË, ›ÂÛË ÂÓÛÊ‹ÓˆÛ˘), fiÛÔ Î·È ˆ˜ ÚÔ˜ ÙËÓ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ (LVEF, LVSWI, RVSWI). ∆· Â˘Ú‹Ì·Ù¿ Ì·˜ Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ ÙˆÓ Mercier Î·È Û˘Ó., ÔÈ ÔÔ›ÔÈ ‰È·›ÛÙˆÛ·Ó fiÙÈ Ù· ·È‰È¿ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ηٷÏËÍ›· Ô˘ η٤ÏËÍ·Ó ·ÚÔ˘Û›·˙·Ó ÂÈ̤ÓÔ˘Û· ˘ÔÔÁηÈÌ›· Î·È ÛÔ‚·ÚfiÙÂÚË Î·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ·, Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ÂÈ‚›ˆÛ·Ó (15). ∆¤ÏÔ˜, ı· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ‰ÈÂıÓÒ˜ ÁÈ· ÙË ¯ÚËÛÈÌÔÔ›ËÛË PiCCO Û ·È‰È¿ Ì ηٷÏËÍ›·.
388
¶. ∫·Ï·Ì·Ï›Î˘ Î·È Û˘Ó.
Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÌÂÙ·‚È‚·ÛÙÒÓ, fiˆ˜ ÔÈ TNF-·, IL-1‚, IL-6, IL-8, IL-10, IFN-Á ·˘Í¿ÓÔÓÙ·È ÛËÌ·ÓÙÈο Û ÂÚÈÙÒÛÂȘ ª™ Î·È Ù· ›‰¿ ÙÔ˘˜ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ (14,16-19). ∞fi ÂÈÚ·Ì·ÙÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰Âȯı› fiÙÈ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙË ª™ ·›˙Ô˘Ó ÔÈ TNF-· Î·È IL-1‚ (14). OÈ ‰‡Ô ·˘Ù¤˜ ΢ÙÙ·ÚÔΛÓ˜ ‰ÈÂÁ›ÚÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ ¿ÏÏˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÂÓÂÚÁÔÔÈÒÓÙ·˜ Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È ÌÔÓÔ·ÙÙ·Ú·, ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÈηÓfiÙËÙ· ÚÔÛÎfiÏÏËÛ˘ ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ Î·È Ì·ÎÚÔÊ¿ÁˆÓ ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, ÚÔηÏÔ‡Ó ‚Ï¿‚Ë ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· Î·È ·ÔÚÚ‡ıÌÈÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÌÔÓÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ (¡O), Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙÚȯÔÂȉÈ΋ ‰È·Ê˘Á‹ Î·È ·ÒÏÂÈ· ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ÙˆÓ ·ÁÁ›ˆÓ (20-22). ∆¤ÏÔ˜, Ë ‰Ú¿ÛË Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙÔ Ì˘ÔοډÈÔ ÚÔηÏ› Ì›ˆÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Î·È ÂÏ¿ÙÙˆÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ (23). ™ÙËÓ Î·Ù·ÏËÍ›· ·Ô‰›‰ÔÓÙ·È Î˘Ú›ˆ˜ ·ÚÎÂÙ¤˜ ·fi ÙȘ ÂÈÏÔΤ˜ Ô˘ ·ÚÔ˘Û›·Û·Ó ÔÈ ·ÛıÂÓ›˜ Ì·˜, fiˆ˜ ÈÛ¯·ÈÌ›· Ì˘Ôηډ›Ô˘, Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (24). ™ÙË ÌÂϤÙË ÙˆÓ Schildkamp Î·È Û˘Ó. 0,4% ÙˆÓ ·È‰ÈÒÓ Ì ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ ÂΉ‹ÏˆÛ·Ó Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È 1,1% ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (25). ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ ˆÛÙfiÛÔ fiÙÈ 2 ·ÛıÂÓ›˜ Ì·˜ ÂΉ‹ÏˆÛ·Ó ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÏfiÁˆ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜, ¯ˆÚ›˜ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÛËÌ›· ηٷÏËÍ›·˜. ¶·ÚfiÙÈ, ·' fiÛÔ ÁÓˆÚ›˙Ô˘ÌÂ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ó¿ÏÔÁ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜, Ë ÂÍ‹ÁËÛË Ô˘ ı· ÌÔÚÔ‡Û ӷ ‰Ôı› Â›Ó·È Ë ·Â˘ı›·˜ ‰Ú¿ÛË ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ‹ ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ ÛÙÔ ÓÂÊÚÈÎfi Û›ڷ̷ ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ì·˜. ¢∂¶ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂΉËψı› ̤۷ Û 24-48 ÒÚ˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ¶ÔÛÔÛÙfi 17,8% ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·ÚÔ˘Û›·Û ¢∂¶, ÂÓÒ ¤Ó· ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÚÔ˘Û›·Û ÌÂÌÔӈ̤Ó˜ ‰È·Ù·Ú·¯¤˜ Û 1 ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘, fiˆ˜ Ë ·ÓÙÈıÚÔÌ‚›ÓË πππ, Ë ÚˆÙ½ÓË C Î·È Ë ÚˆÙ½ÓË S. ™‡Ìʈӷ Ì ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ Ù· ›‰· ÙˆÓ ÙÚÈÒÓ ·˘ÙÒÓ ÚˆÙÂ˚ÓÒÓ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂΉ‹ÏˆÛË ¢∂¶ Î·È Ì η΋ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘. ∏ ˘„ËÏ‹ ıÓËÙfiÙËÙ· Ì¿ÏÈÛÙ· Ù˘ ª™ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ¤¯ÂÈ ·Ô‰Ôı› Î·È ÛÙËÓ ·ÓˆÚÈÌfiÙËÙ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ÚˆÙ½Ó˘ C (26,27). ¶·Ú¿ ÙÔ fiÙÈ Ô ·ıÔÊ˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ¢∂¶ ÛÙË ª™ Â›Ó·È È‰È·›ÙÂÚ· ÔχÏÔÎÔ˜, Ê·›ÓÂÙ·È fiÙÈ Î·È ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ËÎÙÈÎfiÙËÙ·˜ Ô TNF-· ·›˙ÂÈ ÚˆÙ‡ÔÓÙ· ÚfiÏÔ. ∏ Û˘ÁÎÂÎÚÈ̤ÓË Î˘ÙÙ·ÚÔΛÓË ÂÓÂÚÁÔÔÈ› Ù· Ì·ÎÚÔÊ¿Á· ÁÈ· Û‡ÓıÂÛË ÈÛÙÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (tissue factor), Ë ÔÔ›· ·ÏÏËÏÂȉÚÒÓÙ·˜ Ì ٷ ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÂÓÂÚÁÔÔÈ› ÙÔÓ Ì˯·ÓÈÛÌfi Ù˘ ‹Í˘ (28). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ¢∂¶ ¯ÔÚËÁ‹ıËΠÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ÊÚ¤ÛÎÔ Î·Ù„˘Á̤ÓÔ Ï¿ÛÌ·, ÛÂ Û˘Ó‰˘·ÛÌfi Û ÔÚÈ-
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Ṳ̂Ó˜ ÂÚÈÙÒÛÂȘ Ì ·Ú¿ÁÔÓÙ· VII, Ì ڈÙ½ÓË C ‹ Ì ٷ˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ (·ÓÙÈıÚÔÌ‚›ÓË πππ, ÂÓÂÚÁÔÔÈËÙ‹ Ï·ÛÌÈÓÔÁfiÓÔ˘). ∞fi Û¯ÂÙÈο ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ê·›ÓÂÙ·È fiÙÈ Ë ¯ÔÚ‹ÁËÛË Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ ¤¯ÂÈ Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ¤Î‚·ÛË Ù˘ ª™ (29-31). ∏ ·Ú¯È΋ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÂÚÈÂÏ¿Ì‚·Ó ÎÂÊ·ÏÔÛÔÚ›ÓË 3˘ ÁÂÓ¿˜ ‹ Û˘Ó‰˘·ÛÌfi ÂÓÈÎÈÏÏ›Ó˘-¯ÏˆÚ·ÌÊÂÓÈÎfiÏ˘. ™ÙȘ ÂÚÈÙÒÛÂȘ ÌËÓÈÁÁ›Ùȉ·˜ ¯ÔÚËÁ›ÙÔ ÂÈϤÔÓ ‰ÂÍ·ÌÂı·˙fiÓË. ∏ ˆÊÂÏ‹˜ ‰Ú¿ÛË Ù˘ ‰ÂÍ·ÌÂı·˙fiÓ˘, ÛÙË Ì›ˆÛË Î˘Ú›ˆ˜ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·ÎÔ‹˜, ¤¯ÂÈ ‰Âȯı› Û ÂÚÈÙÒÛÂȘ ÌËÓÈÁÁ›Ùȉ·˜ ·fi ·ÈÌfiÊÈÏÔ ÈÓÊÏÔ˘¤ÓÙÛ·˜ Î·È Ó¢ÌÔÓÈfiÎÔÎÎÔ (32-34), ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ ÛÙË ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÌËÓÈÁÁ›Ùȉ· Û¯ÂÙ›˙ÂÙ·È Ì ηχÙÂÚË ¤Î‚·ÛË, ˆ˜ ÚÔ˜ ÙËÓ ·ÎÔ‹ Î·È ÙË Ó¢ÚÔÏÔÁÈ΋ ηٿÛÙ·ÛË (35). À„ËϤ˜ ‰fiÛÂȘ ÛÙÂÚÔÂȉÒÓ ¯ÔÚËÁ‹ıËÎ·Ó Â›Û˘ Û 20 ·ÛıÂÓ›˜ Ì·˜ Ì ÂÎÙÂٷ̤Ó˜ Âί˘ÌÒÛÂȘ Î·È Î·Ù·ÏËÍ›·, Ô˘ ‰ÂÓ Ê¿ÓËΠfï˜ Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ ÙÂÏÈ΋ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘. ∏ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Û ÛËÙÈ΋ ηٷÏËÍ›· Â›Ó·È ·ÌÊÈÛ‚ËÙÔ‡ÌÂÓË. ¢‡Ô Û¯ÂÙÈο ÚfiÛÊ·Ù˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ÛÙÂÚÔÂȉ‹ ‰ÂÓ ÌÂÈÒÓÔ˘Ó ÙË ıÓËÙfiÙËÙ· ·ÛıÂÓÒÓ Ì ÛË„·ÈÌ›· ‹ ÛËÙÈ΋ ηٷÏËÍ›· (36,37). ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Û ηٷÛÙ¿ÛÂȘ ÛËÙÈ΋˜ ηٷÏËÍ›·˜ Ù· ›‰· ÎÔÚÙÈ˙fiÏ˘ ÙÔ˘ ÔÚÔ‡ Â›Ó·È ÌÂÓ Û¯ÂÙÈο ·˘ÍË̤ӷ, ·ÏÏ¿ ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· Â›Ó·È Ôχ ÌÂȈ̤ӷ Û ۯ¤ÛË Ì ÙȘ ·Ó¿ÁΘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ (38). º·›ÓÂÙ·È Â›Û˘ fiÙÈ Ù· ÛÙÂÚÔÂȉ‹ ·˘Í¿ÓÔ˘Ó ÙËÓ Â˘·ÈÛıËÛ›· ÙˆÓ ·‰ÚÂÓÂÚÁÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ, ÒÛÙ ٷ ¯ÔÚËÁÔ‡ÌÂÓ· ÈÓfiÙÚÔ· Ó· ‰ÚÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈο. ¶·ÚfiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›· ÂȉÈο, ÂӉ¯Ô̤ӈ˜ Ë ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Ó· ‚ÔËı¿ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ·˘Ù‹ Û˘Óԉ‡ÂÙ·È ·fi ηٷÏËÍ›·. ∏ ıÓËÙfiÙËÙ· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó 14,4%. ¢ÈÂıÓÒ˜ Ë ıÓËÙfiÙËÙ· Ù˘ ª™ Î˘Ì·›ÓÂÙ·È ·fi 18 ¤ˆ˜ 34% (11,39) Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ηٷÏËÍ›· Êı¿ÓÂÈ ÛÙÔ 50% (40). ø˜ ‰˘ÛÌÂÓ›˜ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÛÙË ÌÂϤÙË Ì·˜ ıˆڋıËÎ·Ó Ë Ù·¯Â›· ¤Îı˘ÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜, Ë ¯·ÌËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË, Ô ÌÂȈ̤ÓÔ˜ ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ, ÙÔ ¯·ÌËÏfi PH Î·È Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘. OÈ Û˘ÁÎÂÎÚÈ̤ÓÔÈ ‰Â›ÎÙ˜ ıˆÚÔ‡ÓÙ·È ‰˘ÛÌÂÓ›˜ Î·È Û ¿ÏϘ ·Ó¿ÏÔÁ˜ ÂÚÁ·Û›Â˜ (41-45). ∞Ó Î·È Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ë ·Ô˘Û›· ÌËÓÈÁÁ›Ùȉ·˜ ıˆÚÂ›Ù·È ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ (44-46), ÛÙË ÌÂϤÙË Ì·˜ ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·ÙfiÓ Ó· ÂÎÙÈÌËı› Ô ·Ú¿ÁÔÓÙ·˜ ·˘Ùfi˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ÔÚÈṲ̂ӷ ·È‰È¿ Ô˘ η٤ÏËÍ·Ó ‰ÂÓ ¤ÁÈÓ ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË, ÏfiÁˆ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ηٿÛÙ·Û‹˜ ÙÔ˘˜.
ªËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÛË„·ÈÌ›·
™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂϤÙË Ì·˜ ÂȂ‚·ÈÒÓÂÈ ¿ÏϘ ·ÚfiÌÔȘ ÂÚÁ·Û›Â˜, ηٿ ÙȘ Ôԛ˜ Ë ª™ Â›Ó·È ÓfiÛÔ˜ ÌÂ Û˘¯Ó¿ Ú·Á‰·›· ÂͤÏÈÍË, Ì ÛËÌ·ÓÙÈ΋ ıÓËÙfiÙËÙ· Î·È Ì ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ı·Ó¿ÙˆÓ Ó· Û˘Ì‚·›ÓÔ˘Ó ÙȘ ÚÒÙ˜ ÒÚ˜ ÓÔÛËÏ›·˜. °È· Ù· ·È‰È¿ ÏÔÈfiÓ Ì ª™ ··ÈÙÂ›Ù·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ ÚÒÙÔ 24ˆÚÔ, ÂӉ¯Ô̤ӈ˜ Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ÙÌ‹Ì·Ù·, ÒÛÙ ӷ ‰È·ÈÛÙÒÓÂÙ·È ¤ÁηÈÚ· Ë Î·Ù·ÏËÍ›· Î·È Ó· ˘¿Ú¯ÂÈ Â·Ú΋˜ ¯ÚfiÓÔ˜ ÁÈ· ·ÈÌÔ‰˘Ó·ÌÈ΋ ÂÎÙ›ÌËÛË, Ô˘ ı· Û˘Óԉ‡ÂÙ·È ÙÔ Ù·¯‡ÙÂÚÔ ‰˘Ó·ÙfiÓ ·fi ÙËÓ ·Ó¿ÏÔÁË Ê·Ú̷΢ÙÈ΋ Î·È ÂÂÌ‚·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Glode M, Smith A. Meningococcal disease. In: Textbook of Pediatric Infectious Disease. 3rd edition. Philadelphia: WB Saunders Co; 1992. p. 1185-1197. 2. Moore P. Meningococcal meningitis in Sub-Saharan Africa: A model for the epidemic process. Clin Inf Dis 1992;14:515-525. 3. Kennedy N, Duncan A. Acute meningococcaemia: Recent advances in management (with particular reference to children). Anaesth Int Care 1996;24:197-216. 4. Salzman M, Rubin L. Meningococcemia. Infect Dis Clin North Am 1996;10:709-725. 5. Mercier JC, Beaufils F, Hartmann JF, Azema D. Hemodynamic patterns of meningococcal shock in children. Crit Care Med 1988;16:27-33. 6. Busund R, Straume B, Revhaug A. Fatal course in severe meningococcemia: Clinical predictors and effect of transfusion therapy. Crit Care Med 1993;21:1699-1705. 7. Ellman H. Capillary permeability in septic patients. Crit Care Med 1984;12:629-633. 8. Hesselvik J, Malm J, Dahlback B, Blomback M. Protein C, protein S and C4b-binding protein in severe infection and septic shock. Thromb Haemostas 1991;65:126-129. 9. Pollard A, Britto J, Nadel S, De Munter C, Habibi P, Levin M. Emergency management of meningococcal disease. Arch Dis Child 1999;80:290-296. 10. Havens P, Garland J, Brook M, Dewitz B, Stremski E, Troshynski T. Trends in mortality in children hospitalized with meningococcal infections,1957 to 1987. Pediatr Infect Dis J 1989;8:8-11. 11. Mok Q, Butt W. The outcome of children admitted to intensive care with meningococcal septicaemia. Intensive Care Med 1996;22:259-263. 12. Jacobs R, His S. Wilson C, Benjamin D, Smith A, Morrow R. Apparent meningococcemia: Clinical features of disease due to Haemophilus influenzae and Neisseria meningitidis. Pediatrics 1983;72:469-472. 13. Cartwright K, Jones D. Investigation of meningococcal disease. J Clin Path 1989:634-639. 14. de Kleijn E, Hazelzet A, Kornelisse R, de Groot R. Pathophysiology of meningococcal sepsis in children. Eur J Pediatr 1998;157:869-880. 15. Mercier JC, Beaufils F, Hartmann JF, Azema D. Hemodynamic patterns of meningococcal shock in children. Crit Care Med 1988;16:27-33.
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16. van Deuren M, van der Ven-Jongekrijg J, Bartelink, A, van Dalen R, Sauerwein R, van der Meer J. Correlation between proinflammatory cytokines and antiinflammatory mediators and the severity of disease in meningococcal infections. J Infect Dis 1995;172:433-439. 17. Derkx B, Marchant A, Goldman M, Bijlmer R, van Deventer S. High levels of interleukin-10 during the initial phase of fulminant meningococcal septic shock. J Infect Dis 1995;171:229-232. 18. Waage A, Brandtzaeg F, Halstensen A, Kierulf P, Espevik T. The complex pattern of cytokines in serum from patients with meningococcal septic shock. J Exp Med 1989;169:333-338. 19. Girardin E, Grau G, Dayer J, Roux-Lombard P, Lambert P. Tumor necrosis factor and interleukin-1 in the serum of children with severe infectious purpura. N Engl J Med 1988;319:397-400. 20. Moncada S, Higgs E. Endogenous nitric oxide: physiology, pathology and clinical relevance. Eur J Clin Invest 1991;21:361-374. 21. Baines P, Stanford S, Bishop-Bailey D, Sills J, Thomson A, Mitchell J et al. Nitric oxide production in meningococcal disease is directly related to disease severity. Crit Care Med 1999;27:1063-1065. 22. Heyderman R, Ison C, Peakman M, Levin M, Klein N. Neutrophil response to Neisseria meningitidis: inhibition of adhesion molecule expression and phagocytosis by recombinant bactericidal/permeability-increasing protein (rBPI21). J Infect Dis 1999;179:1288-1292. 23. Prrillo J. Pathogenetic mechanisms of septic shock. N Engl J Med 1993;328:1471-1477. 24. Kirsch E, Barton P, Kitchen L, Giroir B. Pathophysiology, treatment and outcome of meningococcemia: a review and recent experience. Pediatr Infect Dis J 1996;15:967-979. 25. Schildkamp R, Lodder M, Bijlmer H, Dankert J, Scholten R. Clinical manifestations and course of meningococcal disease in 562 patients. Scand J Infect Dis 1996;28:47-51. 26. Powards D, Larsen R, Johnson J, Hulbert T, Sun T, Patch M et al. Epidemic meningococcemia and purpura fulminans with induced protein C deficiency. Clin Infect Dis 1993;17:254-261. 27. Hazelzet J, Risseeuw-Appel I, Kornelisse R, Hop W, Dekker I, Joosten K et al. Age-related differences in outcome and severity of DIC in children with septic shock and purpura. Thromb Haemost 1996;76:932-938. 28. Nawroth P, Stern D. Modulation of endothelial cell hemostatic properties by tumor necrosis factor. J Exp Med 1986;163:740-745. 29. Aiuto L, Barone S, Cohen P, Boxer R. Recombinant tissue plasminogen activator restores perfusion in meningococcal purpura fulminans. Crit Care Med 1997;25:1079-1082.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 02-12-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 12-07-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶. ∫·Ï·Ì·Ï›Î˘ ¶ª∂¡ (4Ô˜ fiÚÔÊÔ˜), ¡ÔÛ. ¶·›‰ˆÓ "∏ ∞Á›· ™ÔÊ›·" £Ë‚ÒÓ & §Â‚·‰›·˜, 115 27 ∞ı‹Ó·
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30. Fourrier F, Chopin C, Huart J, Runge I, Caron C, Goudemand J. Double-blind, placebo-controlled trial of antithrombin III concentrates in septic shock with disseminated intravascular coagulation. Chest 1993;104:882-888. 31. Rivard G, David M, Farrell C, Schwarz H. Treatment of purpura fulminans in meningococcemia with protein C concentrate. J Pediatr 1995;126:646-652. 32. Schaad U, Lips U, Gnehm H. Dexamethasone therapy for bacterial meningitis in children. Lancet 1993;342:457-461. 33. Kennedy W, Hoyt M, McCracken G. The role of corticosteroid therapy in children with pneumococcal meningitis. Am J Dis Child 1991;145:1374-1378. 34. Bhatt S, Cabellos C, Nadol J. The impact of dexamethasone on hearing loss in experimental pneumococcal meningitis. Pediatr Infect Dis J 1995;14:93-96. 35. Syrogiannopoulos G, Lourida A, Theodoridou M, Pappas I, Babilis G, Economidis J et al. Dexamethasone therapy for bacterial meningitis; 2 versus 4 day regimen. J Infect Dis 1994;169:853-858. 36. Lefering R, Neugebauer E. Steroid controversy in sepsis and septic shock: A meta-analysis. Crit Care Med 1995;23:1294-1303. 37. Crohin L, Cook D, Carlet J, Heyland D, Math D-K, Lansang A, Fischer C. Corticosteroid treatment for sepsis: A critical appraisal and meta-analysis of the literature. Crit Care Med 1995;23:1430-1439. 38. Schein R, Sprung C, Marcial E. Plasma cortisol levels in patients with septic shock. Crit Care Med 1990;18:259-263. 39. Lewis L. Prognostic factors in acute meningococcemia. Arch Dis Child 1979;45:44-48. 40. Giraud T, Dhainaut J, Schremmer B, Regnier B, Desjars P, Loirat P et al. Adult overwhelming meningococcal purpura. Arch Intern Med 1991;151:310-316. 41. Stiehm R, Damrosch. Factors in the prognosis of meningococcal infection. J Pediatr 1966;68:457-467. 42. Niklasson P, Lundbergh P, Strandell T. Prognostic factors in meningococcal disease. Scand J Infect Dis 1971;3:17-25. 43. Tesoro L, Selbst S. Factors affecting outcome in meningococcal infections. Am J Dis Child 1991;145:218-220. 44. Sinclair J, Skeoch C, Hallworth D. Prognosis of meningococcal septicaemia [letter]. Lancet 1987;ii:38. 45. Thomson A, Sills J, Hart A. Validation of the Glasgow Meningococcal Septicemia Prognostic Score: A 10-year retrospective survey. Crit Care Med 1991;19:26-30. 46. Gedde-Dahl T, Bjark P, Hoiby E, Host J, Bruun J. Severity of meningococcal disease: assessment by factors and scores and implications for patient management. Rev Infect Dis 1990;12:973-992.
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∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ ‚ÚÂÊÈ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ù˘ ∫Ú‹Ù˘ Ô˘ ÚԤ΢„·Ó ·fi ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜ ª·ÓfiÏ˘ §ÈÓ·Ú‰¿Î˘, πˆ¿ÓÓ· ªÔÛ¯·Ó‰Ú¤·, ∞ÓÙÒÓ˘ ∫·Ê¿ÙÔ˜ ● ¶ÂÚ›ÏË„Ë: ∏ ¤ÏÏÂÈ„Ë Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ¯ÒÚ·˜ Ì·˜ ȉȷ›ÙÂÚ· ηٿ ÙËÓ ÚÔ-Û¯ÔÏÈ΋ ËÏÈΛ· Ô‰‹ÁËÛ ÛÙËÓ ˘ÏÔÔ›ËÛË Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜. ™Ù· ‚È‚ÏÈ¿ÚÈ· ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Í¤Ó· ÚfiÙ˘· ·Ó¿Ù˘Í˘ ·fi ÙË Á¤ÓÓËÛË ÙÔ˘˜ ¤ˆ˜ ÙÔ 3Ô ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘˜. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ·˘ÙÒÓ ÙˆÓ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¿ÏϘ ¯ÒÚ˜, ·fi ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Ù˘ ¯ÒÚ·˜, ‰ÂÓ Â›Ó·È Î·ıfiÏÔ˘ ·Ô‰ÂÎÙ‹ ‰Â‰ÔÌ¤ÓˆÓ ÙˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ‰È·ÊÔÚÒÓ ÙˆÓ ÏËı˘ÛÌÒÓ. ™Â 1200 ÂÚ›Ô˘ ·È‰È¿ Ù˘ ∫Ú‹Ù˘ ÌÂÙÚ‹ıËΠÙÔ ‚¿ÚÔ˜, Ì‹ÎÔ˜, ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Î·È ÂÎÙÈÌ‹ıËÎÂ Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™) ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔ 6o ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘˜. OÈ ÌÂÙÚ‹ÛÂȘ ·˘Ù¤˜ ‹Ù·Ó ·ÔÙ¤ÏÂÛÌ· ÌÂϤÙ˘ Û˘Ó‰˘·ÛÌÔ‡ ‰È·¯ÚÔÓÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Î·È ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜. ªÂÙ¿ ÙË Á¤ÓÓËÛË, Ô ·Ú¯ÈÎfi˜ ÏËı˘ÛÌfi˜ ÙˆÓ ·È‰ÈÒÓ ÌÂÙ·‚Ï‹ıËΠÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ Î·È ÌfiÓÔ 71 ·È‰È¿ ›¯·Ó Ï‹ÚË ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË. ∆Ô ‚¿ÚÔ˜ ÌÂÙÚ‹ıËΠ̠˙˘Áfi ·ÎÚȂ›·˜ (±20 g), ÙÔ Ì‹ÎÔ˜ Û ‡ÙÈ· ı¤ÛË Ì ÂȉÈ΋˜ ηٷÛ΢‹˜ Û·Ó›‰È Î·È ·ÎÚ›‚ÂÈ· ̤ÙÚËÛ˘ ±0,5 cm (ÌÂϤÙË Â·Ó·ÏË„ÈÌfiÙËÙ·˜) Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Ì ÌÂÙÚÈ΋ Ù·ÈÓ›· ÛÙ·ıÂÚÔ‡ Ì‹ÎÔ˘˜. OÈ Î·Ì‡Ï˜ ·Ó¿Ù˘Í˘ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ ˘ÔÏÔÁ›ÛÙËÎ·Ó ·fi ÙËÓ 5Ë, 10Ë, 25Ë, 50Ë, 75Ë, 90Ë Î·È 95Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Î¿ı ËÏÈΛ·˜, Î·È ÂÍÔ̷χÓıËÎ·Ó Ì ‚¿ÛË ÙË Ì·ıËÌ·ÙÈ΋ - ÛÙ·ÙÈÛÙÈ΋ ̤ıÔ‰Ô ÚÔÛ·ÚÌÔÁ‹˜ ÔÏ˘ˆÓ˘ÌÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ Á' ‚·ıÌÔ‡. ∏ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ÌÂÏÂÙ‹ıËΠ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔ 12 Ì‹Ó· Ì ‚¿ÛË ÌfiÓÔ ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘˜ (·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ‹ Ì Á¿Ï· ·ÁÂÏ¿‰Ô˜). ∆ÔÓ 1Ô Ì‹Ó· ÙÔ 40% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ÌËÙÚÈÎfi Á¿Ï· ÂÓÒ ÙÔ 12% ›¯Â ·ÔÎÏÂÈÛÙÈο ‰È·ÙÚÔÊ‹ Ì Á¿Ï· ·ÁÂÏ¿‰·˜. ™ÙÔÓ 6Ô Î·È 9Ô Ì‹Ó· Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ Û˘Ó¯›ÛÙËΠ·fi ÙÔ 9% Î·È 4% ÙˆÓ ÌËÙ¤ÚˆÓ ·ÓÙ›ÛÙÔȯ·. ¶·Ú¿ÏÏËÏ· ÔÈ ÌÂÙÚ‹ÛÂȘ ¤‰ÂÈÍ·Ó fiÙÈ Ë 50Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÁÈ· Ù· ·ÁfiÚÈ· Â›Ó·È 3,5 kg Î·È ÛÙ· ÎÔÚ›ÙÛÈ· 3,3 kg. OÈ Î·Ì‡Ï˜ ·Ó·Ù‡Í˘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 0-6 ¯ÚfiÓˆÓ ı· ÌÔÚÔ‡Û·Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Û ÂıÓÈÎfi ›‰Ô, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·fi Û˘ÁÎÚ›ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Ê·›ÓÂÙ·È Ó· ÌËÓ ˘¿Ú¯Ô˘Ó ÌÂÁ¿Ï˜ ·ÔÎÏ›ÛÂȘ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘˜ ·fi ·È‰È¿ ÚÔÂÚ¯fiÌÂÓ· ·fi ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Ì ‚¿ÛË Ù· ‰È·ı¤ÛÈÌ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ. ¶·È‰È·ÙÚÈ΋ 2000;63:391-407. §¤ÍÂȘ ÎÏÂȉȿ: ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ, ·Ó¿Ù˘ÍË, ·È‰È¿, ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. M. Linardakis, I. Moschandrea, A. Kafatos. Growth curves of infants and preschool age children from Crete which resulted from longitudinal study. Paediatriki 2000;63:391-407. ● Abstract: The lack of growth curves for the children in our country, particularly those of a pre-school age, was the motivation for the present study. Foreign growth standards are used in child health books from birth to 3 years old. The use of those child growth curves by paediatricians in Greece is not acceptable given the socioeconomic and genetic differences of the populations. In about 1200 children from Crete, weight, length and head circumference were measured and the body mass index (BMI) was estimated from birth to the sixth year of age. These measurements were a result of obtaning both longitudinal and cross-sectional measurements. After birth, the initial population of children changed for various reasons and only 71 children had a full term follow-up. Weights were taken using a precision scale (±20g), the length was measured in a supine position on a purposemade block with an accuracy of ±0.5cm (repeated measurements taken) and the head circumference was measured with a standard length measuring tape. Percentile growth curves of anthropometric measures were calculated from the 5th, 10th, 25th, 50th, 75th, 90th and 95th percentile of each age and were smoothed using
¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘, ∆Ì‹Ì· π·ÙÚÈ΋˜, ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜
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ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
a mathematical-statistical polynomial regression model. The development of the children was studied from birth until the twelfth month of age on the basis of their dietary intake (solely breast-fed versus cow milk fed). 40% of the children were solely breast-fed during their 1st month of life, while 12% were fed only with cow milk. On the 6th and 9th month 9% and 4% of the mothers respectively continued to solely breast-feed. The growth curves showed that the 50th percentile for birth weight is 3.5 kg for boys and 3.3 kg for girls. The growth curves of the children from Crete aged 0-6 years old could be used at a national level, given the fact that there are not any large deviations in the children's development from various regions of the country on the basis of available published data. Key words: percentile, growth, children, pre-school age.
EÈÛ·ÁˆÁ‹ O ÚfiÏÔ˜ Ù˘ ‰È·¯ÚÔÓÈ΋˜ ηٷÁÚ·Ê‹˜ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ ÙˆÓ ·È‰ÈÒÓ Î·È È‰›ˆ˜ ÂÎÂ›ÓˆÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜. ∏ Û‡ÁÎÚÈÛË Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂıÓÈο ÚfiÙ˘· Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Ì ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ˘ÁÈÒÓ ·È‰ÈÒÓ Ì ·ÚfiÌÔÈ· ÁÂÓÂÙÈο Î·È ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο. ŒÓ·˜ ‰Â‡ÙÂÚÔ˜ ÏfiÁÔ˜, Ô˘ ηıÈÛÙ¿ ȉȷ›ÙÂÚ· ··Ú·›ÙËÙÔ˘˜ ÙÔ˘˜ ÂıÓÈÎÔ‡˜ ›Ó·Î˜ ·Ó¿Ù˘Í˘, Â›Ó·È Ë ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È Û‡ÁÎÚÈÛË Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ Û ÏËı˘ÛÌȷ΋ ‚¿ÛË. ªÂÙ¿ ‰ËÏ·‰‹ ·fi ÌÈ· ‹ ÂÚÈÛÛfiÙÂÚ˜ ‰ÂηÂٛ˜ ı· Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ·Ó ‚¿ÚÔ˜, ·Ó¿ÛÙËÌ· ‹ Î·È Ù· ‰˘Ô ·˘Í¿ÓÔÓÙ·È Û ÏËı˘ÛÌÈ·Îfi Â›Â‰Ô Î·È Û ۯ¤ÛË Ì ÙȘ ·ÏÏ·Á¤˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ∞Ó, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ˘ÈÔıÂÙËı› ÌÈ· ÂıÓÈ΋ ÔÏÈÙÈ΋ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ Î·È ÙË ÚfiÏË„Ë ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ı· ˘¿Ú¯ÂÈ ‚¿ÛË Û‡ÁÎÚÈÛ˘ Î·È ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÂÈÙ˘¯›· ‹ ·ÔÙ˘¯›· Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÔÏÈÙÈ΋˜. ∏ ¯ÒÚ· Ì·˜ ¤¯ÂÈ ÁÓˆÚ›ÛÂÈ ÙÂÚ¿ÛÙȘ ÎÔÈÓˆÓÈΤ˜ ·ÏÏ·Á¤˜ ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ Ï›Á˜ ‰ÂηÂٛ˜, fiˆ˜ Ë ÌÂÁ¿ÏË ÔÈÎÔÓÔÌÈ΋ ·Ó¿Ù˘ÍË, Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÁÚÔÙÈÎÔ‡ ÏËı˘ÛÌÔ‡ Ì ·ÓÙ›ÛÙÔÈ¯Ë ·‡ÍËÛË ÙÔ˘ ·ÛÙÈÎÔ‡, Ë ÂÈÛ·ÁˆÁ‹ Ù˘ ÙËÏÂfiÚ·Û˘ Û οı ÂÏÏËÓÈÎfi Û›ÙÈ, Ë ÙÂÚ¿ÛÙÈ· ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô¯ËÌ¿ÙˆÓ, Ë ·ÚÔ˘Û›· ˘ÂÚ·ÁÔÚÒÓ Î·È ¯ÈÏÈ¿‰ˆÓ ÚÔ˚fiÓÙˆÓ Î¿ÙÈ ·‰È·ÓfiËÙÔ ÚÈÓ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ ‘60. OÈ ·ÏÏ·Á¤˜ ·˘Ù¤˜ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó Û˘Ì‚¿ÏÂÈ Ô˘ÛÈ·ÛÙÈο ÛÙËÓ ·‡ÍËÛË ÙˆÓ ‰ÂÈÎÙÒÓ ·¯˘Û·ÚΛ·˜ ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ÏËı˘ÛÌÔ‡(1) ηıÒ˜ Î·È ÛÙËÓ ·‡ÍËÛË ÙˆÓ ‰ÂÈÎÙÒÓ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·fi ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·. OÈ ÂȉڿÛÂȘ ÙˆÓ ÎÔÈΈÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ ·˘ÙÒÓ ·ÏÏ·ÁÒÓ ÛÙÔ˘˜ ‰Â›ÎÙ˜ ˘Á›·˜ ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ı· ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· ÔÛÔÙÈÎÔÔÈËıÔ‡Ó ·Ó ˘‹Ú¯·Ó Ù· ηٿÏÏËÏ· ÚfiÙ˘· Î·È ‚¿ÛÂȘ ‰Â‰ÔÌ¤ÓˆÓ ·fi ÏËı˘ÛÌȷΤ˜ ÌÂϤÙ˜. ∏ ·Ó¿ÁÎË ·˘Ù‹ Â›Ó·È È‰È·›ÙÂÚ· ÌÂÁ¿Ï˘ ÛËÌ·Û›·˜
392
™˘ÓÙÔÌÔÁڷʛ˜: ∂.£. ∂ηÙÔÛÙÈ·›Â˜ £¤ÛÂȘ ¢ª™ ¢Â›ÎÙ˘ ª¿˙·˜ ™ÒÌ·ÙÔ˜ ∂¶∞ ∂ıÓÈο ¶ÚfiÙ˘· ∞Ó¿Ù˘Í˘ CV ™˘ÓÙÂÏÂÛÙ‹˜ ªÂÙ·‚ÏËÙfiÙËÙ·˜ ∞bbreviations: P Percentile BMI Body Mass Index NGS National Growth Standards CV Coefficient of Variation
ÁÈ· Ù· ·È‰È¿ ‚ÚÂÊÈ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÏfiÁˆ Ù·¯Â›·˜ ·Ó¿Ù˘Í˘ Î·È ÌÂÁ·Ï‡ÙÂÚ˘ ¢·ÈÛıËÛ›·˜ ÛÙȘ ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂȉڿÛÂȘ. ∏ ÂÚÌËÓ›· ‚¤‚·È· Ù˘ ÂͤÏÈ͢ Î·È ·Ó¿Ù˘Í˘ ÂÓfi˜ ÏËı˘ÛÌÔ‡ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂ Û˘ÓÂÎÙ›ÌËÛË ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Ì ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜, fiˆ˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ¿ÛÎËÛË Î·È ÁÂÓÈο Ô ÙÚfiÔ˜ ˙ˆ‹˜ Î·È ÔÈ Û˘Óı‹Î˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ˘Á›·. ™Ùfi¯Ô˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ̤ۈ ÙˆÓ ‰È·¯ÚÔÓÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Î·È ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜ (2,3) ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÙÔ˘˜ ÌÂÁÂıÒÓ. OÈ Î·Ì‡Ï˜ ·Ó¿Ù˘Í˘ Û˘ÁÎÚ›ıËÎ·Ó ÛÙË Û˘Ó¤¯ÂÈ·, Ì ˘¿Ú¯ÔÓÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ·fi ¿ÏϘ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜ Î·È ·fi ¿ÏϘ ¯ÒÚ˜ (2,4,5-8,11). ŒÓ·˜ ÂÈÚfiÛıÂÙÔ˜ ÏfiÁÔ˜ Â›Ó·È Ë ÌÂϤÙË Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ ‚ÚÂÊÒÓ ·Ó¿ÏÔÁ· Ì ÙÔÓ ÙÚfiÔ ‰È·ÙÚÔÊ‹˜ ÙÔ˘˜ ‰Â‰Ô̤Ó˘ Ù˘ ÌÂÁ¿Ï˘ ÛËÌ·Û›·˜ ȉȷ›ÙÂÚ· ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ ÙÔ˘˜. M¤ıÔ‰ÔÈ ∏ ÂÚ¢ÓËÙÈ΋ ÂÚÁ·Û›· ‚·Û›ÛÙËΠ۠‰Â‰Ô̤ӷ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ (¤ÙË 19881995). ∆Ô ÂÚÈÁÂÓÓËÙÈÎfi ÚfiÁÚ·ÌÌ· ÔÚÁ·ÓÒıËΠ·Ú¯Èο ÙÔ 1986 Û ÔÏfiÎÏËÚË ÙËÓ ∫Ú‹ÙË, Ì ·Ú·ÎÔÏÔ‡ıËÛË ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ ÛÙ· ‰ËÌfiÛÈ· ÓÔÛÔÎÔÌ›· Î·È Û ÔÚÈṲ̂Ó˜ ȉȈÙÈΤ˜ ÎÏÈÓÈΤ˜ Ô˘ ·Ô‰¤¯ıËÎ·Ó Û˘ÓÂÚÁ·Û›· Ì ÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘. ™ÙË ÌÂϤÙË ·˘Ù‹ ¤ÁÈÓ ·Ú·ÎÔÏÔ‡ıËÛË Î·È Î·Ù·ÁÚ·Ê‹ ‰Â‰ÔÌ¤ÓˆÓ ÁÈ·
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·393
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ÙȘ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ Î·È ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ ·fi ÙȘ Ì·›Â˜ Î·È ÂÈÛΤÙÚȘ ·‰ÂÏʤ˜ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ, ·ÁÚÔÙÈÎÒÓ È·ÙÚ›ˆÓ Î·È Î¤ÓÙÚˆÓ ˘Á›·˜ ÌÂÙ¿ ·fi Û˘ÛÙËÌ·ÙÈ΋ Âη›‰Â˘ÛË Î·È Û˘Ó¯‹ Û˘ÓÂÚÁ·Û›· Ì·˙› ÙÔ˘˜. ∏ ÔÌ¿‰· ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ & ¢È·ÙÚÔÊ‹˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ π·ÙÚÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ ›¯Â ·Ó·Ï¿‚ÂÈ ÙËÓ ÔÚÁ¿ÓˆÛË ÙÔ˘ ¶ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘. ª¤Û· ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ·˘ÙÔ‡ ÂÊ·ÚÌfiÛÙËΠÏÂÙÔÌÂÚ¤˜ ÂÚ¢ÓËÙÈÎfi ÚˆÙfiÎÔÏÏÔ, ‰ËÌÈÔ˘ÚÁ›· Î·È ¤ÏÂÁ¯Ô˜ ·ÍÈÔÈÛÙ›·˜ ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ Î·È ÙˆÓ ÌÂÙÚ‹ÛˆÓ. ∆Ô ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ ›¯Â ¤Ó· ÌfiÓÈÌÔ Û٤ϯԘ Û οı ÓÔÌfi (ÂÎÙfi˜ ÙÔ˘ ÓÔÌÔ‡ ÷ӛˆÓ Ô˘ ‰ÂÓ ‰¤¯ıËÎ·Ó ÙÂÏÈÎÒ˜ ÙË Û˘ÓÂÚÁ·Û›·) Ì ϋÚË ··Û¯fiÏËÛË, ÁÈ· ÙÔÓ ÙÔÈÎfi Û˘ÓÙÔÓÈÛÌfi Î·È ÙË Ï‹„Ë ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÙÚ‹ÛˆÓ. °È· ÏfiÁÔ˘˜ ÔÈÎÔÓÔÌÈÎÔ‡˜, ÙÂÏÈο ·Ú¤ÌÂÈÓ·Ó ‰‡Ô ÛÙÂϤ¯Ë ÛÙÔ˘˜ ÓÔÌÔ‡˜ ƒÂı‡ÌÓ˘ Î·È §·ÛÈı›Ô˘ ÁÈ· ÙË ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ∏ ÂÁÁÚ·Ê‹ ÙˆÓ ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ Î·È ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ ÛÙÔ ÚfiÁÚ·ÌÌ· ¤ÁÈÓ Ì ÙË ÛÂÈÚ¿ ÚÔÛ¤Ï¢Û˘ ÙÔ˘˜ ÛÙÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ƒÂı‡ÌÓÔ˘, ™ËÙ›·˜ Î·È ÛÙÔ ÓÔÌfi ∏Ú·ÎÏ›Ԣ Û ΤÓÙÚ· ˘Á›·˜, ·ÁÚÔÙÈο È·ÙÚ›· Î·È È‰ÈˆÙÈΤ˜ ÎÏÈÓÈΤ˜. ™Â ·˘Ù¿ ·Ú¤ÌÂÈÓ·Ó ÛÙÂϤ¯Ë ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ Ô˘ ¤Î·Ó·Ó fiϘ ÙȘ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. ∆Ô 1988 ¿Ú¯ÈÛ Ì ÙȘ ÚÒÙ˜ ÁÂÓÓ‹ÛÂȘ Ë Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ Ô˘ ·ÊÔÚÔ‡Û ٷ ÓÂÔÁÓ¿ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÂÓÒ Ë Î·Ù·ÁÚ·Ê‹ fiÏˆÓ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚ‹ÛˆÓ, ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ fiˆ˜ ÈÛÙÔÚÈÎfi ÓÔÛËÚfiÙËÙ·˜, „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË, ·È‰È·ÙÚÈ΋ ÂͤٷÛË Î·È ıËÏ·ÛÌfi˜/ ‰È·ÙÚÔÊ‹ ÁÈÓfiÙ·Ó ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘, 2Ô˘, 3Ô˘, 6Ô˘, 9Ô˘, 12Ô˘, 18Ô˘ Î·È ÂÓ Û˘Ó¯›·, οı 6 Ì‹Ó˜ ¤ˆ˜ Î·È ÙÔÓ 72Ô Ì‹Ó·, ‰ËÏ·‰‹ ¤ˆ˜ ÙÔ 6Ô ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘˜. ∆Ô ‚¿ÚÔ˜ ÙˆÓ ·È‰ÈÒÓ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 30 ÌËÓÒÓ ÌÂÙÚ‹ıËΠ̠‚ÚÂÊÔ˙˘Áfi ·ÎÚȂ›·˜ ±20 ÁÚ·ÌÌ·Ú›ˆÓ. O ‚ÚÂÊÔ˙˘Áfi˜ ÌˉÂÓÈ˙fiÙ·Ó ÚÈÓ ·fi οı ̤ÙÚËÛË Î·È ÂϤÁ¯ÂÙÔ Ë ·ÎÚ›‚ÂÈ¿ ÙÔ˘ Ì ÁÓˆÛÙfi ‚¿ÚÔ˜ 2 ÎÈÏÒÓ. ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 30 ÌËÓÒÓ ÙÔ ‚¿ÚÔ˜ ÌÂÙÚÈfiÙ·Ó Ì ˙˘Áfi ·ÎÚȂ›·˜ Secca Ì ·ÎÚ›‚ÂÈ· ±100 ÁÚ·ÌÌ·Ú›ˆÓ ÙÔ˘ ÔÔ›Ô˘ Ë ·ÎÚ›‚ÂÈ· ÂϤÁ¯ÂÙÔ Ì ÁÓˆÛÙfi ‚¿ÚÔ˜ 5 ÎÈÏÒÓ. ∆Ô ·Ó¿ÛÙËÌ· ÂÏ·Ì‚¿ÓÂÙÔ Ì ÂÈ̋Θ Û·Ó›‰È ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ ÂȉÈ΋˜ ηٷÛ΢‹˜ Ì‹ÎÔ˘˜ 1,5 ̤ÙÚÔ˘. ™ÙÔ ¤Ó· ¿ÎÚÔ ÙÔ˘ ›¯Â ηÚʈı› ÌfiÓÈÌÔ Î¿ıÂÙÔ Û·Ó›‰È ÁÈ· Ó· ÂÊ¿ÙÔÓÙ·È Ù· ¤ÏÌ·Ù· ÙÔ˘ ·È‰ÈÔ‡. ™ÙÔ ¿ÏÏÔ ¿ÎÚÔ ÙÔ˘ Û·ÓȉÈÔ‡ ÙÔÔıÂÙ›ÙÔ ÙÔ ÎÂÊ¿ÏÈ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÔÔ›Ô ÂÊ¿ÙÂÙÔ ÎÈÓËÙfi οıÂÙÔ Û·Ó›‰È. ™ÙÔ ¿ÎÚÔ ÙÔ˘ ·Ú·ÏÏËÏfiÁÚ·ÌÌÔ˘ Û·ÓȉÈÔ‡ ηٿ Ì‹ÎÔ˜ ÙÔ˘ ˘Ù›Ô˘ ·È‰ÈÔ‡ ›¯Â ÂÈÎÔÏËı› ÌÂÙÚÈ΋ Ù·ÈÓ›· (ÂηÙÔÛÙ¿ Î·È ‰¤Î·Ù· ÙÔ˘ ÂηÙÔÛÙÔ‡). ∏ Ï‹„Ë ÙÔ˘ Ì‹ÎÔ˘˜ ÙÔ˘ ·È‰ÈÔ‡ ÁÈÓfiÙ·Ó Ì ÙË ‚Ô‹ıÂÈ· ‰‡Ô ·Ùfi-
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
̈Ó. ∆Ô ¤Ó· Û˘Ì›Â˙ ٷ ‰‡Ô ÁfiÓ·Ù· ÙÔ˘ ·È‰ÈÔ‡ ÚÔ˜ Ù· οو Î·È Ì ÙÚfiÔ ÒÛÙ ӷ ÂÊ¿ÙÔÓÙ·È ÙÂÏ›ˆ˜ Ù· ¤ÏÌ·Ù· ÛÙÔ ÌfiÓÈÌÔ Î¿ıÂÙÔ Û·Ó›‰È. ∆Ô ¿ÏÏÔ ¿ÙÔÌÔ ÎÚ·ÙÔ‡Û ·Î›ÓËÙÔ ÙÔ ÎÂÊ¿ÏÈ Î·È ÌÂÙ·ÎÈÓÔ‡Û ÙÔ Î¿ıÂÙÔ ÎÈÓËÙfi Û·Ó›‰È ÒÛÙ ӷ ÂÊ¿ÙÂÙ·È Ï‹Úˆ˜ Ù˘ ÎÂÊ·Ï‹˜. ∏ ¤Ó‰ÂÈÍË ‹Ù·Ó ·Ì¤Ûˆ˜ ÔÚ·Ù‹ ÛÙÔ ÛËÌÂ›Ô fiÔ˘ ÙÔ Î¿ıÂÙÔ ÎÈÓËÙfi Û·Ó›‰È Ì ÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÚÔ˜ ÙÔ ÎÂÊ¿ÏÈ ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÛÙ·˘ÚÒÓÔÓÙ·Ó Ì ÙË ÌÂÙÚÈ΋ Ù·ÈÓ›·. ∏ ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÂÏ·Ì‚¿ÓÂÙÔ Ì ϷÛÙÈ΋ ÌÂÙÚÈ΋ Ù·ÈÓ›· ηϋ˜ ÔÈfiÙËÙÔ˜ ÌË ÌÂÙ·‚·ÏÏfiÌÂÓÔ˘ Ì‹ÎÔ˘˜, Ì ˘Ô‰È·ÈÚ¤ÛÂȘ ÂηÙÔÛÙÒÓ Î·È ‰ÂÎ¿ÙˆÓ ÙÔ˘ ÂηÙÔÛÙÔ‡. ∆Ô ·È‰› ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 24 ÌËÓÒÓ ‹Ù·Ó Û ‡ÙÈ· ı¤ÛË Î·È Ë Ì¤ÙÚËÛË Ï·Ì‚¿ÓÔÓÙ·Ó ÌÂٷ͇ ÙÔ˘ ϤÔÓ ÚÔ¤¯ÔÓÙÔ˜ ÛËÌ›Ԣ Ù˘ ÈÓȷ΋˜ Î·È ÌÂوȷ›·˜ ¯ÒÚ·˜. ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 24 ÌËÓÒÓ ÔÈ ÌÂÙÚ‹ÛÂȘ Ï·Ì‚¿ÓÔÓÙ·Ó Û ηıÈÛÙ‹ ı¤ÛË. ŸÛÔÓ ·ÊÔÚ¿ ÙÔÓ ¢Â›ÎÙË ª¿˙·˜ ™ÒÌ·ÙÔ˜, ¤ÁÈÓ ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ·fi ÙÔ ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ ÙˆÓ ·È‰ÈÒÓ (¢ª™=‚¿ÚÔ˜ / Ì‹ÎÔ˜2, Ì ÙÔ ‚¿ÚÔ˜ ÂÎÊÚ·Ṳ̂ÓÔ Û ÎÈÏ¿ Î·È ÙÔ Ì‹ÎÔ˜ Û ̤ÙÚ·) (9). §fiÁˆ ·ÒÏÂÈ·˜ ·È‰ÈÒÓ ·fi ·Û˘Ó‹ Ù‹ÚËÛË ËÌÂÚÔÌËÓÈÒÓ ÂͤٷÛ˘, ÌÂÙ·ÎÈÓ‹ÛÂˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Î·È ¿ÏÏˆÓ ·ÈÙÈÒÓ, Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙÔ (·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔÓ 72Ô Ì‹Ó·) ÌÂÙ·‚·ÏÏfiÙ·Ó ·fi Ì‹Ó· Û ̋ӷ Ì ̤ÁÈÛÙÔ Ï‹ıÔ˜ ÙÔÓ 1Ô Ì‹Ó· (1142 ·È‰È¿) Î·È ÂÏ¿¯ÈÛÙÔ ÙÔÓ 66Ô Ì‹Ó· (87 ·È‰È¿). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ 71 ·È‰È¿ (38 ·ÁfiÚÈ· Î·È 33 ÎÔÚ›ÙÛÈ·) ›¯·Ó Ï‹ÚË ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔ 72Ô Ì‹Ó·. ∏ ηٷÓÔÌ‹ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚ‹ÛÂˆÓ ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ·fi ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚ‹ÛÂˆÓ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÌÂÙ·‚·ÏÏfiÌÂÓÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÙˆÓ ·È‰ÈÒÓ, Ô˘ ‹Ù·Ó ·ÔÙ¤ÏÂÛÌ· ÌÂϤÙ˘ Û˘Ó‰˘·ÛÌÔ‡ ‰È·¯ÚÔÓÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ Î·È ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜. ∏ ηٿÚÙÈÛË ÙˆÓ Î·Ì˘ÏÒÓ ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ (2,5,12) ÙÔ˘ ‚¿ÚÔ˘˜, Ì‹ÎÔ˘˜, ¢ª™ Î·È ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ·ÊÔÚ¿ ÙȘ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ 5Ë, 10Ë, 25Ë, 50Ë, 75Ë, 90Ë Î·È 95Ë Î·È ÔÈ ÙÈ̤˜ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÛÙȘ ı¤ÛÂȘ ·˘Ù¤˜ ÂÍÔ̷χÓıËÎ·Ó ¯ˆÚÈÛÙ¿ ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ Ù˘ ÚÔÛ·ÚÌÔÁ‹˜ ÔÏ˘ˆÓ˘ÌÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ Á’ ‚·ıÌÔ‡ (5,6,15,16), fiÔ˘ ¤‰ˆÛ·Ó ‚·ıÌÔ‡˜ ÚÔÛ·ÚÌÔÁ‹˜ ÁÈ· ÌÂÓ ÙÔ ‚¿ÚÔ˜, Ì‹ÎÔ˜, ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ R2>99,4% Î·È ÁÈ· ÙÔ ¢ª™ R2>82,5%. ∂›Û˘, ÌÂÏÂÙ‹ıËÎÂ Ë ‡·ÚÍË ‹ ÌË ‰È·ÊÔÚ¿˜ ÛÙ· ۈ̷ÙÔÌÂÙÚÈο ÌÂÁ¤ıË Ì¤Ûˆ Ù˘ ÌÂıfi‰Ô˘ ·Ó¿Ï˘Û˘ ‰È·Î‡Ì·ÓÛ˘ ηٿ ¤Ó·Ó ·Ú¿ÁÔÓÙ· (oneway ANOVA), ÙˆÓ ·È‰ÈÒÓ Ô˘ ı‹Ï·˙·Ó ·ÔÎÏÂÈÛÙÈο Î·È ÂÎÂ›ÓˆÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ ¤ˆ˜ ÙÔÓ 12Ô Ì‹Ó·. ∏ ÂÂÍÂÚÁ·Û›· Î·È ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÛÙ·ÙÈÛÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ SPSS-X 8,0 ÂÓÒ Ë ‰È·ÁÚ·ÌÌ·ÙÈ΋ ·ÚÔ˘Û›·Û‹ ÙÔ˘˜ Ì ÙÔ ÏÔÁÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· MS - Excel 97.
393
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·394
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∞ÔÙÂϤÛÌ·Ù· ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë Î·Ù·ÓÔÌ‹ ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ, ÙˆÓ Ù˘ÈÎÒÓ ·ÔÎÏ›ÛÂÒÓ ÙÔ˘˜ Î·È ÙˆÓ Û˘ÓÙÂÏÂÛÙÒÓ ÌÂÙ·‚ÏËÙfiÙËÙ·˜ (CV) ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚÈÎÒÓ ÌÂÁÂıÒÓ ÙˆÓ ·È‰ÈÒÓ. OÈ Î·Ì‡Ï˜ ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ ÁÈ· Ù· ·ÁfiÚÈ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙ· Û¯‹Ì·Ù· 1-4 Î·È ÙˆÓ ÎÔÚÈÙÛÈÒÓ 5-8. ™ÙȘ η̇Ϙ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÓÒ ·ÂÈÎÔÓ›˙ÔÓÙ·È ÁÚ·ÊÈο ÙÔ ‚¿ÚÔ˜ Û ÎÈÏ¿ (kg), ÙÔ Ì‹ÎÔ˜ Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Û ÂηÙÔÛÙ¿ (cm) Î·È Ô ¢ª™. ∆Ô ‚¿ÚÔ˜ ÙˆÓ ·ÁÔÚÈÒÓ ÛÙË Á¤ÓÓËÛË Î·ıÔÚ›˙ÂÙ·È ÛÙËÓ 5Ë Î·È 95Ë ∂.£. 2,61 kg Î·È 4,25 kg, ·ÓÙ›ÛÙÔȯ· (Ì CV 15,3). ¢È·¯ÚÔÓÈο, ÙÔ ‚¿ÚÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË ‰È·Î‡Ì·ÓÛË fiÛÔ ·˘Í¿ÓÂÙ·È Ë ËÏÈΛ· fiˆ˜ Ê·›ÓÂÙ·È Î·È ÛÙ· Û¯‹Ì·Ù· 1 & 2, ÂÓÒ ÛÙÔÓ 72Ô Ì‹Ó· (6Ô ¤ÙÔ˜) ÔÈ 5Ë Î·È 95Ë ∂.£. Â›Ó·È 15,9 Î·È 32 kg, ·ÓÙ›ÛÙÔȯ· (Ì CV 21,3). ∆Ô Ì‹ÎÔ˜ ¤¯ÂÈ ÂÚÈÛÛfiÙÂÚÔ ÔÌÔÈfiÌÔÚÊË Î·Ù·ÓÔÌ‹ ˆ˜ ÚÔ˜ ÙÔ «¿ÏˆÌ·» ÙˆÓ ∂.£ ¤¯ÔÓÙ·˜ ÛÙÔÓ 1Ô Ì‹Ó· ÛÙËÓ 5Ë Î·È 95Ë ∂.£ 49,9 Î·È 59,8 cm, ·ÓÙ›ÛÙÔȯ· (Ì CV 4.8). ª¤¯ÚÈ ÙÔÓ 36Ô Ì‹Ó· fiˆ˜ Ê·›ÓÂÙ·È ÛÙ· Û¯‹Ì·Ù·, ·Ú·ÙËÚÂ›Ù·È ÌÈ· Û˘Ó¯fiÌÂÓË Ù·¯Â›· ·‡ÍËÛË ÙÔ˘ Ì‹ÎÔ˘˜ (CV 3,9), ÂÓÒ ·ÎÔÏÔ‡ıˆ˜ ̤¯ÚÈ ÙÔÓ 72Ô Ì‹Ó· Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÌÂÈÒÓÂÙ·È. ™ÙÔÓ 72Ô Ì‹Ó· ÔÈ 5Ë Î·È 95Ë ∂.£ Â›Ó·È 113 Î·È 128,6 cm, ·ÓÙ›ÛÙÔȯ· (Ì CV 3,7). O ¢ª™ ÙˆÓ ·ÁÔÚÈÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Ù¿ÛË ·˘ÍÔÌ›ˆÛ˘ fiˆ˜ Ê·›ÓÂÙ·È ÛÙ· ·ÓÙ›ÛÙÔȯ· Û¯‹Ì·Ù·, Ì ÈÔ ¤ÓÙÔÓË ÙË Ì›ˆÛË ÙÔ˘ ¢ª™ ·fi ÙÔ 18Ô Ì‹Ó· ̤¯ÚÈ Î·È ÙÔÓ 60Ô, ÂÓÒ ·ÎÔÏÔ‡ıˆ˜ ·˘Í¿ÓÂÙ·È ÂÓÙ˘ˆÛȷο ̤¯ÚÈ ÙÔÓ 72Ô Ì‹Ó·. ∏ ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÛÙ· ·ÁfiÚÈ· ¤¯ÂÈ ·˘ÍËÙÈ΋ Ù¿ÛË ¤ˆ˜ Î·È ÙÔÓ 24Ô Ì‹Ó· ¤Ú·Ó ÙÔ˘ ÔÔ›Ô˘ ˘Ê›ÛÙ·Ù·È Û¯ÂÙÈ΋ ÂȤ‰ˆÛË. OÈ ÛˆÌ·ÙÔÌÂÙÚ‹ÛÂȘ ÙˆÓ ÎÔÚÈÙÛÈÒÓ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË ‰È·ÁÚ·ÌÌ·ÙÈ΋ ηٷÓÔÌ‹ ÙÔ˘˜ ·fi ÂΛÓË ÙˆÓ ·ÁÔÚÈÒÓ fiˆ˜ ·Ú·ÙËÚÂ›Ù·È ·fi Ù· ·ÓÙ›ÛÙÔȯ· Û¯‹Ì·Ù·. Ÿˆ˜ Ê·›ÓÂÙ·È Î·È ÛÙÔÓ ›Ó·Î· 1, ÔÈ Ì¤ÛÔÈ fiÚÔÈ Â›Ó·È ÂÏ·ÊÚÒ˜ ¯·ÌËÏfiÙÂÚÔÈ ÙˆÓ ·ÁÔÚÈÒÓ. ™ÙÔÓ ¶›Ó·Î· 2.1 ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ô ÙÚfiÔ˜ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ‚ÚÂÊÒÓ ·fi ÙÔÓ 1Ô Ì‹Ó· ¤ˆ˜ ÙÔ 12Ô Ì‹Ó· Ì ÙȘ Û˘¯ÓfiÙËÙ˜ (·fiÏ˘Ù˜ Î·È Û¯ÂÙÈΤ˜) ÂÎÂ›ÓˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Î·È ÂÎÂ›ÓˆÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï·. ªÂÙ¿ ÙÔ 2Ô Ì‹Ó· Ù· ÔÛÔÛÙ¿ ÙˆÓ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο ÌÂÈÒÓÔÓÙ·È Ì ÙËÓ ·Ú¿ÏÏËÏË ·‡ÍËÛË ÂÎÂ›ÓˆÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï·. ™ÙÔÓ 1Ô Ì‹Ó·, ·ıÚÔÈÛÙÈο Ù· ·È‰È¿ Î·È ÙˆÓ ‰‡Ô ηÙËÁÔÚÈÒÓ ·ÔÙÂÏÔ‡Ó ÌfiÏȘ ÙÔ ÌÈÛfi ÂÚ›Ô˘ ÙÔ˘ Û˘ÓfiÏÔ˘ (53%) Î·È ÂÔ̤ӈ˜ ÙÔ ˘fiÏÔÈÔ ÌÈÛfi ÙÔ˘ Û˘ÓfiÏÔ˘ ÙÚ¤ÊÂÙ·È ÌÈÎÙ¿ ‰ËÏ·‰‹, ÌËÙÚÈÎfi Î·È Í¤ÓÔ Á¿Ï· Ì ‰È¿ÊÔÚ˜ ·Ó·ÏÔÁ›Â˜. ∞fi ÙÔÓ 1Ô ÛÙÔÓ 2Ô Ì‹Ó·, ÂÓÒ ·˘Í¿ÓÔÓÙ·È Î·È ÔÈ ‰‡Ô ηÙËÁÔڛ˜,
394
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
Â›Ó·È ÂÓÙ˘ˆÛȷ΋ Ë ·‡ÍËÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· (·fi ÙÔ 12% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ ÛÙÔ 42%) Î·È Ì¤¯ÚÈ ÙÔÓ 12Ô Ì‹Ó· Ù›ÓÂÈ Ó· ηχ„ÂÈ Û¯Â‰fiÓ ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ (ÙÔÓ 12Ô Ì‹Ó· Ù· ·È‰È¿ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· ·ÔÙÂÏÔ‡Ó ÙÔ 97% ÙÔ˘ Û˘ÓfiÏÔ˘). ™ÙÔÓ ¶›Ó·Î· 2.2 ‰›ÓÔÓÙ·È ·ÓÙ›ÛÙÔȯ· ÁÈ· ·ÔÎÏÂÈÛÙÈÎfi ıËÏ·ÛÌfi Î·È Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ Û˘¯ÓfiÙËÙ˜ Î·È ÔÛÔÛÙ¿ ·È‰ÈÒÓ ‹ ÌËÙ¤ÚˆÓ ·fi ¿ÏϘ ¤Ú¢Ó˜ (18-21) ¿ÏÏˆÓ ÂÚÈÔ¯ÒÓ Ù˘ ¯ÒÚ·˜ Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ∫Ú‹Ù˘ (17) Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ·Ú¿ÏÏËÏ· ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980. ªÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‰ËÏÒÓÂÙ·È ÛÙËÓ ¤Ú¢ӷ ÙÔ˘ ÓÔÌÔ‡ ∆ÚÈÎ¿ÏˆÓ (19) ÛÙÔÓ ÚÒÙÔ Ì‹Ó·, ÌfiÏȘ 80%, Û ·ÓÙ›ıÂÛË Ì ¿ÏÏË ¤Ú¢ӷ Û ∞ı‹Ó· / ∂·Ú¯›· (20) Ô˘ ‰ËÏÒÓÂÙ·È ÙÔ 27%. °ÂÓÈο, ¿Óˆ ÙÔ˘ 6Ô˘ Ì‹Ó· ‰ÂÓ ‰ËÏÒÓÂÙ·È ·ÔÎÏÂÈÛÙÈ΋ ‰È·ÙÚÔÊ‹ Ì ıËÏ·ÛÌfi ·Ú¿ ÌfiÓÔ ÛÙÔ ÓÔÌfi ∆ÚÈÎ¿ÏˆÓ Ì 2,8% ÙˆÓ ·È‰ÈÒÓ Î·È ·ÔÎÏÂÈÛÙÈο Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ 81,8%, ÂÓÒ ÛÙÔ ¶ÂÚÈÁÂÓÓËÙÈÎfi ¶ÚfiÁÚ·ÌÌ· ∫Ú‹Ù˘ ÛÙÔÓ 9Ô Ì‹Ó· ‰ËÏÒÓÂÙ·È Û¯Â‰fiÓ 4% ÁÈ· ·ÔÎÏÂÈÛÙÈÎfi ıËÏ·ÛÌfi Î·È 90% ÁÈ· ·ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï·. ™˘ÁÎÚÈÙÈο, ÛÙÔÓ 3Ô Ì‹Ó· Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÛÙËÓ ¤Ú¢ӷ Ù˘ ∞ı‹Ó·˜ / ∂·Ú¯›·˜ Î·È ¡›Î·È·˜ / ∫ÔÚ˘‰·ÏÏÔ‡ (21) Â›Ó·È ÌfiÏȘ 9 Î·È 9,3% ·ÓÙ›ÛÙÔȯ· ÂÓÒ Ù˘ ∫Ú‹Ù˘ (17) 21,6%, ÙÔ˘ ÓÔÌÔ‡ Œ‚ÚÔ˘ (18) 16,8% Î·È ÙÔ˘ ÓÔÌÔ‡ ∆ÚÈÎ¿ÏˆÓ 48,5%. ¢È·ÈÛÙÒÓÂÙ·È ¤ÙÛÈ, fiÙÈ ÚÈÓ ÙÔ Ù¤ÏÔ˜ Ù˘ ÂÚÈfi‰Ô˘ ıËÏ·ÛÌÔ‡ ¤Ó· Ôχ ÌÈÎÚfi ÙÌ‹Ì· ÙˆÓ ·È‰ÈÒÓ Ù˘ ¢ڇÙÂÚ˘ ÂÚÈÔ¯‹˜ ÙˆÓ ∞ıËÓÒÓ ÙÚ¤ÊÂÙ·È Ì ·ÔÎÏÂÈÛÙÈÎfi ıËÏ·ÛÌfi Û ·ÓÙ›ıÂÛË Ì ÙËÓ ·ÔÎÏÂÈÛÙÈο Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ fiÔ˘ ÌfiÏȘ ÙÔÓ 3Ô Ì‹Ó· Û ¡›Î·È· / ∫ÔÚ˘‰·ÏÏfi ‰ËÏÒÓÂÙ·È ÙÔ 85,6%. O ¶›Ó·Î·˜ 3 ‰Â›¯ÓÂÈ ÙÔ˘˜ ̤ÛÔ˘˜ fiÚÔ˘˜ Î·È ÙȘ Ù˘ÈΤ˜ ·ÔÎÏ›ÛÂȘ ÙÔ˘ ‚¿ÚÔ˘˜, Ì‹ÎÔ˘˜, ¢ª™ Î·È ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ı‹Ï·Û·Ó ·ÔÎÏÂÈÛÙÈο Î·È ÂÎÂ›ÓˆÓ Ô˘ ¤·ÈÚÓ·Ó ·ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï·. ∏ ·Ó¿Ï˘ÛË Ù˘ ÌÂÙ·‚ÏËÙfiÙËÙ·˜ ‰Â›¯ÓÂÈ Ì¤¯ÚÈ ÙÔÓ 3Ô Ì‹Ó· Ù· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË Ó· ¤¯Ô˘Ó Û˘ÁÎÚÈÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ ÂÓÒ ÛÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ ÙÔ ‚¿ÚÔ˜ ÙˆÓ ·È‰ÈÒÓ Ì ·ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï· ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο (p<0,05). ∆Ô Ì‹ÎÔ˜ ÙˆÓ ıËÏ·˙fiÓÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È Û˘ÁÎÚÈÙÈο ÌÂÁ·Ï‡ÙÂÚÔ Ì¤¯ÚÈ Î·È ÙÔÓ 2Ô Ì‹Ó· (p<0,05) ÂÓÒ ÁÈ· ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ Ì‹Ó˜ ‰ÂÓ ˘Ê›ÛÙ·Ù·È ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ, ÂÎÂ›ÓˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Î·È ÂÎÂ›ÓˆÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï·. ª¤¯ÚÈ ÙÔÓ 3Ô Ì‹Ó· Ù· ·È‰È¿ Ô˘ ıËÏ¿˙Ô˘Ó ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ¢ª™ Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ (p<0,05) ÂÓÒ ÙÔÓ 12Ô Ì‹Ó· Ô ¢ª™ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· Â›Ó·È Û˘ÁÎÚÈÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ (p<0,05).
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·395
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
¶›Ó·Î·˜ 1. µ¿ÚÔ˜, ª‹ÎÔ˜ (⁄„Ô˜), ¢ª™ & ¶ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ Î·È ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜). ™ˆÌ·ÙÔÌÂÙÚÈο ªÂÁ¤ıË ¶·È‰ÈÒÓ Î·È ªÂÙ·‚ÏËÙfiÙËÙ· ∏ÏÈΛ· º‡ÏÔ (Ì‹Ó˜)
0
1
2
3
6
9
12
18
24
30
36
42
48
54
60
66
72
n
µ¿ÚÔ˜ (ÁÚ·ÌÌ¿ÚÈ·) ª¤ÛÔ˜ ŸÚÔ˜ (∆˘. ∞fiÎÏÈÛË)
CV
ª‹ÎÔ˜ ¢ª™ (ÂηÙÔÛÙ¿) ª¤ÛÔ˜ ŸÚÔ˜ CV ª¤ÛÔ˜ ŸÚÔ˜ (∆˘. ∞fiÎÏÈÛË) (∆˘. ∞fiÎÏÈÛË) -
CV
-
¶ÂÚ›Ì. ∫ÂÊ·Ï‹˜ (ÂηÙÔÛÙ¿) ª¤ÛÔ˜ ŸÚÔ˜ (∆˘. ∞fiÎÏÈÛË)
CV
∞ÁfiÚÈ·
469
3471(531,5)
15,3
∫ÔÚ›ÙÛÈ·
436
3282(480,7)
14,6
-
∞ÁfiÚÈ·
588
4417 (639,7)
14,5
54,6 (2,65)
4,8
14,74 (1,57)
11
37,9 (2,25)
5,9
∫ÔÚ›ÙÛÈ·
555
4106 (542,0)
13,2
53,5 (2,57)
4,8
14,42 (1,90)
13
37,0 (2,25)
6
∞ÁfiÚÈ·
473
5443 (719,7)
13,2
58,0 (2,93)
5
16,22 (2,21)
14
39,7 (1,64)
4,1
∫ÔÚ›ÙÛÈ·
463
4962 (612,6)
12,3
56,8 (2,45)
4,3
15,39 (1,49)
38,6 (1,18)
3
∞ÁfiÚÈ·
423
6300 (703,1)
11,1
61,2 (2,54)
4,2
16,80 (1,70)
41,1 (1,69)
4,1
∫ÔÚ›ÙÛÈ·
421
5738 (671,0)
11,7
59,7 (2,32)
3,9
16,10 (1,52)
39,9 (1,35)
3,4
∞ÁfiÚÈ·
301
7990 (909,3)
11,4
68,0 (3,30)
4,8
17,35 (1,95)
11
43,9 (2,25)
5,1
∫ÔÚ›ÙÛÈ·
304
7490 (836,3)
11,2
66,2 (2,83)
4,3
17,13 (1,76)
10
42,8 (1,83)
4,2
9,7 10 9,4
∞ÁfiÚÈ·
233
9246 (971,5)
10,5
72,8 (3,20)
4,4
17,46 (1,77)
10
46,2 (4,07)
8,8
∫ÔÚ›ÙÛÈ·
225
8712 (930,9)
10,7
70,9 (2,88)
4,1
17,34 (1,94)
11
44,8 (1,73)
3,8
∞ÁfiÚÈ·
215
10200 (1183,9)
11,6
76,8 (3,33)
4,3
17,35 (1,86)
11
47,1 (2,46)
5,2
∫ÔÚ›ÙÛÈ·
195
9660 (1098,4)
11,4
75,0 (3,18)
4,2
17,18 (1,69)
9,8
46,0 (1,43)
3,1
∞ÁfiÚÈ·
116
11790 (1183,8)
10
83,6 (3,05)
3,6
16,85 (1,48)
8,8
48,6 (1,31)
2,7
∫ÔÚ›ÙÛÈ·
123
11254 (1311,9)
11,7
82,3 (3,33)
4
16,6 (1,76)
47,4 (1,25)
2,6
∞ÁfiÚÈ·
102
13067 (1574,0)
12
89,6 (2,72)
3
16,21 (1,44)
8,9
49,7 (1,96)
3,9
∫ÔÚ›ÙÛÈ·
108
12775 (1605,9)
12,6
88,6 (2,97)
3,4
16,26 (1,54)
9,5
48,7 (1,70)
3,5
∞ÁfiÚÈ·
76
14372 (1686,9)
11,7
95,0 (3,08)
3,2
15,87 (1,30)
8,2
50,0 (1,33)
2,7
∫ÔÚ›ÙÛÈ·
84
14132 (1957,6)
13,8
93,8 (3,52)
3,7
16,05 (1,68)
49,7 (3,34)
6,7
11
11
∞ÁfiÚÈ·
70
15650 (2187,8)
14
99,4 (3,92)
3,9
15,79 (1,55)
50,4 (1,41)
2,8
∫ÔÚ›ÙÛÈ·
77
15264 (2530,9)
16,6
98,2 (4,38)
4,5
15,76 (1,82)
12
9,8
49,7 (1,26)
2,5
∞ÁfiÚÈ·
61
16714 (2504,9)
15
103,2 (3,57)
3,5
15,63 (1,66)
11
50,9 (1,31)
2,6
∫ÔÚ›ÙÛÈ·
62
16166 (2241,0)
13,9
102,2 (4,23)
4,1
15,42 (1,53)
50,0 (1,26)
2,5
∞ÁfiÚÈ·
54
17880 (2902,4)
16,2
106,8 (3,96)
3,7
15,60 (1,82)
12
51,4 (1,26)
2,5
∫ÔÚ›ÙÛÈ·
55
17336 (2584,8)
14,9
105,5 (4,02)
3,8
15,51 (1,76)
11
50,5 (1,24)
2,5
∞ÁfiÚÈ·
53
18990 (3288,1)
17,3
110,4 (4,55)
4,1
15,48(1,83)
12
51,7 (1,35)
2,6
∫ÔÚ›ÙÛÈ·
49
18549 (2920,8)
15,7
109,4 (4,30)
3,9
15,42 (1,71)
11
50,8 (1,31)
2,6
∞ÁfiÚÈ·
49
20035 (3429,0)
17,1
113,5 (4,11)
3,6
15,48 (1,86)
12
52,0 (1,46)
2,8
∫ÔÚ›ÙÛÈ·
48
19516 (3072,8)
15,7
113,0 (4,84)
4,3
15,21 (1,70)
11
51,1 (1,26)
2,5
9,9
∞ÁfiÚÈ·
45
21083 (3919,1)
18,6
116,6 (4,40)
3,8
15,42 (2,10)
14
52,2 (1,47)
2,8
∫ÔÚ›ÙÛÈ·
42
21147 (3766,5)
17,8
116,0 (5,00)
4,3
15,62 (2,02)
13
51,4 (1,41)
2,7
∞ÁfiÚÈ·
48
22789 (4848,4)
21,3
120,3 (4,50)
3,7
15,66 (2,60)
17
52,5 (1,51)
2,8
∫ÔÚ›ÙÛÈ·
45
22224 (4001,9)
18
119,3 (5,17)
4,3
15,50 (1,96)
13
51,7 (1,34)
2,6
395
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·396
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 2.1. ª¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Î·È ÔÛÔÛÙ¿ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Î·È ÙˆÓ ·È‰ÈÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· ·fi ÙÔÓ 1Ô ¤ˆ˜ Î·È ÙÔÓ 12Ô Ì‹Ó·. ∏ÏÈΛ· (Ì‹Ó˜)
™‡ÓÔÏÔ ·È‰ÈÒÓ (ηٷÁÚ·Ê‹ Û˘ÓËıÂÈÒÓ ‰È·ÙÚÔÊ‹˜)
∞ÔÎÏÂÈÛÙÈο ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜
∞ÔÎÏÂÈÛÙÈο •¤ÓÔ Á¿Ï·
™‡ÓÔÏÔ
n (%)
n (%)
n (%)
1Ô˜
1150 *
464 (40,3)
141 (12,3)
605 (52,6)
2Ô˜
962
462 (48,0)
406 (42,2)
868 (92,2)
3Ô˜
873
184 (21,0)
524 (60,0)
708 (81,09)
6Ô˜
627
57 (9,1)
499 (79,5)
555 (88,5)
9Ô˜
462
17 (3,7)
416 (90,04)
433 (93,7)
12Ô˜
418
7 (1,7)
407 (97,4)
414 (99,1)
* H ‰È·ÊÔÚ¿ ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ˘fi ·Ú·ÎÔÏÔ‡ıËÛË Â›Ó·È Ù· ·È‰È¿ Ô˘ ‰È·ÙÚ¤ÊÔÓÙ·È ÌÈÎÙ¿ (ÌËÙÚÈÎfi+ͤÓÔ Á¿Ï·)
¶›Ó·Î·˜ 2.2. ª¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Î·È ÔÛÔÛÙ¿ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Î·È ·È‰ÈÒÓ Ì ·ÔÎÏÂÈÛÙÈο Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 1Ô˘ ¤ÙÔ˘˜ ·fi ¤Ú¢Ó˜ ¿ÏÏˆÓ ÂÚÈÔ¯ÒÓ Ù˘ ¯ÒÚ·˜. ∏ÏÈΛ· (Ì‹Ó˜)
∫Ú‹ÙË (1987-89) ∞ÔÎÏ. £ËÏ·ÛÌfi˜
¡. Œ‚ÚÔ˘ (1979-83)
¡. ∆ÚÈÎ¿ÏˆÓ (1980-81)
∞ı‹Ó· & ∂·Ú¯›· (1980)
¡›Î·È· & ∫ÔÚ˘‰·ÏÏfi˜ (1978-79)
∆¯ÓËÙ‹ ∞ÔÎÏ. ∞ÔÎÏ. ∆¯ÓËÙ‹ ∞ÔÎÏ. ∞ÔÎÏ. ¢È·ÙÚÔÊ‹ £ËÏ·ÛÌfi˜ £ËÏ·ÛÌfi˜ ¢È·ÙÚÔÊ‹ £ËÏ·ÛÌfi˜ £ËÏ·ÛÌfi˜
∆¯ÓËÙ‹ ¢È·ÙÚÔÊ‹
n (%) 10ËÌ - 1Ô˜
273 * (67,9)
129 (32,1)
384 (33,9)
422 (80,2)
39 (7,4)
448 (27,0)
25 (32,9)
37 (45.7)
2Ô˜
149 (37,1)
211 (52,5)
282 (24,9)
344 (65,4)
136 (25,9)
265 (16,0)
39 (17,2)
145 (63.8)
3Ô˜
87 (21,6)
274 (68,2)
192 (16,8)
255 (48,5)
223 (42,4)
149 (9,0)
11 (9,3)
101 (85.6)
6Ô˜
26 (6,5)
355 (88,3)
34 (6,5)
420 (79,9)
15 (2,8)
430 (81,8)
>6Ô
* ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ‚Ú¤ÊË Ô˘ ı‹Ï·Û·Ó fiÏÔ ÙÔÓ ÚÒÙÔ Ì‹Ó·
396
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·397
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
¶›Ó·Î·˜ 3. ™˘ÁÎÚ›ÛÂȘ µ¿ÚÔ˘˜, ª‹ÎÔ˘˜, ¢ª™ & ¶ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Î·È ÂÎÂ›ÓˆÓ Ô˘ ÙÚ¤ÊÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì ͤÓÔ Á¿Ï· ·fi ÙÔÓ 1Ô ¤ˆ˜ Î·È ÙÔÓ 12Ô Ì‹Ó·. ∞ÔÎÏÂÈÛÙÈο ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ∞ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï· HÏÈΛ· (Ì‹Ó˜)
n
µ¿ÚÔ˜ (ÁÚ·ÌÌ.)
ª‹ÎÔ˜ (ÂηÙ.)
¢ª™
¶ÂÚ. ∫ÂÊ·Ï‹˜ n (ÂηÙ.)
ª¤ÛÔ˜ ŸÚÔ˜ (∆˘È΋ ∞fiÎÏÈÛË)
µ¿ÚÔ˜ (ÁÚ·ÌÌ.)
ª‹ÎÔ˜ (ÂηÙ.)
ª¤ÛÔ˜ ŸÚÔ˜
¢ª™ ¶ÂÚ. ∫ÂÊ·Ï‹˜ (ÂηÙ.) (∆˘È΋ ∞fiÎÏÈÛË)
1Ô˜
464
4425 *** (562,7)
54,5 *** (2,31)
14,9 *** (1,55)
37,8 *** (2,04)
141
4084 *** (623,6)
2Ô˜
462
5299 *** (664,2)
57,7 * (2,59)
15,96 * (1,94)
39,3 * (1,29)
406
5124 *** (746,7)
57,3* (2,93)
15,63 * (1,86)
39,1 * (1,77)
3Ô˜
184
6127 * (691,9)
60,7 (2,29)
16,66 (1,71)
40,7 (1,25)
524
5987 * (776,4)
60,5 (2,69)
16,36 * (1,61)
40,4 * (1,59)
6Ô˜
57
7668 (841,6)
66,5 (2,33)
17,35 (1,76)
43,2 (1,54)
499
7751 (911,5)
67,3 (3,29)
17,21 (1,89)
43,3 (2,83)
9Ô˜
17
9036 (876,8)
71,1 (2,61)
17,78 (1,83)
45,1 (1,63)
419
8996 (1004,7)
71,9 (3,24)
17,38 (1,88)
45,6 (3,37)
12Ô˜
7
9061 * (939,5)
75,4 (2,03)
15,91 * (1,11)
46,7 (1,48)
407
9952 * (1173,1)
75,9 (3,39)
17,29 * (1,78)
46,6 (2,11)
* p – value < 0,05
** p – value < 0,01
53,6 *** 14,14 *** 37,0 *** (2,85) (1,27) (1,51)
*** p – value < 0,001
™˘˙‹ÙËÛË ∏ ÛËÌ·Û›· Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜, Ô˘ ·ÊÔÚ¿ ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, Â›Ó·È È‰È·›ÙÂÚ· ÌÂÁ¿ÏË ÁÈ·Ù› ‰›ÓÂÈ Ì ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔÓ ÙÚfiÔ ·Ó¿Ù˘Í˘ Û ·˘Ù‹Ó ÙËÓ È‰È·›ÙÂÚ· ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô Ù˘ ˙ˆ‹˜ ÙÔ˘ ·ÓıÚÒÔ˘. ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ ı· ·ÔÙÂϤÛÔ˘Ó ÛÙÔȯ›· ·Ó·ÊÔÚ¿˜ ÁÈ· Ó· ÎÚÈıÔ‡Ó ÌÂÏÏÔÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙËÓ ÔÚ›· ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·. ∆Ô ÂÚÒÙËÌ· fï˜ Â›Ó·È ·Ó ÔÈ Î·Ì‡Ï˜ ·Ó·Ù‡Í˘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ı· ÌÔÚÔ‡Û·Ó Ó· Â›Ó·È ¯Ú‹ÛÈ̘ Û ÂıÓÈÎfi ›‰Ô. ∏ ηٷÏÏËÏfiÙËÙ· ÙˆÓ ÛÙÔȯ›ˆÓ ·˘ÙÒÓ Û ÂıÓÈÎfi Â›Â‰Ô ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ‚·ıÌfi ·ÍÈÔÈÛÙ›·˜ ÙÔ˘˜. ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ÂÈϤ¯ıËΠ‰Â›ÁÌ· Ô˘ ‰ÂÓ ·ÓÙÈÚÔۈ‡ÂÈ Û ·fiÏ˘ÙÔ ‚·ıÌfi (ÁˆÁÚ·ÊÈο) Ô‡ÙÂ Î·Ó ÙÔÓ ÏËı˘ÛÌfi Ù˘ ∫Ú‹Ù˘. ∏ ÂÈÏÔÁ‹ fï˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ÌÂϤÙ˘ ¤ÁÈÓ ÛÙ· Ï·›ÛÈ· ۯ‰fiÓ Ù˘ ·ÔÁÚ·ÊÈ΋˜ ÌÂıfi‰Ô˘ Ì ÂÈÏÔÁ‹ ¤Á΢ˆÓ ÌËÙ¤ÚˆÓ Ù˘ ∫Ú‹Ù˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ, ÛÙÔ˘˜ ÙÚÂȘ ·fi ÙÔ˘˜ Ù¤ÛÛÂÚȘ ÓÔÌÔ‡˜ Ù˘ ∫Ú‹Ù˘. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ¤ÛÙˆ Î·È ÙÔ ÌÈÎÚfi ÛÙ·ıÂÚfi ‰Â›ÁÌ· ÙˆÓ 71 ·È‰ÈÒÓ Ô˘ ›¯·Ó Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 6 ÂÙÒÓ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 1200 ÂÚ›Ô˘ ·È‰ÈÒÓ, ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ ÌÔÚ› Ó· ıˆÚËı› ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ‰Â›ÁÌ· ÁÈ· fiÏË ÙËÓ ∫Ú‹ÙË.
™‡ÁÎÚÈÛË Ì ¿ÏÏË ¤Ú¢ӷ Ô˘ ÂÚÈÏ¿Ì‚·Ó ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ‰Â›ÁÌ· ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ (10) Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ (6-12 ÂÙÒÓ) ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ ‰ÂÓ ˘Ê›ÛÙ·Ù·È ‰È·ÊÔÚ¿ ÛÙÔ ‚¿ÚÔ˜ Î·È ‡„Ô˜ ‹ Ì‹ÎÔ˜ ·Ú¿ ÌfiÓÔ ÛÙÔ ¢ª™ ÙˆÓ ÎÔÚÈÙÛÈÒÓ (p<0,05) ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ·Ó¿ÛÙËÌ· ÌÂÙÚ‹ıËΠÁÈ· Ù· ·È‰È¿ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ Û ‡ÙÈ· ı¤ÛË, ÂÓÒ Ù· ·È‰È¿ Ù˘ ÚÒÙ˘ ‰ËÌÔÙÈÎÔ‡ ˆ˜ ‡„Ô˜ Û fiÚıÈ· ı¤ÛË. ™ÙÔ ÓÔÌfi Ù˘ ºÏÒÚÈÓ·˜, Û ·Ó¿ÏÔÁË ÂÚ¢ÓËÙÈ΋ ÂÚÁ·Û›· (6), ÔÈ Ì¤ÛÔÈ fiÚÔÈ ÁÈ· ‚¿ÚÔ˜, Ì‹ÎÔ˜ Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ÛÙÔ 1Ô ¤ÙÔ˜ ËÏÈΛ·˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ¿Ï˜ ·ÔÎÏ›ÛÂȘ ·fi ·˘Ù¤˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘. ∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Î·È ÙÔ ‚¿ÚÔ˜ ÛÙÔ 2Ô Î·È 12Ô Ì‹Ó· ¤¯ÂÈ Û¯Â‰fiÓ ÙÔ˘˜ ›‰ÈÔ˘˜ ̤ÛÔ˘˜ fiÚÔ˘˜ ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· ÛÙË ∫Ú‹ÙË Î·È ºÏÒÚÈÓ· (‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· 3,5 Î·È 3,3 kg ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ë Ì¤ÁÈÛÙË ‰È·ÊÔÚ¿ ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÛÙÔ 2Ô Î·È 12Ô Ì‹Ó· ÚÔÛÂÁÁ›˙ÂÈ Ù· 500 g). ∆Ô Ì‹ÎÔ˜ ÛÙÔ 2Ô Î·È 12Ô Ì‹Ó· Â›Ó·È Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚÔ ÛÙ· ·È‰È¿ Ù˘ ∫Ú‹Ù˘ (Ë ‰È·ÊÔÚ¿ ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÛÙÔ˘˜ Ì‹Ó˜ ·˘ÙÔ‡˜ Î˘Ì·›ÓÂÙ·È ·fi 0,8 ¤ˆ˜ 3,8 cm). ∏ ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Ù¤ÏÔ˜, ‚Ú›ÛÎÂÙ·È ÛÙ· ›‰È· ›‰· ÙÈÌÒÓ ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· (Ë ‰È·ÊÔÚ¿ ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÛÙÔ 2Ô Î·È 12Ô Ì‹Ó· Î˘Ì·›ÓÂÙ·È ÌfiÏȘ 0,3 ¤ˆ˜ 0,7 cm).
397
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·398
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 4. ∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ 10Ë & 90Ë µ¿ÚÔ˘˜ & ª‹ÎÔ˘˜ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ Î·È ÙˆÓ ∏¶∞ (8) ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ Î·È ÙÔ 6Ô ¤ÙÔ˜. ¶·È‰È¿ ∫Ú‹Ù˘ (1988-95) ∏ÏÈΛ·
∞ÁfiÚÈ· µ¿ÚÔ˜ (ÎÈÏ¿) – ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
¶·È‰È¿ ∏¶∞ (1966-74)
∫ÔÚ›ÙÛÈ· µ¿ÚÔ˜ (ÎÈÏ¿) – ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
∞ÁfiÚÈ· µ¿ÚÔ˜ (ÎÈÏ¿) – ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
∫ÔÚ›ÙÛÈ· µ¿ÚÔ˜ (ÎÈÏ¿) – ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
10%
90%
10%
90%
10%
90%
10%
90%
°¤ÓÓËÛË
2,8 -
4,1 -
2,7 -
3,84 -
2,86 -
4,13 -
2,81 -
3,9 -
1Ô˜ Ì‹Ó·˜
3,6 51,5
5,2 58
3,4 50,5
4,76 56,2
3,8 50,4
5,2 55,5
3,3 50,4
5,0 55,0
6Ô˜ Ì‹Ó·˜
6,9 64,5
9,1 71,5
6,4 63,0
8,6 70,0
6,7 63,9
8,7 69,3
6,4 62,5
8,4 67,8
1Ô ¤ÙÔ˜
8,9 72,6
11,6 81,0
8,2 71,3
11,0 79,2
8,9 72,4
11,5 78,1
8,4 70,6
11,2 77,1
2Ô ¤ÙÔ˜
11,3 86,0
15,3 93,1
10,8 84,5
14,9 93,0
11,2 84,2
14,5 91,1
10,7 82,0
14,4 91,0
3Ô ¤ÙÔ˜
13,5 94,8
19,5 104,8
12,4 93
18,0 105,0
13,0 92,3
16,69 100,5
12,52 90,5
16,9 101,1
4Ô ¤ÙÔ˜
15 102
21,5 113
14,3 100
20,7 112
14,6 99,3
18,8 108,5
14,2 97,6
19,7 109,6
5Ô ¤ÙÔ˜
17 109
26,5 118
15,7 106
23,5 119,1
16,1 103,7
21,2 114,7
15,8 110,6
22,3 115,4
6Ô ¤ÙÔ˜
17,9 114
30,2 126
17 112,2
28,2 126
18,5 111,2
25,6 123,5
17,9 110,6
24,6 122,3
∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ·fi ·Ó¿ÏÔÁË ¤Ú¢ӷ ·È‰ÈÒÓ Ù˘ ∞ı‹Ó·˜ (4) ÛÙËÓ ‰ÂηÂÙ›· ÙÔ˘ 1980 ÔÈ 10Ë, 50Ë Î·È 90Ë ∂.£. ‹Ù·Ó 2,9, 3,5 Î·È 4,0 kg ÁÈ· ·ÁfiÚÈ· ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÁÈ· ÎÔÚ›ÙÛÈ· 2,8, 3,3 Î·È 3,9 kg ·ÓÙ›ÛÙÔȯ·. ¢ÂÓ ˘¿Ú¯ÂÈ ·ÍÈÔÛËÌ›ˆÙË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Î·È ÛÙ· ‰‡Ô ʇϷ. ∆Ô ‚¿ÚÔ˜ Î·È ÙÔ ‡„Ô˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚԤ΢„·Ó ·fi Ù· ∂ıÓÈο ¶ÚfiÙ˘· ∞Ó¿Ù˘Í˘ (∂¶∞) (12) Û ·ÓÂÏÏ·‰ÈÎfi ‰Â›ÁÌ· ·È‰ÈÒÓ ËÏÈΛ·˜ 6 ¤ˆ˜ 18 ÂÙÒÓ ÙÔ 1981 (27000 ·È‰È¿), ¤‰ÂÈÍ fiÙÈ Ë 50Ë ∂.£. ÁÈ· Ù· ·È‰È¿ ËÏÈΛ·˜ 6 ÂÙÒÓ Ù· ·ÁfiÚÈ· ›¯·Ó ‚¿ÚÔ˜ 22,0 kg Î·È Ù· ÎÔÚ›ÙÛÈ· 21,5 kg ÂÓÒ ÛÙ· ·È‰È¿ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ ‹Ù·Ó 21,5 kg Î·È ÛÙ· ‰‡Ô ʇϷ. ∏ 50Ë ∂.£. ÙˆÓ ·ÁÔÚÈÒÓ ÙˆÓ ∂¶∞ ¤¯ÂÈ ‡„Ô˜ 117,0 cm ÂÓÒ Ù· ÎÔÚ›ÙÛÈ· 116,5 cm. ∆Ô Ì‹ÎÔ˜ ÙˆÓ ·ÁÔÚÈÒÓ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ Â›Ó·È 119,5 cm Î·È ÙˆÓ ÎÔÚÈÙÛÈÒÓ 120,0 cm, ‰È·ÊÔÚ¤˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÂÓ Ì¤ÚÂÈ ÛÙÔÓ ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ Ì¤ÙÚËÛ˘ Î·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô.
398
º·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÌÈ· Û˘Ó¯‹˜ ·‡ÍËÛË ÙÔ˘ ‡„Ô˘˜ ÙˆÓ ∂ÏÏ‹ÓˆÓ fiˆ˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó ·fi ÙÔ 1920 Î·È 1928 ·fi ÙÔ˘˜ §·Ì·‰¿ÚÈÔ Î·È ∂Í·Ú¯fiÔ˘ÏÔ (1). ∏ ̤ÛË ·‡ÍËÛË ÙÔ˘ Ì‹ÎÔ˘˜ ÙˆÓ ·È‰ÈÒÓ ·fi ÙÔ 1920 ̤¯ÚÈ ÙÔ 1995 ˘ÔÏÔÁ›ÛÙËΠ۠9 cm ÁÈ· Ù· ·ÁfiÚÈ· Î·È 7 cm ÁÈ· Ù· ÎÔÚ›ÙÛÈ·. ™ÙÔÓ ¶›Ó·Î· 5 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ Ì¤Û˜ ÙÈ̤˜ Î·È ÔÈ Ù˘ÈΤ˜ ·ÔÎÏ›ÛÂȘ ÙÔ˘ ‚¿ÚÔ˘˜ (̤ÙÚËÛË 1984) ÁÈ· ·È‰È¿ Ù˘ £ÂÛÛ·ÏÔӛ΢ (14) Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ ÙÔ˘ ¶ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ ÁÈ· ÙȘ ËÏÈ˘ ÙˆÓ 2-6 ¯ÚÔÓÒÓ. ∆Ô ‚¿ÚÔ˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ Â›Ó·È Û¯ÂÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÂΛÓÔ ÙˆÓ ·È‰ÈÒÓ Ù˘ £ÂÛÛ·ÏÔӛ΢. ªÂÙÚ‹ÛÂȘ ÙÔ˘ ‚¿ÚÔ˘˜, ‡„Ô˘˜ Î·È ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ·È‰ÈÒÓ Ù˘ ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜ (11) ËÏÈΛ·˜ 3-6 ÂÙÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6 fiÔ˘ fï˜, ÙÔ ‡„Ô˜ ÌÂÙÚ‹ıËΠ›Û˘ Û fiÚıÈ· ı¤ÛË. ∆· ·È‰È¿ Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó Ï›ÁÔ ÌÈÎÚfiÙÂÚ˜ ÙÈ̤˜ ÁÈ· ‚¿ÚÔ˜ ηÈ
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·399
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
¶›Ó·Î·˜ 5. ™‡ÁÎÚÈÛË ‚¿ÚÔ˘˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 24-72 ÌËÓÒÓ (2-6 ÂÙÒÓ) ¶ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ Ì ·È‰È¿ Ù˘ fiÏ˘ Ù˘ £ÂÛÛ·ÏÔӛ΢ (10). ¶·È‰È¿ fiÏ˘ Ù˘ £ÂÛÛ·ÏÔӛ΢ ¶·È‰È¿ ¶ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ ∞ÁfiÚÈ· ∏ÏÈΛ· (Ì‹Ó˜)
∫ÔÚ›ÙÛÈ·
∞ÁfiÚÈ·
ª¤ÛÔ˜ fiÚÔ˜ (∆˘È΋ ·fiÎÏÈÛË)
∫ÔÚ›ÙÛÈ·
ª¤ÛÔ˜ fiÚÔ˜ (∆˘È΋ ·fiÎÏÈÛË)
24
12,9 (1,67)
11,9 (1,95)
13,1 (1,57)
12,8 (1,6)
30
13,8 (1,94)
13,5 (1,37)
14,4 (1,69)
14,1 (1,95)
36
14,9 (1,94)
14.8 (2,1)
15,7 (2,19)
15,3 (2,53)
42
16,2 (1,88)
16 (1,79)
16,7 (2,5)
16,2 (2,24)
48
16,7 (2,37)
16,7 (2,4)
17,9 (2,9)
17,3 (2,59)
54
17,9 (2,99)
18 (2,41)
19 (3,29)
18,5 (2,92)
60
19 (2,63)
18,9 (2,69)
20 (3,43)
19,5 (3,07)
66
21,6 (2,91)
20 (3,16)
21 (3,91)
21,1 (3,76)
72
22,4 (2,9)
22,1 (3,07)
22,8 (4,85)
22,2 (4,01)
¶›Ó·Î·˜ 6. ™‡ÁÎÚÈÛË µ¿ÚÔ˘˜, ⁄„Ô˘˜ (Ì‹ÎÔ˘˜) Î·È ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 3-6 ÂÙÒÓ ¶ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘ Î·È ·È‰ÈÒÓ ÂÚÈÔ¯‹˜ Ù˘ ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜ (11). ¶·È‰È¿ ¶ÂÚÈÔ¯‹˜ ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜
¶·È‰È¿ ¶ÂÚÈÁÂÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘
∞ÁfiÚÈ·
∫ÔÚ›ÙÛÈ·
∞ÁfiÚÈ·
∏ÏÈΛ·
µ¿ÚÔ˜
⁄„Ô˜ *
¶ÂÚ›ÌÂÙÚÔ˜ ∫ÂÊ·Ï‹˜
µ¿ÚÔ˜
⁄„Ô˜ *
¶ÂÚ›ÌÂÙÚÔ˜ ∫ÂÊ·Ï‹˜
µ¿ÚÔ˜
(¤ÙË)
(kg)
(cm)
(cm)
(kg)
(cm)
(cm)
(kg)
ª‹ÎÔ˜ ¶ÂÚ›ÌÂÙÚÔ˜ µ¿ÚÔ˜ ª‹ÎÔ˜ ¶ÂÚ›ÌÂÙÚÔ˜ * ∫ÂÊ·Ï‹˜ * ∫ÂÊ·Ï‹˜ (cm)
ª¤ÛÔ˜ ŸÚÔ˜ 3 4 5 6
16,1 18,1 20,5 23,5
101 108 114 122
50,5 51,2 51,3 52
16 17,9 20,3 23
∫ÔÚ›ÙÛÈ·
(cm)
(kg) (cm)
(cm)
ª¤ÛÔ˜ ŸÚÔ˜ 99,6 106 113 119
49,5 50,4 50,8 51,3
15,7 17,9 20 22,8
99,4 106,8 113,5 120,3
50,4 51,4 52 52,5
15,3 98,2 17,3 105,5 19,5 113 22,2 119,3
49,7 50,5 51,1 51,7
* ∏ ̤ÙÚËÛË ÙÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ¤ÁÈÓ Ì ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ
399
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·400
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
‡„Ô˜ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ ÙȘ ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜ ÂÎÙfi˜ Ù˘ ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ Ô˘ ‚Ú¤ıËÎ·Ó Û¯Â‰fiÓ Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚ˜. ∆· ·È‰È¿ Ù˘ ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚ˜ ÙÈ̤˜ ‚¿ÚÔ˘˜ Î·È Ì‹ÎÔ˘˜ ·ÎfiÌË Î·È Û ۇÁÎÚÈÛË Ì ٷ ∂¶∞ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ‰‡Ô ÌÂϤÙ˜ ¤ÁÈÓ·Ó Ì ‰È·ÊÔÚ¿ Ï›ÁˆÓ ÂÙÒÓ (∂¶∞ ÙÔ 1981, ªÂϤÙË ∫ÂÓÙÚÈ΋˜ ª·Î‰ÔÓ›·˜ ÙÔ 1988). ∞fi ·ÚfiÌÔÈ·˜ ÌÔÚÊ‹˜ ÌÂϤÙË ÙÔ˘ ∞˚‚¿˙Ë (2) ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ fiÏ˘ Ù˘ £ÂÛÛ·ÏÔӛ΢, ÛÙÔ ÚÒÙÔ ‰Â›ÁÌ· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·È‰È¿ ·fi 0 ¤ˆ˜ 30 ÌËÓÒÓ, ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ù· ·ÁfiÚÈ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ ‚¿ÚÔ˜ ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔÓ 3Ô Ì‹Ó· Û ۯ¤ÛË Ì ٷ ·ÁfiÚÈ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÌÂÁ·Ï‡ÙÂÚÔ ·fi 6 ¤ˆ˜ 24 ÌËÓÒÓ Î·È ÌÈÎÚfiÙÂÚÔ ¿Óˆ ÙˆÓ 30 ÌËÓÒÓ. ∞ÓÙ›ıÂÙ·, Ù· ÎÔÚ›ÙÛÈ· Ù˘ ·ÚÔ‡Û·˜ ¤Ú¢ӷ˜ ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ ‚¿ÚÔ˜ ·fi ÙÔÓ 1Ô ¤ˆ˜ Î·È ÙÔÓ 24Ô Ì‹Ó· Î·È ÌÂÁ·Ï‡ÙÂÚÔ ¿Óˆ ÙÔ˘ 24Ô˘. ™ÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ˜ ÙÈ̤˜ Ù· ·È‰È¿ Ù˘ ∫Ú‹Ù˘ Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ Û˘ÁÎÚÈÓfiÌÂÓ˘ ËÏÈΛ·˜. O ¢ª™ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙȘ ËÏÈ˘ ÙÔ˘ 1Ô˘ Ì 18Ô˘ Ì‹Ó· Î·È ÌÈÎÚfiÙÂÚÔ˜ ¿Óˆ ÙÔ˘ 24Ô˘. ∆ÔÓ›˙ÂÙ·È ¿ÓÙˆ˜ ÁÈ· ÙȘ ·Ú·¿Óˆ Û˘ÁÎÚ›ÛÂȘ fiÙÈ Ë ÂÚÁ·Û›· ÙÔ˘ ∞˚‚¿˙Ë ÂÚÈÏ·Ì‚¿ÓÂÈ ·È‰È¿ Ô˘ ‰È·Ì¤ÓÔ˘Ó Ì ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜ Û ·ÛÙÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙÔ ‰Â›ÁÌ· ·È‰È¿ ·fi ·ÁÚÔÙÈΤ˜ Î·È ËÌÈ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ∂Ô̤ӈ˜, ÌÔÚԇ̠ӷ Û˘ÌÂÚ¿ÓÔ˘Ì fiÙÈ Ë ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ·fi ÙË ÚÔÛ¯ÔÏÈ΋ ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ· ·ÎÔÏÔ˘ı› ·ÚfiÌÔÈ· ÔÚ›· ·Ó¿Ù˘Í˘ ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜. ∆Ô ‚¿ÚÔ˜ ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ÛÙË Á¤ÓÓËÛË ÌÔÚ› Ó· Û˘ÁÎÚÈı› Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ÙˆÓ ∏¶∞ - ‰ÂηÂÙ›· 1970 (5). ∏ 10Ë, 50Ë Î·È 90Ë ∂.£. ÙˆÓ ·ÁÔÚÈÒÓ Ù˘ ∫Ú‹Ù˘ Â›Ó·È 2,8, 3,5 Î·È 4,1 kg ·ÓÙ›ÛÙÔȯ· ÂÓÒ ÙˆÓ ∏¶∞ 2,5, 3,3 Î·È 4,1 kg. °È· Ù· ÎÔÚ›ÙÛÈ· Ù˘ ∫Ú‹Ù˘ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÛÙË 10Ë, 50Ë Î·È 90Ë ∂.£. ·ÓÙ›ÛÙÔȯ· Â›Ó·È 2,7, 3,3 Î·È 3,8 kg Î·È ÙˆÓ ∏¶∞ 2,4, 3,2 Î·È 3,8 kg. °ÂÓÈο, ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ‚Ú›ÛÎÂÙ·È Û ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚË ı¤ÛË. ∆ÔÓ 1Ô, 2Ô Î·È 3Ô ¯ÚfiÓÔ Ë 50Ë ∂.£. ‚¿ÚÔ˘˜ ÙˆÓ ·ÁÔÚÈÒÓ Ù˘ ∫Ú‹Ù˘ Â›Ó·È 10,2, 12,9 Î·È 15 kgr ÂÓÒ ÙˆÓ ∏¶∞ 10,1, 12,6 Î·È 14,7 kg Î·È ÛÙ· ÎÔÚ›ÙÛÈ· Ù˘ ∫Ú‹Ù˘ Â›Ó·È 9,7, 12,8 Î·È 15 kg ÂÓÒ Û ·˘Ù¿ ÙˆÓ ∏¶∞ Â›Ó·È 9,5, 11,9 Î·È 13,9 kg ·ÓÙ›ÛÙÔȯ·. ™ÙÔ Ì‹ÎÔ˜ Î·È ÛÙËÓ ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ‰ÂÓ ¤¯Ô˘Ó Ô˘ÛÈÒ‰ÂȘ ‰È·ÊÔÚ¤˜. ∞fi ÌÂϤÙË ¿ÏÈ ÙˆÓ ∏¶∞ ÙÔ 1968-70 (8) Ë 10Ë & 90Ë ∂.£. ÁÈ· ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙÔ 6Ô ¤ÙÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∞ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· ÙˆÓ ∏¶∞ ηٿ ÙË Á¤ÓÓËÛË Â›¯·Ó
400
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¯·ÌËÏfiÙÂÚÔ ‚¿ÚÔ˜ ηıÒ˜ ›Û˘ Î·È ÛÙËÓ ËÏÈΛ· ÙÔ˘ 2Ô˘ Î·È 3Ô˘ ¯ÚfiÓÔ˘ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ Ù˘ ∫Ú‹Ù˘. ∞ÓÙ›ıÂÙ·, ÙÔ Ì‹ÎÔ˜ Î·È ÛÙ· ‰‡Ô ʇϷ ÛÙȘ ∏¶∞ ¤¯ÂÈ ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÛÙȘ 10Ë Î·È 90Ë ∂.£. ηıfiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Û ۇÁÎÚÈÛË Ì· Ù· ·È‰È¿ Ù˘ ∫Ú‹Ù˘. ¶ÚfiÛÊ·Ù˜ ÌÂÙÚ‹ÛÂȘ ¢ª™ ÛÙȘ ∏¶∞ (13) ‰Â›¯ÓÔ˘Ó fiÙÈ ·È‰È¿ η˘Î¿ÛÈ·˜ Ê˘Ï‹˜ ¤¯Ô˘Ó Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚÔ ¢ª™ ÛÙȘ ËÏÈ˘ ÙˆÓ 5 Î·È 6 ÂÙÒÓ ·fi ·È‰È¿ ÙÔ˘ ÂÚÈÁÂÓÓËÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∫Ú‹Ù˘. ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ¢ª™ ÛÙȘ ËÏÈ˘ 5 Î·È 6 ¯ÚÔÓÒÓ ÙˆÓ ·ÁÔÚÈÒÓ ÙˆÓ ∏¶∞ ·Ó¤Ú¯ÂÙ·È Û 15,8 Î·È 16 ·ÓÙ›ÛÙÔȯ· Î·È ÙˆÓ ÎÔÚÈÙÛÈÒÓ 15,6 Î·È 15,9 kg/m2. ∆· ·ÁfiÚÈ· Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó ̤ÛË ÙÈÌ‹ ¢ª™ ÛÙ· 5 Î·È 6 ¯ÚfiÓÈ· 15,5 Î·È 15,6 ·ÓÙ›ÛÙÔȯ· ÂÓÒ Ù· ÎÔÚ›ÙÛÈ· 15,2 Î·È 15,5 kg/m2 . Ÿˆ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› Î·È ·fi ¿ÏϘ ÌÂϤÙ˜ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Â˘ÓÔ˚΋ ›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ (22,23). ™ÙË ·ÚÔ‡Û· ÌÂϤÙË ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÔÓԉȿÛٷٷ Ë ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Ë ÔÔ›· ‰Â›¯ÓÂÈ fiÙÈ Ù· ·È‰È¿ Ô˘ ıËÏ¿˙Ô˘Ó ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ ‚¿ÚÔ˜ ·'·˘Ù¿ Ô˘ ·›ÚÓÔ˘Ó ·ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï· ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ‚ÚÂÊÈ΋˜ ÂÚÈfi‰Ô˘, ÂÓÒ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ ÙÔ ‚¿ÚÔ˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‹Ú·Ó ͤÓÔ Á¿Ï· ˘ÂÚ¤¯ÂÈ ÛËÌ·ÓÙÈο. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Èı·ÓfiÓ Ó· ¤¯ÂÈ ÌÂÏÏÔÓÙÈΤ˜ ÂÈÙÒÛÂȘ Î·È Ó· Úԉȷı¤ÙÂÈ Û ·¯˘Û·ÚΛ· ηٿ ÙËÓ ÂÊË‚È΋ Î·È ÂÓ‹ÏÈÎÔ ˙ˆ‹. ¶·Ú¿ÏÏËÏ·, ÔÈ ÌËÙ¤Ú˜ Ô˘ ıËÏ¿˙Ô˘Ó ·ÔÎÏÂÈÛÙÈο Û ۯ¤ÛË Ì ÂΛӘ Ô˘ ÙÚ¤ÊÔ˘Ó Ù· ·È‰È¿ ÙÔ˘˜ Ì ·ÔÎÏÂÈÛÙÈο ͤÓÔ Á¿Ï· ÂȂ‚·ÈÒÓÂÙ·È fiÙÈ ˘ÂÚ¤¯Ô˘Ó ÛÙËÓ Â·Ú¯›· (19) ¤Ó·ÓÙÈ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÛÙÈÎÒÓ fiÏÂˆÓ Î·È fi¯È ÌfiÓÔ ·ÚÈıÌËÙÈο ·ÏÏ¿ Î·È Û ‰È¿ÚÎÂÈ· ıËÏ·ÛÌÔ‡. ¶·Ú¿ ÙȘ ·‰˘Ó·Ì›Â˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÈÛÙ‡ÂÙ·È fiÙÈ ÚԤ΢„·Ó ·ÍÈfiÏÔÁ· ‰Â‰Ô̤ӷ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ·fi ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Ù˘ ¯ÒÚ·˜ Î·È ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ ÛÙÔ ‚È‚ÏÈ¿ÚÈÔ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ. OÈ Î·Ì‡Ï˜ ·Ó¿Ù˘Í˘ ÛÙÔ ‚È‚ÏÈ¿ÚÈÔ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ (‰ÂÓ ·Ó·ÁÚ¿ÊÂÙ·È ËÁ‹), ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, ‰ÂÓ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ∂¶∞ ÙÔ˘ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ÁÈ·Ù› Ë ÌÂϤÙË ·˘Ù‹ ÂÚÈÏ¿Ì‚·Ó ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ (12). ∂›Û˘, Ù· ‰Â‰Ô̤ӷ ·˘Ù¿ ı· ·ÔÙÂϤÛÔ˘Ó ËÁ‹ ·Ó·ÊÔÚ¿˜ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ ·È‰ÈÒÓ fiˆ˜ ÌÔÚԇ̠ӷ οÓÔ˘Ì ۋÌÂÚ· Ì ٷ ÛÙÔȯ›· ÙˆÓ §·Ì·‰¿ÚÈÔ˘ Î·È ∂Í·Ú¯fiÔ˘ÏÔ˘ Ô˘ Û˘ÏϤÁËÛ·Ó ÙÔ 1920 Î·È 1926. ∆· ÛÙÔȯ›· ·˘Ù¿ Â›Ó·È È‰È·ÈÙ¤Úˆ˜ ÌÂÁ¿Ï˘ ÛËÌ·Û›·˜ ‰Â‰Ô̤Ó˘ Ù˘ Ù¿Û˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ ÙˆÓ ÔÛÔÛÙÒÓ ·¯˘Û·ÚΛ·˜ Î·È ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ Î·Ù¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙË ¯ÒÚ· Ì·˜.
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·401
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
µ¿ÚÔ˜ (ÎÈÏ¿)
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∏ÏÈΛ· (Ì‹Ó˜)
™¯‹Ì· 1. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ µ¿ÚÔ˘˜ Û 45 - 588 ∞ÁfiÚÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
401
30-05-03
14:03
™ÂÏ›‰·402
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
SEPT-OCT.2000
∏ÏÈΛ· (Ì‹Ó˜)
™¯‹Ì· 2. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ª‹ÎÔ˘˜ Û 45 - 588 ∞ÁfiÚÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
402
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·403
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
¢ª™
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
™¯‹Ì· 3. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ¢Â›ÎÙË ª¿˙·˜ ™ÒÌ·ÙÔ˜ Û 45 - 588 ∞ÁfiÚÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
¶ÂÚ›ÌÂÙÚÔ˜ ∫ÂÊ·Ï‹˜ (ÂηÙÔÛÙ¿)
∏ÏÈΛ· (Ì‹Ó˜)
™¯‹Ì· 4. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ¶ÂÚÈ̤ÙÚÔ˘ ∫ÂÊ·Ï‹˜ Û 45 - 588 ∞ÁfiÚÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
∏ÏÈΛ· (Ì‹Ó˜)
403
30-05-03
14:03
™ÂÏ›‰·404
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
µ¿ÚÔ˜ (ÎÈÏ¿)
SEPT-OCT.2000
∏ÏÈΛ· (Ì‹Ó˜)
404
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·405
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
ª‹ÎÔ˜ (ÂηÙÔÛÙ¿)
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∏ÏÈΛ· (Ì‹Ó˜)
™¯‹Ì· 6. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ª‹ÎÔ˘˜ Û 42 - 555 ∫ÔÚ›ÙÛÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
405
30-05-03
14:03
™ÂÏ›‰·406
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
ª. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¢ª™
™¯‹Ì· 7. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ¢Â›ÎÙË ª¿˙·˜ ™ÒÌ·ÙÔ˜ Û 42 - 555 ÎÔÚ›ÙÛÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
∏ÏÈΛ· (Ì‹Ó˜)
¶ÂÚ›ÌÂÙÚÔ˜ ∫ÂÊ·Ï‹˜ (ÂηÙÔÛÙ¿)
SEPT-OCT.2000
™¯‹Ì· 8. ∂ηÙÔÛÙÈ·›Â˜ η̇Ϙ ¶ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ Û 42 - 555 ∫ÔÚ›ÙÛÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓÔ Ì¤ÁÂıÔ˜ ‰Â›ÁÌ·ÙÔ˜ Û οı ËÏÈΛ· (Û˘Ó‰˘·ÛÌfi˜ ‰È·¯ÚÔÓÈ΋˜ ̤ÙÚËÛ˘ & ÌÂÙÚ‹ÛÂˆÓ ÙÔÌ‹˜).
406
∏ÏÈΛ· (Ì‹Ó˜)
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·407
¶∞π¢π∞∆ƒπ∫∏ 2000;63:391-407
∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-07-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÒÓ˘ ∫·Ê¿ÙÔ˜, MD ¢È·ÛÙ·‡ÚˆÛË µÔ‡Ù˜ - ™Ù·˘Ú¿ÎÈ·, ∆.£. 1393, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ e-mail: kafatos@med.uoc.gr
407
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·408
¶∞π¢π∞∆ƒπ∫∏ 2000;63:408-411
™›ÙÈÛË ÓÂÔÁÓÒÓ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ ∞ÓÙÒÓ˘ °Ô‡Ó·Ú˘, ¡›ÎË ∞ÏÂ͛Ԣ, ÃÚ‡Û· ¶ÂÙÚÔÔ‡ÏÔ˘, ∂˘·ÁÁÂÏ›· ∫ˆÓÛÙ·ÓÙ¤ÏÏÔ˘, ÃÚ‹ÛÙÔ˜ ∫ÒÛÙ·ÏÔ˜ ● ¶ÂÚ›ÏË„Ë: ∏ ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· (¶∞) ÂËÚ¿˙ÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÙÈÎÔ‡. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ ‹Ù·Ó Ó· ÂÍÂÙ¿ÛÔ˘Ì ·Ó Û˘Óԉ‡ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÛÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ Î·È Û˘Á¯ÚfiÓˆ˜ ÙÔÓ ÙÚfiÔ Û›ÙÈÛ˘ ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ. °È· ÙÔÓ ÛÎÔfi ·˘Ùfi Ù· ›‰· 4 ÔÚÌÔÓÒÓ ÙÔ˘ ÂÙÈÎÔ‡ ÌÂÙÚ‹ıËÎ·Ó Û 16 ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ̤ÙÚÈ· ‹ ÛÔ‚·Ú‹ ¶∞ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ·Ó¿ÓË„Ë (ÔÌ¿‰· ∞). ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 16 ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ¯ˆÚ›˜ ¶∞ (ÔÌ¿‰· µ). ∆· ›‰· ÔÚÌÔÓÒÓ ÌÂÙÚ‹ıËÎ·Ó Û fiÏ· Ù· ÓÂÔÁÓ¿ Û 3 ÂÚÈÙÒÛÂȘ: 1) ÛÙȘ ÚÒÙ˜ 6 ÒÚ˜ ˙ˆ‹˜, 2) 24 ÒÚ˜ ÌÂÙ¿ ÂÓÒ ‹Ù·Ó ·ÎfiÌË ÓËÛÙÈο, 3) fiÙ·Ó ÛÈÙ›˙ÔÓÙ·Ó ÌfiÓÔ Ì Á¿Ï·. ™Ù· ÓÂÔÁÓ¿ Ì ¶∞ Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË ¿Ú¯È˙ ÌÂÙ¿ ÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Î·È Ë ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË ÁÈÓfiÙ·Ó Ì ‚¿ÛË ÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ÎÏÈÓÈ΋˜. ∆Ô ÂÙÈÎfi Û‡ÛÙËÌ· ‚ÚÈÛÎfiÙ·Ó Û ÛÙÂÓ‹ ÎÏÈÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ. ∆· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó: 1) Ù· ›‰· ÌÔÙÈÏ›Ó˘ ÛÙËÓ ÔÌ¿‰· ∞ ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙȘ ‰‡Ô ÚÒÙ˜ ÌÂÙÚ‹ÛÂȘ (ƒ<0,05 Î·È P<0,01 ·ÓÙ›ÛÙÔȯ·). 2) Ù· ›‰· ÙÔ˘ ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÔ‡ ÂÓÙÂÚÈÎÔ‡ ÂÙȉ›Ô˘ (VIP) ÛÙËÓ ÚÒÙË Ì¤ÙÚËÛË ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ¯·ÌËÏfiÙÂÚ· ÛÙËÓ ÔÌ¿‰· ∞ (ƒ<0,05). 3) ‰ÂÓ ˘‹ÚÍ ÛÙ·ÙÈÛÙÈ΋ ‰È·ÊÔÚ¿ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÁÈ· ÙË Á·ÛÙÚ›ÓË Î·È Ó¢ÚÔÙÂÓÛ›ÓË Î·È ÛÙȘ 3 ÌÂÙÚ‹ÛÂȘ. 4) T· ÓÂÔÁÓ¿ Ì ¶∞ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÂÈÏÔΤ˜ ·fi ÙÔ ÂÙÈÎfi Ì ÙÔÓ ÙÚfiÔ Û›ÙÈÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ë ¶∞ ÚÔηÏ› ·ÏÏ·Á¤˜ ÛÙ· ›‰· ÌÔÙÈÏ›Ó˘ Î·È VIP ÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Î·È ·˘Ùfi ÌÔÚ› Ó· Â›Ó·È ÌÈ· ·fi ÙȘ Èı·Ó¤˜ ·Èٛ˜ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÂÙÈÎÔ‡. ∏ ÚÔÛÂÎÙÈ΋ Û›ÙÈÛË ·fi ÙÔ ÛÙfiÌ· ÌÂÙ¿ ÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Â›Ó·È ·Ó·Áη›· Î·È ·ÛÊ·Ï‹˜ Û ·˘Ù¿ Ù· ÓÂÔÁÓ¿. ¶·È‰È·ÙÚÈ΋ 2000;63:408-411. §¤ÍÂȘ ÎÏÂȉȿ: ÔÚÌfiÓ˜ ÂÙÈÎÔ‡, Û›ÙÈÛË ÓÂÔÁÓÒÓ, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·. A. Gounaris, N. Alexiou, C. Petropoulou, E. Constantellou, C. Costalos. Feeding of neonates with perinatal asphyxia and disturbances of gut hormone levels. Paediatriki 2000;63:408-411. ● Abstract: Perinatal asphyxia (PA), by causing hypoxia and reduced perfusion of the neonatal gastrointestinal system, may affect intestinal function. The aim of our study was to examine whether functional disturbances which occur in cases of PA are due to changes in the blood levels of gut hormones. For this purpose 4 gut hormone levels were measured in 16 fullterm infants with moderate or severe birth asphyxia who required resuscitation (group A). Control group (group B) consisted of 16 healthy fullterm infants without birth asphyxia. Gut hormone levels were measured on three occasions: 1) in the first six hours of life; 2) 24 hours after birth while infants were fasting; 3) after full enteral feedings were established. Oral feeding was started in infants with perinatal asphyxia after the first day of life with gradual increase according to our Unit’ s protocol. Symptoms of the Gastrointestinal system were carefully monitored. The results of our study showed. 1) Motiline blood levels in neonates with PA were significantly higher on the first and second measurement (P<0.05 and P<0.01 respectively). 2) VIP levels on the first measurement were statistically lower in group A (P<0.05). 3) There was no statistical difference between the two groups for gastrin and neurotensin levels in all three measurements. 4) Neonates with PA did not demonstrate any serious complications from the gastrointestinal system. To conclude, it seems that PA affects the blood levels of motiline and VIP on the first day of life and this may be one of the possible reasons for gut
ª∂¡ ¡ÂÔÁÓÒÓ Î·È EÚÁ·ÛÙ‹ÚÈÔ EÓ‰ÔÎÚÈÓÔÏÔÁ›·˜ ¶°¡ ¡Èη›·˜
408
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·409
¶∞π¢π∞∆ƒπ∫∏ 2000;63:408-411
™›ÙÈÛË ÓÂÔÁÓÒÓ Î·È ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·
functional disturbances. Therefore careful progression of enteral feeding, after the first day of life is necessary and safe for these neonates. Key words: gut hormones, feeding, perinatal asphyxia.
∂ÈÛ·ÁˆÁ‹ ∏ ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ÏfiÁˆ Ù˘ ÈÛ¯·ÈÌ›·˜ ÙËÓ ÔÔ›· ÚÔηÏ›, ÂËÚ¿˙ÂÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·fi Ù· Û˘ÛÙ‹Ì·Ù· ÂÓfi˜ ÓÂÔÁÓÔ‡. π‰È·›ÙÂÚ· Ù· ÏÂÁfiÌÂÓ· ÌË Â˘ÁÂÓ‹ Û˘ÛÙ‹Ì·Ù· ÛÙ· ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ô Á·ÛÙÚÂÓÙÂÚÈÎfi˜ ۈϋӷ˜. ™˘Ó‹ıˆ˜, Ë Â›‰Ú·ÛË Û ·˘ÙfiÓ Â›Ó·È ‹È·, ·ÏÏ¿ fiÙ·Ó Ë ÈÛ¯·ÈÌ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Û˘Ó‰˘·ÛÙ› Ì ¯ÔÚ‹ÁËÛË Á¿Ï·ÙÔ˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÂÈÏÔΤ˜ fiˆ˜ ¤ÌÂÙÔÈ Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, ·ÎfiÌË Î·È ¡∂∫ (1). ∆Ô ÂÌ‚Ú˘˚Îfi stress ÂËÚ¿˙ÂÈ ÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ (2,3). ∂›Û˘, Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ‚Ú¤ıËÎ·Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÙÈÎÔ‡ (4). ∆· ·Ú·¿Óˆ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÚÔ‚ÏËÌ·ÙÈÛÌfi ÁÈ· ÙÔ Ò˜ ı· Ú¤ÂÈ Ó· ÛÈÙÈÛÙ› ¤Ó· ÓÂÔÁÓfi Ô˘ ·ÚÔ˘Û›·Û ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·. ™ÎÔfi˜ Ù˘ ¤Ú¢ӷ˜ ·˘Ù‹˜ ‹Ù·Ó ÚÒÙÔÓ, Ó· ÂÍÂÙ¿ÛÔ˘Ì ·Ó Ë ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ÂËÚ¿˙ÂÈ ÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡, ‰Â‡ÙÂÚÔÓ, ·Ó Ë ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ÂȉÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ Û›ÙÈÛ˘ ı· ÂÏ·¯ÈÛÙÔÔÈ‹ÛÂÈ ÙȘ ÂÈÏÔΤ˜ Î·È ı· Â›Ó·È ·ÛʷϤ˜. ª¤ıÔ‰ÔÈ ∆Ô ˘ÏÈÎfi ·ÔÙ¤ÏÂÛ·Ó 16 ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ô˘ ›¯·Ó ·ÚÔ˘ÛÈ¿ÛÂÈ ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· Î·È ¯ÚÂÈ¿ÛÙËÎ·Ó ·Ó¿ÓË„Ë (ÔÌ¿‰· ∞). ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 16 ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ô˘ ‰ÂÓ Â›¯·Ó ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, ‰ÂÓ ¯ÚÂÈ¿ÛÙËÎ·Ó ·Ó¿ÓË„Ë Î·È ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ·Ú¯Èο ÚÔ‚Ï‹Ì·Ù· Ô˘ Ó· ·ÊÔÚÔ‡Ó ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· (ÔÌ¿‰· µ). ™ÙËÓ ÔÌ¿‰· ∞ Ë ‚·ıÌÔÏfiÁËÛË ∞pgar ÛÙÔ 1 ÏÂÙfi ‹Ù·Ó 3 (‰È¿ÌÂÛË ÙÈÌ‹ ·ÎÚ·›Â˜ 0-5 Î·È ÛÙÔ 5 ÏÂÙfi 6 ·ÎÚ·›Â˜ 3-9). ™ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ë ‚·ıÌÔÏfiÁËÛË ∞pgar ÛÙÔ 1 ÏÂÙfi ‹Ù·Ó 8 ‰È¿ÌÂÛË ÙÈÌ‹ (·ÎÚ·›Â˜ 8-9) Î·È ÛÙÔ 5 ÏÂÙfi 10 (·ÎÚ·›Â˜ 9-10). ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ÌÂÙÚ‹ıËÎ·Ó ÔÈ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ ÌÔÙÈÏ›ÓË, Á·ÛÙÚ›ÓË, VIP (·ÁÁÂÈÔ‰Ú·ÛÙÈÎfi ÂÓÙÂÚÈÎfi ÂÙ›‰ÈÔ) Î·È Ó¢ÚÔÙÂÓÛ›ÓË ÛÙÔ ·›Ì· ÙÚÂȘ ÊÔÚ¤˜: 1) ™ÙȘ ÚÒÙ˜ 6 ÒÚ˜ ˙ˆ‹˜, 2) ÌÂÙ¿ 24 ÒÚ˜ ÂÓÒ ‰ÂÓ ÛÈÙ›˙ÔÓÙ·Ó ·fi ÙÔ ÛÙfiÌ· Î·È 3) fiÙ·Ó ÛÈÙ›˙ÔÓÙ·Ó Ï‹Úˆ˜ Ì Á¿Ï·. ™ÙËÓ ÔÌ¿‰· ∞ Ë Î·ı˘ÛÙ¤ÚËÛË ¤Ó·Ú͢ Ù˘ ·fi ÙÔ ÛÙfiÌ· Û›ÙÈÛ˘ ·ÔÙ¤ÏÂÛ ÙËÓ ·Ú¯‹ ÂÓfi˜ ÚÔÛÂÎÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘, fiÔ˘ Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ·Ú¤ÌÂÓ·Ó 24 ÒÚ˜ ÌfiÓÔ Ì ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹. ∆Ô 2Ô 24ˆÚÔ Ï¿Ì‚·Ó·Ó 5 ml/2ˆÚÔ Á¿Ï· ÌfiÓÔ, Û ϋÚË ·Ú·›ˆÛË. ∆· ÂfiÌÂÓ· 24ˆÚ· ÙÔ Á¿Ï· ·˘Í·ÓfiÙ·Ó
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ηıËÌÂÚÈÓ¿ ηٿ 10 ml ÛÙÔ Á‡̷, Ì ·ÔÙ¤ÏÂÛÌ· Ù· ÓÂÔÁÓ¿ Ó· ÛÈÙ›˙ÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Ì Á¿Ï· ÙÔ 5Ô 24ˆÚÔ ˙ˆ‹˜ (‰È¿ÌÂÛË ÙÈÌ‹, ·ÎÚ·›Â˜ 3-9), ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓÔ¯‹ ÛÙË Û›ÙÈÛË Ô˘ ·ÚÔ˘Û›·˙·Ó. ∆Ô ÚˆÙfiÎÔÏÏÔ ·˘Ùfi ·ÔÊ·Û›ÛÙËΠ·fi ÙÔ ÙÌ‹Ì· Ì·˜ Ì ‚¿ÛË ·Ï·ÈfiÙÂÚ˜ (5) Î·È ÓÂfiÙÂÚ˜ (6) Ô‰ËÁ›Â˜ ‰È·ÙÚÔÊ‹˜ Ô˘ ıˆÚÔ‡Ó ÂȂ‚ÏË̤ÓË ÙËÓ ÁÈ· ‰È¿ÊÔÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ηı˘ÛÙ¤ÚËÛË ¤Ó·Ú͢ Ù˘ Û›ÙÈÛ˘ Û ÓÂÔÁÓ¿ Ì ¶.∞. ™ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ‹È· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi fiˆ˜ .¯. ·ÚÔ‰È΋ Ù·¯‡ÓÔÈ· ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ·ÈÙ›· Ù˘ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ¤Ó·Ú͢ Û›ÙÈÛ˘. OÈ Ì¿ÚÙ˘Ú˜ ‰ÂÓ ÛÈÙ›ÛÙËÎ·Ó ÙÔ ÚÒÙÔ 24ˆÚÔ Î·È ÙÔ ÚˆÙfiÎÔÏÏÔ Û›ÙÈÛ‹˜ ÙÔ˘˜ ÚÔÛ·ÚÌfiÛÙËΠÛÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ·Ú¯ÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜. ™ÈÙ›ÛÙËÎ·Ó ·ÔÎÏÂÈÛÙÈο Ì Á¿Ï· ÙÔ 4Ô 24ˆÚÔ ˙ˆ‹˜ (‰È¿ÌÂÛË ÙÈÌ‹, ·ÎÚ·›Â˜ 3-11). ∏ ‰È·ÊÔÚ¿ ÛÙË Ì¤ÛË ÙÈÌ‹ Ù˘ Ë̤ڷ˜ fiÔ˘ Ù· ÓÂÔÁÓ¿ ÛÈÙ›ÛÙËÎ·Ó ·ÔÎÏÂÈÛÙÈο Ì Á¿Ï·, ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜. OÈ Ï‹„ÂȘ ·›Ì·ÙÔ˜ ÁÈ· ÙË Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÙÂÛÛ¿ÚˆÓ ÔÚÌÔÓÒÓ ¤ÁÈÓ·Ó Û˘Á¯ÚfiÓˆ˜ Ì ÙȘ ·ÈÌÔÏË„›Â˜ ÁÈ· ÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ. ŸÙ·Ó ·˘Ù¿ ÛÈÙ›˙ÔÓÙ·Ó Ì Á¿Ï· Ë ·ÈÌÔÏË„›· ÁÈÓfiÙ·Ó ÚÈÓ ·fi ÙÔ Á‡̷ ÙËÓ ›‰È· ÚˆÈÓ‹ ÒÚ·. ∏ ̤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÔÚÌÔÓÒÓ ¤ÁÈÓ ÛÙÔ ÔÚÌÔÓÔÏÔÁÈÎfi ÂÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ ¶°¡ ¡Èη›·˜ Î·È ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ú·‰ÈÔ·ÓÔÛÔÏÔÁÈΤ˜ ̤ıÔ‰ÔÈ (7). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙËÓ ‰ÔÎÈÌ·Û›· t-test ÁÈ· ·Ó¿Ï˘-
409
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·410
¶∞π¢π∞∆ƒπ∫∏ 2000;63:408-411
∞. °Ô‡Ó·Ú˘ Î·È Û˘Ó.
ÛË Î·Ù¿ ˙‡ÁË ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ Î·È ÁÈ· ÙȘ 4 ÔÚÌfiÓ˜. ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ì ÛÙÂÓ¿ ÙË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ÂÙÈÎfi Î·È Î·Ù·ÁÚ¿Ê·Ì ÙȘ ÂÈÏÔΤ˜ (¯ÚfiÓÔ˜ ÂÍfi‰Ô˘ ÌËÎˆÓ›Ô˘, Á·ÛÙÚÈÎfi ˘fiÏÂÈÌÌ·, ¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ‰È¿Ù·ÛË ÎÔÈÏ›·˜). ∞ÔÙÂϤÛÌ·Ù· ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ ÙˆÓ ÔÚÌÔÓÒÓ ÙÔ˘ ÂÙÈÎÔ‡ Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î·. ªfiÓÔ 2 ÓÂÔÁÓ¿ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ·ÚÔ˘Û›·Û·Ó ‹È˜ ÂÈÏÔΤ˜ ·fi ÙÔ ÂÙÈÎfi (¤ÌÂÙÔ˜) ÂÓÒ ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ 4 ÓÂÔÁÓ¿ ·ÚÔ˘Û›·Û·Ó ›Û˘ ‹È˜ ÂÈÏÔΤ˜ (2 ¤ÌÂÙÔ, 2 ‰È¿Ù·ÛË ÎÔÈÏ›·˜) Ô˘ Û fiÏ· ˘Ô¯ÒÚËÛ·Ó ÁÚ‹ÁÔÚ·. ∞fi Ù· ·ÔÙÂϤÛÌ·Ù· ÚÔ·ÙÔ˘Ó Ù· ·Ú·Î¿Ùˆ: 1) Ù· ›‰· ÌÔÙÈÏ›Ó˘ ÛÙ· ÓÂÔÁÓ¿ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙËÓ 1Ë Î·È ÙË 2Ë Ì¤ÙÚËÛË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (ƒ<0,05 Î·È ƒ<0,01 ·ÓÙ›ÛÙÔȯ·) ÂÓÒ ÛÙË 3Ë Ì¤ÙÚËÛË ‰ÂÓ ˘‹ÚÍ ‰È·ÊÔÚ¿. 2) ∆Ô VIP ÛÙËÓ 1Ë Ì¤ÙÚËÛË ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ÛÙ· ÓÂÔÁÓ¿ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· (ƒ<0,05) ÂÓÒ ÛÙȘ ¿ÏϘ ‰‡Ô ÌÂÙÚ‹ÛÂȘ ‰ÂÓ ˘‹ÚÍ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿. 3) ∏ Á·ÛÙÚ›ÓË Î·È Ë Ó¢ÚÔÙÂÓÛ›ÓË ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜. 4) ∏ ·Ú·ÎÔÏÔ‡ıËÛË fiÏˆÓ ÙˆÓ ÓÂÔÁÓÒÓ ¤‰ÂÈÍ fiÙÈ ÛÙËÓ ÔÌ¿‰· ∞, Ì ÙË Ì¤ıÔ‰Ô Û›ÙÈÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ, ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÏÈÁfiÙÂÚ˜ Î·È ‹È˜ ÂÈÏÔΤ˜ ·fi ÙÔ ÂÙÈÎfi Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ÂÓÒ Î·Ó¤Ó· ÓÂÔÁÓfi ‰ÂÓ ·ÚÔ˘Û›·Û ¡∂∫. ™˘˙‹ÙËÛË ∂›Ó·È ÁÓˆÛÙ‹ Ë ‰˘ÛÎÔÏ›· Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙËÓ ÚÔÛ¿ıÂÈ· Ó· ÛÈÙÈÛÙ› ¤Ó· ÓÂÔÁÓfi Ì ¶.∞. ¶Ôχ Û˘¯Ó¿ Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ӷ Ê·Ú˘ÁÁÈο ·ÓÙ·Ó·ÎÏ·ÛÙÈο, Á·ÛÙÚÈÎfi ˘fiÏÂÈÌÌ· Î·È ‰È¿Ù·ÛË ÎÔÈÏ›·˜ ÂȉÈο ·Ó ÛÈÙÈÛÙÔ‡Ó Ì ÙËÓ ÔÛfiÙËÙ· Á¿Ï·ÙÔ˜ Ô˘ ¯ÔÚËÁԇ̠۠¤Ó· ÓÂÔÁÓfi Ô˘ ‰ÂÓ ¤¯ÂÈ Úfi‚ÏËÌ· ¶.∞. (4).
∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ú˘ıÌ›˙ÂÙ·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∆Ô ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ÙÔ ÙÔÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÔÈ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ Ô˘ Û‹ÌÂÚ· ÍÂÂÚÓÔ‡Ó ÙȘ 30(8), ¤¯Ô˘Ó Û˘ÌÏËڈ̷ÙÈΤ˜ ‰Ú¿ÛÂȘ ÛÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÁÈ· Ó· ÂÈÙ¢¯ı› Ë ÔÌ·Ï‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘. ∞fi fiϘ ÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ ÌÂÙÚ‹ıËÎ·Ó ÛÙËÓ ¤ÚÂ˘Ó¿ Ì·˜ ÔÈ Ù¤ÛÛÂÚȘ, ηٿ ÚÒÙÔÓ ÁÈ· ÏfiÁÔ˘˜ Ù¯ÓÈÎÔ‡˜, Î·È Î·Ù¿ ‰Â‡ÙÂÚÔ ÁÈ·Ù› ıˆÚԇ̠fiÙÈ ·˘Ù¤˜ ÂȉÚÔ‡Ó Û ÛËÌ·ÓÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ÌÔÙÈÏ›ÓË ÂËÚ¿˙ÂÈ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘. ∏ Á·ÛÙÚ›ÓË Ú˘ıÌ›˙ÂÈ ÙËÓ ¤ÎÎÚÈÛË Á·ÛÙÚÈÎÔ‡ ÔͤԘ Î·È Â˘ÓÔ› ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘. ∏ Ó¢ÚÔÙÂÓÛ›ÓË ¤¯ÂÈ Î·È ·˘Ù‹ ‰Ú¿ÛË ÛÙËÓ ÎÈÓËÙÈÎfiÙËÙ·. ∆Ô VIP ¤¯ÂÈ ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË Î·È ‰Ú· ˆ˜ Ó¢Úԉȷ‚È‚·ÛÙ‹˜ (9). Œ¯ÂÈ ‚ÚÂı› Û Ӥ· ÂÈÚ·Ì·Ùfi˙ˆ· fiÙÈ Ë ÈÛ¯·ÈÌ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ηıÈÛÙ¿ ȉȷ›ÙÂÚ· ¢·›ÛıËÙÔ ÙÔÓ ‚ÏÂÓÓÔÁfiÓÔ ÙÔ˘, Ô ÔÔ›Ô˜ Ì ÙËÓ ·ÚÔ˘Û›· ÙÚÔÊ‹˜ ˘Ê›ÛÙ·Ù·È ‚Ï¿‚Ë (10). ™Ù· ÓÂÔÁÓ¿ Ì ·ÛÊ˘Í›· Ë ¤ÍÔ‰Ô˜ ÌËÎˆÓ›Ô˘ Û˘Ì‚·›ÓÂÈ Ù·¯‡ÙÂÚ·, ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ Î·È ÂÓ‰ÔÌ‹ÙÚÈ·. ™Â ÌÂϤÙË Ô˘ ¤ÁÈÓ ‚Ú¤ıËÎ·Ó Û ·˘Ù¿ ˘„ËÏfiÙÂÚ· ›‰· ÌÔÙÈÏ›Ó˘ Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (2). ∏ Berseth ·Ú·ÎÔÏÔ˘ıÔ‡Û Ì ÂȉÈÎfi ηıÂÙ‹Ú· ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÙÈÎÔ‡. ™ÙËÓ ¤ÚÂ˘Ó¿ Ù˘ ÂȂ‚·›ˆÛ ÙË ÛËÌ·ÓÙÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙ· ÓÂÔÁÓ¿ Ì ¶.∞. ∞ÓÙ›ıÂÙ· ‰ÂÓ ‚ڋΠ‰È·ÊÔÚ¿ ÛÙȘ ÔÚÌfiÓ˜ Ô˘ ÌÂÙÚ‹ıËÎ·Ó (Á·ÛÙÚ›ÓË, Á·ÛÙÚÈÎfi ÂÙ›‰ÈÔ ·Ó·ÛÙÔÏ‹˜ - GIP, ·ÁÎÚ·ÙÈÎfi ÂÙ›‰ÈÔ) Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (4). ∂ÊfiÛÔÓ Ë ÛÔ‚·Ú‹ ¶.∞. ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ·ÛÙ› ¡∂∫ (1) Ë Û›ÙÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶.∞. ·ÔÙÂÏ› ÚfiÎÏËÛË. H Berseth ÚÔÙ›ÓÂÈ Û ÓÂÔÁÓ¿ Ì ¶.∞. Ó· ¯ÚË-
¶›Ó·Î·˜ 1. ∂›Â‰· ÙˆÓ ÔÚÌÔÓÒÓ ÙÔ˘ ÂÙÈÎÔ‡. 1Ë Ì¤ÙÚËÛË ÔÌ¿‰· ∞
ªÔÙÈÏ›ÓË VIP ¡Â˘ÚÔÙÂÓÛ›ÓË °·ÛÙÚ›ÓË ªÔÙÈÏ›ÓË VIP ¡Â˘ÚÔÙÂÓÛ›ÓË °·ÛÙÚ›ÓË
ÔÌ¿‰· µ
* ƒ < 0,05
410
** ƒ<0,01
***ƒ < 0,05
(pmol/l) (ng/dl) (ng/dl) (ng/dl) (pmol/l) (ng/dl) (ng/dl) (ng/dl)
56±21,1* 12,8±7,3*** 29±14,2 62,3±18,6 33,2±19,1* 21,2±12,5*** 29,1±13,6 55±9,9
2Ë Ì¤ÙÚËÛË 82,5±43,3** 15,7±11,2 30,1±9,5 57,2±19 31,1±20** 18,3±11,8 26,7±10,7 51,5±13,6
3Ë Ì¤ÙÚËÛË 70,6±27,5 14,6±8,3 51,6±31,5 79,5±25,1 60,3±25,9 17±12 36,5±20,9 77,5±17,9
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·411
¶∞π¢π∞∆ƒπ∫∏ 2000;63:408-411
ÛÈÌÔÔÈÂ›Ù·È Ë Ì·ÓÔÌÂÙÚÈ΋ Ù¯ÓÈ΋ ÁÈ· Ó· ·ÔÊ·ÛÈÛÙ› Ë ÔÏÈÙÈ΋ Û›ÙÈÛ˘ Ô˘ ı· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıËı› Û ηı¤Ó· ·fi ·˘Ù¿ (4). ∏ Ù¯ÓÈ΋ ·˘Ù‹ fï˜, ‰ÂÓ Â›Ó·È ‰È·‰Â‰Ô̤ÓË Î·È Ú¤ÂÈ Ó· ¯ÚÂÈ¿˙ÂÙ·È È‰È·›ÙÂÚË ÂÌÂÈÚ›·. H ̤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÔÚÈÛÌ¤ÓˆÓ ·fi ÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ Ì ÙȘ ‰˘ÛÎÔϛ˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰ÂÓ ¤¯ÂÈ Ú·ÎÙÈ΋ ·Í›· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÒÛÙ Ì ‚¿ÛË Ù· ›‰· ·˘ÙÒÓ, Ó· ·ÔÊ·Û›˙ÂÙ·È Ë Û›ÙÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶.∞. ™ÙË ‰È΋ Ì·˜ ¤Ú¢ӷ, Ë Û›ÙÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶.∞. ·Ú¯›˙ÂÈ Ô˘ÛÈ·ÛÙÈο ÙÔ ÙÚ›ÙÔ 24ˆÚÔ ˙ˆ‹˜, ÂÊfiÛÔÓ ÙÔ ÚÒÙÔ 24ˆÚÔ ·Ú·Ì¤ÓÂÈ ¯ˆÚ›˜ Û›ÙÈÛË Î·È ÙÔ 2Ô ¯ÔÚËÁÔ‡ÓÙ·È ÌfiÓÔ 5 ml Á¿Ï·ÙÔ˜ ·Ó¿ 2ˆÚÔ (ÂÏ¿¯ÈÛÙË ‰È·ÙÚÔÊ‹). ∏ ·‡ÍËÛË Ù˘ ÔÛfiÙËÙ·˜ ÙÔ˘ Á¿Ï·ÙÔ˜ ·ÎfiÌË Î·È ·fi ÙÔ ÙÚ›ÙÔ 24ˆÚÔ Â›Ó·È ÚÔԉ¢ÙÈ΋ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÓÔ¯‹ ÙÔ˘ ÓÂÔÁÓÔ‡ (‡·ÚÍË Á·ÛÙÚÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜, Â̤وÓ, ‰È¿Ù·ÛË ÎÔÈÏÈ¿˜). ∏ ·Ó¿·˘ÛË ÙÔ˘ ÂÙÈÎÔ‡ ÁÈ· ‰‡Ô 24ˆÚ· Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÚÎÂÙ‹ ÁÈ· Ó· ·Ó¯ıÔ‡Ó Ù· ÓÂÔÁÓ¿ Ù˘ ¤ÚÂ˘Ó¿˜ Ì·˜ ÙË Û›ÙÈÛË ¯ˆÚ›˜ ÂÈÏÔΤ˜. ∞fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ Ê·›ÓÂÙ·È fiÙÈ Ë ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙÔ ÂÙÈÎfi ÓÂÔÁÓÒÓ Ì ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Î·È Û ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÂȤ‰ˆÓ ÛÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ Ô˘ ÚÔηÏ› Ë ¶.∞. ∆· ˘„ËÏfiÙÂÚ· ›‰· ÌÔÙÈÏ›Ó˘ ÙÔ˘ ÂÙȉ›Ô˘ Ô˘ Âȉڿ ÛÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È Ù· ¯·ÌËÏfiÙÂÚ· ›‰· VIP, Ô˘Û›·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹ ÙÔÈο ÛÙÔ ¤ÓÙÂÚÔ, ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È Û ›‰Ú·ÛË Ù˘ ¶.∞. Î·È Ó· Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, Ô˘ Û˘ÌʈÓÔ‡Ó Ì ¿ÏϘ ÌÂϤÙ˜ (2,3), Û˘ÓËÁfiÚËÛ·Ó ÛÙÔ Ó· ÂÈÌ›ÓÔ˘Ì ÛÙËÓ ÚÔÛÂÎÙÈ΋ Û›ÙÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶.∞. ÙȘ ÚÒÙ˜ Ë̤Ú˜. ∆· ›‰· Á·ÛÙÚ›Ó˘ Î·È Ó¢ÚÔÙÂÓÛ›Ó˘ ‰ÂÓ Â›¯·Ó ‰È·ÊÔÚ¿ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜, ÂÓÒ ·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙË Á·ÛÙÚ›ÓË, ›¯Â Î·È Ë Berseth ÛÙËÓ ¤ÚÂ˘Ó¿ Ù˘. ∏ ̤ÙÚËÛË ÙˆÓ 4 ÔÚÌÔÓÒÓ ÌÂÙ¿ ÙËÓ Â‚‰ÔÌ¿‰· ‰ÂÓ ¤‰ÂÈÍ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜, ÛÙÔÈ¯Â›Ô Ô˘ Û˘ÌʈÓÔ‡Û Ì ÙËÓ Î·Ï‹ ·ÓÔ¯‹ Ù˘ Ï‹„˘ Á¿Ï·ÙÔ˜ Ô˘ ·ÚÔ˘Û›·Û·Ó fiÏ· Ù· ÓÂÔÁÓ¿ ÙÔ ›‰ÈÔ ‰È¿ÛÙËÌ·. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ë ¶.∞. ÂËÚ¿˙ÂÈ Î¿ÔȘ ·fi ÙȘ ÔÚÌfiÓ˜ ÙÔ˘ ÂÙÈÎÔ‡ Î·È ¯ÚÂÈ¿˙ÂÙ·È ÚÔÛÂÎÙÈ΋ Û›ÙÈÛË ÁÈ· Ó· Â›Ó·È ·ÛÊ·Ï‹˜ Ë ‰È·ÙÚÔÊ‹ ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ.
™›ÙÈÛË ÓÂÔÁÓÒÓ Î·È ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·
µÈ‚ÏÈÔÁÚ·Ê›· 1. Kliegman RM, Fanaroff AA. Necrotizing enterocolitis N Engl J Med 1984;310;1093-1103. 2. Lucas A, Christofides ND, Adrian TE, Bloom SR, Aynsley Green A. Fetal distress, mecomium and motilin. Lancet 1979; 718. 3. Ishitani N, Ohzeki I, Hanaki K, Motozumi H, Sunagushi M Shiraki K. Elevated venous concentrations of Vasoactive Intestinal Polypeptide in cord blood of infants with fetal distress. Biol Neonate 1993;63;70-74. 4. Berseth CL, Mc Coy HH. Birth asphyxia alters neonatal intestinal motility in term neonates. Pediatrics 1992;90;669-673. 5. Brown G, Sweet Y. Neonatal necrotizing enterocolitis Pediatric Clinics of North America. October 1982: 29, 5, 1149-1170. 6. Berseth C, Abrams S. Necrotizing enterocolitis. In Taeusch W, Ballard R eds. Avery’s. Diseases of the Newborn. Philadelphia. Sawuders; 1998. p. 965-970. 7. Jaffe BM, Walsh JH. Gastrin and related peptides In: Jaffe BM, Behram HR editors. Methods of hormone radio immunoassay. New York: Academic Press; 1979. p. 455477. 8. Aynsley Green A, The endocrinology of feeding in the newborn. Bailierre’s Clin Endocrinol Metab 1989;3:837-868. 9. Ottesen B. Vasoactive intestinal polypeptide as a neurotransmitter in female genital tract. Am J Obstet Gynecol 1983;147;208-224. 10. Crissinger KD, Granger DN. Mucosal injury induced by ischemia and reperfusion in the piglet intestine: Influences of age and feeding gastroenterology. 1983;97;920-926.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 09-03-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: A. °Ô‡Ó·Ú˘ ºÚ‡Ó˘ 5, 116 34 ∞ı‹Ó·
411
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·412
¶∞π¢π∞∆ƒπ∫∏ 2000;63:412-417
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂڷ›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ÃÚ‹ÛÙÔ˜ ¶·ÓÙÂÏÈ¿‰Ë˜, ∞ıËÓ¿ ª·Ï¿Ûη, ª·Ú›· ∆˙ËÙËÚ›‰Ô˘, O˘Ú·Ó›· ∫ÔÙ˙·ÂÚ›‰Ô˘, ∂Ï›˙· ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘
● ¶ÂÚ›ÏË„Ë: ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË (µ∆Ã-∞) ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ۷ÛÙÈΤ˜ ÌÔÚʤ˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ (∂¶). ∏ ıÂڷ›· ·˘Ù‹ Á›ÓÂÙ·È Û ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, ··ÈÙ› ÂÌÂÈÚ›· Î·È ˆ˜ ÛÙfi¯Ô ¤¯ÂÈ ÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ Ê˘ÛÈÎÔıÂڷ›·˜. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ı¤ÛÂȘ Ì˘fi˜, ÛÙ· Ï·›ÛÈ· ÌÈ·˜ ·ÓÔȯً˜ ÌÂϤÙ˘ Û 12 ·È‰È¿ (8 ·ÁfiÚÈ· Î·È 4 ÎÔÚ›ÙÛÈ·) Ì ۷ÛÙÈÎÔ‡ Ù‡Ô˘ ∂¶. OÈ ·ÛıÂÓ›˜ ÂϤÁ¯ıËÎ·Ó Û‡Ìʈӷ Ì ¤Ó· ÛÙ·ıÌÈṲ̂ÓÔ ÚˆÙfiÎÔÏÏÔ Ô˘ ·ÊÔÚÔ‡Û ÙË Ó¢ÚÔÏÔÁÈ΋ ηٿÛÙ·ÛË, ÙÔ Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘ ÛÙȘ ·ÚıÚÒÛÂȘ Î·È ÙËÓ Îϛ̷η Ashworth. ∏ ÂÈÏÔÁ‹ ÙˆÓ Ì˘ÒÓ ¤ÁÈÓ Ì ÎÏÈÓÈ΋ ÂͤٷÛË Û 10 ·ÛıÂÓ›˜ Î·È ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘ Û 2. ÃÔÚËÁ‹ıËÎ·Ó Û˘ÓÔÏÈο 7 ÌÔÓ/Kgµ™. ∆· ıÂڷ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂÙ¿ ·fi 6-8 Ë̤Ú˜ ÂÚ›Ô˘ Î·È Â›¯·Ó ‰È¿ÚÎÂÈ· ηٿ ̤ÛÔÓ fiÚÔ 2-3 Ì‹Ó˜. ¶·ÚÂÓ¤ÚÁÂȘ ‰ÂÓ ·Ú·ÙËÚ‹ıËηÓ. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤‰ÂÈÍ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Ì ‚¿ÛË ÙËÓ Îϛ̷η Ashworth, ·‡ÍËÛË ÙÔ˘ ‡ÚÔ˘˜ ÛÙȘ ÂÓÂÚÁËÙÈΤ˜ Î·È ·ıËÙÈΤ˜ ÎÈÓ‹ÛÂȘ Î·È ·‡ÍËÛË Ù˘ ÁˆÓ›·˜ ÙˆÓ ·ÚıÚÒÛˆÓ. OÈ Ê˘ÛÈÎÔıÂÚ·Â˘Ù¤˜ Î·È ÔÈ ÁÔÓ›˜ ‰È·›ÛÙˆÛ·Ó ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ Ì‹Ó˜ ‚ÂÏÙ›ˆÛË Ù˘ ηıÈÛÙÈ΋˜ ı¤Û˘, Ù˘ ÛÙ‹ÚÈ͢ ÙÔ˘ ÎÔÚÌÔ‡, Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ ¿ÎÚˆÓ Î·È ¤ÁÈÓ ¢ÎÔÏfiÙÂÚË ÂÚÈÔ›ËÛË ÙˆÓ ·È‰ÈÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¯ÔÚ‹ÁËÛË Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ Û ÂÈÏÂÁ̤ÓÔ˘˜ ̇˜ ÌÂÈÒÓÂÈ ÙÔÓ Ì˘˚Îfi ÙfiÓÔ, ÙȘ Û˘Û¿ÛÂȘ Î·È ·˘Í¿ÓÂÈ ÙÔ Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘, ‰È¢ÎÔχÓÔÓÙ·˜ ÙÔ ¤ÚÁÔ ÙÔ˘ Ê˘ÛÈÎÔıÂÚ·Â˘Ù‹, ÙÔ˘ ·È‰ÔÓ¢ÚÔÏfiÁÔ˘ Î·È ÙÔ˘ ÔÚıԷȉÈÎÔ‡. ¶·È‰È·ÙÚÈ΋ 2000;63:412-417. §¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, Û·ÛÙÈÎfiÙËÙ·. C. Panteliadis, A. Balaska, M. Tzitiridou, O. Kotzaeridou, E. Karatza-Xifilidou. Botulinum toxin-A in the treatment of cerebral palsy. Paediatriki 2000;63:412-417. ● Abstract: Botulinum toxin (BTX-A) has been used recently for the treatment of children with spastic type of cerebral palsy. This treatment is used in selected cases, requires experience and aims towards the facilitation of physiotherapy. The purpose of this study was to determine the effectiveness of the local injection of botulinum toxin in specific sites of skeletal muscle, in the context of an open trial research including 12 children (8 boys and 4 girls) with spastic cerebral palsy. The patients were investigated according to a standardized protocol which included neurological assessment, range of motion and Ashworth scale. The muscle selection was based on clinical examination in 10 patients, while in 2 patients we used gait analysis. The total amount of BTX-A administered was 7 units/Kg. The effects of treatment, which lasted for 2-3 months, were evaluated 6-8 days after injection. None of our patients developed side effects. Analysis of our results showed a decrease in muscle hypertonicity and an increase in the range of active and passive motion. During the following months, the physiotherapists and parents observed an improvement on body posture and sitting, and facilitation in patient care. In conclusion, BTX-A injection in specific muscles decreases the muscle hypertonia and muscle contracture, increases the range of motion, and facilitates the work of the physiotherapist, child neurologist and orthopedist. Key words: cerebral palsy, botulinum toxin, spasticity.
°' ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, ∞.¶.£, £ÂÛÛ·ÏÔÓ›ÎË
412
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·413
¶∞π¢π∞∆ƒπ∫∏ 2000;63:412-417
∂ÈÛ·ÁˆÁ‹ ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ (∞∆-∞) ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· ÛÙË ıÂڷ›· ÔÈÎ›ÏˆÓ ‰È·Ù·Ú·¯ÒÓ Ì ·˘ÍË̤ÓË Ì˘˚΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ™ÙËÓ ¶·È‰È·ÙÚÈ΋ Â›Ó·È ÁÓˆÛÙ‹ ·fi ÙË ‰ËÏËÙËÚ›·ÛË ÙÔ˘ ‚Ô˘ÙÔ˘ÏÈÛÌÔ‡ (·ÏÏ·ÓÙ›·ÛË). πÛÙÔÚÈο, Ë ÚÒÙË ÂÓ‰ÔÌ˘˚΋ ¤Á¯˘ÛË ÌÈÎÚÒÓ ‰fiÛÂˆÓ ∞∆-∞ ¤ÁÈÓ ÙÔ 1981 ·fi ÙÔÓ Scott Û ·ÛıÂÓ›˜ Ì ÛÙÚ·‚ÈÛÌfi (1). ∞fi ÙfiÙ ·Ô‰Â›¯ıËΠ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË ıÂڷ›· Ù˘ ÂÛÙȷ΋˜-ÙÌËÌ·ÙÈ΋˜ ‰˘ÛÙÔÓ›·˜ Î·È Û ۷ÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ΛÓËÛ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, fiÙ·Ó ÂÓ›ÂÙ·È Û ÂÈÏÂÁ̤ÓÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ ̇˜ (2,3). ∆· ̤¯ÚÈ Û‹ÌÂÚ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯Ú‹ÛË ∞∆-∞ Â›Ó·È ÂÓı·ÚÚ˘ÓÙÈο Î·È ÙËÓ ÙÂÎÌËÚÈÒÓÔ˘Ó ˆ˜ ·ÛÊ·Ï‹ ıÂڷ¢ÙÈ΋ ̤ıÔ‰Ô Ì ÂÏ¿¯ÈÛÙ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ¯ÔÚËÁ‹ıËΠ۠·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÂÛÙȷ΋ ‰˘ÛÙÔÓÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ΛÓËÛ˘, fiˆ˜ Û·Û̈‰ÈÎfi Ú·È‚fiÎÚ·ÓÔ Ì ηϿ ·ÔÙÂϤÛÌ·Ù· Î·È ¯ˆÚ›˜ ·ÚÂÓ¤ÚÁÂȘ (4,5). ∂Âȉ‹ fï˜, ÔÈ ‰˘ÛÙÔÓÈÎÔ‡ Ù‡Ô˘ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Û¿ÓȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ‰ÂÓ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ıÂڷ¢ÙÔ‡Ó. À¿Ú¯Ô˘Ó fï˜ ÂÛÙȷο ÎÈÓËÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙ· Ï·›ÛÈ· ÌÈ·˜ Û·ÛÙÈ΋˜ ÎÈÓËÙÈ΋˜ ‰È·Ù·Ú·¯‹˜ (6-8). ∏ ∞∆-∞ ˘fiÛ¯ÂÙ·È ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ¡Â˘ÚÔÏÔÁ›· Ӥ˜ ıÂڷ¢ÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ÁÈ· ÙË ıÂڷ›· ·È‰ÈÒÓ Ì ۷ÛÙÈΤ˜ ÌÔÚʤ˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ (∂¶). ∏ Ê˘ÛÈÎÔıÂڷ›· ·ÔÙÂÏ› ÙÔ Î‡ÚÈÔ Ì¤ÛÔ Ì›ˆÛ˘ ÙÔ˘ ·˘ÍË̤ÓÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ÛÙ· ·È‰È¿ Ì ۷ÛÙÈ΋ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∆· ·ÓÙÈÛ·ÛÙÈο Ê¿Ú̷η (Ì·ÎÏÔʤÓË, ÙÈ˙·Óȉ›ÓË, ‚ÂÓ˙ԉȷ˙›Ó˜) ·›˙Ô˘Ó ÌÈÎÚfi ÚfiÏÔ ÛÙË ıÂڷ›· ÁÈ·Ù› ÙÔ ‚·ÛÈÎfi Úfi‚ÏËÌ· ‚Ú›ÛÎÂÙ·È ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ ÎÂÓÙÚÈ΋˜ Ú‡ıÌÈÛ˘ ÙÔ˘ ÙfiÓÔ˘ Î·È ÙÔ˘ Û˘ÓÙÔÓÈÛÌÔ‡ (9). ∏ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ·ÏÎÔfiÏ˘ ‹ Ê·ÈÓfiÏ˘ ··ÈÙ› ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›· Î·È ÚÔηÏ› ¤ÓÙÔÓÔ ÙÔÈÎfi ¿ÏÁÔ˜, Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ÓÂÎÚÒÛÂȘ. ŒÙÛÈ, Û˘¯Ó¿ Ë ÌfiÓË Ï‡ÛË ÁÈ· Ù· ·È‰È¿ ·˘Ù¿ Â›Ó·È ÔÈ ÔÚıԷȉÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ∏ ∞∆ Ù‡Ô˘ ∞ ·ÛΛ ÙË ‰Ú¿ÛË Ù˘ ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë, ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÛÙÔÓ Ì˯·ÓÈÛÌfi ¤ÎÎÚÈÛ˘ Ù˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘. ∞Ó·ÛÙ¤ÏÏÂÈ ÂÎÏÂÎÙÈο ÙË ÚÔ‹ (‰È¿¯˘ÛË) Ù˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ ÛÙȘ Û˘Ó¿„ÂȘ Ù˘ ÙÂÏÈ΋˜ Ì˘˚΋˜ Ͽη˜. ŒÙÛÈ, ÂÌÔ‰›˙ÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË Ù˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ ÛÙË Û˘Ó·ÙÈ΋ Û¯ÈÛÌ‹ Î·È Ë ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜ ·fi ÙÔ ÂÚÈÊÂÚÈÎfi Ó‡ÚÔ ÛÙÔÓ Ì˘ Î·È ÚÔηÏÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ¯ËÌÈ΋ ·ÔÓ‡ڈÛË Ô˘ Ô‰ËÁ› ÛÙË ¯·Ï·Ú‹ ·Ú¿Ï˘ÛË ÙÔ˘ Ì˘fi˜ (4, 5). ∏ ÂÚÈÔ¯‹ ·Ú¿Ï˘Û˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ‰fiÛË Î·È ÙÔÓ ‚·ıÌfi ‰È¿¯˘Û˘ Ù˘ ∞∆-∞ (5). ∫ÏÈÓÈο, Ë Â›‰Ú·ÛË ·˘Ù‹ Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË ÎÈ ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi turn over Ù˘ Ó¢ÚÔÌ˘˚΋˜ Û‡Ó·„˘ Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î·ÓÔÓÈÎÒÓ "Ó¤ˆÓ
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË
ÎÈÓËÙÈÎÒÓ Ï·ÎÒÓ". ∏ ‰È·‰Èηۛ· ·˘Ù‹ ‰ÂÓ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ∞. °È’ ·˘Ùfi, fiϘ ÔÈ ÂȉڿÛÂȘ Ù˘ ∞∆-∞, ÙfiÛÔ ÔÈ ÂÈı˘ÌËÙ¤˜ fiÛÔ Î·È ÔÈ ·ÓÂÈı‡ÌËÙ˜ Â›Ó·È ·Ó·ÛÙÚ¤„È̘. OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ì˘ÔÙ·ÙÈÎÒÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Î·È ÙȘ ·ÎÔ‡ÛȘ Ì˘˚Τ˜ Û˘Û¿ÛÂȘ (Û·ÛÌÔ›). O ·˘ÍË̤ÓÔ˜ Ì˘˚Îfi˜ ÙfiÓÔ˜ ÚÔηÏ› Û˘Ó¯‹ Û‡Û·ÛË ÙÔ˘ Ì˘fi˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÚÈÔÚ›˙ÂÙ·È Ë Î›ÓËÛË Î·È Ë ‰È¿Ù·Û‹ ÙÔ˘ (10). ∏ ‰È¿Ù·ÛË ·ÔÙÂÏ› ÂÚ¤ıÈÛÌ· ÛÙËÓ Î·Ù¿ Ì‹ÎÔ˜ ·‡ÍËÛË ÙÔ˘ Ì˘fi˜, ‰ÈfiÙÈ Ú˘ıÌ›˙ÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Û·ÚÎÔÌÂÚȉ›ˆÓ ÙÔ˘ (5). ∏ ¯ÚfiÓÈ· ·Ó·ÛÙÔÏ‹ Ù˘ ‰È¿Ù·Û˘ Ô‰ËÁ› ÛÙË ‚Ú¿¯˘ÓÛË ÙÔ˘ Ì˘fi˜, ÛÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜, ÛÙËÓ ·ÓÒÌ·ÏË ı¤ÛË ÙˆÓ ·ÚıÚÒÛÂˆÓ Î·È Û ÌfiÓÈ̘ Û˘Áο̄ÂȘ. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂÓ‰ÔÌ˘˚΋˜ ¯ÔÚ‹ÁËÛ˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ı¤ÛÂȘ Ì˘ÒÓ Û ·È‰È¿ Ì ۷ÛÙÈÎÔ‡ Ù‡Ô˘ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∫ÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó Ë Ì¤ÙÚÈ· ˆ˜ ÛÔ‚·Ú‹ Û·ÛÙÈÎfiÙËÙ· Î·È Ë ·Ô˘Û›· ÌfiÓÈÌˆÓ ·Ú·ÌÔÚÊÒÛˆÓ. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi ı· ÂÎÙÈÌËı› Ë ‚ÂÏÙ›ˆÛË Ù˘ ı¤Û˘ ÙˆÓ ¿ÎÚˆÓ, Ù˘ ÛÙ¿Û˘, Ù˘ ‚¿‰ÈÛ˘, Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ·ıËÙÈ΋˜ ΛÓËÛ˘ ÛÙ· ·È‰È¿ ·˘Ù¿. M¤ıÔ‰ÔÈ ™Ù· Ï·›ÛÈ· ÌÈ·˜ ·ÓÔȯً˜ ÌÂϤÙ˘ ÂϤÁ¯ıËÎÂ Ë ‰Ú¿ÛË Ù˘ ∞∆-∞ (Botox-A) ÌÂÙ¿ ·fi ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË Û ÂÈÏÂÁ̤ÓÔ˘˜ ̇˜, Û ·È‰È¿ Ì ۷ÛÙÈΤ˜ ÌÔÚʤ˜ ∂¶. ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 12 ·ÛıÂÓ›˜ (8 ·ÁfiÚÈ·, 4 ÎÔÚ›ÙÛÈ·) ËÏÈΛ·˜ ·fi 15 ÌËÓÒÓ ¤ˆ˜ 10 ÂÙÒÓ (̤ÛË ËÏÈΛ· 5,17 ¤ÙË). ∞fi ·˘ÙÔ‡˜ 5 ·ÛıÂÓ›˜ ›¯·Ó Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, 3 ‰ÈÏËÁ›·, Î·È 4 ËÌÈÏËÁ›· (¶›Ó·Î·˜ 1). ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó Ë Ì˘˚΋ ˘ÂÚÙÔÓ›· Ô˘ ÂËÚ¤·˙ Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ÙËÓ Î›ÓËÛË, ÙÔ ¤ÚÁÔ Ù˘ Ê˘ÛÈÎÔıÂڷ›·˜ Î·È ÙËÓ ÂÚÈÔ›ËÛ‹ ÙÔ˘˜. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ Â›¯Â ÌfiÓÈ̘ Û˘Áο̄ÂȘ ÛÙȘ ·ÚıÚÒÛÂȘ Î·È ÛÂ Î·Ó¤Ó·Ó ‰ÂÓ ÚÔËÁ‹ıËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÔÚıԷȉÈΤ˜ ÂÂÌ‚¿ÛÂȘ (.¯. ÂÈÌ‹Î˘ÓÛË ·¯›ÏÏÂÈÔ˘ Ù¤ÓÔÓÙ· ‹ ÚÔÛ·ÁˆÁÒÓ Ì˘ÒÓ) Ô‡Ù ¯ÔÚ‹ÁËÛË ·ÓÙÈÛ·ÛÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·fi ÙÔ ÛÙfiÌ·, fiˆ˜ ‰È·˙¿ÌË, Ì·ÎÏÔʤÓË Î.¿. ∏ ÌfiÓË Ì¤ıÔ‰Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ ‹Ù·Ó Ë Ê˘ÛÈÎÔıÂڷ›·. OÈ ·ÛıÂÓ›˜ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 6-12 Ì‹Ó˜ ·fi ÙÔ ¶·È‰ÔÓ¢ÚÔÏÔÁÈÎfi ÙÌ‹Ì· Ù˘ ∫ÏÈÓÈ΋˜ ÚÈÓ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙË ÌÂϤÙË. ™‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ, ¤ÁÈÓ Û οı ÂÚ›ÙˆÛË ÏÂÙÔÌÂÚ‹˜ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË fiÔ˘ ÂÎÙÈÌ‹ıËÎÂ Ô ‚·ıÌfi˜ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÙˆÓ Ì˘ÒÓ Ì ‚¿ÛË ÙËÓ ÙÚÔÔÔÈË̤ÓË Îϛ̷η ÙÔ˘ Ashworth (¶›Ó·Î·˜ 2), Î·È ÙÔ Â‡ÚÔ˜ Ù˘ ·ıËÙÈ΋˜ ··ÁˆÁ‹˜ ÙˆÓ
413
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·414
¶∞π¢π∞∆ƒπ∫∏ 2000;63:412-417
Ã. ¶·ÓÙÂÏÈ¿‰Ë˜ Î·È Û˘Ó.
¶›Ó·Î·˜ 1. ∞ÛıÂÓ›˜ Î·È Ì‡Â˜ Ô˘ ÂÓ¤ıËÎ·Ó Ì ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ∞. No
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ÚÔÛ·ÁˆÁÔ› ÚÔÛ·ÁˆÁÔ› ËÌÈÙÂÓÔÓÙÒ‰ÂȘ, ËÌÈÌ‚Ú·ÓÒ‰ÂȘ, Á·ÛÙÚÔÎÓ‹ÌÈÔÈ ÚÔÛ·ÁˆÁÔ›, Á·ÛÙÚÔÎÓ‹ÌÈÔÈ ÚÔÛ·ÁˆÁÔ›, Á·ÛÙÚÔÎÓ‹ÌÈÔÈ ÚÔÛ·ÁˆÁÔ›, Á·ÛÙÚÔÎÓ‹ÌÈÔÈ ËÌÈÙÂÓÔÓÙÒ‰ÂȘ, ËÌÈÌÂÌ‚Ú·ÓÒ‰ÂȘ Á·ÛÙÚÔÎÓ‹ÌÈÔÈ, ËÌÈÙÂÓÔÓÙÒ‰ÂȘ, ËÌÈÌÂÌ‚Ú·ÓÒ‰ÂȘ Á·ÛÙÚÔÎÓ‹ÌÈÔ˜, ηÌÙ‹Ú˜ ηÚÔ‡ ËÌÈÙÂÓÔÓÙ҉˘, ËÌÈÌÂÌ‚Ú·Ó҉˘ ηÌÙ‹Ú˜ ηÚÔ‡ Á·ÛÙÚÔÎÓ‹ÌÈÔ˜ ÚÔÛ·ÁˆÁÔ›, Á·ÛÙÚÔÎÓ‹ÌÈÔÈ Á·ÛÙÚÔÎÓ‹ÌÈÔ˜
¶›Ó·Î·˜ 2. ∆ÚÔÔÔÈË̤ÓË Îϛ̷η Ashworth. 0= 1=
¯ˆÚ›˜ ·‡ÍËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ÌÈÎÚ‹ ·‡ÍËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÂÏ¿¯ÈÛÙË ·ÓÙ›ÛÙ·ÛË ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ‡ÚÔ˘˜ ΛÓËÛ˘ ηٿ ÙËÓ ¤ÎÙ·ÛË ‹ Î¿Ì„Ë 1+ = ÌÈÎÚ‹ ·‡ÍËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÂÏ¿¯ÈÛÙË ·ÓÙ›ÛÙ·ÛË ÛÙÔ ÏÈÁfiÙÂÚÔ ·fi ÙÔ ÌÈÛfi ÙÔ˘ ‡ÚÔ˘˜ ΛÓËÛ˘ 2= ÌÂÁ¿ÏË ·‡ÍËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ·ÓÙ›ÛÙ·ÛË Î·Ù¿ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ‡ÚÔ˘˜ ΛÓËÛ˘ ÙÔ ÚÔۂ‚ÏË̤ÓÔ ¿ÎÚÔ ÎÈÓÂ›Ù·È Ì ¢ÎÔÏ›· 3= ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ·ıËÙÈ΋ ΛÓËÛË Ì ‰˘ÛÎÔÏ›· 4= ·Î·Ì„›· ÚÔۂ‚ÏË̤ÓÔ˘ ¿ÎÚÔ˘ ηٿ ÙËÓ ¤ÎÙ·ÛË ‹ Î¿Ì„Ë ÈÛ¯›ˆÓ, Ù˘ ¤ÎÙ·Û˘ ÙÔ˘ ÁfiÓ·ÙÔ˜, Ù˘ Ú·¯È·›·˜ ο̄˘ ÙÔ˘ Ô‰ÈÔ‡ Î·È Ù˘ Ú·¯È·›·˜ ο̄˘ ÙÔ˘ ηÚÔ‡ (11,12). OÈ ÌÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó Ì ÁˆÓÈfiÌÂÙÚÔ. ™Â ‰‡Ô ·fi Ù· Ù¤ÛÛÂÚ· ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ËÌÈÏËÁ›· ¤ÁÈÓ ÂÈϤÔÓ, ÚÈÓ Î·È ÌÂÙ¿ ÙË ıÂڷ›·, ÎÈÓËÌ·ÙÈ΋ ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘. OÈ ÁÔÓ›˜ ÂÓËÌÂÚÒÓÔÓÙ·Ó Ì οı ÏÂÙÔ̤ÚÂÈ· ÁÈ· ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ıÂڷ›·˜ Î·È ˘‹Ú¯Â Ë Û˘ÁηٿıÂÛ‹ ÙÔ˘˜. OÈ Ì‡Â˜ Ô˘ ÂÓ¤ıËÎ·Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÚ›ÙˆÛË Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. ∏ ‰fiÛË Ù˘ ∞∆-∞ ‹Ù·Ó 7ÌÔÓ/kgµ™ Û˘ÓÔÏÈο. ∂Ó¤ıËÎ·Ó 2 ¤ˆ˜ 4 ÛËÌ›· Û οıÂ Ì˘fi˜ ÛÙÔ Ì¤ÛÔ ÙÚÈÙËÌfiÚÈÔ Ù˘ Á·ÛÙ¤Ú·˜ ÙÔ˘. °È· Ó· ·ÔʇÁÔ˘Ì ÙÔÓ fiÓÔ ÚÔÂÙÔÈÌ¿Û·Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÙÔÈÎfi ›ıÂÌ· Emla Î·È ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË Ìȉ·˙ÔÏ¿Ì˘. OÈ ·ÛıÂÓ›˜ ·Ú¤ÌÂÈÓ·Ó ÁÈ· ÌÈ· Ë̤ڷ ÛÙËÓ ÎÏÈÓÈ΋ Î·È Ô Â·Ó¤ÏÂÁ¯Ô˜ Á›ÓÔÓÙ·Ó 3-4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤ÓÂÛË Î·È Î·ÙfiÈÓ, οı 3-4 Ì‹Ó˜. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ‹Ù·Ó Û ÂÓÙ·ÙÈ΋ Ê˘ÛÈÎÔıÂڷ›·. ™Â 6 ·È‰È¿ ¤ÁÈÓ 2Ë ‰fiÛË ÌÂÙ¿ ·fi ‰È¿ÛÙËÌ· 4-6 ÌËÓÒÓ ·fi ÙËÓ ÚÒÙË ¤ÓÂÛË Î·È Û 2 ·fi ·˘ÙÔ‡˜ Î·È ÙÚ›ÙË. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ MannWhitney test.
414
∂ÈÎfiÓ· 1. ∂ÎÙ›ÌËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ì ÙËÓ Îϛ̷η Ashworth.
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·415
¶∞π¢π∞∆ƒπ∫∏ 2000;63:412-417
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË
¶›Ó·Î·˜ 3. ∞‡ÍËÛË Â‡ÚÔ˘˜ ÂÓÂÚÁËÙÈ΋˜ Î·È ·ıËÙÈ΋˜ ΛÓËÛ˘ ∂›‰Ô˜ ΛÓËÛ˘
∞·ÁˆÁ‹ ÈÛ¯‡ˆÓ πÁÓ˘·Î‹ ÁˆÓ›· ƒ·¯È·›· Î¿Ì„Ë Ô‰fi˜ ƒ·¯È·›· Î¿Ì„Ë Î·ÚÔ‡
N
n=6 n=4 n=9 n=2
ÚÈÓ ÙËÓ ¤ÓÂÛË (ÌÔ›Ú˜) ªean SD
ÌÂÙ¿ ÙËÓ ¤ÓÂÛË (ÌÔ›Ú˜) Mean SD
26,6 112,5 -11,8 -25
48 148,7 +6,8 +7,5
∞ÔÙÂϤÛÌ·Ù· ™Â fiÏÔ˘˜ ÙÔ˘˜ ̇˜ Ô˘ ÂÓ¤ıËηÓ, Ô ‚·ıÌfi˜ Ù˘ Û·ÛÙÈ΋˜ Ì˘˚΋˜ ˘ÂÚÙÔÓ›·˜ Ì ‚¿ÛË ÙËÓ Îϛ̷η ÙÔ˘ Ashworth ·ÚÔ˘Û›·Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË (∂ÈÎfiÓ· 1). ™˘ÓÔÏÈο ÙÔ score ÌÂÈÒıËΠ·fi 3,25±0,7 Û 1,62±0,9 (p<0,001) ÙËÓ 3Ë-4Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ¤ÓÂÛË. ªÂ ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Ì˘˚΋˜ ˘ÂÚ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ·˘Í‹ıËΠÙÔ Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘ ÛÙȘ Û‡ÛÙÔȯ˜ ·ÚıÚÒÛÂȘ ΢ڛˆ˜ Û ·ÛıÂÓ›˜ Ì ۷ÛÌfi ÛÙÔ˘˜ ÚÔÛ·ÁˆÁÔ‡˜ ̇˜. ∏ ··ÁˆÁ‹ ÙˆÓ ÈÛ¯›ˆÓ ‚ÂÏÙÈÒıËΠÛËÌ·ÓÙÈο Î·È ÛÙÔ˘˜ 6 ·ÛıÂÓ›˜ Ô˘ ÂÓ¤ıËÎ·Ó ÔÈ ÚÔÛ·ÁˆÁÔ› ̇˜ (¶›Ó·Î·˜ 3). ∏ Ù¿ÛË ÁÈ· „·ÏȉÈÛÌfi ÛÙ· οو ¿ÎÚ· Ú·ÎÙÈο ÂÍ·Ê·Ó›ÛıËΠÌÂ Û˘Ó¤ÂÈ· ÔÈ 2 ·ÛıÂÓ›˜ Ì ‰ÈÏËÁ›· Î·È ÔÈ 2 Ì ÙÂÙÚ·ÏËÁ›· Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ fiÚıÈ· ÛÙ¿ÛË. ∏ Ì›ˆÛË Ù˘ ˘ÂÚÙÔÓ›·˜ ÙˆÓ ÚÔÛ·ÁˆÁÒÓ ‰È¢ÎfiÏ˘Ó ÙË Ê˘ÛÈÎÔıÂڷ›· Î·È ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ˘ÁÈÂÈÓ‹ ÙÔ˘˜ ÊÚÔÓÙ›‰·. ™Ù· 4 ·È‰È¿ Ô˘ ÂÓ¤ıËÎ·Ó ÔÈ Î·ÌÙ‹Ú˜ ÙÔ˘ ÁfiÓ·ÙÔ˜ (2 ‰ÈÏËÁ›·, 1 ËÌÈÏËÁ›·, 1 ÙÂÙÚ·ÏËÁ›·) ÛËÌÂÈÒıËΠ·‡ÍËÛË Ù˘ ÈÁÓ˘·Î‹˜ ÁˆÓ›·˜ Î·È Ù·˘Ùfi¯ÚÔÓ· ‚ÂÏÙ›ˆÛË ÛÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÁfiÓ·ÙÔ˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‰ÈÏËÁ›· (ÔÈ 2 ÂÚ·ÙÔ‡Û·Ó ÛÙȘ ̇Ù˜ ÙˆÓ Ô‰ÈÒÓ ÌÂ Î¿Ì„Ë ÛÙ· ÁfiÓ·Ù·) Î·È ËÌÈÏËÁ›· ‚ÂÏÙÈÒıËÎÂ Ë ÛÙ‹ÚÈÍË ÙÔ˘ ÎÔÚÌÔ‡ ÛÙËÓ fiÚıÈ· ÛÙ¿ÛË ÌÂ Û˘Ó¤ÂÈ· Ó· ‚ÂÏÙȈı› Ë ÔÚıÔÛÙ¿ÙËÛË Î·È ÙÔ ‚¿‰ÈÛÌ·, ÂÓÒ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÙÂÙÚ·ÏËÁ›· Ë Î·Ï‡ÙÂÚË ÛÙ‹ÚÈÍË ÙÔ˘ ÎÔÚÌÔ‡ ‰È¢ÎfiÏ˘Ó ÙËÓ Î·ıÈÛÙÈ΋ ı¤ÛË. ªÂ›ˆÛË Ù˘ ÂÏÌ·ÙÈ·›·˜ ο̄˘ ÙÔ˘ ¿ÎÚÔ˘ Ô‰ÈÔ‡ ÛËÌÂÈÒıËΠ۠9 ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÓ¤ıËÎ·Ó ÔÈ Á·ÛÙÚÔÎÓ‹ÌÈÔÈ (‡ÚÔ˜ ΛÓËÛ˘ ·fi –11,8±5,3 Û 6,8±9,6). ∆· ¤ÓÙ ·È‰È¿ Ì ۷ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›· Î·È Ù· ÙÚ›· Ì ‰ÈÏËÁ›· ‚ÂÏÙ›ˆÛ·Ó ÙË ÛÙ‹ÚÈÍË ÛÙÔ ¤ÏÌ· ηٿ ÙËÓ ÔÚıÔÛÙ¿ÙËÛË. OÈ 4 ·ÛıÂÓ›˜ Ì ËÌÈÏËÁ›· ›¯·Ó ÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ËÌÈÏËÁÈÎfi ‚¿‰ÈÛÌ·. ∏ ¤ÓÂÛË ÙˆÓ Á·ÛÙÚÔÎÓËÌ›ˆÓ Ì ∞∆-∞ ÛÙÔ˘˜ 3 ·fi ·˘ÙÔ‡˜ ¿ÏÏ·Í ÙÔ ‚¿‰ÈÛÌ· ·fi ‰¿ÎÙ˘Ï·-‰¿ÎÙ˘Ï· Û ٤ÚÓ·-‰¿ÎÙ˘Ï·. ∞˘Ùfi Ô‰‹ÁËÛ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ Î·È Ù˘ Ù·¯‡ÙËÙ·˜ ‚¿‰ÈÛ˘. ™ÙÔ˘˜ 2/4 ·ÛıÂÓ›˜ Ì ËÌÈÏËÁ›·, ÂÎÙfi˜ ·fi ÙÔ˘˜ Á·ÛÙÚÔÎÓ‹ÌÈÔ˘˜, ÂÓ¤ıËÎ·Ó ÔÈ Ì‡Â˜ ÙˆÓ Î·ÌÙ‹ÚˆÓ ÙÔ˘ ηÚÔ‡, ‰È·ÈÛÙÒıËΠ̛ˆÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ·Ï·ÌÈ·›·˜ οÌ-
5,4 6,6 5,3
2,7 6,2 9,6
„˘ Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÎÈÓËÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ¯ÂÚÈÔ‡. ™ÙÔ˘˜ ›‰ÈÔ˘˜ (ÔÈ ·ÛıÂÓ›˜ Ô¯ÙÒ Î·È ‰¤Î·) Ë ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘ η٤ÁÚ·„ Ì ·ÎÚ›‚ÂÈ· ÙÔ ‚·ıÌfi ‚ÂÏÙ›ˆÛ˘. ∏ ‰Ú¿ÛË Ù˘ ∞∆-∞ ‰È‹ÚÎËÛ 4-6 Ì‹Ó˜. ™Â 6/12 ·ÛıÂÓ›˜ ¯ÔÚËÁ‹ıËΠ2Ë ‰fiÛË, 5-6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÚÒÙË Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ·ÚfiÌÔÈ·. ∏ ‰È·‰Èηۛ· ‹Ù·Ó Ôχ ηϿ ·ÓÂÎÙ‹ ·’ fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ÚÂÓ¤ÚÁÂȘ. OÈ ˘fiÏÔÈÔÈ 6 ·ÛıÂÓ›˜, ·Ó Î·È ÛËÌ›ˆÛ·Ó οÔÈÔ˘ ‚·ıÌÔ‡ ‚ÂÏÙ›ˆÛË, ‰ÂÓ ÚÔÛ‹Ïı·Ó ÁÈ· ‰Â‡ÙÂÚË ıÂڷ›·. ™˘˙‹ÙËÛË ∏ Û·ÛÙÈÎfiÙËÙ· Â›Ó·È ÌÈ· ÔχÏÔÎË ‰È·Ù·Ú·¯‹ Ô˘ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ·Ó·ËÚ›· ÛÙ· ÚÔۂ‚ÏË̤ӷ ¿ÙÔÌ·. ∏ Ì›ˆÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ÎÈÓ‹ÛÂˆÓ Î·È ÔÈ ‰˘Ó·ÌÈΤ˜ Û˘Û¿ÛÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È ÚÒÈÌ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∂¶ Î·È Ô‰ËÁÔ‡Ó Û ÌfiÓÈÌË Û·ÛÙÈÎfiÙËÙ·, ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ¤ÓÙÔÓÔ fiÓÔ. ∫·Ù¿ ηÈÚÔ‡˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∂¶ ‰È¿ÊÔÚ· ıÂڷ¢ÙÈο ̤ÙÚ·, fiˆ˜ Ë Ê˘ÛÈÎÔıÂڷ›·, ÔÈ ÔÚıԷȉÈΤ˜ ÂÂÌ‚¿ÛÂȘ, Ë ÂÎÏÂÎÙÈ΋ ÓˆÙÈ·›· ÚÈ˙ÔÙÔÌ‹ Î·È Ê¿Ú̷η. ∆· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· ÚÔÛÙ¤ıËΠÛÙË ıÂڷ›· Ë ÙÔÈ΋ ¯ÔÚ‹ÁËÛË ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ. ∏ ‡ÎÔÏË ¯ÔÚ‹ÁËÛ‹ Ù˘ ¯ˆÚ›˜ ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ÁÂÓÈ΋˜ ·Ó·ÈÛıËÛ›·˜ ‹ ¿ÏÏˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ÂȉڿÛÂˆÓ Î·È Ë Î·Ï‹ ·ÓÔ¯‹ Ù˘ ·fi ÙÔÓ ·ÛıÂÓ‹ ·Ó‹ÎÔ˘Ó ÛÙ· ÏÂÔÓÂÎÙ‹Ì·Ù· ¤Ó·ÓÙÈ Ù˘ Ê·Ú̷΢ÙÈ΋˜/ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂڷ›·˜. ∏ ∞∆-∞ ÂÈÙ˘Á¯¿ÓÂÈ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È ‚ÔËı¿ ÙÔ ¤ÚÁÔ Ù˘ Ê˘ÛÈÎÔıÂڷ›·˜ (3). ∏ Ì˘˚΋ ¯·Ï¿ÚˆÛË Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË Ù˘ ∞∆-∞, ÂÈÙÚ¤ÂÈ ÛÙÔÓ Ì˘ Ó· ·˘ÍËı› Û ̋ÎÔ˜ Î·È Û˘Ì‚¿ÏÏÂÈ ÛÙË ÁÂÓÈÎfiÙÂÚË ·‡ÍËÛË ÙÔ˘ ÛΤÏÔ˘˜. ¶ÚÔ¸fiıÂÛË Â›Ó·È Ó· Á›ÓÂÈ ÛˆÛÙ‹ ÂÈÏÔÁ‹ ÙˆÓ Ì˘ÒÓ. ∫ÏÈÓÈο, ÂÈϤÁÔÓÙ·È ÔÈ Ì‡Â˜ Ô˘ ÚÔηÏÔ‡Ó ¤ÓÙÔÓË Û·ÛÙÈÎfiÙËÙ·, fiÓÔ Î·È ÌÂÚÈ΋ Ì›ˆÛË ÙÔ˘ ÙfiÓÔ˘. ™Â ÌÂϤÙ˜ Ô˘ ‰ËÌÔÛȇıËÎ·Ó Ì¤¯ÚÈ Û‹ÌÂÚ· ıÂڷ‡ÙËΠ¤Ó·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ Ì ∞∆-∞ ÔÈ ÔÔ›ÔÈ ¤·Û¯·Ó ·fi Û·ÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ΛÓËÛ˘ (6-8,13-15). OÈ Gosgrove ηÈ
415
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·416
¶∞π¢π∞∆ƒπ∫∏ 2000;63:412-417
Graham ‰È·›ÛÙˆÛ·Ó Ì ÂÈÚ¿Ì·Ù· Û ÔÓÙ›ÎÈ·, fiÙÈ ÔÈ ÂÓ¤ÛÂȘ Ì ∞∆-∞ fi¯È ÌfiÓÔ ÂÏ¿ÙÙˆÛ·Ó ÙÔÓ Ì˘˚Îfi ÙfiÓÔ, ·ÏÏ¿ Ì›ˆÛ·Ó Ù· ÂÂÈÛfi‰È· ÙˆÓ Ì˘˚ÎÒÓ Û·ÛÌÒÓ (13). O Koman Î·È Û˘Ó. ‰È·›ÛÙˆÛ·Ó ‚ÂÏÙ›ˆÛË Û 6 ·È‰È¿ Ì ‰ÈÏËÁÈÎÔ‡ Ù‡Ô˘ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (6). ∞fi ÙËÓ ÌÂϤÙË ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ì·˜ ‰È·ÈÛÙÒÛ·Ì Ì›ˆÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜, ·‡ÍËÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ·ıËÙÈÎÒÓ Î·È /‹ ÂÓÂÚÁËÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÙˆÓ Ì˘ÒÓ ÛÙȘ ·ÚıÚÒÛÂȘ. ∞˘Ùfi Ô‰‹ÁËÛ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ı¤Û˘ ÙˆÓ ¿ÎÚˆÓ, ÛÙË Ì›ˆÛË ÙÔ˘ ¿ÏÁÔ˘˜ Î·È ÛÙËÓ Î·Ï‡ÙÂÚË ÎÈÓËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÒÌ·ÙÔ˜. ∏ Ì›ˆÛË ÙÔ˘ ÙfiÓÔ˘ ÙˆÓ ÚÔÛ·ÁˆÁÒÓ ÛÙ· 6/12 ·È‰È¿ Ì ¤ÓÙÔÓÔ „·ÏȉÈÛÌfi ‰È¢ÎfiÏ˘Ó ÙËÓ ˘ÁÈÂÈÓ‹ ÙÔ˘˜ ÂÚÈÔ›ËÛË, ÙË ÌÂÙ·ÊÔÚ¿ ̤۷ ÛÙÔ Û›ÙÈ Î·È ÙËÓ Î·ıÈÛÙÈ΋ ÙÔ˘˜ ı¤ÛË Û ηӷ¤ ‹ ·Ó·ËÚÈ΋ ηڤÎÏ·. ŒÙÛÈ, ·ÔʇÁÔÓÙ·È ÔÈ ÓÂÎÚÒÛÂȘ ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ·fi ÙËÓ ›ÂÛË Î·È ÙÚÈ‚‹ Ô˘ ·ÛÎÂ›Ù·È ·Ó¿ÌÂÛ· ÛÙ· fi‰È· Î·È Ë Ó¤ÎÚˆÛË Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘ ÏfiÁˆ ο̄˘ Î·È ÚÔÛ·ÁˆÁ‹˜ ÙˆÓ ÈÛ¯›ˆÓ. O Yong TF Î·È Û˘Ó. ·Ú·Ù‹ÚËÛ·Ó ÛÙÔ˘˜ 38 ·ÛıÂÓ›˜ Ì ∂¶, 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Ù˘ ∞∆-∞, Ì›ˆÛË ·fi 2,7 Û 1,5 ÁÈ· ÙÔ˘˜ ÚÔÛ·ÁˆÁÔ‡˜ Î·È ·fi 2,9 Û 1,9 ÁÈ· ÙÔ˘˜ Á·ÛÙÚÔÎÓ‹ÌÈÔ˘˜, Û‡Ìʈӷ Ì ÙËÓ ÙÚÔÔÔÈË̤ÓË Îϛ̷η Ashwort (16). ™ÙÔ˘˜ ‰ÈÎÔ‡˜ Ì·˜ ·ÛıÂÓ›˜ (¶›Ó·Î·˜ 3), Ë ¯ÔÚ‹ÁËÛË Ù˘ ∞∆∞ ÛÙÔ˘˜ ηÌÙ‹Ú˜ ÙÔ˘ ÁfiÓ·ÙÔ˜ ‰È¢ÎfiÏ˘Ó ÙÔÓ Â˘ıÂÈ·ÛÌfi Î·È ÙËÓ Î›ÓËÛË ÛÙÔÓ ÙÂÙڷΤʷÏÔ Ì˘. ™ÙȘ 7 ÂÚÈÙÒÛÂȘ ¤ÓÂÛ˘ ÙˆÓ Á·ÛÙÚÔÎÓËÌ›ˆÓ, ·˘Í‹ıËÎÂ Ë ÂÈÊ¿ÓÂÈ· ÛÙ‹ÚÈ͢ ÛÙÔ ¤ÏÌ· ηıÒ˜ Î·È ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ‚ËÌ·ÙÈÛÌÔ‡. ∏ ÂÈÛÙÚÔÊ‹ ÙÔ˘ ÙfiÓÔ˘ ÛÙÔ ‰˘Ó·ÙfiÙÂÚÔ Ê˘ÛÈÔÏÔÁÈÎfi ÛËÌÂ›Ô ÂÈÙÚ¤ÂÈ ÙË ‰È¿Ù·ÛË ÙˆÓ Û·ÛÙÈÎÒÓ Ì˘ÒÓ Î·È ‰›ÓÂÈ ÂÚÂı›ÛÌ·Ù· ÚÔ¿ÁÔÓÙ·˜ Ù· ÛÙ¿‰È· Ù˘ ΛÓËÛ˘. ∏ ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘ Ô˘ ¤ÁÈÓ Û ‰‡Ô ·ÛıÂÓ›˜ Ì ËÌÈÏËÁ›· ¤‰ÂÈÍ Ì ·ÓÙÈÎÂÈÌÂÓÈÎfi ÙÚfiÔ ÙË ‚ÂÏÙ›ˆÛË ÛÙË ‚¿‰ÈÛË. O Calderon-Gonzalez Î·È Û˘Ó. Û ÌÂϤÙË 12 ·ÛıÂÓÒÓ Ì ۷ÛÙÈ΋ ÌÔÚÊ‹ ∂¶ η٤ÏËÍ·Ó Û ·ÚfiÌÔÈ· Û˘ÌÂÚ¿ÛÌ·Ù· (8). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË 33 ·È‰ÈÒÓ Ì ∂¶ ·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ¯ÔÚ‹ÁËÛË 200 ÌÔÓ¿‰ˆÓ ∞∆-∞ ηٷÓÂÌË̤Ó˘ Û ٤ÛÛÂÚȘ ‹ ¤ÓÙ ̇˜ ·Ó¿ ¿ÎÚÔ, ›¯Â ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË 100 ÌÔÓ¿‰ˆÓ (10). O ‚·ıÌfi˜ ·ÛÊ¿ÏÂÈ·˜ Î·È ÛÙȘ ‰˘Ô ÂÚÈÙÒÛÂȘ ‹Ù·Ó Ô ›‰ÈÔ˜. ªÂ ÙÔÓ ›‰ÈÔ ÙÚfiÔ Î·Ù·ÓÔÌ‹˜ ÂÓ¤ıËÎÂ Î·È ÛÙÔ˘˜ ‰ÈÎÔ‡˜ Ì·˜ ·ÛıÂÓ›˜ Ë ∞∆∞, Ë ÔÔ›· ·Ó¿ Û˘Ó‰ڛ· ‰ÂÓ Í¤ڷÛ ÛÙ· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚÔ˘ ‚¿ÚÔ˘˜, ÙȘ 200 ÌÔÓ¿‰Â˜. ™·Ê‹˜ Û˘Û¯¤ÙÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂıfi‰Ô˘ Ì ÙËÓ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ‰ÂÓ ˘‹ÚÍÂ. ∏ ÂÎÙ›ÌËÛ‹ Ì·˜ Â›Ó·È fiÙÈ Ë Ì·ÎÚfi¯ÚÔÓË Û·ÛÙÈÎfiÙËÙ· Î·È Ë ·ÚÔ˘Û›· ¤ÛÙˆ Î·È ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ·Ú·ÌÔÚÊÒÛÂˆÓ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÂËÚ¤·Û ·ÚÓËÙÈο Ù· ·ÔÙÂϤÛÌ·Ù·. ™Â ¿ÏϘ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·È‰È¿ οو ÙˆÓ 7 ÂÙÒÓ ¤¯Ô˘Ó ηχÙÂÚË ·ÓÙ·fiÎÚÈÛË ÛÙË
416
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ıÂڷ›· ÁÈ·Ù› ‰ÂÓ ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó ·ÎfiÌË ÌfiÓÈ̘ Û˘Áο̄ÂȘ/Û˘Û¿ÛÂȘ (7). ™‡Ìʈӷ Ì ÙȘ ‰ËÌÔÛȇÛÂȘ, ·ÏÏ¿ Î·È ÙË ‰È΋ Ì·˜ ÌÈÎÚ‹ ÂÌÂÈÚ›·, ηχÙÂÚÔ˜ ¯ÚfiÓÔ˜ ¯ÔÚ‹ÁËÛ˘ Â›Ó·È ÔÈ ËÏÈ˘ οو ÙˆÓ ¤ÓÙ ¯ÚfiÓˆÓ. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯Ú‹ÛË Ù˘ ∞∆-∞ Û ÙÔÈ΋ ¯ÔÚ‹ÁËÛË ÔÈ Âί˘ÌÒÛÂȘ, ÙÔ Ô›‰ËÌ·, Ë ‹È· ÁÂÓÈÎÂ˘Ì¤ÓË Ì˘˚΋ ˘ÔÙÔÓ›·, Ë ÎÂÊ·Ï·ÏÁ›· Î·È Ë Î·Ù·ÎÚ¿ÙËÛË Ô‡ÚˆÓ ÛÙËÓ Î‡ÛÙË. ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·ÚÂÓ¤ÚÁÂȘ ÂÎÙfi˜ ·fi ÙÔÓ fiÓÔ ÙÔ˘ Ì˘fi˜ ηٿ ÙËÓ ¤ÓÂÛË. ø˜ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ·Ó·Ê¤ÚÂÙ·È ·ÎfiÌË Ë ·Ó¿Ù˘ÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ∞∆-∞ Ù· ÔÔ›· ÂÌÔ‰›˙Ô˘Ó ÙËÓ ·¿ÓÙËÛË ÛÙË ıÂڷ›· (18). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ∞∆-∞ ¯ÔÚËÁ›ÙÔ Î¿ı 3 ‚‰ÔÌ¿‰Â˜ Î·È Ì¿ÏÈÛÙ· Û ˘„ËϤ˜ ‰fiÛÂȘ. ∆Ô ÌÂÛԉȿÛÙËÌ· ÙˆÓ 3-4 ÌËÓÒÓ Î·È Ë ·ÔÊ˘Á‹ ‰fiÛÂˆÓ Ô˘ ÍÂÂÚÓÔ‡Ó ÙȘ 300 ÌÔÓ¿‰Â˜ ·Ó¿ Û˘Ó‰ڛ·, ÚÔÏ·Ì‚¿ÓÂÈ Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ·ÓÙȉڿÛÂȘ. ™ÙË ‰È΋ Ì·˜ ÌÂϤÙË ‰ÂÓ ˘‹ÚÍ ‰˘Ó·ÙfiÙËÙ· ̤ÙÚËÛ˘ ·ÓÙÈۈ̿وÓ. ∞ÎÔÏÔ˘ıÒÓÙ·˜ fï˜ ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ ·Ó¿ Û˘Ó‰ڛ· ¯ÔÚËÁ‹ÛÂȘ ‰ÂÓ ˘ÂÚ¤‚·ÈÓ·Ó Û˘ÓÔÏÈο ÙȘ 200 ÌÔÓ¿‰Â˜. ™Ù· ·ÚÓËÙÈο Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜ ·Ó‹ÎÂÈ Ë ÂÚÈÔÚÈṲ̂ÓË ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (2-6 Ì‹Ó˜), Ë ·Ó¿ÁÎË Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ÂÓ¤ÛÂˆÓ Î·È Ê˘ÛÈο ÙÔ ˘„ËÏfi ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜. O Gooch Î·È Û˘Ó. Û ÌÈ· ÙÂÏÂ˘Ù·›· ÂÚÁ·Û›· ÚÔÙ›ÓÔ˘Ó ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ∞∆-A Û ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ÂÍ·ÓÙÏËı› fiÏ· Ù· ¿ÏÏ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· (14). ™‡Ìʈӷ Ì ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜, ·ÏÏ¿ Î·È ·fi ÙË ‰È΋ Ì·˜ ÂÌÂÈÚ›·, Ë ÚÒÈÌË ¯ÔÚ‹ÁËÛË ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Û ‰fiÛË 7 ÌÔÓ¿‰ˆÓ/Kgµ™ Û ÂÈÏÂÁ̤ÓÔ˘˜ ̇˜ Û ·È‰È¿ Ì ∂¶, ÌÂÈÒÓÂÈ ÙÔÓ Ì˘˚Îfi ÙfiÓÔ, ÙȘ Û˘Û¿ÛÂȘ, ·˘Í¿ÓÂÈ ÙÔ Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘ ‰È¢ÎÔχÓÔÓÙ·˜ ÙÔ ¤ÚÁÔ ÙÔ˘ Ê˘ÛÈÎÔıÂÚ·Â˘Ù‹, ÙÔ˘ ·È‰ÔÓ¢ÚÔÏfiÁÔ˘ Î·È ÙÔ˘ ÔÚıԷȉÈÎÔ‡. ª·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜ ı· ‰ÒÛÔ˘Ó ÌÂÏÏÔÓÙÈο ÂÚÈÛÛfiÙÂÚ˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·ÛË Ù˘ ∞∆-∞ ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÏÂÈÙÔ˘ÚÁ›· Ù˘ Ì˘˚΋˜ ÌÔÓ¿‰·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Scott AB. Botulinum A toxin injection of eye muscles to correct strabismus. Trans Am Ophtalmol Soc 1981;79:734-770. 2. Langueny A. Botulinum toxin for spasticity: an overview. Eur J Neur 1995;2:41-46. 3. Snow BJ, Tsui JKC, Bharr MH, Varelas M, Hashimoto SA, Caine DB. Treatment of spasticity with Botox: a double blind study. Ann Neurol 1990;28:512-515. 4. American Academy of Neurology. Assessment: the clinical usefulness of botulinum toxin- A in treating neurological disorders. Neurology 1990;40:1332-1336. 5. Deuchl G. Botulinumtoxin- Forum 1995. 1. Auflage Hamburg: Wissenschaftsverlag Wellingsbuettel, 1995.
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6. Koman LA, Mooney JF, Smith BP. Management of cerebral palsy with Botox A: A randomized double-blind study. Dev Med Child Neurol 1992:34(Suppl 66):23. 7. Chutorian M, Root L. Management of Spasticity in Children with Botulinum-A Toxin. Int Pediatr 1994;9 (Suppl 1):35-43. 8. Calderon-Gonzalez R, Calderon-Sepulveda R, RinconReyes M, Garcia-Ramirez J, Mino-Arango E. Botulinum toxin A in management of cerebral palsy. Pediatr Neurol 1994;14:281-287. 9. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã. ∂ÁÎÂÊ·ÏÈ΋ ¶·Ú¿Ï˘ÛË: ¶·ÚÂÏıfiÓ, ¶·ÚfiÓ, ª¤ÏÏÔÓ. £ÂÛÛ·ÏÔÓ›ÎË: °È·¯Ô‡‰Ë-°È·Ô‡ÏË; 1998. 10. O’Dwyer NJ, Neilson DP, Nash J. Mechanism of muscle growth related to muscle contracture in cerebral palsy. Dev Med Child Neurol 1989;31:543-552. 11. Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practit 1964;92:540-542. 12. Bohannon RW, Smith MB. Interrarer reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206-207. 13. Cosgrore AP, Graham HK. Botulinum toxin - A prevents the development of contracture in the hereditary spastic mouse. Dev Med Child Neurol 1992;34(Supll 66):23. 14. Gooch Judith L, Sandell TV. Botulinum toxin for spasticity and athetosis in children with cerebral palsy. Arch Phys Med Rehabil 1996;77:508-511. 15. Wissel J, Muller J, Heinen F, Mall V, Sojer M, Ebersbach G, Poewe W. Safety and tolerance of single-dose botulinum toxin Type A treatment in 204 patients with spasticity and localized assosiated symptoms. Austrian and German botulinum toxin A spasticity study group. Wien Klin Wochenschr 1999;111:837-842.
∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË
16. Yang TF, Chan RC, Chuang TY, Liu TJ, Chiu JW. Treatment of cerebral palsy with botulinum toxin: evaluation with gross motor function measures. J Formos Med Assoc 1999;98(12):832-836. 17. Wissel J, Heinen F, Schenkel A, Doll B, Ebersbach G, Müller J, Poewe W. Botulinum toxin a in the management of spastic gait disorders in children and young adults with cerebral palsy: A randomized, double-blind study of highdose versus low-dose treatment. Neuropediatrics 1999;30:120-124. 18. Tsui JK, Wong NLM, Wong E, Calne DB. Production of circulating antibodies to botulinum-A toxin in patients receiving repeated injections for dystonia. Ann Neurol 1988;23:181. 19. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group. J Pediatr Orthop 2000;20:108-115. 20. Birklein F, Erbguth F. Pseudomotor testing discriminates between subjects with and without antibodies against botulinum toxin-A: a preliminary observation. Mov Disord 2000;15:146-149. 21. Zaleski P. Advances in botulinum toxin applications. Pol Merkuriusz Lek 1999;7:134-137. 22. ÃÚ. ¶·ÓÙÂÏÈ¿‰Ë˜. £Âڷ¢ÙÈÎfi ÂÁÎfiÏÈÔ ·È‰È·ÙÚÈ΋˜. 3Ë ¤Î‰ÔÛË. £ÂÛÛ·ÏÔÓ›ÎË: °È·¯Ô˘‰‹ - °È·Ô‡ÏË; 1999. 23. Panteliadis Chr, Darras BT. Encyclopaedia of paediatric neurology-Theory and Practice. Second Edition. Stuttgart: Thieme Verlag; 1999.
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:418-421
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™˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË πÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ª¿Úı· ÷ڛÛË1, ∞ÈηÙÂÚ›ÓË ∑ÈÒÁ·2, ∂˘·ÁÁÂÏ›· ∫ÚËÙÈÎÔ‡1, ∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘1, ∑ˆ‹ ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹1 ● ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ı‹ÏÂÔ˜ ‚Ú¤ÊÔ˘˜ ÌÂ Û˘ÁÁÂÓ‹ ·˘ÙÔ˚¿ÛÈÌË ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans. H ÌÈÎÚ‹ ·ÛıÂÓ‹˜ ÂÌÊ¿ÓÈ˙ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 20 ËÌÂÚÒÓ ÁÂÓÈÎÂ˘Ì¤ÓÔ Ê˘Û·ÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ¯ˆÚ›˜ ¿ÏÏÔ ·Ó·ÊÂÚfiÌÂÓÔ Úfi‚ÏËÌ· ˘Á›·˜. OÈ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ˘Ô¯ÒÚËÛ·Ó ·˘ÙfiÌ·Ù· Û ‰È¿ÛÙËÌ· Ï›ÁˆÓ ÌËÓÒÓ. ¢ÂÓ ˘‹ÚÍ·Ó ˘ÔÙÚÔ¤˜ Î·È Ë ÔÚ›· Ù˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ¿ÚÈÛÙË. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ¤‰ÂÈÍ ÙËÓ ‡·ÚÍË Ù˘ÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Langerhans. H Û˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans Â›Ó·È Û˘Ó‹ıˆ˜ ÌÈ· ηÏÔ‹ı˘, ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ‰È·Ù·Ú·¯‹, ÂÌÊ·ÓÈ˙fiÌÂÓË Î·Ù¿ ÙË Á¤ÓÓËÛË ‹ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÙÔ ‰¤ÚÌ·, ·ÏÏ¿ ÚÔÛÂÎÙÈ΋ ÂÎÙ›ÌËÛË ÁÈ· ‡·ÚÍË Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘ Ú¤ÂÈ ¿ÓÙ· Ó· ‰ÈÂÓÂÚÁ›ٷÈ. ∞·Ú·›ÙËÙË Â›Ó·È Â›Û˘ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· Ù˘¯fiÓ ÂÌÊ¿ÓÈÛË ˘ÔÙÚÔ‹˜ ‹ ÁÂÓ›Î¢Û˘ Ù˘ ÓfiÛÔ˘. ∞ӷχÔÓÙ·È Ù· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ Î·È Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ÚfiÛÊ·Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. ¶·È‰È·ÙÚÈ΋ 2000;63:418-421. §¤ÍÂȘ ÎÏÂȉȿ: ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË, Ê˘Û·ÏȉԂϷÙȉ҉˜ ÓÂÔÁÓÈÎfi ÂÍ¿ÓıËÌ·. M. Charisi, A. Zioga, E Kritikou, A. Siamopoulou-Mavridou, Z. Papadopoulou-Couloumbis. Congenital selfhealing Langerhans cell Histiocytosis. Case report and review of the literature. Paediatriki 2000;63:418-421. ● Abstract: We describe the case of a female infant with congenital self-healing Langerhans cell histiocytosis (CSHLCH). ∞t 20 days of age she developed a generalized papulovesicular eruption, without any other evidence of health problem. The dermal lesions resolved spontaneously within a few months. There were no relapses and the patient’s outcome was excellent. Histopathologic study of the skin lesions revealed typical Langerhans cells. CSHLCH is usually a benign, self-limited disorder usually seen at birth or in the neonatal period, which involves mainly the skin, but careful evaluation for extracutaneous disease must be performed. Long-term follow-up for evidence of relapse or progression of disease is essential. The clinical and laboratory characteristics of the disease are discussed and the current literature is reviewed. Key words: histiocytosis, papulovesicular neonatal rash.
∂ÈÛ·ÁˆÁ‹ ∏ Û˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË IÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans (Congenital Self Healing Langerhans Cell Histiocytosis, CSHLCH) ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1973 ·fi ÙÔ˘˜ Hashimoto Î·È Pritzker (1). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÔÏÏ·ÏÒÓ ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ÔÈ Ôԛ˜ ÈÛÙÔÏÔÁÈο Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο ·Ó·‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ‡·ÚÍË Î˘ÙÙ¿ÚˆÓ Langerhans. ™ÙÔ
1 2
™˘ÓÙÔÌÔÁڷʛ˜ LCH: CSHLCH: HBV: HCV: HSV: EBV: CMV: ∂£:
∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ¶.¶.°.¡. πˆ·ÓÓ›ÓˆÓ
418
Langerhans cell histiocytosis Congenital self-healing Langerhans cell histiocytosis Hepatitis B Virus Hepatitis C Virus Herpex simplex virus Epstein Barr virus Cytomegalovirus ∂ηÙÔÛÙÈ·›· ı¤ÛË
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·419
¶∞π¢π∞∆ƒπ∫∏ 2000;63:418-421
ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÂÚÈÙÒÛÂˆÓ Â›Ó·È Ì›· ηÏÔ‹ı˘ ¿ıËÛË ÛÙËÓ ÔÔ›· ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ ˘ÔÛÙÚ¤ÊÔÓÙ·È Û ‰È¿ÛÙËÌ· Ï›ÁˆÓ ÌËÓÒÓ, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· ¿ÏÏˆÓ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ. ªÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ›Ù ÛÙÔ ‰¤ÚÌ· ›Ù Û ¿ÏÏÔ fiÚÁ·ÓÔ (2). ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË Û˘ÁÁÂÓÔ‡˜ ·˘ÙÔ˚¿ÛÈÌ˘ ÈÛÙÈÔ΢ÙÙ¿ÚˆÛ˘ Û ÓÂÔÁÓfi Î·È Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ÚfiÛÊ·Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 21/2 ÌËÓÒÓ, ÂÈÛ‹¯ıË ÛÙËÓ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÏfiÁˆ ÁÂÓÈÎÂ˘Ì¤ÓÔ˘ Ê˘Û·ÏȉԂϷÙÈ‰Ò‰Ô˘˜ ÂÍ·Óı‹Ì·ÙÔ˜ Ô˘ ÂÌÊ¿ÓÈÛ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 20 ËÌÂÚÒÓ. ∆Ô ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2.900 gr. Afi ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ ̤¯ÚÈ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ÛÙËÓ ÎÏÈÓÈ΋ Ë ·ÛıÂÓ‹˜ ›¯Â Ï¿‚ÂÈ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹, ÏfiÁˆ ıÂÙÈ΋˜ ηÏÏȤÚÁÂÈ·˜ ‰ÂÚÌ·ÙÈ΋˜
∂ÈÎfiÓ· 1. ¢È¿Û·ÚÙÔ, ÂÚ˘ıÚfiÊ·ÈÔ˘ ¯ÚÒÌ·ÙÔ˜, ÌË Û˘ÚÚ¤ÔÓ ‚Ï·Ùȉ҉˜ Î·È Ê˘Û·Ïȉ҉˜ ÂÍ¿ÓıËÌ· Ô˘ ηٷϷ̂¿ÓÂÈ ÔÏfiÎÏËÚÔ ÙÔ ÛÒÌ·.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
‚Ï¿‚˘ ÁÈ· ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ, ηıÒ˜ ›Û˘ Î·È ÙÔÈ΋ ·ÁˆÁ‹ Ì Benzogal Î·È Filocot Ì ÙËÓ ˘fiÓÔÈ· „ÒÚ·˜. §fiÁˆ ÌË ‚ÂÏÙ›ˆÛ˘, ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÁÈ· ‰ÈÂÚ‡ÓËÛË. ∫·Ù¿ ÙËÓ Â›ÛÔ‰fi Ù˘ Ù· ۈ̷ÙÔÌÂÙÚÈο Ù˘ ÛËÌ›· ‚¿ÚÔ˘˜, Ì‹ÎÔ˘˜ Î·È ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜ ‹Ù·Ó ÛÙËÓ 10Ë, 10Ë Î·È 50Ë ∂£ ·ÓÙ›ÛÙÔȯ·. ∏ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· ·¤‚Ë ·ÚÓËÙÈ΋ ÂÓÒ ÙÔ ÌfiÓÔ ÂÌÊ·Ó¤˜ ÎÏÈÓÈÎfi ‡ÚËÌ· ÚÔÂÚ¯fiÙ·Ó ·fi ÙÔ ‰¤ÚÌ·. ∂ÌÊ¿ÓÈ˙ ÌË Û˘ÚÚ¤ÔÓ ÂÍ¿ÓıËÌ· Ô˘ ηٷϿ̂·Ó ÔÏfiÎÏËÚÔ ÙÔ ÛÒÌ· (ÙÚȯˆÙfi ÎÂÊ·Ï‹˜, ÚfiÛˆÔ, ÎÔÚÌfi, ¿ÎÚ·, ·Ï¿Ì˜ Î·È ¤ÏÌ·Ù·) ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi ‰È¿Û·ÚÙ˜ ‚Ï·Ù›‰Â˜ Î·È Ê˘Û·Ï›‰Â˜ ‰È·Ì¤ÙÚÔ˘ ~5mm ÂÚ˘ıÚfiÊ·ÈÔ˘ ¯ÚÒÌ·ÙÔ˜ (∂ÈÎfiÓ· 1). ŸÏ˜ ÔÈ ‚Ï¿‚˜ ‰ÂÓ ‹Ù·Ó ÔÌÔÈfiÌÔÚʘ, ·ÏÏ¿ ÔÚÈṲ̂Ó˜ ÂÌÊ¿ÓÈ˙·Ó Ù¿ÛË ÂÈÊ·ÓÂȷ΋˜ ÂͤÏΈÛ˘ Ì ÂÊÂÏÎȉÔÔ›ËÛË. OÈ ÈÔ ·ÏȤ˜ ‚Ï¿‚˜ Ô˘ ‹Ù·Ó Û ·Ô‰ÚÔÌ‹ ÂÁη٤ÏÂÈ·Ó ÌÂÏ·Á¯ÚˆÌ·ÙÈΤ˜ ÎËÏ›‰Â˜ ‰È·Ì¤ÙÚÔ˘ 2-5 mm. OÈ ÛÙÔÌ·ÙÈÎÔ› ‚ÏÂÓÓÔÁfiÓÔÈ ‹Ù·Ó ÂχıÂÚÔÈ ‚Ï·‚ÒÓ. ¶Ï‹Ú˘ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ ÂÎÙfi˜ ·fi ·˘ÍË̤Ó˜ ÙÈ̤˜ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ (AST 164 U/L Î·È ALT 130 U/L, Ì º∆ ̤¯ÚÈ 30U/L). O ÏÔÈfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ (¯ÔÏÂÚ˘ıÚ›ÓË, ËÏÂÎÙÚÔÊfiÚËÛË ÏÂ˘ÎˆÌ¿ÙˆÓ, ¤ÏÂÁ¯Ô˜ ËÎÙÈÎfiÙËÙ·˜). §fiÁˆ ·˘ÙÔ‡ ÙÔ˘ Â˘Ú‹Ì·ÙÔ˜ ·ÎÔÏÔ‡ıËÛ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ηıÒ˜ Î·È ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ (HBV, HCV, HSV1, HSV2, EBV, CMV) Ô ÔÔ›Ô˜ ·¤‚Ë ·ÚÓËÙÈÎfi˜. ∏ ‡·ÚÍË ıÂÙÈÎÔ‡ ÛËÌ›Ԣ Darier, ‰ËÏ·‰‹ ÂÌÊ¿ÓÈÛË ‹È·˜ ÙÔÈ΋˜ ÎÓȉˆÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÌÂÙ¿ ·fi Ì˯·ÓÈÎfi ÂÚÂıÈÛÌfi Ù˘ ‚Ï¿‚˘ ¤ıÂÛ ÙËÓ ˘fiÓÔÈ· Ì·ÛÙÔ·ÙÙˆÛ˘. ∏ ‚ÈÔ„›· fï˜ ‰ÂÚÌ·ÙÈ΋˜ ‚Ï¿‚˘ ¤‰ÂÈÍ ‰È‹ıËÛË ÙÔ˘ ıËÏÒ‰Ô˘˜ ¯ÔÚ›Ô˘ ·fi ·ÙÙ·Ú· ÌÈÎÚÔ‡ Î·È ÌÂÙÚ›Ô˘ ÌÂÁ¤ıÔ˘˜ Ì ·ÚÎÂÙfi
∂ÈÎfiÓ· 2. EÎÙÂٷ̤ÓË ‰È‹ıËÛË ·fi ÓÂÊÚÔÂȉ‹ ÈÛÙÈÔ·ÙÙ·Ú· ηٿ Ì‹ÎÔ˜ ÙÔ˘ ‰ÂÚÌÔÂȉÂÚÌÈÎÔ‡ ÔÚ›Ô˘ (∏ + ∂ x 10).
419
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·420
¶∞π¢π∞∆ƒπ∫∏ 2000;63:418-421
΢ÙÙ·ÚfiÏ·ÛÌ· Î·È ˘Ú‹Ó˜ ÛÙÚoÁÁ˘ÏÔ‡˜, ÂÈÌ‹ÎÂȘ Î·È Û·ÓÈfiÙÂÚ· Ì ÓÂÊÚÔÂȉ¤˜ ‹ ÏÔ‚ˆÙfi Û¯‹Ì· (∂ÈÎfiÓ· 2). ∞ÓÔÛÔ˚ÛÙÔ¯ËÌÈο ˘‹Ú¯Â ıÂÙÈÎfiÙËÙ· ÛÙËÓ S-100 ÚˆÙ½ÓË. ∏ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì πÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans (Langerhans Cell Histiocytosis, LCH). ŒÏÂÁ¯Ô˜ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ‹ ÌË Ù˘ ÁÂÓÈÎÂ˘Ì¤Ó˘ ÌÔÚÊ‹˜ Ù˘ ÓfiÛÔ˘ ·¤‚Ë ·ÚÓËÙÈÎfi˜ (ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË, ·ÎÙÈÓÔÁڷʛ˜ ÎÚ·Ó›Ô˘, Ì·ÎÚÒÓ ÔÛÙÒÓ, ˘¤Ú˯ÔÈ ÎÔÈÏ›·˜ Î·È ‚ÈÔ„›· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ). §fiÁˆ ÌË Û˘ÌÌÂÙÔ¯‹˜ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ıˆڋıËΠÛÎfiÈÌÔ Ó· ÌËÓ ‰Ôı› η̛· ·ÁˆÁ‹. ∏ ÔÚ›· Ù˘ ÌÈÎÚ‹˜ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ¿ÚÈÛÙË. ∂ÌÊ¿ÓÈÛ ÚÔԉ¢ÙÈ΋ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ‚Ï·‚ÒÓ Î·È ÛÙ·‰È·Î‹ ÙÒÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ. ™Â ËÏÈΛ· 4 ÌËÓÒÓ fiϘ ÔÈ ‚Ï¿‚˜ ›¯·Ó ˘Ô¯ˆÚ‹ÛÂÈ Î·È ÔÈ ÙÚ·ÓÛ·ÌÈÓ¿Û˜ ·ÔηٷÛÙ¿ıËÎ·Ó ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi. ª¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ ‰ÂÓ ˘‹ÚÍ ÂÌÊ¿ÓÈÛË Ó¤ˆÓ ‚Ï·‚ÒÓ. ∏ ۈ̷ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ Ù˘ ·Ó¿Ù˘ÍË ÂÍÂÏÈÛÛfiÙ·Ó Ê˘ÛÈÔÏÔÁÈο. ™˘˙‹ÙËÛË ™ÙÔ ·ÚÂÏıfiÓ, Ë ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans (Langerhans cell Histiocytosis, LCH), ·Ï·ÈfiÙÂÚ· ÁÓˆÛÙ‹ Î·È Û·Ó πÛÙÈÔ΢ÙÙ¿ÚˆÛË Ã, ÂÚÈÂÏ¿Ì‚·Ó ÙÚÂȘ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜: ·) ÙË ÓfiÛÔ ÙˆÓ Hand-Schüller-Christian, ‚) ÙË ÓfiÛÔ ÙˆÓ LettererSiwe Î·È Á) ÙÔ ËˆÛÈÓfiÊÈÏÔ ÎÔÎΛˆÌ·. ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ·Ó·ıˆڋıËΠ·˘Ù‹ Ë Ù·ÍÈÓfiÌËÛË Î·È Û‹ÌÂÚ· ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ÌÈ· ÔÓÙfiÙËÙ· Ì ¢ڇ Ê¿ÛÌ· ÂΉËÏÒÛˆÓ, ·ÏÏ¿ Ì ÙËÓ ›‰È· ¿ÓÙ· ‰È·Ù·Ú·¯‹, ÙËÓ ˘ÂÚÏ·Û›· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Langerhans. °È· ÚÔÁÓˆÛÙÈÎÔ‡˜ Î·È ıÂڷ¢ÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ‰È·ÈÚÂ›Ù·È ÛÙËÓ ÂÚÈÔÚÈṲ̂ÓË ÌÔÚÊ‹, fiÔ˘ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÏÔÓÙ·È ÙÔ ‰¤ÚÌ·, ÔÈ ÏÂÌÊ·‰¤Ó˜ ‹ Ù· ÔÛÙ¿, Î·È ÛÙËÓ ÂÎÙÂٷ̤ÓË ÌÔÚÊ‹ fiÔ˘ ˘¿Ú¯ÂÈ ÛÏ·Á¯ÓÈ΋ Û˘ÌÌÂÙÔ¯‹ Ì ‹ ¯ˆÚ›˜ ÔÚÁ·ÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (3,4). ∏ Û˘ÁÁÂÓ‹˜ ·˘ÙÔ˚¿ÛÈÌË πÛÙÈÔ΢ÙÙ¿ÚˆÛË ·fi ·ÙÙ·Ú· Langerhans (Congenital Self-Healing Langerhans Cell Histiocytosis, CSHLCH) ·ÔÙÂÏ› Ì›· ‰È·ÎÚÈÙ‹ ÔÓÙfiÙËÙ· ÂÚÈÔÚÈṲ̂Ó˘ ÈÛÙÈÔ΢ÙÙ¿ÚˆÛ˘. ∆Ô 1973 ÔÈ Hashimoto Î·È Pritzker (1) ÚˆÙÔÂÚȤÁÚ·„·Ó ¤Ó· Ê·ÈÓÔÌÂÓÈο ˘ÁȤ˜ ÎÔÚ›ÙÛÈ, ÙÔ ÔÔ›Ô ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘ ÂÌÊ¿ÓÈ˙ ηıÔÏÈÎfi ÂÍ¿ÓıËÌ· ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi ÂÚ˘ıÚfiÊ·È· ‰È·ÎÚÈÙ¿ Ô˙›‰È·, Ù· ÔÔ›· ˘ÔÛÙÚ¿ÊËÎ·Ó ·˘ÙfiÌ·Ù· ÂÓÙfi˜ 5 ‚‰ÔÌ¿‰ˆÓ, ·Ê‹ÓÔÓÙ·˜ ·ÙÚÔÊÈΤ˜ Ô˘Ï¤˜. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ Ô˙ȉ›ˆÓ ¤‰ÂÈÍ ÙËÓ ‡·ÚÍË Î˘ÙÙ¿ÚˆÓ Langerhans. ∏ ÓfiÛÔ˜ ‰ÂÓ ˘ÔÙÚÔ›·Û Û ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË 14 ÂÙÒÓ. ∞fi ÙÔ 1973 ¤ˆ˜ Û‹ÌÂÚ· ‰ËÌÔÛȇÙËÎ·Ó ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ CSHLCH ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (1,2,5-7). ∆· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ Û fiϘ ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÈÙÒÛÂȘ, ηıÒ˜ Î·È ÛÙË ‰È΋ Ì·˜, Â›Ó·È ÎÔÈÓ¿:
420
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
1) ¢ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙË Á¤ÓÓËÛË ‹ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. OÈ ‚Ï¿‚˜ Û˘Ó›ÛÙ·ÓÙ·È ·fi ¤Ó· Ì›ÁÌ· ·fi ÎËÏ›‰Â˜, ‚Ï·Ù›‰Â˜, Ê˘Û·Ï›‰Â˜ ‹ Ô˙›‰È· Î·È Â›Ó·È ‰È¿Û·ÚÙ˜ Û fiÏÔ ÙÔ ÛÒÌ·. Œ¯Ô˘Ó Ù¿ÛË ÁÈ· ÂÈÊ·ÓÂȷ΋ ÂÊÂÏÎȉÔÔ›ËÛË Î·È fiÙ·Ó ˘ÔÛÙÚ¤ÊÔÓÙ·È ·Ê‹ÓÔ˘Ó ÌÂÏ·Á¯ÚˆÌ·ÙÈΤ˜ ÎËÏ›‰Â˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ˘ÁȤ˜ ‰¤ÚÌ·. 2) ŒÓ· Ê·ÈÓÔÌÂÓÈο ˘ÁȤ˜ ÓÂÔÁÓfi-‚Ú¤ÊÔ˜ ¯ˆÚ›˜ ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. 3) ∞˘ÙfiÌ·ÙË ˘ÔÛÙÚÔÊ‹ ÙˆÓ ‚Ï·‚ÒÓ Û ‰È¿ÛÙËÌ· 1-3 ÌËÓÒÓ Î·È Û·Ó›ˆ˜ ̤¯ÚÈ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜. 4) πÛÙÔ·ıÔÏÔÁÈ΋ ‚‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘. °È· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· (CSHLCH) ·ÚΛ Ë ·Ó‡ÚÂÛË ÙˆÓ Ù˘ÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Langerhans ÛÂ Û˘Ó‰˘·ÛÌfi Ì ıÂÙÈ΋ ¯ÚÒÛË Ì ÙËÓ S-100 ÚˆÙ½ÓË (2). ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ù›ıÂÙ·È Ë ‰È¿ÁÓˆÛË CSHLCH Ú¤ÂÈ ¿ÓÙ· Ó· Á›ÓÂÙ·È Û˘ÛÙËÌ·ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ·ÔÎÏÂÈÛÌfi Â͈‰ÂÚÌ·ÙÈ΋˜ ÚÔÛ‚ÔÏ‹˜ (‹·Ú - ÛÏ‹Ó·˜ - Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ - ÏÂÌÊ·‰¤Ó˜ ÔÛÙ¿). ™ÙËÓ ·ÛıÂÓ‹ Ì·˜ Ô ¤ÏÂÁ¯Ô˜ ·¤‚Ë ·ÚÓËÙÈÎfi˜. ∏ ̤ÙÚÈ· ÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›· Ô˘ ·Ú·ÙËÚ‹ıËΠ‰ÂÓ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË Ë·ÙÈ΋˜ ÚÔÛ‚ÔÏ‹˜ ÁÈ·Ù› ·ÊÂÓfi˜ ÌÂÓ ‹Ù·Ó ·ÚÔ‰È΋ Î·È ·ÊÂÙ¤ÚÔ˘, ‰ÂÓ Û˘Óԉ¢fiÙ·Ó ·fi Ë·ÙÔÌÂÁ·Ï›· Ô˘ ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ¤Ó‰ÂÈÍË Ë·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (3,4). ∂ÈÚfiÛıÂÙ·, Ë ÌÈÎÚ‹ ·ÛıÂÓ‹˜ ‰ÂÓ Â›¯Â η̛· ¤Ó‰ÂÈÍË Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· ÙÔ˘ Lahey (3,4). ¶·ÚÔ‰È΋ ÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›·, ‹ ·ÎfiÌË Î·È ‹È· Ë·ÙÔÌÂÁ·Ï›·, ·Ú·ÙËÚ‹ıËÎÂ Î·È Û ¿ÏϘ ÂÚÈÙÒÛÂȘ ‚ÚÂÊÒÓ Ì CSHLCH Î·È ˘Ô¯ˆÚÔ‡Û Ì ÙËÓ ‡ÊÂÛË ÙˆÓ ‚Ï·‚ÒÓ (1). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙË Û˘Ó‡·ÚÍË ıÂÙÈ΋˜ ÁÈ· LCH ‚ÈÔ„›·˜ ‰¤ÚÌ·ÙÔ˜. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È fiÏ· Ù· Ê˘Û·ÏȉԂϷÙÈ‰Ò‰Ë ÁÂÓÈÎÂ˘Ì¤Ó· ÂÍ·Óı‹Ì·Ù· Ù˘ ÓÂÔÁÓÈ΋˜ ËÏÈΛ·˜ (ÙÔÍÈÎfi ÂÚ‡ıËÌ·, Ïԛ̈ÍË ·fi ·Ïfi ¤ÚËÙ· ‹ ·ÓÂÌ¢ÏÔÁÈ¿, Ì·ÛÙÔ΢ÙÙ¿ÚˆÛË). §fiÁˆ ÙÔ˘ ÂÚËÙfiÌÔÚÊÔ˘ ¯·Ú·ÎÙ‹Ú· ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ¤ÁÈÓ ·Ú¯Èο Î·È Tzanck test ÙÔ ÔÔ›Ô Â›Ó·È Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È Î˘Ú›ˆ˜ ÛÂ Ê˘Û·Ïȉ҉ÂȘ Î·È ÂÏΈÙÈΤ˜ ‚Ï¿‚˜. ∏ ÂͤٷÛË ·˘Ù‹, ·ÓÙ› ÙˆÓ ·Ó·ÌÂÓfiÌÂÓˆÓ ÔÏ˘‡ÚËÓˆÓ ÁÈÁ·ÓÙÔ΢ÙÙ¿ÚˆÓ Ô˘ ·Ó¢ڛÛÎÔÓÙ·È ÛÙȘ ÂÚËÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ·ÔÎ¿Ï˘„Â Ù˘Èο ÈÛÙÈÔ·ÙÙ·Ú· (2,7). ŒÙÛÈ, ¤¯ÂÈ ÚÔÙ·ı› Ë ¯Ú‹ÛË ÙÔ˘ Tzanck test Û·Ó ¤Ó· ÚÒÈÌÔ Ì¤ÛÔ ‰È¿ÁÓˆÛ˘ ÙˆÓ ÈÛÙÈÔ΢ÙÙ·ÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (7). ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ·˘ÙÔ˚¿ÛÈÌ˘ ÈÛÙÈÔ΢ÙÙ¿ÚˆÛ˘ Ú¤ÂÈ Ó· Ù›ıÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î¿ı ‚Ú¤ÊÔ˘˜ Ì ÂÚËÙfiÌÔÚÊÔ ÂÍ¿ÓıËÌ·. ∆¤ÙÔÈ·˜ ÌÔÚÊ‹˜ ÂÍ¿ÓıËÌ· Ê·›ÓÂÙ·È Ó· ÔÊ›ÏÂÙ·È ÈÔ Û˘¯Ó¿ Û CSHLCH ·’ fi,ÙÈ Û ÂÚËÙÈΤ˜ ÏÔÈÌÒÍÂȘ (7).
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·421
¶∞π¢π∞∆ƒπ∫∏ 2000;63:421-426
∏ ¤Ó·ÚÍË Ù˘ LCH ÛÙËÓ ÚÒÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ· Û˘Ó‹ıˆ˜ ˘Ô‰ËÏÒÓÂÈ Î·Î‹ ÚfiÁÓˆÛË. ŸÌˆ˜, Ô ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·Ó·ÊÂÚfiÌÂÓˆÓ ÂÚÈÙÒÛÂˆÓ CSHLCH ‰Â›¯ÓÂÈ fiÙÈ Ë Û˘ÁÁÂÓ‹˜ ÂÌÊ¿ÓÈÛË Ù˘ ÈÛÙÈÔ΢ÙÙ¿ÚˆÛ˘ ·fi ·ÙÙ·Ú· Langerhans ÌÔÚ› Ó· ¤¯ÂÈ ÌÈ· Û¯ÂÙÈο ηϋ ÚfiÁÓˆÛË. ¶·Ú’ fiÏ· ·˘Ù¿, Ë ·˘ÙfiÌ·ÙË ˘Ô¯ÒÚËÛË ÙˆÓ ‚Ï·‚ÒÓ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÛÙÔ ‰¤ÚÌ· ‹ Û ¿ÏÏ· fiÚÁ·Ó·. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ·Ú¿ ÙËÓ ·Ú¯È΋ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ, ÌÂÙ¿ ·fi ¤Ó· ‰È¿ÛÙËÌ· ÂχıÂÚÔ Û˘Ìو̿وÓ, ·ÓÂÌÊ·Ó›ÛÙËÎ·Ó ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ‹ Û˘ÌÌÂÙÔ¯‹ ·fi ¿ÏÏÔ fiÚÁ·ÓÔ (2). ∏ ¿ÚÈÛÙË ÔÚ›· Ù˘ ÌÈÎÚ‹˜ ·ÛıÂÓÔ‡˜ Ì·˜ ̤¯ÚÈ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜ Ù˘, ‰ÂÓ Ì·˜ ÂÊËÛ˘¯¿˙ÂÈ ÂÂȉ‹ Ë Û˘Ó¯‹˜ Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÚÒÈÌË ·Ó›¯Ó¢ÛË ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
3. Egeler RM, D’Angio GJ. Langerhans cell histiocytosis. J Pediatr 1995;127:1-11. 4. Sullivan SL, Woda BA. Lymphohistiocytic Disorders. In: Nathan DG, Orkin SH, eds. Haematology of Infancy and Childhood, 5th ed. Philadelphia: WB Saunders Company. 1998:1359-1380. 5. Herman LE, Rothman KF, Harawi S, Conzalez-Serva A. Congenital Self-Healing Reticulohistiocytosis. A new entity in the differential diagnosis of neonatal papulovesicular eruptions. Arch Dermatol 1990;126:210-212. 6. Schaumburg-Lever G, Rechowicz E, Fehrenbacher B, Moller H, Nau P. Congenital self-healing reticulohistiocytosis - A benign Langerhans cell disease. J Cutan Pathol 1994;21:59-66. 7. Fontanez FC, Eichenfield LF, Krous HF, Friedlander SF. Congenital Langerhans cell histiocytosis: The utility of the Tzanck test as a diagnostic screening tool. Arch Dermatol 1998;134:1039-1040.
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∏ashimoto K, Bale GF, Hawkins HK, Langston C, Pritzker MS. Congenital self-healing reticulohistiocytosis (Hashimoto-Pritzker Type). Int J Dermatol 1986;25:516-523. 2. Longaker MA, Frieden IJ, LeBoit PE, Sherertz EF. Congenital «self-healing» Langerhans cell histiocytosis: The need for long-term follow-up. J Am Acad Dermatol 1994;31:910-916.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 02-05-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-09-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÷ڛÛË ª¿Úı· ¡. ¶·ÙÛÈÌ¿‰Ë 3, 452 21, πˆ¿ÓÓÈÓ·
°Ï˘ÎÔÁÔÓ›·ÛË T‡Ô˘ II (ÓfiÛÔ˜ ÙÔ˘ Pompe): N¤· ÌÂÙ¿ÏÏ·ÍË Û ŒÏÏËÓ· ·ÛıÂÓ‹ Ì ÙË ‚ÚÂÊÈ΋ ÌÔÚÊ‹ EϤÓË MȯÂϷοÎË1, EÈÚ‹ÓË M·˘Ú›‰Ô˘1, Monique Hermans2, X·Ú¿ §¿ÛηÚË3, M·Ú›· KÔ˘ÚÎÔ˘Ï‹3, Arnold Reuser2 ● ¶ÂÚ›ÏË„Ë: H ÁÏ˘ÎÔÁÔÓ›·ÛË Ù‡Ô˘ II ‹ ÓfiÛÔ˜ ÙÔ˘ Pompe (Mc Kusick 23 2300) Â›Ó·È ÎÏËÚÔÓÔÌÈÎfi ÓfiÛËÌ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘ Ô˘ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·. OÊ›ÏÂÙ·È ÛÙËÓ ˘ÔÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ï˘ÛÔÛˆÌÈ·ÎÔ‡ ÂÓ˙‡ÌÔ˘ fiÍÈÓË ·-ÁÏ˘ÎÔ˙ȉ¿ÛË. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ŒÏÏËÓ· ·ÛıÂÓ‹ Ì ÙË ‚ÚÂÊÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ÔÔ›Ô ·Ó¢ڤıË ÌÈ· Ó¤· ÌÂÙ¿ÏÏ·ÍË. H ÌÂÙ¿ÏÏ·ÍË ‹Ù·Ó Ì›· T→C ÌÂٿوÛË ÛÙË ı¤ÛË cDNA 1214 Ô˘ ·ÓÙÈηıÈÛÙ¿ ÙË §Â˘Î›ÓË ÛÙÔ Îˆ‰ÈÎfiÓÈÔ 405 ·fi Ì›· ¶ÚÔÏ›ÓË. H ·ÏÏ·Á‹ ·˘Ù‹ Ê·›ÓÂÙ·È fiÙÈ ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰È·‰Èηۛ· ˆÚ›Ì·ÓÛ˘ Ù˘ ÂÓ˙˘ÌÈ΋˜ ÚˆÙ½Ó˘ Î·È Ô‰ËÁ› Û ۯ‰fiÓ ÌˉÂÓÈ΋ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙÈÎfiÙËÙ·. ™˘Á¯ÚfiÓˆ˜, Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË ÙˆÓ ÚÔÛÊ¿ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ÁÂÓÂÙÈÎfi ˘fi‚·ıÚÔ Ù˘ ÎÏÈÓÈ΋˜ ÂÙÂÚÔÁ¤ÓÂÈ·˜ Ù˘ ÓfiÛÔ˘ Î·È ÛÙȘ ÂÍÂÏ›ÍÂȘ ÛÙÔ ¯ÒÚÔ Ù˘ ıÂڷ›·˜. ¶·È‰È·ÙÚÈ΋ 2000;63:421-426. §¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ Pompe, ÌÂÙ·ÏÏ¿ÍÂȘ, ıÂڷ›·. H. Michelakakis, I. Mavridou, M. Hermans, H. Laskari, M. Kourkouli, A. Reusser. Glycogen storage disease type II (Pompe's disease): New mutation in a Greek infant. Paediatriki 2000;63:421-426. ● Abstract: Glycogen storage disease type II or Pompe's disease is an autosomal recessive disorder of glycogen metabolism due to the deficiency of the lysosomal acid a-glucosidase. We present the case of a
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™ÂÏ›‰·422
¶∞π¢π∞∆ƒπ∫∏ 2000;63:421-426
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
Greek patient with the infantile type of the disease in whom a new mutation was identified. The mutation, a T→C transition at position cDNA 1214, leads to a Leu405Pro substitution that affects the maturation process in the life cycle of the enzyme, leading to practically absent enzymatic activity. The current developments on the genetic basis of the clinical heterogeneity of the disorder, as well as on therapeutic intervention are reviewed. Key words: Pompe’s disease, mutations, therapy.
EÈÛ·ÁˆÁ‹ H ÁÏ˘ÎÔÁÔÓ›·ÛË Ù‡Ô˘ II ‹ ÓfiÛÔ˜ ÙÔ˘ Pompe (Mc Kusick 23 2300) Â›Ó·È ¤Ó· ·fi Ù· ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘. E›Ó·È Ë ÌfiÓË ÌÔÚÊ‹ ÁÏ˘ÎÔÁÔÓ›·Û˘ Ô˘ ·Ô‰Â‰ÂÈÁ̤ӷ ·Ó‹ÎÂÈ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ıÚÔÈÛÙÈÎÒÓ Ï˘ÛÔÛˆÌÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú· ÎÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘. TÔ ¤Ó˙˘ÌÔ ·˘Ùfi ηٷχÂÈ ÙËÓ ˘‰ÚfiÏ˘ÛË ‰È·‰Ô¯ÈÎÒÓ ÌÔÚ›ˆÓ ÁÏ˘Îfi˙˘ ·fi ÙÔ ÁÏ˘ÎÔÁfiÓÔ Ô˘ ‚Ú›ÛÎÂÙ·È ÂÓ‰ÔÏ˘ÛÔÛˆÌȷο, Û·Ó ·ÔÙÂϤÛÌ·Ù· ·˘ÙÔÊ·Á›·˜ ‹/Î·È ÂÓ‰Ô΢ÙÙ¿ÚˆÛ˘ (1). KÏÈÓÈο Ë ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÈ ¤Ó· Ê¿ÛÌ· Ê·ÈÓÔÙ‡ˆÓ Ô˘ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘Ìو̿وÓ, ÙÔ ‚·ıÌfi Û˘ÌÌÂÙÔ¯‹˜ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÔÚÁ¿ÓˆÓ Î·È ÙËÓ Ù·¯‡ÙËÙ· Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘ (2). H ϤÔÓ ‚·ÚÈ¿ ÌÔÚÊ‹ Â›Ó·È Ë ÎÏ·ÛÈ΋ ‚ÚÂÊÈ΋ Ô˘ ÚˆÙÔÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ Pompe (3). H ϤÔÓ ‹È· Â›Ó·È Ë ÌÔÚÊ‹ ÙˆÓ ÂÓËÏ›ÎˆÓ Ì ËÏÈΛ· ¤Ó·Ú͢ ÙË ‰Â‡ÙÂÚË ˆ˜ Î·È ÙËÓ ¤ÎÙË ‰ÂηÂÙ›· ˙ˆ‹˜ Î·È Û˘ÌÙÒÌ·Ù· Ô˘ Û˘Ó‹ıˆ˜ ·ÊÔÚÔ‡Ó ÛÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ ̇˜ (4). MÂٷ͇ ÙˆÓ ‰‡Ô ·ÎÚ·›ˆÓ ·˘ÙÒÓ ÌÔÚÊÒÓ ‚Ú›ÛÎÂÙ·È Ì›· ÂÙÂÚÔÁÂÓ‹˜ ÔÌ¿‰· Ì ËÏÈΛ· ¤Ó·Ú͢ ÙËÓ ·È‰È΋, Î·È ÚÔÂÍ¿Ú¯Ô˘Û· ÙË Û˘ÌÌÂÙÔ¯‹ ·fi ÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ ̇˜, Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ ηډȷ΋ Û˘ÌÌÂÙÔ¯‹ Î·È ÂͤÏÈÍË Ô˘ Â›Ó·È ÈÔ ·ÚÁ‹ ·fi ·˘Ù‹ Ù˘ ‚ÚÂÊÈ΋˜ ÌÔÚÊ‹˜. ™Â fiϘ ÙȘ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ Ë ‰È¿ÁÓˆÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË Ì¤ÙÚËÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ù˘ fiÍÈÓ˘ ·ÁÏ˘ÎÔ˙ȉ¿Û˘ Û ηÏÏȤÚÁÂȘ ÈÓÔ‚Ï·ÛÙÒÓ ‰¤ÚÌ·ÙÔ˜ ‹/Î·È ‚ÈÔ„›· Ì˘fi˜ (5). TÔ ÁÔÓ›‰ÈÔ Ô˘ Έ‰ÈÎÔÔÈ› ÙË Û‡ÓıÂÛË Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ¤¯ÂÈ Ï‹Úˆ˜ ¯·Ú·ÎÙËÚÈÛı› (6). M¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ‚ÚÂı› ÂÚÈÛÛfiÙÂÚ˜ ·fi 50 ‰È·ÊÔÚÂÙÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ Û ·ÛıÂÓ›˜ Ì ÙË ÓfiÛÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ ·fi 30 Ê˘ÛÈÔÏÔÁÈÎÔ› ÔÏ˘ÌÔÚÊÈÛÌÔ› [htt//www.eur.nl/FGG/GH1/pompe] Ô˘ ¤¯Ô˘Ó ‚ÔËı‹ÛÂÈ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÙÂÚÔÁ¤ÓÂÈ·˜ Ù˘ ÓfiÛÔ˘ ÎÈ ¤¯Ô˘Ó ‰ÒÛÂÈ ÙËÓ ‰˘Ó·ÙfiÙËÙ· ‰È¿ÁÓˆÛ˘ ÊÔÚ¤ˆÓ ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ·Û¯fiÓÙˆÓ. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ŒÏÏËÓ· ·ÛıÂÓ‹ Ì ÙË ‚ÚÂÊÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ÔÔ›Ô ·Ó¢ڤıË Ó¤·, ÌË ÂÚÈÁÚ·Ê›۷ ÌÂÙ¿ÏÏ·ÍË, Ë ÔÔ›· Î·È ÌÂÏÂÙ‹ıËΠÛÂ Â›Â‰Ô ÂÓ˙˘ÌÈ΋˜ ÚˆÙ½Ó˘.
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¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ÎÔÚ›ÙÛÈ 4 ÌËÓÒÓ Ô˘ ·Ú·¤ÌÊıËΠ·fi ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘ ÁÈ· ¤ÏÂÁ¯Ô ·Ó·ÚÎÔ‡˜ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜. E›Ó·È ÙÔ ÚÒÙÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ô˘ ‰ÂÓ ·Ó·Ê¤ÚÔ˘Ó Û˘ÁÁ¤ÓÂÈ· ·ÏÏ¿ ηٿÁÔÓÙ·È ·fi ÙÔ ›‰ÈÔ ¯ˆÚÈfi Ù˘ E‡‚ÔÈ·˜. °ÂÓÓ‹ıËΠÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË Î‡ËÛË Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÌË Â̤‰ˆÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘. T· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· Á¤ÓÓËÛ˘ ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Î·È Ë ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ ·Ó·Ê¤ÚÂÙ·È ÔÌ·Ï‹. ™Ù·‰È·Î¿, ·Ú·ÙËÚ‹ıËΠوÙÈ΋ ÔÚ›· Ù˘ η̇Ï˘ ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ Î·È Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ‹Ù·Ó οو ·fi ÙËÓ 3Ë E£. ¶·Ú¿ÏÏËÏ· ·Ó·Ê¤ÚıËΠfiÙÈ ÂÚÈÔ‰Èο ÂÌÊ¿ÓÈ˙ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ΢ڛˆ˜ ηٿ ÙË Û›ÙÈÛË Î·È ÙÔ ÎÏ¿Ì·. K·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙÔ ‚Ú¤ÊÔ˜ ÂÌÊ¿ÓÈ˙ ‰˘ÛÙÚÔÊ›·, ÂÏ·ÊÚ¿ ˘ÔÙÔÓ›·, ˆ¯ÚfiÙËÙ· ‰¤ÚÌ·ÙÔ˜, Ë·ÙÔÌÂÁ·Ï›· (~5cm) Î·È ‚˘ıÈfiÙËÙ· ηډȷÎÒÓ ÙfiÓˆÓ. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ·Ó·ÈÌ›· (Hb=10,5 g/dl) Î·È ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 350 mg/dl; SGPT 191 mg/dl). O ηډÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ÂÈÎfiÓ· ηډÈÔÌ˘Ô¿ıÂÈ·˜ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÛËÌ·ÓÙÈ΋ ˘ÂÚÙÚÔÊ›· Î·È ‰È¿Ù·ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ·ÏÏ¿ Î·È ˘ÂÚÙÚÔÊ›· Ù˘ ‰ÂÍÈ¿˜. XÔÚËÁ‹ıËΠÊÔ˘ÚÔÛÂÌ›‰Ë, ÛÂÈÚÔÓÔÏ·ÎÙfiÓË Î·È ·ÚÁfiÙÂÚ· ‰·ÎÙ˘Ï›Ùȉ·. T· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ë Ì˘ÔηډÈÔ¿ıÂÈ·, Ë Ë·ÙÔ¿ıÂÈ· Î·È Ë ˘ÔÙÔÓ›· ¤ıÂÛ·Ó ÙËÓ ˘fiÓÔÈ· ÌÂÙ·‚ÔÏÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Î·È È‰È·›ÙÂÚ· Ù˘ ÁÏ˘ÎÔÁÔÓ›·Û˘ II (ÓfiÛÔ˜ Pompe) ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ÔÔ›·˜ ÂÏ‹ÊıË ‚ÈÔ„›· ‰¤ÚÌ·ÙÔ˜ ÁÈ· ηÏÏȤÚÁÂÈ· ÈÓÔ‚Ï·ÛÙÒÓ Î·È Ì¤ÙÚËÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘. MÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘ ÙÔ ‚Ú¤ÊÔ˜ ÚÔÛÂÚ¯fiÙ·Ó ÁÈ· ·ÓÂͤٷÛË ·Ú¯Èο ·Ó¿ 20‹ÌÂÚÔ Î·È ·ÎÔÏÔ‡ıˆ˜ ·Ó¿ ‰›ÌËÓÔ. ™ÙÔ˘˜ ·ÓÂϤÁ¯Ô˘˜ ·Ú·ÙËÚ‹ıËΠÂȉ›ӈÛË Ù˘ ‰˘ÛÙÚÔÊ›·˜ Î·È Ù˘ ˘ÔÙÔÓ›·˜, ›ٷÛË Ù˘ ΢¿ÓˆÛ˘, Ô˘ ÛÙ·‰È·Î¿ ¤ÁÈÓ ÌfiÓÈÌË, ÛÙ·‰È·Î‹ Âȉ›ӈÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜-Ù·¯‡ÓÔÈ·˜, ·Ú·ÌÔÓ‹ Ù˘ ‚˘ıÈfiÙËÙ·˜ ÙˆÓ Î·Ú‰È·ÎÒÓ ÙfiÓˆÓ, ·Ú·ÌÔÓ‹ Ù˘ Ë·ÙÔÌÂÁ·Ï›·˜ ÛÙ· ›‰È· ›‰· Î·È ÂÌÊ¿ÓÈÛË ÌÂÌÔÓˆÌ¤ÓˆÓ ˘ÚÂÙÈÎÒÓ Î˘Ì¿ÙˆÓ ˆ˜ 39ÔC ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‚‰ÔÌ¿‰· ˙ˆ‹˜. EÚÁ·ÛÙËÚȷο ·Ú·ÙËÚ‹ıËΠÂȉ›ӈÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (ÛÙËÓ ÙÂÏÂ˘Ù·›· ÂÈÛ·ÁˆÁ‹
SEPT-OCT.2000
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™ÂÏ›‰·423
¶∞π¢π∞∆ƒπ∫∏ 2000;63:421-426
SGOT: 662mg/dl, SGPT: 314mg/dl). H ηډȷ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÌÊ¿ÓÈÛÂ Û˘Ó¯‹ Âȉ›ӈÛË, Ô˘ Û˘Ó‰˘·˙fiÙ·Ó Ì ÌÂÁ¿ÏË ‰È¿Ù·ÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, ·˘ÍË̤ÓÔ ¿¯Ô˜ ÙÔȯˆÌ¿ÙˆÓ Î·È Ôχ ÂÏ·Ùو̤ÓË Û˘ÛÙ·ÏÙÈÎfiÙËÙ·. MÂÙ¿ ·fi 11 Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ Ó‹ÈÔ Î·Ù¤ÏËÍ Û ËÏÈΛ· 15 ÌËÓÒÓ. M¤ıÔ‰ÔÈ K·ÏÏȤÚÁÂȘ ÈÓÔ‚Ï·ÛÙÒÓ ‰¤ÚÌ·ÙÔ˜ ·Ó·Ù‡¯ıËÎ·Ó ·fi ‚ÈÔ„›· ‰¤ÚÌ·ÙÔ˜ Û ıÚÂÙÈÎfi ˘ÁÚfi RPMI 1640 ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì 15% ÔÚfi ÂÌ‚Ú‡Ô˘ ‚Ôfi˜ Î·È ·ÓÙÈ‚ÈÔÙÈο Û ·ÙÌfiÛÊ·ÈÚ· 5% CO2 -95% ·¤Ú· Î·È ıÂÚÌÔÎÚ·Û›· 37ÔC. OÈ ÈÓÔ‚Ï¿ÛÙ˜ Û˘ÏϤ¯ıËÎ·Ó Ì ÙÚ˘„›ÓË/EDTA, Ù· ·ÙÙ·Ú· χıËÎ·Ó ‰‡Ô ÊÔÚ¤˜ Ì PBS Î·È Ù· È˙‹Ì·Ù· ·ÔıË·ıËÎ·Ó ÛÙÔ˘˜ -20ÔC. H ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ÌÂÙÚ‹ıËΠ̠ٷ ˘ÔÛÙÚÒÌ·Ù· 4-ÌÂı˘ÏÔÔ˘ÌÂÏ›ÊÂÚÔ ·-ÁÏ˘ÎÔ˙›‰ÈÔ (4MU·Glu) Î·È ÁÏ˘ÎÔÁfiÓÔ (7). MÂϤÙ˜ ¤ÎÊÚ·Û˘ ÙÔ˘ ÁÔÓȉ›Ô˘ Û COS ·ÙÙ·Ú·, ·ÓÔÛÔÙ‡ˆÛË Î·Ù¿ Western Î·È Û‹Ì·ÓÛË Ù˘ ÂÓ˙˘ÌÈ΋˜ ÚˆÙ½Ó˘ Ì 35SÌÂıÂÈÔÓ›ÓË ¤ÁÈÓ·Ó Û‡Ìʈӷ Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ Reuser Î·È Û˘Ó (8) Î·È Hermans et al (9). °ÂÓÔÌÈÎfi DNA ·ÔÌÔÓÒıËΠ·fi ÙÔ˘˜ ÈÓÔ‚Ï¿ÛÙ˜ Ì ÌÂıfi‰Ô˘˜ ÚÔ˘Ù›Ó·˜, RNA ·ÔÌÔÓÒıËΠ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ·ÓÙȉڷÛÙ‹ÚÈÔ RNAZOL Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹ (Tel-Test USA). cDNA ·Ú·Û΢¿ÛıËΠ·fi 1mg RNA ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ Transcript Preamplification System TM Î·È ·ÎÔÏÔ‡ıˆ˜ 100ng Ù˘¯·›Ô˘˜ ÂÍ·ÌÂÚ›˜ ÂÎÎÈÓËÙ¤˜ Û ÙÂÏÈÎfi fiÁÎÔ 20Ìl (Gibco BRL). TÔ Û‡ÓÔÏÔ ÙÔ˘ cDNA Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ÔÏÏ·Ï·ÛÈ¿ÛıËΠ̠ÙËÓ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ (PCR) Î·È ÙËÓ ¯Ú‹ÛË 6 ˙¢ÁÒÓ ÂÎÎÈÓËÙÒÓ Ô˘ ‹Ù·Ó Û˘ÌÏËڈ̷ÙÈÎÔ› Î·È Î¿Ï˘Ù·Ó ÙÔ Û‡ÓÔÏÔ Ù˘ ·ÏÏËÏÔ˘¯›·˜ ÙÔ˘ ÁÔÓȉ›Ô˘. T· ÚÔ˚fiÓÙ· ÙÔ˘ PCR ηı·Ú›ÛÙËÎ·Ó Ì ÙÔ kit ηı·ÚÈÛÌÔ‡ QIAquick PCR Ù˘ Quiagen. O ηıÔÚÈÛÌfi˜ Ù˘ ·ÏÏËÏÔ˘¯›·˜ ÙˆÓ Î·ı·ÚÈÛı¤ÓÙˆÓ ÚÔ˚fiÓÙˆÓ PCR ¤ÁÈÓ Ì ABI Prism TM Dye Primer Cycle Sequencing Reaction Kit Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ÙˆÓ Î·Ù·Û΢·ÛÙÒÓ (Perkin-Elmer) Î·È ÙË Ì¤ıÔ‰Ô ÙˆÓ Hermans et al (9). O ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÁÂÓÔÌÈÎÔ‡ DNA ¤ÁÈÓ Ì ÙË Ì¤ıÔ‰Ô PCR Ì ÙË ¯Ú‹ÛË ÂȉÈÎÒÓ ÂÎÎÈÓËÙÒÓ Û˘ÌÏËڈ̷ÙÈÎÒÓ ÙˆÓ ÌÂÙ·ÊÚ·˙fiÌÂÓˆÓ Î·È ÌË-ÌÂÙ·ÊÚ·˙fiÌÂÓˆÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ fiÍÈÓ˘ ·ÁÏ˘ÎÔ˙ȉ¿Û˘ Î·È Ë ·ÏÏËÏÔ˘¯›· ÙˆÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘ PCR ÌÂÏÂÙ‹ıËΠۇÌʈӷ Ì ÙÔ˘˜ Kroos et al (10) Î·È Beesley et al (11). AÔÙÂϤÛÌ·Ù· H ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Pompe ÛÙËÓ ·ÛıÂÓ‹ Ì·˜ ÙÂÎÌËÚÈÒıËΠ̠ÙËÓ ·Ó‡ÚÂÛË ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ Û ηÏÏȤÚÁÂÈ· ÈÓÔ‚Ï·ÛÙÒÓ ‰¤ÚÌ·ÙÔ˜ Ô˘ ÌÂÙÚ‹ıËΠ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ˘fiÛÙڈ̷ 4MU·Glu.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
H ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ÙÔ˘ 0,2% Ù˘ ̤Û˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜ (·ÛıÂÓ‹˜: 0,04 nmoles/mg ÚˆÙÂ˚Ó˘/min, ÙÈ̤˜ ·Ó·ÊÔÚ¿˜: 1,2, 1,4, 1,6, 0,5, 1,0 nmoles/mg ÚˆÙ½Ó˘/hr) ÂÓÒ Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚-Á·Ï·ÎÙÔÛȉ¿Û˘, Ë ÔÔ›· ÌÂÙÚ‹ıËΠÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘¯fiÓ ·‰Ú·ÓÔÔ›ËÛ˘ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜, ‹Ù·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο ›‰· (·ÛıÂÓ‹˜ 335 nmoles/mg ÚˆÙ½Ó˘/hr, ÙÈ̤˜ ·Ó·ÊÔÚ¿˜: 298, 386, 212, 220, 288 nmoles/mg ÚˆÙ½Ó˘/hr). H ·Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ ÙÔ˘ cDNA Î·È ÙÔ˘ ÁÂÓÔÌÈÎÔ‡ DNA Ù˘ ·ÛıÂÓÔ‡˜ Ô‰‹ÁËÛ ÛÙËÓ ·ÔÎ¿Ï˘„Ë Ì›·˜ ÌfiÓÔ ÌÂÙ¿ÏÏ·Í˘ Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ù˘ T →C ÌÂٿوÛ˘ ÛÙË ı¤ÛË 1214 ÙÔ˘ cDNA. H ÚˆÙÔÂÚÈÁÚ·ÊfiÌÂÓË ÌÂÙ¿ÏÏ·ÍË Ô‰ËÁ› ÛÙËÓ ·ÓÙÈηٿÛÙ·ÛË Ù˘ Ï¢ΛÓ˘ ÛÙÔ Îˆ‰ÈÎfiÓÈÔ 405 ·fi Ì›· ÚÔÏ›ÓË. MÂϤÙË ÙˆÓ ÁÔÓ¤ˆÓ ¤‰ÂÈÍ ˆ˜ ‹Ù·Ó ÊÔÚ›˜ Ù˘ ›‰È·˜ ÌÂÙ¿ÏÏ·Í˘ ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙËÓ ÔÌÔ˙˘ÁˆÙ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ (™¯‹Ì· 1). H ÌÂÙ¿ÏÏ·ÍË ÂÈÛ‹¯ıË ÛÙÔ cDNA ÙÔ˘ Ê˘ÛÈÎÔ‡ Ù‡Ô˘ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ Î·È ÂÎÊÚ¿ÛıËΠ۠·ÙÙ·Ú· COS. H ÌÂÙ·ÏÏ·Á̤ÓË ÚˆÙ½ÓË Â›¯Â ÌˉÂÓÈ΋ ‰Ú·ÛÙÈÎfiÙËÙ· ˆ˜ ÚÔ˜ ÙËÓ ˘‰ÚfiÏ˘ÛË ÙÔ˘ 4MU·Glu ˘ÔÛÙÚÒÌ·ÙÔ˜ Î·È 0,9% Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ˆ˜ ÚÔ˜ ÙËÓ ˘‰ÚfiÏ˘ÛË ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘, Ô˘ Â›Ó·È ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ˘fiÛÙڈ̷ ÙÔ˘ ÂÓ˙‡ÌÔ˘. H ·ÓÔÛÔÙ‡ˆÛË Î·Ù¿ Western ¤‰ÂÈÍ ÙËÓ Û‡ÓıÂÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂȤ‰ˆÓ Ù˘ Úfi‰ÚÔÌ˘ ÌÔÚÊ‹˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘, ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 110kDa, ÙËÓ ·ÚÔ˘Û›· ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ Ù˘ ÂӉȿÌÂÛ˘ ÌÔÚÊ‹˜ 95kDa Î·È ·Ô˘Û›· Ù˘ ÒÚÈÌ˘ ÌÔÚÊ‹˜ ÙÔ˘˜ ÂÓ˙‡ÌÔ˘ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 76kDa. H ÂÍˆÎ˘ÙÙ·ÚÈο ·ÂÎÎÚÈÓfiÌÂÓË ÌÂÙ·ÏÏ·Á̤ÓË ÚˆÙ½ÓË ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˘ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜. (™¯‹Ì· 2). ™˘˙‹ÙËÛË H ÎÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Ù˘ ÁÏ˘ÎÔÁÔÓ›·Û˘ II ‹ ÓfiÛÔ˘ ÙÔ˘ Pompe ¤ÁÈÓ ÂÌÊ·Ó‹˜ ‹‰Ë ·fi ÙÔ 1965, Û‡ÓÙÔÌ· ÌÂÙ¿ ÙËÓ Ù·˘ÙÔÔ›ËÛË Ù˘ ÚˆÙÔÁÂÓÔ‡˜ ˘ÔÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ï˘ÛÔÛˆÌÈ·ÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ (1).
™¯‹Ì· 1. H ·Ó¿Ï˘ÛË ·ÏÏËÏÔ˘¯›·˜ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘.
423
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·424
¶∞π¢π∞∆ƒπ∫∏ 2000;63:421-426
™¯‹Ì· 2. H ›وÛË Ù˘ ÌÂÙ¿ÏÏ·Í˘ Leu405Pro ÛÙË ‚ÈÔÛ‡ÓıÂÛË Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘. H Û‹Ì·ÓÛË Ù˘ ÚˆÙ½Ó˘ ¤ÁÈÓ Ì ÙËÓ ÚÔÛı‹ÎË 35SÌÂıÂÈÔÓ›Ó˘ ÛÙÔ ıÚÂÙÈÎfi ˘ÏÈÎfi (3 ÒÚ˜) Î·È Ë ÂΉ›ˆÍË ÁÈ· 3 ÒÚ˜ (·ÙÙ·Ú·) Î·È 16 ÒÚ˜ (ıÚÂÙÈÎfi ˘ÏÈÎfi). Leu: Ê˘ÛÈÔÏÔÁÈÎfi˜ Ù‡Ô˜, Pro: ÌÂÙ·ÏÏ·Á̤ÓÔ˜ Ù‡Ô˜, M: „¢‰ÔÌÂÙ·ÁˆÁ‹ OÈ ‰È·ÊÔÚÂÙÈÎÔ› Ê·ÈÓfiÙ˘ÔÈ Ù˘ ÓfiÛÔ˘, Ë ‚ÚÂÊÈ΋, Ë ·È‰È΋ Î·È Ë ÌÔÚÊ‹ ÙˆÓ ÂÓËÏ›ÎˆÓ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘Ìو̿وÓ, ÙÔ ‚·ıÌfi Û˘ÌÌÂÙÔ¯‹˜ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÔÚÁ¿ÓˆÓ, ÙËÓ Ù·¯‡ÙËÙ· ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘ Î·È ÙËÓ ÂÈ‚›ˆÛË (2). H ‚ÚÂÊÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛı› ˆ˜ ‰‡Ô ‰È·ÊÔÚÂÙÈο Û‡Ó‰ÚÔÌ·. H ÎÏ·ÛÛÈ΋ ÌÔÚÊ‹ Ô˘ ÚˆÙÔÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ Pompe Â›Ó·È Ë ÈÔ Û˘¯Ó‹. T· Û˘ÌÙÒÌ·Ù¿ Ù˘ Â›Ó·È Ë ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ηډÈÔÌÂÁ·Ï›·, Ë ¤ÓÙÔÓË ˘ÔÙÔÓ›·, Ë Ù·¯¤ˆ˜ ÂȉÂÈÓÔ‡ÌÂÓË ·‰˘Ó·Ì›·, Ë Ì·ÎÚÔÁψÛÛ›· Î·È Ë Ë·ÙÔÌÂÁ·Ï›·. ™˘¯Ó¿ ÔÈ ·ÛıÂÓ›˜ Êı¿ÓÔ˘Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ‰˘ÛÎÔÏ›·˜ ÛÙËÓ Û›ÙÈÛË Î·È ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. H ÂͤÏÈÍË Â›Ó·È Ù·¯Â›· Î·È ÔÈ ¿Û¯ÔÓÙ˜ ηٷϋÁÔ˘Ó Û˘Ó‹ıˆ˜ ̤۷ ÛÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜ ÏfiÁˆ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (1). Afi ÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È Û·Ê¤˜ ˆ˜ Û ·ÛıÂÓ›˜ Ì ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ˙ˆ‹˜, Ë Î‡ÚÈ· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË ÌÔÚ› Ó· Â›Ó·È ·fi ÙÔ Ì˘˚Îfi Û‡ÛÙËÌ· Î·È Ó· ·Ô˘ÛÈ¿˙ÂÈ Ë Î·Ú‰ÈÔÌÂÁ·Ï›· (4,12). º·›ÓÂÙ·È ‰Â ˆ˜ Ë ÂÌÊ¿ÓÈÛË Î·Ú‰ÈÔÌÂÁ·Ï›·˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Â›Ó·È ÈÔ Û¿ÓÈ· ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘. H Ë·ÙÔÌÂÁ·Ï›· Î·È Ë Ì·ÎÚÔÁψÛÛ›· Â›Ó·È ÈÔ Û¿ÓȘ ÛÙË ÌË ÎÏ·ÛÛÈ΋ ·' fi,ÙÈ ÛÙËÓ ÎÏ·ÛÛÈ΋ ‚ÚÂÊÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ ÂÓÒ Û˘Ó‹ıˆ˜, ÔÈ ·ÛıÂÓ›˜ ηٷϋÁÔ˘Ó ÌÂÙ¿ ÙÔ 2Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜. E›Û˘, Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ÈÔ Û¿ÓÈ· ·fi ÙËÓ ÎÏ·ÛÈ΋ ‚ÚÂÊÈ΋, ›Ûˆ˜ ÁÈ·Ù› ÔÈ ·ÛıÂÓ›˜ ıˆÚÔ‡ÓÙ·È fiÙÈ ¿Û¯Ô˘Ó ·fi ¿ÏÏ· ÓÔÛ‹Ì·Ù· fiˆ˜ Ë WerdnigHoffmann ‹ οÔÈ· ÚÔԉ¢ÙÈ΋ Ì˘˚΋ ‰˘ÛÙÚÔÊ›·. H ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜ Î·È È‰È·›ÙÂÚ· Ë ‡·ÚÍË Î·Ú‰ÈÔÌ˘Ô¿ıÂÈ·˜ ÙËÓ Î·Ù·Ù¿ÛÛÂÈ ÛÙËÓ
424
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
ÎÏ·ÛÛÈ΋ ‚ÚÂÊÈ΋ ÌÔÚÊ‹ Ù˘ ÓfiÛÔ˘ Pompe. H Ï˘ÛÔÛˆÌȷ΋ fiÍÈÓË ·-ÁÏ˘ÎÔ˙ȉ¿ÛË Â˘Ú›ÛÎÂÙ·È Û fiÏÔ˘˜ ÙÔ˘˜ ÈÛÙÔ‡˜ ·ÏÏ¿ Î·È ÛÙÔ˘˜ ÈÓÔ‚Ï¿ÛÙ˜, Ù· ·ÌÓÈÔ·ÙÙ·Ú·, ÙËÓ ÙÚÔÊÔ‚Ï¿ÛÙË, Ù· ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· Ô‡Ú· (1). ¶·ÚfiÏÔ Ô˘ Ù· Ï¢ÎÔ·ÙÙ·Ú· Î·È Ù· Ô‡Ú· ı· ·ÔÙÂÏÔ‡Û·Ó ÌÈ· ‡ÎÔÏ· ‰È·ı¤ÛÈÌË ËÁ‹ ̤ÙÚËÛ˘ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, Ë ‡·ÚÍË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÔÂÓ˙‡ÌÔ˘ Î·È ÛÙ· ‰‡Ô Ù· ηıÈÛÙ¿ ·Î·Ù¿ÏÏËÏ· ÁÈ· ÙËÓ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ì ÌÂıfi‰Ô˘˜ ÚÔ˘Ù›Ó·˜. ŒÙÛÈ, Ë ‰È¿ÁÓˆÛË ÌÔÚ› Ó· Á›ÓÂÙ·È Â‡ÎÔÏ· ÎÈ ·ÍÈfiÈÛÙ· Û ÈÓÔ‚Ï¿ÛÙ˜ ‰¤ÚÌ·ÙÔ˜ ‹ Û ‚ÈÔ„›· Ì˘fi˜ (13). H fiÍÈÓË ·-ÁÏ˘ÎÔ˙ȉ¿ÛË Û˘ÓÙ›ıÂÙ·È ÛÙÔ ·‰Úfi ÂÓ‰ÔÏ·ÛÌ·ÙÈÎfi ‰›ÎÙ˘Ô Î·È ˘Ê›ÛÙ·Ù·È ÂÎÙÂÓ›˜ ÌÂÙ·ÌÂÙ·ÊÚ·ÛÙÈΤ˜ ÙÚÔÔÔÈ‹ÛÂȘ ÙfiÛÔ ÛÙÔ ÚˆÙÂ˚ÓÈÎfi ÙÌ‹Ì· Ù˘ fiÛÔ Î·È ÙÔ˘˜ ÚÔۉ‰Â̤ÓÔ˘˜ ÔÏÈÁÔ۷ί·Ú›Ù˜. H Úfi‰ÚÔÌË ÌÔÚÊ‹ ÙÔ˘ ÂÓ˙‡ÌÔ˘, ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 110kDa, Â›Ó·È Î·Ù·Ï˘ÙÈο ·ÓÂÓÂÚÁ‹ Î·È ÂÚȤ¯ÂÈ ¤Ó· ÛËÌ·ÙÔ‰ÔÙÈÎfi ÂÙ›‰ÈÔ ÙÔ ÔÔ›Ô ·ÔÎfiÙÂÙ·È ÌÂÙ¿ ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÌÔÚ›Ô˘ ‰È· ̤ÛÔ˘ ÙÔ˘ ÂÓ‰ÔÏ·ÛÌ·ÙÈÎÔ‡ ‰ÈÎÙ‡Ô˘. AÎÔÏÔ˘ı› ÂÚ·ÈÙ¤Úˆ ÚˆÙÂÔÏ˘ÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙÔ˘ ÌÔÚ›Ô˘ Ô˘ Ô‰ËÁ› ÛÙËÓ ÂÌÊ¿ÓÈÛË ÌÔÚÊÒÓ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 95, 76 Î·È 70kDa, fiÔ˘ ÔÈ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ·ÔÙÂÏÔ‡Ó ÙȘ ·ÚȘ ÒÚÈ̘ ÌÔÚʤ˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘. H ÚˆÙÂÔÏ˘ÙÈ΋ ‰ÈÂÚÁ·Û›· Ï·Ì‚¿ÓÂÈ ¯ÒÚ· Û fi„ÈÌ· ÂÓ‰ÔÛÒÌ·Ù· ‹/Î·È Ï˘ÛÔۈ̿ÙÈ· Î·È Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Î·Ù·Ï˘ÙÈ΋˜ ‰Ú¿Û˘ Î·È ÙËÓ ·‡ÍËÛË Ù˘ ÈηÓfiÙËÙ·˜ ˘‰ÚfiÏ˘Û˘ ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘ (14). TÔ ÌfiÚÈÔ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÛÙËÓ Úfi‰ÚÔÌË ÌÔÚÊ‹ ÙÔ˘ ÂÚȤ¯ÂÈ 7 ÛËÌ›· ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ ÛÙ· ÔÔ›· ÚÔÛ‰¤ÓÔÓÙ·È ÌÔÓ¿‰Â˜ ۷ί¿ÚˆÓ ÂÓÒ ÛÙȘ ÒÚÈ̘ ÌÔÚʤ˜ ÙÔ˘ ¤¯ÂÈ 5 (76kDa) Î·È 4 (70kDa) ·Ï˘Û›‰Â˜ ۷ί¿ÚˆÓ, ‰‡Ô ÂÎ ÙˆÓ ÔÔ›ˆÓ ¤¯Ô˘Ó ʈÛÊfiÚÔ ÚÔۉ‰Â̤ÓÔ Û ÙÂÚÌ·ÙÈο ÌfiÚÈ· Ì·ÓÓfi˙˘. AÓ·ÛÙÔÏ‹ Ù˘ ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘ ηıÈÛÙ¿ ÙÔ ÌfiÚÈÔ ·ÛÙ·ı¤˜ Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÂÓ‰Ô΢ÙÙ·ÚÈ΋ ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÂÓ˙‡ÌÔ˘ (15). BÈÔ¯ËÌÈΤ˜ Î·È ·ÓÔÛÔ¯ËÌÈΤ˜ ÌÂϤÙ˜ Û ¿Û¯ÔÓÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ ÛÙË Û‡ÓıÂÛË, ʈÛÊÔÚ˘Ï›ˆÛË Î·È ˆÚ›Ì·ÓÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ (7,16,17). TÔ ·ÓıÚÒÈÓÔ ÁÔÓ›‰ÈÔ Ù˘ fiÍÈÓ˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ‹ GAA ¤¯ÂÈ ¯·ÚÙÔÁÚ·ÊËı› ÛÙË ı¤ÛË 17q25,2q25,3. AÔÙÂÏÂ›Ù·È ·fi ~28kb ÔÚÁ·ÓˆÌ¤Ó˜ Û 20 ÂÍÒÓÈ· (6). M¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÛfiÙÂÚ˜ ·fi 50 ‰È·ÊÔÚÂÙÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ [htp:/www.eur.nl/FGG/GH1/pompe] Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ Û‡ÓıÂÛË, ÙËÓ ˆÚ›Ì·ÓÛË, ÙËÓ ÂÓ‰Ô΢ÙÙ·ÚÈ΋ ÌÂÙ·ÊÔÚ¿ Î·È ÙËÓ Î·Ù·Ï˘ÙÈ΋ ÈηÓfiÙËÙ· Ù˘ ÂÓ˙˘ÌÈ΋˜ ÚˆÙ½Ó˘ Î·È ¤‰ˆÛ·Ó ÙË ‰˘Ó·ÙfiÙËÙ· Û˘Û¯¤ÙÈÛ˘ ÁÔÓfiÙ˘Ô˘-Ê·ÈÓfiÙ˘Ô˘ (9,18-21). H ÚˆÙÔÂÚÈÁÚ·ÊfiÌÂÓË ÌÂÙ¿ÏÏ·ÍË Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜ ›¯Â ˆ˜ ·ÔÙÂϤÛÌ·Ù· ÙË ‰Ú·ÛÙÈ΋ Ì›ˆÛË Ù˘ Î·Ù·Ï˘ÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘, ÙfiÛÔ ˆ˜ ÚÔ˜ ÙÔ ÌË-Ê˘ÛÈÔÏÔÁÈÎfi ˘fiÛÙڈ̷ 4MU·Glu, fiÛÔ Î·È ÚÔ˜
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ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ˘fiÛÙڈ̷ ÁÏ˘ÎÔÁfiÓÔ. TÔ ¤ÏÏÂÈÌÌ· ‹Ù·Ó Èı·Ófiٷٷ ÙÔ ·ÔÙ¤ÏÂÛÌ· ‰È·Ù·Ú·¯‹˜ Ù˘ ˆÚ›Ì·ÓÛ˘ ÙÔ˘ ÂÓ˙‡ÌÔ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ÌÂÙ¿ÏÏ·ÍË ‰ÂÓ ÂËÚ¤·Û ÙËÓ Û‡ÓıÂÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÛÔ‡ Ù˘ Úfi‰ÚÔÌ˘ ÌÔÚÊ‹˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘. TÔ ˘„ËÏfiÙÂÚÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ Ù˘ ÌÂÙ·ÏÏ·Á̤Ó˘ ÚˆÙ½Ó˘ ÂÍˆÎ˘ÙÙ·ÚÈο, Èı·ÓÒ˜ Ó· ÔÊ›ÏÂÙ·È Û ‰È·ÊÔÚ¤˜ ÛÙË ÁÏ˘ÎÔ˙˘Ï›ˆÛË Û ۯ¤ÛË Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÚˆÙ½ÓË. H ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ‰È·ÊÔÚÂÙÈÎÒÓ ÔÏ˘ÌÔÚÊÈÎÒÓ ÛËÌ›ˆÓ, ÔÏÏ¿ ÂÎ ÙˆÓ ÔÔ›ˆÓ Â›Ó·È "ȉȈÙÈο", οÓÔ˘Ó ‰‡ÛÎÔÏË ÙËÓ ÂÊ·ÚÌÔÁ‹ ÁÚ‹ÁÔÚˆÓ ÌÂıfi‰ˆÓ ÚÔ˘Ù›Ó·˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·ıÔÁfiÓˆÓ ÌÂÙ·ÏϿ͈Ó. O ÚÔÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Á›ÓÂÈ Â‡ÎÔÏ· ÙÔ 1Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ Ì ÙË Ì¤ÙÚËÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ Û ÙÚÔÊÔ‚Ï¿ÛÙË. H ̤ıÔ‰Ô˜ ·˘Ù‹ ÂÊ·ÚÌfiÛıËΠÛÙË ‰Â‡ÙÂÚË ÂÁ΢ÌÔÛ‡ÓË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜ ÌÂ Ê˘ÛÈÔÏÔÁÈο ·ÔÙÂϤÛÌ·Ù·. EÓı·ÚÚ˘ÓÙÈο Â›Ó·È Ù· Ó¤· ÛÙÔ ¯ÒÚÔ Ù˘ ıÂڷ›·˜ Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, in vitro ÂÈÚ¿Ì·Ù· ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ÁÔÓȉ›Ô˘ GAA Û ÈÓÔ‚Ï¿ÛÙ˜ Î·È Ì˘˚ο ·ÙÙ·Ú· ·ÛıÂÓÒÓ ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ô˘ ¤Êı·ÛÂ Î·È ÙÔ 20Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜, ÔÌ·ÏÔÔ›ËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ÁÏ˘ÎÔÁfiÓÔ˘, ÂÍ·Ê¿ÓÈÛ‹ ÙÔ˘ ·fi Ù· Ï˘ÛÔÛÒÌ·Ù· Î·È ·¤ÎÎÚÈÛË ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ÂÓ˙‡ÌÔ˘ (23). T· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÂÏ›‰Â˜ ÁÈ· ÙËÓ ‰˘Ó·ÙfiÙËÙ· ÁÔÓȉȷ΋˜ ıÂڷ›·˜ Ù˘ ÓfiÛÔ˘. ◊‰Ë fï˜, ‚Ú›ÛÎÂÙ·È Û ÂͤÏÈÍË ÌÂϤÙË ˘ÔηٿÛÙ·Û˘ ÙÔ˘ ÂÓ˙‡ÌÔ˘ (º¿ÛË II). TÔ ¯ÔÚËÁÔ‡ÌÂÓÔ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ·ÓıÚÒÈÓÔ ¤Ó˙˘ÌÔ ·Ú¿ÁÂÙ·È Û ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ (>2g/lt) ÛÙÔ Á¿Ï· ‰È·ÁÔÓȉȷÎÒÓ ÎÔ˘ÓÂÏÈÒÓ Î·È ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÊϤ‚È· ÛÙÔ˘˜ ·ÛıÂÓ›˜. AÓÙ›ÛÙÔȯ· ÂÈÚ¿Ì·Ù· Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÔÓÙÈÎÈÒÓ Ì ÔÏÈ΋ ¤ÏÏÂÈ„Ë ÙÔ˘ ÂÓ˙‡ÌÔ˘ (knock out models) ¤‰ÂÈÍ·Ó ˆ˜ ÙÔ ¯ÔÚËÁÔ‡ÌÂÓÔ ¤Ó˙˘ÌÔ ÚÔÛÏ·Ì‚¿ÓÂÙ·È ·fi ÙËÓ Î·Ú‰È¿ Î·È ÙÔ˘˜ ̇˜, ÂȉÈÔÚıÒÓÂÈ ÙËÓ ÂÓ‰ÔÏ˘ÛÔÛˆÌȷ΋ ¿ıÚÔÈÛË ÁÏ˘ÎÔÁfiÓÔ˘ Î·È ÌÂÈÒÓÂÈ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÈÛÙÒÓ (24,25). BÈ‚ÏÈÔÁÚ·Ê›· 1. Hirschhorn R. Glycogen Storage Disease Type II: Acid aGlucosidase (Acid Maltase) Deficiency. In: Scriver CR, Beaudet AL, Sly WS, Valle D. eds. The metabolic and molecular basis of inherited disease. 7th ed. New York: McGraw-Hill;1995. p. 2443-2465. 2. Engel AG, Gomez MR, Seybold ME, Lambert EH. The spectrum and diagnosis of acid maltase deficiency. Neurology 1973;23:95-100. 3. Pompe JC. Over idiopatische hypertrophie van het hart. Ned Tijdschr Geneeskd 1932; 76:304-311. 4. Engel AG, Hirshhorn R. Acid maltase deficiency. In Engel AG, Franzini-Armstrong C, eds. Myology: Basic and Clinical. New York: McGraw-Hill; 1996. p. 1533-1553. 5. Mehler M, DiMauro S. Residual acid maltase activity in
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late-onset acid maltase deficiency. Neurology 1977; 27:178-184. Hoefsloot LH, Hoogeveen-Westerveld M, Reuser AJ, Oostra BA. Characterization of the human lysosomal aglucosidase gene. Biochem J 1990;272:493-497. Reuser AJJ, Koster JF, Hoogeveen A, Galjaard H. Biochemical, immunological and cell genetic studies in glycogenosis II. Am J Hum Genet. 1978;30:132-143. Reuser AJJ, Kroos M. Willemsen R, Swallow D, Tager JM, Galjaard H. Clinical diversity in glycogenosis type II. Biosynthesis and in situ localization of acid alphaglucosidase in mutant fibroblasts. J Clin Invest 1987; 79:1689-1699. Hermans MMP, Kroos MA, Smeitnik JAM, van der Ploeg AT, Kleijer WJ and Reuser AJJ. Glycogen storage disease type II: Genetic and biochemical analysis of novel mutation in infantile patients from Turkish ancestry. Hum Mut 1998;11:209-215. Kroos M, Waitfield AE, Josse M, Winchester B, Reuser AJJ, McDermot KD. A novel acid a-glucosidase mutation identified in a Pakistani family with glycogen storage disease type II. J Inher Metab Dis 1997;20:556-558. Beesley CE, Child AH and Yacoub MH: The identification of five novel mutations in the lysosomal acid a-(1,4) glucosidase gene from patients with glycogen storage disease type II. Hum Mut 1998; 11:413. Hers HG: Alpha-glucosidase deficiency in generalized glycogen-storage disease (Pompe's Disease). Biochem J 1963; 86:11-16. Galjaard H. Genetic Metabolic Diseases. Early diagnosis and prenatal analysis. Elsevier/North-Holland 1980:64-68. Wisselaar HA, Kroos MA, Hermans MMP, van Beenmen J, Reuser AJJ. Structural and functional changes of lysosomal acid alpha-glucosidase during intracellular transport and maturation. J Biol Chem 1993; 268:22232232. Hermans MMP, Wisselaar HA, Kroos MA, Oostra BA, Reuser AJJ. Human lysosomal alpha-glucosidase. Functional characterization of the glycosylation sites. Biochem J 1993;289:681-686. Reuser AJ, Kroos M, Onde Elferink RP, Tager JM. Defects in synthesis, phosphorylation and maturation of acid alpha-glucosidase in glycogenosis type II. Biol Chem 1985;260:8336-8341. Steckel F, Gieselmann V, Waheed A, Hasilik A, von Figura K. Oude Elferink R et al. Biosynthesis of acid alphaglucosidase in late-onset forms of glycogenosis type II (Pompe's disease) FEBS Lett 1982;150:69-76. Hermans MMP, de Graaft E, Kroos MA, Mohkamsing S, Eussen BJ, Joose M et al. The effect of a single base pair deletion (¢T525) and a C1634T missense mutation (pro545leu) on the expression of lysosomal a-glucosidase in patients with glycogen storage disease type II. Hum Mol Genet 1994;3:2213-2218. Boerkoel CF, Exelbert R, Nicastri C, Nichols RC, Miller FW, Plotz PH, et al. Leaky splicing mutation in the acid maltase gene is associated with delayed onset of glycogenosis type II. Am J Hum Genet 1995;56:887-897. Kroos MA. Van der Kraan M, Van Diggelen OP, Kleijer WJ
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and Reuser AJJ. Two extremes of the clinical spectrum of glycogen storage disease type II in one family. A matter of genotype. Hum Mut 1997;9:17-22. 21. Hermans MMP, Kroos MA, de Graaf E, Oostra BA, Reuser AJ. Two mutations affecting the transport and maturation of lysosomal alpha-glucosidase in an adult case of glycogen storage disease type II.. Hum Mut 1993;2:268-273. 22. Nicolino MP, Puech JP, Kremer EJ, Reuser AJJ, Mbebi C, Verdiere-Sahuque M, et al. Adenovirus-mediated transfer of the acid a-glucosidase gene into fibroblasts, myoblasts and myotubes from patients with glycogen storage disease type II leads to high level of expression of enzyme and corrects glycogen accumulation. Hum Mol Genet 1998;7:1695-1702. 23. Van der Ploeg AT, Van der Hout H, Reuser A, Bijvoet A, van Hirtun H, Kroos M. A phase II clinical trial of enzyme
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replacement therapy for glycogen storage disease type II. [Abstract]. 12th Workshop European Study Group on Lysosomal Diseases; 1999. p. 41. 24. Bijvoet A, Van Hirtun H, Kroos MA, Van de Kamp EHM, Schoneveld O, Visser P et al. Human acid a-glucosidase from rabbit milk has therapeutic effect on mice with glycogen storage disease type II. Hum Molec Genet 1999;8:2145-2153. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 14-04-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢Ú. E. MȯÂϷοÎË ¢È‡ı˘ÓÛË EÓ˙˘ÌÔÏÔÁ›·˜ Î·È K˘ÙÙ·ÚÈ΋˜ §ÂÈÙÔ˘ÚÁ›·˜ IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "AÁ›· ™ÔÊ›·", 11527 °Ô˘‰›, Aı‹Ó·
ƒ·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D - ∆‡Ô˘ π ¢ÈÔÓ‡ÛÈÔ˜ ∫·Ú·Î·˚‰fi˜, ¶·Ú·Û΢‹ ∑ÒÛË, ¢ËÌ‹ÙÚÈÔ˜ ∆ÛÈÏÈ‚¿ÎÔ˜, °ÂÒÚÁÈÔ˜ ∫·ÓÈ¿Ú˘, °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜, ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ ● ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ 6,5 ÌËÓÒÓ Ì ڷ¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙË µÈÙ·Ì›ÓË D (‚ÈÙ D) Ù‡Ô˘ π. ∏ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ù˘ ÓfiÛÔ˘ ÂÚÈÔÚÈ˙fiÙ·Ó Û ÌÂÁ¿ÏË ÚfiÛıÈ· ËÁ‹ ÂÓÒ ·fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ›¯·ÌÂ Â˘Ú‹Ì·Ù· ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡ ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ 25 O∏ ‚ÈÙ D, ¯·ÌËÏ‹ ÙÈÌ‹ 1,25 (O∏)2 ‚ÈÙ D ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ¯ÔÚ‹ÁËÛË 1,25 (O∏)2 ‚ÈÙ D ›¯Â ¿ÌÂÛË ·ÓÙ·fiÎÚÈÛË Ì ηٷگ‹Ó ·ÔηٿÛÙ·ÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ. °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Ù˘ ‚ÈÙ D, ÙËÓ 1·-˘‰ÚÔÍ˘Ï¿ÛË, ÙË Ú‡ıÌÈÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ¿˜ Ù˘, fiˆ˜ Î·È Ù· ÓÂÒÙÂÚ· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙËÓ ¯·ÚÙÔÁÚ¿ÊËÛË ÙÔ˘ ÁfiÓÔ˘ Ô˘ ÂϤÁ¯ÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Ù˘. ¶·È‰È·ÙÚÈ΋ 2000;63:426-429. §¤ÍÂȘ ÎÏÂȉȿ: 1·-˘‰ÚÔÍ˘Ï¿ÛË, Ú·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D- Ù‡Ô˘ π. D. Karakaidos, P. Zosi, D. Tsilivakos, G. Kaniaris, G.Tsolas, C. Karis. Vitamin D dependent RicketsType I. Paediatriki 2000;63:426-429. ● Abstract: A case of a 6ó month old girl with Vitamin D dependent Rickets Type I is reported. The clinical presentation of the disease was limited only to a large frontal fontanel, while laboratory investigation was consistent with secondary hyperparathyroidism with normal levels of 25 OH vitamin D, decreased levels of 1,25(OH)2 vitamin D and normal renal function. Administration of 1,25(OH)2 vitamin D resulted in an immediate response and normalization of the pathologic laboratory values. A review of the literature regarding the metabolism of vitamin D, modulation of 1a-hydroxylase activity, as well as the current developments in genemapping of this disorder, are presented. Key words: 1a-hydroxylase, vitamin D dependent rickets type I.
∂ÈÛ·ÁˆÁ‹ ƒ·¯›Ùȉ· ÔÓÔÌ¿˙Ô˘Ì ÙËÓ Î·Ù¿ÛÙ·ÛË Î·Ù¿ ÙËÓ ÔÔ›· ¤¯Ô˘Ì ·ÓÂÈÙ˘¯‹ ÂÈÌÂÙ¿ÏψÛË ÙÔ˘ ÔÛÙÂÔÂȉԇ˜ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÔÛÙÔ‡ Ì ·ÔÙ¤ÏÂÛÌ· ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡Èη›·˜- ¶ÂÈÚ·È¿ «∞Á. ¶·ÓÙÂÏ‹̈ӻ - ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋
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¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· (ÌÂÁ¿ÏË ÚfiÛıÈ· ËÁ‹, ηı˘ÛÙ¤ÚËÛË Û‡ÁÎÏÂÈÛ˘, ÎÚ·ÓÈfiÊıÈÛË, Ú·¯ÈÙÈÎfi ÎÔÌ‚ÔÏfiÁÈÔ, ·ÚÙˆÛË Ì·ÎÚÒÓ ÔÛÙÒÓ, ÎÏ.). ¶·Ï·ÈfiÙÂÚ· Ë Î˘ÚÈfiÙÂÚË ·ÈÙ›· Ú·¯›Ùȉ·˜ ‹Ù·Ó Ë ¤ÏÏÂÈ-
SEPT-OCT.2000
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:426-429
„Ë ‚ÈÙ D ›Ù ÏfiÁˆ ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ ̤ۈ ÙÚÔÊÒÓ, ›Ù ÏfiÁˆ ·Ó·ÚÎÔ‡˜ ÂÎı¤Ûˆ˜ ÛÙËÓ ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· (1,2). ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘ Î·È ‰È·ÙÚÔÊ‹˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ ÂÚÈfiÚÈÛ ÙËÓ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÎÏ·ÛÈÎÒÓ ÌÔÚÊÒÓ Ú·¯›Ùȉ·˜ (1) Î·È ¤Î·Ó ·Ó·ÏÔÁÈο Û˘¯ÓfiÙÂÚ˜ Û¿ÓȘ ÌÔÚʤ˜ fiˆ˜ ÔÈ Ú·¯›Ùȉ˜ ÔÈ ÂÍ·ÚÙÒÌÂÓ˜ ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π Î·È ππ. ¶·Ú·Î¿Ùˆ ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ Ì ڷ¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜ 6,5 ÌËÓÒÓ ÂÈÛ¿ÁÂÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÁÈ· ¤ÏÂÁ¯Ô ·Ó·ÊÂÚÔÌ¤ÓˆÓ ‰È·ÚÚÔ˚ÎÒÓ ÎÂÓÒÛÂˆÓ ·fi ÌËÓfi˜. ∆Ô ·È‰› Â›Ó·È πÚ·ÎÈÓ‹˜ ηٷÁˆÁ‹˜, ÁÂÓÓË̤ÓÔ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi ÌÂÙ¿ ÙÂÏÂÈfiÌËÓÔ Î‡ËÛË ÛÙÔ πÚ¿Î Î·È ‹Ïı ÛÙËÓ ¯ÒÚ· Ì·˜ Û ËÏÈΛ· 5,5 ÌËÓÒÓ. ∞ӷʤÚÂÙ·È ÌÈÎÚfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ¯ˆÚ›˜ Ó· ‰›ÓÔÓÙ·È ·ÎÚÈ‚‹ ÛÙÔȯ›·. ∞fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘ ÙÔ ·È‰› ÛÈÙ›˙ÂÙ·È Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi ÂÓÒ Û ËÏÈΛ· 6 ÌËÓÒÓ ÚÔÛÙ¤ıËÎ·Ó ÛÙË ‰È·ÙÚÔÊ‹ Îڤ̘ ‰ËÌËÙÚÈ·ÎÒÓ Î·È ÊÚÔ‡ÙˆÓ. ™Â ËÏÈΛ· 3 ÌËÓÒÓ ·Ó·Ê¤ÚÂÙ·È Â̇ÚÂÙÔ ÂÂÈÛfi‰ÈÔ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi. OÈ ÁÔÓ›˜ ÙÔ˘ ·È‰ÈÔ‡, Ê·ÈÓÔÙ˘Èο ˘ÁÈ›˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfi ·Ó¿ÛÙËÌ·: ·Ù¤Ú·˜ 161 cm, ÌËÙ¤Ú· 148 cm. O ÌÂÁ·Ï‡ÙÂÚÔ˜ ·‰ÂÚÊfi˜ Â›Ó·È Ê·ÈÓÔÙ˘Èο ˘ÁÈ‹˜ Ì ‡„Ô˜ Î·È ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ÛÙËÓ 25Ë ÂηÙÔÛÙÈ·›· ı¤ÛË. ∫·Ù¿ ÙËÓ Â›ÛÔ‰Ô ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÙÔ ·È‰› ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË ¯ˆÚ›˜ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, Ë ÚfiÛıÈ· ËÁ‹ ‹Ù·Ó ¢ÌÂÁ¤ı˘ - ÌË ÚÔ¤¯Ô˘Û· ‰È·ÛÙ¿ÛÂˆÓ 6x4 cm. H „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÙËÓ ËÏÈΛ· ÙÔ˘ (µ™=6070 gr (5-10 ∂£) ª™=59 cm (<3Ë ∂£) ¶∫=42 cm (50Ë ∂£)). O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ô ·ÎfiÏÔ˘ıÔ˜: Ht=30,3%, Hb=9,9 g/dl, MCV=65 fl, MCH=21,5 pg, RDW=16,7%, WBC=11000/mmÑ (¶=28%, §=67%, ª=5%) PLT=360000/mmÑ, ºÂÚÈÙ›ÓË=44,73 ng/ml, TKE=30 mm/1h CRP=10,7 mg/L, Na=142 mEq/L, K=4,2 mEq/L, Ca=10 mg/dl, P=3,1 mg/dl, Mg=2 mg/dl, ALP=921 U/L, Cl=107 mEq/L, SGOT=41 U/L, SGPT=27 U/L, O˘Ú›·=7 mg/dl, ∫Ú·ÙÈÓ›ÓË=0,3 mg/dl, Î/· ·›Ì·ÙÔ˜= ÛÙ›ڷ, Î/· Ô‡ÚˆÓ= ÛÙ›ڷ, Î/· ÎÔÚ¿ÓˆÓ= Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰·, §Â˘Î¿ ÎÔÚ¿ÓˆÓ= Û¿ÓÈ·, °ÂÓÈ΋ Ô‡ÚˆÓ= ΛÙÚÈÓ·-‰È·˘Á‹, ∂µ=1010, Û¿ÓÈ· ÂÚ˘ıÚ¿, Û¿ÓÈ· ˘ÔÛÊ·›ÚÈ·. ∫·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÙÔ ·È‰› ·ÚÔ˘Û›·˙ 2-3 ÎÂÓÒÛÂȘ ÙÔ 24ˆÚÔ ËÌÈÛ¯ËÌ·ÙÈṲ̂Ó˜ ¯ˆÚ›˜ ÚfiÛÌÈÍË ‚ϤÓÓ˘ ·fiÏ˘Ù· Ê˘ÛÈÔÏÔÁÈΤ˜ ÁÈ· ‚Ú¤ÊÔ˜ Ô˘ ‰È·ÙÚ¤ÊÂÙ·È Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi. À¤Ú ·˘ÙÔ‡ Û˘ÓËÁÔÚ› Î·È Ô ·ÚÓËÙÈÎfi˜ ÂÚÁ·-
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜. ∏ ÌÂÁ¿ÏˆÓ ‰È·ÛÙ¿ÛÂˆÓ ÚfiÛıÈ· ËÁ‹, Ë ·˘ÍË̤ÓË ALP, Ô ¯·ÌËÏfi˜ P, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ì·˜ ¤Î·Ó·Ó Ó· ÂÂÎÙ›ÓÔ˘Ì ÙÔÓ ¤ÏÂÁ¯Ô Ì·˜ ÚÔ˜ ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ca, P Ì ٷ ·ÎfiÏÔ˘ı· ·ÔÙÂϤÛÌ·Ù·: PTH=248 pg/ml (10-65) OÛÙÂÔηÏÛ›ÓË=11,9 ng/ml (2,4-10) 25 (O∏) µÈÙ D3=21,9 ng/ml (14-42) 1,25 (OH)2 µÈÙ D3=14,8 pg/ml (25-45) OÛÙ¿ÛË=262 Ìg/l (¤ˆ˜ 22,5) ƒ∏ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ:Ê˘ÛÈÔÏÔÁÈο ∆3=219 ng/dl (60-220) T4=11,4 Ìg/dl (4,5-12,5) TSH=3,2 ÌIU/ml (0,3-4) πÔÓÈṲ̂ÓÔ Ca=1,11 mmol/L (1,12-1,3) cAmp Ô‡ÚˆÓ=12,2 nmol/ml (1,6-6,2) OH-ÚÔÏ›ÓË Ô‡ÚˆÓ 24ÒÚÔ˘=121 mg/l (5-25) ∞ÎÙÈÓÔÁÚ·Ê›· Ì·ÎÚÒÓ ÔÛÙÒÓ: ¯ˆÚ›˜ ÂÌÊ·Ó‹ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ™˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24ÒÚÔ˘ ÁÈ· Ca, P, Na, K, ∫Ú·ÙÈÓ›ÓË, O˘Ú›·, O˘ÚÈÎfi Ô͇: ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ ∞ÌÈÓfiÁÚ·ÌÌ· Ô‡ÚˆÓ: ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÀÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ: ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ‚Ú¤ÊÔ˜ Â›Ó·È ·È‰› ÚÔÛʇÁˆÓ Ô˘ ‰È·‚ÈÔ‡Ó Î¿Ùˆ ·fi ‰˘ÛÌÂÓ›˜ Û˘Óı‹Î˜, ÙÔ fiÙÈ ÛÈÙÈ˙fiÙ·Ó ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ·ÔÎÏÂÈÛÙÈο Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi Ì·˜ ¤Î·Ó ӷ ÈÛÙ‡ԢÌ ·Ú¯Èο fiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ D, ÛÈÙÈÛÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∏ ·Ú¯È΋ Ì·˜ ÛΤ„Ë ·ÓÂÙÚ¿Ë ·fi Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ Ô˘ ¤‰ÂÈÍ·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ 25(O∏)‚ÈÙ D3. ∆· Â˘Ú‹Ì·Ù· ÙÔ˘ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡ (¯·ÌËÏfi ÈÔÓÈṲ̂ÓÔ Ca, ¯·ÌËÏfi˜ P, ·˘ÍË̤ÓË PTH, ·˘ÍË̤ÓË ALP, ·˘ÍË̤ÓË ÔÛÙ¿ÛË, ·˘ÍË̤ÓÔ cAMP, ·˘ÍË̤ÓË O∏ ÚÔÏ›ÓË Ô‡ÚˆÓ) Ë Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ 25-O∏ ‚ÈÙ D3, Ë ¯·ÌËÏ‹ ÙÈÌ‹ 1,25(O∏)2 ‚ÈÙ D3 ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ô˘Û›· ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ (Ô˘Ú›·- ÎÚ·ÙÈÓ›ÓË: ÎÊ, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ: ÎÊ, ·ÌÈÓfiÁÚ·ÌÌ· Ô‡ÚˆÓ: ÎÊ, ·Ô‚ÔÏ‹ P-O˘ÚÈÎÔ‡ ÔͤԘ: ÎÊ) ÙÂÎÌËÚÈÒÓÔ˘Ó ÙË ‰È¿ÁÓˆÛË Ù˘ Ú·¯›Ùȉ·˜ ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D Ù‡Ô˘ π. ∏ ÌË ÂÌÊ·Ó‹˜ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ú·¯›Ùȉ·˜ ÏËÓ ÙˆÓ ÌÂÁ¿ÏˆÓ ‰È·ÛÙ¿ÛÂˆÓ Ù˘ ÚfiÛıÈ·˜ ËÁ‹˜ Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ÌÈÎÚ‹ ËÏÈΛ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ Î·È ÛÙËÓ ÌÂÚÈ΋ ¤ÏÏÂÈ„Ë Ù˘ 1,25 (O∏)2 ‚ÈÙ D. ∆Ô ·È‰› ÂÙ¤ıË Û ·ÁˆÁ‹ Ì 1,25 (O∏)2 ‚ÈÙ D3 (Calcitriol Roche 0,25 Ìg/24h) ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Ù· ‚ÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ‹Ù·Ó ÂÏ·ÊÚÒ˜ ‚ÂÏÙȈ̤ӷ Èı·ÓfiÓ ÏfiÁˆ Ù˘ ηχÙÂÚ˘ ‰È·ÙÚÔÊ‹˜ ηٿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ (ALP=588 U/L,
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™ÂÏ›‰·428
¶∞π¢π∞∆ƒπ∫∏ 2000;63:426-429
Ca=10,6 mg/dl, P=4,6 mg/dl). ∂ÓÒ 2 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ›¯·Ì ۷ʋ ‚ÂÏÙ›ˆÛË ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ (Ca=10,5 mg/dl, P=5,7 mg/dl, ALP=387 U/L) ÁÂÁÔÓfi˜ Ô˘ ·Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÁˆÁ‹˜. ∆· ۈ̷ÙÔÌÂÙÚÈο ÙÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó µ™=6650 (5-10Ë∂£), ª™=63 cm (3Ë ∂£), ¶∫=42,5 cm (50Ë ∂£). ∆Ô ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÙÔ˘ ·È‰ÈÔ‡ Èı·Ófiٷٷ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰˘ÛÙÚÔÊ›·˜ ÁÂÁÔÓfi˜ Ô˘ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙËÓ ÈηÓÔÔÈËÙÈ΋ ·Ó¿Ù˘ÍË Î·Ù¿ 4 cm/Ì‹Ó· ÌÂÙ¿ ÙËÓ Â·Ú΋ Û›ÙÈÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ˘ÔÏÔ›ˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È Ô ·ÎfiÏÔ˘ıÔ˜: ¶·Ù¤Ú·˜: Ca=9,5 mg/dl, P=3,8 mg/dl, ALP=81 U/L, O˘Ú›·=35- Cr=0,8 mg/dl ªËÙ¤Ú·: Ca=9,2 mg/dl, P=4,4 mg/dl, ALP=163 U/L, O˘Ú›·=32- Cr=0,8 mg/dl ∞‰ÂÚÊfi˜: Ca=10 mg/dl, P=5,1 mg/dl, ALP=252 U/L, O˘Ú›·=26- Cr=0,4 mg/dl ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡ fiˆ˜ Î·È Ô ÂÚ·ÈÙ¤Úˆ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ˘ÔÏÔ›ˆÓ ÌÂÏÒÓ ‰ÈÂÎfiË ÏfiÁˆ ÌÂÙ·Ó·ÛÙ‡Ûˆ˜ ÙÔ˘ ·È‰ÈÔ‡ Û ¯ÒÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ™˘˙‹ÙËÛË ∏ ‚ÈÙ·Ì›ÓË D Â›Ó·È Ì›ÁÌ· Ô˘ÛÈÒÓ Ô˘ ¯ËÌÈο ÌÔÈ¿˙Ô˘Ó Ì ÙË ¯ÔÏËÛÙÂÚfiÏË: ·) Ë ‚ÈÙ D2 ‹ ÂÚÁÔηÏÛÈÊÂÚfiÏË ·Ú¿ÁÂÙ·È Ì ·ÎÙÈÓÔ‚fiÏËÛË Ù˘ ÂÚÁÔÛÙÂÚfiÏ˘ Î·È ‚Ú›ÛÎÂÙ·È Û ·ÊıÔÓ›· ÛÙË Ê‡ÛË (ȉ›ˆ˜ ÛÙ· ȯı˘¤Ï·È·) ‚) Ë ‚ÈÙ D3 ‹ ¯ÔÏËηÏÛÈÊÂÚfiÏË Û¯ËÌ·Ù›˙ÂÙ·È ÛÙÔ ‰¤ÚÌ· ·fi ÙËÓ 7 ‰Â¸‰ÚÔ¯ÔÏËÛÙÂÚfiÏË Ì ÙËÓ Â›‰Ú·ÛË Ù˘ ˘ÂÚÈÒ‰Ô˘˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ (2). ∆fiÛÔ Ë ‚ÈÙ D2 fiÛÔ Î·È D3 ̤ۈ ÙÔ˘ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ ÂÓ˙‡ÌÔ˘ 25 ˘‰ÚÔÍ˘Ï¿ÛË ÌÂÙ·ÙÚ¤ÔÓÙ·È ÛÙÔ ‹·Ú Û 25(O∏) ‚ÈÙ D. ™ÙË Û˘Ó¤¯ÂÈ· ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ Ì ÙË ‚Ô‹ıÂÈ· Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ ˘Ê›ÛÙ·ÓÙ·È ÂÚ·ÈÙ¤Úˆ ÙÚÔÔÔ›ËÛË Û 1,25 (O∏)2 ‚ÈÙ D Ô˘ ·ÔÙÂÏ› Î·È ÙË ‰Ú·ÛÙÈ΋ ÌÔÚÊ‹ Ù˘ ‚ÈÙ D. ∏ 1·-˘‰ÚÔÍ˘Ï¿ÛË ‚Ú›ÛÎÂÙ·È ÛÙ· ÌÈÙÔ¯fiÓ‰ÚÈ· ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ Î·È Â›Ó·È ÛÙÂÓ¿ Û˘Ó‰Â‰Â̤ÓË Ì ÙÔ Î˘Ùfi¯ÚˆÌ· ƒ-450. ™ÙÔ˘˜ ÓÂÊÚÔ‡˜ ›Û˘, ̤ۈ ÂÓfi˜ ¿ÏÏÔ˘ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ 24-˘‰ÚÔÍ˘Ï¿Û˘ Á›ÓÂÙ·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ÌÂÙ·ÙÚÔ‹ Ù˘ 25(O∏) ‚ÈÙ D ÛÙËÓ ÏÈÁfiÙÂÚÔ ‰Ú·ÛÙÈ΋ 24,25 (O∏) ‚ÈÙ D (1-3). H ·Ú·ÁˆÁ‹ Ù˘ 1,25(O∏)2 ‚ÈÙ D Ú˘ıÌ›˙ÂÙ·È ·fi ÙËÓ ÙÈÌ‹ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (Ca), ÙÔ˘ ʈÛÊfiÚÔ˘ (ƒ), Ù˘ ·Ú·ıÔÚÌfiÓ˘ (ƒ∆∏), ÙËÓ ›‰È· ÙËÓ 1,25 (O∏)2 ‚ÈÙ D, fiˆ˜ ›Û˘ Î·È ·fi ¿ÏϘ ÛÙÂÚÔÂȉ›˜ ÔÚÌfiÓ˜-·Ó‰ÚÔÁfiÓ· (4). ªÂȈ̤ÓÔ Ca, ÌÂȈ̤ÓÔ˜ ƒ, ·˘ÍË̤ÓË ƒ∆∏, ÌÂȈ̤ÓË 1,25(O∏)2 ‚ÈÙ D ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘. ∞ÓÙ›ıÂÙ· ·˘ÍË̤ÓÔ Ca, ·˘ÍË̤ÓÔ˜ ƒ, ÌÂȈ̤ÓË ƒ∆∏, ·˘ÍË̤ÓË 1,25(O∏)2 ‚ÈÙ D ÂÏ·ÙÙÒÓÔ˘Ó ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘, ·˘Í¿ÓÔ˘Ó ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘
428
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
24- ˘‰ÚÔÍ˘Ï¿Û˘ Î·È ¤¯Ô˘Ó Û·Ó ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ 1,25(O∏)2 ‚ÈÙ D Î·È ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ ÏÈÁfiÙÂÚÔ ‰Ú·ÛÙÈ΋˜ 24,25 (O∏)2 ‚ÈÙ D. ∏ ·Ï›Ó‰ÚÔÌË ·ÏÏËÏÔÚ‡ıÌÈÛË Ù˘ 1,25(O∏)2 ‚ÈÙ D Èı·Ófiٷٷ ·ÛÎÂ›Ù·È Ì¤Ûˆ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ‚ÈÙ D (‚ÈÙ DBP)(5) ÂÓÒ ÔÈ ˘fiÏÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ‰ÚÔ˘Ó Ì¤Ûˆ Ù˘ ÎÚ·ÙÔʈÛÊÔÎÈÓ¿Û˘-∞, Ù˘ ÎÚ·ÙÔʈÛÊÔÎÈÓ¿Û˘-µ, ÙÔ˘ cAMP ‹ Î·È Ì ·Â˘ı›·˜ ‰Ú¿ÛË ÙˆÓ ÈfiÓÙˆÓ Ca (3). °ÂÓÂÙÈο ηıÔÚÈṲ̂ÓË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ‹ ·Ú·ÁˆÁ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋˜ 1·-˘‰ÚÔÍ˘Ï¿Û˘, ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÎÏÈÓÈ΋ ÔÓÙfiÙËÙ· Ô˘ ÔÓÔÌ¿˙Ô˘Ì ڷ¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈο ‹ ·˘ÍË̤ӷ ›‰· 25(O∏) ‚ÈÙ D Î·È ÌÂȈ̤ӷ ›‰· 1,25(O∏)2 ‚ÈÙ D. ∏ 1,25(O∏)2 ‚ÈÙ D ·ÛΛ ÙË ‚ÈÔÏÔÁÈ΋ Ù˘ ‰Ú¿ÛË Ì¤Ûˆ ÂȉÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ (‚ÈÙ DTP) ÛÙÔ˘˜ ÈÛÙÔ‡˜ ÛÙfi¯Ô˘˜: ÓÂÊÚÔ›, ¤ÓÙÂÚÔ, ÔÛÙÂÔ‚Ï¿ÛÙ˜, ·Ú·ı˘ÚÂÔÂȉ›˜, ÓËÛȉȷο ·ÙÙ·Ú· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÎÏ. °ÂÓÂÙÈο ηıÔÚÈṲ̂ÓË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ‹ ÏÂÈÙÔ˘ÚÁÈÎfi ¤ÏÏÂÈÌÌ· ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ‚ÈÙ D Ô‰ËÁ› Û ÌÂȈ̤ÓË ‰Ú¿ÛË Ù˘ 1,25 (O∏)2 ‚ÈÙ D ·Ú¿ Ù· ·˘ÍË̤ӷ ›‰· Ù˘, ηٿÛÙ·ÛË Ô˘ ÔÓÔÌ¿˙Ô˘Ì ڷ¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ‚ÈÙ·Ì›ÓË D Ù‡Ô˘ ππ. ∫·È ÔÈ ‰‡Ô Ù‡ÔÈ Ú·¯›Ùȉ·˜ ÂÍ·ÚÙÒÌÂÓ˘ ·fi ÙË ‚ÈÙ·Ì›ÓË D ÎÏËÚÔÓÔÌÔ‡ÓÙ·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ Ù‡Ô (1,6). ∏ ·ÓÙÈÚ·¯ÈÙÈ΋ ‰Ú¿ÛË Ù˘ ‚ÈÙ D Û˘Ó›ÛÙ·Ù·È ÛÙÔ fiÙÈ ·˘Í¿ÓÂÈ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ Ca, P ·fi ÙÔ ¤ÓÙÂÚÔ, ·˘Í¿ÓÂÈ ÙËÓ Â·Ó·ÚÚfiÊËÛË ÙÔ˘ ƒ ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜, fiˆ˜ ›Û˘ ¤¯ÂÈ ·Â˘ı›·˜ ‰Ú¿ÛË ÛÙËÓ ÂÈÌÂÙ¿ÏψÛË ÙˆÓ ÔÛÙÒÓ. ª·˙› Ì ÙËÓ ƒ∆∏ Î·È ÙËÓ Î·ÏÛÈÙÔÓ›ÓË ¤¯ÂÈ Î‡ÚÈÔ ÚfiÏÔ ÛÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙÔ˘ Ca Î·È ÙÔ˘ ƒ. ∏ ¤ÏÏÂÈ„Ë ‰Ú¿Û˘ Ù˘ ‚ÈÙ D ÚÔηÏ› ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi Ì ٷ ·Ó¿ÏÔÁ· Â˘Ú‹Ì·Ù· (·˘ÍË̤ÓË ALP, ·˘ÍË̤ÓË ƒ∆∏, Ê˘ÛÈÔÏÔÁÈÎfi ‹ ÌÂȈ̤ÓÔ Ca, ÂÏ·Ùو̤ÓÔ˜ ƒ). ™ÙÔÓ ›Ó·Î· 1 ˘¿Ú¯Ô˘Ó ηٷÛÙ¿ÛÂȘ Ô˘ ÚÔηÏÔ‡Ó Ú·¯›Ùȉ· Î·È ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi, ÂÓÒ ÛÙÔÓ ›Ó·Î· 2 ˘¿Ú¯Ô˘Ó ηٷÛÙ¿ÛÂȘ Ì ڷ¯›Ùȉ· ¯ˆÚ›˜ ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi (1). ¶›Ó·Î·˜ 1. ∞›ÙÈ· Ú·¯›Ùȉ·˜ Ì ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi 1. ŒÏÏÂÈ„Ë ‚ÈÙ D - ÌÂȈ̤ÓË ¤ÎıÂÛË ÛÙËÓ ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· - ÌÂȈ̤ÓË ÚfiÛÏË„Ë Ì¤Ûˆ ÙÚÔÊÒÓ 2. ¢˘Û·ÔÚÚfiÊËÛË Ù˘ ‚ÈÙ D 3. ∏·ÙÈ΋ ÓfiÛÔ˜ 4. ∞ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η 5. ¡ÂÊÚÈ΋ OÛÙÂÔ‰˘ÛÙÚÔÊ›· 6. ƒ·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π 7. ƒ·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ ππ
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·429
¶∞π¢π∞∆ƒπ∫∏ 2000;63:426-429
¶›Ó·Î·˜ 2. ∞›ÙÈ· Ú·¯›Ùȉ·˜ ¯ˆÚ›˜ ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi 1. ™˘ÁÁÂÓ‹˜ ÚˆÙÔ·ı‹˜ ˘ÔʈÛÊÔÚ·ÈÌ›· 2. ™‡Ó‰ÚÔÌÔ Fanconi - ΢ÛÙ›ÓˆÛË, Ù˘ÚÔÛ›ÓˆÛË, Û‡Ó‰ÚÔÌÔ Lowe, ›ÎÙËÙÔ 3. ¡ÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË Ù‡Ô˘ ππ 4. ∂Ï·Ùو̤ÓË ÚfiÛÏË„Ë ƒ 5. ÀÔʈÛÊ·Ù·Û·ÈÌ›·
™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ ÙÔ ·Ú¯ÈÎfi ‡ÚËÌ· ‹Ù·Ó Ë ·˘ÍË̤ÓË ALP. ∞‡ÍËÛË Ù˘ ALP ¤¯Ô˘Ì Û ηٷÛÙ¿ÛÂȘ Ì ·˘ÍË̤ÓË ÔÛÙÂÔ‚Ï·ÛÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (Paget, ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi˜, ÔÛÙÂÔ̷ϷΛ·, ÔÛÙÂÔ‚Ï·ÛÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ, Ó·ڋ ËÏÈΛ·), Û ·ı‹ÛÂȘ ÙÔ˘ ‹·ÙÔ˜ Î·È ÙˆÓ ¯ÔÏËÊfiÚˆÓ, ÛÙËÓ Î‡ËÛË ÏfiÁˆ ·Ú·ÁˆÁ‹˜ Ù˘ ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ·, ÂÓÒ Û¿ÓÈ· ÌÔÚ› Ó· Â›Ó·È Î·È È‰ÈÔ·ı‹˜ (7). ∏ Û˘Ó¤¯ÈÛË ÙÔ˘ ÂϤÁ¯Ô˘ Ì·˜ ¤‰ÂÈÍ fiÙÈ Ë ·˘ÍË̤ÓË ALP ‹Ù·Ó ·ÔÙ¤ÏÂÛÌ· ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡, ÂÓÒ Â›¯·ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ 25 O∏ ‚ÈÙ D Ì ÂÏ·Ùو̤ÓË ÙÈÌ‹ 1,25(O∏)2 ‚ÈÙ D. ªÂȈ̤Ó˜ ÙÈ̤˜ 1,25(O∏)2 ‚ÈÙ D ¤¯Ô˘ÌÂ: ·) ÛÙËÓ ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ·Ó¿ÚÎÂÈ· Ù˘ 1·- ˘‰ÚÔÍ˘Ï¿Û˘ (Ú·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D Ù‡Ô˘ π), ‚) Û ÓfiÛÔ˘˜ Ì ηٷÛÙÚÔÊ‹ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Á) ·ı‹ÛÂȘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ ÛÙȘ Ôԛ˜ Èı·ÓfiÓ Ó· Á›ÓÂÙ·È ·Ó·Ú΋˜ Ú‡ıÌÈÛË Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ Î·È ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi (1,2), ‰) ¿ÙÔÌ· Ô˘ ¿Û¯Ô˘Ó ·fi HIV ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÏ·Ùو̤Ó˜ ÙÈ̤˜ 1,25(O∏)2 ‚ÈÙ D Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÏ·Ùو̤Ó˜ ÙÈ̤˜ ‚ÈÙ D(8). O ¤ÏÂÁ¯fi˜ Ì·˜ ·¤ÎÏÂÈÛ ÙfiÛÔ ÓfiÛÔ Ì ηٷÛÙÚÔÊ‹ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, fiÛÔ Î·È ÓfiÛÔ ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ (U/S ÓÂÊÚÒÓ: ÎÊ, Ô˘Ú›·ÎÚ·ÙÈÓ›ÓË ·›Ì·ÙÔ˜: ÎÊ, ÁÂÓÈ΋ Ô‡ÚˆÓ: ÎÊ, ηÏÏȤÚÁÂÈ· Ô‡ÚˆÓ: ÛÙ›ڷ, Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË Ca, P, Ô˘ÚÈÎÔ‡ ÔͤԘ, ·ÌÈÓÔͤˆÓ, ÁÏ˘Îfi˙˘) οÓÔÓÙ·˜ ÚÔÊ·Ó‹ ÙËÓ ‰È¿ÁÓˆÛË Ù˘ Ú·¯›Ùȉ·˜ ÂÍ·ÚÙÒÌÂÓ˘ ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π. ∏ ıÂڷ›· Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ÂÊ’ fiÚÔ˘ ˙ˆ‹˜ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË 1,25(O∏)2 ‚ÈÙ D Ì Ôχ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· fiˆ˜ ¤ÁÈÓÂ Î·È ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· η٤ÛÙË ‰˘Ó·ÙfiÓ Ó· ‚ÚÂı› Ì ÌÂıfi‰Ô˘˜ ·Ó·Ï‡ÛÂˆÓ ÙÔ˘ DNA fiÙÈ Ô ÁfiÓÔ˜ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ 1·-˘‰ÚÔÍ˘Ï¿ÛË ‚Ú›ÛÎÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 12q13,3 (9,10). ªÂÙ·ÏÏ¿ÍÂȘ ÛÙÔÓ ·Ú·¿Óˆ ÁfiÓÔ Ô‰ËÁÔ‡Ó Û ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ‹ ÌÂȈ̤ÓË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ Ì ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ 1,25(O∏)2 ‚ÈÙ D Î·È ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ú·¯›Ùȉ·˜. ∏ ÓfiÛÔ˜, fiˆ˜ ·Ó·Ê¤Ú·ÌÂ, ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ·˘ÙÔÛˆÌÈÎfi ˘ÔÏÂÈfiÌÂÓÔ Ù‡Ô. ŸÚÁ·Ó· ÛÙ· ÔÔ›· ˘¿Ú¯ÂÈ Ë 1·-˘‰ÚÔÍ˘Ï¿ÛË ÏËÓ
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È Ù· ÎÂÚ·ÙÈÓÔ·ÙÙ·Ú·, fiÔ˘ ¤ÁÈÓ·Ó Î·È ÔÈ ÚÒÙ˜ ÚÔÛ¿ıÂȘ ·ÔÌfiÓˆÛ˘ ÙÔ˘ DNA ÙÔ˘ ÁfiÓÔ˘ Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ (11), Ô ÂÁΤʷÏÔ˜, ÔÈ fiÚ¯ÂȘ, Ô Ï·ÎÔ‡ÓÙ·˜ (12). ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ ·ÔÌfiÓˆÛ˘ ÙÔ˘ DNA ÙÔ˘ ÁfiÓÔ˘ Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ Î·È Ë Â˘Ú‡ÙÂÚË ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ ı· Ì·˜ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÌÂıfi‰ˆÓ ¿ÌÂÛ˘ ‰È¿ÁÓˆÛ˘ Î·È ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ù˘ Ú·¯›Ùȉ·˜ ÂÍ·ÚÙÒÌÂÓ˘ ·fi ÙËÓ ‚ÈÙ D Ù‡Ô˘ π, ı· Ì·˜ ‚ÔËı‹ÛÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ 1·˘‰ÚÔÍ˘Ï¿Û˘ ·ÏÏ¿ Î·È ÁÂÓÈÎfiÙÂÚ· ÛÙËÓ Î·Ù·ÓfiËÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ‚ÈÙ D Î·È ÙÔ˘ Ca. µÈ‚ÏÈÔÁÚ·Ê›· 1. Russell W Chesney. Metabolic bone disease. Nelson Textbook of Pediatrics 15th edition 1984-87. 2. ª·ÙÚ›ÓÔ˜ §ª. ™‡Á¯ÚÔÓË ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·. ∂Ή. ¶·Û¯·Ï›‰Ë, 1982:515-517, 535-539. 3. Herny HL. Vitamin D hydroxylases. J Cell Biochem 1992;49:4-9. 4. Breslaw NA. Normal and abnormal regulation of 1,25(OH)2 D synthesis. Am J Med Sci 1988;296:417-425. 5. Takeyama K, Kitanaka S, Sato T, Kobori M, Yanagisawa J, Koto S. 25- Hydroxyvitamin D3. 1alpha-hydroxylase and vitamin D synthesis. Science 1997;277:1827-1830. 6. Takeda E, Yamamoto H, Taketani Y, Miyamoto K. Vitamin D-dependent rickets type I and type II. Acta Paediatr Jpn 1997;39:508-513. 7. ∞’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∞ÍÈÔÏfiÁËÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛˆÓ. ™ÙËÓ ∂ÛˆÙÂÚÈ΋ ¶·ıÔÏÔÁ›·. ∂ΉfiÛÂȘ ¶·Û¯·Ï›‰Ë; 1984. p. 226-227. 8. Haug C, Muller F, Aukrust P, Froland SS. Subnormal serum concentration of 1,25- vitamin D in human immunodeficiency virus infection: Correlation with degree of Immune deficiency and survival. JID 1994;169:889-893. 9. St-Arnaud R, Messerlian S, Mair J, Omdahl JL, Glorienx FH. The 25- hydroxyvitamin D 1-alpha-hydroxylase gene maps the pseudovitamin D - deficiency rickets (PDDR) disease locus. J Bone Miner Res 1997;12:1552-1559. 10. Kitanaka S, Takeyama K, Murayama A, Sato T, Kymura O, Nagami M et al. Inactivating mutations in the 25hydroxyvitamin D3 1 alpha hydroxylase gene in patients with pseudovitamin D- deficiency rickets. N Engl J Med 1998;338:653-661. 11. Fu GK, Lin D, Zhang MV, Bikle DD, Shackleton GH, Miller WL et al. Cloning of human 25-hydroxyvitamin D-1 alpha hydroxylase and mutations causing vitamin D dependent rickets type 1. Mol Endocrinol 1997;11:1961-1970. 12. Glorienx FH, Arabian A, Delvin EE. Pseudo-Vitamin D deficiency: absence of 25- hydroxyvitamin D 1 alphahydroxylase activity in human placenta decidual cells. J Clin Endocrinol Metab 1995;80:2255-2258. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-07-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 25-07-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ (¶·È‰›·ÙÚÔ˜-¢È¢ı˘ÓÙ‹˜) ∑·Î‡ÓıÔ˘ 2 - ÷ϿӉÚÈ
429
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:430-433
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
™˘ÁÁÂÓ‹˜ ‰È·Ù·Ú·¯‹ ÛÙËÓ ˆÛÌÔÚÚ‡ıÌÈÛË Ù˘ ‰›„·˜ Î·È Ù˘ ¤ÎÎÚÈÛ˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘ ∞Ó·ÛÙ¿ÛÈÔ˜ ¶··‰ËÌËÙÚ›Ô˘, ∫·Ó¤ÏÏ· ∫ËÔ˘ÚÔ‡+, ÃÚÈÛÙ›Ó· ª·ÓÙ¿, °ÂˆÚÁ›· ∆·¿ÎË, º›ÏÈÔ˜ ºÈÏÈ›‰Ë˜ ● ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ Ì ¯ÚfiÓÈ· ˘ÂÚÓ·ÙÚÈ·ÈÌ›· ÏfiÁˆ Û˘ÁÁÂÓÔ‡˜ ‰È·Ù·Ú·¯‹˜ ÛÙËÓ ˆÛÌÔÚÚ‡ıÌÈÛË Ù˘ ‰›„·˜ Î·È Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ·ÚÁÈÓ›Ó˘ ‚·˙ÔÚÂÛÛ›Ó˘ (AVP). ∂ÚfiÎÂÈÙÔ ÁÈ· ı‹Ï˘ ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 12 ÌËÓÒÓ, Ô˘ ÚÔÛÎÔÌ›ÛıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÂÂȉ‹ ÂÌÊ¿ÓÈ˙ ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ fiÙÈ ÙÔ ‚Ú¤ÊÔ˜ ›¯Â ˘ÂÚÙÔÓÈ΋ ·Ê˘‰¿ÙˆÛË, Ùo Ó¿ÙÚÈÔ ÔÚÔ‡ ‹Ù·Ó 197 mEq/L Î·È Ë ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ 430 mOsm/kg. H ¤ÏÏÂÈ„Ë ÛËÌ›ˆÓ ‰›„·˜, ·Ú¿ ÙË ÛËÌ·ÓÙÈ΋ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·, Ì·˜ Ô‰‹ÁËÛ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ¯ÚfiÓÈ·˜ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜ ÏfiÁˆ ·‰È„›·˜. ¶ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË ¤‰ÂÈÍ fiÙÈ 1) Ù· ›‰· Ù˘ AVP ‹Ù·Ó ¯·ÌËÏ¿ ÁÈ· ÙËÓ ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, 2) Ë ˆÛÌÔÙÈÎfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÁÈ· Ù· ›‰· Ù˘ AVP Î·È 3) ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ˆÛÌÔÙÈÎfiÙËÙ·˜ Ï¿ÛÌ·ÙÔ˜ Î·È Ô‡ÚˆÓ (r=0,72, p<0,02). ŸÌˆ˜ Ë ÎÏ›ÛË Ù˘ ÁÚ·ÌÌ‹˜ Û˘Û¯¤ÙÈÛ˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË, ‡ÚËÌ· Ô˘ Û˘ÓËÁÔÚ› ÁÈ· ÌÂÚÈ΋ ηٷÛÙÚÔÊ‹ ÙˆÓ ˆÛÌÔ¸Ô‰Ô¯¤ˆÓ Ù˘ AVP. ¶·È‰È·ÙÚÈ΋ 2000;63:430-433. §¤ÍÂȘ ÎÏÂȉȿ: xÚfiÓÈ· ˘ÂÚÓ·ÙÚÈ·ÈÌ›·, ˘ÂÚˆÛÌÔÙÈÎfiÙËÙ·, ·‰È„›·, ·ÚÁÈÓ›ÓË ‚·˙ÔÚÂÛÛ›ÓË. A. Papadimitriou, K. Kipourou+, C. Manta, G. Tapaki, P. Philippidis. Congenital defect in the osmoregulation of thirst and the secretion of antidiuretic hormone. Paediatriki 2000;63:430-433. ● Abstract: We report the case of an infant with chronic hypernatremia due to a congenital defect in osmoregulation of thirst and the secretion of Arginine Vasopressin (AVP). A 12 month old female infant, who presented with irritability and signs of dehydration, was found to have hypertonic dehydration with plasma osmolality of 430 mOsm/kg. Despite rehydration she remained hypernatremic (serum Na+ 152-158 mEq/L). Lack of signs of thirst led us to the diagnosis of chronic hypernatremia due to adipsia. Laboratory investigation showed that 1) plasma AVP levels were low as compared to plasma osmolality, 2) urine osmolality was normal as compared to plasma AVP and 3) there was a significant correlation of plasma to urine osmolality (r=0.72, p<0.02). However the slope of the line of correlation was markedly reduced indicating partial destruction of the AVP osmoreceptors. Key words: chronic hypernatremia, hyperosmolality, adipsia, arginine vasopressin.
∏ ˘ÂÚÓ·ÙÚÈ·ÈÌ›· ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È Û˘Ó‹ıˆ˜ ·ÚÔ‰È΋, Î·È ÔÊ›ÏÂÙ·È Û ÂÎÛÂÛËÌ·Ṳ̂ÓË ·ÒÏÂÈ· ÓÂÚÔ‡ (.¯. ÏfiÁˆ Á·ÛÙÚÂÓÙÂÚ›ÙȉԘ) ‹ ÈÔ Û¿ÓÈ· Û ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ·Ï·ÙÈÔ‡ Ô˘ ‰ÂÓ ·ÓÙÈÚÚÔÂ›Ù·È ·fi ·Ú¿ÏÏËÏË ·‡ÍËÛË ÛÙËÓ ÚfiÛÏË„Ë ÓÂÚÔ‡. ∞ÓÙ›ıÂÙ·, Ë ¯ÚfiÓÈ· ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Â›Ó·È Ôχ Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ‰ÂÓ Â›Ó·È ¿ÌÂÛ· ÂÌÊ·Ó‹˜ (1). £ÂˆÚÂ›Ù·È fiÙÈ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‚Ï¿‚˘ ÛÙÔ Ì˯·ÓÈÛÌfi Ù˘ ‰›„·˜ Î·È Ù˘ ˆÛÌÔÚÚ‡ıÌÈÛ˘ Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ·ÚÁÈÓ›Ó˘ ‚·˙ÔÚÂÛÛ›Ó˘ (AVP)(2).
¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ÙËÓ ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ 12 ÌËÓÒÓ Ì ¯ÚfiÓÈ· ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Ô˘ ÔÊÂÈÏfiÙ·Ó ÛÂ Û˘ÁÁÂÓ‹ ‰È·Ù·Ú·¯‹ Ù˘ ˆÛÌÔÚÚ‡ıÌÈÛ˘ Ù˘ ‰›„·˜ Î·È Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ·ÚÌfiÓ˘ (ADH), ·ÚÁÈÓ›ÓË ‚·˙ÔÚÂÛÛ›ÓË. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÂÂȉ‹ ·ÚÔ˘Û›·˙ ˘ÚÂÙfi ¤ˆ˜ 38ÔC, ·ÓËÛ˘¯›· Î·È ¿ÚÓËÛË ÚÔ˜ Ï‹„Ë ÙÚÔÊ‹˜ ·fi ÙÚÈË̤ÚÔ˘. ◊Ù·Ó ÙÔ ÌfiÓÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ ÔÈ ÔÔ›ÔÈ ‰ÂÓ Â›¯·Ó
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ¶·Ï·È¿ ¶ÂÓÙ¤ÏË
430
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14:03
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:430-433
15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
pAVP
ηÌÌ›· Û˘ÁÁ¤ÓÂÈ· ÌÂٷ͇ ÙÔ˘˜. ∆Ô ·È‰› ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË Î‡ËÛË ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi Î·È ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2,8 kg. ∏ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋, ηıÒ˜ Î·È Ë „˘¯ÔÎÈÓËÙÈ΋ ÙÔ˘ ÂͤÏÈÍË. ∞fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ·Ó·ÌÓËÛÙÈÎfi ‰ÂÓ ˘‹Ú¯Â οÙÈ ÙÔ ·ÍÈfiÏÔÁÔ. ∫·Ù¿ ÙË Ê˘ÛÈ΋ ÂͤٷÛË ÙÔ ·È‰› ‹Ù·Ó ÏËı·ÚÁÈÎfi Î·È Ì ÎÏÈÓÈο ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘. ∏ ıÂÚÌÔÎÚ·Û›· ÛÒÌ·ÙÔ˜ ‹Ù·Ó 38,2ÔC, Ë ∞.¶. 90/60 mm Hg Î·È ÔÈ ÛʇÍÂȘ 120/min. TÔ Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ (ª.™.) ‹Ù·Ó 73 ÂηÙ=15Ë ∂.£., ÂÓÒ ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (µ.™.) 6.200 ÁÚ.<3Ë ∂.£. Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ 46 ÂηÙ=10Ë ∂.£. ∏ ÏÔÈ‹ ηٿ Û˘ÛÙ‹Ì·Ù· ÂͤٷÛË ‰ÂÓ ·ÔÎ¿Ï˘„ οÙÈ ÙÔ ·ıÔÏÔÁÈÎfi. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ˘ÂÚÙÔÓÈ΋ ·Ê˘‰¿ÙˆÛË: Ô˘Ú›· 298 mg%, K: 4,7 mEq/L, Na: 197 mEq /L, Cl: 157 mEq/L, ۿί·ÚÔ ·›Ì·ÙÔ˜: 225 mg%, ÎÚ·ÙÈÓ›ÓË ·›Ì: 0,6 mg%, Ca ·›Ì.:9,6 mg%, ˆÛÌÔÙÈÎfiÙËÙ· Ï¿ÛÌ·ÙÔ˜: 430 mOsm/kg, ˆÛÌÔÙÈÎfiÙËÙ· Ô‡ÚˆÓ: 937 mOsm /kg. ∏ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ηıÒ˜ Î·È Ë ÂͤٷÛË ÙÔ˘ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡. ™ÙÔ ‚Ú¤ÊÔ˜ ¯ÔÚËÁ‹ıËÎ·Ó ˘ÁÚ¿ ÂÓ‰ÔÊÏ‚›ˆ˜ Î·È ÌÂÙ¿ ·fi 48 ÒÚ˜ Ë ÎÏÈÓÈ΋ ÙÔ˘ ÂÈÎfiÓ· ‚ÂÏÙÈÒıËÎÂ, Ô ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛÂ, Ô ‰Â ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ·ÎÔÏÔ‡ıËÛ ¤‰ÂÈÍÂ: K: 4,1 mEq/L, Na: 160 mEq/L, Cl: 124 mEq/L, Ô˘Ú›·: 46 mg%, ۿί·ÚÔ ·›Ì·ÙÔ˜: 86 mg%. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜, ·Ú¿ ÙËÓ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ·È‰ÈÔ‡, Ë Ô˘Ú›· Î˘Ì·ÈÓfiÙ·Ó ÌÂٷ͇ 15 ¤ˆ˜ 41 mg%, Î·È ÙÔ ¡· ÔÚÔ‡ 152-158 mEq/L, Ë ˆÛÌÔÙÈÎfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ 316-341 mOsm/kg, Ë ‰Â ˆÛÌÔÙÈÎfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ 136-721 mOsm/kg. ∆Ô ·È‰› ‰ÂÓ ÂÌÊ¿ÓÈ˙ ÔÏ˘Ô˘Ú›·, ¤¯ÔÓÙ·˜ Ê˘ÛÈÔÏÔÁÈÎfi ÈÛÔ˙‡ÁÈÔ ÚÔÛÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ·Ô‚·ÏÏÔÌ¤ÓˆÓ ˘ÁÚÒÓ. ∏ Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ‰ÂÓ ·ÔÎ¿Ï˘Ù ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ˘ÂÚÙÔÓÈ΋˜ ·Ê˘‰¿ÙˆÛ˘ ÙÔ˘ ·È‰ÈÔ‡. ∆Ô ÌfiÓÔ ·ÍÈfiÏÔÁÔ Ô˘ ·Ó¤ÊÂÚ·Ó ÔÈ ÁÔÓ›˜ ‹Ù·Ó fiÙÈ ÙÔ ·È‰› ·ÚÔ˘Û›·˙ ·ÓÔÚÂÍ›· ·fi ËÏÈΛ·˜ 6 ÌËÓÒÓ. ŸÌˆ˜, Ù· ‰È·ÁÚ¿ÌÌ·Ù· Ì‹ÎÔ˘˜ Î·È ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 45 ËÌÂÚÒÓ ÙÔ ·È‰› ·ÚÔ˘Û›·˙ ·Ó·Ú΋ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜, ÂÓÒ Û¯ÂÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ Ú˘ıÌÔ‡ Ù˘ ·‡ÍËÛ˘ ·Ú·ÙËÚ›ÙÔ ÌÂÙ¿ ÙÔÓ 3Ô Ì‹Ó·. ∏ ¤ÏÏÂÈ„Ë ÛËÌ›ˆÓ ‰›„·˜ ·Ú¿ ÙËÓ Ôχ „ËÏ‹ ˆÛÌÔÙÈÎfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ ¤ıÂÛ ÙËÓ ‰È¿ÁÓˆÛË Ù˘ ¯ÚfiÓÈ·˜ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜ ÏfiÁˆ ·‰È„›·˜. ŒÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Ô˘ ‰ÂÓ ¤‰ÂÈÍ οÔÈ· ·ÓˆÌ·Ï›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘. ∂›Û˘, ÂÏ‹ÊıËÛ·Ó ‚·ÛÈΤ˜ ÙÈ̤˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ∆3, ∆4, ∆S∏ Î·È ÎÔÚÙÈ˙fiÏ˘ Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ∏ ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÚÂÓ›Ó˘ Ï¿ÛÌ·ÙÔ˜ (PRA) ‹Ù·Ó >50 ng/kg/ÒÚ· Î·È Ë ·Ï‰ÔÛÙÂÚfiÓË ÔÚÔ‡ 1,16 nmol/L (º.T. 0,69-3,87). OÈ ÙÈ̤˜ Ù˘ ∞Vƒ Ï¿ÛÌ·ÙÔ˜ Î˘Ì·›ÓÔÓÙ·Ó ·fi 1,65-3,87 pmol/L (º.∆.<7,37).
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™¯‹Ì· 1. ™¯¤ÛË AVP (pg/ml) Î·È ˆÛÌÔÙÈÎfiÙËÙ·˜ Ï¿ÛÌ·ÙÔ˜ (mOsm/kg). ∆· ›‰· Ù˘ AVP ‹Ù·Ó ¯·ÌËÏ¿ ÁÈ· ÙËÓ ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∆Ô ÁˆÌÂÙÚÈÎfi Û¯‹Ì· ‰Â›¯ÓÂÈ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜. ¶ÚÔÛ·ÚÌÔṲ̂ÓÔ ·fi ÙÔÓ Robertson (8).
∏ ÛÙ¤ÚËÛË ˘ÁÚÒÓ ÁÈ· 6 ÒÚ˜ ¤ÁÈÓ Ôχ ηϿ ·ÓÂÎÙ‹ ·fi ÙËÓ ·ÛıÂÓ‹ Ì·˜, Ë ÔÔ›· ‰ÂÓ ·ÚÔ˘Û›·Û ÛËÌ·ÓÙÈ΋ ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ ˆÛÌÔÙÈÎfiÙËÙ·˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (0: 324 mOsm/kg, 6 ÒÚ˜: 327 mOsm/kg). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÂÏ‹ÊıËÛ·Ó ·ÚÎÂÙ¿ ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ÁÈ· ̤ÙÚËÛË Ù˘ ˆÛÌÔÙÈÎfiÙËÙ¿˜ ÙÔ˘˜ ηıÒ˜ Î·È Ù˘ AVP Ï¿ÛÌ·ÙÔ˜. OÈ Û˘Û¯ÂÙ›ÛÂȘ ÙˆÓ ·ÓˆÙ¤Úˆ ·Ú·Ì¤ÙÚˆÓ ¤‰ÂÈÍ·Ó fiÙÈ: 1. Ù· ›‰· Ù˘ AVP ‹Ù·Ó ¯·ÌËÏ¿ ÁÈ· ÙËÓ ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (™¯‹Ì· 1) 2. Ë ˆÛÌÔÙÈÎfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÁÈ· Ù· ›‰· Ù˘ AVP Ï¿ÛÌ·ÙÔ˜ (™¯‹Ì· 2) Î·È 3. ˘‹Ú¯Â ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ˆÛÌÔÙÎfiÙËÙ·˜ Ï¿ÛÌ·ÙÔ˜ Î·È Ô‡ÚˆÓ (r:0,72, p<0,02), fï˜, Ë ÎÏ›ÛË Ù˘ ÁÚ·ÌÌ‹˜ Û˘Û¯¤ÙÈÛ˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË Û ۯ¤ÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· (™¯‹Ì· 3). £Âڷ¢ÙÈο ÙÔ ·È‰› Ù¤ıËΠ۠˘Ô¯ÚˆÙÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Û ÔÛfiÙËÙ· ÂÚ› Ù· 1200 ml/24ˆÚÔ Î·È ‰›·ÈÙ· Ùˆ¯‹ Û ӿÙÚÈÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ù· ›‰· ÙÔ˘ Ó·ÙÚ›Ô˘ ·›Ì·ÙÔ˜ Ó· ¤ÛÔ˘Ó ÛÙ· 150-152 mEq/L. ∆Ô ·È‰› ÂÍ‹Ïı ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Û Ôχ ηϋ ηٿÛÙ·ÛË Ì ԉËÁ›Â˜ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ù·ÎÙÈο ÁÈ· ÂÎÙ›ÌËÛË Ù˘ ËÏÂÎÙÚÔÏ˘ÙÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘ ηıÒ˜ Î·È Ù˘ „˘¯ÔÎÈÓËÙÈ΋˜ ÙÔ˘ ÂͤÏÈ͢. ™˘˙‹ÙËÛË ∆Ô Û˘Ó‰ÔÌÔ ˘Ô‰È„›·˜-˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¯ÚfiÓÈ· ˘ÂÚˆÛÌÔÙÈÎfiÙËÙ· Î·È ˘ÂÚÓ·ÙÚÈ·ÈÌ›·, ‹È· ˘ÔoÁηÈÌ›· ·ÏÏ¿ ·Ô˘Û›· ÔÏ˘‰È-
431
30-05-03
14:03
™ÂÏ›‰·432
¶∞π¢π∞∆ƒπ∫∏ 2000;63:430-433
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pOsm
pAVP
™¯‹Ì· 2. ™¯¤ÛË ˆÛÌÔÙÈÎfiÙËÙ·˜ Ô‡ÚˆÓ (mOsm/kg) Î·È AVP (pg/ml) Ï¿ÛÌ·ÙÔ˜. ∏ ÂÚÈÔ¯‹ ÛÙȘ η̇Ϙ ÁÚ·Ì̤˜ ‰Â›¯ÓÂÈ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚÔ˜.
™¯‹Ì· 3. ™¯¤ÛË ˆÛÌÔÙÈÎfiÙËÙ·˜ Ô‡ÚˆÓ (mOsm/kg) Î·È Ï¿ÛÌ·ÙÔ˜ (mOsm/kg) Ô˘ ‰Â›¯ÓÂÈ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË.
¶ÚÔÛ·ÚÌÔṲ̂ÓÔ ·fi ÙÔÓ Robertson (8).
¶ÚÔÛ·ÚÌÔṲ̂ÓÔ ·fi ÙÔ˘˜ Streeten et al (9).
„›·˜ ‹ ÔÏ˘Ô˘Ú›·˜. ∏ ¤ÏÏÂÈ„Ë ‰›„·˜, ·Ú¿ ÙËÓ ˘ÂÚÙÔÓÈ΋ ·Ê˘‰¿ÙˆÛË, Â›Ó·È ·Ó·Áη›· Î·È Â·Ú΋˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‡‰·ÙÔ˜ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ. ∂ÈϤÔÓ, Èı·ÓÒ˜ ÏfiÁˆ ·Ó·ÙÔÌÈ΋˜ ÁÂÈÙÓ›·Û˘ ÙˆÓ ˆÛÌo¸Ô‰Ô¯¤ˆÓ ÁÈ· ÙË ‰›„· Î·È ÙËÓ ¤ÎÎÚÈÛË AVP, Ë ˘Ô‰È„›· ۯ‰fiÓ ¿ÓÙÔÙÂ Û˘Óԉ‡ÂÙ·È ·fi ‰È·Ù·Ú·¯‹ ÛÙËÓ ·ÓÙȉÈÔ‡ÚËÛË. ™ÙËÓ ·ÛıÂÓ‹ Ì·˜, Ë ·Ô˘Û›· ‰›„·˜ ·Ú¿ ÙËÓ Ôχ „ËÏ‹ ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‹Ù·Ó ÙÔ Û‡Ìو̷ Ô˘ Ì·˜ Ô‰‹ÁËÛ ÛÙË ‰È¿ÁÓˆÛË. ∏ ·˘ÍË̤ÓË ÚÂÓ›ÓË ÔÊÂÈÏfiÙ·Ó ÛÙËÓ Û˘Ó˘¿Ú¯Ô˘Û· ˘ÔÔÁηÈÌ›·. ∆· Ê˘ÛÈÔÏÔÁÈο ›‰· Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘ ·Ú¿ ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ÚÂÓ›Ó˘ Ú¤ÂÈ Ó· ·Ô‰ÔıÔ‡Ó ÛÙËÓ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·. ∆· ›‰· Ù˘ AVP ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ‹Ù·Ó fï˜ ‰˘Û·Ó¿ÏÔÁ· ¯·ÌËÏ¿ ÁÈ· ÙËÓ ˆÛÌÔÙÈÎfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ ÁÂÁÔÓfi˜ Ô˘ ‰Â›¯ÓÂÈ fiÙÈ ÛÙËÓ ·ÛıÂÓ‹ Ì·˜ Û˘Ó˘‹Ú¯Â ‰È·Ù·Ú·¯‹ Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ AVP. ∏ ·Ô˘Û›· ÔÏ˘Ô˘Ú›·˜ ηıÒ˜ Î·È Ë Ê˘ÛÈÔÏÔÁÈ΋ ˆÛÌÔÙÈÎfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ ÁÈ· Ù· ›‰· Ù˘ AVP Ï¿ÛÌ·ÙÔ˜, ‰Â›¯ÓÂÈ fiÙÈ Ë ÂÎÎÚÈÓfiÌÂÓË AVP ÌÔÚÔ‡Û ӷ ÚÔηϤÛÂÈ ÈηӋ Û˘Ì‡ÎÓˆÛË ÙˆÓ Ô‡ÚˆÓ. ∏ ‰È·Ù·Ú·¯‹ ÙˆÓ ˆÛÌÔ¸Ô‰Ô¯¤ˆÓ Ù˘ AVP ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ϋÚË ‹ ÌÂÚÈ΋ ÂÎÏÂÎÙÈ΋ ηٷÛÙÚÔÊ‹ ÙÔ˘ ˆÛÌÔÛÙ¿ÙË (3), ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ë AVP ··ÓÙ¿ Ê˘ÛÈÔÏÔÁÈο Û ÌË ˆÛÌÔÙÈο ÂÚÂı›ÛÌ·Ù·. ™ÙËÓ Ï‹ÚË Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ˆÛÌÔ¸Ô‰Ô¯¤ˆÓ Ù˘ AVP Ë ¤ÎÎÚÈÛ‹ Ù˘ ‰ÂÓ ÂËÚ¿˙ÂÙ·È Î·ıfiÏÔ˘ ·fi Ù· ˆÛÌÔÙÈο ÂÚÂı›ÛÌ·Ù· (4) ·ÏÏ¿ ÂÎÎÚ›ÓÂÙ·È Û ¤Ó· Ì¿ÏÏÔÓ ÛÙ·ıÂÚfi ›‰Ô, ÂÚ›Ô˘ ·˘Ùfi Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‚·ÛÈ΋˜ ¤ÎÎÚÈÛ˘ (2). ™Â ÂÚÈÙÒÛÂȘ ÌÂÚÈ΋˜ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ˆÛÌÔ¸Ô‰Ô¯¤ˆÓ Ù˘, Ë AVP ··ÓÙ¿ Û ·ÏÏ·Á¤˜ Ù˘ ˆÛÌÔÙÈÎfiÙËÙ·˜, fï˜ Ë ·¿ÓÙËÛË Â›Ó·È Û·ÊÒ˜
432
ÂÏ·Ùو̤ÓË Û ۯ¤ÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· (5). ∞˘Ùfi ÌÔÚ› Ó· ‰Âȯı› Â¿Ó ·Ó·Ï˘ı› Ë Û˘Û¯¤ÙÈÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÙÈÌÒÓ AVP Ï¿ÛÌ·ÙÔ˜ ηÈ/‹ Ù˘ ˆÛÌÔÙÈÎfiÙËÙ·˜ ÙˆÓ Ô‡ÚˆÓ Ì ÙËÓ ˆÛÌÔÙÈÎfiÙËÙ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ™ÙËÓ ·ÛıÂÓ‹ Ì·˜ Ë ÂÏ·Ùو̤ÓË ÎÏ›ÛË Ù˘ ÁÚ·ÌÌ‹˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ Ù˘ ˆÛÌÔÙÈÎfiÙËÙ·˜ ÙˆÓ Ô‡ÚˆÓ Î·È ÂΛӢ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Û ۯ¤ÛË Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ Î·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó‡ÚÂÛË ÙÈÌÒÓ AVP ÌÂÁ·Ï‡ÙÂÚˆÓ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ·fi ÂΛӘ Ù˘ ‚·ÛÈ΋˜ ¤ÎÎÚÈÛ˘, ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ ÛÙË ÂÚ›ÙˆÛ‹ Ì·˜ Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ˆÛÌÔ¸Ô‰Ô¯¤ˆÓ ‹Ù·Ó ÌÂÚÈ΋. ™ÙËÓ ÚÔÛÈÙ‹ Û ÂÌ¿˜ ‚È‚ÏÈÔÁÚ·Ê›·, ‚ڋηÌ ÏÈÁfiÙÂÚ˜ ·fi 20 ÂÚÈÙÒÛÂȘ ˘Ô‰È„›·˜ - ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜ Ô˘ ·ÊÔÚÔ‡Û·Ó ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 15 ¯ÚfiÓˆÓ, ·fi Ù· ÔÔ›· ÌfiÓÔ ¤Ó· ‹Ù·Ó ‚Ú¤ÊÔ˜ (6). ™Ù· ÂÚÈÛÛfiÙÂÚ· ˘‹Ú¯Â οÔÈ· ·ÓˆÌ·Ï›· ÙÔ˘ ∫.¡.™ (.¯. ÈÛÙÈÔ΢ÙÙ¿ÚˆÛË, ΈӷڛˆÌ·, ‰˘ÛÏ·Û›· ̤Û˘ ÁÚ·ÌÌ‹˜ ÎÏ), ÂÓÒ Û 3 ·È‰È¿ ‰ÂÓ Â›¯Â ‚ÚÂı› ηÌÌ›· ·ÓˆÌ·Ï›· (1), fiˆ˜ Î·È ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜. ∏ ıÂڷ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Û˘Ó›ÛÙ·Ù·È Û ˘Ô¯ÚˆÙÈ΋ ·˘ÍË̤ÓË ÚfiÛÏË„Ë ˘ÁÚÒÓ. ∏ ¯ÔÚ‹ÁËÛË DDAVP Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì Ôχ ÂÚ›Û΄Ë, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û ·˘Ù¿ Ù· ·È‰È¿ ·Ô˘ÛÈ¿˙ÂÈ Ô ÌfiÓÔ˜ Ì˯·ÓÈÛÌfi˜ ÚÔÛÙ·Û›·˜ ·fi ÙËÓ ˘ÂÚ˘‰¿ÙˆÛË, ‰ËÏ·‰‹ Ë ‰›„·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Schaad U, Vassella F, Zuppinger K, Oetliker O. Hypodipsia - hypernatremia syndrome. Helv Paediat Acta 1979;34:63-67. 2. Robertson GL, Aycinena P, Zerbe RL. Neurogenic disorders of osmoregulation. Am J Med 1982;72:339-353.
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3. Robertson GL. Thirst and vasopressin function in normal and disordered states of water balance. J Lab Clin Med 1983;101:351-371. 4. Halter JB, Goldberg AP, Robertson GL, Porte D. Selective osmoreceptor dysfunction in the syndrome of chronic hypernatremia. J Clin Endocrinol Metab 1977;44:609-616. 5. Zerbe RL, Baylis PH, Robertson GL. Vasopressin function in clinical disorders of water balance. In: Robertson G, Beardwell CG, eds. Clinical endocrinology, vol 1. London: Butterworths; 1981. p. 297-329. 6. Schaff-Blass E, Robertson GL, Rosenfield RL. Chronic hypernatremia from a congenital defect in osmoregulation of thirst and vasopressin. J Pediatr 1983;102:703-708. 7. Radetti G, Rizza F, Mengarda G, Pittschieler K. Adipsic hypernatremia in two sisters. Am J Dis Child 1991;145: 321-325.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
8. Robertson GL. The pathophysiology of ADH secretion. In: Tolis G, ed. Clinical neuroendocrinology: A pathophysiological approach. New York: Raven Press; 1979. p. 247-260. 9. Streeten DHP, Moses AM, Miller M. Disorders of the neurohypophysis. In: Braunwald E, Isselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS, eds. Harrison’s principles of internal medicine. 11th ed. New York: McGraw-Hill Book Company; 1987. p. 1722-1732.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-12-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-08-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞Ó·ÛÙ¿ÛÈÔ˜ ¶··‰ËÌËÙÚ›Ô˘ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ï·È¿ ¶ÂÓÙ¤ÏË 152 36
™¿ÓÈ· ÌÔÚÊ‹ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· – ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶·Ú·Û΢‹ ∑ÒÛË, ∏Ú·ÎÏ‹˜ °ÂˆÚÁÈ¿‰Ë˜, ¢ÈÔÓ‡ÛÈÔ˜ ∫·Ú·Î·˚‰fi˜, ¢ËÌ‹ÙÚÈÔ˜ ∆ÛÈÏÈ‚¿ÎÔ˜, £ˆÌ·˝˜ µÏ¿¯Ô˘, ÃÚÈÛÙ›Ó· ¢Ú¿ÎÔ˘, ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ ● ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ËˆÛÈÓÔÊÈÏÈ΋˜ Ì˘˚΋˜ ÂÚÈÙÔÓÈ›Ùȉ·˜ (∏¶) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÔÚÊ·›· Û ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 8,5 ÂÙÒÓ. ∏ ∏¶ ·ÔÙÂÏ› ÌÔÚÊ‹ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·. OÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ Ù˘ ·ÏÏÔÈÒÛÂȘ, Ô˘ ÚÔÛÔÌÔÈ¿˙Ô˘Ó Ì «ÊÏÔÈfi ÔÚÙÔηÏÈÔ‡» (peau d’orange appearance), Û˘Ó‰˘¿˙ÔÓÙ·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ ÌÂ Ù˘ÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÌÔÚÊ·›·˜. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË. ∏ ‰È¿ÎÚÈÛ‹ Ù˘ ·fi ÙȘ ¿ÏϘ ÌÔÚʤ˜ ÂÓÙÔÈṲ̂ÓÔ˘ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ Â›Ó·È ‰˘Û¯ÂÚ‹˜. ∞Ó·ÛÎÔÂ›Ù·È Ë ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÚÔ‚ÔÏ‹, Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È Ë ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘. ¶·È‰È·ÙÚÈ΋ 2000;63:433-437. §¤ÍÂȘ ÎÏÂȉȿ: ÛÎÏËÚfi‰ÂÚÌ·, ˈÛÈÓÔÊÈÏÈ΋ ÂÚÈÙÔÓÈ›Ùȉ·, ÌÔÚÊ·›·. P. Zosi, H. Georgiadis, D. Karakaidos, D. Tsilivakos, T. Vlahou, C. Drakou, C. Karis. ∞ rare case of scleroderma in childhood. Case report. Paediatriki 2000;63:433-437. ● Abstract: We report a case of eosinophilic fasciitis (EF) associated with morphea in a 8.5 year old girl. EF is a type of scleroderma, rare in childhood, which is characterized by thickened, bound-down skin with cobblestone or peau d’orange appearance. EF and morphea commonly occur together, often in different locations. The distinction between EF and various forms of localized scleroderma remains unclear. The various types of the disease, their clinical presentation, treatment and prognosis are reviewed. Key words: scleroderma, eosinophilic fasciitis, morphea.
∂ÈÛ·ÁˆÁ‹ ∆Ô ÛÎÏËÚfi‰ÂÚÌ· ·ÔÙÂÏ› Û¿ÓÈ· ÓfiÛÔ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∞ӷʤÚÔÓÙ·È 4,5-12 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, ·Ó¿ ¤ÙÔ˜. ªfiÓÔ
1,5% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ·ÊÔÚÔ‡Ó ËÏÈ˘ οو ÙˆÓ 10 ÂÙÒÓ, ÂÓÒ ¤Ó· ÂÈϤÔÓ 7,2% ·ÊÔÚ¿ ËÏÈ˘ 10 ¤ˆ˜ 19 ÂÙÒÓ. ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ Á˘Ó·ÈÎÒÓ Â›Ó·È Û˘¯ÓfiÙÂÚË (°/∞ 2/1). ∏ ·Ó·ÏÔÁ›· ÊÙ¿ÓÂÈ
¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜- ¶ÂÈÚ·È¿ «∞Á. ¶·ÓÙÂÏ‹̈ӻ - ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋
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EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
¶›Ó·Î·˜ 1. ∆ÔÈÎfi ÛÎÏËÚfi‰ÂÚÌ·
™˘ÛÙËÌ·ÙÈ΋ ÛÎÏËÚÔ‰ÂÚÌ›·
·) ¶ÂÚÈÁÂÁÚ·Ì̤ÓÔ ‚) °Ú·ÌÌÔÂȉ¤˜
·) ¶ÚÔ˚Ô‡Û· ‰È¿¯˘ÙË ‚) ™‡Ó‰ÚÔÌÔ CREST Á) ™ÎÏËÚÔ‰ÂÚÌ·ÙÔÌ˘ÔÛ›ÙȘ, ÌÈÎÙ‹ ÓfiÛÔ˜ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡
¢Â˘ÙÂÚÔ·ı‹˜ ·fi Ê¿Ú̷η
梉ÔÛÎÏËÚÔ‰ÂÚÌ›·
·) º¿Ú̷η ‚) ÃËÌÈο (ÔÏ˘‚ÈÓ˘Ïԯψڛ‰ÈÔ) Á) ªÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡
·) OȉËÌ·Ù҉˘ (ÛÎÏËÚÔ›‰ËÌ·-ÛÎÏËÚÔÌ˘ÍÔ›‰ËÌ·) ‚) ¢ÈËıËÙÈ΋ (∞Ì˘ÏÔ›‰ˆÛË - ∫·ÚÎÈÓÔÂȉ¤˜ Û‡Ó‰ÚÔÌÔ ‰ÂÚÌ·ÙÈ΋˜ ÔÚʇڷ˜) Á) ∞ÙÚÔÊÈ΋ (¶ÚÔÁËÚ›· - ™ÎÏËÚfi˜ Î·È ·ÙÚÔÊÈÎfi˜ ÏÂȯ‹Ó·˜, Û‡Ó‰ÚÔÌÔ Werner)
ÙÔ 15/1 ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ·. ∏ ÓfiÛÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· (¶›Ó·Î·˜ 1) (1). ™˘¯ÓfiÙÂÚË ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È Ë ÂÓÙÔÈṲ̂ÓË ÌÔÚÊ‹ ›Ù ˆ˜ ÌÔÚÊ·›· ›Ù ˆ˜ Ù·ÈÓÈÔÂȉ¤˜ ÛÎÏËÚfi‰ÂÚÌ·. ∏ ÚÔԉ¢ÙÈ΋ Û˘ÛÙËÌ·ÙÈ΋ ÛÎÏ‹Ú˘ÓÛË ·ÎÔÏÔ˘ı› ÛÂ Û˘¯ÓfiÙËÙ·. ªÔÚ› Ó· ÂÌÊ·ÓÈÛı› Ì ÙË ÌÔÚÊ‹ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ CREST (˘Ô‰fiÚȘ ·Û‚ÂÛÙÒÛÂȘ, Ê·ÈÓfiÌÂÓÔ Raynaud, ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ÛÎÏËÚÔ‰·ÎÙ˘Ï›·, ÙËÏ·ÁÁÂÈÂÎÙ·Û›·) ‹ Ì ÙËÓ ÌÔÚÊ‹ ÙÔ˘ ‚·Ú¤o˜ ÂÍÂÏÈÛÛfiÌÂÓÔ˘ Û˘ÛÙËÌ·ÙÈÎÔ‡ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜, Ì ÚÔÛ‚ÔÏ‹ ÂÎÙfi˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ (‰È·Ù·Ú·¯¤˜ ÎÈÓËÙÈÎfiÙËÙ·˜ ÔÈÛÔÊ¿ÁÔ˘-ÂÓÙ¤ÚÔ˘), ÙˆÓ Ó¢ÌfiÓˆÓ (Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ Ó¢ÌÔÓÔ¿ıÂÈ·), ÙˆÓ ÓÂÊÚÒÓ (˘¤ÚÙ·ÛË, ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·), ÙˆÓ ·ÚıÚÒÛÂˆÓ Î·È Ù˘ ηډȿ˜ (1). ∆Ú›ÙË ÛÂ Û˘¯ÓfiÙËÙ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÂÌÊ·Ó›˙ÂÙ·È Ë ∏¶, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¿¯˘ÓÛË Î·È ÊÏÂÁÌÔÓ‹ Ù˘ Ì˘˚΋˜ ÂÚÈÙÔÓ›·˜, ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ËˆÛÈÓfiÊÈÏˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È ÂÌ-
Ê¿ÓÈÛË ‰¤ÚÌ·ÙÔ˜ ˆ˜ ÊÏÔÈÔ‡ ÔÚÙÔηÏÈÔ‡ (peau d’orange appearance). ∏ ∏¶ Û˘¯Ó¿ ÂÌÊ·Ó›˙ÂÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÔÚÊ·›· (2) fiˆ˜ Î·È Ë ·ÎÔÏÔ‡ıˆ˜ ÂÚÈÁÚ·ÊfiÌÂÓË ÂÚ›ÙˆÛË.
∂ÈÎfiÓ· 1. ŒÓÙÔÓË ÛÎÏËÚ›· ÛÙÔ Î¿Ùˆ ¤Íˆ ÙÂÙ·ÚÙËÌfiÚÈÔ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÁÏÔ˘ÙÔ‡ Ì ¤ÎÙ·ÛË ÚÔ˜ ÙÔ ·ÚÈÛÙÂÚfi Ï¿ÁÈÔ ÎÔÈÏÈ·Îfi ÙÔ›¯ˆÌ·.
∂ÈÎfiÓ· 2. ¢ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÚÔÛÔÌÔÈ¿˙Ô˘Û˜ Ì ÊÏÔÈfi ÔÚÙÔηÏÈÔ‡ (peau d’orange appearance).
434
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 8,5 ¯ÚfiÓˆÓ ÂÈÛ‹¯ıË ÛÙËÓ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜ ·Ú·ÔÓÔ‡ÌÂÓË ÁÈ· ıˆÚ·ÎÈÎfi ¿ÏÁÔ˜, ÏfiÁˆ ÎÙ˘‹Ì·ÙÔ˜ ÛÙË ıˆÚ·ÎÈ΋ ¯ÒÚ·. ∂›Ó·È ÙÔ ÚÒÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi Î·È Î·Ï‹ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2.150 gr. OÈ ÁÔÓ›˜ Î·È Ô ·‰ÂÏÊfi˜ Â›Ó·È ˘ÁÈ›˜. ∆Ô ·ÙÔÌÈÎfi ÙÔ˘ ·Ó·ÌÓËÛÙÈÎfi Â›Ó·È ÂχıÂÚÔ. ∆Ô ·È‰› ηٿ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Ì µ™=40 Kg (>95 ∂£), ª™=125 cm (50 ∂£). ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ¤ÓÙÔÓË ÛÎÏËÚ›· Ô˘ ηٷϿ̂·Ó ÙÔ Î¿Ùˆ ¤Íˆ ÙÂÙ·ÚÙËÌfiÚÈÔ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÁÏÔ˘ÙÔ‡ Î·È ÂÂÎÙÂÈÓfiÙ·Ó ÚÔ˜ ÙÔ ·ÚÈÛÙÂÚfi Ï¿ÁÈÔ ÎÔÈÏÈ·Îfi ÙÔ›¯ˆÌ·, ¯ˆÚ›˜ ÛÙÔȯ›· ÂÓÂÚÁÔ‡ ÊÏÂÁÌÔÓ‹˜
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·435
¶∞π¢π∞∆ƒπ∫∏ 2000;63:433-437
(∂ÈÎfiÓ· 1). ™ÙËÓ ÂÚÈÔ¯‹ Ù˘ ÔÛʇԘ ·Ú·ÙËÚ‹ıËÎ·Ó ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÚÔÛÔÌÔÈ¿˙Ô˘Û˜ Ì ÊÏÔÈfi ÔÚÙÔηÏÈÔ‡ (peau d’orange appearance) (∂ÈÎfiÓ· 2). ¶·ÚfiÌÔȘ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ‰È·ÈÛÙÒıËÎ·Ó Î·È ÛÙȘ ÂÚÈÔ¯¤˜ Ù˘ ‰ÂÍÈ¿˜ ˆÌÔÏ¿Ù˘. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ô ·ÎfiÏÔ˘ıÔ˜: °ÂÓÈ΋ ·›Ì·ÙÔ˜: Ht=34,9%, Hb=11,1 g/dl, §Â˘Î¿=9200/m3 (¶=64%, §=22%, ∏=3%, µ=1%, ª=10%), PLT=391000/m3, ∆∫∂=32 mm/1h, CRP=10,4 mg/L, Glu=77 mg%, O˘Ú›·=30 mg%, ∫Ú·ÙÈÓ›ÓË=0,5 mg%, Na=144 mEq/L, K=4,7 mEq/L, AST=32 IU/L, ALT=49 IU/L, TP=7,1 g/dl ALB=3,5 g/dl °ÂÓÈ΋ Ô‡ÚˆÓ=ÎÊ, TC=157 mg%, HDL=56 mg%, LDL=83 mg%, TG=88 mg%, CPK: 72 U/L, LDH: 245 U/L, O˘ÚÈÎfi Ô͇=3,6 mg%, ∞ÓÙÈ˘ÚËÓÈο ·ÓÙÈÛÒÌ·Ù· (∞¡∞): ·ÛıÂÓÒ˜ ıÂÙÈο Ì ٛÙÏÔ 1/160 Î·È ÛÙÈÎÙfi ÊıÔÚÈÛÌfi. ∞ÓÙÈ-DNA, ·ÓÙÈ-Sm, ·ÓÙÈ-uRNP, ·ÓÙÈ-SSA/Ro, ·ÓÙÈSSB/La, ·ÓÙÈ-Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, ·ÓÙÈÌÈÙÔ¯ÔÓ‰Úȷο: ·ÚÓËÙÈο Scl-70: ·ÚÓËÙÈÎfi Ra test: ·ÚÓËÙÈÎfi ∞ÓÙÈÛÒÌ·Ù· ÁÈ· Borrelia Burgdorferi: ·ÚÓËÙÈο OÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË: ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ÁÏÔ˘ÙÒÓ Î·È ÌËÚÒÓ ¿Ìʈ: ·Û‡ÌÌÂÙÚË Î·Ù·ÓÔÌ‹ ÙÔ˘ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Ì ¿¯˘ÓÛË Ù˘ Ì˘˚΋˜ ÂÚÈÙÔÓ›·˜. πÛÙÔÏÔÁÈ΋ ÂͤٷÛË: ÙÌ‹Ì· ‰¤ÚÌ·ÙÔ˜, Ì˘˚΋˜ ÂÚÈÙÔÓ›·˜ Î·È ÛÎÂÏÂÙÈÎÔ‡ Ì˘fi˜ Ì ÂÈÎfiÓ· ÚÔ¯ˆÚË̤ÓÔ˘ ÛÎÏËÚ˘ÓÙÈÎÔ‡ ÛÙ·‰›Ô˘ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜. ¶ÚÔ˜ ·ÔÎÏÂÈÛÌfi Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘, Ô ¤ÏÂÁ¯Ô˜ Û˘ÌÏËÚÒıËΠ̠˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, ¤ÏÂÁ¯Ô ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·‰¤Ó· ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ÂȂ‚·›ˆÛ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÙÔ˘ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜, ÂÓÒ Ë ÎÏÈÓÈ΋ ÙÔ˘ ÂÈÎfiÓ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ¤ÙÚ„·Ó ÙËÓ Ù˘ÔÔ›ËÛ‹ ÙÔ˘. ªÂ ‰Â‰Ô̤ÓË ÙË ‰È¿ÁÓˆÛË Ù˘ ∏¶ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÔÚÊ·›·, ÙÔ ·È‰› ÂÙ¤ıË Û ·ÁˆÁ‹ Ì Ú‰ÓÈ˙ÔÏfiÓË (1 mg /Kg/ 24ˆÚÔ per os). ŒÍÈ Â‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· ÙÔ ·È‰› ·ÚÔ˘Û›·Û ϋÚË ÂÍ·Ê¿ÓÈÛË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Ù‡Ô˘ «ÊÏÔÈÔ‡ ÔÚÙÔηÏÈÔ‡» ÛÙËÓ ÔÛʇ Î·È ÙËÓ ˆÌÔÏ¿ÙË. ∏ ÂÌÊ¿ÓÈÛË fï˜, Ó¤·˜ Ͽη˜ ÛÙÔÓ ¿ÏÏÔ ÁÏÔ˘Ùfi ¤‚·Ï·Ó ÙËÓ ÚÔÛı‹ÎË DPenicillamine, ÛÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·. ™‹ÌÂÚ·, 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÎÔÚÙÈ˙fiÓ˘ Î·È 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ D-Penicillamine, ÔÈ ÛÎÏËÚ˘ÓÙÈΤ˜ ϿΘ ·Ú¤ÌÂÈÓ·Ó ÛÙ¿ÛÈ̘, ¯ˆÚ›˜ Ù¿ÛË Â¤ÎÙ·Û˘, ÂÓÒ ‰ÂÓ ˘¿Ú¯Ô˘Ó ϤÔÓ ·ÏÏÔÈÒÛÂȘ ΢ÙÙ·Ú›Ùȉ·˜ (peau d’orange). ∏ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ Ì ÌÈÎÚ¤˜ ‰fiÛÂȘ ÎÔÚÙÈ˙fiÓ˘ Î·È D- Penicillamine Û˘Ó¯›˙ÂÙ·È.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
™˘˙‹ÙËÛË ∏ ÌÔÚÊ·›· ·ÔÙÂÏ› Û˘¯Ó‹ ÌÔÚÊ‹ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ∞ÓÙ›ıÂÙ· Ë ∏¶ Ô˘ ÂÚÈÁÚ¿ÊËΠÙÔ 1974 ·fi ÙÔÓ Shulman (3), Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙ· ·È‰È¿. ∞fi ÙÔÓ ¯ÚfiÓÔ ÂÚÈÁÚ·Ê‹˜ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ̤¯ÚÈ Û‹ÌÂÚ· ÂηÙÔÓÙ¿‰Â˜ ÂÚÈÙÒÛÂȘ ∏¶ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÂÚ›Ô˘ 20 ·ÊÔÚÔ‡Ó ·È‰È¿ (4). O Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ÌÔÚÊÒÓ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ∏¶ ·Ú·ÙËÚ‹ıËΠÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ ÂÚÈÙÒÛÂˆÓ (2), ÂÓÒ ÛÙ· ·È‰È¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛÙÔȯ›·, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚÈÙÒÛˆÓ. ∞ӷʤÚÂÙ·È fï˜ Ë ÌÂٿوÛË Ù˘ ∏¶ Û ÌÔÚÊ·›· (5). ™ÙËÓ ÂÚÈÁÚ·ÊfiÌÂÓË ÂÚ›ÙˆÛË Ë ·Ó‡ÚÂÛË ÌÈÎÙÒÓ ‰ÂÚÌ·ÙÈÎÒÓ ·ÏÏÔÈÒÛˆÓ, Ù‡Ô˘ ∏¶ Î·È ÌÔÚÊ·›·˜, ηıÒ˜ Î·È Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜, ·ÔÙÂÏÔ‡Ó ·Ô‰ÂÈÎÙÈο ÛÙÔȯ›· Û˘Ó‰˘·ÛÌÔ‡ ÙˆÓ ‰‡Ô ÌÔÚÊÒÓ. ∏ ¤Ó·ÚÍË fï˜ Ù˘ ÓfiÛÔ˘ 5 ¯ÚfiÓÈ· ÚÈÓ ÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ·È‰ÈÔ‡ ÛÙË ÎÏÈÓÈ΋ Ì·˜ Î·È Ë ¤ÏÏÂÈ„Ë ·ÍÈfiÈÛÙˆÓ ÏËÚÔÊÔÚÈÒÓ Û¯ÂÙÈο Ì ÙËÓ ÂͤÏÈÍË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ, ηıÈÛÙÔ‡Ó ·‰‡Ó·ÙË ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Èı·ÓfiÙËÙ· ÌÂٿوÛ˘ Ù˘ ∏¶ Û ÌÔÚÊ·›·. ∏ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ Î·È ÂȉÈÎfiÙÂÚ· Ù˘ ∏¶ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË. ∏ Û˘Û¯¤ÙÈÛ‹ Ù˘ Ì ˘ÂÚ‚ÔÏÈ΋ ۈ̷ÙÈ΋ ¿ÛÎËÛË ¤¯ÂÈ ·Ó·ÊÂÚı› ۯ‰fiÓ ÛÙȘ ÌÈÛ¤˜ ÂÚÈÙÒÛÂȘ(1,6). ∏ ·ÚÔ˘Û›· ·ÓÙÈ˘ÚËÓÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ· ηıÒ˜ Î·È Ë Û˘Ó‡·ÚÍ‹ Ù˘ Ì ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ·˘ÙÔ·ÓfiÛÔ˘ ·ıÔÁ¤ÓÂÈ¿˜ Ù˘ (6). ™‡Ìʈӷ Ì ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯ÂÈ ÂȯÂÈÚËı› Ë Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ Ì ‰È¿ÊÔÚÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Î·È Ì ÙË Ï‹„Ë Ê·ÚÌ¿ÎˆÓ (L-ÙÚ˘ÙÔÊ¿ÓË, Ï·Ó‰ÔÚ·˙fiÏË, ÊÔÛÈÓÔÚ›ÏË)(7-10). ¶ÚfiÛÊ·Ù· Ë µÔrrelia Burgdorferi ¤¯ÂÈ Â›Û˘ ÂÓÔ¯ÔÔÈËı› ˆ˜ ÂÎÏ˘ÙÈÎfi ·›ÙÈÔ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÂÓfi˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ·ıÔÁÂÓÂÙÈÎÔ‡ ˘ÔÛÙÚÒÌ·ÙÔ˜ ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ (11,12). ∏ ÂÌÊ¿ÓÈÛË Ù˘ ∏¶ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· fiˆ˜ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈο Û‡Ó‰ÚÔÌ· (13,14), ÏÂÌÊÒÌ·Ù· (15), ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ÂÈ‚¿ÏÏÂÈ Û‡Ìʈӷ Ì ÙËÓ ¿Ô„Ë ÔÏÏÒÓ Û˘ÁÁڷʤˆÓ ÙËÓ ÂͤٷÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Û οı ÂÚ›ÙˆÛË ∏¶ (16). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ Ë Î·Ù’ ·ӿÏË„Ë Ê˘ÛÈÔÏÔÁÈ΋ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ·ÔÌ¿ÎÚ˘Ó ·fi ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ ·ÈÌ·ÙÔÏÔÁÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜. ∏ ∏¶ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ÛÙËÓ ¤Ó·ÚÍ‹ Ù˘ ·fi ‰È¿¯˘ÙÔ Ô›‰ËÌ· ÂÓÒ Ë ÔÚ›· Ù˘ ·fi ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ù‡Ô˘ ΢ÙÙ·Ú›Ùȉ·˜ (peau d’orange) Î·È Î·Ù¿ ÙfiÔ˘˜ ÛÎÏËÚ›· (1). ∏ ¿¯˘ÓÛË Î·È Ë ÊÏÂÁÌÔÓ‹ Ù˘ ÂÚÈÙÔÓ›·˜ ÙˆÓ Ì˘ÒÓ ·ÔÙÂÏ› ÙËÓ Ù˘È΋ ˘ÔΛÌÂÓË ÈÛÙÔÏÔÁÈ΋ ‚Ï¿‚Ë (17), ‡ÚËÌ· Ô˘
435
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·436
¶∞π¢π∞∆ƒπ∫∏ 2000;63:433-437
ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË ÂȂ‚·ÈÒıËΠ̠ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÁÏÔ˘ÙÒÓ Î·È ÌËÚÒÓ. ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û˘ÓÔ‰Â‡Ô˘Ó Û˘Áο̄ÂȘ ·ÚıÚÒÛÂˆÓ Î·È Û˘ÓÔÏΤ˜ Ì˘ÒÓ. OÈ ·ÚıÚ·ÏÁ›Â˜ Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜ ¯ˆÚ›˜ fï˜ ·ÚıÚ›Ùȉ· (1). ™˘¯ÓfiÙÂÚ· ÚÔÛ‚¿ÏÏÔÓÙ·È Ù· ¿ÎÚ·, ·ÎÔÏÔ˘ı› Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÔÚÌÔ‡, ÂÓÒ Û¯Â‰fiÓ ÔÙ¤ ‰ÂÓ ÚÔÛ‚¿ÏÏÔÓÙ·È ‰¿ÎÙ˘Ï· Î·È ÚfiÛˆÔ. ™‡Ó‰ÚÔÌÔ Î·ÚÈ·›Ô˘ ۈϋӷ Î·È Ì˘ÔÛ›Ùȉ· ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ. ÷ڷÎÙËÚÈÛÙÈο, ۯ‰fiÓ ÔÙ¤ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È Ê·ÈÓfiÌÂÓÔ Raynaud Î·È ÛÎÏËÚÔ‰·ÎÙ˘Ï›·, ÛÙÔȯ›· Ô˘ ‚ÔËıÔ‡Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·fi ÙȘ Û˘ÛÙËÌ·ÙÈΤ˜ ÌÔÚʤ˜ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ Î·È Ù· Û‡Ó‰ÚÔÌ· ÂÈÎ¿Ï˘„˘. ∏ ÛÏ·Á¯ÓÈ΋ Û˘ÌÌÂÙÔ¯‹ Â›Ó·È Û¿ÓÈ· ·Ó Î·È ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ Ì ÚÔÛ‚ÔÏ‹ Ó¢ÌfiÓˆÓ, ÔÈÛÔÊ¿ÁÔ˘, ηډȿ˜ ‹ ÓÂ‡ÚˆÓ (6). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÔ˘ÌÂ, Ë ·Ô˘Û›· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Raynaud Î·È Ù˘ ÛÎÏËÚÔ‰·ÎÙ˘Ï›·˜ ·ÔÌ¿ÎÚ˘Ó ·fi ÙË ‰È¿ÁÓˆÛË ÙÔ˘ Û˘ÛÙËÌ·ÙÈÎÔ‡ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ ‹ Ù˘ ÌÈÎÙ‹˜ ÓfiÛÔ˘ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡. ∂ÈϤÔÓ, Ô ·Ú·ÎÏÈÓÈÎfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·¤ÎÏÂÈÛ ÙËÓ Û˘ÌÌÂÙÔ¯‹ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ˘ÏÈÎÔ‡ ·fi ÙËÓ ÚÔۂ‚ÏË̤ÓË ÂÚÈÔ¯‹ Ô˘ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ‰¤ÚÌ·-˘Ô‰fiÚÈÔ, ÂÚÈÙÔÓ›· Î·È Ì˘˜. ¢È‹ıËÛË ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú· (ÏÂÌÊÔ·ÙÙ·Ú·, ÈÛÙÈÔ·ÙÙ·Ú·, Ï·ÛÌ·ÙÔ·ÙÙ·Ú·) Î·È ›ÓˆÛË ·Ú·ÙËÚÂ›Ù·È Û fiϘ ÙȘ ÛÙÔÈ‚¿‰Â˜ Â›Ó·È ÈÔ ¤ÓÙÔÓË fï˜ ÛÙËÓ Â·¯˘Ṳ̂ÓË ÂÚÈÙÔÓ›· (17). ¶·ÚÔ˘Û›· ˈÛÈÓÔÊ›ÏˆÓ ·Ó¢ڛÛÎÂÙ·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ Î·È Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ÂÚÈÊÂÚÈ΋ ˈÛÈÓÔÊÈÏ›·. ∏ ·Ô˘Û›· ÙÔ˘˜ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙËÓ ÓfiÛÔ. ªÂ ÌÂϤÙ˜ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ¤¯Ô˘Ó ‚ÚÂı› ›Û˘, ÂÚÈ·ÁÁÂȷ΋ ÂÓ·fiıÂÛË IgG, IgM, Î·È C3 (1,6). ∆· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ù˘ ∏¶ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÂÚÈÊÂÚÈ΋ ˈÛÈÓÔÊÈÏ›·, ÙËÓ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ηıÒ˜ Î·È ÙËÓ ·˘ÍË̤ÓË ∆∫∂ ÛÙÔ 60-80% ÙˆÓ ·ÛıÂÓÒÓ. ∏ ·Ô˘Û›· οÔÈÔ˘ ·fi Ù· ·Ú·¿Óˆ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ‰È¿ÁÓˆÛË (2). ¶ÂÚÈÛÙ·Ûȷο ·Ó¢ڛÛÎÔÓÙ·È ·ÓÙÈ˘ÚËÓÈο ·ÓÙÈÛÒÌ·Ù· Î·È ÚÂ˘Ì·ÙÔÂȉ‹˜ ·Ú¿ÁÔÓÙ·˜ (6). ™ÙËÓ ÂÚÈÁÚ·ÊfiÌÂÓË ÂÚ›ÙˆÛË ‰ÂÓ Â›¯Â Á›ÓÂÈ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ηıÒ˜ Î·È ÛÙÔ ‰È¿ÛÙËÌ· ÙˆÓ ¤ÓÙ ¯ÚfiÓˆÓ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó, ̤¯ÚÈ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ˘˜ ¿ÏÏÔ˘˜ Ù‡Ô˘˜ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜, ÂÓÙÔÈṲ̂ÓÔ˘ Î·È Û˘ÛÙËÌ·ÙÈÎÔ‡ ηıÒ˜ Î·È ·fi Ù· Û‡Ó‰ÚÔÌ· ÂÈÎ¿Ï˘„˘. π‰È·›ÙÂÚË ‰˘ÛÎÔÏ›· ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ∏¶ ·fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ÂÓÙÔÈṲ̂ÓÔ˘ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ (1). ∞ÍÈÔÛËÌ›ˆÙË Â›Ó·È Ë ¿Ô„Ë ·ÚÎÂÙÒÓ Û˘ÁÁÚ·-
436
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ʤˆÓ fiÙÈ Ë ∏¶ ·ÔÙÂÏ› ÌÔÚÊ‹ ÁÂÓÈÎÂ˘Ì¤Ó˘ ÌÔÚÊ·›·˜ (2,5). ∏ ∏¶ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈο Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÛÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ (1-2 mg/Kg/24ˆÚÔ per os). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ˘‹ÚÍ ÈηÓÔÔÈËÙÈ΋ Î·È ÛÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË ·ÊÔ‡ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÍ·Ê¿ÓÈÛË ÙˆÓ Ù˘ÈÎÒÓ ‚Ï·‚ÒÓ Ù˘. °È· ÙË ıÂڷ›· Ù˘ ∏¶, ÂÎÙfi˜ ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹, ˆ˜ Ê¿Ú̷η ‰Â‡ÙÂÚ˘ ÁÚ·ÌÌ‹˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ë D-ÂÓÈÎÈÏÏ·Ì›ÓË, Ë ¯ÏˆÚÔΛÓË, Ë ˘‰ÚÔ͢¯ÏˆÚÔΛÓË, Ë ÛÈÌÂÙȉ›ÓË Î·È Ë ·˙·ıÂÈÔÚ›ÌË (1,6). ∆ÂÏÂ˘Ù·›· Ì ηϿ ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ë Î˘ÎÏÔÛÔÚ›ÓË (6) Î·È Ë ÌÂıÔÙÚÂÍ¿ÙË (1,6). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ·ÚÔ˘Û›· ·ÏÏÔÈÒÛÂˆÓ Î·Ù¿ Ͽη˜ (ÌÔÚÊ·›·) ÂÎÙfi˜ ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Ù‡Ô˘ ÊÏÔÈÔ‡ ÔÚÙÔηÏÈÔ‡ Î·È Î˘Ú›ˆ˜ Ë ÂÌÊ¿ÓÈÛË Ó¤·˜ Ͽη˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ¤‚·Ï ÙËÓ ÂÈÏÔÁ‹ Ù˘ D-ÂÓÈÎÈÏÏ·Ì›Ó˘, Ê·ÚÌ¿ÎÔ˘ Ô˘ ¤¯ÂÈ Î·Ù’ ÂÍÔ¯‹Ó ¯ÚËÛÈÌÔÔÈËı› ÛÙË ıÂڷ›· Ù˘ ÌÔÚÊ·›·˜. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÚfiÁÓˆÛË, ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ηıÔÚÈÛÙ› ‰Â‰Ô̤ÓÔ˘ ÙÔ˘ ÌÈÎÚÔ‡ ¯ÚÔÓÈÎÔ‡ ‰È·ÛÙ‹Ì·ÙÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∆Ô ÁÂÁÔÓfi˜ Ù˘ ·Ô˘Û›·˜ ÛÏ·Á¯ÓÈ΋˜ ÚÔÛ‚ÔÏ‹˜, Ô ÂÓÙÔÈÛÌfi˜ ÙˆÓ ‚Ï·‚ÒÓ Û ÂÚÈÔÚÈṲ̂ÓË ¤ÎÙ·ÛË, ηıÒ˜ Î·È Ë ÈηÓÔÔÈËÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ÂÏȉÔÊfiÚ˜ ÂӉ›ÍÂȘ. ∏ ∏¶ ÌfiÓË ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏÔ˘ Ù‡Ô˘ ÛÎÏËÚÔ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Û˘ÁηٷϤÁÂÙ·È Û ۿÓȘ ÂÚÈÙÒÛÂȘ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜. ∏ ÂÚÈÁÚ·ÊfiÌÂÓË ÂÚ›ÙˆÛË ˘ÔÁÚ·ÌÌ›˙ÂÈ ÙÔ˘˜ ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ Î·È ÙȘ ‰˘ÛÎÔϛ˜ Ù˘ ηٿÏÏËÏ˘ ıÂڷ¢ÙÈ΋˜ ÂÈÏÔÁ‹˜. ∂ÈÚfiÛıÂÙ·, Ë Û˘Ó‡·ÚÍË ÌÈÎÙÔ‡ Ù‡Ô˘ ‰ÂÚÌ·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ˘·ÈÓ›ÛÛÂÙ·È fiÙÈ ÔÈ ÌÔÚʤ˜ ÛÎÏËÚÔ‰¤ÚÌ·ÙÔ˜ Èı·ÓfiÓ Ó· ·ÔÙÂÏÔ‡Ó ·ÏÒ˜ ‰È·ÊÔÚÂÙÈο ÛËÌ›· ÛÙÔ ›‰ÈÔ Ê¿ÛÌ· ÌÈ·˜ ‰È·Ù·Ú·Á̤Ó˘ ·ÓÔÛȷ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Bernhard H, Singsen MD. Scleroderma in Childhood. Ped Clin of North America 1986;33(5):1119-1139. 2. Lakhanpal S, Ginsburg WW, Michet CJ et al. Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases. Semin Arthritis Rheum 1988;17:221-231. 3. Shulman LE. Diffuse fasciitis with hypergammaglobulinemia and eosinophilia: a new syndrome. J Rheumatol 1974;II:569-570. 4. Patrone NA, Kredich DW. Eosinophilic fasciitis in a child. Am J Dis Child 1984;138:363-365. 5. Ansell BM, Rudge S, Schaller JG. Atlas of Pediatric Reumatology. Wolfe Publishing LTD; 1991. 6. Valencia CI, Chang A, Kirsner R, Kerdel AF. Eosinophilic
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fasciitis responsive to treatment with pulsed steroid and cyclosporine. Int J Dermatol 1999;38(5):369-372. Blauvelt A, Falanga V. Idiopathic and L-tryptophan associated eosinophilic fasciitis before and after Ltryptophan contamination. Arch Dermato 1991;127:11591166. Smith JD et al. Possible lansoprazole-induced eosinophilic syndrome. Ann Pharmacother 1998;32(2): 196-200. Biasi et al. Scleroderma and eosinophilic fasciitis in patients taking fosinopril. J Rheumatol 1997;24(6):1242. Bonnotte B et al. L-tryptophan-related eosinophiliamyalgia syndrome possibly associated with a chronic Blymphocytic leukemia. Ann Hematol 1998;77(5):235-238. Granter SR, Barnhill RL, Duray PH. Borrelia fasciitis: diffuse fasciitis and peripheral eosinophilia associated with Borrelia infection. Am J Dermatopathol 1996;18:465473. Hashimoto Y, Takahashi H, Matsuo S, Hinai K, Takemori N, Nakao M et al. Polymerase chain reaction of Borrelia burgdorferi flagellin gene in Shulman syndrome. Dermatology 1996;192(2):136-139.
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13. Farrel AM et al. Eosinophilic fasciitis associated with autoimmune thyroid disease and myelodysplasia treated with pulsed methylprednisolone and antihistamines. Br J Dermatol 1999;140(6):1185-1187. 14. Littlejohn GO, Keystone EC. Eosinophilic fasciitis and aplastic anaemia. J Rheumatol 1980;7:730-732. 15. Masuoka H et al. Eosinophilic fasciitis associated with lowgrade T-cell lymphoma. Br J Dermatol 1998;139(5):928-930. 16. Britto F. Patients with eosinophilic fasciitis shoud have a bone marrow examination to identify myelodysplasia. Br J Dermatol 1997;137:316-317. 17. Barnes L, Rodan GP, Medsger TA Jr et al. Eosinophilic fasciitis: A pathologic study of twenty cases. Am J Pathol 1979;96:493-507.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 01-02-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-09-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫·Ú‹˜ ÃÚ›ÛÙÔ˜ ∑·Î‡ÓıÔ˘ 2 - ÷ϿӉÚÈ
A˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Û ÚfiˆÚ· ‰›‰˘Ì· ÓÂÔÁÓ¿ ™Ù¤Ê·ÓÔ˜ °·Ú‰›Î˘1, EÏ¢ıÂÚ›· X·Ù˙ˉ¿ÎË2, XÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘2, Iˆ¿ÓÓ˘ BÏ·¯¿Î˘1, ™Ù˘ÏÈ·Ófi˜ BÏ·˙¿Î˘1, °ÈÒÚÁÔ˜ X·Ú›Û˘1
● ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÔ˘Ì ‰‡Ô ÂÚÈÙÒÛÂȘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, ¤Ó· ·fi οı ˙‡ÁÔ˜ ‰È˙˘ÁˆÙÈÎÒÓ ‰È‰‡ÌˆÓ Ô˘ ·ÚÔ˘Û›·Û·Ó ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÛÙÔÌ¿¯Ô˘ Î·È ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈο Ì ÂÈÙ˘¯›·. T· ÓÂÔÁÓ¿ Î·È ÙˆÓ ‰‡Ô ÂÚÈÙÒÛÂˆÓ ÁÂÓÓ‹ıËÎ·Ó Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. H ËÏÈΛ· ·ËÛ‹˜ ÙÔ˘˜ ‹Ù·Ó 30 Î·È 32 ‚‰ÔÌ¿‰Â˜, ÂÓÒ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 1400 Î·È 2100 g ·ÓÙ›ÛÙÔȯ·. T· ÓÂÔÁÓ¿ ÓÔÛËχÙËÎ·Ó ÛÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ fiÔ˘ Ù¤ıËÎÂ Î·È Ë ‰È¿ÁÓˆÛË Ù˘ ‰È¿ÙÚËÛ˘. H ÓfiÛÔ˜ ÂÌÊ·Ó›ÛÙËΠ·ÈÊÓ›‰È· Ì ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜ Î·È Ó¢ÌÔÂÚÈÙfiÓ·ÈÔ. TÔ ÛËÌÂ›Ô Ù˘ ڋ͢ ÂÓÙÔ›ÛÙËΠÛÙÔ ÚfiÛıÈÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÎÔÓÙ¿ ÛÙËÓ Á·ÛÙÚÔÔÈÛÔ·Ê·ÁÈ΋ Û˘Ì‚ÔÏ‹. T· ‰›‰˘Ì· ·‰¤ÚÊÈ· ÙÔ˘˜ ‰ÂÓ ·Ó¤Ù˘Í·Ó ·Ó¿ÏÔÁË ÛËÌÂÈÔÏÔÁ›·. K·È Ù· Ù¤ÛÛÂÚ· ÓÂÔÁÓ¿ ÂÍ‹Ïı·Ó ·fi ÙËÓ MÔÓ¿‰· EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ Û ¿ÚÈÛÙË Î·Ù¿ÛÙ·ÛË. ¶·È‰È·ÙÚÈ΋ 2000;63:437-439. §¤ÍÂȘ ÎÏÂȉȿ: ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÛÙÔÌ¿¯Ô˘, ÚfiˆÚÔ ÓÂÔÁÓfi, ÚfiˆÚ· ‰›‰˘Ì· ÓÂÔÁÓ¿. S. Gardikis, E. Hatzidaki, C. Giannakopoulou, J. Vlahakis, S. Vlazakis, G. Charissis. Spontaneous gastric perforation in premature twins. Paediatriki 2000;63:437-439. ● Abstract: We describe two cases of premature neonates each of which resulted from non-identical twin pregnancies, who presented with spontaneous gastric perforation which was succesfully treated by surgery. Both infants, one girl and one boy, were delivered by emergency cesarean section. Their gestational ages were 30 and 32 weeks, and their birth weights 1400g and 2100g, respectively. The infants were in the Neonatal Intensive Care Unit when the diagnosis of perforation was made. They each presented with clinically abrupt symptoms of abdominal distension and pneumoperitoneum. The sites of rupture were both located on the anterior gastric wall near the gastrooesophageal junction. The sibling twins were also observed very carefully, but developed no
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KÏÈÓÈ΋ XÂÈÚÔ˘ÚÁÈ΋˜ ¶·›‰ˆÓ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ KÚ‹Ù˘ NÂÔÁÓÔÏÔÁÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ KÚ‹Ù˘
437
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:437-439
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
similar clinical symptoms. Both sets of twins were ultimately discharged from the hospital in good condition. Key words: premature infants, twins, spontaneous neonatal gastric perforation.
EÈÛ·ÁˆÁ‹ O ·ÚÈıÌfi˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì Ôχ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó Â›Ó·È ·Ó¿ÏÔÁÔ˜ ÙÔ˘ ÂȤ‰Ô˘ Ù˘ ·Ú¯fiÌÂÓ˘ Ì·È¢ÙÈ΋˜ Î·È ÓÂÔÁÓÔÏÔÁÈ΋˜ ÊÚÔÓÙ›‰·˜. T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ Â›Â‰Ô Ù˘ ·Ú¯fiÌÂÓ˘ ÊÚÔÓÙ›‰·˜ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο. AÔÙ¤ÏÂÛÌ· ·˘Ù‹˜ Ù˘ ‚ÂÏÙ›ˆÛ˘ Â›Ó·È Ë ÂÈ‚›ˆÛË fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚˆÓ ÌÈÎÚÒÓ ÚfiˆÚˆÓ Î·È ·ÓÒÚÈÌˆÓ ÓÂÔÁÓÒÓ. MÈ· ·fi ÙȘ ÂÈÏÔΤ˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘Ù¿ Ù· ÓÂÔÁÓ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜ Â›Ó·È Ë ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘. H Û˘¯ÓfiÙËÙ· Ù˘ Â›Ó·È 1 ÛÙȘ 2900 ÁÂÓÓ‹ÛÂȘ ˙ÒÓÙˆÓ ÓÂÔÁÓÒÓ. EÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· ÛÙ· ¿ÚÚÂÓ· ÓÂÔÁÓ¿ Ì ۯ¤ÛË 4:1.(1) °È· ÚÒÙË ÊÔÚ¿ ÂÚÈÁÚ¿ÊËΠ·fi ÙÔÓ Von Sielbond ÙÔ 1825(2). TÔ 1929 ¤ÁÈÓ ·fi ÙÔÓ Stern Ë ÚÒÙË ÚÔÛ¿ıÂÈ· ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ¯ˆÚ›˜ ÂÈÙ˘¯›·, ÂÓÒ ÙÔ 1950 ·Ó·Ê¤ÚıËΠ·fi ÙÔÓ Leger Ë ÚÒÙË ÂÈÙ˘¯‹˜ ÚÔÛ¿ıÂÈ·.(1) ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ 1Ë ¶ÂÚ›ÙˆÛË ¶ÚfiÎÂÈÙ·È ÁÈ· ÓÂÔÁÓfi ı‹Ï˘, ÙÔ ‰Â‡ÙÂÚÔ ‰È˙˘ÁˆÙÈ΋˜ ‰›‰˘Ì˘ ·ËÛ˘, Ô˘ ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ·ËÛË 30 ‚‰ÔÌ¿‰ˆÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 1400 g Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚfiˆÚ˘ ¤Ó·Ú͢ ÙÔÎÂÙÔ‡, Û ȉȈÙÈÎfi Ì·ÈÂ˘Ù‹ÚÈÔ. TÔ Apgar Score ·Ó·Ê¤ÚÂÙ·È fiÙÈ ‹Ù·Ó 3 ÛÙÔ 5Ô ÏÂÙfi ˙ˆ‹˜. H ÌËÙ¤Ú· ‹Ù·Ó ˘ÁÈ‹˜, ËÏÈΛ·˜ 24 ÂÙÒÓ. AӷʤÚÂÙ·È fiÙÈ ‹Ù·Ó Ë ÚÒÙË Ù˘ ·ËÛË Ô˘ ÂÈÙ‡¯ıËΠ̠Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË. EÍ·ÈÙ›·˜ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÔͤˆÛ˘ Î·È Ù˘ ˘ÔÍ›·˜, ÙÔ ÓÂÔÁÓfi Ù¤ıËΠ۠Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Î·È ¿Ú¯ÈÛ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Ì ·ÌÈÎÈÏ›ÓË Î·È ÓÂÙÈÏÌÈΛÓË. ŒÁÈÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Ù˘ ÔÔ›·˜ Ù· Â˘Ú‹Ì·Ù· ‹Ù·Ó Û˘Ì‚·Ù¿ Ì ‹ÈÔ˘ ‚·ıÌÔ‡ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ù‡Ô˘ I. TË ‰Â‡ÙÂÚË Ë̤ڷ ˙ˆ‹˜ ÔÈ ·Ó¿ÁΘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ›¯·Ó ÌÂȈı›, Ô ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ ‹Ù·Ó ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·, ÂÓÒ ·fi ÙȘ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ Ô˘ ›¯·Ó ÏËÊı› ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ‰ÂÓ Â›¯Â ·ÔÌÔÓˆı› ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi˜. TËÓ ÙÚ›ÙË Ë̤ڷ ˙ˆ‹˜ (66 ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË) ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜, ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Î·È ·‡ÍËÛË ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Û ·ıÔÏÔÁÈο ›‰· (17500/mm3) . ŒÁÈÓ ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ıÒڷη Î·È ÎÔÈÏÈ¿˜ Ô ÔÔ›Ô˜ ·ÂÎ¿Ï˘„ ÂχıÂÚÔ ·¤Ú· οو ·fi ÙÔ ‰È¿ÊÚ·ÁÌ· (EÈÎfiÓ· 1). TÔ ÓÂÔÁÓfi ¯ÂÈÚÔ˘ÚÁ‹ıËΠÙËÓ 71Ë ÒÚ· ˙ˆ‹˜. ¢ÈÂÁ¯ÂÈÚËÙÈο ·Ó¢ڤıËΠۯÈ-
438
ÛÌÔÂȉ‹˜ ‰È¿ÙÚËÛË ÂÓÙÔÈ˙fiÌÂÓË ÛÙÔ Ì›˙ÔÓ ÙfiÍÔ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Ì‹ÎÔ˘˜ 3 cm ÎÔÓÙ¿ ÛÙË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ Û˘Ì‚ÔÏ‹. TÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ, ÙÔ ÏÂÙfi Î·È ÙÔ ·¯‡ ¤ÓÙÂÚÔ ‚Ú¤ıËÎ·Ó Ê˘ÛÈÔÏÔÁÈο. ŒÁÈÓ Ó·ÚÔÔ›ËÛË Ù˘ ‚Ï¿‚˘ Î·È Û˘ÚÚ·Ê‹ Û ¤Ó· ÛÙÚÒÌ·. H ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ ‹Ù·Ó ÔÌ·Ï‹ Î·È Ù· ‰‡Ô ‰›‰˘Ì· ‹Ú·Ó ÂÍÈÙ‹ÚÈÔ ·fi ÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ ÌÂÙ¿ ·fi 35 Ë̤Ú˜ ÓÔÛËÏ›·˜ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË. 2Ë ¶ÂÚ›ÙˆÛË ¶ÚfiÎÂÈÙ·È ÁÈ· ÓÂÔÁÓfi ¿ÚÚÂÓ ÙÔ ‰Â‡ÙÂÚÔ ‰È˙˘ÁˆÙÈ΋˜ ‰›‰˘Ì˘ ·ËÛ˘ Ô˘ ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ·ËÛË 32 ‚‰ÔÌ¿‰ˆÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2100 g Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. H ÌËÙ¤Ú· ‹Ù·Ó ‰Â˘ÙÂÚÔÙfiÎÔ˜, ËÏÈΛ·˜ 26 ÂÙÒÓ, ˘ÁÈ‹˜. TÔ Apgar Score ·Ó·Ê¤ÚÂÙ·È fiÙÈ ‹Ù·Ó 4 ÛÙÔ 5Ô ÏÂÙfi. TÔ ÓÂÔÁÓfi Ù¤ıËΠ۠Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Î·È ¿Ú¯ÈÛ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Ì ·ÌÈÎÈÏ›ÓË Î·È ÓÂÙÈÏÌÈΛÓË. §›Á˜ ÒÚ˜ ·ÚÁfiÙÂÚ· (26Ë ÒÚ· ˙ˆ‹˜), ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜ Î·È ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·. O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓ ·ÔÎ¿Ï˘„ ÙËÓ ·ÚÔ˘Û›· ÂχıÂÚÔ˘ ·¤Ú· ÛÙËÓ ÎÔÈÏÈ¿ Î·È ÙÔ fiÛ¯ÂÔ. TÔ ÓÂÔÁÓfi ¯ÂÈÚÔ˘ÚÁ‹ıËΠÙËÓ 33Ë ÒÚ· ˙ˆ‹˜. H ‰È¿ÙÚËÛË ‹Ù·Ó ÛÙÔ ÚfiÛıÈÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÎÔÓÙ¿ ÛÙËÓ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ Û˘Ì‚ÔÏ‹ ÌÂÁ¤ıÔ˘˜ 4 cm. O ˘fiÏÔÈÔ˜ Á·ÛÙÚÂÓÙÂÚÈÎfi˜ ۈϋӷ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ŒÁÈÓÂ Û˘ÚÚ·Ê‹ Û ‰‡Ô ÛÙÚÒÌ·Ù· ·ÊÔ‡ ÚÔËÁ‹ıËΠӷÚÔÔ›ËÛË. ™ÙËÓ 20Ë Ë̤ڷ ˙ˆ‹˜ ÙÔ˘˜ Ù· ‰‡Ô ‰›‰˘Ì· ·‰¤ÚÊÈ· ‹Ú·Ó ÂÍÈÙ‹ÚÈÔ ·fi ÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™˘˙‹ÙËÛË H ·ÈÙÈÔÏÔÁ›· Ù˘ ·˘ÙfiÌ·Ù˘ ‰È¿ÙÚËÛ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÛÙ· ÓÂÔÁÓ¿ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹. K·Ù¿ ηÈÚÔ‡˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ·˘ÍË̤ÓË ˘‰ÚÔÛÙ·ÙÈ΋ ›ÂÛË Û·Ó Û˘Ó¤ÂÈ· ˘ÂډȿٷÛ˘, ηٷÛ΢·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ì˘˚ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ÂÚÈÁÂÓÓËÙÈ΋ ·ÛÊ˘Í›·, È·ÙÚÔÁÂÓ‹˜ ÚfiÎÏËÛË ·fi ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú·, Á·ÛÙÚÈ΋ ˘ÂÚÔ͇ÙËÙ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘ÔÍ›· Î·È ÈÛ¯·ÈÌ›·. XÚ‹ÛË Ê·ÚÌ¿ÎˆÓ fiˆ˜ ÙÔÏ·˙ÔÏ›ÓË Û Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, ÈÓ‰ÔÌÂı·Î›ÓË Û ·Ú·ÌÔÓ‹ ·ÓÔÈÎÙÔ‡ ‚ÔÙ·Ï›Ԣ fiÚÔ˘ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Û ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› ·ÈÙÈÔÏÔÁÈο Ì ÙË ÓfiÛÔ (3-7). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ë ¤ÏÏÂÈ„Ë ÙˆÓ C-KIT+ ÈÛÙÈÔ΢ÙÙ¿ÚˆÓ ·fi ÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Û˘Û¯ÂÙ›ÛıËΠ·ÈÙÈÔÏÔÁÈο Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·˘ÙfiÌ·Ù˘ ‰È¿ÙÚËÛ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (8).
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·439
¶∞π¢π∞∆ƒπ∫∏ 2000;63:437-439
H ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È ÎÏÈÓÈο Ì ‰È¿Ù·ÛË Ù˘ ÎÔÈÏÈ¿˜, ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ¿ÚÓËÛË Ï‹„˘ ÙÚÔÊ‹˜ Î·È ÂËÚ·Ṳ̂ÓË ÁÂÓÈ΋ ηٿÛÙ·ÛË, Û˘Ó‹ıˆ˜ ÌÂٷ͇ 2˘ Î·È 5˘ Ë̤ڷ˜ ˙ˆ‹˜. H Ú‹ÍË Û˘¯ÓfiÙÂÚ· ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Ì›˙ÔÓ ÙfiÍÔ ÙÔ˘ ÛÙÔÌ¿¯Ô˘. O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔηχÙÂÈ ÙËÓ ·ÚÔ˘Û›· ÂχıÂÚÔ˘ ·¤Ú· ÛÙËÓ ÎÔÈÏÈ¿ Ì ·Ú¿ÏÏËÏË ·Ô˘Û›· ·¤Ú· ·fi ÙÔ ÛÙÔÌ¿¯È (5). H ıÓËÙfiÙËÙ· Û˘Ó‹ıˆ˜ ÊÙ¿ÓÂÈ ÙÔ 25%. H ·ÚÔ˘Û›· ÔͤˆÛ˘ Î·È ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÂÈ‚·Ú‡ÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÚfiÁÓˆÛË (5). ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘ÌÂ, Ù· ÓÂÔÁÓ¿ ÁÂÓÓ‹ıËÎ·Ó Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. ◊Ù·Ó Ù· ‰Â‡ÙÂÚ· ÙˆÓ ‰È‰‡ÌˆÓ ΢‹ÛÂˆÓ Ô˘ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÂÎÙ›ıÂÓÙ·È Û ÛÔ‚·ÚfiÙÂÚÔ˘ ‚·ıÌÔ‡ ÂÚÈÁÂÓÓËÙÈÎfi stress. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÙÒÛÂȘ ·˘ÙfiÌ·Ù˘ ‰È¿ÙÚËÛ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÛÙ· ‰˘Ô ÙˆÓ ‰È‰‡ÌˆÓ (9,10). T· ‰›‰˘Ì· ·‰¤ÚÊÈ· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ì ‰ÂÓ ÂΉ‹ÏˆÛ·Ó ·Ó¿ÏÔÁË ÛËÌÂÈÔÏÔÁ›·. ™ÙË ‰È·ÊÔÚԉȷÁÓˆÛÙÈ΋ Ì·˜ ÛΤ„Ë ı· Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, Ë
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, Ë ÛË„·ÈÌ›·, Ô Ó¢ÌÔıÒڷη˜ ˘fi Ù¿ÛË Î·È ÙÔ È‰ÈÔ·ı¤˜ Ó¢ÌÔÂÚÈÙfiÓ·ÈÔ. H ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ¿ÌÂÛË ¯ÂÈÚÔ˘ÚÁÈ΋ Û˘ÚÚ·Ê‹ Ù˘ ‚Ï¿‚˘, Û ¤Ó· ‹ ‰‡Ô ÛÙÚÒÌ·Ù·, Î·È ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ Ì ·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ Î·È ·ÓÙÈ‚ÈÔÙÈÎÒÓ(11). H ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÛÙ· ÓÂÔÁÓ¿ Û˘Ì‚·›ÓÂÈ Û¿ÓÈ·. ¶Ôχ‰˘Ì˜ ΢‹ÛÂȘ Î·È ÚÔˆÚfiÙËÙ· Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÚÈÁÂÓÓËÙÈÎfi stress Ô˘ ·ÔÙÂÏ› ÈÛ¯˘Úfi ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ·. H ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ·fi ÙÔÓ ÎÏÈÓÈÎfi, Ë ÛˆÛÙ‹ ÂÎÙ›ÌËÛË Î·È Ë ÁÚ‹ÁÔÚË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË Â›Ó·È ÎÚÈÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË Î·È ÁÂÓÈÎfiÙÂÚ· ÁÈ· ÙËÓ Î·Ï‹ ÔÚ›· ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ. BÈ‚ÏÈÔÁÚ·Ê›· 1. Rosser Sb, Clark CH, Elechi EN. Spontaneous neonatal gastric perforation. J Pediatr Surg 1982;17: 390-394. 2. Siebold EA. Darmperforation in Neugeborenen. J Geburteh Frauenzimmer Kinderk 1825;5:3. 3. Holgersen LO. The etiology of spontaneous gastric perforation of the newborn. A reevaluation. J Pediatr Surg 1981;16:608-613. 4. Shashikumar VL, Bassuk A, Pilling GPIV, Creson SL. Spontaneous gastric rupture in the newborn. A clinical review of nineteen cases. Ann Surg 1975;182:22-25. 5. Grosfeld JL, Molinari F, Chaet M, Engum SA, West KW, Resclora FJ et al. Gastrointestinal perforation and peritonitis in infants and children. Experience with 179 cases over ten years. Surgery 1996;120:650-655; discussion 655-656. 6. L1oyd JR. The etiology of gastrointestinal perforation in the newborn. J Pediatr Surg 1969;4:77-84. 7. Nagaraj HS, Sandhu AS, Cook LN, Buchino JJ, Groff DB. Gastrointestinal perforation following indomethacin therapy in very low birth weight infant. J Pediatr Surg 1981;16:1003-1007. 8. Yamataka A, Yamataka T, Kobayashi H, Sueyoshi N, Miyano T. Lack of C-KIT+ mast cells and the development of idiopathic gastric perforation in neonates. J Pediatr Surg 1999;34:34-38. 9. Guillois B, Parent P, Gaudin J, Jehannin B, Alix D. Neonatal gastric perforation in twins. Pediatr Surg Int 1987;2:255-256. 10. Hay SA, Mahmoud SAR. Idiopathic gastrointestinal perforation in premature twins. Pediatr Surg Int 1994;9:522-523. 11. Young AE, Sury MR. Spontaneous neonatal gastric perforation. Paediatr Anaesth 1996;6:143-145.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-05-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000
EÈÎfiÓ· 1. AÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ·ÚÔ˘Û›· ÂχıÂÚÔ˘ ·¤Ú· οو ·fi ÙÔ ‰È¿ÊÚ·ÁÌ·.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: XÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ AÙÏ·ÓÙ›‰Ô˜ 37, 71305 HÚ¿ÎÏÂÈÔ
439
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·440
¶∞π¢π∞∆ƒπ∫∏ 2000;63:440-443
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
™˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË ÎÏÂȉfi˜: ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £Âfi‰ˆÚÔ˜ ªÂÛϛη˜, ∫˘ÚÈ¿ÎÔ˜ ¶··‚·ÛÈÏ›Ԣ, ¡ÈÎfiÏ·Ô˜ ¶¿ÓÔ˘, °ÂÒÚÁÈÔ˜ ¶··‰ËÌËÙÚ›Ô˘, µ·Û›ÏÂÈÔ˜ ¶··‚·ÛÈÏ›Ԣ ● ¶ÂÚ›ÏË„Ë: ∏ Û˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË Ù˘ ÎÏÂȉfi˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ·‰˘Ó·Ì›· Û˘Ó¤ÓˆÛ˘ ÙˆÓ ‰‡Ô ˘Ú‹ÓˆÓ ÔÛÙ¤ˆÛ˘ ÙÔ˘ ÔÛÙÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓ‰ÔÌËÙÚ›Ô˘ ˙ˆ‹˜. ™ÙË ÌÂϤÙË ·˘Ù‹ ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÌÈ·˜ ·ÛıÂÓÔ‡˜ 6 ÂÙÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠‰È¤ÎÚÈÛË Ù˘ „¢‰¿ÚıÚˆÛ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Û˘ÁÎÚ¿ÙËÛË Î·È ‰ÈfiÚıˆÛË Ù˘ ı¤Û˘ ÙˆÓ Î·Ù·ÁfiÙˆÓ Ì ۇÛÙËÌ· Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘. ªÂ ÙËÓ Â˘Î·ÈÚ›· Ù˘ ·ÚÔ˘Û›·Û˘ ·˘Ù‹˜ Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜, Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ Û¿ÓÈ·˜ ·˘Ù‹˜ Û˘ÁÁÂÓÔ‡˜ ‰È·Ì·ÚÙ›·˜ ηıÒ˜ Î·È ÙȘ ÌÂıfi‰Ô˘˜ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ¶·È‰È·ÙÚÈ΋ 2000;63:440-443. §¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË, ÎÏ›‰·, ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË. T. Beslikas, K. Papavasiliou, N. Panou, G. Papadimitriou, V. Papavasiliou. Congenital pseudarthrosis of the clavicle: A case report. Paediatriki 2000;63:440-443. ● Abstract: Congenital pseudarthrosis of the clavicle is caused by a failure of normal ossification of the precartilaginous bridge connecting the acromial and sternal ossific centers of the clavicle during gestation. We present the case of a 6 year old female patient who was treated with resection of the pseudarthrosis and external fixation of the clavicle. A review of the literature regarding the aetiological factors and methods of treatment of this rare congenital malformation is presented. Key words: congenital pseudarthrosis, clavicle, surgical treatment.
∂ÈÛ·ÁˆÁ‹ ∏ Û˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË Ù˘ ÎÏÂȉfi˜ Â›Ó·È ÌÈ· ȉȷ›ÙÂÚ· Û¿ÓÈ· ¿ıËÛË. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚ›Ô˘ 110 ÂÚÈÙÒÛÂȘ (1-7), ¤ÂÈÙ· ·fi ÙËÓ ÚÒÙË ÂÚÈÁÚ·Ê‹ Ù˘ ÙÔ 1910 ·fi ÙÔÓ Fitzwilliams (8). ∏ ¿ıËÛË, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÌÊ·Ó›˙ÂÙ·È ÂÙÂÚfiÏ¢ڷ Î·È ‰ÂÍÈ¿. ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ¿ıËÛ˘ ÈÛÙ‡ÂÙ·È fiÙÈ ·ÔÙÂÏ› Ë ‰ÈÂÚÁ·Û›· ÂÌ‚Ú˘ÔÁ¤ÓÂÛ˘ Ù˘ ÎÏÂȉfi˜. ∏ ÎÏ›‰· Â›Ó·È ¤Ó· ˘ÌÂÓÔÁÂÓ¤˜ ÔÛÙÔ‡Ó Î·È ÂÈϤÔÓ ·ÔÙÂÏ› Î·È ÙËÓ ÚÒÙË ÔÛÙÈ΋ «Ì¿˙·» Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ¤Ì‚Ú˘Ô. ∞Ó·Ù‡ÛÛÂÙ·È Î·Ù¿ ÙËÓ 4Ë Â‚‰ÔÌ¿‰· (Ì‹ÎÔ˜ ÂÌ‚Ú‡Ô˘ 11 mm) ˆ˜ Ì›· ÌÂÛÂÁ¯˘Ì·ÙÈ΋ «Ï¿Î·» ΢ÙÙ¿ÚˆÓ Î¿Ùˆ ·fi ÙËÓ ÚÔ-ÎÔÚ·ÎÔÂȉ‹ ÂÚÈÔ¯‹. ¢‡Ô ˘Ú‹Ó˜ ÔÛÙ¤ˆÛ˘ (¤Ó·˜ ·ÎÚˆÌÈ·Îfi˜ Î·È ¤Ó·˜ ÛÙÂÚÓÈÎfi˜) Â›Ó·È ˘Â‡ı˘ÓÔÈ ÁÈ· ÙË Û˘ÓÔÛÙ¤ˆÛË ÙˆÓ
ÚÔ-¯fiÓ‰ÚÈÓˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Î˘ÙÙ¿ÚˆÓ Î·Ù¿ ÙËÓ 7Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰·. OÔÈÔ‰‹ÔÙ ·›ÙÈÔ ·ÚÂÌÔ‰›ÛÂÈ ÙËÓ ÔÛÙÂÔÔ›ËÛË Ù˘ ÚÔ-¯fiÓ‰ÚÈÓ˘ Á¤Ê˘Ú·˜ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ‰‡Ô ˘Ú‹Ó˜ ÔÛÙ¤ˆÛ˘, Ô‰ËÁ› ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ „¢‰¿ÚıÚˆÛ˘ Ù˘ ÎÏÂȉfi˜. ∞fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ (910), ÈÔ Èı·Ófi Ù¤ÙÔÈÔ ·›ÙÈÔ ıˆÚÂ›Ù·È Ë ›ÂÛË Ô˘ ·ÛÎÂ›Ù·È ·fi ÙËÓ ·ÏÏfiÌÂÓË ˘ÔÎÏ›‰ÈÔ ·ÚÙËÚ›·, Ô˘ ‰Ú· ˆ˜ ·Ó·ÛÙ·ÏÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙËÓ ÔÛÙÂÔÔ›ËÛË ÙˆÓ ‰‡Ô ÙÌËÌ¿ÙˆÓ Ù˘ ÎÏÂȉfi˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ‰ÂÍÈ¿ ˘ÔÎÏ›‰ÈÔ˜ ·ÚÙËÚ›· ‚Ú›ÛÎÂÙ·È Û ˘„ËÏfiÙÂÚË ·Ó·ÙÔÌÈ΋ ı¤ÛË ·fi ÙËÓ ·ÚÈÛÙÂÚ‹, ÂÍËÁ› Î·È ÙË Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË ÛÙË ‰ÂÍÈ¿ ÎÏ›‰·. OÈ ÂÚÈÁÚ·ÊfiÌÂÓ˜ ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ „¢‰¿ÚıÚˆÛ˘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÏÂȉfi˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ›Ù ÂÓÙ¿ÛÛÔÓÙ·È Û ·ÌÊÔÙÂÚfiÏ¢ÚË ‰È·Ì·ÚÙ›· (Ì ˘„ËÏ‹ ı¤ÛË Î·È ÙˆÓ ‰‡Ô ˘ÔÎÏÂȉ›ˆÓ ·ÚÙËÚÈÒÓ ÂÍ·ÈÙ›·˜ Ù˘ ‡·Ú͢ ·˘¯ÂÓÈÎÒÓ Ï¢ÚÒÓ ‹ οıÂÙ·
µ' OÚıԷȉÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ ¡.°.¡. £ÂÛÛ·ÏÔӛ΢ “°. °ÂÓÓËÌ·Ù¿˜”
440
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·441
¶∞π¢π∞∆ƒπ∫∏ 2000;63:440-443
ÚÔÛ·Ó·ÙÔÏÈÛÌ¤ÓˆÓ ·ÓˆÙ¤ÚˆÓ Ï¢ÚÒÓ) ›ÙÂ Û˘Ó˘¿Ú¯Ô˘Ó Ì ·Ó·ÛÙÚÔÊ‹ ÛÏ¿¯ÓˆÓ Î·È ‰ÂÍÈÔηډ›·. ÕÏϘ Èı·Ó¤˜ ·Èٛ˜ ·ÚÂÌfi‰ÈÛ˘ Ù˘ Û˘ÓÔÛÙ¤ˆÛ˘ ÙˆÓ ˘Ú‹ÓˆÓ ÔÛÙ¤ˆÛ˘ Ù˘ ÎÏÂȉfi˜ Â›Ó·È ÔÈ ¤ÎÙÔ˜ ·˘¯ÂÓÈΤ˜ Ï¢ڤ˜, Ë ·Ó˘„ˆÌ¤ÓË ı¤ÛË ÙˆÓ ÚÒÙˆÓ Ï¢ÚÒÓ Î·È Ë Î·Î‹ ÂÓ‰ÔÌ‹ÙÚÈÔ˜ ı¤ÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ (9). ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Û ¿ÙÔÌ· Ù˘ ›‰È·˜ ÔÈÎÔÁ¤ÓÂÈ·˜ (10) Ô‰‹ÁËÛ ÛÙË ‰È·Ù‡ˆÛË Ù˘ ıˆڛ·˜ fiÙÈ Ë ¿ıËÛË ÎÏËÚÔÓÔÌÂ›Ù·È Î·Ù¿ ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú·. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· ÂȂ‚·Èˆı›. ∏ Û˘ÁÁÂÓ‹˜ „¢‰¿ÚıÚˆÛË Ù˘ ÎÏÂȉfi˜ ÎÏÈÓÈο ÂÌÊ·Ó›˙ÂÙ·È ˆ˜ Ì›· ·ÓÒ‰˘ÓË ‰ÈfiÁΈÛË Ù˘ ¤Íˆ ÌÔ›Ú·˜ ÙÔ˘ ̤ÛÔ˘ ÙÚÈÙËÌÔÚ›Ô˘ Ù˘, Á›ÓÂÙ·È ·ÓÙÈÏËÙ‹ ‰Â ηٿ ÙË Á¤ÓÓËÛË ‹ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. ™ÙÔ ÛËÌÂ›Ô Ù˘ „¢‰¿ÚıÚˆÛ˘, Ù· ‰‡Ô ¿ÎÚ· Ù˘ Â›Ó·È ‰ÈÔÁΈ̤ӷ, ÂÓÒ ˘¿Ú¯ÂÈ ¿ÏÏÔÙ ¿ÏÏÔ˘ ‚·ıÌÔ‡ ÎÈÓËÙÈÎfiÙËÙ· ·Ó¿ÌÂÛ¿ ÙÔ˘˜. ∆Ô ·ÎÚˆÌÈ·Îfi ¿ÎÚÔ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÒÛË ÏfiÁˆ ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ¿Óˆ ¿ÎÚÔ˘, ÂÓÒ Ô ÒÌÔ˜ Ô˘ ÙÔ ·ÎÔÏÔ˘ı› ÛÙÚÂÊfiÌÂÓÔ˜ Ù·˘Ùfi¯ÚÔÓ· Î·È ÚÔ˜ Ù· ¤Ûˆ, ÂÌÊ·Ó›˙ÂÙ·È ÈÔ ÎÔÓÙ¿ ÛÙÔ ÛÙ¤ÚÓÔ Û ۯ¤ÛË Ì ÙÔÓ ·ÚÈÛÙÂÚfi ÒÌÔ. ∏ ·Ú·ÌfiÚʈÛË ·ÎÔÏÔ˘ı› Û˘Ó‹ıˆ˜ ÙÔÓ Ú˘ıÌfi ·Ó¿Ù˘Í˘ ÙÔ˘ ÛÒÌ·ÙÔ˜, ȉȷ›ÙÂÚ· fiÙ·Ó ˘¿Ú¯ÂÈ ·ÚÎÂÙ‹ ÎÈÓËÙÈÎfiÙËÙ· ÛÙÔ ÛËÌÂ›Ô Ù˘ „¢‰¿ÚıÚˆÛ˘. ∆Ô ‰¤ÚÌ· ÙÔÈο Á›ÓÂÙ·È ÏÂÙfi Î·È ·ÙÚÔÊÈÎfi, ÙÔ ¤Ûˆ ¯Â›ÏÔ˜ Ù˘ ˆÌÔÏ¿Ù˘ ÚÔÂͤ¯ÂÈ Î·È Ë ·Ú·ÌfiÚʈÛË ·˘Í¿ÓÂÈ Û ̤ÁÂıÔ˜ fiÙ·Ó Ô ·ÛıÂÓ‹˜ ·Ó·ÛËÎÒÓÂÈ ÙÔ˘˜ ÒÌÔ˘˜. ªÔÚ› Ó· ˘¿Ú¯ÂÈ ‹ÈÔ˜ fiÓÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÒÌÔ˘ Î·È ÛÙÔ ¿Óˆ ËÌÈÌfiÚÈÔ ÙÔ˘ ‚Ú·¯ÈÔÓ›Ô˘, ÂÓÒ ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰È·Ì·ÚÙ‡ÚÔÓÙ·È ÁÈ· ·‰˘Ó·Ì›· ‹ ÂÚÈÔÚÈÛÌfi Ù˘ ··ÁˆÁ‹˜ ÙÔ˘ Û‡ÛÙÔÈ¯Ô˘ ¿Óˆ ¿ÎÚÔ˘. ∞ÎÙÈÓÔÏÔÁÈο ‰È·ÈÛÙÒÓÂÙ·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ‰ÈfiÁΈÛË ÙˆÓ ‰‡Ô ÔÛÙÈÎÒÓ ¿ÎÚˆÓ: ·ÎÚˆÌÈ·ÎÔ‡ Î·È ÛÙÂÚÓÈÎÔ‡ (EÈÎfiÓ· 1).
EÈÎfiÓ· 1. ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ·ÛıÂÓÔ‡˜. ¢È·ÎÚ›ÓÂÙ·È Ë Â˘ÌÂÁ¤ı˘ ‰ÈfiÁΈÛË ÛÙ· fiÚÈ· ÙÔ˘ ¤Íˆ Î·È Ì¤ÛÔ˘ ÙÚÈÙËÌÔÚ›Ô˘ Ù˘ ‰ÂÍÈ¿˜ ÎÏÂȉfi˜.
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ·Ú·Î¿Ùˆ ·ı‹ÛÂȘ: 1. ª·È¢ÙÈÎfi οٷÁÌ·. AӷʤÚÂÙ·È ÈÛÙÔÚÈÎfi ÙÚ·˘Ì·ÙÈÛÌÔ‡ ηٿ ÙÔÓ ÙÔÎÂÙfi, Û˘Ó˘¿Ú¯ÂÈ „¢‰Ô·Ú¿Ï˘ÛË ÙÔ˘ ¿Óˆ ¿ÎÚÔ˘ Ì ÂÚÈÔÚÈÛÌfi Ù˘ ÂÎÔ‡ÛÈ·˜ ÎÈÓËÙÈÎfiÙËÙ·˜ Î·È fiÓÔ˜ ÛÙȘ ·ıËÙÈΤ˜ ÎÈÓ‹ÛÂȘ ÙÔ˘ Û‡ÛÙÔÈ¯Ô˘ ¿Óˆ ¿ÎÚÔ˘. ∞ÎÙÈÓÔÏÔÁÈο, ‰È·ÈÛÙÒÓÂÙ·È ÂÌÊ·Ó‹˜ ÂÈÎfiÓ· ÒÚÔ˘ Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ·fi ÙËÓ Î¿ÎˆÛË. 2. ªÂÙ·ÙÚ·˘Ì·ÙÈ΋ „¢‰¿ÚıÚˆÛË. À¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∞ÎÙÈÓÔÏÔÁÈο, Ù· ¿ÎÚ· ÙˆÓ Î·Ù·ÁfiÙˆÓ ÂÌÊ·Ó›˙ÔÓÙ·È ÏÂÙ¿ Î·È fi¯È ‰ÈÔÁΈ̤ӷ fiˆ˜ ÛÙË Û˘ÁÁÂÓ‹ „¢‰¿ÚıÚˆÛË. 3. ∫ÏÂȉÔÎÚ·Óȷ΋ ‰˘ÛfiÛÙˆÛË. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋, Û˘Ó˘¿Ú¯Ô˘Ó ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÔÛÙÒÓ ÙÔ˘ ÎÚ·Ó›Ô˘, fiˆ˜ Î·È ÙÔ˘ ˘ÂÏÈÎÔ‡ ‰·ÎÙ˘Ï›Ô˘. 4. ¡Â˘ÚÔ˚ӈ̿وÛË. À¿Ú¯Ô˘Ó Î·È ¿ÏϘ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ fiˆ˜ ηÊÂfi¯ÚˆÂ˜ ÎËÏ›‰Â˜, ÛÎÔÏ›ˆÛË ÎÏ. ŸÙ·Ó Ë ¿ıËÛË ‰ÂÓ ‰ËÌÈÔ˘ÚÁ› ·ÈÛıËÙÈο ‹ ÏÂÈÙÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù· ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Î·Ì›· ıÂڷ›·. ™ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ··ÈÙÂ›Ù·È ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹, ·˘Ù‹ Â›Ó·È ¯ÂÈÚÔ˘ÚÁÈ΋ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ‰È¤ÎÚÈÛË Ù˘ „¢‰¿ÚıÚˆÛ˘ Î·È ÙËÓ ÔÛÙÂÔÛ‡ÓıÂÛË ÙˆÓ Î·Ù·ÁfiÙˆÓ. ∏ ÔÛÙÂÔÛ‡ÓıÂÛË Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Á›ÓÂÈ Ì Ͽη Î·È ‚›‰Â˜, Ì ÂÓ‰ÔÌ˘ÂÏÈ΋ ‹ÏˆÛË ‹ Ì ÙËÓ ÙÔÔı¤ÙËÛË Û˘ÛÙ‹Ì·ÙÔ˜ Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ ÁÈ· ÙË Û˘ÁÎÚ¿ÙËÛË ÙˆÓ Î·Ù·ÁfiÙˆÓ ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË Ù˘ „¢‰¿ÚıÚˆÛ˘. ∏ ·Ê·›ÚÂÛË Ù˘ „¢‰¿ÚıÚˆÛ˘ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ ‚Ú¿¯˘ÓÛË ÙÔ˘ ÔÛÙÔ‡ Î·È Ó· ··ÈÙËı› Ë ÙÔÔı¤ÙËÛË ÔÛÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ Ì‹ÎÔ˘˜ Ù˘ ÎÏÂȉfi˜. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 6 ÂÙÒÓ, ÚÔÛ‹Ïı ÛÙ· Ù·ÎÙÈο Â͈ÙÂÚÈο È·ÙÚ›· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ Ì ‰ÈfiÁΈÛË ÌÂÁ¤ıÔ˘˜ ÂÚ›Ô˘ 2,5 cm ÛÙ· fiÚÈ· ÙÔ˘ ̤ÛÔ˘ Î·È ¤Íˆ ÙÚÈÙËÌÔÚ›Ô˘ Ù˘ ‰ÂÍÈ¿˜ ÎÏÂȉfi˜ (ÂÈÎfiÓ· 1). ∫ÏÈÓÈο ‰È·ÈÛÙÒıËΠfiÙÈ Ë ‰ÈfiÁΈÛË Â›¯Â ˘Ê‹ Ì·Ïı·Î‹, ‰È¤ÎÔÙ ‰Â ÙË Û˘Ó¤¯ÂÈ· Ù˘ ‰È¿Ê˘Û˘ ÙÔ˘ ÔÛÙÔ‡ Ù˘ ÎÏÂȉfi˜. OÈ ÁÔÓ›˜ ·Ó¤ÊÂÚ·Ó fiÙÈ ·Ú·Ù‹ÚËÛ·Ó ÙË ‰ÈfiÁΈÛË ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ¢ÂÓ ÂÚÈÁÚ¿ÊÂÙ·È ÈÛÙÔÚÈÎfi ÂÚÁÒ‰Ô˘˜ ÙÔÎÂÙÔ‡ ‹ Î·È ÌÂÙ·ÁÂÓ¤ÛÙÂÚË Î¿ÎˆÛË Ù˘ ÂÚÈÔ¯‹˜. ∏ ‰ÈfiÁΈÛË ·˘Í·ÓfiÙ·Ó Û ̤ÁÂıÔ˜ Ì ÙȘ ÎÈÓ‹ÛÂȘ ÙÔ˘ ‰ÂÍÈÔ‡ ÒÌÔ˘ Î·È Î·Ù¿ ÙËÓ ··ÁˆÁ‹ Î·È ·Ó‡„ˆÛË ÙÔ˘ ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘. OÈ ·Ú·¿Óˆ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ ·ÛıÂÓÔ‡˜ ÚÔηÏÔ‡Û·Ó ‹ÈÔ ¿ÏÁÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ‰ÈfiÁΈÛ˘. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Ë Î·Ù¿ Ì¤ÙˆÔ ·ÎÙÈÓÔÁÚ·Ê›· ÙÔ˘ ‰ÂÍÈÔ‡ ÒÌÔ˘ Î·È Ù˘ ÎÏÂȉfi˜, ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ „¢‰¿ÚıÚˆÛ˘. ∞ÎÙÈÓÔÏÔÁÈο ‰È·ÈÛÙÒıËΠ‰ÈfiÁΈÛË ÙÔ˘ ÛÙÂÚÓÈÎÔ‡ Î·È ÙÔ˘ ·ÎÚˆÌÈ·ÎÔ‡ ¿ÎÚÔ˘ Ù˘ (EÈÎfiÓ· 2).
441
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·442
¶∞π¢π∞∆ƒπ∫∏ 2000;63:440-443
EӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ
EÈÎfiÓ· 2. ¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ·. ¢È·ÎÚ›ÓÂÙ·È Ë „¢‰¿ÚıÚˆÛË ÛÙË ‰È¿Ê˘ÛË Ù˘ ‰ÂÍÈ¿˜ ÎÏÂȉfi˜ ηıÒ˜ Î·È Ë ‰ÈfiÁΈÛË ÙÔ˘ ÛÙÂÚÓÈÎÔ‡ Î·È ·ÎÚˆÌÈ·ÎÔ‡ ¿ÎÚÔ˘ Ù˘ „¢‰¿ÚıÚˆÛ˘.
EÈÎfiÓ· 3. ∞ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ÌÂÙ¿ ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘.
∂Í·ÈÙ›·˜ ÙˆÓ ÎÔÛÌËÙÈÎÒÓ ·ÏÏ¿ Î·È ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ‰ÂÍÈÔ‡ ÒÌÔ˘ Î·È ÙÔ˘ ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘, ÔÈ ÁÔÓ›˜ ·Ô‰¤¯ıËÎ·Ó ÙËÓ ÚÔÙÂÈÓfiÌÂÓË ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›·. ªÂ ÂÈÌ‹ÎË ÙÔÌ‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Ì‹ÎÔ˘˜ 3 cm ¿Óˆ ·fi ÙË ‰ÈfiÁΈÛË Ù˘ ÎÏÂȉfi˜, ·Ó¢ڤıËÎ·Ó Î·È ·Ú·Û΢¿ÛÙËÎ·Ó Ù· ‰‡Ô ÔÛÙÈο ¿ÎÚ· Ù˘ „¢‰¿ÚıÚˆÛ˘. ªÂÙ¿ ÙËÓ ·Ú·Û΢‹ Ù˘ „¢‰¿ÚıÚˆÛ˘ ·ÎÔÏÔ‡ıËÛÂ Ë ‰È¤ÎÚÈÛ‹ Ù˘. ∞Ê·ÈÚ¤ıËÎ·Ó Ì ÂÈ̤ÏÂÈ· fiÏ· Ù· ÛÙÔȯ›· ÙÔ˘ ÈÓÒ‰Ô˘˜ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·ÚÂÌ‚¿ÏÏÔÓÙ·Ó ÌÂٷ͇ ÙˆÓ ‰‡Ô ¿ÎÚˆÓ Ù˘ ÎÏÂȉfi˜. ™ÙÔ ÛÙÂÚÓÈÎfi Î·È ÙÔ ·ÎÚˆÌÈ·Îfi ¿ÎÚÔ Ù˘ ÎÏÂȉfi˜ ÙÔÔıÂÙ‹ıËÎ·Ó ‰‡Ô Ú·‚‰ˆÙÔ› ‹ÏÔÈ ‰È·Ì¤ÙÚÔ˘ 2 mm ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ Tubular. ªÂ ÙË ‚Ô‹ıÂÈ· ÙˆÓ Ú·‚‰ˆÙÒÓ ‹ÏˆÓ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÎÈÓËÙÔÔÈ‹ıËηÓ, Û˘ÌÏËÛÈ¿ÛıËÎ·Ó Î·È Û˘ÌȤÛıËÎ·Ó Ù· ηÙ·ÁfiÙ· ¿ÎÚ· ÙÔ˘ ÔÛÙÔ‡ (EÈÎfiÓ· 3). ∏ ·ÔηٿÛÙ·ÛË ÙÔ˘ Ì‹ÎÔ˘˜ Ù˘ ÎÏÂȉfi˜ η٤ÛÙË ‰˘Ó·Ù‹ ¯ˆÚ›˜ ÙË ¯ÚËÛÈÌÔÔ›ËÛË
ÔÛÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞ÎÔÏÔ‡ıËÛ ·Ï‹ ·Ó¿ÚÙËÛË ÙÔ˘ ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘ ÁÈ· 3 ‚‰ÔÌ¿‰Â˜. ∆Ô Û‡ÛÙËÌ· Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ (EÈÎfiÓ· 4) ·Ê·ÈÚ¤ıËΠ3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÙÔÔı¤ÙËÛ‹ ÙÔ˘. ∂ÌÊ·Ó‹˜ ·Ó¿Ù˘ÍË ÒÚÔ˘ ‰È·ÈÛÙÒıËΠ4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Î·È Ï‹Ú˘ ÒÚˆÛË 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË (¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ 2 ¤ÙË), ‰È·ÈÛÙÒıËΠÎÏÈÓÈο Ë ·ÔηٿÛÙ·ÛË Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ÔÛÙÔ‡ Î·È Ë Î·Ï‹ ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ‰ÂÍÈÔ‡ ÒÌÔ˘ Î·È ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘. ∏ ÙÂÏÈ΋ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· (EÈÎfiÓ· 5) ÎÚ›ÓÂÙ·È È‰È·›ÙÂÚ· ÈηÓÔÔÈËÙÈ΋. ∞Ó Î·È Ë ‰ÂÍÈ¿ ÎÏ›‰· ˘ÔÏ›ÂÙ·È 1 cm ÛÙÔ Ì‹ÎÔ˜ Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙËÓ ·ÚÈÛÙÂÚ‹, ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ϤÔÓ ‰È¿Ê˘ÛË. ∏ ÂχıÂÚË Ï¤ÔÓ ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÒÌÔ˘ Î·È ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘ (¯ˆÚ›˜ Ó· ÚÔηÏÂ›Ù·È ÙÔÈÎfi ¿ÏÁÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ „¢‰¿ÚıÚˆÛ˘) ηıÒ˜ Î·È ÙÔ ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· (EÈÎfiÓ· 6), ¯·Ú·ÎÙËÚ›˙Ô˘Ó ˆ˜ ÂÈÙ˘¯‹ ÙËÓ ÂÁ¯ÂÈÚËÙÈ΋ ¤̂·ÛË.
EÈÎfiÓ· 4. ∏ ı¤ÛË ÙÔÔı¤ÙËÛ˘ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ ÛÙËÓ ÎÏ›‰·.
EÈÎfiÓ· 5. ∞ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· 2 ¤ÙË ÌÂÙ¿ ÙË ‰È¤ÎÚÈÛË Ù˘ „¢‰¿ÚıÚˆÛ˘. ¢È·ÈÛÙÒÓÂÙ·È Ë ·ÔηٿÛÙ·ÛË Ù˘ ‰È¿Ê˘Û˘ Ù˘ ÎÏÂȉfi˜.
442
SEPT-OCT.2000
30-05-03
14:03
™ÂÏ›‰·443
¶∞π¢π∞∆ƒπ∫∏ 2000;63:440-443
™˘ÁÁÂÓ‹˜ „¢‰¿ıÚˆÛË ÎÏÂȉfi˜
∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Ì ÙËÓ ÙÔÔı¤ÙËÛË Û˘ÛÙ‹Ì·ÙÔ˜ Â͈ÙÂÚÈ΋˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ Â›Ó·È ÌÈ· Ó¤· ̤ıÔ‰Ô˜ Ô˘ ÏÂÔÓÂÎÙ› fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·, ηıÒ˜ ·Ê‹ÓÂÈ ÌÈÎÚ‹ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ô˘Ï‹, ÂÓÒ ‰ÂÓ ··ÈÙÂ›Ù·È ‰Â‡ÙÂÚË Â¤Ì‚·ÛË ÁÈ· ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ ˘ÏÈÎÒÓ ÔÛÙÂÔÛ‡ÓıÂÛ˘. ø˜ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ÌÂıfi‰Ô˘ ÌÔÚ› Ó· ıˆÚËı› Ë ‰˘Û¯ÂÚ‹˜ ÂÚÈÔ›ËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· fiÛÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ʤÚÂÈ ÙÔ Û‡ÛÙËÌ·. µÈ‚ÏÈÔÁÚ·Ê›·
EÈÎfiÓ· 6. ∏ ÂÈÎfiÓ· Ù˘ ·ÛıÂÓÔ‡˜ 2 ¤ÙË ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ¢È·ÈÛÙÒÓÂÙ·È Ë ·ÈÛıËÙÈ΋ ·ÔηٿÛÙ·ÛË Ù˘ ÂÚÈÔ¯‹˜ Ù˘ ‰ÂÍÈ¿˜ ÎÏÂȉfi˜. ™˘˙‹ÙËÛË ∂Í·ÈÙ›·˜ Ù˘ Û·ÓÈfiÙËÙ·˜ Ù˘ ¿ıËÛ˘ Î·È ÙˆÓ Û˘¯ÓÒÓ ·ÔÙ˘¯ÈÒÓ Î·È ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ ÙˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ÌÂıfi‰ˆÓ ·ÔηٿÛÙ·Û˘, ‰ÂÓ ˘¿Ú¯ÂÈ ÌÈ· ÁÂÓÈο ·Ô‰ÂÎÙ‹ ̤ıÔ‰Ô˜ ıÂڷ›·˜, Ë ÔÔ›· Ó· ·ÔÙÂÏ› Î·È ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜(7). O Wall(11) ıˆÚ› fiÙÈ ‰ÂÓ ··ÈÙÂ›Ù·È Î·Ì›· ıÂڷ›·. ∂ÊfiÛÔÓ fï˜, ÔÈ ÁÔÓ›˜ ‹ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜, ı¤ÏÔ˘Ó Ó· ·Ê·ÈÚÂı› Ë ‰ÈfiÁΈÛË ÁÈ· ÎÔÛÌËÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ‹ ÂÂȉ‹ Û˘Ó˘¿Ú¯Ô˘Ó ÏÂÈÙÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ Û˘ÛÙÔ›¯Ô˘ ÒÌÔ˘ Î·È ¿Óˆ ¿ÎÚÔ˘ ÙfiÙ ڤÂÈ Ë ¿ıËÛË Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈο(12). H ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·Ê·›ÚÂÛË Ù˘ „¢‰¿ÚıÚˆÛ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙË Û˘ÁÎÚ¿ÙËÛË ÙˆÓ ‰‡Ô ¿ÎÚˆÓ Ù˘ ÎÏÂȉfi˜. ∏ ÂÓ‰ÔÌ˘ÂÏÈ΋ ‹ÏˆÛË Ì ‚ÂÏfiÓË Steinmann Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ Ô˘ ÚÔÙ›ÓÂÈ Ô Tachdjan(8), ÌÔÏÔÓfiÙÈ ·fi ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÂÈÛËÌ·›ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ «ÌÂÙ·Ó¿ÛÙ¢Û˘» Ù˘ ‚ÂÏfiÓ˘ ÚÔ˜ Ù· ¤Ûˆ Î·È Ù˘ ·ÛÙ·ıÔ‡˜ ÔÛÙÂÔÛ‡ÓıÂÛ˘ Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹. OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ (13-15) ÚÔÙÈÌÔ‡Ó ÙËÓ ÂÛˆÙÂÚÈ΋ ÔÛÙÂÔÛ‡ÓıÂÛË Ì Ͽη Î·È ‚›‰Â˜ Î·È ÙËÓ ÙÔÔı¤ÙËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ. O Owen(16) ÚÔÙ›ÓÂÈ ‰È¤ÎÚÈÛË Ù˘ „¢‰¿ÚıÚˆÛ˘ Î·È ÙÔÔı¤ÙËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ¯ˆÚ›˜ ÙËÓ ÔÛÙÂÔÛ‡ÓıÂÛË ÙˆÓ Î·Ù·ÁfiÙˆÓ. ∆Ô ÂÚÒÙËÌ· Ô˘ Ù›ıÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ÔÈ· ËÏÈΛ· Â›Ó·È Ë Î·Ù·ÏÏËÏfiÙÂÚË ÁÈ· ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ (10,12) ÚÔÙ›ÓÔ˘Ó ÙËÓ ËÏÈΛ· ÙˆÓ 3-4 ÂÙÒÓ. O Tachdjan(8) Û˘ÓÈÛÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Û ËÏÈΛ· 1 ¤ÙÔ˘˜, ηıÒ˜ ‰ÂÓ ÈÛÙ‡ÂÈ fiÙÈ Ë Î·ı˘ÛÙ¤ÚËÛË ÚÔÛʤÚÂÈ ÔÔÈÔ‰‹ÔÙ ÏÂÔÓ¤ÎÙËÌ·. ªÂ ÙËÓ ¿Ô„Ë ·˘Ù‹ Û˘ÌʈÓÔ‡Ó Î·È ÔÚÈṲ̂ÓÔÈ ¿ÏÏÔÈ Û˘ÁÁÚ·Ê›˜ (13), ÁÈ·Ù› ÈÛÙÂ‡Ô˘Ó fiÙÈ Ë ÚÒÈÌË ·Ê·›ÚÂÛË Ù˘ ÈÓÒ‰Ô˘˜ ·ÎfiÌ· „¢‰¿ÚıÚˆÛ˘ ‰ÂÓ ··ÈÙ› ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô‡Ù ÙËÓ ÂÊ·ÚÌÔÁ‹ ÔÛÙÂÔÛ‡ÓıÂÛ˘, ÂÓÒ Â›Ó·È Ôχ Èı·Ófi Ó· ··ÈÙËıÔ‡Ó Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·.
1. Ahmadi B, Steel HH. Congenital pseudarthrosis of the clavicle. Clin Orthop 1977;126:130-134. 2. Hirata S, Miya H, Mizuno K. Congenital pseudarthrosis of the clavicle. Histologic examination for the etiology of the disease. Clin Orthop 1995;315:242-245. 3. Herman S. Congenital bilateral pseudarthrosis of the clavicle. Clin Orthop 1973;91:162-163. 4. Jinkins WJ. Congenital pseudarthrosis of the clavicle. Orthop 1969;62:183-186. 5. Manaschil G, Laufer S. Congenital pseudarthrosis of the clavicle. Report of 3 cases. AJR 1979;132:678-679. 6. Mooney JF, Koman LA. Bilateral congenital pseudarthrosis of the clavicle associated with trisomy 22. Orthop 1991;14(2):171-173. 7. Toledo L, MacEwen GD. Severe complication of surgical treatment of congenital pseudarthrosis of the clavicle. Clin Orthop 1979;139:64-67. 8. Tachdjan MO. Pediatric Orthopedics. Volume 1. WB Saunders Company;1990. p. 168-174. 9. Lloyd-Roberts GC, Appley AG, Owen R. Reflections upon the aetiology of congenital pseudarthrosis of the clavicle. J Bone Joint Surg [Br] 1975;57:24-29. 10. Brooks S. Bilateral congenital pseudarthrosis of the clavicle. Br J Clin Pract 1984;38:432-433. 11. Wall J. Congenital pseudarthrosis of the clavicle. J Bone Joint Surg [Am] 1970;52:1003-1009. 12. Gibson DA, Caroll N. Congenital pseudarthrosis of the clavicle. J Bone Joint Surg [Br] 1970;52:629-643. 13. Grogan DP, Love SM, Guidera KJ, Ogden JA. Operative treatment of congenital pseudarthrosis of the clavicle. J Pediatr Orthop 1991;11(2):176-180. 14. Quinlan WR. Congenital pseudarthrosis of the clavicle. Orthop Scand 1980;51:489-492. 15. Schnall SB, King JD, Marrero G. Congenital pseudarthrosis of the clavicle: a review of the literature and surgical treatment of six cases. J Pediatr Orthop 1988;8:316-321. 16. Owen R. Congenital pseudarthrosis of the clavicle. J Bone Joint Surg [Br] 1970;52:644-652.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-04-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-09-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÂÛϛη˜ £Âfi‰ˆÚÔ˜ °Ú. §·ÌÚ¿ÎË 19, 546 38 £ÂÛÛ·ÏÔÓ›ÎË
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OÈÎȷο ·Ù˘¯‹Ì·Ù·: O‰ËÁ›Â˜ ÚfiÏ˄˘ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ∆ÛÔ˘Ì¿Î·˜ ∆· ·È‰È¿ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚ· ¢·ı‹ ÔÌ¿‰· ÛÙ· ·Ù˘¯‹Ì·Ù·. ø˜ ·ÚȘ ·Èٛ˜ ·˘Ù‹˜ Ù˘ ¢¿ıÂÈ·˜ ıˆÚÔ‡ÓÙ·È Ë ÌÂÈÔÓÂÍ›· ÙÔ˘˜ ÛÙÔ Û˘ÓÙÔÓÈÛÌfi ÙˆÓ ÏÂÙÒÓ ÎÈÓ‹ÛˆÓ, Ë ·ÓˆÚÈÌfiÙËÙ· ÛÙË ÛΤ„Ë Ô˘ ÙÔ˘˜ ÛÙÂÚ› ÙËÓ ¤ÁηÈÚË ·ÓÙ›ÏË„Ë ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, Ë ÁÔËÙ›· Ù˘ ÂÚȤÙÂÈ·˜, Ë ·˘ÍË̤ÓË ÂÚȤÚÁÂÈ· Î·È Ë Ù¿ÛË ÁÈ· ÂÍÂÚ‡ÓËÛË. ∂ÈϤÔÓ, Ë ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ ‰È¢ÎÔχÓÂÙ·È ·fi ÙÔÓ ·ÚÓËÙÈÛÌfi ÙˆÓ ·È‰ÈÒÓ ÛÙȘ Û˘Ì‚Ô˘Ï¤˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ Ó· Â›Ó·È ·ÚÂÛÙ¿ ÛÙÔ˘˜ ÔÌËÏ›ÎÔ˘˜ ÙÔ˘˜. °È· Ù· ·È‰È¿ ̤¯ÚÈ 5 ¯ÚfiÓˆÓ Ù· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ (ÔÈÎȷο ·Ù˘¯‹Ì·Ù·) ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡. ∆· ÈÔ Û˘ÓËıÈṲ̂ӷ ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Â›Ó·È ÔÈ ÙÒÛÂȘ ·fi ÙËÓ ÎÔ‡ÓÈ· ‹ ÙÔ ÎÚ‚·Ù¿ÎÈ, ÙȘ ·ÚÔÛٿ٢٘ ÛοϘ, ÙÔ Á˘·ÏÈṲ̂ÓÔ ¿ÙˆÌ· Î·È ÙË ÛÙÚ¿Ù·, ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Ë ÂÈÛÚfiÊËÛË Í¤ÓˆÓ ÛˆÌ¿ÙˆÓ (ÍËÚÔ› ηÚÔ›, ηÚÊ›ÙÛ˜, ÛÙ·˘ÚÔ˘‰¿ÎÈ· ÎÏ) Î·È Ô ÓÈÁÌfi˜. ∆· ÂÁη‡Ì·Ù· Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ËÏÈ˘ 2 - 5 ¯ÚfiÓˆÓ Î·È Û˘Ì‚·›ÓÔ˘Ó Î˘Ú›ˆ˜ ÛÙËÓ ÎÔ˘˙›Ó·, ÙÔ ÏÔ˘ÙÚfi Î·È ÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ, ÂÓÒ ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Ì ʿÚ̷η ‹ ¿ÏϘ ÙÔÍÈΤ˜ Ô˘Û›Â˜ ·Ú’ fiÏÔ Ô˘ Â›Ó·È Û˘¯Ó‹ ÌÔÚÊ‹ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ, Â˘Ù˘¯Ò˜ Û¿ÓÈ· Â›Ó·È ı·Ó·ÙËÊfiÚ˜. ∆· ·Ù˘¯‹Ì·Ù· ·fi ¯Ú‹ÛË ÂÚÁ·Ï›ˆÓ (Ì·¯·›ÚÈ·, „·Ï›‰È·, ÎÏ), Ì˯·ÓËÌ¿ÙˆÓ (ÙÚ˘¿ÓÈ·) Î·È fiÏˆÓ Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ Î·È ÔÏϤ˜ ÊÔÚ¤˜ ı·Ó·ÙËÊfiÚ·. °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÔÈÎÈ·ÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÔÈ ÁÔÓ›˜ Ú¤ÂÈ Ó· ÂÈÎÂÓÙÚÒÓÔ˘Ó ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ Û¯Â‰›ˆÓ ηٷÛ΢‹˜ ÙÔ˘ ÛÈÙÈÔ‡ Î·È Û’ fi,ÙÈ ˘¿Ú¯ÂÈ Û ·˘Ùfi, Ó· ·ÁÚ˘ÓÔ‡Ó ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË, ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Î·È ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÎÈÓ‰‡ÓˆÓ, Ì ·˘ÛÙËÚfiÙÂÚË ÂÈÙ‹ÚËÛË Ù·˘Ùfi¯ÚÔÓ·. ∂ȉÈÎfiÙÂÚ·, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏ·¯ÈÛÙÔÔÈ‹ÛÔ˘Ì ÙÔÓ Î›Ó‰˘ÓÔ ÔÈÎÈ·ÎÔ‡ ·Ù˘¯‹Ì·ÙÔ˜ ÂÈÛËÌ·›ÓÔ˘Ì ÛÙÔ˘˜ ÁÔÓ›˜: ●
ºÚÔÓÙ›ÛÙ ÁÈ· ÙÔ ‰È·Ì¤ÚÈÛÌ· ‹ ÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ Ó· ˘¿Ú¯Ô˘Ó ÚԉȷÁڷʤ˜ ·ÛÊ·Ï›·˜ Ì ηٿÏÏËÏÔ ÊˆÙÈÛÌfi Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ.
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ªËÓ ÂÁηٷÏ›ÂÙ ÔÙ¤ ÙÔ ·È‰› ÌfiÓÔ ÛÙÔ Û›ÙÈ ‹ Û ÂÈΛӉ˘Ó· ÛËÌ›· ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÓËÏ›ÎÔ˘.
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¡· ·ÔÌ·ÎÚ‡ÓÂÙ ٷ ÂÈΛӉ˘Ó· ·È¯Ó›‰È· ·fi ÙÔ Û›ÙÈ Î·È ÌËÓ ·Ê‹ÓÂÙ ÔÙ¤ ÂÈΛӉ˘Ó· ·ÓÙÈΛÌÂÓ· ÛÙ· ¯¤ÚÈ· ÙˆÓ ·È‰ÈÒÓ.
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ªËÓ ·Ê‹ÓÂÙ ÂχıÂÚÔ ÓÂÚfi Û ÌÂÁ¿Ï· ‰Ô¯Â›· ‹ ÛÙÔ Ì¿ÓÈÔ Î·È ·ÛÊ·Ï›ÛÙ ηϿ Ù· ËÁ¿‰È·, ÙȘ ÛÙ¤ÚÓ˜ ‹ fiÔÈÔ˘˜ ¿ÏÏÔ˘˜ ¯ÒÚÔ˘˜ Û˘ÏÏÔÁ‹˜ ÓÂÚÔ‡.
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ªËÓ Î˘ÎÏÔÊÔÚ›Ù ·ÚfiÛÂÎÙ· ÎÚ·ÙÒÓÙ·˜ ÛÙ· ¯¤ÚÈ· Û·˜ ÊÏÈÙ˙¿ÓÈ· Ì ˙ÂÛÙ¿ ÚÔÊ‹Ì·Ù·. ∞‰ÂÈ¿ÛÙ fiÏ· Ù· ÊÏÈÙ˙¿ÓÈ· Î·È Ù· ÔÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ˘ÔÏ›ÌÌ·Ù· ÔÙÒÓ.
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÷ÌËÏÒÛÙ ÙÔÓ ıÂÚÌÔÛÙ¿ÙË ÙÔ˘ ıÂÚÌÔۛʈӷ, ‰È·ÙËÚ›ÛÙ ۂËÛÙ¤˜ ÙȘ ÂÛٛ˜ Ù˘ ËÏÂÎÙÚÈ΋˜ ÎÔ˘˙›Ó·˜ fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È, ηχÙÂÙ ¿ÓÙÔÙ ÙȘ ËÏÂÎÙÚÈΤ˜ Ú›˙˜.
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µÂ‚·Èˆı›Ù fiÙÈ ‚Ú›ÛÎÔÓÙ·È Û ·ÛÊ·Ï‹ ÛËÌ›· ÙÔ ÛȉÂÚˆÙ‹ÚÈÔ Î·È Ù· Ï·Ì·Ù¤Ú, ÊÚÔÓÙ›ÛÙ ӷ ˘¿Ú¯ÂÈ Û‡ÛÙËÌ· ·ÛÊ·Ï›·˜ ÛÙÔÓ ›Ó·Î· ÙÔ˘ ËÏÂÎÙÚÈÎÔ‡.
¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌ›Ԣ ∫∞∆
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∆ÔÔıÂÙ›ÛÙ Û ·Î›Ó‰˘ÓË ı¤ÛË ¤ÈÏ· Ì Ôͤ· ¿ÎÚ· Î·È ·ÔʇÁÂÙ ÙȘ Ù˙·Ì¤ÓȘ fiÚÙ˜ Î·È ·˘Ù¤˜ Ô˘ ÎÏ›ÓÔ˘Ó ÌfiÓ˜ ÙÔ˘˜.
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µÂ‚·Èˆı›Ù fiÙÈ ÔÈ ÛοϘ ‰ÂÓ Â›Ó·È ·fiÙÔ̘ Î·È fiÙÈ ‰ÂÓ ÁÏÈÛÙÚÔ‡Ó. ∆Ô ›‰ÈÔ Î·È Ù· ·ÙÒÌ·Ù·.
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™˘ÓËı›ÛÙ ӷ ÎÏ›ÓÂÙ ÙÔ Î¿Ï˘ÌÌ· Ù˘ ÙÔ˘·Ï¤Ù·˜, ÌËÓ ·Ê‹ÓÂÙ ӷ ÎÚ¤ÌÂÙ·È ÙÔ ÎÔÚ‰fiÓÈ ·fi ÙȘ ÂÚÛ›‰Â˜, ·ÔÌ·ÎÚ‡ÓÂÙ ÙȘ ηڤÎϘ ·fi Ù· ·Ú¿ı˘Ú· ÙÔ˘ ÛÈÙÈÔ‡.
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ªË ¯ÚËÛÈÌÔÔț٠ϷÛÙÈΤ˜ Û·ÎԇϘ Î·È ÊÚÔÓÙ›ÛÙÂ Ô ÛÎÔ˘È‰ÔÙÂÓÂΤ˜ Ó· ʤÚÂÈ Î¿Ï˘ÌÌ· Ô˘ ·ÓÔ›ÁÂÈ ‰‡ÛÎÔÏ· Î·È Ó· ‚Ú›ÛÎÂÙ·È Û ·ÛʷϤ˜ ÛËÌ›Ô.
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∂Í·Ê·Ó›ÛÙ ٷ Ê˘Ù¿ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ‰ËÏËÙËÚ›·ÛË.
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™Ô‚·Ú¢Ù›ÙÂ Î·È Ê˘Ï¿ÍÙ ÙÔ Î˘ÓËÁÂÙÈÎfi ‹ ÙÔ ˘ËÚÂÛÈ·Îfi Û·˜ fiÏÔ Û ۛÁÔ˘ÚÔ ÛËÌ›Ô, ¿‰ÂÈÔ Î·È ·ÛÊ·ÏÈṲ̂ÓÔ. º˘Ï¿ÍÙ ÙȘ ÛÊ·›Ú˜, Ù· ÛοÁÈ·, ÙÔ Ì·ÚÔ‡ÙÈ Û ¿ÏÏÔ ÛËÌ›Ô, ÙÔ ›‰ÈÔ Û›ÁÔ˘ÚÔ Î·È ·ÛʷϤ˜.
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ªËÓ ·Ê‹ÓÂÙ ʿÚ̷η Î·È ÙÛÈÁ¿Ú· Û ÚÔÛÈÙ¿ ÛËÌ›·. ∫Ï›ÛÙ ηϿ Ù· ÓÙÔ˘Ï¿È· fiÔ˘ Ê˘Ï¿ÛÛÔÓÙ·È.
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:446
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∞Á·ËÙÔ› Û˘Ó¿‰ÂÏÊÔÈ, ∞Ó·Ï·Ì‚¿ÓÔÓÙ·˜ Ù· ηı‹ÎÔÓÙ· Î·È ÙȘ ˘Ô¯ÚÂÒÛÂȘ Û˘ÌÌÂÙÔ¯‹˜ Ì·˜ ÛÙËÓ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ù˘ ∂Ù·ÈÚ›·˜ Ì·˜, ı· ı¤Ï·Ì ӷ ¢¯·ÚÈÛÙ‹ÛÔ˘Ì ıÂÚÌ¿ ÙÔ ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ÁÈ· ÙËÓ ÙÈÌ‹ Ô˘ Ì·˜ ¤Î·Ó·Ó, ηıÒ˜ Î·È ÙÔ˘˜ ÚÔηÙfi¯Ô˘˜ Ì·˜ ÔÈ ÔÔ›ÔÈ ÂÚÁ¿ÛıËÎ·Ó Ì ˙‹ÏÔ Î·È ·ÊÔÛ›ˆÛË ÁÈ· Ó· ÙËÚ‹ÛÔ˘Ó ÙȘ ˘„ËϤ˜ ÂÈÛÙËÌÔÓÈΤ˜ ÚԉȷÁڷʤ˜ Ù˘ «¶∞π¢π∞∆ƒπ∫∏™». £· οÓÔ˘Ì οı ‰˘Ó·Ù‹ ÚÔÛ¿ıÂÈ· Ó· ‰È·ÙËÚ‹ÛÔ˘ÌÂ Î·È Ó· ‚ÂÏÙÈÒÛÔ˘Ì ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÙËÓ ·ÓÔ‰È΋ ÂÈÛÙËÌÔÓÈ΋ ÔÚ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ì·˜ ·ÍÈÔÏÔÁÒÓÙ·˜ Û˘ÛÙËÌ·ÙÈο Î·È ·ÓÒÓ˘Ì· Î·È ‰ËÌÔÛȇÔÓÙ·˜ ÂÓ Û˘Ó¯›·, ÚˆÙfiÙ˘· ¿ÚıÚ· Ù· ÔÔ›· ÔÈ ÂÎÏÂÎÙÔ› ∫ÚÈÙ¤˜ Î·È Ë ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ı· ÎÚ›ÓÔ˘Ó fiÙÈ ‰È¢ڇÓÔ˘Ó ÙÔ˘˜ ÔÚ›˙ÔÓÙ˜ ÙÔ˘ ÂÈÛÙËÌÔÓÈÎÔ‡ ÎÂÎÙË̤ÓÔ˘ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÂÈÛÙ‹Ì˘ ÛÙË ¯ÒÚ· Ì·˜ Î·È ‰ÈÂıÓÒ˜. Œ¯Ô˘ÌÂ, ÁÈ· Ù· ÂfiÌÂÓ· ‰‡Ô ¯ÚfiÓÈ·, ÙÔÔıÂÙ‹ÛÂÈ Ôχ „ËÏ¿ ÙÔÓ ‹¯˘ ÙˆÓ ˘Ô¯ÚÂÒÛÂÒÓ Ì·˜. ªÂ ÙË Û˘ÓÂÚÁ·Û›· Î·È ÙËÓ ·Ú·ÁˆÁÈÎfiÙËÙ· Ù˘ ÂÈÛÙËÌÔÓÈ΋˜ Ì·˜ ÎÔÈÓfiÙËÙ·˜ Â›Ó·È Û¯Â‰fiÓ ‚¤‚·ÈÔ fiÙÈ ı· ÂÎÏËÚÒÛÔ˘Ì ÙȘ ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ Ù˘ ∂ıÓÈ΋˜ µÈ‚ÏÈÔı‹Î˘ π·ÙÚÈ΋˜ ÙˆÓ ∏¶∞ (National Library of Medicine) ÁÈ· ÙËÓ ¤ÓÙ·ÍË Ù˘ «¶·È‰È·ÙÚÈ΋˜» ÛÙÔ Index Medicus, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÂÏÏËÓÈÎÔ‡ ·È‰È·ÙÚÈÎÔ‡ ‰˘Ó·ÌÈÎÔ‡ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·. Œ¯Ô˘Ì ‹‰Ë ÙÚÔÔÔÈ‹ÛÂÈ ÙȘ O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜, Î·È Ï›·Ó Û˘ÓÙfï˜ ı· ÂȯÂÈÚ‹ÛÔ˘Ì ӷ ‚ÂÏÙÈÒÛÔ˘Ì ÙÔ ÂÚȯfiÌÂÓÔ Î·ıÒ˜ Î·È ÙÔ ÂÍÒÊ˘ÏÏÔ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ì·˜. ø˜ ·È‰›·ÙÚÔÈ-ÂÈÛÙ‹ÌÔÓ˜ ›ÛÙÂ, Û ÙÂÏÂ˘Ù·›· ·Ó¿Ï˘ÛË, Ë Î·Ï‡ÙÂÚË ˘Í›‰· ÁÈ· ÙÔÓ ÚÔÛ·Ó·ÙÔÏÈÛÌfi ÙˆÓ ÂÈÏÔÁÒÓ Î·È ‰Ú¿ÛÂÒÓ Ì·˜. OÈ ÚÔÙ¿ÛÂȘ Î·È ·Ú·ÙËÚ‹ÛÂȘ Û·˜ Û¯ÂÙÈο Ì ÙËÓ ÔÈfiÙËÙ· Î·È ÙËÓ ·ÓÙ·ÁˆÓÈÛÙÈÎfiÙËÙ· Ù˘ «¶·È‰È·ÙÚÈ΋˜» ı· Â›Ó·È ¿ÓÙÔÙ ¢ÚfiÛ‰ÂÎÙ˜.
ªÂ ÊÈÏÈÎÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜ Î·È ıÂṲ́˜ ¢¯¤˜ ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹
446
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30-05-03
14:03
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¶∞π¢π∞∆ƒπ∫∏ 2000;63:348
¶PO™EXH ™YNE¢PIA 4-6 OÎÙˆ‚Ú›Ô˘
26th Annual Congress of the Union of Middle-Eastern & Mediterranean Paediatric Societies Information: Dr Ivan Vidmar Division for Paediatric Surgery & Intensive Care 1525 Ljubljana – Slovenia Fax: 0038661 - 1301714 OÚÁ¿ÓˆÛË – °Ú·ÌÌ·Ù›· C&C International ∞.∂. ∆ËÏ.: 01 68 89 100 Fax: 01 68 44 777 E-mail: congress@cnc.gr
Portoroz, Slovenia
7-12 OÎÙˆ‚Ú›Ô˘
4th European Congress on Epileptology Information: PTS Congressi Sri Via Tevere 20, 00198 Rome, Italy Tel.: +39 06 85 83 25 76 Fax: + 39 06 85 35 60 60 E-mail: eceflo@tin.it
Firenze, Italy
12-14 OÎÙˆ‚Ú›Ô˘
1Ô ¶·ÓËÂÈÚˆÙÈÎfi π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: Œ„ÈÏÔÓ – ∆Ô˘ÚÈÛÙÈÎfi Î·È ™˘Ó‰ÚÈ·Îfi ¢›ÎÙ˘Ô ¶··‰È·Ì·ÓÙÔÔ‡ÏÔ˘ 4, ∞ı‹Ó· ∆ËÏ.: 01 72 54 360 Fax: 01 72 54 363 E-mail: epsilonb@hol.gr
πˆ¿ÓÓÈÓ·
12-14 OÎÙˆ‚Ú›Ô˘
NHS 2000, International Conference on Newborn Hearing Screening Diagnosis and Intervention ¶ÏËÚÔÊÔڛ˜: Dr Ferdinando Grandori Center of Biomedical Engineering, Polytechnic of Milan, Piazza Leonardo da Vinci 32, 1-20133 Milan, Italy Fax: +39 02 23 99 33 60 E-mail: NHS2000@biomed.polimi.it
Milan, Italy
29 OÎÙˆ‚Ú›Ô˘ – 3 ¡ÔÂÌ‚Ú›Ô˘
The Promised Childhood Jerusalem 2000 Congress ¶ÏËÚÔÊÔڛ˜: The Promised Childhood Jerusalem 2000 Congress, P.O. Box 50006, Tel Aviv 61500, Israel Tel.: +972 3 514 00 00 Fax: +972 3 517 56 74 +972 3 514 00 77
Jerusalem
23-24 ¡ÔÂÌ‚Ú›Ô˘
2nd European Conference on Paediatric Asthma ¶ÏËÚÔÊÔڛ˜: Conference Secretariat, Castle House Medical Conferences, 3 Linden Close, Tunbridge Wells, Kent, TN 4 8 HH, UK Tel.: +44 (0) 18 92 539606 Fax: + 44 (0) 1892 517773 E-mail: asthma@castlehouse.co.uk
London
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™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˘ÁΤÓÚˆÛË 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
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™˘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 ) 9 giga- (10 ) 6 mega-(10 ) 3 kilo- (10 ) 2 hecto(10 ) 1 deca (10 ) -1 deci (10 ) -2 centi- (10 ) -3 milli(10 ) -5 micro (10 ) -9 nano (10 ) -12 pico (10 ) -15 femto (10 ) -18 atto (10 )
Combining prefixes T G M k h da d c m Ì n p f a
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