Παιδιατρική | Τόμος 66 • Τεύχος 1 • Ιανουάριος - Φεβρουάριος 2003

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·1

¶·È‰È·ÙÚÈ΋ 2003;66:1

Paediatriki 2003;66:1

∂¶π™∆O§∏ ∞¶O ∆∏ ™À¡∆∞∫∆π∫∏ ∂¶π∆ƒO¶∏

∞Á·ËÙÔ› ™˘Ó¿‰ÂÏÊÔÈ, ªÂ ÙËÓ Â˘Î·ÈÚ›· ÙˆÓ ÂÔÚÙÒÓ ÙˆÓ ÃÚÈÛÙÔ˘Á¤ÓÓˆÓ Î·È ÙÔ˘ ·Ó·Ù¤ÏÏÔÓÙÔ˜ ¡¤Ô˘ ŒÙÔ˘˜, Ë ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ “¶∞π¢π∞∆ƒπ∫∏™” Î·È ÂÁÒ ÚÔÛˆÈο, Û·˜ ÛÙ¤ÏÏÔ˘Ì ÙȘ ıÂÚÌfiÙÂÚ˜ ¢¯¤˜ Ì·˜. ∂˘¯fiÌ·ÛÙ Û ۷˜ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ Û·˜ ˘Á›·, ÚÔÎÔ‹ Î·È Î¿ı ÂÈÙ˘¯›· ÛÙÔ˘˜ ÛÙfi¯Ô˘˜ Û·˜. ∏ Ó¤· ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ Ù˘ “¶∞π¢π∞∆ƒπ∫∏™” Ô˘ ·Ó¤Ï·‚ ·fi Ù· ̤۷ ÙÔ˘ ÙÚ¤¯ÔÓÙÔ˜ ¤ÙÔ˘˜, Û˘Ó¯›˙ÔÓÙ·˜ ÙÔ ‰ËÌÈÔ˘ÚÁÈÎfi ¤ÚÁÔ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘, οÓÂÈ Î¿ı ‰˘Ó·Ù‹ ÚÔÛ¿ıÂÈ· ÁÈ· ÙË Û˘Ó¯‹ ·ÓÔ‰È΋ ÔÚ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ì·˜ ÁÈ· ÙË ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È ÙËÓ ¤ÓÙ·Í‹ ÙÔ˘ ̤۷ ÛÙ· ‰ÈÂıÓ‹ È·ÙÚÈο ÂÚÈÔ‰Èο.

ªÂ Û˘Ó·‰ÂÏÊÈÎÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜ ÁÈ· ÙË ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ O ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ™Ù·‡ÚÔ˜ ÷˚‰¿˜

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JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·2

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

∞¡∞™∫O¶∏™∏

Paediatriki 2003;66:2-11

REVIEW ARTICLE

¡Â˘ÚÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ª. ¡. ¶··‰ËÌËÙÚ›Ô˘

Neurological assessment of the newborn infants M. N. Papadimitriou

¶ÂÚ›ÏË„Ë: ™ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ ÛËÌÂÈÒıËΠÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÛÙË ÓÔÛËÏ›· ÙˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∞˘Ùfi Ô‰‹ÁËÛ Û ·˘ÍË̤ÓË ÂÈ‚›ˆÛË ÙˆÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∆·˘Ùfi¯ÚÔÓ· Ì ·˘Ù‹ ÙË ‚ÂÏÙ›ˆÛË, ¤ÁÈÓ ÂÊÈÎÙ‹ Ë ¯Ú‹ÛË ÂÚÈÛÛfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ Î·Ù¿ÏÏËÏˆÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ. ∏ ÚÔÛÔ¯‹ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ΢ڛˆ˜ ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È Doppler ÂÁÎÂÊ¿ÏÔ˘, ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÙËÓ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·Ê›· Î·È ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ. O ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ò˜ Ì›· ÔÏÔÎÏËڈ̤ÓË ÚÔÛ¤ÁÁÈÛË Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯Ú‹ÛË ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂÎÙ›ÌËÛ˘ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ÚfiÁÓˆÛË Ù˘ ·ÒÙÂÚ˘ Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ÂͤÏÈ͢.

Abstract: During the last two decades there has been significant progress in the management of high-risk preterm infants resulting in an increased survival of low-birthweight infants. At the same time more techniques assessing the neurological well being of these infants have become available.

Attention is mainly focused on brain ultrasound, Doppler, MRI, electroencephalography and various evoked potential modalities. The aim of this study is to illustrate how an integrated approach with the combined use of imaging and clinical evaluation can help in predicting neurodevelopmental outcomes.

§¤ÍÂȘ ÎÏÂȉȿ: ÓÂÔÁÓfi, ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘, ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο, Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘.

Key words: newborn infant, electroencephalography, brain ultrasound, evoked potentials, magne-tic resonance imaging.

∂ÈÛ·ÁˆÁ‹ ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ ·Ó·Ù˘¯ı› ·ÚÎÂÙfi ÂӉȷʤÚÔÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ó¢ÚÔÏÔÁ›· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘. ∞˘Ùfi ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Ì ÙËÓ ‡·ÚÍË ‚ÂÏÙÈÒÛÂˆÓ ÛÙË ÓÔÛËÏ›· ÙˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, ηıÒ˜ Î·È Ì ÙËÓ ·Ó·Î¿Ï˘„Ë Î·È ¯Ú‹ÛË Ó¤ˆÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘˜. ∏ ÚÔÁÂÓÓËÙÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ Î·È Ë ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ Û ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (¶Ãµ°) (1,2).

∏ ÚÔÁÂÓÓËÙÈ΋ ¯Ú‹ÛË ÎÔÚÙÈÎÔÂȉÒÓ Á›ÓÂÙ·È Ì ·ÚÎÂÙ‹ ÂÚ›ÛÎÂ„Ë ÙÂÏÂ˘Ù·›·, ·ÊÔ‡ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ù· Ì·ÎÚ¿ (fi¯È fï˜ Î·È Ù· ‚Ú·¯¤· Î·È ÌÂÌÔӈ̤ӷ) Û¯‹Ì·Ù· ÚÔÁÂÓÓËÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÂȉÒÓ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯·ÌËÏfiÙÂÚÔ Ú˘ıÌfi ·Ó¿Ù˘Í˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ·ÏÏ¿ Î·È ÂÌÊ¿ÓÈÛË ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÂÓÒ Ù· Ì·ÎÚ¿ Û¯‹Ì·Ù· ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯ÂÈÚfiÙÂÚË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË (3,4). ™ÙËÓ ∂˘ÚÒË ÂÈ‚ÈÒÓÂÈ ÙÔ 50% ÙˆÓ ÓÂÔÁÓÒÓ Ì ∏∫ 25 ‚‰ÔÌ¿‰Â˜. ™ÙËÓ ∞ÁÁÏ›· Î·È ÙËÓ πÚÏ·Ó‰›· ¤ÁÈÓ ÙÔ 1995 Ë EPICure ÌÂϤÙË, Ë ÔÔ›· ¤‰ÂÈÍÂ

∆Ì‹Ì· ¡ÂÔÁ¤ÓÓËÙˆÓ, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·

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

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JAN-FEB-03

14-05-03

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¶·È‰È·ÙÚÈ΋ 2003;66:2-11

ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ 39% ÁÈ· ÓÂÔÁÓ¿ Ì ∏∫ <26 ‚‰ÔÌ¿‰Â˜. ∞fi Ù· ÓÂÔÁÓ¿ Ô˘ ÂÈ‚›ˆÛ·Ó, ÔÛÔÛÙfi 23% ·˘ÙÒÓ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Û ËÏÈΛ· 2,5 ÂÙÒÓ, ·ÚÔ˘Û›·˙ ٤ÙÔÈ· Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Ô˘ Â¤‚·Ï·Ó ÙËÓ ÂÍ¿ÚÙËÛ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÁÈ· fiÏË ÙÔ˘˜ ÙË ˙ˆ‹ (5,6). ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (7) ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÙÔ 20% ·fi Ù· ·È‰È¿ Ô˘ ÂÈ‚›ˆÛ·Ó ÌÂÙ¿ ·fi ·ËÛË 32 ‚‰ÔÌ¿‰ˆÓ ‹ Ì µ° <1500 g ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈ΋ ÂÎ·›‰Â˘ÛË. ªÂϤÙ˜ ·fi ÙȘ ∏¶∞ ·Ó·Ê¤ÚÔ˘Ó ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÁÈ· ÓÂÔÁÓ¿ Ì µ° <1000 g, Ô˘ Êı¿ÓÔ˘Ó Ì¤¯ÚÈ ÙÔ 72% (8), ·ÏÏ¿ ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ Ì ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÚÔÏÔÁÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ (8,9). ∫ÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË OÈ ÚÒÙ˜ ÚÔÛ¿ıÂȘ Ó¢ÚÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ ¤ÁÈÓ·Ó ·fi ÙÔ˘˜ Andrè-Thomas Î·È Saint-Ann Dargassies (10-12) ÙÔ 1952, 1960 Î·È 1977. ø˜ ÛÙfi¯Ô ›¯·Ó ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ, ·ÏÏ¿ Î·È ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∞˘Ùfi˜ Ô ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ΢ڛˆ˜ ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ Ì˘˚ÎÔ‡ ÙfiÓÔ˘ Î·È ·Ú¯¤ÁÔÓˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Î·È ¤‰ÂȯÓ fiÙÈ Ë ÂͤÏÈÍ‹ ÙÔ˘˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ Î·È fi¯È ·fi ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ™¯Â‰fiÓ Ù·˘Ùfi¯ÚÔÓ· (1977) ÛÙËÓ OÏÏ·Ó‰›·, o Prechtl (13) ÂÊ¿ÚÌÔÛ ̛· ÂͤٷÛË ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÈÎÂÓÙÚÒıËΠÛÙÔÓ Î·ıÔÚÈÛÌfi ‰È·ÊfiÚˆÓ “Û˘Ó‰ÚfïӔ (Û‡Ó‰ÚÔÌÔ ˘ÂÚ¢ÂÚÂıÈÛÙfiÙËÙ·˜, Û‡Ó‰ÚÔÌÔ ·¿ıÂÈ·˜, ËÌÈÛ‡Ó‰ÚÔÌÔ), ·ÏÏ¿ Î·È ‰È·ÊfiÚˆÓ ÛÙ·‰›ˆÓ ÂÁÚ‹ÁÔÚÛ˘, Ù· ÔÔ›· ηıÔÚ›˙Ô˘Ó ÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 1970, Ô Brazelton (14) ÂÛÙ›·Û ÙËÓ ÂͤٷÛË ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ·Ó¿ÌÂÛ· ÛÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ÙÔ ÂÍÂÙ·˙fiÌÂÓÔ ÓÂÔÁÓfi, Ì ÂÈΤÓÙÚˆÛË Û ÛËÌ›· Û˘ÌÂÚÈÊÔÚ¿˜, fiˆ˜ Ë ·¿ÓÙËÛË Û ·ÎÔ˘ÛÙÈο, ÔÙÈο, ·ÙÈο Î·È ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È Ë ÂÎÙ›ÌËÛË ÙfiÓÔ˘ Î·È Â˘ÂÚÂıÈÛÙfiÙËÙ·˜. ŸÏ˜ ÔÈ ÚÔËÁÔ‡ÌÂÓ˜ ̤ıÔ‰ÔÈ ··ÈÙÔ‡Û·Ó ÌÂÁ¿ÏË ÂÌÂÈÚ›· ·fi ÙÔÓ ÂÍÂÙ·ÛÙ‹ Î·È ·ÚÎÂÙfi ¯ÚfiÓÔ ÁÈ· Ó· ÂÚ·ÙˆıÔ‡Ó. ∆Ô 1970, ÔÈ Dubowitz Î·È Û˘Ó (15) ·Ó¤Ù˘Í·Ó ¤Ó· Û‡ÛÙËÌ· ÂÎÙ›ÌËÛ˘ Ù˘ ËÏÈΛ·˜ ·ËÛ˘. ∞ÚÁfiÙÂÚ· (1981), ÔÈ ›‰ÈÔÈ ‰ËÌÈÔ‡ÚÁËÛ·Ó ¤Ó· Ó¤Ô Û‡ÛÙËÌ· Ó¢ÚÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ (16). O ÛÙfi¯Ô˜ ‹Ù·Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ¤Ó· Û‡ÛÙËÌ· ‡ÎÔÏÔ Î·È ÚÔÛÈÙfi Û ÏÈÁfiÙÂÚÔ ¤ÌÂÈÚÔ˘˜ ÁÈ·ÙÚÔ‡˜, ·Ó··Ú·ÁÒÁÈÌÔ Î·È Ì ηϋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÂÍÂÙ·ÛÙÒÓ. ¶ÂÚÈÂÏ¿Ì‚·Ó ÙËÓ ÂÎÙ›ÌËÛË Ì˘˚ÎÔ‡ ÙfiÓÔ˘, ÎÈÓËÙÈÎfiÙËÙ·˜, ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Û ۯ¤ÛË Ì ÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘, ηıÒ˜ Î·È ÙËÓ ÂÎÙ›ÌËÛË ÛËÌ›ˆÓ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË Û˘ÌÂÚÈÊÔÚ¿. ∞Ó Î·È Ë Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı›

Paediatriki 2003;66:2-11

ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÓÂÔÁÓÒÓ Î·È ÙË Û‡ÁÎÚÈÛË ÂÓfi˜ ÓÂÔÁÓÔ‡ Ì ¿ÏÏÔ, ÂÓÙÔ‡ÙÔȘ, Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ∂ÓÒ Ë ÛÙ·ıÂÚ¿ ·Ó¢ÚÈÛÎfiÌÂÓË Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, Ë ·ÚÔ˘Û›· Ó¢ÚÔÏÔÁÈÎÒÓ ·ÔÎÏ›ÛÂˆÓ Î·Ù¿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜ ‰ÂÓ ÌÔÚ› ¿ÓÙÔÙ ӷ ÚÔ‰ÈοÛÂÈ ÙËÓ ·ÚÔ˘Û›·, ÙÔÓ Ù‡Ô ‹ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ (17). ∂ÓÙÔ‡ÙÔȘ, ÓÂfiÙÂÚË ÌÂϤÙË (18) ‰Â›¯ÓÂÈ fiÙÈ Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÓÂÔÁÓÔ‡ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, fiÙ·Ó Á›ÓÂÙ·È ÌÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜, Â›Ó·È ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ ¤Î‚·Û˘ ÁÈ· ·˘Ù¿ Ù· ÓÂÔÁÓ¿ Ì ηϋ Û˘Û¯¤ÙÈÛË ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÈÎfiÓ˜ ‚Ï¿‚˘ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘. ™¯Â‰fiÓ Ù·˘Ùfi¯ÚÔÓ·, Ë ÔÌ¿‰· ÙˆÓ Dubowitz ‰ËÌÔÛȇÂÈ Ì›· Ó¤· ÂΉԯ‹ Ó¢ÚÔÏÔÁÈ΋˜ ÂͤٷÛ˘ Ô˘ ‰›ÓÂÈ È‰È·›ÙÂÚË ¤ÌÊ·ÛË Û Ӥ· ı¤Ì·Ù·, fiˆ˜ ÔÈ ÁÂÓÈΤ˜ ÎÈÓ‹ÛÂȘ Î·È Ù· ÚfiÙ˘· ηٷÓÔÌ‹˜ ÙÔ˘ ÙfiÓÔ˘. ¶·Ú¿ÏÏËÏ·, ηıÔÚ›˙ÂÙ·È ¤Ó· ¢ÓÔ˚Îfi score (optimality score) ÚÔÎÂÈ̤ÓÔ˘ Ó· ηٷÛÙ‹ÛÂÈ ÙËÓ ÂÎÙ›ÌËÛË ÂÚÈÛÛfiÙÂÚÔ ÔÛÔÙÈ΋ Î·È Û˘ÁÎÚ›ÛÈÌË Û ‰È·‰Ô¯ÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ (19). ∏ ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ ÙˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Î·È Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi ÙˆÓ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂıfi‰ˆÓ ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· Ó· ‰›‰ÂÙ·È ÌÈÎÚfiÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ ÎÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Î˘Ú›ˆ˜ ÙÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡. ∞˘Ùfi ÂÈ‚¿ÏÏÂÙ·È ˆ˜ ¤Ó· ‚·ıÌfi ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Û˘ÓÈÛÙ¿Ù·È Ë Ì›ˆÛË ÙˆÓ ¯ÂÈÚÈÛÌÒÓ ÛÙÔ ÂÏ¿¯ÈÛÙÔ, ηıÒ˜ Â›Û˘ Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ›‰È˜ ÔÈ Û˘Óı‹Î˜ ÓÔÛËÏ›·˜ ÙÔ˘˜ (·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ‡·ÚÍË ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ Î.Ï.) ÂËÚ¿˙Ô˘Ó ÙËÓ ·˘ÙfiÌ·ÙË ÎÈÓËÙÈÎfiÙËÙ·. ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ·ÔÛ˘Ó‰ÂıÔ‡Ó ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È Â›Ó·È Û ÛÙ·ıÂÚ‹ ηٿÛÙ·ÛË, Ë ÎÏÈÓÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜. ¶Ôχ ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË Ù˘ ›‰È·˜ ÔÌ¿‰·˜ (20) ÚÔÙ›ÓÂÈ ÙËÓ Â¤ÎÙ·ÛË Ù˘ ¯Ú‹Û˘ ÙÔ˘ optimality score Û ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ fiÙ·Ó Êı¿ÓÔ˘Ó ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ÌËÓÒÓ, Ì ‰˘Ó·ÙfiÙËÙ· Ó· ‰›ÓÂÈ ÚfiÁÓˆÛË ÁÈ· ·ÒÙÂÚË ¤Î‚·ÛË. ∆ÂÏÂ˘Ù·›· ‰›‰ÂÙ·È ÌÂÁ¿ÏË ¤ÌÊ·ÛË ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ Ë ÔÈfiÙËÙ· ÙˆÓ ·˘ÙfiÌ·ÙˆÓ ÎÈÓ‹ÛÂˆÓ Û ۯ¤ÛË Ì ÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË (21-23). ™Ù· Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿, ÔÈ ·‰Ú¤˜ ÎÈÓ‹ÛÂȘ ¤¯Ô˘Ó ÚÔԉ¢ÙÈ΋ ¤Ó·ÚÍË Î·È ÂͤÏÈÍË Û ¤Ó· ̤ÁÈÛÙÔ Â›Â‰Ô ¤ÓÙ·Û˘ ηÈ, ·ÎÔÏÔ‡ıˆ˜, ÔÌ·Ï‹ Î·È ÛÙ·‰È·Î‹ Ì›ˆÛË. ∞ÓÙÈı¤Ùˆ˜, ÔÈ ÛÙÂÚÂfiÙ˘˜ ÎÈÓ‹ÛÂȘ Ô˘ ÍÂÎÈÓÔ‡Ó Î·È Î·Ù·Ï‹ÁÔ˘Ó ·fiÙÔÌ· Û˘ÓÔ‰Â‡Ô˘Ó ·ÓÒÌ·ÏË Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ·.

3

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·4

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ˘¿Ú¯ÂÈ ÏÔ‡ÛÈ· ‚È‚ÏÈÔÁÚ·Ê›· fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘Û¯¤ÙÈÛË ÙˆÓ ÏÂÁfiÌÂÓˆÓ ÁÂÓÈÎÒÓ ÎÈÓ‹ÛÂˆÓ (general movements) Ì ÙËÓ ·ÒÙÂÚË ¤Î‚·ÛË Û ηٷÛÙ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, .¯. ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· Ô˘ Û˘Óԉ‡ÂÈ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ‹ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· (22,23). ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ¤ÏÂÁ¯Ô Ó¢ÚÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÚÔۋψÛË ‚ϤÌÌ·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 32 ‚‰ÔÌ¿‰ˆÓ (24). ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÔÙÈÎÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜, .¯. ÊÔ‡ÓÙ· ÎfiÎÎÈÓÔ˘ Ì·ÏÏÈÔ‡, ·Ú·ÙËÚÂ›Ù·È ·fi ÙȘ 34 ‚‰ÔÌ¿‰Â˜ Î·È ÌÂÙ¿, ÂÓÒ ÚÔۋψÛË ‚ϤÌÌ·ÙÔ˜ Î·È ·Ú·ÎÔÏÔ‡ıËÛË Û ÔÚÈ˙fiÓÙÈÔ Î·È Î¿ıÂÙÔ Â›Â‰Ô Â›Ó·È Î·Ï¿ ·ÓÂÙ˘Á̤ӷ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ Î·È ÌÂÙ¿. ∏ ·ÓÙ›‰Ú·ÛË ÛÙÔÓ ‹¯Ô Â›Ó·È ‹‰Ë ·ÚÔ‡Û· ·fi ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ Î·È ÂΉËÏÒÓÂÙ·È Ì ÙË ÌÂÙ·‚ÔÏ‹ Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘. ªÂÙ¿ ÙË Á¤ÓÓËÛË, Û·Ê‹˜ ·ÓÙ·fiÎÚÈÛË ÛÙÔÓ ‹¯Ô ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÛÙËÓ ËÏÈΛ· ÙˆÓ 28 ‚‰ÔÌ¿‰ˆÓ ÂÚ›Ô˘, fiÙ·Ó ÙÔ ÓÂÔÁÓfi ÌÔÚ› Ó· ·ÓÙȉڿÛÂÈ Ì ·ÓÔÈÁÔÎÏ›ÛÈÌÔ ÙˆÓ Ì·ÙÈÒÓ ‹ Í¿ÊÓÈ·ÛÌ· (12). ™Â ·Ô˘Û›· ·˘Ù‹˜ Ù˘ ·ÓÙ·fiÎÚÈÛ˘, ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜, fiˆ˜ ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο. ∏ ¯Ú‹ÛË ÙÔ˘ ÚÔÙ‡Ô˘ ÂͤٷÛ˘ Ù˘ ÔÌ¿‰·˜ Dubowitz (16) ÛÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜ Â›Ó·È ¯Ú‹ÛÈÌË Î·È Û¯ÂÙÈο ·Ï‹ ÁÈ· ‰È·‰Ô¯ÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÙˆÓ ÓÂÔÁÓÒÓ, ·ÎfiÌË Î·È ·fi ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÂÍÂÙ·ÛÙ¤˜. ∏ ÛÙ·ıÂÚ¿ ·Ó¢ÚÈÛÎfiÌÂÓË Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÈÎfiÓ· Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, ÂÊfiÛÔÓ Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÂÈÎfiÓ˜ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ Ù¯ÓÈΤ˜. ∏ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂÙ¿ ÙË ‰Â‡ÙÂÚË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜ ıˆÚÂ›Ù·È ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Û¯ÂÙ›˙ÂÙ·È ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÈÎfiÓ˜ ‚Ï¿‚˘ ÛÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ Ù¯ÓÈΤ˜ Î·È Î˘Ú›ˆ˜ ÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ·Ó·Ï˘ÙÈο ηو٤ڈ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, Ê·›ÓÂÙ·È fiÙÈ Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÂÚ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙÔ˘ ÙÂÏÂÈfiÌËÓÔ˘ ‹ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÙÌ‹Ì· ÓÂÔÁ¤ÓÓËÙˆÓ ÌÔÚ› Ó· ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›·, Û ۯ¤ÛË ¿ÓÙÔÙ Ì ٷ Â˘Ú‹Ì·Ù· ÛÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘ (·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ηو٤ڈ).

Paediatriki 2003;66:2-11

∞ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ÂÁÎÂÊ¿ÏÔ˘ ÀÂÚ˯ÔÁÚ¿ÊËÌ· ÂÁÎÂÊ¿ÏÔ˘ ∏ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ ÙÔ 1970 Î·È Î˘Ú›ˆ˜ Ë ¯Ú‹ÛË ÙˆÓ Ó¤ˆÓ ˘ÂÚ˯ÔÁÚ¿ÊˆÓ (sector scanners) ÙÔ 1980 η٤ÛÙËÛ·Ó ‰˘Ó·Ùfi ÙÔÓ Î·ıÔÚÈÛÌfi ÙfiÛÔ ÙÔ˘ Ù‡Ô˘ Î·È Ù˘ ı¤Û˘, fiÛÔ Î·È Ù˘ Â›ÙˆÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ‚Ï·‚ÒÓ, Û ۯ¤ÛË ¿ÓÙÔÙ Ì ÙËÓ ËÏÈΛ· ·ËÛ˘. ∏ ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ ¤‰ˆÛ Ú·ÁÌ·ÙÈ΋ ÒıËÛË ÛÙË Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ, ‰ÈfiÙÈ Â›Ó·È Â‡ÎÔÏË, ·ÛÊ·Ï‹˜ Î·È ÊıËÓ‹ ̤ıÔ‰Ô˜, ÂÓÒ ÙÔ Ì˯¿ÓËÌ· Â›Ó·È ÊÔÚËÙfi Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ηٿÏÏËÏÔ ÁÈ· ¯Ú‹ÛË ÚÔ˘Ù›Ó·˜ ÛÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ªÂ ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Â›Ó·È Â‡ÎÔÏÔ Ó· ‰È·ÁÓˆÛÙ› fi¯È ÌfiÓÔ Ë ÂÚÈÎÔÈÏȷ΋-ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (¶∂∞), ·ÏÏ¿ Î·È Ë ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· (¶§), ÁÂÁÔÓfi˜ Ôχ ÛËÌ·ÓÙÈÎfi ·ÊÔ‡ Ë ÙÂÏÂ˘Ù·›· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¯ÂÈÚfiÙÂÚË ¤Î‚·ÛË. ŒÙÛÈ ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ‰Âȯı› fiÙÈ Ë ¶§ Û˘Ì‚·›ÓÂÈ Î˘Ú›ˆ˜ ÌÂٷ͇ 28 Î·È 32 ‚‰ÔÌ¿‰ˆÓ (25), ÂÓÒ Ë ˘ÔÊÏÔÈ҉˘ Ï¢ÎÔ̷ϷΛ· Â›Ó·È Û˘¯ÓfiÙÂÚË Û ÈÔ ÒÚÈÌ· ÓÂÔÁÓ¿. ™¯ÂÙÈο Ì ÙËÓ ¶∂∞, ÁÂÓÈο Â›Ó·È ·Ô‰ÂÎÙ‹ ÙÂÏÂ˘Ù·›· Ë Ù·ÍÈÓfiÌËÛË ÙÔ˘ Volpe (26) Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚÂȘ ‚·ıÌÔ‡˜ Î·È Í¯ˆÚÈÛÙ‹ ÂÚÈÁÚ·Ê‹ Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ (¶›Ó·Î·˜ 1). º·›ÓÂÙ·È fiÙÈ Ë ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Ô˘ Û˘Óԉ‡ÂÈ ÂÙÂÚfiÏ¢ÚË ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· Û˘Ó‰¤ÂÙ·È, Û‹ÌÂÚ·, Ì ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ (26-28). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ·, Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙ‹ Ë Ù·ÍÈÓfiÌËÛË Ù˘ de Vries (29) (¶›Ó·Î·˜ 2). ∏ ¶∂∞ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ Ì ÙËÓ ¶§ Ô˘ Â›Ó·È Ì›· ηٿÛÙ·ÛË ·ÌÊÔÙÂÚfiÏ¢ÚË, ·Ó Î·È fi¯È ¿ÓÙÔÙÂ Û˘ÌÌÂÙÚÈ΋. ∏ ¶§ Û˘Ì‚·›ÓÂÈ Ì¤¯ÚÈ Î·È 11 ‚‰ÔÌ¿‰Â˜ ·fi ÙË Á¤ÓÓËÛË, ·ÎfiÌË Î·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë. ∂ÓÙÔ‡ÙÔȘ, ÔÈ ÌÂÙ·‚ÔϤ˜ Ù˘ ÂÚÈÎÔÈÏȷ΋˜ Ï¢΋˜ Ô˘Û›·˜ Û˘Ì‚·›ÓÔ˘Ó ·ÚÁfiÙÂÚ·. ∞˘ÍË̤ÓË ˘ÂÚ˯ÔÁ¤ÓÂÈ· Û ·˘Ù¤˜ ÙȘ ÂÚÈÔ¯¤˜ Â›Ó·È Û˘¯Ó‹ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜, Á›ÓÂÙ·È fï˜ ÂÓ‰ÂÈÎÙÈ΋ ¶§ ÌfiÓÔÓ fiÙ·Ó ÂÈ̤ÓÂÈ ÁÈ· ¿Óˆ ·fi 7-10 Ë̤Ú˜.

OÈ Â·ÓÂÈÏËÌ̤Ó˜ ÂÍÂÙ¿ÛÂȘ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙȘ ÂfiÌÂÓ˜ 2-3 ‚‰ÔÌ¿‰Â˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰Â›ÍÔ˘Ó ÙËÓ ÂͤÏÈÍË Û ÏÈÁfiÙÂÚÔ ‹ ÂÚÈÛÛfiÙÂÚÔ ÂÎÙÂٷ̤Ó˜ ΢ÛÙÈΤ˜ ÌÂÙ·‚ÔϤ˜, οÔÈÔ˘ ‚·ıÌÔ‡ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‹ Î·È Î·Ì›· ÂÌÊ·Ó‹ ÌÂÙ·‚ÔÏ‹.

¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ÂÚÈÎÔÈÏȷ΋˜-ÂÓ‰ÔÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ µ·ıÌfi˜ 1. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ ¯ˆÚ›˜ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ‹ Ì ÌÈÎÚ‹ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· µ·ıÌfi˜ 2. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ + ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (10-50% Ù˘ Ï¿ÁÈ·˜ ÎÔÈÏ›·˜ Û ·Ú·Ô‚ÂÏÈ·›· ÙÔÌ‹) µ·ıÌfi˜ 3. ∞ÈÌÔÚÚ·Á›· ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ + ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· (>50% Ù˘ Ï¿ÁÈ·˜ ÎÔÈÏ›·˜ + ÔÍ›· ‰È¿Ù·ÛË) •Â¯ˆÚÈÛÙ‹ ÂÚÈÁÚ·Ê‹ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜

4

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·5

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

Paediatriki 2003;66:2-11

¶›Ó·Î·˜ 2. ∆·ÍÈÓfiÌËÛË ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ ηٿ de Vries µ·ıÌfi˜ 1. µ·ıÌfi˜ 2. µ·ıÌfi˜ 3. µ·ıÌfi˜ 4.

¶·ÚÔ‰ÈΤ˜ ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÈ̤ÓÔ˘Û˜ ÁÈ· >7 Ë̤Ú˜ ¶ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÌÈÎÚ¤˜ ÂÓÙÔÈṲ̂Ó˜ ÌÂÙˆÔ‚ÚÂÁÌ·ÙÈΤ˜ ΢ÛÙÈΤ˜ ‚Ï¿‚˜ ¶ÂÚÈÎÔÈÏȷΤ˜ ˘ÂÚ˯ÔÁ¤ÓÂȘ ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÂÎÙÂٷ̤Ó˜ ÂÚÈÎÔÈÏȷΤ˜ ΢ÛÙÈΤ˜ ‚Ï¿‚˜ ÀÂÚ˯ÔÁ¤ÓÂȘ ÂÂÎÙÂÈÓfiÌÂÓ˜ ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ï¢΋ Ô˘Û›·, ÂÍÂÏÈÛÛfiÌÂÓ˜ Û ÂÎÙÂٷ̤Ó˜ ˘ÔÊÏÔÈÒ‰ÂȘ ΢ÛÙÈΤ˜ ‚Ï¿‚˜

∏ ·Ó·ÁÓÒÚÈÛË ÙˆÓ Î˘ÛÙÈÎÒÓ ‚Ï·‚ÒÓ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ ¯ÚfiÓÔ ÂͤٷÛ˘ Î·È ÙË ‰È·ÎÚÈÙÈ΋ ¢¯¤ÚÂÈ· ÙÔ˘ ˯ԂÔϤ·. ∂ÓÒ ÂÎÙÂٷ̤Ó˜ ‚Ï¿‚˜ Û˘Ó‹ıˆ˜ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Ì ÙË ¯Ú‹ÛË Ë¯Ô‚ÔϤ· 5 ª∏z, ÂÓÙÔÈṲ̂Ó˜ ·ÛÙÂȘ ··ÈÙÔ‡Ó Ë¯Ô‚ÔϤ· 7,5 MHz Î·È 10 MHz. ∏ ¢ÎÔÏ›· Ù˘ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ ‚Ï·‚ÒÓ ·˘ÙÒÓ Î·È Ù˘ ÂͤÏÈÍ‹˜ ÙÔ˘˜ ÂÈÙÚ¤ÂÈ ÙË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ù˘ ·Ú¯È΋˜ ÎÏÈÓÈ΋˜ Ó¢ÚÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ Î·È Ù˘ ÂͤÏÈ͢ ÙˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ. ∂ÓÒ Ù· ÎÏÈÓÈο ÛËÌ›· ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È Ù˘ Ï¢ÎÔ̷ϷΛ·˜ ÌÔÚ› Ó· ÌËÓ Â›Ó·È Ôχ ‰È·ÊÔÚÂÙÈο, Û˘Ó‹ıˆ˜ ‰›ÓÔ˘Ó Ôχ ‰È·ÊÔÚÂÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙËÓ ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë. ∏ ÂÈ̤ÓÔ˘Û·, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ˘ÔÙÔÓ›· (Ì ÌÂȈ̤ÓË fï˜ ÈÁÓ˘·Î‹ ÁˆÓ›·) Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ÂÚÈÎÔÈÏȷ΋-ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ¤¯ÂÈ Û˘Ó‹ıˆ˜ ηϋ ¤Î‚·ÛË. ∞ÓÙ›ıÂÙ·, Ô ·˘ÍË̤ÓÔ˜ ÙfiÓÔ˜ ÙˆÓ ÂÎÙÂÈÓfiÓÙˆÓ Ì˘ÒÓ, Ë Â˘ÂÚÂıÈÛÙfiÙËÙ· Î·È Ë ·ÓÒÌ·ÏË ı¤ÛË ÙˆÓ ‰·ÎÙ‡ÏˆÓ ÙˆÓ ¿Óˆ Î·È ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ Ô˘ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÂÈ ÙËÓ ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· Â›Ó·È Û˘Ó‹ıˆ˜ ÚÔÁÓˆÛÙÈο η΋˜ ¤Î‚·Û˘ (30). ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂÍÂÙ¿ÛÂÈ ÙË Û˘Û¯¤ÙÈÛË ·Ó¿ÌÂÛ· ÛÙȘ ·ıÔÏÔÁÈΤ˜ ˘ÂÚ˯ÔÁÚ·ÊÈΤ˜ ÂÈÎfiÓ˜ Î·È ÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË. ªÈÎÚ‹ ‹ η̛· ‰È·ÊÔÚ¿ ¤¯ÂÈ ‚ÚÂı› ÛÙËÓ ¤Î‚·ÛË ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ¯ˆÚ›˜ ¶∂∞ ‹ Î·È Ì 1Ô˘ ‚·ıÌÔ‡ (¯ˆÚ›˜ ‰È¿Ù·ÛË ÎÔÈÏÈÒÓ) ·ÈÌÔÚÚ·Á›· (31). ¡ÂÔÁÓ¿ Ì ∏∫ ≤32 ‚‰ÔÌ¿‰ˆÓ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó ‰È¿Ù·ÛË ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÌÂÙ¿ ¶∂∞ Ì ‹ ¯ˆÚ›˜ ·ÚÂÁ¯˘Ì·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ÔÛÔÛÙfi 75% ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË Î·È ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (32,33).

O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ Ó¢ÚÔÏÔÁÈÎÒÓ Â·ÎfiÏÔ˘ıˆÓ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙË Û˘ÓÔ‰fi ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. µÚ¤ÊË Ô˘ ›¯·Ó ÂÙÂÚfiÏ¢ÚË ·ÚÂÁ¯˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· (ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ) ÌÔÚ› Ó· ¤¯Ô˘Ó ηϋ ¤Î‚·ÛË, ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ÓÔËÙÈ΋ ÂͤÏÈÍË (34). OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÙ›Ï¢ÚË ËÌÈÏËÁ›· (22,34). ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Û˘Ó‹ıˆ˜ fiÙ·Ó ÔÈ ‚Ï¿‚˜ Â›Ó·È ÌÂÁ¿Ï˜ Î·È ÂÓÙÔ›˙ÔÓÙ·È Û ı¤ÛË ÚÔ˜ Ù· ›Ûˆ. ∏ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ÚÒÙÔ˘ ‚·ıÌÔ‡ ¶§

Â›Ó·È ÏÈÁfiÙÂÚÔ Â˘ÓÔ˚΋ ·fi Ù· ÓÂÔÁÓ¿ Ì ¶∂∞ 1Ô˘ Î·È 2Ô˘ ‚·ıÌÔ‡. ¶ÔÛÔÛÙfi ÂÚ›Ô˘ 10% ·Ó·Ù‡ÛÛÂÈ Û·ÛÙÈ΋ ‰ÈÏËÁ›· (35). O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ·˘Í¿ÓÂÈ ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ ‚·ıÌÔ‡˜ ¶§ ηٿ ÙËÓ de Vries. ∏ ı¤ÛË ÙˆÓ Î‡ÛÙÂˆÓ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Î·È Û˘Ó‹ıˆ˜ Ë ÂÓÙfiÈÛ‹ ÙÔ˘˜ ÛÙË ‚ÚÂÁÌ·ÙÔ˚Óȷ΋ ÂÚÈÎÔÈÏȷ΋ Ï¢΋ Ô˘Û›· Û˘Ó‰¤ÂÙ·È Ì ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (‰ÈÏËÁ›·, ÙÂÙÚ·ÏËÁ›·) Ì ‹ ¯ˆÚ›˜ Ù‡ÊψÛË Î·È Û˘Ó‹ıˆ˜ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË (25,36-39). Ÿˆ˜ Â›Ó·È Ê·ÓÂÚfi, Ë ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ¶§ Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ·fi ÂΛÓË ÙˆÓ ÓÂÔÁÓÒÓ Ì ÊÏ‚ÈÎfi ¤ÌÊÚ·ÎÙÔ Ô˘ Û˘Óԉ‡ÂÈ ¶∂∞. ŒÙÛÈ, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÂÙ·È ‰È¿ÎÚÈÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ηٷÛÙ¿ÛÂˆÓ Ì ÙË ¯Ú‹ÛË Â·ÓÂÈÏËÌÌ¤ÓˆÓ ˘ÂÚ˯ÔÁÚ·ÊËÌ¿ÙˆÓ ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È (ÂÈÏÂÁ̤ӷ) Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ¤‰ˆÛ Ӥ· ÌÂÁ¿ÏË ÒıËÛË ÛÙË Ó¢ÚÔÏÔÁ›· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÙ›·˜. ∂›Ó·È ̤ıÔ‰Ô˜ ·ÎÚÈ‚‹, ··ÈÙ› ÌÂÙ·ÊÔÚ¿ Î·È ·Ú·ÌÔÓ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈ· ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÎÔÓÙ¿ ÛÙÔ Ì·ÁÓ‹ÙË, ¤¯ÂÈ fï˜ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Û ۯ¤ÛË Ì ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, fiÙÈ ÛÙÂÚÂ›Ù·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ù˘ ·ÎÙÈÓÔ‚ÔÏ›·˜. ∆ÂÏÂ˘Ù·›·, Ì ÙË ¯Ú‹ÛË ÓÂfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ ¤ÁÈÓ ‰˘Ó·Ù‹ Ë Ï‹„Ë ÂÈÎfiÓˆÓ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜, ·ÎfiÌË Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∏ ÈηÓfiÙËÙ· Ù˘ ·ÂÈÎfiÓÈÛ˘ Û ÙÔ̤˜ ÙÚÈÒÓ ÂÈ¤‰ˆÓ (ÛÙÂÊ·ÓÈ·›Â˜, Ô‚ÂÏÈ·›Â˜ Î·È ·ÍÔÓÈΤ˜) ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÛÙËÓ ·ÂÈÎfiÓÈÛË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ÏÂÙÔÌÂÚÂÈÒÓ. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È Ë Î·Ï‡ÙÂÚË ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ·ÂÈÎfiÓÈÛ˘ Ù˘ ·Ó·ÙÔÌ›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ηıÒ˜ Î·È Ù˘ ÂͤÏÈ͢ Ù˘ Ì˘ÂϛӈÛ˘ in vivo. ŒÙÛÈ, ¤ÁÈÓ ‰˘Ó·Ù‹ Ë ÂÎÙ›ÌËÛË Ù˘ Â›‰Ú·Û˘ ÙˆÓ ‰È·ÊfiÚˆÓ ‚Ï·‚ÒÓ ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÙË Ì˘ÂϛӈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (40,41). ∞˘Ùfi Ê·›ÓÂÙ·È Î·Ï¿ Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ ÙˆÓ Î˘ÛÙÈÎÒÓ ‚Ï·‚ÒÓ ‰È·ÊÔÚÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. º·›ÓÂÙ·È fiÙÈ ÔÈ Î‡ÛÙÂȘ Ô˘ ÚÔ·ÙÔ˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜ Û˘Ó‹ıˆ˜ ηٷϋÁÔ˘Ó Û ‰È¿Ù·ÛË ÙˆÓ ÎÔÈÏÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÁÏÔ›ˆÛË Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ Ì˘ÂϛӈÛ˘ ÛÙË ı¤ÛË ÙˆÓ Î‡ÛÙˆÓ. ∞ÓÙ›ıÂÙ·, ÛÙË ı¤ÛË ÙˆÓ ÔÚÂÁÎÂÊ·ÏÈÎÒÓ Î‡ÛÙÂˆÓ Ô˘ Â›Ó·È ‰Â˘ÙÂÚÔ·ı›˜

5

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·6

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

·ÚÂÁ¯˘Ì·ÙÈ΋˜ Û˘ÌÌÂÙÔ¯‹˜ Ô˘ Û˘Óԉ‡ÂÈ ÂÚÈÎÔÈÏȷ΋ ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›·, ·Ú·ÙËÚÂ›Ù·È “‰È¿ÛˆÛË” Ù˘ Ì˘ÂϛӈÛ˘. Œ¯Ô˘Ó Á›ÓÂÈ ·ÚÎÂÙ¤˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙË ¯Ú‹ÛË Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ˆ˜ ÚÔÁÓˆÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ¤Î‚·Û˘ (18,25,30,42-44). ŒÙÛÈ, ¤ÁÈÓ ‰˘Ó·Ùfi Ó· ‰Âȯı› fiÙÈ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÔÈ ˘ÔÍÈΤ˜ ÈÛ¯·ÈÌÈΤ˜ ‚Ï¿‚˜ ÂÌÊ·Ó›˙Ô˘Ó ¤Ó· Ê¿ÛÌ· ‰È·ÊÔÚÂÙÈÎÒÓ ÂÈÎfiÓˆÓ, Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi ÂÈÎÚ¿ÙËÛË Ù˘ ‚Ï¿‚˘ ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· ̤¯ÚÈ ÙËÓ ÂÈÎÚ¿ÙËÛË Ù˘ ‚Ï¿‚˘ ÛÙË Ï¢΋ Ô˘Û›·. ¡ÂÔÁÓ¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë ÌÂÙ¿ ·fi Ô͇ ÂÚÈÁÂÓÓËÙÈÎfi Úfi‚ÏËÌ·, ÂΉËÏÒÓÔ˘Ó Î˘Ú›ˆ˜ ‚Ï¿‚Ë ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ·, ÂÓÒ ·˘Ù¿ Ô˘ ÂΉËÏÒÓÔ˘Ó ÙËÓ ›‰È· ÂÈÎfiÓ· ÌÂÙ¿ ·fi Â›‰Ú·ÛË ÚÔÁÂÓÓËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, .¯. Â·ÓÂÈÏËÌ̤ÓË ·ÈÌÔÚÚ·Á›· ‹ ÌÂȈ̤Ó˜ ÎÈÓ‹ÛÂȘ ÙÔ˘ ÂÌ‚Ú‡Ô˘, Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙Ô˘Ó ‚Ï¿‚Ë Ù˘ Ï¢΋˜ Ô˘Û›·˜. ∆· ÓÂÔÁÓ¿ Ì ‚Ï¿‚Ë ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ· ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚÔ ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°), ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û·ÛÌÔ‡˜ ÌÂÙ¿ ·fi Ï›Á˜ Ë̤Ú˜ Ô˘ Â›Ó·È ·ÓıÂÎÙÈÎÔ› ÛÙËÓ ·ÓÙÈÛ·Û̈‰È΋ ·ÁˆÁ‹, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÒ̷Ϙ ÎÈÓ‹ÛÂȘ ÙˆÓ ÔÊı·ÏÌÒÓ Î·È ‰˘ÛÎÔϛ˜ ÛÙÔ ıËÏ·ÛÌfi Î·È ÙËÓ Î·Ù¿ÔÛË. ∆· ÓÂÔÁÓ¿ ·˘Ù¿, ÌÂÙ¿ ·fi Ì›· ÌÈÎÚ‹ ÂÚ›Ô‰Ô ‡ÊÂÛ˘, ÂΉËÏÒÓÔ˘Ó ÂÈÎfiÓ· ‰˘ÛÙÔÓÈ΋˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÂÈÏË„›· (45). ™Ù· ÓÂÔÁÓ¿ Ì ‚Ï¿‚Ë Ù˘ Ï¢΋˜ Ô˘Û›·˜, ÙÔ ∏∂° Â›Ó·È ÏÈÁfiÙÂÚÔ ·Û˘Ó¯¤˜, ÔÈ Û·ÛÌÔ› ÂϤÁ¯ÔÓÙ·È Î·Ï‡ÙÂÚ·, ÂÓÒ Î·È Ù· ‰‡Ô (∏∂° Î·È Û·ÛÌÔ›) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚ÂÏÙ›ˆÛË. ∆· ÓÂÔÁÓ¿ ·˘Ù¿, ·Ú¿ ÙÔ fiÙÈ ·Ó·Ù‡ÛÛÔ˘Ó ÌÈÎÚÔÎÂÊ·Ï›·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì›· Ê˘ÛÈÔÏÔÁÈ΋ ·Ú¯Èο ÂÈÎfiÓ·. ™ËÌ›· ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ Á›ÓÔÓÙ·È ÂÌÊ·Ó‹ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 46 ÌËÓÒÓ (45). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ Î·È ÙÔ ÚÒÈÌÔ ∏∂°, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Â›Ó·È Ôχ ‚ÔËıËÙÈο ÛÙËÓ ÚfiÁÓˆÛË ÁÈ· ÂΉ‹ÏˆÛË ËÌÈÏËÁ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÎfiÓ· ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘ (44,46). ª·ÁÓËÙÈ΋ Ê·ÛÌ·ÙÔÛÎÔ›· (Magnetic resonance spectroscopy) ∏ Ì·ÁÓËÙÈ΋ Ê·ÛÌ·ÙÔÛÎÔ›· Â›Ó·È Ì›· ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ Ù˘ ‚ÈÔ¯ËÌ›·˜ ÙˆÓ ÈÛÙÒÓ Ì¤Ûˆ Ù˘ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ Ô˘ÛÈÒÓ ÛÙÔ˘˜ ÂÍÂÙ·˙fiÌÂÓÔ˘˜ ÈÛÙÔ‡˜. ∆ÂÏÂ˘Ù·›·, ÛÙȘ ÌÔÓ¿‰Â˜ Ô˘ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ Ù˘ ÌÂıfi‰Ô˘, ‰›ÓÂÙ·È ÌÂÁ¿ÏË ¤ÌÊ·ÛË ÒÛÙ ̤ۈ Ù˘ ¯Ú‹Û˘ Ù˘ Ó· ÂÎÙÈÌËı› Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ˆÚ›Ì·ÓÛ˘, ·ÏÏ¿ Î·È ÛÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰È·ÊfiÚˆÓ Û˘Ì‚·Ì¿ÙˆÓ Î·È Î˘Ú›ˆ˜

6

Paediatriki 2003;66:2-11

Ù˘ ·ÛÊ˘Í›·˜. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÊÔÚÔ‡Ó ÛÙË Ê·ÛÌ·ÙÔÛÎÔ›· ÙÔ˘ ʈÛÊfiÚÔ˘ Î·È ÙÔ˘ ÚˆÙÔÓ›Ô˘. ªÂϤÙ˜ Û ÓÂÔÁÓ¿ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÏfiÁÔ˘ ʈÛÊÔÎÚ·ٛÓ˘ (Pcr) ÚÔ˜ ÙÔÓ ·ÓfiÚÁ·ÓÔ ÊˆÛÊfiÚÔ (Pi) ÌÂÙ¿ ·fi ·ÛÊ˘Í›·, Û ۯ¤ÛË Ì ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi Î·È ·˘Ùfi Û˘Óԉ‡ÂÙ·È Ì η΋ ¤Î‚·ÛË (47,48). OÈ ÌÂÙ·‚ÔϤ˜, fï˜, ·˘Ù¤˜ Ê·›ÓÔÓÙ·È ÌÂÙ¿ ÙȘ ÚÒÙ˜ 24 ÒÚ˜ ˙ˆ‹˜. ∞ÓÙ›ıÂÙ·, Ë Ê·ÛÌ·ÙÔÛÎÔ›· ÙÔ˘ ÚˆÙÔÓ›Ô˘ η٤ÛÙËÛ ‰˘Ó·Ù‹ ÙË Ï‹„Ë ÚˆÈÌfiÙÂÚˆÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ ÚÔ‰Èο˙Ô˘Ó Î·Î‹ ÚfiÁÓˆÛË. ∏ ·ÚÔ˘Û›· Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ (lactate) ÛÙÔ˘˜ ÈÛÙÔ‡˜ ÌÔÚ› Ó· ·ÓȯÓ¢ı› ·ÎfiÌË Î·È ÙȘ ÚÒÙ˜ 12-24 ÒÚ˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘¤ÛÙËÛ·Ó ·ÛÊ˘Í›·, ÁÂÁÔÓfi˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì η΋ ÚfiÁÓˆÛË (49-51).

Doppler ÂÁÎÂÊ¿ÏÔ˘ ∏ ·ıÔÁ¤ÓÂÈ· ÔÏÏÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ ‚Ï·‚ÒÓ ÛÙÔ ÓÂÔÁÓÈÎfi ÂÁΤʷÏÔ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÂËÚ·Ṳ̂ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙ· ÂÁÎÂÊ·ÏÈο ·ÁÁ›·. ∞˘Ùfi ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· Î·È È‰È·ÈÙ¤Úˆ˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∏ ÚfiÛıÈ· ËÁ‹ ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ ¤¯ÂÈ ‰ÒÛÂÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ·, fi¯È ÌfiÓÔ ÛÙËÓ ·ÂÈÎfiÓÈÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ì ÙË ¯Ú‹ÛË ÙˆÓ ˘ÂÚ‹¯ˆÓ, ·ÏÏ¿ Î·È ÛÙË Ì¤ÙÚËÛË Ù˘ Ù·¯‡ÙËÙ·˜ Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙȘ ÂÁÎÂÊ·ÏÈΤ˜ ·ÚÙËڛ˜ Ì ÙË ¯Ú‹ÛË Ù˘ Ù¯ÓÈ΋˜ Doppler. ªÂ ·˘Ù‹ ÙËÓ Ù¯ÓÈ΋ Á›ÓÂÙ·È Ì¤ÙÚËÛË Ù˘ Ù·¯‡ÙËÙ·˜ Î·È fi¯È Ù˘ ÚÔ‹˜, ηıÒ˜ Ë ‰È¿ÌÂÙÚÔ˜ ÙˆÓ ·ÁÁ›ˆÓ ‰ÂÓ ÌÔÚ› Ó· ÌÂÙÚËı› (ƒÔ‹ = Ù·¯‡ÙËÙ· x ÂÈÊ¿ÓÂÈ·). ™ÙȘ ÂÁÎÂÊ·ÏÈΤ˜ ·ÚÙËڛ˜, ÙÔ ‡„Ô˜ Ù˘ ̤ÁÈÛÙ˘ Û˘ÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ (Peak systolic velocity, PSV) Â›Ó·È ÂÚ›Ô˘ 3 ÊÔÚ¤˜ ÙÔ ‡„Ô˜ Ù˘ ÙÂÏԉȷÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ (End diastolic velocity, EDV).

O ‰Â›ÎÙ˘ ÙÔ˘ Pourcelot (the resistance index of Pourcelot, PI) ˘ÔÏÔÁ›˙ÂÙ·È Ì ÙÔÓ ·ÎfiÏÔ˘ıÔ Ù‡Ô: PI =

PSV-EDV PSV

∆· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÙÔ˘ PI Î˘Ì·›ÓÔÓÙ·È ÌÂٷ͇ 0,65-0,90. ∆Ș ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜, Ù· Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfiÙÂÚË Ù·¯‡ÙËÙ· ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ·ÓÙ›ÛÙ·Û˘ ηٿ Pourcelot, Û ۯ¤ÛË Ì ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜.

OÈ ÂӉ›ÍÂȘ ¯Ú‹Û˘ ÙÔ˘ Doppler ÛÙ· ÓÂÔÁ¤ÓÓËÙ· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·Ó·ÁÓÒÚÈÛË Ê˘ÛÈÔÏÔÁÈ΋˜ Î·È ÌË ·ÁÁÂȷ΋˜ ÚÔ‹˜ Û ·ÚÙËÚÈÔÊÏ‚ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÙËÓ ÙÔÈ΋ ‹ ÁÂÓÈÎÂ˘Ì¤ÓË Ì›ˆÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ÚÔ‹˜ Û ÂÁÎÂÊ·ÏÈο ¤ÌÊÚ·ÎÙ·, ÙËÓ “ÎÏÔ‹ ·›Ì·ÙÔ˜ ̤ۈ ÙÔ˘ ‚ÔÙ¿ÏÂÈÔ˘

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·7

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

fiÚÔ˘” (Ì›ˆÛË Ù˘ ‰È·ÛÙÔÏÈ΋˜ Ù·¯‡ÙËÙ·˜ Ì Â·ÎfiÏÔ˘ıË Î·Ù¿ÚÁËÛ‹ Ù˘ Î·È ÛÙÔ Ù¤ÏÔ˜ ·ÚÓËÙÈ΋ ‰È·ÛÙÔÏÈ΋ Ù·¯‡ÙËÙ· Ô˘ ·ÓÙ·Ó·ÎÏ¿ ÙË ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜ ·fi ÙËÓ ·ÔÚÙ‹ ÛÙËÓ Ó¢ÌÔÓÈ΋ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·ÛÙÔÏ‹˜) Î·È ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ (ηٿÚÁËÛË ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜) (52). ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ‰fiıËΠÌÂÁ¿ÏË ¤ÌÊ·ÛË ÛÙË ¯Ú‹ÛË ÙÔ˘ Doppler ÂÁÎÂÊ¿ÏÔ˘ Û ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. O Archer, ‹‰Ë ·fi ÙÔ 1986 (53), ¤‰ÂÈÍ fiÙÈ ¯·ÌËÏfi˜ ‰Â›ÎÙ˘ ·ÓÙ›ÛÙ·Û˘ ¤¯ÂÈ Â˘·ÈÛıËÛ›· 100% Î·È ÂȉÈÎfiÙËÙ· 81%, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË ÁÈ· ÊÙˆ¯‹ ¤Î‚·ÛË.

O Levene (54), ÙÔ 1989, ¤‰ÂÈÍ fiÙÈ Ì›· ·ÓÒÌ·Ï· ·˘ÍË̤ÓË ·ÈÌ·ÙÈ΋ ÚÔ‹ ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›· 93% Û ۇÁÎÚÈÛË Ì ÚÔÁÓˆÛÙÈ΋ ·Í›· 83% ÁÈ· ¯·ÌËÏfi ‰Â›ÎÙË ·ÓÙ›ÛÙ·Û˘. ∞˘Ù¤˜ ÔÈ ·ÏÏ·Á¤˜, ¿ÓÙˆ˜, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÓȯÓ¢ıÔ‡Ó ÌfiÓÔÓ ÌÂÙ¿ ÙȘ ÚÒÙ˜ 12-24 ÒÚ˜ Ù˘ ˙ˆ‹˜ ηÈ, ÂÔ̤ӈ˜, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈ̇ÛÔ˘Ó Û·Ó ÚÒÈÌÔÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÛÙȘ ÚÒÙ˜ 6 ÒÚ˜ Ù˘ ˙ˆ‹˜ (55). ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (∏∂°) ∆Ô Û˘Ì‚·ÙÈÎfi ÔÏ˘Î¿Ó·ÏÔ (multichannel) ∏∂° Â›Ó·È ¤Ó· Ôχ ÛËÌ·ÓÙÈÎfi ÂÚÁ·ÏÂ›Ô ÛÙË Û˘ÓÔÏÈ΋ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÓÂÔÁ¤ÓÓËÙˆÓ. ∆Ô ∏∂° ‰ÂÓ ·ÔÙÂÏ› ÂͤٷÛË ÚÔ˘Ù›Ó·˜ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ™˘Ó‹ıˆ˜ Á›ÓÂÙ·È Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÌÂÙ¿ ·fi ·ÛÊ˘Í›· ‹ ÁÂÓÈο Û Û·ÛÌÔ‡˜, ÂÓÒ Á›ÓÂÙ·È Û¿ÓÈ· Û ÚfiˆÚ· ÓÂÔÁÓ¿ Î·È Î˘Ú›ˆ˜ ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜. ∏ Ï‹„Ë ÂÓfi˜ Ù˘ÈÎÔ‡ ∏∂° Û ¤Ó· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚÔ ÓÂÔÁÓfi ÂÈ‚¿ÏÏÂÈ ·Ú·ÙÂٷ̤ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, ÂÓÒ Èı·Ófiٷٷ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È artifacts ̤ۈ ËÏÂÎÙÚÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ·fi ·ÚÎÂÙ¤˜ Û˘Û΢¤˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙȘ ÌÔÓ¿‰Â˜. ∂ÈϤÔÓ, Ë ÂÚÌËÓ›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È Ôχ ÈÔ ÔχÏÔÎË Û ۯ¤ÛË Ì ٷ ÙÂÏÂÈfiÌËÓ·, Ì ÌÂÁ¿Ï˜ ÌÂÙ·‚ÔϤ˜ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (background activity) Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË (56). ∏ ηٷÁÚ·Ê‹ ·fi ÔÏÏ·Ï¿ ËÏÂÎÙÚfi‰È· (4 ‹ 8 channels Ì ÙÔ Û‡ÛÙËÌ· Medilog) Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË Î·Ù·ÁÚ·Ê‹ Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚÔ‡Ó Ó· ·Ú¿Û¯Ô˘Ó ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙËÓ ÙÔÔÁÚ·ÊÈ΋ ηٷÓÔÌ‹ ÙˆÓ ·ÚÔ͢ÛÌÈÎÒÓ ÂÎÊÔÚÙ›ÛˆÓ, ÙȘ ·Û˘ÌÌÂÙڛ˜ ·Ó¿ÌÂÛ· ÛÙ· ËÌÈÛÊ·›ÚÈ· Î·È ÙȘ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ (57). ™Â ÔÏϤ˜ ÌÔÓ¿‰Â˜ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ ÊÔÚËÙÒÓ Û˘Û΢ÒÓ ∏∂° (Medilog System) ‹, ÈÔ ÚfiÛÊ·Ù·, ÌÈÎÚÒÓ Û˘ÛÙËÌ¿ÙˆÓ ‚·ÛÈÛÌ¤ÓˆÓ Û computer, Ù· ÔÔ›· ÂÈÙÚ¤Ô˘Ó ÙËÓ ·Ôı‹Î¢ÛË Û ‰ÈÛΤٷ ÙˆÓ Î·Ù·ÁÚ·ÊÒÓ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ¯ˆÚ›˜ Ó· ·ÚÂÌ‚·›ÓÔ˘Ó È‰È·›ÙÂÚ· ÛÙË

Paediatriki 2003;66:2-11

ÊÚÔÓÙ›‰· ÙˆÓ ÓÂÔÁÓÒÓ. À¿Ú¯ÂÈ, Â›Û˘, Ë Ù¯ÓÈ΋ Cerebral Function Monitor (CFM, Lectromed), Ë ÔÔ›· ¤¯ÂÈ ·Ô‰Âȯı› ¯Ú‹ÛÈÌË ÛÙËÓ ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰· ÓÂÔÁÓÒÓ. ∏ ηٷÁÚ·Ê‹ Á›ÓÂÙ·È ÌfiÓÔ ·fi 2 ·ÌÊÈ‚ÚÂÁÌ·ÙÈο ËÏÂÎÙÚfi‰È·. ªÂ ÙÔ CFM ·Ú¤¯ÂÙ·È ¤Ó· Û˘Ì˘Îӈ̤ÓÔ, ÂÓÔÔÈË̤ÓÔ Û‹Ì· ÙÔ˘ ‡ÚÔ˘˜ Ù˘ ‚·ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ì ÙË ¯Ú‹ÛË Ì›·˜ ÌÈÎÚ‹˜ Û˘Û΢‹˜ ‰›Ï· ÛÙË ıÂÚÌÔÎÔÈÙ›‰· ÙÔ˘ ÓÂÔÁÓÔ‡.

OÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Ë ·Ú·ÙÂٷ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Û·ÛÌÒÓ Â›Ó·È Ôχ ‡ÎÔÏÔ Ó· ‰È·ÈÛÙˆıÔ‡Ó ÛÙÔ CFM, ·ÎfiÌË Î·È ·fi ¿ÙÔÌ· Ì ÌÈÎÚ‹ ÂÌÂÈÚ›· ÛÙËÓ ·Ó¿ÁÓˆÛË Î·È ÂÚÌËÓ›· ÙÔ˘ Ù˘ÈÎÔ‡ ∏∂°. ŸÌˆ˜, ÔÈ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ Û·ÛÌÔ›, Ë ·ÚÔ‰È΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ηıÒ˜ Î·È Ë ·Û‡ÌÌÂÙÚË ‰Ú·ÛÙËÚÈfiÙËÙ· ÌÂٷ͇ ÙˆÓ 2 ËÌÈÛÊ·ÈÚ›ˆÓ ‰ÂÓ ·ÓȯÓ‡ÔÓÙ·È ÏfiÁˆ Ù˘ ¯Ú‹Û˘ 2 ÌfiÓÔ ËÏÂÎÙÚÔ‰›ˆÓ. ™Â Û˘ÁÎÂÎÚÈ̤ӷ ÙÌ‹Ì·Ù· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜ Ì ηϋ Û˘Û¯¤ÙÈÛË, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, Ì ÙÔ ÔÏ˘Î¿Ó·ÏÔ ∏∂° Ô˘ ÂÎÙÂÏÂ›Ù·È Ì ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙÔ ÙÌ‹Ì· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊËÌ¿ÙˆÓ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ. ™ÙȘ 27-28 ‚‰ÔÌ¿‰Â˜, Ë ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÛÙÔ ∏∂° Â›Ó·È Î˘Ú›ˆ˜ ·Û˘Ó¯‹˜ (discontinu-ous), Ì ÁÚ‹ÁÔÚ˜ ÂÎÊÔÚÙ›ÛÂȘ (brief bursts) Ô˘ ‰È·ÎfiÙÔÓÙ·È ·fi Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ÂÚÈfi‰Ô˘˜ ¤ÏÏÂȄ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ªÂ ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ·ËÛ˘, ·˘Ù¤˜ ÔÈ ÂÚ›Ô‰ÔÈ ¤ÏÏÂȄ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÚÔԉ¢ÙÈο ÌÂÈÒÓÔÓÙ·È Û ‰È¿ÚÎÂÈ· Î·È ÛÙ· ÙÂÏÂÈfiÌËÓ· Ë ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È Î˘Ú›ˆ˜ Û˘Ó¯‹˜ (continuous). ∞Û˘Ó¯‹˜ ‰Ú·ÛÙËÚÈfiÙËÙ· ·Ú·ÙËÚÂ›Ù·È Ê˘ÛÈÔÏÔÁÈο ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ (58). ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ÙÂÏÂ˘Ù·›· ÂÈÎÂÓÙÚÒÓÔ˘Ó ÙÔ ÂӉȷʤÚÔÓ ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ¤Ó· “ÚÒÈÌÔ” ∏∂°, ‰ËÏ. fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ Û‡ÓÙÔÌ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË. OÈ Wertheim Î·È Û˘Ó (58), Ùo 1994, Ì ÙËÓ Î·Ù·ÁÚ·Ê‹ ∏∂° ÙȘ ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋-ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÚÒÈÌÔ ∏∂° ÌÔÚ› Ó· ‰ÒÛÂÈ ÚfiÁÓˆÛË Û ̷ÎÚÔÚfiıÂÛÌË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ηı˘ÛÙ¤ÚËÛË. ∏ ÌÂϤÙË ·˘Ù‹ ¤‰ÂÈÍ fiÙÈ Ë Ê˘ÛÈÔÏÔÁÈ΋ ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Û˘Óԉ‡ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË, ÂÓÒ Ë ·Û‡ÌÌÂÙÚË Û˘Óԉ‡ÂÙ·È ·fi ËÌÈÏËÁ›·. ∂›Û˘, ‰È·ÈÛÙÒıËΠfiÙÈ fiÔ˘ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË Î·Ù·ÛÙÔÏ‹ Ù˘ ‚·ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ‹ ÂÈÎfiÓ· status epilepticus, ˘¿Ú¯ÂÈ ÊÙˆ¯‹ ÚfiÁÓˆÛË. ÕÏϘ ÌÂϤÙ˜ (59-62) ¤‰ÂÈÍ·Ó ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÂÓÒ ·Ú¿ÏÏËÏ· Û˘Û¯¤ÙÈÛ·Ó ÙËÓ ‡·ÚÍË ÌË Ê˘ÛÈÔÏÔÁÈÎÒÓ Ú˘ıÌÒÓ ÛÙÔ ∏∂° Ì η΋ ¤Î‚·ÛË, ÂÓÒ ÙË ÁÚ‹ÁÔÚË Î·È Û·Ê‹ ‚ÂÏÙ›ˆÛË Û ‰È·‰Ô¯Èο

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JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·8

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

∏∂°, Ì ¢ÓÔ˚΋ ¤Î‚·ÛË. ∆ÂÏÂ˘Ù·›· ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ‰Â›¯ÓÔ˘Ó Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ ÚÒÈÌÔ˘ CFM ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (55,63,64) Ô˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó CFM ̤۷ ÛÙȘ ÚÒÙ˜ 6 ÒÚ˜ Ù˘ ˙ˆ‹˜, ¤‰ÂÈÍ·Ó fiÙÈ ÛÙ·ıÂÚ¿ ·Û˘Ó¯¤˜ ‹ ¯·ÌËÏÔ‡ ‰˘Ó·ÌÈÎÔ‡ CFM Û˘Ó‰˘¿˙ÂÙ·È Ì η΋ ¤Î‚·ÛË, ÂÓÒ Ê˘ÛÈÔÏÔÁÈÎfi CFM Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·ÓÙÈÊ·ÙÈ΋. ª›· Û¯ÂÙÈο ÚfiÛÊ·ÙË ÌÂϤÙË (56) ¤‰ÂÈÍ fiÙÈ Ë ÂÈÌÔÓ‹ ·ÚÔ˘Û›·˜ ÛÙÔ ∏∂°, ÌÂÙ¿ ÙȘ 30-32 ‚‰ÔÌ¿‰Â˜, ÂÈÎfiÓ·˜ Ô˘ Ê˘ÛÈÔÏÔÁÈο ·Ú·ÙËÚÂ›Ù·È Û ∏∫ 28-30 ‚‰ÔÌ¿‰ˆÓ, Â›Ó·È ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÁÈ· η΋ ¤Î‚·ÛË. ∞˘Ùfi Èı·ÓÒ˜ ‰Â›¯ÓÂÈ fiÙÈ, ÂÎÙfi˜ ·fi ÙË ‚·ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ˘¿Ú¯Ô˘Ó Î·È ¿ÏϘ ·Ú¿ÌÂÙÚÔÈ Ô˘ Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌÒÓÙ·È Î·Ù¿ ÙËÓ ÂÚÌËÓ›· ÙÔ˘ ∏∂° ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ¢‡Ô Ôχ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (65,66) ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ CFM Â›Ó·È ÙÔ ›‰ÈÔ ·ÍÈfiÈÛÙÔ Ì ÙÔ ∏∂° fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚÔÁÓˆÛÙÈο ·Í›·. ∞˘Ùfi ηıÈÛÙ¿ ÙÔ CFM ÔχÙÈÌË Ù¯ÓÈ΋ ÛÙ· ¯¤ÚÈ· ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ. ¡Â˘ÚÔÊ˘ÛÈÔÏÔÁ›· ¶ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (∂voked potentials) ∆· ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (ۈ̷ÙÔ·ÈÛıËÙÈο, ÔÙÈο Î·È ·ÎÔ˘ÛÙÈο) Â›Ó·È ËÏÂÎÙÚÈΤ˜ ··ÓÙ‹ÛÂȘ Û Â·ÓÂÈÏËÌ̤ӷ Â͈ÙÂÚÈο ÂÚÂı›ÛÌ·Ù· Ô˘ ÌÔÚ› Ó· Â›Ó·È ÛˆÌ·ÙÔ·ÈÛıËÙÈο, ÔÙÈο ‹ ·ÎÔ˘ÛÙÈο. ∞ÔÙÂÏÔ‡Ó ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ÌÂıfi‰Ô˘˜ ÂÎÙ›ÌËÛ˘ Ù˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. Œ¯Ô˘Ó ÙÔ ÌÂÁ¿ÏÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ Â›Ó·È ÌË ÂÂÌ‚·ÙÈΤ˜ Î·È ÊıËÓ¤˜ ̤ıÔ‰ÔÈ, ·Ú¤¯Ô˘Ó Ì›· ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÛˆÌ·ÙÔ·ÈÛıËÙÈÎÒÓ, ·ÎÔ˘ÛÙÈÎÒÓ Î·È ÔÙÈÎÒÓ Ô‰ÒÓ, ¯ˆÚ›˜ ÙË Û˘ÓÂÚÁ·Û›· ÙÔ˘ ÓÂÔÁÓÔ‡. ∂ÓÙÔ‡ÙÔȘ, οÔȘ Â›Ó·È ¯ÚÔÓÔ‚fiÚ˜ Î·È Ì ‰˘ÛÎÔÏ›· ÛÙËÓ Î·Ù·ÁÚ·Ê‹, ÂÓÒ ÂÈϤÔÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ Ê˘ÛÈÔÏÔÁÈο ‰Â‰Ô̤ӷ. ∆ÂÏÂ˘Ù·›·, Ë ‚ÂÏÙȈ̤ÓË ÌÂıÔ‰ÔÏÔÁ›· ¤¯ÂÈ ÂÈÙÚ¤„ÂÈ ÙË Û˘ÏÏÔÁ‹ ÂÚÈÛÛfiÙÂÚÔ ·ÍÈfiÈÛÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·fi ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿.

O Û˘Ó¯‹˜ ¤ÏÂÁ¯Ô˜ Ì ٷ ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ Î·È ÌË Ê˘ÛÈÔÏÔÁÈ΋ ˆÚ›Ì·ÓÛË ÙˆÓ ·ÈÛıËÙÈÎÒÓ Ô‰ÒÓ (sensory pathways). ∫¿ı ‰È·Ù·Ú·¯‹ Ô˘ ‰˘ÓËÙÈο ÂËÚ¿˙ÂÈ ÙȘ ·ÈÛıËÙÈΤ˜ Ô‰Ô‡˜, ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÁÈ· ¯Ú‹ÛË ÙˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ. ™ÙÂϯȷ›· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Auditory brainstem evoked responses) ∆· ÛÙÂϯȷ›· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο

8

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Â›Ó·È È‰È·ÈÙ¤Úˆ˜ ¯Ú‹ÛÈÌ· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ ·ÒÏÂÈ·˜ ·ÎÔ‹˜ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, .¯. ÛÙ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿, ÙËÓ ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ÙȘ Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ∫¡™, ÙȘ ÎÚ·ÓÈÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÙË ÌËÓÈÁÁ›Ùȉ·, ÙËÓ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ÙÔ ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜. ∏ ηχÙÂÚË ËÏÈΛ· ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÎÔ‹˜ ÛÙ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ Â›Ó·È Ë ËÏÈΛ· ÙˆÓ 40 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË Û‡ÏÏË„Ë ‹ ÚÈÓ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÙÌ‹Ì·, ‰ÈfiÙÈ Ù· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÌÔÚ› Ó· Â›Ó·È ·ıÔÏÔÁÈο ÛÙ· ÚfiˆÚ· fiÙ·Ó Á›ÓÔÓÙ·È ÓˆÚ›˜ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ (ÚÈÓ ÙȘ 36 ‚‰ÔÌ¿‰Â˜), ÂÓÒ ·˘Ùfi Û˘Ó‹ıˆ˜ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È fiÙ·Ó Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û ϛÁ˜ ‚‰ÔÌ¿‰Â˜ (67). ∆· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ηÏfi Â›Ó·È Ó· ÂϤÁ¯ÔÓÙ·È ÚÈÓ ÙÔ˘˜ 3 Ì‹Ó˜, ‰ÈfiÙÈ ÌÂÙ¿ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ‰ÈÂÓÂÚÁËıÔ‡Ó ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÛÙË ‰È¿ÚÎÂÈ· Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡ÓÔ˘. ∆· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Â›Ó·È Ù· ÏÈÁfiÙÂÚÔ Î·Ù¿ÏÏËÏ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ΛӉ˘ÓÔ ÁÈ· ·Ó¿Ù˘ÍË Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ηı˘ÛÙ¤ÚËÛ˘ (68,69).

OÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Visual evoked potentials, VEPs) £ÂˆÚÔ‡ÓÙ·È Â‡ÎÔÏ· ÛÙË ¯Ú‹ÛË ÙÔ˘˜ Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∂›Ó·È ¯Ú‹ÛÈÌ· ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÓÂÔÁÓÒÓ Ì ‹ ¯ˆÚ›˜ Úfi‚ÏËÌ· ÛÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÔÙÈÎÒÓ Ô‰ÒÓ. ™Â ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÂÚÈÎÔÈÏȷ΋ ΢ÛÙÈ΋ Ï¢ÎÔ̷ϷΛ·, ·ıÔÏÔÁÈο ÔÙÈο ‰˘Ó·ÌÈο ÚÔ‰Èο˙Ô˘Ó Î·Î‹ fiÚ·ÛË. ∂ÓÙÔ‡ÙÔȘ, ‰ÂÓ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ‰ÒÛÔ˘Ó ÚfiÁÓˆÛË fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÒÙÂÚË ¤Î‚·ÛË (68). ™Ù· ÙÂÏÂÈfiÌËÓ· Á›ÓÔÓÙ·È Â˘¯ÂÚÒ˜ ·fi ÙË Á¤ÓÓËÛË Î·È ÌÂÙ¿. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ÚÔÎÏËÙÒÓ ‰˘Ó·ÌÈÎÒÓ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ‰È·›ÛÙˆÛ·Ó fiÙÈ, ÂÎ ÙˆÓ ÙÚÈÒÓ, Ù· ÔÙÈο Î·È Ù· ۈ̷ÙÔ·ÈÛıËÙÈο Â›Ó·È ·ÍÈfiÈÛÙ·. ¢ÂÓ ÈÛ¯‡ÂÈ fï˜ ÙÔ ›‰ÈÔ Î·È ÁÈ· Ù· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (70-73). ™ˆÌ·ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο (Somatosensory evoked potentials, SEPs) ∂›Ó·È ¯ÚÔÓÔ‚fiÚ· ‰È·‰Èηۛ· (·fi ÙÔ Ì¤ÛÔ Î·È ÙÔ Ô›ÛıÈÔ ÎÓËÌÈ·›Ô Ó‡ÚÔ). £ÂˆÚÂ›Ù·È fiÙÈ ¤¯Ô˘Ó Ôχ ηϋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ·ÎfiÌË Î·È ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ (ȉȷ›ÙÂÚ· ·fi ÙÔ Ô›ÛıÈÔ ÎÓËÌÈ·›Ô Ó‡ÚÔ). ∞˘Ùfi ·Ô‰›‰ÂÙ·È Î·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÂÈÙÒÛÂȘ ÙˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ÂËÚ¿˙Ô˘Ó Î˘Ú›ˆ˜ Ù· fi‰È· (.¯. ‰ÈÏËÁ›·) (74). ∞ÓÙ›ıÂÙ·, Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙÔ Ì¤ÛÔ Ó‡ÚÔ ‰ÂÓ Â›Ó·È ÙfiÛÔ ·ÍÈfiÈÛÙ· (75,76).

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™Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ù· Ê˘ÛÈÔÏÔÁÈο ۈ̷ÙÔ·ÈÛıËÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο Û˘Ó‰˘¿˙ÔÓÙ·È Ì ηϋ ¤Î‚·ÛË, ÂÓÒ Ù· ·ıÔÏÔÁÈο Û˘Ó‰˘¿˙ÔÓÙ·È Ì η΋ (77). ™Ù· ›‰È· ÓÂÔÁÓ¿, ̤۷ ÛÙȘ 6 ÚÒÙ˜ ÒÚ˜ Ù˘ ˙ˆ‹˜, ÌÔÚÔ‡Ó (fiˆ˜ Î·È Ù· ÔÙÈο ‰˘Ó·ÌÈο) Ó· ‰ÒÛÔ˘Ó ·ÍÈfiÈÛÙË ÚfiÁÓˆÛË ÁÈ· η΋ ¤Î‚·ÛË (7173). ™ÙȘ 72 ÒÚ˜, Ë ÂȉÈÎfiÙËÙ· ·˘Í¿ÓÂÙ·È ÛÙÔ 93%. ªË Ê˘ÛÈÔÏÔÁÈο ·Ú¯Èο ۈ̷ÙÔ·ÈÛıËÙÈο ‰˘Ó·ÌÈο Ú¤ÂÈ Ó· Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È, ‰ÈfiÙÈ fiÙ·Ó ÔÌ·ÏÔÔÈÔ‡ÓÙ·È Ì¤Û· ÛÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜, Â›Ó·È ·ÎfiÌË Èı·Ó‹ Ë Ê˘ÛÈÔÏÔÁÈ΋ ¤Î‚·ÛË. §fiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó‡ÚÂÛ˘ Ó¢ÚÔÚÔÛٷ٢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ˘ÔÍÈ΋ ÈÛ¯·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ¤¯ÂÈ Ôχ ÌÂÁ¿ÏË ÛËÌ·Û›· Ë ·Ó·ÁÓÒÚÈÛË ·˘ÙÒÓ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· η΋ ¤Î‚·ÛË, ‰ÈfiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› Ú¤ÂÈ Ó· ¯ÔÚËÁËıÔ‡Ó Ì¤Û· ÛÙȘ 6 ÚÒÙ˜ ÒÚ˜ Ù˘ ˙ˆ‹˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ·fi fiϘ ÙȘ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÙÔ ∏∂°, ÙÔ CFM Î·È Ù· SEPs ·Ú¤¯Ô˘Ó ÙȘ ϤÔÓ ·ÍÈfiÈÛÙ˜ ÏËÚÔÊÔڛ˜ Á‡Úˆ ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÔÚ›· Ù˘ ˘ÔÍÈ΋˜ ÈÛ¯·ÈÌÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Î·È Ù˘ Â·ÎfiÏÔ˘ı˘ Ó¢ÚÔ·Ó·Ù˘Íȷ΋˜ ÂͤÏÈ͢.

Paediatriki 2003;66:2-11

9.

10.

11.

12.

13.

14.

15.

16.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Garland JS, Buck R, Leviton A. Effect of maternal glycocorticoid exposure on risk of severe intraventricular hemorrhage in surfactant-treated preterm infants. J Pediatr 1995;126:272-279.

2. Mercier CE, Soll RF. Clinical trials of natural surfactant extract in respiratory distress syndrome. Clin Perinatol 1993;91:1083-1088.

3. LeFlore JL, Salhab WA, Broyles RS, Engle WD. Association of antenatal and postnatal dexamethasone exposure with outcomes in extremely low birth weight neonates. Pediatrics 2002;110:275-279.

4. O’Shea TM, Doyle LW. Perinatal glucocorticoid therapy and neurodevelopmental outcome: an epidemiologic perspective. Semin Neonatol 2001;6:293-307.

5. Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability.

Pediatrics 2000;106:659-671.

6. Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR. Neurologic and developmental disability after extremely preterm birth. N Engl J Med 2000;343:378-384.

7. Hill ET, den Ouden AL, Bauer L, van den Oudenrijn C, Brand R, Verloove-Vanhorick SP. School performance at nine years of age in very premature and very low birth weight infants: perinatal risk factors and predictors at five years of age. J Pediatr 1994;125:426-434.

8. Hack M, Wilson-Costello D, Friedman H, Taylor GH, Schluchter M, Fanaroff AA. Neurodevelopment and predictors of outcomes of children with birth weights of less

17.

18.

19.

20.

21.

22.

23.

24.

25.

than 1000 g: 1992-1995. Arch Pediatr Adolesc Med 2000;154:725-731.

Vohr BR, Wright LL, Dusick AM, Mele L, Verter J, Steichen JJ et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics 2000;105:1216-1226.

Thomas A, Saint-Ann Dargassies S. Etudes neurologic sur le nouveau-né et le jeune nourisson. Paris: Masson; 1952.

Thomas A, Chesni Y, Saint-Ann Dargassies S. Neurological examination of the infant. Little Club Clin Dev Med, No 1.

London: Medical Advisory Committee of the National Spastics Society; 1960.

Saint-Ann Dargassies S. Neurological development in fullterm and premature neonate. Amsterdam: Excerpta Medica; 1977.

Prechtl HFR. The neurological examination of the full-term newborn infant: a manual for clinical use. 2nd ed. Clin Dev Med, No 63. London: SIMP. Philadelphia: Heinemman Medical; 1977.

Brazelton TB. Neonatal behavioral assessment scale. Clin Dev Med, No 50. London: SIMP Heinemann Medical; 1973.

Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr 1970;77:1-10.

Dubowitz LMS, Dubowitz V. The neurological assessment of the preterm and full term newborn infant. Clin Dev Med No 79. London: SIMP Heinemann Medical. Philadelphia: Lippincott; 1981.

Dubowitz LM, Dubowitz V, Palmer PG, Miller G, Fawer CL, Levene MI. Correlation of neurologic assessment in the preterm newborn infant with outcome at one year. J Pediatr 1984;105:452-456.

Mercuri E, Guzzetta A, Haataja L, Cowan F, Rutherford M, Counsell S et al. Neonatal neurological examination in infants with hypoxic ischaemic encephalopathy: correlation with MRI findings. Neuropediatrics 1999;30:83-89.

Dubowitz L, Mercuri E, Dubowitz V. An optimality score for the neurologic examination of the term newborn. J Pediatr 1998;133:406-416.

Frisone MF, Mercuri E, Laroche S, Foglia C, Maalouf EF, Haataja L et al. Prognostic value of the neurologic optimality score at 9 and 18 months in preterm infants born before 31 weeks’ gestation. J Pediatr 2002;140:57-60.

Cioni G, Prechtl HF. Preterm and early postterm motor behavior in low-risk premature infants. Early Hum Dev 1990;23:159-191.

Cioni G, Bos AF, Einspieler C, Ferrari F, Martijn A, Paolicelli PB et al. Early neurological signs in preterm infants with unilateral intraparenchymal echodensity. Neuropediatrics 2000;31:240-251.

Bos AF, Martijn A, Okken A, Prechtl HF. Quality of general movements in preterm infants with transient periventricular echodensities. Acta Paediatr 1998;87:233-234.

Hack M, Mostow A, Miranda SB. Development of attention in preterm infants. Pediatrics 1976;58:669-674.

Fujimoto S, Togari H, Banno T, Takashima S, Funato M, Yoshioka H et al. Correlation between magnetic resonance

9

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·10

¶·È‰È·ÙÚÈ΋ 2003;66:2-11

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

imaging and clinical profiles of periventricular leukomalacia.

Tohoku J Exp Med 1999;188:143-151.

Volpe JJ. Neonatal Neurology. 3rd ed. Philadelphia: Saunders; 1995.

Gould SJ, Howard S, Hope PL, Reynolds EO. Periventricular intraparenchymal cerebral haemorrhage in preterm infants: the role of venous infarction. J Pathol 1987;151:197-202. de Vries LS, Roelants-van Rijn AM, Rademaker KJ, Van Haastert IC, Beek FJ, Groenendaal F. Unilateral parenchymal haemorrhagic infarction in the preterm infant.

Eur J Paediatr Neurol 2001;5:139-149. de Vries LS, Eken P, Dubowitz LM. The spectrum of leukomalacia using cranial ultrasound. Behav Brain Res 1992;49:1-6. de Vries LS, Dubowitz LMS, Dubowitz V, Pennock JM. Brain disorders in the newborn. London: Wolfe Medical; 1990.

Roth SC, Baudin J, Pezzani-Goldsmith M, Townsend J, Reynolds EO, Stewart AL. Relation between neurodevelopmental status of very preterm infants at one and eight years. Dev Med Child Neurol 1994;36:1049-1062.

Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation. Ventriculomegaly Trial Group. Arch Dis Child 1990;65:3-10.

Fernell E, Hagberg G, Hagberg B. Infantile hydrocephalus in preterm, low-birth-weight infants: a nationwide Swedish cohort study 1979-1988. Acta Paediatr 1993;82:45-48.

Blackman JA, McGuinness GA, Bale JF Jr, Smith WL Jr. Large postnatally acquired porencephalic cysts: unexpected developmental outcomes. J Clin Neurol 1991;6:58-64. de Vries LS, Eken P, Groenendaal F, van Haastert IC, Meiners LC. Correlation between the degree of periventricular leukomalacia diagnosed using cranial ultrasound and MRI later in infancy in children with cerebral palsy. Neuropediatrics 1993;24:263-268.

Fazzi E, Orcesi S, Caffi L, Ometto A, Rondini G, Telesca C et al. Neurodevelopmental outcome at 5-7 years in preterm infants with periventricular leukomalacia. Neuropediatrics 1994;25:134-139.

Rogers B, Msall M, Owens T, Guernsey K, Brody A, Buck G et al. Cystic periventricular leukomalacia and type of cerebral palsy in preterm infants. J Pediatr 1994;125:S1-8.

Cioni G, Fazzi B, Ipata AE, Canapicchi R, van Hof-van Duin J. Correlation between cerebral visual impairment and MR imaging in children with neonatal encephalopathy. Dev Med Child Neurol 1996;38:120-132.

Pierrat V, Duquennoy C, van Haastert IC, Ernst M, Guilley N, de Vries LS. Ultrasound diagnosis and neurodevelopmental outcome of localised and extensive cystic periventricular leukomalacia. Arch Dis Child Fetal Neonatal Ed 2001;84:F151-F156.

Dubowitz LM, Bydder GM. Nuclear magnetic resonance imaging in the diagnosis and follow-up of neonatal cerebral injury. Clin Perinatol 1985;12:243-260.

Dubowitz LM, Bydder GM, Mushin J. Developmental sequence of periventricular leukomalacia. Correlation of ultrasound, clinical, and nuclear magnetic resonance functions. Arch Dis Child 1985;60:349-355.

10

Paediatriki 2003;66:2-11

42. Rutherford MA, Pennock JM, Dubowitz LM. Cranial ultrasound and magnetic resonance imaging in hypoxicischaemic encephalopathy: a comparison with outcome.

Dev Med Child Neurol 1994;36:813-825.

43. Rutherford MA, Pennock JM, Counsell SJ, Mercuri E, Cowan FM, Dubowitz LM et al. Abnormal magnetic resonance signal in the internal capsule predicts poor neurodevelopmental outcome in infants with hypoxicischaemic encephalopathy. Pediatrics 1998;102:323-328.

44. de Vries LS, Groenendaal F, van Haastert IC, Eken P, Rademaker KJ, Meiners LC. Asymmetrical myelination of the posterior limb of the internal capsule in infants with periventricular haemorrhagic infarction: an early predictor of hemiplegia. Neuropediatrics 1999;30:314-319.

45. Dubowitz LM, Cowan F, Rutherford M, Mercuri E, Pennock J. Neonatal neurology, past present and future. A window on the brain. Brain Dev 1995;17 (Suppl):22-30.

46. Mercuri E, Rutherford M, Cowan F, Pennock J, Counsell S, Papadimitriou M et al. Early prognostic indicators of outcome in infants with neonatal cerebral infarction: a clinical, electroencephalogram, and magnetic resonance imaging study. Pediatrics 1999;103:39-46.

47. Azzopardi D, Wyatt JS, Cady EB, Delpy DT, Baudin J, Stewart AL et al. Prognosis of newborn infants with hypoxicischemic brain injury assessed by phosphorus magnetic resonance spectroscopy. Pediatr Res 1989;25:445-451.

48. Moorcraft J, Bolas NM, Ives NK, Sutton P, Blackledge MJ, Rajagopalan B et al. Spatially localized magnetic resonance spectroscopy of the brains of normal and asphyxiated newborns. Pediatrics 1991;87:273-282.

49. Peden CJ, Cowan FM, Bryant DJ, Sargentoni J, Cox IJ, Menon DK et al. Proton MR spectroscopy of the brain in infants. J Comput Assist Tomogr 1990;14:886-894.

50. Amess PN, Penrice J, Wylezinska M, Lorek A, Townsend J, Wyatt JS et al. Early brain proton magnetic resonance spectroscopy and neonatal neurology related to neurodevelopmental outcome at 1 year in term infants after presumed hypoxic-ischaemic brain injury. Dev Med Child Neurol 1999;41:436-445.

51. Barkovich AJ, Baranski K, Vigneron D, Partridge JC, Hallam DK, Hajnal BL et al. Proton MR spectroscopy for the evaluation of brain injury in asphyxiated, term neonates.

AJNR Am J Neuroradiol 1999;20:1399-1405.

52. McMenamin JB, Volpe JJ. Doppler ultrasonography in the determination of neonatal brain death. Ann Neurol 1983;14:302-307.

53. Archer LN, Levene MI, Evans DH. Cerebral artery Doppler ultrasonography for prediction of outcome after perinatal asphyxia. Lancet 1986;2:1116-1118.

54. Levene MI, Fenton AC, Evans DH, Archer LN, Shortland DB, Gibson NA. Severe birth asphyxia and abnormal cerebral blood-flow velocity. Dev Med Child Neurol 1989;31:427434.

55. Eken P, Toet MC, Groenendaal F, de Vries LS. Predictive value of early neuroimaging, pulsed Doppler and neurophysiology in full term infants with hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 1995;73:F75-F80.

56. Biagioni E, Bartalena L, Boldrini A, Cioni G, Giancola A,

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·11

¶·È‰È·ÙÚÈ΋ 2002;65:394-402

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

Ipata AE. Background EEG activity in preterm infants: correlation of outcome with selected maturational features.

Electroencephalogr Clin Neurophysiol 1994;91:154-162.

Connell JA, Oozeer R, Dubowitz V. Continuous 4-channel EEG monitoring: a guide to interpretation, with normal values, in preterm infants. Neuropediatrics 1987;18:138-145.

Wertheim D, Mercuri E, Faundez JC, Rutherford M, Acolet D, Dubowitz L. Prognostic value of continuous electroencephalographic recording in full term infants with hypoxic-ischaemic encephalopathy. Arch Dis Child 1994;71:F97-102.

Biagioni E, Boldrini A, Bottone U, Pieri R, Cioni G. Prognostic value of abnormal EEG transients in preterm infants and full-term neonates. Electroencephalogr Clin Neurophysiol 1996;99:1-9.

Biagioni E, Bartalena L, Biver P, Pieri R, Cioni G. Electroencephalographic dysmaturity in preterm infants: a prognostic tool in the early postnatal period.

Neuropediatrics 1996;27:1-6.

Pinto LC, Giliberti P. Neonatal seizures: background EEG activity and the electroclinical correlation in full-term neonates with hypoxic-ischaemic encephalopathy. Analysis by computer-synchronized long-term polygraphic videoEEG monitoring. Epileptic Disord 2001;3:125-132.

Zeinstra E, Fock JM, Begeer JH, van Weerden TW, Maurits NM, Zweens MJ. The prognostic value of serial EEG recordings following acute neonatal asphyxia in full-term infants. Eur J Paediatr Neurol 2001;5:155-160.

Hellstrom-Westas L, Rosen I, Svenningsen NW. Predictive value of early continuous amplitude integrated EEG recordings on outcome after severe birth asphyxia in full term infants. Arch Dis Child Fetal Neonatal Ed 1995;72:F34-F38. al Naqeeb N, Edwards AD, Cowan FM, Azzopardi D. Assessment of neonatal encephalopathy by amplitudeintegrated electroencephalography. Pediatrics 1999; 103:1263-1271.

Murdoch-Eaton D, Darowski M, Livingston J. Cerebral function monitoring in paediatric intensive care: useful features for predicting outcome. Dev Med Child Neurol 2001;43:91-96.

Toet MC, van der Meij W, de Vries LS, Uiterwaal CS, van Huffelen KC. Comparison between simultaneously recorded amplitude integrated electroencephalogram (cerebral function monitor) and standard electroencephalogram in neonates. Pediatrics 2002;109:772-779.

Stockard JE, Stockard JJ, Kleinberg F, Westmoreland BF.

Paediatriki 2002;65:394-402

68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

Prognostic value of brainstem auditory evoked potentials in neonates. Arch Neurol 1983;40:360-365.

Beverley DW, Smith IS, Beesley P, Jones J, Rhodes N. Relationship of cranial ultrasonography, visual and auditory evoked responses with neurodevelopmental outcome. Dev Med Child Neurol 1990;32:210-222.

Guinard C, Fawer CL, Despland PA, Calame A. Auditory brainstem responses and ultrasound changes in a high-risk infants population. Helv Paediatr Acta 1989;43:377-388. de Vries LS, Eken P, Pierrat V, Daniels H, Casaer P. Prediction of neurodevelopmental outcome in the preterm infant: short latency cortical somatosensory evoked potentials compared with cranial ultrasound. Arch Dis Child 1992;67:1177-1181.

Taylor MJ, Murphy WJ, Whyte HE. Prognostic reliability of somatosensory and visual evoked potentials of asphyxiated term infants. Dev Med Child Neurol 1992;34:507-515.

Majnemer A, Rosenblatt B. Evoked potentials as predictors of outcome in neonatal intensive care unit survivors: review of the literature. Pediatr Neurol 1996;14:189-195.

Scalais E, Francois-Adant A, Nuttin C, Bachy A, Guerit JM. Multimodality evoked potentials as a prognostic tool in term asphyxiated newborns.

Electroencephalogr Clin Neurophysiol 1998;108:199-207.

White CP, Cooke RW. Somatosensory evoked potentials following posterior tibial nerve stimulation predict later motor outcome. Dev Med Child Neurol 1994;36:34-40.

Pierrat V, Eken P, Duquennoy C, Rousseau S, de Vries LS. Prognostic value of early SEP in neonates with cystic leukomalacia. Dev Med Child Neurol 1993;35:683-690.

Ekert PG, Taylor MJ, Keenan NK, Boulton JE, Whyte HE. Early somatosensory evoked potentials in preterm infants: their prognostic utility. Biol Neonate 1997;71:83-91. de Vries LS, Pierrat V, Eken P, Minami T, Daniels H, Casaer P. Prognostic value of early somatosensory evoked potentials for adverse outcome in full-term infants with birth asphyxia. Brain Dev 1991;13:320-325.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-07-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 22-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª.¡. ¶··‰ËÌËÙÚ›Ô˘ ∞ÚÁÔÓ·˘ÙÒÓ 50, ∆.∫. 151 25, ª·ÚÔ‡ÛÈ

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REVIEW ARTICLE

O ÚfiÏÔ˜ ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙË ‚ÚÂÊÈ΋ ‰È·ÙÚÔÊ‹ ª. ª·˘ÚfiΈÛÙ·, π. ÷ڈӛÙË, ∂. ∫fiÎÔÚË

Polyunsaturated fatty acids in infant nutrition M. Mavrocosta, I. Charoniti, E. Kokori

¶ÂÚ›ÏË„Ë: ∆· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (LC-PUFAs), ΢ڛˆ˜ ÙÔ ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (DHA) Î·È ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ (AA) Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ·ÓıÚÒÈÓÔ, ·ÏÏ¿ fi¯È ÛÙÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο Û˘ÛÙ·ÙÈο ÛÙÔȯ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÈÛ¯˘Ú¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ηıÒ˜ Î·È ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs ¤Ó·ÓÙÈ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜, Û¯ÂÙÈο Ì ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ‰È·ÓÔËÙÈ΋˜ Î·È ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜. ∆· Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ó·Ï˘ıÔ‡Ó, ÏfiÁˆ ÙˆÓ ‰˘ÛÎÔÏÈÒÓ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÔÙÈ΋˜ Î·È ‰È·ÓÔËÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÛÙ· ·È‰È¿. ¶¿ÓÙˆ˜, ÔÈ Ì¤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs ÛÙËÓ ·Ó¿Ù˘ÍË, ȉȷ›ÙÂÚ· ÙˆÓ ÚfiˆÚˆÓ ‚ÚÂÊÒÓ. º˘ÛÈο ‰ÂÓ Ï›Ô˘Ó Î·È ÔÈ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Û¯ÂÙÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· ÙˆÓ LC-PUFAs. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ¤¯ÂÈ Û¯¤ÛË Ì ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Û ÌÂÙÚ‹ÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ Ù˘ ˙ˆ‹˜ ‹ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÔÍÂȉˆÙÈΤ˜ ‚Ï¿‚˜. O ÚfiÏÔ˜ ÙˆÓ LC-PUFAs ÛÙËÓ ÂÌ‚Ú˘˚΋ Î·È ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜ Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·ÎfiÌË ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ȉ·ÓÈ΋˜ ·Ó·ÏÔÁ›·˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜. °È· ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜.

Abstract: LC-PUFAs, especially DHA and AA, are contained in breast milk but not in infant formulas.

They are important components of the brain and retina. Many studies have demonstrated advantages of breastfeeding and of the supplemented with LCPUFAs milk versus the unsupplemented formulas on subsequent cognitive and visual function. The long term effects of the supplementation with LC-PUFAs can not be evaluated properly, because of the difficulty in assessing the visual and the cognitive function in children. Most of the studies however, demonstrate significant advantages of LC-PUFAs supplementation in infant growth, especially in premature infants. There are several concerns regarding the safety of LC-PUFAs supplements. The supplementation with LC-PUFAs may be related to reduced weight gain during the first year of life or increased risk for oxidant damage. The role of LCPUFAs in fetal and infant growth is not completely clarified; moreover there is no reliable method to evaluate the optimal proportions of DHA and AA to be taken. More studies are required so as to ascertain the role and the ideal intake of LC-PUFAs in infants’ diet.

§¤ÍÂȘ ÎÏÂȉȿ: ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘, ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇, ·Ú·¯È‰ÔÓÈÎfi Ô͇, ÏÈÓÔÏÂ˚Îfi Ô͇, ·-ÏÈÓÔÏÂÓÈÎfi Ô͇, ˆ-3 ÏÈ·Ú¿ Ôͤ·, ˆ6 ÏÈ·Ú¿ Ôͤ·.

Key words: long chain polyunsaturated fatty acids, linoleic acid, a-linolenic acid, docosahexaenoid acid, n-3 fatty acids, n-6 fatty acids.

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

1st Pediatric Clinic, Venizelion Hospital of Heraklion, Crete

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™˘ÓÙÔÌÔÁڷʛ˜ LC-PUFAs LA ALA AA DHA §O ∫¡™

¶ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ §ÈÓÔÏÂ˚Îfi Ô͇ ·-ÏÈÓÔÏÂÓÈÎfi Ô͇ ∞Ú·¯È‰ÔÓÈÎfi Ô͇ ¡ÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ §È·Ú¿ Ôͤ· ∫ÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·

∂ÈÛ·ÁˆÁ‹ ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÚ¢ÓËÙÒÓ ¤¯ÂÈ ÂÛÙÈ·ÛÙ› ÛÙËÓ ÚÔÛı‹ÎË LC-PUFAs ÙˆÓ ÔÌ¿‰ˆÓ ˆ-3 Î·È ˆ-6 ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ·ÁÂÏ¿‰·˜. ∏ ·ÚÔ˘Û›· ÙˆÓ LC-PUFAs ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È fi¯È ÛÙ· ÙÚÔÔÔÈË̤ӷ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ Û Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·, ¤¯ÂÈ Û˘ÁÎÂÓÙÚÒÛÂÈ ÙËÓ ÚÔÛÔ¯‹ ÛÙË ÛËÌ·Û›· ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÔÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ∫¡™. °È· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi, Ù· ÏÈ›‰È· ·ÔÙÂÏÔ‡Ó ‚·ÛÈ΋ ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ Î·È Î‡ÚÈ· ‰ÔÌÈο Û˘ÛÙ·ÙÈο ÙˆÓ ÈÛÙÒÓ. ∆· ÏÈ·Ú¿ Ôͤ· ·ÔÙÂÏÔ‡ÓÙ·È ·fi ·ÓıÚ·ÎÈΤ˜ ·Ï˘Û›‰Â˜, Ù· ¿ÎÚ· ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ Â›Ó·È ¯ËÌÈÎÒ˜ fiÌÔÈ· ÌÂٷ͇ ÙÔ˘˜. ™ÙÔ ¤Ó· ¿ÎÚÔ Û˘Ó‰¤ÂÙ·È Ì›· ηڂÔ͢ÏÈ΋ ÔÌ¿‰· (-COOH), ÂÓÒ ÛÙÔ ¿ÏÏÔ ¿ÎÚÔ ¤Ó· ÌÂı‡ÏÈÔ (-CH3). ∆Ô ÙÂÏÂ˘Ù·›Ô ÔÓÔÌ¿˙ÂÙ·È ˆ¿ÎÚÔ. ¶ÔÏ˘·ÎfiÚÂÛÙ· ÔÓÔÌ¿˙ÔÓÙ·È ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ‰‡Ô ¤ˆ˜ ¤ÍÈ ‰ÈÏÔ‡˜ ‰ÂÛÌÔ‡˜. ∞Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚÒÙÔ˘ ‰ÈÏÔ‡ ‰ÂÛÌÔ‡ ˆ˜ ÚÔ˜ ÙÔ ˆ-¿ÎÚÔ, ‰È·ÎÚ›ÓÔÓÙ·È ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ÔÌ¿‰Â˜: ˆ-3, ˆ-6, ˆ9 ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·. ª·ÎÚ¿˜ ·Ï‡ÛÔ˘ ϤÁÔÓÙ·È Ù· ÏÈ·Ú¿ Ôͤ· Ô˘ ¤¯Ô˘Ó ¿Ï˘ÛÔ Ì ¿Óˆ ·fi 18 ¿ÙÔÌ· ¿Óıڷη. ∆Ô ÏÈÓÔÏÂ˚Îfi (LA) (∂ÈÎfiÓ· 1) Î·È ÙÔ ·-ÏÈÓÔÏÂÓÈÎfi (ALA) (∂ÈÎfiÓ· 2) ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ·, ÁÈ·Ù› ‰ÂÓ Û˘ÓÙ›ıÂÓÙ·È ·fi ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi Î·È Ú¤ÂÈ

Paediatriki 2003;66:12-19

Ó· Ï·Ì‚¿ÓÔÓÙ·È ·fi ÙȘ ÙÚÔʤ˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÙÚ·Ô‡Ó Ì ̛· ÛÂÈÚ¿ ·ÓÙȉڿÛÂˆÓ Û ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘. ™˘ÓÂÒ˜, Ë Û‡ÓıÂÛË ÙˆÓ LCPUFAs ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ Úfi‰ÚÔÌˆÓ ÂÓÒÛÂˆÓ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∂›Û˘, Ë ·Ó·ÏÔÁ›· ÙÔ˘ ÏÈÓÔÏÂ˚ÎÔ‡ ÚÔ˜ ÙÔ ·-ÏÈÓÔÏÂÓÈÎfi Ô͇ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô ÁÈ· ÙËÓ ÈÛÔÚÚÔ›· ÙˆÓ LC-PUFAs ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∆· LC-PUFAs ·ÔÙÂÏÔ‡Ó ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· ÙÔÓ ÔÚÁ·ÓÈÛÌfi Î·È Úfi‰ÚÔ̘ ÂÓÒÛÂȘ ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ (ÚÔÛÙ·ÁÏ·Ó‰›Ó˜, ÚÔÛÙ·Î˘ÎϛӘ, ıÚÔÌ‚ÔÍ¿Ó˜ Î·È Ï¢ÎÔÙÚȤÓ˜). ∂ÈϤÔÓ, Ù· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ·ÔÙÂÏÔ‡Ó ‚·ÛÈÎfi ‰ÔÌÈÎfi ÛÙÔÈ¯Â›Ô ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ, fiÔ˘ ˘¿Ú¯Ô˘Ó ΢ڛˆ˜ Û ÌÔÚÊ‹ ʈÛÊÔÏÈȉ›ˆÓ. ∂ȉÈÎfiÙÂÚ·, Ù· ʈÛÊÔÏÈ›‰È· ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ·ÌÊÈ‚ÏÈÛÙÚÔÂȉԇ˜ ¯ÈÙÒÓ· Â›Ó·È È‰È·›ÙÂÚ· ÏÔ‡ÛÈ· Û ‰‡Ô LC-PUFAs, ÛÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ (AA, ˆ-6 ÔÏ˘·ÎfiÚÂÛÙÔ ÏÈ·Úfi Ô͇ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘) (∂ÈÎfiÓ· 3) Î·È ÛÙÔ ÓÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (DHA, ˆ-3 ÔÏ˘·ÎfiÚÂÛÙÔ ÏÈ·Úfi Ô͇ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘) (∂ÈÎfiÓ· 4). ™ÙÔ˘˜ ÈÛÙÔ‡˜ ·˘ÙÔ‡˜, ÙÔ LA Î·È ∞LA ÂÚȤ¯ÔÓÙ·È Û ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜. ∆Ô DHA Â›Ó·È ÙÔ Î‡ÚÈÔ ˆ-3 ÏÈ·Úfi Ô͇ ÙÔ˘ Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ·ÔÙÂÏ› ÙÔ 40% ÙˆÓ ÔÏÈÎÒÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏÈÛÙÚÔÂȉԇ˜. ∆Ô ∞∞ Â›Ó·È ÙÔ Î‡ÚÈÔ ˆ-6 ÏÈ·Úfi Ô͇ ÙÔ˘ Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ·ÔÙÂÏ› Úfi‰ÚÔÌË ¤ÓˆÛË ÁÈ· ÙË Û‡ÓıÂÛË ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, Ï¢ÎÔÙÚÈÂÓ›ˆÓ Î·È ¿ÏÏˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ (1). ∆Ô ∞∞ ÌÔÚ› ‡ÎÔÏ· Ó· Û˘ÓÙÂı› ·fi LA. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ Û˘¯ÓfiÙÂÚ· ··ÓÙÒÌÂÓÔ LC-PUFA Ù˘ ‰È·ÙÚÔÊ‹˜. ∏ Û‡ÓıÂÛË ÙÔ˘ DHA ·fi ÙÔ ∞LA Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÈÔ ÂÚ›ÏÔΘ ·Ó·‚ÔÏÈΤ˜ ‰ÈÂÚÁ·Û›Â˜, Ë ·Ô‰ÔÙÈÎfiÙËÙ· ÙˆÓ ÔÔ›ˆÓ Â›Ó·È Ì¿ÏÏÔÓ ÌÂȈ̤ÓË Î·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ (2,3).

CH3-CH2-CH2-CH2-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-CH2-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 1. §ÈÓÔÏÂ˚Îfi Ô͇ (C 18:2 ˆ-6).

CH3-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-CH2-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 2. ·-§ÈÓÔÏÂÓÈÎfi Ô͇ (C 18:3 ˆ-3).

CH3-CH2-CH2-CH2-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-CH2-COOH ∂ÈÎfiÓ· 3. ∞Ú·¯È‰ÔÓÈÎfi Ô͇ (C 20:4 ˆ-6).

CH3-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH=CH-CH2-CH2-COOH ∂ÈÎfiÓ· 4. ¡ÙÔÎÔÛ·ÂÍ·ÓÔ˚Îfi Ô͇ (C 22:6 ˆ-3).

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¶·È‰È·ÙÚÈ΋ 2003;66:12-19

ª¤¯ÚÈ Û‹ÌÂÚ·, Ù· ÂÚÈÛÛfiÙÂÚ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·, Û ·ÓÙ›ıÂÛË Ì ÙÔ ÌËÙÚÈÎfi Á¿Ï·, ÂÚÈ›¯·Ó ÌfiÓÔ Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ·. ™‹ÌÂÚ·, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ LC-PUFAs ÛÙÔ Ï¿ÛÌ·, ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ ÂÚ˘ıÚÒÓ Î·È ÛÙÔ ÊÏÔÈfi ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÌÂȈ̤Ó˜ ÛÙ· ·È‰È¿ Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ¯ˆÚ›˜ ÚÔÛı‹ÎË LC-PUFAs, Û ۯ¤ÛË Ì ·˘Ù¤˜ Ô˘ ··ÓÙÒÓÙ·È ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ‹ ÛÙ· ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ÛÙ· ÔÔ›· ¤¯Ô˘Ó ÚÔÛÙÂı› LC-PUFAs (4). ∞Ó Î·È ÌÂϤÙ˜ Ì ÛÙ·ıÂÚ¿ ÈÛfiÙÔ· ‰Â›¯ÓÔ˘Ó fiÙÈ ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÙÚ¤„Ô˘Ó LA Û AA Î·È ALA Û DHA, Ù· ÂÓ˙˘ÌÈο Û˘ÛÙ‹Ì·Ù· (·ÔηڂÔÍ˘Ï¿ÛË Î·È ÚÔÛıÂÙ¿ÛË) Ô˘ ÌÂÙ·ÙÚ¤Ô˘Ó Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ· (§O) ÏÈÓÔÏÂ˚Îfi Î·È ÏÈÓÔÏÂÓÈÎfi Û LCPUFAs Â›Ó·È Ì¿ÏÏÔÓ ·ÓÂ·Ú΋ ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ (5,6). ¢ÂÓ Â›Ó·È ÂȂ‚·ÈˆÌ¤ÓÔ ·Ó Ë Û¯ÂÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ÛÙ· ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ‚Ú¤ÊË, Û ̛· ÎÚ›ÛÈÌË ËÏÈΛ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÏÂÈÙÔ˘ÚÁÈΤ˜ Û˘Ó¤ÂȘ. ™˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ¤Ó·ÓÙÈ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· LCPUFAs, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰ÒÛÔ˘Ó ·ÎÚÈ‚¤˜ ·ÔÙ¤ÏÂÛÌ·, ÁÈ·Ù› ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÎÙfi˜ ÙˆÓ LC-PUFAs Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÔÙÈÎÔ‡ ÊÏÔÈÔ‡ Î·È ÙÔ˘ ∫¡™. ŒÙÛÈ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û˘ÁÎÚ›ÓÔ˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ‰È·ÙÚÔÊ‹˜ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Ì ‹ ¯ˆÚ›˜ ÙËÓ ÚÔÛı‹ÎË LC-PUFAs. ŸÏ˜ ÔÈ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙÔ ÂÚȯfiÌÂÓÔ ÙˆÓ §O ÛÙÔ Ï¿ÛÌ· ¤¯Ô˘Ó ‰Â›ÍÂÈ ˘„ËÏfiÙÂÚ· Â›‰· LC-PUFAs ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË (7). ªÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË Û˘ÁΤÓÙÚˆÛË §O ÛÙÔ Ï¿ÛÌ· Î·È ÛÙ· ÏÈ›‰È· ÂÚ˘ıÚÒÓ Û ·È‰È¿ ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï·, Ì ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË LCPUFAs, ¤‰ÂÈÍ·Ó fiÙÈ Ù· Â›‰¿ ÙÔ˘˜ Â›Ó·È ·ÓÙ›ÛÙÔȯ· Ù˘ ‰È·ÈÙËÙÈ΋˜ ÚfiÛÏ˄˘. ¶ÚÔÛı‹ÎË ÌfiÓÔ DHA ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘„ËÏfiÙÂÚ· Â›‰· DHA ÛÙ· ÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÙˆÓ ÂÚ˘ıÚÒÓ Î·È Û˘Ó‹ıˆ˜ ¯·ÌËÏfiÙÂÚ· Â›‰· ∞∞ Î·È ¿ÏÏˆÓ ˆ6 ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (8). ∏ ÚÔÛı‹ÎË AA Î·È DHA Ì·˙› ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ˘„ËÏ¿ Â›‰· Î·È ÙˆÓ ‰‡Ô §O ÛÙÔ Ï¿ÛÌ·. ¶ËÁ¤˜ ÏÈ·ÚÒÓ ÔͤˆÓ ∆· ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ LA, ∞LA, AA Î·È DHA ¤¯Ô˘Ó ȉȷ›ÙÂÚË ‰È·ÙÚÔÊÈ΋ ÛËÌ·Û›· ÁÈ· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi. ª›· ·ÚÈ· ËÁ‹ ÏÈ·ÚÒÓ ÔͤˆÓ Â›Ó·È ÙÔ È¯ı˘¤Ï·ÈÔ Ô˘ ÂÚȤ¯ÂÈ ÌÂÁ¿Ï· ÔÛ¿ ˆ-3, ·ÏÏ¿ ÂÏ¿¯ÈÛÙ· ÔÛ¿ ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘. ∆Ô LA Ô˘ ‚Ú›ÛÎÂÙ·È Î˘Ú›ˆ˜ Û ¤Ï·È·

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Paediatriki 2003;66:12-19

Ï·¯·ÓÈÎÒÓ Î·È ¿ÏÏ· ÙÚfiÊÈÌ·, ıˆÚÂ›Ù·È ÙÔ ‚·ÛÈÎfi ··Ú·›ÙËÙÔ ÏÈ·Úfi Ô͇. ∆Ô ∞LA Î·È ÙÔ DHA ›ӷÈ, Â›Û˘, ··Ú·›ÙËÙ·. ∆· ˆ-3 ÏÈ·Ú¿ Ôͤ· ˘¿Ú¯Ô˘Ó Û ‰È¿ÊÔÚ· ÙÚfiÊÈÌ·, fiˆ˜ ÛÙÔ ¤Ï·ÈÔ ÛfiÁÈ·˜, ÙÔ ÁÔÁÁ‡ÏÈ Î·È Ù· Ú¿ÛÈÓ· Ï·¯·ÓÈο. ∆Ô DHA ‚Ú›ÛÎÂÙ·È Î˘Ú›ˆ˜ ÛÙÔÓ ÎÚfiÎÔ ÙÔ˘ ·˘ÁÔ‡, ÛÙ· ÛÙÚ›‰È· Î·È Ù· „¿ÚÈ·. ∆· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù· ÌÔÚÔ‡Ó Ó· ÂÌÏÔ˘ÙÈÛÙÔ‡Ó Ì LC-PUFAs ·fi ȯı˘¤Ï·ÈÔ, ¤Ï·È· ·fi ÎÚfiÎÔ ·˘ÁÔ‡ ‹ ¤Ï·È· ·ÔÌÔӈ̤ӷ ·fi ÚÔ˚fiÓÙ· ˙‡ÌˆÛ˘ ÌÔÓÔ΢ÙÙ¿ÚÈˆÓ ÔÚÁ·ÓÈÛÌÒÓ (9).

LC-PUFAs Î·È ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ∆· LC-PUFAs ‚Ú›ÛÎÔÓÙ·È ÛÙÔ Á¿Ï· fiÏˆÓ ÙˆÓ ıËÏ·˙Ô˘ÛÒÓ Á˘Ó·ÈÎÒÓ, ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ù· ··Ú·›ÙËÙ· ÏÈ·Ú¿ Ôͤ· Î·È Ù· DHA, ALA, ηıÒ˜ Î·È ¿ÏÏ· LCPUFAs (10). ∆Ô 50% Ù˘ ÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÚÔÛʤÚÂÙ·È ÛÙÔ ‚Ú¤ÊÔ˜ Ì ÙË ÌÔÚÊ‹ ÏÈȉ›ˆÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ÏÈ·Ú¿ Ôͤ· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· ÙÚÈÁÏ˘ÎÂÚ›‰È· (98-99%), ÂÓÒ ¤Ó· ÌÈÎÚfi ÔÛfi ˘¿Ú¯ÂÈ ÛÙ· ʈÛÊÔÏÈ›‰È·, ÌÔÓÔÁÏ˘ÎÂÚ›‰È· Î·È ‰ÈÁÏ˘ÎÂÚ›‰È·. ∆Ô ÔÏÈÎfi ÂÚȯfiÌÂÓÔ ÏÈȉ›ˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ Û˘Ó‹ıˆ˜ ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Á‡̷ÙÔ˜ Î·È Ì ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ ıËÏ·ÛÌÔ‡. ∂ËÚ¿˙ÂÙ·È, Â›Û˘, ·fi ÙËÓ ËÏÈΛ· ·ËÛ˘ ÛÙË Á¤ÓÓËÛË, ÙȘ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔÓ ËÌÂÚ‹ÛÈÔ Ú˘ıÌfi (11,12). ∏ Û‡ÓıÂÛË ÙÔ˘ Ï›Ô˘˜ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂËÚ¿˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÙȘ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Ù˘ ÌËÙ¤Ú·˜. ŒÙÛÈ, fiÙ·Ó ÛÙȘ ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ¯ÔÚËÁËı› DHA, Ù· Â›‰¿ ÙÔ˘ ÛÙÔ Á¿Ï· ·˘Í¿ÓÔÓÙ·È Ì ‰ÔÛÔÂÍ·ÚÙÒÌÂÓÔ Ú˘ıÌfi (13). µÚ¤ÊË Ù· ÔÔ›· Ï¿Ì‚·Ó·Ó DHA ̤ۈ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ›¯·Ó ˘„ËÏfiÙÂÚ· Â›‰· ·˘ÙÔ‡ ÙÔ˘ ÌÔÚ›Ô˘ ÛÙȘ ‚·ÛÈΤ˜ ‰Ô̤˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (14). ∆· ˘„ËÏfiÙÂÚ· Â›‰· LC-PUFAs (AA, DHA) ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ ‡·Ú Î·È ÌÂÙ¿ ·fi ¤Ó· Ì‹Ó· Í·ÊÓÈο ÌÂÈÒÓÔÓÙ·È, Û Â›‰· Ô˘ ‰È·ÙËÚÔ‡ÓÙ·È Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ‚ÚÂÊÈ΋˜ ÂÚÈfi‰Ô˘. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó Û¯Â‰fiÓ ÛÙ·ıÂÚ¤˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ∞∞ Î·È D∏∞ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·, Û ÌÂÙÚ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÒÙˆÓ 12 ÌËÓÒÓ Ù˘ ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡. ∂Ô̤ӈ˜, LC-PUFAs ¯ÔÚËÁÔ‡ÓÙ·È ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË Î·È Î·Ù¿ ÙÔÓ ·Ú·ÙÂٷ̤ÓÔ ıËÏ·ÛÌfi. ∆Ô ·fiÏ˘ÙÔ ÂÚȯfiÌÂÓÔ ·Ó¿ dl ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚfi ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 12 ÌËÓÒÓ. ∏ ʇÛË ÙˆÓ ¯ËÌÈÎÒÓ ÂÓÒÛÂˆÓ ÛÙȘ Ôԛ˜ ÂÚȤ¯ÔÓÙ·È Ù· LC-PUFAs Î·È Î¿ÔȘ Ú˘ıÌÈÛÙÈΤ˜ ‰È·‰Èηۛ˜ ÛÙÔÓ Ì·˙ÈÎfi ·‰¤Ó·, ÌÔÚÔ‡Ó Ó· ÂÍËÁ‹ÛÔ˘Ó ·˘Ùfi ÙÔ ÚÔÊ·ÓÒ˜ ·Ú¿‰ÔÍÔ Ê·ÈÓfiÌÂÓÔ (12,15,16).

LC-PUFAs Î·È ÚÔˆÚfiÙËÙ· Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ë ÈÔ ÁÚ‹ÁÔÚË ·‡ÍËÛË AA Î·È DHA ÛÙÔÓ ÂÁΤʷÏÔ Û˘Ì‚·›ÓÂÈ ÛÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, fiÙ·Ó Ù· LC-PUFAs

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·15

¶·È‰È·ÙÚÈ΋ 2003;66:12-19

·Ú¤¯ÔÓÙ·È ·fi ÙÔÓ Ï·ÎÔ‡ÓÙ·. ∞fi ÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ ̤¯ÚÈ ÙÔ ‰Â‡ÙÂÚÔ ¤ÙÔ˜, Ô ÂÁΤʷÏÔ˜ ·˘Í¿ÓÂÙ·È Ì ÙË ÌÂÁ·Ï‡ÙÂÚ‹ ÙÔ˘ Ù·¯‡ÙËÙ· Î·È ÊÙ¿ÓÂÈ ÙÔ 70% ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ˘ ÂÓËÏ›ÎÔ˘. ∞ÔÙÂÏÂ›Ù·È Î˘Ú›ˆ˜ ·fi ‰ÔÌÈο ʈÛÊÔÏÈ›‰È· Î·È ÓÂÚfi. ∆· ʈÛÊÔÏÈ›‰È· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Â›Ó·È ÌÔÓ·‰Èο, ‰ÈfiÙÈ ¤¯Ô˘Ó Ì›· ·Û˘Ó‹ıÈÛÙ· ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË LCPUFAs, ΢ڛˆ˜ ∞∞ Î·È DHA, Ù· ÔÔ›· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ∫·Ù¿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹, Ù· ÏÈ·Ú¿ Ôͤ· ·Ú¤¯ÔÓÙ·È Ì¤Ûˆ ‰È·Ï·ÎÔ˘ÓÙȷ΋˜ ÌÂÙ·ÊÔÚ¿˜. ªÂÙ¿ ·fi ¤Ó· ÚfiˆÚÔ ÙÔÎÂÙfi, Ë ÌÂÙ·ÊÔÚ¿ ÏÈ·ÚÒÓ ÔͤˆÓ ‰È·ÎfiÙÂÙ·È, ÌÂÈÒÓÔÓÙ·˜ ¤ÙÛÈ ÙË Û˘ÁΤÓÙÚˆÛË ∞∞ Î·È DHA (17-19). Èڛ˜ Ì›· ‰È·ÈÙËÙÈ΋ ËÁ‹, Ù· ‚Ú¤ÊË Ú¤ÂÈ Ó· Û˘Óı¤ÙÔ˘Ó ÌÂÁ¿Ï· ÔÛ¿ DHA Î·È ∞∞ ÁÈ· Ó· ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ŒÙÛÈ, Ù· ÚfiˆÚ· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Â˘¿ÏˆÙ· Û ·ÓÂ¿ÚÎÂÈ· DHA (20-22). ªÂÙ¿ ÙË Á¤ÓÓËÛË, ÙÔ ÌËÙÚÈÎfi Á¿Ï· ·Ú¤¯ÂÈ ÈηÓÔÔÈËÙÈο ÔÛ¿ ∞∞ Î·È DHA, Û ·ÓÙ›ıÂÛË Ì ٷ ÂÚÈÛÛfiÙÂÚ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ¶ÚfiˆÚ· ‚Ú¤ÊË Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·, fiÙ·Ó ÂÍÂÙ¿ÛÙËÎ·Ó Â›¯·Ó ˘„ËÏfiÙÂÚÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ηٿ ÙËÓ ËÏÈΛ· ÙˆÓ 7,5-8 ÂÙÒÓ, Û˘ÁÎÚÈÙÈο Ì ÚfiˆÚ· Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· (23). ªÂÙ¿ ÙËÓ ÚÔÛı‹ÎË LC-PUFAs ÛÙ· Á¿Ï·Ù· ÚfiˆÚˆÓ ‚ÚÂÊÒÓ, Ù· ‚Ú¤ÊË ¤‰ÂÈÍ·Ó ‚ÂÏÙȈ̤Ó˜ ·ÈÛıËÙËÚȷΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ (·ÓÙ·fiÎÚÈÛË ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ÛÙÔ Êˆ˜, ÔÙÈ΋ Ô͇ÙËÙ·), ÔÙÈ΋ ÚÔÛÔ¯‹ Î·È ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ Û ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜. ∂Âȉ‹ Ù· ÚfiˆÚ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ LC-PUFAs ÛÙË Á¤ÓÓËÛË ·’ fiÙÈ Ù· ÙÂÏÂÈfiÌËÓ·, ÌÔÚ› Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó‹ Ù· ÔʤÏË ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ LC-PUFAs ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (24). ŒÙÛÈ, ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ÔÈ ··ÈÙ‹ÛÂȘ Û DHA Ú¤ÂÈ ÈηÓÔÔÈÔ‡ÓÙ·È, ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÂÙ·È Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÊÏÔÈÔ‡ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. ™‹ÌÂÚ·, ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ÛÙÔȯ›· Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÙÔ AA Î·È ÙÔ DHA Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ó¿Ù˘Í˘. ™˘ÁÎÂÓÙÚÒÛÂȘ ∞∞ ÛÙÔ ·›Ì· Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ‚ÚÂÊÒÓ. ∂›Û˘, Ë ÛËÌ·Û›· ÙÔ˘ DHA ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂȉÈÎfiÙÂÚ· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ϤÔÓ ÙÂÎÌËÚȈ̤ÓË (25). Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Û¯ÂÙ›˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ÙËÓ ÚfiÛÏË„Ë ··Ú·›ÙËÙˆÓ §O ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË, ·Ú¿ Ì ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (19,25,26). ∏ ¢ÂÚÁÂÙÈ΋ ‰Ú¿ÛË ÙˆÓ ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, ÙfiÛÔ ÛÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ fiÛÔ Î·È ÛÙȘ ÂÎ˙ÂÌ·ÙÔÂȉ›˜ ‰ÂÚÌ·Ù›Ùȉ˜ ÙˆÓ ‚ÚÂÊÒÓ, ¤¯ÂÈ ·Ú·-

Paediatriki 2003;66:12-19

ÙËÚËı› Â‰Ò Î·È ·ÚÎÂÙ¿ ¯ÚfiÓÈ·. º·›ÓÂÙ·È fiÙÈ Ë ¯ÔÚ‹ÁËÛË ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÚÔ¿ÁÂÈ ÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË Î·È ·ÚÂÌÔ‰›˙ÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ‚ÚÂÊÈÎÔ‡ ÂÎ˙¤Ì·ÙÔ˜ (27,28). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ¯·ÌËÏ‹ ÚfiÛÏË„Ë ··Ú·›ÙËÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ηÈ, Û˘ÓÂÒ˜, ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ (29). ŒÙÛÈ, ÁÈ· Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë ‚¤ÏÙÈÛÙË ÂÌ‚Ú˘˚΋ Î·È ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË, ÔÈ ¤ÁÎ˘Â˜ Î·È ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â·ÚΛ˜ ÔÛfiÙËÙ˜ ÙÚÔÊÒÓ ÏÔ‡ÛÈˆÓ Û LC-PUFAs ÛÙË ‰›·ÈÙ¿ ÙÔ˘˜, fiˆ˜ „¿ÚÈ Î·È ·˘Áfi, ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È·Ï·ÎÔ˘ÓÙȷ΋˜ ÌÂÙ·ÊÔÚ¿˜ ·˘ÙÒÓ ÙˆÓ §O Î·È ÁÈ· ÙËÓ ·‡ÍËÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂÒÓ ÙÔ˘˜ ÛÙÔ Á¿Ï·. ∆· ‚ÚÂÊÈο Á¿Ï·Ù· Î·È ÂȉÈο ·˘Ù¿ Ô˘ ·¢ı‡ÓÔÓÙ·È Û ‚Ú¤ÊË Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Ú¤ÂÈ Ó· Â›Ó·È ÂÌÏÔ˘ÙÈṲ̂ӷ Ì Â·Ú΋ ÔÛ¿ LC-PUFAs, ÒÛÙ ӷ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙȘ ·Ó¿ÁΘ ÙˆÓ Ù·¯¤ˆ˜ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ ‚ÚÂÊÒÓ (9,30).

LC-PUFAs Î·È ÔÙÈ΋ Ô͇ÙËÙ· ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÌÂÌ‚Ú¿Ó˜ ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ÛÙÔÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ ¤¯Ô˘Ó ÙȘ ˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ DHA ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi. ∆· ·ÙÙ·Ú· ÙˆÓ ÊˆÙÔ¸Ô‰Ô¯¤ˆÓ ˆÚÈÌ¿˙Ô˘Ó Ù·¯‡Ù·Ù· ÛÙÔ 3Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ Î·È ÛÙÔ˘˜ ÚÒÙÔ˘˜ 4-6 Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ‰È·ÈÙËÙÈ΋ Â¿ÚÎÂÈ· DHA Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ fiÚ·Û˘. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó Á›ÓÂÈ Û ‚Ú¤ÊË ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ıËÏ·ÛÌÔ‡ ‹ Ù˘ ÚÔÛı‹Î˘ LC-PUFAs ÛÙËÓ ÔÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (31-34). ∏ ÚÔÛı‹ÎË DHA ÛÙË ‰›·ÈÙ· ·Ú¿ÁÂÈ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, Ô˘ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó¤˜ ÛÙ· ÚfiˆÚ· ·Ú¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ª›· ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ÚfiˆÚ· ÛÈÙÈ˙fiÌÂÓ· Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Ì Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ȯı˘¤Ï·ÈÔ, ¤‰ÂÈÍ ‰È·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÛÙÔ˘˜ 2 Î·È ÛÙÔ˘˜ 4 Ì‹Ó˜ ˙ˆ‹˜ ÛÙ· ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÚÔÛı‹ÎË LC-PUFAs. ŸÌˆ˜, ÛÙȘ ËÏÈ˘ ÙˆÓ 6,5, 9 Î·È 12 ÌËÓÒÓ ‰ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (32). ªÔÚ› Ó· Â›Ó·È ‰˘ÛÎÔÏfiÙÂÚÔ Ó· ‚ÚÂıÔ‡Ó ‰È·ÊÔÚ¤˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘, ÁÈ·Ù› Ë ÔÙÈ΋ Ô͇ÙËÙ· ·ÏÏ¿˙ÂÈ Ù·¯‡Ù·Ù· ÙÔ˘˜ ÚÒÙÔ˘˜ ¤ÍÈ Ì‹Ó˜ Î·È ÌÂÙ¿ ÛÙ·ıÂÚÔÔÈ›ٷÈ. ™Â ¿ÏϘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË DHA, ·Ú·ÙËÚ‹ıËΠ˘„ËÏfiÙÂÚË ÔÙÈ΋ Ô͇ÙËÙ· Û ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ·ÎfiÏÔ˘ı˜ ËÏÈ˘: 1, 5, 2, 4, 7 Î·È 12 ÌËÓÒÓ (24,35). ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ Ù˘ ÂÌÏÔ˘ÙÈṲ̂Ó˘ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜ ηÈ

15

JAN-FEB-03

14-05-03

14:37

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¶·È‰È·ÙÚÈ΋ 2003;66:12-19

·˘Ù‹ ¤Ó·ÓÙÈ Ù˘ ÌË ÂÌÏÔ˘ÙÈṲ̂Ó˘ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜, Û ÌÂÙÚ‹ÛÂȘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ (36-39). ª›· ÌÂÙ·-·Ó¿Ï˘ÛË Ô˘ Û˘ÁÎÚ›ÓÂÈ ÌËÙÚÈÎfi Á¿Ï·, ÎÔÈÓfi ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì LC-PUFAs ‰Â›¯ÓÂÈ ÏÂÔÓ¤ÎÙËÌ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‹ Ù˘ ÂÌÏÔ˘ÙÈṲ̂Ó˘ ‰È·ÙÚÔÊ‹˜ Û ÌÂÙÚ‹ÛÂȘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ Û ËÏÈΛ· 2 ÌËÓÒÓ Î·È Û ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂÙÚ‹ÛÂȘ Û ËÏÈΛ· 4 ÌËÓÒÓ. ¶¿ÓÙˆ˜, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û›ÙÈÛ˘ Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÙÂÎÌËÚȈ̤ӷ, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË. ™Ù· ÚfiˆÚ· ‚Ú¤ÊË, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ˘„ËÏfiÙÂÚË ÔÙÈ΋ Ô͇ÙËÙ· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‰È·ÈÙËÙÈÎÒÓ LC-PUFAs. ∆Ô ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Ô˘ ·Ú·ÙËÚÂ›Ù·È Î˘Ú›ˆ˜ ÛÙ· ÚfiˆÚ· ‚Ú¤ÊË, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙÔÓ Ù·¯‡ÙÂÚÔ ‚·ıÌfi ˆÚ›Ì·ÓÛ˘ ÙÔ˘ ÔÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÁÂÁÔÓfi˜ Ô˘ ÌÔÚ› Ó· ÂËÚ¿˙ÂÈ ÙËÓ ÔÛfiÙËÙ· Î·È ÙËÓ ÔÈfiÙËÙ· ÙˆÓ ÚÒÈÌˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∂›Û˘, Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÌÔÚ› Ó· ÂËÚ¿˙ÂÈ ¿ÏÏÔ˘˜ ÙÔÌ›˜ Ù˘ ÔÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È fi¯È ÌfiÓÔ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· (40).

LC-PUFAs Î·È ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ ªÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ì ‹ ¯ˆÚ›˜ ÂÌÏÔ˘ÙÈṲ̂ÓË ‰È·ÙÚÔÊ‹ Î·È Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ηٷϋÁÔ˘Ó Û οÔÈÔ ÔÚÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ª›· ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÔÈ Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ Û ‚Ú¤ÊË Ô˘ ‰È·ÙÚ¤ÊÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓË Ì LC-PUFAs Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ ‹Ù·Ó ıÂÙÈΤ˜ Û ËÏÈΛ· 4 ÌËÓÒÓ, ÂÓÒ ‰ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÛÙÔ˘˜ 12 Î·È 24 Ì‹Ó˜ ˙ˆ‹˜. Œ¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ·ÍÈÔÏfiÁËÛ˘ Ù˘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ Û ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË. ª›· ÌÂÙ·-·Ó¿Ï˘ÛË Û˘ÁÎÚ›ÓÂÈ ‚Ú¤ÊË Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‹ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Î·È ÂÍÂÙ¿ÛÙËÎ·Ó Û ËÏÈ˘ 6-23 ÌËÓÒÓ, ·ÏÏ¿ Î·È ÛÔÚ·‰Èο ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· ̤¯ÚÈ 10-15 ÂÙÒÓ, Ì ‰ÔÎÈ̷ۛ˜ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘. ∆Ô ›‰ÈÔ ÙÂÛÙ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ÎÔÈÓfi ̤ÙÚÔ Û‡ÁÎÚÈÛ˘ ·fi fiϘ ÙȘ ÌÂϤÙ˜ Ô˘ ‹Ú·Ó ̤ÚÔ˜ ÛÙË ÌÂÙ·-·Ó¿Ï˘ÛË. ™Ù· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ·Ú·ÙËÚ‹ıËÎ·Ó ˘„ËÏfiÙÂÚ˜ ÂȉfiÛÂȘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÈ Ôԛ˜ Û˘Ó¯›ÛÙËÎ·Ó Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. Ÿˆ˜ Î·È Ì ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, ·Ú·ÙËÚ‹ıËΠÌÂÁ·Ï‡ÙÂÚÔ ÏÂÔÓ¤ÎÙËÌ· ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÌËÙÚÈÎfi Á¿Ï·, Û ۇÁÎÚÈÛË Ì ٷ ÙÂÏÂÈfiÌËÓ·. ∂›Û˘, ·Ú·ÙËÚ‹ıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ‰È¿Ú-

16

Paediatriki 2003;66:12-19

ÎÂÈ·˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ù˘ ‰È·ÓÔËÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Û˘ÌÂÚÈÊÔÚ¿˜, ÂÓÒ ‰ÂÓ ˘‹ÚÍ·Ó ·ÍÈfiÏÔÁ˜ ‰È·ÊÔÚ¤˜ Û ‚Ú¤ÊË fiÔ˘ Ë ‰È¿ÚÎÂÈ· ıËÏ·ÛÌÔ‡ ‹Ù·Ó 4-7 ‚‰ÔÌ¿‰Â˜. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÚÌËÓ¢ÙÔ‡Ó Â·ÎÚÈ‚Ò˜, ΢ڛˆ˜ ÏfiÁˆ Ù˘ ‡·Ú͢ Â͈ÁÂÓÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚ› Ó· Ù· ÂËÚ¿ÛÔ˘Ó, fiˆ˜ .¯. ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ, Ô ‰Â›ÎÙ˘ ÓÔËÌÔÛ‡Ó˘ ÙˆÓ ÁÔÓ¤ˆÓ, ÔÈ Û¯¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ηٿÛÙ·ÛË Ù˘ ÌËÙ¤Ú·˜ Î·È ¿ÏÏ· (41-44). ÕÏÏË ÌÂϤÙË Ô˘ Û‡ÁÎÚÈÓ ‚Ú¤ÊË ÛÈÙÈ˙fiÌÂÓ· Ì ‹ ¯ˆÚ›˜ ÂÌÏÔ˘ÙÈṲ̂ÓË ‰È·ÙÚÔÊ‹ Ì LC-PUFAs, ¤‰ÂÈÍ fiÙÈ ÔÈ Ó¢ÚÔ·Ó·Ù˘ÍȷΤ˜ ‰ÔÎÈ̷ۛ˜ Û ·È‰È¿ Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· ‹Ù·Ó ıÂÙÈΤ˜ Û ËÏÈΛ· 4 ÌËÓÒÓ, ÂÓÒ ‰ÂÓ ˘‹Ú¯Â ÂÌÊ·Ó‹˜ ‰È·ÊÔÚ¿ ÛÙÔ˘˜ 12 Î·È 24 Ì‹Ó˜ ˙ˆ‹˜. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó ÌË ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È·ÓÔËÙÈ΋ Î·È „˘¯ÔÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ‚ÚÂÊÒÓ (40,45). ∏ ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË, Ô˘ ÂÎÙÈÌ‹ıËΠÛÙÔ˘˜ 10 Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ̤ۈ Ù˘ ÈηÓfiÙËÙ·˜ Â›Ï˘Û˘ οÔÈÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ (ÂÎÙ¤ÏÂÛË ÛÂÈÚ¿˜ ‚ËÌ¿ÙˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÈÙ¢¯ı› οÔÈÔ˜ ÛÙfi¯Ô˜), Ê¿ÓËΠӷ ˘ÂÚ¤¯ÂÈ Û ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Ì LC-PUFAs Á¿Ï·Ù· ·fi ÙË Á¤ÓÓËÛË Î·È ÁÈ· Ù¤ÛÛÂÚȘ Û˘Ó¯›˜ Ì‹Ó˜. ∆Ô Â‡ÚËÌ· ·˘Ùfi ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈÎfi, ÁÈ·Ù› ·˘ÍË̤Ó˜ ÂȉfiÛÂȘ Û ٤ÙÔÈÔ˘ ›‰Ô˘˜ ÈηÓfiÙËÙ· Â›Ï˘Û˘ ÚÔ‚ÏËÌ¿ÙˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶ÈÛÙ‡ÂÙ·È, ·ÎfiÌË, fiÙÈ Ù· LCPUFAs ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ıÂÙÈο Î·È ÙËÓ Ù·¯‡ÙËÙ· ÂÂÍÂÚÁ·Û›·˜ ÏËÚÔÊÔÚÈÒÓ, ηıÒ˜ Î·È ÙȘ ‰È·‰Èηۛ˜ ÂϤÁ¯Ô˘ Ù˘ ÚÔÛÔ¯‹˜. ∂›Û˘, Ê·›ÓÂÙ·È fiÙÈ Ù· ÔʤÏË Ù˘ Û›ÙÈÛ˘ Ì LC-PUFAs ÂÈ̤ÓÔ˘Ó ¤Ú· ·fi ÙËÓ ÂÚ›Ô‰Ô Î·Ù¿ ÙËÓ ÔÔ›· Ù· ‚Ú¤ÊË ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï·. ¶¿ÓÙˆ˜, ÚÔ˜ ÙÔ ·ÚfiÓ, ·Ó Î·È ·Ó·Ê¤ÚÔÓÙ·È ·ÚÎÂÙ¿ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·, ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ÛÙÔȯ›· Ô˘ Ó· ÙÂÎÌËÚÈÒÓÔ˘Ó Ù· Ì·ÎÚÔÚfiıÂÛÌ· ÔʤÏË Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs Û¯ÂÙÈο Ì ÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿ (46,47). ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ì Á¿Ï·Ù· ÂÌÏÔ˘ÙÈṲ̂ӷ Ì LC-PUFAs ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó ¤Ï·È· „·ÚÈÒÓ Ô˘ ÂÚȤ¯Ô˘Ó DHA Î·È ¿ÏÏ· ˆ-3 §O. ™Â Ì›· ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜, fiÔ˘ ¯ÔÚËÁ‹ıËÎ·Ó ÌfiÓÔ ˆ-3 ÏÈ·Ú¿ Ôͤ·, ÚfiˆÚ· ‚Ú¤ÊË ˙‡ÁÈ˙·Ó ÏÈÁfiÙÂÚÔ ‹ ›¯·Ó ÌÈÎÚfiÙÂÚÔ ‚¿ÚÔ˜ Û ۯ¤ÛË Ì ÙÔ ‡„Ô˜ Û ‰È¿ÊÔÚ˜ ÂÚÈfi‰Ô˘˜ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, ·fi fi,ÙÈ ‚Ú¤ÊË ÛÈÙÈ˙fiÌÂÓ· Ì ·Ï¿, ÌË ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù·. ™Â ¿ÏϘ ÌÂϤÙ˜ Ì ¯ÔÚ‹ÁËÛË LC-PUFAs

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·17

¶·È‰È·ÙÚÈ΋ 2003;66:12-19

·fi ȯı˘¤Ï·È· ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ‰È·ÊÔÚ¿. ∂›Û˘, ÙÔ ‚¿ÚÔ˜ ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ∞∞ ÛÙ· ʈÛÊÔÏÈ›‰È· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (fiÛÔ ÌÂÁ·Ï‡ÙÂÚ· Â›Ó·È Ù· ÔÛ¿ ÙÔ˘ ∞A, ÙfiÛÔ ˘„ËÏfiÙÂÚÔ Â›Ó·È ÙÔ ‚¿ÚÔ˜ ÛÙÔ˘˜ 12 Ì‹Ó˜ ˙ˆ‹˜) (48). ¶¤Ú· ·fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ ȯı˘¤Ï·ÈÔ˘ Î·È ÙˆÓ ˆ-3 §O ÛÙËÓ ·Ó¿Ù˘ÍË, ÂÏ¿¯ÈÛÙ˜ Û˘Ó¤ÂȘ Ù˘ ¯ÔÚ‹ÁËÛ˘ LC-PUFAs ¤¯Ô˘Ó ·Ó·ÊÂÚı›. ŸÌˆ˜, ·ÚÎÂÙÔ› ıˆÚËÙÈÎÔ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ¤¯Ô˘Ó ÚÔ·„ÂÈ Û¯ÂÙÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· ÙˆÓ LC-PUFAs. ŒÓ·˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ·ÊÔÚ¿ ÛÙÔ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÔÏ˘·ÎfiÚÂÛÙˆÓ ÂÏ·›ˆÓ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë, ÁÈ·Ù› ÔÈ ÌÂÌ‚Ú¿Ó˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÎfiÚÂÛÙˆÓ §O Á›ÓÔÓÙ·È ÈÔ Â˘¿ÏˆÙ˜ Û ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë. ŒÙÛÈ, Ë ¯ÔÚ‹ÁËÛË LC-PUFAs ÌÔÚ› Ó· ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ÓfiÛÔ˘˜ ÓÂÔÁÓÒÓ Û¯ÂÙÈΤ˜ Ì ÔÍÂȉˆÙÈΤ˜ ‚Ï¿‚˜ ÌÂÌ‚Ú·ÓÒÓ, fiˆ˜ Â›Ó·È Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, Ë ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ ÙˆÓ ÓÂÔÁÓÒÓ, Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜. ∂›Û˘, ¯ÔÚ‹ÁËÛË ¯ˆÚ›˜ ηÏfi ÈÛÔ˙‡ÁÈÔ ÌÂٷ͇ ˆ-3 Î·È ˆ-6 LC-PUFAs ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·ÏÏÔ›ˆÛË ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÂÈÎÔÛ·ÓÔÂȉÒÓ. ŒÓ· ·ÎfiÌË ·ÚÓËÙÈÎfi ÛËÌÂ›Ô Â›Ó·È Ë Èı·Ó‹ ‰Ú¿ÛË ÙˆÓ ÂȉÈÎÒÓ LC-PUFAs ÛÙË ÌÂÙ·ÁÚ·Ê‹ ‰È·ÊfiÚˆÓ ÁÔÓȉ›ˆÓ (1). ŸÏÔÈ ÔÈ ·Ú·¿Óˆ ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ‚ÈÔÏÔÁÈΤ˜ ‰Ú¿ÛÂȘ ÙˆÓ §O. ŸÌˆ˜, Ù· ÛÙÔȯ›· Ô˘ ÙÔ˘˜ ˘ÔÛÙËÚ›˙Ô˘Ó Â›Ó·È ÂÏ¿¯ÈÛÙ·. ™Â Ì›· ÌÂϤÙË Ô˘ ¤ÁÈÓ ۯÂÙÈο Ì ÙËÓ Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜, ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ Î·È ÛË„·ÈÌ›·˜, ‰ÂÓ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ì ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË LC-PUFAs. ¶¿ÓÙˆ˜, Ë Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ Î·È ÛË„·ÈÌ›·˜ ‹Ù·Ó ÂÏ·ÊÚÒ˜ ˘„ËÏfiÙÂÚË ÛÙËÓ ÔÌ¿‰· Ô˘ ÛÈÙÈ˙fiÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· Ì LC-PUFAs. ™Â Ì›· ÚfiÛıÂÙË ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ Ë Â›ÙˆÛË ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË Û ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· Ì ʈÛÊÔÏÈ›‰È· ·fi ÎÚfiÎÔ ·˘ÁÔ‡, ¤Ó·ÓÙÈ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌË ÂÌÏÔ˘ÙÈṲ̂ӷ Á¿Ï·Ù· (49-51). ∂›Û˘, ¤¯Ô˘Ó ÚÔ·„ÂÈ ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ÂÓ Ì¤ÚÂÈ ·fi ÏÈ›‰È· ·˘ÁÔ‡. ∆Ô ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· ÂÚȤ¯ÂÈ ÔÏÏ·Ï¿ÛÈ· ÔÛ¿ ¯ÔÏËÛÙÂÚfiÏ˘ ·’ fiÙÈ ÙÔ ÎÔÈÓfi Á¿Ï·, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ ÚÔηϤÛÂÈ ·ÓËÛ˘¯›· Û¯ÂÙÈο Ì ÙȘ Èı·Ó¤˜ ÂÈÙÒÛÂȘ Ù˘ ÔÚ›·˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙËÓ ÚÒÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ·. ¶Ú¿ÁÌ·ÙÈ, ÛÂ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÌÂٷ͇ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Î·È ÎÔÈÓÔ‡ Á¿Ï·ÎÙÔ˜, ‚Ú¤ıËηÓ

Paediatriki 2003;66:12-19

·˘ÍË̤ӷ Â›‰· ¯ÔÏËÛÙÂÚfiÏ˘, ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ (∞-π, ∞-ππ, µ) ÙËÓ 5Ë Î·È 30‹ Ë̤ڷ ¯ÔÚ‹ÁËÛ˘. ™ÙË Û˘Ó¤¯ÂÈ·, fï˜, ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙÔ˘ ÂÓfi˜ Ì‹Ó· ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û‡ÓıÂÛË Î·È ÙÔ ÂÚȯfiÌÂÓÔ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È Èı·Ófi Ó· ÂÍËÁÔ‡ÓÙ·È Ì Ì˯·ÓÈÛÌÔ‡˜ ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ Û ۯ¤ÛË Ì ÙË ‰È·ÈÙËÙÈ΋ ÚfiÛÏË„Ë, Ú˘ıÌ›˙ÔÓÙ·˜ ·Ó¿ÏÔÁ· ÙËÓ ÂÓ‰ÔÁÂÓ‹ Û‡ÓıÂÛ‹ Ù˘ (52-56). ™˘ÌÂÚ¿ÛÌ·Ù· ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ÛÙÔȯ›· fiÙÈ ÙÔ ∞∞ Î·È ÙÔ DHA ÌÔÚ› Ó· Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ó¿Ù˘Í˘. ∂ȉÈÎfiÙÂÚ·, Ë ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ DHA. ™˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔ ·›Ì· ÙˆÓ ∞∞ Î·È DHA Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ¤Ó·ÓÙÈ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜, ÛÙË ‰È·ÓÔËÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÔÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÁÂÁÔÓfi˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· LC-PUFAs ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∆· ÔʤÏË ¯ÔÚ‹ÁËÛ˘ ÙˆÓ LC-PUFAs Â›Ó·È ÂÌÊ·Ó¤ÛÙÂÚ· ÛÙ· ÚfiˆÚ·, ·Ú¿ ÛÙ· ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË. ªÂϤÙ˜ Ì ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï· Ì LC-PUFAs ¤Ó·ÓÙÈ ÎÔÈÓÔ‡ Á¿Ï·ÎÙÔ˜, ‰Â›¯ÓÔ˘Ó ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘, Û fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÙˆÓ ÚfiˆÚˆÓ ΢ڛˆ˜ ‚ÚÂÊÒÓ, ÛÙË Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÙÔ˘˜ ηٿÛÙ·ÛË, ηıÒ˜ Î·È ÛÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. §ÔÁÈο, ı· ÌÔÚÔ‡Û·Ì ӷ ˘Ôı¤ÛÔ˘Ì fiÙÈ ÔÈ ÂȉڿÛÂȘ ÙˆÓ LC-PUFAs ı· Â›Ó·È Î·È Ì·ÎÚÔÚfiıÂÛ̘, fï˜, ÚÔ˜ ÙÔ ·ÚfiÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ÛÙÔȯ›· Ó· ÂȂ‚·ÈÒÓÔ˘Ó ·˘Ùfi ÙÔ Û˘Ì¤Ú·ÛÌ· (57,58). ¶¿ÓÙˆ˜, ı· ÌÔÚÔ‡Û·Ì ӷ ԇ̠̠ۯÂÙÈ΋ ·ÛÊ¿ÏÂÈ·, ÂÚÈÛÛfiÙÂÚÔ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÚfiˆÚ· ‚Ú¤ÊË, fiÙÈ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÂÓfi˜ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜ Ì LC-PUFAs ı· ›¯Â ÔÏÏ¿ Ó· ÚÔÛʤÚÂÈ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔÓ ÙÚfiÔ ÂÌÏÔ˘ÙÈÛÌÔ‡ ÙÔ˘ Á¿Ï·ÎÙÔ˜ Ì LC-PUFAs, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ˘¿Ú¯ÂÈ ÛˆÛÙfi ÈÛÔ˙‡ÁÈÔ ÌÂٷ͇ ˆ-3 Î·È ˆ-6 ÏÈ·ÚÒÓ ÔͤˆÓ. ∏ ÚÔÛı‹ÎË ÌfiÓÔ ˆ-3 LC-PUFAs ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ¯·ÌËÏfiÙÂÚË Û˘ÓÔÏÈ΋ ·Ó¿Ù˘ÍË, ¯·ÌËÏfiÙÂÚÔ ÏfiÁÔ ÙÔ˘ ‚¿ÚÔ˘˜ ÚÔ˜ ÙÔ ‡„Ô˜ Î·È ·Ó¿Ù˘ÍË ÔÌÈÏ›·˜ ÛÙÔ˘˜ 14 Ì‹Ó˜ ˙ˆ‹˜ Ô˘ ˘ÔÏ›ÂÙ·È. ∏ ȉ·ÓÈ΋ Û˘ÁΤÓÙÚˆÛË DHA Î·È Ë È‰·ÓÈ΋ ·Ó·ÏÔÁ›· ˆ-3 Î·È ˆ-6 LC-PUFAs ÛÙȘ ÌÂÌ‚Ú¿Ó˜ ÙÔ˘ Ó¢ÚÈÎÔ‡ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÁÓˆÛÙ¤˜, ÁÂÁÔÓfi˜ Ô˘ ÚÔηÏ› ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ Û¯ÂÙÈο Ì ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜. ÃÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÔ˘Ó ·ÎfiÌË ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Ù· LC-PUFAs ‰ÚÔ˘Ó ÛÙË ‚ÚÂÊÈ΋ ·Ó¿Ù˘ÍË.

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£ÂˆÚÂ›Ù·È ÛÎfiÈÌÔ Ó· ÚÔÛÙ›ıÂÓÙ·È Ù· ˆ-3 Î·È ˆ6 ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ ÛÙȘ ·Ó·ÏÔÁ›Â˜ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∞˘Ù¤˜ Â›Ó·È 10:1 ÁÈ· Ù· LA Î·È ALA Î·È 2:1 ÁÈ· Ù· AA Î·È DHA (59). ŒÙÛÈ, Ì›· ÈÛÔÚÚÔË̤ÓË Î·È ÚÔÛÂÎÙÈ΋ ÚÔÛı‹ÎË LCPUFAs ı· ÌÔÚÔ‡Û ӷ ÈηÓÔÔÈ‹ÛÂÈ ÙËÓ ·Ó¿ÁÎË ÙˆÓ ‚ÚÂÊÒÓ Û ÏÈ·Ú¿ Ôͤ·, ȉȷ›ÙÂÚ· ÙˆÓ ÚÔÒÚˆÓ Î·È ·˘ÙÒÓ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. º˘ÛÈο, Ô ÚfiÏÔ˜ ÙˆÓ LC-PUFAs ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ï‹Úˆ˜. ∞·ÈÙÔ‡ÓÙ·È ÂÈϤÔÓ ¤Ú¢Ó˜ ÒÛÙ ӷ ÙÂÎÌËÚȈı› Ë Â˘ÂÚÁÂÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ÚfiˆÚˆÓ Î·È ÙÂÏÂÈfiÌËÓˆÓ ‚ÚÂÊÒÓ, ηıÒ˜ Î·È ÔÈ È‰·ÓÈΤ˜ ·Ó·ÏÔÁ›Â˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Heird WC. The role of polyunsaturated fatty acids in term and preterm infants and breastfeeding mothers. Pediatr Clin North Am 2001;48:173-185.

2. Giovannini M, Riva E, Agostoni C. Fatty acids in pediatric nutrition. Pediatr Clin North Am 1995;42:861-877.

3. Voss A, Reinhart M, Sankarappa S, Sprecher H. The metabolism of 7,10,13,16,19-docosapentaenoic acid to 4,7,10,13,16,19-docosahexaenoic acid in rat liver is independent of a 4-desaturase. J Biol Chem 1991;266: 19995-20000.

4. Makrides M, Neumann MA, Byard RW, Simmer K, Gibson RA. Fatty acid composition of brain, retina, and erythrocytes in breast- and formula-fed infants. Am J Clin Nutr 1994;60:189-194.

5. Crawford MA, Costeloe K, Ghebremeskel K, Phylactos A. The inadequacy of the essential fatty acid content of present preterm feeds. Eur J Pediatr 1998;157 (Suppl 1):S23-S27.

6. Innis SM. Plasma and red blood cell fatty acid values as indexes of essential fatty acids in the developing organs of infants fed with milk or formulas. J Pediatr 1992;120:S78-86.

7. Decsi T, Thiel I, Koletzko B. Essential fatty acids in full term infants fed breast milk or formula. Arch Dis Child Fetal Neonatal Ed 1995;72:F23-F28.

8. Maurage C, Guesnet P, Pinault M, Rochette de Lempdes JB, Galent A, Durand G et al. Plasma and erythrocyte phospholipid fatty acids of term infants fed breast milk or formulas supplemented with docosahexaenoic acid (DHA).

J Pediatr Gastroenterol Nutr 1997;24:491.

9. Xiang ª, Zetterstrom R. Relation between polyunsaturated fatty acids and growth. Acta Paediatr 1999;88:78-82.

10. Agostoni C, Marangoni F, Bernardo L, Lammardo AM, Galli C, Riva E. Long-chain polyunsaturated fatty acids in human milk. Acta Paediatr 1999;88 (Suppl):68-71.

11. Jensen RG. The lipids in human milk. Prog Lipid Res 1996;35:53-92.

12. Hachey DL, Thomas MR, Emken EA, Garza C, Brown-Booth L, Adlof RO et al. Human lactation: maternal transfer of dietary triglycerides labeled with stable isotopes. J Lipid Res 1987;28:1185-1192.

13. Farquharson J, Cockburn F, Patrick WA, Jamieson EC, Logan RW. Infant cerebral cortex phospholipid fatty-acid composition and diet. Lancet 1992;340:810-813.

14. Agostoni C, Trojan S, Bellu R, Riva E, Bruzzese MG,

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15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Giovannini M. Developmental quotient at 24 months and fatty acid composition of diet in early infancy: a follow up study. Arch Dis Child 1997;76:421-424.

Koletzko B, Mrotzek M, Bremer HJ. Fatty acid composition of mature milk in Germany. Am J Clin Nutr 1988;47:954-959.

Makrides M, Neumann M, Simmer K, Pater J, Gibson R. Are long-chain polyunsaturated fatty acids essential nutrients in infancy? Lancet 1995;345:1463-1468.

Hamosh M, Salem N Jr. Long-chain polyunsaturated fatty acids. Biol Neonate 1998;74:106-120.

Crawford M. Placental delivery of arachidonic and docosahexaenoic acids: implications for the lipid nutrition of preterm infants. Am J Clin Nutr 2000;71:S275-S284.

Martinez M. Tissue levels of polyunsaturated fatty acids during early human development. J Pediatr 1992;120:S129138.

Clandinin MT, Chappell JE, Leong S, Heim T, Swyer PR, Chance GW. Intrauterine fatty acid accretion rates in human brain: implications for fatty acid requirements. Early Hum Dev 1980;4:121-124.

Zelczak G, Klowat B, Kramer M, Jacobs D, Lentze MJ. Psychomotor development of term infants receiving LCPUFA-enriched formula in a prospective, randomized, double blind study. J Pediatr Gastroenterol Nutr 1997; 24:492.

Carlson SE, Rhodes PG, Ferguson MG. Docosahexaenoic acid status of preterm infants at birth and following feeding with human milk or formula. Am J Clin Nutr 1986;44:798804.

Reynolds A. Breastfeeding and brain development. Pediatr Clin North Am 2001;48:159-169.

Carlson SE. Long-chain polyunsaturated fatty acids and development of human infants. Acta Paediatr Suppl 1999;88:72-77.

Koletzko B, Braun M. Arachidonic acid and early human growth: is there a relation? Ann Nutr Metab 1991;35:128-131.

Olsen SF, Hansen HS, Sorensen TI, Jensen B, Secher NJ, Sommer S et al. Intake of marine fat, rich in (n-3)polyunsaturated fatty acids, may increase birthweight by prolonging gestation. Lancet 1986;2:367-369.

Holman RT. The slow discovery of the importance of omega 3 essential fatty acids in human health. J Nutr 1998;128 (2 Suppl):S427-S433.

Innis SM. Essential fatty acids in growth and development.

Prog Lipid Res 1991;30:39-103.

Crawford MA, Doyle W, Drury P, Lennon A, Costeloe K, Leighfield M. n-6 and n-3 fatty acids during early human development. J Intern Med 1989;225 (Suppl):159-169.

Chirouze V, Lapillonne A, Putet G, Salle BL. Red blood cell fatty acid composition in low-birth-weight infants fed either human milk or formula during the first months of life. Acta Paediatr 1994;405 (Suppl):70-77.

Birch E, Birch D, Hoffman D, Hale L, Everett M, Uauy R. Breast-feeding and optimal visual development. J Pediatr Ophthalmol Strabismus 1993;30:33-38.

Carlson SE, Werkman SH, Rhodes PG, Tolley EA. Visualacuity development in healthy preterm infants: effect of marine-oil supplementation. Am J Clin Nutr 1993;58:35-42.

Gibson RA, Makrides M. Polyunsaturated fatty acids and

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·19

¶·È‰È·ÙÚÈ΋ 2003;66:12-19

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

infant visual development: a critical appraisal of randomised clinical trials. Lipids 1999;34:179-184.

Auestad N, Montalto MB, Hall RT, Fitzgerald KM, Wheeler RE, Connor WE et al. Visual acuity, erythrocyte fatty acid composition, and growth in term infants fed formulas with long chain polyunsaturated fatty acids for one year. Pediatr Res 1997;41:1-10.

Hoffman DR, Uauy R et al. Essentiality of dietary omega 3 fatty acids for premature infants: plasma and red blood cell fatty acid composition. Lipids 1992;27:886-895.

Carlson SE, Werkman SH. A randomised trial of visual attention of preterm infants fed docosahexaenoic acid until two months. Lipids 1996;31:85-90.

Makrides M, Simmer K, Goggin M, Gibson RA. Erythrocyte docosahexaenoic acid correlates with the visual response of healthy, term infants. Pediatr Res 1993;33:425-427.

Birch EE, Hoffman DR, Uauy R, Birch DG, Prestidge C. Visual acuity and the essentiality of docosahexaenoic acid and arachidonic acid in the diet of term infants. Pediatr Res 1998;44:201-209.

Carlson SE, Ford AJ, Werkman SH, Peeples JM, Koo WW. Visual acuity and fatty acid status of term infants fed human milk and formulas with and without docosahexaenoate and arachidonate from egg yolk lecithin. Pediatr Res 1996;39:882-888.

Lucas A, Stafford M, Morley R, Abbott R, Stephenson T, MacFadyen U et al. Efficacy and safety of long-chain polyunsaturated fatty acid supplementation of infantformula milk: a randomized trial. Lancet 1999;354:19481954.

Cogill SR, Caplan HL, Alexandra H, Robson KM, Kumar R. Impact of maternal postnatal depression on cognitive development of young children. Br Med J 1986;292:11651167.

Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr 1999;70:525-535.

Florey CD, Leech AM, Blackhall A. Infant feeding and mental and motor development at 18 months of age in first born singletons. Int J Epidemiol 1995;24 (Suppl 1):S21S26.

Doyle LW, Rickards AL, Kelly EA, Ford GW, Callanan C. Breastfeeding and intelligence [letter]. Lancet 1992; 339:744-745.

Birch EE, Garfield S, Hoffman DR, Uauy R, Birch DG. A randomized controlled trial of early dietary supply of longchain polyunsaturated fatty acids and mental development in term infants. Dev Med Child Neurol 2000;42:174-181.

Willatts P, Forsyth JS, DiModugno MK, Varma S, Colvin M. Effect of long-chain polyunsaturated fatty acids in infant formula on problem solving at 10 months of age. Lancet 1998;352:688-691.

Jacobson SW, Jacobson JL, O’Neill JM, Padgett RJ, Frankowski JJ, Bihun JT. Visual expectation and dimensions of infant information processing. Child Dev 1992;63:711-724.

Paediatriki 2003;66:12-19

48. Carlson SE, Cooke RJ, Werkman SH, Tolley EA. First year growth of preterm infants fed standard compared to marine oil n-3 supplemented formula. Lipids 1992;27:901-907.

49. Carlson SE, Montalto MB, Ponder DL, Werkman SH, Korones SB. Lower incidence of necrotizing enterocolitis in infants fed a preterm formula with egg phospholipids.

Pediatr Res 1998;44:491-498.

50. Uauy R, Hoffman DR, Birch EE, Birch DG, Jameson DM, Tyson J. Safety and efficacy of omega-3 fatty acids in the nutrition of very low birth weight infants: soy oil and marine oil supplementation of formula. J Pediatr 1994;124:612-620.

51. Auestad N, Montalto MB, Hall RT, Fitzgerald KM, Wheeler RE, Connor WE et al. Visual acuity, erythrocyte fatty acid composition, and growth in term infants fed formulas with long chain polyunsaturated fatty acids for one year. Pediatr Res 1997;41:1-10.

52. Decsi T, Fekete M, Koletzko B. Plasma lipid and apolipoprotein concentrations in full term infants fed formula supplemented with long-chain polyunsaturated fatty acids and cholesterol. Eur J Pediatr 1997;156:397-400.

53. Akeson PM, Axelsson IE, Raiha NC. Plasma lipids and apolipoproteins in breastfed and formula-fed Swedish infants. Acta Paediatr 1999;88:1-6.

54. Kallio MJ, Salmenpera L, Siimes MA, Perheentupa J, Miettinen TA. Exclusive breast-feeding and weaning: effect on serum cholesterol and lipoprotein concentrations in infants during the first year of life. Pediatrics 1992;89:663666.

55. Salo P, Viikari J, Ronnemaa T, Hamalainen M, Jokinen E, Valimaki I et al. Milk type during mixed feeding: contribution to serum cholesterol ester fatty acids in late infancy. J Pediatr 1997;130:110-116.

56. Wong WW, Hachey DL, Insull W, Opekun AR, Klein PD. Effect of dietary cholesterol on cholesterol synthesis in breast-fed and formula-fed infants. J Lipid Res 1993;34:1403-1411.

57. Decsi T, Koletzko B. Polyunsaturated fatty acids in infant nutrition. Acta Paediatr 1994;83 (Suppl):31-37.

58. Koletzko B, Thiel I, Abiodun PO. The fatty acid composition of human milk in Europe and Africa. J Pediatr 1992; 120:S62-S70.

59. Clark KJ, Makrides M, Neumann MA, Gibson RA. Determination of the optimal ratio of linoleic acid to alphalinolenic acid in infant formulas. J Pediatr 1992;120:S151S158.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-12-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆ¿ÓÓ· ÷ڈӛÙË ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, µÂÓÈ˙¤ÏÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô ∏Ú¿ÎÏÂÈÔ, ∫Ú‹ÙË

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ORIGINAL ARTICLE

T· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ˆ˜ ·ÈÙ›· ·È‰ÈÎÒÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ, ·ÏÏ¿ Û·Ó›ˆ˜ ÂÁη˘Ì¿ÙˆÓ ∂. ¶ÂÙÚ›‰Ô˘1,2, ¡. ª. ∞ϤÍÂ1, º. ¶··‰fiÔ˘ÏÔ˜1, ¢. ∆ÚȯfiÔ˘ÏÔ˜1,2

Central heating devices cause childhood injuries but rarely burns E. Petridou1,2, D. M. Alexe1, F. Papadopoulos1, D. Trichopoulos1,2

¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· (ηÏÔÚÈʤÚ) Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ë ¤ÎÙ·ÛË Î·È Ê‡ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È Ë ÚfiÙ·ÛË ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ. ÃÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰Â‰Ô̤ӷ ·fi ÙË ‚¿ÛË EDISS (Emergency Department Injury Surveillance System) Ô˘ ·ÊÔÚÔ‡Û·Ó Û ·Ù˘¯‹Ì·Ù· Ù˘ ÂÚÈfi‰Ô˘ 1996-1998, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Û ٤ÛÛÂÚ· ÌÂÁ¿Ï· ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· Ù˘ ¯ÒÚ·˜. ∏ ·ÚÔ‡Û· ÌÂϤÙË Û˘ÌÂÚȤϷ‚ ÂÚÈÛÙ·ÙÈο 533 ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 14 ÂÙÒÓ. ø˜ ÔÌ¿‰· ÂϤÁ¯Ô˘ ıˆڋıËÎ·Ó 21.865 ·È‰È¿ Ô˘ ˘¤ÛÙËÛ·Ó ¿ÏÏÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ. OÈ ·ÓÔȯ٤˜ ηÎÒÛÂȘ Ù˘ ÎÂÊ·Ï‹˜ ‹Ù·Ó Ô Û˘¯ÓfiÙÂÚÔ˜ Ù‡Ô˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡, ÂÓÒ ÌfiÓÔ 8 ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ ˘¤ÛÙËÛ·Ó ¤Áη˘Ì· ·fi Â·Ê‹ Ì ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·. ∆Ô 63% ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ·ÊÔÚÔ‡Û Û ·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ, ÂÓÒ ÙÔ 65% ·ÊÔÚÔ‡Û Û ·ÁfiÚÈ·. ¢‡Ô ‹Ù·Ó ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Ô˘ ÙÚ·˘Ì·Ù›˙ÔÓÙ·Ó ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·: Ë Ì›· ·ÊÔÚÔ‡Û Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (10-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ (΢ڛˆ˜ ηٿÁÌ·Ù·, ÂÍ·ÚıÚ‹Ì·Ù· Î·È ‰È·ÛÙÚ¤ÌÌ·Ù· ¿ÎÚˆÓ) Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ, ÂÓÒ Ë ‰Â‡ÙÂÚË Û˘ÌÂÚÈÏ¿Ì‚·Ó ·È‰È¿ οو ÙˆÓ 4 ÂÙÒÓ, Ù· ÔÔ›· ÙÚ·˘Ì·Ù›˙ÔÓÙ·Ó ÌÂÙ¿ ·fi ÙÒÛË ·fi ‡„Ô˜ ÛÙÔ ¯ÒÚÔ Ù˘ ÎÔ˘˙›Ó·˜ ‹ ÙÔ˘ ηıÈÛÙÈÎÔ‡, ·Ú’ fiÏÔ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ˘fi ÙËÓ ÂÈÙ‹ÚËÛË ÂÓËϛΈÓ. ∂Áη‡Ì·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ·ÔÎÏÂÈÛÙÈο ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰· ·È‰ÈÒÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Ô˘ ÔÊ›ÏÔÓÙ·È Û ıÂÚÌ·ÓÙÈο

Abstract: This research aimed to identify the magnitude, nature and risk factors of childhood injuries related to central heating devices in Greece and to propose preventive strategies. We used data recorded by the Emergency Department Injury Surveillance System (EDISS) over a three-year period (1996-1998) in four major pediatric hospitals across the country. The case group comprised of five hundred and thirty-three children less than 14 years-old, while 21865 children with other indoor injuries were used as controls. Open wounds of the head were the most common injuries and only eight children sustained burn injuries due to these devices. Sixty-three percent of central heating device related injuries were noted among children less than five years-old with a significant male preponderance (65%). Of the clusters identified, two are the most important: the first refers to older children (10-14 years old), who frequently sustain central heating device related injuries (mainly fractures, dislocations and strains of the limbs) in educational buildings. The second cluster includes children less than 4 years old who suffer injuries mainly falls from height - in the kitchen as well as the living room and bedroom despite recorded supervision. Burns were noted exclusively in this group. As a conclusion, injuries related to central heating devices represent a small, but not negligible, fraction of all indoor injuries. Prevention strategies pertain mainly to modifications of the product design or safer use of it and improvements in building design.

1 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ∆Ì‹Ì· ∂ȉËÌÈÔÏÔÁ›·˜, ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜, ¶·ÓÂÈÛÙ‹ÌÈÔ Harvard, ∏¶∞

1 Department of Hygiene and Epidemiology, University of Athens Medical School 2 Department of Epidemiology, Harvard School of Public Health, USA

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ÛÒÌ·Ù· ·ÔÙÂÏÔ‡Ó ÌÈÎÚfi, ·ÏÏ¿ fi¯È ·ÌÂÏËÙ¤Ô ÎÏ¿ÛÌ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. ∆· ̤ÙÚ· ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ Û˘Ó›ÛÙ·ÓÙ·È Î˘Ú›ˆ˜ Û ÙÚÔÔÔ›ËÛË ÙÔ˘ ۯ‰ȷÛÌÔ‡ ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ‹ Î·È ÙˆÓ ÎÙÈÚÈ·ÎÒÓ ˘Ô‰ÔÌÒÓ. §¤ÍÂȘ ÎÏÂȉȿ: ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ηÏÔÚÈʤÚ, ·Ù‡¯ËÌ·, ÙÚ·˘Ì·ÙÈÛÌfi˜, ·È‰›.

Key words: central heating device, childhood injury, safety modifications.

™˘ÓÙÔÌÔÁڷʛ˜

ÂÚÈÛÛfiÙÂÚ˜ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙ· ÂÁη‡Ì·Ù· Ô˘ ÌÔÚ› Ó· ÚÔÎÏËıÔ‡Ó ·fi ÙȘ ÂÁηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ (3-6). ∏ Û˘¯ÓfiÙËÙ·, Ë ‚·Ú‡ÙËÙ· Î·È Ë ¤Î‚·ÛË ¿ÏÏˆÓ Ù‡ˆÓ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·fi Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› Â·ÚÎÒ˜. °È· Ó· ˘ÔÏÔÁÈÛÙ› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ·È‰È¿ Î·È Ó· ÌÂÏÂÙËıÔ‡Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ ·˘ÙÒÓ, ¯ÚËÛÈÌÔÔÈ‹ıËΠ̛· ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ 300.000 ¿ÙÔÌ· Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó Û ÙÌ‹Ì·Ù· ∂ÂÈÁfiÓÙˆÓ ¶ÂÚÈÛÙ·ÙÈÎÒÓ ÂÓfi˜ ‰ÈÎÙ‡Ô˘ Û˘ÓÂÚÁ·˙fiÌÂÓˆÓ ÓÔÛÔÎÔÌ›ˆÓ, ¤¯ÔÓÙ·˜ ˘ÔÛÙ› ÙÚ·˘Ì·ÙÈÛÌfi.

EDISS ∫∂¶¶∞ EHLASS NOMESCO ICD9

Emergency Department Injury Surveillance System ∫¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ ∞Ù˘¯ËÌ¿ÙˆÓ The European Home and Leisure Accidents Surveillance System Nordic Medico - Statistical Committee International Classification of Diseases 9th rev.

∂ÈÛ·ÁˆÁ‹ O ۯ‰ȷÛÌfi˜ ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο ηٿ ÙÔÓ ÙÂÏÂ˘Ù·›Ô ·ÈÒÓ·, fiÛÔÓ ·ÊÔÚ¿ ÙfiÛÔ ÛÙËÓ ·ÛÊ¿ÏÂÈ· fiÛÔ Î·È ÛÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘˜. ∆· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ¤¯Ô˘Ó ϤÔÓ ·ÓÙÈηٷÛÙ‹ÛÂÈ ıÂÚÌ·ÓÙÈΤ˜ ËÁ¤˜ fiˆ˜ ÙÔ Ù˙¿ÎÈ Î·È Ë ÛfiÌ· ͇ÏÔ˘, ‚ÂÏÙÈÒÓÔÓÙ·˜ ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ÌÂÈÒÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ˘ÚηÁÈ¿˜. §fiÁˆ ÙÔ˘ ‡ÎÚ·ÙÔ˘ Îϛ̷ÙÔ˜ Ù˘ ¯ÒÚ·˜ Ì·˜, Ë ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ ÛÙÔ Û›ÙÈ Â›Ó·È ·Ó·Áη›· ÌfiÓÔ ÁÈ· Ù¤ÛÛÂÚȘ Ì‹Ó˜ ÙÔ ¯ÚfiÓÔ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ‰È·ÌÂÚ›ÛÌ·Ù· Ù˘ ¯ÒÚ·˜. ∆· ÎÏ·ÛÈο Ù˙¿ÎÈ· ‰ÂÓ ·ÔÙÂÏÔ‡Û·Ó ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ˘ÚηÁÈ¿˜, ηıÒ˜ Ù· ÂÚÈÛÛfiÙÂÚ· Û›ÙÈ· ‹Ù·Ó ¯ÙÈṲ̂ӷ Ì ÌË Â‡ÊÏÂÎÙ· ˘ÏÈο, fiˆ˜ ¤ÙÚ˜ Î·È ÙÔ‡‚Ï·. ª¤¯ÚÈ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960, fï˜, ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ı·Ó·ÙËÊfiÚˆÓ ÂÚÈÙÒÛÂˆÓ ‰ËÏËÙËÚ›·Û˘ ·fi ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη ηٷÁÚ¿ÊÔÓÙ·Ó Î¿ı ¯ÚfiÓÔ. ™ÙȘ ̤Ú˜ Ì·˜, Ù· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÔÙÂÏÔ‡Ó ÙÔ Î‡ÚÈÔ Ì¤ÛÔ ı¤ÚÌ·ÓÛ˘, ÂÓÒ ÛÙ·‰È·Î¿ ÂÈÛ¿ÁÂÙ·È Î·È Ë ¯Ú‹ÛË ÎÂÓÙÚÈÎÒÓ ÎÏÈÌ·ÙÈÛÙÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ. ∞Ó Î·È Ù· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ıˆÚÔ‡ÓÙ·È ·ÚÎÂÙ¿ ·ÛÊ·Ï‹, ÌÂϤÙ˜ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 ¤‰ÂÈÍ·Ó fiÙÈ ÂÁη‡Ì·Ù· Î·È ¿ÏÏÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› Û˘Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙË ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ (1,2). øÛÙfiÛÔ, Ï›Á˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂÎÔÓËı› Ì ÁÓÒÌÔÓ· ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ·fi ÙË ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ÂÓÒ ÔÈ

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆Ô ∫¤ÓÙÚÔ ŒÚ¢ӷ˜ Î·È ¶ÚfiÏ˄˘ ¶·È‰ÈÎÒÓ ∞Ù˘¯ËÌ¿ÙˆÓ (∫∂¶¶∞) ȉڇıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ ÛÙÔ ∆Ì‹Ì· ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ Ù˘ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË Î·È ÚfiÏË„Ë ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™Â Û˘ÓÂÚÁ·Û›· Ì ٤ÛÛÂÚ· ÌÂÁ¿Ï· ÓÔÛÔÎÔÌ›· Ù˘ ¯ÒÚ·˜, ¤¯ÂÈ ·Ó·Ù˘¯ı› Î·È ‰È·ÙËÚÂ›Ù·È ·fi ÙÔ ∫∂¶¶∞ Ì›· ÌÂÁ¿ÏË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ (Emergency Department Injury Surveillance System-EDISS), Ë ÔÔ›· ηχÙÂÈ fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ÁÈ· fiϘ ÙȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜. ¢‡Ô ·fi Ù· Ù¤ÛÛÂÚ· ÓÔÛÔÎÔÌ›·, ÙÔ ¶·ÓÂÈÛÙËÌÈ·Îfi ¶·È‰È·ÙÚÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” Î·È ÙÔ ¡ÔÛÔÎÔÌÂ›Ô ∞Ù˘¯ËÌ¿ÙˆÓ “∞ÛÎÏËÈ›Ԕ µÔ‡Ï·˜, ÂÓÙÔ›˙ÔÓÙ·È ÛÙËÓ Â˘Ú‡ÙÂÚË ÂÚÈÔ¯‹ ÙˆÓ ∞ıËÓÒÓ. ∆· ¿ÏÏ· ‰‡Ô ÓÔÛÔÎÔÌ›· ‚Ú›ÛÎÔÓÙ·È ÂÎÙfi˜ ∞ıËÓÒÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔ µfiÏÔ (“¡Ô̷گȷÎfi ¡ÔÛÔÎÔÌÂ›Ô ª·ÁÓËÛ›·˜”) Î·È ÛÙËÓ ∫¤Ú΢ڷ (“¡Ô̷گȷÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫¤Ú΢ڷ˜”). ∏ ‚¿ÛË Î·Ï‡ÙÂÈ fiÏ· Ù· ÂÚÈÛÙ·ÙÈο ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÛÙÔ ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙˆÓ Û˘ÓÂÚÁ·˙fiÌÂÓˆÓ ÓÔÛÔÎÔÌ›ˆÓ ÙËÓ ÂÚ›Ô‰Ô 1996-1998. ∂ȉÈο ÂÎ·È‰Â˘Ì¤Ó˜ ÂÈÛΤÙÚȘ ˘Á›·˜ ‹Ú·Ó ÚÔÛˆÈο Û˘Ó¤ÓÙ¢ÍË ·fi ÙÔ ·È‰› Î·È ÙÔ Û˘ÓÔ‰fi ÙÔ˘, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ¤Ó· ÚÔ-Έ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, Û˘ÏϤÁÔÓÙ·˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÎÔÈÓˆÓÈο Î·È ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Î·È ÙȘ ÏÂÙÔ̤ÚÂȘ ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡. ∏ ÂÈÏÔÁ‹ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ¤ÁÈÓ Ì ÎÚÈÙ‹ÚÈÔ ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ıÂÚÌ·ÓÙÈÎÔ‡ ÛÒÌ·ÙÔ˜ ‹ ÙÔ˘ ۈϋӷ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ı¤ÚÌ·ÓÛ˘ ÛÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜. °È· ÙËÓ

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Paediatriki 2003;66:20-28

¶›Ó·Î·˜ 1. ∫·Ù·ÓÔÌ‹ ÙˆÓ 22.398 ·È‰ÈÒÓ (0-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ÛÙÔ EDISS, ÁÈ· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÙÚÈÒÓ ÂÙÒÓ (1996-1998) ˆ˜ ÚÔ˜ ÙȘ ‰È¿ÊÔÚ˜ ÌÂÙ·‚ÏËÙ¤˜ ªÂÙ·‚ÏËÙ‹

¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ∏ÏÈΛ· (¤ÙË) 0-4 5-9 10-14 º‡ÏÔ ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË °ÂˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ∞ı‹Ó· ∞ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜ ÷ڷÎÙËÚÈÛÙÈο ·Ù˘¯‹Ì·ÙÔ˜ ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∏̤ڷ ∫·ıËÌÂÚÈÓ‹ ™·‚‚·ÙÔ·ÚÈ·ÎÔ ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ªË¯·ÓÈÛÌfi˜ οΈÛ˘ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ·fi Û‡ÁÎÚÔ˘ÛË/ ÛÚÒÍÈÌÔ ·fi ÙÚ›ÙÔ ¿ÙÔÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ÷ڷÎÙËÚÈÛÙÈο Ù˘ οΈÛ˘ ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜ ∫·Ì›· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹

22

∞Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· No %

ÕÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ No %

∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘

0,001 335 144 54

62,9 27,0 10,1

12814 5575 3476

58,6 25,5 15,9

346 187

64,9 35,1

12549 9316

57,4 42,6

514 19

96,4 3,6

20834 1031

95,3 4,7

449 84

84,2 15,8

18473 3392

84,5 15,5

0,001

0,21

0,88

0,001 177 164 44 54 94

33,2 30,8 8,3 10,1 17,6

5664 6768 3539 3253 2641

25,9 30,9 16,2 14,9 12,1

439 94

82,4 17,6

18405 3460

84,2 15,8

387 146

72,6 27,4

15470 6395

70,7 29,3

0,26

0,35

0,001 191

35,8

9619

44,0

342

64,2

12246

56,0

109

20,5

5946

27,2

190

35,6

4659

21,3

66 145 8 15

12,4 27,2 1,5 2,8

1097 3513 1026 5624

5,0 16,1 4,7 25,7

374 159

70,2 29,8

14488 7377

66,3 33,7

412 78 11 3 7 8 0 14

77,3 14,6 2,1 0,6 1,3 1,5 0,0 2,6

7325 5581 1855 1972 583 1111 1542 1896

33,5 25,5 8,5 9,0 2,7 5,1 7,0 8,7

279

52,3

4523

20,7

0,001

0,06

0,001

0,001

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¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ∞ÚÈıÌfi˜ ηÎÒÛÂˆÓ ª›· ¶ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ŒÎ‚·ÛË ÃˆÚ›˜ ıÂÚ·›· £ÂÚ·›· ¯ˆÚ›˜ ·Ú·ÎÔÏÔ‡ıËÛË £ÂÚ·›· Ì ·Ú·ÎÔÏÔ‡ıËÛË ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë £¿Ó·ÙÔ˜

Paediatriki 2003;66:20-28

186 58 10

34,9 10,9 1,9

6630 8270 2442

30,3 37,8 11,2

508 25

95,3 4,7

19625 2240

89,8 10,2

52 70 407 4 0

9,8 13,1 76,4 0,7 0,0

5017 5902 9205 1733 4

23,0 27,0 42,2 7,8 0,0

0,001

0,001

¿ÓÙÏËÛË ‰Â‰ÔÌ¤ÓˆÓ Û¯ÂÙÈÎÒÓ Ì ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÂÍ‹˜ ÎÒ‰ÈΘ: ·fi ÙË ‚¿ÛË EDISS 11-15, 38, 51, 53, 55, 60, 62 ÁÈ· ÙÔÓ ÙfiÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, 20220, 20230 ÁÈ· ÙÔ ÂÌÏÂÎfiÌÂÓÔ ·ÓÙÈΛÌÂÓÔ, ·fi ÙÔ ÂÁ¯ÂÈÚ›‰ÈÔ Îˆ‰ÈÎÔÔ›ËÛ˘ ÙÔ˘ European Home and Leisure Accidents Surveillance System (EHLASS-1986) (7) 1382, 2041 ÁÈ· ÙÔ ÂÌÏÂÎfiÌÂÓÔ ·ÓÙÈΛÌÂÓÔ, ·fi ÙËÓ ∆·ÍÈÓfiÌËÛË ∂͈ÙÂÚÈÎÒÓ ∞ÈÙ›ˆÓ ∆Ú·˘Ì·ÙÈÛÌÔ‡ Ù˘ NOMESCO (8) Î·È Ù¤ÏÔ˜, ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ÎÒ‰ÈΘ ÙÔ˘ ICD-9 (9). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ Ù˘ ÌÂϤÙ˘, ÛÙË ‚¿ÛË EDISS ηٷÁÚ¿ÊËÎ·Ó 22.398 ·È‰È¿ Ô˘ ›¯·Ó ·Ù˘¯‹Ì·Ù· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ. ∆· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ÂÓÂÏ¿ÎËÛ·Ó Û 533 ÂÚÈÙÒÛÂȘ. ∆· ÛÙÔȯ›· ·˘Ù¿ Â›Ó·È ÂÚÈÁÚ·ÊÈο Î·È ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È Û ηıÔÚÈṲ̂ӷ ÚfiÙ˘· ¯ÚÔÓÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜-¤ÎıÂÛ˘, ÌÔÚÔ‡Ó ˆÛÙfiÛÔ Ó· ·Ó·Ï˘ıÔ‡Ó ˆ˜ ÌÂϤÙË ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ. ∫·Ù¿ Û˘Ó¤ÂÈ·, ·ÛıÂÓ›˜ ıˆÚÔ‡ÓÙ·È Ù· ·È‰È¿ Ì ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Î·È Ì¿ÚÙ˘Ú˜ Ù· ˘fiÏÔÈ· 21.865 ·È‰È¿ Ì ¿ÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ (10). ∏ ·Ú¯È΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ·Ϥ˜ ÈÓ·ÎÔÔÈ‹ÛÂȘ ÙˆÓ ÛÙÔȯ›ˆÓ. ∞ÎÔÏÔ‡ıˆ˜, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜, ¤Ó· ·Ù‡¯ËÌ· Ó· ÔÊ›ÏÂÙ·È Û ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹ fi¯È ·Ó¿ÏÔÁ· ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÙÈ̤˜ ÙˆÓ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙÒÓ, ˘ÔÏÔÁ›ÛÙËΠ̠ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË. ∆Ô ÚÔÊ›Ï ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ηıÔÚ›ÛÙËΠÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ÛÙÔȯ›ˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÛÙ·ÙÈÛÙÈÎfi ÏÔÁÈÛÌÈÎfi SAS (11).

∞ÔÙÂϤÛÌ·Ù· ∆· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‚Ú¤ıËΠfiÙÈ Â›Ó·È ˘‡ı˘Ó· ÁÈ· ÙÔ 2,4% fiÏˆÓ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. øÛÙfiÛÔ, ÌfiÏȘ 8 ·fi Ù· 533 ·È‰È¿ Ô˘ ÙÚ·˘Ì·Ù›ÛÙËÎ·Ó ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ˘¤ÛÙËÛ·Ó ¤Áη˘Ì·, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÔÈ Û˘Û΢¤˜ ·˘Ù¤˜ Û˘ÓÈÛÙÔ‡Ó Î›Ó‰˘ÓÔ ÁÈ· ·Ù˘¯‹Ì·Ù· ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ȉÈfiÙËÙ¤˜ ÙÔ˘˜ ˆ˜ ÛÒÌ·Ù· Ô˘ ηٷϷ̂¿ÓÔ˘Ó ¯ÒÚÔ Ì¤Û· ÛÙÔ Û›ÙÈ, ·Ú¿ ˆ˜ ·ÓÙÈΛÌÂÓ· Ô˘ ÂÎ¤ÌÔ˘Ó ıÂÚÌfiÙËÙ·. ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ Î·Ù·ÓÔ̤˜

ÙˆÓ ·È‰ÈÒÓ Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹Ù·Ó Ë ·ÈÙ›· ÙÔ˘ ÙÚ·˘Ì·ÙÈÛÌÔ‡ ‹ fi¯È, Û ۯ¤ÛË Ì ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ÛÙÔȯ›· ÙÔ˘ ÙfiÔ˘ Ô˘ ¤ÁÈÓ ÙÔ ·Ù‡¯ËÌ·, ·ÏÏ¿ Î·È Û ۯ¤ÛË Ì ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi. OÈ Û˘ÁÎÚ›ÛÂȘ ÛÙÔÓ ›Ó·Î· ·˘Ùfi ‚·Û›˙ÔÓÙ·È ÛÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ηٷÓÔ̤˜ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ·È‰ÈÒÓ Î·È Â͢ËÚÂÙÔ‡Ó ÙËÓ ÂÚÈÁÚ·Ê‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·Ú¿ ÙËÓ ·Ó¿Ï˘Û‹ ÙÔ˘˜, ηıÒ˜ ‰ÂÓ ¤¯Ô˘Ó ÏËÊı› ˘’ fi„ÈÓ ·ÌÔÈ‚·›ÔÈ Û˘Á¯˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ¶·Ú·ÙËÚÂ›Ù·È Ì›· ‰˘Û·Ó¿ÏÔÁË Û˘ÁΤÓÙÚˆÛË ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, Û ۯ¤ÛË Ì ٷ ¿ÏÏ· ·Ù˘¯‹Ì·Ù· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘, ÛÙ· ·È‰È¿ Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜ Î·È ÛÙ· ·ÁfiÚÈ·, ÂÓÒ Ë ÂıÓÈÎfiÙËÙ· Î·È Ë ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ‰ÂÓ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙȘ Û˘Óı‹Î˜ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ‰ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË Ô‡Ù Ì ÙËÓ ÒÚ· ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜ Ô‡Ù Ì ÙËÓ Ë̤ڷ Ù˘ ‚‰ÔÌ¿‰·˜. ™¯Â‰fiÓ Ù· ‰‡Ô ÙÚ›Ù· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û˘Ó¤‚ËÛ·Ó ÛÙÔ Î·ıÈÛÙÈÎfi ÙÔ˘ ÛÈÙÈÔ‡ ‹ ÙËÓ ÎÚ‚·ÙÔο̷ڷ, ÂȉÈο ÛÙ· ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜ ·È‰È¿, ÂÓÒ Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ê·›ÓÂÙ·È fiÙÈ ˘Ê›ÛÙ·ÓÙ·È Ù· ·Ù˘¯‹Ì·Ù· ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ Û˘¯ÓfiÙÂÚ· Û ÂÎ·È‰Â˘ÙÈÎÔ‡˜ ¯ÒÚÔ˘˜.

OÈ Û˘Û¯ÂÙ›ÛÂȘ ·˘Ù¤˜ ·ÓÙ·Ó·ÎÏÔ‡Ó Èı·ÓÒ˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ Ù‡Ô˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ∏ ›‰È· ˘fiıÂÛË ÌÔÚ› Ó· ‰È·Ù˘ˆı› Î·È ÁÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ ηٿ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘, fiÔ˘ ÔÈ Â͈ÙÂÚÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ·Ú·ÎˆÏ‡ÔÓÙ·È ·fi ÙȘ ηÈÚÈΤ˜ Û˘Óı‹Î˜. ª¿ÏÈÛÙ·, Ë Âԯȷ΋ ·˘Ù‹ ‰È·Î‡Ì·ÓÛË Â›Ó·È ÈÛ¯˘ÚfiÙÂÚË ÁÈ· Ù· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·.

O ÈÔ Û˘¯Ófi˜ Ì˯·ÓÈÛÌfi˜ οΈÛ˘ ÛÙ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Â›Ó·È ÙÔ ·Ú·¿ÙËÌ· ‹ ÙÔ ÁÏ›ÛÙÚËÌ· Î·È Ë Â·ÎfiÏÔ˘ıË Û‡ÁÎÚÔ˘ÛË Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·. ª¿ÏÈÛÙ·, ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ˘‹Ú¯Â ÂȂϤˆÓ ÂÓ‹ÏÈη˜ ÛÙÔ ¯ÒÚÔ ÙÔ˘ ·Ù˘¯‹Ì·ÙÔ˜, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÔÈ ÂȂϤÔÓÙ˜ Â›Ó·È Ì¿ÏÏÔÓ ·Ó˘Ô„›·ÛÙÔÈ

23

JAN-FEB-03

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14:37

™ÂÏ›‰·24

¶·È‰È·ÙÚÈ΋ 2003;66:20-28

Paediatriki 2003;66:20-28

¶›Ó·Î·˜ 2. ™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™.∫.) Î·È 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (O.∞.) ÁÈ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ۯ¤ÛË Ì ÙȘ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙ¤˜ ÌÂÙ¿ ·fi ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·ÏÁÔÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË ªÂÙ·‚ÏËÙ‹

∫·ÙËÁÔÚ›· ‹ ÚÔÛ·‡ÍËÛË

∏ÏÈΛ· º‡ÏÔ

5 ¤ÙË ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ªË¯·ÓÈÛÌfi˜ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ÌÂÙ¿ ·fi Û‡ÁÎÚÔ˘ÛË/ÛÚÒÍÈÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂Ó·ÏÏ·ÎÙÈ΋ ÚÔÛı‹ÎË ÌÂÙ·‚ÏËÙÒÓ ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜/η̛· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹ ¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë Ÿ¯È ¡·È

™.∫.

0,70 ¶.∞.* 0,79 ¶.∞.* 0,85 ¶.∞.* 1,23 ¶.∞.* 1,31 0,99 ¶.∞.* 0,62 0,72 1,20 ¶.∞.* 0,77 0,45 ¶.∞.* 1,51 1,08 0,23 0,07 3,77 ¶.∞.* 0,44 0,21 0,84 0,27 0,48

7,60 2,83 1,19 ¶.∞.* ¶.∞.* 0,19

95% O.∞.

∆ÈÌ‹ ÎÚÈÙËÚ›Ô˘

0,61

0,80

0,001

0,66

0,95

0,01

0,53

1,35

0,49

0,98

1,55

0,08

1,09

1,58

0,003

0,80

1,24

0,97

0,44 0,52 0,91

0,88 0,98 1,60

0,008 0,04 0,19

0,64 0,35

0,94 0,57

0,01 0,0001

1,11 0,87 0,11 0,04

2,05 1,36 0,49 0,12

0,009 0,48 0,0001 0,0001

2,94

4,83

0,0001

0,23 0,07 0,38 0,004 0,27

0,84 0,69 1,84 20,26 0,86

0,01 0,01 0,66 0,55 0,01

3,94 1,46 0,60

14,68 5,49 2,35

0,0001 0,002 0,61

0,07

0,52

0,001

*¶.∞.: ¶ÏËı˘ÛÌfi˜ ·Ó·ÊÔÚ¿˜

Û¯ÂÙÈο Ì ÙÔÓ Î›Ó‰˘ÓÔ ·Ù˘¯‹Ì·ÙÔ˜ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Î·È ¤ÙÛÈ ‰ÂÓ ÂÛÙÈ¿˙Ô˘Ó ÙËÓ ÚÔÛÔ¯‹ ÙÔ˘˜ Û ·˘Ù¿. ™¯ÂÙÈο Ì ÙȘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi, ‚Ú¤ıËΠfiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Â›Ó·È ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔ ÚfiÛˆÔ. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ (ÂÚ›Ô˘ 75%) ¯Ú‹˙ÂÈ ıÂÚ·›·˜ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ Â›Ó·È ·ÚÎÂÙ¿ ÛÔ‚·Ú¿. ∂ÓÙÔ‡ÙÔȘ, Û˘Ó‹ıˆ˜ ‰ÂÓ ··ÈÙÔ‡Ó ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ‰ÂÓ Â›Ó·È ·ÂÈÏËÙÈο ÁÈ· ÙË ˙ˆ‹. ™ÙÔÓ ¶›Ó·Î· 2, ÌÂÙ¿ ·fi ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÏÔ-

24

Á·ÚÈıÌÈÛÙÈ΋ ·Ó¿Ï˘ÛË, ·Ú·Ù›ıÂÙ·È Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (™∫) Î·È Ù· 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% O∞) ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ¤Ó· ·Ù‡¯ËÌ· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ Ó· ÚÔηÏÂ›Ù·È ·fi ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ÁÈ· οı ̛· ·fi ÙȘ ˘fi ÌÂϤÙË ÌÂÙ·‚ÏËÙ¤˜. ∆· ·ÔÙÂϤÛÌ·Ù· Û˘ÌʈÓÔ‡Ó ÁÂÓÈο Ì ÂΛӷ Ù˘ ÌÔÓÔ·Ú·ÁÔÓÙÈ΋˜ ·Ó¿Ï˘Û˘. OÈ ÌÂÁ·Ï‡ÙÂÚ˜ ·ÔÎÏ›ÛÂȘ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙË ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÔÊ›ÏÔÓÙ·È ÛÂ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜.

O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Ó· ÔÊ›ÏÂÙ·È ¤Ó· ·Ù‡¯ËÌ· ÂÛˆÙÂÚÈÎÔ‡ ¯ÒÚÔ˘ Û ıÂÚÌ·ÓÙÈÎfi ÛÒÌ· ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜, Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· Û ۯ¤ÛË Ì ٷ ·ÁfiÚÈ·,

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·25

¶·È‰È·ÙÚÈ΋ 2003;66:20-28

Paediatriki 2003;66:20-28

¶›Ó·Î·˜ 3. ∫·Ù·ÓÔÌ‹ ÙˆÓ 533 ·È‰ÈÒÓ (0-14 ÂÙÒÓ) Ô˘ ˘¤ÛÙËÛ·Ó ·Ù‡¯ËÌ· Û ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ Î·È Î·Ù·ÁÚ¿ÊËÎ·Ó ÛÙÔ EDISS, ÁÈ· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÙÚÈÒÓ ÂÙÒÓ (1996-1998), ˆ˜ ÚÔ˜ Ù· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ηıÒ˜ Î·È ÂΛӷ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ó ÙÔ ·Ù‡¯ËÌ· Î·È ÙËÓ Î¿ÎˆÛË, Û ٤ÛÛÂÚȘ ÔÌ¿‰Â˜, ÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜ ªÂÙ·‚ÏËÙ‹

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∏ÏÈΛ· (¤ÙË) 0-4 5-9 10-14 º‡ÏÔ ÕÚÚÂÓ £‹Ï˘ ∂ıÓÈÎfiÙËÙ· ∂ÏÏËÓÈ΋ ÕÏÏË ∆fiÔ˜ ™›ÙÈ ∫·ıÈÛÙÈÎfi ∫Ú‚·ÙÔο̷ڷ ∫Ô˘˙›Ó· ∞ÏÏÔ‡ ∂Î·È‰Â˘ÙÈÎfi-‰ËÌfiÛÈÔ ÎÙ›ÚÈÔ ÃÚfiÓÔ˜ ¶ÚˆÈÓ¤˜ ÒÚ˜ (9.00-20.59) ¡˘¯ÙÂÚÈÓ¤˜ ÒÚ˜ (21.00-8.59) ∂Ô¯‹ ∑ÂÛÙÔ› Ì‹Ó˜ (∞Ú›ÏÈÔ˜-™Â٤̂ÚÈÔ˜) æ˘¯ÚÔ› Ì‹Ó˜ (OÎÙÒ‚ÚÈÔ˜-ª¿ÚÙÈÔ˜) ªË¯·ÓÈÛÌfi˜ οΈÛ˘ ¶ÙÒÛË ·fi ‡„Ô˜ ¶ÙÒÛË ·fi ·Ú·¿ÙËÌ·/ÁÏ›ÛÙÚËÌ· ¶ÙÒÛË ÌÂÙ¿ ·fi Û‡ÁÎÚÔ˘ÛË/ÛÚÒÍÈÌÔ ™‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ ∂·Ê‹ Ì ˙ÂÛÙfi ·ÓÙÈΛÌÂÓÔ ÕÏÏÔ˜ ∂ÈÙ‹ÚËÛË ¡·È Ÿ¯È ∆‡Ô˜ οΈÛ˘ ∞ÓÔȯÙfi ÙÚ·‡Ì· ∂ί‡ÌˆÛË ∫¿Ù·ÁÌ· ∂Í¿ÚıÚËÌ·, ‰È¿ÛÙÚÂÌÌ· ¢È¿ÛÂÈÛË ŒÁη˘Ì· ÕÏÏÔ˜/η̛· οΈÛË ª¤ÏÔ˜ ÛÒÌ·ÙÔ˜ Ô˘ ˘¤ÛÙË ÙËÓ Î¿ÎˆÛË ∫ÂÊ·Ï‹ ¶ÚfiÛˆÔ ÕÎÚ· ∫ÔÚÌfi˜ ¡ÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë Ÿ¯È ¡·È

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15 23 16

4,5 16,0 29,6

189 13 11

56,4 9,0 20,4

2 79 18

0,6 54,9 33,3

129 29 9

38,5 20,1 16,7

30 24

8,7 12,8

145 68

41,9 36,3

70 29

20,2 15,5

101 66

29,2 35,3

53 1

10,3 5,2

204 9

39,7 47,4

93 6

18,1 31,6

164 3

31,9 15,8

16 13 1 9 15

9,0 7,9 2,3 16,7 16,0

70 81 28 20 14

39,6 49,4 63,6 37,0 14,9

31 13 4 4 47

17,5 7,9 9,1 7,4 50,0

60 57 11 21 18

33,9 34,8 25,0 38,9 19,1

47 7

10,7 7,4

176 37

40,1 39,4

84 15

19,1 16,0

132 35

30,1 37,2

27 27

14,1 7,9

95 118

49,7 34,5

29 70

15,2 20,5

40 127

21,0 37,1

6 7 3 30 0 8

5,5 3,7 4,6 20,7 0,0 53,3

66 82 15 38 8 4

60,6 43,2 22,7 26,2 100,0 26,7

20 27 38 14 0 0

18,3 14,2 57,6 9,7 0,0 0,0

17 74 10 63 0 3

15,6 38,9 15,1 43,4 0,0 20,0

31 23

8,3 14,5

157 56

42,0 35,2

60 39

16,0 24,5

126 41

33,7 25,8

9 32 9 2 0 0 2

2,2 41,0 81,8 66,7 0,0 0,0 14,3

160 28 1 1 6 8 9

38,8 35,9 9,1 33,3 85,7 100,0 64,3

90 5 0 0 1 0 3

21,9 6,4 0,0 0,0 14,3 0,0 21,4

153 13 1 0 0 0 0

37,1 16,7 9,1 0,0 0,0 0,0 0,0

4 1 45 4

1,4 0,5 77,6 40,0

180 19 9 5

64,5 10,2 15,5 50,0

89 9 0 1

31,9 4,9 0,0 10,0

6 157 4 0

2,2 84,4 6,9 0,0

53 1

10,0 25,0

211 2

39,9 50,0

98 1

18,5 25,0

167 0

31,6 0,0

˘„ËÏfiÙÂÚÔ˜ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘ Î·È ˘„ËÏfiÙÂÚÔ˜ fiÙ·Ó ˘¿Ú¯ÂÈ Â›‚ÏÂ„Ë ·fi ÂÓ‹ÏÈη. ∞ÓÙÈı¤Ùˆ˜, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ¯ÒÚÔ fiÔ˘ Û˘Ó¤‚Ë ÙÔ ·Ù‡¯ËÌ·, Ì ÂÍ·›ÚÂÛË ÙË Ì¤ÙÚÈ· Ì›ˆÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ù‡¯ËÌ· ÛÙÔ ¯ÒÚÔ Ù˘ ÎÔ˘˙›Ó·˜. ŸÛÔÓ

·ÊÔÚ¿ ÛÙÔ Ì˯·ÓÈÛÌfi Ù˘ οΈÛ˘, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÙÔ ·Ù‡¯ËÌ· Ó· ÚÔÎÏ‹ıËΠ·fi ıÂÚÌ·ÓÙÈÎfi ÛÒÌ· Â›Ó·È ˘„ËÏfiÙÂÚÔ˜ fiÙ·Ó ˘‹Ú¯Â ·Ú·¿ÙËÌ· ‹ ÁÏ›ÛÙÚËÌ· Î·È Û‡ÁÎÚÔ˘ÛË Ì ·ÓÙÈΛÌÂÓÔ. ∏ ·Ó¿Ï˘ÛË Ù˘ ʇÛ˘ ÙˆÓ Î·ÎÒÛÂˆÓ ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ηٷ‰ÂÈÎÓ‡ÂÈ Î˘Ú›ˆ˜ ·ÓÔȯٿ

25

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·26

¶·È‰È·ÙÚÈ΋ 2003;66:20-28

ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ Î·È ÙÔ ÚfiÛˆÔ.

O ¶›Ó·Î·˜ 3 ·ÚÔ˘ÛÈ¿˙ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ·Ó¿Ï˘ÛË Î·Ù¿ Û˘ÛÙ¿‰Â˜. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù¤ÛÛÂÚȘ ·ÚȘ ÔÌ¿‰Â˜ Ì Êı›ÓÔ˘Û· ÛËÌ·Û›·: ∏ ÚÒÙË ÔÌ¿‰· ·Ó·Ê¤ÚÂÙ·È Û ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ·È‰È¿ (10-14 ¯ÚfiÓˆÓ), Ù· ÔÔ›· Û˘¯Ó¿ ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ·fi ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ Î·È ÙˆÓ ÔÔ›ˆÓ ÔÈ Î·ÎÒÛÂȘ Û˘Ó›ÛÙ·ÓÙ·È Û ηٿÁÌ·Ù·, ÂÍ·ÚıÚÒÛÂȘ Î·È ‰È·ÛÙÚ¤ÌÌ·Ù· ÙˆÓ ¿ÎÚˆÓ. ∏ ‰Â‡ÙÂÚË ÔÌ¿‰· ·ÊÔÚ¿ Û ·È‰È¿ Ôχ Ó·ڋ˜ ËÏÈΛ·˜ (0-4 ¯ÚfiÓˆÓ), Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ÙfiÛÔ ÛÙËÓ ÎÔ˘˙›Ó· fiÛÔ Î·È ÛÙÔ Î·ıÈÛÙÈÎfi Î·È ÙËÓ ÎÚ‚·ÙÔο̷ڷ, ·Ó Î·È ‚Ú›ÛÎÔÓÙ·È ˘fi ÂÈÙ‹ÚËÛË. O ·ÚÈÔ˜ Ì˯·ÓÈÛÌfi˜ Â›Ó·È Ë ÙÒÛË ·fi ‡„Ô˜. ∆· ÂÁη‡Ì·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙËÓ ÔÌ¿‰· ·˘Ù‹. ªÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ‰È·Û›ÛÂˆÓ Î·È ÁÂÓÈÎfiÙÂÚ· ÙˆÓ Î·ÎÒÛÂˆÓ ÙÔ˘ ÎÚ·Ó›Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Â›Û˘ Û ·˘Ù‹ ÔÌ¿‰·. ∏ ÙÚ›ÙË ÔÌ¿‰· ·Ó·Ê¤ÚÂÙ·È Û ·È‰È¿ ÂӉȿÌÂÛ˘ ËÏÈΛ·˜ (5-9 ¯ÚfiÓˆÓ). ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Û Ôχ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·È‰È¿ ÌÂÙ·Ó·ÛÙÒÓ Ô˘ Û˘¯Ó¿ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ Î·È ‰ËÌfiÛÈ· ÎÙ›ÚÈ·, ˆ˜ ·ÔÙ¤ÏÂÛÌ· Û˘ÁÎÚÔ‡ÛÂˆÓ Ì ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ‹ Ûڈ̷͛ÙÔ˜ ·fi ¿ÏÏ· ¿ÙÔÌ·. OÈ Î·ÎÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÌ¿‰·˜ ·˘Ù‹˜ Â›Ó·È Û˘¯Ó¿ Ù· ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÎÂÊ¿ÏÈ. ∏ ٤ٷÚÙË ÔÌ¿‰· ÌÔÈ¿˙ÂÈ Ì ÙË ‰Â‡ÙÂÚË ÛÙÔ fiÙÈ Î·Ï‡ÙÂÈ Î˘Ú›ˆ˜ ·È‰È¿ Ó·ڋ˜ ËÏÈΛ·˜, ·ÏÏ¿ Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË Ù· ·È‰È¿ Â›Ó·È Î˘Ú›ˆ˜ ÂÏÏËÓÈ΋˜ ÂıÓÈÎfiÙËÙ·˜, Ù· ÔÔ›· ˘Ê›ÛÙ·ÓÙ·È ·Ù˘¯‹Ì·Ù· ÛÙÔ Û›ÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ „˘¯ÚÒÓ ÌËÓÒÓ ÙÔ˘ ¤ÙÔ˘˜ ηıÒ˜ Û˘ÁÎÚÔ‡ÔÓÙ·È Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·. OÈ Î·ÎÒÛÂȘ, ˆÛÙfiÛÔ, Â›Ó·È ÌÈÎÚfiÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ·ÓÔȯٿ ÙÚ·‡Ì·Ù· ÛÙÔ ÚfiÛˆÔ. ™˘˙‹ÙËÛË ∆· Û˘ÛÙ‹Ì·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰›ÎÙ˘· ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ·ÔÙÂÏÔ‡Ó ÙÔ Î‡ÚÈÔ Ì¤ÛÔ ı¤ÚÌ·ÓÛ˘ ÙˆÓ Î·ÙÔÈÎÈÒÓ Û ÔÏϤ˜ ¯ÒÚ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ∂ÏÏ¿‰·˜. ∏ ÛÙ·‰È·Î‹ ·‡ÍËÛË Ù˘ ¯Ú‹Û˘ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ·˘ÙÒÓ ¯·ÈÚÂÙ›ÛÙËΠˆ˜ ¤Ó· ÛËÌ·ÓÙÈÎfi ‚‹Ì· ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜, ·ÏÏ¿ Î·È Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ (12). ∫·Ù¿ ÙË ‰ÂηÂÙ›· 1990-2000, ÔÏÏÔ› Û˘ÁÁÚ·Ê›˜ ·fi ¯ÒÚ˜ Ù˘ µfiÚÂÈ·˜ ∂˘ÚÒ˘ Î·È Ù˘ ∞ÌÂÚÈ΋˜ ÂÓÙfiÈÛ·Ó ÎÈÓ‰‡ÓÔ˘˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ¯Ú‹ÛË ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ (3-6). OÈ Û˘ÁÁÚ·Ê›˜ ·˘ÙÔ› ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ϤÔÓ ÚÔÊ·Ó¤˜ Úfi‚ÏËÌ· Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ıÂÚÌ·ÓÙÈÎÒÓ ÛˆÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ù· ÂÁη‡Ì·Ù·. ∞Ó Î·È Ë ‚È‚ÏÈÔÁÚ·Ê›· Á‡Úˆ ·fi ÙÔ ı¤Ì· Â›Ó·È ÂÚÈÔ-

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Paediatriki 2003;66:20-28

ÚÈṲ̂ÓË, ÔÈ ÂÚ¢ÓËÙ¤˜ ÂÂÛ‹Ì·Ó·Ó fiÙÈ Ù· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· ı· ÌÔÚÔ‡Û·Ó Ó· ÂÌϤÎÔÓÙ·È Û ·Ù˘¯‹Ì·Ù· Ì Ì˯·ÓÈÛÌfi ‰È·ÊÔÚÂÙÈÎfi ·fi ·˘ÙfiÓ Ù˘ ÌÂÙ¿‰ÔÛ˘ ıÂÚÌfiÙËÙ·˜. ™‡Ìʈӷ Ì ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ê·›ÓÂÙ·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ¯ÒÚ˜ Ì ‡ÎÚ·ÙÔ Îϛ̷, Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÚfiÎÏËÛË ·Ù˘¯ËÌ¿ÙˆÓ Ì¤Ûˆ Ì˯·ÓÈÛÌÒÓ ÌÂÙ·ÊÔÚ¿˜ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ (ÙÒÛË, Û‡ÁÎÚÔ˘ÛË Î·È ÁÏ›ÛÙÚËÌ·) Î·È fi¯È ıÂÚÌfiÙËÙ·˜ (¤Áη˘Ì·). ∏ ˘ÂÚÔ¯‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È ÙfiÛÔ ÛËÌ·ÓÙÈ΋, Ô˘ ıˆÚÂ›Ù·È Èı·Ófi Ù· ·Ù˘¯‹Ì·Ù· Ì Ì˯·ÓÈÛÌfi ÌÂÙ·ÊÔÚ¿˜ Ì˯·ÓÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ Ó· ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ Û˘ÓÔÏÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÎfiÌ· Î·È Û ¯ÒÚ˜ Ì „˘¯ÚfiÙÂÚÔ Îϛ̷. O ¯·ÌËÏfi˜ ÂÈÔÏ·ÛÌfi˜ ÙˆÓ ÂÁη˘Ì¿ÙˆÓ ÛÙË ÌÂϤÙË ·˘Ù‹ ·ÓÙ·Ó·ÎÏ¿ Èı·ÓÒ˜ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÛÙËÓ ∂ÏÏ¿‰· ·ÔÙÂÏÔ‡Ó ·ÁˆÁÔ‡˜ ˙ÂÛÙÔ‡ ÓÂÚÔ‡, ÙÔ ÔÔ›Ô Û¿ÓÈ· ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 50ÔC, ıÂÚÌÔÎÚ·Û›· Ô˘ ‰ÂÓ ÚÔηÏ› ‡ÎÔÏ· ıÂÚÌÈΤ˜ ‚Ï¿‚˜. ∞ÓÙ›ıÂÙ·, Ë ıÂÚÌÔÎÚ·Û›· ÙˆÓ ·ÁˆÁÒÓ ·ÙÌÔ‡ Â›Ó·È Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚË, ˘ÂÚ‚·›ÓÔÓÙ·˜ Û˘¯Ó¿ ÙÔ˘˜ 90ÔC, ıÂÚÌÔÎÚ·Û›· Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ¿ÌÂÛ· ÛÔ‚·Ú¿ ÂÁη‡Ì·Ù· ÛÙÔ ‰¤ÚÌ· (6,13,14). ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘, Ù· ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÂÌϤÎÔÓÙ·È Û ÂÚ›Ô˘ 1/40 ·È‰Èο ·Ù˘¯‹Ì·Ù· Ô˘ Û˘Ì‚·›ÓÔ˘Ó Û ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜. O ·ÚÈıÌfi˜ ·˘Ùfi˜ ÌÔÚ› Ó· ÌËÓ Ê·›ÓÂÙ·È ÂÓÙ˘ˆÛÈ·Îfi˜, ·ÏÏ¿ Ë ÂÌÂÈÚ›· ¤¯ÂÈ Î·Ù·‰Â›ÍÂÈ fiÙÈ Ë ·Í›· Ù˘ ÚfiÏ˄˘ ¤ÁÎÂÈÙ·È ÛÙËÓ ÂÓ·Û¯fiÏËÛË ·ÎfiÌË Î·È Ì ÌÈÎÚ¿ Û¯ÂÙÈο ÚÔ‚Ï‹Ì·Ù·, ¤ÙÛÈ ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó ÙÂÏÈο ÌÂÁ¿Ï· ‚‹Ì·Ù· (15). ∏ ÚfiÏË„Ë ÛÙÔÓ ÙÔ̤· ·˘Ùfi Â·Ê›ÂÙ·È ·Ú¯ÈÎÒ˜ ÛÙÔ˘˜ ÁÔÓ›˜ Î·È ÊÚÔÓÙÈÛÙ¤˜ ÙˆÓ ·È‰ÈÒÓ, ÔÈ ÔÔ›ÔÈ Ú¤ÂÈ Ó· ÂÓËÌÂÚˆıÔ‡Ó ·fi ÙÔ˘˜ ÁÂÓÈÎÔ‡˜ È·ÙÚÔ‡˜ Î·È ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜. ∆Ô ÁÂÓÈÎfiÙÂÚÔ ÚfiÙ˘Ô ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÒÌ·Ù· ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ·ÊÔÚ¿ ΢ڛˆ˜ Û ÌÈÎÚfiÙÂÚ· ·È‰È¿ Î·È ÂȉÈÎfiÙÂÚ· ·ÁfiÚÈ·, Û˘Ó‹ıˆ˜ ηٿ ÙÔ˘˜ „˘¯ÚÔ‡˜ Ì‹Ó˜ ÙÔ˘ ¯ÚfiÓÔ˘, fiÙ·Ó Ù· ·È‰È¿ ÂÚÈÔÚ›˙Ô˘Ó ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ¤˜ ÙÔ˘˜ ÛÙÔ ¯ÒÚÔ ÛÙÔ ÛÈÙÈÔ‡. ∏ Û˘Ó‹ı˘ ÂÈÙ‹ÚËÛË ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ Â›Ó·È Â·Ú΋˜ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, Ù· ÔÔ›· Û˘Ì‚·›ÓÔ˘Ó Î˘Ú›ˆ˜ fiÙ·Ó Ù· ·È‰È¿ ·›˙Ô˘Ó Î·È ÛÚÒ¯ÓÔÓÙ·È Û ÂÚÈÔÚÈṲ̂ÓÔ ¯ÒÚÔ. §fiÁˆ Ù˘ ηٷÛ΢‹˜ ÙˆÓ ·Ï·ÈfiÙÂÚˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ Ì ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜, Ù· ·Ù˘¯‹Ì·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Û˘¯Ó¿ ·ÊÔÚÔ‡Ó Û ·ÓÔȯ٤˜ ηÎÒÛÂȘ Ù˘ ÎÂÊ·Ï‹˜ Ô˘ ¯Ú‹˙Ô˘Ó È·ÙÚÈ΋˜ ÂÎÙ›ÌËÛ˘.

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™‡Ìʈӷ Ì ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Î·Ù¿ Û˘ÛÙ¿‰Â˜, ÔÈ ÚÔÛ¿ıÂȘ ÚfiÏ˄˘ ı· Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÔÓÙ·È Î˘Ú›ˆ˜ Û ÙÚÂȘ ÔÌ¿‰Â˜. ∏ ÚÒÙË ·ÊÔÚ¿ ÛÙ· ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Î˘Ú›ˆ˜ ÛÙ· ·ÁfiÚÈ·, Ô˘ ˘Ê›ÛÙ·ÓÙ·È Ì¤Û· Û ÂÎ·È‰Â˘ÙÈο ȉڇ̷ٷ ÛÔ‚·ÚÔ‡˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜, fiˆ˜ ηٿÁÌ·Ù·, ›Ûˆ˜ ÏfiÁˆ Ù˘ ‰˘Ó·ÌÈÎfiÙËÙ·˜ Ô˘ Ù· ¯·Ú·ÎÙËÚ›˙ÂÈ Î·Ù¿ Ù· ÂÚÈ-ÂÊË‚Èο ¯ÚfiÓÈ·. ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·È‰È¿ Ôχ ÌÈÎÚ‹˜ ËÏÈΛ·˜, Ù· ÔÔ›· ÚÔÛ·ıÒÓÙ·˜ Ó· ·Ó¤‚Ô˘Ó ¿Óˆ ÛÙ· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù·, ¤ÊÙÔ˘Ó ÛÙÔ ‰¿Â‰Ô Î·È ˘Ê›ÛÙ·ÓÙ·È Û˘¯Ó¿ ‰È¿ÛÂÈÛË ‹ Î·È Î·ÎÒÛÂȘ ÙÔ˘ ÎÚ·Ó›Ô˘. ∆¤ÏÔ˜, Ë ÙÚ›ÙË ÔÌ¿‰· ·ÊÔÚ¿ Û ·È‰È¿ ÌÂÙ·Ó·ÛÙÒÓ, ·ÏÏ¿ ÌÔÚ› Ó· ·ÓÙ·Ó·ÎÏ¿ ηٷÛ΢·ÛÙÈο ÂÏ·ÙÙÒÌ·Ù· Ù˘ ˘Ô‰ÔÌ‹˜ ÙˆÓ Û¯ÔÏ›ˆÓ Û ˘Ô‚·ıÌÈṲ̂Ó˜ Û˘ÓÔÈ˘, ÛÙȘ Ôԛ˜ Û˘¯Ó¿ ηÙÔÈÎÔ‡Ó Ù· ·È‰È¿ ·˘Ù¿. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÓËÁÔÚÔ‡Ó Î·È ˘¤Ú ÔÏÏÒÓ Î·Ù¢ı˘ÓÙ‹ÚÈˆÓ Ô‰ËÁÈÒÓ Û¯ÂÙÈο Ì ÙËÓ Î·Ù·Û΢‹ ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘: ·) Ë ÂÈÊ¿ÓÂÈ· ÙˆÓ ÛˆÌ¿ÙˆÓ ı· Ú¤ÂÈ Ó· Â›Ó·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ Â›‰Ë, ÂÓÒ Ù· ÛÒÌ·Ù· ·Ï·ÈfiÙÂÚ˘ ηٷÛ΢‹˜ Ô˘ ¤¯Ô˘Ó ÔÏÏ·Ϥ˜ ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜ ı· Ú¤ÂÈ ÛÙ·‰È·Î¿ Ó· ·ÓÙÈηٷÛÙ·ıÔ‡Ó, ‚) Ù· ÛÒÌ·Ù· Ì ·È¯ÌËÚ¤˜ ÁˆÓ›Â˜ Ô˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÔÛ˘ÚıÔ‡Ó ı· Ú¤ÂÈ Ó· ÂÚÈ‚ÏËıÔ‡Ó ·fi ¿ÏÏÔ, Â›Â‰Ô ˘ÏÈÎfi, Á) Ù· ÎÚ‚¿ÙÈ· ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ı· Ú¤ÂÈ Ó· Â›Ó·È ÙÔÔıÂÙË̤ӷ ÎÔÓÙ¿ ÛÙ· ÛÒÌ·Ù·, ηıÒ˜ Ù· ·È‰È¿ Û˘¯Ó¿ ÙÔÔıÂÙÔ‡Ó ÂΛ Ù· ¯¤ÚÈ· ÙÔ˘˜ ‹, ¤ÊÙÔÓÙ·˜ ·fi ÙÔ ÎÚ‚¿ÙÈ, ÂÁÎψ‚›˙ÔÓÙ·È ·Ó¿ÌÂÛ· Û ·˘Ùfi Î·È ÙÔ ıÂÚÌ·ÓÙÈÎfi ÛÒÌ·, ‰) Ù· ÛÒÌ·Ù· ‰ÂÓ ı· Ú¤ÂÈ Ó· ÙÔÔıÂÙÔ‡ÓÙ·È Û ÁˆÓȤ˜ ÙÔ˘ ÛÈÙÈÔ‡ Ô˘ Â›Ó·È ÁÂÌ¿Ù˜ Ì ¤ÈÏ·, Â) Ù· ÛÒÌ·Ù· ı· Ú¤ÂÈ Ó· Â›Ó·È ¤ÙÛÈ ÙÔÔıÂÙË̤ӷ ÒÛÙ ӷ ÌËÓ ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ù· ·È‰È¿ Ó· ÏËÛÈ¿ÛÔ˘Ó ÂÓÒ ·›˙Ô˘Ó ÛÙÔ˘˜ ÂÛˆÙÂÚÈÎÔ‡˜ ¯ÒÚÔ˘˜ ÙÔ˘ ÛÈÙÈÔ‡, ÛÙ) ÎÈÓËÙ¿ ·ÓÙÈΛÌÂÓ· ÌÂٷ͇ ÙÔ˘ ıÂÚÌ·ÓÙÈÎÔ‡ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ¯ÒÚÔ˘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Ù· ·È‰È¿ ÁÈ· Ó· ·›˙Ô˘Ó ı· Ú¤ÂÈ Ó· ·ÔÌ·ÎÚ‡ÓÔÓÙ·È, ˙) Ù· ÌÈÎÚ¿ ·È‰È¿ ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÈÙÚ¤ÂÙ·È Ó· ·Ó‚·›ÓÔ˘Ó ¿Óˆ ÛÙ· ıÂÚÌ·ÓÙÈο ÛÒÌ·Ù· (·Ϥ˜ ÚÔÊ˘Ï¿ÍÂȘ, fiˆ˜ Ë ÙÔÔı¤ÙËÛË ÌÈ·˜ ηڤÎÏ·˜ ‹ ÂÓfi˜ ÙÚ·Â˙ÈÔ‡ ÌÚÔÛÙ¿ ·fi ÙÔ ÛÒÌ·, ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ Â›ÙˆÛË ÙˆÓ ÙÚ·˘Ì·ÙÈÛÌÒÓ) Î·È Ë) Û ۯÔÏ›· Î·È ‰ËÌfiÛÈ· ÎÙ›ÚÈ·, ηٿ ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘, Ë ·ÛÊ¿ÏÂÈ· ÙˆÓ ·È‰ÈÒÓ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› ¿ÌÂÛË ÚÔÙÂÚ·ÈfiÙËÙ·, ›Û˘ ‚·Ú‡ÙËÙ·˜ Ì ÙËÓ ÂÓÂÚÁÂȷ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜. O ¤ÏÂÁ¯Ô˜ Ù˘ ·ÛÊ·ÏÔ‡˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î·Ù·Û΢‹˜ ÙˆÓ ÛˆÌ¿ÙˆÓ ÎÂÓÙÚÈ΋˜ ı¤ÚÌ·ÓÛ˘ ÌÔÚ› Ó· Á›ÓÂÈ Ì ‚¿ÛË ÙȘ ÚԉȷÁڷʤ˜ Ô˘ ηıÔÚ›˙ÔÓÙ·È ·fi ÙÔÓ ∂ÏÏËÓÈÎfi OÚÁ·ÓÈÛÌfi ∆˘ÔÔ›ËÛ˘ (16).

Paediatriki 2003;66:20-28

∏ ÚfiÏË„Ë ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ÚÔÎÏ‹ÛÂȘ ÛÙÔ ¯ÒÚÔ Ù˘ ¶·È‰È·ÙÚÈ΋˜ Î·È Ù˘ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ ·ÁÎÔÛÌ›ˆ˜ (17). À¿Ú¯ÂÈ Ì›· Ù¿ÛË ·Ó·ÁÓÒÚÈÛ˘ Ù·˘ÙÔÔÈ‹ÛÈÌˆÓ ·ÈÙÈÒÓ ÁÈ· οı ·Ù‡¯ËÌ·, ÔÈ Ôԛ˜ ÌÔÚÔ‡Ó Ù·˘Ùfi¯ÚÔÓ· Ó· ÚÔ‚ÏÂÊıÔ‡Ó Î·È Ó· ÚÔÏËÊıÔ‡Ó (18). ∏ Ù¿ÛË ·˘Ù‹ ÌÔÚ› Ó· Ê·›ÓÂÙ·È ·ÎÚ·›·, ·ÏÏ¿ Â›Ó·È Û›ÁÔ˘Ú· ·ÍȤ·ÈÓË, ηı’ fiÙÈ ÚÔ¿ÁÂÈ ÙÔÓ ÂÓıÔ˘ÛÈ·ÛÌfi Î·È ÂÓÈÛ¯‡ÂÈ ÙËÓ ¤Ú¢ӷ Î·È ÙÔÓ ·ÎÙÈ‚ÈÛÌfi ÛÙÔ ¯ÒÚÔ Ù˘ ÚfiÏ˄˘ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ. ™ÙÔ Ï·›ÛÈÔ ·˘Ùfi, Ë ÂÈÛ‹Ì·ÓÛË ÙÔ˘ ÚÔÊ›Ï ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜, ¤ÛÙˆ Î·È ÂÓfi˜ ÌÈÎÚÔ‡ ÔÛÔÛÙÔ‡ (2,4% Û ·˘Ù‹ ÙË ÌÂϤÙË) ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·Ù˘¯ËÌ¿ÙˆÓ, ÌÔÚ› Ó· ıˆÚËı› ˆ˜ ¤Ó· ÌÈÎÚfi, ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi ‚‹Ì· ÛÙÔÓ ÙÔ̤· Ù˘ ÚfiÏ˄˘ ÙˆÓ ·È‰ÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Home and Leisure Accident Research (HALAR). Fourteenth Annual Report of the Home Accident Surveillance System.

London: Consumer Safety Unit, Department of Trade and Industry; 1990.

2. US Consumer Product Safety Commission. 1993 Product Summary Report. Washington; DC: National Electronic Injury Surveillance System; 1994.

3. Datubo-Brown DD, Gowar JP. Contact burns in children.

Burns 1989;15:285-286.

4. Harper RD, Dickson WA. Domestic central heating radiators: a cause for concern in all age groups. Burns 1996;22:217-220.

5. Hurren JS, Dunn KW. Entrapment against radiators - an underestimated burn hazard to the elderly. Burns 1993;19:522-523.

6. Quinlan KP. Injury control in practice. Home radiator burns in inner-city children. Arch Pediatr Adolesc Med 1996;150:954-957.

7. EHLASS. European Home and Leisure Surveillance System Coding manual; 1986.

8. NOMESCO. Nordic Medico-Statistical Committee; May, 1994.

9. World Health Organization. International Classification of Diseases. 9th rev. Geneva, Switzerland: World Health Organization; 1980.

10. Miettinen OS. The “case-control” study: valid selection of subjects. J Chronic Dis 1985;38:543-548.

11. SAS/STAT User’s Guide, Version 6. 4th Edition; 1990. SAS Institute Inc. 12. Seretakis D, Lagiou P, Lipworth L, Signorello LB, Rothman KJ, Trichopoulos D. Changing seasonality of mortality from coronary heart disease. JAMA 1997;278:1012-1014.

13. Feldman KW, Schaller RT, Feldman JA, McMillon M. Tap water scald burns in children. Pediatrics 1978;62:1-7.

14. American Academy of Pediatrics Committee on Injury and Poison Prevention. Office-based counseling for injury prevention. Pediatrics 1991;88:1112-1118.

15. Petridou E. Injury prevention: an uphill battle (annotation).

Inj Prev 1995;1:8.

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16. ∂ÏÏËÓÈÎfi˜ OÚÁ·ÓÈÛÌfi˜ ∆˘ÔÔ›ËÛ˘ (∂§O∆). www.elot.gr 17. Rivara FP, Aitken M. Prevention of injuries to children and adolescents. Adv Pediatr 1998;45:37-72.

18. Davis RM, Pless B. BMJ bans “accidents”. BMJ 2001;322:1320-1321.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 29-04-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ¶ÂÙÚ›‰Ô˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ª. ∞Û›·˜ 75, ∆.∫. 115 27, °Ô˘‰› E-mail: epetrid@med.uoa.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂Ó‰ÔÓÔÛÔÎÔÌÂȷ΋ Û‹„Ë Û Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿: Ë ÂÌÂÈÚ›· ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘ - ¢›ÎÙ˘Ô ¤Ú¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜1 ™ÎÔfi˜: OÈ fi„ÈÌ· ÂÌÊ·ÓÈ˙fiÌÂÓ˜ ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ ‹, fiˆ˜ ÔÓÔÌ¿˙ÔÓÙ·È, ÂÓ‰ÔÓÔÛÔÎÔÌÂȷΤ˜ ÏÔÈÌÒÍÂȘ (∂¡§) Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î˘Ú›ˆ˜ ÌÂÙ¿ ÙËÓ ÙÚ›ÙË Ë̤ڷ ˙ˆ‹˜, ·ÔÙÂÏÔ‡Ó ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÁÈ· Ù· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ (¶Ãµ°) ÓÂÔÁÓ¿. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó Ù· ÔÛÔÛÙ¿ ÙˆÓ ∂¡§, ÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ë Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙËÓ ÔÚ›· ÙˆÓ ÓÂÔÁÓÒÓ Î·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∂ÎÙÈÌ‹ıËΠ̛· ÔÌ¿‰· 6956 ¶Ãµ° (µ°=401-1500 g) ÓÂÔÁÓÒÓ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙ· ÎÏÈÓÈο ΤÓÙÚ· ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘-¢›ÎÙ˘Ô ŒÚ¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜ ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1998-2000. ∆Ô ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ Î·È ∞Ó¿Ù˘Í˘ ÙÔ˘ ∞ÓıÚÒÔ˘-¢›ÎÙ˘Ô ŒÚ¢ӷ˜ ¡ÂÔÁÓÈ΋˜ ∏ÏÈΛ·˜ ‰È·ÙËÚ› ¤Ó· Ï‹Ú˜ ·Ú¯Â›Ô ηٷÁÚ·Ê‹˜ fiÏˆÓ ÙˆÓ ÂÈÛ·ÁfiÌÂÓˆÓ ¶Ãµ° ÓÂÔÁÓÒÓ ÛÙ· Û˘ÌÌÂÙ¤¯ÔÓÙ· ÓÂÔÁÓÈο ΤÓÙÚ· ̤۷ Û ‰Âη٤ÛÛÂÚȘ Ë̤Ú˜ ·fi ÙË Á¤ÓÓËÛË. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 6215 ÓÂÔÁÓ¿ Ô˘ Â¤˙ËÛ·Ó ¤Ú·Ó ÙˆÓ 3 ËÌÂÚÒÓ, Ù· 1313 (21%) ·ÚÔ˘Û›·Û·Ó ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È·, ÂȂ‚·ÈˆÌ¤Ó˘ Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, fi„ÈÌ˘ ÛË„·ÈÌ›·˜. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ (70%) ÔÊÂÈÏfiÙ·Ó Û Gram ıÂÙÈο ÌÈÎÚfi‚È·, Ì ÙÔ˘˜ ÎÔ·ÁÎÔ˘Ï¿ÛË ·ÚÓËÙÈÎÔ‡˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˘˜ Ó· ¢ı‡ÓÔÓÙ·È ÁÈ· ÙÔ 48% ÙˆÓ ∂¡§. ∆Ô ÔÛÔÛÙfi ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‹Ù·Ó ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁÔ ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È Ù˘ ËÏÈΛ·˜ ·ËÛ˘. OÈ ÂÈÏÔΤ˜ Ù˘ ÚÔˆÚfiÙËÙ·˜, fiˆ˜ Ô ·ÓÔÈÎÙfi˜ ‚ÔÙ¿ÏÂÈÔ˜ fiÚÔ˜, Ô ·Ú·ÙÂ-

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ٷ̤ÓÔ˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Ë ·Ú·ÙÂٷ̤ÓË ¯Ú‹ÛË ·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ, Ë ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· Î·È Ë ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ‚Ú¤ıËΠӷ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ∂¡§. ∆· ÓÂÔÁÓ¿ Ô˘ ·ÚÔ˘Û›·Û·Ó ∂¡§ ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ (ηٿ ̤ÛÔ fiÚÔ 76 ¤Ó·ÓÙÈ 60 ËÌÂÚÒÓ). ∆· ·È‰È¿ Ì ∂¡§ ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· Âı¿ÓÔ˘Ó ·’ fiÙÈ ÂΛӷ ¯ˆÚ›˜ Ïԛ̈ÍË (18% ¤Ó·ÓÙÈ 7%). O ΛӉ˘ÓÔ˜ ÁÈ· ı¿Ó·ÙÔ ‹Ù·Ó ȉȷ›ÙÂÚ· ÌÂÁ¿ÏÔ˜ fiÙ·Ó Ë Ïԛ̈ÍË ÔÊÂÈÏfiÙ·Ó Û Gram ·ÚÓËÙÈο ÌÈÎÚfi‚È· (36%) ‹ Û ̇ÎËÙ˜ (32%). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ fi„ÈÌË Û‹„Ë ·ÔÙÂÏ› ¤Ó·Ó ÛËÌ·ÓÙÈÎfi ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ı·Ó¿ÙÔ˘ ÛÙ· ¶Ãµ° ÓÂÔÁÓ¿, ηıÒ˜ Â›Û˘ Î·È ÛÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ ÙˆÓ ÂÈ˙ÒÓÙˆÓ. OÈ ÛÙÚ·ÙËÁÈΤ˜ Ì›ˆÛ˘ Ù˘ fi„ÈÌ˘ Û‹„˘ Î·È ÙˆÓ Û˘ÓÂÂÈÒÓ Ù˘ ÎÚ›ÓÔÓÙ·È ¿ÎÚˆ˜ ÂÈÙ·ÎÙÈΤ˜.

1 Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz R et al Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network Pediatrics 2002;110:285-291

™‡ÚÔ˜ ºˆÙfiÔ˘ÏÔ˜ ¶·È‰›·ÙÚÔ˜-¡ÂÔÁÓÔÏfiÁÔ˜ ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ µ’ ª∂¡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2003;66:29-36

ORIGINAL ARTICLE

O fiÓÔ˜ ÛÙ· ÓÂÔÁÓ¿ µ. ¢ÚfiÛÔ˘ - ∞Á·Î›‰Ô˘, ∫. ™·Ú·Ê›‰Ë˜, ¶. ∫·Ú·ÁÈ¿ÓÓË, °. ∫ÚÂÌÂÓfiÔ˘ÏÔ˜

Pain in neonates V. Drossou - Agakidou, K. Sarafidis, P. Karagianni, G. Kremenopoulos

¶ÂÚ›ÏË„Ë: ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (ª∂¡¡) Û¯ÂÙÈο Ì ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ, ηıÒ˜ Î·È ÙˆÓ Ù·ÎÙÈÎÒÓ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙȘ ª∂¡¡. ∞ÓÒÓ˘Ì· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÂÛÙ¿ÏËÛ·Ó ÛÙÔ È·ÙÚÈÎfi ÚÔÛˆÈÎfi Î·È ÛÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ 14 ª∂N¡ ‰ËÌfiÛÈˆÓ Î·È È‰ÈˆÙÈÎÒÓ ÓÔÛÔÎÔÌ›ˆÓ Û fiÏË ÙËÓ ∂ÏÏ¿‰·. ∞ÓÙ·ÔÎÚ›ıËÎ·Ó 106/117 ÁÈ·ÙÚÔ› (90,6%) ·fi 13 ª∂¡¡. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù·, fiÏÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ Ô˘ ¤¯ÂÈ Ô fiÓÔ˜ Û ·˘Ù¿. ∏ ·Ó·ÏÁËÛ›·-ηٷÛÙÔÏ‹ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÌË Â›ÁÔ˘Û·˜ ‰È·ÛˆÏ‹ÓˆÛ˘ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ·fi ÙÔ 81%, 60% Î·È 96% ÙˆÓ ÁÈ·ÙÚÒÓ, ·ÓÙ›ÛÙÔȯ·. øÛÙfiÛÔ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·Ó·ÏÁËÛ›· ÚÈÓ ·fi ÙȘ ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. ¶·Ú¿ÏÏËÏ·, Ë ÏÂÈÔ„ËÊ›· ÈÛÙ‡ÂÈ fiÙÈ ‰È¿ÊÔÚ· ÌË Ê·Ú̷΢ÙÈο ̤ÙÚ· ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙÔÓ fiÓÔ Î·È ÙË ‰˘ÛÊÔÚ›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. ™ÙÔ ÂȉÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÈ· ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÛÙȘ ÌÔÓ¿‰Â˜ ·¿ÓÙËÛ·Ó 12 ‰È¢ı˘ÓÙ¤˜. ªfiÓÔ Û 4/12 ª∂¡¡ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘. ∏ ·Ó·ÏÁËÛ›·-ηٷÛÙÔÏ‹ ÌÂÙÂÁ¯ÂÈÚËÙÈο ·ÔÙÂÏ› ¿ÁÈ· Ù·ÎÙÈ΋ Û fiϘ ÙȘ ª∂¡¡, ÂÓÒ ÌfiÓÔ Û 9 ¯ÔÚËÁÂ›Ù·È Û˘¯Ó¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ Î·È Û 1 ÚÈÓ ·fi ÙË ÌË Â›ÁÔ˘Û· ‰È·ÛˆÏ‹ÓˆÛË. ∆¤ÏÔ˜, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜

Abstract: The objective of the study was to identify views of Greek doctors as to pain perception by neonates and determine current practices regarding pain management in neonatal intensive care units (NICUs). Anonymous postal questionnaires were sent to 117 doctors working in 14 NICUs across Greece concerning their personal views and to 14 heads of NICUs concerning current practices. Overall, 106/117 (90.6 %) doctors working in 13 NICUs responded. All responders believe that neonates experience pain and are aware of the harmful effects pain and stress may have on them. Analgesia and sedation are regarded as necessary or important during mechanical ventilation, prior to non-emergency endotracheal intubation and postoperatively by 81%, 60% and 96% of the doctors, respectively. However, most doctors stated that analgesia is unnecessary during minor procedures, in all but chest tube placement.

Most doctors stated that non-pharmacologic measures are effective in decreasing pain and discomfort during minor procedures. The questionnaires regarding NICUs’ practices were returned completed by 12 directors. Only in 4/12 NICUs there is a certain protocol for pain prevention and management. Analgesia-sedation administration postoperatively is a standard practice in all NICUs, whereas during mechanical ventilation it is often given in 9/12 NICUs and prior to nonemergency intubation in only one. Non-pharmacologic measures to reduce exposure to noxious stimuli and alleviate pain during minor procedures are used in most NICUs. Greek neonatologists believe that neonates experience pain and are aware

¡ÂÔÁÓÔÏÔÁÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ∞.¶.£ πÔÎÚ¿ÙÂÈÔ °¶¡ £ÂÛ/ӛ΢

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

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ª∂¡¡ ÂÊ·ÚÌfi˙ÔÓÙ·È ‰È¿ÊÔÚ· ÌË Ê·ÚÌ·ÎÔÏÔÁÈο ̤ÙÚ· ÁÈ· ÙË Ì›ˆÛË Ù˘ ¤ÎıÂÛ˘ Û ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. OÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȤ˜ ÙÔ˘ Û ·˘Ù¿. ∂ÓÒ Ô ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ fiÓÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Â·ÚÎÒ˜, ‰ÂÓ Û˘Ì‚·›ÓÂÈ ÙÔ ›‰ÈÔ Î·È Ì ÙÔÓ fiÓÔ Ô˘ ÚÔηÏÂ›Ù·È ·fi ¿ÏϘ È·ÙÚÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ. OÈ ÌË Ê·Ú̷΢ÙÈÎÔ› ÙÚfiÔÈ Ì›ˆÛ˘ ÙÔ˘ fiÓÔ˘ Â›Ó·È Â˘Ú¤ˆ˜ ·Ú·‰ÂÎÙÔ› ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜.

of the harmful effects that pain and stress may have on them. Postoperative pain is treated adequately, whereas procedural pain is not. Nonpharmacologic measures are widely accepted.

§¤ÍÂȘ ÎÏÂȉȿ: fiÓÔ˜, ·Ó·ÏÁËÛ›·, ηٷÛÙÔÏ‹, ÓÂÔÁÓfi.

Key words: pain, analgesia, sedation, neonate.

∂ÈÛ·ÁˆÁ‹ ∏ ÂÓÙ·ÙÈ΋ ıÂÚ·›· ÙˆÓ ÓÂÔÁÓÒÓ ÛÙȘ Û‡Á¯ÚÔÓ˜ ÌÔÓ¿‰Â˜ Û˘Óԉ‡ÂÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È ÂÒ‰˘ÓÔÈ ‹ ÚÔηÏÔ‡Ó ‰˘ÛÊÔÚ›· (1). øÛÙfiÛÔ, Ô fiÓÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ηÈ, ηٿ Û˘Ó¤ÂÈ·, οı ÙÚfiÔ˜ Ê·Ú̷΢ÙÈ΋˜ ‹ ÌË ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ Â›Ó·È Î¿ÙÈ Ô˘ ̤¯ÚÈ ÚfiÛÊ·Ù· ›¯Â ·ÁÓÔËı› ÂÛÊ·Ï̤ӷ, ηıÒ˜ ˘‹Ú¯Â Ë ·ÓÙ›ÏË„Ë fiÙÈ Ù· ÓÂÔÁÓ¿ Î·È È‰È·›ÙÂÚ· Ù· ÚfiˆÚ· ‰ÂÓ ÔÓÔ‡Ó. ∂›Ó·È ϤÔÓ Û·Ê¤˜ fiÙÈ Ù· ÓÂÔÁÓ¿ ‰È·ı¤ÙÔ˘Ó ÙË Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ Î·È ·Ó·ÙÔÌÈ΋ ˆÚÈÌfiÙËÙ· Ô˘ Ù· ηıÈÛÙ¿ Èηӿ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ, ·ÎfiÌË Î·È ·Ó Â›Ó·È ÚfiˆÚ· (2). ª¿ÏÈÛÙ·, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÂÌÊ·Ó›˙Ô˘Ó ·ÚfiÌÔȘ ‹ ·˘ÍË̤Ó˜, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ηډÈÔ·Ó·Ó¢ÛÙÈΤ˜, ÔÚÌÔÓÈΤ˜ Î·È ÌÂÙ·‚ÔÏÈΤ˜ ··ÓÙ‹ÛÂȘ (3). ∂ÈϤÔÓ, Ù· ÚfiˆÚ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ú·ÙÂٷ̤Ó˜ ÂÚÈfi‰Ô˘˜ ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜, ·ÎfiÌË Î·È Û ÌË ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù·, ÏfiÁˆ ÂÏ·Ùو̤ÓÔ˘ Ô˘‰Ô‡ ÙÔ˘ fiÓÔ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘ÍË̤ÓË ‰ÈÂÁÂÚÛÈÌfiÙËÙ· ÙˆÓ Ô›ÛıÈˆÓ ÎÂÚ¿ÙˆÓ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡, ÁÂÁÔÓfi˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ˆ˜ “Ê·ÈÓfiÌÂÓÔ ¯ÔÚ‰›ÛÌ·ÙÔ˜” (4,5). ∆·˘Ùfi¯ÚÔÓ·, ÏËı·›ÓÔ˘Ó ÔÈ ÂӉ›ÍÂȘ fiÙÈ Ô fiÓÔ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ, ¿ÌÂÛ˜ ‹ ·ÒÙÂÚ˜ (3,6). ∏ ηٷÓfiËÛË Ù˘ ÛËÌ·Û›·˜ ÙÔ˘ fiÓÔ˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ó· ˘¿ÚÍÔ˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ηÙ¢ı‡ÓÛÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress ÛÙ· ÓÂÔÁÓ¿ ·fi ÊÔÚ›˜ fiˆ˜ Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ (American Academy of Pediatrics) Î·È Ë ∫·Ó·‰È΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· (Canadian Paediatric Society) (7). øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ‰ÈÂıÓÒ˜ ÌÂÁ¿Ï˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·fi ÙȘ ‰È¿ÊÔÚ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ ÓÂÔÁÓÒÓ (MENN), ·ÏÏ¿ Î·È ÛÙȘ ·fi„ÂȘ ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ Ô˘ ÂÚÁ¿-

˙ÔÓÙ·È Û ‰È·ÊÔÚÂÙÈο ‹ Î·È ÛÙÔ ›‰ÈÔ ÙÌ‹Ì·, ·Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ ÛÙ· ÓÂÔÁÓ¿ (8). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ª∂¡¡ ·Ó·ÊÔÚÈο Ì ÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È ÙËÓ ·Ó·ÁηÈfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘. ∂›Û˘, ηٷÁÚ¿ÊËÎ·Ó ÔÈ ÙÚ¤¯Ô˘Û˜ Ù·ÎÙÈΤ˜ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜, Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙ· ÙÚÈÙÔ‚¿ıÌÈ· ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Ù˘ ∂ÏÏ¿‰·˜.

30

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∂ȉÈο ·ÓÒÓ˘Ì· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÂÛÙ¿ÏËÛ·Ó Û 14 ‰ËÌfiÛȘ Î·È È‰ÈˆÙÈΤ˜ ª∂¡¡ Ù˘ ¯ÒÚ·˜, ·ÊÔ‡ ÚÔËÁ‹ıËΠÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›· ÂÓfi˜ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Ì ÙÔ ‰È¢ı˘ÓÙ‹ οı ÌÔÓ¿‰·˜. ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi Ì›· ÂÓfiÙËÙ· Ô˘ ·¢ı˘ÓfiÙ·Ó ÛÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Î·È ·ÊÔÚÔ‡Û ÙȘ ÚÔÛˆÈΤ˜ ÙÔ˘˜ ·fi„ÂȘ ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ó· ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ï‹„˘ ̤ÙÚˆÓ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ Î·È ·fi Ì›· ¿ÏÏË ÂÓfiÙËÙ· Ô˘ ·¢ı˘ÓfiÙ·Ó ÛÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ Î·È ·ÊÔÚÔ‡Û ÙËÓ Ù·ÎÙÈ΋ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙË ª∂¡¡ Ô˘ ‰È¢ı‡ÓÔ˘Ó.

∞ÔÙÂϤÛÌ·Ù· ∆· ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ÂÈÛÙÚ¿ÊËÎ·Ó Û˘ÌÏËڈ̤ӷ ·fi 13 ª∂¡¡, 11 ‰ËÌfiÛȘ Î·È 2 ȉȈÙÈΤ˜. OÈ ÌÔÓ¿‰Â˜ Ô˘ ·¿ÓÙËÛ·Ó ÛÙÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ‹Ù·Ó ÔÈ ·ÎfiÏÔ˘ı˜: ∞’ ª∂¡¡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, µ’ ª∂¡¡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·ÙÚÒÓ “ÕÁÈÔ˜ ∞Ó‰Ú¤·˜”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∞ÏÂÍ¿Ó‰Ú·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “∂. µÂÓÈ˙¤ÏÔ˘”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·31

¶·È‰È·ÙÚÈ΋ 2003;66:29-36

Paediatriki 2003;66:29-36

“π·ÛÒ”, ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ª·È¢ÙËÚ›Ô˘ “ªËÙ¤Ú·”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ∫Ú·ÙÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¡›Î·È·˜ ¶ÂÈÚ·ÈÒ˜, ª∂¡¡ ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ƒ›Ô˘ Î·È ¡ÂÔÁÓÔÏÔÁÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ πÔÎÚ¿ÙÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢. ∂ÚˆÙ‹ıËÎ·Ó Û˘ÓÔÏÈο 117 ÁÈ·ÙÚÔ› Î·È ·¿ÓÙËÛ·Ó 106 (90,6%). ∏ ηٷÓÔÌ‹ ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ·Ó·ÏÔÁ›· ÂȉÈÎÒÓ ÓÂÔÁÓÔÏfiÁˆÓ, ÂȉÈÎÒÓ ·È‰È¿ÙÚˆÓ Ô˘ ÂÚÁ¿˙ÔÓÙ·È Û ÓÂÔÁÓÔÏÔÁÈο ÙÌ‹Ì·Ù· Î·È ÂÍÂȉÈ΢fiÌÂÓˆÓ ÛÙË ¡ÂÔÁÓÔÏÔÁ›· Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™ÙÔ ÂȉÈÎfi ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÁÈ· ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ı› Ë ª∂¡¡ ·¿ÓÙËÛ·Ó 12/13 ‰È¢ı˘ÓÙ¤˜. ∞fi„ÂȘ ÙˆÓ ÁÈ·ÙÚÒÓ OÈ ÂÚˆÙËı¤ÓÙ˜ È·ÙÚÔ› ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿, ·ÎfiÌË Î·È Ù· ÚfiˆÚ·, ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‰˘Û¿ÚÂÛÙ˜ Û˘Ó¤ÂȘ Ô˘ ¤¯ÂÈ Ô fiÓÔ˜ Î·È ÙÔ stress Û ·˘Ù¿. ™ÙÔÓ ¶›Ó·Î· 2 ηٷÁÚ¿ÊÔÓÙ·È ÔÈ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÛÙ· ‰È¿ÊÔÚ· fiÚÁ·Ó· Î·È Û˘ÛÙ‹Ì·Ù· Î·È Ë Û˘¯ÓfiÙËÙ· Ì ÙËÓ ÔÔ›· ·Ó·Ê¤ÚıËÎ·Ó ·fi ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜.

OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› (81%) ıˆÚÔ‡Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Â›Ó·È ··Ú·›ÙËÙË (23%) ‹ ÛËÌ·ÓÙÈ΋ (58%). ¶·Ú¿ÏÏËÏ·, Ë ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˘ ÌË Â›ÁÔ˘Û·˜ ‰È·ÛˆÏ‹ÓˆÛ˘ ÎÚ›ÓÂÙ·È ˆ˜ ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋ ·fi ÙÔ 14% Î·È 46% ÙˆÓ ÂÚˆÙËı¤ÓÙˆÓ, ·ÓÙ›ÛÙÔȯ·. ™¯ÂÙÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ Û ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ fiˆ˜ ·˘Ù¤˜ Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ‰‹ÏˆÛ·Ó fiÙÈ ‰ÂÓ ıˆÚÔ‡Ó ··Ú·›ÙËÙË ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. øÛÙfiÛÔ, ÙÔ 81% ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó ÛÙËÓ ÂÚÒÙËÛË ·˘Ù‹ ıˆÚ› ··Ú·›ÙËÙË ÙË ¯Ú‹ÛË ÙÔÈÎÒÓ ·Ó·ÈÛıËÙÈÎÒÓ ÚÈÓ ÙȘ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ. ∞Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο ÛÙ· ÓÂÔÁÓ¿, ÙÔ 96% ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÙË ¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ È·ÙÚÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË

™‡ÓÔÏÔ ¡ÂÔÁÓÔÏfiÁÔÈ ∂ÍÂȉÈ΢fiÌÂÓÔÈ ¶·È‰›·ÙÚÔÈ

ÕÓ‰Ú˜

°˘Ó·›Î˜

™‡ÓÔÏÔ

35 (33%) 30 2 3

71 (67%) 49 16 6

106 (100%) 79 (74,5%) 18 (17%) 9 (8,5%)

ıˆÚ› ··Ú·›ÙËÙË (78%) ‹ ÛËÌ·ÓÙÈ΋ (18%). ¶Ôχ ÌÈÎÚfi (4%) ‹Ù·Ó ÙÔ ÔÛÔÛÙfi ·˘ÙÒÓ Ô˘ ÈÛÙÂ‡Ô˘Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·Ó·ÏÁËÛ›· ÌÂÙÂÁ¯ÂÈÚËÙÈο. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÌË Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ Ì¤ÙÚˆÓ ÁÈ· ÙË Ì›ˆÛË Ù˘ ¤ÎıÂÛ˘ ÛÙ· ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù· Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛÂˆÓ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ·fi ÙÔ 95% ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·¿ÓÙËÛ·Ó (¶›Ó·Î·˜ 4). ∆Ú¤¯Ô˘Û˜ Ù·ÎÙÈΤ˜ ÛÙȘ ª∂¡¡ ™‡Ìʈӷ Ì ÙȘ ··ÓÙ‹ÛÂȘ ÙˆÓ ‰È¢ı˘ÓÙÒÓ, ÌfiÓÔ ÛÙÔ 33% ÙˆÓ ÌÔÓ¿‰ˆÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘. ™Â 9 ª∂¡¡ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯Ó¿ ηٷÛÙÔÏ‹ Î·È ·Ó·ÏÁËÛ›· ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi, Û 2 ÌÔÓ¿‰Â˜ ÌfiÓÔ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ, fiˆ˜ fiÙ·Ó ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· Î·È Û 1 ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÔÙ¤. ™ÙÔÓ ¶›Ó·Î· 5 Ê·›ÓÔÓÙ·È Ù· ηٷÛÙ·ÏÙÈο-·Ó·ÏÁËÙÈο Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙȘ ‰È¿ÊÔÚ˜ ÌÔÓ¿‰Â˜. ™Â 4 ª∂¡¡ ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ Ë Û˘Ó¯‹˜ ÛÙ¿Á‰ËÓ ¯ÔÚ‹ÁËÛË ÙˆÓ Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î·È ·Ó·ÏÁËÙÈÎÒÓ Ê·Ú̿ΈÓ, ÂÓÒ Û 7 ¯ÔÚËÁÔ‡ÓÙ·È, ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ˘‡ı˘ÓÔ˘ ÁÈ·ÙÚÔ‡, ÛÂ Û˘Ó¯‹ ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË (3 ª∂¡¡) ‹ Û ÚÔηıÔÚÈṲ̂ӷ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· (4 ª∂¡¡). ª˘Ô¯¿Ï·ÛË ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘¯Ó¿ Û 2 ÌÔÓ¿‰Â˜, Û¿ÓÈ· Û 6, ÂÓÒ Û 4 ÌÔÓ¿‰Â˜ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÔÙ¤. ªÂÚÈΤ˜ ÌÔÓ¿‰Â˜ ¯ÚËÛÈÌÔÔÈÔ‡Ó 2 ›‰Ë Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ. ∆· Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Ì˘Ô¯·Ï·ÚˆÙÈο Â›Ó·È ÙÔ ‚ÚˆÌÈÔ‡¯Ô ·ÓÎÔ˘ÚfiÓÈÔ ¶›Ó·Î·˜ 2. ∞fi„ÂȘ ÙˆÓ È·ÙÚÒÓ: ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿ ™˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ ÀÔÍ›· - ÙÒÛË ÎÔÚÂÛÌÔ‡ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ªÂÙ·‚ÔÏ‹ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ªÂÙ·‚ÔÏ‹ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ªÂÙ·‚ÔÏ‹ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ∞ÓÙ·ÁˆÓÈÛÌfi˜ ·Ó·Ó¢ÛÙ‹Ú· ™‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· ∂ȉ›ӈÛË ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÕÓÔÈ· ∂˘ÂÚÂıÈÛÙfiÙËÙ·/stress ªÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ ∞ÒÙÂÚ˜ „˘¯ÔÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜

°È·ÙÚÔ› Ô˘ ·¿ÓÙËÛ·Ó (n=79) % 32

40,5

26

33

22

27,8

9 3 4 4

11,4 3,8 5 5

9 9 15 5

11,4 11,4 19 6,3

21

26,6

31

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·32

¶·È‰È·ÙÚÈ΋ 2003;66:29-36

Paediatriki 2003;66:29-36

¶›Ó·Î·˜ 3. ∞fi„ÂȘ ÙˆÓ È·ÙÚÒÓ: ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ Û ÂÏ¿ÛÛÔÓ˜, ·ÏÏ¿ ÂÒ‰˘Ó˜ ÂÂÌ‚¿ÛÂȘ ∂›‰Ë Â¤Ì‚·Û˘ £ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË OÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ÀÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË ∆ÔÔı¤ÙËÛË ·ÚÙ. ÁÚ·ÌÌ‹˜ ∞Ó·ÚÚÔÊ‹ÛÂȘ ÙÚ·¯ÂÈÔۈϋӷ

∞·Ú·›ÙËÙË n (%)

™ËÌ·ÓÙÈ΋ n (%)

55 (51,8%) 10 (9,4%) 5 (4,7%) 11 (10,3%) 3 (2,8%)

37 (34,9%) 31 (29,2%) 20 (20,7%) 42 (39,6%) 16 (15%)

¶›Ó·Î·˜ 4. ¶ÚÔÙ›ÌËÛË ÙˆÓ È·ÙÚÒÓ Û¯ÂÙÈο Ì ÙÔ˘˜ ÌË Ê·Ú̷΢ÙÈÎÔ‡˜ ÙÚfiÔ˘˜ Ì›ˆÛ˘ ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜ ÛÙ· ÓÂÔÁÓ¿ °È·ÙÚÔ› (n=106) % ¶ÂÚÈÔÚÈÛÌfi˜ ¯ÂÈÚÈÛÌÒÓ ∂Ï¿ÙÙˆÛË ÊˆÙÈÛÌÔ‡ Î·È ıÔÚ‡‚Ô˘ ∞·Ï¿ ·ÙÈο ÂÚÂı›ÛÌ·Ù· (¯¿‰È) ºˆÏȤ˜ ªË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (È›Ï·) ÃÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ

93 85 82 60 70 33

87,7 80,2 77,3 50,6 66 31,1

¶›Ó·Î·˜ 5. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡ (n=11): ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ∫·Ù·ÛÙ·ÏÙÈο-·Ó·ÏÁËÙÈο Ê¿Ú̷η

ª∂¡¡ n (%)

ºÂÓÙ·Ó‡ÏË ªÔÚÊ›ÓË ¶Âıȉ›ÓË ªÈ‰·˙ÔÏ¿ÌË ªÔÚÊ›ÓË + ÊÂÓÙ·Ó‡ÏË ‹ ‰È·˙Â¿ÌË ºÂÓÙ·Ó‡ÏË + Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ‹/Î·È ¯ÏˆÚ¿ÏË ‹ ‚ÂÓ˙ԉȷ˙Â›ÓË

2 (18,3%) 2 (18,3%) 1 (9,1%) 1 (9,1%) 2 (18,3%) 4 (36,3%)

(Pavulon®) (5), ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ (Tracrium®) (3) Î·È ÙÔ cis-·ÙÚ·ÎÔ‡ÚÈÔ (Nimbex®) (2). ™Â 3 ÌÔÓ¿‰Â˜, Ù·˘Ùfi¯ÚÔÓ· Ì ٷ Ì˘Ô¯·Ï·ÚˆÙÈο ¯ÔÚËÁÂ›Ù·È Î·È Î¿ÔÈÔ Î·Ù·ÛÙ·ÏÙÈÎfi-·Ó·ÏÁËÙÈÎfi (Û 1 ÌÔÓ¿‰· ÊÂÓÙ·Ó‡ÏË, Û 1 ‰È·˙Â¿ÌË Î·È Û 1 ¤Ó˘‰ÚË ¯ÏˆÚ¿ÏË), ÂÓÒ Û 5 ÌÔÓ¿‰Â˜ ÂÈÎÚ·Ù› Ë ¿Ô„Ë fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Î·È ¿ÏÏÔ Ê¿ÚÌ·ÎÔ. ™Â η̛· ÌÔÓ¿‰· ‰ÂÓ ¯ÔÚËÁÂ›Ù·È Ì˘Ô¯¿Ï·ÛË ÚÈÓ ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· Â›ÁÔ˘Û·˜ ÌË ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˘ ‰È·ÛˆÏ‹ÓˆÛ˘. ∞Ó·ÊÔÚÈο Ì ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÛÙȘ ÌÔÓ¿‰Â˜ Û¯ÂÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÛÙȘ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Û 8 ÌÔÓ¿‰Â˜ ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ ·Ó·ÏÁËÙÈÎfi, Û˘ÛÙËÌ·ÙÈο ‹ ÙÔÈο. ™ÙÔÓ ¶›Ó·Î· 6 Ê·›ÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ Î·È ÙÔ Â›‰Ô˜ ÙÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ‰È¿ÊÔÚ˜ ª∂¡¡ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÒ‰˘ÓˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. ∞ÓÂÍ¿ÚÙËÙ·, ¿ÓÙˆ˜, ·fi ÙËÓ Ù·ÎÙÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÚÔ˜ ÙÔ ·ÚfiÓ ÛÙÔ ÙÌ‹Ì· ÙÔ˘˜, 9 ‰È¢ı˘ÓÙ¤˜ ıˆÚÔ‡Ó ÙË

32

¢ÂÓ ¯ÚÂÈ¿˙ÂÙ·È n (%) 11 65 75 50 86

(10,3%) (61,3%) (70,7%) (47,1%) (81,1%)

¢ÂÓ ·¿ÓÙËÛ·Ó n (%) 3 (2,8%) 4 (3,7%) 3 (2,8%) 1 (0,9%)

¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ Î·È ·Ó·ÏÁËÛ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÒ‰˘ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋, 2 ÈÛÙÂ‡Ô˘Ó fiÙÈ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È, ÂÓÒ Ô ‰È¢ı˘ÓÙ‹˜ Ì›·˜ ÌÔÓ¿‰·˜ ‰ÂÓ ·¿ÓÙËÛÂ. ªÂÙ¿ ·fi Ì›˙ÔÓ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ·Ó·ÏÁËÛ›· ¯ÔÚËÁÂ›Ù·È Û 11/12 ÌÔÓ¿‰Â˜ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË, ÂÓÒ 1 ÌÔÓ¿‰· ‰ÂÓ ÓÔÛËχÂÈ ¯ÂÈÚÔ˘ÚÁÈο ÂÚÈÛÙ·ÙÈο. ™ÙÔÓ ¶›Ó·Î· 7 Ê·›ÓÔÓÙ·È Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÂÙÂÁ¯ÂÈÚËÙÈο. ∆¤ÏÔ˜, Û fiϘ ÙȘ ÌÔÓ¿‰Â˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î¿ÔÈÔ Â›‰Ô˜ ÌË Ê·Ú̷΢ÙÈ΋˜ ·Ú¤Ì‚·Û˘, Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Â͈ÙÂÚÈÎÒÓ ‰ÈÂÁÂÚÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Î·È ÙË Ì›ˆÛË ÙÔ˘ fiÓÔ˘ Î·È Ù˘ ‰˘ÛÊÔÚ›·˜ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ (¶›Ó·Î·˜ 8). ™˘˙‹ÙËÛË ™ÙË ÌÂϤÙË ·˘Ù‹ ¤ÁÈÓ ÚÔÛ¿ıÂÈ· ηٷÁÚ·Ê‹˜ ÙˆÓ ·fi„ÂˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ÁÈ·ÙÚÒÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· ÓÂÔÁÓÒÓ, ·Ó·ÊÔÚÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. §fiÁˆ Ù˘ ÌÂÁ¿Ï˘ ·ÓÙ·fiÎÚÈÛ˘ ÙˆÓ ÂÚˆÙËı¤ÓÙˆÓ, ıˆÚÂ›Ù·È fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó Â·ÚÎÒ˜ ÙËÓ ÂÏÏËÓÈ΋ Ú·ÁÌ·ÙÈÎfiÙËÙ· ÛÙÔ ı¤Ì· ·˘Ùfi. ∂›Ó·È Ôχ ÂÓı·ÚÚ˘ÓÙÈÎfi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔÓ fiÓÔ Î·È Â›Ó·È ÂÓ‹ÌÂÚÔÈ ÁÈ· ÙȘ ‚Ï·ÙÈΤ˜ Û˘Ó¤ÂȤ˜ ÙÔ˘ Û ·˘Ù¿ Î·È È‰È·›ÙÂÚ· ÛÙÔ Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. øÛÙfiÛÔ, Û ÏÈÁfiÙÂÚ˜ ·fi ÙȘ ÌÈÛ¤˜ ª∂¡¡ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ¯ÔÚ‹ÁËÛ˘ ·Ó·ÏÁËÛ›·˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÒ‰˘ÓÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜. ™ÙȘ ˘fiÏÔÈ˜ ª∂¡¡, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÂÍ·ÚÙ¿Ù·È Ì¿ÏÏÔÓ ·fi ÙȘ ÚÔÛˆÈΤ˜ ·fi„ÂȘ Î·È ÚÔÙÈÌ‹ÛÂȘ ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡. ¶·ÚfiÌÔÈ· Â›Ó·È Ù· ‰Â‰Ô̤ӷ ·fi ÙÔ ‰ÈÂıÓ‹ ¯ÒÚÔ, fiÔ˘ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Ù· ·Ó·ÏÁËÙÈο Ê¿Ú̷η ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ôχ ÏÈÁfiÙÂÚÔ ÛÙȘ ÓÂÔÁÓÈΤ˜ ·’ fiÙÈ ÙȘ ·È‰È·ÙÚÈΤ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜ (9). ŒÙÛÈ, Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿ ·Ú·Ì¤ÓÂÈ ÌË ÈηÓÔÔÈËÙÈ΋, ·Ú¿ ÙËÓ ÈÛ¯˘Ú‹ ÂÔ›ıËÛË ÙˆÓ ÁÈ·ÙÚÒÓ fiÙÈ Ù· ÓÂÔÁÓ¿ ‚ÈÒÓÔ˘Ó ÂÒ‰˘Ó˜ ÂÌÂÈڛ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰È·ÊfiÚˆÓ ¯ÂÈÚÈÛÌÒÓ (10-12).

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·33

¶·È‰È·ÙÚÈ΋ 2003;66:29-36

Paediatriki 2003;66:29-36

¶›Ó·Î·˜ 6. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡: Û˘ÛÙËÌ·ÙÈ΋ ‹ ÙÔÈ΋ ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÚÈÓ ·fi ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ ª∂¡¡ £ˆÚ·ÎÈ΋ ·ÚÔ¯¤Ù¢ÛË OÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË ∆ÔÔı¤ÙËÛË ·ÚÙËÚȷ΋˜ ÁÚ·ÌÌ‹˜ ∂ÎÏÂÎÙÈ΋ ‰È·ÛˆÏ‹ÓˆÛË ∞Ó·ÚÚfiÊËÛË ·fi ÙÚ·¯ÂÈÔۈϋӷ ÀÂÚË‚È΋ ·Ú·Î¤ÓÙËÛË ÕÏÏ·

8 (66,7%) 3 (25%) 1 (8,3%) 2 (17%) 5 (41,7%)

¶›Ó·Î·˜ 7. ∆·ÎÙÈ΋ ÙˆÓ ª∂¡¡ (n=11): ¯Ú‹ÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÌÂÙÂÁ¯ÂÈÚËÙÈο ∞Ó·ÏÁËÙÈÎfi ªÔÚÊ›ÓË ªÔÚÊ›ÓË + ÊÂÓÙ·Ó‡ÏË ªÔÚÊ›ÓË + ·Ú·ÎÂÙ·ÌfiÏË ºÂÓÙ·Ó‡ÏË ºÂÓÙ·Ó‡ÏË + ·Ú·ÎÂÙ·ÌfiÏË ¶·Ú·ÎÂÙ·ÌfiÏË

º¿Ú̷η (·ÚÈıÌfi˜ ª∂¡¡) ºÂÓÙ·Ó‡ÏË (1), ÌÔÚÊ›ÓË (1), ÏȉÔη˝ÓË (4), EMLA (1) §È‰Ôη˝ÓË (2), EMLA (1) ºÂÓÙ·Ó‡ÏË EMLA (2) §È‰Ôη˝ÓË (4), EMLA (1) ¶›Ó·Î·˜ 8. ∆Ú¤¯Ô˘Û· Ú·ÎÙÈ΋ Û¯ÂÙÈο Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÌË Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ÛÙȘ ª∂¡¡ ª∂¡¡ n (%)

ª∂¡¡ n (%) 1 (9,1%) 2 (18,2%) 1 (9,1%) 3 (27,2%) 2 (18,2%) 1 (9,1%)

∏ ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ÛÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÌÔÚ› ηٿ ¤Ó· ̤ÚÔ˜ Ó· ·Ô‰Ôı› ÛÙË ‰˘ÛÎÔÏ›· ÎÏÈÓÈ΋˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ fiÓÔ˘, ÛÙÔ Êfi‚Ô ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ Î·È È‰È·›ÙÂÚ· ÛÙÔÓ ÚÔ‚ÏËÌ·ÙÈÛÌfi Ô˘ ˘¿Ú¯ÂÈ Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÓÂÔÁÓÈÎfi ÂÁΤʷÏÔ (7). ∏ ‰È·ÛˆÏ‹ÓˆÛË Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ô˘ ÚÔηÏ› fiÓÔ Î·È ‰˘ÛÊÔÚ›· ÛÙ· ÓÂÔÁÓ¿. ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ ‰ÂÓ ÓÔ›ٷÈ, ÂÎÙfi˜ ÂȉÈÎÒÓ ÂÚÈÙÒÛˆÓ, ‰È·ÛˆÏ‹ÓˆÛË ¯ˆÚ›˜ Â·Ú΋ ηٷÛÙÔÏ‹, ÏfiÁˆ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ stress Ô˘ Û˘ÓÂ¿ÁÂÙ·È. ∂›Û˘, Û ÌË Î·ÙÂÛÙ·Ï̤ӷ ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·ÛˆÏ‹ÓˆÛ˘ ÂÏ·ÙÙÒÓÂÙ·È Ë ÌÂÚÈ΋ ›ÂÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ (13) Î·È ·˘Í¿ÓÂÙ·È Ë ·ÚÙËÚȷ΋ Î·È ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË (14,15), ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÚfiÎÏËÛË ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜. øÛÙfiÛÔ, ‹Ù·Ó ηÈ, ÂÓ Ì¤ÚÂÈ, ·Ú·Ì¤ÓÂÈ ¿ÁÈ· ‰ÈÂıÓ‹˜ Ù·ÎÙÈ΋ ÛÙȘ ª∂¡¡ Ó· ‰È·ÛˆÏËÓÒÓÔÓÙ·È “Û ÂÁÚ‹ÁÔÚÛË” Ù· ÓÂÔÁÓ¿, ¯ˆÚ›˜ Ê·Ú̷΢ÙÈ΋ ηٷÛÙÔÏ‹, ·Ú¿ ÙȘ ÂӉ›ÍÂȘ fiÙÈ ÔÈ ·Ú·¿Óˆ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ Î·È Î·Ù·ÛÙ·ÏÙÈÎÒÓ ÚÈÓ ÙË ‰È·ÛˆÏ‹ÓˆÛË (16,17). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ÌÈÛÔ› ÁÈ·ÙÚÔ› Ô˘ ·¿ÓÙËÛ·Ó ıˆÚÔ‡Ó ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ Û ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·ÛˆÏ‹ÓˆÛË ··Ú·›ÙËÙË ‹ ÛËÌ·ÓÙÈ΋. ∏ Ù·ÎÙÈ΋ ·˘Ù‹, fï˜, ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔ Û 1 ÌÔÓ¿‰·. ™Â ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ ‚Ú¤ıËΠfiÙÈ ÛÙÔ 37% Î·È 69% ÙˆÓ ÓÂÔÁÓÈÎÒÓ ÌÔÓ¿‰ˆÓ ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· Î·È ∞˘ÛÙÚ·Ï›·, ·ÓÙ›ÛÙÔȯ·, ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ Î·Ù·ÛÙ·ÏÙÈÎfi ÚÈÓ ·fi ÙËÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·ÛˆÏ‹ÓˆÛË. ª¿ÏÈÛÙ·, Î·È ÛÙȘ ‰‡Ô ¯ÒÚ˜ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ Ê·ÚÌ¿-

¶ÂÚÈÔÚÈÛÌfi˜ ¯ÂÈÚÈÛÌÒÓ ∂Ï¿ÙÙˆÛË ÊˆÙÈÛÌÔ‡ Î·È ıÔÚ‡‚Ô˘ ∞·Ï¿ ·ÙÈο ÂÚÂı›ÛÌ·Ù· (¯¿‰È) ºˆÏȤ˜ ªË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (È›Ï·) ÃÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÕÏÏ·

10 (83,3%) 5 (42%) 8 (66,6%) 4 (33,3%) 10 (83,3%) 3 (25%) 1 (8,3%)

ÎˆÓ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙ· ÙÂÏÂÈfiÌËÓ·, ÚÔÊ·ÓÒ˜ ÏfiÁˆ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ‰˘ÛÎÔÏ›·˜ ÛÙË ‰È·ÛˆÏ‹ÓˆÛË ÙÔ˘ ÌÂÁ¿ÏÔ˘ Î·È ˙ˆËÚÔ‡ ÓÂÔÁÓÔ‡ (18,19).

O Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜, Ô˘ Û˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ÙË ‰È·ÛˆÏ‹ÓˆÛË, ·ÔÙÂÏ› ‰˘Û¿ÚÂÛÙÔ, ›Ûˆ˜ Î·È ÂÒ‰˘ÓÔ, ÂÚ¤ıÈÛÌ· ÁÈ· Ù· ÓÂÔÁÓ¿, ÙÔ ÔÔ›Ô ÚÔηÏ› ‰˘ÛÎÔÏ›· Û˘Á¯ÚÔÓÈÛÌÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú·, ÂÂÈÛfi‰È· ˘ÔÍ›·˜, Û‡Ó‰ÚÔÌ· ‰È·Ê˘Á‹˜ ·¤Ú· Î·È ÌÂÙ·‚ÔϤ˜ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ ÂÏ·ÙÙÒÓÔÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÔÈÔÂȉÒÓ (ÌÔÚÊ›ÓË ‹ ÊÂÓÙ·Ó‡ÏË) (20-22). ∞Ó Î·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ Â›Ó·È Ì›˙ÔÓ ËıÈÎfi ‰›ÏËÌÌ·, Ë ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÙÈÎÒÓ ‰ÂÓ ıˆÚÂ›Ù·È ˘Ô¯ÚˆÙÈ΋ Î·È ·ÔÙÂÏ› ‰›Ô ÎÏÈÓÈ΋˜ ¤Ú¢ӷ˜ (23). ™ÙËÓ ∂ÏÏ¿‰·, Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÓÂÔÁÓÔÏfiÁˆÓ ÈÛÙ‡ÂÈ fiÙÈ Ù· ‰È·ÛˆÏËӈ̤ӷ ÓÂÔÁÓ¿ ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ù·ÛÙÔÏ‹ Î·È Â›Ó·È È‰È·›ÙÂÚ· ÂÓı·ÚÚ˘ÓÙÈÎfi fiÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜ ¯ÔÚËÁÂ›Ù·È Î¿ÔÈÔ ·Ó·ÏÁËÙÈÎfi ‹ ηٷÛÙ·ÏÙÈÎfi. ∏ ÔÈÎÈÏ›· ÙˆÓ ·Ó·ÏÁËÙÈÎÒÓ ‹ ηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ‰ÈÂıÓÒ˜ ÔÌÔʈӛ· Û¯ÂÙÈο Ì ÙÔ ÈÔ Î·Ù¿ÏÏËÏÔ Ê¿ÚÌ·ÎÔ ‹ Û˘Ó‰˘·ÛÌfi ÙÔ˘˜. ¶¿ÓÙˆ˜, Ù· ÔÈÔÂȉ‹, ȉȷ›ÙÂÚ· Ë ıÂÈÈ΋ ÌÔÚÊ›ÓË Î·È ÙÔ Û˘ÓıÂÙÈÎfi ÔÈÔÂȉ¤˜ ÊÂÓÙ·Ó‡ÏË, ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÈÔ Û˘¯Ó¿ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ˘˜ ·Ó·ÏÁËÙÈÎÔ‡˜ Î·È Î·Ù·ÛÙ·ÏÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÛÙ· ÓÂÔÁÓ¿, fiˆ˜ Î·È ÛÙȘ ª∂¡¡ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ∏ ¯Ú‹ÛË Î·È ÙˆÓ ‰‡Ô ıˆÚÂ›Ù·È ÁÂÓÈο ·ÛÊ·Ï‹˜ (24,25) Î·È ÚÔÛʤÚÂÈ ·ÚfiÌÔÈÔ ·Ó·ÏÁËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· (26). ∏ Ìȉ·˙ÔÏ¿ÌË, Ô˘ Â›Ó·È ‚Ú·¯Â›·˜ ‰Ú¿Û˘ ‚ÂÓ˙ԉȷ˙Â›ÓË, ÏfiÁˆ ÙˆÓ Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ Ù˘ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ Î·È Î˘Ú›ˆ˜ Ù˘

33

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·34

¶·È‰È·ÙÚÈ΋ 2003;66:29-36

¤ÏÏÂȄ˘ ÂÓÂÚÁÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ, ¤¯ÂÈ ÂÎÙÔ›ÛÂÈ ÙË ‰È·˙Â¿ÌË ·fi ÙȘ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ÓÔÛËÏ›·˜ (7). øÛÙfiÛÔ, ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ı¤ÙÔ˘Ó ˘fi ·ÌÊÈÛ‚‹ÙËÛË ÙËÓ ·Ó·ÁηÈfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ¯Ú‹Û˘ Ù˘, ηı’ fiÛÔÓ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÓÂÔÁÓ¿ Ì ™∞¢ ‰ÂÓ ÌÂÙ¤‚·Ï ÙËÓ ÂͤÏÈÍË Î·È ÙȘ ÂÈÏÔΤ˜ Ù˘ ÓfiÛÔ˘ (27). ∂ÈϤÔÓ, Û˘Û¯ÂÙ›ÛÙËΠ̠ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (27,28) Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ÛËÌ·ÓÙÈÎÒÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ·fi ÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· (Ì˘ÔÎÏÔӛ˜, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ‚·ıÌÔ‡ πππ-πV, ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· Î·È ı¿Ó·ÙÔÈ) (24,29). ™‡Ìʈӷ Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, Ë Ì˘Ô¯¿Ï·ÛË ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ÂÚÈÙÒÛÂȘ ·‰˘Ó·Ì›·˜ Û˘Á¯ÚÔÓÈÛÌÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ÌfiÓÔ Û 2 ª∂¡¡. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Û˘Ì‚·‰›˙ÂÈ Ì ÙË ÁÂÓÈÎfiÙÂÚË Ù¿ÛË Ì›ˆÛ˘ Ù˘ ¯Ú‹Û˘ Ù˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÏfiÁˆ ΢ڛˆ˜ ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ·fi Ù· Ì˘Ô¯·Ï·ÚˆÙÈο Î·È Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ Û˘Á¯ÚÔÓÈṲ̂ÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (30-33). ŒÙÛÈ, Ì ٷ ÛËÌÂÚÈÓ¿ ‰Â‰Ô̤ӷ, Ù· Ì˘Ô¯·Ï·ÚˆÙÈο ¤¯Ô˘Ó ı¤ÛË ÌfiÓÔ ÛÙËÓ ÂÚ›ÙˆÛË fiÔ˘ ÙÔ ÓÂÔÁÓfi ÂÍ·ÎÔÏÔ˘ı› Ó· “Ì¿¯ÂÙ·È” ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ·Ú¿ ÙËÓ Â·Ú΋ ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Î·È Î·Ù·ÛÙÔÏ‹˜ Î·È ÌÂÙ¿ ÙËÓ ·ÔÙ˘¯›· ÙÔ˘ Û˘Á¯ÚÔÓÈṲ̂ÓÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ (33). ŒÓ·˜ Û˘¯Ófi˜ ¯ÂÈÚÈÛÌfi˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Â›Ó·È Ë ·Ó·ÚÚfiÊËÛË Ì¤Ûˆ ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÔ›·˜ ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ Î·È ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Î·È ·ÚÔ‰È΋ ˘ÔÍ·ÈÌ›· (34,35). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ù· Ê·ÈÓfiÌÂÓ· ·˘Ù¿ ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Î·Ù·ÛÙÔÏ‹˜ (24,36). øÛÙfiÛÔ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÓÂÔÁÓÔÏfiÁÔ˘˜ Ô˘ ÂÚˆÙ‹ıËÎ·Ó Ê·›ÓÂÙ·È Ó· ·Ú·‚ϤÔ˘Ó ÙË ÛËÌ·Û›· ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ ·˘ÙÔ‡ ˆ˜ ËÁ‹˜ fiÓÔ˘ Î·È ‰˘ÛÊÔÚ›·˜ Î·È Ó· ıˆÚÔ‡Ó ÌË ··Ú·›ÙËÙË ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ ÚÈÓ ÙËÓ ·Ó·ÚÚfiÊËÛË Ù˘ ÙÚ·¯Â›·˜. ∫·Ù’ Â¤ÎÙ·ÛË, Ë ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ηٷÛÙ·ÏÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÚÈÓ ÙËÓ ·Ó·ÚÚfiÊËÛË ‰ÂÓ ·ÔÙÂÏ› Ù·ÎÙÈ΋ ÙˆÓ ª∂¡¡ ÛÙËÓ ∂ÏÏ¿‰·.

OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÈ·ÙÚÔ› ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰‹ÏˆÛ·Ó fiÙÈ Ô ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ fiÓÔ˜ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Â·ÚÎÒ˜. øÛÙfiÛÔ, ·ÎfiÌË Î·È ÙÔ ÌÈÎÚfi ÔÛÔÛÙfi (4%) Ô˘ ÈÛÙ‡ÂÈ ÙÔ ·ÓÙ›ıÂÙÔ, ıˆÚÂ›Ù·È fiÙÈ ‰ÂÓ Â›Ó·È ·Ô‰ÂÎÙfi. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÔÓ¿‰Â˜, Ô fiÓÔ˜ ÌÂÙ¿ ·fi Ì›˙ÔÓ˜ ÂÂÌ‚¿ÛÂȘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÈηÓÔÔÈËÙÈο, ΢ڛˆ˜ Ì ÔÈÔÂȉ‹. ∞ÓÙ›ıÂÙ·, Û ̛· ÌÔÓ¿‰· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÌfiÓÔ ·Ú·ÎÂÙ·ÌfiÏË, Ë ÔÔ›· fï˜ ‰ÂÓ ÚÔÛʤÚÂÈ ÈηÓÔÔÈËÙÈ΋ ·Ó·ÏÁËÛ›· ÌÂÙÂÁ¯ÂÈÚËÙÈο (37). ∞Ó·ÊÔÚÈο Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÏÁËÛ›·˜ Û ÂÏ¿ÛÛÔÓ˜ ·ÏÏ¿ ÂÒ‰˘Ó˜ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÁÈ·ÙÚÒÓ ÈÛÙ‡ÂÈ fiÙÈ ‰ÂÓ ··ÈÙ›-

34

Paediatriki 2003;66:29-36

Ù·È Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ·Ó·ÏÁËÙÈÎÔ‡ ÁÈ· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜, Ì ÂÍ·›ÚÂÛË ÙËÓ ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘. ∞ÓÙ›ıÂÙ·, Ù· ÙÔÈο ·Ó·ÈÛıËÙÈο ıˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÁÈ· ÙȘ ÌÈÎÚÔÂÂÌ‚¿ÛÂȘ. øÛÙfiÛÔ, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ª∂¡¡ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛˆÓ. O ÂÒ‰˘ÓÔ˜ ¯ÂÈÚÈÛÌfi˜, ÁÈ· ÙÔÓ ÔÔ›Ô Û˘¯ÓfiÙÂÚ· ¯ÔÚËÁÂ›Ù·È Û˘ÛÙËÌ·ÙÈο ‹ ÙÔÈο ·Ó·ÏÁËÛ›·, Â›Ó·È Ë ÙÔÔı¤ÙËÛË ıˆÚ·ÎÈ΋˜ ·ÚÔ¯¤Ù¢Û˘ ηÈ, ÏÈÁfiÙÂÚÔ Û˘¯Ó¿, Ë ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË. ¶·ÚfiÌÔȘ Ù·ÎÙÈΤ˜ ·ÓÂ·ÚÎÔ‡˜ ‹ ÂÏ¿¯ÈÛÙ˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ ÙˆÓ ÌÈÎÚÔÂÂÌ‚¿ÛÂˆÓ ·Ú·ÙËÚÔ‡ÓÙ·È ‰ÈÂıÓÒ˜ (9-11,38). ∂Ӊ¯Ô̤ӈ˜, ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ Êfi‚Ô ÂÌÊ¿ÓÈÛ˘ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ Ë ÌÂı·ÈÌÔÛÊ·ÈÚÈÓ·ÈÌ›· Ô˘ ·Ú·ÙËÚÂ›Ù·È Ì ÙË ¯Ú‹ÛË Ù˘ ·ÏÔÈÊ‹˜ ÏȉÔη˝Ó˘/ÚÈÏÔη˝Ó˘ (EMLA) (39).

OÈ ÌË Ê·Ú̷΢ÙÈÎÔ› ÙÚfiÔÈ ·Ó·ÏÁËÛ›·˜, fiˆ˜ Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ÂÒ‰˘ÓˆÓ ¯ÂÈÚÈÛÌÒÓ, Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ʈÙÈÛÌÔ‡ Î·È ÙÔ˘ ıÔÚ‡‚Ô˘, ÙÔ ¯¿‰È, Ë ÙÔÔı¤ÙËÛË ÙˆÓ ÓÂÔÁÓÒÓ Û ʈÏȤ˜ Î·È Ô ÌË ‰È·ÙÚÔÊÈÎfi˜ ıËÏ·ÛÌfi˜ (È›Ï·) ‹ Ë ¯ÔÚ‹ÁËÛË ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, ·ÔÙÂÏÔ‡Ó ÂÓ·ÏÏ·ÎÙÈο ̤۷ Ì›ˆÛ˘ ÙÔ˘ stress Î·È ÙÔ˘ fiÓÔ˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙȘ ÂÏ¿ÛÛÔÓ˜ ÂÂÌ‚¿ÛÂȘ (40,41). OÈ Ì˯·ÓÈÛÌÔ› Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ¯ÂÈÚÈÛÌÔ› ·˘ÙÔ› ÚÔηÏÔ‡Ó ·Ó·ÏÁËÛ›·, ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›. ŒÙÛÈ, Ë ·Ó·ÏÁËÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌË ‰È·ÙÚÔÊÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÔÙÂÏ› ¤Ó· ΢ڛ·Ú¯Ô Î·È Â˘¯¿ÚÈÛÙÔ ÂÚ¤ıÈÛÌ· Ô˘ ·ÔÛ¿ ÙËÓ ÚÔÛÔ¯‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙÔÓ fiÓÔ, ÂÓÒ ·˘Ù‹ ÙˆÓ ÁÏ˘ÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ ·Ô‰›‰ÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÂÓ‰ÔÁÂÓÒÓ ÔÈÔÂȉÒÓ (42). ∞fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÚÔ·ÙÂÈ fiÙÈ ÔÈ ‰È¿ÊÔÚ˜ ÌË Ê·ÚÌ·ÎÔÏÔÁÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙ¤˜ ·fi ÙË ÌÂÁ¿ÏË ÏÂÈÔ„ËÊ›· ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÂÚˆÙ‹ıËÎ·Ó Î·È fiÙÈ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÓÂÔÁÓÈΤ˜ ÌÔÓ¿‰Â˜. ∆· ̤ÙÚ· Ô˘ Â›Ó·È ·Ô‰ÂÎÙ¿ ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ È·ÙÚÔ‡˜ Â›Ó·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÂÈÚÈÛÌÒÓ Î·È ÙˆÓ ¤ÓÙÔÓˆÓ Â͈ÙÂÚÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ (ʈÙÈÛÌfi˜, ıfiÚ˘‚Ô˜), ηıÒ˜ Î·È Ë ÂÊ·ÚÌÔÁ‹ ··ÏÒÓ ·ÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ (¯¿‰È). ∞ÓÙ›ıÂÙ·, ·fi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ Ù·ÎÙÈÎÒÓ ÙˆÓ ª∂¡¡, Ê·›ÓÂÙ·È fiÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÚÈÔÚÈÛÙ› ÙÔ Êˆ˜ Î·È Ô ıfiÚ˘‚Ô˜, ÂÓÒ Ù· ÌË Ê·Ú̷΢ÙÈο ̤ÙÚ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· Â›Ó·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ ¯ÂÈÚÈÛÌÒÓ Î·È Ë È›Ï·. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÚÔ·ÙÂÈ fiÙÈ ÔÈ ŒÏÏËÓ˜ ÓÂÔÁÓÔÏfiÁÔÈ ÈÛÙÂ‡Ô˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ “ÔÓÔ‡Ó” ηÈ, ·Ú¿ÏÏËÏ·, ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÙȘ ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÙÔ˘ fiÓÔ˘ Î·È ÙÔ˘ stress Û ·˘Ù¿. øÛÙfiÛÔ, Û ϛÁ˜ ª∂¡¡ ÂÊ·ÚÌfi˙ÂÙ·È Î¿ÔÈÔ Û˘ÁÎÂÎÚÈ̤ÓÔ

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ÚˆÙfiÎÔÏÏÔ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ Ô˘ Û˘Óԉ‡ÂÈ ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, Ì ÂÍ·›ÚÂÛË ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÏÁËÛ›·. ∞·ÈÙÂ›Ù·È ÈÔ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ fiÓÔ˘ ÛÙȘ ÂÏÏËÓÈΤ˜ ª∂¡¡. ¶Èı·ÓÒ˜, ÂÈÛÙËÌÔÓÈÎÔ› ÊÔÚ›˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡, fiˆ˜ ÔÈ ¶·È‰È·ÙÚÈΤ˜ Î·È ¶ÂÚÈÁÂÓÓËÙÈΤ˜ ∂Ù·ÈÚ›˜, ı· ¤ÚÂ ӷ ·Ó·Ù‡ÍÔ˘Ó ÔÌ¿‰· ÂÚÁ·Û›·˜ Ë ÔÔ›· ı· ÚÔÙ›ÓÂÈ Û˘ÁÎÂÎÚÈ̤Ó˜ Ô‰ËÁ›Â˜ Ê·ÚÌ·ÎÔÏÔÁÈ΋˜ ÚfiÏ˄˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ fiÓÔ˘ ÛÙ· ÓÂÔÁÓ¿. ∂˘¯·ÚÈÛٛ˜ OÈ Û˘ÁÁÚ·Ê›˜ ¢¯·ÚÈÛÙÔ‡Ó ıÂÚÌ¿ ÙÔ È·ÙÚÈÎfi ÚÔÛˆÈÎfi ÙˆÓ ª∂¡¡ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙË ÌÂϤÙË Î·ıÒ˜ Î·È ÙÔ˘˜ ‰È¢ı˘ÓÙ¤˜ ÙˆÓ ÌÔÓ¿‰ˆÓ: ∞Ó‰ÚfiÓÈÎÔ˘ ™, ¢ÂÏ·ÁÚ·ÌÌ¿ÙÈη ∏, º·ÚÚ‹-∫ˆÛÙÔÔ‡ÏÔ˘ §, °Ô‡Ó·ÚË ∞, ∫·ÏÔÁÈ¿ÓÓË ¡, ∫ˆÛÙ·ÓÙ›ÓÔ˘ °, ∫ÒÛÙ·ÏÔ Ã, ª·ÓÙ·Áfi ™, ¶ÂÙÌÂ˙¿ÎË ™, ™ÈÁ¿Ï· π, ™ÔÊ·Ù˙‹ π Î·È •¿ÓıÔ˘ ª.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Barker DP, Rutter ¡. Exposure to invasive procedures in neonatal intensive care unit admissions. Arch Dis Child Fetal Neonatal Ed 1995;72:F47-48.

2. Anand KJ, Carr DB. The neuroanatomy, neurophysiology, and neurochemistry of pain, stress, and analgesia in newborns and children. Pediatr Clin North Am 1989;36:795821.

3. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317:1321-1329.

4. Porter FL, Wolf CM, Miller JP. Procedural pain in newborn infants: the influence of intensity and development.

Pediatrics 1999;104:e13.

5. Menon G, Anand KJ, McIntosh ¡. Practical approach to analgesia and sedation in the neonatal intensive care unit.

Semin Perinatol 1998;22:417-424.

6. Porter FL, Grunau RE, Anand KJ. Long-term effects of pain in infants. J Dev Behav Pediatr 1999;20:253-261.

7. American Academy of Pediatrics and Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics 2000;105:454-461.

8. Kahn DJ, Richardson DK, Gray JE, Bednarek F, Rubin LP, Shah B et al. Variation among neonatal intensive care units in narcotic administration. Arch Pediatr Adolesc Med 1998;152:844-851.

9. Bauchner ∏, May ∞, Coates ∂. Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. J Pediatr 1992;121:647-649.

10. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics 1997;100:626-632.

11. Johnston CC, Collinge JM, Henderson SJ, Anand KJ. ∞ cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units. Clin J Pain 1997;13:308-312.

12. Heaton ƒ, Herd D. Neonatal pain relief [letter]. Arch Dis Child Fetal Neonatal Ed 2000;83:F77-78.

Paediatriki 2003;66:29-36

13. Gibbons İ, Swedlow DB. Changes in oxygen saturation during elective tracheal intubation in infants. Anesth Analg 1987;66:860-862.

14. Raju ∆¡, Vidyasagar D, Torres C, Grundy D, Bennett EJ. Intracranial pressure during intubation and anesthesia in infants. J Pediatr 1980;96:860-862.

15. Friesen RH, Honda ∞∆, Thieme RE. Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg 1987;66:874-878.

16. Hickey PR, Hansen DD. Fentanyl- and sufentanil-oxygenpancuronium anesthesia for cardiac surgery in infants.

Anesth Analg 1984;63:117-124.

17. Bhutada ∞, Sahni R, Rastogi S, Wung J∆. Randomized controlled trial of thiopental for intubation in neonates. Arch Dis Child Fetal Neonatal Ed 2000;82:F34-37.

18. Whyte S, Birrell G, Wyllie J. Premedication before intubation in UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-41.

19. Hancock S, Newell S, Brierley J, Berry ∞. Premedication for neonatal intubation: current practice in Australia and the United Kingdom [letter]. Arch Dis Child Fetal Neonatal Ed 2000;83:F77.

20. Dyke ªƒ, Kohan R, Evans S. Morphine increases synchronous ventilation in preterm infants. J Paediatr Child Health 1995;31:176-179.

21. Goldstein RF, µrazy JE. Narcotic sedation stabilizes arterial blood pressure fluctuations in sick premature infants. J Perinatol 1991;11:365-371.

22. Sabatino G, Quartulli L, Di Fabio S, Ramenghi LA. Hemodynamic effects of intravenous morphine infusion in ventilated preterm babies. Early Hum Dev 1997;47:263-270.

23. Kennedy KA, Tyson JE. Narcotic analgesia for ventilated newborns: are placebo-controlled trials ethical and necessary? J Pediatr 1999;134:127-129.

24. Anand KJ, Barton µ∞, McIntosh ¡, Lagercrantz ∏, Pelausa ∂, Young ∆∂ et al. Analgesia and sedation in preterm neonates who require ventilatory support: results from the ¡Oƒ∞π¡ trial. Neonatal Outcome and Prolonged Analgesia in Neonates. Arch Pediatr Adolesc Med 1999;153:331-338.

25. Quinn MW, Wild J, Dean HG, Hartley R, Rushforth JA, Puntis JW et al. Randomized double-blind controlled trial of effect of morphine Ôn catecholamine concentrations in ventilated preterm babies. Lancet 1993;342:324-327.

26. Lago ƒ, Benini F, Agosto C, Zacchello F. Randomized controlled trial of low dose fentanyl infusion in preterm infants with hyaline membrane disease. Arch Dis Child Fetal Neonatal Ed 1998;79:F194-197.

27. Jacqz-Aigrain ∂, Daoud ƒ, Burtin ƒ, Desplanques L, Beaufils F. Placebo-controlled trial of midazolam sedation in mechanically ventilated newborn babies. Lancet 1994;344:646-650.

28. Jacqz-Aigrain ∂, Daoud ƒ, Burtin ƒ, Maherzi S, Beaufils F. Pharmacokinetics of midazolam during continuous infusion in critically ill neonates. Eur J Clin Pharmacol 1992;42:329332.

29. Waisman D, Weintraub Z, Rotschild A, Bental Y. Myoclonic movements in very low birth weight premature infants associated with midazolam intravenous bolus administration. Pediatrics 1999;104:579.

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30. Cheung PY, Tyebkhan JM, Peliowski A, Ainsworth W, Robertson CM. Prolonged use of pancuronium bromide and sensorineural hearing loss in childhood survivors of congenital diaphragmatic hernia. J Pediatr 1999; 135:233239.

31. Fanconi S, Ensner S, Knecht B. Effects of paralysis with pancuronium bromide on joint mobility in premature infants.

J Pediatr 1995;127:134-136.

32. McIntosh N. Hypotension associated with pancuronium use in the newborn. Lancet 1985;2:279.

33. Cools F, Offringa M. Neuromuscular paralysis for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2000;4:CD002773.

34. Shah AR, Kurth CD, Gwiazdowski SG, Chance µ, DelivoriaPapadopoulos ª. Fluctuations in cerebral oxygenation and blood volume during endotracheal suctioning in premature infants. J Pediatr 1992;120:769-774.

35. Kohlhauser C, Bernert G, Hermon ª, Popow C, Seidl R, Pollak ∞. Effects of endotracheal suctioning in highfrequency oscillatory and conventionally ventilated lÔw birth weight neonates on cerebral hemodynamics observed by near infrared spectroscopy (NIRS). Pediatr Pulmonol 2000;29:270-275.

36. Ninan ∞, O’Donnell ª, Hamilton ∫, ∆an L, Sankaran ∫.

Physiologic changes induced by endotracheal instillation and suctioning in critically ill preterm infants with and without sedation. Am J Perinatol 1986;3:94-97.

37. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain.

Pediatrics 1994;93:641-646.

38. Fernandez CV, Rees ∂ƒ. Pain management in Canadian level 3 neonatal intensive care units. CMAJ 1994;150:499504.

39. Brisman ª, Ljung µª, Otterbom π, Larsson LE, Andreasson SE. Methaemoglobin formation after the use of EMLA cream in term neonates. Acta Paediatr 1998;87:1191-1194.

40. Franck LS, Lawhon G. Environmental and behavioral strategies to prevent and manage neonatal pain. Semin Perinatol 1998;22:434-443.

41. Bucher HU, Baumgartner R, Bucher N, Seiler M, Fauchere JC. Artificial sweetener reduces nociceptive reaction in term newborn infants. Early Hum Dev 2000;59:51-60.

42. Carbajal R, Chauvet X, Couderc S, Olivier-Martin M. Randomized trial of analgesic effect of sucrose, glucose, and pacifiers in term neonates. BMJ 1999;319:1393-1397.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-05-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™·Ú·Ê›‰Ë˜ ∫ÔÛÌ¿˜ ∫‡Ì˘ 6µ, ∆.∫. 546 55, £ÂÛÛ·ÏÔÓ›ÎË E-mail: saraf@med.auth.gr

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· OÍ›· ÓÂÊÚÈ΋ ‚Ï¿‚Ë ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË Û ÓÂÔÁÓ¿1 ™ÎÔfi˜: ∏ Ô˘ÚÔÏԛ̈ÍË Â›Ó·È Ì›· ·fi ÙȘ ÈÔ Û˘ÓËıÈṲ̂Ó˜ ·Èٛ˜ ˘ÚÂÙÔ‡ ·‰È¢ÎÚ›ÓÈÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ ÛÙ· ÓÂÔÁÓ¿. ™Ùfi¯Ô˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰È·ÈÛÙˆı› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Î·È Ë ÔÍ›· ÓÂÊÚÈ΋ ‚Ï¿‚Ë Û ÓÂÔÁÓ¿ ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 57 ÓÂÔÁÓ¿ (42 ·ÁfiÚÈ· Î·È 15 ÎÔÚ›ÙÛÈ·), ·ÊÔ‡ ·ÔÎÏ›ÛÙËÎ·Ó Ù· ÓÂÔÁÓ¿ Ì ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË ˘‰ÚÔÓ¤ÊÚˆÛ˘. ∏ ̤ÛË ËÏÈΛ· ÛÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 32 Ë̤Ú˜ (5-60 Ë̤Ú˜). ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ÌÂÏÂÙ‹ıËÎ·Ó Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ (99m)Tc-dimercaptosuccinic acid (DMSA). ∞ÔÙÂϤÛÌ·Ù·: ∞ӈ̷ϛ˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔ 35% ÙˆÓ ÓÂÔÁÓÒÓ. ∫˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ‰È·ÁÓÒÛıËΠ۠19 (33%) ÓÂÔÁÓ¿ (12 ·ÁfiÚÈ· Î·È 7 ÎÔÚ›ÙÛÈ·). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÔÍ›˜ ‚Ï¿‚˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÊÏÔÈÔ‡ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔ ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ DMSA Û 19 ÓÂÊÚÔ‡˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌË-

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ÛË Î·È Û 25 ÓÂÊÚÔ‡˜ ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ·ÏÈÓ‰ÚfiÌËÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÓÈÛٿٷÈ, ÌÂÙ¿ ÙËÓ ÚÒÙË Ô˘ÚÔÏԛ̈ÍË, Ó· ‰ÈÂÚ¢ÓÒÓÙ·È Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ, ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È ÛÙ·ÙÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ DMSA fiÏ· Ù· ÓÂÔÁÓ¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 8 ‚‰ÔÌ¿‰ˆÓ.

1 Cascio S, Chertin B, Yoneda A, Rolle U, Kelleher J, Puri P Acute renal damage in infants after first urinary tract infection Pediatr Nephrol 2002;17:503-505

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

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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

Paediatriki 2003;66:37-41

ORIGINAL ARTICLE

∂͈ÓÔÛÔÎÔÌÂȷΤ˜ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ∞. ∆ÛÔ‡ÙÛÔ˘, ¢. °ÎÈÒÓ˘, ¶. ªfiÓÔ˘, §. ∆ÚÔ˘Ì¤Ù·˜, π. ¶··‰¿ÙÔ˜

Interhospital transport of critically ill children A. Tsoutsou, D. Gionis, P. Bonou, L. Troubetas, I. Papadatos

¶ÂÚ›ÏË„Ë: ∏ ÌÂÙ·ÊÔÚ¿ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ ¯ÚÂÈ¿˙ÂÙ·È ÛˆÛÙ‹ ÚÔÂÙÔÈÌ·Û›· Î·È ÛˆÛÙfi ۯ‰ȷÛÌfi, ÒÛÙ ӷ Â›Ó·È ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·fi ΤÓÙÚÔ ˘Á›·˜ ‹ ÓÔÛÔÎÔÌÂ›Ô Ù˘ ÂÚÈʤÚÂÈ·˜ Û ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌ›Ô. ªÂÏÂÙ‹ıËÎ·Ó ‚¿ÛÂÈ ÚˆÙÔÎfiÏÏÔ˘ 100 ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜ Ì›·˜ ‹ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ Î·È ÂÈÛ‹¯ıËÛ·Ó ·¢ı›·˜ ÛÙË ª∂£ (ÂÚ›Ô‰Ô˜ 1/1/1997 1/5/2000). ∆ÚÈ¿ÓÙ· ¤ÓÙ ·ÛıÂÓ›˜ ‹Ù·Ó ÎÔÚ›ÙÛÈ· Î·È 65 ·ÁfiÚÈ·, ËÏÈΛ·˜ ·fi 19 ËÌÂÚÒÓ Ì¤¯ÚÈ Î·È 14 ¯ÚfiÓˆÓ (̤ÛË ËÏÈΛ· 6,8 ¤ÙË). ™·Ú¿ÓÙ· ÔÎÙÒ Â›¯·Ó ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, 14 ‹Ù·Ó ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ Î·È 28 ·ÚÔ˘Û›·˙·Ó ·ıÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Ïԛ̈ÍË, Û·ÛÌÔ‡˜). ∂›ÎÔÛÈ ÙÚÂȘ ÌÂٷʤÚıËÎ·Ó ·fi ÓÔÛÔÎÔÌ›· Ù˘ ∞ÙÙÈ΋˜ Î·È 77 ·fi ÙËÓ ˘fiÏÔÈË ∂ÏÏ¿‰·. ∆Ô ∂∫∞µ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ 54 ·ÛıÂÓÒÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, 62 ·ÛıÂÓ›˜ ‹Ù·Ó Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ¶·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ÁÈÓfiÙ·Ó Û 59 ·ÛıÂÓ›˜, ÂÓÒ Ï‹Ú˘ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÁÈÓfiÙ·Ó ÌfiÓÔ Û 10 ÂÚÈÙÒÛÂȘ. ∂Í‹ÓÙ· ¤ÍÈ ·ÛıÂÓ›˜ ‹Úı·Ó ¯ˆÚ›˜ ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È 30 ·ÛıÂÓ›˜ ¤Êı·Û·Ó ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ÂȉÔÔ›ËÛË. ∫·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∂£, 76 ·ÛıÂÓ›˜ ›¯·Ó ‚ÂÏÙȈı› Î·È 5 ·ÚÔ˘Û›·Û·Ó ˘ÔÏÂÈÌÌ·ÙÈ΋ Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹ (19 ·ÛıÂÓ›˜ ·‚›ˆÛ·Ó).

Abstract: Transfer of pediatric patients has to be well prepared and planned, in order to be safe and harmless. The purpose of this study is to estimate safety of transfer of critically ill children from health centers or regional hospital to a tertiary care center.

We studied 100 patients who were transfered by transfer systems of 1 or 2 directions and were admitted directly in ICU between 1/1/1997 1/5/2000. Thirty five were girls and 65 were boys, aged from 19 days to 14 years (mean age 6.8 years). Forty eight had brain injury, 14 had multiple trauma, 28 presented medical problems (respiratory distress, infection, seizures). Twenty three were transfered from Attica hospitals and 77 from the rest of Greece. The National Emergency System transfered 54 patients. During transfer 62 patients were on mechanical ventilation. Fifty nine patients had saturation monitoring but only 10 had full monitoring of vital signs. Sixty six patients presented without any accompanying medical report and 30 patients presented without previous information. On discharge from ICU, 76 were improved and 5 had neurological sequellae (19 patients died).

§¤ÍÂȘ ÎÏÂȉȿ: ÌÂÙ·ÊÔÚ¿ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, ÔÏ˘ÙÚ·˘Ì·Ù›·˜.

Key words: transport of critically ill children, traumatic brain injury, multiple trauma.

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

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

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∂ÈÛ·ÁˆÁ‹ ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ˘„ËÏ‹ È·ÙÚÈ΋ ÊÚÔÓÙ›‰· Ô˘ ·Ú¤¯Ô˘Ó ÔÈ ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ (ª∂£) Î·È Ë ·Ó¿Ù˘ÍË ÂȉÈÎÒÓ ÙÌËÌ¿ÙˆÓ (.¯. ÓÂÊÚÔÏÔÁÈÎfi, ÔÁÎÔÏÔÁÈÎfi, ηډÈÔ¯ÂÈÚÔ˘ÁÈÎfi) Ô‰‹ÁËÛ·Ó ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·fi ÛÔ‚·Ú¤˜ ·Ûı¤ÓÂȘ Î·È ÙÚ·˘Ì·ÙÈÛÌÔ‡˜. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ª∂£ ·È‰ÈÒÓ ÏÂÈÙÔ˘ÚÁÔ‡Ó Û˘Ó‹ıˆ˜ Û ÙÚÈÙÔ‚¿ıÌÈ· ÓÔÛÔÎÔÌ›·, οÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ·Ó¿ÁÎË Ù¤ÙÔÈ·˜ ÊÚÔÓÙ›‰·˜, ··Ú·›ÙËÙÔ ÎÚ›ÎÔ ÛÙË Û˘ÓÔÏÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ™ÙËÓ ∂ÏÏ¿‰·, ÙÔ ∂∫∞µ ·ÔÙÂÏ› “ÙÔÓ Â›ÛËÌÔ ÊÔÚ¤· ˘ËÚÂÛÈÒÓ Â›ÁÔ˘Û·˜ ÚÔÓÔÛÔÎÔÌÂȷ΋˜ È·ÙÚÈ΋˜” Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ, ÂÎÙfi˜ ·fi ÙËÓ ¿ÌÂÛË ·ÚÔ¯‹ È·ÙÚÈ΋˜ Î·È ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ Î·È ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÛÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ Î·È ÏËÛȤÛÙÂÚÔ ˘ÁÂÈÔÓÔÌÈÎfi Û¯ËÌ·ÙÈÛÌfi. ™ÙËÓ Ú¿ÍË, ÔÈ ÌÂÙ·ÊÔÚ¤˜ Á›ÓÔÓÙ·È ·fi ÚÔÛˆÈÎfi Ô˘ ·Ó‹ÎÂÈ Û ÂÚÈÊÂÚÂȷο ÓÔÛÔÎÔÌ›·, ΤÓÙÚ· ˘Á›·˜ (∫À) ‹ ·ÁÚÔÙÈο È·ÙÚ›· (∞π) Î·È ‰ÂÓ ¤¯ÂÈ ÙËÓ ··Ú·›ÙËÙË ÂÍÂȉ›Î¢ÛË ÛÙȘ ÌÂÙ·ÊÔÚ¤˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·fi ΤÓÙÚÔ ˘Á›·˜, ·ÁÚÔÙÈÎfi È·ÙÚÂ›Ô ‹ ÓÔ̷گȷÎfi ÓÔÛÔÎÔÌÂ›Ô Û ¤Ó· ÙÚÈÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi ÓÔÛÔÎÔÌ›Ô. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆Ô ˘ÏÈÎfi ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜ Ì›·˜ ‹ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ·fi οÔÈÔ ¿ÏÏÔ ÓÔÛÔÎÔÌ›Ô, ∫À ‹ ∞π Î·È ÂÈÛ‹¯ıËÛ·Ó ·¢ı›·˜ ÛÙË ª∂£, ηٿ ÙËÓ ÂÚ›Ô‰Ô 1/1/1997 - 1/5/2000. OÈ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ Â›Ó·È ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ·fi Ù· ÓÔ̷گȷο ÓÔÛÔÎÔÌ›· (Ù· ΤÓÙÚ· ˘Á›·˜ ‹ Ù· ·ÁÚÔÙÈο È·ÙÚ›·), ÂÓÒ ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ Â›Ó·È ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ô˘ ÔÚÁ·ÓÒÓÔÓÙ·È ·fi ÙÔ ÂȉÈÎÂ˘Ì¤ÓÔ Î¤ÓÙÚÔ ÌÂÙ·ÊÔÚÒÓ. ∫·Ù¿ ÙËÓ Â›ÛÔ‰Ô ÙˆÓ ·ÛıÂÓÒÓ, Û˘ÌÏËÚÒıËΠÂÎÙÂٷ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ÂÚÈÏ¿Ì‚·Ó ÛÙÔȯ›· ÁÈ· ÙÔ ·Ù‡¯ËÌ· (‹ Û‡ÓÙÔÌÔ ÈÛÙÔÚÈÎfi, Â¿Ó ÂÚfiÎÂÈÙÔ ÁÈ· ·ıÔÏÔÁÈÎfi ÂÚÈÛÙ·ÙÈÎfi), ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË ÛÙ·ıÂÚÔÔ›ËÛË, ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ Ô˘ ¤ÁÈÓ ÛÙÔÓ ÚÒÙÔ ˘ÁÂÈÔÓÔÌÈÎfi ÛÙ·ıÌfi (∫À, ∞π), ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙË ÛÙ·ıÂÚÔÔ›ËÛË ÛÙÔ ÓÔ̷گȷÎfi ÓÔÛÔÎÔÌ›Ô, ÙË ÌÂÙ·ÊÔÚ¿ ÚÔ˜ ÙÔ ÓÔÛÔÎÔÌÂ›Ô ˘Ô‰Ô¯‹˜, Ì ·Ó·ÊÔÚ¿ ÛÙÔ Ì¤ÛÔ Î·È ÙÔ ÊÔÚ¤· ÌÂÙ·ÊÔÚ¿˜, ÛÙË Û‡ÓıÂÛË Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚ¿˜, ÛÙÔÓ ÂÍÔÏÈÛÌfi ÌÂÙ·ÊÔÚ¿˜ Î·È ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹ ÁÈ· Ù˘¯fiÓ ÂÓ¤ÚÁÂȘ ηٿ ÙË ÌÂÙ·ÊÔÚ¿. ∏ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙËÓ Â›ÛÔ‰Ô ÛÙË ª∂£ ÂÎÙÈÌ‹ıËΠ·fi ÂȉÈÎÂ˘Ì¤ÓÔ È·ÙÚfi Î·È ·Ó·ÁÚ¿ÊËÎÂ Ë ¤Î‚·Û‹ ÙÔ˘ (‚ÂÏÙ›ˆÛË, Ó¢ÚÔÏÔÁÈο ˘ÔÏ›ÌÌ·Ù·, ı¿Ó·ÙÔ˜) ηٿ ÙËÓ ¤ÍÔ‰Ô. ∞ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ۇÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜, ·ÏÏ¿ ‰ÂÓ ÂÈÛ‹¯ıËÛ·Ó ¿ÌÂÛ· ÛÙË ª∂£, ‰ÂÓ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË, ÂÂȉ‹ ‰ÂÓ ÌÔÚÔ‡Û·Ó Ó· Û˘ÏϯıÔ‡Ó fiϘ ·˘Ù¤˜ ÔÈ ÏËÚÔÊÔڛ˜.

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∞ÔÙÂϤÛÌ·Ù· ™Â ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô ÂÈÛ‹¯ıËÛ·Ó ÛÙË ª∂£ 678 ·È‰È¿. ∆Ô ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÔÙ¤ÏÂÛ·Ó 100 ·ÛıÂÓ›˜ Ô˘ ÌÂٷʤÚıËÎ·Ó Ì ÙÔ Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚÒÓ Î·È ÂÈÛ‹¯ıËÛ·Ó ¿ÌÂÛ· ÛÙË ª∂£. ∆· 65 ·È‰È¿ ‹Ù·Ó ·ÁfiÚÈ·, Ù· 35 ÎÔÚ›ÙÛÈ· Î·È Ë Ì¤ÛË ËÏÈΛ· ÙÔ˘˜ ‹Ù·Ó 6,9 ¯ÚfiÓÈ· (19 ËÌÂÚÒÓ ¤ˆ˜ 14 ¯ÚfiÓˆÓ). ¶ÂÚ›Ô˘ Ù· ÌÈÛ¿ ·fi Ù· ·È‰È¿ Ô˘ ÌÂٷʤÚıËÎ·Ó (48%) ›¯·Ó ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË (∫∂∫) Î·È 14% ‹Ù·Ó ÔÏ˘ÙÚ·˘Ì·Ù›Â˜. ∆· ˘fiÏÔÈ· ·È‰È¿ ÌÂٷʤÚıËÎ·Ó ÏfiÁˆ ÂÁη‡Ì·ÙÔ˜ (4%), ‚·ÚÈ¿˜ Ïԛ̈͢ (6%), ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (5%), Û·ÛÌÒÓ (5%), ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·Ó·ÎÔ‹˜ (4%) Î·È ¿ÏÏˆÓ ·ÈÙ›ˆÓ (14%) (∂ÈÎfiÓ· 1). ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ·fiÛÙ·ÛË, ÙÔ 23% ÙˆÓ ·ÛıÂÓÒÓ ÌÂٷʤÚıËΠ·fi ÙËÓ ∞ÙÙÈ΋, ÙÔ 45% ·fi ÓÔÛÔÎÔÌ›· Ù˘ ™ÙÂÚ¿˜ ∂ÏÏ¿‰·˜ Î·È Ù˘ ¶ÂÏÔÔÓÓ‹ÛÔ˘ Î·È ÙÔ 32% ·fi ÙË ÓËÛȈÙÈ΋ ∂ÏÏ¿‰·. ∆Ô ∂∫∞µ ‹Ù·Ó Ô ÊÔÚ¤·˜ Ô˘ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ Û 54 ÂÚÈÙÒÛÂȘ. ∞fi ·˘Ù¤˜, ÔÈ 48 ÌÂÙ·ÊÔÚ¤˜ ‹Ù·Ó ηϿ ÔÚÁ·ÓˆÌ¤Ó˜ (ϋڈ̷ Ì ȷÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi/ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ÂÎ·È‰Â˘Ì¤ÓÔ ÛÙȘ ÌÂÙ·ÊÔÚ¤˜, ηٿÏÏËÏÔ˜ ÂÍÔÏÈÛÌfi˜), ÂÓÒ Û 6 ÂÚÈÙÒÛÂȘ ‰ÂÓ ˘‹Ú¯Â Û˘Óԉ›· È·ÙÚÔ‡.

OÈ ˘fiÏÔÈ˜ 46 ÌÂÙ·ÊÔÚ¤˜ ÔÚÁ·ÓÒıËÎ·Ó ·fi Ù· ηٿ ÙfiÔ˘˜ ÓÔÛÔÎÔÌ›·. ∞fi ·˘Ù¤˜, ÌfiÓÔ Û 11 ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡. ™˘ÓÔÏÈο, Û 59% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡, Û 31% ˘‹Ú¯Â È·ÙÚfi˜, ·ÏÏ¿ ¯ˆÚ›˜ ÙËÓ ··Ú·›ÙËÙË ÂÎ·›‰Â˘ÛË (ÂȉÈ΢fiÌÂÓÔ˜ ‹ ·ÁÚÔÙÈÎfi˜ È·ÙÚfi˜) Î·È Û 10% ÙˆÓ ÂÚÈÙÒÛˆÓ, Ô ‚·Ú¤ˆ˜ ¿Û¯ˆÓ ÌÈÎÚfi˜ ·ÛıÂÓ‹˜ ÌÂٷʤÚıËΠ¯ˆÚ›˜ Û˘Óԉ›· È·ÙÚÔ‡ (∂ÈÎfiÓ· 2). ªfiÓÔ ÙÔ 3% ÙˆÓ ÌÂÙ·ÊÔÚÒÓ ¤ÁÈÓ ÌÂ Û˘Óԉ›· ·È‰È¿ÙÚÔ˘, ¯ˆÚ›˜ fï˜ ÂÌÂÈÚ›· ÛÙȘ ÌÂÙ·ÊÔÚ¤˜. ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙ· ̤۷ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿, ›¯·Ì 34 ·ÂÚÔÌÂÙ·ÊÔÚ¤˜ (32 ·fi ÙÔ ∂∫∞µ), ÂÓÒ ÛÙȘ ˘fiÏÔÈ˜ ÂÚÈÙÒÛÂȘ (66) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·ÛıÂÓÔÊfiÚ· Ô¯‹Ì·Ù·. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, 62 ·ÛıÂÓ›˜ ‹Ù·Ó ‰È·ÛˆÏËӈ̤ÓÔÈ Î·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (ª∞), 33 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÌÂٷʤÚıËÎ·Ó ·fi ÙÔ ∂∫∞µ. ∂›ÎÔÛÈ ¤ÓÙ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Û ª∞ ·ÂÚ›˙ÔÓÙ·Ó Ì ·ÛÎfi (Û˘Û΢‹ Ambu). ∏ ·Ó·›Ì·ÎÙË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ¤ÁÈÓ Û 59 ·ÛıÂÓ›˜, ÂÓÒ Ï‹Ú˘ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ (ÛʇÍÂȘ, ·Ó·ÓÔ¤˜, ∞¶) Ì ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜ ¤ÁÈÓ ÌfiÓÔ Û 10 ÂÚÈÙÒÛÂȘ (ÛËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ ∂∫∞µ ‰ÂÓ ¯ÚËÛÈÌÔÔÈ› ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜, ·Ú¿ ÌfiÓÔ ·Ó·›Ì·ÎÙË Ì¤ÙÚËÛË ÎÔÚÂÛÌÔ‡). ¢Âη٤ÛÛÂÚȘ ·ÛıÂÓ›˜ ‰ÂÓ ¤Ï·‚·Ó Ï‹ÚË Î·Ù·ÛÙÔÏ‹ Î·È Ì˘Ô¯¿Ï·ÛË, 13 ·ÛıÂÓ›˜ ÚÔÛ‹Ïı·Ó ¯ˆÚ›˜ IV ÁÚ·ÌÌ‹, 66 ·ÛıÂÓ›˜ ‰ÂÓ Û˘Óԉ‡ÔÓÙ·Ó ·fi ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È Û 30

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6 4 14 ∂ȉÈÎÂ˘Ì¤ÓÔ˜ ∫∂∫ ∂ȉÈ΢fiÌÂÓÔ˜/∞ÁÚÔÙÈÎfi˜ ¶ÔÏ˘ÙÚ·˘Ì·Ù›Â˜ ∂Áη‡Ì·Ù·

Èڛ˜ È·ÙÚfi ∂ÈÎfiÓ· 2. ™˘Óԉ›· È·ÙÚÔ‡.

§Ô›ÌˆÍË ∞Ó·Ó. ‰˘Û¯¤ÚÂÈ· ™·ÛÌÔ› ∫∞∞ ÕÏÏ· ∂ÈÎfiÓ· 1. ∞Èٛ˜ ÌÂÙ·ÊÔÚ¿˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ.

ÂÚÈÙÒÛÂȘ ÌÂÙ·ÊÔÚÒÓ ‰ÂÓ ˘‹Ú¯Â ÂÓË̤ڈÛË ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ˘Ô‰Ô¯‹˜. ∫·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∂£, 76 ·ÛıÂÓ›˜ ›¯·Ó ‚ÂÏÙȈı› Î·È 5 ·ÚÔ˘Û›·˙·Ó ˘ÔÏÂÈÌÌ·ÙÈ΋ Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹. ¢ÂηÂÓÓ¤· ·ÛıÂÓ›˜ ·‚›ˆÛ·Ó. OÈ ı¿Ó·ÙÔÈ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔÈ ÛÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ ÙÔ˘ ∂∫∞µ (13/54 ¤Ó·ÓÙÈ 6/46). ™˘˙‹ÙËÛË OÈ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚÔ Úfi‚ÏËÌ· ÛÙËÓ ∂ÏÏ¿‰· ÏfiÁˆ Ù˘ ÁˆÁÚ·ÊÈ΋˜ ȉÈÔÌÔÚÊ›·˜ (˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·ÔÌÔӈ̤Ó˜ ÂÚÈÔ¯¤˜ Î·È ÓËÛÈ¿ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈÌÂÙÒÈÛ˘ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·ÛıÂÓÒÓ) Î·È ÏfiÁˆ Ù˘ ·Ô˘Û›·˜ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ Û ·È‰È¿. ª¤¯ÚÈ ÚÈÓ 2 ¯ÚfiÓÈ· ‰ÂÓ ˘‹Ú¯·Ó ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜ ·È‰ÈÒÓ ÂÎÙfi˜ ∞ÙÙÈ΋˜. ªÂ ÙË ‰ËÌÈÔ˘ÚÁ›·, ·Ú¯Èο, Ù˘ ª∂£ ·È‰ÈÒÓ ÛÙË £ÂÛÛ·ÏÔÓ›ÎË Î·È ·ÚÁfiÙÂÚ· ÛÙÔ ∏Ú¿ÎÏÂÈÔ Ù˘ ∫Ú‹Ù˘ ¤¯ÂÈ ÌÂȈı› Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂٷʤÚÔÓÙ·È ÛÙËÓ ∞ı‹Ó·. ∏ ÌÂÏÏÔÓÙÈ΋ ‰ËÌÈÔ˘ÚÁ›· Î·È ¿ÏÏˆÓ ª∂£ ·È‰ÈÒÓ ı· ÂÚÈÔÚ›ÛÂÈ ÂÚÈÛÛfiÙÂÚÔ ·˘Ùfi ÙÔÓ ·ÚÈıÌfi. ¶·Ú’ fiÏ·

·˘Ù¿, Ë ·Ó¿ÁÎË ÁÈ· ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ı· Û˘Ó¯›˙ÂÈ Ó· ˘¿Ú¯ÂÈ (ÏfiÁˆ ·ÎÚÈ‚Ò˜ Ù˘ ÁˆÁÚ·ÊÈ΋˜ ȉÈÔÌÔÚÊ›·˜). ™ÙË ¯ÒÚ· Ì·˜, fiˆ˜ Î·È Û ¿ÏϘ ¯ÒÚ˜ (1), ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ÔÚÁ·ÓÒÓÔÓÙ·È Î·È Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÙfiÛÔ ·fi Ù· ›‰È· Ù· ÂÚÈÊÂÚÂȷο ÓÔÛÔÎÔÌ›· Ô˘ οÓÔ˘Ó ÙËÓ ·Ú·ÔÌ‹ (ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘), fiÛÔ Î·È ·fi ÙÔ ∂∫∞µ, ÙÔ ÔÔ›Ô ‰È·ı¤ÙÂÈ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚÒÓ ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ (ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛˆÓ) (2). °È· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ Ù˘ ·ÛÊ·ÏÔ‡˜ ÌÂÙ·ÊÔÚ¿˜, ÔÈ ˘ËÚÂۛ˜ ÙÔ˘ ∂∫∞µ ·Ó¿ ÂÚÈʤÚÂÈ· (˘¿Ú¯Ô˘Ó 12 ÂÚÈʤÚÂȘ) ÚԂϤÔ˘Ó (3): ·) ÂȯÂÈÚËÛÈ·Îfi ΤÓÙÚÔ ÂÈÎÔÈÓˆÓ›·˜ Î·È Û˘ÓÙÔÓÈÛÌÔ‡ Ô˘ ÛÙÂϯÒÓÂÙ·È ·fi È·ÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi ÚÔÛˆÈÎfi, ηıÒ˜ Î·È ÚÔÛˆÈÎfi ‰ÈÔÈ΋Ûˆ˜ Î·È Ù¯ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, Ô˘ ÂϤÁ¯ÂÈ Î·È Û˘ÓÙÔÓ›˙ÂÈ fiϘ ÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ Î·È ‚) ̤۷ ¿ÌÂÛ˘ Â¤Ì‚·Û˘ Î·È ÌÂÙ·ÊÔÚ¿˜ ·Û¯fiÓÙˆÓ Ô˘ ÛÙÂϯÒÓÔÓÙ·È ·fi È·ÙÚÈÎfi Î·È ·Ú·˚·ÙÚÈÎfi ÚÔÛˆÈÎfi (·ÛıÂÓÔÊfiÚ· - ·Ï¿ Î·È ÎÈÓËÙ¤˜ ÌÔÓ¿‰Â˜ - Î·È ·ÛıÂÓÔÊfiÚ· ·ÂÚÔÛοÊË, ÂÏÈÎfiÙÂÚ· ‹ ·ÂÚÔÏ¿Ó·). §fiÁˆ ÙˆÓ Û˘ÓıËÎÒÓ Ô˘ ÂÈÎÚ·ÙÔ‡Ó ÛÙË ¯ÒÚ· Ì·˜, ÔÈ ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ıˆÚÔ‡ÓÙ·È fiÙÈ Â›Ó·È ·˘Ù¤˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ÙËÓ ··Ú·›ÙËÙË ÊÚÔÓÙ›‰· Î·È ·ÛÊ¿ÏÂÈ· ÛÙÔ˘˜ ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ Î·È ı· Ú¤ÂÈ Ó· ÚÔÙÈÌÒÓÙ·È, Û‡Ìʈӷ Ì ‰Â‰Ô̤ӷ ·fi ÙȘ ÌÂϤÙ˜ (1,2,4). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó ÙÔ ÌÔÓ·‰ÈÎfi ÙÚfiÔ ÌÂÙ·ÊÔÚ¿˜. Œ¯Ô˘Ó, fï˜, ÔÏÏ¿ ÌÂÈÔÓÂÎÙ‹Ì·Ù· (2). ∏ ÛËÌÂÚÈÓ‹ ‰È¿ÚıÚˆÛË ÙÔ˘ ∂∫∞µ ‰ÂÓ Î·Ï‡ÙÂÈ fiϘ ÙȘ ·Ó¿ÁΘ ÌÂÙ·ÊÔÚ¿˜ ‚·Ú¤ˆÓ ·Û¯fiÓÙˆÓ.

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™ÂÏ›‰·40

¶·È‰È·ÙÚÈ΋ 2003;66:37-41

∞fi ÙȘ ÌÂÙ·ÊÔÚ¤˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÙÔ ∂∫∞µ ·Ó¤Ï·‚ ÙË ÌÂÙ·ÊÔÚ¿ ÛÙÔ 54% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ ÔÈ ˘fiÏÔÈ˜ ÌÂÙ·ÊÔÚ¤˜ ÔÚÁ·ÓÒıËÎ·Ó ·fi Ù· ηٿ ÙfiÔ˘˜ ÓÔÛÔÎÔÌ›·. ∆Ô ÚÔÛˆÈÎfi ·ÔÙÂÏ› ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÛÙÔÈ¯Â›Ô Î¿ıÂ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ (4,5). À¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙË Û‡ÓıÂÛË Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚÒÓ, ·Ó¿ÏÔÁ· Ì ÙÔ Û‡ÛÙËÌ· Ô˘ ˘¿Ú¯ÂÈ Û οı ¯ÒÚ·. ™ÙËÓ ∞ÁÁÏ›· ÚÔÙ›ÓÂÙ·È, ÂÊfiÛÔÓ Ë ÙÔÈ΋ ª∂£ ·È‰ÈÒÓ ·Ó·Ï·Ì‚¿ÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ ·È‰ÈÒÓ, Ë ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ Ó· ·ÔÙÂÏÂ›Ù·È ·fi ÂȉÈÎÂ˘Ì¤ÓÔ È·ÙÚfi Î·È ÂÂÈڷ̤ÓË ÓÔÛËχÙÚÈ· (6). ∆· ̤ÏË Ù˘ ÔÌ¿‰·˜ Ú¤ÂÈ Ó· Â›Ó·È ÂÎ·È‰Â˘Ì¤Ó· Î·È ÁÓÒÛÙ˜ ¯ÂÈÚÈÛÌÒÓ fiˆ˜ Â›Ó·È Ë ‰È·ÛˆÏ‹ÓˆÛË, Ô ·ÂÚÈÛÌfi˜, Ë ÛÙ·ıÂÚÔÔ›ËÛË ·ÂÚ·ÁˆÁÔ‡, Ë ÙÔÔı¤ÙËÛË ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ (1,5). ∂›Û˘, ÙÔ ÚÔÛˆÈÎfi ÌÂÙ·ÊÔÚÒÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÍÔÈÎÂȈ̤ÓÔ Ì ÙÔ “ÂÚÈ‚¿ÏÏÔÓ” Ù˘ ÌÂÙ·ÊÔÚ¿˜ (·ÛıÂÓÔÊfiÚÔ, ÂÍÔÏÈÛÌfi˜) Î·È Ó· Â›Ó·È Û ı¤ÛË Ó· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÌÈÎÚ¿ Û˘Ì‚¿ÓÙ· (2). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÛÙÔ 59% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ Û ÌÂÙ·ÊÔÚ¤˜ È·ÙÚÔ‡ (·Ó·ÈÛıËÛÈÔÏfiÁÔ˜), ÛÙÔ 31% ˘‹Ú¯Â È·ÙÚfi˜ ¯ˆÚ›˜, fï˜, ÙȘ ÂȉÈΤ˜ ÁÓÒÛÂȘ (ÂȉÈ΢fiÌÂÓÔÈ Î·È ·ÁÚÔÙÈÎÔ› È·ÙÚÔ›) Î·È ÛÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ˘‹Ú¯Â Û˘Óԉ›· È·ÙÚÔ‡. ™˘ÁÎÚÈÙÈο, Û 48/54 ÌÂÙ·ÊÔÚ¤˜ ‰‡Ô ηÙ¢ı‡ÓÛÂˆÓ ˘‹Ú¯Â Ï‹Ú˜ Î·È ÂÎ·È‰Â˘Ì¤ÓÔ ϋڈ̷, ÂÓÒ ÛÙȘ ÌÂÙ·ÊÔÚ¤˜ Ì›·˜ ηÙ‡ı˘ÓÛ˘ ÌfiÓÔ Û 11/46 ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â Û˘Óԉ›· ÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡. ∞ÎfiÌ· Î·È ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ∂∫∞µ (È·ÙÚÈÎfi Î·È ÓÔÛËÏ¢ÙÈÎfi) ‰ÂÓ ¤¯ÂÈ ÙËÓ ··Ú·›ÙËÙË ÂÎ·›‰Â˘ÛË ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ, ·Ó Î·È ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜. ∏ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ÌÂÙ·ÊÔÚ¿˜ ηıÔÚ›˙ÂÙ·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ·fiÛÙ·ÛË ÌÂÙ·ÊÔÚ¿˜, Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ ¿ıËÛ˘, ÔÈ Î·ÈÚÈΤ˜ Û˘Óı‹Î˜ Î·È Ë ÙÔÈ΋ ÁˆÁÚ·Ê›·, Ë ·ÛÊ¿ÏÂÈ·, Ù· ‰È·ı¤ÛÈÌ· ̤۷ Î·È ÙÔ ÎfiÛÙÔ˜ (1,2). ∂ÎÙfi˜ ·fi ÙËÓ Ù·¯‡ÙËÙ·, οı ̤ıÔ‰Ô˜ ÌÂÙ·ÊÔÚ¿˜ (·ÛıÂÓÔÊfiÚÔ Â‰¿ÊÔ˘˜, ÂÏÈÎfiÙÂÚÔ, ·ÂÚÔÏ¿ÓÔ) ¤¯ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ô˘ ı· ·ÍÈÔÏÔÁËıÔ‡Ó ·Ó¿ÏÔÁ· Ì ÙȘ Û˘Óı‹Î˜ (2,4,6). ™ÙË ÌÂϤÙË ·˘Ù‹, ÂÚ›Ô˘ ÙÔ 1/3 (32%) ÙˆÓ ÌÂÙ·ÊÔÚÒÓ ÚÔÂÚ¯fiÙ·Ó ·fi Ù· ÓËÛÈ¿ Î·È ‹Ù·Ó ·ÂÚÔÌÂÙ·ÊÔÚ¤˜, Ì ÂÈϤÔÓ ‰˘ÛÎÔÏ›· Î·È ÎfiÛÙÔ˜. ∏ ηχÙÂÚË ÔÚÁ¿ÓˆÛË ÙˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ÓËÛÈ¿ Î·È Ë Ì¤ÚÈÌÓ· ÁÈ· ‰È·Û‡Ó‰ÂÛË Ì ٷ ÓÔÛÔÎÔÌ›· ÙˆÓ ÓËÛÈÒÓ ·˘ÙÒÓ ı· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË Ì›ˆÛË ÙˆÓ ·ÂÚÔÌÂÙ·ÊÔÚÒÓ. ª·˙› Ì ÙȘ ÚÔÛ¿ıÂȘ ÁÈ· ÙË Ì›ˆÛ‹ ÙÔ˘˜, fï˜, ı· Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈËı› ÂÓ›Û¯˘ÛË Î·È ‚ÂÏÙ›ˆÛ‹ ÙÔ˘˜, ÒÛÙ ӷ ÌÔÚÔ‡Ó Ó· Â͢ËÚÂÙ‹ÛÔ˘Ó ·Ó¿ ¿Û· ÛÙÈÁÌ‹ Â›ÁÔ˘Û˜ ηٷÛÙ¿ÛÂȘ. ŸÏÔ ÙÔ Ê·Ú̷΢ÙÈÎfi ˘ÏÈÎfi Î·È Ô ··Ú·›ÙËÙÔ˜

40

Paediatriki 2003;66:37-41

ÂÍÔÏÈÛÌfi˜ ÁÈ· ÙË ÛÙ·ıÂÚÔÔ›ËÛË Î·È ÙË ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ Ó· ÌÂٷʤÚÂÙ·È ·fi ÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ (1,6). O ÂÍÔÏÈÛÌfi˜ ÌÂÙ·ÊÔÚÒÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÏ·ÊÚ‡˜ Î·È ÊÔÚËÙfi˜, Ó· Â›Ó·È ÚÔÛ·ÚÌÔṲ̂ÓÔ˜ ÛÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·È‰ÈÔ‡ (‰ËÏ·‰‹ Ó· ˘¿Ú¯Ô˘Ó fiÏ· Ù· ÌÂÁ¤ıË), Ó· ÏÂÈÙÔ˘ÚÁ› Î·È Ó· ÂÊ·ÚÌfi˙ÂÈ Û fiÏÔ˘˜ ÙÔ˘˜ Ù‡Ô˘˜ ÙˆÓ ·ÛıÂÓÔÊfiÚˆÓ (4). ∏ ‰È¿ÚÎÂÈ· Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÂÓۈ̷و̤Ó˘ ËÁ‹˜ ÂÓ¤ÚÁÂÈ·˜ Ú¤ÂÈ Ó· Â›Ó·È ‰ÈÏ¿ÛÈ· Ù˘ ·Ó·ÌÂÓfiÌÂÓ˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ÌÂÙ·ÊÔÚ¿˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, Ô Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ·Ó·Ó¢ÛÙ‹Ú· ÌÂÙ·ÊÔÚ¿˜ (1,4). ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ (ÛʇÍÂȘ, ∞¶, ·Ó·ÓÔ¤˜, ÎÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ıÂÚÌÔÎÚ·Û›·) Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜, ηıÒ˜ Ë ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·ÛıÂÓÔÊfiÚÔ˘ ‰ÂÓ Â›Ó·È ·ÍÈfiÈÛÙË (1,2). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ 62% ÙˆÓ ·ÛıÂÓÒÓ ‚ÚÈÛÎfiÙ·Ó Û ª∞, ÂÓÒ 25/62 ·ÛıÂÓ›˜ ·ÂÚ›˙ÔÓÙ·Ó Ì ·ÛÎfi (Û˘Û΢‹ Ambu) Î·È fi¯È Ì ·Ó·Ó¢ÛÙ‹Ú· ÌÂÙ·ÊÔÚ¿˜ fiˆ˜ Û˘ÓÈÛٿٷÈ. ∏ ·Ó·›Ì·ÎÙË ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ¤ÁÈÓ Û 59% ÙˆÓ ÂÚÈÙÒÛˆÓ, ·ÏÏ¿ ÌfiÓÔ Û 10% ¯ÚËÛÈÌÔÔÈ‹ıËΠÂÈÛÎfiÈÔ ÌÂÙ·ÊÔÚ¿˜ Ì Ï‹ÚË ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ.

OÈ ·Èٛ˜ Ô˘ ηıÈÛÙÔ‡Ó ··Ú·›ÙËÙË ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ·ÛıÂÓ‹ Û ÙÚÈÙÔ‚¿ıÌÈÔ ÓÔÛÔÎÔÌÂ›Ô ‹ ª∂£ Â›Ó·È ÔÈΛϘ. ™ÙË ÌÂϤÙË ·˘Ù‹, ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·È‰ÈÒÓ ÌÂٷʤÚıËΠÏfiÁˆ ÙÚ·‡Ì·ÙÔ˜, ΢ڛˆ˜ ÏfiÁˆ ∫∂∫ (48%), ·ÏÏ¿ Î·È ÔÈÎ›ÏˆÓ ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ (‚·ÚÈ¿ Ïԛ̈ÍË, ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ¤Áη˘Ì·, ∫∞∞, ‰ËÏËÙËÚÈ¿ÛÂȘ, ÓÈÁÌfi˜, ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î.¿.). ∂Ô̤ӈ˜, Ô È·ÙÚfi˜ Ô˘ ı· οÓÂÈ ÙË ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ ·Ú¯Èο Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Î·È Ó· ÛÙ·ıÂÚÔÔÈ‹ÛÂÈ ÙÔ ¿ÚÚˆÛÙÔ ·È‰› Ô˘ ÌÂٷʤÚÂÙ·È Ì ‰È¿ÊÔÚ˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∏ ·Ú¯È΋ ·ÓÙÈÌÂÙÒÈÛË Î·È ÛÙ·ıÂÚÔÔ›ËÛË, Ô˘ Â›Ó·È ÙÔ ÚÒÙÔ ‚‹Ì· Ì›·˜ ÛˆÛÙ‹˜ ÌÂÙ·ÊÔÚ¿˜, ÛÎÔfi ¤¯ÂÈ ÙË ‰È·Ù‹ÚËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο Â›‰·, ¤ˆ˜ fiÙÔ˘ Ô ·ÛıÂÓ‹˜ Ó· ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ï‹Úˆ˜ ÛÙÔ ÙÚÈÙÔ‚¿ıÌÈÔ ÓÔÛÔÎÔÌÂ›Ô (7). ∂¿Ó ÎÚÈı› ··Ú·›ÙËÙË Ë ‰È·ÛˆÏ‹ÓˆÛË (·ÎfiÌ· Î·È Â› ·ÌÊÈ‚ÔÏ›·˜), ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ÙÔ Ù·¯‡ÙÂÚÔ ‰˘Ó·ÙfiÓ, ¯ˆÚ›˜ ·Ó·ÌÔÓ‹ Î·È ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË (1,2). ∏ ·ÁÁÂȷ΋ ÚÔÛ¤Ï·ÛË Î·È Ë ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ (‹ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ) ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ Î·È Ù˘ ∞¶ Ú¤ÂÈ Ó· Â›Ó·È ¿ÌÂÛË. ∏ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· Î·È Ë ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ÙˆÓ ÊÏ‚ÈÎÒÓ ÁÚ·ÌÌÒÓ ‹ ηıÂÙ‹ÚˆÓ ·ÚÔ¯¤Ù¢Û˘ ·ÔÙÂÏÔ‡Ó ·Ï¿ ̤۷ ÚfiÏ˄˘ ·ÓÂÈı‡ÌËÙˆÓ ÂÈÏÔÎÒÓ Î·Ù¿ ÙË ÌÂÙ·ÊÔÚ¿. ∏ ¯ÔÚ‹ÁËÛË Î·Ù¿ÏÏËÏ˘ ηٷÛÙÔÏ‹˜ ‹ Î·È Ì˘Ô¯¿Ï·Û˘ ÌÂÈÒÓÂÈ ÙÔÓ

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·41

¶·È‰È·ÙÚÈ΋ 2003;66:37-41

ΛӉ˘ÓÔ Ù˘ Ù˘¯·›·˜ ·ÔۈϋӈÛ˘ ‹ ÌÂٷΛÓËÛ˘ ηıÂÙ‹ÚˆÓ, ·ÏÏ¿ Î·È ÙȘ Èı·ÓfiÙËÙ˜ ·‡ÍËÛ˘ Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Û ·È‰›· Ì ∫∂∫ (1). ™ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∫∂∫, ıÂÌÂÏÈÒ‰Ô˘˜ ÛËÌ·Û›·˜ Â›Ó·È Ë ÚfiÏË„Ë Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘ Ô˘ ÌÔÚ› Ó· ÚÔÎÏËı› ÏfiÁˆ Ù˘ ˘fiÙ·Û˘, Ù˘ ˘ÔÍ·ÈÌ›·˜ ‹ Ù˘ ÔͤˆÛ˘. ŸÙ·Ó Ë Îϛ̷η °Ï·ÛÎ҂˘ (GCS) Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 10, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‰È·ÛˆÏËÓÒÓÂÙ·È (ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ÛÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, Â¿Ó ‰ÂÓ ¤¯ÂÈ ·ÔÎÏÂÈÛÙ› Ë Èı·ÓfiÙËÙ· ηÎÒÛÂˆÓ Ù˘ ∞ª™™) Î·È Ó· ÌÂٷʤÚÂÙ·È Û Ï‹ÚË Î·Ù·ÛÙÔÏ‹ Î·È Ì˘Ô¯¿Ï·ÛË. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ı· ¤¯ÂÈ ÂȂ‚·ÈÒÛÂÈ ÙËÓ ÔÚı‹ ı¤ÛË ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ. ∂›Û˘, Û ÂÈÁψÙÙ›Ùȉ· ‹ ‚·ÚÈ¿ Ï·Ú˘ÁÁ›Ùȉ·, Ë ÌÂÙ·ÊÔÚ¿ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·ÊÔ‡ Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ‰È·ÛˆÏËÓˆı› Î·È Î·Ù·ÛÙ·Ï›. ™ÙÔ ¤Áη˘Ì·, ÂÎÙfi˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ˘ÁÚÒÓ ÁÈ· ÚfiÏË„Ë Ù˘ ˘ÔÔÁηÈÌÈ΋˜ ηٷÏËÍ›·˜, Â¿Ó ˘¿Ú¯Ô˘Ó ‚Ï¿‚˜ ÛÙÔ ÚfiÛˆÔ ‹ ÛÙÔȯ›· ÂÈÛÓ¢ÛÙÈÎÔ‡ ÂÁη‡Ì·ÙÔ˜, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‰È·ÛˆÏËÓÒÓÂÙ·È ¿ÌÂÛ· ‹ ¤ÁηÈÚ·, ‰ÈfiÙÈ ÛÙËÓ ÚÒÙË ÂÚ›ÙˆÛË ÙÔ Ô›‰ËÌ· Ô˘ ı· ‰ËÌÈÔ˘ÚÁËı› ÌÔÚ› Ó· ‰˘ÛÎÔϤ„ÂÈ ÙË ‰È·ÛˆÏ‹ÓˆÛË, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ ·fi ÙȘ ‚Ï¿‚˜ ÛÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜. ™ÙË ÌÂϤÙË Ì·˜, ·Ó Î·È ÙÔ 62% ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ‰È·ÛˆÏËӈ̤ÓÔ, ÔÈ 29/62 Û˘Óԉ‡ÔÓÙ·Ó ·fi È·ÙÚfi ¯ˆÚ›˜ ÁÓÒÛÂȘ ‰È·ÛˆÏ‹ÓˆÛ˘. ∂ÈϤÔÓ, 14/62 ‰ÂÓ ¤Ï·‚·Ó ηٿÏÏËÏË Î·Ù·ÛÙÔÏ‹. ∏ ÁÚ‹ÁÔÚË Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÈÎÔÈÓˆÓ›· ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ÂÌÏÂÎfiÌÂÓÔ˘˜ ÛÙË ÌÂÙ·ÊÔÚ¿ ÊÔÚ›˜ (ÓÔÛÔÎÔÌÂ›Ô Ô˘ ·Ú·¤ÌÂÈ, ÓÔÛÔÎÔÌÂ›Ô ˘Ô‰Ô¯‹˜ Î·È Û‡ÛÙËÌ· ÌÂÙ·ÊÔÚ¿˜) Â›Ó·È ÂÍ›ÛÔ˘ ÛËÌ·ÓÙÈ΋ (1,2,4). ¢˘ÛÙ˘¯Ò˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÙÔ 66% ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ Û˘Óԉ¢fiÙ·Ó ·fi ÏËÚÔÊÔÚÈ·Îfi ÛËÌ›ˆÌ· Î·È ÛÙÔ 30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ˘‹Ú¯Â ÂÓË̤ڈÛË ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ˘Ô‰Ô¯‹˜. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· “·ÓÂÈı‡ÌËÙ· Û˘Ì‚¿ÓÙ·” ηٿ ÙË ÌÂÙ·ÊÔÚ¿ Â›Ó·È ÈÔ Û¿ÓÈ· fiÙ·Ó Ë ÌÂÙ·ÊÔÚ¿ Á›ÓÂÙ·È ·fi ÂȉÈÎÂ˘Ì¤ÓË ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ, Û ۯ¤ÛË Ì ÙȘ ÌÂÙ·ÊÔÚ¤˜ Ô˘ Á›ÓