Παιδιατρική | Τόμος 64 • Τεύχος 5 • Σεπτέμβριος - Οκτώβριος 2001

ISSN 0377-2551

¶AI¢IATPIKH

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TOMO™ 64

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TEYXO™ 5

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ETO™ 2001

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 5

ANA™KO¶H™H ™¯ÈÛٛ˜ ÙÔ˘ ÛÙÔÌ·ÙÔÁÓ·ıÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜

REVIEW ARTICLE 441

ª. ¡. ™˘ÚÔÔ‡ÏÔ˘

M. N. Spyropoulos

∂¶π∫∞πƒ∞ £∂ª∞∆∞ ∏ ˘¤ÚÙ·ÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·

CURRENT ISSUES 448

∞. ∑ÂÚ‚Ô˘‰¿ÎË, ∫. ∆ÛÔ˘Ì¿Î·˜

™‡Ó‰ÚÔÌÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η

460

ORIGINAL ARTICLES 465

°. ∆ÛfiÏ·˜, ¢. ÃÔϤ‚·˜, ™. ∆ÛÔ˘Î·Ï¿, Ã. ™Ù·˘ÚÈÓ¿‰Ë˜, ¶. ∫Ô˘ÎÔ˘ÙÛ¿Î˘, ¶. ™˘Ú›‰Ë˜, ¢. °Ô˘ÚÁÈÒÙ˘, ∫. ™ÈÓ·ÓÈÒÙ˘ 472

481

Immunologic parameters in the evaluation of the eventual outcome of childhood pneumonia M. Eboriadou, M. Hatzistilianou, K. Haidopoulou, C. Aggouridaki, V. Tsavdaridou, G. Varlamis, S. Karamperis

488

∫.∂. ™Ô‡ÏË, °.∞. ∫·Ú›Î·˜, π. ∆˙·ÌÔ˘Ú¿ÓË, ™. ƒÂÁÎÔ‡Ù·˜, ™. ∆۷ΛÚ˘

∂ȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›·

Management of children with acute renal failure in a pediatric intensive care unit N. Zavras, A. Kapogiannis, P. Kalambalikis, G. Briasoulis, E. Georgaki, A. Hatzis

ª. ∂ÌÔÚÈ¿‰Ô˘, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡, ∫. ÷˚‰ÔÔ‡ÏÔ˘, Ã. ∞ÁÁÔ˘Úȉ¿ÎË, µ. ∆Û·‚‰·Ú›‰Ô˘, °. µ·ÚÏ¿Ì˘, ™. ∫·Ú·Ì¤Ú˘

∏ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÂÈÏËÙÈÎÒÓ ·È‰ÈÒÓ Û ÌÔÓÔıÂÚ·›· Ì ‚·ÏÚÔ˚Îfi Ô͇

Seasonal variation of urinary calcium excretion G. Tsolas, D. Cholevas, S. Tsoukala, C. Stavrinadis, P. Koukoutsakis, P. Spyridis, D. Gouriotis, C. Sinaniotis

¡. ∑¿‚Ú·˜, ∞. ∫·fiÁÈ·ÓÓ˘, ¶. ∫·Ï·Ì·Ï›Î˘, °. ªÚÈ·ÛÔ‡Ï˘, ∂. °ÂˆÚÁ¿ÎË, ∞. ÷Ù˙‹˜

∞ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÌÂÙÚÔÈ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ·È‰È΋˜ Ó¢ÌÔÓ›·˜

Anticonvulsant hypersensitivity syndrome I. Charoniti, D. Lambraki, V. Angelakou

∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™

∏ ÂÌÂÈÚ›· ·fi ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Û ·È‰È¿ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜

Hypertension in childhood A. Zervoudaki, K. Tsoumakas

π. X·ÚˆÓ›ÙË, ¢. §·ÌÚ¿ÎË, µ. ∞ÁÁÂÏ¿ÎÔ˘

∂Ô¯È΋ ÌÂÙ·‚ÔÏ‹ Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú·

Clefts of the lip and palate

Serum biotinidase activity in epileptic children on valproic acid monotherapy K.H. Schulpis, G.A. Karikas, J. Tjamouranis, S. Regoutas, S. Tsakiris

493

Epidemiological study of injuries in adolescence

Õ. ¶·ÓÙ·˙‹, ¡. ÷Ù˙ËΈÓÛÙ·ÓÙ›ÓÔ˘, £. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, °. ∫·Ú·‚¿Ó·, £. ∞ÏÌ·Ó›‰Ë˜, ™. ∞ÁÁÂÏfiÔ˘ÏÔ˜

A. Pantazi, N. Hatzikonstantinou, T. Tragianidis, G. Karavana, T. Almanidis, S. Agelopoulos

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

Continuation of table of contents inside title page

September - October 2001 . Volume 64 . No 5

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

Continuation of table of contents

CASE REPORTS

∂¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ ™‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ Û ·È‰È¿ Ì ¤Áη˘Ì·. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛˆÓ

499

M. Narlioglou, P. Kalabalikis, G. Briassoulis, A. Hatzis

ª. ¡·ÚÏ›ÔÁÏÔ˘, ¶. ∫·Ï·Ì·Ï›Î˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜

™˘ÁÁÂÓ‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË Ì ·˘ÍË̤ӷ Â›‰· ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘

504

508

514

™ÔÁÁÒ‰ÂȘ ÂÁÎÂÊ·ÏÔ¿ıÂȘ. ¡ÂfiÙÂÚ˜ ·fi„ÂȘ

PROGRESS IN MEDICAL SCIENCE 518

527

Factors affecting neurogenesis during the neonatal period. A review K.H. Schulpis, A. Doulgeraki, S. Tsakiris

∫.∂. ™Ô‡ÏË, Õ. ¢Ô˘ÏÁÂÚ¿ÎË, ™. ∆۷ΛÚ˘

™‡Á¯ÚÔÓ˜ ·ÈÙÈÔÏÔÁÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜

Spongiform encephalopathies.

Recent advances K. Karavanaki - Karanasiou

∫. ∫·Ú·‚·Ó¿ÎË - ∫·Ú·Ó¿ÛÈÔ˘

¶·Ú¿ÁÔÓÙ˜ Ó¢ÚÔÁ¤ÓÂÛ˘ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. ¡ÂfiÙÂÚ˜ ·fi„ÂȘ

Crossed renal ectopia with fusion and hydronephrosis in a girl with congenital adrenal hyperplasia D. Karakaidos, P. Zosi, M. Karafezi, A. Moutafi, G. Kaniaris, C. Karis

¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, ª. ∫·Ú·Ê¤˙Ë, ∞. ªÔ˘Ù¿ÊË, °. ∫·ÓÈ¿Ú˘, Ã. ∫·Ú‹˜

∂•∂§π•∂π™ ™∆∏¡ π∞∆ƒπ∫∏ ∂¶π™∆∏ª∏

Congenital muscular dystrophy with laminin-a2 deficiency C. Panteliadis, N. Flaris, E. Karatza-Xifilidou, J. Xinias

Ã. ¶. ¶·ÓÙÂÏÈ¿‰Ë˜, ¡. ºÏ¿Ú˘, ∂. ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘, π. •˘ÓÈ¿˜

¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· Ì ˘‰ÚÔÓ¤ÊÚˆÛË Û ÎÔÚ›ÙÛÈ ÌÂ Û˘ÁÁÂÓ‹ ˘ÂÚÏ·Û›· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ

Congenital erythrocytosis with increased erythropoietin levels.

Case report M. Athanassiou-Metaxa, M. Oikonomou, C. Tsantali, A. Kousi, N. Gombakis

ª. ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿, ª. OÈÎÔÓfiÌÔ˘, Ã. ∆Û¿ÓÙ·ÏË, ∞. ∫Ô‡ÛË, ¡. °ÔÌ¿Î˘

™˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘ ·2

∆oxic shock syndrome in children with burns. Report of 2 cases

535

Recent etiological correlations of childhood leukemia

∞. ¶Ô˘ÚÙÛ›‰Ë˜

A. G. Pourtsidis

™˘Ó¯›˙ÔÓÙ·È

Continued

September - October 2001 . Volume 64 . No 5

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 5

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

Continuation of table of contents

¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ ∞˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÛıÌ·ÙÈÎÔ‡ Ù‡Ô˘ Û˘ÌÙˆÌ¿ÙˆÓ Û ÎÔÚ›ÙÛÈ· Ô˘ Á›ÓÔÓÙ·È ˘¤Ú‚·Ú· ‹ ·¯‡Û·Úη ηٿ ÙË Û¯ÔÏÈ΋ ÂÚ›Ô‰Ô

LITERATURE ABSTRACTS 459

Castro-Rodriguez JA, Holberg CJ, Morgan WJ, Wright AL, Martinez FD ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: £. ∆ÛÈÏÈÁÈ¿ÓÓ˘

ÀÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· ÛÙ· ·È‰È¿. ∫ÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È Ê˘ÛÈ΋ ÈÛÙÔÚ›·

Castro-Rodriguez JA, Holberg CJ, Morgan WJ, Wright AL, Martinez FD Greek translation: T. Tsiligiannis 471

La ªanna A, Polito C, MarÙe A, Iovene A, Di Toro R ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∫. ∆ÛÔ˘Ì¿Î·˜

À¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ·ÓÙÈ·ÛıÌ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ì ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ¿ÛıÌ·;

480

Are asthma medications and management related to deaths from asthma?

Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB et al Greek translation: T. Tsiligiannis

492

Krawiec ME, Westcott JY, Chu HW, Balzar S, Trudeau JB, Schwartz LB et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: £. ∆ÛÈÏÈÁÈ¿ÓÓ˘

™È‰ËÚÔÂÓ›· Î·È ÁÓˆÛÙÈ΋ ·ÓÙ›ÏË„Ë Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÂÊ‹‚Ô˘˜ ÛÙȘ ∏¶∞

Hyperuricosuria in children.

Clinical presentation and natural history La ªanna A, Polito C, MarÙe A, Iovene A, Di Toro R Greek translation: ∫. ∆soumakas

Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: £. ∆ÛÈÏÈÁÈ¿ÓÓ˘

∏ Â›ÌÔÓË Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ Û Ôχ ÌÈÎÚ¿ ·È‰È¿ Û¯ÂÙ›˙ÂÙ·È Ì ÊÏÂÁÌÔÓ‹ ÙˆÓ Î·ÙÒÙÂÚˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ

Increased incidence of asthma like symptoms in girls who become overweight or obese during the school years

Persistent wheezing in very young children is associated with lower respiratory inflammation Krawiec ME, Westcott JY, Chu HW, Balzar S, Trudeau JB, Schwartz LB et al Greek translation: T. Tsiligiannis

507

Halterman JS, Kaczorowski JM, Allgne CA, Auinger P, Szilagyl PG ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∞. Ã. ª¿Î˘

Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States Halterman JS, Kaczorowski JM, Allgne CA, Auinger P, Szilagyl PG Greek translation: A. C. Makis

¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·

xiii

Scheduled Medical Meetings

™˘ÓÙÔÌÔÁڷʛ˜

xvii

Abbreviations

September - October 2001 . Volume 64 . No 5

™Â٤̂ÚÈÔ˜ - √ÎÙÒ‚ÚÈÔ˜ 2001 . ∆fiÌÔ˜ 64

.

∆‡¯Ô˜ 5

¢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

EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∫. ª·Ï·Î¿ ¢È¢ı˘ÓÙ‹˜ : ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ M¤ÏË : ∂. ∞ÁÁÂÏ¿ÎË-°ÂˆÚÁ¿ÎË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ : °. µ·ÚÏ¿Ì˘ : ¶. ∫·ÊÚ›ÙÛ· : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ : £. ∆ÛÈÏÈÁÈ¿ÓÓ˘ : ∫. ∆ÛÔ˘Ì¿Î·˜ : ™. ºˆÙfiÔ˘ÏÔ˜ : A. ÷Ù˙‹˜

Scientific President Editor Members

ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·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

™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜

Publishing Coordinator

E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶·Ú·‰Â›ÛÔ˘ 14, 151 25 M·ÚÔ‡ÛÈ TËÏ.: 68 89 180 Fax: 68 89 290

SCIENTIFIC PUBLICATIONS Ltd Paradisou 14, Marousi 151 25 Tel.: 68 89 180 Fax: 68 89 290

Editorial Board : K. Malaka : Z. Papadopoulou-Couloumbis : E. Agelaki-Georgaki : F. Athanassiadou-Piperopoulou : M. Anthrakopoulos : G. Varlamis : P. Kafritsa : A. Konstadopoulos : Th. Tsiligiannis : K. Tsoumakas : S. Fotopoulos : ∞. Hatzis

Greek Editing I. Karavranou

EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹

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29,35

Annual Subscription

EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜:

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September-October 2001 . Volume 64 .No 5

πSSN 0377-2551 i

O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫◊” Â›Ó·È Ë Â›ÛËÌË 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· Excel 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 40 ËÌÂÚÒÓ 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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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˘ ηÈ

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‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û 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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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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™¯ÈÛٛ˜ ÙÔ˘ ÛÙÔÌ·ÙÔÁÓ·ıÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ ª. ¡. ™˘ÚÔÔ‡ÏÔ˘

Clefts of the lip and palate M. N. Spyropoulos

¶ÂÚ›ÏË„Ë: OÈ Û¯ÈÛٛ˜ ÙÔ˘ ¯Â›ÏÔ˘˜ ‹/Î·È Ù˘ ˘ÂÚÒ·˜ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ÂΉ‹ÏˆÛË Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ Û˘ÁÁÂÓÒÓ ‰˘ÛÌÔÚÊÈÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ÎÚ·ÓÈÔÚÔÛˆÈÎfi Û‡ÌÏÂÁÌ·. ∏ ·ıÔÁ¤ÓÂÈ·, Ë Ù·ÍÈÓfiÌËÛË Î·È ÔÈ ‰È·‰Èηۛ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË Î·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Û˘Ó˘¿Ú¯Ô˘Ó, ·ÊÔÚÔ‡Ó Û ÔÏϤ˜ ÂȉÈÎfiÙËÙ˜ ÙˆÓ ÂÈÛÙËÌÒÓ ˘Á›·˜ ÔÈ Ôԛ˜ ı· Ú¤ÂÈ Ó· Û˘ÓÂÚÁ·ÛÙÔ‡Ó ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ı· ÁÂÓÓËı› ¤Ó· ·È‰› Ì οÔÈ· ÌÔÚÊ‹ Û¯ÈÛÙ›·˜. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ·Ú·Ù›ıÂÓÙ·È Û˘ÓÔÙÈο ÔÈ Û‡Á¯ÚÔÓ˜ ·fi„ÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÛÙ· ÈÔ ¿Óˆ Î·È ‰›ÓÂÙ·È ¤ÌÊ·ÛË ÛÙ· ¯ÚÔÓԉȷÁÚ¿ÌÌ·Ù· ·˘Ù‹˜ Ù˘ Û˘ÓÂÚÁ·ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ fiˆ˜ ÈÛ¯‡Ô˘Ó ÛÙ· ·ÓÙ›ÛÙÔȯ· ÔÚÁ·ÓˆÌ¤Ó· ÂȉÈο ΤÓÙÚ· Î·È ¤¯Ô˘Ó ȉȷÈÙ¤Úˆ˜ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·.

Abstract: Clefts of the lip and/or palate comprise the most frequent expressions of congenital anomalies and the highest percentage of malformations related to the craniofacial complex.

The etiology and pathology of these abnormalities, their classification, their implications and the procedures that minimize the coexisting problems require the close cooperation of many medical and dental specialties starting from the very first day that a child is born with a congenital defect. This review article gives a concise overview of the current concepts regarding the aformentioned problems, and emphasizes the significance of the time-tables that must be followed by the various specialties in the highly organized medical centres in order to obtain the best possible results.

§¤ÍÂȘ ÎÏÂȉȿ: ¯ÂÈÏÂÈÔÛ¯ÈÛٛ˜, ˘ÂÚˆÈÔÛ¯ÈÛٛ˜, ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆÈÔÛ¯ÈÛٛ˜.

Key words: cleft lip, cleft palate, cleft lip and palate.

∂ÈÛ·ÁˆÁ‹ OÈ Û¯ÈÛٛ˜ ÙÔ˘ ¯Â›ÏÔ˘˜ ‹/Î·È Ù˘ ˘ÂÚÒ·˜, ÁÈ· ÙȘ Ôԛ˜ ·Ï·ÈfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡Û·Ì ÙÔ˘˜ ÂÓÙÂÏÒ˜ ·‰fiÎÈÌÔ˘˜ fiÚÔ˘˜ “Ï·ÁÒ¯ÂÈÏÔ˜” Î·È “Ï˘ÎfiÛÙÔÌ·”, ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ÂΉ‹ÏˆÛË Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ (ÔÛÔÛÙfi 8,6% fiÏˆÓ ÙˆÓ ‰È·Ì·ÚÙÈÒÓ ÛÙË ‰È¿Ï·ÛË) Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (65%) ÙˆÓ Û˘ÁÁÂÓÒÓ ‰˘ÛÌÔÚÊÈÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ÎÚ·ÓÈÔÚÔÛˆÈÎfi Û‡ÌÏÂÁÌ·. ªÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Ì ¿ÏϘ ·ÓˆÌ·Ï›Â˜ Û ‰È¿ÊÔÚ· Û‡Ó‰ÚÔÌ· ‹ Ó· Â›Ó·È ÌÂÌÔӈ̤Ó˜ ηٷÛÙ¿ÛÂȘ ÛÂ

¿ÙÔÌ· Ô˘ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó Î·Ó¤Ó· ¿ÏÏÔ Úfi‚ÏËÌ·. ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÌË Û˘Ó‰ÚÔÌÈÎÒÓ Û¯ÈÛÙÈÒÓ ÛÙË Ï¢΋ Ê˘Ï‹, Î˘Ì·›ÓÂÙ·È ·fi 0,8-2 ·Ó¿ 1000 ÁÂÓÓ‹ÛÂȘ. ™ÙË ¯ÒÚ· Ì·˜, ·Ó Î·È ÔÈ ‰˘ÛÎÔϛ˜ ηٷÁÚ·Ê‹˜ Â›Ó·È Ôχ ÌÂÁ¿Ï˜, Ë Û˘¯ÓfiÙËÙ· ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 1 ·Ó¿ 700-800 ÁÂÓÓ‹ÛÂȘ (13). ∏ Û˘¯ÓfiÙËÙ· ·˘Ù‹ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ Î›ÙÚÈÓË Ê˘Ï‹ Î·È ÌÈÎÚfiÙÂÚË ÛÙË Ì·‡ÚË. ™ÎÔfi˜ Ù˘ ·Ó·ÛÎfiËÛ˘ Ô˘ ·ÎÔÏÔ˘ı› Â›Ó·È Ë ·Ó·ÊÔÚ¿ ÛÙȘ Û‡Á¯ÚÔÓ˜ ·fi„ÂȘ, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙËÓ Ù·ÍÈÓfiÌËÛË Î·È

∫·ıËÁ‹ÙÚÈ·-¢È¢ı‡ÓÙÚÈ· ∂ÚÁ·ÛÙ‹ÚÈÔ OÚıÔ‰ÔÓÙÈ΋˜ O‰ÔÓÙÈ·ÙÚÈÎfi ∆Ì‹Ì· ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

Professor and Head Department of Orthodontics University of Athens Dental School, Athens

441

¶·È‰È·ÙÚÈ΋ 2001;64:441-447

Paediatriki 2001;64:441-477

ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÒÓ ÙˆÓ Î·Ù·ÛÙ¿ÛˆÓ. ∏ ÂÓË̤ڈÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÁÈ· Ù· ı¤Ì·Ù· ·˘Ù¿ ıˆÚÂ›Ù·È È‰È·ÈÙ¤Úˆ˜ ÛËÌ·ÓÙÈ΋. ∞ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ∏ ÌÔÚÊ‹ Î·È Ë ¤ÎÙ·ÛË ÙˆÓ Û¯ÈÛÙÈÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÔȘ ·ÔʇÛÂȘ, ·fi ·˘Ù¤˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙË ‰È¿Ï·ÛË ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÚÔÛÒÔ˘ ηٿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ˙ˆ‹, ‰ÂÓ ‹Úı·Ó Û Â·Ê‹ ÛÙËÓ Î·Ù¿ÏÏËÏË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ‹/Î·È ‰ÂÓ Û˘ÓÂÓÒıËηÓ, ÛÙË Û˘Ó¤¯ÂÈ·, Ì ‰È›ۉ˘ÛË ÌÂÛÂÁ¯‡Ì·ÙÔ˜. ÃÂÈÏÂÔÛ¯ÈÛÙ›· ÚÔ·ÙÂÈ ·fi ÙËÓ ·ÔÙ˘¯›· Û˘Ó¤ÓˆÛ˘ Ù˘ ¿Óˆ ÁÓ·ıÈ·›·˜ ·ÔʇÛˆ˜ Ì ÙË ÌÂÛË ÚÈÓÈ΋, ηٿ ÙËÓ 6Ë-7Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰·. ÀÂÚˆÈÔÛ¯ÈÛÙ›· ÚÔ·ÙÂÈ ·fi ÙËÓ ·ÔÙ˘¯›· Û˘Ó¤ÓˆÛ˘ ÙˆÓ ‰‡Ô ˘ÂÚˆ›ˆÓ ÂÙ¿ÏˆÓ ÌÂٷ͇ ÙÔ˘˜ Î·È Ì ٷ ÛÙÔȯ›· Ù˘ ̤Û˘ ÁÚ·ÌÌ‹˜, ÁÈ· ÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ˘ÂÚÒ·˜, ηٿ ÙËÓ 9Ë-10Ë ÂÌ‚Ú˘˚΋ ‚‰ÔÌ¿‰·. ™˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ·˘ÙÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ ÂΉËÏÒÓÂÙ·È Ì ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆÈÔÛ¯ÈÛÙ›·, fiÙ·Ó ÙÔ ¯¿ÛÌ· ·Ú¯›˙ÂÈ ·fi ÙÔ ¯Â›ÏÔ˜, ‰È·Û¯›˙ÂÈ ÙËÓ ¿Óˆ ÁÓ¿ıÔ Î·È Î·Ù·Ï‹ÁÂÈ ÛÙË Ì·Ï·Î‹ ˘ÂÚÒ·. ŸÏ˜ ÔÈ ÈÔ ¿Óˆ ηٷÛÙ¿ÛÂȘ, Ì ‰È¿ÊÔÚÔ˘˜ Û˘Ó‰˘·ÛÌÔ‡˜ Ï‹ÚÔ˘˜, ·ÙÂÏÔ‡˜ ‹ Î·È ˘ÔÙ˘Ò‰Ô˘˜ ÌÔÚÊ‹˜ (ÌÈÎÚÔÌÔÚÊ‹˜), ÌÔÚ› Ó· Â›Ó·È ÂÙÂÚfiÏ¢Ú˜ ‹ ·ÌÊ›Ï¢Ú˜ (∂ÈÎfiÓ· 1). ∏ ·ÈÙÈÔÏÔÁ›· ÙˆÓ Û¯ÈÛÙÈÒÓ ‰ÂÓ Â›Ó·È ·ÎfiÌË Ï‹Úˆ˜ ÂÍ·ÎÚÈ‚ˆÌ¤ÓË. ¢ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ›‰È· ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ÂÓÙÔ›ÛÂȘ Î·È Û˘Ó‹ıˆ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÔÏ˘·Ú·ÁÔÓÙÈ΋. ªÂ ÙËÓ ÚfiÔ‰Ô, fï˜, ÙˆÓ ÂÚ¢ÓÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ÁÔÓȉ›ˆÌ· ÙÔ˘ ·ÓıÚÒÔ˘, ›Ûˆ˜ Ó· ÌËÓ ·¤¯ÂÈ Ôχ Ë ‰˘Ó·ÙfiÙËÙ· ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ôχ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÁÂÓÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙˆÓ Û¯ÈÛÙÈÒÓ. ª¤¯ÚÈ Û‹ÌÂÚ·, ¿ÓÙˆ˜, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Â¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Â›Ó·È ÁÂÓÂÙÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ›. ∞˘ÙÔ› ÔÈ ÙÂÏÂ˘Ù·›ÔÈ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÙÂÚ·ÙÔÁfiÓÔÈ Î·È Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¿ÊÔÚ˜ ÂÓ‰ÔÌ‹ÙÚȘ ηٷÛÙ¿ÛÂȘ, „˘¯ÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ Ù˘ ÌËÙ¤Ú·˜, ÌÔχÓÛÂȘ Ù˘ ÌËÙ¤Ú·˜ ·fi ÈÔ‡˜ ‹ Ï‹„Ë ‰È·ÊfiÚˆÓ Ê·ÚÌ¿ÎˆÓ ·fi ·˘Ù‹Ó, Ì˯·ÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ·ÎÙÈÓÔ‚ÔÏ›· Î.¿. (12). OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› ‰ÚÔ˘Ó Û ÎÚ›ÛÈ̘ ÂÚÈfi‰Ô˘˜ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜, Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÎÙÚÔ‹ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚÈÛÌ¤ÓˆÓ ‚·ÛÈÎÒÓ ÌÔÚÊÔÁÂÓÂÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÙÔ˘ ÎÚ·ÓÈÔÚÔÛˆÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜, fiˆ˜ ›ӷÈ: ·) Ë Î˘ÙÙ·ÚÈ΋ ‰È·ÊÔÚÔÔ›ËÛË, ‚) Ë Î˘ÙÙ·ÚÈ΋ ÌÂÙ·Ó¿ÛÙ¢ÛË, Á) Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡, ‰) ÔÈ ·ÏÏËÏÂȉڿÛÂȘ ÌÂٷ͇ ÁÂÈÙÔÓÈÎÒÓ ÈÛÙÒÓ (Î·È È‰È·›ÙÂÚ· ÌÂٷ͇ ÂÈıËÏ›Ô˘ Î·È ÌÂÛÂÁ¯‡Ì·ÙÔ˜), Â) Ë Î˘ÙÙ·ÚÈ΋ ÚÔÛÎfiÏÏËÛË, ÛÙ) Ô ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˜ ΢ÙÙ·ÚÈÎfi˜ ı¿Ó·ÙÔ˜/·fiÙˆÛË Î·È ˙) Ë

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∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈΤ˜ ·Ú·ÛÙ¿ÛÂȘ ‰È·ÊfiÚˆÓ ÌÔÚÊÒÓ Û¯ÈÛÙÈÒÓ ÙÔ˘ ¯Â›ÏÔ˘˜ Î·È Ù˘ ˘ÂÚÒ·˜, fiˆ˜ Ê·›ÓÔÓÙ·È ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ (·,‚,Á,‰): ·) ∂ÙÂÚfiÏ¢ÚË ¯ÂÈÏÂÔÁÓ·ıÔÛ¯ÈÛÙ›·, ‚) ∂ÙÂÚfiÏ¢ÚË ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆÈÔÛ¯ÈÛÙ›·, Á) ∞ÌÊ›Ï¢ÚË ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆÈÔÛ¯ÈÛÙ›·, ‰) ªÂÌÔӈ̤ÓË ˘ÂÚˆÈÔÛ¯ÈÛÙ›·. ™¯ËÌ·ÙÈΤ˜ ·Ú·ÛÙ¿ÛÂȘ ‰È·ÊfiÚˆÓ Û¯ÈÛÙÈÒÓ ÙÔ˘ ¯Â›ÏÔ˘˜ (Â,ÛÙ): Â) ∂ÙÂÚfiÏ¢ÚË ·ÚÈÛÙÂÚ‹ ¯ÂÈÏÂÔÛ¯ÈÛÙ›·, ÛÙ) ∞ÌÊ›Ï¢ÚË ¯ÂÈÏÂÔÛ¯ÈÛÙ›·. ™¯ËÌ·ÙÈΤ˜ ·Ú·ÛÙ¿ÛÂȘ ÌÈÎÚÔÌÔÚÊÒÓ (˙,Ë): ˙) ∂ÓÙÔÌ‹ ÙÔ˘ ¯Â›ÏÔ˘˜, Ë) ¢Èۯȉ‹˜ ÛÙ·Ê˘Ï‹.

Â›‰Ú·ÛË ÔÚÌÔÓÒÓ Î·È ‰È·ÊfiÚˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ.

OÈ Ì˯·ÓÈÛÌÔ› ·˘ÙÔ› Â›Ó·È Û˘ÓÙÔÓÈṲ̂ÓÔÈ ÌÂٷ͇ ÙÔ˘˜ Î·È ·ÎÔÏÔ˘ıÔ‡Ó ¤Ó·Ó ·˘ÛÙËÚfi ÚÔÁÚ·ÌÌ·ÙÈÛÌfi, ÙÔ˘ ÔÔ›Ô˘ Ë ‰È·Ù·Ú·¯‹ Û ̛· ÎÚ›ÛÈÌË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹, ÌÂÙ¿ ·fi ÚÔÛ‚ÔÏ‹ οÔÈ·˜ ¢¿ÏˆÙ˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÎÚ·ÓÈÔÚÔÛˆÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜, Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË

¶·È‰È·ÙÚÈ΋ 2001;64:441-447

‰˘ÛÌÔÚÊÔÁÂÓÂÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ, fiˆ˜ Â›Ó·È ÔÈ Û¯ÈÛٛ˜. ™Â ÌÔÚÈ·Îfi Â›‰Ô, ÔÈ ÌÔÚÊÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ÎÚ·ÓÈÔÚÔÛˆÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ ‰È·ÌÂÛÔÏ·‚Ô‡ÓÙ·È, ηٿ ·ÚÈÔ ÏfiÁÔ, ·fi ÂÓÒÛÂȘ Ù˘ ÂÍˆÎ˘ÙÙ¿ÚÈ·˜ ıÂÌÂÏ›Ô˘ Ô˘Û›·˜, fiˆ˜ Â›Ó·È ÙÔ ˘·ÏÔ˘ÚÔÓÈÎfi Ô͇, ÙÔ ÎÔÏÏ·ÁfiÓÔ Ù‡Ô˘ πÃ, Ë ÙÂÓ·ÛΛÓË Î.¿. (5) Î·È ·fi ‰È·Ï˘Ù¤˜ Ì·ÎÚÔ- ‹ ÌÈÎÚÔÌÔÚȷΤ˜ ÂÓÒÛÂȘ, ÔÈ Ôԛ˜ Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ·Ó‹ÎÔ˘Ó Û ‰‡Ô ÔÌ¿‰Â˜ (9): ·) ÛÙËÓ ˘ÂÚÔÈÎÔÁ¤ÓÂÈ· ÛÙÂÚÔÂȉÒÓ ÂÓÒÛÂˆÓ - ı˘ÚÂÔÂȉÈÎÒÓ ·Ú·ÁÒÁˆÓ-ÚÂÙÈÓÔ˚ÎÔ‡ ÔͤԘ Î·È ‚) ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (Growth Factors). ∆· ‰Â‰Ô̤ӷ ·fi ÙȘ Û¯ÂÙÈΤ˜ ¤Ú¢Ó˜ ˘Ô‰ËÏÒÓÔ˘Ó ÙÔ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ˆ˜ ÌÂÛÔÏ·‚ËÙÒÓ ÁÈ· ÙË ÌÔÚÊÔÁ¤ÓÂÛË Î·È ‰˘ÛÌÔÚÊÔÁ¤ÓÂÛË ÙÔ˘ ÎÚ·ÓÈÔÚÔÛˆÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ Î·È ÂȉÈÎfiÙÂÚ· ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ·Ó¿Ù˘Í˘ ÙˆÓ Û¯ÈÛÙÈÒÓ, ηıÒ˜ ¤¯ÂÈ ·ÓȯÓ¢ı› ÛÙ· ·ÙÙ·Ú· ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ Ë ‡·ÚÍË ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÙÔ˘ ·ÓÙ›ÛÙÔÈ¯Ô˘ mRNA Ô˘ ÙÔ˘˜ Έ‰ÈÎÔÔÈ›. ¶·Ú·‰Â›ÁÌ·Ù· Ù¤ÙÔÈˆÓ ·Ú·ÁfiÓÙˆÓ Â›Ó·È: ·) Ô ÂȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (EGF), Û ÚÒÈÌ· ÛÙ¿‰È· Û¯ËÌ·ÙÈÛÌÔ‡ Ù˘ ˘ÂÚÒ·˜ (1) Î·È ‚) Ô ÌÂÙ·ÌÔÚʈÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¿ÏÊ· (TGF-a), ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·‰Èηۛ·˜ Û˘Ó¤ÓˆÛ˘ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛˆÓ, fiˆ˜ Â›Û˘ Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ TGF-‚1, TGF-‚2 Î·È TGF-‚3 (1).

O ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PDGF), Ô fiÔÈÔ˜ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ ÂԇψÛ˘ ÙˆÓ ÈÛÙÒÓ, ÌÔÚ› ‰˘ÓËÙÈο Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ÂÈıËÏȷ΋˜ “Ú·Ê‹˜” ÌÂٷ͇ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛˆÓ, ÛÙËÓ ·Ô‰ÈÔÚÁ¿ÓˆÛ‹ Ù˘, ·ÏÏ¿ Î·È ÛÙËÓ ·Ô‰ÈÔÚÁ¿ÓˆÛË Ù˘ ÌÂÛÂÁ¯˘Ì·ÙÈ΋˜ Û˘Ì˘ÎÓÒÛˆ˜ Ô˘ ÙËÓ ·ÎÔÏÔ˘ı› (5). ∆· Â˘Ú‹Ì·Ù· ÂÈÚ·Ì·ÙÈÎÒÓ ÂÚÁ·ÛÈÒÓ ¤¯Ô˘Ó ‰ÒÛÂÈ, ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ‰Â‰Ô̤ӷ Ô˘ ‰È¢ڇÓÔ˘Ó ÂÓÙ˘ˆÛȷο ÙȘ ÁÓÒÛÂȘ Ì·˜ Û¯ÂÙÈο Ì ÙËÓ ÂÍÂȉÈÎÂ˘Ì¤ÓË, ÂÈÏÂÎÙÈ΋ Î·È ¯ÚÔÓÔÛ˘Ó·ÚÙÒÌÂÓË ‰Ú¿ÛË ÙˆÓ ‰È·ÊfiÚˆÓ ·˘ÙÒÓ ·Ú·ÁfiÓÙˆÓ. ∂Âȉ‹ Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ·fi Ù· Â˘Ú‹Ì·Ù· ·˘Ù¿ ı· ·ÔÙÂϤÛÔ˘Ó ÙË ‚¿ÛË ÙˆÓ ÂÚ¢ÓËÙÈÎÒÓ ·Ó·˙ËÙ‹ÛÂˆÓ ÁÈ· Ù· ÚÔÛ¯‹ ¯ÚfiÓÈ·, Â›Ó·È ÛÎfiÈÌÔ Ó· Û˘ÓÔ„ÈÛÙÔ‡Ó ÛÙ· ÂÍ‹˜: ∞) Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ë Û‡ÓıÂÛË (·fi Ù· ÌÂÛÂÁ¯˘Ì·ÙÈο ·ÙÙ·Ú· ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛˆÓ) ˘·ÏÔ˘ÚÔÓÈÎÔ‡ ÔͤԘ, Ì›·˜ Ô˘Û›·˜ Ì ÂÓÂÚÁfi ÚfiÏÔ Î·Ù¿ ÙË Ê¿ÛË Ù˘ ·Ó‡„ˆÛ˘ ÙˆÓ Ï·Á›ˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ ÁÈ· ÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ˘ÂÚÒ·˜, ÚÔ¿ÁÂÙ·È ·fi ÙÔ˘˜ ·˘ÍËÙÈÎÔ‡˜

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·Ú¿ÁÔÓÙ˜ EGF (4) Î·È TGF-‚ (16). µ) ∆· ÌÂÛÂÁ¯˘Ì·ÙÈο ·ÙÙ·Ú· Ù˘ ˘ÂÚÒ·˜ ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ˘Ô‰Ô¯¤ˆÓ ÁÈ· ÙÔÓ EGF (15), ÂÓÒ Ù· ÂÈıËÏȷο ·ÙÙ·Ú· Ù˘ ·Ú˘Ê‹˜ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ ÂÌÊ·Ó›˙Ô˘Ó EGF- ˘ԉԯ›˜ ÌfiÓÔ ÌÂÙ¿ ÙËÓ ÔÚÈ˙ÔÓÙ›ˆÛ‹ ÙÔ˘˜ (5). O EGF ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Â¿ÁÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÌÂÛÂÁ¯˘Ì·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ù˘ ˘ÂÚÒ·˜ (7), ÂÓÒ Î¿Ùˆ ·fi ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÁÂÈÙÔÓÈÎÔ‡ ÌÂÛÂÁ¯‡Ì·ÙÔ˜, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·fiÙˆÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ù˘ “Ú·Ê‹˜” Ô˘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È Î·ıÒ˜ ÔÈ ÂÈıËÏȷΤ˜ ÂÈÊ¿ÓÂȘ ÙˆÓ Ï·Á›ˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ ¤Ú¯ÔÓÙ·È Û Â·Ê‹ (24). °) O ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˜ ΢ÙÙ·ÚÈÎfi˜ ı¿Ó·ÙÔ˜/·fiÙˆÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ù˘ “Ú·Ê‹˜” ÌÂٷ͇ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛˆÓ, ηٿ ÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ˘ÂÚÒ·˜, Â›Ó·È Èı·Ófi Ó· ˘fiÎÂÈÙ·È ÛÙË ‰È·ÌÂÛÔÏ¿‚ËÛË ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· TGF-‚ (5,6,23), ηıÒ˜ Ô ·Ú¿ÁÔÓÙ·˜ ·˘Ùfi˜, ÛÙȘ ‰È¿ÊÔÚ˜ ÈÛÔÌÔÚʤ˜ ÙÔ˘, ·ÓȯÓ‡ÂÙ·È ÛÙËÓ ·Ó·Ù˘ÛÛfiÌÂÓË ‰Â˘ÙÂÚÔÁÂÓ‹ ˘ÂÚÒ· (6) Î·È ¤¯ÂÈ ‚ÚÂı› fiÙÈ Â›Ó·È ÈηÓfi˜ Ó· ÂÓÂÚÁÔÔÈ‹ÛÂÈ ÙÔ ı¿Ó·ÙÔ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ (17). ¢) ∫·Ù¿ ÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ˘ÂÚÒ·˜ ÙˆÓ ÔÓÙÈÎÒÓ, ·ÓȯÓ‡ÂÙ·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ mRNA Ô˘ Έ‰ÈÎÔÔÈ› ÙÔ˘˜ ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ TGF-‚1, TGF-‚2 Î·È TGF-‚3 Î·È Ì›ˆÛË ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÂÈ¤‰ˆÓ ÁÈ· ÙÔÓ TGF-‚2. ∏ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ (Ù· ÔÔ›·, fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ÎÚ›ÛÈ̘ ÂÚÈfi‰Ô˘˜ Ù˘ ·Ó¿Ù˘Í˘, ·ÔÙÂÏÔ‡Ó ÈÛ¯˘ÚÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‰˘ÛÌÔÚÊÔÁÂÓ¤Ûˆ˜ Î·È ÂȉÈÎfiÙÂÚ· Û¯ÈÛÙÈÒÓ) ‰ÂÓ ÂËÚ¿˙ÂÈ ÙȘ ¯ÚÔÓÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ TGF‚1 Î·È TGF-‚3, ·ÏÏ¿ ηı˘ÛÙÂÚ› ηٿ Ì›· Ë̤ڷ ÙË Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ TGF-‚2. ∫·ıÒ˜ Ô TGF-‚2 ·Ó·¯·ÈÙ›˙ÂÈ ÙÔÓ Î˘ÙÙ·ÚÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi, Ë ‰È·Ù‹ÚËÛ‹ ÙÔ˘ Û ˘„ËÏ¿ Â›‰· Û ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô ·˘Í‹Ûˆ˜ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛˆÓ, ›Ûˆ˜ Ó· ·ÔÙÂÏ› Î·È ÙÔ ÎÏÂȉ› Ù˘ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·˜ ÙˆÓ Û¯ÈÛÙÈÒÓ ·fi Ï‹„Ë ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (8). ∂) O ·Ú¿ÁÔÓÙ·˜ TGF-‚3 Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ ¤Ó·Ó ȉȷ›ÙÂÚÔ ÚfiÏÔ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ ˘ÂÚÒ·˜. O Brunet (3) Î·È ÔÈ Taya Î·È Û˘Ó (23) ÙÂÎÌËÚ›ˆÛ·Ó fiÙÈ, Û ÔÓÙ›ÎÈ·, ÂÊfiÛÔÓ ·Ó·ÛÙ·Ï› Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·Ú¿ÁÔÓÙ· ·˘ÙÔ‡, ‰ÂÓ ÔÏÔÎÏËÚÒÓÂÙ·È Ë Û˘Ó¤ÓˆÛË ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ Î·È ÚÔηÏÂ›Ù·È ˘ÂÚˆÈÔÛ¯ÈÛÙ›·. ∞ÓÙ›ÛÙÔȯ·, Û ÂÈÚ¿Ì·Ù· Ô˘ ¤ÁÈÓ·Ó Û ÎÔÙfiÔ˘Ï· (22), ‚Ú¤ıËΠfiÙÈ Ô ·Ú¿ÁÔÓÙ·˜ TGF-‚3 ÚÔ¿ÁÂÈ ÙË “ÌÂÙ·ÌfiÚʈÛË” ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ù˘ ·Ú˘Ê‹˜ ÙˆÓ ˘ÂÚˆ›ˆÓ ·ÔʇÛÂˆÓ Û ÌÂÛÂÁ¯˘Ì·ÙÈο.

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Paediatriki 2001;64:441-477

∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, ·Ó Î·È ‰ÂÓ ··ÓÙÔ‡Ó Û fiÏ· Ù· ÂÚˆÙ‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ÙˆÓ Û¯ÈÛÙÈÒÓ, ¤¯Ô˘Ó ·Ú¯›ÛÂÈ Ó· ·ÔηχÙÔ˘Ó ÙË ÌÔÚȷ΋ ‚ÈÔÏÔÁÈ΋ ‚¿ÛË Ù˘ ÂÈÚ·Ì·ÙÈ΋˜ ÚfiÎÏËÛ‹˜ ÙÔ˘˜. ∂Ô̤ӈ˜, ›Ûˆ˜ Î·È Ó· ÌËÓ Â›Ó·È ·Ú·ÎÈÓ‰˘ÓÂ˘Ì¤ÓÔ Ó· ˘Ôı¤ÛÔ˘Ì fiÙÈ Ì ÙËÓ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË - Û ˘ÂÚÌÈÎÚÔÛÎÔÈÎfi Â›Â‰Ô - Î·È ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ˘‡ı˘ÓˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÁÔÓȉ›ˆÓ, Ë ÂÓ‰ÔÌ‹ÙÚÈ· ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ·ÓÙÈÌÂÙÒÈÛË (.¯. Ì ̛· ÂÓ‰ÔÊϤ‚È· ¤ÓÂÛË ÙÔ˘ ÂÏÏ›ÔÓÙÔ˜ ·Ú¿ÁÔÓÙo˜ ÛÙË ÌËÙ¤Ú·, ÙËÓ Î·Ù¿ÏÏËÏË Ë̤ڷ Î·È ÒÚ·) ı· Û˘Ì‚¿ÏÏÔ˘Ó Ô˘ÛÈ·ÛÙÈο ÛÙËÓ Â›Ï˘ÛË ÙÔ˘ ÛËÌ·ÓÙÈÎÔ‡ ·˘ÙÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜. ∆·ÍÈÓfiÌËÛË Œ¯Ô˘Ó ÚÔÙ·ı›, ηٿ ηÈÚÔ‡˜, ÔÏϤ˜ Ù·ÍÈÓÔÌ‹ÛÂȘ ÙˆÓ ‰È·ÊfiÚˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ÙˆÓ Û¯ÈÛÙÈÒÓ, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ÚÔ·„ÂÈ ·fi ÙÚÂȘ ‚·ÛÈΤ˜ ÚԉȷÁڷʤ˜: ·) ÙËÓ ÂÌ‚Ú˘˚΋ ÚԤϢÛË ÙˆÓ Û¯ÈÛÙÈÒÓ, Ë ÔÔ›· Ô‰ËÁ› ÛÙËÓ Î·ÙËÁÔÚÈÔÔ›ËÛ‹ ÙÔ˘˜ Û ÙÚÂȘ ÔÌ¿‰Â˜ (10), fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔ ™¯‹Ì· 1 (10), ‚) ÙË ÏÂÙÔÌÂÚÂȷ΋ ÔÙÈ΋ ηٷÁÚ·Ê‹ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Î·È Á) ÙËÓ ÚÔÛ¿ıÂÈ· Û‡˙¢Í˘ Ù˘ ÎÏ·ÛÈ΋˜ Î·È ÂÌ‚Ú˘˚ÎÒ˜ ηıÔÚÈṲ̂Ó˘ Ù·ÍÈÓfiÌËÛ˘ Ì ̛· ‡¯ÚËÛÙË ÔÙÈ΋ ÁÚ·ÊÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, Ô˘ Ô‰‹ÁËÛ ÛÙÔ “ÁÚ·Ì̈Ùfi ÏÔÁfiÙ˘Ô Ù‡Ô˘ À” (Kernahan 1971), ÙÔ˘ ÔÔ›-

Ô˘ Ë ÙÂÏÂ˘Ù·›· Û˘ÌÏËڈ̤ÓË ¤Î‰ÔÛË ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ÙËÓ OÌÔÛÔÓ‰›· ÙˆÓ ∫Ú·ÓÈÔÚÔÛˆÈÎÒÓ OÌ¿‰ˆÓ ÙÔ˘ Illinoi˜ ÙˆÓ ∏¶∞ (™¯‹Ì· 2). ™Â ·˘ÙfiÓ ÙÔÓ ÏÔÁfiÙ˘Ô ÛËÌÂÈÒÓÔÓÙ·È Ì ̷‡ÚÈÛÌ· ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÙÌËÌ¿ÙˆÓ, Ï‹Úˆ˜ ‹ Ì ÛÙÈÎÙ¤˜ ÁÚ·Ì̤˜ (·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÙÂÏ‹ ‹ ˘Ô‚ÏÂÓÓÔÁfiÓÈ· Û¯ÈÛÙ›·), Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. ¶ÚÔ·ÙÂÈ, ¤ÙÛÈ, Ì›· ÁÚ‹ÁÔÚË Î·È Ï‹Ú˘ ÂÈÎfiÓ· Ù˘ ÂÎÙ¿Ûˆ˜ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘, ÁÈ· οı ·ÛıÂÓ‹, ÚÔ‚Ï‹Ì·ÙÔ˜. ∂ÈÙÒÛÂȘ OÈ ÂÈÙÒÛÂȘ ·fi ÙȘ ‰È¿ÊÔÚ˜ Û¯ÈÛٛ˜ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ÂÓÙfiÈÛË Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘. ™˘Ó‹ıˆ˜ ·ÊÔÚÔ‡Ó ÛÙË ‰˘Ó·ÙfiÙËÙ· ÔÌ·Ï‹˜ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜, ÛÙËÓ ·ÎÔ‹, ÛÙËÓ ÔÌÈÏ›·, ÛÙËÓ ·ÈÛıËÙÈ΋ ÙÔ˘ ÚÔÛÒÔ˘ Î·È ÛÙË ‰È·ÌfiÚʈÛË Ù˘ Ô‰ÔÓÙÈ΋˜ Û‡ÁÎÏÂÈÛ˘, ‰ÈfiÙÈ ÂÎÙfi˜ ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ, ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ·ÚÈıÌfi, ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙÔ Û¯‹Ì· ÙˆÓ ‰ÔÓÙÈÒÓ (∂ÈÎfiÓ· 2). À¿Ú¯Ô˘Ó ¿ÓÙˆ˜ Î·È ÂÈÙÒÛÂȘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ·ÔÛ·ÛÌ·ÙÈÎfiÙËÙ· Î·È ÙË ¯ˆÚ›˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈ̤ÚÔ˘˜ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ οı ·ÛıÂÓÔ‡˜, Ë ÔÔ›· ÌÔÚ› Ó· ¤¯ÂÈ ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË ÛÙËÓ ·‡ÍËÛË Î·È ÛÙË ‰È·ÌfiÚʈÛË Ù˘ Û˘ÁÎϛۈ˜, ÚÔÛı¤ÙÔÓÙ·˜ ¤ÙÛÈ ·ÚÓËÙÈΤ˜ È·ÙÚÔÁÂÓ›˜ ·Ú·Ì¤ÙÚÔ˘˜ ÛÙÔ ·Ú¯ÈÎfi Úfi‚ÏËÌ·.

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™¯‹Ì· 1. ∆·ÍÈÓfiÌËÛË ÙˆÓ Û¯ÈÛÙÈÒÓ Ì ‚¿ÛË ÙËÓ ÂÌ‚Ú˘˚΋ ÙÔ˘˜ ÚԤϢÛË.

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Paediatriki 2001;64:441-477

∞ ª˘ÎÙ‹Ú·˜ Œ‰·ÊÔ˜ ÚÈÓfi˜ ÛÏÔ˜ º·ÙÓ›Ô

ÀÂÚÒÈ· ÌÔ›Ú· Ê·ÙÓȷ΋˜ ·ÔʇÛˆ˜

∆ÔÌÈÎfi ÙÚ‹Ì· ™ÎÏËÚ‹ ˘ÂÚÒ·

ª·Ï·Î‹ ˘ÂÚÒ·

™Ù·Ê˘Ï‹ ™¯‹Ì· 2. ∏ ÈÔ ÚfiÛÊ·ÙË ÙÚÔÔÔ›ËÛË ÙÔ˘ ÁÚ·Ì̈ÙÔ‡ ÏÔÁfiÙ˘Ô˘ Ù‡Ô˘ "À" ÙÔ˘ Kernahan, fiˆ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ÙËÓ Illinlois Assoc. of Craniofacial Teams ÙˆÓ ∏¶∞.

∞ÓÙÈÌÂÙÒÈÛË O ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ fiÙÈ Ë ÔÏ˘ÏÔÎfiÙËÙ· Î·È ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ·È‰› Ô˘ ¿Û¯ÂÈ ·fi οÔÈ·˜ ÌÔÚÊ‹˜ Û¯ÈÛÙ›· Â›Ó·È ÔÏϤ˜ Î·È ··ÈÙÔ‡Ó Û˘ÓÂÚÁ·Û›· ·fi ÔÌ¿‰· ÂÈÛÙËÌfiÓˆÓ ‰È·ÊfiÚˆÓ ÂȉÈÎÔًوÓ, ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÒÓ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ. ∏ ÔÌ¿‰· ·˘Ù‹ ÛÙÂÁ¿˙ÂÙ·È, ηٿ ηÓfiÓ·, Û` ¤Ó· ÂȉÈÎfi ΤÓÙÚÔ Ô˘ ˘¿ÁÂÙ·È Û οÔÈÔ ¡ÔÛÔÎÔÌÂ›Ô ‹ ¶·ÓÂÈÛÙ‹ÌÈÔ Î·È ·Ú·ÎÔÏÔ˘ı› ÙÔ ·È‰› ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙËÓ ÂÓËÏÈΛˆÛ‹ ÙÔ˘. ∞ÔÙÂÏÂ›Ù·È ‰Â, ηٿ ‰ÈÂıÓ‹ Ú·ÎÙÈ΋, ÂÎÙfi˜ ·fi ÙÔÓ ·È‰›·ÙÚÔ Ô˘ Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ı› οı ·ÚÙÈÌÂϤ˜ Î·È ÌË ·È‰›, ·fi ÔÚıÔ‰ÔÓÙÈÎfi, Ï·ÛÙÈÎfi ¯ÂÈÚÔ˘ÚÁfi, ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏfiÁÔ, ÏÔÁÔ·ıÔÏfiÁÔ, ÁÓ·ıÔ¯ÂÈÚÔ˘ÚÁfi, ÚÔÛıÂÙÔÏfiÁÔ, ·È‰Ô‰ÔÓÙ›·ÙÚÔ, ÎÔÈÓˆÓÈÎfi ÏÂÈÙÔ˘ÚÁfi Î·È ÁÂÓÂÙÈÛÙ‹. OÈ ÂȉÈÎÔ› ÚÔÁÚ·ÌÌ·Ù›˙Ô˘Ó ·fi ÎÔÈÓÔ‡ ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ÙˆÓ ‰È·ÊfiÚˆÓ ÂÂÌ‚¿ÛÂˆÓ Ô˘ ··ÈÙÔ‡ÓÙ·È, ¤ÙÛÈ ÒÛÙÂ Ë ÂÈ̤ÚÔ˘˜ ·ÁˆÁ‹ Ô˘ ı· ÂÊ·ÚÌfiÛÂÈ Ô Î¿ı ÂȉÈÎfi˜ Ó· Á›ÓÂÙ·È ÛÙËÓ Î·Ù¿ÏÏËÏË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Î·È Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰È¢ÎfiÏ˘ÓÛË Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÁˆÁ‹˜ Ô˘ ı· ÂÊ·ÚÌfiÛÔ˘Ó Ù· ¿ÏÏ· ̤ÏË Ù˘ ÔÌ¿‰·˜ (2,20). ŒÓ· ˘fi‰ÂÈÁÌ· ‚·ÛÈÎÔ‡ ¯ÚÔÓԉȷÁÚ¿ÌÌ·ÙÔ˜

∂ÈÎfiÓ· 2. ∞ÎÙÈÓÔÁÚ¿ÊËÌ· status (ÕÓˆ) Î·È ÔÚıÔ·ÓÙÔÌÔÁÚ¿ÊËÌ· (∫¿Ùˆ) ÙˆÓ ÁÓ¿ıˆÓ ·È‰ÈÔ‡ Ì ÂÙÂÚfiÏ¢ÚË ‰ÂÍÈ¿ ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆÈÔÛ¯ÈÛÙ›·. ¢È·ÎÚ›ÓÂÙ·È Û·ÊÒ˜ ÙÔ ÔÛÙÈÎfi ¤ÏÏÂÈÌÌ· Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ¿Óˆ ÁÓ¿ıÔ Î·È Ë Û˘ÁÁÂÓ‹˜ ¤ÏÏÂÈ„Ë ÙÔ˘ ¿Óˆ ‰ÂÍÈÔ‡ Ï·Á›Ô˘ ÙÔ̤·.

ÙˆÓ Î˘ÚÈÔÙ¤ÚˆÓ ÂÂÌ‚¿ÛÂˆÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙË Û˘ÓÔÏÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ·È‰ÈÔ‡ Ô˘ ÂÌÊ·Ó›˙ÂÈ Û¯ÈÛÙ›·, ·Ú·Ù›ıÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞Ó Î·È ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ·˘Ùfi Â›Ó·È ·Ô‰ÂÎÙfi Î·È ÂÊ·ÚÌfi˙ÂÙ·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ÂȉÈο ΤÓÙÚ·, ÌÔÚ› Ó· ¤¯ÂÈ ‰È¿ÊÔÚ˜ ·Ú·ÏÏ·Á¤˜. ∂›Ó·È ¢ÓfiËÙÔ fiÙÈ ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ Ù˘ ·Ó¿Ù˘Í˘ Î·È ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘ ÙÔ˘ οı ·È‰ÈÔ‡ ÌÔÚ› Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙÔ ÔÔÈÔ‰‹ÔÙ ‚·ÛÈÎfi ¯ÚÔÓԉȿÁÚ·ÌÌ·, ¿ÓÙ· ÌÂÙ¿ ·fi Û˘ÓÂÓÓfiËÛË Î·È ÎÔÈÓ‹ ·Ô‰Ô¯‹ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ÂȉÈÎÒÓ Ô˘ ·Ú·ÎÔÏÔ˘ı› ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·È‰›. ∏ ÂÓÂÚÁ‹ Û˘Ì‚ÔÏ‹ ÙÔ˘ οı ̤ÏÔ˘˜ Ù˘ ÔÌ¿‰·˜ ηχÙÂÈ ÔÚÈṲ̂ÓË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ·, Ë ÔÔ›· ÂÓ·ÚÌÔÓ›˙ÂÙ·È Ì ÔÚÈṲ̂Ó˜ Ê¿ÛÂȘ Ù˘ ËÏÈΛ·˜ ÙÔ˘ ·È‰ÈÔ‡, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ∏ Û˘ÓÂÚÁ·ÙÈ΋ ·˘Ù‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈ̤ÚÔ˘˜ ÚÔ‚ÏËÌ¿ÙˆÓ ¤¯ÂÈ È‰È·ÈÙ¤Úˆ˜ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ·ÈÛıËÙÈ΋ Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ (∂ÈÎfiÓ· 3), ·ÏÏ¿ Î·È Û fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ·Ô‰Ô¯‹ Î·È ¤ÓÙ·Í‹ ÙÔ˘˜ ÛÙËÓ ÎÔÈÓˆÓ›· ÙˆÓ Û˘ÓÔÌËÏ›ÎˆÓ ÙÔ˘˜. ∏ ‰˘Ó·ÙfiÙËÙ· ·˘Ù‹ ¤¯ÂÈ, Â›Û˘, Ôχ ÛËÌ·ÓÙÈΤ˜ „˘¯ÔÏÔÁÈΤ˜

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¶›Ó·Î·˜ 1. Àfi‰ÂÈÁÌ· ¯ÚÔÓԉȷÁÚ¿ÌÌ·ÙÔ˜ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ Î·È ÙˆÓ ÔÚıÔ‰ÔÓÙÈÎÒÓ ˘ËÚÂÛÈÒÓ, fiˆ˜ ÂÊ·ÚÌfi˙ÂÙ·È Û ÔÏÏ¿ ·fi Ù· ÔÚÁ·ÓˆÌ¤Ó· ΤÓÙÚ· ∞ÓÙÈÌÂÙÒÈÛ˘ ™¯ÈÛÙÈÒÓ. ∏ÏÈΛ· 0-3 ÌËÓÒÓ Œˆ˜ 2 ÂÙÒÓ 2-4 ÂÙÒÓ 6 ÂÙÒÓ 7-9 ÂÙÒÓ 9-11 ÂÙÒÓ 10-12 ÂÙÒÓ 12-14 ÂÙÒÓ ªÂÙ¿ Ù· 16 ¯ÚfiÓÈ·

ÃÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ñ ™˘Ó¤ÓˆÛË ¯Â›ÏÔ˘˜ ñ ™˘ÚÚ·Ê‹ ¯Â›ÏÔ˘˜ ñ ¢ÈfiÚıˆÛË ˘ÂÚÒ·˜ ñ ¢ÈÔÚıˆÙÈΤ˜ ÂÂÌ‚¿ÛÂȘ

OÚıÔ‰ÔÓÙÈ΋ ÊÚÔÓÙ›‰· ñ ÀÂÚÒÈ· Ͽη ñ ¶·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÏÏ·Á‹ Ͽη˜ ñ ŒÓ·ÚÍË ÔÚıÔ‰ÔÓÙÈ΋˜ ıÂÚ·›·˜ ñ ™˘ÁÎÚ¿ÙËÛË Î·È ·Ú·ÎÔÏÔ‡ıËÛË ñ ¶ÚÔÂÙÔÈÌ·Û›· ·fi ÙÔÓ ÔÚıÔ‰ÔÓÙÈÎfi ÁÈ· Ó· ÙÔÔıÂÙËı› ÙÔ ÔÛÙÈÎfi ÌfiÛ¯Â˘Ì·

ñ OÛÙÈÎfi ÌfiÛ¯Â˘Ì· ñ ™˘ÌÏ‹ÚˆÛË ÔÚıÔ‰ÔÓÙÈ΋˜ ıÂÚ·›·˜ ñ ∞Ó ¯ÚÂÈ¿˙ÂÙ·È, Á›ÓÂÙ·È ÔÚıÔ‰ÔÓÙÈ΋ ÚÔÂÙÔÈÌ·Û›·, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛËÎ·È ÚÔÛıÂÙÈ΋ ·ÔηٿÛÙ·ÛË

ñ ∞ÍÈÔÏfiÁËÛË ÁÈ· ·Ó¿ÁÎË Ù˘¯fiÓ ‰ÈÔÚıˆÙÈÎÒÓ ‹ Î·È ÁÓ·ıÔ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛˆÓ

¶›Ó·Î·˜ 2. ™˘ÓÔÙÈ΋ Û¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ÙˆÓ ˘ËÚÂÛÈÒÓ Ô˘ ÚÔÛʤÚÔ˘Ó ÔÈ ÂÈ̤ÚÔ˘˜ ÂȉÈÎÔ› Ù˘ ÔÌ¿‰·˜, ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ ÙËÓ ÂÓËÏÈΛˆÛË ÂÓfi˜ ·ÙfiÌÔ˘ Ô˘ ÂÌÊ·Ó›˙ÂÈ Û¯ÈÛÙ›·. O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ Â›Ó·È ·˘ÙÔÓÔ‹ÙÔ˜. ∂ȉÈÎÔ› ÂÈÛÙ‹ÌÔÓ˜ Ù˘ ÔÌ¿‰·˜ OÚıÔ‰ÔÓÙÈÎfi˜ ¶Ï·ÛÙÈÎfi˜ ¯ÂÈÚÔ˘ÚÁfi˜ øÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏfiÁÔ˜ ∫ÔÈÓˆÓÈ΋ ÏÂÈÙÔ˘ÚÁfi˜ °ÂÓÂÙÈÛÙ‹˜ §ÔÁÔ·ıÔÏfiÁÔ˜ °Ó·ıÔ¯ÂÈÚÔ˘ÚÁfi˜ ¶ÚÔÛıÂÙÔÏfiÁÔ˜ ¶·È‰Ô‰ÔÓÙ›·ÙÚÔ˜

0-1

1-2

2-4

∏ÏÈΛ· (Û ¯ÚfiÓÈ·) 4-6 6-8 8-12

12-14

14-16

18+

∂ÈÎfiÓ· 3. ∂Ó‰ÔÛÙÔÌ·ÙÈΤ˜ ʈÙÔÁڷʛ˜ ·È‰ÈÔ‡ Ì ·ÌÊ›Ï¢ÚË ¯ÂÈÏÂÔÁÓ·ıÔ¸ÂÚˆ˚ÔÛ¯ÈÛÙ›· ÚÈÓ Î·È ÌÂÙ¿ ÙË Û˘ÓÂÚÁ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·fi ·È‰Ô‰ÔÓÙ›·ÙÚÔ, ÁÓ·ıÔ¯ÂÈÚÔ˘ÚÁfi (ÁÈ· ÙÔÔı¤ÙËÛË ÔÛÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ), ÔÚıÔ‰ÔÓÙÈÎfi Î·È ÚÔÛıÂÙÔÏfiÁÔ.

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ÚÔÂÎÙ¿ÛÂȘ, ÙfiÛÔ ÛÙ· ›‰È· Ù· ·È‰È¿, fiÛÔ Î·È ÛÙÔ˘˜ ÁÔÓ›˜ Î·È ÛÙÔ Û˘ÓÔÏÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÙÔ˘˜ ÂÚÈ‚¿ÏÏÔÓ. ∞ÓÙÈı¤Ùˆ˜, fiÙ·Ó ÙÔ ·È‰› Ô˘ ¿Û¯ÂÈ ·fi Û¯ÈÛÙ›· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ·ÔÛ·ÛÌ·ÙÈο Î·È ÌÂÌÔӈ̤ӷ ·fi οÔÈÔÓ ‹ οÔÈÔ˘˜ ·fi ÙÔ˘˜ ÂȉÈÎÔ‡˜ Ô˘ ··ÈÙ› Ë ÂÚ›ÙˆÛ‹ ÙÔ˘, ¯ˆÚ›˜ ÙÔ Û˘ÓÙÔÓÈÛÌfi Î·È ÙÔ ÌÂÏÂÙË̤ÓÔ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Ô˘ ÈÛ¯‡ÂÈ ÛÙ· ·ÓÙ›ÛÙÔȯ· ΤÓÙÚ·, Ù· ·ÔÙÂϤÛÌ·Ù· ·¤¯Ô˘Ó Ôχ ·fi ÙËÓ ÈηÓÔÔ›ËÛË ÙˆÓ ··Ú·›ÙËÙˆÓ ·ÈÛıËÙÈÎÒÓ Î·È ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÎÚÈÙËÚ›ˆÓ (18).

Paediatriki 2001;64:441-477

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Teratology 1998;58:30-34.

2. µÈ¤ÚÔ˘ ∞ª, ¶··ÁÈ·ÓÓÔ‡ÏË §, ™˘ÚÔÔ‡ÏÔ˘ ª¡. ∏ ·ÓÙÈÌÂÙÒÈÛË Ô˘ ·È‰ÈÔ‡ Ì ۯÈÛÙ›· ·fi ÙË Á¤ÓÓËÛË Ì¤¯ÚÈ Î·È ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÓÂÔÁÈÏÔ‡ ÊÚ·ÁÌÔ‡. O‰ÔÓÙÔÛÙÔÌ·ÙÔÏÔÁÈ΋ ¶ÚfiÔ‰Ô˜ 1989;43:193-202.

3. Brunet CI, Sharpe PM, Ferguson MW. Inhibition of TGF-‚3 (but not TGF-‚1 or TGF-‚2) activity prevents normal mouse embryonic palate fusion. Int J Dev Biol 1995;39:345-355.

4. Dixon MJ, Ferguson MWJ. The effect of EGF, TGF-a and ‚ and PDGF on murine palatal shelves in organ culture.

Arch Oral Biol 1992;37:395-410.

5. Ferguson MWJ. Palate development. Development 1998;103(Suppl):41-60.

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7. Izadnegadhar MF, Rathanaswami P, Shah RM. Effects of EGF and TGF-‚1 on c-myc gene expression and DNA synthesis in enbryonic hamster palate mesenchymal cells.

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9. Johnston MC, Bronsky PT. Prenatal craniofacial development: new insights on normal and abnormal mechanisms. Crit Rev Oral Biol Med 1995;64:368-422.

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12. ¡·Û›Î· ª™. ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁ›· ÙˆÓ Û¯ÈÛÙÈÒÓ. O‰ÔÓÙÔÛÙÔÌ·ÙÔÏÔÁÈ΋ ¶ÚfiÔ‰Ô˜ 1987;41:169-173.

13. ¡·Û›Î· ª™. ∂ȉËÌÔÏÔÁÈ΋ ªÂϤÙË ÙˆÓ ™¯ÈÛÙÈÒÓ ÙÔ˘ Û-

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 26-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫·ıËÁ‹ÙÚÈ· ª.¡. ™˘ÚÔÔ‡ÏÔ˘ ∂ÚÁ·ÛÙ‹ÚÈÔ OÚıÔ‰ÔÓÙÈ΋˜, O‰ÔÓÙÈ·ÙÚÈ΋ ™¯ÔÏ‹ £Ë‚ÒÓ 2, 115 27, °Ô˘‰›, ∞ı‹Ó·

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CURRENT ISSUES

∏ ˘¤ÚÙ·ÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∞. ∑ÂÚ‚Ô˘‰¿ÎË, ∫. ∆ÛÔ˘Ì¿Î·˜

Hypertension in childhood A. Zervoudaki, K. Tsoumakas

¶ÂÚ›ÏË„Ë: ∏ ˘¤ÚÙ·ÛË ·Ú¯›˙ÂÈ ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·, ¯ˆÚ›˜ ·Ú¤Ì‚·ÛË Ù›ÓÂÈ Ó· Û˘Ó¯›˙ÂÙ·È ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Î·È ·ÔÙÂÏ› ÙÔÓ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Ë ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Î·Ï‡ÙÂÚ˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜. ∆Ô ÚÒÙÔ ‚‹Ì· ÛÙË ‰È¿ÁÓˆÛË Â›Ó·È Ë Û˘ÛÙËÌ·ÙÈ΋ ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û οı ·È‰›. ∏ Û˘Ó¯‹˜ ÊÔÚËÙ‹ ηٷÁÚ·Ê‹ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ϤÔÓ Î·È ÛÙ· ·È‰È¿ Î·È Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË ‰È¿ÁÓˆÛË, ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î·È ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ıÂÚ·›·˜. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi Á›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÈÙÈÔÏÔÁ›·, ÙË ‰È¿ÁÓˆÛË, ÙË ıÂÚ·›· Î·È Ù· ̤ÙÚ· ÚfiÏ˄˘.

Abstract: Hypertension starts in childhood and without medical intervention it tends to track into adulthood and constitutes the most significant factor predisposing to cardiovascular disease.

Prompt diagnosis and treatment are instrumental in securing a better quality of life. The first diagnostic step is the systematic measurement of the blood pressure in all children on a yearly basis.

Continuous ambulatory blood pressure monitoring has become very useful for the diagnosis, differential diagnosis, treatment and follow up of hypertension in children. This article reviews the literature regarding etiology, diagnosis, treatment and measures of prevention of hypertension.

§¤ÍÂȘ ÎÏÂȉȿ: ˘¤ÚÙ·ÛË, ·ÚÙËÚȷ΋ ›ÂÛË, ·È‰È΋ ËÏÈΛ·.

Key words: hypertension, blood pressure, children.

∂ÈÛ·ÁˆÁ‹ ∏ ˘¤ÚÙ·ÛË ÌÔÚ› Ó· Û˘Ó·ÓÙ¿Ù·È Û ÔÛÔÛÙfi 1% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÍÂÙ¿˙ÂÈ ¤Ó·˜ ·È‰›·ÙÚÔ˜. Èڛ˜ ·Ú¤Ì‚·ÛË, Ë ˘¤ÚÙ·ÛË Ù›ÓÂÈ Ó· Û˘Ó¯›˙ÂÙ·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (1-5). ¶·È‰È¿ Ì ÂÈ̤ÓÔ˘Û· ·ÚÙËÚȷ΋ ›ÂÛË (∞¶) ÌÂÁ·Ï‡ÙÂÚË Ù˘ 90˘ ∂£, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÈÙÒÛÂȘ ÛÙ· fiÚÁ·Ó· ÛÙfi¯Ô˘˜, fiˆ˜ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ηډȿ˜, ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ·ÏÏ·Á¤˜ ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ηıÒ˜ Î·È ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙ· ÛÙÂÊ·ÓÈ·›·, Ù· ÓÂÊÚÈο Î·È Ù· ·ÁÁ›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ (6,7). ∏ ÔÚ›· Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ Â›Ó·È ÛȈËÚ‹ Î·È ·‰˘ÛÒËÙË, ÌÂ Û˘Ó¤ÂÈ· ·Ú¯fiÌÂÓ˜ ·ÚÙË-

ÚÈÔÛÎÏËÚ˘ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ÔÈ Ôԛ˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯Ó¿ Û ÂÊ‹‚Ô˘˜, ·ÏÏ¿ Î·È Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ (8-10). ∆˘¯·›· ·Ó‡ÚÂÛË ·˘ÍË̤Ó˘ ∞¶ ÌÔÚ› Ó· Â›Ó·È ·fiÚÚÔÈ· ÚˆÙÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘ ‹ Ó· ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂΉ‹ÏˆÛË ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘, fiˆ˜ Ë ·ÚÂÁ¯˘Ì·ÙÈ΋ ‹ Ë ·ÁÁÂȷ΋ ÓÂÊÚÈ΋ ‚Ï¿‚Ë, Ë Î·Ú‰ÈÔ¿ıÂÈ· Î·È Ë ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·.

¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫∞∆ ∞ÙÙÈ΋˜

448

OÚÈÛÌfi˜ Î·È ÁÂÓÈÎfiÙËÙ˜ º˘ÛÈÔÏÔÁÈ΋ ∞¶ Û ‚Ú¤ÊË, ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ÔÚ›˙ÂÙ·È Ë Û˘ÛÙÔÏÈ΋ ‹ Ë ‰È·ÛÙÔÏÈ΋ ›ÂÛË Ô˘ ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi ÙËÓ 90Ë ∂£ ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ ‡„Ô˜ Î·È ÙÔ Ê‡ÏÔ. À„ËÏ‹ “Ê˘ÛÈÔÏÔÁÈ΋” ∞¶ Pediatric Division Peripheral General Hospital KAT of Attiki, Athens

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

¯·Ú·ÎÙËÚ›˙ÂÙ·È Ë Û˘ÛÙÔÏÈ΋ ‹ Ë ‰È·ÛÙÔÏÈ΋ ›ÂÛË ÌÂٷ͇ Ù˘ 90˘-95˘ ∂£. À¤ÚÙ·ÛË ÔÚ›˙ÂÙ·È Ë Û˘ÛÙÔÏÈ΋ ‹ Ë ‰È·ÛÙÔÏÈ΋ ∞¶, fiÙ·Ó ‚Ú›ÛÎÂÙ·È ÌÂٷ͇ 95˘-99˘ ∂£ Î·È ¤¯ÂÈ ÂȂ‚·Èˆı› Û 3 ‹ ÂÚÈÛÛfiÙÂÚ˜ ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Û ‰È·ÊÔÚÂÙÈο ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ∆¤ÏÔ˜, ÛÔ‚·Ú‹ ˘¤ÚÙ·ÛË ‰È·ÈÛÙÒÓÂÙ·È, fiÙ·Ó Ë Û˘ÛÙÔÏÈ΋ ‹ Î·È Ë ‰È·ÛÙÔÏÈ΋ ∞¶ Â›Ó·È ›ÛË ‹ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ 99Ë ∂£ (11-13).

O ÔÚÈÛÌfi˜ Ù˘ ˘¤ÚÙ·Û˘ ‚·Û›˙ÂÙ·È Û ÂȉËÌÈÔÏÔÁÈο Î·È ÛÙ·ÙÈÛÙÈο ‰Â‰Ô̤ӷ ·fi ÂÚÈÛÙ·ÛȷΤ˜ ÌÂÙÚ‹ÛÂȘ Î·È ‰ÂÓ Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ ÔÈ Ù˘¯fiÓ ÂÈÙÒÛÂȘ Ù˘ ˘¤ÚÙ·Û˘ Û fiÚÁ·Ó· ÛÙfi¯Ô˘˜, fiˆ˜ Á›ÓÂÙ·È ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ (7). °È· ÙÔÓ ·ÎÚÈ‚‹, ÏÔÈfiÓ, ηıÔÚÈÛÌfi ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Ù˘ ∞¶ ÛÙ· ·È‰È¿ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜, ÒÛÙ ӷ Á›ÓÂÈ ÁÓˆÛÙfi Û ÔÈ· Â›‰· ∞¶ ˘¿Ú¯Ô˘Ó ÂÈÙÒÛÂȘ ÛÙ· fiÚÁ·Ó· ÛÙfi¯Ô˘˜. O ‚·ıÌfi˜ Ù˘ ‚ÈÔÏÔÁÈ΋˜ ˆÚÈÌfiÙËÙ·˜ ÂÓfi˜ ·È‰ÈÔ‡ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜, ‰ÈfiÙÈ Ë ∞¶ ·˘Í¿ÓÂÙ·È fiÛÔ ÌÂÁ·ÏÒÓÂÈ ÙÔ ·È‰› (14). ∏ ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ· ‰ÂÓ Â›Ó·È Î·ıÔÚÈÛÙÈ΋. ∆Ô ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡, fï˜, Ú¤ÂÈ ¿ÓÙ· Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ, ‰ÈfiÙÈ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‚ÈÔÏÔÁÈ΋ ˆÚÈÌfiÙËÙ· ·ÏÏ¿ Î·È Ì ÙËÓ ∞¶, ·ÓÂÍ¿ÚÙËÙ· Ù˘ ¯ÚÔÓÔÏÔÁÈ΋˜ ËÏÈΛ·˜ (12). ŒÙÛÈ, ¤Ó· ·È‰› Ì ∞¶ ÌÂٷ͇ 90˘ Î·È 95˘ ∂£ ÙÔ˘ ÔÔ›Ô˘ ÙÔ ‡„Ô˜ Â›Ó·È ¿Óˆ ·fi ÙËÓ 90Ë ∂£, ÌÔÚ› Ó· ÌËÓ ¤¯ÂÈ ˘¤ÚÙ·ÛË, ·Ó Ë ∞¶ ·Ó·¯ı› ÛÙÔ ‡„Ô˜ ÙÔ˘. ∂Ô̤ӈ˜, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙÔ ‡„Ô˜, ˘„ËÏ¿ ·È‰È¿ ‰ÂÓ ı· ¯·Ú·ÎÙËÚÈÛÙÔ‡Ó ˆ˜ ˘ÂÚÙ·ÛÈο - Ì fiÛ· ·˘Ùfi Û˘ÓÂ¿ÁÂÙ·È - Î·È Ù·˘Ùfi¯ÚÔÓ· ‰ÂÓ ı· ‰È·Ê‡ÁÔ˘Ó Ù˘ ‰È¿ÁÓˆÛ˘ ˘ÂÚÙ·ÛÈο ·È‰È¿ ¯·ÌËÏÔ‡ ‡„Ô˘˜ (3,14). OÈ ÙÈ̤˜ Ù˘ ∞¶ ÁÈ· ÙËÓ 90Ë Î·È 95Ë ∂£ Û ·È‰È¿ Ù˘ ›‰È·˜ ËÏÈΛ·˜ Î·È ÙÔ˘ ›‰ÈÔ˘ ʇÏÔ˘, ·ÏÏ¿ ‰È·ÊÔÚÂÙÈÎÔ‡ ‡„Ô˘˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Ô˘ Î˘Ì·›ÓÔÓÙ·È ÛÙ· ·ÁfiÚÈ· ·fi 8-9 mmHg ÁÈ· ÙË Û˘ÛÙÔÏÈ΋ Î·È 4-5 mmHg ÁÈ· ÙË ‰È·ÛÙÔÏÈ΋ Î·È ·fi 6-7 mmHg Î·È 3-4 mmHg ÛÙ· ÎÔÚ›ÙÛÈ·, ÁÈ· ÙË Û˘ÛÙÔÏÈ΋ Î·È ÙË ‰È·ÛÙÔÏÈ΋ ·ÓÙ›ÛÙÔȯ·. ∆Ô ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡, ·Ú’ fiÏÔ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙËÓ ˘¤ÚÙ·ÛË, ‰ÂÓ ·ÔÙÂÏ› ηٿÏÏËÏÔ ‰Â›ÎÙË, ‰ÈfiÙÈ ·ÊÂÓfi˜ ‰ÂÓ ·ÓÙ·Ó·ÎÏ¿ ÙË ‚ÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ·ÊÂÙ¤ÚÔ˘ Ë ∞¶ ÂËÚ¿˙ÂÙ·È ·fi ÙÔÓ ˘¿Ú¯ÔÓÙ· ‚·ıÌfi ·¯˘Û·ÚΛ·˜. ∆¤ÏÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ·ÓÒÙ·ÙÔ fiÚÈÔ Ù˘ ‰È·ÛÙÔÏÈ΋˜ ›ÂÛ˘ Û ˘„ËÏÔ‡˜ 17¯ÚÔÓÔ˘˜ ÂÊ‹‚Ô˘˜, ı· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ‰ÈÂıÓÒ˜ ·Ô‰ÂÎÙ‹ ÙÈÌ‹ ÙˆÓ 90 mmHg ı· Ú¤ÂÈ Ó· ÈÛ¯‡ÂÈ Î·È Û ·˘ÙÔ‡˜. TÈ̤˜ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ∞¶ ÁÈ· ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ Î·È ÙÔ ‡„Ô˜, Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2.

Paediatriki 2001;64:448-459

¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ∞¶ º˘ÛÈÔÏÔÁÈΤ˜ ‰È·Î˘Ì¿ÓÛÂȘ Ù˘ ∞¶ ·Ú·ÙËÚÔ‡ÓÙ·È Û οı ¿ÙÔÌÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ËÌÂÚÔÓ˘ÎÙ›Ô˘ (3,4,15). ¢‡Ô ÔÌ¿‰Â˜ ·Ú·ÁfiÓÙˆÓ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ∞¶, ÔÈ ÂÚÈÛÙ·ÛÈ·ÎÔ› Î·È ÔÈ ÂÁÁÂÓ›˜. ∞) ™ÙÔ˘˜ ÂÚÈÛÙ·ÛÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡, Ë ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, Ë ı¤ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜, ÙÔ ¿ÎÚÔ ÛÙÔ ÔÔ›Ô Á›ÓÂÙ·È Ë Ì¤ÙÚËÛË, ÙÔ Â›‰Ô˜ Ù˘ Û˘Û΢‹˜ ̤ÙÚËÛ˘ (˘‰Ú·ÚÁ˘ÚÈÎfi Ì·ÓfiÌÂÙÚÔ, Doppler Î.¿.), ÙÔ ¿Á¯Ô˜ Î·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ·. OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎÔ› ÛÙËÓ ÂÚÈÛÙ·Ûȷ΋ ̤ÙÚËÛË Ù˘ ∞¶, ÂÓÒ ‰ÂÓ ·›˙Ô˘Ó ÙfiÛÔ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ fiÙ·Ó Á›ÓÂÙ·È 24ˆÚË Î·Ù·Ì¤ÙÚËÛË. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› Î·È Ë “˘¤ÚÙ·ÛË Ù˘ Ï¢΋˜ ԉȿ˜”, ‰ËÏ·‰‹ Ë Â˘·ÈÛıËÛ›· ÙˆÓ ·È‰ÈÒÓ Î·È È‰È·›ÙÂÚ· ÙˆÓ ÂÊ‹‚ˆÓ, Ô˘ Ù›ÓÔ˘Ó Ó· ·Ó‚¿˙Ô˘Ó ÙËÓ ›ÂÛ‹ ÙÔ˘˜ ÏfiÁˆ ¿Á¯Ô˘˜, fiÙ·Ó ÂÍÂÙ¿˙ÔÓÙ·È ·fi ÙÔÓ ·È‰›·ÙÚÔ. ¶ÔÛÔÛÙfi 44% ÙˆÓ ·È‰ÈÒÓ Ì ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘ Î·È 18% ÙˆÓ ·È‰ÈÒÓ Ì ·ÚÓËÙÈÎfi, ÂÌÊ·Ó›˙ÂÈ “˘¤ÚÙ·ÛË Ù˘ Ï¢΋˜ ԉȿ˜” (4,7,11). µ) ™ÙÔ˘˜ ÂÁÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, Ë ËÏÈΛ· ΢‹Ûˆ˜, Ë ·ÚÙËÚȷ΋ ›ÂÛË Ù˘ ÌËÙ¤Ú·˜ (Ô˘ Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈο ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·), ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜, Ë ÛˆÌ·ÙÈ΋ Ì¿˙·, ÙÔ Ê‡ÏÔ, ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, ÙÔ ·Ó ·ıÏÂ›Ù·È ‹ fi¯È ÙÔ ·È‰›, Ë ‚ÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË Û ۯ¤ÛË Ì ÙËÓ ËÏÈΛ· Î·È Ë ÂÚÈÂÎÙÈÎfiÙËÙ· Ù˘ ‰È·ÙÚÔÊ‹˜ Û ӿÙÚÈÔ, οÏÈÔ Î·È ·Û‚¤ÛÙÈÔ (4,6,11,16-18). ª¤ÙÚËÛË Ù˘ ∞¶ ∏ ̤ÙÚËÛË Ì ˘‰Ú·ÚÁ˘ÚÈÎfi Ì·ÓfiÌÂÙÚÔ Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ÂÈÏÔÁ‹˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, ÂÓÒ Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ÙÔ Doppler Â›Ó·È Î·Ù·ÏÏËÏfiÙÂÚÔ (3,13). OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó Ó· Á›ÓÂÙ·È Ë Ì¤ÙÚËÛË ÌÂÙ¿ ·fi 3-5 min ·Ó¿·˘Û˘. OÈ Û˘Óı‹Î˜ ̤ÙÚËÛ˘ Ú¤ÂÈ Ó· Â›Ó·È ÛÙ·ıÂÚ¤˜. ™˘ÓÈÛÙ¿Ù·È ÙÔ ·È‰› Ó· Â›Ó·È Î·ıÈÛÙfi Î·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ ‰ÂÍ› ¿Óˆ ¿ÎÚÔ. ∏ ̤ÙÚËÛË Ú¤ÂÈ Ó· Â·Ó·Ï·Ì‚¿ÓÂÙ·È fiÛ˜ ÊÔÚ¤˜ ¯ÚÂÈ¿˙ÂÙ·È, ̤¯ÚÈ Ó· ËÚÂÌ‹ÛÂÈ ÙÔ ·È‰›. ÕÏÏÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÓÈÛÙÔ‡Ó Ó· ÂȉÈÒÎÂÙ·È ÚÒÙÈÛÙ· Ë ËÚÂÌ›· ÙÔ˘ ·È‰ÈÔ‡ Î·È ·Ó Ô ÁÈ·ÙÚfi˜ ÎÚ›ÓÂÈ fiÙÈ Û ‡ÙÈ· ı¤ÛË ·˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Î·Ï‡ÙÂÚ·, ÙfiÙ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Ë ı¤ÛË ·˘Ù‹, ·ÚΛ Ó· Á›ÓÔÓÙ·È Î·Ù¿ ÙÔÓ ›‰ÈÔ ÙÚfiÔ Î·È ÔÈ ÂfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ, ÁÈ· Û˘ÁÎÚÈÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ∂ÈϤÁÂÙ·È Ë ÌÂÁ·Ï‡ÙÂÚË Û ̋ÎÔ˜ ÂÚȯÂÈÚ›‰· Ô˘ ÂÚÈ‚¿ÏÏÂÈ

449

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

Paediatriki 2001;64:448-459

¶›Ó·Î·˜ 1. ∂›‰· ∞¶ ÁÈ· ÙËÓ 90Ë Î·È 95Ë ∂£ ÛÙ· ·ÁfiÚÈ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ ÙÔ˘˜ ™˘ÛÙÔÏÈ΋ ∞¶ (mmHg) ∞Ó¿ÏÔÁ· Ì ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ ∏ÏÈΛ· (¤ÙË) ∂£ 1 90Ë 95Ë 2 90Ë 95Ë 3 90Ë 95Ë 4 90Ë 95Ë 5 90Ë 95Ë 6 90Ë 95Ë 7 90Ë 95Ë 8 90Ë 95Ë 9 90Ë 95Ë 10 90Ë 95Ë 11 90Ë 95Ë 12 90Ë 95Ë 13 90Ë 95Ë 14 90Ë 95Ë 15 90Ë 95Ë 16 90Ë 95Ë 17 90Ë 95Ë

5% 94 98 98 102 101 105 103 107 104 108 105 109 106 110 108 112 109 113 111 115 113 117 115 119 118 121 120 124 123 127 126 130 128 132

10% 95 99 99 103 102 106 104 108 105 109 106 110 107 111 109 113 110 114 112 116 114 118 116 120 119 122 121 125 124 128 127 131 129 133

25% 97 101 101 105 103 107 105 109 107 111 108 112 109 113 110 114 112 116 113 117 115 119 118 122 120 124 123 127 126 130 129 133 131 135

50% 75% 90% 99 101 102 103 105 106 103 104 106 107 108 110 105 107 109 109 111 112 107 109 110 111 113 114 109 111 112 113 114 116 110 112 113 114 116 117 111 113 114 115 117 118 112 114 116 116 118 119 114 116 117 118 119 121 115 117 119 119 121 123 117 119 121 121 123 125 120 121 123 124 125 127 122 124 125 126 128 129 125 127 128 129 131 132 128 130 131 132 133 135 131 132 134 134 136 138 133 135 136 137 139 140

¢È·ÛÙÔÏÈ΋ ∞¶ (mmHg) AÓ¿ÏÔÁ· Ì ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ 95% 103 107 107 110 109 113 111 115 113 117 114 118 115 119 116 120 118 122 119 123 121 125 124 128 126 130 129 133 132 136 134 138 137 141

5% 49 54 54 58 59 63 63 67 66 71 70 74 72 77 74 79 76 80 77 81 77 82 78 83 78 83 79 83 80 84 81 86 83 88

10% 25% 50% 75% 90% 95% 49 50 51 52 53 54 54 55 56 57 58 58 54 55 56 57 58 58 59 60 61 62 63 63 59 60 61 62 63 63 63 64 65 66 67 68 63 64 65 66 67 67 68 68 69 70 71 72 67 68 69 69 70 71 71 72 73 74 75 76 70 71 72 73 74 74 75 75 76 77 78 79 73 73 74 75 76 77 77 78 79 80 81 81 75 75 76 77 78 79 79 80 81 82 83 83 76 77 78 79 80 80 81 81 82 83 84 85 77 78 79 80 81 81 82 83 83 84 85 86 78 79 80 81 81 82 82 83 84 85 86 87 78 79 80 81 82 83 83 84 85 86 87 87 79 80 81 81 82 83 83 84 85 86 87 88 79 80 86 87 87 88 84 85 82 83 83 15 80 81 82 83 84 84 85 86 86 87 88 89 82 82 83 84 85 86 86 87 86 89 90 90 84 85 86 87 87 88 88 89 90 91 92 93

Pediatrics 1996;98(4):649

ÙÔ ‚Ú·¯›ÔÓ· ¯ˆÚ›˜ Ó· Ȥ˙ÂÈ ÙË Ì·Û¯¿ÏË ‹ ÙÔÓ ·ÁΈÓÈ·›Ô ‚fiıÚÔ Î·È Ù˘ ÔÔ›·˜ Ë Î‡ÛÙË Î·Ï‡ÙÂÈ Û Ï¿ÙÔ˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ù· 2/3 ÙÔ˘ ‚Ú·¯›ÔÓ· Î·È ÙÔÓ ÂÚÈ‚¿ÏÏÂÈ Ï‹Úˆ˜. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ·ÛÙ˘ Ù˘ ÂÚȯÂÈÚ›‰·˜ Â›Ó·È ÙÔ ÛËÌ·ÓÙÈÎfi Î·È fi¯È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ˘Ê¿ÛÌ·ÙÔ˜ Ô˘ ÙËÓ Î·Ï‡ÙÂÈ. ∆Ô ‚ÔıÚ›Ô Ù˘ ηÌ‹˜ ÙÔ˘ ·ÁÎÒÓ· Ú¤ÂÈ Ó· Â›Ó·È ÛÙÔ ›‰ÈÔ ‡„Ô˜ Ì ÙËÓ Î·Ú‰È¿. ¶Ôχ ÌÂÁ¿ÏË ÂÚȯÂÈÚ›‰· ‰›ÓÂÈ „¢‰Ò˜ ¯·ÌËϤ˜ ÙÈ̤˜, ÂÓÒ Ë ÌÈÎÚfiÙÂÚË ‰›ÓÂÈ „¢‰Ò˜ ˘„ËϤ˜ ÙÈ̤˜. ∞Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÙÔ Î·Ù¿ÏÏËÏÔ Ì¤ÁÂıÔ˜, Â›Ó·È ÚÔ-

450

ÙÈÌfiÙÂÚÔ Ó· ¯ÚËÛÈÌÔÔÈËı› ÌÂÁ·Ï‡ÙÂÚË ·Ú¿ ÌÈÎÚfiÙÂÚË ÂÚȯÂÈÚ›‰· (5,12). O ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ¤¯ÂÈ ÛÙÔ È·ÙÚÂ›Ô ÙÔ˘ ÙÚÂȘ ·È‰È·ÙÚÈΤ˜ ÂÚȯÂÈÚ›‰Â˜ ‰È·ÊfiÚˆÓ ÌÂÁÂıÒÓ, Ì›· ÌÂÁ¤ıÔ˘˜ ÂÓËÏ›ÎÔ˘ Î·È Ù¤ÏÔ˜ Ì›· ˘ÂÚÌÂÁ¤ıË, ÁÈ· ÌÂÙÚ‹ÛÂȘ ÛÙ· οو ¿ÎÚ· Î·È Û ·¯‡Û·Úη ·È‰È¿ (3). ∏ ÂÚȯÂÈÚ›‰· Ú¤ÂÈ Ó· ÊÔ˘ÛÎÒÓÂÈ ÂÚ›Ô˘ 20-30 mmHg ¿Óˆ ·fi ÙÔ ÛËÌÂ›Ô ÛÙÔ ÔÔ›Ô ÛÙ·Ì·Ù¿ÂÈ Ó· „ËÏ·Ê¿Ù·È Ô ÛÊ˘ÁÌfi˜ ·fi ÙËÓ ÎÂÚÎȉÈ΋ ·ÚÙËÚ›·. O ÚÒÙÔ˜ ‹¯Ô˜ Korotkoff ηıÔÚ›˙ÂÈ ÙË Û˘ÛÙÔÏÈ΋ ›ÂÛË, ÂÓÒ Ô ¤ÌÙÔ˜ ‹¯Ô˜ Korotkoff (Ô

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

Paediatriki 2001;64:448-459

¶›Ó·Î·˜ 2. ∂›‰· ∞¶ ÁÈ· ÙËÓ 90Ë Î·È 95Ë ∂£ ÛÙ· ÎÔÚ›ÙÛÈ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ ÙÔ˘˜ ™˘ÛÙÔÏÈ΋ ∞¶ (mmHg) ∞Ó¿ÏÔÁ· Ì ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ ∏ÏÈΛ· (¤ÙË) ∂£ 1 90Ë 95Ë 2 90Ë 95Ë 3 90Ë 95Ë 4 90Ë 95Ë 5 90Ë 95Ë 6 90Ë 95Ë 7 90Ë 95Ë 8 90Ë 95Ë 9 90Ë 95Ë 10 90Ë 95Ë 11 90Ë 95Ë 12 90Ë 95Ë 13 90Ë 95Ë 14 90Ë 95Ë 15 90Ë 95Ë 16 90Ë 95Ë 17 90Ë 95Ë

5% 98 101 99 103 100 104 101 105 103 107 104 108 106 110 108 112 110 114 112 116 114 118 116 120 118 122 120 124 121 125 122 126 123 127

10% 98 102 99 103 101 104 102 106 103 107 105 109 107 111 109 113 111 115 113 117 115 119 117 121 119 123 121 125 122 126 123 127 123 127

25% 99 103 101 104 102 106 103 107 105 108 106 110 108 112 110 114 112 116 114 118 116 120 118 122 120 124 122 126 123 127 124 128 124 128

50% 101 104 102 106 103 107 104 108 106 110 107 111 109 113 111 115 113 117 115 119 117 121 119 123 121 125 123 127 124 128 125 129 126 130

75% 102 106 103 107 104 108 106 109 107 111 109 113 110 114 112 116 114 118 116 120 119 122 121 125 123 126 124 128 126 130 127 130 127 131

90% 103 107 104 108 105 109 107 111 108 112 110 114 112 115 114 117 116 119 118 122 120 124 122 126 124 128 125 129 127 131 128 132 128 132

¢È·ÛÙÔÏÈ΋ ∞¶ (mmHg) AÓ¿ÏÔÁ· Ì ÙËÓ ∂£ ÙÔ˘ ‡„Ô˘˜ 95% 104 108 105 109 106 110 108 111 109 113 111 114 112 116 114 118 116 120 118 122 120 124 123 126 124 128 126 130 128 131 129 132 129 133

5% 52 56 57 61 61 65 64 68 66 71 69 73 71 75 72 76 74 78 75 79 76 81 78 82 79 83 80 84 80 85 81 85 81 85

10% 25% 50% 75% 90% 95% 52 53 53 54 55 55 56 57 58 58 59 60 57 58 58 59 60 60 61 62 62 63 64 64 61 61 62 63 64 66 65 66 66 67 68 68 64 65 65 66 67 67 68 69 69 70 71 71 67 67 68 69 69 70 71 71 72 73 74 74 69 69 70 71 72 72 73 74 74 75 76 76 71 71 72 73 74 74 75 75 76 77 78 78 72 73 74 74 75 76 77 77 78 79 79 80 74 74 75 76 77 77 78 79 79 80 81 81 75 76 77 77 78 78 79 80 81 81 82 83 77 77 78 79 79 80 81 81 82 83 83 84 78 78 79 80 81 81 82 82 83 84 85 85 79 79 80 81 82 82 83 84 84 85 86 86 80 80 81 82 83 83 84 85 85 86 87 87 81 81 82 83 83 84 85 85 86 87 88 88 81 82 82 83 84 84 85 86 87 87 88 88 81 82 83 83 84 85 86 86 87 88 88 89

Pediatrics 1996;98(4):649

ÙÂÏÂ˘Ù·›Ô˜ Ô˘ ·ÎÔ‡ÁÂÙ·È) ηıÔÚ›˙ÂÈ ÙË ‰È·ÛÙÔÏÈ΋ ›ÂÛË, Û‡Ìʈӷ Ì ÙË Û‡ÛÙ·ÛË Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∫·Ú‰ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜. ™Â ÌÂÚÈο ·È‰È¿, ‹¯ÔÈ Korotkoff ÌÔÚ› Ó· ·ÎÔ‡ÁÔÓÙ·È Ê˘ÛÈÔÏÔÁÈο Î·È Ì¤¯ÚÈ ÙÔ 0 mmHg. ∞˘Ùfi ‰ÂÓ ·ÔÙÂÏ› Úfi‚ÏËÌ·, ÂÊfiÛÔÓ ·ÔÎÏ›ÂÙ·È Ë ‰È·ÛÙÔÏÈ΋ ˘¤ÚÙ·ÛË. ∆ËÓ ÚÒÙË ÊÔÚ¿ Ô˘ ı· ÂϤÁ¯ÂÙ·È Ë ∞¶ ÂÓfi˜ ·È‰ÈÔ‡, Ë Ì¤ÙÚËÛË ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Î·È ÛÙ· Ù¤ÛÛÂÚ· ¿ÎÚ· ÁÈ· Ó· ‰È·ÈÛÙˆı› Ù˘¯fiÓ ˘¿Ú¯Ô˘Û· ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜. ™Â οı ÂfiÌÂÓË ÎÏÈÓÈ΋ ÂͤٷÛË, Ë A¶ Ú¤ÂÈ Ó· ÌÂÙÚ¿Ù·È ÙÔ˘Ï¿¯È-

ÛÙÔÓ ‰‡Ô ÊÔÚ¤˜. O ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ Û˘ÛÙÔÏÈÎÒÓ Î·È ÙˆÓ ‰È·ÛÙÔÏÈÎÒÓ ÙÈÌÒÓ Ô˘ ı· ‚Ú›ÛÎÔÓÙ·È, ı· ·ÔÙÂÏ› ÙËÓ ÙÂÏÈ΋ ›ÂÛË (11,15). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë Û˘Ó¯‹˜ ÊÔÚËÙ‹ ηٷÁÚ·Ê‹ Ù˘ ∞¶ ÂÊ·ÚÌfi˙ÂÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ÛÙ· ·È‰È¿ Î·È ˘¿Ú¯Ô˘Ó ϤÔÓ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ·Ó·ÊÔÚ¿˜. ∂›Ó·È ȉȷ›ÙÂÚ· ¯Ú‹ÛÈÌË ÛÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ ˘¤ÚÙ·Û˘, ηıÒ˜ Î·È ÛÙËÓ ·ÔÊ˘Á‹ ˘ÂډȿÁÓˆÛ˘, ÂȉÈο ‰Â ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ “˘¤ÚÙ·Û˘ Ù˘ Ï¢΋˜ ԉȿ˜”. µÔËı¿ÂÈ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ıÂÚ·›·˜ ηÈ

451

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

ȉȷ›ÙÂÚ· Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈο ÚÔ‚Ï‹Ì·Ù· ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ¤¯ÂÈ Î·Ï‡ÙÂÚË ÚÔÁÓˆÛÙÈ΋ ·Í›·, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Úfi‚ÏÂ„Ë ‚Ï¿‚˘ ÛÙ· fiÚÁ·Ó· ÛÙfi¯Ô˘˜ (4,6,7,15,19,20). Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ë Ì¤ÙÚËÛË Ù˘ ∞¶ ÛÙ· ÓÂÔÁÓ¿ Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· Á›ÓÂÙ·È Ì Doppler. ∏ Ê˘ÛÈÔÏÔÁÈ΋ ∞¶ ÂÓfi˜ ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡ Â›Ó·È Û˘Ó‹ıˆ˜ 60-70 Ë Û˘ÛÙÔÏÈ΋ Î·È 40-50 Ë ‰È·ÛÙÔÏÈ΋ (4,12). ∂Ó‰ÂÈÎÙÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ Û˘ÛÙÔÏÈ΋ ∞¶ ÛÙ·ıÂÚ¿ ¿Óˆ ÙÔ˘ 90/60 ÛÙ· ÙÂÏÂÈfiÌËÓ· Î·È 80/50 ÛÙ· ÚfiˆÚ· ıˆÚÂ›Ù·È ·ıÔÏÔÁÈ΋ (21). ∆ÔÓ›˙ÂÙ·È ‰Â fiÙÈ Ë Û˘ÛÙÔÏÈ΋ ›ÂÛË Â›Ó·È ·˘Ù‹ Ô˘ ηıÔÚ›˙ÂÈ ÙËÓ ‡·ÚÍË ˘¤ÚÙ·Û˘ Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙÔ˘ ¤ÙÔ˘˜ (18). ∂ȉËÌÈÔÏÔÁ›· ∏ Û˘¯ÓfiÙËÙ· Ù˘ ˘¤ÚÙ·Û˘ ÛÙ· ·È‰È¿ ˘ÔÏÔÁ›˙ÂÙ·È Û 1% Î·È Ë Û˘¯ÓfiÙËÙ· Ù˘ ÂÈ̤ÓÔ˘Û·˜ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘ Û 0,1% (3,4,11,15). ¶·Ú’ fiÏÔ Ô˘ Ë ˘¤ÚÙ·ÛË Â›Ó·È ·Û˘Ó‹ı˘ ÛÙ· ÓÂÔÁÓ¿, ÔÚÈṲ̂ӷ ‰È·ÙÚ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ, fiˆ˜ .¯. Ù· ÚfiˆÚ·. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ 0,2% ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ Î·È 0,79-2,5% ÙˆÓ ÚÔÒÚˆÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ˘¤ÚÙ·ÛË (21). ™ËÌ·ÓÙÈÎfi ‡ÚËÌ· ÚfiÛÊ·ÙˆÓ ÌÂÏÂÙÒÓ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ˘¤ÚÙ·ÛË Ù›ÓÂÈ Ó· ‰È·ÙËÚÂ›Ù·È ÂÊ’ fiÚÔ˘ ˙ˆ‹˜. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· Ù· Â›‰· ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÏÈÔÚˆÙÂ˚ÓÒÓ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ (1). ∆· ‰Â‰Ô̤ӷ Ù˘ ‰È·¯ÚÔÓÈ΋˜ ‰È·Ù‹ÚËÛ˘ Û˘Û¯ÂÙ›˙Ô˘Ó Ù· ·È‰Èο Î·È ÂÊË‚Èο Â›‰· ∞¶ Ì ÙËÓ ˘¤ÚÙ·ÛË ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ·ÏÏ¿ ‰˘ÛÙ˘¯Ò˜ ·Ú¿ ÙÔ Û˘Û¯ÂÙÈÛÌfi, ‰ÂÓ ÌÔÚ› Ó· ÚÔ‚ÏÂÊı› ÔÈ· ·fi Ù· ·È‰È¿ Ì ˘„ËÏ‹ ∞¶ ı· Á›ÓÔ˘Ó ˘ÂÚÙ·ÛÈÎÔ› ÂÓ‹ÏÈΘ (4). ™Â ·ÓÙȉȷÛÙÔÏ‹ Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ ∞¶ ‰È·ÊÔÚ¤˜ ÛÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ‹ Ì¿ÏÏÔÓ ÔÈ ÂȉڿÛÂȘ ÙÔ˘˜ ‰ÂÓ ¤¯Ô˘Ó Á›ÓÂÈ ·ÎfiÌË ·ÓÙÈÏËÙ¤˜. ¶ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ Î·È ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ stress Î·È Ë ÚfiÛÏË„Ë ˘„ËÏÒÓ ÔÛÔÙ‹ÙˆÓ ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ Ì ÙȘ ÙÚÔʤ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ∞¶ ÛÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹, ÙfiÛÔ Û ÂÈÚ·Ì·Ùfi˙ˆ· fiÛÔ Î·È ÛÙÔÓ ·ÓıÚÒÈÓÔ ÏËı˘ÛÌfi (22). ∞ӷʤÚÂÙ·È fiÙÈ ÛÙ· ·È‰È¿ ÙÔ˘ ‰˘ÙÈÎÔ‡ ÎfiÛÌÔ˘, Ë ÚfiÛÏË„Ë ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ Ì ÙȘ ÙÚÔʤ˜ Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ·fi ÙȘ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ ·Ó¿ÁΘ. ™Ù· ·È‰È¿, ÏÔÈfiÓ, ·˘Ù¿ Î·È ÂÊfiÛÔÓ ¤¯Ô˘Ó ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, Ë ·˘ÍË̤ÓË ÚfiÛÏË„Ë ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ ·˘Í¿ÓÂÈ ÙËÓ ∞¶ (23). À¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË ·Ú¯›˙ÂÈ ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·, ÙÔ ›‰ÈÔ Î·È Ù· ÚÒÙ· ÛËÌ›· Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÙˆÓ ÂÓËÏ›ÎˆÓ Î·È Ì¿ÏÈÛÙ· ·ÚÎÂÙ¤˜ ‰ÂηÂٛ˜ ÚÈÓ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘Ìو̿وÓ.

452

Paediatriki 2001;64:448-459

πÛ¯˘Úfiٷ٘ ÂӉ›ÍÂȘ ·fi ÓÂÎÚÔÙÔÌÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ·Ú¯›˙ÂÈ Û Ôχ ÌÈÎÚ‹ ËÏÈΛ· Î·È Û˘Ó‰¤ÂÙ·È ÛÙÂÓ¿ Ì ÙËÓ ·˘ÍË̤ÓË ·ÚÙËÚȷ΋ ›ÂÛË, Û˘ÛÙÔÏÈ΋ ‹ ‰È·ÛÙÔÏÈ΋ Î·È ÙËÓ ·¯˘Û·ÚΛ·, Â›Ó·È ‰Â ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ (9). ªÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ, ‹‰Ë ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 15 ÂÙÒÓ, ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ ·ÚÙËÚÈÔÛÎÏËÚ˘ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜ Î·È ÙÔ 100% ÛÙËÓ ·ÔÚÙ‹ (9). ∂›Ó·È ‰Â ÁÓˆÛÙfi fiÙÈ Ë ˘¤ÚÙ·ÛË Ì·˙› Ì ¿ÏÏÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ·¯˘Û·ÚΛ·, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, ÙÔ Î¿ÓÈÛÌ· Î·È ÔÈ ÏÈÔÚˆÙ½Ó˜ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜, Û˘Ó‰¤ÔÓÙ·È ¿ÌÂÛ·, Û·Ó ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, Ì ÙË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ÂÓÒ ÔÈ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½Ó˜ ÚÔÛٷهԢÓ. ™Â ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ¤¯ÂÈ Î·Ù·‰Âȯı› fiÙÈ Ë ·¯˘Û·ÚΛ·, Ë ‰˘ÛÏÈȉ·ÈÌ›· Î·È Ë ˘¤ÚÙ·ÛË ˘‹Ú¯·Ó ‹‰Ë ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ·˘Ùfi Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ÁÈ· ÙË Ï‹„Ë ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ. ∞ÈÙÈÔÏÔÁ›· ∏ ˘¤ÚÙ·ÛË ‰È·¯ˆÚ›˙ÂÙ·È Û ‰Â˘ÙÂÚÔ·ı‹ Î·È ÚˆÙÔ·ı‹. ™ÙË ‰Â˘ÙÂÚÔ·ı‹ ˘¤ÚÙ·ÛË, Ë ·ÈÙÈÔÏÔÁ›· ÌÔÚ› Ó· ηıÔÚÈÛÙ›. ¶ÂÚ›Ô˘ ÙÔ 85-90% ÙˆÓ ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 10 ÂÙÒÓ ¤¯ÂÈ ‰Â˘ÙÂÚÔ·ı‹ ˘¤ÚÙ·ÛË. °ÂÓÈο, fiÛÔ ÈÔ ÌÈÎÚ‹˜ ËÏÈΛ·˜ Â›Ó·È ÙÔ ·È‰› Î·È fiÛÔ ÈÔ ˘„ËÏ‹ Ë ∞¶, ÙfiÛÔ Èı·ÓfiÙÂÚË Á›ÓÂÙ·È Ë ‰È¿ÁÓˆÛË ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘, fiˆ˜ .¯. Ë ÔÊÂÈÏfiÌÂÓË Û ·ÚÂÁ¯˘Ì·ÙÈ΋ ‹ ·ÁÁÂȷ΋ ÓÂÊÚÈ΋ ‚Ï¿‚Ë, Ë ÔÔ›· ÊÙ¿ÓÂÈ ÙÔ 75-80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (12,24). ∏ ‰Â˘ÙÂÚÔ·ı‹˜ ˘¤ÚÙ·ÛË ÌÔÚ› Ó· Â›Ó·È ·ÚÔ‰È΋ ‹ ¯ÚfiÓÈ·. ∏ ·ÚÔ‰È΋ ‹ ‰È·Ï›Ô˘Û· ÌÔÚ› Ó· Â›Ó·È ÓÂÊÚÈ΋˜, ÂÚÈÊÂÚÈ΋˜ ‹ ÎÂÓÙÚÈ΋˜ Ó¢ÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ‹ Ó· ÔÊ›ÏÂÙ·È Û ʿÚ̷η ‹ ‰ËÏËÙËÚ›·ÛË, ·ÏÏ¿ Î·È Û ¿ÏϘ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜. £· Ú¤ÂÈ ÛÙÔ ÛËÌÂ›Ô ·˘Ùfi Ó· ÙÔÓÈÛÙ› Ë ¯Ú‹ÛË Ó·ÚΈÙÈÎÒÓ Î·È ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜. ™Ù· ·›ÙÈ· Ù˘ ¯ÚfiÓÈ·˜ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÓÂÊÚÈΤ˜, ·ÁÁÂȷΤ˜, ÂÓ‰ÔÎÚÈÓÈΤ˜, ηıÒ˜ Î·È ÓfiÛÔÈ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙËÓ ÚˆÙÔ·ı‹ ˘¤ÚÙ·ÛË ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È Û˘ÁÎÂÎÚÈ̤ÓË ˘ÔΛÌÂÓË ÓfiÛÔ˜. ∫ÏËÚÔÓÔÌÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ∞¶ (25). OÈ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÚfiÎÏËÛË Ù˘ ˘¤ÚÙ·Û˘ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË Î·ıÔÚÈÛÙ›, ·ÏÏ¿ Ë ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Â›Ó·È fiÙÈ Ë ÎÏËÚÔÓÔÌÈÎfiÙËÙ· Â›Ó·È ÔÏ˘ÁÔÓÈ΋. ŒÙÛÈ, Ù· ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ Ô ¤Ó·˜ ‹ Î·È ÔÈ ‰‡Ô ÁÔÓ›˜ ›ӷÈ

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

˘ÂÚÙ·ÛÈÎÔ›, ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó ˘¤ÚÙ·ÛË Û ۯ¤ÛË Ì ·È‰È¿ ÌË ˘ÂÚÙ·ÛÈÎÒÓ ÁÔÓ¤ˆÓ (5). ¶·È‰È¿ Ì ∞¶ Û ˘„ËϤ˜ ∂£ ÚÔ¤Ú¯ÔÓÙ·È Û˘Ó‹ıˆ˜ ·fi ÔÈÎÔÁ¤ÓÂȘ Ì ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘ (3). ∞‰¤ÏÊÈ· ˘ÂÚÙ·ÛÈÎÒÓ ·È‰ÈÒÓ ¤¯Ô˘Ó ˘„ËÏfiÙÂÚË ∞¶ ·fi Ù· ·‰¤ÏÊÈ· ÌË ˘ÂÚÙ·ÛÈÎÒÓ ·È‰ÈÒÓ (18). ∂›Û˘, ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Û˘Û¯¤ÙÈÛË ∞¶ ÌÂٷ͇ ÌËÙ¤ÚˆÓ Î·È ·È‰ÈÒÓ ·’ fiÙÈ ÌÂٷ͇ ·Ù¤ÚˆÓ Î·È ·È‰ÈÒÓ, ÁÂÁÔÓfi˜ Ô˘ ˘·ÈÓ›ÛÛÂÙ·È Î·È ÚÔÁÂÓÓËÙÈ΋ Â›‰Ú·ÛË. ¶·Ú’ fiÏ· ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ, Â›Ó·È ·‰‡Ó·ÙÔÓ Ó· ÚÔ‚ÏÂÊı› ÔÈ· ·fi Ù· ÎÏËÚÔÓÔÌÈο ‚‚·Ú˘Ì¤Ó· ·È‰È¿ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ˘¤ÚÙ·ÛË ÛÙÔ Ì¤ÏÏÔÓ. ¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÔ stress Î·È Ë ÂÚÈÂÎÙÈÎfiÙËÙ· Ù˘ ÙÚÔÊ‹˜ Û ·Ï¿ÙÈ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ÚfiÎÏËÛË Ù˘ ˘¤ÚÙ·Û˘. ∂›Û˘, ·È‰È¿ ˘ÂÚÙ·ÛÈÎÒÓ ÁÔÓ¤ˆÓ ·ÓÙȉÚÔ‡Ó Ì ÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË Ù˘ ∞¶ ÌÂÙ¿ ·fi stress ‹ ÊfiÚÙÈÛË Ì ¯ÏˆÚÈÔ‡¯Ô Ó¿ÙÚÈÔ. ∆Ô ›‰ÈÔ Û˘Ì‚·›ÓÂÈ Î·È ÛÙ· ·¯‡Û·Úη ·È‰È¿ (16). °ÂÓÈο, ·¯‡Û·Úη ¿ÙÔÌ· ¤¯Ô˘Ó ˘¤ÚÙ·ÛË Ôχ ÈÔ Û˘¯Ó¿ ·fi Ù· ÏÂÙfiۈ̷. ∆Ô ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜, ηıÒ˜ Î·È Ë ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ηıÔÚÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ∞¶. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ˘¤ÚÙ·ÛË ÛÙË ÌËÙ¤Ú· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Èı·ÓÒ˜ ÌÂÙ¤ÂÈÙ· ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË ‹ Ó· Â›Ó·È ÚÔÔÌfi˜ ˘¤ÚÙ·Û˘ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜. ∞ÎfiÌË, ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Û˘Ó‰¤ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ˘¤ÚÙ·Û˘ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (6,16). ∏ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· Î·È Ù· ˘„ËÏ¿ Â›‰· ÁÏ˘Îfi˙˘ ÛÙÔ ·›Ì· Ê·›ÓÂÙ·È, Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, Ó· Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ˘¤ÚÙ·ÛË, ̤ۈ ÔÏÏ·ÏÒÓ Ì˯·ÓÈÛÌÒÓ (26). ∆· Â›‰· ÚÂÓ›Ó˘ ÛÙÔ ·›Ì· ÌÔÚ› Ó· Â›Ó·È ˘„ËÏ¿, Ê˘ÛÈÔÏÔÁÈο ‹ ¯·ÌËÏ¿. ¶·Ú’ fiÏÔ Ô˘ Ë ÌÂϤÙË ÙˆÓ ÂÈ¤‰ˆÓ ÚÂÓ›Ó˘ ¤¯ÂÈ ·Ô‰Âȯı› ¯Ú‹ÛÈÌË ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ Î·È ÛÙË ıÂÚ·›· Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ‰˘ÛÙ˘¯Ò˜ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ÔÏÔÎÏËÚˆı› ÔÈ ÌÂϤÙ˜ ÛÙ· ·È‰È¿. ™ÙÔ Ì¤ÏÏÔÓ, Ë ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ·Ó·ÛÙÔϤˆÓ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ ÚԂϤÂÙ·È Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ı¤ÛË ·ÎfiÌË Î·È ÛÙËÓ ÚfiÏË„Ë ÔÚÈÛÌ¤ÓˆÓ ÌÔÚÊÒÓ ÚˆÙÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘. ∞Í›˙ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ë Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ ˘¤ÚÙ·Û˘ Â›Ó·È Ë ÚˆÙÔ·ı‹˜ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ÊÙ¿ÓÂÈ ÙÔ 80% (5), ÂÓÒ ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ Î·È Ù· ‚Ú¤ÊË Û˘¯ÓfiÙÂÚË Â›Ó·È Ë ‰Â˘ÙÂÚÔ·ı‹˜ (ÓÂÊÚÈ΋ ·ÚÂÁ¯˘Ì·ÙÈ΋ ÓfiÛÔ˜ Î·È ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜). ¢ÂÓ Ú¤ÂÈ fï˜ Ó· ‰È·Ê‡ÁÂÈ Ù˘ ÛΤ„˘ fiÙÈ ÌÈÎÚ‹ ·‡ÍËÛË Ù˘ ∞¶ Û ÌÈÎÚ¿ ·È‰È¿ ÌÔÚ› Û¿ÓÈ· Ó· ÔÊ›ÏÂÙ·È Û ÚÒÈÌË ÂÌÊ¿ÓÈÛË ÚˆÙÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘. ∂›Û˘, ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Ë

Paediatriki 2001;64:448-459

Èı·ÓfiÙËÙ· Ï‹„˘ ·ÏÎÔfiÏ˘, ·ÌÊÂÙ·Ì›Ó˘, ÎÔη˝Ó˘, ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ Î·È ÙÔ Î¿ÓÈÛÌ· (11). ∆· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· Ù˘ ˘¤ÚÙ·Û˘, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ™Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, Ë ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÓ·ÏÏ·Á¤˜ Ù˘ ∞¶, ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘ Î·È Û˘¯Ó¿ ·¯˘Û·ÚΛ·. ∆· ÂÚÈÛÛfiÙÂÚ· ˘ÂÚÙ·ÛÈο ·È‰È¿ Â›Ó·È ·Û˘Ìو̷ÙÈο fiÙ·Ó ·Ó·Î·Ï‡ÙÂÙ·È Ë ˘¤ÚÙ·ÛË, Ë ÔÔ›· Â›Ó·È Û˘Ó‹ıˆ˜ Ù˘¯·›Ô ‡ÚËÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÎÏÈÓÈ΋˜ ÂͤٷÛ˘ ÚÔ˘Ù›Ó·˜, Û˘¯Ó¿ ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ‚‚·›ˆÛ˘ Û˘ÌÌÂÙÔ¯‹˜ ÛÙÔ Ì¿ıËÌ· Ù˘ Á˘ÌÓ·ÛÙÈ΋˜ (27). ∞Ó, fï˜, Ë ˘¤ÚÙ·ÛË ÚÔ¸¿Ú¯ÂÈ ·fi Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÙfiÙ ÙÔ ·È‰› ÌÔÚ› Ó· ·Ú·ÔÓÂ›Ù·È ÁÈ· ÔÓÔÎÂÊ¿ÏÔ˘˜ ‹ ˙¿ÏË, ÂȉÈο ¤ÓÙÔÓ˜ ÈÓȷΤ˜ ÎÂÊ·Ï·ÏÁ›Â˜ Ô˘ ·Ú¯›˙Ô˘Ó ÌÂÙ¿ ÙËÓ ·Ê‡ÓÈÛË (11). µÚ¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿ Ô˘ ‰˘ÛÎÔχÔÓÙ·È Ó· ÂÎÊÚ·ÛÙÔ‡Ó, ÌÔÚ› Ó· ÂÌÊ·Ó›˙Ô˘Ó ÌÈ· ·ÓÂÍ‹ÁËÙË Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ë ÔÔ›· ˘Ô¯ˆÚ› Ì ÙË ıÂÚ·›· Ù˘ ˘¤ÚÙ·Û˘. ÕÏÏ· Û˘ÌÙÒÌ·Ù· ÛÙËÓ ›‰È· ËÏÈÎȷ΋ ÔÌ¿‰· Â›Ó·È Ë Î·ı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÈ ‰˘ÛÎÔϛ˜ Û›ÙÈÛ˘ Î·È ÔÈ ¤ÌÂÙÔÈ, Ë ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Ë Î˘¿ÓˆÛË, Ë Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ·, ÔÈ Û·ÛÌÔ›, Ë ÔÏ˘‰È„›· Î·È Ë ÔÏ˘Ô˘Ú›·, fiˆ˜ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿. ∂¿Ó Ë ∞¶ Â›Ó·È Ôχ ˘„ËÏ‹, ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Û˘ÌÙÒÌ·Ù· ÂÁÎÂÊ·ÏÈ΋˜ ˘¤ÚÙ·Û˘, ‰ËÏ·‰‹ ¤ÌÂÙÔÈ, ÎÂÊ·Ï·ÏÁ›·, ˘ÚÂÙfi˜, ·Ù·Í›·, ÎÒÌ·, ÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ÊÙ¿ÓÔ˘Ó Ì¤¯ÚÈ Ù‡ÊψÛË ‹ Î·È Û·ÛÌÔ›, ÂÓÒ ÛÙ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ Ô›‰ËÌ· ÙˆÓ ÔÙÈÎÒÓ ıËÏÒÓ Î·È Ë ·Ú¿Ï˘ÛË ÂÁÎÂÊ·ÏÈÎÒÓ Û˘˙˘ÁÈÒÓ, fiˆ˜ Ë ¿ÚÂÛË ÚÔÛˆÈÎÔ‡. ŸÙ·Ó Ë ˘¤ÚÙ·ÛË Â›Ó·È ‰Â˘ÙÂÚÔ·ı‹˜, ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Ù· Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘. ™ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ÂÎÙÈÌËıÔ‡Ó: ·) §ÂÙÔÌÂÚÒ˜ ÙÔ Î˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ·, ÔÈ ÛʇÍÂȘ Û fiÏ· Ù· ¿ÎÚ· (·‰˘Ó·Ì›· „ËÏ¿ÊËÛ˘ ÌËÚÈ·›ˆÓ), Ë Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ·. ‚) ∏ ∞¶ ÛÙÔ ‰ÂÍÈfi ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ. Á) ∏ ηٷÓÔÌ‹ ۈ̷ÙÈÎÔ‡ Ï›Ô˘˜ (·¯˘Û·ÚΛ· Ù‡Ô˘ ‚Ô˘‚¿ÏÔ˘). ‰) ƒ·Á¿‰Â˜ ‰¤ÚÌ·ÙÔ˜, ηÊÂÁ·Ï·ÎÙfi¯ÚÔ˜ ÎËÏ›‰Â˜, Ó¢ÚÈÓÒÌ·Ù·. Â) §ÂÙÔÌÂÚÒ˜ ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ÛÙ) O ı˘ÚÂÔÂȉ‹˜ ·‰¤Ó·˜. ˙) ∏ ÎÔÈÏȷ΋ ¯ÒÚ· ÁÈ· Ì¿˙˜. ¶Ú¤ÂÈ, Â›Û˘, Ó· Á›ÓÂÈ ·ÎÚfi·ÛË ÁÈ· ·ÔÎÏÂÈÛÌfi ‡·Ú͢ Ê˘ÛËÌ¿ÙˆÓ ÛÙË ÓÂÊÚÈ΋ ¯ÒÚ·.

