Παιδιατρική | Τόμος 64 • Τεύχος 3 • Μάιος - Ιούνιος 2001

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M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3

∞ƒ£ƒO ™À¡∆∞•∏™

ETO™ 2001

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TOMO™ 64

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π. §ÂˆÓ›‰·˜

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ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË

EDITORIAL 197

J.C. Leonidas

ANA™KO¶H™H

∏ ÂͤÏÈÍË Ù˘ ıÂÚ·›·˜ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰È· ̤ÛÔ˘ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ CCG Î·È BFM

REVIEW ARTICLE 202

∞. ∫·ÙÙ¿Ì˘, ∂. °Ô˘Û¤Ù˘

1Ô ¶∞¡∂§§∏¡πO ™À¡∂¢ƒπO À¶O∂π¢π∫O∆∏∆ø¡ ∆∏™ ¶∞π¢π∞∆ƒπ∫∏™ ÿÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·. ◊ Ì‹ˆ˜ Î·È Ù· ‰‡Ô;

CONTINUING MEDICAL EDUCATION 207 208

211 215

∞naphylaxis: clinical manifestations and treatment T. Papastavrou - Mavroudi

219

ª. ∆Ú›Áη

ÃÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (Staphylococcus aureus). O ÚfiÏÔ˜ ÙÔ˘ ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·

What is, what is not asthma?

K. N. Priftis

£. ¶··ÛÙ·‡ÚÔ˘ - ª·˘ÚÔ˘‰‹

∞ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË

1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES Jaundice in the breast fed infant C. Costalos

∫. ¡. ¶Ú›ÊÙ˘

∞Ó·Ê˘Ï·Í›·: ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ·ÓÙÈÌÂÙÒÈÛË

Progress in the therapy of childhood acute lymphoblastic leukemia through the CCG and BFM protocols A. Kattamis, E. Goussetis

X. ∫ÒÛÙ·ÏÔ˜

∆È Â›Ó·È, ÙÈ ‰ÂÓ Â›Ó·È ¿ÛıÌ·;

Magnetic resonance imaging in prenatal diagnosis

∞llergy to cow’s milk: diagnosis and management M. Triga

223

M. Valari

¶AI¢IATPIKH

●

ª. µ·Ï¿ÚË

The role of Staphylococcus aureus in atopic dermatitis

ªË¯·ÓÈÛÌÔ› ·˘ÙÔ·ÓÔÛ›·˜

229

ª. °. ∫·Ó¿ÚÈÔ˘

™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·

M. G. Kanariou 233

Ÿ. µÔ˘ÁÈԇη

¢È·ÈÙËÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù·

237

Dietary approach in autoimmune rheumatic diseases A. Siamopoulou-Mavridou

241

∫. ¢. ∫ÔÏÏÈfi˜

NÂfiÙÂÚ˜ ·fi„ÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·

Spondyloarthropathies in childhood O. Vougiouka

A. ™È·ÌÔÔ‡ÏÔ˘-M·˘Ú›‰Ô˘

¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘: ÂÎÙ›ÌËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË

Autoimmune mechanisms

Prenatal diagnosis of hydronephrosis: fetal assessment and postnatal follow-up K. D. Kollios

247

New aspects in the treatment of nephrotic syndrome in childhood

∂. ¡. °ÂˆÚÁ¿ÎË - ∞ÁÁÂÏ¿ÎË

H. N. Georgaki - Angelaki

∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·

Continuation of table of contents inside title page

May - June 2001 . Volume 64 . No 3

MAY- JUNE '01 TELIKO

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18:55

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ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3

™˘Ó¤¯ÂÈ· ÂÚȯÔÌ¤ÓˆÓ I‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÛÙ· ·È‰È¿

Continuation of table of contents 255

∫. π. ™ÙÂÊ·Ó›‰Ë˜

AÙ˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·

C. J. Stefanidis 261

∫. ∆ÛÔ˘Ì¿Î·˜

∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡

268 272

276

280

285

290

293

300

304 308

The pediatrician and the patient with cystic fibrosis S. Doudounakis

312

Hypospadias D. Keramidas

¢. ∫ÂÚ·Ì›‰·˜

∫ÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ

Dental injuries L. Papagiannouli - Laskaridi

™. ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘

ÀÔÛ·‰›·˜

Breastfeeding in Greece. What has been done - Targets for the future T. Zachou

§. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë

O ·È‰›·ÙÚÔ˜ Î·È ÙÔ ·È‰› Ì ÙËÓ ÈÓÔ΢ÛÙÈ΋

Cholestasis of infancy: diagnosis and treatment K. Spiroglou

£. ∑¿¯Ô˘

∆Ú·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ‰ÔÓÙÈÒÓ

Recent developments in pediatric gastroenterology S. Nousia - Arvanitakis

K. ™‡ÚÔÁÏÔ˘

ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÛÙËÓ ∂ÏÏ¿‰·. ∆È ¤¯ÂÈ Á›ÓÂÈ - ªÂÏÏÔÓÙÈΤ˜ ÚˆÙÔ‚Ô˘Ï›Â˜

Modern treatment of thalassaemia. Principles and effectiveness V. A. Ladis

™. ¡Ô‡ÛÈ· - ∞Ú‚·ÓÈÙ¿ÎË

ÃÔÏfiÛÙ·ÛË ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË

Training in Pediatric Hematology - Oncology M. Kalmanti

µ. ∞. §·‰‹˜

∂ÍÂÏ›ÍÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ Á·ÛÙÚÂÓÙÂÚÔÏÔÁ›·

Haematopoietic stem cell transplantation for the treatment of haematological malignant, and genetic diseases S. Graphakos

ª. ∫·ÏÌ·ÓÙ‹

™‡Á¯ÚÔÓË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. µ·ÛÈΤ˜ ·Ú¯¤˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·

Infections in immunosuppressed patients: from the 20th to the 21st century E. Roilides

™. °Ú·Ê¿ÎÔ˜

ªÂÙÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·

Management of the child with multiple trauma K. Papazoglou

∂. ƒÔËÏ›‰Ë˜

∞ÓÙÈÌÂÙÒÈÛË ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ

Accidents in childhood and adolescence C. Tsoumakas

∫. ¶·¿˙ÔÁÏÔ˘

§ÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜: ·fi ÙÔÓ 20Ô ÛÙÔÓ 21Ô ·ÈÒÓ·

Idiopathic hypercalciuria

315

Criteria for referral of children to the ophthalmologist

∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË

A. Koidou-Tsiligianni

™˘Ó¯›˙ÔÓÙ·È

Continued

ªay - June 2001 . Volume 64 . No 3

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ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 3

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

Continuation of table of contents

¶∞ƒOƒ∞ª∞

318

ERRATUM

¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ µÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· Î·È Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH Û ·È‰È¿ Ì Â›ÌÔÓË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi

201

LITERATURE ABSTRACTS Bronchoalveolar lavage and esophageal p∏ monitoring data in children with “difficult to treat” respiratory symptoms

Sacco O, Fregonese B, Silvestri M, Sabatini F, Mattioli G, Rossi GA ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.π. ∫·ÊÚ›ÙÛ·

™¯¤ÛË ÌÂٷ͇ ·ÏÌÈ΋˜ Ô͢ÌÂÙÚ›·˜ Î·È ÎÏÈÓÈÎÔ‡ score Û ·È‰È¿ Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 24 ÌËÓÒÓ

Sacco O, Fregonese B, Silvestri M, Sabatini F, Mattioli G, Rossi GA Greek translation: G.I. Kafritsa 214

Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. OÈÎÔÓfiÌÔ˘

O ÚfiÏÔ˜ Ù˘ ÙÚÔÊÈ΋˜ ‰˘Û·ÓÂÍ›·˜ Û ‚Ú¤ÊË Ì Â›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ ÔÈÛÔÊ·Á›Ùȉ·˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË

Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G Greek translation: G. Oikonomou 228

Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.π. ∫·ÊÚ›ÙÛ·

ŸÙ·Ó Ô “Û˘ÚÈÁÌfi˜” ‰ÂÓ Â›Ó·È Û˘ÚÈÁÌfi˜: ·ÎÔ˘ÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ ÛÙ· ‚Ú¤ÊË

254

260

Effect of long-term treatment with inhaled budesonide on adult height in children with asthma Agertoft L, Pedersen S Greek translation: K. Hatzis

∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∫. ÷Ù˙‹˜ 284

de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al. ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ™. ºˆÙfiÔ˘ÏÔ˜

¢ÂÓ ˘¿Ú¯ÂÈ ·ÓÙÈÎÂÈÌÂÓÈο ÌÂÙÚ‹ÛÈÌÔ fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Ì ·ÂÚÔı¿Ï·ÌÔ Û ‚Ú¤ÊË Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·

When a “wheeze” is not a wheeze: acoustic analysis of breath sounds in infants Elphick HE, Ritson S, Rogers H, Everard ML Greek translation: M. Anthrakopoulos

Agertoft L, Pedersen S

∂ÈÏÔÁ¤˜ ıÂÚ·›·˜ ÁÈ· ÂÍ·ÈÚÂÙÈο ÚfiˆÚ· ÓÂÔÁÓ¿: Ì›· ‰ÈÂıÓ‹˜ ÚÔÔÙÈ΋

Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al Greek translation: G.I. Kafritsa

Elphick HE, Ritson S, Rogers H, Everard ML ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

∏ Â›‰Ú·ÛË Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË Û ·È‰È¿ Ì ¿ÛıÌ·

Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age

Treatment choices for extremely preterm infants: an international perspective de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al.

Greek translation: S. Fotopoulos

311

Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

No objective benefit from steroids inhaled via a spacer in infants recovering from bronchiolitis Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H Greek translation: M. Anthrakopoulos

¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·

xvii

Scheduled Medical Meetings

™˘ÓÙÔÌÔÁڷʛ˜

xxi

Abbreviations

ªay - June 2001 . Volume 64 . No 3

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·7

M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2001

. ∆fiÌÔ˜

64

. ∆‡¯Ô˜

3

¢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·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28

Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28

TËÏ.: (01) 7771 140 / 7771 663, Fax: 7758 354

Tel.: (01) 7771 140 / 7771 663, Fax: 7758 354

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Scientific President Editor Members

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ π. ∫·Ú·‚Ú¿ÓÔ˘

Manuscript Editing

∂È̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹

English Editing Z. Papadopoulou-Couloumbis

∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ.: (01) 7771 140, Fax: 7758 354

Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel.: (01) 7771 140, Fax: 7758 354

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18:55

™ÂÏ›‰·9

O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi "¶∞π¢π∞∆ƒπ∫◊" Â›Ó·È Ë Â›ÛËÌË ÂÈÛÙËÌÔÓÈ΋ ¤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 ÂÈÌfiÚʈÛË ÙˆÓ EÏÏ‹ÓˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: ¿ÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜), ·Ó·ÛÎÔ‹ÛÂȘ, Â›Î·ÈÚ· ı¤Ì·Ù·, ÂÍÂÏ›ÍÂȘ ÛÙËÓ π·ÙÚÈ΋ ∂ÈÛÙ‹ÌË, ÚˆÙfiÙ˘˜ 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΋˜ ÂÎ·›‰Â˘Û˘ Î·È ˘Á›·˜, ‚Ú·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜, ÂÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ, ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ, ‚È‚ÏÈÔÎÚÈۛ˜, ÂÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË, ÂÚÈÏ‹„ÂȘ Ù˘ ÂÏÏËÓÈ΋˜ Î·È Í¤Ó˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ·Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘ÌÔÛ›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 EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi 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 ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. µ. ÀÔ‚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 ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· 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∫◊". ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹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 ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ "¶∞π¢π∞∆ƒπ∫◊" Î·È Ë ÔÏÈ΋ ‹ ÌÂ-

ÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤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˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡.

EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘ԉ›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word .doc ‹ MacWrite Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Exel ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ Â·Ó˘Ô‚ÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 4 ÌËÓÒÓ Û˘ÓÂ¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ÂÙ¿ (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 ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·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˘ÌÂÚÈÏ·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 ‰ÈÏfi ‰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 ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.

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MAY- JUNE '01 TELIKO

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H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ· ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 15-25, ÁÈ· ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 12-15 ÛÂÏ›‰Â˜, ÁÈ· Ù· Â›Î·ÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 3-5 ‰·ÎÙ˘ÏÔÁÚ·ÊË̤Ó˜ ÛÂÏ›‰Â˜, ÂÓÒ ÁÈ· ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000 ϤÍÂȘ Î·È ÁÈ· ÙȘ ÂÈÛÙÔϤ˜ 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 ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ 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 ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›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˘ÌÂÚ¿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˜ ÂÚÈÙÒÛÂȘ ¤¯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· ¯ÚËÛÈÌÔÔÈËıÔ‡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·ÔÌ¤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ªÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤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˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ.

OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆ-

vi

ÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹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·ÔÌ¤˜.

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 ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ Ô ÔÔ›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·ÔÌ¤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·ÔÌ¤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· Â›Î·ÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ.

H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ 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·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ 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·ÎÔÔ‡ÏÔ˘ Ã. ∂Ì‚fiÏÈ·, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ: Â›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1996;59:272-279.

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™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19.

¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡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 ÂÂÍ‹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 ÔÔ›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.

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Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356.

II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500.

¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘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 ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· - fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›· - ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ηٿÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ΛÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ¢¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) - ‚È‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó - ÂÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· Â¿Óˆ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó - Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.

¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¡ÙÔ˘ÓÙÔ˘Ï¿Î˘ π. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂÚ·›· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ÂÍ·ÚıÚ‹Ì·ÙÔ˜ ÙÔ˘ ÈÛ¯›Ô˘ Û ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979.

Kaplan SJ. Post hospital home health care: the

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EDITORIAL

∞ƒ£ƒO ™À¡∆∞•∏™

Magnetic resonance imaging in prenatal diagnosis J.C. Leonidas

ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË π. §ÂˆÓ›‰·˜

Abstract: Recent technological advances, and in particular the development of ultrafast pulse sequences in magnetic resonance imaging (MRI) permit good quality images of the fetus, with important implications for post-natal management.

There is no evidence of any adverse effects on the fetus, although currently the procedure is being withheld during the first trimester. The information obtained supplements prenatal ultrasound (US), which remains the principal method of prenatal evaluation. In many instances however US may be inconclusive or unable to answer specific questions and MRI can become a useful alternative. Experience with MRI is yet limited but its ability to offer good, easily understood anatomic information and precise volumetric assessment without exposure to radiation is an important asset of this newly introduced application of MRI.

¶ÂÚ›ÏË„Ë: ∆· Û‡Á¯ÚÔÓ· Ù¯ÓÔÏÔÁÈο ÂÈÙ‡ÁÌ·Ù· ÛÙÔÓ ÙÔ̤· Ù˘ ·ÂÈÎfiÓÈÛ˘ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (ª∆), Î·È È‰È·›ÙÂÚ· ÔÈ Ù·¯Â›Â˜ ª∆ ·ÎÔÏÔ˘ı›Â˜, ·Ú¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÈηÓÔÔÈËÙÈ΋˜ ·ÂÈÎfiÓÈÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∆· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ÂͤٷÛ˘ ª∆ ÌÔÚÔ‡Ó Ó· ·›ÍÔ˘Ó Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ÌÂÙ¤ÂÈÙ· ÎÏÈÓÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÁÓˆÛÙ¤˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ª∆ ÛÙÔ ¤Ì‚Ú˘Ô, ÂÓÙÔ‡ÙÔȘ, Ë ÂͤٷÛË ·˘Ù‹ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Î·Ù¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·Ú·Ì¤ÓÂÈ Ë ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô˜ ÂÈÏÔÁ‹˜ ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. ∂ÓÙÔ‡ÙÔȘ, Ë ª∆ ÌÔÚ› Ó· ‰ÒÛÂÈ ¯Ú‹ÛÈ̘ Û˘ÌÏËڈ̷ÙÈΤ˜ ÏËÚÔÊÔڛ˜ Î·È ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÂÓ·ÏÏ·ÎÙÈ΋ ̤ıÔ‰Ô Û ÂÚÈÙÒÛÂȘ fiÔ˘ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ‰ÂÓ ÌÔÚ› Ó· ‰ÒÛÂÈ Û·Ê‹ ·¿ÓÙËÛË Û ÔÚÈṲ̂ӷ ÂÚˆÙ‹Ì·Ù·. ∏ ÂÌÂÈÚ›· ÛÙËÓ ª∆ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙȘ ̤Ú˜ Ì·˜ Â›Ó·È ·ÎfiÌ· ÂÚÈÔÚÈṲ̂ÓË. ∂ÓÙÔ‡ÙÔȘ, Â›Ó·È Ì›· ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË Ì¤ıÔ‰Ô˜ ηıÒ˜ ·Ú¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÂÈÎfiÓˆÓ Î·Ï‹˜ ÔÈfiÙËÙ·˜ ÛÙȘ Ôԛ˜ ÌÔÚ› Ó· ÌÂÏÂÙËı› Ë ·Ó·ÙÔÌ›· Î·È Ó· Á›ÓÔ˘Ó ÌÂÙÚ‹ÛÂȘ ¯ˆÚ›˜ ÙÔ ¤Ì‚Ú˘Ô Ó· ÂÎÙ›ıÂÙ·È Û ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·.

Key words: prenatal magnetic imaging, prenatal diagnosis.

resonance

§¤ÍÂȘ ÎÏÂȉȿ: ÚÔÁÂÓÓËÙÈ΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË.

Ultrasound (US) is a powerful diagnostic tool in the evaluation of pregnancy. It can detect congenital defects with precision and it is extremely important for postnatal care and parental counseling. There are, however, limitations to the

information provided by US, including inherent limits to tissue transmission of sound, such as oligohydranios, body habitus, fetal position etc.

Even under the best circumstances the sensitivity and specificity of US are less than perfect, a fact

Division of Pediatric Radiology Schneider Children’s Hospital, New Hyde Park, NY Albert Einstein College of Medicine Bronx, New York, USA

∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÎÙÈÓÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “Schneider”, New Hyde Park, ¡¤· ÀfiÚÎË π·ÙÚÈ΋ ™¯ÔÏ‹ Albert Einstein, Bronx, ¡¤· ÀfiÚÎË, ∏.¶.∞.

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that may at times lead to serious consequences, such as termination of pregnancy of a normal fetus (1,2).

Magnetic Resonance Imaging (MRI) shares, along with US, the advantage of not delivering ionizing radiation, and it can serve as an additional mode of obstetrical and fetal evaluation. Early concerns regarding safety of the fetus from a strong static magnetic field, time-varying magnetic field, and the heat generated by the high frequency electromagnetic waves failed to be substantiated (3-6). Past MRI technology precluded image acquisition fast enough to eliminate the effects of motion. Recent developments of ultra fast MRI techniques, however, have virtually eliminated the problem of fetal motion and maternal breathing, and alleviated concerns of fetal overheating resulting from long application of electromagnetic energy. Although no harmful effects on the fetus attributable to MRI have been reported, scanning during the active organogenesis of the first trimester has been avoided as an extra precaution (6-10).

The purpose of the present short communication is to acquaint professionals in perinatal and neonatal care in the rapidly expanding ultra-fast MRI applications in a spectrum of maternal and fetal abnormalities (3,6-10).

Experience at our center Since the beginning of 1999 we performed close to 50 MRI examinations for evaluation of suspected fetal abnormalities, in which the information provided by US was either incomplete or raised serious concerns regarding the need for prenatal or immediate neonatal intervention. In each case the expected benefit from the MRI was thought to be much higher that the possible risk, as the information was deemed critical for management, and in each instance a complete informed consent was obtained from both parents.

All MR images were obtained on a 1.5 Tesla EchoSpeed system (GE Medical Systems, Milwaukee, WI) using a torso phased array surface coil with four coil elements. This system is equipped with ultra fast gradient system, which has a slew rate of 120 T/m/sec for maximum of 23 mT/m gradient amplitude. Due to short rise and fall time of these gradients one can enhance the existing fast gradient echo sequences to obtain ultra fast sequences appropriate for imaging under breath holding.

T2 pulse sequences were obtained with half fourier sampling, as simple shot fast spin echo

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sequences (SSFSE). As with any T2 weighted pulse sequence fluid has high signal intensity and appears white on the images. Other tissues present with an intermediate signal intensity producing a range of gray densities, with bone occupying the lowest level of signal intensity (black).

In the majority of the cases MRI was performed to exclude additional brain malformations suspected on the basis of isolated mild venticulomegaly, which had been detected on prenatal sonograms usually performed during the second trimester (Figure 1). In 2 cases MRI was performed for evaluation of the placenta (suspected placenta accreta). In both instances it identified invasion of the myometrium, but not beyond the serosa, a valuable information for the obstetrician.

In 3 cases US defined a left congenital diaphragmatic hernia (CDH) and MRI was requested for additional information. In two instances the position of viscera herniated through the defect was far more obvious with MRI, including the position of the liver, information which has been recently shown to be of significant prognostic value (12) (Figure 2). In the third findings are less clear, as the MRI was performed at an earlier gestational age (23 weeks).

Nevertheless there is evidence a lesser degree of pulmonary hypoplasia and a better prognosis.

This case is still unconfirmed since the fetus has not yet been delivered.

Other findings included agenesis of the corpus callosum (Figure 3a, 3b), aqueductal stenosis and a Dandy Walker variant.

The little existing experience in this area makes prognostic conclusions difficult and offers at the same time unique opportunities for expanding information until now impossible. Using computer assisted delineation of areas of different signal intensity we can accurately measure lung volume.

In the two cases of CDH and complete data the combined lung volume was less than 20% of expected volume for gestational age. Preliminary standards of lung volumes appropriate for gestational age, based on limited number of fetuses have been recently published (13). Both our infants could not be resuscitated immediately postpartum (Figure 4a,4b). Information is currently being gathered regarding the critical lung volume necessary for the immediate postpartum survival.

One fetus with prenatally detected bilateral hydrothorax and trisomy 21 survived after

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Figure 1. Parasagittal view of the fetal brain at 30 weeks of gestation. There is appropriate for gestational age formation of cortical sulci. The atrium of the lateral ventricle is wide.

Additional images confirmed isolated colpocephaly.

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Figure 3a. Callosal agenesis: In a coronal view there is the typical separation of the anterior horns of the lateral ventricles (short arrows) and continuity of the interhemispheric fissure (curved arrow) with the elevated third ventricle.

having been done for reasons unrelated to the head) and compare them with those with the US standard of ventricular size, i.e. ventricular dimension at the atria.

Figure 2. Coronal view of fetus with large left CDH. Practically the entire liver (L) is intrathoracic.

immediate postpartum thoracentesis, but prenatal lung volume was 33% of that expected. This degree of accurate volume determination is not currently possible with US. There were two cases of lymhangiomas, presenting as intraperitoneal cysts.

We currently measure the volume of the lateral ventricles of fetuses with normal heads (the MRI

Overall assessment The earliest application of MRI in pregnancy appeared in 1983 (14). Subsequently, taking advantage of the development of fast imaging techniques, several centers reported further experience with the application of MRI in Obstetrics (6-11).

An important consideration of using MRI on the fetus is that of any possible harmful effect.

Although this issue has not been settled entirely, studies have failed to show any injury to the fetus during the second and third trimester of pregnancy (3-6). It is universally accepted nevertheless that MRI examinations should be performed only when the expected benefits justify the potential small risk, and only after detailed review of all aspects with the parents has convinced everyone that the study is appropriate.

The value of prenatal MRI is very promising for the fetuses with restrictive thoracic abnormalities.

As noted, MRI can define the volume of the fetal lungs at various gestational ages, establish normal values, and with accumulated experience will undoubtedly be of prognostic value and affect management.

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Figure 4b. Left CDH. Axial image at the level of the thorax showing stomach (S) and liver (diamond) adjacent to the heart (arrow) and the small lung with high signal (bright) posteriorly. Anteroposterior and left/right orientation varies because of fetal position.

Figure 3b. Callosal agenesis: Sagittal SSFSE image of the fetal head shows absence of the corpus callosum. At this midline section the hemispheric sulci converge towards the thalami.

essentially bypassing the obstacles preventing US from providing full information. Cost considerations, and to a lesser extent safety, dictate that US remain the main imaging modality during pregnancy.

References

Figure 4a. Left CDH. A coronal SSFSE image showing bowel filling the left hemithorax (arrow). The heart (H) has been displaced to the right, and there is a small left lung (L) preserved. K=Kidneys.

The rapid technological advances in imaging, especially the development of high strength MRI scanners and of fast acquisition pulse sequences allow us to obtain high quality images of the fetus, which supplement US findings in certain areas,

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14. Smith SW, Adam AH, Philips WDP. NMR imaging in pregnancy. [letter] Lancet 1983;1:61-62

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 14-03-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: John C. Leonidas, M.D. Division of Pediatric Radiology Schneider Children’s Hospital 270-05 76th Ave New Hyde Park, NY, 11042, USA e-mail: leonidas@lij.edu

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· µÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· Î·È Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ pH Û ·È‰È¿ Ì Â›ÌÔÓË Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi1 ∂ÈÛ·ÁˆÁ‹: H Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ÌÔÚ› Ó· ÂΉËψı› Ì ¯ÚfiÓÈ· ‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ŒÎÏ˘ÛË ‚ÚÔÁ¯fiÛ·ÛÌÔ˘ ̤ۈ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ‹ Î·È ÂÈÛÚfiÊËÛË Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÚÈÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜. ∏ ·ÚÔ˘Û›· ÏÈˆ‰ÒÓ Ì·ÎÚÔÊ¿ÁˆÓ ÛÙȘ ΢„ÂÏ›‰Â˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û·Ó ¤Ó‰ÂÈÍË ÂÈÛÚfiÊËÛ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË Ù˘ 24ˆÚ˘ ¯·ÌÂÙÚ›·˜ Ì ÙËÓ ·ÚÔ˘Û›· ÏÈˆ‰ÒÓ Ì·ÎÚÔÊ¿ÁˆÓ ÛÙȘ ΢„ÂÏ›‰Â˜ Û ·È‰È¿ Ì ÂÈ̤ÓÔ˘Û· Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: 20 ·È‰È¿ Ì ÂÈ̤ÓÔ˘Û·, ·Ú¿ ÙËÓ ·ÁˆÁ‹, Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÈÛÙÔÚÈÎfi ‡ÔÙÔ ÁÈ· °O¶ ˘Ô‚Ï‹ıËÎ·Ó Û 24ˆÚË ¯·ÌÂÙÚ›· Î·È Û ‚ÚÔÁ¯ÔÛÎfiËÛË Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ ¤ÎÏ˘ÛË. ∏ ÔÛfiÙËÙ· Ï›Ô˘˜ ·Ó¿ Ì·ÎÚÔÊ¿ÁÔ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ËÌÈÔÛÔÙÈ΋ ̤ıÔ‰Ô (Nile - Red ¯ÚÒÛË) Î·È ˘ÔÏÔÁ›ÛÙËΠ‰Â›ÎÙ˘ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ. ∞ÔÙÂϤÛÌ·Ù·: ŒÓÙÂη ·È‰È¿ ›¯·Ó ıÂÙÈ΋ ÁÈ· °O¶ ¯·ÌÂÙÚ›·, ÂÓÒ Û 9 Ë ¯·ÌÂÙÚ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. T· ·È‰È¿ Ì ıÂÙÈ΋ ¯·ÌÂÙÚ›· ›¯·Ó ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ, ηıÒ˜ Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·, Û˘ÁÎÚÈÙÈο Ì ٷ ·È‰È¿ Ì ·ÚÓËÙÈ΋ ¯·ÌÂÙÚ›·. ¢ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË

ÙÔ˘ ‚·ıÌÔ‡ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙËÓ ¯·ÌÂÙÚ›· Ì ÙÔ ‰Â›ÎÙË ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙÔ ÔÛÔÛÙfi Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·. ™˘ÌÂÚ¿ÛÌ·Ù·: ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÂȂ‚·ÈˆÌ¤ÓË Ì ¯·ÌÂÙÚ›· °O¶, ·ÚÔ˘ÛÈ¿˙ÂÈ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙÔ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·. ∞˘Ùfi ˘Ô‰ËÏÒÓÂÈ ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È ÂÈÛÚfiÊËÛË Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ∂ÓÙÔ‡ÙÔȘ, Ô ‚·ıÌfi˜ Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘ fiˆ˜ ÔÚ›˙ÂÙ·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯·ÌÂÙÚ›·˜, ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÓÙÔÙ Ì ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜.

1Sacco O, Fregonese B, Silvestri M, Sabatini F Mattioli G, Rossi GA Bronchoalveolar lavage and esophageal p∏ monitoring data in children with "difficult to treat" respiratory symptoms Pediatr Pulmonol 2000;30:313-319

°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜ - °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ

201

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¶·È‰È·ÙÚÈ΋ 2001;64:202-206

∞¡∞™∫O¶∏™∏

Paediatriki 2001;64:202-206

REVIEW ARTICLE

∏ ÂͤÏÈÍË Ù˘ ıÂÚ·›·˜ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰È· ̤ÛÔ˘ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ CCG Î·È BFM ∞. ∫·ÙÙ¿Ì˘1, ∂. °Ô˘Û¤Ù˘2

Progress in the therapy of childhood acute lymphoblastic leukemia through the CCG and BFM protocols A. Kattamis1, E. Goussetis2

¶ÂÚ›ÏË„Ë: ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ë ıÂÚ·›· Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÂÍÂÏ›¯ıËΠ·fi ÙË ÌÔÓÔıÂÚ·›· Û ÔÏ˘Ê·ÛÈο ÚˆÙfiÎÔÏÏ· Û˘Ó‰˘·ÛÙÈ΋˜ ¯ËÌÂÈÔıÂÚ·›·˜. ∆· ÂÚÈÛÛfiÙÂÚ· Û‡Á¯ÚÔÓ· ÚˆÙfiÎÔÏÏ· ‰È·ÎÚ›ÓÔ˘Ó ÙË ¯ËÌÂÈÔıÂÚ·›· Û ʿÛÂȘ ÂÊfi‰Ô˘, ÚÔʇϷ͢ ∫¡™, Û˘ÓÙ‹ÚËÛ˘ Î·È Â·ÓÂÊfi‰Ô˘. OÈ ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È Û ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ ·Ó¿ÏÔÁ· Ì ηϿ ÙÂÎÌËÚȈ̤ӷ ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·. ªÂ ÛÙ·‰È·Î¤˜ ‚ÂÏÙÈÒÛÂȘ Û ‰È·‰Ô¯Èο ÚˆÙfiÎÔÏÏ·, Ë ·ÌÂÚÈηÓÈ΋ ÔÌ¿‰· ÌÂϤÙ˘ CCG Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ÁÂÚÌ·ÓÈ΋ ÔÌ¿‰· BFM ¤¯Ô˘Ó ÂÈÙ‡¯ÂÈ ›·ÛË Û ÔÛÔÛÙfi >80% ÙˆÓ ·ÛıÂÓÒÓ.

Abstract: The treatment of childhood acute lymphoblastic leukemia has progressed enormously in the last decades and has evolved from monotherapy to complicated protocols of combined chemotherapy. Most of the current protocols identify therapy in various phases that include induction, CNS-directed consolidation, maintenance and late intensification phase.

Patients are classified into risk groups according to well-established prognostic criteria. With gradual improvements in sequential protocols the American study group CCG and the German group BFM have succeeded in curing >80% of the patients.

§¤ÍÂȘ ÎÏÂȉȿ: ·È‰È΋ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÚˆÙfiÎÔÏÏ· ıÂÚ·›·˜ Ù˘ O§§.

Key words: acute lymphoblastic leukemia, treatment protocols of ALL.

™˘ÓÙÔÌÔÁڷʛ˜

Â›Ù¢ÁÌ· Ù˘ ·È‰È·ÙÚÈ΋˜ ÔÁÎÔÏÔÁ›·˜. ™ÙË Û˘Ó¤¯ÂÈ·, ı· ·Ó·ÊÂÚıԇ̠ÛÙ· ‚‹Ì·Ù· ·˘Ù¿ ΢ڛˆ˜ ̤۷ ·fi ÙË Û˘ÏÏÔÁÈÛÙÈ΋ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ÙˆÓ ÔÌ¿‰ˆÓ Children’s Cancer Group (CCG) ÙˆÓ ∏.¶.∞. Î·È Berlin-Frankfurt-Muenster (BFM) Ù˘ °ÂÚÌ·Ó›·˜.

√§§ CCG BFM ∫¡™ ∂FS π∆ªtx

ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Children’s Cancer Group Berlin-Frankfurt-Muenster ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿Ó (event-free survival) ÂÓ‰ÔÚ·¯È·›Â˜ ÂÁ¯‡ÛÂȘ ÌÂıÔÙÚÂÍ¿Ù˘

∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ηÎÔ‹ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ÂÙ‹ÛÈ· Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ·Ó¤Ú¯ÂÙ·È ÂÚ› ÙȘ 4 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 15 ÂÙÒÓ. ∏ ıÂÚ·›· Ù˘ O§§ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛËÌ›ˆÛ ÛËÌ·ÓÙÈο ‚‹Ì·Ù· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È ıˆÚÂ›Ù·È ˆ˜ ÙÔ ‚·ÛÈÎfiÙÂÚÔ

1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ √ÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

202

OÈ ÚÒÙ˜ ÂÏ›‰Â˜ ª¤¯ÚÈ Ù· ̤۷ ÙÔ˘ 20Ô‡ ·ÈÒÓ· ‰ÔÎÈÌ¿˙ÔÓÙ·È ‰È¿ÊÔÚ˜ ıÂÚ·›˜ ÛÙËÓ ·È‰È΋ O§§, fiˆ˜ ÂÓÈÎÈÏÏ›ÓË, ·Ú¿ÁˆÁ· ·ÚÛÂÓÈÎÔ‡ Î·È ·Ê·ÈÌ¿ÍÂȘ, ¯ˆÚ›˜ fï˜ ·ÔÙ¤ÏÂÛÌ·. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì O§§ ηٷϋÁÔ˘Ó Û ۇÓÙÔÌÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ‰È¿ÁÓˆÛË. OÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ ‰ÔÎÈÌ¿˙ÔÓÙ·È Û·Ó ¯ËÌÂÈÔıÂÚ·¢ÙÈο ÌÂÙ¿ ÙȘ ·Ú·ÙËÚ‹ÛÂȘ ÁÈ·

1 A’ Pediatric Clinic of the University of Athens 2 Division of Bone Marrow Transplantation “St. Sophia” Children’s Hospital, Athens

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·ÈÌ·ÙÔÏÔÁÈ΋ ÙÔÍÈÎfiÙËÙ· Ì ÙË ¯Ú‹ÛË ÙÔ˘ ·ÂÚ›Ô˘ ÌÔ˘ÛÙ¿Ú‰·˜ ηٿ ÙÔÓ ÚÒÙÔ ·ÁÎfiÛÌÈÔ fiÏÂÌÔ Î·È ÌÂÙ¿ ÙÔ ·Ù‡¯ËÌ· ÙÔ˘ Bari Harbor ηٿ ÙÔ ‰Â‡ÙÂÚÔ ·ÁÎfiÛÌÈÔ fiÏÂÌÔ (1). ∏ ·Ú·Ù‹ÚËÛË fiÙÈ ÙÔ Ê˘ÏÏÈÎfi Ô͇ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÌÔÔ›ËÛË Ô‰ËÁ› ÛÙË ¯Ú‹ÛË ÙÔ˘ Î·È ÛÙË Ï¢¯·ÈÌ›·, Ô˘ fï˜, fiˆ˜ ·Ó·ÌÂÓfiÙ·Ó, ʤÚÓÂÈ ·ÓÙ›ıÂÙÔ ÙÔ˘ ÂÈı˘ÌËÙÔ‡ ·ÔÙ¤ÏÂÛÌ·, ÚÔηÏÒÓÙ·˜ ·‡ÍËÛË ÙÔ˘ Ï¢¯·ÈÌÈÎÔ‡ ÊÔÚÙ›Ô˘. ∆Ô 1947, Ô Sidney Farber ¯ÚËÛÈÌÔÔÈ› ¤Ó·Ó ·ÓÙÈÌÂÙ·‚ÔÏ›ÙË ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ, ÙËÓ ·ÌÈÓÔÙÂÚ›ÓË (·Ó·ÛÙÔϤ·˜ Ù˘ ‰È¸‰ÚÔÊ˘ÏÏÈ΋˜ ·Ó·ÁˆÁ¿Û˘) Î·È ÂÙ˘¯·›ÓÂÈ ·ÚÔ‰È΋ ‡ÊÂÛË Û 10 ·fi 16 ·ÛıÂÓ›˜ (2). ∆Ô 1949, Ô Seeger Û˘Óı¤ÙÂÈ ÙË ÌÂıÔÙÚÂÍ¿ÙË Ô˘ ¤¯ÂÈ ·ÚfiÌÔÈ· ‰Ú¿ÛË Ì ÙËÓ ·ÌÈÓÔÙÂÚ›ÓË ·ÏÏ¿ Â›Ó·È ÏÈÁfiÙÂÚÔ ÙÔÍÈ΋. §›ÁÔ ·ÚÁfiÙÂÚ·, Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È ·ÔÙÂÏÂÛÌ·ÙÈο, ·Ú¯Èο ÛÙÔ˘˜ fiÁÎÔ˘˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Î·È ÛÙË Ï¢¯·ÈÌ›· (1950) (3). ∆Ô 1951, ÔÈ Elion Î·È Hitchings Û˘Óı¤ÙÔ˘Ó Ì›· ·ÓÙÈÔ˘Ú›ÓË, ÙËÓ 6-ÌÂÚηÙÔÔ˘Ú›ÓË, Ë ÔÔ›· ηٷ‰ÂÈÎÓ‡ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ï¢¯·ÈÌ›· (4,5). ∞ÓÙ›ÛÙÔÈ¯Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÂÌÊ·Ó›˙ÂÈ Î·È ¤Ó·˜ Ó¤Ô˜ ·Ï΢ÏȈÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë. ∆Ô 1963, Ô µroome ÛÙËÚÈ˙fiÌÂÓÔ˜ ÛÙȘ ·Ú·ÙËÚ‹ÛÂȘ ÙÔ˘ Kidd fiÙÈ Ô ÔÚfi˜ ·fi ÈÓ‰Èο ¯ÔÈÚ›‰È· Â›Ó·È ÙÔÍÈÎfi˜ ÁÈ· Ù· Ï¢¯·ÈÌÈο ·ÙÙ·Ú·, ·Ó·Î·Ï‡ÙÂÈ ÙËÓ L-·Û·Ú·ÁÈÓ¿ÛË. ™ÙËÓ ÚÔÛ¿ıÂÈ· ·Ó‡ÚÂÛ˘ ·ÓÙȉȷ‚ËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Î·Ï‡ÙÂÙ·È ·fi ÙÔ Âί‡ÏÈÛÌ· ÙˆÓ Ê‡ÏÏˆÓ Ù˘ ‚›Óη˜ Ë ‚ÈÓÎÚÈÛÙ›ÓË. ∆· ·ÏηÏÔÂȉ‹ Ù˘ ‚›Óη˜ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È ‰Ú·ÛÙÈο ÛÙÔ˘˜ ÏÂÌÊÔÁÂÓ›˜ fiÁÎÔ˘˜ Î·È ÛÙË Ï¢¯·ÈÌ›· (6). ∏ ¯Ú˘Û‹ ÂÔ¯‹ ∏ Ê·Ú¤ÙÚ· ÙˆÓ È·ÙÚÒÓ ·Ú¯›˙ÂÈ Ó· ÁÂÌ›˙ÂÈ Î·È ÍÂÎÈÓÔ‡Ó ÔÈ ÚÒÙ˜ ÌÂϤÙ˜ ÌÂ Û˘Ó‰˘·ÛÌfi Ê·ÚÌ¿ÎˆÓ Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (7). ∏ ¯Ú‹ÛË Ù˘ L-·Û·Ú·ÁÈÓ¿Û˘ Ì·˙› Ì ÙË ‚ÈÓÎÚÈÛÙ›ÓË Î·È Ù· ÎÔÚÙÈÎÔÂȉ‹ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· Â›Ù¢Í˘ ‡ÊÂÛ˘ ·fi 85% Û >93%. O Û˘Ó‰˘·ÛÌfi˜ 6-ÌÂÚηÙÔÔ˘Ú›Ó˘ Î·È ÌÂıÔÙÚÂÍ¿Ù˘ Â›Ó·È Î·Ï‡ÙÂÚÔ˜ ÁÈ· ÙË Û˘Ó¤¯ÈÛË Ù˘ ıÂÚ·›·˜. ¶·Ú¿ ÙËÓ Î·Ï‹ ·Ú¯È΋ ·¿ÓÙËÛË, fï˜, Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË Â›Ó·È ·ÎfiÌ· ȉȷ›ÙÂÚ· ¯·ÌËÏ‹. ∆Ô˘Ï¿¯ÈÛÙÔÓ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ˘ÔÙÚÔÈ¿˙ÂÈ ÛÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· (∫¡™). ∏ ·Ó¿ÁÎË ÁÈ· ÚÔʇϷÍË ÙÔ˘ ∫¡™, ‹ ηχÙÂÚ· ÁÈ· ÚÔ-Û˘Ìو̷ÙÈ΋ ıÂÚ·›· ÙÔ˘ ∫¡™ Á›ÓÂÙ·È ÂÈÙ·ÎÙÈ΋. ∆Ô 1968, ÔÈ Pinkel Î·È Simone ÛÙÔ “St. Jude Children’s Research Hospital” ÚÔÙ›ÓÔ˘Ó Ù· ÚˆÙfiÎÔÏÏ· “ÔÏÔÎÏËڈ̤Ó˘” ıÂÚ·›·˜, Ô˘ Û˘Ó‰˘¿˙Ô˘Ó ¯ËÌÂÈÔıÂÚ·¢ÙÈο Ê¿Ú̷η Û ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË. ¶ÂÙ˘¯·›ÓÔ˘Ó Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ-

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‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿Ó (event-free survival - ∂FS) ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Î·È ı¤ÙÔ˘Ó ÙË ‚¿ÛË ÙˆÓ Û‡Á¯ÚÔÓˆÓ ÚˆÙÔÎfiÏÏˆÓ Ô˘ ‰È·ÎÚ›ÓÔ˘Ó ÙË ıÂÚ·›· Ù˘ Ï¢¯·ÈÌ›·˜ Û ʿÛË ÂÊfi‰Ô˘, ÛÙ·ıÂÚÔÔ›ËÛ˘ / ÚÔʇϷ͢ ∫¡™ Î·È Û˘ÓÙ‹ÚËÛ˘ (8). µ¿ÛÂÈ ÂÓfi˜ ıˆÚËÙÈÎÔ‡ ΢ÙÙ·ÚÔÎÈÓËÙÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘, οı ʿÛË ÌÂÈÒÓÂÈ ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô Î·Ù¿ ¤Ó· Û˘ÁÎÂÎÚÈ̤ÓÔ ÎÏ¿ÛÌ·. £ÂˆÚÂ›Ù·È fiÙÈ ÛÙË ‰È¿ÁÓˆÛË, ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ·ÓÙÈÛÙÔȯ› Û 1012 ·ÙÙ·Ú· Î·È ÌÈ· Ì›ˆÛË Î·Ù¿ 99% Ô‰ËÁ› Û ÊÔÚÙ›Ô 1010 ΢ÙÙ¿ÚˆÓ, Ô˘ ÎÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ‡ÊÂÛË. ª¤¯ÚÈ ÙËÓ ÔÏÔÎÏËÚˆÙÈ΋ ÂÍ¿ÏÂÈ„Ë ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ë ıÂÚ·›· ¯ÚÂÈ¿˙ÂÙ·È Ó· Û˘Ó¯ÈÛÙ› Ì ·ÚÎÂÙÔ‡˜ ·ÎÏÔ˘˜ (9). ∆· ÚˆÙfiÎÔÏÏ· CCG ™Ù·ıÂÚ‹ ÚfiÔ‰Ô˜ ∆· ÚˆÙfiÎÔÏÏ· ıÂÚ·›·˜ CCG ·ԂϤÔ˘Ó È· fi¯È ÌfiÓÔ ÛÙËÓ ›·ÛË ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Î·È ÛÙË Û‡ÁÎÚÈÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È ÙÔÍÈÎfiÙËÙ·˜ ‰È·ÊfiÚˆÓ Û˘Ó‰˘·ÛÌÒÓ Ê·ÚÌ¿ÎˆÓ ‚¿ÛÂÈ ÌÂÁ¿ÏˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÌÂÏÂÙÒÓ. ∆Ô ÚˆÙfiÎÔÏÏÔ CCG101 ÙÔ˘ 1970 ıÂÚ·‡ÂÈ ÙÔ 40-50% ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Î·È Î·Ù·‰ÂÈÎÓ‡ÂÈ ˆ˜ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi Û¯‹Ì· ÚÔʇϷ͢ ÙÔ˘ ∫¡™ ÙÔ Û˘Ó‰˘·ÛÌfi ·ÎÙÈÓÔ‚ÔÏ›·˜ ÙÔ˘ ÓÂ˘Ú¿ÍÔÓ· Ì 2400 cGy Î·È 6 ÂÓ‰ÔÚ·¯È·›ˆÓ ÂÁ¯‡ÛÂˆÓ ÌÂıÔÙÚÂÍ¿Ù˘ (π∆ªtx) (10). ∏ ‰È¿ÚÎÂÈ· Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ÌÂÈÒÓÂÙ·È ·fi Ù· 5 ÛÙ· 3 ¤ÙË (ÚˆÙfiÎÔÏÏÔ CCG 141) (11). ™ÙÔ ÚˆÙfiÎÔÏÏÔ CCG 143 ÙÔ˘ 1973, Ë ·ÎÙÈÓÔ‚ÔÏ›· ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· 1800 cGy ¯ˆÚ›˜ Ó· ÂËÚ·ÛÙ› ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘. ∞˘Ù‹ Ë Ì›ˆÛË Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋, ·ÊÔ‡ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ·ÎÙÈÓÔ‚ÔÏ›· Ì 2400 cGy ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ˘„ËÏfi ÔÛÔÛÙfi Ì·ıËÛȷο Î·È Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (12).

OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ∆·˘Ùfi¯ÚÔÓ·, ‰È·Ê·›ÓÂÙ·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË. ∏ ¯Ú‹ÛË ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ¤¯ÂÈ ÍÂÎÈÓ‹ÛÂÈ. ∏ ËÏÈΛ·, ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô, Ô ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÙˆÓ ‚Ï·ÛÙÒÓ, ÙÔ Ê‡ÏÔ, ÔÈ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ·ÔÙÂÏÔ‡Ó ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Î·È ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ∆· ÚˆÙfiÎÔÏÏ· CCG 161, 162, 163 ηٷӤÌÔ˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô Î·È Î·Ù·‰ÂÈÎÓ‡Ô˘Ó fiÙÈ 2 ¤ÙË Û˘ÓÙ‹ÚËÛ˘ Â›Ó·È ·ÚÎÂÙ¿ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· ηıÒ˜ Î·È fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ë ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ ∫¡™ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ·ı› ·fi ITMtx (13). ™ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980, ÔÈ ·ÛıÂÓ›˜ ‰È·ÎÚ›ÓÔÓÙ·È È· Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘: ¯·ÌËÏÔ‡,

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ÂӉȿÌÂÛÔ˘ Î·È ˘„ËÏÔ‡. OÈ ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ıÂÚ·‡ÙËÎ·Ó Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ CCG104 ÙÔ˘ 1983, ·ÚÔ˘ÛÈ¿˙Ô˘Ó 8ÂÙ‹ EFS 70%. ∆Ô ‰È¿‰Ô¯Ô ÚˆÙfiÎÔÏÏÔ Î·Ù·‰ÂÈÎÓ‡ÂÈ fiÙÈ Ë ÚÔÛı‹ÎË Ê¿Û˘ Â·ÓÂÊfi‰Ô˘ ·Ó‚¿˙ÂÈ ÙÔ ÔÛÔÛÙfi 5ÂÙÔ‡˜ ∂FS ÛÙÔ 80% (14). ªÂ ÙË ÌÂϤÙË CCG105 ÂȂ‚·ÈÒÓÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÌ¿‰·˜ BFM ÁÈ· ηχÙÂÚË ÚfiÁÓˆÛË Û ·ÛıÂÓ›˜ ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ ‹Ú·Ó Ê¿ÛË Â·ÓÂÊfi‰Ô˘, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ηٷ‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ë ·ÎÙÈÓÔ‚ÔÏ›· ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË Û ·ÛıÂÓ›˜ οو ÙˆÓ 10 ÂÙÒÓ (14,15). ™ÙȘ ÂfiÌÂÓ˜ ÌÂϤÙ˜ Ô˘ ÍÂÎÈÓÔ‡Ó ÙÔ 1989 Î·È 1995 Ê·›ÓÂÙ·È fiÙÈ Ë ÚÔÛı‹ÎË ‰Â‡ÙÂÚ˘ Â·ÓÂÊfi‰Ô˘ ʤÚÂÈ ·ÎfiÌ· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù·. ∏ ÌÂϤÙË CCG106 ÁÈ· ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ó··Ú¿ÁÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ BFM ÛÂ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË (16). ∂ȉÈο, fï˜, ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÛËÌ›· ÏÂÌÊÒÌ·ÙÔ˜ (Ì¿˙· ÌÂÛÔıˆÚ·Î›Ô˘, ÛÏËÓÔÌÂÁ·Ï›·, ÂÎÛÂÛËÌ·Ṳ̂Ó˜ ÏÂÌÊ·‰ÂÓÈΤ˜ ‰ÈÔÁÎÒÛÂȘ), ÙÔ ÚˆÙfiÎÔÏÏÔ New York Ê·›ÓÂÙ·È Ó· ˘ÂÚÙÂÚ› ÙÔ˘ BFM (ÚˆÙfiÎÔÏÏÔ CCG123). OÈ ·ÛıÂÓ›˜ ÌÂ Ì˘ÂÏÈ΋ ‰È‹ıËÛË ·fi ‚Ï¿ÛÙ˜ ¿Óˆ ·fi 25% ηٿ ÙËÓ 7Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, Ô˘ ÈÛÙÔÚÈο ·ÚÔ˘Û›·˙·Ó EFS 30%, ÂÙ˘¯·›ÓÔ˘Ó EFS 67,7% Ì ÙË ¯Ú‹ÛË “ÂÓÙ·ÙÈÎÔÔÈË̤ÓÔ˘ BFM” (ÚˆÙfiÎÔÏÏÔ CCG1882) (17). ∏ ‰ÂηÂÙ›· ÙÔ˘ ’90 OÈ ÌÂϤÙ˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’90 ·ÔÛÎÔÔ‡Ó Ó· ‚ÂÏÙÈÒÛÔ˘Ó Ù· ‹‰Ë ˘¿Ú¯ÔÓÙ· ÚˆÙfiÎÔÏÏ·, ÂÓۈ̷ÙÒÓÔÓÙ·˜ Ù· ηÈÓÔ‡ÚÁÈ· ‰Â‰Ô̤ӷ Î·È Ù· ÓÂfiÙÂÚ· ÂÈÙ‡ÁÌ·Ù· Ù˘ È·ÙÚÈ΋˜ Î·È ‚ÈÔÙ¯ÓÔÏÔÁ›·˜ (fiˆ˜ Ë PEG-·Û·Ú·ÁÈÓ¿ÛË, ÔÈ Î˘ÙÙ·ÚÔΛÓ˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î.¿.). O Ï‹Ú˘ ¯·Ú·ÎÙËÚÈÛÌfi˜ ÙÔ˘ Ù‡Ô˘ Ù˘ Ï¢¯·ÈÌ›·˜ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Ë Ù·ÍÈÓfiÌËÛ‹ Ù˘ Ì ‚¿ÛË Ù· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, ·ÔÙÂÏ› ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ™‡Ìʈӷ Ì ÙËÓ ÔÌ¿‰· CCG, ÂÎÙfi˜ ·fi ÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ Ô˘ ·Ó·Ê¤Ú·ÌÂ, ‰È·ÊÔÚÂÙÈÎfi ÚˆÙfiÎÔÏÏÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ù· ‚Ú¤ÊË ËÏÈΛ·˜ οو ÙÔ˘ 1 ¤ÙÔ˘˜, ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ʤÚÔ˘Ó ÙËÓ ·ÓÙÈÌÂÙ¿ıÂÛË 9,22 ‹ Ô˘ ‰ÂÓ ‚Ú›ÛÎÔÓÙ·È Û ‡ÊÂÛË ÙËÓ 28Ë Ë̤ڷ Î·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÎÏÈÓÈο ÛËÌ›· ÏÂÌÊÒÌ·ÙÔ˜. ∏ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ¤¯ÂÈ È· EFS ¿Óˆ ÙÔ˘ 70%, ÂÓÒ Û ÂȉÈΤ˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÙÔ EFS ÍÂÂÚÓ¿ ÙÔ 90%. ∏ ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ ∫¡™ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ Û ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (18). ¶ÚfiÛÊ·Ù·, Ë ÔÌ¿‰· CCG ÂÓÒıËΠ̠ÙËÓ ÔÌ¿‰· POG (Pediatric Oncology Group)

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Î·È ‰ËÌÈÔ˘ÚÁ‹ıËÎÂ Ë ÔÌ¿‰· COG (Children’s Oncology Group), ÛÙ· ÚˆÙfiÎÔÏÏ· Ù˘ ÔÔ›·˜ ·Ó·Ì¤ÓÔÓÙ·È Ó· ÂÚÈÏËÊıÔ‡Ó >95% ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ÛÙȘ ∏.¶.∞. ∆· ÚˆÙfiÎÔÏÏ· BFM ª¤Û· ·fi Ù· 8 ıÂÚ·¢ÙÈο ÚˆÙfiÎÔÏÏ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 30 ¯ÚfiÓˆÓ, Ë ÔÌ¿‰· ÌÂϤÙ˘ Ù˘ O§§ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ BFM (Berlin-FrankfurtMuenster), Û‹ÌÂÚ·, ÂÙ˘¯·›ÓÂÈ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ Û˘Ì‚¿ÓÙ· (EFS) ÛÙÔ 80% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ıÂÚ·›· ‰È·ÎÚ›ÓÂÙ·È Û ʿÛÂȘ ÂÊfi‰Ô˘, ÛÙ·ıÂÚÔÔ›ËÛ˘, Â·ÓÂÊfi‰Ô˘ Î·È Û˘ÓÙ‹ÚËÛ˘ Î·È ÚÔÛ·ÚÌfi˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (risk-adapted treatment). ∏ ÂͤÏÈÍË ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ BFM ‰È·ÎÚ›ÓÂÙ·È Û¯ËÌ·ÙÈο Û ÙÚÂȘ ÂÔ¯¤˜ Ì ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÛÙÔȯ›·, Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·fiÏ˘ÙË ·ÓÙÈÛÙÔȯ›· Ì ٷ ÂÈÙ‡ÁÌ·Ù· ÙˆÓ ‚ÈÔ˚·ÙÚÈÎÒÓ ÂÈÛÙËÌÒÓ (19-21). ∏ ÚÒÙË ÂÔ¯‹ (1970-1981) ∆· ÚˆÙfiÎÔÏÏ· ALL-BFM 70, 76, 79 Î·È 81 ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙË ‰ËÌÈÔ˘ÚÁ›· ıÂÚ·¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ÂÚȤ¯Ô˘Ó Û˘Ó‰˘·ÛÌÔ‡˜ 5 ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ Ê·Ú̿ΈÓ, ·fi ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Û ÔÌ¿‰· ¯·ÌËÏÔ‡ ‹ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‚Ï·ÛÙÒÓ ÛÙË ‰È¿ÁÓˆÛË (>25000/Ìl ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘) Î·È ·fi ÙËÓ ÚÔÛı‹ÎË Ù˘ Ê¿Û˘ Â·ÓÂÊfi‰Ô˘ (¶ÚˆÙfiÎÔÏÏÔ ππ) ÛÙË ıÂÚ·›· Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. °È· ÙËÓ ÂÔ¯‹ ÙÔ˘˜, Ù· ÚˆÙfiÎÔÏÏ· Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈο ·ÊÔ‡ ÂÙ˘¯·›ÓÔ˘Ó EFS 62% ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Î·È EFS 45% ÁÈ· ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∏ ÂÔ¯‹ ÙÔ˘ ‰Â›ÎÙË ÎÈÓ‰‡ÓÔ˘ (1983-1986) ∆· ÚˆÙfiÎÔÏÏ· ALL-BFM-83 Î·È 86 ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ “‰Â›ÎÙË ÎÈÓ‰‡ÓÔ˘” (Risk Factor), Ô˘ ηٷٿÛÛÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜ (20). O ‰Â›ÎÙ˘ ·˘Ùfi˜ ·ÓÙÈÚÔÛˆ‡ÂÈ ÙÔ Û˘ÓÔÏÈÎfi Ï¢¯·ÈÌÈÎfi ÊÔÚÙ›Ô ÛÙË ‰È¿ÁÓˆÛË Î·È ˘ÔÏÔÁ›˙ÂÙ·È ‚¿ÛË ÙÔ˘ ·ÚÈıÌÔ‡ ‚Ï·ÛÙÒÓ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Ú‰ÓÈ˙fiÓ˘ ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ıÂÚ·›·˜ ηıÈÂÚÒÓÂÙ·È ˆ˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. ∫·ÏÔ› “··ÓÙËÙ¤˜” ıˆÚÔ‡ÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÙËÓ 8Ë Ë̤ڷ ıÂÚ·›·˜ ·fiÏ˘ÙÔ ·ÚÈıÌfi ΢ÎÏÔÊÔÚÔ‡ÓÙˆÓ ‚Ï·ÛÙÒÓ <1Ã109/L. ™ÙÔ ÚˆÙfiÎÔÏÏÔ ALLBFM-86, ηϋ ·¿ÓÙËÛË ÛÙËÓ Ú‰ÓÈ˙fiÓË ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 90% ÙˆÓ ·ÛıÂÓÒÓ Î·È Û˘Óԉ‡ÂÙ·È ·fi EFS 80%. ™Â ·ÓÙ›ıÂÛË, ·ÛıÂÓ›˜ Ì η΋ ·¿ÓÙËÛË ÛÙËÓ Ú‰ÓÈ˙fiÓË ·ÚÔ˘ÛÈ¿˙Ô˘Ó EFS 45% (22).

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∏ ‰ÂηÂÙ›· ÙÔ˘ ’90 ∏ ÙÚ›ÙË ÂÔ¯‹ Ì ٷ ÚˆÙfiÎÔÏÏ· ALL-BFM90, 95 ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÚÔÛ¿ıÂÈ· Ì›ˆÛ˘ Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜, ȉȷ›ÙÂÚ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ Î·È Î˘Ú›ˆ˜ ÁÈ· ÙËÓ ÔÌ¿‰· ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÚÔÊ˘Ï·ÎÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›·, ÂÓÒ ÛÙ· ·ÁfiÚÈ· Ù˘ ÔÌ¿‰·˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ë Ê¿ÛË Û˘ÓÙ‹ÚËÛ˘ ·˘Í¿ÓÂÈ Î·Ù¿ ¤Ó· ¤ÙÔ˜. ªÂ ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM-90 ÂÈÙ˘Á¯¿ÓÂÙ·È 6ÂÙ‹˜ EFS 84% ÁÈ· ÙȘ ÔÌ¿‰Â˜ ¯·ÌËÏÔ‡ Î·È ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (23). ™ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Á›ÓÂÙ·È ·ÓÙÈηٿÛÙ·ÛË Ù˘ Ê¿Û˘ Â·ÓÂÊfi‰Ô˘ Ì Â·Ó·Ï·Ì‚·ÓfiÌÂÓ· ‚Ú·¯¤· Û¯‹Ì·Ù· ¤ÓÙÔÓ˘ ¯ËÌÂÈÔıÂÚ·›·˜ (blocks). ∏ ·ÏÏ·Á‹ ·˘Ù‹ ‰ÂÓ ·ÔʤÚÂÈ fï˜ ‚ÂÏÙ›ˆÛË ÙÔ˘ EFS Û ۇÁÎÚÈÛË Ì ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ÚˆÙfiÎÔÏÏÔ (6ÂÙ‹˜ EFS: 34% ¤Ó·ÓÙÈ 45%). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ë ıÂÚ·›· Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ fiÙ·Ó Â›Ó·È Û˘Ó¯‹˜ ·Ú¿ fiÙ·Ó Â›Ó·È ‰È·Ï›Ô˘Û· Î·È ÈÔ ÂÓÙ·ÙÈ΋ Î·È ·ÎfiÌ· fiÙÈ Ù· ÂÚÈÛÛfiÙÂÚÔ Ì˘ÂÏÔÙÔÍÈο Ê¿Ú̷η fiˆ˜ Ù· ·Ï΢ÏȈÙÈο, ¤¯Ô˘Ó Î·È ÌÂÁ·Ï‡ÙÂÚË ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË. °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, ÛÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ÔÌ¿‰·˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (ALL-BFM-95) Â·Ó¤Ú¯ÂÙ·È Ë Â·Ó¤ÊÔ‰Ô˜ Î·È ÌÂÈÒÓÔÓÙ·È Ù· Û¯‹Ì·Ù· Ù˘ ¤ÓÙÔÓ˘ ¯ËÌÂÈÔıÂÚ·›·˜. ™ÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÂÓÙ¿ÛÛÔÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ì η΋ “·¿ÓÙËÛË” ÛÙËÓ Ú‰ÓÈ˙fiÓË ‹ Ì ¯ÚˆÌÔÛˆÌÈ΋ ÌÂÙ¿ıÂÛË 4;11 ‹ 9;22, ‹ Ì ÌË Ì˘ÂÏÈ΋ ‡ÊÂÛË ÙËÓ 33Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜. ™ÙÔ ÚˆÙfiÎÔÏÏÔ ALL-BFM 99, Ë ·Ó›¯Ó¢ÛË ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈfiÌÂÓ˘ ÓfiÛÔ˘ ÙËÓ 5Ë Î·È ÙË 12Ë Â‚‰ÔÌ¿‰· ·ÔÙÂÏ› ηıÔÚÈÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÈÏÔÁ‹ Ù˘ ıÂÚ·›·˜. ∂›ÏÔÁÔ˜ ∏ ıÂÚ·›· Ù˘ O§§ ¤¯ÂÈ ÂÍÂÏȯı› Ù· ̤ÁÈÛÙ· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È Ë ›·ÛË ·ÔÙÂÏ› ÂÊÈÎÙfi ÛÙfi¯Ô ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ. ª¤Û· Û ̛· ÙÂÛÛ·Ú·ÎÔÓÙ·ÂÙ›· ÂÚ¿Û·Ì ·fi ÙËÓ ·ÚËÁÔÚËÙÈ΋ ÌÔÓÔıÂÚ·›· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ Î·È ¯Ú‹ÛË ÔχÏÔÎˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ, ÙˆÓ ÔÔ›ˆÓ ÙÔ ˘„ËÏfi ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È Ë ÌÂȈ̤ÓË ¿ÌÂÛË Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ÙÔÍÈÎfiÙËÙ· ¤¯ÂÈ Î·Ù·‰Âȯı› ·fi ÂÎÙÂÓ›˜ ÌÂϤÙ˜ (24). ∏ ÛËÌ·ÓÙÈ΋ ·˘Ù‹ ÚfiÔ‰Ô˜ ¤¯ÂÈ ÂÈÙ¢¯ı› ̤۷ ·fi ÙË Û˘Ó¯‹ ÚÔÛ¿ıÂÈ· ÙˆÓ ÏÂÈÙÔ˘ÚÁÒÓ ˘Á›·˜ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÙˆÓ ·ÛıÂÓÒÓ Û ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜, Ô˘ Ù·˘Ùfi¯ÚÔÓ· ÚÔÛʤÚÔ˘Ó Û˘ÛÙËÌ·ÙÔÔÈË̤ÓË ıÂÚ·›· Î·È Û˘ÁÎÚ›ÓÔ˘Ó ıÂÚ·¢ÙÈΤ˜ ÂÓ·ÏÏ·ÎÙÈΤ˜.

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O ‚·ıÌfi˜ Ù˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ˘‡ı˘ÓˆÓ È·ÙÚÒÓ, ηıÒ˜ Î·È ÌÂٷ͇ ÙˆÓ ÔÁÎÔÏÔÁÈÎÒÓ ÔÌ¿‰ˆÓ Â›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ˜. ™ÙȘ ∏.¶.∞. Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ù˘ ∂ӈ̤Ó˘ ∂˘ÚÒ˘, Ë ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÂÓÙ¿ÛÛÂÙ·È Û ÂÚ¢ÓËÙÈο ıÂÚ·¢ÙÈο ÚˆÙfiÎÔÏÏ·, ÌÈ· Î·È ÔÏÏÔ› ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤¯Ô˘Ó ηχÙÂÚ· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜ ·fi ·˘ÙÔ‡˜ Ô˘ ıÂÚ·‡ÔÓÙ·È ‚¿ÛÂÈ ÌÂÌÔÓˆÌ¤ÓˆÓ ÚÔÛˆÈÎÒÓ ÂÌÂÈÚÈÒÓ ÙÔ˘ ÂȂϤÔÓÙÔ˜ È·ÙÚÔ‡ (25,26). ∞fi ÙÔ˘˜ 60 ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ Ô˘ ¤¯Ô˘Ó ηٿ ηÈÚÔ‡˜ ·Ó·Ï˘ı›, ÌfiÓÔ Ë ËÏÈΛ·, Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Ô Î·Ú˘fiÙ˘Ô˜ ¤¯Ô˘Ó Â·ÓÂÈÏËÌ̤ӈ˜ ‰Â›ÍÂÈ ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· Û ÔÏ˘·Ú·ÁÔÓÙÈΤ˜ ÌÂϤÙ˜ (27). ¡¤· ÎÚÈÙ‹ÚÈ·, fiˆ˜ Ô ÁÔÓÔÙ˘ÈÎfi˜ ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ Ï¢¯·ÈÌ›·˜ Î·È Ë ·Ó›¯Ó¢ÛË Ù˘ ÂÏ¿¯ÈÛÙ˘ ˘ÔÏÂÈfiÌÂÓ˘ ÓfiÛÔ˘, ÌÔÚ› Ó· ·Ô‰ÂȯıÔ‡Ó ÛËÌ·ÓÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜. ∏ ηχÙÂÚË Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÈÙÚ¤„ÂÈ ÙËÓ ÂÚ·ÈÙ¤Úˆ ÚÔÛ·ÚÌÔÁ‹ Ù˘ ıÂÚ·›·˜. ¶ÚfiÛÊ·Ù·, ÚÔÙ¿ıËÎÂ Ë Î·ıȤڈÛË Ó¤·˜ ÔÌ¿‰·˜ ·ÛıÂÓÒÓ È‰È·›ÙÂÚ· ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜, Ô˘ ı· Ï·Ì‚¿ÓÂÈ ÌÂȈ̤ÓË ¯ËÌÂÈÔıÂÚ·›· (28). ∏ ηٷÓfiËÛË ÙˆÓ ÁÔÓȉȷÎÒÓ Ì˯·ÓÈÛÌÒÓ Ù˘ Ï¢¯·ÈÌÔÁ¤ÓÂÛ˘ Î·È Ù˘ ·ÓıÂÎÙÈÎfiÙËÙ·˜ ÛÙË ıÂÚ·›· ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ. ™ÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ, Ô Û¯Â‰È·ÛÌfi˜ Ù˘ ıÂÚ·›·˜ ı· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ¿ÏÏ· ÛÙÔȯ›· fiˆ˜ ÙË ÁÔÓȉȷ΋ ıÂÚ·›·, ÙÔ˘˜ ·ÓÙÈ·ÁÁÂÈÔÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ÚfiÏÔ˘ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞Ó Î·È ÛÙËÓ È·ÙÚÈ΋ ÔÈ ÚԂϤ„ÂȘ Â›Ó·È ¿ÓÙ· ÂÈÛÊ·Ï›˜, ÈÛÙ‡ÂÙ·È fiÙÈ ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ı· Á›ÓÔ˘Ó Î·È Ù· ÌÈÎÚ¿ ‚‹Ì·Ù· ÚÔfi‰Ô˘ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÁÈ· ÙËÓ Â›Ù¢ÍË ›·Û˘ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, Ì ٷ˘Ùfi¯ÚÔÓË ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ¿ÌÂÛˆÓ Î·È ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Goodman LS, Wintrobe NM, Dameshek W, Goodman MJ, Gilman A, McLennan MT. Nitrogen mustard therapy.

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Nachman J, Sather HN, Cherlow JM, Sensel MG, Gaynon PS, Lukens JN et al. Response of children with high risk acute lymphoblastic leukemia treated with and without cranial irradiation: a report from the Children’s Cancer Group. J Clin Oncol 1998;16:920-930.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 09-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙÒÓÈÔ˜ ∫·ÙÙ¿Ì˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È §Â‚·‰›·˜, 115 27, °Ô˘‰› e-mail: ckatamis@cc.uoa.gr

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Paediatriki 2001;64:207-317

CONTINUING MEDICAL EDUCATION

1Ô ¶∞¡∂§§∏¡π√ ™À¡∂¢ƒπO À¶√∂π¢π∫√∆∏∆ø¡ ∆∏™ ¶∞π¢π∞∆ƒπ∫∏™

1st PANHELLENIC MEETING OF THE PEDIATRIC SUBSPECIALTIES

∆Ô 1Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙËÓ ∞ı‹Ó· ÛÙȘ 1 & 2 ∞ÚÈÏ›Ô˘ 2000, ·ÔÙ¤ÏÂÛ ¤Ó· ·fi Ù· ÎÔÚ˘Ê·›· ÂÈÛÙËÌÔÓÈο ÁÂÁÔÓfiÙ· ÙÔ˘ ÎÏ¿‰Ô˘ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙË ¯ÒÚ· Ì·˜. ∏ ·Ó¿ÁÎË Ù˘ Û˘ÓÂÚÁ·Û›·˜ Î·È ·ÓÙ·ÏÏ·Á‹˜ ÂÈÛÙËÌÔÓÔÎÒÓ ÏËÚÔÊÔÚÈÒÓ ÌÂٷ͇ ÙˆÓ ÁÂÓÈÎÒÓ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ·È‰È¿ÙÚˆÓ Û¯ÂÙÈο Ì ÙȘ ÚfiÛÊ·Ù˜ È·ÙÚÈΤ˜ ÂÍÂÏ›ÍÂȘ, Â›Ó·È ÂÈÙ·ÎÙÈ΋ Î·È ı· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÚ·ÈÙ¤Úˆ ÚfiÔ‰Ô Î·È ·Ó¿Ù˘ÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∂ÈÛÙ‹Ì˘. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ¢¯·ÚÈÛÙ› ıÂÚÌ¿ fiÛÔ˘˜ ·fi ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ÂȉÈÎÔ‡˜ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙËÓ ÚfiÛÎÏËÛ‹ Ì·˜ Ó· ‰ËÌÔÛÈ¢ıÔ‡Ó ÔÈ ÂÈÛËÁ‹ÛÂȘ ÙÔ˘˜.

The 1st Panhellenic Meeting of the Pediatric Subspecialties which was held in Athens on April 1 & 2 2000, proved to be one of the most significant events in the field of Pediatrics in our country. The need for cooperation and for exchange of scientific information among pediatric professionals and experts in regards to the latest medical developments, is absolutely essential and will contribute to the overall progress in the development of Pediatrics. The Scientific Editorial Board wishes to thank those participants who kindly responded to our invitation to publish their presentations.

™ÙÔ ∆‡¯Ô˜ ·˘Ùfi Ù˘ "¶∞π¢π∞∆ƒπ∫∏™" ‰ËÌÔÛȇÔÓÙ·È ÔÈ ÂÈÛÙËÌÔÓÈΤ˜ ÂÈÛËÁ‹ÛÂȘ ÙˆÓ Î¿ÙˆıÈ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜:

This issue of the Journal includes scientific presentations of the following Pediatric subspecialties:

1. ¡ÂÔÁÓÔÏÔÁ›· 2. ∞ÏÏÂÚÁÈÔÏÔÁ›· - ¢ÂÚÌ·ÙÔÏÔÁ›· 3. ∞ÓÔÛÔÏÔÁ›· - ƒÂ˘Ì·ÙÔÏÔÁ›· 4. ¡ÂÊÚÔÏÔÁ›· 5. ∂›ÁÔ˘Û· Î·È ∂ÓÙ·ÙÈ΋ ¶·È‰È·ÙÚÈ΋ 6. §ÔÈÌÒÍÂȘ 7. ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· 8. °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· - ∏·ÙÔÏÔÁ›· - ¢È·ÙÚÔÊ‹ 9. ™˘ÓÂÚÁ·˙fiÌÂÓ˜ ∂ȉÈÎfiÙËÙ˜

1.

2.

3.

4.

5.

6.

7.

8.

9.

Neonatology Allergiology - Dermatology Immunology - Rheumatology Nephrology Emergency and Intensive Care Pediatrics Infections Hematology - Oncology Gastroenterology - Hepatology - Nutrition Associated Subspecialties

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NEONATOLOGY

ÿÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·. ◊ Ì‹ˆ˜ Î·È Ù· ‰‡Ô; X. ∫ÒÛÙ·ÏÔ˜

Jaundice in the breast fed infant C. Costalos

¶ÂÚ›ÏË„Ë: ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó ¤¯Ô˘Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÈÎÙ¤ÚÔ˘ Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ·›ÚÓÔ˘Ó Í¤ÓÔ Á¿Ï·. °‡Úˆ ·fi ÙËÓ ·ıÔÁ¤ÓÂÈ· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηٿÛÙ·Û˘ ·˘Ù‹˜ ÂÈÎÚ·Ù› Û‡Á¯˘ÛË Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ Â›Ó·È Â˘Ú¤ˆ˜ ÁÓˆÛÙfi fiÙÈ Ô ›ÎÙÂÚÔ˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó ‰ÂÓ ·ÔÙÂÏ› ÂÓÈ·›· ÔÓÙfiÙËÙ· ·ÏÏ¿ ˘¿Ú¯Ô˘Ó ‰‡Ô ÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ÙÔ˘, Ë ÚÒÈÌË Î·È Ë fi„ÈÌË. ∏ ÚÒÈÌË ÔÊ›ÏÂÙ·È Û ·ÓÂ·Ú΋ ÚfiÛÏË„Ë ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, ÂÓÒ Ë fi„ÈÌË ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Û ÓÂÔÁÓ¿ ·fiÏ˘Ù· Ê˘ÛÈÔÏÔÁÈο Ô˘ ıËÏ¿˙Ô˘Ó Â·ÚÎÒ˜. ∆Ô ¿ÚıÚÔ ·˘Ùfi ·Ó·ÛÎÔ› ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰‡Ô Ù‡ˆÓ ÈÎÙ¤ÚÔ˘ ÌÂ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜.

Abstract: It is well known that breastfed newborns have an increased incidence of jaundice. The epidemiology, physiologic basis and management of this situation has been confusing to many clinicians, primarily from failure to distinguish between the two different causes of exaggerated neonatal jaundice in breastfed infants, namely: 1. Early onset exaggeration of physiologic unconjugated hyperbilirubinemia associated with inadequate breastfeeding, which is the neonatal equivalent of starvation jaundice in the adult, and is designated as “breast feeding jaundice” and 2. Late-onset prolonged unconjugated hyperbilirubinemia associated with ingestion of breast milk, which begins at the end of the first week of life and may continue for several weeks and even months thereafter in healthy, thriving infants. This type is designated as “breast milk jaundice”. This article reviews the etiologic mechanisms of the two types of jaundice, with recommendations on their prevention and management.

§¤ÍÂȘ ÎÏÂȉȿ: ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ›ÎÙÂÚÔ˜.

Key words: breast feeding, hyperbilirubinemia, jaundice.

∞Ó Î·È Ô ›ÎÙÂÚÔ˜, Û ‚Ú¤ÊË Ô˘ ·›ÚÓÔ˘Ó Ê˘ÛÈ΋ ‰È·ÙÚÔÊ‹, ·ÔÙÂÏ› ·Ó¿Ú¯·ÈÔ Ê·ÈÓfiÌÂÓÔ, ÔÏÏ¿ ÂÚˆÙ‹Ì·Ù· ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Î·È Û‹ÌÂÚ· Ó· ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο Ì ÙËÓ ·ıÔÁ¤ÓÂÈ·, ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹˜ Ù˘ ÌÔÚÊ‹˜ ÙÔ˘. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ê·›ÓÂÙ·È ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, Û‡Ìʈӷ Ì ÙȘ Ôԛ˜ ÙÔ 13% ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÂÌÊ·Ó›˙Ô˘Ó ›ÎÙÂÚÔ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ (¤Ó·ÓÙÈ ÔÛÔÛÙÔ‡ 2,2-4% ÛÂ

ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó Í¤ÓÔ Á¿Ï·). ™Â fiÙÈ ·ÊÔÚ¿ ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÈÎÙ¤ÚÔ˘, ÔÚÈṲ̂ÓÔÈ ıˆÚÔ‡Ó fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÌÔÚʤ˜ ÈÎÙ¤ÚÔ˘, Ô ÚÒÈÌÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Î·È Ô fi„ÈÌÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï·, ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ·ÈÙÈÔÏÔÁ›· Î·È ··ÈÙÔ‡Ó ‰È·ÊÔÚÂÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË (1). ÕÏÏÔÈ, ¿ÏÈ, ÂÚ¢ÓËÙ¤˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÔÈ ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘ Û ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó, ·ÔÙÂÏÔ‡Ó ‰‡Ô

¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ÏÂÍ¿Ó‰Ú·, ∞ı‹Ó·

Division of Neonatal Medicine Alexandra General Hospital, Athens

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¶·È‰È·ÙÚÈ΋ 2001;64:208-210

‰È·ÊÔÚÂÙÈΤ˜ fi„ÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÌ›ÛÌ·ÙÔ˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ı· ·Ó·ÊÂÚıԇ̠ͯˆÚÈÛÙ¿ ÛÙȘ ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘, ÙÔÓ›˙ÔÓÙ·˜ fï˜ Î·È ÔÚÈṲ̂ӷ ÎÔÈÓ¿ ÛÙÔȯ›· Ô˘ ÙÔ˘˜ Û˘Ó‰¤Ô˘Ó. ¶ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi O ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ÙȘ ÚÒÙ˜ 3-4 Ë̤Ú˜ ˙ˆ‹˜ Î·È ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Î·È ıÂÚÌ›‰ˆÓ. ™ÙÔ Û˘Ì¤Ú·ÛÌ· ·˘Ùfi Ô‰ËÁÔ‡Ó ÌÂϤÙ˜ Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ: ·) fiÏ· Ù· ÓÂÔÁÓ¿ Ì ÚÒÈÌÔ ›ÎÙÂÚÔ Â›¯·Ó ÌÂÁ¿ÏË ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Û ۇÁÎÚÈÛË Ì ¿ÏÏ· ÓÂÔÁÓ¿ Ô˘ ¤·ÈÚÓ·Ó ÌËÙÚÈÎfi Á¿Ï· Î·È ‰ÂÓ ¤Î·Ó·Ó ›ÎÙÂÚÔ ‹ Ì ·˘Ù¿ Ô˘ ¤·ÈÚÓ·Ó Í¤ÓÔ Á¿Ï·, ‚) ˘‹Ú¯Â ¿ÌÂÛË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜ Î·È Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È Á) Ë ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·fi 6 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Û 12 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Ì›ˆÛ ٷ Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ Û’ ÂΛӷ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ¤·ÈÚÓ·Ó Í¤ÓÔ Á¿Ï·. ∏ ·Ï·ÈfiÙÂÚ· ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë fiÙÈ Ô ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ÔÊ›ÏÂÙ·È Û ·Ê˘‰¿ÙˆÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¢ÛÙ·ı›, ·ÊÔ‡ Ë ÂÈϤÔÓ ¯ÔÚ‹ÁËÛË ÓÂÚÔ‡ ‹ ˙·¯·ÚfiÓÂÚÔ˘ Û ÓÂÔÁÓ¿ Ô˘ ı‹Ï·˙·Ó, fi¯È ÌfiÓÔ ‰ÂÓ Ì›ˆÛ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘, ·ÏÏ¿ ·ÓÙ›ıÂÙ· Ô‰‹ÁËÛ Û ˘„ËÏfiÙÂÚ· Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘. ™¯ÂÙÈο Ì ÙÔ Ì˯·ÓÈÛÌfi ̤ۈ ÙÔ˘ ÔÔ›Ô˘ Ë ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Ô‰ËÁ› Û ›ÎÙÂÚÔ, ‚Ú¤ıËΠfiÙÈ ·˘Ùfi˜ ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹, ÚfiÛÏË„Ë ‹ Û‡˙¢ÍË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙÔ ‹·Ú, ·ÏÏ¿ Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ. ∞˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ: ·) Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‹Ù·Ó ‰ÈÏ¿ÛÈ· Û ÓÂÔÁÓ¿ Ô˘ ·¤‚·ÏÏ·Ó ÌËÎÒÓÈÔ ÌÂÙ¿ ÙȘ ÚÒÙ˜ 8 ÒÚ˜ ˙ˆ‹˜, Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ¤‚Á·Ï·Ó ÌËÎÒÓÈÔ ÓˆÚ›ÙÂÚ· Î·È ‚) Ë ÔÛfiÙËÙ· Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙ· ÎfiÚ·Ó· ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË Û ÓÂÔÁÓ¿ Ì Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›Ì·ÙÔ˜ <5 mg/dL, Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ›¯·Ó ¯ÔÏÂÚ˘ıÚ›ÓË >10 mg/dL. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ Ë ¤ÏÏÂÈ„Ë ÙÚÔÊ‹˜ Ô‰ËÁ› Ì οÔÈÔ ¿ÁÓˆÛÙÔ Ì˯·ÓÈÛÌfi Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ (2). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ ÛËÌ›·: ·) ™ˆÛÙ‹ ÂÎ·›‰Â˘ÛË Ù˘ ÌËÙ¤Ú·˜ ÁÈ· Ù· ÔʤÏË Î·È ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∏ ÂÎ·›‰Â˘ÛË ·˘Ù‹ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Î·È Ó· Û˘Ó¯›˙ÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ·È‰ÈÔ‡, ‚) O ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜ (1 ÒÚ·) ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜, Á) ¡· ÌË ¯ÔÚËÁÂ›Ù·È ÓÂÚfi ‹ ˙·¯·ÚfiÓÂÚÔ ÛÙ· ÂӉȿÌÂÛ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ‰) ∆Ô ÓÂÔÁ¤ÓÓËÙÔ Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÛÙÔ ÛÙ‹ıÔ˜ 10 ‹ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, Â) ∫·Ù¿ ÙËÓ ·-

Paediatriki 2001;64:208-210

Ú·ÌÔÓ‹ ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ, ÙÔ ÓÂÔÁÓfi ÓÔÛËχÂÙ·È ÎÔÓÙ¿ ÛÙË ÌËÙ¤Ú· ÙÔ˘, ÛÙ) ∞Ó ÙÔ ÓÂÔÁ¤ÓÓËÙÔ ‰ÂÓ ¤¯ÂÈ Î·Ï¤˜ ıËÏ·ÛÙÈΤ˜ ÎÈÓ‹ÛÂȘ ‹ Â›Ó·È ÓˆıÚfi, Ë ÌËÙ¤Ú· Ú¤ÂÈ Ó· ·‰ÂÈ¿˙ÂÈ ÙÔ ÛÙ‹ıÔ˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ ıËÏ·ÛÌÔ‡ Î·È ÙÔ ÂÈϤÔÓ Á¿Ï· Ó· ¯ÔÚËÁÂ›Ù·È ÛÙÔ ‚Ú¤ÊÔ˜ Ì ÌÔ˘Î¿ÏÈ. ∞Ó Î·È Ô ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Â›Ó·È Û˘Ó‹ıˆ˜ ·ıÒÔ˜, ÂÈ‚¿ÏÏÂÙ·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂÈ¤‰ˆÓ ¯ÔÏÂÚ˘ıÚ›Ó˘ ·›Ì·ÙÔ˜ Ù· ÚÒÙ· ÙÚ›· 24ˆÚ· ˙ˆ‹˜, ‰ËÏ·‰‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÌÔÓ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘¿Ú¯ÂÈ Ë Ù¿ÛË, ÙfiÛÔ ÛÙË µ. ∞ÌÂÚÈ΋ fiÛÔ Î·È ÛÙË ¢. ∂˘ÚÒË, Ó· ‰›ÓÂÙ·È ÂÍÈÙ‹ÚÈÔ ÛÙË ÌËÙ¤Ú· Î·È ÙÔ ‚Ú¤ÊÔ˜ ̤۷ ÛÙȘ ÚÒÙ˜ 2448 ÒÚ˜ ·fi ÙÔÓ ÙÔÎÂÙfi. ∆Ô Ì¤ÙÚÔ ·˘Ùfi ¤¯ÂÈ Û›ÁÔ˘Ú· ÔÚÈṲ̂ӷ ÔÈÎÔÓÔÌÈο Î·È ÎÔÈÓˆÓÈο ÏÂÔÓÂÎÙ‹Ì·Ù·, ÂÓ¤¯ÂÈ fï˜ Î·È ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜, ·ÊÔ‡ ÌÔÚÔ‡Ó ¤ÙÛÈ Ó· ‰È·Ï¿ıÔ˘Ó ÛÔ‚·Ú¤˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ, ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· ·ÏÏ¿ Î·È ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·. ¶Ú¿ÁÌ·ÙÈ, Ô ·ÚÈıÌfi˜ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÛÔ‚·Ú‹ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· (¯ÔÏÂÚ˘ıÚ›ÓË >30 mg/dL) ÂÙ·Ï·ÛÈ¿ÛÙËΠٷ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™ÙËÓ ÂÍ·ÂÙ›· 1990-1996 ÂÈÛ‹¯ıËηÓ, Û ‰È¿ÊÔÚ· ÓÔÛÔÎÔÌ›· ÙˆÓ ∏¶∞, 31 ÓÂÔÁÓ¿ Ì ˘ÚËÓÈÎfi ›ÎÙÂÚÔ, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ù· 30 ¤·ÈÚÓ·Ó ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ŸÏ· ·˘Ù¿ Ù· ÓÂÔÁÓ¿ ›¯·Ó ¿ÚÂÈ ÂÍÈÙ‹ÚÈÔ ·fi ÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ ÚÈÓ Û˘ÌÏËÚÒÛÔ˘Ó 72 ÒÚ˜. ŸÏ· Ù· ÓÂÔÁÓ¿ ›¯·Ó ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Ô˘ ÍÂÂÚÓÔ‡Û ÙÔ 10% ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘. °È· ÙÔ˘˜ ·Ú·¿Óˆ ÏfiÁÔ˘˜, Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ Û˘ÓÈÛÙ¿: “∞Ó ÙÔ ÓÂÔÁ¤ÓÓËÙÔ ÂͤÏıÂÈ ÙÔ˘ Ì·È¢ÙËÚ›Ô˘ ÚÈÓ Û˘ÌÏËÚÒÛÂÈ 72 ÒÚ˜ ˙ˆ‹˜, ÂÈ‚¿ÏÏÂÙ·È Â·ÓÂÎÙ›ÌËÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘ ·ÏÏ¿ Î·È Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡ ̤۷ Û 2-3 Ë̤Ú˜ ·fi ÙËÓ ¤ÍÔ‰Ô”. ¶ÚÔÁÓˆÛÙÈο ¤¯ÂÈ ‚ÚÂı› fiÙÈ ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·›Ì·ÙÔ˜ ÛÙȘ 24 ÒÚ˜ ˙ˆ‹˜ Â›Ó·È <5 mg/dL, ÙfiÙÂ Ë Èı·ÓfiÙËÙ· Ó· ˘Âڂ› Ë ÙÈÌ‹ Ù˘ Ù· 17 mg ÛÙȘ 7296 ÒÚ˜ ˙ˆ‹˜ Â›Ó·È ·Û‹Ì·ÓÙË. Ÿ„ÈÌÔ˜ ›ÎÙÂÚÔ˜ ‹ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï· Ÿ„ÈÌÔ˜ ›ÎÙÂÚÔ˜ oÓÔÌ¿˙ÂÙ·È Ë ÂÌÊ¿ÓÈÛË ÈÎÙ¤ÚÔ˘ ÌÂÙ¿ ÙËÓ 4Ë Ë̤ڷ ˙ˆ‹˜ Î·È Ë ÂÈÌÔÓ‹ ÙÔ˘ ÁÈ· 1, 2 ‹ Î·È ÂÚÈÛÛfiÙÂÚÔ˘˜ Ì‹Ó˜. ∆Ô 1/3 ÂÚ›Ô˘ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÌÊ·Ó›˙ÂÈ ›ÎÙÂÚÔ ÙËÓ 3Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜. O ›ÎÙÂÚÔ˜ ·˘Ùfi˜ ıˆÚÂ›Ù·È fiÙÈ ‰È·Ê¤ÚÂÈ ·fi ÙÔÓ ÚÒÈÌÔ ›ÎÙÂÚÔ. ¶·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÈÎÙ¤ÚÔ˘. To 1963 Ô ∞rias Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ·ÔÌfiÓˆÛ·Ó Ì›· Ô˘Û›· ÛÙÔ Á¿Ï· (ÚÂÁÓ·Ó‰ÈfiÏË), Ë ÔÔ›· ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰Ú¿ÛË Ù˘ ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿Û˘, ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‰ËÏ·‰‹ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙË Û‡˙¢ÍË Ù˘ ¯ÔÏÂÚ˘-

209

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·210

¶·È‰È·ÙÚÈ΋ 2001;64:208-210

ıÚ›Ó˘ ÛÙÔ ‹·Ú Ì ‰ÈÁÏ˘ÎÔ˘ÚÔÓ›‰È·. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜, fï˜, ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ÙËÓ ·Ó·Î¿Ï˘„Ë ·˘Ù‹. ™ÙË Û˘Ó¤¯ÂÈ·, ‚Ú¤ıËΠfiÙÈ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË ÔÛfiÙËÙ· ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, Ù· ÔÔ›· ·‰Ú·ÓÔÔÈÔ‡Ó ÙË ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿ÛË. O‡ÙÂ Î·È Ë ıˆڛ· ·˘Ù‹ fï˜ ÂȂ‚·ÈÒıËΠ·fi ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜. ªÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·‰Ú·ÓÔÔ›ËÛË Ù˘ ÁÏ˘ÎÔ˘ÚÔÓ˘ÏÙÚ·ÓÛÊÂÚ¿Û˘ ÛÙÔ ‹·Ú, ·ÏÏ¿ Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ¤ÓÙÂÚÔ. ∏ ·˘ÍË̤ÓË ·˘Ù‹ ·ÔÚÚfiÊËÛË ·Ô‰fiıËΠ·Ú¯Èο Û ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‚ÁÏ˘ÎÔ˘ÚÔÓȉ¿Û˘ ÛÙÔ ¤ÓÙÂÚÔ. ∆Ô ¤Ó˙˘ÌÔ ·˘Ùfi, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, ‰È·Û¿ ÙËÓ ¤ÓˆÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Ì ٷ ‰ÈÁÏ˘ÎÔ˘ÚÔÓ›‰È·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÂÏ¢ıÂÚÒÓÂÙ·È Ë ¤ÌÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË, Ë ÔÔ›· ÛÙË Û˘Ó¤¯ÂÈ· ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ¤ÓÙÂÚÔ.

O‡Ù ÎÈ ·˘Ù‹ Ë ¿Ô„Ë, fï˜, ÂȂ‚·ÈÒıËΠÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ. ∏ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Û‹ÌÂÚ· Â›Ó·È fiÙÈ Ù· ·˘ÍË̤ӷ Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ Ì fi„ÈÌÔ ›ÎÙÂÚÔ ÔÊ›ÏÔÓÙ·È Û ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ¯ÔÏÂÚ˘ıÚ›Ó˘ ·fi ÙÔ ÂÙÈÎfi, Û·Ó Û˘Ó¤ÂÈ· ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂÈ¤‰ˆÓ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· (3). ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fi„ÈÌÔ˘ ÈÎÙ¤ÚÔ˘. ∆· ‚Ú¤ÊË Ì ÙÔÓ fi„ÈÌÔ˘ Ù‡Ô˘ ›ÎÙÂÚÔ Â›Ó·È Î·ı’ fiÏ· Ê˘ÛÈÔÏÔÁÈο ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·È Î·ÓÔÓÈο, ÎÂÚ‰›˙Ô˘Ó ‚¿ÚÔ˜ Î·È Ë ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ÙÔ˘˜ Â›Ó·È ¤ÌÌÂÛÔ˘ Ù‡Ô˘. ∂Ô̤ӈ˜, ·Ó ÙÔ ‚Ú¤ÊÔ˜ ÛÙȘ 14 Ë̤Ú˜ ˙ˆ‹˜ Â›Ó·È ˙ˆËÚfi, ‰ÂÓ ¤¯ÂÈ Ë·ÙÔÛÏËÓÈÎfi, Ù· Ô‡Ú· ÙÔ˘ ‰ÂÓ Â›Ó·È ÛÎÔ˘Úfi¯ÚˆÌ· Î·È Ù· ÎfiÚ·Ó¿ ÙÔ˘ ‰ÂÓ Â›Ó·È ·ԯڈ̷ÙÈṲ̂ӷ, ÙfiÙ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·Ì›· Â¤Ì‚·ÛË Î·È Û˘ÓÈÛÙ¿Ù·È Â·ÓÂͤٷÛË ÙÔ˘ ÓÂÔÁÓÔ‡. ∞Ó fï˜ ÙÔ ÓÂÔÁÓfi ÛÙȘ 21 Ë̤Ú˜ ˙ˆ‹˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÌÊ·Ó›˙ÂÈ ›ÎÙÂÚÔ, ÙfiÙ ··ÈÙÂ›Ù·È ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÙ›·˜ ÙÔ˘ ÈÎÙ¤ÚÔ˘. ª›· ÂÓ·ÏÏ·ÎÙÈ΋ χÛË Â›Ó·È Ë ‰È·ÎÔ‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· 24 ÒÚ˜, ÔfiÙ ‰È·ÈÛÙÒÓÂÙ·È ¿ÌÂÛË ÙÒÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÌÂÙ¿ ·fi 24 ÒÚ˜, Ë ÔÔ›· Êı¿ÓÂÈ ÙÔ 50% ̤۷ Û 2-3 Ë̤Ú˜. ∞˘Ù‹ Ë ÂÓ¤ÚÁÂÈ·, fï˜, ‰ÂÓ Û˘ÓÈÛٿٷÈ, ·Ú¿ ÌfiÓÔ ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·›Ì·ÙÔ˜ ˘Âڂ› Ù· 20 mg/dL.

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™¯¤ÛË ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi Î·È ÈÎÙ¤ÚÔ˘ ·fi ÌËÙÚÈÎfi Á¿Ï· ∏ ‚·ÛÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ·˘ÙÒÓ Ù‡ˆÓ ÈÎÙ¤ÚÔ˘ Â›Ó·È fiÙÈ Ô ÌÂÓ ÚÒÈÌÔ˜ ÔÊ›ÏÂÙ·È Û ·ÓÂ·Ú΋ ÚÔÛÊÔÚ¿ ‹ Ï‹„Ë Á¿Ï·ÎÙÔ˜, ÂÓÒ Ô fi„ÈÌÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Û ÓÂÔÁÓ¿ Ô˘ ÙÚ¤ÊÔÓÙ·È ÈηÓÔÔÈËÙÈο. Œ¯ÂÈ ‚ÚÂı›, fï˜, fiÙÈ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÓÂÔÁÓÒÓ Ì fi„ÈÌÔ ›ÎÙÂÚÔ Â›¯Â ˘„ËÏ¿ Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ÙȘ ÚÒÙ˜ 4 Ë̤Ú˜ ˙ˆ‹˜ (ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜). ∫·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ, ÂÍ¿ÏÏÔ˘, ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓÔ˜ ÂÓÙÂÚÔË·ÙÈÎfi˜ ·ÎÏÔ˜ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÔÈ ‰‡Ô ·˘ÙÔ› ›ÎÙÂÚÔÈ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙ˜ ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜, ·ÏÏ¿ ‰È·ÊÔÚÂÙÈΤ˜ fi„ÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÌ›ÛÌ·ÙÔ˜. °È· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ›Ûˆ˜, ı· Ú¤ÂÈ Ó· ÂÍ·ÎÔÏÔ˘ı‹ÛÂÈ Ó· ˘Ê›ÛÙ·Ù·È ·˘Ù‹ Ë ‰È·ÊÔÚÔÔ›ËÛË ÁÈ· Ó· ‰›‰ÂÙ·È ¤ÌÊ·ÛË ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô ÚÒÈÌÔ˜ ›ÎÙÂÚÔ˜ ·fi ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·, ·ÏÏ¿ Û ·ÓÂ·Ú΋ ıËÏ·ÛÌfi. ∂Ô̤ӈ˜, Â›Ó·È Ï¿ıÔ˜ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ‰È·ÎÔ‹ ÙÔ˘ ÛÙ‹ıÔ˘˜ Î·È Î·Ù·Ê˘Á‹ ÛÙÔ ÌÔ˘Î¿ÏÈ. ∞ÓÙ›ıÂÙ·, Û˘ÛÙ‹ÓÂÙ·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ÚÔÛ¿ıÂÈ·˜ ÁÈ· ηχÙÂÚÔ ıËÏ·ÛÌfi ÛÙÔ ÛÙ‹ıÔ˜. ∫·Ù·Ï‹ÁÔÓÙ·˜, ÌÔÚԇ̠ӷ ԇ̠fiÙÈ Ô ›ÎÙÂÚÔ˜ Û ‚Ú¤ÊÔ˜ Ô˘ ıËÏ¿˙ÂÈ ÛˆÛÙ¿ ·ÔÙÂÏ› ·ıÒÔ Ê·ÈÓfiÌÂÓÔ Î·È Û¯Â‰fiÓ ÔÙ¤ ‰ÂÓ Ú¤ÂÈ Ó· ·ÔÙÂÏ› ·ÈÙ›· ‰È·ÎÔ‹˜ ÙÔ˘ ıËÏ·ÛÌÔ‡. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gartner LM, Lee K. Jaundice in the breast fed infant. Clin Perinatol 1999;26:431-445.

2. Maisels MJ, Newman TB. Jaundice in full term and near term babies who leave the hospital within 36 hours. Clin Perinatol 1998;25:295-302.

3. Johnson L, Bhutani VK. Guidelines for management of the jaundiced term and near term infants. Clin Perinatol 1998;25:555-574.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: X. ∫ÒÛÙ·ÏÔ˜ ∞ÚÙ¤ÌȉԘ 130, ¶. º¿ÏËÚÔ, 175 62

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∞§§∂ƒ°π√§√°π∞ - ¢∂ƒª∞∆√§√°π∞

Paediatriki 2001;64:211-214

ALLERGIOLOGY -

∆È Â›Ó·È, ÙÈ ‰ÂÓ Â›Ó·È ¿ÛıÌ·; ∫. ¡. ¶Ú›ÊÙ˘

What is, what is not asthma?

K. N. Priftis

¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÂ Û˘ÓÙÔÌ›· Ô ÔÚÈÛÌfi˜ ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Î·È ÔÈ Î·ıËÌÂÚÈÓ¤˜ ‰È·ÁÓˆÛÙÈΤ˜ ‰˘ÛÎÔϛ˜. ∂Í·ÈÙ›·˜ ÙˆÓ ÔÏÏÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ÔÚÈÛÌfi ·ÏÏ¿ Î·È Ù˘ ÔÈÎÈÏ›·˜ ÙÔ˘ Ê·ÈÓÔÙ‡Ô˘ ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, ÙÔ ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ ·ÔÙÂÏ› ÙË ‚¿ÛË ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ “‡ÔÙÔ˘” Ó·ÚÔ‡ ·ÛıÂÓÔ‡˜. OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÏËÚÔÊÔڛ˜ ¤¯Ô˘Ó Û˘ÌÏËڈ̷ÙÈÎfi ÚfiÏÔ.

Abstract: The definition of bronchial asthma and the every day diagnostic dificulties are briefly described. The complex nature of asthma itself and the phenotypic variety of childhood asthma have lead to the use of the clinical approach as the main diagnostic tool in paediatric practice.

Laboratory investigation has a complementary role.

§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ¿ÛıÌ·, ÔÚÈÛÌfi˜, ‰È¿ÁÓˆÛË.

Key words: diagnosis.

∂ÈÛ·ÁˆÁ‹ ™ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ, Ë ˘ÔÙÚÔÈ¿˙Ô˘Û· ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î·È ÂȉÈÎfiÙÂÚ· Ô ˘ÔÙÚÔÈ¿˙ˆÓ ‚‹¯·˜ Î·È Û˘ÚÈÁÌfi˜ ¤¯Ô˘Ó ηٷÛÙ› ·fi ÙȘ ÚÒÙ˜ ·Èٛ˜ Â›Û΄˘ ·ÛıÂÓÒÓ ÛÙ· ·È‰È·ÙÚÈο È·ÙÚ›·. ∫·Ù¿ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÈÔ ¿Óˆ Û˘Ìو̿وÓ, Ôχ Û˘¯Ó¿ Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó Ù· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ı· Ú¤ÂÈ Ó· ÂÎÏËÊıÔ‡Ó ˆ˜ ‰ËψÙÈο ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜. ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÓÙ·ÂÙ›· ˘‹ÚÍ ÌÂÁ¿ÏË ÚfiÔ‰Ô˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ¢ÂÓ ˘‹ÚÍÂ, fï˜, ·Ó¿ÏÔÁË ÚfiÔ‰Ô˜ ÛÙËÓ ÚÔÙÂÈÓfiÌÂÓË ‰È·ÁÓˆÛÙÈ΋ Ú·ÎÙÈ΋. ∞ÓÙ›ıÂÙ·, ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·‰Ô¯Èο Ú‡̷ٷ Ù¿ÛÂˆÓ ˘ԉȿÁÓˆÛ˘ Î·È ÙÂÏÂ˘Ù·›·, ˘ÂډȿÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘. ø˜ ·Ó¿ÁÎË ϤÔÓ, ·fi ÙȘ ·Ú¯¤˜ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ‰ÂηÂÙ›·˜, ¤ÁÈÓ·Ó ·fiÂÈÚ˜ ‰È·Ù‡ˆÛ˘ ÎÔÈÓ¿ ·Ô‰ÂÎÙÔ‡ ÔÚÈÛÌÔ‡ ÙÔ˘ ¿ÛıÌ·ÙÔ˜.

O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ηÏÂ›Ù·È Ó· ηχ„ÂÈ

·Ó¿ÁΘ, fi¯È ÌfiÓÔ ÛÙÔ Â›Â‰Ô Ù˘ ηıËÌÂÚÈÓ‹˜ ‰È·ÁÓˆÛÙÈ΋˜ Ú·ÎÙÈ΋˜, ·ÏÏ¿ Î·È ÛÙÔ ÂÚ¢ÓËÙÈÎfi Â›‰Ô. ™˘Ó¤ÂÈ· ·˘ÙÔ‡ Â›Ó·È Î·È Ë ÚÔ‚ÔÏ‹ ÙˆÓ ÔÈÎ›ÏˆÓ ÎÚÈÙËÚ›ˆÓ ·Ó¿ÏÔÁ· Ì ÙÔ ÛÎÔfi ÁÈ· ÙÔÓ ÔÔ›Ô ‰È·Ù˘ÒÓÂÙ·È (1). ¢È·ÊÔÚÂÙÈÎfi Â›Ó·È ÙÔ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi Ô˘ ÂÎÙÈÌ¿ ÙÔ ÌÂÌÔӈ̤ÓÔ ·ÛıÂÓ‹ ÙÔ˘ Î·È ‰È·ÊÔÚÂÙÈÎfi ÁÈ· ÙÔÓ ÂȉËÌÈÔÏfiÁÔ Ô˘ ‚·Û›˙ÂÙ·È Û οÔÈÔ ·Ïfi ÎÔÈÓfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘ (Û˘ÚÈÁÌfi˜), ÙÔÓ Ê˘ÛÈÔÏfiÁÔ Ô˘ ·Ó·˙ËÙ¿ ÌÂÙÚ‹ÛÈ̘ ·Ú·Ì¤ÙÚÔ˘˜ (Ì›ˆÛË Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú· ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜), ÙÔÓ ·ÓÔÛÔÏfiÁÔ Ô˘ ¯ÚËÛÈÌÔÔÈ› ·ÓÔÛÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ‹ ÙÔÓ ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ Ô˘ ¯ÚËÛÈÌÔÔÈ› ÈÛÙÔÏÔÁÈο ‰Â›ÁÌ·Ù· ÁÈ· Ó· ÂÓÙÔ›ÛÂÈ ÙË ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ·È‰È¿ÙÚÔ˘ Ô˘ ηÏÂ›Ù·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ Úfi‚ÏËÌ· ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓÔ‡˜, ·ÛÊ·ÏÒ˜ ÚÔ¤¯ÂÈ ÙÔ ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ, ·ÏÏ¿ Î·È ·˘Ùfi ‰ÂÓ ‰È·ÛÊ·Ï›˙ÂÈ ÙË ‰È¿ÁÓˆÛË. ∂ÈϤÔÓ,

∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·

Division of Allergy Penteli Children’s General Hospital, Athens

childhood

asthma,

definition,

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¶·È‰È·ÙÚÈ΋ 2001;64:211-214

ÂÎÊÚ¿˙ÂÙ·È ÂÈÊ˘Ï·ÎÙÈÎfiÙËÙ·, fiÙ·Ó Û˘ÌÂÚ¿ÛÌ·Ù· ·fi ·Ú·ÙËÚ‹ÛÂȘ Û ·ÛıÌ·ÙÈÎÔ‡˜ ÂÓ‹ÏÈÎÔ˘˜ ÌÂٷʤÚÔÓÙ·È ÛÙ· ·È‰È¿ Î·È ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÛÙ· ‚Ú¤ÊË (2).

OÚÈÛÌfi˜ O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ô˘ ÚoÙ¿ıËΠÙÔ 1995 ·fi ÙË GINA (Global Initiative for Asthma) Î·È Â›Ó·È Û‹ÌÂÚ· Ô ϤÔÓ ·Ô‰ÂÎÙfi˜, ‰È·Ù˘ÒÓÂÙ·È ˆ˜ ·ÎÔÏÔ‡ıˆ˜ (3,4): “∆Ô ¿ÛıÌ· ·ÔÙÂÏ› ¯ÚfiÓÈ· ÊÏÂÁÌÔÓÒ‰Ë ‰È·Ù·Ú·¯‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ¤¯Ô˘Ó ‰È¿ÊÔÚ· ·ÙÙ·Ú·, ȉȷ›ÙÂÚ· Ì·ÛÙÔ·ÙÙ·Ú·, ˈÛÈÓfiÊÈÏ· Î·È ∆ ÏÂÌÊÔ·ÙÙ·Ú·. ™Â ¢·ÈÛıËÙÔÔÈË̤ӷ ¿ÙÔÌ·, Ë Î·Ù¿ÛÙ·ÛË Ô‰ËÁ› Û Â·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi Û˘ÚÈÁÌfi, ‰‡ÛÓÔÈ·, Û˘ÛÊÈÎÙÈÎfi ¿ÏÁÔ˜ ÛÙÔ ıÒڷη Î·È ‚‹¯·, ȉȷ›ÙÂÚ· ηٿ ÙȘ Ó˘ÎÙÂÚÈÓ¤˜ Î·È ÚÒÙ˜ ÚˆÈÓ¤˜ ÒÚ˜. ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ Û˘Ó‹ıˆ˜ ÔÊ›ÏÔÓÙ·È Û ÛËÌ·ÓÙÈÎfi (·ÏÏ¿ ‰È¿ÊÔÚÔ˘ ‚·ıÌÔ‡) ÂÚÈÔÚÈÛÌfi Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú·, ÂÓ Ì¤ÚÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ·Ó·ÛÙÚ¤„ÈÌÔ, ›Ù ·˘ÙfiÌ·Ù·, ›Ù Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÁˆÁ‹. ∏ ÊÏÂÁÌÔÓ‹ Ô‰ËÁ›, Â›Û˘, Û ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ”. ¢ËÏ·‰‹, ÁÈ· ÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û ÙÚ›· Â›‰·: ÙÔ ÈÛÙÔÏÔÁÈÎfi (ÊÏÂÁÌÔÓ‹), ÙÔ ÎÏÈÓÈÎfi (Û˘ÌÙÒÌ·Ù·, ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·), ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi (‚ÚÔÁ¯È΋ ·ÓÙȉڷÛÙÈÎfiÙËÙ·). ∞Ó Î·È Ô ÔÚÈÛÌfi˜ ·˘Ùfi˜ ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ Ô‰ËÁfi, Ë ·Í›· ÙÔ˘ ·Ú·Ì¤ÓÂÈ ÂÚÈÔÚÈṲ̂ÓË ÁÈ· ‰‡Ô ·ÚÈÔ˘˜ ÏfiÁÔ˘˜: ¶ÚÒÙÔÓ, ‰ÈfiÙÈ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋ ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈ̘ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ˘¿Ú¯Ô˘Û˜ ÌÂıfi‰Ô˘˜ ÂϤÁ¯Ô˘ ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜, Ù˘ ‚ÚÔÁ¯ÔÛÙ¤ÓˆÛ˘ Î·È Ù˘ ‚ÚÔÁ¯È΋˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜. ¢Â‡ÙÂÚÔÓ, ‰ÈfiÙÈ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ ‰ÂÓ Â›Ó·È ÙÂÎÌËÚȈ̤ÓË Ë ÈÛ¯‡˜ fiÏˆÓ ÙˆÓ ÈÔ ¿Óˆ ÛÙÔȯ›ˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ÔÚÈÛÌfi. ™Ù· ‚Ú¤ÊË, ÔÈ ÁÓÒÛÂȘ Ì·˜ ÁÈ· ÙËÓ ˘ÔΛÌÂÓË ·ıÔÊ˘ÛÈÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ Â›Ó·È ÂÏÏÈ›˜ Î·È Ë ‰È¿ÁÓˆÛË Î·Ù¿ ‚¿ÛË ·Ú·Ì¤ÓÂÈ ÎÏÈÓÈ΋. ∆Ô ‚ÚÂÊÈÎfi ¿ÛıÌ· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÂÈÛfi‰È· ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌÔ‡ ηÈ/‹ Â›ÌÔÓÔ˘ ‚‹¯·, Û ¤‰·ÊÔ˜ Ô˘ ‰È¢ÎÔχÓÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (.¯. Û˘ÓÔ‰fi˜ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·ÙÔÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi) ·ÊÔ‡ ¤¯Ô˘Ó ·ÔÎÏÂÈÛÙ› ÔÈ ¿ÏϘ Èı·Ó¤˜ ·Èٛ˜ (5-8). ™Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο ۷ʤÛÙÂÚ· ‰Â‰Ô̤ӷ, ¤ÙÛÈ ÒÛÙ ӷ ıˆÚÂ›Ù·È Ì›· ÂӉȿÌÂÛË Î·Ù¿ÛÙ·ÛË. ∂ÓÒ, Ì ÙËÓ ÚfiÔ‰Ô Ù˘ ËÏÈΛ·˜ (Û¯ÔÏÈ΋ ËÏÈΛ·) ÈÛ¯‡ÂÈ Â˘Ú¤ˆ˜ Ô ÎÏ·ÛÈÎfi˜ ÔÚÈÛÌfi˜ (2).

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Paediatriki 2001;64:211-214

ÀÔÙÚÔÈ¿˙ˆÓ Û˘ÚÈÁÌfi˜ ‚ÚÂÊÈ΋˜ Î·È ÌÈÎÚ‹˜ ·È‰È΋˜ ËÏÈΛ·˜ ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ ÙÔ˘ F. Martinez (9-11) Ô‰‹ÁËÛ·Ó ÛÙËÓ Ù·ÍÈÓfiÌËÛË 3 ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÚÈÁÌfi: ·) ™Ù· ·È‰È¿ Ì ·ÚÔ‰ÈÎfi ÚÒÈÌÔ Û˘ÚÈÁÌfi Ô˘ ÂΉËÏÒÓÔ˘Ó ÙÔ Û‡Ìو̷ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ·ÏÏ¿ ˆ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ Â›Ó·È ÂχıÂÚ·. ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ Ì ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó, ‚) ™Ù· ·È‰È¿ Ì fi„ÈÌÔ Û˘ÚÈÁÌfi Ô˘ ÂΉËÏÒÓÔ˘Ó ÙÔ Û‡Ìو̷ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ. ¶·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË Ì ÙÔ ÌËÙÚÈÎfi ¿ÛıÌ· Î·È Á) ™Â ÂΛӷ Ì Â›ÌÔÓÔ Û˘ÚÈÁÌfi Ô˘ ÙÔ Û‡Ìو̷ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Î·È ‰È·ÚΛ. ∫·È Â‰Ò ·Ú·ÙËÚÂ›Ù·È Û˘Û¯¤ÙÈÛË Ì ÙÔ ÌËÙÚÈÎfi ¿ÛıÌ·, ÙÔ Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜, ÙËÓ ÂΉ‹ÏˆÛË Û˘ÚÈÁÌÔ‡ ¯ˆÚ›˜ ÈÒÛÂȘ Î·È ÙËÓ ·ÚÔ˘Û›· Û˘ÓÔ‰Ô‡ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ë ÔÏÈ΋ πgE ÙÔ˘ ÔÚÔ‡ Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙ· ·È‰È¿ Ì Â›ÌÔÓÔ Û˘ÚÈÁÌfi, ÂÓÒ ıÂÙÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ (¢·ÈÛıËÙÔÔ›ËÛË) ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ì fi„ÈÌÔ Î·È Â›ÌÔÓÔ Û˘ÚÈÁÌfi. º·›ÓÂÙ·È, ‰ËÏ·‰‹, fiÙÈ Ë ‰È¿ÁÓˆÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ ÌÔÚ› Ó· Û˘˙ËÙÂ›Ù·È “·ÛʷϤÛÙÂÚ·” ÛÙ· ·È‰È¿ Ì ÙÔÓ fi„ÈÌÔ Î·È Â›ÌÔÓÔ Û˘ÚÈÁÌfi.

EÙÂÚÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ∆Ô ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ¤Ó· Ê·ÈÓÔÙ˘Èο ÂÙÂÚÔÁÂÓ¤˜ ÓfiÛËÌ·. ∞˘Ùfi Á›ÓÂÙ·È Úfi‰ËÏÔ ·fi ÙÔ ÌÂÁ¿ÏÔ Â‡ÚÔ˜ Ù˘ ËÏÈΛ·˜ ¤Ó·Ú͢, Ù˘ ÎÏÈÓÈ΋˜ ÚÔ‚ÔÏ‹˜ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ηÈ, Ù¤ÏÔ˜, Ù˘ ‰È·ÊÔÚÂÙÈ΋˜ ·¿ÓÙËÛ˘ ÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ (1). ∂ȉÈÎfiÙÂÚ˜ ÌÔÚʤ˜, fiˆ˜ ÙÔ ‚ÚÂÊÈÎfi ¿ÛıÌ·, ÙÔ ¿ÛıÌ· ÌÂÙ¿ ·fi ¿ÛÎËÛË, ÙÔ Ó˘ÎÙÂÚÈÓfi ¿ÛıÌ·, ÙÔ ÏÔÈÌ҉˜ ¿ÛıÌ· ·ÔÙÂÏÔ‡Ó ‰È·ÊÔÚÂÙÈΤ˜ ÂÎÊÚ¿ÛÂȘ ÙÔ˘ ›‰ÈÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ¶·Ú¿ÏÏËÏ·, ˘¿Ú¯Ô˘Ó ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ Ô˘ ·ÁÁ›˙Ô˘Ó ÙÔ ·È‰ÈÎfi ¿ÛıÌ· Ì ‰˘Û‰È¿ÎÚÈÙ· fiÚÈ·, fiˆ˜ Â›Ó·È Ô ÌÂÙ·‚ÚÔÁ¯ÈÔÏÈÙȉÈÎfi˜ Û˘ÚÈÁÌfi˜, Ô ‚‹¯·˜ ÈÛÔ‰‡Ó·ÌÔ˜ ¿ÛıÌ·ÙÔ˜, Ë °O¶ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·Ó·Ó¢ÛÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î.¿. ™ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È¿ÊÔÚ· ÂÚÁ·Ï›· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÓfiÛÔ˘. ∞˘Ù¿ ›ӷÈ: 1) ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, fiÔ˘ ÌÂ Ù˘ÔÔÈË̤Ó˜ ÂÚˆÙ‹ÛÂȘ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ·ÓȯÓ‡ÂÙ·È Ë ÓfiÛÔ˜ ·fi ÙËÓ ÂΉ‹ÏˆÛË ·ÛıÌ·ÙÈÎÒÓ Û˘Ìو̿وÓ, ‹ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÁÈ·ÙÚÔ‡ Ô˘ ÌÔÚ› Ó· ¤ÁÈÓ Û οÔÈ· Ê¿ÛË Ù˘ ̤¯ÚÈ ÙÒÚ· ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡, 2) OÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜

MAY- JUNE '01 TELIKO

30-05-03

18:55

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¶·È‰È·ÙÚÈ΋ 2001;64:211-214

ÙˆÓ Ó¢ÌfiÓˆÓ, fiˆ˜ Â›Ó·È Ë ‰ÔÎÈÌ·Û›· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜, Ô ¤ÏÂÁ¯Ô˜ ÁÈ· Ù˘¯fiÓ ‚ÚÔÁ¯È΋ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·, 3) O ¤ÏÂÁ¯Ô˜ ·ÙÔ›·˜ (‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜, Rast). ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·È Ù· ÙÚ›· ÈÔ ¿Óˆ ÂÚÁ·Ï›·, ·ÏÏ¿ fiÏ· ¤¯Ô˘Ó ·‰˘Ó·Ì›Â˜ ÒÛÙ ӷ ·Ú·Ì¤ÓÂÈ Úfi‚ÏËÌ· Ô ÙÚfiÔ˜ ·ÎÚÈ‚Ô‡˜ ÂÚÌËÓ›·˜ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Î·È ·Ó›¯Ó¢Û˘ Ù˘ ÓfiÛÔ˘ ÏfiÁˆ Ù˘ Ê·ÈÓÔÙ˘È΋˜ ÂÙÂÚÔÁ¤ÓÂÈ·˜ (12). ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋, Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ‚·Û›˙ÂÙ·È ÚˆÙ›ÛÙˆ˜ ÛÙÔ ÈÛÙÔÚÈÎfi. ™ÙË Û˘Ó¤ÓÙ¢ÍË Ì ÙÔ˘˜ ÁÔÓ›˜ ¯ÚÂÈ¿˙ÂÙ·È Î·Ïfi Îϛ̷ Î·È ÈηÓfi˜ ¯ÚfiÓÔ˜, ÒÛÙ Ì ÙȘ ηٿÏÏËÏ· ‰È·Ù˘ˆÌ¤Ó˜ Î·È Î·Ù·ÓÔËÙ¤˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÚˆÙ‹ÛÂȘ Ô ·È‰›·ÙÚÔ˜ Ó· Â›Ó·È Û ı¤ÛË Ó· Û¯ËÌ·Ù›ÛÂÈ ¿Ô„Ë. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ÛÙËÓ ÔÍ›· ‹ ·ÎfiÌ· Î·È ÛÙËÓ ÂӉȿÌÂÛË Ê¿ÛË ÌÔÚ› Ó· ÚÔÛı¤ÛÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜. øÛÙfiÛÔ ‰ÂÓ ¤¯ÂÈ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ηÏÔ‡ ÈÛÙÔÚÈÎÔ‡. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ·ÓÙÏÔ‡ÓÙ·È Û˘ÌÏËڈ̷ÙÈΤ˜ ÏËÚÔÊÔڛ˜. ∞Ó ¯ÚÂÈ¿˙ÂÙ·È Ì›· ÌfiÓË ÂͤٷÛË, ı· Ú¤ÂÈ Ì¿ÏÏÔÓ Ó· Â›Ó·È Ë ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∫·Ïfi Â›Ó·È Ó· ˘¿Ú¯ÂÈ Û οı ·È‰› Ô˘ Ï·Ì‚¿ÓÂÈ Û˘ÛÙËÌ·ÙÈο Ì·ÎÚÔ¯ÚfiÓÈ· ÚÔÏËÙÈ΋ ·ÁˆÁ‹. ∏ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ÔÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ (IgG, IgM, IgA, IgE) ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈ̘ Û ÂÚÈÙÒÛÂȘ ÂÚ·ÈÙ¤Úˆ ÂÈÌÔÓ‹˜ ÙˆÓ Û˘Ìو̿وÓ, ¿ÓÙÔÙ ηٿ ÙËÓ ÎÚ›ÛË ÙÔ˘ ıÂÚ¿ÔÓÙ· È·ÙÚÔ‡. ŒÏÂÁ¯Ô˜ Ì ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ Ó¢ÌfiÓˆÓ ÌÔÚ› Ó· ˙ËÙËı› Û ·È‰È¿ ¿Óˆ ÙˆÓ 6-7 ÂÙÒÓ. ∞Ï‹ Î·È ¯Ú‹ÛÈÌË Â›Ó·È Ë ‰ÔÎÈÌ·Û›· ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ Ô˘ ÌÔÚ› Ó· Á›ÓÂÈ ÛÙÔ Î¿ı ·È‰È·ÙÚÈÎfi È·ÙÚÂ›Ô Ì ÙÔ ÚÔfiÌÂÙÚÔ. ™Â ÂÈÏÂÁ̤ӷ ·È‰È¿ Ú¤ÂÈ Ó· ˙ËÙÂ›Ù·È Î·È Ë ‰ÔÎÈÌ·Û›· ȉÚÒÙ·. O ÁÂÓÈÎfi˜ ηÓfiÓ·˜ Ù˘ È·ÙÚÈ΋˜ ÈÛ¯‡ÂÈ Î·È ÛÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÙÔ˘ Èı·ÓÔ‡ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜, fiÙÈ ‰ËÏ·‰‹ ÔÈ ‰È·ÁÓˆÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ú¤ÂÈ Ó· ˙ËÙÔ‡ÓÙ·È ÌfiÓÔ fiÙ·Ó Ô ÁÈ·ÙÚfi˜ ÂÚÈ̤ÓÂÈ Ó· ·ÍÈÔÔÈ‹ÛÂÈ ‰È·ÁÓˆÛÙÈο Ù· ·ÔÙÂϤÛÌ·Ù·. ∆¤ÏÔ˜, ȉȷ›ÙÂÚ˘ ÛËÌ·Û›·˜ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ Â›Ó·È ÙÔ ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ÃÔÚËÁÂ›Ù·È ·ÓÙÈ·ÛıÌ·ÙÈ΋ ·ÁˆÁ‹ Î·È ÂÎÙÈÌ¿Ù·È Ë ·¿ÓÙËÛË, ÒÛÙ ·Ó¿ÏÔÁ· Ó· ÂÓÈÛ¯‡ÂÙ·È ‹ Ó· ·Ô‰˘Ó·ÌÒÓÂÙ·È Ë ·Ú¯È΋ ÎÏÈÓÈ΋ ˘Ô„›·. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÓÙ·ÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó Û ÂÚÈÛÛfiÙÂÚÔ ÔÍ›˜ ÂÚÈÙÒÛÂȘ “·Ó·ÎÔ˘ÊÈÛÙÈο” Ê¿Ú̷η, fiˆ˜ Â›Ó·È ÔÈ ÂÈÛÓÂfiÌÂÓÔÈ ‚2-·ÁˆÓÈÛÙ¤˜, ÙÔ ‚ÚˆÌÈÔ‡¯Ô ÈÚ·ÙÚfiÈÔ, ·ÎfiÌ· Î·È ‚Ú·¯˘¯ÚfiÓÈÔ Û¯‹Ì· ÛÙÂÚÔÂȉÒÓ (Û˘Ó‹ıˆ˜ ·fi ÙÔ˘

Paediatriki 2001;64:211-214

ÛÙfiÌ·ÙÔ˜). ™Â ¯ÚÔÓÈfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÌÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó “Ú˘ıÌÈÛÙÈο” Ê¿Ú̷η ηٿ ÙËÓ ÂfiÌÂÓË ÂÚ›Ô‰Ô ÙˆÓ 4-8 ‚‰ÔÌ¿‰ˆÓ Ì ¯ÚˆÌfiÓ˜ ‹ ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÌÂ/‹ ¯ˆÚ›˜ ‚2-·ÁˆÓÈÛÙ‹ Ì·ÎÚ¿˜ ‰Ú¿Û˘. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË, ·ÍÈÔÏÔÁÂ›Ù·È ÙÔ ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. πηÓÔÔÈËÙÈ΋ ·¿ÓÙËÛË ÂÓÈÛ¯‡ÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÂÓÒ Ë ÂÈÌÔÓ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ˘Ô‰ËÏÒÓÂÈ ·Ó¿ÁÎË Â·Ó·‰Ú·ÛÙËÚÈÔÔ›ËÛ˘ Ù˘ ‰È·ÊÔÚԉȷÁÓˆÛÙÈ΋˜ ÛΤ„˘ (13). ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú·ÎÙÈ΋, Â› ˘Ô„›·˜ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ηٿ ÙËÓ ÎÚ›ÛË ÙÔ˘ È·ÙÚÔ‡. ∫·Ïfi Â›Ó·È Ó· ÂÍËÁÂ›Ù·È ÛÙÔ˘˜ ÁÔÓ›˜ Ô ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Î·È Ó· ·ÔʇÁÔÓÙ·È ·fiÏ˘Ù˜ ÂÎÊÚ¿ÛÂȘ, fi¯È ÁÈ· ÏfiÁÔ˘˜ ÂÈÎÔÈÓˆÓÈ·ÎÔ‡˜ ·ÏÏ¿ ÁÈ·Ù› Ë ›‰È· Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È “ηı' Ô‰fiÓ”. ¶ÔÏϤ˜ ÊÔÚ¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÓ·ÏÏ·ÎÙÈο ¿ÏϘ ‰È·ÁÓÒÛÂȘ, fiˆ˜ ·ÛıÌ·ÙÔÂȉ‹˜ ‚ÚÔÁ¯›Ùȉ·, Û·ÛÙÈ΋ ‚ÚÔÁ¯›Ùȉ· Î.¿. ∏ ÛËÌÂÚÈÓ‹ Ù¿ÛË Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÚÚÈÙÈ΋ ÚÔ˜ ·˘Ù¤˜ ÙȘ ÂÎÊÚ¿ÛÂȘ Û ۯ¤ÛË Ì ÙÔ ÚfiÛÊ·ÙÔ ·ÚÂÏıfiÓ, ·ÏÏ¿ Î·È ¿ÏÈ Ë ¯Ú‹ÛË ÙÔ˘˜ ÎÈÓ‰˘Ó‡ÂÈ Ó· Ô‰ËÁ‹ÛÂÈ ÛÙÔ ‰È·ÁÓˆÛÙÈÎfi ÂÊËÛ˘¯·ÛÌfi Î·È ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÒıËÛË (ÁÈ· fiÔÈÔ˘˜ ÏfiÁÔ˘˜), fi¯È ÌfiÓÔ ÙÔ˘ fiÚÔ˘ ¿ÛıÌ· ·ÏÏ¿ Î·È Ù˘ ›‰È·˜ Ù˘ ÓfiÛÔ˘. EÈϤÔÓ, Ô fiÚÔ˜ “‚ÚÔÁ¯›Ùȉ·” ÎÈÓ‰˘Ó‡ÂÈ Ó· Ô‰ËÁ‹ÛÂÈ ›Ûˆ Û ·Ï·ÈfiÙÂÚ˜ ·ÓÙÈÏ‹„ÂȘ ·ÓÙÈÌÂÙÒÈÛ˘ fiÏˆÓ ÙˆÓ ‚ÚÂÊÒÓ ‹ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· ‹ Â›ÌÔÓÔ Û˘ÚÈÁÌfi Ì ·ÓÙÈ‚ÈÔÙÈο. ∞ÓÙ›ıÂÙ·, Ë Â‡ÎÔÏË ˘ÈÔı¤ÙËÛË ÙÔ˘ fiÚÔ˘ ¿ÛıÌ· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ê·Ú̿ΈÓ, ·Ú·Î¿ÌÙÔÓÙ·˜ ÙÔÓ ··ÈÙÔ‡ÌÂÓÔ ‰È·ÁÓˆÛÙÈÎfi ÚÔ‚ÏËÌ·ÙÈÛÌfi. ∞Ó ˘¿Ú¯ÂÈ ‰È·ÁÓˆÛÙÈ΋ ·‰˘Ó·Ì›·, ÚÔÎÂÈ̤ÓÔ˘ Ó· Ù›ıÂÙ·È ·Û·Ê‹˜ ‰È¿ÁÓˆÛË, Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ÂÚÈÁÚ¿ÊÂÙ·È ÙÔ Û‡Ìو̷ (.¯. ˘ÔÙÚÔÈ¿˙ˆÓ ‹ Â›ÌÔÓÔ˜ Û˘ÚÈÁÌfi˜). ∂Ó·ÏÏ·ÎÙÈο, ÌÔÚ› Ó· ‰ËÏÒÓÂÙ·È Ô ‰È·ÁÓˆÛÙÈÎfi˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Ì ÙËÓ ¤ÎÊÚ·ÛË “Èı·Ófi ·È‰ÈÎfi ¿ÛıÌ·”. ™˘ÓÂÒ˜, ‚¿ÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤Ï·Û˘ ÛÙÔ ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË. OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ‚ÔËıÔ‡Ó ÏÈÁfiÙÂÚÔ Î·È Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÂÈÏÂÁ̤ӷ, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÎÏÈÓÈÎfi ÚÔ‚ÏËÌ·ÙÈÛÌfi. ∏ ‰ÔÎÈÌ·ÛÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ·ÛıÌ·ÙÈ΋˜ ·ÁˆÁ‹˜ ÌÔÚ› Ó· ‰È¢ÎÔχÓÂÈ ÙËÓ ÂÍ·ÁˆÁ‹ Ô˘ÛÈ·ÛÙÈÎÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù· ∞) O ÔÚÈÛÌfi˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ Î·È ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈ̤ÓË ÈÛ¯‡ ÛÙ· ‚Ú¤ÊË Î·È Ù· ÌÈÎÚ¿ ·È‰È¿.

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µ) ∆Ô ·È‰ÈÎfi ¿ÛıÌ· ·ÔÙÂÏ› Ê·ÈÓÔÙ˘Èο ÂÙÂÚÔÁÂÓ¤˜ ÓfiÛËÌ·. ∏ ‰È¿ÁÓˆÛ‹ ÙÔ˘ ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ·Ï‹ Î·È ·ÛÊ·Ï‹˜. ™˘¯Ó¿, ‰ÂÓ Ù›ıÂÙ·È ·fi ÙËÓ ÚÒÙË ÂͤٷÛË ·ÏÏ¿ “ηı’ Ô‰fiÓ”. °) µ¿ÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤Ï·Û˘ ·ÔÙÂÏÔ‡Ó ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Koppelman GH, Meijer GG, Postma DS. Defining asthma in genetic studies. Clin Exp Allergy 1999;29(Suppl 4):1-4.

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4. ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ∫·Ú‰È¿˜, ¶Ó‡ÌÔÓÔ˜ Î·È ∞›Ì·ÙÔ˜. ¢ÈÂıÓ‹˜ ÛÙÚ·ÙËÁÈ΋ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÚfiÏË„Ë ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (∂ÏÏËÓÈ΋ ÌÂÙ¿ÊÚ·ÛË. ∂È̤ÏÂÈ·: °ÂˆÚÁ¿ÙÔ˘ ¡, °Î¿Áη ª, °ÎÚ¿ÙÛÈÔ˘ Ã, ¢ËÌ¿‰Ë ª, ªÈÙÛ¿ÎÔ˘ Ã.), publ no 95-3659; 1995.

5. Carlsen KH. What distinguishes the asthmatic amongst the infant wheezers? Pediatr Allergy Immunol 1997;8(Suppl 10):40-45.

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8. Go RO, Martin TR, Lester MR. A wheezy infant unresponsive to bronchodilators. Ann Allergy Asthma Immunol 1997;78:449-455.

9. Martinez FD, Wright AL, Taussing LM, Holberg CJ, Halonen M, Morgan WJ. The Group Health Medical Associates. Asthma and wheezing in the first six years of life. N Engl J Med 1995;332:133-138.

10. Hopp RJ. Recurrent wheezing in infants and young children: a perspective. J Asthma 1999;36:547-553.

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12. Joseph CLM, Foxman B, Leickly FE, Peterson E, Ownby D. Sensitivity and specificity of asthma definition and symptoms used in a survey of childhood asthma. J Asthma 1999;36:565-573.

13. ¶Ú›ÊÙ˘ ∫. √ Û˘ÚÈÁÌfi˜ ÛÙÔ ‚Ú¤ÊÔ˜ ÌÂÙ¿ ÙËÓ ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ¶·È‰È·ÙÚÈ΋˜ 1999. ¢È·ÁÓˆÛÙÈο Î·È ıÂÚ·¢ÙÈο ÚÔ‚Ï‹Ì·Ù·. µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∞ı‹Ó·; 1999. ÛÂÏ. 309-320.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ¡. ¶Ú›ÊÙ˘ ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘ 152 36, ¶. ¶ÂÓÙ¤ÏË

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ™¯¤ÛË ÌÂٷ͇ ·ÏÌÈ΋˜ Ô͢ÌÂÙÚ›·˜ Î·È ÎÏÈÓÈÎÔ‡ score Û ·È‰È¿ Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 24 ÌËÓÒÓ1 ™ÎÔfi˜: ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë Û¯¤ÛË ÌÂٷ͇ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ Ô˘ ÌÂÙÚ‹ıËΠ̠·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Î·È ÙˆÓ ÙÈÌÒÓ ÎÏÈÓÈÎÒÓ score Û 138 ‚Ú¤ÊË (̤Û˘ ËÏÈΛ·˜ ±SD, 6,6±5,5 ÌËÓÒÓ) Ì Ôͤ· ÂÂÈÛfi‰È· Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜, Ô˘ ÚÔÛ‹Ïı·Ó Û·Ó Â͈ÙÂÚÈÎÔ› ·ÛıÂÓ›˜ Û ΤÓÙÚÔ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŒÓ·˜ ÂÚ¢ÓËÙ‹˜ ÂÎÙÈÌÔ‡Û ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ÔͤˆÓ ÂÂÈÛÔ‰›ˆÓ Û˘Ú›ÙÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÎÏÈÓÈÎÔ‡ score ¯ˆÚ›˜ Ó· ÁÓˆÚ›˙ÂÈ ÙȘ ÙÈ̤˜ ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ. ŒÓ·˜ ¿ÏÏÔ˜ ÂÚ¢ÓËÙ‹˜ ÌÂÙÚÔ‡Û ÙÔÓ ÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ Û fiÏ· Ù· ·È‰È¿. ∞ÔÙÂϤÛÌ·Ù·: ∏ ̤ÛË ÙÈÌ‹ (±SD) ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ‹Ù·Ó 98,2±1,1% ÁÈ· ·È‰È¿ Ì ÎÏÈÓÈο scores 2-5 (n=32), 95,4±1,5% ÁÈ· ÂΛӷ Ì scores 6-7 (n=82) Î·È 92,9±2% ÁÈ· ·È‰È¿ Ì scores 8-10 (n=24), (p<0,001 ·fi Bonferroni’s ÔÏÏ·Ï‹ Û‡ÁÎÚÈÛË fiÙ·Ó ÔÈ Û˘ÁÎÚ›ÛÂȘ Á›ÓÔÓÙ·È Ì ‰‡Ô ÙÚfiÔ˘˜ ÁÈ· οı ˙‡ÁÔ˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ). ∆Ô ÎÏÈÓÈÎfi score ¤‰ÂÈÍ ̛· ηϋ Û˘Û¯¤ÙÈÛË ÌÂ

214

ÙÔÓ ÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ (r=–0,76; 95% Cl, –0,83 se –0,68). ™˘ÌÂÚ¿ÛÌ·Ù·: ∂¿Ó ‰ÂÓ Â›Ó·È ‰È·ı¤ÛÈÌÔ ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ, Â›Ó·È ÛÎfiÈÌÔ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘ ÛÙË ıÂÚ·›· ÙˆÓ ‚ÚÂÊÒÓ ÌÂ Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, fiÙ·Ó ÙÔ ÎÏÈÓÈÎfi ÙÔ˘˜ score Â›Ó·È ≥8.

1Pavon D, Gastro-Rodrigez JA, Dubilar L, Girardi G. Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age Pediatr Pulmonol 1999;27:423-427

°ÂÒÚÁÈÔ˜ √ÈÎÔÓfiÌÔ˘ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ

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∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞

Paediatriki 2001;64:215-218

ALLERGIOLOGY - DERMATOLOGY

∞Ó·Ê˘Ï·Í›·: ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ·ÓÙÈÌÂÙÒÈÛË £. ¶··ÛÙ·‡ÚÔ˘ - ª·˘ÚÔ˘‰‹

Anaphylaxis: clinical manifestations and treatment T. Papastavrou - Mavroudi

¶ÂÚ›ÏË„Ë: ∏ ·Ó·Ê˘Ï·Í›· Â›Ó·È Ì›· ÂÈΛӉ˘ÓË ÁÈ· ÙË ˙ˆ‹ ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË, ÁÈ· ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È Â›ÁÔ˘Û· ·ÓÙÈÌÂÙÒÈÛË. OÈ ÁÂÓÈÎÂ˘Ì¤Ó˜ ·ÓÙȉڿÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·, fiˆ˜ ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ηډÈÔ·ÁÁÂÈ·Îfi, Á·ÛÙÚÂÓÙÂÚÈÎfi, ‰¤ÚÌ· ‹ Î·È ÙÔ Û˘Ó‰˘·ÛÌfi ·˘ÙÒÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ. ∏ ¤ÁηÈÚË ¯Ú‹ÛË ·‰ÚÂÓ·Ï›Ó˘, ÂÈÛÓÂfiÌÂÓˆÓ ‚‹Ù· ‰ÈÂÁÂÚÙÒÓ, ηıÒ˜ Î·È ¿ÏÏ· ̤ÙÚ·, Â›Ó·È ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·Í›·˜ Ú¤ÂÈ Ó· ʤÚÔ˘Ó Ì·˙› ÙÔ˘˜ ¿ÓÙÔÙ ¤Ó· kit ¿ÌÂÛ˘ ·ÓÙÈÌÂÙÒÈÛ˘.

Abstract: Anaphylaxis is a life threatening allergic reaction which needs emergency treatment. The generalized reactions involve different systems such as the respiratory, cardiovascular and gastrointestinal system and also the skin, singly or in combination. Early use of adrenaline, inhaled beta-2 agonists as well as other measures, is crucial for successful treatment. A kit containing adrenaline for self treatment must be carried by all patients with a history of anaphylaxis.

§¤ÍÂȘ ÎÏÂȉȿ: ·Ó·Ê˘Ï·Í›·, ·ÓÙÈÌÂÙÒÈÛË.

Key words: anaphylaxis, treatment.

∏ ·Ó·Ê˘Ï·Í›· ‹ ·Ó·Ê˘Ï·ÎÙÈÎfi shock ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È Ì¤¯ÚÈ Û‹ÌÂÚ· ÙÔ ÈÔ ‰Ú·Ì·ÙÈÎfi Ê·ÈÓfiÌÂÓÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÁÈ· ÙÔ ÔÔ›Ô ··ÈÙÂ›Ù·È ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË (1). ∏ ·Ó·Ê˘Ï·Í›· Â›Ó·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ì›· Ù‡Ô˘ π ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Ì Ì˯·ÓÈÛÌfi IgE, ηٿ ÙËÓ ÔÔ›· ÌÂÙ¿ ÙËÓ ÚÒÙË Â·Ê‹ Ì ÙÔ ·ÓÙÈÁfiÓÔ Î·È ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ·ÙfiÌÔ˘ Â›Ó·È ϤÔÓ Û˘Ó‰Â‰Â̤ÓË ÛÙ· ÛÈÙ¢ÙÈο Î·È ‚·ÛÂfiÊÈÏ· ·ÙÙ·Ú·, Ì Â·ÎfiÏÔ˘ıÔ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ, ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ÌÂÙ¿ ·fi οı Ӥ· Â·Ê‹ Ì ÙÔ ›‰ÈÔ ·ÓÙÈÁfiÓÔ (2). ∆· Â›‰· Ù˘ ÈÛÙ·Ì›Ó˘ Â›Ó·È ˘„ËÏ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. ªÂ Ì˯·ÓÈÛÌfi ¯ˆÚ›˜ Û˘ÌÌÂÙÔ¯‹ Ù˘ IgE ÌÔÚ› Ó· ÚÔÎÏËı› ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÛÈÙ¢ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·fi ÙȘ

·Ó·Ê˘Ï·ÙÔ͛Ә C3·, C4· Î·È C5·. OÚÈṲ̂ӷ Ê¿Ú̷η, fiˆ˜ Ù· ·Ú¿ÁˆÁ· ÙÔ˘ ÎÔ˘Ú·Ú›Ô˘ Î·È ·ÎÙÈÓÔÛÎÈ·ÛÙÈΤ˜ Ô˘Û›Â˜, ÌÔÚÔ‡Ó Ó· ‰Ú¿ÛÔ˘Ó ÛÙ· ÛÈÙ¢ÙÈο ·ÙÙ·Ú· Î·È Ó· ·ÂÏ¢ıÂÚÒÛÔ˘Ó ÌÂÛÔÏ·‚ËÙ¤˜ ¯ˆÚ›˜ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi. OÈ ·ÓÙȉڿÛÂȘ ·˘Ù¤˜ ÔÓÔÌ¿˙ÔÓÙ·È ·Ó·Ê˘Ï·ÎÙÔÂȉ›˜ (3). ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ (4,5) OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÔÈΛÏÔ˘Ó Û ‚·Ú‡ÙËÙ· ·fi ÙË ‰È¿¯˘ÙË ÂÚ˘ıÚfiÙËÙ· Î·È ÙÔÓ ÎÓËÛÌfi ̤¯ÚÈ ·ÎfiÌË Î·È ÙÔ ı¿Ó·ÙÔ. ∆Ô ÚÒÙÔ Û‡Ìو̷ ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È ¤Ó· ÁÂÓÈÎfi ·›ÛıËÌ· “fiÙÈ ‰ÂÓ ·ÈÛı¿ÓÂÙ·È Î·Ï¿”. ™‡ÓÙÔÌ· ÂÌÊ·Ó›˙ÂÙ·È ÎÓËÛÌ҉˜ ÂÍ¿ÓıËÌ· ‰È¿¯˘ÙÔ, Ì ·›ÛıËÌ· ˙¤ÛÙ˘, ÂÚ‡ıËÌ·, Êfi‚Ô Î·È Ù¿ÛË ÏÈÔı˘Ì›·˜. ™Â ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ ÂÌÊ·Ó›˙ÂÙ·È ·ÒÏÂÈ· ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, Û˘Ó›‰ËÛ˘, Ô‡ÚˆÓ Î·È ÎÔÚ¿ÓˆÓ.

3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, £ÂÛÛ·ÏÔÓ›ÎË

3rd Pediatric Department of Aristotelion University Ippokration General Hospital, Thessaloniki

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¢ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ O ·Ú¯ÈÎfi˜ ÎÓËÛÌfi˜ Î·È Ë ÂÚ˘ıÚfiÙËÙ· ÂÍÂÏ›ÛÛÔÓÙ·È Û ÎÓȉˆÙÈÎfi ÂÍ¿ÓıËÌ· Î·È ·ÁÁÂÈÔÔ›‰ËÌ·, Ù· ÔÔ›· Â›Ó·È ·ÚÔ‰Èο Î·È Û¿ÓÈ· ‰È·ÚÎÔ‡Ó ÁÈ· Ï›Á˜ ‚‰ÔÌ¿‰Â˜. ™˘ÌÙÒÌ·Ù· ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∆· 2/3 ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ı·Ó¿ÙˆÓ ÔÊ›ÏÔÓÙ·È Û ·ÛÊ˘Í›·. ∆˘Èο, Ë ·fiÊÚ·ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÚÔηÏ› ÂÈÛÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi, ÂÓÒ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÎÓ¢ÛÙÈ΋ ‰‡ÛÓÔÈ·. ∆· ÚÒÙ· ÛÙ¿‰È· ÙÔ˘ Ï·Ú˘ÁÁÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÂΉËÏÒÓÔÓÙ·È Ì ‚Ú¿Á¯Ô˜ ʈӋ˜ Î·È ·›ÛıËÌ· ‰˘ÛÎÔÏ›·˜ Ù˘ ·Ó·ÓÔ‹˜. ∆Ô Â‡ÚËÌ· Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ‰ÈfiÙÈ ÙÔ Ô›‰ËÌ· ÙÔ˘ Ï·Ú˘ÁÁÔÊ¿Ú˘ÁÁ· Ù˘ ÂÈÁψٛ‰·˜ Î·È ÙÔ˘ Ï¿Ú˘ÁÁ· ÌÔÚ› ÁÚ‹ÁÔÚ· Ó· Ô‰ËÁ‹ÛÂÈ Û ı¿Ó·ÙÔ ·fi ·ÛÊ˘Í›·. ∏ ·fiÊÚ·ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂΉËÏÒÓÂÙ·È Ì ·›ÛıËÌ· Û‡ÛÊÈ͢ ÙÔ˘ ıÒڷη, ÂÎÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi Î·È Û‡ÓÙÔÌ· ÂÍÂÏ›ÛÛÂÙ·È Û ÛÔ‚·Úfi Ô͇ ¿ÛıÌ·. ∏ ·fiÊÚ·ÍË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ Û˘Óԉ‡ÂÙ·È Ì ˘ÔÍ·ÈÌ›·. ∫·Ú‰È·ÁÁÂȷο Û˘ÌÙÒÌ·Ù· ∏ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙÔ 1/3 ÙˆÓ ı·Ó¿ÙˆÓ. ∏ ˘fiÙ·ÛË Î·È ÙÔ shock ÔÊ›ÏÔÓÙ·È ÛÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹, ÙËÓ ÂÚÈÊÂÚÈ΋ Ï›ÌÓ·ÛË ÙÔ˘ ·›Ì·ÙÔ˜, ÙËÓ ·˘ÍË̤ÓË ·ÁÁÂȷ΋ ‰È·‚·ÙfiÙËÙ· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∏ ΢ÎÏÔÊÔÚÈ΋ ηٷÏËÍ›· (collapse) ÂÏ·ÙÙÒÓÂÈ ÙË ÚÔ‹ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ Î·È Ë ˘ÔÍ·ÈÌ›·, Ë ÔÔ›· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ˘fiÙ·ÛË, ÂÏ·ÙÙÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÙÔ˘ Ì˘Ôηډ›Ô˘ Ì ·ÔÙ¤ÏÂÛÌ· ·ÚÚ˘ı̛˜, ·ÎfiÌË Î·È ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ™˘ÌÙÒÌ·Ù· Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∆· ÎÔÈÏȷο ¿ÏÁË, Ë Ó·˘Ù›· Î·È ÔÈ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙË Û‡Û·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÙȘ ·˘ÍË̤Ó˜ ÂÎÎÚ›ÛÂȘ. ¢È¿ÁÓˆÛË ∏ ‰È¿ÁÓˆÛË ÛÙËÚ›˙ÂÙ·È ÛÙÔ ÈÛÙÔÚÈÎfi Î·È ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ: ·) ·fi ÙÔ ‰¤ÚÌ· (ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·), ‚) ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (‰‡ÛÓÔÈ· ÂÈÛÓ¢ÛÙÈ΋-ÂÎÓ¢ÛÙÈ΋, ΢¿ÓˆÛË), Á) ·fi ÙÔ Î˘ÎÏÔÊÔÚÈÎfi (˘fiÙ·ÛË, ·ÚÚ˘ıÌ›·) Î·È ‰) ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (¤ÌÂÙÔÈ, ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ, ÎÔÈÏȷο ¿ÏÁË). ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ÌÔÚÔ‡Ó Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÌÔӈ̤ӷ ‹ Î·È ÛÂ Û˘Ó‰˘·ÛÌfi ·fi Ù· ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·.

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£ÂÚ·›· ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock Â›Ó·È Ì›· ÂÍ·ÈÚÂÙÈο Â›ÁÔ˘Û· È·ÙÚÈ΋ Ú¿ÍË Î·È Ë ÂÈÙ˘¯›· Ù˘ ıÂÚ·›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Ù·¯Â›· ¤Ó·ÚÍ‹ Ù˘. ∂È‚¿ÏÏÂÙ·È Ë ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ Û ÌÔÚÊ‹ ˘‰·ÙÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ·‰ÚÂÓ·Ï›Ó˘ 1:1000 Û ‰fiÛË 0,3-0,5 ml (ÛÙ· ·È‰È¿ Ë ‰fiÛË ˘ÔÏÔÁ›˙ÂÙ·È 0,01-0,02 ml/Kg µ™ ·Ó¿ ‰fiÛË). ∏ ̤ÁÈÛÙË ‰fiÛË Â›Ó·È 0,5 ml. À¿Ú¯ÂÈ Î·È ·˘ÙÔÂÓ¤ÛÈÌË (∞uto-injector) ·‰ÚÂÓ·Ï›ÓË Ì›·˜ ¯Ú‹Û˘ (Fastjekt 0,23-0,37 mg, Epipen 0,3 mg Î·È 0,15 mg, Anapen Adult 0,3 mg Î·È Anapen junior 0,15 mg) ÁÈ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (6). EÂȉ‹ Ë ·‰ÚÂÓ·Ï›ÓË ¤¯ÂÈ ÌÈÎÚ‹ ËÌÈÂÚ›Ô‰Ô ˙ˆ‹˜, Ë ·Ú¯È΋ ‰fiÛË ÌÔÚ› Ó· Â·Ó·ÏËÊı› οı 15-20 min ÁÈ· 3-4 ÊÔÚ¤˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ÔÈ Ôԛ˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, Ë ·‰ÚÂÓ·Ï›ÓË 0,25 ml ·Ú·ÈÒÓÂÙ·È Û 10 ml Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ Î·È ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÊÏ‚›ˆ˜ Û ¯ÚfiÓÔ 1-2 ÏÂÙÒÓ Ì ¿ÌÂÛË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ∏ ·‰ÚÂÓ·Ï›ÓË ‰ÈÂÁ›ÚÂÈ ÙÔ˘˜ ·-˘ԉԯ›˜ Î·È ÚÔηÏ› ·ÁÁÂÈÔÛ·ÛÌfi ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ›ÂÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜. ∞ÓÙ‰›ÎÓ˘Ù·È Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Ì ·ÚÚ˘ıÌ›· ‹ Ì ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ‰ÈfiÙÈ ¤¯ÂÈ ·Ú·ÙËÚËı› ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹, ·ÎfiÌË Î·È ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ (3). ∂È‚¿ÏÏÂÙ·È Ë ÙÔÔı¤ÙËÛË ›Û¯·ÈÌ˘ ÂÚ›‰ÂÛ˘ ÎÂÓÙÚÈÎfiÙÂÚ· ÙÔ˘ ÛËÌ›Ԣ Ù˘ ÂÓ¤Ûˆ˜ ‹ ÙÔ˘ ‰‹ÁÌ·ÙÔ˜ ÂÓÙfiÌÔ˘, Ë ÔÔ›· ı· ηı˘ÛÙÂÚ‹ÛÂÈ ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ‚Ï·ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ÃÔÚËÁÂ›Ù·È ¿ÌÂÛ· Ô͢ÁfiÓÔ fiÙ·Ó ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó·ÓÔ‹ ‹ ΢¿ÓˆÛË. ÃÔÚËÁÔ‡ÓÙ·È ∂º ˘ÁÚ¿ ‹ Î·È ˘ÔηٿÛٷٷ Ï¿ÛÌ·ÙÔ˜ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚ·, ÒÛÙ ӷ ÚÔÏËÊı› Ë ‚·ÚÈ¿ ΢ÎÏÔÊÔÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∞Ó Ë ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ Î·È Ë ∂º ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·, ÙfiÙ ¯ÔÚËÁÔ‡ÓÙ·È ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÌÂÙ·Ú·ÌÈÓfiÏË (Aramine) 0,4 mg/Kg µ™ ‚Ú·‰¤ˆ˜ Û 500 ml ˘ÁÚÒÓ, ‹ ÓÙÔ·Ì›ÓË 100-1000 Ìg/mm, ‹ ÓÔÚ·‰ÚÂÓ·Ï›ÓË 8-20 mg/min. O ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È ÛÂ Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË Ì ∏∫°, ̤ÙÚËÛË ∞¶, ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË, ·¤ÚÈ· ·›Ì·ÙÔ˜. ∆· ·ÓÙÈÈÛÙ·ÌÈÓÈο, fiˆ˜ ÔÈ ∏1 ·ÓÙ·ÁˆÓÈÛÙ¤˜, ¯ÔÚËÁÔ‡ÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ¯Ú‹ÛË Ù˘ ·‰ÚÂÓ·Ï›Ó˘. ªÔÚÔ‡Ó Ó· ¯ÔÚËÁËıÔ‡Ó ∂º, Eª ‹ ·fi ÙÔ ÛÙfiÌ· ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘. ŸÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ·

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·217

¶·È‰È·ÙÚÈ΋ 2001;64:215-218

‰ÚÔ˘Ó Û 15-30 min. ∫·Ó¤Ó· fï˜ ·ÓÙÈÈÛÙ·ÌÈÓÈÎfi ‰ÂÓ ÌÔÚ› Ó· Â›Ó·È ˘ÔηٿÛÙ·ÙÔ Ù˘ ·‰ÚÂÓ·Ï›Ó˘, ‰ÈfiÙÈ Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÌfiÓÔ ÙË ‰Ú¿ÛË Ù˘ ÈÛÙ·Ì›Ó˘ ÛÙÔ˘˜ ˘ԉԯ›˜ Ù˘. ∆· ∏1 ·ÓÙÈÈÛÙ·ÌÈÓÈο ÂÌÔ‰›˙Ô˘Ó ÙË Û‡Û·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÙˆÓ ‚ÚfiÁ¯ˆÓ Î·È ÙË ¯¿Ï·ÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ¤ÙÛÈ ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ·ÁÁÂȷ΋ ‰È·‚·ÙfiÙËÙ· (∫ÏÂÌ·ÛÙ›ÓË 2 mg). ∆· ∏2 ·ÓÙÈÈÛÙ·ÌÈÓÈο ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙË ‰È¤ÁÂÚÛË ÙˆÓ ÂÎÎÚ›ÛˆÓ, Ë ÔÔ›· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÈÛÙ·Ì›ÓË (ƒ·ÓÈÙȉ›ÓË 100 mg, ÛÙ· ·È‰È¿ 15 mg/Kg µ™) (4,5). ∂È‚¿ÏÏÂÙ·È Ó· ‰È·ÙËÚÔ‡ÓÙ·È ÂχıÂÚÔÈ ÔÈ ·Ó·Ó¢ÛÙÈÎÔ› Ô‰Ô›. ∏ ·fiÊÚ·ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ·fi Ô›‰ËÌ· Ù˘ ÂÈÁψÙÙ›‰·˜, ÙÔ˘ ˘ÔÊ¿Ú˘ÁÁ· Î·È ÙÔ˘ Ï¿Ú˘ÁÁ· ÌÔÚ› Ó· ·ÔÊÚ¿ÍÂÈ Ù·¯‡Ù·Ù· ÙËÓ ·Ó·Ó¢ÛÙÈ΋ Ô‰fi. ∏ ·‰ÚÂÓ·Ï›ÓË Î·È Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο ÚÔÏ·Ì‚¿ÓÔ˘Ó ÙËÓ Âȉ›ӈÛË ÙÔ˘ Ôȉ‹Ì·ÙÔ˜. Œ¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· Ó· ÌËÓ Î·ı˘ÛÙÂÚ› Ë ÂÈÛ·ÁˆÁ‹ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎÔ‡ ηıÂÙ‹Ú· Î·È ÌÔÚ› Ó· Â·ÚΛ fiÙ·Ó ÙÔ Ô›‰ËÌ· Â›Ó·È Î˘Ú›ˆ˜ ÛÙÔÌ·ÙÔÊ·Ú˘ÁÁÈÎfi. ∞Ó fï˜ Ë ·fiÊÚ·ÍË Â›Ó·È ¿Ú· Ôχ ÚÔ¯ˆÚË̤ÓË ÒÛÙ ӷ ÌËÓ ÂÈÙÚ¤ÂÈ ÙË ‰È·ÛˆÏ‹ÓˆÛË, ÙfiÙ Á›ÓÂÙ·È ÙÔÌ‹ ÛÙËÓ ÚfiÛıÈ· ÙÚ·¯ËÏÈ΋ ¯ÒÚ·, ‰È¿ÓÔÈÍË Ù˘ ÙÚ·¯Â›·˜ Î·È ÙÔÔı¤ÙËÛË ÌÈÎÚÔ‡ ÂÓ‰ÔÙÚ·¯ÂÈ·ÎÔ‡ ۈϋӷ. ™Â ÌÂÁ¿ÏË ·Ó¿ÁÎË ÌÔÚ› Ó· ÙÔÔıÂÙËı› Ì›· ‚ÂÏfiÓË Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ‰È¿ÌÂÙÚÔ, ÒÛÙ ӷ Á›ÓÂÙ·È ·ÂÚÈÛÌfi˜ ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ̤¯ÚÈ Ó· Á›ÓÂÈ ÙÚ·¯ÂÈÔÙÔÌ‹ ·fi ÂȉÈÎfi ¯ÂÈÚÔ˘ÚÁfi (4). ∏ ·fiÊÚ·ÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÌÔÚ› Ó· Â›Ó·È ¿ÌÂÛË Ì ÙËÓ ÂΉ‹ÏˆÛË Û˘ÌÙˆÌ¿ÙˆÓ ¿ÛıÌ·ÙÔ˜. ∂›Ó·È ÛËÌ·ÓÙÈÎfi, Ë ¯ÔÚ‹ÁËÛË Ù·¯Â›·˜ ‰Ú¿Ûˆ˜ ‚2 ‰ÈÂÁÂÚÙÒÓ Û ÂÈÛÓÔ¤˜ Ó· ·Ú¯›˙ÂÈ ¤ÁηÈÚ·. ∞Ó Ô ·ÛıÂÓ‹˜ ‰ÂÓ ÌÔÚ› Ó· Û˘ÓÂÚÁ·ÛÙ› ‹ ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· ¯ÔÚ‹ÁËÛ˘, ÙfiÙ ÌÔÚ› Ó· ¯ÔÚËÁËı› ∂º ·ÌÈÓÔÊ˘ÏÏ›ÓË Û ‰fiÛË 1 mg/Kg ·Ó¿ ÒÚ·. ™ÙË Û˘Ó¤¯ÂÈ·, Ë ·ÌÈÓÔÊ˘ÏÏ›ÓË ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 6 mg/kg µ™ οı 6 ÒÚ˜. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ·Ú’fiÏÔ Ô˘ Ë ‰Ú¿ÛË ÙÔ˘˜ ·Ú¯›˙ÂÈ ÌÂÙ¿ 4-6 ÒÚ˜. Œ¯Ô˘Ó ¤Ó‰ÂÈÍË, ‰ÈfiÙÈ ÛÙ·ıÂÚÔÔÈÔ‡Ó ÙËÓ Î·Ù¿ÛÙ·ÛË Î·È ÚÔÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ˘ÔÙÚÔ‹ Ù˘ (‰ÈÊ·ÛÈ΋ ·ÓÙ›‰Ú·ÛË). ∏ ˘‰ÚÔÎÔÚÙÈ˙fiÓË Â›Ó·È ‰Ú·ÛÙÈ΋ Û ‰fiÛË 200 mg (3 mg/Kg) ‹ ÚÔÙÈÌ¿Ù·È Ë ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË Û ‰fiÛË 40 mg οı 3-4 ÒÚ˜, Û ·ÛıÂÓ›˜ Ì ԛ‰ËÌ· Î·È ˘ÔηÏÈ·ÈÌ›·. ∏ ÂÓ‰ÔÁÂÓ‹˜ ·Ú·ÁˆÁ‹ ÙˆÓ ·‰ÚÂÓÔÎÔÚÙÈÎÔÂȉÒÓ ÔÚÌÔÓÒÓ Â›Ó·È ·ÓÂ·Ú΋˜ Û fiϘ ÙȘ ÌÔÚʤ˜ Ù˘ ·Ó·Ê˘Ï·Í›·˜, ·ÏÏ¿ ΢ڛˆ˜ ÛÙÔ ÛÔ‚·Úfi ·Ó·Ê˘Ï·-

Paediatriki 2001;64:215-218

ÎÙÈÎfi shock. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·ÂÏ¢ı¤ÚˆÛË Ì›·˜ Ô˘Û›·˜ - Ù˘ ÏÈÔÎÔÚÙ›Ó˘ - Ë ÔÔ›· ÂÌÔ‰›˙ÂÈ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ ÓÂÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ·Ó·Ê˘Ï·Í›·˜ Î·È ÂÌÔ‰›˙ÂÈ ÙË Û‡ÓıÂÛË ÎÈÓ›ÓˆÓ. ∏ ∂º ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÚÔηÏ› ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹ ÌÂÙ¿ ·fi 1-4 ÒÚ˜. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÈ‚¿ÏÏÂÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙËÓ Î·Ù·ÛÙÔÏ‹ Ù˘ ÂÈ‚Ú·‰˘ÓfiÌÂÓ˘ IgE ·ÓÙ›‰Ú·Û˘ ·fi ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È ‰ÂÓ ¤¯ÂÈ Â›‰Ú·ÛË ÛÙËÓ ÂÈ‚›ˆÛË ·fi ÔÍ›· ·Ó·Ê˘Ï·Í›· (4,6). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ shock ÛÙ· ÓÔÛÔÎÔÌ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ Ì ÙËÓ ÂÍ‹˜ ÛÂÈÚ¿: ·) ÃÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘ ·ÚÂÓÙÂÚÈο, ˘Ô‰fiÚÈ· ‹ ÂÓ‰ÔÌ˘˚ο Î·È ÛÙȘ ÛÔ‚·ÚfiÙÂÚ˜ ηٷÛÙ¿ÛÂȘ Û˘ÓÈÛÙ¿Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË, ‚) ÃÔÚ‹ÁËÛË ∏1 Î·È ∏2 ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜, Á) ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ∏∫°, Ï‹„Ë ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ›ÂÛ˘, ÚÔÛ‰ÈÔÚÈÛÌfi ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜, ‰ÈfiÚıˆÛË ÙÔ˘ p∏, ¯ÔÚ‹ÁËÛË ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜, ‰È·ÛˆÏ‹ÓˆÛË ÁÈ· Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ¯Ú‹ÛË ·ÈÓȉˆÙ‹. ªÂÙ¿ ÙËÓ Ï‹ÚË ·Ó¿ÓË„Ë, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·Ú·Ì¤ÓÂÈ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â› 24 ÒÚ˜ ÁÈ· ·Ú·ÎÔÏÔ‡ıËÛË, ‰ÈfiÙÈ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È ‰ÈÊ·ÛÈ΋ ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË. ™Â ÔÚÈṲ̂Ó˜ ηٷÛÙ¿ÛÂȘ ·Ó·Ê˘Ï·Í›·˜ ÂÈ‚¿ÏÏÂÙ·È Ì›· ȉȷ›ÙÂÚË ÛÙÚ·ÙËÁÈ΋: ™ÙËÓ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·, ··ÈÙÂ›Ù·È Ë ·Ó‡ÚÂÛË ÙÔ˘ ˘‡ı˘ÓÔ˘ ·ÏÏÂÚÁÈÔÁfiÓÔ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰›‰ÔÓÙ·È ÔÈ Î·Ù¿ÏÏËϘ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ Ï‹ÚË ·ÔÊ˘Á‹ ÙÔ˘ (7). ∏ ÎÓ›‰ˆÛË Ë ÔÔ›· ÚÔηÏÂ›Ù·È ÌÂÙ¿ ·fi ¤ÎıÂÛË ÛÙÔ ÎÚ‡Ô (8), ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ÌÔÚ› Ó· Â›Ó·È ÂÈΛӉ˘ÓË ÁÈ· ÙË ˙ˆ‹ ‰ÈfiÙÈ ÌÔÚ› Ó· ÌÂÙ·¤ÛÂÈ Û ·Ó·Ê˘Ï·ÎÙÈÎfi shock. ∏ ÚÔʇϷÍË Î·È Ë ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Ê·›ÓÂÙ·È fiÙÈ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· ·˘ÙÒÓ ÙˆÓ ·ÓÙȉڿÛˆÓ. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·ÚȤ˜ ·ÓÙȉڿÛÂȘ ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘. ∏ ·Ó·Ê˘Ï·Í›· ÌÂÙ¿ ·fi ¿ÛÎËÛË (9) ·ÔÙÂÏ› ȉȷ›ÙÂÚ· ÂÈΛӉ˘ÓË ÌÔÚÊ‹ Ê˘ÛÈ΋˜ ·ÏÏÂÚÁ›·˜. ∏ ¿ÛÎËÛË Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È ·ÎfiÌË Î·È fiÙ·Ó ÂÌÊ·Ó›˙ÂÙ·È ÂÏ·ÊÚfi˜ ÎÓËÛÌfi˜. ™˘ÓÈÛÙ¿Ù·È Ë ÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ì ·ÓÙÈÈÛÙ·ÌÈÓÈο Î·È ÛÙȘ ‚·ÚȤ˜ ÂΉËÏÒÛÂȘ ··ÈÙÂ›Ù·È ¯ÔÚ‹ÁËÛË ·‰ÚÂÓ·Ï›Ó˘. À¿Ú¯ÂÈ Ì›· ȉȷ›ÙÂÚË ÔÌ¿‰· ·ÛıÂÓÒÓ ÔÈ ÔÔ›ÔÈ ÂÌÊ·Ó›˙Ô˘Ó ÂΉËÏÒÛÂȘ ·Ó·Ê˘Ï·Í›·˜, ÌfiÓÔ fiÙ·Ó Ë ¿ÛÎËÛË Û˘Ó‰˘¿˙ÂÙ·È Ì ϋ„Ë ÔÚÈṲ̂Ó˘ ÙÚÔÊ‹˜ fiˆ˜ Ù· ÔÛÙÚ·ÎÔÂȉ‹ (10), ‹ Î·È ¿ÏϘ ÙÚÔʤ˜ (11). °È· ÙËÓ ·Ó·Ê˘Ï·Í›· ÛÙ· ˘ÌÂÓfiÙÂÚ·, ÂÎÙfi˜ ·fi ÙÔ ÈÛÙÔÚÈÎfi, ··ÈÙÂ›Ù·È Ë ÂȂ‚·›ˆÛË ÙÔ˘

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·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ tests ·ÏÏÂÚÁ›·˜ Î·È ÙÔ˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂȉÈÎÒÓ IgE ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙ· ‰È¿ÊÔÚ· ˘ÌÂÓfiÙÂÚ· (̤ÏÈÛÛ·, ÛʋΘ), ÒÛÙ ÛÙȘ ÂÚÈÙÒÛÂȘ ÔÈ Ôԛ˜ Â›Ó·È ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹ ÔÈ ·ÛıÂÓ›˜ Ó· ʤÚÔ˘Ó ¿ÓÙ· Ì·˙› ÙÔ˘˜ ·˘ÙÔÂÓ¤ÛÈÌË ·‰ÚÂÓ·Ï›ÓË Î·È Ó· ÚÔÁÚ·ÌÌ·ÙÈÛÙÔ‡Ó ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÂȉÈ΋˜ ·¢·ÈÛıËÙÔÔ›ËÛ˘ (12). ∏ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙ· Ê¿Ú̷η Â›Ó·È ›Ûˆ˜ ·fi Ù· ϤÔÓ ‰‡ÛÎÔÏ· ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ È·ÙÚÈ΋ Ú¿ÍË (13). OÈ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÙȉڿÛÂȘ Â›Ó·È ÂÏ·ÊÚ¤˜, ·ÏÏ¿ ¿ÓÙ· ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ Ù˘ ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚÔ˘ ·ÓÙ›‰Ú·Û˘. ™’ ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È Ë Ï‹Ú˘ ·ÔÊ˘Á‹ ·˘ÙÔ‡ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∂¿Ó Ú¤ÂÈ, fiˆ˜ Â›Ó·È ·Ó·ÓÙÈηٿÛÙ·ÙÔ, ÌÔÚ› Ó· ¯ÔÚËÁËı› Ì ÂȉÈÎfi ÙÚfiÔ ·¢·ÈÛıËÙÔÔ›ËÛ˘, Ì ‚·ıÌÈ·›· ·˘Í·ÓfiÌÂÓ˜ ‰fiÛÂȘ Û ¡ÔÛÔÎÔÌ›Ô. O ·Ú¿ÁÔÓÙ·˜ Ô ÔÔ›Ô˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙ· Ê¿Ú̷η Â›Ó·È ÙÔ ıÂÙÈÎfi ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ Û οÔÈ· Ê¿Ú̷η. ∞ÏÏ¿ ·ÎfiÌË Î·È fiÙ·Ó ÙÔ ÈÛÙÔÚÈÎfi Â›Ó·È ·ÚÓËÙÈÎfi, Ô Î¿ı ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· Â›Ó·È ¿ÓÙ· ¤ÙÔÈÌÔ˜ Ó· ·Ó·ÁÓˆÚ›ÛÂÈ Î·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙË Ê·Ú̷΢ÙÈ΋ ˘ÂÚ¢·ÈÛıËÛ›·. ∂›Û˘, ηٿ ÙË ¯ÔÚ‹ÁËÛË ·ÎÙÈÓÔÛÎÈ·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. ŸÙ·Ó ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi Ê·Ú̷΢ÙÈ΋˜ ·ÏÏÂÚÁ›·˜ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ Ù· ÔÔ›· ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ·Ó·Áη›·. ™ÙËÓ È‰ÈÔ·ı‹ ·Ó·Ê˘Ï·Í›·, Ë ·ÈÙÈÔÏÔÁ›· Â›Ó·È ¿ÁÓˆÛÙË Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹, ÔÈ Ôԛ˜ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÔÓÙ·È ·fi ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·, ·fiÊÚ·ÍË ·ÓÒÙÂÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ, ‚ÚÔÁ¯fiÛ·ÛÌÔ ‹ ˘fiÙ·ÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÂÈ‚¿ÏÏÂÙ·È Ë ·ÔÊ˘Á‹ ÙÚÔÊÒÓ ÔÈ Ôԛ˜ ÂÚȤ¯Ô˘Ó Û˘ÓÙËÚËÙÈο Î·È ¯ÚˆÛÙÈΤ˜ Î·È Û ÔÚÈṲ̂Ó˜ ηÎÔ‹ıÂȘ ÌÔÚʤ˜ ȉÈÔ·ıÔ‡˜ ·Ó·Ê˘Ï·Í›·˜ ÂÈ‚¿ÏÏÂÙ·È Ë Ì·ÎÚ¿ ıÂÚ·›· Ì ۇÁ¯ÚÔÓË ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (14). ¶ÚfiÏË„Ë O ΛӉ˘ÓÔ˜ ÙÔ˘ ı·Ó¿ÙÔ˘ ÌÔÚ› Ó· ÚÔÏËÊı› ‹ Ó· ÂÏ·ÙÙˆı› fiÙ·Ó ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛˆÛÙ¿ ÔÈ ·Ú·Î¿Ùˆ Ô‰ËÁ›Â˜: 1) §‹„Ë ÚÔÛÂÎÙÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ Ê·ÚÌ¿ÎÔ˘, 2) ™ˆÛÙ¤˜ Î·È Û·Ê›˜ Ô‰ËÁ›Â˜ ÛÙË ¯Ú‹ÛË Ê·Ú̿ΈÓ, 3) ¡· ÚÔÙÈÌ¿Ù·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ·fi ÙÔ ÛÙfiÌ· ·ÓÙ› Ù˘ ·ÚÂÓÙÂÚÈ΋˜ Ô‰Ô‡, 4) ¡· ·Ú·ÎÔÏÔ˘-

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ıÂ›Ù·È Ô ·ÛıÂÓ‹˜ ÁÈ· 90 ÏÂÙ¿ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÂÓfi˜ ÂÓ¤ÛÈÌÔ˘ Û΢¿ÛÌ·ÙÔ˜, 5) ¡· Â›Ó·È ¤ÙÔÈÌÔ˜ Ô ÁÈ·ÙÚfi˜ ÁÈ· Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ ·Ó·Ê˘Ï·ÎÙÈÎfi shock, 6) ¡· Û˘ÛÙ‹ÛÂÈ ÛÙÔÓ ·ÛıÂÓ‹ Ô˘ ›¯Â οÔÈ· ·Ó·Ê˘Ï·ÎÙÈ΋ ·ÓÙ›‰Ú·ÛË Ó· ʤÚÂÈ ¿ÓÙ· Ì·˙› ÙÔ˘ ·‰ÚÂÓ·Ï›ÓË Î·È Ì¿ÏÈÛÙ· Û ·˘ÙÔÂÓ¤ÛÈÌË ÌÔÚÊ‹.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Becker E. Elements of the history of our present concepts of anaphylaxis hay fever and asthma. Clin Exp Allergy 1999;29:875-895.

2. Coombs RRA, Gell PGH. Classification of allergic reactions responsible for clinical hypersensitivity and disease. In: Gell PGH, Coombs RRA, Lackman PJ, eds.

Clinical aspects of immunology. 3rd ed. Oxford: Blackwell Scientific Publications; 1975. p. 761.

3. Middleton JRE, Reed CE, Ellis EF. Allergy: principles and practice. 2nd ed. Saint Louis: The CV Mosby Company; 1983.

4. Sheffer AL. Anaphylaxis. J Allergy Clin Immunol 1985;75:227-233.

5. ¶··ÛÙ·‡ÚÔ˘-ª·˘ÚÔ˘‰‹ £. ∏ ·Ó·Ê˘Ï·Í›· (‹ ·Ó·Ê˘Ï·ÎÙÈÎfi shock) Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1992;4:127-133.

6. Grabenstein J, Smith L. Incidence of anaphylactic selftreatment in an outpatient population. Ann Allergy 1998; 63:184-188.

7. Metcalfe DD. Food hypersensitivity. J Allergy Clin Immunol 1984;73:749-762.

8. Champion RH, Greaves MW, Kobza Black A, Pye RJ. The urticarias. London: Churchil Livingstone; 1985.

9. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol 1984;73:699-703.

10. Maulitz RM, Pratt DS, Schocket AL. Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol 1979; 63:433-434.

11. Kidd J, Cohen S, Sosman A, Fink J. Food-dependent exercise-induced anaphylaxis. J Allergy Clin Immunol 1983; 71:407-411.

12. Valentine MD. Insect venom allergy: diagnosis and treatment. J Allergy Clin Immunol 1984;73:299-304.

13. Jick H. Adverse drug reactions: the magnitude of the problem. J Allergy Clin Immunol 1984;74(Suppl):555-557.

14. Wiggins CA, Dykewicz MS, Patterson R. Corticosteroiddependent idiopathic anaphylaxis: A report of five cases.

J Allergy Clin Immunol 1989;84:311-315.

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∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞

Paediatriki 2001;64:219-222

ALLERGIOLOGY - DERMATOLOGY

AÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ª. ∆Ú›Áη

Allergy to cow’s milk: diagnosis and management M. Triga

¶ÂÚ›ÏË„Ë: ø˜ ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰o˜ ÔÚ›˙ÂÙ·È Ì›· ÛÂÈÚ¿ ·ÓÂÈı‡ÌËÙˆÓ ÂΉËÏÒÛÂˆÓ Ô˘ ÚÔηÏÔ‡ÓÙ·È Ì ÙË ÌÂÛÔÏ¿‚ËÛË ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜. ™Â Û¯¤ÛË Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜, ÔÈ ·ÓÙȉڿÛÂȘ ·˘Ù¤˜ ¿ÏÏÔÙÂ Â›Ó·È ¿ÌÂÛ˜ Î·È Û˘¯Ó¿ ÛÔ‚·Ú¤˜ (·Ó·Ê˘Ï·Í›·, ·ÁÁÂÈÔÔ›‰ËÌ·, ÎÓ›‰ˆÛË Î.Ï.) Î·È ¿ÏÏÔÙ ÂÌÊ·Ó›˙ÔÓÙ·È Î·ı˘ÛÙÂÚË̤ӷ, ÌÂÙ¿ ÌÂÚÈΤ˜ ÒÚ˜ ‹ ·ÎfiÌ· Î·È ÌÂÙ¿ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· >24 ˆÚÒÓ (Û˘Ó‹ıˆ˜ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi). H Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È 2-2,5% Î·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌÊ·Ó›˙ÂÙ·È Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜. ∏ ÓfiÛÔ˜ Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› Î·È Ê·›ÓÂÙ·È fiÙÈ ÙÔ 85% ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È ÂχıÂÚÔ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ 3Ô˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (·ÓÔÈÎÙ‹ ‹ ‰ÈÏ‹-Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì placebo) ·ÔÙÂÏ› ÙË ¯Ú˘Û‹ ÛÙ·ıÂÚ¿ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î¿ı ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. ™ÙȘ ·Ì¤ÛÔ˘ Ù‡Ô˘ ·ÓÙȉڿÛÂȘ Ë ‰È¿ÁÓˆÛË Â›Ó·È Û¯ÂÙÈο ‡ÎÔÏË ·fi ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙË ‰È·›ÛÙˆÛË Ù˘ ÂȉÈ΋˜ IgE in vivo (‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡) Î·È in vitro (RAST). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰o˜ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ Ï‹ÚË ·ÔÊ˘Á‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙˆÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘. ∂› ·‰˘Ó·Ì›·˜ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ¯ÔÚËÁÂ›Ù·È ÙÔ Î·Ù¿ÏÏËÏÔ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi - Ì ˘‰ÚÔÏ˘Ì¤ÓË ÚˆÙ½ÓË - Á¿Ï·. ∞Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ˘‰ÚfiÏ˘Û˘ Î·È ÙËÓ ËÁ‹ ÚÔ¤Ï¢Û˘ Ù˘ ÚˆÙ½Ó˘, ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎÒÓ Á·Ï¿ÙˆÓ, ÒÛÙ ӷ ÂÈϤÁÂÙ·È ÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ ÁÈ· ÙÔÓ Î¿ı ·ÛıÂÓ‹.

Abstract: Cow’s milk allergy is defined as a set of immunologically mediated adverse reactions to one or more milk proteins. Following the ingestion of milk, the adverse reactions may be immediate and sometimes severe (anaphylaxis, angioedema, urticaria, etc), or delayed occurring within hours or even over a period of days (usually gastrointestinal symptoms). The incidence of cow’s milk allergy in infancy is about 2-3%, and the majority of patients develop symptoms within the first months of life.

The prognosis is regarded as very good with a remission rate of 85% by the age of 3 years. The diagnosis is established by the milk challenge test (open or double-blind, placebo-controlled). In patients with immediate-type reactions the diagnosis is usually based on a careful history and detection of specific IgE antibody to cow’s milk in vivo (skin prick test) and in vitro (RAST). The effective treatment of cow’s milk allergy consists of complete avoidance of cow’s milk protein. When breast-feeding is not possible, a hypoallergenichydrolyzed formula should be given. Based on the source of proteins and the degree of hydrolysis there are several types of hydrolyzed formulas among which the physician may choose the most suitable one for the patient.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜,

Key words: cow’s milk allergy, specific IgE to cow’s

∂ÈÌÂÏ‹ÙÚÈ· ∞’, ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ

Senior Registrar, Department of Pediatrics University of Patras

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ÂȉÈ΋ IgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜, ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì Á¿Ï· ·ÁÂÏ¿‰Ô˜, ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi Á¿Ï· Ì ˘‰ÚÔÏ˘Ì¤ÓË ÚˆÙ½ÓË.

milk proteins, cow’s milk challenge test, hypoallergenic-hydrolyzed milk formula.

H ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· ¢ڇ Ê¿ÛÌ· ·ÓÂÈı‡ÌËÙˆÓ ·ÓÙȉڿÛˆÓ, Ô˘ ÔÊ›ÏÔÓÙ·È Û ·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ¤Ó·ÓÙÈ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜. ∆Ô Ê¿ÛÌ· ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂΉËÏÒÛÂˆÓ Â›Ó·È Â˘Ú‡Ù·ÙÔ Î·È Î˘Ì·›ÓÂÙ·È ·fi ·Ϥ˜ Î·È ·ÚÔ‰ÈΤ˜ ̤¯ÚÈ Ôχ ÛÔ‚·Ú¤˜, ¯ÚfiÓȘ, ÂÓÔ¯ÏËÙÈΤ˜ Î·È - Û¿ÓÈ· - ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ‹ ·ÎfiÌ· Î·È ı·Ó·ÙËÊfiÚ˜ ·ÓÙȉڿÛÂȘ. OÈ ·ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› (ηٿ Gell Î·È Coombs) Ô˘ ÂÌϤÎÔÓÙ·È, Â›Ó·È Î˘Ú›ˆ˜ Ô Ù‡Ô˘ π (πg E) Ì˯·ÓÈÛÌfi˜, Ô ÂÚÈÛÛfiÙÂÚÔ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜ Î·È Î·Ù·ÓÔËÙfi˜, ηıÒ˜ Â›Û˘ Ô Ù‡Ô˘ πππ (·ÓÔÛÔ- Û˘ÌÏÂÁÌ¿ÙˆÓ) Î·È Ô Ù‡Ô˘ πV (΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜). ∏ ‰˘Û·ÓÂÍ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ·ÓÂÈı‡ÌËÙ˜ ÂΉËÏÒÛÂȘ Ô˘ ÚÔηÏÔ‡ÓÙ·È Ì ÙË ÌÂÛÔÏ¿‚ËÛË ÌË-·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ‹ ¿ÏÏˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜ (1,2).

·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÌÔÚÔ‡Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û 3 ÔÌ¿‰Â˜ (2): ™ÙËÓ ÚÒÙË ÔÌ¿‰· ·Ó‹ÎÔ˘Ó ÂΛÓÔÈ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ¿ÌÂÛË ·ÓÙ›‰Ú·ÛË, ̤۷ Û ÂÏ¿¯ÈÛÙ· ÏÂÙ¿ - 1 ÒÚ· ÌÂÙ¿ Ï‹„Ë ÌÈÎÚÒÓ Û˘Ó‹ıˆ˜ ÔÛÔÙ‹ÙˆÓ Á¿Ï·ÎÙÔ˜. ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·Ó·Ê˘Ï·Í›·, ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÔ›‰ËÌ·, ¿ÌÂÛË Âȉ›ӈÛË ÂÎ˙¤Ì·ÙÔ˜. ŸÙ·Ó ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (‚Ú¿Á¯Ô˜ ʈӋ˜, ÂÈÛÓ¢ÛÙÈÎfi˜ ÛÈÁÌfi˜, Û˘ÚÈÁÌfi˜, ‰‡ÛÓÔÈ·) ‹ ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (¤ÌÂÙÔ˜, ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ‰È¿ÚÚÔÈ·), ·ÔÙÂÏÔ‡Ó Ì¤ÚÔ˜ Ù˘ ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘. O ˘ÔΛÌÂÓÔ˜ ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È Ù‡Ô˘ π (πg E). ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰· ·Ó‹ÎÔ˘Ó ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‰È¿ÚÚÔÈ· ‹/Î·È ¤ÌÂÙÔ ÌÂÚÈΤ˜ ÒÚ˜ (Û˘Ó‹ıˆ˜ <20 ÒÚ˜) ÌÂÙ¿ ·fi Ï‹„Ë Ì¤ÙÚÈ·˜ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜ (60-200 ml). ¶ÚfiÎÂÈÙ·È ÁÈ· ÌÈ· ÌË-πgE ÂÓÙÂÚÔ¿ıÂÈ·, fiÔ˘ Ô ˘ÔΛÌÂÓÔ˜ Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. ™ÙËÓ ÙÚ›ÙË ÔÌ¿‰· Ë ·ÓÙ›‰Ú·ÛË ÂÌÊ·Ó›˙ÂÙ·È Î·ı˘ÛÙÂÚË̤ӷ (>20 ÒÚ˜ - ÌÂÚÈΤ˜ Ë̤Ú˜) ÌÂÙ¿ ·fi Ï‹„Ë Î·ÓÔÓÈ΋˜ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜ (>300 ml ËÌÂÚËÛ›ˆ˜ ‹ ÈÛÔ‰‡Ó·Ì· Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ). ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¯ÚfiÓÈ· ‰È¿ÚÚÔÈ· ¯ˆÚ›˜ Â̤ÙÔ˘˜, ·ÓÂ¿ÚÎÂÈ· ·‡ÍËÛ˘, ÎÔÈÏȷ΋ ‰È¿Ù·ÛË, ‰˘Û·ÔÚÚfiÊËÛË (ÂÓÙÂÚÔ¿ıÂÈ·), ÎÔÏ›Ùȉ·, ‰˘ÛÎÔÈÏÈfiÙËÙ·, ‚ÚÂÊÈÎÔ‡˜ ÎÔÏÈÎÔ‡˜, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË. ∆· ·ÓˆÙ¤Úˆ ¿ÏÏÔÙÂ Û˘Óԉ‡ÔÓÙ·È Î·È ¿ÏÏÔÙ fi¯È, ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (¿ÛıÌ·) ‹ ÙÔ ‰¤ÚÌ· (¤Î˙ÂÌ·). OÈ ·ÓÙȉڿÛÂȘ ΢ڛˆ˜ Ù‡Ô˘ πV (΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜) ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ ÙÚ›ÙË ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜. ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ¤¯Ô˘Ì ·ÎfiÌ· Î·È πgE ·ÓÙȉڿÛÂȘ ¯ˆÚ›˜ ·˘ÍË̤ӷ Â›‰· ÔÏÈ΋˜ ‹ ÂȉÈ΋˜ ÁÈ· ÙȘ ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ πgE.

™˘¯ÓfiÙËÙ· Î·È ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, Ë Û˘¯ÓfiÙËÙ· Â›Ó·È 2-2,5% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÙˆÓ ‚ÚÂÊÒÓ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 16% ÌÂٷ͇ ÙˆÓ ‚ÚÂÊÒÓ Ì ‰‡Ô ·ÙÔÈÎÔ‡˜ ÁÔÓ›˜. ∏ ·ÔÚÚfiÊËÛË ÌÂÁ·ÏÔÌÔÚÈ·ÎÒÓ ÚˆÙÂ˚ÓÒÓ ÙˆÓ ÙÚÔÊÒÓ (fiˆ˜ .¯. ·˘ÙÒÓ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜) Î·È Ô Û¯ËÌ·ÙÈÛÌfi˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·˘ÙÒÓ, ·ÔÙÂÏ› Ê˘ÛÈÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∏ ·Ó¿Ù˘ÍË fï˜ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Ê·›ÓÂÙ·È fiÙÈ ÂÍ·ÚÙ¿Ù·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘Ú›ˆ˜ ·fi ÙË ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ·ÙÔ›·˜ Î·È ÙËÓ ÚÒÈÌË ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ ÛÙÔ ÌÈÎÚfi ‚Ú¤ÊÔ˜, Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤ÙÛÈ Ó¤· ·ÓÙÈÁfiÓ· Ì ÙÔ ·ÓÒÚÈÌÔ ·ÓÔÛÔÔÈËÙÈÎfi ÙÔ˘ Û‡ÛÙËÌ· Î·È ÙËÓ ·˘ÍË̤ÓË, ÏfiÁˆ ·ÓˆÚÈÌfiÙËÙ·˜, ‰È·ÂÚ·ÙfiÙËÙ· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ‚ÚÂÊÒÓ ÂÌÊ·Ó›˙ÂÈ Ù· Û˘ÌÙÒÌ·Ù· ̤۷ ÛÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ (82% ̤¯ÚÈ ÙÔÓ 4Ô Ì‹Ó· Î·È 90% ̤¯ÚÈ ÙÔ 1Ô ¤ÙÔ˜ ˙ˆ‹˜). OˆÛ‰‹ÔÙÂ, ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙËÓ ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ô ¯ÚfiÓÔ˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ ÙÔ˘ ‚Ú¤ÊÔ˘˜. ∂›Ó·È ¢ÓfiËÙÔ fiÙÈ Ù· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ÂÌÊ·Ó›˙Ô˘Ó Ù· Û˘ÌÙÒÌ·Ù· Ôχ ·ÚÁfiÙÂÚ· (1,3,4). ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∞Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ·ÓÙ›‰Ú·ÛË Î·È ÙÔÓ ˘ÔΛÌÂÓÔ ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi, ÔÈ ·ÛıÂÓ›˜ ÌÂ

220

¶ÚfiÁÓˆÛË ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙË Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÔÈΛÏÏÔ˘Ó Â˘Ú¤ˆ˜. ªÂÚÈÎÔ› Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Â›Ó·È Ì›· ·ÚÔ‰È΋ ÓfiÛÔ˜ Î·È ÙÔ 85% ÙˆÓ Â˘·›ÛıËÙˆÓ ‚ÚÂÊÒÓ ··ÏÏ¿ÛÛÂÙ·È ·fi Ù· Û˘ÌÙÒÌ·Ù¿ ÙÔ˘ Ì ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ 3Ô˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. ÕÏÏÔÈ fï˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÏÏÔ› ·ÛıÂÓ›˜ (ÂÚ›Ô˘ ÙÔ 40%) ·Ú·Ì¤ÓÔ˘Ó Û˘Ìو̷ÙÈÎÔ› ÌÂÙ¿ ÙÔÓ 4Ô ¯ÚfiÓÔ ˙ˆ‹˜ (3,5). ∏ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ·ÙÔ›·˜

MAY- JUNE '01 TELIKO

30-05-03

18:55

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¶·È‰È·ÙÚÈ΋ 2001;64:219-222

Ê·›ÓÂÙ·È fiÙÈ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÈÌÔÓ‹ Ù˘ ·ÏÏÂÚÁ›·˜. °ÂÓÈο, Ë ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› ̤۷ ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Û ·È‰È¿ Ì ÂΉËÏÒÛÂȘ ·fi ÙÔ ‰¤ÚÌ· (¤Î˙ÂÌ·) ‹ ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· (‰È¿ÚÚÔȘ, ¤ÌÂÙÔÈ, ÎÔÈÏȷο ¿ÏÁË, ·ÓÂ¿ÚÎÂÈ· ·‡ÍËÛ˘), ÂÓÒ Ù›ÓÂÈ Ó· ÂÈ̤ÓÂÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Û ÂÚÈÙÒÛÂȘ Ù‡Ô˘ π (πgE) ÂΉËÏÒÛˆÓ. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ì ÙËÓ ÔÔ›· ÚˆÙÔÂÌÊ·Ó›˙ÂÙ·È Ë ÓfiÛÔ˜, Û˘Ó‹ıˆ˜ ·Ú·Ì¤ÓÂÈ Ë ›‰È· ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÈÌÔÓ‹˜ Ù˘. ªÂÚÈΤ˜ ÊÔÚ¤˜, fï˜, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· ·ÏÏ¿˙ÂÈ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÛÙÔ ›‰ÈÔ ¿ÙÔÌÔ Î·È ÙfiÙ ·˘Ùfi Ô˘ Û˘Ì‚·›ÓÂÈ Â›Ó·È Ë ÌÂÙ¿ÙˆÛË Û ÌÔÚʤ˜ Ì ÂÚÈÛÛfiÙÂÚÔ Î·ı˘ÛÙÂÚË̤ÓË ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Û ۯ¤ÛË Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜. ¶·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Î·È Î˘Ú›ˆ˜ ÂΛӷ Ì ÂÈÌÔÓ‹ Ù˘ ÓfiÛÔ˘, ¤¯Ô˘Ó Ôχ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ·ÏÏÂÚÁ›·˜ Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· (·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· - ¿ÛıÌ·) ηıÒ˜ Î·È ·ÏÏÂÚÁ›·˜ Û ÔÏÏ·Ï¿ ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· (6,7). ¢È¿ÁÓˆÛË Ù˘ ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ÕÌÂÛË ·ÓÙ›‰Ú·ÛË (πgE) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¿ÌÂÛË Ù‡Ô˘ π ·ÓÙ›‰Ú·ÛË, Ë ‰È¿ÁÓˆÛË Â›Ó·È Û˘Ó‹ıˆ˜ ‡ÎÔÏË. ™ÙÔ ÈÛÙÔÚÈÎfi ˘¿Ú¯ÂÈ Û·Ê‹˜ Û˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Ï‹„Ë ÙÔ˘ Á¿Ï·ÎÙÔ˜. ∏ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡ Ì Á¿Ï· ·ÁÂÏ¿‰Ô˜ ‹ Ì ÂȉÈο ‰È·Ï‡Ì·Ù· ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Â›Ó·È ¤ÓÙÔÓ· ıÂÙÈ΋ Î·È Ë ÂȉÈ΋ πgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (RAST) Â›Ó·È Ôχ ·˘ÍË̤ÓË. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (·ÓÔÈÎÙ‹ ‹ ‰ÈÏ‹ Ù˘ÊÏ‹ ÂÏÂÁ¯fiÌÂÓË Ì placebo DBPC - Ô˘ ·ÔÙÂÏ› ÙË ¯Ú˘Û‹ ÛÙ·ıÂÚ¿ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜) Û˘Ó‹ıˆ˜ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·È Û ÂÚÈÙÒÛÂȘ ÌÂ Û˘ÌÙÒÌ·Ù· ·Ó·Ê˘Ï·Í›·˜ ηÏfi Â›Ó·È Ó· ·ÔʇÁÂÙ·È. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û ·È‰È¿ Ì ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ Ù‡Ô˘ ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ¿ÚÔ‰Ô ÔÚÈṲ̂ÓÔ˘ ¯ÚfiÓÔ˘ ·fi ÙË ‰È¿ÁÓˆÛË, ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘¯fiÓ ˘Ô¯ÒÚËÛ˘ Ù˘ ˘ÂÚ¢·ÈÛıËÛ›·˜ (2,4). ∫·ı˘ÛÙÂÚË̤ÓË ·ÓÙ›‰Ú·ÛË ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË. ∆Ô ÈÛÙÔÚÈÎfi ‰ÂÓ ‚ÔËı¿ÂÈ ÁÈ·Ù› Û˘Ó‹ıˆ˜ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË Ï‹„Ë Á¿Ï·ÎÙÔ˜. ∏ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ó˘ÁÌÔ‡ Î·È Ë ÂȉÈ΋ πgE ÁÈ· ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (RAS∆) Û˘Ó‹ıˆ˜ ·Ô‚·›ÓÔ˘Ó ·ÚÓËÙÈΤ˜. OÈ ·fi„ÂȘ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ˜, fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÚfiÏÔ Ù˘ ‰ÔÎÈÌ·Û›·˜ patch ÛÙË ‰È¿ÁÓˆÛË ÙˆÓ Î·ı˘ÛÙÂÚË̤ÓÔ˘ Ù‡Ô˘ ·ÓÙȉڿÛˆÓ. ∏ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ·ÔÙÂÏ› ÙËÓ ·ÎÚÈ‚¤-

Paediatriki 2001;64:219-222

ÛÙÂÚË Ì¤ıÔ‰Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË, ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ™Â ·È‰È¿ <1 ¤ÙÔ˘˜, ·ÓÔÈÎÙ‹ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ¤¯ÂÈ ‰Âȯı› fiÙÈ Â›Ó·È ·ÍÈfiÈÛÙË (4,8,9). ¶ÚÔ¸Ôı¤ÛÂȘ ‰ÔÎÈÌ·Û›·˜ ÚfiÎÏËÛ˘: ¶Ú¤ÂÈ ¿ÓÙ· Ó· Á›ÓÂÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ·fi ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi, ΢ڛˆ˜ ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÌÙˆÌ¿ÙˆÓ ·Ó·Ê˘Ï·Í›·˜ ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ÂÚÌËÓ›· ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜. ∂È‚¿ÏÏÂÙ·È Ë Ï‹„Ë ÏÂÙÔÌÂÚÔ‡˜ ÈÛÙÔÚÈÎÔ‡ Î·È Ë Ï‹Ú˘ Ê˘ÛÈ΋ ÂͤٷÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙÔÓ ÔÔ›Ô ÙÔÔıÂÙÂ›Ù·È ÊÏ‚ÔηıÂÙ‹Ú·˜. °›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ηٷÁÚ·Ê‹ Ûʇ͈Ó, ∞¶, ÎÔÚÂÛÌÔ‡ O2 (SaO2), ÌÂÁ›ÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ (PEF) fiÙ·Ó ÙÔ ·È‰› Â›Ó·È >5 ÂÙÒÓ. À¿Ú¯Ô˘Ó Ê¿Ú̷η ·Ó¿Ó˄˘ Î·È ·ÚÔ¯‹ O2 ‰›Ï· ·fi ÙÔÓ ·ÛıÂÓ‹. ∆¯ÓÈ΋ ‰ÔÎÈÌ·Û›·˜ ÚfiÎÏËÛ˘: ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ÛÙ·‰È·Î‹ ¯ÔÚ‹ÁËÛË - ·Ó¿ 20-30 min - ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓˆÓ ÔÛÔÙ‹ÙˆÓ Á¿Ï·ÎÙÔ˜. ∏ ‰ÔÎÈÌ·Û›· ıˆÚÂ›Ù·È ÂÈÙ˘¯‹˜ fiÙ·Ó Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Ó¯ı› Û˘ÓÔÏÈο 15-20 gr ÚˆÙ½Ó˘ Á¿Ï·ÎÙÔ˜ Î·È 8-10 gr Û·Ó Ì›· ÙÂÏÈ΋ ÌÔÓ·‰È΋ ‰fiÛË. ∞Ó¿ 20-30 min Á›ÓÂÙ·È Ï‹Ú˘ Ê˘ÛÈ΋ ÂͤٷÛË (¤ÏÂÁ¯Ô˜ ÁÈ· ·ÚÔ˘Û›· ÂÍ·Óı‹Ì·ÙÔ˜, ÊÙ·ÚÓÈÛÌ¿ÙˆÓ, ÛÈÁÌÔ‡, Û˘ÚÈÁÌÔ‡, Â̤وÓ, ‰È¿ÚÚÔÈ·˜, ¢ÂÚÂıÈÛÙfiÙËÙ·˜), ηٷÁÚ·Ê‹ Ûʇ͈Ó, ∞¶, SaO2 PEF. ∂¿Ó ÂÌÊ·ÓÈÛÙ› ÔÔÈ·‰‹ÔÙ ·ÓÙ›‰Ú·ÛË, Ë ‰ÔÎÈÌ·Û›· ‰È·ÎfiÙÂÙ·È Î·È Ô ·ÛıÂÓ‹˜ ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· 12-24 ÒÚ˜. ∂¿Ó ‰ÂÓ ÂÌÊ·ÓÈÛÙ› ·ÓÙ›‰Ú·ÛË, Ô ·ÛıÂÓ‹˜ ÂͤگÂÙ·È ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ 23 ÒÚ˜ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ‰ÔÎÈÌ·Û›·˜. ∞ÓÙÈÌÂÙÒÈÛË ·ÏÏÂÚÁ›·˜ ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ ∞) ™Ù· ‚Ú¤ÊË Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Û˘ÓÈÛÙ¿Ù·È Ï‹Ú˘ ·ÔÊ˘Á‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙˆÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘. ∂¿Ó Â›Ó·È ÂÊÈÎÙfi, ÂÓı·ÚÚ‡ÓÂÙ·È Ë Û˘Ó¤¯ÈÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ‰È·ÊÔÚÂÙÈο ÂÈϤÁÂÙ·È ÚÔÛÂÎÙÈο ÙÔ Î·Ù¿ÏÏËÏÔ ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈÎfi Á¿Ï·. ™‹ÌÂÚ·, ˆ˜ ηٷÏÏËÏfiÙÂÚ· ˘Ô·ÏÏÂÚÁÈÔÁÔÓÈο Á¿Ï·Ù· ıˆÚÔ‡ÓÙ·È ÂΛӷ Ì ÂÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ÚˆÙ½Ó˘ (ÂÚȤ¯Ô˘Ó ÂÙ›‰È· <8000 Da). AÓ¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ Ù˘ ÚˆÙ½Ó˘ ‰È·ÎÚ›ÓÔÓÙ·È Û Á¿Ï·Ù· ÌÂ: ∂ÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË Î·˙½Ó˘ (Pregestimil, Nutramigen), EÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ÏÂ˘ÎˆÌ·Ù›Ó˘ (Alfa-Re, Pepti-junior, Nutrilon Pepti), ∂ÎÙÂٷ̤ÓË ˘‰ÚfiÏ˘ÛË ¿ÏÏ˘ ÚˆÙ½Ó˘ (˙ˆ˚΋˜ ‹ Ê˘ÙÈ΋˜) (Pre- gomin, Peptide 0-2, Peptide 2+). ŒÓ· ÌÈÎÚfi ÔÛÔÛÙfi ‚ÚÂÊÒÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜ ·ÎfiÌË Î·È ÛÙ· ·Ú·¿Óˆ Á¿Ï·Ù·, ÔfiÙÂ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ Ì ·ÌÈÓÔͤ· fiˆ˜: ¡utri-junior, Neocate (ÁÈ· ‚Ú¤ÊË), Neocate Advance (ÁÈ· ·È‰È¿ >1 ¤ÙÔ˘˜). ∆Ô

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Á¿Ï· ÛfiÁÈ·˜ ‰ÂÓ ÂӉ›ÎÓ˘Ù·È ÛÙ· ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜, ÂÂȉ‹ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·fi ·˘Ù¿ (17-47%) ·Ó·Ù‡ÛÛÂÈ ·ÏÏÂÚÁ›· ÛÙË ÛfiÁÈ·. ∆Ô Á¿Ï· ÙÔ˘ ÚÔ‚¿ÙÔ˘ Î·È Ù˘ ηÙۛη˜ ¤¯ÂÈ ÔÏϤ˜ ÎÔÈÓ¤˜ ÚˆÙ½Ó˜ Ì ·˘Ùfi Ù˘ ·ÁÂÏ¿‰Ô˜ Î·È ıˆÚÂ›Ù·È ·Î·Ù¿ÏÏËÏÔ ˆ˜ ˘ÔηٿÛÙ·ÙÔ. ∆¤ÏÔ˜, ·Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· Á¿Ï·Ù· Ì ÌÂÚÈ΋ ˘‰ÚfiÏ˘ÛË Ù˘ ÚˆÙ½Ó˘ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ (ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏË ·Ó·ÏÔÁ›· ÚˆÙÂ˚ÓÒÓ 8-40 kD·), fiˆ˜ .¯. ¡∞N ∏∞, ∞ptamil HA, ·ÓÙÂӉ›ÎÓ˘ÓÙ·È Ï‹Úˆ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË - ·ÏÏÂÚÁÈÎÒÓ ÛÙÔ Á¿Ï· - ‚ÚÂÊÒÓ. ÿÛˆ˜ ¤¯Ô˘Ó ı¤ÛË ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· ÚfiÏ˄˘ Ù˘ ·ÙÔ›·˜ (7,10). µ) OÈ ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ ·ÏÏ¿ Î·È ÔÈ ›‰ÈÔÈ ÔÈ ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ (ȉȷ›ÙÂÚ· ÂΛÓÔÈ Ì ·Ó·Ê˘Ï·ÎÙÈÎÔ‡ Ù‡Ô˘ ·ÓÙȉڿÛÂȘ) Ú¤ÂÈ Ó· Â›Ó·È Ôχ ηϿ ÂÓËÌÂڈ̤ÓÔÈ Î·È Ó· ·ÔʇÁÔ˘Ó, fi¯È ÌfiÓÔ ÙÔ Á¿Ï· Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘, ·ÏÏ¿ Î·È ‰È¿ÊÔÚ˜ ÙÚÔʤ˜ Ô˘ ÂÚȤ¯Ô˘Ó ÚˆÙ½ÓË Á¿Ï·ÎÙÔ˜. ŒÙÛÈ, Ú¤ÂÈ Ó· Ì¿ıÔ˘Ó Ó· ‰È·‚¿˙Ô˘Ó ÚÔÛÂÎÙÈο ÙÔ˘˜ ηٷÏfiÁÔ˘˜ Ì ٷ Û˘ÛÙ·ÙÈο ÙˆÓ ‰È·ÊfiÚˆÓ ÙÚÔÊÒÓ Î·È Ó· ÁÓˆÚ›˙Ô˘Ó fiÙÈ Ë ÚˆÙ½ÓË ÙÔ˘ Á¿Ï·ÎÙÔ˜ ÌÔÚ› Ó· ÎÚ‡‚ÂÙ·È ›Ûˆ ·fi fiÚÔ˘˜ fiˆ˜ Ï·ÎÙfi˙Ë, ηڷÌÂÏfi¯ÚˆÌ·, Ê˘ÛÈÎfi ¿ÚˆÌ· Î.Ù.Ï. (4). °) À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ ÔÈ ÚÔ‚ÈÔÙÈÎÔ› ÔÚÁ·ÓÈÛÌÔ› - ÌÈÎÚԂȷο ·ÙÙ·Ú· ‹ ÙÌ‹Ì·Ù· ·˘ÙÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙ· Á¤ÓË lactobacilli ‹ bifidobacteria - ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. ª¤¯ÚÈ ÛÙÈÁÌ‹˜, fï˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ (11). ¢) ∆¤ÏÔ˜, Ù· ·È‰È¿ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜ Ú¤ÂÈ ·Ó¿ 1-2 ¯ÚfiÓÈ· Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘, ÁÈ·Ù› ˘¿Ú¯ÂÈ ÙÔ ÂӉ¯fiÌÂÓÔ ˘Ô¯ÒÚËÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·Ó¿Ù˘Í˘ ·ÓÔ¯‹˜ ÛÙÔ Á¿Ï· Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘ (3-5).

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¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ∆Ú›Áη ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ ¶ÂÚ. ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·ÙÚÒÓ 265 00, ƒ›Ô-¶¿ÙÚ·

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∞§§∂ƒ°πO§O°π∞ - ¢∂ƒª∞∆O§O°π∞

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ALLERGIOLOGY - DERMATOLOGY

XÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (Staphylococcus aureus). O ÚfiÏÔ˜ ÙÔ˘ ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ª. µ·Ï¿ÚË

The role of Staphylococcus aureus in atopic dermatitis M. Valari

¶ÂÚ›ÏË„Ë: ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ‰ÂÚÌ·ÙÔ¿ıÂÈ· ÙˆÓ ·È‰ÈÒÓ. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Â›Ó·È ·ÎfiÌË ¿ÁÓˆÛÙË, ·ÏÏ¿ ÈÛÙ‡ÂÙ·È ÔÙÈ Â›Ó·È Û‡ÌÏÂÁÌ· ·ÏÏËÏÂ›‰Ú·Û˘ ÁÂÓÂÙÈ΋˜ ¢·ÈÛıËÛ›·˜, ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÊÚ·ÁÌÔ‡ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜, ·ÏÏÂÚÁ›Â˜ Î·È ÌÈÎÚfi‚È·. O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÈΛ˙ÂÈ ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ˘„ËÏ¿ Â›‰·, Ù· ÔÔ›· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÂÏ¢ıÂÚÒÓÂÈ ÙÔ͛Ә Ô˘ ‰ÚÔ˘Ó Û·Ó ˘ÂÚ·ÓÙÈÁfiÓ·, Ù· ÔÔ›· ÌÔÚ› Ó· ÚÔηÏÔ‡Ó ÙË ÊÏÂÁÌÔÓ‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÛÙÔ ·ÙÔÈÎfi ¤Î˙ÂÌ·. ™Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿, Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÌÔÚ› Ó· ıÂÚ·¢Ù› Ì ÙËÓ Î·Ï‹ ÊÚÔÓÙ›‰· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙË ¯Ú‹ÛË ÙÔÈÎÒÓ ÛÙÂÚÔÂȉÒÓ Î·È Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈ΋ ıÂÚ·›·.

Abstract: Atopic dermatitis is the most common skin disease affecting children. The etiology of atopic dermatitis is still unknown, but it is believed to be a complex interplay between genetic susceptibility, immune dysregulation, epidermal barrier dysfunction and environmental factors such as irritants, allergies and bacteria. The skin of patients with atopic dermatitis is colonized with high levels of Staphylococcus aureus, depending on the severity of the eczema. Staphylococcus aureus releases toxins that act as superantigens which can induce skin inflammation in patients with atopic eczema. In most children, atopic dermatitis can be controlled with good skin care, the use of topical steroids and the appropriate anti-staphylococcal treatment.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ¤Î˙ÂÌ·, ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ˘ÂÚ·ÓÙÈÁfiÓ·, ·ÓÙÈ‚ÈÔÙÈο, ·È‰È¿.

Key words: atopic dermatitis, eczema, Staphylococcus aureus, superantigens, antibiotics, children.

ªÂϤÙ˜ ÁÈ· ÙÔ ÚfiÏÔ ÙˆÓ ÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ÍÂΛÓËÛ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi 100 ¯ÚfiÓÈ· ÚÈÓ (1-3). ∞fi ÙfiÙÂ, Ë ÁÓÒÛË, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÌÈÎÚÔ‚›ˆÓ Î·È ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Î·È Û‹ÌÂÚ· Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ÛÔ˘‰·›Ô˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁˆÓ ÁÈ· ÙËÓ ÔÍ›· Âȉ›ӈÛË ·ÏÏ¿ Î·È ÙË ‰È·Ù‹ÚËÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜.

∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, Ô˘ ÔÓÔÌ¿˙ÂÙ·È Î·È ·ÙÔÈÎfi ¤Î˙ÂÌ·, Â›Ó·È Ì›· ¯ÚfiÓÈ· ˘ÔÙÚÔÈ¿˙Ô˘Û· ÎÓËÛÌ҉˘ ‰ÂÚÌ·ÙÔ¿ıÂÈ· Ô˘ ÚÔÛ‚¿ÏÏÂÈ ¿ÙÔÌ· Ì ÁÂÓÂÙÈ΋ Úԉȷı¤ÛË. ™˘¯Ó¿ ÙË Û˘Ó·ÓÙԇ̠۠·ÛıÂÓ›˜ Ì ¿ÛıÌ· ‹ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· (4). ∂›Ó·È Ë ÈÔ Û˘¯Ó‹ ‰ÂÚÌ·ÙÔ¿ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ™˘Ó‹ıˆ˜ ÚˆÙÔÂÌÊ·Ó›˙ÂÙ·È fiÙ·Ó ÙÔ ·È‰› Â›Ó·È ‚Ú¤ÊÔ˜ Î·È ÂÚ›Ô˘ ÙÔ 90% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÂΉËÏÒÓÂÈ ÙË ÓfiÛÔ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ¯ÚfiÓˆÓ (5).

∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

Division of Pediatric Dermatology “St. Sophia” Children’s Hospital, Athens

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O ÎÓËÛÌfi˜ Â›Ó·È ÙÔ ·ıÔÁÓˆÌÔÓÈÎfi Û‡Ìو̷ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Û fiϘ ÙȘ ËÏÈ˘. ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÛÙËÓ ÔÍ›· ÌÔÚÊ‹ Ù˘ ÂΉËÏÒÓÂÙ·È Ì ÂÚ‡ıËÌ·, Ô›‰ËÌ·, ‰È·‚ÚÒÛÂȘ Î·È ÂΉÔÚ¤˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÂÓÒ Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÔÚÔÚÚÔ‹ Î·È Ó· Û¯ËÌ·ÙÈÛÙÔ‡Ó ÂÊÂÏΛ‰Â˜. °ÓÒÚÈÛÌ· Ù˘ ¯ÚfiÓÈ·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Â›Ó·È Ë ÏÂȯËÓÔÔ›ËÛË, ‰ËÏ·‰‹ Ë ¯·Ú·ÎÙËÚÈÛÙÈ΋ ¿¯˘ÓÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Ì ·˘ÍË̤ÓË ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÁÚ¿Ì̈ÛË Î·È ·˘ÍË̤ÓË Û˘Ó‹ıˆ˜ ÌÂÏ¿¯ÚˆÛË. ™Ù· ‚Ú¤ÊË, Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÂÓÙÔ›˙ÂÙ·È ÛÙȘ ·ÚÂȤ˜, ÙÔ Ì¤ÙˆÔ, ÙÔ ÎÂÊ¿ÏÈ, ÙÔÓ ÎÔÚÌfi Î·È ÙȘ ¤Íˆ ÂÈÊ¿ÓÂȘ ÙˆÓ ¿ÎÚˆÓ, ÂÓÒ ÎÏÈÓÈο ¤¯Ô˘Ì ÂÈÎfiÓ· ÔÍ›·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÔÈ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÂÓÙÔ›˙ÔÓÙ·È Û Ù˘¯¤˜, fiˆ˜ ÛÙÔ˘˜ ·ÁÎÒÓ˜ Î·È ÛÙ· ÁfiÓ·Ù·, ·ÏÏ¿ Î·È ÛÙÔ˘˜ ηÚÔ‡˜, ÛÙÔ˘˜ ÌËÚÔ‡˜, ÁÏÔ˘ÙÔ‡˜ Î·È Ù· ¯¤ÚÈ·. ∫ÏÈÓÈο, ηıÒ˜ ÙÔ ·È‰› ÌÂÁ·ÏÒÓÂÈ, ÔÈ ‚Ï¿‚˜ Á›ÓÔÓÙ·È ÍËÚfiÙÂÚ˜, ÈÔ ‚Ï·Ùȉ҉ÂȘ Î·È ÏÂȯËÓÔÔÈË̤Ó˜, ÂÓÒ Û˘Ó˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ˜ ÎÓËÛÌfi˜. ¶·ıÔÁ¤ÓÂÈ· ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ·Ú·Ì¤ÓÂÈ ·ÎfiÌË ¿ÁÓˆÛÙË. £ÂˆÚÂ›Ù·È fiÙÈ Â›Ó·È Û‡ÌÏÂÁÌ· ·ÏÏËÏÂ›‰Ú·Û˘ ÁÂÓÂÙÈ΋˜ ¢·ÈÛıËÛ›·˜, ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÊÚ·ÁÌÔ‡ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Â›‰Ú·Û˘ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (6). ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ÁÂÓÂÙÈ΋ ÓfiÛÔ˜, ·Ó Î·È ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜ Ô ÙÚfiÔ˜ ÌÂÙ·‚›‚·Û˘. ∞˘Ùfi Ê·›ÓÂÙ·È ·fi ÙÔÓ ÔÈÎÔÁÂÓ‹ ¯·Ú·ÎÙ‹Ú· Ù˘ ÓfiÛÔ˘ Î·È ·fi ÙËÓ ˘„ËÏ‹ Û˘Ó‡·ÚÍË Û ÌÔÓÔˆÁÂÓ‹ ‰›‰˘Ì· (7). ∏ ÎÏËÚÔÓÔÌÈ΋ ·ÓˆÌ·Ï›· Ê·›ÓÂÙ·È Ó· ÌÂٷʤÚÂÙ·È ÛÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· Î·È Ó· Â›Ó·È ÔÏ˘ÁÔÓȉȷ΋ (8). ∞Ó Î·È Ë ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û˘Ó‰˘¿˙ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏ›· ·ÓÔÛÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ‰‡Ô ‚·ÛÈΤ˜ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ê·›ÓÂÙ·È Ó· ÙËÓ ¯·Ú·ÎÙËÚ›˙Ô˘Ó: ÚÒÙÔÓ, Ë ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ IgE Î·È ‰Â‡ÙÂÚÔÓ, Ë ‹È· ηٷÛÙÔÏ‹ Ù˘ ·ÓÙ›‰Ú·Û˘ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ÂÈ‚Ú·‰˘ÓfiÌÂÓÔ˘ Ù‡Ô˘. ŒÚ¢Ó˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ˘ÔÏËı˘ÛÌfi˜ ∆∏2 ÙˆÓ ∆-

Paediatriki 2001;64:223-228

΢ÙÙ¿ÚˆÓ Ô˘ ˘¿Ú¯Ô˘Ó Û ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë ÛÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·Ú¿ÁÔ˘Ó ·˘ÍË̤ӷ ÔÛ¿ ÈÓÙÂÚÏ¢ΛÓ˘ IL-4 Ô˘ ‰ÚÔ˘Ó ¿Óˆ ÛÙ· µÎ‡ÙÙ·Ú· Î·È ÚÔ¿ÁÔ˘Ó ÙËÓ ˘ÂÚ·Ú·ÁˆÁ‹ IgE. ∞ÎfiÌË, ‚Ú¤ıËΠfiÙÈ ˘¿Ú¯ÂÈ ÌÂȈ̤ÓÔ˜ Ô ∆∏1 ˘ÔÏËı˘ÛÌfi˜ ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ, ÏfiÁˆ ˘ÂÚ·Ú·ÁˆÁ‹˜ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ (PGE ·Ô Ù· ÌÔÓÔ·ÙÙ·Ú·) Î·È ÙÔ˘ TNF (·fi Ù· Ì·ÛÙÔ·ÙÙ·Ú·) Î·È Ô˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ Á-ÈÓÙÂÚÊÂÚfiÓ˘ (IFN). øÛÙfiÛÔ, Ô ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÚÔηÏ› ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ ‰ÂÓ ¤¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ ‰È¢ÎÚÈÓÈÛÙ› (6,9). ∏ ÍËÚÔ‰ÂÚÌ›· Û ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÔÊ›ÏÂÙ·È ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ÏÈȉ›ˆÓ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Û ·˘ÍË̤ÓË ‰È·‰ÂÚÌÈ΋ ·ÒÏÂÈ· ÓÂÚÔ‡. ∞˘Ù¿ ¤¯Ô˘Ó Û·Ó Û˘Ó¤ÂÈ· ÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÊÚ·ÁÌÔ‡ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∏ ÍËÚfiÙËÙ· ‰ËÌÈÔ˘ÚÁ› ‰È·‚ÚÒÛÂȘ, ÔÈ Ôԛ˜ ÂÎı¤ÙÔ˘Ó ÙÔ ˘ÔΛÌÂÓÔ ‰¤ÚÌ· Û ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜, ·ÏÏÂÚÁÈÔÁfiÓ· Î·È ÌÈÎÚfi‚È· Ô˘ ÚÔηÏÔ‡Ó ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ (9). ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ¯ÚfiÓÈ· ÓfiÛÔ˜ Ì ÂÍ¿ÚÛÂȘ Ô˘ ÂÎχÔÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ (10). OÈ ÛÔ˘‰·ÈfiÙÂÚÔÈ ·fi ·˘ÙÔ‡˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÂÏ¿¯ÈÛÙ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ·ÏÏÂÚÁ›· ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÂÓÒ Ê·›ÓÂÙ·È fiÙÈ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÂȉÂÈÓÒÓÂÙ·È ·fi ·˘Ù‹ (11).

O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ (S. aureus), ¤Ó· ÎÔÈÓfi ·ıÔÁfiÓÔ ÌÈÎÚfi‚ÈÔ Ô˘ Û¿ÓÈ· ·ÔÈΛ˙ÂÈ ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‰¤ÚÌ·, ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Û·Ó ÂÚÈ‚·ÏÏÔÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔηÏ› Âȉ›ӈÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ (12). ™Ù· ˘ÁÈ‹ ¿ÙÔÌ·, Ù· ÛËÌ›· Ô˘ Û˘Ó‹ıˆ˜ ·ÔÈΛ˙ÔÓÙ·È Ì S. aureus Â›Ó·È Ë Ì‡ÙË (35% ÙÔ˘ ÏËı˘ÛÌÔ‡), ÔÈ Ù˘¯¤˜, fiˆ˜ Ì·Û¯¿ÏË Î·È Ù˘¯¤˜ Ô‰ÈÒÓ (5% - 10%) Î·È ÙÔ ÂÚ›ÓÂÔÓ (20%) (13). ∞ÓÙ›ıÂÙ·, ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ÌÂϤÙ˜ Ô˘ ÍÂοı·Ú· ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÈΛ˙ÂÈ ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ÔÛÔÛÙfi Ô˘ ÌÔÚ› Ó· Î˘Ì·›ÓÂÙ·È ·fi 70% ÛÙȘ ÌË ÚÔۂ‚ÏË̤Ó˜ ÂÚÈÔ¯¤˜ Î·È Êı¿ÓÂÈ Ì¤¯ÚÈ 100% ÛÙȘ ÂÍȉڈ̷ÙÈΤ˜ ‚Ï¿‚˜

¶›Ó·Î·˜ 1. ∂ÎÏ˘ÙÈο ·›ÙÈ· ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜

∂ÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜ (Û·Ô‡ÓÈ·, Û·ÌÔ˘¿Ó, ·ÔÚÚ˘·ÓÙÈο, Â·Ê‹ Ì ӿ˘ÏÔÓ Î·È Ì¿ÏÏÈÓ·) ∫ϛ̷ (¯ÂÈÌÒÓ·˜ Î·È ¯·ÌËÏ‹ ˘ÁÚ·Û›·) ÕÁ¯Ô˜ ∆ÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· (·˘Á¿, Á¿Ï·, ÍËÚÔ› ηÚÔ›, „¿ÚÈ Î·È ‰ËÌËÙÚȷο) ∂ÈÛÓÂfiÌÂÓ· ·ÏÏÂÚÁÈÔÁfiÓ· (¿Î·ÚÈ Ù˘ ÔÈÎȷ΋˜ ÛÎfiÓ˘, ÁÚ·Û›‰È, ÙÚ›¯ˆÌ· ·fi ηÙÔÈΛ‰È· ˙Ò·) ªÈÎÚfi‚È· (¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÈÙ˘ÚfiÛÔÚÔ)

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(14,15). ∏ ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Â›Ó·È Ôχ ˘„ËÏfiÙÂÚË ÛÙȘ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ Û ۯ¤ÛË Ì ÙÔ ˘ÁȤ˜ ‰¤ÚÌ·, fiˆ˜ Â›Û˘ Â›Ó·È ·Ó¿ÏÔÁ· Û¯ÂÙÈ˙fiÌÂÓË Ì ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. Œ¯ÂÈ ‚ÚÂı› fiÙÈ Û ÂÍȉڈ̷ÙÈΤ˜ ‚Ï¿‚˜, ‰ËÏ·‰‹ ÔÍ›·˜ ÌÔÚÊ‹˜ ‰ÂÚÌ·Ù›Ùȉ·, Ë Ì¤ÛË ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ‹Ù·Ó (ÌÂÁ¿ÏË) 14x106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2, Û ¯ÚfiÓÈ· ÏÂȯËÓÔÔÈË̤ÓÔ ‰¤ÚÌ· (̤ÙÚÈ·) 5x106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 Î·È Û ˘ÁȤ˜ (ÌÈÎÚ‹) 1,3x103 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 (14). ∞˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·fi ·ÚÎÂÙÔ‡˜ ÂÚ¢ÓËÙ¤˜ (16,17). ∞›ÙÈ· ·ÔÈÎÈÛÌÔ‡ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· O ÏfiÁÔ˜ ÙÔ˘ ˘„ËÏÔ‡ ·ÔÈÎÈÛÌÔ‡ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ¿ÁÓˆÛÙÔ˜. ªÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ÍËÚfiÙËÙ· Ô˘ ‰ËÌÈÔ˘ÚÁ› ‰È·‚ÚÒÛÂȘ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÔÈ Ôԛ˜ ÂÈÙÚ¤Ô˘Ó ÙË ‰È›ۉ˘ÛË ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘. ∂›Û˘, ¤¯ÂÈ ·Ô‰Ôı› ÛÙËÓ ·˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, Ô˘ ÔÊ›ÏÂÙ·È Û ÔÚÈṲ̂Ó˜ ÚˆÙ½Ó˜ ÚÔÛÎfiÏÏËÛ˘, fiˆ˜ Ë ÊÈÌÚÔÓÂÎÙ›ÓË (18,19). ∞ÎfiÌË, ¤¯ÂÈ ·Ô‰Ôı› ÛÙË ÌÂȈ̤ÓË ·ÓÙÈÌÈÎÚԂȷ΋ ‰Ú¿ÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÏfiÁˆ Ì›ˆÛ˘ ÙÔ˘ ÛÌ‹ÁÌ·ÙÔ˜ Î·È ÙÔ˘ ȉÚÒÙ·, ·ÏÏ¿ Î·È ÏfiÁˆ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ÏÈȉ›ˆÓ Ù˘ ÂȉÂÚÌ›‰·˜ (17). ™Ù·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ¶ÂÚ›Ô˘ Ù· 2/3 ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎˆÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Û ηÏÏȤÚÁÂȘ ·fi ÙÔ ‰¤ÚÌ· ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ·Ú¿ÁÔ˘Ó Â͈ÙÔ͛Ә, ΢ڛˆ˜ ÙȘ ˘ÂÚ·ÓÙÈÁÔÓÈΤ˜ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ÂÓÙÂÚÔÙÔ͛Ә ∞ Î·È µ (SEA, SEB) Î·È ÙËÓ ÙÔÍ›ÓË ÙÔ˘ ÙÔÍÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (TSST-1) (20). ∏ ˘ÂÚ·ÓÙÈÁÔÓÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ô Î˘ÚÈfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÚÔηÏ› Âȉ›ӈÛË Î·È ‰È·Ù‹ÚËÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›‰·˜, ·Ó Î·È ÔÈ ¤Ú¢Ó˜ Â›Ó·È ·ÎfiÌË ÛÙËÓ ·Ú¯‹ (21-23). ÀÂÚ·ÓÙÈÁfiÓ· ∆· ˘ÂÚ·ÓÙÈÁfiÓ· Â›Ó·È Ì›· Û¯ÂÙÈο ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈṲ̂ÓË ÔÌ¿‰· ·ÓÙÈÁÔÓÈÎÒÓ ÌÔÚ›ˆÓ, Ù· ÔÔ›· ‰È·Ê¤ÚÔ˘Ó ·fi Ù· ÎÏ·ÛÈο ·ÓÙÈÁfiÓ· ÛÙÔ fiÙÈ ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ó· ÂÓÂÚÁÔÔÈÔ‡Ó ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (5-30%) Û ۯ¤ÛË Ì ٷ Û˘Ì‚·ÙÈο ·ÓÙÈÁfiÓ· (0,01-0,0001%) (1,22,23).

OÈ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ¤¯ÂÈ ÚÔÙ·ı›

Paediatriki 2001;64:223-228

fiÙÈ ÚÔηÏÔ‡Ó Âȉ›ӈÛË Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ›Ù ‰ÚÒÓÙ·˜ Û·Ó ·ÏÏÂÚÁÈÔÁfiÓ· Ì ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ Ù‡Ô˘ π ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ (IgE ‰È·ÌÂÛÔÏ·‚Ô‡ÌÂÓË ˘ÂÚ¢·ÈÛıËÛ›·), ›Ù ‰ÚÒÓÙ·˜ Û·Ó ˘ÂÚ·ÓÙÈÁfiÓ· Ì ÙËÓ ¤ÓÓÔÈ· Ù˘ ÌË ÂȉÈ΋˜ ‰È¤ÁÂÚÛ˘ ÙˆÓ ∆-΢ÙÙ¿ÚˆÓ (24). ∆· ˘ÂÚ·ÓÙÈÁfiÓ· Ê·›ÓÂÙ·È fiÙÈ ÚÔηÏÔ‡Ó ‹ ÚÔ¿ÁÔ˘Ó ‚Ï¿‚˜ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Ì ‰È¿ÊÔÚÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜. ŒÙÛÈ, ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì¤Ûˆ ‰È·Û˘Ó‰¤Ûˆ˜ Ù˘ V ÂÚÈÔ¯‹˜ Ù˘ ‚ ·Ï˘Û›‰·˜ ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-΢ÙÙ¿ÚÔ˘ TCR Ì ٷ ÌfiÚÈ· ÙÔ˘ ªÂ›˙ÔÓÔ˜ ™˘ÌϤÁÌ·ÙÔ˜ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ MHC-II, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ¤ÎÎÚÈÛË ÏÂÌÊÔÎÈÓÒÓ Î·È ÙË ÊÏÂÁÌÔÓ‹ (22,23). ∞ÎfiÌË, Ù· ˘ÂÚ·ÓÙÈÁfiÓ· ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó ·¢ı›·˜ ·ÙÙ·Ú· ÙÔ˘ Langerhans, Ì·ÎÚÔÊ¿Á·, ÌÔÓÔ·ÙÙ·Ú· Î·È ÎÂÚ·ÙÈÓÔ·ÙÙ·Ú· Î·È Ó· ÚÔηϤÛÔ˘Ó ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ fiˆ˜ IL-1 (ÈÓÙÂÚÏ¢ΛÓ˘) Î·È TNF-· (·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ fiÁÎÔ˘) Î·È ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Ì¤Û· ÛÙÔ ‰¤ÚÌ· (23). ∂ȉÈο IgE ·ÓÙÈÛÒÌ·Ù· ÂÓ·ÓÙ›ÔÓ ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘, fiˆ˜ ÙȘ ÂÓÙÂÚÔÙÔ͛Ә ∞ Î·È µ Î·È ÙËÓ ÙÔÍ›ÓË ÙÔ˘ ÙÔÍÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (SEA, SEB, TSST-1), ¤¯Ô˘Ó ·ÓȯÓ¢ı› Û ÔÈΛϷ ˘„ËÏ¿ ÔÛÔÛÙ¿ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (24-26). ∆· Â›‰· ÙˆÓ ÂȉÈÎÒÓ ·˘ÙÒÓ IgE ·ÓÙÈÛˆÌ¿ÙˆÓ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘. ™Â ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜ ‚Ú¤ıËΠfiÙÈ ÔÈ ÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ Â͈ÙÔ͛Ә ÌÔÚ› Ó· ‰ÈÂÁ›ÚÔ˘Ó Ù· µ ÏÂÌÊÔ·ÙÙ·Ú· Ó· ·Ú¿ÁÔ˘Ó ÂȉÈο IgE ·ÓÙÈÛÒÌ·Ù· (27). ∞ÔÈÎÈÛÌfi˜ ‹ Ïԛ̈ÍË •·ÊÓÈ΋ Âȉ›ӈÛË Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÔÚÔÚÚÔ‹˜, ÂÊÂÏΛ‰ˆÓ, ÊÏ˘ÎÙ·ÈÓȉ›ˆÓ ‹ ˘Ò‰Ô˘˜ ¤ÎÎÚÈÛ˘ Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ (S. aureus), ·ÏÏ¿ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ‚ÔÏ‹ Î·È ÌÈÎÚÔ‚È·ÈÌ›· Â›Ó·È ·Û˘Ó‹ı˘. ∏ Ïԛ̈ÍË Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ÛÙ· ·È‰È¿ (28). ∏ ‰È¿ÎÚÈÛË ÌÂٷ͇ ·ÔÈÎÈÛÌÔ‡ Î·È Ïԛ̈͢ Â›Ó·È ‰‡ÛÎÔÏË ‚¿ÛÂÈ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜. ∏ ·ÚÔ˘Û›· ÔÚÔÚÚÔ‹˜ ‹ ÂÊÂÏΛ‰ˆÓ ÌÔÚ› Ó· Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ ·ÏÏ¿ Î·È ·Ï‹˜ ¤Í·ÚÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ ·fi ¿ÏÏ· ·ÏÏÂÚÁÈÔÁfiÓ·. ∂›Û˘, ·Ú¿ ÙÔÓ Ôχ ˘„ËÏfi ·ÚÈıÌfi ÛÙ·Ê˘ÏÔÎfiÎÎˆÓ Ô˘ ˘¿Ú¯Ô˘Ó Û ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜, ·˘Ù¤˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÂÈÌÔÏ˘Ṳ̂Ó˜ ‹ Ù· ÎÏÈÓÈο ÛËÌ›· Ù˘ Ïԛ̈͢ Ó· ÌËÓ Â›Ó·È ÂÌÊ·Ó‹. ŒÙÛÈ, ¤¯ÂÈ ÚÔÙ·ı› fiÙÈ ˘ÎÓfiÙËÙ· ÙÔ˘ ÌÈÎÚÔ‚›Ô˘

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¿Óˆ ·fi 106 ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›/cm2 Û ηÏÏȤÚÁÂȘ Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Ïԛ̈ÍË (14). ∞ÓÙÈÌÂÙÒÈÛË O ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ê·›ÓÂÙ·È Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Î·È ÙÔ ÁÂÁÔÓfi˜ Ù˘ ıÂÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Î·È ÙÔ˘ ·ÔÈÎÈÛÌÔ‡ Ì ÛÙ·Ê˘ÏfiÎÔÎÎÔ Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈ΋ ıÂÚ·›· Û ·È‰È¿ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·. ŒÙÛÈ, ÛÙÔ˘˜ ÚˆÙ·Ú¯ÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Âȉ›ӈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ¤Ú·Ó Ù˘ ÂÓ˘‰¿ÙˆÛ˘ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È Ù˘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜, Ú¤ÂÈ Ó· Â›Ó·È Î·È Ë ÂÎÚ›˙ˆÛË ÙˆÓ ÌÈÎÚÔ‚›ˆÓ. ∂›Û˘, ÂÈ‚¿ÏÏÂÙ·È Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ıÂÚ·›·˜, ÁÈ·Ù› Ì ·˘Ù‹ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ·Ó¿ÎÙËÛË Ù˘ ÂÏ·ÛÙÈÎfiÙËÙ·˜ Ù˘ ÂȉÂÚÌ›‰·˜ Î·È ÚÔÏ·Ì‚¿ÓÂÙ·È Ë ‰ËÌÈÔ˘ÚÁ›· ‰È·‚ÚÒÛˆÓ. ªÂ ÙËÓ ÚfiÏË„Ë Ù˘ ÍËÚfiÙËÙ·˜ ‚ÂÏÙÈÒÓÂÙ·È Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÊÚ·ÁÌfi˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ¤ÙÛÈ ÌÂÈÒÓÂÙ·È Ë ‰È›ۉ˘ÛË ÙÔ˘ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ Î·È ÙˆÓ Â͈ÙÔÍÈÓÒÓ ÙÔ˘. ∏ ÂÓ˘‰¿ÙˆÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙÔ Ì¿ÓÈÔ Î·È ÙȘ ÂÓ˘‰·ÙÈΤ˜ Îڤ̘. ∆Ô Ì¿ÓÈÔ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î·ıËÌÂÚÈÓ¿ Û ¯ÏÈ·Úfi ÓÂÚfi Ì ÙËÓ ÚÔÛı‹ÎË ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ Ï·‰ÈÔ‡ Ì¿ÓÈÔ˘. ∂Ó˘‰·ÙÈΤ˜ Îڤ̘ Û˘ÓÈÛÙ¿Ù·È Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ Ì¿ÓÈÔ Î·È ÌÂ Û˘¯ÓfiÙËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ (5,29).

OÈ ·ÓÙÈÊÏÂÁÌÔÓÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, ‰ËÏ·‰‹ Ù· ÙÔÈο ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Â›Ó·È ÙÔ ‚·ÛÈÎfi ̤ÚÔ˜ Ù˘ ıÂÚ·›·˜ Ù˘ ÔÍ›·˜ ¤Í·ÚÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ™Â ‹Ș ÂÚÈÙÒÛÂȘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÂÊ·ÚÌfi˙ÔÓÙ·È ¯·ÌËÏ‹˜ ÈÛ¯‡Ô˜ ÙÔÈο ÛÙÂÚÔÂȉ‹, fiˆ˜ Ë ˘‰ÚÔÎÔÚÙÈ˙fiÓË, ÂÓÒ Û ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ, ̤ÙÚÈ·˜ ‹ ÈÛ¯˘Ú‹˜ ÈÛ¯‡Ô˜. ™Ù· ‚Ú¤ÊË, fiˆ˜ Â›Û˘ ÛÙÔ ÚfiÛˆÔ Î·È ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚÈÔ¯‹, Ù· ÈÛ¯˘Ú‹˜ ÈÛ¯‡Ô˜ ÛÙÂÚÔÂȉ‹ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È. ∆· ÙÔÈο ÛÙÂÚÔÂȉ‹ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙËÓ ¿Û¯Ô˘Û· ÂÚÈÔ¯‹ ÁÈ· ÂÚ›Ô˘ 1 ¤ˆ˜ 2 ‚‰ÔÌ¿‰Â˜ (5,29). ªÈÎÚԂȷ΋ ÂÈÌfiÏ˘ÓÛË Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ˘¿Ú¯ÂÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ Âȉ›ӈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜. ∂¿Ó Ë Ïԛ̈ÍË Â›Ó·È ÂÎÙÂٷ̤ÓË ÂӉ›ÎÓ˘Ù·È Ë Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ÛÙÔ ÔÔ›Ô Ó· Â›Ó·È Â˘·›ÛıËÙÔ˜ Ô ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÁÈ· 7 ¤ˆ˜ 14 ̤Ú˜ (5,28,30). ∫·ıÒ˜ ÂÚ›Ô˘ ÙÔ 88% ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎˆÓ Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È ·fi ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Â›Ó·È

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·ÓıÂÎÙÈÎÔ› ÛÙËÓ ÂÓÈÎÈÏÏ›ÓË Î·È ÂÚ›Ô˘ ÙÔ 30% ÛÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË, Ê¿ÚÌ·ÎÔ ÂÎÏÔÁ‹˜ Â›Ó·È ÔÈ ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈΤ˜ ÂÓÈÎÈÏϛӘ, ÙÔ ÊÔ˘ÛȉÈÎfi Ô͇ ‹ ÎÂÊ·ÏÔÛÔÚ›Ó˜ (15,30-32). ∞ÓÙÈ‚ÈÔÙÈο ‰Ú·ÛÙÈο, ΢ڛˆ˜ ÂÓ·ÓÙ›ÔÓ ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘, ÌÂÈÒÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ·ÓıÂÎÙÈÎÒÓ ÌÈÎÚÔ‚›ˆÓ. ∂¿Ó Ë Ïԛ̈ÍË Â›Ó·È ÂÓÙÔÈṲ̂ÓË ÂӉ›ÎÓ˘Ù·È Î·È Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ë ıÂÚ·›· Ì ÙÔÈο ·ÓÙÈ‚ÈÔÙÈο, fiˆ˜ ÊÔ˘ÛȉÈÎfi Ô͇ (fusidic acid), ÌÔ˘ÈÚÔÛ›ÓË (mupirocin) ÌfiÓÔ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (33-36). ∆ÔÈο ·ÓÙÈ‚ÈÔÙÈο Û ÌÔÚÊ‹ Îڤ̷˜ Â›Ó·È Î·Ï‡ÙÂÚ·, ÁÈ·Ù› ÔÈ ·ÏÔÈʤ˜ ÂÚÂı›˙Ô˘Ó ÙÔ ‰¤ÚÌ· Ô˘ ÊÏÂÁÌ·›ÓÂÈ. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Ô˘ Â›Ó·È ·ÔÈÎÈṲ̂ÓÔÈ Ì ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ¯ˆÚ›˜ Ó· ¤¯Ô˘Ó ÔÚ·Ù¿ Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ Ïԛ̈͢, ‰Â›¯ÓÔ˘Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ì ÙÔÈο ·ÓÙÈ‚ÈÔÙÈο ‹ ¿ÏÏ· ıÂÚ·¢ÙÈο ̤ÙÚ·, Ù· ÔÔ›· ÌÂÈÒÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ì ÙËÓ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ‹ ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÌÂÈÒÓÂÙ·È Î·Ù¿ Ôχ Ô ·ÚÈıÌfi˜ ÙÔ˘ ¯Ú˘Û›˙ÔÓÙÔ˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ (2,33-35). ŸÌˆ˜, ‚Ú¤ıËΠfiÙÈ Î·È Ë ÂÊ·ÚÌÔÁ‹ ÙÔÈο ÌfiÓÔ ÈÛ¯˘ÚÒÓ ÙÔÈÎÒÓ ÛÙÂÚÔÂȉÒÓ ÌÂÈÒÓÂÈ ÙËÓ ˘ÎÓfiÙËÙ· ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ (37). O Û˘Ó‰˘·ÛÌfi˜ ÙÔÈÎÔ‡ ÛÙÂÚÔÂȉԇ˜ Ì ·ÓÙÈ‚ÈÔÙÈÎfi Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Î·Ï‡ÙÂÚ· ·ÔÙÂϤÛÌ·Ù· (23,33-34). ∆· ·ÓÙÈ‚ÈÔÙÈο, ÂÂȉ‹ ÂÎÚÈ˙ÒÓÔ˘Ó ÙÔ ÛÙ·Ê˘ÏfiÎÔÎÎÔ, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·¯‡ÙÂÚË ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›· Î·È ¤ÙÛÈ ÌÂÈÒÓÂÙ·È Î·È Ë ÔÛfiÙËÙ· ÙˆÓ ÛÙÂÚÔÂȉÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È (23). ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÊ·ÚÌÔÁ‹ ÙÔÈÎÒÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë. ∏ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ÓÂÔÌ˘Î›Ó˘ ‹ ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ·ÔʇÁÂÙ·È ÛÙ· ·È‰È¿ (38). ŸÛÔÓ ·ÊÔÚ¿ Ù· ·ÓÙÈÛËÙÈο ˘ÂÚÌ·ÁÁ·ÓÈÎfi οÏÈÔ, ¯ÏˆÚÂÍȉ›ÓË Î·È Ù· ‚ÚˆÌÈÔ‡¯·, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÛÙ·Ê˘ÏfiÎÔÎΈÓ, ÏËÓ fï˜, ÂÚÂı›˙Ô˘Ó Î·È ÍËÚ·›ÓÔ˘Ó ÙÔ ‰¤ÚÌ· Î·È ¤ÙÛÈ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û¿ÓÈ· Û ·È‰È¿ (39). ∞ÔÈÎÈÛÌfi˜ - Í·Ó¿ - ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È Ì fiϘ ÙȘ ·Ó·ÊÂÚı›Û˜ ıÂÚ·›˜ Û οÔÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. µ·ÛÈÎfi ̤ÚÔ˜ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ Â›Ó·È Ë Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Âȉ›ӈÛ˘ Ô˘ ÚԷӷʤÚıËÎ·Ó (5,29). ¶ÚfiÁÓˆÛË ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. °ÂÓÈο, ˘¿Ú¯ÂÈ Ì›· Ù¿ÛË ÁÈ· ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ηıÒ˜ ÙÔ ·È‰› ÌÂÁ·ÏÒÓÂÈ.

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OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ˘Ô¯ˆÚÔ‡Ó Ì¤¯ÚÈ ÙËÓ ÂÊ˂›·, ·Ó Î·È Ë ÓfiÛÔ˜ ÌÔÚ› Ó· ÂÈ̤ÓÂÈ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·Ô 25 ¤ˆ˜ Î·È 40% (40). ™˘Ì¤Ú·ÛÌ·Ù· ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÔÏ˘¿ÚÈı̘ ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Âȉ›ӈÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. ÃÚ˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ ·ÔÌÔÓÒÓÂÙ·È ·fi ÙȘ ‚Ï¿‚˜ Û ÂÚÈÛÛfiÙÂÚÔ ·fi 90% ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·. ∆· ·ÓÙÈ‚ÈÔÙÈο ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Ù·¯‡ÙÂÚË ˘Ô¯ÒÚËÛ‹ ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Noble WC. The role of staphylococci in dermatology. J Eur Acad Dermatol Venereol 1996;7(Suppl):12-14.

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6. Cooper KD. Atopic Dermatitis: recent trends in pathogenesis and therapy. J Invest Dermatol 1994;102:128-137.

7. Larsen FS. Atopic Dermatitis: A genetic-epidemiologic study in a population-based twin sample. J Am Acad Dermatol 1993;28:719-723.

8. Coleman R, Trembath RC, Harper JI. Genetic studies of atopy and atopic dermatitis. Br J Dermatol 1997;136:1-5.

9. Bos JD, Kapsenberg ML, Sillevis Smitt JH. Pathogenesis of atopic eczema. Lancet 1994;343:1338-1341.

10. Morren MA, Przybilla B, Bamelis M, Heykants B, Reynaers A, Degreef H. Atopic dermatitis: triggering factors. J Am Acad Dermatol 1994;31:467-473.

11. Halbert AR, Weston WL, Morelli JG. Atopic dermatitis: Is it an allergic disease? J Am Acad Dermatol 1995;33:1008-1018.

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20. McFadden JP, Noble WC, Camp RDR. Superantigenic exotoxin-secreting potential of staphylococci isolated from atopic eczematous skin. Br J Dermatol 1993;128:631-632.

21. Strange P, Skov L, Lisby S, Lovgreen P, Baadsgaard O. Staphylococcal enterotoxin B applied on intact normal and intact atopic skin induces dermatitis. Arch Dermatol 1996;132:27-33.

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26. Bunikowski R, Mielke M, Skarabis H, Herz U, Bergmann RL et al. Prevalence and role of serum IgE antibodies to the Staphylococcus aureus-derived superantigens SEA and SEB in children with atopic dermatitis. J Allergy Clin Immunol 1999;103:119-124.

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30. Valari M, Zachariadou L, Skarmoutsou C, Pangalis A, Iordanidou A. Fusidic acid suspension in the treatment of skin infections in children. J Eur Acad Dermatol Venereol 1999;12(Suppl 2):293.

31. Veien NK. The clinician’s choice of antibiotics in the treatment of bacterial skin infection. Br J Dermatol 1998;139(Suppl):30-36.

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35.

36.

37.

38.

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Poyner TF, Dass BK. Comparative efficacy and tolerability of fusidic acid/hydrocortisone cream (Fucidin H cream) and miconazole/hydrocortisone cream (Daktacort cream) in infected eczema. J Eur Acad Dermatol Venereol 1996;7(Suppl):23-30.

Nilsson EJ, Henning CG, Magnusson J. Topical corticosteroids and Staphylococcus aureus in atopic dermatitis. J Am Acad Dermatol 1992;27:29-34.

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40. Linna O, Kokkonen J, Lahtela P, Tammela O. Ten year prognosis for generalized infantile eczema. Acta Pediatr 1992;81:1013-1016

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª. µ·Ï¿ÚË ªÂÛÔÏÔÁÁ›Ô˘ 81, 162 31, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· O ÚfiÏÔ˜ Ù˘ ÙÚÔÊÈ΋˜ ‰˘Û·ÓÂÍ›·˜ Û ‚Ú¤ÊË Ì Â›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ ÔÈÛÔÊ·Á›Ùȉ·˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË1 ™ÎÔfi˜: ∏ Â›ÌÔÓË ·ÓËÛ˘¯›· Â›Ó·È ¤Ó· Û˘¯Ófi Û‡Ìو̷ Û ‚Ú¤ÊË Î·È Û˘¯Ó¿ ·Ô‰›‰ÂÙ·È Û Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) ‹ Û ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ÌÂÏÂÙËı› Ë Â›‰Ú·ÛË ˘Ô·ÏÏÂÚÁÈ΋˜ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ Û ‚Ú¤ÊË Ì Â›ÌÔÓË ·ÓËÛ˘¯›· ÏfiÁˆ °O¶ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙË Û˘Ó‹ıË ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ·ÁˆÁ‹. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: 19 ‚Ú¤ÊË (9 ·ÁfiÚÈ· Î·È 10 ÎÔÚ›ÙÛÈ·, ‰È¿ÌÂÛË ËÏÈΛ· 5 Ì‹Ó˜) ˘Ô‚Ï‹ıËÎ·Ó Û 24ˆÚË Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ p∏ (¯·ÌÂÙÚ›·) Î·È Á·ÛÙÚÔÛÎfiËÛË. ™ÙË Û˘Ó¤¯ÂÈ·, ¤ÁÈÓ ‰ÈÏ‹ Ù˘ÊÏ‹ ‰ÔÎÈÌ·Û›·, ·Ú¯Èο Ì ÛÙÔȯÂÈ·Îfi Á¿Ï· ‚·ÛÈṲ̂ÓÔ Û ·ÌÈÓÔͤ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÙÔ Á¿Ï· Ô˘ ¤·ÈÚÓ·Ó Ù· ·È‰È¿ ÚÈÓ ÙË ÌÂϤÙË. ∞ÔÙÂϤÛÌ·Ù·: 9 ‚Ú¤ÊË Â›¯·Ó ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÔÈÛÔÊ·Á›Ùȉ·˜ Î·È 9 ›¯·Ó ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ÛÙÔÌ¿¯È ‹/Î·È ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ. ∆· Û˘ÌÙÒÌ·Ù· ˘Ê¤ıËÎ·Ó Û fiÏ· Ù· ·È‰È¿ ÂÓÙfi˜ 2 ‚‰ÔÌ¿‰ˆÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜. ªÂÙ¿ ·fi 3 Ì‹Ó˜, ¤ÁÈÓ ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì ÙÔ Á¿Ï· Ô˘ ¤·ÈÚÓ οı ·È‰› ÚÈÓ ÙË ÌÂϤÙË.

12 ·fi Ù· 19 ‚Ú¤ÊË ‰ÂÓ ·Ó¤¯ÙËÎ·Ó ÙÔ Î·ÓÔÓÈÎfi Á¿Ï· Î·È Â·ÓÂÌÊ¿ÓÈÛ·Ó Ù· ·Ú¯Èο Û˘ÌÙÒÌ·Ù· (‰È¿ÚÎÂÈ· ·ÓËÛ˘¯›·˜: 580 ¤Ó·ÓÙÈ 287 ÏÂÙ¿/‚‰ÔÌ¿‰·, p=0,01 Î·È score Û˘-

228

ÌÙˆÌ¿ÙˆÓ 36,1 ¤Ó·ÓÙÈ 23,1, p=0,03). ∆· ˘fiÏÔÈ· ‚Ú¤ÊË ‰ÂÓ Â·ÓÂÌÊ¿ÓÈÛ·Ó Û˘ÌÙÒÌ·Ù· (‰È¿ÚÎÂÈ· ·ÓËÛ˘¯›·˜: 581 ¤Ó·ÓÙÈ 470 ÏÂÙ¿/‚‰ÔÌ¿‰·, p=0,77 Î·È score Û˘ÌÙˆÌ¿ÙˆÓ 20,2 ¤Ó·ÓÙÈ 29,5, p=0,89). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯ÔÚ‹ÁËÛË ˘Ô·ÏÏÂÚÁÈ΋˜ ÛÙÔȯÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙË Û˘¯ÓfiÙËÙËÙ· Â›ÌÔÓ˘ ·ÓËÛ˘¯›·˜ Î·È ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û ‚Ú¤ÊË Ì ÙÚÔÊÈ΋ ‰˘Û·ÓÂÍ›·.

1Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE et al Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis J Pediatr 2000;136:641-647

°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜ - °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ

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∞¡O™O§O°π∞ - ƒ∂Àª∞∆O§O°π∞

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IMMUNOLOGY - RHEUMATOLOGY

ªË¯·ÓÈÛÌÔ› ·˘ÙÔ·ÓÔÛ›·˜ ª. °. ∫·Ó¿ÚÈÔ˘

Autoimmune mechanisms M. G. Kanariou

¶ÂÚ›ÏË„Ë: µ·ÛÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÔÙÂÏ› Ë ÈηÓfiÙËÙ¿ ÙÔ˘ Ó· ‰È·ÎÚ›ÓÂÈ Ù· ›‰È· ·fi Ù· ͤӷ ·ÓÙÈÁfiÓ·. ∞˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜ ‰ËÌÈÔ˘ÚÁÂ›Ù·È fiÙ·Ó ·Ó·Ù‡ÛÛÂÙ·È ÂȉÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ, ·˘ÙÔ·ÓÙÈÁfiÓˆÓ Î·È Â›Ó·È ÔÈ ›‰ÈÔÈ ÔÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ·ÓÔÛÔ‰Ú·ÛÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘, ÌË ‰˘Ó¿ÌÂÓÔÈ Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙÔ ·˘ÙÔ·ÓÙÈÁfiÓÔ, Û˘Ó¯›˙Ô˘Ó ÙË ‰Ú¿ÛË ÙÔ˘˜ Î·È ÚÔηÏÔ‡Ó ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, ÈÛÙÈ΋ ‚Ï¿‚Ë Î·È ÓfiÛÔ. ∏ ·ÓÔ¯‹ ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ˆÚ›Ì·ÓÛ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∞fi ·˘Ù‹ ÙËÓ ÔχÏÔÎË ‰È·‰Èηۛ· ÂÈ‚ÈÒÓÔ˘Ó Ù· ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ı· Â›Ó·È Èηӿ Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ÙÔ Ï‹ıÔ˜ Î·È ÙËÓ ÔÈÎÈÏÔÌÔÚÊ›· ÙˆÓ Í¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ Ô˘ Â›Ó·È Èı·Ófi Ó· Û˘Ó·ÓÙ‹ÛÂÈ Ô ÔÚÁ·ÓÈÛÌfi˜, ·ÏÏ¿ Î·È Î¿ÔÈÔÈ ·˘ÙÔ‰Ú·ÛÙÈÎÔ› ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ÎÏÒÓÔÈ, ÔÈ ÔÔ›ÔÈ ˘fi ÔÚÈṲ̂Ó˜ Û˘Óı‹Î˜ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Î·È ·˘ÙÔ·ÓÙȉÚÔ‡Ó. ŒÙÛÈ, ÔÈ ·˘ÙÔ¿ÓÔÛ˜ ··ÓÙ‹ÛÂȘ Â›Ó·È ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi Ê·ÈÓfiÌÂÓÔ, ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ·ÓÔÈÎÙÔ‡ “ÚÂÂÚÙÔÚ›Ô˘” ÙˆÓ ∆ Î·È µ ΢ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ Ô˘ ÙÔ˘˜ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó·ÁÓÒÚÈÛË ÔÔÈÔ˘‰‹ÔÙ ·ıÔÁfiÓÔ˘ Î·È ›Ûˆ˜ Ó· Â›Ó·È Ì›· ÂΉ‹ÏˆÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÓÔÛÔÚÚ‡ıÌÈÛ˘. ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ Ë ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È ÂÌϤÎÔÓÙ·È ·ÌÊfiÙÂÚÔÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ŸÌˆ˜, ·ÎfiÌË ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ ÙÈ ‰ÈÂÁ›ÚÂÈ ÙËÓ ·˘ÙÔ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË Î·È ÔÈÔÈ ·Ú¿ÁÔÓÙ˜ ÙË ÌÔÓÈÌÔÔÈÔ‡Ó, ÒÛÙ ӷ ÂÁηı›ÛÙ·Ù·È ÓfiÛÔ˜.

Abstract: The main function of the immune system is the capacity to distinguish between a self and a non-self antigen. Autoimmune disease occurs when a specific adaptive immune response is mounted against self-antigens, autoantigens, resulting in tissue damage from direct attack on the cells bearing the antigen, from immune-complex formation, or from local inflammation. ∞utoimmune diseases can be mediated by autoantibodies or by autoreactive T cells. The mechanisms of damage are essentially the same as those which operate in protective immunity and hypersensitivity diseases. The current challenge in autoimmunity is to identify the autoantigens recognized by T cells, and to use this information to control the activity of these T cells, or to prevent their activation in the first place. It remains unclear, however, as to what induces the autoimmune response and which are the factors that stabilize it thus resulting in disease development.

§¤ÍÂȘ ÎÏÂȉȿ: ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜, ·˘ÙÔ·Óٛۈ̷, ·˘ÙÔ‰Ú·ÛÙÈÎÔ› ÏÂÌÊÔ·ÙÙ·ÚÈÎÔ› ÎÏÒÓÔÈ, ÈÛÙÈ΋ ‚Ï¿‚Ë.

∫ey words: autoimmune disease, autoantibody, autoeffector lymphocyte clones, tissue damage.

¶·È‰›·ÙÚÔ˜ - ∞ÓÔÛÔÏfiÁÔ˜ ¢È¢ı‡ÓÙÚÈ· ∂™À, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

Pediatric Immunologist Children’s Hospital “Aghia Sophia”, Athens

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∂ÈÛ·ÁˆÁ‹ ∆Ô ·ÓÔÛÔÔÈËÙÈÎfi Ì·˜ Û‡ÛÙËÌ· Â›Ó·È ¤Ó· ÔχÏÔÎÔ Û‡ÓÔÏÔ ÂȉÈÎÒÓ Î·È ÌË ÂȉÈÎÒÓ ÂÍ·ÈÚÂÙÈο Û˘Ó‰˘·ÛÌ¤ÓˆÓ ÛÙÔȯ›ˆÓ-„ËÊ›‰ˆÓ, Ô˘ ÛÎÔfi ¤¯ÂÈ ÙËÓ ÚÔÛÙ·Û›· Ì·˜ ·fi ÔÔÈÔ‰‹ÔÙ ͤÓÔ ÂÈÛ‚ÔϤ·. ª¤¯ÚÈ ÚÈÓ ÌÂÚÈο ¯ÚfiÓÈ·, ·ÔÙÂÏÔ‡Û ‰fiÁÌ· Ë ÏÔÁÈ΋ ȉ¤· fiÙÈ Ô ÔÚÁ·ÓÈÛÌfi˜ ‰ÂÓ ÌÔÚ› Ó· ·ÓÙȉڿ ¤Ó·ÓÙÈ ÙÔ˘ ·˘ÙÔ‡ ÙÔ˘. ŸÌˆ˜ ÛÙË Û˘Ó¤¯ÂÈ·, ·ԉ›¯ıËΠfiÙÈ ÛÙ· Ï·›ÛÈ· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ¿Ì˘Ó·˜ ¢ԉÒÓÂÙ·È ˆ˜ ¤Ó· ‚·ıÌfi ·˘ÙÔ·ÓÔÛÔ·¿ÓÙËÛË, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ‰ËÏ·‰‹ ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Î·È ·˘ÙÔ·ÓÙȉÚÒÓÙ· ∆ ΢ÙÙ·ÚÔÙÔÍÈο ·ÙÙ·Ú· (CD8+) (1-4). ∆· Ê˘ÛÈÔÏÔÁÈο ÏÂÌÊÔ·ÙÙ·Ú· ¤¯Ô˘Ó ÂÎ·È‰Â˘Ù› Ì ٤ÙÔÈÔ ÙÚfiÔ, ÒÛÙ ӷ ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· “›‰È·” ·ÓÙÈÁfiÓ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, Ù· ‰Èο ÙÔ˘, Î·È Ó· Ù· ·Ó¤¯ÔÓÙ·È, ÂÓÒ ·Ú¿ÏÏËÏ· ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· “ÌË ›‰È·” / ͤӷ, ¤Ó·ÓÙÈ ÙˆÓ ÔÔ›ˆÓ Ì¿¯ÔÓÙ·È, ·ÓÔÛÔ·ÓÙȉÚÔ‡Ó. ∞˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ· ‰ËÌÈÔ˘ÚÁÂ›Ù·È fiÙ·Ó ÂȉÈ΋ Â›ÎÙËÙË ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ, ‰ËÏ·‰‹ ÙˆÓ ·˘ÙÔ·ÓÙÈÁfiÓˆÓ. ø˜ ·˘ÙÔ·ÓÙÈÁfiÓ· ÌÔÚÔ‡Ó Ó· Û˘ÌÂÚÈÊÂÚıÔ‡Ó ÔÏÏ¿ ·fi Ù· Û˘ÛÙ·ÙÈο ÌfiÚÈ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÌÂ Û˘Ó¤ÂÈ· Ó· ÂÓÂÚÁÔÔÈ‹ÛÔ˘Ó ÂÓ¿ÓÙÈ¿ ÙÔ˘˜ ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË, ¯˘ÌÈ΋ ‹ ΢ÙÙ·ÚÈ΋, Î·È Ô ÔÚÁ·ÓÈÛÌfi˜ Ó· ·Ó·Ù‡ÍÂÈ ÓfiÛÔ (1-4). °È· ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È ÛÎfiÈÌÔ Ó· ‰È¢ÎÚÈÓ›ÛÔ˘Ì fiÙÈ Ë ·ÓÔÛÔ·Ó·ÁÓÒÚÈÛË ÙˆÓ ‰ÈÎÒÓ Ì·˜ ·ÓÙÈÁfiÓˆÓ Â›Ó·È ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ Â‡Ú˘ıÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ·ÓÔÛÔ·¿ÓÙËÛË ·ÔÙÂÏ› ̤ÚÔ˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ‰È·‰Èηۛ·˜ ¿Ì˘Ó·˜, ÂÓÒ Ë ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÓfiÛÔ. √È ÂÚÈÛÛfiÙÂÚ˜ ÚˆÙ½Ó˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÂÎÊÚ¿˙ÔÓÙ·È Û Â›‰· Ôχ ¯·ÌËÏ¿ ÁÈ· Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ ÛÙfi¯ÔÈ ·Ó·ÁÓÒÚÈÛ˘ ·fi Ù· ∆ ·ÙÙ·Ú· Î·È ¿Ú· ‰ÂÓ Û˘ÌÂÚÈʤÚÔÓÙ·È Î·È ‰ÂÓ ÚÔÛʤÚÔÓÙ·È ˆ˜ ·˘ÙÔ·ÓÙÈÁfiÓ·. ŸÌˆ˜, ¤Ó·˜ ÂÏ¿¯ÈÛÙÔ˜ ·ÚÈıÌfi˜ ÚˆÙÂ˚ÓÒÓ ÂÚȤ¯ÂÈ ÂÙ›‰È·, Ù· ÔÔ›· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·fi Û˘ÁÎÂÎÚÈ̤ӷ MHC ÌfiÚÈ· Û Â›Â‰Ô ÈηÓfi Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË Î·È Èı·Ó‹ ÓfiÛÔ. ªË¯·ÓÈÛÌÔ› ÚfiÎÏËÛ˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ µ·ÛÈο ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ›ӷÈ: ·) fiÙÈ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› Û ÂÈÚ·Ì·Ùfi˙ˆ· Ì ÙË ¯ÔÚ‹ÁËÛË Û ·˘Ù¿ ÙˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ÙˆÓ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ ÎÏÒÓˆÓ ·Û¯fiÓÙˆÓ Î·È ‚) fiÙÈ ÚÔηÏ› ÈÛÙÈ΋ ‚Ï¿‚Ë Î·È Î·Ù·ÛÙÚÔÊ‹ ̤ۈ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ Î·È Ì˯·ÓÈÛÌÒÓ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ÈÔ ¿ÌÂÛË ·fi‰ÂÈÍË Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ·ÈÙÈÔÏÔÁ›·˜ ÂÓfi˜ ÓÔÛ‹Ì·ÙÔ˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙȘ in vivo ηٷÛÙ¿ÛÂȘ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÛÂ Ê˘ÛÈÔÏÔÁÈ-

230

Paediatriki 2001;64:229-232

ο ¿ÙÔÌ· Ì ¿ÌÂÛË ÌÂÙ·ÊÔÚ¿ ·˘ÙÔ·ÓÙÈۈ̿وÓ. ∆¤ÙÔÈÔ ·Ú¿‰ÂÈÁÌ· Â›Ó·È ÙÔ ›ڷ̷ Ô˘ ¤Î·ÓÂ Ô Harrington, Ô ÔÔ›Ô˜ ‰ÈÔ¯¤Ù¢Û Ì ¤ÓÂÛË ÛÙÔÓ Â·˘Ùfi ÙÔ˘ Ï¿ÛÌ· ·fi ¿ÚÚˆÛÙÔ Ì ȉÈÔ·ı‹ ıÚÔÌ‚ÔÂÓ›·, ÌÂ Û˘Ó¤ÂÈ· Ó· ¿ıÂÈ Ô ›‰ÈÔ˜ ıÚÔÌ‚ÔÂÓ›· Î·È ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·ÁÈ΋ ‰È·Ù·Ú·¯‹ (4). ÕÏÏ· Ù¤ÙÔÈ· ·Ú·‰Â›ÁÌ·Ù· Â›Ó·È Ë ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ·ÊÔÚ¿ ·ıÔÁfiÓˆÓ IgG ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂΉ‹ÏˆÛË Ì˘·Ûı¤ÓÂÈ·˜ ‹ ÓfiÛÔ ÙÔ˘ Graves ÛÙÔ ÓÂÔÁÓfi. ¶ÂÈÚ¿Ì·Ù· Ô˘ Ó· ·ÊÔÚÔ‡Ó ÙË ÌÂÙ¿‰ÔÛË ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ̤ۈ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ Â›Ó·È ÈÔ ‰‡ÛÎÔÏÔ Ó· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó Î·È Û˘Ó‹ıˆ˜ ˆ˜ ÂÈÚ·Ì·Ùfi˙ˆ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˙Ò· Ì ‚·ÚÈ¿ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·. ∏ ÈÛÙÈ΋ ‚Ï¿‚Ë ÛÙȘ ·˘ÙÔ¿ÓÔÛ˜ ηٷÛÙ¿ÛÂȘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È ·fi ÛÙÔȯ›· Ô˘ Â›Ó·È Ù· ›‰È· Ù· Ê˘ÛÈÔÏÔÁÈο ÚÔ˚fiÓÙ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ ‚Ï¿‚Ë ‰ËÏ·‰‹, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰Ú¿Û˘ ÙˆÓ ·ÓÙÈۈ̿وÓ, ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ÙˆÓ ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ, ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙˆÓ Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ Î˘ÙÙ¿ÚˆÓ. ¶ÈÔ ÌÂÏÂÙË̤ÓÔ˜ Â›Ó·È Ô ÙÚfiÔ˜ ‰Ú¿Û˘ ÙˆÓ ·˘ÙÔ·ÓÙÈۈ̿وÓ. ∞Ó Ô ÛÙfi¯Ô˜ Â›Ó·È ˘Ô‰Ô¯¤·˜ ΢ÙÙ¿ÚÔ˘, ÙÔ ·˘ÙÔ·Óٛۈ̷ ·ÚÂÌ‚·›ÓÂÈ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ΢ÙÙ¿ÚÔ˘, ÙËÓ ÔÔ›· Î·È ÙÚÔÔÔÈ› Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜. ™ÙË ÓfiÛÔ Graves .¯. ‰ÈÂÁ›ÚÂÈ ÙÔ ı˘ÚÂÔÂȉÈÎfi ·ÙÙ·ÚÔ, ÛÙË Ì˘·Ûı¤ÓÂÈ· Gravis Ô‰ËÁ› ÛÙËÓ “·Ô‰fiÌËÛË” ÙÔ˘ ˘Ô‰Ô¯¤·, ÂÓÒ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ™·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ÙÔ ·˘ÙÔ·Óٛۈ̷ ·ÔÎÏ›ÂÈ ÙÔÓ ˘Ô‰Ô¯¤· Ù˘ ÈÓÛÔ˘Ï›Ó˘ Î·È ÙË ‰Ú¿ÛË Ù˘. ∞Ó Ô ÛÙfi¯Ô˜ Â›Ó·È Î˘ÙÙ·ÚÈ΋ ÌÂÌ‚Ú¿ÓË, ̤ۈ ÙˆÓ ›‰ÈˆÓ Ì˯·ÓÈÛÌÒÓ, ·Ó·Ù‡ÛÛÂÙ·È ÊÏÂÁÌÔÓ‹ Î·È Î·Ù·ÛÙÚÔÊ‹ Ù˘ ÌÂÌ‚Ú¿Ó˘, fiˆ˜ ÛÙÔ Û‡Ó‰ÚÔÌÔ Goodpasture. ™ËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÌÈÎÚÔ‚È·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ Î·È ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ Â›Ó·È fiÙÈ ÙÔ ÚÒÙÔ Â›Ó·È ÂÂÚ·Ṳ̂ÓÔ, ÂÓÒ ÙÔ ‰Â‡ÙÂÚÔ Â›Ó·È ÛÙ·ıÂÚ¿ ·ÚfiÓ Î·È ¿Ú· Û˘Ó¯‹˜ ·Ú¿ÁˆÓ ‰È¤ÁÂÚÛ˘ ·˘ÙÔ·ÓÙ›‰Ú·Û˘, ÌÂ Û˘Ó¤ÂÈ· ÙË ¯ÚÔÓÈfiÙËÙ·. ∞Ó Ù· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· Û¯ËÌ·Ù›˙Ô˘Ó ‰È·Ï˘Ù¿ ·ÓÔÛÔÛ˘ÌϤÁÌ·Ù· Î·È ‰ÂÓ Á›ÓÂÙ·È Ë Ê˘ÛÈÔÏÔÁÈ΋ οı·ÚÛË ·fi ÙÔ ¢∂™, ·ÏÏ¿ ÂÓ·fiıÂÛË ·˘ÙÒÓ ÙˆÓ ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ, ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÊÏÂÁÌÔÓ‹ Î·È ÈÛÙÈ΋ ‚Ï¿‚Ë (̤ۈ ÙˆÓ Ì˯·ÓÈÛÌÒÓ ˘ÂÚ¢·ÈÛıËÛ›·˜ Ù‡Ô˘ πππ), fiˆ˜ ÛÙÔ ™˘ÛÙËÌ·ÙÈÎfi ∂Ú˘ıËÌ·ÙÒ‰Ë §‡ÎÔ (1-4). ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞˘Ù¿ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·ÊÔÚÔ‡Ó ·˘Ùfi Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙÔÓ ÈÛÙfi ÛÙfi¯Ô, ÛÙÔ ÛËÌÂ›Ô Ù˘ ‚Ï¿‚˘. ¶ÔÈ· ›ӷÈ, fï˜, Ë ·Ú¯È΋ ·ÈÙ›·; ∆È Â›Ó·È ÂΛÓÔ Ô˘

MAY- JUNE '01 TELIKO

30-05-03

18:55

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¶·È‰È·ÙÚÈ΋ 2001;64:229-232

ÙÚÔÔÔÈ› ÙËÓ ÂÈı˘ÌËÙ‹ ·ÓÔÛȷ΋ ·¿ÓÙËÛË; ∂›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ë ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. æ˘¯ÔÏÔÁÈÎÔ›, ÔÚÌÔÓÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› Î·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¢ԉÒÓÔ˘Ó ·˘Ù‹ ÙË ÛÙÚÔÊ‹ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÁÈ· ·˘ÙÔ¿ÓÔÛË ·fiÎÚÈÛË Î·È ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÈÛÙÒÓ (3). ¶Ï‹ıÔ˜ ÂÈÚ·Ì·ÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ ˘Ô‰ÂÈÎÓ‡ÂÈ ÙË ÛÙÂÓ‹ ·ÏÏËÏÂÍ¿ÚÙËÛË ÌÂٷ͇ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Î·È ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ÔÚÌÔÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›, ÁÈ·Ù› Ù· ıËÏ˘Î¿ ˘ÁÈ‹ ÂÈÚ·Ì·Ùfi˙ˆ· ·ÔÎÚ›ÓÔÓÙ·È Û ·ÓÙÈÁÔÓÈο ÂÚÂı›ÛÌ·Ù· ÈÔ ¤ÓÙÔÓ· ·’ fiÙÈ Ù· ·ÚÛÂÓÈο Î·È ÛÙÔÓ ¿ÓıÚˆÔ Ù· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ÚÔÛ‚¿ÏÏÔ˘Ó ÈÔ Û˘¯Ó¿ Á˘Ó·›Î˜ ·Ú¿ ¿Ó‰Ú˜. ¶ÂÈÚ·Ì·ÙÈÎÒ˜, Ë ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· ¤¯ÂÈ Û˘Ó‰Âı› Ì ÙËÓ ¤Í·ÚÛË ÙÔ˘ ™∂§. ∏ ˘ÂÚÈ҉˘ ·ÎÙÈÓÔ‚ÔÏ›· ÙÚÔÔÔÈ› ÙÔ DNA ÙˆÓ Î˘ÙÙ¿ÚˆÓ, οÓÔÓÙ¿˜ ÙÔ ÈÔ ·ÓÙÈÁÔÓÈÎfi. OÈ ÏÔÈÌÔÁfiÓÔÈ, ÁÂÓÈÎÒ˜, ·Ú¿ÁÔÓÙ˜ Î·È È‰È·ÈÙ¤Úˆ˜ ÔÈ ÈÔ›, η٤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ù˘ ·˘ÙÔ·ÓÔÛ›·˜. OÈ ÂÍ¿ÚÛÂȘ Î·È ˘Ê¤ÛÂȘ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ ÌÔÈ¿˙Ô˘Ó Ì ÂΛӘ ÙˆÓ ÈÒÛˆÓ. ™ÙÔÓ ÔÚfi ÙÔ˘ ·›Ì·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ‚Ú¤ıËÎ·Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ÈÒÓ. O Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÔÈΛϘ ·˘ÙÔ¿ÓÔÛ˜ ÂΉËÏÒÛÂȘ. ™ÙÔÓ ÔÚfi ÙˆÓ ·ÚÚÒÛÙˆÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ΢ÎÏÔÊÔÚÔ‡Ó ·˘ÍË̤ӷ ÔÛ¿ ÈÓÙÂÚÊÂÚfiÓ˘, ¤Ó·˜ ·ÎfiÌË ¤ÌÌÂÛÔ˜ ‰Â›ÎÙ˘ Ïԛ̈͢ ·fi ÈÔ‡˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÁÂÓÂÙÈÎfi ˘fiÛÙڈ̷, Û·ÊÒ˜ ˘¿Ú¯Ô˘Ó Ù· ÁÔÓ›‰È· Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Î·È Ú˘ıÌ›˙Ô˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘. Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Û˘ÁÁÂÓ›˜ ÚÒÙÔ˘ ‚·ıÌÔ‡ ·ÚÚÒÛÙˆÓ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ˘„ËÏfi ÔÛÔÛÙfi ÎÏÈÓÈΤ˜ Î·È ÔÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·˘ÙÔ·ÓÔÛ›·˜. ∞Ó¿ÌÂÛ· Û ·˘Ù¿ Ù· ÁÔÓ›‰È· ÛËÌ·ÓÙÈ΋ ı¤ÛË Î·Ù¤¯Ô˘Ó ÂΛӷ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC/HLA), ·ÏÏ¿ Û·ÊÒ˜ ÂÌϤÎÔÓÙ·È Î·È ÂΛӷ Ô˘ ηıÔÚ›˙Ô˘Ó ÙȘ ΢ÙÙ·ÚÔΛÓ˜, Ù· ÁÔÓ›‰È· ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ∆-΢ÙÙ¿ÚÔ˘ Î·È Ù· ÁÔÓ›‰È· ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ. ∏ ·Ó‡ÚÂÛË ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ÔÚÈÛÌ¤ÓˆÓ HLA ·ÓÙÈÁfiÓˆÓ (B8, DR3, DR4) ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘fiıÂÛË Ù˘ ÁÂÓÂÙÈ΋˜ ÚԉȿıÂÛ˘. ∞fi ÙȘ ÈÔ ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ Â›Ó·È ÂΛÓË ÙÔ˘ µ27 Ì ÙËÓ ∞Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· Î·È Ôχ ·ÛıÂÓ¤ÛÙÂÚ· Ù˘ ÂÙÂÚÔ˙˘ÁˆÙ›·˜ DR3/DR4 Ì ÙÔÓ ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ ‰È·‚‹ÙË (2,4). ªË¯·ÓÈÛÌÔ› ¢fi‰ˆÛ˘ ·˘ÙÔ·ÓÔÛÔ·ÓÙ›‰Ú·Û˘ ¶·Ú¿ Ù· fiÛ· ͤÚÔ˘Ì ÁÈ· ÙÔ ÙÈ Û˘Ì‚·›ÓÂÈ in situ Î·È Ù· fiÛ· ˘Ô„È·˙fiÌ·ÛÙ ÁÈ· ÙȘ ·Èٛ˜, ÙÔ

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ÎÔ˘Ù› ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·Ú·Ì¤ÓÂÈ ÎÏÂÈÛÙfi. ∏ ÂÎ·›‰Â˘ÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙËÓ ÂÌ‚Ú˘˚΋ ¤ˆ˜ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ÙËÓ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ Û ·ÓÙ›ıÂÛË Ì ÙËÓ Â›ıÂÛË ¤Ó·ÓÙÈ ÙˆÓ Í¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ, ·›˙ÂÈ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ “ȉ·ÓÈ΋” ·ÓÔÛÔ·¿ÓÙËÛË. °È· ÙÔ Ò˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ·˘Ù‹ Ë ÂÎ·›‰Â˘ÛË ¤¯Ô˘Ó ·Ó·Ù˘¯ı› ‰È¿ÊÔÚ˜ ıˆڛ˜. ∏ ıˆڛ· ÙˆÓ ··ÁÔÚÂ˘Ì¤ÓˆÓ ÎÏÒÓˆÓ, ‰ËÏ·‰‹ Ù˘ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ·˘ÙÔ·ÓÙȉÚÒÓÙˆÓ Î˘ÙÙ¿ÚˆÓ, ÂΛÓË Ù˘ ·ÂÓÂÚÁÔÔ›ËÛ˘ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ, Ù˘ ‡·Ú͢ ÂȉÈÎÒÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÂΛÓË ÙÔ˘ ‰ÈÎÙ‡Ô˘ ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈ-ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ¿ÏϘ (5-7). ∆È fï˜, ‰È·Û¿ ·˘Ù‹ ÙËÓ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ Î·È Â˘Ô‰ÒÓÂÈ ÙËÓ ·˘ÙÔ·ÓÔÛÔ·ÓÙ›‰Ú·ÛË ¤Ó·ÓÙ› ÙÔ˘˜; £ÂˆÚËÙÈο, fiÙ·Ó ˘¿Ú¯ÂÈ ÌÂÈÔÓ¤ÎÙËÌ· ‹ ‰ËÌÈÔ˘ÚÁËı› Ú‹ÁÌ· ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔÛÔ·fiÎÚÈÛË ı· ÚÔÎÏËı› ÓfiÛÔ˜. OÈ ÂÍËÁ‹ÛÂȘ ÁÈ· ÙË ‰È¿Û·ÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Â›Ó·È ‰È¿ÊÔÚ˜. OÈ ÂÈÎÚ·Ù¤ÛÙÂÚ˜ ·fi ·˘Ù¤˜ ›ӷÈ: Ë ¤ÎıÂÛË ·ÔÌÔÓˆÌ¤ÓˆÓ “ÂÁÎψ‚ÈṲ̂ӈӔ ·ÓÙÈÁfiÓˆÓ ÛÙËÓ Î˘ÎÏÔÊÔÚ›·, fiˆ˜ Â›Ó·È ÂΛӷ ÙÔ˘ Û¤ÚÌ·ÙÔ˜ Î·È ÙÔ˘ Ê·ÎÔ‡Ø Ë ·ÚfiÛÊÔÚË ¤ÎÊÚ·ÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù¿Í˘ ππ, ‰ËÏ·‰‹ Ë ¤ÎÊÚ·Û‹ ÙÔ˘˜ ·fi ·ÙÙ·Ú· Ô˘ Ê˘ÛÈÔÏÔÁÈο ‰ÂÓ ÂÎÊÚ¿˙Ô˘Ó ÌfiÚÈ· MHC Ù¿Í˘ πI, fiˆ˜ Û˘Ì‚·›ÓÂÈ ·fi ·ÙÙ·Ú· ÙÔ˘ ı˘ÚÂÔÂȉ‹ ·‰¤Ó· Û ·ÛıÂÓ›˜ Ì ı˘ÚÂÔÂȉ›Ùȉ· Hashimoto, ‹ ÛÙ· ‚-·ÙÙ·Ú· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ π, ‹ ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ÙˆÓ Â͈ÎÚÈÓÒÓ ·‰¤ÓˆÓ Û ·ÛıÂÓ›˜ Ì ™. SjogrenØ Ë ÔÏ˘ÎψÓÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓØ Ë ·ıÔÏÔÁÈ΋ ·ÓÔÛÔÚÚ‡ıÌÈÛË ·fi Ù· ∆ ÏÂÌÊÔ·ÙÙ·Ú·, fiˆ˜ ıˆÚÂ›Ù·È fiÙÈ Á›ÓÂÙ·È ÛÙÔ ™ÎÏËÚfi‰ÂÚÌ· ÏfiÁˆ ˘ÂÚÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚ÔËıËÙÈÎÒÓ Â·ÁˆÁÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD4) ‹ ˘ÔÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD8) ÛÙÔÓ ™∂§Ø Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ‰ÈÎÙ‡Ô˘ ȉÈÔÙ˘ÈÎÒÓ - ·ÓÙÈ-ȉÈÔÙ˘ÈÎÒÓ ·ÓÙÈۈ̿وÓ, ‰ËÏ·‰‹ Ë Â·ÁˆÁ‹ ·Ú·ÁˆÁ‹˜ ·ÓÙÈ-·ÓÙÈۈ̿وÓ, ·ÓÙÈ-·ÓÙÈ-·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ô ·˘ÙÔÂÚÈÔÚÈÛÌfi˜ ÙÔ˘˜ Î·È Ù¤ÏÔ˜, ÂΛÓË Ù˘ ÙÚÔÔÔ›ËÛ˘ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ‹ Ù˘ ÌÔÚȷ΋˜ Ì›ÌËÛ˘ ·fi ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜. OÈ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÌÔÚÔ‡Ó Ó· ‰È·Û¿ÛÔ˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔ¯‹ ÙˆÓ È‰›ˆÓ ·ÓÙÈÁfiÓˆÓ Ì ÔÏÏÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ŒÓ·˜ ·fi ÙÔ˘˜ ÈÔ ÌÂÏÂÙË̤ÓÔ˘˜ Î·È Ô Î·Ï‡ÙÂÚ· ηٷÓÔËÙfi˜ Â›Ó·È ÂΛÓÔ˜ Ù˘ ÌÔÚȷ΋˜ Ì›ÌËÛ˘, fiÔ˘ ͤӷ ·ÓÙÈÁfiÓ· ÌÈÌÔ‡ÓÙ·È ·˘ÙÔ·ÓÙÈÁfiÓ·. ŸÌˆ˜, Ù· ·ÓÙÈÁfiÓ· ·˘Ù¿, ·Ó Î·È ÚÔÛÔÌÔÈ¿˙Ô˘Ó ·ÚÎÂÙ¿ Ì ÂΛӷ ÙÔ˘ ·˘ÙÔ‡, ‰È·Ê¤ÚÔ˘Ó ÙfiÛÔ fiÛÔ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· Ó· ÍÂʇÁÔ˘Ó ÙËÓ ·ÓÔ¯‹ Î·È Ó· ÚÔηϤÛÔ˘Ó ·ÓÙ›‰Ú·ÛË

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·fi ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ·. £· ·Ó·Ê¤ÚÔ˘Ì ÙÔ ·Ú¿‰ÂÈÁÌ· Ù˘ ∫ÏÂÌÛȤÏÏ·, Ë ÌfiÏ˘ÓÛË ·fi ÙËÓ ÔÔ›· ı· ¢ԉÒÛÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘, ·ÏÏ¿ ·Ú¿ÏÏËÏ· Î·È ¤Ó·ÓÙÈ ÙÔ˘ ÌÔÚ›Ô˘ HLA-B27, Ì ÙÔ ÔÔ›Ô ¤¯ÂÈ ·Ó¿ÏÔÁË ‰ÔÌ‹. ∆Ô Î‡ÚÈÔ Úfi‚ÏËÌ· ÛÙË ÌÂϤÙË Ù˘ ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È Ò˜ Ó· ÙÔÔıÂÙËıÔ‡Ó ÔÈ ÂÈ̤ÚÔ˘˜ ÂÌÏÂÎfiÌÂÓÔÈ ·Ú¿ÁÔÓÙ˜ Û ̛· ·ÈÙÈÔÏÔÁÈ΋ Û˘Ó¤¯ÂÈ·. ∆È ÚÔËÁÂ›Ù·È Î·È ÙÈ ¤ÂÙ·È; ∂›Ó·È ÙÔ ¤Ó·˘ÛÌ· ¤Ó· ÙÚÔÔÔÈË̤ÓÔ ·ÓÙÈÁfiÓÔ ·fi ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜; ∂›Ó·È Ë ·ÓÂ¿ÚÎÂÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ ‹ ÙˆÓ Ô˘ÛÈÒÓ; ∂›Ó·È Ë ÌÂÈÔÓÂÎÙÈ΋ ÙÔ˘˜ ÂÈÎÔÈÓˆÓ›·; ª¤ÓÔ˘Ó ·ÎfiÌË ÔÏÏ¿ Ó· Ì¿ıÔ˘ÌÂ. ¶Èı·Ófiٷٷ ‰ÂÓ Â›Ó·È Ì›· ÛÂÈÚ¿ ÁÂÁÔÓfiÙˆÓ, ·ÏÏ¿ ¤Ó· ÔχÏÔÎÔ Û‡ÛÙËÌ· ·ÏÏËÏÔÂÍ·ÚÙÒÌÂÓˆÓ ·Ú·ÁfiÓÙˆÓ Î·È Ì˯·ÓÈÛÌÒÓ. ∏ ‡·ÚÍË fiÏˆÓ Î·È Ë ¿ÚÈÛÙË ·ÏÏËÏÔÚ‡ıÌÈÛ‹ ÙÔ˘˜ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË Î·È ÙËÓ Â‡Ú˘ıÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡.

OÈ ıÂÚ·¢ÙÈΤ˜ ÚÔÔÙÈΤ˜ ‚·Û›˙ÔÓÙ·È ÛÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ Â›ÙÔÔ˘ ÙÔ˘ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘, ÛÙË ÁÓÒÛË ÌÔÚ›ˆÓ Î·È Ì˯·ÓÈÛÌÒÓ Ù˘ ·ÓÔÛÔ·¿ÓÙËÛ˘, ÒÛÙ ӷ ·Ó·Ù˘¯ı› Ë Î·Ù¿ÏÏËÏË ·ÓÔÛÔıÂÚ·›·, ›Ûˆ˜ ÂÌ‚ÔÏÈÔıÂÚ·›·, Î·È Â˘fi‰ˆÛË Ù˘ ·ÓÔ¯‹˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·˘ÙÔ·ÓÙÈÁfiÓÔ˘ per os ÌÔÚ› Ó· ‰Ú¿ÛÂÈ ÚÔÛٷ٢ÙÈο ÁÈ· ÙÔ ·˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ· (8). °ÓˆÚ›˙ÔÓÙ·˜ ÙËÓ ‰ÔÌ‹ ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ô˘ ‰›‰Ô˘Ó ÙÔ ¤Ó·˘ÛÌ· ‹ ·ÔÙÂÏÔ‡Ó ÙËÓ ·ÈÙ›· Ù˘ ÓfiÛÔ˘ Î·È Ù· ‰È¿ÊÔÚ· ÛÙ¿‰È· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÓÔÛÔ·¿ÓÙËÛ˘, ı· ÌÔÚԇ̠ӷ ·Ú¤Ì‚Ô˘Ì ‹ ÛÙË ‰ÔÌ‹ ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ‹, ·ÎfiÌË Î·Ï‡ÙÂÚ·, ÛÙËÓ ÂÓ›Û¯˘ÛË Û˘ÁÎÂÎÚÈ̤-

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ÓÔ˘ ÎÏ¿‰Ô˘ ÙˆÓ ·ÓÔÛÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ô˘ÛÈÒÓ ‹ Ì˯·ÓÈÛÌÒÓ, ÒÛÙ ӷ ¢ԉÒÛÔ˘Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ÚÔÛٷ٢ÙÈ΋ ·ÓÔÛÔ·¿ÓÙËÛË, Ë ÔÔ›· ı· Ô‰ËÁ‹ÛÂÈ ÛÙË ıÂÚ·›· Ù˘ ÓfiÛÔ˘ÛÙfi¯Ô˘ ̤ۈ ÙÔ˘ ηٿÏÏËÏÔ˘ ۯ‰ȷÛÌÔ‡ ÛÙÚ·ÙËÁÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. °ÂÚÌÂÓ‹˜ ∞∂, §˘Ì¤ÚË ¶. ∞˘ÙÔ·ÓÔÛ›·. ™ÙÔ: °ÂÚÌÂÓ‹˜ ∞∂, π·ÙÚÈ΋ ∞ÓÔÛÔÏÔÁ›·. ¶··˙‹Û˘; 2000. ÛÂÏ. 237-265.

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3. ªÔ˘ÙÛfiÔ˘ÏÔ˜ ê. ∞ÓÔÛÔÏÔÁ›·. ∞˘ÙÔ¿ÓÔÛ· ƒÂ˘Ì·ÙÈο ¡ÔÛ‹Ì·Ù·. §›ÙÛ·˜; 1990.

4. Roitt I. Autoimmunity and autoimmume disease. In: Roitt I, Brosfoff J, Male D, eds. Immunology. 5th ed. Mosby; 1998. p. 367-380.

5. Kumar V, Sercarz EE. Regulation of autoimmunity. Cur Opin Immunol 1991;3:888-895.

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The environment strikes back. Cur Opin Immunol 1993;5:863-865.

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¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· °. ∫·Ó¿ÚÈÔ˘ §. ∫ËÊÈÛ›·˜ 51, 115 23, ∞ı‹Ó·

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∞¡O™O§O°π∞ - ƒ∂Àª∞∆O§O°π∞

Paediatriki 2001;64:233-236

IMMUNOLOGY - RHEUMATOLOGY

™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ÿ. µÔ˘ÁÈԇη

Spondyloarthropathies in childhood O. Vougiouka

¶ÂÚ›ÏË„Ë: OÈ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂȘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·ÔÙÂÏÔ‡Ó Ì›· ÔÌ¿‰· HLA-B27 Û¯ÂÙÈ˙fiÌÂÓˆÓ ÓÔÛËÌ¿ÙˆÓ, Ù· ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÊÏÂÁÌÔÓ‹ ÙÔ˘ ·ÚıÚÈÎÔ‡ ˘Ì¤Ó·, ÙˆÓ Ì˘˚ÎÒÓ ı˘Ï¿ÎˆÓ, ÂχÙÚˆÓ Î·È ·ÔÓ¢ÚÒÛˆÓ, ηıÒ˜ Î·È ÙˆÓ ÛËÌ›ˆÓ ÚfiÛÊ˘Û˘ ÙˆÓ ÙÂÓfiÓÙˆÓ ÙˆÓ Ì˘ÒÓ ÛÙ· ÔÛÙ¿ ΢ڛˆ˜ ÂÚÈÊÂÚÈÎÒÓ ·ÚıÚÒÛˆÓ. ¶·Ú¿ÏÏËÏ·, Û˘Ó˘¿Ú¯Ô˘Ó Â͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ. ∞ÔÙÂÏÔ‡Ó ÂÚ›Ô˘ ÙÔ 20% Ù˘ ¡Â·ÓÈ΋˜ π‰ÈÔ·ıÔ‡˜ ∞ÚıÚ›Ùȉ·˜. ∏ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÎÂÓÙÚÈÎÒÓ ·ÚıÚÒÛÂˆÓ ÙÔ˘ ÎÔÚÌÔ‡ Û˘Ì‚·›ÓÂÈ Û’ ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ·fi ¯ÚfiÓÈ·, ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÚ›˙ÂÙ·È Û ÎÚÈÙ‹ÚÈ· ÌË ‰È·ÊÔÚÔÔÈË̤Ó˘ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·˜, fiˆ˜ ÂΛӷ Ù˘ ·ÚıÚ›Ùȉ·˜ Û¯ÂÙÈ˙fiÌÂÓ˘ ÌÂ Î·Ù·Ê˘Û›Ùȉ· ‹ Ù˘ ∂˘Úˆ·˚΋˜ OÌ¿‰·˜ ªÂϤÙ˘ ™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·˜.

Abstract: Childhood onset spondyloarthropathies are a group of HLA-B27 related diseases which are characterized by inflammation of joint synovium, entheses, tendon sheaths and bursae that predominantly involve the lower extremities.

Extraarticular manifestations may develop concurrently. They acount for about 20% of the group of juvenile idiopathic arthritis seen in pediatric rheumatology clinics. Axial skeleton involvement occurs later on in early adulthood in a great proportion of affected children. Prompt recognition is based on the criteria of undifferentiated spondyloarthropathies such as Seronegativity - Arthropathy - Enthesopathy Syndrome or the European Spondyloarthropathy Study Group Criteria.

§¤ÍÂȘ ÎÏÂȉȿ: Ó·ÓÈ΋ ÛÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·, Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, Ó·ÓÈ΋ „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, ·ÚıÚ›Ùȉ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘, Û‡Ó‰ÚÔÌÔ Reiter.

Key words: juvenile spondyloarthropathy, juvenile ankylosing spondylitis, ankylosing spondylitis, juvenile psoriatic arthritis, arthritis of inflammatory bowel diseases, Reiter’s syndrome.

O fiÚÔ˜ “¡Â·ÓÈ΋ ™ÔÓ‰˘ÏÔ·ÚıÚÔ¿ıÂÈ·” ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÈ· ÔÌ¿‰· ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ÚÔÛ‚¿ÏÏÔ˘Ó ·ÚıÚÒÛÂȘ, ÙfiÛÔ ÙÔ˘ ÎÔÚÌÔ‡ fiÛÔ Î·È ÙˆÓ ¿ÎÚˆÓ, ÂÓÒ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·ÊÔÚ¤˜ ·fi ÙË ¡Â·ÓÈ΋ π‰ÈÔ·ı‹ ∞ÚıÚ›Ùȉ·. Àfi ÙÔÓ fiÚÔ ·˘Ùfi ·Ó·Ê¤ÚÔÓÙ·È Ë ¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ·, Ë ¡Â·ÓÈ΋ æˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, Ë ·ÚıÚ›Ùȉ· ÙÔ˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Reiter (¶›Ó·Î·˜ 1).

∫ÔÈÓ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È (¶›Ó·Î·˜ 2): ·) Ë ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÚıÚÒÛÂˆÓ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ÙˆÓ ÈÂÚÔÏ·ÁÔÓ›ˆÓ ·ÚıÚÒÛÂˆÓ Î·È ÙˆÓ ÛËÌ›ˆÓ ÚfiÛÊ˘Û˘ ÙÂÓfiÓÙˆÓ, Û˘Ó‰¤Û̈Ó, ·ÚıÚÈÎÒÓ ı˘Ï¿ÎˆÓ Î·È ÂÚÈÙÔÓ›ˆÓ ÛÙ· ÔÛÙ¿, ‚) Ë ·Û‡ÌÌÂÙÚË ÂÚÈÊÂÚÈ΋ ·ÚıÚ›Ùȉ·, Û˘¯ÓfiÙÂÚ· ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, Á) Ë ÔÈÎÔÁÂÓ‹˜ Â›ÙˆÛË Î·È Ë ·˘ÍË̤ÓË ·Ó›¯Ó¢ÛË ÙÔ˘ HLA-B27, ‰) Ë ˘ÂÚÔ¯‹ ÙˆÓ ·ÚÚ¤ÓˆÓ Î·È Ë fi„ÈÌË ¤Ó·ÚÍË ÛÙËÓ

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

2nd Department of Pediatrics of Athens University Medical School, Children’s Hospital “P. & A. Kyriakou”

233

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·È‰È΋ ËÏÈΛ·, Â) ‰È¿ÊÔÚ˜ Â͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜, ÙÔ ‰¤ÚÌ· Î·È ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ Ô˘ ¿ÏÏÔÙ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ¿ÏÏË Û˘¯ÓfiÙËÙ· Î·È ÛÙ) Ë ·Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ· ηıÒ˜ Î·È Ë ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ¿ÏÏˆÓ ·˘ÙÔ·ÓÙÈۈ̿وÓ, fiˆ˜ Ù· ∞¡∞. ∏ ÂÙ‹ÛÈ· Â›ÙˆÛË Ù˘ Ó·ÓÈ΋˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·˜ ÂÎÙÈÌ¿Ù·È ÛÙÔ 5/100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡, ÌÂ Û˘¯ÓfiÙËÙ· Û ‰Â‰Ô̤ÓË ÛÙÈÁÌ‹ 0,2ò. ™˘¯ÓfiÙÂÚË Â›Ó·È Ë Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·. ¶ÔÏÏ¿ ·È‰È¿ ¤¯Ô˘Ó ÌÂÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ì›·˜ ·fi ÙȘ Ó·ÓÈΤ˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂȘ, ‰ÂÓ ¤¯Ô˘Ó ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÛÎÂÏÂÙÔ‡ ÙÔ˘ ÎÔÚÌÔ‡ Î·È ‰ÂÓ ÏËÚÔ‡Ó ÎÚÈÙ‹ÚÈ· ÒÛÙ ӷ ηٷٷÁÔ‡Ó Û ̛· ·fi ·˘Ù¤˜. ŒÙÛÈ ÚԤ΢„Â Ô fiÚÔ˜ “Û‡Ó‰ÚÔÌÔ ÔÚÔ·ÚÓËÙÈ΋˜ ·ÚıÚÔ¿ıÂÈ·˜-Î·Ù·Ê˘Û›Ùȉ·˜” (seronegativity enthesopathy-arthropathy, SEA, syndrome). ∆Ô Û‡Ó‰ÚÔÌÔ ·ÊÔÚ¿ ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 17 ¯ÚfiÓˆÓ, ÔÚÔ·ÚÓËÙÈο, ÌÂ Â˘Ú‹Ì·Ù· ÊÏÂÁÌÔÓ‹˜ ·fi ÙȘ ÔÛÙÈΤ˜ ÚÔÛʇÛÂȘ Î·È ·ÚıÚ·ÏÁ›· ‹ ·ÚıÚ›Ùȉ· (¶›Ó·Î·˜ 3). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂͤÏÈ͢ ÚÔ˜ ÔÚÈÛÙÈ΋ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·, ·ÔÙÂÏ› Ô‰ËÁfi ÛËÌÂ›Ô ÁÈ· ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î·È ÚfiÁÓˆÛË Î·È ˘Ô‰ËÏÒÓÂÈ Â·ÁÚ‡ÓÈÛË ÁÈ· ÙËÓ ÂͤÏÈÍ‹ ÙÔ˘. ∆Ô ÚfiÙ˘Ô ÙˆÓ Ó·ÓÈÎÒÓ ÛÔÓ‰˘Ï·ÚıÚÔ·ıÂÈÒÓ ·ÔÙÂÏ› Ë ¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ·. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ Û ÚÔ¯ˆÚË̤Ó˜ ηٷÛÙ¿ÛÂȘ Â›Ó·È Â‡ÎÔÏË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì fiÓÔ Ú¿¯ÂÔ˜, Â˘Ú‹Ì·Ù· ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· Î·È ·ÚÔ˘Û›· Û˘Ó‰ÂÛÌfiÊ˘ÙˆÓ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË. °È· ÙË ‰È¿ÁÓˆÛ‹ Ù˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ¤¯Ô˘Ó ıÂÛÈÛÙ› ÎÚÈÙ‹ÚÈ·. ∞fi ·˘Ù¿, Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ¡.ÀfiÚ΢ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∏ ‰È·‚¿ıÌÈÛË Ù˘ ·ÎÙÈÓÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ Ù˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ·Ó·ÁÚ¿ÊÂ-

Paediatriki 2001;64:233-236

Ù·È ÛÙÔÓ ¶›Ó·Î· 5. ŸÌˆ˜, ÛÙ· ·È‰È¿ Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈÌ·, ‰ÈfiÙÈ Ê˘ÛÈΤ˜ ÌÂÙÚ‹ÛÂȘ ‹ ‰ÂÓ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ‹ ·Ó ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› Û ÂÚÈÔÚÈṲ̂ÓÔ ÏËı˘ÛÌfi, ‰ÂÓ ¤¯Ô˘Ó ÂÎÙÈÌËı› Â˘Ú¤Ô˜. ∞ÎfiÌ·, Ë Û˘ÌÌÂÙÔ¯‹ ÎÂÓÙÚÈÎÒÓ ·ÚıÚÒÛÂˆÓ ÛÙ· ·È‰È¿ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÔÙÂÏ› ı¤Ì· ¯ÚfiÓÔ˘. ™Â ÔÛÔÛÙfi ÂÚ›Ô˘ 80% Ë ÓfiÛÔ˜ ÍÂÎÈÓ¿ Û·Ó ÂÚÈÊÂÚÈ΋ ·Û‡ÌÌÂÙÚË ÔÏÈÁÔ·ÚıÚ›Ùȉ·, ΢ڛˆ˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ. ∆Ô 20% ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ fiÓÔ, ‰˘Ûη̄›· ‹ ÂÚÈÔÚÈÛÌfi ΛÓËÛ˘ ÛÙË ıˆÚ·ÎÔÔÛÊ˘˚΋ ÌÔ›Ú· ‹ ηٿ ÙȘ ÈÂÚÔÏ·ÁfiÓȘ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. O ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ó¿Ù˘Í˘ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ ÂÎÙÈÌ¿Ù·È ÛÙ· 6,5 ¯ÚfiÓÈ·, ÂÓÒ Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ·›ÚÓÂÈ Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ó· ·Ó·Ù˘¯ı›, Ì ·ÓÒÙÂÚÔ ·Ó·ÊÂÚfiÌÂÓÔ Ù· 30 ¯ÚfiÓÈ·. ∆Ô 1/4 ÙˆÓ ·ÛıÂÓÒÓ ‰›ÓÂÈ ÈÛÙÔÚÈÎfi fiÓÔ˘ ÂÚ› ÙËÓ Ù¤ÚÓ·, ÏfiÁˆ ÂÏÌ·ÙÈ·›·˜ ·ÔÓÂ˘ÚˆÛ›Ùȉ·˜ ‹ ÏfiÁˆ ı˘Ï·Î›Ùȉ·˜ ÙÔ˘ ·¯ÈÏ›Ԣ Ù¤ÓÔÓÙ·. ∂͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ Â›Ó·È Ë ÈÚȉÔ΢ÎÏ›Ùȉ· Û ÔÛÔÛÙfi 14-27% ÂÚ›Ô˘. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÚ˘ıÚfiÙËÙ·, fiÓÔ Î·È ÊˆÙÔÊÔ‚›·. ∂Í·ÈÚÂÙÈο Û¿ÓÈ·, ÚÔËÁÂ›Ù·È ÙˆÓ ÂΉËÏÒÛÂˆÓ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡. ∞Û˘Ó‹ıÈÛÙ˜ ÛÙ· ·È‰È¿ Â›Ó·È ÔÈ ÂΉËÏÒÛÂȘ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi, ÙÔ ∫¡™ Î·È ÙÔ˘˜ ÓÂÊÚÔ‡˜. ∞ÙÏ·ÓÙÔ˚Óȷ΋ ˘ÂÍ¿ÚıÚˆÛË Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ì‚Â›, ÂΉËÏÔ‡ÌÂÓË Ì ‰˘Ó·Ùfi fiÓÔ ÛÙÔÓ ·˘¯¤Ó· Î·È ÛÙÔ ÈÓ›Ô. À¿Ú¯ÂÈ ÂÓÙ˘ˆÛȷ΋ ÔÈÎÔÁÂÓ‹˜ Â›ÙˆÛË Ù˘ ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜, Ë ÔÔ›· Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙÔ˘ HLA-B27, ÙÔ ÔÔ›Ô ·Ó¢ڛÛÎÂÙ·È Û ÔÛÔÛÙfi 95%. ∆Ô 2-10% ¶›Ó·Î·˜ 3. ∫ÚÈÙ‹ÚÈ· ηٿٷ͢ Û. SEA 1.

2.

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¶›Ó·Î·˜ 1. ¡Â·ÓÈ΋ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ· 1.

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¡Â·ÓÈ΋ ∞Á΢ÏÔÔÈËÙÈ΋ ™ÔÓ‰˘Ï›Ùȉ· ¡Â·ÓÈ΋ æˆÚÈ·ÛÈ΋ ∞ÚıÚ›Ùȉ· ∞ÚıÚÔ¿ıÂÈ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ ™‡Ó‰ÚÔÌÔ Reiter

¶›Ó·Î·˜ 2. ∫ÔÈÓ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÛÔÓ‰˘Ï·ÚıÚÔ·ıÂÈÒÓ 1.

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5.

6.

∞ÚıÚ›Ùȉ· ™.™., ÈÂÚÔÏ·ÁÔÓ›Ùȉ·, Î·Ù·Ê˘Û›Ùȉ· ∞Û‡ÌÌÂÙÚË ÂÚÈÊÂÚÈ΋ ·ÚıÚ›Ùȉ· OÈÎÔÁÂÓ‹˜ Â›ÙˆÛË. HLA-B 27 ÀÂÚÔ¯‹ ·ÚÚ¤ÓˆÓ ∂͈·ÚıÚÈΤ˜ ÂΉËÏÒÛÂȘ ∞Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ·

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¶›Ó·Î·˜ 4. ∫ÚÈÙ‹ÚÈ· ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜ (¡¤·˜ ÀfiÚ΢) 1. ¶ÂÚÈÔÚÈÛÌfi˜ ΛÓËÛ˘ Oª™™ Û 3 Â›‰· 2. ¶fiÓÔ˜ ηٿ ÙË ıˆÚ·ÎÔÔÛÊ˘˚΋ Û˘Ì‚ÔÏ‹ 3. ¶ÂÚÈÔÚÈÛÌfi˜ ıˆÚ·ÎÈ΋˜ ‰È¿Ù·Û˘ ≤2,5 cm ¢π∞°¡ø™∏: - ÔÚÈÛÙÈ΋: - ∞ÌÊÔÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 + ¤Ó· ÎÚÈÙ‹ÚÈÔ - ∂ÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 ‹ ·ÌÊÔÙÂÚfiÏ¢ÚË Ù¿Í˘ 2 + ÎÚÈÙ‹ÚÈÔ 1 ‹ ÎÚÈÙ‹ÚÈ· 2 Î·È 3 - Èı·Ó‹: - ∞ÌÊÔÙÂÚfiÏ¢ÚË ÈÂÚÔÏ·ÁÔÓ›Ùȉ· Ù¿Í˘ 3-4 ¯ˆÚ›˜ ÎÚÈÙ‹ÚÈÔ

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ÙˆÓ µ27 ·ÙfiÌˆÓ ¿Û¯Ô˘Ó ·fi ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·. ∏ ÓfiÛÔ˜ Â›Ó·È 10-20 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È 50-80 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ ·‰ÂÏÊÔ‡˜ ÙÔ˘˜. O ΛӉ˘ÓÔ˜ ÂÙÂÚÔ˙˘ÁÒÙË µ27 ·Ù¤Ú· ¿Û¯ÔÓÙ· Ó· ·ÔÎÙ‹ÛÂÈ ¿ÚÚÂÓ Ù¤ÎÓÔ ¿Û¯ÔÓ, Â›Ó·È 20% Û µ27 Ù¤ÎÓÔ. ¢È¿ÊÔÚÔÈ ˘fiÙ˘ÔÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ µ27 ¤¯Ô˘Ó ÌÂÏÂÙËı› ÁÈ· ÙÔ ıÂÙÈÎfi ‹ ·ÔÙÚÂÙÈÎfi ÙÔ˘˜ ÚfiÏÔ, ÂÓÒ ¿ÏϘ ÔÌ¿‰Â˜ ÌÔÚ›ˆÓ Ù¿Í˘ ∏LA I, ÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ ÙÔ˘ µ60, ·›˙Ô˘Ó ÚfiÏÔ. ¶·Ú’ fiÏÔ Ô˘ ÙÔ µ27 Ê·›ÓÂÙ·È ÈÛ¯˘ÚfiÙÂÚÔ, ÙÔ ∞2 ·ÓÙÈÁfiÓÔ Â›Û˘ ÂÌϤÎÂÙ·È. OÈ ÏfiÁÔÈ Û‡Ó‰ÂÛ˘ ÙÔ˘ HLA-B27 Ì ÙËÓ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· Û˘Ì˘ÎÓÒÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ∆Ô HLA-B27 ·Ú¤¯ÂÈ ˘ÔÛÙËÚÈÎÙÈÎfi ÚfiÏÔ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Û ·Ú¯È΋ Ê¿ÛË. ∆· ÛÙÔȯ›· ÁÈ· ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ÂÏÏÈ‹. ∏ η΋ ÚfiÁÓˆÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘, Ë ÔÔ›· Á›ÓÂÙ·È ÛˆÛÙ¿ ÌfiÓÔ ÛÙÔ 2% Ù˘ ∞™. ∏ ∞™ ÙˆÓ ÂÓËÏ›ÎˆÓ ·Ú¯›˙ÂÈ ÛÙË Ó·ÓÈ΋ ËÏÈΛ· Û ÔÛÔÛÙfi 15%. OÏÈ΋ ·ÚıÚÔÏ·ÛÙÈ΋ ÈÛ¯›ˆÓ ˘Ê›ÛÙ·Ù·È ÙÔ 17% Ù˘ ¡∞™ Î·È ÙÔ 4% Ù˘ ∞™ ÙˆÓ ÂÓËϛΈÓ. ∏ ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ÚÔÛ‚¿ÏÏÂÙ·È Û 8,5 ¯ÚfiÓÈ· (8,3±6,4). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ··Û¯fiÏËÛË Ì ̤ÛË ‰È¿ÚÎÂÈ· ÓfiÛÔ˘ 24 ¯ÚfiÓÈ·, 74% Ù˘ ¡∞™ ›¯Â Ï‹ÚË ··Û¯fiÏËÛË Û ۯ¤ÛË Ì ÙÔ 56% ÙˆÓ ÂÓËϛΈÓ.

OÈ ·Ú¯¤˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È ÙÔ˘ fiÓÔ˘ Ô˘ ÚÔηÏ›ٷÈ, ÙË ‰È·Ù‹ÚËÛË Î·È ·ÔηٿÛÙ·ÛË ÙÔ˘ ‡ÚÔ˘˜ ΛÓËÛ˘ ÙˆÓ ·ÚıÚÒÛˆÓ, ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ·Ú·ÌÔÚÊÒÛˆÓ, ÙË ‰È·Ù‹ÚËÛË Î·È ·ÔηٿÛÙ·ÛË Ù˘ Ì˘˚΋˜ ÈÛ¯‡Ô˜, ÙË ‰È·Ù‹ÚËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ ·ÚıÚÒÛˆÓ, ÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ·Û¯fiÓÙˆÓ Î·È ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙÔ˘˜, ÙË ÌfiÚʈÛË Î·È ÂÎ·›‰Â˘ÛË, ÙÔÓ Â·ÁÁÂÏÌ·ÙÈÎfi ÚÔÛ·Ó·ÙÔÏÈÛÌfi (¶›Ó·Î·˜ 7).

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¡Â·ÓÈ΋ „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ· OÚ›˙ÂÙ·È ˆ˜ Ë ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ҉˘ ·ÚıÚ›Ùȉ·, Ë ÔÔ›· ·Ú¯›˙ÂÈ ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 16 ¯ÚfiÓˆÓ Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ·, ÙÔ ÔÔ›Ô ÚÔËÁ›ٷÈ, Û˘Óԉ‡ÂÈ ‹ ¤ÂÙ·È Ù˘ ·ÚıÚ›Ùȉ·˜. ∂Âȉ‹ ÙÔ ÂÍ¿ÓıËÌ· ÌÔÚ› Ó· ÌËÓ ÂÌÊ·ÓÈÛÙ› ÔÏÏ¿ ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ·ÚıÚ›Ùȉ·˜ (̤¯ÚÈ Î·È 15), ÙÔ 1981 ÚÔÙ¿ıËÎ·Ó Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Vancounver (¶›Ó·Î·˜ 8). ∏ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È fiÛÔ Î·Ï‹ ›¯Â ·Ú¯Èο ıˆÚËı›, ‰ÈfiÙÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi (66%) ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ÔÏ˘·ÚıÚÈ΋ ÔÚ›·. ∞ÎÚˆÙËÚÈ·ÛÙÈ΋ ·ÚıÚ›Ùȉ· Î·È ·Ì˘ÏÔ›‰ˆÛË ¤¯Ô˘Ó ÂÚÈÁÚ·Ê›. ™‡Ó‰ÚÔÌÔ Reiter ∂Í ÔÚÈÛÌÔ‡ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÙÚÈ¿‰· ÊÏÂÁÌÔÓˆ‰ÒÓ ·ÏÏÔÈÒÛÂˆÓ ·fi ÙÔÓ ·ÚıÚÈÎfi ˘Ì¤Ó·, ÙÔÓ ÂÈÂÊ˘ÎfiÙ· Î·È ÙËÓ Ô˘Ú‹ıÚ·. ∂›Ó·È ۯ‰fiÓ ‚¤‚·ÈÔ fiÙÈ ·ÔÙÂÏ› ÌÂÙ·ÏÔÈÌÒ‰Ë ‹ ·ÓÙȉڷÛÙÈ΋ ·ÚıÚ›Ùȉ· ·ÏÏ¿ ÂÚÈÁÚ¿ÊÂÙ·È Ì ÙȘ ÔÚÔ·ÚÓËÙÈΤ˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂȘ ÂÍ·ÈÙ›·˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÔÌÔÈÔÙ‹ÙˆÓ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ·Ó‡ÚÂÛ˘ ÙÔ˘ HLA-B27. ™Ù· ·È‰È¿, ÔÈ ·ÏÏÔÈÒÛÂȘ ·fi ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜ Â›Ó·È Û¿ÓȘ, ÂÓÒ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Â›Ó·È Û˘¯Ó¿ Ù· ¤ÏÎË ÛÙfiÌ·ÙÔ˜ Î·È Ë ‚ÏÂÓÓÔ·ÈÌÔÚÚ·ÁÈ΋ ÎÂÚ·ÙÔ‰ÂÚÌ›·. ∞ӷʤÚÂÙ·È fiÙÈ ÛÙ· ·È‰È¿ ÙÔ Û.

Reiter Â›Ó·È ·˘ÙÔ˚ÒÌÂÓÔ. ∏ ¤Î‚·ÛË ·˘Ù‹ ·ÊÔÚ¿ ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ. ¶ÈÔ ÚfiÛÊ·Ù·, Û ÌÂϤÙË 20 ·È‰ÈÒÓ Ì ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 29 Ì‹Ó˜, ÙÔ 21% ›¯Â ÛËÌ›· ÚÔÛ‚ÔÏ‹˜ ÈÂÚÔÏ·ÁÔÓ›ˆÓ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ∂Ӊ¯Ô̤ӈ˜ ÙÔ ¶›Ó·Î·˜ 7. ∞ÓÙÈÌÂÙÒÈÛË ∞.™.

∞ÓÙÈÌÂÙÒÈÛË fiÓÔ˘-ÊÏÂÁÌÔÓ‹˜ º·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ º˘ÛÈÎÔıÂÚ·›· ∂ÚÁ·ÛÈÔıÂÚ·›· æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ™¯ÔÏÈ΋ ÂÎ·›‰Â˘ÛË ∂·ÁÁÂÏÌ·ÙÈÎfi˜ ÚÔÛ·Ó·ÙÔÏÈÛÌfi˜

¶›Ó·Î·˜ 5. ∞ÎÙÈÓÔÏÔÁÈ΋ ‰È·‚¿ıÌÈÛË ÈÂÚÔÏ·ÁÔÓ›Ùȉ·˜ µ·ıÌfi˜ µ·ıÌfi˜ µ·ıÌfi˜ µ·ıÌfi˜

π : ππ : πππ: πV:

∞Û¿ÊÂÈ· ˘Ô¯fiÓ‰ÚÈˆÓ ÔÚ›ˆÓ ¢È‡ڢÓÛË ¿ÚıÚˆÛ˘, ‰È·‚ÚÒÛÂȘ ™ÎÏ‹Ú˘ÓÛË, ÂÎÛÂÛËÌ·Ṳ̂Ó˜ ‰È·‚ÚÒÛÂȘ ∞Á·ψÛË

¶›Ó·Î·˜ 6. ∞›ÙÈ· Û‡Ó‰ÂÛ˘ ∏LA-µ27-∞.™.

1. ∞ÓÈÛÔ˙˘Á›· Û‡Ó‰ÂÛ˘ 2. ªÔÚȷ΋ ·ÔÌ›ÌËÛË, ∞˘ÙÔ·ÓÔÛ›·, ∞ÓÔ¯‹ 3. §ÂÈÙÔ˘ÚÁÈÎfi˜ ÚfiÏÔ˜ HLA ÌÔÚ›ˆÓ, ∞ÓÔÛÔ·Ó·ÁÓÒÚÈÛË, ªÂÌ‚Ú·ÓÈÎÔ› ˘ԉԯ›˜ ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ

¶›Ó·Î·˜ 8. ∫ÚÈÙ‹ÚÈ· Vancouver ¡æ∞ OÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË -∞ÚıÚ›Ùȉ· + Ù˘ÈÎfi „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ· ‹ -∞ÚıÚ›Ùȉ· + 3 ·fi 4 ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·: ñ¢·ÎÙ˘Ï›Ùȉ· ñµÔıÚ›· ÔÓ‡¯ˆÓ ‹ ÔÓ˘¯fiÏ˘ÛË ñÕÙ˘Ô „ˆÚÈ·ÛÈÎfi ÂÍ¿ÓıËÌ· ñOÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi „ˆÚ›·Û˘ (1Ô˘ & 2Ô˘ ‚·ıÌÔ‡ Û˘ÁÁ¤ÓÂÈ·) ¶Èı·Ó‹ ‰È¿ÁÓˆÛË -∞ÚıÚ›Ùȉ· + 2 ÂÏ¿ÛÛÔÓ· ÎÚÈÙ‹ÚÈ·

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¶›Ó·Î·˜ 9. ∞ÚıÚ›Ùȉ· Û¯ÂÙÈ˙fiÌÂÓË ÌÂ Î·Ù·Ê˘Û›Ùȉ· ∞ÚıÚ›Ùȉ· Î·È Î·Ù·Ê˘Û›Ùȉ· ‹ ∞ÚıÚ›Ùȉ· Î·È 2 ·fi Ù· ÂÍ‹˜: 1. ∂˘·ÈÛıËÛ›· ÈÂÚÔÏ·ÁÔÓ›ˆÓ 2. ºÏÂÁÌÔÓ҉˘ fiÓÔ˜ ™.™.

3. HLA B 27 4. OÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÂÓfi˜ ·fi Ù· ·Ú·Î¿Ùˆ: ·) ÚfiÛıÈ· ÈÚȉÔ΢ÎÏ›Ùȉ· Ì fiÓÔ, ÂÚ˘ıÚfiÙËÙ·, ʈÙÔÊÔ‚›· ‚) ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ· Á) ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÂÓÙ¤ÚÔ˘ 5. ¶ÚfiÛıÈ· Ú·ÁÔÂȉ›Ùȉ· Ì fiÓÔ, ÂÚ˘ıÚfiÙËÙ·, ʈÙÔÊÔ‚›· *∞Ô˘Û›· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·Ú¿ÁÔÓÙ·, ∞¡∞, „ˆÚÈ·ÛÈ΋˜ ·ÚıÚ›Ùȉ·˜ Î·È ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÓfiÛÔ˘ ÂÓÙ¤ÚÔ˘.

Û. Reiter Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ó· ·ÔÙÂÏ› ÚÒÈÌË ÂΉ‹ÏˆÛË ·Á΢ÏÔÔÈËÙÈ΋˜ ÛÔÓ‰˘Ï›Ùȉ·˜. ∞ÚıÚÔ¿ıÂÈ· ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘ OÚ›˙ÂÙ·È Î¿ı ¿ÛËÙË ÊÏÂÁÌÔÓ҉˘ ·ÚıÚ›Ùȉ· Ô˘ Û˘Ì‚·›ÓÂÈ ÚÈÓ ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ ‹ Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn. ™˘Ì‚·›ÓÂÈ ÛÙÔ 7-20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ‰‡Ô Ù‡Ô˘˜ ·ÚıÚ›Ùȉ·˜: ÂÚÈÊÂÚÈ΋ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÈÂÚÔÏ·ÁÔÓ›Ùȉ·. ∏ ‰È¿ÚÎÂÈ· Ù˘ ·ÚıÚ›Ùȉ·˜ Â›Ó·È Û‡ÓÙÔÌË, ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜, ‰ÂÓ Ô‰ËÁ› Û ÔÛÙÈΤ˜ ‰È·‚ÚÒÛÂȘ Î·È ‰ÂÓ ·ÎÔÏÔ˘ı› ··Ú·›ÙËÙ· ÙȘ ÂΉËÏÒÛÂȘ ·fi ÙÔ ÂÙÈÎfi, ÙÔ ‰¤ÚÌ· ‹ ÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜. ∞Û˘Ìو̷ÙÈ΋ ÂÓÙÂÚÈ΋ Û˘ÌÌÂÙÔ¯‹ ¤¯ÂÈ ·Ó¢ÚÂı› ÛÙË Ó·ÓÈ΋ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, fiˆ˜ Î·È ÛÙËÓ ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ· ÙˆÓ ÂÓËϛΈÓ.

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™˘ÌÂÚ¿ÛÌ·Ù· ™˘ÓÔ„›˙ÔÓÙ·˜ ÙË Û‡ÓÙÔÌË ·Ó·ÊÔÚ¿ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ù˘ Ó·ÓÈ΋˜ ÛÔÓ‰˘Ï·ÚıÚÔ¿ıÂÈ·˜ ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘˜ ··ÈÙÔ‡ÓÙ·È ÎÔÈÓ¿ ÎÚÈÙ‹ÚÈ·, fiˆ˜ ÂΛӷ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ SE∞ ‹ ¿ÏÏ· ÈÔ ÚfiÛÊ·Ù·, fiˆ˜ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÙÔ̤· Ù˘ ¢ÈÂıÓÔ‡˜ ƒÂ˘Ì·ÙÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (¶›Ó·Î·˜ 9). §ÂÙÔ̤ÚÂȘ ÂÈ̤ÚÔ˘˜ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ‰È·¯ˆÚ›˙Ô˘Ó ÙȘ ˘ÔÔÌ¿‰Â˜. ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÛÎÂÏÂÙÔ‡ ÙÔ˘ ÎÔÚÌÔ‡ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ HLA-B27. µÈ‚ÏÈÔÁÚ·Ê›· 1. Jacobs JC, Bardon WE, Johnston AD. HLA-B27 associated spondyloarthritis and enthesopathy in childhood. Clinical pathologic and radiologic observations in 58 patients. J Pediatr 1982;100:521-528.

2. Burgos-Vargas R, Vazquez-Mallado J. The early clinical recognition of juvenile onset ankylosing spondylitis and its differentation from juvenile rheumatoid arthritis. Arthr Rheum 1995;38:835-844.

3. Burgos-Vargas R, Pacheo-Tena C, Vazquez-Mellado J. Juvenile onset spondyloarthropathies. Rheum Dis Clin N Am 1997;23:569-598.

4. Kayser FD, Elewaut D, De Vos M, De Valm K, Cuvelier C, Mielants H et al. Bowel inflammation and the spondyloarthropathies. Rheum Dis Clin N Am 1998;24: 785-810.

5. Van der Linden S, Van der Heijde D. Ankylosing spondylitis, clinical features. Rheum Dis Clin N Am 1998;24:663-675.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ŸÏÁ· µÔ˘ÁÈԇη ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

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∞¡O™O§O°π∞-ƒ∂Àª∞∆O§O°π∞

Paediatriki 2001;64:237-240

IMMUNOLOGY-RHEUMATOLOGY

¢È·ÈÙËÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· A. ™È·ÌÔÔ‡ÏÔ˘-M·˘Ú›‰Ô˘

Dietary approach in autoimmune rheumatic diseases A. Siamopoulou-Mavridou

¶ÂÚ›ÏË„Ë: TËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ˘¿Ú¯ÂÈ ÌÂÁ¿ÏÔ È·ÙÚÈÎfi ÂӉȷʤÚÔÓ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ‰È·ÈÙËÙÈÎfi ˘fiÛÙڈ̷ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ŒÓ· ÌÂÁ¿ÏÔ Â‡ÚÔ˜ ‰È·ÈÙËÙÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ, ·fi ÌÂÌÔӈ̤ӷ ÛÙÔȯ›· ̤¯ÚÈ ÚˆÙ½Ó˜, ÌÔÚ› Ó· ÙÚÔÔÔÈ‹ÛÂÈ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ¶ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·ÏÏ¿ Î·È Û ·ÓıÚÒÔ˘˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÌÈÎÚ¤˜ ‰fiÛÂȘ ‰È·ÈÙËÙÈÎÒÓ Û˘ÏËÚˆÌ¿ÙˆÓ ÌÔÚ› Ó· ‰Ú¿ÛÔ˘Ó Â·ÁˆÁÈο ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË, ÂÓÒ ·ÓÙ›ıÂÙ· ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÌÔÚ› Ó· ¤¯Ô˘Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË. ¢È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ê·›ÓÂÙ·È ·fi ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ÚÂ˘Ì·ÙÔÂȉ‹ ·ÚıÚ›Ùȉ· (PA) fiÙÈ ·Ó·¯·ÈÙ›˙ÂÈ ÙÚÂȘ Ô‰Ô‡˜ Û‡ÓıÂÛ˘ ÏÈȉÈÎÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜: ·) ÙËÓ Ô‰fi Û‡ÓıÂÛ˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PAF), ‚) ÙËÓ Ô‰fi Ù˘ ΢ÎÏÔ-ÔÍÂÈÁÂÓ¿Û˘ Î·È Á) ÙËÓ Ô‰fi Ù˘ ÏÈÔÍÂÈÁÂÓ¿Û˘. EÚˆÙËÌ·ÙÈο ·Ú·Ì¤ÓÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ Î·Ù¿ÏÏËÏË ‰fiÛË Î·È ÙË ‰È¿ÚÎÂÈ· ·ÁˆÁ‹˜, ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó Ù· ηχÙÂÚ· ‰˘Ó·Ù¿ ·ÔÙÂϤÛÌ·Ù·. H Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· (NIA) Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÓfiÛÔ˜ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ ÛÙ· ·È‰È¿. ŒÓ· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi (2050%) ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÔıÚ„›· ÚˆÙÂïÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (PEM), Ë ÔÔ›· Û˘Óԉ‡ÂÙ·È, ÂÎÙfi˜ ·fi ÂÏ¿ÙÙˆÛË ÙˆÓ ·ÔıËÎÒÓ Ï›Ô˘˜ Î·È ·fi ÂÏ¿ÙÙˆÛË Ù˘ Ì˘˚΋˜ Ì¿˙·˜. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ˘ÔıÚ„›·˜ ÛÙ· ·È‰È¿ Ì NIA Î·È ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ›ӷÈ: ·) Ë ·ÓÔÚÂÍ›·, ‚) Ë ·Ó·ÈÌ›· (¯ÚfiÓÈ·˜ ÓfiÛÔ˘), Á) Ù· Ê¿Ú̷η, ‰) Ë ÌÂȈ̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, Â) ÔÈ Ì˯·ÓÈΤ˜ ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘ Î·È ÛÙ) Èı·ÓfiÓÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜. EÂȉ‹ Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÂÈÂÏÂÁ̤Ó˘ ·˘Ù‹˜ ·ÛÈÙ›·˜ Â›Ó·È Ôχ ÌÂÁ¿ÏÔ˜

Abstract: The past decade has witnessed a resurgence of interest in nutrition and rheumatic diseases. A wide spectrum of nutritional deficiencies, ranging from trace elements to protein, can impair normal immunologic functions. Under some experimental conditions, single nutrient supplementation boosts immunity; however, some mega-dose therapies have been shown to suppress the immune response. Dietary supplementation of ˆ-3 polyunsaturated fatty acids may inhibit three pathways of the synthesis of lipid mediators of inflammation: a) the plateletactivating factor synthesis pathway, b) the cyclooxygenase pathway and c) the 5-lipoxygenase pathway. Investig·tions today focus on the proper dose and duration of therapy with fish-oil supplementation in order to obtain optimum clinical effects. Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease.

The occurrence of protein-energy malnutrition (PEM) has been reported in 20% to 50% of the JIA population. The factors contributing to increased nutritional risk are: anorexia, anemia, drugs and nutritional implications, limitation of physical activity, mechanical feeding difficulties and food allergies. Because the risk for the development of complicated malnutrition pro- blems is great in the JIA population, especially since it is often characterized by the absence of sensitive visual cues that could support the clinical diagnosis of malnutrition, it is imperative that routine clinical and nutritional assessment be performed at regular intervals.

TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ, Iˆ¿ÓÓÈÓ·

Department of Pediatrics University of Ioannina Medical School, Ioannina

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Paediatriki 2001;64:237-240

Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÂÓÂÚÁfi NIA, ı· Ú¤ÂÈ ÂÚÈÔ‰Èο Ó· Á›ÓÂÙ·È ÎÏÈÓÈ΋, ÂÚÁ·ÛÙËÚȷ΋ Î·È ‰È·ÈÙÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ù˘ ˘ÔıÚ„›·˜. §¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÈÙËÙÈο ÂÏÏ›ÌÌ·Ù·, ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË, ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜, Ó·ÓÈ΋ ȉÈÔ·ı‹˜ ·ÚıÚ›Ùȉ·, ˆ-3 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·.

Key words: nutritional deficiences, immunoresponse, protein-energy malnutrition (PEM), juvenile idiopathic arthritis, ˆ-3 polyunsaturated fatty acid.

™ÎÂÙÈÎÈÛÌÔ› ·Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË ‰›·ÈÙ·˜ ·ÚıÚ›Ùȉ·˜ ·Ó·Ê¤ÚÔÓÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ IÔÎÚ¿ÙË. K·Ù¿ ÙÔÓ 20fi ·ÈÒÓ· Î·È Î˘Ú›ˆ˜ ̤¯ÚÈ ÙÔ 1980, Ë Û˘Û¯¤ÙÈÛË ‰›·ÈÙ· - ·ÚıÚ›Ùȉ· ¤¯ÂÈ ÂÈÛÙËÌÔÓÈο ÌÂÏÂÙËı› Î·È ·¤‰ÂÈÍ fiÙÈ Î·Ó¤Ó· ›‰Ô˜ ‰È·ÙÚÔÊ‹˜ ‰ÂÓ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ¯ÚfiÓÈ· ·ÚıÚ›Ùȉ·, Ô‡Ù Âȉڿ ÛÙË ıÂÚ·›· ‹ ÙËÓ “›·ÛË” Ì›·˜ ·ÚıÚ›Ùȉ·˜. ¶·Ú’ fiÏ· ·˘Ù¿, ÔÈ ·ÛıÂÓ›˜ “‰ÂÓ Ì·˜ ÈÛÙ‡ԢӔ Î·È ÍÔ‰Â‡Ô˘Ó ¿Óˆ ·fi ¤Ó· ‰ÈÛÂηÙÔÌ̇ÚÈÔ ‰ÔÏÏ¿ÚÈ· ÂÙËÛ›ˆ˜ ÛÙËÓ AÌÂÚÈ΋ ÁÈ· ‰È·ÈÙËÙÈο ‹ ¿ÏÏ· “ÌË ·Ú·‰ÔÛȷο” Ê¿Ú̷η. ¶ÔÏÏÔ› ¿ÚÚˆÛÙÔÈ ÛÙÚ¤ÊÔÓÙ·È ÛÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ È·ÙÚÈ΋ ÈÛÙ‡ÔÓÙ·˜ fiÙÈ ı· ¤¯Ô˘Ó ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ·' fiÙÈ Ì ÙËÓ ·Ú·‰ÔÛȷ΋ ÎÏ·ÛÈ΋ ·ÁˆÁ‹. ŒÙÛÈ, Ô ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· Â›Ó·È ÁÓÒÛÙ˘ ·˘ÙÒÓ ÙˆÓ ‰ÈÏËÌÌ¿ÙˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ó· ‰Â›¯ÓÂÈ Û˘Ì¿ıÂÈ· Î·È Î·Ù·ÓfiËÛË ÛÙ· ¯ÚfiÓÈ· Î·È Â›ÔÓ· ·˘Ù¿ ÓÔÛ‹Ì·Ù·.

T· ÙÂÏÂ˘Ù·›· 15 ¯ÚfiÓÈ· Ë ¤Ú¢ӷ ÂÈÎÂÓÙÚÒıËΠÛÙÔ ‰È·ÈÙËÙÈÎfi ˘fiÛÙڈ̷ ÙˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ∂›Ó·È ¤Ó· ÂÚ¢ÓËÙÈÎfi ‰›Ô Ì ÌÂÁ¿Ï˜ ÚÔÛ‰Ô˘ Î·È ÔʤÏË. ŒÙÛÈ, Ë Û˘Û¯¤ÙÈÛË ‰È·ÙÚÔÊ‹˜ Î·È ·˘ÙÔ¿ÓÔÛ˘ ÚÂ˘Ì·ÙÈ΋˜ ÓfiÛÔ˘ Â›Ó·È ¤Ó· ·Ú¿‰ÂÈÁÌ· Ì›·˜ Û‡Á¯ÚÔÓ˘ ÚÂ˘Ì·ÙÔÏÔÁÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ (1). TÚ›· ÂӉȷʤÚÔÓÙ· È·ÙÚÈο ‰›· ›ӷÈ: ·) Ë Û˘Û¯¤ÙÈÛË ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ Ì ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË, ‚) Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ Î·È Ë ÌÂÛÔÏ¿‚ËÛ‹ ÙÔ˘˜ ÛÙË ÊÏÂÁÌÔÓ‹ Ù˘ ÚÂ˘Ì·ÙÔÂȉԇ˜ ·ÚıÚ›Ùȉ·˜ (PA) Î·È Á) Ù· ÔÏÏ·Ï¿ ‰È·ÈÙËÙÈο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ Ì Ó·ÓÈ΋ ȉÈÔ·ı‹ ·ÚıÚ›Ùȉ· (NIA). ∞Ó·Ï˘ÙÈÎfiÙÂÚ·: ∞) H Û˘Û¯¤ÙÈÛË ˘ÔıÚ„›·˜ Î·È ·˘ÍË̤Ó˘ ¢·ÈÛıËÛ›·˜ Û ÓÔÛ‹Ì·Ù· ·Ó·Ê¤ÚÂÙ·È ‹‰Ë ·fi ÙÔ˘˜ IÓ‰Ô‡˜ ·fi ÙÔ 5.000 .Ã. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 20Ô‡ ·ÈÒÓ· ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·Ú·ÙËÚ‹ÛÂȘ ·Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË Ïԛ̈ÍË - ˘ÔıÚ„›·, ·ÏÏ¿ ÌfiÏȘ Ù· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· ¤ÁÈÓ·Ó Î·Ù·ÓÔËÙÔ› ÔÈ Ì˯·ÓÈÛÌÔ› ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Û ηٷÛÙ¿ÛÂȘ ˘ÔıÚ„›·˜. H ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (Protein Energy Malnutrition, PEM) Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ ÛÙÔÓ ÎfiÛÌÔ (2). MÂϤÙ˜ Û ·È‰È¿ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘

‰Â›¯ÓÔ˘Ó fiÙÈ ·˘Ù¿ Âı·›ÓÔ˘Ó ·fi ÏÔÈÌÒÍÂȘ, ÏfiÁˆ Ù˘ ˘¿Ú¯Ô˘Û·˜ ηٷÛÙÔÏ‹˜ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. KÔÈÓ¿ ÏÔÈÌÒ‰Ë ·È‰È·ÙÚÈο ÓÔÛ‹Ì·Ù·, fiˆ˜ ·ÚˆÙ›Ùȉ· Î·È ÈÏ·Ú¿, Â›Ó·È ı·Ó·ÙËÊfiÚ· Û ·È‰È¿ ˘Ô·Ó¿Ù˘ÎÙˆÓ ¯ˆÚÒÓ. ™˘ÓÔÙÈο, Ù· ·ÓÔÛÔÏÔÁÈο Â·ÎfiÏÔ˘ı· ÏfiÁˆ PEM Â›Ó·È Ù· ÂÍ‹˜ (3): i) AÙÚÔÊ›· ÙÔ˘ ı‡ÌÔ˘, ii) M›ˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ÛÏ‹Ó·, iii) EÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ T-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, iv) A‡ÍËÛË ÙˆÓ ÊÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, v) ¢È·Ù·Ú·¯‹ ·Ú·ÁˆÁ‹˜ ÏÂÌÊÔÎÈÓÒÓ, vi) K·ı˘ÛÙÂÚË̤ÓË ‰ÂÚÌ·ÙÈ΋ ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜, vii) EÏ·Ùو̤ÓË ·Ú·ÁˆÁ‹ ı˘ÌÈÎÒÓ ÔÚÌÔÓÒÓ.

MÂÌÔӈ̤Ó˜ ıÚÂÙÈΤ˜ Ô˘Û›Â˜ ¤¯Ô˘Ó ÌÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· ÙË ÛˆÛÙ‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. H ¤ÏÏÂÈ„‹ ÙÔ˘˜ ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙË ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ŒÙÛÈ, ÌÔÚ› Ó· Û˘Ì‚Â› ÚˆÙÔ·ı‹˜ ·ÓÔÛÔÏÔÁÈ΋ ‚Ï¿‚Ë ·fi ÌÂÌÔӈ̤ӷ ‰È·ÈÙËÙÈο ÂÏÏ›ÌÌ·Ù·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1.

OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó Ù· ÂÈÚ·Ì·Ùfi˙ˆ·, ÁÈ·Ù› ÌÔÚ› ÈÔ Â‡ÎÔÏ· Ó· ·Ê·ÈÚÂı› ·fi ÙÔ ‰È·ÈÙÔÏfiÁÈfi ÙÔ˘˜ Ì›· ‚ÈÙ·Ì›ÓË ‹ ¤Ó· ȯÓÔÛÙÔȯ›Ô. Y¿Ú¯Ô˘Ó, fï˜, ÏËÚÔÊÔڛ˜ Î·È Û¯ÂÙÈο Ì ÙÔÓ ¿ÓıÚˆÔ. °È· ·Ú¿‰ÂÈÁÌ·, Ë ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ A ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÏ·Ùو̤ÓË ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ‹ ‰È·Ù·Ú·¯¤˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ (4,5). ™Â ÌÂϤÙ˜ ·È‰ÈÒÓ ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, Ë Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ A ¤‰ÂÈÍ ӷ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒ͈Ó. H ÛȉËÚÔÂÓ›· Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi (6). ¶ÔÏϤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÙËÓ ·‡ÍËÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·fi ÏÔÈÌÒÍÂȘ Û ÛȉËÚÔÂÓÈÎÔ‡˜ ·ÛıÂÓ›˜ (7,8). ¶ÂÚÈÏËÙÈο, ÌÂϤÙ˜ ÛÙÔÓ ¿ÓıÚˆÔ Î·È Ù· ˙Ò· ¤‰ÂÈÍ·Ó: ·) MÂÌÔӈ̤Ó˜ ‹ ÔÏÏ·Ϥ˜ ÂÏÏ›„ÂȘ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó Ì¤ÙÚȘ - ‚·ÚȤ˜ ‚Ï¿‚˜ ÛÙËÓ ·ÓÔÛÔ·ÓÙ·fiÎÚÈÛË. ‚) ¢ÂÓ Â›Ó·È ÙÂÎÌËÚȈ̤ÓÔ Â¿Ó ÙÔ ÂÈϤÔÓ ıÚÂÙÈÎfi Û˘Ìϋڈ̷ ÚÔÛʤÚÂÈ Î¿ÙÈ ÛÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË, ÂÊ’ fiÛÔÓ ‰ÂÓ ˘¿Ú¯ÂÈ ‰È·ÈÙËÙÈÎfi ¤ÏÏÂÈÌÌ·.

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Á) ¢ÂÓ Â›Ó·È ·Û‡ÓËı˜ ÁÈ· ¤Ó· ·ÓÔÛÔÊ·Ú̷΢ÙÈÎfi ·Ú¿ÁˆÁÔ Ó· ÌÔÚ› Ó· ¤¯ÂÈ ‰ÈÏ‹ ‰Ú¿ÛË. ¢ËÏ·‰‹, Û ̛· ‰fiÛË Ó· Â›Ó·È ·ÓÔÛÔ‰ÈÂÁÂÚÙÈÎfi Î·È Û ̛· ˘„ËÏfiÙÂÚË ‰fiÛË Ó· Â›Ó·È ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi (3).

B) OÈ ÚÒÙ˜ ·Ú·ÙËÚ‹ÛÂȘ Ù˘ Ô˘ÛÈ·ÛÙÈ΋˜ ÚÔÛÊÔÚ¿˜ ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· ¤ÁÈÓ·Ó ÙÔ 1981, fiÙ·Ó Û NZB Î·È NZW ÔÓÙ›ÎÈ· Ì ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· ÙÔ˘ χÎÔ˘ ¯ÔÚËÁ‹ıËΠ‰È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÏÈ·Ú¿ Ôͤ·. T· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (9). AÎÔÏÔ‡ıËÛ·Ó ÂÈÚ¿Ì·Ù· Û ÌÔÓ٤Ϸ ÔÓÙÈÎÈÒÓ Ì ·ÚıÚ›Ùȉ· Ì ÙÔ ›‰ÈÔ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙË ÊÏÂÁÌÔÓ‹. T· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·, ÌÂϤÙ˜ in vivo Î·È in vitro Û ·ÛıÂÓ›˜ Ì PA ΢ڛˆ˜, ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ‰È·ÈÙËÙÈÎfi Û˘Ìϋڈ̷ Ì ˆ-3 ÏÈ·Ú¿ Ôͤ· ÌÔÚ› Ó· ·Ó·¯·ÈÙ›ÛÂÈ ÙÚÂȘ Ô‰Ô‡˜ Û‡ÓıÂÛ˘ ÏÈȉÈÎÒÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜: ·) ÙËÓ Ô‰fi Û‡ÓıÂÛ˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PAF), ‚) ÙËÓ Ô‰fi Ù˘ ΢ÎÏÔÔ͢ÁÂÓ¿Û˘, Á) ÙËÓ Ô‰fi Ù˘ 5-ÏÈÔÍÂÈÁÂÓ¿Û˘ (10). ¶·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌË, fï˜, ÂÚˆÙËÌ·ÙÈο ÁÈ· ÙÔ˘˜ ·ÎÚȂ›˜ Ì˯·ÓÈÛÌÔ‡˜ ‰Ú¿Û˘ ÙˆÓ ˆ-3 ÏÈ·ÚÒÓ ÔͤˆÓ, fiˆ˜ Â›Û˘ ÁÈ· ÙËÓ È‰·ÓÈ΋ ‰fiÛË, ÙË ‰È¿ÚÎÂÈ· ·ÁˆÁ‹˜ Î·È ÙÔ Û··ÛÌ·. OÈ ÌÂϤÙ˜ Û˘Ó¯›˙ÔÓÙ·È Î·È ›Ûˆ˜ ·Ô‰Âȯı› ÌÂÏÏÔÓÙÈο Ë ÛËÌ·Û›· Ù˘ Ú·ÎÙÈ΋˜ ÙÔ˘˜ ¯Ú‹Û˘ ÛÙ· ·˘ÙÔ¿ÓÔÛ· ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· (1,11). °) H Ó·ÓÈ΋ I‰ÈÔ·ı‹˜ ·ÚıÚ›Ùȉ· (NIA) Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÓfiÛÔ˜ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ ÛÙ· ·È‰È¿. AÓ Î·È ÂÚ›Ô˘ ÚÈÓ 100 ¯ÚfiÓÈ· ›¯Â ÂÈÛËÌ·Óı› Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙÔ ‡„Ô˜ ÙÔ˘˜ ·fi ÙÔÓ Dr. Still, ÂÓÙÔ‡ÙÔȘ, Û¯ÂÙÈο ÚfiÛÊ·Ù· Û˘Û¯ÂÙ›ÛÙËÎÂ Ë ÓfiÛÔ˜ Ì ÙË ‰È·ÈÙËÙÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË (12,13).

T· ‰È·ÈÙËÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ·È‰È¿ Ì NIA ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Î·È Û ·È‰È¿ Ì ¿ÏÏ· ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, ÂÂȉ‹ ˘¿Ú¯ÂÈ ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ Î·È Û˘ÌÌÂÙÔ¯‹ ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ. ™˘ÓÔÙÈο, ÔÈ Î‡ÚÈÔÈ ·Ú¿ÁÔÓÙ˜ (14,15) Ô˘

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Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·‡ÍËÛË ÎÈÓ‰‡ÓÔ˘ ˘ÔıÚ„›·˜ Û ·È‰È¿ Ì NIA Â›Ó·È ÔÈ ·ÎfiÏÔ˘ıÔÈ: ·) ·ÓÔÚÂÍ›· (ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›·), ‚) ·Ó·ÈÌ›· (¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹), Á) Ê¿Ú̷η Î·È ‰È·ÈÙËÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ, ‰) Ì˯·ÓÈΤ˜ ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘ Î·È Â) ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜.

H ·ÓÔÚÂÍ›· Â›Ó·È ÙÔ Î‡ÚÈÔ ‰È·ÈÙËÙÈÎfi Úfi‚ÏËÌ·, ΢ڛˆ˜ Û ÂÚÈfi‰Ô˘˜ ·˘ÍË̤Ó˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÚıÚÒÛˆÓ. ¶ÂÈÚ¿Ì·Ù· Û ˙Ò·, ·ÏÏ¿ Î·È ÛÙÔÓ ¿ÓıÚˆÔ, ¤‰ÂÈÍ·Ó fiÙÈ Û˘ÌÌÂÙ¤¯Ô˘Ó ÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜, fiˆ˜ IL-1 Î·È TNF (16). M›· ÛËÌ·ÓÙÈ΋ ·Ú·Ù‹ÚËÛË Â›Ó·È fiÙÈ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Ù· ÔÔ›· ‰ÂÓ ÚÔÛÏ·Ì‚¿ÓÔ˘Ó ıÂÚÌ›‰Â˜, ¯¿ÓÔ˘Ó ÌfiÓÔ ÏÈÒ‰Ë ÈÛÙfi. H ‰ÈÂÚÁ·Û›· ·˘Ù‹ ϤÁÂÙ·È ÌË ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›· (uncomplicated starvation). ™Ù· ·È‰È¿, fï˜, Ì ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, ÙÔ 50% ÙÔ˘ ¯·Ì¤ÓÔ˘ ‚¿ÚÔ˘˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ Ì˘˜ Î·È ÙÔ ˘fiÏÔÈÔ 50% ·fi ÙÔ Ï›Ô˜. H ÔÓÙfiÙ˘ ·˘Ù‹ ϤÁÂÙ·È ÂÈÂÏÂÁ̤ÓË ·ÛÈÙ›· (complicated starvation) (17).

H ·Ó·ÈÌ›· ÂÌÊ·Ó›˙ÂÙ·È Û˘¯Ó¿, ÔÏϤ˜ ÊÔÚ¤˜ Û ‚·ÚÈ¿ ÌÔÚÊ‹, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙË ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹. ™˘Ì‚¿ÏÏÂÈ Ë ÊÙˆ¯‹ ‰›·ÈÙ· Û ۛ‰ËÚÔ, Ë ‰Â˘ÙÂÚÔ·ı‹˜ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ·fi ÙÔ °E™ ÏfiÁˆ Ù˘ ¯Ú‹Û˘ ÙˆÓ M™Aº ·ÏÏ¿ Î·È ÏfiÁˆ ÂÓ·fiıÂÛ˘ Ûȉ‹ÚÔ˘ ÛÙÔ˘˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÚıÚÈÎÔ‡˜ ÈÛÙÔ‡˜. H Û˘ÌÌÂÙÔ¯‹ Ù˘ ÎÚÔÙ·ÊÔÁÓ·ıÈ΋˜ ¿ÚıÚˆÛ˘, Ë ˘ÔÏ·Û›· Ù˘ οو ÁÓ¿ıÔ˘ ·ÏÏ¿ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÙˆÓ Î·ÚÒÓ ÂÈ‚·Ú‡ÓÔ˘Ó ÙȘ ‰˘ÛÎÔϛ˜ Ù˘ Û›ÙÈÛ˘ (18).

H ˘ÔıÚ„›· ÚˆÙÂ˚ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (PEM) ·ÁÁ›˙ÂÈ ÙÔ 50% ÙˆÓ ·È‰ÈÒÓ Ì NIA Î·È ÂÌÊ·Ó›˙ÂÙ·È Û ·È‰È¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ΢ڛˆ˜ ÌÔÚÊ‹ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ÂÓÂÚÁfiÙËÙ· Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÂÈÂÏÂÁ̤Ó˘ ˘ÔıÚ„›·˜ Â›Ó·È ÌÂÁ¿ÏÔ˜, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÂÌÊ·Ó‹ ÛËÌ›· ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘ÔıÚ„›·˜. OÈ ÌÂÙÚ‹ÛÂȘ Ù˘ ÚÔ·Ï‚Ô˘Ì›Ó˘ Î·È Ù˘ Û˘Ó‰Â‰Â̤Ó˘ ÚÂÙÈÓfiÏ˘ Â›Ó·È ÚÒÈÌÔÈ Î·È Â˘·›ÛıËÙÔÈ ‰Â›ÎÙ˜ Ì›·˜ ÂÌÊ·ÓÈ˙fiÌÂÓ˘ ¤ÏÏÂȄ˘ ÚˆÙ½Ó˘. E›Ó·È ηχÙÂÚÔÈ ‰Â›ÎÙ˜ ·' fiÙÈ Ë Ì¤ÙÚËÛË ·Ï‚Ô˘Ì›Ó˘.

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OÈ ÙÈ̤˜ Ù˘ ÚÂÙÈÓfiÏ˘ Î·È Ù˘ ÚÔ·Ï‚Ô˘Ì›Ó˘ Â›Ó·È ¯·ÌËϤ˜ Û ˘ÔıÚÂÊfiÌÂÓ· ·È‰È¿ Ì NIA Î·È Ë ÊÏÂÁÌÔÓ‹ Ù˘ ÓfiÛÔ˘ Â›Ó·È ÂÓ Ì¤ÚÂÈ ˘‡ı˘ÓË ÁÈ· ÙËÓ ÂÎÙÚÔ‹ Ù˘ Û‡ÓıÂÛ˘ ÚˆÙÂ˚ÓÒÓ ·fi ÙÔ ‹·Ú ÚÔ˜ ÙËÓ ·Ú·ÁˆÁ‹ ÔÍ›·˜ Ê¿Ûˆ˜ ·ÓÙȉڷÛÙÈÎÒÓ Ô˘ÛÈÒÓ (19). °È· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi ¯ˆÚ›˜ ȉȷ›ÙÂÚ˜ ÁÓÒÛÂȘ ‰È·ÈÙËÙÈ΋˜, Ì›· ·Ï‹ ÏËı˘ÛÌȷ΋ ‰ÔÎÈÌ·Û›· (screening test) Ì ÙȘ ·Ú·Î¿Ùˆ 4 ·Ú·Ì¤ÙÚÔ˘˜ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÂÈÛ‹Ì·ÓÛË Ì›·˜ ˘ÔıÚ„›·˜: (·) B¿ÚÔ˜ (·ıÔÏÔÁÈÎfi < 5Ë E£), (‚) B¿ÚÔ˜/‡„Ô˜ (·ıÔÏÔÁÈÎfi <80%), (Á) ¶ÂÚ›ÌÂÙÚÔ˜ ‚Ú·¯›ÔÓ· (·ıÔÏÔÁÈÎfi <5Ë E£), (‰) §Â˘ÎˆÌ·Ù›ÓË ÔÚÔ‡ (<3,5 g%). ∏ ·ÚÔ˘Û›· ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·Ú·Ì¤ÙÚˆÓ ·ıÔÏÔÁÈÎÒÓ ‰ËÏÒÓÂÈ ˘ÔıÚ„›·.

TÔ ∞ÌÂÚÈηÓÈÎfi ÎÔÏϤÁÈÔ Ù˘ PÂ˘Ì·ÙÔÏÔÁ›·˜ (20) ¤¯ÂÈ ¿ÚÂÈ ÔÚÈṲ̂Ó˜ ı¤ÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÂÈÛÙËÌÔÓÈÎfi ‰›Ô “‰›·ÈÙ· - ·ÚıÚ›Ùȉ·”. AӷʤÚÂÈ fiÙÈ, ÂÓÒ ÌÂÚÈο ‰È·ÈÙËÙÈο ·Ú¿ÁˆÁ· ÌÔÚ› Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹, ÂÓÙÔ‡ÙÔȘ ‰È·ÈÙËÙÈΤ˜ ıÂÚ·›˜ ÁÈ· ·ÚıÚ›Ùȉ· Â›Ó·È Û ÂÈÚ·Ì·ÙÈÎfi ·ÎfiÌË ÛÙ¿‰ÈÔ. °È’ ·˘Ùfi ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È Û ÈÛÔÚÚÔË̤Ó˜ Î·È ˘ÁÈÂÈÓ¤˜ ‰›·ÈÙ˜ Î·È Ó· ·ÔʇÁÔ˘Ó Ù· ÂÍ·ÓÙÏËÙÈο Î·È “ȉÈfiÙ˘·” ‰È·ÈÙÔÏfiÁÈ·. ∞˘Ùfi ÙÔ ‰›Ô Ù˘ I·ÙÚÈ΋˜ ÂÈÛÙ‹Ì˘ Â›Ó·È ¤Ó·˜ ·ÓÔȯÙfi˜ ÔÚ›˙ÔÓÙ·˜ Ì ÌÂÁ¿Ï˜ ÚÔÔÙÈΤ˜, fiÛÔÓ ·ÊÔÚ¿ ÙË Û˘Û¯¤ÙÈÛË ÙÚÔÊÈÎÒÓ ·ÓÙÈÁfiÓˆÓ ‹ ‰È·ÈÙËÙÈÎÒÓ ÚÔÙ‡ˆÓ Ì ÙË ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ Î·È ÙËÓ Î·Ï‡ÙÂÚË ÁÓÒÛË ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Henderson JC, Panuch SR. Diets, dietary supplements and nutritional therapies in rheumatic diseases. Rheum Dis Clin North Am 1999;25:937-968.

2. Corman LC. Effects of specific nutrients on the immune response. Med Clin North Am 1985;69:759-791.

3. Delafuente CJ. Nutrients and Immune responses. Rheum Dis Clin North Am 1991;17:203-212.

4. Cohen BE, Elin RJ. Vitamin A induced nonspecific resistance to infection. J Infet Dis 1974;129:597-600.

5. Krishman S, Bhuyan UN, Talwar GP, Ramalingaswami V. Effect of vitamin A and protein-calorie undernutrition on immune responses. Immunology 1974;27:383-392.

6. Hussey GD, Klein M. A randomized controlled trial of vitamin A in children with severe measles. N Engl J Med 1990;323:160-164.

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7. De Sousa MD. Immune cell functions in iron overload. Clin Exp Immunol 1989;75:1-6.

8. Dhur A, Galan P, Hercberg S. Iron status, immune capacity and resistance to infections. Comp Biochem Physiol 1989:94:11-19.

9. Robinson RD. Alleviation of autoimmune disease by dietary lipids containing omega-3 fatty acids. Rheum Dis Clin North Am 1991;17:213-222.

10. Von Schacky C, Siess W, Fischer S, Weber PC. A comparative study of eicosapentaenoic acid metabolism by human platelets in vivo and in vitro. J Lipid Res 1985;26:457-464.

11. Van der Tempel H, Tulleken JE, Limbury PC, Muskief FA, van Rijswijk MH. Effects of fish-oil supplementation in rheumatoid arthritis. Ann Rheum Dis 1990;49:76-80.

12. Hangen MA, Hoyeraal HM, Larsen S, Gilboe IM, Trygg K. Nutrient intake and nutritional status in children with juvenile chronic arthritis. Scand J Rheumatol 1992;21:165-170.

13. Ostrov BE. Nutrition and pediatric rheumatic diseases.

Hypothesis: cytokines modulate nutritional abnormalities in rheumatic diseases. J Rheumatol 1992;19(33 Suppl):49-53.

14. Knops N, Wulffraat N, Lodder S, Honwen R, Kees de Meer. Resting energy expenditure and nutritional status in children with juvenile rheumatoid arthritis. J Rheumatol 1999;26:2039-2043.

15. Henderson CJ, Lovell JD. Nutritional aspects of juvenile rheumatoid arthritis. Rheum Dis Clin North Am 1991;17:403-413.

16. Tracey KJ, Wei H, Manogue KR. Cachectin/tumor necrosis factor induces cachexia, anemia and inflammation. J Exp Med 1988;167:1211.

17. Miller ML, Chacko JA, Young EA. Dietary deficiencies in children with juvenile rheumatoid arthritis. Arthritis Care Res 1989;2:22-24.

18. Garceau AO, Dwyer JT, Holland M. A practical approach to nutrition in the patient with juvenile rheumatoid arthritis.

Clinical Nutrtition 1989;8:55-64.

19. Henderson CJ, Lovell JD. Assesment of protein-energy malnutrition in children and adolescents with juvenile rheumatoid arthritis. Arthritis Care Res 1989;2:108-113.

20. Panuch SR. American College of Rheumatology. Position statement: Diet and arthritis. Rheum Dis Clin North Am 1991;17:443-447.

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NEPHROLOGY

¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘: ÂÎÙ›ÌËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË ∫. ¢. ∫ÔÏÏÈfi˜

Prenatal diagnosis of hydronephrosis: fetal assessment and postnatal follow-up K. D. Kollios

¶ÂÚ›ÏË„Ë: °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ÂÌ‚Ú˘˚΋˜ ˘Ó‰ÚÔÓ¤ÊÚˆÛ˘ Î·È ÂÍÂÙ¿˙ÂÙ·È Ë Û˘¯ÓfiÙËÙ·, Ë ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÔÈ ‰È¿ÊÔÚ˜ ·Èٛ˜ Ô˘ ÙËÓ ÚÔηÏÔ‡Ó. ∂ÍÂÙ¿˙ÔÓÙ·È Í¯ˆÚÈÛÙ¿ Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ËÏÈΛ· Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ ÙˆÓ ÓÂÊÚÒÓ (̤ÙÚËÛË Ù˘ ÚÔÛıÈÔ-Ô›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘). °›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÛÙÔÓ ·Ú¯ÈÎfi ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ηıÒ˜ Î·È ÛÙÔÓ ÙÚfiÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· Ù· ÂfiÌÂÓ· ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË. °È· ÙȘ ÂÚÈÙÒÛÂȘ ÂÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ·Ó·Ù‡ÛÛÔÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· Ì ‚¿ÛË Ù· ÔÔ›· ı· ÂÈÏÂÁ› Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË. AÓÙ›ıÂÙ·, ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ÂÈÛËÌ·›ÓÔÓÙ·È ÔÈ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È Û˘˙ËÙÔ‡ÓÙ·È ÔÈ ÚfiÛÊ·Ù˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ Î·È ÙȘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘ (΢ÛÙÂÔ·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›·).

Abstract: A review of the incidence, pathophysiology and the underlying etiologic factors of fetal hydronephrosis is presented. A detailed analysis follows regarding the criteria that are used to establish the diagnosis during fetal life and in the postnatal period, which are primarily based on the ultrasonographic measurements of the anteroposterior diameter of the renal pelvis. The initial radiologic evaluation that must be performed at birth and the studies required during follow-up are fully discussed. Finally, the criteria for selecting between conservative or surgical intervention during fetal life are presented. For cases of unilateral hydronephrosis the indications for surgical intervention after birth are clear-cut and easy to follow. However, for bilateral fetal hydronephrosis, the adverse effects of hydronephrosis on the fetal kidney and the lungs are underlined, and the current knowledge on the limitations as well as the reservations regarding the efficacy of fetal surgical intervention (vesicoamniotic shunt) are discussed.

§¤ÍÂȘ ÎÏÂȉȿ: ÂÌ‚Ú˘˚΋ ˘‰ÚÔÓ¤ÊÚˆÛË, ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË, ˘¤Ú˯ÔÈ, ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË.

Key words: fetal hydronephrosis, prenatal diagnosis, ultrasonography, prenatal intervention.

∏ ¢Ú›· ÂÊ·ÚÌÔÁ‹ ÙˆÓ ˘ÂÚ‹¯ˆÓ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 ÛËÌ·ÙÔ‰fiÙËÛ ÙËÓ ··Ú¯‹ Ì›·˜ Ó¤·˜ ÂÔ¯‹˜ ÛÙË ‰È¿ÁÓˆÛË Î·È ÚÔÛ¤ÁÁÈÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÓÂÊÚÔ‡ Î·È Ù˘ ·Ô¯ÂÙ¢ÙÈ-

΋˜ Ô˘ÚÔÊfiÚÔ˘ Ô‰Ô‡. ªÂ ÙË Û˘ÓÂÚÁ·Û›· ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ (Ì·ÈÂ˘Ù‹ÚˆÓ, ÓÂÔÁÓÔÏfiÁˆÓ, ·È‰ÔÓÂÊÚÔÏfiÁˆÓ, ·È‰ÔÔ˘ÚÔÏfiÁˆÓ, ·ÎÙÈÓÔÏfiÁˆÓ Î·È ˘ÚËÓÈÎÒÓ È·ÙÚÒÓ) ¤¯ÂÈ ·ÔÎÙËı›

∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ

Department of Pediatrics Division of Pediatric Nephrology University of Ioannina Medical School

241

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·242

¶·È‰È·ÙÚÈ΋ 2001;64:241-246

ÛËÌ·ÓÙÈ΋ ÂÌÂÈÚ›· ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ Î¤ÓÙÚÔ ‚¿ÚÔ˘˜ Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Ó· ¤¯ÂÈ ϤÔÓ ÌÂÙ·ÙÔÈÛÙ› ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· ÛÙÔ ¤Ì‚Ú˘Ô Î·È ÙÔ ÓÂÔÁÓfi. ∆· ‚·ÛÈο ÂÚˆÙ‹Ì·Ù· Ô˘ Ù›ıÂÓÙ·È ÛÙȘ ÂÚÈÙÒÛÂȘ ÚÔÁÂÓÓËÙÈ΋˜ Î·È ÓÂÔÁÓÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Â›Ó·È Ù· ·Ú·Î¿Ùˆ (1): ·) ªÂ ÔÈ· ÎÚÈÙ‹ÚÈ· ÔÚ›˙ÂÙ·È Ë ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘; ‚) ¶ÔȘ Â›Ó·È ÔÈ ÂÈÙÒÛÂȘ ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÔÈ· Â›Ó·È Ë Ê˘ÛÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘; Á) ¶fiÙ ¯ÚÂÈ¿˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË Î·È fiÙ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ‰) À¿Ú¯ÂÈ ÙÚfiÔ˜ ‰È¿ÎÚÈÛ˘ ÌÂٷ͇ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ı· ‚ÂÏÙȈıÔ‡Ó ¯ˆÚ›˜ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË Î·È ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ı· ÂȉÂÈÓˆıÔ‡Ó ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈο; ™ÙËÓ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ı· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ·, ÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· Î·È ÙË Ê˘ÛÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÛÙÔÓ ÚÔÙÂÈÓfiÌÂÓÔ ‰È·ÁÓˆÛÙÈÎfi ¤ÏÂÁ¯Ô, ηıÒ˜ Î·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË Ô˘ ··ÈÙ›ٷÈ. ∆¤ÏÔ˜, ı· ÂÈÛËÌ·ÓıÔ‡Ó, Ì ‚¿ÛË Ù· Û‡Á¯ÚÔÓ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ÔÈ ÂӉ›ÍÂȘ ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘. ™˘¯ÓfiÙËÙ· ∏ ˘‰ÚÔÓ¤ÊÚˆÛË Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÓˆÌ·Ï›· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (50%) ·fi ·˘Ù¤˜ Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È Ì ˘¤ÚË¯Ô˘˜ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ËÏÈΛ· (2). ™‡Ìʈӷ Ì ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ ·Ó¤Ú¯ÂÙ·È Û 1 ·Ó¿ 100 ΢‹ÛÂȘ, ÔÈ ÛÔ‚·Ú¤˜ fï˜ ÂÚÈÙÒÛÂȘ Â›Ó·È Ôχ ÏÈÁfiÙÂÚ˜ Î·È ÊÙ¿ÓÔ˘Ó ÙȘ 1 ·Ó¿ 500 ΢‹ÛÂȘ (3,4). ∞ÎfiÌË, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ù· Â˘Ú‹Ì·Ù· Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÂÈ̤ÓÔ˘Ó Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÛÙȘ ÌÈÛ¤˜ ÂÚ›Ô˘ ÂÚÈÙÒÛÂȘ (5). ¶·ıÔÊ˘ÛÈÔÏÔÁ›· OÈ Û˘Ó¤ÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› ÂÚÈÛÛfiÙÂÚÔ Û ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ·. ∏ Û˘ÌÌÂÙÔ¯‹ Ù˘ ·˘ÍË̤Ó˘ ˘‰ÚÔÛÙ·ÙÈ΋˜ ›ÂÛ˘, ÏfiÁˆ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ‰ÂÓ ÂÍËÁ› ÈηÓÔÔÈËÙÈο ÙË ÓÂÊÚÈ΋ ‚Ï¿‚Ë Ô˘ ÚÔ·ÙÂÈ. ™ÙÔ ÓÂÊÚfi Ì ˘‰ÚÔÓ¤ÊÚˆÛË ¤¯ÂÈ ÂÈÛËÌ·Óı› Ô ÚfiÏÔ˜ Ù˘ ÚÂÓ›Ó˘, ·ÁÁÂÈÔÙÂÓÛ›Ó˘ Î·È ıÚÔÌ‚ÔÍ¿Ó˘ ∞2, ÂÓÒ ÛÙÔÓ ˘ÁÈ‹ ÓÂÊÚfi ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙˆÓ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ Ô˘ÛÈÒÓ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ PG∂2 Î·È PGI2, ÙˆÓ ÎÈÓÈÓÒÓ Î·È ÙÔ˘ ÎÔÏÈÎÔ‡ Ó·ÙÚÈÔÔ˘ÚËÙËÚÈÎÔ‡ ÂÙȉ›Ô˘ (6).

242

Paediatriki 2001;64:241-246

OÈ ÂȉڿÛÂȘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÊÔÚÔ‡Ó ÙfiÛÔ ÙÔ ÓÂÊÚÈÎfi Û›ڷ̷, ÌÂ Û˘Ó¤ÂÈ· ÙË ÌÂȈ̤ÓË ÓÂÊÚÔÁ¤ÓÂÛË Î·È ÙË Û˘Ó·ÎfiÏÔ˘ıË ÌÂȈ̤ÓË ·‡ÍËÛË ÙÔ˘ ÓÂÊÚÔ‡, fiÛÔ Î·È ÙÔ ÓÂÊÚÈÎfi ÛˆÏËÓ¿ÚÈÔ, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂÙ·ÌfiÚʈÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ÌÂÛÂÁ¯˘Ì·ÙÈο, ÙËÓ ·fiÙˆÛË ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ (7). °È· ÙËÓ ÂΉ‹ÏˆÛË ·˘ÙÒÓ ÙˆÓ ÂȉڿÛÂˆÓ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÂÙ·ÌfiÚʈÛ˘ ‚1 (TGF - ‚1), ηıÒ˜ ¤¯ÂÈ ‚ÚÂı› ·˘ÍË̤ÓË ¤ÎÊÚ·Û‹ ÙÔ˘ Û ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ·, ÛÙ· ÔÔ›· ÚÔÎÏ‹ıËΠ·fiÊÚ·ÍË ÙÔ˘ Ô˘ÚËÙ‹Ú· (7). ∞ÈÙÈÔÏÔÁ›· ¢Â‰Ô̤ÓÔ˘ fiÙÈ Ë ·ÚÔ˘Û›· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È ¿ÓÙÔÙ Ì ÙËÓ ‡·ÚÍË ·fiÊڷ͢, ÌÔÚԇ̠ӷ Ù·ÍÈÓÔÌ‹ÛÔ˘Ì ÙȘ ‰È¿ÊÔÚ˜ ·Èٛ˜ Û ÌË ·ÔÊÚ·ÎÙÈΤ˜ Î·È Û ·ÔÊÚ·ÎÙÈΤ˜. ¶·Ú·‰Â›ÁÌ·Ù· ÙˆÓ ÌË ·ÔÊÚ·ÎÙÈÎÒÓ ·ÈÙÈÒÓ Â›Ó·È: Ë Ê˘ÛÈÔÏÔÁÈ΋ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ·ÚÔ˘Û›· ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (∫O¶) Î·È Ë ÌÂÁ·Î·Ï‡ÎˆÛË (2). ™ÙȘ ·ÔÊÚ·ÎÙÈΤ˜ ·Èٛ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È, Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ·, Ë ÛÙ¤ÓˆÛË Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ (44%) Î·È Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜ (21%) Î·È ·ÎÔÏÔ˘ıÔ‡Ó, Ì ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ·, Ô ÏÂÈÔ΢ÛÙÈÎfi˜ ÓÂÊÚfi˜, Ë Ô˘ÚËÙËÚÔ΋ÏË Î·È Ô ¤ÎÙÔÔ˜ Ô˘ÚËÙ‹Ú·˜, ÔÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ (9%) Î·È Ë ·ÙÚËÛ›· Ù˘ Ô˘Ú‹ıÚ·˜ (2). ∞fi ÙËÓ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÚÔ·ÙÂÈ fiÙÈ Ë ∫O¶ ¢ı‡ÓÂÙ·È ÁÈ· ¤Ó· ÔÛÔÛÙfi ÂÚ›Ô˘ 20% ÙˆÓ ÚÔÁÂÓÓËÙÈÎÒÓ ‰È·Ù¿ÛˆÓ, ÂÓÒ ¿ÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (·ÔÊÚ·ÎÙÈ΋˜ ‹ ÌË ·ÔÊÚ·ÎÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜) ηχÙÔ˘Ó ¤Ó· ÔÛÔÛÙfi ÂÚ›Ô˘ 40% Ì 50%, Ì ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÙË ÛÙ¤ÓˆÛË Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜. ªÂϤÙË Ô˘ ¤ÁÈÓ ÛÙËÓ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ Î·Ù¿ ÙËÓ ÙÂÙÚ·ÂÙ›· 1996-1999, ÂÚȤϷ‚ 51 ÂÚÈÙÒÛÂȘ ÓÂÔÁÓÒÓ Î·È ‚ÚÂÊÒÓ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘ (8). ¢È·ÈÛÙÒıËÎ·Ó Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û ÔÛÔÛÙfi 37%, ÂÓÒ ∫O¶ ‰È·ÈÛÙÒıËΠÛÙÔ 24% ÙˆÓ ÂÚÈÙÒÛˆÓ. ÕÏϘ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ÂÎÙfi˜ Ù˘ ∫O¶, ‰È·ÈÛÙÒıËÎ·Ó Û 20 ·fi ÙȘ 51 ÂÚÈÙÒÛÂȘ (ÔÛÔÛÙfi 39%) (8). º˘ÛÈ΋ ÔÚ›· ∏ Ê˘ÛÈ΋ ÔÚ›· Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ù· ·ÎfiÏÔ˘ı·: ·) ˘Ô¯ÒÚËÛË, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ,

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‚) Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·fiÊÚ·ÍË, Û ÌÈÎÚfi ÔÛÔÛÙfi, Á) ·fiÊÚ·ÍË, ·Ú’ fiÏÔ Ô˘ Ô ·Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÌÔÚ› Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜. ™Â ÌÂϤÙ˜, ηٿ ÙȘ Ôԛ˜ ¤ÁÈÓ ٷÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Û ÓÂÔÁÓ¿ Ô˘ ηٿ ÙË Á¤ÓÓËÛË ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡, ‰È·ÈÛÙÒıËΠfiÙÈ Û ̷ÎÚÔ¯ÚfiÓÈ· ‚¿ÛË ¯ÚÂÈ¿ÛÙËΠӷ Á›ÓÂÈ ˘ÂÏÔÏ·ÛÙÈ΋ ÛÙÔ 7% ¤ˆ˜ 23% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÏfiÁˆ Ì›ˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ÂÍÂÏ›¯ıËΠÌÂÙ·ÁÂÓ¤ÛÙÂÚ· (9,10). ∂Ô̤ӈ˜, ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ Î·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Û fiÏ· Ù· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË, ÛÙ· ÔÔ›· ¤¯ÂÈ ÙÂı› ÚÔÁÂÓÓËÙÈο Ë ‰È¿ÁÓˆÛË Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘. ¶ÚÔÁÂÓÓËÙÈ΋ ˘‰ÚÔÓ¤ÊÚˆÛË: ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ ∆· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÂÌ‚Ú˘˚΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ‚·Û›˙ÔÓÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ Ì ÙË Ì¤ÙÚËÛË Ù˘ ÚÔÛıÈÔ›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘. ™‡Ìʈӷ Ì ÙÔÓ Corteville Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ (11), ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Ì ˘¤ÚË¯Ô˘˜ ı· Ú¤ÂÈ Ë ÚÔÛıÈÔ›ÛıÈ· ‰È¿ÌÂÙÚÔ˜ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ Ó· ›ӷÈ: i) >4 mm, ÚÈÓ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ ‹ ii) >7 mm, ÌÂÙ¿ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘. ∫·Ù’ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ, ·ÓȯÓ‡ÔÓÙ·È fiϘ ÔÈ ÂÚÈÙÒÛÂȘ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ (¢·ÈÛıËÛ›· 100%). ¶·Ú’ fiÏ· ·˘Ù¿, ÙÔ ÔÛÔÛÙfi „¢‰ÒÓ ıÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 55% Î·È 21% ·ÓÙ›ÛÙÔȯ·, ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ 33Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ (11). ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ∏ ·Ú¯È΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ Î¿ÙˆıÈ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô: 1) À¤ÚË¯Ô˘˜ (U/S), ÙËÓ 4Ë - 7Ë Ë̤ڷ ˙ˆ‹˜ Î·È fi¯È ÓˆÚ›ÙÂÚ·, ¤ÙÛÈ ÒÛÙ ӷ ·ÔÊ¢¯ıÔ‡Ó „¢-

‰Ò˜ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ‰ÈÔ‡ÚËÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ (12). H ÂÎÙ›ÌËÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ Á›ÓÂÙ·È Ì ‚¿ÛË: ·) ÙËÓ ÚÔÛıÈÔ›ÛıÈ· ‰È¿ÌÂÙÚÔ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘, ‚) ÙË ‰È¿Ù·ÛË ÙˆÓ Î·Ï‡ÎˆÓ Î·È Á) ÙËÓ ·ÚÔ˘Û›· ·ÙÚÔÊ›·˜ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì·. ™ÙËÓ ÚfiÛÊ·ÙË Ù·ÍÈÓfiÌËÛË ÙÔ˘ Rascher 1998 (¶›Ó·Î·˜ 1), Ô ÌÈÎÚfiÙÂÚÔ˜ ‚·ıÌfi˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÓÙÈÛÙÔȯ› Û ‰È¿Ù·ÛË Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ¤ˆ˜ 10 mm, ÂÓÒ Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ (‚·ıÌfi˜ V) ·ÓÙÈÛÙÔȯ› Û ‰È¿Ù·ÛË >15 mm, Ô˘ ÂÈϤÔÓ Û˘Óԉ‡ÂÙ·È Ì ‚·ÚÈ¿ ‰È¿Ù·ÛË ÙˆÓ Î·Ï‡ÎˆÓ Î·ıÒ˜ Î·È ·ÙÚÔÊ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÊÏÔÈÔ‡ (13).

2) ∫˘ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›·, ÙËÓ 4Ë - 6Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜. ™‡Ìʈӷ Ì ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜, Ô ¤ÏÂÁ¯Ô˜ Ì ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ÂӉ›ÎÓ˘Ù·È Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ, ÂÓÒ Î·Ù’ ¿ÏÏÔ˘˜ ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ fiÙ·Ó Ô ÚÒÙÔ˜ ÌÂÙ·ÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ˘¤ÚË¯Ô˘˜ Â›Ó·È ·ıÔÏÔÁÈÎfi˜ (12).

3) ¢ÈÔ˘ÚËÙÈÎfi ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· (DTPA ‹ Mag-3), ÂÎÙÈÌÒÓÙ·˜ ÙȘ ·ÎfiÏÔ˘ı˜ ·Ú·Ì¤ÙÚÔ˘˜: ·) ÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ηıÒ˜ Î·È ÙËÓ ÂηÙÔÛÙÈ·›· Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ οı ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ‚) ÙËÓ ·ÚÔ˘Û›· ·fiÊڷ͢, ÌÂÏÂÙÒÓÙ·˜ ÙËÓ Î·Ì‡ÏË ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜ (Lasix). Œ¯ÂÈ ÚÔÙ·ı› ÔÌfiʈӷ ·fi fiÏÔ˘˜ ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ fiÙÈ ˆ˜ ‚·ÛÈΤ˜ Û˘Óı‹Î˜ Î·È ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙË ÛˆÛÙ‹ ÂÚÌËÓ›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ıˆÚÔ‡ÓÙ·È: ·) Ë Â·Ú΋˜ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ‚) Ë ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜ ÛÙ· 20 min ÌÂÙ¿ ÙËÓ ¤ÓÂÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È Á) Ë ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË, fiÙ·Ó ˘¿Ú¯ÂÈ ˘Ô„›· ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ‹ ÌÂÁ·Ô˘ÚËÙ‹Ú· (14). ™ÙÔÓ ¶›Ó·Î· 2 ÂÚÈÁÚ¿ÊÂÙ·È ÙÔ ÚˆÙfiÎÔÏÏÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÓÂÔÁÓÒÓ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘, fiˆ˜ ·˘Ùfi ÚÔÙ›ÓÂÙ·È Î·È ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ O˘ÚÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Great Ormond Street ÙÔ˘ §ÔÓ‰›ÓÔ˘ (15) Î·È ÙÔ ÔÔ›Ô ‚·Û›˙ÂÙ·È

¶›Ó·Î·˜ 1. T·ÍÈÓfiÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÌÂÙ¿ ÙË Á¤ÓÓËÛË (Rascher, 1998) (13) µ·ıÌfi˜

M¤ÁÂıÔ˜ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ (mm)

¢È¿Ù·ÛË Î·Ï‡ÎˆÓ

NÂÊÚÈÎfi ·Ú¤Á¯˘Ì·

π

10

-

ÎÊ

ππ

10-15

-

>>

πππ

>15

∂Ï·ÊÚ¿

>>

IV

>>

ª¤ÙÚÈ·

>5 mm

V

>>

µ·ÚÈ¿

<5 mm ·ÙÚÔÊ›· ÊÏÔÈÔ‡

243

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¶›Ó·Î·˜ 2. ¶ÚˆÙfiÎÔÏÏÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÛÙ· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ·Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ‰È¿Ù·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ηٿ ÙË Á¤ÓÓËÛË (¶ÚˆÙfiÎÔÏÏÔ Great Ormond Street Hospital) (15) XÚfiÓÔ˜ Î·È ÙÚfiÔ˜ ÂͤٷÛ˘ ¶ÚÔÛıÈÔ-Ô›ÛıÈ· ‰È¿ÌÂÙÚÔ˜ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘

U/S ÓÂÊÚÒÓ

¢˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Tc-DTPA ‹ Mag-3

<12 mm

3Ô˜ Ì‹Ó·˜ Î·È 1Ô, 2Ô, 5Ô, & 10Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜

+/-*

13-19 mm

>>

3Ô˜ Ì‹Ó·˜ Î·È 1Ô, 2Ô, 5Ô, & 10Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜

>20 mm

1Ô˜, 3Ô˜, 6Ô˜ Ì‹Ó·˜ Î·È 1Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜. ™ÙË Û˘Ó¤¯ÂÈ· οı 12 Ì‹Ó˜

1Ô˜, 3Ô˜, 6Ô˜ Ì‹Ó·˜ Î·È 1Ô ¤ÙÔ˜ Ù˘ ˙ˆ‹˜. ™ÙË Û˘Ó¤¯ÂÈ· οı 12 Ì‹Ó˜

* ™Â ‰È¿Ù·ÛË <12mm, Ùo Mag-3 ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ ÂÎÙfi˜: ·) ·Ó ·Ú·ÙËÚËı› ·‡ÍËÛË Ù˘ ‰È¿Ù·Û˘ Î·È ‚) fiÙ·Ó Ë ¯Ú‹ÛË Ù˘ Á›ÓÂÙ·È ˆ˜ ‚·ÛÈ΋ ÂͤٷÛË.

ÛÙȘ ‰È·ÛÙ¿ÛÂȘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘: ·) ¤ÏÂÁ¯Ô˜ ÌfiÓÔ Ì U/S, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ Â›Ó·È <12 mm, ‚) ¤ÏÂÁ¯Ô˜ Ì U/S Î·È ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÓ 3Ô Ì‹Ó· ˙ˆ‹˜, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ˘¤ÏÔ˘ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 13-19 mm, Á) ¤ÏÂÁ¯Ô˜ Ì U/S Î·È ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÛÙÔÓ 1Ô Ì‹Ó· ˙ˆ‹˜, fiÙ·Ó Ë ‰È¿Ù·ÛË Ù˘ ˘¤ÏÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi 20 mm. ∞ÓÙÈÌÂÙÒÈÛË °È· ÙËÓ ÚfiÏË„Ë Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Û˘ÓÈÛÙ¿Ù·È ·ÓÙÈ‚ÈÔÙÈ΋ ÚÔʇϷÍË. ∞Ú¯Èο, Ë ·ÌÔ͢ÎÈÏÏ›ÓË Â›Ó·È ÙÔ ·ÓÙÈ‚ÈÔÙÈÎfi ÂÎÏÔÁ‹˜, Ô˘ ÌÂÙ¿ ·fi ÙÔ 2Ô Ì‹Ó· ˙ˆ‹˜ ÌÔÚ› Ó· ·ÓÙÈηٷÛÙ·ı› Ì ÙÚÈÌÂıÔÚÚ›ÌË - ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË (12). ∫·Ù¿ Ù· ¿ÏÏ·, Ë ·ÓÙÈÌÂÙÒÈÛË ı· ÂÍ·ÚÙËı› ·fi ÙËÓ ·ÈÙ›· Ô˘ ÚÔηÏ› ÙËÓ ˘‰ÚÔÓ¤ÊÚˆÛË. ™ÙȘ ·Èٛ˜ Ô˘ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ¿ÌÂÛË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ‚·Ï‚›‰Â˜ Ù˘ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, Ì ÛÎÔfi Ó· ·ÔηٷÛÙ·ı› Ë ÚÔ‹ ÙˆÓ Ô‡ÚˆÓ Î·È Ó· ÚÔÏËÊı› Ë ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.

EÙÂÚfiÏ¢ÚË ˘‰ÚÔÓ¤ÊÚˆÛË ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰‡Ô ·ÚÈˆÓ ·ÈÙ›ˆÓ ÂÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ‹ÙÔÈ Ù˘ ÛÙ¤ÓˆÛ˘ Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Î·È Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, ÛÙËÚ›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Ô˘ ı· ‰ÒÛÂÈ ·¿ÓÙËÛË: ·) ÛÙËÓ ‡·ÚÍË ‹ ÌË ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ηÌ‡Ï˘ ÙÔ˘ ÓÂÊÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ‚) ÛÙÔ ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ŸÙ·Ó Ë Î·Ì‡ÏË ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È ·ÔÊÚ·ÎÙÈ-

244

ÎÔ‡ Ù‡Ô˘, ÙfiÙ ·Ó¿ÏÔÁ· Ì ÙÔ ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÚÔÙ¿ÛÛÂÙ·È Ë ·ÎfiÏÔ˘ıË ·ÓÙÈÌÂÙÒÈÛË (15): ·) ÓÂÊÚÂÎÙÔÌ‹, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È <10% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ‚) ˘ÂÏÔÏ·ÛÙÈ΋, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È ÌÂٷ͇ 10% Î·È 30% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Á) ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË, fiÙ·Ó Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ Â›Ó·È >30% Ù˘ ÔÏÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™ÙËÓ ÔÚ›· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓfi˜ ·È‰ÈÔ‡ Ì ˘‰ÚÔÓ¤ÊÚˆÛË fiÙ·Ó Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È ·ÌÊ›‚ÔÏ· ‹ ·Û·Ê‹, Ë ÂÈÏÔÁ‹ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· Û˘Ìو̿وÓ, fiˆ˜ .¯. Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÎÔÈÏÈ·Îfi˜ fiÓÔ˜ ‹ ÎÔÏÈÎfi˜, ·ÓÂ·Ú΋˜ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜, ·ÈÌ·ÙÔ˘Ú›·, ÏÈı›·ÛË ‹ ˘¤ÚÙ·ÛË (1). ∞ÌÊÔÙÂÚfiÏ¢ÚË ˘‰ÚÔÓ¤ÊÚˆÛË ™ÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ÚÔÁÂÓÓËÙÈ΋˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÚÔ·ÙÔ˘Ó ‰È¿ÊÔÚ· ‰È·ÁÓˆÛÙÈο ÂÚˆÙ‹Ì·Ù· Î·È ıÂÚ·¢ÙÈο ‰ÈÏ‹ÌÌ·Ù·, ηıÒ˜ Ú¤ÂÈ Ó· ‰Ôı› ·¿ÓÙËÛË ÛÙ· ·ÎfiÏÔ˘ı· (16): i) ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, ii) ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ·ÓˆÌ·Ï›·, iii) ·Ó ˘¿Ú¯Ô˘Ó Û˘ÓÔ‰¤˜ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜, iv) ·Ó ÔÈ ÓÂÊÚÔ› Â›Ó·È ‰˘ÛÏ·ÛÙÈÎÔ› Î·È v) ·Ó ¯ÚÂÈ¿˙ÂÙ·È ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË.

OÈ Î‡ÚȘ ÂÈÏÔΤ˜ Ù˘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ÂÚ›Ô‰Ô Â›Ó·È: ·) ‚·ÚÈ¿ ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· Î·È ‚) ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ. ¢È¿ÊÔÚ˜ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Û ÂÚÈÙÒÛÂȘ

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·245

¶·È‰È·ÙÚÈ΋ 2001;64:241-246

·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜, Ô ‚·ıÌfi˜ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏ·Û›·˜ ηıÒ˜ Î·È Ù˘ ˘ÔÏ·Û›·˜ ÙˆÓ Ó¢ÌfiÓˆÓ Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· Ù˘ ·fiÊڷ͢. O ΢ÚÈfiÙÂÚÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·ÚÔ˘Û›· Ù˘ ˘ÔÏ·Û›·˜ ÙˆÓ Ó¢ÌfiÓˆÓ Â›Ó·È Ë ‡·ÚÍË ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘ ÛÙÔ 2Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ Â›Ó·È ÙÔ Î‡ÚÈÔ ·›ÙÈÔ ıÓËÛÈÌfiÙËÙ·˜ Û ÓÂÔÁÓ¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·. ∏ ÂÈ‚›ˆÛË ÛÙ· ÓÂÔÁÓ¿ ·˘Ù¿ Â›Ó·È Ìˉ·ÌÈÓ‹, fiÙ·Ó Ë ·ÚÔ˘Û›· ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘ Û¯ÂÙ›˙ÂÙ·È Ì ·fiÊÚ·ÍË Ù˘ Ô˘Ú‹ıÚ·˜ (17). ∂Ô̤ӈ˜, Û ÂÚÈÙÒÛÂȘ ‚·ÚÈ¿˜ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ Ô˘ ÂÓÙÔ›˙ÂÙ·È Î·Ù¿ ÙÔ 2Ô ÙÚ›ÌËÓÔ Î‡ËÛ˘, ÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Î·È ÙÔ ÔÔ›Ô ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ, Â›Ó·È ÙÔ Î‡ÚÈÔ Âȯ›ÚËÌ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ó· ‰ÈηÈÔÏÔÁ‹ÛÂÈ, ·fi ËıÈ΋˜ ÏÂ˘Ú¿˜, ÙË ¯Ú‹ÛË Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ ·Ú¿ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ Â›Ó·È Èı·Ófi Ó· ÚÔ·„Ô˘Ó ·fi ·˘Ù‹. ¶ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË Û ¤Ì‚Ú˘· Ì ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ· ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·, fï˜ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ·ÌÊÈÛ‚‹ÙËÛË Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘. ∏ ̤ıÔ‰Ô˜ Ô˘ ΢ڛˆ˜ ÂÊ·ÚÌfi˙ÂÙ·È Â›Ó·È Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ‰ÈÏÔ‡ pig-tail ηıÂÙ‹Ú· ÌÂٷ͇ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙÔ˘ ·ÌÓÈ·ÎÔ‡ ¯ÒÚÔ˘ (΢ÛÙÂÔ-·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›·). ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÁÈ· ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË ÛÙȘ ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ·ÔÙÂÏÔ‡Ó (16): ·) Ë ‡·ÚÍË ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ˘: ‰Â›ÎÙ˘ fiÁÎÔ˘ ·ÌÓÈ·ÎÔ‡ ˘ÁÚÔ‡ <5 cm, ‚) Ë ·Ô˘Û›· ÛÔ‚·ÚÒÓ ·ÓˆÌ·ÏÈÒÓ ·fi ¿ÏÏ· fiÚÁ·Ó·, Á) Ë ·Ô˘Û›· ¯ÚˆÌÔÛˆÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (ÂÎÙ›ÌËÛË Î·Ú˘fiÙ˘Ô˘ ÌÂÙ¿ ·fi ·ÌÓÈÔΤÓÙËÛË ‹ Ï‹„Ë ‰Â›ÁÌ·ÙÔ˜ ¯ÔÚÈ·ÎÒÓ Ï·¯ÓÒÓ), ‰) Ë ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÛÙ· Ô‡Ú· ÙÔ˘ Ó·ÙÚ›Ô˘, ÙÔ˘ ¯ÏˆÚ›Ô˘ Î·È ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, ηıÒ˜ Î·È Ì ¤ÏÂÁ¯Ô Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ÙˆÓ Ô‡ÚˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘. °È· ηχÙÂÚ· Î·È ÈÔ ·ÛÊ·Ï‹ ·ÔÙÂϤÛÌ·Ù·, ¤¯ÂÈ ÚÔÙ·ı› Ó· Á›ÓÂÙ·È Ë ·Ú·¿Óˆ ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Ì ‚¿ÛË ÙË Ï‹„Ë 3 ‰È·‰Ô¯ÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ Ô‡ÚˆÓ. ø˜ ηÏÔ› ÚÔÁÓˆÛÙÈÎÔ› ÓÂÊÚÈÎÔ› ‰Â›ÎÙ˜ ıˆÚÔ‡ÓÙ·È Ù· οوıÈ Â˘Ú‹Ì·Ù· ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ Ô‡ÚˆÓ ÙÔ˘ ÂÌ‚Ú‡Ô˘: ¡¿ÙÚÈÔ <100 mEq/I, ÃÏÒÚÈÔ <90 mEq/l,

Paediatriki 2001;64:241-246

øÛ̈ÙÈÎfiÙËÙ· <210 m√sm/I (18). ÕÏÏÔÈ ‰Â›ÎÙ˜ Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙ· Ô‡Ú· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ›ӷÈ: Ë ‚2-ÌÈÈÎÚÔÛÊ·ÈÚ›ÓË, Ë ·1-ÌÈÎÚÔÛÊ·ÈÚ›ÓË, Ë Û˘Ó‰ÂÙÈ΋ ÚˆÙ½ÓË Ù˘ ÚÂÙÈÓfiÏ˘, Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÌÂÙ·ÌfiÚʈÛ˘ - ‚1 (TGF-‚1) Î·È Ô ÂȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (EGF). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ Ì ΢ÛÙÂÔ·ÌÓȷ΋ ÂÈÎÔÈÓˆÓ›· (∫-∞ ÂÈÎÔÈÓˆÓ›·) ÂÎÙÈÌ‹ıËΠ·fi ÙÔÓ Freedman Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ Û ̛· ÌÂϤÙË 55 ÂÌ‚Ú‡ˆÓ Ì ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, 22 ·fi Ù· ÔÔ›· ˘Ô‚Ï‹ıËÎ·Ó Û ∫-∞ ÂÈÎÔÈÓˆÓ›· (17). TÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ ¯ÂÈÚÔ˘ÚÁËÌ¤ÓˆÓ ÂÌ‚Ú‡ˆÓ ‹Ù·Ó 61% Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ 55 ÂÌ‚Ú‡ˆÓ (ÌÂ Î·È ¯ˆÚ›˜ ∫-∞ ÂÈÎÔÈÓˆÓ›·) Ô˘ ‹Ù·Ó 40%. Ÿˆ˜ ¤‰ÂÈÍ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ú·¿Óˆ ÌÂϤÙ˘, ÔÈ Î›Ó‰˘ÓÔÈ ·fi ·Ú¤Ì‚·ÛË Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· Â›Ó·È ·˘ÍË̤ÓÔÈ. ∏ ÔÌ¿‰· ÙˆÓ ÂÌ‚Ú‡ˆÓ Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· ‰È¤ÙÚ¯ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÚÔˆÚfiÙËÙ·˜ (71%) Î·È ÚfiˆÚ˘ ڋ͢ ˘Ì¤ÓˆÓ (31%), Û ۇÁÎÚÈÛË Ì ٷ ¤Ì‚Ú˘· Ô˘ ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û ∫-∞ ÂÈÎÔÈÓˆÓ›·. EÈϤÔÓ, ·Ú·ÙËÚ‹ıËÎ·Ó Ì˯·ÓÈΤ˜ ÂÈÏÔΤ˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·Ú¤Ì‚·Û˘, Û ÔÛÔÛÙfi 48% ÙˆÓ ÂÌ‚Ú‡ˆÓ, ÔÈ Ôԛ˜ fï˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ·ÔÙÂÏÂÛÌ·ÙÈο ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ ÂÈÏÔΤ˜. ¶·Ú¿ ÙȘ Ì˯·ÓÈΤ˜ ÂÈÏÔΤ˜, Ë ·ÒÏÂÈ· ÂÌ‚Ú‡ˆÓ ÏfiÁˆ Ì·È¢ÙÈÎÒÓ ÂÈÏÔÎÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË (16%) Û ۇÁÎÚÈÛË Ì ٷ ¤Ì‚Ú˘· Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙÔÔı¤ÙËÛË ∫-∞ ÂÈÎÔÈÓˆÓ›·˜ (38%). TÔ ÛÔ‚·ÚfiÙÂÚÔ Úfi‚ÏËÌ· Ô˘ ÂÈÛËÌ¿ÓıËΠ·fi ·˘Ù‹ ÙË ÌÂϤÙË ‹Ù·Ó ÔÈ Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·Ù¿ ÙË ÌÂÁ¿ÏË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ (>2 ¤ÙË) 14 ·È‰ÈÒÓ, Ô˘ ÂÈ‚›ˆÛ·Ó ÌÂÙ¿ ·fi ÚÔÁÂÓÓËÙÈ΋ ·Ú¤Ì‚·ÛË Ì ∫-∞ ÂÈÎÔÈÓˆÓ›· (16). ∏ ·‡ÍËÛË ÙÔ˘ ‡„Ô˘˜ ‹Ù·Ó ÌÈÎÚfiÙÂÚË Ù˘ 5˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ Ë ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ‹Ù·Ó Â›Û˘ ÌÈÎÚfiÙÂÚË Ù˘ 5˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ÛÙÔ 36% ÙˆÓ ÂÚÈÙÒÛˆÓ. º˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ›¯·Ó ÌfiÓÔ Ù· 6 ·fi Ù· 14 ·È‰È¿ (ÔÛÔÛÙfi 43%). ∆Ô ·ÓËÛ˘¯ËÙÈÎfi ‡ÚËÌ· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ (8 ·fi Ù· 14) Ô˘ ‚Ú›ÛÎÔÓÙ·Ó Â›Ù Û ‰È¿ÊÔÚ· ÛÙ¿‰È· ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ‹ Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (Û˘ÓÔÏÈÎfi ÔÛÔÛÙfi 57%). ™˘ÌÂÚ¿ÛÌ·Ù· ™˘ÓÔ„›˙ÔÓÙ·˜, ÂÈÛËÌ·›ÓÔÓÙ·È Ù· ·Ú·Î¿Ùˆ: ∞) ∏ ·ÚÔ˘Û›· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ÓÂÊÚÒÓ ‰ÂÓ Û˘ÓËÁÔÚ› ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ‡·ÚÍË ·fiÊڷ͢. µ) H ·ÚÔ˘Û›· Î·È Ô ‚·ıÌfi˜ Ù˘ ‰È¿Ù·Û˘ ηıÔÚ›˙ÔÓÙ·È Ì ÙÔ˘˜ ˘¤ÚË¯Ô˘˜, Ì ‚¿ÛË ÙȘ

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ÌÂÙÚ‹ÛÂȘ Ù˘ ÚÔÛıÈÔ›ÛıÈ·˜ ‰È·Ì¤ÙÚÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ηٿ ÙËÓ ÚÔÁÂÓÓËÙÈ΋ Î·È ÙËÓ ÚÒÈÌË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. ∂ÈÛËÌ·›ÓÂÙ·È fiÙÈ ÔÈ ·ıÔÏÔÁÈΤ˜ ÙÈ̤˜ ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Ô ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ ÚÔÁÂÓÓËÙÈο ‹ ÌÂÙ·ÁÂÓÓËÙÈο. °) ∏ ÂȂ‚·›ˆÛË Èı·ÓÔ‡˜ ·fiÊڷ͢ ‚·Û›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ·fi ÙÔ ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ, Ë ÂÚÌËÓ›· ÙˆÓ ÔÔ›ˆÓ ÚÔ¸Ôı¤ÙÂÈ Ó· ¤¯Ô˘Ó ÙËÚËı› ÔÈ Û˘Óı‹Î˜ ÛˆÛÙ‹˜ ÚÔÂÙÔÈÌ·Û›·˜ Î·È ÂϤÁ¯Ô˘. ¢) ∏ ÚÔÁÂÓÓËÙÈ΋ ˘‰ÚÔÓ¤ÊÚˆÛË ˘Ô¯ˆÚ› Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛˆÓ. OÈ ÂÚÈÙÒÛÂȘ Ô˘ ı· ¯ÂÈÚÔ˘ÚÁËıÔ‡Ó ı· ÂÈÏÂÁÔ‡Ó Ì ‚¿ÛË Ù· Â˘Ú‹Ì·Ù· ·fi: ·) ÙÔ˘˜ ˘¤ÚË¯Ô˘˜ ÓÂÊÚÒÓ Î·È ‚) ÙÔ ¢˘Ó·ÌÈÎfi ™ÈÓıËÚÔÁÚ¿ÊËÌ· ÙˆÓ ÓÂÊÚÒÓ ÁÈ· ÙË ‰È·›ÛÙˆÛË Ù˘ ·ÚÔ˘Û›·˜ ·fiÊڷ͢ ηıÒ˜ Î·È Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÊÚÔ‡ ÛÙËÓ ÔÏÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∂) Y¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ÂÈÊ˘Ï¿ÍÂȘ Û¯ÂÙÈο Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ·Ú¤Ì‚·Û˘ Û ÂÚÈÙÒÛÂȘ ·ÌÊÔÙÂÚfiÏ¢Ú˘ ˘‰ÚÔÓ¤ÊÚˆÛ˘. OÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÈηÓÔÔÈËÙÈο (60%) Î·È fiÙÈ Ë Èı·ÓfiÙËÙ· ·ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰· ·Ó¤Ú¯ÂÙ·È ÌfiÓÔ ÛÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Trip BM, Homsy YL. Neonatal hydronephrosis - The controversy and the management. Pediatr Nephrol 1995;9:503-509.

2. Reddy PP, Mandell J. Ureteropelvic Junction obstruction: Prenatal diagnosis. Urol Clin N Am 1998;25:171-180.

3. Housley HT, Harrison MR. Fetal urinary tract abnormalities: Natural history, pathophysiology, and treatment. Urol Clin N Am 1998;25:63-73.

4. Thomas DF. Fetal Uropathy. Br J Urol 1990;66:225-231.

5. Grignon A, Fillion R, Filiatrault D, Robitaille P, Homsy Y, Boutin H et al. Urinary tract dilatation in Utero: classification and clinical applications. Radiology 1986;160:645-647.

6. Klahr S, Harris K, Purkerson ML. Effects of obstruction on renal functions. Pediatr Nephrol 1998;2:34-42.

7. Chevalier RL. Molecular and cellular pathophysiology of obstructive nephropathy. Pediatr Nephrol 1999;13:612-619.

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8. Sionti I, Pavlou M, Kollios K, Daskas N, Papadopoulou L. Antenatal ultrasonographic diagnosis of fetal urinary tract anomalies and postnatal follow-up. Proceedings of the First Joint Congress of the UNEPSA and CESP (Europediatrics 2000); 2000 March 18-21; Rome: UNEPSA and CESP; 2000. p. 169.

9. Ransley PG, Dhillon HK, Gordon I, Duffy PG, Dillon MJ, Barratt TM. The postnatal management of hydronephrosis diagnosed by prenatal ultrasound. J Urol 1990;144:584-587.

10. Koff SA, Canlell KD. The non operative management of unilateral neonatal hydronephrosis: natural history of poorly functioning kidneys. J Urol 1994;152:593-595.

11. Corteville JE, Gray DL, Crane JP. Congenital hydronephrosis: Correlation of fetal ultrasonograhpic findings with infant outcome. Am J Obstet Gynecol 1991;165:384-388.

12. Elder JS. Antenatal hydronephrosis: Fetal and neonatal management. Pediatr Clin N Am 1997;44:1299-1321.

13. Rascher W, Meyer-Schwickerath, Olbing H. Congenital anomalies of the urinary tract. In: Davison AM, Cameron JS, Grünfeld J-P, Kerr DNS, Ritz E, Winearls CG, eds.

Oxford Textbook of Clinical Nephrology. 2nd ed. New York: Oxford University Press; 1998. p. 2543-2563.

14. O’ Reilly P, Aurell M, Britton K, Kletter K, Rosenthal L, Testa T. Consensus on Diuresis Renography for investigating the dilated Upper urinary tract. J Nucl Med 1996;37:18721876.

15. Dhillon HK. Prenatally diagnosed hydronephrosis: the Great Ormond Street experience. Br J Urol 1998;81(2 Suppl):39-44.

16. Freedman AL, Johnson MP, Gonzalez R. Fetal therapy for obstructive uropathy: Past, present ... future? Pediatr Nephrol 2000;14:167-176.

17. Freedman AL, Bukowski TP, Smith CA, Evans MI, Johnson MP, Gonzalez R. Fetal therapy for obstructive uropathy: specific outcomes diagnosis. J Urol 1996;156:720-724.

18. Glick PL, Harrison MR, Golbus MS, Adrick NS, Filly RA, Callen PW et al. Management of the fetus with congenital hydronephrosis. II. Prognostic criteria and selection for treatment. J Pediatr Surg 1985;20:376-387.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: KˆÓÛÙ·ÓÙ›ÓÔ˜ ¢. KÔÏÏÈfi˜ ¶·È‰È·ÙÚÈ΋ NÂÊÚÔÏÔÁ›·, TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ, 451 10, Iˆ¿ÓÓÈÓ·

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NEPHROLOGY

¡ÂfiÙÂÚ˜ ·fi„ÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∂. ¡. °ÂˆÚÁ¿ÎË - ∞ÁÁÂÏ¿ÎË

New aspects in the treatment of nephrotic syndrome in childhood H. N. Georgaki - Angelaki

¶ÂÚ›ÏË„Ë: ∆Ô È‰ÈÔ·ı¤˜ ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ (¡™) Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Ì ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· 27 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡, ·Ó‹ÎÂÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÛÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ıÂÚ·›· Ì ÎÔÚÙÈÎÔÂȉ‹. ∏ ¢ÈÂıÓ‹˜ ªÂϤÙË ÙˆÓ ¡ÂÊÚÈÎÒÓ ¶·ı‹ÛÂˆÓ Ù˘ ¶·È‰È΋˜ ËÏÈΛ·˜ (ISDC) ıÂÌÂÏ›ˆÛ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 ÙȘ ‚·ÛÈΤ˜ ·Ú¯¤˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¡™, ÔÏϤ˜ ·fi ÙȘ Ôԛ˜ ÈÛ¯‡Ô˘Ó ¤ˆ˜ Û‹ÌÂÚ·. ∆· ÓÂfiÙÂÚ· ıÂÚ·¢ÙÈο Û¯‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο ‹ ·ÓÔÛÔÙÚÔÔÔÈËÙÈο Ê¿Ú̷η Ù· ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ÎÔÚÙÈÎÔÂȉ‹ ¤¯Ô˘Ó Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘, ÙË ‚ÂÏÙ›ˆÛË ÛÙËÓ ÚfiÁÓˆÛË Î·È ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ. ∆Ô ¡™ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·Ó‹ÎÂÈ Û˘Ó‹ıˆ˜ ÈÛÙÔÏÔÁÈο ÛÙÔÓ Ù‡Ô Ù˘ ∂ÛÙȷ΋˜ ™ÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Î·È Î·Ù¿ ηÓfiÓ· ÂËÚ¿˙ÂÙ·È Ôχ Ï›ÁÔ ·fi Ù· ÓÂfiÙÂÚ· ıÂÚ·¢ÙÈο Û¯‹Ì·Ù·. ¶·Ú¿ ÙȘ ‰È¯ÔÁÓˆÌÔ‡ÌÂÓ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·fi„ÂȘ, Ê·›ÓÂÙ·È fiÙÈ Ô Ù‡Ô˜ ·˘Ùfi˜ ¡™ Ô‰ËÁ› Û ¿ÏÏÔÙ ¿ÏÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÔ›·˜ ··ÈÙÂ›Ù·È ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË.

Abstract: The idiopathic Nephrotic Syndrome (NS) of childhood, with an annual incidence of 2-7 new cases in 100.000 children’s population, is by histology due primarily to the type of minimal change disease which is characterized by response to steroid treatment. Most of our current knowledge is attributed to the fundamental principles of the International Study of Kidney Disease in Childhood (ISKDC) started in 1970, most of which are operative even today. The new therapeutic regimens consist of immunosuppressive or immunoregulatory agents which, in combination with corticosteroids, have contributed significantly to the better management of nephrotic children. µased on the above regimens, and the prevention of previously fatal complications, the prognosis of the disease is now better. The type of NS resistant to steroids and to the other more aggressive immunosuppressive agents is com- monly due to Focal Segmental Glomerulosclerosis (FSGS). Although, according to the literature, there is conflicting data regarding the effectiveness of the new therapeutic agents and the outcome of this disease, many children progress to chronic renal failure and need treatment with renal trans- plantation.

§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ıÂÚ·›·.

Key words: nephrotic syndrome, treatment.

∆Ô È‰ÈÔ·ı¤˜ ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ Ì ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· 2-7 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ οو ÙˆÓ 16 ¯ÚfiÓˆÓ (1), ·ÔÙÂÏ› ÎÔÈÓfi ·È‰È·ÙÚÈÎfi ÓfiÛËÌ· Ì ·ÚÈ· Â›ÙˆÛË ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘, ·ÊÔ‡ ÙÔ 90% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ Î·È Ì¿ÏÈÛÙ· ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛˆÓ, ·ÊÔÚ¿ Û ·È‰È¿ οو

ÙˆÓ 7 ¯ÚfiÓˆÓ (2).

O ·È‰È·ÙÚÈÎfi˜ ÎfiÛÌÔ˜ ·Ó¿ ÙËÓ ˘Ê‹ÏÈÔ ÔÊ›ÏÂÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ÁÓÒÛ˘ Î·È Ù˘ ÂÌÂÈÚ›·˜ ÁÈ· ÙÔ ÓfiÛËÌ· ·˘Ùfi ÛÙËÓ ÂÔÓÔÌ·˙fiÌÂÓË ¢ÈÂıÓ‹ ªÂϤÙË. ∏ ÌÂϤÙË ·˘Ù‹, ÁÓˆÛÙ‹ ˆ˜ ¢ÈÂıÓ‹˜ ÌÂϤÙË ÙˆÓ ¡ÂÊÚÈÎÒÓ ¡ÔÛËÌ¿ÙˆÓ Ù˘ ¶·È‰È΋˜ ËÏÈΛ·˜ (ISKDC), ÍÂΛÓËÛ ÙË ‰ÂηÂÙ›·

¢È¢ı‡ÓÙÚÈ· ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

Director of Paediatric Nephrology Unit “Agia Sophia” Children’s Hospital, Athens

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ÙÔ˘ ’70 (2) Î·È ‰ÈÂÓÂÚÁ‹ıËΠ·fi 27 ¶·È‰ÔÓÂÊÚÔÏÔÁÈο ΤÓÙÚ· Û 24 Û˘ÓÔÏÈο ¯ÒÚ˜ ·fi ÙË ¢. ∂˘ÚÒË, ÙË µ. ∞ÌÂÚÈ΋ Î·È ÙÔ Hong Kong (2). ªÂÚÈΤ˜, ÏÔÈfiÓ, ·fi ÙȘ ϤÔÓ ·ÍÈÔÛËÌ›ˆÙ˜ ÁÓÒÛÂȘ Ô˘ ÚԤ΢„·Ó ·fi ÙË ¢ÈÂıÓ‹ ªÂϤÙË Î·È Ô˘ ÈÛ¯‡Ô˘Ó ¤ˆ˜ Î·È Û‹ÌÂÚ· Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜: ∆Ô ¡ÂÊÚˆÛÈÎfi ™‡Ó‰ÚÔÌÔ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘ ȉÈÔ·ı¤˜, ·Ó‹ÎÂÈ ÈÛÙÔÏÔÁÈο ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È Î·Ù¿ ηÓfiÓ· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ıÂÙÈο ÛÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·fi Ù· 561 ·È‰È¿ Ì ÙÔ ÓfiÛËÌ· ·˘Ùfi, 430 (76,6%) Ù·ÍÈÓÔÌ‹ıËÎ·Ó ÌÂÙ¿ ·fi ‚ÈÔ„›· ÓÂÊÚÔ‡ fiÙÈ ·Ó‹Î·Ó ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È ·fi ·˘Ù¿, ÙÔ 94% ·ÚÔ˘Û›·Û ‡ÊÂÛË ÌÂÙ¿ ÙË ıÂÚ·›· Ì ÎÔÚÙÈÎÔÂȉ‹ (¶ÚÂ˙ÔÏfiÓË, ¶Ú‰ÓÈ˙ÔÏfiÓË), ÂÓÒ Ù· 41 (7,3%,) ·Ó‹Î·Ó ÛÙÔÓ Ù‡Ô Ù˘ ÂÛÙȷ΋˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Ì ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ÌfiÓÔÓ ÙÔ 19,5% ÂÍ’ ·˘ÙÒÓ Î·È ·ÓıÂÎÙÈÎfiÙËÙ· fiÏˆÓ ÙˆÓ ˘ÔÏÔ›ˆÓ. ∏ ‚·ÛÈ΋ ·˘Ù‹ ÁÓÒÛË Ù˘ ¿ÌÂÛ˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Ì ÙË ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Û ÔÛÔÛÙfi 94%, ıÂÌÂÏ›ˆÛ ÙË ÁÓˆÛÙ‹ Î·È ÈÛ¯‡Ô˘Û· ¤ˆ˜ Û‹ÌÂÚ· ¿Ô„Ë fiÙÈ Î¿ı ·È‰› ËÏÈΛ·˜ ÌÂٷ͇ 1 Î·È 10 ¯ÚfiÓˆÓ ÌÔÚ› - ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ - Ó· ˘Ô‚ÏËı› Û ıÂÚ·›· Ì ÎÔÚÙÈÎÔÂȉ‹ ·ÊÔ‡ Ë Èı·ÓfiÙËÙ·, fiˆ˜ ÚÔ·ÙÂÈ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¢ÈÂıÓÔ‡˜ ªÂϤÙ˘, Ó· ¿Û¯ÂÈ ·fi ÙË ÓfiÛÔ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Â›Ó·È Ù˘ ٿ͈˜ ÙÔ˘ 76,6% Î·È Ë ·ÓÙ·fiÎÚÈÛË ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ÛÙË ıÂÚ·›· Ì ÎÔÚÙÈÎÔÂȉ‹ 94%. ∆· ıÂÚ·¢ÙÈο Û¯‹Ì·Ù· Ô˘ ¤¯Ô˘Ó ÚÔÙ·ı› ·fi ÙfiÙ ÛÙËÓ ÔÚ›· ÙÚÈÒÓ ‰ÂηÂÙÈÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È ·ÚÎÂÙ¿. ªÂ ÌÈÎÚ¤˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜, Ô˘ÛÈ·ÛÙÈο fiÏ· ÚÔÙ›ÓÔ˘Ó ÙËÓ ¿ÌÂÛË ¤Ó·ÚÍË Ù˘ ÚÂ˙ÔÏfiÓ˘ ‹ Ú‰ÓÈ˙ÔÏfiÓ˘ Û ‰fiÛË 2 mg/kg Û 34 ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ ËÌÂÚËÛ›ˆ˜, ˘ÔÏÔÁ›˙ÔÓÙ·˜ ÙÔ È‰·ÓÈÎfi ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‚¿ÛÂÈ ÙÔ˘ ‡„Ô˘˜ ÙÔ˘ Î·È fi¯È ÙÔ ÔȉËÌ·Ù҉˜ ‚¿ÚÔ˜. ∏ ·ÁˆÁ‹ ·˘Ù‹ ‰›‰ÂÙ·È Â› ¤Ó· Ì‹Ó· Î·È ·ÎÔÏÔ˘ı› ·Ú‹ÌÂÚË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ‰fiÛË 1,5-2 mg/kg ÙÔ Úˆ›, Ì ÛÙfi¯Ô ÙË ÛÙ·‰È·Î‹ Ì›ˆÛË Î·È ‰È·ÎÔ‹ ÙÔ˘ Û’ ¤Ó· Ì‹Ó· (3). ªÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË ‰‡Ô ÌËÓÒÓ ıÂÚ·›·˜ Ì ÎÔÚÙÈÎÔÂȉ‹, ÙÔ 93,8% ÙˆÓ ·È‰ÈÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ¢ÈÂıÓ‹ ªÂϤÙË Â›¯·Ó ·ÓÙ·ÔÎÚÈı› Û’ ·˘Ù¿ (2). ∞ÎÔÏÔ‡ıËÛÂ, ÂÓÙÔ‡ÙÔȘ, Ï‹ıÔ˜ ÂÚÁ·ÛÈÒÓ Ô˘ ÙÂÎÌËÚ›ˆÛ·Ó ÙËÓ ¿Ô„Ë fiÙÈ Û¯Â‰fiÓ ÙÔ 85% ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ú¯Èο ›¯·Ó ·ÓÙ·ÔÎÚÈı› ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ ·ÚÔ˘Û›·Û·Ó ÂÓ Û˘Ó¯›· ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘, ›Ù ηٿ ÙË Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Â›Ù Û ‚Ú·¯‡

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¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ‰È·ÎÔ‹ ÙÔ˘˜ (4-6). OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È fiÙÈ ¿Û¯Ô˘Ó ·fi ÙÔÓ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô Î·È ·Ó·ÏfiÁˆ˜ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ˘ÔÙÚÔÒÓ Ô˘ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, Ù·ÍÈÓÔÌÔ‡ÓÙ·È Â›Ù ˆ˜ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓÙ˜ (‰‡Ô ˘ÔÙÚÔ¤˜ ÙÔ ÂÍ¿ÌËÓÔ ‹ ÙÚÂȘ ÙÔ ¯ÚfiÓÔ), ›Ù ˆ˜ ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔÈ ·fi ÌÈÎÚ‹ ‹ ÌÂÁ¿ÏË ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ, ÂÊfiÛÔÓ ˘ÔÙÚÔÈ¿˙Ô˘Ó ÛÙËÓ ÚÔÛ¿ıÂÈ· Ì›ˆÛ˘ ‹ ‰È·ÎÔ‹˜ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ. ∏ ÔÌ¿‰· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ·˘ÙÒÓ ·ÛıÂÓÒÓ ·ÔÙÂÏ› Û˘¯Ó¿ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ¤Ó· Úfi‚ÏËÌ· ‰‡ÛÎÔÏ· ·ÓÙÈÌÂÙˆÈ˙fiÌÂÓÔ. ∞fi ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û˘ÁÎÚ›ÓÔÓÙ·˜ ÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙËÓ ÎÏ·ÛÈ΋ ‰›ÌËÓË ¯ÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ÚÔ˜ ¿ÏÏË ÔÌ¿‰· ÛÙËÓ ÔÔ›· ¯ÔÚËÁ‹ıËÎ·Ó Ù· ÎÔÚÙÈÎÔÂȉ‹ Û ϤÔÓ Ì·ÎÚfi¯ÚÔÓË ‰È¿ÚÎÂÈ· ÌÂ Û˘ÓÔÏÈ΋ ¯ÔÚ‹ÁËÛË ¤ÍÈ ÌËÓÒÓ Û ۯ‹Ì· ÛÙ·‰È·Î‹˜ Î·È Û ·ÚÁfi Ú˘ıÌfi ÌÂÈÔ‡ÌÂÓ˘ ‰fiÛ˘, ‰›¯ıË fiÙÈ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰·, ÙfiÛÔ ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ˘ÔÙÚÔÒÓ fiÛÔ Î·È ˆ˜ ÚÔ˜ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÚÔ˘Û›·˙·Ó ÎÔÚÙÈÎÔÂÍ¿ÚÙËÛË, ¯ˆÚ›˜ ÔÈ Ì·ÎÚfi¯ÚÔÓ˜ ·ÚÂÓ¤ÚÁÂȘ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÂÚÈÛÛfiÙÂÚ˜ (6). ∏ ıÂÚ·¢ÙÈ΋ ·˘Ù‹ ¿Ô„Ë ¤¯ÂÈ ϤÔÓ ˘ÈÔıÂÙËı› Î·È ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ·ÚÎÂÙ¿ ·È‰ÔÓÂÊÚÔÏÔÁÈο ΤÓÙÚ·, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È ÂΛÓÔ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∞ıËÓÒÓ. ¶ÏËÓ Ù˘ ¢·ÈÛıËÛ›·˜ ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ȉÈÔ·ı¤˜ ¡™ ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛˆÓ, ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏ· ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ηıÔ‰ËÁÔ‡Ó ÙÔ ıÂÚ¿ÔÓÙ· ÛÙËÓ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ∏ Èı·ÓfiÙËÙ· ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÌÂÈÒÓÂÙ·È ÛÙÔ ÔÛÔÛÙfi ÙˆÓ 50% - 60% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™, Â¿Ó ÛÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÔÛÙÂı› ˘¤ÚÙ·ÛË ‹ ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›·. ™ÙËÓ ÂÚ›ÙˆÛË ‰Â, Û˘Ó‡·Ú͢ Î·È ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î·Ù·ÛÙ¿ÛˆÓ, Ë Èı·ÓfiÙËÙ· ÓfiÛÔ˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÌÂÈÒÓÂÙ·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ·ÊÔ‡ ··ÓÙ¿Ù·È ÌfiÓÔ ÛÙÔ 20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ (3). ¶ÏËÓ Ù˘ ‚·ÛÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ÎÔÚÙÈÎÔÂȉ‹, ÛËÌ·ÓÙÈ΋ ·Í›· ¤¯ÂÈ Î·È Ë ÁÓÒÛË ÌÂÚÈÎÒÓ ¿ÏÏˆÓ ıÂÚ·¢ÙÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÙˆÓ ·È‰ÈÒÓ Ì ¡™ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÂȉÈ΋ ̤ÚÈÌÓ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤Á¯˘Û˘ Ù˘ ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘. ∏ ·ÚÔ˘Û›· ÙÔ˘ Ôȉ‹Ì·ÙÔ˜, Ô˘ ·ÔÙÂÏ› ·ÚÈÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÓfiÛÔ˘, ‰ÂÓ ·ÔÙÂÏ› ˘Ô¯ÚˆÙÈο ·fiÏ˘ÙË ¤Ó‰ÂÈÍË

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·249

¶·È‰È·ÙÚÈ΋ 2001;64:247-254

ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘, Ë ÔÔ›· ·ÓÙ›ıÂÙ· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÈÏÂÎÙÈο Û fiÛÔ˘˜ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ÛËÌ›· ˘ÔÔÁηÈÌ›·˜, Ô˘ Û˘ÓÔÙÈο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∂Ê’fiÛÔÓ ÏÔÈfiÓ ÎÚÈı› ÛÎfiÈÌË ‚¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ Ë ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘, ·˘Ù‹ Ú¤ÂÈ Ó· Â›Ó·È Î·Ù¿ ÚÔÙ›ÌËÛË ÂχıÂÚË NaCl Î·È ·fi ÙÔ ‰È¿Ï˘Ì· 20% Ó· ¯ÔÚËÁÂ›Ù·È 1 gr/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Û ‰È¿ÛÙËÌ· ÙÂÛÛ¿ÚˆÓ ˆÚÒÓ. ∆Ô ‰ÈÔ˘ÚËÙÈÎfi ÊÔ˘ÚÔÛÂÌ›‰Ë ÌÔÚ› Ó· ÚÔÛÙÂı› ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ÒÚ˜, ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÏÂ˘ÎˆÌ·Ù›ÓË Â›Ù ÂÊ¿·Í ηٿ ÙÔ Ù¤ÏÔ˜ Ù˘ ¤Á¯˘Û˘ Û ‰fiÛË 1 mgr/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (7). ™ÙȘ ÂÚÈÙÒÛÂȘ ˘ÔÔÁηÈÌÈÎÒÓ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ‰ÈÔ˘ÚËÙÈÎfi ÚÔ Ù˘ ¤Á¯˘Û˘ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ÎÈÓ‰‡ÓÔ˘ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ‹ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∏ Ù·¯‡ÙÂÚË ¤Á¯˘ÛË ÙÔ˘ ·ÓˆÙ¤Úˆ ‰È·Ï‡Ì·ÙÔ˜ ÂÓ¤¯ÂÈ ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Û ÔÛÔÛÙfi 11% Î·È ˘ÂÚÙ·ÛÈÎÒÓ ÎÚ›ÛÂˆÓ 46% (7). ÕÏÏ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ÙÔ ·È‰› Ì ¡™ Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ù· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È·. ø˜ ÚÔ˜ ÙȘ ÏÔÈÌÒÍÂȘ, Â›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ ÔÊ›ÏÔÓÙ·È Û ÌÂÁ¿ÏË ·ÒÏÂÈ· ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ πgG Î·È ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ µ Î·È D ÛÙ· Ô‡Ú·. ∞fi ÙȘ ÏÔÈÌÒÍÂȘ ·˘Ù¤˜, Ë ÂÚÈÙÔÓ›Ùȉ· ·fi gram ·ÚÓËÙÈο ‚·ÎÙËÚ›‰È· ‹ Ó¢ÌÔÓÈfiÎÔÎÎÔ Û ÔÛÔÛÙ¿ 28% Î·È 50% ·ÓÙÈÛÙÔ›¯ˆ˜, Â›Ó·È ·fi ÙȘ ÛÔ‚·ÚfiÙÂÚ˜. Ÿ¯È Û¿ÓÈ·, Ë Ïԛ̈ÍË ·˘Ù‹ ÂÚÌËÓ‡ÂÙ·È Ï·Óı·Ṳ̂ӷ ˆ˜ Ú‹ÍË ÛΈÏËÎÔÂȉԇ˜ ·fiÊ˘Û˘ Î·È ‰ÈÂÓÂÚÁÂ›Ù·È Î·Ù’ Â¤ÎÙ·ÛË Ì›· ¯ˆÚ›˜ ÏfiÁÔ ÛΈÏËÎÔÂȉÂÎÙÔÌ‹, Ô˘ ‚‚·›ˆ˜ ˆ˜ Â¤Ì‚·ÛË Î·Ù·ÔÓ› Â› ϤÔÓ ÙÔÓ ‹‰Ë ¢¿ÏˆÙÔ ·ÛıÂÓ‹ Ì ÂÓ ÂÓÂÚÁ›· ¡™. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·˘ÙÔ‡ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 6% (28). ∆· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· ·ÊÔÚÔ‡Ó Û˘Ó‹ıˆ˜ Û ÌÂÁ¿Ï· ·ÁÁ›·, fiˆ˜ οو ÎÔ›ÏË ÊϤ‚·, ÓÂÊÚÈΤ˜ Î·È Ë·ÙÈΤ˜ ÊϤ‚˜, ÌËÚÈ·›· ·ÁÁ›· Î·È ÂÓ Ùˆ ‚¿ıÂÈ ·ÁÁ›· οو ¿ÎÚˆÓ ‹ Ù¤ÏÔ˜ Î·È ÂÁÎÂÊ·ÏÈΤ˜ ÊϤ‚˜, Ë ‰Â Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙ¿ Î˘Ì·ÈÓfiÌÂÓ· ·fi 1,8-5%. ∂ÎÙfi˜ Ù˘ ÎÏ·ÛÈ΋˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Ô˘ Û˘Óԉ‡ÂÈ Ù· ÂÂÈÛfi‰È· ·˘Ù¿, ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ˘ÔÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ÂÈÏÔÎÒÓ ÂÎ ÙˆÓ ·ÓˆÙ¤Úˆ ·ÁÁ›ˆÓ ÛÂ Û˘¯ÓfiÙËÙ· Ô˘ ·Ó¤Ú¯ÂÙ·È Û 28% (28). µÂ‚·›ˆ˜, ÔÈ Î·Ù·ÛÙ¿ÛÂȘ ·˘Ù¤˜ Û˘Ì‚·›ÓÔ˘Ó Û¯Â‰fiÓ ¿ÓÙÔÙ Û ¤‰·ÊÔ˜ ÛÔ‚·Ú‹˜ Î·È ·Ú·ÙÂٷ̤Ó˘ ˘ÔÔÁηÈÌ›·˜. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Û˘Ó›ÛÙ·Ù·È ÛÙË ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË, ÂÓÒ ·fi ÌÂÚÈÎÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÚÔÙ›ÓÂÙ·È Û ̷ÎÚfi¯ÚÔÓË ‚¿ÛË Ë Î·ıËÌÂÚÈ-

Paediatriki 2001;64:247-254

Ó‹ ¯ÔÚ‹ÁËÛË Warfarin ÁÈ· ÚÔÊ˘Ï·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ¶ÚÔÏËÙÈο ÚÔÙ›ÓÂÙ·È Â›Û˘ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ‰ËÏ·‰‹ ÂΛÓÔ˘˜ Ì Â›‰· ÈÓˆ‰ÔÁfiÓÔ˘ ¿Óˆ ÙˆÓ 6 gr/L ‹ Â›‰· ·ÓÙÈıÚÔÌ‚›Ó˘ πππ ÏÈÁfiÙÂÚ· ·fi 70%, Ë ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÛÈÚ›Ó˘ (50 mg ‰‡Ô ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜) Î·È ‰È˘Úȉ·ÌfiÏ˘, ÂÓÒ ÁÂÓÈÎfiÙÂÚ· ÚÔÏËÙÈο ̤ÙÚ· ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÓ ÂÓÂÚÁ›· ¡™ ·ÔÙÂÏÔ‡Ó Ë ¤ÁηÈÚË Î·È ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÔÁηÈÌ›·˜ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ (28). ∞fi ÙȘ ·Ó·ÌÂÓfiÌÂÓ˜ ·ÚÂÓ¤ÚÁÂȘ ÂÎ Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ ÛÙÔ ˘ÔÙÚÔÈ¿˙ˆÓ ¡™ Â›Ó·È Ë ÔÛÙÂÔÂÓ›·, Ë ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ¯ÚfiÓÈ· ·ÒÏÂÈ· ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ µÈÙ·Ì›Ó˘ D ÛÙ· Ô‡Ú· ··ÈÙ› ÙËÓ Î·Ù¿ ÂÚ›ÙˆÛË ¯ÔÚ‹ÁËÛË ·Û‚ÂÛÙ›Ô˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ (500 mg/Ë̤ڷ) Î·È µÈÙ·Ì›Ó˘ D, 2000-4000 ÌÔÓ¿‰Â˜ ËÌÂÚËÛ›ˆ˜ ‹ 1,·-O∏VitD, Û ‰fiÛË 0,25-0,50 Ìg/Ë̤ڷ (28). ∞ÓÂÍ·Úًو˜ ÙˆÓ ·Ú·¿Óˆ ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ Î·È Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ·Ó·Ê¤ÚıËηÓ, ÙÔ È‰ÈÔ·ı¤˜ ¡™ ÙÔ˘ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Ô˘ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙ· ÎÔÚÙÈÎÔÂȉ‹, ¤¯ÂÈ, ‚¿ÛÂÈ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ¢ÈÂıÓÔ‡˜ ªÂϤÙ˘, ηϋ ÚfiÁÓˆÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·fi 389 ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· 9,4 ¯ÚfiÓÈ·, ÙÔ 75% ·ÚÔ˘Û›·Û ÌfiÓÈÌË ‡ÊÂÛË ‹ ˘ÔÙÚÔ›·Û Û·Ó›ˆ˜, ÂÓÒ ÌfiÓÔ ÙÔ 4% ›¯Â Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜. ∆ËÓ Î·Ï‡ÙÂÚË ÚfiÁÓˆÛË ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Â›¯·Ó ÂΛӷ Ô˘ ‰ÂÓ ˘ÔÙÚÔ›·Û·Ó ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ÂÍ·Ì‹ÓÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘. ªË Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜ ·ÚÔ˘Û›·Û ÙÔ 20-34% ÙˆÓ ·Û¯fiÓÙˆÓ. ∫·Ù¿ ÙËÓ ÙÂÏÈ΋ ÂÎÙ›ÌËÛË, ÙÔ 95% ·fi ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ›¯Â ηϋ ÂͤÏÈÍË, ·ÏÏ¿ ¤Ó· ÔÛÔÛÙfi 4-5% ·‚›ˆÛ ·fi Ïԛ̈ÍË ‹ η٤ÏËÍ Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (3,8,28). ™Ù· ·È‰È¿ ÌÂ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓ ¡™ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ›Ù ηٿ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Â›Ù ηٿ ÙË Ê¿ÛË Ù˘ ÛÙ·‰È·Î‹˜ Ì›ˆÛ˘ ·˘ÙÒÓ, ÚÔÙ›ÓÂÙ·È ÙÔ ·ÎfiÏÔ˘ıÔ ıÂÚ·¢ÙÈÎfi Û¯‹Ì·: ¶Ú‰ÓÈ˙fiÓË 40-60 mg/m2 ¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ˘ÔÔÁηÈÌ›·˜ ñ∫ÏÈÓÈο - ∫ÔÈÏȷο ¿ÏÁË, ¤ÌÂÙÔÈ, Ù·¯˘Î·Ú‰›·, „˘¯Ú¿ ¿ÎÚ·, ÔÏÈÁÔ˘Ú›·, ˘¤ÚÙ·ÛË ‹ ˘fiÙ·ÛË - ¢È·ÊÔÚ¿ ÎÂÓÙÚÈ΋˜-ÂÚÈÊÂÚÈ΋˜ ıÂÚÌÔÎÚ·Û›·˜ >3oC ñ∂ÚÁ·ÛÙËÚȷο - ·ÈÌ·ÙÔÎÚ›ÙË, Ô˘Ú›·˜, ·ÏÏ¿ fi¯È ÎÚ·ÙÈÓ›Ó˘, Na Ô‡ÚˆÓ <5 moml/L* *ÙÔ Na+ ÙˆÓ Ô‡ÚˆÓ ÌÂÙÚ¿Ù·È Û ‰Â›ÁÌ· Ì›·˜ Ô‡ÚËÛ˘ Î·È ·ÍÈÔÏÔÁÂ›Ù·È ÌfiÓÔ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ‰ÈÔ˘ÚËÙÈÎÒÓ

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¶·È‰È·ÙÚÈ΋ 2001;64:247-254

Paediatriki 2001;64:247-254

ËÌÂÚËÛ›ˆ˜, ¤ˆ˜ fiÙÔ˘ ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Î·È ·Ú¤ÏıÔ˘Ó ÙÚÂȘ ¤ˆ˜ ¤ÓÙ Â› ϤÔÓ Ë̤Ú˜. ∞ÎÔÏÔ˘ı› ÛÙ·‰È·Î‹ Ì›ˆÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·Ú¯Èο Û ηıËÌÂÚÈÓ‹ Î·È ÂÓ Û˘Ó¯›· Û ·Ú‹ÌÂÚË ‚¿ÛË, Ì ÛÙfi¯Ô Ù· ÎÔÚÙÈÎÔÂȉ‹ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Û ‰fiÛË 15-20 mg/m2 ̤ڷ ·Ú¿ ̤ڷ. ∏ ‰fiÛË ·˘Ù‹ ı· Ú¤ÂÈ Ó· ·ÓÙÈÚÔÛˆ‡ÂÈ ÛÙËÓ Ú¿ÍË ÙË ‰fiÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ˘fi ÙËÓ ÔÔ›· Ô ·ÛıÂÓ‹˜ ˘ÔÙÚÔ›·ÛÂ Î·È Â› ϤÔÓ 5 mg Î·È Ì ÙÔ ıÂÚ·¢ÙÈÎfi ·˘Ùfi Û¯‹Ì· Ó· Û˘Ó¯ÈÛÙ› Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ Â› 12-18 Ì‹Ó˜. ∆fiÙ ı· ÂȯÂÈÚËı› Ë ÛÙ·‰È·Î‹ ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ (6). OÈ Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÙÒÛÂȘ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ÁÂÓÈο ÁÓˆÛÙ¤˜, Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2.

O ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ Ô˘ ΢ڛˆ˜ ·ÊÔÚÔ‡Ó ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÓËÏ›ÎˆÓ ·ÏÏ¿ Î·È ·È‰ÈÒÓ Ì ÙÔÓ ˘ÔÙÚÔÈ¿˙ÔÓÙ· Ù‡Ô ÙÔ˘ ¡™, Ô‰ËÁ› Û˘¯Ó¿ ÙÔ ıÂÚ¿ÔÓÙ· ÁÈ·ÙÚfi ÛÙËÓ ·Ó·˙‹ÙËÛË ¿ÏÏˆÓ ıÂÚ·¢ÙÈÎÒÓ Ï‡ÛˆÓ, ÔÈ Ôԛ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¿ÊÔÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù·, fiˆ˜ ı· ·Ó·ÊÂÚı› ÏÂÙÔÌÂÚÒ˜ ÛÙË Û˘Ó¤¯ÂÈ·. °È· ÙÔÓ ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, ÚÒÙ˘ ÂÈÏÔÁ‹˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Ê¿ÚÌ·ÎÔ Â›Ó·È Ë ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (Endoxan), Ë ÔÔ›· ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 2 mg/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Â› 2,5-3 Ì‹Ó˜, ˘fi ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÈÌ·ÙÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÏfiÁˆ ΢ڛˆ˜ Ù˘ ·ÚÂÓ¤ÚÁÂÈ·˜ Ù˘ Ï¢ÎÔÂÓ›·˜ Ô˘ ÌÔÚ› Ó· ·Ú·ÙËÚËı›, Â˘Ù˘¯Ò˜ fi¯È Û˘¯Ó¿ (9,11,12). ∏ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹ ·˘Ù‹ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÚÔËÁËı›۷ ·ÓÙ·fiÎÚÈÛË ÛÙ· ÎÔÚÙÈÎÔÂȉ‹, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ 75% ÙˆÓ ·È‰ÈÒÓ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ - Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓÙ· - Ù‡Ô ¡™ ·ÚÔ˘Û›·Û ̷ÎÚfi¯ÚÔÓË ‡ÊÂÛË ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜, ÂÓÒ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙÔ Ê¿ÚÌ·ÎÔ ÌÂÈÒıËΠ۠30% fiÙ·Ó ¯ÔÚËÁ‹ıËΠ۠·È‰È¿ Ì ÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ Î·È È‰È·›ÙÂÚ· ·fi ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÂȉÒÓ Ù‡Ô ¡™. ™‡Ìʈӷ Ì ÙË ¢ÈÂıÓ‹ ªÂϤÙË, ·ÏÏ¿ Î·È ·fi ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ, Ê·›ÓÂÙ·È fiÙÈ ‡ÊÂÛË ÙÔ˘ ¡™ ‰È¿Ú-

ÎÂÈ·˜ 2 ¯ÚfiÓˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ 67% ÙˆÓ ·È‰ÈÒÓ fiÙ·Ó ÙÔ˘˜ ¯ÔÚËÁÂ›Ù·È Ë ∫˘ÎÏÔʈÛÊ·Ì›‰Ë Â› ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ Î·È 30% ÌÂÙ¿ ¯ÔÚ‹ÁËÛË 2 ÌËÓÒÓ, ·ÓÙÈÛÙÔȯ· (8,9). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ÃÏˆÚ·Ì‚Ô˘Î›ÏË Û ‰fiÛË 0,2 mg/kg ËÌÂÚËÛ›ˆ˜ Â› 2 Ì‹Ó˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÎÔ‡ ¡™ ›ӷÈ, Û‡Ìʈӷ Ì ٷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, fiÌÔÈ· Ì ÂΛӷ Ù˘ ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜ (5,10). ∆· ‰‡Ô ÚÔ·Ó·ÊÂÚı¤ÓÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ¯ÔÚËÁÔ‡ÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÎÔÚÙÈÎÔÂȉ‹, Ë ‰fiÛË ÙˆÓ ÔÔ›ˆÓ ÛÙ·‰È·Î¿ ÌÂÈÒÓÂÙ·È ·Ú¯Èο Û ËÌÂÚ‹ÛÈÔ Î·È ÂÓ Û˘Ó¯›· Û ·Ú‹ÌÂÚÔ Û¯‹Ì·, ¤ˆ˜ ÙËÓ Ï‹ÚË ‰È·ÎÔ‹ ÙÔ˘˜, Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ‰È·ÎÔ‹ ÙˆÓ ˘fi Û˘˙‹ÙËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ. ÕÌÂÛ· ıÂÙÈο Î·È ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ıÂÚ·¢ÙÈ΋ ·˘Ù‹ ·Ú¤Ì‚·ÛË ÂÊ`fiÛÔÓ ÎÚÈı› ÂÈÙ˘¯‹˜ Â›Ó·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Û ‡„Ô˜, Ë ·ÒÏÂÈ· Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ÙÔ˘ ·ÓÛÂÏËÓÔÂȉԇ˜ ÚÔÛˆ›Ԣ Î·È Ë ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘. ∞fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ, ÛÔ‚·ÚfiÙÂÚË ıˆÚÂ›Ù·È Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂ Û˘Ó¤ÂÈ· ΢ڛˆ˜ ÙË Ï¢ÎÔÂÓ›·. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Â› ·ÚÈıÌÔ‡ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ <3000mm3, Ù· ·Ó·ÊÂÚı¤ÓÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ‰È·ÎfiÙÔÓÙ·È ¤ˆ˜ ÙËÓ Â¿ÓÔ‰Ô ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·, ÔfiÙ Â·Ó·¯ÔÚËÁÔ‡ÓÙ·È Ì¤¯ÚÈ ÙË Û˘ÌÏ‹ÚˆÛË Ù˘ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜ Ô˘ ¤¯ÂÈ ÚÔηıÔÚÈÛÙ› ÁÈ· ÙÔÓ ·ÛıÂÓ‹. ∂›Û˘, Ù· Ê¿Ú̷η ·˘Ù¿ ‰È·ÎfiÙÔÓÙ·È ·ÚÔ˘Û›· ÛÔ‚·Ú‹˜ Ïԛ̈͢, ȉȷ›ÙÂÚ· ·ÓÂÌ¢ÏÔÁÈ¿˜, ÁÈ· ÙËÓ ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÔ›·˜ Ë ¤Ó·ÚÍË ·ÁˆÁ‹˜ Ì ·Û˘ÎÏÔ‚›ÚË ıˆÚÂ›Ù·È ÂȂ‚ÏË̤ÓË. §ÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ Â›Ó·È Ë ·ÏˆÂΛ· Î·È Ë ·ÈÌÔÚÚ·ÁÈ΋ ΢ÛÙ›Ùȉ·. ø˜ ÚÔ˜ ÙÔ ı¤Ì· Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ÁÔÓ¿‰ˆÓ, Ô Î›Ó‰˘ÓÔ˜ Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ıˆÚÂ›Ù·È Èı·ÓfiÙÂÚÔ˜ ÁÈ· Ù· ·ÁfiÚÈ· Û ۯ¤ÛË Ì ٷ ÎÔÚ›ÙÛÈ·. ∂ȉÈÎfiÙÂÚ·, ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÛÙËÓ ˘ÎÓfiÙËÙ·

¶›Ó·Î·˜ 2. ™˘ÓÔÙÈ΋ ηٷÁÚ·Ê‹ ·ÚÂÓÂÚÁÂÈÒÓ ÂÎ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ™ Cushing ∫·Ù·ÚÚ¿ÎÙ˘ ™ÎÂÏÂÙÈÎfi ™. ∫¡™ ™·Î¯·Ú҉˘ ¢È·‚‹Ù˘ ∫·Ú‰È·ÁÁÂÈ·Îfi ™.

250

7,5 mg/ËÌ <10 mg/ËÌ 12% Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ 3% 20 mg

ªÂÙ¿ ‰›ÌËÓÔ ∂› 1 ¯ÚfiÓÔ 1Ô ¯ÚfiÓÔ ∫¿ı Â› ϤÔÓ ¯ÚfiÓÔ ∫·Ù¿ıÏÈ„Ë 10% ÀÔÌ·Óȷ΋ Û˘ÌÂÚÈÊÔÚ¿ 30% 10 mg/ËÌ 1,5 ÊÔÚ¿ ·‡ÍË̤ÓË Èı·ÓfiÙËÙ· 40 mg/ËÌ 8 ÊÔÚ¤˜ ·‡ÍË̤ÓË Èı·ÓfiÙËÙ· §fiÁˆ ·˘ÍË̤Ó˘ Û‡ÓıÂÛ˘ VLD ÏÈȉ›ˆÓ

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·251

¶·È‰È·ÙÚÈ΋ 2001;64:247-254

ÙÔ˘ Û¤ÚÌ·ÙÔ˜ ·Ó‰ÚÒÓ Î·Ù¿ ÙËÓ ËÏÈΛ· ·Ó··Ú·ÁˆÁ‹˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ›¯Â ¯ÔÚËÁËı› ΢ÎÏÔʈÛÊ·Ì›‰Ë ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ¤‰ÂÈÍ Ì›ˆÛË Î·Ù¿ 35% Ù˘ ˘ÎÓfiÙËÙ·˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ˘ÁÈ›˜ Ì¿ÚÙ˘Ú˜ ÌÂÙ¿ ‰›ÌËÓË Î·È 50% ÌÂÙ¿ ÙÂÙÚ¿ÌËÓË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. °ÂÓÈο, ˆ˜ ÚÔ˜ ÙËÓ ÙÔÍÈÎfiÙËÙ· ÙˆÓ ÁÔÓ¿‰ˆÓ Î·È ÙËÓ ÚfiÏË„Ë ÂÎ Ù˘ ·˙ˆÔÛÂÚÌ›·˜ ¤¯ÂÈ ıˆÚËı› ·ÛʷϤ˜ fiÙ·Ó Ë Û˘ÓÔÏÈο ¯ÔÚËÁÔ‡ÌÂÓË ∫˘ÎÏÔʈÛÊ·Ì›‰Ë ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 200-300 mg/kg Î·È Ë ÃÏˆÚ·Ì‚Ô˘Î›ÏË Ù· 8-10 mg/kg ȉ·ÓÈÎÔ‡ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (10,11). ∏ ıÂÙÈ΋ ‹ fi¯È ıÂÚ·¢ÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ·˘Ù¿ Ê¿Ú̷η ·Ó·Ê¤ÚÂÙ·È fiÙÈ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔ‚ÏÂÊı› Ì ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ∏L∞. ∞Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÛÙÔ ı¤Ì· ·˘Ùfi Â› 54 ·È‰ÈÒÓ ·Û¯fiÓÙˆÓ ·fi ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ ¡™, ¤‰ÂÈÍ fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ ∏L∞-Dr 7 ·ÓÙÈÁfiÓÔ˘ ‰ÂÓ Û˘ÓËÁÔÚÔ‡Û ˘¤Ú Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ‡ÊÂÛ˘ ÙÔ˘ ¡™, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Â› ıÂÙÈÎÔ‡ Dr7 Ë ÙÚÈÂÙ‹˜ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ ∫˘ÎÏÔʈÛÊ·Ìȉ˘ ·ÊÔÚÔ‡Û ÔÛÔÛÙfi 36% ÌfiÓÔ ÙˆÓ ·Û¯fiÓÙˆÓ ¤Ó·ÓÙÈ 81% Â› ·ÚÓËÙÈÎÔ‡ Dr 7 (13). ∞fi Ù· ÓÂfiÙÂÚ· Î·È ÏÈÁfiÙÂÚÔ ÁÓˆÛÙ¿ Ê¿Ú̷η Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Â›Ó·È Ë §È‚·ÌÈ˙fiÏË, Ô˘Û›· ·fi Ì·ÎÚÔ‡ ÁÓˆÛÙ‹ ˆ˜ ·ÓıÂÏÌÈÓıÈÎfi Ê¿ÚÌ·ÎÔ. ™ÙÔ ¡™ ‰ÔÎÈÌ¿ÛÙËΠ̠ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ‹‰Ë ·fi ÙÔ 1984 (14), ·ÏÏ¿ ÂÚÁ·Û›· ˘fi ÌÔÚÊ‹ ÔÏ˘ÎÂÓÙÚÈ΋˜ ÌÂϤÙ˘ ‰ËÌÔÛȇÙËΠ·fi ÙË µÚÂÙ·ÓÈ΋ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ·ÚÎÂÙ¿ ·ÚÁfiÙÂÚ· (15). ∞fi Ù· ‰Â‰Ô̤ӷ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜, Ë ÔÔ›· ÂÚÈÂÏ¿Ì‚·Ó 61 ·È‰È¿ Î·È ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠ›Ù §È‚·ÌÈ˙fiÏË Û ‰fiÛË 2,5 mg/kg ȉ·ÓÈÎÔ‡ ‚¿ÚÔ˘˜ Û ·Ú‹ÌÂÚÔ Û¯‹Ì· ›Ù placebo, ·Ú·ÙËÚ‹ıËΠ‡ÊÂÛË ÙÔ˘ ¡™ Û 14 ÂÍ ·˘ÙÒÓ Ô˘ ¤Ï·‚·Ó §È‚·ÌÈ˙fiÏË Û ۯ¤ÛË Ì 4 ·fi ÙËÓ ÔÌ¿‰· placebo. ∏ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ ‰È‹ÚÎÂÛ ÌfiÓÔÓ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ, ·ÏÏ¿ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ÔÈ ·ÛıÂÓ›˜ ˘ÔÙÚÔ›·Û·Ó ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ §È‚·ÌÈ˙fiÏ˘, Ë ÔÔ›· fï˜ ‰ÂÓ Â›¯Â ¯ÔÚËÁËı› ¤Ú·Ó ÙˆÓ 6 ÌËÓÒÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·˘ÙÔ‡, Â› Û˘ÓfiÏÔ˘ 140 ·Û¯fiÓÙˆÓ ‰È·ÈÛÙÒıËÎ·Ó 3 ÂÚÈÙÒÛÂȘ Ô˘‰ÂÙÂÚÔÂÓ›·˜ ·Ó·ÛÙÚ¤„ÈÌ˘ (14,15). ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ §È‚·ÌÈ˙fiÏ˘ Û 36 ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™ ÁÈ· ‰È¿ÛÙËÌ· ·fi 6 Ì‹Ó˜ ¤ˆ˜ 7 ¯ÚfiÓÈ·, ¤‰ÂÈÍ ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÂÍ¿ÚÙËÛË ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹ Û ÔÛÔÛÙfi 53,6% (16). ™Â Û˘Ìʈӛ· Ì ÙË µÚÂÙ·ÓÈ΋ ¶·È‰ÔÓÂÊÚÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Î·È ÛÙË

Paediatriki 2001;64:247-254

‰È΋ Ì·˜ ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ Ê¿ÚÌ·ÎÔ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi fiÙ·Ó ÛÙË ‰È¿ÚÎÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¡™ ¤¯ÂÈ ÚÔËÁËı› Ë ıÂÚ·›· Ì ∫˘ÎÏÔʈÛÊ·Ì›‰Ë (15). ŒÓ· ¿ÏÏÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Ê¿ÚÌ·ÎÔ Ô˘ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Â˘Ú‡Ù·Ù· ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÓÙ·ÂÙ›· Î·È ¤¯ÂÈ ·ÔÎÙËı› ÌÂÁ¿ÏË ÂÌÂÈÚ›· ˆ˜ ÚÔ˜ ÙË ‰Ú¿ÛË ÙÔ˘ ÛÙÔ ¡™, Â›Ó·È Ë ∫˘ÎÏÔÛÔÚ›ÓË (28). ∆Ô Ê¿ÚÌ·ÎÔ ·˘Ùfi ·¢ı‡ÓÂÙ·È Î·Ù¿ ‚¿ÛË Û ¿Û¯ÔÓÙ˜ ·fi ÎÔÚÙÈÎÔ¢·›ÛıËÙÔÎÔÚÙÈÎÔÂÍ·ÚÙÒÌÂÓÔ Ù‡Ô ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ôχ ÏÈÁfiÙÂÚÔ ÛÙÔÓ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô, fiÔ˘ Ë ·ÓÙ·fiÎÚÈÛË Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·ÚÎÂÙ¿ ÂÚÈÔÚÈṲ̂ÓË. ÃÔÚËÁÔ‡ÌÂÓÔ Û ‰fiÛË 150 mg/m2 ËÌÂÚËÛ›ˆ˜ Û ‰‡Ô ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ Î·È Ì ÛÙfi¯Ô Ó· ÂÈÙ¢¯ıÔ‡Ó Â›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ÔÏÈÎfi ·›Ì· ÌÂٷ͇ 100-200 mg/kg, ‰È·ÈÛÙÒıËΠ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Û ÔÛÔÛÙfi 85% Â› Û˘ÓfiÏÔ˘ 129 ·È‰ÈÒÓ (17,20,21). ∏ ÛÔ‚·Ú‹ ˘ÂÚ¯ÔÏËÛÙÂÚÈÓ·ÈÌ›· Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ Ù· ·È‰È¿ ·˘Ù¿ Ì ÙȘ Û˘¯Ó¤˜ ˘ÔÙÚÔ¤˜ ‹ ÙÔ ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô ÙÔ˘ ¡™, ·ÔÙÂÏ› Û˘¯Ó¿ ÂÌfi‰ÈÔ ÛÙË ‰Ú¿ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ÙÔ ÔÔ›Ô ˆ˜ ÏÈÔÊÈÏÈ΋ Ô˘Û›· ÌÂٷʤÚÂÙ·È ÛÙÔ ·›Ì· ̤ۈ ÙˆÓ HDL Î·È LDL. ¶·Ú·Ì¤ÓÔÓÙ·˜ ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Ë ∫˘ÎÏÔÛÔÚ›ÓË ‰ÂÛÌÂ˘Ì¤ÓË, ÏfiÁˆ ÙˆÓ ˘„ËÏÒÓ ÂÈ¤‰ˆÓ ÙˆÓ ÏÈȉ›ˆÓ ·˘ÙÒÓ, ‰ÂÓ ·Ô‰›‰ÂÈ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ıÂÚ·¢ÙÈο Â›‰·. ™Â ‰fiÛÂȘ ÂÓÙÔ‡ÙÔȘ, ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÌÔÚÔ‡Ó Ó· ÂÈÙ¢¯ıÔ‡Ó ıÂÚ·¢ÙÈο Â›‰· ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ‡ÊÂÛË ÙÔ˘ ¡™, ·ÏÏ¿ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÂÎ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Â›Ó·È Ôχ Èı·Ó‹ Î·È Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ Â›Ó·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ÓÂÊÚÈ΋˜ ‚ÈÔ„›·˜. AÙ˘¯Ò˜, ÔÈ ·ÛıÂÓ›˜ Ô˘ ı· ·ÓÙ·ÔÎÚÈıÔ‡Ó ÛÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ˘ÔÙÚÔÈ¿˙Ô˘Ó Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ Î·È Ë ·Ó·ÁηÛÙÈ΋ Â·Ó·¯ÔÚ‹ÁËÛ‹ Ù˘ ‰ÂÓ ÚÔ‰Èο˙ÂÈ ¿ÓÙÔÙ ¢ÓÔ˚Îfi ·ÔÙ¤ÏÂÛÌ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÌÈÎÚ‹ ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ (0,5 mg/kg Û ·Ú‹ÌÂÚÔ Û¯‹Ì·) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ∫˘ÎÏÔÛÔÚ›ÓË ¤¯ÂÈ Â˘ÓÔ˚Îfi ·ÔÙ¤ÏÂÛÌ·. ∏ Ì·ÎÚfi¯ÚÔÓË, ÂÓÙÔ‡ÙÔȘ, ¯ÔÚ‹ÁËÛ‹ Ù˘ (¤Ú·Ó ÙˆÓ ‰‡Ô ÂÙÒÓ) Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂÚ›ÛÎÂ„Ë Î·È ÂÎÙfi˜ ·fi ÙÔ Û˘¯Ófi ¤ÏÂÁ¯Ô ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ÓÂÊÚÈ΋ ‚ÈÔ„›· ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘. ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· ·fi 38 ·ÛıÂÓ›˜ fiÔ˘ ÙÔ Ê¿ÚÌ·ÎÔ ¯ÔÚËÁ‹ıËΠ·fi 2 Ì‹Ó˜ ¤ˆ˜ 7,5 ¯ÚfiÓÈ· ¤‰ÂÈÍ ıÂÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙ· 31 ·fi ·˘Ù¿, ÔÛÔÛÙfi 81,5%, Ë ‰Â Â·Ó·ÏËÙÈ΋ ÓÂÊÚÈ΋ ‚ÈÔ„›· Ô˘ ¤ÁÈÓ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÂÎ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Û ¤ÍÈ ÂÚÈÙÒÛÂȘ ÂÍ ·˘ÙÒÓ ‰ÂÓ ¤‰ˆÛÂ

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·ÔÙÂϤÛÌ·Ù· ÂÓ‰ÂÈÎÙÈο ÙÔÍÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi (18). ªÂÙ¿ ¿ÚÔ‰Ô ¯ÚfiÓÔ˘, ¤Ó· ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, Ô˘ Û ÔÛÔÛÙfi ·Ó¤Ú¯ÂÙ·È Û ÂÚ›Ô˘ 20% Î·È Ô˘ ÈÛÙÔÏÔÁÈο ·Ó‹ÎÂÈ ÛÙÔÓ Ù‡Ô ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ı· Û˘Ó¯›ÛÂÈ Ó· ˘ÔÙÚÔÈ¿˙ÂÈ. ∏ Â·Ó·ÏËÙÈ΋ ‚ÈÔ„›· ÓÂÊÚÔ‡ Ô˘ Û˘¯Ó¿ ‰ÈÂÓÂÚÁÂ›Ù·È ÛÙ· ¿ÙÔÌ· ·˘Ù¿ ·ÔηχÙÂÈ Û ÔÛÔÛÙfi 45%-75% ÂͤÏÈÍË ÙÔ˘ ÈÛÙÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Û ÂΛÓÔ Ù˘ ∂ÛÙȷ΋˜ ∆ÌËÌ·ÙÈ΋˜ ™ÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ (∂∆™). ∂¿Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ÚÔÛÙÂı› Î·È ¤Ó·˜ ·Ú¯ÈÎfi˜ ·ÚÈıÌfi˜ ÂÎ ÙˆÓ ·È‰ÈÒÓ Ô˘ Ô˘‰¤ÔÙ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙËÓ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È Ô˘ ·ÔÙÂÏ› ÂÚ›Ô˘ ÙÔ 15% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Á›ÓÂÙ·È ·ÓÙÈÏËÙfi fiÙÈ ¤Ó·˜ fi¯È ·Û‹Ì·ÓÙÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ı· Êı¿ÛÂÈ ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· ‹ ı· ÂÓËÏÈÎȈı› Ì ÙË ÓfiÛÔ ·˘Ù‹. ∆Ô ÁÂÁÔÓfi˜ ÏÔÈfiÓ fiÙÈ ·ÚÎÂÙ¿ ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓ ¡™ ı· ÂÍÂÏȯıÔ‡Ó, fiˆ˜ ÚԷӷʤÚıËÎÂ, Û ∂∆™ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÈÛ¯‡Ô˘Û· ·Ú·Ù‹ÚËÛË fiÙÈ 20%-25% ÙˆÓ ÚˆÙÔ·ıÒÓ ÂÚÈÙÒÛÂˆÓ ∂∆™ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙËÓ ·Ú¯È΋ ıÂÚ·¢ÙÈ΋ ÙÔ˘˜ ·ÓÙÈÌÂÙÒÈÛË Ì ÎÔÚÙÈÎÔÂȉ‹, ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÛÙËÓ ¿Ô„Ë fiÙÈ Ë ÓfiÛÔ˜ ÙˆÓ ÂÏ·¯›ÛÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Î·È Ë ∂∆™ ¤¯Ô˘Ó ÎÔÈÓ‹ ·ıÔÁ¤ÓÂÈ·. Œˆ˜ ÙÔ 1974, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·Ó ·ıÔÁÔÓÂÙÈο οÔÈ· ÚˆÙÔ·ı‹˜ ‚Ï¿‚Ë ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÁÂÓÈο. ∞ÚÁfiÙÂÚ· ·‰›¯ıË Ì ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔȯ›· fiÙÈ ˘¿Ú¯Ô˘Ó ·˘ÍË̤ӷ Â›‰· ÎÈÙÔÎÈÓÒÓ ÛÙÔ ·›Ì· Î·È È‰È·›ÙÂÚ· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 1 Î·È 8 Ù· ÔÔ›· ıˆڋıËÎ·Ó ˘‡ı˘Ó· ÁÈ· ÙËÓ ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜. ∏ ϤÔÓ ÚfiÛÊ·ÙË, ÂÓÙÔ‡ÙÔȘ, ¿Ô„Ë ˆ˜ ÚÔ˜ ÙËÓ ÎÔÈÓ‹ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ ÂÛÙÈ¿˙ÂÈ ÙÔ ÂӉȷʤÚÔÓ ÛÙÔ ÌÂÙ·ÙÚÂÙÈÎfi ·˘ÍËÙÈÎfi ·Ú¿ÁÔÓÙ· TGF-8, Ë ÁÔÓȉȷ΋ ¤ÎÊÚ·ÛË ÙÔ˘ ÔÔ›Ô˘ ÌÂÏÂÙ‹ıËΠ۠‚ÈÔ„È·Îfi ˘ÏÈÎfi 53 ·È‰ÈÒÓ Ì ¡™ Î·È ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ÙÔ˘ Û 2 ·fi 14 ·È‰È¿ Ì ÎÔÚÙÈÎÔ¢·›ÛıËÙÔ Ù‡Ô ¡™, Û 18 ·fi 20 Ì ÎÔÚÙÈÎÔ·ÓıÂÎÙÈÎfi Ù‡Ô Î·È Û 33 ·fi 39 ·È‰È¿ Ì ∂∆™. ∞fi ÙË ÁÂÓÂÙÈ΋ ·˘Ù‹ ÌÂϤÙË ÚÔ·ÙÂÈ fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÔÚ› Ó· ıˆÚËı› ‰Â›ÎÙ˘ ÚÒÈÌ˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ Ô˘ ¿ÏÏÔÙ ı· ÂÍÂÏȯı› Û ∂∆™. °ÂÓÂÙÈο, Ù¤ÏÔ˜, ‰Â‰Ô̤ӷ ·fi ÌÂϤÙË Ô˘ ¤¯ÂÈ ¤ˆ˜ ÙÒÚ· ‰ÈÂÓÂÚÁËı› Û ¤ÓÙ ÔÈÎÔÁ¤ÓÂȘ Ì ÔÈÎÔÁÂÓ¤˜ ¡™ ¤‰ÂÈÍ·Ó ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú· ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÛÙȘ ÙÚÂȘ Î·È ˘ÔÏÂÈfiÌÂÓÔ ÛÙȘ ‰‡Ô, Ë ‰Â ¯·ÚÙÔÁÚ¿ÊËÛË ÙÔ˘ ˘‡ı˘ÓÔ˘ ÁÈ· ÙË ÓfiÛÔ ÁÔÓȉÈÒÌ·ÙÔ˜ ¤¯ÂÈ

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ÂÓÙÔÈÛÙ› ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· 19q, 13,11q, q21q22, Iq25-q31, Iq (19). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ∂∆™ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·˘Í·ÓfiÌÂÓË Î·Ù¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÚÈÓ ÙÔ 1990 ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 20% ÁÈ· ÙË Ï¢΋ Ê˘Ï‹, 38% ÁÈ· ÙË Ì·‡ÚË Î·È 8% ÁÈ· ÙËÓ ¤Á¯ÚˆÌË ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÌÂÙ¿ ÙÔ 1990 Ù· ÔÛÔÛÙ¿ ·˘Ù¿ ·Ó¤Ú¯ÔÓÙ·È ÁÈ· ÙȘ ·ÓÙ›ÛÙÔȯ˜ Ê˘Ï¤˜ Û 45%, 69% Î·È 33% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¡™ (24). ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∂∆™ ·ÎÔÏÔ˘ı›, ηٿ ÙË Ê¿ÛË Ù˘ ÚÒÙ˘ ‰È¿ÁÓˆÛ˘, Ù· ›‰È· ıÂÚ·¢ÙÈο ÛÙ¿‰È· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ·Ó·ÛÔηٷÛÙ·ÏÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ÚԷӷʤÚıËηÓ. ¶ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó 378 ·ÛıÂÓ›˜ Ì ∂∆™ ¤‰ÂÈÍ fiÙÈ ÔÛÔÛÙfi 25% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ı` ·ÓÙ·ÔÎÚÈı› ÛÙ· ÎÔÚÙÈÎÔÂȉ‹ Ï‹Úˆ˜, 3% ı· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÂÚÈ΋ ·ÓÙ·fiÎÚÈÛË Î·È ÙÔ ˘fiÏÔÈÔ 72% ı· Â›Ó·È ·ÓıÂÎÙÈÎfi ÛÙ· ‰È¿ÊÔÚ· ıÂÚ·¢ÙÈο Û¯‹Ì·Ù· (20,21). OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÚ¢ÓËÙ¤˜ Û˘ÌʈÓÔ‡Ó ÛÙËÓ ¿Ô„Ë fiÙÈ Ë Î˘ÎÏÔʈÛÊ·Ì›‰Ë ‰ÂÓ ¤¯ÂÈ ıÂÙÈÎfi ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û ·ÓÙ›ıÂÛË Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ÁÈ· ÙËÓ ÔÔ›· Ù· ÔÛÔÛÙ¿ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ Î˘Ì·›ÓÔÓÙ·È Â˘Ú‡Ù·Ù· ·fi 20%-80%. ∏ ‰Ú¿ÛË Ù˘ ¿ÓÙˆ˜ Â›Ó·È Î·Ï‡ÙÂÚË fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ÌÈÎÚ‹ ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ (21). ŒÓ· ¿ÏÏÔ ıÂÚ·¢ÙÈÎfi Û¯‹Ì· Ô˘ ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ Ì ∂∆™ Â›Ó·È ÙÔ ÚˆÙfiÎÔÏÏÔ Mendoza, ÙÔ ÔÔ›Ô ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ¤Á¯˘ÛË IV Methylprednisolone 30 mg/kg (Solu-Medrol) ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (30 Û˘ÓÔÏÈΤ˜ ‰fiÛÂȘ Û 20 Ì‹Ó˜). ™ÙËÓ ÂÚÁ·Û›· ·˘Ù‹, ÔÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û 66% ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘˜, ÌfiÓÈÌË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È Ì›ˆÛË Ù˘ GFR Û ÔÛÔÛÙfi 9%, á∞ ÌË ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ 16% Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ 9% (22). ∏ ÚÔÛˆÈ΋ Ì·˜ ÂÌÂÈÚ›· Â› Ì›· ‰ÂηÂÓÙ·ÂÙ›· ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË 23 ·È‰ÈÒÓ Ì ∂∆™ ¤‰ÂÈÍ ̷ÎÚfi¯ÚÔÓË ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ÔÛÔÛÙfi 66,6%, Ù· ıÂÚ·¢ÙÈο ‰Â Û¯‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó fiÌÔÈ· Ì ٷ ÚÔ·Ó·ÊÂÚı¤ÓÙ· (23). ŒÓ· ¿ÏÏÔ ıÂÚ·¢ÙÈÎfi Û¯‹Ì· Ôχ Ï›ÁÔ ‰ÔÎÈÌ·Ṳ̂ÓÔ, ·ÊÔÚ¿ ÛÙË ¯ÔÚ‹ÁËÛË µÈÓÎÚÈÛÙ›Ó˘ πV, ¿·Í ‚‰ÔÌ·‰È·›ˆ˜ Û ‰fiÛË 1,5 mg/m2 Â› ÔÎÙÒ Â‚‰ÔÌ¿‰Â˜. ∆· ·ÔÙÂϤÛÌ·Ù· ·fi ÚÒÙË ÂÎÙ›ÌËÛË ÎÚ›ÓÔÓÙ·È ÂÓı·ÚÚ˘ÓÙÈο (24). ∞fi ¿ÏÏË ÔÌ¿‰· ÂÚ¢ÓËÙÒÓ ÛÙȘ ∏.¶.∞. ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Ë Ê·Ú̷΢ÙÈ΋ Ô˘Û›· Tacrolimus (FK 508) Û ‰fiÛË 0,15 mg/kg Û ‰‡Ô ‰È·ÈÚÂ̤Ó˜ ‰fiÛÂȘ. ∆Ô Ê¿ÚÌ·ÎÔ ¯ÔÚËÁ‹ıËΠ۠20 ·È‰È¿ Ì ∂∆™ Î·È Ù· ÚÔηٷÚÙÈο ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó Ï‹ÚË ‡ÊÂÛË ÛÙÔ 40% Î·È ÌÂÚÈ΋ ÛÙÔ 25% ÙˆÓ ·Û¯fiÓÙˆÓ.

MAY- JUNE '01 TELIKO

30-05-03

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∏ Ê·Ú̷΢ÙÈ΋ ‰Ú¿ÛË Ù˘ Ô˘Û›·˜ ·˘Ù‹˜, fiˆ˜ Î·È ÔÈ ·ÚÂÓ¤ÚÁÂȘ, ÂÚÈÁÚ¿ÊÔÓÙ·È fiÌÔȘ Ì ÂΛӘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ Èı·Ó‹˜ ÙÔÍÈÎfiÙËÙ·˜ Ú¤ÂÈ Ó· ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ù· Â›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ·›Ì· (25). ø˜ ÚÔ˜ ÙËÓ ÂÊ·ÚÌÔÁ‹, Ù¤ÏÔ˜, ¿ÏÏˆÓ Ù¯ÓÈÎÒÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∂∆™ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ˘¿Ú¯Ô˘Ó ÌÂÌÔӈ̤ӷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ¯Ú‹ÛË Ù˘ ÏÈȉԷʷ›ÚÂÛ˘ (26), Ù˘ Ï·ÛÌ·Ê·›ÚÂÛ˘ (27), fiˆ˜ Â›Û˘ Î·È Ù˘ πV ¯Ú‹Û˘ Ù˘ ∫˘ÎÏÔʈÛÊ·Ì›‰Ë˜ Û ̛· ÂÊ¿·Í ‰fiÛË ÙˆÓ 50 mg/m2 ÌËÓÈ·›ˆ˜ Â› 6 Ì‹Ó˜. ∂¿Ó Ô ·ÛıÂÓ‹˜ ηٷϋÍÂÈ Û ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÌÔÚ› Ó· ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Enfants Malades ÙÔ˘ ¶·ÚÈÛÈÔ‡, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙÔ 35% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·È‰ÈÒÓ ÌÂٷ͇ 1973-1996. ∞Ù˘¯Ò˜, Ë ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ·Ú¯È΋ ÚÔÛ‚ÔÏ‹ ÂÍ ·˘Ù‹˜ ·ÊÔÚ¿ Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 6 ¯ÚfiÓˆÓ, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·Ó¤Ú¯ÂÙ·È ÛÙËÓ ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ÙÔ˘ 54% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ∂∆™. ∞fi ÙÔ ›‰ÈÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ·Ó·Ê¤ÚÂÙ·È ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÔÛÔÛÙ¿ Ù˘ ٿ͈˜ ÙÔ˘ 60% Û˘ÓÂ›· Ù˘ ÚÔ·Ó·ÊÂÚı›۷˜ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·. ∞fi ÙȘ ıÂÚ·¢ÙÈΤ˜ ÚÔÙ¿ÛÂȘ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ı¤Ì· ·˘Ùfi, ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ‰›‰ÂÙ·È ÛÙËÓ Ï·ÛÌ·Ê·›ÚÂÛË (28).

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¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ¡. °ÂˆÚÁ¿ÎË-∞ÁÁÂÏ¿ÎË ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ŸÙ·Ó Ô “Û˘ÚÈÁÌfi˜” ‰ÂÓ Â›Ó·È Û˘ÚÈÁÌfi˜: ·ÎÔ˘ÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ ÛÙ· ‚Ú¤ÊË1 ∂ÈÛ·ÁˆÁ‹: OÈ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ “Û˘ÚÈÁÌÔ‡” (“wheeze”) Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏfi˜ ηٿ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜. ∂ÓÙÔ‡ÙÔȘ, ¤¯ÂÈ Á›ÓÂÈ Ê·ÓÂÚfi fiÙÈ ÙfiÛÔ ÔÈ ÁÔÓ›˜, fiÛÔ Î·È ÔÈ ÁÈ·ÙÚÔ› ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔÓ fiÚÔ “Û˘ÚÈÁÌfi˜” ÁÈ· Ì›· ÔÈÎÈÏ›· ·ÎÔ˘ÛÙÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ. OÈ Û˘¯ÓfiÙÂÚÔÈ ·ÎÔ˘ÛÙÔ› ‹¯ÔÈ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ˘˜ ηÙÒÙÂÚÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È “ÚfiÁ¯ÔÈ” (“ruttles”), ÔÈ ÔÔ›ÔÈ ‰È·Ê¤ÚÔ˘Ó ·fi ÙÔÓ ÎÏ·ÛÈÎfi Û˘ÚÈÁÌfi ‰ÈfiÙÈ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi Ôχ ¯·ÌËÏfiÙÂÚ˜ Û˘¯ÓfiÙËÙ˜, Û˘Ó¯fiÌÂÓÔ “ÎÚÔÙ¿ÏÈÛÌ·” Î·È ÛÙÂÚÔ‡ÓÙ·È ÌÔ˘ÛÈÎfiÙËÙ·˜. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó, Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ·ÎÔ˘ÛÙÈ΋˜ ·Ó¿Ï˘Û˘, Ó· Á›ÓÂÈ Û·Ê‹˜ ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘ Û˘ÚÈÁÌÔ‡ ·fi ÙÔ˘˜ “ÚfiÁ¯Ô˘˜”. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ¤Ó· ÌÈÎÚfi ¢·›ÛıËÙÔ ÈÂ˙ÔËÏÂÎÙÚÈÎfi ·ÈÛıËÙ‹Ú· ÂÈÙ¿¯˘ÓÛ˘ (piezoelectric accelerometer) ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ó¢ÌÔÓÈÎÒÓ ‹¯ˆÓ Û 15 ‚Ú¤ÊË, ÂÙ¿ ÌÂ Û˘ÚÈÁÌfi Î·È ÔÎÙÒ Ì “ÚfiÁ¯Ô˘˜”. ¶ÏËÚÔÊÔڛ˜ Û¯ÂÙÈΤ˜ Ì ÙÔÓ Î‡ÎÏÔ Ù˘ ·Ó·ÓÔ‹˜ ÂÏ‹ÊıËÛ·Ó Ì ÙË ¯Ú‹ÛË Â·ÁˆÁÈ΋˜ ÏËı˘ÛÌÔÁÚ·Ê›·˜. ∆· ·ÎÔ˘ÛÙÈο Û‹Ì·Ù· ·Ó·Ï‡ıËÎ·Ó Ì ÙË ‚Ô‹ıÂÈ· Ù·¯Â›·˜ ηٿ Fourier ÌÂÙ·ÙÚÔ‹˜ (Respiratory Acoustics Laboratory Environment programme). ∞ÔÙÂϤÛÌ·Ù·: ¢Â›¯ıËΠfiÙÈ ÔÈ ·ÎÔ˘ÛÙÈΤ˜ ȉÈfiÙËÙ˜ ÙˆÓ ‰‡Ô ‹¯ˆÓ ‹Ù·Ó ÂÓÙÂÏÒ˜ ‰È·ÎÚÈÙ¤˜. O ÎÏ·ÛÈÎfi˜ Û˘ÚÈÁÌfi˜

254

¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi Î˘Ì·ÙÔÂȉ‹ ÌÔÚÊÔÏÔÁ›· Ù˘ ηÌ‡Ï˘, Ì ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ ‰È·ÎÚÈÙ¤˜ ÎÔÚ˘Ê¤˜ ÛÙË ‰È¿Ù·ÍË Ê·ÛÌ·ÙÈ΋˜ ÈÛ¯‡Ô˜, ÂÓÒ ÔÈ “ÚfiÁ¯ÔÈ” ·ÓÙÈÚÔÛˆ‡ÔÓÙ·Ó ·fi Ì›· ·Î·ÓfiÓÈÛÙË, ÌË Î˘Ì·ÙÔÂȉ‹ ηÌ‡ÏË, Ì ‰È¿¯˘Ù˜ ÎÔÚ˘Ê¤˜ ÛÙË Ê·ÛÌ·ÙÈ΋ ÈÛ¯‡ Î·È Ì ·˘ÍË̤ÓË ¤ÓÙ·ÛË ÙÔ˘ ‹¯Ô˘ ÛÙȘ Û˘¯ÓfiÙËÙ˜ <600 Hz. ™˘ÌÂÚ¿ÛÌ·Ù·: ∂›Ó·È ÛËÌ·ÓÙÈ΋ Ë ‰È¿ÎÚÈÛË, ÙfiÛÔ ÁÈ· ÙÔ˘˜ ÎÏÈÓÈÎÔ‡˜ ÁÈ·ÙÚÔ‡˜, fiÛÔ Î·È ÁÈ· ÙÔ˘˜ ÂȉËÌÈÔÏfiÁÔ˘˜, ÙˆÓ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ·ÎÔ˘ÛÙÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ, Ì ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ·ÎÔ˘ÛÙÈΤ˜ ȉÈfiÙËÙ˜, ηٿ Ù· ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜.

1

Elphick HE, Ritson S, Rogers H, Everard ML When a “wheeze” is not a wheeze: acoustic analysis of breath sounds in infants Eur Respir J 2000;16:593-597 ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ

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Paediatriki 2001;64:255-260

NEPHROLOGY

π‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÛÙ· ·È‰È¿ ∫. π. ™ÙÂÊ·Ó›‰Ë˜

Idiopathic hypercalciuria C. J. Stefanidis

¶ÂÚ›ÏË„Ë: ∏ ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ·, ·ÊÔ‡ ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ 7% ÙÔ˘ ÏËı˘ÛÌÔ‡. ∞ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘ Î·È Û˘¯Ó¿ ‰È·ÈÛÙÒÓÂÙ·È Û ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Û˘¯ÓÔ˘Ú›·˜‰˘ÛÔ˘Ú›·˜. ∂›Û˘, ¤¯ÂÈ ·ÈÙÈÔÏÔÁÈο Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÔÛÙÂÔfiÚˆÛ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· ·È‰È¿ Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 3,5 mg/kg/24ˆÚÔ, ÂÓÒ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ‰È·ÈÛÙÒÓÔÓÙ·È Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË. ™Ù· ·È‰È¿ ıˆÚÂ›Ù·È ·˘ÍË̤ÓÔ ÙÔ ËÏ›ÎÔ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË ÂÓfi˜ Ù˘¯·›Ô˘ ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ, fiÙ·Ó Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi 0,2 mg/mg ‹ 0,5 mmol/mmol. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ πÀ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. ¶ÚfiÛÊ·Ù· ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Ù· ÁÔÓ›‰È· ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D, Ù˘ 1· ˘‰ÚÔÍ˘Ï¿Û˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D Î·È ÙˆÓ ‰È·‡ÏˆÓ ¯ÏˆÚ›Ô˘ ˆ˜ ˘‡ı˘Ó· ÁÈ· ÙËÓ πÀ. ™‡ÓÙÔÌ· ·Ó·Ì¤ÓÂÙ·È Î·È ¿ÏÏ· ÁÔÓ›‰È· Ó· Ù·˘ÙÔÔÈËıÔ‡Ó. ∏ Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË Ù˘ Àπ ÂÍ·ÚÙ¿Ù·È Î·È ·fi ‰È·ÙÚÔÊÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, fiˆ˜ Â›Ó·È Ë ÚfiÛÏË„Ë ÙÔ˘ Ó·ÙÚ›Ô˘, ÙÔ˘ Î·Ï›Ô˘ Î·È ÙˆÓ ÚˆÙÂ˚ÓÒÓ. ¢ÂÓ Û˘ÓÈÛÙ¿Ù·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ πÀ, ÁÈ·Ù› Ì·ÎÚfi¯ÚÔÓÈ· ÚÔηÏ› ÂÏ¿ÙÙˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜. OÈ ·ÛıÂÓ›˜ Ì πÀ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ÂÚÈÔÚÈÛÌfi ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È Ì ·˘ÍË̤ÓË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ. ∂›Û˘, Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ˘‰ÚԯψÚÔıÂÈ·˙›‰Ë Û ·È‰È¿ Ì πÀ Î·È ˘ÔÙÚÔÈ¿˙Ô˘Û· Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ‹ ÓÂÊÚÔÏÈı›·ÛË.

Abstract: Idiopathic hypercalciuria (IH) is a common disorder affecting about 7% of the population. IH is the main cause of renal stone disease and it is frequently diagnosed in children with hematuria and the frequency-dysuria syndrome. Its role in the development of osteoporosis in adults is also documented. Normal calcium excretion rate in children is defined as being lower than 3.5 mg/kg per day, while significantly higher values are observed in infants.

In children a urinary calcium/creatinine ratio, obtained in a single voided morning specimen, that is greater than 0.2 mg/mg or 0.5 mmol/mmol is regarded as elevated. Recent studies indicate a multifactorial etiology of IH. Some candidate genes responsible for idiopathic hypercalciuria include those of the vitamin D receptor, the 1 alphahydroxylase of vitamin D and chloride channels, but others remain to be identified. The phenotypic expression of IH depends on many nutritional factors, such as the intake of sodium, potassium and proteins. Dietary calcium restriction can no longer be recommended for the treatment of IH, because on a long-term basis it may cause decreased bone mineral density. Patients with IH should be kept on a dietary sodium restriction and high fluid intake. Hydrochlorothiazide should be prescribed when IH is associated with recurrent episodes of macroscopic hematuria or stone disease.

§¤ÍÂȘ ÎÏÂȉȿ: ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ÓÂÊÚÔÏÈı›·ÛË, ·ÈÌ·ÙÔ˘Ú›·, ˘‰ÚԯψÚÔıÂÈ·˙›‰Ë.

Key words: idiopathic hypercalciuria, renal stone disease, hematuria, hydrochlorothiazide.

∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ NÂÊÚÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ AıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

∞ssociate Director Division of Nephrology “A. & P. Kyriakou” Children’s Hospital, Athens

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∏ ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) Â›Ó·È ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ·, ·ÊÔ‡ ÂÌÊ·Ó›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 7% ÙÔ˘ ÏËı˘ÛÌÔ‡, Ì ÙËÓ ›‰È· Û˘¯ÓfiÙËÙ· ÙfiÛÔ ÛÙ· ·È‰È¿, fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (1). O fiÚÔ˜ πÀ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Albright Î·È Henneman Ùo 1953 Û ·ÛıÂÓ›˜ Ì ·Û‚ÂÛÙÈÔ˘Ú›· Î·È ÓÂÊÚÔÏÈı›·ÛË Ì ϛıÔ˘˜ ·fi ·Û‚¤ÛÙÈÔ, ÔÈ ÔÔ›ÔÈ Â›¯·Ó Ê˘ÛÈÔÏÔÁÈÎfi ·Û‚¤ÛÙÈÔ Î·È ÊˆÛÊfiÚÔ ÔÚÔ‡ Î·È Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÎÙÈÓÔÁڷʛ˜ ÔÛÙÒÓ (2). ŒÙÛÈ, ÁÈ· Ó· ‰È·ÁÓˆÛÙ› πÀ Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó fiϘ ÔÈ ¿ÏϘ ·Èٛ˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (¶›Ó·Î·˜ 1). ø˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÔÚ›˙ÂÙ·È Ë ËÌÂÚ‹ÛÈ· ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Û ÔÛfiÙËÙ· ÌÂÁ·Ï‡ÙÂÚË ·fi 3,5 mg/kg (‹ 0,18 mmol/kg). ™Â ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, ÙfiÛÔ Û ÂÓ‹ÏÈΘ fiÛÔ Î·È Û ·È‰È¿ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë ¿Ô„Ë fiÙÈ Ë ‰È¿ÁÓˆÛË Â›Ó·È Ôχ Èı·Ó‹ fiÙ·Ó ÙÔ ËÏ›ÎÔ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË ÂÓfi˜ Ù˘¯·›Ô˘ ‰Â›ÁÌ·ÙÔ˜ Ô‡ÚˆÓ (Ca/Cr Ô‡ÚˆÓ) Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi 0,2 mg/mg ‹ 0,5 mmol/mmol (3,4). OÚȷΤ˜ ÙÈ̤˜ ÙÔ˘ ËÏ›ÎÔ˘ Ca/Cr Ô‡ÚˆÓ ÌÂٷ͇ 0,15 mg/mg Î·È 0,20 mg/mg Ú¤ÂÈ Ó· ‚¿˙Ô˘Ó ÙËÓ ˘Ô„›· ÁÈ· Èı·Ó‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ·ÊÔ‡ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ı· ‰È·ÁÓˆÛÙ› ÙÂÏÈο ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ 65% ÙˆÓ ·È‰ÈÒÓ Ì ÙȘ ÙÈ̤˜ ·˘Ù¤˜ (3). ™Ù· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ÌËÓÒÓ ‰ÂÓ ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÂ›Ù·È Ë ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·fi ÙÔ ËÏ›ÎÔ Ca/Cr Ô‡ÚˆÓ, ·ÏÏ¿ ÌfiÓÔ ·fi Û˘ÏÏÔÁ¤˜ Ô‡ÚˆÓ 24ÒÚÔ˘. ™ÙËÓ ËÏÈΛ· ·˘Ù‹, ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ Ô‡ÚˆÓ 24ÒÚÔ˘ Û ÔÛfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 3,5 mg/kg (‹ 0,18 mmol/kg) ıˆÚÔ‡ÓÙ·È ·ıÔÁÓˆÌÔÓÈΤ˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (3). ¶ÚfiÛÊ·Ù·, ÂÎÙfi˜ ·Ô ÙË ÓÂÊÚÔÏÈı›·ÛË, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ πÀ Î·È ·ÚÎÂÙ¿ ¿ÏÏ· ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù·. ∂›Û˘, ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ë ·ÈÙÈÔÏÔÁ›· Ù˘ Î·È ¤¯Ô˘Ó ·Ó·ıˆÚËı› ÔÏϤ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘.

Paediatriki 2001;64:255-260

∫ÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ È‰ÈÔ·ı‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ∏ πY Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘, ·ÊÔ‡ ÂÚ›Ô˘ ÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔÏÈı›·ÛË Ì ϛıÔ˘˜ ·fi ·Û‚¤ÛÙÈÔ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔ Úfi‚ÏËÌ· ·˘Ùfi (4). ∂›Û˘, ¤¯ÂÈ ÙÂÎÌËÚȈı› Ì ÔÏϤ˜ ÌÂϤÙ˜ fiÙÈ ÔÈ Ï›ıÔÈ Ì ·Û‚¤ÛÙÈÔ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ÓÂÊÚÔÏÈı›·Û˘. ∏ ‰È¢ÎÚ›ÓÈÛË Ù˘ ÔÈÎÔÁÂÓÔ‡˜ ÚԉȿıÂÛ˘ ÁÈ· ÓÂÊÚÔÏÈı›·ÛË Û ·ÛıÂÓ›˜ Ì πÀ Â›Ó·È ‰˘Û¯ÂÚ‹˜, ÁÈ·Ù› Ë πÀ ·ÔÙÂÏ› ¤Ó· ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓÂÊÚÔÏÈı›·Û˘. ŒÙÛÈ, ÔÈ ·ÛıÂÓ›˜ Ì ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·fi ·˘ÍË̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ ÌÔÚ› Ó· ÌËÓ ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÔÙ¤ πÀ, ·Ó Ë ÚfiÛÏË„Ë ·Û‚ÂÛÙ›Ô˘ ‹/Î·È Ó·ÙÚ›Ô˘ Â›Ó·È ¯·ÌËÏ‹ (5). ∞ÎfiÌ·, Ë ÂÌÊ¿ÓÈÛË ÓÂÊÚÔÏÈı›·Û˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Û˘Ó‡·Ú͢ ‰È·ÊfiÚˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ŒÙÛÈ, ÛÙ· ·È‰È¿ Ì ÓÂÊÚÔÏÈı›·ÛË Û˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó Ì ÙËÓ πÀ Î·È ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù· (6), fiˆ˜ Ë ·‡ÍËÛË Ô˘ÚÈÎÔ‡ ÔͤԘ Ô‡ÚˆÓ (ÛÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ), Ë ˘ÂÚÔÍ·ÏÔ˘Ú›· (ÛÙÔ 30 ˆ˜ 40%) Î·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÎÈÙÚÈÎÒÓ ÙˆÓ Ô‡ÚˆÓ (ÛÙÔ 25%) (5). ∆¤ÏÔ˜, Ë ÔÈÎÔÁÂÓ‹˜ ÂÈ‚¿Ú˘ÓÛË Ê·›ÓÂÙ·È fiÙÈ Û˘Ó‹ıˆ˜ ‰ÂÓ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ ÂÓfi˜ ÁÔÓȉ›Ô˘, ·ÏÏ¿ Û ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÏÏËÏÂ›‰Ú·ÛË ÔÏÏ·ÏÒÓ ÁÔÓȉ›ˆÓ Ì ‰È·ÊÔÚÂÙÈ΋ Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË ÛÙ· ‰È¿ÊÔÚ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (4). ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë πÀ Â›Ó·È Ì›· Û˘¯Ó‹ ·ÈÙ›· ·ÈÌ·ÙÔ˘Ú›·˜ (7-10). ŒÙÛÈ, Ôχ Û˘¯Ó¿ Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ πÀ Á›ÓÂÙ·È ·fi ÙËÓ ·ÈÙÈÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Ë Û˘Û¯¤ÙÈÛË Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Ì ÙËÓ πÀ ¤ÁÈÓ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1981 ·fi ÙÔÓ Moore (10) Î·È ÛÙȘ ÂfiÌÂÓ˜ ‰‡Ô ‰ÂηÂٛ˜ ÂȂ‚·ÈÒıËΠ̠·ÚÎÂÙ¤˜ ÌÂϤÙ˜. ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Î˘Ì·›ÓÂÙ·È ·fi ÙÔ 9% ¤ˆ˜ ÙÔ 35% ÙˆÓ ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔ˘Ú›· (79,11). ∂›Û˘, ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Ë πÀ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Î·È Û ÂÓ‹ÏÈΘ

¶›Ó·Î·˜ 1. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ ÔÚÔ‡ (3) 1.

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π‰ÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· (πÀ) ∫ÏËÚÔÓÔÌÈ΋ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ì ˘ÔʈÛÊ·Ù·ÈÌÈ΋ Ú·¯›Ùȉ· (¡fiÛÔ˜ ÙÔ˘ Dent) ªÂÙ¿ÏÏ·ÍË ÙÔ˘ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘ CLCN5 ™·ÚÎÔ›‰ˆÛË ™‡Ó‰ÚÔÌÔ Bartter NÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ÔͤˆÛË ª·ÎÚfi¯ÚÔÓË ·ÎÈÓËÙÔÔ›ËÛË A˘ÍË̤ÓË ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘, ‚ÈÙ·Ì›Ó˘ D ‹ ·Û‚ÂÛÙ›Ô˘ £ÂÚ·›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÊÔ˘ÚÔÛÂÌ›‰Ë ‹ ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂ ™‡Ó‰ÚÔÌÔ Seyberth (˘ÂÚÚÔÛÙ·ÁÏ·Ó‰ÈÓ·ÈÌ›· ∂) £˘ÚÂÔÙÔ͛ΈÛË

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¶·È‰È·ÙÚÈ΋ 2001;64:255-260

(15). ∆· ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì πÀ Û˘Ó‹ıˆ˜ Â›Ó·È ·ÁfiÚÈ· Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÓÂÊÚÔÏÈı›·Û˘, Ì ÎÚ˘ÛÙ¿ÏÏÔ˘˜ ÔÍ·ÏÈÎÔ‡ ·Û‚ÂÛÙ›Ô˘ ÛÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË Ô‡ÚˆÓ Î·È ·ÚÔ˘Û›·˙·Ó ÈÔ Û˘¯Ó¿ Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· (11). ∂›Û˘, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜ ·ÚÔ˘Û›·Û·Ó ÓÂÊÚÔÏÈı›·ÛË Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·fi fiÙÈ Ù· ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ (17). ŒÙÛÈ Ê·›ÓÂÙ·È fiÙÈ Ë ‰È·›ÛÙˆÛË πÀ Û ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ÓÂÊÚÔÏÈı›·ÛË Î·È Ì ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ πÀ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÏËÊıÔ‡Ó ÛËÌ·ÓÙÈο ÌÂÏÏÔÓÙÈο ÚÔ‚Ï‹Ì·Ù·. ∂ÎÙfi˜ ·fi ÙËÓ ·ÈÌ·ÙÔ˘Ú›·, Ë πÀ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ٷ ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ Î·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË Â›Ó·È Ë ‰È·›ÛÙˆÛË ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ˘ÂÚ˯ÔÁÂÓÒÓ ÎËÏ›‰ˆÓ ÛÙȘ Î¿Ï˘Î˜. ∞fi Ù· 196 ·È‰È¿ ËÏÈΛ·˜ 0,9 ¤ˆ˜ 15,9 ÂÙÒÓ ÛÙ· ÔÔ›· ‰È·ÈÛÙÒıËΠÙÔ Úfi‚ÏËÌ· ·˘Ùfi, ÛÙÔ 70% ˘‹Ú¯Â ÈÛÙÔÚÈÎfi ÓÂÊÚÔÏÈı›·Û˘ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ¤Ó· Û˘ÁÁÂÓ‹ ÚÒÙÔ˘ ‹ ‰Â˘Ù¤ÚÔ˘ ‚·ıÌÔ‡. ∆· ·È‰È¿ ·˘Ù¿ ›¯·Ó ·ÚÔ˘ÛÈ¿ÛÂÈ ·ÈÌ·ÙÔ˘Ú›· Û ÔÛÔÛÙfi 41%, ÎÔÈÏȷο ¿ÏÁË ‹/Î·È Î˘ÛÙÈο ÂÓԯϋ̷ٷ. ™ÙÔ 33% ÙˆÓ ·ÛıÂÓÒÓ ‰È·ÈÛÙÒıËΠ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ÂÓÒ ÛÙÔ 20% ·‡ÍËÛË ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÙˆÓ Ô‡ÚˆÓ. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÙÔ 33% ÙˆÓ 29 ·È‰ÈÒÓ ·ÚÔ˘Û›·Û ÓÂÊÚÔÏÈı›·ÛË ÌÂÙ¿ ·fi 2-9 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ (16). ∏ Î·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË ÌÔÚ› Ó· Â›Ó·È ¤Ó· ·Ú¯ÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÔÏÈı›·Û˘ Î·È Èı·ÓÒ˜ ÂÍËÁ› ÔÏÏ¿ ·fi Ù· Û˘ÌÙÒÌ·Ù· Î·È Â˘Ú‹Ì·Ù· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ (16). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ¤¯ÂÈ Á›ÓÂÈ

Paediatriki 2001;64:255-260

ÈÔ Û˘¯Ó‹ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ (18,19). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ·fi Ù· 16 ·È‰È¿ Ì ÙÔ Úfi‚ÏËÌ· ·˘Ùfi, ÌfiÓÔ Ù· ‰‡Ô ›¯·Ó ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ÎÔÈÏ›·˜ (19). ™˘¯Ó¿, ÙÔ ÌfiÓÔ Â‡ÚËÌ· ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È ÔÈ ˘ÂÚ˯ÔÁÂÓ›˜ ÓÂÊÚÈΤ˜ ˘Ú·Ì›‰Â˜.

AÈÙÈÔÏÔÁ›· ∏ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌÔÚ› Ó· ÚÔÎÏËı› ·fi ÙËÓ ·ÏÏËÏÂ›‰Ú·ÛË ‰È·ÊfiÚˆÓ ÁÂÓÂÙÈÎÒÓ ‹ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (¶›Ó·Î·˜ 3). ∏ πÀ Ê·›ÓÂÙ·È fiÙÈ ÌÂÙ·‚È‚¿˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ·˘ÙfiÛˆÌÔ ÂÈÎÚ·ÙÔ‡ÓÙ· Ù‡Ô ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ (21). ŸÌˆ˜, Ë ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌÔÚ› Ó· ÌÂÙ·‚È‚¿˙ÂÙ·È Î·È Ì ˘ÔÏÂÈfiÌÂÓÔ Ê˘ÏÔÛ‡Ó‰ÂÙÔ Ù‡Ô ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÂÙ·ÏÏ¿ÍÂȘ Û ÁÔÓ›‰È· Ù· ÔÔ›· ÂϤÁ¯Ô˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÂÓfi˜ ÓÂÊÚÈÎÔ‡ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘, Ô˘ ¤¯ÂÈ ÚfiÛÊ·Ù· ÂÚÈÁÚ·Ê› (22). To ›‰ÈÔ Úfi‚ÏËÌ· ÌÔÚ› Ó· ¤¯ÂÈ Î·È ÔÈÎÔÁÂÓ‹ ¯·Ú·ÎÙ‹Ú·, fï˜ ·ÎfiÌË ‰ÂÓ ¤¯ÂÈ Ù·˘ÙÔÔÈËı› Ë ÁÔÓȉȷ΋ ‚Ï¿‚Ë (3). OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ‰È·‡ÏÔ˘ ¯ÏˆÚ›Ô˘ ¤¯Ô˘Ó ÌÂÁ¿ÏË ÔÈÎÈÏ›· Ê·ÈÓÔÙ˘È΋˜ ¤ÎÊÚ·Û˘. ŒÙÛÈ, ÔÈ ·ÛıÂÓ›˜ Ì ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÙË ÓfiÛÔ ÙÔ˘ Dent, Ô˘ ÂΉËÏÒÓÂÙ·È Û· Û‡Ó‰ÚÔÌÔ Fanconi Ì ڷ¯›Ùȉ· Î·È Û˘¯Ó¿ Û˘Ó˘¿Ú¯ÂÈ Î·È ÌÈÎÚÔÌÔÚȷ΋ ÚˆÙÂ˚ÓÔ˘Ú›· ÛˆÏËÓ·Úȷ΋˜ ÚÔ¤Ï¢Û˘ (23-25). OÚÈṲ̂ÓÔÈ, ¿ÏÈ, ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‹È· ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÊÚÔÏÈı›·Û˘ ‹ ÓÂÊÚ·Û‚¤ÛÙˆÛ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ŸÌˆ˜, ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ ηÈ

¶›Ó·Î·˜ 2. ∫ÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ È‰ÈÔ·ı‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· 1.

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6.

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9.

∫ÔÈÏȷο ¿ÏÁË (3) ∂ÓÔ‡ÚËÛË (12) ∫˘ÛÙÈο ÂÓԯϋ̷ٷ (‰˘ÛÔ˘Ú›·, Û˘¯ÓÔ˘Ú›·) (13,14) ¢˘ÛÂÍ‹ÁËÙË ˘Ô˘Ú›· (3) ™˘¯Ó¤˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ (19) ªÈÎÚÔÛÎÔÈ΋ Î·È Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· (7-10,15) ∫·Ï˘ÎÈ΋ ÌÈÎÚÔÏÈı›·ÛË (16) ¡ÂÊÚÔÏÈı›·ÛË ¡ÂÊÚ·Û‚¤ÛÙˆÛË (18,19)

¶›Ó·Î·˜ 3. ¶·Ú¿ÁÔÓÙ˜, Ô˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ °ÂÓÂÙÈ΋ ÚԉȿıÂÛË

¶·Ú¿ÁÔÓÙ˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜

ñOÈÎÔÁÂÓ‹˜ ÂÈ‚¿Ú˘ÓÛË ñ¢È·Ù·Ú·¯¤˜ ΢ÙÙ·ÚÈ΋˜ ÌÂÙ·ÊÔÚ¿˜ ·Û‚ÂÛÙ›Ô˘, ¯ÏˆÚ›Ô˘ Î·È Ó·ÙÚ›Ô˘ ñ¢È·Ù·Ú·¯¤˜ ΢ÙÙ·ÚÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ ·Û‚ÂÛÙ›Ô˘ ñ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ‚ÈÙ·Ì›Ó˘ D

ñ¶ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘ Î·È Î·Ï›Ô˘ ñ¶ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë ñ¢ÈÔ˘ÚËÙÈο

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ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (26). ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠ۠ÌÂϤÙ˜ Ì ÂÈÚ·Ì·Ùfi˙ˆ· fiÙÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‰È·‡ÏÔ˘ ·Û‚ÂÛÙ›Ô˘ (ECaC) ÌÔÚ› Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì οÔȘ ÌÔÚʤ˜ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜. O ‰›·˘ÏÔ˜ ·˘Ùfi˜ ¤¯ÂÈ ·ÔÌÔÓˆı› ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ, ÛÙÔÓ ÂÈÏÂfi Î·È ÛÙÔ ÓÂÊÚfi Î·È ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ 1,25 DHVD ÂÍ·Úو̤ÓË Î·ÏÌÈÓ‰›ÓË (calbindin) D28k (27). ∂›Û˘, ¤¯ÂÈ ÂÚÈÁÚ·Ê› ¤Ó· ÔÈÎÔÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ·Û‚ÂÛÙ›Ô˘ (28). ∆¤ÏÔ˜, ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ÔÈÎÔÁ¤ÓÂȘ °·ÏÏÔηӷ‰ÒÓ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·fi ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÁÔÓȉ›Ô˘, Ô˘ ÂϤÁ¯ÂÈ ÙÔ˘˜ ˘ԉԯ›˜ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÛÙÔ ¯ÚˆÌfiۈ̷ 12q 12-14 (29). ™Â ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë ¿Ô„Ë fiÙÈ Ë πÀ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÂÓ˙˘ÌÈ΋˜ ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘. ŒÙÛÈ, Ë Ca/ªg ATP¿ÛË ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ·ÛıÂÓÒÓ Ì πÀ ‚Ú¤ıËΠ·˘ÍË̤ÓË, ÂÓÒ ‰ÂÓ ‚Ú¤ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ Ù˘ Na/K ATP-¿Û˘ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì πÀ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∂›Ó·È Èı·Ófi Ë ‰È·Ù·Ú·¯‹ ÛÙË Ca/ªg ATP¿ÛË ÙˆÓ ·ÛıÂÓÒÓ Ó· ·ÔÙÂÏ› Ì›· ÎÏËÚÔÓÔÌÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ·Û‚ÂÛÙ›Ô˘ Î·È Ó· Û˘Û¯ÂÙ›˙ÂÙ·È ·ÈÙÈÔÏÔÁÈο Ì ÙËÓ πÀ (30). ∂›Û˘, ‰È·ÈÛÙÒıËΠÂÏ¿ÙÙˆÛË Ù˘ Na/K ATP-¿Û˘ Î·È ÂÏ¿ÙÙˆÛË Ù˘ Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿˜ Û ·È‰È¿ Ì πÀ. OÈ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ ·ÔηٷÛÙ¿ıËÎ·Ó ÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ (31). ™Â ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ ÁÈÓfiÙ·Ó ‰È¿ÎÚÈÛË Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Û ÂÓÙÂÚÈÎfi Ù‡Ô, Ô˘ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ Î·È Û ÓÂÊÚÈÎfi Ù‡Ô, Ô˘ ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË ÛˆÏËÓ·Úȷ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ∏ ‰È¿ÎÚÈÛË ÙˆÓ Ù‡ˆÓ ·˘ÙÒÓ ÁÈÓfiÙ·Ó ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·˘ÍË̤Ó˘ ÔÛfiÙËÙ·˜ ·Û‚ÂÛÙ›Ô˘ Î·È ÌÂÙ¿ ·fi ÂÚÈÔÚÈÛÌfi Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘ (3). ™‹ÌÂÚ· Â›Ó·È ·Ô‰ÂÎÙfi ˆ˜ ÔÈ ‰‡Ô ·˘Ù¤˜ ÌÔÚʤ˜ ·ÔÙÂÏÔ‡Ó ·ÎÚ·›Â˜ ÌÔÚʤ˜ Ù˘ ›‰È·˜ ÓÔÛÔÏÔÁÈ΋˜ ÔÓÙfiÙËÙ·˜. ŒÙÛÈ, Û ̛· ÚfiÛÊ·ÙË ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ Û 16 ·fi Ù· 30 ·È‰È¿ Ë πÀ ‹Ù·Ó ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ Î·È Û 14 ÓÂÊÚÈÎÔ‡ Ù‡Ô˘. ŸÙ·Ó, fï˜, Ù· 16 ·È‰È¿ Ì ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ πÀ Â·ÓÂÎÙÈÌ‹ıËÎ·Ó ÌÂÙ¿ ·fi 3-7 ¯ÚfiÓÈ·, ÌfiÓÔ Ù· 7 Û˘Ó¤¯È˙·Ó Ó· ¤¯Ô˘Ó ÙÔ˘ ›‰ÈÔ˘ Ù‡Ô˘ πÀ, Ù· 6 ›¯·Ó ÓÂÊÚÈÎÔ‡ Ù‡Ô˘ πÀ Î·È Ù· 3 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ∂ÓÒ, ·fi Ù· 14 ·È‰È¿ Ì ÓÂÊÚÈÎÔ‡ Ù‡Ô˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÌfiÓÔ Ù· 6 Û˘Ó¤¯È˙·Ó Ó· ¤¯Ô˘Ó πÀ ÙÔ˘ ›‰ÈÔ˘ Ù‡Ô˘, Ù· 4 ›¯·Ó ÂÓÙÂÚÈÎÔ‡ Ù‡Ô˘ πÀ Î·È Ù· 4 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ (32). O ÌfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ›¯Â Â›‰Ú·ÛË ÛÙËÓ ·¤ÎÎÚÈÛË

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·Û‚ÂÛÙ›Ô˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‹Ù·Ó Ë ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘. ÕÏψÛÙÂ, ¤¯Ô˘Ó ‰È·ÈÛÙˆı› ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÛÙ· ̤ÏË ÔÈÎÔÁÂÓ›ˆÓ Ì πÀ (33). ∏ ÛËÌ·Û›· Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘ ÛÙËÓ ÚfiÎÏËÛË ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ÙÔÓ›˙ÂÙ·È Î·È Û ̛· ¿ÏÏË ÌÂϤÙË, fiÔ˘ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ËÏ›ÎÔ˘ Ca/ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ Ì ÙÔ ËÏ›ÎÔ Na/K Ô‡ÚˆÓ (34). ∞˘Ùfi ‰Â›¯ÓÂÈ ÙËÓ ·ÓÙ›ÛÙÚÔÊË ÛËÌ·Û›· ÙÔ˘ Ó·ÙÚ›Ô˘ Î·È ÙÔ˘ Î·Ï›Ô˘ ÛÙËÓ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘. ™ÙËÓ ›‰È· ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË Î·Ï›Ô˘ ›¯Â ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÚÔηÏÒÓÙ·˜ ÂÏ¿ÙÙˆÛË ÙÔ˘ ËÏ›ÎÔ˘ Na/K Ô‡ÚˆÓ (34). Œ¯ÂÈ ¿ÏψÛÙ ‰È·ÈÛÙˆı› Û ÂÓ‹ÏÈΘ fiÙÈ ÙÔ Ó¿ÙÚÈÔ ÙˆÓ Ô‡ÚˆÓ Ô˘ ·ÓÙ·Ó·ÎÏ¿ ÙËÓ ÚfiÛÏË„Ë Ó·ÙÚ›Ô˘, Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË Û˘¯ÓfiÙËÙ· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ (35). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÚfiÛÊ·Ù· ÂÈÚ·Ì·ÙÈο ÛÙÔȯ›· ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ¿Ô„Ë fiÙÈ Ë Ì·ÎÚfi¯ÚÔÓË ˘ÂÚ‚ÔÏÈ΋ ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÎϤÛÂÈ ·‡ÍËÛË Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘. ŒÙÛÈ, ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÚÔÎÏ‹ıËΠ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Û ¤Ó·Ó ·ÚÈıÌfi ÂÈÚ·Ì·Ùfi˙ˆˆÓ Ì ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÌÂÙ¿ ·fi Ì·ÎÚfi¯ÚÔÓË ˘ÂÚ‚ÔÏÈ΋ ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë, Ô˘ ÔÊÂÈÏfiÙ·Ó Û ·‡ÍËÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ Ì¿˙·˜ Î·È ˘ÂÚ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘ (36). ∞ÓÙÈÌÂÙÒÈÛË ∏ ıÂÚ·›· Ù˘ πÀ ·ÔÛÎÔ› ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·Ô‚ÔÏ‹˜ ·Û‚ÂÛÙ›Ô˘ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·. ¶Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ·Û‚ÂÛÙ›Ô˘, ÂÂȉ‹ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÙËÓ ÔÛÙÂÔÂÓ›·, Ë ÔÔ›· Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó‹ ÛÙËÓ πÀ (3). ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘. ∞Ó Ô ÂÚÈÔÚÈÛÌfi˜ ·˘Ùfi˜ ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ‰›·ÈÙ· ÏÔ‡ÛÈ· Û οÏÈÔ ‹/Î·È ÎÈÙÚÈÎfi οÏÈÔ. ∂¿Ó Ë ·ÓÙÈÌÂÙÒÈÛË ·˘Ù‹ ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ¤¯ÂÈ ‰È·ÈÛÙˆı› ÓÂÊÚÔÏÈı›·ÛË, Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ‰ÈÔ˘ÚËÙÈο Ù˘ ÔÌ¿‰·˜ ÙˆÓ ıÂÈ·˙ȉÒÓ Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙË ÛˆÏËÓ·Úȷ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙÔ ·ÓÈfiÓ ÛΤÏÔ˜ Ù˘ ·Á·Ï˘ ÙÔ˘ Henle (3). Œ¯ÂÈ ‰È·ÈÛÙˆı› ÂÏ¿ÙÙˆÛË Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ ÙˆÓ ·È‰ÈÒÓ Ì πÀ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ (31). ™ÙËÓ ›‰È· ÌÂϤÙË ·˘Í‹ıËΠÛËÌ·ÓÙÈο Ë Na/K ATP-¿ÛË Î·È ÂÏ·ÙÙÒıËÎÂ Ë Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ Û ·È‰È¿ Ì πÀ. ∏ ·ÔηٿÛÙ·ÛË Ù˘ Na/K ATP-

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¿Û˘ Î·È ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ Na/H ·ÓÙÈÌÂÙ·ÊÔÚ¿˜ ÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË Ù˘ ¢ÂÚÁÂÙÈ΋˜ ÙÔ˘˜ Â›‰Ú·Û˘ ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÛˆÏËÓ·Úȷ΋˜ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ·ÛıÂÓÒÓ Ì πÀ (31). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó οÔȘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙË Ì·ÎÚfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÙˆÓ ıÂÈ·˙ȉÒÓ, ÁÈ·Ù› ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈȉ›ˆÓ (37). ∞fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ıÂÈ·˙ȉÒÓ Û ·ÛıÂÓ›˜ Ì πÀ Ì ÈÛÙÔÚÈÎfi Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ (3). ÿÛˆ˜, fï˜, Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ıÂÈ·˙›‰Â˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓÂÊÚÔÏÈı›·Û˘, ·ÊÔ‡ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ·È‰È¿ Ì πÀ Î·È Ì·ÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· ·ÚÔ˘Û›·Û·Ó Û˘¯ÓfiÙÂÚ· ÓÂÊÚÔÏÈı›·ÛË Û ۯ¤ÛË Ì ·È‰È¿ Ì πÀ ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi Ì·ÎÚÔÛÎÔÈ΋˜ ·ÈÌ·ÙÔ˘Ú›·˜ (17).

H ıÂÚ·›· Ù˘ ȉÈÔ·ıÔ‡˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ ·Ú·Ì¤ÓÂÈ ÂÌÂÈÚÈ΋ Î·È Û˘¯Ó¿ ‚·Û›˙ÂÙ·È Û ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Î·È fi¯È Û Â·ÚΛ˜ Ì·ÎÚÔ¯ÚfiÓȘ ÌÂϤÙ˜. ª¤¯ÚÈ Ó· ˘¿ÚÍÔ˘Ó ÛÙÔȯ›· ·fi Ù¤ÙÔȘ ÌÂϤÙ˜ Â›Ó·È ÛÎfiÈÌÔ Ó· ÂÚÈÔÚÈÛÙ› Ë ·ÏfiÁÈÛÙË ¯Ú‹ÛË ÙˆÓ ıÂÈ·˙ȉÒÓ, Ô˘ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÌfiÓÔ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÔÈ Î·Ù¿ÏÏËϘ ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ. ∂›Û˘, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ˘ÂÚ‚ÔÏÈ΋˜ ÚfiÛÏ˄˘ ÚˆÙÂ˚ÓÒÓ, Ù˘ ÚfiÛÏ˄˘ Ó·ÙÚ›Ô˘ Î·È Ë ·‡ÍËÛË Ù˘ ÚfiÛÏ˄˘ Î·Ï›Ô˘ Ê·›ÓÂÙ·È fiÙÈ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÏ¿ÙÙˆÛË Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜, ÂÓÒ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÚfiÛÏ˄˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (3).

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Reusz GS, Dobos M, Tulassay T. Hydrochlorothiazide treatment of children with hypercalciuria: effects and side effects. Pediatr Nephrol 1993;6:699-702.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ π. ™ÙÂÊ·Ó›‰Ë˜ ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· H Â›‰Ú·ÛË Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË Û ·È‰È¿ Ì ¿ÛıÌ·1 ∂ÈÛ·ÁˆÁ‹: ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ ÌÔÚ› ‚Ú·¯˘ÚfiıÂÛÌ· Ó· ÂËÚ¿ÛÔ˘Ó ‰˘ÛÌÂÓÒ˜ ÙËÓ ·Ó¿Ù˘ÍË ·È‰ÈÒÓ Ì ¿ÛıÌ·. øÛÙfiÛÔ, Ù· ·ÒÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÁˆÁ‹˜ ·˘Ù‹˜ ÛÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̛· ÚÔÔÙÈ΋ ÌÂϤÙË Û ·È‰È¿ Ì ¿ÛıÌ· ÁÈ· Ó· ÂÍÂÙ·ÛÙ› ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ıÂÚ·›·˜ Ì ÂÈÛÓÂfiÌÂÓË ‚Ô˘‰ÂÛÔÓ›‰Ë ˆ˜ ÚÔ˜ ÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛ‹ ÙÔ˘˜. ªÂÏÂÙ‹ıËÎ·Ó 211 ·È‰È¿ Ô˘ ¤Êı·Û·Ó Û ·Ó¿ÛÙËÌ· ÂÓËÏ›ÎÔ˘: 142 ·È‰È¿ Ì ¿ÛıÌ· Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë, 18 Ì¿ÚÙ˘Ú˜, ÔÈ ÔÔ›ÔÈ ‹Ù·Ó ·È‰È¿ Ì ¿ÛıÌ· Ô˘ ‰ÂÓ Â›¯·Ó Ï¿‚ÂÈ ÔÙ¤ ÂÈÛÓÂfiÌÂÓ· ÛÙÂÚÔÂȉ‹ Î·È 51 ˘ÁÈ‹ ·‰¤ÚÊÈ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë Î·È Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, Â›Û˘, ˆ˜ Ì¿ÚÙ˘Ú˜. ∞ÔÙÂϤÛÌ·Ù·: ∆· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ Ù˘ ‚Ô˘‰ÂÛÔÓ›‰Ë˜ ¤Êı·Û·Ó Û ·Ó¿ÛÙËÌ· ÂÓËÏ›ÎÔ˘ ÌÂÙ¿ ·fi ̤ÛË ‰È¿ÚÎÂÈ· Ï‹„˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ 9,2 ÂÙÒÓ (‡ÚÔ˜ 3 - 13) Î·È Ì¤ÛË ËÌÂÚ‹ÛÈ· ‰fiÛË 412 Ìg (‡ÚÔ˜ 110 - 877). ∏ Û˘ÓÔÏÈ΋ ̤ÛË ‰fiÛË Ù˘ ‚Ô˘‰ÂÛÔÓ›‰Ë˜ ‹Ù·Ó 1,35 g (‡ÚÔ˜ 0,41 – 3,99). ∏ ̤ÛË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÌÂÙÚËı¤ÓÙÔ˜ Î·È ÚÔ‚ÏÂfiÌÂÓÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÂÓËÏ›ÎÔ˘ ‹Ù·Ó +0,3 cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, 0,6 ¤ˆ˜ +1,2) ÁÈ· Ù· ·È‰È¿ Ô˘ Ï¿Ì‚·Ó·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë, -

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0,2cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, -2,4 ¤ˆ˜ +2,1) ÁÈ· ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ì ¿ÛıÌ· Î·È +0,9cm (95% ‰È¿ÛÙËÌ· ·ÍÈÔÈÛÙ›·˜, -0,4 ¤ˆ˜ +2,2) ÁÈ· Ù· ˘ÁÈ‹ ·‰¤ÚÊÈ·. ∆Ô ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ÂÍ·ÚÙ‹ıËΠÛËÌ·ÓÙÈο (p<0,001) ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ıÂÚ·›·˜ Ì ‚Ô˘‰ÂÛÔÓ›‰Ë. ¶·Ú¿ ÙÔ fiÙÈ Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ ÂÙÒÓ ıÂÚ·›·˜ Ì ‚Ô˘‰ÂÛÔÓ›‰Ë, ÙÔ ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË ‰ÂÓ ÂËÚ¿ÛÙËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·È‰È¿ Ì ¿ÛıÌ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó Ì·ÎÚÔ¯ÚfiÓÈ· ‚Ô˘‰ÂÛÔÓ›‰Ë ÊÙ¿ÓÔ˘Ó ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ÂÓËÏÈΛˆÛË.

1Agertoft L, Pedersen S Effect of long-term treatment with inhaled budesonide on adult height in children with asthma N Engl J Med 2000;343:1064-1069

∫. ÷Ù˙‹˜

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∂¶∂π°OÀ™∞ ∫∞π ∂¡∆∞∆π∫∏ ¶∞π¢π∞∆ƒπ∫∏

Paediatriki 2001;64:261-267

EMERGENCY AND INTENSIVE CARE PEDIATRICS

∞Ù˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ∫. ∆ÛÔ˘Ì¿Î·˜

Accidents in childhood and adolescence C. Tsoumakas

¶ÂÚ›ÏË„Ë: ∆· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Ó ÛÔ‚·ÚfiÙ·ÙÔ Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜, ·ÊÔ‡ Â›Ó·È Ë ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ Î·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó. ŸÛÔÓ ·ÊÔÚ¿ ·È‰È¿ οو ÙˆÓ 5 ¯ÚfiÓˆÓ, Ù· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘˜ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Û fiÏÔ ÙÔÓ ÎfiÛÌÔ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙËÓ ÂÊ˂›· Î·È ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi Á›ÓÂÙ·È ·ÎfiÌË ¯ÂÈÚfiÙÂÚÔ ·Ó ˘ÔÏÔÁÈÛÙ› Î·È ÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ÂÈ˙ÒÓÙˆÓ Ô˘ ̤ÓÔ˘Ó ·Ó¿ËÚÔÈ. ∆· ·Ù˘¯‹Ì·Ù· ·Ó·„˘¯‹˜ ηıÒ˜ Î·È Ù· Â·ÁÁÂÏÌ·ÙÈο ÌÔÚÔ‡Ó Ó· ÂÚÈÔÚÈÛÙÔ‡Ó ÛËÌ·ÓÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ‚·ÛÈÎÒÓ Î·ÓfiÓˆÓ ·ÛÊ·Ï›·˜, ÂÓÒ ÁÈ· Ù· ÂÚÈ‚·ÏÏÔÓÙÈο Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÔÚÁ·ÓˆÌ¤ÓË ·ÓÙÈÌÂÙÒÈÛË ·fi ÙËÓ ÔÏÈÙ›·. OÈ ·È‰›·ÙÚÔÈ ¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜ ‰˘Ó·ÌÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·.

Abstract: Accidents in childhood and adolescence are regarded as a very serious problem of public health, since they constitute the first cause of death and can be prevented to a great extent.

For children under the age of 5 years, accidents at home and in the surrounding area comprise 60% of the total number of accidents, and their type has a direct relationship with the age of the children.

Road accidents are regarded all over the world as the first cause of death in adolescence and this is even worse if we add the great percentage of the survivors who become handicapped. Accidents which result from both pleasure and business trips can be constrained to a great extent by adaptating basic safety measures, while for environmental accidents there must be an organized confrontation by the society. Pediatricians have significant opportunities for dynamic intervention in order to prevent most accidents in childhood and adolescence.

§¤ÍÂȘ ÎÏÂȉȿ: ·Ù˘¯‹Ì·Ù·, ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, ÔÈÎȷο ·Ù˘¯‹Ì·Ù·, ÚfiÏË„Ë.

Key words: accidents, road accidents, home accidents, prevention.

¶ÚÈÓ ÌÂÚÈο ¯ÚfiÓÈ· Ë π·ÙÚÈ΋ Î·È Ë ¶ÔÏÈÙ›· ·ÓÙÈÌÂÙÒÈ˙·Ó Ù· ·Ù˘¯‹Ì·Ù· ¯ˆÚ›˜ Û˘ÓÙÔÓÈÛÌfi Î·È ÚfiÁÚ·ÌÌ·. ™‹ÌÂÚ·, fï˜, Ù· ·Ù˘¯‹Ì·Ù· Î·È Ô ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ Ù˘ ÚfiÏË„‹˜ ÙÔ˘˜ ·ÔÙÂÏÔ‡Ó ÚÒÙÈÛÙË ÊÚÔÓÙ›‰· ÙˆÓ ˘ËÚÂÛÈÒÓ ÀÁ›·˜ fiÏˆÓ ÙˆÓ ÚÔËÁÌ¤ÓˆÓ ¯ˆÚÒÓ Î·È ·ÓÙÈΛÌÂÓÔ ‰È‰·Ûηϛ·˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ™‹ÌÂÚ· Á›ÓÔÓÙ·È ÌÂÁ¿Ï˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ÏËÚ¤ÛÙÂÚË ÌÂϤÙË ÙˆÓ ·ÈÙ›ˆÓ, Ù˘ ÂȉËÌÈÔÏÔÁ›·˜, Ù˘ ·ÓÙÈÌÂÙÒÈ-

Û˘ Î·È Ù˘ ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁËı› ΤÓÙÚ· ‰ËÏËÙËÚÈ¿ÛˆÓ, ÙÚ·˘Ì·ÙÈÔÏÔÁÈο ΤÓÙÚ·, ΤÓÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÂÁη˘Ì¿ÙˆÓ Î.Ï., fiÔ˘ ÙÔ ı‡Ì· ·Ù˘¯‹Ì·ÙÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Û˘ÓÙÔÓÈṲ̂ӷ ·fi ÔÌ¿‰· ÂȉÈÎÒÓ.

O fiÚÔ˜ ·Ù‡¯ËÌ· ÛËÌ·›ÓÂÈ ÙÔ Û˘Ì‚¿Ó Ô˘ ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë Ù‡¯Ë˜. ∏ ·ÓÙ›ÏË„Ë ·˘Ù‹ ·ÔÙÂÏÔ‡Û ÛÙÔ ·ÚÂÏıfiÓ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÊÚ·ÁÌfi ÁÈ· ÙËÓ ÚfiÔ‰Ô ÛÙÔÓ ¤ÏÂÁ¯Ô Î·È ÙËÓ

¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ∫.∞.∆. ∞ÙÙÈ΋˜

Director of Pediatric Division K.A.T. Hospital of Attica, Athens

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ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™‹ÌÂÚ· ÈÛÙ‡ԢÌ ˆ˜ 9 ÛÙȘ 10 ÊÔÚ¤˜ ÙÔ ·Ù‡¯ËÌ· ÔÊ›ÏÂÙ·È Û ·ÓıÚÒÈÓÔ Ï¿ıÔ˜, Û ·Ì¤ÏÂÈ·, Û ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ∂ȉÈÎfiÙÂÚ·, fiÛÔÓ ·ÊÔÚ¿ Ù· ·Ù˘¯‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ ÚÔÛÙ›ıÂÙ·È Î·È Ô ·Ú¿ÁÔÓÙ·˜ ¿ÁÓÔÈ·˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È fiÏˆÓ fiÛˆÓ ¤¯Ô˘Ó ÂÈ̤ÏÂÈ· ·È‰ÈÒÓ. ∆· ·Ù˘¯‹Ì·Ù·, ÂÔ̤ӈ˜, ‰ÂÓ Â›Ó·È Î·ÎÔÙ˘¯›· ·ÏÏ¿ ÓfiÛÔ˜ Î·È ÂȉËÌ›·, ÂÓ·ÓÙ›ÔÓ Ù˘ ÔÔ›·˜ ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· ÂÌ‚fiÏÈÔ Î·È ‰ÂÓ ÌÔÚ› Ó· ˘¿ÚÍÂÈ ·ÓÔÛ›·. ∏ ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÛÈÌfiÙËÙ· ·fi Ù· ·Ù˘¯‹Ì·Ù· Â›Ó·È ·˘ÍË̤ÓË Û 3 ȉȷ›ÙÂÚ· ¢·ı›˜ ÔÌ¿‰Â˜ ÏËı˘ÛÌÔ‡: ÛÙ· ·È‰È¿, ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ Î·È Ù· ¿ÙÔÌ· Ô˘ ÌÂÈÔÓÂÎÙÔ‡Ó ÛˆÌ·ÙÈο, ÓÂ˘Ì·ÙÈο Î·È ÎÔÈÓˆÓÈο. ∆· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÁÈ· Ù· ·È‰È¿ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ (50%), Ì ‰Â‡ÙÂÚË ÙȘ ηÎÔ‹ıÂȘ (15%) Î·È ÙÚ›ÙË ÙȘ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜ (8%).

OÈ ÏfiÁÔÈ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ·È‰È¿ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚ· ¢·ı‹ ÔÌ¿‰· Â›Ó·È ÔÈ ÂÍ‹˜: ·) ¤¯Ô˘Ó ·˘ÍË̤ÓË ÂÚȤÚÁÂÈ· Î·È Ù¿ÛË ÁÈ· ÂÍÂÚ‡ÓËÛË, ‚) ÌÂÈÔÓÂÎÙÔ‡Ó ÛÙÔ Û˘ÓÙÔÓÈÛÌfi ÙˆÓ ÎÈÓ‹ÛˆÓ, Á) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔԉ¢ÙÈ΋ ·Ó¿Ù˘ÍË Ù˘ ·‰Ú‹˜ ÎÈÓËÙÈÎfiÙËÙ·˜, ‰) ·Ú¯›˙Ô˘Ó Ó· Û˘ÓÂȉËÙÔÔÈÔ‡Ó ÙË Û¯¤ÛË ·ÈÙ›Ô˘-·ÔÙÂϤÛÌ·ÙÔ˜, Â) ‰ÂÓ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È Â‡ÎÔÏ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜, ÛÙ) ÂΉËÏÒÓÔ˘Ó ·ÚÓËÙÈÛÌfi ‹ Î·È Â¯ıÚfiÙËÙ· ÛÙȘ Û˘Ì‚Ô˘Ï¤˜ ÙˆÓ ÁÔÓ¤ˆÓ, ˙) Ô ‰‡ÛÙÚÔÔ˜ ¯·Ú·ÎÙ‹Ú·˜ ÔÚÈÛÌ¤ÓˆÓ ‰Ú· ¢ÓÔ˚ο ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ, Ë) ¤¯Ô˘Ó ·ÓÒÚÈÌË Î·È ÂÁˆÎÂÓÙÚÈ΋ ÛΤ„Ë (ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·), ı) ÂӉȷʤÚÔÓÙ·È Ó· Â›Ó·È ·Ô‰ÂÎÙ¿ ·fi ÙÔ˘˜ Û˘ÓÔÌ‹ÏÈÎÔ‡˜ ÙÔ˘˜ (Û¯ÔÏÈ΋ ËÏÈΛ·), È) ¤ÏÎÔÓÙ·È ·fi ÙË ÁÔËÙ›· Ù˘ ÂÚÈ¤ÙÂÈ·˜ (ÚÔÂÊË‚È΋ ËÏÈΛ·). ∫¿ı ËÏÈΛ· ¤¯ÂÈ ÙÔ˘˜ ‰ÈÎÔ‡˜ Ù˘ ȉȷ›ÙÂÚÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜: i) ™ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: OÈ ÙÒÛÂȘ ¤Ú¯ÔÓÙ·È ÚÒÙ˜ ÛÂ Û˘¯ÓfiÙËÙ· Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ë ·ÛÊ˘Í›· ·fi ÂÈÛÚfiÊËÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Î·È Ù· ÂÁη‡Ì·Ù·. ii) ™ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·: ∆Ș ÙÒÛÂȘ ·ÎÔÏÔ˘ıÔ‡Ó Ô ÓÈÁÌfi˜, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ, Ù· ÂÁη‡Ì·Ù·, ÂÓÒ Ù· ÙÚÔ¯·›· ˘ÔÏ›ÔÓÙ·È ÚÔ˜ ÙÔ ·ÚfiÓ. iii) ™ÙË Û¯ÔÏÈ΋ ËÏÈΛ·: ¶ÚÒÙË ı¤ÛË ¤¯Ô˘Ó Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Ì ÙÔ ·È‰› Â˙fi, ÂÈ‚¿ÙË ‹ Ô‰ËÏ¿ÙË Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ô ÓÈÁÌfi˜ Î·È Ù· ÂÁη‡Ì·Ù·, ÂÓÒ ÌÂÈÒÓÔÓÙ·È ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ. iv) ™ÙËÓ ÂÊË‚È΋ ËÏÈΛ·: ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÎÚ·ÙÔ‡Ó ÙËÓ ÚÒÙË ı¤ÛË Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ·Ù˘¯‹Ì·Ù· ·fi ·ıÏ‹Ì·Ù·, Ô ÓÈÁÌfi˜, Ù· ÂÁη‡Ì·Ù·, Ù· ·Ù˘¯‹Ì·Ù· ·fi ¯Ú‹ÛË ·ÏÎÔfiÏ Î·È Ó·ÚΈÙÈÎÒÓ Î·È ÔÈ ·fiÂÈÚ˜ ·˘ÙÔÎÙÔÓ›·˜. °È· ‰È‰·ÎÙÈÎÔ‡˜ ΢ڛˆ˜ ÏfiÁÔ˘˜ Ù· ·Ù˘¯‹Ì·Ù· ÛÙ· ·È‰È¿ ı· ÌÔÚÔ‡Û·Ó Ó· Ù·ÍÈÓÔÌËıÔ‡Ó Û ÔÚÈṲ̂Ó˜ ηÙËÁÔڛ˜, ·Ó Î·È Ù· fiÚÈ· οı ηÙË-

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ÁÔÚ›·˜ Â›Ó·È ·Û·Ê‹: - √ÈÎȷο (ÛÙÔ Û›ÙÈ) - ∞ıÏËÙÈο Î·È ·Ó·„˘¯‹˜ (ÛÙË Ê‡ÛË) - ∆ÚÔ¯·›· (ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜) - ∂·ÁÁÂÏÌ·ÙÈο (ÛÙËÓ ÂÚÁ·Û›·) - ¶ÂÚÈ‚·ÏÏÔÓÙÈο (˘ÚËÓÈο, ˘ÚηÁȤ˜, ÛÂÈÛÌÔ›, ıÂÔÌËӛ˜) Ô˘ ÂËÚ¿˙Ô˘Ó ÌÂÁ¿ÏÔ˘˜ ÏËı˘ÛÌÔ‡˜.

OÈÎȷο ·Ù˘¯‹Ì·Ù· ∆· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ¯ÚfiÓˆÓ. ∆Ô Â›‰Ô˜ ÙÔ˘˜ ‚¤‚·È· ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ·) OÈ ÙÒÛÂȘ Â›Ó·È ·fi Ù· ÈÔ Û˘ÓËıÈṲ̂ӷ ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ. ∆· ‚Ú¤ÊË ¤ÊÙÔ˘Ó 2 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·fi Ù· ÌÈÎÚ¿ ·È‰È¿ Î·È 10 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ·. ∏ ÙÒÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÌÔÚ› Ó· Á›ÓÂÈ ·fi ÙËÓ ÎÔ‡ÓÈ·, ÙÔ ÎÚ‚·Ù¿ÎÈ ÙÔ˘, ÙÔ baby relax, ÙȘ ·ÚÔÛٿ٢٘ ÛοϘ, ÙÔ Á˘·ÏÈṲ̂ÓÔ ¿ÙˆÌ· Î·È ÙË ÛÙÚ¿Ù·. ‚) ∏ ÂÈÛÚfiÊËÛË Í¤ÓˆÓ ÛˆÌ¿ÙˆÓ (ÍËÚÔ› ηÚÔ›, ηÚÊ›ÙÛ˜, ÛÙ·˘ÚÔ˘‰¿ÎÈ· Î.Ï. ÌÔÚ› Ó· Á›ÓÂÈ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Ô˘ ÙÔ ‚Ú¤ÊÔ˜ ÌÔÚ› Ó· ‚¿ÏÂÈ ÛÙÔ ÛÙfiÌ· ÙÔ˘ fi,ÙÈ ÎÚ·Ù¿ÂÈ ÛÙÔ ¯¤ÚÈ ÙÔ˘. Á) ∆· ·Ù˘¯‹Ì·Ù· ·fi ÓÈÁÌfi Â›Ó·È 5 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚ· ÛÙ· ·È‰È¿ 2-4 ¯ÚfiÓˆÓ ·’ fiÙÈ ÛÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜ Î·È 2 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·o fiÙÈ ÛÙ· ·È‰È¿ 6-12 ¯ÚfiÓˆÓ. ‰) ∆· ÂÁη‡Ì·Ù· Â›Ó·È Ù· Û˘¯ÓfiÙÂÚ· Î·È ÛÔ‚·ÚfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ ÁÈ· ·È‰È¿ 2-5 ¯ÚfiÓˆÓ Î·È ·Ú·ÙËÚÔ‡ÓÙ·È 3 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚÔ ·’ fiÙÈ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘. ∆Ô 80% ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ ·Ù˘¯ËÌ¿ÙˆÓ Û˘Ì‚·›ÓÂÈ ÛÙËÓ ÎÔ˘˙›Ó· ÙÔ˘ ÛÈÙÈÔ‡ Î·È ÏÈÁfiÙÂÚÔ ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ Î·È ÙÔ ÏÔ˘ÙÚfi. ∆Ô 90% ÚÔηÏÂ›Ù·È ·fi ˘ÁÚ‹ Î·È ÙÔ 10% ·fi ÍËÚ‹ ıÂÚÌfiÙËÙ·. ∂›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·ÁfiÚÈ·, ÛÙ· ÚˆÙfiÙÔη ·È‰È¿, Û ‰È·ÌÂÚ›ÛÌ·Ù·, ÂÍ·ÚÙÒÌÂÓ· ¿ÓÙ· ·fi ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∂˘Ù˘¯Ò˜, ÔÈ ËÏÂÎÙÚÔÏË͛˜ ¤¯Ô˘Ó ÂÚÈÔÚÈÛÙ› ÁÈ·Ù› Û ÔÏÏ¿ Û›ÙÈ· ÙÔÔıÂÙÔ‡ÓÙ·È È· ·˘ÙfiÌ·ÙÔÈ ‰È·ÎfiÙ˜. Â) OÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Â›Ó·È Û˘¯Ó‹ ÌÔÚÊ‹ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿, ·ÏÏ¿ Û¿ÓÈ· ı·Ó·ÙËÊfiÚ˜. OÈ Û˘¯ÓfiÙÂÚÔÈ ÙÚfiÔÈ ‰ËÏËÙËÚ›·Û˘ ÛÙ· ·È‰È¿ Â›Ó·È Ë Î·Ù¿ÔÛË Î·È Û·ÓÈfiÙÂÚ· Ë ÂÈÛÓÔ‹ ‹ Ë ·ÔÚÚfiÊËÛË ·fi ÙÔ ‰¤ÚÌ·. ∞fi ¤Ú¢ӷ ÛÙËÓ ∞¶∫¶∞, ÙÔ 80% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÓÔÛËχÙËÎ·Ó ÂÍ·ÈÙ›·˜ ‰ËÏËÙËÚÈ¿ÛˆÓ, Â›Ó·È Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ. ∆Ô Â›‰Ô˜ Ì ÙÔ ÔÔ›Ô ‰ËÏËÙËÚÈ¿˙ÔÓÙ·È Ù· ·È‰È¿ ¤¯ÂÈ Û¯¤ÛË: i) ªÂ ÙÔ ÂıÓÈÎfi Î·È ‚ÈÔÙÈÎfi Â›Â‰Ô (.¯. ÛÙȘ ˘fi ·Ó¿Ù˘ÍË ¯ÒÚ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ʈÙÈÛÙÈÎfi Î·È ıÂÚÌ·ÓÙÈÎfi ÙÔ ÂÙڤϷÈÔ, ÙÔ 40% ÙˆÓ

MAY- JUNE '01 TELIKO

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‰ËÏËÙËÚÈ¿ÛÂˆÓ ÔÊ›ÏÔÓÙ·È Û’·˘Ùfi). ii) ªÂ ÙȘ Û˘Ó‹ıÂȘ Ù˘ ˙ˆ‹˜ ÙÔ˘ Ï·Ô‡. ™ÙȘ ¯ÒÚ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ Áο˙È, ÔÈ ‰ËÏËÙËÚÈ¿ÛÂȘ Ì CO η٤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË. iii) ªÂ ÙË Û‡ÓıÂÛË ÙÔ˘ ÏËı˘ÛÌÔ‡: ·È‰È¿ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‰ËÏËÙËÚÈ¿˙ÔÓÙ·È Â˘ÎÔÏfiÙÂÚ· ÌÂ Ê˘ÙÔÊ¿Ú̷η Î·È ÂÓÙÔÌÔÎÙfiÓ·. iv) ªÂ ÙÔ Ú‡̷ Ù˘ Û‡Á¯ÚÔÓ˘ Û˘ÓÙ·ÁÔÁÚ·Ê›·˜. ÛÙ) ∆· ·Ù˘¯‹Ì·Ù· ÏfiÁˆ ¯Ú‹Û˘ ÂÚÁ·Ï›ˆÓ (Ì·¯·›ÚÈ·, „·Ï›‰È·), Ì˯·ÓËÌ¿ÙˆÓ (ÙÚ˘¿ÓÈ·) Î·È fiÏˆÓ Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ ·È‰ÈÒÓ ·fi ÂÎ˘ÚÛÔÎÚfiÙËÛË ÁÂÌ¿ÙÔ˘ ˘ÚÔ‚fiÏÔ˘ fiÏÔ˘ Â›Ó·È ÙÔ ¯ÂÈÚfiÙÂÚÔ ·Ú¿‰ÂÈÁÌ· ÁÔÓÂ˚΋˜ ·Ì¤ÏÂÈ·˜). ∆· ̤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ˘Ô¯ÚÂÒÛÂȘ ÙfiÛÔ Ù˘ ÔÏÈÙ›·˜ fiÛÔ Î·È Ù˘ ›‰È·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ÔÏÈÙ›· Ú¤ÂÈ: ·) Ó· ÂÓËÌÂÚÒÓÂÈ Ì ÂȉÈο ÛÂÌÈÓ¿ÚÈ·, fiˆ˜ Î·È ÂȉÈΤ˜ ÂÎÔÌ¤˜ ÛÙ· ªª∂, ·È‰È¿, ÁÔÓ›˜ Î·È ‰·ÛοÏÔ˘˜ ÁÈ· ÙÔ˘˜ ÙÚfiÔ˘˜ ·ÔÊ˘Á‹˜ Î·È ÚÔÛÙ·Û›·˜ ·fi Ù· ·Ù˘¯‹Ì·Ù·, ‚) Ó· ÂÓÈÛ¯‡ÂÈ Ù· ΤÓÙÚ· ‰ËÏËÙËÚÈ¿ÛÂˆÓ ‹ ¿ÏÏ· ÂȉÈο ΤÓÙÚ· Ô˘ ¤¯Ô˘Ó ÁÈ· ¤ÚÁÔ ÙÔ˘˜ ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, Á) Ó· ˘Ô¯ÚÂÒÓÂÈ ÙȘ Ê·ÚÌ·ÎÔ‚ÈÔÌ˯·Ó›Â˜, ‚ÈÔÌ˯·Ó›Â˜ ·È¯ÓȉÈÒÓ Î.Ï. Ó· ÂÊ·ÚÌfi˙Ô˘Ó ÂȉÈÎÔ‡˜ ηÓfiÓ˜ ·ÛÊ·Ï›·˜. ∏ ÔÈÎÔÁ¤ÓÂÈ· Ú¤ÂÈ Ó· ÂÈÎÂÓÙÚÒÓÂÈ ÙÔ ÂӉȷʤÚÔÓ Ù˘: ·) ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ Û¯Â‰›ˆÓ ηٷÛ΢‹˜ ÙÔ˘ ÛÈÙÈÔ‡ Î·È Û fi,ÙÈ ˘¿Ú¯ÂÈ Û ·˘Ùfi, ‚) ÛÙËÓ ·Ó·ÁÓÒÚÈÛË, ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Î·È ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÎÈÓ‰‡ÓˆÓ, ·Ú¿ÏÏËÏ· Ì ÙËÓ ·˘ÛÙËÚfi-

Paediatriki 2001;64:261-267

ÙÂÚË ÂÈÙ‹ÚËÛË. ™ÙÔÓ ¶›Ó·Î· 1 ·Ó·Ê¤ÚÔÓÙ·È ÂÈÁÚ·ÌÌ·ÙÈο Ù¤ÙÔȘ Ô‰ËÁ›Â˜. ∞Ù˘¯‹Ì·Ù· ·Ó·„˘¯‹˜ Î·È ·ıÏËÙÈο ∞ÊÔÚÔ‡Ó ÌÂÌÔӈ̤ӷ ¿ÙÔÌ· ‹ Î·È ÔÌ¿‰Â˜. ∆· ·ıÏ‹Ì·Ù· Î·È „˘¯·ÁˆÁÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ô˘ ÚÔηÏÔ‡Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·Ù˘¯ËÌ¿ÙˆÓ, Û˘¯Ó¿ ÛÔ‚·ÚÒÓ, Â›Ó·È Ë ÎÔχ̂ËÛË, Ë È·Û›·, ÙÔ „¿ÚÂÌ·, ÙÔ ÛÎÈ (ÛÙÔ ‚Ô˘Ófi Î·È ÙË ı¿Ï·ÛÛ·), Ë ¿ÏË, ÂÓÒ Û˘¯Ó¿ Â›Ó·È Ù· ·Ù˘¯‹Ì·Ù· Î·È ÛÙËÓ ·È‰È΋ ¯·Ú¿. ∂ȉÈÎfiÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÎÔχ̂ËÛË, ·Ó Î·È Ë ∂ÏÏ¿‰· Â›Ó·È ¯ÒÚ· Ô˘ ‚Ú¤¯ÂÙ·È ·fi ı¿Ï·ÛÛ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ¿ÓıÚˆÔÈ ‰ÂÓ Í¤ÚÔ˘Ó ÎÔχÌÈ. ŒÙÛÈ, Ô ÓÈÁÌfi˜ ·ÔÙÂÏ› ÛÔ‚·Ú‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ (ÙË ‰Â‡ÙÂÚË) ÛÙËÓ ÂÊË‚›·. ∞˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ‰È·ÙÚ¤¯Ô˘Ó fiÛÔÈ ‚Ú›ÛÎÔÓÙ·È ˘fi ÙËÓ Â‹ÚÂÈ· ·ÏÎÔfiÏ˘ Î·È Ó·ÚΈÙÈÎÒÓ ‹ Â›Ó·È ÂÈÏËÙÈÎÔ›. º˘ÛÈο, ‰È·Ê¤ÚÂÈ Ô ÓÈÁÌfi˜ ÛÙË ı¿Ï·ÛÛ· ·’ fiÙÈ ÛÙËÓ ÈÛ›Ó·, fiÔ˘ ÏfiÁˆ ˘ÂÚˆÛ̈ÙÈÎfiÙËÙ·˜ ÚÔηÏ› ÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. ∏ ÂÊ·ÚÌÔÁ‹ ηÓfiÓˆÓ ·ÛÊ·Ï›·˜ Â›Ó·È Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ÚfiÏ˄˘ ·fi Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿: ∆¤ÙÔÈÔÈ Î·ÓfiÓ˜ ›ӷÈ: ·) OÈ ·È‰fiÙÔÔÈ ‰ÂÓ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È ‰›Ï· Û ‰ÚfiÌÔ˘˜, Ó· Â›Ó·È ·Ê‡Ï·ÎÙ˜ ‹ ¯ˆÚ›˜ ÂÚ›ÊÚ·ÍË. ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· ËÁ·›ÓÔ˘Ó ÂΛ ÌfiÓ· ÙÔ˘˜. ‚) ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· ËÁ·›ÓÔ˘Ó ÁÈ· ÎÔχ̂ËÛË ¯ˆÚ›˜ ÛˆÛ›‚ÈÔ. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË. ∏ Â·ÁÚ‡ÓËÛË ÛÙȘ ‰ËÌfiÛȘ ÈÛ›Ó˜ Î·È ÛÙȘ ·ÎÙ¤˜ Ì ÂȉÈΤ˜ ÔÌ¿‰Â˜ ÂÏ·ÙÙÒÓÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÈÁÌÒÓ. ™ÙȘ ȉȈÙÈΤ˜ ÈÛ›Ó˜ ÂÈ‚¿ÏÏÂÙ·È

¶›Ó·Î·˜ 1. O‰ËÁ›Â˜ ÁÈ· ÙËÓ ÚfiÏË„Ë ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ 1. ºÚÔÓÙ›ÛÙ ÒÛÙ ÛÙÔ ‰È·Ì¤ÚÈÛÌ· ‹ ÛÙÔ Û›ÙÈ Û·˜ Î·È ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ¯ÒÚÔ Ó· ˘¿Ú¯Ô˘Ó ÚԉȷÁڷʤ˜ ·ÛÊ¿ÏÂÈ·˜.

O ηٿÏÏËÏÔ˜ ʈÙÈÛÌfi˜ ̤۷ Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ Â›Ó·È ··Ú·›ÙËÙÔ ÛÙÔȯ›Ô.

2. ªËÓ ÂÁηٷÏ›ÂÙ ÔÙ¤ ÙÔ ·È‰› Û·˜ ÌfiÓÔ ÛÙÔ Û›ÙÈ ‹ Û ÂÈΛӉ˘Ó· ÛËÌ›· ̤۷ Î·È ¤Íˆ ·fi ÙÔ Û›ÙÈ, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÓ‹ÏÈÎÔ˘.

3. ∞ÔÌ·ÎÚ‡ÓÂÙ ٷ ÂÈΛӉ˘Ó· ·È¯Ó›‰È· ·fi ÙÔ Û›ÙÈ Î·È ÌËÓ ·Ê‹ÓÂÙ ÔÙ¤ ÂÈΛӉ˘Ó· Ú¿ÁÌ·Ù· ÛÙ· ¯¤ÚÈ· ÙˆÓ ·È‰ÈÒÓ.

4. ªËÓ ·Ê‹ÓÂÙ ÛËÌ·ÓÙÈ΋ ÔÛfiÙËÙ· ÓÂÚÔ‡ Û ÌÂÁ¿Ï· ‰Ô¯Â›· ‹ ÛÙÔ Ì¿ÓÈÔ Î·È ·ÛÊ·Ï›ÛÙ ηϿ ËÁ¿‰È·, ÛÙ¤ÚÓ˜ ‹ ¿ÏÏÔ˘˜ ¯ÒÚÔ˘˜ Û˘ÏÏÔÁ‹˜ ÓÂÚÔ‡.

5. ªËÓ Î˘ÎÏÔÊÔÚ›Ù Ì ÊÏÈÙ˙¿ÓÈ· ˙ÂÛÙÒÓ ÚÔÊËÌ¿ÙˆÓ ·ÚfiÛÂÎÙÔÈ Î·È ·‰ÂÈ¿ÛÙ fiÏ· Ù· ÔÙ‹ÚÈ· ÌÂ Ù˘¯fiÓ ˘ÔÏ›ÌÌ·Ù· ÔÙÒÓ.

6. ÷ÌËÏÒÛÙ ÙÔ ıÂÚÌÔÛÙ¿ÙË ÙÔ˘ ıÂÚÌÔۛʈӷ, ‰È·ÙËÚ›ÛÙ ۂËṲ̂Ó˜ ÙȘ ÂÛٛ˜ Ù˘ ÎÔ˘˙›Ó·˜ fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·È Î·Ï‡ÙÂÙ ¿ÓÙÔÙ ÙȘ ËÏÂÎÙÚÈΤ˜ Ú›˙˜.

7. µÂ‚·Èˆı›Ù fiÙÈ ‚Ú›ÛÎÔÓÙ·È Û ·ÛÊ·Ï‹ ÛËÌ›· ÙÔ ÛȉÂÚˆÙ‹ÚÈÔ Î·È Ù· ʈÙÈÛÙÈο Î·È ÊÚÔÓÙ›ÛÙ ӷ ˘¿Ú¯ÂÈ Û‡ÛÙËÌ· ·ÛÊ·Ï›·˜ ÛÙÔÓ ›Ó·Î· ÙÔ˘ ËÏÂÎÙÚÈÎÔ‡.

8. ∆ÔÔıÂÙ›ÛÙ Û ·Î›Ó‰˘ÓË ı¤ÛË ¤ÈÏ· Ì ·È¯ÌËÚ¿ ¿ÎÚ· Î·È ·ÔʇÁÂÙ ÙȘ fiÚÙ˜ Ì Ù˙¿ÌÈ· Î·È ·˘Ù¤˜ Ô˘ ÎÏ›ÓÔ˘Ó ÌfiÓ˜ ÙÔ˘˜.

9. ∂Í·ÛÊ·Ï›ÛÙ fiÙÈ ÔÈ ÛοϘ ‰ÂÓ Â›Ó·È ·fiÙÔ̘ Î·È Á˘·ÏÈÛÙÂÚ¤˜, fiˆ˜ Î·È Ù· ·ÙÒÌ·Ù· ÙÔ˘ ÛÈÙÈÔ‡.

10. ™˘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˜ Î·È ·ÔÌ·ÎÚ‡ÓÂÙ ηڤÎϘ ‹ ÙÚ·¤˙È· ·fi Ù· ·Ú¿ı˘Ú· ÙÔ˘ ÛÈÙÈÔ‡.

11. ™Ù·Ì·Ù›ÛÙ ӷ ¯ÚËÛÈÌÔÔț٠Ï·ÛÙÈΤ˜ Û·ÎԇϘ Î·È ÂÍ·ÛÊ·Ï›ÛÙ fiÙÈ Ô ÛÎÔ˘ȉÔÙÂÓÂΤ˜ ʤÚÂÈ Î¿Ï˘ÌÌ· Ô˘ ·ÓÔ›ÁÂÈ ‰‡ÛÎÔÏ· Î·È ‚Ú›ÛÎÂÙ·È Û ·ÛʷϤ˜ ÛËÌ›Ô.

12. ∂Í·Ê·Ó›ÛÙ ٷ Ê˘Ù¿ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ‰ËÏËÙËÚ›·ÛË.

13. ™Ô‚·Ú¢Ù›ÙÂ Î·È Ê˘Ï¿ÍÙ ÙÔ Î˘ÓËÁÂÙÈÎfi ‹ ÙÔ ˘ËÚÂÛÈ·Îfi Û·˜ fiÏÔ Û ۛÁÔ˘ÚÔ ÛËÌ›Ô, ¿‰ÂÈÔ Î·È ·ÛÊ·ÏÈṲ̂ÓÔ. º˘Ï¿ÍÙ ÛÊ·›Ú˜, ÛοÁÈ· Î·È Ì·ÚÔ‡ÙÈ Û ¿ÏÏÔ ÛËÌ›Ô, Û›ÁÔ˘ÚÔ Î·È ·ÛʷϤ˜.

14. ªËÓ ·Ê‹ÓÂÙ ʿÚ̷η Î·È ÙÛÈÁ¿Ú· Û ÚÔÛÈÙ¿ ÛËÌ›· Î·È ÎÏ›ÛÙ ηϿ Ù· ÓÙÔ˘Ï¿È·.

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¶·È‰È·ÙÚÈ΋ 2001;64:261-267

ÂÚ›ÊÚ·ÍË. ŸÔ˘ ‰ÂÓ ˘¿Ú¯ÂÈ, ÔÈ ÓÈÁÌÔ› Â›Ó·È 10Ï¿ÛÈÔÈ. ∞Ó¿ÏÔÁ· ̤ÙÚ· Ú¤ÂÈ Ó· ÙËÚÔ‡ÓÙ·È Û fiÏ· Ù· ·ıÏ‹Ì·Ù·. ∆ÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ∆· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙËÓ ÂÊ˂›·. ™Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ÛȉËÚÔ‰ÚÔÌÈο Î·È Ù· ·ÂÚÔÔÚÈο, Ù· ÔÔ›· ·Ó Î·È Û˘Ì‚·›ÓÔ˘Ó Û·ÓÈfiÙÂÚ·, Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÛÔ‚·Ú¿. ™ÙËÓ ∂˘ÚÒË, Ë ∂ÏÏ¿‰·, Ë ¶ÔÚÙÔÁ·Ï›· Î·È Ë πÛ·Ó›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔ˘˜ ÈÔ ·˘ÍË̤ÓÔ˘˜ ‰Â›ÎÙ˜ Ô‰È΋˜ ıÓËÛÈÌfiÙËÙ·˜. ∏ ∂ÏÏ¿‰· ‰Â, η٤¯ÂÈ ÙËÓ ÚÒÙË ı¤ÛË ÛÙËÓ Â› ÙÔȘ ÂηÙfi ·Ó·ÏÔÁ›· ‰È¿ıÂÛ˘ ÙÔ˘ ∞∂¶ (2,5% ÂÚ›Ô˘) ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÂÓÒ Ù· ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ÛÙȘ ∏¶∞ Â›Ó·È 1,5% Î·È ÛÙË ™Ô˘Ë‰›· 0,85%. ¶·Ú’ fiÏ· ·˘Ù¿, ÛÙËÓ ∂ÏÏ¿‰· ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈÔÈ ·’ fiÙÈ ·ÁÎÔÛÌ›ˆ˜, Û ۯ¤ÛË Ì ÙÔÓ ÏËı˘ÛÌfi Ù˘. ™ÙËÓ ∂ÏÏ¿‰· ¤¯Ô˘Ì ÂÙËÛ›ˆ˜ 2.000 ı·Ó¿ÙÔ˘˜, 4.000 ÛÔ‚·ÚÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ Î·È 30.000 ÂÏ·ÊÚ‡ÙÂÚÔ˘˜. ™ÙËÓ ∂˘ÚÒË, ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ·ÚÈıÌÔ› Â›Ó·È 70.000 ı¿Ó·ÙÔÈ Î·È 2.000.000 ÙÚ·˘Ì·Ù›Â˜, ÂÓÒ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ ÛËÌÂÈÒÓÔÓÙ·È 300.000 ı¿Ó·ÙÔÈ Î·È 8.000.000 ÙÚ·˘Ì·Ù›Â˜. ªÂ ÙÔ˘˜ Ú˘ıÌÔ‡˜ ·˘ÙÔ‡˜ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ 1:3 E˘Úˆ·›Ô˘˜ ·ı·›ÓÂÈ ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Î·È 1:100 ¯¿ÓÂÈ ÙË ˙ˆ‹ ÙÔ˘. ∆Ô 1/3 ÙˆÓ ÓÂÎÚÒÓ Î·È ÙˆÓ ÙÚ·˘Ì·ÙÈÒÓ Â›Ó·È ·È‰È¿. ∆Ô ÙÚ·ÁÈÎfi ·˘Ùfi ÁÂÁÔÓfi˜ Á›ÓÂÙ·È ¯ÂÈÚfiÙÂÚÔ ·Ó ˘ÔÏÔÁ›ÛÂÈ Î·Ó›˜ fiÙÈ ÂÎÙfi˜ ·fi ÙÔ˘˜ ı·-

Paediatriki 2001;64:261-267

Ó¿ÙÔ˘˜, ÔÏÏÔ› ·fi ÙÔ˘˜ ÙÚ·˘Ì·Ù›Â˜ ̤ÓÔ˘Ó ·Ó¿ËÚÔÈ Î·È fiÙÈ Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ˘ÁÈ‹ Î·È Ó·ڿ ¿ÙÔÌ·.

OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÎÏËÛË Ô‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ Ê·›ÓÂÙ·È ˆ˜ ¤¯Ô˘Ó Û¯¤ÛË: ·) Ì ÙÔ ›‰ÈÔ ÙÔ ·È‰›, ÙËÓ ËÏÈΛ· ÙÔ˘ Î·È ÙȘ Ê˘ÛÈΤ˜ ·‰˘Ó·Ì›Â˜ Ô˘ ÔÊ›ÏÔÓÙ·È Û ·˘Ù‹, ‚) Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘, ÙÔ˘˜ ÁÔÓ›˜ Î·È ÙÔ˘˜ ‰·ÛοÏÔ˘˜ ÙÔ˘, ÙËÓ ÂÎ·›‰Â˘ÛË Î·È ÙËÓ ÂÓË̤ڈÛË Ô˘ ÙÔ˘ ·Ú¤¯Ô˘Ó, Á) Ì ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô‰ÈÎÔ‡ ‰ÈÎÙ‡Ô˘ Î·È ‰) Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Ô‰ËÁÒÓ (¶›Ó·Î·˜ 2).

OÈ ÛÔ‚·ÚfiÙÂÚ˜ ·Ú·‚¿ÛÂȘ ·fi ÙÔ˘˜ Ô‰ËÁÔ‡˜, Ô˘ ηٿ ηÓfiÓ· Ô‰ËÁÔ‡Ó Û ı·Ó·ÙËÊfiÚ· ‹ ÛÔ‚·Ú¿ ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∞fi ÛÙÔȯ›· Ù˘ ÙÚÔ¯·›·˜ Ê·›ÓÂÙ·È ˆ˜ ÙÔ ™·‚‚·ÙÔ·ÚÈ·ÎÔ Á›ÓÔÓÙ·È Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· Î·È ˆ˜ ÙȘ Ó˘¯ÙÂÚÈÓ¤˜ ÒÚ˜, ·Ó Î·È Î˘ÎÏÔÊÔÚ› ÙÔ 1/10 ÙˆÓ Ô¯ËÌ¿ÙˆÓ, Û˘Ì‚·›ÓÂÈ ÙÔ 1/3 ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™ÙËÓ ∞ı‹Ó· Ê·›ÓÂÙ·È ˆ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ô Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤¯ÂÈ ÌÂȈı›, ¤¯Ô˘Ó fï˜ ·˘ÍËı› Ù· ı·Ó·ÙËÊfiÚ· ·Ù˘¯‹Ì·Ù·. ∆Ô ·˘ÙÔΛÓËÙÔ ¤¯ÂÈ ‚ÚÂı› ˆ˜ Â›Ó·È 45 ÊÔÚ¤˜ ÂÈÛʷϤÛÙÂÚÔ Û ۯ¤ÛË Ì ÙÔ ·ÂÚÔÏ¿ÓÔ Î·È ÙÔ ÛȉËÚfi‰ÚÔÌÔ. ∆Ô ·È‰›, ‚¤‚·È·, ÌÔÚ› Ó· ‚ÚÂı› ˆ˜ ı‡Ì· ÙÚÔ¯·›Ô˘ ›Ù ˆ˜ Â˙fi˜, ›Ù ˆ˜ ÂÈ‚¿Ù˘ ‹ Ô‰ËÏ¿Ù˘ ‹ Î·È ˆ˜ Ô‰ËÁfi˜, ·ÚÁfiÙÂÚ·, Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·. ∆Ô ·È‰› ˆ˜ Â˙fi˜ ∆Ô 30% ÙˆÓ ÓÂÎÚÒÓ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È Â˙Ô› Î·È Î˘Ú›ˆ˜ ·È‰È¿ ηÈ

¶›Ó·Î·˜ 2. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÚfiÎÏËÛË Ô‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ ∞) ∏ ÌÈÎÚ‹ ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ì ÙȘ ·‰˘Ó·Ì›Â˜ Ù˘ - ÙÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È ÙÔ ÌÈÎÚfiÙÂÚÔ ÔÙÈÎfi ‰›Ô - Ë ·ÈÛıËÙËÚȷ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·ÓˆÚÈÌfiÙËÙ· - Ë ·‰˘Ó·Ì›· ÁÓÒÛ˘ ÙˆÓ ÛËÌ¿ÙˆÓ - Ë ÔÚÌËÙÈÎfiÙËÙ· Î·È ·ÚÔÚÌËÙÈÎfiÙËÙ· - Ë ÁÔËÙ›· Ô˘ ÚÔηÏ› Ô Î›Ó‰˘ÓÔ˜ - Ë ËÏÈΛ·, ÙÔ Ê‡ÏÔ, Ë ÎÔÈÓˆÓÈ΋ Ù¿ÍË, Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜, Ô ¯ÚfiÓÔ˜ Û˘Ì‚¿ÓÙÔ˜ µ) ∆Ô ·ÓıÚÒÈÓÔ ÂÚÈ‚¿ÏÏÔÓ (ÁÔÓ›˜, ÎˉÂÌfiÓ˜ Î.Ï.)

- ·ÁÓÔÔ‡Ó ÙÔ˘˜ ÛÙ·ıÌÔ‡˜ ÂͤÏÈ͢ Î·È ˆÚ›Ì·ÓÛ˘ ÙˆÓ ·È‰ÈÒÓ - ˘ÂÚÂÎÙÈÌÔ‡Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙˆÓ ·È‰ÈÒÓ - Á›ÓÔÓÙ·È ÔÈ ›‰ÈÔÈ Î·Î¿ ·Ú·‰Â›ÁÌ·Ù· - ‰ÂÓ ‰›ÓÔ˘Ó ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙËÓ ÂÎ·›‰Â˘ÛË Î·È ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ - ‰ÂÓ ÂӉȷʤÚÔÓÙ·È È‰È·›ÙÂÚ· ÁÈ· ÙËÓ Î˘ÎÏÔÊÔÚȷ΋ ·ÁˆÁ‹ ÙˆÓ ·È‰ÈÒÓ °) O ¯ˆÚÔÙ·ÍÈÎfi˜ Î·È Î˘ÎÏÔÊÔÚÈ·Îfi˜ ÂÚ›Á˘ÚÔ˜ - Ô Û¯Â‰È·ÛÌfi˜ ÙˆÓ ‰ÚfiÌˆÓ (ÌÔÓfi‰ÚÔÌÔÈ, ‰È·‚¿ÛÂȘ, ÛËÌ·ÙÔ‰fiÙËÛË) - Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ΢ÎÏÔÊÔÚ›·˜ (ÙÚÔ¯ÔÊfiÚ·, Ù·¯‡ÙËÙ˜ Î.Ï.)

- ¿ÏÏÔÈ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (‰fiÌËÛË ÁÂÈÙÔÓÈ¿˜, ·È‰fiÙÔÔÈ, Û¯ÔÏ›·, ηٷÛÙ‹Ì·Ù· Î.Ï.) ¢) OÈ ·‰˘Ó·Ì›Â˜ ÙˆÓ Ô‰ËÁÒÓ - η΋ Û˘ÓÙ‹ÚËÛË Ô¯ËÌ¿ÙˆÓ - ÂÈÔÏ·ÈfiÙËÙ·, ¤ÏÏÂÈ„Ë ÂÎ·›‰Â˘Û˘ - ÌË Ù‹ÚËÛË Î·ÓfiÓˆÓ Î.Ô.Î.

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¶·È‰È·ÙÚÈ΋ 2001;64:261-267

¤ÊË‚ÔÈ, ÂÓÒ ÛÙËÓ ∂˘ÚÒË ÙÔ ÔÛÔÛÙfi η٤گÂÙ·È ÛÙÔ 20% Î·È ÛÙȘ ∏¶∞ ÛÙÔ 16%. ∆Ô ·È‰› ˆ˜ Â˙fi˜ ÌÂÈÔÓÂÎÙ› ÛËÌ·ÓÙÈο ÁÈ· ÙÔ˘˜ ÏfiÁÔ˘˜ Ô˘ ‹‰Ë ·Ó·Ê¤ÚıËÎ·Ó ÎÈ ¤ÙÛÈ ¯ÚÂÈ¿˙ÂÙ·È ÂÈÙ‹ÚËÛË Î·È ÂÎ·›‰Â˘ÛË: ·) ·È‰È¿ <5 ¯ÚfiÓˆÓ ¤¯Ô˘Ó ·Ó¿ÁÎË ·fi Û˘Ó¯‹ Î·È ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË fiÙ·Ó Â›Ó·È ÛÙÔ ‰ÚfiÌÔ, ‚) ·È‰È¿ <7 ¯ÚfiÓˆÓ Â›Ó·È ·ÓÒÚÈÌ· Î·È ·ÚÔÚÌËÙÈο Î·È Â‡ÎÔÏ· ·ÎÔÏÔ˘ıÔ‡Ó ÙËÓ ·Ú¤·, Á) ·È‰È¿ <9 ¯ÚfiÓˆÓ ÌÔÚÔ‡Ó Ó· ‰È·Û¯›ÛÔ˘Ó ÙÔ ‰ÚfiÌÔ ¯ˆÚ›˜ ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ·ÊÔ‡ ÂÎ·È‰Â˘ÙÔ‡Ó, ÂÓÒ, ‰) ·È‰È¿ >12 ¯ÚfiÓˆÓ ÌÔÚÔ‡Ó Ó· Û˘ÌÂÚÈʤÚÔÓÙ·È ÛˆÛÙ¿ Û·Ó Â˙Ô› ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜. ™ÙËÓ Î˘ÎÏÔÊÔÚȷ΋ ·ÁˆÁ‹ ¤Ú·Ó ÙˆÓ ÁÓˆÛÙÒÓ ‚·ÛÈÎÒÓ ÂÓÓÔÈÒÓ (Ë ÛËÌ·ÙÔ‰fiÙËÛË ˆ˜ ·Ú¿‰ÂÈÁÌ·) Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë Î·Ù·ÓfiËÛË ÙˆÓ fiÚˆÓ: ‹¯Ô˜ ·fiÛÙ·ÛË, Ù·¯‡ÙËÙ·. ∆Ô ·È‰› ˆ˜ ÂÈ‚¿Ù˘ °È· ÙËÓ ·ÛÊ·Ï‹ ÌÂÙ·ÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂ÓÔÈ ‚·ÛÈÎÔ› ηÓfiÓ˜ Ô˘ ÔÈΛÏÔ˘Ó ·fi ¯ÒÚ· Û ¯ÒÚ· (¶›Ó·Î·˜ 4): ·) ∆· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· οıÔÓÙ·È ÁÈ· ηӤӷ ÏfiÁÔ ÛÙÔ ÌÚÔÛÙÈÓfi οıÈÛÌ· ·ÏÏ¿ ¿ÓÙÔÙ ÛÙÔ ›Ûˆ. ∂›Û˘, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÛÙÔ fiÚÙÌÂÌ¤, ÛÙ· ÁfiÓ·Ù· ‹ ÛÙËÓ ·ÁηÏÈ¿ οÔÈÔ˘. ™Â ÂӉ¯fiÌÂÓË -·ÎfiÌË Î·È ÂÏ·ÊÚÈ¿- Û‡ÁÎÚÔ˘ÛË ‹ Û ·fiÙÔÌÔ ÊÚÂÓ¿ÚÈÛÌ· ÙÔ ·È‰› ÎÈÓ‰˘Ó‡ÂÈ Ó· ÎÙ˘‹ÛÂÈ ÛÙÔ Ù·ÌÏfi ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘. Œ¯ÂÈ ‚ÚÂı› ˆ˜ ÙÔ 90% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Î·È ÛÒıËηÓ, ÔÈ ÔÔ›ÔÈ ÎÚ·ÙÔ‡Û·Ó ·È‰È¿ ÛÙËÓ ·ÁηÏÈ¿ ÙÔ˘˜, ÛÒıËÎ·Ó ÂÂȉ‹ ÙÔ ·È‰› ÙÔ˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ·Û›‰·. ‚) ∆Ô ·È‰› Ú¤ÂÈ ¿ÓÙÔÙ ӷ οıÂÙ·È ÛÙÔ ÂȉÈÎfi οıÈÛÌ· ·ÛÊ·Ï›·˜, Ì ÙËÓ ÂȉÈ΋ ˙ÒÓË ·ÛÊ·Ï›·˜. ¶ÔÙ¤ ‰ÂÓ Ú¤ÂÈ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È 2 ·È‰È¿ Ì·˙› Û ÌÈ›· ˙ÒÓË. ªÂ ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ·È‰ÈÎÒÓ Î·ıÈÛÌ¿ÙˆÓ, ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂȈıÔ‡Ó Î·Ù¿ 70% Î·È ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› ηٿ 67%. ∞fi ÙÔ˘˜ ÁÔÓ›˜, fï˜, Ô˘ ̤ÓÔ˘Ó ÛÙËÓ ∞ı‹Ó· Î·È ¤¯Ô˘Ó ·˘ÙÔΛÓËÙÔ, ÌfiÓÔ ÙÔ 58% ·ÁÔÚ¿˙ÂÈ ·È‰Èο ηı›ÛÌ·Ù· ·˘ÙÔ¶›Ó·Î·˜ 3. ¶Ô‡ ÔÊ›ÏÔÓÙ·È Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·; 1.

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¶·Ú·‚È¿ÛÂȘ ÛËÌ·ÙÔ‰fiÙË ¶·Ú·‚È¿ÛÂȘ ÚÔÙÂÚ·ÈfiÙËÙ·˜ ªË Ù‹ÚËÛË ·fiÛÙ·Û˘ ·ÛÊ·Ï›·˜ ÀÂÚ‚ÔÏÈ΋ Ù·¯‡ÙËÙ· ∫›ÓËÛË ÛÙÔ ·ÓÙ›ıÂÙÔ Ú‡̷ ∞ÓÙÈηÓÔÓÈ΋ ·ÏÏ·Á‹ ψڛ‰·˜ ΢ÎÏÔÊÔÚ›·˜ O‰‹ÁËÛË ˘fi ÙËÓ Â‹ÚÂÈ· „˘¯ÔÙÚfiˆÓ Ô˘ÛÈÒÓ ÕÁÓÔÈ· ÛˆÛÙ‹˜ Ô‰‹ÁËÛ˘ ∫Ô‡Ú·ÛË ÙÔ˘ Ô‰ËÁÔ‡, ·fiÛ·ÛË ÚÔÛÔ¯‹˜ ÃÚ‹ÛË ÂÎÙ˘ÊψÙÈÎÒÓ ÊÒÙˆÓ ∫·Î‹ ηٿÛÙ·ÛË ÙÚÔ¯ÔÊfiÚÔ˘

Paediatriki 2001;64:261-267

ÎÈÓ‹ÙÔ˘ ÂÓÒ ÛÙËÓ Â·Ú¯›· ÙÔ 32%. ∏ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÁÔÚ¿. ∫·È Ê˘ÛÈο ÌfiÓÔ ÙÔ 0,51% ·ÁÔÚ¿˙ÂÈ ÙÔ ÙÂÏÂ˘Ù·›·˜ Ù¯ÓÔÏÔÁ›·˜ οıÈÛÌ· ·ÛÊ·Ï›·˜ Ô˘ Â›Ó·È ÂȉÈÎfi ÁÈ· ÙÔ ‚¿ÚÔ˜, ÙËÓ ËÏÈΛ·, ÙÔ ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ·Ú¤¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÚÔÛÙ·Û›·. ∏ ˙ÒÓË ·ÛÊ·Ï›·˜ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÛÙ· ›Ûˆ ηı›ÛÌ·Ù·, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÂÈ ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ηٿ 22% Î·È ÙÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ 50%. ∆ÔÓ›˙ÂÙ·È, ‚¤‚·È·, ˆ˜ Ë ˙ÒÓË ·ÛÊ·Ï›·˜ ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË fiÙ·Ó ÙÔ ‰È·ÁÒÓÈÔ ÙÌ‹Ì· Ù˘ ÂÚÓ¿ ·fi ÙÔ Ì¤ÛÔ ÂÚ›Ô˘ Ù˘ ·fiÛÙ·Û˘ ÌÂٷ͇ ÙÔ˘ ¿ÎÚÔ˘ ÙÔ˘ ÒÌÔ˘ Î·È ÙÔ˘ Ï·ÈÌÔ‡. Á) ¶ÔÙ¤ Ù· ·È‰È¿ ÛÙÔ ·˘ÙÔΛÓËÙÔ Ì ÎÚ·ÙÒÓÙ·˜ ÂÈΛӉ˘Ó· ·È¯Ó›‰È·. ‰) OÈ fiÚÙ˜ ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ú¤ÂÈ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È ·fi ÙËÓ ¤Íˆ ÏÂ˘Ú¿. ¶ÔÏÏ¿ ·È‰È¿ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È ‹ Î·È ÛÎÔÙÒÓÔÓÙ·È ¤ÊÙÔÓÙ·˜ ¤Íˆ ·fi ÙËÓ fiÚÙ· ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ô˘ ·ÓÔ›ÁÂÈ ·fiÙÔÌ· Û ÛÙÚÔÊ‹ ‹ fiÙ·Ó ·›˙Ô˘Ó Ì ÙËÓ fiÚÙ· ¯ˆÚ›˜ Ó· ÊÔÚÔ‡Ó ˙ÒÓË. ∆Ô ·È‰› ˆ˜ Ô‰ËÁfi˜ ∆Ô ·È‰› ÌÔÚ› Ó· Â›Ó·È Ô‰ËÁfi˜ Ô‰ËÏ¿ÙÔ˘, ÌÔÙÔÛ˘ÎϤٷ˜ ‹, ˆ˜ ¤ÊË‚Ô˜, ·˘ÙÔÎÈÓ‹ÙÔ˘. ∫·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ·È‰› Ô˘ ·›˙ÂÈ Î·È ÙÔ ÚfiÏÔ ÙÔ˘ Ô‰ËÁÔ‡, ÙËÓ ˆÚÈÌfiÙËÙ·, ÙËÓ ÂÎ·›‰Â˘ÛË, ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô¯‹Ì·ÙÔ˜, ÙËÓ ·˘ÛÙËÚ‹ Ù‹ÚËÛË ÙÔ˘ ÎÒ‰Èη Ô‰È΋˜ ΢ÎÏÔÊÔÚ›·˜ Û ۯ¤ÛË ¿ÓÙ· Ì ÙÔ ¯ˆÚÔÙ·ÍÈÎfi ÂÚ›Á˘ÚÔ. OÈ ŒÏÏËÓ˜ Û˘ÁÎÔÈÓˆÓÈÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó ˆ˜ Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ô‰ÈÎÔ‡ ‰ÈÎÙ‡Ô˘ Ù˘ ¯ÒÚ·˜ ¢ı‡ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi fiÏÔ˘˜ ÙÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ. ª¤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ∆· ÚÔÛ¯‹ ¯ÚfiÓÈ· ·Ó·Ì¤ÓÂÙ·È Ó· ·˘ÍËı› Ë ıÓËÙfiÙËÙ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·fi Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, Û·Ó ·ÔÙ¤ÏÂÛÌ· Ù˘ ·‡ÍËÛ˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Ù·ÍȉÈÒÓ Ì ·˘ÙÔΛÓËÙÔ (ÂÚÈÛÛfiÙÂÚ˜ ÔÈÎÔÁ¤ÓÂȘ ·ÔÎÙÔ‡Ó ·˘ÙÔΛÓËÙÔ Î·È ¶›Ó·Î·˜ 4. ¶Ò˜ Ú¤ÂÈ Ó· Ù·ÍÈ‰Â‡Ô˘Ó Ù· ·È‰È¿; ·) ¶ÔÙ¤ ÛÙÔ ÌÚÔÛÙÈÓfi, ·ÏÏ¿ ¿ÓÙ· ÛÙÔ ›Ûˆ οıÈÛÌ· ‚) ¶ÔÙ¤ ÛÙÔ ÔÚÙ-ÌÂÌ¤, ÛÙ· ÁfiÓ·Ù· ‹ ÙËÓ ·ÁηÏÈ¿ οÔÈÔ˘ Á) ¡· ÌËÓ ÎÚ·ÙÔ‡Ó ÂÈΛӉ˘Ó· ·È¯Ó›‰È· ‰) ¶¿ÓÙ· ÛÙÔ ÂȉÈÎfi οıÈÛÌ· ·ÛÊ·Ï›·˜ Ì ÙËÓ ÂȉÈ΋ ˙ÒÓË Â) ¶ÔÙ¤ ‰‡Ô ·È‰È¿ Û ̛· ˙ÒÓË ·ÛÊ·Ï›·˜ ÛÙ) OÈ fiÚÙ˜ ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È ·’ ¤Íˆ.

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ÂÍÔ¯È΋ ηÙÔÈΛ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ù·ÍÈ‰Â‡Ô˘Ó Û˘¯ÓfiÙÂÚ·, ÂÓÒ ÌÂÁ·Ï‡ÙÂÚÔ˜ Â›Ó·È Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÙ·ÎÈÓÂ›Ù·È Ì ·˘ÙÔΛÓËÙÔ ÛÙÔ˘˜ ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜ Î·È Ù· Û¯ÔÏ›·). °È· ÙÔ ÏfiÁÔ ·˘Ùfi ¯ÚÂÈ¿˙ÂÙ·È È‰È·›ÙÂÚË ÚÔÛ¿ıÂÈ· Î·È Î·Ù¿ÏÏËÏÔ˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ ÚfiÏ˄˘, ÒÛÙ ӷ ‚ÂÏÙȈıÔ‡Ó ÔÈ ‰Â›ÎÙ˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ó· ˘¿ÚÍÂÈ Ì›ˆÛË ·Ó·ËÚÈÒÓ Î·È ı·Ó¿ÙˆÓ. ∆¤ÙÔÈ· ÚÔÁÚ¿ÌÌ·Ù· ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Û ÔÏϤ˜ ¯ÒÚ˜ Î·È ·¤‰ˆÛ·Ó. ™ÙËÓ ∂ÏÏ¿‰· ¯ÚÂÈ¿˙ÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ÚÔÛ¿ıÂÈ·. ∆· ηχÙÂÚ· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ‰ÈÂıÓÒ˜ Ê·›ÓÂÙ·È Ó· ·Ô‰›‰Ô˘Ó ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: 1) ÃÚ‹ÛË Î·Ù¿ÏÏËÏ˘ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ Î·È ÂȉÈÎÔ‡ ηı›ÛÌ·ÙÔ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÛÙ· ‚Ú¤ÊË, Ù· ÌÈÎÚfiÙÂÚ· Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∏ ¯Ú‹ÛË ÎÚ¿ÓÔ˘˜ ·fi ÙÔ˘˜ ÌÔÙÔÛ˘ÎÏÂÙÈÛÙ¤˜ Î·È ÙÔ˘˜ Ô‰ËÏ¿Ù˜ Ê·›ÓÂÙ·È ˆ˜ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÛÙÔ ÎÂÊ¿ÏÈ Î·Ù¿ 85%, 2) ·˘ÛÙËÚfiÙÂÚË ·ÛÙ˘ÓfiÌ¢ÛË ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ∫.O.∫., 3) ·˘ÛÙËÚfiÙÂÚÔ ¤ÏÂÁ¯Ô ·Ó›¯Ó¢Û˘ ·ÏÎÔfiÏ˘ ÛÙÔ ·›Ì· ηٿ ÙËÓ Ô‰‹ÁËÛË, 4) ηχÙÂÚË ÂÎ·›‰Â˘ÛË Î·È ·˘ÛÙËÚfiÙÂÚË ÂͤٷÛË ÁÈ· ÙË Ï‹„Ë ¿‰ÂÈ·˜ Ô‰‹ÁËÛ˘, 5) ÛˆÛÙ‹ Û˘ÓÙ‹ÚËÛË ÙˆÓ Ô¯ËÌ¿ÙˆÓ Î·ıÒ˜ Î·È ·˘ÛÙËÚfi˜ Î·È Ù·ÎÙÈÎfi˜ ¤ÏÂÁ¯fi˜ ÙÔ˘˜, 6) ‚ÂÏÙ›ˆÛË ÙˆÓ Ô‰ÈÎÒÓ ‰ÈÎÙ‡ˆÓ, ÛˆÛÙ‹ Û‹Ì·ÓÛË, ηχÙÂÚË ÔÚ·ÙfiÙËÙ·, ηχÙÂÚË ‰fiÌËÛË. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ ÛËÌÂÚÈÓfi Ô‰ÈÎfi ‰›ÎÙ˘Ô Ù˘ ¯ÒÚ·˜ Ì·˜ ‰ÂÓ ¤¯ÂÈ ÚÔ¸Ôı¤ÛÂȘ ·ÛÊ·Ï›·˜ ÂÓÒ ÌfiÓÔ ÛÙÔ 10% ÙˆÓ Ô‰ÒÓ ÌÔÚÔ‡Ó Ó· ·Ó·Ù˘¯ıÔ‡Ó Ù·¯‡ÙËÙ˜ Ô˘ Ó· ÍÂÂÚÓÔ‡Ó Ù· 80 ¯ÈÏ./ÒÚ·. ∂·ÁÁÂÏÌ·ÙÈο ·Ù˘¯‹Ì·Ù· ∂·ÁÁÂÏÌ·ÙÈο Â›Ó·È Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÁ·Û›·˜. ¢˘ÛÙ˘¯Ò˜ Î·È Û‹ÌÂÚ·, ÛÙÔÓ 21Ô ·ÈÒÓ·, Ù¤ÙÔÈ· ·Ù˘¯‹Ì·Ù· Û˘Ì‚·›ÓÔ˘Ó ÂÎÙfi˜ ·fi ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Û ÌÈÎÚfiÙÂÚ· ·È‰È¿, ·ÊÔ‡ Ë ÂÚÁ·Û›· ÁÈ· ÔÏÏ¿ ·È‰È¿ Â›Ó·È ÙÔ ÌÔÓ·‰ÈÎfi ̤ÛÔ ÂÈ‚›ˆÛ˘. ¢ÈÂıÓÒ˜, Ë ıÓËÛÈÌfiÙËÙ· ·fi Â·ÁÁÂÏÌ·ÙÈο ·Ù˘¯‹Ì·Ù· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ÂÚÁ·˙fiÌÂÓÔ˘˜ Û ÔÚ˘¯Â›·, Ï·ÙÔÌ›·, ÔÈÎÔ‰Ô̤˜, ÁˆÚÁÈÎÔ‡˜ ¯ÒÚÔ˘˜, ηıÒ˜ Î·È ÛÙÔ Û˘ÁÎÔÈÓˆÓÈ·Îfi ÙÔ̤·, ÙȘ ÌÂÙ·ÊÔÚ¤˜, ÙË ‚ÈÔÌ˯·Ó›· Î·È Ù· Ó·˘ÙÈο Â·ÁÁ¤ÏÌ·Ù·. ø˜ Û˘¯ÓfiÙÂÚÔÈ ÙÚfiÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·Ó·Ê¤ÚÔÓÙ·È: ·) ÔÈ ¯ÂÈÚÈÛÌÔ› ¯ÂÈÚˆÓ·ÎÙÈÎÒÓ ÂÚÁ·Ï›ˆÓ ‹ Ì˯·ÓËÌ¿ÙˆÓ Î·È Ë ÙÒÛË ÙÔ˘ ·ÙfiÌÔ˘ ‹ ·ÓÙÈÎÂÈ̤ӈÓ, ‚) Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, Ô ÔÔ›Ô˜ Â›Ó·È Ô ¯ÂÈÚfiÙÂÚÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜. ∞ÎÔÏÔ˘ıÔ‡Ó ÙÔ ÎÂÊ¿ÏÈ, Ù· Ì¿ÙÈ· Î·È Ù· ‰¿ÎÙ˘Ï· ÙˆÓ ¯ÂÚÈÒÓ.

OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Â·ÁÁÂÏÌ·ÙÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ Â›‰Ô˜ Ù˘ ÂÚÁ·Û›·˜, ηıÒ˜ Î·È ÙËÓ ÂÌÂÈÚ›·, ÙËÓ ¤ÓÙ·ÛË, ÙËÓ ÂÍ¿ÓÙÏËÛË, ÙËÓ ÚÔÛˆÈÎfiÙËÙ·

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ÙÔ˘ ÂÚÁ·˙fiÌÂÓÔ˘ Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜. ∆Ô 95% ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙÔ ¯ÒÚÔ ÂÚÁ·Û›·˜ ı· ÌÔÚÔ‡Û·Ó Ó· ÚÔÏËÊıÔ‡Ó ·Ó ÂÊ·ÚÌfi˙ÔÓÙ·Ó Ù· ÂÓ‰ÂÈÎÓ˘fiÌÂÓ· ̤ÙÚ· ÚfiÏ˄˘. ¶ÂÚÈ‚·ÏÏÔÓÙÈο ·Ù˘¯‹Ì·Ù· ™Ù· ÂÚÈ‚·ÏÏÔÓÙÈο ·Ù˘¯‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ˘ÚËÓÈο, Ù· ¯ËÌÈο, ÔÈ ˘ÚηÁȤ˜, ÔÈ ıÂÔÌËӛ˜ (ÛÂÈÛÌÔ›, ÏËÌ̇Ú˜, Ù˘ÊÒÓ˜), Ù· ÔÔ›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂËÚ¿ÛÔ˘Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÙÔ˘ ÏËı˘ÛÌÔ‡. °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ Û˘ÓÂÂÈÒÓ ·˘ÙÒÓ ÙˆÓ Î·Ù·ÛÙÚÔÊÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÔÚÁ·ÓˆÌ¤ÓË Ì¤ıÔ‰Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ ·fi ÙËÓ ÔÏÈÙ›· Î·È Ï‹Ú˘ ÂÓË̤ڈÛË fiÏÔ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È ÙˆÓ ·È‰ÈÒÓ ÁÈ· ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ∏ ÔÚ›· ÙˆÓ ı˘Ì¿ÙˆÓ ·Ù˘¯‹Ì·ÙÔ˜ ∆Ô ·È‰›, ÌÂÙ¿ ÙÔ ·Ù‡¯ËÌ·, ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜, ÒÛÙ ӷ ·Ú·Û¯Âı› Ë Î·Ù·ÏÏËÏfiÙÂÚË Î·È Ë ϤÔÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‚Ô‹ıÂÈ·. ™ÙÔ ™¯‹Ì· 1 ·ÂÈÎÔÓ›˙ÂÙ·È Ë ÔÚ›· ÙÔ˘ ı‡Ì·ÙÔ˜ ·fi ·Ù‡¯ËÌ·. ¶ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ∆· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÛÔ‚·ÚfiÙ·ÙÔ Úfi‚ÏËÌ· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ fiÏˆÓ ÙˆÓ ¯ˆÚÒÓ Î·È ·˘Ùfi ÂÂȉ‹ ΢ڛˆ˜ ·ÊÔÚÔ‡Ó ÙÔ Ó·ÓÈÎfi Î·È ˘ÁÈ‹ ÏËı˘ÛÌfi, ¿ÏÏ· Î·È ‰ÈfiÙÈ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó. ∆· ·Ù˘¯‹Ì·Ù· ‰ÂÓ ÚÔηÏÔ‡ÓÙ·È ·fi “ηÎÔÙ˘¯›·”. E›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÙÔ ·ÓıÚÒÈÓÔ Ï¿ıÔ˜, Ë ·Ê¤ÏÂÈ·, Ë ·ÂÚÈÛ΄›·, Ë ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, Ë ¿ÁÓÔÈ·. A˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ì ˘Ô¯Ú¤ˆÛË Ó· ÚÔÏ¿‚Ô˘ÌÂ. ∏ ÂÊ·ÚÌÔÁ‹ ÔÏÔÎÏËÚˆÌ¤ÓˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ ÚÔ¸Ôı¤ÙÂÈ ÌÂϤÙË ·fi Û·Ê‹ ÂȉËÌÈÔÏÔÁÈ΋ ¿Ô„Ë Î·È ·Ó¿Ï˘ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË Û˘¯ÓfiÙËÙ·, ÙË ‚·Ú‡ÙËÙ·, ÙÔ ÎfiÛÙÔ˜ Î·È ÁÂÓÈο ÙȘ Û˘Ó¤ÂȘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÚÒÙ· ÁÈ· Ù· ı‡Ì·Ù· Î·È ‡ÛÙÂÚ· ÁÈ· ÙËÓ ∂ıÓÈ΋ OÈÎÔÓÔÌ›·. ∏ ™˘ÓÔÌÔÛÔÓ‰›· ∂˘Úˆ·˚ÎÒÓ ∂ȉÈÎÔÙ‹ÙˆÓ ÛÙËÓ ¶·È‰È·ÙÚÈ΋, ·fi ÙË Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ Ô˘ ¤Î·Ó ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, η٤ÏËÍ ÛÙÔ Û˘Ì¤Ú·ÛÌ· ˆ˜ Ë ‰ËÌÈÔ˘ÚÁ›· ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Â›Ó·È ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Ì¤ÙÚÔ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿, ÂÓÒ Ë ÂÎ·›‰Â˘ÛË ¤ÂÙ·È ÛÙË ÛÂÈÚ¿. ™ÙËÓ ∂ÏÏ¿‰·, Ôχ Ï›Á· ̤ÙÚ· ÚfiÏ˄˘ Â›Ó·È ˘Ô¯ÚˆÙÈο Ì ÓfiÌÔ˘˜, ·ÏÏ¿ Î·È fiÛ· ¤¯Ô˘Ó ıÂÛÈÛÙ› ‰ÂÓ ÙËÚÔ‡ÓÙ·È, ·Ú’ fiÏÔ Ô˘ Ë Î·Ù¿ÛÙ·ÛË ÛÙÔ ¯ÒÚÔ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Â›Ó·È ·fi ÙÚ·ÁÈ΋ ¤ˆ˜ ‰Ú·Ì·ÙÈ΋. OÈ ·È‰›·ÙÚÔÈ Î·Ù¤¯Ô˘Ó ÛËÌ·ÓÙÈ΋ ı¤ÛË, Ë ÔÔ›· ÙÔ˘˜ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·Ú¤Ì‚Ô˘Ó ‰˘Ó·ÌÈο ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ

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·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. ªÔÚÔ‡Ó Ó· ›ÛÔ˘Ó ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ·˘ÍË̤ÓË Â·ÁÚ‡ÓËÛË Î·È ·˘ÛÙËÚ‹ ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ ÁÈ· ·ÔÊ˘Á‹ ·Ù˘¯ËÌ¿ÙˆÓ, Û˘Ì‚Ô˘Ï‡ÔÓÙ¿˜ ÙÔ˘˜ ÌËÓ ˘ÂÚÂÎÙÈÌÔ‡Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙˆÓ ·È‰ÈÒÓ Î·È Ó· ÌËÓ ÂÚÈÊÚÔÓÔ‡Ó ÙÔÓ Î›Ó‰˘ÓÔ. ∂›Û˘, ÌÔÚÔ‡Ó Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙÔ Ó· ÏËÊıÔ‡Ó Ì¤ÙÚ· ÁÈ· ÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÒÛÙ ӷ ‰ËÌÈÔ˘ÚÁËı› ·ÛʷϤ˜ ÂÚÈ‚¿ÏÏÔÓ ÛÙÔ Û›ÙÈ, ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜, ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ·Ó·„˘¯‹˜. OÈ ·È‰›·ÙÚÔÈ ÌÔÚÔ‡Ó Ó· ··ÈÙ‹ÛÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·ÛÊ·ÏÒÓ ÚÔ˚fiÓÙˆÓ, fiˆ˜ ·È¯Ó›‰È· Î·È Û˘Û΢·Û›Â˜ Ê·ÚÌ¿ÎˆÓ ÂÊ·ÚÌfi˙ÔÓÙ·˜ ÓÔÌÔıÂÙÈΤ˜ ·ÏÏ·Á¤˜. ™ËÌ·ÓÙÈ΋, Â›Û˘, Â›Ó·È Ë ·Ú¤Ì‚·Û‹ ÙÔ˘˜ ÛÙËÓ ÂÎ·›‰Â˘ÛË, ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ÛÙÔ È·ÙÚ›Ô, ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô Î·È ÛÙ· ªª∂. ∆Ô ·Ú¯·›Ô ÚËÙfi “ηχÙÂÚ· Ó· ÚÔÏ·Ì‚¿ÓÂȘ ·Ú¿ Ó· ıÂÚ·‡ÂȘ” ÈÛ¯‡ÂÈ Î·ÙÂÍÔ¯‹Ó ÛÙÔÓ ÙÔ̤· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ.

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µÈ‚ÏÈÔÁÚ·Ê›· 1. ∞Ó·ÛÙ·Û¤·-µÏ¿¯Ô˘ ∫. ∞Ù˘¯‹Ì·Ù· ÛÙËÓ ∂Ê˂›·. ¢ÂÏÙ. ∞’ ¶·È‰È·ÙÚ. ∫ÏÈÓ. ¶·ÓÂ. ∞ıËÓÒÓ 1997;44:138-141.

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Eichelberger M, Gotschall C, Feely H, Harstad P, Bowman L. Parental attitudes and knowledge of child safety. Am J Dis Child 1990;144:714-720.

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Pediatrics 1994;93:960-965. ∫ÙÂÓ¿˜ ∂. O‰Èο ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÛÙËÓ ∂ÏÏ¿‰·. π·ÙÚÈ΋ 1994;65:181-183. ∫ˆÛÙ·Ú›‰Ô˘ ™, ∞Ó·ÛÙ·Û¤·-µÏ¿¯Ô˘ ¶, ™ˆÙËÚÔÔ‡ÏÔ˘ º, ¶·Ó·ÁÔÔ‡ÏÔ˘ ª, ¶·Ó·ÁÔÔ‡ÏÔ˘ °, ∑·¯·ÚÈ¿‰Ë ∞ Î·È Û˘Ó. ¶ÚfiÏË„Ë ÙÚÔ¯·›ˆÓ ηÎÒÛˆÓ: ™˘Óı‹Î˜ ÌÂÙ·ÊÔÚ¿˜ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ì ÙÔ ·˘ÙÔΛÓËÙÔ. ¶·È‰È·ÙÚÈ΋ 1996;59:325-333.

Rivara F, Thompson D, Thompson R. The seattle children’s bicycle helmet campaign, changes in helmet use and head injury admissions. Pediatrics 1994;93:567-569.

Rosenberg M, Rodriguez J, Chorba T. Childhood injuries, where we are. Pediatrics 1990;89(Suppl):1084-1091.

Sosin D, Sacks J, Holmgreen P. Head injuryassociated deaths from motorcycle crashes. JAMA 1990;264:2395-2399. ™ÙÔȯ›· ÛÔÎ ÁÈ· ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ÙÚÔ¯·›·. ∆· ¡¤·; 2000, 23 ª·ÚÙ›Ô˘.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: KˆÓÛÙ·ÓÙ›ÓÔ˜ ∆ÛÔ˘Ì¿Î·˜ ¢. ªfiÛ¯· 8, ª·ÚÔ‡ÛÈ, 151 24 ∞ı‹Ó·

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EMERGENCY AND INTENSIVE CARE PEDIATRICS

AÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ∫. ¶·¿˙ÔÁÏÔ˘

Management of the child with multiple trauma K. Papazoglou

¶ÂÚ›ÏË„Ë: ∆Ô ·È‰ÈÎfi ÙÚ·‡Ì· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfiÙ·ÙÔ Úfi‚ÏËÌ· ÂÂȉ‹ Ù· ·È‰È¿, ›Ù ˆ˜ Â˙Ô› ›Ù ˆ˜ Ô‰ËÏ¿Ù˜, ˘fiÎÂÈÓÙ·È Û 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ··ÈÙ› ¿ÌÂÛË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È ·ÍÈÔÏfiÁËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ù˘ ΢ÎÏÔÊÔÚ›·˜ Î·È Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘ Î·È ÂÓ Û˘Ó¯›· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ ÂÓÂÚÁÂÈÒÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó¿ÓË„Ë Î·È ÛÙ·ıÂÚÔÔ›ËÛË ÙˆÓ ÙÚÈÒÓ ·˘ÙÒÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. ∏ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ¿ÌÂÛË ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì¤Û· ÛÙËÓ ÚÒÙË ÒÚ· - ÙË ÏÂÁfiÌÂÓË “¯Ú˘Û‹ ÒÚ·” - Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË fiÛÔ Î·È ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ‹ ÙÔ˘ ·È‰ÈÔ‡ Ì ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË.

Abstract: Pediatric trauma remains a significant problem because children as pedestrians or bicyclists have a threefold danger as compared to adults. Successful resuscitation of the injured child begins with the recognition of the critical nature of the airway. Children could tolerate hypotension, but they are exquisitely sensitive to cerebral hypoxia. The early assessment and the rapid and prompt resuscitation and treatment of the respiratory, circulatory and nervous systems during the first “golden hour” remains the cornerstone not only for the survival, but also for the good prognosis and outcome of the severely injured children.

§¤ÍÂȘ ÎÏÂȉȿ: ·È‰ÈÎfi ÙÚ·‡Ì·, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË ÛÙ· ·È‰È¿, ÂÎÙ›ÌËÛË, ·ÓÙÈÌÂÙÒÈÛË, “¯Ú˘Û‹ ÒÚ·”.

Key words: pediatric trauma, initial assessment, treatment, “golden hour”.

™ÙȘ Û‡Á¯ÚÔÓ˜ ÎÔÈӈӛ˜, Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·, ÙÔ ÙÚ·‡Ì· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ˘Á›·˜. ™ÙËÓ EÏÏ¿‰· ¤¯ÂÈ Ï¿‚ÂÈ Û¯Â‰fiÓ ‰È·ÛÙ¿ÛÂȘ ÂȉËÌÈ΋˜ ÓfiÛÔ˘ ÏfiÁˆ ÙˆÓ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. TÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ, ηıÒ˜ Ù· ·È‰È¿ - Û·Ó Â˙Ô› ‹ Ô‰ËÏ¿Ù˜ - ‰È·ÙÚ¤¯Ô˘Ó 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·’ fiÙÈ ÔÈ ÂÓ‹ÏÈΘ. ™ÙȘ H¶A, 8.000 ·È‰È¿ ¤ı·Ó·Ó Û’ ¤Ó· ¯ÚfiÓÔ ÏfiÁˆ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ÂÚ›Ô˘ 2.000.000 ÓÔÛËχıËÎ·Ó Î·È 100.000 ·Ú¤ÌÂÈÓ·Ó Ì ÌfiÓÈÌ· Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·.

∆· ‰Â‰Ô̤ӷ ÛÙËÓ EÏÏ¿‰· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·fi Ù· ·ÎfiÏÔ˘ı· ÛÙÔȯ›·: ™Â ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜ (1996) 230 ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 15 ÂÙÒÓ ÚÔÛ‹Ïı·Ó ÛÙÔ NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡” Ì ÙÚ·‡Ì·Ù· ÏfiÁˆ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ηٿ ÙÔ ÔÔ›Ô ‹Ù·Ó ÂÈ‚¿Ù˜ ·˘ÙÔÎÈÓ‹ÙÔ˘. ™ÙÔ˘˜ 12 Ì‹Ó˜ ÙÔ˘ 1998, 612 ·È‰È¿ - ÙÚ·˘Ì·Ù›Â˜ ÙÚÔ¯·›Ô˘ ·Ù˘¯‹Ì·ÙÔ˜, ÂÈ‚¿Ù˜ Î·È Â˙Ô›, ÚÔÛ‹Ïı·Ó ÛÙ· E͈ÙÂÚÈο I·ÙÚ›· ÙÔ˘ ·ÓˆÙ¤Úˆ NÔÛÔÎÔÌ›Ԣ. T· ÛÙÔȯ›· ·˘Ù¿ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ K¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ AÙ˘¯ËÌ¿ÙˆÓ, Ù˘ Œ‰Ú·˜ YÁÈÂÈÓ‹˜ Î·È EȉËÌÈÔÏÔÁ›·˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ.

¶·È‰›·ÙÚÔ˜ - EÓÙ·ÙÈÎÔÏfiÁÔ˜ AÓ·ÏËÚÒÙÚÈ· ¢È¢ı‡ÓÙÚÈ· Ù˘ M.E.£.

NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

Pediatric Intensive Care Specialist Associate Director of PICU Children’s Hospital “P. & A. Kyriakou”, Athens

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Paediatriki 2001;64:268-271

™ÙË MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ÙÔ˘ NÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & A. K˘ÚÈ·ÎÔ‡” ÂÈÛ¿ÁÔÓÙ·È ÂÙËÛ›ˆ˜ 26-30 ·È‰È¿ Ì ‚·Ú‡ ÙÚ·˘Ì·ÙÈÛÌfi, ÏfiÁˆ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ¢ÂÓ Â›Ó·È ·ÎÚÈ‚‹˜, Â›Û˘, Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ô˘ ηٷϋÁÔ˘Ó ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Û fiÏË ÙËÓ EÏÏ¿‰·.

OÈ ı¿Ó·ÙÔÈ ÛÙ· ·È‰È¿ ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ ÂÈÛ˘Ì‚·›ÓÔ˘Ó Û 2 ¯ÚfiÓÔ˘˜: ¿ÌÂÛ· Î·È Ì¤Û· ÛÙȘ ÚÒÙ˜ ÒÚ˜ ‹ ÌÂÙ¿ ·fi ÂÚ›Ô˘ 4 Ë̤Ú˜. A˘Ùfi Â›Ó·È È‰È·›ÙÂÚ˘ ÛËÌ·Û›·˜, ÁÈ·Ù› Ë Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È Ë ¿ÌÂÛË ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì¤Û· ÛÙËÓ ÚÒÙË ÒÚ· ·fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi - ÙË “¯Ú˘Û‹ ÒÚ·” - Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜, ÙfiÛÔ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË, fiÛÔ Î·È ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡.

A˘Ùfi˜ Ô ¯ÚfiÓÔ˜ Ù˘ ÚÒÙ˘ “¯Ú˘Û‹˜” ÒÚ·˜ ¯ˆÚ›˙ÂÙ·È Û 2 ÛÙ¿‰È·: ̤۷ ÛÙ· ÚÒÙ· 30 min ı· Ú¤ÂÈ Ó· Á›ÓÂÈ Ù·˘Ùfi¯ÚÔÓ· Ë ÚÒÙË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ·È‰ÈÔ‡ ÔÏ˘ÙÚ·˘Ì·Ù›· Î·È Ë ·Ó¿ÓË„Ë ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ (primary survey). ŒÂÈÙ·, ÛÙÔ 2Ô ÛÙ¿‰ÈÔ, ·ÎÔÏÔ˘ı› Ì›· ‰Â‡ÙÂÚË - ÈÔ ÏÂÙÔÌÂÚÂȷ΋ - ÎÏÈÓÈ΋ ÂͤٷÛË, Ë ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ Î·È Ô ‰È·ÁÓˆÛÙÈÎfi˜ Î·È ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (second survey).

EÂȉ‹ ̤۷ ÛÙÔÓ fiÚÔ “·ÓÙÈÌÂÙÒÈÛË” ÂÌÂÚȤ¯ÂÙ·È, ÂȉÈο fiÛÔÓ ·ÊÔÚ¿ οÔÈ· Â›ÁÔ˘Û· ηٿÛÙ·ÛË, Ë ‚·ÛÈÎfiÙ·ÙË ¤ÓÓÔÈ· Ù˘ ·ÍÈÔÏfiÁËÛ˘, ÙÔ Ï·›ÛÈÔ ÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ‹ ÙÔ˘ È·ÙÚÔ‡ Ô˘ ı· ‚ÚÂı› ÙËÓ ÚÒÙË ÒÚ· ÎÔÓÙ¿ ÛÙÔ ·È‰› Ú¤ÂÈ Ó· Â›Ó·È ÙÔ ÂÍ‹˜: Ë ÚÒÙË ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ÁÚ‹ÁÔÚ· - Û 1 min Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·˜ ·ÍÈÔÏfiÁËÛË: ·) Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ‚) Ù˘ ΢ÎÏÔÊÔÚ›·˜ Î·È Á) Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘.

T· ·È‰È¿ Ì ÛÔ‚·Ú‹ οΈÛË ‰È·ÎÚ›ÓÔÓÙ·È Û¯ÂÙÈο ‡ÎÔÏ· ·fi ÙËÓ ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ ÛÙËÓ ·Ó·ÓÔ‹, ÙËÓ ‡·ÚÍË ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ηٷÏËÍ›·˜ Î·È ·fi ÙË Ì›ˆÛË ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘.

E› ˘¿Ú͈˜ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó·ÎÔ‹˜ ÂÊ·ÚÌfi˙ÂÙ·È ¿ÌÂÛ· Ë B·ÛÈ΋ AÓ¿ÓË„Ë (∂ÈÎfiÓ· 1). ¢È·ÊÔÚÂÙÈο, ÔÈ ÂÓ¤ÚÁÂȘ Ô˘ ··ÈÙÔ‡ÓÙ·È

Airway (·ÂÚ·ÁˆÁÔ›)

ηٿ ÛÂÈÚ¿ ÚÔÙÂÚ·ÈfiÙËÙ·˜ Â›Ó·È ÔÈ ÂÍ‹˜: ∏ ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô˘ ı· Á›ÓÂÈ Ì ÙËÓ ·Ú·Ù‹ÚËÛË Ù˘ Û˘ÌÌÂÙÚÈ΋˜ ‹ ÌË ¤ÎÙ˘Í˘ ÙÔ˘ ıÒڷη, Ù˘ ‡·Ú͢ Ù·¯‡ÓÔÈ·˜ ‹ ÂÚÁÒ‰Ô˘˜ ·Ó·ÓÔ‹˜ ‹ ˘fiÓÔÈ·˜, ‹ ·Ú¿‰Ô͢ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜. ∆·˘Ùfi¯ÚÔÓ·, Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁËı› ÙÔ ¯ÚÒÌ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ.

H ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ë ÔÔ›· Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË Î·È Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË O2 100% Ì ̿Ûη ‹ Ì ̿Ûη Î·È ambu, ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÂÈÛÚfiÊËÛ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ·È‰ÈÔ‡ Û ηٿÏÏËÏË ı¤ÛË, ÙËÓ ÂÓ‰ÔÙÚ·¯Âȷ΋ ‰È·ÛˆÏ‹ÓˆÛË Î·È ÂÓ ·Ó¿ÁÎË ÙËÓ ÎÚÈÎÔı˘ÚÂÔÂȉÔÙÔÌ‹ ‰È¿ ‚ÂÏfiÓ˘ (Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· Û ÓÔÛÔÎÔÌÂ›Ô ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÍÂȉÈÎÂ˘Ì¤Ó˘ ÌÂÙ·ÊÔÚ¿˜).

OÈ ÙÚÂȘ ÛÔ‚·ÚfiÙÂÚ˜ ηÎÒÛÂȘ ÙÔ˘ ıÒڷη ›ӷÈ: ·) Ô Ó¢ÌÔÓÔıÒڷη˜ ˘fi Ù¿ÛË, Ô˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο Â›ÁÔÓ Úfi‚ÏËÌ· Î·È ··ÈÙ› ¿ÌÂÛË ·Ú·Î¤ÓÙËÛË ‰È¿ ‚ÂÏfiÓ˘ ÛÙÔ 2Ô ÌÂÛÔχÚÈÔ ‰È¿ÛÙËÌ·, ÛÙË ÌÂÛÔÎÏÂȉÈ΋ ÁÚ·ÌÌ‹ Î·È ÂÓ Û˘Ó¯›· ÙÔÔı¤ÙËÛË Büllau, ‚) Ô ·ÓÔÈÎÙfi˜ Ó¢ÌÔÓÔıÒڷη˜, Ô˘ ··ÈÙ› ÂÈˆÌ·ÙÈÛÌfi Ì Á¿˙˜ Î·È ÙÔÔı¤ÙËÛË Büllau Û ¿ÏÏÔ ÛËÌÂ›Ô ÙÔ˘ ıÒڷη Î·È Á) Ù· ‰ÈÏ¿ ηٿÁÌ·Ù· ÂÚÈÛÛfiÙÂÚˆÓ ÙˆÓ 2 Ï¢ÚÒÓ, Ô˘ ÂÂȉ‹ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÙËÓ ·Ó·ÓÔ‹, ··ÈÙÔ‡Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ŒÓ· ¿ÏÏÔ ÛËÌÂ›Ô ˘„›ÛÙ˘ ÛËÌ·Û›·˜ ÂΛÓË ÙËÓ ÚÒÙË ‰‡ÛÎÔÏË, ·ÏÏ¿ ÎÚ›ÛÈÌË, ÒÚ· Â›Ó·È fiÙÈ Ë ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ‚·ÙfiÙËÙ·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È Ë Ô͢ÁfiÓˆÛË ÙÔ˘ ·È‰ÈÔ‡ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ٷ˘Ùfi¯ÚÔÓË ÚÔÛÙ·Û›· Ù˘ ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (∞ª™™).

K¿ı ·È‰› ÔÏ˘ÙÚ·˘Ì·Ù›·˜ ı· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ Î¿ÎˆÛË Ù˘ ∞ª™™, ̤¯ÚȘ ·ԉ›Íˆ˜ ÙÔ˘ ÂÓ·ÓÙ›Ô˘. £· Ú¤ÂÈ, ÏÔÈfiÓ, Ó· ·ÔʇÁÔÓÙ·È ÔÈ ‚›·ÈÔÈ ¯ÂÈÚÈÛÌÔ› (fi¯È ¤ÎÙ·ÛË ‹ ¤ÓÙÔÓË Î¿Ì„Ë ÙÔ˘ ·˘¯¤Ó·), ÙÔ ÎÂÊ¿ÏÈ ı· Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È Û Ԣ‰¤ÙÂÚË ı¤ÛË, “ÛÙÂÚˆ̤ÓÔ” Û ·˘Ù‹

Breathing (·Ó·ÓÔ‹)

Circulation (΢ÎÏÔÊÔÚ›·)

EÈÎfiÓ· 1. µ·ÛÈ΋ ·Ó¿ÓË„Ë.

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ÙË ı¤ÛË Ì ÙË ‚Ô‹ıÂÈ· Ù·ÈÓ›·˜ Ï¢ÎÔÏ¿ÛÙË ‹ ‚·Ú¤ˆÓ ·ÓÙÈÎÂÈÌ¤ÓˆÓ ÙÔÔıÂÙËÌ¤ÓˆÓ Âη٤ڈıÂÓ Ù˘ ÎÂÊ·Ï‹˜ (ÛÙÔ ‡„Ô˜ ÙˆÓ ·˘ÙÈÒÓ). E¿Ó ˘¿Ú¯ÂÈ, ÙÔÔıÂÙÂ›Ù·È ·˘¯ÂÓÈÎfi ÎÔÏ¿ÚÔ.

EÊfiÛÔÓ ·ÔηٷÛÙ·ı› ηı·Úfi˜ Î·È ·ÓÔÈÎÙfi˜ ·ÂÚ·ÁˆÁfi˜, Â·Ú΋˜ ·ÂÚÈÛÌfi˜ Î·È Ô͢ÁfiÓˆÛË, ÂfiÌÂÓË ÚÔÙÂÚ·ÈfiÙËÙ· Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ·È‰ÈÔ‡. ∆· ÛÔ˘‰·ÈfiÙÂÚ· ÎÏÈÓÈο ÛËÌ›· ÂÎÙ›ÌËÛ˘ ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ ›ӷÈ: ·) ∏ ηډȷ΋ Û˘¯ÓfiÙËÙ·, Ô˘ Â›Ó·È ÁÈ· Ù· ·È‰È¿ Ô ϤÔÓ Â˘·›ÛıËÙÔ˜ ‰Â›ÎÙ˘ Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∆· ·È‰È¿ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ·ÓÙÈÚÚÔÔ‡Ó Ì ·ÁÁÂÈÔÛ‡Û·ÛË Î·È ‰È·ÙËÚÔ‡Ó ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Ì ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Û ÔÛÔÛÙfi ̤¯ÚÈ Î·È 25% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ fiÁÎÔ˘. ‚) H ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ·. ∂¿Ó ˘¿Ú¯ÂÈ Ù·¯‡ÓÔÈ· Â›Ó·È ‰Â›ÎÙ˘ Á·Ï·ÎÙÈ΋˜ ÔͤˆÛ˘ ÔÊÂÈÏfiÌÂÓ˘ Û ÈÛÙÈ΋ ˘ÔÍ›· - ÌË Î·Ï‹ ¿Ú‰Â˘ÛË ÙˆÓ ÈÛÙÒÓ. Á) H ÙÚȯÔÂȉÈ΋ ΢ÎÏÔÊÔÚ›·, Ô˘ ÂϤÁ¯ÂÙ·È Ì ÙËÓ ›ÂÛË Ù˘ ÎÔ›Ù˘ ÙÔ˘ fiÓ˘¯Ô˜. E¿Ó Ë ÙÚȯÔÂȉÈ΋ Â·Ó·ÊÔÚ¿ Â›Ó·È >2 sec, ‰ËÏÒÓÂÙ·È Î˘ÎÏÔÊÔÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ‰) H ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∆Ô „˘¯Úfi Î·È ÎÔÏÏ҉˜ ‰¤ÚÌ· Â›Ó·È ‰Â›ÎÙ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡. Â) H Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ·. ∂¿Ó ˘¿Ú¯ÂÈ Û‡Á¯˘ÛË ‹/Î·È ÎÒÌ·, ›Ûˆ˜ ‰ËÏÒÓÂÙ·È Î·Î‹ ·ÈÌ¿ÙˆÛË ÙÔ˘ K.N.™.

H ΢ÎÏÔÊÔÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ·ÒÏÂÈ· ·›Ì·ÙÔ˜, ÓˆÙÈ·›Ô Shock (ÔÊÂÈÏfiÌÂÓÔ Û ·ÒÏÂÈ· ÙÔ˘ ÙfiÓÔ˘ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ˘fiÙ·ÛË, ‚Ú·‰˘Î·Ú‰›· Î·È ˘ÔıÂÚÌ›·) Î·È Û Ó¢ÌÔıÒڷη ˘fi Ù¿ÛË.

H ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ: i) ÙËÓ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛ‹ Ù˘, ii) ÙË ¯ÔÚ‹ÁËÛË O2 100%, iii) ÙËÓ ¿ÛÎËÛË ›ÂÛ˘ ÛÙË ı¤ÛË Ù˘ ÂÓÂÚÁÔ‡ ·ÈÌÔÚÚ·Á›·˜, iv) ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË ÊÏ‚È΋˜ Ô‰Ô‡ (ÌÂÙ¿ ·fi ÚÔÛ¿ıÂÈ· 1-2 min, Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È ÂÓ‰ÔÔÛÙÈ΋ ‚ÂÏfiÓË) Î·È v) ÙËÓ ÂÈıÂÙÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, ÚÈÓ ÂÁηٷÛÙ·ı› ˘fiÙ·ÛË.

T· ¯ÔÚËÁÔ‡ÌÂÓ· ‰È·Ï‡Ì·Ù· Û shock Â›Ó·È Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹: Ringer’s Lactate, Nacl 0,9% Î·È Ù· ÎÔÏÏÔÂȉ‹: ·ÓıÚÒÈÓË ÏÂ˘ÎˆÌ·Ù›ÓË, Hea- maccel, HAES-steril 10%. XÔÚËÁÔ‡ÓÙ·È Û ‰fiÛË 20 ml/kg*, Û 10-15 min ‹ Ì ۇÚÈÁÁ· push. E› ÌË ·Ó·Ù¿Íˆ˜ ÙÔ˘ shock, ¯ÔÚËÁÔ‡ÓÙ·È ÂÎ Ó¤Ô˘ Ì 20 ml/kg* Î·È ÛÙË Û˘Ó¤¯ÂÈ· ¯ÔÚËÁÔ‡ÓÙ·È Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿ 10 ml/kg*.

270

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E¿Ó, ·Ú¿ ÙËÓ ·ÓˆÙ¤Úˆ ·ÁˆÁ‹, ‰ÂÓ ˘¿Ú¯ÂÈ ‚ÂÏÙ›ˆÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜, ÙfiÙÂ Ë Èı·ÓfiÙËÙ· ÂÛˆÙÂÚÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ÎÔÈÏ›·˜ ‹ ıÒÚ·ÎÔ˜ Î·È Î·Ù·ÁÌ¿ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ Â›Ó·È ÌÂÁ¿ÏË.

MÂÙ¿ ÙËÓ ÂÎÙ›ÌËÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ù˘¯fiÓ Î˘ÎÏÔÊÔÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·ÎÔÏÔ˘ı› Ë ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡.

H Ù·¯Â›· Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ “ÛËÌ›·-ÎÏÂȉȿ”: ·) ̤ÁÂıÔ˜ Î·È ·ÓÙ›‰Ú·ÛË Ù˘ ÎfiÚ˘ ÙˆÓ ÔÊı·ÏÌÒÓ ÛÙÔ Êˆ˜, ‚) ‡·ÚÍË ·ÓÈÛÔÎÔÚ›·˜ ‹ fi¯È, Á) Â›Â‰Ô Û˘Ó›‰ËÛ˘ Î·È ‰) Ù‡Ô˜ ·Ó·ÓÔ‹˜ (·ıÔÏÔÁÈ΋ ‹ ¿ÚÚ˘ıÌË).

OÈ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ (KEK) ·ÔÙÂÏÔ‡Ó ÙÔ Û˘¯ÓfiÙÂÚÔ ÙÚ·˘Ì·ÙÈÛÌfi ÌÂÙ¿ ·fi ¤Ó· ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· ‹ ÙÒÛË ‹ ¿ÏÏÔ˘ ›‰Ô˘˜ ·Ù‡¯ËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ™Ù· ·È‰È¿, ÔÈ ÂÚÈÔ¯¤˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ Ô˘ ˘Ê›ÛÙ·ÓÙ·È Î¿ÎˆÛË, ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Â›Ó·È ÔÈ ÂÍ‹˜: ÎÂÊ·Ï‹ 51%, ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚ· 38,8%, ıÒڷη˜ 4,5%, ÎÔÈÏ›· 4,5%. TÔ 75% ÙˆÓ ·È‰ÈÒÓ Ì ÔÏÏ·Ï¿ ÙÚ·‡Ì·Ù· ¤¯ÂÈ K∂K Î·È ÙÔ 80% ÙˆÓ ı·Ó¿ÙˆÓ ÔÏ˘ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ·È‰ÈÒÓ ¤¯ÂÈ Û¯¤ÛË Ì ‚·ÚÈ¿ KEK. ø˜ ·ÈÙ›· ·˘ÙÒÓ ·Ó·Ê¤ÚÂÙ·È ÙÔ ÌÂÁ¿ÏÔ ÎÂÊ¿ÏÈ ÙˆÓ ·È‰ÈÒÓ Û ۯ¤ÛË Ì ÙÔ ˘fiÏÔÈÔ ÛÒÌ·, Ë ¯·Ï·Ú‹ Ì˘ÔÛÎÂÏÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ÙÚ·¯‹ÏÔ˘, Ë ˙ÂÏ·ÙÈÓ҉˘ Û‡ÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘˜ (ÌË Ì˘ÂÏÈÓÔÔ›ËÛË) ηıÒ˜ Î·È ¿ÏÏÔÈ ·Ó·ÙÔÌÈÎÔ› ÂÓ‰ÔÎÚ·ÓÈ·ÎÔ› ÏfiÁÔÈ.

H ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û KEK ‰È·ÎÚ›ÓÂÙ·È Û ÚˆÙÔ·ı‹, Ô˘ ÂÈÛ˘Ì‚·›ÓÂÈ ·ÎÚÈ‚Ò˜ ÙËÓ ÒÚ· ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ (ηٿÁÌ·Ù· ÎÚ·Ó›Ô˘, ˘fiÂÈÛÎÏËÚ›‰ÈÔ ·È̿و̷, ˘·Ú·¯ÓÔÂȉ‹˜ ·ÈÌÔÚÚ·Á›·, ·ÈÌÔÚÚ·ÁÈΤ˜ ıÏ¿ÛÂȘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘) Î·È Û ‰Â˘ÙÂÚÔ·ı‹, Ô˘ ¯Ú‹˙ÂÈ È‰È·›ÙÂÚ˘ ÚÔÛÔ¯‹˜. H ‰Â˘ÙÂÚÔ·ı‹˜ ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈ„Ë O2 ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. H ·Ï‹ Â͛ۈÛË Ô˘ ‰›ÓÂÈ ÙËÓ ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û·Ó ÙË ‰È·ÊÔÚ¿ Ù˘ M¤Û˘ AÚÙËÚȷ΋˜ ¶›ÂÛ˘ Î·È Ù˘ EÓ‰ÔÎÚ¿ÓÈ·˜ ¶›ÂÛ˘, ‰›ÓÂÈ Î·È ÙË ‰È¿ÛÙ·ÛË ÙˆÓ ‰‡Ô ·˘ÙÒÓ ‚·ÛÈÎfiÙ·ÙˆÓ ·Ú·Ì¤ÙÚˆÓ (¶›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÂÁÎÂÊ¿ÏÔ˘ = AÚÙËÚȷ΋ ›ÂÛË - EÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË). H ̤ÛË A¶ Ú¤ÂÈ, ÏÔÈfiÓ, Ó· ‰È·ÙËÚËı› ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÁÈ· Ó· ÂÈÙ¢¯ı› ÊÚÔÓÙ›‰· ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Î·È Ë ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË Ó· ·Ú·Ì›ÓÂÈ ≤ 20 mmHg, ¤ÙÛÈ ÒÛÙ ӷ ·ÓÙÈÌÂÙˆÈÛÙ› ÙÔ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ·. H ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ı· Ú¤ÂÈ Ó· Â›Ó·È ÛÙ·ıÂÚ‹ >50 mmHg. H ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì KEK ı· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·fi ÙË ÛÙÈÁÌ‹ ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÁÈ· ÙËÓ ÚfiÏË„Ë, ΢ڛˆ˜, ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ‚Ï·‚ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ·) ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ‚·ÙfiÙËÙ·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ‚) ÙËÓ

MAY- JUNE '01 TELIKO

30-05-03

18:55

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¶·È‰È·ÙÚÈ΋ 2001;64:268-271

¿ÌÂÛË ¯ÔÚ‹ÁËÛË O2, Á) ÙËÓ ·ÎÈÓËÙÔÔ›ËÛË Ù˘ AM™™, ‰) ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ (¿ÚÛË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜), Â) ÙËÓ Î·Ù¿ÏÏËÏË ı¤ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÛÙ) ÙË ¯ÔÚ‹ÁËÛË Ì·ÓÈÙfiÏ˘ 20% (‰fiÛË: 0,25-0,5 mg/kg* IV) Â› ÂӉ›ÍÂˆÓ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜.

MÂÙ¿ ÙË ÛÙ·ıÂÚÔÔ›ËÛË Î·È ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Î˘ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙËÓ ·ÍÈÔÏfiÁËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ KN™, ·ÎÔÏÔ˘ı› Ì›· ÁÚ‹ÁÔÚË ÎÏÈÓÈ΋ ÂͤٷÛË.

T· ·Ú¯Èο A, B, C, D, E, ‰ÈÂıÓÒ˜ Û‹ÌÂÚ·, Û˘ÌÏ‹ÚˆÛ·Ó ϤÔÓ ÙËÓ Îϛ̷η Ù˘ ÂÎÙ›ÌËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·Ù›·, ÛËÌ·ÙÔ‰ÔÙÒÓÙ·˜ Î·È ÙË ÛÂÈÚ¿ ÚÔÙÂÚ·ÈÔًوÓ.

A: Airway AÂÚ·ÁˆÁÔ› B: Breathing AÓ·ÓÔ‹ C: Circulation K˘ÎÏÔÊÔÚ›· D: Disability N¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ E: Exposure ŒÎıÂÛË-ÂͤٷÛË fiÏÔ˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ TÔ ÙÂÏÂ˘Ù·›Ô, Ë ÁÚ‹ÁÔÚË ‰ËÏ·‰‹ ¤ÎıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È Ë ÎÏÈÓÈ΋ Ì ٷ ¯¤ÚÈ· ÂͤٷÛË Û 1 min, ÌÔÚ› Ó· ·Ó·Î·Ï‡„ÂÈ ÛËÌ›· - ÎÏÂȉȿ ÁÈ· ÙË Û˘ÓÔÏÈ΋ ÂÊ·ÚÌÔÁ‹ ·Ó¿Ó˄˘. ŒÌÊ·ÛË ‰›ÓÂÙ·È Î·È ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÌÂٷ͇ 36-37ÔC, Û·Ó ·Ú¿ÁÔÓÙ· ÌË ·ÔÛÙ·ıÂÚÔÔ›ËÛ˘ fiÏˆÓ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜.

T· fiÛ· ·Ó·Ê¤ÚıËÎ·Ó Ì¤¯ÚÈ ÙÒÚ· ·ÊÔÚÔ‡Ó Î·È Ú¤ÂÈ Ó· ·ÊÔÚÔ‡Ó Ù· ÚÒÙ· ÏÂÙ¿ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ̤۷ ÛÙÔ ·ÛıÂÓÔÊfiÚÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ Î·È Î·Ù¿ ÙËÓ ÚÒÙË ÒÚ· ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ̤۷ ÛÙË M.E.£.

H ‰Â‡ÙÂÚË ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ ÔÏ˘ÙÚ·˘Ì·Ù›· (secondary survey) ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙÔ NÔÛÔÎÔÌÂ›Ô È· - ÌÈ· ÈÔ ÏÂÙÔÌÂÚ‹ ÎÏÈÓÈ΋ ÂͤٷÛË fiÏˆÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È Î·ÎÒÛˆÓ, ÙÔÓ ·Ó·Áη›Ô ·ÎÙÈÓÔÏÔÁÈÎfi Î·È ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È ÙËÓ ¤Ó‰ÂÈÍË - ‹ fi¯È - ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘. H ÏÔÈ‹ ÎÏÈÓÈ΋ ÂͤٷÛË ı· ÂÚÈÏ¿‚ÂÈ Ù· ÂÍ‹˜: ÙÔ ıfiÏÔ ÙÔ˘ ÎÚ·Ó›Ô˘ Î·È ÙÔ ÙÚȯˆÙfi Ù˘ ÎÂÊ·Ï‹˜ ÁÈ· Ù˘¯fiÓ Î·Ù¿ÁÌ·Ù·, ÎÂÊ·Ï·È̿و̷, ÂÎÚÔ‹ ENY ‹ ·›Ì·ÙÔ˜ - ÛËÌ›· ηٿÁÌ·ÙÔ˜ Ù˘ ‚¿Û˘ ÙÔ˘ ÎÚ·Ó›Ô˘. £· ÂϯıÔ‡Ó ÛËÌ›· ‚Ï¿‚˘ Ù˘ AM™™, fiˆ˜ ¯·Ï·Ú‹ ·Ú¿Ï˘ÛË (ÙÂÙÚ·ÏËÁ›·, ·Ú·ÏËÁ›·), ·Ó·ÈÛıËÛ›· οو ·fi ÙȘ ÎÏ›‰Â˜, ·ÓÂÍ‹ÁËÙË ˘fiÙ·ÛË ‹ ˘ÔıÂÚÌ›· Î·È ‰È·ÊÚ·ÁÌ·ÙÈ΋ ·Ó·ÓÔ‹. T· Ì·ÎÚ¿ ÔÛÙ¿ ÂϤÁ¯ÔÓÙ·È ÁÈ· ÙËÓ ‡·ÚÍË ·Ú·ÌfiÚʈÛ˘, Ôȉ‹Ì·ÙÔ˜ ‹ ¢·ÈÛıËÛ›·˜. H ÔÚıÔ‰È΋ οΈÛË ‰ÂÓ ÚÔηÏ› ·ÂÈÏËÙÈο ÁÈ· ÙË ˙ˆ‹ ÚÔ‚Ï‹Ì·Ù·, ·ÏÏ¿ Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜. H ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ı· ·ÎÔÏÔ˘ı‹ÛÂÈ ÌÂÙ¿ ÙȘ ·Ó¿ÏÔÁ˜ ÂӉ›ÍÂȘ. OÈ ·Ôχو˜ ·Ó·Áη›Â˜ ·ÎÙÈÓÔÁڷʛ˜ Û ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı‹ ·ÛıÂÓ‹ ›ӷÈ

Paediatriki 2001;64:268-271

·˘Ù¤˜ ÙÔ˘ ıÒڷη, Ë Ï¿ÁÈ· AM™™ Î·È ÙˆÓ ÔÛÙÒÓ ÏÂοÓ˘. H ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÂͤٷÛË ÂÎÏÔÁ‹˜ Û ·È‰› Ì KEK, ÂÊfiÛÔÓ Î·È fiÙ·Ó ÛÙ·ıÂÚÔÔÈËı›. ¶ÙÒÛË ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘ ·ÔÙÂÏ› ¿ÌÂÛË ¤Ó‰ÂÈÍË ÁÈ· CT ÂÁÎÂÊ¿ÏÔ˘. TÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú‡Ù·Ù· ÏfiÁˆ Ù˘ ¢ÎÔÏ›·˜ Ù˘ ÂͤٷÛ˘. H ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Â›Ó·È Ë ÂͤٷÛË ÂÎÏÔÁ‹˜ Û ÛÙ·ıÂÚÔÔÈË̤ÓÔ ·ÛıÂÓ‹ ÁÈ· ÙȘ ηÎÒÛÂȘ Ù˘ ÎÔÈÏ›·˜. ŸÌˆ˜, ÛËÌ·ÓÙÈÎfiÙ·ÙË Â›Ó·È Ë ‚Ô‹ıÂÈ· Ù˘ ÂÚÈÙÔÓ·˚΋˜ χÛ˘ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ·ÈÌÔÚÚ·Á›·˜ Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ‹·ÙÔ˜ Î·È ÛÏËÓfi˜ - Û ·ÛÙ·ı‹ ·ÛıÂÓ‹. ÕÌÂÛ˜ ÂӉ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ ·ÔÙÂÏÔ‡Ó Ë ·ÓÈÛÔÎÔÚ›· Ì ÂÙÂÚfiÏ¢ÚË ËÌÈ¿ÚÂÛË (= ˘fi ‹ ÂÈÛÎÏËÚ›‰ÈÔ ·È̿و̷ - ΛӉ˘ÓÔ˜ ÂÁÎÔÏ·ÛÌÔ‡ ÛÙÂϤ¯Ô˘˜) Î·È ·ÛıÂÓ‹˜ Ì ÌË ·Ó·Ù·ÛÛfiÌÂÓË Î˘ÎÏÔÊÔÚÈ΋ ηٷÏËÍ›·, ·Ú¿ ÙË Û˘Ó¯‹ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ·›Ì·ÙÔ˜ Î·È ¯ˆÚ›˜ ÂÌÊ·Ó‹ ·ÈÌÔÚÚ·ÁÈ΋ ÂÛÙ›·. ™˘ÓÔ„›˙ÔÓÙ·˜, ˆ˜ ‚·ÛÈο ÛËÌ›· Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÂÈÛËÌ·›ÓÔÓÙ·È Ù· ÂÍ‹˜: ·) ™ÙÔ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ ·È‰›, fiˆ˜ Î·È Û οı Â›ÁÔÓ ÂÚÈÛÙ·ÙÈÎfi, Ë ·ÍÈÔÏfiÁËÛË, Ë ‰È¿ÁÓˆÛË Î·È Ë ıÂÚ·›· Â›Ó·È Ù·˘Ùfi¯ÚÔÓË ÙËÓ ÚÒÙË ¯Ú˘Û‹ ÒÚ·, ‚) T· ·È‰È¿ Ì ÛÔ‚·Úfi ÙÚ·‡Ì· ͯˆÚ›˙Ô˘Ó ·fi ÙËÓ ·ÚÔ˘Û›· ÎÒÌ·ÙÔ˜, ‰È·Ù·Ú·¯ÒÓ Ù˘ ·Ó·ÓÔ‹˜ Î·È ÛËÌ›ˆÓ ηٷÏËÍ›·˜, Á) H Îϛ̷η ÚÔÙÂÚ·ÈÔÙ‹ÙˆÓ ·ÓÙÈÌÂÙÒÈÛ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ABCDE Î·È ‰) H Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ Î·È Ë ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ·È‰ÈÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi: i) ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ‰˘Ó·ÙÔÙ‹ÙˆÓ ·Ó¿Ó˄˘ ÛÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ii) ÙËÓ ÔÚÁ·ÓˆÌ¤ÓË, Ù·¯Â›· Î·È ·ÛÊ·Ï‹ ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹ Û ÔÚÁ·ÓˆÌ¤ÓÔ Î¤ÓÙÚÔ.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Kochanek P. Ischemic and traumatic brain injury.

Pathobiology and cellular mechanisms. Crit Care Med 1993;21:333-335.

2. Evaluation, stabilization and initial management after multiple trauma. In: Zimmerman J, editor. Pediatric Critical Care. Mosby Year Book; 1992. p. 1158-1164.

3. Multiple trauma in the pediatric patient. In: Rogers M, editor. Pediatric Intensive Care. Third edition; 1996. p.

1467-1503.

4. Head and spinal cord injury. In: Rogers M, editor. Pediatric Intensive care. Third edition. 1996. p. 836-847.

5. Julie I, Sanchez MD, Charles N, Paidas MD. Trauma care in the new millenium. Childhood trauma. Surg Clin N Am 1999;79:1503-1528. ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔÓ›ÎË ¶·¿˙ÔÁÏÔ˘ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

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§Oπªø•∂π™

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INFECTIONS

§ÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜: ·fi ÙÔÓ 20Ô ÛÙÔÓ 21Ô ·ÈÒÓ· ∂. ƒÔËÏ›‰Ë˜

Infections in immunosuppressed patients: from the 20th to the 21st century E. Roilides

¶ÂÚ›ÏË„Ë: OÈ ·ÓÔÛÔÏÔÁÈΤ˜ ·ÓÂ¿ÚÎÂȘ ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜. ∆· ·›ÙÈ· ·‡ÍËÛ˘ ÙˆÓ ·ÓÔÛÔ·ÓÂ·ÚÎÒÓ ·ÛıÂÓÒÓ ÛÙȘ Ë̤Ú˜ Ì·˜ Â›Ó·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋˜ ıÂÚ·›·˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ (AIDS), Ë ÌÂÁ¿ÏË ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ë ÂÓÙ·ÙÈ΋ ÓÔÛËÏ›· Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ¿ÏÏˆÓ ·ÛıÂÓÒÓ. ∞Ó¿ÏÔÁ· Ì ÙÔ ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, Ô ·ÛıÂÓ‹˜ Â›Ó·È ¿ÏÏÔÙ ¢·›ÛıËÙÔ˜ Û ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. π‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎÔ› Â›Ó·È ÔÈ ÈÔ› ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ô Èfi˜ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÔÈ ÂÈÔÏ‹˜ Î·È ÂÓ Ùˆ ‚¿ıÂÈ Ì˘ÎËÙÈ¿ÛÂȘ. ∏ ηχÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ÈÔ ÌÂÁ¿ÏË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â¤ÊÂÚ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ.

Abstract: Immunodeficiencies can be either congenital or acquired. Causes of the recent increase of immunodeficient patients are the intensification of antineoplastic therapy, tissue and organ transplantation, acquired immunodeficiency syndrome (AIDS), the frequent use of immunosuppressive drugs and the intense treatment of very-low-birth neonates and of other patients.

Depending on the immune defect, patients may at times be susceptible to different organisms.

Particularly significant are respiratory viruses, varicella virus and superficial or invasive mycoses.

Better management of infections and longer survival of these patients has led to a significant improvement of patients’ quality of life.

§¤ÍÂȘ ÎÏÂȉȿ: ÏÔÈÌÒÍÂȘ, ·ÓÔÛÔηٷÛÙÔÏ‹.

Key words: infections, immunosuppression.

OÈ ·ÓÔÛÔÏÔÁÈΤ˜ ·ÓÂ¿ÚÎÂȘ ‰È·ÎÚ›ÓÔÓÙ·È ÛÂ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜, ηıÒ˜ Â›Û˘ Û ÚˆÙÔ·ı›˜ Î·È ‰Â˘ÙÂÚÔ·ı›˜. OÈ Î˘ÚÈfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞Ó¿ÏÔÁ· Ì ÙÔ ÂÈÎÚ·ÙÔ‡Ó ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·, Ô ·ÛıÂÓ‹˜ Â›Ó·È Â˘·›ÛıËÙÔ˜ Û ¿ÏÏÔÙ ¿ÏÏÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ¶·Ú·‰Â›ÁÌ·Ù· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Â˘·›ÛıËÙÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÂÏÏ›ÌÌ·Ù· ÛÙËÓ ∆ ΢ÙÙ·ÚÈ΋ ‹ ÛÙË µ ΢ÙÙ·ÚÈ΋ (¯˘ÌÈ΋) ‹ ÛÙË Ê·ÁÔ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2.

O ·ÚÈıÌfi˜ ÙˆÓ ·ÓÔÛÔ·ÓÂ·ÚÎÒÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ·˘ÍËı› ¿Ú· Ôχ ÛÙȘ Ë̤Ú˜ Ì·˜. ∆· ·›ÙÈ·

Ù˘ ·‡ÍËÛ˘ ÙˆÓ ·ÓÔÛÔ·ÓÂ·ÚÎÒÓ ·ÛıÂÓÒÓ, ȉȷ›ÙÂÚ· ÛÙËÓ ¶·È‰È·ÙÚÈ΋, Â›Ó·È Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋˜ ıÂÚ·›·˜, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ (AIDS), Ë ÌÂÁ¿ÏË ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ë ÂÓÙ·ÙÈ΋ ÓÔÛËÏ›· Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ¿ÏÏˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, Ë Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ Ë Ì·ÎÚfiÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ ‹ Â›ÎÙËÙË ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· Û˘Ó¤‚·Ï ÛÙË ÌÂÁ¿ÏË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙÔ˘˜ ÛÙȘ Ë̤Ú˜ Ì·˜. ∂ȉÈÎfiÙÂÚ·, Ë ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈ΋ ıÂÚ·›·, ΢ÙÙ·ÚÔÙÔÍÈ΋ ¯ËÌÂÈÔıÂÚ·›· ‹ ·ÎÙÈÓÔıÂÚ·›·,

3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢

3rd Department of Pediatrics Aristotelion University of Thessaloniki

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¶›Ó·Î·˜ 1. ™˘¯ÓfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ

¶›Ó·Î·˜ 2. ¶·Ú·‰Â›ÁÌ·Ù· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È Â˘·›ÛıËÙÔÈ ·ÛıÂÓ›˜ Ì ·ÓÔÛÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù·

™˘ÁÁÂÓ›˜ - ™˘ÁÁÂÓ‹˜ Ô˘‰ÂÙÂÚÔÂÓ›· - ÃÚfiÓÈ· ÎÔÎÎȈ̷Ù҉˘ ÓfiÛÔ˜ - ÀÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·È̛˜ - ∫ÔÈÓ‹ ÌÂÙ·‚ÏËÙ‹ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· - ÕÏϘ ·ÓÂ¿ÚÎÂȘ Ù˘ ∆ Î·È µ ΢ÙÙ·ÚÈ΋˜ ÛÂÈÚ¿˜ ∂›ÎÙËÙ˜ - ¡ÂÔϷۛ˜ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ (Ï¢¯·È̛˜, ÓfiÛÔ˜ Hodgkin, ¿ÏÏ· ÏÂÌÊÒÌ·Ù·) - ∞Ï·ÛÙÈ΋ ·Ó·ÈÌ›· - ¯ÚfiÓÈ· Ô˘‰ÂÙÂÚÔÂÓ›· - HIV Ïԛ̈ÍË - ªÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ - ÈÛÙÒÓ

ñ T ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· - πÔ› (΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜) - ¶ÚˆÙfi˙ˆ· (ÙÔÍfiÏ·ÛÌ·) - ª‡ÎËÙ˜ (Ó¢ÌÔÓÔ·ÛÙË carinii, ÎÚ˘ÙfiÎÔÎÎÔ˜ Î·È Î¿ÓÙÈÓÙ·) ñ B ΢ÙÙ·ÚÈ΋ ‹ ¯˘ÌÈ΋ ·ÓÔÛ›· - ¶˘ÔÁfiÓ· Î·È ¿ÏÏ· ÌÈÎÚfi‚È· ñ º·ÁÔ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· – ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, Ì·ÎÚÔÊ¿Á· - ¶·ıÔÁfiÓ· Î·È ÌË ·ıÔÁfiÓ· ÌÈÎÚfi‚È· - ª‡ÎËÙ˜ (οÓÙÈÓÙ·, ·Û¤ÚÁÈÏÏÔ˜)

¯ÔÚËÁÂ›Ù·È Ì ÈÔ ÂÈıÂÙÈÎfi ÙÚfiÔ. OÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÂÁ·‰fiÛÂȘ Ê·ÚÌ¿ÎˆÓ ˘Ô‚ÔËıÔ‡ÌÂÓ˜ ·fi ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ·˘ÙfiÏÔÁË ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. µ·ıÈ¿ Î·È ·Ú·ÙÂٷ̤ÓË Ô˘‰ÂÙÂÚÔÂÓ›· Â›Ó·È Û‡ÓËı˜ Ê·ÈÓfiÌÂÓÔ, ηıÒ˜ Â›Û˘ Î·È Ì›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ∆ ‚ÔËıËÙÈÎÒÓ (Th) ΢ÙÙ¿ÚˆÓ. ∆· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Â›Ó·È Â›Ù ÌË ÂȉÈο, fiˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Ë ·˙·ıÂÈÔÚ›ÓË, ›Ù ÂȉÈο, fiˆ˜ Ë Î˘ÎÏÔÛÔÚ›ÓË A Î·È Ù· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ ∆ ‚ÔËıËÙÈÎÔ‡ ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘. H ¯Ú‹ÛË ·˘ÙÒÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Ì¤ÓÂÙ·È Ó· ·˘ÍËı› Ôχ ÛÙÔ Ì¤ÏÏÔÓ ÏfiÁˆ Ù˘ Û˘Ó¯ԇ˜ ·‡ÍËÛ˘ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ, ·ÏÏ¿ ı· Á›ÓÔ˘Ó ÈÔ ÂÎÏÂÎÙÈο Î·È Ì ÏÈÁfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·ÓÔÛÔηٷÛÙÔÏ‹ ΢ڛˆ˜ Ù˘ T ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜, ηıÒ˜ Â›Û˘ Î·È Ù˘ Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜. ∏ ¯˘ÌÈ΋ ·ÓÔÛ›· ÂËÚ¿˙ÂÙ·È ÎÈ ·˘Ù‹ ¤ÌÌÂÛ·. ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÙˆÓ ·ÛıÂÓÒÓ Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο Û ÌÂÁ¿Ï˜ ‰fiÛÂȘ (>2 mg/kg ËÌÂÚ‹ÛÈ·) Î·È ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (>15 Ë̤Ú˜). OÈ ÌÈÎÚ¤˜ ‰fiÛÂȘ, Ë ÙÔÈ΋ ¯Ú‹ÛË (.¯. ‰ÂÚÌ·ÙÔÏÔÁÈ΋) ηıÒ˜ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û ÂÈÛÓÔ¤˜ ÁÈ· ÙÔÈ΋ ‰Ú¿ÛË ÛÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜, Û˘Ó‹ıˆ˜ ‰ÂÓ ÚÔηÏÔ‡Ó ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∆Ô AIDS ˘‹ÚÍÂ Ë ·ÈÙ›· Ó· ·˘ÍËı› ÛËÌ·ÓÙÈο Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÏÏ¿ Î·È ÔÈΛϷ ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· Û ÙÂÚ¿ÛÙȘ ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ Ï·Ó‹ÙË Ì·˜ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·. ∂ÓÙÔ‡ÙÔȘ, Ë ÚfiÔ‰Ô˜ Ù˘ Ôχ ‰Ú·ÛÙÈ΋˜ ·ÓÙÈÚÂÙÚÔ˚È΋˜ ıÂÚ·›·˜ Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÓÔ˘ÎÏÂÔÛȉÈÎÒÓ ·Ó·ÏfiÁˆÓ Î·È ·Ó·ÛÙÔϤˆÓ Ù˘ ÚˆÙ¿Û˘, ηıÒ˜ Â›Û˘ Î·È Ë Î·Ï‡ÙÂÚË ÚfiÏË„Ë

¤¯Ô˘Ó ÚÔηϤÛÂÈ ÂÓÙ˘ˆÛȷ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì AIDS ÛÙȘ ‰˘ÙÈΤ˜ ¯ÒÚ˜. ∞ÓÙ›ıÂÙ·, Ê·›ÓÂÙ·È Ì›· ÌÂÁ¿ÏË ·‡ÍËÛË ÛÙȘ ¯ÒÚ˜ Ù˘ AÊÚÈ΋˜ Î·È Ù˘ AÛ›·˜, fiÔ˘ Ë ÂȉËÌ›· Û˘Ó¯›˙ÂÈ Ó· ÂÂÎÙ›ÓÂÙ·È ÏfiÁˆ ¤ÏÏÂȄ˘ Ê·ÚÌ¿ÎˆÓ ‹ ÏfiÁˆ ÎÔÈÓˆÓÈÎÒÓ ‰ÔÌÒÓ ÛÙȘ ¯ÒÚ˜ ·˘Ù¤˜. H Ù¿ÛË Ô˘ ı· ·ÎÔÏÔ˘ı‹ÛÂÈ Ë ›‰È· Ë ÓfiÛÔ˜ ı· ηıÔÚ›ÛÂÈ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ù‹.

OÈ ÏÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÚÔηÏÔ‡ÓÙ·È ·fi ÎÔÈÓ¿ ‹ ¢ηÈÚȷο ·ıÔÁfiÓ·. OÚÈṲ̂ӷ ·Ú·‰Â›ÁÌ·Ù· Ù¤ÙÔÈˆÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È Ù· ÂÍ‹˜: ·) O˘‰ÂÙÂÚÔÂÓ›· Î·È ÂÏÏ›ÌÌ·Ù· Ù˘ Ê·ÁÔ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜. OÈ Î·Ù·ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÛË„·ÈÌ›· ·fi ÎÔÈÓ¿ ÌÈÎÚfi‚È·, Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÏÔÈÌÒÍÂȘ ‰¤ÚÌ·ÙÔ˜ Î·È Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, Ó¢ÌÔӛ˜ Î·È ¿ÏϘ Û˘Ó‹ıÂȘ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ. ∂›Û˘, ÛÙ· ·È‰È¿ ·˘Ù¿ fiˆ˜ Î·È ÛÙÔÓ ˘fiÏÔÈÔ ·È‰ÈÎfi ÏËı˘ÛÌfi Â›Ó·È Û˘Ó‹ıÂȘ ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ.

OÈ ÏÔÈÌÒÍÂȘ Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ͤӷ ÛÒÌ·Ù· Î·È Î˘Ú›ˆ˜ ÂÓ‰ÔÊϤ‚ÈÔ˘˜ ηıÂÙ‹Ú˜ Â›Ó·È Ôχ Û˘¯Ó¤˜. OÈ ÂÓ‰ÔÊϤ‚ÈÔÈ Î·ıÂÙ‹Ú˜ Ì ÙËÓ ÈÓÈ΋ Ô˘ ÂÓ·ÔÙ›ıÂÙ·È ÛÙÔ ¿ÎÚÔ ÙÔ˘˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·ÔÈÎÈÛÌÔ‡ ÙÔ˘˜ Î·È Ïԛ̈͢ ÛÙ· ·È‰È¿ ·˘Ù¿. ‚) HIV Ïԛ̈ÍË. OÈ ·ÛıÂÓ›˜ Ì AIDS ·ı·›ÓÔ˘Ó ÏÔÈÌÒÍÂȘ Î·È ·fi ÎÔÈÓ¿ ·ıÔÁfiÓ· ·ÏÏ¿ Î·È ·fi ¢ηÈÚÈ·ÎÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ ¶Ó¢ÌÔÓÔ·ÛÙË carinii, TÔÍfiÏ·ÛÌ· gondii, ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·. ∂›Û˘, ·ı·›ÓÔ˘Ó Û˘¯Ó¿ ηÓÙÈÓÙÈ·ÛÈ΋ ÛÙÔÌ·Ù›Ùȉ·, ÂÎı‡ÛÂȘ ¤ÚËÙ· Î·È ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. Á) §ÔÈÌÒÍÂȘ ·ÛıÂÓÒÓ Ì ·ÓÂ¿ÚÎÂÈ· Ù˘ ¯˘ÌÈ΋˜ ·ÓÔÛ›·˜. ∆· ·È‰È¿ Ì ·ÓÂ·Ú΋ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ·ı·›ÓÔ˘Ó Û˘¯Ó¿ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·fi ÂÏ˘ÙÚÔÊfiÚ· ÌÈÎÚfi‚È·, .¯. Ó¢ÌÔӛ˜, ˆÙ›Ùȉ˜ Î·È ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ˜.

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¶·È‰È·ÙÚÈ΋ 2001;64:272-275

Paediatriki 2001;64:272-275

¢‡Ô ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈΤ˜ ηÙËÁÔڛ˜ ÈÒÓ ÁÈ· Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Â›Ó·È ÔÈ ÈÔ› ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Î˘Ú›ˆ˜ Ô ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜ (RSV), ÔÈ ÈÔ› Ù˘ ÁÚ›˘ ∞ Î·È µ, Ù˘ ·Ú·ÁÚ›˘ 1 Î·È 3 Î·È ÔÈ ·‰ÂÓÔ˚Ô›. OÈ ÈÔ› ·˘ÙÔ› ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ‚·ÚÈ¿ Ó¢ÌÔÓ›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜, Ô˘ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÌÔÚ› Ó· Â›Ó·È ı·Ó·ÙËÊfiÚ·. ∂›Û˘, ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ¯ÚfiÓÈ· ÊÔÚ›· Î·È ‰È·ÛÔÚ¿ ÙÔ˘˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô.

O Èfi˜ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÚÔηÏ› ÈÔ ‚·ÚÈ¿ Ïԛ̈ÍË ÛÙ· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Ô˘ ÌÔÚ› Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙȘ ÎÏÈÓÈΤ˜ Ù˘ ÂΉËÏÒÛÂȘ Ó¢ÌÔÓ›· Î·È ˘ÎÓfi, ·ÈÌÔÚÚ·ÁÈÎfi ÂÍ¿ÓıËÌ·. ∏ ¤ÎıÂÛË ÛÙÔÓ Èfi Á›ÓÂÙ·È ÔÏϤ˜ ÊÔÚ¤˜ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›·, fiÔ˘ ·ÚΛ ÎÔÈÓfi ·È¯Ó›‰È ÁÈ· ÌÂÚÈο ÏÂÙ¿ ‹ ·Ú·ÌÔÓ‹ ÛÙÔ ¯ÒÚÔ ÁÈ· 1 ÒÚ· ÁÈ· Ó· ÌÂÙ·‰Ôı›. ∏ ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÙˆÓ Â›ÓÔÛˆÓ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ Á›ÓÂÙ·È Ì ˘ÂÚ¿ÓÔÛË Á-ÛÊ·ÈÚ›ÓË ÙȘ ÚÒÙ˜ 72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË. ∏ ÂÓÂÚÁËÙÈ΋ ·ÓÔÛÔÔ›ËÛË Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚·ÚÈ¿˜ ·˘Ù‹˜ ÂÈÏÔ΋˜. ª›· ¿ÏÏË, Ôχ ÛËÌ·ÓÙÈ΋ ηÙËÁÔÚ›· ÏÔÈÌÒÍÂˆÓ ÛÙÔ˘˜ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È ÔÈ ÂÈÔÏ‹˜ Î·È ÂÓ Ùˆ ‚¿ıÂÈ Ì˘ÎËÙÈ¿ÛÂȘ. ∆¤ÙÔȘ Â›Ó·È Ë Î·ÓÙÈÓÙ›·ÛË ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È Ù˘ ÂÚÈÔ¯‹˜ ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ, ÔÈ ‰ÂÚÌ·ÙÔÊ˘ÙÈ¿ÛÂȘ, ÔÈ ÂÓ‰ËÌÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ, Ë Ì˘ÎËı·ÈÌ›·, ÂÓÙÔÈṲ̂Ó˜ ÂÓ Ùˆ ‚¿ıÂÈ ÏÔÈÌÒÍÂȘ Î·È Ë ÓÂÔÁÓÈ΋ Û˘ÛÙËÌ·ÙÈ΋ ηÓÙÈÓÙ›·ÛË. ™Â Ì›· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË fiÏˆÓ ÙˆÓ ÓÂÎÚÔÙÔÌÒÓ Ô˘ ¤ÁÈÓ·Ó Û ÌÂÁ¿ÏÔ E˘Úˆ·˚Îfi ÓÔÛÔÎÔÌÂ›Ô ·fi ÙÔ 1978 ̤¯ÚÈ ÙÔ 1982 (1) ‚Ú¤ıËΠfiÙÈ ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ ›¯·Ó ˘ÂÚÙÚÈÏ·ÛÈ·ÛÙ› ηٿ ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi (™¯‹Ì· 1).

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Έτος ™¯‹Ì· 1. ∂ÈÔÏ·ÛÌfi˜ Û˘ÛÙËÌ·ÙÈÎÒÓ Ì˘ÎËÙÈ¿ÛÂˆÓ Û ÓÂÎÚÔÙÔ̤˜ (1).

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∆Ë ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ Ì˘ÎËÙÈ¿ÛÂˆÓ ‰Â›¯ÓÂÈ Î·È Ë ·ÏÌ·Ù҉˘ ·Ó¿Ù˘ÍË ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ Ê·Ú̿ΈÓ. ∂Ó‰ÂÈÎÙÈÎfi Ù˘ ÛÔ˘‰·ÈfiÙËÙ·˜ Ô˘ ¤¯Ô˘Ó ÚÔÛÏ¿‚ÂÈ ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ ÛÙË Û‡Á¯ÚÔÓË È·ÙÚÈ΋ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ì¤¯ÚÈ Ù· Ù¤ÏË Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’70 ˘‹Ú¯·Ó ÌfiÓÔ ÂÏ¿¯ÈÛÙ· ·ÓÙÈÌ˘ÎËÙÈ·ÛÈο Ê¿Ú̷η, ÁÈ· Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ¤Ó·˜ ηٷÈÁÈÛÌfi˜ Ê·ÚÌ¿ÎˆÓ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· (™¯‹Ì· 2) (2).

OÈ Û˘ÛÙËÌ·ÙÈΤ˜ Ì˘ÎËÙÈ¿ÛÂȘ, Û‹ÌÂÚ·, Â›Ó·È ¤Ó· ˘·ÚÎÙfi Î·È ÔÏÔ¤Ó· ÌÂÁ·Ï‡ÙÂÚÔ Úfi‚ÏËÌ· ÛÙËÓ ¶·È‰È·ÙÚÈ΋. £ÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ÁÈ· ̇ÎËÙ˜ ‰ÂÓ Â›Ó·È “ÂÈÌÔχÓÛÂȘ” Î·È Ú¤ÂÈ ¿ÓÙ· Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Ì ÔÏÏ‹ ÚÔÛÔ¯‹. À¿Ú¯Ô˘Ó ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Û˘ÛÙËÌ·ÙÈ΋ Ì˘ÎËÙ›·ÛË Î·È Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË Î·È Î·ı˘ÛÙÂÚ›. ¶·Ú’ fiÏÔ Ô˘ ÙÔ ·ÓÙÈÌ˘ÎËÙfiÁÚ·ÌÌ· ¤¯ÂÈ È· ÚÔÙ˘ÔÔÈËı› ÁÈ· ÙÔ˘˜ ‚Ï·ÛÙÔ̇ÎËÙ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ Candida, ÁÈ· ÙÔ˘˜ ˘ÊÔ̇ÎËÙ˜ (∞Û¤ÚÁÈÏÏÔÈ Î·È ¿ÏÏÔÈ), ·Ú·Ì¤ÓÂÈ ·ÎfiÌË Î·ı·Ú¿ ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜ ¯ˆÚ›˜ η̛· ÚÔÙ˘ÔÔ›ËÛË ‹ Û˘Û¯ÂÙÈÛÌfi ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ÎÏÈÓÈ΋˜ ·¿ÓÙËÛ˘. ∏ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ ‰‡ÛÎÔÏË Î·È Ë ÚfiÁÓˆÛË Û˘Ó¯›˙ÂÈ Ó· Â›Ó·È Ôχ ‚·ÚÈ¿. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ··ÈÙ› Î·È ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ηٷÛÙÔÏ‹˜ ÙÔ˘ ·Ì˘ÓÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞˘Ù‹ Û˘Ó›ÛÙ·Ù·È Û ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‹/Î·È ¿ÏÏˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ, Â·Ó·ÊÔÚ¿ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ ÛÙÔ ·›Ì·, ¯ÔÚ‹ÁËÛË ·ÈÌÔÔÈËÙÈÎÒÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÌÂÙ·ÁÁ›ÛÂȘ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Ì·˙› Ì ‹ ¯ˆÚ›˜ ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Î˘ÙÙ·ÚÔΛÓ˜. OÈ ÙÂÏÂ˘Ù·›Â˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi ·ÏÏ¿ Î·È ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ. ŒÓ· ı¤Ì· Ôχ ÛËÌ·ÓÙÈÎfi Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÂÌ˘Ú¤ÙÔ˘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ ·ÛıÂÓ‹. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ‚ÚÂı› fiÙÈ fiÏÔÈ ÔÈ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ¤¯Ô˘Ó ÙÔÓ ›‰ÈÔ Î›Ó‰˘ÓÔ ÁÈ· ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. ŒÙÛÈ, Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‚·ıÌÔ‡ ÎÈÓ‰‡ÓÔ˘ Û ÌÈÎÚfi, ̤ÙÚÈÔ Î·È ÌÂÁ¿ÏÔ Â›Ó·È ÚˆÙ·Ú¯È΋˜ ÛËÌ·Û›·˜. ∆Ô ÈÔ ÛÔ˘‰·›Ô Â›Ó·È Ë ¿ÌÂÛË ÂÌÂÈÚÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ì¤¯ÚÈ ÙË ÁÓˆÛÙÔÔ›ËÛË ÙˆÓ ÌÈÎÚÔ‚ÈÔÏÔÁÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ªÂ ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ô ·ÛıÂÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹ ÛÙÔ Û›ÙÈ. ∆fiÛÔ ÛÙË Ì›· fiÛÔ Î·È ÛÙËÓ ¿ÏÏË ÂÚ›ÙˆÛË, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Ï‹„Ë fiÏˆÓ ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·È Î·ÏÏÈÂÚÁÂÈÒÓ. ∞ÓÂÍ¿ÚÙËÙ· ·fi ÙË ÓÔÛËÏ›· ÙÔ˘ ·È‰ÈÔ‡ ·Ú¯›˙ÂÈ ÂÌÂÈÚÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ Â˘Ú¤Ô˜ Ê¿ÛÌ·ÙÔ˜ ·fi ÙÔ ÛÙfiÌ· ‹ ·ÚÂÓÙÂÚÈο Î·È Â·Ó·ÚÔÛ‰ÈÔÚ›˙ÂÙ·È

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Echinocandin, pneumocandin, pradimidin, nikkomyicin, voricinazole, SCH56592, Nyotran, KY-62 AmBisome Amphocil

lipid AmB’s

Abelcet intraconazole fluconazole

oral solution

ketoconazole terbinafine

Amphotericin B

miconazole 5-flucytosine

Nystatin Griseofulvin 1950

1960

1970

1980

1990

2000

™¯‹Ì· 2. ∞ÏÌ·Ù҉˘ ·‡ÍËÛË ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ Ê·Ú̿ΈÓ.

Ô ‚·ıÌfi˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Û ‹È·, ̤ÙÚÈ· ‹ ‚·ÚÈ¿. ªÂ ÙËÓ ÂÈÏÂÎÙÈ΋ ·˘Ù‹ ÔÏÈÙÈ΋ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌÂÁ¿ÏË ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎfiÛÙÔ˘˜ Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. ¶ÚfiÏË„Ë ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ∏ ÚfiÏË„Ë ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙ· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ Â›Ó·È ·) ÂÓÂÚÁËÙÈ΋, Ì ٷ ÂÌ‚fiÏÈ· Î·È ‚) ·ıËÙÈ΋, Ì ·ÓÔÛÔÛÊ·ÈÚ›Ó˜. °ÂÓÈ΋ ·Ú¯‹ ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ Â›Ó·È fiÙÈ Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ·È‰È¿ ‰ÂÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ˙ˆÓÙ·ÓÔ‡˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜. OÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ٷ Û˘Ó‹ıË ÂÌ‚fiÏÈ· Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÔÓÙ·È. T· ·È‰È¿ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· Ì‹Ó· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÂÈÛ¢Ṳ̂ÓÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏ›ˆÓ Î·È ‰ÂÓ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ˙ˆÓÙ·ÓÔ‡˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. O ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi˜, ȉȷ›ÙÂÚ· Û ·È‰È¿ ̠Ϣ¯·ÈÌ›·. E›Û˘, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ηٿ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Î·È Ù˘ ÁÚ›˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎÔ› Î·È Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È.

T· ·È‰È¿ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÎÔÚÙÈÎÔıÂÚ·›· Û ‰fiÛË >2 mg/kg ‰ÂÓ Ú¤ÂÈ Ó· ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Î·Ù¿ ÙË ıÂÚ·›· Î·È ÁÈ· 1-2 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹

Ù˘, ȉȷ›ÙÂÚ· Ì ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜. T· ·‰¤ÏÊÈ· ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·È‰ÈÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Ì ÂÌ‚fiÏÈÔ Sabin ÁÈ·Ù› ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÈÔ‡˜ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ (3).

H ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÂȉÈÎÒÓ ‹ ÌË ÂȉÈÎÒÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ.

MËÓÈ·›Â˜ ÂÓ‰ÔÊϤ‚Ș ÂÁ¯‡ÛÂȘ ÌË ÂȉÈ΋˜ ÁÛÊ·ÈÚ›Ó˘ (IVIG) ¯ÔÚËÁÔ‡ÓÙ·È Û ¯˘ÌÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∂ȉÈΤ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜, .¯. ηٿ ÙÔ˘ ÈÔ‡ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Î·È ÙÔ˘ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô‡ (VZV Î·È CMV), ¯ÔÚËÁÔ‡ÓÙ·È ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ÏÔÈÌÒÍÂȘ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ÏÔÈÌÒÍÂȘ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ·˘ÍËı› ¿Ú· Ôχ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ™’ ·˘Ùfi ÂËÚ¤·ÛÂ Ë ÌÂÁ¿ÏË Â›Ù¢ÍË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·È Ù˘ ·ÓÙÈ·ÔÚÚÈÙÈ΋˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È.

EÓÙÔ‡ÙÔȘ, ηχÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ÈÔ ÌÂÁ¿ÏË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â¤ÊÂÚ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. H ÚfiÔ‰Ô˜ ·˘Ù‹ ·ÔÙ¤ÏÂÛ ÛÙ·ıÌfi ÛÙËÓ ÂͤÏÈÍË Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÏÔÈÌÒÍÂˆÓ Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ Î·È ·ÊÂÙËÚ›· ÁÈ· ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘˜ ÛÙ· ÂfiÌÂÓ· ¯ÚfiÓÈ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Groll AH, Shah PM, Mentzel C, Schneider M, JustNuebling G, Huebner K. Trends in the postmortem epidemiology of invasive fungal infections at a University Hospital. J Infect 1996;33:23-32.

2. Edwards JE Jr, Bodey GP, Bowden RA, Buchner T, de Pauw BE, Filler SG, et al. International Conference for the Development of a Consensus on the Management and Prevention of Severe Candida Infections. Clin Infect Dis 1997;25:43-59.

3. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡-™È‰ËÚÔÔ‡ÏÔ˘ M. ∂Ì‚ÔÏÈ·ÛÌÔ› ·ÛıÂÓÒÓ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡. ¢ÂÏÙ ∞’¶·È‰·ÙÚ ∫ÏÈÓ ¶·ÓÂ ∞ıËÓÒÓ 1996; 43:101-105.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ÌÌ·ÓÔ˘‹Ï ƒÔËÏ›‰Ë˜ 3Ë ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49, 546 42, £ÂÛÛ·ÏÔÓ›ÎË e-mail: roilides@med.auth.gr

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∞πª∞∆O§O°π∞ - O°∫O§O°π∞

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HEMATOLOGY - ONCOLOGY

∞ÓÙÈÌÂÙÒÈÛË ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ™. °Ú·Ê¿ÎÔ˜

Haematopoietic stem cell transplantation for the treatment of haematological, malignant, and genetic diseases S. Graphakos

¶ÂÚ›ÏË„Ë: ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª∞∫) ·ÔÙÂÏ› ηıÈÂڈ̤ÓË ıÂÚ·›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÚÈÛÌ¤ÓˆÓ ÛÔ‚·ÚÒÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. O ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο. ™ÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 250 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÂÙËÛ›ˆ˜. ∆· ÌÔۯ‡̷ٷ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì·. °È· Ó· ıˆÚËı› ÔÛÔÙÈο Â·ÚΤ˜ ÙÔ ÌfiÛ¯Â˘Ì· Ú¤ÂÈ ÙÔ Ì˘ÂÏÈÎfi Ó· ÂÚȤ¯ÂÈ >3x108 ÂÌ‡ÚËÓ· ·ÙÙ·Ú·/Kgr µ™ ÙÔ˘ ‰¤ÎÙË, ÙÔ ÂÚÈÊÂÚÈÎfi >5x106 CD34+/Kgr µ™ Î·È ÙÔ ÔÌÊ·ÏÈÎfi >5x107 ÌÔÓÔ˘ÚËÓÈο ·ÙÙ·Ú·/Kgr µ™. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÏÏÔÁÂÓÂÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÌÔۯ‡̷ٷ ·fi ÂıÂÏÔÓÙ¤˜ ‰fiÙ˜ ÌË Û˘ÁÁÂÓÈÎÔ‡˜ ÚÔ˜ ÙÔÓ ¿Û¯ÔÓÙ· (Volunteer Unrelated Donor). À¿Ú¯Ô˘Ó ÔÚÈṲ̂Ó˜ ‚·ÛÈΤ˜ ÚÔ¸Ôı¤ÛÂȘ, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ˘ÔΛÌÂÓÔ ÓfiÛËÌ·, ÙËÓ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔÓ Ù‡Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ™ÙȘ ÔÍ›˜ Ï¢¯·È̛˜, Ë ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Î˘Ì·›ÓÂÙ·È ·fi 55-75%, ÛÙË ‚·ÚÈ¿ ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ˘ÂÚ‚·›ÓÂÈ ÙÔ 80%, ÂÓÒ ÛÙË ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Ë Ï‹Ú˘ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Ôχ ˘„ËÏ‹. ™ÙË ÌÔÓ¿‰· Ì·˜ Û˘ÁÎÂÎÚÈ̤ӷ, ÙÔ ÔÛÔÛÙfi ›·Û˘ Û ۇÓÔÏÔ 47 ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 92%.

Abstract: Haematopoietic stem cell transplantation is an established therapeutic method for the treatment of various haematological, malignant, and genetic diseases. The source of haematopoietic graft could be either bone marrow or peripheral blood or cord blood. The number of allogeneic transplants performed from volunteer unrelated donors has substantially increased during the last few years with satisfactory results.

The nature of the underlying disease, the patient’s clinical condition and the type of transplantation are the main factors that influence the outcome. In acute leukemia the five year survival after transplantation free of disease is estimated to be between 55-75%, while in severe aplastic anaemia it exceeds 80%. Excellent results have been achieved in patients with thalassaemia, and currently in our unit, disease free survival in 47 transplanted thalassaemic children is 92%.

§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÔÌÊ·ÏÈÎfi ·›Ì·.

Key words: haematopoietic stem cell transplantation, cord blood.

ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

Division of Bone Marrow Transplantation “St. Sophia” Children’s Hospital, Athens

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¶·È‰È·ÙÚÈ΋ 2001;64:276-279

∏ ªÂÙ·ÌfiÛ¯Â˘ÛË ª˘ÂÏÔ‡ ÙˆÓ √ÛÙÒÓ ‹ fiˆ˜ Ú¤ÂÈ ÔÚıfiÙÂÚ· Ó· ·ÔηÏÂ›Ù·È ªÂÙ·ÌfiÛ¯Â˘ÛË ∞Ú¯¤ÁÔÓˆÓ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ (ª∞∫), ·ÔÙÂÏ› ηıÈÂڈ̤ÓË ıÂÚ·›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÔÚÈÛÌ¤ÓˆÓ ÛÔ‚·ÚÒÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (1). ∏ ª∞∫ ‰È·ÎÚ›ÓÂÙ·È Û ·˘ÙfiÏÔÁË, fiÔ˘ ‰fiÙ˘ Î·È Ï‹Ù˘ Â›Ó·È ÙÔ ›‰ÈÔ ¿ÙÔÌÔ, Û˘ÁÁÂÓÂÙÈ΋ fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ÁÂÓÂÙÈο Ù·˘ÙfiÛËÌÔ˜ Ì ÙÔÓ ¿Û¯ÔÓÙ· (ÌÔÓÔˆ˚ÎÔ› ‰›‰˘ÌÔÈ) Î·È ·ÏÏÔÁÂÓÂÙÈ΋, fiÔ˘ ‰fiÙ˘ Î·È Ï‹Ù˘ ‰È·Ê¤ÚÔ˘Ó ÁÂÓÂÙÈο. ™ÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË, Ô ‰fiÙ˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÈÛÙÔÛ˘Ì‚·Ùfi˜ ·‰ÂÏÊfi˜ ÙÔ˘ ¿Û¯ÔÓÙ·, ÌÔÚ› fï˜ Ó· Â›Ó·È Î·È ÌË ·fiÏ˘Ù· Û˘Ì‚·Ùfi˜ Û˘ÁÁÂÓ‹˜ ›Ù ÂıÂÏÔÓÙ‹˜, Ô ÔÔ›Ô˜ ‰ÂÓ ¤¯ÂÈ Û˘ÁÁ¤ÓÂÈ· Ì ÙÔÓ ¿Û¯ÔÓÙ· Î·È ÂÌÊ·Ó›˙ÂÈ ÌÂÚÈ΋ ‹ Î·È Ï‹ÚË ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· Ì ·˘ÙfiÓ. O ·ÚÈıÌfi˜ ÙˆÓ ª∞∫ ¤¯ÂÈ ·˘ÍËı› Ú·Á‰·›· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È ÙÔ 1999 ηٷÁÚ¿ÊËÎ·Ó ·fi ÙËÓ ∂˘Úˆ·˚΋ ÔÌ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ (∂µª∆) 6441 ·ÏÏÔÁÂÓÂÙÈΤ˜ Î·È 14989 ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ÂÓÒ ÛÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙË ¯ÚÔÓÈ¿ ·˘Ù‹ 200 ªÂÙ·ÌÔۯ‡ÛÂȘ ∞ÈÌÔÔÈËÙÈÎÒÓ ∫˘ÙÙ¿ÚˆÓ. ∆· ·ÈÌÔÔÈËÙÈο ÌÔۯ‡̷ٷ (2) ÚÔ¤Ú¯ÔÓÙ·È: ·) ·fi Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, Ô ÔÔ›Ô˜ ·Ú·Ì¤ÓÂÈ Ë Î‡ÚÈ· ËÁ‹ ΢ÙÙ¿ÚˆÓ ÁÈ· ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ‚) ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Ô˘ ηÙÂÍÔ¯‹Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ (ÛÙÔÓ ·ÛıÂÓ‹ ¯ÔÚËÁÂ›Ù·È ·˘ÍËÙÈÎfi˜ ·ÈÌÔÔÈËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (G-CSF), Ù· ·Ú¯¤ÁÔÓ· ·ÈÌÔÔÈËÙÈο ·ÙÙ·Ú· ÎÈÓËÙÔÔÈÔ‡ÓÙ·È ·fi ÙÔ Ì˘ÂÏfi ÛÙËÓ ÂÚÈʤÚÂÈ· Î·È Î·ÙfiÈÓ Û˘ÏϤÁÔÓÙ·È Ì Ì˯·Ó‹Ì·Ù· ΢ÙÙ·ÚÔ·Ê·›ÚÂÛ˘ Û 2-3 Û˘Ó‰ڛ˜), Á) ·fi ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· (O¶∞), ÙÔ ÔÔ›Ô ÂÚȤ¯ÂÈ ÈηÓfi ·ÚÈıÌfi ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÌÔÚ› Ó· Á›ÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ¿ÙÔÌ· ‚¿ÚÔ˘˜ <40 kgr. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì O¶∞ Á›ÓÔÓÙ·È Î˘Ú›ˆ˜ Û ·È‰È¿. ¶ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ °È· ÙËÓ ÂÈÙ˘¯›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂Ó˜ ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ: 1) ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ‰fiÙË. ¶Ú¤ÂÈ Ó· Â›Ó·È ÈÛÙÔÛ˘Ì‚·Ùfi˜ Ì ÙÔÓ ¿Û¯ÔÓÙ·. ∏ Èı·ÓfiÙËÙ· Ó· ‚ÚÂı› Û˘Ì‚·Ùfi ̤ÏÔ˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ÂÚ›Ô˘ 30%. ™Â ÂÚ›ÙˆÛË ·‰˘Ó·Ì›·˜ ·Ó‡ÚÂÛ˘ Á›ÓÂÙ·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÂÓ·ÏÏ·ÎÙÈÎÔ‡˜ ‰fiÙ˜, fiˆ˜ Â›Ó·È Ô ÌË ·fiÏ˘Ù· Û˘Ì‚·Ùfi˜ Û˘ÁÁÂÓ‹˜, Ô ÂıÂÏÔÓÙ‹˜ ‰fiÙ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ô˘ ·Ó¢ڛÛÎÂÙ·È ·fi ÙȘ ‰ÈÂıÓ›˜ ÙÚ¿Â˙˜ ‰ÔÙÒÓ ‹ ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· Ô˘ ·Ó·˙ËÙ›ٷÈ

Paediatriki 2001;64:276-279

·fi ·ÓÙ›ÛÙÔȯ˜ ‰ÈÂıÓ›˜ ÙÚ¿Â˙˜. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·ÓÔÛÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ, Û˘Ó‹ıˆ˜ Á›ÓÂÙ·È ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ∆ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙÔ ÌfiÛ¯Â˘Ì·. O ϤÔÓ ‰È·‰Â‰Ô̤ÓÔ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜ Â›Ó·È Ë ıÂÙÈ΋ ÂÈÏÔÁ‹ ÙˆÓ CD34+ ΢ÙÙ¿ÚˆÓ Ì ·ÓÔÛÔÌ·ÁÓËÙÈΤ˜ ÌÂıfi‰Ô˘˜.

2) ∏ ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∂¿Ó ˘¿Ú¯ÂÈ ÓÂÔÏ·ÛÌ·ÙÈÎfi ÓfiÛËÌ·, ηٿÏÏËÏÔ˜ ¯ÚfiÓÔ˜ Â›Ó·È fiÙ·Ó ¤¯ÂÈ ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÓfiÛÔ˘. ™Â ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ‹ ÁÂÓÂÙÈÎfi ÓfiÛËÌ·, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· Á›ÓÂÈ ÛÙÔ Û˘ÓÙÔÌfiÙÂÚÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË.

3) ∏ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∫·Ù¿ ÙË ÛÙÈÁÌ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ô ·ÛıÂÓ‹˜ ‰ÂÓ Ú¤ÂÈ Ó· ¤¯ÂÈ ÂÓÂÚÁfi Ïԛ̈ÍË Î·È Ù· fiÚÁ·Ó· ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ (ηډȿ, ÓÂÊÚÔ›, Ó‡ÌÔÓ˜, ‹·Ú) ‰ÂÓ Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜.

4) ∏ “ÚÔÂÙÔÈÌ·Û›·” ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. °›ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Î˘ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Û Ôχ ˘„ËϤ˜ ‰fiÛÂȘ Ô˘ ÌÔÚ› Ó· Û˘Ó‰˘·ÛÙÔ‡Ó Î·È Ì ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›·. ™ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, Ù· ϤÔÓ Û˘Ó‹ıË ÚˆÙfiÎÔÏÏ· Â›Ó·È ·˘Ù¿ Ô˘ Û˘Ó‰˘¿˙Ô˘Ó Î˘ÎÏÔʈÛÊ·Ì›‰Ë Ì ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· ‹ ΢ÎÏÔʈÛÊ·Ì›‰Ë Ì ‚Ô˘ÛÔ˘ÏÊ¿ÓË. ™Ù· ·È‰È¿, Ë ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ÓË ÂÊ·ÚÌÔÁ‹ ÏfiÁˆ ÙˆÓ ÛÔ‚·ÚÒÓ ¿ÌÂÛˆÓ Î·È ·ÒÙÂÚˆÓ ·ÚÂÓÂÚÁÂÈÒÓ Ô˘ ÂÌÊ·Ó›˙ÂÈ. ∏ “ÚÔÂÙÔÈÌ·Û›·” ·˘Ù‹ ¤¯ÂÈ ¤Ó·Ó ÙÚÈÏfi ÛÙfi¯Ô: ·) ÙË ‰ËÌÈÔ˘ÚÁ›· “¯ÒÚÔ˘” ÛÙË Ì˘ÂÏÈ΋ ÎÔÈÏfiÙËÙ· ÁÈ· Ó· ÌÔÚ¤ÛÂÈ Ó· ÂÁηٷÛÙ·ı› Î·È Ó· ·Ó·Ù˘¯ı› ÙÔ ÌfiÛ¯Â˘Ì·, ‚) ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· Ó· ÌËÓ ·Ó·ÁÓˆÚ›ÛÂÈ ˆ˜ ͤÓÔ ÙÔ ÌfiÛ¯Â˘Ì· Î·È ÙÔ ·ÔÚÚ›„ÂÈ Î·È Á) ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ˘ÔÏÂÈfiÌÂÓˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ÛÙÔ ÛÒÌ·, ÁÈ· Ó· ·ÔÊ¢¯ı› Ô Î›Ó‰˘ÓÔ˜ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘.

5) ∏ ¤ÓÙÔÓË Î·È Û˘Ó¯‹˜ ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘ Î·È Ô˘‰ÂÙÂÚÔÂÓÈÎÔ‡ ·ÛıÂÓÔ‡˜ ̤¯ÚÈ ÙËÓ Ï‹ÚË ·ÈÌÔÔÈËÙÈ΋ Î·È ÏÂÌÊÈ΋ ·ÔηٿÛÙ·Û‹ ÙÔ˘. °È· ÙËÓ ÚÔʇϷÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·fi ÙË ÓfiÛÔ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹ (GVHD), ¯ÔÚËÁÂ›Ù·È Î˘ÎÏÔÛÔÚ›ÓË ∞, ÁÈ· ‰È¿ÛÙËÌ· 3-12 ÌËÓÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‚Ú·¯Â›· ¯ÔÚ‹ÁËÛË ÌÂıÔÙÚÂÍ¿Ù˘. ∞ÈÌÔÔÈËÙÈο ÌÔۯ‡̷ٷ ∆Ô Ì˘ÂÏÈÎfi ÌfiÛ¯Â˘Ì· ÁÈ· Ó· ıˆÚËı› Â·ÚΤ˜ Ú¤ÂÈ Ó· ÂÚȤ¯ÂÈ >3x108 ÂÌ‡ÚËÓ· ·ÙÙ·Ú·/kgr µ™ ÙÔ˘ ‰¤ÎÙË Î·È Ô fiÁÎÔ˜ Ô˘ ÙÔ ÂÚȤ¯ÂÈ Â›Ó·È 10-20 ml/kg µ™ ‰¤ÎÙË. ™Â ·Û‡Ì‚·Ù˜ Î·È Û ÌË Û˘ÁÁÂÓÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ηıÒ˜ Â›Û˘ ÛÂ

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ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, Ô ·ÚÈıÌfi˜ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜. ŸÙ·Ó ¯ÚËÛÈÌÔÔÈԇ̠ÂÚÈÊÂÚÈÎfi ·›Ì·, Ô ·ÚÈıÌfi˜ 3,5-5,0 106/kg µ™ CD34+ ΢ÙÙ¿ÚˆÓ ıˆÚÂ›Ù·È Ôχ ÈηÓÔÔÈËÙÈÎfi˜ ÁÈ· ÙËÓ Ù·¯Â›· ·Ó·Á¤ÓÓËÛË Ù˘ ·ÈÌÔÔ›ËÛ˘, ÂÓÒ Ì ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì·, Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÔÓÔ˘ÚËÓÈÎÒÓ Î·È CD34+ ΢ÙÙ¿ÚˆÓ Ô˘ Ú¤ÂÈ Ó· Ï¿‚ÂÈ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· Â›Ó·È Ù˘ Ù¿Í˘ ÙˆÓ 5x107/kg Î·È 0,5x106/kg, ·ÓÙ›ÛÙÔȯ·. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·ÈÌÔÔÈËÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Á›ÓÂÙ·È ÛÙÔÓ ·ÛıÂÓ‹ ÂÓ‰ÔÊϤ‚È· ̤ۈ ηıÂÙ‹Ú· Ù‡Ô˘ Hickman Î·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·fi 15-20 Ë̤Ú˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· >500 Ô˘‰ÂÙÂÚfiÊÈÏ·/ί, ÂÓÒ ·ÈÌÔÂÙ¿ÏÈ· >20000/ί ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ÙËÓ 21Ë-25Ë Ë̤ڷ. ∂ÈÏÔΤ˜ ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÚÔÛʤÚÂÈ ÙËÓ ›·ÛË Û ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ·ÛıÂÓÒÓ, ·ÏÏ¿ ‰ËÌÈÔ˘ÚÁ› ÔÏÏ·Ï¿ ÚÔ‚Ï‹Ì·Ù· Î·È ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Û ÔÚÈṲ̂ÓÔ˘˜. ™˘ÓËıÈṲ̂Ó˜ ÚÒÈ̘ ÂÈÏÔΤ˜ Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ, Ë Ó¢ÌÔÓ›Ùȉ·, Ë ÊÏ‚ԷÔÊÚ·ÎÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜ (3), ÔÈ ‚Ï¿‚˜ ÙÔ˘ ÂÙÈÎÔ‡, Ë ÔÍ›· Î·È ¯ÚfiÓÈ· ÓfiÛÔ˜ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹ (GVHD) (4). ∏ ıÓËÙfiÙËÙ· ·fi ÙËÓ ÙÔÍÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ ·Ó¤Ú¯ÂÙ·È Û 3-5% ÁÈ· ÙȘ ·˘ÙfiÏÔÁ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È 5-10% ÁÈ· ÙȘ ·ÏÏÔÁÂÓÂÙÈΤ˜. ŸÙ·Ó ·˘Ù¤˜ Á›ÓÔÓÙ·È Ì ÌË Û˘Ì‚·Ùfi ‹ ÌË Û˘ÁÁÂÓÈÎfi ‰fiÙË, ÙÔ ÔÛÔÛÙfi ˘ÂÚ‚·›ÓÂÈ ÔÏϤ˜ ÊÔÚ¤˜ ÙÔ 25%. ∞ÔÙÂϤÛÌ·Ù· ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ª∞∫ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ˘ÔΛÌÂÓÔ ÓfiÛËÌ· Î·È ÙÔ ÛÙ¿‰Èfi ÙÔ˘, ÙÔÓ Ù‡Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙËÓ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. °ÂÓÈο, Â›Ó·È Î·Ï‡ÙÂÚ· ÛÙ· ·È‰È¿ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, fiˆ˜ Â›Û˘ Î·È ÛÙ· ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù·, ÂÓÒ ÛÙȘ ÓÂÔÏ·ÛÌ·ÙÈΤ˜ ·ı‹ÛÂȘ, fiÙ·Ó ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û Ï‹ÚË ‡ÊÂÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ ‚·ÚÈ¿ ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· Û ·È‰È¿ Ô˘ ¤¯Ô˘Ó ÈÛÙÔÛ˘Ì‚·Ùfi Û˘ÁÁÂÓÈÎfi ‰fiÙË Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¿ÌÂÛ· Ì ª∞∫, ¯ˆÚ›˜ Ó· ÂȯÂÈÚÂ›Ù·È ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÂÈÙ˘Á¯¿ÓÂÙ·È ›·ÛË ÛÙÔ 90% ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙˆÓ ·ÛıÂÓÒÓ (5). ∏ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Â›Ó·È ÓfiÛËÌ· ÙÔ ÔÔ›Ô Û‹ÌÂÚ· ıÂÚ·‡ÂÙ·È ÂÈÙ˘¯Ò˜ ÌÂ Û˘Ì‚·ÙÈ΋ ¯ËÌÂÈÔıÂÚ·›·. ŒÙÛÈ, ª∞∫ Á›ÓÂÙ·È ÌfiÓÔ Û ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔÈ¿˙Ô˘Ó Î·È ÛÙËÓ 1Ë ‡ÊÂÛË, ÌfiÓÔ Û Û¿ÓȘ ÌÔÚʤ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. OÌÔ›ˆ˜, Ë ÔÍ›· Ì˘ÂÏÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· ¤·„ ӷ ¤¯ÂÈ ÙË ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË Ô˘ ›¯Â

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ÚÔ 10ÂÙ›·˜ Î·È ÙÔ 60% ÙˆÓ ·È‰ÈÒÓ ıÂÚ·‡ÂÙ·È Û‹ÌÂÚ· Ì ¤ÓÙÔÓË ¯ËÌÂÈÔıÂÚ·›·. ª∞∫ Î·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Á›ÓÂÙ·È ÛÙȘ Ï›Á˜ ÌÔÚʤ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÛÙȘ ˘ÔÙÚÔ¤˜ (6). ∏ Èı·ÓfiÙËÙ· ›·Û˘ Ù˘ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ Ì ª∞∫ Î˘Ì·›ÓÂÙ·È ·fi 55-75%, ÂÓÒ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÁÈ· ÙÔ˘˜ 32 ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÌÂÙ·ÌÔÛ¯Â˘ı› ÛÙË ÌÔÓ¿‰· Ì·˜ Â›Ó·È 63%. °È· Ù· Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈο Û‡Ó‰ÚÔÌ· Î·È ÙË ¯ÚfiÓÈ· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, Ë ª∞∫ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ıÂÚ·›· Î·È Ù· ¿Û¯ÔÓÙ· ·È‰È¿ Ú¤ÂÈ Û‡ÓÙÔÌ· Ó· ÚÔˆıÔ‡ÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi Û˘Ì‚·Ùfi ‹ ÌË Û˘ÁÁÂÓÈÎfi ‰fiÙË. ∆· ˘ÔÙÚÔÈ¿˙ÔÓÙ· Î·È ·ÓıÂÎÙÈο ÛÙË ıÂÚ·›· ÏÂÌÊÒÌ·Ù· Hodgkin Î·È ÌË Hodgkin ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·˘ÙfiÏÔÁË ª∞∫, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÈ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙ· ·È‰È¿. ∞ÛıÂÓ›˜ Ù˘ ÌÔÓ¿‰·˜ Ì·˜ ÂÌÊ·Ó›˙Ô˘Ó 5ÂÙ‹ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ (Ô˘ Ú·ÎÙÈο ÈÛÔ‰˘Ó·Ì› Ì Ï‹ÚË ›·ÛË) Ô˘ ·Ó¤Ú¯ÂÙ·È Û 65% ÛÙ· ÌË Hodgkin Î·È 77% ÛÙ· Hodgkin ÏÂÌÊÒÌ·Ù·. ¶ÔÏÏÔ› Û˘Ì·Á›˜ fiÁÎÔÈ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·˘ÙfiÏÔÁË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŸÌˆ˜, ÁÈ· ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ·˘ÙÔ‡˜ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÊÙˆ¯¿, ‰ÈfiÙÈ Û˘Ó‹ıˆ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌfiÓÔ ·Ú¿Ù·ÛË Ù˘ ‡ÊÂÛ˘ Î·È Ë ÓfiÛÔ˜ ˘ÔÙÚÔÈ¿˙ÂÈ ·ÚÁfiÙÂÚ·. ∞Ó Î·È Ù· ¿Û¯ÔÓÙ· ·È‰È¿ ·Ó¤¯ÔÓÙ·È Î·Ï¿ ˘„ËϤ˜ ‰fiÛÂȘ ¯ËÌÂÈÔıÂÚ·›·˜ (ÌÂÁ·ıÂÚ·›·) Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·È‰ÈÎÔ› fiÁÎÔÈ Â›Ó·È ¯ËÌÂÈÔ¢·›ÛıËÙÔÈ, ̤¯ÚÈ Û‹ÌÂÚ· ۯ‰fiÓ Î·Ó¤Ó·˜ Û˘Ì·Á‹˜ fiÁÎÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ‰ÂÓ ·ÔÙÂÏ› ·fiÏ˘ÙË ¤Ó‰ÂÈÍË ÁÈ· ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË. ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ ÛÙ·‰›Ô˘ 4 ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÂÈÙ˘¯Ò˜ ÛÙÔ 15% ÙˆÓ ·ÛıÂÓÒÓ Ì ÙË Û˘Ì‚·ÙÈ΋ ıÂÚ·›· (¯ËÌÂÈÔıÂÚ·›· ·ÎÙÈÓÔ‚ÔÏ›·, ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË). ªÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ (›·ÛË) Î˘Ì·›ÓÂÙ·È ÛÙÔ 35% (7). ∞fi Ù· ‰È¿ÊÔÚ· ÎÏËÚÔÓÔÌÈο ÓÔÛ‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ª∞∫, ‰‡Ô Â›Ó·È ·˘Ù¿ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂӉȷʤÚÔÓ Î·È ÂȉÂÈÎÓ‡Ô˘Ó Î·Ï¿ ·ÔÙÂϤÛÌ·Ù·: ÔÈ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ (΢ڛˆ˜ Ë ‚·ÚÈ¿ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· - SCID) Î·È Ë ªÂÛÔÁÂȷ΋ ∞Ó·ÈÌ›·. OÈ ÚˆÙÔ·ı›˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂȘ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ¤ÁηÈÚ·, ÚÈÓ Ô ·ÛıÂÓ‹˜ ÂÈ‚·Ú˘Óı› Ì ÏÔÈÌÒÍÂȘ. ∂¿Ó Ô ‰fiÙ˘ Â›Ó·È Û˘Ì‚·Ùfi˜ ·‰ÂÏÊfi˜, Ë ÂÈÙ˘¯‹˜ ‰ÈfiÚıˆÛË Ù˘ ÁÂÓÂÙÈ΋˜ ·˘Ù‹˜ ‚Ï¿‚˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ 80% ÙˆÓ ·È‰ÈÒÓ. ŸÙ·Ó Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Á›ÓÂÈ ·fi ÌÂÚÈÎÒ˜ Û˘Ì‚·Ùfi (·ÏÔÙ·˘ÙfiÛËÌÔ) ÁÔÓ¤·, ÙfiÙ ٷ ÔÛÔÛÙ¿ ›·Û˘ Î˘Ì·›ÓÔÓÙ·È ÛÙÔ 60%. ∏ ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Â›Ó·È ÙÔ ÈÔ Û˘¯Ófi ÁÂÓÂÙÈÎfi ÓfiÛËÌ· Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Î·È ¤¯ÂÈ

MAY- JUNE '01 TELIKO

30-05-03

18:55

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ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙË ¯ÒÚ· Ì·˜ ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Û¯fiÓÙˆÓ. ™‹ÌÂÚ·, ÔÈ ¿Û¯ÔÓÙ˜ ·fi ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ÔÈ ÔÔ›ÔÈ ˘Ô‚¿ÏÏÔÓÙ·È Û ٷÎÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ Î·È ÛˆÛÙ‹ ·ÔÛȉ‹ÚˆÛË, ÂÈÙ˘Á¯¿ÓÔ˘Ó ÈηÓÔÔÈËÙÈ΋ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ¤¯Ô˘Ó ÚÔÛ‰fiÎÈÌÔ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÂÈ‚›ˆÛ˘. ¶·Ú’ fiÏ· ·˘Ù¿ Ë ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Â›Ó·È ¤Ó· Ôχ ÛÔ‚·Úfi ÓfiÛËÌ· Ô˘ ˘Ô‚¿ÏÏÂÈ ÙÔÓ ·ÛıÂÓ‹ Û ÛÔ‚·ÚÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ (ÏÔÈÌÒÍÂȘ, ·ÈÌÔÛȉ‹ÚˆÛË Î.Ï.), ÂÓÒ ÚÈ˙È΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Á›ÓÂÙ·È ÌfiÓÔ Ì ª∞∫. OÈ ı·Ï·ÛÛ·ÈÌÈÎÔ› ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È Û 3 ÔÌ¿‰Â˜ ÎÈÓ‰‡ÓÔ˘, (I) ¯·ÌËÏÔ‡, (II) ÂӉȷ̤ÛÔ˘ Î·È (III) ˘„ËÏÔ‡, Ì 3 ÎÚÈÙ‹ÚÈ· Ù· ÔÔ›· ¤¯Ô˘Ó ıÂÛÈÛÙ› ·fi ÙËÓ ÔÌ¿‰· Pesaro Ù˘ πÙ·Ï›·˜. ∞˘Ù¿ ›ӷÈ: Ë Ë·ÙÔÌÂÁ·Ï›· ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô ‚·ıÌfi˜ ·ÔÛȉ‹ÚˆÛ˘ Î·È Ë ‡·ÚÍË Ë·ÙÈ΋˜ ›ÓˆÛ˘. ∏ ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È ÂÍ·ÈÚÂÙÈ΋, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ˘ԉ¤ÛÙÂÚ· ÛÙËÓ ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜. ™Â Û‡ÓÔÏÔ 850 ·ÛıÂÓÒÓ ÙÔ˘ Pesaro, Ë ‰ÈfiÚıˆÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜ ÂÂÙ‡¯ıË ÛÙÔ 86% Ù˘ ÔÌ¿‰Ô˜ I, ÛÙÔ 74% Ù˘ ÔÌ¿‰Ô˜ II Î·È ÛÙÔ 53% Ù˘ ÔÌ¿‰Ô˜ III, ÂÓÒ Ë ıÓËÙfiÙËÙ· ·ÓÙ›ÛÙÔȯ· ‹Ù·Ó 5%, 16% Î·È 33%. ™ÙË ªÔÓ¿‰· ªªO ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ·›‰ˆÓ “∞Á›· ™ÔÊ›·” ¤¯Ô˘Ó ÌÂÙ·ÌÔÛ¯Â˘ı› 46 ı·Ï·ÛÛ·ÈÌÈο ·È‰È¿. ∞fi ·˘Ù¿, ÙÔ ¤Ó· ¤¯ÂÈ ·ÔÚÚ›„ÂÈ ÙÔ ÌfiÛ¯Â˘Ì·, ÙÚ›· ¤¯Ô˘Ó ηٷϋÍÂÈ Î·È Ù· ˘fiÏÔÈ· 42 Â›Ó·È ıÂÚ·Â˘Ì¤Ó·, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÈÌÔÔ›ËÛË ÙÔ˘ ‰fiÙË ÙÔ˘˜, ‰ËÏ·‰‹ Ë ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Ì ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 26 Ì‹Ó˜ (5-64 Ì‹Ó˜) ·Ó¤Ú¯ÂÙ·È ÛÙÔ fi¯È Â˘Î·Ù·ÊÚfiÓËÙÔ ÔÛÔÛÙfi ÙÔ˘ 92% (8). ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÛÙÔ ‰È¿ÛÙËÌ· ÙˆÓ 30 ¯ÚfiÓˆÓ Ô˘ ¤Ú·Û·Ó ·fi ÙfiÙ Ô˘ ÁÈ· ÚÒÙË ÊÔÚ¿ ÂÊ·ÚÌfiÛÙËΠ۠·È‰› Ô˘ ¤·Û¯Â ·fi SCID, ·ԉ›¯ıËΠ·fiÏ˘Ù· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂÚ·›· ÁÈ· ¯ÈÏÈ¿‰Â˜ ·ÛıÂÓ›˜. ªÂ ÙËÓ Î·Ï‡ÙÂÚË ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ·ÛıÂÓÒÓ, ÙË

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¯Ú‹ÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙËÓ ·‡ÍËÛË ÙˆÓ ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ Î·È ÙËÓ Î·Ï‡ÙÂÚË ÂÈÏÔÁ‹ ÙÔ˘˜ Ì Ù¯ÓÈΤ˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜, Â›Ó·È ‚¤‚·ÈÔ fiÙÈ fi¯È ÌfiÓÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ı· ·˘ÍËı›, ·ÏÏ¿ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Û˘Ó¯Ҙ ı· ‚ÂÏÙÈÒÓÔÓÙ·È. µÈ‚ÏÈÔÁÚ·Ê›· 1. Goldman JM, Schmitz N, Niethammer D, Gratwohl A. Indications for stem cell transplantation. In: Apperley J, Gluckman E, Gratwohl A, editors. Blood and Marrow Transplantation. The EBMT Handbook; 1998. p. 59-70.

2. Gluckman E. Sources of haematopoietic stem cells for allogeneic transplantation. In: Apperley J, Gluckman E, Gratwohl A, editors. Blood and Marrow Transplantation.

The EBMT Handbook; 1998. p. 59-70.

3. Bearman SI. The syndrome of hepatic VOD after marrow transplantation. Blood 1995;85:3005-3020.

4. Storb R, Deeg J. Methotrexate and cyclosporine compared with cyclosporine alone for prophylaxis of acute graft versus host disease after BMT for leukemia. N Engl J Med 1986;314:729-735.

5. Kojima S, Horibe K, Inaba J, Yoshimi A, Takahashi Y, Kudo K et al. Long-term outcome of acquired aplastic anaemia in children: comparison between immunosuppressive therapy and bone marrow transplantation.

Brit J Haem 2000;111:321-328.

6. Gorin NC. Stem cell transplantation in acute leukemia.

Annals N York Acad Sciences 1995;770:262-287.

7. Camani NR. Autotransplants for neuroblastoma. Bone Marrow Transplant 1996;17:301-304.

8. Peristeri J, Kitra V, Goussetis E, Petropoulos D, Theodosaki M, Kattamis A et al. Haematopoietic stem cell transplantation for the management of haemoglobinopathies in Greek patients. Transf Science 2000;23:263-264.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù¤ÏÈÔ˜ °Ú·Ê¿ÎÔ˜ MÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, 115 27, ∞ı‹Ó·

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∞πª∞∆O§O°π∞ - O°∫O§O°π∞

Paediatriki 2001;64:280-284

HEMATOLOGY - ONCOLOGY

ªÂÙÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· ª. ∫·ÏÌ·ÓÙ‹

Training in Pediatric Hematology - Oncology M. Kalmanti MD

¶ÂÚ›ÏË„Ë: ∞ӷχÔÓÙ·È Ù· ÎÚ·ÙÔ‡ÓÙ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ÂÎ·›‰Â˘ÛË ÛÙËÓ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ¶ÚÔÙ›ÓÔÓÙ·È ÙÚfiÔÈ, ¯ÒÚÔÈ Î·È ·ÓÙÈΛÌÂÓ· ÂÎ·›‰Â˘Û˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ıˆÚÂ›Ù·È ÔÏÔÎÏËڈ̤ÓË ˘ÔÂȉÈÎfiÙËÙ· Î·È ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ.

Abstract: The recent data regarding training requirements in the subspecialty of Pediatric Hematology - Oncology are analyzed. The criteria for training programs, hospital settings and fields of training are suggested in order for it to succeed in becoming an accepted subspecialty in Greece.

§¤ÍÂȘ ÎÏÂȉȿ: ˘ÔÂȉÈÎfiÙËÙ·, ·È‰È·ÙÚÈ΋ ·ÈÌ·ÙÔÏÔÁ›· - ÔÁÎÔÏÔÁ›·.

Key words: subspecialty, pediatric hematology oncology.

πÛÙÔÚÈ΋ ·Ó·‰ÚÔÌ‹ ™·Ó ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜, Ë ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· Â›Ó·È ÙfiÛÔ ·ÏÈ¿ fiÛÔ Î·È Ë ¤Ú¢ӷ ÛÙËÓ ¶·È‰È·ÙÚÈ΋.

OÈ ‚·ÛÈΤ˜ ·Ú¯¤˜ Ù˘ Â›Ó·È fiÌÔȘ Ì ·˘Ù¤˜ Ù˘ ¶·ıÔÏÔÁ›·˜ - ∞ÈÌ·ÙÔÏÔÁ›·˜ Î·È ÔÈ ÚÒÙ˜ ÛËÌ·ÓÙÈΤ˜ ÂÚÁ·Û›Â˜ Î·È ·Ú·ÙËÚ‹ÛÂȘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔÓ ÙÔ̤· ÙˆÓ µ·ÛÈÎÒÓ ∂ÈÛÙËÌÒÓ. ∂›Ó·È ··Ú·›ÙËÙÔ Ó· ·Ó·Ê¤ÚÔ˘Ì ÔÓfiÌ·Ù· Ô˘ Û˘Ó¤ÙÂÈÓ·Ó ÛÙËÓ ·Ó¿Ù˘ÍË ·˘ÙÔ‡ ÙÔ˘ ‰›Ô˘, fiˆ˜ ÙˆÓ Ehrlich, Metchnikoff, Landsteiner, Chauffard, Downey, Minot, Castle, Whipple, Wintrobe, Jaksch, Lederer, Cooley, Blackfan, Fanconi (1). ™ËÌ·ÓÙÈÎfi ÛÙ·ıÌfi ÛÙËÓ ·Ó·Î¿Ï˘„Ë ‰È·ÊÔÚÒÓ ÌÂٷ͇ ·ÈÌ·ÙÔÏÔÁ›·˜ ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ ·ÔÙ¤ÏÂÛÂ Ë ÌÂϤÙË Ù˘ ÂÈÎfiÓ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙÔÓ Hayem ÙÔ 1889, Ë ·Ú·Ù‹ÚËÛË ÙÔ 1909 ·fi ÙÔÓ Flesh fiÙÈ ÔÈ ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ·Ó¿ÏÔÁ· Ì ÙȘ ËÏÈ˘ ÙˆÓ ·È‰ÈÒÓ, Â›Ó·È ÙfiÛÔ ÛËÌ·ÓÙÈΤ˜ Ô˘ ηÓ›˜ ‰ÂÓ Â›Ó·È Û ı¤ÛË Ó· ‰ÒÛÂÈ ÔÚÈÛÙÈο Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜, Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ù· ÓÂÔÁÓ¿ ÂÌÊ·Ó›˙Ô˘Ó ·ÚÔ‰È΋

ÂÚ˘ıÚÔ‚Ï¿ÛÙˆÛË ·fi ÙÔÓ Lippman ÙÔ 1924 Î·È ·ÚÎÂÙ¿ ·ÚÁfiÙÂÚ· Ë ÂÚÈÁÚ·Ê‹ Ù˘ ¿ÁÓˆÛÙ˘ ̤¯ÚÈ ÙfiÙ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ÙÔ 1944, ·fi ÙÔÓ Halbrech (2). ∆· ÚÒÙ· ¿ÚıÚ· Ô˘ ·Ó·Ê¤ÚıËÎ·Ó Û ÛËÌ·ÓÙÈΤ˜ ÎÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·ÙËÚ‹ÛÂȘ ÁÈ· Ê˘ÛÈÔÏÔÁÈΤ˜ ‹ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙ· ·È‰È¿, ‰ËÌÔÛȇÙËÎ·Ó ÙÔ 1925 ÛÙÔ American Journal of Diseases of Children, ÛÙÔ ÔÔ›Ô ·Ó·Ê¤ÚıËΠfiÙÈ Ë ·‡ÍËÛË ÙˆÓ ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Â›Ó·È ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi ‡ÚËÌ· ÛÙÔ ·›Ì· ÙˆÓ ÓÂÔÁÓÒÓ, ÂÓÒ ÙÔÓ ›‰ÈÔ ¯ÚfiÓÔ ÛÙËÓ πÙ·Ï›· Î·È 3 ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÛÙË °ÂÚÌ·Ó›·, ‰ËÌÔÛȇÙËÎ·Ó ·Ú·ÙËÚ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙÔÓ fiÁÎÔ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÂÚ˘ıÚÒÓ ÛÂ Ê˘ÛÈÔÏÔÁÈΤ˜ Î·È ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÛÙ· ·È‰È¿ (3-5). ∏ Û˘Ì‚ÔÏ‹ ÙÔ˘ Thomas B. Cooley ·fi ÙÔ Detroit, Ô˘ ¯ÒÚÈÛ ÙËÓ ÔÓÙfiÙËÙ· “ı·Ï·ÛÛ·ÈÌ›·” ·fi ÙËÓ ·Ú¯È΋ Ù˘ ÂÚÈÁÚ·Ê‹ Û·Ó ÂÚ˘ıÚÔ‚Ï·ÛÙÈ΋ ·Ó·ÈÌ›·, ÛËÌ·ÙÔ‰fiÙËÛ ÙË ÌÂϤÙË ÙˆÓ ·ÈÌÔÛÊ·ÈÚÈÓÔ·ıÂÈÒÓ, ·Ó Î·È Ê˘ÛÈο ÙfiÙ ‰ÂÓ ‹Ù·Ó ÁÓˆÛÙfi fiÙÈ Ë ÙÂÏÈ΋ ‰È·Ù·Ú·¯‹ ÂÛÙÈ·˙fiÙ·Ó ÛÙËÓ

¢È¢ı‡ÓÙÚÈ· ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ Î·È MÔÓ¿‰·˜ ªÂÙ·ÌÔÛ¯Â˘Û˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, ∫Ú‹ÙË

Head of the Department of Pediatric Hematology-Oncology and the Division of Bone Marrow Transplantation University Hospital of Heraklion, Crete

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·ÈÌÔÛÊ·ÈÚ›ÓË. ¶·Ú’ fiÏ· ·˘Ù¿, ‹Ù·Ó ·˘Ùfi˜ Ô˘ ÚÒÙÔ˜ Û˘Ó¤Ï·‚ ÙËÓ È‰¤· fiÙÈ ·˘Ù¤˜ ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÌÔÔ›ËÛ˘ ‹Ù·Ó ÁÂÓÂÙÈο ηıÔÚÈṲ̂Ó˜ (6-7). ™Ù· ÌÂÙ¤ÂÈÙ· ¯ÚfiÓÈ·, ¿Ú¯ÈÛ ӷ ·Ó·Ù‡ÛÛÂÙ·È Ë ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· ÛÙËÓ ∂˘ÚÒË, Ì ÚˆÙÔfiÚÔ˘˜ ÙÔÓ Guido Fanconi, ÙÔÓ Conrad Gasser, ÙÔÓ Zuelzer, ÙÔÓ Kostmann, ÙÔÓ Clanzmann Î·È Ì ÙÔ˘˜ ÚˆÙÔfiÚÔ˘˜ ·fi ÙËÓ ∞ÌÂÚÈ΋ ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Ù˘ µÔÛÙÒÓ˘ Blackfan Î·È Diamond. OÈ ÙÂÏÂ˘Ù·›ÔÈ ¤ıÂÛ·Ó ÙË ‚¿ÛË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ∞ÌÂÚÈ΋. ∞˘ÙÔ› ÔÈ ‰‡Ô Âͤ‰ˆÛ·Ó ÙÔÓ ÚÒÙÔ ¿ÙÏ·ÓÙ· ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ÓfiÛˆÓ ÛÙ· ·È‰È¿ ÙÔ 1944 (8-10). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁ›·, Ë ÚˆÙÔÔÚ›· ·Ú¯›˙ÂÈ Ì ‰È¿ÛËÌÔ˘˜ ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˘˜ ÂΛӢ Ù˘ ÂÔ¯‹˜, fiˆ˜ Ô Wardrop Ô˘ ¤Î·Ó ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÚÂÙÈÓÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ÙÔ 1809, ÙÔ 1814 Ô Rance Ì ÂÚÈÁÚ·Ê‹ fiÁÎˆÓ ÓÂÊÚÒÓ, Î·È fiÁÎˆÓ ÎÔÈÏ›·˜ ÙÔ 1814 ·fi ÙÔÓ Gairdner. ∆Ô 1828 ·fi ÙÔÓ Hodgkin, Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÙˆÓ 7 ÚÒÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÔÌÒÓ˘Ì˘ ÓfiÛÔ˘ Î·È ÙÔ 1832 Ô Jessop ÂÚÈÁÚ¿ÊÂÈ ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÓÂÊÚÂÎÙÔÌ‹ Û ·È‰›. ¶ÂÚ·ÈÙ¤Úˆ ÛÙ·ıÌÔ‡˜ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁ›· ·ÔÙ¤ÏÂÛ·Ó Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ 7 ÂÚÈÙÒÛÂˆÓ ÓÂÊÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁfi Wilms ÙÔ 1877, Ë ÚÒÙË Ï‹„Ë ÊˆÙÔÁÚ·Ê›·˜ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ ÙÔ 1864 ·fi ÙÔÓ Damon, Ë ÚÒÙË ÂȯÔÚ‹ÁËÛË ¤Ú¢ӷ˜ ÛÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· ÛÙÔÓ Farber ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ Ù˘ µÔÛÙÒÓ˘ ÁÈ· ÙȘ ÌÂϤÙ˜ ÙÔ˘ ÛÙË ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÙÂÚ›Ó˘ ÙÔ 1947, Î·È Ë ÚÒÙË Û˘ÁÎÚfiÙËÛË Û ÔÌ¿‰· ÌÂϤÙ˘ Î·È ıÂÚ·›·˜ ÔÏÏÒÓ Î¤ÓÙÚˆÓ ÛÙËÓ ∞ÌÂÚÈ΋ ÙÔ 1952 (Children’s Cancer study group), ÛÙÔ ÔÔ›Ô ¿Ú¯ÈÛ·Ó Ó· ÌÂÏÂÙÒÓÙ·È 200-250 ·È‰È¿ ÙÔ ¯ÚfiÓÔ Ì ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ηÎÔ‹ıÂÈ·˜. ™ÙËÓ ∂ÏÏ¿‰·, ÔÈ ÚÒÙÔÈ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ı¤Ì·Ù· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ ‹Ù·Ó ÔÈ Î.Î ∫. ÈڤÌ˘, §. ∑¿ÓÓÔ˘ Î·È Ã. ∫·ÙÙ¿Ì˘ Ì ÛËÌ·ÓÙÈΤ˜ ÌÂϤÙ˜ ÛÙȘ ÂÓ˙˘ÌÔ¿ıÂȘ, ·ÈÌÔÏ˘ÙÈÎfi ›ÎÙÂÚÔ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ. µ·ÛÈο ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· ™‡Ìʈӷ Ì ÙȘ ‰ÈÂıÓ›˜ ÛÙ·ÙÈÛÙÈΤ˜ Ô˘ ÈÛ¯‡Ô˘Ó Î·È ÁÈ· ÙË ¯ÒÚ· Ì·˜, ÙÔ 1972 Ô Î·ÚΛÓÔ˜ ÛÙ· ·È‰È¿ ›¯Â Â›ÙˆÛË 12 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿, ÂÓÒ ÙÔ 1990 14 ·Ó¿ 100.000 ·È‰È¿. ªÂ ÙË ÛËÌÂÚÈÓ‹ ÂÈÙ˘¯Ë̤ÓË ıÂÚ·›·, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ÁÓÒÛË ªÔÚȷ΋˜ µÈÔÏÔÁ›·˜ Î·È ·Ó¿Ù˘ÍË ÔÏÏ·ÏÒÓ ÂȉÈÎÔÙ‹ÙˆÓ Î·ıÒ˜ Î·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ÚfiÁÓˆÛË Ô˘ ¤¯Ô˘Ó Ù· ·È‰È¿

Paediatriki 2001;64:280-284

·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ, Ù· ‰ÈÂıÓ‹ ÛÙ·ÙÈÛÙÈο ‰Â‰Ô̤ӷ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ 65% Û˘ÓÔÏÈο ÙˆÓ ·È‰ÈÒÓ Ì ηÚΛÓÔ ıÂÚ·‡ÂÙ·È Ï‹Úˆ˜, ÙÔ 90% ‚ÂÏÙÈÒÓÂÙ·È, ÂÓÒ ¤Ó·˜ ÛÙÔ˘˜ 900 ÂÓ‹ÏÈΘ ÛÙȘ ∏¶∞ ËÏÈΛ·˜ 18-44 ÂÙÒÓ ¤¯ÂÈ ÂÈ‚ÈÒÛÂÈ ·fi οÔÈ· ÌÔÚÊ‹ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ Î·È ˙ÂÈ Ì›· Ê˘ÛÈÔÏÔÁÈ΋ ÂÈÙ˘¯‹ ˙ˆ‹ (11). ™ÙȘ ηÏÔ‹ıÂȘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ ÛÙ· ·È‰È¿, ‰ËÏ·‰‹ ÛÙÔÓ ÎÏ¿‰Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) ÔÈ Û˘ÁÁÂÓ›˜ Î·È Â›ÎÙËÙ˜ ‰È·Ù·Ú·¯¤˜ (ÂÚ˘ıÚÒÓ, ‹Í˘), ‚) ÔÈ ·Ï·ÛÙÈΤ˜ ·Ó·È̛˜, Ô˘‰ÂÙÂÚÔÂӛ˜, ÔÈÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ Î·È Á) ÔÈ ıÚÔÌ‚ÔÂӛ˜ (·ÈÌÔÚÚÔÊÈÏ›·, ıÚÔÌ‚ˆÙÈΤ˜ ‰È·Ù·Ú·¯¤˜). ™ÙÔȯ›· ÁÈ· ÙËÓ ˘ÔÂȉÈÎfiÙËÙ· (∏.¶.∞., ∂˘ÚÒË) §fiÁˆ Ù˘ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓ˘ ÁÓÒÛ˘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›·, ¤ÁÈÓ ۷ʋ˜ Ë ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ ÂÎ·›‰Â˘Û˘ ÛÙÔÓ ÎÏ¿‰Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜. ∏ ÚÒÙË ¯ÒÚ· Ô˘ ÙÔ Âȯ›ÚËÛ ‹Ù·Ó Ë ∞ÌÂÚÈ΋ Ì 3 ¯ÚfiÓÈ· ÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È 3 ¯ÚfiÓÈ· ÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. ∞ÎÔÏÔ‡ıËÛÂ Ë ∂˘ÚÒË, ¯ˆÚ›˜ Â›ÛËÌÔ Ù›ÙÏÔ ÂȉÈÎfiÙËÙ·˜ fiˆ˜ ÔÈ ∏¶∞, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ù˘ ÔÔ›·˜ ÚÔÙ›ÓÔÓÙ·È 5 ¯ÚfiÓÈ· ¶·È‰È·ÙÚÈ΋˜ Î·È 3 ¯ÚfiÓÈ· ÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· – OÁÎÔÏÔÁ›·. ™ÙËÓ ∂ÏÏ¿‰·, ·ÎfiÌË ‰ÂÓ Â›Ó·È Î·ıÔÚÈṲ̂ÓÔ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÛÙÔ ÔÔ›Ô ÌÔÚ› Ó· ıˆÚËı› ¤Ó·˜ ÁÂÓÈÎfi˜ ¶·È‰›·ÙÚÔ˜ ÈηÓfi˜ Ó· ÂÍ·Û΋ÛÂÈ ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ·ÊÔ‡ Ë ÂȉÈÎfiÙËÙ· ÛÙË °ÂÓÈ΋ ¶·È‰È·ÙÚÈ΋ ·ÎfiÌË Â›Ó·È 4 ¯ÚfiÓÈ·. ªÂ ·˘Ùfi ÙÔ ‰Â‰Ô̤ÓÔ, Ù· ÙÚ›· ÂÈϤÔÓ ¯ÚfiÓÈ· ˘ÔÂȉÈÎfiÙËÙ·˜ ıˆÚÔ‡ÓÙ·È ¿ÎÚˆ˜ ··Ú·›ÙËÙ·. ™‡Ìʈӷ Ì ÙËÓ American Society of Pediatric Hematology-Oncology (ASPHO), ÛÙȘ ∏¶∞ ·˘Ù‹ ÙË ÛÙÈÁÌ‹ ˘¿Ú¯Ô˘Ó 65 ΤÓÙÚ· Ô˘ ¯ÔÚËÁÔ‡Ó ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ÂÓÒ ÛÙÔÓ ∫·Ó·‰¿ ÌfiÓÔÓ 6. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· Ù˘ ·Ú·¿Óˆ ÂÙ·ÈÚ›·˜, ·fi ÙÔ 1974-1998 ηٷÁÚ¿ÊËÎ·Ó 1.348 ¶·È‰›·ÙÚÔÈ ∞ÈÌ·ÙÔÏfiÁÔÈ - OÁÎÔÏfiÁÔÈ ÛÙȘ ∏¶∞, 1.1001.200 ÂÍ·ÛÎÔ‡Ó ÙËÓ ˘ÔÂȉÈÎfiÙËÙ·, ÂÓÒ 50-60 ·Ô¯ˆÚÔ‡Ó Î¿ı ¯ÚfiÓÔ. ªÂ ‚¿ÛË ·˘Ù¿, Ë ·Ó¿ÁÎË ÁÈ· Ó¤Ô˘˜ ¶·È‰È¿ÙÚÔ˘˜ ∞ÈÌ·ÙÔÏfiÁÔ˘˜ - √ÁÎÔÏfiÁÔ˘˜ ÙÔÔıÂÙÂ›Ù·È Û 80-100 ÂÙËÛ›ˆ˜ (12). ™‡Ìʈӷ Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· Ù˘ ∞ÌÂÚÈ΋˜, Ù· ··Ú·›ÙËÙ· ÛÙÔȯ›· Ô˘ Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ¤Ó· ∫¤ÓÙÚÔ ÁÈ· Ó· ÂÎ·È‰Â‡ÂÈ ¶·È‰È¿ÙÚÔ˘˜ ∞ÈÌ·ÙÔÏfiÁÔ˘˜ - OÁÎÔÏfiÁÔ˘˜ ›ӷÈ: ·) ÂÎ·È‰Â˘Ì¤Ó˜ ÓÔÛËχÙÚȘ, ‚) ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ·È‰ÈÒÓ, Á) ¶·È‰Ô·ÎÙÈÓԉȷÁÓˆÛÙÈ΋ ÌÔÓ¿‰·, ‰) ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ÌÔÓ¿‰·/ÎÏÈÓÈ΋, Â) ¯ÂÈÚÔ˘ÚÁÔ‡˜ Ì ÂÌÂÈÚ›· ÛÙË Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈ΋,

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¶·È‰È·ÙÚÈ΋ 2001;64:280-284

Ô˘ÚÔÏÔÁ›·, ÔÚıÔ‰È΋ ·›‰ˆÓ, ÛÙ) „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË, ˙) ÂÚÁ·ÛÙ‹ÚÈ· ∞ÈÌ·ÙÔÏÔÁÈο-∫˘ÙÙ·ÚÔÏÔÁÈο, Ë) ÂÚÁ·ÛÙ‹ÚÈ· ÎÏÈÓÈ΋˜ ¯ËÌ›·˜ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÂÈ¤‰ˆÓ Ê·Ú̿ΈÓ, ı) ÙÚ¿Â˙· ·›Ì·ÙÔ˜, È) Ê·ÚÌ·ÎÂ›Ô (ÁÈ· ·Ú·Û΢‹ Î·È ‰È¿ıÂÛË ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ), È·) ‰˘Ó·ÙfiÙËÙ· ·ÔÌfiÓˆÛ˘ ·ÛıÂÓÒÓ ·fi ÌÈÎÚfi‚È· Ô˘ ÙÔ˘˜ ÌÔχÓÔ˘Ó ‰È· ÙÔ˘ ·¤ÚÔ˜, È‚) OÁÎÔÏÔÁÈÎfi ¶·È‰È·ÙÚÈÎfi Û˘Ì‚Ô‡ÏÈÔ Û ٷÎÙ¿ ‰È·ÛÙ‹Ì·Ù·, ÈÁ) Û˘ÌÌÂÙÔ¯‹ Û ÎÔÈÓ¿ ÚˆÙfiÎÔÏÏ· ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (15). ™ÙÔȯ›· ÁÈ· ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜ ·fi ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ ™ÙËÓ ∂ÏÏ¿‰· ÏÂÈÙÔ˘ÚÁÔ‡Ó Ù· ηو٤ڈ ÙÌ‹Ì·Ù·: ™ÙËÓ ∞ı‹Ó·: ∞) ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1 ∫ÏÈÓÈ΋ (¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁÈ΋/OÁÎÔÏÔÁÈ΋) (∂™À), 1 ªÔÓ¿‰· (∞ÈÌ·ÙÔÏÔÁÈ΋/OÁÎÔÏÔÁÈ΋, ¶·ÓÂÈÛÙËÌȷ΋), 2 ªÔÓ¿‰Â˜ ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ (Ì›· ∂™À, Ì›· ¶·ÓÂÈÛÙËÌȷ΋), 1 ªÔÓ¿‰· ∞ÈÌÔÚÚ·ÁÈÎÒÓ ¢È·ı¤ÛÂˆÓ (∂™À), 1 ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ (∂™À). µ) ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡”, Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1 ¶·È‰È·ÙÚÈ΋ OÁÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ (∂™À) ™ÙË £ÂÛÛ·ÏÔÓ›ÎË: ∞) 1 ∫ÏÈÓÈ΋ ∂™À (OÁÎÔÏÔÁÈ΋) πÔÎÚ¿ÙÂÈÔ, µ) 1 ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ (¶·ÓÂÈÛÙËÌȷ΋) πÔÎÚ¿ÙÂÈÔ, °) 1 ªÔÓ¿‰· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜/OÁÎÔÏÔÁ›·˜ (¶·ÓÂÈÛÙËÌȷ΋) ∞Ã∂¶∞, ¢) 1 ªÔÓ¿‰· ªªO ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ ∂™À, °. ¶··ÓÈÎÔÏ¿Ô˘. ™ÙËÓ ∫Ú‹ÙË: ∞) 1 ∫ÏÈÓÈ΋ (¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁÈ΋/√ÁÎÔÏÔÁÈ΋ Î·È ªªO) (¶·ÓÂÈÛÙËÌȷ΋). ªÂ ‚¿ÛË Ù· ÛÙÔȯ›· ·fi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁÈ΋˜/OÁÎÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜, ÛÙËÓ ∂ÏÏ¿‰· οı ¯ÚfiÓÔ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È 150 ÂÚÈÙÒÛÂȘ Û˘Ì·ÁÒÓ fiÁÎˆÓ Î·È 100 Ï¢¯·ÈÌ›·˜, Ô˘ ÓÔÛËχÔÓÙ·È Î·Ù¿ 95% ÛÙ· ·Ú·¿Óˆ ÙÌ‹Ì·Ù· ÌÂ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÎÏÈÓÒÓ ÁÈ· ÙËÓ ∞ı‹Ó· 65 Î·È 6 ÁÈ· ÙË ªªO, ÁÈ· ÙË £ÂÛÛ·ÏÔÓ›ÎË 40 Î·È 2 ÁÈ· ÙË ªªO Î·È ÁÈ· ÙËÓ ∫Ú‹ÙË 20 Î·È 2 ÁÈ· ÙË ªªO, ¯ˆÚ›˜ ‚¤‚·È· Ó· ˘¿Ú¯ÂÈ ·ÎfiÌË Â›ÛËÌË ÛÙ·ÙÈÛÙÈ΋. ™Ù· ·Ú·¿Óˆ ˘¿Ú¯ÔÓÙ· ∆Ì‹Ì·Ù· ÙÔ˘ ∂ÏÏËÓÈÎÔ‡ ¯ÒÚÔ˘, ¿‰ÂÈ· ¯ÔÚ‹ÁËÛ˘ ÂȉÈÎfiÙËÙ·˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ ¤¯ÂÈ ‰Ôı› Û ÙÚ›·, ·fi Ù· ÔÔ›· Û ‰‡Ô Ï‹Ú˘ (3,5 ¯ÚfiÓÈ·) Î·È Û ¤Ó· ÌÂÚÈ΋ (1,5 ¯ÚfiÓÔ˜).

OÈ ÁÈ·ÙÚÔ› Ô˘ ·ÛÎÔ‡Ó ÙËÓ ÂȉÈÎfiÙËÙ· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ¶·È‰›·ÙÚÔÈ, ¶·È‰›·ÙÚÔÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ (∂ÏÏ¿‰·, ∂˘ÚÒË, ∏.¶.∞.) Î·È ∞ÈÌ·ÙÔÏfiÁÔÈ (Ì Âȉ›Î¢ÛË Û ¶·È‰È·ÙÚÈο ∞ÈÌ·ÙÔÏÔÁÈο - OÁÎÔÏÔÁÈο ∫¤ÓÙÚ·). ∏ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ -

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OÁÎÔÏÔÁ›·˜ ȉڇıËΠÙÔ 1986 Î·È ·ÚÈıÌ› ÂÚ› Ù· 70 ÂÚ›Ô˘ ̤ÏË. ∞˘Ù¿, ·Ó¿ ÂȉÈÎfiÙËÙ˜, ›ӷÈ: 44 ¶·È‰›·ÙÚÔÈ, 6 ∞ÈÌ·ÙÔÏfiÁÔÈ, 7 ¶·È‰›·ÙÚÔÈ Ì ¿‰ÂÈ· ·Û΋Ûˆ˜ Â·ÁÁ¤ÏÌ·ÙÔ˜ ÛÙȘ ∏¶∞ Î·È 13 ÂÈÛÙ‹ÌÔÓ˜ ¿ÏÏˆÓ ÂȉÈÎÔًوÓ. ∂Î·›‰Â˘ÛË ∞·Ú·›ÙËÙ· ÎÚÈÙ‹ÚÈ· ÁÈ· ÂÎ·›‰Â˘ÛË Â›Ó·È Ë ¿ÚÈÛÙË ÁÓÒÛË Ù˘ ∫ÏÈÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ (ÂÏ¿¯ÈÛÙÔ 3 ¯ÚfiÓÈ·), ÂÓÒ ÁÈ· ÁÈ·ÙÚÔ‡˜ Ì ÂȉÈÎfiÙËÙ· ∞ÈÌ·ÙÔÏÔÁ›·˜, Ë ÂÎ·›‰Â˘ÛË Ù˘ ˘Ô¯ÚˆÙÈ΋˜ ‰ÈÂÙ›·˜ Û ¶·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· ‹ ÙÌ‹Ì·Ù· Ô˘ ‰È·ı¤ÙÔ˘Ó ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ÂÎ·›‰Â˘Û˘, ÛÙfi¯Ô˜ Â›Ó·È Ë ·fiÎÙËÛË ÂÌÂÈÚ›·˜ ÛÙËÓ ∫ÏÈÓÈ΋ Î·È Ù· Â͈ÙÂÚÈο È·ÙÚ›·, Ë ÁÓÒÛË ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, ·ÈÌfiÛÙ·Û˘ Î·È ‹Í˘ ·Ú¿ÏÏËÏ· Ì ÙË ÁÓÒÛË ÂȉËÌÈÔÏÔÁ›·˜/·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÓÔÛËÌ¿ÙˆÓ ·›Ì·ÙÔ˜ (ηÏÔ‹ıˆÓ Î·È Î·ÎÔ‹ıˆÓ ·fi ÙË ÓÂÔÁÓÈ΋ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 10 ¯ÚfiÓˆÓ) ηıÒ˜ Î·È Î·ÎÔ‹ıˆÓ fiÁΈÓ. π‰È·›ÙÂÚË ‚·Ú‡ÙËÙ· ·ÔÎÙ¿ Î·È Ë ÂÎ·›‰Â˘ÛË ÛÙËÓ ÎÏÈÓÈ΋ ¤Ú¢ӷ (·Ó¿Ï˘ÛË ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ, ÂȉËÌÈÔÏÔÁ›·, ÚˆÙfiÎÔÏÏ·), ηıÒ˜ Î·È ÛÙ· ÂÚÁ·ÛÙ‹ÚÈ· (·ÈÌ·ÙÔÏÔÁÈÎfi, ·ÓÔÛÔÏÔÁÈÎfi, ‹Í˘, ·ÈÌÔ‰ÔÛ›·˜, ÈÛÙÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi, ΢ÙÙ·ÚÔÁÂÓÂÙÈÎfi). °È· Ó· ıˆÚËı› ¤Ó· ÙÌ‹Ì· ηٿÏÏËÏÔ Ó· ÂÎ·È‰Â‡ÂÈ ¶·È‰È¿ÙÚÔ˘˜ ÛÙËÓ ∞ÈÌ·ÙÔÏÔÁ›·, ı· Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ÔÌ¿‰· ·ÙfiÌˆÓ ·Û¯ÔÏÔ‡ÌÂÓˆÓ Ì ÙÔ ·ÓÙÈΛÌÂÓÔ, Ó· ¤¯ÂÈ Û˘ÓÂÚÁ·Û›· Ì ÂıÓÈÎÔ‡˜ Î·È ‰ÈÂıÓ›˜ ÔÚÁ·ÓÈÛÌÔ‡˜, Ó· ÌÔÚ› Ó· ÂÈÙÂÏ› ÛˆÛÙ‹ ηٷÁÚ·Ê‹ Î·È Ó· ¤¯ÂÈ Û˘ÌÌÂÙÔ¯‹ Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Î·È ÚˆÙfiÎÔÏÏ· (13). ™Ù· Ï·›ÛÈ· Ù˘ ··Ú·›ÙËÙ˘ ÂÎ·›‰Â˘Û˘ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) Ë ·˘Ù¿ÚÎÂÈ· ÛÙË ‰È¿ÁÓˆÛË Î·ÏÔ‹ıˆÓ Î·È Î·ÎÔ‹ıˆÓ ÓÔÛËÌ¿ÙˆÓ ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, Ì˘ÂÏfi, ÔÛÙÂÔÌ˘ÂÏÈ΋ ‚ÈÔ„›·, ‚ÈÔÏÔÁÈο ˘ÁÚ¿, ‚) Ë ·˘Ù¿ÚÎÂÈ· ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ıÂÚ·¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Î·È ‰˘Ó·ÙfiÙËÙ· ÂÈÎÔÈÓˆÓ›·˜ Ì ¿ÏÏ· ΤÓÙÚ· (ÂÛˆÙÂÚÈÎÔ‡ Î·È ‰ÈÂıÓ‹), Á) Ë ·˘Ù¿ÚÎÂÈ· ÛÙÔÓ Ï‹ÚË ÚÔÁÚ·ÌÌ·ÙÈÛÌfi ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ηÏfiËı˜ ‹ ηÎfiËı˜ ÓfiÛËÌ· (14). ∂Èı˘ÌËÙ‹ ÂÎ·›‰Â˘ÛË, ÙËÓ ÔÔ›· ‰‡Ó·ÓÙ·È Ó· ·Ú¤¯Ô˘Ó ÌÂÚÈο ΤÓÙÚ·, Â›Ó·È Ë ÁÓÒÛË ÂÎÙ¤ÏÂÛ˘ ·ÏÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ·ÈÌÔ‰ÔÛ›·˜, ‹Í˘ Î·È ÂÚÁ·ÛÙËÚȷ΋˜ ·ÈÌ·ÙÔÏÔÁ›·˜ (ÂÎ·›‰Â˘ÛË Î˘ÎÏÔÙÂÚÒ˜ ÛÙ· ·ÓÙ›ÛÙÔȯ· ÂÚÁ·ÛÙ‹ÚÈ·), Ë ·‰Ú‹ ÁÓÒÛË ÂÎÙ›ÌËÛ˘ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ (CAT SCAN, NMR, ™ÈÓıËÚÔÁÚ·Ê‹Ì·Ù·), ‚·ÛÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È ÂÚÌËÓ›·˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ë ·‰Ú‹ ÁÓÒÛË Î˘ÙÙ·Ú·Ê·›ÚÂÛ˘, Ï·ÛÌ·Ê·›ÚÂÛ˘, ·ÈÌÔÂÙ·ÏÈÔ·Ê·›ÚÂÛ˘.

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ŒÓ· ÚÔÙÂÈÓfiÌÂÓÔ Û¯‹Ì· ÁÈ· 3ÂÙ‹ ÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›·/OÁÎÔÏÔÁ›· ÂÚÈÏ·Ì‚¿ÓÂÈ: I) ∫ÏÈÓÈ΋ ∂Î·›‰Â˘ÛË: 21 Ì‹Ó˜, II) ¢È·Ù·Ú·¯¤˜ ‹Í˘-·ÈÌfiÛÙ·Û˘: 3 Ì‹Ó˜, III) ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘: 3 Ì‹Ó˜, IV) ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜: 3 Ì‹Ó˜, V) ∂ÚÁ·ÛÙËÚȷ΋ ∞ÈÌ·ÙÔÏÔÁ›·: 3 Ì‹Ó˜, VI) ∞ÈÌÔ‰ÔÛ›·: 3 Ì‹Ó˜. ŸÛÔÓ ·ÊÔÚ¿ Ù· ·Ú·¿Óˆ, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÛÙÔ˘˜ 21 Ì‹Ó˜ ÂÎ·›‰Â˘Û˘ ÛÙËÓ ∫ÏÈÓÈ΋ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÂÚÈÛÙ·ÙÈο Ô˘ ·ÊÔÚÔ‡Ó fiϘ ÙȘ ÂÈ̤ÚÔ˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Î·È ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ Î·È ¤¯Ô˘Ó ηıÔÚÈÛÙ› Û ÙÚ›ÌËÓË ÂÎ·›‰Â˘ÛË, ‰ËÏ. ‰È·Ù·Ú·¯¤˜ ‹Í˘ - ·ÈÌfiÛÙ·Û˘, ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ, ¿ÚÚˆÛÙÔÈ Î·È ·È‰È¿ Ì ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ηÙÔ¯˘Úˆı› Ë ÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜, Â›Ó·È ··Ú·›ÙËÙÔ Ó· ·˘ÍËı› Ô ·ÚÈıÌfi˜ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ¤¯Ô˘Ó ÂÎ·›‰Â˘ÛË ÛÙÔ ·ÓÙÈΛÌÂÓÔ. ∂ÈϤÔÓ, ÙÔ Ì¿ıËÌ· ÛÙ· ¶·ÓÂÈÛÙ‹ÌÈ· Ú¤ÂÈ Ó· Á›ÓÂÈ ·˘ÙÔÙÂϤ˜, Ú¤ÂÈ Ó· ÂÎÔÓÔ‡ÓÙ·È ‰È‰·ÎÙÔÚÈΤ˜ ‰È·ÙÚÈ‚¤˜ Ì ı¤Ì·Ù· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ OÁÎÔÏÔÁ›·˜, Ó· Á›ÓÔÓÙ·È ‰ËÌÔÛȇÛÂȘ Û ‰ÈÂıÓ‹ ÂÚÈÔ‰Èο Ì ۇÛÙËÌ· ÎÚÈÙÒÓ,ηıÒ˜ Î·È Ó· ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÛÙȘ ‰ÈÂıÓ›˜ ÔÚÁ·ÓÒÛÂȘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜ (International Society of Pediatric Oncology [SIOP], American Society of Pediatric Hematology/Oncology [ASPHO], European Society of Pediatric Hematology & Immunology [ESPHI], European Group for Blood & Marrow Transplantation [EBMT]). ∆· ∫¤ÓÙÚ· Ô˘ ıˆÚÔ‡ÓÙ·È Î·Ù¿ÏÏËÏ· ÁÈ· ¯ÔÚ‹ÁËÛË ÂȉÈÎfiÙËÙ·˜ Ú¤ÂÈ Ó· Â›Ó·È ¶·ÓÂÈÛÙËÌȷΤ˜ ∫ÏÈÓÈΤ˜ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ OÁÎÔÏÔÁ›·˜ ·˘ÙÔÙÂÏ›˜ ‹ ¶·È‰È·ÙÚÈΤ˜ Ì ·ÓÙ›ÛÙÔȯ˜ ÌÔÓ¿‰Â˜, ∫ÏÈÓÈΤ˜ ÙÔ˘ ∂™À Ì ¶·È‰È·ÙÚÈΤ˜ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ - OÁÎÔÏÔÁÈΤ˜ ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜, ∫ÏÈÓÈΤ˜ ‹ ªÔÓ¿‰Â˜ Ì ÁÈ·ÙÚÔ‡˜ Ô˘ ‰È·ı¤ÙÔ˘Ó Â›ÛËÌ· ·ԉ‰ÂÈÁ̤ÓË ÂÎ·›‰Â˘ÛË Û ·Ó·ÁÓˆÚÈṲ̂ӷ ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ (ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 ¯ÚfiÓÈ·) ‹ Û ΤÓÙÚ· Ù˘ ∂ÏÏ¿‰·˜ (ÙÔ˘Ï¿¯ÈÛÙÔÓ 6 ¯ÚfiÓÈ·). ™Ù· ∫¤ÓÙÚ· ÂÎ·›‰Â˘Û˘ ÛÙËÓ ∂ÏÏ¿‰·, ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ ηıÔÚ›˙ÔÓÙ·È ÁÈ·: ∞) ∞ÈÌ·ÙÔÏÔÁÈο - OÁÎÔÏÔÁÈο ∆Ì‹Ì·Ù·, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÎÏÈÓÒÓ (15), ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù’ ¤ÙÔ˜ (20 ·ÛıÂÓ›˜), ÙÔÓ ·ÚÈıÌfi ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ Î·Ù’ ¤ÙÔ˜ (100 ·ÛıÂÓ›˜), ÙˆÓ ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (500 ·ÛıÂÓ›˜), Î·È ˆ˜ ÚÔ˜ ÙÔ ÚÔÛˆÈÎfi (¶·È‰›·ÙÚÔÈ ∞ÈÌ·ÙÔÏfiÁÔÈ-OÁÎÔÏfiÁÔÈ, ¤ÌÂÈÚ˜ ÓÔÛËχÙÚȘ, „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË).

Paediatriki 2001;64:280-284

µ) ªÔÓ¿‰Â˜ ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi ÎÏÈÓÒÓ (10), ÙÔÓ ·ÚÈıÌfi ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ ·È‰ÈÒÓ (100), ÙË Û˘ÓÂÚÁ·Û›·/Û‡Ó‰ÂÛË ÌÔÓ¿‰·˜ Ì ÂȉÈο ÙÌ‹Ì·Ù· (ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi, ηډÈÔÏÔÁÈÎfi Î.Ï.), Î·È ˆ˜ ÚÔ˜ ÙË Û˘ÓÂÚÁ·Û›· Ì ÂÚÁ·ÛÙ‹ÚÈÔ fiÔ˘ ı· Á›ÓÂÙ·È ‰È¿ÁÓˆÛË Î·È ¤ÏÂÁ¯Ô˜ ·ÈÌÔÛÊ·ÈÚÈÓÔ·ıÂÈÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ Î·È ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜. °) ªÔÓ¿‰Â˜ ∞ÈÌfiÛÙ·Û˘-∞ÈÌÔÚÚÔÊÈÏ›·˜, ˆ˜ ÚÔ˜ ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù’ ¤ÙÔ˜ (50), ÙÔÓ ·ÚÈıÌfi ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (1000 ·ÛıÂÓ›˜), ˆ˜ ÚÔ˜ ÙÔ ÚÔÛˆÈÎfi (3 ¶·È‰›·ÙÚÔÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ, ‚ÈÔÏfiÁÔÈ ‹ ‚ÈÔ¯ËÌÈÎÔ›, Ê˘ÛÈÔıÂÚ·Â˘Ù¤˜, ÎÔÈÓˆÓÈ΋ ÏÂÈÙÔ˘ÚÁfi˜, „˘¯ÔÏfiÁÔ˜), Î·È ˆ˜ ÚÔ˜ ÙË Û˘ÓÂÚÁ·Û›·Û‡Ó‰ÂÛË Ì ÔÚıÔ‰ÈÎfi Î·È Ô‰ÔÓÙÈ·ÙÚÈÎfi ÙÌ‹Ì· Î·È ÂÚÁ·ÛÙ‹ÚÈÔ ÛÙÔ ÔÔ›Ô ÂÈÙÂÏÂ›Ù·È Ï‹Ú˘ ¤ÏÂÁ¯Ô˜ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜, ıÚÔÌ‚ÔÊÈÏ›·˜, Â›ÎÙËÙˆÓ ·Ó·ÛÙ·ÏÙÒÓ Î·È ÚÔÁÂÓÂÙÈ΋˜ ‰È¿ÁÓˆÛ˘ ·ÈÌÔÚÚÔÊÈÏ›·˜. ¢) °È· ÙȘ ªÔÓ¿‰Â˜ ªÂÙ·ÌfiÛ¯Â˘Û˘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ, ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Î·È Î˘ÙÙ¿ÚˆÓ ·›Ì·ÙÔ˜ ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘) ηıÔÚ›˙ÂÙ·È Ô ·ÚÈıÌfi˜ ÎÏÈÓÒÓ (2-4), Ô ·ÚÈıÌfi˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÂÙËÛ›ˆ˜ (15, ÂÎ ÙˆÓ ÔÔ›ˆÓ 5 ·ÏÏÔÁÂÓÂÙÈΤ˜), Ô ·ÚÈıÌfi˜ ÂÍÂÙ·˙fiÌÂÓˆÓ ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ηْ ¤ÙÔ˜ (150 ·ÛıÂÓ›˜), ÙÔ ÚÔÛˆÈÎfi (3 ÂÍÂȉÈÎÂ˘Ì¤ÓÔÈ ¶·È‰›·ÙÚÔÈ ‹ ∞ÈÌ·ÙÔÏfiÁÔÈ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· OÁÎÔÏÔÁ›·, ‚ÈÔÏfiÁÔ˜, ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÓÔÛËχÙÚȘ, „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË) ηıÒ˜ Î·È ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÂÂÍÂÚÁ·Û›·˜ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™Â ·˘Ùfi ÂÈÙÂÏÂ›Ù·È ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË Î·Ù¿„˘ÍË/ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÂÂÍÂÚÁ·Û›· Î·È Î¿ı·ÚÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ, ¤ÏÂÁ¯Ô˜ ¯ÈÌ·ÈÚÈ΋˜ ηٿÛÙ·Û˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ Î·È Î·ÏÏȤÚÁÂȘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ªÂ ‚¿ÛË ÙȘ ·ÓˆÙ¤Úˆ ÚÔÙ¿ÛÂȘ Î·È Ì ÙË Û˘Ì‚ÔÏ‹, ÂÎÙfi˜ ·fi ÙËÓ ∂Ù·ÈÚ›· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜ - OÁÎÔÏÔÁ›·˜, Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ·ÏÏ¿ Î·È fiÏˆÓ ÙˆÓ ¶·ÓÂÈÛÙËÌ›ˆÓ Ù˘ ¯ÒÚ·˜, Â›Ó·È ÂÊÈÎÙ‹ Ë ¿ÚÈÛÙË ÂÎ·›‰Â˘ÛË - ÌÂÙÂÎ·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Flesch H, quoted by Baar H, Stransky E. Die Klinische Hamatologie des Kindesalters; Leipzig: Franz Deuticke; 1928.

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13. ∫·ÏÌ·ÓÙ‹ ª. ∂Î·›‰Â˘ÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋. ∂ÈÛ‹ÁËÛË ÛÙÔ ECTS Erasmus Program. 1997.

14. Voute PA. Personal communication; 17/3/2000.

15. American Board of Pediatrics. Program Requirements for Residency Education in Pediatric Hematology/Oncology, Accreditation Council for Graduate Medical Education 2000 (ACGME). www.Abp.org.

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¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂ÈÏÔÁ¤˜ ıÂÚ·›·˜ ÁÈ· ÂÍ·ÈÚÂÙÈο ÚfiˆÚ· ÓÂÔÁÓ¿: Ì›· ‰ÈÂıÓ‹˜ ÚÔÔÙÈ΋1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· Á›ÓÂÈ Û‡ÁÎÚÈÛË ÙˆÓ ÂÈÏÔÁÒÓ ıÂÚ·›·˜ ·fi ÓÂÔÁÓÔÏfiÁÔ˘˜ Î·È ÓÔÛËχÙÚȘ 11 ∂˘Úˆ·˚ÎÒÓ ¯ˆÚÒÓ, Û ̛· ˘ÔıÂÙÈ΋ ÂÚ›ÙˆÛË ÂÍ·ÈÚÂÙÈο ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (∏∫=24 ‚‰ÔÌ¿‰ˆÓ, µ°=560 ÁÚ. Î·È Ì Apgar score 1 ÛÙÔ 1’). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŒÓ· ·ÓÒÓ˘ÌÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û˘ÌÏËÚÒıËΠ·fi 1401 È·ÙÚÔ‡˜ Î·È 3425 ÓÔÛËχÙÚȘ (ÔÛÔÛÙfi ·¿ÓÙËÛ˘ 89% Î·È 86% ·ÓÙ›ÛÙÔȯ·) Û ¤Ó· ÌÂÁ¿ÏÔ ·ÓÙÈÚÔÛˆ¢ÙÈÎfi ‰Â›ÁÌ· 143 Â˘Úˆ·˚ÎÒÓ ÌÔÓ¿‰ˆÓ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ. ™ÙË ÌÂϤÙË ·˘Ù‹ ¤Ï·‚ ̤ÚÔ˜ Ë πÙ·Ï›·, Ë πÛ·Ó›·, Ë °·ÏÏ›·, Ë °ÂÚÌ·Ó›·, Ë OÏÏ·Ó‰›·, ÙÔ §Ô˘ÍÂÌ‚Ô‡ÚÁÔ, Ë ªÂÁ¿ÏË µÚÂÙ·Ó›·, Ë ™Ô˘Ë‰›·, Ë O˘ÁÁ·Ú›·, Ë ∂ÛıÔÓ›· Î·È Ë §ÈıÔ˘·Ó›·. ∞ÔÙÂϤÛÌ·Ù·: ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ È·ÙÚÒÓ Î¿ı ¯ÒÚ·˜, ÂÎÙfi˜ Ù˘ OÏÏ·Ó‰›·˜, ı· ÚÔ¯ˆÚÔ‡Û Û ·Ó¿ÓË„Ë ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ı· ¿Ú¯È˙ ÂÓÙ·ÙÈ΋ ıÂÚ·›·. ™Â ÂÚ›ÙˆÛË Âȉ›ӈÛ˘ Ù˘ ÎÏÈÓÈ΋˜ ÙÔ˘˜ ÂÈÎfiÓ·˜ ·fi ‚·ÚÈ¿ ÂÓ‰ÔÎÔÈÏȷ΋ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, Ë ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ‰È·Ê¤ÚÂÈ. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÓÂÔÁÓÔÏfiÁÔÈ ÛÙË °ÂÚÌ·Ó›·, πÙ·Ï›·, ∂ÛıÔÓ›· Î·È O˘ÁÁ·Ú›· ı· Û˘Ó¤¯È˙·Ó ÙË ıÂÚ·›·, ÂÓÒ ÛÙȘ ¿ÏϘ ¯ÒÚ˜ οÔÈÔ˘ Ù‡Ô˘ ÂÚÈÔÚÈÛÌÔ‡ Ù˘ ıÂÚ·›·˜ ı· ‹Ù·Ó Ë ÚÔÙÂÈÓfiÌÂÓË ÂÈÏÔÁ‹. ∏ ÂÈı˘Ì›· ÙˆÓ ÁÔÓÈÒÓ Ê·›ÓÂÙ·È fiÙÈ ·›˙ÂÈ Î¿ÔÈÔ ÚfiÏÔ ÛÙË ªÂÁ¿ÏË µÚÂ-

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Ù·Ó›· Î·È ÙËÓ OÏÏ·Ó‰›·. OÈ ÓÔÛËχÙÚȘ, ÂÓÒ ‚Ú›ÛÎÂÙ·È ÙÔ ÓÂÔÁÓfi ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡, ÚÔÙÈÌÔ‡Ó Ó· ¿ÚÔ˘Ó ÙËÓ ÁÓÒÌË ÙˆÓ ÁÔÓÈÒÓ ÁÈ· ÙȘ ÂÚ·ÈÙ¤Úˆ ÂÈÏÔÁ¤˜ ıÂÚ·›·˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ŒÓ· ÂÍ·ÈÚÂÙÈο ÚfiˆÚÔ ÓÂÔÁÓfi ıˆÚÂ›Ù·È ‚ÈÒÛÈÌÔ ·fi ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÁÈ·ÙÚÒÓ, ÂÓÒ ÌÂÙ¿ ·fi οÔÈ· Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ηٿÛÙ·Û˘, Ë ·fiÊ·ÛË ÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ∆· ÛÙÔȯ›· ·˘Ù¿ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÛËÌ·Û›· ÁÈ· Ù· ËıÈο ‰ÈÏ‹ÌÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Î·Ù¿ ÙË ıÂÚ·›· ÓÂÔÁÓÒÓ Ô˘ Â›Ó·È ÔÚȷο ‚ÈÒÛÈÌ· Î·È ÁÈ· ÙËÓ ÂÚÌËÓ›· Î·È ÙË Û‡ÁÎÚÈÛË ÙˆÓ ‰ÈÂıÓÒÓ ÛÙ·ÙÈÛÙÈÎÒÓ.

1de Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al.

Treatment choices for extremely preterm infants: an international perspective J Pediatr 2000;137:608-615

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∞πª∞∆O§O°π∞ - O°∫O§O°π∞

Paediatriki 2001;64:285-289

HEMATOLOGY - ONCOLOGY

™‡Á¯ÚÔÓË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜. µ·ÛÈΤ˜ ·Ú¯¤˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· µ. ∞. §·‰‹˜

Modern treatment of thalassaemia. Principles and effectiveness V. A. Ladis

¶ÂÚ›ÏË„Ë: O ÎÏÈÓÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ Ù˘ ªÂÛÔÁÂȷ΋˜ ·Ó·ÈÌ›·˜ (ª∞) Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ‚·ıÌfi Ù˘ ·ÓÂ¿ÚÎÂÈ·˜ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ÔÏ˘ÂÙȉÈÎÒÓ ·Ï˘Û›‰ˆÓ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ï‹ÚË ·‰˘Ó·Ì›· (‚0) ‹ ÙË ÛÔ‚·Ú‹ ·ÓÂ¿ÚÎÂÈ· (‚+) ·Ú·ÁˆÁ‹˜ ‚-·Ï˘Û›‰ˆÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ªÂ›˙ÔÓ· ‚-ª∞, ÂÓÒ ·˘Ù¤˜ Ô˘ Ô‰ËÁÔ‡Ó Û ̤ÙÚÈ· (‚++) ‹ ÂÏ·ÊÚ¿ ·ÓÂ¿ÚÎÂÈ· (‚+++), Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂӉȿÌÂÛË ÌÔÚÊ‹ Ù˘ ‚-ª∞. ŒÙÛÈ Û‹ÌÂÚ·, ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÔÚÈÛÙ› Ë Î·Ù¿ÏÏËÏË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹, Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË, ıˆÚÂ›Ù·È ··Ú·›ÙËÙÔ˜ Î·È Ô ÁÔÓÔÙ˘ÈÎfi˜ ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘. §·Óı·Ṳ̂ÓË ÂÈÏÔÁ‹ Î·È Î˘Ú›ˆ˜ ·‰˘Ó·Ì›· Û˘ÌÌfiÚʈÛ˘ ÚÔ˜ ÙËÓ ÂÓ‰ÂÈÎÓ˘fiÌÂÓË ıÂÚ·›·, ÂȉÂÈÓÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË, Ì ·ÚÈÔ ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÙËÓ ·ÈÌÔÛȉ‹ÚˆÛË. To ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 25 ÂÙÒÓ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ì ÂÏ·ÊÚÔ‡ ‚·ıÌÔ‡ ·ÈÌÔÛȉ‹ÚˆÛË (n: 53, ÊÂÚÚÈÙ›ÓË <2000 Ìg/L) ˘ÂÚ‚·›ÓÂÈ ÙÔ 98%, Ì ̤ÙÚÈ· ·ÔÛȉ‹ÚˆÛË (n: 60, ÊÂÚÚÈÙ›ÓË 20004000 Ìg/L) ÂÚ›Ô˘ 94%, ÂÓÒ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ì ‚·ÚÈ¿ ·ÈÌÔÛȉ‹ÚˆÛË (n: 29, >4000 Ìg/L) ÌÂÈÒÓÂÙ·È ÛÙÔ 69%. °È· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·Û¯fiÓÙˆÓ (n: 594), ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 92% ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ, 72% ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 30 ÂÙÒÓ, ÂÓÒ ÙÔ 68,5% ˘ÂÚ‚·›ÓÂÈ ÙËÓ ËÏÈΛ· ÙˆÓ 40 ÂÙÒÓ. ∏ ÔÚÁ·ÓˆÌ¤ÓË ·Ú·ÎÔÏÔ‡ıËÛË Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÔÛȉ‹ÚˆÛË ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÂÊ·ÚÌfiÛÙËΠÌÂÙ¿ ÙÔ 1975, ‚ÂÏÙÈÒÓÂÈ ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ (93%) Û ۯ¤ÛË Ì ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ù˘ ›‰È·˜ ËÏÈΛ·˜ (24 ÂÙÒÓ) Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ·fi ÙÔ 1975 (81%). ∏ ·‡ÍËÛË Ù˘ ̤Û˘ ËÏÈΛ·˜ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·Ó¿ ‰ÂηÂÙ›·,

Abstract: The clinical severity of thalassaemia syndromes is closely related to the degree of suppression of globin chain synthesis, which is depended on the type of ‚ gene mutation. As a rule, mutations leading to total (‚0) or severe suppression (‚+) of ‚-chain production are related to ‚-thalassaemia major, while those with moderate (‚++) or mild (‚+++) suppression are related to ‚-thalassaemia intermedia. Thus, precise molecular characterization on diagnosis predicts the prognosis and determines the early application of transfusions in patients with thalassaemia major, or the restriction of unnecessary transfusions in thalassaemia intermedia. Failure in therapeutic options or poor compliance with conventional treatment, worsen the morbidity and reduce the survival due to iron toxicity. In a series of selected patients aged 21-25 yrs, we found that the expected survival by the age of 25 years was related to compliance of chelation.

Specifically, the expected survival of well-chelated patients (n: 53, ferritin <2000 Ìg/L) was over 98%, in moderately chelated patients (n: 60, ferritin 2000-4000 Ìg/L) 94%, and only 69% in nonchelated patients (n: 29, ferritin >4000 Ìg/L). The overall survival for a cohort of 594 patients was estimated to be 92% up to the age of 20 years, 72% up to the age of 30 while 68.5% of the patients live over the age of 40 yrs. Close followup and intensive chelation of patients followed in our clinic since 1975 improved survival to 93% as compared to a survival of 81% of patients of the same age (24 years old) born before 1975 and not closely followed. The effectiveness of modern conventional treatment is demonstrated by the

ªÔÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

Division of Mediterranean Anemia A’ Pediatric Clinic of University of Athens “Agia Sophia” Children’s Hospital, Athens

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Paediatriki 2001;64:285-289

·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Û‡Á¯ÚÔÓ˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ (1980: 7,6 ÂÙÒÓ, 1990: 15 ÂÙÒÓ, 2000: 23 ÂÙÒÓ), Ë ‰Â Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ, ·fi 100 ÂÚ›Ô˘ ÙÔ 1980, Û 15 ÙÔ 1990 Î·È Û ÏÈÁfiÙÂÚ· ·fi 5 ÙÔ 2000, ·Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ÂÈÙ˘¯›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚfiÏ˄˘. ªÂٷ͇ ÙˆÓ ÓÂfiÙÂÚˆÓ ıÂÚ·¢ÙÈÎÒÓ ÚÔÛÂÁÁ›ÛˆÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¤¯ÂÈ ·Ô‰ÒÛÂÈ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ÂÓÒ Ë ¯Ú‹ÛË Ó¤ˆÓ ¯ËÏÈÎÒÓ Ô˘ÛÈÒÓ ·fi ÙÔ ÛÙfiÌ· Î·È Ê·ÚÌ¿ÎˆÓ Ô˘ ÚÔ¿ÁÔ˘Ó ÙË ‚ÈÔÛ‡ÓıÂÛË ÙˆÓ Á-·Ï˘Û›‰ˆÓ, ·Ó·Ì¤ÓÂÙ·È Ó· ‚ÂÏÙÈÒÛo˘Ó ÙËÓ ÂÈ‚›ˆÛË Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·Û¯fiÓÙˆÓ.

increase of the mean age of our patient cohort at ten year intervals (1980: mean age 7.6 y., 1990: mean age 15 y., 2000: mean age 23y.), while the progressive reduction of new cases demonstrates the effectiveness of the prevention programs. The number of patients below 5 yrs was nearly 100 in 1980, 15 in 1990 and less than 5 in 2000. Among the new therapeutic approaches, transplantation of hematopoietic cells has given positive results, while the use of new oral chelators and substances inducing Á-chain synthesis are expected to improve the survival and quality of life.

§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ıÂÚ·›·, ÚfiÏË„Ë, ÂÈ‚›ˆÛË.

Key words: thalassaemia, treatment, prevention, survival.

∆· Û‡Ó‰ÚÔÌ· Ù˘ ª∞ Î·È ÁÂÓÈÎfiÙÂÚ· ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ Û‡ÓıÂÛ˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ÔÌ¿‰· ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙËÓ ∂ÏÏ¿‰·. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÏ˘ÂÙȉÈ΋ ·Ï˘Û›‰· ÛÙË ‰ÔÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ù˘ ÔÔ›·˜ Ë Û‡ÓıÂÛË ÂËÚ¿˙ÂÙ·È, Ù· Û‡Ó‰ÚÔÌ· Ù˘ ª∞ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È Û ·, ‚, Á, ‰ ÌÔÚʤ˜ ‹ Î·È Û˘Ó‰˘·ÛÌÔ‡˜ ·˘ÙÒÓ. ∞fi fiϘ ·˘Ù¤˜, ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ ¤¯Ô˘Ó ÔÈ ·, ‚ Î·È ‰‚ ÌÔÚʤ˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ë ‚-ª∞ ·ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ Î·È ÈÔ ‚·ÚÈ¿ ÌÔÚÊ‹ ÛÙË ¯ÒÚ· Ì·˜, fiˆ˜ Î·È ÛÙȘ ˘fiÏÔÈ˜ ªÂÛÔÁÂȷΤ˜ ¯ÒÚ˜ (1,2). ∏ ÎÏÈÓÈ΋ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ÂÎÊÚ¿˙ÂÙ·È Ì ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ·, Ë ÔÔ›· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙË ÌÔÚȷ΋ ‚Ï¿‚Ë Ô˘ ÚÔηÏ› ÙË ‰È·Ù·Ú·¯‹. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚ›Ô˘ 200 ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ÎÒ‰Èη Ô˘ ·ÊÔÚÔ‡Ó ÙË Û‡ÓıÂÛË ÙˆÓ ‚-·Ï˘Û›‰ˆÓ. ∞Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi ·Ó·ÛÙÔÏ‹˜ Ù˘ Û‡ÓıÂÛ˘ Ô˘ ÚÔηÏÔ‡Ó Î·È ¿Ú· ÙËÓ ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ Â·ÚÎÔ‡˜ ÔÛfiÙËÙ·˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ∞, Ê·›ÓÂÙ·È ˆ˜ ‰È·ÌÔÚÊÒÓÂÙ·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· (3). ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ï‹ÚË ·‰˘Ó·Ì›· (‚Ô) ‹ ÙË ÛËÌ·ÓÙÈ΋ ·Ó·ÛÙÔÏ‹ (‚+) Ù˘ ·Ú·ÁˆÁ‹˜ ÙˆÓ ‚·Ï˘Û›‰ˆÓ, Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÁÓˆÛÙ‹ Ì·˜ ÎÏ·ÛÈ΋ ªÂ›˙ÔÓ· ª∞, ÂÓÒ ÌÂÙ·ÏÏ¿ÍÂȘ Ì ÈÔ ‹È· (‚++) ‹ Ôχ ÂÏ·ÊÚ¿ (‚+++) ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ ‚·Ï˘Û›‰ˆÓ, Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÔηÏÔ‡ÌÂÓË ∂ӉȿÌÂÛË ÌÔÚÊ‹ ª∞. ™‹ÌÂÚ· ˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ ÂӉȷʤÚÔÓ ÛÙË ÌÂϤÙË Ù˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÁfiÓÔ˘ (ÁÔÓfiÙ˘Ô˘), Ì ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi Î·È ÎÏÈÓÈÎfi Ê·ÈÓfiÙ˘Ô. ∞fi ÌÂϤÙ˜ Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÁÈ· ÙÔ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ÌÔÚȷ΋˜ ‰È·Ù·Ú·¯‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Ì ªÂ›˙ÔÓ· ηÈ

∂ӉȿÌÂÛË ‚-ª∞, ÂÓÙÔ›ÛÙËÎ·Ó ¿Óˆ ·fi 25 ÌÂÙ·ÏÏ¿ÍÂȘ Ù˘ ‰ÔÌ‹˜ ÙˆÓ ‚-·Ï˘Û›‰ˆÓ, Ô˘ ›¯·Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂΉ‹ÏˆÛË ‚·Ú¤Ô˜, ‹ ‹ÈÔ˘ ÎÏÈÓÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·Ú‡ ÎÏÈÓÈÎfi Ê·ÈÓfiÙ˘Ô Ì›˙ÔÓÔ˜ ª∞, ÔÈ Û˘¯ÓfiÙÂÚ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ·ÊÔÚÔ‡Û·Ó ÙÔ˘˜ Ù‡Ô˘˜ codon 39 (17%), IVS1-1 (13%) Î·È Ì ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÙÔÓ Ù‡Ô IVS1-110 (45,5%). OÈ ÌÂÙ·ÏÏ¿ÍÂȘ ·˘Ù¤˜ Ô‰ËÁÔ‡Ó Û ‚Ô ‹ ‚+ ÌÔÚʤ˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂӉȿÌÂÛË ÌÔÚÊ‹ ª∞, ÔÈ Û˘¯ÓfiÙÂÚ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ·ÊÔÚÔ‡Û·Ó ÙÔ˘˜ Ù‡Ô˘˜ IVS1-6, -87 Î·È -101 Ô˘ Ô‰ËÁÔ‡Ó Û ‚++ ‹ ‚+++ ÌÔÚʤ˜ (4,5) (¶›Ó·Î·˜ 1). ∞Ó Î·È Ë ÌÔÚÊ‹ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘ ÛÙÔÓ ‚ÁfiÓÔ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÎÏÈÓÈ΋˜ ‚·Ú‡ÙËÙ·˜, ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÎÏÈÓÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘. µÂÏÙ›ˆÛË .¯. Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ·ıÔÏÔÁÈÎfi˜ ÁfiÓÔ˜ ·-ª∞ ‹ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ Á-ÁfiÓÔ˘ Ô˘ ÂÓÂÚÁÔÔÈ› ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ÂÌ‚Ú˘˚΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ÂÓÒ Âȉ›ӈÛË ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ÙÚÈÏ·ÛÈ·Ṳ̂ÓÔ˜ ·ıÔÏÔÁÈÎfi˜ ·-ÁfiÓÔ˜ (6,7). ∏ ÛÙÂÓ‹ ·˘Ù‹ Û˘Û¯¤ÙÈÛË ÁÔÓfiÙ˘Ô˘-Ê·ÈÓfiÙ˘Ô˘ ÂÓÈÛ¯‡ÂÈ ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÙÔ˘ ¯·Ú·ÎÙËÚÈÛÌÔ‡ Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘, Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ

286

¶›Ó·Î·˜ 1. ∞‰Ú‹ Û˘Û¯¤ÙÈÛË ÎÏÈÓÈÎÔ‡ Î·È ·ÈÌ·ÙÔÏÔÁÈÎÔ‡ Ê·ÈÓfiÙ˘Ô˘ Ì ÁÔÓfiÙ˘Ô ·ÛıÂÓÒÓ Ì ‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· º·ÈÓfiÙ˘Ô˜ π. ª∂π∑ø¡ ª.∞. ππ. ∂¡¢π∞ª∂™∏ ª.∞.

1. µ·Ú‡˜ Ù‡Ô˜ ( ‚++) 1. µ·Ú‡˜ Ù‡Ô˜ ( ‚Ô ) 2. ◊ÈÔ˜ Ù‡Ô˜ ( ‚+++) 2. ◊ÈÔ˜ Ù‡Ô˜ ( ‚+ ) °ÔÓfiÙ˘Ô˜ cd-39, IVSI-1, IVSI-110 IVSI-6, -87, -101

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·287

¶·È‰È·ÙÚÈ΋ 2001;64:285-289

·ÈÌ·ÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË, Ì ÛÙfi¯Ô ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÚfiÁÓˆÛ˘, ÙÔ Û¯Â‰È·ÛÌfi Ù˘ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Î·È ÙË ‰È·ÌfiÚʈÛË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Î·È ÁÂÓÂÙÈ΋˜ ηıÔ‰‹ÁËÛ˘ (8).

Paediatriki 2001;64:285-289

£ÂÚ·¢ÙÈΤ˜ ·Ú¯¤˜ ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË Ì¿˜ ÂÈÙÚ¤ÂÈ ÙËÓ ¤ÁηÈÚË Î·È ¯ˆÚ›˜ ÂÈ‚Ï·‚›˜ ηı˘ÛÙÂÚ‹ÛÂȘ ¤Ó·ÚÍË ıÂÚ·›·˜ Ì ÌÂÙ·ÁÁ›ÛÂȘ, fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ªÂ›˙ÔÓ· ÌÔÚÊ‹, ‹ ÙËÓ ·ÔÊ˘Á‹ ¿ÛÎÔˆÓ ÌÂÙ·ÁÁ›ÛˆÓ, fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ∂ӉȿÌÂÛË ÌÔÚÊ‹. ∏ ÁÓÒÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ - ‹ ÌË - ·Ú·ÁˆÁ‹˜ Â·ÚÎÔ‡˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ∞, ·ÔÙÂÏ› Û‹ÌÂÚ· ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÁÁ›ÛˆÓ.

OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ Î·È Ë ÂÓÙ·ÙÈ΋ ·ÔÛȉ‹ÚˆÛË ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÎÚÔÁˆÓÈ·›Ô˘˜ Ï›ıÔ˘˜ Ù˘ Û˘Ì‚·ÙÈ΋˜ ıÂÚ·›·˜ Ù˘ ª∞ (9). Œ¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ Ë ª∞ ÌÔÚ› Ó· ıˆÚËı› È¿ÛÈÌË ÓfiÛÔ˜, Ì ÙËÓ ÚÔ¸fiıÂÛË ÂÍ·ÛÊ¿ÏÈÛ˘ Â·ÚÎÒÓ Î·È ·ÛÊ·ÏÒÓ ÌÂÙ·ÁÁ›ÛÂˆÓ Î·È ÙË ‰È· ‚›Ô˘, ÌÂ Û˘Ó¤ÂÈ·, Ï‹ÚË Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· ÂÓÙ·ÙÈ΋˜ ·ÔÛȉ‹ÚˆÛ˘. ŸÌˆ˜, ÛËÌ·ÓÙÈο Ú·ÎÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Â›Ù Ì ÙË ‰È·‰Èηۛ· ÙˆÓ ÌÂÙ·ÁÁ›ÛˆÓ, ›Ù Ì ÙËÓ ·‰˘Ó·Ì›· Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·Û¯fiÓÙˆÓ ÛÙË ıÂÚ·›· ·ÔÛȉ‹ÚˆÛ˘, ηıÔÚ›˙Ô˘Ó ÙËÓ Ú·ÁÌ·ÙÈ΋ ηٿÛÙ·ÛË, fiˆ˜ ·˘Ù‹ ‰È·ÌÔÚÊÒÓÂÙ·È Ì ÙËÓ ·ÔÙ‡ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ÙÂÏÈο ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘.

92%, ÛÙËÓ ËÏÈΛ· ÙˆÓ 30 ÂÙÒÓ ¤ÊÙÂÈ ÛÙÔ 72%, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ¤ÊÙÂÈ Ì Ôχ ÌÈÎÚfiÙÂÚÔ Ú˘ıÌfi, ̤¯ÚÈ 68,4% ÁÈ· ÙȘ ËÏÈ˘ ÌÂÙ¿ Ù· 40 ¯ÚfiÓÈ· (™¯‹Ì· 2). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ÎÏÈÓÈ΋ Ì·˜ ·Ú·Ù‹ÚËÛË, fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ı¿Ó·ÙÔÈ Û˘Ì‚·›ÓÔ˘Ó Û ̛· ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô ÌÂٷ͇ ÙˆÓ ËÏÈÎÈÒÓ ÙˆÓ 20 Î·È 30 ÂÙÒÓ, Ô˘ ·Ú·ÙËÚÂ›Ù·È Î·È Ë ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· (10). ∏ ÂÈÛ·ÁˆÁ‹ Ù˘ ¢ÂÛÊÂÚÈÔÍ·Ì›Ó˘ ÁÈ· ÙË ıÂÚ·›· ·ÔÛȉ‹ÚˆÛ˘ ÙÔÔıÂÙÂ›Ù·È ¯ÚÔÓÈο ÛÙËÓ ·Ú¯‹ Ù˘ 10ÂÙ›·˜ ÙÔ˘ ’70, ÂÓÒ Ú·ÎÙÈο ÛÙË ¯ÒÚ· Ì·˜ ÁÂÓÈ·ÂÙ·È ÙÔ 1975 Ì ÙËÓ ÔÚÁ¿ÓˆÛË Î·È ÏÂÈÙÔ˘ÚÁ›· ÂȉÈÎÒÓ ÌÔÓ¿‰ˆÓ ·Ú·ÎÔÏÔ‡ıËÛ˘ ·Û¯fiÓÙˆÓ Ì ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ (11). ªÂ ÎÚÈÙ‹ÚÈÔ ÙËÓ ÂÈ‚›ˆÛË, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ıÂÚ·›·˜ ¿Ú¯ÈÛ·Ó Ó· Ê·›ÓÔÓÙ·È 25 ¯ÚfiÓÈ· ÌÂÙ¿. ∆Ô ÚÔÛ‰fiÎÈÌÔ Ù˘ ÂÈ‚›ˆÛ˘ ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1975 Î·È ‹Ù·Ó οو ·fi ÙËÓ Â›‰Ú·ÛË Ù˘ ÓÂfiÙÂÚ˘ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, Û˘ÁÎÚ›ÓÂÙ·È Ì ÙËÓ ÂÈ‚›ˆÛË Ù˘ ÔÌ¿‰·˜ ·ÙfiÌˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ·fi ÙÔ 1975 Î·È ¿Ú· ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ›¯·Ó ˘ÔÛÙ› ÙȘ ‚Ï·ÙÈΤ˜ ÂȉڿÛÂȘ Ù˘ ˘ÔÍ›·˜ Î·È Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ûȉ‹ÚÔ˘ (™¯‹Ì· 3). ∏ ηÌ‡ÏË ÂÈ‚›ˆÛ˘ ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚÈÓ ÙÔ ’75 Â›Ó·È ¯ÂÈÚfiÙÂÚË Û˘ÁÎÚÈÙÈο Ì ÙË Û˘ÓÔÏÈ΋ ηÌ‡ÏË (64,7% ¤Ó·ÓÙÈ 68,4%), fiˆ˜ Â›Û˘ Î·È ·fi ÙËÓ Î·Ì‡ÏË Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·Û¯fiÓÙˆÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1975 (81% ¤Ó·ÓÙÈ 93%) , ËÏÈΛ·˜ Û‹ÌÂÚ· 24-25 ÂÙÒÓ.

∞ÈÌÔÛȉ‹ÚˆÛË Î·È ÂÈ‚›ˆÛË ∂ÎÙfi˜ ·fi ÙÔ˘˜ ÁÓˆÛÙÔ‡˜ ‹ ¿ÁÓˆÛÙÔ˘˜ ÚÔÏ‹„ÈÌÔ˘˜ - ‹ fi¯È - ÎÈÓ‰‡ÓÔ˘˜, fiˆ˜ Ù· ·ÈÌ·ÙÔÁÂÓÒ˜ ÌÂÙ·‚È‚·˙fiÌÂÓ· ÈÔÁÂÓ‹ ÓÔÛ‹Ì·Ù·, Ô Î‡ÚÈÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¿˙ÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È Ë ·ÈÌÔÛȉ‹ÚˆÛË ÙˆÓ ÔÚÁ¿ÓˆÓ. ™Â ÙÚÂȘ ÔÌ¿‰Â˜ ·Û¯fiÓÙˆÓ Ì ª∞ (n: 142) Ù˘ ÎÏÈÓÈ΋˜ Ì·˜, ËÏÈΛ·˜ 21-25 ÂÙÒÓ, Ì ÂÏ·ÊÚ¿, ̤ÙÚÈ· Î·È ‚·ÚÈ¿ ·ÈÌÔÛȉ‹ÚˆÛË, Û˘ÁÎÚ›ıËÎÂ Ë Â›ÙˆÛË Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ûȉ‹ÚÔ˘ Û ۯ¤ÛË Ì ÙËÓ ÂÈ‚›ˆÛË. ™ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 53) Ì ̤ÛË ÙÈÌ‹ ÊÂÚÚÈÙ›Ó˘ οو ·fi 2000 ng/dl Ù· ÙÂÏÂ˘Ù·›· ¤ÓÙ ¯ÚfiÓÈ·, ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÁÈ· Ù· 25 ÙÔ˘˜ ¯ÚfiÓÈ· Â›Ó·È ¿Óˆ ·fi 98%, ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 60) Ì Â›‰· ÊÂÚÚÈÙ›Ó˘ ÌÂٷ͇ 20004000 ÂÚ›Ô˘ 94%, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο ÛÙÔ 69% ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ (n: 29) Ì ÊÂÚÚÈÙ›ÓË ¿Óˆ ·fi 4000 ng/dl (™¯‹Ì· 1). ™Â Û‡ÓÔÏÔ 594 ·Û¯fiÓÙˆÓ, ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÁÈ· ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ Êı¿ÓÂÈ ÛÙÔ

∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ıÂÚ·›·˜ Î·È ÚfiÏ˄˘ ™ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ª∞ ÛÙË ¯ÒÚ· Ì·˜, ÂÎÙfi˜ ·fi ÙËÓ Â›‰Ú·ÛË Ù˘ Û‡Á¯ÚÔÓ˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘, Û˘Ó¤‚·ÏÂ Î·È Ë ÂÈÙ˘¯›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÚfiÏ˄˘ (12). ¢ÂÓ ı· ·Ó·Ï˘ı› Ë ÌÂıÔ‰ÔÏÔÁ›· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ, Ô‡Ù ı· ÂÎÙÈÌËı› Ô ‚·ıÌfi˜ ÚÔÛ¤ÁÁÈÛ˘ ÙˆÓ ÛÙfi¯ˆÓ Ô˘ ¤¯Ô˘Ó ÙÂı› ·ÓÂÏÏ·‰Èο. £· Á›ÓÂÈ ·Ó·ÊÔÚ¿ ÛÙËÓ ÂͤÏÈÍË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ËÏÈÎÈÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ Ù˘ ÌÔÓ¿‰·˜ Ì·˜ ηٿ ÙÔ ‰È¿ÛÙËÌ· ÙˆÓ 25 ÂÙÒÓ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘, Ô˘ ·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙfiÛÔ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜, fiÛÔ Î·È ÙËÓ ÂÈÙ˘¯›· Ù˘ ÚfiÏ˄˘. ∫·Ù¿ ÙÔ ¤ÙÔ˜ 1980, Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈÒÓ 441 ·Û¯fiÓÙˆÓ Ô˘ ›¯·Ó Û˘ÁÎÂÓÙÚˆı› ·fi ÙÔ 1975 Î·È ÓÔÛËχÔÓÙ·Ó ÛÙË ÌÔÓ¿‰· Ì·˜, Ê·›ÓÂÙ·È ÛÙÔ ™¯‹Ì· 4. O ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È ËÏÈΛ·˜ ̤¯ÚÈ 10 ÂÙÒÓ, Ë Ì¤ÛË ËÏÈΛ· 7,6 ¤ÙË, ÂÓÒ Ù· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ ‹Ù·Ó ÂÚ›Ô˘ 100.

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¿Óˆ ÙˆÓ 15 ÂÙÒÓ. ¶·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ, Â›Ó·È ÏÈÁfiÙÂÚ· ·fi 5 (™¯‹Ì· 6). ¢Â‰Ô̤ÓÔ˘ fiÙÈ, ÛÙÔÓ ÂÏ¿¯ÈÛÙÔ ·ÚÈıÌfi ÙˆÓ ·Û¯fiÓÙˆÓ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÂÈÛ·ÁfiÌÂÓÔÈ ·ÛıÂÓ›˜, ΢ڛˆ˜ ÂÍ ∞Ï‚·Ó›·˜, ‡ÎÔÏ· ÌÔÚԇ̠ӷ ‰È·ÈÛÙÒÛÔ˘Ì ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÂÈÙ˘¯›·˜ Ù˘ ÚfiÏ˄˘.

™¯‹Ì· 1

™¯‹Ì· 2

™¯‹Ì· 3

∆Ô 1990, Ë Î·Ì‡ÏË Î·Ù·ÓÔÌ‹˜ ÙˆÓ ËÏÈÎÈÒÓ 554 ·Û¯fiÓÙˆÓ ÌÂÙ·ÎÈÓÂ›Ù·È ÚÔ˜ ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘, Ì ̤ÛË ËÏÈΛ· Ù· 15 ¯ÚfiÓÈ·. ¶·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, Â›Ó·È ÂÚ›Ô˘ 15 (™¯‹Ì· 5). ∆Ô ¤ÙÔ˜ 2000, Ë Ì¤ÛË ËÏÈΛ· ·˘Í¿ÓÂÈ ÛÙ· 23 ¯ÚfiÓÈ·, ÂÓÒ ÙÔ 85% ÙˆÓ 555 ·Û¯fiÓÙˆÓ Â›Ó·È ËÏÈΛ·˜

288

¡ÂfiÙÂÚ˜ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ∆ÔÓ ·Ú¯ÈÎfi ÛÙfi¯Ô Ù˘ ÔÛÔÙÈ΋˜, ˆ˜ ÚÔ˜ ÙËÓ ÂÈ‚›ˆÛË, ÂÈÙ˘¯›·˜ ·ÎÔÏÔ‡ıËÛÂ Ë ÚÔÛ¿ıÂÈ· ‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ Ù˘ ˙ˆ‹˜ Ì ÚÔÔÙÈ΋ ÙËÓ Ï‹ÚË ¤ÓÙ·ÍË ÙˆÓ ·Û¯fiÓÙˆÓ ÛÙËÓ ÎÔÈÓˆÓ›· (13). ™ËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· ÁÈ· ÙËÓ ÂÈÙ˘¯›· ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ Â›Ó·È Ë ÚfiÛÊ·ÙË Î˘ÎÏÔÊÔÚ›· ÓÂfiÙÂÚˆÓ ¯ËÏÈÎÒÓ Ô˘ÛÈÒÓ ·fi ÙÔ ÛÙfiÌ·, Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË Û˘ÌÌfiÚʈÛË ÛÙË ıÂÚ·›· ·ÔÛȉ‹ÚˆÛ˘ (14). ¶·Ú¿ÏÏËÏ· Ì ÙË ÌÂÚÈ΋ ‹ Ï‹ÚË ·ÓÙÈηٿÛÙ·ÛË Ù˘ ·ÚÂÓÙÂÚÈ΋˜ ıÂÚ·›·˜ Ì ¯¿È·, ·Ó·Ì¤ÓÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜, Ë Ì›ˆÛË Î·È ÙˆÓ ·Ó·ÁÎÒÓ ÁÈ· ÌÂÙ·ÁÁ›ÛÂȘ Ì ÙË ¯Ú‹ÛË Ê·Ú̿ΈÓ, fiˆ˜ Ë ˘‰ÚÔ͢Ԣڛ· Î·È ÔÈ ÂÓÒÛÂȘ ÙÔ˘ ‚Ô˘Ù˘ÚÈÎÔ‡ Ôͤˆ˜, Ô˘ ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ Á-·Ï˘Û›‰ˆÓ, ·˘Í¿ÓÔ˘Ó Ù· Â›‰· Ù˘ ÂÌ‚Ú˘˚΋˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÌË ·Ô‰ÔÙÈ΋ ÂÚ˘ıÚÔÔ›ËÛË (15). ¶·Ú¿ ÙË ÌÂÁ¿ÏË ÚfiÔ‰Ô Ù˘ ÁÔÓȉȷ΋˜ ıÂÚ·›·˜ Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠ӷ ÂȯÂÈÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ÚÔÔÙÈ΋ ÂÊ·ÚÌÔÁ‹˜ Ù˘ ÛÙË ª∞ Ê·›ÓÂÙ·È ·ÎfiÌ· ·ÔÌ·ÎÚ˘Ṳ̂ÓË (16). ∂ÓÙÔ‡ÙÔȘ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÂΛ Ô˘ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË, Û‹ÌÂÚ· ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÌÂ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÔÌ¿‰· ÙˆÓ ÚÒËÓ ı·Ï·ÛÛ·ÈÌÈÎÒÓ, fiˆ˜ ·ÔηÏÔ‡ÓÙ·È ‰ÈÂıÓÒ˜ (ex-thalassaemics), ÔÈ ÔÔ›ÔÈ ·Ó Î·È ‰ÂÓ ¤¯Ô˘Ó ··ÏÏ·Á› ·fi ÙÔ ÁÂÓÂÙÈÎfi ÙÔ˘˜ ÓfiÛËÌ·, ¤¯Ô˘Ó ·Ô‰ÂÛÌ¢Ù› ÙÂÏ›ˆ˜ ·fi ÙËÓ ·Ó¿ÁÎË ÙˆÓ ÌÂÙ·ÁÁ›ÛÂˆÓ (17). ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ô˘ ÚÔ·ÙÂÈ ÙÂÏÈο ·fi ÙËÓ ÚÔÛ¿ıÂÈ· ·˘Ù‹, Â›Ó·È Ë ÙÚÔÔÔ›ËÛË Ù˘ ª∞ ·fi ¤Ó· ı·Ó·ÙËÊfiÚÔ ÓfiÛËÌ· Ù˘ ÚÒÙ˘ ·È‰È΋˜ ËÏÈΛ·˜ Û ¯ÚfiÓÈÔ ÓfiÛËÌ·, Ì ÚÔ‚Ï‹Ì·Ù· ΢ڛˆ˜ ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ, ·ÏÏ¿ Î·È ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÚÔÔÙÈΤ˜ Ì·ÎÚ¿˜ ÂÈ‚›ˆÛ˘ Î·È ·Ô‰ÂÎÙ‹˜ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ (18). µÈ‚ÏÈÔÁÚ·Ê›· 1. Kattamis C, Metaxotou-Mavromati A, Wood WG, Nash JR, Weatherall DJ. The heterogeneity of normal HbA2 ‚thalassemia in Greece. Br J Haematol 1979;42:109.

2. Kattamis C, Metaxotou-Mavromati A, Ladis V, Tsiarta H, Laskari S, Kanavakis E. The clinical phenotype of ‚ and ‰‚ thalassemia in Greece. Eur J Pediatr 1982;139:135-138.

3. Baysal E, Carver MFH. The ‚- and ‰- thalassemia repository. Hemoglobin 1995;19:213-236.

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6. Ho PJ, Hall GW, Luo LY, Weatherall DJ, Thein SL. Betathalassaemia intermedia; is it possible consistently to predict phenotype from genotype? Br J Haematol 1998;100:70-78.

7. Traeger-Synodinos J, Kanavakis E, Vrettou C, Maragoudaki E, Michael T, Metaxotou-Mavromati A et al.

The triplicated a-globin gene locus in ‚-thalassemia heterozygotes: clinical, haematological, biosynthetic, and molecular studies. Br J Haematol 1996;95:467-471.

8. Kattamis C. Genotypes and clinical and hematological phenotypes of ‚ and ‰‚ thalassemias. In: Bartsokas C, Loukopoulos D, eds. Genetics of Hematological Disorders. New York: Hemisphere; 1992. p. 65-77.

9. Kattamis C, Ladis V. Conventional treatment of ‚Thalassemia syndromes. (A personal experience). Int J Pediatr Hematol Oncol 1997;4:513-522.

10. Ladis V, Berdousi H, Palamidou F, Agrafioti C, Papadopoulou A, Anagnostopoulos G et al. Morbidity and mortality of iron intoxication in adult patients with thalassemia major, and effectiveness of chelation.

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11. ∫·ÙÙ¿Ì˘ Ã, §·‰‹˜ µ, ªÂٷ͈ÙÔ‡-ª·˘ÚÔÌÌ¿ÙË ∞, ÷Ù˙ËÛ˘ÌÂÒÓ ª, ª·ÎÚ˘ÁÈ¿ÓÓ˘ ∫, ª·ÙÛ·ÓÈÒÙ˘ ¡. OÚÁ¿ÓˆÛË Î·È ÏÂÈÙÔ˘ÚÁ›· ÌÔÓ¿‰·˜ ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ Î·È ıÂÚ·›·˜ Â͈ÙÂÚÈÎÒÓ ·ÛıÂÓÒÓ Ì ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·. π·ÙÚÈ΋ ∂ÈıÂÒÚËÛË ∂ÓfiÏˆÓ ¢˘Ó¿ÌÂˆÓ 1997;11:379-383.

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16. Smith AE. Gene therapy where we go? Molecular Medicine. Lancet 1999;354:S11-S13.

17. Lucarelli G, Galiberti M, Giardini G, Polchi P, Angelucci E, Boronciani D et al. Bone Marrow Transplantation in Thalassemia. In: Cohen A, editor. Cooley’s Anemia. 7th Symposium. New York: The New York Academy of Sciences; 1998. p. 270-275.

18. Rund D, Rachmilewitz E. Thalassemia Major 1995: Older patients, new therapies. Blood Rev 1995;9:25-32.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: µ. ∞. §·‰‹˜ MoÓ¿‰· ªÂÛÔÁÂȷ΋˜ ∞Ó·ÈÌ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

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°∞™∆ƒ∂¡∆∂ƒO§O°π∞-∏¶∞∆O§O°π∞-¢π∞∆ƒOº∏

Paediatriki 2001;64:290-292

GASTROENTEROLOGY-HEPATOLOGY-NUTRITION

∂ÍÂÏ›ÍÂȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ Á·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ™. ¡Ô‡ÛÈ· - ∞Ú‚·ÓÈÙ¿ÎË

Recent developments in pediatric gastroenterology S. Nousia - Arvanitakis

¶ÂÚ›ÏË„Ë: ∏ Ú·Á‰·›· ÂͤÏÈÍË Ù˘ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜. ∏ ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË Î·ıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË Î·È Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘. ∏ ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË ÂÈÙÚ¤ÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ ¯ÂÈÚÈÛÌÒÓ, fiˆ˜ ÙËÓ ·Ê·›ÚÂÛË Í¤ÓˆÓ ÛˆÌ¿ÙˆÓ, ÙËÓ ÔÏ˘ÂÎÙÔÌ‹ Î·È ÙË ÛÎÏËÚÔıÂÚ·›·. ∏ ÌÔÚȷ΋ ‚ÈÔÏÔÁ›· Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÔÏÏÒÓ ÓfiÛˆÓ, Ô‰‹ÁËÛ Û ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, Û Ӥ˜ ıÂÚ·¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ Î·È Û ÚÔÔÙÈΤ˜ ÁÔÓȉȷ΋˜ ıÂÚ·›·˜.

Abstract: The rapid development of Pediatric Gastroenterology is due primarily to the application of endoscopy of the gastrointestinal tract in pediatric patients and the application of molecular biology. Diagnostic endoscopy allows direct observation of the upper and lower gastrointestinal tract mucosa and the performance of biopsies. Therapeutic endoscopy allows, among others, the removal of foreign bodies, polypectomy and sclerotherapy. Molecular biology has contributed to the understanding of many gastrointestinal diseases of childhood, and has led to the application of specialized diagnostic methods, new therapeutic approaches and the prospect of gene therapy.

§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË, ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË, ÌÔÚȷ΋ ‚ÈÔÏÔÁ›·.

Key words: diagnostic endoscopy, therapeutic endoscopy, molecular biology.

∏ ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ÍÂΛÓËÛ ˆ˜ ˘ÈÔıÂÙË̤ÓÔ ·È‰› Ù˘ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÙˆÓ ÂÓËϛΈÓ, ηٿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960. ¶·È‰›·ÙÚÔÈ Ì ÂӉȷʤÚÔÓ ÛÙË °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·, Ì·ıËÙ‡۷Ì Û ΤÓÙÚ· °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ÙˆÓ ÂÓËϛΈÓ. ∆Ô ¤ÙÔ˜ 1991, Ë ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ·Ó·ÁÓˆÚ›ÛÙËΠˆ˜ ˘ÔÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙȘ ∏¶∞ Î·È ıÂÛ›ÛÙËÎ·Ó ÂÍÂÙ¿ÛÂȘ ÁÈ· ÙËÓ ·fiÎÙËÛË ‰ÈÏÒÌ·ÙÔ˜. ∆Ô ¤ÙÔ˜ 1999, Ë ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ·Ó·ÁÓˆÚ›ÛÙËΠÛÙËÓ ∂˘ÚÒË. ¶ÚÈÓ ·ÎfiÌË ·Ó·ÁÓˆÚÈÛÙ› Ë ÂȉÈÎfiÙËÙ· Â›ÛËÌ·, ÂÙ·ÈÚ›˜ ·È‰È¿ÙÚˆÓ Ì ÂӉȷʤÚÔÓ ÛÙË °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ›¯·Ó È‰Ú˘ı› ÛÙȘ ∏¶∞ ÙÔ ¤ÙÔ˜ 1972, ·ÏÏ¿ Î·È ÛÙËÓ ∂˘ÚÒË, §·ÙÈÓÈ΋ ∞ÌÂÚÈ΋ Î·È ∞Û›·. ∆Ô 1999, ȉڇıËÎÂ Ë ∂ÏÏË-

ÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜.

∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ·, ¶·È‰È·ÙÚÈ΋˜-°·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢

Associate Professor of Pediatrics-Gastroenterology Aristotelion University of Thessaloniki

290

∂ÍÂÏ›ÍÂȘ ÛÙËÓ Ù¯ÓÔÏÔÁ›· ÙˆÓ ÂÓ‰ÔÛÎÔ›ˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÓ‰ÔÛÎfiËÛ˘ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤¯ÂÈ ÌÂÙ·ÌÔÚÊÒÛÂÈ ÙÔ ‰›Ô Ù˘ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜. ¶·Ï·ÈfiÙÂÚ·, Ë ‰È·ÁÓˆÛÙÈ΋ ‰ÈÂÚ‡ÓËÛË ÙˆÓ Á·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ‚·ÛÈ˙fiÙ·Ó ÛÙËÓ ÎÏÈÓÈ΋ ·Ú·Ù‹ÚËÛË, ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙËÓ ·Ó¿Ï˘ÛË ‚ÈÔÏÔÁÈÎÒÓ ˘ÁÚÒÓ Î·È ÛÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∏ ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ ηıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË Î·È ÙË Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘, ¯ˆÚ›˜

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¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË. O ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤¯ÂÈ ·ÓÙÈηٷÛÙ‹ÛÂÈ ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ ۈϋӷ. OÈ ÂÍÂÏ›ÍÂȘ ÛÙËÓ Ù¯ÓÔÏÔÁ›· ÙˆÓ ÂÓ‰ÔÛÎÔ›ˆÓ ¤‰ˆÛ ÒıËÛË ÛÙËÓ ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·. ∆Ô 1971 ηٷÛ΢¿ÛÙËΠÙÔ ÚÒÙÔ Â‡Î·ÌÙÔ Á·ÛÙÚÔÛÎfiÈÔ ÁÈ· ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∆Ë ‰ÂηÂÙ›· ÙÔ˘ 1980 ·Ó·Ù‡¯ıËÎÂ Ë ‰È·ÁÓˆÛÙÈ΋ ÂÓ‰ÔÛÎfiËÛË Î·È ÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 Ì ÙËÓ ·Ú·ÁˆÁ‹ Î·È ÙËÓ Â˘Ú›· ‰È¿ıÂÛË ÂÓ‰ÔÛÎÔ›ˆÓ ÌÈÎÚ‹˜ ‰È·Ì¤ÙÚÔ˘, ·Ó·Ù‡¯ıËÎÂ Ë ÂÂÌ‚·ÙÈ΋ ÂÓ‰ÔÛÎfiËÛË. ∏ ÂÓ‰ÔÛÎfiËÛË ı· ÂȂ‚·ÈÒÛÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÈÛÔÊ·Á›Ùȉ·˜ Ì ÂÌ‚¤ÏÂÈ· Î·È Û·Ê‹ÓÂÈ· Î·È ·Ú¿ÏÏËÏ· ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ù˘ ¿ÌÂÛ˘ ·Ó·ÁÓÒÚÈÛ˘ Ù˘ ÌÔÓÈÏÈ·ÛÈ΋˜ ÔÈÛÔÊ·Á›Ùȉ·˜ Î·È Ù˘ ¿ÌÂÛ˘ ÂÈÛÎfiËÛ˘ Î·È ÌÂϤÙ˘ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ Á·ÛÙÚÈÎÒÓ ÂÏÎÒÓ. ∏ ÂÓ‰ÔÛÎfiËÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Ô‰‹ÁËÛ ÛÙËÓ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘ ÙÔ˘ ˘ÏˆÚÔ‡ ·fi ÙÔ˘˜ Warren Î·È Marshal. ∏ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ·, Ë ÔÔ›· ‰Â›¯ÓÂÈ ¿¯˘ÓÛË ÙˆÓ Á·ÛÙÚÈÎÒÓ Ù˘¯ÒÓ ·ÏÏ¿ Î·È Ë ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙˆÓ ÙÚÈÒÓ ÂÈ¤‰ˆÓ ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ‰›ÓÔ˘Ó ÌfiÓÔ ˘Ô„›· Á·ÛÙÚ›Ùȉ·˜. O ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÔηχÙÂÈ ÙËÓ ÂÈÎfiÓ· Ù˘ Á·ÛÙÚ›Ùȉ·˜ ÙÔ˘ ¿ÓÙÚÔ˘, ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ï‹„˘ ‰ÂÈÁÌ¿ÙˆÓ ÁÈ· ÙËÓ Ù·¯Â›· ‰ÔÎÈÌ·Û›· Ù˘ Ô˘Ú¿Û˘ Î·È ÁÈ· ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË (1). ¶·Ï·ÈfiÙÂÚ·, Ë ·Ê·›ÚÂÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜ ‹Ù·Ó ÚÔ‚ÏËÌ·ÙÈ΋. ªÂ ÙËÓ ÂÓ‰ÔÛÎfiËÛË Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ê·›ÚÂÛË Ù˘ Ô‰ÔÓÙÔÁÏ˘Ê›‰·˜, Ë ÔÔ›· ¤¯ÂÈ ÛÊËÓˆı› ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ. ∂›Ó·È ‰˘Ó·Ù‹ Ë ÂÎÙÔÌ‹ ÌÈÛ¯ˆÙÔ‡ ÔχÔ‰· ÙÔ˘ ÛÈÁÌÔÂȉԇ˜. ÕÏÏË ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÂÌ‚·ÙÈ΋˜ ÂÓ‰ÔÛÎfiËÛ˘ ·ÔÙÂÏ› Ë ÛÎÏËÚÔıÂÚ·›· ÙˆÓ ÎÈÚÛÒÓ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. ∏ ÂÊ·ÚÌÔÁ‹ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Î·È ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÓfiÛˆÓ ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ÂÍÂÏ›ÍÂȘ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ô‰‹ÁËÛ·Ó Û ÂÈÎfiÓ˜ ·›ÛÙ¢Ù˘ Û·Ê‹ÓÂÈ·˜. ∂ÍÂÏ›ÍÂȘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›· OÈ ÂÍÂÏ›ÍÂȘ ÛÙË ªÔÚȷ΋ µÈÔÏÔÁ›· Û˘Ó¤‚·Ï·Ó ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ ÔÏÏÒÓ ÓfiÛˆÓ, Ô‰‹ÁËÛ·Ó Û ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ‰È·ÁÓˆÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Ì ‚¿ÛË ÙËÓ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘, Û Ӥ˜ ıÂÚ·¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ Ì ‚¿ÛË ÙËÓ ·Ó·Û‡ÓıÂÛË ÙÔ˘ DNA Î·È Û ÚÔÔÙÈΤ˜ ÁÔÓȉȷ΋˜ ıÂÚ·›·˜. ∫Ï·ÛÈÎfi ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› Ë Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ÁÔÓ›‰ÈÔ˘ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ ÛÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌ·ÙÔÛÒÌ·ÙÔ˜ 7 ÙÔ ¤ÙÔ˜ 1989 (2). ∏ ÁÓÒÛË Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘, Ë ÔÔ›· Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙË ‰È·Ù·Ú·¯‹ ÛÙË ÌÂÙ·ÊÔÚ¿ ÈfiÓÙˆÓ ‰È·-

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̤ÛÔ˘ ÂÓ‰Ô·˘ÏÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ, Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ Ù˘ ÓfiÛÔ˘. ø˜ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› 750 ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘. ∞fi ·˘Ù¤˜, Ë ÌÂÙ¿ÏÏ·ÍË ¢F508 ÚÔÛ‚¿ÏÏÂÈ ÙÔ 70% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì ∫π. ∏ ÚˆÙ½ÓË Ë ÔÔ›· Έ‰ÈÎÔÔÈÂ›Ù·È ·fi ÙÔ ÁÔÓ›‰ÈÔ Ù˘ ∫π, ·ÔÙÂÏ› ‰›·˘ÏÔ ¯ÏˆÚ›Ô˘, Ô ÔÔ›Ô˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Î˘ÎÏÈÎfi AMP Î·È ¤¯ÂÈ Ù·˘ÙÔÔÈËı› Û ÔÏÏ¿ ÎÔÚ˘Ê·›· ÂÈı‹ÏÈ·: ÙÔ˘ ‚ÚÔÁ¯ÈÎÔ‡ ‰¤Ó‰ÚÔ˘, ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ fiÚÔ˘, ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘. ∞˘Ùfi ÂÍËÁ› ÙËÓ ÚÔÛ‚ÔÏ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ, Ù· ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· fiÚˆÓ. ∏ ÚˆÙ½ÓË CFTR Û˘ÓÙ›ıÂÙ·È ÛÙÔ ÂÓ‰ÔÏ·ÛÌ·ÙÈÎfi ‰›ÎÙ˘Ô, ·Ó·‰ÈÏÒÓÂÙ·È ÛÙË Û˘Û΢‹ Golgi Î·È ÌÂٷʤÚÂÙ·È ÛÙËÓ ÎÔÚ˘Ê·›· ÌÂÌ‚Ú¿ÓË ˆ˜ ‰›·˘ÏÔ˜ ¯ÏˆÚ›Ô˘ (3). ∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‰È·‡ÏÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ∫π. OÈ ÌÂÙ·ÏÏ¿ÍÂȘ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û 5 ‚·ÛÈΤ˜ Ù¿ÍÂȘ. ™ÙËÓ ÚÒÙË Ù¿ÍË π, Ë ÚˆÙ½ÓË ‰ÂÓ ·Ú¿ÁÂÙ·È Î·ıfiÏÔ˘. ∂‰Ò ·Ó‹ÎÂÈ Ë Û¯ÂÙÈο Û˘¯Ó‹ ·ÓÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË G542X. ™ÙË ‰Â‡ÙÂÚË Ù¿ÍË ππ, Ë ÚˆÙ½ÓË ·Ú¿ÁÂÙ·È ÛÙÔ ÂÓ‰ÔÏ·ÛÌ·ÙÈÎfi ‰›ÎÙ˘Ô, ·ÏÏ¿ ˘¿Ú¯ÂÈ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó·‰›ψÛË Î·È ÌÂÙ·ÊÔÚ¿ Ù˘ ÛÙËÓ ÎÔÚ˘Ê·›· ÂÈÊ¿ÓÂÈ·. ∂‰Ò ·Ó‹ÎÂÈ Ë ÈÔ Û˘¯Ó‹ ÌÂÙ¿ÏÏ·ÍË ¢F508. ™ÙËÓ ÙÚ›ÙË Ù¿ÍË πππ, Ë ÚˆÙ½ÓË ‰ÂÓ ··ÓÙ¿ ÛÙÔ Î˘ÎÏÈÎfi AMP. ∂‰Ò ·Ó‹ÎÂÈ Ë Û¯ÂÙÈο Û˘¯Ó‹ ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË G551D. ∞˘Ù¤˜ ÔÈ ÙÚÂȘ Ù¿ÍÂȘ ·ÊÔÚÔ‡Ó ‚·ÚȤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ, ÔÈ Ôԛ˜ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÛÙÔÓ Ï‹ÚË Ê·ÈÓfiÙ˘Ô Ù˘ ∫π. OÈ ÂfiÌÂÓ˜ ‰‡Ô Ù¿ÍÂȘ ·ÊÔÚÔ‡Ó ‹Ș ÌÂÙ·ÏÏ¿ÍÂȘ. ™ÙËÓ Ù¤Ù·ÚÙË Ù¿ÍË πV, Ë ÚˆÙ½ÓË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂȈ̤ÓË ·ÁˆÁÈÌfiÙËÙ·. ∂‰Ò ·Ó‹ÎÂÈ Ë ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË R117H, Ë ÔÔ›· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È ÛÙËÓ ÎÏËÚÔÓÔÌÈ΋ ·ÁÎÚ·ٛÙȉ·. ∆¤ÏÔ˜, ÛÙËÓ ¤ÌÙË Ù¿ÍË V, Ë Û‡ÓıÂÛË Ù˘ ÚˆÙ½Ó˘ Â›Ó·È ÌÂȈ̤ÓË ‹ ˘¿Ú¯ÂÈ ÂÏ·ÊÚ¿ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó·‰›ψÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘. ∂‰Ò ·Ó‹ÎÂÈ Ë ‰˘ÛÂÚÌ‹Ó¢ÙË ÌÂÙ¿ÏÏ·ÍË ∞455∂. À¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÚˆÙ½Ó˘ CFTR Î·È Ù˘ ‚Ï¿‚˘ ÙˆÓ ÔÚÁ¿ÓˆÓ. ŸÙ·Ó Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÚˆÙ½Ó˘ ·ÔÙÂÏ› ÙÔ 1% Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜, Ô Ê·ÈÓfiÙ˘Ô˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÎÏ·ÛÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ∫π. ÀÔÏÂÈfiÌÂÓË ÏÂÈÙÔ˘ÚÁ›· 5% ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ·ÁÎÚ·ÙÈ΋ Â¿ÚÎÂÈ·, ÂÓÒ 10% ÙË Û˘ÁÁÂÓ‹ ·ÙÚËÛ›· ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘. ∏ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ηÙÈÔÓÈÎÔ‡ ıÚ˘„ÈÓÔÁfiÓÔ˘ ·fi ÙÔÓ Whitcomb ÙÔ 1996

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Û˘Ó¤‚·Ï ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ Ù˘ ÎÏËÚÔÓÔÌÈ΋˜ ·ÁÎÚ·ٛÙȉ·˜, Ë ÔÔ›· ÂÍËÁÂ›Ù·È Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÌÂÙ·ÏÏ·Á̤Ó˘ ıÚ˘„›Ó˘ ÛÂ Û˘ÁΤÓÙÚˆÛË Ë ÔÔ›· ˘ÂÚ‚·›ÓÂÈ ÙË ‰Ú¿ÛË ÙÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ıÚ˘„›Ó˘ Î·È Ô‰ËÁ› Û ·˘ÙÔ„›· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ (4). ∏ ·Ó‡ÚÂÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Ù˘ ÚˆÙ½Ó˘ CFTR Û ·ÛıÂÓ›˜ Ì ȉÈÔ·ı‹ ¯ÚfiÓÈ· ·ÁÎÚ·ٛÙȉ· ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ˘ÔÔÌ¿‰· Ì ·ıÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ CFTR Ë ÔÔ›· ·ÊÔÚ¿ ÂȉÈο ÙÔ ¿ÁÎÚ·˜ (5). ∂Ê·ÚÌÔÁ‹ Ù˘ ÚˆÙ½Ó˘ CFTR ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·ÔÙÂÏ› Ë ÁÔÓÔÙ˘È΋ ÂȂ‚·›ˆÛË Ù˘ ∫π Î·È Ë ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË. ∏ ÁÓÒÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ CFTR ‚Ô‹ıËÛ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ÎÏ·ÛÈ΋˜ ‰ÔÎÈÌ·Û›·˜ ȉÚÒÙ·. ∆¤ÏÔ˜, Ë ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ÛÙȘ ÚÔÔÙÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·ÁÎÚ·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÚÔÛ¿ıÂÈ· ηٷÛ΢‹˜ Û΢·ÛÌ¿ÙˆÓ ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ÏÈ¿Û˘ ÌÈÎÚÔ‚›ˆÓ ‹ Ì˘Î‹ÙˆÓ, ÛÙË Û‡ÓıÂÛË ·Ó·Û˘Ó‰˘·Ṳ̂Ó˘ ÁψÛÛÈ΋˜ ÏÈ¿Û˘ Î·È ÛÙË ÁÔÓȉȷ΋ ıÂÚ·›·, Ë ÔÔ›· Û˘Ó›ÛÙ·Ù·È ÛÙË ÌÂÙ·ÊÔÚ¿ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ÁÔÓ›‰ÈÔ˘ Ù˘ ÏÈ¿Û˘ ‹ ¿ÏÏˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔ Ë·ÙÔ¯ÔÏÈÎfi Û‡ÛÙËÌ· ‹ ÛÙÔ ¤ÓÙÂÚÔ, ÒÛÙÂ Ô ·ÛıÂÓ‹˜ Ó· ·Ô¯Ù‹ÛÂÈ ÙË ‰˘-

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¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™¿ÓÙ· ¡Ô‡ÛÈ·-∞Ú‚·ÓÈÙ¿ÎË ∆£ 322, £¤ÚÌË, 570 01, £ÂÛÛ·ÏÔÓ›ÎË e-mail: sarvanit@med.auth.gr

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GASTROENTEROLOGY-HEPATOLOGY-NUTRITION

ÃÔÏfiÛÙ·ÛË ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·: ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË K. ™‡ÚÔÁÏÔ˘

Cholestasis of infancy: diagnosis and treatment K. Spiroglou

¶ÂÚ›ÏË„Ë: ∏ ¯ÔÏfiÛÙ·ÛË ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ·ÔÙÂÏ› ¤Ó· Û˘¯Ófi Úfi‚ÏËÌ· Î·È Û˘¯Ó¿ ··ÈÙ› ¿ÌÂÛË ‰È·ÊÔÚԉȿÁÓˆÛË ÌÂٷ͇ ·ÙÚËÛ›·˜ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ Î·È ÓÂÔÁÓÈ΋˜ Ë·Ù›Ùȉ·˜. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ‰›ÓÂÙ·È ¤ÌÊ·ÛË ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¯ÔÏfiÛÙ·Û˘ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· fiÔ˘ Â›Ó·È Û˘¯ÓfiÙÂÚË Î·È ÙÔÓ›˙ÂÙ·È Î˘Ú›ˆ˜ Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ì ٷ ˘¿Ú¯ÔÓÙ· ÂÚÁ·ÛÙËÚȷο ̤۷. ∂›Û˘, ·Ó·Ï‡ÂÙ·È Ë ·ÓÙÈÌÂÙÒÈÛË, ÙfiÛÔ ÁÂÓÈο fiÛÔ Î·È ·ÈÙÈÔÏÔÁÈο.

Abstract: Cholestasis in infancy is an important diagnostic problem, which in the neonatal period needs prompt evaluation and exclusion of extrahepatic biliary atresia from other causes of neonatal hepatitis. This discussion emphasizes the evaluation of cholestasis in infancy, especially in the neonatal period where it represents a small but important group of disorders. It also describes the clinical and laboratory diagnostic evaluation as well as the therapeutic approach based on general principles as well as on etiology.

§¤ÍÂȘ ÎÏÂȉȿ: ¯ÔÏfiÛÙ·ÛË, ›ÎÙÂÚÔ˜, ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·.

Key words: cholestasis, jaundice, neonatal hepatitis.

ø˜ ¯ÔÏfiÛÙ·ÛË ıˆÚÂ›Ù·È Ë ‰È·Ù·Ú·¯‹ ·Ú·ÁˆÁ‹˜ - ·ÚÔ¯¤Ù¢Û˘ Ù˘ ¯ÔÏ‹˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ù·ÎÚ¿ÙËÛË Ô˘ÛÈÒÓ ÛÙÔ ·›Ì· Î·È ÙÔ˘˜ ÈÛÙÔ‡˜, ÔÈ Ôԛ˜ Ê˘ÛÈÔÏÔÁÈο ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙË ¯ÔÏ‹. ∫ÏÈÓÈο ηıÔÚ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÈÎÙ¤ÚÔ˘, ÛÎÔÙÂÈÓfi¯ÚÔˆÓ Ô‡ÚˆÓ, ÎÓËÛÌÔ‡ Î·È Í·ÓıÂÏ·ÛÌ¿ÙˆÓ (1-5). I‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÔÎÙ¿ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·. ™ÙȘ ËÏÈ˘ ·˘Ù¤˜ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÁÓˆÛÙ‹ Î·È Û·Ó ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·, ·Ú·ÙÂٷ̤ÓÔ˜ ÓÂÔÁÓÈÎfi˜ ·ÔÊÚ·ÎÙÈÎfi˜ ›ÎÙÂÚÔ˜ ‹ ÓÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË (4). ∞ÔÙÂÏ› ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ì ÔÏϤ˜ ÔÌÔÈfiÙËÙ˜ ·ÏÏ¿ Î·È ‰È·ÊÔÚ¤˜ (4,6,7).

O ¯ÔÏÔÛÙ·ÙÈÎfi˜ ›ÎÙÂÚÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ÂÌÊ·Ó›˙ÂÙ·È ÌÂ Û˘¯ÓfiÙËÙ· 1:2500 ¤ˆ˜ 1:5000 ˙ÒÓÙ· ÓÂÔÁ¤ÓÓËÙ· (1) Î·È ÂÚ›Ô˘ ÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∆· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó

¯ÔÏfiÛÙ·ÛË ÛÙ· ·È‰È¿ Â›Ó·È ÔÏ˘¿ÚÈıÌ· (¶›Ó·Î·˜ 1). ™Â ·‰Ú¤˜ ÁÚ·Ì̤˜, Ù· ÓÂÔÁÓ¿ Ì ¯ÔÏfiÛÙ·ÛË ¯ˆÚ›˙ÔÓÙ·È Û 2 ηÙËÁÔڛ˜: ·) ·˘Ù¿ Ì ÂÓ‰ÔË·ÙÈ΋ ÓfiÛÔ Î·È ‚) ·˘Ù¿ Ì Â͈Ë·ÙÈ΋ (™¯‹Ì· 1). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÔÏÏÒÓ ÂÚÁ·ÛÈÒÓ Ê·›ÓÂÙ·È fiÙÈ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌ›ÙÂÈ ‚·ÛÈο Û 2 ηÙËÁÔڛ˜: ÙËÓ ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (∞∂ö) Ì ̛· Û˘¯ÓfiÙËÙ· 1:8000 ¤ˆ˜ 1:12000 ˙ÒÓÙ· ÓÂÔÁÓ¿ (8,9) Î·È ÙËÓ È‰ÈÔ·ı‹ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· (π¡∏) Ì ̛· Û˘¯ÓfiÙËÙ· 1:4800 ¤ˆ˜ 1:9000 ˙ÒÓÙ· ÓÂÔÁÓ¿ (1). OÈ ‰‡Ô ·˘Ù¤˜ ηٷÛÙ¿ÛÂȘ ·ÔÙÂÏÔ‡Ó ÙÔ 70-80 % ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¯ÔÏfiÛÙ·Û˘ Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, ÂÓÒ Ï›Á· ¯ÚfiÓÈ· ÚÈÓ, ÂÍ›ÛÔ˘ Û˘¯Ó‹ ‹Ù·Ó Î·È Ë ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· ·fi ÏÔÈÌÒÍÂȘ. ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ¯ÔÏfiÛÙ·Û˘ ÔÊ›ÏÔÓÙ·È Û ÔÍ›· ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· (4).

°’ ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔÓ›ÎË

3rd Pediatric Department of the Aristotelion University Ippokration General Hospital, Thessaloniki

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¶›Ó·Î·˜ 1. ∞›ÙÈ· ¯ÔÏfiÛÙ·Û˘ ÛÙ· ·È‰È¿ π. ∂͈Ë·ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·. ¯ÔÏÈ΋ ·ÙÚËÛ›· ‚. ¯ÔÏÈ΋ ˘ÔÏ·Û›· Á. ÛÙ¤ÓˆÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‰. ·˘ÙfiÌ·ÙË ‰È¿ÙÚËÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ Â. ÓÂÔÏ·Û›·, ¯ÔÏfiÏÈıÔÈ ππ. ∂Ó‰ÔË·ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·. π‰ÈÔ·ı‹ 1. π‰ÈÔ·ı‹˜ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ· 2. ∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË, Â›ÌÔÓË ·. ·ÚÙËÚÈÔË·ÙÈ΋ ‰˘ÛÏ·Û›· (Û‡Ó‰ÚÔÌÔ Alagille) ‚. ÓfiÛÔ˜ ÙÔ˘ Byler Á. ÙÚȸ‰ÚÔÎÔÚ·ÛÙ·ÓÔ˚΋ Ô͢·ÈÌ›· ‰. Û‡Ó‰ÚÔÌÔ Zellweger (ÂÁÎÂÊ·ÏÔ-Ë·ÙÔ-ÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ) Â. ÌË Û˘Ó‰ÚÔÌÈ΋ Ì›ˆÛË ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‚. ∞Ó·ÙÔÌÈο ·›ÙÈ· 1. ™˘ÁÁÂÓ‹˜ Ë·ÙÈ΋ ›ÓˆÛË ‹ Ó·ÓÈ΋ ÔÏ˘Î˘ÛÙÈ΋ ÓfiÛÔ˜ ÓÂÊÚÒÓ–‹·ÙÔ˜) 2. ¡fiÛÔ˜ Caroli Á. ªÂÙ·‚ÔÏÈο ·›ÙÈ· ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·ÌÈÓÔͤˆÓ ñ ∆˘ÚÔÛÈÓ·ÈÌ›·. ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÏÈȉ›ˆÓ ñ ¡fiÛÔ˜ ÙÔ˘ Wolman ñ ¡fiÛÔ˜ Niemann-Pick ñ ¡fiÛÔ˜Gaucher ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ˘‰·Ù·ÓıÚ¿ÎˆÓ ñ °·Ï·ÎÙÔ˙·ÈÌ›· ñ ºÚÔ˘ÎÙÔ˙·ÈÌ›· ñ °Ï˘ÎÔÁÔÓ›·ÛË ¢È·Ù·Ú·¯¤˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ¯ÔÏÈÎÒÓ ÔͤˆÓ ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· ¯ˆÚ›˜ ÁÓˆÛÙfi ¤ÏÏÂÈÌÌ· ·ÓÂ¿ÚÎÂÈ· ·1 ·ÓÙÈıÚ˘„›Ó˘ ΢ÛÙÈ΋ ›ÓˆÛË È‰ÈÔ·ı‹˜ ˘Ô¸ÔÊ˘ÛÈÛÌfi˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ‰. ∏·Ù›Ùȉ˜ 1. §ÔÈÌÒ‰Ë ·›ÙÈ· ñ ªÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ ñ ∏·Ù›Ùȉ· µ ñ πÔ› Reo, Coxsackie, Echo Î.Ï. ñ ∆ÔÍÔÏ¿Û̈ÛË ñ ™‡ÊÈÏȘ ñ º˘Ì·Ù›ˆÛË 2. ∆ÔÍÈο ·›ÙÈ· ñ ¶·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ñ ™Ë„·ÈÌ›· Â. °ÂÓÂÙÈο ‹ ¯ÚˆÌÔۈ̷ÙÈο ñ ÙÚÈۈ̛· ∂ ñ Û‡Ó‰ÚÔÌÔ Down ñ ÏÂÚÂÎÔÓÈÛÌfi˜ (Û‡Ó‰ÚÔÌÔ Donahue’s) ÛÙ. ¢È¿ÊÔÚ· πÛÙÈÔ·ÙÙˆÛË Ã ∂ÓÙÂÚÈ΋ ·fiÊÚ·ÍË ™‡Ó‰ÚÔÌÔ ÔÏ˘ÛÏËÓ›·˜

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∞) ¡ÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË ∞ÓÙÈÌÂÙˆ›˙ÔÓÙ·˜ ¤Ó· ÓÂÔÁÓfi Ì ¯ÔÏfiÛÙ·ÛË, ·˘ÙfiÌ·Ù· ÚÔ·ÙÔ˘Ó Ù¤ÛÛÂÚ· ÂÚˆÙËÌ·ÙÈο: ·) À¿Ú¯Ô˘Ó ¿ÌÂÛ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÂÈÏÔ‡Ó ÙË ˙ˆ‹; ‚) ∂›Ó·È ‚¤‚·ÈÔ fiÙÈ ‰ÂÓ Â›Ó·È ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ; Á) ª‹ˆ˜ ¤¯ÂÈ Î¿ÔÈ· Ë·Ù›Ùȉ· ÁÈ· ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È ıÂÚ·›· ‹ ÁÂÓÂÙÈΤ˜ Û˘Ì‚Ô˘Ï¤˜; ‰) ¶Ò˜ ı· ÌÔÚÔ‡Û·Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ıÚ¤„˘; °ÂÓÈο, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ¯ÔÏÔÛÙ·ÙÈÎÔ‡ ·È‰ÈÔ‡ ·Ú·Ì¤ÓÂÈ ¤Ó· ‰‡ÛÎÔÏÔ ¤ÚÁÔ Ô˘ ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÛÙËÓ ·ÓÔÌÔÈÔÁ¤ÓÂÈ· ÙˆÓ ¯ÔÏÔÛÙ·ÙÈÎÒÓ Û˘Ó‰ÚfiÌˆÓ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙË ÛÎÔÙÂÈÓ‹ ·ıÔÁ¤ÓÂÈ· ÔÏÏÒÓ ·fi ÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ (10). ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË Î·È ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ‰È·Ù·Ú·¯ÒÓ Ô˘ ˘fiÎÂÈÓÙ·È Û ÂȉÈ΋ ıÂÚ·›· (.¯. Á·Ï·ÎÙÔ˙·ÈÌ›·) ‹ ÚÒÈÌË ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË, fiˆ˜ Ë ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∞ÎfiÌË ÎÈ ·Ó Ë ıÂÚ·›· ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹, ·È‰È¿ Ì ¯ÚfiÓÈ· ÂÍÂÏÈÛÛfiÌÂÓË Ë·ÙÔ¿ıÂÈ· ÌÔÚÔ‡Ó Ó· ˆÊÂÏËıÔ‡Ó ·fi ÙȘ ÚÔÛ¿ıÂȘ ÁÈ· ηχÙÂÚË ıÚÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ‹ Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ (1). πÛÙÔÚÈÎfi Î·È Ê˘ÛÈ΋ ÂͤٷÛË: ¶ÚˆÙ·Ú¯ÈÎfi˜ ÛÎÔfi˜ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÓÂÔÁÓÈ΋˜ ¯ÔÏfiÛÙ·Û˘ Â›Ó·È o ‰È·¯ˆÚÈÛÌfi˜ Ù˘ ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ ·fi ÙËÓ Â͈Ë·ÙÈ΋ ‚Ï¿‚Ë, Ë ·Ó·˙‹ÙËÛË ÓfiÛˆÓ Ô˘ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Î·È Ë ·Ó·ÁÓÒÚÈÛË ÎÏÈÓÈÎÒÓ ÂÈÏÔÎÒÓ, ÁÈ· ÙȘ Ôԛ˜ Ë ÁÂÓÈ΋ ıÂÚ·›· ÌÔÚ› Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∆· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο (¶›Ó·Î·˜ 2) ÔÔÈ·Û‰‹ÔÙ ·ÈÙ›·˜ Ô˘ ÚÔηÏ› ¯ÔÏfiÛÙ·ÛË Â›Ó·È Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ fiÌÔÈ· (1). ∆Ô Î‡ÚÈÔ Û‡Ìو̷ Â›Ó·È Ô ›ÎÙÂÚÔ˜, Ô ÔÔ›Ô˜ Á›ÓÂÙ·È ÂÌÊ·Ó‹˜ fiÙ·Ó Ë ¯ÔÏÂÚ˘ıÚ›ÓË ˘Âڂ› Ù· 2-3 mg/dl, ÙÔ ÓÂÔÁÓfi fï˜ ÌÔÚ› Ó· ÌË Ê·›ÓÂÙ·È ÈÎÙÂÚÈÎfi ̤¯ÚÈ Ë ¯ÔÏÂÚ˘ıÚ›ÓË Ó· ÊÙ¿ÛÂÈ Ù· 7 mg/dl (1,11). ∂ÌÊ·Ó›˙ÂÙ·È ·Ú¯Èο ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÚÔԉ¢ÙÈο ¶›Ó·Î·˜ 2. ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓÂÔÁÓÈ΋˜ Ë·Ù›Ùȉ·˜ ñ ñ ñ ñ ñ

ÿÎÙÂÚÔ˜ ∞ԯڈ̷ÙÈÛÌfi˜ ÎÔÚ¿ÓˆÓ (ηıËÌÂÚÈÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË) À¤Ú¯ÚˆÛË Ô‡ÚˆÓ ¢ÈfiÁΈÛË ‹·ÙÔ˜ Ì ‹ ¯ˆÚ›˜ ‰ÈfiÁΈÛË ÛÏ‹Ó· °ÂÓÈο Û˘ÌÙÒÌ·Ù·: ˆ¯ÚfiÙËÙ·, Ô›‰ËÌ·, ÚÔˆÚfiÙËÙ·, ‰˘ÛˆÚÈÌfiÙËÙ· ñ ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ·: ÂÌÂÙÔ›, ·ÓÔÚÂÍ›·, ¿ÚÓËÛË ıËÏ·ÛÌÔ‡ (ÌÔÚ› Ó· ÚÔËÁÔ‡ÓÙ·È ÙÔ˘ ÈÎÙ¤ÚÔ˘) ñ ™˘ÌÙÒÌ·Ù· ·fi ÙÔ ∫¡™: ˘ÔÙÔÓ›·, ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·Ú¯¤ÁÔÓˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ (Moro, ıËÏ·ÛÌÔ‡, ηٿÔÛ˘)

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¡ÂÔÁÓÈ΋ ¯ÔÏfiÛÙ·ÛË

Â͈Ë·ÙÈ΋

Â͈Ë·ÙÈ΋ ·ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ

ÂÓ‰ÔË·ÙÈ΋

Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë

‚Ï¿‚Ë ¯ÔÏËÊfiÚˆÓ fiÚˆÓ

ÂÓ‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· ‹ Ì›ˆÛË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ÌÂÙ·‚ÔÏÈ΋ ÓfiÛÔ˜

ȉÈÔ·ı‹ ·›ÙÈ· ÈÔÁÂÓ‹˜ ÓfiÛÔ˜ Û˘Ó‰ÚÔÌÈÎfi˜ Ù‡Ô˜

ÌË Û˘Ó‰ÚÔÌÈÎfi˜ Ù‡Ô˜

™¯‹Ì· 1. ∫‡ÚȘ ηÙËÁÔڛ˜ ¯ÔÏfiÛÙ·Û˘

ÂÂÎÙ›ÓÂÙ·È ÚÔ˜ ÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·, ηıÒ˜ Ë ¯ÔÏÂÚ˘ıÚ›ÓË ·˘Í¿ÓÂÈ (11). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ fiÛÔ ÓˆÚ›ÙÂÚ· ·ÓÙÈÌÂÙˆÈÛÙ› Ë Â͈Ë·ÙÈ΋ ·ÙÚËÛ›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ÙfiÛÔ Î·Ï‡ÙÂÚ· Â›Ó·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ·fi„ˆ˜ ÚÔ‹˜ ¯ÔÏ‹˜. £· Ú¤ÂÈ ÏÔÈfiÓ, ·Ó Ô ›ÎÙÂÚÔ˜ ·Ú·Ù›ÓÂÙ·È ÌÂÙ¿ ÙË 14Ë Ë̤ڷ Ù˘ ˙ˆ‹˜, Ó· Á›ÓÂÈ ‰ÈÂÚ‡ÓËÛË ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Â͈Ë·ÙÈ΋˜ ·ÙÚËÛ›·˜ (12). ÕÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ¯ÔÏfiÛÙ·Û˘ Ô˘ ı· Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó Â›Ó·È Ô ·ԯڈ̷ÙÈÛÌfi˜ ÙˆÓ ÎÔÚ¿ÓˆÓ Î·È Ë ˘¤Ú¯ÚˆÛË ÙˆÓ Ô‡ÚˆÓ. ¢ÈfiÁΈÛË ‹·ÙÔ˜ Î·È ÛÏËÓfi˜, ·ÛΛÙ˘, Ô›‰ËÌ·, Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ·ÚÁfiÙÂÚ· (1,3). ∞ӷʤÚÂÙ·È fiÙÈ ÔÚÈṲ̂ӷ ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ Î·È Â͈Ë·ÙÈ΋˜ ‚Ï¿‚˘ (3) (¶›Ó·Î·˜ 3). ∆· ÎÏÈÓÈο ·˘Ù¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÌÔÚÔ‡Ó Ó· ı¤ÛÔ˘Ó ‰È¿ÁÓˆÛË Û ÔÛÔÛÙfi 82% ÙˆÓ ÂÚÈÙÒÛˆÓ. øÛÙfiÛÔ, Ë ÚÔÛı‹ÎË Î·È ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·˘Í¿ÓÂÈ ÙË ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· ÌfiÓÔ Î·Ù¿ 3% (‰ËÏ. 85%). ∏ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Û˘Ìو̿وÓ, fiˆ˜ Ë Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ë ÌÂȈ̤ÓË ıÚ¤„Ë, Ë ·ÓÔÚÂÍ›· ‹ ÔÈ ÂÌÂÙÔ› Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ÌÂÙ·‚ÔÏÈ΋˜ ‰È·Ù·Ú·¯‹˜, fiˆ˜ Ë Á·Ï·ÎÙÔ˙·ÈÌ›· ‹ Ù˘ÚÔÛÈÓ·ÈÌ›·, ÂÓÒ Â˘Ú‹Ì·Ù· fiˆ˜ ÙÔ ÂÌ‚Ú˘fiÙÔÍÔ, ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÛÔÓ‰‡ÏˆÓ ‹ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· ÛÙËÓ ÂÛÙ›· ·ÎÚfi·Û˘ Ù˘ Ó¢ÌÔÓÈ΋˜, ı¤ÙÔ˘Ó ÙËÓ ¤Ó‰ÂÈÍË ¤Ó‰ÂÈ·˜ ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ÁÓˆÛÙ‹ Î·È ˆ˜ ·ÚÙËÚÈÔ-Ë·ÙÈ΋ ‰˘ÛÏ·Û›· (Û‡Ó‰ÚÔÌÔ Alagille) (3,13,14). ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜: O ÂÚÁ·ÛÙËÚÈ·Îfi˜

¤ÏÂÁ¯Ô˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â›Ó·È ·ÚÎÂÙ¿ ÔχÏÔÎÔ˜ Î·È Û˘¯Ó¿ ··ÈÙ› ÔÏϤ˜ Î·È Â·ÓÂÈÏËÌ̤Ó˜ ÂÍÂÙ¿ÛÂȘ (¶›Ó·Î·˜ 4). µ·ÛÈÎfi˜ ÛÎÔfi˜ ÂÓfi˜ ·Ú¯ÈÎÔ‡ ÂϤÁ¯Ô˘ Â›Ó·È Ó· ÂȂ‚·Èˆı› Ë ·ÚÔ˘Û›· ¯ÔÏfiÛÙ·Û˘, Ó· ηıÔÚÈÛÙ› Ë ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Î·È Ó· ‰È·ÁÓˆÛÙÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ, ÔÈ Ôԛ˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Â‡ÎÔÏ· Î·È ÁÚ‹ÁÔÚ·. °È· ÙÔ ÛÎÔfi ·˘Ùfi, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÏ˘¿ÚÈı̘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ. øÛÙfiÛÔ ‰ÂÓ ˘¿Ú¯ÂÈ Î¿ÔÈÔ ‰È·ÁÓˆÛÙÈÎfi test Ô˘ Ó· ‚ÔËı‹ÛÂÈ ÛÙÔ ‰È·¯ˆÚÈÛÌfi ÂÓ‰Ô-Ë·ÙÈ΋˜ Î·È Â͈-Ë·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ÙË ‚ÈÔ„›· ‹·ÙÔ˜.

OÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ì›· ÏËıÒÚ· ÂÍÂÙ¿ÛˆÓ. ∞Ú¯Èο ÂϤÁ¯ÂÙ·È Ë Ë·ÙÈ΋ Î·È ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙÔ ·ÈÌÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Î·È Ô ËÎÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜, ÂÍÂÙ¿ÛÂȘ ÁÂÓÈΤ˜ Ô˘ ı· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ‚¤‚·È· Î·È ÙÔ˘ ‹·ÙÔ˜ (3,10). ™ÙË Û˘Ó¤¯ÂÈ·, Ô ¤ÏÂÁ¯Ô˜ ÔÏÔÎÏËÚÒÓÂÙ·È Ì ÂȉÈÎfiÙÂÚ˜ ÂÍÂÙ¿ÛÂȘ fiˆ˜ Ô ¤ÏÂÁ¯Ô˜ ·Ó·˙‹ÙËÛ˘ ÏÔÈÌÒ͈Ó, ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÁÂÓÂÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÂÓ‰ÔÎÚÈÓÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ‹ ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛˆÓ. OÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, ÁÓˆÛÙÔ‡˜ Ì ÙÔ ·ÎÚˆÓ‡ÌÈÔ TORCH (ÙÔÍfiÏ·ÛÌ·, Ô˘ÚÔÏԛ̈ÍË, ÂÚ˘ıÚ¿, CMV, ¤Ú˘), SLAVE (Û‡ÊÈÏË, ÏÈÛÙ¤ÚÈ·, Ë·Ù›Ùȉ· µ, ·ÓÂÌ¢ÏÔÁÈ¿, ÏÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË) ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÙfiÛÔ ÛÙÔ ÓÂÔÁÓfi fiÛÔ Î·È ÛÙË ÌËÙ¤Ú· (1,3). ∞ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜: O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ ÛÙÔÓ ÛÈÓıËÚÔÁÚ·ÊÈÎfi Î·È Û ÂΛÓÔÓ Ì ˘ÂÚ‹¯Ô˘˜. ∏ real-time

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18:55

™ÂÏ›‰·296

¶·È‰È·ÙÚÈ΋ 2001;64:293-299

Paediatriki 2001;64:293-299

¶›Ó·Î·˜ 3. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓ‰Ô- Î·È Â͈- Ë·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘ ÷ڷÎÙËÚÈÛÙÈο

∂͈Ë·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË

∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË

3200

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79

26

16 87

30 53

94 86 63

47 30 1

µ¿ÚÔ˜ Á¤ÓÓËÛ˘ Û g ÃÚÒÌ· ÎÔÚ¿ÓˆÓ ÂÓÙfi˜ 10 ËÌÂÚÒÓ ·fi ÂÈÛ·ÁˆÁ‹ (% ·¯ÔÏÈο) ∏ÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ·¯ÔÏÈÎÒÓ ÎÔÚ¿ÓˆÓ Û Ë̤Ú˜ ∏·ÙÔÌÂÁ·Ï›· ‹ ·ıÔÏÔÁÈ΋ Û‡ÛÙ·ÛË (%) µÈÔ„›· ‹·ÙÔ˜ ñ ¶˘Ï·›· ›ÓˆÛË (% ıÂÙÈ΋) ñ ¶ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (% ıÂÙÈ΋) ñ µ‡ÛÌ·Ù· ¯ÔÏ‹˜

¶›Ó·Î·˜ 4. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË 1. ∫ÏÈÓÈ΋ ÂÎÙ›ÌËÛË (ÈÛÙÔÚÈÎfi, Ê˘ÛÈ΋ ÂͤٷÛË, ¯ÚÒÌ· ÎÔÚ¿ÓˆÓ) 2. µÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ñ ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ (ÔÏÈ΋-¿ÌÂÛË) ñ ∞ÌÈÓÔÙÚ·ÓÛÊÂÚ¿Û˜ (SGOT, SGPT) ñ ŒÏÂÁ¯Ô˜ Û˘ÓıÂÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ‹·ÙÔ˜ (Ï¢ÎÒÌ·Ù· ÔÚÔ‡, ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘) ñ ∫·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ñ OÚÔÏÔÁÈ΋ ·Ó›¯Ó¢ÛË ÈÒÓ (HbsAG, HIV Î.Ï.) ñ º·ÈÓfiÙ˘Ô˜ ·1 ·ÓÙÈıÚ˘„›Ó˘ ñ ∆4 Î·È TSH ñ ÃψÚÈÔ‡¯· ȉÚÒÙ· ñ ŒÏÂÁ¯Ô˜ ÌÂÙ·‚ÔÏÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (·ÌÈÓfiÁÚ·ÌÌ· ÔÚÔ‡ Î·È Ô‡ÚˆÓ, ·Ó·ÁˆÁÈΤ˜ Ô˘Û›Â˜) ÊÂÚÚÈÙ›ÓË ÔÚÔ‡ 3. ∞ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ñ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ñ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ñ ‰È·‰ÂÚÌÈ΋ ‰ÈË·ÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ñ ·Ï›Ó‰ÚÔÌË ÂÓ‰ÔÛÎÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· 4. µÈÔ„›· ‹·ÙÔ˜

˘ÂÚ˯ÔÁÚ·Ê›· ÌÔÚ› Ó· ‰ÒÛÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙË Û‡ÛÙ·ÛË ÙÔ˘ ‹·ÙÔ˜ Î·È Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜, Ó· ‰Â›ÍÂÈ ÙËÓ ·ÚÔ˘Û›· ¯ÔÏfiÏÈıˆÓ, ·ÛΛÙË ‹ ΢ÛÙÈÎÒÓ ‰È·Ù¿ÛÂˆÓ ÙÔ˘ ¯ÔÏÈÎÔ‡ ‰¤Ó‰ÚÔ˘ (15,16). O ÛÈÓıËÚÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì Ù¯ӋÙÈÔ Û˘Ó‰Â‰Â̤ÓÔ Ì ·Ú¿ÁˆÁÔ IDA (ÈÌÈÓԉȷÎÂÙÈÎfi Ô͇) ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â͈Ë·ÙÈ΋˜ ·ÙÚËÛ›·˜ ·fi ÌË ·ÔÊÚ·ÎÙÈ΋ ¯ÔÏfiÛÙ·ÛË (17-19). ÕÏϘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Â›Ó·È Ë ‰È·‰ÂÚÌÈ΋ ‰ÈË·ÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· Î·È Ë ·Ï›Ó‰ÚÔÌË ÂÓ‰ÔÛÎÔÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›·. ¶ÚÔ¸Ôı¤ÙÔ˘Ó, fï˜, ÔÚÁ·ÓˆÌ¤Ó˜ ÌÔÓ¿‰Â˜ Ì ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi. ∆¤ÏÔ˜, Ë ‚ÈÔ„›· ‹·ÙÔ˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ Ë ÈÔ ··Ú·›ÙËÙË Î·È Î·ıÔÚÈÛÙÈ΋ ÂͤٷÛË ÛÙËÓ ÂÎÙ›ÌËÛË ‚Ú¤ÊÔ˘˜ Ì Â›ÌÔÓË ˘ÂÚ¯ÔÏÂÚ˘-

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ıÚÈÓ·ÈÌ›·. ∏ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (ductular proliferation), ‚˘ÛÌ¿ÙˆÓ ¯ÔÏ‹˜, ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ˘Ï·›Ô˘ ‰È·ÛÙ‹Ì·ÙÔ˜ Î·È ·Ú¯fiÌÂÓ˘ ›ÓˆÛ˘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ·ÙÚËÛ›·˜ ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (20,21). ∞Ó ·Ú’ fiÏ· ·˘Ù¿, ÂÍ·ÎÔÏÔ˘ı› Ó· ˘¿Ú¯ÂÈ Úfi‚ÏËÌ·, ÙÔ ÂfiÌÂÓÔ ‚‹Ì· Â›Ó·È Ë ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· Ì ٷ˘Ùfi¯ÚÔÓË ‚ÈÔ„›· Î·È ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›·. ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ¯ÔÏfiÛÙ·Û˘ (¶›Ó·Î·˜ 5) ™Â ÓÂÔÁÓ¿-‚Ú¤ÊË Ô˘ Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È Ë ‚ÈÔ„›· ‹·ÙÔ˜ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú ·fiÊڷ͢ ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ‰ÈÂÓÂÚÁÂ›Ù·È ‰ÈÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· Î·È ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ÒÛÙ ӷ ηıÔÚÈÛÙ› Ë ı¤ÛË Î·È Ë ¤ÎÙ·ÛË Ù˘ ·fiÊڷ͢ Î·È ÙÔ Â›‰Ô˜ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‰ÈfiÚıˆÛ˘ Ù˘ ‚Ï¿‚˘ (.¯. ÂÁ¯Â›ÚËÛË Kasai). ™Â ‚Ú¤ÊË Ì ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË ‹ ‚Ú¤ÊË Ì Â͈-Ë·ÙÈ΋ ·ÙÚËÛ›· ¯ÂÈÚÔ˘ÚÁË̤ӷ, Ô˘ ‰ÂÓ Î·ÙÔÚıÒıËΠÂ·Ú΋˜ ÚÔ‹ Ù˘ ¯ÔÏ‹˜, Ë ·ÓÙÈÌÂÙÒÈÛË Î·ıÔÚ›˙ÂÙ·È ·fi ÙȘ ÎÏÈÓÈΤ˜ Û˘Ó¤ÂȘ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ¯ÔÏfiÛÙ·Û˘ (3,4). OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· ‹ ¤ÌÌÂÛ· Ì ÙË ÌÂȈ̤ÓË ÚÔ‹ Ù˘ ¯ÔÏ‹˜ Î·È ÔÊ›ÏÔÓÙ·È ÛÂ: 1) ηٷÎÚ¿ÙËÛË ·fi ÙÔ ‹·Ú Ô˘ÛÈÒÓ Ô˘ Ê˘ÛÈÔÏÔÁÈο ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙË ¯ÔÏ‹ (¯ÔÏÂÚ˘ıÚ›ÓË, ȯÓÔÛÙÔȯ›·, ¯ÔÏÈο Ôͤ·, ¯ÔÏÂÛÙÂÚ›ÓË), 2) ÌÂȈ̤ÓË ·¤ÎÎÚÈÛË ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ (Ì›ˆÛË ˘ÎÓÔÙ‹ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ ÛÙÔ ¤ÓÙÂÚÔ Ì ·ÔÙ¤ÏÂÛÌ· ‰˘Û·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ) Î·È 3) Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë ÂÍÂÏÈÛÛfiÌÂÓË Û ΛÚÚˆÛË, ˘Ï·›· ˘¤ÚÙ·ÛË Î·È Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (™¯‹Ì· 2). °ÂÓÈο, η̛· ıÂÚ·›· ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ‹ ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘, ÁÈ’ ·˘Ùfi Î·È ·ÔÛÎÔ› ÛÙÔ Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Î·È Ó· ÌÂÈÒÛÂÈ ÙȘ ÂÈÏÔΤ˜ (22). ª›· ·fi ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ Î·È ÈÔ ¿ÌÂÛ˜ ÂÈÏÔΤ˜ Ù˘ ¯ÚfiÓÈ·˜ ¯ÔÏfiÛÙ·Û˘ Â›Ó·È Ë ÌÂȈ̤ÓË

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·297

¶·È‰È·ÙÚÈ΋ 2001;64:293-299

¶›Ó·Î·˜ 5. ∞ÓÙÈÌÂÙÒÈÛË ·È‰ÈÔ‡ Ì ¯ÔÏfiÛÙ·ÛË 1. ¢È·ÙÚÔÊ‹ °¿Ï· Û‡Ìʈӷ Ì ÙȘ ıÂÚÌȉÈΤ˜ ÙÔ˘ ·Ó¿ÁΘ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ MCT (OÈÏ – ÊfiÚÌÔ˘Ï·) 2. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙË ÚÔ‹ Ù˘ ¯ÔÏ‹˜ º·ÈÓÔ‚·Ú‚ÈÙ¿ÏË 5 mg/kg, H ÃÔÏÂÛÙ˘Ú·Ì›ÓË 4 - 16 g/H ∆ÂÚÊÂÓ·‰›ÓË 1 - 3 mg/kg, H 3. π¯ÓÔÛÙÔȯ›· ·Û‚¤ÛÙÈÔ 25 - 100 mg/kg, H (ÛÙÔȯÂÈÒ‰ÂȘ ·Ó¿ÁΘ) ʈÛÊfiÚÔ˜ 25 - 50 mg/kg, H „¢‰¿ÚÁ˘ÚÔ˜ 1 mg/kg, H 4. µÈٷ̛Ә ·) ˘‰·ÙÔ‰È·Ï˘Ù¤˜ Û ‰‡Ô ‰fiÛÂȘ ‚) ÏÈÔ‰È·Ï˘Ù¤˜ ∞ 10000 - 15000 iu/H D 1200 - 5000 iu/H E 100 - 400 iu/H K 5 - 10 mg/ ·Ó¿ 3 - 5 Ë̤Ú˜ 5. ∞ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛΛÙË ™ÂÈÚÔÓÔÏ·ÎÙfiÓË 3 - 5 mg/kg, H ºÔ˘ÚÔÛÂÌ›‰Ë 1 - 2 mg/kg Ë̤ڷ ·Ú’ Ë̤ڷ, ¤ˆ˜ ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ ¶ÂÚÈÔÚÈÛÌfi˜ Na: ¤ˆ˜ 1 mg/kg, H

·¤ÎÎÚÈÛË ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ. ∏ ÌÂȈ̤ÓË ·˘Ù‹ ·¤ÎÎÚÈÛË Ù˘ ¯ÔÏ‹˜ ÛÙÔ ¤ÓÙÂÚÔ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ηٷÎÚ¿ÙËÛË Û˘ÛÙ·ÙÈÎÒÓ Ù˘ ¯ÔÏ‹˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÎÓËÛÌÔ‡, Í·ÓıˆÌ¿ÙˆÓ, ÈÎÙ¤ÚÔ˘, ηıÒ˜ Î·È Î·Ù·ÎÚ¿ÙËÛË ¯ÔÏÈÎÒÓ ÔͤˆÓ Î·È ÌÂÙ·ÏÏÈÎÒÓ ÈfiÓÙˆÓ (Cu, Mg, Al) Ô˘ ‰ÚÔ˘Ó ÙÔÍÈο ÛÙÔ ‹·Ú (3,4). ∂›Û˘, Ë ÌÂȈ̤ÓË ˘ÎÓfiÙËÙ· ¯ÔÏÈÎÒÓ ÔͤˆÓ ÛÙÔ ¤ÓÙÂÚÔ Ô‰ËÁ› Û η΋ ıÚ¤„Ë ÏfiÁˆ ·ÔÚÚfiÊËÛ˘ ÙÔ˘ Ï›Ô˘˜, ÙˆÓ ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ Î·È ‰È¿ÚÚÔȘ. ¶¤Ú·, fï˜, ·fi ÙȘ ÏÈÔ‰È·Ï˘Ù¤˜ ‚Èٷ̛Ә ··ÈÙÂ›Ù·È Ú‡ıÌÈÛË ÙˆÓ ıÚÂÙÈÎÒÓ ·Ó·ÁÎÒÓ. ∂Âȉ‹ Ô ‚·ıÌfi˜ Ù˘ ‰˘Û·ÔÚÚfiÊËÛ˘ ÙˆÓ ÏÈÒÓ ÌÔÚ› Ó· Â›Ó·È Ôχ ÌÂÁ¿ÏÔ˜ ·Ó Ë ÚÔ‹ Ù˘ ¯ÔÏ‹˜ ¤¯ÂÈ ÌÂȈı› ÛËÌ·ÓÙÈο, Ë Î¿Ï˘„Ë ÙˆÓ ıÂÚÌȉÈÎÒÓ ·Ó·ÁÎÒÓ (19) Ô˘ ·Ú¤¯ÔÓÙ·È Ì ÙȘ ÙÚÔʤ˜ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 125% ¤ˆ˜ 150%. ∏ η΋ ·ÔÚÚfiÊËÛË ÙÔ˘ Ï›Ô˘˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Ì¤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ ÏÈ·ÚÒÓ ·Ï‡ÛÂˆÓ (MC∆ formula-oil), ÂÓÒ ÔÈ ·Ó¿ÁΘ Û ÏÈÔ‰È·Ï˘Ù¤˜ ‚Èٷ̛Ә ·ÓÙÈÌÂÙˆ›˙oÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ‚ÈÙ·ÌÈÓÒÓ Û ‰fiÛÂȘ 2-4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ (3,16). ∏ ·ÚÔ˘Û›· Í·ÓıˆÌ¿ÙˆÓ Î·È ÎÓËÛÌÔ‡ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ Û˘Ó‹ıˆ˜ ÙËÓ Î·Ù·ÎÚ¿ÙËÛË Î·È ·‡ÍËÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÙÔ˘ ÔÚÔ‡ Î·È ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ, ·ÓÙ›ÛÙÔȯ·. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηٿÛÙ·Û˘ ·˘Ù‹˜ ¯ÔÚËÁÔ‡ÓÙ·È ¯ËÏÈΤ˜ Ô˘Û›Â˜ (.¯. ¯ÔÏÂÛÙ˘Ú·Ì›ÓË), ÔÈ Ôԛ˜ ·˘Í¿ÓÔ˘Ó ÙËÓ ¤ÎÎÚÈÛË (ÚÔ‹) Ù˘ ¯ÔÏ‹˜, ÌÂÈÒÓÔÓÙ·˜ ÙÔÓ ÂÓÙÂÚÔË·ÙÈÎfi ·ÎÏÔ Î·È Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ë ÔÔ›· ‰ÈÂÁ›-

Paediatriki 2001;64:293-299

ÚÂÈ ÙË ÚÔ‹ ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ (23). ∏ ¯ÔÏfiÛÙ·ÛË, Û·Ó ¯ÚfiÓÈ· ÂÍÂÏÈÛÛfiÌÂÓË ÓfiÛÔ˜, Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·Ó¿Ù˘ÍË ›ÓˆÛ˘, Ë ÔÔ›· ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË Î›ÚÚˆÛ˘ Î·È Ù· Â·ÎfiÏÔ˘ı¿ Ù˘, ÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË (˘ÂÚÛÏËÓÈÛÌfi˜, ·ÛΛÙ˘, ·ÈÌÔÚÚ·Á›· ·fi ÎÈÚÛÔ‡˜ ÔÈÛÔÊ¿ÁÔ˘) Î·È ÙËÓ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (1,3). ªÔÚ›, fï˜, Ë ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ Ó· ÔÊ›ÏÂÙ·È Û Á·ÛÙÚ›Ùȉ· ‹ ÂÙÈÎfi ¤ÏÎÔ˜. ∂Âȉ‹ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ‰È·ÊÔÚÂÙÈ΋, Â›Ó·È ··Ú·›ÙËÙË Ë ÂÓ‰ÔÛÎfiËÛË ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (4). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛΛÙË ˘·ÁÔÚ‡ÂÙ·È ·fi ÙËÓ ·Ó·ÎÔ‡ÊÈÛË Ù˘ ‰˘ÛÊÔÚ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔÓ Î›Ó‰˘ÓÔ ÂÚÈÙÔÓ·˚΋˜ ÌfiÏ˘ÓÛ˘. ™Â ‹ÈÔ ·ÛΛÙË, ·Ú¯Èο Û˘ÓÈÛÙ¿Ù·È ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ Ó·ÙÚ›Ô˘. ∏ ÚfiÛÏË„‹ ÙÔ˘ ÂÚÈÔÚ›˙ÂÙ·È ÛÙÔ 0,5 g ËÌÂÚËÛ›ˆ˜ (ÂÚ›Ô˘ 1-2 mEq/kg/24ˆÚÔ). ∞Ó Ë ÓÂÊÚÈ΋ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ÈηÓÔÔÈËÙÈ΋, ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ˜ Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÔÚËÁÔ˘Ì¤ÓˆÓ ˘ÁÚÒÓ. ∏ ‰ÈÔ‡ÚËÛË Û˘¯Ó¿ Ú˘ıÌ›˙ÂÙ·È Ì ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ fiˆ˜ Ë ÊÔ˘ÚÔÛÂÌ›‰Ë, ÌfiÓË ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÛÂÈÚÔÓÔÏ·ÎÙfiÓË, Ù· ÔÔ›· ·Ó·ÎÔ˘Ê›˙Ô˘Ó ÙÔÓ ·ÛıÂÓ‹ ÂÚÈÔÚ›˙ÔÓÙ·˜ ÙË Û˘ÛÛÒÚ¢ÛË ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡ ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ·. ™Â ·ÓıÂÎÙÈÎfi ·ÛΛÙË ‹ ·ÛΛÙË Ì ÌÂÁ¿ÏË ÔÛfiÙËÙ· ˘ÁÚÔ‡, Ë ÂÎÎÂÓˆÙÈ΋ ·Ú·Î¤ÓÙËÛË Î·È Ù·˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÏÂ˘ÎˆÌ·Ù›Ó˘ Î·È ÊÔ˘ÚÔÛÂÌ›‰Ë˜ ÌÔÚ› Ó· ·Ó·ÎÔ˘Ê›ÛÂÈ ÙÔÓ ·ÛıÂÓ‹ (24).

OÈ ÎÈÚÛÔ› ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Î·È ÙÔ˘ ıfiÏÔ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ·ÔÙÂÏÔ‡Ó Ì›· ÛÔ‚·Ú‹ ÂÈÏÔ΋ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Ô˘ ÌÔÚ› Ó· ·ÂÈÏ‹ÛÂÈ ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∫·Ù¿ ηÈÚÔ‡˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ̤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÎÈÚÛÒÓ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, fiˆ˜ Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ‚·ÛÔÚÂÛ›Ó˘, ‚ ·‰ÚÂÓÂÚÁÈÎÔ› ·Ó·ÛÙÔÏ›˜ (b blocking agents) fiˆ˜ Ë ÚÔÚ·ÓÔÏfiÏË (3,4) ‹ ‰È¿ÊÔÚ· ·Ó·ÛÙÔ̈ÙÈο ΢ÎÏÒÌ·Ù·. ™Â ‚·ÚȤ˜ ·ÈÌÔÚÚ·Á›Â˜ Ô˘ ÂÈ̤ÓÔ˘Ó, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ Ì·ÏfiÓÈ Sengstaken - Blakemore (25). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â˘Ú¤ˆ˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÈÌÔÚÚ·Á›·˜ Ë ÛÎÏËÚÔıÂÚ·›· Î·È Ù· ÂÏ·ÛÙÈο ‰·ÎÙ˘Ï›‰È· (rubber rings). ∏ ·Ó¿Ù˘ÍË ÈÓÒ‰Ô˘˜ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ‰È¿ÊÔÚ· Ê¿Ú̷η, fiˆ˜ Ë ÎÔϯÈΛÓË, Ë D-ÂÓÈÎÈÏÏ·Ì›ÓË Î·È Ù· ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉ‹. ŸÌˆ˜, Ù· ÂÚÈÛÙ·ÙÈο Â›Ó·È Ï›Á· Î·È ¯ÚÂÈ¿˙ÔÓÙ·È Î·È ¿ÏϘ ÌÂϤÙ˜ ÁÈ· Ó· ÂȂ‚·Èˆı› Ë ˆÊ¤ÏÂÈ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ (26,27). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ Ï‹„˘, Û˘ÓÙ‹ÚËÛ˘ Î·È ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜

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ªÂȈ̤ÓË ¤ÎÎÚÈÛË ¯ÔÏÈÎÒÓ ÔͤˆÓ ‰˘Û·ÔÚÚfiÊËÛË Ï›Ô˜ : η΋ ıÚ¤„Ë, ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘

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Î·È Ë ¯Ú‹ÛË ÙˆÓ ÓÂfiÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ë ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ó· ·ÔÙÂÏ› Û‹ÌÂÚ· ηıÈÂڈ̤ÓË Î·È ÁÂÓÈÎÒ˜ ·Ô‰ÂÎÙ‹ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË, fiÙ·Ó ˘¿Ú¯Ô˘Ó ÔÈ ·Ó¿ÏÔÁ˜ ÂӉ›ÍÂȘ. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ·È‰ÈÒÓ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (28) ·Ó¤Ú¯ÂÙ·È Û‹ÌÂÚ· ÛÙÔ 80% - 90%. ∆¤ÏÔ˜, ηٿ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ¯ÔÏÔÛÙ·ÙÈÎÔ‡ ·È‰ÈÔ‡ ı· Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó Î¿ÔÈ· ÁÂÓÈο ̤ÙÚ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÚÔ‚ÏËÌ¿ÙˆÓ, fiˆ˜ Ë ·Ó¿Ù˘ÍË, ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ›, Ë ˘ÁÈÂÈÓ‹ ÙˆÓ ‰ÔÓÙÈÒÓ Î·È Ë „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. µ) ÃÔÏfiÛÙ·ÛË Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ¯ÔÏfiÛÙ·Û˘ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÔÊ›ÏÔÓÙ·È Û ÏÔÈÌÒÍÂȘ Ô˘ ÚÔηÏÔ‡ÓÙ·È ÌÂÙ¿ ÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·. ∂›Û˘, ÔÏϤ˜ ·fi ÙȘ ηٷÛÙ¿ÛÂȘ Ô˘ ÚÔηÏÔ‡Ó ¯ÔÏfiÛÙ·ÛË ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ·ÚÁfiÙÂÚ· Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∆· Û˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ¯ÔÏfiÛÙ·ÛË ÛÙ· ·È‰È¿ ·˘Ù¿ Î·È ı· Ú¤ÂÈ Ó· ·Ó·˙ËÙËıÔ‡Ó, Â›Ó·È Ë ¯ÚfiÓÈ· Ë·Ù›Ùȉ· (ÈÔÁÂÓ‹˜, ·˘ÙÔ¿ÓÔÛË ‹ Ê·Ú̷΢ÙÈ΋), ·ÓÂ¿ÚÎÂÈ· Ù˘ ·1 ·ÓÙÈıÚ˘„›Ó˘, ÓfiÛÔ˜ Wilson, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Û‡Ó‰ÚÔÌ· ÂÓ‰ÔË·ÙÈ΋˜ ¯ÔÏfiÛÙ·Û˘, ¯ÔÏÔÏÈı›·ÛË, fiÁÎÔÈ Î.Ï.

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∏ ‰ÈÂÚ‡ÓËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ‰ÂÓ ‰È·Ê¤ÚÂÈ Ô˘ÛÈ·ÛÙÈο ·fi ÂΛÓË ÙˆÓ ÓÂÔÁÓÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Sucky FJ. Approach to the infant with cholestasis.

Chapter 20. In: Sucky FJ, editor. Liver Disease in Children. London: Mosby; 1994. p. 349-355.

2. Reichen J. Pharmacologic treatment of cholestasis. Sem Liv Dis 1993;13:302-315.

3. Moyer MS, Balistreri WF. Prolonged neonatal obstructive jaundice. In: Walker WA, Durie PR, Hamilton JR, WalkerSmith JA, Watkins JB, eds. Pediatric Gastrointestinal Disease-Pathophysiology-diagnosis-management. Philadelphia: Dc Decker Inc; 1991. p. 835-848.

4. Balistreri WF. Cholestasis in Behrman: Nelson Textbook of Pediatrics. 15th ed. W.B. Saunders Co; 1996.

5. Craig JM, Landing BH. Form of hepatitis in the neonatal period simulating biliary atresia. Arch Pathol 1952;54:321-333.

6. ∑ˆÁÚ¿ÊÔ˜ Ã, ™‡ÚÔÁÏÔ˘ ∫, §ÂΛ‰Ô˘ O. ÃÔÏÔÛÙ·ÙÈÎfi˜ ›ÎÙÂÚÔ˜ ÛÙ· ‚Ú¤ÊË: ¶·Ú·ÎÔÏÔ‡ıËÛË 49 ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ 1989;52:356-363.

7. ™‡ÚÔÁÏÔ˘ K, º·ÚÛ¿ÚË M, ∫·Ú·ÁÎÈfi˙ÔÁÏÔ˘-§·ÌÔ‡‰Ë £, ∑ˆÁÚ¿ÊÔ˜ Ã. π‰ÈÔ·ı‹˜ ÓÂÔÁÓÈ΋ Ë·Ù›Ùȉ·: ÔÚ›· Î·È ÚfiÁÓˆÛË. ¶·È‰È·ÙÚÈ΋ µ∂ 1995;7:269-272.

8. Mieli-Vergani G, Howard ER, Mowat A. Liver disease in infancy: a 20 year perspective. Gut 1991;32(Suppl): S123-S128.

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Extahepatic biliary atresia: preoperative assessment and surgical results in 47 consecutive cases. Arch Dis Child 1980;55:851.

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12. DeBelle RC, Vaupshas V, Vitullo BB et al. Intestinal absorption of bile salts: immature development in the neonate. J Pediatr 1979;94:472-476.

13. Franken EA, Smith WL, Siddiqui A. Noninvasive evaluations of liver disease in pediatrtics. Radiol Clin N Am 1980;18:239-252.

14. ª·Ï¿Ûη ∞, •˘ÓÈ¿˜ π, ¶··¯Ú‹ÛÙÔ˘ º, ¡Ù·Ú›Ï˘ ∂, ™‡ÚÔÁÏÔ˘ ∫. ™‡Ó‰ÚÔÌÔ Alagille. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ µ∂ 1999;11:125-129.

14·. Krishnamurthy S, Krishnamurthy GT. Technetium-99m iminodiacetic acid organic anions: review of biokinetcs and clinical application in hepatology. Hepatology 1989;9:139-153.

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20. Ferry DG, Selby ML, Udall J et al. Guide to early diagnosis of biliary obstruction in infancy. Review of 143 cases. Clin Pediatr 1985;24:305-311.

21. Brough AJ, Bernstein J. Conjugated hyperbilirubinaemia in early infancy. Human Pathol 1974;5:507-514.

22. Bloomer JR, Boyer JL. Phenobarbital effects in cholestatic liver disease. Ann Intern Med 1985;82:310-317.

23. Gines P, Tito L, Arroyo V et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493-1502.

24. Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices: a decadal progress report.

Dig Dis Sci 1980;25:267-272.

25. Starzl TE, Iwatsuki S, VanThiel DH et al. Evolution of liver transplantation. Hepatology 1982;2:614-636.

26. Lee H, Vacanti JP. Liver transplantation and its long term management in children. Pediatr Clin N Am 1996;43:99-124.

27. Zifroni A, Schaffner F. Long term follow-up of patients with PBC on colchicine therapy. Hepatology 1991;14:990-993.

28. Ramirez RO, Sokol RJ. Medical management of cholestasis. In: Sucky F, ed. Liver disease in children.

London: Mosby; 1994. p. 356-388.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌ›Ô, 546 42, £ÂÛÛ·ÏÔÓ›ÎË e-mail: klspirog@med.auth.gr

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GASTROENTEROLOGY-HEPATOLOGY-NUTRITION

ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÛÙËÓ ∂ÏÏ¿‰·. ∆È ¤¯ÂÈ Á›ÓÂÈ - ªÂÏÏÔÓÙÈΤ˜ ÚˆÙÔ‚Ô˘Ï›Â˜ £. ∑¿¯Ô˘

Breastfeeding in Greece. What has been done - Targets for the future T. Zachou

¶ÂÚ›ÏË„Ë: ∏ ¶·ÁÎfiÛÌÈ· ∞genda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË ·fi ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ›ӷÈ: 1981, ı¤ÛÈÛË ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. 1989, ηıÔÚÈÛÌfi˜ ÙˆÓ “¢¤Î· µËÌ¿ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. 1990, “¢È·Î‹Ú˘ÍË Innocenti”, ÁÈ· ÙËÓ ¶ÚÔÛÙ·Û›·, ÀÔÛÙ‹ÚÈÍË Î·È ¶ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. 1992-1993, ¶ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԕ, “ºÈÏÈÎfi ÃÒÚÔ ∂ÚÁ·Û›·˜ Ù˘ ªËÙ¤Ú·˜” Î·È ı¤ÛÈÛË Ù˘ “¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”.

2000, ÛÙfi¯Ô˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌÔ‡ ÀÁ›·˜ ÙˆÓ ∏.¶.∞, ÒÛÙ ٷ ÔÛÔÛÙ¿ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ó· ÊÙ¿ÛÔ˘Ó ÙÔ 75%. ™ÙË ¯ÒÚ· Ì·˜ ·Ú·ÙËÚÂ›Ù·È ÛÙ·ıÂÚ¿ ·˘Í·ÓfiÌÂÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ·fi ÙËÓ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ· Î·È ÙËÓ ¶ÔÏÈÙ›·. ∆Ô 1979-81 Ú·ÁÌ·ÙÔÔÈ‹ıËΠηÌ¿ÓÈ· “∂ÈÛÙÚÔÊ‹ ÛÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. ∆Ô 1983 ˘ÈÔıÂÙ‹ıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ÂÓ·ÚÌÔÓ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ∆Ô 1985 ȉڇıËΠÛÙÔ ª·ÈÂ˘Ù‹ÚÈÔ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘” ªÔÓ¿‰· ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ∆Ô 1993 Û˘ÛÙ‹ıËΠ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ∆Ô 1995 ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÛÙ· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µËÌ¿ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. ∆Ô 1996 ıÂÛ›ÛÙËÎÂ Ë “¶·ÁÎfiÛÌÈ· ∂‚‰ÔÌ¿‰· ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”. ∆Ô 1997 ηıÈÂÚÒıËÎ·Ó ÛÂÌÈÓ¿ÚÈ· 40 ˆÚÒÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ÁÈ· Â·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜. ∆Ô 1999 Ë ÁÔÓÈ΋ ¿‰ÂÈ· ¤ÁÈÓ ÂÙ‹ÛÈ· Ì Ï‹ÚÂȘ ·Ô‰Ô¯¤˜ Ù˘ ÂÚÁ·˙fiÌÂÓ˘ ÌËÙ¤Ú·˜. ¢Â‰Ô̤ÓÔ˘ fiÙÈ

Abstract: The World Breastfeeding Agenda is full of dates for breastfeeding promotion. The most important are the following: 1981, “International Code of Marketing of Breast Milk Substitutes”.

1989, Statement of WHO and UNICEF for the “Ten Steps to Successful Breastfeeding”. 1990, “Innocenti Declaration on Protecting, Supporting and Promoting Breastfeeding”. 1992-3, “BabyFriendly Hospital Initiative”, “Mother-Friendly Work Place Initiative” and establishment of the “World Breastfeeding Week”. 2000, The National Health Promotion and Disease Prevention objectives of U.S.A. targets to increase to 75% the percentage of breastfeeding mothers. In our country, there is an increasing interest in breastfeeding among health professionals and the Government. 197981, campaign “Return to Breastfeeding”. 1983, the Greek Government adopted the “International Code of marketing of Breast Milk Substitutes”.

1985, a Breastfeeding Promotion Unit was established at “Helena Venizelou” Maternity Hospital in Athens. 1993, a National Breastfeeding Committee was established. 1995, the Ministry of Health sent a circular to all Maternity Hospitals requesting the implementation of the “Ten Steps to Successful Breastfeeding”. Since 1996, the “World Breastfeeding Week” is celebrated in Greece. Since 1997, a 40-hour Breastfeeding seminar has been established for health professionals. In 1999, maternity leave was increased to one year, with the mother being granted full salary. In Greece, there has been no recent data concerning national breastfeeding

¶·È‰›·ÙÚÔ˜ - ¡ÂÔÁÓÔÏfiÁÔ˜ ∆¤ˆ˜ ¢È¢ı‡ÓÙÚÈ· Ù˘ ªÔÓ¿‰·˜ º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁ¤ÓÓËÙˆÓ - ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ∆Ú¿Â˙·˜ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜ ÙÔ˘ ¡ÂÔÁÓÔÏÔÁÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ¶.°.¡. ª·È¢ÙËÚ›Ô˘ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘”

Pediatrician - Neonatologist Former Director of the Unit of Normal Newborns Promotion of Breast Feeding - Maternal Milk Bank, Neonatology Division of the General Maternity Hospital “Elena Venizelou”, Athens

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Paediatriki 2001;64:300-303

ÛÙË ¯ÒÚ· Ì·˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚfiÛÊ·Ù· ÔÛÔÛÙ¿ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi Â›‰Ô, ÚˆÙ·Ú¯ÈÎfi ̤ÏËÌ· ı· ‹Ù·Ó Ì›· ·ÓÂÏÏ‹ÓÈ· ¤Ú¢ӷ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘˜ Î·È ÌÂÙ¿, ÁÓˆÚ›˙ÔÓÙ·˜ ÙËÓ Ù˘¯fiÓ ·ÓÂ¿ÚÎÂÈ·, Ì ·fiÏ˘ÙË ÁÓÒÛË Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Î·Ù¿ÏÏËϘ Û˘Óı‹Î˜ ÒÛÙÂ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Ó· Á›ÓÂÈ Ë ÂÈÎÚ·Ù¤ÛÙÂÚË ‰È·ÙÚÔÊ‹.

rates, and therefore there is a great need for a national census the results of which will help to create the appropriate conditions for making breastfeeding the predominant feeding modality.

§¤ÍÂȘ ÎÏÂȉȿ: ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÔÏÈÙÈ΋, ÚÔ·ÁˆÁ‹, ˘ÔÛÙ‹ÚÈÍË.

Key words: breastfeeding, policy, promotion, support.

∏ ÂÔ¯‹ Ì·˜ Â›Ó·È ÂÔ¯‹ ¤ÎÚË͢ ÁÓÒÛÂˆÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È Ô ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ Í·Ó·ÎÂÚ‰›˙ÂÈ ÙË ¯·Ì¤ÓË ÙÔ˘ ı¤ÛË Û·Ó ÙË ÌÔÓ·‰È΋ Î·È ·Ó·ÓÙÈηٿÛÙ·ÙË ÙÚÔÊ‹ ÁÈ· ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Î·È ÙÔ ‚Ú¤ÊÔ˜. ∆·˘Ùfi¯ÚÔÓ· ÚÔ‚¿ÏÏÔÓÙ·È Î·È Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÁÈ· ÙÔ ·È‰›, ÙË ÌËÙ¤Ú·, ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÙËÓ ÎÔÈÓˆÓ›·, ÙËÓ ÔÏÈÙ›·, ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù· ÔÔ›· Â›Ó·È ·Ó·ÌÊÈÛ‚‹ÙËÙ·. ∏ ¶·ÁÎfiÛÌÈ· ∞genda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË ·fi ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘. ¶ÚÈÓ ‰Ô‡Ì ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙË ¯ÒÚ· Ì·˜, ı· ·Ó·ÊÂÚıԇ̠۠ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜, ÁÈ·Ù› fiÔÈÔ˜ ÂӉȷʤÚÂÙ·È ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‰ÂÓ ı· ¤ÚÂ ӷ ÙȘ ·ÁÓÔ›. ŒÙÛÈ, ÙÔ 1981 ÛÙËÓ ¶·ÁÎfiÛÌÈ· ™˘Ó¿ÓÙËÛË ÀÁ›·˜ ıÂÛ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” ÁÈ· ÙË ÛˆÛÙ‹ ¯Ú‹ÛË ÙÔ˘˜, ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Ì ȷÙÚÈ΋ Û˘ÓÙ·Á‹ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÓÂͤÏÂÁÎÙ˘ ‰È·Ê‹ÌÈÛ‹˜ ÙÔ˘˜ (1). ∞ÔÙ¤ÏÂÛÌ· ·˘ÙÒÓ ˘‹ÚÍÂ Ë ÚÔÛÙ·Û›· ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. O ∫Ò‰Èη˜ ÈÛ¯‡ÂÈ ‰ÈÂıÓÒ˜ ·fi ÙÔ 1983. ∆Ô 1989 ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ Î·È ÙËÓ UNICEF, ÙÔÓ›ÛÙËÎÂ Ô ÂȉÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ ÚÔÛˆÈÎÔ‡ ÙˆÓ ª·È¢ÙËÚ›ˆÓ ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚÈÍË, ÙËÓ ÚÔ¿ÛÈÛË Î·È ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Î·È ÔÚ›ÛÙËÎ·Ó Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ÂÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” (2). £· ·Ó·ÊÂÚıԇ̠ÌÂ Û˘ÓÙÔÌ›· Û ·˘Ù¿. ¶Ú¤ÂÈ: 1) ¡· ˘¿Ú¯ÂÈ ÁÚ·Ù‹ ÔÏÈÙÈ΋ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Î·È Ë ÔÏÈÙÈ΋ ·˘Ù‹ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ª·È¢ÙËÚ›Ô˘, Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘. 2) ∆Ô ÚÔÛˆÈÎfi Ó· ÂÎ·È‰Â‡ÂÙ·È, ÒÛÙ ӷ Â›Ó·È ÈηÓfi Ó· ÂÊ·ÚÌfiÛÂÈ ÙËÓ ÔÏÈÙÈ΋ ·˘Ù‹. 3) ¡· ÂÓËÌÂÚÒÓÔÓÙ·È fiϘ ÔÈ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ ÁÈ· Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ó· ÂÎ·È‰Â‡ÔÓÙ·È.

4) ¡· ‰›‰ÂÙ·È ‚Ô‹ıÂÈ· ÛÙȘ Ӥ˜ ÌËÙ¤Ú˜ Ó· ÍÂÎÈÓ‹ÛÔ˘Ó ÙÔ ıËÏ·ÛÌfi ̤۷ ÛÙÔ ÚÒÙÔ ËÌ›ˆÚÔ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. 5) OÈ ÌËÙ¤Ú˜ Ó· ÍÂÎÈÓ‹ÛÔ˘Ó ÛˆÛÙ¿ ÙÔ ªËÙÚÈÎfi ıËÏ·ÛÌfi, ÁÈ·Ù› Ë ÛˆÛÙ‹ ÙÔÔı¤ÙËÛË ÙÔ˘

·È‰ÈÔ‡ ÛÙÔ ÛÙ‹ıÔ˜ Ù˘ ÌËÙ¤Ú·˜ Â›Ó·È ÙÔ ∞ Î·È ÙÔ ø Ù˘ ÂÈÙ˘¯›·˜ ÙÔ˘. ∞ÎfiÌË, Ú¤ÂÈ Ó· ÂÎ·È‰Â‡ÔÓÙ·È ÒÛÙ ӷ ‰È·ÙËÚÔ‡Ó ÙË Á·ÏÔ˘¯›· Û ÂÚ›ÙˆÛË Ô˘ Ù˘¯fiÓ ı· ·Ô¯ˆÚÈÛÙÔ‡Ó Ù· ·È‰È¿ ÙÔ˘˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ¤Ó· ÚfiˆÚÔ ÙÔÎÂÙfi ‹ ÛÙË Á¤ÓÓËÛË ÂÓfi˜ ÚÔ‚ÏËÌ·ÙÈÎÔ‡ ·È‰ÈÔ‡. 6) ™ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Ó· ‰›ÓÂÙ·È ÌfiÓÔ ÌËÙÚÈÎfi Á¿Ï·, Ô‡Ù ˘ÁÚ¿, Ô‡ÙÂ Û˘Ìϋڈ̷ ͤÓÔ˘ Á¿Ï·ÎÙÔ˜, ÂÎÙfi˜ Â¿Ó ˘¿Ú¯ÂÈ ÂȉÈÎfi˜ È·ÙÚÈÎfi˜ ÏfiÁÔ˜. 7) ¡· ÂÊ·ÚÌfi˙ÂÙ·È ÙÔ Û‡ÛÙËÌ· “rooming in”, Ô˘ ÛËÌ·›ÓÂÈ ÙÔ ÓÂÔÁ¤ÓÓËÙÔ Ó· Â›Ó·È ‰›Ï· ÛÙË ÌËÙ¤Ú· ÙÔ˘ 24 ÒÚ˜ ÙÔ 24ˆÚÔ. 8) ¡· ÂÓı·ÚÚ‡ÓÂÙ·È Ô Î·Ù¿ ‚Ô‡ÏËÛË ıËÏ·ÛÌfi˜. ∆Ô ·È‰› Ó· ÙÚÒÂÈ fiÔÙ ı¤ÏÂÈ, fiÛÔ ı¤ÏÂÈ ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙË Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ÙˆÓ ÁÂ˘Ì¿ÙˆÓ. 9) ¡· ÌËÓ ‰›ÓÔÓÙ·È È›Ï˜ ÛÙ· ·È‰È¿ Ô˘ ıËÏ¿˙Ô˘Ó. 10) ¡· È‰Ú˘ıÔ‡Ó ÔÌ¿‰Â˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙȘ Ôԛ˜ Ó· ÌÂÙ¤¯Ô˘Ó ÌËÙ¤Ú˜, ÁÈ· ÙË Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ª·ÈÂ˘Ù‹ÚÈÔ. ∆Ô 1990, ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜, ÙËÓ UNICEF Î·È ¿ÏÏÔ˘˜ ¢ÈÂıÓ›˜ OÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ÀÁ›· Î·È ¢È·ÙÚÔÊ‹ ÙÔ˘ ¶·È‰ÈÔ‡ ·Ó·ÎÔÈÓÒıËÎÂ Ë “¢È·Î‹Ú˘ÍË Innocenti” (1) Û‡Ìʈӷ Ì ÙËÓ ÔÔ›·: i) ŸÏ˜ ÔÈ Î˘‚ÂÚÓ‹ÛÂȘ ̤¯ÚÈ ÙÔ 1995 ı· Ú¤ÂÈ Ó· ÔÚ›ÛÔ˘Ó ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ii) ¶Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Û fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi”. O ·ÔÎÏÂÈÛÙÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È Ì¤¯ÚÈ Î·È ÙÔÓ 6Ô Ì‹Ó· Î·È Ô ÌÂÚÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ (‰ËÏ·‰‹ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ¿ÏϘ ÙÚÔʤ˜) Ó· Û˘Ó¯›˙ÂÙ·È Î·È ¤Ú· ·fi Ù· 2 ¯ÚfiÓÈ·. iii) ¶Ú¤ÂÈ Ó· ÙËÚÔ‡ÓÙ·È Ù· ¿ÚıÚ· ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. iv) ¶Ú¤ÂÈ Ó· ıÂÛÈÛÙ› ¢ÂÚÁÂÙÈ΋ ÓÔÌÔıÂÛ›· ÁÈ· ÙȘ ÌËÙ¤Ú˜ Ô˘ ıËÏ¿˙Ô˘Ó Î·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Û˘Óı‹Î˜, ÒÛÙÂ Ë ÓÔÌÔıÂÛ›· Ó· ÂÊ·ÚÌfi˙ÂÙ·È. ∆Ô 1992 ·Ó·ÎÔÈÓÒıËΠ·fi ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ Î·È ÙËÓ UNICEF Ë ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌÂ›Ô - Baby Friendly Hospital Initiative”. O ·ÎÚÔÁˆÓÈ·›Ô˜ Ï›ıÔ˜ ÙÔ˘ “ºÈÏÈÎÔ‡ ÁÈ· ÙÔ µÚ¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԣ” Â›Ó·È Ë

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ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µ‹Ì·ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Î·È Ë Ù‹ÚËÛË ÙˆÓ ¿ÚıÚˆÓ ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ™‹ÌÂÚ·, Ô ·ÚÈıÌfi˜ ÙÔ˘˜ ÍÂÂÚÓ¿ ÙȘ 15.000 Û 128 ¯ÒÚ˜. ∆· 6000 ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ∫›Ó·. ŸÏ˜ ÔÈ ∂˘Úˆ·˚Τ˜ ¯ÒÚ˜ ¤¯Ô˘Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ “ºÈÏÈÎfi ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ ¡ÔÛÔÎÔÌ›Ԕ. ∏ °ÂÚÌ·Ó›· ¤¯ÂÈ 11. ∏ ∞ÁÁÏ›· ¤¯ÂÈ 23. ™ÙË ™Î·Ó‰ÈÓ·‚›· fiÏ· Ù· ¡ÔÛÔÎÔÌ›· Â›Ó·È ºÈÏÈο ÁÈ· ÙÔ ‚Ú¤ÊÔ˜. ŸÏ˜ ÔÈ ¯ÒÚ˜ Ù˘ µ·ÏηÓÈ΋˜ ¤¯Ô˘Ó ·fi ¤Ó·. ∏ ∞Ï‚·Ó›· ·¤ÎÙËÛ ÚfiÛÊ·Ù· ÙÔ ‰Â‡ÙÂÚÔ. ∏ ∆Ô˘ÚΛ· ¤¯ÂÈ ¿Óˆ ·fi 70. ∏ ∞›Á˘ÙÔ˜ ¤¯ÂÈ 117, ÂÓÒ Ë ∂ÏÏ¿‰· ηӤӷ. ∂›Û˘, ÙÔ ›‰ÈÔ ¤ÙÔ˜ ηıÈÂÚÒıËÎÂ Ë “¶·ÁÎfiÛÌÈ· ∂‚‰ÔÌ¿‰· ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ 1-7 ∞˘ÁÔ‡ÛÙÔ˘” ·fi ÙËÓ W.A.B.A. (World Alliance for Breastfeeding Action). ∫¿ı ¯ÚfiÓÔ, ÁÈ· ÙÔÓ ÂÔÚÙ·ÛÌfi Ù˘ ÔÚ›˙ÂÙ·È ¤Ó· ı¤Ì·. °È· ·˘Ùfi ÙÔ ¤ÙÔ˜ ÙÔ ı¤Ì· ›ӷÈ: “ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ - ¢Èη›ˆÌ· ÛÔ˘”. ∆Ô 1993 ·Ó·ÎÔÈÓÒıËΠ·fi ÙËÓ W.A.B.A. Î·È ˘ÔÛÙËÚ›¯ÙËΠ·fi ÙËÓ ¶.O.À. Î·È UNICEF, Ë ÚˆÙÔ‚Ô˘Ï›· ÁÈ· ÙÔ “ºÈÏÈÎfi ÃÒÚÔ ∂ÚÁ·Û›·˜ Ù˘ ªËÙ¤Ú·˜ - Mother-Friendly Work Place Initiative”, Ô˘ ¤¯ÂÈ ÛÙfi¯Ô Ó· ‰›‰ÂÙ·È ‰˘Ó·ÙfiÙËÙ· ÛÙË ÌËÙ¤Ú· Ó· ıËÏ¿˙ÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÁ·Û›·˜ Ù˘ Ì ÂȉÈο ‰È·Ï›ÌÌ·Ù· Î·È Û ÂȉÈÎfi ¯ÒÚÔ (4). ªÂ fiÏ· ·˘Ù¿ Ù· ̤ÙÚ·, ÙȘ ÚˆÙÔ‚Ô˘Ï›Â˜, ÙÔ˘˜ ıÂÛÌÔ‡˜ Î·È ÔÏÏ¿ ¿ÏÏ· (·ÊÔ‡, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ë Agenda ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È ÁÂÌ¿ÙË Ì ËÌÂÚÔÌËӛ˜-ÛÙ·ıÌÔ‡˜ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘) Û fiÏÔ ÙÔÓ ÎfiÛÌÔ, Û˘Ó¯Ҙ Ù· ÔÛÔÛÙ¿ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·˘Í¿ÓÔ˘Ó. ∫·È ¿ÏÈ, Ù· ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿, Ô˘ ÍÂÂÚÓÔ‡Ó ÙÔ 95%, η٤¯Ô˘Ó ÔÈ ™Î·Ó‰ÈÓ·‚ÈΤ˜ ¯ÒÚ˜.

O ∂ıÓÈÎfi˜ ¶ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ ÀÁ›·˜ ÙˆÓ ∏.¶.∞. ¤¯ÂÈ ÛÙfi¯Ô ηٿ ÙÔ ¤ÙÔ˜ 2000, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ıËÏ¿˙Ô˘Ó Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ Ó· Êı¿ÛÂÈ ÙÔ 75%, ÂÓÒ Î·Ù¿ ÙÔÓ ¤ÎÙÔ Ì‹Ó· ÙÔ 50% (5).

O ÙfiÔ˜ Ì·˜ ıˆÚÂ›Ù·È Ë ¯ÒÚ· Ì ٷ ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·fi fiϘ ÙȘ ¯ÒÚ˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘. ∂›Ó·È fï˜ ‚¤‚·ÈÔ, fiÙÈ ·Ú·ÙËÚÂ›Ù·È ÛÙ·ıÂÚ¿ ·˘Í·ÓfiÌÂÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi ΢ڛˆ˜ ·fi ÙÔ˘˜ Ó¤Ô˘˜ ÁÈ·ÙÚÔ‡˜, ·È‰›·ÙÚÔ˘˜ ·ÎfiÌË Î·È Ì·ÈÂ˘Ù‹Ú˜, Ì·›Â˜ ·ÏÏ¿ Ôχ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙȘ ÌËÙ¤Ú˜. ∂ÍÂÙ¿˙ÔÓÙ·˜ ÙÈ ¤ÁÈÓ ÛÙÔÓ ÙfiÔ Ì·˜ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi, ·Ú¯›˙Ô˘Ì ·fi ÙÔ 1979-1981 Ì ÙËÓ Î·Ì¿ÓÈ· : “∂ÈÛÙÚÔÊ‹ ÛÙÔÓ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Ù˘ ∞’ ¶·ÓÂÈÛÙËÌȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ. ∂› ‰‡Ô ¯ÚfiÓÈ· ·Ú·ÙËÚ‹ıËΠÌÈ· ·‡ÍËÛË ÙˆÓ ÔÛÔÛÙÒÓ. ªÂÙ¿, fï˜, ·fi ·˘Ùfi ‹ÏıÂ Î·È ¿ÏÈ ÙÔ Ù¤ÏÌ·. ∆Ô 1983 ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ-

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·˜, ˘ÈÔıÂÙ‹ıËÎÂ Î·È ÂÓ·ÚÌÔÓ›ÛÙËÎÂ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” (6). ∞fi ÙÔ 1985 ÛÙÔ ª·ÈÂ˘Ù‹ÚÈÔ “ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘” ÏÂÈÙÔ˘ÚÁ› ÂȉÈ΋ ªÔÓ¿‰· º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁ¤ÓÓËÙˆÓ - ¶ÚÔ·ÁˆÁ‹˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ∆Ú¿Â˙· ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜, Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÔÔ›·˜ ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi ÙÔ 1947 (7). ∏ ªÔÓ¿‰·, ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Ù˘, Ì ÂȉÈο ÚÔÁÚ¿ÌÌ·Ù· ÂÎ·È‰Â‡ÂÈ ÂȉÈ΢fiÌÂÓÔ˘˜ ·È‰›·ÙÚÔ˘˜, ÊÔÈÙËÙ¤˜ ª·È¢ÙÈÎÒÓ Î·È ¡ÔÛËÏ¢ÙÈÎÒÓ ™¯ÔÏÒÓ Î·ıÒ˜ Î·È Ì¤ÏÏÔÓÙ˜ Î·È Ó¤Ô˘˜ ÁÔÓ›˜. ∆Ô 1993 Û˘ÛÙ‹ıËÎÂ Ë ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ (8). ∆Ô 1995 ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜ ÚÔ˜ fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· Ô˘ ¤¯Ô˘Ó Ì·È¢ÙÈο Î·È ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Ì ÛÎÔfi Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È, Û‡Ìʈӷ Ì ÙË “¢È·Î‹Ú˘ÍË Innocenti”, Ù· “¢¤Î· µ‹Ì·Ù· ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” Ô˘ ıÂÛ›ÛÙËÎ·Ó ·fi ÙËÓ ¶.O.À. Î·È ÙËÓ UNICEF (9). ∆Ô 1996 ηıÈÂÚÒıËÎÂ Î·È ÂÓ·ÚÌÔÓ›ÛÙËΠ̠ÙȘ Û˘Óı‹Î˜ Ù˘ ¯ÒÚ·˜ Ì·˜ Ô ÂÔÚÙ·ÛÌfi˜ Ù˘ “¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡”, ·fi 1-7 ¡ÔÂÌ‚Ú›Ô˘ οı ¯ÚfiÓÔ, ÁÈ· ÂÓË̤ڈÛË Î·È Â˘·ÈÛıËÙÔÔ›ËÛË, ÙfiÛÔ ÙˆÓ ˘‡ı˘ÓˆÓ ÁÈ· ÙËÓ ÚÔ·ÁˆÁ‹ ÙÔ˘, fiÛÔ Î·È Ù˘ ÎÔÈÓˆÓ›·˜ ÁÂÓÈÎfiÙÂÚ· (10). ∆Ô 1997 ηıÈÂÚÒıËÎ·Ó ÛÂÌÈÓ¿ÚÈ· 40 ˆÚÒÓ ÁÈ· ÙÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi, 2 ÊÔÚ¤˜ ÙÔ ¯ÚfiÓÔ ÁÈ· ·È‰›·ÙÚÔ˘˜, Ì·›Â˜ Î·È ¿ÏÏÔ˘˜ Â·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜ Ô˘ ˘ËÚÂÙÔ‡Ó Û ‰ËÌfiÛÈ· ȉڇ̷ٷ, ÒÛÙ ӷ Á›ÓÔ˘Ó ˘Ú‹Ó˜ ÂÎ·›‰Â˘Û˘ ÛÙÔ˘˜ ¯ÒÚÔ˘˜ ÂÚÁ·Û›·˜ ÙÔ˘˜ (11). ∂›Û˘, ηıÈÂÚÒıËΠÂÙ‹ÛÈ· ËÌÂÚ›‰· ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Ì ¢ÈÂıÓ‹ ™˘ÌÌÂÙÔ¯‹ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ∂·ÁÁÂÏ̷ٛ˜ ÀÁ›·˜. ∞ÎfiÌË, Â›Ó·È ÁÓˆÛÙfi fiÙÈ Û οı ÂÈÛÙËÌÔÓÈ΋ ·È‰È·ÙÚÈ΋ Û˘Ó¿ÓÙËÛË Î·È Û˘Ó¤‰ÚÈÔ Á›ÓÔÓÙ·È ·Ó·ÎÔÈÓÒÛÂȘ Î·È ·Ó·ÊÔÚ¤˜ ÛÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi. ∆Ô 1998 ¤ÁÈÓ ÂÚÒÙËÛË ÛÙËÓ µÔ˘Ï‹ ·) ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ÏËÚÔÊfiÚËÛ˘ Î·È ÂÎ·›‰Â˘Û˘ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi ·fi ÙÔ ÓËÈ·ÁˆÁÂ›Ô ˆ˜ ÙËÓ ∞ÓÒÙ·ÙË ∂Î·›‰Â˘ÛË, ‚) ÁÈ· ‰˘Ó·ÙfiÙËÙ· ı¤ÛÈÛ˘ ¢ÂÚÁÂÙÈ΋˜ ÓÔÌÔıÂÛ›·˜ ÁÈ· ÙËÓ ÂÚÁ·˙fiÌÂÓË ÌËÙ¤Ú· Ô˘ ıËÏ¿˙ÂÈ Î·È Á) ÁÈ· ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎÔÈÓÔ‡ Ì ٷ ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘. ∆Ô 1999 ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ÂÛÙ¿ÏË ÂÁ·ÎÏÈÔ˜ ÚÔ˜ fiÏ· Ù· ª·ÈÂ˘Ù‹ÚÈ· Î·È ¡ÔÛÔÎÔÌ›· Ó· ÙËÚÂ›Ù·È Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜”. ∆ÔÓ ›‰ÈÔ ¯ÚfiÓÔ Â›Û˘, „ËÊ›ÛÙËΠÓfiÌÔ˜ Û‡Ìʈӷ Ì ÙÔÓ ÔÔ›Ô Ë ÁÔÓÈ΋ ¿‰ÂÈ· ¤ÁÈÓ ¤Ó·˜ ¯ÚfiÓÔ˜, Ì Ï‹ÚÂȘ ·Ô‰Ô¯¤˜ Ù˘ ÂÚÁ·˙fiÌÂÓ˘ ÌËÙ¤Ú·˜. ∏ ·Í›· ·˘ÙÒÓ fï˜, ı· ‹Ù·Ó ÛËÌ·ÓÙÈ΋ ¿Ó

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fiÏ· ·˘Ù¿ ÂÊ·ÚÌfi˙ÔÓÙ·Ó. ŸÏÔÈ Í¤ÚÔ˘Ì fiÙÈ Ô “¢ÈÂıÓ‹˜ ∫Ò‰Èη˜ ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” Û˘Ó¯Ҙ ·Ú·‚È¿˙ÂÙ·È Â›ÛËÌ· Î·È ·ÓÂ›ÛËÌ·. ∆Ô ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜ ¤ÛÙÂÈÏ ÙËÓ ÂÁ·ÎÏÈÔ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µ‹Ì·ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ ªËÙÚÈÎfi £ËÏ·ÛÌfi” ÙÔ 1995. ™‹ÌÂÚ·, ¤ÓÙ ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ù· ª·ÈÂ˘Ù‹ÚÈ· Ô˘ ÂÊ·ÚÌfi˙Ô˘Ó ¤ÛÙˆ Î·È ÌÂÚÈο ·fi Ù· ‚‹Ì·Ù· Â›Ó·È ÂÏ¿¯ÈÛÙ·. ∏ ÚÔ·ÁˆÁ‹ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ‰ÂÓ Â›Ó·È ı¤Ì· ·Ïfi. ÃÚÂÈ¿˙ÂÙ·È ÛˆÛÙ‹ ÂÓË̤ڈÛË, Û˘ÓÂÚÁ·Û›· ÔÏÏÒÓ ÊÔÚ¤ˆÓ, ·ÓȉÈÔÙ¤ÏÂÈ·, ·ÓıÚÒÈÓË Â·Ê‹ Î·È Î˘Ú›ˆ˜ ·Ó·ÁÓÒÚÈÛË Ù˘ ÛÔ˘‰·ÈfiÙËÙ¿˜ ÙÔ˘ ÁÈ· ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. ∞fi‰ÂÈÍË Ù˘ ·Ó·ÁÓÒÚÈÛ˘ Ù˘ ÛÔ˘‰·ÈfiÙËÙ·˜ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Â›Ó·È Î·È Ë ·ÔÓÔÌ‹ ÙÔ 1998, ·ÚÂÌÊÂÚÔ‡˜ ‚Ú·‚›Ԣ Nobel, (Ô˘ ηıÈÂÚÒıËΠÁÈ· ÙË ‚Ú¿‚¢ÛË ·ÙfiÌˆÓ ‹ ÔÚÁ·ÓÈÛÌÒÓ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó Ì ÙÔ ¤ÚÁÔ ÙÔ˘˜ ÛÙÔ Î·Ïfi Ù˘ ·ÓıÚˆfiÙËÙ·˜), Û ÌË ∫˘‚ÂÚÓËÙÈÎfi OÚÁ·ÓÈÛÌfi, ÛÙÔ International Baby Food Action Network (¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô µÚÂÊÈÎÒÓ ∆ÚÔÊÒÓ), ÁÈ·Ù› Â› 15 ¯ÚfiÓÈ· Ì¿¯ÂÙ·È ÁÈ· ÙËÓ Ù‹ÚËÛË ÙÔ˘ “¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜” (12). °ÓˆÚ›˙ÔÓÙ·˜ ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙÔÓ ÙfiÔ Ì·˜ Î·È ¤¯ÔÓÙ·˜ Ù· ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·Ó¿ÌÂÛ· Û ¿ÏϘ ¯ÒÚ˜, ı· ¤ÚÂ ӷ ÁÓˆÚ›˙Ô˘Ì Û ÙÈ ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ·˘Ù‹ Ë ı¤ÛË. ¶·Ú’ fiÏ· ·˘Ù¿, ÚfiÛÊ·Ù· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi Â›Â‰Ô ÛÙÔÓ ÙfiÔ Ì·˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó. ∆· ÙÂÏÂ˘Ù·›· Â›Ó·È ÙÔ˘ 1990. ∂Ô̤ӈ˜, ÚˆÙ·Ú¯ÈÎfi Ì·˜ ̤ÏËÌ· ı· ‹Ù·Ó Ó· ÍÂÎÈÓ‹ÛÂÈ ÌÈ· ¶·ÓÂÏÏ‹ÓÈ· ŒÚ¢ӷ ÁÈ· Ù· ÔÛÔÛÙ¿ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ Û ÂıÓÈÎfi Â›‰Ô. ŒÂÈÙ·, Û˘ÓÂȉËÙÔÔÈÒÓÙ·˜ ÙËÓ Ù˘¯fiÓ ·ÓÂ¿ÚÎÂÈ¿ Ì·˜, ÌÔÚԇ̠ӷ ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ì ηٿÏÏËϘ Û˘Óı‹Î˜ ÚÔ·ÁˆÁ‹˜ ÙÔ˘ Ì ·fiÏ˘ÙË ÁÓÒÛË ÙˆÓ È‰ÈÔÙ‹ÙˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ·Ú·ÁˆÁ‹˜ ÙÔ˘, ÙˆÓ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ ÙÔ˘ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡, ÙˆÓ ÎÈÓ‰‡ÓˆÓ Ù˘ Ù¯ÓÈ΋˜ ‰È·ÙÚÔÊ‹˜ Î·È Ù˘ ÛˆÛÙ‹˜ ÔÏÈÙÈ΋˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡. ªfiÓÔ ÙfiÙÂ, ÔÈ ÌËÙ¤Ú˜ ı· ÌÔÚ¤ÛÔ˘Ó Ì ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi Ó· ıÂÌÂÏÈÒÛÔ˘Ó ÙË ÛˆÌ·ÙÈ΋, ÓÂ˘Ì·ÙÈ΋ Î·È „˘¯È΋ ˘Á›· ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜.

Paediatriki 2001;64:300-303

µÈ‚ÏÈÔÁÚ·Ê›· 1. International Code of Marketing of Breast Milk Substitutes.

W.H.O. & UNICEF World Health Assembly; 1981.

2. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Statement W.H.O. & UNICEF, Geneva; 1989.

3. Innocenti Declaration on Protecting, Promoting and Supporting Breastfeeding. W.H.O., UNICEF, S.I.D.A, A.I.D USA, Florence; 1990.

4. Baby-Friendly Hospital Initiative. W.H.O. & UNICEF; 1992.

World Breastfeeding Week. W.A.B.A. (World Alliance for Breastfeeding Action); 1992. Mother-Friendly Work Place Initiative. W.H.O. & UNICEF; 1993.

5. Healthy People 2000. National and Human Services, U.S Department of Health and Human Services, Public Health Services Publication. No (PHS) 91-50213.

6. ∂Ê·ÚÌÔÁ‹ ¢ÈÂıÓÔ‡˜ ∫Ò‰Èη ∂ÌÔÚ›·˜ ÀÔηٿÛÙ·ÙˆÓ ªËÙÚÈÎÔ‡ °¿Ï·ÎÙÔ˜. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ÀÁÈÂÈÓ‹˜, °Ú·ÊÂ›Ô ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜. ∞¶. 23630 9/11/1983.

7. OÚÁ·ÓÈÛÌfi˜ ¡ÔÛÔÎÔÌ›Ԣ ª·È¢ÙËÚ›Ô˘ Ô˘ ȉڇıËΠ̠ÙÔ .‰/ÁÌ· 321/85 ∞Ú. ∞3‚. ∂ÊËÌÂÚ›‰· Ù˘ ∫˘‚ÂÚÓ‹Ûˆ˜ Ù˘ ∂ÏÏËÓÈ΋˜ ¢ËÌÔÎÚ·Ù›·˜. ∞Ú. Ê˘Ï. 47; 29/1/1990.

8. ™‡ÛÙ·ÛË ∂ıÓÈ΋˜ ∂ÈÙÚÔ‹˜ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ.

5311; 20/7/1993.

9. ªËÙÚÈÎfi˜ £ËÏ·ÛÌfi˜ - ·Ó·Ê·›ÚÂÙÔ ‰Èη›ˆÌ· οı ÓÂÔÁ¤ÓÓËÙÔ˘. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 3618; 9/10/1995.

10. ∫·ıȤڈÛË ÂÔÚÙ·ÛÌÔ‡ ¶·ÁÎfiÛÌÈ·˜ ∂‚‰ÔÌ¿‰·˜ ªËÙÚÈÎÔ‡ £ËÏ·ÛÌÔ‡ ÛÙË ¯ÒÚ· Ì·˜. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 3756; 28/8/1996.

11. ∂Î·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ÁÈ· ÙÔ ªËÙÚÈÎfi £ËÏ·ÛÌfi: 1-7 ¡ÔÂÌ‚Ú›Ô˘ 1997. ŒÁÁÚ·ÊÔ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ºÚÔÓÙ›‰·˜ ÀÁ›·˜. ∞Ú. ¶ÚˆÙ. À3Á/ÔÈÎ. 5019; 8/9/1997.

12. Breastfeeding N.G.O wins alternative Nobel Prize. B.F.H.I. Newsletter; 9/12/1998.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: £¤ÌȘ ∑¿¯Ô˘ §ÂˆÊ. ∞ÏÂÍ¿Ó‰Ú·˜ 201, 115 23, ∞ı‹Ó·

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™À¡∂ƒ°∞∑Oª∂¡∂™ ∂π¢π∫O∆∏∆∂™

Paediatriki 2001;64:304-307

ASSOCIATED SUBSPECIALTIES

∆Ú·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ‰ÔÓÙÈÒÓ §. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë

Dental injuries L. Papagiannouli - Laskaridi

¶ÂÚ›ÏË„Ë: ∏ ÂÚÁ·Û›· ·˘Ù‹ Ú·ÁÌ·Ù‡ÂÙ·È ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ ‰ÔÓÙÈÒÓ Î·È ÙˆÓ ÂÚÈÔ‰ÔÓÙÈÎÒÓ ÈÛÙÒÓ. ∂ȉÈÎfiÙÂÚ· ÂÚÈÁÚ¿ÊÂÈ Ù· ›‰Ë ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ‰ÔÓÙÈÒÓ Î·È ÙˆÓ ÂÚÈÔ‰ÔÓÙÈÎÒÓ ÈÛÙÒÓ, ÙÔÓ›˙ÂÈ ÙËÓ ¿ÌÂÛË ÂͤٷÛË Î·È ıÂÚ·›· ÙÔ˘ ·ÛıÂÓ‹ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÙËÓ Î·Ù¿ÏÏËÏË ıÂÚ·›· ÁÈ· οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∆¤ÏÔ˜, ·Ó·Ê¤ÚÔÓÙ·È Ù· ÚÔÏËÙÈο ̤ÙÚ· ÁÈ· ÙË Ì›ˆÛË ‹ ÂÍ¿ÏÂÈ„Ë ÙÔ˘ Ô‰ÔÓÙÈÎÔ‡ ÙÚ·˘Ì·ÙÈÛÌÔ‡.

Abstract: This paper deals with the injuries of the teeth as well as the periodontal tissue injuries.

More specifically, the paper describes each type of injury, emphasizes the need for immediate examination and treatment of the patient and presents the appropriate treatment for each type of injury. Finally, it reports the preventive measures to reduce or eliminate dental trauma (in children and adolescents).

§¤ÍÂȘ ÎÏÂȉȿ: Ô‰ÔÓÙÈÎfi˜ ÙÚ·˘Ì·ÙÈÛÌfi˜, ıÂÚ·›·, ÚfiÏË„Ë.

Key words: dental injuries, treatment, prevention.

Ÿˆ˜ Û οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ¤ÙÛÈ Î·È ÛÙÔ Ô‰ÔÓÙÈÎfi ÙÚ·‡Ì· ¤Ó· Û¯ÔÏ·ÛÙÈÎfi ÈÛÙÔÚÈÎfi Â›Ó·È ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË Ì›·˜ ÛˆÛÙ‹˜ ‰È¿ÁÓˆÛ˘ Î·È ıÂÚ·›·˜ (1,2). ∏ ·ÍÈÔÏfiÁËÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡ Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ë ‰È¿ÁÓˆÛË ¿ÏÏˆÓ Èı·ÓÒÓ Î·ÎÒÛˆÓ, ȉȷ›ÙÂÚ· ·˘ÙÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ∫¡™ (ÂÁÎÂÊ·ÏÈ΋ ‰È¿ÛÂÈÛË, ˘ÔÛÎÏËÚ›‰ÈÔ ·È̿و̷, ·ÈÌÔÚÚ·Á›·), ÚÔËÁÔ‡ÓÙ·È Î¿ı ¿ÏÏ˘ ıÂÚ·¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. O ÎÏÈÓÈÎfi˜ Ú¤ÂÈ Ó· ¤¯ÂÈ ˘„ËÏfi ‚·ıÌfi ˘Ô„›·˜ ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ Ó· ÔÊ›ÏÂÙ·È Û ηÎÔÔ›ËÛË ÙÔ˘ ·È‰ÈÔ‡. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô ÁÈ· Èı·Ó¿ ηٿÁÌ·Ù· ÛÙ· ÔÛÙ¿ Ù˘ ÎÂÊ·Ï‹˜ Î·È ÙÔ˘ ÙÚ·¯‹ÏÔ˘, ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ Ì·Ï·ÎÒÓ ÈÛÙÒÓ ÙÔ˘ ÚÔÛÒÔ˘, ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È ÙˆÓ ·ÚıÚÒÛˆÓ. ™ÙËÓ ÂÓ‰ÔÛÙÔÌ·ÙÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È, ÏËÓ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ ‰ÔÓÙÈÔ‡ Î·È ÔÈ ¤ÚÈÍ ÈÛÙÔ› ÁÈ· Èı·ÓfiÙËÙ· ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡. O ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È ··Ú·›ÙËÙÔ˜ Û οı ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ (1-3).

∞ÓÙÈÌÂÙÒÈÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÌfiÓÈÌˆÓ ‰ÔÓÙÈÒÓ 1. ∆Ú·˘Ì·ÙÈÛÌfi˜ ÛÎÏËÚÒÓ ÈÛÙÒÓ ‰ÔÓÙÈÔ‡-ÔÏÊÔ‡ ™Â ÂÚ›ÙˆÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ Ù˘ ̇Ï˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ (·‰·Ì·ÓÙ›Ó˘-Ô‰ÔÓÙ›Ó˘), ··Ú·›ÙËÙË Â›Ó·È Ë ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ì ÚˆÙ·Ú¯ÈÎfi ÛÎÔfi ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÔÏÊÔ‡. Œ¯ÂÈ ‚ÚÂı› ˆ˜ Ë ¤ÎıÂÛË 1 mm Ô‰ÔÓÙ›Ó˘ ¤¯ÂÈ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÔÎ¿Ï˘„Ë 20.000-45.000 Ô‰ÔÓÙÈÓÔÛˆÏËÓ·Ú›ˆÓ ̤ۈ ÙˆÓ ÔÔ›ˆÓ ÌÈÎÚfi‚È· Î·È ÂÚÂı›ÛÌ·Ù· ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ıÂÚÌÈο, ¯ËÌÈο ÌÂٷʤÚÔÓÙ·È ÛÙÔÓ ÔÏÊfi, Ì ·ÔÙ¤ÏÂÛÌ· Ë ˘Á›· ÙÔ˘ ÔÏÊÔ‡ Ó· Ù›ıÂÙ·È Û ΛӉ˘ÓÔ (1). ∞Ó ÙÔ ÙÌ‹Ì· ÙÔ˘ ‰ÔÓÙÈÔ‡ Ô˘ ·ÔÛ¿ÛÙËΠ‰ÂÓ ·ÔηٷÛÙ·ı› ¿ÌÂÛ·, ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ÊÏÂÁÌÔÓ‹˜ ‹ Î·È Ó¤ÎÚˆÛ˘ ÙÔ˘ ÔÏÊÔ‡. ™‹ÌÂÚ· Ì ٷ ˘ÏÈο ·ÈÛıËÙÈÎÒÓ ·ÔηٷÛÙ¿ÛÂˆÓ Ô˘ ‰È·ı¤ÙÂÈ Ô Ô‰ÔÓÙ›·ÙÚÔ˜, Â›Ó·È ‰˘Ó·Ù‹ Ë ·fi‰ÔÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Î·È Ù˘ ·ÈÛıËÙÈ΋˜ ÙˆÓ ‰ÔÓÙÈÒÓ Û ̛· ÌfiÓÔ Â›Û΄Ë. ∏ ·Ó·ÁηÈfiÙËÙ· Ù˘ ¿ÌÂÛ˘ ·ÔηٿÛÙ·Û˘ ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ‰ÔÓÙÈÒÓ ˘·ÁÔÚ‡ÂÙ·È Î·È ·fi „˘¯ÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘, ÁÈ· ¢ÓfiËÙÔ˘˜ ÏfiÁÔ˘˜, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊË‚È΋˜

√‰ÔÓÙÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¢È¢ı‡ÓÙÚÈ· ∂ÚÁ·ÛÙËÚ›Ô˘ ¶·È‰Ô‰ÔÓÙÈ·ÙÚÈ΋˜

Athen’s University Dental School Director of Pediatric Dentistry Laboratory

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ËÏÈΛ·˜ Â›Ó·È ÈÔ ÛËÌ·ÓÙÈÎÔ›. ™Â ÂÚ›ÙˆÛË Î·Ù¿ÁÌ·ÙÔ˜ Ù˘ ̇Ï˘, Ôχ ÛËÌ·ÓÙÈÎfi Â›Ó·È Ó· ‚ÚÂı› Î·È Ó· Ê˘Ï·¯Ù› Û ÓÂÚfi ÙÔ Û·Ṳ̂ÓÔ ÎÔÌÌ¿ÙÈ ÙÔ˘ ‰ÔÓÙÈÔ‡. ªÂ Ù· Û‡Á¯ÚÔÓ· Û˘ÁÎÔÏÏËÙÈο ˘ÏÈο Â›Ó·È ‰˘Ó·Ù‹, Ê˘ÛÈο οو ·fi ÔÚÈṲ̂Ó˜ ÚÔ¸Ôı¤ÛÂȘ, Ë Â·Ó·Û˘ÁÎfiÏÏËÛË ÙÔ˘ Û·Ṳ̂ÓÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (2). ™Â ÂÚÈÙÒÛÂȘ ηٷÁÌ¿ÙˆÓ ‰ÔÓÙÈÒÓ Î·È Ù·˘Ùfi¯ÚÔÓÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÙÔ˘ ÚÔÛÒÔ˘, ı· Ú¤ÂÈ, ·Ó ‰ÂÓ ‚ÚÂı› ÙÔ Û·Ṳ̂ÓÔ ÎÔÌÌ¿ÙÈ ÙÔ˘ ‰ÔÓÙÈÔ‡, Ó· Á›ÓÂÙ·È ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Î·È ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÁÈ· Ù˘¯fiÓ ÂÓÛÊ‹ÓˆÛ‹ ÙÔ˘ ÛÙÔ˘˜ Ì·Ï·ÎÔ‡˜ ÈÛÙÔ‡˜. ™Â ÂÚÈÙÒÛÂȘ ηٿÁÌ·ÙÔ˜ Ù˘ ̇Ï˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙÔÓ ÔÏÊfi, ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ÔÎ¿Ï˘„˘ Î·È ÙÔ ¯ÚfiÓÔ Ô˘ ÌÂÛÔÏ¿‚ËÛ ̤¯ÚÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, Ë ıÂÚ·›· ÔÈΛÏÏÂÈ ·fi ·Ï‹ Î¿Ï˘„Ë ÙÔ˘ ÔÏÊÔ‡ ̤¯ÚÈ Î·È ÂÓ‰Ô‰ÔÓÙÈ΋ ıÂÚ·›· (·ÔÓ‡ڈÛË). ¢fiÓÙÈ· Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ¤ÁηÈÚ· ÌÔÚ› Ó· ÓÂÎÚˆıÔ‡Ó, Ì ÌÔÓ·‰ÈÎfi Û‡Ìو̷ ÔÏϤ˜ ÊÔÚ¤˜ ÙËÓ ·ÏÏ·Á‹ ÙÔ˘ ¯ÚÒÌ·ÙÔ˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (1-3). ™‹ÌÂÚ·, ÂÎÙÂٷ̤ӷ ηٿÁÌ·Ù· Ù˘ ̇Ï˘ ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Û˘ÓÙËÚËÙÈο, Ì ˘ÏÈο Ô˘ ·Ô‰›‰Ô˘Ó ÈηÓÔÔÈËÙÈο ÙÔ ¯ÚÒÌ· Î·È ÙÔ Û¯‹Ì· ÙÔ˘ ‰ÔÓÙÈÔ‡. ∂ÓÙÔ‡ÙÔȘ, ÌÂÚÈΤ˜ ÊÔÚ¤˜ ··ÈÙÂ›Ù·È ÚÔÛıÂÙÈ΋ ·ÔηٿÛÙ·ÛË, ‰ËÏ. ÔÏÈ΋ Î¿Ï˘„Ë Ù˘ ̇Ï˘ Ì ̛· ÛÙÂÊ¿ÓË ÎÂÚ·ÌÈ΋ ‹ ÌÂÙ·ÏÏÔÎÂÚ·ÌÈ΋ (ÔÚÛÂÏ¿ÓË). O ÈÔ ÛÔ‚·Úfi˜ Î·È ÂÈΛӉ˘ÓÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ ÙˆÓ ‰ÔÓÙÈÒÓ Â›Ó·È Ù· ηٿÁÌ·Ù· Ù˘ Ú›˙·˜, ȉȷ›ÙÂÚ· ·Ó ‰ÂÓ ‰È·ÁÓˆÛÙÔ‡Ó ¤ÁηÈÚ· Î·È ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛıÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈο (2). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù¤ÙÔÈˆÓ Î·Ù·ÁÌ¿ÙˆÓ Û˘Ó›ÛÙ·Ù·È Û ·ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ‰ÔÓÙÈÒÓ ÁÈ· 2-3 Ì‹Ó˜ Ì ÂȉÈÎfi Ó¿ÚıËη. ™Â Ù¤ÙÔȘ ÂÚÈÙÒÛÂȘ, Ë ÚfiÁÓˆÛË Ù˘ ‰È·Ù‹ÚËÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ı¤ÛË ÙÔ˘ ηٿÁÌ·ÙÔ˜, ·fi ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È ÙÔ ‚·ıÌfi ÂÎÙfiÈÛ˘ ÙˆÓ Î·Ù·ÁfiÙˆÓ ÙÌËÌ¿ÙˆÓ, ·fi ÙÔ ÛÙ¿‰ÈÔ ‰È¿Ï·Û˘ Ù˘ Ú›˙·˜ Î·È ·fi ÙËÓ ÔÈfiÙËÙ· Ù˘ ıÂÚ·›·˜.

2. ∆Ú·˘Ì·ÙÈÛÌfi˜ ‰ÔÓÙÈÔ‡ ÌÂ Û˘ÌÌÂÙÔ¯‹ Î·È ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘ O ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙȘ ·ÎfiÏÔ˘ı˜ ÂÚÈÙÒÛÂȘ: ·) ¢È¿ÛÂÈÛË ‹ ÙÚ¿ÓÙ·ÁÌ· ¯ˆÚ›˜ ÙËÓ ‡·ÚÍË ÎÈÓËÙÈÎfiÙËÙ·˜ ‹ ÂÎÙfiÈÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ Ê·ÙÓ›Ô. ‚) ∫ÈÓËÙÈÎfiÙËÙ· ¯ˆÚ›˜ ÌÂÙ·ÙfiÈÛË ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ™ÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ Û˘ÓÈÛÙ¿Ù·È Ì·Ï·Î‹ ‰È·ÙÚÔÊ‹ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡. ™Â ÂÚ›ÙˆÛË Ô˘ ηٿ ÙË Û‡ÁÎÏÂÈÛË Ì ٷ ‰fiÓÙÈ· ÙÔ˘ ·ÓÙ›ıÂÙÔ˘ ÊÚ·ÁÌÔ‡ (·ÓÙ·ÁˆÓÈÛÙ¤˜) ˘¿Ú¯ÂÈ

Paediatriki 2001;64:304-307

›ÂÛË ÛÙ· ÙÚ·˘Ì·ÙÈṲ̂ӷ ‰fiÓÙÈ·, Á›ÓÂÙ·È ÂÎÏÂÎÙÈÎfi˜ ÙÚÔ¯ÈÛÌfi˜ ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ. Á) ¶Ï¿ÁÈ· ÌÂÙ·ÙfiÈÛË Î·È ÂÎÙfiÈÛË ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ÂÈ‚¿ÏÏÂÙ·È Ë Â·Ó·ÙÔÔı¤ÙËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË Ô˘ ›¯Â ÛÙÔ Ê·ÙÓ›Ô ÚÈÓ ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi Î·È Ë ·ÎÈÓËÙÔÔ›ËÛ‹ ÙÔ˘ Ì ÂȉÈÎfi Ó¿ÚıËη. ‰) ∂Ì‚‡ıÈÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ̤۷ ÛÙÔ Ê·ÙÓ›Ô. O ÙÚ·˘Ì·ÙÈÛÌfi˜ ·˘Ùfi˜ Û˘Óԉ‡ÂÙ·È ·fi Û‡ÓıÏÈ„Ë ‹ οٷÁÌ· ÙÔ˘ Ê·ÙÓ›Ô˘. ∏ ÂÌ‚‡ıÈÛË ÌÔÚ› Ó· Â›Ó·È ÌÂÚÈ΋ ‹ ÔÏÈ΋. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Á›ÓÂÙ·È Ë ÚÔԉ¢ÙÈ΋ Î·È ÂÏÂÁ¯fiÌÂÓË Â·Ó·ÊÔÚ¿ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË ÙÔ˘ ÛÙÔ ÊÚ·ÁÌfi Ì ÔÚıÔ‰ÔÓÙÈΤ˜ ‰˘Ó¿ÌÂȘ.

OÈ ÈÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙËÓ ÂÌ‚‡ıÈÛË Â›Ó·È Ë Ó¤ÎÚˆÛË ÙÔ˘ ÔÏÊÔ‡ Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ·ÔÚÚfiÊËÛË Ù˘ Ú›˙·˜ (Â͈ÙÂÚÈ΋ ‹ ÂÛˆÙÂÚÈ΋), ÂÓ·Û‚ÂÛÙ›ˆÛË ÙÔ˘ ÔÏÊÔ‡, ·ÎfiÌ· Î·È ·ÒÏÂÈ· Ù˘ ÛÙ‹ÚÈ͢ ÙÔ˘ ‰ÔÓÙÈÔ‡ (Ê·ÙÓÈÔÏ˘Û›·). Â) ªÂÚÈ΋ ÂÎÁfiÌʈÛË ·fi ÙÔ Ê·ÙÓ›Ô. ∏ ÂÚ›ÙˆÛË ·˘Ù‹ ÙÚ·˘Ì·ÙÈÛÌÔ‡ Â›Ó·È Ë ·ÓÙ›ıÂÙË ·fi ÙËÓ ÚÔËÁÔ‡ÌÂÓË, ‰ËÏ. Ë ÌÂÚÈ΋ ¤ÍÔ‰Ô˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ Ê·ÙÓ›Ô Î·È ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙËÓ ¿ÌÂÛË Â·Ó·ÊÔÚ¿ ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙË ı¤ÛË ÙÔ˘ ÂÓÙfi˜ ÙÔ˘ Ê·ÙÓ›Ô˘ Î·È ÙËÓ ·ÎÈÓËÙÔÔ›ËÛ‹ ÙÔ˘ Ì ӿÚıËη. ™Â ÔÚÈṲ̂Ó˜ fï˜ ÂÚÈÙÒÛÂȘ, fiÙ·Ó ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ Â·Ó·ÊÔÚ¿ ‹ fiÙ·Ó Ë ·ÓÙÈÌÂÙÒÈÛË Á›ÓÂÈ ÌÂÙ¿ ¿ÚÔ‰Ô ÔÏÏÒÓ ˆÚÒÓ ‹ ËÌÂÚÒÓ, ÂӉ›ÎÓ˘Ù·È Ë Â·Ó·ÊÔÚ¿ Ì ÔÚıÔ‰ÔÓÙÈΤ˜ ‰˘Ó¿ÌÂȘ. ∫·È Û’·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ˘Ê›ÛÙ·Ù·È Ô Î›Ó‰˘ÓÔ˜ ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÚԷӷʤÚıËηÓ. ÛÙ) OÏÈ΋ ÂÎÁfiÌʈÛË. ∆Ô ÈÔ ‰Ú·Ì·ÙÈÎfi ›‰Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ Â›Ó·È Ë ÔÏÈ΋ ÂÎÁfiÌʈÛË, ‰ËÏ. Ë ÔÏÈ΋ ¤ÍÔ‰Ô˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ ·fi ÙË ı¤ÛË ÙÔ˘ ÛÙÔ Ê·ÙÓ›Ô. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÔÏÈ΋˜ ÂÎÁfiÌʈÛ˘ ·ÔÙÂÏ› ÂÚ›Ô˘ ÙÔ 3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜, Â›Ó·È ‰Â Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· Û˘ÌÏÔÎÒÓ, ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ‹ ·Ù˘¯ËÌ¿ÙˆÓ Î·Ù¿ ÙȘ ·ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ (1-3). ™˘¯ÓfiÙÂÚ· ·ÊÔÚ¿ ¤Ó· ‰fiÓÙÈ, ˘¿Ú¯Ô˘Ó fï˜ ÂÚÈÙÒÛÂȘ ÂÌÏÔ΋˜ Î·È ÂÚÈÛÛÔÙ¤ÚˆÓ ‰ÔÓÙÈÒÓ. ™˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-10 ¯ÚfiÓˆÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· ‰ËÏ. Ù˘ ·Ó·ÙÔÏ‹˜ ÙˆÓ ÙÔ̤ˆÓ ‰ÔÓÙÈÒÓ Î·È ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ (ÂÚÈÔ‰fiÓÙÈÔ) ‰ÂÓ ¤¯ÂÈ ÔÚÁ·Óˆı›, Ì ·ÔÙ¤ÏÂÛÌ· Ë ‰ÔÌ‹ ÙÔ˘ Ó· Â›Ó·È ¯·Ï·Ú‹. ∆· ‰fiÓÙÈ· Ô˘ ÈÔ Û˘¯Ó¿ ÂÎÁÔÌÊÒÓÔÓÙ·È Â›Ó·È ÔÈ ÎÂÓÙÚÈÎÔ› ÙÔÌ›˜ Ù˘ ¿Óˆ ÁÓ¿ıÔ˘. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÎÁfiÌʈÛ˘ Â›Ó·È Ë ¿ÌÂÛË Â·Ó·ÙÔÔı¤ÙËÛË ÙÔ˘ ‰ÔÓÙÈÔ‡ ÛÙÔ Ê·ÙÓ›Ô (Â·ÓÂÌʇÙ¢ÛË). ∆Ô ÎÏÂȉ› Ù˘ ÂÈÙ˘¯›·˜ Ù˘ Â·ÓÂÌʇÙ¢Û˘ Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ù˘ ˙ˆÙÈÎfiÙËÙ·˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘. O

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¯ÚfiÓÔ˜ Ô˘ ·Ú·Ì¤ÓÂÈ ÙÔ ‰fiÓÙÈ ÂÎÙfi˜ Ê·ÙÓ›Ô˘ Î·È Ô ÙÚfiÔ˜ ‰È·Ù‹ÚËÛ‹˜ ÙÔ˘ Â›Ó·È ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ Û˘ÓÙÂÏÂÛÙ¤˜ ÂÈÙ˘¯›·˜ Ù˘ Â·ÓÂÌʇÙ¢Û˘. ∆Ô È‰·ÓÈÎfiÙÂÚÔ Â›Ó·È ÙÔ ‰fiÓÙÈ Ó· ÙÔÔıÂÙËı› Í·Ó¿ ÛÙË ı¤ÛË ÙÔ˘ ̤۷ ÛÙÔ Ê·ÙÓ›Ô ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÎÁfiÌʈÛË ·fi ÙÔÓ ÙÚ·˘Ì·Ù›· ‹ οÔÈÔ ¿ÏÏÔ ¿ÙÔÌÔ Î·È Ó· Û˘ÁÎÚ·ÙÂ›Ù·È ÛÙË ı¤ÛË ÙÔ˘ Ì ̛· Á¿˙· ‹ Ì·ÓÙ‹ÏÈ. ∆Ô Ê·ÙÓ›Ô Â›Ó·È ÙÔ Î·Ï‡ÙÂÚÔ Ì¤ÛÔ ÌÂÙ·ÊÔÚ¿˜ ̤¯ÚÈ Ó· Êı¿ÛÂÈ Ô ·ÛıÂÓ‹˜ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚ›Ô. ¢˘ÛÙ˘¯Ò˜ fï˜ ·˘Ùfi Û˘Ì‚·›ÓÂÈ Û¿ÓÈ·. ™˘Ó‹ıˆ˜ Ô ÙÚ·˘Ì·Ù›·˜ ÔÓ¿, ‰ÂÓ Â›Ó·È Û˘ÓÂÚÁ¿ÛÈÌÔ˜ Î·È Ô‡Ù ·˘Ùfi˜ Ô‡Ù ηÓ›˜ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ (ÁÔÓ›˜, ‰¿ÛηÏÔ˜, ÚÔÔÓËÙ‹˜ Û ·ıÏÔ·È‰È¤˜) ÙÔÏÌ¿ Ó· οÓÔ˘Ó ÙËÓ Â·ÓÂÌʇÙ¢ÛË. ∂ÈϤÔÓ, Û˘¯Ó¿ ÊÔ‚Ô‡ÓÙ·È ÙÔ ·›Ì·, ÌË Ù˘¯fiÓ ÎÔÏÏ‹ÛÔ˘Ó Î¿ÔÈ· ÌÂÙ·‰ÔÙÈ΋ ·Ûı¤ÓÂÈ·, ‹ ÌËÓ ÚÔηϤÛÔ˘Ó ÂÈϤÔÓ ÙÚ·˘Ì·ÙÈÛÌfi. ™Â ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ Á›ÓÂÙ·È ¿ÌÂÛË Â·ÓÂÌʇÙ¢ÛË, ÙÔ ‰fiÓÙÈ Ú¤ÂÈ Ó· ‰È·ÙËÚËı› ̤¯ÚÈ ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚ›Ô, ¤ÙÛÈ ÒÛÙ ӷ ÚÔÎÏËı› Ô ÌÈÎÚfiÙÂÚÔ˜ ‰˘Ó·Ùfi˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘. ™˘ÁÎÂÎÚÈ̤ӷ, Ú¤ÂÈ Ó· Û˘ÁÎÚ·ÙÂ›Ù·È ·fi ÙË Ì‡ÏË Ì ÚÔÛÔ¯‹ Ó· ÌËÓ ÂÈÚ·¯ı› Ë Ú›˙· Î·È Ó· ηı·ÚÈÛÙ›, Ì ÓÂÚfi ¯ˆÚ›˜ ÈÛ¯˘Ú‹ ›ÂÛË, Ó· ÙÔÔıÂÙËı› Û ¤Ó· ÌÈÎÚfi ‰Ô¯Â›Ô Ì Á¿Ï· ‹ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ‹ Û¿ÏÈÔ. ∆· ηχÙÂÚ· ˘ÁÚ¿ ÌÂÙ·ÊÔÚ¿˜ ıˆÚÔ‡ÓÙ·È ÙÔ ‰È¿Ï˘Ì· Hank (Hank’s solution) Î·È ÙÔ Á¿Ï· (1,2). ŸÙ·Ó ÊÙ¿ÛÂÈ Ô ·ÛıÂÓ‹˜ ÛÙÔ Ô‰ÔÓÙÈ·ÙÚÂ›Ô Î·È ·ÊÔ‡ ÂÍ·ÎÚÈ‚ˆı› Ì ÙÔ ÈÛÙÔÚÈÎfi Î·È Ì›· ηϋ ÎÏÈÓÈ΋ Î·È ·ÎÙÈÓÔÁÚ·ÊÈ΋ ÂͤٷÛË fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÏÏÔ˜ ÛÔ‚·ÚfiÙÂÚÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜ Ù˘ ÎÂÊ·Ï‹˜ ‹ ÙÔ˘ ·˘¯¤Ó·, Ô Ô‰ÔÓÙ›·ÙÚÔ˜ ÙÔ Â·Ó·ÙÔÔıÂÙ› Î·È ÙÔ ·ÎÈÓËÙÔÔÈ› Ì ÂȉÈÎfi Ó¿ÚıËη ÁÈ· 7-10 Ë̤Ú˜ ÂÚ›Ô˘. À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ›‰Ë Ó¿ÚıËη ÁÈ· ·ÎÈÓËÙÔÔ›ËÛË ‰ÔÓÙÈÔ‡. ¶ÚÔÙÈÌÒÓÙ·È ÔÈ Ó¿ÚıËΘ Ô˘ Â›Ó·È ÛÙ·ıÂÚÔ›, ·ÏÏ¿ Û˘Á¯ÚfiÓˆ˜ ÂÍ·ÛÊ·Ï›˙Ô˘Ó Ì›· ÌÈÎÚ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ÛÙÔ ‰fiÓÙÈ. OÈ Ó¿ÚıËΘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·fi ÙÔ˘˜ ÁÓ·ıÔ¯ÂÈÚÔ˘ÚÁÔ‡˜ ÁÈ· ·ÎÈÓËÙÔÔ›ËÛË ‰ÔÓÙÈÒÓ Û ÂÚ›ÙˆÛË Î·Ù·ÁÌ¿ÙˆÓ ÙˆÓ ÁÓ¿ıˆÓ ·ÓÙÂӉ›ÎÓ˘ÓÙ·È. ∆¤ÙÔÈÔÈ ¿Î·ÌÙÔÈ Ó¿ÚıËΘ Ô˘ Û˘Ó‹ıˆ˜ ÙÔÔıÂÙÔ‡ÓÙ·È ÁÈ· ÌÂÁ¿Ï· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÚÔηÏÔ‡Ó ·Á·ψÛË Î·È ·ÔÚÚfiÊËÛË Ù˘ Ú›˙·˜ ÙÔ˘ ‰ÔÓÙÈÔ‡ (2,3). ∏ ÚfiÁÓˆÛË Ù˘ ‰È·Ù‹ÚËÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡ Â›Ó·È Û˘Ó¿ÚÙËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÌÔÓ‹˜ ÂÎÙfi˜ Ê·ÙÓ›Ô˘, ÙÔ˘ ̤ÛÔ˘ ‰È·Ù‹ÚËÛ˘ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ÌÂÛÔÏ¿‚ËÛ ·fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ̤¯ÚÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË. ∏ ÚfiÁÓˆÛË Â›Ó·È ·ÚÎÂÙ¿ ηϋ ·Ó ÙÔ ‰fiÓÙÈ Â¯ÂÈ ‰È·ÙËÚËı› Û ˘ÁÚfi ÂÚÈ‚¿ÏÏÔÓ Î·È Â·ÓÂÌÊ˘Ù¢ı› ̤۷ Û 30 min. ªÂÙ¿ ÙËÓ ¿ÚÔ‰Ô 2 ˆÚÒÓ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ ÌÂÈÒÓÂÙ·È Î·Ù·ÎfiÚ˘Ê· (1,2).

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°È· ÙË Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÌfiÏ˘ÓÛ˘ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Ô˘ Û˘ÓÂ¿ÁÂÙ·È Î·È ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·ÔÚÚfiÊËÛ˘ Ù˘ Ú›˙·˜, Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÁÈ· Ù¤ÛÛÂÚȘ Ë̤Ú˜ (ÂÓÈÎÈÏ›ÓË, 1.000.000 IU ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi Î·È ÛÙË Û˘Ó¤¯ÂÈ· 2.000.000 4.000.000 IU ÁÈ· 4 Ë̤Ú˜) (1). ª›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ Â·ÓÂÌʇÙ¢ÛË Û˘ÓÈÛÙ¿Ù·È ÂÓ‰Ô‰ÔÓÙÈ΋ ıÂÚ·›· ÙÔ˘ Â·ÓÂÌÊ˘Ù¢ı¤ÓÙÔ˜ ‰ÔÓÙÈÔ‡, ÂÂȉ‹ Û˘Ó‹ıˆ˜ Ô ÔÏÊfi˜ ÓÂÎÚÒÓÂÙ·È Î·Ù¿ ÙËÓ ÂÎÁfiÌʈÛË. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÙÚ·‡Ì·ÙÔ˜, ·ÏÏ¿ ȉȷ›ÙÂÚ· ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘, Û˘ÓÈÛÙ¿Ù·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Û¯ÔÏ·ÛÙÈ΋ ÛÙÔÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ Î·È ¯Ú‹ÛË ·ÓÙÈÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ, .¯. ‰È·Ï‡Ì·ÙÔ˜ ¯ÏˆÚÂÍȉ›Ó˘, ÁÈ· ÙË Ì›ˆÛË ÙÔ˘ Û¯ËÌ·ÙÈÛÌÔ‡ Ù˘ Ô‰ÔÓÙÈ΋˜ ÌÈÎÚԂȷ΋˜ Ͽη˜. ∏ Û˘Ì‚Ô˘Ï‹ ·È‰È¿ÙÚÔ˘ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÙÂÙ·ÓÈÎÔ‡ ÔÚÔ‡ Â›Ó·È ··Ú·›ÙËÙË. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÙˆÓ ÛÎÏËÚÒÓ ÈÛÙÒÓ ÙÔ˘ ‰ÔÓÙÈÔ‡ Î·È ÙÔ˘ ÔÏÊÔ‡, ηıÒ˜ Î·È Û ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÂÚÈÔ‰ÔÓÙ›Ô˘, Ë Û˘ÛÙËÌ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË - ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË Î·Ù¿ ÂÚ›ÙˆÛË ÙÚ·‡Ì·ÙÔ˜ Î·È ·ÛıÂÓÔ‡˜ - Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È ÙËÓ ÚfiÏË„Ë ÂÈÏÔÎÒÓ. ∞ÓÙÈÌÂÙÒÈÛË ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ OÈ ÈÔ Û˘¯ÓÔ› ÙÚ·˘Ì·ÙÈÛÌÔ› ÛÙ· ÓÂÔÁÈÏ¿ ‰fiÓÙÈ· Â›Ó·È ÂÌ‚‡ıÈÛË, ÌÂÙ·ÙfiÈÛË, ÂÎÁfiÌʈÛË Î·È Î¿Ù·ÁÌ· Ù˘ ̇Ï˘ (1,2). O ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Â›Ó·È Ô ›‰ÈÔ˜ Ì ٷ ÌfiÓÈÌ·, Ì ÂÍ·›ÚÂÛË ÙȘ ÂÚÈÙÒÛÂȘ ÔÏÈ΋˜ ÂÎÁfiÌʈÛ˘, ÌÂÚÈ΋˜ ÌÂÙ·ÙfiÈÛ˘ Î·È ÂÓÛÊ‹ÓˆÛ˘. ∏ Â·ÓÂÌʇÙ¢ÛË ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ ·ÓÙÂӉ›ÎÓ˘Ù·È ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ ÚfiÎÏËÛ˘ ‚Ï¿‚˘ ÛÙÔ Û¤ÚÌ· ÙÔ˘ ÌfiÓÈÌÔ˘ ‰ÔÓÙÈÔ‡. ∏ ‰È·Ù‹ÚËÛË ÙÔ˘ ¯ÒÚÔ˘ Ô˘ ηÙ›¯Â ÙÔ ‰fiÓÙÈ ÌÂÙ¿ ÙËÓ ÂÎÁfiÌʈۋ ÙÔ˘ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ ÚÔÛı›ˆÓ Ù˘ ¿Óˆ ÁÓ¿ıÔ˘. ™Â ÂÚÈÙÒÛÂȘ ÌÂÚÈ΋˜ ÌÂÙ·ÙfiÈÛ˘ ‹ ÂÌ‚‡ıÈÛ˘, Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ÓÂÔÁÈÏÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·Ó Ù›ıÂÙ·È Û ΛӉ˘ÓÔ ÙÔ ‰È¿‰Ô¯Ô ÌfiÓÈÌÔ. °È· ·Ú¿‰ÂÈÁÌ·, Û ÂÚÈÙÒÛÂȘ ÂÌ‚‡ıÈÛ˘ ÓÂÔÁÈÏÔ‡ ‰ÔÓÙÈÔ‡ ÔÏϤ˜ ÊÔÚ¤˜ Ë ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È Ë ·Ó·ÌÔÓ‹ Â·ÓÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ‰ÔÓÙÈÔ‡, ÌÔÚ› fï˜ Ó· ÎÚÈı› ·Ó·Áη›· Ë ¿ÌÂÛË ÂÍ·ÁˆÁ‹ ÙÔ˘, ·Ó ·ÎÙÈÓÔÁÚ·ÊÈο ‰È·ÈÛÙˆı› ÛÙÂÓ‹ Â·Ê‹ ÙÔ˘ Ì ÙÔ ÌfiÓÈÌÔ Ô‰ÔÓÙÈÎfi Û¤ÚÌ·. ∏ ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌ¤ÓˆÓ ÓÂÔÁÈÏÒÓ ‰ÔÓÙÈÒÓ Â›Ó·È ··Ú·›ÙËÙË ÁÈ·Ù› ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÔÏϤ˜ ‚Ï·ÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔ˘˜ ‰È·‰fi¯Ô˘˜ ÌfiÓÈÌÔ˘˜, fiˆ˜ ·ԯڈ̷ÙÈÛÌfi˜ ·‰·Ì·ÓÙ›Ó˘, ˘ÔÏ·Û›· ·‰·Ì·ÓÙ›Ó˘, ·Ú·ÌfiÚʈÛË Ù˘ ̇Ï˘, Ô‰fiÓو̷, ‰ÈÏ·ÛÈ·ÛÌfi˜

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Ù˘ Ú›˙·˜, ÌÂÚÈ΋ ‹ ÔÏÈ΋ ‰È·ÎÔ‹ Ù˘ ‰È¿Ï·Û˘ Ù˘ Ú›˙·˜, ‰È·Ù·Ú·¯‹ Ù˘ ·Ó·ÙÔÏ‹˜ (1,2). ¶ÚfiÏË„Ë °È· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ÂÈ‚¿ÏÏÔÓÙ·È Ù· ·ÎfiÏÔ˘ı·: ·) ™ÙÂÓ‹ Â›‚ÏÂ„Ë ÙˆÓ ÓË›ˆÓ fiÙ·Ó ·Ú¯›˙Ô˘Ó Ó· ÂÚ·ÙÔ‡Ó, ‚) ¢È·ÌfiÚʈÛË ·ÛÊ·ÏÒÓ ¯ÒÚˆÓ Ô˘ ÎÈÓÔ‡ÓÙ·È Î·È ·›˙Ô˘Ó Ù· ÌÈÎÚ¿ ·È‰È¿, Á) ∂Ê·ÚÌÔÁ‹ ÙˆÓ ‰ÈÂıÓÒÓ Î·ÓfiÓˆÓ Î˘ÎÏÔÊÔÚ›·˜ Ì ÙÚÔ¯ÔÊfiÚ· (˙ÒÓË ·ÛÊ·Ï›·˜, ÎÚ¿ÓË), ‰) OÚÁ¿ÓˆÛË ·ıÏËÙÈÎÒÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ÚfiÙ˘·, Â) ÃÚ‹ÛË ÚÔÛٷ٢ÙÈÎÒÓ Ó·Úı‹ÎˆÓ ÙˆÓ ‰ÔÓÙÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ·ıÏËÌ¿ÙˆÓ (.¯. basket, Ô‰fiÛÊ·ÈÚÔ) Î·È ÛÙ) OÚıÔ‰ÔÓÙÈ΋ ıÂÚ·›· Û ÂÚÈÙÒÛÂȘ ·˘ÍË̤Ó˘ ÔÚÈ˙fiÓÙÈ·˜ ÚfiÙ·Í˘ ÙˆÓ ¿Óˆ ‰ÔÓÙÈÒÓ. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ÚÔÛٷ٢ÙÈÎÔ‡˜ Ó¿ÚıËΘ ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ·˘ÙÔ› Â›Ó·È ÂÍ·ÈÚÂÙÈο ¯Ú‹ÛÈÌÔÈ Î·È ¤¯Ô˘Ó ηıÈÂÚˆı› Û Â·ÁÁÂÏ̷ٛ˜ ·›ÎÙ˜ ÙÔ˘ basket Î·È ÙÔ˘ Ô‰ÔÛÊ·›ÚÔ˘ ÁÈ·Ù› ÌÂÈÒÓÔ˘Ó ÙËÓ Èı·ÓfiÙËÙ·: i) ηٿÁÌ·ÙÔ˜ Ù˘ ̇Ï˘ ·fi ÙÚ·˘Ì·ÙÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÁÚÔıÈ¿, ·ÁΈÓȤ˜ Î.Ï., ii) ‚›·È˘ ÂÎÙfiÈÛ˘ ‰ÔÓÙÈÔ‡ ·fi ÙÔ˘˜ ›‰ÈÔ˘˜ ·Ú¿ÁÔÓÙ˜, iii) ‚›·È˘ Â·Ê‹˜ ÙˆÓ ¿Óˆ Î·È Î¿Ùˆ ‰ÔÓÙÈÒÓ Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î¿Ù·ÁÌ· ‹ ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ ÈÛÙÒÓ Ô˘ ÛÙËÚ›˙Ô˘Ó Ù· ‰fiÓÙÈ·, iv) ÂÁÎÂÊ·ÏÈ΋˜ ‰È¿ÛÂÈÛ˘, ·ÈÌÔÚÚ·-

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Á›·˜ Î·È v) ÂÎÙfiÈÛ˘ ÙÔ˘ ÎÔÓ‰‡ÏÔ˘ Ù˘ οو ÁÓ¿ıÔ˘ ÚÔ˜ Ù· ›Ûˆ Î·È ¿Óˆ. À¿Ú¯Ô˘Ó ÚÔηٷÛ΢·Ṳ̂ÓÔÈ Î·È ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓÔÈ Ó¿ÚıËΘ. ¶ÚÔÙÈÌfiÙÂÚÔÈ Â›Ó·È ÔÈ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓÔÈ. ∏ ‰È·‰Èηۛ· ··ÈÙ› ÙË Ï‹„Ë ÂÓfi˜ ·ÔÙ˘ÒÌ·ÙÔ˜ ÙˆÓ ‰ÔÓÙÈÒÓ, ·fi ÙÔ ÔÔ›Ô ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÙÔ ÂÎÌ·ÁÂ›Ô ÙÔ˘˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· - Ì ÙË ‚Ô‹ıÂÈ· ÂȉÈ΋˜ Û˘Û΢‹˜ - Á›ÓÂÙ·È Ë Î·Ù·Û΢‹ ÙÔ˘ Ó¿ÚıËη ·fi Ï·ÛÙÈÎfi ‰È·Ê·Ó¤˜ ˘ÏÈÎfi (1,2). µÈ‚ÏÈÔÁÚ·Ê›· 1. Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Munksgaard, Copenhagen: Mosby; 1994.

2. µ·Ó‰¤Ú·˜ ∞. ∆Ô ∆Ú·‡Ì· ÛÙ· ‰fiÓÙÈ·. 1Ë ÂΉ. ∞ı‹Ó·: ∞ÚÁ˘ÚÈ¿‰Ë˜; 1991.

3. American Academy of Pediatric Dentistry and P and G Oral Health Products: Smiles For Tomorrow. A Program designed for the pediatric physicians. 1995.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: §. ¶··ÁÈ·ÓÓÔ‡ÏË - §·Ûηڛ‰Ë ∂ÚÁ·ÛÙ‹ÚÈÔ ¶·È‰Ô‰ÔÓÙÈ·ÙÚÈ΋˜ √‰ÔÓÙÈ·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

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Paediatriki 2001;64:308-311

ASSOCIATED SUBSPECIALTIES

O ·È‰›·ÙÚÔ˜ Î·È ÙÔ ·È‰› Ì ÙËÓ ÈÓÔ΢ÛÙÈ΋ ™. ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘

The pediatrician and the patient with cystic fibrosis S. Doudounakis

¶ÂÚ›ÏË„Ë: ∆· ·È‰È¿ Ì ÈÓÔ΢ÛÙÈ΋, ÂÎÙfi˜ ·fi Ù·ÎÙÈ΋ ÂÚÈÔ‰È΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ ÙÔ˘ ÂȉÈÎÔ‡ ΤÓÙÚÔ˘, Û˘Ó¯›˙Ô˘Ó Ó· ÂÈÛΤÙÔÓÙ·È ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ Ô˘ ˙Ô˘Ó Ì·ÎÚÈ¿ ·fi ÙÔ Î¤ÓÙÚÔ ÈÓÔ΢ÛÙÈ΋˜. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ô ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· Â›Ó·È Û ı¤ÛË Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Ù· ÚÒÈÌ· Û˘ÌÙÒÌ·Ù· Ù˘ ÓfiÛÔ˘ ηıÒ˜ Î·È ÂΛӘ ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙËÓ ÂͤÏÈÍ‹ Ù˘. ™ÎÔfi˜ Ù˘ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ˘ÔÁÚ·ÌÌÈÛÙÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù· ηıÒ˜ Î·È Ù· ‰È·ÁÓˆÛÙÈο Î·È ıÂÚ·¢ÙÈο ÚÔ‚Ï‹Ì·Ù· Ù˘ ÈÓÔ΢ÛÙÈ΋˜, ¤ÙÛÈ ÒÛÙ ӷ ÂÓÈÛ¯˘ı› Ô ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘.

Abstract: Children with cystic fibrosis, apart from the frequent visits to a cystic fibrosis center, are simultaneously followed by a pediatrician. The role of the pediatrician is particularly significant for those patients who live far from the cystic fibrosis center and their visits are not as regular as required. It is therefore essential that every pediatrician should be familiar with the most common diagnostic and therapeutic problems in cystic fibrosis. More specifically, pediatricians should be able to recognize the early symptoms as well as those clinical signs that are associated with the progress of the disease. The aim of this review is to highlight these issues in order to strengthen the role of pediatricians in the treatment of cystic fibrosis.

§¤ÍÂȘ ÎÏÂȉȿ: ÈÓÔ΢ÛÙÈ΋, ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë.

Key words: cystic fibrosis, primary care.

∏ ÈÓÔ΢ÛÙÈ΋ (π¡∫) Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ÎÏËÚÔÓÔÌÈ΋ ÓfiÛÔ˜ ÛÙËÓ ∂˘ÚÒË. ∏ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ Ù·ÎÙÈ΋˜ Î·È Â›ÌÔÓ˘ Ê˘ÛÈÔıÂÚ·›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÈıÂÙÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫. ŒÙÛÈ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ù· ·È‰È¿ ÛÙ· ÔÔ›· ¤ÁÈÓÂ Ë ‰È¿ÁÓˆÛË ÌÂÙ¿ ÙÔ ¤ÙÔ˜ 1990, ı· ¤¯Ô˘Ó ̤ÛÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ 40 ¯ÚfiÓÈ·, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ù· ›‰È· ıÂÚ·¢ÙÈο ̤۷ Ô˘ ¤¯Ô˘Ì ۋÌÂÚ· (1).

OÈ ·ÛıÂÓ›˜ Ì π¡∫ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ÂȉÈο ΤÓÙÚ· ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÛÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ·˘Ù¿ (2).

∞fi ÙËÓ ·Ó·Î¿Ï˘„Ë ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÈÓÔ΢ÛÙÈ΋˜ ÛÙÔ Ì·ÎÚfi ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 7 ÙÔ 1989, ‚Ú¤ıËΠfiÙÈ ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ÙÔ ÁÔÓ›‰ÈÔ ·˘Ùfi Έ‰ÈÎÔÔÈ› Ì›· ÚˆÙ½ÓË, Ë ÔÔ›· ·ÔÙÂÏÂ›Ù·È ·fi 1480 ·ÌÈÓÔͤ· Î·È ‚Ú›ÛÎÂÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Â͈ÎÚÈÓÒÓ ·‰¤ÓˆÓ. ∏ ÚˆÙ½ÓË ·˘Ù‹ ÏÂÈÙÔ˘ÚÁ› Û·Ó ·ÓÙÏ›· CI (3). ™Â ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋, Ë ÚˆÙ½ÓË Ù˘ π¡∫ ·) ‰ÂÓ ·Ú¿ÁÂÙ·È ‹ ‚) ·Ú¿ÁÂÙ·È Î·È Î·Ù·ÛÙÚ¤ÊÂÙ·È ÂÓ‰Ô΢ÙÙ¿ÚÈ· ‹ Á) ·Ú¿ÁÂÙ·È Û Ôχ ÌÈÎÚ‹ ÔÛfiÙËÙ· ‹ ‰) ·˘Ù‹ Ô˘ ·Ú¿ÁÂÙ·È ‰˘ÛÏÂÈÙÔ˘ÚÁ› (4).

OÈ ÁÓÒÛÂȘ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ̤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯Ô˘Ó Û˘Ó‰Ú¿ÌÂÈ ÛÙË ıÂÚ·›· Ù˘ π¡∫

¢È¢ı˘ÓÙ‹˜ ∆Ì‹Ì·ÙÔ˜ πÓÔ΢ÛÙÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

Director, Division of Cystic Fibrosis Children’s Hospital “St. Sophia”, Athens

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18:55

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˘¤Ú ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ™ÙË ‰ÂηÂÙ›· Ô˘ ¿Ú¯ÈÛ ·Ó·Ì¤ÓÂÙ·È ÂÓÙÔÓfiÙÂÚË Î·È Û˘ÛÙËÌ·ÙÈÎfiÙÂÚË ÚÔÛ¿ıÂÈ· ÁÈ· Ó· ÂÈÙ¢¯ı›, ›Ù ‰È· Ù˘ ·ÔηٿÛÙ·Û˘ Ù˘ ·Ú·ÁˆÁ‹˜ ‹ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÚˆÙ½Ó˘, ‹ Ù˘ ÁÔÓȉȷ΋˜ ıÂÚ·›·˜ ÔÈ Ôԛ˜ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË.

O ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ÈÓÔ΢ÛÙÈ΋ Î·È Ó· Û˘ÌÌÂÙ¤¯ÂÈ: ·) ÛÙË ‰È¿ÁÓˆÛË, ‚) ÛÙËÓ ÚfiÏË„Ë, Á) ÛÙËÓ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË Î·È ‰) ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë. ·) ¢È¿ÁÓˆÛË: ∏ ÈÓÔ΢ÛÙÈ΋, ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ, ÚÔ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi, ÂÓÒ ÌÂÙ¿ Ù· 6 ¯ÚfiÓÈ· ÚÔ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ª¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÌËÓÒÓ ¤¯Ô˘Ó ‰È·ÁÓˆÛÙ› Ù· 2/3 ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘ ∆Ì‹Ì·ÙÔ˜ Ù˘ πÓÔ΢ÛÙÈ΋˜ Ù˘ ∞ı‹Ó·˜. ‚) ¶ÚfiÏË„Ë: °È· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ Â›Ó·È ··Ú·›ÙËÙË Ë ÚÔÙÚÔ‹ ÙˆÓ ÛÙÂÓÒÓ Û˘ÁÁÂÓÒÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÁÂÓÂÙÈÎfi ¤ÏÂÁ¯Ô. Á) æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË: ∆Ô ¯ÚfiÓÈÔ ÓfiÛËÌ· Ì ÙËÓ Î·Î‹ ÚfiÁÓˆÛË, Ë ÂÓÂÚÁ‹ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙËÓ Î·ıËÌÂÚÈÓ‹ Ê˘ÛÈÔıÂÚ·›· ηıÒ˜ Î·È ÔÈ Û˘¯Ó¤˜ ÓÔÛËÏ›˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÎÔ˘Ú¿˙Ô˘Ó ÙÔ˘˜ ÁÔÓ›˜. O ·È‰›·ÙÚÔ˜, Ì ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ Ê›ÏÔ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ηÏÂ›Ù·È Ó· ÙËÓ ˘ÔÛÙËÚ›ÍÂÈ. ‰) ¶ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë: O ·È‰›·ÙÚÔ˜ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ÚÔÛ¿ıÂÈ· ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫, ·Ó·Ï·Ì‚¿ÓÔÓÙ·˜ ÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Ì π¡∫. ∏ ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È Ë Î·Ï‹ Û˘ÓÂÚÁ·Û›· Ì ÙÔ Î¤ÓÙÚÔ ÈÓÔ΢ÛÙÈ΋˜ ‚ÔËıÔ‡Ó ÛÙËÓ ¤ÁηÈÚË Î·È ÂÈÙ˘¯‹ Â›Ï˘ÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Ì π¡∫, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ıÂÙÈ΋ Â›‰Ú·ÛË fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÈÌ‹Î˘ÓÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. £ÂÚ·›· Ù˘ ÈÓÔ΢ÛÙÈ΋˜ ∏ ıÂÚ·›· Ù˘ π¡∫ Û‹ÌÂÚ· Â›Ó·È Û˘Ìو̷ÙÈ΋ Î·È Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ÂÙÈÎÔ‡ Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ηıÒ˜ Î·È ÛÙËÓ ÚfiÏË„Ë Ù˘ ·Ê˘‰¿ÙˆÛ˘. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ÂÙÈÎÔ‡: ∆Ô 85% ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫ ¤¯ÂÈ ·ÁÎÚ·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Â›Ó·È ··Ú·›ÙËÙË Ë ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì·. ∏ ‰ÔÛÔÏÔÁ›· ÂÍ·ÙÔÌÈ·ÂÙ·È Î·È ÔÈΛÏÏÂÈ Â˘Ú¤ˆ˜. ƒ˘ıÌ›˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÛfiÙËÙ· Î·È ÙÔ Â›‰Ô˜ Ù˘ ‰È·ÙÚÔÊ‹˜ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ph ‹ ÙËÓ Î¤ÓˆÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ¿ÏÏ·. ¶fiÛ· ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· Ú¤ÂÈ Ó· ‰ÒÛÔ˘ÌÂ

Paediatriki 2001;64:308-311

Û ¤Ó· ·ÛıÂÓ‹ Ì π¡∫; ∆· ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· ¯ÔÚËÁÔ‡ÓÙ·È, ¤ÙÛÈ ÒÛÙ ӷ ¤¯Ô˘Ì 1-2 ÎÂÓÒÛÂȘ ηϋ˜ Û‡ÛÙ·Û˘ Î·È Ó· ÂÈÙ‡¯Ô˘Ì ηϋ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË. ª›· Û˘Ó‹ı˘ ‰fiÛË Â›Ó·È 500-1500 IU/ÏÈ¿ÛË/kg/Á‡̷ (6). ∏ ¯ÔÚ‹ÁËÛË ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ ∞, D, ∂ Â›Ó·È ··Ú·›ÙËÙË Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÁÎÚ·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÁÈ· ÙȘ ‚Èٷ̛Ә ∞ Î·È D Â›Ó·È Ë ‰ÈÏ¿ÛÈ· ÙˆÓ ËÌÂÚ‹ÛÈˆÓ ·Ó·ÁÎÒÓ ÁÈ· Ù· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∏ ‚ÈÙ·Ì›ÓË ∂ ¯ÔÚËÁÂ›Ù·È ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·: Ë ‰fiÛË ÛÙ· ‚Ú¤ÊË Â›Ó·È 25-50 mg/24ˆÚÔ, ÛÙ· ·È‰È¿ 100 mg/24ˆÚÔ Î·È ÛÙÔ˘˜ ¤ÊË‚Ô˘˜ 100-200 mg/24ˆÚÔ (6). ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡: 1. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ È͈‰ÒÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ. ∏ Ê˘ÛÈÔıÂÚ·›· ·ÔÙÂÏ› ÙÔÓ Î˘ÚÈfiÙÂÚÔ ÙÚfiÔ ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚÈÌ¿ÙˆÓ Î·È Â›Ó·È ÙÔ ‚·ÛÈÎfiÙÂÚÔ ÙÌ‹Ì· Ù˘ ıÂÚ·›·˜. O ÁÂÓÈÎfi˜ ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÂÈ Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÁÔÓ›˜ Î·È Ó· ÙÔ˘˜ ÚÔÙÚ¤ÂÈ ÛÙËÓ Î·Ù‡ı˘ÓÛË ·˘Ù‹. ÕÏÏÔÈ ÙÚfiÔÈ Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛÂˆÓ Â›Ó·È Ë ÂÓ˘‰¿ÙˆÛË, Ù· ‚ÏÂÓÓÔÏ˘ÙÈο Î·È rhDNA (Pulmozyme), ÙÔ ˘¤ÚÙÔÓÔ NaCl. 2. ∏ ·ÓÙÈÌÂÙÒÈÛË Î·È ÚfiÏË„Ë ÙˆÓ ÏÔÈÌÒ͈Ó. ∏ π¡∫ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË ¯ÚfiÓÈ· ÂÓ‰Ô‚ÚÔÁ¯È΋ Ïԛ̈ÍË, fiÔ˘ Û˘Ó‹ıˆ˜ ·Ó·Ù‡ÛÛÔÓÙ·È St.aureus, H.Influenzae, Ps.Aeruginosa.

OÈ ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ∏ ηı˘ÛÙ¤ÚËÛË ‹ Ë Î·Î‹ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÔÚ› Ó· ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ÌfiÓÈÌË Ì›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.

OÈ Â·ÓÂÈÏËÌ̤Ó˜ ÏÔÈÌÒÍÂȘ, Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, ÂÈʤÚÔ˘Ó ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÂÁηٿÛÙ·ÛË ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ™ÙȘ ·ÚÔ͇ÓÛÂȘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ¯ÔÚËÁԇ̠·ÓÙÈ‚›ˆÛË Â›Ù ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ›Ù ∂º, ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ ÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÛÙȘ ηÏÏȤÚÁÂȘ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ. ∆· Û˘ÌÙÒÌ·Ù· Ô˘ Ô‰ËÁÔ‡Ó ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚›ˆÛ˘ Û ·ÛıÂÓ›˜ Ì π¡∫ ‰ÂÓ Â›Ó·È ÌfiÓÔ ·˘Ù¿ Ù˘ ÔÍ›·˜ Ïԛ̈͢ (Ô ˘ÚÂÙfi˜ Ì ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù· ηٿ ÙËÓ ·ÎÚfi·ÛË ÙÔ˘ ıÒڷη), ·ÏÏ¿ Ô‰ËÁԇ̷ÛÙ ÂΛ, ‰ËÏ·‰‹ ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÒÛˆ˜, Î·È fiÙ·Ó ˘¿Ú¯ÂÈ ·Úfi͢ÓÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ Ô˘

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¶·È‰È·ÙÚÈ΋ 2001;64:308-311

Paediatriki 2001;64:308-311

¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ Î·È ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù·. ¢‡Ô ˘ÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ Î·È ‰‡Ô ·ÓÙÈÎÂÈÌÂÓÈο Â˘Ú‹Ì·Ù· Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ‰È·ÈÛÙÒÛÔ˘Ì fiÙÈ ¤Ó·˜ ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (7) (¶›Ó·Î·˜ 1). ŒÓ· ·È‰› Ì π¡∫, ÙÔ ÔÔ›Ô ·ÚÔ˘ÛÈ¿˙ÂÈ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜, ı· Ú¤ÂÈ Ó· ·›ÚÓÂÈ ·ÓÙÈ‚›ˆÛË. ∏ ·ÓÔÛ›·, ÙfiÛÔ Ë ¯˘ÌÈ΋ fiÛÔ Î·È Ë Î˘ÙÙ·ÚÈ΋, fiÛÔ ÌÔÚÔ‡Ó Ó· ÂÏÂÁ¯ıÔ‡Ó, Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì π¡∫. ∞fi‰ÂÈÍË ·˘ÙÔ‡ ·ÔÙÂÏ› ÙÔ fiÙÈ Ù· ·È‰È¿ Ì π¡∫ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÂÈÙ˘¯Ò˜ ÙȘ ÏÔÈÌÒÍÂȘ Ô˘ ‰ÂÓ ·ÊÔÚÔ‡Ó ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ∆ÔÈο, fï˜, ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ÙˆÓ ·ÛıÂÓÒÓ Ì π¡∫ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Â˘·›ÛıËÙÔ. ŒÙÛÈ, ‰È¿ÊÔÚ˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜) ÚÔηÏÔ‡Ó ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ∆¤ÙÔȘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Ô˘ Û˘¯Ó¿ ÚÔηÏÔ‡Ó ·Úfi͢ÓÛË Â›Ó·È ÏÔÈÌÒÍÂȘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi, ·‰ÂÓÔ˚Ô‡˜, ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘, ÁÚ›˘ Î·È ·Ú·ÁÚ›˘, ·ÓÂÌÔ‚ÏÔÁÈ¿˜, ÂÚ˘ıÚ¿˜, ÈÏ·Ú¿˜, ηıÒ˜ Â›Û˘ ÏÔÈÌÒÍÂȘ ·fi ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, fiˆ˜ Â›Ó·È ÎÔÎ·Ù˘, ¯Ï·Ì‡‰È·, Ì˘ÎfiÏ·ÛÌ·, Ì˘ÎÔ‚·ÎÙËÚ›‰È·, ÏÂÁȈӤϷ (8). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÈ ÏÔÈÌÒÍÂȘ ·˘Ù¤˜ ı· Ú¤ÂÈ Ó· ÚÔÏ·Ì‚¿ÓÔÓÙ·È, fiÙ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Ì ÂÌ‚ÔÏÈ·ÛÌÔ‡˜. ∆· ÂÌ‚fiÏÈ· Ô˘ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· Ù· ·È‰È¿ Ì ÙËÓ π¡∫ Â›Ó·È Ù· ›‰È· Ô˘ Á›ÓÔÓÙ·È Î·È ÛÙ· ¿ÏÏ· ·È‰È¿, ‰ËÏ·‰‹ DTP, MMR, ·ÈÌÔÊ›ÏÔ˘, Ê˘Ì·Ù›ˆÛ˘. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÌ‚fiÏÈÔ ÁÚ›˘ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ Ì ‰‡Ô ÌÈÛ¤˜ ‰fiÛÂȘ (0,25 ml x 2) ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ÂÓÒ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 3-12 ÂÙÒÓ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì 2 ÔÏfiÎÏËÚ˜ ‰fiÛÂȘ (0,5 ml x 2) ÂÊ’ fiÛÔÓ Â›Ó·È Ô ÚÒÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜. ∆Ô ÂÌ‚fiÏÈÔ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ̛· ÔÏfiÎÏËÚË ‰fiÛË (0,5 ml x 1) οı ¯ÚfiÓÔ, ÂÊ’ fiÛÔÓ ÚfiÎÂÈÙ·È ÁÈ· Â·ÓÂÌ‚ÔÏÈ·ÛÌfi. Œˆ˜ fiÙÔ˘ ΢ÎÏÔÊÔÚ‹ÛÂÈ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜, ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È acyclovir (1530 mg/kg/24ˆÚÔ) ÁÈ· 5 Ë̤Ú˜, Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÚÒÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜. ∂›Û˘, Ô ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ο-

ÓÂÈ Ù· ÂÌ‚fiÏÈ· Ù˘ Ë·Ù›Ùȉ·˜ µ Î·È Ë·Ù›Ùȉ·˜ ∞, ÏfiÁˆ Ù˘ ¯ÚfiÓÈ·˜ Ë·ÙÔ¿ıÂÈ·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ë ÓfiÛÔ˜. ™˘Ó‹ıË Û˘ÌÙÒÌ·Ù· ·ÛıÂÓÒÓ Ì ÈÓÔ΢ÛÙÈ΋ Ô˘ ηÏÂ›Ù·È Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Ô ·È‰›·ÙÚÔ˜ (5) µ‹¯·˜: O ‚‹¯·˜ Â›Ó·È ¤Ó·˜ Ê˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜, Ô ÔÔ›Ô˜ ÚÔÛٷهÂÈ ÙÔ˘˜ Ó‡ÌÔÓ˜ ·fi ÙËÓ ÂÈÛÓÔ‹ Í¤ÓˆÓ ÛˆÌ·Ùȉ›ˆÓ. ∂›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ Û‡Ìو̷ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ™ÙÔ ·È‰› Ì ÈÓÔ΢ÛÙÈ΋ ·ÔÙÂÏ› Ì˯·ÓÈÛÌfi ·Ô‚ÔÏ‹˜ ÙˆÓ ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ, ÔÈ Ôԛ˜ ·‰˘Ó·ÙÔ‡Ó Ó· ‚ÁÔ˘Ó ÏfiÁˆ ÌÂÈÔÓÂÎÙÈ΋˜ ‚ÏÂÓÓÔÎÚÔÛÛˆÙ‹˜ οı·ÚÛ˘. ∆Ô ·È‰› Ì ÈÓÔ΢ÛÙÈ΋ ‚‹¯ÂÈ ÁÈ·Ù› Ú¤ÂÈ Ó· ‚Á¿ÏÂÈ ÙȘ ‚ÚÔÁ¯ÈΤ˜ ÂÎÎÚ›ÛÂȘ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ Ô˘ ‚Ú›ÛÎÂÙ·È ÙÔ ·È‰›, ‰ÂÓ Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÈ ÙÔ ‚‹¯· ÙÔ˘ Î·È ‰ÂÓ Ú¤ÂÈ Ó· ÙÔ˘ ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙȂ˯Èο. ∏ ·‡ÍËÛË ÙÔ˘ ‚‹¯· Î·È ÙˆÓ Ù˘¤ÏˆÓ, fiˆ˜ ·Ó·Ê¤Ú·ÌÂ, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ·Úfi͢ÓÛ˘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ¶fiÓÔ˜ ÛÙÔ ıÒڷη: O ·ÈÊÓ›‰ÈÔ˜, Ô͇˜ ÂÙÂÚfiÏ¢ÚÔ˜ fiÓÔ˜ ÛÙÔ ıÒڷη ÌÔÚ› Ó· Â›Ó·È Ó¢ÌÔıÒڷη˜ Î·È ÂȉÈÎfiÙÂÚ· Â¿Ó Û˘Óԉ‡ÂÙ·È Ì ‰‡ÛÓÔÈ·. ∏ ‡·ÚÍ‹ ÙÔ˘ ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∞ÌÊÔÙÂÚfiÏ¢ÚÔ˜ fiÓÔ˜ ÛÙÔ ıÒڷη Èı·Ófiٷٷ ‰ÂÓ Â›Ó·È Ó¢ÌÔıÒڷη˜, ·ÏÏ¿ Â›Ó·È Û˘Ó‹ıˆ˜ Ì˘˚΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∞ÈÌfiÙ˘ÛË: ∞Ó¿ÏÔÁ· Ù˘ ÔÛfiÙËÙ¿˜ Ù˘ ‰È·ÎÚ›ÓÂÙ·È Û ÌÈÎÚ‹, ÌÂÛ·›· Î·È ÌÂÁ¿ÏË. ŸÙ·Ó Ë ·ÚÔ˘Û›· ·›Ì·ÙÔ˜ ÛÙ· Ù‡ÂÏ· Â›Ó·È ÁÚ·ÌÌÔÂȉ‹˜ ‹ ·Ó¿ÌÈÎÙË, Û˘¯Ó¿, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ıÂÚ·›·. ªÈÎÚ‹, fï˜, Î·È Â›ÌÔÓË ·ÚÔ˘Û›· Ù˘ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ·Úfi͢ÓÛ˘ Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ Î·È Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Ó¿ÁÎË ıÂÚ·›·˜. ∆·˘Ùfi¯ÚÔÓ·, Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë ·Ó·˙‹ÙËÛË ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·ÈÌÔÚÚ·Á›·, .¯. Û·Ï˘ÎÈÏÈο, ÎÈÚÛÔ› ÔÈÛÔÊ¿ÁÔ˘. ¶fiÓÔ˜ ÛÙËÓ ÎÔÈÏÈ¿: ∏ η΋ ¤„Ë ÛÙÔ ¤ÓÙÂÚÔ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ÔÁÎÒ‰ÂȘ ÏÈ·Ú¤˜ ÎÂÓÒÛÂȘ, Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÙÔ “ÈÛÔ‰‡Ó·ÌÔ ÂÈÏÂÔ‡ ·fi Ì˘ÎÒÓÈÔ” Ô˘ ÂΉËÏÒÓÂÙ·È Ì fiÓÔ ÛÙËÓ ÎÔÈÏÈ¿ Î·È ÌË ·Ô‚ÔÏ‹ ÎÔÚ¿ÓˆÓ ϤÔÓ ÙÔ˘ 24ÒÚÔ˘.

¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ·Úfi͢ÓÛË Ù˘ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ÀÔÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ

∞ÓÙÈÎÂÈÌÂÓÈο ÂÓԯϋ̷ٷ

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¶·È‰È·ÙÚÈ΋ 2001;64:308-311

™˘ÌÂÚ·›ÓÔ˘Ì fiÙÈ Ë ÈÓÔ΢ÛÙÈ΋ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÛÔ‚·Ú¿ ˘fi„Ë Î·È Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ¤ÓÙÔÓË ˘·ÎÙÈ΋ ·ÁˆÁ‹, ·ÊÔ‡ ‚¤‚·È· ·ÔÎÏÂÈÛÙ› Ë ‡·ÚÍË ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜, fiˆ˜ Ë ÛΈÏËÎÔÂȉ›ÙȘ ‹ Ô ÂÁÎÔÏ·ÛÌfi˜.

Paediatriki 2001;64:308-311

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3. Riordan J, Rommens J, Kerem BJ et al. Identification of the cystic fibrosis gene: Cloning and characterisation of complementary DNA. Science 1989;245:1066-1073.

4. Welsh J, Smith E. Molecular mechanisms of CFTR

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Ramsey B, Gore E, Smith A, Cooney M, Redding G, Foy H. The effect of respiratory viral infections on patients with cystic fibrosis. Am J Dis Child 1989;143:662-668.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù·‡ÚÔ˜ ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘ ¢/ÓÙ‹˜ ∆Ì‹Ì·ÙÔ˜ πÓÔ΢ÛÙÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¢ÂÓ ˘¿Ú¯ÂÈ ·ÓÙÈÎÂÈÌÂÓÈο ÌÂÙÚ‹ÛÈÌÔ fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Ì ·ÂÚÔı¿Ï·ÌÔ Û ‚Ú¤ÊË Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·1 ™ÎÔfi˜: ¢ÈÂÓÂÚÁ‹ıËΠ̛· ‰ÈÏ‹-Ù˘ÊÏ‹, ÂÏÂÁ¯fiÌÂÓË Ì placebo, Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË, ÁÈ· Ó· ‰ÈÂÚ¢ÓËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ, fiÙ·Ó ·˘Ù¿ ¯ÔÚËÁÔ‡ÓÙ·Ó Â› ÙÚ›ÌËÓÔ Ì ·ÂÚÔı¿Ï·ÌÔ Î·È Ì¿Ûη ÚÔÛÒÔ˘ Û ‚Ú¤ÊË Ô˘ ·Ó¤ÚÚˆÓ·Ó ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™·Ú¿ÓÙ· ÔÎÙÒ, ˘ÁÈ‹ ηٿ Ù· ¿ÏÏ·, ‚Ú¤ÊË Ô˘ ·Ó¤ÚÚˆÓ·Ó ·fi ÙÔ ÚÒÙÔ ÂÂÈÛfi‰ÈÔ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜, Ù˘¯·ÈÔÔÈ‹ıËηÓ, ÒÛÙ ӷ Ï¿‚Ô˘Ó 150 Ìg ÚÔÈÔÓÈ΋˜ ÊÏÔ˘ÙÈη˙fiÓ˘ (FP) ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‹ placebo Ì ·ÂÚÔı¿Ï·ÌÔ Babyhaler. ∆· ‚Ú¤ÊË ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Ì·ÎÚÔÚfiıÂÛÌ·, Ú·ÁÌ·ÙÔÔÈÒÓÙ·˜ ÂÙ¿ ÂÎÙÈÌ‹ÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ¤ÙÔ˘˜, Ì ÙË ‚Ô‹ıÂÈ· ËÌÂÚÔÏÔÁ›ˆÓ Û˘Ìو̿وÓ, ‚È‚ÏÈ·Ú›ˆÓ ˘Á›·˜, ÎÏÈÓÈ΋˜ ÂͤٷÛ˘, ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ηٷÁÚ·Ê‹˜ Ó˘ÎÙÂÚÈÓÔ‡ ‚‹¯· Î·È ÙÈÌÒÓ ÎÔÚÂÛÌÔ‡ Ô͢ÁfiÓÔ˘. ∏ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÂÙÚ‹ıËΠ6 Ì‹Ó˜ ÌÂÙ¿ ÙÔ ÂÍÈÙ‹ÚÈÔ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ™·Ú¿ÓÙ· ÙÚ›· ‚Ú¤ÊË ÔÏÔÎÏ‹ÚˆÛ·Ó ÙË ÌÂϤÙË (FP 21, placebo 22). ∞ÔÙÂϤÛÌ·Ù·: ¢ÂÓ Â˘Ú¤ıËÛ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÚÂȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÌÂÙÚ‹ıËηÓ, ‰ËÏ·‰‹ ÙÔ Ó˘ÎÙÂÚÈÓfi ‚‹¯·, ÙÔÓ ÎÔÚÂÛÌfi Ô͢ÁfiÓÔ˘ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÙˆÓ Ó¢ÌfiÓˆÓ. ∏ ‚·ıÌÔÏÔÁ›· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó ¯·ÌËÏ‹ ÙfiÛÔ ÛÙËÓ ÔÌ¿‰· Ô˘ ¤Ï·‚ FP, fiÛÔ Î·È Û ÂΛÓË Ô˘ ¤Ï·‚ placebo, Ì ·Ô˘Û›· (0) Û˘-

ÌÙˆÌ¿ÙˆÓ ‹ ‹È· (1) Û˘ÌÙÒÌ·Ù· Û ≥90% ÙˆÓ ËÌÂÚÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘. ¢ÂÓ Â˘Ú¤ıËÛ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ìو̿وÓ, ÛÙË ¯Ú‹ÛË Î·Ù’ Â›ÎÏËÛÈÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‹ ÛÙȘ ÂÈÛ·ÁˆÁ¤˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ıÂÚ·›·˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÌÂϤÙ˘ ‹ ηٿ ÙËÓ ÂÓ Û˘Ó¯›· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ‰ÂÓ Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿Ù·È Ë ¯Ú‹ÛË ÂÈÛÓÂfiÌÂÓ˘ ÊÏÔ˘ÙÈη˙fiÓ˘ Û ·È‰È¿ Ô˘ ·Ó·ÚÚÒÓÔ˘Ó ·fi ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·.

1 Wong JYW, Moon S, Beardsmore C O’Callaghan C, Simpson H No objective benefit from steroids inhaled via a spacer in infants recovering from bronchiolitis Eur Respir J 2000;15:388-394

ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ

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ASSOCIATED SUBSPECIALTIES

ÀÔÛ·‰›·˜ ¢. ∫ÂÚ·Ì›‰·˜

Hypospadias D. Keramidas

¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ›ڷ Ì·˜ ·fi 441 ÂÚÈÙÒÛÂȘ ˘ÔÛ·‰›· Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ 1986 - 1999. ∏ ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÎÂÓÙÚÈÎÒ˜ Ù˘ ‚·Ï¿ÓÔ˘ Û ‰È¿ÊÔÚ˜ ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ ·fi ÙË ‚¿ÛË Ù˘ ‚·Ï¿ÓÔ˘ ¤ˆ˜ ÙÔ ÂÚ›ÓÂÔ, Û˘Ó‰˘·˙fiÙ·Ó Ì ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ¤ÏÏÂÈÌÌ· ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ̤ÚÔ˘˜ Ù˘ ·ÎÚÔÔÛı›·˜ Î·È Ì ·ÚÔ˘Û›· ¯ÔÚ‰‹˜ ÂÚÈÊÂÚÈο Ù˘ Ô˘Ú‹ıÚ·˜ ÚÔηÏÔ‡Û·˜ Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜. OÈ ˆ˜ ¿Óˆ ·ÓˆÌ·Ï›Â˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ Ì ÛÙfi¯Ô ÙÔÓ Â˘ıÂÈ·ÛÌfi ÙÔ˘ ¤Ô˘˜ Î·È ÙËÓ Â΂ÔÏ‹ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘. ∏ ËÏÈΛ· ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ÂÁ¯Â›ÚËÛË Î˘Ì·ÈÓfiÙ·Ó ·fi 20 ÌËÓÒÓ Ì¤¯ÚÈ 3 ÂÙÒÓ. ∏ ·ÓÒÌ·ÏË Â΂ÔÏ‹ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙË ‚¿Ï·ÓÔ Î·È ˘fi ÙË ÛÙÂÊ¿ÓË, ·ÓÙÈÚÔÛˆ‡ÂÈ ÙÔ 50,3% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ Ù¯ÓÈ΋ Ì·˜ Ù˘ ÌÂÙ·ÙfiÈÛ˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈ΋ ı¤ÛË ÛÙË ‚¿Ï·ÓÔ ¯ÚËÛÈÌÔÔÈ‹ıËΠ̠ηÏfi ÏÂÈÙÔ˘ÚÁÈÎfi Î·È ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. O ÚfiÛıÈÔ˜ Â˚Îfi˜ ˘ÔÛ·‰›·˜ ·ÓÙÈÚÔÛˆ‡ÂÈ 40,5% ÙˆÓ ÂÚÈÙÒÛˆÓ. ÃÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù¯ÓÈ΋ Ù˘ Ô˘ÚËıÚÔÏ·ÛÙÈ΋˜ ηٿ ªathieu. °È· ÙȘ ‰ÈÔÚıÒÛÂȘ ÙˆÓ ˘fiÏÔÈˆÓ ÌÔÚÊÒÓ ˘ÔÛ·‰›·, Ô Â˘ıÂÈ·ÛÌfi˜ Û˘Ó‰˘¿ÛÙËΠ̠ԢÚËıÚÔÏ·ÛÙÈ΋ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÂÁοÚÛÈÔ ÛˆÏËÓˆÙfi ÎÚËÌÓfi Ì ·ÁÁÂÈ·Îfi Ì›Û¯Ô ·fi ÙÔ ¤Ûˆ ¤Ù·ÏÔ Ù˘ ·ÎÚÔÔÛı›·˜. ∫˘ÚÈfiÙÂÚË ÂÈÏÔ΋ ÙˆÓ ˆ˜ ¿Óˆ ÂÁ¯ÂÈÚËÙÈÎÒÓ ÌÂıfi‰ˆÓ ‹Ù·Ó ÙÔ Û˘Ú›ÁÁÈÔ Ù˘ Ô˘Ú‹ıÚ·˜. ¶·ÚÔ˘ÛÈ¿ÛÙËΠ۠13,4% ÙˆÓ ¯ÂÈÚÔ˘ÚÁËı¤ÓÙˆÓ Î·È ·ÓÙÈÌÂÙˆ›ÛÙËΠÂÈÙ˘¯Ò˜ Ì ÂÁ¯Â›ÚËÛË ‹ Â·ÓÂÁ¯Â›ÚËÛË Û‡ÁÎÏÂÈÛ˘ ÙÔ˘ Û˘ÚÈÁÁ›Ô˘.

Abstract: Our experience with 441 cases of hypospadias operated upon during a 13-year period is presented. The anatomical abnormality of termination of the urethral orifice proximally to the normal site was associated with ventral deficiency of the prepuce and ventral flexion of the shaft due to chordee situated distal to the orifice. One-stage repair for shaft straitening and urethroplasty was used in all forms of hypospadias. In the majority of patients the age at time of operation varied from 20 months to 3 years. Distal hypospadias was the most common lesion. The glandular and subcoronal meatus accounted for 50.3% of cases.

Our technique of urethra advancement, combined with glanuloplasty and prepuceoplasty, was used with very good cosmetic and functional results.

Penile hypospadias with urethra orifice on the distal shaft accounted for 40.5% of cases. The perimeatal - based flap (Mathieu procedure) was used. All other forms of hypospadias were surgically corrected using transverse preputial island flap.

Main postoperative complication was fistula formation needing surgical repair in 13.4% of the cases.

§¤ÍÂȘ ÎÏÂȉȿ: ˘ÔÛ·‰›·˜, ÎÔÈÏÈ·Îfi ÛÙfiÌÈÔ Ô˘Ú‹ıÚ·˜, Î¿Ì„Ë ¤Ô˘˜, ¤Ó·˜ ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ¯ÚfiÓÔ˜.

Key words: hypospadias, ventral urethral orifice, chordee, one-stage operation.

¢È¢ı˘ÓÙ‹˜ ÙÔ˘ µ’ ÃÂÈÚÔ˘ÚÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”

Director, 2nd Department of Pediatric Surgery “Aghia Sophia” Children’s Hospital, Athens

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¶·È‰È·ÙÚÈ΋ 2001;64:312-314

O ˘ÔÛ·‰›·˜ Â›Ó·È Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, Ù˘ ÔÔ›·˜ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÁÓˆÚÈÛÌ· Â›Ó·È Ë Â΂ÔÏ‹ ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÙÔ˘ ¿ÚÚÂÓ· Û ¿Ù˘˜ ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ ÎÂÓÙÚÈÎfiÙÂÚ· Ù˘ ÎÔÚ˘Ê‹˜ Ù˘ ‚·Ï¿ÓÔ˘. OÈ ı¤ÛÂȘ ·˘Ù¤˜ ÔÈΛÏÏÔ˘Ó ·fi ÙËÓ ›‰È· ÙË ‚¿Ï·ÓÔ ¤ˆ˜ ÙÔ ÂÚ›ÓÂÔ. ™ÎÔfi˜ Ù˘ ÔÌÈÏ›·˜ ·˘Ù‹˜ ÂÈÓ·È Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÔÈ Û‡Á¯ÚÔÓ˜ ·fi„ÂȘ fiˆ˜ ·˘Ù¤˜ ÂÊ·ÚÌfi˙ÔÓÙ·È, ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÙË ‰ÈfiÚıˆÛË Ù˘ ·ÓˆÌ·Ï›·˜ ÛÙË µ' ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”. ∆· ·Ó·ÙÔÌÈο ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ˘ÔÛ·‰›· ‰È·ÎÚ›ÓÔÓÙ·È Û ÚˆÙ‡ÔÓÙ· Î·È Û˘Ó˘¿Ú¯ÔÓÙ·. ¶ÚˆÙ‡ÔÓ ÁÓÒÚÈÛÌ· Â›Ó·È Ë ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜, ‚¿ÛÂÈ Ù˘ ÔÔ›·˜ Ô ˘ÔÛ·‰›·˜ Ù·ÍÈÓÔÌÂ›Ù·È Î·Ù¿ Duckett Û ÙÚÂȘ ·ÚȘ ÔÌ¿‰Â˜: ÙÔÓ ÚfiÛıÈÔ, ÙÔ Ì¤ÛÔ Î·È ÙÔÓ Ô›ÛıÈÔ. ™ÙÔÓ ÚfiÛıÈÔ ˘ÔÛ·‰›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ‚·Ï·ÓÈÎfi˜, Ô ÛÙÂÊ·ÓÈ·›Ô˜ Î·È Ô ˘Ô‚·Ï·ÓÈÎfi˜. ∏ ÔÌ¿‰· ·˘Ù‹ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ Ù‡Ô, ·ÓÙÈÚÔÛˆ‡ÔÓÙ·˜ 50% ÙÔ˘ Û˘ÓfiÏÔ˘. ™ÙÔÓ Ô›ÛıÈÔ ˘ÔÛ·‰›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ô ÔÛ¯ÂÔÂ˚Îfi˜, Ô ÔÛ¯Â˚Îfi˜ Î·È Ô ÂÚÈÓÂ˚Îfi˜. OÈ Ù‡ÔÈ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ÙÔ 20% ÙÔ˘ Û˘ÓfiÏÔ˘. ∆¤ÏÔ˜, Ô Ì¤ÛÔ˜ ˘ÔÛ·‰›·˜ (ÂÚÈÊÂÚÈÎfi˜, ÌÂÛÔÂ˚Îfi˜, ÎÂÓÙÚÈÎfi˜) ·ÓÙÈÚÔÛˆ‡ÂÈ ÙÔ 30% ÙÔ˘ Û˘ÓfiÏÔ˘. ™˘Ó˘¿Ú¯ÔÓÙ· ÁÓˆÚ›ÛÌ·Ù· ÙÔ˘ ˘ÔÛ·‰›· Â›Ó·È ÙÔ ¤ÏÏÂÈÌÌ· Ù˘ ·ÎÚÔÚÔÛı›·˜ Î·È Ë Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜. OÈ ·ÓˆÌ·Ï›Â˜ ·˘Ù¤˜ ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó Ì ÙÔÓ ˘ÔÛ·‰›· ηÙ' ·fiÏ˘ÙË ¤ÓÓÔÈ·. ∂ȉÈÎfiÙÂÚ·, ÙÔ ¤ÏÏÂÈÌÌ· Ù˘ ·ÎÚÔÚÔÛı›·˜ ·ÊÔÚ¿ ÙÔ ÎÔÈÏÈ·Îfi ·˘Ù‹˜ ̤ÚÔ˜, ÂÓÒ Ë Î¿Ì„Ë ·ÊÔÚ¿ ÙÔ Ì¤ÚÔ˜ ÙÔ˘ ¤Ô˘˜ Ô˘ Â›Ó·È ÂÚÈÊÂÚÈο ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜. O ‚·ıÌfi˜ ο̄˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙÔ˘˜ Ù‡Ô˘˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ˘ÔÛ·‰›·, ÌÈÎÚfiÙÂÚÔ˜ ‰Â ÛÙÔ˘˜ Ù‡Ô˘˜ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ˘ÔÛ·‰›·. ∆Ô Ì¤ÁÂıÔ˜ Ù˘ ο̄˘ Ú¤ÂÈ Ó· ·Ó·˙ËÙÂ›Ù·È Î·Ù¿ ÙË Ê˘ÛÈ΋ ÂͤٷÛË. ∏ Î¿Ì„Ë ·Ó·‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔÓ ÂÍÂÙ¿˙ÔÓÙ· Ì ¤ÏÍË Ù˘ fiÛı˘ ÚÔ˜ ÙË ‚¿ÛË ÙÔ˘ ¤Ô˘˜. ™Ù· Û˘Ó˘¿Ú¯ÔÓÙ· ÁÓˆÚ›ÛÌ·Ù· ÌÔÚÔ‡Ó Ó· ÂÚÈÏËÊıÔ‡Ó Î·È ·ÓˆÌ·Ï›Â˜ ÙˆÓ fiÚ¯ÂˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙËÓ ·Ó·ÙÔÌÈ΋ ÙÔ˘˜ ı¤ÛË. ∞ӈ̷ϛ˜ ÙˆÓ fiÚ¯ÂˆÓ ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó Û˘¯Ó¿ Ì ÙÔÓ ˘ÔÛ·‰›·. ™ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ÔÈ fiÚ¯ÂȘ Â›Ó·È ·„ËÏ¿ÊËÙÔÈ ‹ ˘ÔÏ·ÛÙÈÎÔ› Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÂÍÂÙ¿ÛÂȘ ηıÔÚÈÛÌÔ‡ ÙÔ˘ ʇÏÔ˘. ∏ ̤ÛË Û˘¯ÓfiÙËÙ· ÙÔ˘ ˘ÔÛ·‰›· Â›Ó·È 1:300 ÁÂÓÓ‹ÛÂȘ. ™˘¯ÓfiÙÂÚÔÈ Â›Ó·È ÔÈ ‚·Ï·ÓÈÎfi˜ Î·È ˘Ô‚·Ï·ÓÈÎfi˜ ˘ÔÛ·‰›·˜ Ì ·Ó·ÏÔÁ›· 1:140 ÁÂÓÓ‹ÛÂȘ, ·ÎÔÏÔ˘ı› Ô Â˚Îfi˜ ˘ÔÛ·‰›·˜ Ì ·Ó·ÏÔÁ›· 1:1250 ÁÂÓÓ‹ÛÂȘ Î·È ¤ÂÙ·È Ô ÔÛ¯Â˚Îfi˜ Î·È Ô ÂÚÈÓÂ˚Îfi˜ ˘ÔÛ·‰›·˜, ÔÈ ÔÔ›ÔÈ ··ÓÙÒÓÙ·È Ì›·

Paediatriki 2001;64:312-314

ÊÔÚ¿ Û οı 3.330 ÁÂÓÓ‹ÛÂȘ.

O ˘ÔÛ·‰›·˜ ÚÔηÏ› ÛÔ‚·Ú¿ ÏÂÈÙÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù·. ∞˘Ù¿ ·ÊÔÚÔ‡Ó ÙË ÊÔÚ¿ Ù˘ ·ÎÙ›Ó·˜ ÙˆÓ Ô‡ÚˆÓ Î·È ÙË Û˘ÓÔ˘Û›·. ∞ÓÙ›ıÂÙ·, Ë ÁÔÓÈÌfiÙËÙ· ‰ÂÓ ÂËÚ¿˙ÂÙ·È ‰ÈfiÙÈ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ Û¤ÚÌ·ÙÔ˜. ∏ ·ÎÙ›Ó· ÙˆÓ Ô‡ÚˆÓ ¤¯ÂÈ ÊÔÚ¿ ۯ‰fiÓ Î¿ıÂÙË ÛÙÔ ‚·Ï·ÓÈÎfi ˘ÔÛ·‰›·, οıÂÙË ÛÙÔ ÛÙÂÊ·ÓÈ·›Ô Î·È ÌÂÛÔÂ˚Îfi ˘ÔÛ·‰›·, ÂÓÒ ÛÙÔÓ ÔÛ¯Â˚Îfi Ë Ô‡ÚËÛË Á›ÓÂÙ·È Û ηıÈÛÙ‹ ı¤ÛË. ∫·Ù¿ ÙË Û˘ÓÔ˘Û›·, Ë Â›ÛÔ‰Ô˜ ÙÔ˘ ¤Ô˘˜ ÛÙÔÓ ÎfiÏÔ ÌÔÚ› Ó· Â›Ó·È ÂÒ‰˘ÓË ·Ó Ë Î¿Ì„Ë ÙÔ˘ ¤Ô˘˜ Â›Ó·È ÌÈÎÚ‹ Î·È ·‰‡Ó·ÙË ·Ó Ë Î¿Ì„Ë Â›Ó·È ÌÂÁ¿ÏË. ∏ ÂÎÛÂÚÌ¿ÙÈÛË Á›ÓÂÙ·È ÂÎÙfi˜ ÙÔ˘ ÎfiÏÔ˘ ·Ó Ô ˘ÔÛ·‰›·˜ Â›Ó·È ÎÂÓÙÚÈÎfi˜ (ÔÛ¯ÂÔÂ˚Îfi˜, ÔÛ¯Â˚Îfi˜, ÂÚÈÓÂ˚Îfi˜).

OÈ Ô‰ËÁ›Â˜ ·fi ÙÔÓ ·È‰›·ÙÚÔ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ Ú¤ÂÈ Ó· ‰›‰ÔÓÙ·È Ì ÌÂÁ¿ÏË ÂÚ›Û΄Ë. ∏ ÏËÚÔÊÔÚ›· ÁÈ· ÙÔ ‚·Ï·ÓÈÎfi ‹ ÙÔ ÛÙÂÊ·ÓÈ·›Ô ˘ÔÛ·‰›· fiÙÈ “Â›Ó·È ·Ïfi Úfi‚ÏËÌ·” Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È. ∂›Û˘, Ë ÏËÚÔÊÔÚ›· fiÙÈ Ë ÂÚÈÛÛÂ‡Ô˘Û· Ú·¯È·›· ·ÎÚÔÔÛı›· ÌÔÚ› Ó· ·Ê·ÈÚÂ›Ù·È ÁÈ· ÏfiÁÔ˘˜ ÎÔÛÌËÙÈÎÔ‡˜ Â›Ó·È Ï¿ıÔ˜. ∆Ô Ì¤ÚÔ˜ ·˘Ùfi Ù˘ ·ÎÚÔÔÛı›·˜ Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È Ì¤¯ÚÈ Ó· ÔÏÔÎÏËÚˆı› Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Ù˘ ·ÓˆÌ·Ï›·˜. ∞ÔÙÂÏ› ··Ú·›ÙËÙÔ ÈÛÙfi ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÓÂÔÔ˘Ú‹ıÚ·˜, ̤ۈ ÌÈÛ¯ˆÙÔ‡ ÎÚËÌÓÔ‡, ÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡, ΢ڛˆ˜ ˘ÔÛ·‰›· ·ÏÏ¿ Î·È ÁÈ· Â·ÓÂÁ¯Â›ÚËÛË ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ¿ÏÏˆÓ ·Ï·ÈfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ. ∏ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ˘ÔÛ·‰›· ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÁÓˆÛÙ‹. ¶·ÚÔ˘ÛÈ¿˙ÂÈ ÔÈÎÔÁÂÓ‹ Â›ÙˆÛË (10% 28%). °ÓˆÚ›˙Ô˘Ì fï˜ Ù· ÂÌ‚Ú˘˚ο ÛÙ¿‰È· ÂͤÏÈ͢ ÛÙË ‰È¿Ï·ÛË ÙˆÓ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ Î·È Ù˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ ÂͤÏÈ͢ ÌÂ Û˘Ó¤ÂÈ· ÙË Û˘ÁÁÂÓ‹ ·ÓˆÌ·Ï›·. ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ ÙËÓ 6Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰· ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÁÂÓÓËÙÈÎfi ʇ̷ ÂÚÈÊÂÚÈο ÙÔ˘ Ô˘ÚÔÁÂÓÓËÙÈÎÔ‡ fiÚÔ˘. ∆ËÓ 7Ë Â‚‰ÔÌ¿‰· ÂÌÊ·Ó›˙ÔÓÙ·È 2 ̤Û˜ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ Ú·¯È·›ˆ˜ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ ʇ̷ÙÔ˜ Î·È 2 Ï¿ÁȘ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜. ∞fi ÙÔ ÁÂÓÓËÙÈÎfi ʇ̷ ‰È·Ï¿ÛÛÔÓÙ·È Ë ‚¿Ï·ÓÔ˜ Î·È Ë ‚·Ï·ÓÈ΋ ÌÔ›Ú· Ù˘ Ô˘Ú‹ıÚ·˜. ∞fi ÙȘ ̤Û˜ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ ‰È·Ï¿ÛÛÂÙ·È Ë Ô˘Ú‹ıÚ· ÏËÓ Ù˘ ‚·Ï·ÓÈ΋˜. ∞fi ÙȘ Ï¿ÁȘ ÁÂÓÓËÙÈΤ˜ Ù˘¯¤˜ ‰È·Ï¿ÛÛÔÓÙ·È ÙÔ ‰¤ÚÌ· ÙÔ˘ ¤Ô˘˜ (fiÛıË) Î·È ÙÔ fiÛ¯ÂÔ. ∆¤ÏÔ˜, ·fi ÙÔ ÌÂÛfi‰ÂÚÌ· ÚÔ¤Ú¯ÔÓÙ·È Ù· ÛËÚ·ÁÁÒ‰Ë ÛÒÌ·Ù·, Ô ‰·ÚÙfi˜ ¯ÈÙÒÓ·˜ Î·È Ë ÂÚÈÙÔÓ›·. ™˘Ó˘¿Ú¯Ô˘Û˜ ·ÓˆÌ·Ï›Â˜ Ì ÙÔÓ ˘ÔÛ·‰›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÊÔÚÔ‡Ó ÙÔ˘˜ fiÚ¯ÂȘ Î·È ÂȉÈÎfiÙÂÚ· ÙË ı¤ÛË ÙˆÓ fiگˆÓ. ∫Ú˘„ÔÚ¯›· Û˘Ó˘¿Ú¯ÂÈ Û ÔÛÔÛÙfi 10% - 20%. ∂›Ó·È Èı·Ófi Ë Û˘Ó‡·ÚÍË Ù˘ ÎÚ˘„ÔÚ¯›·˜ Ó· ÔÊ›ÏÂÙ·È Û ·ÓÂ·Ú΋ ·Ú·ÁˆÁ‹ ·Ó‰ÚÔÁfiÓˆÓ Î·Ù¿ ÙËÓ Î‡ËÛË. ÕÏϘ Û˘Ó˘¿Ú¯Ô˘Û˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Ë ·ÙÚÔÊ›· ÙˆÓ

313

MAY- JUNE '01 TELIKO

30-05-03

18:55

™ÂÏ›‰·314

¶·È‰È·ÙÚÈ΋ 2001;64:312-314

fiگˆÓ, Ë ÎÈÚÛÔ΋ÏË Î·È Ë ÛÂÚÌ·ÙÔ΋ÏË. ™ÙÔÓ ¿ÚÚÂÓ· „¢‰ÂÚÌ·ÊÚÔ‰ÈÙÈÛÌfi Ì ÂÚÈÓÂ˚Îfi ˘ÔÛ·‰›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂϤÙË Ì ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÂͤٷÛË Î·ıÔÚÈÛÌÔ‡ ÙÔ˘ ʇÏÔ˘. ∞ӈ̷ϛ˜ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi fiˆ˜ Ô ÌÔÓ‹Ú˘ ÓÂÊÚfi˜, ÔÈ ‰ÈÏÔ› Ô˘ÚËÙ‹Ú˜ Î·È ¿ÏϘ, ··ÓÙÔ‡Ó ÌÂ Û˘¯ÓfiÙËÙ· 4%, Û ·ÓÙ›ıÂÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi fiÔ˘ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ·˘ÙÒÓ Â›Ó·È Î¿Ùˆ ÙÔ˘ 2%. ∆¤ÏÔ˜, Ô ˘ÔÛ·‰›·˜ ÌÔÚ› Ó· ·ÔÙÂÏ› ̤ÚÔ˜ Û¿ÓÈˆÓ Û˘Ó‰ÚfïÓ. ™Ùfi¯ÔÈ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‰ÈfiÚıˆÛ˘ ÙÔ˘ ˘ÔÛ·‰›· ›ӷÈ: ·) Ô Â˘ıÂÈ·ÛÌfi˜ ÙÔ˘ ¤Ô˘˜, ‚) Ë ÙÔÔı¤ÙËÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ó¤ÔÔ˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘. OÈ ÛÙfi¯ÔÈ ·˘ÙÔ› Ú¤ÂÈ Ó· ÂÈÙ˘Á¯¿ÓÔÓÙ·È Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ Î·È Ó· ÂÍ·ÛÊ·Ï›˙Ô˘Ó Î·Ïfi ÏÂÈÙÔ˘ÚÁÈÎfi Î·È ÎÔÛÌËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ∆Ô Ë̤ÙÂÚÔ ˘ÏÈÎfi ·ÔÙÂÏÔ‡Ó 441 ÂÚÈÙÒÛÂȘ Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ 1986-1999. ∏ ËÏÈΛ· ÙˆÓ “·ÛıÂÓÒÓ” ·˘ÙÒÓ Î˘Ì·›ÓÂÙ·È ·fi 20 ÌËÓÒÓ Ì¤¯ÚÈ 3 ÂÙÒÓ. À¿Ú¯Ô˘Ó fï˜ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ·ÙfiÌˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ̤¯ÚÈ 16 ÂÙÒÓ. OÈ Ù‡ÔÈ ˘ÔÛ·‰›· Ô˘ ¯ÂÈÚÔ˘ÚÁ‹Û·Ì ÛÙË µ' ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” ‹Ù·Ó Ì ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ ÔÈ ·ÎfiÏÔ˘ıÔÈ: 1) ÚfiÛıÈÔÈ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ì ÙÔ ‚·Ï·ÓÈÎfi, ÙÔ ÛÙÂÊ·ÓÈ·›Ô Î·È ÙÔÓ ˘Ô‚·Ï·ÓÈÎfi, 2) ÎÂÓÙÚÈÎÔ›, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ì ÙÔÓ ÔÛ¯ÂÔÂ˚Îfi, ÙÔÓ ÔÛ¯Â˚Îfi Î·È ÙÔÓ ÂÚÈÓÂ˚Îfi Î·È 3) ̤ÛÔÈ ˘ÔÛ·‰›Â˜.

OÈ ÂÁ¯ÂÈÚËÙÈΤ˜ Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹Û·Ì ‹Ù·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ÙÚÂȘ: ·) ¶ÚÔÒıËÛË Ù˘ Ô˘Ú‹ıÚ·˜ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋. ¶ÚfiÎÂÈÙ·È ÁÈ· ËÌÂÙ¤Ú· Ù¯ÓÈ΋ Ì ÂӉ›ÍÂȘ ÙÔ ‚·Ï·ÓÈÎfi Î·È ÙÔ ÛÙÂÊ·ÓÈ·›Ô ˘ÔÛ·‰›· (1). ‚) ∞ÓÂÛÙÚ·Ì̤ÓÔ˜ Î·È Ï¿ÁÈÔÈ ÎÚËÌÓÔ› ηٿ Mathieu (2). ∏ Ù¯ÓÈ΋ ·˘Ù‹ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ˘Ô‚·Ï·ÓÈÎÔ‡ Î·È ÙÔ˘ ÌÂÛÔÂ˚ÎÔ‡ ˘ÔÛ·‰›·. Á) ªÈÛ¯ˆÙfi˜ ÎÚËÌÓfi˜ (island flap) ·fi ÙËÓ ·ÎÚÔÔÛı›· ηٿ Duckett (3). ÃÚËÛÈÌÔÔÈ‹ıËΠ(·fi ÙÔ ¤ÙÔ˜ 1996) ÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ ÔÛ¯ÂÔÂ˚ÎÔ‡, ÔÛ¯Â˚ÎÔ‡ Î·È ÂÚÈÓÂ˚ÎÔ‡ ˘ÔÛ·‰›·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 441 ÂÁ¯ÂÈÚ‹ÛˆÓ, Ë ÚÒÙË (ÚÔÒıËÛË Ô˘Ú‹ıÚ·˜ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋) ¤ÁÈÓ Û 222 “·ÛıÂÓ›˜”, Ë ÂÁ¯Â›ÚËÛË ªathieu ¤ÁÈÓ Û 179 “·ÛıÂÓ›˜”, ÂÓÒ ÂÁ¯Â›ÚËÛË Ì ÌÈÛ¯ˆÙfi ÎÚËÌÓfi ·ÎÚÔÔÛı›·˜ ¤ÁÈÓ Û 40 “·ÛıÂÓ›˜”. OÈ ‰ÈÔÚıÒÛÂȘ fiÏˆÓ ÙˆÓ ÌÔÚ-

314

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ÊÒÓ ˘ÔÛ·‰›·, ‰ËÏ·‰‹ ¢ıÂÈ·ÛÌfi˜ ÙÔ˘ ¤Ô˘˜ Î·È ÙÔÔı¤ÙËÛË ÙÔ˘ ÛÙÔÌ›Ô˘ Ù˘ Ô˘Ú‹ıÚ·˜ ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘ ¤ÁÈÓ·Ó Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ. ªÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜ ÙÔ˘ ˘ÔÛ·‰›· ›ӷÈ: 1) ÙÔ Û˘Ú›ÁÁÈÔ (‹ Û˘Ú›ÁÁÈ·) Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜, ÙÔ ÔÔ›Ô ·ÚÔ˘Û›·Û·Ó 59 ÂÚÈÙÒÛÂȘ ÛÙÔ ˘ÏÈÎfi Ì·˜ (13,4%), 2) Ë ˘Ô¯ÒÚËÛË Ù˘ Ô˘Ú‹ıÚ·˜ ÌÂÙ¿ ÂÁ¯Â›ÚËÛË ÚÔÒıËÛ˘ Î·È ‚·Ï·ÓÔÏ·ÛÙÈ΋ Û 4 ÂÚÈÙÒÛÂȘ (1,8%). ∞˘Ù¤˜ ÔÈ 4 ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Ó ÙȘ ÚÒÙ˜ ÂÁ¯ÂÈÚ‹ÛÂȘ Ù˘ ÛÂÈÚ¿˜ ÙˆÓ 222 ‚·Ï·ÓÈÎÒÓ Î·È ÛÙÂÊ·ÓÈ·›ˆÓ ˘ÔÛ·‰›ˆÓ Ô˘ ‰ÈÔÚıÒÛ·Ì Ì ÙËÓ Ù¯ÓÈ΋ Ì·˜. ∏ ˘Ô¯ÒÚËÛË Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠Â·ÓÂÁ¯Â›ÚËÛË Î·Ù¿ Mathieu, ÂÓÒ Ù· Û˘Ú›ÁÁÈ· Ù˘ Ô˘Ú‹ıÚ·˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÙË ÁÓˆÛÙ‹ ÎÏ·ÛÈ΋ Ù¯ÓÈ΋, Ô˘ Û˘Ó›ÛÙ·Ù·È Û Ó·ÚÔÔ›ËÛË ÙˆÓ ÈÛÙÒÓ ÙÔ˘ Û˘ÚÈÁÁ›Ô˘ Î·È Û˘ÚÚ·Ê‹ Û ÛÙÚÒÌ·Ù· Ì ·ÚÈÔ Ì¤ÏËÌ· ÙËÓ ·ÔÊ˘Á‹ Â·Ê‹˜ ÙˆÓ Ú·ÌÌ¿ÙˆÓ ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ÛÙÚÒÌ·ÙÔ˜ Ì ٷ Ú¿ÌÌ·Ù· ÙÔ˘ ˘ÂÚΛÌÂÓÔ˘. ™˘ÌÂÚ¿ÛÌ·Ù· ∞fi ÙÔ ˘ÏÈÎfi ·˘Ùfi Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ô ˘ÔÛ·‰›·˜ ·) Â›Ó·È ÌÈ· Û˘Ó‹ı˘ Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ‚) ÚÔηÏ› ÛÔ‚·Ú¿ ÏÂÈÙÔ˘ÚÁÈο Î·È Î·Ù' Â¤ÎÙ·ÛË „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, Á) ÌÔÚ› Ó· ‰ÈÔÚıˆı› Û ¤Ó· ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ, Ô ÔÔ›Ô˜ ÛÙԯ‡ÂÈ ÛÙÔÓ Â˘ıÂÈ·ÛÌfi ÙÔ˘ ¤Ô˘˜ Î·È ÛÙËÓ ÙÔÔı¤ÙËÛË Ù˘ Ô˘Ú‹ıÚ·˜ ‹ Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ ÛÙË ÎÔÚ˘Ê‹ Ù˘ ‚·Ï¿ÓÔ˘, ‰) ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÏÔ΋, Ë ÔÔ›· Â›Ó·È Û˘ÚÚ›ÁÈÔ Ù˘ ÓÂÔÔ˘Ú‹ıÚ·˜ Û ÔÛÔÛÙfi 13,4%. µÈ‚ÏÈÔÁÚ·Ê›· 1. Keramidas D, Soutis M. Urethra advancement, granduloplasty and preputioplasty in distal hypospadias.

Eur J Peditr Surg 1995;5:348-351.

2. Mathieu P. Traitement en un temps de l’ hypospadias balanique et juxta-balanique. J Chir 1932;39:481-484.

3. Duckett JW. The island flap techique for hypospadias repair. Urol Clin N ∞m1981;8:503-511.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢. ∫ÂÚ·Ì›‰·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” 115 27, °Ô˘‰›, ∞ı‹Ó·

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Paediatriki 2001;64:315-317

ASSOCIATED SUBSPECIALTIES

∫ÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË

Criteria for referral of children to the ophthalmologist A. Koidou-Tsiligianni

¶ÂÚ›ÏË„Ë: O ·È‰›·ÙÚÔ˜ Â›Ó·È Ô ÚÒÙÔ˜ ÁÈ·ÙÚfi˜ Ô ÔÔ›Ô˜ ı· ‰È·ÈÛÙÒÛÂÈ ÙËÓ ‡·ÚÍË ÔÊı·ÏÌÔÏÔÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔ ·È‰›, ›Ù ÛÙ· Ï·›ÛÈ· Ù˘ ÂÚÈÔ‰È΋˜ ÂͤٷÛ˘, ›Ù ÁÈ·Ù› Û ·˘ÙfiÓ Û˘Ó‹ıˆ˜ ·¢ı‡ÓÔÓÙ·È ÚˆÙ·Ú¯Èο ÔÈ ÁÔÓ›˜ fiÙ·Ó ‰È·ÈÛÙÒÛÔ˘Ó Î¿ÔÈÔ ·Ó¿ÏÔÁÔ Úfi‚ÏËÌ·. ∆· ÎÚÈÙ‹ÚÈ· Ì ٷ ÔÔ›· ı· ·Ú·ÂÌÊı› ÙÔ ·È‰› ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ·ÊÔÚÔ‡Ó Ù· ·È‰È¿ ÌÂ Ù˘¯·›· ‰È·›ÛÙˆÛË ÔÊı·ÏÌÔÏÔÁÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ Û ÂͤٷÛË ÚÔ˘Ù›Ó·˜ (.¯. Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ‰È·Ù·Ú·¯‹ fiÚ·Û˘), Ì ¿ıËÛË ÙˆÓ ÔÊı·ÏÌÒÓ Ô˘ ··ÈÙ› ÂȉÈ΋ ÂͤٷÛË Î·È ıÂÚ·›· ·fi ÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ (.¯. ÊÏÂÁÌÔÓ‹, Ïԛ̈ÍË, ÙÚ·‡Ì·), ‹ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ¿ıËÛË Ô˘ ¤¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ‹ ÂÈÏÔΤ˜ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜.

Abstract: The general pediatrician is the first doctor who will ascertain the presence of an eye disorder in the child, either during a routine physical examination (well child physical examination), or because of the parents’ concern when they notice a relevant disorder. The criteria for referring a child to the pediatric ophthalmologist include the incidental finding of an eye disorder during a routine physical examination (i.e. congenital anomaly, vision disorder), the presence of an ophthalmological condition that requires specific examination and treatment by an ophthalmologist (i.e. inflammation, infection, trauma), or the existence of a systemic disorder associated with eye pathology or complications from the eyes.

§¤ÍÂȘ ÎÏÂȉȿ: ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, ·Ú·ÔÌ‹ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ.

Key words: ophthalmological disorder, referral to the ophthalmologist.

O ·È‰›·ÙÚÔ˜, fiÓÙ·˜ ÂÍ ÔÚÈÛÌÔ‡ Ô ÁÈ·ÙÚfi˜ ÙÔ˘ ·È‰ÈÔ‡, Â›Ó·È ·˘Ùfi˜ Ô˘ ı· ÂÍÂÙ¿ÛÂÈ ÚÒÙÔ˜ Ù· Ì¿ÙÈ· Î·È ÙËÓ fiÚ·Û‹ ÙÔ˘ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ı· ÁÂÓÓËı›. °È· ÔÏÏ¿ ¯ÚfiÓÈ· Â›Ó·È ·˘Ùfi˜ ÛÙÔÓ ÔÔ›Ô ı· ·¢ı˘ÓıÔ‡Ó ÔÈ ÁÔÓ›˜ fiÙ·Ó ‰È·ÈÛÙÒÛÔ˘Ó Î¿ÔÈÔ ÔÊı·ÏÌÔÏÔÁÈÎfi Úfi‚ÏËÌ· (1). £· ·Ú·ı¤ÛÔ˘ÌÂ Û˘ÓÔÙÈο Ù· ÎÚÈÙ‹ÚÈ· Ì ٷ ÔÔ›· Ô ·È‰›·ÙÚÔ˜ ı· ·Ú·¤Ì„ÂÈ ÙÔ ·È‰› ÁÈ· ÂͤٷÛË Î·È ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË ÛÙÔÓ ÂȉÈÎfi ÔÊı·ÏÌ›·ÙÚÔ. °È· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ¯ˆÚ›˙Ô˘Ì ٷ ·È‰È¿ o˘ ¯Ú‹˙Ô˘Ó ·Ú·ÔÌ‹˜ Û ÙÚÂȘ ηÙËÁÔڛ˜: ·) Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, ‚) ·È‰È¿ Ì ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, Á) ·È‰È¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ.

¶·Ú·ÔÌ‹ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ ¶ÚfiÎÂÈÙ·È ÁÈ· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, Ô˘ ηٿ ÙËÓ ÂÚÈÔ‰È΋ ÂͤٷÛË ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜ ‰È·ÈÛÙÒÓÂÙ·È ÔÊı·ÏÌÔÏÔÁÈÎfi Úfi‚ÏËÌ·. ∫·ÙˆÙ¤Úˆ ·Ú·ı¤ÙÔ˘Ì ÙËÓ ÚÔÙÂÈÓfiÌÂÓË ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘, ηıÒ˜ Î·È Ù· ÎÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ (2,3).

1. ¡ÂÔÁÓ¿: ∂ÍÂÙ¿˙ÂÙ·È ÚˆÙ›ÛÙˆ˜ Ë ·ÎÂÚ·ÈfiÙËÙ· ÙˆÓ ÔÊı·ÏÌÒÓ, Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÎfiÁ¯Ô˘ Î·È Ë ·ÚÔ˘Û›· ‹ ÌË ·Ó·ÙÔÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ì ·Ïfi Ê·Îfi ¯ÂÈÚfi˜ (ÂÈÛÎfiËÛË) Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂϤÁ¯ÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘ Ì ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÙÔ˘ ʈÙfi˜.

OÊı·ÏÌÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

Division of Ophthalmology “P. & A. Kyriakou” Children’s Hospital of Athens

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¶·È‰È·ÙÚÈ΋ 2001;64:315-317

ªÂ ÙÔ ÔÊı·ÏÌÔÛÎfiÈÔ Û ·fiÛÙ·ÛË 30 ÂηÙÔÛÙÒÓ ÂϤÁ¯ÂÙ·È Ë ÚÔ‰›ÓË ·ÓÙ·‡ÁÂÈ· ÙÔ˘ ‚˘ıÔ‡. ¶·Ú·¤ÌÔÓÙ·È Ù· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ‰È·ÈÛÙÒÓÂÙ·È ÔÔÈ·‰‹ÔÙÂ Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ·‰˘Ó·Ì›· ¤ÎÏ˘Û˘ ÙÔ˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ÙÔ˘ ʈÙfi˜, Ô˘ Ê˘ÛÈÔÏÔÁÈο ÂÎχÂÙ·È ÌÂÙ¿ ÙËÓ 32Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘, ‹ ÛÎÔÙÂÈÓfi, ‹ Ï¢Îfi ¤ÏÏÂÈÌÌ· ÛÙË ÚÔ‰›ÓË ·ÓÙ·‡ÁÂÈ· ÙÔ˘ ‚˘ıÔ‡.

2. µÚ¤ÊË 6 - 8 ÌËÓÒÓ: ™ÙËÓ ËÏÈΛ· ·˘Ù‹ ÂÍÂÙ¿˙ÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘, ÂϤÁ¯ÔÓÙ·˜ Ò˜ ÚÔÛËÏÒÓÂÈ Î·È Ò˜ ·Ú·ÎÔÏÔ˘ı› ¤Ó· ʈÙÂÈÓfi ÛÙfi¯Ô ‹ ¤Ó· ·ÓÙÈΛÌÂÓÔ Î¿ı ̿ÙÈ ¯ˆÚÈÛÙ¿. ∂ÍÂÙ¿˙ÂÙ·È Â›Û˘, Ô Û˘Á¯ÚÔÓÈÛÌfi˜ ÙˆÓ ÎÈÓ‹ÛÂˆÓ ÙˆÓ ‚ÔÏ‚ÒÓ Î·È Ë ‡·ÚÍË - ‹ ÌË - ÛÙÚ·‚ÈÛÌÔ‡ Ì ÙȘ ·ÓÙ·Ó·ÎÏ¿ÛÂȘ ÙÔ˘ ʈÙfi˜ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ Î·È ÙË ‰ÔÎÈÌ·Û›· Î¿Ï˘„˘. ∂ÊfiÛÔÓ ‰È·ÈÛÙˆı› ÛÙÚ·‚ÈÛÌfi˜, ¿ÚÓËÛË ÛÙËÓ Î¿Ï˘„Ë ÙÔ˘ ÂÓfi˜ ÔÊı·ÏÌÔ‡ Î·È ·‰˘Ó·Ì›· ÚÔۋψÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ÛÙfi¯Ô˘, ÙfiÙ ÙÔ ‚Ú¤ÊÔ˜ ·Ú·¤ÌÂÙ·È ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ÁÈ· ¤ÏÂÁ¯Ô Ù˘ ·ÈÙ›·˜ ηْ ·Ú¯¿˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÁÈ· ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡ Î·È Ù˘ ÌÂȈ̤Ó˘ fiÚ·Û˘. ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ÚÔ‰›Ó˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ ‚˘ıÔ‡ Ì ÙÔ ÔÊı·ÏÌÔÛÎfiÈÔ.

3. ¡‹È· 3 - 5 ÂÙÒÓ: ∏ ËÏÈΛ· ·˘Ù‹ Â›Ó·È Ë Î·Ù¿ÏÏËÏË ÁÈ· Ó· Á›ÓÂÈ Î·È Ë ÔÛÔÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ fiÚ·Û˘. ™ÙÔÓ ÔÈÎÂ›Ô ¯ÒÚÔ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ È·ÙÚ›Ԣ, ÙÔ ·È‰› ÂÍÂÙ¿˙ÂÙ·È Û ÂȉÈÎÔ‡˜ ›Ó·Î˜ ÂϤÁ¯Ô˘ Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÁÈ· Ù· Ó‹È·. ¶·Ú·¤ÌÔÓÙ·È Ù· ·È‰È¿, ÛÙ· ÔÔ›· ‰È·ÈÛÙÒÓÂÙ·È ÔÙÈ΋ Ô͇ÙËÙ· ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜, ÌÈÎÚfiÙÂÚË ‹ ›ÛË ·fi 5/10. ∂›Û˘, ÂϤÁ¯ÂÙ·È Ë ÔÊı·ÏÌÔÎÈÓËÙÈÎfiÙËÙ· Î·È Ë ‡·ÚÍË - ‹ ÌË ÛÙÚ·‚ÈÛÌÔ‡. ∂ÎÙfi˜ ·fi ÙÔ Û˘ÁÁÂÓ‹ ÛÙÚ·‚ÈÛÌfi, ÛÙËÓ ËÏÈΛ· ·˘Ù‹ ·Ú·ÙËÚÂ›Ù·È Î·È Ô ÚÔÛ·ÚÌÔÛÙÈÎfi˜ ÛÙÚ·‚ÈÛÌfi˜, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È ·Ó·Áη›Ô Ó· Á›ÓÂÈ ¤ÁηÈÚ· Ì ٷ ηٿÏÏËÏ· ‰ÈoÚıˆÙÈο Á˘·ÏÈ¿. ∏ ·Ó·Î¿Ï˘„Ë Ù˘ ·Ì‚Ï˘ˆ›·˜ Î·È ÙÔ˘ ·ÈÙ›Ô˘ Ô˘ ÙËÓ ÚÔοÏÂÛÂ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÈ, ÙÔ ·ÚÁfiÙÂÚÔ, ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· (4).

4. ¶·È‰È¿ >5 ÂÙÒÓ: ™ÙÔ˘˜ ›Ó·Î˜ ÙÔ˘ Snellen ÂÍÂÙ¿˙ÂÙ·È Î¿ı ¯ÚfiÓÔ Ë ÔÙÈ΋ Ô͇ÙËÙ· Î·È ÙÔ ·È‰› ·Ú·¤ÌÂÙ·È fiÙ·Ó ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜ ¤¯ÂÈ fiÚ·ÛË Î¿Ùˆ ·fi 7/10. O ¤ÏÂÁ¯Ô˜ Ù˘ ÔÊı·ÏÌÔÎÈÓËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ‚˘ıÔ‡ Û˘ÌÏËÚÒÓÔ˘Ó ÙËÓ ÂͤٷÛË. ¶·Ú·ÔÌ‹ ·È‰ÈÒÓ Ì ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ· ¶ÚfiÎÂÈÙ·È ÁÈ· ·È‰È¿ Ô˘ ÚˆÙÔÂÌÊ·Ó›˙Ô˘Ó ÔÊı·ÏÌÔÏÔÁÈÎfi ÓfiÛËÌ·, ·ÏÏ¿ ·Ú¯Èο ·¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÚÒÙË ÂͤٷÛË ÛÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜.

OÈ Û˘ÓËı¤ÛÙÂÚ˜ ·Èٛ˜ ›ӷÈ:

316

Paediatriki 2001;64:315-317

1. ∆Ô “∫fiÎÎÈÓÔ Ì¿ÙÈ” ¶¿Óˆ ·fi 20 Èı·Ó¤˜ ·Èٛ˜ ÚÔηÏÔ‡Ó ÂÚ˘ıÚfiÙËÙ· ÛÙÔÓ ¤Ó· ‹ Î·È ÛÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÚfiÎÂÈÙ·È ÁÈ· ·Ϥ˜ ÈÔÁÂÓ›˜ ‹ ÌÈÎÚԂȷΤ˜ ÂÈÂÊ˘Î›Ùȉ˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·Ï¿ ·ÓÙÈ‚ÈÔÙÈο ÎÔÏχÚÈ· ·fi ÙÔÓ ·È‰›·ÙÚÔ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, Û˘Ó‹ıˆ˜, Ë ÂÚ˘ıÚfiÙËÙ· Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚË, ˘¿Ú¯Ô˘Ó ˘‰·Ú›˜ ‹ ˘Ò‰ÂȘ ÂÎÎÚ›ÛÂȘ, ÈÛÙÔÚÈÎfi ÚfiÛÊ·Ù˘ ›ˆÛ˘ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÊÔ›ÙËÛË Û ·È‰ÈÎfi ÛÙ·ıÌfi Î.Ï. ∆Ô ·È‰› ‰ÂÓ ˘ÔʤÚÂÈ, Ô‡Ù ÔÓ¿ÂÈ. ¶ÂÚÈÛÛfiÙÂÚÔ, ÔÈ ÁÔÓ›˜ ÂÓÔ¯ÏÔ‡ÓÙ·È ·fi ÙË ı¤· ÙˆÓ ÎfiÎÎÈÓˆÓ Ì·ÙÈÒÓ.

OÈ Û˘¯ÓfiÙÂÚ˜ ηÙËÁÔڛ˜ ÓfiÛˆÓ Ô˘ ÂΉËÏÒÓÔÓÙ·È Ì “ÎfiÎÎÈÓÔ Ì¿ÙÈ” (5,6) ›ӷÈ: ∞) ºÏÂÁÌÔÓ¤˜ ¶ÚfiÛıÈÔ˘ ∏ÌÈÌÔÚ›Ô˘, fiˆ˜ i) ¡ÂÔÁÓÈ΋ ÔÊı·ÏÌ›·, ii) ∂ÈÂÊ˘Î›Ùȉ· (ªÈÎÚԂȷ΋, πÔÁÂÓ‹˜, ∞ÏÏÂÚÁÈ΋), iii) ∫ÂÚ·Ù›Ùȉ· (∂ÚËÙÈ΋, ŒÏÎÔ˜ ÎÂÚ·ÙÔÂȉԇ˜), iv) πÚȉÔ΢ÎÏ›Ùȉ· (π‰ÈÔ·ı‹˜, Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘). µ) ∆Ú·‡Ì·Ù·, fiˆ˜ i) ÀfiÛÊ·ÁÌ·, ii) ∆Ú·˘Ì·ÙÈ΋ ·fiÙˆÛË ÂÈıËÏ›Ô˘ ÎÂÚ·ÙÔÂȉԇ˜, iii) •¤ÓÔ ÛÒÌ· ÎÂÚ·ÙÔÂȉԇ˜, iv) ¢È·ÌÂÚ¤˜ ÙÚ·‡Ì· ‚ÔÏ‚Ô‡. °) ŒÁη˘Ì·. ¢) °Ï·‡ÎˆÌ·, i) ¶ÚˆÙÔ·ı¤˜-™˘ÁÁÂÓ¤˜, ii) ¢Â˘ÙÂÚÔ·ı¤˜ (ÚÂÙÈÓÔ‚Ï¿Ûو̷). ∆· ÎÚÈÙ‹ÚÈ· ·Ú·ÔÌ‹˜ ı· Â›Ó·È Ë ‰·ÎÚ‡ÚÚÔÈ·, Ô fiÓÔ˜, Ë ıfiψÛË ÎÂÚ·ÙÔÂȉԇ˜, ÙÔ ÈÛÙÔÚÈÎfi ÚfiÛÊ·ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÙÔ ÂÚËÙÈÎfi ÂÍ¿ÓıËÌ· ‚ÏÂÊ¿ÚˆÓ ‹ ÙÔ ÈÛÙÔÚÈÎfi Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘.

2. ªÂȈ̤ÓË fiÚ·ÛË ÕÏÏÔ Û‡Ìو̷ ÔÊı·ÏÌÔÏÔÁÈ΋˜ ÓfiÛÔ˘ Â›Ó·È Ë ‰È·›ÛÙˆÛË, ·fi Ù· ›‰È· Ù· ·È‰È¿ ‹ ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, ÌÂȈ̤Ó˘ fiÚ·Û˘ ÛÙÔÓ ¤Ó· ‹ Î·È ÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜. ø˜ ·›ÙÈ· ÌÂȈ̤Ó˘ fiÚ·Û˘ ·Ó·Ê¤ÚÔÓÙ·È: i) ÔÈ ·Ó·ÙÔÌÈΤ˜ ‚Ï¿‚˜ ÔÙÈ΋˜ Ô‰Ô‡, ii) ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, iii) Ô ÛÙÚ·‚ÈÛÌfi˜ ·Ì‚Ï˘ˆ›·, iv) ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, v) Ë ËÌÈÎÚ·Ó›· Î·È vi) Ë ˘ÛÙÂÚÈ΋ Ù‡ÊψÛË. ∏ ÌÂȈ̤ÓË fiÚ·ÛË Â›Ó·È ·fi ÌfiÓË Ù˘ ÎÚÈÙ‹ÚÈÔ ·Ú·ÔÌ‹˜. ∆Ô Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Â›Ó·È ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ŸÙ·Ó, fï˜, Û˘Ì‚·›ÓÂÈ ·ÈÊÓ›‰È· ‹ Û ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÙfiÙ Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛıÔ‡Ó ¿ÏϘ ÛÔ‚·Ú¤˜ ·Èٛ˜. O ·È‰›·ÙÚÔ˜ ı· Ú¤ÂÈ Ó· ÂϤÁÍÂÈ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, fiÙ·Ó ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi, ÛÙ· ·È‰È¿ Ô˘ Û˘ÓÂÚÁ¿˙ÔÓÙ·È, ‹ ÙËÓ ÈηÓfiÙËÙ· ÚÔۋψÛ˘ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÓfi˜ ÛÙfi¯Ô˘ ÛÙ· ‚Ú¤ÊË, Û οı ̿ÙÈ ¯ˆÚÈÛÙ¿. ∂¿Ó ‰È·ÈÛÙˆı› Ì›ˆÛË Ù˘ fiÚ·Û˘, ÙÔ ·È‰› ı· Ú¤ÂÈ Ó· ·Ú·ÂÌÊı› ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ.

3. ¡ÔÛ‹Ì·Ù· ÙÔ˘ ÎfiÁ¯Ô˘ ª›· ÂȉÈ΋ ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ ÁÈ· Ù· ÔÔ›·

MAY- JUNE '01 TELIKO

30-05-03

18:55

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¶·È‰È·ÙÚÈ΋ 2001;64:315-317

·¢ı‡ÓÔÓÙ·È ·Ú¯Èο ÛÙÔÓ ·È‰›·ÙÚÔ, Â›Ó·È Ù· ÓÔÛ‹Ì·Ù· ÙÔ˘ ÎfiÁ¯Ô˘. OÈ Î˘ÚÈfiÙÂÚ˜ ·ı‹ÛÂȘ ÙÔ˘ ÎfiÁ¯Ô˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È Ë ÂÚÈÎÔÁ¯È΋ ÎÔÁ¯È΋ ΢ÙÙ·Ú›ÙȘ, ÔÈ ·ÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜, Ë ı˘ÚÂÔÂȉÈ΋ ÔÊı·ÏÌÔ¿ıÂÈ·, ÔÈ fiÁÎÔÈ (ηÏÔ‹ıÂȘ, ηÎÔ‹ıÂȘ), Ù· ÙÚ·‡Ì·Ù· (·È̿و̷, οٷÁÌ·). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÚfiÎÂÈÙ·È ÁÈ· ÊÏÂÁÌÔÓ¤˜ Ù˘ ÂÚÈÎÔÁ¯È΋˜ ÂÚÈÔ¯‹˜ Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÁÈ· ÛÔ‚·Ú¤˜ ÊÏÂÁÌÔÓ¤˜ ÙÔ˘ ÎÔÁ¯ÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ∆· ÛËÌ›· Ù˘ ÊÏÂÁÌÔÓ‹˜, ÙÔ Ô›‰ËÌ· ÙˆÓ ‚ÏÂÊ¿ÚˆÓ, Ë ˘ÂÚ·ÈÌ›·, Ô fiÓÔ˜, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ‚ÔÏ‚Ô‡, Ë ‰Èψ›· Â›Ó·È Û˘Ó‹ıˆ˜ ÚÔÂÍ¿Ú¯ÔÓÙ· Î·È ·ÔÙÂÏÔ‡Ó ·ÈÙ›· ¿ÌÂÛ˘ ÂͤٷÛ˘ ·fi ÔÊı·ÏÌ›·ÙÚÔ. ∂ÎÙfi˜ fï˜ ·fi ·˘Ù¿, Ë ‰È·›ÛÙˆÛË, Û οı ÂÚ›ÛÙ·ÛË, ÂÍfiÊı·ÏÌÔ˘ Ô˘ - ‹ ¯ˆÚ›˜ Ó· - Û˘Óԉ‡ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÛÙËÓ fiÚ·ÛË, ·ÔÙÂÏ› ÛÔ‚·Úfi ÏfiÁÔ ·Ú·ÔÌ‹˜ (6). ¶·Ú·ÔÌ‹ ·È‰ÈÒÓ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ ¶·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ·fi Û˘ÛÙËÌ·ÙÈ΋ ‹ ¿ÏÏË ÓfiÛÔ ÛÙËÓ ÔÔ›· ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯ÂÈ ‹ Ó· ÚÔÛ‚¿ÏÂÙ·È Ô ÔÊı·ÏÌfi˜, Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÁÈ· ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË, Ô˘ ¿ÏÏÔÙ ¯ÚËÛÈ̇ÂÈ ÛÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ¿ÏÏÔÙ ÚÔÏ·Ì‚¿ÓÂÈ ÙȘ ÂÈÙÒÛÂȘ Ù˘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜ (7).

OÈ Î˘ÚÈfiÙÂÚ˜ ÔÌ¿‰Â˜ Ù¤ÙÔÈˆÓ ÓÔÛËÌ¿ÙˆÓ Â›Ó·È: ∞) ¡ÔÛ‹Ì·Ù· Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡: Û˘ÁÁÂÓ‹ (‚ÏÂÓÓÔÔÏ˘Û·Î¯·ÚȉÒÛÂȘ), ÎÔÏÏ·ÁÔÓÒÛÂȘ (ÚÂ˘Ì·ÙÔÂȉ‹˜ ·ÚıÚ›ÙȘ, ‰ÂÚÌ·ÙÔÌ˘ÔÛ›ÙȘ, ÛÎÏËÚÔ‰ÂÚÌ›· Î.Ï.), ¿ÏÏ· ÓÔÛ‹Ì·Ù· (Û‡Ó‰ÚÔÌÔ Marfan). µ) ™˘ÁÁÂÓ›˜ ‹ Â›ÎÙËÙ˜ Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ: ÈÔÁÂÓ›˜ (ÂÚËÙÈΤ˜ ÏoÈÌÒÍÂȘ, AIDS), ÌÈÎÚԂȷΤ˜ (ÛË„·ÈÌ›·, ‚·ÎÙËÚȷ΋ ÂÓ‰Ôηډ›Ùȉ·), Ì˘ÎËÙÈ·ÛÈΤ˜ (ÈÛÙÔÏ¿Û̈ÛË, ηÓÙÈÓÙ›·ÛË), ·Ú·ÛÈÙÈΤ˜ (ÙÔÍÔÏ¿Û̈ÛË, ÏÂ˚ÛÌ·Ó›·ÛË). °) ∞ÏÏÂÚÁÈΤ˜ Î·È ¿ÏϘ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜. ¢) ∂Ó‰ÔÎÚÈÓÔÏÔÁÈο ÓÔÛ‹Ì·Ù·: ÓÔÛ‹Ì·Ù· ı˘ÚÂÔÂȉԇ˜, ÓÔÛ‹Ì·Ù· ·Ú·ı˘ÚÂÔÂȉÒÓ, ۷ί·Ú҉˘ ‰È·‚‹Ù˘. ∂) ¶·ı‹ÛÂȘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜: ˘‰ÚÔΤʷÏÔ˜, Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, Û˘ÁÁÂÓ›˜ ÏÔÈÌÒ-

Paediatriki 2001;64:315-317

ÍÂȘ, ʷΈ̷ÙÒÛÂȘ, ÂÎÊ˘ÏÈÛÙÈο ÓÔÛ‹Ì·Ù· (™∫¶), fiÁÎÔÈ. ™Ù) ∫ÂÊ·Ï·ÏÁ›·, Ë ÔÔ›· ·ÔÙÂÏ› ¤Ó· ηıËÌÂÚÈÓfi Úfi‚ÏËÌ· Ô˘ ··Û¯ÔÏ› ÙÔÓ ·È‰›·ÙÚÔ. ¶Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ Â¿Ó Î·È fiÙ ı· ·Ú·¤Ì„ÂÈ ¤Ó· ·È‰› Ô˘ ·Ú·ÔÓÂ›Ù·È ÁÈ· ÎÂÊ·Ï·ÏÁ›·, ·fi ÙË ÛÙÈÁÌ‹ Ô˘ Â›Ó·È ¤Ó· Û˘¯Ófi Û‡Ìو̷, ÙÔ ÔÔ›Ô Ô‰ËÁ› Ù· ·È‰È¿ ÛÙÔÓ ·È‰›·ÙÚÔ. ¢‡Ô Â›Ó·È ÔÈ ÏfiÁÔÈ Ô˘ ı· ˙ËÙËı› ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ÛÙ· Ï·›ÛÈ· ÂϤÁ¯Ô˘ Ù˘ ÎÂÊ·Ï·ÏÁ›·˜ Î·È ‰È¤Ô˘Ó ÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë: Ë ÂͤٷÛË ÙÔ˘ ‚˘ıÔ‡ ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ë ‰È·›ÛÙˆÛË Ù˘¯fiÓ ‰È·ıÏ·ÛÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Ô˘ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÎÂÊ·Ï·ÏÁ›·. ∞Ó¿ÏÔÁ· Ì ÙÔ ÈÛÙÔÚÈÎfi, ÙÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘, ÙË Û˘ÓÔ‰fi - ‹ ÌË - Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î.Ï., Ë ·Ú·ÔÌ‹ ı· Á›ÓÂÈ ÂÂÈÁfiÓÙˆ˜ ‹ ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ÂͤٷÛË. ™Â ÔÔÈ·‰‹ÔÙ ÂÚ›ÙˆÛË, Ë ·Á·ÛÙ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰È¿ÙÚÔ˘ Ì ÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ ı· Â›Ó·È ÚÔ˜ fiÊÂÏÔ˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓ‹. µÈ‚ÏÈÔÁÚ·Ê›· 1. Bacal DA, Rousta ST, Herte RW. Why early vision screening matters. Contemp Pediatr 1999;16:155-167.

2. American Academy of Pediatrics. Eye examination and vision screening in infants, children and young adults.

Pediatrics 1996;98:53-55.

3. American Academy of Ophthalmology. Policy statement: Vision screening for infants and children; 1996.

4. Bacal DA, Herte RV. Don’t be lazy about looking for amblyopia. Contemp Pediatr 1998;15:99-107.

5. Grin TR, Nelson NB, Jeffers JB. Eye injuries in Childhood.

Pediatrics 1987;80:13-18.

6. Robinson H. Diseases of the Orbit. In: Harley RB, ed.

Pediatric Ophthalmology. 2nd ed. Philadelphia: W.B.Saunders Company; 1983. p. 349.

7. Day S. Uveal Manifastations (noninflammatory) of Systemic Disease. In: Taylor D, ed. Pediatric √phthalmology. 1st ed. Boston: Blackwell Scientific Publications; 1990. p. 287.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ∫Ô˚‰Ô˘-∆ÛÈÏÈÁÈ¿ÓÓË OÊı·ÏÌÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “ ¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

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Paediatriki 2001;64:318

¶∞ƒOƒ∞ª∞ / ∂RRATUM ™ÙËÓ ÂÚÁ·Û›· Ì ٛÙÏÔ “∆ÔÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Ï·Ú˘ÁÁÔÙÚ·¯ÂÈÔ‚ÚÔÁ¯›Ùȉ·˜” Ë ÔÔ›· ‰ËÌÔÛȇıËΠÛÙÔÓ ∆fiÌÔ 64, ÛÂÏ. 59-64 ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫∏”, ·Ó·ÁÚ¿ÊËÎÂ Ô ÂÈÛÙËÌÔÓÈÎfi˜ Ù›ÙÏÔ˜ Ù˘ Î. ª·Ú›·˜ ∂ÌÔÚÈ¿‰Ô˘ ˆ˜ “∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ·” ·ÓÙ› ÁÈ· “∂›ÎÔ˘ÚË ∫·ıËÁ‹ÙÚÈ·”. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶∞π¢π∞∆ƒπ∫∏”, ηıÒ˜ Î·È Ô ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡, Ô˘‰fiψ˜ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ ·Ú·¿Óˆ Ï¿ıÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤ÙÛÈ ‹Ù·Ó ‰È·Ù˘ˆÌ¤ÓÔ˜ Ô ÂÈÛÙËÌÔÓÈÎfi˜ Ù›ÙÏÔ˜ Ù˘ Î. ∂ÌÔÚÈ¿‰Ô˘ ÛÙËÓ ÚˆÙfiÙ˘Ë ÂÚÁ·Û›· Ô˘ ˘Ô‚Ï‹ıËΠÁÈ· ÎÚ›ÛË, ÙËÓ ÔÔ›· ›¯·Ó ˘ÔÁÚ¿„ÂÈ fiÏÔÈ ÔÈ Û˘ÁÁÚ·Ê›˜. ∂ÈϤÔÓ, ‰ÂÓ ¤ÁÈÓ η̛· ·ÏÏ·Á‹ ÙÔ˘ ÂÈÛÙËÌÔÓÈÎÔ‡ Ù›ÙÏÔ˘ Ù˘ Î. ∂ÌÔÚÈ¿‰Ô˘ ÛÙÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ Ô˘ ÂÛÙ¿ÏË ÛÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÁÈ· Ù˘¯fiÓ ‰ÈÔÚıÒÛÂȘ ÚÈÓ ÙËÓ ÙÂÏÈ΋ ‰ËÌÔÛ›Â˘ÛË. ªÂÙ¿ ÙË ‰ËÌÔÛ›Â˘ÛË Ù˘ ·Ú·¿Óˆ ÂÚÁ·Û›·˜ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫∏”, Ë Î. ª. ∂ÌÔÚÈ¿‰Ô˘ ˙‹ÙËÛ ÂÁÁڿʈ˜ Ó· ‰ÈÔÚıˆı› ÙÔ Ï¿ıÔ˜ Ô˘ ¤ÁÈÓ ÂÎ ·Ú·‰ÚÔÌ‹˜ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û¯ÂÙÈο Ì ÙÔÓ ÂÈÛÙËÌÔÓÈÎfi Ù˘ Ù›ÙÏÔ.

∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹

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¶PO™EXH ™YNE¢PIA 5-6 ª·˝Ô˘

10Ë ¢ÈËÌÂÚ›‰· ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛÂˆÓ ¶ÏËÚÔÊÔڛ˜: ∫ÒÛÙ·˜ ¶Ú›ÊÙ˘ ∆ËÏ.: 8036 472 Fax: 6131 173

∞ı‹Ó·

8-12 ª·˝Ô˘

27Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ ª·È¿Ó‰ÚÔ˘ 23 ∆ËÏ.: 7211 845 & 7243 161 Fax: 7215 082 e-mail: iea@mednet.gr

∞ı‹Ó·

10-12 ª·˝Ô˘

¢ÈÂıÓ¤˜ ™˘Ó¤‰ÚÈÔ Ì ı¤Ì·: "The Consequences in adult age of endocrine diseases in childhood" ¶ÏËÚÔÊÔڛ˜: µ·ÛÈÏÈ΋ ª¿‰Ô˘ ∆ËÏ.: 031-447 444 Fax: 031-282 476 e-mail: Krassas@the.forthnet.gr

£ÂÛÛ·ÏÔÓ›ÎË

18-20 ª·˝Ô˘

2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¶·È‰Ô„˘¯È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ ∂ÏÏ¿‰Ô˜ "æ˘¯Ôۈ̷ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ – £ÂˆÚËÙÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ" ¶ÏËÚÔÊÔڛ˜: Easy Travel ∆ËÏ.: 3615 201 & 3609 442 Fax: 3125 572 e-mail: easytravel@fol.gr

∞ı‹Ó·

1-3 πÔ˘Ó›Ô˘

39Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: C & C International Convention & Congresses ¶·Ú·‰Â›ÛÔ˘ 16, 151 25, ∞ı‹Ó· ∆ËÏ.: 01 68 89 100 Fax: 01 68 44 777

∫Ú‹ÙË

17-20 πÔ˘Ó›Ô˘

European Society for Paediatric Hematology and Oncology (ESPHI)

Lucerne, ∂Ï‚ÂÙ›·

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2Ô ¶·ÁÎfiÛÌÈÔ ™˘Ó¤‰ÚÈÔ §Â˚ÛÌ·Ó›·Û˘ ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∆ËÏ.: 7499 312 ¤ˆ˜ 317 Fax: 7705 752

∫Ú‹ÙË

5-8 ∞˘ÁÔ‡ÛÙÔ˘

European Society for Pediatric Research Congreszon Ltd/ESPR Itälahdenkatu 22A 00210 Helsinki, Finland Fax: +358 9 5840 9555

∂ÏÛ›ÓÎÈ, ºÈÏ·Ó‰›·

2-4 ™ÂÙÂÌ‚Ú›Ô˘

The fetus as a patient: International course ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∫· ¶¤ÓË Ã·Ù˙ËÁˆÚÁ›Ô˘ ∆ËÏ.: 01 7499 312 ¤ˆ˜ 317 Fax: 01 7705 752

πˆ¿ÓÓÈÓ·

9-14 ™ÂÙÂÌ‚Ú›Ô˘

11th International Clinical Genetics Seminar "The Genetics of Diabetes Mellitus" ¶ÏËÚÔÊÔڛ˜: Triaena Tours and Congress S.A ∆ËÏ.: 01 7499 300 Fax: 01 7713 795 e-mail: congress@triaenatours.gr

∏Ú¿ÎÏÂÈÔ

9-14 ™ÂÙÂÌ‚Ú›Ô˘

23rd International Congress of Pediatrics ¶ÏËÚÔÊÔڛ˜: Chinese Medical Association 42 Dongsi Xidajie, Beijing 100710, China ∆ËÏ.: 86-10-6527 8804 / 6527 8803 Fax: 86-10-65-123-754 e-mail: 231CP@chinamed.com.cn.

Beijing, ∫›Ó·

23-27 ™ÂÙÂÌ‚Ú›Ô˘

World Congress of Perinatal Medicine ¶ÏËÚÔÊÔڛ˜: Santiago Dexeus Font Foundation Paeso Bonanova 67, 08017 Barcelona ∆ËÏ.: +34 (93) 227 4709 Fax: +34 (93) 418 78 32 e-mail: Fundacio@indexus.uab.es

µ·ÚÎÂÏÒÓË, πÛ·Ó›·

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™YNTOMO°PAºIE™

ABBREVIATIONS

™˘ÓÙÔÌÔÁڷʛ˜

EÏÏËÓÈÎÔ› fiÚÔÈ

AÁÁÏÈÎÔ› fiÚÔÈ

AIDS

Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿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˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ 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΋˜ ıÂÚ·›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚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 ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÙÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·

acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability

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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˘ÙÂÚfiÏÂÙÔ ˘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 ) -6 micro (10 ) -9 nano (10 ) -12 pico (10 ) -15 femto (10 ) -18 atto (10 )

xxii

Combining prefixes T G M k h da d c m Ì n p f a

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Συνταγογραφικές Πληροφορίες ∆ιαφηµιζόµενων Προϊόντων

CECLOR: ¶∂ƒπ§∏æ∏ Ã∞ƒ∞∫∆∏ƒπ™∆π∫ø¡ ¶ƒO´O¡∆O™ ∂N¢EI•EI™: ∆Ô CECLOR® ÂӉ›ÎÓ˘Ù·È ÛÙË ıÂÚ·›· ÙˆÓ ·ÎfiÏÔ˘ıˆÓ ÏÔÈÌÒ͈Ó, fiÙ·Ó ·˘Ù¤˜ ÚÔηÏÔ‡ÓÙ·È ·fi Ù· ·Ó·ÊÂÚfiÌÂÓ· ηو٤ڈ ÛÙÂϤ¯Ë ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÂÊfiÛÔÓ ·˘Ù¿ Â›Ó·È Â˘·›ÛıËÙ· Û ·˘Ùfi: §ÔÈÌÒÍÂȘ ÙˆÓ ·ÓˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ. ª¤ÛË ˘Ò‰Ë˜ ˆÙ›Ùȉ·: ÚÔηÏÔ‡ÌÂÓË ·fi S. pneumoniae, H. influenzae, Staphylococci (ÂÍ·ÈÚÔ˘Ì¤ÓˆÓ ÙˆÓ ÛÙÂϯÒÓ Ô˘ Â›Ó·È ·ÓıÂÎÙÈο ÛÙË ÌÂıÈÎÈÏÏ›ÓË), ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ Î·È ª. catarrhalis. º·Ú˘ÁÁ›Ùȉ· Î·È ·Ì˘Á‰·Ï›Ùȉ·, ·fi ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞.¶·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· ·fi ¢·›ÛıËÙ· ÛÙÂϤ¯Ë H. influenzae ( ‚-Ï·ÎÙ·Ì¿ÛË ±), ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞, S. pneumoniae, M. catarrhalis Î·È S. aureus ( ‚-Ï·ÎÙ·Ì¿Û˘ ±). ™ÙË ¯ÚfiÓÈ· ÌÔÚÊ‹ ··ÈÙÂ›Ù·È Û˘Ó‹ıˆ˜ ÚÔÛı‹ÎË Î·È ÂÓfi˜ ¿ÏÏÔ˘ ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ‡ ·Ú¿ÁÔÓÙ·, ‰Ú·ÛÙÈÎÔ‡ ÛÙÔ˘˜ ·Ó·ÂÚfi‚ÈÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜. §ÔÈÌÒÍÂȘ ÙˆÓ Î·ÙˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ: √Í›· ‚ÚÔÁ¯›Ùȉ·, Î·È ÔÍ›˜ ÂÍ¿ÚÛÂȘ ¯ÚfiÓÈ·˜ ‚ÚÔÁ¯›Ùȉ·˜ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿ÛË ±), H. parainfluenzae, M. catarrhalis (‚-Ï·ÎÙ·Ì¿ÛË ±), S. aureus. ¶Ó¢ÌÔÓ›· Û ·ÛıÂÓ›˜ Ù˘ ÎÔÈÓfiÙËÙ·˜ Ô˘ ÚÔηÏÂ›Ù·È ·Ô S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿Û˱) Î·È M. catarrhalis(‚-Ï·ÎÙ·Ì¿Û˱). ªË ÂÈÂÏÂÁ̤Ó˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È Î˘ÛÙ›Ùȉ·˜, (Ì ٷ˘Ùfi¯ÚÔÓË Î¿Ï˘„Ë ÁÈ· Ù· ·Ó·ÂÚfi‚È· ) Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ∂. coli, P. mirabilis, Klebsiella spp. §ÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi Staphylococcus aureus (‚-Ï·ÎÙ·Ì¿Û˱) Î·È ‚-·ÈÌÔÏ˘ÙÈÎÒÓ ÛÙÚÂÙÔÎfiÎÎˆÓ ÔÌ¿‰·˜ ∞. ANTEN¢EI•EI™: °ÓˆÛÙ‹ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙË ÎÂÊ·ÎÏfiÚË Î·È ¿ÏϘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ηıÒ˜ Î·È ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙȘ ÂÓÈÎÈÏϛӘ. ∞¡∂¶π£Àª∏∆∂™ ∂¡∂ƒ°∂π∂™: ∞ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ (‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÏÏÂÚÁ›· Ì ÙȘ ÂÓÈÎÈÏϛӘ10%). ¡·˘Ù›·,¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ÂÈÁ·ÛÙÚÈÎfi˜ ÊfiÚÙÔ˜. ∞§§∏§∂¶π¢ƒ∞™∂π™: ∏ Û‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÚÔ‚ÂÓÂÛ›‰Ë˜ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ CECLOR® ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È Ì ¿ÏÏ· ·ÓÙÈ‚ÈÔÙÈο. ™‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË Ì ÙÂÙڷ΢ÎϛӘ ‹ ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË, ¤¯ÂÈ ·ÓÙ·ÁˆÓÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ŸÙ·Ó ¯ÔÚËÁÂ›Ù·È Û ÌÂÁ¿Ï˜ ‰fiÛÂȘ Ì·˙› Ì ¿ÏÏ· ÓÂÊÚÔÙÔÍÈο Ê¿Ú̷η, fiˆ˜ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ¢√™√§√°π∞: XÔÚËÁÂ›Ù·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, Ì ‹ ¯ˆÚ›˜ Ê·ÁËÙfi. ∂Ó‹ÏÈΘ: 250 mg οı 8 ÒÚ˜, ‰ÈÏ·ÛÈ·˙fiÌÂÓË Û ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. M¤ÁÈÛÙË ‰fiÛË ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ 4 gr ËÌÂÚËÛ›ˆ˜ ¶·È‰È¿: 20-40 mg/kg ËÌÂÚËÛ›ˆ˜ ‰È·ÈÚÂ̤ÓË Û ÙÚÂȘ ›Û˜ ‰fiÛÂȘ. ™ÙË ıÂÚ·›· Ù˘ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È Ê·Ú˘ÁÁ›Ùȉ·˜, Ë Û˘ÓÔÏÈ΋ ËÌÂÚ‹ÛÈ· ‰fiÛË ÌÔÚ› Ó· ‰È·ÈÚÂı› Î·È Ó· ¯ÔÚËÁËı› ·Ó¿ 12ˆÚÔ. ª¤ÁÈÛÙË Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÛÙ· ·È‰È¿ Â›Ó·È 1 gr ËÌÂÚËÛ›ˆ˜. ªOƒº∂™: Susp 125mg/5ml, 60ml, Susp 250mg/5ml, 60ml, Susp 375mg/5ml, 60ml, Caps 500mg Û ÎÔ˘Ù› ÙˆÓ 12. ¶ÔÛÔÛÙfi ÂȯÔÚ‹ÁËÛ˘ ·fi Ù· Ù·Ì›·: 75 %