Παιδιατρική | Τόμος 65 • Τεύχος 3 • Μάιος - Ιούνιος 2002

COVER MAY-JUNE02 24-04-02 14:33 ™ÂÏ›‰·1 ISSN 0377-2551

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TOMO™ 65

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TEYXO™ 3

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ETO™ 2002

ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3

∞ƒ£ƒO ™À¡∆∞•∏™ ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘

EDITORIAL 147

∞. ™Î·Ú‰Ô‡ÙÛÔ˘

A. Skardoutsou

∞¡∞™∫O¶∏™∂π™ π‰ÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙ· ·È‰È¿ (πº¡∂)

REVIEW ARTICLES 151

∂. ƒÒÌ·-°È·ÓÓ›ÎÔ˘

™‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ: ¶·ıÔÁ¤ÓÂÈ· Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘

160

ORIGINAL ARTICLES 167

∞. ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ 174

Comparison of high-frequency oscillatory ventilation with conventional mechanical ventilation in the treatment of respiratory distress syndrome in preterm infants V. Drossou-Agakidou, K. Sarafidis, P. Karagianni, E. Diamanti, N. Nikolaidis, G. Kremenopoulos

182

ª. ÷ڛÛË, ∂. °·Ï·Ó¿Î˘, ª. ∆˙Ô‡ÊË, ™. ™ÙÂÊ¿ÓÔ˘-§Â‚ÂȉÈÒÙÔ˘, ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹

™˘ÌÂÚÈÊÔÚ¿, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹, ÙËÏÂı¤·ÛË Î·È ·È¯Ó›‰È Ì·ıËÙÒÓ ÛÙÔȯÂÈÒ‰Ô˘˜ ÂÎ·›‰Â˘Û˘ ÛÙËÓ ∫Ú‹ÙË

Botulinum toxin type A intramuscular injections in the treatment of spasticity in cerebral palsy A. Syrigou-Papavasiliou

µ. ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, ∂. ¢È·Ì·ÓÙ‹, ¡. ¡ÈÎÔÏ·˝‰Ë˜, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜

∏ ÛÈÁΤÏψÛË ÛÙËÓ ◊ÂÈÚÔ Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985 - 1999

Increased capillary permeability syndrome (Leak syndrome): Pathogenesis and the newest evidence for its management M. Katsara, K. Papazoglou

Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™

™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙÔ˘ ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÓÂÔÁÓÒÓ

Inflammatory bowel disease (IBD) in children E. Roma-Giannikou

ª. ∫·ÙÛ¿Ú·, ∫. ¶·¿˙ÔÁÏÔ˘

∂Ó‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË

Botulinum toxin A for the treatment of cerebral palsy

Shigellosis in the region of Epirus during the 15year period from 1985 to 1999 M. Charisi, E. Galanakis, M. Tzoufi, S, Stephanou-Levidiotou, Z. Papadopoulou-Couloumbis

186

Nutritional habits, TV viewing, body health care and playing behavior of elementary school students in Crete, Greece

∫. ∞Ó˘Ê·ÓÙ¿Î˘, ª. ∞Ó˘Ê·ÓÙ¿ÎË, ∂. •˘ÏÔ‡ÚË, ∂. ™·Îο, Ã. §ÈÔÓ‹˜, ¡. ∞ÓÙˆÓ¿Î˘

K. Anyphantakis, M. Anyphantaki, I. Xylouri, I. Sakka, C. Lionis, N. Antonakis

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

Continuation of table of contents inside title page

May - June 2002 . Volume 65 . No 3

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·1

M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

Continuation of table of contents

CASE REPORTS

∂¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ À‰Ú·ÓÂÁÎÂÊ·Ï›· Û ÓÂÔÁ¤ÓÓËÙÔ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘

195

G. Baroutis, J. Kaleyias, C. Kacoulis, I. Paulidis, A. Gouliamos

°. ª·ÚÔ‡Ù˘, π. ∫·Ï¤ÁÈ·˜, ∫. ∫·ÎÔ˘ÏÏ‹˜, π. ¶·˘Ï›‰Ë˜, ∞. °Ô˘ÏÈ¿ÌÔ˜

™˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi

199

203

208

CURRENT ISSUES

∂¶π∫∞πƒ∞ £∂ª∞∆∞ 212

The assessment and management of pain in children G. Tsolas, G. Kafalidis, G. Triantafyllidis

°. ∆ÛfiÏ·˜, °. ∫·Ê·Ï›‰Ë˜, °. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜

LITERATURE ABSTRACTS

¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ ÕÛıÌ· Ô˘ “ÍÂÂÚ¿ÛÙËΔ ‰ÂÓ ÛËÌ·›ÓÂÈ ·Ô˘Û›· ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ

Rickettsial disease with clinical presentation mimicking Kawasaki disease M. Bitsori, E. Galanakis, D. Mamoulakis, E. Vasilaki, M. Antoniou, S. Sbyrakis

ª. ªÈÙÛÒÚË, ∂. °·Ï·Ó¿Î˘, ¢. ª·ÌÔ˘Ï¿Î˘, ∂. µ·ÛÈÏ¿ÎË, ª. ∞ÓÙˆÓ›Ô˘, ™. ™Ì˘Ú¿ÎȘ

∂ÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿

Congenital tuberculÔus lymphadenitis in a preterm infant Z. Hatzistamatiou, J. Kaleyias, U. Ikonomidou, E. Papathoma, E. Prifti, V. Petrocheilou-Paschou, Ch. Kostalos

∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘, π. ∫·Ï¤ÁÈ·˜, O. OÈÎÔÓÔÌ›‰Ô˘, ∂. ¶··ıˆÌ¿, ∂. ¶Ú›ÊÙË, µ. ¶ÂÙÚԯ›ÏÔ˘-¶¿Û¯Ô˘, Ã. ∫ÒÛÙ·ÏÔ˜

ƒÈÎÂÙÙÛÈÒÛÂȘ Ì ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓfiÛÔ˘ Kawasaki

Congenital chylothorax in a neonate G. Baroutis, M. Apostolou, J. Kaleyias, S. Sevastiadou, A. Antsaklis, C. Costalos

°. ª·ÚÔ‡Ù˘, ª. ∞ÔÛÙfiÏÔ˘, π. ∫·Ï¤ÁÈ·˜, ™. ™Â‚·ÛÙÈ¿‰Ô˘, ∞. ∞ÓÙ˙·ÎÏ‹˜, Ã. ∫ÒÛÙ·ÏÔ˜

™˘ÁÁÂÓ‹˜ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ÚfiˆÚÔ ÓÂÔÁÓfi

Hydranencephaly in a neonate.

A case report

150

Outgrown asthma does not mean no airways inflammation

Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜

Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al Greek translation: M. Anthrakopoulos

™˘Ó¯›˙ÔÓÙ·È

Continued

May - June 2002 . Volume 65 . No 3

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·2

ª¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002 . ∆fiÌÔ˜ 65 . ∆‡¯Ô˜ 3

™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ

ªÂϤÙË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Ì·ÁÓËÛ›Ô˘ ÛÂ Û˘ÁÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT

Continuation of table of contents

166

Hoshino K, Ogawa K, Hishitani T, Kitazawa R ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.™. µ·ÚÏ¿Ì˘

ª›· ·Ï‹ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÚÔÛÒÔ˘

Hoshino K, Ogawa K, Hishitani T, Kitazawa R Greek translation: G.S, Varlamis 173

Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °.™. µ·ÚÏ¿Ì˘

∏ ¯Ú‹ÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡

181

A 13C-urea breath test in children with Helicobacter pylori infection: assessment of eradication therapy and follow-up after treatment Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al Greek translation: G. Kafritsa

211

Kalliomaki M, Salminen S, Avrilomni H, Kero P, Koskinen P, Isolauri E ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. ∫·ÊÚ›ÙÛ·

™‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ Úfi‚Ï„˘ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÛÙ· ·È‰È¿

A simple method for evaluating abnormal lengthening of the QT interval during the face immersion test Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al Greek translation: G.S, Varlamis

Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: °. ∫·ÊÚ›ÙÛ·

∆· ÚÔ‚ÈÔÙÈο ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘

Studies of magnesium in congenital long QT syndrome

Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial Kalliomaki M, Salminen S, Avrilomni H, Kero P, Koskinen P, Isolauri E Greek translation: G. Kafritsa

218

Manczur TI, Greenough A, Pryor D, Rafferty GF ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ∞. ÷Ù˙‹˜

Comparison of predictors of extubation from mechanical ventilation in children Manczur TI, Greenough A, Pryor D, Rafferty GF Greek translation: A. Hatzis

¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·

xiii

Scheduled Medical Meetings

™˘ÓÙÔÌÔÁڷʛ˜

xvii

Abbreviations

May - June 2002 . Volume 65 . No 3

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·3

M¿ÈÔ˜ - πÔ‡ÓÈÔ˜ 2002

.

∆fiÌÔ˜ 65

. ∆‡¯Ô˜

3

¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜

Bimonthly Publication The Official Journal of the Hellenic Paediatric Society

EΉfiÙ˘ K. °ÚÈ‚¤·˜

Publisher K. Griveas

I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28

Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28

TËÏ.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

Tel.: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

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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: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 010-7771 140 / 010-7771 663, Fax: 010-7758 354

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

Greek Editing I. Karavranou

M a y - J u n e 2 0 0 2 .V o l u m e 6 5 .N o 3

πSSN 0377-2551 i

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·5

O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶∞π¢π∞∆ƒπ∫H” 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∫H” ·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∫H”. ∂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∫H” 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 30 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 ‰‡Ô (2) Ë̤Ú˜.

T· ¤ÍÔ‰· ÙˆÓ ÊÈÏ̘ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ.

T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı›, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (22x28 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È Ê·Ú‰È¿ ÂÚÈıÒÚÈ· (2,5 cm) ÛÙȘ ‰‡Ô Ï¢ڤ˜.

TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘.

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·6

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

vi

‚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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Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679.

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

¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm.

OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, ÎÏ.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο.

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

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

¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ - ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜ - 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜ - ÛÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·): ÂÚÈÏ·Ì‚¿ÓÂÈ - Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ - fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· - fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›· - ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ηٿÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ΛÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ¢¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) - ‚È‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó - ÂÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· Â¿Óˆ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó - Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.

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

Kaplan SJ. Post hospital home health care: the

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∞ƒ£ƒO ™À¡∆∞•∏™

Paediatriki 2002;65:147-150

EDITORIAL

∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ∞. ™Î·Ú‰Ô‡ÙÛÔ˘

Botulinum toxin A for the treatment of cerebral palsy A. Skardoutsou

¶ÂÚ›ÏË„Ë: ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·ÛÊ·Ï‹˜ Î·È Î·ÏÒ˜ ·ÓÂÎÙ‹ Û ¿Û¯ÔÓÙ˜ ·fi ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ·ÔÙÂÏ› Ë Î·Ù¿ÏÏËÏË ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ. ∆· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÂÈÙ˘Á¯¿ÓÔÓÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ÂÛÙȷ΋ Û·ÛÙÈÎfiÙËÙ· ÛÙÔ˘˜ Ì˘˜ ÌÈ·˜ ¿ÚıÚˆÛ˘ ‹ Û ÛÂÈÚ¿ ÁÂÈÙÔÓÈÎÒÓ Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Á΢ÏÒÛÂȘ, Ô‡Ù ÛËÌ·ÓÙÈ΋ Ì˘˚΋ ·‰˘Ó·Ì›·. ∏ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ ·ÔÙÂÏ› ıÂÚ·¢ÙÈÎfi ÛÙfi¯Ô, ·ÏÏ¿ ÂȉÈÒÎÂÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÂÏÙȈı› Ë Î›ÓËÛË, Ë Ê˘ÛÈÔıÂÚ·›·, Ó· ÚÔÏËÊıÔ‡Ó ÔÈ ·Á΢ÏÒÛÂȘ Î·È Ó· ÌÂÙ·ÙÂıÔ‡Ó ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ. OÈ ıÂÚ·¢ÙÈÎÔ› ÛÙfi¯ÔÈ Ú¤ÂÈ Ó· Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ÓÔÈ Î·È ÚÔÛ·ÚÌÔṲ̂ÓÔÈ ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ οı ·ÛıÂÓ‹.

Abstract: Botulinum toxin is a well tolerated, safe, and effective mode of therapy for the treatment of patients with spastic cerebral palsy. Appropriate patient selection is imperative. Best results are achieved in patients with focal spasticity, involving one or more neighboring joints, in the absence of fixed contractures or significant weakness of the injected muscles. Reduction of the spasticity is not necessarily the final therapeutic goal. The purpose of its administration is to control the spasticity and, in so doing, optimize patient function and comfort and prevent contractures. The expected goals of therapy should definitely be established and reviewed prior to therapy in order to develop an individualized plan that is appropriate for the needs of each patient.

§¤ÍÂȘ ÎÏÂȉȿ: ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, ·ÓÙÈÌÂÙÒÈÛË.

Key words: cerebral palsy, botulinum toxin, treatment.

∂ÈÛ·ÁˆÁ‹ ∏ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Â›Ó·È ÌË ÚÔԉ¢ÙÈ΋ ÎÏÈÓÈ΋ Û˘Ó‰ÚÔÌ‹, ÚÔηÏÂ›Ù·È ·fi ‚Ï¿‚˜ ÛÙËÓ ÎÈÓËÙÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ·ÓÒÚÈÌÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ì›· ÔÈÎÈÏ›· ·fi ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ™ÙË Û·ÛÙÈ΋ ÌÔÚÊ‹, Ë ÔÔ›· Û˘Ó·ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ·, ÂÛÙȷΤ˜ ÂÚÈÔ¯¤˜ Û·ÛÙÈÎfiÙËÙ·˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ·ÓÈÛÔÚÚÔ›· ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Âη٤ڈıÂÓ Ù˘ ¿ÚıÚˆÛ˘, Ë ÔÔ›· ÂÎÙfi˜ ·fi ÙËÓ ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Á΢ÏÒÛÂȘ, ·Ó·ÛÙÔÏ‹ Ù˘ ·‡ÍËÛ˘ ÙˆÓ ·ÁˆÓÈÛÙÒÓ Ì˘ÒÓ Î·È ÂÈÌ‹Î˘ÓÛË Î·È Ì˘˚΋ ·‰˘Ó·Ì›· ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ. °È· Ó· ·ÔηٷÛÙ·ı› Ë ÈÛÔÚÚÔ›· Ú¤ÂÈ Ó· ÌÂȈı› Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ ÙˆÓ ÈÔ ÂÓÂÚÁËÙÈÎÒÓ Ì˘ÒÓ Ù˘ ¿ÚıÚˆÛ˘. °È· ÙÔ ÛÎÔfi ·˘Ùfi ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ıÂÚ·¢ÙÈο ̤ÙÚ· fiˆ˜ Ë Ê˘ÛÈÔıÂ-

Ú·›·, Ë ÂÎÏÂÎÙÈ΋ ÓˆÙÈ·›· ÚÈ˙ÔÙÔÌ‹, ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ Î·È Ê¿Ú̷η. ∆· ÙÂÏÂ˘Ù·›· ‰¤Î· ¯ÚfiÓÈ· ÚÔÛÙ¤ıËΠÛÙË ıÂÚ·›· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È Ë ÙÔÈ΋ ¤Á¯˘ÛË ÛÙÔ˘˜ Ì˘˜ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ. º·ÚÌ·ÎÔÏÔÁ›· Î·È Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ·Ú¿ÁÂÙ·È ·fi ÙÔ Clostiridium Botulinum Î·È ÚÔηÏ› ·Ú¿Ï˘ÛË, ÂÂȉ‹ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ Ó¢ÚÔÌ˘˚ÎÔ‡ ‰È·‚È‚·ÛÙ‹ ·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË ·fi ÙȘ Ó¢ÚÈΤ˜ ·ÔÏ‹ÍÂȘ fiÙ·Ó ÂÓÂı› ÎÔÓÙ¿ ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë. ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÔÓ‡ڈÛË ÙÔ˘ Ì˘fi˜ Î·È Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌÔ. ∏ ÙÔÍ›ÓË ¤¯ÂÈ ÂÈϤÔÓ ÙËÓ ›‰È· ‰Ú¿ÛË ÛÙȘ ¯ÔÏÈÓÂÚÁÈΤ˜, ·Ú·Û˘Ì·ıËÙÈΤ˜ Î·È Û˘Ì·ıËÙÈΤ˜ ›Ó˜, Ì ·ÔÙ¤ÏÂÛÌ·

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

2nd Pediatric Clinic of University of Athens Children’s Hospital “P. & A. Kyriakou”, Athens

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Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. Œ¯Ô˘Ó Ù·˘ÙÔÔÈËı› ÂÙ¿ ·ÓÙÈÁÔÓÈο ‰È·ÊÔÚÂÙÈÎÔ› ÔÚfiÙ˘ÔÈ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ, fiˆ˜ ÔÈ Ù‡ÔÈ A, B, C, D, E, F Î·È G. ™ÙÔ ÂÌfiÚÈÔ ‰È·Ù›ıÂÓÙ·È ‰‡Ô ·Ú·Û΢¿ÛÌ·Ù· ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ (BOTOX Î·È DYSPORT) Ù· ÔÔ›·, ·Ú¿ ÙÔ ÎÔÈÓfi Û‡ÛÙËÌ· ηÙËÁÔÚÈÔÔ›ËÛ˘, ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ÈÛ¯‡, ÂÓÒ ÂÈϤÔÓ ¤Ó· ·Ú·Û··ÛÌ· ÙÔ˘ Ù‡Ô˘ µ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÂÍÂÚÁ·Û›·˜. ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Â›Ó·È ÔÏ˘ÂÙ›‰ÈÔ ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi Ì›· ‚·Ú›· Î·È Ì›· ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ. ∏ ‚·Ú›· ¿Ï˘ÛÔ˜ Û˘Ó‰¤ÂÙ·È Ì¤Ûˆ ˘Ô‰Ô¯¤ˆÓ ˘„ËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ Ì ÙȘ Ó¢ÚÈΤ˜ ·ÔÏ‹ÍÂȘ Î·È Ë ÙÔÍ›ÓË ÂÈÛ¤Ú¯ÂÙ·È ÛÙÔ ÂÛˆÙÂÚÈÎfi Ù˘ ·fiÏË͢ Ì ÂÓ‰Ô·ÙÙˆÛË. ∂Λ, Ë ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ˜ ‰È·Û¿ ÂȉÈÎÔ‡˜ ‰ÂÛÌÔ‡˜ Ù˘ ÚˆÙ½Ó˘ Ô˘ ÚÔηÏ› ÙË Û‡ÓÙËÍË ÙˆÓ ¯ÔÏÈÓÂÚÁÈÎÒÓ Î˘ÛÙȉ›ˆÓ Ì ÙËÓ ÚÔÛ˘Ó·ÙÈ΋ ÌÂÌ‚Ú¿ÓË Î·È ÂÌÔ‰›˙ÂÈ ÙËÓ ÚÔÛ˘Ó·ÙÈ΋ ·ÂÏ¢ı¤ÚˆÛË Ù˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ (1). ∏ ·ÎÂÙ˘ÏÔ¯ÔÏ›ÓË Ê˘ÛÈÔÏÔÁÈο ˘ÚÔ‰ÔÙ› ËÏÂÎÙÚÈο ‰˘Ó·ÌÈο Ù· ÔÔ›· ÚÔηÏÔ‡Ó ÙË Ì˘˚΋ Û‡Û·ÛË. ∏ ‰Ú¿ÛË Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙȘ ¯ÔÏÈÓÂÚÁÈΤ˜ Û˘Ó¿„ÂȘ Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Î·È ·Ó·ÛÙÚ¤„ÈÌË, ÂÂȉ‹ Ë ¯ÔÏÈÓÂÚÁÈ΋ ΢ÎÏÔÊÔÚ›· ·Ôηı›ÛÙ·Ù·È Î·È ÂÂȉ‹ ÛÙȘ ›‰È˜ ı¤ÛÂȘ Â΂ϷÛÙ¿ÓÔ˘Ó ÚÔÛˆÚÈÓ¿ Ӥ˜ Ó¢ÚÔÌ˘˚Τ˜ Û˘Ó¿„ÂȘ. ∏ Û·ÛÙÈÎfiÙËÙ· Â›Ó·È ¿ıÚÔÈÛÌ· ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ, fiˆ˜ ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ ÛÙËÓ ·ıËÙÈ΋ ‰È¿Ù·ÛË, ˘ÂÚÂÚÁÈο ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο Î·È ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ÎÈÓ‹ÛˆÓ. ∂›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ηٿÚÁËÛ˘ Ù˘ ·Ó·ÛÙÔÏ‹˜ Ô˘ ·ÛΛ ÙÔ ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ¿Óˆ ÛÙ· ·-ÎÈÓËÙÈο ·ÙÙ·Ú· ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Ù· ÔÔ›· Á›ÓÔÓÙ·È ˘ÂÚ¢ÂÚ¤ıÈÛÙ·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ ÙfiÍÔ˘, ÌÂٷ͇ ·-ÎÈÓËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ì˘˚ÎÒÓ ·ÙÚ¿ÎÙˆÓ, ÙÔ ÔÔ›Ô Ú˘ıÌ›˙ÂÈ ÙÔ Ì˘˚Îfi ÙfiÓÔ. ™ÎÔfi˜ Ù˘ ıÂÚ·›·˜ Ì ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Â›Ó·È Ë ÌÂÚÈ΋ ‹ Ï‹Ú˘ ·Ú¿Ï˘ÛË ÙÔ˘ ÂȉÈÎÔ‡ ÛÙfi¯Ô˘ (·ÁˆÓÈÛÙ¤˜ ̇˜) ¯ˆÚ›˜ Ó· ÂËÚ¿˙ÔÓÙ·È ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜. ∆Ô ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ΛÓËÛ˘ Î·È Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ̤ÏÔ˘˜, ÂÓÒ ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ̇˜ ÈÛ¯˘ÚÔÔÈÔ‡ÓÙ·È Ì ÙË Ê˘ÛÈÔıÂÚ·›·. ∂ȉÈÒÎÂÙ·È Ë ‰È·Ù‹ÚËÛË Ù˘ ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÂϤÁ¯Ô˘ Ù˘ ΛÓËÛ˘ Î·È ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ‰Ú¿Û˘ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ. ∏ ÂÍ·Ê¿ÓÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ Ô‰ËÁ› ·Ó·ÁηÛÙÈο Û ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ Ì˘˚΋˜ ÔÌ¿‰·˜, ·ÏÏ¿ ·ÓÙ›ıÂÙ· ÌÔÚ› Ó· ·Ôηχ„ÂÈ Ù· ·ÚÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Ô˘ Â›Ó·È Ë Ì˘˚΋ ·‰˘Ó·Ì›· Î·È Ë ·ÒÏÂÈ· Ù˘ ÂȉÂÍÈfiÙËÙ·˜.

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∂ÎÙ›ÌËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ per se ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Â›Ó·È ÙÔ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ·, Ë Ì¤ÙÚËÛË ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ΛÓËÛ˘ ÛÙËÓ ¿ÚıÚˆÛË, Ù˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ Ì˘fi˜, Ù˘ Ì˘˚΋˜ ÈÛ¯‡Ô˜, Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘fi˜, fiˆ˜ Á›ÓÂÙ·È Ì ÙȘ Îϛ̷Θ Ashworth (2) Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂȉÂÍÈfiÙËÙ·˜. ∏ ÂÎÙ›ÌËÛË Á›ÓÂÙ·È 1-3 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙȘ ÂÓ¤ÛÂȘ. ™ËÌ·ÓÙÈÎfi Â›Ó·È Ó· ·ÔÙÈÌËı› ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Û˘ÓÔÏÈ΋˜ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ (·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, Ê˘ÛÈÔıÂÚ·›·, ÂÚÁÔıÂÚ·›·, Á‡„ÈÓÔÈ Ó¿ÚıËΘ Î·È ÔÚıÒÛÂȘ). °È· ÙË Û˘ÓÔÏÈ΋ ·ÔÙ›ÌËÛË ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ̤ıÔ‰ÔÈ fiˆ˜ Â›Ó·È Ë ÎÈÓËÌ·ÙÈ΋ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘, Ë Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ Î·È ÔÈ ÌÂÙ·‚ÔϤ˜ ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ Î›ÓËÛË, ηıÒ˜ Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Ì ‚¿ÛË ÔÚÈṲ̂Ó˜ Îϛ̷Θ. ∂›Û˘, ·ÔÙÈÌ¿Ù·È Î·È Ë ÚÔÛˆÈ΋ ÈηÓÔÔ›ËÛË ÙÔ˘ ÎˉÂÌfiÓ· Î·È ÙÔ˘ ¿Û¯ÔÓÙ·. °È· ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‚ÈÓÙÂÔÙ·Èӛ˜ Ù˘ ‚¿‰ÈÛ˘, Û‡ÛÙËÌ· ·Ó¿Ï˘Û˘ Ù˘ ΛÓËÛ˘ Û ‰‡Ô ‹ ÙÚÂȘ ‰È·ÛÙ¿ÛÂȘ (3) ‹ ËÏÂÎÙÚÔÁˆÓÈfiÌÂÙÚ· Ô˘ ÌÂÙÚÔ‡Ó ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ΛÓËÛ˘. OÈ ÌÂÙÚ‹ÛÂȘ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Ì Îϛ̷Θ, fiˆ˜ Â›Ó·È Ë Gross Motor Functional Measure Î·È Performance Measure (4) Î·È Ë Physician Rating Scales (5), ¤¯Ô˘Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ÂÊ·ÚÌÔÁ‹. ¢ÂÓ ··ÈÙÔ‡Ó ÂȉÈÎfi ÂÍÔÏÈÛÌfi, ·ÏÏ¿ ‚·Û›˙ÔÓÙ·È ÛÙËÓ ·Ú·Ù‹ÚËÛË ÔÚÈÛÌ¤ÓˆÓ ‰˘Ó·ÌÈÎÒÓ ÎÈÓ‹ÛÂˆÓ fiˆ˜ Â›Ó·È ÙÔ Î¿ıÈÛÌ· ÔÎÏ·‰fiÓ, Ë ÈÔÔ‰›·, Ë ÁˆÓ›· ÙÔ˘ ÁfiÓ·ÙÔ˜, Ë Ù·¯‡ÙËÙ· Ù˘ ‚¿‰ÈÛ˘ Î·È Ô Ù‡Ô˜ Ù˘ ‚¿‰ÈÛ˘, Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ‚¿‰ÈÛ˘ ‰›ÓÔ˘Ó ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· ÙˆÓ Ì˘ÒÓ-ÛÙfi¯ˆÓ Ô˘ ¤¯Ô˘Ó ÂÈÏÂÁ› Î·È ÙËÓ ·Ó¿ÁÎË Û˘ÌÏËڈ̷ÙÈ΋˜ ıÂÚ·›·˜. OÈ Îϛ̷Θ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ¤¯Ô˘Ó ÂÈÎÚÈı› fiÙÈ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÓȯÓ‡ÛÔ˘Ó ÌÈÎÚ¤˜ ÌÂÙ·‚ÔϤ˜ Û ¿Û¯ÔÓÙ˜ Ì ̤ÙÚÈ· ·ÓÈηÓfiÙËÙ· Î·È fiÙÈ Û·Ó Ì¤Û· Ù˘ ¤Î‚·Û˘ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ͯˆÚ›ÛÔ˘Ó ÙË ‚ÂÏÙ›ˆÛË, ·fi ÂΛÓË Ô˘ ·Ó·Ì¤ÓÂÙ·È ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ ÛÙË ıÂÚ·›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi ·ÚÎÂÙ¤˜ ·ÓÔÈÎÙ¤˜, ·ÏÏ¿ Î·È ‰ÈϤ˜ Ù˘ÊϤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÙÔ˘˜ Ì˘˜ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, ȉȷ›ÙÂÚ· ÙÔÓ Á·ÛÙÚÔÎÓ‹ÌÈÔ Î·È ÙÔ˘˜ ÚÔÛ·ÁˆÁÔ‡˜. ¢È·ÈÛÙÒıËΠÂÏ¿ÙÙˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ Á·ÛÙÚÔÎÓËÌ›Ô˘ Ì˘fi˜, ‚ÂÏÙ›ˆÛË Ù˘ ·ıËÙÈ΋˜ ·ÏÏ¿ Î·È Ù˘ ‰˘Ó·ÌÈ΋˜ Ú·¯È·›·˜ ¤ÎÙ·Û˘

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·149

¶·È‰È·ÙÚÈ΋ 2002;65:147-150

ÙÔ˘ ¿ÎÚÔ˘ Ô‰fi˜, ÙfiÛÔ Î·Ù¿ ÙËÓ fiÚıÈ· ÛÙ¿ÛË fiÛÔ Î·È Î·Ù¿ ÙË ‚¿‰ÈÛË (2,3,5-7). ∂›Û˘, ‚ÂÏÙ›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ‰Ú¿Û˘ ÙÔ˘ ÚfiÛıÈÔ˘ ÎÓËÌÈ·›Ô˘ Î·È ‚ÂÏÙ›ˆÛË ÙÔ˘ ‰È·ÛÎÂÏÈÛÌÔ‡ (6). ∏ ‚ÂÏÙ›ˆÛË ‰È·ÚΛ 3 ¤ˆ˜ 6 Ì‹Ó˜, ·ÏÏ¿ ÌÂÙ¿ ·fi ‰È·‰Ô¯ÈΤ˜ ÂÁ¯‡ÛÂȘ, ̤¯ÚÈ Î·È 2 ¯ÚfiÓÈ· (5), ‰È·›ÛÙˆÛË Ô˘ ‰È·ÌfiÚʈÛ ÙËÓ ˘fiıÂÛË fiÙÈ Ë · ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÌÔÚ› Ó· ÌÂÙ·ı¤ÛÂÈ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÛÙÔ˘˜ ·¯›ÏÏÂÈÔ˘˜ Ù¤ÓÔÓÙ˜ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, fiÙ·Ó Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ˘ÔÙÚÔ¤˜ ÌÂÈÒÓÂÙ·È. ™ÙÔ ·ÓÒÙ·ÙÔ ¿ÎÚÔ, Û ̛· ÌÂϤÙË 14 ·È‰ÈÒÓ, Ë ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ·‡ÍËÛ ÛËÌ·ÓÙÈο ÙË Ì¤ÁÈÛÙË ÂÓÂÚÁËÙÈ΋ ¤ÎÙ·ÛË ÛÙÔÓ ·ÁÎÒÓ· Î·È ÙÔ ÌÂÁ¿ÏÔ ‰¿ÎÙ˘ÏÔ, fiˆ˜ Î·È ÙËÓ Î¿Ì„Ë Î·È ÙÔ ¿ÓÔÈÁÌ· Ù˘ ·Ï¿Ì˘, fï˜ Ë ÏÂÙ‹ ÎÈÓËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, fiˆ˜ ·˘Ù‹ ÂÎÙÈÌ‹ıËΠ̠ÙË Û‡ÏÏË„Ë ÓÔÌÈÛÌ¿ÙˆÓ, ‰ÂÓ ‚ÂÏÙÈÒıËÎÂ Î·È Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ˘Û›·Û ÚÔÛˆÚÈÓ‹ Âȉ›ӈÛË (8).

OÈ ¶·ÓÙÂÏÈ¿‰Ë˜ Î·È Û˘Ó ÌÂϤÙËÛ·Ó 12 ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÛÙ· ÔÔ›· Ô ‚·ıÌfi˜ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÂÎÙÈÌ‹ıËΠ̠ÙËÓ ÙÚÔÔÔÈË̤ÓË Îϛ̷η Ashworth Î·È ÙË ¯Ú‹ÛË ÁˆÓÈfiÌÂÙÚÔ˘ (9).

OÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ˘ÂÚÙÔÓ›·˜ Û fiÏÔ˘˜ ÙÔ˘˜ Ì˘˜ Ô˘ ÂÓ¤ıËÎ·Ó Î·È ·‡ÍËÛË ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ·ıËÙÈÎÒÓ Î·È ÂÓÂÚÁËÙÈÎÒÓ ÎÈÓ‹ÛÂˆÓ ÛÙÔ ÈÛ¯›Ô, ÙÔ ÁfiÓ·ÙÔ, ÙË Ú·¯È·›· ¤ÎÙ·ÛË ÙÔ˘ ¿ÎÚÔ˘ Ô‰fi˜, fiˆ˜ Î·È ÙÔ˘ ηÚÔ‡. ∏ Â·Ó¿ÏË„Ë ÙˆÓ ›‰ÈˆÓ ‰fiÛÂˆÓ ÌÂÙ¿ 5-6 Ì‹Ó˜ ›¯Â ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù·. ™Â Ì›· ‰Â‡ÙÂÚË ÂÚÁ·Û›·, Ë ÔÔ›· ‰ËÌÔÛȇÂÙ·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜, ¯ÔÚËÁ‹ıËΠ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Û 67 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, Û 89 Û˘Ó‰ڛ˜, Ù· ÔÔ›· ÂÎÙÈÌ‹ıËÎ·Ó ÎÏÈÓÈο. ∏ Û˘ÁÁڷʤ·˜ ·Ó·Ê¤ÚÂÈ fiÙÈ ÙÔ 85% ÙˆÓ ·ÛıÂÓÒÓ ¤Ù˘¯Â Ï‹Úˆ˜ ‹ ÌÂÚÈÎÒ˜ ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ÛÙfi¯Ô Ô˘ ›¯Â ÙÂı› ÚÈÓ ÙËÓ ¤Á¯˘ÛË. ∂ÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ∏ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ‰ÂÓ ·ÔÙÂÏ› ıÂÚ·¢ÙÈÎfi ÛÙfi¯Ô, ·ÏÏ¿ ÂȉÈÒÎÂÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ‚ÂÏÙȈı› Ë Î›ÓËÛË, Ó· ‰È¢ÎÔÏ˘Óı› ÙÔ ÚfiÁÚ·ÌÌ· Ù˘ Ê˘ÛÈÎÔıÂÚ·›·˜ Î·È Ë ÂÚÈÔ›ËÛË ÙÔ˘ ·ÛıÂÓ‹, Î·È Ó· ÚÔÏËÊıÔ‡Ó ÔÈ ·Á΢ÏÒÛÂȘ Î·È ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ¶ÚÈÓ ·Ú¯›ÛÂÈ Ë ıÂÚ·›·, Ú¤ÂÈ Ó· ˘ÔÏÔÁÈÛÙ› ÙÔ ÎÏÈÓÈÎfi fiÊÂÏÔ˜ ÁÈ· ÙÔÓ Û˘ÁÎÂÎÚÈ̤ÓÔ ·ÛıÂÓ‹ Î·È Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ¤Ó·˜ ÛÙfi¯Ô˜ Ì ÙË Û˘ÓÂÚÁ·Û›· ÔÌ¿‰·˜ ÁÈ·ÙÚÒÓ, ıÂÚ·¢ÙÒÓ Î·È ÎˉÂÌfiÓˆÓ, ·ÊÔ‡ ÏËÊıÔ‡Ó ˘’ fi„ÈÓ fiÏ· Ù· ˘¿Ú¯ÔÓÙ· ηٿÏÏËÏ· ıÂÚ·¢ÙÈο ̤۷ Ù· ÔÔ›· ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË. OÈ Û˘¯ÓfiÙÂÚÔÈ ÏÂÈÙÔ˘ÚÁÈÎÔ› ÛÙfi¯ÔÈ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ‚¿‰ÈÛ˘ Î·È Ù˘ ÛÙ¿Û˘. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·Û¯fiÓÙˆÓ Â›Ó·È ÎÚ›ÛÈÌË ÁÈ· ÙËÓ ÂÈÙ˘¯›· Ù˘ ıÂÚ·›·˜. ∆Ô ‚·ÛÈÎfi ÎÚÈÙ‹ÚÈÔ Â›Ó·È Ë ·ÚÔ˘Û›· Â›ÌÔÓ˘

Paediatriki 2002;65:147-150

‹ ‰˘Ó·ÌÈ΋˜ ˘ÂÚÙÔÓ›·˜ Î·È Ë ·Ô˘Û›· ·Á΢ÏÒÛˆÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË ‹ ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ ·Ú¿Ï˘Û˘. ™ÙÔ˘˜ ÂÓÂı¤ÓÙ˜ Ì˘˜ ‰ÂÓ ı· Ú¤ÂÈ, Â›Û˘, Ó· ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÂÏÂÁ¯fiÌÂÓË (·fi ÙË Û·ÛÙÈÎfiÙËÙ·) Ì˘˚΋ ·‰˘Ó·Ì›·, Ë ÔÔ›· ÌÔÚ› Ó· ·ÔÎ·Ï˘Êı› ÌÂÙ¿ ÙȘ ÂÓ¤ÛÂȘ. ∂Ӊ›ÍÂȘ ÁÈ· ÙË ıÂÚ·›· ÛÙÔ ¿Óˆ ¿ÎÚÔ Â›Ó·È Ë Â›ÌÔÓË Î¿Ì„Ë ÙÔ˘ ·ÓÙ›¯ÂÈÚ·, Ë ÌfiÓÈÌË ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ̤۷ ÛÙËÓ ·Ï¿ÌË, Ë Î¿Ì„Ë ÙÔ˘ ηÚÔ‡ Ô˘ ÂÌÔ‰›˙ÂÈ ÙË ¯Ú‹ÛË ÙÔ˘ ¯ÂÚÈÔ‡, Ë ÌÂÁ¿ÏË Î¿Ì„Ë ÙÔ˘ ·ÁÎÒÓ·. ™ÙÔ Î¿Ùˆ ¿ÎÚÔ, ÔÈ ÂӉ›ÍÂȘ Â›Ó·È Ë ‰˘Ó·ÌÈ΋ ÈÔÔ‰›· Û fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ·ÎÏÔ˘ ‚¿‰ÈÛ˘, Ë ‰˘Ó·ÌÈ΋ Î¿Ì„Ë ÙÔ˘ ÁfiÓ·ÙÔ˜ Û ÁˆÓ›· 20Ô Û fiÏÔ ÙÔÓ Î‡ÎÏÔ Ù˘ ‚¿‰ÈÛ˘ Î·È Ë ÛËÌ·ÓÙÈ΋ ÂÊ›¢ÛË ÙˆÓ ÈÛ¯›ˆÓ. ∞ÊÔ‡ ·ÔÊ·ÛÈÛÙ› Ë ıÂÚ·›·, ÂÊ·ÚÌfi˙ÂÙ·È ¤Ó· Û¯¤‰ÈÔ ‚¿ÛÂÈ ·ÏÁfiÚÈıÌˆÓ (10). ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ‰È·Ù›ıÂÙ·È Û·Ó Î·Ù„˘Á̤ÓË ÍËÚ‹ ÛÎfiÓË Û ÊÈ·Ï›‰È·, Ù· ÔÔ›· ‰È·ÙËÚÔ‡ÓÙ·È Û 4ÔC Î·È Ú¤ÂÈ Ó· ·Ó·Û˘ÓÙÂı› Ì ‰È¿Ï˘Ì· ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ 0,9%. ªÂ ÙÔ BOTOX, ÔÈ ÌÈÎÚÔ› ̇˜ ÂÓ›ÂÓÙ·È Ì ‰fiÛË 1-3 U/kg B.™. Î·È ÔÈ ÌÂÁ¿ÏÔÈ 3-6 U/kg B.™. ∏ ̤ÁÈÛÙË ‰fiÛË ÛÙË ı¤ÛË Î¿ı ¤ÓÂÛ˘ Â›Ó·È 50 U. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÔÏÔÎÏ‹ÚˆÛ˘ ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ Ì ÂÓ¤ÛÂȘ, Ë Û˘ÓÔÏÈ΋ ‰fiÛË ÙÔ˘ BOTOX ·Ó¤Ú¯ÂÙ·È Û 15 U/kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ∏ ¤ÓÂÛË Á›ÓÂÙ·È Ì ۇÚÈÁÁ· Mantoux Î·È ‚ÂÏfiÓ· ÌÂÁ¤ıÔ˘˜ 27 Î·È Ì‹ÎÔ˘˜ 4 cm. O Ì˘˜ ‰È·Ù›ÓÂÙ·È Î·È Ë ¤Á¯˘ÛË Á›ÓÂÙ·È ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ̤ÁÈÛÙ˘ Ì˘˚΋˜ Ì¿˙·˜. ¶ÚˆÙfiÎÔÏÏ· Ù· ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ÂÓ¤ÛÂˆÓ ÌÔÚ› Ó· ··ÈÙ‹ÛÔ˘Ó ÌfiÓÔ ÙÔÈÎfi ·Ó·ÈÛıËÙÈÎfi. °È· ÈÔ ÂÎÙÂٷ̤ӷ ÚˆÙfiÎÔÏÏ· ÌÔÚ› Ó· ··ÈÙËı› Ë Î·Ù·ÛÙÔÏ‹ Ù˘ Û˘Ó›‰ËÛ˘ Î·È ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›·. ™Â ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, ÔÈ ÂÓ¤ÛÂȘ ÌÔÚ› Ó· Â·Ó·ÏËÊıÔ‡Ó. ∂¿Ó ‰ÂÓ ·Ú·ÙËÚËı› ·¿ÓÙËÛË ÛÙȘ ÂÓ¤ÛÂȘ, ·˘Ùfi ÌÔÚ› Ó· ÛËÌ·›ÓÂÈ ·ÔÙ˘¯›· ‹ ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ ÙÔ͛Ӣ, Ù· ÔÔ›· ·Ó·Ù‡ÛÛÔÓÙ·È Û ÔÛÔÛÙfi 7% ÙˆÓ ·Û¯fiÓÙˆÓ.

OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ì ÙËÓ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ∞ Â›Ó·È Û¿ÓȘ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó fiÓÔ ÛÙË ı¤ÛË Ù˘ ¤ÓÂÛ˘, ·ÈÌÔÚÚ·Á›·, ·›ÛıËÌ· „‡¯Ô˘˜ ÛÙÔ˘˜ ÂÓÂı¤ÓÙ˜ Ì˘˜, ÂÍ¿ÓıËÌ·, ·ÏÏÂÚÁÈ΋ ·ÓÙ›‰Ú·ÛË, Û˘ÌÙÒÌ·Ù· ÁÚ›˘, ˘ÂÚ‚ÔÏÈ΋ ·‰˘Ó·Ì›·, ‰˘ÛÎÔÈÏÈfiÙËÙ· Î·È ÎfiˆÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Brin MF. Botulinum toxin: Chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 1997;6:S146-S168.

2. Boyd RN, Pliatsios V, Starr R, Wolfe R, Graham HK. Biomechanical transformation of the gastrocnemius muscle with botulinum toxin A in children with cerebral palsy. Dev

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Med Child Neurol 2000;42:32-41.

3. Graham HK, Aoki KR, Autti-Ramo I, Boyd RN, Delgado MR, Gaebler-Spira DJ et al. Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture 2000;11:67-79.

4. Boyce W, Gowland C, Rosenbaum P, Lane M, Plews N, Goldsmith C et al. Gross motor performance measure for children with cerebral palsy: study design and preliminary findings. Can J Public Health 1992;83(Suppl 2):S34-S40.

5. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial.

BOTOX Study Group. J Pediatr Orthop 2000;20:108-115.

6. Koman LA, Brashear A, Rosenfeld S, Chambers H, Russman B, Rang M et al. Botulinum toxin type A neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial. Pediatrics 2001;108:1062-1071.

7. Bakheit AM, Severa S, Cosgrove A, Morton R, Rousso SH,

Doderlein L et al. Safety profile and efficacy of botulinum toxin A (Dysport) in children with muscle spasticity. Dev Med Child Neurol 2001;43:234-238.

8. Corry IS, Cosgrove AP, Walsh EG, McClean D, Graham HK. Botulinum toxin A in the hemiplegic upper limb: a double-blind trial. Dev Med Child Neurol 1997;39:185-193.

9. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã, ª·Ï¿Ûη ∞, ∆˙ËÙËÚ›‰Ô˘ ª, ∫ÔÙ˙·ÂÚ›‰Ô˘ O, ∫·Ú·Ù˙¿-•ÈÊÏ›‰Ô˘ ∂. ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂÚ·›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. ¶·È‰È·ÙÚÈ΋ 2000;63:412-417.

10. Edgar TS. Clinical utility of botulinum toxin in the treatment of cerebral palsy: Comprehensive Review. J Child Neurol 2001;16:37-46.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 16-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÁÁÂÏÈ΋ ™Î·Ú‰Ô‡ÙÛÔ˘ Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 54, ∆.∫. 115 28, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ÕÛıÌ· Ô˘ “ÍÂÂÚ¿ÛÙËΔ ‰ÂÓ ÛËÌ·›ÓÂÈ ·Ô˘Û›· ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ∆Ô 30-80% ÙˆÓ ·ÛıÌ·ÙÈÎÒÓ ·È‰ÈÒÓ Ô˘ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙË ÓfiÛÔ, Â·ÓÂΉËÏÒÓÔ˘Ó ·ÛıÌ·ÙÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ·ÚÁfiÙÂÚ· ÛÙË ˙ˆ‹ ÙÔ˘˜. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÈ· Ù¤ÙÔÈ· ÂͤÏÈÍË Â›Ó·È ÂÓ ÔÏÏÔ›˜ ¿ÁÓˆÛÙÔÈ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂϤÁ¯ıËÎÂ Ë ‡·ÚÍË ˘ÔΛÌÂÓ˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ÛÙ· ·È‰È¿ Ô˘ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙÔ ¿ÛıÌ· ÙÔ˘˜. ªÂ ÌË ‚ÚÔÁ¯ÔÛÎÔÈ΋ ̤ıÔ‰Ô ÂÏ‹ÊıË ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì· ·fi Ê˘ÛÈÔÏÔÁÈο ·È‰È¿ (n=35) Î·È ·fi ·È‰È¿ Ì ÈÛÙÔÚÈÎfi Û˘ÚÈÁÌÔ‡ (n=35). µÚ¤ıËΠ·‡ÍËÛË ÙˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÛÙÔ ¤ÎÏ˘Ì· ·ÙÔÈÎÒÓ ·È‰ÈÒÓ Ô˘ ÂıˆÚ›ÙÔ fiÙÈ ¤¯Ô˘Ó “ÍÂÂÚ¿ÛÂÈ” ÙÔ ¿ÛıÌ· ÙÔ˘˜ (̤ÛË ÙÈÌ‹ [‡ÚÔ˜ ÌÂÛ·›ˆÓ ÙÂÙ·ÚÙËÌÔÚ›ˆÓ] 0,36 [0,050,74] Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ 0,10 [0-018], p=0,002). ¢ÂÓ ·Ó¢ڤıË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‰È¿ÚÎÂÈ·˜

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‡ÊÂÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙÔ˘ ‚·ıÌÔ‡ ˈÛÈÓÔÊÈÏ›·˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. ™˘ÌÂÚ·›ÓÔÓÙ·˜, ˘¿Ú¯ÂÈ ÂÈÌÔÓ‹ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Û ÌÂÚÈο ·È‰È¿ Ô˘ ¤¯Ô˘Ó "ÍÂÂÚ¿ÛÂÈ" ÙÔ ¿ÛıÌ· ÙÔ˘˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ›Ûˆ˜ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘.

1

Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis M et al Outgrown asthma does not mean no airways inflammation Eur Respir J 2002;19:284-287

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REVIEW ARTICLE

π‰ÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙ· ·È‰È¿ (πº¡∂) ∂. ƒÒÌ· - °È·ÓÓ›ÎÔ˘

Inflammatory bowel disease (IBD) in children E. Roma - Giannikou

¶ÂÚ›ÏË„Ë: ∏ ȉÈÔ·ı‹˜ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ¯ÚfiÓÈÔ ÓfiÛËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Û˘¯Ó¿ ‰Â ÚÔ‚ÏËÌ·Ù›˙ÂÈ ÛÙË ‰È¿ÁÓˆÛË Î·È Î·Ù’ ÂÍÔ¯‹Ó ÛÙË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ¶ÂÚ›Ô˘ ÙÔ 20% ÙˆÓ ÂÓËÏ›ÎˆÓ ¤¯ÂÈ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, fiÔ˘ Û˘Ó‹ıˆ˜ ¤¯ÂÈ ‚·Ú‡ÙÂÚË ÔÚ›·. ™‹ÌÂÚ· Ë ÚfiÔ‰Ô˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤Ú¢ӷ ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ¤¯ÂÈ ‚ÔËı‹ÛÂÈ ÛÙËÓ ·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏˆÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÊÏÂÁÌÔÓ‹˜. °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÁÈ· ÙËÓ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·, ÙËÓ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹, ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤Ï·ÛË Î·È ÙË ıÂÚ·›·.

Abstract: Inflammatory bowel disease (πµD) is an important chronic disease of childhood that often presents problems regarding the diagnosis and especially the therapeutic approach. Almost 20% of adult cases have their oncet in childhood.

The progress noted during the recent years concerning the pathogenesis of the disease has contributed significantly to the discovery of appropriate drugs for the treatment of the inflammatory process. This review article gives the current data concerning the pathogenesis, clinical presentation, diagnostic approach and the treatment of this disease entity.

§¤ÍÂȘ ÎÏÂȉȿ: πº¡∂, ÂÏÎ҉˘ ÎÔÏ›ÙȘ, ÓfiÛÔ˜ Crohn, ·È‰È¿.

Key words: IBD, ulcerative colitis, Crohn’s disease, children.

∂ÈÛ·ÁˆÁ‹ O fiÚÔ˜ πº¡∂ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ÂÚÈÁÚ·Ê‹ Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn, ‰‡Ô ȉÈÔ·ıÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ Î·È Í¯ˆÚ›˙Ô˘Ó ÌÂٷ͇ ÙÔ˘˜ ·fi ÙËÓ ÂÓÙfiÈÛË Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÊÏÂÁÌÔÓ‹˜ (1-3). ∞ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ·ÎfiÌ· Î·È ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, ·ÏÏ¿ ηْ ÂÍÔ¯‹Ó ÛÙËÓ ÂÊ˂›· (3,4). ∂ȉËÌÈÔÏÔÁ›· OÈ ÌÂϤÙ˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÓfiÛÔ˘, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ·fiÎÏÈÛË ÌÂٷ͇ ÙÔ˘˜ (5,6). ¶·ÁÎÔÛÌ›ˆ˜ ˘ÔÏÔÁ›˙ÂÙ·È

fiÙÈ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚ›Ô˘ 20 Ӥ˜ ÂÚÈÙÒÛÂȘ/100.000 ηÙÔ›ÎÔ˘˜ ÙÔ ¯ÚfiÓÔ, ÂÓÒ ‰È·ÈÛÙÒÓÂÙ·È ÛÙ·ıÂÚ‹ ·‡ÍËÛË Ù˘ Ó. Crohn ÌÂÙ¿ ·fi ÙÔ 1950. ™ÙËÓ ∞ÌÂÚÈ΋, Ë Û˘¯ÓfiÙËÙ· Û ·È‰È¿ 10-19 ¯ÚÔÓÒÓ Â›Ó·È 2/100.000 ÁÈ· ÙËÓ ∂∫ Î·È 3,5/100.000 ÁÈ· ÙË Ó. Crohn, ÂÓÒ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÚÔԉ¢ÙÈο ÌÂÈÒÓÂÙ·È Ë ËÏÈΛ· ¤Ó·Ú͢. Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÂÚ›Ô˘ Û ÔÛÔÛÙfi 20% ÙˆÓ ·ÛıÂÓÒÓ Ì πº¡∂, Ù· Û˘ÌÙÒÌ·Ù· ·Ú¯›˙Ô˘Ó ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·. ™ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ·ÎfiÌË Î·Ù·ÁÚ·Ê‹ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ô‡Ù ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ Ô‡Ù ÛÙ· ·È‰È¿ ÛÙÔ Û‡ÓÔÏÔ Ù˘ ¯ÒÚ·˜. ™Ù· Ï·›ÛÈ· ∂˘Úˆ·˚΋˜ ÌÂϤÙ˘, ÌÂÌÔӈ̤ӷ ÛÙËÓ ∫Ú‹ÙË ·fi ÙÔÓ ª·ÓÔ‡ÛÔ Î·È Û˘Ó ‚Ú¤ıËÎÂ Ë Û˘¯ÓfiÙËÙ· Ù˘ ∂∫ 16,6 Î·È Ù˘ Ó. Crohn 7,5 ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜ Î·È ÛÙ· πˆ¿ÓÓÈÓ· ·fi ÙÔ˘˜ ∆ÛÈ¿ÓÔ Î·È Û˘Ó

¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

Pediatric Gastroenterology 1st Pediatric Clinic of University of Athens

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¶·È‰È·ÙÚÈ΋ 2002;65:151-159

Paediatriki 2002;65:151-159

8,5 Î·È 1 ·Ó¿ 100.000 ηÙÔ›ÎÔ˘˜, ·ÓÙ›ÛÙÔȯ· (6). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· ÓÔÛËχıËÎ·Ó 320 ·È‰È¿ (236 Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È 69 Ì ÓfiÛÔ Crohn) (¶›Ó·Î·˜ 1). °ÂÁÔÓfi˜ Â›Ó·È fiÙÈ ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· Û ÔÛÔÛÙfi 15-25% Î·È Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË Ì ˘‡ı˘Ó· Û˘ÁÎÂÎÚÈ̤ӷ ÁÔÓ›‰È· (7,8). ∫ÏÈÓÈ΋ ÂÈÎfiÓ· À¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ÌÂٷ͇ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È ÓfiÛÔ˘ Crohn (1-4) (¶›Ó·Î·˜ 2). ™ÙËÓ ÏÂÈÔÓfiÙËÙ·, Ù· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ∂∫ ¤¯Ô˘Ó ‹È· Û˘ÌÙÒÌ·Ù·, fiˆ˜ ‰È·ÚÚÔ˚Τ˜ ·ÈÌÔÚÚ·ÁÈΤ˜ ÎÂÓÒÛÂȘ Î·È ‹È· ÎÔÈÏȷο ¿ÏÁË Ô˘ Û˘Ó‹ıˆ˜ ÂÓÙÔ›˙ÔÓÙ·È ÛÙÔ ·ÚÈÛÙÂÚfi ÎfiÏÔÓ. ªfiÓÔ Û ÔÛÔÛÙfi 5% ÚÔ¤¯Ô˘Ó ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, ·ÚıÚÔ¿ıÂÈ·, ‰ÂÚÌ·ÙÈΤ˜ ‹ Ë·ÙÈΤ˜ ÂΉËÏÒÛÂȘ. °ÂÓÈο, Ë ‚·Ú‡ÙËÙ· ÙˆÓ ·Ú¯ÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ù˘ ∂∫ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ ÂÓÙÂÚÈ΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ Ù˘ ÂÚ·ÈÙ¤Úˆ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘ (1). ∂ÓÒ Ë ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ÚÚÔÈ· Â›Ó·È ÙÔ Î‡ÚÈÔ Û‡Ìو̷ Û ÂÚÈÛÛfiÙÂÚÔ ·fi 90% ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, Ë ·Ú¯È΋ ÚÔ‚ÔÏ‹ Ù˘ ÓfiÛÔ˘ Crohn Â›Ó·È ÈÔ ·ıfiÚ˘‚Ë. ∏ ÎÏ·ÛÈ΋ ÂÈÎfiÓ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÔÈÏȷο ¿ÏÁË, ‰È¿ÚÚÔÈ·, ·ÓÔÚÂÍ›· Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜. ∂ÓÙÔ‡ÙÔȘ, Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ë ÚÔ‚ÔÏ‹ Â›Ó·È Ï·Óı¿ÓÔ˘Û· Ì ÚÔÂÍ¿Ú¯Ô˘Û˜ ÙȘ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ηı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ‹È· ÌË ÂȉÈο ÂÓÙÂÚÈο Û˘ÌÙÒÌ·Ù·, Ô˘ Ô‰ËÁÔ‡Ó ÙÂÏÈο Û ¶›Ó·Î·˜ 1. ¶·È‰È¿ Ì πº¡∂ ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ* ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ¡fiÛÔ˜ Crohn Indeterminate ÎÔÏ›ÙȘ ∞˘ÙÔ¿ÓÔÛË ™‡ÓÔÏÔ

236 69 8 7 320

* ÌË ‰ËÌÔÛÈÂ˘Ì¤Ó· ‰Â‰Ô̤ӷ

¶›Ó·Î·˜ 2. ∫ÏÈÓÈ΋ ÂÈÎfiÓ·

¢È¿ÚÚÔÈ· ∞ÈÌÔÚÚ·Á›· ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ∫·ı˘ÛÙ. ÛˆÌ. ·Ó¿Ù˘ÍË ¶ÚÔ¤¯Ô˘Ó

152

∂ÏÎ.ÎÔÏ›ÙȘ

Crohn

50% >90% 65% 10% ∆ÂÈÓÂÛÌfi˜

80% 50% 80% 35% ∞ÓÔÚÂÍ›·, ÎÔÈÏ. ¿ÏÁË, Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ

ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘. ¶Ú¿ÁÌ·ÙÈ, ·fi ÙË ÌÂϤÙË Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÛÙ· ·È‰È¿ Ì Crohn Ë ÓfiÛÔ˜ ‰È·ÁÓÒÛıËΠηٿ ̤ÛÔ fiÚÔ ÌÂÙ¿ 16 Ì‹Ó˜, ÂÓÒ Û ·˘Ù¿ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ÌÂÙ¿ 10 Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ™Ù· Ê·ÈÓÔÌÂÓÈο ·Û˘Ìو̷ÙÈο ·È‰È¿, ÌÂÏÂÙÒÓÙ·˜ ÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ ÙȘ ηÌ‡Ï˜ ۈ̷ÙÈ΋˜ ÙÔ˘˜ ·Ó¿Ù˘Í˘, ‰È·ÈÛÙÒÓÂÙ·È Î·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·‡ÍËÛ˘ ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, Ô˘ ÛËÌ·›ÓÂÈ ˘ÔÎÏÈÓÈ΋ ÌÂÓ, ·ÏÏ¿ ÛËÌ·ÓÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÓfiÛÔ˘. ™Â ÔÏÏ¿ ·fi ·˘Ù¿ Ù· ·È‰È¿ ‰È·ÁÈÁÓÒÛÎÂÙ·È Ë ÓfiÛÔ˜ fiÙ·Ó ÂÌÊ·Ó›ÛÔ˘Ó ÎÔÈÏȷο Û˘ÌÙÒÌ·Ù· ‹ ·Ú·¤ÌÔÓÙ·È ·fi ÙÔÓ ÂÓ‰ÔÎÚÈÓÔÏfiÁÔ. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Ó. Crohn ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ Ô˘ Â›Ó·È Î·Ù’ ÂÍÔ¯‹Ó ÛÙÔÓ ÙÂÏÈÎfi ÂÈÏÂfi, ÂÓÒ Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi Û˘ÌÌÂÙ¤¯ÂÈ ÙÔ ·¯‡ ¤ÓÙÂÚÔ. ™Â ÔÛÔÛÙfi ̤¯ÚÈ 40% ˘¿Ú¯ÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ (ÔÈÛÔÊ¿ÁÔ˘, ÛÙÔÌ¿¯Ô˘ ‹ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘) ÛÙ· ·È‰È¿ Î·È ÁÈ’ ·˘Ùfi Û˘Ó‰˘¿˙ÂÙ·È ÂÓ‰ÔÛÎÔÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÓÒÙÂÚÔ˘ Î·È Î·ÙÒÙÂÚÔ˘ ÂÙÈÎÔ‡ Û˘Á¯ÚfiÓˆ˜ (1,2). ∞Ó·ÏfiÁˆ˜ Ù˘ ÂÓÙfiÈÛ˘, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› 3 Ù‡ÔÈ: ·) ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ì ӷ˘Ù›·, Â̤ÙÔ˘˜, ‰È¿ÚÚÔÈ·, ·ÓÔÚÂÍ›·, ÌÂÙ·ÁÂ˘Ì·ÙÈο ÎÔÏÈÎÔÂȉ‹ ¿ÏÁË Î·È Û˘ÌÙÒÌ·Ù· ‰˘Û„›·˜, ‚) ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ÌÂ Û˘ÌÙÒÌ·Ù· fiÌÔÈ· Ì ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÔfiÙÂ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· Á›ÓÂÈ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ·ÏÏ¿ ÛÙË Ó. Crohn ˘¿Ú¯ÂÈ Û˘¯Ó¿ ÂÚÈÚˆÎÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Î·È Á) Ì Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË.

OÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ (Û˘¯ÓfiÙËÙ· ÂÚ›Ô˘ 25-36%) ÛÙËÓ πº¡∂ (1-4) Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∏ Û˘¯ÓfiÙÂÚË Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË Â›Ó·È Ë ·ÚıÚ›Ùȉ· (ÔÛÔÛÙfi 7-26%), Ô˘ Û˘¯Ó¿ ·Ú¯Èο ıˆÚÂ›Ù·È ÚÂ˘Ì·ÙÔÂȉ‹˜, ÂÓÒ Ë ÛÔÓ‰˘Ï›Ùȉ· ÂÌÊ·Ó›˙ÂÙ·È Ì ÔÛÔÛÙfi 2-6%. ∏ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜ Î·È ÙˆÓ ¯ÔÏËÊfiÚˆÓ ·ÔÙÂÏ› Â›Û˘ Û˘¯Ó‹ Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË, ÙfiÛÔ Ù˘ πº¡∂ ÚˆÙÔ·ıÒ˜, fiÛÔ Î·È Û·Ó ·ÔÙ¤ÏÂÛÌ· Ù˘ ıÂÚ·›·˜. ™Ù· ·È‰È¿ ÌÔÚ› Ó· ÚÔËÁÂ›Ù·È Ù˘ ÂΉ‹ÏˆÛ˘ Ù˘ πº¡∂ ‹ Ó· ÂÌÊ·Ó›˙ÂÙ·È ·ÎfiÌ· Î·È ÌÂÙ¿ ÔÏÈ΋ ÎÔÏÂÎÙÔÌ‹. ∏·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi 5-8% Î·È Ë ‚Ï¿‚Ë ÌÔÚ› Ó· Â›Ó·È ÂÓ‰ÔË·ÙÈ΋ (¯ÚfiÓÈ· ÂÓÂÚÁfi˜ Ë·Ù›ÙȘ, ΛÚÚˆÛË, ·Ì˘ÏÔ›‰ˆÛË, ÏÈ҉˜ ‹·Ú, ÂÚȯÔÏ·ÁÁÂÈ›ÙȘ), Â͈Ë·ÙÈ΋ (¯ÔÏÔÏÈı›·ÛË) ‹ ÌÈÎÙ‹ (ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›ÙȘ). ∏ ÙÂÏÂ˘Ù·›· ··ÓÙ¿Ù·È Û ÔÛÔÛÙfi 3,5% ÙˆÓ ·È‰ÈÒÓ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È 1% ÙˆÓ ·È‰ÈÒÓ Ì ÓfiÛÔ Crohn. ∏ Â›ÌÔÓË ·Ú·ÌÔÓ‹ ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ¿Óˆ ·fi 6 Ì‹Ó˜ ·ÔÙÂÏ› ·fiÏ˘ÙË ¤Ó‰ÂÈÍË ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ë·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜. ÕÏÏÔÙ ¿ÏÈ Ù· ·ÚÈ· Û˘ÌÙÒÌ·Ù· ÌÔÚ› Ó· Â›Ó·È ÂÚÈÚˆÎÙÈ΋ ÓfiÛÔ˜, ÛÙÔÌ·Ù›Ùȉ·

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·153

¶·È‰È·ÙÚÈ΋ 2002;65:151-159

¶›Ó·Î·˜ 3. ∂͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ ñ ∞ÚıÚ›Ùȉ· (7-26%), ÛÔÓ‰˘Ï›Ùȉ· (6%) ñ OÛÙÂÔÂÓ›·, ¿ÛËÙË Ó¤ÎÚˆÛË ñ O˙҉˜ ÂÚ‡ıËÌ· (5-10%), Á·ÁÁÚ·ÈÓ҉˜ ˘fi‰ÂÚÌ· ñ OÊı·ÏÌÈ΋ Û˘ÌÌÂÙÔ¯‹ (Ú·ÁÔÂȉ›Ùȉ·, ÂÈÛÎÏËÚ›Ùȉ·, ÎÂÚ·Ù›Ùȉ·) ñ ∞ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ıÚÔÌ‚ÒÛÂȘ, Ó¢Ì. ÂÌ‚ÔÏ‹) ñ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ (·Ó·ÈÌ›·, ıÚÔÌ‚Ô΢ÙÙ¿ÚˆÛË) ñ ∏·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ (ÛÎÏËÚ. ¯ÔÏ·ÁÁ/ÙȘ, ¯Ú. Ë·Ù›ÙȘ, ΛÚÚˆÛË) ñ ¶·ÁÎÚ·ٛÙȘ ñ ¡ÂÊÚÔÏÈı›·ÛË, ˘‰ÚÔÓ¤ÊÚˆÛË, ÂÓÙÂÚÔ΢ÛÙÈο Û˘Ú›ÁÁÈ·, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›ÙȘ ñ ÀÔÛÈÙÈÛÌfi˜, ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, ÂÓ‹‚ˆÛË

‹ Ô˙҉˜ ÂÚ‡ıËÌ· (5-10%), ÂÓÒ Ë ÔÊı·ÏÌÈ΋ Û˘ÌÌÂÙÔ¯‹ Â›Ó·È ÂÚ›Ô˘ 4% (ÂÈÛÎÏËÚ›Ùȉ· Î·È Ú·ÁÔÂȉ›ÙȘ). OÈ ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (ıÚfiÌ‚ˆÛË, Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹) Â›Ó·È Û¿ÓȘ, ·ÏÏ¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ∏ ıÚÔÌ‚ÔÂÌ‚ÔÏÈ΋ ÓfiÛÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ πº¡∂ ıˆÚÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ˘ÂÚËÎÙÈÎfiÙËÙ· Ô˘ Û˘Ì‚·‰›˙ÂÈ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È ÂΉËÏÒÓÂÙ·È Ì ıÚÔÌ‚Ô·ÙÙˆÛË, ·‡ÍËÛË ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘, ÙÔ˘ ·Ú¿ÁÔÓÙ· V, VIππ Î·È Ì›ˆÛË Ù˘ ·ÓÙÈıÚÔÌ‚›Ó˘ IIπ. Œ¯ÂÈ ‰È·ÈÛÙˆı› ·ÓÙÔ¯‹ Ù˘ ·ÓÙÈËÎÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ÚˆÙ½Ó˘ C Î·È Ë ÌÔÚȷ΋ ‚Ï¿‚Ë Ô˘ Â›Ó·È ˘‡ı˘ÓË Â›Ó·È Ë ÌÂÙ¿ÏÏ·ÍË ÛÙÔ ÌfiÚÈÔ ÙÔ˘ ·Ú¿ÁÔÓÙ· V (factor Leiden) (9). ∂›Û˘, ·Ú·ÙËÚÔ‡ÓÙ·È ·ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ fiˆ˜ ·Ó·ÈÌ›· (ÛȉËÚÔÂÓÈ΋, ÌÂÁ·ÏÔ‚Ï·ÛÙÈ΋, ¯ÚfiÓÈ·˜ ÓfiÛÔ˘, ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋) (10), ÂΉËÏÒÛÂȘ ·fi ÙÔ Ô˘ÚÔÔÈËÙÈÎfi fiˆ˜ ÓÂÊÚÔÏÈı›·ÛË (5%), ˘‰ÚÔÓ¤ÊÚˆÛË, ÂÈÏÂÔ΢ÛÙÈο Û˘Ú›ÁÁÈ·, Ô˘ÚÔÏÔÈÌÒÍÂȘ Î·È ·Ì˘ÏÔ›‰ˆÛË. °ÂÓÈο, ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Û˘ÓÔ‰Â‡Ô˘Ó Û˘¯ÓfiÙÂÚ· ÙË ÓfiÛÔ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ÂÓÒ Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÂÓ‹‚ˆÛË ·ÔÙÂÏ› ÎÏ·ÛÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Crohn ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (1,2,4). ÀÔÛÈÙÈÛÌfi˜ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË O ˘ÔÛÈÙÈÛÌfi˜ ·ÔÙÂÏ› Ì›˙ÔÓ· ÂÈÏÔ΋ Ù˘ πº¡∂ Û fiϘ ÙȘ ËÏÈ˘ (˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ 85% ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ Ì ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ ˘ÔÛÈÙÈÛÌfi ÚˆÙ½Ó˘ Î·È ÂÓ¤ÚÁÂÈ·˜) Î·È Ô‰ËÁ› Û ηı˘ÛÙ¤ÚËÛË Ù˘ ÔÛÙÈ΋˜ ˆÚ›Ì·ÓÛ˘, Ù˘ ÂÌÌËÓ·Ú¯‹˜, ÂÓÒ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ÂÌÊ·Ó›˙ÂÈ ÙÂÏÈο ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (1-4). π‰È·›ÙÂÚ· ÛÙË Ó. Crohn ÂËÚ¿˙ÂÙ·È ÙÔ ·Ó¿ÛÙËÌ· Î·È ¤¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÙÂÏÈο ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ÌfiÓÔ ÙÔ 12% ‰ÂÓ ı· ÂËÚ·ÛÙ› ·fi ÙË ÓfiÛÔ (3). ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ¤¯ÂÈ ÙÔ 65% ÛÙËÓ ∂∫ Î·È ÙÔ 85% ÛÙËÓ Crohn Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË 10% Î·È 30% ·ÓÙ›ÛÙÔȯ·. ∞˘Ùfi ÔÊ›ÏÂÙ·È

Paediatriki 2002;65:151-159

ÛÙË ÌÂȈ̤ÓË ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ, ÙË ‰˘Û·ÔÚÚfiÊËÛË, ÙËÓ ·‡ÍËÛË ÙˆÓ ·ˆÏÂÈÒÓ ·fi ÙÔ ¤ÓÙÂÚÔ, ÙËÓ Â›‰Ú·ÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙȘ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ. O ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈÎfi˜, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÎÔÚÙÈ˙fiÏË Î·È ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÌÔÚ› Ó· Â›Ó·È ÌÂȈ̤ÓË, ·ÏÏ¿ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ‰È¤ÁÂÚÛË, ηıÒ˜ Â›Û˘ Ô insulin-like growth factor-1 Â›Ó·È ÌÂȈ̤ÓÔ˜ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÛÙËÓ ·Ó¿Ù˘ÍË, Â˘Ú‹Ì·Ù· Ô˘ ·ÓÙ·Ó·ÎÏÔ‡Ó ÙË ÌÂȈ̤ÓË ıÚ¤„Ë. ∂›Û˘, Ë ÛˆÌ·ÙỔ›ÓË-C Â›Ó·È ÌÂȈ̤ÓË Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Â·Ó¤Ú¯ÂÙ·È ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÌÂÙ¿ ·fi ÙË ‰È·ÈÙËÙÈ΋ ·Ú¤Ì‚·ÛË. ∞Ó Î·È Ù· ÛÙÂÚÔÂȉ‹ ÂÓ‰¤¯ÂÙ·È Ó· ÚÔηϤÛÔ˘Ó Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË, Û˘Ó‹ıˆ˜ ÂÈÙÚ¤Ô˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË (1,2). ∂›Û˘, ·Ú·ÙËÚÂ›Ù·È ·ÓÂ¿ÚÎÂÈ· Û ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›·, fiˆ˜ Ê˘ÏÏÈÎfi Î·È µ12, ∞DEK, Ûȉ‹ÚÔ˘ Î·È „¢‰·ÚÁ‡ÚÔ˘, ÛÂÏËÓ›Ô˘, ¯·ÏÎÔ‡, ÓÈÎÂÏ›Ô˘. ∞ÈÙÈÔ·ıÔÁ¤ÓÂÈ· ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Ù˘ ÓfiÛÔ˘ ÙÔ˘ Crohn Â›Ó·È ·ÎfiÌË ¿ÁÓˆÛÙË. ¶Èı·ÓfiÓ ˘ÂÈÛ¤Ú¯ÔÓÙ·È ÁÂÓÂÙÈÎÔ› Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (4,7,8). ∞Ó Î·È Ë ·ÎÚÈ‚‹˜ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ¯ÚfiÓÈ· ‰È¤ÁÂÚÛË ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙÔ ¤ÓÙÂÚÔ Û ÁÂÓÂÙÈο ¢¿ÏˆÙ· ¿ÙÔÌ·, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ¯ÚfiÓÈ· ‚ÏÂÓÓÔÁÔÓÈ΋ ‚Ï¿‚Ë (11). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ¤ÓÙÂÚÔ ‚Ú›ÛÎÂÙ·È Û ÌfiÓÈÌË ·ÓÔÛÔÏÔÁÈ΋ ‰È¤ÁÂÚÛË ·fi ÌÈÎÚԂȷο Î·È ÙÚÔÊÈο ·ÓÙÈÁfiÓ·. ™˘ÓÂÒ˜, ÙÔ ¤ÓÙÂÚÔ ‚Ú›ÛÎÂÙ·È Û ÌfiÓÈÌË “Ê˘ÛÈÔÏÔÁÈ΋ ÊÏÂÁÌÔÓ‹”, Ì ̤ÙÚÈÔ ·ÚÈıÌfi ·ÓÔÛÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ¯fiÚÈÔ (ÏÂÌÊÔ·ÙÙ·Ú·, Ì·ÎÚÔÊ¿Á·, Ï·ÛÌ·ÙÔ·ÙÙ·Ú·) (11). ¶ÈÛÙ‡ÂÙ·È fiÙÈ ·˘Ù‹ Ë ÈÛÔÚÚÔ›· ‰È·Ù·Ú¿ÛÛÂÙ·È ÛÙËÓ πº¡∂ Î·È ÚÔηÏÂ›Ù·È ·ıÔÏÔÁÈ΋ ÊÏÂÁÌÔÓ‹ Ì ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë. OÈ Î˘ÙÙ·ÚÔΛÓ˜ ·ÔÙÂÏÔ‡Ó ÙÔ ÎÏÂȉ› ÛÙËÓ ·ÓÔÛÔÚÚ‡ıÌÈÛË (4,12). ™ÙËÓ πº¡∂ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÈÛÔÚÚÔ›· ÌÂٷ͇ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î·È ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (IL-4, IL-10 Î·È TGF-‚). Œ¯Ô˘Ó, ‰ËÏ·‰‹, ‰È·ÈÛÙˆı› ·˘ÍË̤ӷ Â›‰· ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ (IL-1,6,8 Î·È TNF·) Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ·fi Ù· Ì·ÎÚÔÊ¿Á·, ÏÂÌÊÔ·ÙÙ·Ú· Î·È ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·. ∞˘Ùfi˜ Ô Î·Ù·ÚÚ¿ÎÙ˘ Ô‰ËÁ› ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÈÛÙÔ‡, Ô˘ ·ÓÙÈηı›ÛÙ·Ù·È ·fi ÈÓÒ‰Ë ÈÛÙfi. OÈ ›‰ÈÔÈ ·Ú¿ÁÔÓÙ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙËÓ ¤ÎÎÚÈÛË ËÏÂÎÙÚÔÏ˘ÙÒÓ Ô˘ ÂÈÙ›ÓÔ˘Ó ÙË ‰È¿ÚÚÔÈ·, ÂÓÒ ÛÙË ÓfiÛÔ ÙÔ˘ Crohn ÂÈϤÔÓ, ˘¿Ú¯ÂÈ ‰˘Û·ÔÚÚfiÊËÛË ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, ·ÒÏÂÈ· ¯ÔÏÈÎÒÓ ·Ï¿ÙˆÓ Î·È ˘ÂÚ·Ó¿Ù˘ÍË ÌÈÎÚÔ‚›ˆÓ. ∏ ÂÎÙÂٷ̤ÓË ‚Ï¿‚Ë ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Ô‰ËÁ› Û ·ÒÏÂÈ· ÏÂ˘ÎˆÌ¿ÙˆÓ Î·È ·ÈÌÔÚÚ·Á›· (4).