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¶›Ó·Î·˜ 3. ∞ÈÙÈÔÏÔÁ›· Ù˘ ˘¤ÚÙ·Û˘ ¡ÂÔÁÓ¿ Î·È µÚ¤ÊË ñ ™˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· - £ÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ‹ ÊϤ‚·˜ ÌÂÙ¿ ηıÂÙËÚÈ·ÛÌfi ÔÌÊ·ÏÈ΋˜ ·ÚÙËÚ›·˜ - πÛıÌÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜ - ™˘ÁÁÂÓ›˜ ÓÂÊÚÈΤ˜ ·ÓˆÌ·Ï›Â˜ - ™Ù¤ÓˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ñ §ÈÁfiÙÂÚÔ Û˘¯Ó¿ ·›ÙÈ· - µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· - µÔÙ¿ÏÂÈÔ˜ fiÚÔ˜ - ∂Ó‰ÔÎÔÈÏȷ΋ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· - ŸÁÎÔÈ, π·ÙÚÔÁÂÓ‹˜ ¶·È‰È¿ 1-10 ÂÙÒÓ ñ ™˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· - ¡ÂÊÚÈ΋ ÓfiÛÔ˜ - πÛıÌÈ΋ ÛÙ¤ÓˆÛË ·ÔÚÙ‹˜ ñ §ÈÁfiÙÂÚÔ Û˘¯Ó¿ ·›ÙÈ· - ™Ù¤ÓˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ - ÀÂÚ·Û‚ÂÛÙÈ·ÈÌ›· - ¡Â˘ÚÔ˚ӈ̿وÛË - ¡Â˘ÚÔÁÂÓ›˜ fiÁÎÔÈ - º·ÈÔ¯ÚˆÌÔ·Ùو̷ - ÀÂÚ¤ÎÎÚÈÛË ·Ï·ÙÔÎÔÚÙÈÎÔÂȉÒÓ - ÀÂÚı˘ÚÂÔÂȉÈÛÌfi˜ - ¶·ÚÔ‰È΋ ˘¤ÚÙ·ÛË ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË Ô˘ÚÔÔÈËÙÈÎÔ‡ - À¤ÚÙ·ÛË ÏfiÁˆ ÎÏÈÓÔÛÙ·ÙÈÛÌÔ‡ - À¤ÚÙ·ÛË Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¿ÓÔÈ· ‡ÓÔ˘ - ¶ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË (Û¿ÓÈ·) ¶·È‰È¿ >11 ÂÙÒÓ Î·È ¤ÊË‚ÔÈ ñ ™˘ÓËı¤ÛÙÂÚ· ·›ÙÈ· - ¡ÂÊÚÈ΋ ÓfiÛÔ˜ - ¶ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË ñ §ÈÁfiÙÂÚÔ Û˘¯Ó¿ ·›ÙÈ· - ŸÌÔÈ· Ì ٷ ·È‰È¿ 1-10 ÂÙÒÓ (ÏËÓ Ù˘ ÚˆÙÔ·ıÔ‡˜) The New England J of Medicine 1996;335:1968

Ë) ⁄·ÚÍË Ôȉ‹Ì·ÙÔ˜. ı) ⁄„Ô˜ Î·È ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡ (ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘). È) ŒÍˆ ÁÂÓÓËÙÈο fiÚÁ·Ó· Î·È ÛÙ¿‰ÈÔ Tanner. È·) O ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜. ™ÙË ‚˘ıÔÛÎfiËÛË ÌÔÚ› Ó· ‚ÚÂıÔ‡Ó ·ÏÏÔÈÒÛÂȘ ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ™Â Ì›· ÌÂϤÙË ·È‰ÈÒÓ Ì ∞¶ >90˘ ∂£ Â› ÙÚ›ÌËÓÔ, ‚Ú¤ıËÎ·Ó ·ÏÏÔÈÒÛÂȘ ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Û ÛËÌ·ÓÙÈο ÔÛÔÛÙ¿ Î·È ÔÈ Û˘ÁÁÚ·Ê›˜ ÙÔÓ›˙Ô˘Ó ÙË ÛÔ˘‰·ÈfiÙËÙ· Ù˘ ‚˘ıÔÛÎfiËÛ˘ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ˘¤ÚÙ·Û˘ (6,11). ŸÙ·Ó Ë ·‡ÍËÛË Ù˘ ∞¶ Â›Ó·È ÔÍ›· Î·È Î˘Ì·›ÓÂÙ·È Û ˘„ËÏ¿ Â›‰·, ÚfiÎÂÈÙ·È ÂÚ› ˘ÂÚÙ·ÛÈ΋˜ ÎÚ›Û˘, Ë ÔÔ›· ·ÂÈÏ› ÙË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡. ∫·ÙÂ›ÁÔ˘Û· ıˆÚÂ›Ù·È Ë ÎÚ›ÛË, ηٿ ÙËÓ ÔÔ›· Ë ∞¶ Â›Ó·È 1,3-1,5 ÊÔÚ¤˜ ˘„ËÏfiÙÂÚË ·fi ÙËÓ 95Ë ∂£ Î·È ˘¿Ú¯Ô˘Ó ÛËÌ›· ‚Ï¿‚˘ ÙˆÓ ÔÚÁ¿ÓˆÓ

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ÛÙfi¯ˆÓ, fiˆ˜ ÂÁÎÂÊ·ÏÈÎfi ¤ÌÊÚ·ÎÙÔ, ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·, Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·, ˘ÂÚÙ·ÛÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ‹ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·. OÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÛÙ· ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÎÂÊ·Ï·ÏÁ›·, ÚÈÓÈ΋ ·ÈÌÔÚÚ·Á›·, ıfiψÛË Ù˘ fiÚ·Û˘ Î·È ¤ÌÂÙÔÈ. ™Â Â›ÁÔ˘Û· ÎÚ›ÛË, Ë ÔÔ›· Â›Ó·È Î·È Û˘¯ÓfiÙÂÚË, ‰ÂÓ ˘¿Ú¯ÂÈ Û˘ÓÔ‰fi˜ ‚Ï¿‚Ë ÙÂÏÈÎÒÓ ÔÚÁ¿ÓˆÓ ÛÙfi¯ˆÓ Î·È Ù· Û˘ÌÙÒÌ·Ù· Â›Ó·È ÏÈÁfiÙÂÚÔ ‰Ú·Ì·ÙÈο (28,29). ¢È¿ÁÓˆÛË AÓ Ë ∞¶ ‰È·ÈÛÙˆı› Â·ÓÂÈÏËÌ̤ӷ (ÙÔ˘Ï¿¯ÈÛÙÔÓ Û 3 ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Û ‰È·ÊÔÚÂÙÈο ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·) fiÙÈ Â›Ó·È ¿Óˆ Ù˘ 95˘ ∂£, ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ ‡„Ô˜ Î·È ÙÔ Ê‡ÏÔ, ÙfiÙ ÙÔ ·È‰› ıˆÚÂ›Ù·È fiÙÈ ¤¯ÂÈ ˘¤ÚÙ·ÛË Î·È ·ÎÔÏÔ˘ı› ¤ÏÂÁ¯Ô˜ ηıÔÚÈÛÌÔ‡ Ù˘ ·ÈÙÈÔÏÔÁ›·˜. ∏ ¤ÌÊ·ÛË ÛÙȘ ÔÏÏ·Ϥ˜ ÌÂÙÚ‹ÛÂȘ ‰ÈηÈÔÏÔÁÂ›Ù·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· Â›‰· Ù˘ ∞¶ Ù›ÓÔ˘Ó Ó· ‚Ú›ÛÎÔÓÙ·È ¯·ÌËÏfiÙÂÚ· ÌÂÙ¿ ·fi Â·ÓÂÈÏËÌ̤ÓÔ˘˜ ηıÔÚÈÛÌÔ‡˜ (3,5,12,13). ∞Ó Ë ∞¶ Û ̛· ̤ÙÚËÛË ‚ÚÂı› ˘„ËÏ‹, ·ÏÏ¿ Û ÂfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙËÓ 95Ë ∂£, ¯ÚÂÈ¿˙ÂÙ·È ¿ÏÈ Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ‰ÈfiÙÈ ÌÂÚÈο ·fi ·˘Ù¿ Ù· ·È‰È¿ ÙÂÏÈο ·Ó·Ù‡ÛÛÔ˘Ó ˘¤ÚÙ·ÛË. ¶·Ú’ fiÏÔ Ô˘ Â›Ó·È Û¿ÓÈÔ Ó· ‚ÚÂı› ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 10 ÂÙÒÓ, Ù· ˘ÂÚÙ·ÛÈο, ˘¤Ú‚·Ú· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 5 ÂÙÒÓ Ì ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi, Â›Ó·È Èı·Ófi Ó· ¿Û¯Ô˘Ó ·fi ÚˆÙÔ·ı‹ ˘¤ÚÙ·ÛË. §ÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È ÎÏÈÓÈ΋ ÂͤٷÛË ı· ‚ÔËı‹ÛÔ˘Ó ÛËÌ·ÓÙÈο, ÂȉÈο ÛÙËÓ ·Ó·˙‹ÙËÛË Ù˘ ·ÈÙÈÔÏÔÁ›·˜ (ÚˆÙÔ·ı‹˜ ‹ ‰Â˘ÙÂÚÔ·ı‹˜) Î·È Î·Ù’ Â¤ÎÙ·ÛË Ù˘ ÂÓ‰ÂÈÎÓ˘fiÌÂÓ˘ ÂÚÁ·ÛÙËÚȷ΋˜ ‰ÈÂÚ‡ÓËÛ˘. ∂Ó‰ÂÈÎÙÈο ·Ó·Ê¤ÚÂÙ·È fiÙÈ Î·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Û˘¯Ó¿ ÂÌ‡ÚÂÙ· ÂÂÈÛfi‰È· ÌÔÚ› Ó· ˘ÔÛËÌ·›ÓÔ˘Ó ˘¤ÚÙ·ÛË ÓÂÊÚÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∂›Û˘, ÈÛÙÔÚÈÎfi ÚÔˆÚfiÙËÙ·˜ Î·È ÔÌÊ·ÏÈÎÔ‡ ηıÂÙ‹Ú· ÌÔÚ› Ó· ˘ÔÎÚ‡ÙÂÈ ÓÂÊÚÈο-·ÁÁÂȷο ÚÔ‚Ï‹Ì·Ù·. ∞˘Ùfi ·ÔÎÙ¿ ÌÂÁ·Ï‡ÙÂÚË ÛÔ˘‰·ÈfiÙËÙ· Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ô˘ Ë ÂÈ‚›ˆÛË ÌÈÎÚÒÓ ÚÔÒÚˆÓ Î·È ÚÔ‚ÏËÌ·ÙÈÎÒÓ ÓÂÔÁÓÒÓ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ÂÚÈÛÛfiÙÂÚ· ÚfiˆÚ· Î·È ÓÂÔÁÓ¿ Û ۯ¤ÛË Ì ÙÔ ·ÚÂÏıfiÓ ÌÔÚ› Ó· Â›Ó·È ˘ÂÚÙ·ÛÈο. ∞ÎfiÌË, ·‰˘Ó·Ì›· „ËÏ¿ÊËÛ˘ ÌËÚÈ·›ˆÓ Ô‰ËÁ› Û ‰È¿ÁÓˆÛË ÛÙ¤ÓˆÛ˘ ÈÛıÌÔ‡ ·ÔÚÙ‹˜. O ·ÏÁfiÚÈıÌÔ˜ ÛÙÔ ™¯‹Ì· 1 ‰›ÓÂÈ Ì›· Û˘ÓÔÙÈ΋ ÂÈÎfiÓ· Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ˘¤ÚÙ·Û˘. ¶·Ú·ÎÏÈÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ ∞Ó ÙÔ ÈÛÙÔÚÈÎfi Î·È Ë ÎÏÈÓÈ΋ ÂͤٷÛË Î·ıÈÛÙÔ‡Ó ÚÔÊ·Ó¤˜ fiÙÈ Ë ˘¤ÚÙ·ÛË Â›Ó·È ‰Â˘ÙÂÚÔ·ı‹˜, Ô

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

Paediatriki 2001;64:448-459

ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ú¤ÂÈ Ó· ηÙ¢ı‡ÓÂÙ·È ÛÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ·ÈÙ›Ô˘. ∞Ó Èı·ÓÔÏÔÁÂ›Ù·È ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË, ÙfiÙ ÛÙȘ ÚÒÙ˜ ÁÂÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÌfiÓÔ Ï›Á˜ ‚·ÛÈΤ˜, fiˆ˜ ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, ÁÂÓÈ΋ Ô‡ÚˆÓ Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ, Ô˘Ú›· ÎÚ·ÙÈÓ›ÓË, ۿί·ÚÔ, ËÏÂÎÙÚÔχÙ˜, ·Û‚¤ÛÙÈÔ, Ô˘ÚÈÎfi Ô͇, ÏÈȉfiÁÚ·ÌÌ·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Î·È ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈ΋ ÌÂϤÙË (3,13). ∂¿Ó Ë ˘¤ÚÙ·ÛË Â›Ó·È ÛÔ‚·Ú‹ (∞¶≥99˘ ∂£) ‹ Â¿Ó Ë ∞¶ ·Ú·Ì¤ÓÂÈ ÌÂٷ͇ 95˘-99˘ ∂£ ·Ú¿ ÙË ÌË Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ¤Ú·Ó ÙˆÓ 6 ÌËÓÒÓ, ÙfiÙ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÏÂÙÔÌÂÚ¤ÛÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ Ô˘ ı· ÂÚÈÏ·Ì‚¿ÓÂÈ, ÂÎÙfi˜ ÙˆÓ fiÛˆÓ ‹‰Ë ·Ó·Ê¤ÚıËηÓ, Ù· ÂÍ‹˜: ¯ÔÏËÛÙÂÚfiÏË, ËÏÂÎÙÚÔÊfiÚËÛË ÏÈÔÚˆÙÂ˚ÓÒÓ, ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È Ô˘ÚÈÎfi Ô͇, ÙÔ ÔÔ›Ô Û˘¯Ó¿ ‚Ú›ÛÎÂÙ·È ·˘ÍË̤ÓÔ Û ӤԢ˜ ·ÓıÚÒÔ˘˜ Ì ˘¤ÚÙ·ÛË. ∂›Û˘, ·/· ıÒÚ·ÎÔ˜, ∏∫° Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, Ù· ÔÔ›· ÂÈÚÔÛı¤Ùˆ˜ ı· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ Ù˘¯fiÓ ÂÈÙÒÛÂˆÓ Ù˘ ˘¤ÚÙ·Û˘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·. ¢ÂÓ

˘¿Ú¯ÂÈ ÔÌÔʈӛ· fiÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Î·È ÛÙÔÓ ÂÓ‰ÂÈÎÓ˘fiÌÂÓÔ ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô (5,11). ∞fi ÌÂÚÈÎÔ‡˜ Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÂÙ·È Ë ·Ú·ÔÌ‹ ÙÔ˘ ·È‰ÈÔ‡ Û ÂȉÈÎÔ‡˜, ÂÓÒ ¿ÏÏÔÈ Û˘ÓÈÛÙÔ‡Ó ÓÂÊÚÔÁÚ¿ÊËÌ·, ÓÂÊÚÈ΋ ·ÁÁÂÈÔÁÚ·Ê›· Î·È ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ‰Ú·ÛÙÈÎÔ‡ ÎÏ¿ÛÌ·ÙÔ˜ ÚÂÓ›Ó˘ ·Ó Èı·ÓÔÏÔÁÂ›Ù·È ÓÂÊÚ·ÁÁÂȷ΋ ÓfiÛÔ˜, ηıÒ˜ Î·È ¤ÏÂÁ¯Ô ηÙ¯ÔÏ·ÌÈÓÒÓ Î·È ÛÙÂÚÔÂȉÒÓ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ. ∆¤ÏÔ˜, ‰ÂÓ ı· Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È ¤Ó· ÙÂÛÙ Î˘‹Ûˆ˜ Û ¤Ê˂˜ Ì ˘¤ÚÙ·ÛË. £ÂÚ·›· ™ÎÔfi˜ Ù˘ ıÂÚ·›·˜ Â›Ó·È Ë ÂÏ¿ÙÙˆÛË Ù˘ ∞¶ οو ·fi ÙËÓ 95Ë ∂£. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÚÔ˜ ÙÔ ·ÚfiÓ ·ÓÙÈÎÂÈÌÂÓÈο ‰Â‰Ô̤ӷ ÛÙ· ÔÔ›· ÌÔÚ› Ó· ‚·ÛÈÛÙ› ÙÔ Â›‰Ô˜ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ Ô˘ ı· ¯ÔÚËÁËı› Û ·È‰È¿ Ì ˘¤ÚÙ·ÛË, Ô‡ÙÂ Â›Ó·È ÁÓˆÛÙfi ·Ó Ù· ÔʤÏË Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ÛÙȘ ËÏÈ˘ ·˘Ù¤˜. ŒÙÛÈ, Ë ÌË Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË, ÌÂ

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∂·Ó·Ì¤ÙÚËÛË ∞¶ Û ÂfiÌÂÓ˜ ÂÈÛΤ„ÂȘ. ÀÔÏÔÁÈÛÌfi˜ ∂£

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90-95 ∂£

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∞Ó ∞¶ ·Ú·Ì¤ÓÂÈ ≥95 ∂£ - ¢È·ÁÓˆÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ± ÌË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ± Ê¿Ú̷η

¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ∞¶ – ·Ó Â›Ó·È ˘„ËÏ‹ Î·È ÂÚÌËÓ‡ÂÙ·È ·fi ÙÔ ‡„Ô˜ ‹ ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·È‰ÈÔ‡

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∞Ó ÙÔ ·È‰› Â›Ó·È ˘„ËÏfi ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘

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™¯‹Ì· 1. ∞ÏÁfiÚÈıÌÔ˜ ‰È¿ÁÓˆÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ˘¤ÚÙ·Û˘ ÛÙ· ·È‰È¿.

455

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

ÙÔ˘˜ ÂÏ¿¯ÈÛÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ÂÌÂÚÈÎÏ›ÂÈ, Ê·›ÓÂÙ·È Ó· Â›Ó·È Ë ÚÒÙË ÂÈÏÔÁ‹ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÚˆÙÔ·ı‹ ˘¤ÚÙ·ÛË Î·È Û˘Ó‹ıˆ˜ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Û ·˘Ù‹ ÙÔ 85% ÙˆÓ ·È‰ÈÒÓ (12,13). ∞Ó ‰ÂÓ ˘¿ÚÍÂÈ ·ÓÙ·fiÎÚÈÛË ‹ ·Ó ˘¿Ú¯ÂÈ ÛÔ‚·Ú‹ ˘¤ÚÙ·ÛË, ··ÈÙÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ·Ú¤Ì‚·ÛË (3). ∞Ó Ë ·‡ÍËÛË Ù˘ ∞¶ Â›Ó·È Ôχ ÌÂÁ¿ÏË (‚·ÚÈ¿ ˘¤ÚÙ·ÛË), Ë ·ÓÙÈÌÂÙÒÈÛË Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË. ∏ ÌË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ: ·) O‰ËÁ›Â˜ ‰È·ÙÚÔÊ‹˜ ÁÈ· ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ‰ÈfiÙÈ Ôχ Û˘¯Ó¿ Ù· ·È‰È¿ ·˘Ù¿ Â›Ó·È ·¯‡Û·Úη. ∏ ‰È·ÙÚÔÊ‹ Ú¤ÂÈ Ó· Â›Ó·È ¯·ÌËÏ‹ Û ÏÈ·Ú¿ (ȉȷ›ÙÂÚ· Û ÎÂÎÔÚÂṲ̂ӷ ÏÈ·Ú¿ Ôͤ·) Î·È ˘„ËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ›Ó˜, Ì ÊÚ¤Ûη ÊÚÔ‡Ù· Î·È Ï·¯·ÓÈο. ∏ ÂÈÌfiÚʈÛË Î·È Ë Û˘ÌÌÂÙÔ¯‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÛÙÔ˘˜ ηÓfiÓ˜ ÛˆÛÙ‹˜ ‰È·ÙÚÔÊ‹˜ Â›Ó·È ÛËÌ·ÓÙÈ΋. ¶·Ú·ÔÌ‹ Û ‰È·ÈÙÔÏfiÁÔ Á›ÓÂÙ·È ·Ó ·˘Ùfi ÎÚÈı› ··Ú·›ÙËÙÔ. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Î·È Ì¤ÙÚÈ· ÂÏ¿ÙÙˆÛË ÙÔ˘ ‚¿ÚÔ˘˜ Û˘Óԉ‡ÂÙ·È ·fi ÂÏ¿ÙÙˆÛË Ù˘ ∞¶. ‚) ∂Ï¿ÙÙˆÛË ÙÔ˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ Ì ÙȘ ÙÚÔʤ˜ ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ Î·È ·‡ÍËÛË ÙÔ˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ Î·Ï›Ô˘. Á) ¶ÚfiÛÏË„Ë Â·ÚÎÔ‡˜ ÔÛfiÙËÙ·˜ ·Û‚ÂÛÙ›Ô˘. ‰) ™˘ÛÙËÌ·ÙÈ΋ ۈ̷ÙÈ΋ ¿ÛÎËÛË. ∏ ¿ÛÎËÛË ˆÊÂÏ› ÔÏÏ·Ï¿ ÙÔ ·È‰› Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ¤Ó‰ÂÈÍË ÛÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘, ÂÎÙfi˜ Â¿Ó ÙÔ ·È‰› ¿Û¯ÂÈ ·fi ηډȷ΋ ÓfiÛÔ ÁÈ· ÙËÓ ÔÔ›· ·ÓÙÂӉ›ÎÓ˘Ù·È Ë Á˘ÌÓ·ÛÙÈ΋ ‹ ¤¯ÂÈ ˘ÂÚÙ·ÛÈ΋ ÎÚ›ÛË (30,31). ∞Ó Û˘Ó˘¿Ú¯ÂÈ ‚Ï¿‚Ë ÙÂÏÈÎÒÓ ÔÚÁ¿ÓˆÓ, Û˘ÓÈÛÙ¿Ù·È Û˘ÓÂÎÙ›ÌËÛË Ì ÙÔÓ Î·Ú‰ÈÔÏfiÁÔ (32). ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ‰›·ÈÙ·˜ Î·È ¿ÛÎËÛ˘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ˜ ÛÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ∞¶. Â) ¢È·ÎÔ‹ ηÓ›ÛÌ·ÙÔ˜ Î·È Î·Ù¿¯ÚËÛ˘ ·ÏÎÔÔÏÔ‡¯ˆÓ ÔÙÒÓ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜. ÛÙ) ¶Ú¤ÂÈ Ó· ÙÔÓ›˙ÂÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ fiÙÈ ··ÁÔÚ‡ÂÙ·È Ë Ï‹„Ë Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ, ÂÎÙfi˜ ÂÎÂ›ÓˆÓ Ô˘ Û˘ÛÙ‹ÓÔÓÙ·È ·fi ÁÈ·ÙÚfi. ∞ÎfiÌË Î·È Ù· ·ÔÛ˘ÌÊÔÚËÙÈο ÙÔ˘ ÚÈÓÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ÌÔÚ› Ó· ·˘Í‹ÛÔ˘Ó ÙËÓ ∞¶. ˙) ÃÚËÛÈÌÔÔ›ËÛË „˘¯ÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ÙÚÔÔÔ›ËÛ˘ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜. ∏ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Û˘ÛÙ‹ÓÂÙ·È: 1) ÛÂ Û˘Ìو̷ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, 2) Û ·˘ÙÔ‡˜ Ô˘ ¤¯Ô˘Ó ÛÔ‚·Ú‹ ˘¤ÚÙ·ÛË, ‰ËÏ·‰‹ Ë ‰È·ÛÙÔÏÈ΋ ›ÂÛË Â›Ó·È 12 mmHg ˘„ËÏfiÙÂÚË ‹ Ë Û˘ÛÙÔÏÈ΋ Â›Ó·È 25 mmHg ˘„ËÏfiÙÂÚË Ù˘ 99˘ ∂£, 3) Û ·È‰È¿ Ô˘ ¤¯Ô˘Ó ¤Ó‰ÂÈÍË ‚Ï¿‚˘ ÙÂÏÈÎÒÓ ÔÚÁ¿ÓˆÓ Î·È 4) Û ·ÛıÂÓ›˜ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË. º·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Û˘ÛÙ‹ÓÂÙ·È, Â›Û˘, Û ˘ÂÚÙ·ÛÈο ·È‰È¿ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙË ÌË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Î·È ÛÙ· ÔÔ›·

456

Paediatriki 2001;64:448-459

Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÔ ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÁÈ· ˘¤ÚÙ·ÛË ‹ ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù· ·fi ÙÔ Î˘ÎÏÔÊÔÚÈÎfi. ∞Ó ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜, ÙÔ ·È‰› Â›Ó·È ·Û˘Ìو̷ÙÈÎfi, ¯ˆÚ›˜ ÚˆÙÂ˚ÓÔ˘Ú›·, ηډÈÔÌÂÁ·Ï›· ‹ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ¤Ó‰ÂÈÍË ˘ÂÚÙÚÔÊ›·˜ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜, ÙfiÙ ›Ûˆ˜ Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ηı˘ÛÙÂÚ‹ÛÂÈ Ë ¤Ó·ÚÍË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. ™˘Ó‹ıˆ˜ Á›ÓÂÙ·È ¤Ó·ÚÍË ıÂÚ·›·˜ Ì ¤Ó· ÌfiÓÔ ·ÓÙÈ˘ÂÚÙ·ÛÈÎfi (‚-·Ó·ÛÙÔϤ· ‹ ·ÓÙ·ÁˆÓÈÛÙ‹ ·Û‚ÂÛÙ›Ô˘ ‹ ‰ÈÔ˘ÚËÙÈÎfi) Û ¯·ÌËÏ‹ ‰fiÛË. ∂› ÌË ÂϤÁ¯Ô˘ Ù˘ ˘¤ÚÙ·Û˘, ˘Ôηı›ÛÙ·Ù·È ·˘Ùfi ·fi ¿ÏÏÔ ·ÓÙȸÂÚÙ·ÛÈÎfi Ù˘ ›‰È·˜ ηÙËÁÔÚ›·˜ ‹ ÚÔÛÙ›ıÂÙ·È Î·È ‰Â‡ÙÂÚÔ Ê¿ÚÌ·ÎÔ (3,12,28). OÈ Î·ÙËÁÔڛ˜ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ™ÙËÓ ÂÚ›ÙˆÛË ˘ÂÚÙ·ÛÈ΋˜ ÎÚ›Û˘, ÙÔ ·È‰› Ú¤ÂÈ Ó· ÂÈÛ·¯ı› ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∏ ıÂÚ·›· Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· Á›ÓÂÈ ÂÓ‰ÔÊÏ‚›ˆ˜, Û˘Ó‹ıˆ˜ ÌÂ Û˘Ó¯‹ ¤Á¯˘ÛË, ‰ÈfiÙÈ ¤ÙÛÈ ÂϤÁ¯ÂÙ·È Î·Ï‡ÙÂÚ· Ô Ú˘ıÌfi˜ ¯ÔÚ‹ÁËÛ˘ Ê·Ú̿ΈÓ. ∞fiÙÔÌË ÂÏ¿ÙÙˆÛË Ù˘ ∞¶ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È ‰ÈfiÙÈ ÂÌÂÚÈÎÏ›ÂÈ ÎÈÓ‰‡ÓÔ˘˜, ÁÈ’ ·˘Ùfi Î·È ¯ÚÂÈ¿˙ÂÙ·È Û˘Ó¯‹˜ ηٷÁÚ·Ê‹ Ù˘ ›ÂÛ˘. ∆Ô ÓÈÙÚÔÚˆÛÛÈÎfi Ó¿ÙÚÈÔ (0,5-8 Ìg/kg/min) Î·È Ë Ï·‚ÂÙ·ÏfiÏË (0,4-1 mg/kg/‰fiÛË), Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ˘ÂÚÙ·ÛÈ΋ ÎÚ›ÛË ÏfiÁˆ Ê·ÈÔ¯ÚˆÌÔ΢ÙÙÒÌ·ÙÔ˜, Â›Ó·È ‰‡Ô ·fi Ù· ÂÓ‰ÂÈÎÓ˘fiÌÂÓ· Ê¿Ú̷η (12,28,33). ∏ ˘‰Ú·Ï·˙›ÓË Ô˘ ˘‹ÚÍ ÙÔ Ê¿ÚÌ·ÎÔ ÂÎÏÔÁ‹˜ ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, Ù›ÓÂÈ ϤÔÓ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÏÈÁfiÙÂÚÔ, ‰ÈfiÙÈ Û ۇÁÎÚÈÛË Ì ٷ ÓÂfiÙÂÚ· Ê¿Ú̷η Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ¤¯ÂÈ ÂÚÈÛÛfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ (28,29). ¶ÚfiÁÓˆÛË ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂÚÁ·Û›Â˜ Ô˘ Ó· ¤¯Ô˘Ó ÔÏÔÎÏËÚÒÛÂÈ ÙË ÌÂϤÙË ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘ ÚˆÙÔ·ıÔ‡˜ ˘¤ÚÙ·Û˘ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ. ∫·Ì›· ÔÌ¿‰· ·È‰ÈÒÓ ‰ÂÓ ¤¯ÂÈ ·Ú·ÎÔÏÔ˘ıËı› ·ÎfiÌË ÁÈ· ÙfiÛÔ Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, fiÛÔ ··ÈÙÂ›Ù·È Ì¤¯ÚÈ Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ÔÈ ÂÈÏÔΤ˜ Ù˘ ˘¤ÚÙ·Û˘. ∞fi ÌÂϤÙ˜ Û ÂÓËÏ›ÎÔ˘˜ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘¤ÚÙ·Û˘ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ·ÔÊÚ·ÎÙÈ΋˜ ·ÚÙËÚÈÔÛÎÏËÚ˘ÓÙÈ΋˜ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘, ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ÂÁÎÂÊ·ÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ¤¯ÂÈ ‹‰Ë ÂÁηٷÛÙ·ı› Ôχ ÚÈÓ ·Ó·ÁÓˆÚÈÛÙ› Ë ˘¤ÚÙ·ÛË Î·È ·Ú¯›ÛÂÈ Ë ıÂÚ·¢ÙÈ΋ Ù˘ ·ÓÙÈÌÂÙÒÈÛË. ∞˘Ùfi οÓÂÈ ÂÈÙ·ÎÙÈ΋ ÙËÓ ·Ó¿ÁÎË Ù˘ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘. Œ¯ÂÈ, Â›Û˘, ηٷ‰Âȯı› ·fi ÌÂϤÙ˜ fiÙÈ ·È‰È¿ Î·È Î˘Ú›ˆ˜ ¤ÊË‚ÔÈ Ì ˘„ËÏ‹ ∞¶ ¤¯Ô˘Ó

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ÂÌÊ·Ó›ÛÔ˘Ó ·ÚÁfiÙÂÚ· ˘¤ÚÙ·ÛË. ™ÙË ‰Â˘ÙÂÚÔ·ı‹ ˘¤ÚÙ·ÛË, Ë ÚfiÁÓˆÛË Â›Ó·È ÛÙÂÓ¿ Û˘Ó‰Â‰Â̤ÓË Ì ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ·˘Ù‹Ó. ¶ÚfiÏË„Ë ∏ ÚˆÙÔ·ı‹˜ ˘¤ÚÙ·ÛË Û˘Û¯ÂÙ›˙ÂÙ·È ıÂÙÈο Ì ÙËÓ ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË Î·È Ì·˙› Ì ÙË ‰˘ÛÏÈȉ·ÈÌ›· Î·È ÙÔ Î¿ÓÈÛÌ·, ·ÔÙÂÏÔ‡Ó Ù· ÙÚ›· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÁÂÓÂÛÈÔ˘ÚÁ¿ ·›ÙÈ· Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È Ù˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∞ÎfiÌË Î·È ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ˘¤ÚÙ·ÛË Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· ¤¯ÂÈ ÂÈÙÒÛÂȘ ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· (18). ∏ ·ÚÔ˘Û›· ·¯˘Û·ÚΛ·˜ ‰Ú· Û·Ó ¤Ó·˜ ·ÎfiÌË ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. OÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰Â, Ù›ÓÔ˘Ó Ó· ÂÓÈÛ¯‡Ô˘Ó Ô ¤Ó·˜ ÙÔÓ ¿ÏÏÔ Î·È Ó· ÂȉÚÔ‡Ó ·ıÚÔÈÛÙÈο. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÚÔÏËÙÈο ̤ÙÚ· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ·ÚÈÔ ÛÙfi¯Ô ¤ÓÙ ‚·ÛÈο ‰›·: ·) ÙËÓ ·¯˘Û·ÚΛ·, ‚) ÙËÓ ˘¤ÚÙ·ÛË, Á) ÙËÓ Î·Ï‹ ηډȷÁÁÂȷ΋ ηٿÛÙ·ÛË, ‰) ÙËÓ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È Â) ÙÔ Î¿ÓÈÛÌ· (34). OÈ Î·Ú‰È·ÁÁÂȷΤ˜ ÓfiÛÔÈ, ·Ú¿ ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ¿˜ ÙÔ˘˜, ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·Ú·Ì¤ÓÔ˘Ó ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·Èٛ˜ ı·Ó¿ÙÔ˘ ÛÙÔ ‰˘ÙÈÎfi ÎfiÛÌÔ. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ˘¤ÚÙ·Û˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ ›ӷÈ: ·) ˘„ËÏ‹ Ê˘ÛÈÔÏÔÁÈ΋ ∞¶ (>90˘ ∂£) Û Â·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ, ‚) ∞¶ ÛÙ·ıÂÚ¿ ÛÙ· ·ÓÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (>70˘ ∂£) ‹ ∞¶ Ô˘ ηٿ Ê¿ÛÂȘ ÍÂÂÚÓ¿ ÙËÓ 95Ë ∂£, Á) ·¯˘Û·ÚΛ·, ÂȉÈÎfiÙÂÚ· ·¯‡Û·Úη ·È‰È¿, ·¯˘Û¿ÚÎˆÓ ÁÔÓ¤ˆÓ). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ·¯˘Û·ÚΛ· (΢ڛˆ˜ ·˘Ù‹ Ì ÎÂÓÙÚÈ΋ ηٷÓÔÌ‹) Û˘Ó‰¤ÂÙ·È Ì ˘¤ÚÙ·ÛË, ‰˘ÛÏÈȉ·ÈÌ›·, ·˘ÍË̤ÓÔ Û¿Î¯·ÚÔ ·›Ì·ÙÔ˜, ·˘ÍË̤ӷ Â›‰· ÈÓÛÔ˘Ï›Ó˘, ÂÓÒ fiÙ·Ó ·Ú¯›˙ÂÈ ÎÔÓÙ¿ ÛÙËÓ ÂÊ˂›·, Ù›ÓÂÈ Ó· Û˘Ó¯›˙ÂÙ·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ Î·È Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ¿ÏÏˆÓ ÓfiÛˆÓ ÛÙ· ¿ÙÔÌ· ·˘Ù¿ (35,36), ‰) ˘ÂÚÏÈȉ·ÈÌ›· ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘ÂÚÏÈȉ·ÈÌ›·˜, ÂȉÈο Â¿Ó Û˘Ó˘¿Ú¯ÂÈ Î·È ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ‹ ÂÁÎÂÊ·ÏÈÎfi, Â) ۷ί·Ú҉˘ ‰È·‚‹Ù˘, ÛÙ) ˘¤ÚÙ·ÛË Ô˘ ··ÈÙ› Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, Û ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ˙) ·˘ÍË̤ÓË ÚfiÛÏË„Ë ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘, Ë) ¤ÏÏÂÈ„Ë ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘ Î·È ı) ηٿ¯ÚËÛË ·ÏÎÔfiÏ˘ Î·È Î¿ÓÈÛÌ· (¤ÊË‚ÔÈ). ¶ÔÏÏÔ› ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÌÂϤÙ˜, Ù›ÓÔ˘Ó Ó· Û˘Ó˘¿Ú¯Ô˘Ó Â·˘Í¿ÓÔÓÙ·˜ Ô ¤Ó·˜ ÙÔÓ ¿ÏÏÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Û˘Ó¯›˙ÔÓÙ·È ÂÊ’ fiÚÔ˘ ˙ˆ‹˜ (8).

Paediatriki 2001;64:448-459

¶›Ó·Î·˜ 4. ∫·ÙËÁÔڛ˜ Ê·ÚÌ¿ÎˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘¤ÚÙ·Û˘ ¢ÈÔ˘ÚËÙÈο ñ ¶·Ú·ÙÂٷ̤Ó˘ ‰Ú¿Û˘ - ÊÔ˘ÚÔÛÂÌ›‰Ë=1, [max=12] [2-6 ¢∏¢] ñ º¿Ú̷η Ô˘ ‰È·ÙËÚÔ‡Ó ÙÔ Î¿ÏÈÔ: - ™ÈÚÔÓÔÏ·ÎÙfiÓË=1, [max=3] [1-2 ¢∏¢] ñ £ÂÈ·˙ȉÈο ‰ÈÔ˘ÚËÙÈο - À‰ÚԯψÚÔıÂÈ·˙›‰Ë=1, [max=2-3] [2 ¢∏¢] ∞‰ÚÂÓÂÚÁÈÎÔ› ·Ó·ÛÙÔÏ›˜ ñ ‚-·‰ÚÂÓÂÚÁÈÎÔ› ·ÓÙ·ÁˆÓÈÛÙ¤˜ - ∞ÙÂÓÔÏfiÏË=1, [max=8] [1-2 ¢∏¢] - ¶ÚÔ·ÓÔÏfiÏË=1, [max=8] [2-3¢∏¢] ∫ÂÓÙÚÈÎÔ› ·‰ÚÂÓÂÚÁÈÎÔ› ·Ó·ÛÙÔÏ›˜ ñ ·-·‰ÚÂÓÂÚÁÈÎÔ› ·ÓÙ·ÁˆÓÈÛÙ¤˜ - ¶Ú·˙ÔÛ›ÓË=0,05-0,1, [max=0,5] [3-4 ¢∏¢] AÁÁÂÈԉȷÛÙ·ÏÙÈο ñ ¶·Ú¿ÁÔÓÙ˜ Ô˘ ¯·Ï·ÚÒÓÔ˘Ó ÙȘ Ï›˜ Ì˘˚Τ˜ ›Ó˜ - ¡ÈÙÚÔÚˆÛÛÈÎfi ¡¿ÙÚÈÔ=0,5 Ìg/kg/‰fiÛË [max=8] ñ ∞ÓÙ·ÁˆÓÈÛÙ¤˜ ·Û‚ÂÛÙ›Ô˘ - ¡ÂʉÈ›ÓË=1, [max=2], [4-6 ¢∏¢] ñ ∞Ó·ÛÙÔÏ›˜ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ - ∂Ó·Ï·Ú›ÏË=0,15, [max=?] [1-2 ¢∏¢] - ∫·ÙÔÚ›ÏË=1,5, [max=6] [3 ¢∏¢] OÈ ·Ó·ÊÂÚfiÌÂÓ˜ ‰fiÛÂȘ Â›Ó·È Û mg/kg/Ë̤ڷ, ÂÎÙfi˜ ·Ó ˘¿Ú¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ ¤Ó‰ÂÈÍË.

[Max: ̤ÁÈÛÙË ‰fiÛË] [¢∏¢: ‰È·ÈÚÂ̤Ó˜ ËÌÂÚ‹ÛȘ ‰fiÛÂȘ]

O ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ™ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Â·Ê›ÂÙ·È Ë ÚfiÏË„Ë Ù˘ ˘¤ÚÙ·Û˘ Ì ÙȘ ηٷÛÙÚÂÙÈΤ˜ Ù˘ Û˘Ó¤ÂȘ. ∞˘Ùfi Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ∞¶ ·Ó¿ Ù·ÎÙ¿ ‰È·ÛÙ‹Ì·Ù·, ÙË ‰È¿ÁÓˆÛË Ù˘ ˘¤ÚÙ·Û˘ Î·È ÙËÓ ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘. ∏ ∞ÌÂÚÈηÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· Û˘ÓÈÛÙ¿ ÂÙ‹ÛÈÔ ¤ÏÂÁ¯Ô Ù˘ ∞¶. ∂¿Ó ˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜, Ë Ì¤ÙÚËÛË Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û˘¯ÓfiÙÂÚ·. ∏ ‰È·ÙÚÔÊ‹ ·ÔÙÂÏ› ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÂÚÈ‚·ÏÏÔÓÙÈÎfi ·Ú¿ÁÔÓÙ· Ô˘ Úԉȷı¤ÙÂÈ Û ·¯˘Û·ÚΛ·, ˘ÂÚÏÈȉ·ÈÌ›· Î·È ˘¤ÚÙ·ÛË (38). OÈ ·È‰›·ÙÚÔÈ ÌÔÚÔ‡Ó Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó Û ÂÈÌÔÚʈÙÈο ÚÔÁÚ¿ÌÌ·Ù·, ·ÎfiÌË Î·È ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÎ·›‰Â˘ÛË, fiÛÔÓ ·ÊÔÚ¿ ÙË ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ Î·È ÙȘ ηıËÌÂÚÈÓ¤˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ô˘ ÚÔ¿ÁÔ˘Ó ÙËÓ Î·Ï‹ Ê˘ÛÈ΋ ηٿÛÙ·ÛË. ªÔÚÔ‡Ó, Â›Û˘, Ó· ·›ÍÔ˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÈÌfiÚʈÛË fiÏˆÓ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÛÙÔ˘˜ ÙÔÌ›˜ ·˘ÙÔ‡˜, ÂÏ·ÙÙÒÓÔÓÙ·˜ ¤ÙÛÈ ÌÂÏÏÔÓÙÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ (39). ªÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ fiÙ·Ó fiÏ· Ù· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Û˘ÌÌÂÙ¤¯Ô˘Ó, Ù· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙË Û˘ÌÌfiÚʈÛË Â›Ó·È Î·Ï‡ÙÂÚ·. ™ÙËÓ ∞ÌÂÚÈ΋, ÙÔ 80% ÙˆÓ ·È‰ÈÒÓ Î·Ù·Ó·ÏÒÓÂÈ ÙÚÔʤ˜ Ì ÂÚÈÂÎÙÈÎfiÙËÙ· Û ÎÂÎÔÚÂṲ̂ӷ ÏÈ·Ú¿ Ôͤ· ÌÂÁ·Ï‡ÙÂÚË Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘ Î·È ÙÔ 60-70% ÌÂ

457

¶·È‰È·ÙÚÈ΋ 2001;64:448-459

ÂÚÈÛÛfiÙÂÚË Ù˘ ÂÈÙÚÂfiÌÂÓ˘ ¯ÔÏËÛÙÂÚ›ÓË. ™ÙÔ ‰˘ÙÈÎfi ÎfiÛÌÔ, Ù· ÙÂÏÂ˘Ù·›· 15-20 ¯ÚfiÓÈ·, ¤¯ÂÈ ·Ú·ÙËÚËı› ·‡ÍËÛË ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘ ‚¿ÚÔ˘˜ ηٿ 10 ÎÈÏ¿ ÂÚ›Ô˘, ÂÓÒ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÙÔ 25% ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ∞ÌÂÚÈ΋ Â›Ó·È ·¯‡Û·Úη, ηıÒ˜ Î·È 1 ÛÙ· 5 ÂÏÏËÓfiÔ˘Ï· 2-12 ÂÙÒÓ. ∂›Û˘, ¤¯ÂÈ ·Ú·ÙËÚËı› ÂÏ¿ÙÙˆÛË Ù˘ ¿ıÏËÛ˘ ÙˆÓ ·È‰ÈÒÓ, Ë ÔÔ›· Èı·ÓÒ˜ ÂÓ¤¯ÂÙ·È ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘. O ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ·Ú¤Ì‚ÂÈ Û˘ÛÙ‹ÓÔÓÙ·˜ ÏÈÁfiÙÂÚÔ ¯ÚfiÓÔ ÛÙËÓ ÙËÏÂfiÚ·ÛË ‹ ÙÔÓ ËÏÂÎÙÚÔÓÈÎfi ˘ÔÏÔÁÈÛÙ‹ Î·È ÂÚÈÛÛfiÙÂÚË ¿ıÏËÛË, Û˘Ì‚¿ÏÏÔÓÙ·˜ ¤ÙÛÈ ÛÙËÓ Î·Ù·ÔϤÌËÛË Î·ÎÒÓ Û˘ÓËıÂÈÒÓ. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘ ̤¯ÚÈ ÙËÓ ÂÓËÏÈΛˆÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ, ‰›ÓÂÈ Û’ ·˘ÙfiÓ ÙË ‰˘Ó·ÙfiÙËÙ· ÛËÌ·ÓÙÈ΋˜ ·Ú¤Ì‚·Û˘. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÙÔ 73% ÙˆÓ ∞ÌÂÚÈηÓÒÓ ·È‰È¿ÙÚˆÓ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰È·ÌfiÚʈÛË Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ fiÏË ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. CHD Coronary Heart Disease. Overview and summary.

Pediatrics 1992;89:S525-S536.

2. Berenson GS, Pickoff AS. Preventive cardiology and its potential influence on the early natural history of adult heart diseases: The Bogalusa Heart Study and the Heart Smart Program. Am J Med Sci 1995;301(Suppl 1):S134-S138.

3. National High Blood Pressure Education Program Working Group on Hypertension Control in children and adolescents. Update on the 1987 task force report on high blood pressure in children and adolescents: A Working Group Report from the National High Blood Pressure Education Program. Pediatrics 1996;98:649-658.

4. Portman RJ, Yetman RJ. Temporal blood pressure patterns in children. Ann NY Acad Sci 1996;783:227-241.

5. Mahan JD, Turman MA, Mentser MI. Evaluation of hematuria, proteinuria and hypertension in adolescents.

Pediatr Clin N Am 1997;44:1573-1589.

6. Schieken RM. New perspectives in childhood blood pressure. Curr Opin Cardiol 1995;10:87-91.

7. Sorof MJ, Portman RJ. Ambulatory blood pressure monitoring in the pediatric patient. J Pediatr 2000;136:578-586.

8. Lenfant C, Savage PJ. The early natural history of atherosclerosis and hypertension in the young: National Institutes of Health perspectives. Am J Med Sciences 1995;310(Suppl 1):S3-S7.

9. Oalmann MC, Strong JP, Tracy RE, Malcom GT. Atherosclerosis in youth: are hypertension and the other coronary heart disease risk factors at work? Pediatr Nephrol 1997;11:99-107.

10. Berenson GS, Wattigney WA, Bao W, Srinivasan SR, Radhakrishnamurthy B. Rationale to study the early natural history of heart disease: The Bogalusa Heart Study. Am J Med Sci 1995;(Suppl 310):S22-S28.

11. Sinaiko AR. Hypertension in children. NEJM

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12. Sadowski RH, Falkner B. Hypertension in pediatric patients. Am J Kidney Dis 1996;27:305-315.

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15. Steiss JO, Rascher W. Automated blood pressure in children. Zeitschrift fur Kardiologie 1996;85(Suppl 3):81-84.

16. Hollyday MA. Is blood pressure in later life affected by events in infancy? Pediatr Nephrol 1995;9:663-666.

17. Gidding SS. A perspective on obesity. Am J Med Sci 1995;301(Suppl 1):S68-S71.

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20. Soergel M, Kirschstein M, Busch C, Danne T, Gellermann J, Holl R et al. Oscillometric twenty-four hour ambulatory blood pressure values in healthy children and adolescents: A multicenter trial including 1141 subjects. J Pediatr 1997;130:178-184.

21. Goble MM. Hypertension in infancy. Pediatr Clin N Am 1993;40:105-122.

22. Myers MM. Enduring effects of infant feeding experiences on adult pressure. Psychosom Med 1996;58:612-621.

23. Falkner B, Michel S. Blood pressure response to sodium in children and adolescents. Am J Clin Nutr 1997;65(Suppl 2):618S-621S. 24. Brouhard BH. Hypertension in children and adolescents.

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25. Schieken RM. Genetic factors that predespose the child to develop hypertension. Pediatr Clin North Am 1993;40:1-11.

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28. ¢. ¶··ı·Ó·Û›Ô˘-∫ÏÒÓÙ˙·. À¤ÚÙ·ÛË: £ÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ¶·È‰È·ÙÚÈ΋ £ÂÚ·¢ÙÈ΋ ∂ÓË̤ڈÛË.

1997. ÛÂÏ. 45-50.

29. Fivush B, Neu A, Furth S. Acute hypertensive crises in children: emergencies and urgencies. Curr Opin Pediatr 1997;9:233-226.

30. Harsha DW. The benefits of physical activity in childhood.

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34. Bronfin DR, Urbina EM. The role of the pediatrician in the promotion of cardiovascular health. Am J Med Sci 1995;310(Suppl 1):S42-47.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-12-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞Ó·ÛÙ·Û›· ∑ÂÚ‚Ô˘‰¿ÎË ºÚ·ÁÎÔÎÎÏËÛÈ¿˜ 55, 151 25, ¶Ôχ‰ÚÔÛÔ ∞Ì·ÚÔ˘Û›Ô˘

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∞˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÛıÌ·ÙÈÎÔ‡ Ù‡Ô˘ Û˘ÌÙˆÌ¿ÙˆÓ Û ÎÔÚ›ÙÛÈ· Ô˘ Á›ÓÔÓÙ·È ˘¤Ú‚·Ú· ‹ ·¯‡Û·Úη ηٿ ÙË Û¯ÔÏÈ΋ ÂÚ›Ô‰Ô1 ™ÎÔfi˜: ∏ Èı·ÓfiÙËÙ· ‡·Ú͢ ·ÈÙÈÔÏÔÁÈ΋˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ·¯˘Û·ÚΛ·˜ Î·È ¿ÛıÌ·ÙÔ˜ ¤¯ÂÈ ˘Ô‰Ëψı› ·fi ÙËÓ ÚfiÛÊ·ÙË ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ¿˜ ÙÔ˘˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™Â ‰Â›ÁÌ· ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, Ë Û˘¯ÓfiÙËÙ· Î·È Ô ÂÈÔÏ·ÛÌfi˜ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Î·È Ô ‰Â›ÎÙ˘ ۈ̷ÙÈ΋˜ Ì¿˙·˜ (Body Mass Index - BMI), ÙÂÎÌËÚÈÒıËÎ·Ó Û ̤ÛË ËÏÈΛ· Ù· 6,3 ¤ÙË (n=688) Î·È Ù· 10,9 ¤ÙË (n=600). OÈ ‰ÔÎÈ̷ۛ˜ ‚ÚÔÁ¯Ô‰È·ÛÙÔÏ‹˜ Î·È Ë ËÌÂÚ‹ÛÈ· ‰È·Î‡Ì·ÓÛË Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ ÌÂÙÚ‹ıËÎ·Ó ÛÙ· 11 ¯ÚfiÓÈ·. ∞ÔÙÂϤÛÌ·Ù·: ¢ÂÓ ˘‹Ú¯Â Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‰Â›ÎÙË ÛˆÌ·ÙÈ΋˜ Ì¿˙·˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ Û˘ÚÚ›ÙÔ˘Û·˜ ·Ó·ÓÔ‹˜ (wheezing) Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·. ∆· ÎÔÚ›ÙÛÈ·, ·ÏÏ¿ fi¯È Ù· ·ÁfiÚÈ·, Ô˘ ‹Ù·Ó ˘¤Ú‚·Ú· ‹ ·¯‡Û·Úη ÛÙËÓ ËÏÈΛ· ÙˆÓ 11 ¯ÚfiÓˆÓ Â›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ÂÌÊ·Ó›ÛÔ˘Ó Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ ÛÙȘ ËÏÈ˘ ÙˆÓ 11 Î·È 13 ÂÙÒÓ, ·ÏÏ¿ fi¯È ÛÙȘ ËÏÈ˘ ÙˆÓ 6 ‹ 8 ÂÙÒÓ. ∞˘Ù‹ Ë Û¯¤ÛË ‹Ù·Ó ÂÓÙÔÓfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ· Ô˘ ›¯·Ó ¤Ó·ÚÍË ÂÓ‹‚ˆÛ˘ ÚÈÓ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 11 ÂÙÒÓ. ∆· ÎÔÚ›ÙÛÈ· Ô˘ ¤ÁÈÓ·Ó ˘¤Ú‚·Ú· ‹ ·¯‡Û·Úη ÌÂٷ͇ ÙˆÓ 6 Î·È 11 ÂÙÒÓ, ›¯·Ó ÂÙ·Ï¿ÛÈ· Èı·ÓfiÙËÙ· Ó· ÂΉËÏÒÛÔ˘Ó Ó¤· Û˘ÌÙÒÌ·Ù· ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 11 ‹ 13 ÂÙÒÓ

(p=0,0002), ÂÓÒ ÛÙËÓ ËÏÈΛ· ÙˆÓ 11 ÂÙÒÓ, Ë ‰È·Î‡Ì·ÓÛË Ù˘ ̤ÁÈÛÙ˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔ‹˜ Î·È Ë ·ÓÙ·fiÎÚÈÛË ÛÙ· ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο ›¯·Ó Ôχ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· Â›Ó·È ·˘ÍË̤Ó˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ÎÔÚ›ÙÛÈ· Ô˘ Á›ÓÔÓÙ·È ˘¤Ú‚·Ú· ‹ ·¯‡Û·Úη Û ËÏÈΛ· 6-11 ÂÙÒÓ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ Ó¤ˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ¿ÛıÌ·ÙÔ˜ Î·È ·˘ÍË̤ÓË ‚ÚÔÁ¯È΋ ··ÓÙËÙÈÎfiÙËÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚÒÈÌ˘ ÂÊË‚È΋˜ ËÏÈΛ·˜.

1 Castro-Rodriguez JA, Holberg CJ, Morgan WJ, Wright AL, Martinez FD Increased incidence of asthma like symptoms in girls who become overweight or obese during the school years Am J Respir Crit Care Med 2001;163:1344-1349

£ÂÔÊ¿Ó˘ ∆ÛÈÏÈÁÈ¿ÓÓ˘ ¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡·˘ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ıËÓÒÓ

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™‡Ó‰ÚÔÌÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η π. X·ÚˆÓ›ÙË, ¢. §·ÌÚ¿ÎË, µ. ∞ÁÁÂÏ¿ÎÔ˘

Anticonvulsant hypersensitivity syndrome I. Charoniti, D. Lampraki, V. Aggelakou

¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (™À∞) ·ÔÙÂÏ› ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋, ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ·ÓÙ›‰Ú·ÛË, Ô˘ ÎÏ·ÛÈο ·Ô‰›‰ÂÙ·È ÛÙ· ·ÚˆÌ·ÙÈο ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (Ê·ÈÓ˘ÙÔ˝ÓË, Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È Î·Ú‚·Ì·˙Â›ÓË) Î·È Û·ÓÈfiÙÂÚ· ÛÙË Ï·ÌÔÙÚÈÁ›ÓË. ∆Ô ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ Î·È Ë ·ÈıÔÛÔ˘ÍÈÌ›‰Ë ¤¯Ô˘Ó Â›Û˘ ÂÓÔ¯ÔÔÈËı›, ·Ó Î·È Ë Û·ÓÈfiÙËÙ· ÙˆÓ ·Ó·ÊÂÚfiÌÂÓˆÓ ÂÚÈÙÒÛÂˆÓ ‰›ÓÂÈ ·ÎfiÌË ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂÚ·›· Û ÂÚÈÙÒÛÂȘ Û˘Ó‰ÚfiÌÔ˘ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÚˆÌ·ÙÈο ·ÓÙÈÂÈÏËÙÈο. ∏ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÙÚÈ¿‰· ÙÔ˘ ™À∞ Â›Ó·È ˘ÚÂÙfi˜, ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Î·È ÂÍ¿ÓıËÌ·. ¶·Ú’ fiÏ· ·˘Ù¿, ÌÔÚ› Ó· ÌÈÌÂ›Ù·È ÏÔÈÌÒ‰ÂȘ Î·È ·˘ÙÔ¿ÓÔÛ˜ ÓfiÛÔ˘˜ ‹ ·ÎfiÌË Î·È Î·ÎÔ‹ıÂȘ. ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, ÙÔ ÔÔ›Ô ÂÌÊ·Ó›˙ÂÙ·È Ì ÔÈΛϘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, Â›Ó·È ÙÔ ÎÏÂȉ› ÁÈ· ÙËÓ ¿ÌÂÛË ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ÙË ÛˆÛÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ¶·Ú¿ÏÏËÏ·, Ë ÛˆÛÙ‹ ‰È¿ÁÓˆÛË Â›Ó·È ÛËÌ·ÓÙÈ΋, ÁÈ·Ù› ¤ÙÛÈ ı· ·ÔÊ¢¯ı› Ë ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· Â·Ó¤ÎıÂÛË ÛÙÔ ˘‡ı˘ÓÔ Ê¿ÚÌ·ÎÔ Î·È ı· ηıÔÚÈÛÙ› Ë ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹.

Abstract: Anticonvulsant hypersensitivity syndrome (AHS) is a multisystem, potentially fatal, drug reaction, classically attributed to the arene oxide-producing anticonvulsants (phenobarbital, carbamazepine, phenytoin), and less frequently to lamotrigine. Sodium valporate and ethosuximide have been also implicated but the reported cases are still rare, so they can still be used as an alternative treatment in cases of AHS due to arene oxide-producing anticonvulsants. The characteristic triad of symptoms of AHS is fever, rash and lymphadenopathy. The syndrome however may mimic infectious and autoimmune diseases or even malignancies. Early recognition of the syndrome, which has a variable presentation, is of great importance for the prompt discontinuation of the anticonvulsant drug as well as for close followup and therapeutic intervention. Furthermore, prompt diagnosis is crucial for the prevention of a potentially fatal outcome by re-exposure to the offending drug as well as for planning the type of antiepileptic therapy to be administered.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, Û‡Ó‰ÚÔÌÔ ˘ÂÚ¢·ÈÛıËÛ›·˜.

Key words: syndrome.

∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (™À∞) Â›Ó·È ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÓÙ›‰Ú·ÛË È‰ÈÔÛ˘ÁÎÚ·Û›·˜, ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· (1). ¶ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1934 ·fi ÙÔ˘˜ Silber Î·È Ebstein Î·È ÙÔ ÂÓÔ¯ÔÔÈÔ‡ÌÂÓÔ ÙfiÙÂ

·ÓÙÈÂÈÏËÙÈÎfi Ê¿ÚÌ·ÎÔ ‹Ù·Ó Ë Ê·ÈÓ˘ÏÂı˘Ï˘‰·ÙÔ˝ÓË, Ô˘ ÚfiÛÊ·Ù· ›¯Â ¯ÚËÛÈÌÔÔÈËı› ÛÙË ıÂÚ·›· Ù˘ ¯ÔÚ›·˜ Sydenham. ŒÎÙÔÙÂ, ·˘Í¿ÓÔ˘Ó ÔÈ ·Ó·ÊÔÚ¤˜, ·Ú¯Èο ÁÈ· ÙȘ ˘‰·ÓÙÔ˝Ó˜ Î·È ·ÚÁfiÙÂÚ· ÁÈ· Ù· ˘fiÏÔÈ· ·ÓÙÈÂÈÏËÙÈο Ô˘ ʤÚÔ˘Ó ·ÚˆÌ·ÙÈÎfi ‰·ÎÙ‡ÏÈÔ ÛÙÔ ÌfiÚÈfi ÙÔ˘˜, fiˆ˜ Ë

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘

∞’ Pediatric Clinic of Venizelio Hospital Heraklion, Crete

460

anticonvulsant

hypersensitivity

¶·È‰È·ÙÚÈ΋ 2001;64:460-464

Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ë Î·Ú‚·Ì·˙Â›ÓË Î·È Ë Ï·ÌÔÙÚÈÁ›ÓË (2,3). ∆ÂÏÂ˘Ù·›·, ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Î·È ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η Ì Ôχ ‰È·ÊÔÚÂÙÈ΋ ¯ËÌÈ΋ ‰ÔÌ‹, fiˆ˜ Ë ·ÈıÔ˘ÛÔÍÈÌ›‰Ë Î·È ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ, ·Ó Î·È ÔÈ ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È Â›Ó·È ·ÎfiÌË Û·ÓÈfiٷ٘ (¤¯ÂÈ ·Ó·ÊÂÚı› Ì›· ÂÚ›ÙˆÛË ™À∞ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‚·ÏÚÔ˚ÎÔ‡ Ó·ÙÚ›Ô˘ Î·È Ì›· ÌÂÙ¿ ·fi Ù·˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ‚·ÏÚÔ˚ÎÔ‡ Ó·ÙÚ›Ô˘ Î·È ·ÈıÔ˘ÛÔÍÈÌ›‰Ë˜) (4). ªfiÏȘ ÙÔ 1988 ·Ó·ÁÓˆÚ›ÛÙËΠÙo ™À∞ ˆ˜ ͯˆÚÈÛÙ‹ ÔÓÙfiÙËÙ·. ∞ÎfiÌË Î·È Û‹ÌÂÚ·, fï˜, ÂÍ·ÎÔÏÔ˘ı› Ó· ÚÔηÏ› Û‡Á¯˘ÛË Î·È ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜. ∏ ·ÎÚÈ‚‹˜ ‰È¿ÁÓˆÛË Â›Ó·È ‰‡ÛÎÔÏË ÏfiÁˆ ÙˆÓ ÔÈÎ›ÏˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Î·È ‚ÈÔ¯ËÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ô˘ ÌÈÌÔ‡ÓÙ·È ÔÈÎÈÏ›· ÏÔÈ̈‰ÒÓ, ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ·˘ÙÔ¿ÓÔÛˆÓ ‰È·Ù·Ú·¯ÒÓ (5). ∏ ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜, ÁÈ·Ù› Ë ÌË ‰È·ÎÔ‹ ÙÔ˘ ‡ÔÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ı¤ÙÂÈ Û ΛӉ˘ÓÔ ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. ªÂ ·ÊÔÚÌ‹ ÙËÓ ÚfiÛÊ·ÙË ÓÔÛËÏ›· ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ‰‡Ô ·ÛıÂÓÒÓ Ì ™À∞, ·Ó·ÛÎÔԇ̠ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Î·È ÂÚÈÁÚ¿ÊÔ˘Ì ÙȘ ÂÚÈÙÒÛÂȘ. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ∏ ÚÒÙË ÂÚ›ÙˆÛË ·ÊÔÚ¿ ÎÔÚ›ÙÛÈ 7,5 ÂÙÒÓ Ô˘ ÚÔÛ‹Ïı Ì ˘ÚÂÙfi ˆ˜ 39,5ÔC ·fi 2Ë̤ÚÔ˘, ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ, ÂͤڢıÚ· ·Ú›ÛıÌÈ·, ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ΢ڛˆ˜ ÛÙËÓ ÔÈÛıÔˆÙÈ·›· ÂÚÈÔ¯‹ Î·È Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· (‹·Ú 6 cm „ËÏ·ÊËÙfi, ÛÏ‹Ó·˜ 4 cm „ËÏ·ÊËÙfi˜). ™ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·ÊÂÚfiÙ·Ó fiÙÈ Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÂÂÈÛfi‰È· ·Ê·ÈÚ¤ÛˆÓ, ÁÈ· Ù· ÔÔ›· ›¯Â ÚÔ ÌËÓfi˜ ·Ú¯›ÛÂÈ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ Ì ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ›¯Â: °ÂÓÈ΋ ·›Ì·ÙÔ˜: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 8120/mmÑ (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 72%, ÏÂÌÊÔ·ÙÙ·Ú· 10%, ÌÔÓÔ·ÙÙ·Ú· 10%, Ú·‚‰Ô‡ÚËÓ· 8%), Hgb 12 g/dl, Hct 36,6%, Aª¶ 224.000/mmÑ. ∆∫∂ 15 mm/h, SGOT 113,2 U/L, SGPT 112,4 U/L, ÁGT 39 U/L, ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË 0,8 mg/dl, ÔÏÈο Ï¢ÎÒÌ·Ù· 6,7 g/dl, ·Ï‚Ô˘Ì›ÓË 4,1 g/dl. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜, Ë Î·Ù¿ÛÙ·ÛË Ù˘ ·ÛıÂÓÔ‡˜ ÂȉÂÈÓÒıËÎÂ. ¶·ÚÔ˘Û›·˙ ˘ÚÂÙÈο ·̷ٷ ˆ˜ 40ÔC ·Ó¿ ÙÚ›ˆÚÔ, Ô˘ Û˘Óԉ‡ÔÓÙ·Ó ·fi Ú›ÁÔ˜. ∆Ô ÂÍ¿ÓıËÌ· ÂÍ·ÏÒıËΠÛÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·, ¤ÁÈÓÂ Û˘ÚÚ¤ÔÓ Î·È ÎÓËÛÌ҉˜, Ì ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ· Î·È Î·Ù¿ ÙfiÔ˘˜ ·ÈÌÔÚÚ·ÁÈο ÛÙÔȯ›·. ∏ Â·Ó¿ÏË„Ë ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ¤‰ÂȯÓ Âȉ›ӈÛË: °ÂÓÈ΋ ·›Ì·ÙÔ˜: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 20.100/mmÑ (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 10%,

Paediatriki 2001;64:460-464

ÏÂÌÊÔ·ÙÙ·Ú· 60%, ÌÔÓÔ·ÙÙ·Ú· 15%, Ú·‚‰Ô‡ÚËÓ· 11%), Hgb 12,3 g/dl, Hct 36,2%, AªT 188.000/mmÑ. H·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·: SGOT 867 U/L, SGPT 1111 U/L, ÔÏ. ¯ÔÏÂÚ˘ıÚ›ÓË 2,23 mg/dl, ¿ÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË 1,59 mg/dl, ÔÏÈο Ï¢ÎÒÌ·Ù· 5,8 g/dl, ·Ï‚Ô˘Ì›ÓË 3,2 g/dl, PT 17 sec, INR 1,59, aPTT 37,55 sec, D-Dimers 1031,76 Ìg/l (ÊÙ: 125-375 Ìg/l).

M ÙËÓ ˘Ô„›· ™À∞, ‰ÈÂÎfiË Ë ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ÙËÓ 3Ë Ë̤ڷ ÓÔÛËÏ›·˜. ∏ ·ÛıÂÓ‹˜, ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ ‡ÔÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·ÚÔ˘Û›·Û ÛÙ·‰È·Î‹ ‡ÊÂÛË ÙÔ˘ ˘ÚÂÙÔ‡ Î·È ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜, ÙÔ ÔÔ›Ô ÛÙËÓ ·Ô‰ÚÔÌ‹ ÙÔ˘ ¤ÁÈÓ ·ÔÊÔÏȉˆÙÈÎfi. O ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛ Ï‹Úˆ˜ Û ̛· ‚‰ÔÌ¿‰· Î·È ÙÔ ÂÍ¿ÓıËÌ· Û 9 Ë̤Ú˜. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, ÛÙÔ Ù¤ÏÔ˜ Ù˘ ‰Â‡ÙÂÚ˘ ‚‰ÔÌ¿‰·˜ Ù˘ ÓfiÛÔ˘ Ù˘, ‹Ù·Ó ÛËÌ·ÓÙÈο ‚ÂÏÙȈ̤ÓÔ˜: °ÂÓÈ΋ ·›Ì·ÙÔ˜: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 8.000/mmÑ (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 30%, ÏÂÌÊÔ·ÙÙ·Ú· 42%, ÌÔÓÔ·ÙÙ·Ú· 2%, ˈÛÈÓfiÊÈÏ· 26%), ∏gb 10,3 g/dl, Hct 30,2%, AªT 247.000/mmÑ. H·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·: SGOT 88 U/L, SGPT 193 U/L. O ¤ÏÂÁ¯Ô˜ ÁÈ· ÈÔÁÂÓ›˜ Î·È ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ (HAV, HBV, HCV, EBV, CMV, toxoplasma, ·‰ÂÓÔ˚Ô‡˜, echo-ÈÔ‡˜, parvo-ÈÔ‡˜, ƒÈΤÙÛȘ, Borrelia Burgdorferi, Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜) ·¤‚Ë ·ÚÓËÙÈÎfi˜. O ¤ÏÂÁ¯Ô˜ ÁÈ· ÎÔÈÓ¿ ·ıÔÁfiÓ· Ì ÔÏÏ·Ϥ˜ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, Â›Û˘ ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∏ ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ·ÊÔÚ¿ ÎÔÚ›ÙÛÈ 11 ÂÙÒÓ Ô˘ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÁÈ·Ù› ·fi 24ÒÚÔ˘ ·ÚÔ˘Û›·Û ˘ÚÂÙfi ˆ˜ 38ÔC Î·È ÁÂÓÈÎÂ˘Ì¤ÓÔ ÎËÏȉ҉˜ ÂÍ¿ÓıËÌ· Ì ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ·. ™ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi Ù˘ ·ÛıÂÓÔ‡˜ ·Ó·Ê¤ÚÔÓÙ·Ó ÂÂÈÛfi‰È· ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ÙÔÓÈÎÔÎÏÔÓÈÎÒÓ Û·ÛÌÒÓ, ÁÈ· Ù· ÔÔ›· ¿Ú¯ÈÛ ӷ Ï·Ì‚¿ÓÂÈ ıÂÚ·›· Ì ηڂ·Ì·˙Â›ÓË ·fi 11Ë̤ÚÔ˘. ∏ Ê˘ÛÈ΋ ÂͤٷÛË ·ÔÎ¿Ï˘„ ‰ÈÔÁΈ̤ÓÔ˘˜ ˘ÔÁÓ¿ıÈÔ˘˜ Î·È ÙÚ·¯ËÏÈÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜ Ô˘ ‹Ù·Ó ¢·›ÛıËÙÔÈ ÛÙËÓ „ËÏ¿ÊËÛË.

O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ‹Ù·Ó ¯ˆÚ›˜ ȉȷ›ÙÂÚË ·ıÔÏÔÁ›· Î·È ·Ú¤ÌÂÈÓ ¤ÙÛÈ ¤ˆ˜ ÙËÓ ¤ÍÔ‰fi Ù˘: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· 4700/mmÑ (ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 64,7%, ÏÂÌÊÔ·ÙÙ·Ú· 22%, ÌÔÓÔ·ÙÙ·Ú· 7%), Hgb 13,4 g/dl, Hct 40%, AªT 239.000/mmÑ, ∆∫∂ 20 mm/h. H·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·: SGOT 19 U/L, SGPT 15 U/L, ÔÏ. ¯ÔÏÂÚ˘ıÚ›ÓË 0,39 mg/dl, ÔÏÈο Ï¢ÎÒÌ·Ù· 7,3 g/dl, ·Ï‚Ô˘Ì›ÓË 4,7 g/dl, PT 12 sec, INR 1,09, aPTT 35,6 sec. ªÂ ÙËÓ ˘Ô„›· ™À∞, ¤ÁÈÓ ¿ÌÂÛ· ‰È·ÎÔ‹ Ù˘ ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜, ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓ˘ Î·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË ˘‰ÚÔ͢˙›Ó˘. O ˘ÚÂÙfi˜, ÙÔ ÂÍ¿ÓıËÌ· Î·È Ë ÏÂÌÊ·‰ÂÓÈ΋ ‰ÈfiÁΈÛË ¿Ú¯ÈÛ·Ó Ó· ˘Ô¯ˆÚÔ‡Ó ·fi ÙÔ 3Ô 24ˆÚÔ ÓÔÛËÏ›·˜. ∏ ·ÛıÂÓ‹˜, ÙËÓ 4Ë

461

¶·È‰È·ÙÚÈ΋ 2001;64:460-464

Ë̤ڷ ÓÔÛËÏ›·˜, ÂÌÊ¿ÓÈÛ ÂÂÈÛfi‰ÈÔ ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ÙÔÓÈÎÔÎÏÔÓÈÎÒÓ Û·ÛÌÒÓ ‰È¿ÚÎÂÈ·˜ Ï›ÁˆÓ ‰Â˘ÙÂÚÔϤÙˆÓ. °È· ·˘ÙfiÓ ÙÔ ÏfiÁÔ, ÎÚ›ıËΠ··Ú·›ÙËÙË Ë ¤Ó·ÚÍË Ó¤·˜ ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ Ù˘ Î·È ÚÈÓ ÙËÓ Ï‹ÚË ·Ó¿ÚÚˆÛ‹ Ù˘. ª›· ‚‰ÔÌ¿‰· ÌÂÙ¿, ‹Ù·Ó Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, Ì ٷ Û˘ÌÙÒÌ·Ù· Û Ï‹ÚË ·Ô‰ÚÔÌ‹. O ¤ÏÂÁ¯Ô˜ ÁÈ· ÈÔÁÂÓ›˜ Î·È ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ ·¤‚Ë ·ÚÓËÙÈÎfi˜. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ∆Ô ™À∞ ÂΉËÏÒÓÂÙ·È ÙÔ˘˜ ‰‡Ô ÚÒÙÔ˘˜ Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜ Î·È Û˘Ó‹ıˆ˜ ÙË 2Ë ¤ˆ˜ 4Ë Â‚‰ÔÌ¿‰·. ™˘Ì‚·›ÓÂÈ ÓˆÚ›ÙÂÚ· Û ‹‰Ë ¢·ÈÛıËÙÔÔÈË̤ӷ ¿ÙÔÌ·. ™Â ÂÚ›ÙˆÛË Â·Ó·¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ‡ÔÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÂÌÊ·Ó›˙ÂÙ·È ÙȘ ÚÒÙ˜ 24 ÒÚ˜ ·fi ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘. ∂ÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜, Ì Â›ÙˆÛË ÂÚ›Ô˘ 1 ÂÚ›ÙˆÛË ÛÙȘ 3000 (6). ∆· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1.

O Û˘Ó‰˘·ÛÌfi˜ ˘ÚÂÙÔ‡, ÂÍ·Óı‹Ì·ÙÔ˜ Î·È ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·˜ Û ·ÛıÂÓ‹ Ô˘ Ï·Ì‚¿ÓÂÈ ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ Ì ·ÚˆÌ·ÙÈο ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, Ú¤ÂÈ Ó· ÂÁ›ÚÂÈ ˘Ô„›Â˜ ÁÈ· ÙÔ ™À∞. ™ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, fï˜, Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ ™À∞ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÔχÏÔÎË. ∆· ÎÏÈÓÈο ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· ÌÔÚ› Ó· ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ ¤Ó·ÚÍ‹˜ ÙÔ˘˜ Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ÌÂÌÔӈ̤ӷ ‹ ηٿ Û˘ÚÚÔ‹. ŒÙÛÈ, ‰˘Û¯ÂÚ·›ÓÂÙ·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛ‹ ÙÔ˘. ∂È‚¿ÏÏÂÙ·È ·˘ÍË̤ÓÔ˜ ‰Â›ÎÙ˘ ˘Ô„›·˜, ÚÔÎÂÈ̤ÓÔ˘ ÙÔ ™À∞ Ó· ·Ó·ÁÓˆÚÈÛÙ›, ¿Ú· Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ·. O ˘ÚÂÙfi˜ Û˘Ó·ÓÙ¿Ù·È ÛÙÔ Û‡ÓÔÏÔ Û¯Â‰fiÓ ÙˆÓ ÂÚÈÙÒÛˆÓ. ™˘Ó‹ıˆ˜ ÚÔËÁÂ›Ù·È ‹ ÂÌÊ·Ó›˙ÂÙ·È Ù·˘Ùfi¯ÚÔÓ· Ì ٷ ˘fiÏÔÈ· Û˘ÌÙÒÌ·Ù·. ∂›Ó·È ˘„ËÏfi˜, Î˘Ì·›ÓÂÙ·È ·fi 38ÔC ¤ˆ˜ 40ÔC Î·È ‰ËÌÈÔ˘ÚÁ› ˘Ô„›Â˜ ÁÈ· ˘ÔΛÌÂÓË Ïԛ̈ÍË. ªÔÚ› Ó· ÂÈ̤ÓÂÈ ÁÈ· ‚‰ÔÌ¿‰Â˜, ¤ˆ˜ fiÙÔ˘ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ˘‡ı˘ÓÔ˘ Ê·ÚÌ¿ÎÔ˘ ‰È·ÎÔ›, ÔfiÙ ÙÂÏÈο Î·È ˘Ô¯ˆÚ› ¿ÌÂÛ· ‹, ÛÙȘ ÈÔ ÛÔ‚·Ú¤˜ ÂÚÈÙÒÛÂȘ, ÛÙ·‰È·Î¿. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ÂÍ¿ÓıËÌ·, ÚfiÎÂÈÙ·È Û˘Ó‹ıˆ˜ ÁÈ· ÂÚ˘ıËÌ·ÙÒ‰ÂȘ ÎËÏ›‰Â˜ Ô˘ ÛÙËÓ ÔÚ›· ·˘Í¿ÓÔÓÙ·È, Û˘ÚÚ¤Ô˘Ó, Ï·Ì‚¿ÓÔ˘Ó ÛÎÔ‡ÚÔ ÎfiÎÎÈÓÔ ¯ÚÒÌ· Î·È ÌÂÙ·ÙÚ¤ÔÓÙ·È Û ‚Ï·Ù›‰Â˜. ∞Ú¯›˙ÂÈ ·fi ÙÔÓ ÎÔÚÌfi, ÙÔ ÚfiÛˆÔ, Ù· ¿Óˆ ¿ÎÚ· Î·È ÂÍ·ÏÒÓÂÙ·È ÛÙ· οو ¿ÎÚ·. ∆Ô Ô›‰ËÌ· ÙÔ˘ ÚÔÛÒÔ˘ ÌÔÚ› Ó· Â›Ó·È ÙfiÛÔ ÛÔ‚·Úfi Î·È ÂÎÙÂٷ̤ÓÔ, ÒÛÙ ӷ ·Ú·ÌÔÚÊÒÓÔÓÙ·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·ÛıÂÓÔ‡˜. ™ÙËÓ ÔȉË-

462

Paediatriki 2001;64:460-464

¶›Ó·Î·˜ 1. ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û˘Ó‰ÚfiÌÔ˘ ˘ÂÚ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (1) ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ¶˘ÚÂÙfi˜ ∂Í¿ÓıËÌ· §ÂÌÊ·‰ÂÓÔ¿ıÂÈ· ¶ÔÏ˘ÔÚÁ·ÓÈ΋ Û˘ÌÌÂÙÔ¯‹ ∏·Ù›Ùȉ· ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ¶ÂÚÈÔÊı·ÏÌÈÎfi ‹ Ô›‰ËÌ· ÚÔÛÒÔ˘ ª˘·ÏÁ›Â˜ - ∞ÚıÚ·ÏÁ›Â˜ º·Ú˘ÁÁ›Ùȉ·

∂›ÙˆÛË (%) 90-100 90 70 60 50-60 50 25 21 10

1

Arch Intern Med 1995;155:2285-2289

Ì·ÙÒ‰Ë ÂÚÈÔ¯‹ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Ê˘Û·Ï›‰Â˜, ÂÚÈÊÂÚÈο ÙˆÓ ÔÔ›ˆÓ ÙÔ ‰¤ÚÌ· ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÔϤÈÛË Î·È ÔÈ Ôԛ˜ ·ÚÁfiÙÂÚ· ı· ÂÍÂÏȯıÔ‡Ó Û ÊχÎÙ·ÈÓ˜. ªÂ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ¤ÓÙÔÓË ·ÔÊÔÏ›‰ˆÛË. ™·ÓÈfiÙÂÚ·, ÔÈ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÌÔÚ› Ó· Á›ÓÔ˘Ó ÙfiÛÔ ÛÔ‚·Ú¤˜, ÒÛÙ ӷ ¿ÚÔ˘Ó ÙË ÌÔÚÊ‹ ÙÔ˘ ÔχÌÔÚÊÔ˘ ÂÚ˘ı‹Ì·ÙÔ˜ ‹ Ù˘ ÂȉÂÚÌÔÓÂÎÚfiÏ˘Û˘. ™Ô‚·Ú¤˜ ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û˘Ì‚·›ÓÔ˘Ó Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔ ˘‡ı˘ÓÔ ·ÓÙÈÂÈÏËÙÈÎfi Ê¿ÚÌ·ÎÔ Â·Ó·¯ÔÚËÁ‹ıËÎÂ, ÂÓÒ ÛÙÔ ·ÚÂÏıfiÓ Â›¯Â ÚÔÍÂÓ‹ÛÂÈ ·ÚÂÓ¤ÚÁÂȘ Î·È Û ÂΛÓÔ˘˜ Ô˘ Ë ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ Û˘Ó¯›˙ÂÙ·È ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ˘ÂÚ¢·ÈÛıËÛ›·˜.

H ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ÌÔÚ› Ó· ·ÊÔÚ¿ ÌÂÌÔӈ̤ÓÔ˘˜ ÏÂÌÊ·‰¤Ó˜ ‹ Ó· Â›Ó·È ÁÂÓÈÎÂ˘Ì¤ÓË. OÈ ÏÂÌÊ·‰¤Ó˜ Â›Ó·È ‰ÈÔÁΈ̤ÓÔÈ Î·È Â˘·›ÛıËÙÔÈ. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ‹·ÙÔ˜ Ì ÙË ÌÔÚÊ‹ Ë·Ù›Ùȉ·˜. ∏ Ë·ÙÈ΋ ÚÔÛ‚ÔÏ‹ ıˆÚÂ›Ù·È Ë ÛÔ‚·ÚfiÙÂÚË ÂÈÏÔ΋ ÁÈ·Ù› Â›Ó·È ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ·. ∏ ıÓËÛÈÌfiÙËÙ· ÙÔ˘ ™À∞ ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ‹·ÙÔ˜ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 18-40%. ∏ Ë·Ù›Ùȉ· Â›Ó·È Û˘Ó‹ıˆ˜ ·ÓÈÎÙÂÚÈ΋. ∏ ·ÚÔ˘Û›· ÈÎÙ¤ÚÔ˘ ‰ËÏÒÓÂÈ ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË. ™ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ·Ó¢ڛÛÎÂÙ·È Ë·ÙÔÌÂÁ·Ï›· Ì ‹ ¯ˆÚ›˜ ÛÏËÓÔÌÂÁ·Ï›·. OÈ ÙÚ·ÓÛ·ÌÈÓ¿Û˜ Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤Ó˜ Î·È ÂӉ¯Ô̤ӈ˜ Ó· Û˘Ó¯›˙Ô˘Ó Ó· ·˘Í¿ÓÔÓÙ·È Î·È ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ ‡ÔÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡. ∂ÈϤÔÓ, ÂËÚ¿˙ÔÓÙ·È ÔÈ ·Ú¿ÁÔÓÙ˜ ‹Í˘, ηıÒ˜ Î·È Ë Û˘ÓıÂÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‹·ÙÔ˜. O ‚·ıÌfi˜ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ‹·ÙÔ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ÌÂÛÔÏ·‚› ̤¯ÚÈ ÙË ‰È·ÎÔ‹ ÙÔ˘ ˘‡ı˘ÓÔ˘ Ê·ÚÌ¿ÎÔ˘. ∏ Ï‹Ú˘ ·ÔηٿÛÙ·ÛË ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ Ì‹Ó˜.

OÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û˘Ó›ÛÙ·ÓÙ·È Û Ï¢ÎÔ΢ÙÙ¿ÚˆÛË, ˈÛÈÓÔÊÈÏ›· Î·È Û¿ÓÈ· ۠ϢÎÔÂÓ›·. ∏ ˈÛÈÓÔÊÈÏ›· ÂÌÊ·Ó›˙ÂÙ·È Û¯ÂÙÈο

¶·È‰È·ÙÚÈ΋ 2001;64:460-464

·ÚÁ¿ ÛÙËÓ ÔÚ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, Û˘Ó‹ıˆ˜ 1-2 ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ ¤Ó·ÚÍ‹ ÙÔ˘. Œ¯ÂÈ, Â›Û˘, ÂÚÈÁÚ·Ê› ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Ì ·ÚÓËÙÈ΋ Coombs.

OÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈΤ˜, fiˆ˜ Â›Û˘ Ë ∆∫∂ Î·È ÙÔ Û˘Ìϋڈ̷. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙÔ˘ ™À∞ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ¶·ıÔÁ¤ÓÂÈ· O ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ ÙÔ˘ ™À∞ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ›. °ÂÁÔÓfi˜ Â›Ó·È fiÙÈ ÙÔ ™À∞ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Ê‡ÏÔ, ÙË ‰fiÛË Î·È Ù· Â›‰· ÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘. ¢È¿ÊÔÚÔÈ Ì˯·ÓÈÛÌÔ›, ·ÓÔÛÔÏÔÁÈÎÔ› Î·È ÌË, ¤¯Ô˘Ó ÚÔÙ·ı›. ªÂÚÈÎÔ› ˘ÔÛÙËÚ›˙Ô˘Ó ˆ˜ ÚfiÎÂÈÙ·È ÁÈ· Ì›· ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÌÔۯ‡̷ÙÔ˜ ÂÓ·ÓÙ›ÔÓ ÍÂÓÈÛÙ‹, ·ÊÔ‡ Ë ·Ú·¿Óˆ ·ÓÙ›‰Ú·ÛË Î·È ÙÔ ™À∞ ¤¯Ô˘Ó ÎÔÈÓ¿ ¯·Ú·ÎÙËÚÈÛÙÈο (1). ¶ÚÔÙ›ÓÂÙ·È ·ÎfiÌË fiÙÈ Ù· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η ÙÚÔÔÔÈÔ‡Ó Ù· ÏÂÌÊÔ·ÙÙ·Ú·, ÒÛÙ ӷ ‰È·Ù·Ú¿ÛÛÂÙ·È Ô Ì˯·ÓÈÛÌfi˜ ·Ó·ÁÓÒÚÈÛ‹˜ ÙÔ˘˜ ˆ˜ “›‰È·” ·ÙÙ·Ú· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ÕÏÏÔÈ ÚÔÙ›ÓÔ˘Ó fiÙÈ ÙÔ ™À∞ ÔÊ›ÏÂÙ·È Û ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈÛÒÌ·Ù·. ª›· ¿ÏÏË ıˆڛ· ÂÓÔ¯ÔÔÈ› ÙÔ˘˜ ÙÔÍÈÎÔ‡˜ ÌÂÙ·‚Ôϛ٘ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·Ú̿ΈÓ, Ì ·ÚˆÌ·ÙÈÎfi ‰·ÎÙ‡ÏÈÔ, Ô˘ ·Ú¿ÁÔÓÙ·È ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘˜ ·fi ÙÔ Î˘Ùfi¯ÚˆÌ· P-450 ÙÔ˘ ‹·ÙÔ˜. ™‡Ìʈӷ Ì ÙËÓ ·Ú·¿Óˆ ıˆڛ·, ˘¿Ú¯Ô˘Ó ¿ÙÔÌ· Ô˘ ʤÚÔ˘Ó ÌÂÙ¿ÏÏ·ÍË ‹ ÛÙÂÚÔ‡ÓÙ·È ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÂÔÍÈ΋ ˘‰ÚÔÍ˘Ï¿ÛË, Ô˘ Â›Ó·È ˘‡ı˘ÓÔ ÁÈ· ÙËÓ ÂÍÔ˘‰ÂÙ¤ÚˆÛË ÙˆÓ ÙÔÍÈÎÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÙˆÓ ·ÓˆÙ¤Úˆ ·Ó·ÊÂÚı¤ÓÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·Ú̿ΈÓ. ∫·Ù¿ Û˘Ó¤ÂÈ·, fiÙ·Ó Ë ·‰Ú·ÓÔÔ›ËÛË ÙˆÓ ÙÔÍÈÎÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ Â›Ó·È ÂÏ·Ùو̷ÙÈ΋, Ë ¿ıÚÔÈÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î˘ÙÙ·ÚÈÎfi ı¿Ó·ÙÔ ‹ Ó· Ô‰ËÁ‹ÛÂÈ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ÓÂÔ·ÓÙÈÁfiÓˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ˘ÚÔ¶›Ó·Î·˜ 2. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙÔ˘ ™À∞ §ÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË ÕÙ˘Ë ÈÏ·Ú¿ §Ô›ÌˆÍË ·fi CMV §Ô›ÌˆÍË ·fi HIV πÔÁÂÓ›˜ Ë·Ù›Ùȉ˜ ™ËÙÈÎfi shock ∆ÔÍÈÎfi Û‡Ó‰ÚÔÌÔ Î·Ù·ÏËÍ›·˜ ™‡ÊÈÏË ™‡Ó‰ÚÔÌÔ Kawasaki ™˘ÛÙËÌ·ÙÈÎfi˜ ÂÚ˘ıËÌ·Ù҉˘ χÎÔ˜ ÀÂÚˈÛÈÓÔÊÈÏÈÎfi Û‡Ó‰ÚÔÌÔ ¶ÔÚÊ˘Ú›· ∆ÔÍÈ΋ ÂȉÂÚÌÈ΋ ÓÂÎÚfiÏ˘ÛË (LYELL Syndrome) ¶ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· §¤Ìʈ̷

Paediatriki 2001;64:460-464

‰ÔÙËı› ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË (7). ¢ÔÎÈ̷ۛ˜ in vitro ¤‰ÂÈÍ·Ó ˆ˜ ˘¿Ú¯ÂÈ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÓÙ›‰Ú·ÛË ÌÂٷ͇ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ô˘ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È Ì¤Ûˆ ÙÔ˘ ΢ÙÔ¯ÚÒÌ·ÙÔ˜ P-450 ÙÔ˘ ‹·ÙÔ˜ Û ÔÛÔÛÙfi ÂÚ›Ô˘ 75%. ∏ ·ÈıÔ˘ÛÔÍÈÌ›‰Ë Î·È ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È Ì¤Ûˆ ‰È·ÊÔÚÂÙÈÎÒÓ Ô‰ÒÓ. ŒÙÛÈ, ıˆÚÂ›Ù·È fiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfi ΛӉ˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·ÓÙȉڿÛÂˆÓ ·fi ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ˘ÂÚ¢·ÈÛıËÛ›·. ¶ÚfiÛÊ·Ù˜ ‰ËÌÔÛȇÛÂȘ ÂÓÔ¯ÔÔÈÔ‡Ó ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ÈÒÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘. πÔ› Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Â›Ó·È ÔÈ: HHV6, EBV, HIV, HAV, HBV, HCV, CMV, HSV, Parvovirus B19 Î.¿. ∂›Û˘, ÂÓÔ¯ÔÔÈÂ›Ù·È ÙÔ Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ¶ÈÛÙ‡ÂÙ·È ‰ËÏ. fiÙÈ ÔÈ ÈÔ› ›Ûˆ˜ ‰ÚÔ˘Ó ˆ˜ Û˘Ì·Ú¿ÁÔÓÙ˜ ÛÙËÓ ÙÚÔÔÔ›ËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÍÂÓÈÛÙ‹, ˘ÚÔ‰ÔÙÒÓÙ·˜ ¤ÙÛÈ ÛÙËÓ ÂΉ‹ÏˆÛË ™À∞. ÕÏÏÔÈ ˘ÔÛÙËÚ›˙Ô˘Ó ˆ˜ Ù· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, ›Ûˆ˜ ̤ۈ ‰È¤ÁÂÚÛ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Â·ÓÂÓÂÚÁÔÔÈÔ‡Ó ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. Œ¯ÂÈ, Â›Û˘, ÂÎÊÚ·ÛÙ› Ë ¿Ô„Ë ˆ˜ ÔÈ ÈÔ›, fiˆ˜ Ô HHV6, ηıÈÛÙÔ‡Ó Ù· ÂÓ˙˘ÌÈο Û˘ÛÙ‹Ì·Ù· ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÏÈÁfiÙÂÚÔ ‰Ú·ÛÙÈο (4,8,9). ¶¿ÓÙˆ˜, ÂÂȉ‹ Ô ·ÎÚÈ‚‹˜ ÚfiÏÔ˜ ÙˆÓ ÈÒÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÍÂοı·ÚÔ˜, ÈÛÙ‡ÂÙ·È ˆ˜ ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Ú¤ÂÈ Ó· ıÂÚ·‡ÔÓÙ·È Ì ·ÓÙÈ-ÈÈο Ê¿Ú̷η, fiÔ˘ ˘¿Ú¯Ô˘Ó ÔÈ Û¯ÂÙÈΤ˜ ÂӉ›ÍÂȘ. £ÂÚ·›· Î·È ÚfiÁÓˆÛË ¶ÚÒÙÔ Ì¤ÏËÌ· ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÁÈ·ÙÚÔ‡, fiÙ·Ó Ù›ıÂÙ·È Ë ˘Ô„›· ™À∞, ·ÔÙÂÏ› Ë ¿ÌÂÛË Î·È ¤ÁηÈÚË ‰È·ÎÔ‹ ÙÔ˘ ‡ÔÙÔ˘ Ê·ÚÌ¿ÎÔ˘ (1). §fiÁˆ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Û·ÛÌÒÓ ı· Ú¤ÂÈ Ó· ‰Ôı› ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ıÂÚ·¢ÙÈ΋˜ ·ÁˆÁ‹˜, ÙfiÛÔ ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ fiÛÔ Î·È Ì·ÎÚÔÚfiıÂÛÌ·, Ï·Ì‚¿ÓÔÓÙ·˜ ˘` fi„ÈÓ ÙÔ ˘„ËÏfi ÔÛÔÛÙfi (70%) ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ ÌÂٷ͇ ÙˆÓ ·ÚˆÌ·ÙÈÎÒÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ (2). ∫·Ù¿ ÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ™À∞, ¯ÔÚ‹ÁËÛË Ó¤·˜ ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ ÁÈ· ÙËÓ ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Û·ÛÌÒÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ Ë·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹, ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂÚ·›· ·ÊÔ‡ ÌÂÙ·‚ÔÏ›˙ÂÙ·È Ì ÙÚfiÔ ‰È·ÊÔÚÂÙÈÎfi ·fi ÂΛÓÔ ÙˆÓ ·ÚˆÌ·ÙÈÎÒÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ. ™˘ÓÈÛÙ¿Ù·È ¿ÓÙˆ˜ ÚÔÛÔ¯‹ ÛÙË ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘, ÁÈ·Ù› ·Ó·ÛÙ¤ÏÏÂÈ ÙÔ ¤Ó˙˘ÌÔ ÂÔÍÈ΋ ˘‰ÚÔÏ¿ÛË ÂÈ‚Ú·‰‡ÓÔÓÙ·˜ ÙËÓ ·Ô‚ÔÏ‹ ÙˆÓ ·ÚˆÌ·ÙÈÎÒÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ ·fi ÙÔÓ ÔÚÁ·ÓÈÛÌfi (5). ÕÏÏË ·ÛÊ·Ï‹˜ ÂÓ·ÏÏ·ÎÙÈ΋ ·ÁˆÁ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ ÙÔ˘ ™À∞ Â›Ó·È Ë ÁηÌ·ÂÓÙ›ÓË.

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∂›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ·Ó·‚¿ÏÏÂÙ·È Ë ¤Ó·ÚÍË Ù˘ Ó¤·˜ ·ÓÙÈÂÈÏËÙÈ΋˜ ·ÁˆÁ‹˜ ̤¯ÚÈ Ó· ·Ó·ÚÚÒÛÂÈ Ï‹Úˆ˜ Ô ·ÛıÂÓ‹˜. ¡ÂfiÙÂÚ· ·ÓÙÈÂÈÏËÙÈο, fiˆ˜ Ë ÁηÌ·ÂÓÙ›ÓË, Ë ÙÔÈÚÈÌ¿ÙË Î·È Ë ÙÈ·ÁηÌ›ÓË ıˆÚÔ‡ÓÙ·È ·ÛÊ·Ï›˜, ·ÒÙÂÚ˜ ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂÚ·¢ÙÈΤ˜ ÚÔÔÙÈΤ˜. ∏ Ï·ÌÔÙÚÈÁ›ÓË, ·Ú’ fiÏÔ Ô˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙÔ ™À∞, ÌÔÚ›, Â›Û˘, Ó· ¯ÚËÛÈÌÔÔÈËı›, ÂÂȉ‹ Ô ÌÂÙ·‚ÔÏÈÎfi˜ Ù˘ ‰ÚfiÌÔ˜ Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi˜ ·fi ÂΛÓÔÓ ÙˆÓ ·ÚˆÌ·ÙÈÎÒÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ (1,10,11). ∞ÛıÂÓ›˜ Ì ™À∞ Ú¤ÂÈ Ó· ÓÔÛËχÔÓÙ·È, Ì ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ Ë·ÙÈ΋˜ Î·È ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Â›Û˘ ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ÙÔ˘˜ ‰È·Ù·Ú·¯ÒÓ. ™ËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ù˘ ˘ÔÛÙËÚÈÎÙÈ΋˜ ÙÔ˘˜ ıÂÚ·›·˜ Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÈÛÔ˙˘Á›Ô˘ ‡‰·ÙÔ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ.

O ÚfiÏÔ˜ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓÔ˜ (5). ∆· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Ê·›ÓÂÙ·È Ó· ÂÈÙ·¯‡ÓÔ˘Ó ÙËÓ ÂԇψÛË ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ, ·ÏÏ¿ Ó· ÌËÓ ÂËÚ¿˙Ô˘Ó ÙËÓ ÂͤÏÈÍË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ˘fiÏÔÈ· Û˘ÛÙ‹Ì·Ù·. ¶ÔÏÏÔ› Â›Ó·È ÂΛÓÔÈ Ô˘ ÚÔÙÈÌÔ‡Ó ÙËÓ ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘ÁÚ¤˜ ÎÔÌÚ¤Û˜ Î·È ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ. °È· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ë ‰ÔÎÈÌ·Û›· ÂϤÁ¯Ô˘ Ù˘ ÏÂÌÊÔ΢ÙÙ·ÚÔÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓÔ¯ÔÔÈÔ‡ÌÂÓÔ˘ Ê·ÚÌ¿ÎÔ˘, Ë ÔÔ›· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÌfiÓÔ Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·. ŒÙÛÈ, ‰ËÌÈÔ˘ÚÁ‹ıËÎÂ Ë ·Ó¿ÁÎË Ì›·˜ ·Ï‹˜, ‰È·ÁÓˆÛÙÈο, ÌÂıfi‰Ô˘. ¶ÚfiÛÊ·Ù· ¤¯Ô˘Ó ·Ú¯›ÛÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È patch tests Ì ÙÔ ÂÓÔ¯ÔÔÈÔ‡ÌÂÓÔ Ê¿ÚÌ·ÎÔ, Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (4,12). ∆Ô ıÂÙÈÎfi patch test ÂȂ‚·ÈÒÓÂÈ ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Î·È ÙÚÔÔÔÈ› ÙË ÌÂÏÏÔÓÙÈ΋ ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. O‰ËÁ›Â˜ ‰›ÓÔÓÙ·È Î·È ÛÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ¿Û¯Ô˘Ó ·fi ÂÈÏË„›· Î·È Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹, ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· Ó· ÂÌÊ·Ó›ÛÔ˘Ó Î·È ÔÈ ›‰ÈÔÈ ™À∞, ·ÊÔ‡ Ê·›ÓÂÙ·È Ó· ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ¿ ÙÔ˘ Î·È ÎÏËÚÔÓÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜.

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9. Suzuki Y, Inagi R, Aono T, Yamanishi K, Shiohara T. Human herpesvirus 6 infection as a risk factor for the development of severe drug induced hypersensitivity syndrome. Arch Dermatol 1998; 134:1108-1112.

10. Alldredge BK, Knusten AP, Ferriero D. Antiepileptic drug hypersensitivity syndrome: in vitro and clinical observations. Pediatr Neurol 1994;10:169-171.

11. Handfield-Jones SE, Jerkins RE. The anticonvulsant hypersensitivity syndrome. Br J Dermatol 1993;129:175-177.

12. Mosquera MR, Iglesias A, Saez A, Vidal C. Patch test diagnosis of carbamazepine sensitivity? Contact Dermatitis 1991;25:137-138.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-12-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆ¿ÓÓ· ÷ڈӛÙË ∫ÔÓ‰˘Ï¿ÎË 85, 713 05, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ e-mail: charon@otenet.gr

¶·È‰È·ÙÚÈ΋ 2001;64:465-471

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2001;64:465-471

ORIGINAL ARTICLE

∂Ô¯È΋ ÌÂÙ·‚ÔÏ‹ Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· °. ∆ÛfiÏ·˜, ¢. ÃÔϤ‚·˜, ™. ∆ÛÔ˘Î·Ï¿, Ã. ™Ù·˘ÚÈÓ¿‰Ë˜, ¶. ∫Ô˘ÎÔ˘ÙÛ¿Î˘, ¶. ™˘Ú›‰Ë˜, ¢. °Ô˘ÚÁÈÒÙ˘, ∫. ™ÈÓ·ÓÈÒÙ˘

Seasonal variation of urinary calcium excretion G. Tsolas, D. Cholevas, S. Tsoukala, C. Stavrinadis, P. Koukoutsakis, P. Spyridis, D. Gouriotis, C. Sinaniotis

¶ÂÚ›ÏË„Ë: ∏ ÁÓÒÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ¤¯ÂÈ ÛËÌ·Û›· ÁÈ· ÙË ‰È¿ÁÓˆÛË ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·˘ÍË̤ÓË ·Ô‚ÔÏ‹ ÙÔ˘. ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË Ì·˜ ›¯·Ì ‰È·ÈÛÙÒÛÂÈ fiÙÈ Ë Û¯¤ÛË ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr ÛÂ Ù˘¯·›Ô ‰Â›ÁÌ· Ô‡ÚˆÓ ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, Ë ÔÔ›· ·ÔÙÂÏ› ‰Â›ÎÙË Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘, Â›Ó·È 0,16±0,10. ªÂ ÛÎÔfi Ó· ‰È·ÈÛÙˆı› Â¿Ó Ë Û¯¤ÛË ·˘Ù‹ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜, fiˆ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ÂÓ‹ÏÈΘ, ÌÂÏÂÙ‹Û·Ì 150 ˘ÁÈ‹ ·È‰È¿ ËÏÈΛ·˜ 6-12 ÂÙÒÓ Û ‰‡Ô ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜. ∏ ÚÒÙË Ì¤ÙÚËÛË Ù˘ Û¯¤Û˘ UCa/UCr ¤ÁÈÓ ÙÔÓ OÎÙÒ‚ÚÈÔ, ÂÔ¯‹ Ô˘ ·ÓÙÈÛÙÔȯԇÛ Û ÚÔËÁËı›۷ ÛËÌ·ÓÙÈ΋ ¤ÎıÂÛË Û ËÏÈÔÊ¿ÓÂÈ· ηٿ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜. ∂·Ó·Ï‹ÊıËΠÙÔÓ ∞Ú›ÏÈÔ ÙÔ˘ ÂfiÌÂÓÔ˘ ¤ÙÔ˘˜ Ô˘ ·ÓÙÈÛÙÔȯԇÛ Û ÂÚ›Ô‰Ô ¯·ÌËÏ‹˜ ËÏÈÔÊ¿ÓÂÈ·˜ ÙÔ˘ ¯ÂÈÌÒÓ· Ô˘ ›¯Â ÚÔËÁËı›. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ÙÈ̤˜ UCa/UCr ηٿ ÙËÓ ÚÒÙË Ì¤ÙÚËÛË (OÎÙÒ‚ÚÈÔ˜) ‹Ù·Ó ˘„ËÏfiÙÂÚ˜ Ù˘ ‰Â‡ÙÂÚ˘ ̤ÙÚËÛ˘ (∞Ú›ÏÈÔ˜), 0,17±0,11 Î·È 0,14±0,12 ·ÓÙ›ÛÙÔȯ· (p=0,022). OÈ ÙÈ̤˜ ·˘Ù¤˜ ‹Ù·Ó ·ÓÙ›ÛÙÔȯ˜ ·˘ÙÒÓ Ô˘ ›¯·Ó ‰È·ÈÛÙˆı› ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘. ∫·Ù¿ ÙËÓ ÚÒÙË ÂÚ›Ô‰Ô, ‰È·ÈÛÙÒıËΠ·˘ÍË̤ÓË ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ (UCa/UCr >0,35) Û 11 ·È‰È¿ Î·È ·Ú¤ÌÂÈÓ ·˘ÍË̤ÓË Î·Ù¿ ÙË ‰Â‡ÙÂÚË ÂÚ›Ô‰Ô Û 3 ·fi ·˘Ù¿. ∆¤ÏÔ˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ÛÙËÓ ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ. ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Î·È ÂÔ̤ӈ˜ Ù˘¯fiÓ ˘„ËϤ˜ ÙÈ̤˜ ·¤ÎÎÚÈÛ˘ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌÒÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹.

Abstract: Hypercalciuria is of continuing interest since it is one of the risk factors for stone disease in children. The measurement of the urinary calcium/creatinine concentration ratio (UCa/UCr) expressed in mg/dl per mg/dl, is an accepted screening test for elevated calcium excretion.

Therefore, the knowledge of reference values for UCa/UCr ratio in children is very important. In a previous study we had found that UCa/UCr ratio for normal children is 0.16±0.10. In the present study we evaluated the possibility of seasonal variation in urinary calcium excretion in 150 healthy children, 6-12 year-old (82 boys, 68 girls), during two different seasons. Calcium excretion was studied in October, following exposure to summer sunshine, and after six months, in April, following a decreased exposure to sunlight during the winter months. It was found that there is a distinct seasonal variation in urinary calcium excretion (0.17±0.11 in October vs 0.14±0.12 in April, p=0.022). Eleven children were found to have an increased ratio of UCa/UCr (>0.35) in the first study period, but only three of them continued to have increased UCa/UCr ratios after the winter season. No difference was found between boys and girls. The findings of this study suggest that urinary calcium excretion is influenced by the season of the year, probably because of differences in sunshine exposure. This parameter should be taken into account when evaluating children for hypercalciuria.

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

2nd Dept. of Paediatrics of University of Athens “ƒ. & ∞. Kyriakou” Children's Hospital, Athens

465

¶·È‰È·ÙÚÈ΋ 2001;64:465-471

Paediatriki 2001;64:465-471

§¤ÍÂȘ ÎÏÂȉȿ: ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘, ËÏ›ÎÔ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ, ÂÔ¯È΋ ηٷÓÔÌ‹, ËÏÈÔÊ¿ÓÂÈ·.

Key words: hypercalciuria, calcium excretion, urinary calcium-creatinine ratio, seasonal variation, sunshine exposure.

∂ÈÛ·ÁˆÁ‹ ∏ ȉÈÔ·ı‹˜ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· Ô˘ÚÔÏÈı›·Û˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ¿ÏË ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú·, ÂÓÒ Ù· Â›‰· ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÙÔ˘ ÔÚÔ‡ Â›Ó·È Ê˘ÛÈÔÏÔÁÈο (1,2) (¶›Ó·Î·˜ 1). ∞˘ÍË̤ÓË ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ ¤¯ÂÈ ‰È·ÈÛÙˆı› ÛÙÔ 50-80% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì ÏÈı›·ÛË, ÂÓÒ Û¯ÂÙ›˙ÂÙ·È Î·È Ì ÙËÓ È‰ÈÔ·ıÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜ ·ÈÌ·ÙÔ˘Ú›· ÛÙ· ·È‰È¿. ™˘ÓÂÒ˜, Ë ÁÓÒÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ Ì ٷ Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. ¶·Ú¿ Ù·‡Ù·, Ù· ÛÙÔȯ›· Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο Ì ÙËÓ ·¤ÎÎÚÈÛ‹ ÙÔ˘ ÛÙ· Ô‡Ú· Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ, Ù· ‰Â ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰È·ÊfiÚˆÓ ÂÚ¢ÓÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜. ªÂ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÔÈ ÙÈ̤˜ ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ¯ÒÚ· Û ¯ÒÚ·, ÂÓÒ ·ÍÈfiÏÔÁ˜ ‰È·ÊÔÚ¤˜ ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Î·È ÛÙȘ ›‰È˜ ÙȘ ¯ÒÚ˜ ÛÙȘ Ôԛ˜ ¤ÁÈÓ·Ó Û¯ÂÙÈΤ˜ ÌÂϤÙ˜. Œ¯ÂÈ ˘ÔÛÙËÚȯı› fiÙÈ ÔÈ ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ ÔÊ›ÏÔÓÙ·È Û ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ ηٿ ÙËÓ ÔÔ›· ¤ÁÈÓÂ Ë ÌÂϤÙË ÏfiÁˆ Ù˘ ‰È·ÊÔÚÂÙÈ΋˜ ËÏÈÔÊ¿ÓÂÈ·˜, Ë ‰È·ÙÚÔÊ‹, Ô ÎÈÚο‰ÈÔ˜ Ú˘ıÌfi˜ ·Ô‚ÔÏ‹˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Î.Ï. (3-17). ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË Ì·˜ (18) ›¯·Ì ‰È·ÈÛÙÒÛÂÈ ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ fiÙÈ Ë Û¯¤ÛË ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË ÛÂ Ù˘¯·›Ô ‰Â›ÁÌ· Ô‡ÚˆÓ, Ë ÔÔ›· ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏ› ‰Â›ÎÙË Ù˘ ·¤ÎÎÚÈÛ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú·, ‹Ù·Ó 0,16±0,10. ™ÙË ÌÂϤÙË, fï˜, ÂΛÓË ‰ÂÓ Â›¯·Ó Û˘ÓÂÎÙÈÌËı› ¿ÏϘ ·Ú¿ÌÂÙÚÔÈ, fiˆ˜ Ë ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ ηٿ ÙËÓ ÔÔ›· ‰ÈÂÍ‹¯ıË Ë ÌÂϤÙË Î·È Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ·È-

‰ÈÒÓ Ù· ÔÔ›· Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù‹. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰È·ÈÛÙˆı› Â¿Ó Ë ·¤ÎÎÚÈÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Î·È ÂÊ’ fiÛÔÓ ‰È·ÈÛÙˆı› fiÙÈ ˘¿Ú¯ÂÈ fiÓÙˆ˜ ‰È·ÊÔÚ¿ ÛÙË Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜, Ó· ‰Ôı› ÈηÓÔÔÈËÙÈ΋, ηٿ ÙÔ ‰˘Ó·ÙfiÓ, ÂÚÌËÓ›· ÛÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi Î·È Ó· Û˘˙ËÙËı› Ë Ú·ÎÙÈ΋ ÛËÌ·Û›· ÙÔ˘.

¶›Ó·Î·˜ 1. ÀÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ñ π‰ÈÔ·ı‹˜ ·) ∞˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ ·fi ÙÔ ¤ÓÙÂÚÔ ‚) ∞˘ÍË̤ÓË ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ ·fi ÓÂÊÚfi ñ ¢Â˘ÙÂÚÔ·ı‹˜ - ™ˆÏËÓ·Úȷ΋ ÔͤˆÛË Ù‡Ô˘ π (ÎÏ·ÛÈ΋) - ™‡Ó‰ÚÔÌÔ Bartter - ¡Â·ÓÈ΋ ÚÂ˘Ì·ÙÔÂȉ‹˜ ·ÚıÚ›Ùȉ· - ∞ÎÈÓËÛ›· - ¶ÚˆÙÔ·ı‹˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi˜ - ÀÂÚı˘ÚÂÔÂȉÈÛÌfi˜ - ™·ÚÎÔ›‰ˆÛË Î.Ï.

466

ÀÏÈÎfi Î·È ÌÂıÔ‰ÔÏÔÁ›· ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 150 ˘ÁÈ‹ ·È‰È¿ ËÏÈΛ·˜ 6-12 ÂÙÒÓ, Ù· ÔÔ›· ÊÔÈÙÔ‡Û·Ó Û ‰ËÌÔÙÈο Û¯ÔÏ›· ÙˆÓ ÂÚÈÔ¯ÒÓ ¶·¿ÁÔ˘ Î·È µ‡ÚˆÓ· ÙÔ˘ ÓÔÌÔ‡ ∞ÙÙÈ΋˜. ∆· 82 ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· 68 ÎÔÚ›ÙÛÈ·. ∏ ÌÂϤÙË ‰ÈÂÍ‹¯ıË Û ‰‡Ô ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜. ∏ ÚÒÙË Ì¤ÙÚËÛË Ù˘ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ¤ÁÈÓ ÙÔÓ OÎÙÒ‚ÚÈÔ, ÂÔ¯‹ Ë ÔÔ›· ·ÓÙÈÛÙÔȯԇÛ Û ÛËÌ·ÓÙÈ΋ ÚÔËÁËı›۷ ¤ÎıÂÛË Û ËÏÈÔÊ¿ÓÂÈ· ηٿ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜ Ô˘ ÚÔËÁ‹ıËÎ·Ó Ù˘ ÌÂϤÙ˘ Î·È Â·Ó·Ï‹ÊıËÎÂ, ÛÙ· 140 ·fi Ù· ›‰È· ·ÎÚÈ‚Ò˜ ·È‰È¿, ÙÔÓ ∞Ú›ÏÈÔ ÙÔ˘ ÂfiÌÂÓÔ˘ ¤ÙÔ˘˜ Ô˘ ·ÓÙÈÛÙÔȯԇÛ Û ÚÔËÁËı›۷ ÂÚ›Ô‰Ô ¯·ÌËÏ‹˜ ËÏÈÔÊ¿ÓÂÈ·˜ ÏfiÁˆ ÙÔ˘ ¯ÂÈÌÒÓ· Ô˘ ›¯Â ÚÔËÁËı›. ¢¤Î· ·fi Ù· 150 ·È‰È¿ ‰ÂÓ ÚÔÛ‹Ïı·Ó ηٿ ÙË ‰Â‡ÙÂÚË Ì¤ÙÚËÛË ÙÔ˘ ∞ÚÈÏ›Ô˘. ™ÙÔȯ›·, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ËÏÈÔÊ¿ÓÂÈ· Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÙȘ ÌËÓÈ·›Â˜ ÙÈ̤˜ ËÏÈÔÊ¿ÓÂÈ·˜ Û ÒÚ˜, ÂÏ‹ÊıËÛ·Ó ·fi ÙËÓ ∂ıÓÈ΋ ªÂÙˆÚÔÏÔÁÈ΋ ÀËÚÂÛ›· Î·È ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÂÙÚ‹ÛÂȘ ÔÈ Ôԛ˜ ¤ÁÈÓ·Ó ÛÙÔ ªÂÙˆÚÔÏÔÁÈÎfi ™Ù·ıÌfi Ù˘ ¡¤·˜ ºÈÏ·‰¤ÏÊÂÈ·˜. ™Â fiÏ· Ù· ·È‰È¿, ÙfiÛÔ ÙÔÓ OÎÙÒ‚ÚÈÔ fiÛÔ Î·È ÙÔÓ ∞Ú›ÏÈÔ, ÂÏ‹ÊıËÛ·Ó Ù· ‰Â‡ÙÂÚ· ÚˆÈÓ¿ Ô‡Ú·. ∏ ÂÈÏÔÁ‹ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ‰Â›ÁÌ·ÙÔ˜ ¤ÁÈÓ ÁÈ· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ÂÓÒ Î·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ë Ï‹„Ë ÙˆÓ ‰Â‡ÙÂÚˆÓ ÚˆÈÓÒÓ Ô‡ÚˆÓ ıˆÚÂ›Ù·È ·Ô‰ÂÎÙ‹ Î·È ·ÍÈfiÈÛÙË. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ fiÏ· Ù· ·È‰È¿ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË ‰ÂÓ Â›¯·Ó ¿ÚÂÈ ÚfiÁÂ˘Ì· Ì Á¿Ï· ‹ Á·Ï·ÎÙÔÎÔÌÈο ÚÔ˚fiÓÙ· ηٿ ÙȘ ‰‡Ô Ë̤Ú˜ - ÙÔÓ OÎÙÒ‚ÚÈÔ Î·È ÙÔÓ ∞Ú›ÏÈÔ, ·ÓÙ›ÛÙÔȯ· - ‰ÈÂÍ·ÁˆÁ‹˜ Ù˘ Û˘ÏÏÔÁ‹˜ ÙˆÓ Ô‡ÚˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛÙ› Ë ·ÔÚÚfiÊËÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Ù˘ ÙÚÔÊ‹˜ ·fi ÙÔ ¤ÓÙÂÚÔ. ∏ ̤ÙÚËÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙ· Ô‡Ú· ¤ÁÈÓ ÛÙÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ Ù˘ µ’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·ÙÔÌÈ΋˜ ·ÔÚÚfiÊËÛ˘. ∂›Û˘, ˘Ô‚Ï‹ıËΠÏÂÙÔÌÂÚ¤˜ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, ÚÈÓ ·fi ÙËÓ Î¿ı ‰ÂÈÁÌ·ÙÔÏË„›·, ÛÙÔ˘˜ ÁÔÓ›˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È·ÙÚÔÊ‹, Ì ¤ÌÊ·ÛË ÛÙË Ï‹„Ë ÙÚÔÊÒÓ ÏÔ‡ÛÈˆÓ Û ·Û‚¤ÛÙÈÔ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙˆıÔ‡Ó

¶·È‰È·ÙÚÈ΋ 2001;64:465-471

Paediatriki 2001;64:465-471

Ù˘¯fiÓ ‰È·ÊÔÚ¤˜ ÛÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ËÌÂÚËÛ›ˆ˜ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ ·Û‚ÂÛÙ›Ô˘, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜. ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÂÚÈÂÏ¿Ì‚·Ó ηٷÁÚ·Ê‹ Ù˘ ËÌÂÚËÛ›ˆ˜ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÔÛfiÙËÙ·˜ Á¿Ï·ÎÙÔ˜, Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ, ·ÏÏ¿ Î·È ¿ÏÏˆÓ ÏÔ˘Û›ˆÓ Û ·Û‚¤ÛÙÈÔ ÙÚÔÊÒÓ (·˘Á¿, Ï·¯·ÓÈο, ÂÏȤ˜, ÍËÚÔ› ηÚÔ›, ۇη, ÏÔÈ¿ ÊÚÔ‡Ù·) Î·È ˘ÔÏÔÁÈ˙fiÙ·Ó Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÚÔÛ¤ÁÁÈÛË Ë Ì¤ÛË ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ·Û‚ÂÛÙ›Ô˘, ÙfiÛÔ ÁÈ· ÙÔ “ıÂÚÈÓfi” ÂÍ¿ÌËÓÔ ª·˝Ô˘ - OÎÙˆ‚Ú›Ô˘, ÙÔ ÔÔ›Ô ÚÔËÁ‹ıËÎ Ù˘ ÚÒÙ˘ ÌÂÙÚ‹Ûˆ˜, fiÛÔ Î·È ÁÈ· ÙÔ “¯ÂÈÌÂÚÈÓfi” ÂÍ¿ÌËÓÔ ¡ÔÂÌ‚Ú›Ô˘ - ∞ÚÈÏ›Ô˘ Ô˘ ÚÔËÁ‹ıËÎ Ù˘ ‰Â‡ÙÂÚ˘ ÌÂÙÚ‹Ûˆ˜. ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ‰ÔÎÈÌ·Û›· t-test ·Ó¿ ˙‡ÁË.

∞ÔÙÂϤÛÌ·Ù· ∏ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂϤÙ˘ ¤‰ÂÈÍ fiÙÈ: ·) OÈ ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ ÚÔ˜ ÎÚ·ÙÈÓ›ÓË Ô‡ÚˆÓ (UCa/UCr) ηٿ ÙËÓ ÚÒÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ˜ (̤ÛË ÙÈÌ‹: 0,17±0,11) ·fi ÙȘ ÙÈ̤˜ Ù˘ ‰Â‡ÙÂÚ˘ ̤ÙÚËÛ˘ ÙÔ˘ ∞ÚÈÏ›Ô˘ (̤ÛË ÙÈÌ‹: 0,14±0,12), p=0,022 Î·È ‹Ù·Ó ·ÓÙ›ÛÙÔȯ˜ ÂΛӈÓ, ÔÈ Ôԛ˜ ›¯·Ó ‰È·ÈÛÙˆı› ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Ì·˜ (18). ∞fi Ù· ÛÙÔȯ›· Ù˘ ∂ıÓÈ΋˜ ªÂÙˆÚÔÏÔÁÈ΋˜ ÀËÚÂÛ›·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ë Ì¤ÛË ËÏÈÔÊ¿ÓÂÈ· ηٿ ÙÔ ÂÍ¿ÌËÓÔ ª·˝Ô˘ - OÎÙˆ‚Ú›Ô˘, ÙÔ ÔÔ›Ô ÚÔËÁ‹ıËÎ Ù˘ ÚÒÙ˘ ÌÂÙÚ‹Ûˆ˜ ‹Ù·Ó

1645 ÒÚ˜, ۯ‰fiÓ ‰ÈÏ¿ÛÈ· ÙˆÓ 877 ˆÚÒÓ Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÂÚÈfi‰Ô˘ ¡ÔÂÌ‚Ú›Ô˘ - ∞ÚÈÏ›Ô˘ Ô˘ ÚÔËÁ‹ıËÎ Ù˘ ‰Â‡ÙÂÚ˘ ̤ÙÚËÛ˘. O˘ÛÈ·ÛÙÈΤ˜ ‰È·ÊÔÚ¤˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È·ÙÚÔÊ‹ Û ۯ¤ÛË Ì ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ËÌÂÚËÛ›ˆ˜ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ ·Û‚ÂÛÙ›Ô˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ, ‰ÂÓ ‰È·ÈÛÙÒıËηÓ. ™ÙÔ ™¯‹Ì· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÙÈ̤˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ÛÙȘ ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÌÂÙÚ‹ÛÂȘ. ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÂÓÒ Î·Ù¿ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ÙÔÓ OÎÙÒ‚ÚÈÔ, Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ¤¯Ô˘Ó ÙÈÌ‹ UCa/UCr Á‡Úˆ ÛÙÔ 0,15 ‹ Î·È ÌÂÁ·Ï‡ÙÂÚË, ÛÙËÓ Â·ÓÂÎÙ›ÌËÛË ÙÔ˘ ∞ÚÈÏ›Ô˘ Ë Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Â›¯·Ó ÙÈÌ‹ UCa/UCr <0,15. ‚) ™ÙÔÓ ¶›Ó·Î· 2 ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÙÈ̤˜, ÔÈ Ôԛ˜ ·ÓÙÈÛÙÔÈ¯Ô‡Ó ÛÙȘ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr, ÙfiÛÔ Î·Ù¿ ÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘, fiÛÔ Î·È Î·Ù¿ ÙË Ì¤ÙÚËÛË ÙÔ˘ ∞ÚÈÏ›Ô˘. ∞fi ÙË ÌÂϤÙË ÙÔ˘ ›Ó·Î· ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ ÔÈ ÙÈ̤˜ UCa/UCr Â›Ó·È ·ÚÎÂÙ¿ ˘„ËÏfiÙÂÚ˜ ÙÔ˘ ËÏ›ÎÔ˘ 0,25, Ô˘ ¤¯ÂÈ ıˆÚËı› fiÙÈ ·ÔÙÂÏ› ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹. ∂Ô̤ӈ˜, ÙÈ̤˜ ·ÚÎÂÙ¿ ˘„ËÏfiÙÂÚ˜ ÙÔ˘ 0,25 ı· ÌÔÚÔ‡Û·Ó Ó· ıˆÚËıÔ‡Ó ˆ˜ Ê˘ÛÈÔÏÔÁÈΤ˜ ÁÈ· Ù· ÂÏÏËÓÈο ‰Â‰Ô̤ӷ. Á) ¢È·ÊÔÚ¿ ÙÈÌÒÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó Î·Ù¿ ÙȘ ‰‡Ô ÌÂÙÚ‹ÛÂȘ. ‰) ∏ Û‡ÁÎÚÈÛË ÙˆÓ ÙÈÌÒÓ UCa/UCr ÌÂٷ͇

35

™¯ÂÙÈ΋ Û˘¯ÓfiÙËÙ· (%)

30

O∫∆øµƒπO™ A¶ƒπ§πO™

25 20 15 10 5 0 -0,05 0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

0,45

0,5

0,55

0,6

0,65 0,7

Ca/Cr{(mg/dl)/(mg/dl)} ™¯‹Ì· 1. ∞¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ Û ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÂÔ¯¤˜ ÙÔ˘ ¤ÙÔ˘˜

467

¶·È‰È·ÙÚÈ΋ 2001;64:465-471

Paediatriki 2001;64:465-471

¶›Ó·Î·˜ 2. ∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ Û¯¤Û˘ Ca/Cr Ô‡ÚˆÓ [(mg/dl) / (mg/dl)] Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ Û ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÂÔ¯¤˜ ÙÔ˘ ¤ÙÔ˘˜ UCa/UCr [(mg/dl) / (mg/dl)] ∂.£.

5 25 50 75 95

OÎÙÒ‚ÚÈÔ˜ (ÌÂÁ¿ÏË ÚÔËÁËı›۷ ËÏÈÔÊ¿ÓÂÈ·) 0,03 0,10 0,15 0,23 0,37

∞Ú›ÏÈÔ˜ (ÌÂȈ̤ÓË ÚÔËÁËı›۷ ËÏÈÔÊ¿ÓÂÈ·) 0,02 0,05 0,11 0,18 0,39

OÎÙˆ‚Ú›Ô˘ Î·È ∞ÚÈÏ›Ô˘, ͯˆÚÈÛÙ¿ ÁÈ· οı ¤ÙÔ˜ ËÏÈΛ·˜, ¤‰ÂÈÍ fiÙÈ ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ÌfiÓÔ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 7, 8 Î·È 9 ÂÙÒÓ, ÂÓÒ ÛÙȘ ˘fiÏÔÈ˜ ËÏÈ˘ (6, 10 Î·È 11 ÂÙÒÓ) ‰ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (¶›Ó·Î·˜ 3). Â) ¶·ıÔÏÔÁÈ΋ ÙÈÌ‹ ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ·Û‚ÂÛÙ›Ô˘ (UCa/UCr >0,35) ‰È·ÈÛÙÒıËΠ۠11 ·È‰È¿ ηٿ ÙËÓ ÚÒÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘. ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô ÙÔÓ ∞Ú›ÏÈÔ, ÛÙÔÓ ÔÔ›Ô Û˘ÌÌÂÙ›¯·Ó Ù· 10 ÂÍ ·˘ÙÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ ÛÙ· 7 ·È‰È¿ ÔÈ ÙÈ̤˜ ›¯·Ó ˘Ô¯ˆÚ‹ÛÂÈ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·, ÂÓÒ 3 ÌfiÓÔ ·È‰È¿ ÂÍ·ÎÔÏÔ˘ıÔ‡Û·Ó Ó· ¤¯Ô˘Ó ÙÈÌ‹ ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 0,35. ∆· ·È‰È¿ ·˘Ù¿ ‹Ù·Ó ·Û˘Ìو̷ÙÈο, Ô ‰Â ÏÂÙÔÌÂÚ‹˜ ·Ú·ÎÏÈÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÛÙÔÓ ÔÔ›Ô ˘Ô‚Ï‹ıËÎ·Ó ·¤‚Ë ·ÚÓËÙÈÎfi˜ ÁÈ· ·ÈÌ·ÙÔ˘Ú›·, Ô˘ÚÔÏÈı›·ÛË ‹ ¿ÏÏÔ ·ıÔÏÔÁÈÎfi ‡ÚËÌ· (¶›Ó·Î·˜ 4). ™˘˙‹ÙËÛË ∆Ô ‚·ÛÈÎfi Û˘Ì¤Ú·ÛÌ· Ô˘ ÚÔ·ÙÂÈ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂϤÙ˘ Ì·˜, Ì Ú·ÎÙÈ΋ ·Í›·, Â›Ó·È Ë ‰È·ÊÔÚ¿ Ô˘ ‰È·ÈÛÙÒıËΠÛÙËÓ ·Ô‚ÔÏ‹ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Î·È Ë ÔÔ›· Ê·›ÓÂÙ·È fiÙÈ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙË ‰È·ÊÔÚÂÙÈ΋ ËÏÈÔÊ¿ÓÂÈ·. ∂Ó‰¤¯ÂÙ·È Ì¿ÏÈÛÙ· Ó· Â›Ó·È ÙfiÛÔ ÌÂÁ¿ÏË Ë Âԯȷ΋ ·˘Ù‹ ‰È·Î‡Ì·ÓÛË Ù˘ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, ÒÛÙ ÌÂÚÈο ·È‰È¿ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Âԯȷ΋ ·ÚÔ‰È΋ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, fiˆ˜ ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÛÙËÓ ÔÔ›· ·fi Ù· 11 ·È‰È¿ Ì ÙÈÌ‹ UCa/UCr >0,35 ÛÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘, ÛÙ· 8 Ë ÙÈÌ‹ ÙÔ˘ ËÏ›ÎÔ˘ Â·Ó‹Ïı ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰· ηٿ ÙË Ó¤· ̤ÙÚËÛË Ô˘ ¤ÁÈÓ ÌÂÙ¿ 6 Ì‹Ó˜. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÙÈÌ‹ ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌ¿Ù·È, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, Î·È Ì ‚¿ÛË ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜, ηٿ ÙËÓ ÔÔ›· ¤Ï·‚ ¯ÒÚ· Ë Ì¤ÙÚËÛË. ∏ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ·È-

468

Ù›· Ô˘ÚÔÏÈı›·Û˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (¶›Ó·Î·˜ 1). ™˘¯ÓfiÙÂÚË ÌÔÚÊ‹ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Â›Ó·È Ë È‰ÈÔ·ı‹˜, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ¿ÏË ·Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú·, ÂÓÒ ÙÔ ·Û‚¤ÛÙÈÔ ÙÔ˘ ÔÚÔ‡ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi. Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ··ÓÙ¿Ù·È ÛÙÔ 50-80% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÏÈı›·Û˘ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ÂÓÒ Û¯ÂÙ›˙ÂÙ·È Î·È Ì ÙËÓ È‰ÈÔ·ıÔ‡˜ ÂΉ‹ÏˆÛ˘ ·ÈÌ·ÙÔ˘Ú›· ÛÙ· ·È‰È¿ (1,2).

O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ Ca ÛÙ· Ô‡Ú· 24ÒÚÔ˘ Î·È Ù˘ Û¯¤Û˘ Ca ÚÔ˜ ÎÚ·ÙÈÓ›ÓË (UCa/UCr) ÛÂ Ù˘¯·›· ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ, ·ÔÙÂÏ› ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË Ù˘ ·Ô‚ÔÏ‹˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú·, Ë ‰Â ÙÈÌ‹ ÙÔ˘ ‰Â›ÎÙË Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ÙËÓ ËÏÈΛ·. º˘ÛÈÔÏÔÁÈΤ˜ ıˆÚÔ‡ÓÙ·È ÔÈ ÙÈ̤˜, fiÙ·Ó ÙÔ Ca Ô‡ÚˆÓ 24ÒÚÔ˘ Â›Ó·È ÌÈÎÚfiÙÂÚÔ ·fi 4 mg/kg Î·È Ë ÙÈÌ‹ UCa/UCr ÌÈÎÚfiÙÂÚË ·fi 0,25 mg/mg ÛÂ Ù˘¯·›Ô ‰Â›ÁÌ· Ô‡ÚˆÓ ‹ Û ԇڷ 24ÒÚÔ˘ (1,19). ∏ ÁÓÒÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÙÔ˘ ·Ô‚·ÏÏfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘, ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. O ηıÔÚÈÛÌfi˜, fï˜, Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ Â›Ó·È ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏÔ˜, ÂÍ·ÈÙ›·˜ ΢ڛˆ˜ ÙˆÓ ‰È·ÊÔÚÒÓ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ·fi ¯ÒÚ· Û ¯ÒÚ·, ·ÏÏ¿ Î·È ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜. ∆· ÛÙÔȯ›·, ÂÍ¿ÏÏÔ˘, ·fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ. À¿Ú¯Ô˘Ó, ΢ڛˆ˜, ÌÂϤÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ÂÓ‹ÏÈΘ, ÂÓÒ fiÛ˜ ·ÊÔÚÔ‡Ó Û ·È‰È¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÔÙÂϤÛÌ·Ù· Ì ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜. ∂ÈϤÔÓ, ÔÈ ÌÂϤÙ˜ ·˘Ù¤˜ ›¯·Ó Î·È Ù· ÁÓˆÛÙ¿ ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÌÈÎÚfi ·ÚÈıÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·‰˘Ó·Ì›· ÌÂϤÙ˘ ÌÂÁ¿ÏˆÓ ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Û οı ËÏÈÎȷ΋ ÔÌ¿‰·, ·ÏÏ¿ Î·È Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÈÂÍ¿ÁÔÓÙ·Ó Û ·È‰È¿ ÓÔÛËÏ¢fiÌÂÓ· ÁÈ· ¿ÏÏÔ˘˜ ÌÂÓ ÏfiÁÔ˘˜, ÙˆÓ ÔÔ›ˆÓ fï˜ ÙfiÛÔ ÙÔ ‰È·ÈÙÔÏfiÁÈÔ fiÛÔ Î·È Ë Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· fiÓÙ·˜ ‰È·ÊÔÚÂÙÈ΋ ·' fiÙÈ ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, ı· ÌÔÚÔ‡Û ›Ûˆ˜ Ó· ÂËÚ¿˙ÂÈ Î·È ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (2-5). ¶·Ú¿ Ù· ˘¿Ú¯ÔÓÙ· ÌÂÈÔÓÂÎÙ‹Ì·Ù·, fï˜, ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ ÚÔ·ÙÔ˘Ó ÂӉȷʤÚÔÓÙ· Î·È ¯Ú‹ÛÈÌ· ÛÙÔȯ›·. ŒÙÛÈ, ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘, ÙfiÛÔ ·fi ¯ÒÚ· Û ¯ÒÚ·, fiÛÔ Î·È Ì¤Û· ÛÙËÓ ›‰È· ¯ÒÚ·, ·fi ÂÚÈÔ¯‹ Û ÂÚÈÔ¯‹ (6). ∂›Û˘ ‰È·ÊÔÚ¤˜ (·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ·ÓÙÈÊ·ÙÈΤ˜) ¤¯Ô˘Ó ·Ú·ÙËÚËı› Î·È ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Ô˘ ·Ô‰›‰ÔÓÙ·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ËÏÈÔÊ¿ÓÂÈ·, ÛÙË ‰È·ÙÚÔÊ‹, ÛÙÔÓ ÎÈÚο‰ÈÔ Ú˘ıÌfi Ù˘ ·Ô‚ÔÏ‹˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Î.Ï. ŒÙÛÈ, ÂÓÒ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÌÂÁ·Ï‡ÙÂÚË ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ηٿ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜ (7-11), ÙÔ ·ÎÚÈ‚Ò˜ ·ÓÙ›ıÂÙÔ ¤¯ÂÈ

¶·È‰È·ÙÚÈ΋ 2001;64:465-471

Paediatriki 2001;64:465-471

¶›Ó·Î·˜ 3. ∞¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ Û ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ÂÔ¯¤˜ ÙÔ˘ ¤ÙÔ˘˜ ηٿ ËÏÈΛ·

∏ÏÈΛ· (¤ÙË)

n

6 7 8 9 10 11

16 49 15 27 25 18

™À¡O§O

150

UCa/UCr Ô‡ÚˆÓ [(mg/dl) / (mg/dl)] (ª¤ÛË ÙÈÌ‹ ± SD) OÎÙÒ‚ÚÈÔ˜ n ∞Ú›ÏÈÔ˜ (ÌÂÁ¿ÏË ÚÔËÁËı›۷ (ÌÂȈ̤ÓË ÚÔËÁËı›۷ ËÏÈÔÊ¿ÓÂÈ·) ËÏÈÔÊ¿ÓÂÈ·) 0,15 ± 0,08 12 0,15 ± 0,1 0,16 ± 0,11 46 0,11 ± 0,1 0,21 ± 0,1 13 0,075 ± 0,05 0,21 ± 0,13 27 0,16 ± 0,13 0,18 ± 0,11 24 0,2 ± 0,17 0,14 ± 0,09 18 0,12 ± 0,1 0,17 ± 0,11

140

0.14 ± 0.12

P

ª™ 0,017 0,002 0,05 ª™ ª™ 0,022

ª™: ÌË ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

¶›Ó·Î·˜ 4. ¶·È‰È¿ Ì ÙÈÌ‹ Ca/Cr Ô‡ÚˆÓ [(mg/dl) / (mg/dl)] >0,35 ÌÂÙ¿ ÙË ıÂÚÈÓ‹ ÂÚ›Ô‰Ô Ù˘ ÌÂÁ¿Ï˘ ËÏÈÔÊ¿ÓÂÈ·˜ Î·È ·ÔÙÂϤÛÌ·Ù· Â·ÓÂϤÁ¯Ô˘ ÌÂÙ¿ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô Ù˘ ÌÂȈ̤Ó˘ ¤ÎıÂÛ˘ ÛÙÔÓ ‹ÏÈÔ º‡ÏÔ ∞ ∞ ∞ ∞ ∫ ∞ ∞ ∫ ∞ ∞ ∫

UCa/UCr [(mg/dl) / (mg/dl)] OÎÙÒ‚ÚÈÔ˜ ∞Ú›ÏÈÔ˜ 0,35 0,26 0,55 0,44 0,48 0,32 0,35 0,42 0,41 0,57 0,37 0,075 0,38 0,18 0,41 0,30 0,44 0,30 0,57 0,07 0,36 -

∞: ∞ÁfiÚÈ, ∫: ∫ÔÚ›ÙÛÈ

‰È·ÈÛÙˆı› Û ÌÂϤÙË, Ë ÔÔ›· ÂÚÈÂÏ¿Ì‚·Ó ÌÈÎÚfi ·ÚÈıÌfi ·È‰ÈÒÓ ÛÙËÓ πÓ‰›· (12). ™Â ÌÂϤÙË Ô˘ ‰ÈÂÍ‹¯ıË ÛÙË ¡fiÙÈ· πÙ·Ï›·, Û ۇÓÔÏÔ 220 ˘ÁÈÒÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 3-16 ÂÙÒÓ, Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr ‹Ù·Ó 0,076±0,060 mg/mg (13). ™˘ÁÎÚ›ÓÔÓÙ·˜ ÙȘ ÙÈ̤˜ ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ÛÙȘ ·ÓÙ›ÛÙÔȯ˜, Ì ÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ, Ë Ì¤ÛË ÙÈÌ‹ UCa/UCr ÛÙ· ·È‰È¿ 6-8 ÂÙÒÓ Â›Ó·È 0,072±0,062, ÂÓÒ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 9-11 ÂÙÒÓ Ë Ì¤ÛË ÙÈÌ‹ UCa/UCr Â›Ó·È 0,063±0,042. ™ËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ˆ˜ ÚÔ˜ ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ· Ô‡Ú· ·Û‚ÂÛÙ›Ô˘ ‰ÂÓ ‰È·ÈÛÙÒıËÎÂ, fiˆ˜ ¿ÏψÛÙÂ Î·È ÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, fï˜ ÔÈ ÙÈ̤˜ UCa/UCr ÔÈ Ôԛ˜ ηٷÁÚ¿ÊËÎ·Ó ÛÙË ÌÂϤÙË ·˘Ù‹, ÙfiÛÔ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ, fiÛÔ Î·È ·Ó¿ ËÏÈÎȷ΋ ÔÌ¿‰·, Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚ˜ ·fi ÙȘ ·ÓÙ›ÛÙÔȯ˜ Ù˘ ‰È΋˜ Ì·˜ ÌÂϤÙ˘, ‡ÚËÌ· ÙÔ ÔÔ›Ô Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÚÌËÓ¢ı›, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ¡fiÙÈ· πÙ·Ï›· ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿Ï˜ ÔÌÔÈfiÙËÙ˜ Ì ÙË ‰È΋ Ì·˜ ¯ÒÚ·, ÙfiÛÔ ˆ˜ ÚÔ˜

ÙȘ ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ, fiÛÔ Î·È ·fi ÏÂ˘Ú¿˜ ÎÏÈÌ·ÙÔÏÔÁÈÎÒÓ Û˘ÓıËÎÒÓ. ™Â ÌÂϤÙË ÙÔ˘ ∆ÛÂÎÂÓÙ˙‹ Î·È Û˘ÓÂÚÁ·ÙÒÓ ÙÔ˘, Û 282 ˘ÁÈ‹ ·È‰È¿ ËÏÈΛ·˜ 3 ¤ˆ˜ 14 ÂÙÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ ÛÙÔ 96,2% ÙˆÓ ·ÁÔÚÈÒÓ Î·È Û fiÏ· Ù· ÎÔÚ›ÙÛÈ·, Ë Ì¤ÁÈÛÙË ÙÈÌ‹ ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr ‹Ù·Ó ÌÈÎÚfiÙÂÚË ÙÔ˘ 0,12 (14). ∂Í¿ÏÏÔ˘, Ë Û‡ÁÎÚÈÛË ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr Ù˘ ‰È΋˜ Ì·˜ ÌÂϤÙ˘ (¶›Ó·Î·˜ 2) Ì ·˘Ù¤˜ ¿ÏÏˆÓ ÌÂÏÂÙÒÓ, ηٷ‰ÂÈÎÓ‡ÂÈ ÔÌÔÈfiÙËÙ˜ Ì ÔÚÈṲ̂Ó˜ Î·È ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ¿ÏϘ. ŒÙÛÈ, Û ÌÂϤÙË ÙˆÓ Esbjorner E Î·È Jones IL ·fi ÙË ™Ô˘Ë‰›· (15) ‚Ú¤ıËÎ·Ó ÙÈ̤˜ ÌÈÎÚfiÙÂÚ˜ ·fi ÙȘ ‰ÈΤ˜ Ì·˜ ÁÈ· ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ. ∂Ó‰ÂÈÎÙÈο, Û ·È‰È¿ ËÏÈΛ·˜ 2-6 ÂÙÒÓ, ̤ÛË ÙÈÌ‹ UCa/UCr 0,20±0,17, 50‹ ÂηÙÔÛÙÈ·›· ı¤ÛË (∂£) 0,16, 97Ë ∂£ 0,63 Î·È Û ·È‰È¿ 7-10 ÂÙÒÓ, ËÏÈÎȷ΋ ÔÌ¿‰· Ë ÔÔ›· ÚÔÛÂÁÁ›˙ÂÈ ÂÚÈÛÛfiÙÂÚÔ ÙÔ ‰ÈÎfi Ì·˜ ‰Â›ÁÌ·, ̤ÛË ÙÈÌ‹ 0,15±0,12, 50‹ ∂£ 0,112 Î·È 97Ë ∂£ 0,42. ∆È̤˜ ËÏ›ÎÔ˘ UCa/UCr ·ÚfiÌÔȘ Ì ·˘Ù¤˜ Ù˘ ‰È΋˜ Ì·˜ ÌÂϤÙ˘ ‰›‰ÂÈ, ·fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÌÂϤÙË ÙÔ˘ Reusz GS Î·È Û˘ÓÂÚÁ·ÙÒÓ ÙÔ˘ ·fi ÙËÓ O˘ÁÁ·Ú›· (16). Ÿˆ˜ ÚԷӷʤÚıËÎÂ, fï˜, ÙÔ ‚·ÛÈÎfi ‡ÚËÌ· Ù˘ ‰È΋˜ Ì·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ηٿ ÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘ Û ۯ¤ÛË Ì ·˘Ù‹ ÙÔ˘ ∞ÚÈÏ›Ô˘. ∆Ô Â‡ÚËÌ· ·˘Ùfi Û˘ÌʈÓ› Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÌÂÏÂÙÒÓ Ô˘ ¤ÁÈÓ·Ó Û ÂÓ‹ÏÈΘ. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ, Â›Û˘, ÙÔ ÁÂÁÔÓfi˜ Ù˘ Û˘Û¯¤ÙÈÛ˘ Ô˘ ‚Ú¤ıËΠÌÂٷ͇ ÙÔ˘ ËÏ›ÎÔ˘ UCa/UCr Î·È Ù˘ ËÏÈÔÊ¿ÓÂÈ·˜, ÂÓÒ ·Ó¿ÏÔÁË Û˘Û¯¤ÙÈÛË ‰ÂÓ Î·Ù¤ÛÙË ‰˘Ó·Ùfi Ó· ÛÙÔȯÂÈÔıÂÙËı› Ì ÙËÓ ÂÚÈÂÎÙÈÎfiÙËÙ· Ù˘ ÙÚÔÊ‹˜ Û ·Û‚¤ÛÙÈÔ ÛÙȘ ‰‡Ô ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜. ∆Ô Â‡ÚËÌ¿ Ì·˜ ·˘Ùfi, Â›Û˘ Û˘ÌʈÓ› Ì ٷ ˘ÔÛÙËÚÈ˙fiÌÂÓ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ηı’ fiÛÔÓ Ë ·˘ÍË̤ÓË ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘ ηٿ Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ˘˜

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ıÂÚÈÓÔ‡˜ Ì‹Ó˜ ·Ô‰›‰ÂÙ·È ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÛÙ· ·˘ÍË̤ӷ Â›‰· Ù˘ 25-O∏ ‚ÈÙ·Ì›Ó˘ D, Ù· ÔÔ›· ‚Ú›ÛÎÔÓÙ·È Û ¢ı›· ·Ó·ÏÔÁ›· Ì ÙËÓ ·˘ÍË̤ÓË ‰È¿ÚÎÂÈ· Ù˘ ËÏÈÔÊ¿ÓÂÈ·˜ ηٿ ÙË ıÂÚÈÓ‹ ÂÚ›Ô‰Ô (17). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ú¤ÂÈ Ó· Û¯ÔÏÈ·ÛÙ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ, ·Ú¿ ÙË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ Ù˘ ̤Û˘ ÙÈÌ‹˜ Ù˘ Û¯¤Û˘ UCa/UCr ÙÔÓ OÎÙÒ‚ÚÈÔ Î·È Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÙÈÌ‹˜ ÙÔ˘ ∞ÚÈÏ›Ô˘, Ë Ú·ÁÌ·ÙÈ΋ ‰È·ÊÔÚ¿ ÙˆÓ ÙÈÌÒÓ (0,17±0,11 ¤Ó·ÓÙÈ 0,14±0,12), ÔÈ Ôԛ˜ ›ӷÈ, Ô‡Ùˆ˜ ‹ ¿Ïψ˜, ·ÌÊfiÙÂÚ˜ Ê˘ÛÈÔÏÔÁÈΤ˜, ÛÙÂÚÂ›Ù·È ‚ÈÔÏÔÁÈ΋˜ ÛËÌ·Û›·˜ Î·È Î·Ù' Â¤ÎÙ·ÛË Ú·ÎÙÈÎÔ‡ ÎÏÈÓÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. øÛÙfiÛÔ, ÙÔ Â‡ÚËÌ· ÂΛÓÔ Ù˘ ÌÂϤÙ˘ Ì·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÂӉȷʤÚÔÓ, ·ÎÚÈ‚Ò˜ ÂÂȉ‹ ·ÚÔ˘ÛÈ¿˙ÂÈ ÎÏÈÓÈ΋ ÛËÌ·Û›·, Â›Ó·È ÂΛÓÔ ÙÔ ÔÔ›Ô Û˘ÓÔÙÈο ·ÂÈÎÔÓ›˙ÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4, Û‡Ìʈӷ Ì ÙÔ ÔÔ›Ô ÌfiÓÔ 3 ·fi Ù· 11 ·È‰È¿ Ì “˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·” (UCa/UCr >0,35) ηٿ ÙË Ì¤ÙÚËÛË ÙÔ˘ OÎÙˆ‚Ú›Ô˘, ÂÍ·ÎÔÏÔ˘ıÔ‡Û·Ó Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ıÔÏÔÁÈ΋ ÙÈÌ‹ ÙÔ˘ ËÏ›ÎÔ˘ Î·È Î·Ù¿ ÙË ‰Â‡ÙÂÚË Ì¤ÙÚËÛË ÙÔ˘ ∞ÚÈÏ›Ô˘. £ÂˆÚ‹Û·Ì ÙÔ 0,35 ˆ˜ fiÚÈÔ ‰È¿ÎÚÈÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ·fi ÂΛӷ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·¤ÎÎÚÈÛË ·Û‚ÂÛÙ›Ô˘, Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙȘ ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ Ù˘ ‰È΋˜ Ì·˜ ÌÂϤÙ˘, ıˆÚÒÓÙ·˜ ˆ˜ ·ıÔÏÔÁÈΤ˜ ÙȘ ÙÈ̤˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ¿Óˆ ·fi ÙËÓ 90‹ ÂηÙÔÛÙÈ·›· ı¤ÛË. ∞Í›˙ÂÈ ÛÙÔ ÛËÌÂ›Ô ·˘Ùfi Ó· ·Ó·ÊÂÚı› fiÙÈ fiÏ· ·˘Ù¿ Ù· ·È‰È¿ (Î·È Ù· 11) ‹Ù·Ó ·Û˘Ìو̷ÙÈο, Ô ‰Â ÂÓ‰Âϯ‹˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ (ÌÂÙ·‚ÔÏÈÎfi˜ Î·È ·ÂÈÎÔÓÈÛÙÈÎfi˜) ¤ÏÂÁ¯Ô˜ ÛÙÔÓ ÔÔ›Ô ˘Ô‚Ï‹ıËηÓ, ·¤‚Ë ·ÚÓËÙÈÎfi˜ ÁÈ· ·ÈÌ·ÙÔ˘Ú›·, ÏÈı›·ÛË ‹ ¿ÏÏÔ ·ıÔÏÔÁÈÎfi ‡ÚËÌ·. ∂Ô̤ӈ˜, Ë ·Ó‡ÚÂÛË ·ıÔÏÔÁÈÎÔ‡ ËÏ›ÎÔ˘ UCa/UCr Î·È ÁÂÓÈο Ë ‰È·›ÛÙˆÛË ·˘ÍË̤Ó˘ ·Ô‚ÔÏ‹˜ ·Û‚ÂÛÙ›Ô˘ ÛÙ· Ô‡Ú· ı· Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌ¿Ù·È Ì ·Ú·Ì¤ÙÚÔ˘˜ fiˆ˜ Ë ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Î·È Ë ËÏÈÔÊ¿ÓÂÈ·. ¶Ú¤ÂÈ ‰Â, Ó· Â·Ó·Ï·Ì‚¿ÓÂÙ·È Î·È Ó· ÂȂ‚·ÈÒÓÂÙ·È ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ÚÈÓ ıˆÚËı› fiÙÈ ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ¿ÙÔÌÔ ¿Û¯ÂÈ ·fi ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·, Ì ÙË Û˘Ó·ÎfiÏÔ˘ıË Ù·Ï·ÈˆÚ›· ÂÓfi˜ ÂÎÙÂÓÔ‡˜ ·Ú·ÎÏÈÓÈÎÔ‡ ÂϤÁ¯Ô˘ ηÈ, ‚‚·›ˆ˜, ÚÈÓ ÏËÊıÔ‡Ó Ì¤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ˘ÔÙÈı¤ÌÂÓÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·¤ÎÎÚÈÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜, Ô˘ ÔÊ›ÏÂÙ·È Èı·Ófiٷٷ, ÛÙË ‰È·ÊÔÚÂÙÈ΋ ËÏÈÔÊ¿ÓÂÈ· Î·È ÙË Û˘Ó·ÎfiÏÔ˘ıË ‰È·ÊÔÚ¿ ÛÙËÓ ÂÓ‰ÔÁÂÓ‹ Û‡ÓıÂÛË Ù˘ ‚ÈÙ·Ì›Ó˘ D, Ì fiÛ· ·˘Ùfi Û˘ÓÂ¿ÁÂÙ·È, ‰Â‰Ô̤ÓÔ˘ Ì¿ÏÈÛÙ· fiÙÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙÔ ¯ÂÈÌÒÓ· Î·È ÙÔ Î·ÏÔη›ÚÈ, ˆ˜ ÚÔ˜ ÙËÓ ÂÚÈÂÎÙÈÎfiÙËÙ· Ù˘ ÙÚÔÊ‹˜ Û ·Û‚¤ÛÙÈÔ, ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÛÙË ÌÂϤÙË Ì·˜. ™˘ÓÂÒ˜, Ë ÁÓÒÛË ÙˆÓ ‰È·Î˘Ì¿ÓÛÂˆÓ ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ·ÂÎÎÚÈÓfiÌÂÓÔ˘ ÛÙ·

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17. Houhala MA, Parviainen MT, Pyykko K, Visakorpi JK. Serum 25-hydroxyvitamin D levels in Finnish children aged 2-17 years. Acta Paediatr Scand 1984;73:232-236.

18. ™Ù·˘ÚÈÓ¿‰Ë˜ Ã, ™ÈÓ·ÓÈÒÙ˘ ∫∞, ªԇ΢ ¢, ∫Ô˘ÙÛÂÏ›Ó˘ ∞. ∞Ô‚ÔÏ‹ ·Û‚ÂÛÙ›Ô˘ Î·È Ì·ÁÓËÛ›Ô˘ Ì ٷ Ô‡Ú· ÛÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∞Ó·ÎÔ›ÓˆÛË ÛÙÔ 17Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ: µfiÏÔ˜; 1979.

19. §··ÙÛ¿Ó˘ ¶¢. ÀÂÚ·Û‚ÂÛÙÈÔ˘Ú›· ÛÙ· ·È‰È¿. ¢ÂÏÙ ∞’ ¶·È‰È·ÙÚ ∫ÏÈÓ ¶·ÓÂ ∞ıËÓÒÓ 1995;42:117-120.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-11-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 08-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ ¶¿ÚÓËıÔ˜ 32, 190 13, ™·ÚˆÓ›‰· ∞ÙÙÈ΋˜

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ÀÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· ÛÙ· ·È‰È¿. ∫ÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È Ê˘ÛÈ΋ ÈÛÙÔÚ›·1 ∂ÈÛ·ÁˆÁ‹: ∏ ȉÈÔ·ı‹˜ ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· ¤¯ÂÈ ·Ó·ÊÂÚı› ÛÙÔ ·ÚÂÏıfiÓ Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔ˘Ú›·. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÚÈÁÚ·Ê› Ë ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È Ë Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›·˜, fi¯È ÌfiÓÔ Û ·È‰È¿ Ì ·ÈÌ·ÙÔ˘Ú›· ·ÏÏ¿ Î·È Û ÂΛӷ Ì ‰˘ÛÔ˘Ú›· ηÈ/‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· ¿ÏÁË ÛÙËÓ ÎÔÈÏÈ¿ ‹ ÙÔ˘˜ ÓÂÊÚÔ‡˜ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Ô˘ÚÔÏÈı›·Û˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰Ô˜: ŒÁÈÓ ·Ó·‰ÚÔÌÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ ·fi 102 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· Î·È Ù˘ ¤Î‚·Û˘ Û 26 ·fi ·˘Ù¿ Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· ‰È¿ÛÙËÌ· ÂÓfi˜ ‹ ÂÚÈÛÛÔÙ¤ÚÔ˘ ¯ÚfiÓÔ˘ (̤ÛÔ˜ fiÚÔ˜ 3,1 ¯ÚfiÓÈ·) ¯ˆÚ›˜ ÂȉÈ΋ ıÂÚ·›·. ∞ÔÙÂϤÛÌ·Ù·: ∆· 61 ·È‰È¿ ›¯·Ó ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· Î·È Ù· 41 ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›· Î·È ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·. ¶ÂÓ‹ÓÙ· ‰‡Ô ·ÛıÂÓ›˜ ‰ÂÓ ·Ó¤ÊÂÚ·Ó ·Ó¿ÌÂÛ· ÛÙ· Û˘ÌÙÒÌ·Ù· ·ÈÌ·ÙÔ˘Ú›· Î·È Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ÙÔ 1/3 ÙˆÓ ·ÛıÂÓÒÓ Ë ·Ó¿Ï˘ÛË Ô‡ÚˆÓ ÛÙËÓ ÚÒÙË ÂͤٷÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ™ÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô, ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ‰È·ÈÛÙÒıËÎ·Ó Ï›ıÔÈ ‰È·Ì¤ÙÚÔ˘ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 mm Î·È ÛÙÔ 12% ‰È·Ì¤ÙÚÔ˘ 4-18 mm. ™Â 30 ·fi ÙÔ˘˜ 39 ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ·ÈÌ·ÙÔ˘Ú›· ÛÙËÓ ÚÒÙË ÂͤٷÛË (77%), ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô ÌÈÎÚÔ› ‹ ÌÂÁ¿ÏÔÈ Ï›ıÔÈ. ∏ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· Ï›ıˆÓ ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ·fi ÂΛÓË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· Ï›-

ıˆÓ. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘, 4 ·fi ÙÔ˘˜ 26 ·ÛıÂÓ›˜ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÔÙ¤ ·ÈÌ·ÙÔ˘Ú›· Î·È 8 ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ·ÈÌ·ÙÔ˘Ú›· ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‰È¿ÛÙËÌ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘. ¢‡Ô ·ÛıÂÓ›˜ Ô˘ ·ÚÔ˘Û›·Û·Ó Ï›ıÔ˘˜ ·fi ÙËÓ ·Ú¯‹ Î·È ÙÚÂȘ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Û¯ËÌ·Ù›ÛÙËÎ·Ó Ï›ıÔÈ ‰È·Ì¤ÙÚÔ˘ 4-12 mm, ÙÔ˘˜ ·¤‚·Ï·Ó 1-3,5 ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÛÙ· Ô‡Ú·. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ·Ô˘Û›· ·ÈÌ·ÙÔ˘Ú›·˜ ‰ÂÓ ·ÔÙÂÏ› ‰Â›ÎÙË ·Ô˘Û›·˜ Ô˘ÚÔÏÈı›·Û˘, ÁÈ’ ·˘Ùfi Ë ÂÍ·Ê¿ÓÈÛË ÌfiÓÔ Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ ·ÔÙÂÏ› Ï¿ıÔ˜ ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÂÊ·ÚÌÔ˙fiÌÂÓ˘ ıÂÚ·›·˜. ∏ ˘fiÓÔÈ· ˘ÂÚÔ˘ÚÈÎÔ˙Ô˘Ú›·˜ Î·È ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜ Ú¤ÂÈ Ó· Ù›ıÂÙ·È Û ·È‰È¿ Ì ‰˘ÛÔ˘Ú›· ηÈ/‹ ˘ÔÙÚÔÈ¿˙ÔÓÙ· ¿ÏÁË ÛÙËÓ ÎÔÈÏÈ¿ ‹ ÙÔ˘˜ ÓÂÊÚÔ‡˜ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Ô˘ÚÔÏÈı›·Û˘, ·ÎfiÌË Î·È ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ·ÈÌ·ÙÔ˘Ú›·˜.

1 La ªanna A, Polito C, MarÙe A, Iovene A, Di Toro R Hyperuricosuria in children. Clinical presentation and natural history Pediatrics 2001;107:86-90

∆ÛÔ˘Ì¿Î·˜ ∫ˆÓ/ÓÔ˜ ¶·È‰›·ÙÚÔ˜ - ¢È¢ı˘ÓÙ‹˜ ∂™À ¡ÔÛÔÎÔÌÂ›Ô ∫∞∆ - ∞ÙÙÈ΋˜

471

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2001;64:472-480

ORIGINAL ARTICLE

∏ ÂÌÂÈÚ›· ·fi ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Û ·È‰È¿ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ¡. ∑¿‚Ú·˜1, ∞. ∫·fiÁÈ·ÓÓ˘2, ¶. ∫·Ï·Ì·Ï›Î˘1, °. ªÚÈ·ÛÔ‡Ï˘1, ∂. °ÂˆÚÁ¿ÎË2, ∞. ÷Ù˙‹˜1

Management of children with acute renal failure in a pediatric intensive care unit N. Zavras1, A. Kapogiannis2, P. Kalambalikis1, G. Briasoulis1, E. Georgaki2, A. Hatzis1

¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ Ù˘ ÂÌÂÈÚ›·˜ ·fi ÙË Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙˆÓ ÌÂıfi‰ˆÓ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (O¡∞) ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ (ª∂£). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÙÂÙÚ·ÂÙ›·˜, 25/1359 ·ÛıÂÓ›˜ (1,84%), ̤Û˘ ËÏÈΛ·˜ 5,56±1,13 ¤ÙË, ÓÔÛËχıËÎ·Ó ÛÙË ª∂£ Ì O¡∞ Ô˘ ÔÊÂÈÏfiÙ·Ó Â›Ù ÛÙÔ Û‡Ó‰ÚÔÌÔ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ [17/25, (68%)] ‹ Û ¿ÏÏ· ·›ÙÈ· [8/25 (32%)]. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ̤ıÔ‰ÔÈ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘: Û 7 ·fi ÙÔ˘˜ 25 ·ÛıÂÓ›˜ (28%) ÂÊ·ÚÌfiÛıËΠÔÍ›· ÂÚÈÙÔÓ·˚΋ οı·ÚÛË (¶∫), Û 16/25 (64%) Û˘Ó¯‹˜ ·ÈÌԉȋıËÛË (™∞¢) Î·È Û 2/25 (8%) ·ÈÌÔοı·ÚÛË (∞∫). ∞fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÚÔ·ÙÂÈ fiÙÈ Î·È Ì ÙȘ ÙÚÂȘ ÌÂıfi‰Ô˘˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ·ÔÙÂÏÂÛÌ·ÙÈο ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›Ù¢ÍË ·ÚÓËÙÈÎÔ‡ ÈÛÔ˙˘Á›Ô˘ ˘ÁÚÒÓ, ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì·˜ Ê·›ÓÂÙ·È fiÙÈ Ë ™∞¢ ˘ÂÚÙÂÚ› Ù˘ ¶∫ (p<0,005). ∆Ô ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì O¡∞ ÛÙ· Ï·›ÛÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ‹Ù·Ó ¯·ÌËÏfi (20%), ÂÓÒ fiÏ· Ù· ·È‰È¿ Ì O¡∞ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ Â¤˙ËÛ·Ó. ™˘ÌÂÚ·ÛÌ·ÙÈο, Î·È ÔÈ ÙÚÂȘ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˘ÔηıÈÛÙÔ‡Ó ÈηÓÔÔÈËÙÈο ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. OÈ ‰È·ÊÔÚ¤˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ Ê·›ÓÂÙ·È Ó· ÔÊ›ÏÔÓÙ·È ÛÙË ‚·Ú‡ÙËÙ· Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ Î·È fi¯È ÛÙË ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓË Ù¯ÓÈ΋.

Abstract: ∆he aim of this study was to report our experience based on the comparative study of the various modalities of renal replacement therapy (RRT) used for the management of patients with acute renal failure (ARF), during their hospitalization in our Pediatric Intensive Care Unit (PICU). During a 4-year period from October 1996 to November 2000, 25/1359 patients (1,84%), with a mean age 6,24±1,2 yrs, were admitted to the PICU with ARF, that occurred either as part of multiple organ system failure (MOSF) [17/25, (68%)] or due to other causes (8/25, 32%). Of these patients 7/25 (28%) were treated with acute peritoneal dialysis (PD), 16/25 (64%) with continuous hemofiltration (CHF) and 2/25 (8%) with hemodialysis (HD). Our results showed that acute renal failure and acid-base disturbances were successfully corrected with RRT. Nevertheless, negative fluid balance was better achieved by CHF, compared to PD (p<0,005).

Survival of children with ARF and MOSF was low (20%), while all children with ARF, due to other causes, survived. We conclude, that children with ARF could be treated effectively with RRT. The outcome of these patients is mainly dependent on the severity of the underlying disease and not to the mode of RRT used.

1 MÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ¡ÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

1 Intensive Care Unit “Agia Sophia” Children’s Hospital, Athens 2 Nephrology Department, “Agia Sophia” Children’s Hospital

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Paediatriki 2001;64:472-480

§¤ÍÂȘ ÎÏÂȉȿ: ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, Â͈ÓÂÊÚÈ΋ οı·ÚÛË, ÂÚÈÙÔÓ·˚΋ οı·ÚÛË, ·ÈÌԉȋıËÛË, ·ÈÌÔοı·ÚÛË.

Key words: acute renal failure, renal replacement therapy, peritoneal dialysis, hemofiltration, hemodialysis.

∂ÈÛ·ÁˆÁ‹ H ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (O¡∞) ÛÙË ‚ÚÂÊÈ΋ Î·È ·È‰È΋ ËÏÈΛ· ÔÊ›ÏÂÙ·È Û ‰È¿ÊÔÚ· ·›ÙÈ· (1,2) Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ Ô‡ÚˆÓ (<1 ml/kg/h) Î·È ·Ú¿ÏÏËÏË ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘, ηıÒ˜ Î·È ¿ÏÏˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ÚÔ˚fiÓÙˆÓ ÛÙÔ ·›Ì· (3,4). ∂ÓÙÔ‡ÙÔȘ, ÔÈ ÂÚÈÙÒÛÂȘ O¡∞ ÛÙȘ Ôԛ˜ Ë ·Ú·ÁˆÁ‹ Ô‡ÚˆÓ ·Ú·Ì¤ÓÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ‹ Î·È ·˘ÍË̤ÓË (ÔÏ˘Ô˘ÚÈÎÔ‡ Ù‡Ô˘ O¡∞) Ì ·Ú¿ÏÏËÏË ‰È·Ù·Ú·¯‹ ÛÙËÓ ·¤ÎÎÚÈÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ·˙ÒÙÔ˘, ‰ÂÓ Â›Ó·È Û¿ÓȘ ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. OÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó O¡∞ ÏfiÁˆ ÂÓ‰ÔÁÂÓÔ‡˜ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘ ¤¯Ô˘Ó ηٿ ηÓfiÓ· ηϋ ¤Î‚·ÛË, Ì ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ οو ·fi 10% (5,6). ∞ÓÙ›ıÂÙ·, fiÙ·Ó Ë O¡∞ ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÌ¿ÙˆÛ˘ Î·È Û˘Ó˘¿Ú¯ÂÈ ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÙÔ ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ Î˘Ì·›ÓÂÙ·È ·fi 60-100% (7). ∞ÛıÂÓ›˜ Ì O¡∞ Ô˘ ÔÊ›ÏÂÙ·È Û ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·, ¤¯Ô˘Ó ·˘ÍË̤Ó˜ ·Ó¿ÁΘ Û ˘ÁÚ¿, ÔÈ Ôԛ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ Î¿Ï˘„Ë ÙˆÓ ıÂÚÌȉÈÎÒÓ ·Ó·ÁÎÒÓ Î·È ÙËÓ ·˘ÍË̤ÓË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ¶·Ú¿ÏÏËÏ·, ÂÍ·ÈÙ›·˜ Ù˘ ÌÂȈ̤Ó˘ ·ÂÎÎÚÈÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÙˆÓ ÓÂÊÚÒÓ, ÌÂÈÒÓÂÙ·È Ë ·Ô‚ÔÏ‹ ÙÔÍÈÎÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ. °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜, Ì ÙËÓ ¤ÁηÈÚË ¤Ó·ÚÍË Ù˘ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Â›Ó·È ÂÊÈÎÙ‹ Ë ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÔÌ¿ÎÚ˘ÓÛË ˘ÁÚÒÓ Î·È Ë ÈηÓÔÔÈËÙÈ΋ ıÂÚÌȉÈ΋ Î¿Ï˘„Ë (8). OÈ Â͈ÓÂÊÚÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ó·È Ë ÂÚÈÙÔÓ·˚΋ οı·ÚÛË (¶∫), Ë Û˘Ó¯‹˜ ·ÈÌԉȋıËÛË (™∞¢) Î·È Ë ·ÈÌÔοı·ÚÛË (∞∫). ∏ ·ÈÌÔοı·ÚÛË (∞∫) ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ú¯Èο ˆ˜ ·ÚÈÔ Ì¤ÛÔ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Û ·È‰È¿ Ì O¡∞ (5). ∏ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, fï˜, Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ª∂£ ¤¯ÂÈ ÂÚÈÔÚ›ÛÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ (9). ∏ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË (¶∫) ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı›, Â›Û˘, ηٿ ÙÔ ·ÚÂÏıfiÓ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· (10,11). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Û ÔÏϤ˜ ÌÂϤÙ˜, ÙÔ ÂӉȷʤÚÔÓ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ O¡∞ Û ÓÂÔÁÓ¿, ‚Ú¤ÊË Î·È ·È‰È¿ Ì ÙË Û˘Ó¯‹ ·ÈÌԉȋıËÛË (™∞¢) (12-15). ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ Á›ÓÂÙ·È Î·Ï‡ÙÂÚ· ·ÓÂÎÙ‹ ÛÙÔ˘˜ ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ·ÚÚÒÛÙÔ˘˜, ÂÓÒ ·Ú¿ÏÏËÏ· ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ·Ê·›ÚÂÛ˘ ÛËÌ·ÓÙÈÎÔ‡ fiÁÎÔ˘ ˘ÁÚÒÓ (16). ™ÙË ÌÂϤÙË ·˘Ù‹ ÂÚÈÁÚ¿ÊÔ˘Ì ÙËÓ ÂÌÂÈÚ›·

Ì·˜ ·fi ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ O¡∞ Ì ÙȘ ·Ú·¿Óˆ ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∫·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· OÎÙÒ‚ÚÈÔ˜ 1996 - ¡Ô¤Ì‚ÚÈÔ˜ 2000, ÓÔÛËχıËÎ·Ó 1359 ·ÛıÂÓ›˜ ÛÙË ª∂£ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”. TÚÈ¿ÓÙ· ·fi ·˘ÙÔ‡˜ (2,2%), ·ÚÔ˘Û›·Û·Ó O¡∞, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËΠ̛̠· ·fi ÙȘ ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘: ÔÍ›· ÂÚÈÙÔÓ·˚΋ οı·ÚÛË (¶∫) Û 8 ·È‰È¿, Û˘Ó¯‹˜ ·ÈÌԉȋıËÛË (™∞¢) Û 20 Î·È ‰È·Ï›Ô˘Û· ·ÈÌÔοı·ÚÛË (∞∫) Û 2 ·È‰È¿. ∞ÛıÂÓ›˜ Ô˘ Â¤˙ËÛ·Ó ÏÈÁfiÙÂÚÔ ·fi 24 ÒÚ˜ ‰ÂÓ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÛÙË ÌÂϤÙË Ì·˜. ∏ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ¤ÁÈÓ Û ۯ¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ ÁÂÓÈ΋˜ ÙÔ˘ ηٿÛÙ·Û˘. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ¶∫ ‹Ù·Ó 1,8 ¤ÙË (‡ÚÔ˜: 48 Ë̤Ú˜ ¤ˆ˜ 7 ¤ÙË) Î·È Û ™∞¢ 7,8 ¤ÙË (‡ÚÔ˜: 1,1 ¤ˆ˜ 17 ¤ÙË). ∆· 2 ·È‰È¿ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ∞∫ ›¯·Ó ÙËÓ ›‰È· ËÏÈΛ· (11 ¤ÙË) (¶›Ó·Î·˜ 1). ∞fi Ù· 30 ·È‰È¿, ·ÔÎÏ›ÛÙËÎ·Ó 5 ·fi ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ¤Ó·˜ ·ÛıÂÓ‹˜ ‹Ù·Ó Û ¯ÚfiÓÈ· ¶∫ Î·È ÓÔÛËχÙËΠÛÙË ª∂£ ÁÈ· <48 ÒÚ˜ ÏfiÁˆ ·ÙÂÏÔ‡˜ ÂÈÏÂÔ‡, ÂÓÒ 4 ·È‰È¿ Ì ™∞¢ Â¤˙ËÛ·Ó <24 ÒÚ˜. ™Ù· ˘fiÏÔÈ· 25 ·È‰È¿, Ù· ·›ÙÈ· Ô˘ ÚÔοÏÂÛ·Ó ÙËÓ O¡∞ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ‰‡Ô oÌ¿‰Â˜. ∏ ÚÒÙË ÔÌ¿‰· ÂÚÈÂÏ¿Ì‚·Ó 17 ·È‰È¿ (68%), ÛÙ· ÔÔ›· ÙÔ ·›ÙÈÔ Ù˘ O¡∞ ‹Ù·Ó ÙÔ Û‡Ó‰ÚÔÌÔ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È Ë ‰Â‡ÙÂÚË ÔÌ¿‰· ÂÚÈÂÏ¿Ì‚·Ó 8 ·È‰È¿ (32%), ÛÙ· ÔÔ›· ¿ÏÏ· ·›ÙÈ· ‹Ù·Ó ˘‡ı˘Ó· ÁÈ· ÙËÓ O¡∞ (¶›Ó·Î·˜ 2).

OÚÈÛÌÔ› ø˜ O¡∞ ÔÚ›ÛÙËÎÂ Ë ÂÌÊ¿ÓÈÛË ÔÏÈÁÔ˘Ú›·˜ (·Ú·ÁˆÁ‹ Ô‡ÚˆÓ <1 ml/kg/h) ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 4 ˆÚÒÓ, ·Ú¿ ÙËÓ Â·Ú΋ ÂÓ˘‰¿ÙˆÛË Î·È ÙË ¯ÔÚ‹ÁËÛË ÓÙÔ·Ì›Ó˘ ‹/Î·È ÊÔ˘ÚÔÛÂÌ›‰Ë˜ Î·È Ë ·fiÙÔÌË ·‡ÍËÛË ÙˆÓ ÙÈÌÒÓ Ù˘ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ ·›Ì·ÙÔ˜ (17). ø˜ ÛËÙÈ΋ ηٷÏËÍ›· ÔÚ›ÛÙËÎÂ Ë ·ÚÔ˘Û›· Û‹„˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÒÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ·Ú¿ ÙËÓ Â·Ú΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È Û˘Ó‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ ·ÈÌ¿ÙˆÛ˘, ÔÈ Ôԛ˜ ÌÔÚ› Ó· ÂΉËÏÒÓÔÓÙ·Ó Ì Á·Ï·ÎÙÈ΋ ÔͤˆÛË, ÔÏÈÁÔ˘Ú›· Î·È ‰È·Ù·Ú·¯‹ ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘ (18). ø˜ Û‡Ó‰ÚÔÌÔ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (™¶A) ÔÚ›ÛÙËÎÂ Ë ·ÓÂ¿ÚÎÂÈ· 2 ÙÔ˘Ï¿¯ÈÛÙÔÓ Û˘ÛÙËÌ¿ÙˆÓ (19). ∏ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Û οı ·È‰› ÂÎÙÈÌ‹ıËΠ̠ÙËÓ

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË (n: 25) ∂›‰Ô˜

AÚÈıÌfi˜ ·ÛıÂÓÒÓ

∏ÏÈΛ· Û ¤ÙË (̤Û˱sem)

PRISM

™¶∞ (·Ú. ·ÛıÂÓÒÓ)

¶∫ ™∞¢ ∞∫

7 (28%) 16 (64 %) 2 (8%)

1,70±0,82 6,79±1,57 11

23,5±1,5 26,2±2,4 11,7±2,5

3 16 -

473

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

Paediatriki 2001;64:472-480

¶›Ó·Î·˜ 2. ∞›ÙÈ· O¡∞ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙË ª∂£ ∞›ÙÈÔ ∞) ¶ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· - ÛËÙÈ΋ ηٷÏËÍ›· - Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ - Ú·‚‰ÔÌ˘fiÏ˘ÛË B) ÕÏÏ· ·›ÙÈ· - ÂÓ‰ÔÁÂÓ‹˜ ÓÂÊÚÈ΋ ‚Ï¿‚Ë (˘ÔÏ·ÛÙÈÎÔ›-‰˘ÛÏ·ÛÙÈÎÔ› ÓÂÊÚÔ›, Ô˘Ú·ÈÌÈÎfi-·ÈÌÔÏ˘ÙÈÎfi Û‡Ó‰ÚÔÌÔ, Û˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÓÂÊÚÈÎÒÓ ·ÚÙ.Û‡Ó‰ÚÔÌÔ Williams, ÂÛÙȷ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË) - ÙÔÍÈ΋ Â›‰Ú·ÛË Ê·ÚÌ¿ÎˆÓ ™‡ÓÔÏÔ

∞ÛıÂÓ›˜

%

15 1 1

60 4 4

5

20

3

12

25

100

Îϛ̷η ¶·È‰È·ÙÚÈÎÔ‡ ∫ÈÓ‰‡ÓÔ˘ £ÓËÛÈÌfiÙËÙ·˜ (Pediatric Risk of Mortality - PRISM score) (20). ∏ Â¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ ÂÎÙÈÌ‹ıËΠ̠ÎÚÈÙ‹ÚÈÔ ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ˘ÁÚÒÓ, ÙË Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ ÛÙÔ ·›Ì·, ηıÒ˜ Î·È ÙË ‰ÈfiÚıˆÛË ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ¢Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ Ï·Ì‚¿ÓÔÓÙ·Ó ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· οı 12 ÒÚ˜. ∞Ú¯¤˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÂÚÈÁÚ·Ê‹ ÙˆÓ Ù¯ÓÈÎÒÓ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ŸÏ˜ ÔÈ Ù¯ÓÈΤ˜ ÛÙËÚ›˙ÔÓÙ·È ÛÙËÓ Î¿ı·ÚÛË ÙÔ˘ ‡‰·ÙÔ˜ ̤ۈ ËÌȉȷÂÚ·Ù‹˜ ÌÂÌ‚Ú¿Ó˘ Î·È ÂÓfi˜ Â͈ۈ̷ÙÈÎÔ‡ ΢ÎÏÒÌ·ÙÔ˜. ∏ ‰È·‰Èηۛ· ·˘Ù‹ ηÏÂ›Ù·È ˘ÂډȋıËÛË (ultrafiltration) Î·È Â›Ó·È ›‰È· Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÛÂÈÚ¿Ì·ÙÔ˜. ™ÙËÓ ¶∫, ÙÔ ›‰ÈÔ ÙÔ ÂÚÈÙfiÓ·ÈÔ ·ÔÙÂÏ› ÙË Ê˘ÛÈ΋ ÌÂÌ‚Ú¿ÓË ·ÓÙ·ÏÏ·Á‹˜ ÓÂÚÔ‡, ÂÓÒ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ™∞¢ Î·È Ù˘ ∞∫ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ù¯ÓËÙ‹ Â͈ۈ̷ÙÈ΋ ÌÂÌ‚Ú¿ÓË. °È· ÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ ˘ÂÚ‰ÈËı‹Ì·ÙÔ˜ ··ÈÙÂ›Ù·È Ë ·Ó¿Ù˘ÍË Ô‰ËÁÔ‡ ›ÂÛ˘ ‰È‹ıËÛ˘ (‰È·ÌÂÌ‚Ú·ÓÈ΋ ›ÂÛË). ™ÙË ™∞º∞, Ë Ô‰ËÁfi˜ ›ÂÛË ÂÈÙ˘Á¯¿ÓÂÙ·È ·fi ÙËÓ Î·Ú‰È·Î‹ ·ÓÙÏ›·. ™ÙË ™ºº∞ Î·È ÛÙËÓ ∞∫, Ë Ô‰ËÁfi˜ ›ÂÛË ÂÍ·ÛÊ·Ï›˙ÂÙ·È Ì ÙË ‚Ô‹ıÂÈ· ·ÓÙÏ›·˜. ∆¤ÏÔ˜, ÛÙËÓ ¶∫, Ë ·Ê·›ÚÂÛË ˘ÁÚÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ˆÛ̈ÙÈÎfiÙËÙ· ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ οı·ÚÛ˘. ™Ù· ÂÚÈÙÔÓ·˚ο ‰È·Ï‡Ì·Ù·, Ë ˆÛ̈ÙÈο ‰Ú·ÛÙÈ΋ Ô˘Û›· Â›Ó·È Ë ÁÏ˘Îfi˙Ë. ∞‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ۷ί¿ÚÔ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ê·›ÚÂÛË ÌÂÁ·Ï‡ÙÂÚÔ˘ fiÁÎÔ˘ ˘ÁÚÒÓ. ∏ οı·ÚÛË ÙˆÓ ‰È·Ï˘Ì¤ÓˆÓ Ô˘ÛÈÒÓ ·fi ÙȘ ËÌȉȷÂÚ·Ù¤˜ ÌÂÌ‚Ú¿Ó˜ ÙÔ˘ Ê›ÏÙÚÔ˘ Á›ÓÂÙ·È Ì ÙË ‰È·‰Èηۛ· Ù˘ ‰È¿¯˘Û˘ (diffusion) Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi Ì ÌÂÙ·ÊÔÚ¿ (convection) ÙˆÓ Ô˘ÛÈÒÓ, ηıÒ˜ Û˘Ì·Ú·Û‡ÚÔÓÙ·È ·fi ÙÔ ÓÂÚfi Ì ÙË ‰È·‰Èηۛ· Ù˘ ˘ÂډȋıËÛ˘. O Ú˘ıÌfi˜ ·Ô‚ÔÏ‹˜ ÙˆÓ Ô˘ÛÈÒÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ οı·ÚÛ˘, ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ fiÚˆÓ Ù˘ ÌÂÌ‚Ú¿Ó˘ ηÈ, Ù¤ÏÔ˜, ·fi ÙË ‰È·ÊÔÚ¿ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ‰È·Ï˘Ì¤ÓˆÓ Ô˘ÛÈÒÓ (21). ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ ¶∫, Ë ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ‰È·Ï˘Ì¤ÓˆÓ Ô˘ÛÈÒÓ Ì¤Ûˆ ÙÔ˘ ÂÚÈÙÔÓ·›Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ fiÁÎÔ ÙÔ˘ ÂÚÈÙÔÓ·˚ÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ Î·È ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÏÏ·ÁÒÓ. ·) ¶ÂÚÈÙÔÓ·˚΋ οı·ÚÛË: ∏ ¶∫ ÁÈÓfiÙ·Ó ÌÂÙ¿ ·fi ÙÔ-

474

Ôı¤ÙËÛË ÂÓfi˜ ηıÂÙ‹Ú· Tenckhoff Ì ‰ÈÏfi ‰·ÎÙ‡ÏÈÔ (cuff), ›Ù ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô Â›Ù ÛÙË ª∂£ (∂ÈÎfiÓ· 1). ∏ ¤Ó·ÚÍË Ù˘ ¶∫ ÁÈÓfiÙ·Ó Ì ÌÈÎÚÔ‡˜ fiÁÎÔ˘˜ ÙÔ ÚÒÙÔ 24ˆÚÔ (10-15 ml/kg/·Ó¿ ·ÎÏÔ) Ô˘ ÚÔԉ¢ÙÈο ·‡Í·Ó·Ó ̤¯ÚÈ 40 ml/kg/·Ó¿ ·ÎÏÔ, ·Ó ÁÈÓfiÙ·Ó Î·Ï¿ ·ÓÂÎÙfi. To ÂÚÈÙÔÓ·˚Îfi ‰È¿Ï˘Ì· ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi ÁÏ˘Îfi˙Ë: 1,5%, 2,5% ‹ 4,25% Î·È ËÏÂÎÙÚÔχÙ˜ (¡a+: 136 mEq/l, Ca++: 3,5 mEq/l, Mg++: 0,76 mEq/l Î·È Á·Ï·ÎÙÈÎfi Ô͇). ∫·ÏÏȤÚÁÂȘ ·fi ÙÔ ˘ÂډȋıËÌ· Ï·Ì‚¿ÓÔÓÙ·Ó Î·ıËÌÂÚÈÓ¿. ‚) ™˘Ó¯‹˜ ·ÈÌԉȋıËÛË: ∏ ™∞¢ ÁÈÓfiÙ·Ó Â›Ù ˆ˜ Û˘Ó¯‹˜ ·ÚÙËÚÈÔÊÏ‚È΋ ·ÈÌԉȋıËÛË (™∞º∞) (∂ÈÎfiÓ· 2), ›Ù ˆ˜ Û˘Ó¯‹˜ ÊÏ‚Ô-ÊÏ‚È΋ ·ÈÌԉȋıËÛË (™ºº∞) Ì ÙË ‚Ô‹ıÂÈ· ÂÚÈÛÙÚÔÊÈ΋˜ ·ÓÙÏ›·˜ (CHERRY CHF-VER 10,ERGO) (∂ÈÎfiÓ· 3). ∏ ÂÊ·ÚÌÔÁ‹ ÁÈÓfiÙ·Ó ÌÂÙ¿ ·fi ηıÂÙËÚÈ·ÛÌfi ÙˆÓ ÌËÚÈ·›ˆÓ ·ÁÁ›ˆÓ Ì ÙË Ì¤ıÔ‰Ô Seldinger. H ™∞º∞ ÂÊ·ÚÌÔ˙fiÙ·Ó Û ·ÛıÂÓ›˜ Ì Â¿ÚÎÂÈ· Ù˘ ηډȷ΋˜ ·ÓÙÏ›·˜, ÂÓÒ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÂÊ·ÚÌÔ˙fiÙ·Ó Ë ™ºº∞. ∆Ô Û‡ÛÙËÌ· Ù˘ Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi ÙÔ Ê›ÏÙÚÔ ÔÏ˘ÛÔ˘ÏÊfiÓ˘ (Diafilter, D20-NR, D30-NR) Ì ÂÈÊ¿ÓÂÈ· 0,3-0,66 m2. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ›¯Â Û¯¤ÛË Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜. ∆Ô Ì‹ÎÔ˜ Ù˘ ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ÁÚ·ÌÌ‹˜ ‹Ù·Ó 30 cm Î·È 40 cm ·ÓÙ›ÛÙÔȯ·. °È· ÙËÓ ·ÔÊ˘Á‹ ‰ËÌÈÔ˘ÚÁ›·˜ ıÚfiÌ‚ˆÓ ÛÙÔ Â͈ۈ̷ÙÈÎfi ·Îψ̷, ÁÈÓfiÙ·Ó ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘ ÛÂ Û˘Ó¯‹ ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË ·fi ÙËÓ ÚÔ¤ÎÙ·ÛË Ù˘ ·ÚÙËÚȷ΋˜ ÁÚ·ÌÌ‹˜ ÙÔ˘ ΢ÎÏÒÌ·ÙÔ˜ Î·È ÛÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ ·ÈÌԉȋıËÛ˘, Ì ڢıÌfi 5-10 IU/kg/h. ™Ùfi¯Ô˜ ‹Ù·Ó Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (∞PTT) ÛÙÔ Â͈ۈ̷ÙÈÎfi ·Îψ̷ ÛÙ· 90 sec. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ·Ô‚ÔÏ‹ ÙˆÓ Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ ‰ÂÓ ‹Ù·Ó ÈηÓÔÔÈËÙÈ΋ ÌÂÙ¿ ·fi ·Ú¤Ï¢ÛË 24 ˆÚÒÓ Û˘Ó¯ԇ˜ ·ÈÌԉȋıËÛ˘, Ë ™∞¢ (·ÚÙËÚÈÔÊÏ‚È΋ ‹ ÊÏ‚ÔÊÏ‚È΋) ÌÂÙ·ÙÚÂfiÙ·Ó ÛÂ Û˘Ó¯‹ ·ÈÌԉȷ‰È‹ıËÛË (™∞¢¢). ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹, ‰È¿Ï˘Ì· Ì ۇÛÙ·ÛË ¡a+: 140 mEq/l, HCO3-:40 mEq/l ,Cl-:100 mEq/l (‰È¿Ï˘Ì· D6 Bieffe Medital, BELCO) ‰ÈÔ¯ÂÙ¢fiÙ·Ó ÛÙÔ ÌË ·ÈÌ·ÙÈÎfi ¯ÒÚÔ ÙÔ˘ Ê›ÏÙÚÔ˘, Û ·ÓÙ›ıÂÙË ÚÔ‹ ·fi ·˘Ù‹ ÙÔ˘ ·›Ì·ÙÔ˜. ∏ ™∞¢¢ ·ÔÙÂÏ› ·Ú·ÏÏ·Á‹ Ù˘ ™∞¢ Î·È Û˘Ó‰˘¿˙ÂÈ ÙË ‰È¿¯˘ÛË Î·È ÙË ÌÂÙ·ÊÔÚ¿, Ì ÛÎÔfi ÙËÓ ·‡ÍËÛË Ù˘ οı·ÚÛ˘ ÙˆÓ Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ (22).

H ·ÔηٿÛÙ·ÛË ÙˆÓ ·ˆÏÂÈÒÓ ÁÈÓfiÙ·Ó Ì ‰È¿Ï˘Ì· ˘ÔηٿÛÙ·Û˘ ·ÈÌÔ‰ÈËı‹Ì·ÙÔ˜: Na+: 135 mmol/l, K+: 2

∂͈Ù. ÙÌ‹Ì· ÙÔ˘ ηıÂÙ‹Ú·

∂ȉÂÚÌ›‰· ÀÔ‰fiÚÈÔ˜ ‰·ÎÙ‡ÏÈÔ˜ ∫ÔÈÏÈ·Îfi ÙÔ›¯ˆÌ· ∆ÔȯˆÌ·ÙÈÎfi ÂÚ.

∂Ó Ùˆ ‚¿ıÂÈ ‰·ÎÙ‡ÏÈÔ˜

∂›ÏÔ˘Ó

∂ÓÙÂÚÈΤ˜ ¤ÏÈΘ ∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ ÙÔÔı¤ÙËÛ˘ ÂÓ‰ÔÂÚÈÙÔÓ·˚ÎÔ‡ ηıÂÙ‹Ú· Tenckhoff.

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

Paediatriki 2001;64:472-480

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∂ÈÎfiÓ· 3. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ Û˘Ó¯ԇ˜ ÊÏ‚Ô-ÊÏ‚È΋˜ ·ÈÌԉȋıËÛ˘.

mmol/l, Ca++: 1,87 mmol/l, Mg++: 0,75 mmol/l, Cl-: 108,5 mmol/l, Á·Ï·ÎÙÈÎfi Ô͇: 33,75 mmol/l, osmolality: 290 mosm/l (Hemofiltration solution 2, Laboratorium Dr. G. Bichel AG 3800 Interlaken Switzerland) Û ÔÛfiÙËÙ· ·Ó¿ÏÔÁË Ì ÙȘ ˘‰ÚÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ ·ÛıÂÓÔ‡˜. °) ∞ÈÌÔοı·ÚÛË: °È· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ∞∫ ÁÈÓfiÙ·Ó Î·ıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ Ì ÙËÓ ›‰È· ̤ıÔ‰Ô ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ™∞º∞ ‹ ™ºº∞. °È· ÙËÓ ·ÈÌÔοı·ÚÛË ¯ÚËÛÈÌÔÔÈ›ÙÔ ÙÔ Ì˯¿ÓËÌ· AK-10 Ì ‰ÈÙÙ·ÓıÚ·ÎÈο (GABRO CO) Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ Ê›ÏÙÚÔ˘ (GFE-12,GABRO) ‹Ù·Ó 0,81,3 m2, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÛÒÌ·Ùfi˜ ÙÔ˘. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∞fi ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÂÍ·ÈÚ¤Û·Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ∞∫, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ‰Â›ÁÌ·ÙÔ˜ (2 ·ÛıÂÓ›˜). T· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ˆ˜ ̤ÛË ÙÈÌ‹±sem (ÛÙ·ıÂÚfi ÛÊ¿ÏÌ·). OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ‚·Ú‡ÙËÙ·˜ Û˘ÁÎÚ›ıËÎ·Ó Û ۯ¤ÛË Ì ÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ, ηıÒ˜ Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÌÂıfi‰ˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ Î·È ÙˆÓ ÙÈÌÒÓ Ô˘Ú›·˜/ÎÚ·ÙÈÓ›Ó˘, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ÔÏÏ·ÏÒÓ ÌÂÙÚ‹ÛˆÓ. ∆¤ÏÔ˜, Ë Û‡ÁÎÚÈÛË ¶∫/™∞¢ ˆ˜ ÚÔ˜ ÙËÓ Â›Ù¢ÍË ·ÚÓËÙÈÎÔ‡ ÈÛÔ˙˘Á›Ô˘ ˘ÁÚÒÓ ¤ÁÈÓ Ì ÙË ‰ÔÎÈÌ·Û›· t ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ (two tailed-t-test). ∆È̤˜ Èı·ÓfiÙËÙ·˜ <0,05 ıˆڋıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. OÈ ·Ó·Ï‡ÛÂȘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ™Ù·ÙÈÛÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÁÈ· ÙȘ ∫ÔÈÓˆÓÈΤ˜ ∂ÈÛً̘ (SPSS) ÁÈ· Windows, ¤Î‰ÔÛË 8.

∞ÔÙÂϤÛÌ·Ù· ∞fi ÙÔ˘˜ 25 ·ÛıÂÓ›˜ Ì O¡∞, ‚Ú¤ıËΠfiÙÈ Â›¯·Ó ·ÓÔ˘Ú›· ÔÈ 23 (92%), Ô˘Ú·ÈÌ›· ÔÈ 24 (96%), ·‡ÍËÛË ÎÚ·ÙÈÓ›Ó˘ ÔÈ 25 (100%), Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· ÔÈ 12 (48%) Î·È ˘ÂÚηÏÈ·ÈÌ›· ÔÈ 3 (12%). ∏ ¶∫ ÂÊ·ÚÌfiÛÙËΠ۠7 ·ÛıÂÓ›˜ (28%), Ë ™∞¢ Û 16 (64%), ÂÓÒ Ë ∞∫ Û 2 (8%). ™Â 3 ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ™∞¢, ÂÊ·ÚÌfiÛÙËΠÂÈϤÔÓ ·ÈÌԉȷ‰È‹ıËÛË ÁÈ· ÌÂÁ·Ï‡ÙÂÚË ·Ô‚ÔÏ‹ Ô˘Ú·ÈÌÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ̤ÛË ‰È¿ÚÎÂÈ· ÂÊ·ÚÌÔÁ‹˜ Ù˘ ¶∫ ‹Ù·Ó 24,4±1 Ë̤Ú˜, Ù˘ ™∞¢ 7,31±2,8 Ë̤Ú˜, ÂÓÒ Ù˘ ∞∫ 2,2±0,54 Ë̤Ú˜. ™ÙÔÓ ¶›Ó·Î· 3 Ê·›ÓÂÙ·È Ë Ì¤ÛË ‰È¿ÚÎÂÈ· ÁÈ· οı ̤ıÔ‰Ô ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Î·È Ë ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ ˆ˜ ÚÔ˜ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙË ıÓËÛÈÌfiÙËÙ·. ∏ Ì›ˆÛË ÙˆÓ ÙÈÌÒÓ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ Ì ÙË Û˘ÌÏ‹ÚˆÛË 48 ˆÚÒÓ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ οı ÌÂıfi‰Ô˘ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋, fiˆ˜ Ê·›ÓÂÙ·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ (¶›Ó·Î·˜ 4). ™˘ÁÎÚ›ÓÔÓÙ·˜, fï˜, ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ (™∞¢/¶∫) ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜. ™ÙȘ ∂ÈÎfiÓ˜ 4 Î·È 5 Ê·›ÓÂÙ·È Ë ‰È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Ì ÙȘ 2 ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ô‚ÔÏ‹ Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘, Ê¿ÓËΠfiÙÈ ÂÈÙ˘Á¯¿ÓÂÙ·È ÌÂÁ·Ï‡ÙÂÚË ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ Ì ™∞¢¢, Û˘ÁÎÚÈÙÈο Ì ÙË ™∞¢ Î·È Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,05). ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ ÙÈ̤˜ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ Û ·È‰È¿ Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ·ÔÎÏÂÈÛÙÈο Ì ™∞¢, ‹Ù·Ó ·ÓÙ›ÛÙÔȯ· 135±2 mg/dl Î·È 1,8±0,58 mg/dl (ÚÒÙÔ 24ˆÚÔ) Î·È ÌÂÈÒıËÎ·Ó Û 104,8±18 mg/dl Î·È 1,5±0,3 mg/dl (‰Â‡ÙÂÚÔ 24ˆÚÔ). OÈ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Î·È Û ™∞¢¢ ÛÙÔ ‰Â‡ÙÂÚÔ 24ˆÚÔ ‹Ù·Ó ÁÈ· ÙËÓ Ô˘Ú›· 140±5,69 mg/dl (ÚÒÙÔ 24ˆÚÔ) Î·È 86,3±6 mg/dl (‰Â‡ÙÂÚÔ 24ˆÚÔ) Î·È ÁÈ· ÙËÓ ÎÚ·ÙÈÓ›ÓË 2,7±0,5 mg/dl (ÚÒÙÔ 24ˆÚÔ) Î·È 1,6±0,2 mg/dl (‰Â‡ÙÂÚÔ 24ˆÚÔ). §·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ¶∫ ÂÈÙ˘Á¯¿ÓÂÈ ÙÔ Ì¤ÁÈÛÙÔ Ù˘ ·fi‰ÔÛ˘ ÛÙ·‰È·Î¿, Û˘ÁÎÚ›Ó·Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ Û ۯ¤ÛË Ì ÙËÓ ™∞¢/™∞¢¢ ·Ó·ÊÔÚÈο Ì ÙËÓ ·Ô‚ÔÏ‹ ˘ÁÚÒÓ Ì ÙË Û˘ÌÏ‹ÚˆÛË 48 ˆÚÒÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. ∞ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ ÂÈÙ‡¯ıËΠ۠22 ·ÛıÂÓ›˜ (96%), ÂÓÒ ıÂÙÈÎfi ÈÛÔ˙‡ÁÈÔ ·Ú·ÙËÚ‹ıËΠ۠1 ·ÛıÂÓ‹ (4%) Ì ¶∫, ÏfiÁˆ ·Ó¿Ù˘Í˘ ÂÚÈÙÔÓ›Ùȉ·˜. ∞fi ÙË Û‡ÁÎÚÈÛË ÙˆÓ ‰‡Ô Ù¯ÓÈÎÒÓ ÚÔ·ÙÂÈ

475

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

Paediatriki 2001;64:472-480

¶›Ó·Î·˜ 3. ¢È¿ÚÎÂÈ· Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Î·È ¤Î‚·ÛË ·ÛıÂÓÒÓ

¶∫ ™∞¢ / ™∞¢¢ ∞∫

∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ

¢È¿ÚÎÂÈ· (̤Û˱sem)

ÂÈ‚›ˆÛË

ŒÎ‚·ÛË Ã¡∞

ı¿Ó·ÙÔ˜

7 15 2

24,40±1,0 Ë̤Ú˜ 7,31±2,8 Ë̤Ú˜ 2,20±0,54 Ë̤Ú˜

3 3 2

2 1

4 (57,1%) 13 (81,2%) -

á∞: ÃÚfiÓÈ· ¡ÂÊÚÈ΋ ∞ÓÂ¿ÚÎÂÈ·

fiÙÈ Ë ™∞¢ ˘ÂÚÙÂÚ› Ù˘ ¶∫ ˆ˜ ÚÔ˜ ÙËÓ ·Ê·›ÚÂÛË ˘ÁÚÒÓ (p<0,005) (∂ÈÎfiÓ· 6). ∂ÈÏÔΤ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ™∞¢ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó Û 3 ·È‰È¿ (18,7%). ∏ ÚÒÙË ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ıÚfiÌ‚ˆÛË Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ıÚÔÌ‚ÔÏ˘ÙÈ΋ ·ÁˆÁ‹ Î·È ÙÚÔÔÔ›ËÛË Ù˘ ™∞º∞ Û ™ºº∞, ÂÓÒ ÔÈ ¿ÏϘ ‰‡Ô ·ÊÔÚÔ‡Û·Ó ·ÔÈÎÈÛÌfi ÙˆÓ ·ÁÁ›ˆÓ Ì ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ Ô‰‹ÁËÛ Û ·ÓÙÈηٿÛÙ·ÛË Ù˘ ™∞¢ Ì ¶∫. ∞fi Ù· ·È‰È¿ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ¶∫, 3 (33,3%) ·ÚÔ˘Û›·Û·Ó ÂÈÏÔΤ˜. OÈ 2 ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Û·Ó ÂÚÈÙÔÓ›Ùȉ· Î·È Ë 1 ˘‰ÚÔıÒڷη. OÈ ÂÚÈÙÒÛÂȘ Ì ÂÚÈÙÔÓ›Ùȉ· ·ÓÙÈÌÂÙˆ›ÛÙËηÓ, Ë Ì›· ÌÂ Û˘ÛÙËÌ·ÙÈ΋ Î·È ÂÓ‰ÔÂÚÈÙÔÓ·˚΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Ë ¿ÏÏË Ì ·Ê·›ÚÂÛË ÙÔ˘ ÂÚÈÙÔÓ·˚ÎÔ‡ ηıÂÙ‹Ú· Î·È ÂÊ·ÚÌÔÁ‹ ™∞¢, ÂÓÒ Ô ˘‰ÚÔıÒڷη˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÚÔÛˆÚÈÓ‹ ‰È·ÎÔ‹ Ù˘ ¶∫ Î·È Û˘Ó¤¯ÈÛË Ù˘ ÌÂıfi‰Ô˘ Ì ÌÈÎÚfiÙÂÚÔ˘˜ fiÁÎÔ˘˜. ™Ù· 2 ·È‰È¿ Û ∞∫ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÂÈÏÔΤ˜.

Afi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 25 ·È‰ÈÒÓ Û ıÂÚ·›· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘, Ù· 16 (64%) ·‚›ˆÛ·Ó.

H ·ÚÈ· ·ÈÙ›· ı·Ó¿ÙÔ˘ ‹Ù·Ó Ë ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· ÏfiÁˆ ÛËÙÈ΋˜ ηٷÏËÍ›·˜. ∂›Û˘, ·Ú·ÙËÚ‹ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó Î·È ·˘ÙÒÓ Ô˘ ¤ı·Ó·Ó fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ PRISM score (12±2 Û ۇÁÎÚÈÛË Ì 24±4,2, p<0,001) Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÓÂ·ÚÎÔ‡ÓÙˆÓ ÔÚÁ·ÓÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ (·ÓÂ·ÚÎÔ‡ÓÙ· Û˘ÛÙ‹Ì·Ù· 2 Û ۇÁÎÚÈÛË Ì 4, p<0,001). ™˘˙‹ÙËÛË ∆· ·›ÙÈ· O¡∞ Û ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È ÛÙË ª∂£ Â›Ó·È ÔÈΛϷ. ∏ ÛËÙÈ΋ ηٷÏËÍ›· ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·fi ·˘Ù¿, ÂÓÒ ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ Û˘Ó˘¿Ú¯ÂÈ Ì ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Î·È Â› ·ÔÙ˘¯›·˜ ÙˆÓ Û˘ÓÙËÚËÙÈÎÒÓ Ì¤ÛˆÓ, ÂÈ‚¿ÏÏÂÙ·È Ë ¤ÁηÈÚË ¤Ó·ÚÍË Â͈ÓÂÊÚÈÎÒÓ ÌÂıfi‰ˆÓ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘. ™ÙËÓ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙ÂÈ Ë ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ: Û ‚Ú¤ÊË Î·È Ôχ ÌÈÎÚ¿ ·È‰È¿, fiÔ˘ Ë ·ÁÁÂȷ΋ ÚÔÛ¤Ï·ÛË Â›Ó·È ÔÏϤ˜ ÊÔÚ¤˜ ·‰‡Ó·ÙË, ·ÏÏ¿ Î·È Ô Î›Ó‰˘ÓÔ˜

476

¶›Ó·Î·˜ 4. ∞fi‰ÔÛË ÌÂıfi‰ˆÓ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ (̤ÛË ± sem) ™∞¢

¶∫

131,56±7,8 83,25±6,9 (p<0,001)

124,57±15,02 97,10±12,63 (p<0,001)

2,16±0,15 1,40±0,17 (p<0,001)

2,97±0,92 2,39±0,73 (p<0,001)

¢ÈÙÙ·ÓıÚ·ÎÈο (mEq/l) 0 ÒÚ˜ 14,65±0,3 12 ÒÚ˜ 21,20±0,4 (p<0,005)

16,40±1,5 21,89±0,32 (p<0,005)

O˘Ú›· (mg/dl) 0 ÒÚ˜ 48 ÒÚ˜ ∫Ú·ÙÈÓ›ÓË (mg/dl) 0 ÒÚ˜ 48 ÒÚ˜

ph 0 ÒÚ˜ 12 ÒÚ˜

7,21±0,8 7,38±0,14 (p<0,005)

7,27±0,2 7,40±0,1 (p<0,05)

0 ÒÚ˜ 6 ÒÚ˜

7,20±0,8 4,40±0,45 (p<0,05)

6,40±1,67 4,70±0,45 (p<0,05)

K

ÂÈÏÔÎÒÓ ·fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙˆÓ ·ÁÁ›ˆÓ ηٿ ÙÔÓ Î·ıÂÙËÚÈ·ÛÌfi Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÂÊ·ÚÌfi˙ÂÙ·È Î˘Ú›ˆ˜ Ë ¶∫, ÂÓÒ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÂÊ·ÚÌfi˙ÔÓÙ·È ÔÈ ‰‡Ô ¿ÏϘ ̤ıÔ‰ÔÈ (23-25). ∏ ¶∫, Â›Û˘, ·ÔÙÂÏ› ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜ Û ·È‰È¿ Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· Ó· ·Ó·Ù‡ÍÔ˘Ó ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÏfiÁˆ ÂÓ‰ÔÁÂÓÔ‡˜ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ (23). ™ÙË ÌÂϤÙË Ì·˜, Ù· ·È‰È¿ Ì ÂÓ‰ÔÁÂÓ‹ ÓÂÊÚÈ΋ ‚Ï¿‚Ë ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ¶∫. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë O¡∞ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘. ™·Ú¿ÓÙ· ÔÎÙÒ ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ (¶∫ ‹ ™∞¢) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ·Ú·ÙËÚ‹ıËΠÙÒÛË ÙˆÓ ÂÈ¤‰ˆÓ Ô˘Ú›·˜ Î·È ÎÚ·ÙÈÓ›Ó˘ Û ·Ô‰ÂÎÙ¿ Â›‰· (26). ∞Ó Î·È Ë ÚÒÙË ÂÓÙ‡ˆÛË ‹Ù·Ó fiÙÈ Ë ™∞¢ ˘ÂÚÙÂÚÔ‡Û Ù˘ ¶∫ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ, ÂÓÙÔ‡ÙÔȘ, ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

Paediatriki 2001;64:472-480

3

™∞¢ ¶∫ 100

50

0

24

48

flÚ˜

∫Ú·ÙÈÓ›ÓË (mg/dl)

O˘Ú›· (mg/dl)

150

2,5

™∞¢ ¶∫

2

1,5

1

0

24

48

flÚ˜

∂ÈÎfiÓ· 4. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ Ù˘ Ô˘Ú›·˜ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÚÈÙÔÓ·˚΋˜ οı·ÚÛ˘ Î·È Ù˘ Û˘Ó¯ԇ˜ ·ÈÌԉȋıËÛ˘.

∂ÈÎfiÓ· 5. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ÎÚ·ÙÈÓ›Ó˘ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÚÈÙÔÓ·˚΋˜ οı·ÚÛ˘ Î·È Ù˘ Û˘Ó¯ԇ˜ ·ÈÌԉȋıËÛ˘.

ÌÂıfi‰ˆÓ. ™Ù· ›‰È· Û˘ÌÂÚ¿ÛÌ·Ù· ηٷϋÁÔ˘Ó Î·È ¿ÏϘ ÌÂϤÙ˜ (17). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ô‚ÔÏ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘, ·Ó Î·È Ë ™∞¢ Ê·ÈÓfiÙ·Ó ϤÔÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·fi ÙËÓ ¶∫ Î·È Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜. ∏ ™∞¢¢ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ Geronymous ÙÔ 1984 (27) Î·È Û˘Ó‰˘¿˙ÂÈ Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ Û˘Ó¯ԇ˜ ·ÈÌԉȋıËÛ˘ Ì ÙË Û˘Ó¯‹ ·Ô‚ÔÏ‹ ‰È·Ï˘ÙÒÓ Ô˘ÛÈÒÓ Î·È ˘ÁÚÒÓ Ì ÂÈϤÔÓ ÙËÓ ·‡ÍËÛË Ù˘ οı·ÚÛ˘ ÙˆÓ Ô˘ÛÈÒÓ ·˘ÙÒÓ. ∞˘Ùfi ·ÔÙÂÏ› ¤Ó· ÂÈÚfiÛıÂÙÔ ÏÂÔÓ¤ÎÙËÌ· Û ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ·ÚÚÒÛÙÔ˘˜ Ô˘ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·Ó¯ıÔ‡Ó ÙÔ Û˘Ó‰˘·ÛÌfi ™∞¢ Î·È ∞∫ ÁÈ· ·Ô‚ÔÏ‹ ˘ÁÚÒÓ Î·È Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ, ·ÓÙ›ÛÙÔȯ·. ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ ¿ÏÏˆÓ ‰ËÌÔÛȇÛÂˆÓ (22,28), ¯ÚÂÈ¿˙ÂÙ·È fï˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ ÁÈ· Ó· ÂÍ·¯ıÔ‡Ó ·ÛÊ·Ï‹ Û˘ÌÂÚ¿ÛÌ·Ù·. ∏ Ú‡ıÌÈÛË ÙˆÓ ˘ÁÚÒÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O¡∞. ∏ ·Ê˘‰¿ÙˆÛË ÌÂÈÒÓÂÈ ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹, ÂÓÒ Ë ˘ÂÚÊfiÚÙˆÛË Ì ˘ÁÚ¿ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ηډȷÎÔ‡ ¤ÚÁÔ˘ Û ̛· ‹‰Ë ÂËÚ·Ṳ̂ÓË Î·Ú‰È·Î‹ ÏÂÈÙÔ˘ÚÁ›·. ∏ ηٿÛÙ·ÛË ·˘Ù‹ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Ô˘ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ÈÔ ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ Ù˘ O¡∞. ∂ȉÈο, ÁÈ· Ù· ÌÈÎÚ¿ ‚Ú¤ÊË Î·È ·È‰È¿ Ì ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ¤¯Ô˘Ó ·˘ÍË̤Ó˜ ·Ó¿ÁΘ Û ۛÙÈÛË, ÛÂ Û˘¯Ó¤˜ ÌÂÙ·ÁÁ›ÛÂȘ Î·È ¯ÔÚËÁ‹ÛÂȘ Ê·Ú̿ΈÓ, Ô Î›Ó‰˘ÓÔ˜ Ó· ˘ÂÚÊÔÚÙˆıÔ‡Ó Ì ˘ÁÚ¿ Â›Ó·È ·˘ÍË̤ÓÔ˜ (29). ∞ÓÙ›ıÂÙ·, Ë ·fiÙÔÌË ·Ô‚ÔÏ‹ ˘ÁÚÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÙÒÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ∏

˘fiÙ·ÛË ·ÔÙÂÏ› Û˘¯Ó‹ ÂÈÏÔ΋, ΢ڛˆ˜ Ù˘ ∞∫ Î·È ·Ô‰›‰ÂÙ·È Û ÔÏÏ¿ ·›ÙÈ·, ÛÙ· ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ÚÔ¸¿Ú¯Ô˘Û· ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, Ë Ù·¯Â›· ·Ô‚ÔÏ‹ ˘ÁÚÒÓ, Ë ˘ÔˆÛ̈ÙÈÎfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È Ë ·ÂÏ¢ı¤ÚˆÛË ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ ÙÔ ÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘, ÔÈ ÚÔÛÙ·ÁÏ·Ó‰›Ó˜ Î·È ÔÈ ÈÓÙÂÚÏ¢ΛÓ˜ (30,31). ∞ÓÙ›ıÂÙ·, Ë ™∞¢ ·ÔÙÂÏ› ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜, ȉȷ›ÙÂÚ· ÁÈ· ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ·ÛıÂÓ›˜. A˘Ùfi ÔÊ›ÏÂÙ·È ÛÙË ‚·ıÌÈ·›· ·Ô‚ÔÏ‹ ‰È·Ï˘Ì¤ÓˆÓ Ô˘ÛÈÒÓ Î·È ÓÂÚÔ‡, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌË ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ˆÛ̈ÙÈ΋ ÈÛÔÚÚÔ›· Î·È Ó· ‰È·ÙËÚÂ›Ù·È Â·Ú΋˜ Ô ÂÓ‰Ô·ÁÁÂÈ·Îfi˜ ¯ÒÚÔ˜ (32). ∂ÈÚfiÛıÂÙ·, ÌÂÚÈÎÔ› ÂÚ¢ÓËÙ¤˜ ·Ô‰›‰Ô˘Ó ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ‚ÂÏÙ›ˆÛË ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÈÌԉȋıËÛ˘ ÌÂÛ·›Ô˘ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ô˘ÛÈÒÓ, fiˆ˜ ‚Ú·‰˘ÎÈÓ›Ó˘, Ï¢ÎÔÙÚÈÂÓÒÓ Î·È ıÚÔÌ‚ÔÍ¿Ó˘, Ô˘ Ë ·ÚÔ˘Û›· ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¤Ó·ÚÍË Ù˘ ÛËÙÈ΋˜ ηٷÏËÍ›·˜ (33). ™ÙË ÌÂϤÙË Ì·˜, Ë ·Ô‚ÔÏ‹ ˘ÁÚÒÓ Î·È Ì ÙȘ ÙÚÂȘ ÌÂıfi‰Ô˘˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ‹Ù·Ó ÈηÓÔÔÈËÙÈ΋, ¯ˆÚ›˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÂÈÙÚ¤ÔÓÙ·˜ ÙË Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ Ì οı ̤ıÔ‰Ô Ô˘ ÂÊ·ÚÌfiÛÙËÎÂ.

OÈ ·ÛıÂÓ›˜ ÛÙË ª∂£ Û˘¯Ó¿ ¤¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ ‹Í˘ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Ô˘ Û˘Ó˘¿Ú¯ÂÈ Ì O¡∞. O ηıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ ·ÁÁ›ˆÓ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÈÌÔÚÚ·Á›Â˜ Î·È ‰ËÌÈÔ˘ÚÁ›· ·ÈÌ·ÙˆÌ¿ÙˆÓ ÛÙ· ÛËÌ›· ηıÂÙËÚÈ·ÛÌÔ‡ (34). ∂›Û˘, Ë ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ Ì ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘ Ô˘ Á›ÓÂÙ·È ÁÈ· ÙËÓ ·ÔÙÚÔ‹ ‰ËÌÈÔ˘ÚÁ›·˜ ıÚfiÌ‚ˆÓ ÛÙÔ Â͈ۈ̷ÙÈÎfi ·Îψ̷ (Ê›ÏÙÚÔ, ·ÚÙËÚȷΤ˜-ÊÏ‚ÈΤ˜ ÁÚ·Ì̤˜), ÌÔÚ› Ó·

477

™‡ÁÎÚÈÛË ·ÚÓËÙÈÎÔ‡ ÈÛo˙˘Á›Ô˘ (ml)

¶·È‰È·ÙÚÈ΋ 2001;64:472-480

Paediatriki 2001;64:472-480

200 0 -200 -400 -600 -800

P <0,05

-1000 -1200 -1400 N=

16

7

∞πªO¢π∏£H™∏

¶∂ƒπ∆O¡∞´∫∏ ∫∞£∞ƒ™∏

∂ÈÎfiÓ· 6. £ËÎfiÁÚ·ÌÌ· (box-plot) ÛÙÔ ÔÔ›Ô Ê·›ÓÂÙ·È ÙÔ Â‡ÚÔ˜, Ë Ì¤ÛË ÙÈÌ‹ Î·È Ë ÛÙ·ÙÈÛÙÈ΋ ‰È·ÊÔÚ¿ ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ÁÈ· οı ̤ıÔ‰Ô.

ÚÔηϤÛÂÈ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË. ¶·Ú’ fiÏ· ·˘Ù¿, Ô Î·ıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ ÂÓ¤¯ÂÈ ¿ÓÙ· ÙÔÓ Î›Ó‰˘ÓÔ ‰ËÌÈÔ˘ÚÁ›·˜ ıÚfiÌ‚ˆÓ (35). ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÈÏÔÎÒÓ ·fi ÙËÓ ÙÔÔı¤ÙËÛË ÎÂÓÙÚÈÎÒÓ ·ÁÁ›ˆÓ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 3-4% (35). ™ÙË ÌÂϤÙË Ì·˜ ›¯·Ì ̛· ÂÚ›ÙˆÛË ÂÈÏÔ΋˜ ·fi ıÚfiÌ‚ˆÛË ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ Û ·È‰› Ì ™∞¢. ™ËÌ·ÓÙÈ΋, Â›Û˘, ÂÈÏÔ΋ ÙˆÓ ÌÂıfi‰ˆÓ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Â›Ó·È Ë ÂÌÊ¿ÓÈÛË ÏÔÈÌÒÍÂˆÓ Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Â›Ù Ì ÙÔÓ ·ÔÈÎÈÛÌfi ÙˆÓ ÂÓ‰Ô·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ Ù˘ ™∞¢ ‹ ÙÔ˘ ÂÓ‰ÔÂÚÈÙÔÓ·˚ÎÔ‡ ηıÂÙ‹Ú· Ù˘ ¶∫. ∆Ô ÔÛÔÛÙfi ÙˆÓ ÏÔÈÌÒÍÂˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ¯Ú‹ÛË ÂÓ‰Ô·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ Û ª∂£ ·Ó¤Ú¯ÂÙ·È ¤ˆ˜ 40% (36,37) Î·È ¤¯ÂÈ Û¯¤ÛË Ì ÙË ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ ÙˆÓ Î·ıÂÙ‹ÚˆÓ, ÙËÓ Ù‹ÚËÛË Ì¤ÙÚˆÓ ·ÓÙÈÛË„›·˜ ÁÈ· ÙËÓ ÙÔÔı¤ÙËÛË ·˘ÙÒÓ, ÙË ¯Ú‹ÛË ÙÔ˘˜ ÁÈ· ¿ÏÏÔ˘˜ ÏfiÁÔ˘˜ (Ï‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ·›Ì·ÙÔ˜, ¯ÔÚ‹ÁËÛË Ê·Ú̿ΈÓ) Î·È ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ™ÙË ÌÂϤÙË Ì·˜, ‰‡Ô ·ÛıÂÓ›˜ (13,3%) ·ÚÔ˘Û›·Û·Ó ‚·ÎÙËÚÈ·ÈÌ›· Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÂÓ‰Ô·ÁÁÂÈ·Îfi ηıÂÙ‹Ú·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¶∫, Ë ÂÚÈÙÔÓ›Ùȉ· ·ÔÙÂÏ› ÙË ÛËÌ·ÓÙÈÎfiÙÂÚË ÂÈÏÔ΋ Ù˘ Î·È ÔÊ›ÏÂÙ·È Û˘Ó‹ıˆ˜, ›Ù Û ·ÈÌ·ÙÔÁÂÓ‹ ‰È·ÛÔÚ¿ (38) ›Ù Û ÂÈÌfiÏ˘ÓÛË ·fi ‚·ÎÙËÚȉȷÎÔ‡˜ ÔÚÁ·ÓÈÛÌÔ‡˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ (39). ∆Ô ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÂÚÈÙÔÓ›Ùȉ·˜ Î˘Ì·›ÓÂÙ·È ·fi 9-40% (40,41) Î·È Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÈÙÔÓ·˚΋˜ οı·ÚÛ˘ (42,43). ™ÙË ÌÂϤÙË Ì·˜, ‰‡Ô ·ÛıÂÓ›˜ (28%) Ì ̤ÛË ‰È¿ÚÎÂÈ· ¶∫ 22±6 Ë̤Ú˜ ·ÚÔ˘Û›·Û·Ó ÂÚÈÙÔÓ›Ùȉ·. ∏ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Á›ÓÂÙ·È Ì ÂÓ‰ÔÂÚÈÙÔÓ·˚΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ-

478

‚ÈÔÙÈÎÒÓ ‚¿ÛÂÈ ÚˆÙÔÎfiÏÏÔ˘ ·ÁˆÁ‹˜. ∞Ó¿ÏÔÁ· Ì ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÌÈÎÚÔ‚›Ô˘ Î·È ÙËÓ ·ÓÙ·fiÎÚÈÛË ‹ ·ÓÙÔ¯‹ ·˘ÙÔ‡ ÛÙË ıÂÚ·›·, ·ÔÊ·Û›˙ÂÙ·È Ë Û˘Ó¤¯ÈÛË ‹ Ë ‰È·ÎÔ‹ Ù˘ ¶∫ Î·È Ë ·ÏÏ·Á‹ Ù˘ Û ¿ÏÏË ÌÔÚÊ‹ οı·ÚÛ˘. O ˘‰ÚÔıÒڷη˜ ·ÔÙÂÏ› Ì›· Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ ¶∫ ÛÙ· ·È‰È¿ (43,44). ∞Ó Î·È Ë ·ÈÙ›· ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, Èı·ÓÔÏÔÁÂ›Ù·È Ë ‰È·Ê˘Á‹ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ·fi ÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· ÚÔ˜ ÙË ıˆÚ·ÎÈ΋ ÏfiÁˆ ‰È·ÊÔÚ¿˜ ›ÂÛ˘, ̤ۈ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ÙˆÓ ÏÂÌÊ·ÁÁ›ˆÓ. ∞ÓÙÈÌÂÙˆ›˙ÂÙ·È Â›Ù ÌÂ Û˘Ó¤¯ÈÛË Ù˘ ¶∫ Ì ÌÈÎÚfiÙÂÚÔ˘˜ fiÁÎÔ˘˜ ‰È·Ï‡Ì·ÙÔ˜, ›Ù - ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ Â·ÓÂÌÊ·ÓÈÛÙ› Ô ˘‰ÚÔıÒڷη˜ - Ì ‰È·ÎÔ‹ Ù˘ ÌÂıfi‰Ô˘ Î·È ÂÊ·ÚÌÔÁ‹ ¿ÏÏ˘ ÌÔÚÊ‹˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. Ÿˆ˜ Ê·›ÓÂÙ·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, Ë ¤Î‚·ÛË ÙˆÓ ·È‰ÈÒÓ Ì O¡∞ Î·È ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· Û˘Óԉ‡ÙËΠ·fi ÌÂÁ¿ÏË ıÓËÛÈÌfiÙËÙ· (68%). ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› Î·È Û ¿ÏϘ ÌÂϤÙ˜ (27,4547) Î·È fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙÔ PRISM score, Ë ‰˘ÛÌÂÓ‹˜ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙË ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ù˘ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘, ·ÏÏ¿ ÛÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ (48,49). ∞ÓÙ›ıÂÙ·, Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì O¡∞ Ô˘ ÔÊÂÈÏfiÙ·Ó Û ¿ÏÏ· ·›ÙÈ· (·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë, ÙÔÍÈ΋ Â›‰Ú·ÛË Ê·Ú̿ΈÓ) Î·È ‰ÂÓ Û˘Óԉ¢fiÙ·Ó ·fi ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·, ‹Ù·Ó 100%, ÔÛÔÛÙfi Ô˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È Û ¿ÏϘ ÌÂϤÙ˜ (5,6). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÂÚÈÙÔÓ·˚΋ οı·ÚÛË, Ë ·ÈÌԉȋıËÛË Î·È Ë ·ÈÌÔοı·ÚÛË ·ÔÙÂÏÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ÌÂıfi‰Ô˘˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ O¡∞ ÛÙË ª∂£. ∂Î ÙˆÓ ÙÚÈÒÓ, Ë ÂÈÏÔÁ‹ Ù˘ ϤÔÓ Î·Ù¿ÏÏËÏ˘ ÌÂıfi‰Ô˘ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÙËÓ ËÏÈΛ· Î·È ÙËÓ ·Ó¿ÁÎË Ù·¯Â›·˜ ·ÔÌ¿ÎÚ˘ÓÛ˘ ÓÂÚÔ‡. ∫·È ÔÈ ÙÚÂȘ ̤ıÔ‰ÔÈ ·ÔÙÂÏÂÛÌ·ÙÈο ˘ÔηıÈÛÙÔ‡Ó ÙË ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÈÏÔÎÒÓ Â›Ó·È ÌÈÎÚfi. ŸÌˆ˜, Ë ÙÂÏÈ΋ ¤Î‚·ÛË Î·ıÔÚ›˙ÂÙ·È ·fi ÙËÓ ÂͤÏÈÍË Ù˘ ·ÓÂ¿ÚÎÂÈ·˜ ÙˆÓ ¿ÏÏˆÓ ÔÚÁ¿ÓˆÓ Î·È fi¯È ÌfiÓÔ ·fi ÙË ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gianantonio CA, Vitacco M, Mendilarzu F, Rutty A. Acute renal failure in infancy and childhood. J Pediatr 1962;62:660-662.

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49. Bagshava O, Anaes F, Huthinson A. Continuous arteriovenous haemofiltration and respiratory function in multiple organ system failure. Intensive Care Med 1992;18:334-338.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-02-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¡ÈÎfiÏ·Ô˜ ∑¿‚Ú·˜ µÂÓÙÔ‡ÚË 33, 155 61, ÃÔÏ·ÚÁfi˜ e-mail: nikzav@otenet.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· À¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ·ÓÙÈ·ÛıÌ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Ì ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ¿ÛıÌ·;1 ™ÎÔfi˜: À¿Ú¯ÂÈ ‰È¯ÔÁӈ̛· Û¯ÂÙÈο Ì ÙÔ ÚfiÏÔ ÙˆÓ ‚-·ÁˆÓÈÛÙÒÓ ÛÙË ıÓËÙfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÂÓÒ Ë Â›‰Ú·ÛË ÙˆÓ Û¯Â‰›ˆÓ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ·Ú·Ì¤ÓÂÈ ·Û·Ê‹˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™˘ÁÎÚ›Ó·Ì ٷ Â›‰· ‚-·ÁˆÓÈÛÙÒÓ ·›Ì·ÙÔ˜ Û ·ÛıÂÓ›˜ Ô˘ ¤ı·Ó·Ó ·fi ¿ÛıÌ· Ì ÂΛӷ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ Î·È ÂÎÙÈÌ‹Û·Ì ÙÔÓ Î›Ó‰˘ÓÔ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÂȉÈΤ˜ ηÙËÁÔڛ˜ Ê·ÚÌ¿ÎˆÓ Î·È ÙÚfiÔ˘˜ ·ÓÙÈÌÂÙÒÈÛ˘. ªÂÏÂÙ‹Û·Ì 89 ÂÚÈÙÒÛÂȘ ı·Ó¿ÙˆÓ ·fi ¿ÛıÌ· Î·È ÂÈϤͷÌ ˆ˜ ÔÌ¿‰· ÂϤÁ¯Ô˘ 322 ·ÛıÂÓ›˜ Ô˘ ÚÔÛ‹Ïı·Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Ì ÔÍ›· ÎÚ›ÛË ¿ÛıÌ·ÙÔ˜. ŒÓ· ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ‰fiıËΠÁÈ· Û˘ÌÏ‹ÚˆÛË ÛÙÔ ÛÙÂÓfiÙÂÚÔ Û˘ÁÁÂÓ‹ ı·ÓfiÓÙÔ˜ Û 51 ÂÚÈÙÒÛÂȘ Î·È Û 202 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. ∞›Ì· Ô˘ ÂÏ‹ÊıË ·fi 35 ÂÚÈÙÒÛÂȘ ı·Ó¿ÙÔ˘ Î·È ·fi 229 Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘, ÂϤÁ¯ıËΠÁÈ· Â›‰· Û·Ï‚Ô˘Ù·ÌfiÏ˘. ∞ÔÙÂϤÛÌ·Ù·: ∆Ô Î¿ÓÈÛÌ·, Ë ¯Ú‹ÛË ÔÈÓÔÓÂ˘Ì·Ùˆ‰ÒÓ Î·È Ù· ÔÈÎÔÁÂÓÂȷο ÚÔ‚Ï‹Ì·Ù· ‹Ù·Ó ÛËÌ·ÓÙÈο ÂÚÈÛÛfiÙÂÚ· ÌÂٷ͇ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙˆÓ ı·Ó¿ÙˆÓ ·fi ¿ÛıÌ· ·’ fiÙÈ ÛÙ· ¿ÙÔÌ· Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. OÈ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó ηϿ ÂÓ·ÚÌÔÓÈṲ̂Ó˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ‰Â›ÎÙ˜ Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ¯ÚfiÓÈÔ˘ ¿ÛıÌ·ÙÔ˜. ∏ ¯Ú‹ÛË ÚÔÔ̤ÙÚÔ˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË ÛÙȘ ÂÚÈÙÒÛÂȘ ı·Ó¿ÙÔ˘ ·’ fiÙÈ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. ∏ ·ÚÔ˘Û›· ÁÚ·ÙÔ‡ ۯ‰›Ô˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘

480

¿ÛıÌ·ÙÔ˜ Û¯ÂÙÈ˙fiÙ·Ó Ì 70% Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ı·Ó¿ÙÔ˘. ∏ ¯Ú‹ÛË ÓÂÊÂÏÔÔÈËÌ¤ÓˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ ‹ ÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ· ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙȘ ÂÚÈÙÒÛÂȘ ı·Ó¿ÙˆÓ ·fi ¿ÛıÌ·. ∏ ̤ÛË Û˘ÁΤÓÙÚˆÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘ ÛÙÔ ·›Ì· ‹Ù·Ó 2,5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ Ì Ô͇ ¿ÛıÌ·. ∏ ¯Ú‹ÛË ÛÙÂÚÔÂȉÒÓ ·fi ÙÔ ÛÙfiÌ· ÛÙËÓ ·ÛıÌ·ÙÈ΋ ÎÚ›ÛË Ì›ˆÛ ÙÔÓ Î›Ó‰˘ÓÔ ı·Ó¿ÙÔ˘ ηٿ 90%. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¢ڇÙÂÚË ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÁÚ·ÙÒÓ Û¯Â‰›ˆÓ ·ÓÙÈÌÂÙÒÈÛ˘ ¿ÛıÌ·ÙÔ˜ Ì ÌÈÎÚfiÙÂÚË ÂÍ¿ÚÙËÛË ·fi ÙÔ˘˜ ‚-·ÁˆÓÈÛÙ¤˜ Î·È Ë ÛÙÂÓfiÙÂÚË È·ÙÚÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ı· ÌÂÈÒÛÂÈ ÙË ıÓËÙfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜.

1 Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB et al Are asthma medications and management related to deaths from asthma?

Am J Respir Crit Care Med 2001;163:12-18

£ÂÔÊ¿Ó˘ ∆ÛÈÏÈÁÈ¿ÓÓ˘ ¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡·˘ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ıËÓÒÓ

¶·È‰È·ÙÚÈ΋ 2001;64:481-487

∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2001;64:481-487

ORIGINAL ARTICLE

∞ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÌÂÙÚÔÈ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ·È‰È΋˜ Ó¢ÌÔÓ›·˜ ª. ∂ÌÔÚÈ¿‰Ô˘1, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡2, ∫. ÷˚‰ÔÔ‡ÏÔ˘1, Ã. ∞ÁÁÔ˘Úȉ¿ÎË3, µ. ∆Û·‚‰·Ú›‰Ô˘3, °. µ·ÚÏ¿Ì˘1, ™. ∫·Ú·Ì¤Ú˘1

Immunologic parameters in the evaluation of the eventual outcome of childhood pneumonia M. Eboriadou1, M. Hatzistilianou2, K. Haidopoulou1, C. Aggouridaki3, V. Tsavdaridou3, G. Varlamis1, S. Karamperis1

¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ÂÎÙÈÌ‹ÛÔ˘Ì ÙË ‰È·ÁÓˆÛÙÈ΋ ·Í›· ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÛÙËÓ ÂͤÏÈÍË Ù˘ Ó¢ÌÔÓ›·˜ ÛÙ· ·È‰È¿. ∏ ÌÂϤÙË ÂÚÈÂÏ¿Ì‚·Ó ‰‡Ô ÔÌ¿‰Â˜ ·È‰ÈÒÓ, ∞ Î·È µ. ∆ËÓ ÔÌ¿‰· ∞ ·ÔÙÂÏÔ‡Û·Ó 39 ·È‰È¿ ËÏÈΛ·˜ 5±1,2 ÂÙÒÓ, Ì ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓ›·˜, ÂÓÒ ÙËÓ ÔÌ¿‰· µ, 30 ˘ÁÈ‹ ·È‰È¿ Ù˘ ›‰È·˜ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘. ™Ù· ·È‰È¿ Î·È ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ¤ÁÈÓ ÛÂÈÚÈ·Îfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜: ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· Î·È ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ (CRP), ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgG, IgM Î·È IgA, ÙˆÓ Î˘ÙÔÎÈÓÒÓ 2 (IL-2) Î·È 6 (IL-6) ηıÒ˜ Î·È ÙˆÓ ‰È·Ï˘ÙÒÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2 (sIL-2R). ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù¿ Ì·˜, Ë CRP Î·È Ë IL-6 Â›Ó·È ÔÈ ·ÓÔÛÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ Ô˘ ÌÂÙ·‚¿ÏÏÔÓÙ·È ÓˆÚ›˜ ‹‰Ë ·fi ÙËÓ 3Ë Ë̤ڷ ıÂÚ·›·˜, ÂÓÒ Ë IL-2 Î·È ÔÈ sIL-2R ÌÂÙ·‚¿ÏÏÔÓÙ·È ÌÂÙ¿ ÙËÓ 5Ë Ë̤ڷ ıÂÚ·›·˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË, ÏÔÈfiÓ, Ù˘ CRP Î·È Ù˘ IL-6 ‚ÔËı¿ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ·È‰È΋˜ Ó¢ÌÔÓ›·˜.

Abstract: The aim of this study was to evaluate the diagnostic value of the immunologic parameters in the outcome of lung infection (pneumonia). A total of 39 hospitalized patients (mean age±SD: 5±1.2 years) with pneumonia (group A) and 30 healthy children (group B) were included in the study. Serial determinations of the white blood cell count, absolute number of total neutrophils, C-reactive protein, immunoglobulins IgG, IgM and IgA, interleukin-2 (IL-2), interleukin-6 (IL-6) and soluble interleukin-2 receptor (sIL-2R) were evaluated in all patients. Our results revealed that CRP and IL-6 were the two immunologic markers that changed early (on the 3rd day of treatment), while the levels of IL-2 and sIL-2R changed later (5th day of treatment). In conclusion, repeated examinations of CRP and IL-6 are important in evaluating the course and outcome of pneumonia in children.

§¤ÍÂȘ ÎÏÂȉȿ: Ó¢ÌÔÓ›·, ÈÓÙÂÚÏ¢ΛÓË 2, ÈÓÙÂÚÏ¢ΛÓË 6, ‰È·Ï˘ÙÔ› ˘ԉԯ›˜ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2, C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË.

Key words: pneumonia, interleukin-2, interleukin6, soluble interleukin-2 receptor, C-reactive protein.

∂ÈÛ·ÁˆÁ‹ ∏ Ó¢ÌÔÓ›· ·Ú·Ì¤ÓÂÈ Ì›· Û˘¯Ó‹ ÓfiÛÔ˜ Î·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋˜ ÓÔÛËÏ›·˜ ÌÂٷ͇ ÙˆÓ ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ (1,2). ∏ Â¿ÚÎÂÈ· ÙÔ˘ ·ÓÔÛÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙËÓ ¤Î‚·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜

Û ·ÛıÂÓ›˜ Ì Ó¢ÌÔÓ›· (3,4). ™Â Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, Ù· ΢„ÂÏȉÈο Ì·ÎÚÔÊ¿Á· Â›Ó·È Ù· ΢ڛˆ˜ ·ÙÙ·Ú· Ô˘ ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ˘˜ Ó‡ÌÔÓ˜ ·fi ÙËÓ Â›ÛÔ‰Ô ÙˆÓ ÌÈÎÚÔ‚›ˆÓ (3-5). ∆· ·ÙÙ·Ú· ·˘Ù¿, ÛÂ Û˘ÓÂÚÁ·Û›· Ì ٷ ¿ÏÏ· ·ÙÙ·Ú· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û˘Ì‚¿ÏÏÔ˘Ó, Ì ÙËÓ

1 ¢’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£.

2 µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£.

3 OÚÔÏÔÁÈÎfi ∆Ì‹Ì· ªÈÎÚÔ‚ÈÔÏÔÁÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘ ¡ÔÛÔÎÔÌÂ›Ô ∞.Ã.∂.¶.∞., ∞.¶.£.

1 4th Pediatric Clinic of Aristotelion University, Thessaloniki 2 2nd Pediatric Clinic of Aristotelion University, Thessaloniki 3 Serology Division of Microbiology Laboratory AHEPA Hospital, Aristotelion University, Thessaloniki

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¶·È‰È·ÙÚÈ΋ 2001;64:481-487

Paediatriki 2001;64:481-487

ÚÈÙÈÎfi˜ fiÓÔ˜, ÂÓÙÔÈṲ̂ÓË Ì›ˆÛË Ì¤¯ÚÈ ÂÍ·Ê¿ÓÈÛË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜ (΢ڛˆ˜ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿), ‚ÚÔÁ¯È΋ ·Ó·ÓÔ‹ ‹ ÛˆÏËÓ҉˜ ʇÛËÌ· Î·È ÏÂÙÔ› ˘ÁÚÔ› ÚfiÁ¯ÔÈ ÂÓÙÔÈṲ̂ÓÔÈ. ‚) ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·, fiˆ˜: ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (>15.000 ·ÙÙ·Ú·/mm3) Ì ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÛË Î·È Èı·ÓfiÓ ÛÙÚÔÊ‹ ÙÔ˘ Ï¢ÎÔ΢ÙÙ·ÚÈÎÔ‡ Ù‡Ô˘ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿ (Ú·‚‰Ô‡ÚËÓ·), ÌÂÁ¿ÏË ·‡ÍËÛË ∆∫∂ Î·È CRP Î·È ıÂÙÈΤ˜ ηÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ÁÈ· ÌÈÎÚԂȷ΋ Ïԛ̈ÍË Î·È Î·ÌÈ¿ ÊÔÚ¿ ˘ÔÍ·ÈÌ›· Ì ÎÔÚÂÛÌfi Ô͢·ÈÌÔÛÊ·ÈÚ›Ó˘ (SaO2) οو ÙˆÓ 93-95%. Á) ∞ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, fiˆ˜ ÂÓÙÔÈṲ̂ÓË ‡ÎÓˆÛË (Û˘Ó‹ıˆ˜ ÏԂ҉˘) Ì ‹ ¯ˆÚ›˜ ·ÚÔ˘Û›· Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ ÂÎÙÈÌ‹ıËΠ·fi ÙËÓ Ë̤ڷ ¤Ó·Ú͢ ÙÔ˘ ˘ÚÂÙÔ‡. ¶ÂÚÈÙÒÛÂȘ Ì ·Î·ıfiÚÈÛÙË Ë̤ڷ ¤Ó·Ú͢ ÙÔ˘ ˘ÚÂÙÔ‡ ‹ Ì ·ÌÊ›‚ÔÏÔ ÈÛÙÔÚÈÎfi ‹ Â˘Ú‹Ì·Ù· ·fi ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ·ÔÎÏ›ÛÙËÎ·Ó ·fi ÙË ÌÂϤÙË. ∆· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÙˆÓ ·ÛıÂÓÒÓ ÌÂÏÂÙ‹ıËÎ·Ó ·fi ·ÎÙÈÓÔÏfiÁÔ˘˜ Ô˘ ‰ÂÓ ÁÓÒÚÈ˙·Ó Ù· ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·. ∆· ·È‰È¿ Ù˘ ÌÂϤÙ˘ ¯ˆÚ›ÛÙËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜ (∞ Î·È µ). ∏ ÔÌ¿‰· ∞ ÂÚÈÂÏ¿Ì‚·Ó 39 ·È‰È¿ Ì Ó¢ÌÔÓ›· ËÏÈΛ·˜ 5±1,2 ÂÙÒÓ Ì ÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓ›·˜, ÂÓÒ Ë ÔÌ¿‰· µ ÂÚÈÂÏ¿Ì‚·Ó 30 ˘ÁÈ‹ ·È‰È¿. ™Ù· ·È‰È¿ Î·È ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·: Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Ì ·Ó·Ï˘Ù‹ (coulter), Ô ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Î·È Ë ∆∫∂ ·fi ¿ÌÂÛÔ ·Ú·Û··ÛÌ· Î·È Ù· Â›‰· Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ (CRP) Î·È ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgG, IgM Î·È IgA Ì ÓÂÊÂÏÔÌÂÙÚ›·. ∂›Û˘, ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÔÈ ÈÓÙÂÚÏ¢ΛÓ˜ 2 (IL-2) Î·È 6 (IL-6) Î·È ÔÈ ‰È·Ï˘ÙÔ› ˘ԉԯ›˜ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2 (sIL-2R) Ì ÙË Ì¤ıÔ‰Ô ELISA. ÃÚËÛÈÌÔÔÈ‹ıËΠkit ÂÌÔÚ›Ô˘ (R & D System) ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙȘ Ô‰ËÁ›Â˜ Ù˘ ηٷÛ΢¿ÛÙÚÈ·˜ ÂÙ·ÈÚ›·˜. OÈ ·Ú·¿Óˆ ·Ú¿ÌÂÙÚÔÈ, ÂÎÙfi˜ ·fi ÙËÓ ∆∫∂, ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙËÓ ÔÌ¿‰· ∞ ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ Ù˘ ıÂÚ·›·˜, ÂÓÒ ÛÙËÓ ÔÌ¿‰· µ (ÂϤÁ¯Ô˘) Ì›· ÊÔÚ¿. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÂÎÙ›ÌËÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ±SD Î·È ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ test ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÌÂ-

¤ÎÎÚÈÛË ÙˆÓ Î˘ÙÔÎÈÓÒÓ, ÛÙËÓ ÂͤÏÈÍË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ (3-7). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Û ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı›, ‚Ú¤ıËΠ̛· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î·È ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÔÎÈÓÒÓ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ó¢ÌÔÓ›·˜ (8-10). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó: ·) Ë ‰ÈÂÚ‡ÓËÛË ÙˆÓ ÂÈ¤‰ˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ Ó¢ÌÔÓ›·˜ ÛÙ· ·È‰È¿, ‚) Ë Û˘Û¯¤ÙÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ Î·È Á) Ë ÂÎÙ›ÌËÛË Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÛÙËÓ ÂͤÏÈÍË Ù˘ Ó¢ÌÔÓ›·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ

∞ÚÈıÌfi˜ Ï¢ÎÒÓ/ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ/mm3

∆Ô ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 39 ·È‰È¿ (19 ·ÁfiÚÈ· Î·È 20 ÎÔÚ›ÙÛÈ·) ËÏÈΛ·˜ 14 ÌËÓÒÓ ¤ˆ˜ 13 ¯ÚfiÓˆÓ Ì ̤ÛË ËÏÈΛ· ±SD: 5±1,2 ¯ÚfiÓÈ·, Ô˘ ÓÔÛËχıËÎ·Ó ÛÙËÓ ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£.(¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË) ÁÈ· Èı·Ó‹ ÌÈÎÚԂȷ΋ Ó¢ÌÔÓ›· ÙÔ ‰È¿ÛÙËÌ· 19971998. ™Ù· ·È‰È¿, ÂÎÙfi˜ ·fi Ù· ÓÂÔÁÓ¿ Ô˘ ¤¯Ô˘Ó ÔÍ›· Ó¢ÌÔÓ›·, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÍÈfiÈÛÙ· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ‹ ÛËÌ›· Ô˘ Ó· ‰È·ÊÔÚÔÔÈÔ‡Ó ÙË ÌÈÎÚԂȷ΋ Ó¢ÌÔÓ›· ·fi ¿ÏÏ· ÏÔÈÌÒ‰Ë ·›ÙÈ·. ∆· ÂÈÎÚ·Ù¤ÛÙÂÚ·, fï˜, ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û‡Ìʈӷ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›· (11-12), ÛÙ· ÔÔ›· Î·È ÛÙËÚȯı‹Î·ÌÂ, ‹Ù·Ó: ·) ∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, fiˆ˜ ˘„ËÏfi˜ ˘ÚÂÙfi˜ Ì ·ÈÊÓ›‰È· ¤Ó·ÚÍË, ‚‹¯·˜, ·›ÛıËÌ· ÎfiˆÛ˘, ·ÚÓËÙÈο ÛËÌ›· ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ fiˆ˜ ÚÈÓÈ΋ Û˘ÌÊfiÚËÛË, ÚÈÓfiÚÚÔÈ·, ÂÈÂÊ˘Î›Ùȉ· Î·È Ù¤ÏÔ˜ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· (·Ó·¤Ù·ÛË ÚÈÓÈÎÒÓ ÙÂÚ˘Á›ˆÓ, ÂÈÛÔÏΤ˜ ÌÂÛÔχÚÈˆÓ ‰È·ÛÙËÌ¿ÙˆÓ, ˘ÂÚÎÏ›‰È˜ Î·È ÂÈÁ·ÛÙÚ›Ô˘, Ù·¯‡ÓÔÈ· ≥50-60 ·Ó·ÓÔ¤˜/min ÁÈ· ·È‰È¿ οو ÙˆÓ 12 ÌËÓÒÓ Î·È ≥40 ·Ó·ÓÔ¤˜/min ÁÈ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, Ù·¯˘Î·Ú‰›· Î·È ÁÔÁÁ˘ÛÌfi˜) ȉȷ›ÙÂÚ· Û ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿, ÂÓÒ Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÂÈÚfiÛıÂÙ·, ·ÓËÛ˘¯›· Î·È fiÓÔ˜ ÛÙÔ ÛÙ‹ıÔ˜. ∂›Û˘, Ï¢-

45000 40000

A

35000

A

30000 25000 A

20000 15000

A B

10000 5000 0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

∏̤Ú˜ ıÂÚ·›·˜ ∂ÈÎfiÓ· 1. ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ ÚÈÓ Î·È ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ ıÂÚ·›·˜ ÛÙȘ ÔÌ¿‰Â˜ ∞ Î·È µ.

482

¶·È‰È·ÙÚÈ΋ 2001;64:481-487

Paediatriki 2001;64:481-487

30

IgG (gr/L)

25 20

A

µ

A

A

A

15 10 5 0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

6 5 A IgM (gr/L)

4

A A

3 A µ

2 1 0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

4 3,5

A

A

IgA (gr/L)

3

A

A

2,5 2 µ

1,5 1 0,5 0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

∏̤Ú˜ ıÂÚ·›·˜

∂ÈÎfiÓ· 2. ∂›‰· ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgG (2A), IgM (2B) Î·È IgA (2°) ÚÈÓ Î·È ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ ıÂÚ·›·˜ ÛÙȘ ÔÌ¿‰Â˜ ∞ Î·È µ.

483

¶·È‰È·ÙÚÈ΋ 2001;64:481-487

Paediatriki 2001;64:481-487

25

CRP (mg/dl)

20 A 15

10

A

5

A µ

A

0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

∏̤Ú˜ ıÂÚ·›·˜ ∂ÈÎfiÓ· 3. ª¤ÛË ÙÈÌ‹ ± SD ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ CRP ÚÈÓ Î·È ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ ıÂÚ·›·˜ ÛÙȘ ÔÌ¿‰Â˜ ∞ Î·È µ.

ٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. OÈ ·Ú¿ÌÂÙÚÔÈ Û˘Û¯ÂÙ›ÛÙËÎ·Ó ÌÂٷ͇ ÙÔ˘˜ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson (r).

∞ÔÙÂϤÛÌ·Ù· ¢È·ÁÓÒÛÙËΠÏԂ҉˘ ‹ ÙÌËÌ·ÙÈ΋ Ó¢ÌÔÓ›· Û 31/39 ÂÚÈÙÒÛÂȘ Î·È Î·Ù¿ ÙfiÔ˘˜ ‰ÈËı‹ÛÂȘ ‹ ·ÙÂÏÂÎÙ·Û›· Û 8/39 ·È‰È¿. ™ÙËÓ ∂ÈÎfiÓ· 1 Ê·›ÓÂÙ·È ·Ó·Ï˘ÙÈο Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ ÛÙ· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ∞ Î·È µ. ∏ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ‹Ù·Ó 12,6%, 5,6% Î·È 39,5% ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ ıÂÚ·›·˜ ·ÓÙ›ÛÙÔȯ· Î·È ÙˆÓ ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ ‹Ù·Ó 29,7%, 3,3% Î·È 50,4% ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ∂ÈÎfiÓ· 2 Ê·›ÓÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÈ̤˜ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgG (∂ÈÎfiÓ· 2·), IgM (∂ÈÎfiÓ· 2‚) Î·È IgA (∂ÈÎfiÓ· 2Á). ∏ ·‡ÍËÛË ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgG, IgM Î·È IgA ÙËÓ 3Ë Ë̤ڷ ‹Ù·Ó 16,7%, 36%, 25,8%, ÙËÓ 5Ë Ë̤ڷ 18,9%, 31,3% Î·È 26,3% Î·È ÙËÓ 10Ë Ë̤ڷ 19,6%, 58,1% Î·È 43,1% ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ∂ÈÎfiÓ· 3 Ê·›ÓÂÙ·È Ë Ì¤ÛË ÙÈÌ‹ Î·È Ë ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ CRP. ∏ ÙÒÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ CRP ÛÙËÓ ÔÌ¿‰· ∞ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,001) ÌÂٷ͇ ·˘ÙÒÓ ÚÈÓ Î·È ÙËÓ 3Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜. ™ÙËÓ ∂ÈÎfiÓ· 4 Ê·›ÓÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÈ̤˜ ÙˆÓ IL-2 (∂ÈÎfiÓ· 4·), IL-6 (∂ÈÎfiÓ· 4‚) Î·È sIL-2R (∂ÈÎfiÓ· 4Á). ™ÙÔÓ ¶›Ó·Î· 1 Ê·›ÓÔÓÙ·È ÔÈ Î·Ù¿ Pearson Û˘Û¯ÂÙ›ÛÂȘ (r) ÙˆÓ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚˆÓ Î·È Ù˘ ∆∫∂. ™˘˙‹ÙËÛË ∆· Â›‰· ÙˆÓ Î˘ÙÔÎÈÓÒÓ ÙÔ˘ ÔÚÔ‡ Û ۯ¤ÛË Ì ‰È¿ÊÔÚ˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ηٷÛÙ¿ÛÂȘ, ¤¯Ô˘Ó

484

ÌÂÏÂÙËı› Û ‰È¿ÊÔÚ˜ ÏÔÈÌÒÍÂȘ fiˆ˜ ÛËÙÈÎfi shock (6,13), ÛËÙÈÎfi Û‡Ó‰ÚÔÌÔ (7), Ó¢ÌÔӛ˜ (8-10,14-18) Î.¿. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ¤ÁÈÓ ÚÔÛ¿ıÂÈ· Ó· ÌÂÏÂÙËıÔ‡Ó Ù· Â›‰· ΢ÎÏÔÊÔÚÔ‡ÓÙˆÓ Î˘ÙÔÎÈÓÒÓ Û ·È‰È¿ Ì ÂÓ‰ÂÈÎÙÈο ÛÙÔȯ›· ÌÈÎÚԂȷ΋˜ Ó¢ÌÔÓ›·˜ ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘, ÒÛÙ ӷ ÂÎÙÈÌËıÔ‡Ó ÂÚ·ÈÙ¤Úˆ Û·Ó ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÛÙËÓ ÂÎÙ›ÌËÛË Î·È ÙËÓ ÂͤÏÈÍË Ù˘ Ïԛ̈͢.

OÈ ÚˆÙ½Ó˜ ÔÍ›·˜ Ê¿Û˘ Î·È Ì¿ÏÈÛÙ· Ë CRP, ÚˆÙ½ÓË ÔÍ›·˜ Ê¿Û˘ Ô˘ ·Ú¿ÁÂÙ·È, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, ÛÙÔ ‹·Ú ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘, Â›Ó·È ‰Â›ÎÙ˘ ÊÏÂÁÌÔÓ‹˜, ‡ÎÔÏ· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È, ·ÏÏ¿ ·Ó¢ڛÛÎÂÙ·È Î·È Û ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ (19). ÃÚËÛÈÌÔÔÈÂ›Ù·È Ôχ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, fi¯È ÌfiÓÔ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË, ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ Ù˘ ÂͤÏÈ͢ Ù˘ ÊÏÂÁÌÔÓ‹˜. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ Ú¤ÂÈ, ÂÔ̤ӈ˜, Ó· Á›ÓÂÙ·È Û ٷÎÙÈο ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·, ÁÈ·Ù› ¤¯ÂÈ ‰È·ÁÓˆÛÙÈ΋ Î·È ÚÔÁÓˆÛÙÈ΋ ·Í›·. ™ÙËÓ ÚÔÛ¿ıÂÈ¿ Ì·˜ Ó· ‰ÈÂÚ¢ӋÛÔ˘Ì ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·ÁÓˆÛÙÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÛÙËÓ Ó¢ÌÔÓ›·, ÂÈϤͷÌ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÚÔÊÏÂÁÌÔÓÒ‰Ô˘˜ IL-6 Î·È Ù˘ ÌÂÙ·ÊÏÂÁÌÔÓÒ‰Ô˘˜ IL-2 ηıÒ˜ Î·È ÙˆÓ sIL-2R. ™ÙË ÌÂϤÙË Ì·˜, Ë CRP ‚Ú¤ıËΠfiÙÈ ‹Ù·Ó Ë ÚÒÙË ·Ú¿ÌÂÙÚÔ˜ Ô˘ ÂÏ·ÙÙÒıËΠÛËÌ·ÓÙÈο (p<0,001) Ôχ ÓˆÚ›˜ ‹‰Ë ·fi ÙËÓ 3Ë Ë̤ڷ ıÂÚ·›·˜ Ù˘ Ó¢ÌÔÓ›·˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÚÚÒÛÙˆÓ (∞), ÂÓÒ Ë IL-6 ÛËÌ›ˆÛ ÛËÌ·ÓÙÈ΋, Â›Û˘, ÙÒÛË ·fi ÙËÓ 5Ë Ë̤ڷ ıÂÚ·›·˜. ∏ ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË Ô˘ ‚Ú¤ıËΠÁÈ· Ù· ÚÔ Ù˘ ıÂÚ·›·˜ Â›‰· ÌÂٷ͇ Ù˘ CRP Î·È Ù˘ πL-6 (r=0,81) ˘Ô‰ËÏÒÓÂÈ Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÙËÓ ¿ÌÂÛË

¶·È‰È·ÙÚÈ΋ 2001;64:481-487

Paediatriki 2001;64:481-487

100 90 A

80

A

IL-2 (pg/ml)

70

A

60 A

µ

50 40 30 20 10 0

¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

200 180

πÓÙÂÚÏ¢ΛÓË-6 (pg/ml)

160 A 140

A

120 A 100 80

A

60 40 µ 20 0

¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

3000

2500 A A sIL-2R (IU/ml)

2000

A A

1500 µ 1000

500

0 ¶ÚÈÓ ÙË ıÂÚ·›·

3Ë Ë̤ڷ

5Ë Ë̤ڷ

10Ë Ë̤ڷ

∏̤Ú˜ ıÂÚ·›·˜ ∂ÈÎfiÓ· 4. ∂›‰· Ù˘ IL-2 (4∞), Ù˘ IL-6 (4µ) Î·È ÙˆÓ sIL-2R (4°) ÚÈÓ Î·È ÙËÓ 3Ë, 5Ë Î·È 10Ë Ë̤ڷ ıÂÚ·›·˜ ÛÙȘ ÔÌ¿‰Â˜ ∞ Î·È µ.

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Paediatriki 2001;64:481-487

¶›Ó·Î·˜ 1. ™˘ÓÙÂÏÂÛÙ¤˜ ÁÚ·ÌÌÈ΋˜ Û˘Û¯¤ÙÈÛ˘ (r) ηٿ Pearson ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ÁÈ· fiϘ ÙȘ ˘fi ÌÂϤÙË ·Ú·Ì¤ÙÚÔ˘˜

§Â˘Î¿ ∞ÈÌÔÛÊ·›ÚÈ· ¶ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· IL-6 IL-2 sIL-2R CRP TKE

§Â˘Î¿ ∞ÈÌÔÛÊ·›ÚÈ· -

¶ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· 0,99

IL-6

IL-2

sIL-2R

CRP

TKE

0,81

0,57

0,74

0,60

0,62

0,99

-

0,80

0,50

0,75

0,60

0,64

0,81 0,57 0,74 0,60 0,62

0,80 0,52 0,75 0,60 0,64

0,45 0,66 0,81 0,39

0,45 0,57 0,41 0,40

0,66 0,57 0,51 0,58

0,81 0,41 0,51 0,69

0,39 0,40 0,58 0,69 -

Û˘Û¯¤ÙÈÛË Ù˘ CRP Î·È Ù˘ IL-6 ÛÙËÓ ÂͤÏÈÍË Ù˘ Ó¢ÌÔÓ›·˜ (19). ∂Ê' fiÛÔÓ Ë Ì¤ÙÚËÛË Ù˘ CRP ÛÙÔÓ ÔÚfi Â›Ó·È ·Ï‹ Î·È Â‡ÎÔÏË, Ë ÚˆÙ½ÓË ·˘Ù‹ ÌÔÚ› Ó· Â›Ó·È ¤Ó·˜ ¯Ú‹ÛÈÌÔ˜ ·Ú·ÎÏÈÓÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂͤÏÈ͢ Ù˘ Ó¢ÌÔÓ›·˜ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È Ë IL-6 Ó· ÂÎÙÈÌ¿Ù·È ÛÙËÓ ÔÚ›·, ̤¯ÚÈ Î·È ÙËÓ 5Ë Ë̤ڷ, Û ‚·Ú‡ÙÂÚ˜ ÌÔÚʤ˜ Ïԛ̈͢. ∏ IL-6 Èı·Ófiٷٷ Â›Ó·È Ë Î˘ÙÔΛÓË Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ÚfiÁÓˆÛË, Ú¿ÁÌ· Ô˘ ¤¯ÂÈ ÌÂÏÂÙËı› Û ·ÛıÂÓ›˜ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ù‡Ô˘ ÂÓ‹ÏÈη Û ‰Â›ÁÌ·Ù· ÔÚÔ‡ Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· (20,21).

O ¯ÚfiÓÔ˜ Ô˘ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ù· Â›‰· ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÚÈÓ Î·È ÌÂÙ¿ ÙË ıÂÚ·›·, ÂÈϤ¯ıËΠ̠‚¿ÛË ÙË ÁÓÒÛË fiÙÈ ÔÈ ÚˆÙ½Ó˜ ÔÍ›·˜ Ê¿Û˘ Î·È ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜, fiˆ˜ Ë IL-6 Î·È Ë IL-2, ·˘Í¿ÓÔÓÙ·È ÛËÌ·ÓÙÈο ÛÙË ÊÏÂÁÌÔÓ‹, ÌÂÈÒÓÔÓÙ·È ÁÚ‹ÁÔÚ· Ù· Â›‰¿ ÙÔ˘˜ (6,12,22) Î·È ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ÛÙÔÓ ÔÚfi 36-48 ÒÚ˜ ÌÂÙ¿ ÙË ÊÏÂÁÌÔÓ‹ (6,22). ™ÙË ÌÂϤÙË Ì·˜ ¤ÁÈÓ ÛÂÈÚȷ΋ ̤ÙÚËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ, ÁÈ· Ó· ÂÎÙÈÌËı› Ô ¯ÚfiÓÔ˜ ‰È¿ÚÎÂÈ·˜ Ù˘ ÔÍ›·˜ Ïԛ̈͢ Î·È Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ÂÌÂÈÚÈ΋ ·ÓÙÈÌÈÎÚԂȷ΋ ıÂÚ·›· (20,21). ™˘ÌÂÚ¿ÛÌ·Ù· ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù¿ Ì·˜, Ë CRP Î·È Ë IL-6 Â›Ó·È ÔÈ ·ÓÔÛÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ Ô˘ ÌÂÙ·‚¿ÏÏÔÓÙ·È Ôχ ÓˆÚ›˜, ‹‰Ë ·fi ÙËÓ 3Ë Î·È 5Ë Ë̤ڷ ıÂÚ·›·˜ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ë IL-2 Î·È Ô sIL-2R ÌÂÙ¿ ÙËÓ 5Ë Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ÛÙËÓ Ó¢ÌÔÓ›·. OÈ Ì¤ıÔ‰ÔÈ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ Î˘ÙÔÎÈÓÒÓ Û‹ÌÂÚ· Â›Ó·È ·ÎfiÌË ¯ÚÔÓÔ‚fiÚ˜ Î·È ‰··ÓËÚ¤˜, Ú¿ÁÌ· Ô˘ ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Û·Ó Ì¤ıÔ‰Ô ÚÔ˘Ù›Ó·˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. ¶ÈÛÙ‡ԢÌ fiÙÈ Ë ÈÛ¯˘Ú‹ ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ∆∫∂ Î·È Ù˘ CRP, Ù˘ CRP Î·È Ù˘ IL-6 ˘Ô‰ËÏÒÓÂÈ fiÙÈ Ë ∆∫∂ Î·È Ë CRP ÌÔÚÔ‡Ó Ó· ·Ú·Ì›ÓÔ˘Ó Û·Ó ÂÍÂÙ¿ÛÂȘ ÚÔ˘Ù›Ó·˜ ÛÙË ‰È¿ÁÓˆÛË

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 09-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ∂ÌÔÚÈ¿‰Ô˘ ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢, ¡ÔÛÔÎÔÌÂ›Ô ∞.Ã.∂.¶.∞. ™Ù›ÏˆÓÔ˜ ∫˘ÚȷΛ‰Ë 1, 546 36, £ÂÛÛ·ÏÔÓ›ÎË

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ORIGINAL PAPER

∏ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÂÈÏËÙÈÎÒÓ ·È‰ÈÒÓ Û ÌÔÓÔıÂÚ·›· Ì ‚·ÏÚÔ˚Îfi Ô͇ ∫.∂. ™Ô‡ÏË1, °.∞. ∫·Ú›Î·˜2, π. ∆˙·ÌÔ˘Ú¿ÓË1, ™. ƒÂÁÎÔ‡Ù·˜2, ™. ∆۷ΛÚ˘3

Serum biotinidase activity in epileptic children on valproic acid monotherapy K.H. Schulpis1, G.A. Karikas2, J. Tjamouranis1, S. Regoutas2, S. Tsakiris3

¶ÂÚ›ÏË„Ë: ∆Ô µ·ÏÚÔ˚Îfi Ô͇ (µ∞) Â›Ó·È ¤Ó· ·ÔÙÂÏÂÛÌ·ÙÈÎfi ·ÓÙÈÂÈÏËÙÈÎfi Ê¿ÚÌ·ÎÔ, ÙÔ˘ ÔÔ›Ô˘ Ë ¯Ú‹ÛË ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂٷ͇ ¿ÏÏˆÓ ·ÚÂÓÂÚÁÂÈÒÓ, ÂÍ¿ÓıËÌ·, ·ÒÏÂÈ· Ì·ÏÏÈÒÓ (·ÏˆÂΛ·) Î.Ï. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Ï‹ÚÔ˘˜, fiˆ˜ Î·È Ù˘ ÌÂÚÈ΋˜, ·ÓÂ¿ÚÎÂÈ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛÓË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó µ∞. ™ÎÔfi˜, ÏÔÈfiÓ, Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, Û ۯ¤ÛË Ù˘ Ì ÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙÔÓ ÔÚfi ÂÈÏËÙÈÎÒÓ ·È‰ÈÒÓ Û ÌÔÓÔıÂÚ·›· Ì µ∞. ∂‚‰ÔÌ‹ÓÙ· ¤ÓÙ (¡=75) ·ÛıÂÓ›˜ Ì ̤ÛË ËÏÈΛ· 8,6±1,9 ¯ÚfiÓÈ·, ‰È·ÈÚ¤ıËÎ·Ó Û ÈÛ¿ÚÈı̘ ÔÌ¿‰Â˜. ™ÙËÓ ÔÌ¿‰· ∞ (¡=25) ¯ÔÚËÁ‹ıËΠ28,7±8,5 mg/Kg/24h µ∞, ÛÙËÓ ÔÌ¿‰· µ (¡=25) 41,6±4,9 mg/Kg/24h Î·È ÛÙËÓ ÔÌ¿‰· ° 54,5±5,8 mg/Kg/24h. T· Â›‰· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔÓ ÔÚfi ÙÔ˘˜ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Û 40,9±13,2, 86,25±11,5 Î·È 137±14 5 Ìg/ml ·ÓÙ›ÛÙÔȯ·. ∏ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 50 (¡=50) ˘ÁÈ‹ ·È‰È¿ ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜. ∆fiÛÔ ÛÙÔ˘˜ ·ÛıÂÓ›˜, fiÛÔ Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ¤ÁÈÓ Ë·ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, ÌÂÙÚ‹ıËÎÂ Ë ·Ì̈ӛ· ÛÙÔÓ ÔÚfi ÙÔ˘˜, fiˆ˜ Î·È Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ Ì ÊıÔÚÈÔÌÂÙÚÈ΋ ̤ıÔ‰Ô, ÌÂÙ¿ 45 Ë̤Ú˜ ıÂÚ·›·˜. ∆· Ë·ÙÈο ¤Ó˙˘Ì· Î·È Ë ·Ì̈ӛ· ‹Ù·Ó ·˘ÍË̤ӷ ÛÙÔ ·›Ì· ÙˆÓ ·ÛıÂÓÒÓ ÙˆÓ ÔÌ¿‰ˆÓ µ Î·È °. ∞ÓÙ›ıÂÙ·, Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË (p<0,001) ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ µ Î·È Ù˘ ÔÌ¿‰·˜ ° (1,22±1,11, 0,97±0,07 mmol/min/L ·ÓÙ›ÛÙÔȯ·), Û˘ÁÎÚÈÓfiÌÂÓË

Abstract: Valproic acid (VPA) is an effective antiepileptic drug which is associated with dose related adverse reactions such as skin rash, hair loss (alopecia) etc. Profound as well as partial biotinidase deficiency is known to cause dermatological manifestations such as those mentioned above. Therefore, it was of interest to evaluate the serum biotinidase activity in relation to liver enzymes in patients on VPA monotherapy.

Seventy five (N=75) children with recurrent seizure activity, mean age 8,6±1,9 yrs, were divided into three groups. Group A (N=25) was treated with VPA 28,7±8,5 mg/kg/24h, Group B (N=25) with 41,6±4,9 mg/Kg/24h and Group C with 54,5±5,8 mg/kg/24h. The “trough” VPA serum levels were 40,9±13,2, 86,25±11,5 and 137±14,5 Ìg/ml respectively. Fifty (N=50) healthy children were used as controls. Patients and controls underwent various laboratory examinations that included liver function tests, complete blood counts, NH3 levels etc.

Biotinidase serum levels were evaluated fluorometrically. Liver enzymes as well as NH3 levels were found to be elevated in groups B and C. On the contrary, biotinidase activity was significantly statistically lower in groups B and C (1,22±1,11, 0,97±0,07 mmol/min/l resp.), as compared to controls (5,20±0,90 mmol/min/l) (p<0,001). Strong inverse correlations were observed between the levels of liver enzymes and the activity of biotinidase. Additionally, no direct

1 πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 2 ªÔÓ¿‰· ∂Ó‰ÔÊϤ‚ÈˆÓ ¢È·Ï˘Ì¿ÙˆÓ Î·È º·ÚÌ·ÎÔÎÈÓËÙÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 3 ∂ÚÁ·ÛÙ‹ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ º˘ÛÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

1 Institute of Child Health “Saint Sophia” Children’s Hospital, Athens 2 Division of Intravenous Solutions and Pharmacokinetics “Saint Sophia” Children’s Hospital, Athens 3 Laboratory of Experimental Physiology University of Athens Medical School

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Paediatriki 2001;64:488-492

Ì ÂΛÓË ÙˆÓ Ì·ÚÙ‡ÚˆÓ (5,2±0,9 mmol/min/L). πÛ¯˘Ú¤˜ ·ÚÓËÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ Ù˘ ÛÙ¿ıÌ˘ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ in vitro ÌÂϤÙ˘ Ì·˜ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ µ∞ ‰ÂÓ ÂËÚ¿˙ÂÈ ¿ÌÂÛ· ÙË ‚ÈÔÙÈÓȉ¿ÛË ·ÎfiÌË Î·È fiÙ·Ó Âˆ¿ÛÙËΠÙÔ ¤Ó˙˘ÌÔ ÛÙÔÓ ÔÚfi Ì ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË (1,2 mM) ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÙÔ µ∞ ÂȉÚÒÓÙ·˜ ÛÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘. °È· ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÌÂÚÈÎÒÓ ·ÚÂÓÂÚÁÂÈÒÓ ÙÔ˘ µ∞, ı· ÌÔÚÔ‡Û ӷ ÚÔÙ·ı› Ë ¯ÔÚ‹ÁËÛË ‚ÈÔÙ›Ó˘.

inhibitory effect of VPA on biotinidase activity was demonstrated even when the enzyme was incubated in vitro with high (1,2 mM) concentrations of the drug. Our results suggest that VPA, by impairing liver function, may result in a decrease of the biotinidase activity in the serum. It is suggested that biotin supplementation could restore some of the aforementioned side effects of the drug.

§¤ÍÂȘ ÎÏÂȉȿ: ‚ÈÔÙÈÓȉ¿ÛË, ‚·ÏÚÔ˚Îfi Ô͇.

Key words: biotinidase, valproic acid.

∂ÈÛ·ÁˆÁ‹ ∆Ô µ·ÏÚÔ˚Îfi Ô͇ (µ∞) (Depakine) ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÈÏË„›·˜ Â› ·ÚÎÂÙ¿ ¯ÚfiÓÈ·. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ µ∞, ÙÔ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ·ÛʷϤ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÙÔ˘˜ ÂÓ‹ÏÈΘ, Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ¿ÏÏ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (1-3). OÈ ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó¿ ·Ó·ÊÂÚfiÌÂÓ˜ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜, ÙÔÓ ÙÚfiÌÔ, ÙËÓ ÂÌÊ¿ÓÈÛË ÂÍ·Óı‹Ì·ÙÔ˜ Î·È ÙËÓ ·Ú·›ˆÛË ‹ ·fiÙˆÛË ÙˆÓ ÙÚȯÒÓ Ù˘ ÎÂÊ·Ï‹˜ (·ÏˆÂΛ·). ∏ ·ÓˆÙ¤Úˆ Û˘Ìو̷ÙÔÏÔÁ›· ›Ù ‚ÂÏÙÈÒÓÂÙ·È, ›Ù ÂÍ·Ê·Ó›˙ÂÙ·È Ì ÙË Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ‹ ÙË ‰È·ÎÔ‹ ÙÔ˘ (2,3). ∆· ÂÚÈÁÚ·ÊfiÌÂÓ· ÙÔÍÈο Î·È ÔÏϤ˜ ÊÔÚ¤˜ ı·Ó·ÙËÊfiÚ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ‹·Ú ı· Ú¤ÂÈ Ó· ıˆÚËıÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ È‰ÈÔÛ˘ÁÎÚ·Ûȷο, ·Ú¿ Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙË ‰fiÛË ÙÔ˘ µ∞ (1,3). ∏ ‚ÈÔÙÈÓȉ¿ÛË Â›Ó·È ¤Ó· ¤Ó˙˘ÌÔ Ô˘ ·Ó·Î˘ÎÏÒÓÂÈ ÙË ‚ÈÔÙ›ÓË, ·ÏÏ¿ Î·È ¿ÏÏ· ÌÈÎÚ¿ ÂÙ›‰È· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ‚ÈÔÙÈÓÔ-ÂÍ·ÚÙÒÌÂÓ˜ ηڂÔÍ˘Ï¿Û˜. ∆Ô ¤Ó˙˘ÌÔ ÂÈÙÚ¤ÂÈ ÛÙËÓ ÂχıÂÚË ‚ÈÔÙ›ÓË Ó· Â·Ó·Î˘ÎÏÒÓÂÙ·È ·ÏÏ¿ Î·È Ó· ÙËÓ ·ÔÛ¿ fiÙ·Ó Â›Ó·È Û˘Ó‰Â‰Â̤ÓË Ì ÙȘ ÚˆÙ½Ó˜ Ù˘ ÙÚÔÊ‹˜. ∏ ‚ÈÔÎ˘Ù›ÓË, ¤Ó· Â-Ï˘ÛÈÓÔ-·ÌÈÓÔ-·Ì›‰ÈÔ Ù˘ ‚ÈÔÙ›Ó˘, ÚÔ¤Ú¯ÂÙ·È Èı·ÓfiÓ ·fi ÙËÓ ÚˆÙÂfiÏ˘ÛË ÙˆÓ ÂÍ·ÚÙˆÌ¤ÓˆÓ ·fi ÙË ‚ÈÔÙ›ÓË Î·Ú‚ÔÍ˘Ï·ÛÒÓ (4). ∏ Û˘Ìو̷ÙÔÏÔÁ›·, ÙfiÛÔ ÛÙËÓ ÔÏÈ΋ fiÛÔ Î·È ÛÙË ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, Û˘Óԉ‡ÂÙ·È ·fi ÎÏÈÓÈο ‰ÂÚÌ·ÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ·ÚfiÌÔÈ· Ì ÂΛӷ Ù˘ ¤ÏÏÂȄ˘ Ù˘ ‚ÈÔÙ›Ó˘, Èı·ÓfiÓ ·fi ‰È·Ù·Ú·Á̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË, ΢ÙÙ·ÚÈ΋ ¯Ú‹ÛË, ÓÂÊÚÈ΋ ·Ô‚ÔÏ‹ Ù˘ ‚ÈÔÙ›Ó˘, ηıÒ˜ Â›Û˘ ·fi Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ÔÈ Û·ÛÌÔ›, ÛÙÔ Ì¤ÙÚÔ Ô˘ Â›Ó·È ÂÏ¿-

¯ÈÛÙË Ë ÌÂÙ·‚ÔÏÈο ÂÎÌÂÙ·ÏχÛÈÌË ‚ÈÔÙ›ÓË (5). ŒÙÛÈ, Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ë ÂÓ‰ÔÁÂÓ‹˜ ÌÂÙ·‚ÔÏÈ΋ ·ÓÂ¿ÚÎÂÈ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙÔ ‰¤ÚÌ· Î·È ÙÔ ÙÚȯˆÙfi Ù˘ ÎÂÊ·Ï‹˜ ·ÚfiÌÔÈ· Ì ÂΛÓË Ô˘ ÂÓÙÔ›˙ÂÙ·È Û ·ÛıÂÓ›˜ Û ıÂÚ·›· Ì µ∞, Ì·˜ Ô‰‹ÁËÛ ÛÙË ÌÂϤÙË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ Û ۯ¤ÛË Ì ÙȘ ÙÈ̤˜ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔÓ ÔÚfi ÂÈÏËÙÈÎÒÓ ·È‰ÈÒÓ Û ıÂÚ·›· Ì µ∞. ¶·Ú¿ÏÏËÏ·, ÌÂÏÂÙ‹ıËÎÂ Ë ¿ÌÂÛË Â›‰Ú·ÛË ÙÔ˘ µ∞ ÛÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ Û in vitro ›ڷ̷. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∂‚‰ÔÌ‹ÓÙ· ¤ÓÙ (¡=75) ·ÛıÂÓ›˜, Ì ̤ÛË ËÏÈΛ· Ù· 8,6±1,9 ¯ÚfiÓÈ· Û ÌÔÓÔıÂÚ·›· Ì µ∞, ‰È·¯ˆÚ›ÛÙËÎ·Ó Û 3 ÈÛ¿ÚÈı̘ ÔÌ¿‰Â˜. ¶ÂÓ‹ÓÙ· (¡=50) ˘ÁÈ‹, ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜, ·È‰È¿ ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (Ì¿ÚÙ˘Ú˜). ∏ ÔÌ¿‰· ∞ ÙˆÓ ·ÛıÂÓÒÓ (¡=25) ÂÏ¿Ì‚·Ó 28,7±8,5 mg/Kg/24h BA, Ë ÔÌ¿‰· µ (¡=25) ÂÏ¿Ì‚·Ó 41,6±4,9mg/Kg/24h µ∞ Î·È Ë ÔÌ¿‰· ° (¡=25) 64,5±5,8 mg/Kg/24h. ŸÏ· Ù· ˘fi ÌÔÓÔıÂÚ·›· ·È‰È¿ ˘¤ÊÂÚ·Ó ·fi Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ (2-3/‚‰ÔÌ¿‰·). ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÂϤÁ¯ıËÎ·Ó Ù· Ë·ÙÈο ¤Ó˙˘Ì· (SGOT, SGPT, ÁGt, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË), Ù· Â›‰· ¡∏3 Î·È Ù· ÔÏÈο Ï¢ÎÒÌ·Ù·, ÚÈÓ ÙË ÌÔÓÔıÂÚ·›· ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi 45 Ë̤Ú˜ ıÂÚ·›·˜ Ì µ∞. ∂›Û˘, ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ù· Â›‰· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÌÂÙ¿ ÙÔ ›‰ÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ıÂÚ·›·˜, Ì ·ÓÔÛÔÊıÔÚÈÛÌÔÌÂÙÚÈ΋ ̤ıÔ‰Ô (6). ∏ ÌÂϤÙË Ù˘ in vitro Â›‰Ú·Û˘ ÙÔ˘ µ∞ ÛÙËÓ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ¤ÁÈÓ ÌÂÙ¿ ·fi ÂÒ·ÛË ÔÚÔ‡ ÁÓˆÛÙ‹˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ì ‰È¿ÊÔÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ¶ÚfiÙ˘Ë Ô˘Û›· µ∞ ÚÔÛʤÚıËΠ¢ÁÂÓÈο ·fi ÙËÓ ÂÙ·ÈÚ›· Sanofi Ltd. T· Â›‰· ÙÔ˘ µ∞ ÛÙÔÓ ÔÚfi ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì ÙÔ Û‡ÛÙËÌ· (∆DX) Ù˘ ABBOTTR (7). °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ‰ÔÎÈ̷ۛ˜ Student's Î·È Spearman ·fi ÙÔ ÛÙ·ÙÈÛÙÈÎfi ·Î¤ÙÔ SPSS 7,5 Ì ∏/À.

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¶·È‰È·ÙÚÈ΋ 2001;64:488-492

Paediatriki 2001;64:488-492

∞ÔÙÂϤÛÌ·Ù· ∆· ÈÔ Û˘¯Ó¿ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÌÂÙ¿ ÙË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ Ì µ∞ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÂÛÙÈ¿ÛÙËÎ·Ó Û ÁÂÓÈÎÂ˘Ì¤ÓÔ ÂÍ¿ÓıËÌ· (6/25 ÛÙËÓ ÔÌ¿‰· µ Î·È 7/25 ÛÙËÓ ÔÌ¿‰· °) Î·È Û ·ÒÏÂÈ· ÙˆÓ ÙÚȯÒÓ Ù˘ ÎÂÊ·Ï‹˜ (3/25 Î·È 6/25 ÛÙȘ ÔÌ¿‰Â˜ µ Î·È °). ∏ Û˘Ìو̷ÙÔÏÔÁ›· ·˘Ù‹ ·Ô˘Û›·˙ ÛÙËÓ ÔÌ¿‰· ∞ (¶›Ó·Î·˜ 1) ∆· Ë·ÙÈο ¤Ó˙˘Ì· Î·È Ù· Â›‰· Ù˘ ¡∏3 ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÛÙȘ ÔÌ¿‰Â˜ µ Î·È ° (¶›Ó·Î·˜ 2). ∆· Â›‰· ÙÔ˘ µ∞ ÛÙÔÓ ÔÚfi, Û‡Ìʈӷ Ì ÙË Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ¯·Ú·ÎÙËÚ›ÛÙËÎ·Ó ˆ˜ “˘ÔıÂÚ·¢ÙÈο” ÛÙËÓ ÔÌ¿‰· ∞ (40,9±13,2 Ìg/ml), ˆ˜ “ıÂÚ·¢ÙÈο” (86,25±11,5 Ìg/ml) ÛÙËÓ ÔÌ¿‰· µ Î·È ˆ˜ “ÙÔÍÈο” (137±14,5 Ìg/ml) ÛÙËÓ ÔÌ¿‰· °. Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 3, Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË ÛÙȘ ÔÌ¿‰Â˜ µ Î·È °, Û ۇÁÎÚÈÛË Ì ÂΛÓË ÙˆÓ Ì·ÚÙ‡ÚˆÓ Î·È Ù˘ ÔÌ¿‰·˜ ∞. ∞ÚÓËÙÈΤ˜ Â›Û˘, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ µ∞ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ (¶›Ó·Î·˜ 4). ∫·Ì›· ·fi ÙȘ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ Û˘ÁÎÂÓÙÚÒ-

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Â˘Ú‹Ì·Ù· ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ Ì µ∞ Û ۯ¤ÛË Ì ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÙÔ˘˜ ∫ÏÈÓÈο OÌ¿‰· ∞ OÌ¿‰· µ Â˘Ú‹Ì·Ù· (¡=25) (¡=25) °ÂÓ. ÂÍ¿ÓıËÌ· 6/25 ∞ÒÏÂÈ· ÙÚȯÒÓ 3/25 µÈÔÙÈÓȉ¿ÛË (mmol/min/l) 3,95±1,08a 1,1±1,0b

OÌ¿‰· ° ª¿ÚÙ˘Ú˜ (¡=25) (¡=50) 7/25 6/25 0,9±0,9c 5,2±0,9d

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ™Ù·ıÂÚ‹ ·fiÎÏÈÛË a/b, a/c, a/d, b/d, c/d = p<0,001 b/c = NS (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹)

ÛÂȘ ÙÔ˘ µ∞ ‰ÂÓ ¤‰ÂÈÍ ¿ÌÂÛÔ ·ÔÙ¤ÏÂÛÌ· ÛÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, fiÙ·Ó Âˆ¿ÛÙËΠ̠ÙÔ µ∞ (ÂÈÚ·Ì·ÙÈ΋ ÌÂϤÙË in vitro) (¶›Ó·Î·˜ 5). ™˘˙‹ÙËÛË ™‡Ìʈӷ Ì ÙÔ ÁÂÓÈÎÒ˜ ·Ô‰ÂÎÙfi ıÂÚ·¢ÙÈÎfi Û¯‹Ì·, ÙÔ µ∞ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Û ·Ú¯È΋ ‰fiÛË 15 mg/Kg/24h Ì ÛÙ·‰È·Î‹ ·‡ÍËÛË ·Ó¿ 1 ‚‰ÔÌ¿‰· ηٿ 5-10 mg, ¤ˆ˜ fiÙÔ˘ ÛÙ·Ì·Ù‹ÛÔ˘Ó ÔÈ Û·ÛÌÔ› ‹ ÂÌÊ·ÓÈÛÙÔ‡Ó ÔÈ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∏ ÌÂÁ·Ï‡ÙÂÚË Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÌÔÚ› Ó· ·Ó¤ÏıÂÈ Û 60 mg/Kg/24h (3), fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ °. ™‡Ìʈӷ Ì ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ÌÂٷ͇ ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, fiÙ·Ó ÙÔ‡ÙÔ ¯ÔÚËÁÂ›Ù·È Û ıÂÚ·¢ÙÈΤ˜ ‰fiÛÂȘ, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Ë ·ÏˆÂΛ· (13/134), ÙÔ ‰ÂÚÌ·ÙÈÎfi ÂÍ¿ÓıËÌ· (15/134) Î·È Ô ÎÓËÛÌfi˜ (10/71) (3). ŸÙ·Ó Ë ¯ÔÚËÁÔ‡ÌÂÓË ‰fiÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·˘Í¿ÓÂÙ·È, ·˘Í¿ÓÂÈ Î·È Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÚÔ·Ó·ÊÂÚÔÌ¤ÓˆÓ Û˘Ìو̿وÓ, fiˆ˜ Ë ·ÏˆÂΛ· (23/131), ÙÔ ÂÍ¿ÓıËÌ· (30/131) Î·È Ô ÎÓËÛÌfi˜ (21/131). ∆· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘.

OÈ ÌÈÎÚ¤˜ ·˘Í‹ÛÂȘ ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜, Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ¯ÔÚËÁÔ‡ÌÂÓË ‰fiÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∆Ô ›‰ÈÔ Û˘Ì‚·›ÓÂÈ Î·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ·Ì̈ӛ·˜ (3). ∏ Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÙÔ˘˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÙÔ˘˜ Û˘ÌÙˆÌ¿ÙˆÓ (¶›Ó·Î·˜ 1). ™‡Ìʈӷ ¿ÏÈ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ·fi ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂÌÊ·Ó›˙ÔÓÙ·È Û ÂΛÓÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ï‹ÚË ·ÓÂ¿ÚÎÂÈ· ‚ÈÔÙÈÓȉ¿Û˘. ∏ ·Ô˘Û›· ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜, Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È Û ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘, Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ÎÏÈÓÈΤ˜

¶›Ó·Î·˜ 2. ∏·ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, ¡∏3 Ê·ÚÌ·ÎÔÎÈÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ µ∞ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ

SGOT, U/L SGPT, U/L ∞ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË U/L ÁGt U/L NH3 Á% OÏ. Ï¢ÎÒÌ·Ù· (g/l) µ∞ Ìg/ml

OÌ¿‰· ∞ (N=25) 24,6±8,0a 20,4±8,1a 63,5±21a 10,5±4a 34,0±7,8a 6,7±0,3a 40,9±15,2a

a/b = b/c= p<0,01, a/c = p<0,001 a/a = a/d = d/d = NS (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹)

490

OÌ¿‰· B (N=25) 39,8±11,4b 39,6±15,7b 86,9±27b 17,3±7,5b 76,8±8,5b 5,93±0,6d 86,2±13,5b

OÌ¿‰· ° (N=25) 44,6±12c 43,9±16c 90,9±28c 19,6±8,5c 98±9,5c 5,8±0,5d 137,9±14,5c

ª¿ÚÙ˘Ú˜ (N=50) 23,0±9,0a 21,0±8,9a 60±15a 12,0±4,0a 28±9,0a 6,6±0,4a -

¶·È‰È·ÙÚÈ΋ 2001;64:488-492

Paediatriki 2001;64:488-492

¶›Ó·Î·˜ 3. ¢Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÔÚÔ‡ ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ OÌ¿‰Â˜ A (¡=25) µ (¡=25) °(¡= 25) ª¿ÚÙ˘Ú˜ (N=50)

¢Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ (mmol/min/L) 3,95±1,08a 1,22±1,11b 0,97±0,07c 5,20±0,90d

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ™Ù·ıÂÚ‹ ·fiÎÏÈÛË a/b p<0,01, a/d = b/c = ¡S (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹) a/c = b/d p<0,001, c/d p<0,0001

¶›Ó·Î·˜ 4. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ‚ÈÔÙÈÓȉ¿Û˘, Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ÔÏÈÎÒÓ ÏÂ˘ÎˆÌ¿ÙˆÓ Î·È ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ µ∞ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ OÌ¿‰Â˜ SGOT

SGPT

∞ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË

ÁGt

µA

OÏ. ¶ÚˆÙ½ÓË

A B C ∞ B C ∞ µ C A B C A B C A B C

¢Ú·ÛÙÈÎfiÙËÙ· ‚ÈÔÙÈÓȉ¿Û˘ -0,59* -0,62** -0,61*** -0,59* -0,59* -0,64** -0,48 -0,50 -0,52 -0,60* -0,64** -0,69*** -0,62** -0,61** -0,66*** 0,48 0,34 0,31

* p<0,05 ** p<0,01 *** p<0,001

¶›Ó·Î·˜ 5. ∏ Â›‰Ú·ÛË ÙÔ˘ µ∞ ÛÙËÓ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ (in vitro) µ∞ Û˘ÁÎÂÓÙÚÒÛÂȘ (mM) 0,3 (60 mg/100 ml) 0,6 (120 mg/100 ml) 0,9 (180 mg/100 ml) 1,2 (240 mg/100 ml)

¢Ú·ÛÙÈÎfiÙËÙ· (mmol/min/l) 4,3 4,3 5,8 4,8 4,6

¢Ú·ÛÙÈÎfiÙËÙ· (%) ‚ÈÔÙÈÓȉ¿Û˘ 100 100 134 111 106

OÈ ÙÈ̤˜ ÂÎÊÚ¿˙ÔÓÙ·È: ª¤ÛË ÙÈÌ‹ ± ™Ù·ıÂÚ‹ ·fiÎÏÈÛË

ÂΉËÏÒÛÂȘ (8). ∏ ÌÂÁ·Ï‡ÙÂÚË ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ¤¯ÂÈ ·Ú·ÙËÚËı› ÛÙÔ ‹·Ú Î·È ÙÔÓ ÔÚfi (9) Î·È ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË ÛÙÔÓ ÂÁΤʷÏÔ (10).

O Pispa (11) ·Ú·Ù‹ÚËÛ ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ·

Û ÔÛÔÛÙfi (-30%) Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÌÂÚÈÎÒ˜ Ë·ÙÂÎÙÔÌËı¤ÓÙˆÓ ÔÓÙÈÎÒÓ, ·Ô‰ÂÈÎÓ‡ÔÓÙ·˜ fiÙÈ ÙÔ ‹·Ú Â›Ó·È Ô ÙfiÔ˜ ·Ú·ÁˆÁ‹˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘. ™Â Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË (12), Ù· Â›‰· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ‚Ú¤ıËÎ·Ó ÌÂȈ̤ӷ ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi Û ÂÈÏËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, Ë Û˘ÁΤÓÙÚˆÛ‹ Ù˘, fï˜, ÛÙÔÓ ÔÚfi, ÌfiÏȘ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο Û ۯ¤ÛË Ì ÂΛÓË ÙˆÓ ˘ÁÈÒÓ. ™Â ÚÔËÁÔ‡ÌÂÓË ÂÚÁ·Û›· Ì·˜ (13), ÙÔ Ê¿ÚÌ·ÎÔ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ıÂÚ·›· Ù˘ ΢ÛÙÈ΋˜ ·ÎÌ‹˜, Ë ÈÛÔÙÚÂÙÈÓÔ˝ÓË, ‚Ú¤ıËΠfiÙÈ ÚÔηÏ› ÌÂÚÈ΋ ·Ó·ÛÙÔÏ‹ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, Ô˘ Èı·ÓfiÓ ÔÊ›ÏÂÙ·È ÛÙÔ˘˜ ÈÛÔÌÂÚ›˜ ÌÂÙ·‚Ôϛ٘ Ù˘ ÈÛÔÙÚÂÙÈÓÔ˝Ó˘ Ô˘ ‰ÚÔ˘Ó Â›Ù ¿ÌÂÛ· ›Ù ¤ÌÌÂÛ· ÛÙÔ ‹·Ú, ÌÂ Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË ÙÂÏÈο Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘. ÕÏÏ· ÚfiÛÊ·Ù· ÛÙÔȯ›· ·¤‰ÂÈÍ·Ó fiÙÈ Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ Â›Ó·È ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË ÙˆÓ ˘ÁÈÒÓ (14). £· ÌÔÚÔ‡ÛÂ, ÏÔÈfiÓ, Ó· ˘ÔÙÂı› fiÙÈ ÙÔ µ∞, ÂËÚ¿˙ÔÓÙ·˜ ÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· (3), Ô‰ËÁ› ÛÙË Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÛÙÔÓ ÔÚfi (14). ∆Ô‡ÙÔ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙÔ fiÙÈ Ë in vitro ÌÂϤÙË Ì·˜ ·¤‰ÂÈÍ fiÙÈ Ë ÂÒ·ÛË ÙÔ˘ µ∞ Ì ÔÚfi ÁÓˆÛÙ‹˜ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘, ‰ÂÓ ÌÂÙ¤‚·Ï ÙËÓ ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘, ÂÓÈÛ¯‡ÔÓÙ·˜ ÂÚ·ÈÙ¤Úˆ ÙËÓ ¿Ô„Ë fiÙÈ Â›Ó·È ¤ÌÌÂÛË Èı·Ó¿ Ë ·ÈÙ›· Ì›ˆÛ˘ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì·˜. ™˘ÌÂÚ¿ÛÌ·Ù· H ·Ú·ÙËÚÔ‡ÌÂÓË Ì›ˆÛË Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Â›Ó·È ‰ÔÛÔ-ÂÍ·ÚÙÒÌÂÓË Î·È Èı·Ófiٷٷ ÔÊ›ÏÂÙ·È ÛÙËÓ Ë·ÙÈ΋ ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ µ∞ ‹ ·ÎfiÌË Î·È Û οÔÈÔ ¿ÏÏÔ ¤ÌÌÂÛÔ Ì˯·ÓÈÛÌfi Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ٷ ¯·ÌËÏ¿ Â›‰· Ù˘ ‚ÈÔÙ›Ó˘ ÛÙÔÓ ÔÚfi, ÙÔ Ê˘ÛÈÎfi ˘fiÛÙڈ̷ ÙÔ˘ ÂÓ˙‡ÌÔ˘.

OÈ ‰ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ (·ÏˆÂΛ·˜, ÂÍ¿ÓıËÌ·) Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙˆÓ ÔÌ¿‰ˆÓ µ Î·È °, ı· ÌÔÚÔ‡Û·Ó Ó· ·Ô‰ÔıÔ‡Ó Û ·Ú¯Èο Û˘ÌÙÒÌ·Ù· ÌÂÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ‚ÈÔÙÈÓȉ¿Û˘. ¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ·Ó·Ê¤ÚÔÓÙ·È Û ·ÛıÂÓ›˜ Ì ÂÁÁÂÓ‹ ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘. ™ÙÔ Ì¤ÙÚÔ Ô˘ Ë ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Ù˘ ‚ÈÔÙÈÓȉ¿Û˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Ì ÙË ¯ÔÚ‹ÁËÛË ‚ÈÔÙ›Ó˘, ı· ÌÔÚÔ‡ÛÂ Ë ¯ÔÚ‹ÁËÛË Ù˘ ÙÂÏÂ˘Ù·›·˜ Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó µ∞ Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ÚÔÂÚ¯fiÌÂÓˆÓ ·fi ÙÔ µ∞ ‰ÂÚÌ·ÙÈÎÒÓ ÂΉËÏÒÛˆÓ.

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Paediatriki 2001;64:488-492

∂˘¯·ÚÈÛٛ˜ OÈ Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó ˘Ô¯Ú¤ˆÛ‹ ÙÔ˘˜ Ó· ¢¯·ÚÈÛÙ‹ÛÔ˘Ó ÙȘ Î.Î. ∫. ∆·ÛÛÔÔ‡ÏÔ˘ Î·È ÕÓÓ· ™Ù·Ì¿ÙË ÁÈ· ÙËÓ ÂÈÌÂÏË̤ÓË ‰·ÎÙ˘ÏÔÁÚ¿ÊËÛË ·˘Ù‹˜ Ù˘ ÂÚÁ·Û›·˜.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 24-07-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: KÏÂÔ¿ÙÚ· ∂. ™Ô‡ÏË πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, 115 27, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∏ Â›ÌÔÓË Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹ Û Ôχ ÌÈÎÚ¿ ·È‰È¿ Û¯ÂÙ›˙ÂÙ·È Ì ÊÏÂÁÌÔÓ‹ ÙˆÓ Î·ÙÒÙÂÚˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ1 ™ÎÔfi˜: ¶·Ú¿ ÙȘ ÚÔfi‰Ô˘˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ ¿ÛıÌ·ÙÔ˜, Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· ÛÙ· ·È‰È¿ Û˘Ó¯›˙ÂÈ Ó· ·˘Í¿ÓÂÈ. §›Á· Â›Ó·È ÁÓˆÛÙ¿ Û¯ÂÙÈο Ì ÙËÓ ¤Ó·ÚÍË Î·È ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ ÊÏÂÁÌÔÓ‹˜ Ô˘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙÔ ¿ÛıÌ· ÛÙÔ Ó·Úfi ·˘Ùfi ÏËı˘ÛÌfi. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹Û·Ì 20 ·È‰È¿ ÌÂ Û˘ÚÈÁÌfi (wheezing) ̤Û˘ ËÏÈΛ·˜ 14,9 ÌËÓÒÓ Ì 2 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÂÈÛfi‰È· Û˘ÚÈÁÌÔ‡ ‹ ·Ú·ÙÂٷ̤ÓÔ˘ Û˘ÚÈÁÌÔ‡ ¿Óˆ ÙˆÓ 2 ÌËÓÒÓ, Û ‰È¿ÛÙËÌ· 6 ÌËÓÒÓ, Ì ‚ÚÔÁ¯ÔÛÎfiËÛË Î·È ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· (BAL). ™˘ÁÎÚ›ÛÂȘ ¤ÁÈÓ·Ó Ì 6 Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ (̤Û˘ ËÏÈΛ·˜ 23,3 ÌËÓÒÓ) Ô˘ ‹Ú·Ó ÁÂÓÈ΋ Ó¿ÚΈÛË ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË. ¶ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ô ·ÚÈıÌfi˜ Î·È Ô Ù‡Ô˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎÔ‡ ÂÎÎڛ̷ÙÔ˜. ∆· ÂÈÎÔÛ·ÓÔÂȉ‹, Ù· Ï¢ÎÔÙÚȤÓÈ· LTB4, LTE4, Ë ÚÔÛÙ·ÁÏ·Ó‰›ÓËPGE2 Î·È ÙÔ 15-˘‰ÚÔ͢-ÂÈÎÔÛ·ÓÔÙÂÙÚ·ÓÔ˚Îfi Ô͇ Î·È ÔÈ ‰È·‚È‚·ÛÙ¤˜ ÙˆÓ Ì·ÛÙÔ΢ÙÙ¿ÚˆÓ ‚-ÙÚ˘Ù¿ÛË Î·È PGD2 ÂÎÙÈÌ‹ıËÎ·Ó Ì ·ÓÔÛÔÂÓ˙˘Ì·ÙÈ΋ ̤ıÔ‰Ô. ∞ÔÙÂϤÛÌ·Ù·: ∆· ·È‰È¿ ÌÂ Û˘ÚÈÁÌfi ›¯·Ó ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ Î˘Ù¿ÚˆÓ ÙÔ˘ BAL/ml ηıÒ˜ Î·È ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙÔ˘ ÏfiÁÔ˘ Ì·ÎÚÔÊ¿ÁˆÓ/ÌÔÓÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ, ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ

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Î·È ÙˆÓ ËˆÛÈÓÔʛψÓ, Û ۇÁÎÚÈÛË ÌÂ Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∆· Â›‰· ÙˆÓ PGE4 (p=0,0005), 15-HETE (p=0,002), LTE4 (p=0,04) Î·È LTB4 (p=0,05) ‹Ù·Ó Â›Û˘ ·˘ÍË̤ӷ ÛÙ· ·È‰È¿ ÌÂ Û˘ÚÈÁÌfi Û ۇÁÎÚÈÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ Ë PGD4 Î·È Ë ‚-ÙÚ˘Ù¿ÛË ‰ÂÓ ‹Ù·Ó. ™˘ÌÂÚ¿ÛÌ·Ù·: ∞˘Ù‹ Ë ÌÂϤÙË ÂȂ‚·ÈÒÓÂÈ ÙÔ fiÙÈ Ë ÊÏÂÁÌÔÓ‹ Â›Ó·È ·ÚÔ‡Û· ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ÙˆÓ Ôχ ÌÈÎÚÒÓ ·È‰ÈÒÓ ÌÂ Û˘ÚÈÁÌfi Î·È ÌÔÚ› Ó· ‰È·Ê¤ÚÂÈ ·fi ÙÔÓ Ù‡Ô Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ¿ÛıÌ·.

1 Krawiec ME, Westcott JY, Chu HW, Balzar S, Trudeau JB, Schwartz LB et al Persistent wheezing in very young children is associated with lower respiratory inflammation Am J Respir Crit Care Med 2001;163:1338-1343

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∂ȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›· Õ. ¶·ÓÙ·˙‹, ¡. ÷Ù˙ËΈÓÛÙ·ÓÙ›ÓÔ˘, £. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, °. ∫·Ú·‚¿Ó·, £. ∞ÏÌ·Ó›‰Ë˜, ™. ∞ÁÁÂÏfiÔ˘ÏÔ˜

Epidemiological study of injuries in adolescence A. Pantazi, N. Hatzikonstantinou, T. Tragianidis, G. Karavana, T. Almanidis, S. Agelopoulos

¶ÂÚ›ÏË„Ë: ™Ùfi¯Ô˜ Ù˘ ¤Ú¢ӷ˜ ·˘Ù‹˜ Â›Ó·È Ë Û˘ÏÏÔÁ‹ Î·È Ë ÌÂϤÙË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÙȘ ηÎÒÛÂȘ ÙˆÓ ÂÊ‹‚ˆÓ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ƒÔ‰fi˘, ÒÛÙ ӷ ηıÔÚÈÛÙÔ‡Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È Ó· ¯·Ú·¯ÙÔ‡Ó ÛÙÚ·ÙËÁÈΤ˜ ÚfiÏ˄˘. ∏ ÌÂϤÙË Ì·˜ ·ÊÔÚ¿ 3334 ÂÊ‹‚Ô˘˜ ËÏÈΛ·˜ 13-19 ¯ÚfiÓˆÓ Ô˘ ÚÔÛ‹Ïı·Ó ÛÙÔ ∆Ì‹Ì· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ Ù· 3 ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÁÈ· ·Ù˘¯‹Ì·Ù· Î·È ‰ËÏËÙËÚÈ¿ÛÂȘ. ∆· ÛÙÔȯ›· Ô˘ ÂϤÁÍ·Ì ·ÊÔÚÔ‡Û·Ó ÛÙÔ Ê‡ÏÔ, ÙËÓ ËÏÈΛ·, ÙËÓ ÏËı˘ÛÌȷ΋ ÔÌ¿‰· ÛÙËÓ ÔÔ›· ·Ó‹Î·Ó, ÙËÓ ·ÈÙ›· Ù˘ οΈÛ˘, ÙËÓ ÎÏÈÓÈ΋ ʇÛË Î·È ÙË ‚·Ú‡ÙËÙ¿ Ù˘. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÊ‹‚ˆÓ, ÙÔ 67,8% ‹Ù·Ó ¿ÚÚÂÓ˜ Î·È ÙÔ 32,2% ı‹ÏÂȘ. OÈ Î·ÎÒÛÂȘ ÔÊ›ÏÔÓÙ·Ó ÛÙ· ÛÔÚ ‹ ÙÔ ·È¯Ó›‰È Û ÔÛÔÛÙfi 40,8%, Û ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Û ÔÛÔÛÙfi 38% Î·È Û ·Ù˘¯‹Ì·Ù· ηٿ ÙËÓ ÂÚÁ·Û›· Û ÔÛÔÛÙfi 11,2%. ™˘ÓËı¤ÛÙÂÚ˜ ‹Ù·Ó ÔÈ Î·ÎÒÛÂȘ ÙˆÓ ¿ÎÚˆÓ (ÛÔÚ 38,1%, ÙÚÔ¯·›· 42%, ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· 56,4%). OÈ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ ÛËÌÂÈÒıËÎ·Ó Î˘Ú›ˆ˜ ÛÙ· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· (77,8%). OÈ ÃÚÈÛÙÈ·ÓÔ› ˘¤ÛÙËÛ·Ó Î·ÎÒÛÂȘ ΢ڛˆ˜ ÛÙ· ÛÔÚ (46,3%), ÂÓÒ ÔÈ ªÔ˘ÛÔ˘ÏÌ¿ÓÔÈ Î·È ÔÈ ∞ı›ÁÁ·ÓÔÈ ÛÙËÓ ÂÚÁ·Û›· (20,8%, 23,1%). OÈ ‰ËÏËÙËÚÈ¿ÛÂȘ ·Ó‹Ïı·Ó Û ÔÛÔÛÙfi 6,9% Î·È ÔÊ›ÏÔÓÙ·Ó Î˘Ú›ˆ˜ ÛÙË Ï‹„Ë ·ÏÎÔfiÏ. OÈ ·fiÂÈÚ˜ ·˘ÙÔÎÙÔÓ›·˜ ·ÓÙÈÚÔÛÒ¢·Ó ÙÔ 2,8%. ∏ ‚·Ú‡ÙËÙ· ÙˆÓ Î·ÎÒÛÂˆÓ ÂϤÁ¯ıËΠ̠‚¿ÛË ÙȘ ÂÈÛ·ÁˆÁ¤˜, Ô˘ ·Ó‹Ïı·Ó ÛÙÔ 14%. ∆Ô 52% ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ·ÊÔÚÔ‡Û ٷ ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·. ∆Ô 0,4% ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Î·Ù¤ÏËÍ Û ı¿Ó·ÙÔ, Ô˘ ÚÔÎÏ‹ıËΠ΢ڛˆ˜ ·fi ÙÚÔ¯·›· Î·È ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· (75%, 16,7%). ŒÓ· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÛÙË Û‡Á¯ÚÔÓË ÎÔÈÓˆÓ›· Â›Ó·È ÔÈ Î·ÎÒÛÂȘ ÛÙËÓ ÂÊ˂›·.

O ηıÔÚÈÛÌfi˜ ÙÔ˘ ÚÔÊ›Ï ÙˆÓ Î·ÎÒÛÂˆÓ ı· Ú¤ÂÈ

Abstract: The aim of the study was to collect data concerning accidents in adolescents who live in the area of Rodopi, in order to determine the risk factors and recommend strategies for their prevention. The population of the study consisted of 3334 adolescents, 13-19 years of age, who presented during the last three years to the Emergency Room because of accidents and poisoning. The demographic data, the clinical nature, severity and cause of the injury were reviewed. The male to female ratio was about 2:1.

Injuries due to sports accounted for 40,8% of the cases, traffic 38%, and labor accidents 11,2%.

More common were injuries to the extremities (sports 38,1%, traffic accidents 42%, and occupational 56,4). Craniocerebral injuries were observed mostly in traffic accidents (77,8%). Sport accidents were observed most commonly in the Christian population while occupational accidents involved mainly Muslims (20,8%) and Gypsies (23,1%). Poisoning (6,9%) was usually due to alcohol abuse. Suicide attempts comprised 2,8% of the cases. The severity of injuries was evaluated on the basis of the number of admissions which comprised 14% of the cases. 52% of admissions concerned traffic injuries. 0,4% of injuries were fatal and were due primarily to traffic and occupational accidents (75%, 16,7% respectively). Injuries during adolescence constitute one of the greatest public health problems in today’s society. The magnitude of the problem requires a multidisciplinary approach and is therefore important to give priority to the investigation of the profile of injuries in order to plan strategies for their prevention.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ™ÈÛÌ·ÓfiÁÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∫ÔÌÔÙËÓ‹˜

Pediatric Clinic Sismanoglio Hospital of Komotini, Komotini

493

¶·È‰È·ÙÚÈ΋ 2001;64:493-498

Paediatriki 2001;64:493-498

Ó· ·ÔÙÂϤÛÂÈ ÔÏÈÙÈ΋ ÚÔÙÂÚ·ÈfiÙËÙ·, ÒÛÙ ӷ ۯ‰ȷÛÙÔ‡Ó ÔÈ ÛÙfi¯ÔÈ Î·È ÔÈ ÛÙÚ·ÙËÁÈΤ˜ ·Ú¤Ì‚·Û˘.

§¤ÍÂȘ ÎÏÂȉȿ: ηÎÒÛÂȘ, ÂÊ˂›·, ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜

Key words: injuries, adolescence, population groups.

∂ÈÛ·ÁˆÁ‹ ¢ÂÓ ˘¿Ú¯ÂÈ Û·Ê‹˜ ÔÚÈÛÌfi˜ ÁÈ· ÙËÓ ÂÊ˂›·, Ô ÔÔ›Ô˜ Ó· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·. ™‡Ìʈӷ Ì ÙÔÓ Piaget, Ë ÂÊ˂›· ·ÓÙÈÚÔÛˆ‡ÂÈ ÙËÓ ÂÚ›Ô‰Ô Ù˘ Ï‹ÚÔ˘˜ ÂÁηٿÛÙ·Û˘ ÙˆÓ Â›ÛËÌˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ·ÓıÚÒÔ˘. ™’ ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ·, Ë ‰È·‰Èηۛ· Ù˘ ˆÚ›Ì·ÓÛ˘ ÙˆÓ ÛˆÌ·ÙÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Î·È Ù˘ ·fiÎÙËÛ˘ ÙˆÓ ‰ÂÍÈÔÙ‹ÙˆÓ ÙÔ˘ ÂÓ‹ÏÈη ÔÏÔÎÏËÚÒÓÂÙ·È, ̤۷ Û ¤Ó· Ï·›ÛÈÔ Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ ÂÓ·ÏÏ·ÁÒÓ Î·È ‰È·Ù·Ú·¯ÒÓ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ô˘ Û ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ· ı· ÌÔÚÔ‡Û·Ó Ó· ¯·Ú·ÎÙËÚÈÛÙÔ‡Ó ·ıÔÏÔÁÈΤ˜. OÈ ¤ÊË‚ÔÈ ·Ó·Ù‡ÛÛÔ˘Ó Û˘¯Ó¿ ¤Ó· ·›ÛıËÌ· ·ı·Ó·Û›·˜, Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘ÂÚÂÎÙ›ÌËÛË ÙˆÓ ÈηÓÔÙ‹ÙˆÓ ÙÔ˘˜, ¢ı‡ÓÂÙ·È ÁÈ· ¤Ó· ÛËÌ·ÓÙÈÎfi ·ÚÈıÌfi ηÎÒÛÂˆÓ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó ·ÎfiÌË Î·È ÛÙÔ ı¿Ó·ÙÔ (1). ™ÙȘ ∏¶∞, ÙÔ 1987, ÔÈ ı¿Ó·ÙÔÈ Û ӤԢ˜ 15-19 ÂÙÒÓ ‹Ù·Ó 84,6/100.000 ηÙÔ›ÎÔ˘˜, Ì ÚÔÂÍ¿Ú¯Ô˘Û· ·ÈÙ›· Ù· ·Ù˘¯‹Ì·Ù· (2). ∞Ó¿ÏÔÁ· ÔÛÔÛÙ¿, Û ‰ÈÂıÓ¤˜ Â›‰Ô, ·Ó·Ê¤ÚÔÓÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜, ÔÈ ÔÔ›ÔÈ Î·Ù·ÓfiËÛ·Ó ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Î·È Î·Ù¤ÁÚ·„·Ó ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›·, ÛÙ¤ÏÓÔÓÙ·˜ ÙÔ ·ÓËÛ˘¯ËÙÈÎfi Ì‹Ó˘Ì· fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘Í¿ÓÂÈ ‰Ú·Ì·ÙÈο οı ¯ÚfiÓÔ, Ì ·Ó˘ÔÏfiÁÈÛÙ˜ ÎÔÈÓˆÓÈΤ˜ Î·È ÔÈÎÔÓÔÌÈΤ˜ Û˘Ó¤ÂȘ (3-9). ∏ ∂ÏÏ¿‰·, Ì›· ¯ÒÚ· Ì ¤ÓÙÔÓÔ ‰ËÌÔÁÚ·ÊÈÎfi Úfi‚ÏËÌ·, η٤¯ÂÈ Ù· ıÏÈ‚ÂÚ¿ ÚˆÙ›· ÛÙËÓ ∂˘Úˆ·˚΋ ŒÓˆÛË Û ı·Ó¿ÙÔ˘˜ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· (10), ÁÂÁÔÓfi˜ Ô˘ ηıÈÛÙ¿ ÂÈÙ·ÎÙÈ΋ ÙËÓ ·Ó¿ÁÎË ÁÈ· ÔÏ˘Â›Â‰Ë ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ۯ‰ȷÛÌfi ÛÙÚ·ÙËÁÈÎÒÓ ÚfiÏ˄˘ Î·È ¿ÌÂÛË ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜. ªÂ ÙËÓ ¤ÚÂ˘Ó¿ Ì·˜ ·˘Ù‹, ÚÔÛ·ı‹Û·Ì ӷ Û˘ÏϤÍÔ˘ÌÂ Î·È Ó· ÌÂÏÂÙ‹ÛÔ˘Ì ٷ ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÙȘ ηÎÒÛÂȘ ηٿ ÙËÓ ÂÊ˂›· ÛÙËÓ ÂÚÈÔ¯‹ Ì·˜, ı¤ÏÔÓÙ·˜ ¤ÙÛÈ Ó· ηıÔÚ›ÛÔ˘Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È Ó· Û˘Ì‚¿ÏÔ˘Ì ÛÙË Ï‹„Ë Ì¤ÙÚˆÓ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÂÓfi˜ ·Ú·ÁÓˆÚÈṲ̂ÓÔ˘ - ÛÙË ¯ÒÚ· Ì·˜ - ÚÔ‚Ï‹Ì·ÙÔ˜.

01/01/1994 ¤ˆ˜ 31/12/1996. °È· οı ¤ÊË‚Ô Î·Ù·ÁÚ¿„·Ì ٷ ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›·, ÙËÓ ÏËı˘ÛÌȷ΋ ÔÌ¿‰· (ÃÚÈÛÙÈ·ÓÔ›, ªÔ˘ÛÔ˘ÏÌ¿ÓÔÈ, ∞ı›ÁÁ·ÓÔÈ, ¶·ÏÈÓÓÔÛÙÔ‡ÓÙ˜), ÙËÓ ·ÈÙ›· Ù˘ οΈÛ˘, ÙËÓ ÎÏÈÓÈ΋ ʇÛË Î·È ÙË ‚·Ú‡ÙËÙ¿ Ù˘. ∫·Ù¿ ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ÔÈ ·Èٛ˜ ÙˆÓ Î·ÎÒÛÂˆÓ ÔÌ·‰ÔÔÈ‹ıËÎ·Ó Û ¤ÓÙ ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜: ·) ηÎÒÛÂȘ ÛÙ· ÛÔÚ (¿ıÏËÛË, ·È¯Ó›‰È), ‚) ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, Á) ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù·, ‰) ·˘ÙÔÎÙÔӛ˜ Î·È Â) ηÎÒÛÂȘ ·fi ¿ÛÎËÛË ‚›·˜.

OÈ Î·ÎÒÛÂȘ, ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ÙÔ˘˜ ʇÛË, ÔÌ·‰ÔÔÈ‹ıËÎ·Ó Û‡Ìʈӷ Ì ÙÔ SCIPP (¶ÔÏÈÙÂÈ·Îfi ÚfiÁÚ·ÌÌ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ Î·ÎÒÛÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÙˆÓ ∏¶∞) (¶›Ó·Î·˜ 1). ∏ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· SPSS.

∞ÔÙÂϤÛÌ·Ù· ™Â ‰È¿ÛÙËÌ· ÙÚÈÒÓ ÂÙÒÓ, ÚÔÛ‹Ïı·Ó ÛÙÔ ∆Ì‹Ì· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ 6635 ·ÛıÂÓ›˜ ËÏÈΛ·˜ 0-19 ÂÙÒÓ, ÁÈ· ·Ù˘¯‹Ì·Ù· ‹ ‰ËÏËÙËÚÈ¿ÛÂȘ.

OÈ ÌÈÛÔ› ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ (3334) ‹Ù·Ó ¤ÊË‚ÔÈ ËÏÈΛ·˜ 13-19 ÂÙÒÓ. ∏ ηٷÓÔÌ‹ ÙˆÓ Î·ÎÒÛÂˆÓ ÙˆÓ ÂÊ‹‚ˆÓ ÂÙËÛ›ˆ˜, ÛÙ· ÙÚ›· ¯ÚfiÓÈ· Ù˘ ÌÂϤÙ˘, Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ™‡Ìʈӷ Ì ٷ ‰ËÌÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ÙˆÓ ÌÂÏÂÙËı¤ÓÙˆÓ ÂÊ‹‚ˆÓ, Ë ·Ó·ÏÔÁ›· ÙˆÓ ·ÚÚ¤ÓˆÓ Ô˘ ˘¤ÛÙËÛ·Ó Î¿ÎˆÛË Â›Ó·È ˘ÂÚ‰ÈÏ¿ÛÈ· (67,8%) ·fi ·˘Ù‹ ÙˆÓ ıËϤˆÓ (32,2%). ÀÂÚ‰ÈÏ¿ÛÈ·, Â›Û˘, ‹Ù·Ó Ë ·Ó·ÏÔÁ›· ÙˆÓ ÂÊ‹‚ˆÓ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (66,7%) Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (33,3%). ŒÓ· ·ÎfiÌË ÛÙÔÈ¯Â›Ô Ô˘ ÚԤ΢„ ‹Ù·Ó fiÙÈ ÔÈ ÃÚÈÛÙÈ·ÓÔ› ˘¤ÛÙËÛ·Ó ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·Ù˘¯ËÌ¿ÙˆÓ (57,6%) ·fi ÙÔ˘˜ ªÔ˘ÛÔ˘ÏÌ¿ÓÔ˘˜ (26,2%), Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ Ù· ¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ʇÛ˘ ÙˆÓ Î·ÎÒÛÂˆÓ Û‡Ìʈӷ Ì ÙÔ ÔÏÈÙÂÈ·Îfi ÚfiÁÚ·ÌÌ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ Î·ÎÒÛÂˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÙˆÓ ∏¶∞ (SCIPP)

ÀÏÈÎfi Î·È Ì¤ıÔ‰Ô˜

∆·ÍÈÓfiÌËÛË Î·ÎÒÛÂˆÓ Î·Ù¿ ÙÔ SCIPP* ñ ∫·Ù¿ÁÌ·Ù· ñ ∂Í·ÚıÚ‹Ì·Ù· ñ ∞ÓÔÈÎÙ¿ Î·È Û˘ÓıÏÈÙÈο ÙÚ·‡Ì·Ù· ñ ∫ÂÊ·Ï‹˜ ñ ÕÎÚˆÓ ñ ÕÏÏ· ñ ªÒψ˜-∂ΉÔÚ¤˜ ñ ∫Ú·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ ñ ∫·ÎÒÛÂȘ ÔÚÁ¿ÓˆÓ ñ ÕÏϘ

ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 3334 ¤ÊË‚ÔÈ, ËÏÈΛ·˜ 1319 ÂÙÒÓ, Ô˘ ˘¤ÛÙËÛ·Ó Î¿ÎˆÛË ÛÙÔ ‰È¿ÛÙËÌ· ·fi

*Statewide Childhood Injury Preventive Program

494

¶·È‰È·ÙÚÈ΋ 2001;64:493-498

Paediatriki 2001;64:493-498

¶›Ó·Î·˜ 2. ∫·Ù·ÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘¤ÛÙËÛ·Ó Î¿ÎˆÛË Î·Ù¿ ʇÏÔ, ηÙÔÈΛ· Î·È ÏËı˘ÛÌȷ΋ ÔÌ¿‰· º‡ÏÔ

ÕÚÚÂÓ˜

£‹ÏÂȘ

% ∆fiÔ˜ ηÙÔÈΛ·˜ % ¶ÏËı˘ÛÌȷ΋ ÔÌ¿‰· %

67,8 ∞ÛÙÔ› 66,7 ÃÚÈÛÙÈ·ÓÔ› 57,6 ∞ı›ÁÁ·ÓÔÈ 9,5

32,2 ∞ÁÚfiÙ˜ 33,3 ªÔ˘ÛÔ˘ÏÌ¿ÓÔÈ 26,2 ¶·ÏÈÓÓÔÛÙÔ‡ÓÙ˜ 6,7

%

19 18 17 16 15 14 13

1600 1400 1200

ÂÙÒÓ ÂÙÒÓ ÂÙÒÓ ÂÙÒÓ ÂÙÒÓ ÂÙÒÓ ÂÙÒÓ

1000 800 600 400

ÔÛÔÛÙ¿ ÙˆÓ ÔÌ¿‰ˆÓ ·˘ÙÒÓ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ™¯ÂÙÈο Ì ÙȘ ·Èٛ˜ ÚfiÎÏËÛ˘ Ù˘ οΈÛ˘ Î·È ÙË Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Û οı ËÏÈÎȷ΋ ÔÌ¿‰·, ÚԤ΢„ fiÙÈ ÙÔ 41,7% ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ Û˘Ó¤‚·ÈÓ ηٿ ÙËÓ ¿ıÏËÛË Î·È ÙÔ ·È¯Ó›‰È, ÙÔ 36,6% ÔÊÂÈÏfiÙ·Ó Û ÙÚÔ¯·›· Û˘Ì‚¿ÓÙ· Î·È ÙÔ 11,2% ÙˆÓ Î·ÎÒÛÂˆÓ ·ÊÔÚÔ‡Û ٷ ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· (∂ÈÎfiÓ· 1). ∂›Û˘, Ô Ú˘ıÌfi˜ ÙˆÓ Î·ÎÒÛÂˆÓ ·˘Í·ÓfiÙ·Ó ·Ú¿ÏÏËÏ· Ì ÙËÓ ËÏÈΛ·, ÒÛÙ ÙÔ 35% ·˘ÙÒÓ Ó· ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ËÏÈ˘ ÙˆÓ 17 Î·È 18 ÂÙÒÓ (∂ÈÎfiÓ· 1). ™ÙÔ˘˜ Ó¤Ô˘˜ ¿Óˆ ÙˆÓ 16 ÂÙÒÓ, Ë ·‡ÍËÛË ·ÊÔÚÔ‡Û ÛÙ· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù·, ÂÓÒ ÛÙȘ ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘ ·ÊÔÚÔ‡Û ÛÙ· ·Ù˘¯‹Ì·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÛÔÚ (¿ıÏËÛË, ·È¯Ó›‰È). ™Ù·‰È·Î‹ ·‡ÍËÛË ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙ· ·Ù˘¯‹Ì·Ù· ηٿ ÙËÓ ÂÚÁ·Û›·, ·ÏÏ¿ Î·È ÛÙȘ ‰ËÏËÙËÚÈ¿ÛÂȘ Ì ·ÏÎÔfiÏ.

O ÙÚfiÔ˜ ˙ˆ‹˜ Ê·›ÓÂÙ·È fiÙÈ Úԉȷı¤ÙÂÈ Û ‰È·ÊÔÚÂÙÈο ›‰Ë ·Ù˘¯ËÌ¿ÙˆÓ, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙË Û˘Û¯¤ÙÈÛË Ù˘ ·ÈÙ›·˜ Ù˘ οΈÛ˘ Î·È Ù˘ ÏËı˘ÛÌȷ΋˜ ÔÌ¿‰·˜ ÛÙËÓ ÔÔ›· ·Ó‹ÎÂ Ô ¤ÊË‚Ô˜ (∂ÈÎfiÓ· 2). ™ÙËÓ ÔÌ¿‰· ÙˆÓ ÃÚÈÛÙÈ·ÓÒÓ, Û˘ÓËı¤ÛÙÂÚ˜ ‹Ù·Ó ÔÈ Î·ÎÒÛÂȘ Ô˘ Û˘Ó¤‚·ÈÓ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ·È¯ÓȉÈÔ‡ Î·È Ù˘ ¿ıÏËÛ˘ (46,2%), ηıÒ˜ Î·È Ù· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· (37,6%). ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ∞ı›ÁÁ·ÓˆÓ (23,1%) Î·È ªÔ˘ÛÔ˘ÏÌ¿ÓˆÓ (20,8%) ˘¤ÛÙË Î¿ÎˆÛË Û ÂÚÁ·ÙÈÎfi ·Ù‡¯ËÌ·, ÂÓÒ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÏÈÓÓÔÛÙÔ‡ÓÙˆÓ ·Ú·ÙËÚ‹ıËΠÙÔ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ (42%) ÌÂٷ͇ fiÏˆÓ ÙˆÓ ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ. ∏ ÎÏÈÓÈ΋ ʇÛË ÙˆÓ Î·ÎÒÛÂˆÓ Ê·›ÓÂÙ·È Ó· Û˘Ó‰¤ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·ÈÙ›· ÚfiÎÏËÛ˘ Ù˘ οΈÛ˘ (∂ÈÎfiÓ· 3). ™ÙË ÌÂϤÙË Ì·˜, ÔÈ Î·ÎÒÛÂȘ ÙˆÓ ¿ÎÚˆÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚ˜ ÛÙ· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· (30,4%), ÂÓÒ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÓÙÈÚÔÛÒ¢·Ó Î·È Ù· ÂÁη‡Ì·Ù· ÙˆÓ ¿ÎÚˆÓ (11,6%). ™’ ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›· ·Ù˘¯ËÌ¿ÙˆÓ ÛËÌÂÈÒıËÎ·Ó ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ (∫∂∫) (6,8%).

OÈ Î·ÎÒÛÂȘ ÙˆÓ ¿ÎÚˆÓ ÂÈÎÚ·ÙÔ‡Û·Ó Î·È ÛÙÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ ÙËÓ ¿ıÏËÛË (48,1%), ·ÏÏ¿ Î·È ÛÙ· ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· (56,4%). ™ÙËÓ Î·ÙË-

200 0 ∆ÚÔ¯·›·

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∂ÚÁ·Û›· ∞˘ÙÔÎÙÔӛ˜ ∞ÏÎÔfiÏ

∂ÈÎfiÓ· 1. ∞ÂÈÎfiÓÈÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Î·ÎÒÛÂˆÓ Î·Ù¿ ËÏÈÎȷ΋ ÔÌ¿‰·.

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∆ÚÔ¯·›· ™fiÚ ∂ÚÁ·Û›· ∞˘ÙÔÎÙÔӛ˜ ∞ÏÎÔfiÏ

300 200 100 0 ÃÚÈÛÙÈ·ÓÔ› ªÔ˘ÛÔ˘ÏÌ¿ÓÔÈ ∞ı›ÁÁ·ÓÔÈ ¶·ÏÈÓÔÛÙÔ‡ÓÙ˜ ∂ÈÎfiÓ· 2. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÈÙ›·˜ Ù˘ οΈÛ˘ ηٿ ÏËı˘ÛÌȷ΋ ÔÌ¿‰·.

ÁÔÚ›·, fï˜, ÙˆÓ ÂÚÁ·ÙÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ, Û˘¯ÓfiÙÂÚ· ‹Ù·Ó Ù· ηٿÁÌ·Ù· (11,2%).

OÈ ·fiÂÈÚ˜ ·˘ÙÔÎÙÔÓ›·˜ ·Ó‹Ïı·Ó ÛÙÔ 2,9% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î·ÎÒÛˆÓ. ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·˘ÙÒÓ ÔÊÂÈÏfiÙ·Ó Û ϋ„Ë Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ ‹ Ê˘ÙÔÊ·Ú̿ΈÓ. ™ÙȘ ‰ËÏËÙËÚÈ¿ÛÂȘ, Û˘¯ÓfiÙÂÚÔ Â›‰Ô˜ ‹Ù·Ó Ë Ï‹„Ë ·ÏÎÔfiÏ Î·È ·Ú·ÙËÚ‹ıËΠ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÃÚÈÛÙÈ·ÓÒÓ. ŒÓ· ÌÈÎÚfi ÔÛÔÛÙfi ·Ù˘¯ËÌ¿ÙˆÓ (2,1%) ÔÊÂÈÏfiÙ·Ó ÛÙË ¯Ú‹ÛË ‚›·˜ ÌÂٷ͇ ÙˆÓ ÂÊ‹‚ˆÓ, ȉȷ›ÙÂÚ· ÛÙȘ ËÏÈ˘ 15-18 ÂÙÒÓ. °È· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ‚·Ú‡ÙËÙ·˜ ÙˆÓ Î·ÎÒÛˆÓ, ıˆڋıËΠ·Ó·Áη›Ô ÁÈ· ÂÚÈÁÚ·ÊÈÎÔ‡˜

495

¶·È‰È·ÙÚÈ΋ 2001;64:493-498

Paediatriki 2001;64:493-498

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∫·Ì›· ªÈÎÚÔÂÂÌ‚¿ÛÂȘ ∂ÈÛ·ÁˆÁ‹ £¿Ó·ÙÔ˜

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™ÔÚ 0 ∂ Í¿ ∆Ú ∫ Úı ¿Ù ·‡ Œ ∫∂ Á ·Á ËÌ Ì· ∫ Ì· η˘ · Ì·

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20% ¶Ô Ï˘ ÙÚ ·˘ Ì.

∂ÈÎfiÓ· 3. ∞ÂÈÎfiÓÈÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÎÏÈÓÈ΋˜ ʇÛ˘ ÙˆÓ Î·ÎÒÛÂˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÈÙ›· Ô˘ ÙȘ ÚÔηÏÔ‡Ó.

ÛÎÔÔ‡˜ Ó· ÔÌ·‰ÔÔÈËıÔ‡Ó ÔÈ Î·ÎÒÛÂȘ Û 4 Â›‰·, ·Ó¿ÏÔÁ· Ì ÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∏ ηٿٷÍË ÙˆÓ Î·ÎÒÛÂˆÓ Ì ‚¿ÛË ÙÔ ÌÔÓÙ¤ÏÔ ·˘Ùfi ¤‰ÂÈÍ fiÙÈ ·fi ÙÔ˘˜ 3334 ·ÛıÂÓ›˜, ÔÈ 1663 (ÔÛÔÛÙfi 51%) ‰ÂÓ ¤¯ÚË˙·Ó ȉȷ›ÙÂÚ˘ ·ÓÙÈÌÂÙÒÈÛ˘, ÔÈ 1123 ˘‚ϋıËÛ·Ó Û ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, ÔÈ 461 ÂÈÛ‹¯ıËÛ·Ó Î·È ÔÈ 12 η٤ÏËÍ·Ó. ™˘Û¯ÂÙ›˙ÔÓÙ·˜ ÙË ‚·Ú‡ÙËÙ· Ù˘ οΈÛ˘ Ì ÙËÓ ·ÈÙ›· ÚfiÎÏËÛ˘ (∂ÈÎfiÓ· 4) ÚÔ·ÙÂÈ fiÙÈ ÛÙ· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ÂÈÛ‹¯ıË ÙÔ 20% (239 ·ÛıÂÓ›˜), ÂÓÒ ÔÈ ÓÂÎÚÔ› ·Ó‹Ïı·Ó ÛÙÔ˘˜ ÂÓÓ¤·, ÛÙÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ ÙËÓ ¿ıÏËÛË ÔÈ ÂÈÛ·ÁˆÁ¤˜ ÌfiÏȘ ÏËÛ›·Û·Ó ÙÔ 5,1% (70 ·ÛıÂÓ›˜) Î·È ÛÙ· ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· ÔÈ ÂÈÛ·ÁˆÁ¤˜ ‹Ù·Ó 34 (9,1%) Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ‰‡Ô ı¿Ó·ÙÔÈ. ¢‡Ô ·ÎfiÌË ı¿Ó·ÙÔÈ ÔÊ›ÏÔÓÙ·Ó Û ·˘ÙÔÎÙÔÓ›·. ™˘˙‹ÙËÛË ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜, Ù· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ú¿ÙÔÏÌË Î·È ÚÈ„ÔΛӉ˘ÓË Û˘ÌÂÚÈÊÔÚ¿, Ë ÔÔ›· ·Ô‰›‰ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ Ù¿ÛË ÁÈ· ·ÓÂÍ·ÚÙËÛ›· Î·È ÛÙËÓ ·Ó¿ÁÎË ÁÈ· ·fiÎÙËÛË Ó¤ˆÓ ÂÌÂÈÚÈÒÓ, Ô‰ËÁ› fï˜ Û˘¯Ó¿ Û ·Ù˘¯‹Ì·Ù· (11). OÈ ¤ÊË‚ÔÈ Â›Ó·È Ë ÌfiÓË ËÏÈÎȷ΋ ÔÌ¿‰· Ô˘ ·Ó Î·È Â›Ó·È ··ÏÏ·Á̤ÓË ·fi ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, ·ÚÔ˘ÛÈ¿˙ÂÈ ·˘ÍË̤ÓÔ˘˜ Ú˘ıÌÔ‡˜ ı·Ó¿ÙÔ˘, ÔÈ ÔÔ›ÔÈ Û·Ó Î‡ÚÈ· ·ÈÙ›· ¤¯Ô˘Ó ÙȘ ηÎÒÛÂȘ (6,12). ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi, Ô˘ Ù›ÓÂÈ Ó· ¿ÚÂÈ ÙË ÌÔÚÊ‹ ÂȉËÌ›·˜, ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘ ÛÙȘ ÚÔËÁ̤Ó˜ ¯ÒÚ˜, fiÔ˘ ÔÈ ÚÔÙ·ı›Û˜ ÛÙÚ·ÙËÁÈΤ˜ ÚfiÏ˄˘ ¤¯Ô˘Ó ‹‰Ë ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·

496

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∂ÚÁ·Û›· ∞˘ÙÔÎÙÔӛ˜ ∞ÏÎÔfiÏ

∂ÈÎfiÓ· 4. ∏ ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÍÈÔÏÔÁ‹ıËΠ̠‚¿ÛË ÙÔÓ ÙÚfiÔ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘. ™ÙËÓ ÂÈÎfiÓ· Ê·›ÓÂÙ·È Ë ‚·Ú‡ÙËÙ· Û ۯ¤ÛË Ì ÙËÓ ·ÈÙ›· ÚfiÎÏËÛ˘ Ù˘ οΈÛ˘.

(9,13). ∞ÓÙ›ıÂÙ·, ÛÙË ¯ÒÚ· Ì·˜, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ÂÎÙÈÌËı› ÛˆÛÙ¿, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ô‰ËÁÔ‡ÓÙ·È ÔÈ ˘ÁÈ›˜ ¤ÊË‚ÔÈ Û˘¯Ó¿ Û ·Ó·Ëڛ˜ ‹ ·ÎfiÌË Î·È ÛÙÔ ı¿Ó·ÙÔ (14). OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó Î·ÎÒÛÂȘ ÂÈÎÂÓÙÚÒÓÔ˘Ó ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ ÛÙȘ ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘, ·Ú·‚ϤÔÓÙ·˜ ¤ÙÛÈ ÙÔ ÛËÌ·ÓÙÈÎfi ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi Úfi‚ÏËÌ· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›· (9,14). ∞fi ÙË ÌÂϤÙË Ì·˜ ÚÔ·ÙÂÈ fiÙÈ ÙÔ 50% ÙˆÓ Î·ÎÒÛÂˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 19 ÂÙÒÓ, ·ÊÔÚ¿ ÂÊ‹‚Ô˘˜. ™ÙÔ Û˘Ì¤Ú·ÛÌ· ·˘Ùfi Ô‰ËÁÔ‡ÓÙ·È Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (9,13,14). ª›· ¿ÏÏË ÎÔÈÓ‹ ‰È·›ÛÙˆÛË Â›Ó·È fiÙÈ Ô Ú˘ıÌfi˜ ηÎÒÛÂˆÓ ÛÙÔ˘˜ ¿ÚÚÂÓ˜ ÂÊ‹‚Ô˘˜ Â›Ó·È ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜, Û˘ÁÎÚÈÓfiÌÂÓÔ˜ Ì ·˘ÙfiÓ ÙˆÓ ıËϤˆÓ (15,16), ÁÂÁÔÓfi˜ Ô˘ Ê·›ÓÂÙ·È Î·È ÛÙË ‰È΋ Ì·˜ ¤Ú¢ӷ, fiÔ˘ Ë ·Ó·ÏÔÁ›· ·ÚÚ¤ÓˆÓ ÚÔ˜ ı‹ÏÂȘ Â›Ó·È 2 ÚÔ˜ 1. ª›· ÂÚÌËÓ›· Ô˘ ÚÔÙ›ÓÂÙ·È ÁÈ· ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi Â›Ó·È fiÙÈ Ù· ·ÁfiÚÈ· ˘ÈÔıÂÙÔ‡Ó ÈÔ ÂÈıÂÙÈÎÔ‡˜ Î·È ÚÈ„ÔΛӉ˘ÓÔ˘˜ ÙÚfiÔ˘˜ Û˘ÌÂÚÈÊÔÚ¿˜ ηٿ ÙË ‰È·‰Èηۛ· Ù˘ ˆÚ›Ì·ÓÛ˘, ÚÔÛ·ıÒÓÙ·˜ Ó· ·ÓÙ·ÔÎÚÈıÔ‡Ó Î·Ï‡ÙÂÚ· ÛÙÔÓ ·Ú¯ËÁÈÎfi ÚfiÏÔ Ô˘ ÙÔ˘˜ ÂÈ‚¿ÏÏÂÈ Ë ÎÔÈÓˆÓ›·. ∂›Û˘, Û‡Ìʈӷ Ì ÙËÓ ¤ÚÂ˘Ó¿ Ì·˜ ·ÏÏ¿ Î·È Ì ٷ Û˘ÌÂÚ¿ÛÌ·Ù· ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ, ÔÈ Î·ÎÒÛÂȘ Û˘Ì‚·›ÓÔ˘Ó Û˘Ó‹ıˆ˜ Û ÂÊ‹‚Ô˘˜ Ô˘ ˙Ô˘Ó ÛÙËÓ fiÏË. ∏ ‰È·›ÛÙˆÛË ·˘Ù‹ ÂÎÊÚ¿˙ÂÈ ÙËÓ

¶·È‰È·ÙÚÈ΋ 2001;64:493-498

Ú·ÁÌ·ÙÈÎfiÙËÙ·, ·ÊÔ‡ ÔÈ Ó¤ÔÈ Â›Ó·È ·Ó·ÁηṲ̂ÓÔÈ Ó· ÎÈÓÔ‡ÓÙ·È Î·È Ó· ‰Ú·ÛÙËÚÈÔÔÈÔ‡ÓÙ·È Ì¤Û· Û ¤Ó· ÔÏ˘Û‡¯Ó·ÛÙÔ Î·È ÂÈΛӉ˘ÓÔ ÂÚÈ‚¿ÏÏÔÓ, ÂÎı¤ÙÔÓÙ·˜ ¤ÙÛÈ ÙÔÓ Â·˘Ùfi ÙÔ˘˜ Û˘Ó¯Ҙ Û ΛӉ˘ÓÔ. ŒÓ· ÛËÌ·ÓÙÈÎfi ÎÂÊ¿Ï·ÈÔ ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ Î·ÎÒÛÂˆÓ ·ÔÙÂÏ› Ô Î·ıÔÚÈÛÌfi˜ ÙÔ˘ ·ÈÙ›Ô˘ Ô˘ ÙȘ ÚÔηÏ›. OÈ Î·ÎÒÛÂȘ Û˘Ì‚·›ÓÔ˘Ó fiÙ·Ó Ù· ÛÙÔȯ›· ÍÂÓÈÛÙ‹˜, ·Ú¿ÁÔÓÙ·˜ Î·È ÂÚÈ‚¿ÏÏÔÓ Û˘Ì›ÙÔ˘Ó Û ̛· Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹. °È· ¤Ó· ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ·ÚÈıÌfi ηÎÒÛˆÓ, Ù· ÛÙÔȯ›· ·˘Ù¿ ÌÔÚÔ‡Ó Ó· ÚÔ‚ÏÂÊıÔ‡Ó Î·È Ó· ·ÔÙÚ·Ô‡Ó. ŒÙÛÈ, Ë ÌÂϤÙË Ù˘ ·ÈÙ›·˜ Ù˘ οΈÛ˘ Â›Ó·È ÎÚÈÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Î·ÎÒÛˆÓ. ∞ӷχÔÓÙ·˜ Ù· ‰Â‰Ô̤ӷ ÁÈ· ÙȘ ·Èٛ˜ οΈÛ˘ ÛÙËÓ ÂÚÈÔ¯‹ Ì·˜, ·Ú·ÙËÚԇ̠fiÙÈ ÙËÓ ÚÒÙË ı¤ÛË Î·Ù¤¯Ô˘Ó Ù· ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙËÓ ¿ıÏËÛË Î·È ÙÔ ·È¯Ó›‰È (ÛÔÚ). ™ÙÔ ·ÔÙ¤ÏÂÛÌ· ·˘Ùfi Ô‰ËÁÔ‡ÓÙ·È Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜, ÔÈ ÔÔ›ÔÈ Î·Ù·Ù¿ÛÛÔ˘Ó Ù· ÛÔÚ Û·Ó ÙËÓ ÚÒÙË ‹ ÙË ‰Â‡ÙÂÚË ·ÈÙ›· ÚfiÎÏËÛ˘ ηÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›· (9,15,17). Ÿˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ ¤ÚÂ˘Ó¿ Ì·˜, ÛÙËÓ ËÏÈΛ· ÙˆÓ 13-16 ÂÙÒÓ, Ù· ·Ù˘¯‹Ì·Ù· ÛÙ· ÛÔÚ ·ÔÙÂÏÔ‡Ó ÛÙ·ıÂÚ¿ ÙË ‚·ÛÈÎfiÙÂÚË ·ÈÙ›· οΈÛ˘, ÂÓÒ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ·˘Ù‹ ÔÈ Ú˘ıÌÔ› ÌÂÈÒÓÔÓÙ·È. ™˘Ó‹ıˆ˜ ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Â›Ó·È Ì¤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜, ·ÊÔÚÔ‡Ó Ù· ¿ÎÚ· Î·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚfi ÙÔ˘˜ ÔÛÔÛÙfi ‰ÂÓ ¯Ú‹˙Ô˘Ó ÂȉÈ΋˜ ÓÔÛËÏ›·˜ (17). øÛÙfiÛÔ, Â›Ó·È ÛËÌ·ÓÙÈΤ˜ ÔÈ ÎÔÈÓˆÓÈΤ˜ Î·È ÔÈÎÔÓÔÌÈΤ˜ ÂÈÙÒÛÂȘ ·fi Ù· ·Ù˘¯‹Ì·Ù· ·˘Ù¿, ·ÊÔ‡ ÌÂÙ·ÊÚ¿˙ÔÓÙ·È Û ·ÒÏÂÈ· Û¯ÔÏÈÎÔ‡ ¯ÚfiÓÔ˘, ·Ô¯‹ ·fi ÙËÓ ÂÚÁ·Û›· ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÎfiÛÙÔ˜ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∆· ÙÚÔ¯·›· Û˘Ì‚¿ÓÙ· ·ÔÙÂÏÔ‡Ó ÙË ‰Â‡ÙÂÚË ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ηÎÒÛÂˆÓ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ù˘ ÂÚÈÔ¯‹˜ Ì·˜. ¶·Ú·ÙËÚԇ̛̠· ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ Î·ÎÒÛÂˆÓ ·˘ÙÒÓ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 16 ÂÙÒÓ Î·È ¿Óˆ, Ë ÔÔ›· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ Î·È ÛÙËÓ Â˘Ú›· ¯Ú‹ÛË Ì˯·ÓÔΛÓËÙˆÓ ‰È·ÎψÓ, fiˆ˜ ˘ÔÛÙËÚ›˙Ô˘Ó Î·È ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (18). OÈ Ì˯·Ó¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ˘˜ Ó¤Ô˘˜ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜, ÏÂÈÙÔ˘ÚÁÒÓÙ·˜ ·ÊÂÓfi˜ ˆ˜ ̤ÛÔ ÚÔ‚ÔÏ‹˜ Î·È ·Ó·ÁÓÒÚÈÛ˘ Î·È ·ÊÂÙ¤ÚÔ˘ ˆ˜ ‡¯ÚËÛÙÔ Ì¤ÛÔ ÌÂÙ·ÊÔÚ¿˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ô˘Û›· ΢ÎÏÔÊÔÚȷ΋˜ ·ÁˆÁ‹˜ Î·È ÙËÓ Î·Î‹ ηٿÛÙ·ÛË ÙÔ˘ Ô‰ÈÎÔ‡ ‰ÈÎÙ‡Ô˘, Û˘Ì‚¿ÏÏÂÈ ÛÙË Ú·Á‰·›· ·‡ÍËÛË ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘¯Ó¿ ·Ô‚·›ÓÔ˘Ó ÌÔÈÚ·›·, fiˆ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› Î·È Û ¿ÏϘ ¯ÒÚ˜ (4,5,8). ∏ ηÙËÁÔÚ›· ·˘Ù‹ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô‰ËÁ› Û ÈÔ ÛÔ‚·Ú¤˜ ηÎÒÛÂȘ (19,20). ÷ڷÎÙËÚÈÛÙÈο ·Ó·Ê¤ÚÔ˘Ì fiÙÈ ÙÔ 6,8% ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô‰ËÁ› Û ‚·ÚȤ˜ ∫∂∫,

Paediatriki 2001;64:493-498

ÂÓÒ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ·fi ·Ù˘¯‹Ì·Ù· (8,13). ª›· ÔÌ¿‰· ·Ù˘¯ËÌ¿ÙˆÓ, ÛÙËÓ ÔÔ›· ‰ÂÓ ¤¯ÂÈ ‰Ôı› Ë ‰¤Ô˘Û· ÚÔÛÔ¯‹, Â›Ó·È ·˘Ù¿ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙËÓ ÂÚÁ·Û›·. OÈ ¤ÊË‚ÔÈ, Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ Û·Ó ÊıËÓfi ÂÚÁ·ÙÈÎfi ‰˘Ó·ÌÈÎfi, ‰È·ı¤ÙÔ˘Ó ÙË ÛˆÌ·ÙÈ΋ ‰È¿Ï·ÛË ÙˆÓ ÂÓËϛΈÓ, ¯ˆÚ›˜ fï˜ Ó· ¤¯Ô˘Ó ÙËÓ ·Ó¿ÏÔÁË ÂÌÂÈÚ›· Î·È ˆÚÈÌfiÙËÙ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Â›Ó·È ÂÈÚÚÂ›˜ Û ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔÓ ÂÚÁ·ÛÈ·Îfi ¯ÒÚÔ. ™ÙËÓ ÂÚÈÔ¯‹ Ì·˜, Ù· ÂÚÁ·ÙÈο ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÙËÓ ÙÚ›ÙË Î·Ù¿ ÛÂÈÚ¿ ·ÈÙ›· ηÎÒÛÂˆÓ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Â›Ó·È ÈÔ Û˘¯Ó¿ ÌÂٷ͇ ÙˆÓ ¯·ÌËÏfiÙÂÚˆÓ ÔÈÎÔÓÔÌÈο Ù¿ÍÂˆÓ (∞ı›ÁÁ·ÓÔÈ 23,1%, ªÔ˘ÛÔ˘ÏÌ¿ÓÔÈ 20,8%), fiÔ˘ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÚÁ·˙fiÌÂÓˆÓ ÂÊ‹‚ˆÓ Â›Ó·È ˘„ËÏfiÙÂÚÔ. ™Â ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›·, Â›Û˘, Û˘ÓËı¤ÛÙÂÚÔÈ Â›Ó·È ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› ÙˆÓ ¿ÎÚˆÓ Î·È È‰È·›ÙÂÚ· Ù· ηٿÁÌ·Ù· (21). ∏ ¤Ú¢ӷ ÁÈ· ÙȘ ηÎÒÛÂȘ ÛÙËÓ ÂÊ˂›· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙȘ ‰ËÏËÙËÚÈ¿ÛÂȘ ·fi Ï‹„Ë ‰È·ÊfiÚˆÓ Ô˘ÛÈÒÓ. ∞Ó Î·È Û ÔÏϤ˜ ÌÂϤÙ˜ ÙÔÓ›˙ÂÙ·È Ë ·˘Í·ÓfiÌÂÓË ¯Ú‹ÛË Ó·ÚΈÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÂٷ͇ ÙˆÓ ÂÊ‹‚ˆÓ, ·fi ÙË ‰È΋ Ì·˜ ¤Ú¢ӷ ‰ÂÓ ÚԤ΢„·Ó Ù¤ÙÔÈ· ÛÙÔȯ›·. ™˘ÓËı¤ÛÙÂÚË Â›Ó·È Ë Î·Ù·Ó¿ÏˆÛË ·ÏÎÔfiÏ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ 4,3% ÙˆÓ ÂÊ‹‚ˆÓ Ô˘ ÚÔÛ¤Ú¯ÔÓÙ·È ÛÙȘ ∞’ µÔ‹ıÂȘ Î·È Â˘Ú›ÛÎÔÓÙ·È Û ηٿÛÙ·ÛË Ì¤ı˘. OÈ ¤ÊË‚ÔÈ ·˘ÙÔ› ·Ó‹ÎÔ˘Ó ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÃÚÈÛÙÈ·ÓÒÓ. ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ·Ú·ÙËÚÂ›Ù·È Û ÔÏϤ˜ ÚÔËÁ̤Ó˜ ÎÔÈӈӛ˜ Î·È Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÈı˘Ì›· ÙˆÓ ÂÊ‹‚ˆÓ Ó· ·Ô‰Ú¿ÛÔ˘Ó ·fi ‰˘Û¿ÚÂÛÙ˜ ηٷÛÙ¿ÛÂȘ ‹ Ó· Á›ÓÔ˘Ó ·Ô‰ÂÎÙÔ› ·fi ÙÔ˘˜ Ê›ÏÔ˘˜ ÙÔ˘˜ (22). ™ÙȘ ηÎÒÛÂȘ ·Ó‹ÎÔ˘Ó Î·È ÔÈ ·fiÂÈÚ˜ ·˘ÙÔÎÙÔÓ›·˜ Ô˘ ·ÔÙÂÏÔ‡Ó, Û‡Ìʈӷ Ì ¿ÏϘ ÌÂϤÙ˜, ÙËÓ ÙÚ›ÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙȘ ËÏÈ˘ 15-19 ¯ÚfiÓˆÓ (22). ™ÙËÓ ¤ÚÂ˘Ó¿ Ì·˜ ηٷÁÚ¿„·Ì 95 ÂÊ‹‚Ô˘˜ (57 ÎÔÚ›ÙÛÈ· Î·È 38 ·ÁfiÚÈ·) Ô˘ ÚÔÛ¿ıËÛ·Ó Ó· ı¤ÛÔ˘Ó Ù¤ÏÔ˜ ÛÙË ˙ˆ‹ ÙÔ˘˜. ™˘ÓËı¤ÛÙÂÚË Ì¤ıÔ‰Ô˜ ‹Ù·Ó Ë Ï‹„Ë Ê·Ú̿ΈÓ. ∞fi ·˘ÙÔ‡˜ η٤ÏËÍ·Ó ‰‡Ô ·ÁfiÚÈ· Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÈÔ ‚›·È˜ ÌÂıfi‰Ô˘˜ (··Á¯ÔÓÈÛÌfi˜, ˘ÚÔ‚ÔÏÈÛÌfi˜). Ÿˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ ¤ÚÂ˘Ó¿ Ì·˜, Ù· ÎÔÚ›ÙÛÈ· ÚÔËÁÔ‡ÓÙ·È ·ÚÈıÌËÙÈο ÛÙȘ ·fiÂÈÚ˜, ·ÏÏ¿ Ù· ·ÁfiÚÈ· Â›Ó·È ÂΛӷ Ô˘ ÂÈÙ˘Á¯¿ÓÔ˘Ó (22). ¢˘ÛÙ˘¯Ò˜ ÛÙËÓ ÂÊ˂›· Â›Ó·È ‰˘Ó·ÙfiÓ Ë Û˘Ó·ÈÛıËÌ·ÙÈ΋ ·ÛÙ¿ıÂÈ· Î·È Ë „˘¯È΋ ÊfiÚÙÈÛË Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ηٿÛÙ·ÛË ·˘ÙÔÎÙÔÓÈÎÔ‡ ȉ·ÛÌÔ‡ (23). ™ÙËÓ ∂ÏÏ¿‰·, Ù· ÔÛÔÛÙ¿ ·˘ÙÔÎÙÔÓÈÒÓ Â›Ó·È È‰È·›ÙÂÚ· ¯·ÌËÏ¿, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ·˘Ù¿ ¿ÏÏˆÓ ¯ˆÚÒÓ Î·È ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÂÊ‹‚Ô˘˜ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (23). ™ÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÔÈ ·fiÂÈÚ˜

497

¶·È‰È·ÙÚÈ΋ 2001;64:493-498

·˘ÙÔÎÙÔÓ›·˜ ‹Ù·Ó Û˘¯ÓfiÙÂÚ˜ ÌÂٷ͇ ÙˆÓ ıËϤˆÓ ªÔ˘ÛÔ˘ÏÌ¿ÓˆÓ (24 ÎÔÚ›ÙÛÈ·) Èı·ÓfiÓ ÏfiÁˆ ÙÔ˘ ηٷÈÂÛÙÈÎÔ‡ Î·È ÂÚÈÔÚÈÛÙÈÎÔ‡ ÙÚfiÔ˘ ˙ˆ‹˜ Ô˘ ÂÈ‚¿ÏÏÂÈ ·˘Ù‹ Ë ÌÂÈÔÓfiÙËÙ· ÛÙȘ Á˘Ó·›Î˜. ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÌÂϤÙË ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· Û˘ÓÈÛÙ¿ ¤Ó· ¢ڇ ‰›Ô ¤Ú¢ӷ˜ Û ‰ÈÂıÓ¤˜ Â›‰Ô. ¢˘ÛÙ˘¯Ò˜, ·Ó Î·È ÙÔ Úfi‚ÏËÌ· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ¯ÒÚ· Ì·˜ ¤¯ÂÈ ‹‰Ë Ï¿‚ÂÈ ·ÓËÛ˘¯ËÙÈΤ˜ ‰È·ÛÙ¿ÛÂȘ, ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌ· ηٷÚÙÈÛÙ› ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Ô˘ ı· ÚÔÙ›ÓÔ˘Ó Ì›· ÛÊ·ÈÚÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ı· ‰ÒÛÔ˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÛÙËÓ ÔÏÈÙ›· Ó· ۯ‰ȿÛÂÈ ¤Ó· ÔÏÔÎÏËڈ̤ÓÔ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÚfiÁÚ·ÌÌ· ÚfiÏ˄˘. ∏ ÂÌÂÈÚ›· ¿ÏÏˆÓ ¯ˆÚÒÓ Ì¿˜ ‰È‰¿ÛÎÂÈ fiÙÈ ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ÛËÌ·ÓÙÈο Ú·ÎÙÈο ‚‹Ì·Ù· ̤۷ ·fi ÂÎ·È‰Â˘ÙÈΤ˜, ‰ÈÔÈÎËÙÈΤ˜ Î·È ÓÔÌÔıÂÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ. ∏ ÂÎ·È‰Â˘ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ê·›ÓÂÙ·È Ó· ·Ô‰›‰ÂÈ ÂÚÈÛÛfiÙÂÚÔ fiÙ·Ó ·¢ı‡ÓÂÙ·È Û ·È‰È¿ ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜, fiÔ˘ ÔÈ Î·Ù¿ÏÏËÏÔÈ ·È‰·ÁˆÁÈÎÔ› ¯ÂÈÚÈÛÌÔ› ÌÔÚÔ‡Ó Ó· ÂȉڿÛÔ˘Ó ıÂÙÈο ‰È·ÌÔÚÊÒÓÔÓÙ·˜ Û˘ÁÎÚÔÙË̤ÓÔ˘˜ ÙÚfiÔ˘˜ Û˘ÌÂÚÈÊÔÚ¿˜. °È· ÙÔ˘˜ ÂÊ‹‚Ô˘˜, Ë ÚfiÏË„Ë ÂÚÈÔÚ›˙ÂÙ·È ÛÙË ‰È·ÌfiÚʈÛË ·ÛÊ·ÏÔ‡˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈËıÔ‡Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ¶¤Ú· ·fi ·˘Ù¤˜ ÙȘ ÛÙÚ·ÙËÁÈΤ˜ ÚfiÏ˄˘, ÁÈ· ÙÔ Û¯Â‰È·ÛÌfi ÙˆÓ ÔÔ›ˆÓ ÙË ‚·ÛÈ΋ ¢ı‡ÓË ¤¯ÂÈ Ë ÔÏÈÙ›·, Ë ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÎÔÈÓˆÓ›· ı· Ú¤ÂÈ Ó· ‰È·‰Ú·Ì·Ù›ÛÔ˘Ó Ô˘ÛÈ·ÛÙÈÎfi ÚfiÏÔ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÂÚÂÈÛÌ¿ÙˆÓ, ÒÛÙÂ Ô Â˘¿ÏˆÙÔ˜ ¤ÊË‚Ô˜ Ó· ‚Ú›ÛÎÂÈ ÂÔÈÎÔ‰ÔÌËÙÈΤ˜ ‰ÈÂÍfi‰Ô˘˜ ÛÙ· ‰ÈÏ‹ÌÌ·Ù¿ ÙÔ˘, ÌÂÈÒÓÔÓÙ·˜ ¤ÙÛÈ ÙËÓ Èı·ÓfiÙËÙ· Ó· ¯¿ÛÂÈ ÙËÓ ·˘ÙÔÂÎÙ›ÌËÛ‹ ÙÔ˘ Î·È Ó· Ô‰ËÁËı› ÛÙË ¯Ú‹ÛË ÂıÈÛÙÈÎÒÓ Ô˘ÛÈÒÓ, ÛÙËÓ ˘ÈÔı¤ÙËÛË ‚›·È˘ Û˘ÌÂÚÈÊÔÚ¿˜ ‹ Û ٿÛÂȘ ·˘ÙÔÎÙÔÓ›·˜. ¶ÈÛÙ‡ԢÌ fiÙÈ fiÛÔ ·˘Í¿ÓÔ˘Ó ÔÈ ÁÓÒÛÂȘ Ì·˜ Á‡Úˆ ·fi ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ Î·ÎÒÛÂˆÓ ÛÙËÓ ÂÊ˂›·, ı· Ì·˜ ‰›ÓÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÂÊ·ÚÌfi˙Ô˘Ì ·ÔÙÂÏÂÛÌ·ÙÈο ÌÔÓ٤Ϸ ÚfiÏ˄˘, ÛÙԯ‡ÔÓÙ·˜ ÛÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ.

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498

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CASE REPORT

™‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ Û ·È‰È¿ Ì ¤Áη˘Ì·. ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛÂˆÓ ª. ¡·ÚÏ›ÔÁÏÔ˘, ¶. ∫·Ï·Ì·Ï›Î˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜

∆oxic shock syndrome in children with burns. Report of 2 cases M. Narlioglou, P. Kalabalikis, G. Briassoulis, A. Hatzis

¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ ·ÔÙÂÏ› ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ÓfiÛÔ Î·È ÔÊ›ÏÂÙ·È ÛÙË ‰Ú¿ÛË Â͈ÙÔÍÈÓÒÓ Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙÔ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ‹ ÙÔÓ ˘ÔÁfiÓÔ ÛÙÚÂÙfiÎÔÎÎÔ. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ¤Ó· ¢ڇ Ê¿ÛÌ· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Â›Ó·È o ˘ÚÂÙfi˜, ÙÔ ÂÍ¿ÓıËÌ· Î·È Ë Î·Ù·ÏËÍ›·. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È 2 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ ËÏÈΛ·˜ 9 Î·È 18 ÌËÓÒÓ Ì ÂÁη‡Ì·Ù· 2% Î·È 35% Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ·ÓÙ›ÛÙÔȯ·, Ô˘ ·ÚÔ˘Û›·Û·Ó Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜. ∞fi ÙȘ ÂÁη˘Ì·ÙÈΤ˜ ÂÈÊ¿ÓÂȘ ÙˆÓ 2 ·È‰ÈÒÓ ·ÔÌÔÓÒıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜, Ô˘ ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ ÂΉËÏÒÛÂˆÓ ·ÚÔ˘Û›·Û·Ó Î·È Û‡Ó‰ÚÔÌÔ ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (ARDS), Ô ¤Ó·˜ η٤ÏËÍÂ.

Abstract: ∆oxic shock syndrome (TSS) is a multisystem illness that is caused by exotoxins produced by Staphylococcus aureus or Streptococcus pyogenes. It is characterized by a broad spectrum of clinical manifestations that include fever, rash and shock. We describe two children, aged 9 and 18 months, with burns of 2 and 35 per cent of total body surface area respectively, who developed TSS. Staphylococcus aureus was isolated from burn swabs from both children. Of our patients who, in addition to the TSS manifestations, developed adult respiratory distress syndrome, one succumbed to the illness.

§¤ÍÂȘ ÎÏÂȉȿ: Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜, ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ηٷÏËÍ›·, ¤Áη˘Ì·.

∫ey words: toxic shock Staphylococcus, shock, burn.

∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ (™∆∫) ·Ú·ÙËÚ‹ıËÎÂ Î·È ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1978 ·fi ÙÔÓ Todd, Û 7 ·È‰È¿ ËÏÈΛ·˜ 8-17 ÂÙÒÓ (1). ∆Ô 1979 ‰fiıËΠÌÂÁ¿ÏË ‰ËÌÔÛÈfiÙËÙ· ÛÙÔ Û‡Ó‰ÚÔÌÔ, ‰ÈfiÙÈ Û¯ÂÙ›ÛÙËΠ̠ÙË ¯Ú‹ÛË ÎÔÏÈÎÒÓ Ù·ÌfiÓ ÛÙȘ Á˘Ó·›Î˜ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ (2).

TÔ ™∆∫ Â›Ó·È ÔÏ˘Û˘ÛÙËÌ·ÙÈÎfi ÓfiÛËÌ·, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ ·fi ¤Ó· ÂÙÂÚÔÁÂÓ¤˜ Ê¿ÛÌ· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Î·È ÔÊ›ÏÂÙ·È ÛÙË ‰Ú¿ÛË Â͈ÙÔÍÈÓÒÓ Ô˘ ·Ú¿ÁÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙÔ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ ·ÏÏ¿ Î·È ·fi ÙÔÓ ˘ÔÁfiÓÔ ÛÙÚÂÙfiÎÔÎÎÔ (3) (¶›Ó·Î·˜ 1). OÈ Û˘ÁÎÂÎÚÈ̤Ó˜ ÙÔ͛Ә, ‰ÚÒÓÙ·˜ ˆ˜ ˘ÂÚ·ÓÙÈÁfiÓ·, ‰ÈÂÁ›ÚÔ˘Ó ¤Ó· ÌÂÁ¿ÏÔ

·ÚÈıÌfi ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ô˘ Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ ÚÔηÏÔ‡Ó ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ, ÔÈ Ôԛ˜ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Î·È Î˘Ú›ˆ˜ ÁÈ· ÙËÓ Î·Ù·ÏËÍ›· (4,5). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ ÂÍ·ÚÙ¿Ù·È Ô‡Ù ÂȂ‚·ÈÒÓÂÙ·È ·fi ÙËÓ ·ÔÌfiÓˆÛË ÌÈÎÚÔ‚›Ô˘, ÙËÓ ·Ó›¯Ó¢ÛË Â͈ÙÔÍÈÓÒÓ ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Â͈ÙÔÍÈÓÒÓ, ·ÏÏ¿ Ù›ıÂÙ·È ·ÔÎÏÂÈÛÙÈο Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· (6,7) (¶›Ó·Î·˜ 2). ¢È·ÎÚ›ÓÔ˘Ì ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘: ÙËÓ ÂÌÌËÓÔÚÚ˘Ûȷ΋ ÌÔÚÊ‹, Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û Á˘Ó·›Î˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÂÓ‰ÔÎÔÏÈο Ù·ÌfiÓ Î·Ù¿ ÙËÓ ¤ÌÌËÓÔ Ú‡ÛË Î·È ÙË ÌË ÂÌÌËÓÔÚÚ˘Ûȷ΋ ÌÔÚÊ‹, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ·È‰È¿ ηÈ

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

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¶·È‰È·ÙÚÈ΋ 2001;64:499-503

¶›Ó·Î·˜ 1. E͈ÙÔ͛Ә Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ ∂͈ÙÔÍ›ÓË ªÈÎÚÔÔÚÁ·ÓÈÛÌfi˜ ∆ÔÍ›ÓË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÃÚ˘Û›˙ˆÓ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ (TSST-1) ÛÙ·Ê˘ÏfiÎÎÔÎÔ˜ ∂ÓÙÂÚÔÙÔÍ›ÓË ∞ (SEA) >> ∂ÓÙÂÚÔÙÔÍ›ÓË µ (S∂µ) >> ∂ÓÙÂÚÔÙÔÍ›ÓË C (SEC) (SEC1 - SEC2 - SEC3) >> ∂ÓÙÂÚÔÙÔÍ›ÓË D (SED) >> ∂ÓÙÂÚÔÙÔÍ›ÓË E (SEE) >> ∂ÓÙÂÚÔÙÔÍ›ÓË G (SEG) >> ∂ÓÙÂÚÔÙÔÍ›ÓË H (SEH) >> ∂ÓÙÂÚÔÙÔÍ›ÓË π (SEπ) >> ∞ÔÊÔÏȉˆÙÈ΋ ÙÔÍ›ÓË ∞ (ExF-A) >> ∞ÔÊÔÏȉˆÙÈ΋ ÙÔÍ›ÓË B (ExF-B) >> ™ÙÚÂÙÔÎÔÎÎÈ΋ ¶˘ÔÁfiÓÔ˜ ˘ÚÂÙÔÁfiÓÔ˜ ÙÔÍ›ÓË ∞ (SPE-A) ÛÙÚÂÙfiÎÔÎÎÔ˜ >> >> >> B (SPE-B) >> >> >> >> C (SPE-C) >>

Ó¤Ô˘˜ ÂÓ‹ÏÈΘ Î·È ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, ÙÚ·˘Ì·ÙÈÛÌfi ‹ ¤Áη˘Ì· (8). ™ÙËÓ ÂÚÁ·Û›· Ì·˜ ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ô˘ ·ÚÔ˘Û›·Û·Ó ™∆∫ ÌÂÙ¿ ·fi ¤Áη˘Ì·, ÙÔ ÔÔ›Ô Â›¯Â ÂÈÌÔÏ˘Óı› ·fi ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ∏ ÚÒÙË ÂÚ›ÙˆÛË ·ÊÔÚ¿ ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 9 ÌËÓÒÓ Ô˘ ÂÈÛ‹¯ıË ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ (ª∂£) ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜ ÏfiÁˆ ˘ÚÂÙÔ‡, ΢¿ÓˆÛ˘ Î·È ÎˆÌ·ÙÒ‰Ô˘˜ ηٿÛÙ·Û˘. ∂ÚfiÎÂÈÙÔ ÁÈ· ÙÔ ‰Â‡ÙÂÚÔ ·È‰› ·ı›ÁÁ·ÓˆÓ, Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ™ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·ÊÂÚfiÙ·Ó ÌËÓÈÁÁ›Ùȉ· Û ËÏÈΛ· 45 ËÌÂÚÒÓ Î·È ÎÔÎ·Ù˘ Û ËÏÈΛ· 4 ÌËÓÒÓ. ∏ ·ÛıÂÓ‹˜, 7 Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ Ù˘ ÛÙÔ ÙÌ‹Ì· Ì·˜, ›¯Â ˘ÔÛÙ› ¤Áη˘Ì· ÛÙÔ ‰ÂÍÈfi ·ÓÙÈ‚Ú¿¯ÈÔ ·fi η˘Ùfi ÓÂÚfi, ÙÔ ÔÔ›Ô ¤Ù˘¯Â ÏËÌÌÂÏÔ‡˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∞fi ÂÓıË̤ÚÔ˘ ·ÚÔ˘Û›·˙ ˘„ËÏfi ˘ÚÂÙfi Î·È ·fi ‰ÈË̤ÚÔ˘ ¿ÚÓËÛË Ï‹„˘ ÙÚÔÊ‹˜, Â̤ÙÔ˘˜ Î·È ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙË ª∂£ ‹Ù·Ó Û Έ̷ÙÒ‰Ë Î·Ù¿ÛÙ·ÛË (ÎÒÌ· ÛÙ¿‰ÈÔ ππ), Ì ÂÈfiÏ·È· ·Ó·ÓÔ‹, Ù·¯‡ÓÔÈ· Î·È Î˘¿ÓˆÛË, ·‡ÚÂÙË (ıÂÚÌÔÎÚ·Û›· ÔÚıÔ‡: 36,0ÔC), Ì ÂÈÎfiÓ· ηٷÏËÍ›·˜ (ÛʇÍÂȘ: 160/min, ∞¶: 65/40 mmHg, η΋ ÙÚȯÔÂȉÈ΋ ΢ÎÏÔÊÔÚ›·) Î·È ·Ê˘‰¿ÙˆÛË ÂÚ›Ô˘ 7%. À‹Ú¯Â ¤Áη˘Ì· 2Ô˘ ‚·ıÌÔ‡ ÂÎÙ¿Ûˆ˜ 2% ÛÙÔ ‰ÂÍÈfi ·ÓÙÈ‚Ú¿¯ÈÔ Î·È ‰È¿¯˘ÙÔ ÌÈÎÚÔÎËÏȉ҉˜ ÂÍ¿ÓıËÌ· ÛÙÔ ÚfiÛˆÔ, ÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·,

500

Paediatriki 2001;64:499-503

ηıÒ˜ Î·È ˘ÂÚ·ÈÌ›· ÙˆÓ ÂÈÂÊ˘ÎfiÙˆÓ. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÈÛfi‰Ô˘ ¤‰ÂÈÍ ·Ó·ÈÌ›· Î·È ÂËÚ·Ṳ̂Ó˜ ‚ÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ: ·ÈÌÔÛÊ·ÈÚ›ÓË: 7 gr/dl, ·ÈÌ·ÙÔÎÚ›Ù˘: 22%, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 5500/mm3 (¶: 20%, §: 80%), ·ÈÌÔÂÙ¿ÏÈ·: 93000/mm3, Ô˘Ú›·: 83 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,6 mg/dl, SGOT: 210 U/L, SGPT: 45 U/L, CPK: 43 U/L, ÔÏÈο Ï¢ÎÒÌ·Ù·: 4,3 gr/dl, ·Ï‚Ô˘Ì›ÓË: 2,3 gr/dl, CRP: 198 mg/dl. ∏ O¡¶ ‹Ù·Ó ·ÚÓËÙÈ΋ ÁÈ· ÌËÓÈÁÁ›Ùȉ·. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ‹Ù·Ó ÛÙ›Ú˜, ÂÓÒ ·fi ÙËÓ ÂÁη˘Ì·ÙÈ΋ ÂÈÊ¿ÓÂÈ· ·ÔÌÔÓÒıËΠSt·phylococcus aureus ·ÓıÂÎÙÈÎfi˜ ÛÙË ÌÂıÈÎÈÏÏ›ÓË. ∏ ·ÛıÂÓ‹˜, ÂÎÙfi˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚·ÎÙËÚȷ΋˜ ·ÁˆÁ‹˜ (ÎÂÊÔÙ·Í›ÌË-ÎÏÈÓ‰·Ì˘Î›ÓË) Î·È Ù˘ ÂÚÈÔ›ËÛ˘ Ù˘ ÂÁη˘Ì·ÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜, ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜, Ì ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ (ÊÔÚÙ›ÛÂȘ Ì ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù·) Î·È ÈÓÔÙÚfiˆÓ (ÓÙÔ·Ì›ÓËÓÙÔÔ˘Ù·Ì›ÓË Â› 12 Ë̤Ú˜) Î·È ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜. ∆Ë 2Ë Ë̤ڷ ÓÔÛËÏ›·˜ ·ÚÔ˘Û›·Û ÂÈÎfiÓ· Û˘Ó‰ÚfiÌÔ˘ ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (ARDS) Ì ÛÔ‚·Ú‹ Âȉ›ӈÛË ÙfiÛÔ Ù˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒÚ·ÎÔ˜, fiÛÔ Î·È ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜. ™ÙËÓ ÚÔÛ¿ıÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ARDS ¤ÁÈÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ì ˘„›Û˘¯ÓÔ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ·Ó·Ó¢ÛÙ‹Ú· Ù·Ï·ÓÙÒÛˆÓ) Î·È ¯ÔÚËÁ‹ıËÎ·Ó 2 ‰fiÛÂȘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (surfactant) ÂÓ‰ÔÙÚ·¯Âȷο. µ·ıÌÈ·›·, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ‚ÂÏÙ›ˆÛË. ∆Ô ÌÈÎÚÔÎËÏȉ҉˜ ÂÍ¿ÓıËÌ· ÛÙ·‰È·Î¿ ÂÍ·Ê·Ó›ÛÙËÎÂ Î·È ÙË 10Ë Ë̤ڷ ¿Ú¯ÈÛ ·ÔϤÈÛË Û fiÏÔ ÙÔ ÛÒÌ·, ȉȷ›ÙÂÚ· ¤Î‰ËÏË ÛÙȘ ·Ï¿Ì˜ Î·È Ù· ¤ÏÌ·Ù·. ∂Í‹Ïı ·fi ÙÔ ÙÌ‹Ì· Ì·˜ ÙË 16Ë Ë̤ڷ Ù˘ ÓfiÛÔ˘ Û ηϋ ηٿÛÙ·ÛË. ∏ ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ·ÊÔÚ¿ ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 18 ÌËÓÒÓ ·fi ·ı›ÁÁ·ÓÔ˘˜ ÁÔÓ›˜ Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi Ô˘ ÂÈÛ‹¯ıË ÛÙË ª∂£ ÏfiÁˆ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘. ∆Ô ·È‰› ›¯Â ˘ÔÛÙ› ÚÔ 24ÒÚÔ˘ ¤Áη˘Ì·, ÙÔ ÔÔ›Ô ·ÓÙÈÌÂÙˆ›ÛÙËΠ·fi ÙÔ˘˜ ÁÔÓ›˜ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ οÔÈ·˜ ·ÏÔÈÊ‹˜. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙÔ ÙÌ‹Ì· Ì·˜ ‹Ù·Ó Û ‚˘ıÈfiÙËÙ·, Ë ıÂÚÌÔÎÚ·Û›· ÔÚıÔ‡ ‹Ù·Ó 39,0ÔC, ›¯Â ηϋ ·ÚÙËÚȷ΋ ›ÂÛË Î·È Ê˘ÛÈÔÏÔÁÈÎfi ·Ó·Ó¢ÛÙÈÎfi „Èı‡ÚÈÛÌ·. ¶·ÚÔ˘Û›·˙ ¤Áη˘Ì· 2Ô˘ ‚·ıÌÔ‡ ÂÎÙ¿Ûˆ˜ 35%, ÛÙ· οو ¿ÎÚ·, ÙÔ ÂÚ›ÓÂÔ Î·È ÙÔ˘˜ ÁÏÔ˘ÙÔ‡˜. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ٷ ·ÎfiÏÔ˘ı·: °ÂÓÈ΋ ·›Ì·ÙÔ˜: ·ÈÌÔÛÊ·ÈÚ›ÓË: 9,6 gr/dl, ·ÈÌ·ÙÔÎÚ›Ù˘: 29%, ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 3000/mm3 (¶: 69%, §: 25%, ª: 6%), ·ÈÌÔÂÙ¿ÏÈ·: 157000/mm3, Na: 127 meq/L, Ca: 6,2

¶·È‰È·ÙÚÈ΋ 2001;64:499-503

Paediatriki 2001;64:499-503

¶›Ó·Î·˜ 2. ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û˘Ó‰ÚfiÌÔ˘ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ (7) ¶˘ÚÂÙfi˜: £ÂÚÌÔÎÚ·Û›· ≥38,9ÔC EÍ¿ÓıËÌ·: ¢È¿¯˘ÙÔ ÎËÏȉ҉˜ ÂÍ¿ÓıËÌ· ∞ÔϤÈÛË: 1-2 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, ȉȷ›ÙÂÚ· Û ¤ÏÌ·Ù· Î·È ·Ï¿Ì˜ ÀfiÙ·ÛË: ™˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ≤90 mmHg ÁÈ· ÂÓËÏ›ÎÔ˘˜ ‹ <5Ë ∂£ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘˜ Û ·È‰È¿ <16 ÂÙÒÓ, ÙÒÛË Ù˘ ‰È·ÛÙÔÏÈ΋˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ≥15 mmHg ηٿ ÙË ÌÂÙ¿‚·ÛË ·fi ÙËÓ Î·Ù·ÎÂÎÏÈ̤ÓË ÛÙËÓ fiÚıÈ· ı¤ÛË, ÔÚıÔÛÙ·ÙÈÎfi Û˘ÁÎÔÈÎfi ÂÂÈÛfi‰ÈÔ ‹ ˙¿ÏË ÛÙËÓ fiÚıÈ· ı¤ÛË 5. ¶ÚÔÛ‚ÔÏ‹ ÙÚÈÒÓ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·fi Ù· ·ÎfiÏÔ˘ı·: ñ °·ÛÙÚÂÓÙÂÚÈÎfi: ŒÌÂÙÔÈ ‹ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ñ ª˘˚Îfi: ™ËÌ·ÓÙÈ΋ Ì˘·ÏÁ›· ‹ CPK ÔÚÔ‡ >2Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜ ñ µÏÂÓÓÔÁfiÓÔÈ: ÀÂÚ·ÈÌ›· ÂÈÂÊ˘ÎfiÙˆÓ, ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ·, ÎfiÏÔ˘ ñ O˘ÚÔÔÈËÙÈÎfi: O˘Ú›· ‹ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ >2Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜ ‹ ˘ÔÛÊ·›ÚÈ· ≥5 ÎÔ Â› ·Ô˘Û›·˜ Ô˘ÚÔÏԛ̈͢ ñ ◊·Ú: OÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË, SGOT ‹ SGPT >2Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜ ñ ∞ÈÌÔÔÈËÙÈÎfi: ∞ÈÌÔÂÙ¿ÏÈ· <100.000/mm3 ñ ∫¡™: ¢È·Ù·Ú·¯¤˜ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡ ‹ ÙÔ˘ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘ ¯ˆÚ›˜ ÂÛÙȷο Ó¢ÚÔÏÔÁÈο ÛËÌ›·, Â› ·Ô˘Û›·˜ ˘ÚÂÙÔ‡ Î·È ˘fiÙ·Û˘ 6. ∞ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ·ÎfiÏÔ˘ıˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛˆÓ, Â¿Ó ÏËÊıÔ‡Ó: ñ ∫·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ Î·È ∂¡À (Ë Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È ıÂÙÈ΋ ÁÈ· ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ) ñ OÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÎËÏÈ‰Ò‰Ë ˘ÚÂÙfi ÙˆÓ ‚Ú·¯ˆ‰ÒÓ ÔÚ¤ˆÓ, ÏÂÙÔÛ›ڈÛË ‹ ÈÏ·Ú¿

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4.

¶Èı·Ó‹ ‰È¿ÓˆÛË: ŸÙ·Ó ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È 5 ·fi Ù· 6 ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· µÂ‚·›· ‰È¿ÁÓˆÛË: ŸÙ·Ó ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È Ù· 6 ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ·ÔϤÈÛ˘, ÂÎÙfi˜ Â¿Ó Ô ·ÛıÂÓ‹˜ ηٷϋÍÂÈ ÚÈÓ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·ÔϤÈÛ˘

mg/dl, ÁÏ˘Îfi˙Ë: 38 mg/dl, Ô˘Ú›·: 32 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,7 mg/dl, SGOT: 145 U/L, SGPT: 53 U/L, CPK: 3020 U/L, ÔÏÈο Ï¢ÎÒÌ·Ù·: 3,8 gr/dl, ·Ï‚Ô˘Ì›ÓË: 1,8 gr/dl, CRP: 382 mg/dl. ∏ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‹Ù·Ó ÛÙ›ڷ, ÂÓÒ ·fi ÙËÓ Î·ÏÏȤÚÁÂÈ· ˘ÏÈÎÔ‡ ·Ô ÙËÓ ÂÁη˘Ì·ÙÈ΋ ÂÈÊ¿ÓÂÈ· ·ÔÌÔÓÒıËÎ·Ó St. aureus, Enterobacter cloacae Î·È Klebsiella oxytoca. ÃÔÚËÁ‹ıËÎ·Ó ÂÓ‰ÔÊϤ‚È· ÔÈ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ ÙÔ˘ Û ˘ÁÚ¿ Î·È Î·Ï‡ÊıËΠ̠ÂÓÈÎÈÏÏ›ÓË G. ∆Ô Â›Â‰Ô Û˘Ó›‰ËÛ˘ ·ÔηٷÛÙ¿ıËΠÁÚ‹ÁÔÚ· Î·È ·fi ÙË 2Ë Ë̤ڷ ÓÔÛËÏ›·˜ Ô ˘ÚÂÙfi˜ ÛËÌ›ˆÛ ‡ÊÂÛË. ∆ËÓ 3Ë Ë̤ڷ ¿Ú¯ÈÛ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ ÔÏ˘¿ÚÈı̘ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ Î·È ·Ú¿ÏÏËÏ· ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (50000/mm3). To 6o 24ˆÚÔ Î·È ÂÓÒ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ÂÌÊ¿ÓÈÛ ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ΢ڛˆ˜ ÛÙÔ ÚfiÛˆÔ Î·È ÙÔÓ ÎÔÚÌfi Î·È ıÂÚÌÔÎÚ·Û›· 38,2ÔC. ∆Ș ÂfiÌÂÓ˜ ÒÚ˜ ÛËÌ›ˆÛ ڷÁ‰·›· Âȉ›ӈÛË, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÂÈÎfiÓ· ηٷÏËÍ›·˜ Î·È ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. ¶·Ú¿ ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Î·È ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ÈÓfiÙÚÔ·, ÙÔ ·È‰› η٤ÏËÍ ÙËÓ ›‰È· Ë̤ڷ. ™ÙËÓ ÙÂÏÂ˘Ù·›·

ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ·ÔÌÔÓÒıËΠS. aureus. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÙÔÍÈÓÒÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÛÙÂϤ¯Ô˘˜ ¤‰ÂÈÍ ÙÔÍ›ÓË Û˘Ó‰ÚfiÌÔ˘ ÙÔÍÈ΋˜ ηٷÏËÍ›·˜ (TSST-1) ηıÒ˜ Î·È ·ÔÊÔÏȉˆÙÈ΋ ÙÔÍ›ÓË (ExF-A). ™˘˙‹ÙËÛË ∆Ô ™∆∫ ·ÔÙÂÏ› Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ ÛÙ·Ê˘ÏÔÎÔÎÎÈ΋˜ Ïԛ̈͢ (3). ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ·Ó¤Ú¯ÂÙ·È ÛÙȘ ∏¶∞ Û 0,50 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜ Î·È ·fi ·˘Ù¤˜ ÙÔ 20-40% ·ÊÔÚ¿ ÙË ÌË ÂÌÌËÓÔÚÚ˘Ûȷ΋ ÌÔÚÊ‹ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, Ô˘ Û˘Ì‚·›ÓÂÈ ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ‹ ÂÁη‡Ì·Ù· (9). H Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Û ÌÈÎÚ¿ ·È‰È¿ Ì ¤Áη˘Ì· Â›Ó·È ÛËÌ·ÓÙÈ΋ Î·È Î˘Ì·›ÓÂÙ·È ÂÚ›Ô˘ ÛÙÔ 10% ÙˆÓ ·ÛıÂÓÒÓ (6,10). ™˘ÁÎÂÎÚÈ̤ӷ, ·fi Ù· 64 ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 24 ÌËÓÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó Û ªÔÓ¿‰· ∂Áη˘Ì·ÙÈÒÓ Ù· 6 (9,4%) ·ÚÔ˘Û›·Û·Ó ™∆∫ (10).

OÈ ‰‡Ô ·ÛıÂÓ›˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ™∆∫ (7). ∏ ÚÒÙË ÂÚ›ÙˆÛË ÏËÚÔ‡ÛÂ Î·È Ù· ¤ÍÈ ÎÚÈÙ‹ÚÈ·, ÂÓÒ Ë ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË Ù· ¤ÓÙ ·fi Ù· ¤ÍÈ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·Ô˘Û›·˙ ÙÔ ÎÚÈÙ‹ÚÈÔ Ù˘ ·ÔϤÈÛ˘. ∫·Ù¿ ÙËÓ ·Ó·ÛÎfiËÛË ÙˆÓ de Saxe Î·È Û˘Ó, ÌfiÓÔ ÔÈ ÌÈÛ¤˜ ·fi

501

¶·È‰È·ÙÚÈ΋ 2001;64:499-503

ÙȘ ÂÚÈÙÒÛÂȘ ÌË ÂÌÌËÓÔÚÚ˘Ûȷ΋˜ ÌÔÚÊ‹˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÏËÚÔ‡Ó fiÏ· Ù· ÎÚÈÙ‹ÚÈ· (11). ∞˘Ù¿ Ô˘ ·Ô˘ÛÈ¿˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Â›Ó·È Ë ˘fiÙ·ÛË Î·È Ë ·ÔϤÈÛË. ŒÙÛÈ, Û‡Ìʈӷ Ì ÙÔÓ ÚfiÛÊ·ÙÔ ÔÚÈÛÌfi ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ Î·È ¶ÚfiÏ˄˘ ¡ÔÛËÌ¿ÙˆÓ (CDC) ÙˆÓ ∏¶∞, Û ÂÚ›ÙˆÛË ı·Ó¿ÙÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ·ÔϤÈÛË ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÙÔ˘ ™∆∫ (7). °È· ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™∆∫ ··ÈÙÂ›Ù·È Ô Û˘Ó‰˘·ÛÌfi˜ ÙÚÈÒÓ ·Ú·ÁfiÓÙˆÓ (21): ¤Ó· ¢ÓÔ˚Îfi ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂÓfi˜ ·ıÔÁfiÓÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡, Ô ÔÔ›Ô˜ ı· ·Ú¿ÁÂÈ Â·Ú΋ ÔÛfiÙËÙ· ÙÔ͛Ӣ, ÒÛÙ ӷ ÂΉËÏÒÛÂÈ Û˘ÌÙÒÌ·Ù· ¤Ó·˜ ¢·ı‹˜ ÍÂÓÈÛÙ‹˜. ŸÛÔÓ ·ÊÔÚ¿ ÙÔÓ ÍÂÓÈÛÙ‹, Ë Â˘¿ıÂÈ¿ ÙÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ‡·ÚÍË ‹ fi¯È ÚÔÛٷ٢ÙÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ·Ú·ÁfiÌÂÓˆÓ Â͈ÙÔÍÈÓÒÓ Î·È Î˘Ú›ˆ˜ Ù˘ TSST-1 (22). ∏ ·Ô˘Û›· ·ÓÔÛ›·˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë ÚÔËÁÔ‡ÌÂÓ˘ ¤ÎıÂÛ˘ ‹ ÛÙËÓ ·‰˘Ó·Ì›· ·Ú·ÁˆÁ‹˜ ·˘ÙÒÓ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (14,16). O Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ TSST-1 ·˘Í¿ÓÂÈ Ì ÙËÓ ËÏÈΛ·. ŒÙÛÈ ÂÍËÁÂ›Ù·È ÁÈ·Ù› ÚÔÛ‚¿ÏÏÔÓÙ·È Û˘¯ÓfiÙÂÚ· ·È‰È¿ ÌÈÎÚ‹˜ ËÏÈΛ·˜. ™‡Ìʈӷ Ì ÙÔ˘˜ Vergerant Î·È Û˘Ó, ÌfiÓÔ ÙÔ 30% ˘ÁÈÒÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 1 ¤ˆ˜ 2 ÂÙÒÓ Â›¯Â ÚÔÛٷ٢ÙÈÎÔ‡˜ Ù›ÙÏÔ˘˜ ·ÓÙÈÛˆÌ¿ÙˆÓ (≥1:100) ¤Ó·ÓÙÈ Ù˘ TSST-1 (13). ∞ÓÙ›ıÂÙ·, Û‡Ìʈӷ Ì ÙË ÌÂϤÙË ÙˆÓ Notermans Î·È Û˘Ó, ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ¤Êı·Ó ÙÔ 90% (12). £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, Â›Û˘, fiÙÈ ÌËÙÚÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ TSST-1 ·ÓȯÓ‡ÔÓÙ·È Û ‚Ú¤ÊË ËÏÈΛ·˜ ̤¯ÚÈ 9 ÌËÓÒÓ (13,14). º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ÔÈ ‰‡Ô ÂÁη˘Ì·Ù›Â˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜, 9 Î·È 18 ÌËÓÒÓ, ·Ó‹Î·Ó ÏfiÁˆ ËÏÈΛ·˜ Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ˆ˜ ÚÔ˜ ÙËÓ ÂΉ‹ÏˆÛË ™∆∫. π‰È·›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ ÙÔ fiÙÈ Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ÂÁη˘Ì·ÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ™∆∫ Ì ¤Áη˘Ì· ÂÎÙ¿Ûˆ˜ 2% (15). ∏ ÂÚÁ·Û›· Ì·˜, ÛÙËÓ ÔÔ›· Ô ¤Ó·˜ ·ÛıÂÓ‹˜ ›¯Â ÂÁη˘Ì·ÙÈ΋ ÂÈÊ¿ÓÂÈ· ÂÎÙ¿Ûˆ˜ 2%, ÂȂ‚·ÈÒÓÂÈ ÙË ‰È·›ÛÙˆÛË ·˘Ù‹. ™ÙÔÓ ¤Ó· ·ÛıÂÓ‹ Ì·˜ ·ÓȯÓ‡ıËÎ·Ó ÔÈ Â͈ÙÔ͛Ә TSST-1 Î·È ExF-A. ∏ TSST-1 ·ÓȯÓ‡ÂÙ·È Û˘¯ÓfiÙÂÚ· Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ Â͈ÙÔ͛Ә ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ™∆∫ (16). Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÌÌËÓÔÚÚ˘Ûȷ΋˜ ÌÔÚÊ‹˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, ÂÚÈÛÛfiÙÂÚÔ ·fi 90% ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ·Ú¿ÁÔ˘Ó ÙËÓ TSST-1, ÂÓÒ ÛÙȘ ÂÚÈÙÒÛÂȘ ÌË ÂÌÌËÓÔÚÚ˘Ûȷ΋˜ ÌÔÚÊ‹˜ ÙÔ 6065% ÙˆÓ ÛÙÂϯÒÓ Û˘Óı¤ÙÔ˘Ó ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÙÔÍ›ÓË (11). ∏ ·Ó›¯Ó¢ÛË ÙÔÍÈÓÒÓ, fiˆ˜ ·Ó·Ê¤Ú-

502

Paediatriki 2001;64:499-503

ıËΠÛÙËÓ ÂÈÛ·ÁˆÁ‹, ‰ÂÓ ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ™∆∫, ·ÏÏ¿ ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÂÈ ÌfiÓÔ ÁÈ· ÂȉËÌÈÔÏÔÁÈÎÔ‡˜ ‹ ÂÚ¢ÓËÙÈÎÔ‡˜ ÏfiÁÔ˘˜ (6). ¶Ú¿ÁÌ·ÙÈ, ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÙÔ 25-30% ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ¯Ú˘Û›˙ÔÓÙ· ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘ ·Ú¿ÁÔ˘Ó Â͈ÙÔ͛Ә (12). ¶ÚÔÛ‚ÔÏ‹ ·fi Ù· Û˘ÁÎÂÎÚÈ̤ӷ ÌÈÎÚԂȷο ÛÙÂϤ¯Ë (Ì ٷ˘Ùfi¯ÚÔÓË ·Ú·ÁˆÁ‹ ÙÔÍÈÓÒÓ) ‰ÂÓ ÚÔηÏ› ··Ú·›ÙËÙ· ™∆∫ (17). ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ Î·È ÔÈ ‰‡Ô ·ÛıÂÓ›˜ Ì·˜ ·ÚÔ˘Û›·Û·Ó ÂÈÎfiÓ· ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· Ê·›ÓÂÙ·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ™∆∫ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ARDS. ™‡Ìʈӷ, Ì¿ÏÈÛÙ·, Ì ÙË ÌÂϤÙË ÙˆÓ Stevens Î·È Û˘Ó, Û 20 ·ÛıÂÓ›˜ Ì ™∆∫ ÔÊÂÈÏfiÌÂÓÔ Û Â͈ÙÔ͛Ә ·Ú·ÁfiÌÂÓ˜ ·fi ÛÙÚÂÙfiÎÔÎÎÔ, ÔÈ 11 (55%) ÂΉ‹ÏˆÛ·Ó ARDS (18). ∂ÈϤÔÓ, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ARDS ˘ÚÔ‰ÔÙÂ›Ù·È ·fi Û˘ÁÎÂÎÚÈ̤ÓÔ˘˜ ÂÎÏ˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ïԛ̈ÍË, ÙÚ·˘Ì·ÙÈÛÌfi˜, ¤Áη˘Ì·, ÌÂÙ·ÁÁ›ÛÂȘ (19). ¶ÚÔÊ·ÓÒ˜, ÔÈ ‰‡Ô ÂÁη˘Ì·Ù›Â˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ ·ÚÔ˘Û›·˙·Ó ÔÏÏÔ‡˜ ÂÎÏ˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ¤Ú·Ó ÙÔ˘ ™∆∫, Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÚÔηϤÛÔ˘Ó ÙËÓ ÂΉ‹ÏˆÛË ARDS. ∏ ıÂÚ·›· Ô˘ ÂÊ·ÚÌfiÛÙËΠÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜, ÂÎÙfi˜ ·fi ÙËÓ ÙÔÈ΋ ÂÚÈÔ›ËÛË Ù˘ ÂÁη˘Ì·ÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜, ÂÚÈÂÏ¿Ì‚·Ó ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈ΋˜ ·ÁˆÁ‹˜, ÊÔÚÙ›ÛÂˆÓ Ì ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· Î·È ÈÓÔÙÚfiˆÓ Ê·Ú̿ΈÓ. ∏ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ Î·È Á-ÛÊ·ÈÚ›Ó˘, ·Ó Î·È ÂÊ·ÚÌfi˙ÂÙ·È ·fi ÔÚÈṲ̂ÓÔ˘˜, ıˆÚÂ›Ù·È ·ÌÊÈÛ‚ËÙÔ‡ÌÂÓË (8).

O ¤Ó·˜ ·fi ÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ Ù˘ ÂÚÁ·Û›·˜ Ì·˜ η٤ÏËÍÂ. °ÂÓÈο, Ë ıÓËÙfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Î˘Ì·›ÓÂÙ·È ·fi 2-15%, ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ fï˜ Ì ¤Áη˘Ì· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂΉ‹ÏˆÛË Î·Ù·ÏËÍ›·˜, ÔfiÙ ÌÔÚ› Ó· ·Ó¤ÏıÂÈ ¤ˆ˜ 57% (6,8,20). ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ ÙÔ Û‡Ó‰ÚÔÌÔ ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ıÓËÙfiÙËÙ·, Â›Ó·È ÂÈı˘ÌËÙfi Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Î·È Ó· ıÂÚ·‡ÂÙ·È ¯ˆÚ›˜ ηı˘ÛÙ¤ÚËÛË (6). ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÛËÌÂ›Ô Ù˘ ıÂÚ·›·˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È Èı·ÓfiÓ Ë ÁÓÒÛË Ù˘ ‡·ÚÍ‹˜ ÙÔ˘. ∏ ‰È¿ÁÓˆÛË Ù˘ ÛÙ·Ê˘ÏÔÎÔÎÎÈ΋˜ ÙÔÍÈÓ·ÈÌ›·˜ Ú¤ÂÈ Ó· ÙÂı› ÚÔÙÔ‡ Á›ÓÂÈ ÂÌÊ·Ó¤˜ ÔÏfiÎÏËÚÔ ÙÔ Û‡Ó‰ÚÔÌÔ, ‰ËÏ·‰‹ ¯ˆÚ›˜ Ó· ¤¯Ô˘Ì fiÏ· Ù· ÎÚÈÙ‹ÚÈ· Ù˘ ÔÚÈÛÙÈ΋˜ ‰È¿ÁÓˆÛ˘ Î·È ÙfiÙ ӷ ·Ú¯›ÛÂÈ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË. ∞˘Ù¿ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÔ˘Ó ÚÈÓ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ηٷÏËÍ›·˜ (10). ∏ ÚÒÈÌË ‰È¿ÁÓˆÛË ÙÔ˘ ™∆∫ ÛÙ· ·È‰È¿ Ì ¤Áη˘Ì·, Ô˘ÛÈ·ÛÙÈο ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ shock, ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ¤ÁηÈÚË ¤Ó·ÚÍË ıÂÚ·›·˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ÛÙ· ·È‰È¿ ·˘Ù¿.

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CASE REPORT

™˘ÁÁÂÓ‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË Ì ·˘ÍË̤ӷ Â›‰· ÂÚ˘ıÚÔÔÈËÙ›Ó˘. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿, ª. OÈÎÔÓfiÌÔ˘, Ã. ∆Û¿ÓÙ·ÏË, ∞. ∫Ô‡ÛË, ¡. °ÔÌ¿Î˘

Congenital erythrocytosis with increased erythropoietin levels. Case report M. Athanassiou-Metaxa, M. Oikonomou, C. Tsantali, A. Kousi, N. Gombakis

¶ÂÚ›ÏË„Ë: O fiÚÔ˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ÂÚÈÏ·Ì‚¿ÓÂÈ Ì›· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ‰È·Ù·Ú·¯ÒÓ, ÔÈ Ôԛ˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·‡ÍËÛË Ù˘ Ì¿˙·˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Û¯ÂÙÈ΋ ‹ ·fiÏ˘ÙË. ∏ ·fiÏ˘ÙË ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ÌÔÚ› Ó· Â›Ó·È ÚˆÙÔ·ı‹˜ ‹ ‰Â˘ÙÂÚÔ·ı‹˜, Û˘ÁÁÂÓ‹˜ ‹ Â›ÎÙËÙË. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ ËÏÈΛ·˜ 20 ÌËÓÒÓ Ì ·fiÏ˘ÙË ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË, Èı·Ófiٷٷ Û˘ÁÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜, Ì›· ·ÈÌ·ÙÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ Û¿ÓÈ· ÛÙËÓ ·È‰È΋ Î·È È‰È·›ÙÂÚ· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ÷ڷÎÙËÚÈÛÙÈ΋ ‹Ù·Ó, ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ë È‰È·›ÙÂÚ· ·˘ÍË̤ÓË ÙÈÌ‹ Ù˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ÙÔ˘ ÔÚÔ‡, ¯ˆÚ›˜ Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È·›ÛÙˆÛË, ·Ú¿ ÙÔÓ ÂÎÙÂٷ̤ÓÔ ¤ÏÂÁ¯Ô, οÔÈ·˜ ÂÌÊ·ÓÔ‡˜ ·ÈÙ›·˜ ˘ÂÚ¤ÎÎÚÈÛ‹˜ Ù˘. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ, Â›Û˘, Ë ·Ó›¯Ó¢ÛË ·˘ÙfiÌ·Ù˘ ·Ó¿Ù˘Í˘ ·ÔÈÎÈÒÓ Ù˘ ÂÚ˘ıÚ¿˜ ÛÂÈÚ¿˜ (CFU-E) ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ΢ÙÙ¿ÚˆÓ Ì˘ÂÏÔ‡, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÚ˘ıÚÔÔÈËÙ›Ó˘. ¶·Ú¿ ÙÔ fiÙÈ ÙÔ Â‡ÚËÌ· ·˘Ùfi ıˆÚÂ›Ù·È ÂÓ‰ÂÈÎÙÈÎfi ÚˆÙÔ·ıÔ‡˜ Ì˘ÂÏÔ¸ÂÚÏ·ÛÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Î·È ÂȉÈÎfiÙÂÚ· Ù˘ ·ÏËıÔ‡˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜ (polycythemia vera), Ë ·ÛıÂÓ‹˜ ‰ÂÓ ÏËÚÔ‡Û ٷ ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ ÓÔÛÔÏÔÁÈ΋˜ ·˘Ù‹˜ ÔÓÙfiÙËÙ·˜.

Abstract: The term erythrocytosis denotes a heterogenous group of disorders characterized by an increased red blood cell mass, absolute or relative. Absolute erythrocytocis may be primary or secondary, congenital or acquired. We report the case of a 20 month old girl who presented with absolute erythrocytosis, probably congenital, a disorder that is rarely seen in children.

Erythropoietin levels were found to be significantly increased, although extensive evaluation failed to reveal a cause for such an inappropriate elevation.

Of interest is the finding of spontaneous erythroid colony formation (CFU-E) in the patient’s bone marrow cultures. Although such a finding is considered typical of polycythemia vera, the diagnostic criteria of this myeloproliferative disorder were not met.

§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË, ‚ÚÂÊÈ΋ ËÏÈΛ·, ÂÚ˘ıÚÔÔÈËÙ›ÓË.

Key words: congenital erythrocytosis, infancy, erythropoietin.

∂ÈÛ·ÁˆÁ‹ H ·fiÏ˘ÙË ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË Â›Ó·È Ì›· ‰È·Ù·Ú·¯‹ ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· (1). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ·‡ÍËÛË Ù˘ Ì¿˙·˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÌÔÚ› Ó· Â›Ó·È ÚˆÙÔ·ı‹˜ ‹ ‰Â˘ÙÂÚÔ·ı‹˜, Û˘ÁÁÂÓ‹˜ ‹ Â›ÎÙËÙË. ™ÙËÓ

ÚˆÙÔ·ı‹ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÙˆÓ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙË Ê˘ÛÈÔÏÔÁÈο ÂÎÎÚÈÓfiÌÂÓË ÂÚ˘ıÚÔÔÈËÙ›ÓË ÂÓÒ ÛÙË ‰Â˘ÙÂÚÔ·ı‹, ·˘ÍË̤ÓË ‰È¤ÁÂÚÛË ÙˆÓ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘ÂÚ¤ÎÎÚÈÛ˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘.

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, °¶¡£ πÔÎÚ¿ÙÂÈÔ £ÂÛÛ·ÏÔÓ›ÎË

1st Pediatric Department of Aristotelion University of Thessaloniki, Ippokration General Hospital, Thessaloniki

504

¶·È‰È·ÙÚÈ΋ 2001;64:504-507

¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ ËÏÈΛ·˜ 20 ÌËÓÒÓ Ì ·fiÏ˘ÙË ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË, ÏfiÁˆ Ù˘ Û·ÓÈfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ Ù˘ ‰È·Ù·Ú·¯‹˜ ·˘Ù‹˜ ÛÙËÓ ·È‰È΋ Î·È È‰È·›ÙÂÚ· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ µÚ¤ÊÔ˜ ı‹Ï˘, ËÏÈΛ·˜ 20 ÌËÓÒÓ, ÚÔÛ‹Ïı ÛÙËÓ ∞’ ¶/¢ ∫ÏÈÓÈ΋ ÙÔ˘ πÔÎÚ¿ÙÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢ ÁÈ· ¤ÏÂÁ¯Ô ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘, Ë ÔÔ›· ‰È·ÈÛÙÒıËΠÛÂ Ù˘¯·›Ô ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ÌÔÓ·‰ÈÎfi ·È‰› Ê·ÈÓÔÌÂÓÈο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ·Ó·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙÔ˘˜ Û˘ÁÁ¤ÓÂÈ·. ∆fiÛÔ ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi, fiÛÔ Î·È ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi Ù˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂχıÂÚ·. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠÂÚ˘ıÚfiÙËÙ· ÚÔÛÒÔ˘, ¿ÎÚˆÓ ‰·¯Ù‡ÏˆÓ Î·È ‚ÏÂÓÓÔÁfiÓˆÓ, Ë ÔÔ›· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ˘‹Ú¯Â ·fi ÙË Á¤ÓÓËÛË. O ÛÏ‹Ó·˜ ‹Ù·Ó ·„ËÏ¿ÊËÙÔ˜ Î·È Ë ·ÚÙËÚȷ΋ ›ÂÛË Î˘Ì·ÈÓfiÙ·Ó ÛÂ Ê˘ÛÈÔÏÔÁÈο - ÁÈ· ÙËÓ ËÏÈΛ· Ù˘ ·ÛıÂÓÔ‡˜ - Â›‰·. ∏ ˘fiÏÔÈË ÎÏÈÓÈ΋ ÂͤٷÛË ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ·Ú¯ÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠȉȷ›ÙÂÚ· ˘„ËÏ‹ ÙÈÌ‹ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ·ÈÌ·ÙÔÎÚ›ÙË Î·È ·ÚÈıÌÔ‡ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (∏b 17,3 g/dl, Ht 61,5%, RBC 9,3x106/Ìl) ηıÒ˜ Î·È ¯·ÌËÏÔ› ÁÈ· ÙËÓ ËÏÈΛ· Ù˘ ·ÛıÂÓÔ‡˜ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎÔ› ‰Â›ÎÙ˜ (MCV 67,4 Ìm3, MCH 18,9 pg, MCHC 28,1%). O ·ÚÈıÌfi˜ ‰ÈÎÙ˘ÔÂÚ˘ÚıÔ΢ÙÙ¿ÚˆÓ ‹Ù·Ó 2,5%, Ô ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 8,3x103/Ìl, Ô ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ 277x103/Ìl Î·È Ë ÊÂÚÚÈÙ›ÓË 21 ng/ml. ∏ ÌÔÚÊÔÏÔÁ›· ÂÚ˘ıÚÒÓ ¤‰ÂÈÍ ˘ԯڈ̛·, ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË, ·ÓÈÛÔ΢ÙÙ¿ÚˆÛË Î·È ÔÏ˘¯ÚˆÌ·Û›·. O ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ·ÈÌ·ÙÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ‹Ù·Ó Â›Û˘ Ê˘ÛÈÔÏÔÁÈÎfi˜.

O Û˘ÓÔÏÈÎfi˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ, ÌÂÙ¿ ·fi Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ̤ÙÚËÛË Ì ÛÂÛËÌ·Ṳ̂ӷ ÂÚ˘ıÚ¿, ‚Ú¤ıËΠȉȷ›ÙÂÚ· ·˘ÍË̤ÓÔ˜ (937 ml), ÂÓÒ Ë Ì¿˙· ÙˆÓ ÂÚ˘ıÚÒÓ ‹Ù·Ó 85 ml/kg (Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ <35 ml/kg). ∏ ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË ÙˆÓ Ï¢ÎÒÓ ‚Ú¤ıËΠ·˘ÍË̤ÓË (LAPA score=276, Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹=25-180), ÂÓÒ Ë ÙÈÌ‹ Ù˘ ‚ÈÙ·Ì›Ó˘ µ12 ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∆· Â›‰· ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ‚Ú¤ıËÎ·Ó ÂÍ·ÈÚÂÙÈο ·˘ÍË̤ӷ Û Â·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ, ÙfiÛÔ ÚÈÓ fiÛÔ Î·È ÌÂÙ¿ ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛË ·Ê·›Ì·Í˘, Ì ‰È·Î‡Ì·ÓÛË ·fi 800 IU/L ̤¯ÚÈ Î·È 2.500 IU/L (Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ 9,4±4,1 IU/L). ∏ ËÏÂÎÙÚÔÊfiÚËÛË Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, fiˆ˜ Î·È Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ DNA Ì ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆· Â›‰· ÙÔ˘ P50 Î·È ÙÔ˘ 2,3-DPG ‹Ù·Ó Â›Û˘ Ê˘ÛÈÔÏÔÁÈο (P50=28 mmHg, 2,3 DPG=5,4 mmol/L).

Paediatriki 2001;64:504-507

∫·Ù¿ ÙËÓ ÂͤٷÛË ÂȯڛÛÌ·ÙÔ˜ ·Ú·Î¤ÓÙËÛ˘ Ì˘ÂÏÔ‡ Î·È ‰Â›ÁÌ·ÙÔ˜ ÔÛÙÂÔÌ˘ÂÏÈ΋˜ ‚ÈÔ„›·˜, ‰È·ÈÛÙÒıËΠ·ÚÔ˘Û›· Î·È ÙˆÓ ÙÚÈÒÓ ÛÂÈÚÒÓ Û fiÏ· Ù· ÛÙ¿‰È· ˆÚ›Ì·ÓÛ˘, Ì ˘ÂÚÏ·Û›· Ù˘ ÂÚ˘ıÚ¿˜ ÛÂÈÚ¿˜ Î·È ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÂÚ˘ıÚÔ‚Ï·ÛÙÒÓ. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·Ú·ÙËÚ‹ıËΠ·˘ÙfiÌ·ÙË ·Ó¿Ù˘ÍË ·ÔÈÎÈÒÓ Ù˘ ÂÚ˘ıÚ¿˜ ÛÂÈÚ¿˜, ÌfiÓÔ CFU-E, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÚ˘ıÚÔÔÈËÙ›Ó˘ (4 CFU-E/105 ÌÔÓÔ‡ÚËÓ· ·ÙÙ·Ú· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ). ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Ù˘ ·ÛıÂÓÔ‡˜ ·ÔÎ¿Ï˘„ ̛· ‹È· ÂÚÈ‚ÚÔÁ¯È΋ ·ÓÙ›‰Ú·ÛË ·ÌÊÔÙÂÚfiÏ¢ڷ, ÂÓÒ Ì ÙËÓ ·ÏÌÈ΋ Ô͢ÌÂÙÚ›· ‰È·ÈÛÙÒıËΠSaO2 99%. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¿Óˆ Î·È Î¿Ùˆ ÎÔÈÏ›·˜, ÙÔ Ú·‰ÈÔ˚ÛÔÙÔÈÎfi ÓÂÊÚfiÁÚ·ÌÌ· Î·È Ë Ì·ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. §fiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ ÂΉ‹ÏˆÛ˘ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, Ë ·ÛıÂÓ‹˜ Ù¤ıËΠ۠ÚfiÁÚ·ÌÌ· Ù·ÎÙÈÎÒÓ ·Ê·ÈÌ¿ÍÂˆÓ (10-15 ml/kg). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÍ¿ÌËÓ˘ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ Ù˘, ·Ú·Ì¤ÓÂÈ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË Ì¤¯ÚÈ Û‹ÌÂÚ· ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ ÚÔ‚Ï‹Ì·Ù·, ÂÓÒ Ë ÙÈÌ‹ ÙÔ˘ ·ÈÌ·ÙÔÎÚ›ÙË ‰È·ÙËÚÂ›Ù·È Û Â›Â‰Ô ~55%. ™˘˙‹ÙËÛË ∏ ÚˆÙÔ·ı‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ÛÙ· ·È‰È¿ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·, ÂÓÒ Ë ‰Â˘ÙÂÚÔ·ı‹˜ ··ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ·, Û˘Ó‹ıˆ˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ¯ÚfiÓÈ·˜ ·ÚÙËÚȷ΋˜ ˘ÔÍ›·˜ ‹ ˘ÂÚ¤ÎÎÚÈÛ˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ·fi οÔÈÔÓ fiÁÎÔ (1,2) (¶›Ó·Î·˜ 1). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ë ·ÛıÂÓ‹˜ ‰ÂÓ ÏËÚÔ‡Û ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ÚˆÙÔ·ıÔ‡˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜ (¶›Ó·Î·˜ 2) (3), ÂÓÒ Ë ·˘ÍË̤ÓË ÙÈÌ‹ Ù˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÙË ‰È¿ÁÓˆÛË ‰Â˘ÙÂÚÔ·ıÔ‡˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘. øÛÙfiÛÔ, ·Ú¿ ÙÔÓ ÂÎÙÂٷ̤ÓÔ ¤ÏÂÁ¯Ô, ‰ÂÓ ‰È·ÈÛÙÒıËΠη̛· ·fi ÙȘ Â›ÎÙËÙ˜ ·Èٛ˜ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘. ∂Í¿ÏÏÔ˘, ηıÒ˜ ÛÙÔ ÈÛÙÔÚÈÎfi Ù˘ ·ÛıÂÓÔ‡˜ ·Ó·Ê¤ÚÂÙ·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÚ˘ıÚfiÙËÙ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ·fi ÙË Á¤ÓÓËÛË, Èı·ÓÔÏÔÁԇ̠fiÙÈ Ë ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ‹Ù·Ó Û˘ÁÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜. OÈ ‰Â˘ÙÂÚÔ·ı›˜ ÌÔÚʤ˜ Ù˘ Û˘ÁÁÂÓÔ‡˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘ ÔÊ›ÏÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ ‡·ÚÍË ·ıÔÏÔÁÈÎÒÓ ·ÈÌÔÛÊ·ÈÚÈÓÒÓ (ÌÂı·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÓıÚ·Î˘Ï·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÈÌÔÛÊ·ÈÚ›Ó˜ Ì ·˘ÍË̤ÓË Û˘ÁÁ¤ÓÂÈ· ÚÔ˜ ÙÔ Ô͢ÁfiÓÔ) ‹ Û ÂÓ˙˘ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (ÂÏ·Ùو̤ӷ Â›‰· 2,3-DPG) (1,2). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ô ¤ÏÂÁ¯Ô˜ ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ÙËÓ ‡·ÚÍË ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂÈ·˜ ‹ ÂÓ˙˘ÌÔ¿ıÂÈ·˜. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ ‹ ÔÈÎÔÁÂÓÔ‡˜

505

¶·È‰È·ÙÚÈ΋ 2001;64:504-507

Paediatriki 2001;64:504-507

¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ÂÚ˘ıÚÔ΢ÙÙ·ÚÒÛÂˆÓ (11) ¶ÚˆÙÔ·ı‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ñ ™˘ÁÁÂÓ‹˜ - ¢È·Ù·Ú·¯‹ ˘Ô‰Ô¯¤· ÂÚ˘ıÚÔÔÈËÙ›Ó˘

ñ ∂›ÎÙËÙË - ∞ÏËı‹˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›· (polycythemia vera) - π‰ÈÔ·ı‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË

¢Â˘ÙÂÚÔ·ı‹˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛË ñ ™˘ÁÁÂÓ‹˜ - ¶·ıÔÏÔÁÈ΋ ·ÈÌÔÛÊ·ÈÚ›ÓË (ÌÂı·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÓıÚ·Î˘Ï·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÈÌÔÛÊ·ÈÚ›ÓË ÌÂ Û˘ÁÁ¤ÓÂÈ· ÚÔ˜ ÙÔ O2) - ∂Ó˙˘ÌÔ¿ıÂÈ· ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ( 2,3-DPG) - ∞˘ÙfiÓÔÌË ˘ÂÚ¤ÎÎÚÈÛË ÂÚ˘ıÚÔÔÈËÙ›Ó˘(‚Ï¿‚Ë Ô‰Ô‡ ·›ÛıËÛ˘ O2;) ñ ∂›ÎÙËÙË - ÀÔÍ›· (Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·, Ó¢ÌÔÓÔ¿ıÂÈ·) - ŸÁÎÔÈ (ÓÂÊÚÔ‡, ‹·ÙÔ˜, ·ÚÂÁÎÂÊ·Ï›‰·˜)

¶›Ó·Î·˜ 2. ¡ÂfiÙÂÚ· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ·ÏËıÔ‡˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜ (3) ∞1 ∞2 ∞3 ∞4

∞˘ÍË̤ÓË Ì¿˙· ÂÚ˘ıÚÒÓ (>25% ÊÙ) ∞Ô˘Û›· ·ÈÙ›·˜ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘ æËÏ·ÊËÙ‹ ÛÏËÓÔÌÂÁ·Ï›· ¶·ÛÚÔ˘Û›· ‰Â›ÎÙË ÎψÓÈÎfiÙËÙ·˜

¢È·ÁÓˆÛÙÈο: ∞1 + ∞2 + ∞3 ‹ ∞4

µ1 µ2

£ÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË (>400 x 109/l) O˘‰ÂÙÂÚÔÊÈÏ›· (>10 x 109/l)

µ3 µ4

™ÏËÓÔÌÂÁ·Ï›· Ô˘ ‰È·ÈÛÙÒÓÂÙ·È Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ ∂Ó‰ÔÁÂÓ›˜ ÂÚ˘ıÚÔÂȉ›˜ ·ÔÈ˘ ‹/Î·È ÂÏ·Ùو̤ÓË ∂ƒO ÔÚÔ‡

∞1 + ∞2 + 2 ·fi Ù· µ

ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘, ÔÈ Ôԛ˜ ‰ÂÓ ÔÊ›ÏÔÓÙ·È ÛÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ ‰È·Ù·Ú·¯¤˜, ·ÏÏ¿ Û ˘ÂÚ¤ÎÎÚÈÛË ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ·Î·ıfiÚÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ (4-7). ¶Èı·ÓÔÏÔÁÂ›Ù·È Ë ‡·ÚÍË ‚Ï¿‚˘ ÛÙÔ ÓÂÊÚÈÎfi ·ÈÛıËÙ‹Ú· ÙÔ˘ Ô͢ÁfiÓÔ˘ ‹ Û οÔÈÔ ÛËÌÂ›Ô Ù˘ Ô‰Ô‡ ·›ÛıËÛ˘ ÙÔ˘ Ô͢ÁfiÓÔ˘ (oxygen sensing pathway) (6-8), Èı·ÓfiÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘ÂÚ¤ÎÎÚÈÛ˘ ÙÔ˘ hypoxia-inducable factor-1 (HIF-1) (7). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÂÓ‰ÔÁÂÓ‹˜ ·Ó¿Ù˘ÍË ·ÔÈÎÈÒÓ CFU-E ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ΢ÙÙ¿ÚˆÓ, ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ÂÚ˘ıÚÔÔÈËÙ›Ó˘, Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ù˘ ÚˆÙÔ·ıÔ‡˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜ (polycythemia vera) (1,2). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È fiˆ˜ Î·È Û ¿ÏϘ ·Ó·ÊÂÚfiÌÂÓ˜ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÈÏÈÔÁÚ·Ê›· ÂÚÈÙÒÛÂȘ, ‰È·ÈÛÙÒıËΠ·˘ÙfiÌ·ÙË ·Ó¿Ù˘ÍË ·ÔÈÎÈÒÓ Ù˘ ÂÚ˘ıÚ¿˜ ÛÂÈÚ¿˜ (CFU-E) ¯ˆÚ›˜ Ó· ÏËÚÔ‡ÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜ (4,9,10). ∞ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ Ì˯·ÓÈÛÌfi ˘ÂÚ¤ÎÎÚÈÛ˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘, Ô Î›Ó‰˘ÓÔ˜ ÂΉ‹ÏˆÛ˘ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘ÂÚÁÏÔÈfiÙËÙ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ ·Ú·Ì¤ÓÂÈ. ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÛ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛË ·Ê·È͈̿Ó, ÙË ¯ÔÚ‹ÁËÛË ˘‰ÚÔ͢Ԣڛ·˜ ‹ Ì˘ÂÏÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (1,2). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ Ù˘ ËÏÈΛ·˜ Ù˘ ·ÛıÂÓÔ‡˜, ˆ˜ ıÂÚ·›· ÂÎÏÔÁ‹˜ ÎÚ›ıËÎÂ Ë Ú·ÁÌ·ÙÔÔ›ËÛË Ù·ÎÙÈÎÒÓ ·Ê·È͈̿Ó, Ì ÛÎÔfi ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ·ÈÌ·ÙÔÎÚ›ÙË Û ¯·ÌËÏ¿ Â›‰·, Ì ٷ˘Ùfi¯ÚÔÓÔ ¤ÏÂÁ¯Ô ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÊÂÚÚÈÙ›Ó˘, ηıÒ˜ ÔÈ Û˘¯Ó¤˜ ·Ê·ÈÌ¿ÍÂȘ Ô‰ËÁÔ‡Ó Û˘¯Ó¿ Û ÛȉËÚÔÂÓ›·.

506

∏ ‰È¢ÎÚ›ÓÈÛË Ù˘ ·ÎÚÈ‚Ô‡˜ ÌÔÚȷ΋˜ ‚Ï¿‚˘ Ô˘ Ô‰ËÁ› ÛÙËÓ ˘ÂÚ¤ÎÎÚÈÛË Ù˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘, ı· ÌÔÚ¤ÛÂÈ ›Ûˆ˜ ÛÙÔ Ì¤ÏÏÔÓ Ó· ‚ÔËı‹ÛÂÈ ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÛˆÛÙ‹˜ ·ÓÙÈÌÂÙÒÈÛ˘ fiˆ˜ Î·È Ù˘ ÚfiÁÓˆÛ˘, ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙË ‰È·Ù·Ú·¯‹ ·˘Ù‹. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ÙÔÓ ¶·È‰›·ÙÚÔ-°ÂÓÂÙÈÛÙ‹ ∞Ó·ÏËÚˆÙ‹ ∫·ıËÁËÙ‹ Î. ª. ∫·Ó·‚¿ÎË ·fi ÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ÙÔ˘ ∂ıÓÈÎÔ‡ Î·È ∫·Ô‰ÈÛÙÚÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ηıÒ˜ Î·È ÙËÓ ∞ÈÌ·ÙÔÏfiÁÔ Î. ∂. πˆ·ÓÓ›‰Ô˘, ∂›ÎÔ˘ÚË ∫·ıËÁ‹ÙÚÈ· Ù˘ µ’ ¶/£ ∫ÏÈÓÈ΋˜ ∞¶£ ÁÈ· ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Nathan DG, Oski FA, eds. Therapeutic plasma exchange and cytapheresis. In: Hematology of Infancy and Childhood. 4th ed. W.B. Saunders Company; 1993. p.

1823-1824.

2. Hoffman R, Benz EJ, Shattil SJ, Furil B, Cohen HJ, Silberstein LE, eds. Diseases of the blood: Polycythemia.

In: Hematology. Basic Principles and Practice. 2nd ed.

Churchill Livingstone Inc; 1995. p. 1056-1057.

3. Pearson TC, Messinezy H. The diagnostic criteria of polycythemia rubra vera. Leuk Lymphoma 1996;22(Suppl 1):87-93.

4. Borgna-Pignatti C, Liberato NL, Marradi P, Rosti V, Barosi G. Regulation of erythropoietin production in a case of congenital erythropoietin-dependent pure erythrocytosis.

Am J Hematol 1994;46:348-353.

5. Yonemitsu H, Yamaghuchi K, Shigeta H, Okuda K, Takaku F. Two cases of familial erythrocytosis with increased erythropoietin activity in plasma and urine. Blood 1973;42:793-797.

6. Manglani M, DeGroff C, Dukes P, Ettinger L. Congenital

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7.

8.

9.

10.

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erythrocytosis with elevated erythropoietin level: An incorrectly set “erythrostat?”. J Pediatr Hematol Oncol 1998;20:560-562.

Sokol L, Kralovics R, Ren S, Luhovy M, Prchal JF, Prchal JT. Secondary polycythemia with putative defect in HIF-1 transcription activation pathway. Blood 1995;86:312a.

Whitcomb WH, Peschle C, Moore M, Nitschke R, Adamson J. Congenital erythrocytocis: a new form associated with an erythropoietin-dependant mechanism. Br J Haematol 1980;44:17-24.

Mankad V, Moore B, Mc Ryan D, Zuckerman K. Erythrocytosis associated with spontaneous erythroid colony formation and idiopathic hypererythropoietinemia.

J Pediatr 1987;111:743-745.

Dainiak N, Hoffman R, Lewbowitz AI, Solomon L, Maffei L, Ritsey K. Erythropoietin-dependent primary pure

erythrocytosis. Blood 1979;53:1076-1084.

11. ¶·ÓÙÂÏ›‰Ô˘ ¢, ∏ÏÈ¿Î˘ ¶. ¢È¿ÁÓˆÛË-∫ÏÈÓÈΤ˜ ∂ΉËÏÒÛÂȘ-∂ͤÏÈÍË Ù˘ ∞ÏËıÔ‡˜ ¶ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·˜. ª˘ÂÏÔ¸ÂÚÏ·ÛÙÈο ™‡Ó‰ÚÔÌ·. ∂Ù‹ÛÈÔ ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ. £ÂÛÛ·ÏÔÓ›ÎË, ∞ı‹Ó·; ª¿ÈÔ˜-πÔ‡ÓÈÔ˜ 2000. ÛÂÏ. 72-77.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÈÚ¿ÓÙ· ∞ı·Ó·Û›Ô˘ ∞Á. ™ÔÊ›·˜ 30, 546 22, £ÂÛÛ·ÏÔÓ›ÎË

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ™È‰ËÚÔÂÓ›· Î·È ÁÓˆÛÙÈ΋ ·ÓÙ›ÏË„Ë Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÂÊ‹‚Ô˘˜ ÛÙȘ ∏¶∞1 ∂ÈÛ·ÁˆÁ‹: OÈ Halterman Î·È Û˘Ó ·fi ÙËÓ π·ÙÚÈ΋ ™¯ÔÏ‹ Rochester Ù˘ ¡¤·˜ ÀfiÚ΢ ÛÙȘ ∏¶∞, ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ù· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ÛȉËÚÔÂÓ›·, ¯ˆÚ›˜ ··Ú·›ÙËÙ· Ì ·Ó·ÈÌ›·, ¤¯Ô˘Ó ¯·ÌËϤ˜ ÂȉfiÛÂȘ ÛÂ Ù˘ÔÔÈË̤Ó˜ Ì·ıËÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜. ™Ù· ‚Ú¤ÊË, Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›· ÚÔηÏ› ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË. ∏ Â›‰Ú·ÛË, fï˜, Ù˘ ÛȉËÚÔÂÓÈ΋˜ ·Ó·ÈÌ›·˜ ‹ ·ÎfiÌË Î·È Ù˘ ÛȉËÚÔÂÓ›·˜, ÛÙË ÁÓˆÛÙÈ΋ ·ÓÙ›ÏË„Ë ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÂÊ‹‚ˆÓ ·Ú·Ì¤ÓÂÈ Û¯ÂÙÈο ·‰È¢ÎÚ›ÓÈÛÙË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: OÈ ÂÚ¢ÓËÙ¤˜ Halterman Î·È Û˘Ó ¯ÚËÛÈÌÔÔ›ËÛ·Ó ‰Â‰Ô̤ӷ ·fi ÙËÓ ÂıÓÈ΋ ÌÂϤÙË “National Health and Nutrition Examination Survey III1988-1994” Û¯ÂÙÈο Ì ÙËÓ Â¿ÚÎÂÈ· Ûȉ‹ÚÔ˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ·È‰ÈÒÓ ËÏÈΛ·˜ 6-16 ÂÙÒÓ, fiˆ˜ Â›Ó·È Ô ÎÔÚÂÛÌfi˜ ÙÚ·ÓÛÊÂÚÚ›Ó˘, Ë ÂχıÂÚË ÚˆÙÔÔÚÊ˘Ú›ÓË ÂÚ˘ıÚÒÓ Î·È Ë ÊÂÚÚÈÙ›ÓË ÛÙÔÓ ÔÚfi. ∂¿Ó ‰‡Ô ·fi ÙȘ ÙÚÂȘ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚÔ˘˜ ‹Ù·Ó ·ıÔÏÔÁÈΤ˜ ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÙÔ˘ ·È‰ÈÔ‡, ÙfiÙ ÙÔ ·È‰› ·˘Ùfi ÔÚÈ˙fiÙ·Ó fiÙÈ Â›¯Â ÛȉËÚÔÂÓ›·. ∏ ÙÈÌ‹ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ·Ó·ÈÌ›·˜. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 5398 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ù˘ ÂıÓÈ΋˜ ÌÂϤÙ˘, ¤Ó· ÔÛÔÛÙfi 3% ›¯Â ÛȉËÚÔÂÓ›·. ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÛȉËÚÔÂÓ›·˜ (8,7%) ·Ú·ÙËÚ‹ıËΠÛÙ· ÎÔÚ›ÙÛÈ· ÂÊË‚È΋˜ ËÏÈΛ·˜. OÈ ÂÚ¢ÓËÙ¤˜ Û˘Ó¤ÎÚÈÓ·Ó ÙȘ ‚·ıÌÔÏÔÁ›Â˜ ·fi Ù˘ÔÔÈË̤Ó˜ Ì·ıËÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜, ÛÙȘ Ôԛ˜ ˘Ô‚Ï‹ıËÎ·Ó ·È‰È¿ ¯ˆÚ›˜ ÛȉËÚÔÂÓ›·, ·È‰È¿ Ì ÛȉËÚÔ-

ÂÓ›· ·ÏÏ¿ ¯ˆÚ›˜ ·Ó·ÈÌ›· Î·È ·È‰È¿ Ì ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·. ¢È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ì ÛȉËÚÔÂÓ›· (Ì ‹ ¯ˆÚ›˜ ·Ó·ÈÌ›·) ›¯·Ó ¿Óˆ ·fi ‰‡Ô ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ‚·ıÌÔÏÔÁËıÔ‡Ó Î¿Ùˆ ·fi ÙÔ Ì¤ÛÔ fiÚÔ ÛÙȘ Ì·ıËÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ ¯ˆÚ›˜ ÛȉËÚÔÂÓ›·. ∞˘Ù‹ Ë Û˘Û¯¤ÙÈÛË ·Ú¤ÌÂÈÓ ÈÛ¯˘Ú‹, ·ÎfiÌË Î·È ÛÙ· ·È‰È¿ Ì ÛȉËÚÔÂÓ›· Ù· ÔÔ›· ‰ÂÓ Â›¯·Ó ·Ó·ÈÌ›·. ™˘ÌÂÚ¿ÛÌ·Ù·: OÈ Halterman Î·È Û˘Ó Û˘ÌÂÚ·›ÓÔ˘Ó fiÙÈ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙË ÁÈ· Ó· ηıÔÚÈÛÙ› Â¿Ó Ô Ì·˙ÈÎfi˜ ¤ÏÂÁ¯Ô˜ (screening) ·È‰ÈÒÓ Û ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ÛȉËÚÔÂÓ›· Î·È Ë ıÂÚ·›· ÙÔ˘˜ ·ÔÙÂÏ› ÂӉ‰ÂÈÁ̤ÓË Ù·ÎÙÈ΋ Î·È ÙÔÓ›˙Ô˘Ó fiÙÈ ·Ó Ù· Â˘Ú‹Ì·Ù· Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘˜ ÂȂ‚·ÈˆıÔ‡Ó Û ÌÂÏÏÔÓÙÈΤ˜ ÚÔÔÙÈΤ˜ ÌÂϤÙ˜, ›Ûˆ˜ ¯ÚÂÈ·ÛÙ› Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÛÙ· ÎÔÚ›ÙÛÈ· ÂÊË‚È΋˜ ËÏÈΛ·˜ ÁÈ· ÛȉËÚÔÂÓ›·.

1

Halterman JS, Kaczorowski JM, Allgne CA, Auinger P, Szilagyl PG Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States Pediatrics 2001;107:1381-1386

∞ϤͷӉÚÔ˜ Ã. ª¿Î˘ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ

507

¶·È‰È·ÙÚÈ΋ 2001;64:508-513

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2001;64:508-513

CASE REPORT

™˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘ ·2 Ã. ¶. ¶·ÓÙÂÏÈ¿‰Ë˜1, ¡. ºÏ¿Ú˘2, ∂. ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘1, π. •˘ÓÈ¿˜1

Congenital muscular dystrophy with laminin-a2 deficiency C. Panteliadis1, N. Flaris2, E. Karatza-Xifilidou1, J. Xinias1

¶ÂÚ›ÏË„Ë: ∏ Û˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Â›Ó·È ÂÙÂÚÔÁÂÓ‹˜ ÔÌ¿‰· Ó¢ÚÔÌ˘˚ÎÒÓ ·ı‹ÛÂˆÓ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ˘ÔÙÔÓ›· ·fi ÙË Á¤ÓÓËÛË ‹ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ªÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔ ÛˆÌ·ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Î·È ÛÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë Ù˘ Ï·ÌÈÓ›Ó˘ ·2 ‹ ÌÂÚÔÛ›Ó˘. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ ÌÂ Û˘ÁÁÂÓ‹ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘ ·2 Ì ¤Ó·ÚÍË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÚ›¯ıËΠÛÙ· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù·, ÛÙ· ÂÓ‰ÂÈÎÙÈο ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Î·È ÂȂ‚·ÈÒıËΠ̠ÙËÓ ÈÛÙÔÏÔÁÈ΋ Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ÌÂϤÙË Ù˘ ‚ÈÔ„›·˜ Ì˘fi˜.

Abstract: Congenital muscular dystrophy is a heterogeneous group of neuromuscular disorders characterized by muscle weakness and hypotonia at birth or within the first few months of life. It is inherited in an autosomal recessive pattern. About half of the patients have a deficiency of the alpha 2-chain of laminin-2 (merosin). We describe a case of congenital muscular dystrophy in an infant with laminin a2-chain deficiency, whose onset of symptoms appeared in early infancy. The diagnosis was based on clinical symptoms as well as on laboratory findings, and was confirmed by histological and immunohistochemical studies on muscle biopsy.

§¤ÍÂȘ ÎÏÂȉȿ: Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, Ï·ÌÈÓ›ÓË ·2.

Key words: muscular dystrophy, laminin a2.

∂ÈÛ·ÁˆÁ‹ OÈ Ì˘˚Τ˜ ‰˘ÛÙÚÔʛ˜ Â›Ó·È Ì›· ÔÌ¿‰· ÂÎÊ˘ÏÈÛÙÈÎÒÓ ÓfiÛˆÓ ÙˆÓ Ì˘ÒÓ Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È ÁÂÓÂÙÈο. ∏ Û˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (™ª¢) ÂΉËÏÒÓÂÙ·È Ì ÙË Á¤ÓÓËÛË ‹ Ï›ÁÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ (1-4). O ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ ™ª¢ ‰›ÓÂÙ·È Û ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ˘ÔÙÔÓ›· Î·È ·‰˘Ó·Ì›·, Û˘¯Ó¿ Ì ·ÚıÚÔÁÚ‡ˆÛË ‹ Û˘Áο̄ÂȘ Ì˘ÒÓ, ÙˆÓ ÔÔ›ˆÓ Ë ÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË ˘ÔÏ›ÂÙ·È ÛËÌ·ÓÙÈο Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ (1-4). ∏ ÎÏÈÓÈ΋ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ ÂȉÂÈÓÒÓÂÙ·È ÚÔԉ¢ÙÈο. ¶ÂÚÈÁڷʤ˜ Ù˘ ÓfiÛÔ˘ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 Ù·ÍÈÓÔÌÔ‡Ó ÙË ™ª¢ fi¯È ·Ó¿ÏÔÁ· Ì ÙÔ Ú˘ıÌfi ÂͤÏÈÍ‹˜ Ù˘, ·ÏÏ¿ Ì ÙÔ Î·Ù¿ fiÛÔ Û˘Ó˘¿Ú¯ÂÈ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·-

ÙÔ˜ (∫¡™). ¶ÚÒÙ· ÔÈ Fukuyama Î·È Û˘Ó (5) Î·È ·ÚÁfiÙÂÚ· ÔÈ Fowler Î·È Manson (6) ÂÚȤÁÚ·„·Ó ·È‰È¿ Ù· ÔÔ›· ÁÂÓÓ‹ıËÎ·Ó ˘ÔÙÔÓÈο ÌÂ Û˘Áο̄ÂȘ Ì˘ÒÓ, ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ·ÚÔ˘Û›·˙·Ó ÂÎÙÂٷ̤Ó˜ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÛÙÔ ∫¡™. OÈ Santavuori Î·È Û˘Ó (7) ÂÚȤÁÚ·„·Ó ÙË ÓfiÛÔ ÔÊı·ÏÌÒÓ, Ì˘ÒÓ, ÂÁÎÂÊ¿ÏÔ˘, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ™ª¢, ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ÔÊı·ÏÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û ·ÛıÂÓ›˜ ·fi ÙË ºÈÓÏ·Ó‰›·. ∏ Û˘ÓÔ‰fi˜ Û·ÛÙÈÎfiÙËÙ· Î·È Ù· ÔÊı·ÏÌÈο Â˘Ú‹Ì·Ù· ÙÔ ‰È·¯ˆÚ›˙Ô˘Ó ·fi ÙË ÌÔÚÊ‹ Fukuyama Ù˘ ™ª¢ (™ª¢F). ∆Ô Û‡Ó‰ÚÔÌÔ WalkerWarburg (™WW) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ™ª¢, ˘‰ÚÔΤʷÏÔ, Ì·ÎÚÔÎÂÊ·Ï›·, ÏÈÛÂÁÎÂÊ·Ï›· Ù‡Ô˘ 2, ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜, ÙÔ˘

1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£ πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 2 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ πÔÎÚ·Ù›Ԣ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢

1 3rd Pediatric Department of Aristotelion University Ippokration General Hospital, Thessaloniki 2 Pathology Laboratory Ippokration General Hospital, Thessaloniki

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·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Î·È ÁÈ’ ·˘Ùfi ıˆÚÂ›Ù·È ‰È·ÊÔÚÂÙÈÎfi Ù˘ ™ª¢F (8). ∆Ô 1986, Ô Brooke ‰È·ÈÛÙÒÓÂÈ fiÙÈ ÁÈ· ¤Ó· ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ˘ÔÙÔÓ›·, Û˘Û¿ÛÂȘ Ì˘ÒÓ Î·È ¿ÏÏ· ÛÙÔȯ›· ÂÓ‰ÂÈÎÙÈο ÚÔÛ‚ÔÏ‹˜ ÙˆÓ Ì˘ÒÓ, ¯ÚÂÈ¿˙ÂÙ·È Ì›· ·‰È·ÌÊÈÛ‚‹ÙËÙË ‚ÈÔ¯ËÌÈ΋ ‰ÔÎÈÌ·Û›·, Ë ÔÔ›· ı· ÌÔÚ› Ó· ‰È·¯ˆÚ›ÛÂÈ ÙȘ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ (1,2). ŒÙÛÈ, ÚfiÛÊ·Ù· ÂÚÈÁÚ¿ÊËÎÂ Ë ¤ÏÏÂÈ„Ë Ù˘ ÌÂÚÔÛ›Ó˘ (Ï·ÌÈÓ›ÓË-2) ÛÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË ÙˆÓ Ì˘˚ÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÛÙË ÌÔÚÊ‹ Ù˘ ™M¢ Ô˘ ÁÂÓÂÙÈο Û˘Ó‰¤ÂÙ·È Ì ÙÔ ¯ÚˆÌfiۈ̷ 6q22-23 Î·È Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û˘¯ÓfiÙÂÚ· ÛÙÔ˘˜ ∂˘Úˆ·˚ÎÔ‡˜ Ï·Ô‡˜. ∏ ¤ÏÏÂÈ„Ë ·˘Ù‹ ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÌÂÚÔÛ›Ó˘ (9,10). ªÂ ÙËÓ ·Ó·Î¿Ï˘„Ë ·˘Ù‹ ‰È·¯ˆÚ›ÛÙËÎ·Ó ÔÈ ÌÔÚʤ˜ ™ª¢ Û ·ÚÓËÙÈΤ˜ Î·È ıÂÙÈΤ˜ ÁÈ· ÌÂÚÔÛ›ÓË (11-15). ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ Ì ™ª¢ ·ÚÓËÙÈ΋ ÁÈ· ÌÂÚÔÛ›ÓË Î·È Á›ÓÂÙ·È Û˘˙‹ÙËÛË ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÙÔ˘˜ ÙÚfiÔ˘˜ ‰È¿ÁÓˆÛ˘, ÙËÓ ÚfiÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ·˘Ù‹ ÙË ÌÔÚÊ‹ Ù˘ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜ 57 ËÌÂÚÒÓ ÂÈÛ¿ÁÂÙ·È ÁÈ· ¤ÏÂÁ¯Ô ÁÂÓÈÎÂ˘Ì¤Ó˘ ˘ÔÙÔÓ›·˜, ÓˆıÚfiÙËÙ·˜ Î·È ÂÏ·Ùو̤Ó˘ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜. ∏ ·ËÛË, Ô ÙÔÎÂÙfi˜ Î·È Ë ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó ¯ˆÚ›˜ ÚÔ‚Ï‹Ì·Ù·. ∆Ô ·È‰› ÁÂÓÓ‹ıËΠÙÂÏÂÈfiÌËÓÔ, Ì ‚¿ÚÔ˜ 3450 gr, Ì‹ÎÔ˜ 52 cm Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ 35,5 cm. ™ÙËÓ ËÏÈΛ· ÙˆÓ 57 ËÌÂÚÒÓ Â›¯Â ‚¿ÚÔ˜ 4060 gr (10Ë ∂£), Ì‹ÎÔ˜ 58 cm (75Ë ∂£) Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ 38 cm (25Ë ∂£). ∏ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ΢ÎÏÔÊÔÚÈÎfi Î·È Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·. ∫·Ù¿ ÙË Ó¢ÚÔ-·Ó·Ù˘Íȷ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÙÔÓ›· ÌÂ Ì˘˚΋ ·‰˘Ó·Ì›· ÛÙ· ¿Óˆ ¿ÎÚ· Î·È Ì¤ÙÚÈ· ÛÙ· οو Ì ÂÏ¿¯ÈÛÙ˜ ÂÓÂÚÁËÙÈΤ˜ ÎÈÓ‹ÛÂȘ, ·‰˘Ó·Ì›· ÛÙ‹ÚÈ͢ ÎÂÊ·Ï‹˜, ·Ô˘Û›· ·Ú¯¤ÁÔÓˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ. OÈ ÙÂÓfiÓÙȘ ·ÓÙ·Ó·ÎÏ¿ÛÂȘ ÛÙ· ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚ· ‹Ù·Ó ÂÏ·Ùو̤Ó˜. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠ̤ÙÚÈ· ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 205 mU/ml, SGPT 150 mU/ml, ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ¤ˆ˜ 40 mU/ml) Î·È Ôχ ˘„ËϤ˜ ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘ ʈÛÊÔÎÈÓ¿Û˘ (CPK), 8400 mU/ml Î·È Á·Ï·ÎÙÈ΋˜ ‰Â¸‰ÚÔÁÂÓ¿Û˘ LDH, 1373 mU/ml (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ 25-190 mU/ml Î·È 225-400 mU/ml, ·ÓÙ›ÛÙÔȯ·). O ¤ÏÂÁ¯Ô˜ ÁÈ· Ù· Û˘ÓËı¤ÛÙÂÚ· ÓÔÛ‹Ì·Ù· ÌÂÙ·‚ÔÏÈÛÌÔ‡, fiˆ˜ ·ÌÈÓfiÁÚ·ÌÌ·, ۷ί·ÚfiÁÚ·ÌÌ· ÔÚÔ‡ Î·È Ô‡ÚˆÓ, ÔÚÁ·ÓÈο Ôͤ·, ·Ì̈ӛ·, Á·Ï·-

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ÎÙÈÎfi Ô͇ ÔÚÔ‡ Î·È ÔÍÂÔ‚·ÛÈ΋ ÈÛÔÚÚÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∆· ·ÎÔ˘ÛÙÈο Î·È ÔÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο Î·È ÙÔ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· (ÚfiÛıÈÔ˜ ÎÓËÌÈ·›Ô˜ Î·È ÙÂÙڷΤʷÏÔ˜) Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘.

O ¤ÏÂÁ¯Ô˜ ÙÔ˘ ∫¡™, ·Ú¯Èο Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (CT) ÂÁÎÂÊ¿ÏÔ˘, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ·, Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI), ¤‰ÂÈÍ ÂÈÎfiÓ· ˘ÔÌ˘ÂϛӈÛ˘, Èı·Ó¿ ÛÙ· Ï·›ÛÈ· ÓfiÛÔ˘ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜. ™ÙËÓ ∆2 ·ÎÔÏÔ˘ı›· ηٷÁÚ¿ÊËΠÂÚÈÎÔÈÏȷο ˘„ËÏfi Ì·ÁÓËÙÈÎfi Û‹Ì·, ÂÓÒ ÛÙËÓ ∆1 ·ÎÔÏÔ˘ı›· ¯·ÌËÏfi. ∏ MRI ÂÁÎÂÊ¿ÏÔ˘ ¤‰ÂÈÍ ·ÎfiÌË ÔÏÈÁÔÁ˘Ú›· Î·È ·Á˘Ú›· ÛÙÔ˘˜ ÈÓÈ·ÎÔ‡˜ ÏÔ‚Ô‡˜, ηıÒ˜ Î·È ÊÏÔÈ˚΋ ‰˘ÛÏ·Û›· Á‡Úˆ ·fi ÙËÓ ·ÚÈÛÙÂÚ‹ Û¯ÈÛÌ‹ ÙÔ˘ Silvius, ·Û˘ÌÌÂÙÚ›· ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ, ˘ÂÚÛÎËÓȉȷÎÒÓ Î·È ˘·Ú·¯ÓÔÂȉÒÓ ¯ÒÚˆÓ (∂ÈÎfiÓ· 1). ∆· ·ÓˆÙ¤Úˆ ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Û˘ÓËÁÔÚÔ‡Û·Ó ˘¤Ú Ù˘ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜. ŒÙÛÈ, ·ÎÔÏÔ‡ıËÛ ‚ÈÔ„›· Ì˘fi˜ ·fi ÙÔÓ ÙÂÙڷΤʷÏÔ ÁÈ· ÔÏÔÎÏ‹ÚˆÛË Ù˘ ‰È¿ÁÓˆÛ˘. ™ÙË ‚ÈÔ„›· ÙÔ˘ Ì˘fi˜ ·Ú·ÙËÚ‹ıËΠ¤ÓÙÔÓË ›ÓˆÛË Î·È ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜. OÈ ›Ó˜ ·ÚÔ˘Û›·˙·Ó ‰È·Î‡Ì·ÓÛË ÙÔ˘ ‡ÚÔ˘˜ ÙÔ˘˜, ·ÔÛÙÚÔÁÁ‡ÏˆÛË ÙÔ˘ ÂÚÈÁÚ¿ÌÌ·Ùfi˜ ÙÔ˘˜, ·ÙÚÔÊ›·, ˘ÂÚÙÚÔÊ›· Î·È ÂÛÙȷ΋ ÂÎʇÏÈÛË (EÈÎfiÓ˜ 2·, 2‚, 2Á Î·È 2‰). ¢È·ÎÚ›ıËÎ·Ó Ï›Á˜

∂ÈÎfiÓ· 1. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Ù˘ ¿ÚÚˆÛÙ˘. ·) ∂ÈÎfiÓ· ˘ÔÌ˘ÂϛӈÛ˘ ÂÚÈÎÔÈÏȷο. ‚) OÏÈÁÔÁ˘Ú›·, ·Á˘Ú›·. Á) ∞Û˘ÌÌÂÙÚ›· ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ.

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‰È¿Û·ÚÙ˜ ›Ó˜ Ì ‚·ÛÂfiÊÈÏÔ ‹ ÎÔÎÎÈ҉˜ ΢ÙÙ·ÚfiÏ·ÛÌ·. ™Â ¯ÚÒÛÂȘ ÁÈ· ÔÍÂȉˆÙÈο ¤Ó˙˘Ì· ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·Ú¯ÈÙÂÎÙÔÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÒÓ ·ÏÏÔÈÒÛˆÓ. ™Â ¯ÚÒÛÂȘ ÁÈ· fiÍÈÓË ÊˆÛÊ·Ù¿ÛË Î·È ÌË ÂȉÈ΋ ÂÛÙÂÚ¿ÛË, ·Ú·ÙËÚ‹ıËΠÂÛÙȷ΋ ‰È‹ıËÛË ·fi Ì·ÎÚÔÊ¿Á· Î·È Ï›Á˜ ÌÂÌÔӈ̤Ó˜ ÂÎÊ˘ÏÈ˙fiÌÂÓ˜ ›Ó˜. ¢È·ÎÚ›ıËÎ·Ó ÔÏϤ˜ ‰È¿Û·ÚÙ˜ ›Ó˜, ıÂÙÈΤ˜ ÁÈ· ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙˆÓ ÈÓÒÓ Û ÁÏ˘ÎÔÁfiÓÔ ‹ Ï›Ô˜ Û ¯ÚÒÛÂȘ ƒ∞S Î·È Ì ÌÂÏ·Ófi ÙÔ˘ ™Ô˘‰¿Ó, ·ÓÙ›ÛÙÔȯ·. ™Â ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ¯ÚÒÛÂȘ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÏ¿ÙÙˆÛË Ù˘ ÌÂÌ‚Ú·ÓÈ΋˜ ¯ÚÒÛ˘ ÙˆÓ ÈÓÒÓ ÁÈ· ‰˘ÛÙÚÔÊ›ÓË, Û·ÚÎÔÁÏ˘Î¿Ó˜ Î·È ‰˘ÛÙÚÔÁÏ˘Î¿ÓË Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú·. ∞ÓÙ›ıÂÙ·, ·Ú·ÙËÚ‹ıËΠÏ‹Ú˘ ¤ÏÏÂÈ„Ë ¯ÚÒÛ˘ ÁÈ· ÌÂÚÔÛ›ÓË (·2 Ï·ÌÈÓ›ÓË). ∆· ÈÛÙÔÏÔÁÈο Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο Â˘Ú‹Ì·Ù· Ù˘ ‚ÈÔ„›·˜

Â›Ó·È Û˘Ì‚·Ù¿ ÌÂ Û˘ÁÁÂÓ‹ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘ ·2, ÚˆÙ½Ó˘ Ô˘ Ê˘ÛÈÔÏÔÁÈο ‚Ú›ÛÎÂÙ·È ÛÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË ÙˆÓ Ì˘˚ÎÒÓ Î˘ÙÙ¿ÚˆÓ (ÁÚ·Ì̈ÙÔ› ̇˜ Î·È Ì˘ÔοډÈÔ), ÛÙ· ÂÚÈÊÂÚÈο Ó‡ڷ (·ÙÙ·Ú· Schwan), ÛÙ· ·ÈÌÔÊfiÚ· ·ÁÁ›· ÂÁÎÂÊ¿ÏÔ˘ (‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË), ÛÙÔÓ Ï·ÎÔ‡ÓÙ·, ÛÙÔ ÓÂÊÚfi Î·È ÛÙÔ ‰¤ÚÌ· (16-18).

O ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜ ·¤ÎÏÂÈÛ ÙËÓ ÚÔ˚Ô‡Û· ÓˆÙÈ·›· Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (Werdnig-Hoffmann) Î·È ÙË Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Ù‡Ô˘ Duchenne, Ô˘ ·ÔÎÏ›ÛÙËÎÂ Î·È Ì ÙËÓ ·Ó‡ÚÂÛË Ê˘ÛÈÔÏÔÁÈ΋˜ ‰˘ÛÙÚÔÊ›Ó˘.

O ÁÔÓȉȷÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ ‹Ù·Ó ‰‡ÛÎÔÏÔ ¤ˆ˜ ·‰‡Ó·ÙÔ Ó· Á›ÓÂÈ ÛÙËÓ ∂ÏÏ¿‰·, ·ÏÏ¿ Î·È Û ÂÚ¢ÓËÙÈο ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ÛÙ· ÔÔ›· ·¢ı˘Óı‹Î·ÌÂ. ∏ ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒıËΠ̠ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÈÛÙÔÏÔÁÈ΋˜ Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋˜

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∂ÈÎfiÓ· 2. ªÔÚÊÔÏÔÁÈο Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ‚ÈÔ„›·˜ ÙÂÙÚ·ÎÂÊ¿ÏÔ˘ Ù˘ ¿ÚÚˆÛÙ˘. ·. ∞ÈÌ·ÙÔÍ˘Ï›ÓË-∏ˆÛ›ÓË (x 350). ¶·Ú·ÙËÚÂ›Ù·È ¤ÓÙÔÓË ›ÓˆÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÛÙÚÒÌ·ÙÔ˜ Î·È Â˘Ú›· ‰È·Î‡Ì·ÓÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ÈÓÒÓ Ì ¤ÓÙÔÓË ·ÙÚÔÊ›· Î·È ˘ÂÚÙÚÔÊ›· ÙˆÓ ÈÓÒÓ. ‚. ∞ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ¯ÚÒÛË ÁÈ· ‰˘ÛÙÚÔÊ›ÓË (x 85) (¡CL-Dys 2). ¶·Ú·ÙËÚÂ›Ù·È Ê˘ÛÈÔÏÔÁÈ΋ ¯ÚÒÛË Î·È ‰È·ÁÚ·Ê‹ ÙÔ˘ ÂÚÈÁÚ¿ÌÌ·ÙÔ˜ ÙˆÓ ÈÓÒÓ Ì ¢Ú›· ‰È·Î‡Ì·ÓÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘˜. Á. ∞ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ¯ÚÒÛË ÁÈ· ÌÂÚÔÛ›ÓË (x 350) ‚ÈÔ„›·˜ ·ÛıÂÓÔ‡˜. ¶·Ú·ÙËÚÂ›Ù·È Û¯Â‰fiÓ ·ÓÙÂÏ‹˜ ¤ÏÏÂÈ„Ë ¯ÚÒÛ˘ ÙˆÓ ÈÓÒÓ ÁÈ· ÌÂÚÔÛ›ÓË Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú·. ‰. ∞ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ¯ÚÒÛË ÁÈ· ÌÂÚÔÛ›ÓË ‚ÈÔ„›·˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Ì¿ÚÙ˘Ú· (x 350).

510

¶·È‰È·ÙÚÈ΋ 2001;64:508-513

ÌÂϤÙ˘ Ù˘ ‚ÈÔ„›·˜ Ì˘fi˜, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È Û ·Ó¿ÏÔÁ· ÂÚÈÛÙ·ÙÈο Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ (18). ∆Ô ·È‰› Û˘Ó¯›˙ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ™ÙÔ˘˜ Â·ÓÂϤÁ¯Ô˘˜, Û ËÏÈΛ· 15, 18 Î·È 27 ÌËÓÒÓ, ÂÌÊ·Ó›˙ÂÈ ‚·ÚÈ¿ ÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ÂÈÎfiÓ· ÁÂÓÈÎÂ˘Ì¤Ó˘ ˘ÔÙÔÓ›·˜ ÌÂ Ì˘˚΋ ·‰˘Ó·Ì›· ¯ˆÚ›˜ η̛· ÂÓÂÚÁËÙÈ΋ ΛÓËÛË, Ï‹ÚË Î·Ù¿ÚÁËÛË ÙˆÓ ÙÂÓfiÓÙÈˆÓ ·ÓÙ·Ó·ÎÏ¿ÛˆÓ, ·Ú·ÎÔÏÔ˘ı› Î·È Ï¤ÂÈ ·ÚÎÂÙ¤˜ ϤÍÂȘ. ÀÔÏ›ÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË Ì ‚¿ÚÔ˜ Î·È ‡„Ô˜ οو ·fi ÙËÓ 3Ë ∂£.

O ηډÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· Î·È ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·, ÙfiÛÔ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È ÛÙÔ˘˜ Â·ÓÂϤÁ¯Ô˘˜, ¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ Î·È Ê˘ÛÈÔÏÔÁÈÎfi ¿¯Ô˜ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ÙÔ˘ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏÈ¿˜. ∆Ô ·È‰›, ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 27 ÌËÓÒÓ, ‰ÂÓ ÂÌÊ¿ÓÈÛ ÂÂÈÛfi‰ÈÔ Û·ÛÌÒÓ Î·È ÛÙÔ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ¿ ÙÔ˘ ηٷÁÚ¿ÊËÎ·Ó ¯·ÌËÏ¿ ‰˘Ó·ÌÈο, ηıÒ˜ Î·È ·ÛÙ¿ıÂÈ· Ú˘ıÌÔ‡ Î·È ‰˘Ó·ÌÈÎÔ‡. ∏ ‰Â‡ÙÂÚË MRI ÂÁÎÂÊ¿ÏÔ˘, ÛÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ, ·ÂÈÎÔÓ›˙ÂÈ Ù· ›‰È· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ì ÙËÓ ÚÒÙË, Ì ÈÔ ÂÎÙÂٷ̤ÓË ÂÈÎfiÓ· ‰˘ÛÌ˘ÂϛӈÛ˘. ∆Ô ÂÎ Ó¤Ô˘ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· Â›Ó·È Û·ÊÒ˜ Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘ Ì ηٷÛÙÚÔÊ‹ Ù˘ Ì˘˚΋˜ ›Ó·˜. ™Ù· ۈ̷ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ·Ú·ÙËÚÂ›Ù·È ‰È·ÊÔÚ¿ ÌÂٷ͇ ·ÚÈÛÙÂÚÔ‡ Î·È ‰ÂÍÈÔ‡ ËÌÈÌÔÚ›Ô˘, Ì ۷ʋ ηı˘ÛÙ¤ÚËÛË Î˘Ì·ÙÔÌÔÚÊÒÓ ÛÙÔ ‰ÂÍÈfi ÎÓËÌÈ·›Ô Ì˘. ∆· ·ÎÔ˘ÛÙÈο ‰˘Ó·ÌÈο Â›Ó·È ·ÚÈÛÙÂÚ¿ Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ ‰ÂÍÈ¿ ·Ú·ÙËÚÂ›Ù·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÎÔ¯ÏÈ·ÎÔ‡ ˘Ú‹Ó· Î·È ¿Óˆ ÂÏ·›·˜. ∆· Ì˘˚ο ¤Ó˙˘Ì·, ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô, ‰ÂÓ Â˘Ú›ÛÎÔÓÙ·È ϤÔÓ ÛÙȘ ›‰È˜ ˘„ËϤ˜ ÙÈ̤˜ (CPK 304 mU/ml, LDH 609 mU/ml), Û ۇÁÎÚÈÛË Ì ÙȘ ÚÒÙ˜, Èı·Ófiٷٷ ÏfiÁˆ Ù˘ ÂÎÙÂٷ̤Ó˘ ÂÎʇÏÈÛ˘, ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Î·È ·ÙÚÔÊ›·˜ ÙÔ˘ Ì˘˚ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. £ÂÚ·¢ÙÈο Á›ÓÂÙ·È ˘ÔÛÙËÚÈÎÙÈ΋ Ê˘ÛÈÎÔıÂÚ·›· ÁÈ· ÙËÓ ÂÓ›Û¯˘ÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙËÓ ÎÏÈÓÈ΋ Ì·˜. ™˘˙‹ÙËÛË ∏ Û˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ÎÏËÚÔÓÔÌÂ›Ù·È Ì ÙÔÓ ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì˘˚΋ ·‰˘Ó·Ì›· ‹ ˘ÔÙÔÓ›· ·fi ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ Î·È Ë Û˘¯ÓfiÙËÙ¿ Ù˘ ·Ó¤Ú¯ÂÙ·È Û 1/10.000 ÁÂÓÓ‹ÛÂȘ (19). ™ÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘¿Ú¯ÂÈ Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ ·2 ·Ï˘Û›‰·˜ Ù˘ Ï·ÌÈÓ›Ó˘ 2 ‹ ÌÂÚÔÛ›Ó˘, ÁÓˆÛÙ‹ ˆ˜ Û˘ÁÁÂÓ‹˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘. ∏ Ï·ÌÈÓ›ÓË 2, Ë ÔÔ›· ·Ï·ÈfiÙÂÚ· ÔÓÔÌ·˙fiÙ·Ó Î·È ÌÂÚÔÛ›ÓË ‹ Ï·ÌÈÓ›ÓË-ª, Â›Ó·È ¤Ó· ÂÙÂÚÔÙÚÈÌÂ-

Paediatriki 2001;64:508-513

Ú¤˜, Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi Ì›· ‚·ÚÈ¿ ·Ï˘Û›‰·, ÙËÓ ·2 Î·È ‰‡Ô ÂÏ·ÊÚ¤˜, ÙË ‚1 Î·È Á1. ∆Ô ÌfiÚÈfi Ù˘ ʤÚÂÈ ¤Ó· Ì·ÎÚ‡ Î·È ‰‡Ô ‚Ú·¯¤· ÛΤÏË Î·È Û˘Ó‰¤ÂÙ·È ¤ÌÌÂÛ· Ì ÙËÓ ÚˆÙ½ÓË Ù˘ ‰˘ÛÙÚÔÊ›Ó˘ ‰È·Ì¤ÛÔ˘ Ì›·˜ ÔÌ¿‰·˜ ÁÏ˘ÎÔÚˆÙÂ˚ÓÒÓ (16,19). OÈ ÚˆÙ½Ó˜ ·˘Ù¤˜ ‚Ú›ÛÎÔÓÙ·È ÛÙÔ Û·ÚΛÏËÌ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ÛÙ· ÂÁοÚÛÈ· ÛˆÏËÓ¿ÚÈ· ÙÔ˘ ηډȷÎÔ‡ Ì˘fi˜ (3). O ˘‡ı˘ÓÔ˜ ÁfiÓÔ˜ Ù˘ Ï·ÌÈÓ›Ó˘ ·2 ÂÓÙÔ›ÛÙËΠÛÙÔ ¯ÚˆÌ·Ùfiۈ̷ 6q22-23 Î·È Ë ¤ÏÏÂÈ„Ë ·˘ÙÔ‡ ‹ ÔÈ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ Â›Ó·È ˘‡ı˘Ó˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ (19,20). ∞ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ¤ÏÏÂÈ„Ë Ù˘ ·2 ·Ï˘Û›‰·˜ ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ ¤¯ÔÓÙ˜ ¤ÏÏÂÈ„Ë Ù˘ ÌÂÚÔÛ›Ó˘ ‹ Ï·ÌÈÓ›Ó˘ ·2 ÂÍ·ÈÙ›·˜ Ù˘ ·Ù¤ÏÂÈ·˜ ÙÔ˘ ÂÙÂÚÔÙÚÈÌÂÚÔ‡˜. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤¯Ô˘Ó ‚·Ú‡ÙÂÚÔ Ê·ÈÓfiÙ˘Ô, Û˘ÁÎÚÈÓfiÌÂÓÔÈ Ì ıÂÙÈÎÔ‡˜ ÁÈ· ÌÂÚÔÛ›ÓË ·ÚÚÒÛÙÔ˘˜ Ì ™ª¢ Î·È Û˘Ó‹ıˆ˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‚·‰›ÛÔ˘Ó ¯ˆÚ›˜ ‚Ô‹ıÂÈ·, ÁÈ·Ù› ¿Û¯Ô˘Ó ÙfiÛÔ ÔÈ ÛÎÂÏÂÙÈÎÔ› ̇˜ fiÛÔ Î·È ÙÔ ÂÚÈÊÂÚÈÎfi Î·È ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· (19,21-23). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ¿ÚÚˆÛÙË ÂÌÊ¿ÓÈÛ ˘ÔÙÔÓ›· Î·È Ì˘˚΋ ·‰˘Ó·Ì›· ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È ‰ÂÓ Â›¯Â „˘¯ÔÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ‹ ‰È·Ù·Ú·¯¤˜ ·fi Ù· Ì¿ÙÈ·. ∞fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ì ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜ ·Ó·Ù‡ÛÛÂÙ·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È Û ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ·ÚÚÒÛÙÔ˘˜, ‰È·Ù·ÙÈÎÔ‡ Ù‡Ô˘ Ì˘ÔηډÈÔ¿ıÂÈ· Û ÔÛÔÛÙfi 40%, Ì ÂÏ·Ùو̤ÓÔ ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ Û ÔÛÔÛÙfi ÂÚ›Ô˘ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (24,25). ¶ÚÔ˜ ÙÔ ·ÚfiÓ, Ë ·ÛıÂÓ‹˜, ÂÍ·ÈÙ›·˜ Ù˘ ËÏÈΛ·˜ Ù˘, ‰ÂÓ ÂÌÊ¿ÓÈÛ Úfi‚ÏËÌ· ·fi ÙËÓ Î·Ú‰È¿. ∆· Ì˘˚ο ¤Ó˙˘Ì· (CPK, LDH, SGOT Î·È SGPT) ‹Ù·Ó Û ˘„ËϤ˜ ÙÈ̤˜, fiˆ˜ ·Ó¢ڛÛÎÔÓÙ·È Û fiÏÔ˘˜ ۯ‰fiÓ ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ·fi ÙË ÓfiÛÔ. ∆Ô ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· ‹Ù·Ó Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘, Ù· ۈ̷ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Î·È Ù· ·ÎÔ˘ÛÙÈο ‰˘Ó·ÌÈο ·ıÔÏÔÁÈο fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ηı’ fiÛÔÓ ˘¿Ú¯ÂÈ ÂÏ·Ùو̤ÓË Ù·¯‡ÙËÙ· ·ÁˆÁ‹˜ ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ÓÂ‡ÚˆÓ (4,19). ∏ ÚÔÛ‚ÔÏ‹ ·˘Ù‹ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Â›Ó·È Èı·Ófi Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ·2 ·Ï˘Û›‰·˜ Ù˘ Ï·ÌÈÓ›Ó˘ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ Schwan (4,19). O ¤ÏÂÁ¯Ô˜ ÙÔ˘ ∫¡™ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Û˘Ó‹ıˆ˜ ‰›ÓÂÈ Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ÂÓÒ Ë ªRI ·ÔηχÙÂÈ ÛÙËÓ ∆2 ·ÎÔÏÔ˘ı›·, ·ÏÏÔÈÒÛÂȘ Ù˘ ÂÚÈÎÔÈÏȷ΋˜ Ï¢΋˜ Ô˘Û›·˜ Ì ˘„ËÏfi Ì·ÁÓËÙÈÎfi Û‹Ì· (15,16,19,26).

OÈ ›‰È˜ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ‚Ï¿‚˜ ÛÙÔ ∫¡™ Ô˘ ·ÂÈÎÔÓ›˙ÔÓÙ·È Ì ÙËÓ MRI ÂÁÎÂÊ¿ÏÔ˘ (·ÏÏÔÈÒÛÂȘ Ù˘ ÂÚÈÎÔÈÏȷ΋˜ Ï¢΋˜ Ô˘Û›·˜ Î·È ˘„ËÏfi Ì·ÁÓËÙÈÎfi Û‹Ì· ÛÙËÓ ∆2 ·ÎÔÏÔ˘ı›·) ·Ú·ÙËÚ‹ıËÎ·Ó Î·È ÛÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË. ∏ ‰Â‡ÙÂÚË MRI Ô˘ ¤ÁÈÓ Û ËÏÈΛ· 18 ÌËÓÒÓ ¤‰ÂÈÍ ÂÎÙÂٷ̤ÓË Û˘ÌÌÂÙÚÈ΋ Ï¢ÎÔÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂ Û˘ÌÌÂÙÔ¯‹ ηÈ

511

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ÙˆÓ ‰ÂÌ·Ù›ˆÓ, ¯ˆÚ›˜ Û˘ÌÌÂÙÔ¯‹ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ Î·È ÙˆÓ ‚·ÛÈÎÒÓ Á·ÁÁÏ›ˆÓ. ∏ ·ÈÙ›· ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ∫¡™ ‰ÂÓ ¤¯ÂÈ ‰È·Û·ÊËÓÈÛÙ› Ï‹Úˆ˜ (19), ÁÈ·Ù› Ê˘ÛÈÔÏÔÁÈο Ë ¿Ï˘ÛÔ˜ Ù˘ Ï·ÌÈÓ›Ó˘ ·2 ˘¿Ú¯ÂÈ ÛÙ· ·ÈÌÔÊfiÚ· ·ÁÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È fi¯È ÛÙÔ˘˜ ÔÏÈÁÔ‰ÂÓ‰Ú›Ù˜. ™‡Ìʈӷ Ì ̛· ¿Ô„Ë, ÔÈ ‚Ï¿‚˜ Ù˘ Ï¢΋˜ Ô˘Û›·˜, ÔÈ ÂÌÊ·Ó›˜ Ì ÙËÓ MRI ÂÁÎÂÊ¿ÏÔ˘, ÔÊ›ÏÔÓÙ·È ÛÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÈÌ·ÙÔÂÁÎÂÊ·ÏÈÎÔ‡ ÊÚ·ÁÌÔ‡ ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘ Ï·ÌÈÓ›Ó˘ (4,9,27). ¢ÂÓ ˘¿Ú¯ÂÈ Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘ Ù˘ Ï¢΋˜ Ô˘Û›·˜ Î·È ÙÔ˘ Ê·ÈÓfiÙ˘Ô˘ ‹ Ù˘ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ÎÏ·ÛÌ¿ÙˆÓ Ù˘ Ï·ÌÈÓ›Ó˘ ·2. ªÂϤÙ˜ Û ·ÚÚÒÛÙÔ˘˜ Ì ÂÎÙÂٷ̤Ó˜ ·ÏÏÔÈÒÛÂȘ Ù˘ Ï¢΋˜ Ô˘Û›·˜ ‰Â›¯ÓÔ˘Ó ‹ÈÔ Ê·ÈÓfiÙ˘Ô, Û ·ÓÙ›ıÂÛË Ì ¿ÏÏÔ˘˜, fiÔ˘ ÂÓÒ ˘‹Ú¯·Ó ‹Ș ‚Ï¿‚˜ ÛÙË Ï¢΋ Ô˘Û›·, ¤¯Ô˘Ó ‚·Ú‡ÙÂÚÔ Ê·ÈÓfiÙ˘Ô ·ÎfiÌË Î·È Ì ÂÌÊ¿ÓÈÛË ÂÂÈÛÔ‰›ˆÓ Û·ÛÌÒÓ (18,19). ∏ ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰˘ÛÙÚÔÊ›·˜ Ù›ıÂÙ·È ÎÏÈÓÈο Î·È ÂȂ‚·ÈÒÓÂÙ·È Ì ÙË ‚ÈÔ„›· Ì˘fi˜, fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ÏÈ҉˘ ‰È‹ıËÛË, ›ÓˆÛË Î·È ·Ô‰ÈÔÚÁ¿ÓˆÛË ÙˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, ·ÙÚÔÊ›·, ˘ÂÚÙÚÔÊ›· Î·È ÂÛÙȷ΋ ÂÎʇÏÈÛË ÙÔ˘ Ì˘fi˜ (25). ™Ù· ÈÛÙÔÏÔÁÈο Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο ·Ú·Û΢¿ÛÌ·Ù· Ì˘fi˜ ‰È·ÈÛÙÒÓÂÙ·È Ë ¤ÏÏÂÈ„Ë Ù˘ Ï·ÌÈÓ›Ó˘ ·2. ™ÙË ‚ÈÔ„›· Ì˘fi˜ Ù˘ ÂÚ›ÙˆÛ‹˜ Ì·˜ ·Ú·ÙËÚ‹ıËΠÏ‹Ú˘ ¤ÏÏÂÈ„Ë ¯ÚÒÛ˘ ÁÈ· ÌÂÚÔÛ›ÓË (·2 Ï·ÌÈÓ›ÓË). ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÂÏ¿ÙÙˆÛË Ù˘ ÌÂÌ‚Ú·ÓÈ΋˜ ¯ÚÒÛ˘ ÁÈ· ‰˘ÛÙÚÔÊ›ÓË, Û·ÚÎÔÁÏ˘Î¿Ó˜ Î·È ‰˘ÛÙÚÔÁÏ˘Î¿Ó˜, Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ¿ÏϘ Ì˘Ô¿ıÂȘ (4,25) (∂ÈÎfiÓ· 2). ™˘ÓÂÒ˜, Ù· Â˘Ú‹Ì·Ù· Ù˘ ‚ÈÔ„›·˜ Â›Ó·È Û˘Ì‚·Ù¿ Ì ™ª¢, ÏfiÁˆ ¤ÏÏÂȄ˘ Ù˘ ÌÂÚÔÛ›Ó˘ ‹ ·2 Ï·ÌÈÓ›Ó˘ (4,18,25). ªÂ ÙÔÓ ÁÔÓȉȷÎfi ¤ÏÂÁ¯Ô ·ÔÎÏ›ÛÙËÎÂ Ë ÓˆÙÈ·›· Ì˘˚΋ ·ÙÚÔÊ›· (Werdnig Hoffmann) Î·È Ë Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Ù‡Ô˘ Duchenne. ªÂÚÈ΋ ¤ÏÏÂÈ„Ë Ù˘ ·2 ·Ï˘Û›‰·˜ Ù˘ Ï·ÌÈÓ›Ó˘ ¤¯ÂÈ ·Ú·ÙËÚËı›: ·) ÛÙÔÓ Ù‡Ô Ù˘ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ ÛÙË ÓfiÛÔ “ÔÊı·ÏÌÒÓ Ì˘ÒÓ ÂÁÎÂÊ¿ÏÔ˘” (muscle-eye-brain), fiÔ˘ ˘¿Ú¯Ô˘Ó Ù¤ÛÛÂÚȘ ˘ÔÔÌ¿‰Â˜ Û‡Ìʈӷ Ì ÙÔ ‚·ıÌfi ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙˆÓ ÔÊı·ÏÌÒÓ Î·È ‚) ÛÙË Û˘ÁÁÂÓ‹ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Ù‡Ô˘ Fukuyama, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ·ÓˆÌ·Ï›Â˜ ·fi ÙÔÓ ÂÁΤʷÏÔ (19,23). ∏ ı¤ÛË ÙÔ˘ ÁfiÓÔ˘ Û ·˘Ù‹ ÙË ÓfiÛÔ Â›Ó·È ÛÙÔ ¯ÚˆÌfiۈ̷ 9q3133 Î·È Ë ·ÓÂ¿ÚÎÂÈ· Ù˘ Ï·ÌÈÓ›Ó˘ ·2 Â›Ó·È ‰Â˘ÙÂÚÔ·ı‹˜, Û ·ÓÙ›ıÂÛË Ì ÙË ÌÔÚÊ‹ Ù˘ ™ª¢ ÏfiÁˆ ¤ÏÏÂȄ˘ Ï·ÌÈÓ›Ó˘, fiÔ˘ Ë ¤ÏÏÂÈ„Ë ·˘Ù‹ Â›Ó·È ÚˆÙÔ·ı‹˜ (19,20,23). ™ÙȘ ÌÔÚʤ˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ Ù‡Ô˘ Fukuyama Î·È ªuscle-eye-brain Û˘Ó˘¿Ú¯Ô˘Ó ÂÎÙÂٷ̤Ó˜ ·Ó·ÙÔÌÈΤ˜ ‰È·Ù·Ú·-

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¯¤˜ ÙÔ˘ ∫¡™ (Fukuyama, Muscle-eye-brain) Î·È ÙÔ˘ ÔÊı·ÏÌÔ‡ (Muscle-eye-brain) Î·È Û˘ÓÔ‰fi˜ ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ¯·Ú·ÎÙËÚÈÛÙÈο Ù· ÔÔ›· ‰ÂÓ ¤¯ÂÈ Ë ·ÛıÂÓ‹˜ Ì·˜. ∏ ÂͤÏÈÍË ÙˆÓ ·ÚÚÒÛÙˆÓ ÌÂ Û˘ÁÁÂÓ‹ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· ·fi ¤ÏÏÂÈ„Ë Ï·ÌÈÓ›Ó˘ Â›Ó·È ‚·Ú‡ÙÂÚË. ™˘Ó‹ıˆ˜ ‰ÂÓ Î·ÙÔÚıÒÓÔ˘Ó Ó· ÛÙ·ıÔ‡Ó fiÚıÈÔÈ ‹ Ó· ÂÚ·Ù‹ÛÔ˘Ó, Ô‡Ù ӷ ηı›ÛÔ˘Ó ¯ˆÚ›˜ ‚Ô‹ıÂÈ·. ∏ ‚·ıÌÈ·›· ÂÍÂÏÈÛÛfiÌÂÓË Ì˘ÔηډÈÔ¿ıÂÈ· Î·È ÔÈ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÈ‚·Ú‡ÓÔ˘Ó ‰Ú·Ì·ÙÈο ÙËÓ ÚfiÁÓˆÛ‹ ÙÔ˘˜ (4,19,24). ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ Â›Ó·È Û˘Ìو̷ÙÈ΋ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ηډȿ˜ Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·, ÙËÓ ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ Ê˘ÛÈÎÔıÂÚ·›· (4,25). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Ì ÙËÓ ·Ó·˙‹ÙËÛË Ù˘ Ï·ÌÈÓ›Ó˘ ·2 ÛÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ Ì˘˜ Î·È ÛÙÔ ‰¤ÚÌ· ÌÂÙ¿ ·fi ‚ÈÔ„›· Î·È Ì ÁÔÓȉȷÎfi ¤ÏÂÁ¯Ô, fiÔ˘ ·ÔηχÙÂÙ·È ¤ÏÏÂÈ„Ë ‹ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ˘‡ı˘ÓÔ˘ ÁfiÓÔ˘ (18-21). ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ÂӉ›ÎÓ˘Ù·È Û ΢‹ÛÂȘ Ì ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È Á›ÓÂÙ·È Ì ÙË ‚ÈÔ„›· ¯ÔÚÈ·ÎÒÓ Ï·¯ÓÒÓ ÙÔ˘ Ï·ÎÔ‡ÓÙ· (12Ë Â‚‰ÔÌ¿‰· ·ËÛ˘), fiÔ˘ ·ÓȯÓ‡ÂÙ·È Ë ·Ï˘Û›‰· Ù˘ ·2 Ï·ÌÈÓ›Ó˘, ›Ù Ì ÙË ¯Ú‹ÛË ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ Ï·ÌÈÓ›Ó˘ ·2, ›Ù Ì ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ¯ÚÒÛÂȘ ‰ÂÈÁÌ¿ÙˆÓ ¯ÔÚÈ·ÎÒÓ Ï·¯ÓÒÓ (18,25,28). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ Û˘ÁÁÂÓ›˜ Ì˘˚Τ˜ ‰˘ÛÙÚÔʛ˜ Â›Ó·È Ì›· ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ì ÚÔ˚Ô‡Û· ÂͤÏÈÍË Î·È ¯ˆÚ›˜ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÈÙÈÔÏÔÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÚÔ˜ ÙÔ ·ÚfiÓ. ∏ ‰È¿ÁÓˆÛ‹ ÙÔ˘˜, fï˜, ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›·, ÙfiÛÔ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ¿ÏÏˆÓ ÓÔÛËÌ¿ÙˆÓ fiÛÔ Î·È ÁÈ· ÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ÙˆÓ ·Û¯fiÓÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Brooke MH, ed. A clinician’s view of neuromuscular diseases. 2nd ed. Baltimore: Williams & Wilkins; 1986. p.

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2. Banker BQ. The congenital muscular dystrophies. In: Engel AG, Franzini-Armstrong C, eds. Myology. 2nd ed.

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Amsterdam: Elsevier; 1973. p. 192-197.

7. Santavuori P, Leisti J, Kruus S. Muscle eye, brain disease: A new syndrome. Neuropädiatrie 1977;8:553-558.

8. Dobyns WB, Pagon RA, Armstrong D, Curry CJR, Greenberg F, Grix A et al. Diagnostic criteria for WalkerWarburg Syndrome. Am J Med Genet 1989;32:195-210.

9. Tome FMS, Evangelista T, Leclerc A, Sunada Y, Mande E, Esturnet B et al. Congenital muscular dystrophy with merosin deficiency CR. Acad Sci Paris 1994;317:351-357.

10. Helbling-Leclerc A, Zhang X, Topaloglu H, Gruand C, Tesson F, Weissenbach J et al. Mutations in the laminin a2chain gene (LAMA-2) cause merosin-deficient congenital muscular dystrophy. Nat Genet 1995;11:216-218.

11. Kobayashi K, Nakahori Y, Miyake M, Matsumura K, Kandolida E, Mormura Y et al. An ancient retrotransposal insertion causes Fukuyama type 6 congenital muscular dystrophy. Nature 1998;394:388-392.

12. Toba T, Kobayashi K, Kondo-lida E, Sasaki J, Nakamura Y. The fukuyama congenital muscular dystrophy story.

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13. Cormand B, Avela K, Pihko H, Santavuori P, Talim P, Topaloglu H et al. Assignment of the muscle-eye-brain disease gene to 1p32-34 by linkage analysis and homozygosity mapping. Am J Hum Genet 1999;64:126-135.

14. Moghadaszadeh B, Desguerre I, Topaloglu H, Muntoni F, Pavek S, Sewrg C et al. Identification of a new locus for a peculiar form of congenital muscular dystrophy with early rigidity of the spine on chromosome 1p35-36. Am J Hum Genet 1998;62:1439-1445.

15. Flannigan KM, Kerr L, Bromberg MB, Leonard C, Tsuruda J, Zhang P et al. Congenital muscular dystrophy with rigid spine syndrome: a clinical, pathological, radiological and genetic study. Ann Neurol 2000;47:147-161.

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17. Engrail E. Laminin variants: why where and when? Kidney Internat 1993;43:2-6.

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19. Cohn RD, Herrmann R, Sorokin L, Wener MU, Volt T. Laminin a2 chain-deficient congenital muscular epitage expression in severe and mild cases. Neurology 1998;51:94-100.

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Spyrou ¡, Philpot J, Foale R, Camici ƒ, Muntoni F. Evidence of left ventricular dysfunction in children with merosin-deficient congenital muscular dystrophy. Am Heart J 1998;136:474-476.

Klietsch R, Ervasti JM, Arnold W, Campobell KP, Jorgensen AO. Dystrophin-glycoprotein complex and laminin localize to the sarcolemma and transverse tubules of cardiac muscle. Circ Res 1993;72:349-360.

Tsao CY, Mendell JR, Rusin J, Laquette M. Congenital muscular dystrophy with complete laminin-alpha 2deficiency cortical dysplasia and cerebral white matter changes in children. J Child Neurol 1988;13:253-256.

Caro PA, Scavina M, Hoffman E, Pergoraro E, Marks HG. MR imaging findings in children with merosin deficient congenital muscular dystrophy. Am J Neuroradiol 1999;20:324-326.

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CASE REPORT

¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· Ì ˘‰ÚÔÓ¤ÊÚˆÛË Û ÎÔÚ›ÙÛÈ ÌÂ Û˘ÁÁÂÓ‹ ˘ÂÚÏ·Û›· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ ¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, ª. ∫·Ú·Ê¤˙Ë, ∞. ªÔ˘Ù¿ÊË, °. ∫·ÓÈ¿Ú˘, Ã. ∫·Ú‹˜

Crossed renal ectopia with fusion and hydronephrosis in a girl with congenital adrenal hyperplasia D. Karakaidos, P. Zosi, M. Karafezi, A. Moutafi, G. Kaniaris, C. Karis

¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ 17 ÂÙÒÓ Ì ηÙÒÙÂÚË ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· ÌÂ Û˘ÁÎfiÏÏËÛË. ∏ ‰È¿ÁÓˆÛË ·ÔÙ¤ÏÂÛÂ Ù˘¯·›Ô ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ‡ÚËÌ· ÛÙ· Ï·›ÛÈ· ÂϤÁ¯Ô˘ ÁÈ· ˘ÂÚ·Ó‰ÚÔÁÔÓ·ÈÌ›· Ô˘ ·‰›¯ıË fiÙÈ ÔÊÂÈÏfiÙ·Ó ÛÂ Û˘ÁÁÂÓ‹ ˘ÂÚÏ·Û›· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ÙËÓ ·ÚÔ˘Û›· ˘‰ÚÔÓ¤ÊÚˆÛ˘ Î·È ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ Ì ÌÂȈ̤ÓË ·ÚÔ¯¤Ù¢ÛË Ô‡ÚˆÓ, ȉ›ˆ˜ ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, ηıÒ˜ Î·È ÂÚÈÔ¯¤˜ ÂÏϷو̤Ó˘ ÚfiÛÏ˄˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜. ∞Ó·ÛÎÔÂ›Ù·È Ë ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ ÚÔ˜ ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ·˘Ù‹˜ Ù˘ Û¿ÓÈ·˜ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜, ηıÒ˜ Î·È ÙËÓ ÂȉËÌÈÔÏÔÁ›·, ÙËÓ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ÚÔ‚ÔÏ‹ Î·È ÙËÓ ÚfiÁÓˆÛË.

Abstract: A case of a 17 year old girl with crossed renal ectopia with fusion is described. The diagnosis was based on an incidental ultrasonographic finding during the course of a thorough investigation for hyperadrogenemia, which ultimately proved to be due to congenital adrenal hyperplasia. Imaging studies confirmed the presence of hydronephrosis of both kidneys with decreased urinary drainage which was more prominent on the ectopic kidney. DMSA revealed segments of reduced uptake of the radioisotope in both kidneys. The etiology of this rare condition as well as the clinical presentation, diagnosis and prognosis are reviewed.

§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›·, ˘‰ÚÔÓ¤ÊÚˆÛË, Û˘ÁÁÂÓ‹˜ ˘ÂÚÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ.

Key words: crossed renal ectopia, hydronephrosis of both kidneys, congenital adrenal hyperplasia.

∂ÈÛ·ÁˆÁ‹ ŒÎÙÔÔ˜ ÔÓÔÌ¿˙ÂÙ·È o ÓÂÊÚfi˜ Ô˘ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ ‰È·ÎfiÙÂÙ·È Ë ¿ÓÔ‰fi˜ ÙÔ˘ ÚÔ˜ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÙÔ˘ ı¤ÛË, Ë ÔÔ›· Â›Ó·È ·Ú·ÛÔÓ‰˘ÏÈο ÛÙÔ ‡„Ô˜ ÙÔ˘ £12 ¤ˆ˜ O3 ÛÔÓ‰‡ÏÔ˘ Î·È ·Ú·Ì¤ÓÂÈ Û ·ÓÒÌ·ÏË ı¤ÛË (1). ∏ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· (¢¡∂) Â›Ó·È Ì›· Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›·, ÛÙËÓ ÔÔ›· Ô ¤ÎÙÔÔ˜ ÓÂÊÚfi˜

‚Ú›ÛÎÂÙ·È ÛÙÔ ·ÓÙ›ıÂÙÔ ËÌÈÌfiÚÈÔ ÙÔ˘ ÛÒÌ·ÙÔ˜, ÂÓÒ Ô Ô˘ÚËÙ‹Ú·˜ ÙÔ˘ ¯·Ú·ÎÙËÚÈÛÙÈο ‰È·ÛÙ·˘ÚÒÓÂÙ·È Ì ÙË Ì¤ÛË ÁÚ·ÌÌ‹ Î·È ÂÈÛ¤Ú¯ÂÙ·È Û ÔÚıfiÙÔË ı¤ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË (1-4). OÈ ªc Donald Î·È Mc Clellan Î·Ù¤Ù·Í·Ó ÙË ¢¡∂ ÛÙȘ ·ÎfiÏÔ˘ı˜ ÌÔÚʤ˜ (1,2,5): 1) ¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÂÎÙÔ›· ÌÂ Û˘ÁÎfiÏÏËÛË (¢¡∂ª™), Ô˘ Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ Ì ÔÛÔÛÙfi 90%, 2) ¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÂÎÙÔ›· ¯ˆÚ›˜ Û˘ÁÎfiÏÏËÛË, Ô˘ ·ÎÔÏÔ˘ı› ÛÂ Û˘¯ÓfiÙËÙ·, 3) ªÔÓ‹Ú˘ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÂÎÙÔ›· Î·È 4) ∞ÌÊÔÙÂÚfiÏ¢ÚË ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ÂÎÙÔ›·, Ô˘ Â›Ó·È Ë Û·ÓÈfiÙÂÚË ÌÔÚÊ‹.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜-¶ÂÈÚ·È¿ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ

Department of Pediatrics General Hospital of Nikea-Piraeus “St. Panteleimon”, Athens

™˘ÓÙÔÌÔÁڷʛ˜ ¢¡∂ ¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· ¢¡∂ª™ ¢È·ÛÙ·˘ÚÔ‡ÌÂÓË ÓÂÊÚÈ΋ ÂÎÙÔ›· ÌÂ Û˘ÁÎfiÏÏËÛË

514

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∏ ¢¡∂ª™ Ì ÙË ÛÂÈÚ¿ Ù˘ ‰È·ÎÚ›ÓÂÙ·È ÛÙȘ ·Ú·Î¿Ùˆ ÌÔÚʤ˜ (1-3): ·) ∫·ÙÒÙÂÚË ÂÎÙÔ›·, fiÙ·Ó Ô Î¿Ùˆ fiÏÔ˜ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÓÂÊÚÔ‡ ÂÓÒÓÂÙ·È Ì ÙÔÓ ¿Óˆ fiÏÔ ÙÔ˘ ¤ÎÙÔÔ˘ ÓÂÊÚÔ‡ (ÂÚ›Ô˘ ÙÔ 60%), ‚) ™ÈÁÌÔÂȉ‹˜ ÂÎÙÔ›·, Á) ™¯‹Ì·ÙÔ˜ -L-ÂÎÙÔ›·, fiÙ·Ó Ô ¤ÎÙÔÔ˜ ÓÂÊÚfi˜ Â›Ó·È Î¿ıÂÙÔ˜, ‰) ¡ÂÊÚfi˜ Û¯‹Ì·ÙÔ˜ ‚ÒÏÔ˘ (Lump-kindey), fiÙ·Ó ¤¯Ô˘Ì ÂÎÙÂٷ̤ÓË ¤ÓˆÛË ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ, Â) ¢ÈÛÎÔÂȉ‹˜ ÓÂÊÚfi˜, fiÙ·Ó ¤¯Ô˘Ì ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ¤ÓˆÛË ÛÙȘ ¤Ûˆ ÂÈÊ¿ÓÂȘ ÙˆÓ ÓÂÊÚÒÓ Î·È ÛÙ) ∞ÓÒÙÂÚË ÂÎÙÔ›·, fiÙ·Ó Ô ¤ÎÙÔÔ˜ ÓÂÊÚfi˜ ‚Ú›ÛÎÂÙ·È Û ˘„ËÏfiÙÂÚË ·fi ÙÔÓ ÔÚıfiÙÔÔ, Ô˘ Â›Ó·È Î·È Ë Û·ÓÈfiÙÂÚË ÌÔÚÊ‹. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 16 ÂÙÒÓ ·Ú·¤ÌÊıËΠÛÙÔ ∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi π·ÙÚÂ›Ô Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÏfiÁˆ ˘ÂÚ·Ó‰ÚÔÁÔÓ·ÈÌ›·˜, Ô˘ ‰È·ÈÛÙÒıËΠ۠¤ÏÂÁ¯Ô ÁÈ· ˘ÂÚÙÚ›¯ˆÛË ¿ÎÚˆÓ Î·È ·Ú·›ˆÛË ÙÚ›¯ˆÛ˘ ÎÂÊ·Ï‹˜. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ‰ÂÓ ·Ó·Ê¤ÚıËÎ·Ó Ô˘ÚÔÏÔÈÌÒÍÂȘ, fï˜ ÛËÌÂÈÒÓÂÙ·È Ë ·ÚÔ˘Û›· ·ÚÎÂÙÒÓ ÂÌ˘Ú¤ÙˆÓ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Ô˘ ·Ô‰fiıËÎ·Ó Û ÏÔÈÌÒÍÂȘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∞fi ÙËÓ ËÏÈΛ· ÙˆÓ 14 ÂÙÒÓ ÙÔ ·È‰› ¿Ú¯ÈÛ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ ÎÚ›ÛÂȘ Ù‡Ô˘ ·Ê·ÈÚ¤Ûˆ˜ ÌÂ Û˘ÓÔ‰¤˜ ·ÎÔ˘ÛÙÈΤ˜ „¢‰·ÈÛı‹ÛÂȘ, Ô˘ ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο ÛÙËÓ ·ÁˆÁ‹ Ì Ô͢ηڂ·Ì·˙Â›ÓË. ™ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ ‰È·ÈÛÙÒıËΠÌÈÎÚfi ÊÏ‚҉˜ ·ÁÁ›ˆÌ· ÛÙÔ ‰ÂÍÈfi ÌÂÙˆÈ·›Ô ÏÔ‚fi Ô˘ ‰ÂÓ Û˘Û¯ÂÙ›ÛÙËΠ̠ÙȘ ÎÚ›ÛÂȘ. ∫·Ù¿ ÙËÓ Â›ÛÔ‰Ô ÛÙËÓ ÎÏÈÓÈ΋, Ë ·ÛıÂÓ‹˜ ·-

∂ÈÎfiÓ· 1. I.V ˘ÂÏÔÁÚ·Ê›·: Ë ‡ÂÏÔ˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ ÂÏ·ÊÚ¿ ‰È·ÙÂٷ̤ÓË ‰È·ÎÚ›ÓÂÙ·È Û ‰ÂÍÈ¿ ÂÓ‰Ô˘ÂÏÈ΋ ı¤ÛË, ÂÓÒ Ô Û‡ÛÙÔȯԘ Ô˘ÚËÙ‹Ú·˜ ÂÈÛ¤Ú¯ÂÙ·È Û ÔÚıfiÙÔË ı¤ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. ∏ ‡ÂÏÔ˜ ÙÔ˘ ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡ Û ÔÚıfiÙÔË ı¤ÛË Ì ‰È¿Ù·ÛË Ô˘ Èı·ÓÒ˜ ˘ÂÚÂÎÙÈÌ¿Ù·È ÏfiÁˆ Ù˘ ¤Íˆ ÛÙÚÔÊ‹˜ ÙÔ˘ Û‡ÛÙÔÈ¯Ô˘ ÓÂÊÚÔ‡.

Paediatriki 2001;64:514-517

ÚÔ˘Û›·˙ ·Ú·›ˆÛË ÙÚ›¯ˆÛ˘ ÎÂÊ·Ï‹˜, ȉ›ˆ˜ ÛÙË ÌÂÙˆÈ·›· ¯ÒÚ·, ˘ÂÚÙÚ›¯ˆÛË ¿ÎÚˆÓ, Ê˘ÛÈÔÏÔÁÈο ¤Íˆ ÁÂÓÓËÙÈο fiÚÁ·Ó· ı‹ÏÂÔ˜ Î·È Ô ‚·ıÌfi˜ ÂÓ‹‚ˆÛ˘ ‹Ù·Ó ÛÙÔ 5Ô ÛÙ¿‰ÈÔ Î·Ù¿ Tanner. ∞fi Ù· ˘fiÏÔÈ· Û˘ÛÙ‹Ì·Ù·, Ë ÂͤٷÛË ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·.

O ÔÚÌÔÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ ·˘ÍË̤ӷ Â›‰· ·Ó‰ÚÔÁfiÓˆÓ (ÙÂÛÙÔÛÙÂÚfiÓ˘, ‰È¸‰ÚÔÂÈ·Ó‰ÚÔÛÙÂÚfiÓ˘, ·Ó‰ÚÔÛÙÂÓ‰ÈfiÓ˘, 17 O∏-ÚÔÁÂÛÙÂÚfiÓ˘) Ì ·‡ÍËÛË ÙfiÛÔ ÙˆÓ ‚·ÛÈÎÒÓ ÙÈÌÒÓ, fiÛÔ Î·È ÙˆÓ ÙÈÌÒÓ ÌÂÙ¿ ·fi ‰È¤ÁÂÚÛË Ì ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ACTH. OÈ ˘fiÏÔÈ˜ ÔÚÌfiÓ˜ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Â›¯·Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜. ∏ ˘ÂÚ·Ó‰ÚÔÁÔÓ·ÈÌ›· ·Ô‰fiıËΠ۠ÌË ÎÏ·ÛÈ΋ ÌÔÚÊ‹ Û˘ÁÁÂÓÔ‡˜ ˘ÂÚÏ·Û›·˜ ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ Î·È Ë ·ÛıÂÓ‹˜ ÂÙ¤ıË Û ·ÁˆÁ‹ Ì ˘‰ÚÔÎÔÚÙÈ˙fiÓË (20 mg/m2/24h). ™Ù· Ï·›ÛÈ· ÙÔ˘ ÂϤÁ¯Ô˘ ÙˆÓ ¤Ûˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Ô˘ ¤‰ÂÈÍ ÙÔÓ ·ÚÈÛÙÂÚfi ÓÂÊÚfi Ó· ‚Ú›ÛÎÂÙ·È Û ¤ÎÙÔË ı¤ÛË ‰ÂÍÈ¿ ÂÓ‰Ô˘ÂÏÈο Î·È Èı·ÓfiÓ Ô ¿Óˆ fiÏÔ˜ ÙÔ˘ Ó· Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ Î¿Ùˆ fiÏÔ ÙÔ˘ ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡, Ô ÔÔ›Ô˜ ·ÚÔ˘Û›·˙ ¤Íˆ ÛÙÚÔÊ‹. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ‰ÂÓ ·ÂÎ¿Ï˘„ ·ıÔÏÔÁ›· ·fi Ù· ÂÈÓÂÊÚ›‰È·, ÂȂ‚·›ˆÛ fï˜ Ù· Â˘Ú‹Ì·Ù· ÙÔ˘ ˘ÂÚ˯ÔÁÚ·ÊÈÎÔ‡ ÂϤÁ¯Ô˘. ∞ÎÔÏÔ‡ıˆ˜, ¤ÁÈÓ ÂÓ‰ÔÊϤ‚È· ˘ÂÏÔÁÚ·Ê›·, ÛÙËÓ ÔÔ›· Ë ‡ÂÏÔ˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ¤ÎÙÔÔ˘ ÓÂÊÚÔ‡ ÂÌÊ·ÓÈ˙fiÙ·Ó ÂÏ·ÊÚÒ˜ ‰È·ÙÂٷ̤ÓË Û ‰ÂÍÈ¿ ÂÓ‰Ô˘ÂÏÈ΋ ı¤ÛË, ÂÓÒ Ô Û‡ÛÙÔȯԘ Ô˘ÚËÙ‹Ú·˜ ÂÈÛÂÚ¯fiÙ·Ó Û ÔÚıfiÙÔË ı¤ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. ∏ ‡ÂÏÔ˜

∂ÈÎfiÓ· 2. ¢˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· DTPA: ÈηÓfiÙËÙ· ·ÚÔ¯¤Ù¢Û˘ ÂËÚ·Ṳ̂ÓË Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜, ȉȷ›ÙÂÚ· fï˜ ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, ÛÙÔÓ ÔÔ›Ô ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ·fiÎÚÈÛË ÛÙË ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜.

515

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Î·È ÔÈ Î¿Ï˘Î˜ ÙÔ˘ ‰ÂÍÈÔ‡ ÓÂÊÚÔ‡ Û ÔÚıfiÙÔË ı¤ÛË ·ÚÔ˘Û›·˙·Ó ‰È¿Ù·ÛË, Ë ÔÔ›· Èı·ÓÒ˜ Ó· ˘ÂÚÂÎÙÈÌ‹ıËΠÏfiÁˆ Ù˘ ¤Íˆ ÛÙÚÔÊ‹˜ ÙÔ˘ Û‡ÛÙÔÈ¯Ô˘ ÓÂÊÚÔ‡ (∂ÈÎfiÓ· 1). ∂ÈϤÔÓ, ·Ú·ÙËÚ‹ıËÎÂ Ë ·ÚÔ˘Û›· ÛÎÈ·ÁÚ·ÊÈÎÔ‡ Û ·ÌÊfiÙÂÚ˜ ÙȘ ˘¤ÏÔ˘˜ ÛÙȘ ·Ú·ÙÂٷ̤Ó˜ Ï‹„ÂȘ. O ¤ÏÂÁ¯Ô˜ Û˘Ó¯›ÛÙËΠ̠‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (DTPA) Ô˘ ¤‰ÂÈÍ ÂËÚ·Ṳ̂ÓË ·Ô¯ÂÙ¢ÙÈ΋ ÈηÓfiÙËÙ· Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜, ȉȷ›ÙÂÚ· fï˜ ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, Ô ÔÔ›Ô˜ ‰ÂÓ ·ÓÙ·ÔÎÚ›ıËΠÛÙË ¯ÔÚ‹ÁËÛË ÊÔ˘ÚÔÛÂÌ›‰Ë˜ (∂ÈÎfiÓ· 2). ∆Ô ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (DMSA) ·ÔÎ¿Ï˘„ ÂÚÈÔ¯¤˜ ÂÏϷو̤Ó˘ ÚfiÛÏ˄˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜ (∂ÈÎfiÓ· 3) Ì ۯÂÙÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· 62% ÛÙÔÓ ‰ÂÍÈfi ÓÂÊÚfi Î·È 38% ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, Î·È Ì ‰È·ÛÙ¿ÛÂȘ 115 mm ÛÙÔÓ ‰ÂÍÈfi ÓÂÊÚfi Î·È 129 mm ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi. ∏ Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ˘fiÏÔÈÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, fiˆ˜ Î·È Ë ·ÚÙËÚȷ΋ ›ÂÛË, ‹Ù·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ (Ô˘Ú›· 24 mg%, ÎÚ·ÙÈÓ›ÓË 0,6 mg%, χΈ̷ Ô‡ÚˆÓ 24ÒÚÔ˘ ·ÚÓËÙÈÎfi, οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ 148 ml/min/1,73 mÇ). ∞ÎÔÏÔ‡ıˆ˜, ¤ÁÈÓ ԢÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Î·È Û˘ÛÙ‹ıËΠٷÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· Ù˘¯fiÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ (ÏÈı›·ÛË, Ïԛ̈ÍË) Î·È Â·ÓÂÎÙ›ÌËÛË ·Ô¯ÂÙ¢ÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÓÂÊÚÒÓ ÌÂ Ó¤Ô ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Û 6 Ì‹Ó˜. ™˘˙‹ÙËÛË ∏ Û˘¯ÓfiÙËÙ· Ù˘ ¢¡∂ª™ Û ÓÂÎÚÔÙÔÌÈÎfi ˘ÏÈÎfi ÔÈΛÏÏÂÈ ·fi 1/1000 ¤ˆ˜ 1/7000 (1-3,5). ¶·Ú·ÙËÚÂ›Ù·È Ì›· ˘ÂÚÔ¯‹ Ù˘ Û˘¯ÓfiÙËÙ·˜ ÛÙÔ˘˜ ¿Ó‰Ú˜ (2/1 ¤ˆ˜ 3/2), ÂÓÒ Â›Ó·È 3 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË Ë ÌÂÙ·Ó¿ÛÙ¢ÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ ÛÙË ‰ÂÍÈ¿ ÏÂ˘Ú¿ (1,4) fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ¢¡∂ ·Ú·Ì¤ÓÂÈ ·Û·Ê‹˜ (1). ∞ÚÎÂÙ¤˜ ıˆڛ˜ ¤¯Ô˘Ó ‰È·Ù˘ˆı› Ì ÂÈÎÚ·Ù¤ÛÙÂÚ˜ ÙȘ ·ÎfiÏÔ˘ı˜: ∞) ªË¯·ÓÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ì›· ·ÓÒÌ·ÏË ÔÌÊ·ÏÈ΋ ·ÚÙËÚ›·, ÂÌÔ‰›˙Ô˘Ó ÙËÓ ¿ÓÔ‰Ô ÙÔ˘ ÓÂÊÚÔ‡ Ô‰ËÁÒÓÙ·˜ ÙÔÓ ÛÙÔ ¿ÏÏÔ ËÌÈÌfiÚÈÔ ÙÔ˘ ÛÒÌ·ÙÔ˜ (1,2,4,5). µ) ∞ÓÒÌ·ÏË ÙÔÔı¤ÙËÛË Ù˘ Ô˘ÚËÙËÚÈ΋˜ ηٷ‚ÔÏ‹˜ Â¿ÁÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÙÂÚfiÏ¢ÚÔ˘ ÓÂÊÚÔÁfiÓÔ˘ ‚Ï·ÛÙ‹Ì·ÙÔ˜. ∞ӈ̷ϛ˜ ÛÙË ÛÙÚÔÊ‹ Î·È ÙËÓ Î¿Ì„Ë ÙÔ˘ ÂÌ‚Ú‡Ô˘ Èı·ÓfiÓ Ó· ·ÔÙÂÏÔ‡Ó ÙËÓ ·ÈÙ›· Ù˘ ÙÔÔı¤ÙËÛ˘ Î·È ÙˆÓ ‰‡Ô Ô˘ÚËÙËÚÈÎÒÓ Î·Ù·‚ÔÏÒÓ ÛÙËÓ ›‰È· ÏÂ˘Ú¿ (1,2,4,5). °) ¢È¿ÊÔÚÔÈ ÙÂÚ·ÙÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÂȉÚÔ‡Ó ÛÙÔ ÂÌ‚Ú˘˚Îfi ÂÚÈ‚¿ÏÏÔÓ, ¤¯ÔÓÙ·˜ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙfiÛÔ ÙË ¢¡∂, fiÛÔ Î·È ÙȘ ¿ÏϘ Û˘Á-

516

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∂ÈÎfiÓ· 3. ™Ù·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· DMSA: ·ÓÔÌÔÈÔÁÂÓ‹˜ ηı‹ÏˆÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜.

ÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ô˘ Û˘¯Ó¿ ÙË Û˘ÓÔ‰Â‡Ô˘Ó (1,2,4).

OÈ ÂÚÈÙÒÛÂȘ ¢¡∂ ·Ú·Ì¤ÓÔ˘Ó ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ·Û˘Ìو̷ÙÈΤ˜, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙË Û¯ÂÙÈο ˘„ËÏ‹ Û˘¯ÓfiÙËÙ¿ Ù˘ ÛÙȘ ÓÂÎÚÔÙÔ̤˜ Û ۯ¤ÛË Ì ÙȘ ·Ó·ÊÂÚfiÌÂÓ˜ ÂÚÈÙÒÛÂȘ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· (1). ∞fi ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È, ¤Ó· ÔÛÔÛÙfi 60% ÂÚ›Ô˘ ÚÔ‚¿ÏÏÂÈ Ì ÂÈÎfiÓ· ÏÈı›·Û˘ ‹ Ïԛ̈͢ Ô˘ÚÔÔÈËÙÈÎÔ‡ (ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ·ÈÌ·ÙÔ˘Ú›·, ‰˘ÛÔ˘ÚÈο ÂÓԯϋ̷ٷ, ˘Ô˘Ú›·), ÂÓÒ Û ÔÛÔÛÙfi 30% ÂÚ›Ô˘ ÚÔ‚¿ÏÏÂÈ ˆ˜ ÎÔÈÏȷ΋ Ì¿˙·. ∆¤ÏÔ˜, Û ÔÛÔÛÙfi 10-20% Ë ‰È¿ÁÓˆÛË ·ÔÙÂÏ› Ù˘¯·›Ô ‡ÚËÌ·, fiˆ˜ Î·È ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ (1,3). ™ÙȘ ̤Ú˜ Ì·˜, Ë Â˘Ú›· ÂÊ·ÚÌÔÁ‹ ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ı· ·˘Í‹ÛÂÈ ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÙÔ ÔÛÔÛÙfi ÙˆÓ Ù˘¯·›· ·Ó¢ÚÈÛÎfiÌÂÓˆÓ ÂÚÈÙÒÛÂˆÓ (1).

O ¤ÎÙÔÔ˜ ÓÂÊÚfi˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È¿Ù·ÛË ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÛÙ¤ÓˆÛË Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È Î˘ÛÙÈ΋ ‰˘ÛÏ·Û›· (1,4,5,6). ∏ ·ÓÒÌ·ÏË ı¤ÛË ÙÔ˘ ¤ÎÙÔÔ˘ ÓÂÊÚÔ‡, Ë ˘„ËÏ‹ ›ÛÔ‰Ô˜ ÙÔ˘ Ô˘ÚËÙ‹Ú· ÛÙËÓ ‡ÂÏÔ, Ô ·ÓÒÌ·ÏÔ˜ ÂÚÈÛÙ·ÏÙÈÛÌfi˜ Ù˘ ˘¤ÏÔ˘ ÙÔ˘ ¤ÎÙÔÔ˘ ÓÂÊÚÔ‡, ›ÂÛË ·fi ·Ú·Î›ÌÂÓ· ÌfiÚÈ· (fiˆ˜ ¤ÎÙÔ· ·ÁÁ›·), ‰ËÌÈÔ˘ÚÁÔ‡Ó Û˘Óı‹Î˜ η΋˜ ·ÚÔ¯¤Ù¢Û˘ ÙˆÓ Ô‡ÚˆÓ Î·È ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ‰ËÌÈÔ˘ÚÁ›· Ï›ıˆÓ Î·È ÏÔÈÌÒÍÂˆÓ Ô˘ÚÔÔÈËÙÈÎÔ‡ (4). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ·ÚÔ¯¤Ù¢ÛË ÙˆÓ Ô‡ÚˆÓ ˘ÔÏÂÈfiÙ·Ó Î·È ÛÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜, Û ÛËÌ·ÓÙÈο fï˜ ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, ¯ˆÚ›˜ Ó· ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ·ÎÚÈ‚‹˜ ·ÈÙÈÔÏÔÁ›·. ∂˘Ú‹Ì·Ù· ÏÈı›·Û˘ ·Ô˘Û›·˙·Ó, ÂÓÒ ÔÈ ·ÏÏÔÈÒÛÂȘ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ DMSA Èı·ÓÒ˜ ÔÊ›ÏÔÓÙ·Ó Û ˘ÂÏÔÓÂÊÚÈÙȉÈΤ˜ Ô˘Ï¤˜ ·fi ÚÔËÁÔ‡ÌÂÓ˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ ‹ ‹Ù·Ó ÙÔ ·ÔÙ¤ÏÂÛÌ·

¶·È‰È·ÙÚÈ΋ 2001;64:514-517

‰˘ÛÏ·Û›·˜. ¶Ú¤ÂÈ Ó· ÛËÌÂÈÒÛÔ˘Ì fiÙÈ ÔÈ ÓÂÊÚÔ› ÛÙË ¢¡∂ Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓˆÌ·Ï›Â˜ ÛÙÚÔÊ‹˜, Ô˘ ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ˘ÂÚÂÎÙ›ÌËÛË Ù˘ ‰È¿Ù·Û˘ ÙÔ˘ ˘ÂÏÔÎ·Ï˘ÎÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ηٿ ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, fiˆ˜ Û˘Ó¤‚Ë ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ (1).

O ÌÔÓ‹Ú˘ ¤ÎÙÔÔ˜ ÓÂÊÚfi˜, Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ÌÔÚʤ˜ ¢¡∂, ·ÚÔ˘ÛÈ¿˙ÂÈ ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ, ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙȘ ÛÎÂÏÂÙÈΤ˜ (50%), ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (40%) (ÎÚ˘„ÔÚ¯›·, ·ÙÚËÛ›· ÎfiÏÔ˘, ·ÓˆÌ·Ï›Â˜ Û¯‹Ì·ÙÔ˜ Ì‹ÙÚ·˜, ˘ÔÛ·‰›·˜ Î.Ï.), ÙËÓ ·ÙÚËÛ›· ÔÚıÔ‡ (20%) (1,2,4). ™ÙȘ ¿ÏϘ ÌÔÚʤ˜ ¢¡∂, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Â›Ó·È Ôχ ÌÈÎÚfiÙÂÚË, ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙËÓ ·ÙÚËÛ›· ÔÚıÔ‡ (4%), ÔÚıÔ‰ÈΤ˜ Î·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (ËÌÈÛfiÓ‰˘ÏÔ˜, ÛÎÔÏ›ˆÛË, ·ʈÛË, Û˘ÁÁÂÓ¤˜ ÂÍ¿ÚıËÌ· ÙÔ˘ ÈÛ¯›Ô˘), ÂÏÏ›ÌÌ·Ù· ÙÔ˘ ÎÔÏÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, ¿ÏϘ ·ÓˆÌ·Ï›Â˜ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ (ÔÈÛÔÊ·ÁÈ΋ ·ÙÚËÛ›·, ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎfi Û˘Ú›ÁÁÈÔ), ·ÓˆÌ·Ï›Â˜ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (1,4-6). ∞ÛıÂÓ›˜ ÌÂ Ì˘ÂÏÔ‰˘ÛÏ·Û›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¢¡∂ ÛÂ Û˘¯ÓfiÙËÙ· Ô˘ Êı¿ÓÂÈ ¤ˆ˜ 3,3%, ÔÛÔÛÙfi Ôχ ˘„ËÏfiÙÂÚÔ ·fi ÂΛÓÔ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ (6,7). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ Û˘Ó˘‹Ú¯·Ó Â˘Ú‹Ì·Ù· ·fi ÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· (ÊÏ‚È΋ ·ÁÁÂȷ΋ ‰˘ÛÏ·Û›· ÛÙÔ ‰ÂÍÈfi ÌÂÙˆÈ·›Ô ÏÔ‚fi), ηıÒ˜ Î·È ·fi Ù· ÂÈÓÂÊÚ›‰È· (Û˘ÁÁÂÓ‹˜ ˘ÂÚÏ·Û›· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ ηı˘ÛÙÂÚË̤Ó˘ ¤Ó·Ú͢), Ù· ÔÔ›· fï˜ ‰Â ÁÓˆÚ›˙Ô˘Ì ηٿ fiÛÔ ÌÔÚÔ‡Ó Ó· Û˘Û¯ÂÙÈÛÙÔ‡Ó Ì ÙË ¢¡∂. ™ÙÔ ·ÚÂÏıfiÓ, Ë ÂÓ‰ÔÊϤ‚È· ˘ÂÏÔÁÚ·Ê›· ‹Ù·Ó Ë Ì¤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ¢¡∂. ™‹ÌÂÚ·, ÙfiÛÔ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· fiÛÔ Î·È ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (ÛÙ·ÙÈÎfi Î·È ‰˘Ó·ÌÈÎfi) ¤¯Ô˘Ó ·Ôηχ„ÂÈ ·ÚÎÂÙ¤˜ ·Û˘Ìو̷ÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¢¡∂. ∏ ·ÓÈÔ‡Û· ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ÂÓÒ ÙÔ ‰˘Ó·ÌÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ ‚ÔËı¿ÂÈ ÛËÌ·ÓÙÈο Û ÂÚÈÙÒÛÂȘ ˘‰ÚÔÓ¤ÊÚˆÛ˘ ÒÛÙ ӷ ηıÔÚÈÛÙ› Ë ÈηÓfiÙËÙ· ·ÚÔ¯¤Ù¢Û˘ ÙˆÓ Ô‡ÚˆÓ, fiˆ˜ ¤ÁÈÓÂ Î·È ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ (1). ¶ÔÏϤ˜ ÊÔÚ¤˜, Ô ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ÌÔÚ› Ó· ‰È·ÎÚ›ÓÂÈ ·Ó ˘¿Ú¯ÂÈ ‹ fi¯È Û˘ÁÎfiÏÏËÛË ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ Î·È Ë ‰È¿ÁÓˆÛË Û˘¯Ó¿ Ù›ıÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘

Paediatriki 2001;64:514-517

¯ÂÈÚÔ˘ÚÁ›Ԣ. ∆· ·ÁÁ›· ÛÙË ¢¡∂, ȉ›ˆ˜ ÛÙÔÓ ¤ÎÙÔÔ ÓÂÊÚfi, ¤¯Ô˘Ó Ôχ Û˘¯Ó¿ ·ÓÒÌ·ÏË ÚԤϢÛË, ÁÂÁÔÓfi˜ Ô˘ οÓÂÈ ·Ó·Áη›· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·ÁÁÂÈÔÁÚ·Ê›·˜ ÚÈÓ ·fi ÂÎÙÂٷ̤ӷ ¯ÂÈÚÔ˘ÚÁ›· (1,2).

OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ Ì ¢¡∂ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ï‹ ÚfiÁÓˆÛË Î·È Ê˘ÛÈÔÏÔÁÈÎfi ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘. ŸÛÔÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Èı·Ó‹ ·fiÊÚ·ÍË ÙÔ˘ ·Ô¯ÂÙ¢ÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‚Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· Ïԛ̈ÍË Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È ÏÈı›·ÛË. ¶ÂÚ›Ô˘ ÙÔ 1/3 ÙˆÓ Û˘Ìو̷ÙÈÎÒÓ ·ÛıÂÓÒÓ ··ÈÙ› ˘ÂÏÔÏÈıÔÙÔÌ‹ ÁÈ· Ï›ıÔ Ô˘ ÚÔηÏ› ·fiÊÚ·ÍË (1). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¢¡∂ Â›Ó·È Ì›· Û¿ÓÈ· ÔÓÙfiÙËÙ·. ¢È·ÁÈÁÓÒÛÎÂÙ·È ·ÎfiÌ· Û·ÓÈfiÙÂÚ· ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÂÈÏÔÎÒÓ Ù˘, ÔÈ Ôԛ˜ fiÙ·Ó ·Ó¢ڛÛÎÔÓÙ·È ··ÈÙÔ‡Ó ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Bauer S. Anomalies of the kidney and ureteropelvic junction. In: Campbell’s Urology. 7th ed. Philadelphia: WB Saunders Company; 1998. p. 1720-1725.

2. Baniel J, Glezerson G, Tobiaw M, Manning AJ. Crossed renal ectopia. Scad J Urol Nephrol 1991;25:241-244.

3. Fowlis GA, Mee AD, Colbeck R, Twomey B. Acute abdomen, an unusual presentation of crossed renal ectopia. Br J Urol 1994;73:328-329.

4. Felzenberg J, Nasrallah PF. Crossed renal ectopia without fusion associated with hydronephrosis in an infant.

Urology 1991;38:450-452.

5. Marshal FF, Freedman MT. Crossed renal ectopia. J Urol 1978;119:188-191.

6. Dragun MJ, Flemming D, Knorr A, Borden T, Smith A. Crossed fused renal ectopy in children with myelodysplasia. Urology 1994;44:562-564.

7. Robson WLM, Leung AKC. Crossed fused renal ectopy and myelodysplasia [letter]. Urology 1995;45:1087.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-11-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 23-03-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ ∑·Î‡ÓıÔ˘ 2, ÷ϿӉÚÈ

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Paediatriki 2001;64:518-526

PROGRESS IN MEDICAL SCIENCE

™ÔÁÁÒ‰ÂȘ ÂÁÎÂÊ·ÏÔ¿ıÂȘ. ¡ÂfiÙÂÚ˜ ·fi„ÂȘ ∫. ∫·Ú·‚·Ó¿ÎË - ∫·Ú·Ó¿ÛÈÔ˘

Spongiform encephalopathies. Recent advances K. Karavanaki - Karanasiou

¶ÂÚ›ÏË„Ë: OÈ ÛÔÁÁÒ‰ÂȘ ÂÁÎÂÊ·ÏÔ¿ıÂȘ ·ÔÙÂÏÔ‡Ó Ì›· ÔÌ¿‰· ÌÂÙ·‰È‰fiÌÂÓˆÓ, ÚÔԉ¢ÙÈο ÂÍÂÏÈÛÛfiÌÂÓˆÓ Ó¢ÚÔÂÎÊ˘ÏÈÛÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ·fi ÙȘ Ôԛ˜ Ë Û˘ÓËı¤ÛÙÂÚ· ÂÌÊ·ÓÈ˙fiÌÂÓË ÛÙÔÓ ¿ÓıÚˆÔ Â›Ó·È Ë ÓfiÛÔ˜ Creutzfeldt-Jakob (CJD). ∏ CJD ‰È·ÎÚ›ÓÂÙ·È Û ÎÏËÚÔÓÔÌÈ΋, ÏÔÈÌÒ‰Ë (Kuru, È·ÙÚÔÁÂÓ‹ CJD) Î·È ÛÔÚ·‰È΋ (ȉÈÔ·ı‹). ∏ Ó¤· ÔÈÎÈÏ›· Ù˘ ÛÔÚ·‰È΋˜ CJD (new variant CJD) ·ÔÙÂÏ› ÙËÓ ·ÓıÚÒÈÓË ÛÔÁÁÒ‰Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ë ¤Í·ÚÛË Ù˘ ÔÔ›·˜ Û˘Û¯ÂÙ›ÛÙËΠ̠ÙËÓ ÂȉËÌ›· Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙˆÓ ‚ÔÔÂȉÒÓ (™∂µ). O ˘‡ı˘ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Ë ·ıÔÏÔÁÈ΋ ÚˆÙ½ÓË prion (proteinaceous infectious), Ë ÔÔ›· ‰ÂÓ ÂÚȤ¯ÂÈ DNA ‹ RNA. ∏ ÚˆÙ½ÓË prion, ÌÂÙ¿ ÙËÓ Â›ÛÔ‰fi Ù˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi, ·Ú¯Èο ÂÓ·ÔÙ›ıÂÙ·È ÛÙÔ ‰ÈÎÙ˘ÔÂÓ‰ÔıËÏÈ·Îfi Û‡ÛÙËÌ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÚÔÛ‚¿ÏÏÂÈ Ù· ÂÚÈÊÂÚÈο Ó‡ڷ Î·È ÙÔÓ ÂÁΤʷÏÔ, ÚÔηÏÒÓÙ·˜ ÙËÓ ÚÔԉ¢ÙÈ΋ ÂÎʇÏÈÛ‹ ÙÔ˘˜. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Ì ÙËÓ ·ÔÌfiÓˆÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ prions ÛÙÔÓ ÂÁΤʷÏÔ ‹ ÙȘ Ê·Ú˘ÁÁÈΤ˜ ·Ì˘Á‰·Ï¤˜, ÂÓÒ Ù· Â˘Ú‹Ì·Ù· ·fi ÙÔ ÏÔÈfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰ÂÓ Â›Ó·È ÂȉÈο. ∏ CJD ÌÂÙ·‰›‰ÂÙ·È ÛÙÔÓ ¿ÓıÚˆÔ È·ÙÚÔÁÂÓÒ˜, Ì ÙË ¯Ú‹ÛË و̷ÙÈ΋˜ ·ÓıÚÒÈÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Ì ÙË ÌÂÙ¿ÁÁÈÛË ÌÔÏ˘Ṳ̂ÓÔ˘ ·›Ì·ÙÔ˜ ‹ ·Ú·ÁÒÁˆÓ Î·È ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ. ∂›Û˘, ÌÂÙ·‰›‰ÂÙ·È ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡, Ì ÙË ‚ÚÒÛË ÎÚ¤·ÙÔ˜ ‚Ô‰ÈÓÔ‡, ÚÔÂÚ¯fiÌÂÓÔ˘ ·fi ˙ÒÔ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ Ô˘ ¿Û¯ÂÈ ·fi ™Eµ. ∆· Úfi‚·Ù·, Ù· ¯ÔÈÚÈÓ¿, Ù· Ô˘ÏÂÚÈο Î·È ÙÔ Á¿Ï· ‰ÂÓ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ™Eµ ·Ó¿ÌÂÛ· ÛÙ· ‚ÔÔÂȉ‹,

Abstract: The human transmissible spongiform encephalopathies are a group of rapidly progressive neurodegenerative disorders. The most common human type is Creutzfeldt-Jakob disease (CJD).

CJD is classified as a genetic, or infectious (Kuru, iatrogenic) or a sporadic (idiopathic) form. The new variant CJD (nvCJD) is considered to be the human type of the bovine spongiform encephalopathy (BSE). The factor responsible is the abnormal prion (proteinaceous infectious), which is a protein without DNA or RNA. After ingestion, prion initially accumulates in the lymphoreticular tissues and progressively causes neuroinvasion and fatal neurodegeneration. The diagnosis of CJD is based on the demonstration of prion in the brain parenchyma or in biopsy specimens of the pharyngeal tonsil, while the rest of the laboratory findings are non-specific for the disease. CJD is transmissible iatrogenically, through cadaveric human growth hormone, human blood and blood products and organ transplantation. It is also transmissible orally through the consumption of bovine meat originating from cattle, older than 2 years of age, with confirmed BSE. Sheep, pigs, poultry and bovine milk are not sources of transmission of the disease. Age, sex and maternal transmission are not considered responsible for the transmission of BSE among cattle, while the use of commercial concentrated feed containing animal derived products is considered the major source of epidemics among cattle. The pronounced resistance of prions to proteinases, to heat and to the host defense mechanisms are factors facilitating the transmission through the oral route. In Greece, up

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∞ı‹Ó·

µ’ Pediatric Clinic, Children’s Hospital “Aghia Sophia”, Athens

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Ë ËÏÈΛ·, ÙÔ Ê‡ÏÔ Î·È Ë ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ¿‰ÔÛË ‰ÂÓ Â˘ı‡ÓÔÓÙ·È ÁÈ· ÙË ‰È·ÛÔÚ¿ Ù˘ ÓfiÛÔ˘, ÂÓÒ ÛÙ·ıÂÚfi ·›ÙÈÔ ıˆÚÂ›Ù·È Ë ‚ÚÒÛË ÂȉÈο ÂÂÍÂÚÁ·ÛÌ¤ÓˆÓ ˙ˆÔÙÚÔÊÒÓ. ∏ ÌfiÏ˘ÓÛË ÙÔ˘ ·ÓıÚÒÔ˘ ·fi ÌÔÏ˘Ṳ̂ÓÔ ÎÚ¤·˜ Â›Ó·È ÂÊÈÎÙ‹ ÏfiÁˆ Ù˘ ÌÂÁ¿Ï˘ ·ÓÙÔ¯‹˜ ÙˆÓ prions ÛÙȘ ÚˆÙ¿Û˜, ÙË ı¤ÚÌ·ÓÛË Î·È ÙÔ˘˜ ·Ì˘ÓÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ™ÙË ¯ÒÚ· Ì·˜ ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È Ì¤¯ÚÈ Û‹ÌÂÚ· ÂÚÈÛÙ·ÙÈο Ù˘ Ó¤·˜ ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜. ¶·Ú¿ Ù·‡Ù·, Û·Ê›˜ ÂӉ›ÍÂȘ ÁÈ· ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ı· ¤¯Ô˘Ì ÌÂÙ¿ ·fi ¯ÚfiÓÈ·, ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ¯ÚfiÓÔ˘ ÂÒ·Û˘ Ù˘ ÓfiÛÔ˘.

to now, there have been no reported cases of the new sporadic form of the disease (nvCJD).

However, clear indications on the incidence of the nvCJD will not be available for a considerable period of time, due to the long incubation period of the disease.

§¤ÍÂȘ ÎÏÂȉȿ: ÛÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ÓfiÛÔ˜ Creutzfeldt-Jakob (CJD), Ó¤· ÔÈÎÈÏ›· ÓfiÛÔ˘ CJD, ÛÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ‚ÔÔÂȉÒÓ.

Key words: spongiform encephalopathy, Creutzfeldt-Jakob disease (CJD), new variant CJD, bovine spongiform encephalopathy.

∂ÈÛ·ÁˆÁ‹ ∞˘Ùfi Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙË ÛÔÁÁÒ‰Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ‚ÔÔÂȉÒÓ (™∂µ), ÁÓˆÛÙ‹ ˆ˜ ÓfiÛÔ ÙˆÓ “ÙÚÂÏÒÓ ·ÁÂÏ¿‰ˆÓ”, Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ·‚‚·ÈfiÙËÙ·. ∏ ÂȉËÌ›· Ù˘ ™∂µ ͤÛ·Û ÙÔ 1986 ÛÙËÓ ∞ÁÁÏ›·. °È· ÙË ÌfiÏ˘ÓÛË ÙˆÓ ·ÁÂÏ¿‰ˆÓ ÂÓÔ¯ÔÔÈ‹ıËÎ·Ó ˙ˆÔÙÚÔʤ˜ Ô˘ ÂÚÈ›¯·Ó ÌÔÏ˘Ṳ̂ӷ ÂÓÙfiÛıÈ· ÚÔ‚¿ÙˆÓ Ô˘ ¤·Û¯·Ó ·fi ÙË ÓfiÛÔ scrapie (ÙÚÔÌÒ‰Ë ÓfiÛÔ ÙˆÓ ÚÔ‚¿ÙˆÓ). À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë ÓfiÛÔ˜ ¤Ú·Û ·fi Ù· Úfi‚·Ù· ÛÙȘ ·ÁÂÏ¿‰Â˜ Î·È ·fi ·˘Ù¤˜ ÛÙÔÓ ¿ÓıÚˆÔ. ∫‡ÚÈÔ˜ ·ÓÙÈÚfiÛˆÔ˜ ÙˆÓ ÛÔÁÁˆ‰ÒÓ ÂÁÎÂÊ·ÏÔ·ıÂÈÒÓ ÛÙÔÓ ¿ÓıÚˆÔ Â›Ó·È Ë ÓfiÛÔ˜ CreutzfeldtJakob (CJD) (1).

ÔÈÎÔÁÂÓ‹˜ ·¸Ó›· Î·È Ë prion ·Ì˘ÏÔÂȉÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (1). ™Ù· ˙Ò· ¤¯Ô˘Ó ·Ó·ÊÂÚı› 6 ·Ûı¤ÓÂȘ (¶›Ó·Î·˜ 1): Ë ÓfiÛÔ˜ Scrapie, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Ù· ·ÈÁÔÚfi‚·Ù·, Ë ÛÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ‚ÔÔÂȉÒÓ, Ô˘ ÚÔÛ‚¿ÏÏÂÈ ÙȘ ·ÁÂÏ¿‰Â˜, Ë ¯ÚfiÓÈ· ÂÎÊ˘ÏÈÛÙÈ΋ ÓfiÛÔ˜, Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÛÙ· ÂÏ¿ÊÈ· Î·È ÙÔ˘˜ Ù·Ú¿Ó‰Ô˘˜, Ë ÌÂÙ·‰È‰fiÌÂÓË ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ÈÎÙȉÒÓ, Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÛÙȘ Ó˘Ê›ÙÛ˜, Ë ÛÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ·ÈÏÔ˘ÚÔÂȉÒÓ, Ô˘ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÛÙȘ Á¿Ù˜ Î·È Ù¤ÏÔ˜, Ë Â͈ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ÔÏËÊfiÚˆÓ ıËÏ·ÛÙÈÎÒÓ, Ô˘ ÚÔÛ‚¿ÏÏÂÈ ÙȘ ·ÓÙÈÏfi˜ ÛÙË ¡fiÙÈ· ∞ÊÚÈ΋ (1). ∏ ÓfiÛÔ˜ CJD Â›Ó·È Ô Û˘ÓËı¤ÛÙÂÚÔ˜ Ù‡Ô˜ ·fi ÙȘ ·ÓıÚÒÈÓ˜ ÛÔÁÁÒ‰ÂȘ ÂÁÎÂÊ·ÏÔ¿ıÂȘ (¶›Ó·Î·˜ 2). ∞˘Ù‹ ηٷٿÛÛÂÙ·È ˆ˜ ÂÍ‹˜ (2): ∞) ∫ÏËÚÔÓÔÌÈ΋ (ÔÈÎÔÁÂÓ‹˜ CJD), ÌÂÙ·‰È‰fiÌÂÓË Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ PrP

∫·Ù¿Ù·ÍË ÛÔÁÁˆ‰ÒÓ ÂÁÎÂÊ·ÏÔ·ıÂÈÒÓ O fiÚÔ˜ “ÛÔÁÁÒ‰ÂȘ ÂÁÎÂÊ·ÏÔ¿ıÂȘ” ‹ ·Ûı¤ÓÂȘ prion ÂÚÈÏ·Ì‚¿ÓÂÈ Ù·¯¤ˆ˜ ÂÍÂÏÈÛÛfiÌÂÓ· ÓÔÛ‹Ì·Ù· ÊıÔÚ¿˜ ÙÔ˘ ∫¡™, Ô˘ ÚÔÛ‚¿ÏÏÔ˘Ó ·ÓıÚÒÔ˘˜ Î·È ˙Ò·. ∆Ô Î¿ı ›‰Ô˜ ˙ÒÔ˘ (Úfi‚·Ù·, ·ÁÂÏ¿‰Â˜, Ó˘Ê›ÙÛ˜, ÂÏ¿ÊÈ· Î.Ï.) ·ı·›ÓÂÈ ÙË ‰È΋ ÙÔ˘ ÌÔÚÊ‹ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜, Ô˘ ¤¯ÂÈ Ù· ͯˆÚÈÛÙ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ›‰Ô˘˜. ªÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÂȉÒÓ, ˘¿Ú¯ÂÈ Ô ÊÚ·ÁÌfi˜ ÙÔ˘ ›‰Ô˘˜, Ô ÔÔ›Ô˜ Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· Î·Ù·Ï˘ı› fiÙ·Ó Ë ÌÔÏ˘ÛÌ·ÙÈ΋ ‰fiÛË Â›Ó·È ÌÂÁ¿ÏË ‹ fiÙ·Ó Ô ÌÔÏ˘ÛÌ·ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È ÂÈıÂÙÈÎfi˜ (1). ∏ ÂÚ¢ÓËÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ÔÓÙÔÙ‹ÙˆÓ ·˘ÙÒÓ ·ÔÙÂÏ› ·Ú¿‰ÂÈÁÌ· Û˘ÓÂÚÁ·Û›·˜ ÔÏÏÒÓ ÎÏ¿‰ˆÓ Ù˘ È·ÙÚÈ΋˜ Î·È Ù˘ ‚ÈÔÏÔÁ›·˜. ∏ ¤Ú¢ӷ Û˘Ó¯›˙ÂÙ·È Î·È ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌ· ‰Ôı› fiϘ ÔÈ ··ÓÙ‹ÛÂȘ ÁÈ· ÙË ÌÂϤÙË ÙˆÓ ·ı‹ÛÂˆÓ ·˘ÙÒÓ. ™ÙÔÓ ¿ÓıÚˆÔ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ¤ÓÙ ÔÓÙfiÙËÙ˜ ·ÛıÂÓÂÈÒÓ prion (¶›Ó·Î·˜ 1): Ë ÓfiÛÔ˜ Kuru, Ë ÓfiÛÔ˜ Creutzfeldt-Jakob, ÙÔ Û‡Ó‰ÚÔÌÔ Gerstmann-Straussler-Scheinker, Ë ı·Ó·ÙËÊfiÚÔ˜

¶›Ó·Î·˜ 1. ¡ÔÛ‹Ì·Ù· prion ¡fiÛËÌ· ñ Kuru ñ Creutzfeldt-Jacob ñ Gerstmann-Straussler-Scheinker ñ £·Ó·ÙËÊfiÚÔ˜ ÔÈÎÔÁÂÓ‹˜ ·¸Ó›· ñ Prion ·Ì˘ÏÔÂȉÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ñ Scrapie ñ ™ÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ‚ÔÔÂȉÒÓ ñ ÃÚfiÓÈ· ÂÎÊ˘ÏÈÛÙÈ΋ ÓfiÛÔ˜ ñ ªÂÙ·‰È‰fiÌÂÓË ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ÈÎÙȉÒÓ ñ ™ÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ·ÈÏÔ˘ÚÔÂȉÒÓ ñ ∂͈ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ÔÏËÊfiÚˆÓ ıËÏ·ÛÙÈÎÒÓ

º˘ÛÈÎfi˜ ÍÂÓÈÛÙ‹˜ ÕÓıÚˆÔ˜ ÕÓıÚˆÔ˜ ÕÓıÚˆÔ˜ ÕÓıÚˆÔ˜ ÕÓıÚˆÔ˜ ∞ÈÁÔÚfi‚·Ù· ∞ÁÂÏ¿‰Â˜ ∂Ï¿ÊÈ·, Ù¿Ú·Ó‰ÔÈ ¡˘Ê›ÙÛ˜ °¿Ù˜ ∞ÓÙÈÏfiË, Nyala, Tragelaphus angasi

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Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 20 Î·È ÂϤÁ¯ÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ÚˆÙ½Ó˘ prion. Œ¯Ô˘Ó ·Ú·ÙËÚËı› ÌÂÙ·ÏÏ¿ÍÂȘ Û 12 ÛËÌ›· Î·È ·ÚÎÂÙ¤˜ ÂÈÛ·ÁˆÁ¤˜ ˙¢ÁÒÓ ‚¿ÛˆÓ, ÔÈ Ôԛ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÔÈÎÔÁÂÓ‹ CJD (3). OÈ ‰‡Ô ÁÓˆÛÙfiÙÂÚ˜ ÂÓÙÔ›ÛÂȘ Ù˘ ÔÈÎÔÁÂÓÔ‡˜ CJD ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù˘ ™ÏÔ‚·Î›·˜ Î·È ÛÙÔ˘˜ §È‚˘Î‹˜ ηٷÁˆÁ‹˜ ∂‚Ú·›Ô˘˜ Ô˘ ηÙÔÈÎÔ‡Ó ÛÙÔ πÛÚ·‹Ï. ∏ ÔÈÎÔÁÂÓ‹˜ CJD ·Ú·ÙËÚÂ›Ù·È ÛÂ Û˘¯ÓfiÙËÙ· 6-15% ÙˆÓ ÂÚÈÙÒÛÂˆÓ CJD Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (3). µ) §ÔÈÌ҉˘: ·. π·ÙÚÔÁÂÓ‹˜, Ë ÔÔ›· ·Ú·ÙËÚ‹ıËΠÙÔ 1985 ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ÁÔÓ·‰ÔÙÚÔÈÓÒÓ, ÚÔÂÚ¯fiÌÂÓˆÓ ·fi Âί˘Ï›ÛÌ·Ù· و̷ÙÈÎÒÓ ˘ÔʇÛˆÓ. ‚. NfiÛÔ˜ ∫uru (ÂȉËÌ›· ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ηÓÈ‚¿ÏÔ˘˜ ÙˆÓ Papua Ù˘ ¡¤·˜ °Ô˘˚Ó¤·˜). °) π‰ÈÔ·ı‹˜: ·. ™ÔÚ·‰È΋ ÌÔÚÊ‹, Ô˘ Â›Ó·È ÁÓˆÛÙ‹ ·fi ÙÔ 1920 Î·È ÂÌÊ·Ó›˙ÂÈ Ù˘¯·›· ηٷÓÔÌ‹. ∏ ÓfiÛÔ˜ Â›Ó·È ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ì ̤ÛË ËÏÈΛ· ¤Ó·Ú͢ Ù· 63 ¤ÙË (‡ÚÔ˜ ËÏÈÎÈÒÓ: 55-70 ¤ÙË). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ Â›Ó·È 0,5-1,5 ÂÚÈÙÒÛÂȘ/1.000.000/¤ÙÔ˜ Î·È ‰ÂÓ ¤¯ÂÈ ·˘ÍËı› Ë Û˘¯ÓfiÙËÙ· ·˘Ù‹ ·fi ÙÔ 1968, fiÙ·Ó ÚˆÙԉȷÈÛÙÒıËΠÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ (4). ∏ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Âԯȷ΋ ‹ ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹ Î·È ‰ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› Ë ÌÂÙ¿‰ÔÛË ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ù˘ ›‰È·˜ ÔÈÎÔÁ¤ÓÂÈ·˜. ‚. ∏ Ó¤· ÔÈÎÈÏ›· Ù˘ CJD (4), fiÔ˘ Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È Ù· 28 ¤ÙË (‡ÚÔ˜ ËÏÈÎÈÒÓ: 10-39 ¤ÙË). ∆· ÚÒÙ· ÂÚÈÛÙ·ÙÈο Ù˘ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÛÙË ª. µÚÂÙ·Ó›· ÙÔ 1994. Œ¯Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ó¢ÚÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Î·È Ë ÎÏÈÓÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È Ë Ù˘È΋ Ù˘ ÛÔÚ·‰È΋˜ CJD. ∏ ÓfiÛÔ˜ ·˘Ù‹ Û˘Û¯ÂÙ›ÛÙËΠ·ÈÙÈÔÏÔÁÈο Ì ÙË ÛÔÁÁÒ‰Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ‚ÔÔÂȉÒÓ (™∂µ), ‰ÈfiÙÈ ·ÚÔ˘ÛÈ¿ÛÙËΠ̠·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Û ÎÙËÓÔÙÚfiÊÔ˘˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·Ó Ì ÙËÓ ÂÎÙÚÔÊ‹ ‚ÔÔÂȉÒÓ ÛÙË ª. µÚÂÙ·Ó›·. ∏ ʇÛË ÙÔ˘ ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ· - Ë ıˆڛ· ÙˆÓ Prions ∏ ÓfiÛÔ˜ CJD Î·È Ë ÛÔÁÁ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÙˆÓ ‚ÔÔÂȉÒÓ ÔÊ›ÏÔÓÙ·È Û ¤Ó· ÌÔÏ˘ÛÌ·ÙÈÎfi ¶›Ó·Î·˜ 2. ∫·Ù¿Ù·ÍË Ù˘ ÓfiÛÔ˘ Creutzfeldt-Jacob (CJD) 1. ∫ÏËÚÔÓÔÌÈ΋ (ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ ÂϤÁ¯ÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ prion) 2. §ÔÈÌ҉˘: ·) π·ÙÚÔÁÂÓ‹˜ (·ÓıÚÒÈÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË) ‚) ¡fiÛÔ˜ Kuru 3. π‰ÈÔ·ı‹˜: ·) ™ÔÚ·‰È΋ (variant CJD) ‚) ¡¤· ÔÈÎÈÏ›· ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜ (new variant CJD)

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Paediatriki 2001;64:518-526

·Ú¿ÁÔÓÙ·, ÙÔ prion (proteinaceous infectious), Ô˘ Â›Ó·È Ì›· ÚˆÙ½ÓË Ô˘ ‰ÂÓ ÂÚȤ¯ÂÈ DNA ‹ RNA. ∏ ÚˆÙ½ÓË ·˘Ù‹ Â›Ó·È È‰È·›ÙÂÚ· ·ÓıÂÎÙÈ΋ ÛÙȘ ÚˆÙ¿Û˜ Î·È ‰ÂÓ Î·Ù·ÛÙÚ¤ÊÂÙ·È ·fi ÙËÓ ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· ‹ Ù· ¤Ó˙˘Ì· ÚÈ‚ÔÓÔ˘ÎÏ¿Û˜ (ÂÊfiÛÔÓ ‰ÂÓ ÂÚȤ¯ÂÈ DNA ‹ RNA) (5). ∏ ÌÔÏ˘ÛÌ·ÙÈ΋ ·˘Ù‹ ÚˆÙ½ÓË Â›Ó·È ÈÛfiÌÔÚÊË Ì ̛· Ê˘ÛÈÔÏÔÁÈ΋ ÚˆÙ½ÓË PrPC, ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 33-35 Kd, Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È ·fi ¤Ó· ÁÔÓ›‰ÈÔ Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 20 (1). ∏ ÚˆÙ½ÓË ·˘Ù‹ ˘¿Ú¯ÂÈ ÛÙ· Ê˘ÛÈÔÏÔÁÈο ·ÙÙ·Ú·, ·ÏÏ¿ ΢ڛˆ˜ ÛÙËÓ Â͈ÙÂÚÈ΋ ÛÙÈ‚¿‰· ÙˆÓ Ó¢ÚÒÓˆÓ (1). ™ÙÔÓ ¿ÓıÚˆÔ Ô ÚfiÏÔ˜ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ Â›Ó·È ¿ÁÓˆÛÙÔ˜. ™Ù· ÎÔÙfiÔ˘Ï· Ê·›ÓÂÙ·È fiÙÈ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ÔÌ·Ï‹ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Û˘Ó¿„ÂˆÓ (6). ªÂÙ·ÏÏ¿ÍÂȘ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ÚˆÙ½ÓË, ›Ù ÙÔ˘ Ù‡Ô˘ Ù˘ ÛËÌÂȷ΋˜ ÌÂÙ¿ÏÏ·Í˘, ›Ù ÙÔ˘ Ù‡Ô˘ Ù˘ ÚÔÛı‹Î˘ ˙¢ÁÒÓ ‚¿ÛˆÓ, ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ prion ·ÛıÂÓÂÈÒÓ ÙÔ˘ ·ÓıÚÒÔ˘ (¶›Ó·Î·˜ 1), fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ GerstmannStraussler-Scheinker, Ë ı·Ó·ÙËÊfiÚÔ˜ ÔÈÎÔÁÂÓ‹˜ ·¸Ó›·, Ë prion ·Ì˘ÏÔÂȉÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÔÈ ÎÏËÚÔÓÔÌÔ‡ÌÂÓÔÈ Ù‡ÔÈ Ù˘ ÓfiÛÔ˘ Creutzfeldt-Jakob (7). ∏ ·ıÔÏÔÁÈ΋ ÚˆÙ½ÓË PrPCJD ·ÚÔ˘ÛÈ¿˙ÂÈ ÙËÓ ›‰È· ¯ËÌÈ΋ Û‡ÛÙ·ÛË Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋, ·ÏÏ¿ ¤¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ ÛÙÂÚÂÔ¯ËÌÈ΋ ‰ÔÌ‹. ∏ PrPCJD ÂÈÛ¤Ú¯ÂÙ·È ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ·fi ‰È¿ÊÔÚ˜ Ô‰Ô‡˜ (ÂÙÈÎfi, ·ÚÂÓÙÂÚÈο Î.Ï.). ∏ ›ÛÔ‰Ô˜ Ù˘ ·ıÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ ·fi ÙËÓ ÂÙÈ΋ Ô‰fi ·ÎÔÏÔ˘ı› ÙËÓ ÂÍ‹˜ ÔÚ›·: ·ÊÔ‡ ·ÓÙÈÛÙ·ı› ÛÙÔ˘˜ ¯ËÌÈÎÔ‡˜ Î·È ÂÓ˙˘ÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘, ‰È·ÂÚÓ¿ ÙÔÓ ÂÓÙÂÚÈÎfi ÊÚ·ÁÌfi ‰È·Ì¤ÛÔ˘ ÙˆÓ Ï·ÎÒÓ ÙÔ˘ Payer ÙÔ˘ ÂÓÙ¤ÚÔ˘. ∫·ÙfiÈÓ ÚÔÛÏ·Ì‚¿ÓÂÙ·È ·fi ÙÔ ‰ÈÎÙ˘ÔÂÓ‰ÔıËÏÈ·Îfi Û‡ÛÙËÌ· (·Ì˘Á‰·Ï¤˜, ÛΈÏËÎÔÂȉ‹˜ ·fiÊ˘ÛË, ÏÂÌÊ·‰¤Ó˜) Î·È ÙÔ ÛÏ‹Ó·, fiÔ˘ Î·È ÂÓ·ÔÙ›ıÂÙ·È ¯ÚÔÓ›ˆ˜. ™ÙË Û˘Ó¤¯ÂÈ·, ÚÔÛ‚¿ÏÏÂÈ Ù· ÂÚÈÊÂÚÈο Ó‡ڷ, fiÔ˘ ÔÏÏ·Ï·ÛÈ¿˙ÂÙ·È Î·È Ô‰ËÁ› ÛÙËÓ ÂÎʇÏÈÛ‹ ÙÔ˘˜. ∆ÂÏÈο, ÂÁηı›ÛÙ·Ù·È ÛÙÔÓ ÂÁΤʷÏÔ, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙËÓ ÎÂÓÙÚÔÌfiÏÔ Ô‰fi, Ì ‚¿ÛË ÙÔ ÌÔÓÙ¤ÏÔ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ (8). ∏ fiÏË ‰È·‰Èηۛ· Ù˘ ÂÓ·fiıÂÛ˘ Ù˘ ·ıÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ‰È·ÚΛ ÔÏÏ¿ ¤ÙË, fiˆ˜ ÛÙ· Ó¢ÚÔÂÎÊ˘ÏÈÛÙÈο ÓÔÛ‹Ì·Ù· Î·È Ô ·ÛıÂÓ‹˜ ·Ú·Ì¤ÓÂÈ ·Û˘Ìو̷ÙÈÎfi˜.

O Ì˯·ÓÈÛÌfi˜ ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ Ù˘ ·ıÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ prion Î·È Ù˘ ÌfiÏ˘ÓÛ˘ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·ÂÈÎÔÓ›˙ÂÙ·È ÛÙÔ ™¯‹Ì· 1. ∏ ·ıÔÏÔÁÈ΋ ÚˆÙ½ÓË, Û ·Ï‹ Â·Ê‹ Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÚˆÙ½ÓË, ÙË ÌÂÙ·ÙÚ¤ÂÈ Û ·ıÔÏÔÁÈ΋ (8). ∆· prions Ù›ıÂÓÙ·È ‰ÔÌÈο ÙÔ ¤Ó· ‰›Ï· ÛÙÔ ¿ÏÏÔ Î·È ‰ËÌÈÔ˘ÚÁÂ›Ù·È ¤ÙÛÈ Ì›· ·Ï˘Û›‰·

¶·È‰È·ÙÚÈ΋ 2001;64:518-526

Paediatriki 2001;64:518-526

·ıÔÏÔÁÈÎÒÓ prions (Ͽη), Ë ÔÔ›· ηٷÛÙÚ¤ÊÂÈ Ù· Ó¢ÚÈο ·ÙÙ·Ú· Î·È Ì·ÎÚÔÛÎÔÈο Ô ÂÁΤʷÏÔ˜ ·ÔÎÙ¿ ÙËÓ ÂÈÎfiÓ· ÛÊÔ˘ÁÁ·ÚÈÔ‡. ∏ Û˘ÛÛÒÚ¢ÛË Ù˘ ·ıÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ ÛÙÔÓ ÂÁΤʷÏÔ Â›Ó·È ‚Ú·‰Â›· Î·È ÙÔ ¿ÙÔÌÔ Â›Ó·È ·Û˘Ìو̷ÙÈÎfi. ªÂ ÙËÓ ¿ÚÔ‰Ô ÙˆÓ ÂÙÒÓ, Ë Û˘ÛÛÒÚ¢ÛË Ù˘ ÚˆÙ½Ó˘ ·˘Í¿ÓÂÙ·È ‰›ÎËÓ ¯ÈÔÓÔÛÙÈ‚¿‰·˜ Î·È Ô ÂÁΤʷÏÔ˜ ·Ô‰ÈÔÚÁ·ÓÒÓÂÙ·È Ï‹Úˆ˜ (8). ∏ Ó¤· ÛÔÚ·‰È΋ ÌÔÚÊ‹ ÂΉËÏÒÓÂÙ·È Ì „˘¯È·ÙÚÈο Ê·ÈÓfiÌÂÓ· Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, ÛÙȘ Ôԛ˜ ÌÂÙ¿ ·fi Ì‹Ó˜ ÚÔÛÙ›ıÂÙ·È Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·, fiˆ˜ Ì˘ÔÎÏÔӛ˜, ‰˘Û·ÈÛıËۛ˜, ·ÚÂÁÎÂÊ·ÏȉÈ΋ ·Ù·Í›· Î·È ÚÔԉ¢ÙÈ΋ ÂÌÊ¿ÓÈÛË ¿ÓÔÈ·˜ (10). O ·ÛıÂÓ‹˜ Ô‰ËÁÂ›Ù·È ÛÙÔ ı¿Ó·ÙÔ Ì¤Û· Û ¤Ó· ¯ÚfiÓÔ (6-22 Ì‹Ó˜) ·fi ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ Û˘Ìو̿وÓ. O ¯ÚfiÓÔ˜ ÂÒ·Û˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È ¿ÁÓˆÛÙÔ˜. ∏ ÎÏ·ÛÈ΋ ÛÔÚ·‰È΋ ÌÔÚÊ‹ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¿ÓÔÈ·, Ì˘fiÎÏÔÓÔ ‹ ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ¯ÔÚ›· ‹ ‰˘ÛÙÔÓ›·, ˘Ú·ÌȉÈ΋ ‹ Â͈˘Ú·ÌȉÈ΋ Û˘Ó‰ÚÔÌ‹ Î·È ·ÚÂÁÎÂÊ·ÏȉÈ΋ ·Ù·Í›· Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ηٷϋÁÔ˘Ó 1 ¯ÚfiÓÔ ÌÂÙ¿ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘, ¤¯ÔÓÙ·˜ ÂÚÈ¤ÛÂÈ Û ·Ê·Û›· Î·È Ï‹ÚË ·ÎÈÓËÛ›· (9). ∞Ó¿Ï˘ÛË Ù˘ ÚˆÙ½Ó˘ PrPCJD Ù˘ Ó¤·˜ ÛÔ-

ªË¯·ÓÈÛÌfi˜ ÌfiÏ˘ÓÛ˘

¡Â˘ÚÈÎfi ·ÙÙ·ÚÔ

ÀÁÈ›˜ ÚˆÙ½Ó˜ prions

1

ªÔÏ˘Ṳ̂Ó˜ ÚˆÙ½Ó˜

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ªË¯·ÓÈÛÌfi˜ ÌfiÏ˘ÓÛ˘: 1. ∂·Ê‹ ·ıÔÏÔÁÈ΋˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÚˆÙ½ÓË prion 2. ªÂÙ·ÙÚÔ‹ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ Û ·ıÔÏÔÁÈ΋ 3. ¢ËÌÈÔ˘ÚÁ›· ·Ï˘Û›‰·˜ prions (Ͽη) Ô˘ ηٷÛÙÚ¤ÊÂÈ Ù· Ó¢ÚÈο ·ÙÙ·Ú· ™¯‹Ì· 1. ∏ ‰Ú¿ÛË ÙˆÓ prions.

Ú·‰È΋˜ ÌÔÚÊ‹˜ Ì ÌÂıfi‰Ô˘˜ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ηٿ Western, ¤‰ÂÈÍ ÔÌÔÈfiÙËÙ˜ Ì ·ÓÙ›ÛÙÔȯ· Â˘Ú‹Ì·Ù· ·fi ÙȘ ·ÓÒ̷Ϙ ÚˆÙ½Ó˜ Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÂÚÈÙÒÛÂȘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙˆÓ ‚ÔÔÂȉÒÓ, fi¯È fï˜ Ì ÂΛӷ ·fi ÙȘ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ Creutzfeld-Jakob (11). ∂ÚÁ·ÛÙËÚȷΤ˜ ̤ıÔ‰ÔÈ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘ Creutzfeldt-Jakob OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ̤ıÔ‰ÔÈ ‰ÂÓ Â›Ó·È ¯Ú‹ÛÈ̘ ÛÙË ‰È¿ÁÓˆÛË Ù˘ CJD. ∏ ÂͤٷÛË ÙÔ˘ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ (∂¡À) ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ, ÂÓÒ Î·Ù¿ Ù· ¿ÏÏ· Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. ªÂ ÙË ¯Ú‹ÛË Ù·¯¤ˆÓ Ú·‰ÈÔ·ÓÔÛÔÏÔÁÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ¤¯Ô˘Ó ·ÔÌÔÓˆı› ÛÙÔ ∂¡À ·ÚÎÂÙ¤˜ Ê˘ÛÈÔÏÔÁÈΤ˜ ÚˆÙ½Ó˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÔÈ Ôԛ˜ ‰ÂÓ ·Ó¢ڛÛÎÔÓÙ·È Ê˘ÛÈÔÏÔÁÈο ÛÙÔ ∂¡À Î·È ¯ÚËÛÈÌÂ‡Ô˘Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ CJD ÚÈÓ ÙÔ ı¿Ó·ÙÔ (9). ∏ ÛËÌ·ÓÙÈÎfiÙÂÚË ·fi ·˘Ù¤˜ ÙȘ ÚˆÙ½Ó˜ Â›Ó·È Ë 14-3-3, ÂÓÒ ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È Ë ÚˆÙ½ÓË PrPCJD. ∏ ÚˆÙ½ÓË 14-3-3 ¤¯ÂÈ ·Ó¢ÚÂı› Î·È Û ¿ÏϘ Ó¢ÚÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ ÛÙÔ ∂¡À ·ÛıÂÓÒÓ Ì ÔÍ›· ÈÔÁÂÓ‹ ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ· ‹ Û ·ÛıÂÓ›˜ Ì ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ. ∆Ô ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·, ÛÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ÎÏ·ÛÈ΋˜ CJD, Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi ‹ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌË ÂȉÈο ¯·ÌËÏ¿ ·̷ٷ, ÂÓÒ ÛÙ·‰È·Î¿ ÂÍÂÏ›ÛÛÂÙ·È Û ÂÚÈÔ‰È΋ ÂÌÊ¿ÓÈÛË ‰ÈÊ·ÛÈÎÒÓ ‹ ÙÚÈÊ·ÛÈÎÒÓ Û˘ÌÏÂÁÌ¿ÙˆÓ ·È¯ÌËÚÒÓ Î˘Ì¿ÙˆÓ ÛÙ· 2/3 ÙˆÓ ·ÛıÂÓÒÓ (9). ™Â ϤÔÓ ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ CJD, ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ú·ÙËÚÂ›Ù·È ÁÂÓÈÎÂ˘Ì¤ÓË ·ÙÚÔÊ›·, ÂÓÒ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ú·ÙËÚÔ‡ÓÙ·È ˘„ËÏ‹˜ ¤ÓÙ·Û˘ Û‹Ì·Ù· ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· (9). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰È·ÈÛÙÒÓÔÓÙ·È ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ Û ÚÔ¯ˆÚË̤ÓÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘. ¡Â˘ÚÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο, ÔÈ ÂÁΤʷÏÔÈ ÙˆÓ ·ÛıÂÓÒÓ Ì CJD Ì·ÎÚÔÛÎÔÈο Û˘Ó‹ıˆ˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ô˘ÛÈ·ÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ÂÓÒ Û ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ·ÙÚÔÊ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ô ÔÔ›Ô˜ ˙˘Á›˙ÂÈ ÌÂٷ͇ 850-1000 gr. ªÂ ÙË ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ‰ÂÈÁÌ¿ÙˆÓ ·fi ‚ÈÔ„›· ÂÁÎÂÊ¿ÏÔ˘ ·fi ·ÓıÚÒÔ˘˜ Ì fiϘ ÙȘ ÌÔÚʤ˜ CJD ‰È·ÈÛÙÒÓÔÓÙ·È ÛÔÁÁÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÒÏÂÈ· Ó¢ÚÒÓˆÓ Î·È ÁÏÔ›ˆÛË (13). OÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ù˘ Ó¤·˜ ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜ CJD Â›Ó·È ÔÈ ‰È¿Û·ÚÙ˜ ϿΘ ·Ì˘ÏÔÂȉԇ˜ ÛÙË Ê·È¿ Ô˘Û›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È È‰È·›ÙÂÚ· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜, Ô˘ ÂÚÈ‚¿ÏÏÔÓÙ·È ·fi ÎÂÓÔÙÔÈÒ‰ÂȘ ‚Ï¿‚˜. ÷ڷÎÙËÚÈÛÙÈ΋ Â›Ó·È Î·È Ë ·ÓÙȉڷÛÙÈ΋ ·ÛÙÚÔ·ÙÙˆÛË. ∏

521

¶·È‰È·ÙÚÈ΋ 2001;64:518-526

Ï¢΋ Ô˘Û›· ·Ú·Ì¤ÓÂÈ ·Ó¤·ÊË. OÈ ÛÔÁÁÈÒ‰ÂȘ ‚Ï¿‚˜ Â›Ó·È ÈÔ ¤ÓÙÔÓ˜ ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· Î·È ÙÔ ı¿Ï·ÌÔ (13). ∏ ‰È¿ÁÓˆÛË Ù˘ CJD ‰È¢ÎÔχÓÂÙ·È ·fi ÙË ‰È·›ÛÙˆÛË Ù˘ ‡·Ú͢ ÙˆÓ ÚˆÙÂ˚ÓÒÓ PrP ÛÙÔ ·Ú¤Á¯˘Ì· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ÙË ¯Ú‹ÛË ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈÎÒÓ ÌÂıfi‰ˆÓ. ∂ÈϤÔÓ, ÌÔÚ› Ó· ·Ó¢ÚÂıÔ‡Ó ϿΘ PrP, ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜. ™ÙË Ó¤· ÛÔÚ·‰È΋ ÌÔÚÊ‹, ¯·Ú·ÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· ·ÔÙÂÏÔ‡Ó ÔÈ “·ÓıÔÛÙfiÏÈÛÙ˜” ϿΘ, ‰ËÏ·‰‹ ϿΘ ·Ì˘ÏÔÂȉԇ˜ ‰›ÎËÓ ·Óı¤ˆÓ, Ô˘ ÂÚÈ‚¿ÏÏÔÓÙ·È ·fi ÎÂÓÔÙfiÈ· (12). ∏ ‚ÈÔ„›· ·Ì˘Á‰·ÏÒÓ Â›Ó·È ¯Ú‹ÛÈÌË ÛÙË ‰È¿ÁÓˆÛË Ù˘ Ó¤·˜ ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜ Ù˘, ‰ÈfiÙÈ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ÚˆÙ½Ó˘ PrPCJD (12). ™ÙË Û‡Á¯ÚÔÓË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ¤ˆ˜ Û‹ÌÂÚ· ̤ıÔ‰Ô˜ ÂÚÁ·ÛÙËÚȷ΋˜ ‰È·›ÛÙˆÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔ ·›Ì· ·ÛıÂÓÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙË Ó¤· ÛÔÚ·‰È΋ ÌÔÚÊ‹ CJD. π·ÙÚÔÁÂÓ‹˜ ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ∏ ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (¶›Ó·Î·˜ 3), ÚÔÂÚ¯fiÌÂÓ˘ ·fi Âί˘Ï›ÛÌ·Ù· و̷ÙÈÎÒÓ ˘ÔʇÛˆÓ, ÚÔοÏÂÛ ٷ ÚÒÙ· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ ÙÔ 1985 (14), Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÔÛ˘Úı› ·ÁÎÔÛÌ›ˆ˜ ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›· Î·È Ó· ·ÓÙÈηٷÛÙ·ı› ·fi ÙË ‚ÈÔÛ˘ÓıÂÙÈ΋ ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ·Ú·Û΢·˙fiÌÂÓË Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA. ∂›Û˘, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È Î·È ÔÈ ·ÓıÚÒÈÓ˜ ÁÔÓ·‰ÔÙÚÔ›Ó˜ ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ (14). °È· ÙËÓ Èı·ÓfiÙËÙ· ÌÂÙ¿‰ÔÛ˘ Ù˘ CJD ̤ۈ ÌÂÙ·ÌÔۯ‡ÛˆÓ, ÌÂÙ¿ÁÁÈÛ˘ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ Â›Ó·È ÁÓˆÛÙ¿ Ù· ÂÍ‹˜: Œ¯Ô˘Ó ·Ó·ÊÂÚı› 4 ÂÚÈÙÒÛÂȘ CJD ·fi ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜, Ì›· ÌÂÙ¿ ·fi ¤Á¯˘ÛË ·Ï‚Ô˘Ì›Ó˘, Ì›· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ‡ÛÙÂÚ· ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÎÂÚ·ÙÔÂȉԇ˜ (15,16). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È ÂÚ›ÙˆÛË CJD ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÎÏËÚ¿˜ Ì‹ÓÈÁÁ·˜ (14). ∂ÍÂÙ¿˙ÂÙ·È, Â›Û˘, ÙÔ ÂӉ¯fiÌÂÓÔ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ ·fi ηıÂÙ‹Ú˜ ·ÁÁÂÈÔÏ·ÛÙÈ΋˜, ‚ËÌ·ÙÔ‰fiÙ˜, ηıÒ˜ Î·È Ì ٷ Ú¿ÌÌ·Ù· catgut. ¢ÂÓ ¤¯ÂÈ ·Ó·ÊÂÚı› ÂÚ›ÙˆÛË ·fi ¯ÔÚ‹ÁËÛË ·Ú¿ÁÔÓÙ· VIII ‹ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û˘ÌÌÂÙ¤¯Ô˘Ó 20.000-60.000 ·ÈÌÔ‰fiÙ˜ ÛÙË ¶›Ó·Î·˜ 3. π·ÙÚÔÁÂÓ‹˜ ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ñ ÃÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ·fi و̷ÙÈΤ˜ ˘ÔʇÛÂȘ ñ ªÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ (·Ï‚Ô˘Ì›Ó˘, ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜, ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ) ñ ∂·Ó·¯ÚËÛÈÌÔÔ›ËÛË Î·ıÂÙ‹ÚˆÓ ·ÁÁÂÈÔÏ·ÛÙÈ΋˜ ‹ ‚ËÌ·ÙÔ‰ÔÙÒÓ ñ ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÎÂÚ·ÙÔÂȉÒÓ ‹ ÛÎÏËÚ¿˜ Ì‹ÓÈÁÁ·˜

522

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‰ÂÍ·ÌÂÓ‹ Ï¿ÛÌ·ÙÔ˜, ·fi ÙËÓ ÔÔ›· ÊÙÈ¿¯ÓÔÓÙ·È ÔÈ Û˘Ì˘Îӈ̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ Î·È Ë Èı·ÓfiÙËÙ· ÌfiÏ˘ÓÛ˘ Â›Ó·È ˘„ËÏ‹ (17). ø˜ ̤ÛÔ ÚÔÛÙ·Û›·˜ ÙˆÓ ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ, ÙÔ FDA (US Food and Drug Administration) ¤¯ÂÈ ÚÔÙ›ÓÂÈ ÙËÓ ·fiÛ˘ÚÛË fiÏˆÓ ÙˆÓ ÔÛÔÙ‹ÙˆÓ ·›Ì·ÙÔ˜ ‹ ·Ú·ÁÒÁˆÓ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‰ÔÙÒÓ, ÚÈÓ ·˘Ùfi ÙÔÔıÂÙËı› Û ‰ÂÍ·ÌÂÓ¤˜ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜), Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¿ÙÔÌ· Ù· ÔÔ›· ·ÚÁfiÙÂÚ· ·Ó¤Ù˘Í·Ó ÛÔÚ·‰È΋ CJD ‹ Ó¤· ÛÔÚ·‰È΋ CJD, fiˆ˜ Î·È ·fi ·ÈÌÔ‰fiÙ˜ Ô˘ ¤¯Ô˘Ó ÂÎÙÂı› ÛÙÔÓ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó CJD. ∆· ̤ÙÚ· Â›Ó·È ‰Ú·ÛÙÈο, ‰ÈfiÙÈ ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË ÛÙÔ ÏÔÈÌÔÁfiÓÔ ·Ú¿ÁÔÓÙ·, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚÔ˜ ÙÔ ·ÚfiÓ ·ÍÈfiÈÛÙÔÈ ÙÚfiÔÈ ÁÈ· Ó· ·ÚÂÌÔ‰ÈÛÙ› Ë Â¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘, Ô‡Ù ˘¿Ú¯ÂÈ ·ÍÈfiÈÛÙË ÂÚÁ·ÛÙËÚȷ΋ ̤ıÔ‰Ô˜ ÁÈ· Ó· ·ÓȯÓ¢ı› Ë ÓfiÛÔ˜ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ªÂÙ¿‰ÔÛË Ù˘ ™∂µ ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡ °È· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙˆÓ ‚ÔÔÂȉÒÓ ÛÙÔÓ ¿ÓıÚˆÔ ÂÓÔ¯ÔÔÈÂ›Ù·È Ë ‚ÚÒÛË ‚Ô‰ÈÓÔ‡ ÎÚ¤·ÙÔ˜ ˙ÒÔ˘ ¿Û¯ÔÓÙÔ˜ ·fi ÙË ÓfiÛÔ. O ·Ú¿ÁÔÓÙ·˜ ™∂µ ‰ÂÓ ·ÓȯÓ‡ÂÙ·È Û ÛËÌ·ÓÙÈΤ˜ ÔÛfiÙËÙ˜ ÛÙÔ˘˜ ÈÛÙÔ‡˜ ÙˆÓ ‚ÔÔÂȉÒÓ, fiˆ˜ ·ÓȯÓ‡ÂÙ·È Ô ·Ú¿ÁÔÓÙ·˜ Ù˘ ÓfiÛÔ˘ scrapie ÛÙ· Úfi‚·Ù· (¶›Ó·Î·˜ 4). ªÂϤÙ˜ Û ÈÛÙÔ‡˜ ·ÁÂÏ¿‰ˆÓ Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ ·Ú¿ÁÔÓÙ· ™∂µ ¤‰ÂÈÍ·Ó ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ· ÌfiÓÔ ÛÙÔÓ ÂÁΤʷÏÔ, ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi, ÙÔÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ Î·È ÙÔÓ ÂÈÏÂfi, 6-18 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ Â·Ê‹ Ì ÙË ÓfiÛÔ. ∂›Û˘, ÌÂÏÂÙ‹ıËÎ·Ó ÛÏ‹Ó·˜ Î·È ÏÂÌÊ·‰¤Ó˜ ‚ÔÔÂȉÒÓ 40 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË ÌfiÏ˘ÓÛ‹ ÙÔ˘˜ ·fi ÙÔÓ ·Ú¿ÁÔÓÙ· ™∂µ Î·È ‰ÂÓ ·ÓȯÓ‡ıËÎ·Ó ÌÔÏ˘ÛÌ·ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ÔÈ Ù›ÙÏÔÈ ÙÔ˘ ÌÔÏ˘ÛÌ·ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ™∂µ Â›Ó·È Ôχ ¯·ÌËÏÔ› ÛÙÔ˘˜ ÈÛÙÔ‡˜ ·˘ÙÔ‡˜ Î·È ·Ó·Ì¤ÓÂÙ·È fiÙÈ ÛÙÔ˘˜ Ì˘˜ Î·È ÙÔ Á¿Ï· ı· Â›Ó·È Ôχ ¯·ÌËÏfiÙÂÚÔÈ (18). ∂ÎÙfi˜ ·fi Ù· ‚ÔÔÂȉ‹, ÂÈÚ¿Ì·Ù· Ô˘ ¤ÁÈÓ·Ó Û ¿ÏÏ· ›‰Ë ˙ÒˆÓ ¤‰ÂÈÍ·Ó fiÙÈ fiÙ·Ó Ô ·Ú¿ÁÔÓÙ·˜ ™∂µ ¯ÔÚËÁÂ›Ù·È ·ÚÂÓÙÂÚÈο ÁÈ· ÂÈÚ·Ì·ÙÈÎÔ‡˜ ÛÎÔÔ‡˜ Û Úfi‚·Ù·, ηÙۛΘ (19) Î·È ¯Ô›ÚÔ˘˜ (20), ·˘Ù¿ ÌÔχÓÔÓÙ·È Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÔÁÁÒ‰Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ì ÂÍ·›ÚÂÛË Ù· ÎÔÙfiÔ˘Ï·, Ù· ÔÔ›· 3 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ Â·Ê‹ Ì ÙË ÓfiÛÔ, ‰ÂÓ ÓfiÛËÛ·Ó. ∂›Û˘, ¯ÔÚËÁÒÓÙ·˜ ˆÌ¿ Ì˘·Ï¿ ·Û¯fiÓÙˆÓ ‚ÔÔÂȉÒÓ Û Úfi‚·Ù·, ηÙۛΘ Î·È ¯Ô›ÚÔ˘˜, ÌÂÙ·‰fiıËÎÂ Ë ÓfiÛÔ˜ Û ·˘Ù¿, ÂÓÒ ‰ÂÓ ÌÂÙ·‰fiıËΠÛÙ· ÎÔÙfiÔ˘Ï· (21). ¶·Ú¿ ÙËÓ ÂÈÙ˘¯‹ ÂÈÚ·Ì·ÙÈ΋ ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ™∂µ Û Úfi‚·Ù·, ηÙۛΘ Î·È ¯Ô›ÚÔ˘˜, ·˘Ùfi ‰ÂÓ Û˘ÓÂ¿ÁÂÙ·È ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ‰È¿ ÙˆÓ ˙ˆÔÙÚÔÊÒÓ, Ô‡ÙÂ

¶·È‰È·ÙÚÈ΋ 2001;64:518-526

Paediatriki 2001;64:518-526

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πۯȷÎfi Ó‡ÚÔ, ı‡ÌÔ˜, Ó‡ÌÔÓ·˜, ¿ÁÎÚ·˜, ÓˆÙÈ·›Ô˜ Ì˘ÂÏfi˜, ηÙÈfiÓ ÎfiÏÔÓ £ÚfiÌ‚ÔÈ ·›Ì·ÙÔ˜, ηډ›·, ÓÂÊÚfi˜, Ì·˙ÈÎfi˜ ·‰¤Ó·˜, ÛÎÂÏÂÙÈÎÔ› ̇˜, Á¿Ï·, ÔÚfi˜, fiگȘ

˘¿Ú¯Ô˘Ó ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi. °È· ÙËÓ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Ù˘ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Ì ÙȘ ˙ˆÔÙÚÔʤ˜ Û Úfi‚·Ù·, ηÙۛΘ Î·È ¯Ô›ÚÔ˘˜, ¯ÔÚËÁ‹ıËÎ·Ó Û ·˘Ù¿ ˙ˆÔÙÚÔʤ˜ Ì ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· ™∂µ. ª¤¯ÚÈ Û‹ÌÂÚ·, ‰ËÏ·‰‹ ÂÙ¿ ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌfiÏ˘ÓÛ‹ ÙÔ˘˜, Ù· ˙Ò· ·˘Ù¿ ‰ÂÓ ¤¯Ô˘Ó ÂÌÊ·Ó›ÛÂÈ Û˘ÌÙÒÌ·Ù· ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜. §fiÁˆ fï˜ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ¯ÚfiÓÔ˘ ÂÒ·Û˘ Ù˘ ÓfiÛÔ˘, Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ÔÚÈÛÙÈο Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ÒˆÓ Û˘Ó¯›˙ÂÙ·È. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ Á¿Ï·, ıˆÚÂ›Ù·È ·ÛʷϤ˜ ̤¯ÚÈ ÛÙÈÁÌ‹˜, ‰ÈfiÙÈ ·fi ÂÈÚ¿Ì·Ù· Û ÔÓÙ›ÎÈ· Ô˘ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠÂ› Ì·ÎÚfiÓ Î·È Û ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ Á¿Ï· ÌÔÏ˘ÛÌ¤ÓˆÓ ‚ÔÔÂȉÒÓ, ‰ÂÓ ‚Ú¤ıËÎ·Ó ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ‹ ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ (22). ∂›Û˘, ·ÌÓÔ› Ô˘ ı‹Ï·Û·Ó ·fi ÚÔ‚·Ù›Ó˜ ÌÔÏ˘Ṳ̂Ó˜ ÂÈÚ·Ì·ÙÈο Ì ÙÔÓ ·Ú¿ÁÔÓÙ· ™∂µ, ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó Û˘ÌÙÒÌ·Ù· ‹ ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘ (22). ™‡ÓÙÔÌ· ı· ÍÂÎÈÓ‹ÛÂÈ ÛÂÈÚ¿ ÂÈÚ·Ì¿ÙˆÓ ·Ó›¯Ó¢Û˘ Ù˘ ÚˆÙ½Ó˘ prion Û Á¿Ï· ‚ÔÔÂȉÒÓ Ô˘ ÌÔχÓıËÎ·Ó ÂÈÚ·Ì·ÙÈο Ì ÙÔÓ ·Ú¿ÁÔÓÙ· ™∂µ. ªË¯·ÓÈÛÌÔ› ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ ™∂µ ·Ó¿ÌÂÛ· ÛÙ· ‚ÔÔÂȉ‹ °È· ÙË ÌfiÏ˘ÓÛË ÙˆÓ ‚ÔÔÂȉÒÓ ¤¯Ô˘Ó ‰ÈÂÚ¢ÓËı› ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ (23), fiˆ˜: ·) Ë ¯Ú‹ÛË ÂÌ‚ÔÏ›ˆÓ, Ê·ÚÌ¿ÎˆÓ ‹ Ê˘ÙÔÊ·Ú̿ΈÓ, ‚) Ë ¿ÌÂÛË Â·Ê‹ ÙˆÓ ‚ÔÔÂȉÒÓ Ì ˙ÒÓÙ· Úfi‚·Ù·, Á) Ë ËÏÈΛ· ÙˆÓ ‚ÔÔÂȉÒÓ, ÙÔ Ê‡ÏÔ, Ë ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ¿‰ÔÛË, Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ÌÔÛ¯·ÚÈÒÓ Ì ıËÏ·ÛÌfi ‹ Ì ˙ˆÔÙÚÔʤ˜. ∞fi fiϘ ÙȘ ·ÓˆÙ¤Úˆ ·Ú·Ì¤ÙÚÔ˘˜, ÌfiÓÔ Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ÌÔÛ¯·ÚÈÒÓ Ì ˙ˆÔÙÚÔʤ˜ ·ÔÙÂÏÔ‡Û ÙÔÓ ÎÔÈÓfi ·Ú¿ÁÔÓÙ·, ˘‡ı˘ÓÔ ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ™∂µ ·Ó¿ÌÂ-

πۯȷÎfi Ó‡ÚÔ, ı‡ÌÔ˜, ÓˆÙÈ·›Ô˜ Ì˘ÂÏfi˜, ‹·Ú, Ó‡̈Ó, ¿ÁÎÚ·˜, ηډ›·, ÓÂÊÚfi˜, Ì·˙ÈÎfi˜ ·‰¤Ó·˜, Á¿Ï·, ·›Ì·, ÔÚfi˜, ÛÎÂÏÂÙÈÎÔ› ̇˜, fiگȘ

Û· ÛÙ· ‚ÔÔÂȉ‹.

OÈ ˙ˆÔÙÚÔʤ˜ ·˘Ù¤˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÂÂÍÂÚÁ·Û›· ÎÚ¿وÓ, Ï›Ô˘˜ Î·È ÔÛÙÒÓ ‚ÔÔÂȉÒÓ ·fi Ù· ÛÊ·Á›· Î·È Ù· ÎÚÂÔˆÏ›·. ∏ ÂȉÈ΋ ÂÂÍÂÚÁ·Û›· ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ó¿ÌÂÈÍË, Û‡ÓıÏÈ„Ë, ‚Ú·ÛÌfi Î·È Ê˘ÁÔΤÓÙÚÈÛË ‹ ·ÎfiÌ· Î·È ÚÔÛı‹ÎË ‰È·Ï˘Ì¿ÙˆÓ ˘‰ÚÔÁÔÓ·ÓıÚ¿ÎˆÓ ÁÈ· Ó· ·Ê·ÈÚÂı› ÙÔ Ï›Ô˜ (23). ∆Ô Â›‰Ô˜ Ù˘ ÂÂÍÂÚÁ·Û›·˜ ÙˆÓ ˙ˆÔÙÚÔÊÒÓ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ¿˜ ÙÔ˘˜. ŒÙÛÈ, Ë ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ· ·˘Í¿ÓÂÙ·È Ì ÙËÓ ÂÂÍÂÚÁ·Û›· ÙÔ˘˜ Ì ˘‰ÚÔÁÔÓ¿ÓıڷΘ Û ÂÚÈÔÚÈṲ̂ÓÔ ‚·ıÌfi, ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È ˘„ËÏfi ÔÛÔÛÙfi Ï›Ô˘˜ (7-14%), ÙÔ ÔÔ›Ô ÚÔÊ˘Ï¿ÛÛÂÈ Ù· prions ·fi ÙËÓ Î·Ù·ÛÙÚÔÊ‹ Ì Ì˯·ÓÈο ̤۷ (14). ∂›Û˘, Ë ˘ÁÚ‹ ı¤ÚÌ·ÓÛË ÙˆÓ ˙ˆÔÙÚÔÊÒÓ Â›Ó·È ϤÔÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ì›ˆÛË Ù˘ ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ·˜ ·fi ÙË ÓfiÛÔ scrapie, Û ۇÁÎÚÈÛË Ì ÙËÓ ÍËÚ‹ ı¤ÚÌ·ÓÛË (14). ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ù· ‚ÔÔÂȉ‹ ‹Ù·Ó ¿ÓÙ· ÂÎÙÂıÂÈ̤ӷ ÛÙË ÓfiÛÔ scrapie, ·ÏÏ¿ ÔÈ Ì¤ıÔ‰ÔÈ ÂÂÍÂÚÁ·Û›·˜ ÙˆÓ ˙ˆÔÙÚÔÊÒÓ ÙÚÔÔÔÈ‹ıËÎ·Ó Î·È ¤ÙÛÈ ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó ÔÈ Û˘Óı‹Î˜ ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ™∂µ ÛÙ· ‚ÔÔÂȉ‹ (24). ∞Ó·ÊÔÚÈο Ì ÙȘ ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌfiÏ˘ÓÛË ÙˆÓ ‚ÔÔÂȉÒÓ, fiˆ˜ Ë ËÏÈΛ·, ÙÔ Ê‡ÏÔ, Ë ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ¿‰ÔÛË, Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ÌÔÛ¯·ÚÈÒÓ, ·Ó·Ê¤ÚÔÓÙ·È Ù· ÂÍ‹˜: Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘ ™∂µ ·Ó¿ÌÂÛ· ÛÙ· ‚ÔÔÂȉ‹ Â›Ó·È ÌˉÂÓÈ΋ Û ÌÔÛ¯¿ÚÈ· ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ (18), ÂÓÒ Ë Ì¤ÁÈÛÙË Û˘¯ÓfiÙËÙ· ·Ú·ÙËÚÂ›Ù·È Û ËÏÈ˘ 4 Î·È 5 ÂÙÒÓ (™¯‹Ì· 2). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂÚÌËÓ‡ÂÙ·È ˆ˜ ÂÍ‹˜: Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ÌÔÛ¯·ÚÈÒÓ ÁÈ· ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ˙ˆ‹˜ Á›ÓÂÙ·È ·ÔÎÏÂÈÛÙÈο Ì Á¿Ï·. ∂¿Ó ÙÔ ÌÔÛ¯¿ÚÈ ÚÔ¤Ú¯ÂÙ·È ·fi ÌË Á·Ï·ÎÙÔÊfiÚ· ·ÁÂÏ¿‰·, ÙfiÙ ıËÏ¿˙ÂÈ ·ÔÎÏÂÈÛÙÈο. ∂¿Ó, ·ÓÙÈı¤Ùˆ˜, Ë ·ÁÂÏ¿‰· Â›Ó·È Á·Ï·ÎÙÔÊfiÚ· (Ù˘ ÔÔ›·˜ ÙÔ Á¿Ï· ÚÔÔÚ›˙ÂÙ·È ÁÈ· ÂÎÌÂÙ¿ÏÏ¢ÛË), ÙfiÙ ¯ÔÚËÁÂ›Ù·È ÛÙÔ ÌÔÛ¯¿ÚÈ Á¿Ï·

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ÎÔÓÈÔÔÈË̤ÓÔ ‹ Î·È ÏÔ‡ÛÈ· Û ÚˆÙ½Ó˜ Û˘Ì˘Îӈ̤ÓË ˙ˆÔÙÚÔÊ‹ Û ÔÛÔÛÙfi 5%. ŒÙÛÈ, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙˆÓ ‚ÔÔÂȉÒÓ ÛÙ· ÎÔ¿‰È· Á·Ï·ÎÙÔÊfiÚˆÓ ·ÁÂÏ¿‰ˆÓ Ô˘ ‰ÂÓ ı‹Ï·˙·Ó Ù· ÌÔÛ¯¿ÚÈ· ÙÔ˘˜ ·Ó·Ê¤ÚıËΠÛÙË ª. µÚÂÙ·Ó›· Û ÔÛÔÛÙfi 45,6% (πÔ‡ÏÈÔ˜ 1993) Î·È ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË Û ۇÁÎÚÈÛË Ì ÂΛÓË ÙˆÓ ÌË Á·Ï·ÎÙÔÊfiÚˆÓ ·ÁÂÏ¿‰ˆÓ Ô˘ ı‹Ï·˙·Ó Ù· ÌÔÛ¯¿ÚÈ· ÙÔ˘˜ (9,9%) (21). ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ ÌÔÛ¯¿ÚÈ ÙÚ¤ÊÂÙ·È ·ÔÎÏÂÈÛÙÈο Ì Á¿Ï· ÁÈ· ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ˙ˆ‹˜ Î·È Ô ¯ÚfiÓÔ˜ ÂÒ·Û˘ Ù˘ ÓfiÛÔ˘ ÛÙ· ‚ÔÔÂȉ‹ Â›Ó·È 4-5 ¯ÚfiÓÈ·, Ë Ì¤ÁÈÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ™∂µ ÛÙ· ‚ÔÔÂȉ‹ ÂÌÊ·Ó›˙ÂÙ·È Û ˙Ò· 4-5 ÂÙÒÓ, ÂÓÒ ÛÙ· ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ ÌÔÛ¯¿ÚÈ· Â›Ó·È ÌˉÂÓÈ΋ (™¯‹Ì· 2). ∞Ó·ÊÔÚÈο Ì ÙÔ Ê‡ÏÔ ÙˆÓ ·Û¯fiÓÙˆÓ ‚ÔÔÂȉÒÓ, Ë ÏÂÈÔ„ËÊ›· Â›Ó·È ·ÁÂÏ¿‰Â˜, ‰ÈfiÙÈ Ù· ‚fi‰È· Ô˘ ÚÔÔÚ›˙ÔÓÙ·È ÁÈ· ÎÚ·ÙÔ·Ú·ÁˆÁ‹ ı·Ó·ÙÒÓÔÓÙ·È Û ËÏÈΛ· 12-14 ÌËÓÒÓ, ÂÓÒ ÂΛӷ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ·Ó··Ú·ÁˆÁ‹, ı·Ó·ÙÒÓÔÓÙ·È Û ËÏÈΛ· 2 ÂÙÒÓ (21). ∏ ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ scrapie ÛÙ· Úfi‚·Ù· (25) Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ οıÂÙ˘ ·ÏÏ¿ Î·È ÔÚÈ˙fiÓÙÈ·˜ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ (‰È¿ Ù˘ ‚ÚÒÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ·fi ¿ÏÏ· ˙Ò·). ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ÙÔ fiÚÁ·ÓÔ ÌÂÙ¿‰ÔÛ˘ Â›Ó·È Ô Ï·ÎÔ‡ÓÙ·˜. OÈ Pattison Î·È Û˘Ó (25) ¤‰ÂÈÍ·Ó fiÙÈ ¯ÔÚ‹ÁËÛË Ï·ÎÔ‡ÓÙ· ·Û¯fiÓÙˆÓ ÚÔ‚¿ÙˆÓ Û ˘ÁÈ‹ ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡ ‹ ÔÚÔÏÔÁÈο, ÚÔοÏÂÛ ÙË ÌfiÏ˘ÓÛË ÙˆÓ ÚÔ‚¿ÙˆÓ ·˘ÙÒÓ. ∞ÓÙ›ıÂÙ·, Ë ¯ÔÚ‹ÁËÛË ÔÚÔ‡ ·fi Ï·ÎÔ‡ÓÙ· ·Û¯fiÓÙˆÓ ·ÁÂÏ¿‰ˆÓ Û ˘ÁÈ›˜ ·ÁÂÏ¿‰Â˜, ‰ÂÓ ÚÔοÏÂÛ ÙË ÓfiÛÔ ÌÂÙ¿ 3,5 ¤ÙË ·fi ÙËÓ ÚfiÎÏËÛË. ∂›Û˘, ‚ÔÔÂȉ‹ Ô˘ ı·Ó·ÙÒıËÎ·Ó 2 ¤ÙË ÌÂÙ¿ ÙËÓ ÚfiÎÏËÛË ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ Ù˘ ÓfiÛÔ˘. ∏ ÛËÌ·Û›· Ù˘ οıÂÙ˘ ‹ Ù˘ ÔÚÈ-

™¯‹Ì· 2. ∂Ù‹ÛÈ· Û˘¯ÓfiÙËÙ· ™∂µ ÛÙ· ‚ÔÔÂȉ‹ ·Ó¿ ËÏÈΛ· (21).

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Paediatriki 2001;64:518-526

˙fiÓÙÈ·˜ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ scrapie ·Ó¿ÌÂÛ· ÛÙ· Úfi‚·Ù· ‰È¿ Ù˘ ‚ÚÒÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ·Û¯fiÓÙˆÓ ˙ÒˆÓ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ÚfiÎÏËÛË ÂȉËÌÈÒÓ Ù˘ ÓfiÛÔ˘ Û ÎÔ¿‰È· ÚÔ‚¿ÙˆÓ. ∏ ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ¿‰ÔÛË ·fi ÙËÓ ·ÁÂÏ¿‰· ÛÙÔ ÌÔÛ¯¿ÚÈ Â›Ó·È ¤Ó·˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂÍÂÙ¿˙ÂÙ·È ÂÎÙÂÓÒ˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·Û·ÊËÓÈÛÙ› Ë ÚԤϢÛË Ù˘ ÂȉËÌ›·˜ Ù˘ ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙˆÓ ‚ÔÔÂȉÒÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ ˘¿Ú¯Ô˘Ó ‰‡Ô ÌÂϤÙ˜ Û ÂͤÏÈÍË (21). ∏ ÚÒÙË ÂÚÈÏ·Ì‚¿ÓÂÈ 316 ˙‡ÁË ÌÔÛ¯·ÚÈÒÓ Ô˘ ÌÂÏÂÙÒÓÙ·È Â› 7 ¯ÚfiÓÈ·. ∆Ô Î¿ı ˙‡ÁÔ˜ ·ÔÙÂÏÂ›Ù·È ·fi ¤Ó· ÌÔÛ¯¿ÚÈ Ô˘ ÁÂÓÓ‹ıËΠ·fi ·ÁÂÏ¿‰· ¿Û¯Ô˘Û· ·fi ™∂µ, ÂÓÒ ÙÔ ¿ÏÏÔ ÚÔ¤Ú¯ÂÙ·È ·fi ·ÁÂÏ¿‰· ˘ÁÈ‹. ªÂÙ¿ 5 ¯ÚfiÓÈ· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘, ‰È·ÈÛÙÒıËÎ·Ó 10 ÂÚÈÙÒÛÂȘ ™∂µ, ȉȷ›ÙÂÚ· ·Ó¿ÌÂÛ· ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ÌÔÛ¯¿ÚÈ·. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÏÔÈfiÓ, Ë Î¿ıÂÙË ÌÂÙ¿‰ÔÛË ‰ÂÓ Á›ÓÂÙ·È Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi, ·ÏÏ¿ ̤¯ÚÈ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ÌÂϤÙ˘ Î·È ÙË ı·Ó¿ÙˆÛË fiÏˆÓ ÙˆÓ ˙ÒˆÓ, ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÌÂϤÙË ÙˆÓ ÂÁÎÂÊ¿ÏˆÓ Î·È ÙËÓ ·ÔΈ‰ÈÎÔÔ›ËÛË ÙˆÓ ÛÙÔȯ›ˆÓ ÙˆÓ ÌËÙ¤ÚˆÓ, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÂÍ·¯ıÔ‡Ó Û·Ê‹ Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙË ‰Â‡ÙÂÚË ¤Ú¢ӷ (21), ÌÂÏÂÙ¿Ù·È Ë ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· Ù˘ ™∂µ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ ·Û¯Ô˘ÛÒÓ ·ÁÂÏ¿‰ˆÓ Î·È Û˘ÁÎÚ›ÓÂÙ·È Ì ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÂÙ‹ÛÈ· Û˘¯ÓfiÙËÙ· ÌÂÙ¿‰ÔÛ˘ ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡. T· ÚÒÙ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ ÙˆÓ ·ÁÂÏ¿‰ˆÓ Ì ™∂µ ‰ÂÓ ‰È·Ê¤ÚÂÈ ·fi ÂΛÓË Ù˘ ÌÂÙ¿‰ÔÛ˘ ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡. ™¯ÂÙÈο Ì ÙËÓ ·ÙÚÈ΋ ÌÂÙ¿‰ÔÛË, ‰ÂÓ ‰È·ÈÛÙÒıËΠ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ™∂µ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ ·Û¯fiÓÙˆÓ Ù·‡ÚˆÓ ηÈ, Û˘ÓÂÒ˜, Ë ÌÂÙ¿‰ÔÛË ‰È¿ ÙÔ˘ Û¤ÚÌ·ÙÔ˜ Â›Ó·È ·ÌÂÏËÙ¤· (21). ∂¿Ó ÏÔÈfiÓ ıˆÚËı› Ë Î¿ıÂÙË ÌÂÙ¿‰ÔÛË ˆ˜ ÌË ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‰È¿‰ÔÛ˘ ÛÙ· ‚ÔÔÂȉ‹, ÙfiÙÂ Ô ÌfiÓÔ˜ ÛËÌ·ÓÙÈÎfi˜ ÙÚfiÔ˜ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ Á›ÓÂÙ·È Ì ÙȘ ˙ˆÔÙÚÔʤ˜. ™Â ·˘Ùfi ÙÔ ÛËÌ›Ô, ϤÔÓ, ÂÓÙ›ÓÔÓÙ·È Ù· ̤ÙÚ· ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ‰È¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘. ªÂÙ·‰ÔÙÈÎfiÙËÙ· Î·È ·ÓÙÔ¯‹ ÙˆÓ prions ∏ ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ÂÈÚ·Ì·ÙÈο ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Âί˘ÏÈÛÌ¿ÙˆÓ ÂÁÎÂÊ¿ÏÔ˘ ‹ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡, ÔÊı·ÏÌÒÓ, Ó¢ÌfiÓˆÓ, ‹·ÙÔ˜, ÓÂÊÚÒÓ Î·È ÛÏ‹Ó·, ηıÒ˜ Î·È ÏÂÌÊ·‰¤ÓˆÓ ·fi ¿Û¯ÔÓÙ˜. ∂›Û˘, ∂¡À ·ÛıÂÓÒÓ Ì CJD ÌÔÚ› Ó· ÌÔχÓÂÈ ıËÏ·ÛÙÈο (9). OÈ ÂÎÎÚ›ÛÂȘ ÙˆÓ ·‰¤ÓˆÓ (Á¿Ï·, Û¤ÚÌ·) Î·È ÔÈ ·ÂÎÎÚ›ÛÂȘ (Ô‡Ú·, ÎfiÚ·Ó·, ‰¿ÎÚ˘·, Û¿ÏÈÔ, ȉÚÒÙ·˜) ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÌÂÙ·‰›‰Ô˘Ó ÙË ÓfiÛÔ. ™˘ÓÂÒ˜, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·ÔÌfiÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì CJD. O ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ Û ¿ÙÔÌ· Ù˘ ›‰È·˜ ÔÈÎÔÁ¤ÓÂÈ·˜ ‹ ÛÙÔ ˘ÁÂÈÔÓÔÌÈÎfi ÚÔÛˆÈÎfi Â›Ó·È ¯·ÌËÏfi˜. ÃÚÂÈ¿˙ÂÙ·È, fï˜,

¶·È‰È·ÙÚÈ΋ 2001;64:518-526

ÚÔÛÔ¯‹ ÛÙËÓ Â·Ê‹ Ì ÙÔ ∂¡À ‹ Ù· ÈÛÙÔÏÔÁÈο ·Ú·Û΢¿ÛÌ·Ù· ÙˆÓ ·ÛıÂÓÒÓ Ì CJD (9). °È· ÙËÓ ·Ôχ̷ÓÛË ÙˆÓ ÂÚÁ·Ï›ˆÓ Û˘ÓÈÛÙ¿Ù·È Ë ÙÔÔı¤ÙËÛ‹ ÙÔ˘˜ Û ‰È¿Ï˘Ì· ¡·O∏ >/1¡ ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 1 h Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·ÔÛÙ›ڈÛË ÛÙÔ˘˜ 134ÔC ÁÈ· 1 h. ¶ÚÔÙÈÌ¿Ù·È Ë ¯Ú‹ÛË ÂÚÁ·Ï›ˆÓ Ì›·˜ ¯Ú‹Û˘ Î·È ÙÔ Î¿„ÈÌÔ ÙˆÓ ˘ÏÈÎÒÓ Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› ·fi ÈÛÙÔ‡˜ ·Û¯fiÓÙˆÓ (9). ∆›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· Â¿Ó ÙÂÏÈο ˘¿Ú¯ÂÈ ‹ fi¯È ΛӉ˘ÓÔ˜ ηٿ ÙË ‚ÚÒÛË ÙÔ˘ ‚Ô‰ÈÓÔ‡ ÎÚ¤·ÙÔ˜. ∏ ÌfiÏ˘ÓÛË ÙˆÓ ˙ÒˆÓ ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡ Â›Ó·È Ôχ ‡ÎÔÏË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ··ÈÙÂ›Ù·È Ì›· ÎÔ˘Ù·ÏÈ¿ ˙ˆÔÙÚÔÊ‹˜ Ì ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· ™∂µ ÁÈ· Ó· ÌÔÏ˘Óı› Ì›· ·ÁÂÏ¿‰· (26). ∏ ÂÏ¿¯ÈÛÙË ‰fiÛË ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹. ª¤¯ÚÈ ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990, Ë Î·Ù·Ó¿ÏˆÛË ‚Ô‰ÈÓÔ‡ Ì˘·ÏÔ‡ ‹ ÂÓÙÔÛı›ˆÓ ‹Ù·Ó ÂχıÂÚË Î·È Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi ÌÔÚ› Ó· ‰È·‰fiıËÎ·Ó Ù· prions ÛÙÔ ·ÓıÚÒÈÓÔ ÂÙÈÎfi Û‡ÛÙËÌ·. ∏ ÌÂÙ·‰ÔÙÈÎfiÙËÙ· ‰È¿ Ù˘ ÙÚÔÊÈ΋˜ Ô‰Ô‡ ‰È¢ÎÔχÓÂÙ·È ·fi ÙËÓ ·ÓÙÔ¯‹ ÙˆÓ prions ÛÙȘ Û˘Óı‹Î˜ ÙÔ˘ Ì·ÁÂÈڤ̷ÙÔ˜ Î·È ÛÙÔ˘˜ ·Ì˘ÓÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∆· prions ¤¯Ô˘Ó Ôχ ÌÂÁ¿ÏË ·ÓÙÔ¯‹ ÛÙË ı¤ÚÌ·ÓÛË, ÙËÓ ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·, ÙË ÊÔÚÌfiÏË Î·È, fiˆ˜ ÚԷӷʤÚıËÎÂ, ÛÙȘ ÚˆÙ¿Û˜ Î·È ÚÈ‚ÔÓÔ˘ÎÏ¿Û˜. ∞ÓÙ¤¯Ô˘Ó ÛÙȘ Û˘Ó‹ıÂȘ ıÂÚÌÔÎڷۛ˜ Ì·ÁÂÈڤ̷ÙÔ˜, ÛÙȘ ¯‡ÙÚ˜ ·ÙÌÔ‡ Î·È ÛÙÔ˘˜ ÊÔ‡ÚÓÔ˘˜ ÌÈÎÚÔÎ˘Ì¿ÙˆÓ. ∂›Û˘, ¤¯Ô˘Ó ¯ËÌÈ΋ ·ÓÙÔ¯‹ Î·È ÔÈ ÚˆÙ½Ó˜ ÙÔ˘ Á‡̷ÙÔ˜ Ù· ÚÔÛÙ·ÙÂ‡Ô˘Ó ·fi ÙÔ˘˜ ·Ì˘ÓÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (27,28). ∂Ӊ¯Ô̤ӈ˜, ·Ú¿ÁÔÓÙ˜ ÙÔÈÎÔ›, fiˆ˜ ·ÏÎÔfiÏË, ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë, ÂËÚ¿˙Ô˘Ó ÙË ‰È·‚·ÙfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈıËÏ›Ô˘ (26). ∂›Û˘, ÔÈ ·Ì˘ÓÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÌÔÚ› Ó· ηٷÛÙ·ÏÔ‡Ó ·fi ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÏÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË, ÈÏ·Ú¿ ‹ influenza, ηٷÛÙ¤ÏÏÔÓÙ·˜ ÙË ‰Ú¿ÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ (26). ∆ÂÏÈο, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍÔ˘‰ÂÙÂÚˆı› Ô ·Ú¿ÁˆÓ ™∂µ ÛÙ· ˙ˆÈο ÚÔÈfiÓÙ·, ··ÈÙÂ›Ù·È ı¤ÚÌ·ÓÛ‹ ÙÔ˘˜ ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 20 min ÛÙÔ˘˜ 130ÔC Î·È Û ›ÂÛË 3 atm, ÒÛÙ ӷ Â›Ó·È ·ÛÊ·Ï‹ ÁÈ· ÙÔÓ Î·Ù·Ó·ÏˆÙ‹ (29). ™ÙȘ ¯‡ÙÚ˜ Ù·¯‡ÙËÙ·˜ ·Ó·Ù‡ÛÛÂÙ·È ıÂÚÌÔÎÚ·Û›· 115ÔC Î·È ›ÂÛË 1,5 atm. ™˘ÓÂÒ˜, ÔÈ ˘¿Ú¯Ô˘Û˜ ¯‡ÙÚ˜ Ù·¯‡ÙËÙ·˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ηٷÛÙÚ¤„Ô˘Ó Ù· prions. ŒÎÙ·ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ™Â fi,ÙÈ ·ÊÔÚ¿ ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ˆ˜ ÙȘ 3/11/2000 ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› 77 ÂȂ‚·ÈˆÌ¤Ó· ÂÚÈÛÙ·ÙÈο ·ÛıÂÓÒÓ ·Û¯fiÓÙˆÓ ·fi ÙË Ó¤· ÔÈÎÈÏ›· ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜ CJD, Ô˘ ¤ı·Ó·Ó ÛÙË ª. µÚÂÙ·Ó›· ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1995-2000, ÂÓÒ Î·Ó¤Ó· ÂÚÈÛÙ·ÙÈÎfi ‰ÂÓ ·Ó·Ê¤ÚıËΠηٿ ÙË

Paediatriki 2001;64:518-526

‰È¿ÚÎÂÈ· Ù˘ ÂÓÙ·ÂÙ›·˜ 1990-1995 (30,31). ™ÙË µfiÚÂÈ· ∞ÌÂÚÈ΋ ‰ÂÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› η̛· ÂÚ›ÙˆÛË Ó¤·˜ ÛÔÚ·‰È΋˜ CJD, Ô‡Ù ÛÔÁÁÒ‰Ô˘˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ‚ÔÔÂȉÒÓ Î·È ‰ÂÓ ·˘Í‹ıËÎÂ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÎÏ·ÛÈÎÒÓ ÌÔÚÊÒÓ Ù˘ CJD ηٿ Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· (9). ™ÙË ¯ÒÚ· Ì·˜, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÛÙÔȯ›· ·fi ÙËÓ ¤‰Ú· Ù˘ ∂ȉËÌÈÔÏÔÁ›·˜ ÙÔ˘ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ (¡Ô¤Ì‚ÚÈÔ˜ 2000), ‰ÂÓ ˘¿Ú¯Ô˘Ó ÎÚÔ‡ÛÌ·Ù· Ù˘ Ó¤·˜ ÛÔÚ·‰È΋˜ ÌÔÚÊ‹˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‚ÚÒÛË ‚Ô‰ÈÓÔ‡ ÎÚ¤·ÙÔ˜. À¿Ú¯Ô˘Ó 20 ‚‚·ÈˆÌ¤Ó· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ Î·È 7 ˘fi ‰ÈÂÚ‡ÓËÛË, Ù· ÔÔ›· ‰È·ÁÓÒÛÙËÎ·Ó ÌÂÙ¿ ÙÔ 1997. ŸÏ˜ ÔÈ ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Û·Ó ËÏÈÎȈ̤ӷ ¿ÙÔÌ· Î·È ·Ó‹Î·Ó ÛÙË ÛÔÚ·‰È΋ ÌÔÚÊ‹. ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÎÏËÚÔÓÔÌÈ΋ ÚԉȿıÂÛË ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÛÔÚ·‰È΋˜ Î·È Ù˘ È·ÙÚÔÁÂÓÔ‡˜ ÌÔÚÊ‹˜ Ù˘ ÓfiÛÔ˘. ŸÏÔÈ ÔÈ ¿Û¯ÔÓÙ˜, ‰ËÏ·‰‹, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔÓ ›‰ÈÔ ÁÔÓfiÙ˘Ô, Ô ÔÔ›Ô˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ‡·ÚÍË ÌÂıÂÈÔÓ›Ó˘ Û ÔÌfi˙˘ÁË ÌÔÚÊ‹ ÛÙÔ Îˆ‰ÈÎfiÓÈÔ 129 ÙÔ˘ ÁÔÓȉ›Ô˘ PrP (31). ø˜ ÙÒÚ·, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÙË Ó¤· ÛÔÚ·‰È΋ ÌÔÚÊ‹ Â›Ó·È ÔÌfi˙˘ÁÔÈ ÁÈ· ÙË ÌÂıÂÈÔÓ›ÓË ÛÙË ı¤ÛË ·˘Ù‹, ÂÓÒ ¿ÏÏÔÈ ÁÔÓfiÙ˘ÔÈ ÌÔÚ› Ó· Â›Ó·È ·ÓıÂÎÙÈÎÔ› ÛÙË ÓfiÛÔ ‹ Ó· ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ ÂÒ·Û˘ (32). ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë Û˘¯ÓfiÙËÙ· ·˘ÙÔ‡ ÙÔ˘ ÁÔÓfiÙ˘Ô˘ ÛÙÔÓ ÏËı˘ÛÌfi Ù˘ ª. µÚÂÙ·Ó›·˜ Â›Ó·È 40% (32). ¶ÚfiÛÊ·Ù·, ·Ó·ÎÔÈÓÒıËÎÂ Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ·Û˘Ìو̷ÙÈÎÒÓ ÊÔÚ¤ˆÓ Ù˘ ÓfiÛÔ˘. ∆Ô Û˘Ì¤Ú·ÛÌ· ·˘Ùfi ÚԤ΢„ ·fi ÌÂϤÙ˜ Û ÔÓÙ›ÎÈ· Ô˘ ÌÔχÓıËÎ·Ó Ì prions, ÙˆÓ ÔÔ›ˆÓ Ë Û˘ÁΤÓÙÚˆÛË ÛÙÔÓ ÂÁΤʷÏÔ ‹Ù·Ó Ôχ ˘„ËÏ‹ Î·È ÂÓÙÔ‡ÙÔȘ ‰ÂÓ ·ÚÔ˘Û›·˙·Ó Û˘Ìو̷ÙÔÏÔÁ›· (33). ∏ ‡·ÚÍË ·Û˘Ìو̷ÙÈÎÒÓ ÊÔÚ¤ˆÓ ·˘Í¿ÓÂÈ ÙȘ Èı·ÓfiÙËÙ˜ ÌÂÙ¿‰ÔÛ˘ ̤ۈ ÌÂÙ¿ÁÁÈÛ˘ ·›Ì·ÙÔ˜ ‹ ·Ú·ÁÒÁˆÓ Î·È Î¿ÓÂÈ ÙËÓ ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘ ·ÚÔÛ‰ÈfiÚÈÛÙË. ∏ ÌfiÓË ·¿ÓÙËÛË Ô˘ ÌÔÚ› Ó· ‰Ôı› ÛÙÔ ÌÂÁ¿ÏÔ ÂÚÒÙËÌ· Ù˘ ηٷӿψÛ˘ ‹ fi¯È ‚Ô‰ÈÓÔ‡ ÎÚ¤·ÙÔ˜, Â›Ó·È ÙÔ “·Ó ̤ÙÚÔÓ ¿ÚÈÛÙÔÓ”. ª›· ‰È·ÙÚÔÊ‹ Ì ÔÈÎÈÏ›· ÙÚÔÊÒÓ Î·È ÎÔÓÙ¿ ÛÙËÓ ·Ú·‰ÔÛȷ΋ ÌÂÛÔÁÂȷ΋ ‰›·ÈÙ· Â›Ó·È Ë ÌfiÓË Ï‡ÛË ÁÈ· ÙËÓ ÚÔÛÙ·Û›· Ì·˜ ·fi ¤Ó·Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÓÔÛËÌ¿ÙˆÓ Î·È fi¯È ÌfiÓÔ ·fi ÙË ÓfiÛÔ ÙˆÓ “ÙÚÂÏÒÓ ·ÁÂÏ¿‰ˆÓ”. µÈ‚ÏÈÔÁÚ·Ê›· 1. Ghetti B, Piccardo P, Frangione B, Bugiani O, Giaccone G, Young K et al. Prion protein amyloidosis. Brain Pathol 1996;6:127-145.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 14-02-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫. ∫·Ú·‚·Ó¿ÎË-∫·Ú·Ó¿ÛÈÔ˘ ∂ÏÏËÓÈÎÔ‡ ™ÙÚ·ÙÔ‡ 22∞, 152 37 ºÈÏÔı¤Ë, ∞ı‹Ó·

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PROGRESS IN MEDICAL SCIENCE

¶·Ú¿ÁÔÓÙ˜ Ó¢ÚÔÁ¤ÓÂÛ˘ ηٿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. ¡ÂfiÙÂÚ˜ ·fi„ÂȘ ∫. ∂. ™Ô‡ÏË1, Õ. ¢Ô˘ÏÁÂÚ¿ÎË2, ™. ∆۷ΛÚ˘2

Factors affecting neurogenesis during the neonatal period. A review K. H. Schulpis1, A. Doulgeraki2, S. Tsakiris2

¶ÂÚ›ÏË„Ë: O Û¯ËÌ·ÙÈÛÌfi˜ Î·È Ë ÔÚÁ¿ÓˆÛË ÙˆÓ Ó¢ÚÒÓˆÓ Û ‰›ÎÙ˘·, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Â›Ó·È ÔχÏÔη Ê·ÈÓfiÌÂÓ· Ô˘ Ú˘ıÌ›˙ÔÓÙ·È ·fi Ì›· ÔÈÎÈÏ›· ·Ú·ÁfiÓÙˆÓ. ¢›ÓÂÙ·È ¤ÌÊ·ÛË ÛÙÔ ÚfiÏÔ ÙˆÓ Ó¢ÚÔÙÚÔÊÈÓÒÓ, Ù˘ Ó¢ÚÔÁÏÔ›·˜, ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ù˘ Û˘Ó·ÙÈ΋˜ ËÏÂÎÙÚÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ. ∏ ÌÂٷ͇ ÙÔ˘˜ Û˘ÓÂÚÁ·Û›· Ú˘ıÌ›˙ÂÈ ÙËÓ ÂÈÌ‹Î˘ÓÛË Î·È ‰È·ÎÏ¿‰ˆÛË ÙˆÓ Ó¢ÚÒÓˆÓ, ·ÏÏ¿ Î·È ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ÙÔ˘˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Ë ıÂÙÈ΋ Â›‰Ú·ÛË ‰È·ÙÚÔÊÈÎÒÓ ÛÙÔȯ›ˆÓ, fiˆ˜ Ë ÁÏ˘Îfi˙Ë, Ô Û›‰ËÚÔ˜ Î·È ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÛÙË ‰È·ÌfiÚʈÛË Î·È ˆÚ›Ì·ÓÛË ÙˆÓ ÓÂ˘ÚˆÓÈÎÒÓ Û˘Ó‰¤ÛˆÓ. ™¯ÔÏÈ¿˙ÂÙ·È Ë ÈÛÔÚÚÔ›· ÌÂٷ͇ Ù˘ ÂÈ‚›ˆÛ˘ Î·È ÙÔ˘ ı·Ó¿ÙÔ˘ ÙˆÓ Ó¢ÚÒÓˆÓ, ηıÒ˜ Î·È ÔÈ Èı·Ó¤˜ ÂÊ·ÚÌÔÁ¤˜ ÙˆÓ Ó¤ˆÓ ·fi„ÂˆÓ ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Ï·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ηıÒ˜ Â›Û˘ Î·È ÛÙË ıÂÚ·›· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ Î·È ÂÎÊ˘ÏÈÛÙÈÎÒÓ ·ı‹ÛˆÓ.

Abstract: The most recent data regarding the structure of the neuronal circuits during postnatal development are reviewed. These phenomena are rather complex because they include processes regulated by many different factors. The role of neurotrophins, neuroglia, growth factors, synaptic electrical activity and neurotransmitters are strongly emphasized. The mutual interactions of the above factors control the elongation and branching of the neurons, as well as their functional efficacy. Of great interest is the positive influence of nutritional elements, such as glucose, iron and maternal milk, on the morphology and maturation of the neuronal connections. Finally, the balance between neuronal survival and death is discussed, as well as the application of known data on the study of neural plasticity and the therapeutic approach of the neurodegenerative diseases.

§¤ÍÂȘ ÎÏÂȉȿ: ·Ó¿Ù˘ÍË, Ó¢ÚÔÁ¤ÓÂÛË, Û˘Ó·ÙÔÁ¤ÓÂÛË, ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜.

Key words: development, neurogenesis, synaptogenesis, growth factors, newborns.

™˘ÓÙÔÌÔÁڷʛ˜ ACh AChE BDGF

·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË ·ÎÂÙ˘ÏÔ¯ÔÏÈÓÂÛÙÂÚ¿ÛË ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ·Ú¿ÁÂÙ·È ·fi ÙÔÓ ÂÁΤʷÏÔ cAMP ΢ÎÏÈ΋ ÌÔÓÔʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË CAMs ÌfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ DSCAM ÌfiÚÈÔ Î˘ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Down EGF ÂȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜

1 πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ¶·È‰ÈÔ‡, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ º˘ÛÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

Fe FGF 5-HT ICAMs IFN-Á IGF-I IL-1 IL-2 IL-3

Û›‰ËÚÔ˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÈÓÔ‚Ï·ÛÙÒÓ 5-˘‰ÚÔ͢ÙÚ˘Ù·Ì›ÓË (ÛÂÚÔÙÔÓ›ÓË) ‰È·Î˘ÙÙ·ÚÈο ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ ÈÓÙÂÚÊÂÚfiÓË-Á ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË, Ù‡Ô˜ π ÈÓÙÂÚÏ¢ΛÓË-1 ÈÓÙÂÚÏ¢ΛÓË-2 ÈÓÙÂÚÏ¢ΛÓË-3

1 Institute of Child Health “Saint Sophia” Children’s Hospital, Athens 2 Laboratory of Experimental Physiology University of Athens Medical School

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IL-6 LTP MAGs MOG

ÈÓÙÂÚÏ¢ΛÓË-6 Ì·ÎÚÔÚfiıÂÛÌË ÂÓ›Û¯˘ÛË ÙˆÓ Û˘Ó¿„ÂˆÓ ÁÏ˘ÎÔÚˆÙ½Ó˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Ì˘ÂÏ›ÓË ÁÏ˘ÎÔÚˆÙ½ÓË Ù˘ Ì˘ÂÏ›Ó˘ ÙˆÓ ÔÏÈÁÔ‰ÂÓ‰ÚÔ΢ÙÙ¿ÚˆÓ NCAMs ÓÂ˘ÚˆÓÈο ÌfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ NgCAMs Ó¢ÚÔÁÏÔȷο ÌfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ NGF ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÓÂ‡ÚˆÓ ¡™ Ó¢ÚÈÎfi Û‡ÛÙËÌ· ¡-∆ Ó¢ÚÔÙÚÔÊ›ÓË ƒ∂∆ ÙÔÌÔÁÚ·Ê›· ÂÎÔÌ‹˜ Ô˙ÈÙÚÔÓ›ˆÓ TNF-· ·Ú¿ÁÔÓÙ·˜ Ó¤ÎÚˆÛ˘ ÙˆÓ fiÁΈÓ, Ù‡Ô˘ ·

∂ÈÛ·ÁˆÁ‹ °È· ÔÏÏ¿ ¯ÚfiÓÈ· ıˆÚ›ÙÔ fiÙÈ Ô ÂÁΤʷÏÔ˜ Î·È Ô ÓˆÙÈ·›Ô˜ Ì˘ÂÏfi˜ ‹Ù·Ó ·Ó›Î·ÓÔÈ ÁÈ· ·‡ÍËÛË ‹ ‰ÈÂÚÁ·Û›Â˜ ‰ÈfiÚıˆÛ˘. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, fï˜, Â›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ Î¿ÙÈ Ù¤ÙÔÈÔ ‰Â Û˘Ì‚·›ÓÂÈ, ·ÊÔ‡ Ì ÙÔ Î·Ù¿ÏÏËÏÔ ÂÚ¤ıÈÛÌ·, Ô ÂÁΤʷÏÔ˜ ÌÔÚ› Ó· ·Ó·ÁÂÓÓ‹ÛÂÈ Ù· ΢ÎÏÒÌ·Ù¿ ÙÔ˘. ∆Ô ÂÚ¤ıÈÛÌ· ÌÔÚ› Ó· Â›Ó·È ÙÚ·‡Ì· ‹ ÌÂÙ·‚ÔÏÈ΋ ‰È·Ù·Ú·¯‹ ‹ ·ÎfiÌË, Ô ÂÍ·Ó·ÁηÛÌfi˜ ÁÈ· ÙËÓ ÂÎÌ¿ıËÛË Ó¤Ô˘ ηı‹ÎÔÓÙÔ˜ ‹ Û˘ÌÂÚÈÊÔÚ¿˜. ªÔÚ›, Â›Û˘, Ó· Â›Ó·È ÌfiÛ¯Â˘Ì· Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡. ∆ÒÚ· ÁÓˆÚ›˙Ô˘Ì fiÙÈ ÔÈ ÎÂÓÙÚÈÎÔ› ÓÂ˘Ú¿ÍÔÓ˜, Ô˘ ÚÈÓ ÓÔÌ›˙·Ì fiÙÈ ‰ÂÓ ·Ó·ÁÂÓÓÈÔ‡ÓÙ·È, ÌÔÚÔ‡Ó Ó· ÌÂÁ·ÏÒÛÔ˘Ó Ì¤Ûˆ ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ Ó‡ÚÔ˘ ‹ Ì Ù¯ÓËÙ¤˜ “Á¤Ê˘Ú˜” Î·È Ó· Û¯ËÌ·Ù›ÛÔ˘Ó Û˘Ó‰¤ÛÂȘ Ì ·ÔÓÂ˘ÚˆÌ¤ÓÔ˘˜ ÛÙfi¯Ô˘˜. ∂ÈÚfiÛıÂÙ·, ÔÏfiÎÏËÚ· ÓÂ˘ÚˆÓÈο ‰›ÎÙ˘· ÌÔÚÔ‡Ó Ó· ·ÓÙÈηٷÛÙ·ıÔ‡Ó Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÌ‚Ú˘˚ÎÒÓ ‹ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ Ó¢ÚÒÓˆÓ ÛÙÔÓ ÂÓ‹ÏÈÎÔ ÂÁΤʷÏÔ. ∆ÂÏÈο, Ì ÙËÓ Â˘Ú‡ÙÂÚË ¤ÓÓÔÈ·, Ë ·Ó¿Ù˘ÍË Û˘Ó¯›˙ÂÙ·È Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË. ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Ì›· Û˘Ó¯‹ ·Ôı‹Î¢ÛË ‚Ú·¯˘ÚfiıÂÛÌˆÓ Î·È Ì·ÎÚÔÚfiıÂÛÌˆÓ ÏËÚÔÊÔÚÈÒÓ, fiÔ˘ Û οı ‚‹Ì· Ù˘ ·Ó¿Ù˘Í˘, ÁÂÓÂÙÈΤ˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂȉڿÛÂȘ ·ÓÙÈÚÔÛˆ‡ÔÓÙ·È ÛÙÔ ÂÍÂÏÈÛÛfiÌÂÓÔ ‰ÔÌÈÎfi Î·È ÏÂÈÙÔ˘ÚÁÈÎfi Û¯¤‰ÈÔ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (1). ∆· ·Ó·Ù˘ÛÛfiÌÂÓ· ·ÙÙ·Ú· ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (¡™) ÂÌϤÎÔÓÙ·È Û ÔχÏÔη ‰›· Ì˯·ÓÈ΋˜ Î·È ËÏÂÎÙÚÈ΋˜ Ù¿Û˘, fiˆ˜ Â›Û˘ ‚ÈÔ¯ËÌÈÎÒÓ ‰ÈÂÚÁ·ÛÈÒÓ. ∞˘Ù¤˜ ÔÈ Û˘Ó¯Ҙ ÌÂÙ·‚·ÏÏfiÌÂÓ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ ¯ÒÚÔ Î·È ÙÔ ¯ÚfiÓÔ ÁÈ· οı ·ÙÙ·ÚÔ, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È, ηٿ ÌÂÁ¿ÏÔ Ì¤ÚÔ˜, ·fi ÙË ¯ËÌ›· ÙˆÓ ›‰ÈˆÓ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Â›Ó·È ÔÈ ‚·ÛÈΤ˜ ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ‰˘Ó¿ÌÂȘ Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ·ÏÏËÏÔ˘¯›· ÙˆÓ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·‰ÈηÛÈÒÓ. ∞˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË Ó¢ÚÔÁ¤ÓÂÛË O ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÓÂ‡ÚˆÓ (NGF), Ô˘ ·ÔÌÔÓÒıËΠ·fi ÙÔ ÛÈÂÏÔÁfiÓÔ ·‰¤Ó· ÔÓÙÈÎÔ‡, ÂÌÊ·Ó›˙ÂÙ·È Ì ÙË ÌÔÚÊ‹ Û˘ÌÏfiÎÔ˘, Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ ˘ÔÌÔÓ¿‰Â˜ ·, ‚ Î·È Á ÛÂ

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·Ó·ÏÔÁ›· ‚:2·:2Á. ∏ ˘ÔÌÔÓ¿‰· ‚ Â›Ó·È Ô ÌfiÓÔ˜ Ó¢ÚÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ·fi ÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ÙÚÂȘ.

OÈ ÂȉڿÛÂȘ ÙÔ˘ NGF ıˆÚÂ›Ù·È fiÙÈ ·Ú¯›˙Ô˘Ó Ì ÙÔ Û¯ËÌ·ÙÈÛÌfi Û˘ÌÏÂÁÌ¿ÙˆÓ NGF-˘Ô‰Ô¯¤· ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ÂÈÊ¿ÓÂÈ· Î·È ·ÎÔÏÔ˘ı› ÌÂÙ·ÙfiÈÛË ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·. ∆· ·ÙÙ·Ú·-ÛÙfi¯ÔÈ ‰È·ı¤ÙÔ˘Ó Î·È ˘„ËÏ‹˜ Î·È ¯·ÌËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ ˘ԉԯ›˜. OÈ ¯·ÌËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ ˘ԉԯ›˜, ·ÚÔ˘Û›· ÙÔ˘ NGF, ÌÔÚÔ‡Ó Ó· ·ÏÏËÏÂȉڿÛÔ˘Ó, Ó· Û˘Ûۈ̷وıÔ‡Ó Î·È Ó· ÌÂÙ·ÙÚ·Ô‡Ó Û ˘„ËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ ˘ԉԯ›˜, ˆ˜ ̤ÚÔ˜ ÌÈ·˜ ‚ÈÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘. ™Ù· Û˘Ì·ıËÙÈο Ó¢ÚÈο ·ÙÙ·Ú· Ô˘ ¤¯Ô˘Ó ·ÍÔÓÈΤ˜ ·ÔʇÛÂȘ, Ô NGF Û˘Ó‰¤ÂÙ·È ÂÎÏÂÎÙÈο Û ˘ԉԯ›˜ ÙˆÓ ·ÍÔÓÈÎÒÓ ·ÔÏ‹ÍÂˆÓ Î·È ÂÛˆÙÂÚÈÎÔÔÈÂ›Ù·È ÁÈ· Ó· ÌÂÙ·ÊÂÚı› ηٿ Ì‹ÎÔ˜ ÙÔ˘ ¿ÍÔÓ· ÛÙÔ Î˘ÙÙ·ÚÈÎfi ÛÒÌ·. ª›· ÛÂÈÚ¿ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ˘ÚËÓÈÎÒÓ ÁÂÁÔÓfiÙˆÓ Û˘Ì‚·›ÓÔ˘Ó Ì ¯ÚÔÓÈ΋ ·ÏÏËÏÔ˘¯›· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi ÂÏ¿¯ÈÛÙ· ‰Â˘ÙÂÚfiÏÂÙ· ¤ˆ˜ ·ÚÎÂÙ¤˜ Ë̤Ú˜.

OÈ Ê˘ÛÈÔÏÔÁÈΤ˜ ÂȉڿÛÂȘ ÙÔ˘ NGF (2,3) Ù·ÍÈÓÔÌÔ‡ÓÙ·È ÛÂ: ·) Ó¢ÚÔÙÚÔÊÈΤ˜ Î·È ıÚÂÙÈΤ˜ ηٿ ÙËÓ ·Ú¯È΋ ·Ó¿Ù˘ÍË, ‚) ‰Ú·ÛÙÈΤ˜ ÛÙË ‚ÈÔ¯ËÌÈ΋ Î·È ÌÔÚÊÔÏÔÁÈ΋ ‰È·ÊÔÚÔÔ›ËÛË, Á) ÈÛ¯˘Ú¿ Ó¢ÚÔÙÚÔÈΤ˜ ÛÙËÓ Â›‰Ú·ÛË Î·È ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ Ó¢ڛÙË. ∏ ÙÔÈ΋ ‰Ú¿ÛË ÙÔ˘ NGF ¤¯ÂÈ ÛÎÔfi Ó· ÂϤÁ¯ÂÈ ÙË ‰È·Ù‹ÚËÛË ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ‰ÈÂÚÁ·ÛÈÒÓ Î·È ÌÔÚ› Ó· ÌÂÙ·ÊÂÚı› ÁÈ· Ó· ÂÍ·ÛÊ·Ï›ÛÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÛÒÌ·ÙÔ˜ Ô˘ ‚Ú›ÛÎÂÙ·È Û οÔÈ· ·fiÛÙ·ÛË, Û ÂÚÈ‚¿ÏÏÔÓ, ‰ËÏ·‰‹, Ô˘ ÛÙÂÚÂ›Ù·È NGF. ¶ÚfiÛÊ·Ù˜ ¤Ú¢Ó˜ (4) ¤‰ÂÈÍ·Ó fiÙÈ Ô NGF ÚÔηÏ› ·‡ÍËÛË Ù˘ ÚÔ‹˜ ÙÔ˘ ÈÔÓÙÈṲ̂ÓÔ˘ Ca2+, Ô‰ËÁÒÓÙ·˜ Û ·‡ÍËÛË ÙÔ˘ ÚÔÛ˘Ó·ÙÈÎÔ‡ Ca2+. ∞˘Ù‹ Ë ·‡ÍËÛË Â›Ó·È ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô Ù˘ ‰Ú¿Û˘ ÙÔ˘ NGF ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ Î·È Ô‰ËÁ› ÛÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ Ì·ÎÚÔÚfiıÂÛÌ˘ ÂÓ›Û¯˘Û˘ ÙˆÓ Û˘Ó¿„ÂˆÓ (LTP). ∂›Û˘, Ô ¤ÏÂÁ¯Ô˜ Ù˘ ‰È·Î›ÓËÛ˘ ÙÔ˘ Ca2+ ·fi ÙÔÓ NGF, ÂËÚ¿˙ÂÈ ÙȘ Ì·ÎÚÔÚfiıÂÛ̘ Û˘Ó¤ÂȘ ÙÔ˘ ·Ú¿ÁÔÓÙ· ·˘ÙÔ‡ ÛÙË ÓÂ˘ÚˆÓÈ΋ ÂÈ‚›ˆÛË Î·È ÚÔÛÙ·Û›·. ∞fi ÙÔÓ ÂÁΤʷÏÔ Î·È ÙËÓ ˘fiÊ˘ÛË (5) ¤¯ÂÈ ·ÔÌÔÓˆı› Ô ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÈÓÔ‚Ï·ÛÙÒÓ (FGF), Ì ‰Ú¿ÛË Ó¢ÚÔÙÚÔÊÈ΋ Î·È Ó¢ÚÔÙÚÔÈ΋ ÛÙÔ˘˜ Ó¢ÚÒÓ˜ Î·È ÛÙË Ó¢ÚÔÁÏÔ›·. ¶Èı·ÓfiÓ ‰Ú· Î·È ÛÙËÓ ·ÁÁÂÈÔÁ¤ÓÂÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È Û ÂÌ‚Ú˘˚ÎÔ‡˜ ÌÂÙ·Û¯ËÌ·ÙÈÛÌÔ‡˜. ∂›Ó·È ÂӉȷʤÚÔ˘Û· Ë ·Ú·Ù‹ÚËÛË fiÙÈ Ë Ó¢ÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ú˘ıÌ›˙ÂÈ ÙËÓ ¤ÎÊÚ·ÛË ÙˆÓ ÙÚÔÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∆· Â›‰· ÙÔ˘ FGF ·˘Í¿ÓÔÓÙ·È Î·Ù¿ ÙË ‰È·‰Èηۛ· ÂÎÌ¿ıËÛ˘ ÂÓfi˜ ηı‹ÎÔÓÙÔ˜. ŸÙ·Ó Ë ‰È·‰Èηۛ· ·˘Ù‹ Û˘Óԉ‡ÂÙ·È Î·È ·fi

¶·È‰È·ÙÚÈ΋ 2001;64:527-534

Paediatriki 2001;64:527-534

ÌÔ, ‰Ú· ÚÔÛ˘Ó·ÙÈο, ÒÛÙ ӷ ÚÔηϤÛÂÈ Ì·ÎÚÔÚfiıÂÛÌË ÂÓ›Û¯˘ÛË ÙˆÓ Û˘Ó¿„ˆÓ, Û˘Ì‚¿ÏÏÔÓÙ·˜ ÛÙË ‰È·ÌfiÚʈÛË Ù˘ ÌÓ‹Ì˘. ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È Î·È ˆ˜ Ú˘ıÌÈÛÙ‹˜ Ù˘ ¤ÎÎÚÈÛ˘ ÙˆÓ Ó¢Úԉȷ‚È‚·ÛÙÒÓ (10).

·˘ÍË̤ÓË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙfiÙÂ Ô FGF ‚Ú›ÛÎÂÙ·È ·ÎfiÌ· ÈÔ ·˘ÍË̤ÓÔ˜ (6). ∆· ˘„ËÏ¿ Â›‰· ÙÔ˘ FGF ÚÔηÏÔ‡Ó ·‡ÍËÛË Ù˘ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ ÛÙÔÓ ÈfiηÌÔ. ∂Ô̤ӈ˜, Ë Ì¿ıËÛË ÂÓÈÛ¯‡ÂÈ ÙȘ ÂȉڿÛÂȘ Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÛÙË ‰È¤ÁÂÚÛË ÙˆÓ Ó¢ÚÔÙÚÔÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ŒÓ·˜ ¿ÏÏÔ˜ ÛËÌ·ÓÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Ô ÂȉÂÚÌÈÎfi˜ (EGF). ¢Ú· ˆ˜ ÌÈÙÔÁfiÓÔ ÁÈ· ÔÏÏ¿ ›‰Ë ΢ÙÙ¿ÚˆÓ, fiˆ˜ Ù· ·ÛÙÚÔ·ÙÙ·Ú· Î·È ‰ÈÂÁ›ÚÂÈ ÙË ‰È·ÊÔÚÔÔ›ËÛË Ù˘ Ó¢ÚÔÁÏÔ›·˜.

O EGF ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ó¢ÚÒÓ· Ì ¿ÌÂÛÔ ÙÚfiÔ. ∂›Û˘, ÂÌϤÎÂÙ·È Î·È ÛÙËÓ ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË. OÈ Ó¢ÚÔ‰Ú·ÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÚÔ¿ÁÔ˘Ó Ì›· ÔÈÎÈÏ›· ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·‰ÈηÛÈÒÓ, Ô˘ ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔÓ Î˘ÙÙ·ÚÈÎfi Ù‡Ô, ÙÔ ÛÙ¿‰ÈÔ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ (¶›Ó·Î·˜ 1).

O ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË, Ù‡Ô˘ π (IGF-I), ·ÚÔ˘ÛÈ¿˙ÂÈ ÔÏϤ˜ ‰Ú¿ÛÂȘ, ÂÓÂÚÁÒÓÙ·˜ Ì ·˘ÙÔÎÚÈÓ‹ ‹/Î·È ·Ú·ÎÚÈÓ‹ ÙÚfiÔ, Û ÂȉÈο ÛÙ¿‰È· Ù˘ ·Ó¿Ù˘Í˘ (7). ƒ˘ıÌ›˙ÂÈ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÚÒÓˆÓ Î·È ÙË Ó¢ÚÔÁÏÔ›·. ∂›Û˘, ·˘Í¿ÓÂÈ ÙÔ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Ca2+ ÛÙ· ·ÙÙ·Ú· Purkinje Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜. ∞fi ÙÔÓ ÂÁΤʷÏÔ ·Ú¿ÁÂÙ·È ¤Ó·˜ ÂȉÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ô BDGF, Ì ÔÏÏ·Ϥ˜ ÏÂÈÙÔ˘ÚÁ›Â˜. ∞˘Í¿ÓÂÈ ÙËÓ ÔÏ˘ÏÔÎfiÙËÙ· Ù˘ ‰È¿Ù·Í˘ ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ (8) Î·È Û˘Ì‚¿ÏÏÂÈ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ‰ÈÂÁÂÚÙÈÎÒÓ Î·È ·Ó·ÛÙ·ÏÙÈÎÒÓ Û˘Ó¿„ˆÓ. ∂ËÚ¿˙ÂÈ ÙË ‰È·ÎÏ¿‰ˆÛË ÙˆÓ Ó¢ڷÍfiÓˆÓ, ηıÒ˜ Î·È ÙÔ Û˘ÓÔÏÈÎfi ÙÔ˘˜ Ì‹ÎÔ˜ (9). ™ÙÔÓ Èfiη-

¡Â˘ÚÔÙÚÔʛӘ (¡-∆) ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÔÌ¿‰· ÚˆÙÂ˚ÓÒÓ, Ì ΢ÚÈfiÙÂÚÔ˘˜ ÂÎÚÔÛÒÔ˘˜ ÙȘ ¡-∆-3 Î·È ¡-∆-4, Ô˘ ‰ÚÔ˘Ó Ì¤Ûˆ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Trk (11). ƒ˘ıÌ›˙Ô˘Ó ÙË Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ Ó¢ÚÒÓˆÓ. ∏ Ó¢ÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (.¯. Û˘Ó·ÙÈ΋ Ï·ÛÙÈÎfiÙËÙ· Î·È ·Ó¿Ù˘ÍË) ·˘Í¿ÓÂÈ Ù· Â›‰¿ ÙÔ˘˜ ÛÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· (12). OÈ ¡-∆ ÚÔηÏÔ‡Ó ÔÍ›· ·‡ÍËÛË Ù˘ Û˘Ó·ÙÈ΋˜ ‰È·‚›‚·Û˘. ∂›Û˘, Ú˘ıÌ›˙Ô˘Ó Ù· Â›‰· ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ca2+, Ô˘ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ó¢ÚÒÓˆÓ Î·È ÙËÓ Ï·ÛÙÈÎfiÙËÙ· ÙˆÓ Û˘Ó¿„ˆÓ. ∂ËÚ¿˙Ô˘Ó Î·È ÙË Ó¢ÚÔÁÏÔ›·, Ú˘ıÌ›˙ÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ Î·È ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ó¢ÚÔÁÏÔÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™¯ÂÙ›˙ÔÓÙ·È ÛÙÂÓ¿ Ì ÙÔ ‚·ıÌfi ËÏÂÎÙÚÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ ÓÂ˘ÚˆÓÈÎÒÓ ‰ÈÎÙ‡ˆÓ (13). ∫˘ÙÔΛÓ˜ OÈ ÈÓÙÂÚÏ¢ΛÓ˜ 1‚, 3 Î·È 6 (IL-1‚, IL-3, IL-6), Ë ÈÓÙÂÚÊÂÚfiÓË-Á (IFN-Á) Î·È Ô ·Ú¿ÁÔÓÙ·˜ Ó¤ÎÚˆÛ˘ ÙˆÓ fiÁΈÓ-· (TNF·), ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ó¢ÚÔÙÚÔÊÈ΋ ‰Ú¿ÛË, ·ÏÏ¿ fiÙ·Ó ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏ¿ Â›‰·, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· Ó¢ÚÔÏÔÁÈο ÓÔÛ‹Ì·Ù· fiˆ˜ Ë ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜, Ë ÓfiÛÔ˜ Alzheimer Î·È ÙÔ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ. ∏ Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙÔ ÔÓÙ›ÎÈ ‰È·ÊÔÚÔÔÈ›ٷÈ,

¶›Ó·Î·˜ 1. ∞˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ÓÂ˘ÚˆÓÈ΋ ·Ó¿Ù˘ÍË (1) ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜

ªÔÚÈ·Îfi ‚¿ÚÔ˜ (kDa)

∫‡ÙÙ·Ú·ÛÙfi¯ÔÈ

∂ÁÎÂÊ·ÏÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁoÓÙ·˜ ÃÔÏÈÓÂÚÁÈÎfi˜ Ó¢ÚÔÙÚÔÊÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ∂ȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ πÓÔ‚Ï·ÛÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (fiÍÈÓÔ˜)

12 20 6 16

¡ ¡ ∞,¡ ∞,¡

πÓÔ‚Ï·ÛÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (‚·ÛÈÎfi˜)

16

∞,O,¡

∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ó¢ÚÔÁÏÔ›·˜ ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË-π ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÈ¿˙ÂÈ Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË-ππ

31 7 7

∞,S O,N

πÓÙÂÚÏ¢ΛÓË π (·,‚)

16

A,O

πÓÙÂÚÏ¢ΛÓË ππ ¡Â˘ÚÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¡Â˘ÚÔÏ¢ΛÓË ∞˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÚÔÂÚ¯fiÌÂÓÔ˜ ·fi Ù· ·ÈÌÔÂÙ¿ÏÈ·

15 26 56 32

O N N A,O

¢Â›ÁÌ· ÈÛÙÔ‡ ∂ÁΤʷÏÔ˜ OÊı·ÏÌfi˜, ÈۯȷÎfi Ó‡ÚÔ ÀÔÁÓ¿ıÈÔ˜ ·‰¤Ó·˜ ∂ÁΤʷÏÔ˜, ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜, ˘Ôı¿Ï·ÌÔ˜ ∂ÁΤʷÏÔ˜, ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜, ˘Ôı¿Ï·ÌÔ˜, ˘fiÊ˘ÛË ÀfiÊ˘ÛË, ÎÂÚÎÔÊfiÚÔ˜ ˘Ú‹Ó·˜ ◊·Ú, ¿ÏÏ· ·ÙÙ·Ú· ∂Ì‚Ú˘˚Îfi ‹·Ú, ÂÌ‚Ú˘˚Îfi˜ ÂÁΤʷÏÔ˜ ª·ÎÚÔÊ¿Á·, ·ÛÙÚÔ·ÙÙ·Ú·, ÌÈÎÚÔÁÏÔ›· ∆-·ÙÙ·Ú· ÀÔÁÓ¿ıÈÔ˜ ·‰¤Ó·˜, Ï·ÎÔ‡ÓÙ·˜ ÀÔÁÓ¿ıÈÔ˜ ·‰¤Ó·˜ ∞ÈÌÔÂÙ¿ÏÈ·, Ï·ÎÔ‡ÓÙ·˜, ·ÛÙÚÔ·ÙÙ·Ú·

∞: ·ÛÙÚÔ·ÙÙ·Ú·, ¡: Ó¢ÚÒÓ˜, O: ÔÏÈÁÔ‰ÂÓ‰ÚÔ·ÙÙ·Ú·, S: ·ÙÙ·Ú· Schwann

529

¶·È‰È·ÙÚÈ΋ 2001;64:527-534

·Ó¿ÏÔÁ· Ì ÙÔ ·Ó ‰ÚÔ˘Ó ÂÚÈÊÂÚÈο ‹ ÛÙ· ·ÛÙÚÔ·ÙÙ·Ú· ‹ ÛÙÔ˘˜ Ó¢ÚÒÓ˜ (14). ªfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ (CAMs) (1) ¶ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ ˘ÔÛÙÚÒÌ·ÙÔ˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË Ó¢ÚÈ΋ ·Ó¿Ù˘ÍË Ì¤Ûˆ Ù˘ Ú‡ıÌÈÛ˘ ÙˆÓ È‰ÈÔÙ‹ÙˆÓ ÚÔÛÎfiÏÏËÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ. OÈ ·ÏÏËÏÂȉڿÛÂȘ ÌÔÚÔ‡Ó Ó· Û˘Ì‚Ô‡Ó ¿ÌÂÛ· ÌÂٷ͇ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ‹ ÌÂٷ͇ ÂÓfi˜ ΢ÙÙ¿ÚÔ˘ Î·È Ù˘ ÂÍˆÎ˘ÙÙ¿ÚÈ·˜ Ô˘Û›·˜ ÙÔ˘ ÌÈÎÚÔÂÚÈ‚¿ÏÏÔÓÙÔ˜. ∆· ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ó· ÌÂÙ·Ó·ÛÙ‡ԢÓ, Ó· Ù·ÍÈÓÔÌÔ‡ÓÙ·È Î·È Ó· ÛÙ·ıÂÚÔÔÈÔ‡Ó ÙȘ ¯ˆÚÔÙ·ÍÈΤ˜ ÙÔ˘˜ Û¯¤ÛÂȘ, Ô˘ ıˆÚÔ‡ÓÙ·È ÛËÌ·ÓÙÈΤ˜ ÁÈ· ÙËÓ ÔÚ›· Ù˘ ‰È·ÊÔÚÔÔ›ËÛ˘ (15,16). ™˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ Ï·ÛÙÈÎfiÙËÙ· Î·È ÛÙ·ıÂÚfiÙËÙ· ÙˆÓ Û˘Ó¿„ÂˆÓ (ÂËÚ¿˙ÔÓÙ·˜ ÙÔ Ê·ÈÓfiÌÂÓÔ LTP), ηıÒ˜ Î·È ÛÙËÓ ·Ó·Á¤ÓÓËÛË ÙˆÓ Ó¢ÚÒÓˆÓ (17). ∞˘Ù¿ Ù· ÌfiÚÈ· ÔÓÔÌ¿˙ÔÓÙ·È ÌfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ (CAMs) Î·È ‰È·Î˘ÙÙ·ÚÈο ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ (ICAMs).

OÈ ÈÓÙÂÁÎÚ›Ó˜ (integrins) Â›Ó·È Ì›· ÔÈÎÔÁ¤ÓÂÈ· ‰ÔÌÈο Û¯ÂÙÈÎÒÓ Û˘ÌÏÂÁÌ¿ÙˆÓ ÁÏ˘ÎÔÚˆÙ½Ó˘, Ô˘ ‰ÚÔ˘Ó ˆ˜ ˘ԉԯ›˜ ÁÈ· ÔÈÎÈÏ›· CAMs Î·È ICAMs (18). ∞ÔÙÂÏÔ‡ÓÙ·È ·fi · Î·È ‚ ˘ÔÌÔÓ¿‰Â˜ Î·È Èı·ÓfiÓ ·›˙Ô˘Ó ÚfiÏÔ ÛÙË Û‡Ó‰ÂÛË ÙÔ˘ ΢ÙÙ·ÚÔÛÎÂÏÂÙÔ‡ Î·È ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ì ÙÔ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ÂÚÈ‚¿ÏÏÔÓ. ∏ Ï·ÌÈÓ›ÓË ·Ó‹ÎÂÈ ÛÙ· ICAMs Î·È ÂÓÂÚÁ› ÁÈ· Ó· Û˘Ó‰¤ÛÂÈ Î˘ÙÙ·ÚÈΤ˜ ÂÈÊ¿ÓÂȘ Î·È ÙȘ ÁÏ˘ÎÔÚˆÙ½Ó˜ Ù˘ ÌÂÛÔ΢ÙÙ¿ÚÈ·˜ Ô˘Û›·˜ (19,20). ª¤Ûˆ ‰È·Î˘ÙÙ·ÚÈÎÒÓ ·ÏÏËÏÂȉڿÛˆÓ, Ë Ï·ÌÈÓ›ÓË ÙÚÔÔÔÈ› ÙË Ó¢ÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. À¿Ú¯ÂÈ ÔÌfiÏÔÁÔ ÂÙ›‰ÈÔ ÙÔ˘ ηڂÔ͢ÙÂÏÈÎÔ‡ ¿ÎÚÔ˘ Ù˘ Á1-·Ï˘Û›‰·˜ Ù˘ Ï·ÌÈÓ›Ó˘, Ô˘ Ú˘ıÌ›˙ÂÈ ÙËÓ ËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ˘Ú·ÌȉÈÎÒÓ Ó¢ÚÒÓˆÓ ÛÙÔ ÊÏÔÈfi ÙÔ˘ ÂÓ‹ÏÈη. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ, Ë Ï·ÌÈÓ›ÓË ·˘Í¿ÓÂÈ ÙË ÓÂ˘ÚˆÓÈ΋ ‰ÈÂÁÂÚÛÈÌfiÙËÙ· (21). Œ¯ÂÈ, Â›Û˘, ·Ô‰Âȯı› Ë ÛÙÂÓ‹ Û¯¤ÛË Ï·ÌÈÓ›Ó˘ Î·È ı˘ÚÔ͛Ӣ. ¶ÙÒÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÚÌfiÓ˘ Ô‰ËÁ› Û ÂÏ¿ÙÙˆÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Ù˘ Ï·ÌÈÓ›Ó˘ Î·È ·ÒÏÂÈ· ÙÔ˘ ÛˆÛÙÔ‡ Û˘Á¯ÚÔÓÈÛÌÔ‡ Ù˘ ÓÂ˘ÚˆÓÈ΋˜ ·‡ÍËÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ô‰ÈÔÚÁ¿ÓˆÛË ÙˆÓ Ó¢ÚÒÓˆÓ (22). ∏ ÊÈÌÚÔÓÂÎÙ›ÓË (‹ ÈÓÔ‰ÂÛÌ›ÓË) ·Ó‹ÎÂÈ Â›Û˘ ÛÙ· ICAM. ∂ȉڿ ΢ڛˆ˜ ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ΛÓËÛË Î·È ÙË ‰È·Î˘ÙÙ·ÚÈ΋ Û˘Ûۈ̿وÛË Î·È ‰È·ÊÔÚÔÔ›ËÛË Î·Ù¿ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¡™. ∆· CAMs Â›Ó·È ÁÏ˘ÎÔÚˆÙ½Ó˜ Ì ÌÔÚÊÔÚÚ˘ıÌÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¡™ (15). À¿Ú¯Ô˘Ó Ó¢ÚÈο CAMs (NCAMs) Ô˘ ÂÓÙÔ›˙ÔÓÙ·È ÓˆÚ›˜ ÛÙËÓ ÂÌ‚Ú˘ÔÁ¤ÓÂÛË Î·È Î·Ù¿ ÙËÓ ·Ó¿-

530

Paediatriki 2001;64:527-534

Ù˘ÍË ÙÔ˘ ¡™ Î·È ÛÙ· Ó¢ÚÈο Î·È ÛÙ· Ó¢ÚÔÁÏÔȷο ·ÙÙ·Ú·. À¿Ú¯Ô˘Ó Î·È Ó¢ÚÔÁÏÔȷο CAMs (NgCAMs), Ô˘ ‚Ú›ÛÎÔÓÙ·È ÌfiÓÔ ÛÙ· Ó¢ÚÈο ·ÙÙ·Ú· Î·È Èı·ÓfiÓ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙË Û‡Ó‰ÂÛË ÌÂٷ͇ ÙˆÓ Ó¢ÚÈÎÒÓ Î·È Ó¢ÚÔÁÏÔÈ·ÎÒÓ ÌÂÌ‚Ú·ÓÒÓ.

OÈ ÁÏ˘ÎÔÚˆÙ½Ó˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Ì˘ÂÏ›ÓË (MAGs), ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ˘‡ı˘Ó˜ ÁÈ· ÙËÓ ·ÏÏËÏÂ›‰Ú·ÛË Ó¢ÚÔÁÏÔ›·˜-·ÍfiÓˆÓ Î·Ù¿ ÙË Ì˘ÂÏÈÓÔÔ›ËÛË. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÌfiÚÈÔ Î˘ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ Down (DSCAM) (23). ∂ÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ Ó¢ÚÈÎfi ۈϋӷ, ÙÔ ÊÏÔÈfi, ÙÔÓ ÈfiηÌÔ, ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi Î·È ÛÙÔ˘˜ ÈÛÙÔ‡˜ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙË Ó¢ÚÈ΋ ·ÎÚÔÏÔÊ›·. ∂ËÚ¿˙ÂÈ ‰˘ÛÌÂÓÒ˜ ÙË ‰È·ÊÔÚÔÔ›ËÛË Î·È ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÒÓˆÓ, ηıÒ˜ Î·È ÙË Û˘Ó·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. π‰È·›ÙÂÚË ·Ó·ÊÔÚ¿ Ú¤ÂÈ Ó· Á›ÓÂÈ ÛÙȘ ÚˆÙÂÔÁÏ˘Î¿Ó˜ (24). ¶ÚfiÎÂÈÙ·È ÁÈ· Ì·ÎÚÔÌfiÚÈ· Ì ÔÏÏ·Ϥ˜ ÏÂÈÙÔ˘ÚÁ›Â˜, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¤Ó· ÔÏ˘ÂÙȉÈÎfi ΤÓÙÚÔ Î·È ÔÈΛϘ ·Ï˘Û›‰Â˜ ÁÏ˘ÎÔ˙·ÌÈÓÔÁÏ˘Î·ÓÒÓ. OÈ ÚˆÙÂÔÁÏ˘Î¿Ó˜ Ú˘ıÌ›˙Ô˘Ó ÙË ‰ÔÌÈ΋ ÔÚÁ¿ÓˆÛË Ù˘ ÂÍˆÎ˘ÙÙ¿ÚÈ·˜ Ô˘Û›·˜, ÙÚÔÔÔÈÔ‡Ó ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ηıÒ˜ Î·È Ù· Ê·ÈÓfiÌÂÓ· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ Î·È ÎÈÓËÙÈÎfiÙËÙ·˜, fiˆ˜ Ë ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÒÓˆÓ Î·È Ë ·‡ÍËÛË ÙˆÓ Ó¢ڷÍfiÓˆÓ. ∂Ô̤ӈ˜, ÔÈ ÚˆÙÂÔÁÏ˘Î¿Ó˜ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ÙÚÔÔÔÈËÙ¤˜ Ù˘ Ó¢ÚÈÙÈ΋˜ ·‡ÍËÛ˘ Î·È Ù˘ ÔÏÈÎfiÙËÙ·˜ ÙˆÓ Ó¢ÚÒÓˆÓ. øÛÙfiÛÔ, ÂȉÈΤ˜ ˘ÔηÙËÁÔڛ˜ ·˘ÙÒÓ ÙˆÓ Ì·ÎÚÔÌÔÚ›ˆÓ Ê·›ÓÂÙ·È fiÙÈ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ Â¤ÎÙ·ÛË ÙˆÓ Ó¢ÚÈÙÒÓ, ÙfiÛÔ Î·Ù¿ ÙËÓ ·Ó¿Ù˘ÍË, fiÛÔ Î·È Î·Ù¿ ÙËÓ ·Ó·Á¤ÓÓËÛË ÙÔ˘ ¡™. ∫·ıÒ˜ Ë ·Ó¿Ù˘ÍË ÚÔ¯ˆÚ›, ·Ú·ÙËÚÂ›Ù·È ÈÛÔÚÚÔ›· ÌÂٷ͇ ΢ÙÙ·ÚÈ΋˜ ÂÈ‚›ˆÛ˘ Î·È Î˘ÙÙ·ÚÈÎÔ‡ ı·Ó¿ÙÔ˘. ¶ÔÈÔÈ Â›Ó·È ÔÈ ·Ú¿ÁÔÓÙ˜, ÏÔÈfiÓ, Ô˘ ÂËÚ¿˙Ô˘Ó ·˘Ù‹ ÙËÓ ÈÛÔÚÚÔ›·; O ¤ÏÂÁ¯Ô˜ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ·ˆÏÂÈÒÓ Î·Ù¿ ÙËÓ ·Ó¿Ù˘ÍË Â›Ó·È Èı·Ófi Ó· Á›ÓÂÙ·È ·fi ÙÔ Î˘ÙÙ·ÚÈÎfi ÌÈÎÚÔÂÚÈ‚¿ÏÏÔÓ. ™ÙË Ú‡ıÌÈÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ı·Ó¿ÙÔ˘ Û˘Ì‚¿ÏÏÔ˘Ó Ù· ÂÏ·Ùو̤ӷ Â›‰· ‰È·Ï˘ÙÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ·fi Ù· ·ÙÙ·Ú·-ÛÙfi¯Ô˘˜, Ù· ÔÔ›· Ô‰ËÁÔ‡Ó Û ·ÓÙ·ÁˆÓÈÛÌfi ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÁÈ· ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜ (1). ∂ÈÚfiÛıÂÙ·, Ë ËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ô NGF (2) ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË ÓÂ˘ÚˆÓÈ΋ ÂÈ‚›ˆÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ¤¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÔÈ ÌÈÛÔ› Ó¢ÚÒÓ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Âı·›ÓÔ˘Ó fiÙ·Ó Û¯ËÌ·Ù›˙ÔÓÙ·È ÔÈ Û˘Ó‰¤ÛÂȘ ÙÔ˘˜ (25). Œ¯ÂÈ, Â›Û˘, ·Ú·ÙËÚËı› ¤Ó· ·ÚÁfi “Û‹Ì· ÂÈ‚›ˆÛ˘” (̤ۈ ÙˆÓ ¡-∆) ÎÈ ¤Ó· ÁÚ‹ÁÔÚÔ “Û‹Ì· ı·Ó¿ÙÔ˘” (›ÛÔ‰Ô˜

¶·È‰È·ÙÚÈ΋ 2001;64:527-534

Ca2+ ÛÙÔ Î‡ÙÙ·ÚÔ), Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ÚÔÛ˘Ó·ÙÈÎÒÓ ·Ôϋ͈Ó. ªÂ ÙËÓ ÙÚÔÔÔ›ËÛË ·˘ÙÒÓ ÙˆÓ ÛËÌ¿ÙˆÓ, Â¤Ú¯ÂÙ·È Â›Ù ÚÔÛÙ·Û›· ÙˆÓ Ó¢ÚÒÓˆÓ Â›Ù ÓÂ˘ÚˆÓÈÎfi˜ ı¿Ó·ÙÔ˜. ™¯ÂÙÈο Ì ÙÔÓ NGF, Ê·›ÓÂÙ·È fiÙÈ ·Ó·ÛÙ¤ÏÏÂÈ ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ı·Ó¿ÙÔ˘ (·fiÙˆÛË), ÔÈ ÔÔ›ÔÈ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È ÛÙÔ˘˜ Ó¢ÚÒÓ˜ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ¡-∆ (26). ∂Í¿ÏÏÔ˘, Ë ÂÎfiψÛË ÙˆÓ Ó¢ÚÒÓˆÓ ·fi ÙÔ ∫+ ·Ú·Ù›ÓÂÈ ÙË ÓÂ˘ÚˆÓÈ΋ ÂÈ‚›ˆÛË, ÔfiÙÂ, ÔÈ ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ∫+ ÚÔηÏÔ‡Ó ·fiÙˆÛË, Ì ¤Ó·Ó “ηٷÚÚ¿ÎÙË” ΢ÙÙ·ÚÈÎÒÓ ÁÂÁÔÓfiÙˆÓ. ¶ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË (27) Û˘Û¯ÂÙ›˙ÂÈ ÙÔÓ NGF Ì ÙÔ Ê·ÈÓfiÌÂÓÔ ·Ú·ÁˆÁ‹˜ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ. ¶ÂÈÚ¿Ì·Ù· Û Â›Ì˘˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ Ù˘ ˘ÂÚÔÍ›·˜ (Ô˘ ÂÏ·ÙÙÒÓÂÈ Ù· Â›‰· ÙÔ˘ NGF) Î·È ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ Û‡ÓıÂÛ˘ Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘ (Ô˘ ÚÔηÏÔ‡Ó ÂÔ̤ӈ˜ ÂÏ¿ÙÙˆÛË Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘), Ô‰ËÁ› Û ‰Ú·Ì·ÙÈ΋ ·‡ÍËÛË Ù˘ ·fiÙˆÛ˘ ÛÙÔÓ ÂÁΤʷÏÔ, ·ÔÙÂÏÒÓÙ·˜ Ì›· Èı·Ó‹ ÂÍ‹ÁËÛË ÁÓˆÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ Â¤Ú¯ÔÓÙ·È Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. ŒÏÂÁ¯Ô˜ Ù˘ ÂÈÌ‹Î˘ÓÛ˘ Î·È Ù˘ ‰È·ÎÏ¿‰ˆÛ˘ ÙˆÓ Ó¢ÚÒÓˆÓ ∫·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë Û˘Ó·ÙÔÁ¤ÓÂÛË Â˘Ô‰ÒÓÂÙ·È ·Ú¿ÏÏËÏ· Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ, ÙˆÓ Ó¢ڷÍfiÓˆÓ Î·È Ù˘ Ì˘ÂÏÈÓÔÔ›ËÛ˘, fiˆ˜ Â›Û˘ ·˘Í¿ÓÔÓÙ·È ÔÈ ‰È·ÎÏ·‰ÒÛÂȘ ÙˆÓ Ó¢ÚÈÎÒÓ ‰ÈÎÙ‡ˆÓ Î·È Ë ‰È¿ÌÂÙÚÔ˜ ÙˆÓ Ó¢ڷÍfiÓˆÓ. ∏ Ï¢΋ Ô˘Û›· Á›ÓÂÙ·È ÈÔ ˘ÎÓ‹ Î·È ·˘Í¿ÓÂÙ·È Ë Ì˘ÂÏ›ÓË. ∫·Ù¿ ÙËÓ ÂÊ˂›· Î·È ÙËÓ ÂÓËÏÈΛˆÛË, ÂÍ·Ï›ÊÔÓÙ·È Û¯Â‰fiÓ ÔÈ ÌÈÛ¤˜ ·fi ÙȘ Û˘Ó¿„ÂȘ, ÔÈ ÈÔ “·‰‡Ó·Ì˜” ÏÂÈÙÔ˘ÚÁÈο, ÂÓÒ ÂΛӘ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÙÚÔÔÔÈÔ‡ÓÙ·È ‚¿ÛÂÈ ÙÔ˘ fiÁÎÔ˘ ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Ô˘ ‰¤¯ÔÓÙ·È ÛÙ· Ï·›ÛÈ· Ù˘ Û˘Ó·ÙÈ΋˜ Ï·ÛÙÈÎfiÙËÙ·˜. ∏ ˆÚ›Ì·ÓÛË ÙˆÓ Ó¢ÚÈÎÒÓ Ô‰ÒÓ Á›ÓÂÙ·È ÛÙ·‰È·Î¿, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ÙÔ˘ ·ÔÛÙÔÏ‹ (28-30). ∫·Ù¿ ̤ÛÔ fiÚÔ, ηı¤Ó· ·fi Ù· ‰ÈÛÂηÙÔÌ̇ÚÈ· Ó¢ÚÈο ·ÙÙ·Ú· Û¯ËÌ·Ù›˙ÂÈ ÂÚ›Ô˘ 10.000 ÂȉÈΤ˜ ‰È·ÓÂ˘ÚˆÓÈΤ˜ Û˘Ó‰¤ÛÂȘ (1). ∞˘Ù‹ Ë ‰È·‰Èηۛ· ÌÔÚÊÔÏÔÁÈ΋˜ ‰È·ÊÔÚÔÔ›ËÛ˘ ··ÈÙ› ÙËÓ Î·Ù¢ı˘ÓfiÌÂÓË ·‡ÍËÛË ÛËÌ·ÓÙÈÎÔ‡ ·ÚÈıÌÔ‡ ΢ÙÙ·ÚÈÎÒÓ ·Ôϋ͈Ó. ¶Èı·ÓfiÓ ÔÈ ‰È¿ÊÔÚ˜ Ê¿ÛÂȘ Ù˘ ÂÓÂÚÁËÙÈ΋˜ ÂÈÌ‹Î˘ÓÛ˘ Ì›·˜ ΢ÙÙ·ÚÈ΋˜ ·fiÏË͢ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÙÔ ÙÂÏÈÎfi ̤ÁÂıÔ˜ Î·È ÙË ÁˆÌÂÙÚ›· ÙÔ˘ ÓÂ˘Ú¿ÍÔÓ· Î·È ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ (31,32). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ·˘ÍËÙÈÎÔ› ÎÒÓÔÈ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ Ó¢ڛÙË. ŸÙ·Ó fï˜ ÂÓÂÚÁÔÔÈÔ‡-

Paediatriki 2001;64:527-534

ÓÙ·È, Ê·ÓÂÚÒÓÔ˘Ó Â˘Î›ÓËÙ˜ ‰Ô̤˜, Ù· ÓËÌ·ÙÔÂȉ‹ Î·È ÂÙ·ÏÔÂȉ‹ „¢‰Ôfi‰È·. ∞˘Ù¤˜ ÔÈ ÏÂÙ¤˜, Ô‰ÔÂȉ›˜ ‰Ô̤˜ ‚Ú›ÛÎÔ˘Ó “ÌÔÓÔ¿ÙÈ·” ÁÈ· ÙËÓ ·‡ÍËÛË Î·È ÙË ‰È·ÎÏ¿‰ˆÛË ÙÔ˘ Ó¢ÚÒÓ·.

O ¤ÏÂÁ¯Ô˜ Ù˘ ÌÔÚÊÔÏÔÁÈ΋˜ ‰È·ÊÔÚÔÔ›ËÛ˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈÎfi˜. ŒÙÛÈ, ÙÔÈΤ˜ ÎÏ›ÛÂȘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ NGF ηÙ¢ı‡ÓÔ˘Ó ÙËÓ ·‡ÍËÛË Î·È ÙËÓ Î›ÓËÛË. ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ·›˙ÂÈ, Â›Û˘ Î·È Ë ËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ·ÊÔ‡ Ë ·˘ıfiÚÌËÙË ˘ÚÔ‰fiÙËÛË ÙˆÓ Ó¢ÚÒÓˆÓ Î·Ù¿ ÙËÓ ·Ó¿Ù˘ÍË Û¯ËÌ·Ù›˙ÂÈ ÓÂ˘ÚˆÓÈο ΢ÎÏÒÌ·Ù· Î·È Û˘Ó‰¤ÛÂȘ Û fiÏÔ ÙÔÓ ÂÁΤʷÏÔ (33). ∆· ÌfiÚÈ· ΢ÙÙ·ÚÈ΋˜ ÚÔÛÎfiÏÏËÛ˘ (CAMs) Û˘Ì‚¿ÏÏÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·‡ÍËÛË ÙÔ˘ Ó¢ڛÙË, ÙÚÔÔÔÈÒÓÙ·˜ ÙȘ ¿ÏÏËÏÂȉڿÛÂȘ Ó¢ڛÙË-Ó¢ڛÙË Î·È Ó¢ڛÙË-Ó¢ÚÔÁÏÔ›·˜. ∂ȉÈο ÁÈ· ÙË Ï·ÌÈÓ›ÓË, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Û˘ÓÂÚÁ¿˙ÂÙ·È ÛÙÂÓ¿ Ì ÙË ı˘ÚÔÍ›ÓË, Ë ÔÔ›· ÔÏ˘ÌÂÚ›˙ÂÈ ÙËÓ ·ÎÙ›ÓË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÛÎÂÏÂÙÔ‡ ÛÙ· ·ÛÙÚÔ·ÙÙ·Ú·. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ, Èı·ÓfiÓ Ú˘ıÌ›˙ÔÓÙ·È ÔÈ Û˘Ó‰¤ÛÂȘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È Î·ıÔ‰ËÁÔ‡ÓÙ·È ÛˆÛÙ¿ ÚÔ˜ ÙȘ ÂÚÈÔ¯¤˜ ÌÂÙ·Ó¿ÛÙ¢Û˘ (34). ™ÙËÓ ·‡ÍËÛË ÂÌϤÎÂÙ·È Î·È Ë ·ÏÏËÏÂ›‰Ú·ÛË Ó¢ÚÒÓˆÓ-Ó¢ÚÔÁÏÔ›·˜. OÈ Û˘Ì·ıËÙÈÎÔ› Ó¢ÚÒÓ˜ Ô˘ ÌÂÁ·ÏÒÓÔ˘Ó ¯ˆÚ›˜ ·ÙÙ·Ú· Schwann, ÂÂÎÙ›ÓÔÓÙ·È ¯ˆÚ›˜ ‰È·ÎÏ·‰ÒÛÂȘ Ì ÙÔ˘˜ Ó¢ڛÙ˜ ˆ˜ ¿ÍÔÓ·. ¶·ÚÔ˘Û›· Ó¢ÚÔÁÏÔÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ, fï˜, ·Ú·ÙËÚÂ›Ù·È ÂÎÙÂٷ̤ÓË ‰È·ÎÏ¿‰ˆÛË ÙˆÓ ·Ôϋ͈Ó, Ô˘ ı˘Ì›˙ÂÈ ‰ÂÓ‰Ú›Ù˜. ∂ÈÚfiÛıÂÙ·, ÂÓ‰Ô΢ÙÙ¿ÚȘ Ô‰Ô› Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙË Ú‡ıÌÈÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ Ó¢ڛÙË. ºˆÛÊÔÏÈ›‰È· ÈÓÔÛÈÙfiÏ˘ Î·È cAMP ¤¯Ô˘Ó ·Ó·ÊÂÚı› ˆ˜ ÂÓ‰Ô΢ÙÙ¿ÚÈÔÈ Ú˘ıÌÈÛÙ¤˜. ¶·Ú¿ÏÏËÏ·, ÚÔÛ˘Ó·ÙÈÎÔ› Ù‡ÔÈ ‰È·‡ÏˆÓ Ca2+, Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Ó¢Úԉȷ‚È‚·ÛÙÒÓ, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÍÈfiÏÔÁË ·Ó¿Ù˘ÍË ÛÙËÓ ÚÒÈÌË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô (35). ∂ÈϤÔÓ, ÙÔ Ca2+ Ú˘ıÌ›˙ÂÈ ÙËÓ ÂÈÌ‹Î˘ÓÛË ÙÔ˘ Ó¢ڛÙË Î·È ÙȘ ÎÈÓ‹ÛÂȘ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ÎÒÓÔ˘ (36). ∂ȉÈÎÔ› Ó¢Úԉȷ‚È‚·ÛÙ¤˜ ÌÔÚÔ‡Ó Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙË Ó¢ÚÈÙÈ΋ ÂÈÌ‹Î˘ÓÛË Î·È ÙȘ ÎÈÓ‹ÛÂȘ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ÎÒÓÔ˘. ∏ ÛÂÚÔÙÔÓ›ÓË (5-∏∆) ÂÏ·ÙÙÒÓÂÈ ÙÔ Ú˘ıÌfi Ù˘ Û˘Ó·ÙÔÁ¤ÓÂÛ˘ Î·È ÙË Û˘Ó·ÙÈ΋ ˘ÎÓfiÙËÙ·, ‰ÚÒÓÙ·˜ ̤ۈ Ù˘ ·ÛÙÚÔÁÏÔȷ΋˜ ÚˆÙ½Ó˘ S-100‚ (37). ∞˘Ùfi˜ Ô Ó¢Úԉȷ‚È‚·ÛÙ‹˜ ÂËÚ¿˙ÂÈ ÙË ÓÂ˘ÚˆÓÈ΋ ΢ÙÙ·ÚÈ΋ ‰È·›ÚÂÛË (38), ÌÂÙ·Ó¿ÛÙ¢ÛË (39) Î·È ÚÔηÏ› ‚ÈÔ¯ËÌÈΤ˜ Î·È ÌÔÚÊÔÏÔÁÈΤ˜ ·ÏÏ·Á¤˜ ÛÙÔ˘˜ ·˘ÍËÙÈÎÔ‡˜ ÎÒÓÔ˘˜. ∏ ·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË (ACh) ‰ÈÂÁ›ÚÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÚÔ‰ÚfiÌˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÊÏÔÈÔ‡, ̤ۈ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ÌÔ˘ÛηÚÈÓÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ (40). ∏ ¯ÔÏ›ÓË ·›˙ÂÈ ÚfiÏÔ ·ÁÁÂÏÈÔÊfiÚÔ˘ ηٿ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ¡™ Î·È Î·Ù¿ ÙȘ ÂÚÈfi‰Ô˘˜ ·˘ÍË̤Ó˘

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Û˘Ó·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (41). ∂Í¿ÏÏÔ˘, Ì ·ÊÔÚÌ‹ ÙËÓ ·Ú·Ù‹ÚËÛË fiÙÈ Ë ·ÎÂÙ˘ÏÔ¯ÔÏÈÓÂÛÙÂÚ¿ÛË (AChE) Â›Ó·È È‰È·›ÙÂÚ· ·˘ÍË̤ÓË ÛÙË Ì¤Ï·ÈÓ· Ô˘Û›· (42), ÚÔÙ¿ıËΠ¤Ó·˜ ÂÓ·ÏÏ·ÎÙÈÎfi˜ ÚfiÏÔ˜ ÁÈ· ÙËÓ ACh, ÂÎÙfi˜ ·fi ÙÔ ÚfiÏÔ ÙÔ˘ Ó¢Úԉȷ‚È‚·ÛÙ‹. À¿Ú¯Ô˘Ó οÔÈÔÈ Ù‡ÔÈ AChE (ÌÔÓÔÌÂÚ‹ ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜) Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ÂÈ‚›ˆÛË Î·È ·‡ÍËÛË ÙˆÓ Ó¢ÚÒÓˆÓ, ·›˙Ô˘Ó ÂÔ̤ӈ˜ ÙÚÔÊÈÎfi (ÌË ¯ÔÏÈÓÂÚÁÈÎfi) ÚfiÏÔ. ∞Í›˙ÂÈ ·ÎfiÌË Ó· ÛËÌÂȈı› Ë Û¯¤ÛË ÙÔ˘ stress Ì ÙËÓ Ï·ÛÙÈÎfiÙËÙ· ÙˆÓ Ó¢ÚÒÓˆÓ (43). O ÈfiηÌÔ˜ ÙÔ˘ Â›Ì˘Ô˜ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙȘ ÔÚÌfiÓ˜ ÙÔ˘ stress, ηıÒ˜ Â›Û˘ ÛÙȘ ı˘ÚÂÔÂȉÈΤ˜, ÁÔÓ·‰ÈΤ˜ Î·È ÂÈÓÂÊÚȉȷΤ˜ ÔÚÌfiÓ˜, ·ÏÏ¿˙ÔÓÙ·˜ ÙÔ Û¯ËÌ·ÙÈÛÌfi ÙˆÓ Û˘Ó¿„ÂˆÓ Î·È ÙË ‰ÔÌ‹ ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ. ¢‡Ô Ù‡ÔÈ Û˘Ó·ÙÈ΋˜ Ï·ÛÙÈÎfiÙËÙ·˜ ÂËÚ¿˙ÔÓÙ·È ·fi ÙÔ stress: ·) Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ stress ÚÔηÏ› ·ÙÚÔÊ›· ÙˆÓ ‰ÂÓ‰ÚÈÙÒÓ ÛÙËÓ ÂÚÈÔ¯‹ CA3 ÙÔ˘ ÈÔοÌÔ˘ Î·È ‚) Ô͇ Î·È ¯ÚfiÓÈÔ stress ηٷÛÙ¤ÏÏÔ˘Ó ÙË Ó¢ÚÔÁ¤ÓÂÛË ÛÙËÓ Ô‰ÔÓوً ¤ÏÈη ÙÔ˘ ÈÔοÌÔ˘. ∏ ·Ú·ÁˆÁ‹ Ó¢ÚÒÓˆÓ ÛÙ·Ì·Ù¿ ÓˆÚ›˜ ηٿ ÙËÓ ÂÌ‚Ú˘ÔÁ¤ÓÂÛË (1), ÂÓÒ Ù· Ó¢ÚÔÁÏÔȷο ·ÙÙ·Ú· Û˘Ó¯›˙Ô˘Ó Ó· ‰È·ÈÚÔ‡ÓÙ·È, ·ÎfiÌ· Î·È ÛÙË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô ·Ó¿Ù˘Í˘. ∂ȉÈÎfiÙÂÚ·, Ù· ·ÛÙÚÔ·ÙÙ·Ú· π Î·È ππ ÂÌÊ·Ó›˙ÔÓÙ·È Ôχ ÓˆÚ›˜ ηٿ ÙËÓ ·Ó¿Ù˘ÍË, ÂÓÒ Ë ÁÂÓÈ¿ ÙˆÓ ÔÏÈÁÔ‰ÂÓ‰ÚÔ΢ÙÙ¿ÚˆÓ ·ÎÔÏÔ˘ı› ÙÚ›· ÛÙ¿‰È· ·Ó¿Ù˘Í˘: ·) ·Ú¯Èο ÂÌÊ·Ó›˙ÂÙ·È ÙÔ ÚÔ-ÔÏÈÁÔ‰ÂÓ‰ÚÔ·ÙÙ·ÚÔ, ‚) ·ÎÔÏÔ˘ı› ÙÔ ·ÓÒÚÈÌÔ (ÚÒÈÌÔ) ÔÏÈÁÔ‰ÂÓ‰ÚÔ·ÙÙ·ÚÔ Î·È Á) ÙÂÏÈο ÚÔ·ÙÂÈ ÙÔ ÒÚÈÌÔ ÔÏÈÁÔ‰ÂÓ‰ÚÔ·ÙÙ·ÚÔ, Ô˘ ·Ú¯›˙ÂÈ ÙÔ Û¯ËÌ·ÙÈÛÌfi Ù˘ Ì˘ÂÏÈÓÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∆· ÛÙÚÒÌ·Ù· Ì˘ÂÏ›Ó˘ ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ ÓÂ˘Ú¿ÍÔÓ· ·fi ÙËÓ ÂÎʇÏÈÛË (44). ∆· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ÛÙ¿‰È· ·Ó¿Ù˘Í˘ Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÚÔ˘Û›· ‹ ·Ô˘Û›· ÔÚÈÛÌ¤ÓˆÓ ‰ÂÈÎÙÒÓ. ŒÓ·˜ ·fi ·˘ÙÔ‡˜ Â›Ó·È Ë ÁÏ˘ÎÔÚˆÙ½ÓË Ù˘ Ì˘ÂÏ›Ó˘ ÙˆÓ ÔÏÈÁÔ‰ÂÓ‰ÚÔ΢ÙÙ¿ÚˆÓ (MOG) Ô˘ ·ÔÙÂÏ› Î·È ‰Â›ÎÙË Ù˘ ˆÚ›Ì·ÓÛ‹˜ ÙÔ˘˜, ÂϤÁ¯ÂÈ Î·È ‰È·ÙËÚ› ÙË Ì˘ÂÏÈÓÔÔ›ËÛË, fiˆ˜ Â›Û˘ Î·È ÙȘ ‰È·Î˘ÙÙ·ÚÈΤ˜ ÂȉڿÛÂȘ (45). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·Ó·Á¤ÓÓËÛË ÙˆÓ Ó¢ÚÒÓˆÓ, Ô Martin Schwab Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô ÚˆÙ½Ó˜ ÛÙÔ ˘fiÛÙڈ̷ Ù˘ Ì˘ÂÏ›Ó˘ Ô˘ ÂÚÈ‚¿ÏÏÂÈ Ù· Ó‡ڷ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡, ÔÈ Ôԛ˜ ÂÌÔ‰›˙Ô˘Ó ÙËÓ ·Ó·Á¤ÓÓËÛË ·˘ÙÒÓ ÙˆÓ ÓÂ‡ÚˆÓ (46). ∞Ó ·˘Ù¤˜ ÔÈ ÚˆÙ½Ó˜ ·Ô˘ÛÈ¿ÛÔ˘Ó ‹ ·ÂÓÂÚÁÔÔÈËıÔ‡Ó, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Û˘Ì‚Â› Ë ·Ó·Á¤ÓÓËÛË ÙˆÓ ÓÂ‡ÚˆÓ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÓ Ì¤ÚÂÈ, ·ÊÔ‡ ˘¿Ú¯Ô˘Ó ÎÈ ¿ÏÏ· ÂÌfi‰È· ÁÈ· ÙË ÓÂ˘ÚˆÓÈ΋ ÙÔ˘˜ ·Ó¿Ù˘ÍË. ŒÙÛÈ, Ù· Ó¢ÚÈο ·ÙÙ·Ú· Èı·ÓfiÓ Ó· ·ÔÙ˘Á¯¿ÓÔ˘Ó Ó· ·Ó·ÁÂÓÓËıÔ‡Ó, ÏfiÁˆ ÙˆÓ ‰˘ÛÓfiËÙˆÓ ÎÏË-

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ÚÔÓÔÌÔ‡ÌÂÓˆÓ È‰ÈÔÙ‹ÙˆÓ ÙÔ˘˜ ‹ ÂÂȉ‹ ÛÙÂÚÔ‡ÓÙ·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ‹, ·ÎfiÌË, ÂÂȉ‹ Ï›Ô˘Ó ÂΛӷ Ù· ÌfiÚÈ· Ô˘ ı· Ù· ‚ÔËı‹ÛÔ˘Ó Ó· Û˘ÁÎÚ·ÙËıÔ‡Ó Û ̛· ÂÈÊ¿ÓÂÈ· ηıÒ˜ ÌÂÁ·ÏÒÓÔ˘Ó. ¡ÂfiÙÂÚ˜ ·fi„ÂȘ Û¯ÂÙÈο Ì ÙË Ó¢ÚÔÁ¤ÓÂÛË ªÂϤÙ˜ Ì ÙÔÌÔÁÚ·Ê›· ÂÎÔÌ‹˜ Ô˙ÈÙÚÔÓ›ˆÓ (ƒ∂∆) ¤‰ÂÈÍ·Ó fiÙÈ Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Û¯ÂÙ›˙ÂÙ·È ÛÙÂÓ¿ Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ ÁÏ˘Îfi˙˘. ¢È·ÈÛÙÒıËÎ·Ó ÌÂÙ·‚ÔÏÈΤ˜ ·ÏÏ·Á¤˜, Ô˘ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙËÓ ÂͤÏÈÍË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜. ∏ ˆÚ›Ì·ÓÛË ÙÔ˘ ¡™ Â›Ó·È Ì›· ‰˘Ó·ÌÈ΋ ‰È·‰Èηۛ·. ∂›Û˘, ˘¿Ú¯ÂÈ Û¯¤ÛË ÌÂٷ͇ Û˘Ó·ÙÔÁ¤ÓÂÛ˘ Î·È ÂÈ¤‰ˆÓ ÁÏ˘Îfi˙˘, Ô˘ Â›Ó·È Ê·ÓÂÚ‹ Û ÂÚÈfi‰Ô˘˜ Ì¿ıËÛ˘, fiÔ˘ Ë Ï·ÛÙÈÎfiÙËÙ· ÙˆÓ Û˘Ó¿„ÂˆÓ Â›Ó·È ¤ÓÙÔÓË (47). ª›· ¿ÏÏË ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ ÁÈ· ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ Û˘Ó¿„ˆÓ, Â›Ó·È Ù· Â›‰· ÙÔ˘ Ûȉ‹ÚÔ˘ (Fe) ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. O Fe Û˘Ì‚¿ÏÏÂÈ ÛÙÔ Û¯ËÌ·ÙÈÛÌfi Î·È ÙË Û˘ÓÙ‹ÚËÛË Ù˘ Ì˘ÂÏ›Ó˘. ∂Ô̤ӈ˜, ÛÙË ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·, ·Ó·Ì¤ÓÂÙ·È ·ÏÏ·Á‹ ÛÙË Ì˘ÂÏÈÓÔÔ›ËÛË, ‰ËÏ·‰‹ ÂÏ¿ÙÙˆÛË Ù˘ Ù·¯‡ÙËÙ·˜ ·ÁˆÁ‹˜ ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ, ηıÒ˜ Â›Û˘ Ù˘ Ù·¯‡ÙËÙ·˜ ˆÚ›Ì·ÓÛ˘ ÙˆÓ Û˘Ó¿„ˆÓ, Û ‚Ú¤ÊË Ì ËÏÈΛ· ̤¯ÚÈ 6 ÌËÓÒÓ (48). ™¯ÂÙÈο Ì ÙÔ ÌËÙÚÈÎfi Á¿Ï·, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ÏÈ›‰È· Ô˘ ÂÚȤ¯ÂÈ ·ÔÙÂÏÔ‡Ó Úfi‰ÚÔ̘ Ô˘Û›Â˜ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ Î·È ÚÔÛÙ·Î˘ÎÏÈÓÒÓ, Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‰fiÌËÛË ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ Ó¢ÚÒÓˆÓ (49). ∂ӉȷʤÚÔ˘Û˜ Â›Ó·È ÔÈ ‚Ï·ÙÈΤ˜ ÂȉڿÛÂȘ ÙÔ˘ ·ÏÎÔfiÏ ÛÙË Ó¢ÚÔÁ¤ÓÂÛË. ∏ ÌÂÙ·Ó¿ÛÙ¢ÛË Î·È Ë ÛˆÛÙ‹ ηıÔ‰‹ÁËÛË ÙˆÓ Ó¢ڷÍfiÓˆÓ ·ÚÂÌÔ‰›˙ÔÓÙ·È, ÏfiÁˆ Ù˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ Ï·ÌÈÓ›Ó˘ ·fi ÙÔ ·ÏÎÔfiÏ (50). ∂›Û˘, ÙÔ ·ÏÎÔfiÏ ÂÓÙ›ÓÂÈ ÙËÓ ·fiÙˆÛË Î·È ÙËÓ ÂÎʇÏÈÛË ÙˆÓ Ó¢ÚÒÓˆÓ, ÛÙË Ê¿ÛË Ù˘ Û˘Ó·ÙÔÁ¤ÓÂÛ˘ (·fi ÙÔÓ 6Ô Ì‹Ó· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ ̤¯ÚÈ Î·È ÌÂÚÈο ¯ÚfiÓÈ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË). ∂›Û˘, ÚÔηÏ› ÙËÓ ÂÍ¿ÏÂÈ„Ë ÂηÙÔÌÌ˘Ú›ˆÓ Ó¢ÚÒÓˆÓ ·fi ÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÂÁΤʷÏÔ, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙË Û˘ÓÔÏÈ΋ Ì¿˙· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÚÔ¿ÁÔÓÙ·˜ ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜, fiˆ˜ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙÔ Û‡Ó‰ÚÔÌÔ ÙÔ˘ ·ÏÎÔÔÏÈÎÔ‡ ÓÂÔÁÓÔ‡-‚Ú¤ÊÔ˘˜ (51) (Ô˘ Â›Ó·È Ë Û˘Ó¤¯ÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ù˘ ·ÏÎÔÔÏÈ΋˜ ÂÌ‚Ú˘Ô¿ıÂÈ·˜). ¶ÚÔÔÙÈΤ˜ ÛÙËÓ ¤Ú¢ӷ OÈ ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È ¯Ú‹ÛÈÌ· ÂÚÁ·Ï›· ·ÏÏ¿ Î·È Û‡Á¯ÚÔÓ· ıÂÚ·¢ÙÈο ̤۷ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 20-02-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù˘ÏÈ·Ófi˜ ∆۷ΛÚ˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ¶ÂÈÚ·Ì·ÙÈ΋˜ º˘ÛÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ∆.£. 65257, 154 01 ∞ı‹Ó· e-mail: stsakir@cc.uoa.gr

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Recent etiological correlations of childhood leukemia A. G. Pourtsidis

¶ÂÚ›ÏË„Ë: O ηÚΛÓÔ˜ Â›Ó·È Ë ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ·ÈÙ›· ı·Ó¿ÙÔ˘ ·È‰ÈÒÓ, ÌÂÙ¿ Ù· ·Ù˘¯‹Ì·Ù·, ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜. OÈ Ï¢¯·È̛˜ ·ÔÙÂÏÔ‡Ó ÙË Û˘¯ÓfiÙÂÚË ÌÔÚÊ‹ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ ÛÙȘ ¯ÒÚ˜ ·˘Ù¤˜ Î·È ˘ÔÏÔÁ›˙ÔÓÙ·È ÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ ÂÚÈÙÒÛˆÓ. ¶·Ú¿ ÙȘ ÂÎÙÂٷ̤Ó˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ·Ú·Ì¤ÓÂÈ ˆ˜ Â› ÙÔ Ï›ÛÙÔÓ ·‰È¢ÎÚ›ÓÈÛÙË. ∞Ó·ÁÓˆÚÈṲ̂ÓÔÈ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Û ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÔÚÈṲ̂Ó˜ ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÂÍËÁÔ‡Ó ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÂÚÈÙÒÛÂˆÓ Ï¢¯·ÈÌ›·˜ Û ·È‰È¿. MÂϤÙ˜ ÛÙÔ ·ÚÂÏıfiÓ ÚfiÙÂÈÓ·Ó Î¿ÔÈÔ˘˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›·, ·ÏÏ¿ Ù· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ·ÛÙ·ı‹ Î·È ÌË ÂÈÛÙÈο. ∆Ô È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÚ¢ÓËÙÒÓ ¤¯ÂÈ ÂÓÙÔÈÛÙ› ÛÙËÓ ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÛÙÔ ÚfiÏÔ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ·È‰› Î·È ÙË ÌËÙ¤Ú· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. Œ¯ÂÈ ÌÂÏÂÙËı› Ë Â›‰Ú·ÛË Ù˘ ¤ÎıÂÛ˘ Û ¿ÏϘ ÌÔÚʤ˜ ·ÎÙÈÓÔ‚ÔÏ›·˜, ÂÎÙfi˜ ·fi ÙËÓ ÈÔÓ›˙Ô˘Û·, fiˆ˜ Ë ¤ÎıÂÛË Û ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›·, Û ÌÈÎÚÔ·̷ٷ ÙËÏÂÈÎÔÈÓˆÓÈ·ÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È Ú·‰ÈÔÙËÏÂÔÙÈÎÒÓ ÂÎÔÌÒÓ, Û ʈÙÔıÂÚ·›· Î·È ¯Ú‹ÛË ˘ÂÚ‹¯ˆÓ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ∂›Û˘, ÌÂÏÂÙÒÓÙ·È ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÂÚÈÁÂÓÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰ÈÔ‡, ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂÎı¤ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ÂȉÈÎfiÙÂÚ· ‰Â, ÂÎı¤ÛÂȘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È Ù˘ ÂÁ·Ԣ, ˆ˜ Î·È Ë Â·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ ÚÈÓ ÙË Û‡ÏÏË„Ë. ∏ ·Ó·ÛÎfiËÛË ·˘Ù‹ ÂÍÂÙ¿˙ÂÈ ÏÂÙÔÌÂÚÂȷο ÙËÓ ÚfiÔ‰Ô Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ¤Ú¢ӷ˜ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜.

Abstract: Cancer is the second most common cause of death, following accidents, among children in developed countries. The leukemias constitute the most common form of childhood cancer in these countries, accounting for about one third of the cases. In spite of extensive epidemiologic studies the etiology of childhood leukemia remains for the most part unclarified.

Established causes such as exposure of the fetus to ionizing radiation, and certain genetic disorders explain only a small fraction of leukemia cases in children. Past studies suggested some causative factors but the results were unconvincing.

Researchers today have focused their interest on the effect of radiation and the role of infections in the child and the mother during pregnancy. The effect of exposure to certain types of radiation, other than ionizing, have also been investigated, including extremely low frequency electric and magnetic fields, microwaves of telecommunication systems and radiotelevision transmission, phototherapy and use of ultrasound for diagnostic purposes. In addition, the role of socioeconomic factors of the family, perinatal characteristics of the child, environmental exposure of the child and the parents, especially exposure of the fetus and mother during pregnancy, as well as parental occupational exposure before conception are being investigated. This review surveys in detail the progress of epidemiologic research on the etiology of childhood leukemia.

∂ÈÌÂÏËÙ‹˜ OÁÎÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶ & ∞ ∫˘ÚÈ·ÎÔ‡”

Registrar, Division of Oncology Children’s Hospital of “P & A Kyriakou”, Athens

535

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

Paediatriki 2001;64:535-546

§¤ÍÂȘ ÎÏÂȉȿ: ·È‰È΋ Ï¢¯·ÈÌ›·, ÏÔÈÌ҉˘ ·ÈÙÈÔÏÔÁ›·, ËÏÂÎÙÚÔÌ·ÁÓËÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›·, ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜.

Key words: childhood leukemia, infectious etiology, electromagnetic radiation, socioeconomic factors.

™˘ÓÙÔÌÔÁڷʛ˜

¶›Ó·Î·˜ 1: ∂Ȃ‚·ÈˆÌ¤ÓÔÈ Î·È ‡ÔÙÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜

O§§ Oª§ ∂Ù ∏ª¶ Ì∆ (microTesla)

ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· ÔÍ›· Ì˘ÂÏÔÁÂÓ‹˜ Ï¢¯·ÈÌ›· ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›· ÌÔÓ¿‰· ̤ÙÚËÛ˘ Ì·ÁÓËÙÈÎÒÓ ‰›ˆÓ

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536

∂Ȃ‚·ÈˆÌ¤ÓÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ñ In utero ¤ÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›· ñ ªÂÙ¿ ÙË Á¤ÓÓËÛË ˘„ËÏ‹ ‰fiÛË ·ÎÙÈÓÔ‚ÔÏ›·˜ (.¯ ·ÎÙÈ ÓÔıÂÚ·›· ) ñ ™‡Ó‰ÚÔÌÔ Down ñ ∞Ó·ÈÌ›· Fanconi ñ ∞Ù·Í›· - ÙËÏ·ÁÁÂÈÂÎÙ·Û›· ñ ¡Â˘ÚÔ˚ӈ̿وÛË ñ OÈÎÔÁÂÓ‹˜ ÌÔÓÔۈ̛· 7 ñ ÃËÌÂÈÔıÂÚ·¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ⁄ÔÙÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ñ ¶ÚÔ¯ˆÚË̤ÓË ËÏÈΛ· ÌËÙ¤Ú·˜ ñ À„ËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ñ ªÂÁ¿ÏÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (>4000 gr) ñ ¶ÚˆÙfiÙÔη ·È‰È¿ ñ πÛÙÔÚÈÎfi ıÓËÛÈÁÂÓÔ‡˜ ÂÌ‚Ú‡Ô˘ ñ ∫¿ÓÈÛÌ· ÙˆÓ ÁÔÓ¤ˆÓ ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ñ ÃÚ‹ÛË ·ÏÎÔfiÏ ·fi ÙË ÌËÙ¤Ú· ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ñ ÃÚ‹ÛË Ì·ÚÈ¯Ô˘¿Ó·˜ ·fi ÙË ÌËÙ¤Ú· ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË ñ ∏ÏÂÎÙÚÔÌ·ÁÓËÙÈο ‰›· ñ ∂ÓÙÔÌÔÎÙfiÓ· ñ ∂·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ (.¯ ‰È·Ï˘ÙÈο, ̤ٷÏÏ·, ˘‰ÚÔÁÔÓ¿ÓıڷΘ) ñ ¢È·ÈÙËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜

Ù·ÁÚ·Ê‹˜ ‹/Î·È Ë ‚ÂÏÙȈ̤ÓË ·Ó·ÊÔÚ¿ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ›Ûˆ˜ ÂÍËÁÔ‡Ó, ÂÓ Ì¤ÚÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ÙËÓ ·‡ÍËÛË. ∏ Â›ÙˆÛË Ù˘ Oª§ ÎÚ·Ù‹ıËΠÂÚ›Ô˘ ÛÙ·ıÂÚ‹ ·Ó Î·È ·Ó·Ê¤ÚıËΠοÔÈ· ·‡ÍËÛË Û Ó·ڿ ÎÔÚ›ÙÛÈ·. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ÌÈÎÚ¤˜ Û¯ÂÙÈο ·ÔÎÏ›ÛÂȘ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ÛÙ· ÎÚ¿ÙË Ù˘ ∂˘ÚÒ˘. OÈ ÌÂϤÙ˜ ·˘Ù¤˜, Ì ÛËÌ·ÓÙÈ΋ ÏËÚfiÙËÙ· ÛÙËÓ ÂÍ·ÎÚ›‚ˆÛË ÙˆÓ ÛÙÔȯ›ˆÓ, ·Ó¤ÊÂÚ·Ó Â›ÙˆÛË ·fi 31,0 ¤ˆ˜ 49,2 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ (6). ∂›Ó·È Èı·Ófi, ÌÂÙ·‚ÔϤ˜ ÛÙÔÓ ÂÈÔÏ·ÛÌfi ‹ ÛÙ· Â›‰· ¤ÎıÂÛ˘ ÔÚÈÛÌ¤ÓˆÓ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ Ï¢¯·ÈÌÔÁfiÓˆÓ, ȉȷ›ÙÂÚ· ·˘Ù¿ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ O§§ Û ÌÈÎÚ¿ ·È‰È¿, Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙȘ ÚfiÛηÈÚ˜ Ù¿ÛÂȘ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ¯ÚfiÓˆÓ. ™ÙËÓ ∞ÌÂÚÈ΋ Î·È Û ¿ÏϘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÎÔڇʈÛË ÛÙËÓ Â›ÙˆÛË Ù˘ ·È‰È΋˜ O§§ ÌÂٷ͇ ÙˆÓ ËÏÈÎÈÒÓ 2 Î·È 5 ÂÙÒÓ, ÁÓˆÛÙ‹ Î·È Û·Ó ÎÔÈÓÔ‡ Ù‡Ô˘ (common) O§§. ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë Â›ÙˆÛË Ù˘ O§§ ÛÙÔ˘˜ Ó¤ÁÚÔ˘˜ Â›Ó·È ÛÙ·ıÂÚ¿ ÛÙÔ ‹ÌÈÛ˘ ÂΛӢ ÙˆÓ Ï¢ÎÒÓ. ∂›Û˘, ÙÔ ˘„ËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Û˘Û¯ÂÙ›ÛÙËΠ̠·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ O§§

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

Paediatriki 2001;64:535-546

ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÌÂÏÂÙÒÓ. OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÈ Û˘Û¯ÂÙ›ÛÂȘ Ì ÙË ‚ÈÔÌ˯·ÓÔÔ›ËÛË Ù˘ ˙ˆ‹˜ ›Ûˆ˜ Ô‰ËÁÔ‡Ó ÛÙËÓ ËÏÈÎȷ΋ ·˘Ù‹ ¤Í·ÚÛË Î·È ¤ÙÛÈ Â›¯·Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·ÌfiÚʈÛË ÔÚÈÛÌ¤ÓˆÓ ÛËÌ·ÓÙÈÎÒÓ ˘Ôı¤ÛÂˆÓ Û¯ÂÙÈο Ì ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ¤ÎıÂÛË Û ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ (7,8). ∏ ÔÍ›· Ï¢¯·ÈÌ›·, fiˆ˜ Î·È ¿ÏÏÔÈ Î·ÚΛÓÔÈ, Â›Ó·È Ì›· ÂÍÂÏÈÛÛfiÌÂÓË ÎψÓÈ΋ ‰È·Ù·Ú·¯‹, Ë ÔÔ›· ηıÔ‰ËÁÂ›Ù·È ·fi ÌÂÙ·ÏÏ¿ÍÂȘ (9). ¶¿ÓÙˆ˜, ¤Ó· ÌÈÎÚfi ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (̤¯ÚÈ Î·È 5%) ÙˆÓ ÔͤˆÓ Ï¢¯·ÈÌÈÒÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÎÏËÚÔÓÔÌÔ‡ÌÂÓ·, ÚԉȷıÂÛÈο ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ·, fiˆ˜ Û‡Ó‰ÚÔÌÔ Down, Û‡Ó‰ÚÔÌÔ Bloom, Û‡Ó‰ÚÔÌÔ Schwachman, Ó¢ÚÔ˚ӈ̿وÛË, ·Ù·Í›· ÙËÏ·ÁÁÂÈÂÎÙ·Û›· Î·È Èı·ÓfiÓ ÙÔ Û‡Ó‰ÚÔÌÔ Klinefelter’s (10). O ·ÈÙÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È Èı·Ófiٷٷ ÔÏ˘·Ú·ÁÔÓÙÈÎfi˜ (™¯‹Ì· 1). OÈ Ì˯·ÓÈÛÌÔ› Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·Ú¯È΋ ÌÂÙ¿ÏÏ·ÍË ‰È·Ê¤ÚÔ˘Ó ·fi ÂΛÓÔ˘˜ Ô˘ ÚÔηÏÔ‡Ó ‹ ÚÔˆıÔ‡Ó ·ÎÔÏÔ˘ı›Û˜ ÌÂÙ·ÏÏ¿ÍÂȘ Î·È Ù· ¯ÚÔÓÈο fiÚÈ· Ô˘ ηχÙÔ˘Ó ÙȘ Û¯ÂÙÈΤ˜ ÂÎı¤ÛÂȘ, ÙȘ Èı·Ó¤˜ ÌÂÙ·ÏÏ¿ÍÂȘ Î·È ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· Â›Ó·È Ôχ ÂÎÙÂٷ̤ӷ. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÙÔ ˙ËÙÔ‡ÌÂÓÔ Â›Ó·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ - Èı·Ófiٷٷ ÔÏÏ·ÏÒÓ - ·ÈÙ›ˆÓ ‹ Ì˯·ÓÈÛÌÒÓ Ù˘ ÌÂÙ¿ÏÏ·Í˘ ÛÙÔ Û‡ÓÔÏÔ Ù˘ Ê˘ÛÈ΋˜ ÈÛÙÔÚ›·˜ Ù˘

ÓfiÛÔ˘. ∞Ó Î·È Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ Â›Ó·È ¿ÁÓˆÛÙË, ÔÚÈṲ̂ÓÔÈ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, fiˆ˜ Ë ·ÎÙÈÓÔ‚ÔÏ›·, ¯ËÌÈο ΢ڛˆ˜ ÔÚÁ·ÓÈÎÔ› ‰È·Ï‡Ù˜ (‚ÂÓ˙›ÓË) Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·˜ Èfi˜, Ô Èfi˜ Ù˘ ∆ Ï¢¯·ÈÌ›·˜ ÙˆÓ ÂÓËÏ›ÎˆÓ (HTLV-I). ∆Ô È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÚ¢ÓËÙÒÓ ¤¯ÂÈ ÂÓÙÔÈÛÙ› ÛÙËÓ ·ÎÙÈÓÔ‚ÔÏ›· ÈÔÓ›˙Ô˘Û· Î·È ÌË - Î·È ÛÙÔ ÚfiÏÔ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ·È‰›, ÙË ÌËÙ¤Ú· Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ô˘ ˙ÂÈ. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÂÏÂÙÒÓÙ·È Â›Ó·È ÁÔÓÂ˚ο ¯·Ú·ÎÙËÚÈÛÙÈο, ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂÎı¤ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ÂȉÈÎfiÙÂÚ· ‰Â ÂÎı¤ÛÂȘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È Ù˘ ÂÁ·Ԣ ˆ˜ Î·È Ë Â·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ. πÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›· H ÌÂϤÙË Ù˘ ηÚÎÈÓÔÁfiÓÔ˘ ‰Ú¿Û˘ Ù˘ ÈÔÓ›˙Ô˘Û·˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ ÚÔÛÂÏ·ÂÈ ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘ È·ÙÚÈÎÔ‡ Î·È ÂÈÛÙËÌÔÓÈÎÔ‡ ÎfiÛÌÔ˘. ∏ ηÚÎÈÓÔÁfiÓÔ˜ Â›‰Ú·ÛË Û¯ÂÙÈο ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ ·ÎÙÈÓÔ‚ÔÏ›·˜ ÛÙÔÓ ¿ÓıÚˆÔ ¤¯ÂÈ ÙÂÎÌËÚȈı› Ï‹Úˆ˜, ÂÓÒ ÔÈ ÌÈÎÚ¤˜ ‰fiÛÂȘ Â›Ó·È Ôχ Èı·ÓfiÓ, ·ÏÏ¿ fi¯È ·ԉ‰ÂÈÁ̤ÓÔ, fiÙÈ Â›Û˘ ·ÛÎÔ‡Ó Î·ÚÎÈÓÔÁfiÓÔ Â›‰Ú·ÛË. ∏ Û˘Û¯¤ÙÈÛË ¯·ÌËÏÒÓ ‰fiÛÂˆÓ ·ÎÙÈÓÔ‚ÔÏ›·˜ Î·È ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓË Î·È ÁÂÓÈο ‰ÂÓ ÌÔÚԇ̠ӷ ·ÔÎÏ›ÛÔ˘Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÚÈṲ̂Ó˜ È·ÙÚÈΤ˜

∆˘¯·›Ô ÁÂÁÔÓfi˜

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¶∂ƒπµ∞§§O¡∆π∫∂™ ∂∫£∂™∂π™ ∞. °ÔÓȉÈÔÙÔÍÈÎÔ› ñ πÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›· ñ ¢È·Ï˘ÙÈο (¯ËÌÈο) µ. ¢È¤ÁÂÚÛË Î˘ÙÙ·ÚÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ñ §Ô›ÌˆÍË ñ ∆Ô͛Ә ñ ¢›·ÈÙ· °. πÔ› ÌÂÙ·ÙÚÔ›˜

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°∂¡∂∆π∫Oπ ∆ƒO¶O¶Oπ∏∆∂™ ∞. ªÂ›˙ÔÓ Û‡ÛÙËÌ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ µ. ∫·ÚÎÈÓÔÁfiÓ· ÌÂÙ·‚ÔÏÈÛÌÔ‡ °. EȉÈfiÚıˆÛË DNA ¢. ∫ÏËÚÔÓÔÌÔ‡ÌÂÓ· ·ÏÏ‹ÏÈ· ÌÂÙ·ÏϿ͈Ó

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ª∂∆∞§§∞•∂π™

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∂¶π∫∆∏∆Oπ ∆ƒO¶O¶Oπ∏∆∂™ ∞. ¢›·ÈÙ· µ. §Ô›ÌˆÍË °. ∞ÓÔÛÔηٷÛÙÔÏ‹

∆˘¯·›Ô ÁÂÁÔÓfi˜ ™¯‹Ì· 1. ∞ÈÙÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ηÚΛÓÔ˘.

537

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

ÂÊ·ÚÌÔÁ¤˜ Î·È ÂÍÂÙ¿ÛÂȘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Î·ÚΛÓÔ˘ ÛÙ· ·È‰È¿. ∏ Èı·ÓfiÙËÙ· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ Ï¢¯·ÈÌ›·˜ ·fi ¯·ÌËϤ˜ ‰fiÛÂȘ ‰È·ÁÓˆÛÙÈ΋˜ ·ÎÙÈÓÔ‚ÔÏ›·˜, Â·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË ÙˆÓ ÂÚÁ·˙ÔÌ¤ÓˆÓ Û ˘ÚËÓÈο ÂÚÁÔÛÙ¿ÛÈ·, ¤ÎıÂÛË ·fi ˘ÚËÓÈΤ˜ ‰ÔÎÈ̤˜ ‹ ‰È·ÚÚÔ¤˜ ÌÂÙ¿ ·fi ·Ù‡¯ËÌ· ˘ÚËÓÈÎÒÓ ÛÙ·ıÌÒÓ Î·È ·fi Ê˘ÛÈ΋ ‹ ÙÔ˘ ˘‰¿ÊÔ˘˜ ·ÎÙÈÓÔ‚ÔÏ›·, ‰ËÌÈÔ‡ÚÁËÛ ÔÏϤ˜ ‰È·Ì¿¯Â˜ (11). ∏ ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Û ·ÎÙÈÓÔÁڷʛ˜ Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ÂÏ¿¯ÈÛÙÔ˘˜ ÂȂ‚·ÈˆÌ¤ÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›· Î·È ÔÈ ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó 40 ¤ˆ˜ 50% ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÌÂÙ¿ ·fi 2-3 ·ÎÙÈÓÔÁڷʛ˜ ÎÔÈÏ›·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ (12). O ΛӉ˘ÓÔ˜ ·˘Ùfi˜, fï˜, Û˘Ó¯Ҙ ÌÂÈÒÓÂÙ·È, Èı·Ófiٷٷ ÏfiÁˆ Ì›ˆÛ˘ Ù˘ ¯Ú‹Û˘ ÙˆÓ ·ÎÙÈÓÔÁÚ·ÊÈÒÓ ÛÙË Ì·È¢ÙÈ΋ Ú·ÎÙÈ΋ Î·È ÙˆÓ Û˘Ó‹ıˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ ‰fiÛÂˆÓ ·ÎÙÈÓÔ‚ÔÏ›·˜. ªÂÙ¿ ÙÔ 1996 ‰ËÌÔÛȇıËÎ·Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙË ‰È·Ù˘ˆı›۷ ˘fiıÂÛË fiÙÈ Ë ¤ÎıÂÛË ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ·ÎÙÈÓÔ‚ÔÏ›· ·fi ÙÔ ˘ÚËÓÈÎfi ·Ù‡¯ËÌ· ÙÔ˘ Chernobyl ÙÔ 1986 Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· Ï¢¯·ÈÌ›·. OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ‰ÂÓ ·Ó·Ê¤ÚÔ˘Ó Î¿ÔÈ· ˘ÔÏÔÁ›ÛÈÌË ·‡ÍËÛË ÛÙÔÓ Î›Ó‰˘ÓÔ Ï¢¯·ÈÌ›·˜ ÛÙ· ·È‰È¿ Ô˘ ˙Ô‡Û·Ó Û ÂÚÈÔ¯¤˜ Ô˘ Â¤‰Ú·Û ÙÔ Ú·‰ÈÂÓÂÚÁfi Ó¤ÊÔ˜ ηٿ ÙË ÛÙÈÁÌ‹ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ (13). ∂ÓÙÔ‡ÙÔȘ, Ì›· ÚfiÛÊ·ÙË ÌÂϤÙË ÛÙË ¯ÒÚ· Ì·˜ ·Ó·Ê¤ÚÂÈ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ‚ÚÂÊÈ΋˜ Ï¢¯·ÈÌ›·˜ ηٿ 2,6 ÊÔÚ¤˜ Ô˘ Û¯ÂÙ›ÛÙËΠ̠ÙËÓ ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙÔ Ú·‰ÈÂÓÂÚÁfi Ó¤ÊÔ˜ ÙÔ˘ Chernobyl (14). ŒÎıÂÛË Û ·ÎÙÈÓÔ‚ÔÏ›· ÏfiÁˆ ‰È·ÁÓˆÛÙÈÎÒÓ ·ÎÙÈÓÔÁÚ·ÊÈÒÓ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· Ï¢¯·ÈÌ›· (15). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÙ›·˜, Û˘¯Ó¿ ÂÌÊ·Ó›˙ÂÙ·È ÛÔ‚·Ú‹ ‰È·Ì¿¯Ë fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË Ô˘ ¤¯ÂÈ ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ Ï¢¯·ÈÌ›·˜ ÛÙ· ·È‰È¿ Ë ¤ÎıÂÛË ÙÔ˘ ·Ù¤Ú· Û ¯·ÌËϤ˜ ‰fiÛÂȘ ·ÎÙÈÓÔ‚ÔÏ›·˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÚÈÓ ÙË Û‡ÏÏË„Ë. ∆Ô˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ÌÂϤÙ˜ ·Ó¤ÊÂÚ·Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ·fi ¤ÎıÂÛË ÙˆÓ ·Ù¤ÚˆÓ Û ·ÎÙÈÓÔ‚ÔÏ›·, ›Ù ÁÈ· Â·ÁÁÂÏÌ·ÙÈÎÔ‡˜ ›Ù ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜ (16). ∆¤ÏÔ˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ Ô˘ Ó· ÂÓÔ¯ÔÔÈÔ‡Ó ÙË Ê˘ÛÈ΋ Á‹ÈÓË ‹ ÎÔÛÌÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· Û·Ó ÂȂ‚·ÈˆÌ¤ÓË ·ÈÙ›· Ï¢¯·ÈÌ›·˜, ·ÏÏ¿ Ë Ì¤ÛË ÂÙ‹ÛÈ· ¤ÎıÂÛË (~1 mSv) ÈÛÙ‡ÂÙ·È fiÙÈ ÚÔηÏ› ¤Ó· ÌÈÎÚfi, ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi, (~5%) ÔÛÔÛÙfi ·fi ÙË Û˘ÓÔÏÈ΋ Â›ÙˆÛË Ù˘ Ï¢¯·ÈÌ›·˜ (11). §Ô›ÌˆÍË ∏ ‰È·Ù˘ˆı›۷ ȉ¤·, ÁÈ· ÙËÓ ÔÔ›· ˘¿Ú¯Ô˘Ó Û·Ê›˜ - ·Ó Î·È ¤ÌÌÂÛ˜ - ÂȉËÌÈÔÏÔÁÈΤ˜ ÂӉ›-

538

Paediatriki 2001;64:535-546

ÍÂȘ, Â›Ó·È fiÙÈ ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ï¢¯·ÈÌ›·˜ ÎÔÈÓÔ‡ Ù‡Ô˘ ÛÙ· ·È‰È¿ ÂÌÊ·Ó›˙ÔÓÙ·È Û·Ó Û˘Ó¤ÂÈ· Û¿ÓÈ·˜ ·ıÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ Û οÔÈ· ÎÔÈÓ‹ Ïԛ̈ÍË (17,18). ∏ Ïԛ̈ÍË ÌÔÚ› Ó· Â›Ó·È ·Û˘Ó‹ı˘ Î·È fi¯È ÙfiÛÔ ÛÔ‚·Ú‹ ÙË ÛÙÈÁÌ‹ Ô˘ Û˘Ì‚·›ÓÂÈ, ·ÏÏ¿ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‹ Ë È‰È·›ÙÂÚË Â˘·ÈÛıËÛ›· ÙÔ˘ ÍÂÓÈÛÙ‹ ›Ûˆ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ·ÓÒÌ·ÏË ·¿ÓÙËÛË Ô˘ Ô‰ËÁ› ÛÙË Ï¢¯·ÈÌ›· (19). ∂›Û˘, ¤¯ÂÈ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ë ·È‰È΋ Ï¢¯·ÈÌ›· Î·È È‰È·›ÙÂÚ· Ë O§§ Û ·È‰È¿ 2 ¤ˆ˜ 5 ¯ÚfiÓˆÓ, Èı·ÓfiÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë ÚÔÛÙ·Û›·˜ ¤Ó·ÓÙÈ ÎÔÈÓÒÓ ÏÔÈÌÒÍÂˆÓ Ô˘ ÚԂϤÂÙ·È ·fi ÙËÓ ·ıËÙÈ΋ ·ÓÔÛ›· ÔÌ¿‰·˜ (8) ‹ fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ·ÓÙÈÁÔÓÈ΋ ÚfiÎÏËÛË Û ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ Ù˘ Û˘Ó‹ıÔ˘˜ ¤ÎıÂÛ˘ ηٿ ÙË ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô (17). ∆Ô 1988, Ô Kinlen (8) ‰È·Ù‡ˆÛ ÙËÓ È‰¤· fiÙÈ Ë ·È‰È΋ Ï¢¯·ÈÌ›· Èı·ÓfiÓ ÔÊ›ÏÂÙ·È Û ̛· Û¿ÓÈ· ·ÓÙ›‰Ú·ÛË Û οÔÈ· ·ÚÔÛ‰ÈfiÚÈÛÙË Ïԛ̈ÍË ‹ ÏÔÈÌÒÍÂȘ. OÈ ÂȉË̛˜ ·fi ÈÒÛÂȘ Â›Ó·È Èı·ÓfiÙÂÚ˜ fiÙ·Ó ÊÔÚ›˜ Î·È Â˘·›ÛıËÙ· ¿ÙÔÌ· ¤Ú¯ÔÓÙ·È Û Â·Ê‹ ÌÂÙ¿ ·fi ÌÂÁ¿ÏË ·Ó¿ÌÂÈÍË ÏËı˘ÛÌÒÓ (ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÌÂÙ·Ó¿ÛÙ¢Û˘). ªÂ ·˘Ù¤˜ ÙȘ Û˘Óı‹Î˜ ı· ÌÔÚÔ‡Û ӷ ˘¿ÚÍÂÈ ·ÓÙ›ÛÙÔȯ· ˘„ËÏ‹ Â›ÙˆÛË Ï¢¯·ÈÌ›·˜ Û ·È‰È¿, ÙˆÓ ÔÔ›ˆÓ Ë ·ÓÔÛ›· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ¡¤· ‰Â‰Ô̤ӷ ‰Â›¯ÓÔ˘Ó fiÙÈ Ì·˙È΋ ·Ó¿ÌÂÈÍË ·ÔÌÔÓˆÌ¤ÓˆÓ ‹ ·ÁÚÔÙÈÎÒÓ ÏËı˘ÛÌÒÓ Ì ·ÛÙÈΤ˜ ÔÌ¿‰Â˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ÓÂÔ·ÛÙÈÎÔÔÈË̤Ó˜ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, fiÏÂȘ Ì ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ ı¤ÛÂˆÓ ÂÚÁ·Û›·˜ Î·È ÂÚÈÔ¯¤˜ Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÛÙÚ·ÙȈÙÒÓ, ÙÔ˘ÚÈÛÙÒÓ Î·È ÚÔÛʇÁˆÓ ÔϤÌÔ˘ (20). ™ËÌ·ÓÙÈ΋ Û˘ÛÛÒÚ¢ÛË - Û ¯ÚfiÓÔ Î·È Û ÙfiÔ - Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ O§§ Û ·È‰È¿ 0 ¤ˆ˜ 4 ¯ÚfiÓˆÓ, ·Ó·ÎÔÈÓÒıËÎÂ Î·È ÛÙË ¯ÒÚ· Ì·˜ fiÙ·Ó ÌÂÏÂÙ‹ıËÎ·Ó 872 ÂÚÈÙÒÛÂȘ ÂȉËÌÈÔÏÔÁÈο, ¤ÌÌÂÛ· ˘ÔÛÙËÚ›˙ÔÓÙ·˜ ÙËÓ ˘fiıÂÛË ÁÈ· ÎÔÈÓfi ÏÔÈÌÔÁfiÓÔ ·Ú¿ÁÔÓÙ· (21). ¶ÔÏÏ·Ϥ˜ ÂӉ›ÍÂȘ, fiˆ˜ ‰ÈÂıÓ›˜ Û˘ÁÎÚ›ÛÂȘ Â›ÙˆÛ˘/Û˘¯ÓfiÙËÙ·˜, ‰È·¯ÚÔÓÈΤ˜ Ù¿ÛÂȘ, ÁˆÁÚ·ÊÈΤ˜ ηٷÓÔ̤˜, Û˘Û¯ÂÙ›ÛÂȘ Ì ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÎÔÈÓfiÙËÙ·˜ fiˆ˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Î·È ‚ÈÔÏÔÁÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ, ‰Â›¯ÓÔ˘Ó Û˘ÓÔÏÈο fiÙÈ Ë ÎÔÈÓÔ‡ Ù‡Ô˘ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Â›Ó·È ÓfiÛÔ˜ ÏÔ‡ÛÈˆÓ ÎÔÈÓˆÓÈÒÓ Û·Ó ÁÂÓÈ΋ ·ÓÙ›ÏË„Ë, ÂÌÂÚȤ¯ÔÓÙ·˜ ÛÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ¿ Ù˘ Ì›· Û¿ÓÈ· ·¿ÓÙËÛË Û ÎÔÈÓ‹ Ïԛ̈ÍË/ÏÔÈÌÒÍÂȘ. ∏ ˘fiıÂÛË ·˘Ù‹, Ô˘ Û¯ËÌ·ÙÈο ‰›ÓÂÙ·È ÛÙÔ ™¯‹Ì· 2 (9), ÙÔÓ›˙ÂÈ ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ ÙÚfiÔ˘ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙËÓ ÚÒÙË ·È‰È΋ ËÏÈΛ· Û ۯ¤ÛË Ì ÙËÓ ·Ó·Ù˘Íȷ΋ ‰È·‰Èηۛ· ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô ‚ÈÔÏÔÁÈο “Ê˘ÛÈÔÏÔÁÈÎfi” ÁÈ· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÎÔÈÓ¤˜ ‹ ÂÓ‰ËÌÈΤ˜

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

Paediatriki 2001;64:535-546

➝

∞Ô˘Û›· ·ÓÔÛÔÏÔÁÈ΋˜ Ú‡ıÌÈÛ˘ ÛÙ· ‚Ú¤ÊË

“∫·ı˘ÛÙÂÚË̤ÓË” ¤ÎıÂÛË Û ÏÔÈÌÒÍÂȘ

➝

➝

“À„ËÏ‹” ··ÓÙËÙÈ΋ ηٿÛÙ·ÛË

➝ ➝

ÀÂÚ·ÓÙȉڷÛÙÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË

∞ÓÔÛÔÏÔÁÈ΋ ·ÔÚ‡ıÌÈÛË Ù˘ ÏÂÌÊÔÔ›ËÛ˘ ÙˆÓ µ-΢ÙÙ¿ÚˆÓ: ŒÓÙÔÓË ˘ÂÚÏ·Û›· ÙˆÓ µ ·Ú¯¤ÁÔÓˆÓ Î˘ÙÙ¿ÚˆÓ

➝ “∂ÈÏÔÁ‹” ÙÔ˘ ˘ÂÚÏ·ÛÙÈÎÔ‡ ÎÏÒÓÔ˘ Û ·Ó·ÛÙÔÏ‹ ‰È·ÊÔÚÔÔ›ËÛ˘

➝ ∫ÔÈÓÔ‡ Ù‡Ô˘ O§§ (common)

™¯‹Ì· 2. ∞ÓÔÛÔÏÔÁÈÎfi ÚfiÙ˘Ô ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ ÎÔÈÓÔ‡ Ù‡Ô˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜.

ÏÔÈÌÒÍÂȘ Â›Ó·È Ë Ù˘¯·›· Â·Ê‹ Ì ·˘Ù¤˜ ÂÚÈÁÂÓÓËÙÈο, ‰È¿ ̤ÛÔ˘ Ù˘ ÌËÙ¤Ú·˜ ‹ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ‰È¿ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÙˆÓ ·‰ÂÏÊÒÓ ‹ ¿ÏÏˆÓ ·È‰ÈÒÓ (‚ÚÂÊÔÓËÈ·ÎÔ› ÛÙ·ıÌÔ›). ¶ÚÒÈ̘ ÂÎı¤ÛÂȘ ı· Ú˘ıÌ›ÛÔ˘Ó ‹ ı· ÚÔÂÙÔÈÌ¿ÛÔ˘Ó ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙȘ Èı·Ó¤˜ ÌÂÏÏÔÓÙÈΤ˜ ÂÎı¤ÛÂȘ. OÈ ·ÏÏ·Á¤˜ ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â¤ÎÙ·ÛË Î·È Î·Ù·ÛÙÔÏ‹ ÔÚÈÛÌ¤ÓˆÓ ˘ÔÔÌ¿‰ˆÓ ∆ ΢ÙÙ¿ÚˆÓ ‹ ÎÏÒÓˆÓ. ™˘Ó‹ıÂȘ Î·È ÙÚfiÔ˜ ˙ˆ‹˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, fiˆ˜ Ô ıËÏ·ÛÌfi˜ Î·È Ë ·Ó·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡, ·fi ·Ì¤ÏÂÈ· ÂÎı¤ÙÔ˘Ó Û ΛӉ˘ÓÔ ·˘Ù‹ ÙËÓ ÂÍÂÏÈÎÙÈ΋ ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∫·Ù’ ·Ú¯¿˜, ¤ÁÎ˘Â˜ ÌËÙ¤Ú˜ ›Ûˆ˜ ‰ÂÓ ¤¯Ô˘Ó ÂÎÙÂı› Î·È ¤ÙÛÈ ‰ÂÓ Â›Ó·È ÈηӤ˜ Ó· ‰ÒÛÔ˘Ó ·ÓÔÛÔÏÔÁÈ΋ ÚÔÛÙ·Û›· ‹ Ú‡ıÌÈÛË. ∂ÈÚfiÛıÂÙ·, ÔÈ ÂÎı¤ÛÂȘ ÙˆÓ ›‰ÈˆÓ ÙˆÓ ·È‰ÈÒÓ Û ÏÔÈÌÒÍÂȘ ¤¯Ô˘Ó ÂÏ·ÙÙˆı› ÏfiÁˆ Ù˘ ‚ÂÏÙ›ˆÛ˘ ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ Î·È ÙˆÓ ·ÏÏ·ÁÒÓ ÛÙÔ˘˜ ÙÚfiÔ˘˜ ÎÔÈÓˆÓÈÎÒÓ Â·ÊÒÓ. OÈ ÌÂÙ·‚ÔϤ˜ ·˘Ù¤˜ Û˘Ì‚·›ÓÔ˘Ó ÙËÓ ›‰È· ÛÙÈÁÌ‹ Ô˘ ‰ÈÂıÓÒ˜ ·Ú·ÙËÚ›ٷÈ, ÁÈ· ÎÔÈÓˆÓÈÎÔ‡˜ ÏfiÁÔ˘˜, ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ ·Ú·ÙÂٷ̤ÓÔ˘ ıËÏ·ÛÌÔ‡. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ¤¯ÂÈ ‰È·ÙÚÔÊÈΤ˜ Î·È ·ÓÔÛÔÏÔÁÈΤ˜ ÂȉڿÛÂȘ

ÛÙÔ ‚Ú¤ÊÔ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ÌÂÙ¿‰ÔÛ˘ ‚·ÎÙËÚȉ›ˆÓ Î·È ÈÒÓ, Ô˘ Èı·ÓfiÓ ·ÔÙÂÏ› ÙËÓ ÚÒÈÌË ·Ú¯È΋ Â·Ê‹. ª›· ÂÓ·ÏÏ·ÎÙÈ΋ ÂÍ‹ÁËÛË ÙÔ˘ ™¯‹Ì·ÙÔ˜ 2 ‰fiıËΠ·fi ÙÔ˘˜ Greaves Î·È Û˘Ó (17). ∆Ô Úfi‚ÏËÌ· ‰ÂÓ Â›Ó·È Ë ¤ÏÏÂÈ„Ë ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘, ·ÏÏ¿ Ì›· ˘ÂÚ‚ÔÏÈ΋ ‹ ÌË ÂÍÈÛÔÚÚÔË̤ÓË ·ÓÙ›‰Ú·ÛË Û ÔÚÈṲ̂ӷ ÏÔÈÌÒ‰Ë ·ÓÙÈÁfiÓ· ‹ ˘ÂÚ·ÓÙÈÁfiÓ·. À¿Ú¯Ô˘Ó ÔÏÏÔ› Èı·ÓÔ› Ì˯·ÓÈÛÌÔ›, ·ÓÔÛÔÏÔÁÈÎÔ› ‹ ‰È·Ì¤ÛÔ˘ ΢ÙÔÎÈÓÒÓ, Ô˘ Â¿ÁÔ˘Ó ˘ÂÚϷۛ˜ ÛÙ· ·Ú¯¤ÁÔÓ· ÏÂÌÊÔÔÈËÙÈο ·ÙÙ·Ú· ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. ∏ ˘ÂÚÏ·ÛÙÈ΋ ·˘Ù‹ ·ÓÙ›‰Ú·ÛË Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÌÂÙ·ÙÚ¤„ÂÈ Ê˘ÛÈÔÏÔÁÈο ·ÙÙ·Ú· ۠Ϣ¯·ÈÌÈο ‰È·Ì¤ÛÔ˘ ÌÂÙ¿ÏÏ·Í˘ ‹ ÂÓ·ÏÏ·ÎÙÈο ÌÔÚ› Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÂÈ Û·Ó ÚÔ·ÁˆÁ¤·˜ ÚÔ¸·Ú¯fiÓÙˆÓ ÌÂÙ·ÏÏ·ÁÌ¤ÓˆÓ ·˘ÙÔÌ¿Ùˆ˜ ÎÏÒÓˆÓ. ∏ ·È‰È΋ Ï¢¯·ÈÌ›· ›Ûˆ˜ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ‰‡Ô ÌÂÙ·ÏϿ͈Ó, Ë ÚÒÙË ÂÓ‰ÔÌËÙÚÈο Î·È Ë ‰Â‡ÙÂÚË ÌÂÙ¿ ÙË Á¤ÓÓËÛË. ∏ ÙÂÏÂ˘Ù·›· ·Ô‰›‰ÂÙ·È Û ‰È·Ù·Ú·¯¤˜ ηٿ ÙËÓ ÂͤÏÈÍË ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. O Greaves, ÙÔ 1988, ‰ËÌÔÛ›Â˘Û ̛· ˘fiıÂÛË (22) Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· Ë ÈÔ ÎÔÈÓ‹ ÌÔÚÊ‹ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ (Ë ÎÔÈÓÔ‡ Ù‡Ô˘ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, Ô˘ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÂÙ·È Î·Ù¿ ÙËÓ ÚÒÈÌË ·È‰È΋ ËÏÈΛ·) ›Ûˆ˜ ÔÊ›ÏÂÙ·È Û ‰‡Ô ͯˆÚÈÛÙ¿ ÁÂÓÂÙÈο Û˘Ì‚¿Ì·Ù· (·˘ÙfiÌ·Ù˜ ÌÂÙ·ÏÏ¿ÍÂȘ). ∏ ÚÒÙË ıˆÚÂ›Ù·È ‰Â‰Ô̤ÓÔ fiÙÈ Â›Ó·È ·˘ÙfiÌ·ÙË Î·È Û˘Ì‚·›ÓÂÈ Î·Ù¿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹, fiÙ·Ó Ù· µ ·Ú¯¤ÁÔÓ· ·ÙÙ·Ú· ÔÏÏ·Ï·ÛÈ¿˙ÔÓÙ·È Ù·¯‡Ù·Ù· ÛÙÔ ‹·Ú Î·È ÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ. O ›‰ÈÔ˜ ıˆÚ› fiÙÈ ·˘Ùfi˜ Ô ÌÂÙ·ÏÏ·Á̤ÓÔ˜ ÎÏÒÓÔ˜ ÙÔ˘ ÚÒÈÌÔ˘ µ ΢ÙÙ¿ÚÔ˘ ı· ˘ÂÚÔÏÏ·Ï·ÛÈ·ÛÙ› fiÙ·Ó ·ÚÁfiÙÂÚ· ÂÎÙÂı› Û οÔÈÔ ·ÓÙÈÁÔÓÈÎfi ÂÚÂıÈÛÌfi-ÚfiÎÏËÛË (.¯. ¤Ó· ÏÔÈÌÒ‰Ë ·Ú¿ÁÔÓÙ·). ∏ ηı˘ÛÙÂÚË̤ÓË ¤ÎıÂÛË Û ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ Î·È Ë ÌÂÁ·Ï‡ÙÂÚË ·ÓÔÛÔÏÔÁÈ΋ ÚfiÎÏËÛË ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙÔ ÌË ÂÏÂÁ¯fiÌÂÓÔ Î˘ÙÙ·ÚÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi. ∞˘Ùfi, ÛÙË Û˘Ó¤¯ÂÈ·, Ô‰ËÁ› ÛÙË ‰Â‡ÙÂÚË ÌÂÙ¿ÏÏ·ÍË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÎÏÒÓÔ˘ Ô˘ ‹‰Ë ›¯·Ó ÂÂÎÙ·ı› Û·Ó Û˘Ó¤ÂÈ· Ù˘ ÚÒÙ˘ ÌÂÙ¿ÏÏ·Í˘ Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË Ù˘ Ï¢¯·ÈÌ›·˜. ¶ÈÛÙ‡ÂÈ ‰Â fiÙÈ ·˘Ù‹ Ë ÎÚ›ÛÈÌË ÂÚ›Ô‰Ô˜ ÚÔ·ÁˆÁ‹˜ ›Ûˆ˜ Û˘Ì‚·›ÓÂÈ ÙÔ ‰Â‡ÙÂÚÔ ‹ ÙÚ›ÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙËÓ ·Ú¯È΋ Â·Ê‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ì ‰È¿ÊÔÚ· ·ÓÙÈÁfiÓ·. ∂›Û˘, Ô ›‰ÈÔ˜ ıˆÚ› fiÙÈ ·È‰È¿ Ô˘ ¤¯Ô˘Ó ÂÎÙÂı› Û ÏÔÈÌÒÍÂȘ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ¤¯Ô˘Ó ‹‰Ë ·Ó·Ù‡ÍÂÈ ÌÂÚÈ΋ ·ÓÔÛ›· Î·È ¤ÙÛÈ Ù· µ ·ÙÙ·Ú¿ ÙÔ˘˜ ‰ÂÓ Â˘Ú›ÛÎÔÓÙ·È Û ¤ÓÙÔÓË ˘ÂÚÏ·ÛÙÈ΋ Ê¿ÛË fiÙ·Ó ÂÎÙ›ıÂÓÙ·È Û ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ ·ÚÁfiÙÂÚ· ÛÙËÓ ÚÒÈÌË ·È‰È΋ ËÏÈΛ·. ∆Ô˘Ï¿¯ÈÛÙÔÓ Ì›· ÌÂϤÙË (23) Ô˘ Â›Ó·È Û˘Ì‚·Ù‹ Ì ÙËÓ ·ÓˆÙ¤Úˆ ˘fiıÂÛË,

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¤‰ÂÈÍ fiÙÈ Ë ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÎÔ‡ ÛÙ·ıÌÔ‡ Û ÚÒÈÌË ËÏÈΛ· Û¯ÂÙ›˙ÂÙ·È Ì ¯·ÌËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ. ∂›Û˘, Û˘Û¯ÂÙ›ÛÂȘ Ì ÙË ÛÂÈÚ¿ Á¤ÓÓËÛ˘ Î·È ÙÔ ·ÓÒÙÂÚÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ›Ûˆ˜ ÂÍËÁÔ‡ÓÙ·È ·fi ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ¤ÎıÂÛË Û ÏÔÈÌÒÍÂȘ, ÏfiÁˆ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·‰ÂÏÊÒÓ Î·È/‹ ηı˘ÛÙÂÚË̤ÓË ÂÈÛ·ÁˆÁ‹ Û ‚ÚÂÊÔÓËÈ·Îfi ÛÙ·ıÌfi (24). ¶·Ú¿ÁÔÓÙ˜ fiˆ˜ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÂÌ‚ÔÏÈ·ÛÌÔ›, ·ÏÏÂÚÁ›Â˜, ÏÔÈÌÒÍÂȘ, ¤ÎıÂÛË Û ˙Ò·, ÛÂÈÚ¿ Á¤ÓÓËÛ˘ ¤¯Ô˘Ó ‹‰Ë ÂÚ¢ÓËı› ÛÂ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ˘fiıÂÛË Greaves. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÒÓ ÙˆÓ ÌÂÏÂÙÒÓ Â›Ó·È ÁÂÓÈο ·ÓÙÈÊ·ÙÈο. ™Â Ì›· ÌÂϤÙË ÂÚÈÙÒÛÂˆÓ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜, Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, ‚Ú¤ıËΠÈÛ¯˘Ú¿ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ÚÒÙÔ˘ ÂÍ·Ì‹ÓÔ˘ Ù˘ ˙ˆ‹˜, ÂÓÒ ¿ÏÏË ÌÂϤÙË ‰ÂÓ ¤‰ÂÈÍ ÔÔÈ·‰‹ÔÙÂ Û˘Û¯¤ÙÈÛË Ì ÎÔÈÓ¿ ÎÚ˘ÔÏÔÁ‹Ì·Ù·, ˘ÚÂÙÈο ÂÂÈÛfi‰È·, ·È‰ÈΤ˜ ·ÚÚÒÛÙȘ (ÈÏ·Ú¿, ·ÓÂÌÔ‚ÏÔÁÈ¿, ·ÚˆÙ›Ùȉ·, ÂÚ˘ıÚ¿) Î·È ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ Ù˘ ˙ˆ‹˜ ÁÈ· ÙȘ Ôԛ˜ ··ÈÙ‹ıËΠ·Ú·ÌÔÓ‹ Û ÓÔÛÔÎÔÌÂ›Ô (25). ∏ ˘fiıÂÛË fiÙÈ ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› Ì BCG, DTP ‹ ÔÈ ÂÌ‚ÔÏÈ·ÛÌÔ› ÁÈ· ¿ÏÏ· ÈÔÁÂÓ‹ ÓÔÛ‹Ì·Ù· Èı·ÓfiÓ ÚÔÛÙ·ÙÂ‡Ô˘Ó ·fi ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· ‰ÂÓ ÂȂ‚·ÈÒıËΠÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜. ∆¤ÏÔ˜, Û˘Û¯¤ÙÈÛË Î·ÎÔËıÂÈÒÓ ÙÔ˘ ÏÂÌÊÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ Î·È ¤ÎıÂÛË Û ¿ÚÚˆÛÙË Á¿Ù· ‹ Û˘Ó‡·ÚÍË Ì ˙Ò· ÛÙÔ Û›ÙÈ ¤¯ÂÈ ·Ó·ÊÂÚı›, ·ÏÏ¿ Û ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ Î·È ¯ˆÚ›˜ ÛˆÛÙ‹ ÂÍ·ÎÚ›‚ˆÛË ÙˆÓ ÛÙÔȯ›ˆÓ (26). °ÔÓÂ˚ÎÔ› Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ∫·ÓÈÛÙÈΤ˜ Û˘Ó‹ıÂȘ ÁÔÓ¤ˆÓ ¢ÂÓ ˘¿Ú¯ÂÈ ÛÙ·ıÂÚfiÙËÙ· ¢ÚËÌ¿ÙˆÓ ÌÂٷ͇ ηÓ›ÛÌ·ÙÔ˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È Ï¢¯·ÈÌ›·˜ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ·Ó¤ÊÂÚ·Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Î·È ¿ÏϘ fi¯È (27). OÈ ·Ú¯ÈΤ˜, fï˜, ÌÂϤÙ˜ ÂÛÙ›·Û·Ó ΢ڛˆ˜ ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ ÛÙËÓ ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ‰ÂÓ ÌÔÚÔ‡Û·Ó Ó· ‰È·¯ˆÚ›ÛÔ˘Ó ÙȘ ‰˘ÓËÙÈο ‚Ï·‚ÂÚ¤˜ Û˘Ó¤ÂȘ ·fi ÙÔ Î¿ÓÈÛÌ· ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙÔ ·ıËÙÈÎfi οÓÈÛÌ· ÙÔ˘ ·È‰ÈÔ‡ (28). ¶ÚfiÛÊ·Ù·, ‰‡Ô ÌÂϤÙ˜ ÛÙËÓ ∞ÁÁÏ›· Î·È ÙËÓ ∫›Ó· ·Ó¤ÊÂÚ·Ó fiÙÈ ÙÔ Î¿ÓÈÛÌ· ÙÔ˘ ·Ù¤Ú· ÙËÓ ÂÚ›Ô‰Ô ÚÈÓ ÙË Û‡ÏÏË„Ë Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘. ∏ ÌÂϤÙË ·fi ÙËÓ ∫›Ó· (29) ‹Ù·Ó ͯˆÚÈÛÙ‹ ÁÈ·Ù› ̤¯ÚÈ ÂΛÓË ÙË ÛÙÈÁÌ‹ Ï›Á˜ Á˘Ó·›Î˜ οÓÈ˙·Ó Î·È ¤ÙÛÈ Ë Â›‰Ú·ÛË ÙÔ˘ ηÓ›ÛÌ·ÙÔ˜ ·fi ÙÔÓ ·Ù¤Ú· ‹Ù·Ó ‰˘Ó·Ùfi Ó· ÂÎÙÈÌËı› ·ÓÂÍ¿ÚÙËÙ· ·fi οıÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ηÓ›ÛÌ·ÙÔ˜. OÈ Û˘ÁÁÚ·Ê›˜ ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÌÂÏÂÙÒÓ ıˆÚÔ‡Ó fiÙÈ ÙÔ Î¿ÓÈÛÌ· ›Ûˆ˜ ÚÔηÏ› ÁÂÓÂÙÈ΋ ‚Ï¿‚Ë ÛÙ· ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ· Î·È ·˘Ùfi Ô‰ËÁ› Û ۇÌÊ˘Ù˜

540

Paediatriki 2001;64:535-546

ÌÂÙ·ÏÏ¿ÍÂȘ, Ô˘ Â›Ó·È Ë ·ÈÙ›· ‹ Úԉȷı¤ÙÔ˘Ó Û ηÚΛÓÔ, ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜. ∏ ¤Ó‰ÂÈÍË ·˘Ù‹˜ Ù˘ ˘fiıÂÛ˘ ÈÛ¯˘ÚÔÔÈÂ›Ù·È ·fi ÛÙÔȯ›· ÂÚ¢ÓÒÓ in vitro, ÛÙȘ Ôԛ˜ ÙÔ Î¿ÓÈÛÌ· ‚Ú¤ıËΠӷ ·˘Í¿ÓÂÈ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ DNA ÛÙ· ·ÓıÚÒÈÓ· ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ· Î·È Ó· ÚÔηÏ› ÌÂÙ¿ÏÏ·ÍË ÛÙ· ÁÂÓÓËÙÈο ·ÙÙ·Ú· (30). ∫·Ù·Ó¿ÏˆÛË ·ÏÎÔfiÏ ∞ÛÙ·ı‹ Â˘Ú‹Ì·Ù· ·Ó·Ê¤ÚıËÎ·Ó Î·È ÛÙË Û˘Û¯¤ÙÈÛË Î·Ù·Ó¿ÏˆÛ˘ ·ÏÎÔfiÏ Î·Ù¿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË Î·È ÎÈÓ‰‡ÓÔ˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜. ™Â ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚıËÎÂ Û˘Û¯¤ÙÈÛË Î·Ù·Ó¿ÏˆÛ˘ ·ÏÎÔfiÏ ·fi ÙË ÌËÙ¤Ú· Î·È ÎÈÓ‰‡ÓÔ˘ Oª§ Û ÌÈÎÚ¿ ·È‰È¿, ıˆÚÒÓÙ·˜ fiÙÈ Ë ¤ÎıÂÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÛÙÔ ·ÏÎÔfiÏ ›Ûˆ˜ ¤¯ÂÈ Î¿ÔÈ· ËÏÈÎȷ΋ Â›‰Ú·ÛË ÁÈ· ÙËÓ Oª§ (31). O ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Û˘Û¯ÂÙ›ÛÙËΠ̠fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ·ÏÎÔÔÏÔ‡¯ˆÓ ÔÙÒÓ Î·È ‹Ù·Ó ȉȷ›ÙÂÚ· ˘„ËÏfi˜ ÁÈ· ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÌËÙ¤Ú˜ ¤ÈÓ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ‹ ÙÚ›ÙÔ˘ ÙÚÈÌ‹ÓÔ˘ Ù˘ ·ËÛ˘. OÈ ‚ÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÁÈ· ÙËÓ ·Ú·ÙËÚËı›۷ Û˘Û¯¤ÙÈÛË Â›Ó·È ·Û·Ê›˜, ·ÏÏ¿ ÙÔ ·ÏÎÔfiÏ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ Ù· Â›‰· ÔÚÈÛÌ¤ÓˆÓ ÂÓ˙‡ÌˆÓ, fiˆ˜ ÙÔ Î˘ÙÙfi¯ÚˆÌ· P450, Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÚÔηÚÎÈÓÔÁfiÓˆÓ. ¢È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ O Èı·Ófi˜ ÚfiÏÔ˜ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ‰ÂÓ ÌÂÏÂÙ‹ıËΠ̤¯ÚÈ ÙÔ 1994, fiÙ·Ó ‰‡Ô Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ·Ó¤ÊÂÚ·Ó Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ηٷӿψÛ˘ ηÓÈÛÙÔ‡ ÎÚ¤·ÙÔ˜ ·fi ÙÔ˘˜ ÁÔÓ›˜ ‹ Ù· ·È‰È¿ Î·È ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜. ∏ ʇÛË ·˘Ù‹˜ Ù˘ Û˘Û¯¤ÙÈÛ˘ ·Ú·Ì¤ÓÂÈ ÚÔ˜ ‰È¢ÎÚ›ÓÈÛË, ÁÈ·Ù› Û ̛· ¿ÏÏË ÌÂϤÙË ‰È·ÈÛÙÒıËΠÌÂȈ̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· Oª§ Î·È O§§ Û ·È‰È¿ Ì ̷ÎÚÔ¯ÚfiÓÈ· ¯Ú‹ÛË ÌÔ˘ÚÔ˘Ó¤Ï·ÈÔ˘. ¶ÚfiÛÊ·Ù·, Û ̛· Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË 84 ÂÚÈÙÒÛÂˆÓ ‚ÚÂÊÈ΋˜ Ï¢¯·ÈÌ›·˜ Î·È 97 ‚ÚÂÊÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Û·Ó ÔÌ¿‰· ÂϤÁ¯Ô˘ (32), Ë ÚfiÛÏË„Ë ·fi ÙË ÌËÙ¤Ú· ÙÚÔÊ›ÌˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÙÔÔ˚ÛÔÌÂÚ¿ÛË ππ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È ıÂÙÈο Ì ΛӉ˘ÓÔ ‚ÚÂÊÈ΋˜ Oª§, ÂÓÒ ‰ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË Ì O§§. ™Ù· ÙÚfiÊÈÌ· ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· Ê·ÛfiÏÈ·, ÊÚ¤Ûη Ï·¯·ÓÈο, ÎÔÓÛÂÚ‚ÔÔÈË̤ӷ Ï·¯·ÓÈο, ÊÚÔ‡Ù·, ÛfiÁÈ·, ηÓÔÓÈÎfi˜ ηʤ˜, Ì·‡ÚÔ ÙÛ¿È, Ú¿ÛÈÓÔ ÙÛ¿È, Ù‡ÔÈ ÎfiÏ·˜ Î·È ÎÚ·Û›. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ Â›Ó·È ·ÓËÛ˘¯ËÙÈο, ·ÊÔ‡ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ÙÔÔ˚ÛÔÌÂÚ¿ÛË ππ ÙÔ˘ DNA ÚÔηÏÔ‡Ó ÂÓ›ÔÙ ‰Â˘ÙÂÚÔ·ı‹ Oª§ Ì ·ÓˆÌ·Ï›· ÛÙÔ ÁÔÓ›‰ÈÔ MLL (mixed lineage leukemia) ÛÙË ı¤ÛË 11q23. ∏ ·ÓˆÌ·Ï›· ·˘Ù‹ ·Ó¢ڛÛÎÂÙ·È ÛÙÔ

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

80% ÙˆÓ ÓÂԉȷÁÓˆÛÌ¤ÓˆÓ ÂÚÈÙÒÛÂˆÓ ‚ÚÂÊÈ΋˜ Ï¢¯·ÈÌ›·˜. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı›, fï˜, fiÙÈ ÔÏÏ¿ ·fi Ù· ÙÚfiÊÈÌ· Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È, fiˆ˜ Ù· ÊÚ¤Ûη Ï·¯·ÓÈο Î·È ÊÚÔ‡Ù·, ›Ûˆ˜ ÂÚȤ¯Ô˘Ó Î·È ·˘ÍË̤ӷ Â›‰· Ê˘ÙÔÊ·ÚÌ¿ÎˆÓ Ô˘, Â›Û˘, Â›Ó·È ‡ÔÙ· Ï¢¯·ÈÌÔÁfiÓ·. ∂Âȉ‹ ·˘Ù‹ Ë ÌÂϤÙË ‹Ù·Ó ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ Î·È Ì ÂÏ¿¯ÈÛÙË ÂÎÙ›ÌËÛË Ù˘ ‰È·ÈÙËÙÈ΋˜ ÚfiÛÏ˄˘, ÔÈ Û˘ÁÁÚ·Ê›˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ıˆÚËıÔ‡Ó ÚÔηٷÚÎÙÈο. ¶ÂÚÈÁÂÓÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ∆Ô ÌÂÁ¿ÏÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ›¯Â ÛÙÔ ·ÚÂÏıfiÓ Û˘Û¯ÂÙÈÛÙ› Ì ΛӉ˘ÓÔ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜, ȉȷ›ÙÂÚ· ÁÈ· ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ¯ÚfiÓˆÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ, ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÈÏ¿ÛÈÔ, Û ·È‰È¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ¿Óˆ ·fi 4000 gr, ÂÓÒ ¿ÏϘ ‰ÂÓ ·Ó¤ÊÂÚ·Ó Û˘Û¯¤ÙÈÛË (33). O ˘ÔΛÌÂÓÔ˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È ¿ÁÓˆÛÙÔ˜. ªÂ ‚¿ÛË ÙȘ ·Ú·ÙËÚ‹ÛÂȘ fiÙÈ 1) ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Û¯ÂÙ›˙ÂÙ·È Ì ٷ Â›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· π insuline-like Ù˘ ·‡ÍËÛ˘ (IGF-1), 2) Ô ·Ú¿ÁÔÓÙ·˜ ·˘Ùfi˜ ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙȘ ‰ÈÂÚÁ·Û›Â˜ Ù˘ ·ÈÌÔÔ›ËÛ˘ Î·È 3) Ë ‚ÚÂÊÈ΋ Ï¢¯·ÈÌ›· ÚÔηÏÂ›Ù·È Î˘Ú›ˆ˜ ·fi ÂÎı¤ÛÂȘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ÔÈ Ross Î·È Û˘Ó (34) ‰ÈÂÙ‡ˆÛ·Ó ÙËÓ ˘fiıÂÛË fiÙÈ ˘„ËÏ¿ Â›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· IGF-1 ‰˘ÓËÙÈο ÌÔÚÔ‡Ó fi¯È ÌfiÓÔ Ó· ‰ËÌÈÔ˘ÚÁÔ‡Ó ¤Ó· ÌÂÁ¿ÏÔ ÌˆÚfi, ·ÏÏ¿ Î·È Ó· Û˘Ó‰Ú¿ÌÔ˘Ó ÛÙË Ï¢¯·ÈÌÔÁ¤ÓÂÛË.

AÓ··Ú·ÁˆÁÈÎfi ÈÛÙÔÚÈÎfi ÌËÙ¤Ú·˜ ¶ÚÔËÁÔ‡ÌÂÓ˜ ·ÒÏÂȘ ÂÌ‚Ú‡ˆÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜, ·Ó Î·È Ì›· ÌÂϤÙË ·Ó¤ÊÂÚ ·Ó¿ÛÙÚÔÊË Û˘Û¯¤ÙÈÛË (32). ™Â ÌÈ· ÚfiÛÊ·ÙË Û¯ÂÙÈο ÌÂϤÙË ·ÛıÂÓÒÓ/Ì·ÚÙ‡ÚˆÓ (35) Û 1507 ÂÚÈÙÒÛÂȘ O§§ ‰È·ÁÓˆÛı¤ÓÙˆÓ Û ËÏÈΛ· <2 ¯ÚfiÓˆÓ, ÙÔ ÈÛÙÔÚÈÎfi ‰‡Ô ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·Ô‚ÔÏÒÓ, Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, Û¯ÂÙÈ˙fiÙ·Ó Ì ÂÓÙ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ (p<0,001). ∆Ô ÈÛÙÔÚÈÎfi ıÓËÛÈÁÂÓÒÓ ÂÌ‚Ú‡ˆÓ ‹ ·˘ÙfiÌ·ÙˆÓ ·Ô‚ÔÏÒÓ ›Ûˆ˜ ‰Â›¯ÓÂÈ Î¿ÔÈ· ÎÔÈÓ‹ ÂÚÈ‚·ÏÏÔÓÙÈ΋ ¤ÎıÂÛË Î·È/‹ οÔÈ· ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ÁÂÓÂÙÈ΋ ·ÓˆÌ·Ï›· Ô˘ ‰‡Ó·Ù·È Ó· ¤¯ÂÈ ÔÈΛϘ ÂȉڿÛÂȘ ÛÙÔ ¤Ì‚Ú˘Ô (.¯. ·fi ıÓËÛÈÁÂÓ¤˜ ̤¯ÚÈ Ï¢¯·ÈÌ›·). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ˜ ¿ÏϘ Û˘Û¯ÂÙ›ÛÂȘ, Ì ‹ ¯ˆÚ›˜ ȉȷ›ÙÂÚË ÛËÌ·ÓÙÈÎfiÙËÙ·, Ì ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›·, fiˆ˜ Ë ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, Ë ÛÂÈÚ¿ Á¤ÓÓËÛ˘ ÙÔ˘ ·È‰ÈÔ‡, Ë ¤ÎıÂÛË Û ÂÓÙÔÌÔÎÙfiÓ· (Â·ÁÁÂÏÌ·ÙÈ΋ ‹ ÔÈÎȷ΋), Ë ¤ÎıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ Û ‰È·Ï˘ÙÈο Î·È ·Ú¿ÁˆÁ· ‚ÂÓ˙›Ó˘, Ë ¯Ú‹ÛË, Ì·ÚÈ¯Ô˘¿Ó·˜, ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ Î·È ¿ÏÏˆÓ ÔÚÌÔÓÒÓ ·fi ÙË ÌËÙ¤Ú· ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË (34,36,37).

Paediatriki 2001;64:535-546

ªË ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›· ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÂÎÊÚ¿ÛÙËÎ·Ó ÛΤ„ÂȘ ÁÈ· Èı·Ó‹ ηÚÎÈÓÔÁfiÓÔ Â›‰Ú·ÛË Ù˘ ÌË ÈÔÓ›˙Ô˘Û·˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È Ù· ·È‰È¿. Œ¯ÂÈ ÌÂÏÂÙËı› Ë Â›‰Ú·ÛË Ù˘ ¤ÎıÂÛ˘ Û ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›· (∂Ù ∏ª¶) (38), Û ÌÈÎÚÔ·̷ٷ ÙËÏÂÈÎÔÈÓˆÓÈ·ÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È Ú·‰ÈÔÙËÏÂÔÙÈÎÒÓ ÂÎÔÌÒÓ (39), Û ʈÙÔıÂÚ·›· (40) Î·È ¯Ú‹ÛË ˘ÂÚ‹¯ˆÓ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜ (41). ∆· Â˘Ú‹Ì·Ù· ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÓÙÈÊ·ÙÈο. ∂ȉÈÎfiÙÂÚ·, ÙËÓ ÙÂÏÂ˘Ù·›· 20ÂÙ›· ¤¯Ô˘Ó Á›ÓÂÈ ·ÚÎÂÙ¤˜ ÌÂÁ¿Ï˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ÛÙËÓ ∞ÌÂÚÈ΋ Î·È ÙËÓ ∂˘ÚÒË ·Ó·ÊÔÚÈο Ì ÙË Û¯¤ÛË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ÙËÓ ¤ÎıÂÛË Û ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ Ì·ÁÓËÙÈο ‰›· 50-60 Hz Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ÂÓ·¤ÚȘ ÁÚ·Ì̤˜ ÌÂÙ·ÊÔÚ¿˜ ˘„ËÏ‹˜ Ù¿Û˘, ·fi ηψ‰ÈÒÛÂȘ ÛÙȘ ηÙÔÈ˘ Î·È ·fi ÔÈÎȷΤ˜ ËÏÂÎÙÚÈΤ˜ Û˘Û΢¤˜. ∏ ÂÚ¢ÓËÙÈ΋ ·˘Ù‹ ÚÔÛ¿ıÂÈ· ηχÊıËΠ·fi Ù· ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ Ì ¤Ó· ¤ÏÔ Ì˘ÛÙËÚ›Ô˘, ·ÓÙÈı¤ÛÂˆÓ Î·È Û‡Á¯˘Û˘. ∏ ‰È·Ì¿¯Ë ÛÙËÓ ÂÈÛÙËÌÔÓÈ΋ ÎÔÈÓfiÙËÙ· ‹Ù·Ó ¤ÓÙÔÓË Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ˘ÂÚ‚ÔÏÈ΋. ∞ÎfiÌË Î·È Ë ∂ıÓÈ΋ ∞η‰ËÌ›· ∂ÈÛÙËÌÒÓ Ù˘ ∞ÌÂÚÈ΋˜ ÙÔ ¡Ô¤Ì‚ÚÈÔ ÙÔ˘ 1997, ÂÓÒ ‰ËÌÔÛÈÔÔ›ËÛ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ÎÈÓ‰‡ÓÔ˘, ˘ÔÛÙ‹ÚÈÍÂ Û˘Á¯ÚfiÓˆ˜ ÙËÓ ÂÚ·ÈÙ¤Úˆ ÂÚ¢ÓËÙÈ΋ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· (42). “∏ÏÂÎÙÚÈΤ˜ ÁÚ·Ì̤˜, ηÚΛÓÔ˜ Î·È Êfi‚Ô˜” ‹Ù·Ó Ô Ù›ÙÏÔ˜ ·ÚÈÔ˘ ¿ÚıÚÔ˘ ÛÙÔ New England Journal of Medicine ÛÙȘ 3 πÔ˘Ï›Ô˘ 1997 (43). OÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜ ÈÛ¯˘Ú›ÛÙËÎ·Ó fiÙÈ Ë ‰È·ÌÔÓ‹ ÎÔÓÙ¿ Û ÁÚ·Ì̤˜ ˘„ËÏÔ‡ ÊÔÚÙ›Ô˘ (˘ÏÒÓ˜, ÁÚ·Ì̤˜ ˘„ËÏ‹˜ Ù¿Û˘ Î.Ï.) ÚÔηÏ› ηÚΛÓÔ Î·È ÂȉÈÎfiÙÂÚ· Ï¢¯·ÈÌ›· ÛÙ· ·È‰È¿ (44). ÕÌÂÛ·, ÔÈÎÔÏÔÁÈΤ˜ ÔÚÁ·ÓÒÛÂȘ Î·È Ù· ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ ¿Ú¯ÈÛ·Ó Ó· ‰È·‰›‰Ô˘Ó ÙËÓ Â›‰ËÛË fiÙÈ Ù· ∂Ù ∏ª¶ ÚÔηÏÔ‡Ó Î·ÚΛÓÔ. OÈ Ù˘¯ÈÔ‡¯ÔÈ º˘ÛÈ΋˜ ÁÓˆÚ›˙Ô˘Ó ·˘Ù¿ Ù· ·fiÚ·Ù· ‰›· ηϿ, ·ÏÏ¿ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ›, ÁÔÓ›˜ Î·È ·ÛıÂÓ›˜ fi¯È. ∏ ΛÓËÛË ÙˆÓ ËÏÂÎÙÚÈÎÒÓ ÊÔÚÙ›ˆÓ ‰ËÌÈÔ˘ÚÁ› ¤Ó· Ì·ÁÓËÙÈÎfi ÊÔÚÙ›Ô Ô˘ ÌÔÚ› Ó· ÌÂÙÚËı›. ∞ÎfiÌË Î·È ÙˆÓ 60 Hz (ÛÙËÓ ∞ÌÂÚÈ΋) ‹ 50 Hz (ÛÙËÓ ∂˘ÚÒË) ËÏÂÎÙÚÈÎfi Ú‡̷ ÙˆÓ ¯ÒÚˆÓ ‰È·ÌÔÓ‹˜ ‰ËÌÈÔ˘ÚÁ› ¤Ó· Ôχ ·ÛıÂÓ¤˜ ‰›Ô, ÙÔ ÔÔ›Ô - fiˆ˜ fiÏ· Ù· Ì·ÁÓËÙÈο ‰›· - ‰È·ÂÚÓ¿ ˙ˆÓÙ·ÓÔ‡˜ ÈÛÙÔ‡˜. ∞˘Ù¿ Ù· ∂Ù ∏ª¶ Â›Ó·È ÁÓˆÛÙ¿ Û·Ó ÌË ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·, ·ÊÔ‡ ÙÔ ÔÛÔÛÙfi ÂÓ¤ÚÁÂÈ·˜ Ô˘ ʤÚÔ˘Ó Â›Ó·È Î·Ù¿ Ôχ ¯·ÌËÏfiÙÂÚÔ ·fi ÂΛÓÔ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· Ó· ‰È·Û¿ÛÂÈ ÌÔÚÈ·ÎÔ‡˜ ‰ÂÛÌÔ‡˜, fiˆ˜ ·˘ÙÔ‡˜ ÛÙÔ DNA. ¶Ú·ÁÌ·ÙÈο, Â›Ó·È ÂÓÙ˘ˆÛÈ·Îfi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÓËÛ˘¯Ô‡Ì ÁÈ· Ù· ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜

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Û˘¯ÓfiÙËÙ·˜ ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›· fiÙ·Ó ˙ԇ̠̤۷ ÛÙÔ Á‹ÈÓÔ ÛÙ·ÙÈÎfi Ì·ÁÓËÙÈÎfi ‰›Ô ¤ÓÙ·Û˘ 50 Ì∆ Ô˘ Â›Ó·È ÂηÙÔÓÙ¿‰Â˜ ÊÔÚ¤˜ ÈÛ¯˘ÚfiÙÂÚÔ ·fi ÙÔ Ì·ÁÓËÙÈÎfi ‰›Ô ¤ÓÙ·Û˘ 0,01 ¤ˆ˜ 0,05 Ì∆ Ô˘ ·Ú¿ÁÂÙ·È ·fi ÙÔ ËÏÂÎÙÚÈÎfi Ú‡̷ 110/220 V ÛÙ· Û›ÙÈ·. ∞ÎfiÌË Î·È ·ÎÚÈ‚Ò˜ οو ·fi Ì›· ÁÚ·ÌÌ‹ ˘„ËÏ‹˜ Ù¿Û˘, ÙÔ Ì·ÁÓËÙÈÎfi ‰›Ô Â›Ó·È ÌfiÓÔ 3 ¤ˆ˜ 10 Ì∆ ¯·ÌËÏfiÙÂÚÔ ·fi ÂΛÓÔ Ì¤Û· Û ¤Ó· fi¯ËÌ· ËÏÂÎÙÚÈÎÔ‡ ÙÚ¤ÓÔ˘ Î·È Î·Ù¿ Ôχ ·ÛıÂÓ¤ÛÙÂÚÔ ÂΛÓÔ˘ Ô˘ ·Ú¿ÁÂÙ·È ÛÙÔ ÎÂÊ¿ÏÈ Î·Ù¿ ÙË ¯Ú‹ÛË ËÏÂÎÙÚÈ΋˜ ͢ÚÈÛÙÈ΋˜ Ì˯·Ó‹˜ (ÂÚ›Ô˘ 60 Ì∆). ∂ÓÒ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ º˘ÛÈÎÒÓ ıˆÚÔ‡Ó ·›ÛÙ¢ÙË ÙËÓ ¿Ô„Ë fiÙÈ Ù· ∂Ù ∏ª¶ Â›Ó·È ·ÂÈÏ‹ ÁÈ· ÙËÓ ˘Á›· ÙˆÓ ·ÓıÚÒˆÓ, ‰Âο‰Â˜ ÂȉËÌÈÔÏÔÁÈÎÒÓ ÌÂÏÂÙÒÓ ·Ó¤ÊÂÚ·Ó ·ÛıÂÓ›˜ ıÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηÚΛÓÔ Î·È Ù˘ ÁÂÈÙÓ›·Û˘ Ì ÁÚ·Ì̤˜ ˘„ËÏ‹˜ Ù¿Û˘. OÈ ·ÚÓËÙÈΤ˜ ‹ ·Û·Ê›˜ ÌÂϤÙ˜ ‰ÂÓ ¤ÎÏÂÈÛ·Ó ÙËÓ ·ÓÙ›ıÂÛË. ™ËÌÂÈÒÓÂÙ·È fiÙÈ, ÂÂȉ‹ ‰ÂÓ ˘¿Ú¯Ô˘Ó Ô˘ÛÈ·ÛÙÈο ÌË ÂÎÙÂıÂÈ̤ÓÔÈ Û ‰›· ËÏÂÎÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ, Ë Ú·ÁÌ·ÙÈ΋ Û‡ÁÎÚÈÛË Â›Ó·È ÌÂٷ͇ “˘„ËÏ¿ ÂÎÙÂıÂÈ̤ӈӔ Î·È “¯·ÌËÏ¿ ÂÎÙÂıÂÈ̤ӈӔ. OÈ ·Ú¯ÈΤ˜ ÌÂϤÙ˜ Ô˘ ˘ÔÛÙ‹ÚÈÍ·Ó ÙË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ËÏÂÎÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ Î·È ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙÔ Û˘Ó‰˘·ÛÌfi ÙÔ˘ Ù‡Ô˘ ÙˆÓ Î·Ïˆ‰ÈÒÛÂˆÓ Î·È ÙËÓ ·fiÛÙ·ÛË ·fi ÙÔ Û›ÙÈ Û·Ó ÂÌÂÈÚÈÎfi ̤ÙÚÔ ¤ÎıÂÛ˘, ¤Ó· Û‡ÛÙËÌ· Ô˘ ÔÓÔÌ¿ÛÙËΠ“Έ‰ÈÎÔ› ηψ‰›ˆÓ” (44). ÕÏϘ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔ›ËÛ·Ó Û·Ó Ì¤ÙÚÔ ¤ÎıÂÛ˘ ÙËÓ ·fiÛÙ·ÛË ·fi ÙȘ ÁÚ·Ì̤˜ ÌÂÙ·ÊÔÚ¿˜ ‹ ÙÔ˘˜ ˘ÔÛÙ·ıÌÔ‡˜, ¿ÌÂÛ˜ ÌÂÙÚ‹ÛÂȘ ‰›ˆÓ ‹ ˘ÔÏÔÁÈÛı¤ÓÙ· ·Ó·‰ÚÔÌÈο ‰›· (ÚÔÙ˘ÔÔÈË̤Ó˜ ÌÂÙÚ‹ÛÂȘ) (45). ∫·Ì›· ·fi ÙȘ ÌÂÙÚ‹ÛÂȘ ¤ÎıÂÛ˘ ‰ÂÓ ˘ÂÚ¤¯ÂÈ Û·ÊÒ˜ ÙˆÓ ¿ÏÏˆÓ Î·È Î·Ì›· ‰ÂÓ Â›Ó·È ÎÔÈÓ‹ ÁÈ· ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ÌÂϤÙ˜. πÛÙÔÚÈο, ¤Ó· ·fi Ù· ÂÚÈÛÛfiÙÂÚÔ ·ÈÓÈÁÌ·ÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌÂÏÂÙÒÓ ÁÈ· ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· ‹Ù·Ó ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û˘Û¯¤ÙÈÛË Ù˘ “¤ÎıÂÛ˘” Ì ÙËÓ Â›ÙˆÛË ÙÔ˘ ηÚΛÓÔ˘ ÂÌÊ·ÓÈ˙fiÙ·Ó ˘„ËÏfiÙÂÚË fiÙ·Ó Ô Ù‡Ô˜ ÙˆÓ Î·Ïˆ‰›ˆÓ ‹ Ë ÁÂÈÙÓ›·ÛË Ì ÙȘ ÁÚ·Ì̤˜ ‹Ù·Ó ÙÔ Ì¤ÙÚÔ ¤ÎıÂÛ˘ Î·È fi¯È fiÙ·Ó ÁÈÓfiÙ·Ó ¿ÌÂÛË Ì¤ÙÚËÛË ÙˆÓ ‰›ˆÓ ÛÙ· Û›ÙÈ·. ∞˘Ùfi Ô‰‹ÁËÛ ÛÙËÓ ˘fiıÂÛË fiÙÈ Ë Û˘Û¯¤ÙÈÛË ÙÔ˘ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ Ì ÙË ‰È·ÌÔÓ‹ ÎÔÓÙ¿ Û ËÏÂÎÙÚÔÊfiÚ˜ ÁÚ·Ì̤˜ ı· ÌÔÚÔ‡Û ӷ ÔÊ›ÏÂÙ·È Û ¿ÏÏÔ ·Ú¿ÁÔÓÙ· Î·È fi¯È ÛÙËÓ ¤ÎıÂÛË ÛÙ· ‰›· ·˘Ù¿. °È· ·Ú¿‰ÂÈÁÌ·, ˘ÔÛÙËÚ›¯ıËΠfiÙÈ Ë ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ Ù¿ÍË ı· ÌÔÚÔ‡Û ӷ Â›Ó·È ¤Ó·˜ Û˘Ì·Ú¿ÁÔÓÙ·˜ Î·È “ÂÎÙÂıÂÈ̤Ó˜” Î·È “ÌË ÂÎÙÂıÂÈ̤Ó˜” ÔÌ¿‰Â˜ ›Ûˆ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ‰È·ÊÔÚÂÙÈΤ˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ Ù¿ÍÂȘ. ∞˘Ùfi ·ÊÔÚ¿ ȉȷ›ÙÂÚ· ÙȘ ÌÂϤÙ˜ ÔÈÎȷ΋˜ ¤ÎıÂÛ˘ ÛÙËÓ ∞ÌÂÚÈ΋ Ô˘ ‚·Û›˙ÔÓÙ·È

542

Paediatriki 2001;64:535-546

ÛÙËÓ Îˆ‰ÈÎÔÔ›ËÛË ÙˆÓ Î·Ïˆ‰ÈÒÛÂˆÓ Û·Ó Ì¤ÙÚÔ ¤ÎıÂÛ˘ Î·È Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ Ù‡ÔÈ Î·Ïˆ‰›ˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ·È‰ÈÎfi ηÚΛÓÔ ·Ó¢ڛÛÎÔÓÙ·È Î˘Ú›ˆ˜ Û ·ÏȤ˜ ÊÙˆ¯È¤˜ Û˘ÓÔÈ˘ ηÈ/‹ ÛÂ Û˘ÓÔÈ˘ Ì „ËÏfi ÔÛÔÛÙfi ÂÓÔÈÎÈ·˙fiÌÂÓˆÓ ÛÈÙÈÒÓ (46). ¶ÚÔÛ¿ıÂȘ Ô˘ ¤ÁÈÓ·Ó ÁÈ· Ì›· ÁÂÓÈ΋ ·Ó·ÛÎfiËÛË ·˘ÙÒÓ ÙˆÓ ÌÂÏÂÙÒÓ ·¤Ù˘¯·Ó, ÂÂȉ‹ ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ù‹ Ë “ÔÌÔÁÂÓÔÔ›ËÛË” ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÂÊ’ fiÛÔÓ ÔÈ ‰È¿ÊÔÚÔÈ ÙÚfiÔÈ ÂÎÙ›ÌËÛ˘ Ù˘ ¤ÎıÂÛ˘ ‰ÂÓ ÂÈÙÚ¤Ô˘Ó ÙË Û˘ÓÔÏÈ΋ ·ÔÙ‡ˆÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ∆Ô 1996, ÙÔ ∂ıÓÈÎfi ™˘Ì‚Ô‡ÏÈÔ ŒÚ¢ӷ˜ Ù˘ ∞ÌÂÚÈ΋˜ (NRC) ·ÚÔ˘Û›·Û ÙȘ Â›ÛË̘ ı¤ÛÂȘ ÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·fi 500 Î·È ϤÔÓ ÌÂϤÙ˜ ¤ÎıÂÛ˘ Û ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›·. ∏ ÂÈÙÚÔ‹ ÂÂÍÂÚÁ¿ÛÙËΠÙËÓ ϤÔÓ ÏÂÙÔÌÂÚ‹ Î·È ÂÚ›ÏÔÎË ÌÂÙ·-·Ó¿Ï˘ÛË ÌÂÏÂÙÒÓ, ̤¯ÚÈ ÙÔ 1996, Û ÂÈÚ·Ì·Ùfi˙ˆ·, in vitro ÌÂϤÙ˜ Î·È ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Û ·ÓıÚÒÔ˘˜. O Úfi‰ÚÔ˜ Ù˘ ÂÈÙÚÔ‹˜ ·Ó·ÎÔ›ÓˆÛ (47) fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË fiÙÈ Ù· ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›· ÂÍ·ÈÚÂÙÈο ¯·ÌËÏÒÓ Û˘¯ÓÔًوÓ, ‰ËÏ·‰‹ ÛÙÔ Â›Â‰Ô ÙˆÓ ÔÈÎÈ·ÎÒÓ ÂÎı¤ÛˆÓ, ÚÔηÏÔ‡Ó Î·ÚΛÓÔ ‹ ¤¯Ô˘Ó ÂÈ‚Ï·‚›˜ Û˘Ó¤ÂȘ ÛÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ÙËÓ ·Ó··Ú·ÁˆÁ‹ Î·È ·Ó¿Ù˘ÍË. ∂ÓÙÔ‡ÙÔȘ, ·Ú·Ì¤ÓÂÈ ·ÓÂÍ‹ÁËÙË Ì›· ·ÛıÂÓ‹˜, ·ÏÏ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋, Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ¤ÎıÂÛ˘ Û Ôχ ˘„ËÏ¿ (>0,4 Ì∆) Â›‰· ¤ÓÙ·Û˘ Ì·ÁÓËÙÈÎÒÓ ‰›ˆÓ, Ù· ÔÔ›· fï˜ ·ÊÔÚÔ‡Ó ÂÏ¿¯ÈÛÙÔ ·ÚÈıÌfi ÔÈÎÈ·ÎÒÓ ÂÎı¤ÛˆÓ. ∏ ÂÈÙÚÔ‹ ‰ÂÓ ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ Ë ¤ÎıÂÛË ÚÔηÏ› ÙË Ï¢¯·ÈÌ›· ÛÙ· ·È‰È¿, ·ÏÏ¿ ÙÔ Â‡ÚËÌ· ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙË ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÚfiÔÈ ÂÎÙ›ÌËÛ˘ Ù˘ ¤ÎıÂÛ˘, ËÏÈΛ· ÙÔ˘ ÛÈÙÈÔ‡, Ú‡·ÓÛË Ù˘ ·ÙÌfiÛÊ·ÈÚ·˜, ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ ∞ÌÂÚÈ΋ ÙˆÓ Linet Î·È Û˘Ó (48) Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË Û ̤ÁÂıÔ˜ Û˘ÓÂÚÁ·ÙÈ΋ ÌÂϤÙË ÙÔ˘ πÓÛÙÈÙÔ‡ÙÔ˘ ∫·ÚΛÓÔ˘ Ù˘ ∞ÌÂÚÈ΋˜ (NCI) Î·È Ù˘ ÔÌ¿‰·˜ ÌÂϤÙ˘ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ (CCSG). ∏ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ÌÂϤÙ˘ ¤‰ÂÈÍ fiÙÈ ‰ÂÓ ˘Ê›ÛÙ·Ù·È ¤Ó‰ÂÈÍË ÔÔÈ·Û‰‹ÔÙÂ Û˘Û¯¤ÙÈÛ˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ¤ÎıÂÛ˘ Û ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›·, ·ÎfiÌË Î·È ÁÈ· Ôχ ˘„ËϤ˜ ÂÓÙ¿ÛÂȘ ¿Óˆ ÙˆÓ 0,4 Ì∆. ™ÙË Û˘ÁÎÚÈÙÈ΋ ·˘Ù‹ ÌÂϤÙË, ÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó¤ÊÂÚ·Ó fiÙÈ ·È‰È¿ Ô˘ ‰È¤ÌÂÓ·Ó Û Û›ÙÈ· Ù· ÔÔ›· Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ˘„ËϤ˜ ηÙËÁÔڛ˜ ¤ÎıÂÛ˘ Ì ‚¿ÛË ÙÔ˘˜ “Έ‰ÈÎÔ‡˜ ηψ‰ÈÒÛˆӔ Ô˘ Â›Ó·È Î·Ù¿ ÚÔÛ¤ÁÁÈÛË Ì¤ÙÚÔ ¤ÎıÂÛ˘ Û ̷ÁÓËÙÈο ‰›· Î·È ‚·Û›˙ÂÙ·È ÛÙÔ ¿¯Ô˜, ÙË ‰È¿Ù·ÍË Î·È ÙËÓ ·fiÛÙ·ÛË ÙˆÓ ËÏÂÎÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ ·fi ÙÔ ¯ÒÚÔ ‰È·ÌÔÓ‹˜, ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

·˘ÍË̤ÓË Â›ÙˆÛË Ï¢¯·ÈÌ›·˜. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ¤Ú¯ÔÓÙ·È Û ۷ʤÛÙ·ÙË ·ÓÙ›ıÂÛË Ì ÙÔ ÙÂÏÈÎfi Û˘Ì¤Ú·ÛÌ· Ù˘ ·Ó¿Ï˘Û˘ Ù˘ ∂ıÓÈ΋˜ ∞η‰ËÌ›·˜ ∂ÈÛÙËÌÒÓ (42) Ô˘ η٤ÏËÁ Ì ÙËÓ ¿Ô„Ë fiÙÈ Ë ÂÏ¿¯ÈÛÙË ÂȉËÌÈÔÏÔÁÈ΋ ¤Ó‰ÂÈÍË ÁÈ· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ηÚΛÓÔ˘ Î·È ËÏÂÎÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ, Â¿Ó ˘¿Ú¯ÂÈ, ‹Ù·Ó ·˘Ù‹ ÌÂٷ͇ Ôχ ˘„ËÏÒÓ ÂÎı¤ÛÂˆÓ Î·È Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ·ÓˆÙ¤Úˆ ·Ó¿Ï˘ÛË ·Ó¤ÊÂÚ ۯÂÙÈÎfi ΛӉ˘ÓÔ 1,5 Ì fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O∞) 1,2 ¤ˆ˜ 1,8. ªÂ ·ÚfiÌÔÈÔ ÔÚÈÛÌfi ¤ÎıÂÛ˘, Ë ÌÂϤÙË ·fi ÙÔ ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ∫·ÚΛÓÔ˘ (NCI / CCSG, 48) ‰›ÓÂÈ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ 1,0 (O∞ 0,7-1,3). ™Ê¿ÏÌ·Ù· ηٿ ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ΢ڛˆ˜ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë Ì¤ıÔ‰Ô˜ Ù˘ Ù˘¯·›·˜ ÙËÏÂʈÓÈ΋˜ ÂÈÏÔÁ‹˜, Â›Ó·È Èı·ÓfiÓ Ó· ÂËÚ¤·Û·Ó Ù· ‰Â‰Ô̤ӷ Ì ÙËÓ ÂÈÛ·ÁˆÁ‹ Ì·ÚÙ‡ÚˆÓ ·fi ˘„ËÏfiÙÂÚ˜ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο Ù¿ÍÂȘ. ∏ Ù·˘Ùfi¯ÚÔÓË Â›‰Ú·ÛË Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›· Ú¤ÂÈ Ó· ÂÎÙÈÌËı› Ì ȉȷ›ÙÂÚË ÚÔÛÔ¯‹. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰È¿ÊÔÚ˜ ÂÈÙÚÔ¤˜ Î·È ÔÌ¿‰Â˜ ÂȉÈÎÒÓ ¤¯Ô˘Ó ηٷϋÍÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÂÈÛÙÈ΋ ¤Ó‰ÂÈÍË ÁÈ· ÂÈ‚Ï·‚›˜ ÂȉڿÛÂȘ ÛÙËÓ ·ÓıÚÒÈÓË ˘Á›· ‹ ÚfiÎÏËÛË Î·ÚΛÓÔ˘ ·fi ÙȘ ÁÚ·Ì̤˜ ÌÂÙ·ÊÔÚ¿˜ ˘„ËÏ‹˜ Ù¿Û˘. OÈ ÛˆÛÙ¿ ۯ‰ȷṲ̂Ó˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, fiˆ˜ Ë ·ÓˆÙ¤Úˆ ·fi ÙËÓ Linet Î·È Û˘Ó (48) ηٷϋÁÔ˘Ó ÛÙÔ ›‰ÈÔ ·ÎÚÈ‚Ò˜ Û˘Ì¤Ú·ÛÌ·. ∆Ë ‰ÈÂÙ›· 1993-94 Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙË ¯ÒÚ· Ì·˜ ·ÚfiÌÔÈ· ÌÂϤÙË, Û ÂıÓÈÎfi Â›‰Ô, Ì ÛÎÔfi ÙË ‰È·›ÛÙˆÛË ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›· ÛÙË ¯ÒÚ· Ì·˜. ∆Ô ÚˆÙfiÎÔÏÏÔ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ·ÚfiÌÔÈÔ Ì ÂΛÓÔ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ·Ú¿ÏÏËϘ ÌÂϤÙ˜ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó Û˘Á¯ÚfiÓˆ˜ Û ¿ÏϘ ∂˘Úˆ·˚Τ˜ ¯ÒÚ˜. π‰È·›ÙÂÚË ¤ÌÊ·ÛË ‰fiıËΠÛÙÔÓ ÙÔ̤· ÙˆÓ ËÏÂÎÙÚÔÌ·ÁÓËÙÈÎÒÓ ‰›ˆÓ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙË ¢ËÌfiÛÈ· ∂ȯ›ÚËÛË ∏ÏÂÎÙÚÈÛÌÔ‡ (¢∂∏) Ô˘ ÂÎÙ›ÌËÛ ÙÔ˘˜ ‰Â›ÎÙ˜ ¤ÎıÂÛ˘ ÌÂ Ù˘ÊÏfi ¤ÏÂÁ¯Ô. O˘ÛÈ·ÛÙÈο ‰ÂÓ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔÈ Î›Ó‰˘ÓÔÈ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‰È·Ì¤ÓÔ˘Ó Û ÂÚÈÔ¯¤˜ ˘„ËÏ‹˜ ηÙËÁÔÚ›·˜ ¤ÎıÂÛ˘ ËÏÂÎÙÚÈÎÒÓ Î·È Ì·ÁÓËÙÈÎÒÓ ‰›ˆÓ Î·È Ë Û˘ÓÔÏÈ΋ ¤ÎÊÚ·ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Â›Ó·È Û˘Ì‚·Ù‹ Ì ٷ ‰Â‰Ô̤ӷ ·Ï·ÈfiÙÂÚˆÓ ÂÚ¢ÓËÙÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó Û ÚfiÛÊ·ÙË ∞ÌÂÚÈηÓÈ΋ ¤ÎıÂÛË. ™·Ê¤ÛÙÂÚ· ‹Ù·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Û ۯ¤ÛË Ì ÙȘ ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂÎı¤ÛÂȘ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ÔÈ Ôԛ˜ ‹Ù·Ó Û·ÊÒ˜ ·Ó‡·ÚÎÙ˜. O‡Ù ÔÈ ·ÎÙÈÓÔÁڷʛ˜ ηٿ ÙËÓ Î‡ËÛË, Ô˘ Á›ÓÔÓÙ·È Û¿ÓÈ·, Ô‡ÙÂ Ë Ôχ Û˘¯Ó‹ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Û¯ÂÙ›ÛÙËÎ·Ó Ì ·È‰È΋ Ï¢¯·ÈÌ›· Î·È Ë ‰È·ÌÔÓ‹ ÛÙÔ ÈÛfiÁÂÈÔ ˆ˜

Paediatriki 2001;64:535-546

‰Â›ÎÙ˘ Èı·Ó‹˜ ¤ÎıÂÛ˘ Û ڷ‰fiÓÈÔ ‰ÂÓ ‚Ú¤ıËÎ·Ó Ó· ·ÔÙÂÏÔ‡Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›·. ∂ÈϤÔÓ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Ô˘ ÂÚ‡ÓËÛ·Ó ÙË Û¯¤ÛË ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ Î·È ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ‰ÂÓ ·Ó¤ÊÂÚ·Ó Û˘Û¯¤ÙÈÛË. ∏ ¯Ú‹ÛË ËÏÂÎÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Î·È ÛÙÂÁÓˆÙ‹Ú· Ì·ÏÏÈÒÓ ·Ú¿ÁÂÈ ˘„ËÏ‹˜ ¤ÓÙ·Û˘ ËÏÂÎÙÚÔÌ·ÁÓËÙÈο ‰›·, ·ÏÏ¿ ÔÈ Û˘Û¯ÂÙ›ÛÂȘ Ô˘ ÛËÌÂÈÒıËÎ·Ó ÛÙË ÌÂϤÙË ‹Ù·Ó ÂÏ¿¯ÈÛÙ˜ Î·È ÛÙ·ÙÈÛÙÈο ÌË ÛËÌ·ÓÙÈΤ˜, fiˆ˜ ·Ó¤ÊÂÚ·Ó Î·È ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (49). ∏ ·Ó·ÌÂÓfiÌÂÓË, Â‰Ò Î·È ¯ÚfiÓÈ·, ÌÂϤÙË ·fi ÙË µÚÂÙ·ÓÈ΋ ÔÌ¿‰· ÌÂϤÙ˘ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ (UKCCSG) ‰ËÌÔÛȇıËΠÛÙȘ 4 ¢ÂÎÂÌ‚Ú›Ô˘ ÙÔ˘ 1999 (50) ÛÙÔ Lancet. ¶ÚfiÎÂÈÙ·È ÁÈ· ÌÂÁ¿ÏË Û˘ÓÂÚÁ·ÙÈ΋ ÌÂϤÙË Ô˘ ·ÊÔÚ¿ 2226 ‚·ÛÈΤ˜ ÂÚÈÙÒÛÂȘ Ï¢¯·ÈÌ›·˜ ·È‰È΋˜ ËÏÈΛ·˜ Î·È ›‰ÈÔ ·ÚÈıÌfi Ì·ÚÙ‡ÚˆÓ. ∏ ÂÎÙ›ÌËÛË Ù˘ ¤ÎıÂÛ˘ ¤ÁÈÓ Ì ÌÂÙÚ‹ÛÂȘ ÛÙÔ Û›ÙÈ Î·È ÙÔ Û¯ÔÏÂ›Ô Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÛÙ¿ıÌÈÛË ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ ·˘ÙÒÓ Ì ÚÔÙ˘ÔÔÈË̤Ó˜ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ÊÔÚÙ›ˆÓ ÙˆÓ ËÏÂÎÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ Î·È ÙˆÓ ‰›ˆÓ ÙˆÓ ËÏÂÎÙÚÈÎÒÓ Û˘Û΢ÒÓ ÁÈ· ¤Ó· ¯ÚfiÓÔ ÚÈÓ ÙË ‰È¿ÁÓˆÛË. °È· ·È‰È¿ Ì ‰È¿ÌÂÛË ¤ÎıÂÛË >0,2 Ì∆ Û ۇÁÎÚÈÛË Ì ·È‰È¿ Ì ‰È¿ÌÂÛË ¤ÎıÂÛË <0,1 Ì∆, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ‹Ù·Ó: - 0,92 (95% O∞ 0,47-1,79) ÁÈ· ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· - 0,90 (95% O∞ 0,49-1,63) ÁÈ· fiϘ ÙȘ Ï¢¯·È̛˜ - 0,46 (95% O∞ 0,11-1,86) ÁÈ· fiÁÎÔ˘˜ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ - 0,97 (95% O∞ 0,46-2,05) ÁÈ· ¿ÏÏÔ˘˜ Û˘Ì·Á›˜ fiÁÎÔ˘˜ - 0,87 (95% O∞ 0,47-1,79) ÁÈ· ·È‰ÈÎfi ηÚΛÓÔ ÁÂÓÈο. À„ËϤ˜ ÂÎı¤ÛÂȘ (>0,4 Ì∆) ·Ó·Ê¤ÚıËÎ·Ó ÌfiÓÔ Û 17 (<0,4%) ·È‰È¿ (8 ÂÚÈÙÒÛÂȘ, 9 Ì¿ÚÙ˘Ú˜). ∏ ÌÂϤÙË ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ÁÈ· Û˘Û¯¤ÙÈÛË ¤ÎıÂÛ˘ Û ̷ÁÓËÙÈο ‰›·, ÔÊÂÈÏfiÌÂÓ· Û ·ÚÔ¯¤˜ ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Î·È ·˘ÍËÌ¤ÓˆÓ ÎÈÓ‰‡ÓˆÓ ÁÈ· Ï¢¯·ÈÌ›·, fiÁÎÔ˘˜ ÂÁÎÂÊ¿ÏÔ˘ ‹ ÔÔÈ·‰‹ÔÙ ¿ÏÏË ÌÔÚÊ‹ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘. ∏ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ (WHO), Û ۯfiÏÈfi Ù˘ Ô˘ ‰ËÌÔÛȇÂÙ·È Û˘Á¯ÚfiÓˆ˜ (51), ‰¤¯ÂÙ·È fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÌÂÁ¿ÏË Î·È ÛˆÛÙ¿ ‰ÔÌË̤ÓË ÌÂϤÙË, ·ÏÏ¿ ‰ÂÓ ÙË ıˆÚ› “ηıÔÚÈÛÙÈ΋” fiˆ˜ ›ÛÙ¢·Ó ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ Î·È ÂȉËÌÈÔÏfiÁÔÈ. O ÚÒÙÔ˜ ÏfiÁÔ˜ Â›Ó·È fiÙÈ Ë ÌÂϤÙË Û¯Â‰È¿ÛÙËΠÔÏÏ¿ ¯ÚfiÓÈ· ÚÈÓ (·fi ÙÔ 1988) Î·È ¤ÙÛÈ Ë ÂÎÙ›ÌËÛË Ù˘ ¤ÎıÂÛ˘ ‚·Û›ÛÙËΠ̤۠Û˜ - ‰È·¯ÚÔÓÈο - ÙÈ̤˜ ‰›ˆÓ (time-weighted average, TWA). ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ηٿ ÙÔ ·ÚÂÏıfiÓ ·ÏÏ¿ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì οÔÈÔ Ì˯·ÓÈÛÌfi Â›‰Ú·Û˘ ÙˆÓ

543

¶·È‰È·ÙÚÈ΋ 2001;64:535-546

¯·ÌËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ‰›ˆÓ ÛÙÔ˘˜ ÈÛÙÔ‡˜. ∏ WHO ÁÈ· ÌÂÏÏÔÓÙÈΤ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Î·È ÁÈ· ÏfiÁÔ˘˜ Û‡ÁÎÚÈÛ˘ Û˘ÓÈÛÙ¿ ÙËÓ TWA Û·Ó Ì¤ıÔ‰Ô ÂÎÙ›ÌËÛ˘, ·ÏÏ¿ ··Ú·Èًو˜ ÙÔ ÚˆÙfiÎÔÏÏÔ ÂÎÙ›ÌËÛ˘ Ù˘ ¤ÎıÂÛ˘ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ¿ÏÏÔ˘˜ ÙÚfiÔ˘˜ ̤ÙÚËÛ˘ Ù˘ ¤ÎıÂÛ˘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ˘˜ ÁÓˆÛÙÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Â›‰Ú·Û˘ ÙˆÓ ‰›ˆÓ ·˘ÙÒÓ (52). O ‰Â‡ÙÂÚÔ˜ ÏfiÁÔ˜ Â›Ó·È Ô ¯·ÌËÏfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ÛÙȘ ˘„ËÏfiÙÂÚ˜ ηÙËÁÔڛ˜ ¤ÎıÂÛ˘. ™‡Ìʈӷ Ì ÙËÓ ·ÓˆÙ¤Úˆ ÌÂϤÙË, ÌfiÓÔ 2,3% ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÂÎÙ¤ıËΠ̷۠ÁÓËÙÈο ‰›· >0,2 Ì∆. ∞Ó Î·È ·˘Ùfi ÙÔ ÔÛÔÛÙfi Â›Ó·È ·ÚfiÌÔÈÔ Ì ÂΛÓÔ Ù˘ °ÂÚÌ·Ó›·˜ (2%) (53), ÛÙË ÌÂϤÙË Ù˘ ∞ÌÂÚÈ΋˜ (48) ‹Ù·Ó 11,4% Î·È ÛÙËÓ ∫·Ó·‰È΋ ÌÂϤÙË 15,4% (54). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÌÂٷ͇ ÙˆÓ ‰‡Ô ËÂ›ÚˆÓ ·ÓÙ·Ó·ÎÏ¿ fi¯È ÌfiÓÔ ÙË ‰È·ÊÔÚ¿ Ù¿Û˘ ÛÙ· ‰‡Ô Û˘ÛÙ‹Ì·Ù· ·ÚÔ¯‹˜ ËÏÂÎÙÚÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (110 V ¤Ó·ÓÙÈ 220 V) ·ÏÏ¿ Î·È ÙË ‰È·ÓÔÌ‹ ÙÔ˘ Ú‡̷ÙÔ˜ Û ۯ¤ÛË Ì ÙȘ ηψ‰ÈÒÛÂȘ Î·È ÙË Á›ˆÛË ÙˆÓ ·ÚÔ¯ÒÓ. ¶ÚfiÛÊ·Ù·, Â›Û˘, ‰ËÌÔÛȇÙËÎ·Ó Ù· ‰Â‰Ô̤ӷ ‰‡Ô Ó¤ˆÓ ÌÂÏÂÙÒÓ ·fi ÙË ¡¤· ∑ËÏ·Ó‰›· (55) Î·È ÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ OÓÙ¿ÚÈÔ ÙÔ˘ ∫·Ó·‰¿ (56). ∏ ÚÒÙË ·ÚÔ˘ÛÈ¿˙ÂÈ ÙȘ ›‰È˜ ·Ù¤ÏÂȘ fiˆ˜ Î·È Ë µÚÂÙ·ÓÈ΋, Û‡Ìʈӷ Ì ÙÔ Û¯ÔÏÈ·ÛÌfi Ù˘ WHO, ·ÏÏ¿ Ù·˘Ùfi¯ÚÔÓ· ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ‰ÂÓ ˘Ê›ÛÙ·Ù·È ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ï¢¯·ÈÌ›·˜ Î·È Ì¤ÛˆÓ - ‰È·¯ÚÔÓÈο - ÙÈÌÒÓ Ì·ÁÓËÙÈÎÒÓ ‹ ËÏÂÎÙÚÈÎÒÓ ‰›ˆÓ 50 Hz ÛÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ Î·ıÈÛÙÈÎfi Û˘Ó‰˘·Ṳ̂ӷ. ∏ ‰Â‡ÙÂÚË ·Ó·Ê¤ÚÂÈ fiÙÈ Ù· Â˘Ú‹Ì·Ù¿ ÙÔ˘˜ ‰ÂÓ ˘ÔÛÙËÚ›˙Ô˘Ó Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ï¢¯·ÈÌ›·˜ Î·È ÁÂÈÙÓ›·Û˘ Ì ËÏÂÎÙÚÈΤ˜ ÁÚ·Ì̤˜ ˘„ËÏ‹˜ Î·È ˘ÂÚ˘„ËÏ‹˜ Ù¿Û˘. ™ÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ·Ó·Ì¤ÓÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Ì›·˜ ·Ó¿Ï˘Û˘ ·fi ÙËÓ ∂˘Úˆ·˚΋ ŒÓˆÛË Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È Ù· ‰Â‰Ô̤ӷ Ù˘ µÚÂÙ·ÓÈ΋˜ ÌÂϤÙ˘. ∂›Û˘, Ì›· ÌÂÁ¿ÏË ÌÂϤÙË ·Ó·Ì¤ÓÂÙ·È ·fi ÙÔ ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ¶ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ÌÂÏÂÙÒÓ Ù˘ π·ˆÓ›·˜. ∏ ÌÂϤÙË ·˘Ù‹ ı· Ï¿‚ÂÈ ˘’ fi„ÈÓ Ù˘ ÙËÓ ÂÚÈÔ‰ÈÎfiÙËÙ· ÙˆÓ Ì·ÁÓËÙÈÎÒÓ ‰›ˆÓ ηٿ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ¤ÎıÂÛ˘. ¶ÂÚ›Ô˘ 1500 ‚·ÛÈΤ˜ ÂÚÈÙÒÛÂȘ (1000 Ï¢¯·ÈÌ›·˜ Î·È 500 fiÁÎˆÓ ÂÁÎÂÊ¿ÏÔ˘) ı· Û˘ÌÂÚÈÏËÊıÔ‡Ó Î·È ·Ó·Ì¤ÓÂÙ·È ˘„ËÏfi˜ ·ÚÈıÌfi˜ ÂÎÙÂıÂÈÌ¤ÓˆÓ ÛÙȘ Ôχ ˘„ËϤ˜ ηÙËÁÔڛ˜ ¤ÎıÂÛ˘, ÏfiÁˆ Ù˘ ‚·ÚÈ¿˜ ‚ÈÔÌ˯·Ó›·˜ ÛÙË ¯ÒÚ· ·˘Ù‹. ∏ ÌÂϤÙË ·˘Ù‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ÌÂϤÙ˜ Ô˘ Û˘Ó¯›˙ÔÓÙ·È ÛÙËÓ ∞ÌÂÚÈ΋, °ÂÚÌ·Ó›·, πÙ·Ï›· ›Ûˆ˜ ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ··ÓÙÒÓÙ·˜ ÛÙË ‰È·Ù˘ˆı›۷ ˘fiıÂÛË Â¿Ó Ú·ÁÌ·ÙÈο ˘Ê›ÛÙ·Ù·È ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ï¢¯·ÈÌ›·˜ ·È‰È΋˜ ËÏÈΛ·˜ ·fi ÙËÓ ¤ÎıÂÛË ÛÙ· Ì·ÁÓËÙÈο ‰›· ‹ Â¿Ó Ë

544

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·ÛıÂÓ‹˜ Û˘Û¯¤ÙÈÛË Â›Ó·È ı¤Ì· Ù‡¯Ë˜. ¶ÔÏÏÔ› ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ Ï¢¯·È̛˜ ÛÙ· ·È‰È¿ Â›Ó·È Ì›· ÔÌ¿‰· ‚ÈÔÏÔÁÈο ·ÏÏ¿ Î·È ·ÈÙÈÔÏÔÁÈο ÂÙÂÚÔÁÂÓ‹˜ Î·È fiÙÈ ÔÈ ÂȉڿÛÂȘ ·fi ÙȘ ÂÎı¤ÛÂȘ Û ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÍ·ÚÙÒÓÙ·È fi¯È ÌfiÓÔ ·fi Ù· Â›‰· ¤ÎıÂÛ˘ ·ÏÏ¿ Î·È ·fi ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ Û˘Ì‚·›ÓÂÈ (.¯. ÚÈÓ ÙË Û‡ÏÏË„Ë, ηٿ ÙËÓ Î‡ËÛË, ÌÂÙ¿ ÙË Á¤ÓÓËÛË) (57).

OÈ ÌÂÏÏÔÓÙÈΤ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ı· Ú¤ÂÈ Ó· ۯ‰ȿ˙ÔÓÙ·È Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ‰Â›ÁÌ·ÙÔ˜, ¤ÙÛÈ ÒÛÙ ÔÈ ÂȉڿÛÂȘ ·fi ÙȘ ‰È¿ÊÔÚ˜ ÂÎı¤ÛÂȘ Û ‰È·ÊÔÚÂÙÈο ÛÙ¿‰È· ·Ó¿Ù˘Í˘ Ó· ÂÎÙÈÌÒÓÙ·È Ì¤Û· Û ηÏÒ˜ ۯ‰ȷṲ̂Ó˜ ˘ÔÔÌ¿‰Â˜ Ï¢¯·ÈÌÈÒÓ. ∏ ·Ô˘Û›· ¿ÌÂÛ˘ ‚ÈÔÏÔÁÈ΋˜ ¤Ó‰ÂÈ͢ ÁÈ· ÏÔÈÌÒ‰Ë ·ÈÙ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ô‰ËÁ› ÛÙËÓ ·Ó·˙‹ÙËÛË Ó¤ˆÓ ·ÈÙÈÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì ÂÚ·ÈÙ¤Úˆ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜. ™ÙËÓ ∞ÌÂÚÈ΋, Ë ÔÌ¿‰· ÌÂϤÙ˘ ÙÔ˘ ·È‰ÈÎÔ‡ ηÚΛÓÔ˘ (CCSG) ÂÂÍÂÚÁ¿˙ÂÙ·È Ù· ‰Â‰Ô̤ӷ 2500 ÂÚÈÙÒÛÂˆÓ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ ·fi ÙÔ 1988 (58). ∂ÈÎÂÓÙÚÒÓÔ˘Ó ÙËÓ ¤ÚÂ˘Ó¿ ÙÔ˘˜ ȉȷ›ÙÂÚ· ÛÙ· ËÏÂÎÙÚÔÌ·ÁÓËÙÈο ‰›·, ÙÔ Ú·‰fiÓÈÔ Î·È Û ÂÎı¤ÛÂȘ ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ Û ¯ËÌÈο Î·È ÂÓÙÔÌÔÎÙfiÓ·, ·ÏÏ¿ Û˘Á¯ÚfiÓˆ˜ Û˘ÏϤÁÔ˘Ó ÏËÚÔÊÔڛ˜ Î·È ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙË ÏÔÈÌÒ‰Ë ˘fiıÂÛË. ™ÙË °ÂÚÌ·Ó›·, Â›Û˘, ÍÂΛÓËÛ ÙÔ 1988 (59) Ì›· ·ÓÂıÓÈ΋ ÂȉËÌÈÔÏÔÁÈ΋ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙÔ˘ ηÚΛÓÔ˘ ÛÙ· ·È‰È¿, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ Ï¢¯·ÈÌ›·˜. ∏ ÌÂϤÙË ·˘Ù‹ ÂÂÍÂÚÁ¿˙ÂÙ·È ‰È¿ÊÔÚ˜ ˘Ôı¤ÛÂȘ ÁÈ· ÙË Ï¢¯·ÈÌ›· Î·È ¿ÏÏÔ˘˜ ηÚΛÓÔ˘˜ ÛÙ· ·È‰È¿, fiˆ˜ ¤ÎıÂÛË ÛÙË Ê˘ÛÈ΋ ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›· (Ú·‰fiÓÈÔ, ·ÎÙ›Ó˜ Á), ËÏÂÎÙÚÈο Î·È Ì·ÁÓËÙÈο ‰›·, ¤ÎıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ¯ËÌÈο ‹ ·ÎÙÈÓÔ‚ÔÏ›·, ÎÏËÚÔÓÔÌÔ‡ÌÂÓË ÚԉȿıÂÛË Î·È ÙËÓ ¤ÎıÂÛË Û ÏÔÈÌÒÍÂȘ. ∏ ÚfiÔ‰Ô˜ ÛÙȘ ÌÂıfi‰Ô˘˜ ˘ÔÏÔÁÈÛÌÔ‡ Ù˘ ÂÚÈ‚·ÏÏÔÓÙÈ΋˜ ¤ÎıÂÛ˘, fiˆ˜ Â›Û˘ Î·È Ë ·Ó‡ÚÂÛË ÁÂÓÂÙÈÎÒÓ ÚԉȷıÂÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÙˆÓ ·ÏÏËÏÂȉڿÛÂÒÓ ÙÔ˘˜ Ì ÙÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜, Â›Ó·È Èı·Ófi Ó· ‚ÂÏÙÈÒÛÂÈ ÙȘ ÁÓÒÛÂȘ Ì·˜ Û¯ÂÙÈο Ì ÙË Û˘¯Ó‹ ·˘Ù‹ ÔÌ¿‰· ηÎÔËıÂÈÒÓ ÛÙ· ·È‰È¿. ∂›Û˘, Â›Ó·È Èı·Ófi Ó· ˘¿ÚÍÔ˘Ó ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›· ÁÈ· ÙË ‰È·Ù˘ˆı›۷ ˘fiıÂÛË Ù˘ “Â›‰Ú·Û˘ ÙˆÓ ÏÔÈÌÒÍÂˆÓ Ù˘ ÚÒÙ˘ ·È‰È΋˜ ËÏÈΛ·˜” ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ Ï¢¯·ÈÌ›·˜ ÛÙ· ·È‰È¿. À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÂΛӘ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ¤ÎıÂÛ˘ Û ÏÔÈÌÒÍÂȘ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ÙËÓ ÎÔÈÓÔ‡ Ù‡Ô˘ O§§ ·˘Í¿ÓÂÙ·È ÛÂ Û˘Û¯¤ÙÈÛË Ì ÔÚÈṲ̂ÓÔ˘˜ ˘fiÙ˘Ô˘˜ (60) ÙÔ˘ ªÂ›˙ÔÓÔ˜ ™˘ÌϤÁÌ·ÙÔ˜ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ·Ô˘Û›· ·Ú·ÙÂٷ̤ÓÔ˘ ıËÏ·ÛÌÔ‡, ÌÂȈ̤Ó˜ ÏÔÈÌÒÍÂȘ ÛÙË

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45. Savitz DA, Wachtel H, Barnes FA, John EM, Tvrdik JG. Case-control study of childhood cancer and exposure to 60-Hz magnetic fields. Am J Epidemiol 1988;128:21-38.

46. Gurney JG. Childhood cancer occurrence in relation to power line configurations: A study of potential selection bias in case-control studies. Epidemiology 1995;6:31-35.

47. EMF exposure study rules out “causing” cancer, finds “association” with Leukemia puzzling but real. JAMA 1996;276:21.

48. Linet MS, Hatch EE, Kleinerman RA, Robison LL, Kaune WT, Friedman DR et al. Residential exposure to magnetic fields and acute lymphoblastic leukemia in children. N Engl J Med 1997;337:1-7.

49. ¶Ô˘ÚÙÛ›‰Ë˜ ∞, ¶ÂÙÚ›‰Ô˘ ∂, ∆ÚȯfiÔ˘ÏÔ˜ ¢, ∫·ÏÌ·ÓÙ‹ ª, ∫ÔÏÈÔ‡Ûη˜ ¢, ∫ÔÛÌ›‰Ë ∂ Î·È Û˘Ó. ∏ÏÂÎÙÚÔÌ·ÁÓËÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜: ·ÔÙÂϤÛÌ·Ù· ·ÓÂÏÏ‹ÓÈ·˜ ¤Ú¢ӷ˜. ¶·È‰È·ÙÚÈ΋ 1998;61:557-572.

50. UK Childhood Cancer Study Investigators. Exposure to power - frequency magnetic fields and the risk of childhood cancer. Lancet 1999;354:1925-1931.

51. Repacholi M, Ahlbom A. Link between electromagnetic fields and childhood cancer unresolved (Commentary).

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52. McKinlay AF, Repacholi MH, eds. Exposure metrics and dosimetry for EMF epidemiology: Proceedings of an International Workshop held at the National Radiological Protection Board, Chilton, UK, Sept 7-9, 1998. Radiation Protection Dosimetry 1999;83:1-194.

53. Michaelis J, Schuz H, Meiner R, Zemann E, Grigat JP, Kaatsch et al. Combined risk estimates for two German population-based case-control studies on residential magnetic fields and childhood adult leukemia.

Epidemiology 1998;9:92-94.

54. McBride ML, Gallagher RP, Thériault G, Armstrong BG, Tamaro S, Spinelli JJ et al. Power-frequency electric and magnetic fields and risk of childhood leukemia in Canada.

Am J Epidemiol 1999;149:831-842.

55. Dockerty JD, Elwood JM, Skegg DC, Herbison GP. Electromagnetic field exposures and childhood cancers in New Zealand. Cancer Causes Control 1998;9:299-300.

56. Green L, Miller B, Villeneuve P, Greenberg M, Donnelly E. A case-control study of childhood leukemia in southern Ontario, Canada, and exposure to magnetic fields in residences. Internat J Cancer 1999;82:161-170.

57. Cnattingius S, Zack M, Ekbom A, Gunnarskog J, Linet M, Adami HO. Prenatal and neonatal risk factors for childhood myeloid leukemia. Cancer Epidemiol Biomarkers Prev 1995;4:441-445.

58. Robison LL, Buckley JD, Bumin G. Assessment of environmental and genetic factors in the etiology of childhood cancers: the children’s cancer group epidemiology programm. Env Health Perspectives 1995;103:111-116.

59. Kaatsch P, Kaletsch U, Krummenauer F, Meinert R, Miesner A, Haaf G et al. Case control study on childhood leukemia in Lower Saxony, Germany. Basic considerations, methodology, and summary of results.

Klin Pediatr 1996;208:179-185.

60. Taylor GM, Birch JM. The hereditary basis of human leukemia. In: Henderson ES, Lister TA, Greaves MF, eds.

Leukemia. 6th ed. WB Saunders; 1996. p. 34-45.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-12-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 30-04-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞fiÛÙÔÏÔ˜ ¶Ô˘ÚÙÛ›‰Ë˜ ∞Ê·›·˜ 14, 154 54 æ˘¯ÈÎfi

¶·È‰È·ÙÚÈ΋ 2001;64:132-135

Paediatriki 2001;64:132-135

¶PO™EXH ™YNE¢PIA 9-12 ™ÂÙÂÌ‚Ú›Ô˘ 2001

European Asthma Congress Congress Secretariat Dr. T. Slavyanskaya 16/10 Miklukho-Maklaya street Moscow, 117997 Russia Tel.: (++7 -095) 336-5000 & 429-9620 Fax: (++7 -095) 336-5000 E-mail: acicis@ibch.ru Web site: http://www.isir.ru

ªfiÛ¯·, ƒˆÛ›·

9-14 ™ÂÙÂÌ‚Ú›Ô˘ 2001

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˘ 2001

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.

¶ÂΛÓÔ, ∫›Ó·

23-27 ™ÂÙÂÌ‚Ú›Ô˘ 2001

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›·

27-30 ™ÂÙÂÌ‚Ú›Ô˘ 2001

24Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ÃÂÈÚÔ˘ÚÁÈ΋˜ ¶·›‰ˆÓ °Ú·ÌÌ·Ù›·: ªÂıÒÓ˘ 64 106 83, ∞ı‹Ó· ∆ËÏ.: (01) 330 62 50 Fax: (01) 330 62 40 E-mail: charissi@her.forthnet.gr

∞ı‹Ó·

xiii

¶PO™EXH ™YNE¢PIA 2-6 OÎÙˆ‚Ú›Ô˘ 2001

IXth Congress of European Society for the study and prevention of infant death ESPID, Prenatal Health Care and Postnatal Development Organizing Secretariat: Figure Congress Organization Ayazmaderesi Cad. Karadut Sk. No: 780888 Dikilitas, Istanbul, Turkey Tel.: +90 212 258 60 20 Fax: +90 212 258 60 78 E-mail: espid@figur.net

6-7 OÎÙˆ‚Ú›Ô˘ 2001

11Ë ∂ÈÛÙËÌÔÓÈ΋ ∂Ή‹ÏˆÛË πˆ¿ÓÓÈÓ· ¶·È‰È·ÙÚÈ΋˜ ∆Ô̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ •ÂÓÔ‰Ô¯Â›Ô Du Lac °Ú·ÌÌ·Ù›·: ∆ËÏ.: (0651) 97 546 & 97 544 Fax: (0651) 97 032 Web site: http://www.uoi.gr/conf_sem/11paediatr

20-21 OÎÙˆ‚Ú›Ô˘ 2001

¢ÈÂÈÛÙËÌÔÓÈÎfi ™˘Ó¤‰ÚÈÔ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ °Ú·ÌÌ·Ù›·: C&C International A.E ¶·Ú·‰Â›ÛÔ˘ 16, 151 24 ∞ı‹Ó· ∆ËÏ.: (01) 68 89 100 Fax: (01) 68 44 777 E-mail: congress@cnc.gr

∞ı‹Ó·

31 OÎÙ.-3 ¡ÔÂÌ‚Ú›Ô˘ 2001

¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜ °Ú·ÌÌ·Ù›·: AFEA Congress S.A §˘Î·‚ËÙÔ‡ 39-41, 106 72 ∞ı‹Ó· ∆ËÏ.: (01) 36 04 413 Fax: (01) 36 43 511 E-mail: info@afea.gr

∞ı‹Ó·

10 ¡ÔÂÌ‚Ú›Ô˘ 2001

14Ë ∂ÈÛÙËÌÔÓÈ΋ ∏ÌÂÚ›‰· ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ “¡ÂÒÙÂÚ· ‰Â‰Ô̤ӷ ÛÙË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›· ∞ÈÌ·ÙÔÏÔÁÈÎÒÓ - OÁÎÔÏÔÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜” ¶ÏËÚÔÊÔڛ˜: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜/OÁÎÔÏÔÁ›·˜ ∆ËÏ.: 7467 303-6 & 7792 200 Fax: 7792 200

∞ı‹Ó·

xiv

∫ˆÓ/ÔÏË, ∆Ô˘ÚΛ·

™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

xvii

™˘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 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9

6

3

2

1

-1

-2

-3

-6

-9

-12

-15

-18

xviii

Combining prefixes T G M k h da d c m Ì n p f a