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¶·È‰È·ÙÚÈ΋ 2002;65:151-159

Paediatriki 2002;65:151-159

¢È¿ÁÓˆÛË ¢˘ÛÙ˘¯Ò˜ ‰ÂÓ ˘¿Ú¯ÂÈ Ì›· ÂȉÈ΋ ÂͤٷÛË ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ πº¡∂ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ÌËÓ ˘¿Ú¯Ô˘Ó ÙË ÛÙÈÁÌ‹ Ô˘ Á›ÓÂÙ·È Ô ¤ÏÂÁ¯Ô˜. ∏ ‰È¿ÁÓˆÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Ï‹ÚË ÂÎÙ›ÌËÛË ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛˆÓ, ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ, ÂÓ‰ÔÛÎÔÈÎÒÓ Î·È ÈÛÙÔÏÔÁÈÎÒÓ ‰Â‰Ô̤ӈÓ. ∏ ÂÓ‰ÔÛÎfiËÛË Ì ÔÏÏ·Ϥ˜ ‚ÈÔ„›Â˜ ÂÈÙÚ¤ÂÈ ÙËÓ ¿ÌÂÛË ÂÈÛÎfiËÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ÙËÓ ÈÛÙÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË Ù˘ ÓfiÛÔ˘ Î·È ·ÔÙÂÏ› ÙËÓ ÈÔ ÂȉÈ΋ Î·È Â˘·›ÛıËÙË Ì¤ıÔ‰Ô. ∏ ÈÛÙÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË Ù˘ πº¡∂ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4 ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Ì ÚÔÂÍ¿Ú¯Ô˘Û· ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È Crohn. ∏ ÊÏÂÁÌÔÓ‹ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Â›Ó·È Î·Ù¿ Û˘Ó¤¯ÂÈ· ÈÛÙÔ‡ (¶›Ó·Î·˜ 5), ·Ú¯›˙ÂÈ ·fi ÙÔ ÔÚıfi Î·È Û˘Ó‹ıˆ˜ Ô ÙÂÏÈÎfi˜ ÂÈÏÂfi˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ÊÏÂÁÌÔÓ‹ ÛÙËÓ Crohn ÌÔÚ› Ó· Â›Ó·È ›‰È· Ì ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ·ÏÏ¿ Û˘Ó‹ıˆ˜ Â›Ó·È ÂÛÙȷ΋ ‹ ÙÌËÌ·ÙÈ΋, Û˘Ó‹ıˆ˜ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ÔÚıfi Î·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ· Û˘ÌÌÂÙ¤¯ÂÈ Ô ÙÂÏÈÎfi˜ ÂÈÏÂfi˜. ÷ڷÎÙËÚÈÛÙÈο Â›Ó·È Ù· ·ÊıÒ‰Ë ¤ÏÎË. πÛÙÔÏÔÁÈο ˘¿Ú¯Ô˘Ó Ù· ·ÔÛÙËÌ¿ÙÈ· ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È Ù· ÎÔÎÎÈÒÌ·Ù· ÛÙËÓ Crohn, Ô˘ fï˜ ·Ó¢ڛÛÎÔÓÙ·È Û ÌÈÎÚfi ÔÛÔÛÙfi. ™˘ÓÂÒ˜, ¿ÏÏÔÈ ‰Â›ÎÙ˜ fiˆ˜ Ë ÂÓ‰ÔÛÎÔÈ΋ ÂÈÎfiÓ· (fiÙ·Ó Â›Ó·È Ù˘È΋) Î·È Ë ÂÛÙȷ΋ ÊÏÂÁÌÔÓ‹ ÈÛÙÔÏÔÁÈο, Â›Ó·È ÂÓ‰ÂÈÎÙÈο Ù˘ Crohn. ∂‰Ò ı· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÂÎÙfi˜ ·fi ÙËÓ ÎÏ·ÛÈ΋ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ˘¿Ú-

¯ÂÈ Ë ·˘ÙÔ¿ÓÔÛË Î·È Ë ·ÚÔÛ‰ÈfiÚÈÛÙË (indeterminate) ÎÔÏ›ÙȘ, Ô˘ ¤¯Ô˘Ó ‰È·ÊÔÚÂÙÈ΋ ÚfiÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË. ∏ ÙÂÏÂ˘Ù·›· ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi ̤¯ÚÈ 25% Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÓ‰ÔÛÎÔÈο Î·È ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ ı˘Ì›˙Ô˘Ó Î·È Ù· ‰‡Ô ÓÔÛ‹Ì·Ù·, ·ÏÏ¿ ÌÔÚ› ÌÂÏÏÔÓÙÈο Ó· Ï¿‚ÂÈ Ù˘È΋ ÂÈÎfiÓ· Crohn (13). ∏ ·˘ÙÔ¿ÓÔÛË Î·È È‰È·›ÙÂÚ· Ë ÌÈÎÚÔÛÎÔÈ΋ (ÎÔÏÏ·ÁÔÓÈ΋ Î·È ÏÂÌÊÔ΢ÙÙ·ÚÈ΋) ÎÔÏ›Ùȉ· Â›Ó·È Û¿ÓȘ ÛÙ· ·È‰È¿ Î·È ¤¯Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· (14).

O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (·ÈÌ·ÙÔÏÔÁÈÎfi˜, ‚ÈÔ¯ËÌÈÎfi˜) ‰ÂÓ ‚ÔËı¿ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ‰‡Ô ÓÔÛËÌ¿ÙˆÓ, ·ÏÏ¿ ‚ÔËı¿ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÓÂÚÁfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, Ù˘ ηٿÛÙ·Û˘ ‰È·ÙÚÔÊ‹˜ Î·È ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ÏÔÈÌÒ‰Ô˘˜ ·Ú¿ÁÔÓÙ·. ∂Ó‰ÂÈÎÙÈο ÂÓÂÚÁÔ‡ ÓfiÛÔ˘ Â›Ó·È Ë ·‡ÍËÛË Ù˘ ∆∫∂, ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ù˘ C-·ÓÙȉÚÒÛ·˜ ÚˆÙ½Ó˘ Î·È Ù· ¯·ÌËÏ¿ Â›‰· ÏÂ˘ÎˆÌ·Ù›Ó˘. ∏ ·Ó‡ÚÂÛË ÙˆÓ pANCA ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È ÙˆÓ ASCA ÓfiÛÔ˘ Crohn (15).

O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË, ÂÓÙÔ›˙ÂÈ ÙËÓ ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘, ‚ÔËı¿ ÛÙË ‰È·ÊÔÚԉȿÁÓˆÛË ÎÔÏ›Ùȉ·˜ Î·È Crohn Î·È ÂÓÙÔ›˙ÂÈ ÙȘ ÂÈÏÔΤ˜. ™ËÌ·ÓÙÈ΋ ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂÓÂÚÁfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘ Crohn (PCDAI) Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÈÛÙÔÚÈÎfi, ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, ÏÂ˘ÎˆÌ·Ù›ÓË, ηÌ‡Ï˜ ·Ó¿Ù˘Í˘ (2).

¶›Ó·Î·˜ 4. ∆‡ÔÈ πº¡∂

∞ÓÙÈÌÂÙÒÈÛË ™Ùfi¯ÔÈ Ù˘ Â›Ó·È Ë ‡ÊÂÛË Ù˘ ÓfiÛÔ˘, Ë ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ, Ë ‰ÈfiÚıˆÛË ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ, Ë Ê˘ÛÈÔÏÔÁÈ΋ ·‡ÍËÛË Î·È ·Ó¿Ù˘ÍË. ∏ ıÂÚ·›· ‚·Û›˙ÂÙ·È Û 4 ÙÔÌ›˜: ·) Ê·Ú̷΢ÙÈ΋, ‚) ÛÈÙÈÛÙÈ΋, Á) ¯ÂÈÚÔ˘ÚÁÈ΋ Î·È ‰) „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË.

ñ ñ ñ ñ ñ ñ

∂ÏÎ҉˘ ÎÔÏ›ÙȘ ¡fiÛÔ˜ ÙÔ˘ Crohn Indeterminate colitis ∞˘ÙÔ¿ÓÔÛË ÎÔÏ›ÙȘ ∫ÔÏÏ·ÁÔÓÈ΋ §ÂÌÊÔ΢ÙÙ·ÚÈ΋

¶›Ó·Î·˜ 5. ™‡ÁÎÚÈÛË ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ Î·È Crohn ÛÙ· ·È‰È¿ ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ™˘¯ÓfiÙËÙ· ŒÓ/ÍË ·È‰. ËÏÈÎ. ∂Ó‰ÔÛÎÔÈο

πÛÙÔÏÔÁÈο

∂ÈÏÔΤ˜

154

2/100.000 15-20% ™˘Ó¯fiÌÂÓË ÊÏÂÁÌÔÓ‹ 100% ÔÚıfi ‚Ï¿‚˜ ÛÂ: ¶¿Û¯ÔÓÙ· ‚ÏÂÓÓÔÁ. º˘ÛÈÔÏ. ÂÈÏÂfi˜ ∂Ï¿ÙÙˆÛË ‚ϤÓÓ˘ ∫Ú˘ÙÈο ·ÔÛÙ‹Ì·Ù· ∂ÓÙfiÈÛË ÛÙÔ ‚ÏÂÓ/ÓÔ ™˘Ó¯fiÌÂÓË ‚Ï¿‚Ë ¢È¿ÙÚËÛË ∆ÔÍ. ÌÂÁ¿ÎÔÏÔ Ca ·¯. ÂÓÙ¤ÚÔ˘

Crohn 3,5/100.000 20-25% ∂ÛÙȷ΋ ™˘Ó‹ıˆ˜ fi¯È ÔÚıfi º˘ÛÈÔÏÔÁÈÎfi ‚ÏÂÓÓÔÁ. ¶¿Û¯ˆÓ ÂÈÏÂfi˜ 50% ∂ÈıËÏ. ÎÔÎÎÈÒÌ·Ù· ¶ÂÚÈÎÚ˘Ù›Ùȉ· ∂¤ÎÙ·ÛË ˘Ô‚ÏÂÓ/ÓÈÔ ∆ÌËÌ·ÙÈ΋ ‚Ï¿‚Ë ∞fiÊÚ·ÍË, ·ÔÛÙ‹Ì·Ù· ™˘Ú›ÁÁÈ·, ÂÚÈÚˆÎÙ. ÓfiÛÔ˜ Ca ·¯. Î·È Ï. ÂÓÙ¤ÚÔ˘ ·ÓÂ¿ÚÎÂÈ· µ12

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¶·È‰È·ÙÚÈ΋ 2002;65:151-159

∞. º·Ú̷΢ÙÈ΋: ™Â fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ··ÈÙÂ›Ù·È Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Ô˘ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Î·È ÙËÓ ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘. OÈ Î·ÙËÁÔڛ˜ Î·È Ô Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ∆· ·Ú·‰ÔÛȷο Ê¿Ú̷η, ·ÌÈÓÔÛ·ÏÈ΢ÏÈο Î·È ÎÔÚÙÈ˙fiÓË, ·ÔÙÂÏÔ‡Ó ÙÔÓ ·ÎÚÔÁˆÓÈ·›Ô Ï›ıÔ. ∏ ÛÔ˘ÏÊ·Û·Ï·˙›ÓË Î·È 5-ASA ·Ú·Ì¤ÓÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‹È·˜ ¤ˆ˜ ̤ÙÚÈ·˜ ÓfiÛÔ˘ Î·È ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ·, ÂÓÒ Ù· ÎÔÚÙÈÎÔÂȉ‹ ·Ú·Ì¤ÓÔ˘Ó Ë ÚÒÙË ıÂÚ·›· ÛÙË Ì¤ÙÚÈ· ¤ˆ˜ ‚·ÚÈ¿ ÓfiÛÔ Î·È ÂÈÙ˘Á¯¿ÓÔ˘Ó ‡ÊÂÛË Û ÔÛÔÛÙfi 70-80% ÂÚ›Ô˘. ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Î·È ÛÙ· ·È‰È¿ ¤Ó· ÓÂfiÙÂÚÔ ÎÔÚÙÈÎÔÂȉ¤˜, Ë ‚Ô˘‰Â˙ÔÓ›‰Ë (·fi ÙÔ ÛÙfiÌ· Î·È ·fi ÙÔ ÔÚıfi), Ô˘ ¤¯ÂÈ ÏÈÁfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ, ·ÏÏ¿ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ ˘ÔÏ›ÂÙ·È ·˘Ù‹˜ Ù˘ Ú‰ÓÈ˙fiÓ˘ (16). ∏ ÙÔÍÈÎfiÙËÙ· ηٿ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ¯Ú‹ÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Û·Ó ıÂÚ·›· Û˘ÓÙ‹ÚËÛ˘ Ô‰‹ÁËÛ·Ó ÛÙË Û¯ÂÙÈο ÌÂÁ¿ÏË ¯Ú‹ÛË ÙˆÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÒÓ (∞zathioprine, 6-MP) ÁÈ· ÂÍ·ÚÙÒÌÂÓË ‹ ·ÓıÂÎÙÈ΋ ÛÙ· ÛÙÂÚÔÂȉ‹ ÓfiÛÔ (1719). O ÚfiÏÔ˜ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ‹ ·Ó·‚ÔÏ‹ Ù˘ ÎÔÏÂÎÙÔÌ‹˜ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·Ôı·ÚÚ˘ÓÙÈο ÛÙË Ó. Crohn. ™Â ÂÏ¿¯ÈÛÙ˜ ·ÂÏÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ Ó. Crohn Î·È ÎÔÏ›Ùȉ·˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È Û ¿ÏÏÔ ıÂÚ·¢ÙÈÎfi Û¯‹Ì·, ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› ÙÔ FK (506) Tacrolimus Ô˘ Â›Ó·È Ì·ÎÚÔÏ›‰Ë, Ì ÂÚÈÛÛfiÙÂÚ˜ fï˜ ·ÚÂÓ¤ÚÁÂȘ Û˘ÁÎÚÈÙÈο Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË (1,17). ™Â ÂÚÈÙÒÛÂȘ Crohn Ì ·ÔÛÙ‹Ì·Ù· ‹ Û˘Ú›ÁÁÈ·, ÚÔÛÙ›ıÂÓÙ·È ÌÂÙÚÔÓȉ·˙fiÏË ‹ ciprofloxacin. Ÿˆ˜ ÂϤ¯ıË ‹‰Ë, Ô TNF-· ·ÔÙÂÏ› Ì›· ΢ÙÙ·ÚÔΛÓË ÎÏÂȉ› ÁÈ· ÙËÓ ÂÓÙÂÚÈ΋ ÊÏÂÁÌÔÓ‹ Î·È Û˘ÓÂÒ˜, Ë ‰¤ÛÌ¢ÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· ·˘ÙÔ‡ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÊÏÂÁÌÔÓ‹˜. ∆¤ÙÔÈÔ Û··ÛÌ· Â›Ó·È ÙÔ ÌÔÓÔÎψÓÈ-

Paediatriki 2002;65:151-159

Îfi ¯ÈÌ·ÈÚÈÎfi ·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ·Ú¿ÁÔÓÙ· Ó¤ÎÚˆÛ˘ ÙÔ˘ fiÁÎÔ˘ · (·ÓÙÈ- TNF·), Ô˘ ·ÔÙÂÏ› ÚfiÛıÂÙÔ ıÂÚ·¢ÙÈÎfi ̤ÛÔ ÁÈ· ÙË ¯ÚfiÓÈ· ÂÓÂÚÁfi ÓfiÛÔ Crohn ‹ ÌÂ Û˘Ú›ÁÁÈ· (20,21). ¶·Ú¿ Ù· Û¯ÂÙÈο ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂӉ›ÍÂȘ Û˘ÁÎÚÈÙÈο Ì ¿ÏÏÔ Ê¿ÚÌ·ÎÔ, ˘¿Ú¯ÂÈ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ÁÈ· ÙËÓ ·ÓÙÈÁÔÓÈÎfiÙËÙ¿ ÙÔ˘, ‰ÈfiÙÈ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÍÂÓÈÛÙ‹. ¢ÂÓ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ÂÌÂÈÚ›· Ì ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÚÈÔ‰È΋ ¯ÔÚ‹ÁËÛË (οı 2 Ì‹Ó˜). ¶¿ÓÙˆ˜, 3 ·fi ÙÔ˘˜ 37 ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó Ì·ÎÚÔ¯ÚfiÓÈ· ÙÔ Ê¿ÚÌ·ÎÔ ·ÚÔ˘Û›·Û·Ó ·ÓıÚÒÂÈ· ·ÓÙȯÈÌÂÚÈο ·ÓÙÈÛÒÌ·Ù· (20). ∞ӷʤÚÂÙ·È, Â›Û˘, ‡ÊÂÛË Ù˘ ÓfiÛÔ˘ Crohn ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (22). £· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ë ÔÚ›· Â›Ó·È ‚·ÚÈ¿ ÛÙ· ·È‰È¿ Î·È ··ÈÙ› Û˘Ó‰˘·ÛÌfi Ê·ÚÌ¿ÎˆÓ ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ·. ∞fi Ù· 320 ·È‰È¿ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ (¶›Ó·Î·˜ 7), ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÌÈÛ¿ ¯ÚÂÈ¿ÛÙËÎ·Ó ÎÔÚÙÈÎÔÂȉ‹, ÂÓÒ Û ÌÂÚÈο ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› fiÏ· Ù· ÈÔ ¿Óˆ ıÂÚ·¢ÙÈο Û¯‹Ì·Ù·. ŸÌˆ˜ Ù· Ú¿ÁÌ·Ù· ‰ÂÓ Â›Ó·È ÙfiÛÔ ·Ï¿. ŒÓ·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ·ÔÙÂÏ› ÙÚfiÊÈÌÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÁÈ· ÔÏÏÔ‡˜ Ì‹Ó˜ ‹ ÌÂ Û˘¯Ó¤˜ ÂÈÛ·ÁˆÁ¤˜, ÁÈ·Ù› ·Ú¿ ÙËÓ ¤ÓÙÔÓË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ‡ÊÂÛË. ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ Û˘Ó‹ıˆ˜ ·Ó‹ÎÔ˘Ó ·È‰È¿ Ì ‚·ÚÈ¿ ÓfiÛÔ ÙÔ˘ Crohn ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ·ÔÛÙ‹Ì·Ù· ‹ Û˘Ú›ÁÁÈ·, ‹ ·È‰È¿ Ì ·˘ÙÔ¿ÓÔÛË ÎÔÏ›Ùȉ·, Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÓ‰ÔÊϤ‚È· ıÂÚ·›· Î·È ·ÚÂÓÙÂÚÈ΋ Û›ÙÈÛË. À¿Ú¯Ô˘Ó fï˜ Î·È ¿ÏÏ· Ê¿Ú̷η Ô˘ Â›Ó·È ˘fi ‰ÔÎÈÌ‹, fiˆ˜ Ë ı·ÏȉÔÌ›‰Ë, Ë ‚ÈÙ·Ì›ÓË ∂, Ù· ÏÈ·Ú¿ Ôͤ· ‚Ú·¯Â›·˜ ·Ï‡ÛÔ˘ Î·È Ë ÓÈÎÔÙ›ÓË (ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·), ÙÔ ‚ÈÛÌÔ‡ıÈÔ, ÙÔ ÎÂÙÔÙÈÊ·›ÓÈÔ, Ë Ë·Ú›ÓË, Ë ¯ÏˆÚÔΛÓË, Ë ÂÓ‰ÔÊϤ‚È· ÁÛÊ·ÈÚ›ÓË, Ë ÏÂ˘Î·Ê·›ÚÂÛË Î·È ÔÈ Ó¢ÚÔ·ÓÔÛÔÚÚ˘ıÌÈÛÙ¤˜ (Ù· Ó¢ÚÔÂÙ›‰È· Ô˘Û›·-ƒ, VIP Î·È Y)

¶›Ó·Î·˜ 6. º¿Ú̷η Î·È ÙÚfiÔ˜ ‰Ú¿Û˘ º¿Ú̷η ™Ô˘ÏÊ·Û·Ï·˙›ÓË, 5-ASA ∫ÔÚÙÈÎÔÂȉ‹

Azathioprine, 6-MP Methotrexate Cyclosporin Tacrolimus (FK506) Metronidazole πnfliximab

∆ÚfiÔ˜ ‰Ú¿Û˘

[ PG, Tromb/x, PAF, IL-1, Lym, Monoc., NF΂ [ cyclo- and lipooxygenase [ ¡F΂, IL-1, IL-2, Ê·Á/ÛË ÔÏ. [ ¯ËÌÂÈÔÙ. ÔÏ., ˈÛ., ÌÔÓ/Ó· + ·ÔÚÚfiÊËÛË Na, ‡‰·ÙÔ˜ [ natural killer, cytotoxic T-cells [ DNA, IL-1, + apoptosis [ IL-1, IL-3, IL-4, Á-IFN, TNF-· [ IL-2, IL-3, IL-4 ∞ÓÙÈÌÈÎÚԂȷ΋, ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋

[ TNF-·

155

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Paediatriki 2002;65:151-159

¶›Ó·Î·˜ 7. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ 320 ·È‰ÈÒÓ Ì πº¡∂ ñ ñ ñ ñ ñ ñ

™Ô˘Ï/˙›ÓË ‹ 5-ASA ∫ÔÚÙÈÎÔÂȉ‹ Azathioprine Cyclosporine ÃÂÈÚ/΋ Â¤Ì‚·ÛË Anti-TNF

318 182 88 12 28 2

Î·È Ë ÛˆÌ·ÙÔÛÙ·Ù›ÓË (4). ∆¤ÏÔ˜, ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Ù· anti-sense ÔÏÈÁÔÓÔ˘ÎÏÂÔÙ›‰È· Ô˘ ‰ÂÛÌÂ‡Ô˘Ó ÙÔ m-RNA Ô˘ ¯ÚËÛÈ̇ÂÈ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ adhesion molecule 1 (ICAM-1). ∆Ô ı¤Ì· fï˜ Ù˘ ıÂÚ·›·˜ Ì ·Ú¤Ì‚·ÛË ÛÙȘ ΢ÙÙ·ÚÔΛÓ˜ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌ· Ï˘ı›. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÙÔ ‰›Ô Ù˘ Ê·ÚÌ·ÎÔÁÂÓÂÙÈ΋˜ Â›Ó·È Û ÂÌ‚Ú˘˚΋ ηٿÛÙ·ÛË. ∏ ÏËıÒÚ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ ‰Â›¯ÓÂÈ ÍÂοı·Ú· ÙÔ ÛÔ‚·Úfi Úfi‚ÏËÌ· Ô˘ ˘¿Ú¯ÂÈ Û˘¯Ó¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ∆ÂÏÈο, Ë Û˘Ó¯‹˜ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Ù˘ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·˜ Ù˘ πº¡∂ ÚÔÊ·ÓÒ˜ ı· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó·Î¿Ï˘„Ë Ó¤ˆÓ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚˆÓ ÙÚfiˆÓ ıÂÚ·›·˜. µ) ¢È·ÈÙËÙÈ΋: O ÚfiÏÔ˜ Ù˘ ‰È·ÈÙËÙÈ΋˜ ·Ú¤Ì‚·Û˘ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ‰Ú·Ì·ÙÈο ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· (23-25). ∏ Û›ÙÈÛË Û˘ÓÈÛÙ¿Ù·È Û ·È‰È¿ Ì πº¡∂ ÁÈ· Ó· ‰ÈÔÚıÒÛÂÈ Ù· ÂÏÏ›ÌÌ·Ù· (ÚfiÏË„Ë ‹ ·Ó¿Ù·ÍË ÙÔ˘ ˘ÔÛÈÙÈÛÌÔ‡ Î·È Ù˘ ¤ÏÏÂȄ˘ ȯÓÔÛÙÔȯ›ˆÓ), ·ÏÏ¿ Î·È Û·Ó ÚˆÙÔÁÂÓ‹˜ ıÂÚ·›· Ù˘ ÂÓÂÚÁ‹˜ ÓfiÛÔ˘. ∏ ·ÚÔ˘Û›· Ù˘ ÙÚÔÊ‹˜ ÛÙÔ ¤ÓÙÂÚÔ ·ÛΛ ¿ÌÂÛË ÙÚÔÊÈ΋ ‰Ú¿ÛË ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ, ÚÔÛٷهÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Î·È ›Ûˆ˜ ÂÌÔ‰›˙ÂÈ ÙËÓ ·ıÔÁfiÓÔ ‰Ú¿ÛË ÙˆÓ ÌÈÎÚÔ‚›ˆÓ. ∂ÈϤÔÓ, ¤¯ÂÈ ÙËÓ È‰ÈfiÙËÙ· Ó· Ú˘ıÌ›˙ÂÈ ÙË ÊÏÂÁÌÔÓ‹ (1). ∆Ô ·È‰› Ì πº¡∂ Û˘Ó‹ıˆ˜ ˘ÔÏ›ÂÙ·È Û ·Ó¿Ù˘ÍË Î·È Ú·ÁÌ·ÙÈο ‰ÂÓ ÌÔÚ› Ó· ÂÈÙ¢¯ı› ‡ÊÂÛË ·Ó ‰ÂÓ ‰ÈÔÚıˆıÔ‡Ó Ù· ÂÏÏ›ÌÌ·Ù·. ∆· ‰È·ÈÙËÙÈο Û˘ÌÏËÚÒÌ·Ù· Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ· ‹ Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· fiÏÔ ÙÔ 24ˆÚÔ ‹ ÌfiÓÔ ÙÔ ‚Ú¿‰˘ ·ÔÙÂÏÔ‡Ó ÙÚfiÔ˘˜ ·Ó¿Ù·Í˘ ÙÔ˘ ¯ÚfiÓÈÔ˘ ˘ÔÛÈÙÈÛÌÔ‡ Î·È Ù˘ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘. ∆· ‰È·Ï‡Ì·Ù· ·˘Ù¿ Â›Ó·È ÔÏ˘ÌÂÚÈο, ËÌÈÛÙÔȯÂȷο Î·È ÛÙÔȯÂȷο. ∞Ú¯Èο ˘‹Ú¯Â ÚÔÙ›ÌËÛË ÛÙ· ÛÙÔȯÂȷο (ÁÈ·Ù› ¤¯Ô˘Ó ÌÂȈ̤ÓË ·ÓÙÈÁÔÓÈÎfiÙËÙ·), ·ÏÏ¿ ÙÂÏÂ˘Ù·›· Ù· ÔÏ˘ÌÂÚÈο ıˆÚÔ‡ÓÙ·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈο, ÂÎÙfi˜ Î·È ·Ó ‰ÂÓ Â›Ó·È ·ÓÂÎÙ¿ ·fi ÙÔ ¤ÓÙÂÚÔ ‹ ˘¿Ú¯ÂÈ Û‡Ó‰ÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ∏ ÏËıÒÚ· Ù¤ÙÔȈÓ, ÏÔ‡ÛÈˆÓ Û ıÂÚÌ›‰Â˜, ÂÓÙÂÚÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ¤¯ÂÈ ÌÂÈÒÛÂÈ ÙË ¯Ú‹ÛË Ù˘ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜, Ô˘ ÂÚÈÔÚ›˙ÂÙ·È Û·Ó ˘ÔÛÙËÚÈÎÙÈ΋ ıÂÚ·›· ÛÙÔ ˘ÔÛÈÙÈṲ̂ÓÔ ·È‰› ÚÈÓ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, ÌÂÙ¿ ·fi ÂÎÙÂٷ̤Ó˜ ÂÓÙÂÚÂÎÙÔ̤˜ Î·È Û‡Ó‰ÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ‹

156

Û ÌÂÁ¿ÏË ·ÈÌÔÚÚ·Á›·, ‰È¿ÙÚËÛË Î·È ÙÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ. O ÚfiÏÔ˜ Ù˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÛÙÂÓÒÛˆÓ, Û˘ÚÈÁÁ›ˆÓ ‹ ÂÚÈÚˆÎÙÈ΋˜ ÓfiÛÔ˘ ‰ÂÓ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ (1,24). °ÂÓÈο, Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË Ì ÛÙÔȯÂȷ΋ ‰›·ÈÙ· Â›Ó·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·ÛʷϤÛÙÂÚË Î·È ÊıËÓfiÙÂÚË Î·È ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂÈÏÔÁ‹ fiÙ·Ó ÙÔ ¤ÓÙÂÚÔ ÌÔÚ› Ó· ÙË ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ. ∆Ô Â›‰Ô˜ ·˘Ùfi Ù˘ ıÂÚ·›·˜ ÌÔÚ› Ó· Â›Ó·È Ë ·ÔÎÏÂÈÛÙÈ΋ ıÂÚ·›· ÛÙË Ó. Crohn Î·È ÌfiÓÔ Û˘ÌÏËڈ̷ÙÈ΋ ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ ÌÂ Û˘ÁÎÚ›ÛÈÌ· ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ٷ ÎÔÚÙÈÎÔÂȉ‹ ÛÙË Ó. Crohn. ∏ ÌÂÙ·-·Ó¿Ï˘ÛË fï˜ ¤‰ÂÈÍ fiÙÈ ÛÙÔȯÂȷ΋ ‹ ÔÏ˘ÌÂÚÈ΋ ‰›·ÈÙ· Û·Ó ÌÔÓ·‰È΋ ÙÚÔÊ‹ ÁÈ· 2 Ì‹Ó˜ ÌÔÚ› Ó· ÂÈÙ‡¯ÂÈ ‡ÊÂÛË Ù˘ Crohn, ·ÏÏ¿ Ë ˘ÔÙÚÔ‹ Â›Ó·È Û˘¯Ó‹ (24,25). ™˘ÓÂÒ˜, ¤¯ÂÈ ·fiÏ˘ÙË ¤Ó‰ÂÈÍË Û·Ó Û˘ÌÏËڈ̷ÙÈ΋ ÛÙË Ê·Ú̷΢ÙÈ΋ ıÂÚ·›· (1,24). ∞fi Ù· 320 ·È‰È¿ Ô˘ ÓÔÛËχıËÎ·Ó ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ¯ÚÂÈ¿ÛÙËΠÂÓÙÂÚÈ΋ Û›ÙÈÛË Û·Ó Û˘ÌÏËڈ̷ÙÈ΋ ıÂÚ·›· Ù˘ Ê·Ú̷΢ÙÈ΋˜, ÂÓÒ Û 2 ÌfiÓÔ ·È‰È¿ Ì ÓfiÛÔ Crohn ÌÂÙ¿ ·fi 6 ‚‰ÔÌ¿‰Â˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Û·Ó ·ÔÎÏÂÈÛÙÈ΋ ıÂÚ·›·, ¯ÚÂÈ¿ÛÙËΠӷ ÚÔÛÙÂı› Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ÏfiÁˆ ÌË ·ÓÙ·ÔÎÚ›Ûˆ˜ Ù˘ ÓfiÛÔ˘ ÛÙÔ ¤Ó· ·È‰› Î·È Âȉ›ӈÛ˘ ÛÙÔ ¿ÏÏÔ. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Á›ÓÂÙ·È ÌÂÁ¿ÏË Û˘˙‹ÙËÛË ÁÈ· ÙÔ È¯ı˘¤Ï·ÈÔ (ˆ-3 ÏÈ·Ú¿ Ôͤ·) (26,27). Ÿˆ˜ ‹‰Ë ÂϤ¯ıË, ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜ ‰ÈÂÁ›ÚÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹. ªÂٷ͇ ·˘ÙÒÓ Â›Ó·È Î·È Ë Ï¢ÎÔÙÚȤÓË µ4, Ù˘ ÔÔ›·˜ Ë ¤ÎÎÚÈÛ‹ ‰ÈÂÁ›ÚÂÙ·È ·fi ÙÔ ·Ú·¯È‰ÔÓÈÎfi, Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi Ù· ʈÛÊÔÏÈ›‰È· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∆· ˆ-3 ÏÈ·Ú¿ Ôͤ· ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ·Ú·¯È‰ÔÓÈÎÔ‡ Î·È ÂÌÔ‰›˙Ô˘Ó ÙËÓ ·Ú·ÁˆÁ‹ Ï¢ÎÔÙÚȤÓ˘ µ4. ∏ ¯ÔÚ‹ÁËÛË Î·„Ô˘ÏÒÓ Ì ȯı˘¤Ï·ÈÔ Û ·ÛıÂÓ›˜ Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ¤‰ÂÈÍ·Ó ÂÍ›ÛÔ˘ ηϿ ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ Ù· ÎÔÚÙÈÎÔÂȉ‹ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (26,27). ∆ÂÏÂ˘Ù·›·, Á›ÓÔÓÙ·È ÌÂϤÙ˜ ÁÈ· ÙË ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ LactÔbacillus GG Û ·È‰È¿ Ì Crohn (ÌfiÓÔ 4 ·È‰È¿), Ì ÙÔ ÛÎÂÙÈÎfi fiÙÈ Ë Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÚÔÛٷهÂÈ ÙËÓ ÚÔÛÎfiÏÏËÛË ÙˆÓ ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ (28,29). ™Ù· ·È‰È¿ ·˘Ù¿, Ô˘ ›¯·Ó ̤ÙÚÈ· ‚·Ú‡ÙËÙ· ÓfiÛÔ˘, ·Ú·ÙËÚ‹ıËΠ‚ÂÏÙ›ˆÛË. °) ÃÂÈÚÔ˘ÚÁÈ΋: OÈ ÛÙfi¯ÔÈ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂÚ·›·˜ ‰È·Ê¤ÚÔ˘Ó ÛÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Î·È ÙËÓ Crohn, ·Ó Î·È ÔÈ ÂӉ›ÍÂȘ Û˘¯Ó¿ Â›Ó·È ÔÈ ›‰È˜ (30,31). ™ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Â›Ó·È ıÂÚ·¢ÙÈ΋, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ‰ÂÓ Ê¤ÚÓÂÈ ÌfiÓÈÌÔ ·ÔÙ¤ÏÂÛÌ· (¶›Ó·Î·˜ 8). ∞ηٿۯÂÙË ·ÈÌÔÚÚ·Á›·, ‰È¿ÙÚËÛË, ·fiÊÚ·ÍË, ÙÔÍÈÎfiÙËÙ· ·fi ÙË Û˘Ó¤¯ÈÛË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ ‹ ·ÔÙ˘¯›· Ù˘ ıÂÚ·¢ÙÈ΋˜

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·157

¶·È‰È·ÙÚÈ΋ 2002;65:151-159

Paediatriki 2002;65:151-159

·ÁˆÁ‹˜ ·ÔÙÂÏÔ‡Ó ÎÔÈÓ¤˜ ÂӉ›ÍÂȘ Î·È ÁÈ· Ù· ‰‡Ô ÓÔÛ‹Ì·Ù·. ∂Ó›ÔÙÂ, ¤¯ÂÈ ¤Ó‰ÂÈÍË ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, ȉȷ›ÙÂÚ· fiÙ·Ó ‰È¢ÎÔχÓÂÈ ÙË ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ. ∏ ÂÚÈÚˆÎÙÈ΋ ÓfiÛÔ˜ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ¯ÚÂÈ¿˙ÂÙ·È Â¤Ì‚·ÛË Î·È ‚¤‚·È· fiÙ·Ó ˘¿Ú¯ÂÈ Î·ÚΛÓÔ˜, Ô˘ ·ÔÙÂÏ› ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘. À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ˜ Ù¯ÓÈΤ˜, ·ÏÏ¿ ÚÔÙÈÌ¿Ù·È ÁÈ· ÙËÓ ∂∫ ÔÏÈ΋ ÎÔÏÂÎÙÔÌ‹ Î·È ÂÈÏÂÔÚˆÎÙÈ΋ ·Ó·ÛÙfïÛË Ì ‰ËÌÈÔ˘ÚÁ›· ı˘Ï¿ÎÔ˘ (30-32). ¶·Ú¿ ÙËÓ ÎÔÏÂÎÙÔÌ‹, ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ Ô˘ Êı¿ÓÂÈ ÙÔ 40% ÂÌÊ·Ó›˙ÂÈ ÛÙË Û˘Ó¤¯ÂÈ· ı˘Ï·Î›Ùȉ· (pouchitis) Î·È ¯ÚÂÈ¿˙ÂÙ·È ÙÔÈ΋ ıÂÚ·›·. ∂ΛÓÔ fï˜ Ô˘ ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ·, ÙfiÛÔ ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ fiÛÔ ÛÙËÓ ·fiÊ·ÛË ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Â›Ó·È Ë ·˘ÙÔ¿ÓÔÛË Î·È Ë ·ÚÔÛ‰ÈfiÚÈÛÙË ÎÔÏ›Ùȉ· (Indeterminate colitis) Î·È ·˘Ùfi ÁÈ·Ù› Ë ·Ê·›ÚÂÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ‰ÂÓ ı· ·Ó·ÎÔ˘Ê›ÛÂÈ ·fi ÙÔ Úfi‚ÏËÌ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ڋ͢ ÙˆÓ ·Ó·ÛÙÔÌÒÛˆÓ, ÂÓÒ ÙÔ ÂÓ·ÔÌ›ÓÔÓ ¤ÓÙÂÚÔ ı· ÓÔÛ›. ∞˘Ùfi˜ Â›Ó·È Ô ÏfiÁÔ˜ Ô˘ ÂÈ‚¿ÏÏÂÙ·È Ó· ÙÂı› Ì ‚‚·ÈfiÙËÙ· Ë ‰È¿ÁÓˆÛË (33). ™ÙË Ó. Crohn Ë ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ‰ÂÓ ÛËÌ·›ÓÂÈ ›·ÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Â›Ó·È Û˘¯Ó‹ Ë ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÛËÌÂ›Ô Ù˘ Â¤Ì‚·Û˘ Û ÔÛÔÛÙfi ̤¯ÚÈ 70%, ÂÓÒ ÛÙÔ ¯ÂÈÚÔ˘ÚÁfi Â›Ó·È ÁÓˆÛÙfi˜ Ô Î·ÓfiÓ·˜ fiÛÔ ÌÔÚ› Ó· ÌËÓ “·ÎÔ˘Ì‹ÛÂÈ” Ù· ¯¤ÚÈ· ÙÔ˘ ÛÙË Ó. Crohn. ∂ÓÙÔ‡ÙÔȘ, ÌÂÚÈΤ˜ ÊÔÚ¤˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÈ ÙÌËÌ·ÙÈ΋ ÂÓÙÂÚÈ΋ ·Ê·›ÚÂÛË, Û˘Ó‹ıˆ˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÂÈÏÂÔ‡ Î·È ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ∂ȉÈ΋ Ï·ÛÙÈ΋ (ÂÈÌ‹Î˘ ÙÔÌ‹ Î·È ÂÁοÚÛÈ· Ú·Ê‹ ÁÈ· Ó· ·˘ÍËı› Ô ·˘Ïfi˜) ÌÔÚ› Ó· Á›ÓÂÈ Û ÌÈÎÚ¿ ÙÌ‹Ì·Ù· ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Ô˘ ¤¯Ô˘Ó οÓÂÈ ›ÓˆÛË Î·È ÛÙ¤ÓˆÛË, ·ÏÏ¿ ‰ÂÓ ¤¯Ô˘Ó ÂÓÂÚÁ‹ ÊÏÂÁÌÔÓ‹ (32). ¢) æ˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË: ∆· ‰‡Ô ·˘Ù¿ ÓÔÛ‹Ì·Ù· ÂıˆÚÔ‡ÓÙÔ Î¿ÔÙ „˘¯Ôۈ̷ÙÈο ÓÔÛ‹Ì·Ù·. ¶·Ú’ fiÏÔ Ô˘ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ „˘¯ÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘, ÂÓÙÔ‡ÙÔȘ Ë ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ „˘¯ÔÏÔÁ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙË ¯ÚfiÓÈ· ÓfiÛÔ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË (1-4). ∏ ¯ÚfiÓÈ· ¶›Ó·Î·˜ 8. ∂Ӊ›ÍÂȘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ ÛÙËÓ πº¡∂ ∂ÏÎ҉˘ ÎÔÏ›ÙȘ ñ ñ ñ ñ ñ ñ ñ ñ

∞ÈÌÔÚÚ·Á›· ¢È¿ÙÚËÛË ∆ÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ ∫ÂÚ·˘ÓÔ‚fiÏÔ˜ ÃÚfiÓÈ· ˘ÔÙÚ/˙Ô˘Û· ÓfiÛÔ˜ ÃÚ. ·ÓıÂÎÙÈ΋ ÓfiÛÔ˜ ™ˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË ¢È¿ÚÎÂÈ· >10 ¯Ú. Ì ‰˘ÛÏ·Û›·

Crohn ñ ñ ñ ñ

¢È¿ÙÚËÛË ∞fiÊÚ·ÍË ∞ηٿۯÂÙË ·ÈÌÔÚÚ·Á›· ™˘Ú›ÁÁÈ·, ·ÔÛÙ‹Ì·Ù· (·ÚÔ¯¤Ù¢ÛË) ñ ∫·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ (·Ê·›ÚÂÛË ¿Û¯ÔÓÙÔ˜ ÙÌ‹Ì·ÙÔ˜)

¿ıËÛË, Ù· Ê¿Ú̷η Î·È ÔÈ Û˘¯Ó¤˜ ÓÔÛËÏ›˜ Û˘Ì›ÙÔ˘Ó Ì ÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ÂÊ˂›· fiÔ˘ Û˘Ì‚·›ÓÔ˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙËÓ ÚÔÛˆÈÎfiÙËÙ¿ ÙÔ˘ Î·È Ú·ÁÌ·ÙÈο Û˘¯Ó¿ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙË ¯ÔÚ‹ÁËÛË Ù˘ ıÂÚ·›·˜. ∂›Ó·È ‡ÏÔÁÔ fiÙÈ ¯ÚÂÈ¿˙ÂÙ·È fi¯È ÌfiÓÔ ÙÔ ·È‰›, ·ÏÏ¿ Î·È fiÏË Ë ÔÈÎÔÁ¤ÓÂÈ· „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË. ∂ȉÈο ÔÈ ¤ÊË‚ÔÈ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ·fi ηı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÂÓ‹‚ˆÛË, ·fi ÙËÓ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜ ·fi ÙÔ ÚÔÛˆÂ›Ô Cushing Î·È ÙËÓ ·ÎÌ‹ ·fi Ù· ÎÔÚÙÈÎÔÂȉ‹, ÂÓÒ ·ÔʇÁÔ˘Ó ÙȘ ·Ú¤Â˜ ÁÈ·Ù› ÔÓ¿Ó ‹ ¤¯Ô˘Ó ‰È¿ÚÚÔÈ·. ∞·ÈÙÂ›Ù·È ÛˆÛÙ‹ „˘¯ÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ¤ÁηÈÚË ‰È·›ÛÙˆÛË ÙˆÓ „˘¯ÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÁÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË. ∂ÈÏÔΤ˜ ·. ∂ÓÙÂÚÈΤ˜: OÈ Î‡ÚȘ ÂÈÏÔΤ˜ Â›Ó·È Ë Ì·˙È΋ ·ÈÌÔÚÚ·Á›· (1-3%), Ë ‰È¿ÙÚËÛË, ÙÔ ÙÔÍÈÎfi ÌÂÁ¿ÎÔÏÔ (3-5%), ÂÓÒ ÂÈϤÔÓ ÛÙËÓ Crohn Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË (8%), Ù· ·ÔÛÙ‹Ì·Ù· Î·È Ù· Û˘Ú›ÁÁÈ·. MÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ·Ó¿Ù˘ÍË Î·ÚΛÓÔ˘ (34-36). ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ·Ó Ë ÓfiÛÔ˜ ·Ú¯›ÛÂÈ Ù· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, ·˘Í¿ÓÂÈ Ô Î›Ó‰˘ÓÔ˜ ÛÙËÓ ÂÊ˂›· Î·È Û˘ÓÂÒ˜ ¯ÚÂÈ¿˙ÂÙ·È ·ÊÂÓfi˜ ÌÂÓ screening, ·ÊÂÙ¤ÚÔ˘ ‰Â „˘¯ÔÏÔÁÈ΋ ÚÔÂÙÔÈÌ·Û›· ÁÈ· Ù˘¯fiÓ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË. ™ÙËÓ ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· Ô Î›Ó‰˘ÓÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜, ·ÏÏ¿ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ÂÚÈÙÒÛÂȘ ηÚΛÓÔ˘ Û ÓfiÛÔ ÙÔ˘ Crohn ÙfiÛÔ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ Ì Èı·ÓfiÙËÙ· 4 ¤ˆ˜ 20 ÊÔÚ¤˜, fiÛÔ Î·È ÛÙÔ ÏÂÙfi (ϤÌʈ̷) 50 ¤ˆ˜ 100 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· (3). ‚. ∂͈ÂÓÙÂÚÈΤ˜: OÛÙÂÔfiÚˆÛË ·fi ÙËÓ ÎÔÚÙÈ˙fiÓË ‹ ÙË ÓfiÛÔ ‰ÂÓ Â›Ó·È Û¿ÓÈ· (1,2,37,38). ∏ ıÚfiÌ‚ˆÛË Î·È ÔÈ ÂÌ‚ÔϤ˜ ·ÔÙÂÏÔ‡Ó ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ (9), ηıÒ˜ Â›Û˘ Ë ÓÂÊÚÔÏÈı›·ÛË, Ë ˘‰ÚÔÓ¤ÊÚˆÛË, Ë ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· Ì ·ÓÔÛÔÏÔÁÈο Û˘ÌϤÁÌ·Ù· Î·È Ù· ÂÓÙÂÚÔ΢ÛÙÈο Û˘Ú›ÁÁÈ· Î·È ÔÊı·ÏÌÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜. ¶ÚfiÁÓˆÛË ∆˘Èο, Ë πº¡∂ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÚÈfi‰Ô˘˜ ÂÍ¿ÚÛÂˆÓ Î·È ˘Ê¤ÛˆÓ. (¶›Ó·Î·˜ 9). ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ∂∫ (70%) ÂÈÛ¤Ú¯ÔÓÙ·È Û ‡ÊÂÛË ÌÂÙ¿ ÙÔ˘˜ 3 ÚÒÙÔ˘˜ Ì‹Ó˜ Î·È ÂÚ›Ô˘ Ù· ÌÈÛ¿ Û˘ÓÔÏÈο ı· Ì›ÓÔ˘Ó Û ‡ÊÂÛË ÙÔÓ ÂfiÌÂÓÔ ¯ÚfiÓÔ (4). ∫ÔÏÂÎÙÔÌ‹ ı· ¯ÚÂÈ·ÛÙ› Û 26% ÙˆÓ ·È‰ÈÒÓ Ì ‚·ÚÈ¿ ÓfiÛÔ Î·È Û 10% Ì ‹È·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì πº¡∂ Ù˘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¤ÁÈÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ÎÔÏÂÎÙÔÌ‹ Û 28 ·È‰È¿ (9%). ªfiÓÔ ÙÔ 1% ÙˆÓ ·ÛıÂÓÒÓ Ì Crohn Ô˘ ¯ÂÈÚÔ˘ÚÁÔ‡ÓÙ·È ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ

157

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·158

¶·È‰È·ÙÚÈ΋ 2002;65:151-159

Paediatriki 2002;65:151-159

¶›Ó·Î·˜ 9. ¶ÚfiÁÓˆÛË πº¡∂ ÛÙ· ·È‰È¿ ∂ÏÎ҉˘ ∫ÔÏ›ÙȘ

N. Crohn

⁄ÊÂÛË ÂÓÙfi˜ 3 ÌËÓÒÓ: 70%

1% ¯ˆÚ›˜ ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË

ÀÔÙÚÔ‹ ÂÓÙfi˜ 1 ¤ÙÔ˘˜: 50% ∫ÔÏÂÎÙÔÌ‹ ÂÓÙfi˜ 5 ÂÙÒÓ: 26%

∂ÈÏÂÔÎÔÏ›ÙȘ: ·ÓÙ·/ÛË, ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚. ¶ÂÚ›Ô˘ 70% ¯ÂÈÚÔ˘ÚÁÂ›Ô ÂÓÙfi˜ 10-20 ¯Ú.

¶ÚˆÎÙ›Ùȉ·: Â¤Î/ÛË ÓfiÛÔ˘: 70% ∫›Ó‰˘ÓÔ˜ Ca ÌÂÙ¿ 10¯Ú.:

+

˘ÔÙÚÔ‹. ∆· ·È‰È¿ Ì ÂÈÏÂÔÎÔÏ›Ùȉ· ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚË ·ÓÙ·fiÎÚÈÛË ÛÙ· Ê¿Ú̷η Î·È ··ÈÙÂ›Ù·È Û˘¯ÓfiÙÂÚ· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Û˘ÁÎÚÈÙÈο Ì ·˘Ù¿ Ô˘ ¿Û¯ÂÈ ÌfiÓÔ ÙÔ ÏÂÙfi ¤ÓÙÂÚÔ. ∆ÂÏÈο, Û ÔÛÔÛÙfi 70% ÛÙ· ÂfiÌÂÓ· 10-20 ¯ÚfiÓÈ· ·fi ÙË ‰È¿ÁÓˆÛË ı· ¯ÚÂÈ·ÛÙ› ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ÛÙËÓ Crohn.

O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ ÛÙÔ ¿Û¯ÔÓ ¤ÓÙÂÚÔ Â›Ó·È ·˘ÍË̤ÓÔ˜ Î·È ÛÙ· ‰‡Ô ÓÔÛ‹Ì·Ù·. OÈ ·Ú¿ÁÔÓÙ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È Ë ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ (ÂȉÈο ¿Óˆ ·fi 10 ¯ÚfiÓÈ·, Ô Î›Ó‰˘ÓÔ˜ ÊÙ¿ÓÂÈ Û ÔÛÔÛÙfi 20%) Î·È Ë ¤ÎÙ·Û‹ Ù˘ (·ÓÎÔÏ›Ùȉ·), ηٷÛÙ¿ÛÂȘ ηْ ÂÍÔ¯‹Ó Û˘¯Ó¤˜ ÛÙ· ·È‰È¿, ηıÒ˜ Â›Û˘ Î·È Ë ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ·. °È’ ·˘Ùfi, ÌÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ··ÈÙÂ›Ù·È Û˘ÛÙËÌ·ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÂÓ‰ÔÛÎfiËÛË Î·È ÔÏÏ·Ϥ˜ ‚ÈÔ„›Â˜ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ‰˘ÛÏ·Û›·˜, Ô˘ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÎÔÏÂÎÙÔÌ‹˜. ¢˘ÛÙ˘¯Ò˜, fï˜, ·˘Ù‹ Ë Ì¤ıÔ‰Ô˜ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ·ÛÊ·Ï‹˜, ÁÈ·Ù› ÂϤÁ¯ÂÙ·È ÂÏ¿¯ÈÛÙÔ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÈÛÙÔÏÔÁÈο Î·È ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ‰˘ÛÏ·Û›· Û ̷ÎÚÔÛÎÔÈο Ê˘ÛÈÔÏÔÁÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ÂÓÒ ÛÙÔ 40% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÌÊ·Ó›ÛıËΠηÚΛÓÔ˜ Î·È ¤Î·Ó·Ó ÎÔÏÂÎÙÔÌ‹ ‰ÂÓ ˘‹Ú¯Â ‰˘ÛÏ·Û›·. ∞fi Ì·ıËÌ·ÙÈο ÌÔÓ٤Ϸ ÁÈ· ÙÔ ÔÈ· Â›Ó·È Ë Î·Ï‡ÙÂÚË ÚfiÏË„Ë ‚Ú¤ıËΠfiÙÈ Ë ÔÏÈ΋ ÚÔÏËÙÈ΋ ÎÔÏÂÎÙÔÌ‹ ÌÂÙ¿ Ù· ÚÒÙ· 10 ¯ÚfiÓÈ· ÓfiÛÔ˘ ·˘Í¿ÓÂÈ ÙËÓ ÂÈ‚›ˆÛË Î·Ù¿ 1,5 ¯ÚfiÓÔ, Û˘ÁÎÚÈÙÈο Ì ٷ ¿ÙÔÌ· Ô˘ ‰ÂÓ Á›ÓÂÙ·È Î·È Î·Ù¿ 10 Ì‹Ó˜ fiÙ·Ó Á›ÓÂÙ·È screening Ì ÂÓ‰ÔÛÎfiËÛË Î·È ‚ÈÔ„›Â˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ÂÓÙÂÚÈ΋˜ ‰˘ÛÏ·Û›·˜. ∆ÂÏÈο, Ë πº¡∂ ·ÔÙÂÏ› ¤Ó· ÛËÌ·ÓÙÈÎfi Î·È ‰‡ÛÎÔÏÔ ÓfiÛËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ÏËıÒÚ· ÙˆÓ Ê·Ú̷΢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ ‰ËÏÒÓÂÈ ÙËÓ ·‰˘Ó·Ì›· Ì·˜ Ó· ‰·Ì¿ÛÔ˘Ì ÙË ÓfiÛÔ Û ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ (39). ™Â Ì›· ÔÌ¿‰· ·È‰ÈÒÓ ··ÈÙÂ›Ù·È ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· ÁÈ· Ó· ÂÈÙ¢¯ı› ‡ÊÂÛË Ù˘ ÓfiÛÔ˘. ™Ùfi¯Ô˜ Â›Ó·È fi¯È ÌfiÓÔ Ë ‡ÊÂÛË, ·ÏÏ¿ Î·È ÙÔ Ó· Â›Ó·È ÙÔ ·È‰› ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜ ˘ÁȤ˜ Î·È Ó· ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË. À¿Ú¯Ô˘Ó fï˜ ÛËÌ·ÓÙÈο ÂÚˆÙ‹Ì·Ù·: ª‹ˆ˜ fiÏ· ·˘Ù¿ Ù· Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈԇ̠ÁÈ· ÙË ¯ÚfiÓÈ· ·ÓÔÛÔηٷÛÙÔÏ‹ Á›ÓÔ˘Ó ·ÊÔÚÌ‹ Ó· ·Ó·Ù˘¯ı› ηÎÔ‹ıÂÈ· ·ÚÁfiÙÂÚ·; £· ˘¿ÚÍÂÈ ÈÔ ·ÍÈfiÈÛÙÔ˜ ÙÚfiÔ˜ ¤ÁηÈÚ˘ ÂÓÙfiÈÛ˘ Ù˘ ÂÓÙÂ-

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ÚÈ΋˜ ‰˘ÛÏ·Û›·˜ Ô˘ ·ÔÙÂÏ› ÚÔηÚÎÈÓÈÎfi ÛÙ¿‰ÈÔ Î·È ··ÈÙ› ÎÔÏÂÎÙÔÌ‹; ◊ Ì‹ˆ˜ ¯ÚÂÈ¿˙ÂÙ·È ÚÔÏËÙÈ΋ ·ÎÚˆÙËÚÈ·ÛÙÈ΋ Â¤Ì‚·ÛË ÓˆÚ›ÙÂÚ·; ™Â ·˘Ù‹ ÙË ÚÈ˙È΋ χÛË Ë ·¿ÓÙËÛË Â›Ó·È ·ÚÓËÙÈ΋. ∫·È ·˘Ùfi ÁÈ·Ù› ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Î·ÚΛÓÔ fiÏ· Ù· ¿ÙÔÌ· Ì ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ÂÓÒ ÛÙËÓ Crohn Ô˘ Û˘Ó¤¯ÂÈ· ·˘Í¿ÓÂÈ ÛÂ Û˘¯ÓfiÙËÙ·, Ë ÂÁ¯Â›ÚËÛË ‰ÂÓ ·ÔÙÂÏ› ÚÈ˙È΋ χÛË. ∆Ô ·ÚÓËÙÈÎfi Â›Ó·È ˆ˜ fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· ·˘Í¿ÓÔÓÙ·È Ù· ·˘ÙÔ¿ÓÔÛ· Î·È Ì·˙› ÔÈ ·˘ÙÔ¿ÓÔÛ˜ ÎÔÏ›Ùȉ˜ Ô˘ ·ÔÙÂÏÔ‡Ó Ú·ÁÌ·ÙÈο ÛÔ‚·Úfi Úfi‚ÏËÌ·. ∆Ô È‰·ÓÈÎfi ı· ‹Ù·Ó Ë ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. ÿÛˆ˜ ÌÂÚÈο ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· ÔÈ ¤Ú¢Ó˜ ʤÚÔ˘Ó ÛÙÔ Êˆ˜ Ó¤· ÌÔÓÔ¿ÙÈ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Hofley P, Piccoli D. Inflammatory bowel disease in children. Med Clin N Am 1994;78:1281-1302.

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4. Hyams J. Inflammatory bowel disease. Pediatr Rev 2000;21:291-295.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 31-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂. ƒÒÌ· - °È·ÓÓ›ÎÔ˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÂÛÙËÌ›Ô˘ ∞ıËÓÒÓ

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REVIEW ARTICLE

™‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ: ¶·ıÔÁ¤ÓÂÈ· Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ª. ∫·ÙÛ¿Ú·, ∫. ¶·¿˙ÔÁÏÔ˘

Increased capillary permeability syndrome (Leak syndrome): Pathogenesis and the newest evidence for its management M. Katsara, K. Papazoglou

¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ··Û¯ÔÏ› Û˘¯Ó¿ Î·È ÚÔ‚ÏËÌ·Ù›˙ÂÈ ¤ÓÙÔÓ· ÙÔ˘˜ ÎÏÈÓÈÎÔ‡˜ ÁÈ·ÙÚÔ‡˜ fiÏˆÓ ÙˆÓ ÂȉÈÎÔًوÓ, fiÙ·Ó ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜. ∞Ó·ÛÎÔÔ‡ÓÙ·È Ë ·ÈÙÈÔÏÔÁ›·, Ë ·ıÔÁ¤ÓÂÈ·, Ë ıÂÚ·¢ÙÈ΋ ÙÔ˘ ·ÓÙÈÌÂÙÒÈÛË Î·È ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ¯ÔÚ‹ÁËÛ˘ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÎÔÏÏÔÂȉÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÛÙËÓ ·Ó¿ÓË„Ë ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ÓÔÛ› ÛÔ‚·Ú¿.

Abstract: The increased capillary permeability syndrome (Leak syndrome) is a severe condition that challenges the clinicians who treat critically ill patients. This review discusses the etiology and the pathogenesis of the syndrome, the therapeutic approach as well as the newest data concerning the controversy regarding the administration of crystalloid-colloid solutions for the resuscitation of the critically ill patient.

§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ, Û‡Ó‰ÚÔÌÔ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ, ‰È¿¯˘ÙË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË, ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ÎÔÏÏÔÂȉ‹, ·Ó¿ÓË„Ë Ì ˘ÁÚ¿.

Key words: capillary permeability, capillary leak, diffuse inflammatory response, crystalloids, colloids, fluid resuscitation.

∂ÈÛ·ÁˆÁ‹ ø˜ Û‡Ó‰ÚÔÌÔ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ÔÚ›˙ÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È¿¯˘ÙË ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ÙÚȯÔÂȉÈÎÒÓ ·ÁÁ›ˆÓ, Û˘ÛÙËÌ·ÙÈ΋ ‰È·Ê˘Á‹ Ï¿ÛÌ·ÙÔ˜ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È ·ÔÙÂÏ› ‰È·Ù·Ú·¯‹ Ù˘ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Û οÔÈÔ ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ· (1-3). ∏ ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ (Leak syndrome) ·Ú·ÙËÚÂ›Ù·È Û ‰È¿ÊÔÚ˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ: ÛÙË ÛË„·ÈÌ›·, ÙÔ ¤Áη˘Ì·, ÙÔ ÙÚ·‡Ì·, ÙȘ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ÙÔ ARDS, Û ηÚÎÈÓÔ·ı›˜ Î·È Û η¯ÂÎÙÈÎÔ‡˜ ·ÛıÂÓ›˜ (1,3-6). ∆· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‰˘ÛÌÂÓ‹ ÁÈ· ÙËÓ ¤Î‚·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ‰ÈfiÙÈ ÚÔηÏ› Ì›ˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, ·ÓıÂÎÙÈ΋ ˘fiÙ·ÛË ÛÙË ıÂÚ·›· Ì ÂÓ‰ÔÊϤ‚È· ˘ÁÚ¿, Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·, ¯·ÌËÏ¿ Â›‰· ·Ï‚Ô˘Ì›Ó˘ ÛÙÔ ·›Ì·, η΋ Ô͢ÁfiÓˆÛË ÙˆÓ ÈÛÙÒÓ, ÔÏ˘ÔÚÁ·-

ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· (2,5,7,8). ∏ ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÂΛÓÔ˘˜ Ô˘ ηٷϋÁÔ˘Ó, ·Ô‰›‰ÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ¤Ó· ̤ÚÔ˜, ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·˜ Ô˘ Ô‰ËÁ› ÛÙËÓ Î·Î‹ Ô͢ÁfiÓˆÛË ÙˆÓ ÈÛÙÒÓ.

ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

Intensive Care Unit Children’s Hospital “P. & A. Kyriakou”, Athens

160

™ÙÔȯ›· ‚·ÛÈ΋˜ Ê˘ÛÈÔÏÔÁ›·˜ (9) ™Ù· ÙÚȯÔÂȉ‹ ·ÁÁ›· ÂÈÙÂÏÂ›Ù·È Ë ÛËÌ·ÓÙÈÎfiÙÂÚË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ‰ËÏ·‰‹ Ë ·ÓÙ·ÏÏ·Á‹ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ Î·È Î˘ÙÙ·ÚÈÎÒÓ ·Ô‚Ï‹ÙˆÓ ÌÂٷ͇ ÙˆÓ ÈÛÙÒÓ Î·È ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·›Ì·ÙÔ˜. À¿Ú¯Ô˘Ó ÂÚ›Ô˘ 10 ÂηÙÔÌ̇ÚÈ· ÙÚȯÔÂȉ‹ ÌÂ Û˘ÓÔÏÈ΋ ÂÈÊ¿ÓÂÈ· 500-700 m2 Ô˘ Â›Ó·È ˘‡ı˘Ó· ÁÈ’ ·˘Ù‹ ÙË ÏÂÈÙÔ˘ÚÁ›·. ∆Ô ÙÚȯÔÂȉÈÎfi ÙÔ›¯ˆÌ· ·ÔÙÂÏÂ›Ù·È ·fi ÌÔÓ‹ ÛÙÔÈ‚¿‰· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË (™¯‹Ì· 1). ™ÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË ˘¿Ú¯Ô˘Ó fiÚÔÈ Ô˘ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfiÙ·ÙÔ ÚfiÏÔ ÛÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ

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Paediatriki 2002;65:160-166

Ô˘ÛÈÒÓ ÌÂٷ͇ Ï¿ÛÌ·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡. ™ÙÔ˘˜ fiÚÔ˘˜ ·˘ÙÔ‡˜ ˘¿ÁÔÓÙ·È ÔÈ ÌÂÛÔ΢ÙÙ¿ÚȘ Û¯ÈṲ̂˜ ÌÂٷ͇ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ, Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ¤Ó· ¯·Ï·Úfi ϤÁÌ· ‰ÈÎÙ˘ˆÙÒÓ ÈÓȉ›ˆÓ ·fi ÚˆÙÂÔÁÏ˘Î¿Ó˜, ‰È·Ì¤ÛÔ˘ ÙˆÓ ÔÔ›ˆÓ ‰È·ÎÈÓÔ‡ÓÙ·È Ù· ÂÚÈÛÛfiÙÂÚ· ˘‰·ÙÔ‰È·Ï˘Ù¿ ÈfiÓÙ· Î·È ÌfiÚÈ·. ∂›Û˘, ÛÙÔ ÂÓ‰ÔıËÏÈ·Îfi ·ÙÙ·ÚÔ ˘¿Ú¯Ô˘Ó Ù· Ê·ÁÔ΢ÙÙ·ÚÈο ΢ÛÙ›‰È· Ô˘ ÌÂٷʤÚÔ˘Ó ÌÂÁ¿Ï· ÌfiÚÈ·, ·ÎfiÌË Î·È ÛÙÂÚ¿ ۈ̷ٛ‰È·, ·fi ÙË Ì›· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙËÓ ¿ÏÏË. ∏ ·ÓÙ·ÏÏ·Á‹ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÂٷ͇ ·›Ì·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ Á›ÓÂÙ·È Î˘Ú›ˆ˜ Ì ‰È¿¯˘ÛË. ∏ ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÙȘ ‰È¿ÊÔÚ˜ Ô˘Û›Â˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜, ÙÔ Û¯‹Ì· Î·È ÙÔ ËÏÂÎÙÚÈÎfi ÙÔ˘˜ ÊÔÚÙ›Ô (10). ∆· ÌfiÚÈ· ÙÔ˘ ÓÂÚÔ‡, Ô˘ Â›Ó·È Ù· ÌÈÎÚfiÙÂÚ·, ¤¯Ô˘Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ‰È·ÂÚ·ÙfiÙËÙ·. OÈ ÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È ÂÏ·ÊÚ¿ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙÔ˘˜ fiÚÔ˘˜, Ì ·ÔÙ¤ÏÂÛÌ· Ë ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË Ó· Â›Ó·È ·‰È·¤Ú·ÛÙË Û¯Â‰fiÓ ÛÙË ÏÂ˘ÎˆÌ·Ù›ÓË, ·Ó Î·È ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ ÚˆÙ½Ó˘ ÂÚÓÔ‡Ó ·fi ÙÔ Ï¿ÛÌ· ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ. ∆Ô ÈÓˆ‰ÔÁfiÓÔ Ô˘ ¤¯ÂÈ Ôχ ÌÂÁ·Ï‡ÙÂÚÔ ªµ ·fi ÙË ÏÂ˘ÎˆÌ·Ù›ÓË ÌÔÚ› Ó· ÂÚ¿ÛÂÈ ·fi ÙÔ˘˜ ÙÚȯÔÂȉÈÎÔ‡˜ fiÚÔ˘˜ Û ηٿÛÙ·ÛË ÊÏÂÁÌÔÓ‹˜, ÏfiÁˆ ÙÔ˘ Û¯‹Ì·Ùfi˜ ÙÔ˘ Ô˘ Â›Ó·È Û·Ó ‚ÂÏfiÓË (10). OÈ ÚˆÙ½Ó˜ ʤÚÔ˘Ó ·ÚÓËÙÈÎfi ËÏÂÎÙÚÈÎfi ÊÔÚÙ›Ô Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ̤۷ ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ, ηıÒ˜ ·ˆıÔ‡ÓÙ·È ·fi ÙȘ ÚˆÙÂÔÁÏ˘Î¿Ó˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ ÙÚȯÔÂȉÒÓ (Ô˘ Â›Ó·È ÎÈ ·˘Ù¤˜ ·ÚÓËÙÈο ÊÔÚÙÈṲ̂Ó˜), ÏfiÁˆ ÛÙ·ÙÈÎÔ‡ ËÏÂÎÙÚÈÛÌÔ‡ (11).

O ‰È¿ÌÂÛÔ˜ ¯ÒÚÔ˜ (™¯‹Ì· 2) ·ÔÙÂÏÂ›Ù·È ·fi ÈÛ¯˘Ú¤˜ ›Ó˜ ÎÔÏÏ·ÁfiÓÔ˘ Ô˘ ÚÔÛ‰›‰Ô˘Ó ÙËÓ Ù¿ÛË Ô˘ Û˘ÁÎÚ·Ù› ÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ·fi ÏÂÙ¿ ÈÓ›‰È· ÚˆÙÂÔÁÏ˘Î¿Ó˘ Ô˘ Û˘Ó‰¤ÔÓÙ·È ¯·Ï·Ú¿ ÌÂٷ͇ ÙÔ˘˜ Û¯ËÌ·Ù›˙ÔÓÙ·˜ ¤Ó· ϤÁÌ·. ª¤Û· ÛÙÔ ϤÁÌ· ·˘Ùfi ÂÁÎψ‚›˙ÂÙ·È ÙÔ ˘ÂډȋıËÌ· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÙÔ “˙ÂϤ” ÙˆÓ ÈÛÙÒÓ. ∞Ó¿ÌÂÛ· Û ·˘Ùfi ÙÔ ϤÁÌ· ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ

˘¿Ú¯Ô˘Ó Î·È Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜. ŸÙ·Ó fï˜ ·Ó·Ù‡ÛÛÂÙ·È ÈÛÙÈÎfi Ô›‰ËÌ·, ·˘Ù¤˜ ·ÎÚÈ‚Ò˜ ÔÈ ÂÚÈÔ¯¤˜ Ì ÙÔ ÂχıÂÚÔ ˘ÁÚfi ÂÎÙ‡ÛÛÔÓÙ·È ˘ÂÚ‚ÔÏÈο. À¿Ú¯Ô˘Ó 4 ‰˘Ó¿ÌÂȘ Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ Î›ÓËÛË ÙÔ˘ ÓÂÚÔ‡ ‰È·Ì¤ÛÔ˘ Ù˘ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi (™¯‹Ì· 3): ·) ∏ ̤ÛË ∆ÚȯÔÂȉÈ΋ ¶›ÂÛË (Pc) Ô˘ Ù›ÓÂÈ Ó· ÌÂÙ·ÎÈÓ› ÙÔ ÓÂÚfi ÚÔ˜ Ù· ¤Íˆ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÙÚȯÔÂȉԇ˜. ‚) ∏ ¶›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (Pif) Ô˘ Ù›ÓÂÈ Ó· ÌÂÙ·ÎÈÓ› ÙÔ ÓÂÚfi ÚÔ˜ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ (ÚÔ˜ Ù· ̤۷) fiÙ·Ó Â›Ó·È ıÂÙÈ΋, ·ÏÏ¿ ÚÔ˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (ÚÔ˜ Ù· ¤Íˆ) fiÙ·Ó Â›Ó·È ·ÚÓËÙÈ΋. Á) ∏ OÁÎÔÙÈ΋ ¶›ÂÛË (ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (¶p) Ô˘ Ù›ÓÂÈ Ó· ÚÔηÏ› fiÛ̈ÛË ÙÔ˘ ÓÂÚÔ‡ ÚÔ˜ Ù· ̤۷, ‰È·Ì¤ÛÔ˘ Ù˘ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ‰) ∏ ∫ÔÏÏÔÂȉÔÛ̈ÙÈ΋ ¶›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (¶if) Ô˘ Ù›ÓÂÈ Ó· ÚÔηÏ› fiÛ̈ÛË ÙÔ˘ ÓÂÚÔ‡ ÚÔ˜ Ù· ¤Íˆ ‰È·Ì¤ÛÔ˘ Ù˘ ÌÂÌ‚Ú¿Ó˘. ∏ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (Pif) Â›Ó·È ÂÏ·ÊÚ¿ ·ÚÓËÙÈ΋, Û ۯ¤ÛË Ì ÙËÓ ·ÙÌÔÛÊ·ÈÚÈ΋ ›ÂÛË Ô˘ ÂÍ·ÛÎÂ›Ù·È ÛÙÔ ‰¤ÚÌ· Ô˘ ıˆÚÂ›Ù·È ÌˉÂÓÈ΋. ∏ ·ÚÓËÙÈ΋ ·˘Ù‹ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ ·ÛΛ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ¤Ó·ÓÙÈ Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ Ôȉ‹Ì·ÙÔ˜ Î·È Â›Û˘ Û˘Ì‚¿ÏÏÂÈ ÛÙË Û˘ÓÂÎÙÈÎfiÙËÙ· ÙˆÓ ÈÛÙÒÓ, ηıÒ˜ ‰Ú· ˆ˜ ÎÂÓfi ·¤ÚÔ˜. ∏ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (¶p) ÚÔ¤Ú¯ÂÙ·È ·fi ÙȘ ‰È·Ï˘Ì¤Ó˜ ÚˆÙ½Ó˜ ÛÙÔ Ï¿ÛÌ·, ÂÓÒ Ë ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ (¶if) ÂÍ·ÛÎÂ›Ù·È ·fi Ù· ÌfiÚÈ· ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ Â›Ó·È Û˘ÁÎÂÓÙڈ̤ӷ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (‰È‹ıËÛË Ì¤Ûˆ fiÚˆÓ, Ê·ÁÔ·وÛË). ™ÙËÓ Î·Ù·ÓÔÌ‹ ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ÓÂÚÔ‡ ÌÂٷ͇

Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡

Ê˘Û·Ï›‰Â˜ ÂχıÂÚÔ˘ ˘ÁÚÔ‡

ÂÓ‰ÔıËÏÈ·Îfi ·ÙÙ·ÚÔ ÙÚȯÔÂȉ¤˜ ÌÂÛÔ΢ÙÙ¿ÚÈ· Û¯ÈÛÌ‹

ÈÓ›‰È· ÚˆÙÂÔÁÏ˘Î¿Ó˘

Ê·ÁÔ΢ÙÙ·ÚÈο ΢ÛÙ›‰È·

›Ó˜ ÎÔÏÏ·ÁfiÓÔ˘ ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË

™¯‹Ì· 1

™¯‹Ì· 2

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Paediatriki 2002;65:160-166

Ï¿ÛÌ·ÙÔ˜ Î·È ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡ ÈÛ¯‡ÂÈ Ô ÓfiÌÔ˜ ÙÔ˘ Starling, Ô˘ ÚÈÓ ·fi ¤Ó·Ó ·ÈÒÓ· ÂÚ›Ô˘ ‰È·Ù‡ˆÛ ÙËÓ ÈÛÔÚÚÔ›· Ô˘ ˘¿Ú¯ÂÈ ÛÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË: Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Ô˘ ÊÈÏÙÚ¿ÚÂÙ·È ¤Íˆ ·fi ÙËÓ ÙÚȯÔÂȉÈ΋ ÌÂÌ‚Ú¿ÓË ÛÙÔ ·ÚÙËÚÈ·Îfi ¿ÎÚÔ ÈÛÔ‰˘Ó·Ì› Ì ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ˘ÁÚÔ‡ Ô˘ Â·Ó·ÚÚÔÊ¿Ù·È ·fi Ù· ÙÚȯÔÂȉ‹ ÛÙÔ ÊÏ‚ÈÎfi ¿ÎÚÔ. ¢ËÏ·‰‹, ÈÛ¯‡ÂÈ Ë Â͛ۈÛË: ¢È‹ıËÛË ˘ÁÚÔ‡ = ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ÌÂÌ‚Ú¿Ó˘ x ›ÂÛË ‰È‹ıËÛ˘ ¢È‹ıËÛË ˘ÁÚÔ‡ (Fluid flux): FF=Kfc[(Pc-Pif)6d(¶p-¶if)] Kfc = ÛÙ·ıÂÚ¿ ÙÚȯÔÂȉÈ΋˜ ‰È¿¯˘Û˘, 6d = ÛÙ·ıÂÚ¿ ·Ó¿ÎÏ·Û˘ ¶ÂÚ›Ô˘ ÙÔ 0,5% ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÊÈÏÙÚ¿ÚÂÙ·È ÂÎÙfi˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÙÔ ·ÚÙËÚÈ·Îfi ¿ÎÚÔ Î·È ‰È·¯¤ÂÙ·È ÚÔ˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ, ÁÈ· Ó· Â·Ó·ÚÚÔÊËı› ۯ‰fiÓ fiÏÔ ·fi ÙÔ ÊÏ‚ÈÎfi ¿ÎÚÔ ÙˆÓ ÙÚȯÔÂȉÒÓ. ∆Ô 1/10 ÂÚ›Ô˘ Ù˘ ÔÛfiÙËÙ·˜ Ô˘ ÂÍ·ÁÁÂÈÒÓÂÙ·È ‰ÂÓ Â·Ó·ÚÚÔÊ¿Ù·È, ·ÏÏ¿ ÔÈ ÈÛÙÔ› ‰ÂÓ ÂÍÔȉԇÓÙ·È, ‰ÈfiÙÈ ·˘Ù‹ Ë ÂÈϤÔÓ ÔÛfiÙËÙ· ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ÏÂÌÊ·ÁÁÂÈ·Îfi ‰›ÎÙ˘Ô. ŸÙ·Ó ˘¿Ú¯ÂÈ ·ÓÈÛÔÚÚÔ›· ÛÙȘ ‰˘Ó¿ÌÂȘ Ô˘ ·ÛÎÔ‡ÓÙ·È Âη٤ڈıÂÓ Ù˘ ÌÂÌ‚Ú¿Ó˘, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Û˘Óı‹Î˜ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· Ôȉ‹Ì·ÙÔ˜. ŒÙÛÈ, Ô›‰ËÌ· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ÛÂ: ·) ·˘ÍË̤ÓË ›ÂÛË ÙˆÓ ÙÚȯÔÂȉÒÓ, ‚) ·ÒÏÂÈ· ÚˆÙÂ˚ÓÒÓ Ï¿ÛÌ·ÙÔ˜, Á) ·fiÊÚ·ÍË ÏÂÌÊ·ÁÁ›ˆÓ Î·È ‰) ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· ÙÚȯÔÂȉÒÓ (Leak syndrome). ∏ ‰ËÌÈÔ˘ÚÁ›· Ôȉ‹Ì·ÙÔ˜ ÚÔ‚ÏËÌ·Ù›˙ÂÈ Ôχ ÙÔÓ ıÂÚ¿ÔÓÙ· È·ÙÚfi, ‰ÈfiÙÈ ÙÔ Ô›‰ËÌ· Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ (12): η΋ ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ ÛÙÔÓ Ó‡ÌÔÓ·, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ì˘Ôηډ›Ô˘, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ηı˘ÛÙÂÚË̤ÓË ÂԇψÛË ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÙÚ·˘Ì¿ÙˆÓ, ÌÂȈ̤ÓË ‰È·ıÂÛÈÌfiÙËÙ· Ô͢ÁfiÓÔ˘ ÛÙÔ˘˜ ÈÛÙÔ‡˜, ¤ÏÎË Î·Ù¿ÎÏÈÛ˘.

ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ ¤¯ÂÈ ÌÂÏÂÙËı› ΢ڛˆ˜ ÛÙÔ ÛËÙÈÎfi shock. ∂ΛÓÔ Ô˘ ¿Û¯ÂÈ ÛÙÔ Leak syndrome Â›Ó·È Ë ÌÈÎÚÔ΢ÎÏÔÊÔÚ›· (13). ™ÙË ÛË„·ÈÌ›·, ÔÈ ÂÓ‰ÔÙÔ͛Ә ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ·ÏÏ¿ Î·È ¿ÏÏÔÈ ÂӉȿÌÂÛÔÈ ·Ú¿ÁÔÓÙ˜ ÊÏÂÁÌÔÓ‹˜ (TNF-·, IL-1, IL-2, IL-6, IL-8, ·Ú¿ÁÔÓÙ˜ C1, C3, C5 ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ·Ú¿ÁÔÓÙ˜ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, Ï¢ÎÔÙÚȤÓÈ·, ‚Ú·‰˘ÎÈÓ›ÓË, Ï·ÛÌ›ÓË, ÂÏ·ÛÙ¿ÛË Î.Ï.) ÂÓÂÚÁÔÔÈÔ‡Ó Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú·, Ù· ÔÔ›· Û˘ÁÎÔÏÏÒÓÙ·È Ì ٷ Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È ˘Ê›ÛÙ·ÓÙ·È Ù·¯Â›· ÌÂÙ·‚ÔÏ‹ Ù˘ ‰ÔÌ‹˜ Î·È ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜, Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Î·È ÙËÓ ·‡ÍËÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ¿˜ ÙÔ˘ (3,4,10,14,15). ∏ Û˘ÁÎfiÏÏËÛË ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ‚·ÛÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘ (SIRS). ªÂ ÙÔ Ì˯·ÓÈÛÌfi ·˘Ùfi ÚÔηÏÂ›Ù·È ·¢ı›·˜ ‚Ï¿‚Ë ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÂχıÂÚˆÓ ÚÈ˙ÒÓ O2, ˘‰ÚÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ηıÒ˜ Î·È Ì ÙËÓ ·fiÊÚ·ÍË ÙÔ˘ ·˘ÏÔ‡ ÙˆÓ ÙÚȯÔÂȉÒÓ ·fi Ù· Û˘ÛÛˆÚÂ˘Ì¤Ó· Ï¢ÎÔ·ÙÙ·Ú· (14).

H ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÚÔ··ÈÙÂ›Ù·È ÁÈ· Ó· Â·ÎÔÏÔ˘ı‹ÛÂÈ Ë Û˘ÁÎfiÏÏËÛË Ì ٷ ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· (16). ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Û˘Ó‰¤Ô˘Ó ÙÔ ¡O Ì ÙËÓ ÚÔÒıËÛË Ù˘ Û˘ÁÎfiÏÏËÛ˘ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÛÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·. ∆Ô puzzle ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ÊÏÂÁÌÔÓ‹˜ ‰ÂÓ Â›Ó·È Ï‹Ú˜, ·ÏÏ¿ Ê·›ÓÂÙ·È fiÙÈ ÙÔ ¡O ·›˙ÂÈ ÛÔ˘‰·›Ô ÚfiÏÔ, fi¯È ÌfiÓÔ Ú˘ıÌ›˙ÔÓÙ·˜ ÙÔÓ ÙfiÓÔ ÙˆÓ ·ÁÁ›ˆÓ, ·ÏÏ¿ Î·È ÂËÚ¿˙ÔÓÙ·˜ ÙË ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ Î·È ÙË ÊÏÂÁÌÔÓÒ‰Ë ·¿ÓÙËÛË (16). ∏ ‚Ï¿‚Ë Ô˘ Û˘Ì‚·›ÓÂÈ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ÙÚȯÔÂȉÒÓ ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜, Û˘Ó›ÛÙ·Ù·È Û ‰È·Ù·Ú·¯‹ ÙÔ˘ ‰ÈÎÙ‡Ô˘ ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ Ô˘ Û˘Óı¤ÙÔ˘Ó ÙȘ ÌÂÛÔ΢ÙÙ¿ÚȘ Û¯ÈṲ̂˜ (4), Ì ·ÔÙ¤ÏÂÛÌ· ÙË ¯·Ï¿ÚˆÛË ÙˆÓ ÛÙÂÓÒÓ Û˘Ó‰¤ÛÂˆÓ ÌÂٷ͇ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙË ‰È·Ê˘Á‹ ÚˆÙÂ˚ÓÒÓ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (3). º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÛÔ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙˆÓ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ ÛÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ¶ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠÂÚÁ·Û›· (11) Ô˘ Û˘Û¯¤ÙÈÛ ÙÔ ÛËÙÈÎfi shock Ì ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÁÏ˘ÎÔ˙·ÌÈÓÔÁÏ˘Î·ÓÒÓ ÛÙÔ ·›Ì· Î·È ÛÙ· Ô‡Ú·, Ô˘ Èı·Ófiٷٷ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ÂÓ˙˘Ì·ÙÈο ·fi ÙÔ ÂÓ‰Ôı‹ÏÈÔ Î·È ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË. ∂›Û˘, ÚfiÛÊ·Ù· Ê¿ÓËÎÂ Ë Û˘Û¯¤ÙÈÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ Leak syndrome Î·È Ù˘ ·¤ÎÎÚÈÛ˘ ÚˆÙÂÔÁÏ˘Î·ÓÒÓ ÛÙ· Ô‡Ú· (11).

¶·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ∏ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ ·Ú·Ì¤ÓÂÈ ·Û·Ê‹˜. ∏ ·˘ÍË̤ÓË ‰È·-

£ÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∂›Ó·È ÁÓˆÛÙfi ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ ÂÈÎÔÛÙÔ‡ ·ÈÒÓ· fiÙÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ

ÙÚȯÔÂȉÈ΋ ›ÂÛË 17 mmHg (Pc)

ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ 28 mmHg (¶Ú)

›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ˘ÁÚÔ‡ -5,3 mmHg (Pif) 6 mmHg (¶if) ™¯‹Ì· 3

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¶·È‰È·ÙÚÈ΋ 2002;65:160-166

·ÔηٿÛÙ·ÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È Ë ¤Á¯˘ÛË ÂÓ‰ÔÊϤ‚ÈˆÓ ˘ÁÚÒÓ (17). ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηχÙÂÚÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓË (17,18). ∞fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ˘Ê›ÛÙ·Ù·È Ë ·ÓÙÈ·Ú¿ıÂÛË: “ÎÚ˘ÛÙ·ÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹”; ∏ ȉ·ÓÈ΋ ηÙËÁÔÚ›· ˘ÁÚÒÓ Â›Ó·È ÂΛÓË Ô˘ ·ÔηıÈÛÙ¿ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi fiÁÎÔ, ·˘Í¿ÓÂÈ ÙËÓ ·fi‰ÔÛË ÙÔ˘ O2 ÛÙÔ˘˜ ÈÛÙÔ‡˜, ¯ˆÚ›˜ Ó· ÚÔηÏ› Ô›‰ËÌ· ÂÍ·ÈÙ›·˜ ‰È·Ê˘Á‹˜ ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ (24). ∆· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ·ÔÙÂÏÔ‡Ó Û˘Ó‹ıˆ˜ ÙËÓ ÚÒÙË ÂÎÏÔÁ‹, ‰ÈfiÙÈ Â›Ó·È Â˘Ú¤ˆ˜ ‰È·ı¤ÛÈÌ· Î·È ÏÈÁfiÙÂÚÔ ·ÎÚÈ‚¿ (8,19). ∂›Û˘, Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ·˘Í¿ÓÔ˘Ó ÙÔ Ú˘ıÌfi ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR), ·Ó·ÏËÚÒÓÔ˘Ó ÙÔ Û˘ÚÚÈÎӈ̤ÓÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ‚ÂÏÙȈ̤ÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. O fiÁÎÔ˜ ηٷÓÔÌ‹˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ Â›Ó·È Î˘Ú›ˆ˜ Ô ÂÍ·ÁÁÂÈ·Îfi˜ ¯ÒÚÔ˜ (12,19): οو ·fi ȉ·ÓÈΤ˜ Û˘Óı‹Î˜, ÙÔ 25% ÂÚ›Ô˘ ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ ·Ú·Ì¤ÓÂÈ ÂÓ‰·ÁÁÂȷο, ÂÓÒ ÙÔ ˘fiÏÔÈÔ ‰È·¯¤ÂÙ·È ÛÙÔÓ ÂÍ·ÁÁÂÈ·Îfi ¯ÒÚÔ (20). ŒÙÛÈ, 1 lit ÈÛfiÙÔÓÔ˘ ‰È·Ï‡Ì·ÙÔ˜ NaCl 0,9% ·Ó·Ì¤ÓÂÙ·È Ó· ·˘Í‹ÛÂÈ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ Î·Ù¿ ÂÚ›Ô˘ 100-300 ml. ∆· ·ÈÌÔ‰˘Ó·ÌÈο ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‚Ú·¯˘ÚfiıÂÛÌ· Î·È ··ÈÙÔ‡Ó 2-4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ fiÁÎÔ˘˜ Û ۯ¤ÛË Ì ٷ ÎÔÏÏÔÂȉ‹. O ÌÂÁ¿ÏÔ˜ fiÁÎÔ˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙÔ ÂÈı˘ÌËÙfi ·ÔÙ¤ÏÂÛÌ· (ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜) ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÏ¿ÙÙˆÛË Ù˘ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋˜ ›ÂÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ‰È¿ÌÂÛÔ˘ Ôȉ‹Ì·ÙÔ˜ ‹ ·ÎfiÌ· Î·È Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÛÙÔÓ ·ÛıÂÓ‹ (12,17). À¿Ú¯Ô˘Ó fï˜ Î·È Ù· ˘¤ÚÙÔÓ· ‰È·Ï‡Ì·Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ (NaCl 7,5%) Ô˘ ÂÍ·ÛÎÔ‡Ó ÔÛ̈ÙÈ΋ ›ÂÛË ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ Î˘ÙÙ¿ÚˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â·Ó·Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ˘ÁÚÔ‡ ÛÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ (17). ∆· ˘¤ÚÙÔÓ· ‰È·Ï‡Ì·Ù·, Û ·ÓÙ›ıÂÛË Ì ٷ ÈÛfiÙÔÓ·, ·ÔηıÈÛÙÔ‡Ó ÙÔÓ fiÁÎÔ Ï¿ÛÌ·ÙÔ˜, ‰È·ÙËÚÒÓÙ·˜ ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ ÛÂ Û˘ÛÙÔÏ‹. £ÂˆÚËÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ˘¤ÚÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ Â›Ó·È ÔÈ ÌÈÎÚÔ› fiÁÎÔÈ Ô˘ ··ÈÙÔ‡ÓÙ·È Î·È Ë ·¢ı›·˜ ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË (21). ™Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù¿ ÙÔ˘˜ ˘¿ÁÂÙ·È Ë ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Î·È Ë ˘ÂگψڷÈÌÈ΋ ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó. ∏ ¯Ú‹ÛË ÙÔ˘˜ Û ·ÈÌÔÚÚ·ÁÈÎfi shock ÌÂ Û˘Ó¯È˙fiÌÂÓË ·ÈÌÔÚÚ·Á›· ·ÌÊÈÛ‚ËÙ›ٷÈ, ηıÒ˜ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÔ˘Ó ÙËÓ ·ÈÌÔÚÚ·Á›· ÏfiÁˆ Ù˘ ·ÁÁÂÈԉȷÛÙÔÏ‹˜ Ô˘ ÚÔηÏÔ‡Ó (12). ¶·Ú’ fiÙÈ Ë ·Ó¿Ù·ÍË ÙÔ˘ shock ÁÂÓÈο ÍÂÎÈÓ¿ Ì ÎÚ˘ÛÙ·ÏÔÂȉ‹, Ù· ÎÔÏÏÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ÂÓ·ÏÏ·ÎÙÈ-

Paediatriki 2002;65:160-166

΋ χÛË Ô˘ ÚÔÙÈÌ¿Ù·È ·fi ÔÏÏÔ‡˜ (12). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ∞’ ¶·ÁÎÔÛÌ›Ô˘ ÔϤÌÔ˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ¤Ó· Ê˘ÙÈÎfi ÎÔÏÏÔÂȉ¤˜ ÚÔÂÚ¯fiÌÂÓÔ ·fi ÙÔ ÎfiÌÌÈ Ù˘ ·Î·Î›·˜. ™ÙÔ µ’ ¶·ÁÎfiÛÌÈÔ fiÏÂÌÔ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·›Ì· Î·È Û˘ÛÙ·ÙÈο ·›Ì·ÙÔ˜ (12). ∆· ÎÔÏÏÔÂȉ‹ ıˆÚÔ‡ÓÙ·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο ˘ÁÚ¿ ·Ó¿Ó˄˘ Û ۯ¤ÛË Ì ٷ ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ (21,22), ‰ÈfiÙÈ Î·Ù¿ ÚÔÙÂÚ·ÈfiÙËÙ· ·˘Í¿ÓÔ˘Ó ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (‰È·Ù›ÓÔ˘Ó ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ), ÂÊ’ fiÛÔÓ Ë ‰È·ÂÚ·ÙfiÙËÙ· ÙˆÓ ÙÚȯÔÂȉÒÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋. ∫¿ı ÁÚ·ÌÌ¿ÚÈÔ ÎÔÏÏÔÂȉԇ˜ Û˘ÁÎÚ·Ù› ÂÚ›Ô˘ 20 ml ∏2O ÛÙËÓ Î˘ÎÏÔÊÔÚ›·. ∫·ıÒ˜ Ô fiÁÎÔ˜ ηٷÓÔÌ‹˜ ÙÔ˘˜ Â›Ó·È Î˘Ú›ˆ˜ Ô ÂÓ‰·ÁÁÂÈ·Îfi˜, Ù· ÎÔÏÏÔÂȉ‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ÂÍ‹˜ ÏÂÔÓÂÎÙ‹Ì·Ù· (20): ·) ∞·ÈÙÔ‡ÓÙ·È ÌÈÎÚfiÙÂÚÔÈ fiÁÎÔÈ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ fiÁÎÔ˘ Ï¿ÛÌ·ÙÔ˜, ‚) ÚÔηÏÔ‡Ó ÌÈÎÚfiÙÂÚÔ ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·, Á) ‰È·ÙËÚÔ‡Ó ÛÙ·ıÂÚ‹ ÙËÓ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋ ›ÂÛË Ï¿ÛÌ·ÙÔ˜, ‰) Ù· ·ÈÌÔ‰˘Ó·ÌÈο ÙÔ˘˜ ·ÔÙÂϤÛÌ·Ù· ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÁÚËÁÔÚfiÙÂÚ· Î·È ‰È·ÚÎÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ Î·È Â) ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÌÂÙ·ÊÔÚ¿ O2, ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ÙÔÓ fiÁÎÔ ·ÏÌÔ‡.

OÈ ˘ÔÛÙËÚÈÎÙ¤˜ ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ·ÓÙÈ·Ú·ı¤ÙÔ˘Ó fiÙÈ (17,22): ·) ∆· ÎÔÏÏÔÂȉ‹ Â›Ó·È Ôχ ·ÎÚÈ‚fiÙÂÚ· ·fi Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ‚) ÛÂ Û˘Óı‹Î˜ ·˘ÍË̤Ó˘ ÙÚȯÔÂȉÈ΋˜ ‰È·ÂÚ·ÙfiÙËÙ·˜, Ù· ÎÔÏÏÔÂȉ‹ ÂÚÓÔ‡Ó ÛÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ, Û˘ÁÎÚ·ÙÒÓÙ·˜ ÓÂÚfi, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏÔ‡Ó ÂÓÙÔÓfiÙÂÚÔ Î·È ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ Ô›‰ËÌ·, ÙfiÛÔ Û˘ÛÙËÌ·ÙÈÎfi fiÛÔ Î·È Ó¢ÌÔÓÈÎfi, Á) Ù· Ê˘ÛÈο ÎÔÏÏÔÂȉ‹ ÌÔÚÔ‡Ó Ó· ÌÂÙ·‰ÒÛÔ˘Ó ÌÔÏ˘ÛÌ·ÙÈΤ˜ ·Ûı¤ÓÂȘ (HBV, HCV, HIV) ‹ ·ÎfiÌ· Ó· ÚÔηϤÛÔ˘Ó ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ Î·È ‰) fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ÌÂÁ¿ÏÔ˘˜ fiÁÎÔ˘˜ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ‹Í˘ (Ù· Ù¯ÓËÙ¿ ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù·). ∆· ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›Ó·È: ·) ¢È·Ï‡Ì·Ù· ·Ï‚Ô˘Ì›Ó˘ (5%, 20%). ∏ ·Ï‚Ô˘Ì›ÓË Â›Ó·È Î‡ÚÈ· ÚˆÙ½ÓË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ (ªµ 66.000 daltons) Î·È ·ÔÙÂÏ› ÙÔ 50% ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (12,23). ŒÁ¯˘ÛË 1 lit ∏∞ 5% ·˘Í¿ÓÂÈ ÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi fiÁÎÔ Î·Ù¿ 500-1000 ml. ∆Ô ‰È¿Ï˘Ì· ∏∞ 20% ÎÈÓËÙÔÔÈ› ˘ÁÚfi ·fi ÙÔ ‰È¿ÌÂÛÔ ¯ÒÚÔ ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi Ì ·ÔÙ¤ÏÂÛÌ· ¤Á¯˘ÛË 100 ml Ó· ·˘Í¿ÓÂÈ ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ηٿ 400-500 ml Ì›· ÒÚ· ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË. ™Â ηٷÛÙ¿ÛÂȘ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜, fiˆ˜ ÛÙÔ ÛËÙÈÎfi ÛÔÎ, ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚ˜ ÔÛfiÙËÙ˜ ˘ÁÚÔ‡ ÌÔÚ› Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó (22). ∆· ‰È·Ï‡Ì·Ù· ·Ï‚Ô˘Ì›Ó˘ ‰ÂÓ ÂËÚ¿˙Ô˘Ó

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·164

¶·È‰È·ÙÚÈ΋ 2002;65:160-166

ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘ Î·È ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ. ¶·Ú¿ÁÔÓÙ·È ·fi Ï¿ÛÌ· ÔÏÏÒÓ ‰ÔÙÒÓ Î·È Ú·ÎÙÈο ‰ÂÓ ¤¯Ô˘Ó ΛӉ˘ÓÔ ÌÂÙ¿‰ÔÛ˘ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ, ηıÒ˜ ÂÂÍÂÚÁ¿˙ÔÓÙ·È Ì ıÂÚÌfiÙËÙ· Î·È ·ÔÛÙÂÈÚÒÓÔÓÙ·È Ì ˘ÂډȋıËÛË. ‚) ∆Ô ÚfiÛÊ·Ù· ηÙ„˘Á̤ÓÔ Ï¿ÛÌ· (FFP) (22,24) ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ˘¿Ú¯ÂÈ ‰È·Ù·Ú·¯‹ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ¶·Ú’ fiÙÈ ÙÔ Ï¿ÛÌ· ÚÔ¤Ú¯ÂÙ·È ·fi ÂıÂÏÔÓÙ¤˜ ·ÈÌÔ‰fiÙ˜ Î·È ¤¯ÂÈ ˘ÔÛÙ› ÚÔÛ¯ÙÈÎfi ¤ÏÂÁ¯Ô, ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ: ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ HCV 1/33.000ÌÔÓ¿‰Â˜, HBV 1/200.000 ÌÔÓ¿‰Â˜, HIV 1/225.000 ÌÔÓ¿‰Â˜. Á) ¢È·Ï‡Ì·Ù· ¢ÂÍÙÚ¿Ó˘ (40, 70) (12,22). ∂›Ó·È ÔÏ˘ÌÂÚ‹ ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘ Ì ̤ÛÔ ªµ 40.0000 Î·È 70.000 daltons, ·ÓÙ›ÛÙÔȯ·. £ÂˆÚÂ›Ù·È fiÙÈ Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ Û ‚·ÚÈ¿ ÓÔÛÔ‡ÓÙ˜ ·ÛıÂÓ›˜ ‚ÂÏÙÈÒÓÂÈ ÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·, ‰ÈfiÙÈ ÌÂÈÒÓÔ˘Ó ÙË ÁÏÔÈfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜, ·ÏÏ¿ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÛÙÔ 0,03% ÙˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, ÌÔÚ› Ó· ·ÚÂÌ‚ÏËıÔ‡Ó ÛÙȘ ·ÓÙȉڿÛÂȘ ‰È·ÛÙ·‡ÚˆÛ˘ ÙÔ˘ ·›Ì·ÙÔ˜, ÂÓÒ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ‹Í˘. ‰) ∑ÂÏ·Ù›Ó˜ - Gelatins (Haemacel, Gelofusine) (12). ¶ÚÔ¤Ú¯ÔÓÙ·È ·fi ¯Ô›ÚÂÈÔ ÎÔÏÏ·ÁfiÓÔ. ∆Ô ªµ ÙÔ˘˜ Î˘Ì·›ÓÂÙ·È ·fi 24,5 K Da ¤ˆ˜ 22,6 K Da. Œ¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ·Ï·ÈfiÙÂÚ· ÛÙËÓ ∂˘ÚÒË. Œ¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ·Ú’ fiÏÔ Ô˘ Ô ÙÚfiÔ˜ ·Ú·Û΢‹˜ ÙÔ˘ Haemacel ¤¯ÂÈ ÙÚÔÔÔÈËı›. ∏ ¯Ú‹ÛË ÙÔ˘˜ ¤¯ÂÈ ÂÚÈÔÚÈÛÙ›, ηıÒ˜ Ê·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó ÌÈÎÚ‹ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·. Â) À‰ÚÔ͢ÏȈ̤ÓÔ ‰È¿Ï˘Ì· ·Ì‡ÏÔ˘ (Hetastarch, ∏aessteril) (12,25). ∂›Ó·È ‰È·ı¤ÛÈÌÔ ˆ˜ ‰È¿Ï˘Ì· ˘‰ÚÔÏ˘Ì¤Ó˘ ·Ì˘ÏÔÂÎÙ›Ó˘ 6% ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi. ¶·Ú¿ÁÂÙ·È ·fi ηϷÌfiÎÈ ‹ ίڛ. ∆· ۈ̷ٛ‰È¿ ÙÔ˘ ¤¯Ô˘Ó ªµ Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 30.000 ¤ˆ˜ 2.400.000 daltons (22). ŒÓ· lit ‰È·Ï‡Ì·ÙÔ˜ ·Ì‡ÏÔ˘ ·˘Í¿ÓÂÈ ÙÔÓ fiÁÎÔ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ηٿ 700 ml-1 lit. ¶ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠ(10,25) fiÙÈ Ù· ‰È·Ï‡Ì·Ù· ·Ì‡ÏÔ˘ ÛÊÚ·Á›˙Ô˘Ó ÂÎÏÂÎÙÈο ÙÔ˘˜ fiÚÔ˘˜ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ÙÚȯÔÂȉÒÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÌÂÙ¿ ·fi οı ÏÔÁ‹˜ ‚Ï·ÙÈÎfi ÂÚ¤ıÈÛÌ·. À¿Ú¯Ô˘Ó ¤Ú¢Ó˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ù· ‰È·Ï‡Ì·Ù· ·˘Ù¿ ‚ÂÏÙÈÒÓÔ˘Ó ÙÔ Á·ÛÙÚÈÎfi pH (ÂÓ‰Ô‚ÏÂÓÓÔÁfiÓÈÔ) (25), ·Ó Î·È ·fi ¿ÏϘ ·ÌÊÈÛ‚ËÙÂ›Ù·È (26). ∆· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ Â›Ó·È fiÙÈ ÌÔÚ› Ó· ‰È·Ù·Ú¿ÍÔ˘Ó ÙËÓ ËÎÙÈÎfiÙËÙ·, Ó· ÚÔηϤÛÔ˘Ó ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‹ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ. ÛÙ) ∆· Û˘Ó‰˘·Ṳ̂ӷ ‰È·Ï‡Ì·Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ-ÎÔÏÏÔÂȉÒÓ (NaCl 7,5% + Dextran) (12) Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ¤Ú¢ӷ. ∆Ô ˘¤ÚÙÔÓÔ ÙÌ‹Ì· ÙˆÓ

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Paediatriki 2002;65:160-166

‰È·Ï˘Ì¿ÙˆÓ ·˘ÙÒÓ Ùp·‚¿ ÓÂÚfi ·fi ÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ ÁÈ· Ó· ·ÔηٷÛÙ‹ÛÂÈ Ù· ÌÂȈ̤ӷ ·Ôı¤Ì·Ù· ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ¯ÒÚÔ˘, ÂÓÒ ÙÔ ˘ÂÚÔÛ̈ÙÈÎfi ÙÌ‹Ì· ·ÚÔ‰Èο ·ÔÌÔÓÒÓÂÈ ÙÔ ˘ÁÚfi ·˘Ùfi ÂÓ‰·ÁÁÂȷο. Ë) ∆¤ÏÔ˜, ˘¿Ú¯Ô˘Ó Î·È Ù· ˘ÔηٿÛٷٷ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (12,21) Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÔÓ¿‰Â˜ Û˘Ì˘ÎÓˆÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ Ô˘ ¤¯Ô˘Ó Ï‹ÍÂÈ. ∆· ÏÂÔÓÂÎÙ‹Ì·Ù· Â›Ó·È ·Ó¿ÏÔÁ· ÙˆÓ ÌÂÙ·ÁÁ›ÛÂˆÓ ÌÂ Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿, ÂÓÒ ‰ÂÓ ÌÂÙ·‰›‰Ô˘Ó ÌÔÏ˘ÛÌ·ÙÈΤ˜ ·Ûı¤ÓÂȘ Î·È ‰ÂÓ ··ÈÙÔ‡Ó ‰È·ÛÙ·‡ÚˆÛË. ∞Ú¯ÈΤ˜, fï˜, ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ ÛÙ·Ì¿ÙËÛ·Ó, ‰ÈfiÙÈ ‰È·ÈÛÙÒıËΠ··ÁÔÚ¢ÙÈ΋ ÓÂÊÚÈ΋ ÙÔÍÈÎfiÙËÙ·. øÛÙfiÛÔ, Ӥ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È Ì ˘ÔηٿÛٷٷ ÔÏ˘ÌÂÚÈṲ̂Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘, Ô˘ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó Ôχ ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ. ªÂϤÙ˜ ¶ÚÔ˜ Â›Ï˘ÛË Ù˘ ·ÓÙÈ·Ú¿ıÂÛ˘ “ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹;” ¤¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÌÂϤÙ˜, ¯ˆÚ›˜ fï˜ Ó· ‰Â›¯ÓÔ˘Ó Û·Ê‹ ˘ÂÚÔ¯‹ Ù˘ Ì›·˜ ‹ Ù˘ ¿ÏÏ˘ ηÙËÁÔÚ›·˜. OÈ ÌÂϤÙ˜ ·˘Ù¤˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˘ ·Í›·˜ ÂÍ·ÈÙ›·˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÂÚȤϷ‚·Ó, ·ÏÏ¿ Î·È ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ-ÎÚÈÙËÚ›ˆÓ Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó. °È’ ·˘Ùfi ÙÔ ÏfiÁÔ, ·fi ‰ÂηÂÙ›·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ¿Ú¯ÈÛ ӷ ÂÊ·ÚÌfi˙ÂÙ·È Ë ÌÂÙ·-·Ó¿Ï˘ÛË, Ì ÙË Û˘ÁΤÓÙÚˆÛË ÛÙÔȯ›ˆÓ ·fi ·ÚfiÌÔÈ· ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ (27) ÁÈ· ÙË ‰ÈÂÍ·ÁˆÁ‹ ÈÔ ·ÍÈfiÈÛÙˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ. ŒÙÛÈ, Ô Velanovich ·fi ÙËÓ ∫·ÏÈÊfiÚÓÈ· ‰ËÌÔÛ›Â˘Û ÙÔ 1989 ÌÂϤÙË (27), fiÔ˘ ¯ÚËÛÈÌÔÔ›ËÛ ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ÁÈ· Ó· ÂÎÙÈÌ‹ÛÂÈ ·Ó ˘‹Ú¯Â ‰È·ÊÔÚ¿ ıÓËÙfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹ ˆ˜ ˘ÁÚ¿ ·Ó¿Ó˄˘. ™˘Ó¤ÏÂÍ ÛÙÔȯ›· ·fi 8 ÚÔÁÂÓ¤ÛÙÂÚ· ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜, ·ÚfiÌÔÈ· ۯ‰ȷṲ̂Ó˜, fiÔ˘ ·Ó·ÊÂÚfiÙ·Ó Î·È Ë ıÓËÙfiÙËÙ· Î·È Î·Ù¤ÏËÍ fiÙÈ ˘‹Ú¯Â Û¯ÂÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ· ηٿ 5,7% ˘¤Ú ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ. ¢‡Ô ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ë π·ÙÚÈ΋ ™¯ÔÏ‹ Ù˘ OÎÏ·¯fiÌ· ‰ËÌÔÛ›Â˘Û ¿ÏÏË ÌÂÙ·-·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ (28), Ì ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ‰ÂÓ ˘‹Ú¯Â Û·Ê‹˜ ‰È·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ· Û ·ÛıÂÓ›˜ Ô˘ ‰È·¯ˆÚ›ÛÙËÎ·Ó Û 3 ηÙËÁÔڛ˜: ˘Ô‚ÔÏ·ÈÌ›·, ¯ÂÈÚÔ˘ÚÁÈÎfi ÛÙÚ˜ Î·È ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. øÛÙfiÛÔ, ÂΛÓÔ Ô˘ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ ‰‡Ô ηÙËÁÔڛ˜ ‹Ù·Ó ÙÔ ÎfiÛÙÔ˜: Ë ·Ó¿ÓË„Ë Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ÎfiÛÙÈ˙ 45,13 ‰ÔÏ¿ÚÈ·, ÂÓÒ Ô Î¿ı ‰È·Ûˆı›˜ Ì ÎÔÏÏÔÂȉ‹ ·ÛıÂÓ‹˜ ÎfiÛÙÈ˙ 1493,6 ‰ÔÏ¿ÚÈ·! ŒÙÛÈ, ÔÈ ÂÚ¢ÓËÙ¤˜ ÚfiÙÂÈÓ·Ó Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ˆ˜ ˘ÁÚ¿ ÚÒÙ˘ ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·Ó¿Ù·ÍË ÙÔ˘ shock.

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¶·È‰È·ÙÚÈ΋ 2002;65:160-166

∆Ô 1998 ·ÎÔÏÔ‡ıËÛ·Ó ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ ÂÚÈÔ‰ÈÎfi British Medical Journal Î·È ÍÂÛ‹ÎˆÛ·Ó Û¿ÏÔ Û˘˙ËÙ‹ÛÂˆÓ Î·È ·ÓÙÈ·Ú·ı¤ÛÂˆÓ ÛÙÔ˘˜ È·ÙÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. ∏ ÈÔ ÁÓˆÛÙ‹ ·fi ·˘Ù¤˜ (29) Û˘Ó¤ÏÂÍ ‰Â‰Ô̤ӷ ·fi 30 ÚÔËÁÔ‡ÌÂÓ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Î·È ÂÚȤϷ‚ 1419 ·ÛıÂÓ›˜. ∂ϤÁ¯ıËÎÂ Ë ıÓËÙfiÙËÙ· ·fi οı ·ÈÙ›·, fiˆ˜ ηٷÁÚ¿ÊËΠÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ follow up Ù˘ οı ÌÂϤÙ˘. ∆Ô ·ÔÙ¤ÏÂÛÌ· ‹Ù·Ó fiÙÈ, ÁÈ· fiϘ ÙȘ ηÙËÁÔڛ˜ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó, Ô Î›Ó‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙËÓ ÔÌ¿‰· Ô˘ ÂÏ¿Ì‚·Ó ·Ï‚Ô˘Ì›ÓË Î·Ù¿ 6%, ‰ËÏ·‰‹ ÁÈ· οı 17 ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ·Ï‚Ô˘Ì›ÓË, ˘‹Ú¯Â ¤Ó·˜ ÂÈϤÔÓ ı¿Ó·ÙÔ˜! OÈ Û˘ÁÁÚ·Ê›˜ ÚfiÙÂÈÓ·Ó Ó· Â·ÓÂÎÙÈÌËı› ÂÂÈÁfiÓÙˆ˜ Ë ¯Ú‹ÛË Ù˘ ·Ï‚Ô˘Ì›Ó˘ ÛÙËÓ ·Ó¿ÓË„Ë ÙˆÓ ·ÛıÂÓÒÓ Î·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ Û ÚÔÛÂÎÙÈο ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜. ¡ÂfiÙÂÚË ÌÂÙ·-·Ó¿Ï˘ÛË (17) ·fi ÙÔÓ ∫·Ó·‰¿ ÌÂϤÙËÛ 105 ¿ÚıÚ· Î·È Û˘Ó¤ÏÂÍ 17 ÚˆÙÔÁÂÓ›˜ ÌÂϤÙ˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó·Ó Û˘ÓÔÏÈο 814 ·ÛıÂÓ›˜. ∂ϤÁ¯ıËÎÂ Ë ıÓËÙfiÙËÙ·, Ë ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È Ë ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜. ∆Ô ÙÂÏÈÎfi Û˘Ì¤Ú·ÛÌ· ‹Ù·Ó fiÙÈ ‰ÂÓ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Î·È ÛÙȘ ÙÚÂȘ ÂÍÂÙ·˙fiÌÂÓ˜ ·Ú·Ì¤ÙÚÔ˘˜ ·Ó¿ÌÂÛ· ÛÙȘ ÔÌ¿‰Â˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ Î·È Û ÂΛӘ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÎÔÏÏÔÂȉ‹. ∫·È ¿ÏÈ ÚÔÙ¿ıËÎ·Ó ÌÂÁ·Ï‡ÙÂÚ˜, ηϿ ۯ‰ȷṲ̂Ó˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, ÒÛÙ ӷ ηٷÛÙ› ‰˘Ó·Ùfi Ó· ·Ó·‰ÂȯıÔ‡Ó ÌÈÎÚ¤˜ ‰È·ÊÔÚ¤˜ ÛÙ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰‡Ô ıÂÚ·ÂÈÒÓ, ·Ó Ú·ÁÌ·ÙÈο ˘¿Ú¯Ô˘Ó. ∆· ‰Â‰Ô̤ӷ ÙˆÓ ÌÂÙ·-·Ó·Ï‡ÛˆÓ, fiÙ·Ó ÂÚÌËÓ¢ÙÔ‡Ó ÚÔÛÂÎÙÈο, ‰ÂÓ ‰Â›¯ÓÔ˘Ó Û·Ê‹ ˘ÂÚ›Û¯˘ÛË ÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÙˆÓ ÎÔÏÏÔÂȉÒÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ·. ∆Ô Â›‰Ô˜ ÙˆÓ ˘ÁÚÒÓ ·Ó¿Ó˄˘ ‰ÂÓ ‚Ú¤ıËΠӷ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ıÓËÙfiÙËÙ·˜ ÛÙÔ˘˜ ‚·ÚÈ¿ ·ÛıÂÓ›˜, Ô‡Ù ÌÔÚÔ‡Ó Ó· ˘ÔÛÙËÚȯıÔ‡Ó ·ÏÏ·Á¤˜ ÛÙËÓ ÙÚ¤¯Ô˘Û· Ú·ÎÙÈ΋ (30). ∂ΛÓÔ Ô˘ ÚÔÙ›ÓÂÙ·È Â›Ó·È Î·Ï¿ ۯ‰ȷṲ̂Ó˜, ÌÂÁ¿Ï˜ ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ı· ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ ÙÚ¤¯Ô˘Û· È·ÙÚÈ΋ Ú·ÎÙÈ΋ Î·È ı· ÌÔÚ¤ÛÔ˘Ó Ó· Ú›ÍÔ˘Ó Êˆ˜ ÛÙËÓ ·ıÔÊ˘ÛÈÔÏÔÁ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·Ê˘Á‹˜ ÙˆÓ ÙÚȯÔÂȉÒÓ Î·È Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ÔÚıÔÏÔÁÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ™ÙÔ ÌÂٷ͇, Ë ¯ÔÚ‹ÁËÛË ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÎÔÏÏÔÂȉÒÓ ı· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È Û οı ·ÛıÂÓ‹ Ì ‚¿ÛË Ù· ·ıÔÊ˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ, ÙËÓ ÎÏÈÓÈ΋ ÂÌÂÈÚ›·, ÙÔ ÎfiÛÙÔ˜ Î·È ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜ ÙÔ˘ ™˘ÛÙ‹Ì·ÙÔ˜ ¶·ÚÔ¯‹˜ ÀËÚÂÛÈÒÓ ÀÁ›·˜ (17,30).

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 24-09-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ∫·ÙÛ¿Ú· ¢ÈÛÙfiÌÔ˘ 9, ¡. ∑ˆÁÚ¿ÊÔ˘ ∆.∫. 157 72, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ªÂϤÙË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Ì·ÁÓËÛ›Ô˘ ÛÂ Û˘ÁÁÂÓ¤˜ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT1 ∆Ô Î·ÙÈfiÓ Ì·ÁÓ‹ÛÈÔ Î·Ù·Ï‡ÂÈ ‹ ÂÓÂÚÁÔÔÈ› ÂÚÈÛÛfiÙÂÚ· ·fi 300 ¤Ó˙˘Ì· Î·È Ô ÚfiÏÔ˜ ÙÔ˘ ¤¯ÂÈ ÌÂÏÂÙËı› ȉȷ›ÙÂÚ· ÛÙÔ Û‡Ó‰ÚÔÌÔ ÙÔ˘ Ì·ÎÚÔ‡ QT (Û. QT), ·ÏÏ¿ fi¯È ÙfiÛÔ Ôχ ÛÙË Û˘ÁÁÂÓ‹ ÌÔÚÊ‹ ÙÔ˘. OÈ Û˘ÁÁÚ·Ê›˜ ÂÍÂÙ¿˙Ô˘Ó ÙÔ ÚfiÏÔ ÙÔ˘ Mg ÛÙÔ Û˘ÁÁÂÓ¤˜ Û. QT Î·È ÂÎÙÈÌÔ‡Ó ÙË Û¯¤ÛË ÙÔ˘ Ì ¯·Ú·ÎÙËÚÈÛÙÈο ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. ™˘˙ËÙÔ‡Ó, Â›Û˘, ÙËÓ Èı·ÓfiÙËÙ· Û˘ÌÏËڈ̷ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ Mg ˆ˜ ıÂÚ·›· ˘ÔÙÚÔÒÓ Û˘ÁÎÔÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Û ÂÚÈÙÒÛÂȘ ¤ÏÏÂÈ„‹˜ ÙÔ˘. ∏ ÌÂϤÙË ÂÚÈÂÏ¿Ì‚·Ó 22 ·ÛıÂÓ›˜, 14 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Ì ıÂÙÈÎfi Î·È 8 Ì ·ÚÓËÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi, ηıÒ˜ Î·È 30 Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ∏ ̤ÛË ËÏÈΛ· ‹Ù·Ó ≈12,5 ¯ÚfiÓˆÓ Î·È Ë Ì¤ÛË ÙÈÌ‹ QTc ≈519 ms. ™Ù· ¿ÙÔÌ· ·˘Ù¿ ÌÂÙÚ‹ıËÎ·Ó Ù· Â›‰· ÙÔ˘ Mg ÙÔ˘ ÔÚÔ‡ (SMg) Î·È ÙÔ˘ ηٷÎÚ·ÙÔ‡ÌÂÓÔ˘ Mg (MgR). O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÁÈÓfiÙ·Ó Ì هÔ Ô˘ ‚·ÛÈ˙fiÙ·Ó ÛÙȘ ÙÈ̤˜ SMg, Mg ÙˆÓ Ô‡ÚˆÓ Î·È ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÚÈÓ Î·È ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Mg ÂÓ‰ÔÊϤ‚È·. ∆· ˘„ËÏ¿ Â›‰· ηٷÎÚ·ÙÔ‡ÌÂÓÔ˘ Mg ıˆڋıËÎ·Ó ˆ˜ ¤ÏÏÂÈ„Ë Mg. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Û. QT ‚Ú¤ıËÎ·Ó ¯·ÌËÏ¿ Â›‰· SMg Î·È ˘„ËÏ¿ MgR. ∏ ¯ÔÚ‹ÁËÛË Mg ‰ÂÓ ‚Ú¿¯˘Ó ÙÔ QT, Ô‡Ù ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ÂÈ¤‰ˆÓ Mg Î·È ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QTc. ∞ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi Û˘ÁÎÔÈÎÒÓ ÎÚ›ÛÂˆÓ Â›¯·Ó ˘„ËÏfiÙÂÚ· Â›-

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‰· MgR Û ۯ¤ÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ Î·È Ë ¯ÔÚ‹ÁËÛË Mg ‚ÂÏÙ›ˆÛ ÙËÓ ¤ÏÏÂÈ„‹ ÙÔ˘. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË fiÙÈ ÌÂÚÈÎÔ› ·ÛıÂÓ›˜ Ì Û. QT ¤¯Ô˘Ó ¤ÏÏÂÈ„Ë Mg Î·È fiÙÈ ·˘Ù‹ Û˘Óԉ‡ÂÙ·È ·fi Û˘ÁÎÔÈΤ˜ ÚÔÛ‚ÔϤ˜, ÔÈ Ôԛ˜ ÂȉÈο Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÌÔÚÔ‡Ó Ó· ÚÔÏ·Ì‚¿ÓÔÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Mg. ∂Âȉ‹, fï˜, ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ù‡ÔÈ Û. QT Ì ‰È·ÊÔÚÂÙÈÎfi ÁÔÓȉȷÎfi ¯·Ú·ÎÙ‹Ú·, Ë ¤ÏÏÂÈ„Ë Mg Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Û·Ó ÚfiÛıÂÙÔ˜ ·Ú¿ÁˆÓ Û ÔÚÈṲ̂Ó˜ ÌÔÚʤ˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘.

1 Hoshino K, Ogawa K, Hishitani T, Kitazawa R Studies of magnesium in congenital long QT syndrome Pediatr Cardiol 2002;23:41-48

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ORIGINAL ARTICLE

∂Ó‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Ù‡Ô˘ ∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ∞. ™˘Ú›ÁÔ˘ - ¶··‚·ÛÈÏ›Ԣ

Botulinum toxin type A intramuscular injections in the treatment of spasticity in cerebral palsy A. Syrigou - Papavasiliou

¶ÂÚ›ÏË„Ë: ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ Û ÂÓ‰ÔÌ˘˚΋ ¤Á¯˘ÛË ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ÙËÓ ÂÌÂÈÚ›· Ì·˜ Û 67 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ̤Û˘ ËÏÈΛ·˜ 5,3 ÂÙÒÓ (2-13,5 ÂÙÒÓ), Ù· ÔÔ›· ¤Ï·‚·Ó ÙËÓ ÙÔÍ›ÓË Û 89 Û˘Ó‰ڛ˜. ∏ ·ÍÈÔÏfiÁËÛË Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ ¤ÁÈÓ Ì ‚¿ÛË ÚˆÙfiÎÔÏÏÔ Î·È Ë Û˘ÏÏÔÁ‹ ÙˆÓ ÛÙÔȯ›ˆÓ ¤ÁÈÓ ÚÔ‰ÚÔÌÈο. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔȯ›· ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘, fiˆ˜ ·˘Ù‹ ÎÚ›ÓÂÙ·È Ì ÙËÓ Â›Ù¢ÍË ÚÔ·ÔÊ·ÛÈṲ̂ÓÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘. ∏ ̤ıÔ‰Ô˜ ˘‹ÚÍ ·ÛÊ·Ï‹˜, ηıÒ˜ ‹Ș Î·È Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„È̘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Û˘Ó¤‚ËÛ·Ó Û 3 ·fi ÙȘ 89 Û˘Ó‰ڛ˜ (3,3%). ∂›Û˘, ˘‹ÚÍ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ηıÒ˜ 57 ·fi ÙÔ˘˜ 67 ·ÛıÂÓ›˜ (85%) Â¤Ù˘¯·Ó Ï‹Úˆ˜ ‹ ÌÂÚÈÎÒ˜ ÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ÛÙfi¯Ô Ô˘ ›¯Â ÙÂı› ÚÔ ÙˆÓ ÂÁ¯‡ÛˆÓ. ∆· ÈηÓÔÔÈËÙÈο ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ·ÏÏ¿ Î·È ÛÙËÓ ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ, ÙˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÚÔ˜ ¤Á¯˘ÛË, Î·È ÛÙÔÓ Î·ıÔÚÈÛÌfi ηٿ ÙËÓ ·Ú¯È΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙˆÓ Ú·ÏÈÛÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÛÙfi¯ˆÓ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÈÙ¢¯ıÔ‡Ó.

Abstract: Botulinum toxin type A intramuscular injections have been utilized for the management of spasticity in patients with cerebral palsy. We present our experience with 67 children and adolescents with cerebral palsy, mean age 5.3 years (range 213.5 years), who received the toxin in 89 sessions.

The evaluation and management of our patient population was performed according to a specific protocol, and the data collection was done prospectively. In this study we present data regarding the safety and efficacy of the method as this was evaluated through the attainment of predetermined functional goals. The method was safe since mild and fully reversible side effects occurred in 3 out of 89 sessions (3.3%). In addition it was effective, since 57 out of 67 patients (85%) demonstrated full or partial functional goal attainment. These satisfactory results are attributed to the therapeutic efficacy of the drug, but also to the careful selection of the patients, the muscle groups to be injected as well as to the designation, during the initial patient evaluation, of the realistic functional goals expected to be achieved.

§¤ÍÂȘ ÎÏÂȉȿ: ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË, Û·ÛÙÈÎfiÙËÙ·, ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË.

Key words: botulinum toxin, spasticity, cerebral palsy.

ø˜ Û·ÛÙÈÎfiÙËÙ· ÔÚ›˙ÂÙ·È Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÈÛıËÙÈÎÔ-ÎÈÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·‡ÍËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ Ù·¯‡ÙËÙ· Ù˘ ΛÓËÛ˘ Î·È Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ӷ ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο. ∞ÔÙÂÏ› Ì›· ·fi ÙȘ ÂΉËÏÒÛÂȘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ·, Ì·˙› Ì ÙËÓ ·‰˘Ó·-

Ì›·, ÙË ÌÂȈ̤ÓË ÂȉÂÍÈfiÙËÙ· ÛÙȘ ÎÈÓ‹ÛÂȘ ηÈ, Û ‚·Ú‡ÙÂÚË ÚÔÛ‚ÔÏ‹, ÙËÓ ¿ÚÂÛË Î·È ÙȘ Û˘Áο̄ÂȘ.

O ·ÓÒÙÂÚÔ˜ ÎÈÓËÙÈÎfi˜ Ó¢ÚÒÓ·˜ ÌÔÚ› Ó· ‚Ï·ÊÙ› ·fi ÔÈΛϷ ·›ÙÈ· Î·È Û ‰È¿ÊÔÚ· Â›‰·. ∏ ‚Ï¿‚Ë ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ÓˆÚ›˜ ÛÙË ˙ˆ‹, ·fi ·›ÙÈ· ÚÔÁÂÓÓËÙÈο, ÂÚÈÁÂÓÓËÙÈο ‹

¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘, ∞ı‹Ó·

Neurology Clinic, Children’s Hospital of Penteli, Athens

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·168

¶·È‰È·ÙÚÈ΋ 2002;65:167-173

ÌÂÙ·ÁÂÓÓËÙÈο, Ô‰ËÁ› ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (∂¶). ªÂ ÙÔÓ fiÚÔ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ·Ó·ÊÂÚfiÌ·ÛÙ Û ̛· ÔÌ¿‰· Û˘Ó‰ÚfiÌˆÓ ÂÙÂÚÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜ Ì ÌÂÙ·‚·ÏÏfiÌÂÓË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ô˘ ÔÊ›ÏÂÙ·È Û ÛÙ·ÙÈ΋ ‚Ï¿‚Ë ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∂ΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ Ì ÎÈÓËÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ·ÏÏ¿ ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó‹ıˆ˜ Î·È ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ÏËÓ Ù˘ ÎÈÓËÙÈ΋˜. ∏ ∂¶ Ù·ÍÈÓÔÌÂ›Ù·È Û Û·ÛÙÈ΋, ‰˘ÛÎÈÓËÙÈ΋, ·Ù·ÍÈ΋ Î·È ÌÈÎÙ‹ ÌÔÚÊ‹. ∏ Û·ÛÙÈ΋ ÌÔÚÊ‹ Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ Î·È ÂÚ·ÈÙ¤Úˆ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙÔ˘˜ ηو٤ڈ Ù‡Ô˘˜: Û·ÛÙÈ΋ ËÌÈÏËÁ›·, Ô˘ Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ ÌÔÚÊ‹, Û·ÛÙÈ΋ ‰ÈÏËÁ›·, Ô˘ ·Ó¢ڛÛÎÂÙ·È Î·Ù’ ÂÍÔ¯‹Ó Û ÚfiˆÚ· ·È‰È¿, Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, Ô˘ Â›Ó·È Ë ‚·Ú‡ÙÂÚË ÌÔÚÊ‹ Ô˘ Û˘¯Ó¿ Û˘Ó‰˘¿˙ÂÙ·È Ì ¿ÏϘ ‚·ÚȤ˜ ·Ó·Ëڛ˜ Î·È Ù¤ÏÔ˜, Û·ÛÙÈ΋ ÌÔÓÔÏËÁ›·, Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È ·ÙÂÏ‹˜ ËÌÈÏËÁ›·. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜, ȉȷ›ÙÂÚ· fiÙ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏϘ ‚·ÚȤ˜ ·Ó·Ëڛ˜, fiˆ˜ .¯. ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÂÊ’ fiÛÔÓ Ë Ì˘˚΋ ÈÛ¯‡˜ ÙÔ˘ Û·ÛÙÈÎÔ‡ ̤ÏÔ˘˜ (‹ Û·ÛÙÈÎÒÓ ÌÂÏÒÓ) Â›Ó·È Â·Ú΋˜, ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜, ‰ËÏ·‰‹ Ó· ‚ÔËı‹ÛÂÈ ÙÔ ·È‰› Ó· ηı‹ÛÂÈ, Ó· ÔÚıÔÛٷًÛÂÈ Î·È Ó· ‚·‰›ÛÂÈ.

OÈ ÛÙfi¯ÔÈ Ù˘ ıÂÚ·›·˜ Ù˘ ∂¶ Â›Ó·È Ó· ÌÂÁÈÛÙÔÔÈ‹ÛÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·, Ó· ÂÏ·¯ÈÛÙÔÔÈ‹ÛÂÈ ÙȘ Û˘Áο̄ÂȘ Î·È ¿ÏϘ ÂÈÏÔΤ˜ Î·È Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ÙȘ ÔÚıÔ‰ÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ¤ÙÛÈ ÒÛÙ ӷ Á›ÓÔ˘Ó Û ·È‰› ÌÂÁ·Ï‡ÙÂÚÔ ‹ ÈÔ ÒÚÈÌÔ, Ì ٷ ηχÙÂÚ· ‰˘Ó·Ù¿ ·ÔÙÂϤÛÌ·Ù·. ∏ ·ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË Ù‡Ô˘ ∞ (∞∆-∞) Â›Ó·È Ì›· ·fi ÙȘ 7 Ó¢ÚÔÙÔ͛Ә (Ô˘ ÔÓÔÌ¿˙ÔÓÙ·È ∞-G), ÔÈ Ôԛ˜ ·Ú¿ÁÔÓÙ·È ·fi ‰È¿ÊÔÚ· ÛÙÂϤ¯Ë ÙÔ˘ ∫ψÛÙËÚȉ›Ô˘ Ù˘ ·ÏÏ·ÓÙ›·Û˘ (Clostridium botulinum). ∂›Ó·È Ë ÈÔ ÌÂÏÂÙË̤ÓË ·fi ÙÔ˘˜ 7 Ù‡Ô˘˜ Î·È ¤¯ÂÈ Â›ÛËÌË ¤ÁÎÚÈÛË ÁÈ· ¯Ú‹ÛË Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ· (1,2). ªÂÈÒÓÂÈ ÂÎÏÂÎÙÈο ÙËÓ ˘ÂÚ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Ì˘fi˜ Î·È ÂÈϤÔÓ, ÂÂȉ‹ ÂÓ›ÂÙ·È ÙÔÈο, ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ ˙¿ÏË, ·ÒÏÂÈ· ÌÓ‹Ì˘, ÎfiˆÛË Î.¿. Ô˘ ÚÔηÏÔ‡Ó Ù· ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ê¿Ú̷η (3). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ë ·Ó·ÊÔÚ¿ ÛÙËÓ ÂÌÂÈÚ›· Ì·˜ Ì ÂÓ‰ÔÌ˘˚Τ˜ ÂÁ¯‡ÛÂȘ ·ÏÏ·ÓÙÈ΋˜ ÙÔ͛Ӣ Û ·È‰È¿ Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ¤ÙÛÈ ÒÛÙ ӷ ·Ó·‰ÂȯıÔ‡Ó ÔÈ ÂӉ›ÍÂȘ, Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· Ù˘ ÌÂıfi‰Ô˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ÌÂϤÙË ÂÚÈÂÏ¿Ì‚·Ó 67 ·È‰È¿ Ì ∂¶ Ô˘ ¤Ï·‚·Ó ∞∆∞ Û 89 ‰È·‰Ô¯ÈΤ˜ Û˘Ó‰ڛ˜ ∂.ª. ÂÁ¯‡ÛˆÓ. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó 5,3 ¤ÙË (2-13,5 ¤ÙË) Î·È Ù· 20 ›¯·Ó Û·-

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Paediatriki 2002;65:167-173

ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›· ¯ˆÚ›˜ ‰˘Ó·ÙfiÙËÙ· ·ÓÂÍ¿ÚÙËÙÔ˘ ηı›ÛÌ·ÙÔ˜, Ù· 28 Û·ÛÙÈ΋ ‰ÈÏËÁ›·, Ì ‰˘Ó·ÙfiÙËÙ· ·ÓÂÍ¿ÚÙËÙ˘ fiÚıÈ·˜ ÛÙ¿Û˘ Î·È ¯ˆÚ›˜ ·ÓÂÍ¿ÚÙËÙË ‚¿‰ÈÛË, Ù· 14 Û·ÛÙÈ΋ ËÌÈÈÏËÁ›·, fiÏ· Ì ·ÓÂÍ¿ÚÙËÙË ‚¿‰ÈÛË Î·È Ù· 5 ÌÈÎÙ‹ Û·ÛÙÈ΋ ‰˘ÛÙÔÓÈ΋ ÌÔÚÊ‹ ∂¶, ¯ˆÚ›˜ ·ÓÂÍ¿ÚÙËÙÔ Î¿ıÈÛÌ·. ∆Ô ÚˆÙfiÎÔÏÏÔ ·ÍÈÔÏfiÁËÛ˘ ·È‰ÈÒÓ Ì ∂¶ ÁÈ· Èı·Ó‹ ¯Ú‹ÛË ∞-∆ ÂÊ·ÚÌfiÛÙËΠÂÍ·Ú¯‹˜ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Î·È Î·ÏÔ‡Û ÁÈ· Ù· ÂÍ‹˜: ·) ∞ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ Ù·˘Ùfi¯ÚÔÓ· ·fi Ó¢ÚÔÏfiÁÔ, ÔÚıÔ‰ÈÎfi Î·È Ê˘ÛÈÔıÂÚ·Â˘Ù‹, Ì ÛÙfi¯Ô ÙË Û‡ÌʈÓË ÁÓÒÌË ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ ‰˘Ó·ÌÈÎfi ÙÔ˘ ÚÔ˜ ‚ÂÏÙ›ˆÛË. ‚) ∫·ıÔÚÈÛÌfi ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÛÙfi¯ˆÓ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÈÙ¢¯ıÔ‡Ó Ì ÙË ¯Ú‹ÛË ∞∆-∞. Á) ™˘˙‹ÙËÛË ÁÈ· ÂÓ·ÏÏ·ÎÙÈΤ˜ ‹ ÚfiÛıÂÙ˜ ıÂÚ·›˜, fiˆ˜ Á˘„ÒÛÂȘ, Ê¿Ú̷η, ÔÚıÔ‰ÈÎfi ¯ÂÈÚÔ˘ÚÁ›Ô. ‰) ∂ÓË̤ڈÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Û˘Ìʈӛ· ÁÈ· ÙËÓ ÂÎÙ¤ÏÂÛË ÙˆÓ ÂÁ¯‡ÛˆÓ. Â) ¶ÂÚ·ÈÙ¤Úˆ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙËÓ ÔÌ¿‰· Ì Îϛ̷Θ Î·È ‚ÈÓÙÂÔÛÎfiËÛË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙˆı› ·ÓÙÈÎÂÈÌÂÓÈο Ë ÌÂÙ·‚ÔÏ‹ Ù˘ ηٿÛÙ·Û˘ ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ. °È· ·˘ÙfiÓ ÙÔ ÛÎÔfi ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, ·ÏÏ¿ ‰ÂÓ ı· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Û ·˘Ù‹ ÙË ÌÂϤÙË, Î·È ÁˆÓÈÔÌÂÙÚ›·, Îϛ̷η Ashworth ÁÈ· ÙË Ì¤ÙÚËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘, Îϛ̷η Gross Motor Function Measure (GMFM) ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È ‚ÈÓÙÂÔÛÎfiËÛË Û‡Ìʈӷ Ì ηıÔÚÈṲ̂Ó˜ Ô‰ËÁ›Â˜ ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ı¤ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡. ÛÙ) ∂›ÛÔ‰Ô ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ¤Ó· Úˆ›. ÃÚ‹ÛË ·Ó·ÈÛıËÙÈ΋˜ Îڤ̷˜ ÛÙ· ÛËÌ›· Ô˘ ÂÈϤÁÔÓÙ·È ÁÈ· ¤Á¯˘ÛË. ÃÔÚ‹ÁËÛË ËÚÂÌÈÛÙÈÎÔ‡ Î·È ·Ó·ÏÁËÙÈÎÔ‡ ·fi ÙÔ˘ ÔÚıÔ‡ (ªÈ‰·˙ÔÏ¿ÌË 0,2-0,3 mg/kg, ¶Âıȉ›ÓË 1 mg/kg). AÎÔÏÔ‡ıËÛ·Ó ÂÁ¯‡ÛÂȘ ∞∆-∞ ÛÙÔ˘˜ ÂÈÏÂÁ̤ÓÔ˘˜ Ì˘˜. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó Î·È Ù· 2 Û΢¿ÛÌ·Ù· Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙËÓ ∂ÏÏ¿‰·. ∆Ô ·Ï·ÈfiÙÂÚÔ, Botox, Û ̤ÁÈÛÙË ‰ÔÛÔÏÔÁ›· 13 U/kg/Û˘Ó‰ڛ· Î·È ÙÔ ÓÂfiÙÂÚÔ, Dysport, Û ‰ÔÛÔÏÔÁ›· 40 U/kg/Û˘Ó‰ڛ·. ∆Ô Ê¿ÚÌ·ÎÔ ÂÁ¯‡ıËΠÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ̇˜ Û‡Ìʈӷ Ì ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ·fi ÙȘ Ê·Ú̷΢ÙÈΤ˜ ÂÙ·ÈÚ›˜ ‰ÔÛÔÏÔÁ›· ·Ó¿ Ì˘. ˙) ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· 2-3 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË Î·È ¤ÍÔ‰Ô˜ ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. Ë) ∂·Ó·ÍÈÔÏfiÁËÛË Û 1, 3 Î·È 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË. ŒÁÈÓ ÚÔÛ¿ıÂÈ· ÂÊ·ÚÌÔÁ‹˜ ÙˆÓ ÚÔ·Ó·ÊÂÚıÂÈÛÒÓ ÎÏÈ̿ΈÓ, Ë ÔÔ›· ‹Ù·Ó ÌÂÚÈÎÒ˜ ÂÈÙ˘¯‹˜, ‰ÈfiÙÈ ÔÈ ·ÍÈÔÏÔÁ‹ÛÂȘ ÙˆÓ È·ÙÚÒÓ Î·È ÙˆÓ Ê˘ÛÈÔıÂÚ·¢ÙÒÓ ‰ÂÓ Û˘Ó¤ÂÛ·Ó ¯ÚÔÓÈο ‹ ‰ÂÓ ¤ÁÈÓ·Ó ·fi Ù· ›‰È· ¿ÙÔÌ· ÛÙÔ˘˜ ·ÎÚÈ‚Ò˜ ÚÔηıÔÚÈṲ̂ÓÔ˘˜ ¯ÚfiÓÔ˘˜. ø˜ ·ÔÙ¤ÏÂÛÌ·, ˘¿Ú¯ÂÈ ·Ó·ÁηÈfiÙËÙ· ÁÈ· ÂÚ·ÈÙ¤Úˆ Û˘ÏÏÔÁ‹ Î·È ÂÂÍÂÚÁ·Û›· ·˘ÙÒÓ ÙˆÓ ‰Â‰Ô̤ӈÓ. ™Ù·ıÂÚ¿ Î·È ·fi ÙÔÓ ›‰ÈÔ È·ÙÚfi ÂÎÙÈÌ‹ıËΠÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È Ë Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ ·ÍÈÔÏÔÁ‹ıËΠˆ˜ ÂÍ‹˜: i) ¶Ôχ ηϋ, fiÙ·Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ÂÂÙ‡¯ıË Ï‹Úˆ˜ (.¯. Â¿Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ‹Ù·Ó ÙÔ ·È‰› Ó· ηı›ÛÂÈ ·ÓÂÍ¿ÚÙËÙ·, ·˘Ùfi˜ ı· fiÊÂÈÏ ӷ ÂÈÙ¢¯ı› Ï‹Úˆ˜), ii) ∫·Ï‹, fiÙ·Ó Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ ÂÂÙ‡¯ıË ÌÂÚÈÎÒ˜, iii) ªÈÎÚ‹, fiÙ·Ó Â‹Ïı ÌfiÓÔ Ì›ˆÛË ÙÔ˘

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·169

¶·È‰È·ÙÚÈ΋ 2002;65:167-173

Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ¯ˆÚ›˜ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Î·È iv) O˘‰ÂÌ›·, Â› ·Ô˘Û›·˜ οı ÌÂÙ·‚ÔÏ‹˜. ı) ∂·ÓÂÁ¯‡ÛÂȘ ¤ÁÈÓ·Ó Û 22 ·È‰È¿ Ì ÙËÓ ›‰È· ·ÎÚÈ‚Ò˜ ÌÂıÔ‰ÔÏÔÁ›·. ∏ ·fiÊ·ÛË ÁÈ· Â·Ó¤Á¯˘ÛË ‹Ù·Ó ÚÔ˚fiÓ Ù˘ ›‰È·˜ ‰È·‰Èηۛ·˜ Ì ÙËÓ ·Ú¯È΋ ¤Á¯˘ÛË. ¢ËÏ·‰‹, Ë ÔÌ¿‰· Â·ÓÂͤٷ˙ ÙÔ˘˜ ıÂÚ·¢ÙÈÎÔ‡˜ ÛÙfi¯Ô˘˜, ·ÍÈÔÏÔÁÔ‡Û ηٿ fiÛÔ Ë Û·ÛÙÈÎfiÙËÙ· οÔÈˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ·ÔÙÂÏÔ‡Û ÂÌfi‰ÈÔ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Âͤٷ˙ ÙËÓ Èı·ÓfiÙËÙ· ÁÈ· ÂÓ·ÏÏ·ÎÙÈΤ˜ ıÂÚ·›˜ (ÔÚıÒÛÂȘ, Á˘„ÒÛÂȘ, ¯ÂÈÚÔ˘ÚÁ›Ô). ¶ÚÔÊ·ÓÒ˜, Ë ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ¤Á¯˘ÛË ¤·È˙ ηıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·fiÊ·ÛË. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ÔÊı·ÏÌÔÊ·Ó‹˜ Ë ·Ó¿ÁÎË ÁÈ· Â·Ó¤Á¯˘ÛË, ηıÒ˜ Ë Û·ÛÙÈÎfiÙËÙ· Â·ÓÂÁηı›ÛÙ·ÙÔ Ì ÙËÓ ¿ÚÔ‰Ô ÙˆÓ ÌËÓÒÓ. ÕÏÏÔÙ ¿ÏÈ, Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ê˘ÛÈÔıÂÚ·›·˜ Î·È ÙˆÓ ÔÚıÒÛˆÓ, Ë Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û οÔȘ Ì˘˚Τ˜ ÔÌ¿‰Â˜ ıˆÚÔ‡ÓÙ·Ó Â·Ú΋˜ Î·È ÙÂÏÈο ÚÔ¯ˆÚÔ‡Û·Ì Û ÂÁ¯‡ÛÂȘ ¿ÏÏˆÓ Ì˘ÒÓ. ø˜ ÂÏ¿¯ÈÛÙÔ˜ ¯ÚfiÓÔ˜ ÁÈ· Â·Ó¤Á¯˘ÛË Â›¯Â ·ÔÊ·ÛÈÛÙ› ÙÔ ÙÂÙÚ¿ÌËÓÔ.

∞ÔÙÂϤÛÌ·Ù· ∞) ∂Á¯‡ÛÂȘ ∞∆-∞ ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·Ó·ÊÂÚfiÌ·ÛÙ Û ÂÁ¯‡ÛÂȘ Ì˘ÒÓ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ. ŒÁ¯˘ÛË ¤ÁÈÓ ÛÙÔ˘˜ ÂÍ‹˜ Ì˘˜: ¶ÚÔÛ·ÁˆÁÔ‡˜, Ô›ÛıÈÔ˘˜ ÌËÚÈ·›Ô˘˜, Á·ÛÙÚÔÎÓ‹ÌÈÔ˘˜, ˘ÔÎÓËÌ›‰ÈÔ˘˜, ÚfiÛıÈÔ˘˜ Î·È Ô›ÛıÈÔ˘˜ ÎÓËÌÈ·›Ô˘˜. ŒÁÈÓ·Ó ·Ó¿ Û˘Ó‰ڛ· 2-11 ÂÁ¯‡ÛÂȘ Ì ‰ÔÛÔÏÔÁ›· Ô˘ Î˘Ì¿ÓıËΠ·fi 3,5-13 U/kg ÁÈ· ÙÔ Botox, Î·È ·fi 10-40 U/kg ÁÈ· ÙÔ Dysport. ª¤ÁÈÛÙË ‰fiÛË ·Ó¿ ÛËÌÂ›Ô ¤Á¯˘Û˘ ÁÈ· ÙÔ Botox ‹Ù·Ó 50 U Î·È ÁÈ· ÙÔ Dysport 150 U. µ) ¶ÚÔ‚Ï‹Ì·Ù· ηٿ ÙȘ ÂÁ¯‡ÛÂȘ Î·È ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ∞∆-∞ ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ·Ó¤¯ıËÎ·Ó ÙȘ ÂÁ¯‡ÛÂȘ ηϿ. ŒÓ· ·È‰› ÂÌÊ¿ÓÈÛ ˘ÓËÏ›· Î·È ·ÚÔ‰ÈÎfi ˘Ô-·ÂÚÈÛÌfi Î·È Ù¤ıËΠ۠·Ú·ÎÔÏÔ‡ıËÛË Ì Ô͢ÌÂÙÚ›·. O ÎÔÚÂÛÌfi˜ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ ¤Êı·Û ÛÙÔ 92% Î·È ÌÂÙ¿ Ï›Á˜ ÒÚ˜ ÙÔ ·È‰› ‹Ù·Ó ÙÂÏ›ˆ˜ ηϿ. ∆Ô Û‡Ì‚·Ì· ·Ô‰fiıËΠÛÙ· Ê¿Ú̷η Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó PR ˆ˜ ËÚÂÌÈÛÙÈÎfi Î·È ·Ó·ÏÁËÙÈÎfi. ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ∞∆-∞ ÂÌÊ·Ó›ÛÙËÎ·Ó Û 3 ·È‰È¿ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ 89 Û˘Ó‰ÚÈÒÓ. ◊Ù·Ó fiϘ ÂÏ¿ÛÛÔÓ˜ Î·È ‹Ù·Ó ÔÈ ÂÍ‹˜: ·ÚÔ‰È΋ ÂÓÔ‡ÚËÛË (1), ÙÔÈÎfi˜ ÂÚÂıÈÛÌfi˜ (1), ·ÚÔ‰È΋ Ì˘˚΋ ·‰˘Ó·Ì›· (1). ∏ ‰È¿ÚÎÂÈ· ÙˆÓ ·ÓˆÙ¤Úˆ ‹Ù·Ó ·fi Ï›Á˜ ÒÚ˜ ¤ˆ˜ Ï›Á˜ Ë̤Ú˜ Î·È Ù· Ê·ÈÓfiÌÂÓ· ‹Ù·Ó Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„ÈÌ·. °) ∂›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ ™Â 29 ·fi 67 ·È‰È¿ (43,3%) ÂÂÙ‡¯ıË Ï‹Úˆ˜ Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜, Û 28 (41,8%) ÂÂÙ‡¯ıË ÌÂÚÈÎÒ˜ Ô ÏÂÈÙÔ˘ÚÁÈÎfi˜ ÛÙfi¯Ô˜ Î·È Û 7 ˘‹ÚÍ Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜, ¯ˆÚ›˜ ·ÍÈfiÏÔ-

Paediatriki 2002;65:167-173

ÁÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· (™¯‹Ì· 1). µÂÏÙ›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ·Ú·ÙËÚ‹ıËΠηٿ ÙËÓ 1Ë Â·ÓÂͤٷÛË (1Ô˜ Ì‹Ó·˜) Û 64 ·ÛıÂÓ›˜. ∏ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘, Ï‹Ú˘ ‹ ÌÂÚÈ΋, ηٷÁÚ¿ÊËΠÛÙËÓ ÂͤٷÛË ÙÔ˘ ÙÚÈÌ‹ÓÔ˘ Î·È Â›¯Â ·Ú·ÙËÚËı› ·Ó¿ÌÂÛ· ÛÙÔÓ 1Ô Î·È ÙÔÓ 3Ô Ì‹Ó· ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ ÛÙÔ˘˜ 57 ·ÛıÂÓ›˜. ¢) ∂·ÓÂÁ¯‡ÛÂȘ ∞˘Ù¤˜ ¤ÁÈÓ·Ó ÌÂÙ¿ ̤ÛÔ ‰È¿ÛÙËÌ· 6,2 ÌËÓÒÓ (38 Ì‹Ó˜) Î·È Â›¯·Ó fiϘ Ôχ ηÏfi ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ·, ‰ËÏ·‰‹ Ï‹ÚË ‹ ÌÂÚÈ΋ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘. ŒÁÈÓ·Ó fiϘ Û ·È‰È¿ Ô˘ ›¯·Ó ·ÓÙ·ÔÎÚÈı› ¿ÚÈÛÙ· ÛÙË ÚÔËÁÔ‡ÌÂÓË ¤Á¯˘ÛË Î·È ·ÊÔÚÔ‡Û·Ó Â›Ù ÙȘ ›‰È˜ Ì˘˚Τ˜ ÔÌ¿‰Â˜ ‹ ¿ÏϘ. ªfiÓÔ Û ¤Ó·Ó ·ÛıÂÓ‹ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ·Ú¤Ï¢ÛË ÙÚÈÌ‹ÓÔ˘ Î·È fi¯È ÙÂÙÚ·Ì‹ÓÔ˘, fiˆ˜ ›¯Â ·Ú¯Èο ·ÔÊ·ÛÈÛÙ›. O ÏfiÁÔ˜ ‹Ù·Ó fiÙÈ ÙÔ ·È‰› ·˘Ùfi, ÙÔ ÔÔ›Ô ¤·Û¯Â ·fi ÙÂÙÚ·ÏËÁ›· Î·È Â›¯Â ÂÈÙ‡¯ÂÈ Ó· ηı›ÛÂÈ ÌÂÙ¿ ÙËÓ ÚÒÙË ¤Á¯˘ÛË, ¤¯·Ó ÙË ‰˘Ó·ÙfiÙËÙ· ·˘Ù‹ ÌÂÙ¿ ·fi ÙËÓ ·Ú¤Ï¢ÛË ÙÚÈÌ‹ÓÔ˘ ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÛÙÔ˘˜ Ô›ÛıÈÔ˘˜ ÌËÚÈ·›Ô˘˜ Î·È ÚÔÛ·ÁˆÁÔ‡˜ ÔÈ ÔÔ›ÔÈ Â›¯·Ó ÂÁ¯˘ı›. ™˘˙‹ÙËÛË OÈ ÂΉËÏÒÛÂȘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ÂÓÙfiÈÛË, ÙËÓ ¤ÎÙ·ÛË Î·È ÙË ¯ÚÔÓÈfiÙËÙ· Ù˘ ‚Ï¿‚˘ ÛÙÔÓ ÂÁΤʷÏÔ ‹ ÛÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi. ªÔÚ› Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜, Ù˘ ·ÓÙ›Ï˄˘, ηıÒ˜ Î·È ÚÔ‚Ï‹Ì·Ù· ÁÓˆÛÙÈο Î·È ÎÈÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ ÎÈÓËÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂΉËψı› Ì Û·ÛÙÈÎfiÙËÙ·, Ì˘˚ÎÔ‡˜ Û·ÛÌÔ‡˜ Û ο̄Ë, ·‰˘Ó·Ì›· Î·È ·ÒÏÂÈ· ÙÔ˘ ÎÈÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ÏÂÙÒÓ ÎÈÓ‹ÛˆÓ. ∞Ó·ÏfiÁˆ˜ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ‚Ï¿‚˘ Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ¶Ï‹Ú˘ Â›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘: 29 ·È‰È¿ (43,3%)

10/28 8/20 ÙÂÙÚ·ÏËÁ›Â˜ ‰ÈÏËÁ›Â˜

9/14 2/4 ‰˘ÛÙÔÓÈΤ˜ ËÌÈÏËÁ›Â˜ ÌÔÚʤ˜ ∂.¶.

ªÂÚÈ΋ Â›Ù¢ÍË ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘: 28 ·È‰È¿ (41,8%)

4/14 1/4 ‰˘ÛÙÔÓÈΤ˜ 14/28 9/20 ÙÂÙÚ·ÏËÁ›Â˜ ‰ÈÏËÁ›Â˜ ËÌÈÏËÁ›Â˜ ÌÔÚʤ˜ ∂.¶. ªÂ›ˆÛË Û·ÛÙÈÎfiÙËÙ·˜ ¯ˆÚ›˜ ·ÍÈfiÏÔÁÔ ÏÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ·: 7 ·È‰È¿ (10,4%) ™¯‹Ì· 1. §ÂÈÙÔ˘ÚÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ÂÁ¯‡ÛÂˆÓ ∞∆-∞.

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¶·È‰È·ÙÚÈ΋ 2002;65:167-173

ÙˆÓ ÂΉËÏÒÛˆÓ, Ë ÎÈÓËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÚÈÔÚ›˙ÂÙ·È Î·È ÚÔ·ÙÂÈ ·Ó·ËÚ›·. ∏ Û·ÛÙÈÎfiÙËÙ· ÔÊ›ÏÂÙ·È Û ˘ÂÚ‰ÈÂÁÂÚÛÈÌfiÙËÙ· ÙÔ˘ Ì˘ÔÙ·ÙÈÎÔ‡ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÔ‡ Î·È ˆ˜ Û‡Ìو̷ ÌÔÚ› Ó· ÂÚÈÔÚ›ÛÂÈ ÛËÌ·ÓÙÈο ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ·ÙfiÌÔ˘ ÛÙËÓ ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹, ηıÒ˜ ·fi ÌfiÓË Ù˘ Ô‰ËÁ› Û ηٷӿψÛË ·˘ÍË̤Ó˘ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· ÙËÓ Î›ÓËÛË, Ó· ÚÔηϤÛÂÈ Û˘Áο̄ÂȘ Î·È fiÓÔ Î·È Ó· ÂÚÈÔÚ›ÛÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÔÚıÒÛÂˆÓ (4). ŒÓ·˜ ·fi ÙÔ˘˜ ·ÚÈÔ˘˜ ÛÙfi¯Ô˘˜ Ì›ˆÛ˘ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÂÈ¤‰Ô˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ¢ËÏ·‰‹, Â¿Ó Ë ‚Ï¿‚Ë ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Ù¤ÙÔÈ· ¤ÙÛÈ ÒÛÙ Ì Ì›ˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Ô ·ÛıÂÓ‹˜ Ó· ÌÔÚ¤ÛÂÈ Ó· ‚·‰›ÛÂÈ, Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ¤Ó·˜ ηÏfi˜ ÛÙfi¯Ô˜ Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙȘ ·ÔÊ¿ÛÂȘ Ì·˜ Û¯ÂÙÈο Ì ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ı· Û˘˙ËÙËıÔ‡Ó ÂÚ·ÈÙ¤Úˆ. ∂›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ηıÔÚ›˙ÂÈ ÙÔÓ ÙÚfiÔ ıÂÚ·¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘. º˘ÛÈÔıÂÚ·›· Î·È ÔÚıˆÙÈÎÔ‡ Ù‡Ô˘ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È Û˘Ó‹ıˆ˜ Â·ÚΛ˜ ÁÈ· ÙËÓ ÂÏ·ÊÚ¿ Û·ÛÙÈÎfiÙËÙ·. ∏ ̤ÙÚÈ· Î·È ÛÔ‚·Ú‹ Û·ÛÙÈÎfiÙËÙ·, fï˜, Û˘Ó‹ıˆ˜ ··ÈÙÔ‡Ó ÂÈÚfiÛıÂÙË Î·È ÈÔ ÂÈıÂÙÈ΋ ıÂÚ·›·. ¶·Ï·ÈfiÙÂÚ·, ÔÈ ÔÚıÔ‰ÈΤ˜ ÂÂÌ‚¿ÛÂȘ ‹Ù·Ó Ô Î·Ù’ ÂÍÔ¯‹Ó ÙÚfiÔ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÌË ‚ÂÏÙÈÔ‡ÌÂÓ˘ Ì ¿ÏϘ ÌÂıfi‰Ô˘˜ Û·ÛÙÈÎfiÙËÙ·˜. ∆· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÔÈΛϷ Î·È ¿ÓÙÔÙ ÂÍ·ÚÙÒÌÂÓ· ·fi ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ Î·È ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ÛˆÛÙÔ‡ ¯ÚfiÓÔ˘ ÁÈ· ÙËÓ Â¤Ì‚·ÛË Î·ıÒ˜ Î·È ÙˆÓ Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÛÙȘ Ôԛ˜ Ô ¯ÂÈÚÔ˘ÚÁfi˜ Â¤ÏÂÁ ӷ Â¤Ì‚ÂÈ. OÈ ÔÚıÔ‰ÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Û˘Ó¯›˙Ô˘Ó Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ˆ˜ Ë ÔÚÈÛÙÈ΋ χÛË. ¡Â˘ÚÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÙÔ˘ Ù‡Ô˘ ÙˆÓ Ô›ÛıÈˆÓ ÂÎÏÂÎÙÈÎÒÓ ÚÈ˙ÔÙÔÌÒÓ ‰ÔÎÈÌ¿ÛÙËÎ·Ó Û ·ÚÎÂÙÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ÔÈ ÂӉ›ÍÂȘ ‹Ù·Ó ÂÚÈÔÚÈṲ̂Ó˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· fi¯È ¿ÓÙ· Ù· ·Ó·ÌÂÓfiÌÂÓ·. ø˜ ·ÔÙ¤ÏÂÛÌ·, Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ ‰ÂÓ ‚ڋΠ¢Ú›· ÂÊ·ÚÌÔÁ‹ ÛÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·È ÂÚÈÔÚ›ÛÙËΠÛÙ· ·È‰È¿ Ì Û·ÛÙÈ΋ ‰ÈÏËÁ›·, ηϋ ÓÔËÌÔÛ‡ÓË, ηÏfi ÎÔÚÌfi Î·È ¯¤ÚÈ·. ∆Ô ‰›Ô ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ¿ÏÏˆÓ ÌÔÚÊÒÓ Ì¤ÙÚÈ·˜ Î·È ÛÔ‚·Ú‹˜ Û·ÛÙÈÎfiÙËÙ·˜ ¤ÌÂÈÓÂ Î·È ¿ÏÈ ·ÓÔÈÎÙfi. ∏ ηٷÓÔÌ‹ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ηıÔÚ›˙ÂÈ Â¿Ó Ô ·ÛıÂÓ‹˜ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì “ÙÔÈΤ˜” ·ÚÂÌ‚¿ÛÂȘ ‹ fi¯È. ∂¿Ó Ë Û·ÛÙÈÎfiÙËÙ· Â›Ó·È Î·ıÔÏÈ΋ ‹ ‚·Ú›·, ÔÈ ÂÈÏÔÁ¤˜ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜, ¤¯Ô˘Ó ·Ó·ÎÔ˘ÊÈÛÙÈÎfi ¯·Ú·ÎÙ‹Ú· Î·È fi¯È ÛÙfi¯Ô ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó·‚¿ıÌÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì·˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Û˘¯Ó¿ ηıÔÚ›˙ÂÈ ÙȘ

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‰˘Ó·ÙfiÙËÙ˜ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, ΢ڛˆ˜ Û ÂÚÈÙÒÛÂȘ fiÔ˘ ÔÈ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ Î·È Ë Û·ÛÙÈÎfiÙËÙ· ÛÔ‚·Ú‹. π‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ fiÔ˘ ÙÔ ÛÙ¿‰ÈÔ ÂͤÏÈ͢ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁΤʷÏÔ˘ Û·ÊÒ˜ ηıÔÚ›˙ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÙfiÓÔ˘, ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó¿‰˘Û˘ Ù˘ ˘ÂÚÙÔÓ›·˜ Î·È ÙÔ Ú˘ıÌfi Ù˘ Âȉ›ӈۋ˜ Ù˘, Ë ÂÈÏÔÁ‹ ÙÔ˘ ÛˆÛÙÔ‡ ¯ÚfiÓÔ˘ ·Ú¤Ì‚·Û˘ Â›Ó·È Ô˘ÛÈ·ÛÙÈ΋. O ÂÓÙÔÈÛÌfi˜ ÙÔ˘ ÂÈ¤‰Ô˘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÎÈÓËÙÈÎÔ‡ Ó¢ÚÒÓ· ¤¯ÂÈ Â›Û˘ ÛËÌ·Û›· ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ ıÂÚ·›·˜, ηıÒ˜ Ë Û·ÛÙÈÎfiÙËÙ· ÛÙ· οو ¿ÎÚ· Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÓˆÙÈ·›· ‚Ï¿‚Ë ÌÔÚ› Ó· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ‰È·ÊÔÚÂÙÈο ·fi ·˘Ù‹Ó Ô˘ ÔÊ›ÏÂÙ·È Û ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∆¤ÏÔ˜, Ë ÂÈÏÔÁ‹ Ù˘ ·Ú¤Ì‚·Û˘ ÔÊ›ÏÂÈ Ó· Ï·Ì‚¿ÓÂÈ ˘’ fi„ÈÓ ÙË Û˘ÓÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·È‰ÈÔ‡, ‰ËÏ·‰‹ ÙË ÓÔËÌÔÛ‡ÓË ÙÔ˘, ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘, ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÚfiÁÓˆÛË Ì ‚¿ÛË ÙË Ê‡ÛË Î·È ÙÔÓ ÂÓÙÔÈÛÌfi Ù˘ ‚Ï¿‚˘ Î·È ÙÔ ·Ó·Ù˘ÍÈ·Îfi ÛÙ¿‰ÈÔ ÛÙÔ ÔÔ›Ô ‚Ú›ÛÎÂÙ·È. ¶fiÛË ÛËÌ·Û›· ÛÙÔ ÏÂÈÙÔ˘ÚÁÈÎfi Â›Â‰Ô ÌÔÚ› Ó· ¤¯ÂÈ Ë ÂÏ¿ÙÙˆÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ÂÓfi˜ ̤ÏÔ˘˜, Â¿Ó ÙÔ ·È‰› ·‰˘Ó·Ù› Ó· ÂÊ·ÚÌfiÛÂÈ ÂÎÔ‡ÛÈÔ ¤ÏÂÁ¯Ô ÛÙËÓ Î›ÓËÛ‹ ÙÔ˘; ∏ ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË, ÔÈ Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ÈÛÔÚÚÔ›Â˜, ÙÔ ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈÎfi Â›‰Ô, fiÏ· ηıÔÚ›˙Ô˘Ó ÙȘ ‰˘Ó·ÙfiÙËÙ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ó· ·ÓÙ¤ÍÂÈ ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Î·È Ó· ÂÊ·ÚÌfiÛÂÈ ·˘Ù¿ Ô˘ ÂÌ›˜ Û˘ÓÈÛÙԇ̠(6). ∏ ∞∆-∞ ¯ÚËÛÈÌÔÔÈ‹ıËΠıÂÚ·¢ÙÈο ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 Î·È ·ԉ›¯ÙËΠ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·Ú¯Èο ÛÙË ıÂÚ·›· Ù˘ ‰˘ÛÙÔÓ›·˜ Î·È Î·ÙfiÈÓ Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ (7,8). ªÂÙ¿ ÙËÓ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË, Ë ∞∆-∞ Û˘Ó‰¤ÂÙ·È Ì ¯ÔÏÈÓÂÚÁÈΤ˜ ÚÔÛ˘Ó·ÙÈΤ˜ ÌÂÌ‚Ú¿Ó˜ ÛÙË Ó¢ÚÔÌ˘˚΋ Û‡Ó·„Ë. ªÂ ÙÔ Ì˯·ÓÈÛÌfi Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚˆÛ˘, ÙÔ ÌfiÚÈÔ ÂÈÛ¤Ú¯ÂÙ·È ÛÙ· ÂÓ‰Ô΢ÙÙ·ÚÈο ΢ÛÙ›‰È·, ‰È·¯ˆÚ›˙ÂÙ·È ÛÙËÓ ÂÏ·ÊÚ¿ Î·È ‚·Ú›· ¿Ï˘ÛÔ Ô˘ ÙÔ ·ÔÙÂÏÔ‡Ó Î·È Ë ÂÏ·ÊÚ¿ ¿Ï˘ÛÔ˜ ·ÂÏ¢ıÂÚÒÓÂÙ·È ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·. ∂Λ, Ì ÂÓ˙˘ÌÈÎfi Ì˯·ÓÈÛÌfi ÚÔηÏ› ÙÂÏÈο ·Ó·ÛÙÔÏ‹ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ·ÎÂÙ˘ÏÔ¯ÔÏ›Ó˘ ÛÙË Û‡Ó·„Ë, ÌÏÔοÚÔÓÙ·˜ ¤ÙÛÈ ÙË Ó¢Úԉȷ‚›‚·ÛË (1). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ·Ó·Ù‡ÛÛÔÓÙ·È ·ÓÙÈÛÒÌ·Ù· ÂÓ·ÓÙ›ÔÓ Ù˘ ∞∆-∞, ·Ó Î·È ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi fiÛÔ Û˘¯Ó¿ Û˘Ì‚·›ÓÂÈ ·˘Ùfi. ∏ ·Ó¿Ù˘ÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÍÔ˘‰ÂÙÂÚÒÓÂÈ ÙËÓ Â˘ÂÚÁÂÙÈ΋ ‰Ú¿ÛË Ù˘ ∞∆-∞ Î·È Û ·ÛıÂÓ›˜ Ô˘ ·Ú¯Èο ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÈηÓÔÔÈËÙÈο Û ·˘Ù‹ ÙË ÌÔÚÊ‹ ıÂÚ·›·˜ Â›Ó·È Â˘ÓfiËÙÔ fiÙÈ Ô‰ËÁ› Û ·ÒÏÂÈ· Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Û ÂfiÌÂÓ˜ ÂÁ¯‡ÛÂȘ. ∂›Ó·È, ÂÔ̤ӈ˜, ÏÔÁÈÎfi Ó· Ï·Ì‚¿ÓÂÙ·È ÚfiÓÔÈ· ¤ÙÛÈ ÒÛÙ ӷ ÌÂȈı› Ô Î›Ó‰˘ÓÔ˜ Û¯ËÌ·ÙÈÛÌÔ‡ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ. OÈ ·Ú¿ÁÔÓÙ˜

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·171

¶·È‰È·ÙÚÈ΋ 2002;65:167-173

Ô˘ ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙÔ Û¯ËÌ·ÙÈÛÌfi ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È Ù· ÁÂÓÂÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ë Û˘ÓÔÏÈ΋ ¤ÎıÂÛ‹ ÙÔ˘ ÛÙÔ Û‡ÌÏÂÁÌ· Ó¢ÚÔÙÔ͛Ӣ-ÚˆÙ½Ó˘, Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÛfiÙËÙ· ÚˆÙ½Ó˘ ·Ó¿ ÂÁ¯˘fiÌÂÓË ‰fiÛË ∞∆-∞, ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÁ¯‡ÛÂˆÓ Î·È ÙË ¯ÔÚËÁÔ‡ÌÂÓË ‰ÔÛÔÏÔÁ›· ·Ó¿ ¤Á¯˘ÛË (9). °È· Ó· ÂÏ·¯ÈÛÙÔÔÈËı› ÂÔ̤ӈ˜ Ô Î›Ó‰˘ÓÔ˜ Û¯ËÌ·ÙÈÛÌÔ‡ ·ÓÙÈۈ̿وÓ, Â›Ó·È ·Ó·Áη›Ô Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë ‰fiÛË ÛÙ· ¯·ÌËÏfiÙÂÚ· ‰˘Ó·Ù¿ ıÂÚ·¢ÙÈο Â›‰· Î·È Ó· ÌÂÁÂı‡ÓÔÓÙ·È Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ¯ÔÚ‹ÁËÛ˘ Ù˘ ∞∆-∞ ÛÙÔ Ì¤ÁÈÛÙÔ ‰˘Ó·Ùfi (10). O ηıÔÚÈÛÌfi˜ Ù˘ ‰fiÛ˘ Á›ÓÂÙ·È Ì ‚¿ÛË ÙÔ˘˜ ›Ó·Î˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ‰ÔÛÔÏÔÁÈÎfi ‡ÚÔ˜ ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÙ· ·È‰È¿ Î·È ·Ó¿ÏÔÁ· Ì ÙÔ Ì˘ Ô˘ ÂÁ¯‡ÂÙ·È. ∏ ÂÌÂÈÚ›· ÙÔ˘ È·ÙÚÔ‡ ÛÙË Û˘Ó¤¯ÂÈ· ηıÔÚ›˙ÂÈ Â¿Ó Ë ‰fiÛË Ô˘ ı· ÂÁ¯˘ı› Â›Ó·È ÛÙÔ Î·ÙÒÙÂÚÔ ¿ÎÚÔ ÙÔ˘ ‰ÔÛÔÏÔÁÈÎÔ‡ ‡ÚÔ˜ ‹ ÛÙÔ ·ÓÒÙÂÚÔ. ∏ ̤ÙÚËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ÛÙË ıÂÚ·›· Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ ıˆÚÂ›Ù·È ·Ó·Áη›·, ·Ó Î·È ÔÈ ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ Î·È Îϛ̷Θ ¤¯Ô˘Ó Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ Â˘Ú›·˜ ÎÚÈÙÈ΋˜. ∏ ›ÂÛË ÁÈ· ·ÓÙÈÎÂÈÌÂÓÈΤ˜ Îϛ̷Θ ̤ÙÚËÛ˘ ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ì›·˜ ıÂÚ·›·˜ ¤¯ÂÈ ˘·ÁÔÚ¢ı› ·ÊÂÓfi˜ ·fi ÙÔ˘˜ ·ÛÊ·ÏÈÛÙÈÎÔ‡˜ ÊÔÚ›˜ Î·È ·ÊÂÙ¤ÚÔ˘ ·fi ÙËÓ ·Ó·ÁηÈfiÙËÙ· ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ, fiˆ˜ ·˘Ù‹ ÚÔ·ÙÂÈ ·fi ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ̤ıÔ‰Ô Î·È ÙËÓ ·Î·‰ËÌ·˚΋ È·ÙÚÈ΋. ∂ȉÈο ÁÈ· ÙË Û·ÛÙÈÎfiÙËÙ·, ηı›ÛÙ·Ù·È ‰˘Û¯ÂÚ‹˜ Ë ÔÛÔÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜, Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ¿ÏÁÔ˘˜ (11). ŸÌˆ˜, ÙÂÏÈο, ·Ó·Ù‡¯ıËÎ·Ó Ì¤ıÔ‰ÔÈ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ ÛÙË Û·ÛÙÈÎfiÙËÙ·, ÌÔÏÔÓfiÙÈ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÌÂÙÚËıÔ‡Ó ÔÚÈṲ̂ӷ Ê·ÈÓfiÌÂÓ·, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ô fiÓÔ˜ Û ÌÔÓ¿‰Â˜, fiˆ˜ ÌÂÙÚ¿Ù·È Ë ·ÈÌÔÛÊ·ÈÚ›ÓË. ∞fi ÙËÓ ·ÍÈÔÏfiÁËÛË ÚÈÓ Î·È ÌÂÙ¿ ÙË ıÂÚ·›· ÌÔÚ› Ó· ÚÔ·„ÂÈ ÙÔ ÔÛÔÛÙfi Ù˘ ÌÂÙ·‚ÔÏ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì·˜. ∆· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ·Ú¤Ì‚·Û˘ ·ÍÈÔÏÔÁÔ‡ÓÙ·È ˆ˜ ÏÂÈÙÔ˘ÚÁÈο ‹ Ù¯ÓÈο, ÂÓÒ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Î·Ù¤¯ÂÈ Ô ‚·ıÌfi˜ ÈηÓÔÔ›ËÛ˘ ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÏÏ¿ Î·È Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Û ۯ¤ÛË Ì ÙÔ ÎfiÛÙÔ˜. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Â›Ó·È ÛÎfiÈÌÔ Ó· Û˘˙ËÙËıÔ‡Ó ÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Î·È Ë ÎÚÈÙÈ΋ Á‡Úˆ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, ηıÒ˜ Î·È Ë ÙÔÔı¤ÙËÛË Â›ÛËÌˆÓ ÔÚÁ·ÓÈÛÌÒÓ (U.K. Botulinum toxin and Cerebral Palsy Working Party) Û¯ÂÙÈο Ì ÙËÓ ∞∆-∞ Û ·È‰È¿ Ì ∂¶ (12). ∏ ¯Ú‹ÛË Ù˘ ∞∆-∞ ¤¯ÂÈ ‰Â›ÍÂÈ Â˘ÓÔ˚ο ‚Ú·¯˘ÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Û·ÛÙÈÎfiÙËÙ·˜ Î·È Ù˘ ‰˘ÛÙÔÓ›·˜ ÛÙËÓ ∂¶. £¤Ì· ÚÔ˜ Û˘˙‹ÙËÛË ·ÔÙÂÏ› Ë ‰ÔÛÔÏÔÁ›· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·Ó¿ Ì˘, Ë ÔÔ›· ¤¯ÂÈ Î·ıÔÚÈ-

Paediatriki 2002;65:167-173

ÛÙ› Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ Ì˘fi˜, ·ÏÏ¿ Ì ÌÂÁ¿ÏË ·fiÎÏÈÛË ·fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ¯Ú‹Û˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ™ÙËÓ ·ÚÔ‡Û· Ê¿ÛË ÔÈ ·fi„ÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ Û˘ÁÎÏ›ÓÔ˘Û˜ Î·È ÔÈ ÚÔÙÂÈÓfiÌÂÓ˜ ‰fiÛÂȘ Â›Ó·È Û˘Ó‹ıˆ˜ ·˘Ù¤˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙÔ ‰ÈÎfi Ì·˜ ˘ÏÈÎfi, ‰ËÏ·‰‹ 13 U/kg Botox Î·È 40 U/kg Dysport. ∆· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Ôχ ÛËÌ·ÓÙÈο, ηıÒ˜ ·ÎfiÌË ‰ÂÓ ¤¯ÂÈ ·Ôχو˜ ‰È¢ÎÚÈÓÈÛÙ› ÔÈÔÈ Â›Ó·È ÔÈ Î·Ï‡ÙÂÚÔÈ ˘Ô„‹ÊÈÔÈ ÁÈ· ·˘Ù‹ ÙË ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ∆Ô Î‡ÚÈÔ ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ Â›Ó·È Ë ˘ÂÚÙÔÓ›· ¯ˆÚ›˜ Û‡Áη̄Ë, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ Î·Ù·ÓÔÌ‹ Ù˘ ∂¶. ¶ÂÚÈÛÛfiÙÂÚÔ Û·Ê¤˜ Â›Ó·È Û ÔÈÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È Ë ·ÁˆÁ‹ Î·È ·˘ÙÔ› Â›Ó·È ÔÈ ÂÍ‹˜: ·) ∞ÛıÂÓ›˜ Ì ÌfiÓÈÌË ÈÔÔ‰›· (ÁˆÓ›· οو ÙˆÓ 90 ÌÔÈÚÒÓ Ì ÙÔ ÁfiÓ˘ ÛÂ Î¿Ì„Ë Î·È ¤ÓÙÔÓË ·ÓÙ›ÛÙ·ÛË). ‚) ÀÔÙÔÓÈ΋ ÌÔÚÊ‹ ∂¶ Ì ¤ÓÙÔÓË Ì˘˚΋ ·‰˘Ó·Ì›·. Á) ªË Û˘ÓÂÚÁ¿ÛÈÌË ÔÈÎÔÁ¤ÓÂÈ· ‹ ıÂÚ·Â˘Ù¤˜. ‰) ∂Ӊ›ÍÂȘ ·Ú·ÁˆÁ‹˜ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ ÙÔ͛Ӣ. ∞ÎfiÌË ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó Ì·ÎÚÔÚfiıÂÛÌ· Ë ¯Ú‹ÛË Ù˘ ∞∆-∞ ı· ·Ô‰Âȯı› ÎÏÈÓÈο ÂˆÊÂÏ‹˜ Î·È - ·fi ÔÈÎÔÓÔÌÈ΋ ¿Ô„Ë - ˆ˜ ηϋ Â¤Ó‰˘ÛË ÚÔ˜ fiÊÂÏÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜. ¶¿ÓÙˆ˜, Ë ‰˘Ó·ÙfiÙËÙ· Ù˘ ∞∆-∞ Ó· ÌÂÈÒÛÂÈ ÙË Û·ÛÙÈÎfiÙËÙ· Î·È Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∂¶ ˘ÔÛÙËÚ›˙ÂÙ·È ·fi ·ÚÎÂÙ¤˜ ‰ÈϤ˜ Ù˘ÊϤ˜ ‹ ·ÓÔÈÎÙ¤˜ ÌÂϤÙ˜ (13-20). OÈ ·Ú¯ÈΤ˜ ÌÂϤÙ˜ Âͤٷ˙·Ó ÙË ‚Ú·¯˘ÚfiıÂÛÌË ˆÊ¤ÏÂÈ· (21), fï˜ ÔÈ ÈÔ ÚfiÛÊ·Ù˜ ÂÍÂÙ¿˙Ô˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·Ú¤Ì‚·Û˘ ÂÚÈÛÛfiÙÂÚÔ Ì·ÎÚÔÚfiıÂÛÌ· (22). ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·Ó·ÊÂÚı‹Î·Ì ÛÙËÓ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Ô˘ Ë ıÂÚ·¢ÙÈ΋ ÔÌ¿‰· ¤ıÂÛ ηٿ ÙËÓ ·Ú¯È΋ ·ÍÈÔÏfiÁËÛË, ÂÓÒ Û ·ÒÙÂÚÔ ¯ÚfiÓÔ ı· ·ÍÈÔÏÔÁËıÔ‡Ó ÔÈ ÏÔÈ¤˜ Îϛ̷Θ ÔÈ Ôԛ˜ Û˘ÏϤÁÔÓÙ·È. Ÿˆ˜ ÚԷӷʤÚıËÎÂ, Ë Û˘ÏÏÔÁ‹ ÙˆÓ ÛÙÔȯ›ˆÓ ·˘ÙÒÓ ÛÙ· ÛˆÛÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· Î·È Ì Ù¯ÓÈΤ˜ ·ÍÈfiÈÛÙ˜ ¤¯ÂÈ ·Ô‰Âȯı› ȉȷ›ÙÂÚ· ‰˘Û¯ÂÚ‹˜ Î·È Â›ÔÓË Î·È ıˆÚԇ̠fiÙÈ Ù· ̤¯ÚÈ ÛÙÈÁÌ‹˜ Û˘Ïϯı¤ÓÙ· ‰Â‰Ô̤ӷ, ·Ó Î·È ÔÏÏ¿ Î·È Û ÔÈΛÏÔ˘˜ ÙÔÌ›˜, ‰ÂÓ Â›Ó·È ·ÎfiÌË Û˘ÓÔÏÈο ·ÍÈÔÏÔÁ‹ÛÈÌ·. £· Ú¤ÂÈ ÛÙÔ ÛËÌÂ›Ô ·˘Ùfi Ó· ÛËÌÂȈı› fiÙÈ Ë ¯Ú‹ÛË ·ÓÙÈÎÂÈÌÂÓÈÎÒÓ ÌÂıfi‰ˆÓ ·ÍÈÔÏfiÁËÛ˘ Û ÌÈÎÚ¿ ΢ڛˆ˜ ·È‰È¿ Â›Ó·È Úfi‚ÏËÌ·, ηıÒ˜ ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ˆ˜ ÚÔ˜ ÙË ‰È·ıÂÛÈÌfiÙËÙ· ÙˆÓ ÌÂıfi‰ˆÓ ·ÏÏ¿ Î·È ˆ˜ ÚÔ˜ ÙËÓ ·ÍÈÔÈÛÙ›· ÙÔ˘˜ (23). ∆Ô Â‡ÚÔ˜ Ù˘ ΛÓËÛ˘ ÌÂÙÚ¿Ù·È ·ıËÙÈο, ÂÓÒ ÙÔ Â‡ÚÔ˜

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¶·È‰È·ÙÚÈ΋ 2002;65:167-173

Ù˘ ÂÓÂÚÁËÙÈ΋˜ ΛÓËÛ˘ ‰ÂÓ ÌÔÚ› Ó· ÌÂÙÚËı› Û ÌÈÎÚ¤˜ ËÏÈ˘. OÈ ÌÂÙ·‚ÔϤ˜ ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ ‰‡ÛÎÔÏ· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Û ·È‰È¿, ÂÓÒ Ë ÎÚÈÙÈ΋ ÁÈ· ÙȘ ˘¿Ú¯Ô˘Û˜ ÌÂıfi‰Ô˘˜, .¯. Ashworth, Â›Ó·È fiÙÈ ¤¯Ô˘Ó ηٷÛ΢·ÛÙ› ÁÈ· ÂÓ‹ÏÈΘ. OÈ ‰˘ÛÎÔϛ˜ ÛÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ Îϛ̷Θ, fiˆ˜ Ë GMFM, Â›Ó·È ÔÏϤ˜, ηıÒ˜ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ Û˘¯Ó¿ ‰ÂÓ Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· ÂÂȉ‹ ‰ÈÂÎÂÚ·ÈÒÓÔÓÙ·È ·fi ıÂÚ·Â˘Ù¤˜ Ì ‹ ¯ˆÚ›˜ Û¯ÂÙÈ΋ ÂÎ·›‰Â˘ÛË Î·È Â›Ó·È ¯ÚÔÓÔ‚fiÚ˜. ∏ Û˘ÁÎÂÎÚÈ̤ÓË ¿ÓÙˆ˜ ̤ıÔ‰Ô˜ ¤¯ÂÈ ÂȉÈο ·Ó·Ù˘¯ı› ÁÈ· ·È‰È¿ Ì ∂¶ Î·È ‰›ÓÂÈ ·ÎÚȂ›˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ‰ÂÍÈfiÙËÙ˜ Ô˘ ¤¯ÂÈ ÙÔ ·È‰› ˆ˜ ÚÔ˜ ÙËÓ ·‰Ú‹ ÎÈÓËÙÈÎfiÙËÙ·. ∏ ÔÈfiÙËÙ· ÙˆÓ ÎÈÓ‹ÛÂˆÓ ‰ÂÓ ÂÍÂÙ¿˙ÂÙ·È (24). ™ËÌ·Û›· ¤¯ÂÈ fiÙÈ ·ÎfiÌË Î·È ¤Ó· ˘ÁȤ˜ ·È‰› 5 ÂÙÒÓ ÌÔÚ› Ó· ÂÎÙÂϤÛÂÈ ÙË Îϛ̷η. O Ê˘ÛÈÔıÂÚ·Â˘Ù‹˜ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ›Ô˘ 60 min ·fi ÙÔ ¯ÚfiÓÔ ÙÔ˘ Î·È ÚÔËÁÔ‡ÌÂÓË ÂÎ·›‰Â˘ÛË. ∆¤ÏÔ˜, Ë ·Ó¿Ï˘ÛË ‚¿‰ÈÛ˘ ‰ÂÓ Â›Ó·È Â˘Ú¤ˆ˜ ‰È·ı¤ÛÈÌË Î·È Â›Ó·È ‰‡ÛÎÔÏË fiÙ·Ó ÙÔ ·È‰› Â›Ó·È ÌÈÎÚfi Î·È ÌË Û˘ÓÂÚÁ¿ÛÈÌÔ. ∆Ô Ì‹Ó˘Ì· ÙÔ ÔÔ›Ô ÂÈı˘Ìԇ̠ӷ ÌÂٷʤÚÔ˘Ì Ì ÙË ÌÂϤÙË ·˘Ù‹ Â›Ó·È fiÙÈ ÔÈ ÂÁ¯‡ÛÂȘ ∞∆-∞ Â›Ó·È Ì¤ıÔ‰Ô˜ ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∏ Ï‹Ú˘ ‹ ÌÂÚÈ΋ Â›Ù¢ÍË ÙÔ˘ ÏÂÈÙÔ˘ÚÁÈÎÔ‡ ÛÙfi¯Ô˘ Û 57 ·fi Ù· 67 ·È‰È¿ (85%) ıˆÚÂ›Ù·È ˆ˜ ¿ÎÚˆ˜ ÈηÓÔÔÈËÙÈ΋, ȉȷ›ÙÂÚ· Â¿Ó ÏËÊı› ˘’ fi„ÈÓ Ô Ôχ ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÂÏ·ÊÚÒÓ Î·È Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„ÈÌˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ. £ÂˆÚԇ̠fiÙÈ ÙÔ Î·Ïfi ·˘Ùfi ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹ ˘Ô„‹ÊÈˆÓ ·ÛıÂÓÒÓ Î·È Ì˘˚ÎÒÓ ÔÌ¿‰ˆÓ ÁÈ· ¤Á¯˘ÛË, ·ÏÏ¿ Î·È ÛÙÔ˘˜ Ú·ÏÈÛÙÈÎÔ‡˜ ıÂÚ·¢ÙÈÎÔ‡˜ ÛÙfi¯Ô˘˜ Ô˘ ı¤Û·ÌÂ. ∂ÈϤÔÓ, ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Î·È Ë Û˘ÌÌfiÚʈÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ ˆ˜ ÚÔ˜ ÙÔ ··Ú·›ÙËÙÔ Ê˘ÛÈÔıÂÚ·¢ÙÈÎfi ÚfiÁÚ·ÌÌ· ÌÂÙ¿ ÙȘ ÂÁ¯‡ÛÂȘ. ∆· ·ÓÙ›ıÂÙ·, ‰ËÏ·‰‹ Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÂÁ¯‡ÛÂˆÓ Û ̇˜ Ì ÌfiÓÈÌË Û‡ÁÎ·Ì„Ë Ô˘ ÌfiÓÔÓ ¤Ó· ¯ÂÈÚÔ˘ÚÁÂ›Ô ÌÔÚ› Ó· ·Ó·Ù¿ÍÂÈ, Ë ˘ÂÚ‚ÔÏÈ΋ ‰ÔÛÔÏÔÁ›·, ÔÈ ˘„ËÏÔ›, ÌË Ú·ÁÌ·ÙÔÔÈ‹ÛÈÌÔÈ ÏÂÈÙÔ˘ÚÁÈÎÔ› ÛÙfi¯ÔÈ Ô˘ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ˘’ fi„ÈÓ ÙË Û˘ÓÔÏÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙȘ ÏÔÈ¤˜ ·Ó·Ëڛ˜ ÙÔ˘, ı· Ô‰ËÁÔ‡Û·Ó Û ÌË ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· Î·È ÛÙËÓ ·‰ÈηÈÔÏfiÁËÙË Û·Ù¿ÏË ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ (Ê¿Ú̷η Ì ˘„ËÏfi ÎfiÛÙÔ˜, ¯ÚfiÓÔ˜ È·ÙÚÈÎÔ‡ Î·È ·Ú·˚·ÙÚÈÎÔ‡ ÚÔÛˆÈÎÔ‡). ∆¤ÏÔ˜, ÙÔÓ›˙ÂÙ·È Ë ·Ó·ÁηÈfiÙËÙ· Ù˘ ÛÙÂÓ‹˜ Û˘ÓÂÚÁ·Û›·˜ Ù˘ ÔÌ¿‰·˜ (ÔÚıÔ‰ÈÎfi˜, Ê˘ÛÈÔıÂÚ·Â˘Ù‹˜, Ó¢ÚÔÏfiÁÔ˜) ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ ÚÈÓ Î·È ÌÂÙ¿ ·fi ÙȘ ÂÁ¯‡ÛÂȘ. ∏ ·fiÙÔÌË Ì›ˆÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Ô˘ Â¤Ú¯ÂÙ·È Ì ÙË ¯Ú‹ÛË Ù˘ ∞∆-∞, ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÛÙÔ˘˜ ıÂÚ·Â˘Ù¤˜ Ó· ÂÛÙÈ¿ÛÔ˘Ó Û ÏÂÈÙÔ˘ÚÁÈ-

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ÎÔ‡˜ ÛÙfi¯Ô˘˜ Î·È ÛÙËÓ ÔÌ¿‰· ·ÓÙÈÌÂÙÒÈÛ˘ Ó· ÂÊ·ÚÌfiÛÂÈ ·ÚÂÌ‚¿ÛÂȘ ÁÚ‹ÁÔÚ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο. µÈ‚ÏÈÔÁÚ·Ê›· 1. Dolly JO. Therapeutic and research exploitation of botulinum neurotoxins. Eur J Neurol 1997;4(Suppl 2):S5-S10.

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20. ¶·ÓÙÂÏÈ¿‰Ë˜ Ã, ª·Ï¿Ûη ∞, ∆˙ËÙËÚ›‰Ô˘ ª, ∫ÔÙ˙·ÂÚ›‰Ô˘ O, ∫·Ú·Ù˙¿-•ÈÊÈÏ›‰Ô˘. ∞ÏÏ·ÓÙÈ΋ ÙÔÍ›ÓË ÛÙË ıÂÚ·›· Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘. ¶·È‰È·ÙÚÈ΋ 2000;63:412-417.

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¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ª›· ·Ï‹ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÚÔÛÒÔ˘*1 ∆Ô Û¿ÓÈÔ Û‡Ó‰ÚÔÌÔ Ì·ÎÚÔ‡ QT (Û. QT) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÈÌ‹Î˘ÓÛË Ù˘ ÎÔÈÏȷ΋˜ ÂÓ·fiψÛ˘ Î·È ·fi ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘. ™Â ÔÏÏÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È ÎÏËÚÔÓÔÌÈÎfi. Œ¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› ÌÂÙ·ÏÏ¿ÍÂȘ ÔÏÏÒÓ ÁfiÓˆÓ, Ô˘ Ô Î·ı¤Ó·˜ Έ‰ÈÎÔÔÈ› Ì›· ‰›Ô‰Ô ÈfiÓÙˆÓ. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ ÛÙËÓ ÎÔχ̂ËÛË Î·È È‰È·›ÙÂÚ· ÛÙ· ·È‰È¿, ÌÔÚ› Ó· Û˘Ì‚Â› ÂȉÈ΋ ÂÓÂÚÁÔÔ›ËÛË Î·È Û˘¯Ó¿ Â¤Ú¯ÂÙ·È Û˘ÁÎÔÈ΋ ÎÚ›ÛË, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Ì¤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ ·˘ÙÔ‡ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ¶ÚfiÛÊ·Ù· ·Ó·Ê¤ÚıËÎÂ Ë ‰ÔÎÈÌ·Û›· ÂÌ‚¿ÙÈÛ˘ Û ÎÚ‡Ô ÓÂÚfi (10ÔC) Û ıÂÚÌÔÎÚ·Û›· ÂÚÈ‚¿ÏÏÔÓÙÔ˜ 20ÔC, ÌÂÙ¿ ·fi ‚·ıÈ¿ ÂÈÛÓÔ‹. ŸÙ·Ó ÙÔ Ì·ÎÚfi QT ‰ÂÓ Â›Ó·È ÔÈÎÔÁÂÓÔ‡˜ ÌÔÚÊ‹˜, ›¯Â ‚ÚÂı› fiÙÈ Ë Û¯¤ÛË QT/HR (‰È¿ÚÎÂÈ· QT/ηډȷ΋ Û˘¯ÓfiÙËÙ·) Ô˘ ˘ÔÏÔÁÈ˙fiÙ·Ó ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÚÈÓ Î·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÈÔ ¿Óˆ ‰ÔÎÈÌ·Û›·˜, ·ÚÔ˘Û›·˙ ̛· ‰È·ÊÔÚ¿ (ÎÏ›ÛË) Ô˘ Â›Ó·È ¯Ú‹ÛÈÌÔ˜ ‰Â›ÎÙ˘ Úfi‚Ï„˘ ÁÈ· ·ÓÒÌ·ÏË ÂÈÌ‹Î˘ÓÛË ÙÔ˘ QT***.

OÈ Û˘ÁÁÚ·Ê›˜ (ı¤ÏÔÓÙ·˜ ÚÔÊ·ÓÒ˜ Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË Ì¤ıÔ‰fi ÙÔ˘˜) ÌÂϤÙËÛ·Ó 19 ·È‰È¿ Ì Û. QT Î·È 54 ˆ˜ ÔÌ¿‰· ÂϤÁ¯Ô˘. ∏ ÎÏ›ÛË Ô˘ ÌÂÙÚ‹ıËΠ·fi ÙÔ˘Ï¿¯ÈÛÙÔÓ 4 ÂÈÏÂÁ̤ӷ ‰Â‰Ô̤ӷ ÛËÌ›· ÚÈÓ Î·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ‹Ù·Ó Û‡ÌʈÓË Ì ÙËÓ ÎÏ›ÛË Ô˘ ÌÂÙÚ‹ıËΠ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰Ô̤ӈÓ. ∂›Û˘, Ë Û¯¤ÛË ÌÂٷ͇ ÎÏ›Û˘ Î·È ÙÈÌ‹˜ QTc** ÛÙËÓ ÂÏ¿¯ÈÛÙË Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· ‹Ù·Ó Ôχ ıÂÙÈ΋. ™˘ÌÂÚ·›ÓÂÙ·È, ÂÔ̤ӈ˜, fiÙÈ Â›Ó·È ‰˘Ó·Ùfi ·ÓÙ› Ó· ˘ÔÏÔÁ›˙ÂÙ·È Ë ÈÔ ¿Óˆ Û¯¤ÛË ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰Ô̤ӈÓ, Ó· ˘ÔÏÔÁ›˙ÂÙ·È Ì ٷ ‰Â‰Ô̤ӷ ·fi 4 ÌfiÓÔ ÂÈÏÂÁ̤ӷ ÛË-

Ì›· Î·È fiÙÈ ÌÔÚԇ̠ӷ ·ÓÙÈηٷÛÙ‹ÛÔ˘Ì ÙÔÓ ˘ÔÏÔÁÈÛÌfi ·˘Ù‹˜ Ù˘ ‰È·ÊÔÚ¿˜ (ÎÏ›Û˘) ·¢ı›·˜ Ì ÙËÓ ÙÈÌ‹ QTc ÛÙËÓ ÂÏ¿¯ÈÛÙË Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ÂÌ‚¿ÙÈÛ˘ Ù˘ ÎÂÊ·Ï‹˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Èı·ÓfiÙËÙ· ·ÓÒÌ·Ï˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ QT ηٿ ÙËÓ ÎÔχ̂ËÛË ÌÔÚ› Ó· ÂϤÁ¯ÂÙ·È Ì ÙË ‰ÔÎÈÌ·Û›· ÂÌ‚¿ÙÈÛ˘ ÙÔ˘ ÎÂÊ·ÏÈÔ‡ Î·È Ó· ˘ÔÏÔÁ›˙ÂÙ·È ·¢ı›·˜ ÙÔ QTc. *¢ÔÎÈÌ·Û›· ·Ó¿ÏÔÁË Ì ÙÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ηٿ‰˘Û˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi Ù˘ ·ÁÔ·ÛÙ˘ **QTc=QT/√RR ***Yoshinaga M, Kamimura J, Fukushige T, Kusubae R, Shimago A, Nishi J et al. Face immersion in cold water induces prolongation of the QT interval and T-wave changes in children with nonfamilial long QT syndrome. Am J Cardiol 1999;83:1494-1497

1 Kamimura J, Yoshinaga M, Kono Y, Yanagi S, Nishi J, Nomura Y et al A simple method for evaluating abnormal lengthening of the QT interval during the face immersion test Pediatr Cardiol 2002;23:122-126

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ORIGINAL ARTICLE

™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÙÔ˘ ˘„›Û˘¯ÓÔ˘ ·ÂÚÈÛÌÔ‡ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÓÂÔÁÓÒÓ µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, ∂. ¢È·Ì·ÓÙ‹, ¡. ¡ÈÎÔÏ·˝‰Ë˜, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜

Comparison of high-frequency oscillatory ventilation with conventional mechanical ventilation in the treatment of respiratory distress syndrome in preterm infants V. Drossou - Agakidou, K. Sarafidis, P. Karagianni, E. Diamanti, N. Nikolaidis, G. Kremenopoulos

¶ÂÚ›ÏË„Ë: O ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ (High Frequency Oscillatory Ventilation, HFOV) ÂÊ·ÚÌfi˙ÂÙ·È Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (™∞¢), ·ÏÏ¿ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·ÎfiÌË ·Ó Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ·fi ÙÔ Û˘Ì‚·ÙÈÎfi ·ÂÚÈÛÌfi (™∞) Î·È ·Ó ÌÂÈÒÓÂÈ ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ HFOV Î·È ÙÔ˘ ™∞ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ Î·È ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘. ¶ÚfiˆÚ· ÓÂÔÁÓ¿ (µ° <1250 g) Ì ™∞¢ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Ù˘¯·›· Û ‰‡Ô ÔÌ¿‰Â˜, ÙËÓ ÔÌ¿‰· ™∞, ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ™∞, Î·È ÙËÓ ÔÌ¿‰· HFOV/™∞, ÛÙËÓ ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ™∞¢ Î·È ·ÎÔÏÔ‡ıËÛ ™∞ ηٿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi. ∆· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ™∞ (n=20) ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌ· Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ HFOV/™∞ (n=10) ˆ˜ ÚÔ˜ Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÙÔ˘˜ ÂÚÈÁÂÓÓËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÙË ‚·Ú‡ÙËÙ· ™∞¢. ∫·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË, ÔÈ ‰˘Ô ÔÌ¿‰Â˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙËÓ Î˘„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ (AaDO2) Î·È ÙÔ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ (¢O) ÙȘ ÚÒÙ˜ 48 ÒÚ˜ ıÂÚ·›·˜ ηıÒ˜ Î·È ÛÙË Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∂›Û˘, ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ IIIÔ˘ Î·È IVÔ˘ ‚·ıÌÔ‡, ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜ ÚÔˆÚfiÙËÙ·˜ (∞Ù¶) ≥3+, ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘, ÙËÓ ÂÈ‚›ˆÛË Î·È ÙË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜. øÛÙfiÛÔ, Ô ™∞ ·¤Ù˘¯Â Û 7/20 ÓÂÔÁÓ¿. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ À∞ Ì ٷϷÓÙÒÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ

Abstract: High-frequency oscillatory ventilation (HFOV) is used for the treatment of respiratory distress syndrome (RDS) in preterm neonates. It has not been clarified yet whether HFOV is more effective than conventional mechanical ventilation (CMV) in improving oxygenation and ventilation and decreasing the incidence of complications of RDS. The aim of this study was to compare the effect of HFOV and CMV on oxygenation and ventilation of very low birth weight neonates with RDS, and on the incidence of its complications.

Premature neonates (BW <1250 g) were randomly divided into two groups, the CMV group treated with CMV, and the HFOV/CMV group treated with HFOV during the acute stage of RDS followed by CMV during weaning. It was found that the CMV group (n=20) was comparable to the HFOV/CMV group (n=10) with regard to demographic characteristics, perinatal factors and severity of RDS. On follow up, the two groups did not differ significantly regarding the arterial-alveolar oxygen difference, the oxygenation index in the first 48 hours of treatment and the duration of mechanical ventilation. The incidence of complications (air leak syndromes, intra-periventricular hemorrhage of grade III-IV, chronic lung disease and retinopathy of prematurity of at least 3+ degree), as well as the survival and duration of hospitalization did not differ significantly between the two groups. However, CMV failed in 7/20 neonates. We conclude that the use of HFOV, as initial treatment of RDS in very premature neonates, is effective in improving oxygenation and ventilation. The rate of successful treatment of RDS is higher with the use of HFOV, although it

¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. πÔÎÚ¿ÙÂÈÔ °¶¡ £ÂÛÛ·ÏÔӛ΢

Department of Neonatology, Aristotelion University of Thessaloniki, “Ippokration” General Hospital, Thessaloniki

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¶·È‰È·ÙÚÈ΋ 2002;65:174-181

Paediatriki 2002;65:174-181

Ô͢ÁfiÓˆÛË Î·È ÙÔÓ ·ÂÚÈÛÌfi ÙˆÓ Ó¢ÌfiÓˆÓ. OÈ Èı·ÓfiÙËÙ˜ ÂÈÙ˘¯Ô‡˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ™∞¢ Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ Ì ÙÔÓ À∞, ·Ó Î·È ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ˘ÂÚÔ¯‹ ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞.

has not been found to have a significant advantage regarding the effectiveness and the incidence of complications as compared to CMV.

§¤ÍÂȘ ÎÏÂȉȿ: ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜, Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜, Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ÚfiˆÚ· ÓÂÔÁÓ¿.

Key words: high-frequency oscillatory ventilation, conventional mechanical ventilation, respiratory distress syndrome, premature neonates.

™˘ÓÙÔÌÔÁڷʛ˜

Ê·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ À∞ (6). øÛÙfiÛÔ, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó ‹Ù·Ó ÈÔ ÂÏȉÔÊfiÚ·, ηıÒ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ À∞ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ™∞¢ Î·È ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ö¡, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (7-10). ∆· ‰È·ÊÔÚÂÙÈο ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· ·Ô‰fiıËÎ·Ó ÛÙË ‰È·ÊÔÚÂÙÈ΋ ÛÙÚ·ÙËÁÈ΋ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ À∞. ¶ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË Î·Ù·Ï‹ÁÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ·fi ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ˘¿Ú¯Ô˘Ó ‰ÂÓ ‰È¢ÎÚÈÓ›˙ÂÙ·È ·Ó Ô À∞ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ·fi ÙÔ ™∞ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ Î·È ·Ó ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ¿ÌÂÛˆÓ ‹ Ì·ÎÚÔÚfiıÂÛÌˆÓ ÂÈÏÔÎÒÓ (11). ™ÙËÓ ∂ÏÏ¿‰·, ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ À∞ ˘¿Ú¯ÂÈ Û ÂÏ¿¯ÈÛÙ· ÓÂÔÁÓÈο ÙÌ‹Ì·Ù· ηÈ, Û˘ÓÂÒ˜, Ë ÂÌÂÈÚ›· ‰ÂÓ Â›Ó·È ÌÂÁ¿ÏË. ™ÙÔ ÙÌ‹Ì· Ì·˜ ·ÔÊ·Û›ÛÙËÎÂ Ë ÌÂϤÙË ·˘Ù‹ ÌÂÙ¿ ·fi ÙËÓ ·fiÎÙËÛË 5ÂÙÔ‡˜ ÂÌÂÈÚ›·˜ ·fi ÙË ¯Ú‹ÛË ÙÔ˘, ΢ڛˆ˜ ˆ˜ ıÂÚ·›·˜ ‰È¿ÛˆÛ˘. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ë Û‡ÁÎÚÈÛË ‰‡Ô ÙÚfiˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÙÔ˘ À∞ Ì ٷϷÓÙÒÛÂȘ Î·È ÙÔ˘ ™∞, ˆ˜ ÚÔ˜ ÙËÓ Ô͢ÁfiÓˆÛË Î·È ·ÂÚÈÛÌfi ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ™∞¢ Î·È ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ.

∞Ù¶ ¢O ¢P FiO2 AaDO2 PaO2 ™∞ ™∞¢ À∞ HFOV ö¡

∞ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ· ÚÔˆÚfiÙËÙ·˜ ¢Â›ÎÙ˘ Ô͢ÁfiÓˆÛ˘ ∂‡ÚÔ˜ Ù·Ï¿ÓÙˆÛ˘ ∫Ï¿ÛÌ· ÂÈÛÓÂfiÌÂÓÔ˘ Ô͢ÁfiÓÔ˘ ∫˘„ÂÏȉԷÚÙËÚȷ΋ ‰È·ÊÔÚ¿ Ô͢ÁfiÓÔ˘ ªÂÚÈ΋ ›ÂÛË Ô͢ÁfiÓÔ˘ ÛÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· ™˘Ì‚·ÙÈÎfi˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ™‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ À„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ ÃÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜

∂ÈÛ·ÁˆÁ‹ OÈ ÛËÌ·ÓÙÈÎfiٷ٘ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÙˆÓ ÚÔÒÚˆÓ, Î·È È‰È·›ÙÂÚ· Ë ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ù¯ÓÈ΋˜ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ™∞, Û˘Ó¤‚·Ï·Ó ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ™ÙËÓ ÚÔÛ¿ıÂÈ· ÂÚ·ÈÙ¤Úˆ Ì›ˆÛ˘ ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, fiˆ˜ Â›Ó·È Ù· Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· Î·È Ë Ã¶¡, ·Ó·˙ËÙ‹ıËÎ·Ó ÂÓ·ÏÏ·ÎÙÈÎÔ› ÙÚfiÔÈ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Ì ÛÙfi¯Ô ÙË Ì›ˆÛË ÙÔ˘ ‚·ÚÔ(ÔÁÎÔ)ÙÚ·‡Ì·ÙÔ˜. ŒÓ·˜ Ù¤ÙÔÈÔ˜ ÙÚfiÔ˜ Â›Ó·È Î·È Ô À∞ Ô˘ ıˆÚÂ›Ù·È ÏÈÁfiÙÂÚÔ “ÙÚ·˘Ì·ÙÈÎfi˜”, ηıÒ˜ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È ÔÈ Î˘ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ¤ÎÙ˘Í˘ ÙˆÓ Î˘„ÂÏ›‰ˆÓ (1). À¿Ú¯Ô˘Ó 3 ›‰Ë À∞: Ô À∞ Ì ٷϷÓÙÒÛÂȘ (high frequency oscillatory ventilation, HFOV), Ô À∞ Ì ·ÂÚÈÒıËÛË (high frequency jet ventilation) Î·È Ô À∞ Ì ‰È·ÎÔ‹ ÚÔ‹˜ (high frequency flow interrupter) (2). ∞Ú¯Èο, ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô À∞ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ Î·È ÙÔ˘ ·ÂÚÈÛÌÔ‡ ÓÂÔÁÓÒÓ Ì ™∞¢, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ·¤Ù˘¯Â Ô ™∞, ¯ˆÚ›˜ Ó· ÚÔηÏ› ‚·ÚfiÙÚ·˘Ì· (3-5). ™ÙËÓ ÚÒÙË, fï˜, ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠÌÂÁ·Ï‡ÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ À∞ Û ÓÂÔÁÓ¿ Ì ™∞¢ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, ÂÓÒ ˘‹Ú¯·Ó ÂӉ›ÍÂȘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂ-

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó ÚÔÁÚ·ÌÌ·ÙÈṲ̂ӷ ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÛÔ‚·Úfi ™∞¢ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞ÚÈÛÙÔÙ¤ÏÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ Û ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜ (π·ÓÔ˘¿ÚÈÔ˜-¢ÂΤ̂ÚÈÔ˜ 2000), Ù· ÔÔ›· ¯ÚÂÈ¿ÛÙËÎ·Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÔ‚·Ú‹˜ ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∫ÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ ÛÙË ÌÂϤÙË ‹Ù·Ó Ù· ÂÍ‹˜: ·) ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ≤1250 g Î·È ‰È¿ÚÎÂÈ· ·ËÛ˘ 26-32 ‚‰ÔÌ¿‰Â˜, ‚) ·ÚÔ˘Û›· ™∞¢ ≥2Ô˘ ‚·ıÌÔ‡ ·ÎÙÈÓÔÏÔÁÈο Î·È Á) ·Ó¿ÁÎË ÂÊ·ÚÌÔÁ‹˜ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ̤۷ ÛÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ ·fi ÙË Á¤ÓÓËÛË. ∞fi ÙË ÌÂϤÙË ·ÔÎÏ›ÛÙËÎ·Ó ÓÂÔÁÓ¿ Ì Ì›˙ÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· IVÔ˘ ‚·ıÌÔ‡ ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÓÂÔÁÓ¿ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË. ∆· ÓÂÔÁÓ¿ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Ù˘¯·›·, Û‡Ìʈӷ Ì ÙË

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·176

¶·È‰È·ÙÚÈ΋ 2002;65:174-181

ÛÂÈÚ¿ ÂÈÛ·ÁˆÁ‹˜ ÛÙÔ ÙÌ‹Ì·, Û ‰‡Ô ÔÌ¿‰Â˜, ÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ Î·È ÙËÓ ÔÌ¿‰· ÙÔ˘ HFOV/™∞. ∏ ηٷÓÔÌ‹ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ¤ÁÈÓ Ì ·Ó·ÏÔÁ›· 2:1 ÁÈ· Ú·ÎÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜. ™ÙËÓ ÔÌ¿‰· ™∞ ÂÊ·ÚÌfiÛÙËΠÂÏÂÁ¯fiÌÂÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ·Ó·Ó¢ÛÙ‹Ú· ›ÂÛ˘ (SLE 2000). OÈ ·Ú¯ÈΤ˜ Ú˘ıÌ›ÛÂȘ ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ‹Ù·Ó: ·) ̤ÁÈÛÙË ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË (PIP) 18-25 cm H2O, ‚) ¯ÚfiÓÔ˜ ÂÈÛÓÔ‹˜ (π∆) 0,36-0,40 sec, Á) ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË (PEEP) 4-5 cm H2O Î·È ‰) Û˘¯ÓfiÙËÙ· ·Ó·ÓÔÒÓ 60/min. ™ÙËÓ ÔÌ¿‰· HFOV/™∞ ÂÊ·ÚÌfiÛÙËΠHFOV Ì ·Ó·Ó¢ÛÙ‹Ú· Sensormedics 3100A, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ™∞, Ô ÔÔ›Ô˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ ˙ˆ‹˜, ‰ËÏ·‰‹ ηٿ ÙË Ê¿ÛË ÛÙ·ıÂÚÔÔ›ËÛ˘ ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV, ηıÒ˜ Î·È Î·Ù¿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·fi ÙÔÓ HFOV. ∫·Ù¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù·ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ (12-15). ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ ·Ú¯ÈΤ˜ Ú˘ıÌ›ÛÂȘ ÛÙÔÓ HFOV ‹Ù·Ó: ·) ·Ú¯È΋ ̤ÛË ›ÂÛË ·ÂÚÔÊfiÚˆÓ (Paw) ηٿ 2-4 cm H2O ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ™∞, ‚) ‡ÚÔ˜ Ù·Ï¿ÓÙˆÛ˘ (¢P) ÙfiÛÔ, ÒÛÙ ӷ ÚÔηÏÔ‡ÓÙ·È ÔÚ·Ù¤˜ ‰ÔÓ‹ÛÂȘ ÙÔ˘ ıÒڷη, Á) FiO2 ›‰ÈÔ Ì ·˘Ùfi Ô˘ ··ÈÙÔ‡ÓÙ·Ó ÛÙÔ ™∞ ηٿ ÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ Ù˘ ÛÙ·ıÂÚÔÔ›ËÛ˘, ‰) Û˘¯ÓfiÙËÙ· Ù·Ï¿ÓÙˆÛ˘ (Frequency) 10 Hz Î·È Â) I:∂ ratio=1:2. OÈ ·Ú¿ÌÂÙÚÔÈ ·˘Ù¤˜ ÙÚÔÔÔÈÔ‡ÓÙ·Ó ·Ó¿ÏÔÁ· Ì ٷ ·¤ÚÈ· ·›Ì·ÙÔ˜ Î·È ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. ∏ ¤ÎÙ˘ÍË ÙÔ˘ ıÒڷη ıˆÚÔ‡ÓÙ·Ó ÈηÓÔÔÈËÙÈ΋ fiÙ·Ó ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÙÔ ‰ÂÍÈfi ‰È¿ÊÚ·ÁÌ· ‚ÚÈÛÎfiÙ·Ó ÛÙÔ ‡„Ô˜ Ù˘ 8˘-9˘ ÏÂ˘Ú¿˜ ηٿ Ì‹ÎÔ˜ Ù˘ ÌÂÛÔÎÏÂȉÈ΋˜ ÁÚ·ÌÌ‹˜. ∏ ·Ó¿Ù˘ÍË ·Ó·Ó¢ÛÙÈ΋˜ ·ÏοψÛ˘ ·ÓÙÈÌÂÙˆÈ˙fiÙ·Ó Ì Ì›ˆÛË Ù˘ ¢ƒ. ∆· ÎÚÈÙ‹ÚÈ· ·ÔÁ·Ï·ÎÙÈÛÌÔ‡ ·fi ÙÔÓ HFOV Î·È ÌÂÙ·ÊÔÚ¿˜ Û ™∞ ‹Ù·Ó Paw <8 cm H2O Î·È FiO2 <0,3. ∫ÚÈÙ‹ÚÈÔ ·ÔÙ˘¯›·˜ ÙÔ˘ ™∞ ‹Ù·Ó Ë ·‰˘Ó·Ì›· ‰È·Ù‹ÚËÛ˘ PaO2 >50 mmHg Ì PIP >25 cm H2O Î·È FiO2 ≥0,8, ÂÓÒ ÎÚÈÙ‹ÚÈÔ ·ÔÙ˘¯›·˜ ÙÔ˘ HFOV ‹Ù·Ó Ë ·‰˘Ó·Ì›· ‰È·Ù‹ÚËÛ˘ PaO2 >50 mmHg, ·Ú¿ ÙËÓ ÈηÓÔÔÈËÙÈ΋ ¤ÎÙ˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ÙËÓ ·Ô˘Û›· ˘fiÙ·Û˘. ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‚fiÂÈ·˜ ÚÔ¤Ï¢Û˘ (Survanta® Abbott Laboratories USA, Ross). ∏ ÚÒÙË ‰fiÛË ¯ÔÚËÁ‹ıËΠ30-60 min ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÛÙ· ÚfiˆÚ· Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô, Î·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÛÙ· ÌÂÙ·ÊÂÚfiÌÂÓ· ·fi ¿ÏϘ ÎÏÈÓÈΤ˜ Î·È ÓÔÛÔÎÔÌ›·. ∏ ¯ÔÚ‹ÁËÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Ì¤¯ÚÈ 3 ÊÔÚ¤˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· Î·È ÙȘ ·Ó¿ÁΘ Û Ô͢ÁfiÓÔ. ∫·Ù·ÁÚ¿ÊËÎ·Ó Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÂÔÁÓÒÓ (‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ‰È¿ÚÎÂÈ· ·ËÛ˘ Î·È Ê‡ÏÔ), Ë ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ, Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi 24 ÒÚ˜, Ë ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ë Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÔÈ ÂÈÏÔΤ˜ (Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· IIIÔ˘ - IVÔ˘ ‚·ıÌÔ‡), Ë Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ô͢ÁfiÓÔ˘, Ë ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È Ë ÂÈ‚›ˆÛË. ∏ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›· ÂÎÙÈÌ‹ıËΠ̠‚¿ÛË ÙȘ

176

Paediatriki 2002;65:174-181

ÌÂÙ·‚ÔϤ˜ Ù˘ ̤Û˘ ›ÂÛ˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, Ù˘ ΢„ÂÏȉԷÚÙËÚȷ΋˜ ‰È·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘ [AaDO2= (716xFiO2)(PaCO2/0,8)-PaO2] Î·È ÙÔ˘ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ [¢O= (MAPÃFiO2)/PaO2] ÛÙȘ 2 ÒÚ˜ (Î·È ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·Ó Ì ™∞) Î·È Î·ÙfiÈÓ ÛÙȘ 6, 24 Î·È 48 ÒÚ˜ ˙ˆ‹˜. ∆· ÓÂÔÁÓ¿ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó ÁÈ· ÂÌÊ¿ÓÈÛË Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, ö¡ Î·È ∞Ù¶. °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Á›ÓÔÓÙ·Ó ‰È·‰Ô¯Èο ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ÂÁÎÂÊ¿ÏÔ˘ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙËÓ 3Ë Î·È 10Ë Ë̤ڷ ÓÔÛËÏ›·˜. OÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ÁÈÓfiÙ·Ó ÙËÓ 32Ë-34Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë Î·È Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Î¿ı 2-4 ‚‰ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ٷ Â˘Ú‹Ì·Ù·. ø˜ ö¡ ÔÚ›ÛÙËÎÂ Ë ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ·fi ÙË Û‡ÏÏË„Ë. ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ̤Û˜ ÙÈ̤˜ Î·È ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ. °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· t ÙÔ˘ student (unpaired student’s t-test), ÂÓÒ ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÔÛÔÛÙÈ·›ˆÓ ·Ó·ÏÔÁÈÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ·ÎÚÈ‚‹˜ ‰ÔÎÈÌ·Û›· ÙÔ˘ Fischer (Fischer’s exact test).

∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó 30 ÓÂÔÁÓ¿, 20 ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ Î·È 10 ÛÙËÓ ÔÌ¿‰· HFOV/™∞.

OÈ ‰‡Ô ÔÌ¿‰Â˜ ÓÂÔÁÓÒÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘, ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ÙËÓ ·Ó·ÏÔÁ›· ·ÁÔÚÈÒÓ / ÎÔÚÈÙÛÈÒÓ, ÙÔÓ ÙÚfiÔ ÙÔÎÂÙÔ‡ Î·È ÙÔ Apgar score ÛÙÔ 1Ô Î·È 5Ô min (¶›Ó·Î·˜ 1). ∂›Û˘, ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó Û˘ÁÎÚ›ÛÈ̘ ˆ˜ ÚÔ˜ ÙË ‚·Ú‡ÙËÙ· ÙÔ˘ ™∞¢ Î·È ÙÔ˘˜ ÚÔÁÂÓÓËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ¿ ÙÔ˘, fiˆ˜ Â›Ó·È Ë Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ ÁÈ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 24 ÒÚ˜ Î·È Ë ÚÔÁÂÓÓËÙÈ΋ Ï‹„Ë ÛÙÂÚÔÂȉÒÓ (¶›Ó·Î·˜ 1). ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Î·È Ô Ì¤ÛÔ˜ ·ÚÈıÌfi˜ ‰fiÛÂˆÓ ·Ó¿ ÓÂÔÁÓfi ‹Ù·Ó ·ÚfiÌÔÈÔ˜ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 2). ∫·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË, Ë Ì¤ÛË ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· HFOV/™∞ ÛÙȘ 2, 6, 24 Î·È 48 ÒÚ˜ ˙ˆ‹˜, ·’ fiÙÈ ÛÙËÓ ÔÌ¿‰· ™∞, ÏfiÁˆ ÙÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÌÂϤÙ˘, ‰ËÏ·‰‹ Ù˘ Ù·ÎÙÈ΋˜ ÙÔ˘ “ηχÙÂÚÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ” (∂ÈÎfiÓ· 1). ¢ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ AaDO2 Î·È ÙÔ ¢O ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÛÙ· ·ÓÙ›ÛÙÔȯ· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (∂ÈÎfiÓ· 2). ∆· ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ·Ú¤ÌÂÈÓ·Ó ÛÙÔÓ À∞ ÁÈ· 3,65±2,45 Ë̤Ú˜. OÈ ‰‡Ô ÔÌ¿‰Â˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ÌfiÓÔ ™∞ ‹ HFOV+™∞). ™Â ¤ÓÙ ÓÂÔÁÓ¿ ·fi οı ÔÌ¿‰· ÂÊ·ÚÌfiÛÙËΠÚÈÓÈÎfi CPAP ÌÂÙ¿ ÙËÓ ·ÔۈϋӈÛË. ∂›Û˘, ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·177

¶·È‰È·ÙÚÈ΋ 2002;65:174-181

Paediatriki 2002;65:174-181

¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ

µ° (g) (x ± SD) ¢∫ (‚‰.) (x ± SD) ™∞¢ 2Ô˘/ ™∞¢ 3Ô˘-4Ô˘ ‚·ıÌÔ‡ (n) KoÏÈÎfis ÙÔÎÂÙfi˜/ηÈÛ·ÚÈ΋ ÙÔÌ‹ (n) ∞ÁfiÚÈ·/ÎÔÚ›ÙÛÈ· (n) ƒ∂À >24 ÒÚ˜ (n) ™ÙÂÚÔÂȉ‹ ÚÔÁÂÓÓËÙÈο (n) APGAR score: 1Ô min (x ± SD) 5Ô ÏÂÙfi (x± SD)

™∞ (n=20)

HFOV/™∞ (n=10)

P

996 ± 196 27,5 ± 1,8 7/13 10/10 12/8 5 13 4,0 ± 1,8 7,2 ± 1

1019 ± 244 27,2 ± 1,1 4/6 7/3 3/7 3 7 3,3 ± 2,7 6,1 ± 2,5

0,78 0,69 1 0,44 0,24 1 1 0,41 0,15

ƒ∂À: Ú‹ÍË ÙˆÓ ÂÌ‚Ú˘˚ÎÒÓ ˘Ì¤ÓˆÓ

¶›Ó·Î·˜ 2. ¢È¿ÚÎÂÈ· Î·È ¿ÌÂÛ˜ ÂÈÏÔΤ˜ ÙˆÓ ‰‡Ô Ù‡ˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ OÌ¿‰· ™∞ (n=20) ¢È¿ÚÎÂÈ· HFOV (ËÌ., x ± SD) ™˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· Û ª∞ (ËÌ., x ± SD) 17,9 ± 11 ∞ÔÙ˘¯›· ª∞ (n) 7* ∂¶ (‰fiÛÂȘ/ÓÂÔÁÓfi, x ± SD) 2,2 ± 0,8 ™‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú·: ¶Ó¢ÌÔıÒڷη˜ (n) 5 ∂ӉȿÌÂÛÔ Ó¢ÌÔÓÈÎfi ÂÌʇÛËÌ· (n) 1 ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ‚·ıÌÔ‡ IIπ-IV (n) 5

OÌ¿‰· HFOV/™∞ (n=10)

P

3,65 ± 2,45 17 ± 12,4 2,4 ± 1,3 1 3 3

0,87 0,06 0,19 0,63 0,09 1

HFOV: ˘„›Û˘¯ÓÔ˜ ·ÂÚÈÛÌfi˜ Ì ٷϷÓÙÒÛÂȘ ™∞: Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜ ª∞: Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ∂¶: ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ * ™Ù· 7 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ·¤Ù˘¯Â Ô Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜, ÂÊ·ÚÌfiÛÙËΠHFOV ˆ˜ ıÂÚ·›· ‰È¿ÛˆÛ˘

ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· Ó¢ÌÔıÒڷη, ÂӉȿÌÂÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ÂÌÊ˘Û‹Ì·ÙÔ˜ Î·È ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ πIπÔ˘ Î·È IVÔ˘ ‚·ıÌÔ‡ (¶›Ó·Î·˜ 2). ™ÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ Â¤˙ËÛ·Ó 12/20 (65%) Î·È ÛÙËÓ ÔÌ¿‰· ÙÔ˘ HFOV 7/10 (70%) ÓÂÔÁÓ¿, ¯ˆÚ›˜ Ë ‰È·ÊÔÚ¿ ·˘Ù‹ Ó· Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (¶›Ó·Î·˜ 3). øÛÙfiÛÔ, Û 7 ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ÙÔ˘ ™∞ ·¤Ù˘¯Â Ô ™∞ Î·È ¯ÚÂÈ¿ÛÙËΠӷ ÂÊ·ÚÌÔÛÙ› HFOV ˆ˜ ıÂÚ·›· ‰È¿ÛˆÛ˘. ∆· 7 ·˘Ù¿ ÓÂÔÁÓ¿ Â¤˙ËÛ·Ó. ∏ Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Ô˘ Â¤˙ËÛ·Ó ‰ÂÓ ¤‰ÂÈÍ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙȘ ·Ó¿ÁΘ Û O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ·fi ÙË Û‡ÏÏË„Ë, ÛÙË Û˘¯ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ∞Ù¶ Î·È ÛÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (¶›Ó·Î·˜ 3). ™˘˙‹ÙËÛË ¶·Ú¿ ÙËÓ 20ÂÙ‹ ¤Ú¢ӷ, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ‰È¢ÎÚÈÓÈÛÙ› ·Ó Ô À∞ ˘ÂÚ¤¯ÂÈ Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞ Ì ıÂÙÈΤ˜ ȤÛÂȘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢, ηıÒ˜ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Ì HFOV Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. OÈ ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ ¤¯Ô˘Ó ·Ô‰Ôı› ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ Ù·ÎÙÈΤ˜ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ À∞. ™ÙË ÌÂϤÙË Ì·˜ ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù·-

ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ, ηٿ ÙËÓ ÔÔ›· ÂȉÈÒÎÂÙ·È Ô Î·Ï‡ÙÂÚÔ˜ fiÁÎÔ˜ Ó¢ÌfiÓˆÓ (optimal lung volume), Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤Û˘ ›ÂÛ˘ ·ÂÚÔÊfiÚˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ ·fi ·˘Ù‹ ÛÙÔ ™∞ (12-14). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë Ì¤ÛË ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ HFOV ‰È·ÙËÚ‹ıËΠÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ·’ fiÙÈ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ™∞, Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ ÙÔ˘ ™∞¢. ªÂ ÙËÓ Ù·ÎÙÈ΋ ·˘Ù‹ ‚ÂÏÙÈÒÓÂÙ·È Ë Ô͢ÁfiÓˆÛË, ηıÒ˜ ‰È·ÓÔ›ÁÔÓÙ·È ÔÈ ·ÛÙ·ı›˜ ·ÙÂÏÂÎÙ·ÛÈΤ˜ ΢„ÂÏ›‰Â˜ Î·È ·˘Í¿ÓÂÈ Ë ÏÂÈÙÔ˘ÚÁÈ΋ ˘ÔÏÂÈfiÌÂÓË ¯ˆÚËÙÈÎfiÙËÙ· ÙˆÓ Ó¢ÌfiÓˆÓ (16). ∂ÈÚfiÛıÂÙ·, Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ηχÙÂÚÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ HFOV ‰Ú· ÚÔÏËÙÈο ÛÙËÓ ÚfiÎÏËÛË Ó¢ÌÔÓÈ΋˜ ‚Ï¿‚˘, ÛÙËÓ ÔÔ›· Û˘Ì‚¿ÏÏÔ˘Ó ÔÈ ÌÂÁ¿Ï˜ ΢ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ›ÂÛ˘ Î·È ÙÔ˘ fiÁÎÔ˘ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (17).

O ·Ú¯ÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó Ó· ÂÎÙÈÌËı› ·Ó Ô HFOV ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ô͢ÁfiÓˆÛË ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓÒÓ Ì ™∞¢ Ù·¯‡ÙÂÚ· ·fi ÙÔ ™∞. ∆· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ô HFOV ‰ÂÓ ˘ÂÚÙÂÚ› Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, ηıÒ˜ ‰ÂÓ ‰È·ÈÛÙÒÛ·Ì ٷ¯‡ÙÂÚË ‚ÂÏÙ›ˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ HFOV, fiˆ˜ ·˘Ù‹ ηٷÁÚ¿ÊËΠÛÙȘ

177

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¶·È‰È·ÙÚÈ΋ 2002;65:174-181

HFOV ™∞

20 *

*

15

Mean PAW

Paediatriki 2002;65:174-181

* *

10 5

0

2

6

24

48

flÚ˜ ˙ˆ‹˜ ∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ÙÈÌÒÓ (x ± SD) Ù˘ ̤Û˘ ›ÂÛ˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ (mean, PAW) ÛÙȘ ÔÌ¿‰Â˜ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (™∞) Î·È ÙÔ˘ ˘„›Û˘¯ÓÔ˘/Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (HFOV), *P<0,05.

ÌÂÙ·‚ÔϤ˜ Ù˘ AaDO2 Î·È ÙÔ˘ ¢O ÛÙȘ ÚÒÙ˜ 48 ÒÚ˜ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘. ¶·ÚfiÌÔÈ· ‹Ù·Ó Ù· Â˘Ú‹Ì·Ù· ¿ÏÏˆÓ Û˘ÁÁڷʤˆÓ, ÔÈ ÔÔ›ÔÈ ÂÊ·ÚÌfi˙ÔÓÙ·˜ ·ÚfiÌÔÈ· ÛÙÚ·ÙËÁÈ΋ À∞ ‰ÂÓ ‰È·›ÛÙˆÛ·Ó ‰È·ÊÔÚ¿ ÛÙËÓ Ô͢ÁfiÓˆÛË ÓÂÔÁÓÒÓ Ì ™∞¢ ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠHFOV, Û˘ÁÎÚÈÙÈο Ì ÂΛӷ ÛÙ· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËΠ™∞ (9,18,19). ∞ÓÙ›ıÂÙ·, Û ¿ÏϘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ÓÂÔÁÓ¿ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì HFOV ›¯·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË AaDO2 ÙȘ ÚÒÙ˜ 12 ÒÚ˜ ÙÔ˘ ª∞ Î·È ¯ÚÂÈ¿ÛÙËÎ·Ó ÏÈÁfiÙÂÚ˜ ‰fiÛÂȘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (10,20,21). ∆Ô ÙÂÏÂ˘Ù·›Ô ‡ÚËÌ·, ·Ó Î·È ‰ÂÓ ÂȂ‚·ÈÒıËΠÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, ·Ô‰›‰ÂÙ·È ÛÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ó¢ÌfiÓˆÓ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ·Ó¿Ù˘Í˘ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È Ù˘ ÂÍfi‰Ô˘ ÚˆÙÂ˚ÓÒÓ ÛÙȘ ΢„ÂÏ›‰Â˜ ηÈ, ÙÂÏÈο, ÛÙËÓ ·Ú¿Ù·ÛË Ù˘ ‰Ú¿Û˘ ÙÔ˘ Â͈ÁÂÓÔ‡˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (22,23). ¢Â‡ÙÂÚÔ˜ ÛÙfi¯Ô˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË Ù˘ Â›‰Ú·Û˘ ÙÔ˘ HFOV ÛÙȘ ¿ÌÂÛ˜ Î·È ·ÒÙÂÚ˜ ÂÈÏÔΤ˜, ηıÒ˜ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ôχ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ™∞¢. ∞fi ÙȘ ¿ÌÂÛ˜ ÂÈÏÔΤ˜, ÌÂÏÂÙ‹ıËÎÂ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú· Î·È ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜.

OÈ ÌÂÁ·Ï‡ÙÂÚ˜ ̤Û˜ ȤÛÂȘ ·ÂÚÔÊfiÚˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔ HFOV Û˘ÁÎÚÈÙÈο Ì ÙÔ ™∞, οÓÔ˘Ó Èı·Ó‹ ÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·. øÛÙfiÛÔ, ·fi ÙË ÌÂϤÙË Ì·˜ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·‡ÍËÛË ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú· Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘. Ÿˆ˜ ÂȂ‚·ÈÒÓÔ˘Ó Î·È ¿ÏϘ ÌÂϤÙ˜, Ì ÙÔ HFOV, fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛˆÛÙ¿, ‰ÂÓ ·˘Í¿ÓÂÙ·È (8,10,18-20), ‹ Î·È ÂÏ·ÙÙÒÓÂÙ·È, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘Ó‰ÚfiÌˆÓ ‰È·Ê˘Á‹˜ ·¤Ú·. ∞˘Ùfi ·Ô‰›‰ÂÙ·È

178

ÛÙÔ ÌÈÎÚfiÙÂÚÔ ‡„Ô˜ Î·È ‰È·Î˘Ì¿ÓÛÂȘ (swings) Ù˘ ›ÂÛ˘ Ô˘ ·ÛÎÂ›Ù·È Ì ÙÔÓ À∞ ÛÙÔ Â›Â‰Ô ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ·Ú¿ ÙË ÌÂÁ·Ï‡ÙÂÚË Ì¤ÛË ›ÂÛË Ô˘ ÌÂÙÚ¿Ù·È ÛÙÔ Î‡Îψ̷ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· (24). ∆Ô ÂӉȷʤÚÔÓ fï˜ ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÂÈÎÂÓÙÚÒÓÂÙ·È ÂÍ›ÛÔ˘ ÛÙË Û¯¤ÛË ÙÔ˘ HFOV Ì ÙËÓ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë. OÈ Û˘ÁÁÚ·Ê›˜ Ù˘ HiFi ÌÂϤÙ˘ (6) ‚Ú‹Î·Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘, Ô˘ ÙËÓ ·¤‰ˆÛ·Ó ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ Û˘Ó¯ԇ˜ ›ÂÛ˘ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜ ÂÏ·ÙÙÒÓÂÈ ÙË ÊÏ‚È΋ Â·Ó·ÊÔÚ¿ Î·È ÚÔηÏ› ÊÏ‚È΋ Û˘ÌÊfiÚËÛË ÂÓ‰ÔÎÚ·Óȷο (6). ™ÙË ÌÂϤÙË Ì·˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· Ù˘ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜, fiˆ˜ ¿ÏψÛÙÂ Î·È Û ¿ÏϘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ì HFOV, ÛÙȘ Ôԛ˜ ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù·ÎÙÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘ (8,10,18-20). ∞Ó Î·È ÛÙȘ ÌÂÙ·-·Ó·Ï‡ÛÂȘ Ê·›ÓÂÙ·È fiÙÈ Ô HFOV ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜, ÛËÌÂÈÒÓÂÙ·È ·’ fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ fiÙÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ·˘Ù¿ ÂËÚ¿˙ÔÓÙ·È ¤ÓÙÔÓ· ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ HiFi ÌÂϤÙ˘ (25,26). µ·ÛÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ‰ÈÂÚ‡ÓËÛ˘ Ó¤ˆÓ ÙÚfiˆÓ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÚÔÒÚˆÓ Ì ™∞¢ Â›Ó·È Ë ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ö¡. OÈ ÂÏ›‰Â˜ ÁÈ· ÂÏ¿ÙÙˆÛË Ù˘ ö¡ ‚·Û›ÛÙËÎ·Ó ÛÙËÓ ÂÔ›ıËÛË fiÙÈ Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ‰È·ÊÔÚÂÙÈÎÔ‡ ÙÚfiÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ı· ‹Ù·Ó ‰˘Ó·Ù‹ Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·Ó¿Ù˘Í‹ Ù˘. ™ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ Ô͢ÁfiÓÔ˘, ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ë ·Ó¿Ù˘ÍË ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, ηıÒ˜ Î·È ÔÈ ÌÂÁ¿Ï˜ ΢ÎÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ›ÂÛ˘ Î·È ÙÔ˘ fiÁÎÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ™∞ (27). ªÂ ÙÔ HFOV ÌÔÚ› Ó· ÂÏ·ÙÙˆı› Ô ¯ÚfiÓÔ˜ ¤ÎıÂÛ˘ ÛÙÔ Ô͢ÁfiÓÔ, ηıÒ˜ ‚ÂÏÙÈÒÓÂÙ·È Ù·¯‡ÙÂÚ· Ë Ô͢ÁfiÓˆÛË. ∂ÈϤÔÓ, fiˆ˜ ¤¯ÂÈ ÚÔ·Ó·ÊÂÚı›, ÔÈ ȤÛÂȘ Ô˘ ·ÛÎÔ‡ÓÙ·È ÛÙÔ Â›Â‰Ô ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ·ÏÏ¿ Î·È ÔÈ ‰È·Î˘Ì¿ÓÛÂȘ (swings) ÙÔ˘˜, Â›Ó·È ÌÈÎÚfiÙÂÚ˜ (24). ∞Ó·ÊÔÚÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ HFOV ÛÙËÓ ·Ó¿Ù˘ÍË ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜, ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ Û ˙Ò· ¤‰ÂÈÍ·Ó fiÙÈ Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÌÂÈÒÓÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË ‰È·ÊfiÚˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙȘ ·ÂÚÔÊfiÚÔ˘˜ Ô‰Ô‡˜ (28,29). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿, fï˜, ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·fi ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Û ÓÂÔÁÓ¿ Ì ™∞¢ (1). ∞fi ÎÏÈÓÈ΋ ¿Ô„Ë, Ù· ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù· Ù˘ HiFi ÌÂϤÙ˘, Ô˘ ‹Ù·Ó Ë ÚÒÙË ÌÂÁ¿ÏË ÌÂϤÙË, ‹Ù·Ó ·ÔÁÔËÙ¢ÙÈο ˆ˜ ÚÔ˜ ÙËÓ Â›‰Ú·Û‹

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Paediatriki 2002;65:174-181

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∂ÈÎfiÓ· 2. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ÙÈÌÒÓ (x ± SD) ÙÔ˘ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ (¢O) Î·È Ù˘ ΢„ÂÏȉԷÚÙËÚȷ΋˜ ‰È·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘ (AaDO2) ÛÙȘ ÔÌ¿‰Â˜ ÙÔ˘ Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (™∞) Î·È ÙÔ˘ ˘„›Û˘¯ÓÔ˘/Û˘Ì‚·ÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (HFOV). ¶›Ó·Î·˜ 3. ∂ͤÏÈÍË ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ Â¤˙ËÛ·Ó

∂È‚›ˆÛË (n,%) ∏̤Ú˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (x ± SD) ÃÔÚ‹ÁËÛË O2 (ËÌ., x ± SD) O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ (n) O2 ÙËÓ 36Ë Â‚‰. ÌÂÙ¿ ÙË Û‡ÏÏË„Ë (n) ∞Ù¶ ≥3+

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∞Ù¶: ∞ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜ * ™˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È 7 ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠHFOV ˆ˜ ıÂÚ·›· ‰È¿ÛˆÛ˘

ÙÔ˘ HFOV ÛÙË Ã¶¡ (6). ™ÙË ÌÂϤÙË ·˘Ù‹, fï˜, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÌÈÎÚ¤˜ ȤÛÂȘ, Ì ÛÎÔfi Ó· ÂÏ·ÙÙˆı› ÙÔ ‚·ÚfiÙÚ·˘Ì· ÙÔ˘ Ó‡ÌÔÓ·, ÂÓÒ ÙËÓ ÂÔ¯‹ ÂΛÓË ‰ÂÓ ‹Ù·Ó ‰È·ı¤ÛÈÌÔ˜ Ô ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÎÏÈÓÈ΋ ¯Ú‹ÛË (6,25). ∞fi ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó, ÛÙȘ Ôԛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ ȉ·ÓÈÎÔ‡ fiÁÎÔ˘, ÔÚÈṲ̂Ó˜ ¤‰ÂÈÍ·Ó ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ö¡ (4,5,9,10,15), ÂÓÒ Û ¿ÏϘ ‰ÂÓ ÂËÚ¿ÛÙËΠÛËÌ·ÓÙÈο (8,21). øÛÙfiÛÔ, ‰‡Ô ÚfiÛÊ·Ù˜ ÌÂÙ·-·Ó·Ï‡ÛÂȘ ÙˆÓ ÌÂÏÂÙÒÓ Û‡ÁÎÚÈÛ˘ ÙÔ˘ HFOV Ì ÙÔ ™∞ Û ÓÂÔÁÓ¿ Ì ™∞¢, ‰Â›¯ÓÔ˘Ó Ù¿ÛË ÂÏ¿ÙÙˆÛ˘ Ù˘ ö¡ fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô HFOV (11,25). ™ÙË ÌÂϤÙË Ì·˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È ÛÙȘ ·Ó¿ÁΘ Û O2 ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË Û‡ÏÏË„Ë. ¶ÈÛÙ‡ԢÌ fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂËÚ¿ÛÙËÎ·Ó ‰˘ÛÌÂÓÒ˜ ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙËÓ ÔÌ¿‰· HFOV/™∞ ‰ÂÓ ÂÊ·ÚÌfiÛÙËΠ·ÔÎÏÂÈÛÙÈο HFOV Û fiÏÔ ÙÔ ‰È¿ÛÙËÌ· Ô˘ ¯ÚÂÈ·˙fiÙ·Ó Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ·ÏÏ¿ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Î·È ™∞, ÙfiÛÔ Î·Ù¿ ÙȘ ‰‡Ô ÚÒÙ˜ ÒÚ˜ Ù˘ ÛÙ·ıÂÚÔÔ›ËÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ fiÛÔ Î·È Î·Ù¿ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·fi ÙÔÓ HFOV. ÕÏψÛÙÂ, ÌÂϤÙ˜ Û ˙Ò· ¤‰ÂÈÍ·Ó fiÙÈ ·Îfi-

Ì· Î·È ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ¯ÔÚ‹ÁËÛË ıÂÙÈÎÒÓ ȤÛÂˆÓ Ô‰ËÁ› Û ÂÈıËÏȷ΋ ‚Ï¿‚Ë, ¤ÍÔ‰Ô ÚˆÙÂ˚ÓÒÓ ÛÙȘ ΢„ÂÏ›‰Â˜ Î·È Â˘Ú‹Ì·Ù· ˘·ÏÔÂȉԇ˜ ÌÂÌ‚Ú¿Ó˘ (30). ∂ÈϤÔÓ, ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¿ÌÂÛË ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ HFOV, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ Ì ™∞¢ Î·È Ë ·ÔÎÏÂÈÛÙÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ̤¯ÚÈ ÙÔÓ ·ÔÁ·Ï·ÎÙÈÛÌfi ·¢ı›·˜ Û CPAP ‹ οÛη Ô͢ÁfiÓÔ˘ (Head box), ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Ã¶¡ (15,16,26). ∆¤ÏÔ˜, ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÛÔ‚·Ú‹˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜, ÙË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È ÙËÓ ÂÈ‚›ˆÛË, fiˆ˜ Î·È Û ¿ÏϘ ÌÂϤÙ˜ (8,10,19,20). ¶Ú¤ÂÈ, fï˜, Ó· ÂÈÛËÌ¿ÓÔ˘Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Û˘Ì‚·ÙÈÎfi˜ ·ÂÚÈÛÌfi˜ ·¤Ù˘¯Â Û 7 ÓÂÔÁÓ¿, ·ÓÙ›ıÂÙ· Ì ÙÔÓ HFOV Ô˘ ‰ÂÓ ·¤Ù˘¯Â Û ηӤӷ ·fi Ù· ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËÎÂ. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ HFOV ˆ˜ ıÂÚ·›·˜ ‰È¿ÛˆÛ˘ ÛÙ· 7 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· ·¤Ù˘¯Â Ô ™∞ Èı·ÓÒ˜ ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ™∞ (31). ™˘ÌÂÚ·ÛÌ·ÙÈο, ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ Ê·›ÓÂÙ·È fiÙÈ Ë ÚÒÈÌË ÂÊ·ÚÌÔÁ‹ ÙÔ˘ HFOV ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ™∞¢ ÛÙ· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ‚ÂÏÙÈÒÓÂÈ ÙËÓ

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Ô͢ÁfiÓˆÛË Î·È ÙÔÓ ·ÂÚÈÛÌfi ÙˆÓ Ó¢ÌfiÓˆÓ ¯ˆÚ›˜, fï˜, Û·Ê‹ ˘ÂÚÔ¯‹ ·¤Ó·ÓÙÈ ÛÙÔ ™∞. ∂›Û˘, ‰ÂÓ ·˘Í¿ÓÂÈ ÙËÓ ÂÈ‚›ˆÛË, ·Ó Î·È Ë Èı·ÓfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ™∞¢ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Ì ÙÔÓ À∞ ·’ fiÙÈ Ì ÙÔ ™∞. ∆¤ÏÔ˜, ‰ÂÓ ÂÏ·ÙÙÒÓÂÈ ÙȘ ¿ÌÂÛ˜ Î·È Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÏÔΤ˜ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡. ∂Ӊ¯Ô̤ӈ˜, Ë ¯Ú‹ÛË ÙÔ˘ HFOV ˆ˜ ·ÔÎÏÂÈÛÙÈÎÔ‡ ÙÚfiÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÓÂÔÁÓÒÓ Ì ™∞¢ Ó· ‚ÂÏÙÈÒÛÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘. ¶¿ÓÙˆ˜, ·fi ÙËÓ 6ÂÙ‹ ÂÌÂÈÚ›· Ì·˜ ÛÙË ¯Ú‹ÛË ÙÔ˘ HFOV ıˆÚԇ̠fiÙÈ ÁÈ· ÙËÓ ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ··ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÂÍÔÈΛˆÛË Î·È ÂÎ·›‰Â˘ÛË, ηıÒ˜ ÌÔÚ› Ó· Á›ÓÂÈ ÂÈΛӉ˘ÓÔ˜, ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ Â·Ú΋˜ ÂÌÂÈÚ›· ÛÙË ¯Ú‹ÛË ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Sugiura M, McCulloch PR, Wren S, Dawson RH, Froese AB. Ventilator pattern influences neutrophil influx and activation in atelectasis - prone rabbit lung. J Appl Physiol 1994;77:1355-1365.

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4. deLemos RA, Coalson JJ, Meredith KS, Gestmann DR, Null DM Jr. A comparison of ventilation strategies for the use of high-frequency oscillatory ventilation in the treatment of hyaline membrane disease. Acta Anaesthesiol Scand 1989;90[Suppl]:102-107.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-09-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ µ·ÛÈÏÈ΋ °ÏËÓÔ‡ 28, ∆.∫. 543 52, £ÂÛÛ·ÏÔÓ›ÎË E-mail: agaki@med.auth.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∏ ¯Ú‹ÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› Ë ¯ÚËÛÈÌfiÙËÙ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ (H. pylori), ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ ÂÎÚ›˙ˆÛ˘ Î·È ÙË ÌÂÙ¤ÂÈÙ· ·Ú·ÎÔÏÔ‡ıËÛË. ∞ÛıÂÓ›˜ Î·È Ì¤ıÔ‰ÔÈ: 72 ·È‰È¿ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·ÓÒÙÂÚÔ˘ ÂÙÈÎÔ‡ ˘Ô‚Ï‹ıËÎ·Ó Û Á·ÛÙÚÔÛÎfiËÛË Î·È Ï‹„Ë ‚ÈÔ„ÈÒÓ ÁÈ· ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË, ηÏÏȤÚÁÂÈ· Î·È Ù·¯Â›· ̤ıÔ‰Ô Ô˘Ú¿Û˘ (CLO-test). ¶·Ú¿ÏÏËÏ·, ¤ÁÈÓ ̤ÙÚËÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi Î·È fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÂÛËÌ·Ṳ̂ÓË Ì 13C. ∞ÔÙÂϤÛÌ·Ù·: 47 ·fi ÙÔ˘˜ 72 ·ÛıÂÓ›˜ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó Ïԛ̈ÍË ·fi H. pylori Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ‚ÈÔ„›·˜. ∏ ¢·ÈÛıËÛ›· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÁÈ· ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi H. pylori ‹Ù·Ó 95% ÛÙ·ÙÈÛÙÈο Û˘ÁÎÚ›ÛÈÌË Ì ·˘Ù‹ Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘ (94%), Ù˘ Ù·¯Â›·˜ ÌÂıfi‰Ô˘ Ô˘Ú¿Û˘ (96%) Î·È Ù˘ ÔÚÔÏÔÁÈ΋˜ ÌÂıfi‰Ô˘ (91%) Î·È ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ Ù˘ ηÏÏȤÚÁÂÈ·˜ (79%). ∏ ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ‚Ú¤ıËΠӷ Â›Ó·È 100%, Û˘ÁÎÚ›ÛÈÌË Ì ·˘Ù‹ ÙˆÓ ¿ÏÏˆÓ ‰ÔÎÈÌ·ÛÈÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ ÂÎÙÈÌ‹ıËΠ̠Á·ÛÙÚÔÛÎfiËÛË Î·È ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· ÛÙÔ˘˜ 24 H. pylori ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜. °È· ÙÔ ÛÎÔfi ·˘Ùfi, Ë Â˘·ÈÛıËÛ›· Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Î·È Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘

‹Ù·Ó 100%, ÂÓÒ Ù˘ ηÏÏȤÚÁÂÈ·˜ Î·È Ù˘ Ù·¯Â›·˜ ÌÂıfi‰Ô˘ Ô˘Ú¿Û˘ ‹Ù·Ó 88%. 11 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û Á·ÛÙÚÔÛÎfiËÛË Î·È ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜. ¢ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ‰ÔÎÈÌ·Û›·˜ ·Ó·ÓÔ‹˜ Ì Ԣڛ· Î·È Ù˘ ‚ÈÔ„›·˜ ÛÂ Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ ·ÛıÂÓ›˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ‰ÔÎÈÌ·Û›· ·Ó·ÓÔ‹˜ Ì Ԣڛ· Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ Ïԛ̈͢ ·fi H. pylori Û ·È‰È¿ ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·ÓÒÙÂÚÔ ÂÙÈÎfi, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂÚ·›·˜ ÂÎÚ›˙ˆÛ˘ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ıÂÚ·›·.

1 Yoshimura N, Tajiri H, Sawada A, Kozwaiwa K, Ida S, Fujisawa T et al A 13C-urea breath test in children with Helicobacter pylori infection: assessment of eradication therapy and follow-up after treatment J Gastroenterol 2001;36:606-611

°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

181

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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

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ORIGINAL ARTICLE

∏ ÛÈÁΤÏψÛË ÛÙËÓ ◊ÂÈÚÔ Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985 - 1999 ª. ÷ڛÛË1, ∂. °·Ï·Ó¿Î˘1, ª. ∆˙Ô‡ÊË1, ™. ™ÙÂÊ¿ÓÔ˘ - §Â‚ÂȉÈÒÙÔ˘2, ∑. ¶··‰ÔÔ‡ÏÔ˘ - ∫Ô˘ÏÔ˘Ì‹1

Shigellosis in the region of Epirus during the 15year period from 1985 to 1999 M. Charisi1, E. Galanakis1, M. Tzoufi1, S. Stephanou - Levidiotou2, Z. Papadopoulou - Couloumbis1

¶ÂÚ›ÏË„Ë: ∏ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÈ¤‰Ô˘ ˘ÁÈÂÈÓ‹˜ ¤¯ÂÈ ÂÈʤÚÂÈ Ô˘ÛÈÒ‰Ë Ì›ˆÛË ÛÙË ÓÔÛËÚfiÙËÙ· Ù˘ ÛÈÁΤÏψÛ˘ ÛÙË ¯ÒÚ· Ì·˜. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ÛÙË 15ÂÙ›· 1985-1999. ∫·Ù·ÁÚ¿ÊËÎ·Ó fiϘ ÔÈ ÂÚÈÙÒÛÂȘ ÛÈÁΤÏψÛ˘ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ÂÚ›Ô‰Ô 1985-1999, ηıÒ˜ Î·È fiÏ· Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÈfi‰Ô˘ ÌÂϤÙ˘ ÓÔÛËχÙËÎ·Ó 46 ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ (27 ·ÁfiÚÈ· Î·È 19 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 3 ÌËÓÒÓ-13 ÂÙÒÓ). ∏ ̤ÛË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ˘ÔÏÔÁ›ÛÙËΠ۠5 ÂÈÛ·ÁˆÁ¤˜/100.000 ·È‰È¿/¤ÙÔ˜, ¯ˆÚ›˜ ÛËÌ·ÓÙÈΤ˜ ÂÙ‹ÛȘ ‰È·Î˘Ì¿ÓÛÂȘ. ™ËÌÂÈÒıËΠfï˜ Û·Ê‹˜ ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù¿ ÙÔÓ Ì‹Ó· ∞‡ÁÔ˘ÛÙÔ (39% ÙÔ˘ Û˘ÓfiÏÔ˘, p<0,001). ∞fi Ù· 46 ·È‰È¿, Ù· 7 (15%) ÂÌÊ¿ÓÈÛ·Ó ˘ÚÂÙÈÎÔ‡˜ Û·ÛÌÔ‡˜, 2 ›¯·Ó ÂÈÎfiÓ· ‚·ÚÈ¿˜ ·Ê˘‰¿ÙˆÛ˘ Î·È 1 ·Ú·Ï˘ÙÈÎfi ÂÈÏÂfi. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÎÔÚ¿ÓˆÓ ·Ó·Ù‡¯ıËÎ·Ó S. flexneri (67%), S. boydii (13%), S. sonnei (13%) Î·È S. dysenteriae (7%). ™ËÌ·ÓÙÈ΋ ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∏ ÂȉËÌÈ΋ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ ÛËÌÂÈÒıËΠ۠ΈÌfiÔÏË ÙÔ˘ ÓÔÌÔ‡ πˆ·ÓÓ›ÓˆÓ Î·È ·ÊÔÚÔ‡Û 84 ·È‰È¿, ·fi Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó Ù· 26 (14 ·ÁfiÚÈ· Î·È 12 ÎÔÚ›ÙÛÈ·). ∞Ô‰fiıËΠÛÙË ÌfiÏ˘ÓÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ‡‰Ú¢Û˘ ·fi Shigella sonnei. ™ÙËÓ ÔÌ¿‰· ·˘Ù‹ ‰ÂÓ ˘‹ÚÍ·Ó ÂÈÏÔΤ˜. ŸÏ· Ù· ·È‰È¿ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ¤Î‚·ÛË.

Abstract: The improvement of hygiene standards in Greece has resulted in a substantial decrease in the incidence of shigellosis. The aim of the present study was to record the number of children with shigellosis in the region of Epirus, during the 15year period from 1985 to 1999. All shigella cases that were hospitalized from 1985 to 1999 were recorded, as well as the disease cases in children during a local outbreak in October 1996. During the study period, 46 sporadic cases of shigellosis (27 boys and 19 girls, aged 3 months to 13 years), were admitted to the hospital. The mean incidence of the disease was estimated to be 5 hospital admissions per 100000 children per year, without any significant annual fluctuations.

However an increased prominence of the disease was noted during the month of August (39% in total, p<0.001). Seven of the 46 hospitalized children (15%) had febrile seizures, two had serious dehydration and one had paralytic ileus.

The stool cultures were positive for S. flexneri (67%), S. boydii (13%), S. sonnei (13%) and S. dysenteriae (7%). No significant resistance to antibiotics was observed. The epidemic outbreak occurred in a small town near the city of Ioannina and involved 84 children, 26 of whom (14 boys and 12 girls) were hospitalized. This localised epidemic was associated with the infection of the water supply by S. sonnei. There were no complications.

All children in the study had an excellent outcome.

§¤ÍÂȘ ÎÏÂȉȿ: ÛÈÁΤÏψÛË, ·È‰È¿, ÂȉËÌÈÔÏÔÁ›·, ◊ÂÈÚÔ˜.

Key words: shigellosis, children, epidemiology, Epirus.

1 ∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ 2 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¶.¶.°.¡. πˆ·ÓÓ›ÓˆÓ

1 Department of Child Health University of Ioannina Medical School 2 Laboratory of Microbiology, General University Hospital of Ioannina

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∂ÈÛ·ÁˆÁ‹ ∏ ÛÈÁΤÏψÛË Â›Ó·È ÓfiÛÔ˜ Ì ·ÁÎfiÛÌÈ· ηٷÓÔÌ‹ Î·È ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÁÈ· ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ (1). ™ÙË ¯ÒÚ· Ì·˜, Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ÂÈ¤‰Ô˘ ˘ÁÈÂÈÓ‹˜ ¤¯ÂÈ ÌÂÈÒÛÂÈ Ô˘ÛȈ‰Ò˜ ÙË ÓÔÛËÚfiÙËÙ· Ù˘ ÛÈÁΤÏψÛ˘. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ∂ȉÈÎÔ‡ ∫¤ÓÙÚÔ˘ ∂ȉËÌÈÔÏÔÁÈ΋˜ ¶·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ¶·Ú¤Ì‚·Û˘, ηٿ ÙÔ ¤ÙÔ˜ 1999 ‰ËÏÒıËÎ·Ó Û˘ÓÔÏÈο 80 Ó¤· ÎÚÔ‡ÛÌ·Ù· ·ÓÂÏÏËÓ›ˆ˜ (2). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ηٿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999. ÀÏÈÎfi Î·È Ì¤ıÔ‰Ô˜ ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÏ‹ÊıËÛ·Ó fiϘ ÔÈ ÛÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ÛÈÁΤÏψÛ˘ Û 46 ·È‰È¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ÛÙÔ ‰È¿ÛÙËÌ· 1985-1999, ηıÒ˜ Î·È Ù· ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘ Û 84 ·È‰È¿ ÛÙË ‰È¿ÚÎÂÈ· Ì›·˜ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996. ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο Ù· ÈÛÙÔÚÈο ÙˆÓ ·ÛıÂÓÒÓ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó Ù· ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Ù˘ ÓfiÛÔ˘, Ù· ÛÙÂϤ¯Ë ÛÈÁΤÏÏ·˜ Ô˘ ·ÔÌÔÓÒıËÎ·Ó Î·È Ë Â˘·ÈÛıËÛ›· ÙÔ˘˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, ÔÈ Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ Î·È Ù¤ÏÔ˜, Ë ·ÁˆÁ‹ Î·È Ë ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ. ŸÏ· Ù· ‰Â›ÁÌ·Ù· ÎÔÚ¿ÓˆÓ Î·ÏÏÈÂÚÁ‹ıËÎ·Ó Û Mac Conkey ¿Á·Ú Î·È Salmonella-Shigella ¿Á·Ú. ∏ Ù·˘ÙÔÔ›ËÛË Î·È Ë ‰ÔÎÈÌ·Û›· ¢·ÈÛıËÛ›·˜ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο ¤ÁÈÓ·Ó Ì ÙÔ Û‡ÛÙËÌ· Pasco MIC/ID Î·È ·ÓÙÈÔÚÔ‡˜ ÙÔ˘ Ô›ÎÔ˘ Wellcome.

AÔÙÂϤÛÌ·Ù· 1. ™ÔÚ·‰ÈΤ˜ ÂÚÈÙÒÛÂȘ ™ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999 ÓÔÛËχÙËÎ·Ó Û˘ÓÔÏÈο 46 ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· ÛÈÁΤÏψÛ˘, 27 ·ÁfiÚÈ· Î·È 19 ÎÔÚ›ÙÛÈ·. ∏ ËÏÈΛ· ÙÔ˘˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 3 ÌËÓÒÓ ¤ˆ˜ 13 ÂÙÒÓ (̤ÛË ËÏÈΛ· Ù· 5 ¤ÙË). MÈÎÚfiÙÂÚ· ÙˆÓ 24 ÌËÓÒÓ ‹Ù·Ó 13 ·È‰È¿ (28%). ªÂ ‚¿ÛË ÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi Ù˘ ∏›ÚÔ˘, Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ˘ÔÏÔÁ›ÛÙËΠ۠5 ÂÈÛ·ÁˆÁ¤˜ ·Ó¿ 100.000 ·È‰È¿ ·Ó¿ ¤ÙÔ˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·Î˘Ì¿ÓÛÂȘ ·fi ¤ÙÔ˜ Û ¤ÙÔ˜. ∏ ÌËÓÈ·›· ηٷÓÔÌ‹ ·ÚÔ˘Û›·Û ۷ʋ ¤Í·ÚÛË Î·Ù¿ ÙÔÓ ∞‡ÁÔ˘ÛÙÔ, Ô ÔÔ›Ô˜ Û˘ÁΤÓÙÚˆÓ ÙÔ 39% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ (p<0,001) (™¯‹Ì· 1).

K·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, ÔÈ ·ÛıÂÓ›˜ ÂÌÊ¿ÓÈ˙·Ó ˘ÚÂÙfi >38,5ÔC ۯ‰fiÓ ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ (97%) Î·È ‹ÈÔ˘ ‹ ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ·Ê˘‰¿ÙˆÛË Û ÔÛÔÛÙfi 30%. ™Ô‚·Ú‹ ·Ê˘‰¿ÙˆÛË (>10%) ·Ú·ÙËÚ‹ıËΠ۠‰‡Ô ·È‰È¿ (ÔÛÔÛÙfi 4%). §Â˘ÎÔ΢ÙÙ¿ÚˆÛË (>10.000/Ìl, ·ÓÒÙÂÚË ÙÈÌ‹ 26.200/Ìl) ÂÌÊ¿ÓÈÛ ÙÔ 58% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‹Ù·Ó ·˘ÍË̤ÓË ÛÙÔ˘˜ 19 ·fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ fiÔ˘ ÌÂÙÚ‹ıËΠ(‡ÚÔ˜ 10-326 mg/dl).

Paediatriki 2002;65:182-185

20 18 16 14 12 10 8 6 4 2 0

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™¯‹Ì· 1. ªËÓÈ·›· ηٷÓÔÌ‹ ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÛÈÁΤÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999.

ÀÔÓ·ÙÚÈ·ÈÌ›· ÂÌÊ¿ÓÈÛ·Ó ÌfiÓÔ ‰‡Ô Ó‹È· ËÏÈΛ·˜ 3 ÂÙÒÓ (¤Ó· ·ÁfiÚÈ Î·È ¤Ó· ÎÔÚ›ÙÛÈ), ÂÓÒ ¤Ó· ·ÁfiÚÈ 6 ÂÙÒÓ ÚÔÛ‹Ïı Ì ˘·Û‚ÂÛÙÈ·ÈÌ›· (6,5 mg/dl). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘ ·ÔÌÔÓÒıËÎ·Ó Î·È Ù· 4 ÛÙÂϤ¯Ë ÛÈÁΤÏÏ·˜ Ì ÙËÓ ·ÎfiÏÔ˘ıË Û˘¯ÓfiÙËÙ·: Shigella flexneri 67%, Shigella sonnei 13%, Shigella boydii 13% Î·È Shigella dysenteriae 7%. AÓıÂÎÙÈο ÛÙÂϤ¯Ë ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂÙ¿ ÙÔ 1994 Î·È ·ÊÔÚÔ‡Û·Ó ·ÔÎÏÂÈÛÙÈο ÙË Shigella flexneri: ·ÓÙÔ¯‹ ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË 63% Î·È ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË 25%. AÓıÂÎÙÈÎfiÙËÙ· ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Î·È ÙȘ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∏ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ ‹Ù·Ó ıÂÙÈ΋ ÌfiÓÔ Û ̛· ÂÚ›ÙˆÛË Ïԛ̈͢ ·fi Shigella flexneri. ∆¤ÏÔ˜, ηٿ ÙË ‰È·‰ÚÔÌ‹ Ù˘ ÓfiÛÔ˘, 2 ·ÛıÂÓ›˜ ËÏÈΛ·˜ 2 ÂÙÒÓ Î·È 6 ÂÙÒÓ ÂÌÊ¿ÓÈÛ·Ó Ô˘ÚÔÏԛ̈ÍË ·fi Escherichia coli Î·È Klebsiella oxytoca ·ÓÙ›ÛÙÔȯ·.

2. ∫ÚÔ‡ÛÌ·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜ ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂȉËÌÈ΋ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ, ·˘Ù‹ ÛËÌÂÈÒıËΠÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 1996 Û ̛· ΈÌfiÔÏË-ÚÔ¿ÛÙÈÔ Ù˘ fiÏ˘ ÙˆÓ πˆ·ÓÓ›ÓˆÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ¿ Ù˘ ÓfiÛËÛ·Ó 84 ·È‰È¿. ∏ ËÏÈΛ· ÙÔ˘˜ Î˘Ì¿ÓıËΠ·fi 1-14 ¤ÙË, Ì ̤ÛË ËÏÈΛ· Ù· 9 ¤ÙË. ∞fi Ù· 84 ·È‰È¿ Ô˘ ÓfiÛËÛ·Ó, ·Ó¿ÁÎË ÓÔÛËÏ›·˜ ›¯·Ó Ù· 26 (ÔÛÔÛÙfi 31%). ∏ ÂȉËÌÈ΋ ·˘Ù‹ Û˘ÛÛÒÚ¢ÛË ÎÚÔ˘ÛÌ¿ÙˆÓ ·Ô‰fiıËΠÛÙË ÌfiÏ˘ÓÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ‰ÈÎÙ‡Ô˘ ‡‰Ú¢Û˘ Ù˘ ÂÚÈÔ¯‹˜ ·fi χ̷ٷ. ∆Ô Û٤ϯԘ Ô˘ ·ÔÌÔÓÒıËΠ‹Ù·Ó Shigella sonnei ·ÓıÂÎÙÈ΋ Û ·ÌÈÎÈÏÏ›ÓË, ·ÌÔ͢ÎÈÏÏ›ÓË-ÎÏ·‚Ô˘Ï·ÓÈÎfi Ô͇, ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË Î·È ÙÂÙڷ΢ÎϛӘ, ÂÓÒ ‹Ù·Ó ¢·›ÛıËÙÔ Û ÎÂÊ·ÏÔÛÔÚ›Ó˜, ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜ Î·È ÎÈÓÔÏfiÓ˜. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÓÙÔÈṲ̂ÓË ÂȉËÌ›· ÓfiÛËÛ·Ó Î·È 76 ÂÓ‹ÏÈΘ, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÓÔÛËχÙËÎ·Ó ÔÈ 24, ÔÛÔÛÙfi 32%, ›‰ÈÔ Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÙˆÓ ·È‰ÈÒÓ (3).

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3. ∂ÈÏÔΤ˜ ∂ÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÌfiÓÔ ÛÙ· ·È‰È¿ Ì ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, ·fi Ù· 46 ·È‰È¿, Ù· 7 (15%) ÂÌÊ¿ÓÈÛ·Ó Û·ÛÌÔ‡˜ Ì ˘ÚÂÙfi, Ù· 2 (4%) ÂÈÎfiÓ· ‚·ÚÈ¿˜ ·Ê˘‰¿ÙˆÛ˘ Ì ·Ú·ÙÂٷ̤ÓË ÓfiÛËÛË Î·È 1 ı‹Ï˘ ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 7 ÌËÓÒÓ ·Ú·Ï˘ÙÈÎfi ÂÈÏÂfi Ì ‹È· ÛÏËÓÔÌÂÁ·Ï›· Î·È ÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÙÔÓ›·. ∏ ÙÈÌ‹ ÙÔ˘ Î·Ï›Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ (5,1 mEq/l) Î·È Ô ÂÈÏÂfi˜ ˘Ô¯ÒÚËÛ ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ (¶›Ó·Î·˜ 1). ∞fi Ù· 7 ·È‰È¿ (4 ·ÁfiÚÈ·, 3 ÎÔÚ›ÙÛÈ·) Ô˘ ÂÌÊ¿ÓÈÛ·Ó Û·ÛÌÔ‡˜, Ù· 3 ›¯·Ó ıÂÙÈÎfi ·ÙÔÌÈÎfi ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ Î·È 1 ›¯Â ˘ÔΛÌÂÓÔ Ó¢ÚÔÏÔÁÈÎfi ÓfiÛËÌ· (Û‡Ó‰ÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 6 Î·È ·˘ÙÈÛÌfi). ∞fi Ù· ˘fiÏÔÈ· 3, ÛÙÔ 1 Û˘Ó˘‹Ú¯Â ˘·Û‚ÂÛÙÈ·ÈÌ›· ηٿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Û·ÛÌÒÓ Î·È Û 1 ÏÂÈÔ·ÙÙˆÛË ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (15 ·ÙÙ·Ú·/mm3). OÈ Û·ÛÌÔ› ·Ú·ÙËÚ‹ıËÎ·Ó ÙȘ ÚÒÙ˜ 24 ÒÚ˜ Ù˘ ÓfiÛÔ˘, Ì ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· 38,5Ô40,0ÔC (̤ÛË 39,3ÔC), ‹Ù·Ó ÁÂÓÈÎÂ˘Ì¤ÓÔÈ ÙÔÓÈÎÔÎÏÔÓÈÎÔ›, Ì ‰È¿ÚÎÂÈ· Ï›ÁˆÓ ÏÂÙÒÓ. ∂Í·›ÚÂÛË ·ÔÙ¤ÏÂÛ·Ó 2 ·ÛıÂÓ›˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ Û·ÛÌÔ› ‰È‹ÚÎÂÛ·Ó ¿Óˆ ·fi 30 ÏÂÙ¿. ÀÔÙÚÔ‹ ·ÚÔ˘Û›·Û 1 ·È‰›, ÙÔ ÔÔ›Ô Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ›‰È·˜ ÓÔÛËÏ›·˜, ÂΉ‹ÏˆÛÂ Î·È ÂÛÙÈ·ÎÔ‡˜ Û·ÛÌÔ‡˜. ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤ÁÈÓ Û 3 ·ÛıÂÓ›˜ Î·È ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ™Â ηӤӷ ·È‰› ‰ÂÓ ··ÈÙ‹ıËΠ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹. ∫·È ÔÈ 7 ·ÛıÂÓ›˜ ·Ó‹Î·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÂÚÈÙÒÛÂˆÓ Ù˘ ÛÈÁΤÏψÛ˘. ŸÏÔÈ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÚfiÁÓˆÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ηٿ ̤ÛÔÓ fiÚÔ 10ÂÙÔ‡˜ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜, Ì ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË ÙÔ ·È‰› Ì ÙÔÓ ·˘ÙÈÛÌfi, Ô˘ Û˘Ó¤¯ÈÛ ӷ ÂÌÊ·Ó›˙ÂÈ Û‡ÓıÂÙ˜ ÂÛÙȷΤ˜ ÎÚ›ÛÂȘ Î·È ¤Ï·‚ ̷ÎÚÔ¯ÚÔÓ›ˆ˜ ‰ÈÏ‹ ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹. ™˘˙‹ÙËÛË ™ÙËÓ ÂÚÈÔ¯‹ Ì·˜, Ë ÛÈÁΤÏψÛË ÛÙ· ·È‰È¿ ÂÈ̤ÓÂÈ Ì ¯·ÌËÏ‹ Â›ÙˆÛË Î·È Ì ¤Í·ÚÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜ (80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·Ù¿ ÙÔ ‰È¿ÛÙËÌ· πÔ‡ÏÈÔ˜-OÎÙÒ‚ÚÈÔ˜). ∆Ô Û٤ϯԘ Ô˘ ÂÈÎÚ·Ù› Â›Ó·È Ë Shigella flexneri, Ë ÔÔ›· ¢ı‡ÓÂÙ·È ÁÈ· Ù· ‰‡Ô ÙÚ›Ù· ÙˆÓ ÛÔÚ·‰ÈÎÒÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘. ∆Ô ·ÔÙ¤ÏÂÛÌ· ·˘Ùfi Â›Ó·È ÛÂ Û˘Ìʈӛ· Ì ¤Ú¢ӷ Ô˘ ¤ÁÈÓ ÛÙË µfiÚÂÈÔ ∂ÏÏ¿‰· ηٿ ÙËÓ ›‰È· ÂÚ›Ô‰Ô Î·È ÛÙËÓ ÔÔ›· Ë Shigella flexneri ·ÔÌÔÓÒıËΠÛÙÔ 55% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (4). ∞ÓÙ›ıÂÙ·, ÙÔ Û٤ϯԘ Ô˘ ÂÈÎÚ·Ù› Û ¿ÏϘ ‰˘ÙÈΤ˜ ¯ÒÚ˜ Â›Ó·È Ë Shigella sonnei (1,5), ÂÓÒ ÛÙȘ ¯ÒÚ˜ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘ Â›Ó·È ·ÎfiÌË ˘„ËÏ‹ Ë Â›ÙˆÛË Ù˘ Shigella dysenteriae, ÙfiÛÔ Û ÛÔÚ·‰Èο ÎÚÔ‡ÛÌ·Ù· fiÛÔ

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¶›Ó·Î·˜ 1. ∂ΉËÏÒÛÂȘ Ù˘ ÛÈÁΤÏψÛ˘ Û 72 ·È‰È¿ ·fi ÙËÓ ◊ÂÈÚÔ Ô˘ ÓÔÛËχÙËÎ·Ó Î·Ù¿ ÙË ‰ÂηÂÓÙ·ÂÙ›· 1985-1999. ∂Ή‹ÏˆÛË

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71 72 28 7 2 1

98,6 100 39 9,7 2,8 1,4

Î·È Û ÂȉË̛˜ (6,7). ∏ ‰È·‰ÚÔÌ‹ Ù˘ ÛÈÁΤÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ηٿ ηÓfiÓ· ‹È·. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 72 ·È‰ÈÒÓ Ô˘ ÓÔÛËχıËηÓ, ÌfiÓÔ ‰‡Ô ‚Ú¤ÊË ËÏÈΛ·˜ <12 ÌËÓÒÓ ÂÌÊ¿ÓÈÛ·Ó ·Ú·ÙÂٷ̤ÓÔ ÂÌ‡ÚÂÙÔ Î·È ‰È¿ÚÚÔȘ Ì Â·ÎfiÏÔ˘ıË ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ ËÎÙÈÎfiÙËÙ·˜. ∏ ÙÂÏÈ΋ ¤Î‚·ÛË ‹Ù·Ó ¿ÚÈÛÙË Û fiÏ· Ù· ·È‰È¿. ∏ ÈÔ Û˘¯Ó‹ Â͈ÂÓÙÂÚÈ΋ ÂΉ‹ÏˆÛË ‹Ù·Ó ÔÈ Û·ÛÌÔ› (5,3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Î·È 9,7% ÙˆÓ ·È‰ÈÒÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ÓÔÛÔÎÔÌÂȷ΋ ·ÁˆÁ‹), ÔÛÔÛÙfi Û·ÊÒ˜ ÌÈÎÚfiÙÂÚÔ ·fi ·˘Ùfi Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ¿ÏϘ ÌÂϤÙ˜, fiÔ˘ Ù· ÔÛÔÛÙ¿ ·Ó¤Ú¯ÔÓÙ·È ¤ˆ˜ Î·È ¿Óˆ ·fi 45% (4,8,9). ŸÌˆ˜, Û ÌÂϤÙ˜ fiÔ˘ ·Ó·Ê¤ÚÂÙ·È ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· Û·ÛÌÒÓ Ê·›ÓÂÙ·È fiÙÈ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·È‰È¿ Ì Ôχ ÛÔ‚·Ú¤˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ (4,9), ÂÓÒ Û ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ú·ÙËÚÂ›Ù·È ·ÚfiÌÔÈ· Ì ÙË ‰È΋ Ì·˜, ¯·ÌËÏ‹ Û˘¯ÓfiÙËÙ· Û·ÛÌÒÓ, ÙfiÛÔ Û Â͈ÙÂÚÈÎÔ‡˜ fiÛÔ Î·È Û ÓÔÛËÏ¢fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ (5,7% Î·È 1,7% ·ÓÙ›ÛÙÔȯ·) (8). ¶Èı·ÓfiÓ Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ Û·ÛÌÒÓ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÓfiÛÔ˘ Î·È fi¯È ÛÙËÓ ÙÔÍ›ÓË Ù˘ ÛÈÁΤÏÏ·˜, ηıÒ˜ ˆ˜ ·ıÔÁÂÓÂÙÈο ·›ÙÈ· ıˆÚÔ‡ÓÙ·È Û‹ÌÂÚ· Ô ˘ÚÂÙfi˜ Î·È ÔÈ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ (8,10). ™Â ·˘Ùfi Û˘ÓËÁÔÚÔ‡Ó Î·È Ù· ‰Èο Ì·˜ ‰Â‰Ô̤ӷ, ηıÒ˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Û·ÛÌÔ› Û ηӤӷ ·fi Ù· 84 ·È‰È¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓÙÔÈṲ̂Ó˘ ÂȉËÌ›·˜, ÛÙ· ÔÔ›· ›¯Â ·Ú·Û¯Âı› Ôχ ¤ÁηÈÚ· È·ÙÚÈ΋ ÊÚÔÓÙ›‰·. ™Â ·È‰È¿ Ì Û·ÛÌÔ‡˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÛÈÁΤÏψÛ˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔÈ·˙fiÓÙˆÓ ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘˜ (11,12), ‡ÚËÌ· Û‡ÌʈÓÔ Î·È Ì ٷ ‰Èο Ì·˜ ‰Â‰Ô̤ӷ, ·ÊÔ‡ Ù· 3 ·fi Ù· 7 ·È‰È¿ Ì Û·ÛÌÔ‡˜ ›¯·Ó ıÂÙÈÎfi ·ÙÔÌÈÎfi ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ˘ÚÂÙÈÎÒÓ Û·ÛÌÒÓ. ∞fi Ù· Â˘Ú‹Ì·Ù¿ Ì·˜ ÚÔ·ÙÂÈ fiÙÈ ÔÈ Û·ÛÌÔ› ÛÙË ÛÈÁΤÏψÛË Â›Ó·È Ì¿ÏÏÔÓ Ì›· ·Û˘Ó‹ı˘ ÂÈÏÔ΋, ȉȷ›ÙÂÚ· fiÙ·Ó Ë ÓfiÛÔ˜ ·ÓÙÈÌÂÙˆÈÛÙ› ¤ÁηÈÚ·. ∫·Ù¿ ηÓfiÓ· ÚfiÎÂÈÙ·È ÁÈ· ηÏÔ‹ıÂȘ Û·ÛÌÔ‡˜, Ô˘ ‰ÂÓ ˘ÔÙÚÔÈ¿˙Ô˘Ó Î·È ¤¯Ô˘Ó ¿ÚÈÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÚfiÁÓˆÛË, ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈο ηٿÏÔÈ· (1,4,8,11).

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∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·Ú·ÎÔÏÔ‡ıËÛ˘, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÚfiÁÓˆÛË. ∏ Û‡Á¯ÚÔÓË Ù¿ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ó· ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙÈ‚ÈÔÙÈο Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ ‰È·ÈÛو̤Ó˘ ÛÈÁΤÏψÛ˘, ηıÒ˜ ·ÊÂÓfi˜ ÌÂÓ ÌÂÈÒÓÂÙ·È Ë ‰È¿ÚÎÂÈ· Ù˘ ‰È¿ÚÚÔÈ·˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÂÍ·Ï›ÊÂÙ·È Ù·¯‡ÙÂÚ· Ë ÛÈÁΤÏÏ· ·fi Ù· ÎfiÚ·Ó· Î·È ÌÂÈÒÓÂÙ·È Ë ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Ù˘ ÓfiÛÔ˘ (5). ∞·ÈÙÂ›Ù·È ‚‚·›ˆ˜ ‡ÏÔÁË ¯Ú‹ÛË ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. °È· ÙËÓ ÙÂÏÈ΋ ·fiÊ·ÛË ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ Ú¤ÂÈ ÂÈÈϤÔÓ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·È ÔÈ Û˘Óı‹Î˜ οı ¯ÒÚ·˜. ™ÙË ÌÂϤÙË Ì·˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÔÛÔÛÙ¿ ·ÓıÂÎÙÈÎfiÙËÙ·˜ ·Ó¿ÏÔÁ· Ì ·˘Ù¿ ¿ÏÏˆÓ Â˘Úˆ·˚ÎÒÓ ¯ˆÚÒÓ Î·È Û·ÊÒ˜ ¯·ÌËÏfiÙÂÚ· ·fi Ù· ·ÓÙ›ÛÙÔȯ· ÙˆÓ ¯ˆÚÒÓ ÙÔ˘ ÙÚ›ÙÔ˘ ÎfiÛÌÔ˘, fiÔ˘ Ë ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË ·ÁÁ›˙ÂÈ ÙÔ 97% Î·È ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË ÙÔ 93% (6,13). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ÂÌÊ·Ó›˙ÂÈ Î·È Ë ÁÂÈÙÔÓÈ΋ ¯ÒÚ· Ù˘ ∞Ï‚·Ó›·˜, Ì ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙËÓ ·ÌÈÎÈÏÏ›ÓË 87% Î·È ÛÙËÓ TMP-SMZ 48,5% (14). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ, ·Ú¿ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘, Ô Î›Ó‰˘ÓÔ˜ ÂÓÙÔÈÛÌ¤ÓˆÓ ÂȉËÌÈÒÓ Â›Ó·È ¿ÓÙ· ˘·ÚÎÙfi˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·fiÙÔÌË ¤Í·ÚÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜, ÙfiÛÔ Û ·È‰È¿ fiÛÔ Î·È Û ÂÓ‹ÏÈΘ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ·È‰È¿ Ù˘ ∏›ÚÔ˘, Ë ÛÈÁΤÏψÛË ÂÌÊ·Ó›˙ÂÙ·È Ì ÛÔÚ·‰Èο Û˘Ó‹ıˆ˜ ÎÚÔ‡ÛÌ·Ù·. ªÂ ÙËÓ ¤ÁηÈÚË ÂÓ˘‰¿ÙˆÛË, Ë ¤Î‚·ÛË Â›Ó·È ¿ÚÈÛÙË. °È· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ȉȷ›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ Ë ˘ÁÈÂÈÓ‹ ÙˆÓ ÎÂÓÙÚÈÎÒÓ ‰ÈÎÙ‡ˆÓ ‡‰Ú¢Û˘, ηıÒ˜ Î·È ÔÈ ·˘ÛÙËÚÔ› ηÓfiÓ˜ ·ÙÔÌÈ΋˜ ˘ÁÈÂÈÓ‹˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Gomez HF, Cleary TG. Shigella. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 4th ed.

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ORIGINAL ARTICLE

™˘ÌÂÚÈÊÔÚ¿, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹, ÙËÏÂı¤·ÛË Î·È ·È¯Ó›‰È Ì·ıËÙÒÓ ÛÙÔȯÂÈÒ‰Ô˘˜ ÂÎ·›‰Â˘Û˘ ÛÙËÓ ∫Ú‹ÙË ∫. ∞Ó˘Ê·ÓÙ¿Î˘1, ª. ∞Ó˘Ê·ÓÙ¿ÎË1, ∂. •˘ÏÔ‡ÚË 1, ∂. ™·Îο1, Ã. §ÈÔÓ‹˜2, ¡. ∞ÓÙˆÓ¿Î˘1,2

Nutritional habits, TV viewing, body health care and playing behavior of elementary school students in Crete, Greece K. Anyphantakis1, M. Anyphantaki1, I. Xylouri1, I. Sakka1, C. Lionis2, N. Antonakis1,2

¶ÂÚ›ÏË„Ë: ¢ÈÂÚ¢ÓÒÓÙ·È Ù˘¯fiÓ ‰È·ÊÔÚ¤˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È·ÙÚÔÊ‹, ÙÔ ·È¯Ó›‰È, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ Î·È ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ ÌÂٷ͇ Ì·ıËÙÒÓ ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ∫Ú‹Ù˘ Î·È Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ÂÓÙÔÈÛÙÔ‡Ó Ï¿ıË Î·È Ó· ÚÔÙ·ıÔ‡Ó Ï‡ÛÂȘ. ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 284 ·È‰È¿, 6 ‰ËÌÔÙÈÎÒÓ Û¯ÔÏ›ˆÓ Ù˘ ∫Ú‹Ù˘. ∆· 4 ‚Ú›ÛÎÔÓÙ·Ó ÛÙËÓ ‡·ÈıÚÔ, ÂÓÒ Ù· 2 Û ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ∏ ÏËÚÔÊÔÚ›· Û˘ÏϤ¯ıËΠ̠ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ Û˘ÌÏËÚˆÓfiÙ·Ó ÛÙÔ Û¯ÔÏ›Ô, ·ÚÔ˘Û›· ‰·ÛÎ¿ÏˆÓ Î·È ÂÚ¢ÓËÙÒÓ. ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÎfiÎÎÈÓÔ Î·È ¿ÛÚÔ ÎÚ¤·˜ (p<0,02), ÂÓÒ Ë Î·Ù·Ó¿ÏˆÛË Ù˘ÔÔÈËÌ¤ÓˆÓ ÙÚÔÊÒÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚË Û ·È‰È¿ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (p<0,001). ∆· ·È‰È¿ Ù˘ ˘·›ıÚÔ˘ ›¯·Ó Û˘¯ÓfiÙÂÚ· ÙÂÚˉÔÓÈṲ̂ӷ ‰fiÓÙÈ· (p<0,0005). ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤‚ÏÂ·Ó ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË (p<0,03), ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÙËÓ ÒÚ· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË (p<0,0005). ∆· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤·È˙·Ó Û˘¯ÓfiÙÂÚ· ̤۷ ÛÙÔ Û›ÙÈ (p<0,0001), ÂÚ·ÙÔ‡Û·Ó ÏÈÁfiÙÂÚÔ (p<0,001) Î·È ¤·È˙·Ó Û˘¯ÓfiÙÂÚ· ηıÈÛÙÈο ·È¯Ó›‰È· (p<0,0001). ∏ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ·È¯ÓȉÈÔ‡ Î·È ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘. ∫·Ù·ÁÚ¿ÊËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË, Ô˘ Èı·ÓfiÓ ÔÊ›ÏÔÓÙ·Ó ÛÙÔÓ ÙÚfiÔ ˙ˆ‹˜ Ô˘ ‰È·Ê¤ÚÂÈ ÌÂٷ͇ ˘·›ıÚÔ˘ Î·È fiÏ˘, ·ÏÏ¿ Î·È ÛÙȘ ÔÏÂÔ‰ÔÌÈΤ˜ Û˘Óı‹Î˜ Ù˘ fiÏ˘. ∆· ·È‰È¿ ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi Ù· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· Î·È ÛÙÚ¤ÊÔÓÙ·È ÛÙËÓ

Abstract: The behavior of elementary school students associated with nutrition, TV viewing, playing and body health care, was investigated in a rural and an urban area of Crete, Greece. This study attempts to examine wrong behaviors and to suggest possible solutions. A questionnaire was used to register these behaviors in 6 elementary schools (2 in urban and 4 in rural areas). The questionnaires were completed with the assistance of the teachers and the investigators.

284 children (142 males, 142 females) comprised the population of the study. Children from rural areas, as compared to children from urban areas, were eating more red and white meat (p<0.02), while children from urban areas were eating larger amounts of conserved foods (p<0.001). Children from rural areas demonstrated more dental caries (p<0.0005), and were spending more time watching TV (p<0.03), Children from urban areas most often consumed food while watching TV (p<0.0005). Children from urban areas were spending more time playing in the house (p<0.0001), walked less (p<0.001) and often played table games (p<0.0001). The age and the gender were correlated with playing behavior and exercise. The differences observed between rural and urban areas were possibly the result of the different life style especially in the urban areas which tend to be overcrowded. In the urban areas the children cannot play traditional games outside the home and therefore they spend more time playing in the house. Better health education, housing improvement in the cities and development

1 ∫¤ÓÙÚÔ ÀÁ›·˜ ∞ÓˆÁ›ˆÓ, ∫Ú‹ÙË 2 ∫ÏÈÓÈ΋ ∫ÔÈÓˆÓÈ΋˜ Î·È OÈÎÔÁÂÓÂȷ΋˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘

1 Anogia Health Center, Crete 2 Clinic of Social and Family Medicine of University of Crete

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Paediatriki 2002;65:186-194

ÙËÏÂfiÚ·ÛË Î·È ÛÙ· ηıÈÛÙÈο ·È¯Ó›‰È·. ∏ ·ÁˆÁ‹ ˘Á›·˜, Ë ‚ÂÏÙ›ˆÛË Ù˘ ¯ˆÚÔÙ·Í›·˜ ÙˆÓ fiÏÂˆÓ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÚfiÏ˄˘ ÛÙËÓ ‡·ÈıÚÔ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ‰ÈÂÚÂ˘Ó‹Û·ÌÂ.

of prevention programs in the rural areas are possible solutions for these problems.

§¤ÍÂȘ ÎÏÂȉȿ: ‰È·ÙÚÔÊ‹, ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹, ÙËÏÂfiÚ·ÛË, ·È¯Ó›‰È, ۈ̷ÙÈ΋ ˘ÁÈÂÈÓ‹.

Key words: nutrition, TV viewing, playing, body health care, rural areas.

™˘ÓÙÔÌÔÁڷʛ˜

Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿ ¤¯ÂÈ Â›Û˘ Û˘Û¯ÂÙÈÛÙ› Ì η΋ ·fi‰ÔÛË ÛÙÔ Û¯ÔÏÂ›Ô (20), ‚›·ÈË Û˘ÌÂÚÈÊÔÚ¿ (17,21), Ì›ˆÛË ÙˆÓ Â˘Î·ÈÚÈÒÓ ÁÈ· Û˘˙‹ÙËÛË Ì ٷ ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (22) Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ (23). ∆Ô ·È¯Ó›‰È Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ Î·È ÓÂ˘Ì·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Î·È ıˆÚÂ›Ù·È Ì¤ÛÔ ÎÔÈÓˆÓÈÎÔÔ›ËÛ˘, ·ÁˆÁ‹˜ Î·È Ì¿ıËÛ˘ (24). ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ô ÙÚfiÔ˜ Ô˘ ·›˙Ô˘Ó Ù· ·È‰È¿ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ Î·È Ù· ËÏÂÎÙÚÔÓÈο ·È¯Ó›‰È· ¤¯Ô˘Ó ÂÈÛ‚¿ÏÂÈ ÛÙ· Û›ÙÈ· Î·È ··Û¯ÔÏÔ‡Ó ÔÏϤ˜ ÒÚ˜ Ù· ·È‰È¿ (4). ∆· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· ·ÓÔÈÎÙÔ‡ ¯ÒÚÔ˘ ‰ÂÓ Â›Ó·È Û‹ÌÂÚ· ÛÙȘ ÚÒÙ˜ ÚÔÙÈÌ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ·˘Ù¿ Ó· ÎÈÓÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ (4). ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ·ÎfiÌË ·Ú¿ÌÂÙÚÔ Ô˘ Û˘Ó‰¤ÂÙ·È Î·È Ì ÙËÓ ·¯˘Û·ÚΛ· Î·È Ì ÙËÓ Î·Î‹ ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘ Î·È ¤¯ÂÈ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ. º·›ÓÂÙ·È, ÏÔÈfiÓ, fiÙÈ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·¯˘Û·ÚΛ·˜, η΋˜ ¯Ú‹Û˘ Ù˘ ÙËÏÂfiÚ·Û˘ Î·È ·ÏÏ·Á‹˜ ÛÙ· ·È¯Ó›‰È· Ô˘ ·›˙Ô˘Ó Ù· ·È‰È¿ Û‹ÌÂÚ·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ‰ÈÂÚ¢ӋÛÂÈ ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ Ì·ıËÙÒÓ ‚·ÛÈ΋˜ ÂÎ·›‰Â˘Û˘, ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ, Û ۯ¤ÛË Ì ÙË ‰È·ÙÚÔÊ‹, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙÔ ·È¯Ó›‰È Î·È ÙË ÊÚÔÓÙ›‰· Ù˘ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, Ó· ÂÓÙÔ›ÛÂÈ Ù˘¯fiÓ Ï·Óı·Ṳ̂Ó˜ Û˘ÌÂÚÈÊÔÚ¤˜ Î·È Ó· ÚÔÙ›ÓÂÈ Ï‡ÛÂȘ.

∏.¶.∞.

MS SPSS TV SD p df

∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ ∞ÌÂÚÈ΋˜ Microsoft Statistical Package for Social Sciences Television Standard Deviation ™˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜

∂ÈÛ·ÁˆÁ‹ ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙȘ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ Û˘Ó‹ıÂȘ, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ·ÏÏ¿ Î·È ÙÔ ·È¯Ó›‰È ÂËÚ¿˙ÂÈ ¿ÌÂÛ· Î·È Ì·ÎÚÔÚfiıÂÛÌ· ÙË ÛˆÌ·ÙÈ΋ Î·È ÙËÓ „˘¯È΋ ÙÔ˘˜ ˘Á›· (1-4). OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚԷӷʤÚıËÎ·Ó Û¯ÂÙ›˙ÔÓÙ·È ÌÂٷ͇ ÙÔ˘˜ (2) Î·È Û‹ÌÂÚ· ÂÈÎÚ·Ù› Ë ·ÓÙ›ÏË„Ë fiÙÈ Ë ÚfiÏË„Ë Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·fi Ôχ ÌÈÎÚ‹ ËÏÈΛ· (5), ÂÓÒ ÂÎ·È‰Â˘ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (6). ™‹ÌÂÚ·, Ë ·¯˘Û·ÚΛ· ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈÎfiÙ·ÙË ¯ÚfiÓÈ· ÓfiÛÔ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ë ·‡ÍËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ·ÚÔÌÔÈ¿˙ÂÙ·È Ì ÙËÓ ·Ê‡ÓÈÛË ÎÔÈÌÒÌÂÓÔ˘ Á›Á·ÓÙ· (1,7). ∏ Û˘Û¯¤ÙÈÛË Ù˘ ·¯˘Û·ÚΛ·˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ì ÙË ÌÂÏÏÔÓÙÈ΋ ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ·fi ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· ¤¯ÂÈ ÙÔÓÈÛÙ› ·fi ÔÏÏÔ‡˜ Û˘ÁÁÚ·Ê›˜ (8,9). ∂›Û˘, Ë ·¯˘Û·ÚΛ· ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÔÏϤ˜ ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ Ë ˘¤ÚÙ·ÛË, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ë ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Î·È ÔÈ Î·ÎÒÛÂȘ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (9-13).

OÈ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ·¯˘Û·ÚΛ·˜, fiˆ˜ Ë ÌÂȈ̤ÓË ·˘ÙÔÂÎÙ›ÌËÛË, Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó Â›Û˘ ÙÔÓÈÛÙ› (14). ∏ ÙËÏÂfiÚ·ÛË ·Ó·ÌÊÈÛ‚‹ÙËÙ· ¤¯ÂÈ ÂÈÛ‚¿ÏÂÈ ‰˘Ó·ÌÈο ÛÙË ˙ˆ‹ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ·È‰ÈÒÓ (15,16) Î·È ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ù· ·È‰È¿ ÛÙȘ ∏.¶.∞. ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÙfiÛ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË fiÛ˜ Î·È Ì¿ıËÌ· ÛÙÔ Û¯ÔÏÂ›Ô (17). ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ıÂÙÈο Ì ÙËÓ ·¯˘Û·ÚΛ·, ·ÊÂÓfi˜ ÌÂÓ ÁÈ·Ù› ÌÂÈÒÓÂÙ·È Ë Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡ Î·È ·ÊÂÙ¤ÚÔ˘ ÁÈ·Ù› Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ÙÚÒÓ ¤ÙÔÈ̘ (Û˘Û΢·Ṳ̂Ó˜) ÙÚÔʤ˜ fiÙ·Ó ·Ú·ÎÔÏÔ˘ıÔ‡Ó ÙËÏÂfiÚ·ÛË (2,18,19). ∏ ˘ÂÚ‚ÔÏÈ΋ Î·È ¯ˆÚ›˜ ÂÈÏÔÁ‹ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·-

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó fiÏ· Ù· ·È‰È¿ ÙˆÓ ÙÂÛÛ¿ÚˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ Ù¿ÍÂˆÓ ÙÔ˘ ‰ËÌÔÙÈÎÔ‡, Û ¤ÍÈ ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ∫Ú‹Ù˘. ∆· Ù¤ÛÛÂÚ· ‰ËÌÔÙÈο Û¯ÔÏ›· (∞ÍÔ‡, µÂÓ›Ô˘, ∑ˆÓÈ·ÓÒÓ, ∞ÓˆÁ›ˆÓ) ‚Ú›ÛÎÔÓÙ·È Û ÔÚÂÈÓ‹ ·ÁÚÔÙÔÎÙËÓÔÙÚÔÊÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ÓÔÌÔ‡ ƒÂı‡ÌÓ˘. ∆· ˘fiÏÔÈ· ‰‡Ô ‚Ú›ÛÎÔÓÙ·È Û ˘ÎÓÔηÙÔÈÎË̤Ó˜ ÂÚÈÔ¯¤˜ Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ (13Ô Î·È 42Ô ‰ËÌÔÙÈο Û¯ÔÏ›· ∏Ú·ÎÏ›Ԣ). ∆· ·È‰È¿ Û˘ÌÏ‹ÚˆÛ·Ó ·ÓÒÓ˘ÌÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ¯ˆÚÈ˙fiÙ·Ó Û ¤ÓÙ ÂÓfiÙËÙ˜: ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙÔ˘ ·È‰ÈÔ‡, Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜, Û˘Ó‹ıÂȘ Û¯ÂÙÈΤ˜ Ì ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹, Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ Î·È Ì ÙÔ ·È¯Ó›‰È. OÈ ÂÚˆÙ‹ÛÂȘ ‹Ù·Ó ·Ϥ˜ Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ÔÏÏ·Ï‹˜ ÂÈÏÔÁ‹˜. ∏ Û˘ÌÏ‹ÚˆÛË ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ ¤ÁÈÓ ηٿ ÙÔ˘˜ Ì‹Ó˜ ™Â٤̂ÚÈÔ Î·È OÎÙÒ‚ÚÈÔ ÙÔ˘ ¤ÙÔ˘˜ 2000, ·ÚÔ˘Û›· ÙˆÓ ÂÚ¢ÓËÙÒÓ Î·È ÙˆÓ ‰·ÛοψÓ, ̤۷ ÛÙËÓ Ù¿ÍË. ¶ÚÈÓ ·fi ÙË

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¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Paediatriki 2002;65:186-194

Û˘ÌÏ‹ÚˆÛË ÙˆÓ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ, Ô ÂÚ¢ÓËÙ‹˜ ÂÍËÁÔ‡Û ÛÙ· ·È‰È¿ ÙÔ ÛÎÔfi Î·È ÙÔÓ ÙÚfiÔ Û˘ÌÏ‹ÚˆÛ˘ ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ Î·È Ù· ηıÔ‰ËÁÔ‡Û Ì ÛÙÂÚÂfiÙ˘˜ Ô‰ËÁ›Â˜ ÛÙË Û˘ÌÏ‹ÚˆÛ‹ ÙÔ˘. ∆· ‰Â‰Ô̤ӷ Ô˘ Û˘ÁÎÂÓÙÚÒıËÎ·Ó Î·Ù·¯ˆÚ‹ıËÎ·Ó Û ËÏÂÎÙÚÔÓÈ΋ ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ηٷÛ΢¿ÛÙËΠÁÈ· ÙȘ ·Ó¿ÁΘ Ù˘ ÌÂϤÙ˘ Î·È Ë ÂÂÍÂÚÁ·Û›· ¤ÁÈÓ Ì ÙË ‚Ô‹ıÂÈ· ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ù· ÚÔÁÚ¿ÌÌ·Ù· MS Access 2000, MS Excel 2000 Î·È SPSS 10.1. OÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‹Ù·Ó ÙÔ t test ÁÈ· ÙË Û‡ÁÎÚÈÛË Ì¤ÛˆÓ ÙÈÌÒÓ, ÙÔ ¯2 test ÁÈ· ÙË Û‡ÁÎÚÈÛË ÔÛÔÛÙÒÓ, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ·Ú·ÌÂÙÚÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ÌË ·Ú·ÌÂÙÚÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ Î·È Ë Logistic Regression ·Ó¿Ï˘ÛË ÁÈ· Û˘Û¯ÂÙ›ÛÂȘ ÛÙȘ Ôԛ˜ ÂÌϤÎÔÓÙ·Ó ‰ÈˆÓ˘ÌÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜.

∞ÔÙÂϤÛÌ·Ù· O Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Ï·‚·Ó ̤ÚÔ˜ ÛÙË ÌÂϤÙË ‹Ù·Ó 284 (142 ·ÁfiÚÈ· Î·È 142 ÎÔÚ›ÙÛÈ·). ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Ô˘ Û˘ÌÏËÚÒıËÎ·Ó ‹Ù·Ó Â›Û˘ 284, ÂÓÒ ˘‹Ú¯·Ó 8 Û˘ÓÔÏÈο ·Ó·¿ÓÙËÙ˜ ÂÚˆÙ‹ÛÂȘ Û 8 ‰È·ÊÔÚÂÙÈο ÂÚˆÙËÌ·ÙÔÏfiÁÈ· (ÔÛÔÛÙfi ·Ó·¿ÓÙËÙˆÓ ÂÚˆÙ‹ÛÂˆÓ 0,07%). ∞fi Ù· 284 ·È‰È¿, Ù· 133 (70 ·ÁfiÚÈ·, 63 ÎÔÚ›ÙÛÈ·) ÚÔ¤Ú¯ÔÓÙ·Ó ·fi Ù· Ù¤ÛÛÂÚ· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ˘·›ıÚÔ˘ Î·È Ù· ˘fiÏÔÈ· 151 (72 ·ÁfiÚÈ·, 79 ÎÔÚ›ÙÛÈ·) ·fi Ù· ‰‡Ô ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ. ∏ ηٷÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ËÏÈΛ· Î·È Ê‡ÏÔ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜: ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (n=151, ÔÛÔÛÙfi 51,2%) ·¿ÓÙËÛ·Ó fiÙÈ ¤ÙÚˆÁ·Ó 5 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, 88 ·È‰È¿ (31%) ¤ÙÚˆÁ·Ó 4 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ, 43 (15,1%) 3 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ Î·È ÌfiÓÔ 2 ·È‰È¿ (0,7%) 2 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ. ¢ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ··ÓÙ‹ÛÂˆÓ ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ Î·È ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ ÁÂ˘Ì¿ÙˆÓ ·Ó¿ Ë̤ڷ (t value=1,93, df=282, p>0,05). ™ÙÔÓ ¶›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ··ÓÙ‹ÛÂˆÓ ÛÙȘ ÂÚˆÙ‹ÛÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ·È‰ÈÒÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (59,6%) ·¿ÓÙËÛ·Ó fiÙÈ ¤ÙÚˆÁ·Ó ÁÈ· ÚˆÈÓfi ¤ÙÔȶ›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ηٿ ËÏÈΛ· Î·È Ê‡ÏÔ

8 ÂÙÒÓ (3Ë Ù¿ÍË) 9 ÂÙÒÓ (4Ë Ù¿ÍË) 10 ÂÙÒÓ (5Ë Ù¿ÍË) 11 ÂÙÒÓ (6Ë Ù¿ÍË) ™‡ÓÔÏÔ

188

∞ÁfiÚÈ

∫ÔÚ›ÙÛÈ

™‡ÓÔÏÔ

23 41 33 45 142

38 38 31 35 142

61 79 64 80 284

Ì· Ù˘ÔÔÈË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ÂÓÒ Ù¤ÙÔÈ· ÙÚfiÊÈÌ· ¤ÙÚˆÁ·Ó Ôχ Ï›Á· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (3,8%). ∏ ‰È·ÊÔÚ¿ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∞Ó¿ÏÔÁ· ·ÔÙÂϤÛÌ·Ù· ¤‰ˆÛÂ Î·È Ë ·Ó¿Ï˘ÛË ÙˆÓ ··ÓÙ‹ÛÂˆÓ Û¯ÂÙÈο Ì ÙÔ ·ÔÁÂ˘Ì·ÙÈÓfi Ê·ÁËÙfi. ∆Ô 34,5% ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤ÙÚˆÁ·Ó ÁÈ· ÚˆÈÓfi Ù˘ÔÔÈË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ¤ÙÚˆÁ ÙÔÓ ›‰ÈÔ Ù‡Ô ÙÚÔÊ›ÌˆÓ Î·È ÙÔ ·fiÁÂ˘Ì·. ∂›Û˘, Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ú¤ıËΠfiÙÈ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÎfiÎÎÈÓÔ, ·ÏÏ¿ Î·È ¿ÛÚÔ, ÎÚ¤·˜ Û ۯ¤ÛË Ì ٷ ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). µÚ¤ıËÎÂ, Ù¤ÏÔ˜, fiÙÈ ˘‹Ú¯Â ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ ÙˆÓ ·È‰ÈÒÓ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ Ì ÙËÓ ÔÔ›· ¤ÙÚˆÁ·Ó ¯fiÚÙ· (Rs=0,240, p<0,001). ™ˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹: OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ ‰ÔÓÙÈÒÓ ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. ∆Ô 10,5% ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ‰ÂÓ ‚Ô‡ÚÙÛÈ˙ ηıfiÏÔ˘ Ù· ‰fiÓÙÈ· ÙÔ˘, ¤Ó·ÓÙÈ ÙÔ˘ 1,3% ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿). ∂›Û˘, ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ô‡ÚÙÛÈ˙·Ó Û˘¯ÓfiÙÂÚ· Ù· ‰fiÓÙÈ· ÙÔ˘˜ Î·È Â›¯·Ó ÏÈÁfiÙÂÚ· ¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ›¯Â ÛÊÚ·Á›ÛÌ·Ù· ‰ÂÓ ‰È¤ÊÂÚ ÛÙȘ ‰‡Ô ÂÚÈÔ¯¤˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙËÓ Î·ı·ÚÈfiÙËÙ· ÙÔ˘ ÛÒÌ·ÙÔ˜ (¶›Ó·Î·˜ 4), Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ϤÓÔÓÙ·Ó Û˘¯ÓfiÙÂÚ·, ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÂÚÈÔÈÔ‡ÓÙ·Ó Û˘¯ÓfiÙÂÚ· Ù· Ó‡¯È· ÙÔ˘˜. ŸÏ˜ ÔÈ ·Ú·¿Óˆ ‰È·ÊÔÚ¤˜ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. ¶·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘: ™ÙÔÓ ¶›Ó·Î· 5 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘. ∆· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË ÙȘ ηıËÌÂÚÈÓ¤˜ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿), ÂÓÒ Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó Û˘¯ÓfiÙÂÚ· ÙËÓ ÒÚ· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË Î·È Ì¿ÏÈÛÙ· ¤ÙÚˆÁ·Ó Ù˘ÔÔÈË̤ӷ - Û˘ÓÙËÚË̤ӷ ÙÚfiÊÈÌ· ÙÔ˘ ÂÌÔÚ›Ô˘, ·ÏÏ¿ Î·È Ì·ÁÂÈÚÂ̤ÓÔ ÛÙÔ Û›ÙÈ Ê·ÁËÙfi (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). ∆Ô 80,1% ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ ÂÓÒ ¤‚ÏÂ ÙËÏÂfiÚ·ÛË. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Û¯ÂÙÈο Ì ÙËÓ ÒÚ· Ô˘ ÛÙ·Ì·ÙÔ‡Û·Ó Ó· ‚ϤÔ˘Ó ÙËÏÂfiÚ·ÛË ÙÔ ‚Ú¿‰˘ Î·È Û¯ÂÙÈο Ì ÙÔ ÔÈÔ˜ Â¤ÏÂÁ ٷ ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ·È‰È¿. ™Â ÔÛÔÛÙfi 38% Ù· ·È‰È¿ ·ÔÊ¿ÛÈ˙·Ó ÌfiÓ· ÙÔ˘˜ ÁÈ· ÙÔ ÚfiÁÚ·ÌÌ· Ô˘ ı· ·Ú·ÎÔÏÔ˘ı‹ÛÔ˘Ó Î·È Û ÔÛÔÛÙfi 27,5% ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ÚÔ‚¿ÏÏÔÓÙ·Ó ÌÂÙ¿ ÙȘ 9:00 ÌÌ.

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·189

¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Paediatriki 2002;65:186-194

¶›Ó·Î·˜ 2. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ÂÚˆÙ‹ÛÂȘ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜. ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙÚˆ˜ οı Ë̤ڷ; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ÎfiÎÎÈÓÔ ÎÚ¤·˜; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ¿ÛÚÔ ÎÚ¤·˜; (fi¯È „¿ÚÈ) ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ ¯fiÚÙ·; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙÚˆ˜ „¿ÚÈ;

ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p

4,46 ± 0,7

4,28 ± 0,8

1,93

282

ª™**

2,27 ± 1,5

1,81 ± 1,6

2,42

282

<0,02

1,83 ± 1,2

1,45 ± 1

2,72

282

<0,01

4,16 ± 2,4

4,59 ± 2,6

-1,46

282

ª™

1,63 ± 1,2

1,87 ± 1,3

-1,54

282

ª™

∂ÚÒÙËÛË

ñ ∆È ÙÚˆ˜ ÙÔ Úˆ›; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÛÙÔ Û¯ÔÏ›Ô; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ÌÂÛË̤ÚÈ; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ·fiÁÂ˘Ì·; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ∆È ÙÚˆ˜ ÙÔ ‚Ú¿‰˘; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·;

£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test

n1

%

n2

%

¯2

5 111 17

3,76 83,46 12,78

90 37 23

59,60 24,50 15,23

96,39 96,15 0,18

1 <0,0001 1 <0,0001 1 ª™

43 85 5

32,33 63,91 3,76

50 92 9

33,11 60,93 5,96

0,00 1,15 0,32

1 1 1

ª™ ª™ ª™

1 129 2

0,75 96,99 1,50

2 147 1

1,32 97,35 0,66

1,01 0,03 0,01

1 1 1

ª™ ª™ ª™

27 67 38

20,30 50,38 28,57

58 36 56

38,41 23,84 37,09

10,21 20,41 1,94

1 <0,002 1 <0,0005 1 ª™

2 119 11

1,50 89,47 8,27

12 122 16

7,95 80,79 10,60

4,97 3,49 0,21

1 1 1

df

p

<0,05 ª™ ª™

* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

¶›Ó·Î·˜ 3. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ Î·Ù¿ÛÙ·ÛË Î·È ÙËÓ ˘ÁÈÂÈÓ‹ ÙˆÓ ‰ÔÓÙÈÒÓ ÙÔ˘˜

∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‚Ô˘ÚÙÛ›˙ÂȘ Ù· ‰fiÓÙÈ· ÛÔ˘; ∂ÚÒÙËÛË

ñ Œ¯ÂȘ ¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·; ñ Œ¯ÂȘ ÛÊÚ·Á›ÛÌ·Ù·; ñ µÔ˘ÚÙÛ›˙ÂȘ Ù· ‰fiÓÙÈ· ÛÔ˘;

ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜ 2,17 ± 1,1

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df** p

2,64 ± 1,3

-3,26

£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜ n1 75 54 119

% 56,39 40,60 89,47

n2 39 64 149

% 25,83 42,38 98,68

282

<0,001

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test ¯2 26,22 0,03 9,61

df* 1 1 1

p <0,0005 ª™** <0,005

* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

189

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·190

¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Paediatriki 2002;65:186-194

¶›Ó·Î·˜ 4. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· οÓÂȘ ÔÏfiÛˆÌÔ Ì¿ÓÈÔ; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÏÔ‡˙ÂȘ ÙÔ ÎÂÊ¿ÏÈ ÛÔ˘; ñ ¶fiÛ˜ ÊÔÚ¤˜ ÙÔ Ì‹Ó· Îfi‚ÂȘ Ù· Ó‡¯È· ÛÔ˘;

ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

t-value

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË df*

p

2,86 ± 1,5

3,38 ± 2,3

-4,14

282

<0,0001

2,59 ± 1,7

3,24 ± 2,7

-2,40

282

<0,02

6,43 ± 3,7

5,1 ± 3,2

3,29

282

<0,001

* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ¶›Ó·Î·˜ 5. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙË ¯Ú‹ÛË Ù˘ ÙËÏÂfiÚ·Û˘

∂ÚÒÙËÛË ñ ¶fiÛ˜ ÒÚ˜ ÙËÓ Ë̤ڷ ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ∂ÚÒÙËÛË

ñ ∆È ÙÚˆ˜ fiÙ·Ó ‚ϤÂȘ ÙËÏÂfiÚ·ÛË; º·ÁËÙfi Û ۷ÎÔ˘Ï¿ÎÈ; ª·ÁÂÈÚÂ̤ÓÔ Ê·ÁËÙfi; ∆›ÔÙ·; ñ ¶ÔÈÔ˜ ÂÈϤÁÂÈ Ù· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ ‚ϤÂȘ ÛÙËÓ ÙËÏÂfiÚ·ÛË; ∂Û‡; OÈ ÁÔÓ›˜ ÛÔ˘; ∂Û‡ Î·È ÔÈ ÁÔÓ›˜ ÛÔ˘;

ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p

2,48 ± 1,7 3,89 ± 2,4

2,04 ± 1,6 3,57 ± 2,4

2,23 1,13

282 282

<0,03 ª™**

17,95 ± 6,0 17,99 ± 6,0

17,77 ± 6,0 17,73 ± 5,1

0,25 0,39

282 280

ª™ ª™

£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test

n1

%

n2

%

¯2

df

p

23 36 74

17,29 27,07 55,64

43 78 34

28,48 51,66 22,52

4,36 16,78 31,57

1 1 1

<0,05 <0,0005 <0,0005

50 23 60

37,59 17,29 45,11

57 27 68

37,75 17,88 45,03

0,00 0,00 0,01

1 1 1

ª™ ª™ ª™

* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

¶·È¯Ó›‰È: ∞fi ÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û¯ÂÙÈο Ì ÙÔ ·È¯Ó›‰È (¶›Ó·Î·˜ 6) ‚Ú¤ıËΠfiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ Ô˘ ‰È¤ıÂÙ·Ó Ù· ·È‰È¿ ÛÙȘ ·ÛÙÈΤ˜ Î·È ÛÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ÁÈ· ·È¯Ó›‰È, ‚Ú¤ıËÎ·Ó fï˜ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙÔ Ò˜ ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó ÙÔ ¯ÚfiÓÔ ·˘Ùfi. ∂ÎÙfi˜ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6, ‚Ú¤ıËÎ·Ó ıÂÙÈΤ˜ Î·È ·ÚÓËÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ù˘ ËÏÈΛ·˜ Î·È ÙÔ˘ ʇÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ·È¯Ó›‰È, ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘ (¶›Ó·Î·˜ 7). ¶·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘, ·ÏÏ¿ Î·È ÙÔ˘ ·È¯ÓȉÈÔ‡ ¤Íˆ ·fi ÙÔ Û›ÙÈ, Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜. ∆· ·ÁfiÚÈ· ‰··ÓÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ·fi Ù· ÎÔÚ›ÙÛÈ· ÁÈ· ·È¯Ó›‰È Î·È Ô ÂÈϤÔÓ ·˘Ùfi˜ ¯ÚfiÓÔ˜

190

·ÊÈÂÚˆÓfiÙ·Ó Û ·È¯Ó›‰È· ¤Íˆ ·fi ÙÔ Û›ÙÈ. ∆· ·È‰È¿ Ô˘ ‰‹ÏˆÛ·Ó fiÙÈ ¤·È˙·Ó ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ (n=216) ¤‚ÏÂ·Ó ÏÈÁfiÙÂÚ˜ ÒÚ˜ ÙËÏÂfiÚ·ÛË Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ¤·È˙·Ó ηıÈÛÙÈο ·È¯Ó›‰È· (n=68) ÙȘ ηıËÌÂÚÈÓ¤˜ (t value=2,89, df=282, p<0,005), ·ÏÏ¿ Î·È Ù· ™·‚‚·ÙÔ·Úȷη (t value=3,33, df=282, p<0,001). ™˘˙‹ÙËÛË OÈ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿ÊËÎ·Ó ÛÙȘ Û˘Ó‹ıÂȘ ÙˆÓ ·È‰ÈÒÓ ·ÁÚÔÙÈÎÒÓ Î·È ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ÛÙË ÌÂϤÙË ·˘Ù‹ ‹Ù·Ó ÔÏϤ˜ Î·È ÂÓÙ˘ˆÛȷΤ˜. ∞Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Ë ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ô˘ ÂÈϤͷÌ ·¤¯ÂÈ ÂÚ›Ô˘ 40 ¯ÈÏÈfiÌÂÙÚ· ·fi ÙËÓ fiÏË ÙÔ˘ ∏Ú·ÎÏ›Ԣ Î·È 50 ¯ÈÏÈfiÌÂÙÚ· ·fi ÙËÓ fiÏË ÙÔ˘ ƒÂı‡ÌÓÔ˘. À¿Ú¯ÂÈ Û˘ÁÎÔÈÓˆÓ›· Ì ÙȘ fiÏÂȘ ·˘Ù¤˜ ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ Î·È ÔÈ Â-

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·191

¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Paediatriki 2002;65:186-194

¶›Ó·Î·˜ 6. OÈ ··ÓÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ∂ÚÒÙËÛË ñ ¶fiÛ˜ ÒÚ˜ ÂÚ›Ô˘ ·›˙ÂȘ οı ̤ڷ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛ˜ ÒÚ˜ ·›˙ÂȘ ̤۷ ÛÙÔ Û›ÙÈ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛ˜ ÒÚ˜ ·›˙ÂȘ ¤Íˆ ·fi ÙÔ Û›ÙÈ; ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ñ ¶fiÛË ÒÚ˜ ÂÚ·Ù¿˜ ÙËÓ Ë̤ڷ (Û ÏÂÙ¿); ∆Ș ηıËÌÂÚÈÓ¤˜; ∆· ™·‚‚·ÙÔ·Úȷη; ∂ÚÒÙËÛË

ñ ∆È Â›‰Ô˘˜ ·È¯Ó›‰È· ·›˙ÂȘ; ∫·ıÈÛÙÈο ·È¯Ó›‰È· ¶·È¯Ó›‰È· Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ÙÚ¤ÍÂȘ

ª¤ÛË ÙÈÌ‹ ± 1SD ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË t-value df* p

3,24 ± 1,9 5,26 ± 2,6

3,1 ± 1,9 5,46 ± 2,9

0,583 -0,59

282 282

ª™** ª™

1,07 ± 0,8 1,83 ± 1,4

1,53 ± 1,3 2,70 ± 2,1

-3,63 -4,03

281 281

<0,0001 <0,0001

2,18 ± 1,5 3,47 ± 1,9

1,57 ± 1,3 2,82 ± 2,0

3,68 2,51

281 282

<0,0001 <0,02

62,62 ± 57,2 87,91 ± 93,6

41,63 ± 51,2 50,83 ± 65,2

3,24 3,90

281 280

<0,001 <0,0001

£ÂÙÈΤ˜ ··ÓÙ‹ÛÂȘ ∞ÁÚÔÙÈΤ˜ ∞ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ÂÚÈÔ¯¤˜

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯2 test

n1

%

n2

%

¯2

df**

p

28 103

21,05 77,44

113 113

74,83 74,83

79,68 0,14

1 1

<0,0001 ª™

* µ·ıÌÔ› ÂÏ¢ıÂÚ›·˜ ** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

ÚÈÛÛfiÙÂÚÔÈ Î¿ÙÔÈÎÔÈ ¤¯Ô˘Ó ȉȈÙÈ΋˜ ¯Ú‹Û˘ ·˘ÙÔΛÓËÙÔ. ∏ ËÏÂÎÙÚÔ‰fiÙËÛË ÙˆÓ ¯ˆÚÈÒÓ Ù˘ ÂÚÈÔ¯‹˜ Ô˘ ÂÈϤͷÌ ¤¯ÂÈ Á›ÓÂÈ ÚÈÓ ÙÔ 1970 Î·È Û¯Â‰fiÓ fiÏ· Ù· Û›ÙÈ· ‰È·ı¤ÙÔ˘Ó „ËÊȷΤ˜ ÙËÏÂʈÓÈΤ˜ ÁÚ·Ì̤˜. OÈ ÂÚÈÔ¯¤˜ Ù˘ fiÏ˘ ÙÔ˘ ∏Ú·ÎÏ›Ԣ Ô˘ ÂÈϤͷÌÂ Â›Ó·È ˘ÎÓÔηÙÔÈÎË̤Ó˜, Ì ΢ÎÏÔÊÔÚÈ·Îfi Úfi‚ÏËÌ·, ¯ˆÚ›˜ ÔÏÏÔ‡˜ ·ÓÔÈÎÙÔ‡˜ ¯ÒÚÔ˘˜ Î·È Ì ·ÚÎÂÙ¿ ÔÈÎÔ‰ÔÌ‹Ì·Ù· ¯ˆÚ›˜ ÓfiÌÈÌË ¿‰ÂÈ·. ∏ Û˘Û¯¤ÙÈÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ì ÙËÓ ÏÔ‡ÛÈ· Û ˙ˆÈο Ï›Ë ‰È·ÙÚÔÊ‹ (13) ¤¯ÂÈ ·Ó·ÁοÛÂÈ ÙÔ˘˜ ÁÔÓ›˜ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¿ÊıÔÓ· Ê˘ÙÈο ÙÚfiÊÈÌ· ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜, ÁÂÁÔÓfi˜ Ô˘ οÔȘ ÊÔÚ¤˜ ÊÙ¿ÓÂÈ ÛÙËÓ ˘ÂÚ‚ÔÏ‹ Î·È ‰ËÌÈÔ˘ÚÁ› ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ (25,26). ™ÙË ÌÂϤÙË Ì·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¤ÙÚˆÁ·Ó ηٿ ̤ÛÔÓ fiÚÔ 1,8 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È 4,6 ÊÔÚ¤˜ ¯fiÚÙ· (¶›Ó·Î·˜ 2). ™ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, Ë ‰È·ÊÔÚ¿ ·˘Ù‹ ‹Ù·Ó ÌÈÎÚfiÙÂÚË (2,3 ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È 4,2 ¯fiÚÙ·). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ú¿ÁÌ·ÙÈ ˘¿Ú¯ÂÈ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ÁÔÓ¤ˆÓ ÛÙÔ ı¤Ì· Ù˘ ‰È·ÙÚÔÊ‹˜ Ì ÎÚ¤·˜, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÎfiÌË Û˘ÓÔÏÈο Ë ‰È·ÙÚÔÊ‹ Ì ˙ˆÈο ÙÚfiÊÈÌ· (ÎfiÎÎÈÓÔ ÎÚ¤·˜, ¿ÛÚÔ ÎÚ¤·˜, „¿ÚÈ) Â›Ó·È Û˘¯ÓfiÙÂÚË ·˘Ù‹˜

ÌÂ Ê˘ÙÈο (¶›Ó·Î·˜ 2). ™ÙË ÌÂϤÙË Ì·˜, Â›Û˘, ‰È·ÈÛÙÒÛ·Ì fiÙÈ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ÙÔ˘ ·È‰ÈÔ‡ ÌÂȈÓfiÙ·Ó Ë Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ¤ÙÚˆÁ·Ó ¯fiÚÙ· (ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË) Î·È ·˘Ùfi ›Ûˆ˜ ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÙÚÔÊÒÓ ·fi Ù· ›‰È· Ù· ·È‰È¿ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ Î·È ÛÙËÓ Î·Î‹ ‰È··È‰·ÁÒÁËÛË ÙˆÓ ·È‰ÈÒÓ. ∆Ô Â‡ÚËÌ· fiÙÈ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Ù· ·È‰È¿ ¤ÙÚˆÁ·Ó ηٿ ̤ÛÔ fiÚÔ 2,5 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ¯fiÚÙ· ·fi fiÙÈ ÎfiÎÎÈÓÔ ÎÚ¤·˜ (¶›Ó·Î·˜ 2), ‰Â›¯ÓÂÈ fiÙÈ Èı·ÓfiÓ Î¿ÔȘ ÔÈÎÔÁ¤ÓÂȘ ÂÚÈfiÚÈ˙·Ó ˘ÂÚ‚ÔÏÈο ÙËÓ ÔÛfiÙËÙ· ˙ˆÈÎÒÓ ÙÚÔÊÒÓ ·fi ÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ (12 ·È‰È¿ ‰ÂÓ ¤ÙÚˆÁ·Ó ηıfiÏÔ˘ ÎfiÎÎÈÓÔ ÎÚ¤·˜, ÂÓÒ ‰‡Ô ·fi ·˘Ù¿ ‰ÂÓ ¤ÙÚˆÁ·Ó Ô‡Ù ¿ÛÚÔ ÎÚ¤·˜). ¶ÈÛÙ‡ԢÌ ÏÔÈfiÓ, fiÙÈ Û‹ÌÂÚ·, Ë ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Ú¤ÂÈ Ó· Â›Ó·È Î·È ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË ÙÔ˘ ÂÚÈÔÚÈÛÌÔ‡ ÙˆÓ ˙ˆÈÎÒÓ ÙÚÔÊÒÓ, ·ÏÏ¿ Î·È ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ Â·ÚÎÔ‡˜ ÚfiÛÏ˄˘ ÙˆÓ ··Ú·›ÙËÙˆÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ô˘ÛÈÒÓ, ÛÙËÓ ÔÔ›· Ù· ˙ˆÈο ÙÚfiÊÈÌ· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ (25,26). ∏ ηٷӿψÛË ¤ÙÔÈÌˆÓ Ù˘ÔÔÈËÌ¤ÓˆÓ ÙÚÔÊÒÓ ÙÔ˘ ÂÌÔÚ›Ô˘ (snacks) ‚Ú¤ıËΠӷ Â›Ó·È Û˘¯Ó‹, ΢ڛˆ˜ ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (¶›Ó·Î·˜ 2). ∆· ÙÚfiÊÈÌ· ·˘Ù¿ Â›Ó·È Â‡Á¢ÛÙ· ηÈ

191

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·192

¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Û˘¯Ó¿ ˆÏÔ‡ÓÙ·È Ì ÌÈÎÚ¿ “‰ÒÚ·” ̤۷ ÛÙË Û˘Û΢·Û›·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ù· ˙ËÙÔ‡Ó Â›ÌÔÓ· Ù· ·È‰È¿, ÂÓÒ ÁÈ· ÙÔ˘˜ ÁÔÓ›˜ ·ÔÙÂÏÔ‡Ó Â‡ÎÔÏË Ï‡ÛË. ∏ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙˆÓ ÙÚÔÊÒÓ ·˘ÙÒÓ Û ˙ˆÈο Ï›Ë Î·È Ë ·fi‰ÔÛ‹ ÙÔ˘˜ Û ıÂÚÌ›‰Â˜ Â›Ó·È ÌÂÁ¿ÏË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÚÔηÏÔ‡Ó ·¯˘Û·ÚΛ· Î·È Ó· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘, ÂÓÒ ¤¯Ô˘Ó ηÙËÁÔÚËı› fiÙÈ ÚÔηÏÔ‡Ó Ï‹ıÔ˜ ¿ÏÏˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ (1). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Â›¯·Ó ÛˆÛÙfiÙÂÚ˜ Û˘Ó‹ıÂȘ (¶›Ó·Î·˜ 2). ∏ ÙÂÏÂ˘Ù·›· ·˘Ù‹ ‰È·ÊÔÚ¿ Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Î·Ù·Ó·ÏÒÓÔ˘Ó, ÛÙ· ÌÂÛԉȷÛÙ‹Ì·Ù· ÙˆÓ Î‡ÚÈˆÓ ÁÂ˘Ì¿ÙˆÓ, ÙÚfiÊÈÌ· Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙȘ ·ÁÚÔÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘˜ Î·È ¤ÙÛÈ ·ÔʇÁÔ˘Ó Ù· ¤ÙÔÈÌ· ÙÚfiÊÈÌ·. ∆Ô ı¤Ì· ·˘Ùfi ··ÈÙ› ÂÚÈÛÛfiÙÂÚË ‰ÈÂÚ‡ÓËÛË. ∆Ô Â‡ÚËÌ· fiÙÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Î·È ÛÙȘ ·ÁÚÔÙÈΤ˜ Î·È ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ÙÚÒÓ ÚˆÈÓfi (¶›Ó·Î·˜ 2) ÛËÌ·›ÓÂÈ fiÙÈ ÔÈ ÁÔÓ›˜, ·ÏÏ¿ Î·È Ù· ›‰È· Ù· ·È‰È¿, Ú¤ÂÈ Ó· ÂÓËÌÂÚˆıÔ‡Ó ÁÈ· ÙË ÛËÌ·Û›· Ù˘ Ï‹„˘ ÚˆÈÓÔ‡. ¶¿ÓÙˆ˜, ·Ó¿ÏÔÁ· ÔÛÔÛÙ¿ ·Ú¿ÏÂȄ˘ ÙÔ˘ ÚˆÈÓÔ‡ Ê·ÁËÙÔ‡ ·Ó·Ê¤ÚÔÓÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ ·fi ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ (27). ∆Ô ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó¤ÊÂÚ·Ó Ô‰ÔÓÙÈ·ÙÚÈο ÚÔ‚Ï‹Ì·Ù· ÛÙȘ ‰‡Ô ÂÚÈÔ¯¤˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ÂÚ›Ô˘ ÙÔ ›‰ÈÔ Î·È ÂÚ›Ô˘ ›ÛÔ Ì ·˘Ùfi Ô˘ ·Ó·Ê¤ÚÂÙ·È Û ¿ÏϘ ÌÂϤÙ˜ (28-29). OÈ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿„·Ì ۯÂÙÈο Ì ÙË ÛÙÔÌ·ÙÈ΋ ˘Á›· ÙˆÓ Ì·ıËÙÒÓ ‹Ù·Ó ÛËÌ·ÓÙÈΤ˜ (¶›Ó·Î·˜ 3). ∆Ô ÔÛÔÛÙfi ÙˆÓ Ì·ıËÙÒÓ Ô˘ ·Ó¤ÊÂÚ·Ó fiÙÈ Â›¯·Ó “¯·Ï·Ṳ̂ӷ ‰fiÓÙÈ·”, ‰ËÏ·‰‹ ‰fiÓÙÈ· Ô˘ ›¯·Ó ÌË ıÂÚ·Â˘Ì¤ÓË ÙÂÚˉfiÓ·, ‹Ù·Ó ˘ÂÚ‰ÈÏ¿ÛÈÔ ÛÙȘ ·ÁÚÔÙÈΤ˜ ·fi fiÙÈ ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. ∂›Û˘, ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‚Ô‡ÚÙÛÈ˙ ٷ ‰fiÓÙÈ· ÙÔ˘, Û ۯ¤ÛË Ì ٷ ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ, ·ÏÏ¿ Î·È Ù· ‚Ô‡ÚÙÛÈ˙·Ó ÏÈÁfiÙÂÚ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ (ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÌÔÚ› Ó· ·Ô‰ÔıÔ‡Ó ÛÙÔ ¯·ÌËÏfiÙÂÚÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ (28), ·ÏÏ¿ Î·È ÛÙË ‰˘ÛÎÔÏfiÙÂÚË ÚfiÛ‚·Û‹ ÙÔ˘˜ Û ԉÔÓÙÈ·ÙÚÈΤ˜ ˘ËÚÂۛ˜. ™ÙËÓ ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹ Ô˘ ÌÂÏÂÙ‹Û·Ì ‰ÂÓ ˘¿Ú¯ÂÈ Ô‰ÔÓÙ›·ÙÚÔ˜ Î·È ¤ÙÛÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ˘ËÚÂۛ˜ Ô‰ÔÓÙÈ·ÙÚÈ΋˜ ÚfiÏ˄˘, ·ÁˆÁ‹˜ ˘Á›·˜ Î·È ıÂÚ·›·˜. ¶·Ú¿ ÙȘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Ô˘ ηٷÁÚ¿ÊËÎ·Ó Û¯ÂÙÈο Ì ÙËÓ ·ÙÔÌÈ΋ ˘ÁÈÂÈÓ‹ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ˘fi ÌÂϤÙË ÂÚÈÔ¯¤˜ (¶›Ó·Î·˜ 4), Ë ÂÓ·Û¯fiÏËÛ‹ ÙÔ˘˜ Ì ÙËÓ Î·ı·ÚÈfiÙËÙ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÎÚ›ÓÂÙ·È ÈηÓÔÔÈËÙÈ΋ Î·È ÁÈ· ÙȘ ‰‡Ô ÂÚÈÔ¯¤˜. ™ÙÔÓ ÙÔ̤· ·˘Ùfi, Ë ·ÁˆÁ‹ ˘Á›·˜ ı· ›¯Â Ï›-

192

Paediatriki 2002;65:186-194

Á· Ó· ÚÔÛʤÚÂÈ, ÙÔ˘Ï¿¯ÈÛÙÔÓ ˆ˜ ÚÔ˜ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÚˆÙ‹ıËÎ·Ó Ù· ·È‰È¿. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÙËÏÂfiÚ·Û˘, Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÏÈÁfiÙÂÚ˜ ÒÚ˜ ÙËÓ Â‚‰ÔÌ¿‰· ÙËÏÂfiÚ·ÛË ·fi fiÙÈ Û ·ÓÙ›ÛÙÔÈ¯Ë ÌÂϤÙË ÙˆÓ ∏.¶.∞. (17). ™ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜, Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚË ÒÚ· ÙËÏÂfiÚ·ÛË, Û ۯ¤ÛË Ì ÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ ÙȘ ηıËÌÂÚÈÓ¤˜ (¶›Ó·Î·˜ 5), Û ·ÓÙ›ıÂÛË Ì ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙËÓ πÛ·Ó›· (30), fiÔ˘ Ù· ·È‰È¿ ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ‰··ÓÔ‡Û·Ó ÏÈÁfiÙÂÚË ÒÚ· ÛÙËÓ ÙËÏÂfiÚ·ÛË ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ. ∆Ô Â‡ÚËÌ· fiÙÈ Û¯Â‰fiÓ ÙÔ 38% ÙˆÓ ·È‰ÈÒÓ ‚ϤÂÈ ·ÓÂͤÏÂÁÎÙ· fi,ÙÈ ÚfiÁÚ·ÌÌ· ı¤ÏÂÈ Î·È ÙÔ Â‡ÚËÌ· fiÙÈ ÔÏÏ¿ ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó Ù· ÚfiÁÚ·ÌÌ·Ù· Ô˘ ÚÔ‚¿ÏÏÔÓÙ·Ó ÌÂÙ¿ ÙȘ 9:00 ÌÌ, ˘Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ ÂÏÏÈ‹ ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ Û ı¤Ì·Ù· ÛˆÛÙ‹˜ ı¤·Û˘ Ù˘ ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿. ∞Ó¿ÏÔÁÔ Úfi‚ÏËÌ· ÂÓÙÔ›ÛÙËÎÂ Î·È ÛÙË ÌÂϤÙË Ô˘ ÚԷӷʤڷÌ (30). ∏ ηٷӿψÛË Û˘ÓÙËÚËÌ¤ÓˆÓ ÙÚÔÊ›ÌˆÓ ÙÔ˘ ÂÌÔÚ›Ô˘, ·ÏÏ¿ Î·È Ê·ÁËÙÔ‡ Ô˘ ·Ú·Û΢·˙fiÙ·Ó ÛÙÔ Û›ÙÈ, ηٿ ÙËÓ ÒÚ· Ô˘ Ù· ·È‰È¿ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙȘ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ (¶›Ó·Î·˜ 5). ∞˘Ùfi ·ÔÙÂÏ› ÌÈ· ·ÎfiÌË ÂÈ‚Ï·‚‹ Û˘Ó‹ıÂÈ· ÁÈ· ÙËÓ ˘Á›·, ·ÊÔ‡ ıˆÚÂ›Ù·È ·fi ÔÏÏÔ‡˜ Û˘ÁÁÚ·Ê›˜ Û·Ó Ì›· ·fi ÙȘ ·Èٛ˜ Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ (2,30). ∏ ÙÚÔÊ‹ Ô˘ ηٷӷÏÒÓÂÙ·È Î·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ Û˘Ó‹ıˆ˜ Ï·Ì‚¿ÓÂÙ·È ÂÈϤÔÓ ·fi ·˘Ù‹ Ô˘ Ú·ÁÌ·ÙÈο ¯ÚÂÈ¿˙ÂÙ·È ÙÔ ·È‰› (30). OÈ ·Èٛ˜ Ù˘ Û˘¯ÓfiÙÂÚ˘ ηٷӿψÛ˘ ÙÚÔÊ‹˜ ηٿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘ ·fi Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÈϤÔÓ ‰ÈÂÚ‡ÓËÛË. ™Â ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó Ù¤ÙÔȘ ‰È·ÊÔÚ¤˜ (30).

OÈ ıÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ˆÚÒÓ Ô˘ ‚ϤÔ˘Ó ÙËÏÂfiÚ·ÛË (¶›Ó·Î·˜ 7) ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ·Ó·ÌÂÓfiÌÂÓ˜ (·˘ÙÔÓfiÌËÛË ÙÔ˘ ·È‰ÈÔ‡), ·Ó Î·È ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì· (23). ∞ÓÙÈı¤Ùˆ˜, ¤¯ÂÈ Î·Ù·ÁÚ·Ê› ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ˆ˜ ÚÔ˜ ÙÔ ¯ÚfiÓÔ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Û·Ó ÙËÏÂfiÚ·ÛË (23), ÂÓÒ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‰È·ÈÛÙÒıËΠ٤ÙÔÈ· ‰È·ÊÔÚ¿. ∆· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ¯ÚfiÓÔ˜ Ô˘ ‰È¤ıÂÙ·Ó Ù· ·È‰È¿ ÁÈ· ·È¯Ó›‰È ÛÙȘ ·ÛÙÈΤ˜ Î·È ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ‹Ù·Ó Ô ›‰ÈÔ˜ (¶›Ó·Î·˜ 6). ∞˘Ùfi Èı·Ófiٷٷ ÔÊÂÈÏfiÙ·Ó ÛÙ· ÂÓÈ·›· ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÙˆÓ ·È‰ÈÒÓ Û fiϘ ÙȘ ÂÚÈÔ¯¤˜ Ù˘ ∂ÏÏ¿‰·˜, Ô˘ ·ÔÚÚÔÊÔ‡Û·Ó ›‰ÈÔ

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·193

¶·È‰È·ÙÚÈ΋ 2002;65:186-194

Paediatriki 2002;65:186-194

¶›Ó·Î·˜ 7. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ Ù˘ ËÏÈΛ·˜ Î·È ÙÔ˘ ʇÏÔ˘ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ Û˘ÓËıÂÈÒÓ Û¯ÂÙÈο Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙÔ ·È¯Ó›‰È Î·È ÙË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ™˘Û¯ÂÙ›ÛÂȘ ∏ÏÈΛ· / flÚ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / flÚ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙËÏÂfiÚ·Û˘ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂÈ ÙËÏÂfiÚ·ÛË ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ª¤¯ÚÈ ÔÈ· ÒÚ· ‚ϤÂÈ ÙËÏÂfiÚ·ÛË Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ¶fiÛË ÒÚ· ÂÚ·Ù¿ οı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜* ∏ÏÈΛ· / ¶fiÛË ÒÚ· ÂÚ·Ù¿ οı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη* ∏ÏÈΛ· / ∞Ó ·›˙ÂÈ Î·ıÈÛÙÈο ·È¯Ó›‰È·** ∏ÏÈΛ· / ∞Ó ·›˙ÂÈ ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Î¿ı Ë̤ڷ Ù· ™·‚‚·ÙÔ·Úȷη** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ ÙȘ ηıËÌÂÚÈÓ¤˜** º‡ÏÔ / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ ¤Íˆ ·fi ÙÔ Û›ÙÈ Ù· ™·‚‚·ÙÔ·Úȷη** ¶fiÛ˜ ÒÚ˜ ÂÚ·Ù¿ (ηı.) / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ (ηı.)*** ¶fiÛ˜ ÒÚ˜ ÂÚ·Ù¿ (™∫) / ¶fiÛ˜ ÒÚ˜ ·›˙ÂÈ Ì¤Û· ÛÙÔ Û›ÙÈ (™∫)***

™˘ÓÙÂÏÂÛÙ‹˜ Rs = 0,153 Rs = -0,036 Rs = 0,077 Rs = 0,172 Rs = 0,076 Rs = 0,073 Rs = -0,59 Rs = -0,64 Rs = 0,190 Rs = 0,209 Rs = 0,340 Rs = 0,394 B = -0,595 B = 0,285 µ = 0,197 µ = 0,155 µ = -0,108 µ = -0,032 µ = 0,438 µ = 0,408 Rp = -0,165 Rp = -0,202

p <0,01 ª™**** ª™ <0,005 ª™ ª™ ª™ ª™ <0,001 <0,0001 <0,0001 <0,0001 <0,0001 <0,03 <0,005 <0,001 ª™ ª™ <0,0001 <0,0001 <0,01 <0,001

* YÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman (Rs) ** Logistic Regression *** YÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson (Rp) **** ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿

¯ÚfiÓÔ ·fi ÙËÓ Ë̤ڷ ÙˆÓ ·È‰ÈÒÓ. ∏ ¤ÏÏÂÈ„Ë fï˜ ˘·›ıÚÈˆÓ ¯ÒÚˆÓ Î·È ÔÈ Î›Ó‰˘ÓÔÈ Ô˘ ˘¿Ú¯Ô˘Ó ¤Íˆ ·fi ÙÔ Û›ÙÈ ÁÈ· Ù· ·È‰È¿ Ù˘ fiÏ˘, ·Ó¿Áη˙·Ó Ù· ·È‰È¿ ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ÌÂϤÙ˘ Ì·˜ Ó· ·›˙Ô˘Ó Ì¤Û· ÛÙÔ Û›ÙÈ, Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·fi Ù· ·È‰È¿ ÙˆÓ ¯ˆÚÈÒÓ (¶›Ó·Î·˜ 6). ∞˘Ùfi Ù· ÛÙÚ¤ÊÂÈ ÂÚÈÛÛfiÙÂÚÔ ÛÙ· ηıÈÛÙÈο ·È¯Ó›‰È· Î·È Î˘Ú›ˆ˜ ÛÙ· Û‡Á¯ÚÔÓ· ËÏÂÎÙÚÔÓÈο ·È¯Ó›‰È· (video-games Î·È ·È¯Ó›‰È· ËÏÂÎÙÚÔÓÈÎÒÓ ˘ÔÏÔÁÈÛÙÒÓ) Ô˘ ÔÏϤ˜ ÊÔÚ¤˜ (fi¯È fï˜ ¿ÓÙ·) ¤¯Ô˘Ó ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÁÈ· ÙËÓ ˘Á›· ÙÔ˘˜ (4,31-33). ∆· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ¤·È˙·Ó ÂÚÈÛÛfiÙÂÚÔ Û ·ÓÔÈÎÙÔ‡˜ ¯ÒÚÔ˘˜ Î·È Ù· ·ÁfiÚÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi Ù· ÎÔÚ›ÙÛÈ· (¶›Ó·Î·˜ 7). ∆Ô ·È¯Ó›‰È Û ·ÓÔȯÙÔ‡˜ ¯ÒÚÔ˘˜ ʤÚÓÂÈ Ù· ·È‰È¿ ÎÔÓÙ¿ ÛÙ· ·Ú·‰ÔÛȷο ·È¯Ó›‰È· Ô˘ ··ÈÙÔ‡Ó ÙÚ¤ÍÈÌÔ Î·È ¤ÓÙÔÓË Ì˘˚΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (4). ∆· ·È¯Ó›‰È· ·˘Ù¿ ÂÌÔ‰›˙Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ·¯˘Û·ÚΛ·˜ Î·È ·Ó·Ù‡ÛÛÔ˘Ó ÙÔ Ó‡̷ Û˘ÓÂÚÁ·Û›·˜ Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÔÌ¿‰ˆÓ (24). ∆· ÛÙÔȯ›· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ·ÁÚÔÙÈÎÒÓ Î·È ÙˆÓ ·ÛÙÈÎÒÓ ÂÚÈÔ¯ÒÓ Ù˘ ÌÂϤÙ˘, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È·ÙÚÔÊ‹, ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙËÏÂfiÚ·Û˘, ÙË ÛˆÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹ Î·È ÙÔ ·È¯Ó›‰È, ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο. ∆Ô Â›Â‰Ô Ù˘ ˘ÁÈÂÈÓ‹˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ (΢ڛˆ˜ Ù˘ ˘ÁÈÂÈÓ‹˜ ÙˆÓ ‰ÔÓÙÈÒÓ) ‹Ù·Ó ˘„ËÏfiÙÂÚÔ ÛÙȘ fiÏÂȘ, ·ÏÏ¿ Ë ‰È·ÙÚÔÊ‹ Î·È Ë

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞ÓÙˆÓ¿Î˘ ¡›ÎÔ˜ ™ÂÚÚÒÓ 3, ∆.∫. 713 07, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ E-mail: antonakisnikos@yahoo.gr

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CASE REPORT

À‰Ú·ÓÂÁÎÂÊ·Ï›· Û ÓÂÔÁ¤ÓÓËÙÔ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ °. ª·ÚÔ‡Ù˘1, π. ∫·Ï¤ÁÈ·˜1, ∫. ∫·ÎÔ˘ÏÏ‹˜2, π. ¶·˘Ï›‰Ë˜2, ∞. °Ô˘ÏÈ¿ÌÔ˜3

Hydranencephaly in a neonate. A case report G. Baroutis1, J. Kaleyias1, C. Kacoulis2, I. Paulidis2, A. Gouliamos3

¶ÂÚ›ÏË„Ë: ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È Ì›· Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤ÏÏÂÈ„Ë ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Î·È ·ÓÙÈηٿÛÙ·Û‹ ÙÔ˘˜ ·fi ·ÛÙÂȘ Ï‹ÚÂȘ Ì ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi. ∆Ô ÓÂÔÁÓfi Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ÌÔÚ› Ó· Ê·›ÓÂÙ·È Ê˘ÛÈÔÏÔÁÈÎfi Î·È Ë ‰È¿ÁÓˆÛË Ó· ÌË Á›ÓÂÈ ·ÓÙÈÏËÙ‹ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜. ∏ ÙÂÏÈ΋ ¤Î‚·ÛË Â›Ó·È ‰˘ÛÌÂÓ‹˜ Î·È Ô ı¿Ó·ÙÔ˜ Â¤Ú¯ÂÙ·È Î·Ù¿ ηÓfiÓ· ÚÈÓ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ˙ˆ‹˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Ô˘ ‰È·ÁÓÒÛÙËΠÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘.

Abstract: Hydranencephaly is a rare central nervous system malformation in which the brain’s cerebral hemispheres are absent and replaced by sacs with cerebrospinal fluid. An infant with hydranencephaly may appear normal at birth.

Diagnosis may be delayed for several months because early behavior appears to be relatively normal. The outlook for children with hydranencephaly is poor. Death generally occurs before the age of one year. This is a case report of an infant with hydranencephaly who was diagnosed on the first day of life using ultrasound of the brain.

§¤ÍÂȘ ÎÏÂȉȿ: ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ÓÂÔÁ¤ÓÓËÙÔ.

Key words: hydranencephaly, neonate.

∂ÈÛ·ÁˆÁ‹ OÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (∫¡™) ÂÌÊ·Ó›˙ÔÓÙ·È Û ÔÛÔÛÙfi 0,2% ÙˆÓ ÁÂÓÓËı¤ÓÙˆÓ ˙ˆÓÙ·ÓÒÓ ÓÂÔÁÓÒÓ. ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ∫¡™. O Tang (1) ÌÂϤÙËÛ ·Ó·‰ÚÔÌÈο ÙȘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ∫¡™ ÁÈ· Ì›· ‰ÂηÂÙ›· Î·È ‰È·›ÛÙˆÛ 79 ÂÚÈÛÙ·ÙÈο Â› Û˘ÓfiÏÔ˘ 59392 ÓÂÔÁÓÒÓ (0,13%). À‰Ú·ÓÂÁÎÂÊ·Ï›· ›¯·Ó Ù· 4 ·fi Ù· 79 ÓÂÔÁÓ¿, ‰ËÏ·‰‹ ÌfiÏȘ ÙÔ 5% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ∫¡™. ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ï‹ÚË ¤ÏÏÂÈ„Ë Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ Ô˘Û›·˜ Î·È ·ÓÙÈηٿÛÙ·Û‹ Ù˘ ·fi Ú¢ÛÙ‹ Ô˘Û›· ‹ ˘ÁÚfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤ÎÙ·ÛË Ù˘ ‚Ï¿‚˘ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ, ·˘Ù‹ ÌÔÚ› Ó· Â›Ó·È Ï‹Ú˘ ‹ ÌÂÚÈ΋, ¯ˆÚ›˜ Û˘Ó‹ıˆ˜ Ó· ÂËÚ¿˙ÔÓÙ·È ÙÔ Û٤ϯԘ ÙÔ˘

ÂÁÎÂÊ¿ÏÔ˘ Î·È Ô ÚÔÌ‚ÔÂȉ‹˜ ÂÁΤʷÏÔ˜ (2). ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ì ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Ô˘ ‰È·ÈÛÙÒıËΠÙËÓ ÚÒÙË Ë̤ڷ ˙ˆ‹˜ ˘ÂÚ˯ÔÙÔÌÔÁÚ·ÊÈο, ÏfiÁˆ Û¯ÂÙÈο ÌÂÁ¿Ï˘ ÂÚÈ̤ÙÚÔ˘ ÎÂÊ·Ï‹˜.

1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶.°.¡.∞. “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 2 ∞’ ª·È¢ÙÈ΋-°˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¶.°.¡.∞. “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 3 ∆Ì‹Ì· ∞ÍÔÓÈ΋˜ Î·È ª·ÁÓËÙÈ΋˜ ∆ÔÌÔÁÚ·Ê›·˜ ¶.°.¡.∞. “∞ÚÂÙ·›ÂÈÔ”, ∞ı‹Ó·

1 Neonatal Department, General District Hospital of Athens “Alexandra”, Athens 2 1st Obstetric-Gynecology Clinics of University of Athens General District Hospital of Athens “Alexandra”, Athens 3 Department of CT and MRI General District Hospital of Athens “Areteio”, Athens

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÙÂÏÂÈfiÌËÓÔ ÓÂÔÁ¤ÓÓËÙÔ ·ÁfiÚÈ, ÙÔ ÚÒÙÔ ·È‰› ¿Á·Ì˘ Á˘Ó·›Î·˜ 17 ÂÙÒÓ, Ë ÔÔ›· ‰ÂÓ ¤Ù˘¯Â Ì·È¢ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. O ·Ù¤Ú·˜ ÙÔ˘ ·È‰ÈÔ‡ ‰ÂÓ Â›¯Â Û˘ÁÁÂÓÈ΋ Û¯¤ÛË Ì ÙË ÌËÙ¤Ú·. ∏ ÌËÙ¤Ú· ‰ÂÓ ‹Ù·Ó ηÓ›ÛÙÚÈ·. ∆Ô ÓÂÔÁÓfi ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi, ¤ÎÏ·„ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘ Î·È ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠ·Ó¿ÓË„Ë (Apgar score ÛÙÔ 1Ô Î·È 5Ô min=9). ∆· ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο Î·È Ë

195

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ÂͤٷÛË ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÙÔ˘ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆· ÓÂÔÁÓÈο ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÂÎχÔÓÙ·Ó Ê˘ÛÈÔÏÔÁÈο Î·È Ô Ì˘˚Îfi˜ ÙfiÓÔ˜ ‹Ù·Ó Â›Û˘ Ê˘ÛÈÔÏÔÁÈÎfi˜. ∆· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó: µ¿ÚÔ˜ Á¤ÓÓËÛ˘: 3200 g, (∂£=50Ë), Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜: 53 cm (∂£=90Ë), ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜: 38,5 cm (∂£>90˘). ∏ ÚfiÛıÈ· Î·È Ô›ÛıÈ· ËÁ‹ ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Î·È ‰ÂÓ Â›¯Â ‰È¿ÛÙ·ÛË Ú·ÊÒÓ. ∏ ÌÔÓ·‰È΋ ¤Ó‰ÂÈÍË Ô˘ Ô‰‹ÁËÛ ÛÙËÓ ÂÎÙ¤ÏÂÛË ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÂÁÎÂÊ¿ÏÔ˘ (Real-time, 5 MHz) ‹Ù·Ó Ë ÌÂÁ¿ÏË ÂÚ›ÌÂÙÚÔ˜ Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜: ¢ÌÂÁ¤ı˘ ·ÛÙË Ì ‰È·˘Á¤˜ ˘ÁÚfi Ô˘ ηٷϷ̂¿ÓÂÈ ÙÔÓ ˘ÂÚÛÎËÓ›‰ÈÔ ¯ÒÚÔ. OÈ ı¿Ï·ÌÔÈ, ÙÔ ‰Ú¤·ÓÔ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ë ·ÚÂÁÎÂÊ·Ï›‰· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· ‰ÂÓ ·ÂÈÎÔÓ›ÛÙËÎ·Ó (¶›Ó·Î·˜ 1) (∂ÈÎfiÓ˜ 1-3). O ¤ÏÂÁ¯Ô˜ Û˘ÌÏËÚÒıËΠ̠˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· (∂ÈÎfiÓ˜ 4 Î·È 5). ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È Î·Ú‰È¿˜ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ‚˘ıÔÛÎfiËÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (TORCH) ‹Ù·Ó ·ÚÓËÙÈÎfi˜. O ηڢfiÙ˘Ô˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ (46ÃÀ). ∆Ô ÓÂÔÁÓfi ·‚›ˆÛ ÙË 15Ë Ë̤ڷ ˙ˆ‹˜. ¢ÂÓ ‰ÈÂÓÂÚÁ‹ıËΠÓÂÎÚÔÙÔÌÈÎfi˜ ¤ÏÂÁ¯Ô˜. ™˘˙‹ÙËÛË ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È Ì›· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÛÙËÓ ÔÔ›· ˘¿Ú¯ÂÈ Ï‹Ú˘ ¤ÏÏÂÈ„Ë ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Ì ·Ó¤·ÊÔ ÙÔ ıfiÏÔ ÙÔ˘ ÎÚ·Ó›Ô˘ Î·È ÙȘ Ì‹ÓÈÁÁ˜. ∏ ·ÚÂÁÎÂÊ·Ï›‰·, Ô ÌÂÛÂÁΤʷÏÔ˜, ÔÈ ı¿Ï·ÌÔÈ Î·È Ù· ‚·ÛÈο Á¿ÁÁÏÈ· Â›Ó·È Ê˘ÛÈÔÏÔÁÈο (3). ∞Ó Î·È Ë ·ÎÚÈ‚‹˜ ·ÈÙÈÔÏÔÁ›· Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Â›Ó·È ¿ÁÓˆÛÙË, Ë ϤÔÓ ÂÈÎÚ·ÙÔ‡Û· ˘fiıÂÛË Â›Ó·È fiÙÈ ÚÔηÏÂ›Ù·È ·fi ¤ÌÊÚ·ÎÙÔ, ÚÔÂÚ¯fiÌÂÓÔ ·fi ·ÌÊÔÙÂÚfiÏ¢ÚË ‹ ÂÙÂÚfiÏ¢ÚË ·fiÊÚ·ÍË ÙˆÓ ¤Ûˆ ηڈٛ‰ˆÓ ‹ ÙˆÓ ¤Ûˆ ÛÊ·Á›ÙȉˆÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ∞˘Ùfi Ô‰ËÁ› Û ӤÎÚˆÛË Î·È ·ÔÚÚfiÊËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÈÛÙÔ‡, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿Ù˘ÍË Ì›·˜ ÎÔÈÏfiÙËÙ·˜ Ï‹ÚÔ˘˜ ˘ÁÚÔ‡ Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi Ì‹ÓÈÁÁ˜. O ·ıÔÁÂÓÂÙÈÎfi˜ ·˘Ùfi˜ Ì˯·ÓÈÛÌfi˜ ÂÓÈÛ¯‡ÂÙ·È ·fi ÙË ‰È·›ÛÙˆÛË Ù˘ ·Ó¿Ù˘Í˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜

Paediatriki 2002;65:195-198

Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ Èı‹ÎˆÓ Î·È ÚÔ‚¿ÙˆÓ (4), ηıÒ˜ Î·È ÙË ÛÙ·‰È·Î‹ ÂÁηٿÛÙ·ÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Û ·ÓıÚÒÈÓ· ¤Ì‚Ú˘·, Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÛÂ Û˘Ó¯‹ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÛÙ· Ï·›ÛÈ· Ù˘ ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ (5). ÕÏÏÔÈ Èı·ÓÔ› ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ›, Ô˘ ÌÔÚ› Ó· Â›Ó·È ·fi ̤ÚÔ˘˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘, Â›Ó·È Ë ·-

∂ÈÎfiÓ· 1. ™ÙÂÊ·ÓÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘). ∞ÂÈÎÔÓ›˙ÂÙ·È Ë Â˘ÌÂÁ¤ı˘ ·ÛÙË Ô˘ ·ÓÙÈηıÈÛÙ¿ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· Î·È ÙÔ ·Î¤Ú·ÈÔ ‰Ú¤·ÓÔ.

∂ÈÎfiÓ· 2. ™ÙÂÊ·ÓÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ·). ∞ÂÈÎÔÓ›˙ÂÙ·È Ë Â˘ÌÂÁ¤ı˘ ·ÛÙË Ô˘ ·ÓÙÈηıÈÛÙ¿ Ù· ÂÁÎÂÊ·ÏÈο ËÌÈÛÊ·›ÚÈ· Î·È ÔÈ Âӈ̤ÓÔÈ ı¿Ï·ÌÔÈ.

¶›Ó·Î·˜ 1. ÀÂÚ˯ÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ñ ¶Ï‹Ú˘ ·Ô˘Û›· ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ ñ ª›· ÌÂÁ¿ÏË, ÁÂÌ¿ÙË ˘ÁÚfi, ÎÔÈÏfiÙËÙ· ÂÓÙfi˜ ÙÔ˘ ıfiÏÔ˘ ÙÔ˘ ÎÚ·Ó›Ô˘ ηٷϷ̂¿ÓÔ˘Û· ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ ñ º˘ÛÈÔÏÔÁÈÎÔ› ı¿Ï·ÌÔÈ Î·È ËÌÈÛÊ·ÈÚ›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ ñ ∞Ó¤·ÊÔ ÙÔ ‰Ú¤·ÓÔ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘

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∂ÈÎfiÓ· 3. ¶·Ú·Ô‚ÂÏÈ·›· ÙÔÌ‹ ÂÁÎÂÊ¿ÏÔ˘ (˘ÂÚ˯ÔÁÚ¿ÊËÌ·). ∞ÂÈÎÔÓ›˙ÂÙ·È Ô ı¿Ï·ÌÔ˜ Î·È Ô ÛÎÒÏËη˜.

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Paediatriki 2002;65:195-198

∂ÈÎfiÓ· 4 Î·È 5. ÀÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘. ∂Ȃ‚·ÈÒÓÂÙ·È Ë Ï‹Ú˘ ˘ÔηٿÛÙ·ÛË ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ Ì ∂¡À (·ÚÈÛÙÂÚ¿), Ë ¤ÓˆÛË ÙˆÓ ı·Ï¿ÌˆÓ Î·È Ë ·ÚÔ˘Û›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜ Î·È ÙÔ˘ ‰ÚÂ¿ÓÔ˘ (‰ÂÍÈ¿).

Ú·ÙÂٷ̤ÓË ÂÌ‚Ú˘˚΋ ˘ÔÍ›· ηÈ, ·fi ̤ÚÔ˘˜ Ù˘ ÂÁ·Ԣ, Ë ÂÌÊ¿ÓÈÛË ˘ÔÙ·ÛÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, Ù· ÔÔ›· ÂӉ¯Ô̤ӈ˜ Ó· ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÈÊÓ›‰È· ‰È·ÛÙÔÏ‹ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ, ÌÂ Û˘Ó¤ÂÈ· ÙË Ú‹ÍË Â‡ıÚ·˘ÛÙˆÓ ·ÁÁ›ˆÓ Î·È ÙË Ì·˙È΋ ·ÈÌÔÚÚ·Á›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (6). OÚÈṲ̂ÓÔÈ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ (ÙÔÍfiÏ·ÛÌ· Î·È Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜) Ô˘ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÔ˘Ó ÙÔ ¤Ì‚Ú˘Ô Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜, ˆ˜ Û˘Ó¤ÂÈ· ÓÂÎÚˆÙÈ΋˜ ·ÁÁÂÈ›Ùȉ·˜ ‹ ÙÔÈ΋˜ ηٷÛÙÚÔÊ‹˜ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ Ô˘Û›·˜. O ¤ÏÂÁ¯Ô˜ Û˘ÁÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‹Ù·Ó ·ÚÓËÙÈÎfi˜ Î·È Ë ‚˘ıÔÛÎfiËÛË ‰ÂÓ Î·Ù¤‰ÂÈÍ ¯ÔÚÈÔ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ· ‹ ¿ÏϘ ‚Ï¿‚˜. ∞ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ˘ÔÏ·Û›· ÙˆÓ ˘ÂÚÎÏÈÓÔÂȉÒÓ ÙÌËÌ¿ÙˆÓ ÙˆÓ ¤Ûˆ ηڈٛ‰ˆÓ Î·È Ê˘ÛÈÔÏÔÁÈΤ˜ ÙË ‚·ÛÈ΋, ÙȘ Ô›ÛıȘ ÂÁÎÂÊ·ÏÈΤ˜ Î·È ÙȘ ÛÔÓ‰˘ÏÈΤ˜ ·ÚÙËڛ˜ (5).

OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛÔÚ·‰ÈΤ˜, ÂÓÙÔ‡ÙÔȘ ˘¿Ú¯Ô˘Ó ÌÂÚÈΤ˜ ·Ó·ÎÔÈÓÒÛÂȘ ÔÈÎÔÁÂÓÒÓ ˘‰Ú·ÓÂÁÎÂÊ·ÏÈÒÓ. OÈ Hamby Î·È Û˘Ó (2) ‰ËÌÔÛ›Â˘Û·Ó ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ‰›‰˘ÌˆÓ, ·ÁfiÚÈ Î·È ÎÔÚ›ÙÛÈ, Ù· ÔÔ›· ›¯·Ó ˘‰Ú·ÓÂÁÎÂÊ·Ï›·. ™ÙÔ ·ÁfiÚÈ ‰È·ÈÛÙÒıËΠÂÈϤÔÓ ·ÁÂÓÂÛ›· Ù˘ ÎÓ‹Ì˘ Î·È ÛÙÔ ÎÔÚ›ÙÛÈ ÂÎÛÙÚÔÊ‹ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È ·ÁÂÓÂÛ›· ÙˆÓ ÓÂÊÚÒÓ. OÈ Foweler Î·È Û˘Ó (7) ÂÚȤÁÚ·„·Ó ÂÓÙ¿‰˘Ì· ÎÔÚ›ÙÛÈ·, Ù· ÔÔ›· ›¯·Ó ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ˘‰ÚÔΤʷÏÔ Î·È ·ÚıÚÔÁÚ‡ˆÛË.

OÈ ÓÂÎÚÔÙÔÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ ¤‰ÂÈÍ·Ó ·ÓÒÌ·ÏË ·ÁÁ›ˆÛË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. O Siber (8) ·ÚÔ˘Û›·Û ¤Ó· Û‡Ó‰ÚÔÌÔ, Èı·ÓÒ˜ ÎÏËÚÔÓÔÌÔ‡ÌÂÓÔ ÌÂ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ¯·Ú·ÎÙ‹Ú·, ÙÔ˘ ÔÔ›Ô˘ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ·ÔÙÂÏÔ‡Ó Ë ÌÈÎÚÔÎÂÊ·Ï›·, Ë ÌÈÎÚÔÊı·ÏÌ›·, Ë ıÔÏÂÚfiÙËÙ· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜, Ë Û·ÛÙÈ΋ ÙÂÙÚ·ÏËÁ›·, o ˘ÔÛ·‰›·˜, Ë ÎÚ˘„ÔÚ¯›· Î·È Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· (10). ∏ ÁÔÓȉȷ΋ ÌÂϤÙË Ì›·˜ ÌÂÁ¿Ï˘ ·ÈÌÔÌÈÎÙÈ΋˜ ÔÈÎÔÁ¤ÓÂÈ·˜ ÂÓÙfiÈÛ ‡ÔÙÔ ÁÔÓȉ›ˆÌ· ÛÙÔ

‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 16 (1613.3-12) (9). ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÂÚ›ÙˆÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Û ·È‰› Ô˘ ·‚›ˆÛ Û ËÏÈΛ· 4 ÂÙÒÓ, ÛÙÔ ÔÔ›Ô ‰È·ÁÓÒÛÙËΠÂÈϤÔÓ Î·È ‰È·Ù·Ú·¯‹ ÛÙË ÌÈÙÔ¯ÔÓ‰Úȷ΋ ·Ó·Ó¢ÛÙÈ΋ ·Ï˘Û›‰· (10). ∏ Û·ÓÈfiÙËÙ· ÙˆÓ ÔÈÎÔÁÂÓÒÓ ÂÚÈÙÒÛÂˆÓ Î·È Ë ÂÓÙ˘ˆÛȷ΋ ·fi‰ÂÈÍË Ù˘ ‡·Ú͢ Ì›·˜ ηٷÛÙÚÔÊÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ‰ÂÓ Â›Ó·È ÁÂÓÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ (6). Œ¯ÂÈ ·Ó·ÊÂÚı› Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ÌÈÎÚ‹˜ ËÏÈΛ·˜ Ù˘ ÌËÙ¤Ú·˜ (<18 ÂÙÒÓ) Î·È Î·Ó›ÛÌ·ÙÔ˜ Ù˘ ÂÁ·Ԣ (11). ∏ ÌËÙ¤Ú· ÙÔ˘ ÓÂÔÁÓÔ‡ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‹Ù·Ó ÌÈÎÚ‹˜ ËÏÈΛ·˜ (17 ÂÙÒÓ), ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È Î·Ó›ÛÙÚÈ·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ˙ÒÓÙ· ÓÂÔÁÓ¿, Ú¤ÂÈ Ó· ÙÂı› ·fi ÙË ‚·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜ Î·È ÙËÓ ·ÏÔ‚Ò‰Ë ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·, Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (¶›Ó·Î·˜ 2) (12). ™ÙȘ ÂÚÈÙÒÛÂȘ Ì ‚·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜, Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ‰˘Û¯ÂÚ‹˜. ∏ ·ÚÔ˘Û›· Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÌÊÈ‚ÚÂÁÌ·ÙÈ΋˜ ‰È·Ì¤ÙÚÔ˘, Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ ÙËÓ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·, ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÂÈ ˆ˜ ̤ÛÔ ‰È·ÎÚ›Ûˆ˜ ÙˆÓ ‰‡Ô ·˘ÙÒÓ ·ıÔÏÔÁÈÎÒÓ ÔÓÙÔÙ‹ÙˆÓ (3). ∂ÓÙÔ‡ÙÔȘ, Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È Â›Û˘ Ì ÌÂÁ¿ÏË ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜, fiˆ˜ Î·È ÛÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ™ÙËÓ ˘‰ÚÔÎÂÊ·Ï›·, ÌÔÚ› ÌÂÚÈΤ˜ ÊÔÚ¤˜ Ó· Ê·Ó› ˘ÂÚ˯ÔÁÚ·ÊÈο ¤Ó· ÏÂÙfi ¯Â›ÏÔ˜ Ï¢΋˜ Ô˘Û›·˜ Î·È ÊÏÔÈÔ‡ Á‡Úˆ ·fi ÙȘ ÎÔÈϛ˜ Û ‡·ÚÍË ÛÔ‚·ÚÔ‡ ˘‰ÚÔÎÂÊ¿ÏÔ˘, ÂÓÒ Û ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ‰ÂÓ ˘¿Ú¯ÂÈ Î·ıfiÏÔ˘ ÂÚÈÊÂÚÈÎfi˜ ÈÛÙfi˜. ™Â ·ÌÊÈ‚ÔÏ›·, ‰ÈÂÓÂÚÁÂ›Ù·È ˘ÔÏÔÁÈÛÙÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, Ô˘ Â›Ó·È Î·Ï‡ÙÂÚ˜ Ù¯ÓÈΤ˜ ÛÙËÓ ·ÂÈÎfiÓÈÛË Ù˘ ÂÚÈʤÚÂÈ·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ ‰È¿ÎÚÈÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ˘‰ÚÔÎÂÊ¿ÏÔ˘ Â›Ó·È Ô˘ÛÈ҉˘ ÁÈ·Ù› ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÚfiÎÂÈÙ·È ÁÈ· ˘‰ÚÔΤʷÏÔ, ÌÔÚ› Ë ÔÚ›· ÙÔ˘ ÓÂÔÁÓÔ‡ Ó· Â›Ó·È Î·Ï‹ Ì ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘

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¶·È‰È·ÙÚÈ΋ 2002;65:195-198

Paediatriki 2002;65:195-198

¶›Ó·Î·˜ 2. ÀÂÚ˯ÔÁÚ·ÊÈ΋ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ ∞ӈ̷ϛ· ∫¡™

∞Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο

µ·ÚÈ¿ ÌÔÚÊ‹ ˘‰ÚÔÎÂÊ·Ï›·˜

ñ ¶·ÚÔ˘Û›· ‰ÚÂ¿ÓÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ñ ¶·ÚÔ˘Û›· ‰È¿Û·ÚÙˆÓ ÙÌËÌ¿ÙˆÓ ÙÔ˘ ÊÏÔÈÔ‡ ñ ¶·ÓÙÂÏ‹˜ ¤ÏÏÂÈ„Ë ÙÔ˘ ‰ÚÂ¿ÓÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ñ ⁄·ÚÍË ÚfiÛıÈÔ˘ ÊÏÔÈÔ‡, ËÌÈÛÂÏËÓÔÂȉԇ˜ Û¯‹Ì·ÙÔ˜ ñ ªÔÓfi¯ˆÚË ÎÔÈÏ›·, Û¯‹Ì·ÙÔ˜ ¤ÏÌ·ÙÔ˜ ·ÏfiÁÔ˘ ñ ™˘Ó¤ÓˆÛË ı·Ï¿ÌˆÓ ÛÙË Ì¤ÛË ÁÚ·ÌÌ‹ ñ ∞Ô˘Û›· 3˘ ÎÔÈÏ›·˜ Î·È Ó¢ÚÔ¸ÔʇÛˆ˜ ñ ™Ô‚·Ú¤˜ ·ÓˆÌ·Ï›Â˜ ÛÙË Ì¤ÛË ÁÚ·ÌÌ‹ ÙÔ˘ ÚÔÛÒÔ˘, fiˆ˜ ΢Îψ›·, ËıÌÔÎÂÊ·Ï›·, ‡·ÚÍË “ÚÔ‚ÔÛΛ‰·˜”, Ï·ÁÒ¯ÂÈÏÔ, ·Ô˘Û›· ÔÊı·ÏÌÈÎÒÓ ÎfiÁ¯ˆÓ Î·È Ì‡Ù˘, ˘ÔÙÂÏÔÚÈÛÌfi˜

∞ÏԂ҉˘ ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·

∂¡À Â¿Ó ·˘Ù‹ Á›ÓÂÈ ¤ÁηÈÚ·, ÂÓÒ Û ÂÚ›ÙˆÛË ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜, Ë ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ∂¡À ‰ÂÓ ı· ‚ÂÏÙÈÒÛÂÈ Î·ıfiÏÔ˘ ÙËÓ ¤Î‚·ÛË (13). ∏ ˘‰Ú·ÓÂÁÎÂÊ·Ï›· ¤¯ÂÈ ÂÍ·ÈÚÂÙÈο ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÂÚÈÛÙ·ÙÈο Ô˘ Â¤˙ËÛ·Ó Â› Ì·ÎÚfiÓ (14). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜ ÙÔ˘˜ ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÂÌÊ·Ó›˙Ô˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙȘ Ó¢ÚÔÏÔÁÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÚÔۋψÛ˘ Î·È ·Ó·˙‹ÙËÛ˘ ÙˆÓ Ì·ÙÈÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ˘ÂÚ˯ÔÁÚ·Ê›· ·ÔÙÂÏ› Ì›· ·Ï‹ Î·È ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô ‰È¿ÁÓˆÛ˘ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ë ÔÔ›· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ¤ÁηÈÚ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ÒÛÙ ·ÚfiÌÔȘ ÂÚÈÙÒÛÂȘ ÂÌ‚Ú‡ˆÓ ÌË Û˘Ì‚·ÙÒÓ Ì ÙË ˙ˆ‹ Ó· ·ÓȯÓ‡ÔÓÙ·È ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ì ÛÙfi¯Ô ÙË ‰È·ÎÔ‹ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ˘‰Ú·ÓÂÁÎÂÊ·Ï›·˜ Î·È ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·˜ Ì ‚¿ÛË Ù· ˘ÂÚ˯ÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ‰‡Ô ·˘ÙÒÓ ÔÓÙÔÙ‹ÙˆÓ Â›Ó·È ‰˘Û¯ÂÚ‹˜, fï˜ ¯ˆÚ›˜ ȉȷ›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌ·Û›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Î·È ÔÈ ‰‡Ô ηٷÛÙ¿ÛÂȘ Â›Ó·È ·Û‡Ì‚·Ù˜ Ì ÙË ˙ˆ‹ Î·È Ë Ì·È¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ›‰È·.

O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Â·ÓÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ôχ ÌÈÎÚfi˜ fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·Ó¿ÏÔÁÔ ÚÔËÁÔ‡ÌÂÓÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ™‹ÌÂÚ·, Ë ˘‰Ú·ÓÂÁÎÂÊ·Ï›· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û ÓÂÔÁÓ¿, ÏfiÁˆ Ù˘ Û¯ÔÏ·ÛÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ·ËÛ˘. ∂ÓÙÔ‡ÙÔȘ, Û ÂÁ·Ԣ˜ Ì ·ÓÂ·Ú΋ Ì·È¢ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, Ë Èı·ÓfiÙËÙ· ‰È¿ÁÓˆÛ˘ ÛÙÔ ÓÂÔÁÓfi Â›Ó·È ˘·ÚÎÙ‹ Î·È ÁÈ’ ·˘Ùfi Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Tang MH. The association between maternal smoking and fetal hydranencephaly. J Obstet Gynecol Res 1999;25:39-42.

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Dublin AB, French BN. Diagnostic image evaluation of hydranencephaly and pictorially similar entities, with emphasis on computed tomography. Radiology 1980;137:81-90.

Mc Abee GN, Chan A, Erde EL. Prolonged survival with hydranencephaly: report of two patients and literature review. Pediatr Neurol 2000;23:80-84.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-10-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ Õıˆ 31 Î·È øÚÔÔ‡, ∆.∫. 262 26, ¶¿ÙÚ· E-mail: kaleyias@hotmail.com

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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2002;65:199-202

CASE REPORT

™˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi °. ª·ÚÔ‡Ù˘1, ª. ∞ÔÛÙfiÏÔ˘1, π. ∫·Ï¤ÁÈ·˜1, ™. ™Â‚·ÛÙÈ¿‰Ô˘1, ∞. ∞ÓÙ˙·ÎÏ‹˜2, Ã. ∫ÒÛÙ·ÏÔ˜1

Congenital chylothorax in a neonate G. Baroutis1, M. Apostolou1, J. Kaleyias1, S. Sevastiadou1, A. Antsaklis2, C. Costalos1

¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ‰›‰˘ÌÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÌÂ Û˘ÁÁÂÓ‹ ¯˘ÏÔıÒڷη. ø˜ ¯˘ÏÔıÒڷη˜ ÔÚ›˙ÂÙ·È Ë Û˘ÏÏÔÁ‹ ÏÂÌÊÈÎÔ‡ ˘ÁÚÔ‡ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. ™ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Ô Û˘ÁÁÂÓ‹˜, fiÛÔ Î·È Ô ÙÚ·˘Ì·ÙÈÎfi˜ ¯˘ÏÔıÒڷη˜. ∏ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È ÛËÌ·ÓÙÈ΋, ÂÂȉ‹ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ¤ÁηÈÚ˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ Î‡ÚÈˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÓfiÛÔ˘, Ô˘ Â›Ó·È Ë ·ÛÊ˘Í›· Î·È Ë ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·. ∏ ıÂÚ·›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ ϤÌÊÔ˘ ·fi ÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ì ·ÔηٿÛÙ·ÛË ÙˆÓ ˘ÁÚÒÓ-ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ¯¿ÓÔÓÙ·È, ÛÙË ¯Ú‹ÛË Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È ÛÙËÓ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹. ∏ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ·Ú¯›˙ÂÈ ÌfiÓÔ fiÙ·Ó ÛÙ·Ì·Ù‹ÛÂÈ Ë ‰È·Ê˘Á‹ ϤÌÊÔ˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· Î·È Û˘Ó›ÛÙ·Ù·È Û ¯ÔÚ‹ÁËÛË Á¿Ï·ÎÙÔ˜ Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È·. ¶Ôχ Û¿ÓÈ· ¯ÚÂÈ¿˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË.

Abstract: This is a case report of a twin premature newborn with congenital chylothorax.

Chylothorax is defined as the effusion of lymph in the pleural cavity. In the neonatal period, both congenital and traumatic forms of chylothorax exist with equal frequency. Major symptoms at birth include asphyxia and respiratory distress, therefore the antenatal diagnosis, by the use of ultrasound, is essential in order to initiate appropriate therapeutic intervention soon after birth. Treatment consists of mechanical ventilation, drainage of chyle, replacement of fluid-electrolyte and protein losses, and parenteral nutrition.

Introduction of oral feeding should be initiated only after the chyle effusion in the pleural cavity is successfully terminated, and consists of feeding with a medium-chain triglyceride containing formula. In a minority of cases surgical intervention may be necessary.

§¤ÍÂȘ ÎÏÂȉȿ: ¯˘ÏÔıÒڷη˜, ÓÂÔÁ¤ÓÓËÙÔ.

Key words: chylothorax, newborn.

∂ÈÛ·ÁˆÁ‹ O ¯˘ÏÔıÒڷη˜ Â›Ó·È Û¿ÓÈ· ·ÈÙ›· ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Û ÓÂÔÁÓfi Î·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ˘ÁÚÔ‡ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (1). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙÔ˘ ¯˘ÏÔıÒڷη Î·È Ë ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈο ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË (1,2). ∏ ‰È¿ÁÓˆÛË ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Ú¤ÂÈ Ó· Èı·ÓÔÏÔÁÂ›Ù·È fiÙ·Ó Û ÚÔÁÂÓÓËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ·Ú·ÙËÚÂ›Ù·È ¿ıÚÔÈÛË ˘ÁÚÔ‡ ÛÙÔ ıÒڷη ÂÙÂÚfiÏ¢ڷ ‹ ·ÌÊÔÙÂÚfiÏ¢ڷ, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ÂÌ‚Ú˘˚Îfi˜ ‡‰Úˆ-

·˜, ·ÛΛÙ˘ ‹ Ô›‰ËÌ·, ÂÓÒ Â›Ó·È ·Ó¤·ÊÔ ÙÔ ‰È¿ÊÚ·ÁÌ· Î·È ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ë Î·Ú‰ÈÔ¿ıÂÈ· (3).

1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·” 2 ∞’ ª·È¢ÙÈ΋-°˘Ó·ÈÎÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞ıËÓÒÓ “∞ÏÂÍ¿Ó‰Ú·”

1 Neonatology Department, General District Hospital of Athens “Alexandra” 2 1st Department of Obstetric-Gynecology, General District Hospital of Athens “Alexandra”

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¢›‰˘ÌË Î‡ËÛË, ηٿ ÙËÓ 32Ë Â‚‰ÔÌ¿‰·, ·ÚÔ˘Û›·Û ˘‰Ú¿ÌÓÈÔ Î·È Û ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠÏ¢ÚÈÙÈ΋ Û˘ÏÏÔÁ‹ ÛÙÔ ¤Ó· ¤Ì‚Ú˘Ô. ∆Ô ¿ÏÏÔ ¤Ì‚Ú˘Ô ‹Ù·Ó Î·È ·Ú¤ÌÂÈÓÂ Ê˘ÛÈÔÏÔÁÈÎfi. §fiÁˆ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ·˘ÙÒÓ Ô ÙÔÎÂÙfi˜ ¤ÁÈÓ Ì ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ∫∆ ÛÙËÓ 32Ë Â‚‰ÔÌ¿‰· ÂÁ΢ÌÔÛ‡Ó˘. ∞̤ۈ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ÙÔ

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¿Û¯ÔÓ ÓÂÔÁÓfi, ¿ÚÚÂÓ Ì µ°=2560 g, ª™=48 cm, ¶∫=32 cm ¯ÚÂÈ¿ÛÙËΠ·Ó¿ÓË„Ë Ì ¯ÔÚ‹ÁËÛË O2 Ì ·ÛÎfi. ∆Ô Apgar score ÛÙÔ 1Ô Î·È 5Ô min ‹Ù·Ó 5 Î·È 7 ·ÓÙ›ÛÙÔȯ·. ™ÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘Û›·Û ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÚÔԉ¢ÙÈο ÂȉÂÈÓÔ‡ÌÂÓË, ÔfiÙ ٤ıËΠ۠Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, ÛÙÔÓ ÔÔ›Ô ·Ú¤ÌÂÈÓ ÁÈ· 5 ÂÈÎÔÛÈÙÂÙÚ¿ˆÚ·. ∆Ô ÓÂÔÁÓfi ‰ÂÓ ·ÚÔ˘Û›·˙ ÛËÌ›· ‡‰Úˆ· ‹ ÏÂÌÊÔ›‰ËÌ·. ∏ ·/· ıÒڷη ¤‰ÂÈÍ ÂÎÙÂٷ̤ÓË Ï¢ÚÈÙÈ΋ Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ‰ÂÍÈ¿, ¯ˆÚ›˜ Û˘ÓÔ‰fi ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë (∂ÈÎfiÓ· 1). ™·Ó Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ Û˘ÏÏÔÁ‹˜ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Û˘ÁÁÂÓÒ˜ Ù¤ıËÎ·Ó Ô ¯˘ÏÔıÒڷη˜, ÙÔ ÂÌ‡ËÌ· Î·È Ë ·ÈÌÔÚÚ·Á›·. ŒÁÈÓ·Ó ‰‡Ô ÂÎÎÂÓˆÙÈΤ˜ ·Ú·ÎÂÓÙ‹ÛÂȘ ıÒڷη (1Ë Î·È 2Ë ·ÓÙ›ÛÙÔȯ·: pH: 7,4 Î·È 7, ·ÙÙ·Ú·: 2440 Î·È 12.000/ml, ÏÂÌÊÔ·ÙÙ·Ú·: 80 Î·È 80%, χΈ̷: 4,3 Î·È 3,6 g/dl, ۿί·ÚÔ: 126 Î·È 82 mg/dl, LDH: 176 Î·È 316 IU/L, Î/˜: ÛÙ›Ú˜) Î·È ·Ú¤ÌÂÈÓÂ Û˘Ó¯‹˜ ·ÚÔ¯¤Ù¢ÛË ÁÈ· 3 Ë̤Ú˜. ∆Ô ˘ÁÚfi Ù˘ ·ÚÔ¯¤Ù¢Û˘ ‹Ù·Ó ·¯‡ÚÚ¢ÛÙÔ, ‰È·˘Á¤˜, ÎÈÙÚÈÓfi¯ÚÔ˘Ó. ∏ ËÏÂÎÙÚÔÊfiÚËÛË ÏÈȉ›ˆÓ ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ ¤‰ÂÈÍ ÙÚÈÁÏ˘ÎÂÚ›‰È· 752 mg/dl, ÔÏÈο ÏÈ›‰È· 1047 mg/dl Î·È ¯ÔÏËÛÙÂÚfiÏË 30 mg/dl. ∞fi ÙÔÓ ˘fiÏÔÈÔ ¤ÏÂÁ¯Ô ÛËÌÂÈÒÓÔÓÙ·È Ù· Ï¢ÎÒÌ·Ù· ÔÚÔ‡ (5,1 g/dl, ·Ï‚Ô˘Ì›ÓË 3,3 g/dl), ÔÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÔÚÔ‡ [IgG=230 mg/dl (ÊÙ. 600-1200), IgA=6,5 mg/dl (ÊÙ. 3-13), IgM=15,2 (ÊÙ. 15-59)]. O ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (TORCH) ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∫·Ú˘fiÙ˘Ô˜ ›¯Â Á›ÓÂÈ ÚÔÁÂÓÓËÙÈο Î·È ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ ¿ÚÚÂÓÔ˜. ªÂ ‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÙÔ˘ ÂÈÎfiÓ· ÂȂ‚·ÈÒıËÎÂ Ë Èı·ÓÔÏÔÁÔ‡ÌÂÓË ‰È¿ÁÓˆÛË ÙÔ˘ ¯˘ÏÔıÒڷη. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘ ·ÚÔ˘Û›·Û Ó¢ÌÔıÒڷη Î·È ÛË„·ÈÌ›· ·fi staphylococcus epidermidis, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ·ÚÔ¯¤Ù¢ÛË Î·È ·ÓÙÈ‚›ˆÛË, ·ÓÙ›ÛÙÔȯ·.

∂ÈÎfiÓ· 1. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÓÂÔÁÓÔ‡ ÌÂ Û˘ÁÁÂÓ‹ ÂÙÂÚfiÏ¢ÚÔ ¯˘ÏÔıÒڷη (ÔÌÔÈÔÁÂÓ‹˜ ıÔÏÂÚfiÙËÙ· ‰ÂÍÈÔ‡ ËÌÈıˆÚ·Î›Ô˘).

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∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÚÈ·˜ ÓfiÛÔ˘ ÙÔ˘, Ô˘ ‹Ù·Ó Ô ¯˘ÏÔıÒڷη˜, ¤ÁÈÓ Ì ·ÔÊ˘Á‹ Û›ÙÈÛ‹˜ ÙÔ˘ Ì Á¿Ï· ̤¯ÚÈ ÙÔ 10Ô 24ˆÚÔ ˙ˆ‹˜, ÔfiÙ ¿Ú¯ÈÛÂ Ë ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÁÈ· 7 Ë̤Ú˜. ¢È·ÎfiËΠfï˜ ÏfiÁˆ ˘ÔÙÚÔ‹˜ ÙÔ˘ ¯˘ÏÔıÒڷη. ∏ Â·Ó·Û›ÙÈÛË ¤ÁÈÓ ÌÂÙ¿ ·fi 15 Ë̤Ú˜ (32Ô 24ˆÚÔ ˙ˆ‹˜) Ì ÂȉÈÎfi Á¿Ï· Ô˘ ÂÚÈ›¯Â ÏÈ·Ú¿ Ôͤ· ̤Û˘ ·Ï‡ÛÔ˘ (MCT). ∆Ô ÂȉÈÎfi Á¿Ï· ¯ÔÚËÁ‹ıËÎÂ Û˘ÓÔÏÈο ÁÈ· 3 Ì‹Ó˜ ÂÚ›Ô˘ Î·È ·ÎÔÏÔ‡ıˆ˜ ÙÔ ‚Ú¤ÊÔ˜ ÛÈÙ›ÛÙËΠ̠ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ¯ˆÚ›˜ Ó· ÛËÌÂȈı› ˘ÔÙÚÔ‹ ÙÔ˘ ¯˘ÏÔıÒڷη (∂ÈÎfiÓ· 2). ∆Ô ‚Ú¤ÊÔ˜ Û‹ÌÂÚ· Â›Ó·È 15 ÌËÓÒÓ Î·È Â›Ó·È ·Ôχو˜ Ê˘ÛÈÔÏÔÁÈÎfi. ™˘˙‹ÙËÛË O ¯˘ÏÔıÒڷη˜ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›· Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ˘ÁÚÔ‡ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, ·ÏÏ¿ ·ÔÙÂÏ› ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Î·È Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ·Ó¤Ú¯ÂÙ·È Û 1/10000 ÙÔÎÂÙÔ‡˜ Î·È 1/2000 ÂÈÛ·ÁˆÁ¤˜ ÓÂÔÁ¤ÓÓËÙˆÓ. ∏ Û¯¤ÛË ·ÁÔÚÈÒÓ:ÎÔÚÈÙÛÈÒÓ Â›Ó·È 2:1 (4). ∏ ÂÙÂÚfiÏ¢ÚË ÌÔÚÊ‹, ΢ڛˆ˜ ‰ÂÍÈ¿, Â›Ó·È Ë ϤÔÓ Û˘Ó‹ı˘, fiˆ˜ Î·È Ë ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ∞˘Ùfi Èı·ÓÒ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó·ÙÔÌ›· ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘. ™¯ÂÙÈο Ì ÙËÓ ÂÍ‹ÁËÛË ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη ˘¿Ú¯Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ. ªÈ· Èı·Ó‹ ÂÍ‹ÁËÛË ı· ÌÔÚÔ‡Û ӷ Â›Ó·È Ë Â˘¿ÏˆÙË ‰È·‰ÚÔÌ‹ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘. ªÔÚ› ‰ËÏ·‰‹ Ó· ÚÔÎÏËı› ¯˘ÏÔıÒڷη˜ ·fi ÙË Ú‹ÍË ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘ ÏfiÁˆ ˘ÂÚ¤ÎÙ·Û˘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Î·È ÏfiÁˆ ·˘ÍË̤Ó˘ ÊÏ‚È΋˜ ›ÂÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÔÎÂÙÔ‡. ∏ ·ÈÙ›· ·˘Ù‹ fï˜ Û·Ó›ˆ˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο. ™˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ÏÂÌÊÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙÔ Â›Â‰Ô ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÚÔ˘ ¿ÓˆıÂÓ ‹ οوıÂÓ ÙÔ˘ ¤ÌÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ô‰ËÁ› Û ‰ÂÍÈfi ‹

∂ÈÎfiÓ· 2. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ¯˘ÏÔıÒڷη.

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¶·È‰È·ÙÚÈ΋ 2002;65:199-202

·ÚÈÛÙÂÚfi ¯˘ÏÔıÒڷη ·ÓÙ›ÛÙÔȯ· (4). ™ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Â›Ó·È ÂÌÊ·Ó‹ ÛÙË Á¤ÓÓËÛË Î·È ÛÙȘ ˘fiÏÔÈ˜ ÂÚÈÙÒÛÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜ (4). ∂›Ó·È Èı·ÓfiÓ Ô Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Û‡Ó‰ÚÔÌÔ Turner, ÙÔ Û‡Ó‰ÚÔÌÔ Noonan, ÙÔ Û‡Ó‰ÚÔÌÔ Down ‹ ÙÔÓ ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· (5). ∞ÎfiÌË ¤¯ÂÈ ·Ó·ÊÂÚı› Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ Û ÓÂÔÁÓfi Ì ı˘ÚÂÔÙÔ͛ΈÛË ‰Â˘ÙÂÚÔ·ıÒ˜ ÚÔ˜ ÙË ÓfiÛÔ Grave Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ (6) Î·È ÔÏϤ˜ ÊÔÚ¤˜ Û˘Ó‰˘¿˙ÂÙ·È Ì ÔÏ˘¸‰Ú¿ÌÓÈÔ.

O ¯˘ÏÔıÒڷη˜ ÂΉËÏÒÓÂÙ·È Ì ÛËÌ›· ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ì ÂÏ¿ÙÙˆÛË Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ıÒڷη Î·È ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜ ηٿ ÙËÓ ·ÎÚfi·ÛË, ÂÓÒ Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Â›Ó·È ÔÌÔÈÔÁÂÓ‹˜ ıÔÏÂÚfiÙËÙ· ÂÙÂÚfiÏ¢ڷ ‹ ·ÌÊÔÙÂÚfiÏ¢ڷ, Ì ‹ ¯ˆÚ›˜ ÌÂÙ·ÙfiÈÛË ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÚÔ˜ ÙËÓ ˘ÁÈ‹ ÏÂ˘Ú¿ (∂ÈÎfiÓ· 1). ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Û fiÚıÈ· ı¤ÛË ‰Â›¯ÓÂÈ Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ÛÙË ‚¿ÛË Ù˘ ˘Â˙ˆÎÔÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜. ∏ ·ÎÙÈÓÔÁÚ·ÊÈ΋ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÌËÓ Â›Ó·È Â‡ÎÔÏË ÏfiÁˆ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ Ù˘ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ Ì ÛÔ‚·Ú‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ, fiˆ˜ Â›Û˘ Ë Ù˘È΋ ÂÈÎfiÓ· Ù˘ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÂÌÊ·Ó‹˜. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ, Ô ¤ÏÂÁ¯Ô˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ˘ ıÒڷη Â›Ó·È ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ ‹ÈˆÓ Û˘ÏÏÔÁÒÓ. ∏ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÂȂ‚·Èˆı› Ì ÙËÓ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη Î·È ÙË ‰È·›ÛÙˆÛË Ù˘ Ù˘È΋˜ Û‡ÓıÂÛ˘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ˘ÁÚÔ‡. ∏ ϤÌÊÔ˜ Â›Ó·È Î›ÙÚÈÓË, ‰È·˘Á‹˜, Á›ÓÂÙ·È Á·Ï·ÎÙ҉˘ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È Ï·Óı·Ṳ̂ӷ ÂÎÏ·Ì‚¿ÓÂÙ·È ˆ˜ ‡ÔÓ. ªÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Î·È ÙË ¯ÔÚ‹ÁËÛË Ì¤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ, Ë Ï¤ÌÊÔ˜ Á›ÓÂÙ·È ‰È·˘Á‹˜ Î·È Î›ÙÚÈÓË Í·Ó¿ (7). ∆· ‚ÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ϤÌÊÔ˘ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (1). ¶·ıÔÁÓˆÌÔÓÈÎfi ‡ÚËÌ· ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Â›Ó·È ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Î˘Ú›ˆ˜ ÙˆÓ ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ¶›Ó·Î·˜ 1. µÈÔ¯ËÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ï¢ÚÈÙÈÎÔ‡ ˘ÁÚÔ‡ Û ¯˘ÏÔıÒڷη ñ ¢È·˘Á¤˜ Î·È Î›ÙÚÈÓÔ (ÌÂÙ¿ ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË Á·Ï·ÎÙ҉˜) ñ ™Ù›ÚÔ ÌÈÎÚÔ‚›ˆÓ ñ ÕÔÛÌÔ ñ Â.‚.: 1.012-1.025 ñ ÷ڷÎÙËÚÈÛÙÈο ÚˆÙÂ˚ÓÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ, fiˆ˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ñ À„ËÏ¿ Â›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ñ ÷ÌËÏ¿ Â›‰· ¯ÔÏËÛÙÂÚ›Ó˘ ñ §Â˘ÎÔ·ÙÙ·Ú·: 6,0-8,0 x 109/l ñ §ÂÌÊÔ·ÙÙ·Ú· >80%, ΢ڛˆ˜ ∆ ÏÂÌÊÔ·ÙÙ·Ú·

Paediatriki 2002;65:199-202

O ¯˘ÏÔıÒڷη˜ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È Ì ÌË·ÓÔÛÔÏÔÁÈÎfi ÂÌ‚Ú˘˚Îfi ‡‰Úˆ·, Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙËÓ ·Ú·ÎÒÏ˘ÛË Ù˘ Â·Ó·ÊÔÚ¿˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙËÓ Î·Ú‰È¿ Ȥ˙ÔÓÙ·˜ ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÊϤ‚˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙË Ì·˙È΋ ·ÒÏÂÈ· ÚˆÙÂ˚ÓÒÓ ÛÙÔÓ Ï¢ÚԉȷÊÚ·ÁÌ·ÙÈÎfi ¯ÒÚÔ, Ë ÔÔ›· Ô‰ËÁ› Û ÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÚˆÙÂ˚Ó·ÈÌ›· Î·È Ô›‰ËÌ·. O Û˘ÁÁÂÓ‹˜ ¯˘ÏÔıÒڷη˜ ÌÔÚ› Ó· Â›Ó·È Ë ·ÈÙ›· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡. ∆· ÁÂÓÈο ̤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ¯˘ÏÔıÒڷη ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ ϤÌÊÔ˘, ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜, ÙËÓ ·Ó·Ï‹ÚˆÛË ÙˆÓ ·ÔÏÂÛı¤ÓÙˆÓ ˘ÁÚÒÓ Î·È ÙËÓ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ (7,8). ™ÙȘ ÂÚÈÙÒÛÂȘ ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ Ë ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ÒÛÙ ӷ ‰ÈÂÓÂÚÁËı› ¤ÁηÈÚ· ∫∆ Î·È Ó· ·ÔÊ¢¯ı› Ë ÂÚ·ÈÙ¤Úˆ ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘Û¯¤ÚÂÈ· (3,9). O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ۯ‰fiÓ ¿ÓÙÔÙÂ Â›Ó·È ··Ú·›ÙËÙÔ˜, ÂÂȉ‹ ˘¿Ú¯ÂÈ ·ÓÂ·Ú΋˜ ¤ÎÙ˘ÍË ÙˆÓ Ó¢ÌfiÓˆÓ, ÂÌ̤ÓÔ˘Û· ÂÌ‚Ú˘˚΋ ΢ÎÏÔÊÔÚ›· ‹ Î·È ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ. ∂Ó‰ÔÌ‹ÙÚÈ· ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη ¤¯ÂÈ ÂÊ·ÚÌÔÛÙ› ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊ¢¯ı› Ë ˘ÔÏ·Û›· ÙˆÓ Ó¢ÌfiÓˆÓ Î·È Ë ·ÛÊ˘Í›· ηٿ ÙË Á¤ÓÓËÛË, Ì ΛӉ˘ÓÔ fï˜ ÙËÓ ˘Ô-ÔÁηÈÌ›· ÙÔ˘ ÂÌ‚Ú‡Ô˘. ªÂÙ¿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ¯˘ÏÔıÒڷη, Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ Û˘Ó¯›˙ÂÙ·È Û ‚¿ÚÔ˜ ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ (‰È·Ê˘Á‹ ÛÙÔÓ ÙÚ›ÙÔ ¯ÒÚÔ), ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈηٿÛÙ·Û˘ ÙˆÓ ·ÔÏÂÛı¤ÓÙˆÓ ˘ÁÚÒÓ (fiˆ˜ Á›ÓÂÙ·È Â͈ÌËÙÚ›ˆ˜) (10). ŸÌˆ˜, Ë ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ·Ú·Î¤ÓÙËÛ˘ ÙÔ˘ ıÒڷη, Â›Ó·È Ì›· ηϋ ÂÓ·ÏÏ·ÎÙÈ΋ Ù·ÎÙÈ΋ (3,10). ™ÙȘ ÂÚÈÙÒÛÂȘ ÛÔ‚·ÚÔ‡ ¯˘ÏÔıÒڷη Ô˘ ÚÔηÏ› ÌË ·ÓÔÛÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ÂÌ‚Ú˘˚Îfi ‡‰Úˆ· ÌÔÚ› Ó· ÂȯÂÈÚËı› Ë ÚÔÁÂÓÓËÙÈ΋ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη (11) ‹ Ë Û˘Ó¯‹˜ Ï¢ÚÔ-·ÌÓȷ΋ ·ÚÔ¯¤Ù¢ÛË (pleuro-amniotic shunt) ϤÌÊÔ˘ (12). ∞Ó Á›ÓÂÈ ·Ú·Î¤ÓÙËÛË ÙÔ˘ ıÒڷη ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, Û˘Ì‚·›ÓÂÈ ÁÚ‹ÁÔÚË ˘ÔÙÚÔ‹ Î·È ÙfiÙ Ú¤ÂÈ Ó· ÙÔÔıÂÙÂ›Ù·È Û˘Ó¯‹˜ ·ÚÔ¯¤Ù¢ÛË ·Ú¿ÏÏËÏ· Ì ÌÈÎÚ‹ ›ÂÛË ·Ó·ÚÚfiÊËÛ˘. ∞˘Ù‹ Ë Ù·ÎÙÈ΋ ıˆÚÂ›Ù·È ÚÔÙÈÌfiÙÂÚË ·fi ÙȘ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ·Ϥ˜ ·Ú·ÎÂÓÙ‹ÛÂȘ. ªÂÚÈΤ˜ ÊÔÚ¤˜, Ë ËÌÂÚ‹ÛÈ· ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi ÙÔÓ Î˘ÎÏÔÊÔÚÔ‡ÌÂÓÔ fiÁÎÔ ˘ÁÚÒÓ, Ô‰ËÁÒÓÙ·˜ Û ˘Ô-ÔÁηÈÌ›·, ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›·, ˘ÔÓ·ÙÚÈ·ÈÌ›·, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Î·È ‰È·Ù·Ú·¯‹ ÛÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· (12). ∞˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ıˆÚÔ‡ÓÙ·È ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔÈ ÂÂȉ‹ ¯¿ÓÔ˘Ó Ù· ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ù· ·ÓÙÈÛÒÌ·Ù·. ∏ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· Â›Ó·È ·ÚÔ‰È΋ Î·È ‰È·ÚΛ fiÛÔ Î·È Ë ·ÒÏÂÈ· ϤÌÊÔ˘ (13). ∂Ô̤ӈ˜, ·ÛıÂÓ›˜ Ì ¯˘ÏÔıÒڷη

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·202

¶·È‰È·ÙÚÈ΋ 2002;65:199-202

Ú¤ÂÈ Ó· ·ÔÌÔÓÒÓÔÓÙ·È ·fi ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ÈÔÁÂÓ‹ Ïԛ̈ÍË Î·È Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÂÌ‚ÔÏ›ˆÓ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Û ËÏÈ˘ Ô˘ ·˘Ù¿ ÂӉ›ÎÓ˘ÓÙ·È (13). °È· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ϤÌÊÔ˘ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ›ÛÔÈ fiÁÎÔÈ ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿ÛÌ·ÙÔ˜. OÈ Kosloke Î·È Û˘Ó (8) ·Ú·Ù‹ÚËÛ·Ó ÂÏ¿ÙÙˆÛË ÛÙËÓ ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ fiÙ·Ó ¯ÔÚËÁÂ›Ù·È Á¿Ï· Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È·, Û ۇÁÎÚÈÛË Ì ÙÔ Î·ÓÔÓÈÎfi Á¿Ï·. ŸÌˆ˜, Ë Ù·ÎÙÈ΋ ·˘Ù‹ ·ÌÊÈÛ‚ËÙÂ›Ù·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∞ÊÔ‡ ·ÎfiÌË Î·È Ë fiÛË ‡‰·ÙÔ˜ ÚÔηÏ› ·‡ÍËÛË ÛÙËÓ Î˘ÎÏÔÊÔÚ›· Ù˘ ϤÌÊÔ˘, Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ÂÚÈÙÒÛÂȘ ˘ÂÚ·Ú·ÁˆÁ‹˜ ϤÌÊÔ˘ (5). ™Â ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ÛÙȘ ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη, Û˘ÁÎÚ›ıËÎÂ Ë ÔÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ì ÙËÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË Ì¤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰ÈˆÓ Î·È ÙÔ Û˘Ì¤Ú·ÛÌ· Â›Ó·È fiÙÈ Ë ÚÒÙË Ì¤ıÔ‰Ô˜ ˘ÂÚÙÂÚ› Ù˘ ‰Â‡ÙÂÚ˘ ÏfiÁˆ Ù˘ ÛËÌ·ÓÙÈ΋˜ Ì›ˆÛ˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ (10 Ë̤Ú˜ ¤Ó·ÓÙÈ 23, ·ÓÙ›ÛÙÔȯ·) (8). ™Â ÈÔ ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û˘ÁÁÂÓÔ‡˜ ¯˘ÏÔıÒڷη Ì›·˜ ‰ˆ‰ÂηÂÙ›·˜, ÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÓÈÛÙÔ‡Ó Ó· ·Ú¯›˙ÂÈ Ë Û›ÙÈÛË Ì ÌËÙÚÈÎfi ‹ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Û ·ÔÙ˘¯›· Ó· ¯ÔÚËÁÂ›Ù·È Á¿Ï· Ì ̤Û˘ ·Ï‡ÛÔ˘ ÙÚÈÁÏ˘ÎÂÚ›‰È· (14). °ÂÓÈο, Ë ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ Á¿Ï·ÎÙÔ˜ ·Ú¯›˙ÂÈ ·ÊÔ‡ Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ ¤¯ÂÈ ÛÙ·Ì·Ù‹ÛÂÈ ÁÈ· Ì›· ‚‰ÔÌ¿‰·, ÂÎÙfi˜ ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‹Ș ÌÔÚʤ˜ ¯˘ÏÔıÒڷη. ™Â ÂÚÈÙÒÛÂȘ ÂÎÙÂٷ̤ÓÔ˘ Î·È ÛÔ‚·ÚÔ‡ ¯˘ÏÔıÒڷη Ô˘ ηٷϋÁÂÈ Û ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ Î·È ÂÓÒ Ë Û˘ÓÙËÚËÙÈ΋ ıÂÚ·›· ¤¯ÂÈ ·ÔÙ‡¯ÂÈ, Ë ÂÚ¢ÓËÙÈ΋ ıˆÚ·ÎÔÙÔÌ‹ Â›Ó·È ÙÔ ÂfiÌÂÓÔ ‚‹Ì·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÂÓÒ Ë ıÓËÛÈÌfiÙËÙ· ÙÔ˘ ÂÙÂÚfiÏ¢ÚÔ˘ ¯˘ÏÔıÒڷη Â›Ó·È ¯·ÌËÏ‹, ÙÔ˘ ·ÌÊÔÙÂÚfiÏ¢ÚÔ˘ Â›Ó·È Ôχ ˘„ËÏ‹ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 60% (9). ∆ÔÓ›˙ÂÙ·È fiÙÈ Ë ¤ÁηÈÚË Î·È Î·Ù¿ÏÏËÏË Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ Â›Ó·È Û¯Â‰fiÓ ¿ÓÙ· ÂÈÙ˘¯‹˜ Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Û¿ÓÈ· ¯ÚÂÈ¿˙ÂÙ·È, ·ÎfiÌË Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ·Ú·ÁˆÁ‹ Ù˘ ϤÌÊÔ˘ ‰È·ÚΛ Ôχ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Straaten van HLM, Gerards LJ, Krediet TG. Chylothorax in the neonatal period. Eur J Pediatr 1993;152:2-5.

2. Vade A, Kramer L. Extralobar pulmonary sequestration

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Van Aerde J, Campell AN, Smyth JA, Lyoyd D, Bryan MH. Spontaneous chylothorax in newborns. Am J Dis Child 1984;138:961-964.

Puddy V, Lam BC, Tang M, Wong KY, Lam YH, Wong K et al. Variable levels of mosaicism for trisomy 21 in a nonimmune hydropic infant with chylothorax. Prenat Diagn 1999;19:764-766.

Ibrahim H, Asamoah A, Krouskop RW, Lewis D, Webster P, Pramanik AK. Congenital chylothorax in neonatal thyrotoxicosis. J Perinatol 1999;19:68-71.

Femandez Alvarez JR, Kalache KD, Grauel EL. Management of spontaneous congenital chylothorax: oral medium-chain triglycerides versus total parenteral nutrition. Am J Perinatol 1999;16:415-420.

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Carmant L, Le Guennec JC. Congenital chylothotax and persistent pulmonary hypertension of the neonate. Acta Paediatr Scan 1989;78:789-792.

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Booth P, Nicolaides KH, Greenough A, Gamsu HR. Pleuroamniotic shunting for fetal chylothorax. Early Hum Dev 1987;15:365-367.

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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-08-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ª·ÚÔ‡Ù˘ ∞Á›·˜ ∂ϤÓ˘ 2, ∆.∫. 157 72, ∑ˆÁÚ¿ÊÔ˘

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¶·È‰È·ÙÚÈ΋ 2002;65:203-207

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Paediatriki 2002;65:203-207

CASE REPORT

™˘ÁÁÂÓ‹˜ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ÚfiˆÚÔ ÓÂÔÁÓfi ∑. ÷Ù˙ËÛÙ·Ì·Ù›Ô˘1, π. ∫·Ï¤ÁÈ·˜1, O. OÈÎÔÓÔÌ›‰Ô˘1, ∂. ¶··ıˆÌ¿1, ∂. ¶Ú›ÊÙË2, µ. ¶ÂÙÚԯ›ÏÔ˘ - ¶¿Û¯Ô˘2, Ã. ∫ÒÛÙ·ÏÔ˜1

Congenital tuberculÔus lymphadenitis in a preterm infant Z. Hatzistamatiou1, J. Kaleyias1, U. Ikonomidou1, E. Papathoma1, E. Prifti2, V. Petrocheilou - Paschou2, Ch. Kostalos1

¶ÂÚ›ÏË„Ë: ∏ Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È Ì›· Û¿ÓÈ· ÓfiÛÔ˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡, ÙÔ ÔÔ›Ô ·ÚÔ˘Û›·ÛÂ Ê˘Ì·ÙÈÒ‰Ë ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ËÏÈΛ· 2 ‚‰ÔÌ¿‰ˆÓ. ∏ ÌËÙ¤Ú· ÙÔ˘ ÓÂÔÁÓÔ‡, 20 Ë̤Ú˜ ÚÈÓ ÙÔÓ ÙÔÎÂÙfi, ÓfiÛËÛ ·fi ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È ÌËÓÈÁÁ›Ùȉ·. ∏ ÌË ÂȉÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÚÔ‚ÔÏ‹˜ Ù˘ ÓfiÛÔ˘ Î·È Ë ˘„ËÏ‹ ıÓËÙfiÙËÙ· ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›· Ù˘ ÓfiÛÔ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·.

Abstract: Congenital tuberculosis is a rare disease. This is a case report of a two week-old premature infant with tuberculÔus lymphadenitis.

His mother, twenty days prior to labour, presented miliary tuberculosis and meningitis. The nonspecific nature of presenting signs and symptoms and the high mortality rate in the absence of early therapy, signify the importance of early diagnosis and treatment during the neonatal period and infancy.

§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË, ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÓÂÔÁ¤ÓÓËÙÔ.

Key words: congenital tuberculosis, lymphadenitis, newborn.

∂ÈÛ·ÁˆÁ‹ ∏ ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÙfiÙËÙ· Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ· Â›Ó·È ˘„ËÏfiÙÂÚË Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ÂÚÈfi‰Ô˘˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ· ·Ô‰›‰ÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙË Û˘¯ÓfiÙÂÚË Â›ÙˆÛË Ù˘ ÎÂÁ¯ÚÔÂȉԇ˜ Ê˘Ì·Ù›ˆÛ˘ Î·È Ù˘ Ê˘Ì·ÙÈÒ‰Ô˘˜ ÌËÓÈÁÁ›Ùȉ·˜, ·ÊÂÙ¤ÚÔ˘ ‰Â Û ηı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ ÏfiÁˆ Û˘¯Ó¿ ¿Ù˘ˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (1,2). OÈ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ÓfiÛÔ˘ Î·È Ë ÂÍ¿ψÛË ÙÔ˘ AIDS Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ïԛ̈͢ Û Á˘Ó·›Î˜ Ù˘ ·Ó··Ú·ÁˆÁÈ΋˜ ËÏÈΛ·˜ (3,4). ø˜ Â·ÎfiÏÔ˘ıÔ, ÂΉ‹ÏˆÛË Ê˘Ì·Ù›ˆÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Ô‰ËÁ› Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·fi Û˘ÁÁÂÓ‹ Ê˘Ì·Ù›ˆÛË. ¶ÂÚÈÁÚ¿ÊÂÙ·È Û¿ÓÈ· ÂÚ›ÙˆÛË ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡, ÌËÙ¤Ú·˜ Ô˘ ÓfiÛËÛ Ì ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È Ê˘Ì·ÙÈÒ‰Ë ÌËÓÈÁÁ›Ùȉ·, 20 Ë̤Ú˜ ÚÈÓ

ÙÔÓ ÙÔÎÂÙfi. ∆Ô ÓÂÔÁÓfi ·ÚÔ˘Û›·ÛÂ Ê˘Ì·ÙÈÒ‰Ë ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· ÙË ‰¤Î·ÙË ¤ÌÙË Ë̤ڷ Ù˘ ˙ˆ‹˜ ÙÔ˘.

¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·”, ∞ı‹Ó· 1 ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∫ÏÈÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiˆÚÔ ¿ÚÚÂÓ ÓÂÔÁÓfi 29 ‚‰ÔÌ¿‰ˆÓ, ÙÔ ‰Â‡ÙÂÚÔ ‰›‰˘Ì˘ ·ËÛ˘, ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. ∆Ô ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó 1150 g (50Ë ∂£) Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ 26,5 cm. (50Ë ∂£).∆Ô Apgar score ÛÙÔ ÚÒÙÔ Î·È ÙÔ ¤ÌÙÔ ÏÂÙfi ‹Ù·Ó 8 Î·È 9, ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔ ÈÛÙÔÚÈÎfi Ù˘ ÌËÙ¤Ú·˜, Ë ÔÔ›· ‹Ù·Ó ∂ÏÏËÓ›‰·, ÚˆÙ¤ÁÎ˘Ô˜ Î·È ÚˆÙÔÙfiÎÔ˜, ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÙËÓ 26Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ ÓfiÛËÛ ·fi ÎÂÁ¯ÚÔÂȉ‹ Ê˘Ì·Ù›ˆÛË Î·È Ê˘Ì·ÙÈÒ‰Ë ÌËÓÈÁÁ›Ùȉ·, ÔfiÙ ¤ÁÈÓ ÂÈÛ·ÁˆÁ‹ Ù˘ Û ÓÔÛÔÎÔÌÂ›Ô Î·È ¿Ú¯ÈÛ ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹. ∆ËÓ 29Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ ÌÂٷʤÚıËΠ̷۠È¢ÙÈ΋ ÎÏÈÓÈ΋ Î·È ˘Ô‚Ï‹ıËΠ۠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚfiˆÚ˘ ¤Ó·Ú͢ ˆ‰›ÓˆÓ. ∏ ÌËÙ¤Ú· ‹Ù·Ó ¯ÚfiÓÈÔ˜ General District Hospital “Alexandra”, Athens 1 Neonatal Department 2 Microbiology Department

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¶·È‰È·ÙÚÈ΋ 2002;65:203-207

Paediatriki 2002;65:203-207

ÊÔÚ¤·˜ Ë·Ù›Ùȉ·˜ µ, ÂÓÒ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∆Ô ÓÂÔÁÓfi ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ·fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰ÂÓ ˘‹Ú¯·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ë ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È Ù· Ë·ÙÈο ¤Ó˙˘Ì· ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ Î·È Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‹Ù·Ó ·ÚÓËÙÈ΋. ™ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÂÛÙ¿ÏËÛ·Ó ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÁÈ· ηÏÏȤÚÁÂÈ·, ∂¡À ÁÈ· ÁÂÓÈ΋ ÂͤٷÛË Î·È Î·ÏÏȤÚÁÂÈ·, ηıÒ˜ Î·È ÙÚ›· ‰Â›ÁÌ·Ù· Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ÁÈ· ·Ó·˙‹ÙËÛË Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. H ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ‹Ù·Ó ·ÚÓËÙÈ΋. ªÂÙ¿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘, ÙÔ ÓÂÔÁÓfi ‰ÂÓ ‹Ïı ϤÔÓ Û Â·Ê‹ Ì ÙË ÌËÙ¤Ú· ÙÔ˘. ¡ÔÛËχıËΠ۠ÎÏÂÈÛÙ‹ ıÂÚÌÔÎÔÈÙ›‰· ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ÏfiÁˆ ÚÔˆÚfiÙËÙ·˜ Î·È ¤Ï·‚ ¯ËÌÂÈÔÚÔʇϷÍË Ì ÈÛÔÓÈ·˙›‰Ë (10 mg/k/Ë̤ڷ) ÏfiÁˆ Ù˘ ÎÂÁ¯ÚÔÂȉԇ˜ Ê˘Ì·Ù›ˆÛ˘ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘. ∆Ô ÓÂÔÁÓfi, ÙË 12Ë Ë̤ڷ ˙ˆ‹˜, ·ÚÔ˘Û›·Û ÛË„·ÈÌ›· ·fi Klebsiella pneumoniae, ÁÈ· ÙËÓ ÔÔ›· ¤Ï·‚ ·ÓÙÈÛË„·ÈÌÈ΋ ·ÁˆÁ‹ (Amoxycillinclavulanic acid Î·È Netromycin). O Ó¤Ô˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜, ÂÎÙfi˜ ·fi ÙË ıÂÙÈ΋ ηÏÏȤÚÁÈ· ·›Ì·ÙÔ˜, ¤‰ÂÈÍ ·ÚÈıÌfi Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 9200/Ìl (¶ 60%, § 35%, ª 5%), ·ÈÌÔÂÙ·Ï›ˆÓ 80.000/Ìl Î·È Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË Â›¯Â ıÂÙÈÎÔÔÈËı› (13,5 mg/dl). H ÁÂÓÈ΋ ÙÔ˘ ∂¡À ¤‰ÂÈÍ ·ÙÙ·Ú· 30/Ìl (ÏÂÌÊÔ·ÙÙ·Ú·), ۿί·ÚÔ 67 mg/dl (Ì ۿί·ÚÔ ·›Ì·ÙÔ˜ 90 mg/dl), χΈ̷ 40mg/dl. ÕÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù· ∂¡À ¯ÚˆÌ·ÙÈṲ̂ӷ ηٿ Gram, ‹Ù·Ó ·ÚÓËÙÈο ÁÈ· ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Î·È Ë Î·ÏÏȤÚÁÂÈ· ÛÙ›ڷ ÁÈ· ÎÔÈÓ¿ ÌÈÎÚfi‚È·. ∆Ë 15Ë Ë̤ڷ ˙ˆ‹˜ Î·È ÂÓÒ ÙÔ ÓÂÔÁÓfi ‹Ù·Ó ˘fi ·ÓÙÈÛË„·ÈÌÈ΋ ·ÁˆÁ‹, ·ÚÔ˘Û›·Û ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· Î·È Ë·ÙÔÛÏËÓÈ΋ ‰ÈfiÁΈÛË

(‹·Ú 4 cm, ÛÏ‹Ó·˜ 3 cm). ∞Ú¯Èο, ›¯Â ÙÚÂȘ ÌÈÎÚÔ‡˜ ÙÚ·¯ËÏÈÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜ ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘, ÌË Â˘Î›ÓËÙÔ˘˜, ÌÂÁ¤ıÔ˘˜ ÂÚ›Ô˘ 0,5 cm. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰¤Ó˜ ÛÙËÓ ˘ÈÓȷ΋ ¯ÒÚ·, ÂÓÒ ÔÈ ÙÚ·¯ËÏÈÎÔ› ÏÂÌÊ·‰¤Ó˜ ‰ÈÏ·ÛÈ¿ÛÙËÎ·Ó Û ̤ÁÂıÔ˜ (1 cm) (∂ÈÎfiÓ· 1 Î·È 2). §fiÁˆ Ù˘ Âȉ›ӈÛ˘ Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ Î·È ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Ù˘ ÌËÙ¤Ú·˜, ÎÚ›ıËΠÛÎfiÈÌÔ Ó· ÏËÊı› ˘ÏÈÎfi ·fi ÙÔ˘˜ ÏÂÌÊ·‰¤Ó˜ ÁÈ· ‚ÈÔ„›· Î·È ÌÈÎÚÔ‚ÈÔÏÔÁÈ΋ ÂͤٷÛË. ∂›Û˘, ÂÏ‹ÊıËÛ·Ó ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ÂÛÙ¿ÏËÛ·Ó ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÁÈ· ·Ó·˙‹ÙËÛË M. tuberculosis. ∂ÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË: ∞fi ÙÔ ˘ÏÈÎfi ·Ú·Î¤ÓÙËÛ˘ ÙÔ˘ ÏÂÌÊ·‰¤Ó· ¤ÁÈÓ·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ: ∞) ÕÌÂÛ· ÌÈÎÚÔÛÎÔÈο ·Ú·Û΢¿ÛÌ·Ù·, Ù· ÔÔ›· ¯ÚˆÌ·Ù›ÛÙËηÓ: i) ηٿ Gram Î·È ii) Ì ¯ÚÒÛË Zielh-Neelsen (∑-¡). ∫·Ù¿ ÙË ÌÈÎÚÔÛÎfiËÛË ‰ÂÓ ·Ó¢ڤıËÛ·Ó Ì ÙË ¯ÚÒÛË Gram ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, ÂÓÒ ÛÙ· ·Ú·Û΢¿ÛÌ·Ù· Ì ¯ÚÒÛË ∑-¡ ·Ú·ÙËÚ‹ıËÎ·Ó ¿ÊıÔÓ· ÏÂÙ¿, ÂÏ·ÊÚ¿ ηÌ˘ÏˆÙ¿, Ô͢¿ÓÙÔ¯· ‚·ÎÙËÚ›‰È·, Ù· ÔÔ›· ‰È·Ù¿ÛÛÔÓÙ·Ó Î·Ù¿ ÌÈÎÚÔ‡˜ ÛˆÚÔ‡˜ ‹ ÌÂÌÔӈ̤ӷ ˙‡ÁË. ∏ ÌÔÚÊÔÏÔÁ›· ·˘Ù‹ ‹Ù·Ó Ù˘È΋ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ. µ) °È· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ›‰Ô˘˜ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙ· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù·, ÂÊ·ÚÌfiÛÙËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ıÂÚÌÔ·ÓıÂÎÙÈ΋˜ ÔÏ˘ÌÂÚ¿Û˘ (PCR) Û ˘ÏÈÎfi ÏÂÌÊ·‰ÂÓÈÎÔ‡ ÈÛÙÔ‡ (5). °È· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙÔ˘ DNA ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ, Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹, ÙÔ ‰È·ÁÓˆÛÙÈÎfi Û‡ÛÙËÌ· PCR-Amlicor MTB (Roche Diagnostic Systems Inc. Branchburg N.J. U.S.A.) Ô˘ ÂÓÈÛ¯‡ÂÈ ÙÔ DNA ÛÙfi¯Ô (ÌÂÁ¤ıÔ˘˜ 584 ÓÔ˘ÎÏÂÔÙȉ›ˆÓ), Ô ÔÔ›Ô˜ Έ‰ÈÎÔÔÈ› ÙÔ 16S RNA ÙÔ˘ M. Tuberculosis complex.

∂ÈÎfiÓ· 1. ∆Ú·¯ËÏÈ΋ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·.

∂ÈÎfiÓ· 2. ÀÈÓȷ΋ Î·È ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·.

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·205

¶·È‰È·ÙÚÈ΋ 2002;65:203-207

∆Ô ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂͤٷÛ˘ ‹Ù·Ó Û˘Ì‚·Ùfi Ì ÙËÓ ·ÚÔ˘Û›· ÛÙÔÓ ÈÛÙfi M. tuberculosis. °) ∫·ÏÏȤÚÁÂÈ·: ∞fi ÙÔ ˘ÏÈÎfi ÙÔ˘ ÏÂÌÊ·‰¤Ó· ¤ÁÈÓ ηÏÏȤÚÁÂÈ·, ÙfiÛÔ ÁÈ· ÎÔÈÓ¿ ÌÈÎÚfi‚È· Û ·ÈÌ·ÙÔ‡¯Ô ¿Á·Ú, fiÛÔ Î·È ÁÈ· Ì˘ÎÔ‚·ÎÙËÚ›‰È· Û ÂȉÈÎfi ıÚÂÙÈÎfi ˘ÏÈÎfi Lowenstein-Jensen. ™ÙÔ ·ÈÌ·ÙÔ‡¯Ô, ÌÂÙ¿ ·fi ÂÒ·ÛË ·ÂÚÔ‚›ˆ˜ Û ·ÙÌfiÛÊ·ÈÚ· CO2 Î·È ·Ó·ÂÚÔ‚›ˆ˜, ‰ÂÓ ·Ó·Ù‡¯ıËÎ·Ó ·ÔÈ˘ ÌÈÎÚÔ‚›ˆÓ. ™ÙÔ ˘ÏÈÎfi Lowenstein-Jensen, ÌÂÙ¿ ·fi ÂÒ·ÛË ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ ·Ó·Ù‡¯ıËÎ·Ó ·ÔÈ˘ Ô͢¿ÓÙÔ¯Ô˘ ‚·ÎÙËÚȉ›Ô˘ Ô˘ ‹Ù·Ó ÍËÚ¤˜, ‡ıÚ˘Ù˜, ΛÙÚÈÓÔ˘ ¯ÚÒÌ·ÙÔ˜. ∆Ô ‚·ÎÙËÚ›‰ÈÔ ·˘Ùfi Ù·˘ÙÔÔÈ‹ıËΠˆ˜ ª. tuberculosis. ¢) ∂˘·ÈÛıËÛ›· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο: ∆Ô M. tuberculosis Ô˘ ·ÔÌÔÓÒıËΠ·fi ÙÔÓ ÏÂÌÊ·‰¤Ó· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ¢·›ÛıËÙÔ Û fiÏ· Ù· ÚˆÙ‡ÔÓÙ· ·ÓÙÈÊ˘Ì·ÙÈο Ê¿Ú̷η (ÈÛÔÓÈ·˙›‰Ë, ÚÈÊ·ÌÈΛÓË, ÛÙÚÂÙÔÌ˘Î›ÓË, ˘Ú·˙›Ó·Ì›‰Ë Î·È Âı·Ì‚Ô˘ÙfiÏË).

OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÁÈ· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ‹Ù·Ó ·ÚÓËÙÈΤ˜.

O ÏÔÈfi˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ·ÚÈıÌfi˜ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ 9100/Ìl (¶ 37%, § 48%, ª 15%), ∆∫∂ 12 mm/1Ë ÒÚ·, SGOT 33 IU/L, SGPT 11 IU/L, ÁGt 231 IU/L. ¡¤· ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó Î·È ¿ÏÈ Ê˘ÛÈÔÏÔÁÈ΋. ∏ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ·Ú¤ÌÂÈÓ ·ÚÓËÙÈ΋ Î·È ıÂÙÈÎÔÔÈ‹ıËΠ·ÚÁfiÙÂÚ· Û ËÏÈΛ· 4 ÌËÓÒÓ (7 mm). O ¤ÏÂÁ¯Ô˜ ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∏ ‚˘ıÔÛÎfiËÛË ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. §fiÁˆ ÌË Âȉ›ӈÛ˘ Ù˘ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜, ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Ë·ÙÈÎÔ‡ ÂϤÁ¯Ô˘, Ù˘ ÛÙ·ıÂÚ‹˜ ηٿÛÙ·Û˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ù˘ ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ÓfiÛÔ˘ ·fi ˘ÏÈÎfi ÂÚÈÊÂÚÈÎÔ‡ ÏÂÌÊ·‰¤Ó·, ‰ÂÓ ÎÚ›ıËΠÛÎfiÈÌÔ Ó· ÂÏÂÁ¯ı› ÂÚ·ÈÙ¤Úˆ Ë Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Ì ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô ‹ ‚ÈÔ„›·. ™ÙÔ ÓÂÔÁÓfi ¯ÔÚËÁ‹ıËΠ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ (ÈÛÔÓÈ·˙›‰Ë 10 mg/k/Ë̤ڷ, ÚÈÊ·ÌÈΛÓË 15 mg/k/Ë̤ڷ, ˘Ú·˙ÈÓ·Ì›‰Ë 30 mg/k/Ë̤ڷ Î·È ÛÙÚÂÙÔÌ˘Î›ÓË 30 mg/k/Ë̤ڷ). ∏ ÛÙÚÂÙÔÌ˘Î›ÓË ¯ÔÚËÁ‹ıËΠÙÔ˘˜ ‰‡Ô ÚÒÙÔ˘˜ Ì‹Ó˜ Î·È Ë ÏÔÈ‹ ·ÁˆÁ‹ ÁÈ· 9 Ì‹Ó˜ Û˘ÓÔÏÈο. ∏ ÔÚ›· ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ÔÌ·Ï‹, Ì ÛÙ·‰È·Î‹ ˘Ô¯ÒÚËÛË ¤ˆ˜ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (∂ÈÎfiÓ· 3) Î·È Â¿ÓÔ‰Ô ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ‹·ÙÔ˜ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. ™Â Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÁÈÓfiÙ·Ó ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Î·È ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, ÔÈ Ôԛ˜ ‹Ù·Ó ¿ÓÙ· ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ∆Ô ¿ÏÏÔ ÓÂÔÁÓfi ‰ÂÓ ÂÌÊ¿ÓÈÛ ÎÏÈÓÈο ÛËÌ›· Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ Î·È fiϘ ÔÈ Î·ÏÏȤÚÁÂȘ Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡, ·›Ì·ÙÔ˜, ∂¡À Î·È Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ‹Ù·Ó ·ÚÓËÙÈΤ˜ ÛÙËÓ ·Ó·˙‹ÙËÛË Ì˘ÎÔ‚·-

Paediatriki 2002;65:203-207

∂ÈÎfiÓ· 3. ∆Ú·¯ËÏÈ΋ Ê˘Ì·ÙÈ҉˘ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ·Ô‰ÚÔÌ‹ ÌÂÙ¿ ·fi ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹.

ÎÙËÚȉ›ˆÓ. ¶·Ú¤ÌÂÈÓ ÛÙÔ ÙÌ‹Ì· ÏfiÁˆ ÚÔˆÚfiÙËÙ·˜ Î·È ÙÔ˘ ¯ÔÚËÁ‹ıËΠÚÔʇϷÍË Ì ÈÛÔÓÈ·˙›‰Ë. ™Â ËÏÈΛ· 3 ÌËÓÒÓ Ë ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ·Ú¤ÌÂÈÓ ·ÚÓËÙÈ΋, ÔfiÙÂ Î·È ÂÌ‚ÔÏÈ¿ÛÙËΠ̠BCG. ∫·È Ù· ‰‡Ô ÓÂÔÁÓ¿ ÂÍ‹Ïı·Ó ·fi ÙÔ ÙÌ‹Ì· Û ËÏÈΛ· 4 ÌËÓÒÓ Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™Â ËÏÈΛ· 6 ÌËÓÒÓ Î·È ÛÙ· ‰‡Ô ÓÂÔÁÓ¿ ¤ÁÈÓ·Ó ÚÔÎÏËÙ¿ ·ÎÔ˘ÛÙÈο ‰˘Ó·ÌÈο (ABR) Ù· ÔÔ›· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆· ‚Ú¤ÊË ‹Ù·Ó Û ٷÎÙÈ΋ ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ Î·È Â›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË, ¯ˆÚ›˜ ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·. ™˘˙‹ÙËÛË ª¤¯ÚÈ ÙÔ 19Ô ·ÈÒÓ·, Ë ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë ÁÈ· ÙË Û¯¤ÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ Ì ÙËÓ Î‡ËÛË ‹Ù·Ó ·˘Ù‹ Ô˘ ›¯Â ‰È·Ù˘ÒÛÂÈ Ô πÔÎÚ¿Ù˘, fiÙÈ ‰ËÏ·‰‹ Ë Î‡ËÛË Â›¯Â ¢ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÛÙËÓ ÔÚ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘ (6). ™‹ÌÂÚ·, fï˜, Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ Ë Î‡ËÛË ÂÈ‚·Ú‡ÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÔÚ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘. ∏ Á¤ÓÓËÛË ÂÓfi˜ ÓÂÔÁÓÔ‡ ÌÂ Ê˘Ì·Ù›ˆÛË Ô˘ ÌÔχÓıËΠηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ‹ ηٿ ÙÔÓ ÙÔÎÂÙfi ·ÔÙÂÏ› Û¿ÓÈ· ÂÚ›ÙˆÛË (3,7). ∏ ‚·ÎÙËÚÈ·ÈÌ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ ۈϋӷ Ù˘ ÌËÙ¤Ú·˜ Î·È Ó· ÚÔηϤÛÂÈ ÌfiÏ˘ÓÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ (8). ∏ ÌÂÙ¿‰ÔÛË Ù˘ Ïԛ̈͢ ÛÙÔ ÓÂÔÁÓfi ÌÔÚ› Ó· Á›ÓÂÈ Ì ÙÚÂȘ ÙÚfiÔ˘˜ (9): ·) ∞ÈÌ·ÙÔÁÂÓ‹˜ ‰È·ÛÔÚ¿: ∆· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ÌÔÚ› Ó· ‰È·Û·ÚÔ‡Ó ·ÈÌ·ÙÔÁÂÓÒ˜, ‰È·Ì¤ÛÔ˘ Ù˘ ÔÌÊ·ÏÈ΋˜ ÊϤ‚·˜ fiÙ·Ó ˘¿Ú¯Ô˘Ó Ê˘Ì·ÙÈÒ‰ÂȘ ·ÔÈ˘ ÛÙÔÓ Ï·ÎÔ‡ÓÙ·. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Û¯ËÌ·Ù›˙ÂÙ·È ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔ ‹·Ú ‹ ÔÏÏ·Ϥ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜,

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Paediatriki 2002;65:203-207

fiÙ·Ó Ù· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ·Ú·Î¿Ì„Ô˘Ó ÙÔ ‹·Ú ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÊÏÂ‚Ò‰Ô˘˜ fiÚÔ˘. ‚) ªÂ ηٿÔÛË: ∞ÌÓÈ·Îfi ˘ÁÚfi ÌÔÏ˘Ṳ̂ÓÔ Â›Ù ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ· ›Ù ·fi ÙÔ ÂÓ‰ÔÌ‹ÙÚÈÔ (Û ÂÚ›ÙˆÛË Ê˘Ì·ÙÈÒ‰Ô˘˜ ÂÓ‰ÔÌËÙÚ›ÙȉԘ), ÌÔÚ› Ó· ηٷÔı› ·fi ÙÔ ¤Ì‚Ú˘Ô Î·È Ó· Û¯ËÌ·ÙÈÛÙ› ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔÓ ÂÓÙÂÚÈÎfi ۈϋӷ. Á) ªÂ ÂÈÛÚfiÊËÛË: ªÔÏ˘Ṳ̂ÓÔ ·ÌÓÈ·Îfi ˘ÁÚfi ÌÔÚ› Ó· ÂÈÛÚÔÊËı› Î·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ‰È¿Û·ÚÙ˜ ÂÛٛ˜ ÛÙÔ˘˜ Ó‡ÌÔÓ˜. ∏ Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜. ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÏÈÁfiÙÂÚ˜ ·fi 300 ÂÚÈÙÒÛÂȘ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· (10) Î·È 3 ÛÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÂÏÏËÓÈ΋ (7,11). ∏ ̤ÛË ËÏÈΛ· ÎÏÈÓÈ΋˜ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ Â›Ó·È 24 Ë̤Ú˜ (‡ÚÔ˜ ·fi 1 ̤¯ÚÈ 84 Ë̤Ú˜). ∏ Û¯¤ÛË ·ÁÔÚÈÒÓ/ÎÔÚÈÙÛÈÒÓ Â›Ó·È 2/1. OÈ ϤÔÓ Û˘¯Ó¤˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 (9). ∏ Â͈Ó¢ÌÔÓÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Ô˘ ·ÚÔ˘Û›·Û ÙÔ ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Â›Ó·È ·Û˘Ó‹ı˘ ÂΉ‹ÏˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ (8%). ∆· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ ¤¯Ô˘Ó ÙÂı› ‹‰Ë ·fi ÙÔ 1935 ·fi ÙÔÓ Beitzke (4,9,12). OÈ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ú¤ÂÈ Ó· ‚Ú›ÛÎÔÓÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ‹ Ï›Á˜ Ë̤Ú˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Î·È Ó· ÙÂÎÌËÚÈÒÓÂÙ·È Ë Ê˘Ì·ÙÈ҉˘ ʇÛË ÙÔ˘˜. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ÌÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÚˆÙÔ·ı¤˜ Û‡ÌÏÂÁÌ· ÛÙÔ ‹·Ú ‹ Ó· ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ì ‚‚·ÈfiÙËÙ· Ë Èı·ÓfiÙËÙ· Â͈ÌËÙÚ›Ô˘ ÌfiÏ˘ÓÛ˘ Ì ÙËÓ ¿ÌÂÛË ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË ÌËÙ¤Ú· ‹ ·fi ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÁ‹ ÌfiÏ˘ÓÛ˘. ∆Ô ÓÂÔÁÓfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ ‹Úı Û Â·Ê‹ Ì ÙË ÌËÙ¤Ú· ÙÔ˘ ·fi ÙËÓ Ë̤ڷ Á¤ÓÓËÛ˘, Ô‡Ù ÂÎÙ¤ıËΠ¿ÌÂÛ· Û ¿ÏÏÔ ¿ÙÔÌÔ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜, ·ÊÔ‡ ÓÔÛËÏ¢fiÙ·Ó Û ¶›Ó·Î·˜ 1. ∫ÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘* ™˘ÌÙÒÌ·Ù· ‹ ÛËÌ›·

™˘¯ÓfiÙËÙ· (%)

ñ ∏·ÙÔÛÏËÓÔÌÂÁ·Ï›· ñ ∞Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ñ ¶˘ÚÂÙfi˜ ñ §ÂÌÊ·‰ÂÓÔ¿ıÂÈ· ñ ∫ÔÈÏȷ΋ ‰È¿Ù·ÛË ñ §‹ı·ÚÁÔ˜ ‹ ¢ÂÚÂıÈÛÙfiÙËÙ· ñ øÙ›ÙȘ ñ µÏ·Ùȉ҉˘ ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë ñ ŒÌÂÙÔ˜, ¿ÓÔÈ·, ΢¿ÓˆÛË, ·Ú·ÙÂÈÓfiÌÂÓÔ˜ ›ÎÙÂÚÔ˜, Û·ÛÌÔ›, ÂÙ¤¯ÂȘ

76 72 48 38 24 21 17 14 <10

* Cantwell M, Sheab Z, Costello A, Sands L, Green W, Ewing S et al. Congenital tuberculosis. NEJM 1994; 330:1051-1054

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ÎÏÂÈÛÙ‹ ıÂÚÌÔÎÔÈÙ›‰· ÛÙË ÌÔÓ¿‰· ÙÔ˘ ÙÌ‹Ì·ÙÔ˜. ¶ÚfiÛÊ·Ù·, ¤¯Ô˘Ó ÚÔÙ·ı› Ó¤· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ·ÛÊ·Ï‹ ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ (4). ªÂ ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ÙÔ ÓÂÔÁÓfi Ú¤ÂÈ Ó· ¤¯ÂÈ Ê˘Ì·ÙÈÒ‰Ë ÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ·fi Ù· ·ÎfiÏÔ˘ı·: ·) Ë ÔÚÁ·ÓÈ΋ Ê˘Ì·ÙÈ҉˘ ‚Ï¿‚Ë Ó· ¤¯ÂÈ ‰È·ÈÛÙˆı› ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜, ‚) ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi Û‡ÌÏÂÁÌ· ‹ Ë·ÙÈÎfi ÎÔÎΛˆÌ·, Á) Ê˘Ì·ÙÈ҉˘ ÊÏÂÁÌÔÓ‹ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ‹ ÙÔ˘ ÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ÌËÙ¤Ú·˜ Î·È ‰) ·ÔÎÏÂÈÛÌfi˜ Ù˘ Èı·ÓfiÙËÙ·˜ ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Â͈ÌËÙÚ›ˆ˜, Ì ÂϤÁ¯Ô ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙfi˜ ÙÔ˘. ∞fi Ù· ‰È¿ÊÔÚ· fiÚÁ·Ó·, ÔÈ Ó‡ÌÔÓ˜ Î·È ÙÔ ‹·Ú Â›Ó·È ÂΛӷ ÛÙ· ÔÔ›· ÂÓÙÔ›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· Ù· Ì˘ÎÔ‚·ÎÙËÚ›‰È· (13). ÕÏϘ ÂÓÙÔ›ÛÂȘ Â›Ó·È ÙÔ ∫¡™ (50%), Ô Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ, ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, Ô ÛÏ‹Ó·˜, ÔÈ ÓÂÊÚÔ›, Ô ÏÂÌÊÈÎfi˜ ÈÛÙfi˜, ÙÔ ‰¤ÚÌ·, ÙÔ Ì¤ÛÔ Ô˘˜ (Û˘Ó‹ıˆ˜ ‰ÂÍÈ¿ Ô˘ ÔÊ›ÏÂÙ·È Û ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ì·ÛÙÔÂȉԇ˜ ÔÛÙÔ‡) (14). °È· ÙËÓ ÙÂÎÌËÚ›ˆÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ Ë·ÙÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ ··ÈÙÂ›Ù·È ·ÓÔÈÎÙ‹ ‚ÈÔ„›· ‹ ·˘ÙÔ„›· (12). ¶ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi Û‡ÌÏÂÁÌ· ÙÂÎÌËÚÈÒÓÂÙ·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË (2 ÂÚÈÙÒÛÂȘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÌÂÙ¿ ÙÔ 1980 ÌÂÙ¿ ·fi ÓÂÎÚÔÙÔÌ‹). ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ ‰ÈÂÓÂÚÁ‹ıËΠ‚Ô„›· ‹·ÙÔ˜, ÂÂȉ‹ Ë ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒıËΠ·fi ‰Â›ÁÌ· ÂÚÈÊÂÚÈÎÔ‡ ÏÂÌÊ·‰¤Ó·, Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ú¤ÌÂÈÓÂ Ê˘ÛÈÔÏÔÁÈ΋, Ë ‰ÈfiÁΈÛË ÙÔ˘ ‹·ÙÔ˜ ‰ÂÓ ÂȉÂÈÓÒıËÎÂ Î·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ‹Ù·Ó ÛÙ·ıÂÚ‹. ∏ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙËÚ›˙ÂÙ·È Û ÌÂıfi‰Ô˘˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔ‚Ï‹Ì·Ù·, ·ÊÂÓfi˜ ÌÂÓ Â˘·ÈÛıËÛ›·˜ Î·È ÂȉÈÎfiÙËÙ·˜, fiˆ˜ Ë ·Ó·˙‹ÙËÛË ÙˆÓ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ ÛÙ· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù·, ·ÊÂÙ¤ÚÔ˘ ‰Â ··ÈÙÔ‡Ó ÌÂÁ¿ÏÔ ¯ÚfiÓÔ ÂÒ·Û˘ (8 ‚‰ÔÌ¿‰Â˜), fiˆ˜ ÔÈ Î·ÏÏȤÚÁÂȘ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË Ù· ¿ÌÂÛ· ·Ú·Û΢¿ÛÌ·Ù· ‹Ù·Ó ıÂÙÈο Î·È ·fi ÙÔ ÈÛÙÔÚÈÎfi Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó ‰˘Ó·ÙfiÓ Ô ÎÏÈÓÈÎfi˜ È·ÙÚfi˜ Ó· ı¤ÛÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÔÚȷ΋˜ ÌÂıfi‰Ô˘ (PCR) ¤‰ˆÛ ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ›‰Ô˘˜ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Ù·¯‡Ù·Ù·, ÂÓÒ ‰È·ÊÔÚÂÙÈο ı· ¯ÚÂÈ·˙fiÙ·Ó ·Ó·ÌÔÓ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚÈÒÓ Â‚‰ÔÌ¿‰ˆÓ (5). µÂ‚·›ˆ˜, Ë Î·ÏÏȤÚÁÂÈ· Â›Ó·È ·ÎfiÌË ··Ú·›ÙËÙË ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¢·ÈÛıËÛ›·˜ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘, ·ÏÏ¿ Â›Ó·È ÛËÌ·ÓÙÈÎfi Î·È ÎÚ›ÛÈÌÔ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ıÂÚ·›· ÌÔÚ› Ó· ·Ú¯›ÛÂÈ ·Ì¤Ûˆ˜ Ì ٷ ηٿ ÙÂÎÌ‹ÚÈÔ Î·Ù¿ÏÏËÏ· Ê¿Ú̷η ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Â›‰Ô˜ ÌÈÎÚÔ‚›Ô˘. ∏ ıÓËÙfiÙËÙ· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘ ›ӷÈ

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Paediatriki 2002;65:203-207

¶›Ó·Î·˜ 2. º¿Ú̷η Î·È ‰fiÛÂȘ ÁÈ· ÙË ıÂÚ·›· Ù˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘* º¿Ú̷η

πÛÔÓÈ·˙›‰Ë ƒÈÊ·ÌÈΛÓË ¶˘Ú·˙ÈÓ·Ì›‰Ë ™ÙÚÂÙÔÌ˘Î›ÓË ∂ı·Ì‚Ô˘ÙfiÏË

∫·ıËÌÂÚÈÓ‹ ‰fiÛË (mg/k/Ë̤ڷ)

¢‡Ô ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· (mg/k/‰fiÛË)

10-15 10-20 20-40 20-40 10-25

20-30 10-20 50 20-40 50

* Starke SR. Tuberculosis. Clin Perinatol 1997;24:107-126

˘„ËÏ‹ Î·È ·Ó¤Ú¯ÂÙ·È ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÍ·ÈÙ›·˜ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ‰È¿ÁÓˆÛ˘, Ë ÔÔ›· ÔÏϤ˜ ÊÔÚ¤˜ ‰˘ÛÙ˘¯Ò˜ Ù›ıÂÙ·È ÓÂÎÚÔÙÔÌÈο (15). ∆· Ê¿Ú̷η Î·È ÔÈ ‰fiÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ıÂÚ·›· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (9). ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ Ù· ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó ÈÛÔÓÈ·˙›‰Ë Ú¤ÂÈ Ó· ·›ÚÓÔ˘Ó Î·È ˘ÚȉÔÍ›ÓË. ∏ ¯ÔÚ‹ÁËÛË Ù˘ ˘ÚȉÔ͛Ӣ ÚÔÏ·Ì‚¿ÓÂÈ ÙË Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, ÛÙËÓ ÔÔ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Ë ÂÚÈÔÚÈṲ̂ÓË ÈηÓfiÙËÙ· ·ÎÂÙ˘Ï›ˆÛ˘ Ù˘ ÈÛÔÓÈ·˙›‰Ë˜ ·fi ÙÔ ‹·Ú, ¯ˆÚ›˜ Ó· ·ÚÂÌÔ‰›˙ÂÙ·È Ë ·ÓÙÈÊ˘Ì·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÌÈÓÔÁÏ˘ÎÔÛȉÒÓ ÌÔÚ› Ó· ÂÈ‚Ú·‰‡ÓÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Û·Ê‹˜ ÂÚÌËÓ›· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ (16). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÓfiÛÔ˜. ŸÌˆ˜, ÔÈ ÚfiÛÊ·Ù˜ ÌÂÙ·‚ÔϤ˜ ÛÙ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Ì ÙË ÌÂÁ¿ÏË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌÂÙ¿ ÙÔ 1985, ÂÍ·ÈÙ›·˜ ÙÔ˘ AIDS, Ù˘ ÌÂÙ·Ó¿ÛÙ¢Û˘ ·ÙfiÌˆÓ ·fi ¯ÒÚ˜ ÂÓ‰ËÌÈΤ˜ Î·È Ù˘ ‰È·ÛÔÚ¿˜ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ, ·˘Í¿ÓÔ˘Ó ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Û˘ÁÁÂÓÔ‡˜ Ê˘Ì·Ù›ˆÛ˘. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›· Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜ Ê˘Ì·Ù›ˆÛ˘ Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ÚfiÁÓˆÛË ÁÈ· ÙË ÌËÙ¤Ú· Î·È ÙÔ ÓÂÔÁÓfi.

3. Adhikari M, Pillay T, Pillay DS. Tuberculosis in the newborn: an emerging disease. Pediatr Infect Dis J 1997;16:1108-1112.

4. Cantwell M, Sheab Z, Costello A, Sands L, Green W, Ewing S et al. Congenital tuberculosis. NEJM 1994; 330:1051-1054.

5. ∑¤Ú‚· §. ªÔÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘. π·ÙÚÈ΋ 2001;79:226-228.

6. Snider DE Jr. Pregnancy and tuberculosis. Chest 1984;86:115-121.

7. ∫Ô˘ÙÛÔ˘ÏȤÚ˘ ∏, ∫·˙Ï·Ú‹˜ ∂. ™˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË. π·ÙÚÈ΋ 1970;17:419-423.

8. ™ÔψÌfi˜ °, ∫Ô˘ÙÛÔ˘ÏȤÚ˘ ∏. ∂Á΢ÌÔÛ‡ÓË Î·È Ê˘Ì·Ù›ˆÛË: ÎÏÈÓÈ΋ Î·È ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÁ·Ԣ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡. ¶·È‰È·ÙÚÈ΋ 1990;53:193-202.

9. Starke SR. Tuberculosis. Clin Perinatol 1997;24:107-126.

10. Nemir RL, O’ Haze D. Congenital tuberculosis review and diagnostic guidelines. Am J Dis Child 1985;139:284-287.

11. ∆Û›ÙÛÈη ∞, æ‡¯Ô˘ º, ™˘ÚÈÔÔ‡ÏÔ˘ µ, ∫Ú›ÎÔ˜ •, ¡ÈÎÔÏ·˝‰Ô˘ ¶. ™˘ÁÁÂÓ‹˜ Ê˘Ì·Ù›ˆÛË. ¶Ú·ÎÙÈο 38Ô˘ ¶·ÓÂÏÏËÓ›Ô˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; ∫ˆ˜. πÔ‡ÓÈÔ˜ 16-18 2000; ÛÂÏ. 112.

12. Beitzke H. Uber die angeborene tuberkulose infektion.

Ergeb Gesamten Tuberculose Forsch 1935;7:1-30.

13. Schaat HS, Nel ED. Tuberculosis presenting as cholestatic jaundice in early infancy. J Pediatr Gastroenterol Nutr 1992;15:437-439.

14. Ng PC, Hiu J, Fok TF, Nelson EA, Cheung KL, Wong W. Isolated congenital tuberculosis otitis in a preterm infant.

Acta Paediatr 1995;84:955-956.

15. Pillet P, Crill J, Rakotonirina G, Holvoet-Vermant L, Auregen G, Guyon P. Congenital tuberculosis: difficulties in early diagnosis. Arch Pediatr 1999;6:635-639.

16. Mazade MA, Evans EM, Starke SR, Corree AG. Congenital tuberculosis presenting as sepsis syndrome: case report and review of the literature. Pediatr Infect Dis J 2001;20:439-442.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Snider DE, Bloch AB. Congenital tuberculosis. Tubercle 1984;65:81-82.

2. Hageman J, Shulman S, Schreiber M, Luck S, Yogev R. Congenital tuberculosis: critical reappraisal of clinical findings and diagnostic procedures. Pediatrics 1980;66:980-984.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-01-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∑ˆ‹ ÷Ù˙ËÛÙ·Ì·Ù›Ô˘ ™ÔψÌÔ‡ 2, ∆.∫. 185 47, ¡. º¿ÏËÚÔ E-mail: kaleyias@hotmail.com

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¶·È‰È·ÙÚÈ΋ 2002;65:208-211

∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏

Paediatriki 2002;65:208-211

CASE REPORT

ƒÈÎÂÙÙÛÈÒÛÂȘ Ì ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÓfiÛÔ˘ Kawasaki ª. ªÈÙÛÒÚË1, ∂. °·Ï·Ó¿Î˘1, ¢. ª·ÌÔ˘Ï¿Î˘1, ∂. µ·ÛÈÏ¿ÎË1, ª. ∞ÓÙˆÓ›Ô˘2, ™. ™Ì˘Ú¿ÎȘ1

Rickettsial disease with clinical presentation mimicking Kawasaki disease M. Bitsori1, E. Galanakis1, D. Mamoulakis1, E. Vasilaki1, M. Antoniou2, S. Sbyrakis1

¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÂÚÈÙÒÛÂȘ ‰‡Ô ·È‰ÈÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ÓfiÛÔ Kawasaki, Ô˘ ·ԉ›¯ÙËΠÙÂÏÈο fiÙÈ Â›¯·Ó ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ. ∆Ô ÚÒÙÔ ·È‰› ‹Ù·Ó ÎÔÚ›ÙÛÈ 4 ÂÙÒÓ Ì Ïԛ̈ÍË ·fi Rickettsia typhi (ÂÓ‰ËÌÈÎfi˜ Ù‡ÊÔ˜) Î·È ÙÔ ‰Â‡ÙÂÚÔ ‹Ù·Ó ·ÁfiÚÈ 18 ÌËÓÒÓ Ì Ïԛ̈ÍË ·fi Coxiella burnetii (˘ÚÂÙfi˜ Q). ∏ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ¤ÁÈÓ Ì ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∫·È Ù· ‰‡Ô ·È‰È¿ ›¯·Ó ÈÛÙÔÚÈÎfi Â·Ê‹˜ Ì ˙Ò·. ™˘˙ËÙÔ‡ÓÙ·È ÔÈ ÔÌÔÈfiÙËÙ˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ Kawasaki Ì ÙȘ ÚÈÎÂÙÙÛÈÒÛÂȘ Î·È Ù· ‰È·ÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù· ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜.

Abstract: We report two children with a clinical presentation resembling Kawasaki disease. The first patient was a 4-year-old girl with Rickettsia typhi infection (murine typhus), and the second an 18-month-old boy with Coxiella burnetii infection (Q fever). The diagnosis was confirmed with positive serology. Both children had a history of animal contact. The similarity of manifestations of Kawasaki disease to rickettsial infections and the diagnostic pitfalls in such cases are discussed.

§¤ÍÂȘ ÎÏÂȉȿ: ÚÈÎÂÙÙÛÈÒÛÂȘ, ÓfiÛÔ˜ Kawasaki.

Key words: rickettsioses, Kawasaki disease.

∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ Kawasaki Â›Ó·È ÔÍ›· ÂÌ‡ÚÂÙË ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ· ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ô˘ ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ‚Ú¤ÊË Î·È Ó‹È·. ∞ÚÎÂÙÔ› ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ›, fiˆ˜ ›‰Ë Rickettsiae Î·È Yersinia, ÙÔ Propionibacterium acnes, Ô Èfi˜ Epstein-Barr, ÔÈ ÂÚËÙÔ˚Ô› 6 Î·È 7, ÚÂÙÚÔ˚Ô› Î·È Ô Èfi˜ Parvo, ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÙË ÓfiÛÔ, ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· ¤¯ÂÈ ÔÙ¤ ·Ô‰ÂȯÙ› ÔÔÈ·‰‹ÔÙ ۷ʋ˜ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË (1). ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki Á›ÓÂÙ·È Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË Ô˘ Ó· ÙËÓ ÂȂ‚·ÈÒÓÂÈ. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÂÚÈÙÒÛÂȘ ‰‡Ô ·È‰ÈÒÓ Ì Èı·Ó‹ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË ÓfiÛÔ˘ Kawasaki, Ô˘ ÙÂÏÈο ‰È·ÁÓÒÛÙËÎ·Ó ˆ˜ ÚÈÎÂÙÙÛÈÒÛÂȘ. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË 1Ë ∫ÔÚ›ÙÛÈ 4 ÂÙÒÓ, Ì ÂχıÂÚÔ ÚÔËÁÔ‡ÌÂÓÔ

ÈÛÙÔÚÈÎfi, ÂÈÛ‹¯ıË Ì ˘ÚÂÙfi ¤ˆ˜ 40ÔC ·fi 8Ë̤ÚÔ˘, Ì ڛÁÔ˜, Ì˘·ÏÁ›Â˜, η΋ ‰È¿ıÂÛË Î·È ÂÍ¿ÓıËÌ· Ô˘ ÂÌÊ·Ó›ÛÙËΠ‰‡Ô Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ Ù˘. ™ÙÔ ·È‰› ›¯Â ¯ÔÚËÁËı› ÎÂÊÔ˘ÚÔÍ›ÌË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ÂͤڢıÚ· ·Ú›ÛıÌÈ·, ·ÌÊÔÙÂÚfiÏ¢ÚË ÔÚ҉˘ ÂÈÂÊ˘Î›Ùȉ·, ·ÌÊÔÙÂÚfiÏ¢ÚË ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ ̤ÁÈÛÙ˘ ‰È·Ì¤ÙÚÔ˘ 2 cm, ÂÎÛÂÛËÌ·Ṳ̂ÓË ÂÚ˘ıÚfiÙËÙ· ¯ÂÈϤˆÓ Ì ڷÁ¿‰Â˜ Î·È ÁÂÓÈÎÂ˘Ì¤ÓÔ ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·Ï·ÌÒÓ Î·È ÙˆÓ ÂÏÌ¿ÙˆÓ. ∆Ô ‹·Ú Î·È Ô ÛÏ‹Ó·˜ ‹Û·Ó „ËÏ·ÊËÙ¿, 2 cm Î·È 6 cm ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó Ï¢ÎÔÂÓ›· Ì ·fiÏ˘ÙÔ ·ÚÈıÌfi Ï¢ÎÒÓ 3,5x109/L, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ 2,6x109/L, ·ÈÌÔÛÊ·ÈÚ›ÓË 11 g/dL, ıÚÔÌ‚ÔÂÓ›· Ì ·fiÏ˘ÙÔ ·ÚÈıÌfi ·ÈÌÔÂÙ·Ï›ˆÓ 103x109/L, ÌÈÎÚ‹ ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 62 U/L Î·È SGPT 85 U/L) Î·È Ù·-

1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ 2 ∆Ì‹Ì· µ·ÎÙËÚÈÔÏÔÁ›·˜-¶·Ú·ÛÈÙÔÏÔÁ›·˜-∑ˆÔÓfiÛˆÓ Î·È °ÂˆÁÚ·ÊÈ΋˜ π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘

1 Department of Pediatrics, University of Crete 2 Department of Bacteriology-Parasitology-Zoonoses and Geographical Medicine, University of Crete

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¶·È‰È·ÙÚÈ΋ 2002;65:208-211

¯‡ÙËÙ· ηı›˙ËÛ˘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (∆∫∂) 41 mm/h. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜. ™ÙÔ Ù¤Ù·ÚÙÔ 24ˆÚÔ ÓÔÛËÏ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÈÛÙÒıËΠ·˘¯ÂÓÈ΋ ‰˘Ûη̄›· Î·È Ô›‰ËÌ· ÂÏÌ¿ÙˆÓ. ∏ ÁÂÓÈ΋ ÂͤٷÛË ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ (∂¡À) ¤‰ÂÈÍ 22 ÏÂ˘Î¿/mm3 (18 ÏÂÌÊÔ·ÙÙ·Ú· Î·È 4 Ô˘‰ÂÙÂÚfiÊÈÏ·), ÌÂ Ê˘ÛÈÔÏÔÁÈο Â›‰· ÁÏ˘Îfi˙˘ Î·È ÚˆÙ½Ó˘. ªÂ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki, ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· Á-ÛÊ·ÈÚ›ÓË Û ̛· ‰fiÛË ÙˆÓ 2 g/kg Î·È ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘ (5 mg/kg/24ˆÚÔ) ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ŒÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙÒıËΠÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Èfi Epstein-Barr, ÂÚËÙÔ˚Ô‡˜ 1 Î·È 2, ·‰ÂÓÔ˚fi, Borrelia burgdoferi Î·È Leishmania donovani ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ÔÍ›· Ïԛ̈ÍË. OÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· Rickettsia typhi, Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡, ÙËÓ ÚÒÙË Î·È ÙËÓ Ù¤Ù·ÚÙË Ë̤ڷ ÓÔÛËÏ›·˜ ‹Ù·Ó IgM 1:400 Î·È 1:25.600 Î·È IgG 1:30.720 Î·È 1:61.440 ·ÓÙ›ÛÙÔȯ·, ÂȂ‚·ÈÒÓÔÓÙ·˜ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÓ‰ËÌÈÎÔ‡ Ù‡ÊÔ˘. ™Â ÂÚÒÙËÛË ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· Èı·Ó‹ Â·Ê‹ Ì ˙Ò·, ¤ÁÈÓ ÁÓˆÛÙfi ÂÎ ÙˆÓ ˘ÛÙ¤ÚˆÓ fiÙÈ ÙÔ ·È‰› ‚Ú¤ıËΠӷ ·›˙ÂÈ Ì ÓÂÎÚ¿ ÔÓÙ›ÎÈ· ÛÙÔ ˘fiÁÂÈÔ Ù˘ ηÙÔÈΛ·˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ï›Á˜ Ë̤Ú˜ ÚÈÓ ÂÌÊ·ÓÈÛÙÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù¿ ÙÔ˘. ™ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜, Ù· Û˘ÌÙÒÌ·Ù· ˘Ô¯ÒÚËÛ·Ó ÛÙ·‰È·Î¿ ¯ˆÚ›˜ οÔÈ· ÂÈϤÔÓ ·ÁˆÁ‹. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·ÔϤÈÛË. ∆Ô ·È‰› ÂÍ‹Ïı ÌÂÙ¿ ·fi ÓÔÛËÏ›· ‰¤Î· ËÌÂÚÒÓ. ™Â Â·Ó·ÏËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ‰‡Ô ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹. ™Â ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 16 ÌËÓÒÓ ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÚÔ‚Ï‹Ì·Ù·. ¶ÂÚ›ÙˆÛË 2Ë ∞ÁfiÚÈ 18 ÌËÓÒÓ ÂÈÛ‹¯ıË Ì ˘ÚÂÙfi Î·È ‚‹¯· ·fi 8Ë̤ÚÔ˘. ∞ӷʤÚıËÎÂ, Â›Û˘, fiÙÈ ·ÚÔ˘Û›·Û ÂÍ¿ÓıËÌ· ÛÙÔÓ ÎÔÚÌfi ¤ÓÙ Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘, Ô˘ ˘Ô¯ÒÚËÛ Û ÙÚÂȘ Ë̤Ú˜. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ·ÌÊÔÙÂÚfiÏ¢ÚË ˘Ò‰Ë˜ ÂÈÂÊ˘Î›Ùȉ·, ÂͤڢıÚ· ÊÏÂÁÌ·›ÓÔÓÙ· ·Ú›ÛıÌÈ· Î·È ¿Êı˜ ÛÙÔ ÛÙÔ-

Paediatriki 2002;65:208-211

Ì·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ·ÌÊÔÙÂÚfiÏ¢ÚÔÈ ˘ÁÚÔ› ÚfiÁ¯ÔÈ Î·È ‹ÈÔ Ô›‰ËÌ· ·Ï·ÌÒÓ Î·È ÂÏÌ¿ÙˆÓ. ∆Ô ‹·Ú Î·È Ô ÛÏ‹Ó·˜ ‹Ù·Ó „ËÏ·ÊËÙ¿, 5 cm Î·È 2 cm οو ·fi Ù· ·ÓÙ›ÛÙÔȯ· Ï¢ÚÈο ÙfiÍ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ï¢ÎÒÓ 13,3x109/L, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ 6,9x109/L, ·ÈÌÔÛÊ·ÈÚ›ÓË 9,2 g/dL, ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ 903x109/L, ÌÈÎÚ‹ ·‡ÍËÛË ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ (SGOT 45 U/L Î·È SGPT 60 U/L) Î·È ∆∫∂ 85 mm/h. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜ Î·È Ë Î·ÏÏȤÚÁÂÈ· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·Ó¤‰ÂÈÍÂ Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù¤ıËΠ˘fiÓÔÈ· ÓfiÛÔ˘ Kawasaki, ÙÔ ·È‰› ‰ÂÓ ‹Ú ÙËÓ ÂӉ‰ÂÈÁ̤ÓË ·ÁˆÁ‹, ηıÒ˜ ‰ÂÓ ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ÃÔÚËÁ‹ıËΠÌfiÓÔ ÎÏ·ÚÈıÚÔÌ˘Î›ÓË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÈÔ‡˜ ÁÚ›˘, ·Ú·ÁÚ›˘ Î·È Coxsackie, ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi, ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi, Èfi Epstein-Barr Î·È Mycoplasma pneumoniae ‹Ù·Ó ·ÚÓËÙÈÎfi˜ ÁÈ· ÔÍ›· Ïԛ̈ÍË. OÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Ù˘ Ê¿Û˘ ππ Ù˘ Coxiella burnetii Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ‹Ù·Ó IgM 1:100 Î·È IgG 1:400. O ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛ ÛÙȘ ÂfiÌÂÓ˜ ‰‡Ô Ë̤Ú˜ Î·È Ù· ÏÔÈ¿ ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ‚ÂÏÙÈÒıËÎ·Ó ÛÙ·‰È·Î¿. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·ÔϤÈÛË ÛÙȘ ·Ï¿Ì˜ Î·È Ù· ¤ÏÌ·Ù·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Ô˘ ¤ÁÈÓ ÙËÓ ¤ÌÙË Ë̤ڷ ÓÔÛËÏ›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. ª›· ‚‰ÔÌ¿‰· ·ÚÁfiÙÂÚ·, ÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· Coxiella burnetii ‹Ù·Ó IgM 1:400 Î·È IgG 1:1920. ŒÙÛÈ ÂȂ‚·ÈÒıËÎÂ Ë ‰È¿ÁÓˆÛË ˘ÚÂÙÔ‡ Q. Ÿˆ˜ ‰È¢ÎÚÈÓ›ÛÙËΠ·fi ÙÔ ÈÛÙÔÚÈÎfi, ÙÔ ·È‰› ‰ÂÓ Â›¯Â ¿ÏÏË Â·Ê‹ Ì ˙Ò·, ÂÎÙfi˜ ·fi ÙÔ˘˜ ÙÚÂȘ Û·ÏÔ˘˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™Â ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 3 ÂÙÒÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ¿ÏÏ· ÚÔ‚Ï‹Ì·Ù·. ™˘˙‹ÙËÛË O ÂÓ‰ËÌÈÎfi˜ Ù‡ÊÔ˜ (Rickettsia typhi) Î·È Ô ˘ÚÂÙfi˜ Q (Coxiella burnetii) Â›Ó·È ÂÓ‰ËÌÈΤ˜ ÏÔÈÌÒÍÂȘ ÛÙȘ ªÂÛÔÁÂȷΤ˜ ¯ÒÚ˜ Î·È ÛÙÔ ÓËÛ› Ù˘

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÓfiÛÔ˘ Kawasaki Û ‰‡Ô ·È‰È¿ Ì Ïԛ̈ÍË ·fi R. typhi Î·È C. Burnetii ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÓfiÛÔ˘ Kawasaki

¶ÂÚ›ÙˆÛË 1Ë

¶ÂÚ›ÙˆÛË 2Ë

ñ ¶˘ÚÂÙfi˜ ‰È¿ÚÎÂÈ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ 5 ËÌÂÚÒÓ ñ ¶·ÚÔ˘Û›· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÂÛÛ¿ÚˆÓ ·fi Ù· ·ÎfiÏÔ˘ı· ¤ÓÙ ÛËÌ›· ∞ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ·, Û˘Ó‹ıˆ˜ ÌË ˘Ò‰Ë˜ ∞ÏÏÔÈÒÛÂȘ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ· ∞ÏÏÔÈÒÛÂȘ ¿ÎÚˆÓ ¯ÂÈÚÒÓ-Ô‰ÒÓ ∂Í¿ÓıËÌ·, ΢ڛˆ˜ ÎÔÚÌÔ‡, ÔχÌÔÚÊÔ ·ÏÏ¿ ÌË Ê˘Û·Ïȉ҉˜ ∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ· >1,5 cm, Û˘Ó‹ıˆ˜ ÂÙÂÚfiÏ¢ÚË

¡·È (13 Ë̤Ú˜)

¡·È (10 Ë̤Ú˜)

¡·È ¡·È ¡·È ¡·È ¡·È, ·ÌÊÔÙÂÚfiÏ¢ÚË

¡·È, ˘Ò‰Ë˜ ¡·È ¡·È ¡·È Ÿ¯È

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·210

¶·È‰È·ÙÚÈ΋ 2002;65:208-211

∫Ú‹Ù˘ (2,3). ∏ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ Ïԛ̈͢ Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ (IFAT, bioMérieux) ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÂȉÈÎÒÓ IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Û ٛÙÏÔ˘˜ >1:40 ‹/Î·È ÙÂÙÚ·Ï·ÛÈ·ÛÌfi ÙÔ˘ Ù›ÙÏÔ˘ Û Â·Ó·ÏËÙÈÎfi ‰Â›ÁÌ· 2-3 ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ·. ™ÙÔ ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜, Ë Ì¤ıÔ‰Ô˜ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ¤Ó·ÚÍË ÙËÓ ·Ú·›ˆÛË 1:25 ÁÈ· Ù· πgª ·ÓÙÈÛÒÌ·Ù· Î·È ÙËÓ ·Ú·›ˆÛË 1:60 ÁÈ· Ù· IgG. ∏ ÓfiÛÔ˜ Kawasaki Û˘Ó‰¤ıËΠ̠ÙȘ ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ ’70, fiÙ·Ó ‰È·ÈÛÙÒıËÎ·Ó ÛˆÌ·Ù›‰È· Ì ÌÂÁ¿ÏË ÔÌÔÈfiÙËÙ· Ì ÚÈΤÙÙÛȘ Û ˘ÏÈÎfi ‚ÈÔ„›·˜ ÛÏ‹Ó· ·ÛıÂÓÒÓ Ì ÓfiÛÔ Kawasaki (4). ™ÙË Û˘Ó¤¯ÂÈ·, ÂÚÈÁÚ¿ÊËÎ·Ó ·ÛıÂÓ›˜ ÌÂ Û˘ÌÙÒÌ·Ù· ÂÓ‰ÂÈÎÙÈο ÓfiÛÔ˘ Kawasaki Î·È ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Û˘Ì‚·Ùfi Ì ÔÍ›· Ïԛ̈ÍË ·fi C. burnetii (5). MÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ÙË Û˘Û¯¤ÙÈÛË (6), ˆÛÙfiÛÔ Ù· ÎÔÈÓ¿ ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·fi ÚÈΤÙÙÛȘ Î·È Ù˘ ÓfiÛÔ˘ Kawasaki, fiˆ˜ ·Ú·ÙÂÈÓfiÌÂÓÔ˜ ˘ÚÂÙfi˜, ÂÍ¿ÓıËÌ· Î·È Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Î·È ÙÔ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· Ô˘ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó, ¤¯Ô˘Ó ‹‰Ë ÂÈÛËÌ·Óı› ÁÈ· ÙÔ ªÂÛÔÁÂÈ·Îfi ÎËÏÈ‰Ò‰Ë ˘ÚÂÙfi (R. conorii) (7,8). ∏ ·ÛıÂÓ‹˜ Ì·˜ Ì Ïԛ̈ÍË ·fi R. typhi ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki (¶›Ó·Î·˜ 1). ∏ ÏÂÈÔ·ÙÙˆÛË ÙÔ˘ ∂¡À, Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÓfiÛÔ˘ Kawasaki, ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ›˜ Ì ÂÓ‰ËÌÈÎfi Ù‡ÊÔ (9). ∏ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹ Ô˘ ‰È·ÈÛÙÒıËΠÛÙËÓ ·ÛıÂÓ‹ Ì·˜ ‰ÂÓ ¤¯ÂÈ, ·’ fiÛÔ ÁÓˆÚ›˙Ô˘ÌÂ, ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ‹ Ì Ïԛ̈ÍË ·fi R. typhi, ı· ÌÔÚÔ‡Û fï˜ Ó· Â›Ó·È Û˘Ì‚·Ù‹ Ì ÓfiÛÔ Kawasaki. ∆Ô ·È‰› ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠Á-ÛÊ·ÈÚ›ÓË ÚÈÓ Á›ÓÔ˘Ó ÁÓˆÛÙ¿ Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÔÚÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘. OÈ ˘„ËÏÔ› Ù›ÙÏÔÈ IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ Ù˘ R. typhi ÙËÓ fiÁ‰ÔË Î·È ‰ˆ‰¤Î·ÙË Ë̤ڷ Ù˘ ÓfiÛÔ˘ Î·È Ô ÙÂÙÚ·Ï·ÛÈ·ÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgM ·ÓÙÈÛˆÌ¿ÙˆÓ ÂȂ‚·›ˆÛ·Ó ÙËÓ ÔÍ›· Ïԛ̈ÍË. O Ù›ÙÏÔ˜ ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔ Â·Ó·ÏËÙÈÎfi ‰Â›ÁÌ· ‹Ù·Ó ÌfiÓÔ ‰ÈÏ¿ÛÈÔ˜ ÙÔ˘ ·Ú¯ÈÎÔ‡, fï˜ Ù· ‰‡Ô ‰Â›ÁÌ·Ù· ÂÏ‹ÊıËÛ·Ó Ì ÌÈÎÚ‹ ¯ÚÔÓÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙÔ˘˜, ÏfiÁˆ Ù˘ ÂÈΛÌÂÓ˘ ¯ÔÚ‹ÁËÛ˘ Ù˘ Á-ÛÊ·ÈÚ›Ó˘. §fiÁˆ Ù˘ Ï‹„˘ Ù˘ Á-ÛÊ·ÈÚ›Ó˘, ÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ‰ÂÓ Â·Ó·Ï‹ÊıËÎ·Ó ÛÙË Ê¿ÛË ·Ó¿ÚÚˆÛ˘. ∆· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·È‰ÈÔ‡ ˘Ô¯ÒÚËÛ·Ó ¯ˆÚ›˜ ÂȉÈ΋ ıÂÚ·›· Î·È ‰ÂÓ ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹. Ÿˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÂÓ‰ËÌÈÎÔ‡ Ù‡ÊÔ˘ ÛÙ· ·È‰È¿ Ë ÓfiÛÔ˜ ¤¯ÂÈ ‹È· ÔÚ›· Î·È ˘Ô-

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¯ˆÚ› ·ÎfiÌË Î·È ¯ˆÚ›˜ ÂȉÈ΋ ·ÁˆÁ‹ (3).

O ˘ÚÂÙfi˜ Q ıˆÚÂ›Ù·È ·Û˘Ó‹ı˘ ÛÙ· ·È‰È¿ Î·È Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ Â›Ó·È ÏÈÁfiÙÂÚÔ Î·Ï¿ ÁÓˆÛÙ‹ ÛÙËÓ ËÏÈΛ· ·˘Ù‹. ∞Ó Î·È ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ˆ˜ Ó¢ÌÔÓ›Ùȉ·, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ Ïԛ̈ÍË Ì ¢ڇ Ê¿ÛÌ· ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (10). ∂Í¿ÓıËÌ· ¤¯ÂÈ ·Ó·ÊÂÚı› Û¿ÓÈ· (10). O ·ÛıÂÓ‹˜ Ì·˜ ›¯Â Û˘ÌÙÒÌ·Ù· Û˘Ì‚·Ù¿ Ì ÓfiÛÔ Kawasaki, fï˜ Ë ‰È¿ÁÓˆÛË ‰ÂÓ ÙÂÎÌËÚÈÒıËÎÂ, ηıÒ˜ ‰ÂÓ ÏËÚÔ‡Û fiÏ· Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). ∆Ô ·È‰› ‰ÂÓ ¤Ï·‚ ·ÁˆÁ‹ Ì Á-ÛÊ·ÈÚ›ÓË, ÂϤÁ¯ıËΠfï˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Î·È ·Ú·ÎÔÏÔ˘ı‹ıËΠÌÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘. O ÙÂÙÚ·Ï·ÛÈ·ÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgM ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Ë ·‡ÍËÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgG ÂȂ‚·›ˆÛ·Ó ÙË ‰È¿ÁÓˆÛË ÔÍ›·˜ Ïԛ̈͢ ·fi Coxiella burnetii. ∏ ÂÓÂÚÁÔÔ›ËÛË ∆-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ˘ÂÚ·ÓÙÈÁfiÓ· ¤¯ÂÈ ıˆÚËı› ˆ˜ Èı·Ófi˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ÓfiÛÔ˘ Kawasaki Î·È ÂÓ‰¤¯ÂÙ·È Û ¤Ó· ÔÛÔÛÙfi ÂÚÈÙÒÛÂˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› fiˆ˜ ÔÈ ÚÈΤÙÙÛȘ Ó· ÌÔÚÔ‡Ó Ó· ‰Ú¿ÛÔ˘Ó Ì ·˘Ùfi ÙÔÓ ÙÚfiÔ (13). ªÔÏÔÓfiÙÈ Ë Ì¤¯ÚÈ ÙÒÚ· ¤Ú¢ӷ ‰ÂÓ ¤¯ÂÈ ·ԉ›ÍÂÈ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË ÙˆÓ ÚÈÎÂÙÙÛÈÒÓ Ì ÙË ÓfiÛÔ Kawasaki, ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÚÈΤÙÙÛȘ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki Û ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜. O Û˘Ó‹ı˘ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ Â›Ó·È ÂȉÈÎfi˜ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÚÔ˜ ÙÔ ·ÚfiÓ Ì¤ıÔ‰Ô˜ Ô˘ Ó· ÌÔÚ› Ó· ÙÂÎÌËÚÈÒÛÂÈ ÓˆÚ›˜ ÙË ‰È¿ÁÓˆÛË. ŸÌˆ˜, ·ÊÔ‡ Ë ÓfiÛÔ˜ Kawasaki ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛÙ›, Ë Î·Ù¿ÏÏËÏË ·ÁˆÁ‹ ‰ÂÓ ı· Ú¤ÂÈ Ó· ηı˘ÛÙÂÚ› Û ÂÚÈÙÒÛÂȘ Ô˘ ÏËÚÔ‡ÓÙ·È Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘ ÓfiÛÔ˘ Kawasaki, ·ÎfiÌË Î·È ·Ó Ù›ıÂÙ·È ˘fiÓÔÈ· ÚÈÎÂÙÙÛ›ˆÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Melish ME. Kawasaki syndrome. Pediatr Rev 1996; 17:153-162.

2. Antoniou M, Tselentis Y, Gikas A, Stratigakis N, Vlachonikolis I, Kafatos A et al. The seroprevalence of ten zoonoses in two villages in Crete, Greece. Eur J Epidemiol 1995;11:415-423.

3. ™Ù·˘Ú¿Î˘ π, ¶··ÁˆÚÁ›Ô˘ Ã, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢, ª·ÏˆÌÂÓ¿ÎË ∂. §Ô›ÌˆÍË ·fi Rickettsia typhi - Ì˘˚Îfi˜ ÂÍ·ÓıËÌ·ÙÈÎfi˜ Ù‡ÊÔ˜ - Û ·È‰È¿. ¶·È‰È·ÙÚÈ΋ 1996; 59:194-200.

4. Carter RF, Haynes ME, Morton J. Rickettsia like bodies and splenitis in Kawasaki disease. Lancet 1976;ii: 1254-1255.

5. Swaby ED, Fisher-Hoch S, Lambert HP, Stern H. Is Kawasaki disease a variant of Q fever? Lancet 1980;2:146.

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Parha S, Garoufi A, Yiallouros P, Theodoridis CH, Karpathios TH. Carbamazepine hypersensitivity and rickettsiosis mimicking Kawasaki disease. Eur J Pediatr 1993;52:1040-1041.

Jenkins Dr, Rees JC, Pollitt C, Cant A, Craft AW. Mediterranean spotted fever mimicking Kawasaki disease.

BMJ 1997;314:655-666.

Dumler JS, Taylor JP, Walker DH. Clinical and laboratory features of murine typhus in south Texas, 1980 though 1987. JAMA 1991;266:1365-1370.

Tselentis Y, Gikas A, Kofteridis D, Kyriakakis E, Lydataki N,

Bouros D et al. Q fever in the Greek island of Crete: epidemiological, clinical and therapeutic data from 98 cases. Clin Infect Dis 1995;20:1311-1316.

11. Meissner HC, Leung DYM. Superantigens, conventional antigens and the etiology of Kawasaki syndrome. Pediatr Infect Dis J 2000;19:91-94.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 13-11-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 04-04-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ªÈÙÛÒÚË ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶∂¶∞°¡∏ ∆.£. 1352, ∆.∫. 711 10, ∏Ú¿ÎÏÂÈÔ E-mail: bitmar@hol.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∆· ÚÔ‚ÈÔÙÈο ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘1 ∂ÈÛ·ÁˆÁ‹: ∏ Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ ı· ‹Ù·Ó ¤Ó· ÛËÌ·ÓÙÈÎfi Â›Ù¢ÁÌ· ÁÈ· ÙË ‰ËÌfiÛÈ· ˘Á›·, ȉ›ˆ˜ ÙˆÓ ‰˘ÙÈÎÒÓ ÎÔÈÓˆÓÈÒÓ. ™‡Ìʈӷ Ì ÙËÓ ˘ÁÈÂÈÓÈÛÙÈ΋ ˘fiıÂÛË, Ë ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ ·Ô‰›‰ÂÙ·È ÛÙË ÌÂȈ̤ÓË ÌÈÎÚԂȷ΋ ¤ÎıÂÛË ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ∆· ÚÔ‚ÈÔÙÈο Â›Ó·È Î·ÏÏȤÚÁÂȘ ‰˘ÓËÙÈο “¢ÂÚÁÂÙÈÎÒÓ” ÌÈÎÚÔ‚›ˆÓ, Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó ÛÙË ¯ÏˆÚ›‰· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÂÓÙ¤ÚÔ˘. ™ÎÔfi˜: ∫‡ÚÈÔ ÛÎÔfi ·ÔÙ¤ÏÂÛÂ Ë ÌÂϤÙË Ù˘ Â›‰Ú·Û˘ ÛÙËÓ ·ÙÔÈ΋ ÓfiÛÔ ÙÔ˘ Ï·ÎÙÔ‚¿ÎÈÏÏÔ˘ GG (Ë ¯Ú‹ÛË ÙÔ˘ ¤¯ÂÈ ·Ô‰Âȯı› ·ÛÊ·Ï‹˜ ÛÙË ÌÈÎÚ‹ ËÏÈΛ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË ıÂÚ·›· Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™Â ‰ÈÏ‹ Ù˘ÊÏ‹ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ‰fiıËΠϷÎÙÔ‚¿ÎÈÏÏÔ˜ GG ÚÈÓ ÙÔÓ ÙÔÎÂÙfi Û ÌËÙ¤Ú˜ Ô˘ ›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó·Ó ÚÒÙ˘ ‚·ıÌ›‰·˜ Û˘ÁÁÂÓ‹ (‹ Û‡ÓÙÚÔÊÔ) Ì ·ÙÔÈÎfi ¤Î˙ÂÌ·, ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‹ ¿ÛıÌ· Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÁÈ· 6 Ì‹Ó˜ ÛÙ· ‚Ú¤ÊË ÙÔ˘˜. ∆Ô ¯ÚfiÓÈÔ ˘ÔÙÚÔÈ¿˙ÔÓ ·ÙÔÈÎfi ¤Î˙ÂÌ· Ô˘ Â›Ó·È Ë Î˘ÚÈfiÙÂÚË ÂΉ‹ÏˆÛË ·ÏÏÂÚÁ›·˜ Ù· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ‹Ù·Ó Ë Î‡ÚÈ· ·Ú¿ÌÂÙÚÔ˜ ÌÂϤÙ˘. ∞ÔÙÂϤÛÌ·Ù·: ∞ÙÔÈÎfi ¤Î˙ÂÌ· ‰È·ÁÓÒÛÙËΠ۠46 ·fi Ù· 132 ·È‰È¿ (35%) ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ. ÕÛıÌ· ‰È·ÁÓÒÛÙËΠ۠6 Î·È ·ÏÏÂÚÁÈ΋ ÚÈÓ›ÙȘ Û ¤Ó·. ∏ Û˘¯ÓfiÙËÙ· ÂÎ˙¤Ì·ÙÔ˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ô˘ ‹Ú ÚÔ‚ÈÔÙÈο ‹Ù·Ó

ηٿ ÙÔ ‹ÌÈÛ˘ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ ÔÌ¿‰· placebo (15/64 [23%] vs 31/68 [46%], Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ 0,51 [95% CI 0,320,84]). ™˘ÌÂÚ¿ÛÌ·Ù·: O Ï·ÎÙÔ‚¿ÎÈÏÏÔ˜ GG ‚ÔËı¿ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÚÒÈÌ˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘ Û ·È‰È¿ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. º·›ÓÂÙ·È fiÙÈ Ë ¯ÏˆÚ›‰· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ËÁ‹ Ê˘ÛÈÎÒÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÒÓ Î·È ÚÔ‚ÈÔÙÈÎÒÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ÓfiÛÔ˘.

1 Kalliomaki M, Salminen S, Arvilomni H, Kero P, Koskinen P, Isolauri E Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial Lancet 2001;357:1076-1079

°ÈÒÙ· π. ∫·ÊÚ›ÙÛ· ¶·È‰›·ÙÚÔ˜-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜ ¢È‰¿ÎÙˆÚ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

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CURRENT ISSUES

∂ÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ °. ∆ÛfiÏ·˜, °. ∫·Ê·Ï›‰Ë˜, °. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜

The assessment and management of pain in children G. Tsolas, G. Kafalidis, G. Triantafyllidis

¶ÂÚ›ÏË„Ë: O Ô͇˜ fiÓÔ˜ ·ÔÙÂÏ› ÙÔ Û˘ÓËı¤ÛÙÂÚÔ, ·ÏÏ¿ Î·È ÙÔ ϤÔÓ ÂÓÔ¯ÏËÙÈÎfi ˘ÔÎÂÈÌÂÓÈÎfi Û‡Ìو̷ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤Ó· ·È‰› ÛÙÔ Ï·›ÛÈÔ ÙÚ·˘Ì·ÙÈÛÌÒÓ, ÓÔÛËÌ¿ÙˆÓ ‹ Î·È ·Ó·Áη›ˆÓ È·ÙÚÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ Î·È ÙÔ ÔÔ›Ô Û¯Â‰fiÓ ¿ÓÙ· Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ Â›Â‰Ô ·ÓËÛ˘¯›·˜ Î·È Â·ÁÚ‡ÓËÛ˘ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶·Ú¿ ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÂÈÙÒÛÂˆÓ Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ÙÔ ·›ÛıËÌ· ÙÔ˘ fiÓÔ˘ ÛÙÔ ·È‰› , Û˘¯Ó¿ ˘ÔÂÎÙÈÌ¿Ù·È Î·È ˘ÔıÂÚ·‡ÂÙ·È ÂÍ·ÈÙ›·˜ ÂÛÊ·ÏÌ¤ÓˆÓ ·ÓÙÈÏ‹„ˆÓ, fiˆ˜ .¯. fiÙÈ Ù· ·È‰È¿ ‰ÂÓ ·ÈÛı¿ÓÔÓÙ·È ÙÔÓ fiÓÔ fiˆ˜ ÔÈ ÂÓ‹ÏÈΘ ‹ fiÙÈ “Ô fiÓÔ˜ ‰È·ÌÔÚÊÒÓÂÈ ¯·Ú·ÎÙ‹Ú·”, ηıÒ˜ Î·È ÏfiÁˆ ÙÔ˘ Êfi‚Ô˘ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ Ê·Ú̿ΈÓ. OÈ ·ÓÙÈÏ‹„ÂȘ ·˘Ù¤˜, ηıÒ˜ Î·È ÔÈ ·ÓÂ·ÚΛ˜ ÁÓÒÛÂȘ ÙˆÓ ·È‰È¿ÙÚˆÓ Á‡Úˆ ·fi ÙÔ ı¤Ì· ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘, ·ÚÂÌ‚·›ÓÔ˘Ó ·Ó·ÛÙ·ÏÙÈο ÛÙË ‰È·‰Èηۛ· ·Ó·ÁÓÒÚÈÛ˘, ÛˆÛÙ‹˜ ÂÎÙ›ÌËÛ˘ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ıÂÚ·›·˜ ÙÔ˘. ∏ ÂΉ‹ÏˆÛË ÙÔ˘ fiÓÔ˘ ·ÔÙÂÏ› ÙË Û˘ÓÈÛٷ̤ÓË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ, „˘¯ÔÏÔÁÈÎÒÓ Î·È Û˘Ó·ÈÛıËÌ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ηıÒ˜ Î·È ¿ÏÏˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹, ÂÓÒ Ì¤Ûˆ ·˘ÙÔ‡ ÙÔ ·È‰› ÂÎÊÚ¿˙ÂÈ ÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯È΋ ‰˘Û·Ú¤ÛÎÂÈ· Ô˘ ·ÈÛı¿ÓÂÙ·È ÌÂÙ¿ ·fi Ú·ÁÌ·ÙÈ΋ ‹ ‰˘ÓËÙÈ΋ ‚Ï¿‚Ë ÙˆÓ ÈÛÙÒÓ. O fiÓÔ˜ Â›Ó·È ÌÈ· ÂÓ‰ÔÁÂÓ‹˜ ˘ÔÎÂÈÌÂÓÈ΋ Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÂÌÂÈÚ›· Î·È ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÂ›Ù·È Î·È Ó· ıÂÚ·‡ÂÙ·È ˆ˜ Ù¤ÙÔÈ·. ŸÙ·Ó ÏÔÈfiÓ ÙÔ ÂÈ‚¿ÏÏÔ˘Ó ÔÈ ÂÚÈÛÙ¿ÛÂȘ, ÔÈ ·È‰›·ÙÚÔÈ ı· Ú¤ÂÈ Ó· Â›Ó·È ˘‡ı˘ÓÔÈ ÁÈ· ÙË Ì¤ÚÈÌÓ· ˆ˜ ÚÔ˜ ÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙÔ˘˜. ∏ Â›Ù¢ÍË ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ÁÓÒÛÂÒÓ ÙÔ˘˜ Á‡Úˆ ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì·,

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ ¡›Î·È·˜, ¶ÂÈÚ·È¿˜

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Abstract: Acute pain is one of the most common and most disturbing subjective symptoms experienced by children as a result of injury or illness, and during necessary medical procedures.

The sensation of pain is the result of a variety of sensory, emotional, cognitive and behavioral components that go well beyond that of a simple sensory experience. It is associated with increased anxiety, withdrawal, somatic symptoms, and increased parental distress. Despite of the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. Numerous myths such as the idea that children and especially infants do not feel pain the way adults do, insufficient knowledge among caregivers, fears about side effects of pain medications, and the belief by some health care workers “that pain builds character in children”, contribute to the lack of effective management.

Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatricians are responsible for eliminating or relieving pain and suffering in children when possible. To accomplish this, pediatricians need to expand their knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly, use a multimodal as well as a multidisciplinary approach to pain when possible by involving the family and advocating for the use of effective analgesic treatment in children.

Pediatric Clinic of Peripheral General Hospital “Ag. Panteleimon”, Nikea, Piraeus

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¶·È‰È·ÙÚÈ΋ 2002;65:212-218

Paediatriki 2002;65:212-218

ÙË ÛˆÛÙ‹ Ú·ÎÙÈ΋ ÙÔ˘˜ ÛÙÔ˘˜ ÂοÛÙÔÙ ¯ÂÈÚÈÛÌÔ‡˜, ÙËÓ Úfi‚Ï„‹ ÙÔ˘˜ ÁÈ· ÙÔ Èı·Ófi ÂӉ¯fiÌÂÓÔ Ó· ÚÔÎÏËı› ¿ÏÁÔ˜ ÛÙÔ ·È‰› ÛÙ· Ï·›ÛÈ· ÓfiÛÔ˘ ‹ ÏfiÁˆ È·ÙÚÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ ‹ ÂÂÌ‚¿ÛˆÓ, ÙËÓ Î·Ù¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÔ‡ ηÈ, Ù¤ÏÔ˜, ÙË ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘˜ Ì ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙËÓ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ·È‰ÈÔ‡ ·fi ÙÔÓ fiÓÔ. ∏ ·Ó·ÎÔ‡ÊÈÛË ·fi ÙÔÓ fiÓÔ Ô˘ Û˘Óԉ‡ÂÈ Ì›· ·ÚÚÒÛÙÈ· ‹ Ô˘ ÚÔηÏÂ›Ù·È È·ÙÚÔÁÂÓÒ˜ ·fi ‰È·ÁÓˆÛÙÈÎÔ‡˜ ‹ ıÂÚ·¢ÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, ·ÔÙÂÏ› ‚·ÛÈ΋ ·Ú¯‹ Ù˘ È·ÙÚÈ΋˜ Î·È Î‡ÚÈ· ˘Ô¯Ú¤ˆÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘, Ë ÔÔ›· ‰ÂÓ Ú¤ÂÈ ÔÙ¤ Ó· ˘ÔÙÈÌ¿Ù·È ‹ Ó· ·Ú·ÁÓˆÚ›˙ÂÙ·È. §¤ÍÂȘ ÎÏÂȉȿ: fiÓÔ˜ (¿ÏÁÔ˜), ·Ó·ÏÁËÙÈο Ê¿Ú̷η, ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘.

Key words: pain, analgesics, pain treatment.

∂ÈÛ·ÁˆÁ‹ ∞ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ¢ı‡ÓË Î·È ˘Ô¯Ú¤ˆÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Ë ÚÔÛ¿ıÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘, Ì ÛÎÔfi ÙËÓ ÂÍ¿ÏÂÈ„‹ ÙÔ˘ ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙË ÌÂÚÈ΋ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·È‰ÈÔ‡, ÂÊfiÛÔÓ ‚‚·›ˆ˜ ÙÔ‡ÙÔ Â›Ó·È ÂÊÈÎÙfi. ¶·Ú¿ Ù·‡Ù·, Â›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ ˘ÔıÂÚ·‡ÂÙ·È (1). O Û˘ÓËı¤ÛÙÂÚÔ˜ Ù‡Ô˜ fiÓÔ˘ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ¤Ó· ·È‰› Â›Ó·È Ô Ô͇˜ fiÓÔ˜ Ô˘ ·ÎÔÏÔ˘ı› ÙÚ·˘Ì·ÙÈÛÌÔ‡˜, ÓÔÛ‹Ì·Ù·, ηıÒ˜ Î·È È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜. ∂ÓÒ ˘¿Ú¯ÂÈ ÂÎÙÂٷ̤ÓË ‚È‚ÏÈÔÁÚ·Ê›·, Ë ÔÔ›· ·Ú¤¯ÂÈ ÁÓÒÛÂȘ ˆ˜ ÚÔ˜ ÙËÓ ·ÍÈÔÏfiÁËÛË Î·È ÙË ıÂÚ·›· ÙÔ˘ ÔͤԘ fiÓÔ˘ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ¢ڤˆ˜ ‰È·ı¤ÛÈ̘, ¯·ÌËÏÔ‡ ÎfiÛÙÔ˘˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ÌÂıfi‰Ô˘˜, ÔÈ ÁÓÒÛÂȘ ·˘Ù¤˜ Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛˆÛÙ¿. ∞Ó Î·È Ë ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÈÎÂÓÙÚÒÓÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÂÎÙ›ÌËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÔͤԘ fiÓÔ˘, ˘Ô¯Ú¤ˆÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ·ÏÏ¿ Î·È ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ ·ÔÙÂÏ› Ë ·Ó·ÁÓÒÚÈÛË fiÏˆÓ ÙˆÓ Ù‡ˆÓ ·˘ÙÔ‡, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ·˘ÙÒÓ ÙÔ˘ ¯ÚfiÓÈÔ˘ fiÓÔ˘, ÙÔ˘ ‰È·Ï›ÔÓÙÔ˜ fiÓÔ˘, ÙÔ˘ fiÓÔ˘ ÙÔ˘ Û¯ÂÙÈ˙fiÌÂÓÔ˘ Ì ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ‹ Ì ηٷÏËÎÙÈ΋ ÓfiÛÔ (2). ºÚ·ÁÌÔ‡˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ ·ÔÙÂÏÔ‡Ó: ·) Ô Ì‡ıÔ˜ fiÙÈ Ù· ·È‰È¿ Î·È ÂȉÈο Ù· ‚Ú¤ÊË ‰ÂÓ ·ÈÛı¿ÓÔÓÙ·È ÙÔÓ fiÓÔ fiˆ˜ ÔÈ ÂÓ‹ÏÈΘ ‹ Î·È ·Ó ÙÔÓ ·ÈÛı¿ÓÔÓÙ·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÓÂÈı‡ÌËÙ˜ Û˘Ó¤ÂȘ ·fi ·˘ÙfiÓ, ‚) Ë ·Ô˘Û›· ·ÍÈÔÏfiÁËÛ˘ Î·È Â·Ó·ÍÈÔÏfiÁËÛ˘ ˆ˜ ÚÔ˜ ÙËÓ ‡·ÚÍË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ·˘ÙÔ‡, Á) Ë ¤ÏÏÂÈ„Ë ÈηÓfiÙËÙ·˜ Û‡ÏÏ˄˘ Î·È ÔÛÔÙÈÎÔÔ›ËÛ˘ ÌÈ·˜ ηٿ Ù· ¿ÏÏ· ˘ÔÎÂÈÌÂÓÈ΋˜ ÂÌÂÈÚ›·˜, ‰) Ë ¤ÏÏÂÈ„Ë Â·ÚÎÔ‡˜ ÁÓÒÛ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘, Â) Ë È‰¤· fiÙÈ Ë ÂÓ·Û¯fiÏËÛË Ì ÙÔÓ fiÓÔ ÛÙ· ·È‰È¿ ··ÈÙ› ¯ÚfiÓÔ

Î·È ÚÔÛ¿ıÂÈ· Î·È ÛÙ) Ô Êfi‚Ô˜ ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘ ·Ó·ÏÁËÙÈ΋˜ ıÂÚ·›·˜, fiˆ˜ Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ΤÓÙÚÔ˘ Î·È Ô ÂıÈÛÌfi˜. ∆¤ÏÔ˜, ÚÔÛˆÈΤ˜ ·ÓÙÈÏ‹„ÂȘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚÌËÓ›· Î·È ÙÔ ÚfiÏÔ ÙÔ˘ ¿ÏÁÔ˘˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÂÓfi˜ ·È‰ÈÔ‡ (fiˆ˜ Ï.¯. Ë ·ÓÙ›ÏË„Ë fiÙÈ “Ô fiÓÔ˜ ‰È·ÌÔÚÊÒÓÂÈ ¯·Ú·ÎÙ‹Ú·”) Ê·›ÓÂÙ·È ‰˘ÛÙ˘¯Ò˜ ˆ˜ ·ÚÂÌ‚·›ÓÔ˘Ó ·Ó·ÛÙ·ÏÙÈο ÛÙË ‰È·‰Èηۛ· Ù˘ ·Ó·ÁÓÒÚÈÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Û fiÏ· Ù· ·È‰È¿ (3). ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ (AAP) ˘ÔÛÙËÚ›˙ÂÈ ÙÔ ËıÈÎfi ¯Ú¤Ô˜ Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈÌÂÙÒÈÛ˘ fiÏˆÓ ÙˆÓ ÂȉÒÓ ÙÔ˘ fiÓÔ˘ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔͤԘ fiÓÔ˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÌÔÚÔ‡Ó Û‹ÌÂÚ· Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ÂÈÙ˘¯›·, Ú¤ÂÈ fï˜ Ó· ÂÈÛËÌ·Óı› fiÙÈ ÙfiÛÔ ÔÈ ·ÓËÛ˘¯›Â˜ ÙˆÓ ·È‰ÈÒÓ fiÛÔ Î·È Ù˘¯fiÓ ¿ÏÏ· Û˘Ó˘¿Ú¯ÔÓÙ· Û˘ÌÙÒÌ·Ù· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·Ù¿ ÙË ‰È·‰Èηۛ· ÂÈÏÔÁ‹˜ ÙÔ˘ ıÂÚ·¢ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÁÈ· ÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·È‰ÈÔ‡. ∂ÎÙ›ÌËÛË Î·È ·ÍÈÔÏfiÁËÛË ÙÔ˘ fiÓÔ˘ OÈ Â·ÁÁÂÏ̷ٛ˜ ÛÙÔ ¯ÒÚÔ Ù˘ ˘Á›·˜ ı· Ú¤ÂÈ Ó· ÚԂϤÔ˘Ó ÂÈΛÌÂÓ˜ ÂÒ‰˘Ó˜ ÂÌÂÈڛ˜, ÚÔ‚·›ÓÔÓÙ·˜ ÛÙȘ ·Ó·Áη›Â˜ ηٿÏÏËϘ Ú˘ıÌ›ÛÂȘ Î·È ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÂΛ Ô˘ Ú¤ÂÈ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÚÔ¸Ôı¤ÙÂÈ ÙË ÛˆÛÙ‹ ÂÎÙ›ÌËÛË Î·È Û˘Ó¯‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ ¯·Ú·ÎÙ‹ÚˆÓ Î·È Ù˘ ¤ÓÙ·Û‹˜ ÙÔ˘, ηıÒ˜ Î·È ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÙÔ˘ ·È‰ÈÔ‡ ÛÙË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹, Ú¿ÁÌ· ·Ôχو˜ ÂÊÈÎÙfi Û fiϘ ÙȘ ËÏÈ˘, ·fi ÙË ÓÂÔÁÓÈ΋ ¤ˆ˜ Î·È ÙËÓ ÂÊ˂›· (4). ™ÙÔ ¯ÒÚÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ, Ô fiÓÔ˜, Ë ·ÓÙ·fiÎÚÈÛ‹ ÙÔ˘ ÛÙË ıÂÚ·›·, ·ÏÏ¿ Î·È ÔÈ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ

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¶·È‰È·ÙÚÈ΋ 2002;65:212-218

Ê·ÚÌ¿ÎˆÓ ı· Ú¤ÂÈ Ó· ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔ ‰È¿ÁÚ·ÌÌ· ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÒÛÙ ӷ ˘Ô‚ÔËıÂ›Ù·È Î·Ù’ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ Ë ÂÈÎÔÈÓˆÓ›· ÌÂٷ͇ ÙˆÓ ıÂÚ·fiÓÙˆÓ È·ÙÚÒÓ. O fiÓÔ˜ ÌÔÚ› Ó· ·ÍÈÔÏÔÁËı› Ì ÙËÓ ·Ó·˙‹ÙËÛË ÏËÚÔÊÔÚÈÒÓ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹, ÙËÓ ·Ú·Ù‹ÚËÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ ÚÔÛÒÔ˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ηÈ, Ù¤ÏÔ˜, Ì ÙËÓ ÂÎÙ›ÌËÛË ÛÙÔȯ›ˆÓ Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ¯·Ú·ÎÙ‹Ú· ÙÔ˘, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÂÈÎÔÈÓˆÓ›·˜ Ô˘ ‰È·ı¤ÙÂÈ. ∏ ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ÙÔ˘ fiÓÔ˘ ÚÔ¸Ôı¤ÙÂÈ ÛˆÛÙ‹ ÂÎÙ›ÌËÛË Ù˘ ÔÏ˘ÏÔÎfiÙËÙ·˜ ̤ۈ Ù˘ ÔÔ›·˜ ÙÔ ·È‰› ·ÈÛı¿ÓÂÙ·È ÙËÓ ÂÒ‰˘ÓË ÂÌÂÈÚ›·, ηıÒ˜ Î·È Ù˘ Â›‰Ú·Û˘ „˘¯ÔÏÔÁÈÎÒÓ Î·È ·Ó·Ù˘ÍÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∂Âȉ‹ Ô fiÓÔ˜ ·ÔÙÂÏ› Ì›· ˘ÔÎÂÈÌÂÓÈ΋ ÂÌÂÈÚ›·, Ë ÂÚÈÁÚ·Ê‹ Ù˘ ‰È·Ê¤ÚÂÈ ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ (5). ŸÌˆ˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ‚‚·Èˆı› ηÓ›˜ fiÙÈ Ù· ·È‰È¿, ȉȷ›ÙÂÚ· Ù˘ ËÏÈΛ·˜ ÙˆÓ 3-7 ÂÙÒÓ, Â›Ó·È Û ı¤ÛË Ó· ‰ÒÛÔ˘Ó ÏËÚÔÊÔڛ˜, ÚÈÓ Î¿ı ÂÚÈÁÚ·Ê‹ ÁÈ· ÙË ı¤ÛË, ÙËÓ ÔÈfiÙËÙ·, ÙËÓ ¤ÓÙ·ÛË Î·È ÙËÓ ·ÎÙÈÓÔ‚ÔÏ›· ÙÔ˘ fiÓÔ˘ Á›ÓÂÈ ·Ô‰ÂÎÙ‹. ∏ ·Ú·Ù‹ÚËÛË ÙÔ˘ ÙÚfiÔ˘ ·ÓÙ›‰Ú·Û‹˜ ÙÔ˘˜ ÛÙÔ ÂÒ‰˘ÓÔ ÂÚ¤ıÈÛÌ· ı· Ú¤ÂÈ Ó· Û˘ÌÏËÚÒÓÂÈ ÙËÓ ˘ÔÎÂÈÌÂÓÈ΋ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ·È‰ÈÔ‡, ¤ÙÛÈ ÒÛÙ ӷ ·ÔÙÂÏ› ÌÈ· ·ÍÈfiÈÛÙË ÂÓ·ÏÏ·ÎÙÈ΋ χÛË fiÙ·Ó Ë ÙÂÏÂ˘Ù·›· ‰ÂÓ ÌÔÚ› Ó· ÏËÊı› ‹ fiÙ·Ó ‰ÂÓ ıˆÚÂ›Ù·È ·ÚÎÔ‡ÓÙˆ˜ ·ÍÈfiÈÛÙË. ŸÙ·Ó Ë ÂÈÎÔÈÓˆÓ›· ηı›ÛÙ·Ù·È ‰˘Û¯ÂÚ‹˜, Ë ÛËÌ·Û›· Ô˘ ¤¯ÂÈ Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ ·¤Ó·ÓÙÈ ÛÙÔ ÂÚ¤ıÈÛÌ· ı· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È Û¯ÔÏ·ÛÙÈο. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ fiÓÔ ·ÓÙ·Ó·ÎÏ¿ ÙË Ê˘ÛÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÔ˘ ηٿÛÙ·ÛË, ÙÔ fiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈο ÙÔÓ ·ÓÙÈÌÂÙˆ›˙ÂÈ, ηıÒ˜ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ Î·È Î·Ù’ Â¤ÎÙ·ÛË ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. °È· ·Ú¿‰ÂÈÁÌ·, ¤Ó· ÛÙˆÈÎfi ‹ ηٷıÏÈÙÈÎfi ·È‰› Ì ÈÛ¯˘Úfi fiÓÔ ÌÔÚ› Ó· ÌËÓ ÙÔÓ ÂÚÈÁÚ¿„ÂÈ fiÙ·Ó ÚˆÙËı› Î·È Ó· ÌËÓ ÂÌÊ·Ó›˙ÂÈ Ù· ·Ó·ÌÂÓfiÌÂÓ· ÁÈ· ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜ ÛÙÔȯ›· ÛÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘. ∆Ô ¿ÏÁÔ˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·È‰È¿ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ, ηıÒ˜ Î·È Ì ·Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏÔ Ó· ÂÎÙÈÌËı› ÛˆÛÙ¿. ¶ÔÏÈÙÈÛÙÈΤ˜ Î·È ÁψÛÛÈΤ˜ ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ÙÔÓ ÂÍÂÙ·˙fiÌÂÓÔ Î·ıÈÛÙÔ‡Ó, ÌÂÚÈΤ˜ ÊÔÚ¤˜, ÚÔ‚ÏËÌ·ÙÈ΋ ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ fiÓÔ˘. ∂ÊfiÛÔÓ, ÏÔÈfiÓ, ˘¿Ú¯Ô˘Ó Ù¤ÙÔÈ· ÚÔ‚Ï‹Ì·Ù·, ·ÍÈfiÈÛÙË ÌÔÚ› Ó· Â›Ó·È Ë Ì·ÚÙ˘Ú›· ÙÔ˘ ÁÔÓ¤· ‹ οÔÈÔ˘ ¿ÏÏÔ˘ ·ÙfiÌÔ˘ Ô˘ ÁÓˆÚ›˙ÂÈ Î·Ï¿ ÙÔ ·È‰›, ·Ó Î·È Â‰Ò ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÌÈ· Ù¿ÛË ˘ÔÂÎÙ›ÌËÛ˘ ÙÔ˘ Û˘ÌÙÒÌ·ÙÔ˜.

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¶fiÓÔ˜ ÔÊÂÈÏfiÌÂÓÔ˜ Û ȷÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ ∏ ÚÔÛ¤ÁÁÈÛË ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ ¿ÏÁÔ˘˜ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ¤ÓÙ·ÛË Î·È ‰È¿ÚÎÂÈ¿ ÙÔ˘, ÙÔ ¿Á¯Ô˜ Ô˘ ÂӉ¯Ô̤ӈ˜ ˘¿Ú¯ÂÈ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ÙÔÓ ÙÚfiÔ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹, ·ÏÏ¿ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ È·ÙÚÈÎÔ‡ ¯ÂÈÚÈÛÌÔ‡ ‹ Ù˘ Â¤Ì‚·Û˘ (6,7). OÈ È·ÙÚÈÎÔ› ¯ÂÈÚÈÛÌÔ› ı· Ú¤ÂÈ Ó· ÂÎÙÂÏÔ‡ÓÙ·È ·fi ¤ÌÂÈÚÔ ÚÔÛˆÈÎfi, ¤ÙÛÈ ÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë ¤ÓÙ·ÛË ·˘Ù‹˜ Ù˘ ÂÒ‰˘Ó˘ ÁÈ· ÙÔ ·È‰› ‰È·‰Èηۛ·˜. ∞Ó¿ÏÔÁ· Ì ÙË Ê‡ÛË Ù˘ Â¤Ì‚·Û˘ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰ÈÔ‡, ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ fiÓÔ˘ ÌÔÚ› Ó· ÂÈÙ¢¯ı› Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÌÂıfi‰ˆÓ ‚·ıÈ¿˜ ηٷÛÙÔÏ‹˜ ‹ Î·È ·Ó·ÈÛıËÛ›·˜ ¤ˆ˜ ÙËÓ ˘ÈÔı¤ÙËÛË ÛÙÚ·ÙËÁÈÎÒÓ Û˘ÌÂÚÈÊÔÚ¿˜, ÔÈ Ôԛ˜ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ ÂÓ›Û¯˘ÛË Ù˘ ·˘ÙÔÂÔ›ıËÛ˘ ÙÔ˘ ·È‰ÈÔ‡, ·Ú¿ÏÏËÏ· ‹ fi¯È Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (8). ∏ ÂÊ·ÚÌÔÁ‹ ÙÔÈÎÒÓ ·Ó·ÈÛıËÙÈÎÒÓ, fiˆ˜ .¯. ÙÔ ÁÓˆÛÙfi Ì›ÁÌ· ·Ó·ÈÛıËÙÈÎÒÓ EMLA, ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› Ú·ÎÙÈ΋ ÚÔ˘Ù›Ó·˜ ·ÎfiÌË Î·È Û ·ÏÔ‡˜ È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, fiˆ˜ Â›Ó·È ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ·ÈÌÔÏË„›·. ∆Ô ¿ÏÁÔ˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÌÂÚÈΤ˜ ÌÈÎÚ¤˜, ·ÏÏ¿ ·ÚÎÂÙ¿ ÂÒ‰˘Ó˜, È·ÙÚÈΤ˜ ÂÂÌ‚¿ÛÂȘ fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë ÂÚÈÙÔÌ‹, ‰ÂÓ ¤¯ÂÈ Ï¿‚ÂÈ ÙË ‰¤Ô˘Û· ÚÔÛÔ¯‹ ¤ÙÛÈ ÒÛÙ ӷ ·Ó·ÎÔ˘Ê›˙ÂÙ·È Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÚÔ·Ó·ÊÂÚı›۷ Â¤Ì‚·ÛË fi¯È ÌfiÓÔ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· fiÓÔ˘, ·ÏÏ¿ Û˘Ó‰¤ÂÙ·È Â›Û˘ Ì ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ‰˘ÛÎÔϛ˜ ÛÙËÓ Ô‡ÚËÛË ÁÈ· ·ÚÎÂÙ¤˜ Ë̤Ú˜ ·ÚÁfiÙÂÚ·. ∏ ıÂÚ·¢ÙÈ΋ ÏÔÈfiÓ ·Ú¤Ì‚·ÛË Â›Ó·È ÂȂ‚ÏË̤ÓË ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ·, ·ÏÏ¿ Î·È ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ™ÙËÓ ÂÚ›ÙˆÛË ÂÂÌ‚¿ÛÂˆÓ Î·Ù¿ ÙȘ Ôԛ˜ Ô fiÓÔ˜ ÚԂϤÂÙ·È Ó· Â›Ó·È È‰È·›ÙÂÚ· Ô͇˜, fiˆ˜ ·˘Ùfi˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙË ‚ÈÔ„›· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÂÈ‚¿ÏÏÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ıÂÚ·›·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔÈ΋˜ ·Ó·ÈÛıËÛ›·˜ (9-11). ∏ ¯Ú‹ÛË Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ˆ˜ ÌÔÓÔıÂÚ·›· fi¯È ÌfiÓÔ ‰ÂÓ ÚÔηÏ› ·Ó·ÏÁËÛ›·, ·ÏÏ¿ ÂÈÚÔÛı¤Ùˆ˜ ηıÈÛÙ¿ ‰‡ÛÎÔÏË ÙËÓ ÂÈÎÔÈÓˆÓ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙÔ ÁÈ·ÙÚfi (12-17). ∏ ∞∞ƒ Û˘ÓÈÛÙ¿ ÙË ¯Ú‹ÛË Î·Ù·ÛÙÔÏ‹˜ Î·È ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÒ‰˘Ó˜ ÂÂÌ‚¿ÛÂȘ Û‡Ìʈӷ ÌÂ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ (18,19). ¶fiÓÔ˜ Û¯ÂÙÈ˙fiÌÂÓÔ˜ Ì ÂÁ¯ÂÈÚ‹ÛÂȘ Î·È ÙÚ·‡Ì·Ù· ∏ ÌÂϤÙË ÙÔ˘ ‰ÈÂÁ¯ÂÈÚËÙÈÎÔ‡ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ fiÓÔ˘ ¤¯ÂÈ Û˘ÓÂÈÛʤÚÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ÂÎÙ›ÌËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ (7). ªÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙË

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·215

¶·È‰È·ÙÚÈ΋ 2002;65:212-218

ıˆڛ· fiÙÈ Ë ÓÔÛËÚfiÙËÙ· Î·È Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ Î·È ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ÌÔÚÔ‡Ó Ó· ÌÂȈıÔ‡Ó ÛËÌ·ÓÙÈο ¯¿ÚË ÛÙËÓ ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ (20). ∞Ó Î·È ÛËÌ·ÓÙÈΤ˜ ̤ıÔ‰ÔÈ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ fiÓÔ˘ ·ÔÙÂÏÔ‡Ó Ë ÂÈÛÎÏËÚ›‰ÈÔ˜ ·Ó·ÈÛıËÛ›· Î·È Ë ÂÏÂÁ¯fiÌÂÓË ·fi ÙÔÓ ·ÛıÂÓ‹ ·Ó·ÏÁËÛ›·, Ù· ÂÚÈÛÛfiÙÂÚ· ÂÚÈÛÙ·ÙÈο ÌÔÚÔ‡Ó Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ÙÔÓ ·È‰›·ÙÚÔ ¯ˆÚ›˜ ÙËÓ ˘ÈÔı¤ÙËÛË ÔχÏÔÎˆÓ Ù¯ÓÈÎÒÓ. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÂÏÂÁ¯fiÌÂÓË ·fi ÙÔÓ ·ÛıÂÓ‹ ·Ó·ÏÁËÛ›· (PCA-Patient Controlled Analgesia) ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 6 ÂÙÒÓ (2125). ∆Ô ı¤Ì· Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ·Ó·ÏÁËÛ›·˜ ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È Ì ÙÔ˘˜ ÁÔÓ›˜ ÚÈÓ ÙËÓ Â¤Ì‚·ÛË (7). µ·ÛÈο ÛÙÔȯ›· Ù˘ Ê·ÚÌ·ÎÔÏÔÁÈ΋˜ ıÂÚ·›·˜ ·ÔÙÂÏÔ‡Ó ÙÔ Â›‰Ô˜ ÙÔ˘ ·Ó·ÏÁËÙÈÎÔ‡, Ë ‰fiÛË ÙÔ˘, Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· Î·È Ë Ô‰fi˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ Ê·Ú̿ΈÓ, fiˆ˜ Ù· ÔÈÔÂȉ‹, ηıÒ˜ Î·È Ù· ÌË ÔÈÔÂȉ‹ ·Ó·ÏÁËÙÈο Î·È ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η. OÈÔÂȉ‹ fiˆ˜ Ë ÎÈÙÚÈ΋ Ê·ÈÓÙ·Ó‡ÏË, Ë ıÂÈÈ΋ ÌÔÚÊ›ÓË Î·È Ë ˘‰ÚԯψÚÈ΋ ˘‰ÚÔÌÔÚÊfiÓË ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ì¤ÙÚÈ·˜ ¤ˆ˜ Î·È ÛÔ‚·Ú‹˜ ÂÓÙ¿Ûˆ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ ¿ÏÁÔ˘˜. ∏ Ê·ÈÓÙ·Ó‡ÏË, ÏfiÁˆ Ù˘ ÈÛ¯˘Ú‹˜ ηٷÛÙÔÏ‹˜ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔÓ ÎÔÈÓfi ı¿Ï·ÌÔ, ·Ú¿ ÌfiÓÔ ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ‹ Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜. ∏ ˘‰ÚԯψÚÈ΋ ÌÂÂÚȉ›ÓË (Âıȉ›ÓË) ‰ÂÓ ·ÔÙÂÏ› ÔÈÔÂȉ¤˜ ÂÎÏÔÁ‹˜, ÏfiÁˆ Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ Ù˘ ÚÔ˚fiÓÙˆÓ Î·È ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ù˘ (7,26). ∏ ¯Ú‹ÛË Ù˘ ·Ú·ÎÂÙ·ÌfiÏ˘ Î·È ÙˆÓ ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ ÔÈÔÂȉ‹, ÌÔÚ› Ó· ÂÏ·ÙÙÒÛÂÈ ÙË ‰fiÛË ÙÔ˘ ÔÈÔÂȉԇ˜ Ô˘ ı· ¯ÚÂÈ·ÛÙ› ÁÈ· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ›‰ÈÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜. ªÔÚ›, Â›Û˘, Ó· ¯ÔÚËÁËı› Î·È Ë Ó·Ï‚Ô˘ÚÊ›ÓË (nubaine), Ë ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ÂÂÌ‚¿ÛÂȘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘fiıÂÙ· ·Ú·ÎÂÙ·ÌfiÏ˘ ·Ó¿ ÂÍ¿ˆÚÔ Ì ¿ÚÈÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∂Âȉ‹ ÛËÌ·ÓÙÈÎfi ÛÙfi¯Ô ·ÔÙÂÏ› Ë fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘, Ë ‰fiÛË ¤Ó·Ú͢ ı· Ú¤ÂÈ Ó· Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·Ù‹, ÂÓÒ ÔÈ ÂfiÌÂÓ˜ ı· Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (7). ∏ ¯ÔÚ‹ÁËÛË ÔÏÏ·ÏÒÓ, ÌÈÎÚÒÓ Î·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ‰fiÛÂˆÓ ·Ó·ÏÁËÙÈÎÒÓ ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ fiÓÔ˘, ÙËÓ Â›Ù·ÛË Ù˘ ·ÓËÛ˘¯›·˜, ηıÒ˜ Î·È ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ fiˆ˜ Â›Ó·È ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ΤÓÙÚÔ˘. ∏ Ù·¯Â›· Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Â›Ó·È ·ÛʷϤÛÙÂÚË ·fi ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË

Paediatriki 2002;65:212-218

¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ÂÂȉ‹ Ô‰ËÁ› Û ÁÚ‹ÁÔÚË ·Ó·ÎÔ‡ÊÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ì ÙË ÌÈÎÚfiÙÂÚË Û˘ÓÔÏÈ΋ ‰fiÛË ÙÔ˘ ÂοÛÙÔÙ ÂÈÏÂÁfiÌÂÓÔ˘ ·Ó·ÏÁËÙÈÎÔ‡. ∂ÎÙfi˜ ÌÂÌÔÓˆÌ¤ÓˆÓ ÂÚÈÙÒÛˆÓ, Ù· ·Ó·ÏÁËÙÈο ‰ÂÓ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÂÓ‰ÔÌ˘˚ÎÒ˜, ÏfiÁˆ ÙÔ˘ ÙÔÈÎÔ‡ ¿ÏÁÔ˘˜ ·ÏÏ¿ Î·È Ù˘ ·ÛÙ·ıÔ‡˜ ·ÔÚÚfiÊËÛ‹˜ ÙÔ˘˜ ηْ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ. ∏ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË ÚÔÙÈÌ¿Ù·È ÁÈ· fiÓÔ ‹ÈÔ ‹ ̤ÙÚÈ·˜ ¤ÓÙ·Û˘. ŸÙ·Ó fï˜ ÙÔ ·È‰› ¯ÚÂÈ¿˙ÂÙ·È ¿ÌÂÛË ·Ó·ÎÔ‡ÊÈÛË ·fi ÙÔÓ fiÓÔ, ÂӉ›ÎÓ˘Ù·È Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜. °È· ̤ÙÚÈ·˜ ·ÏÏ¿ Î·È ÛÔ‚·Ú‹˜ ÂÓÙ¿Ûˆ˜ fiÓÔ Ô˘ ÂÈ̤ÓÂÈ, ÂӉ›ÎÓ˘Ù·È 24ˆÚË Û˘Ó¯‹˜ ¯ÔÚ‹ÁËÛË ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ÌÂÛԉȷÛÙ‹Ì·Ù·. ∏ ‰ÔÛÔÏÔÁ›· Î·È Ù· ÌÂÛԉȷÛÙ‹Ì·Ù· ÚÔÛ·ÚÌfi˙ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂÈÛËÌ·›ÓÔÓÙ·È ÛÙÔ˘˜ ÁÔÓ›˜ ÔÈ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ÔÈÔÂȉÒÓ, fiˆ˜ Ë Ó·˘Ù›·, Ô ¤ÌÂÙÔ˜ Î·È Ô ÎÓËÛÌfi˜, ¤ÙÛÈ ÒÛÙ ӷ ÂÏ·ÙÙÒÓÂÙ·È Ë ·ÓËÛ˘¯›· ÙÔ˘˜ Î·È Ó· ·ÔʇÁÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ·˘ı·›ÚÂÙ˘ ‰È·ÎÔ‹˜ Ù˘ ·Ó·ÏÁËÙÈ΋˜ ·ÁˆÁ‹˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ¿‰ÈÎË Ù·Ï·ÈˆÚ›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜. ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙËÓ ·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË ÔÈÔÂȉÒÓ (.¯. ‰˘ÛÎÔÈÏÈfiÙËÙ·) Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Î·Ù¿ÏÏËÏ·. ∏ Èı·Ó‹ ·ıÚÔÈÛÙÈ΋ Û˘Ó¤ÚÁÂÈ· ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ, ·Á¯ÔÏ˘ÙÈÎÒÓ, ·ÓÙÈÂÌÂÙÈÎÒÓ Î·È ·ÓÙÈÈÛÙ·ÌÈÓÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÂÈ‚¿ÏÏÂÈ ÙËÓ ·‰È¿ÏÂÈÙË ·ÍÈÔÏfiÁËÛË ÙfiÛÔ Ù˘ ÚÔÎÏËı›۷˜ ·Ó·ÏÁËÛ›·˜, fiÛÔ Î·È ÙÔ˘ ÂÈ¤‰Ô˘ ηٷÛÙÔÏ‹˜. ªÂÙ¿ ÙËÓ ·Ó¿ÓË„Ë ·fi Ì›· ÂÒ‰˘ÓË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Ë ·Ó·ÏÁËÙÈ΋ ·ÁˆÁ‹ ÌÔÚ› Ó· ÌÂÙ·‚ÏËı› ·Ó·ÏfiÁˆ˜ ÙˆÓ ·Ó·ÁÎÒÓ, ÔÙ¤ fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ‰È·ÎÔ› ·fiÙÔÌ·. ∞Ó Î·È ˘¿Ú¯ÂÈ ϤÔÓ ·˘ÍË̤ÓË Ù¿ÛË ÁÈ· “ÂÁ¯ÂÈÚ‹ÛÂȘ Ù˘ Ì›·˜ Ë̤ڷ˜” ‹ ÁÈ· ÁÚ‹ÁÔÚË ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ÌÂÙ¿ ·fi ¤Ó· “·Ïfi ¯ÂÈÚÔ˘ÚÁ›Ԕ (.¯. ·Ì˘Á‰·ÏÂÎÙÔÌ‹ ‹ ·Ê·›ÚÂÛË ·‰ÂÓÔÂȉÒÓ Â΂ϷÛÙ‹ÛˆÓ), ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Î·È ÂÌÂÈÚ›· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÏÁÔ˘˜ Ô˘ ÙȘ Û˘Óԉ‡ÂÈ, ¤ÙÛÈ ÒÛÙ ӷ ÙÂÎÌËÚÈÒÓÂÙ·È Ë ÔÚıfiÙËÙ· Ù˘ ÂÈÏÔÁ‹˜ Ù˘ ‚Ú·¯Â›·˜ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ¶¿ÓÙˆ˜, ÛÙȘ ÂÂÌ‚¿ÛÂȘ ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜, ÙÔ ˘fiıÂÙÔ Ù˘ ·Ú·ÎÂÙ·ÌfiÏ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙÔ ›‰ÈÔ Ê¿ÚÌ·ÎÔ ·fi ÙÔ ÛÙfiÌ· Ê·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ¿ÚÈÛÙ· ·ÔÙÂϤÛÌ·Ù·. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Ô˘ ÔÊ›ÏÂÙ·È Û ÛÔ‚·Úfi ÙÚ·˘Ì·ÙÈÛÌfi, Ô ÔÔ›Ô˜ ÂÈ‚¿ÏÏÂÈ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÙÚ·˘Ì·Ù›· Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜, ÌÔÚ› Ó· ˘ÔÙÈÌËı› ÏfiÁˆ Ù˘ ÚÔÙÂÚ·ÈfiÙËÙ·˜ Ô˘ ¤¯Ô˘Ó ¯ÂÈÚÈÛÌÔ› ‰È¿ÛˆÛ˘ Ù˘ ˙ˆ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ì ÛËÌ·ÓÙÈÎfiٷ٘ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ ÛÙÔÓ ¿ÚÚˆÛÙÔ. ŒÙÛÈ, ÏÔÈfiÓ,

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·216

¶·È‰È·ÙÚÈ΋ 2002;65:212-218

Â›Ó·È ÚÔÊ·Ó¤˜ fiÙÈ ÌÂÙ¿ ·fi ÛÔ‚·Úfi ÙÚ·˘Ì·ÙÈÛÌfi ηı›ÛÙ·Ù·È ·Ó·Áη›· Ë ¿ÌÂÛË Î·È ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘, fiÛÔ ÎÈ ·Ó ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ‰Â˘ÙÂÚÂ‡Ô˘Û·˜ ÛËÌ·Û›·˜. O fiÓÔ˜ ·˘Ùfi˜ ÌÔÚ› Ó· ·Ô‰Ôı› Û ÔÈΛϷ ·›ÙÈ· fiˆ˜ Â›Ó·È ÙÔ ›‰ÈÔ ÙÔ ÙÚ·‡Ì·, ÔÈ ¯ÂÈÚÔ˘ÚÁÈÎÔ› ¯ÂÈÚÈÛÌÔ›, Ù˘¯fiÓ ˘ÔΛÌÂÓË ÓfiÛÔ˜ ‹ Î·È ÙÔ Û‡ÓÔÏÔ Ù˘ ‰È·‰Èηۛ·˜ ÙÔÔıÂÙ‹Ûˆ˜ ÊÏ‚ÈÎÒÓ Ô‰ÒÓ Î·È ·ÚÔ¯ÂÙ‡ÛÂˆÓ (27). ∏ ÂÈÏÔÁ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘, Ù˘ ‰ÔÛÔÏÔÁ›·˜, Ù˘ Ô‰Ô‡ ·ÏÏ¿ Î·È ÙÔ˘ ÙÚfiÔ˘ ¯ÔÚ‹ÁËÛ˘ (Û˘Ó¯‹˜ ‹ ‰È·Ï›Ô˘Û·) Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÛıÂÓ‹. π‰È·›ÙÂÚË Ì¤ÚÈÌÓ· ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÁÈ· ÙËÓ ÔÌ·Ï‹ ÂÓ·ÏÏ·Á‹ ÙˆÓ Î‡ÎÏˆÓ ‡ÓÔ˘-·Ê‡ÓÈÛ˘ ÎÈ ·˘Ùfi ÂÂȉ‹ Ë ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÙÔ˘ ÛÙ·‰›Ô˘ ÙÔ˘ ‡ÓÔ˘, ‚ÔËı¿ ÙÔÓ ·ÛıÂÓ‹ Ó· ·ÓÙÂÂͤÏıÂÈ Î·Ï‡ÙÂÚ· ÛÙËÓ „˘¯ÔÊıfiÚÔ ÂÒ‰˘ÓË ÂÌÂÈÚ›· ÙÔ˘. ∏ ·Ú¿Ù·ÛË ÙÔ˘ fiÓÔ˘ ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ ÙËÓ ·Ú¿ÏÏËÏË ·Ú¿Ù·ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ÔÈÔÂȉÒÓ (28). OÈ ‰fiÛÂȘ ı· Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Î·Ï¿ ·ÓÂÎÙ¤˜, ÂÓÒ ÂÈ‚¿ÏÏÂÙ·È Ë ÛÙ·‰È·Î‹ Î·È ·ÚÁ‹ ‰È·ÎÔ‹ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ ÚÔ˜ ·ÔÊ˘Á‹ ÛÙÂÚËÙÈÎÒÓ Ê·ÈÓÔÌ¤ÓˆÓ (29). ¶fiÓÔ˜ ÛÙ· Ï·›ÛÈ· ÔÍ›·˜ ÓfiÛÔ˘ O fiÓÔ˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÔÍ›· ÓfiÛÔ, fiˆ˜ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, Ê·Ú˘ÁÁ›Ùȉ·, ÌËÓÈÁÁ›Ùȉ· (ÎÂÊ·Ï·ÏÁ›·) Î·È ÊÏÂÁÌÔÓÒ‰Ë ÓÔÛ‹Ì·Ù· Ù˘ ˘¤ÏÔ˘ (˘ÂÏÈÎfi˜ fiÓÔ˜), ı· Ú¤ÂÈ Â›Û˘ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È. ∏ Ê·Ú̷΢ÙÈ΋ ·Ú¤Ì‚·ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯Ú‹ÛË ·Ú·ÎÂÙ·ÌfiÏ˘, ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Ô˘ÛÈÒÓ Î·È Û·ÓÈfiÙÂÚ· ÔÈÔÂȉÒÓ Î·È ÙÔÈÎÒÓ ·Ó·ÏÁËÙÈÎÒÓ. ∆¤ÏÔ˜, ÌË Ê·ÚÌ·ÎÔÏÔÁÈΤ˜ ıÂÚ·¢ÙÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Ë ¯·Ï¿ÚˆÛË Î·È Ë „˘¯ÔıÂÚ·›· ÌÔÚÔ‡Ó Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Ì ÂÈÙ˘¯›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜. º¿Ú̷η ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ∆· Ê¿Ú̷η Ô˘ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ‰È·ÎÚ›ÓÔÓÙ·È Û ÌË ÔÈÔ‡¯·, ÔÈÔ‡¯· Î·È Û ¿ÏÏ· Ê¿Ú̷η Ù· ÔÔ›· Û˘ÌÏËÚÒÓÔ˘Ó ÙË ‰Ú¿ÛË ÙˆÓ ·Ú·¿Óˆ (30). ™ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ÌË ÔÈÔ‡¯ˆÓ ·Ó·ÏÁËÙÈÎÒÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·ÛÈÚ›ÓË (‰fiÛË: 10-15 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÔÔ›· fï˜ ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ϤÔÓ ·Ú¿ ÌfiÓÔ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ (fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÛÙȘ ÚÂ˘Ì·ÙÈΤ˜ ·ı‹ÛÂȘ, Kawasaki Î.Ï.), Ë ·Ú·ÎÂÙ·ÌfiÏË (‰fiÛË: 10-15 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÚÔ·Ú·ÎÂÙ·ÌfiÏ˘ (‰fiÛË: 20 mg/kg/6 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜) Î·È Ù· ÌË ÛÙÂÚÈÓÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë, fiˆ˜ ÙÔ ÌÂÊÂÓ·ÌÈÎfi Ô͇

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(‰fiÛË: 5-6 mg/kg/6 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë Ó·ÚÔͤÓË (‰fiÛË: 5-7 mg/kg/8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÙÔÏÌÂÙ›ÓË (‰fiÛË: 5-7 mg/kg/6-8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë È‚Ô˘ÚÔÊ·›ÓË (‰fiÛË: 4-10 mg/kg/6-8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·) Î·È Ë ÈÓ‰ÔÌÂı·Î›ÓË (‰fiÛË: 0,5-2 mg/kg/8-12 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·). ™Ù· ·Ó·ÏÁËÙÈο Ù˘ ηÙËÁÔÚ›·˜ ·˘Ù‹˜ ‰ÂÓ ·Ó·Ù‡ÛÛÂÙ·È Ê˘ÛÈ΋ ÂÍ¿ÚÙËÛË ‹ ·ÓÔ¯‹. ∆· ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο ·ÔÙÂÏÔ‡Ó Ù· ·ÚÈ· Ê¿Ú̷η ÁÈ· ÛÔ‚·Úfi fiÓÔ (.¯. Û ıÚÔÌ‚ˆÙÈΤ˜ ÎÚ›ÛÂȘ ‰ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜ ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ Ì ηÚΛÓÔ ‹ Î·È ÂÓ›ÔÙ ÛÙÔÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi fiÓÔ) Î·È ‰ÚÔ˘Ó ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ·ÓÙÔ¯‹ ÛÙ· ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù·, ¯ˆÚ›˜ Ó· ηٷÚÁÔ‡Ó ÙËÓ ·›ÛıËÛË ÙÔ˘ fiÓÔ˘. ÃÔÚËÁÔ‡ÓÙ·È Ì ÔÈΛÏÔ˘˜ ÙÚfiÔ˘˜ [·fi ÙÔ ÛÙfiÌ·, ÂÓ‰ÔÌ˘˚ÎÒ˜, ˘Ô‰ÔÚ›ˆ˜, ÂÓ‰Ô‰ÂÚÌÈÎÒ˜, ‰È·‚ÏÂÓÓÔÁÔÓ›ˆ˜ (̇ÙË, ÔÚıfi), ηıÒ˜ Î·È ÛÙÔÓ ÂÈÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ] Î·È ¤¯Ô˘Ó ÔÈΛÏË ‰È¿ÚÎÂÈ· ‰Ú¿Ûˆ˜ (·fi 30 ÏÂÙ¿ - 2 ÒÚ˜ ÁÈ· ÙË Ê·ÈÓÙ·Ó‡ÏË ¤ˆ˜ 3-8 ÒÚ˜ ÁÈ· ÙË ÌÔÚÊ›ÓË, ÙËÓ ˘‰ÚÔÌÔÚÊfiÓË, ÙË ÌÂı·‰fiÓË Î·È ÙË Ó·Ï‚Ô˘ÚÊ›ÓË). ∆· Ê¿Ú̷η ·˘Ù¿ ÚÔηÏÔ‡Ó ·ÓÔ¯‹ (ÂÏ¿ÙÙˆÛË Ù˘ ÚÔηÏÔ‡ÌÂÓ˘ ·Ó·ÏÁËÛ›·˜ ÌÂÙ¿ ·fi Â·Ó·Ï·Ì‚·ÓfiÌÂÓË ¯ÔÚ‹ÁËÛË), Ê˘ÛÈ΋ ÂÍ¿ÚÙËÛË Î·È Û·Ó›ˆ˜ ÂıÈÛÌfi. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› Ë ‰Ú¿ÛË ÙˆÓ ÔÈÔ‡¯ˆÓ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi ΤÓÙÚÔ Î·È ÛÙ· ·ÁÁ›· Ù˘ ·ÚÙËÚȷ΋˜ Î·È ÊÏ‚È΋˜ ΢ÎÏÔÊÔÚ›·˜, ÌÂ Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ ·›Ì·ÙÔ˜. ™Â ÂÚ›ÙˆÛË ˘ÂÚ‰ÔÛÔÏÔÁ›·˜ ÙˆÓ ÔÈÔ‡¯ˆÓ Ê·ÚÌ¿ÎˆÓ ÂÌÊ·Ó›˙ÂÙ·È ÎÒÌ·, ·ÚÁ‹ ÂÈfiÏ·ÈË ·Ó·ÓÔ‹ Î·È Ì‡ÛË. ∂ȉÈÎfi ·ÓÙ›‰ÔÙÔ Û ÂÚÈÙÒÛÂȘ ‰ËÏËÙËÚÈ¿Ûˆ˜ Ì ÔÈÔ‡¯· Â›Ó·È Ë Ó·ÏÔÍfiÓË Û ‰fiÛË 0,002 mg/kg. ∆· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο Â›Ó·È Ë ÌÔÚÊ›ÓË (‰fiÛË: 0,1 mg/kg/2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜ ‹ 0,1-0,15 mg/kg/3-4 ÒÚ˜ ÂÓ‰ÔÌ˘˚ÎÒ˜ ‹ 0,05-0,06 mg/kg/1 ÒÚ· ÛÂ Û˘Ó¯‹ ¤Á¯˘ÛË ‹ 0,3-0,6 mg/kg/8 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ· ˘fi ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ‚Ú·‰Â›·˜ ·Ô‰ÂÛ̇ۈ˜), Ë Âıȉ›ÓË (‰fiÛË: 0,8-1 mg/kg/2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜ ‹ 0,8-1,3 mg/kg/3-4 ÒÚ˜ ÂÓ‰ÔÌ˘˚ÎÒ˜ ‹ ˘Ô‰ÔÚ›ˆ˜), Ë Îˆ‰Â˝ÓË (‰fiÛË: 0,5-1 mg/kg/4 ÒÚ˜ ·fi ÙÔ ÛÙfiÌ·), Ë ÌÂı·‰fiÓË (‰fiÛË: 0,1 mg/kg/4 ÒÚ˜ ·Ú¯Èο, ÛÙË Û˘Ó¤¯ÂÈ· ·Ó¿ 6-12 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜), Ë Ê·ÈÓÙ·Ó‡ÏË (‰fiÛË: 1-2 Ìg/kg/1-2 ÒÚ˜ ÂÓ‰ÔÊÏ‚›ˆ˜) Î·È Ë ˘‰ÚÔÌÔÚÊfiÓË (‰fiÛË: 0,05-0,1 mg/kg/6ÒÚ˜, ¤ˆ˜ Î·È 5 mg/‰fiÛË ·fi ÙÔ ÛÙfiÌ·). ŸÏ· Ù· ·Ú·¿Óˆ ÔÈÔ‡¯· ·Ó·ÏÁËÙÈο Ê¿Ú̷η ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ‹ Û ªÔÓ¿‰Â˜ ∞˘ÍË̤Ó˘ ºÚÔÓÙ›‰·˜ Ì Ôχ ηϋ ηٷÁÚ·Ê‹ ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ (monitoring) Î·È Ì ·Ú¿ÏÏËÏË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘.

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¶·È‰È·ÙÚÈ΋ 2002;65:212-218

∆¤ÏÔ˜, Ê¿Ú̷η ÌÂ Û˘ÌÏËڈ̷ÙÈ΋ ‰Ú¿ÛË Â›Ó·È Ù· ·ÓÙÈÈÛÙ·ÌÈÓÈο, Ù· ËÚÂÌÈÛÙÈο-˘ÓˆÙÈο, Ù· ÙÔÈο ·Ó·ÈÛıËÙÈο, Ë Î·Ú‚·Ì·˙Â›ÓË ·fi Ù· ·ÓÙÈÂÈÏËÙÈο, Ë ÔÔ›· ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ÂÚÈÙÒÛÂȘ ËÌÈÎÚ·Ó›·˜ Î·È Ó¢ڷÏÁ›·˜, ηıÒ˜ Î·È ÔÚÈṲ̂ÓÔÈ ·Ó·ÛÙÔÏ›˜ ÙˆÓ ‚-˘Ô‰Ô¯¤ˆÓ ‹ Ù˘ ·ÓÙ·ÏÏ·Á‹˜ ÙˆÓ ÈfiÓÙˆÓ ·Û‚ÂÛÙ›Ô˘ Ô˘ ¤¯Ô˘Ó Â›Û˘ ¯ÚËÛÈÌÔÔÈËı› ÛÙËÓ ËÌÈÎÚ·Ó›·. ™Ù· Ê¿Ú̷η ·˘Ù¿ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ·Ó‹ÎÔ˘Ó Î·È Ù· ÎÔÚÙÈÎÔÛÙÂÚÈÓÔÂȉ‹, Ù· ÔÔ›· ‰ÚÔ˘Ó ·Ó·ÏÁËÙÈο, ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÛÙÔ Ô›‰ËÌ· Î·È ÙË ÊÏÂÁÌÔÓ‹, .¯. Û fiÁÎÔ˘˜ ÂÁÎÂÊ¿ÏÔ˘, ÔÛÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Î·È ÛÙȘ ·ÚıÚ·ÏÁ›Â˜ ÙˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ™˘ÌÂÚ¿ÛÌ·Ù· ∞ÔÙÂÏ› ‚·ÛÈÎfi ηı‹ÎÔÓ ÙˆÓ ·È‰È¿ÙÚˆÓ ·ÏÏ¿ Î·È fiÏˆÓ fiÛˆÓ ‰Ú·ÛÙËÚÈÔÔÈÔ‡ÓÙ·È ÛÙÔ ¯ÒÚÔ Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡, Ó· ÂȉÂÈÎÓ‡Ô˘Ó ÙËÓ ··ÈÙÔ‡ÌÂÓË ÚÔÛÔ¯‹ ˆ˜ ÚÔ˜ ÙËÓ ÚfiÏË„Ë Î·È ÙË ÛˆÛÙ‹ ÂÓ Á¤ÓÂÈ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜ Î·È ·ÈÙÈÔÏÔÁ›·˜. ∂›Ó·È ·Ôχو˜ ÂÛÊ·Ï̤ÓË Ë ·ÓÙ›ÏË„Ë fiÙÈ Ù· ·È‰È¿ ‰ÂÓ ÔÓÔ‡Ó fiÛÔ ÔÈ ÂÓ‹ÏÈΘ. ∂›Û˘, Ë ıÂÒÚËÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ·È‰È¿ ˆ˜ ·Ó·Áη›Ô˘ ·Ú¿ÁÔÓÙ· ÁÈ· ÙË ‰È·ÌfiÚʈÛË ÈÛ¯˘ÚÔ‡ ¯·Ú·ÎÙ‹Ú· ‹ Î·È ˆ˜ ı¤Ì·ÙÔ˜ ‹ÛÛÔÓÔ˜ ÛËÌ·Û›·˜ Â›Ó·È ·ÓÂ›ÙÚÂÙË Î·È Ú¤ÂÈ Ó· ·Ó‹ÎÂÈ ÔÚÈÛÙÈο ÛÙÔ ·ÚÂÏıfiÓ. µÂ‚·›ˆ˜, ··ÈÙÂ›Ù·È Ó· ¤¯Ô˘Ó fiÏÔÈ ÔÈ ·È‰›·ÙÚÔÈ ÙȘ ·Ó·Áη›Â˜ ÁÓÒÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ fiÓÔ˘ ÛÙËÓ Î¿ı ÂÚ›ÙˆÛË Î·È Ó· ÚÔ‚·›ÓÔ˘Ó ÛÙËÓ Î·Ù¿ÏÏËÏË, οı ÊÔÚ¿, ·ÓÙÈÌÂÙÒÈÛË. ¶ÚÔ·ÓÙfi˜, fï˜, Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÙËÓ Ú¤Ô˘Û· ÛÙ¿ÛË Î·È Â˘·ÈÛıËÛ›·, ÊÚÔÓÙ›˙ÔÓÙ·˜ Ó· ÂÊ·ÚÌfi˙Ô˘Ó ÚÔÏËÙÈ΋ ·Ó·ÏÁËÛ›· ÂÓ fi„ÂÈ ‰˘ÓËÙÈο ÂÒ‰˘ÓˆÓ ¯ÂÈÚÈÛÌÒÓ, Ó· ·ÍÈÔÏÔÁÔ‡Ó ÛˆÛÙ¿ ÙÔÓ fiÓÔ ÙÔ˘ ·È‰ÈÔ‡ Û˘Ó˘ÔÏÔÁ›˙ÔÓÙ·˜ ÙË ‚ÈÔÏÔÁÈ΋, ÓÔËÙÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÔ˘ ˆÚ›Ì·ÓÛË Î·ıÒ˜ Î·È ÙÔ˘˜ ÎÔÈÓˆÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÛˆÛÙ¿ Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η Î·È Ó· ˘ÔÛÙËÚ›˙Ô˘Ó „˘¯ÔÏÔÁÈο ÙÔ ·È‰› Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Schechter NL, Berde CB, Vaster M. Pain in infants, children, and adolescents: an overview. In: Schechter NL, Berde CB, Vaster M, eds. Pain in infants, children, and adolescents.

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30. ∆·Ú·ÓÙ˙‹-¶ÔÙ·ÌÈ¿ÓÔ˘ ¶, ºÚÂÙ˙¿ÁÈ·˜ ∞. O fiÓÔ˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ªÂÙÂÎ·È‰Â˘ÙÈÎfi ™ÂÌÈÓ¿ÚÈÔ ¶·È‰È·ÙÚÈ΋˜, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 1989;9:109-130.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 27-11-2001 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 27-03-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ ¶¿ÚÓËıÔ˜ 32, ∆.∫. 190 13, ™·ÚˆÓ›‰· ∞ÙÙÈ΋˜

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ™‡ÁÎÚÈÛË ÙˆÓ ‰ÂÈÎÙÒÓ Úfi‚Ï„˘ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÛÙ· ·È‰È¿1 ™ÎÔfi˜: ∏ ·ÔÙ˘¯›· Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·È‰ÈÒÓ ·fi ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ª∞) Û˘Óԉ‡ÂÙ·È ·fi ·‡ÍËÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ Î·È Ù˘ ÓÔÛËÚfiÙËÙ·˜. °È’ ·˘Ùfi Î·È Â›Ó·È ÂÈı˘ÌËÙ‹ Ë Â͇ÚÂÛË ÂÓfi˜ ‰Â›ÎÙË ÂÈÙ˘¯Ô‡˜ ·ÔÛ‡Ó‰ÂÛ˘ ·fi ÙÔ ª∞. ∏ ÌÂϤÙË ·˘Ù‹ ¤ÁÈÓ Ì ÛÎÔfi Ó· ‰Â›ÍÂÈ ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·ÏÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ÌÂÙÚ‹ÛˆÓ, ÂȉÈÎfiÙÂÚ· ÔÈ ·Ó·ÊÂÚfiÌÂÓÔÈ ˆ˜ Û˘Ó‰˘·Ṳ̂ÓÔÈ ‰Â›ÎÙ˜ ·ÔۈϋӈÛ˘, ‹Ù·Ó ÈÔ ·ÍÈfiÈÛÙÔÈ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Úfi‚ÏÂ„Ë Ù˘ ·ÔÙ˘¯›·˜ Ù˘ ·Ô‰¤ÛÌ¢Û˘ ·È‰ÈÒÓ ·fi ÙÔ ª∞, ·’ fiÙÈ Ù· ·Ó¿ÏÔÁ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. ™¯Â‰È·ÛÌfi˜: ¶ÚÔÔÙÈ΋ ÌÂϤÙË ·Ú·Ù‹ÚËÛ˘. ÃÒÚÔ˜: ∆ÚÈÙÔ‚¿ıÌÈ· ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ¶·È‰ÈÒÓ (ª∂£¶). ∞ÛıÂÓ›˜: ŸÏ· Ù· ·È‰È¿ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ª∞ ÁÈ· >24 ÒÚ˜ Û ‰È¿ÛÙËÌ· 12 ÌËÓÒÓ, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÁÔÓ›˜ ›¯·Ó ‰ÒÛÂÈ ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË. ŒÏÂÁ¯Ô˜: OÈ ·Ó·Ó¢ÛÙÈΤ˜ ÌÂÙÚ‹ÛÂȘ Á›ÓÔÓÙ·Ó Î·Ù¿ ̤ÛÔ fiÚÔ 7 ÒÚ˜ (‡ÚÔ˜ 0,2-25 ÒÚ˜) ÚÈÓ ÙËÓ ·ÔۈϋӈÛË. ∞¤ÚÈ· ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ Ï·Ì‚¿ÓÔÓÙ·Ó ·ÎÚÈ‚Ò˜ ÚÈÓ ÙËÓ ·ÔۈϋӈÛË. OÈ ÙÈ̤˜ fiÏˆÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ·Ó·Ï‡ÔÓÙ·Ó ˆ˜ ÚÔ˜ ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙËÓ ÂȉÈÎfiÙËÙ· Î·È Û˘ÁÎÚ›ÓÔÓÙ·Ó ÔÈ ÂÚÈÔ¯¤˜ οو ·fi ÙȘ ηÌ‡Ï˜, Ì ÛÙfi¯Ô Ó· ‚ÚÂı› Ô ϤÔÓ ·ÎÚÈ‚‹˜ ‰Â›ÎÙ˘ Úfi‚Ï„˘ Ù˘ ÂÈÙ˘¯Ô‡˜ ·ÔۈϋӈÛ˘. ªÂÙÚ‹ÛÂȘ Î·È Î˘ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù·: ™˘ÓÔÏÈο ÌÂÏÂÙ‹ıËÎ·Ó 47 ·È‰È¿ (̤Û˘ ËÏÈΛ·˜ 3,9 ¤ÙË, ‡ÚÔ˜ 0,1-17,3 ¤ÙË). ∏ ·ÔۈϋӈÛË ·¤Ù˘¯Â Û 7. O ÌÈÎÚfi˜ ·Ó·ÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ (<7,5 ml/kg) Î·È Ô ¯·ÌËÏfi˜ ηٿ ÏÂÙfi ·ÂÚÈÛÌfi˜ (<250 ml/kg) ›¯·Ó ÙË ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· (86% Î·È 71%

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1 Manczur TI, Greenough A, Pryor D, Rafferty GF Comparison of predictors of extubation from mechanical ventilation in children Pediatr Crit Care Med 2000;1:28-32

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19-21 ™ÂÙÂÌ‚Ú›Ô˘ 2002

27 UMEMPS Congress Congress Secretariat: Viajes Pacifico, S.L. c/ Maria Cubi, 4 entlo Tel.: +34 93 238 8777 Fax: +34 93 238 7488 E-mail: pg@pacif-meetings.com

Alicante, Spain

20-25 ™ÂÙÂÌ‚Ú›Ô˘ 2002

9th International Child Neurology Congress and the 7th Asian and Oceanian Congress of Child Neurology ¶ÏËÚÔÊÔڛ˜: Dr. Yu-Wu Jiang, Xin-Hua Bao E-mail: icnc@public3.bta.net.cn Website: http://www.ciccs-t.org.cn/icnc2002

Beijing, China

27-29 ™ÂÙÂÌ‚Ú›Ô˘ 2002

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£ÂÛÛ·ÏÔÓ›ÎË

28 ™ÂÙÂÌ‚Ú›Ô˘ 2002

∏ÌÂÚ›‰· Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎÒÓ Û˘Ó‰ÚfiÌˆÓ ∂ÏÏËÓÈ΋˜ ∞ÈÌ·ÙÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ ¶ÏËÚÔÊÔڛ˜: ∂æπ§O¡ ∆ËÏ.: 010 - 72 54 360-2 Fax: 010 - 72 54 363 E-mail: epsilon@hol.gr

¡·‡ÏÈÔ

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MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·221

™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

xv

MAY-JUNE02TELIKO 24-04-02 15:05 ™ÂÏ›‰·222

™˘ÓÙÔÌÔÁڷʛ˜

·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¿‰·

p.o.

RIA RNA RDS sec s.c. ‹ À.¢.

SD SE U

™˘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

xvi

EÏÏËÓÈÎÔ› fiÚÔÈ

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

AÁÁÏÈÎÔ› fiÚÔÈ by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit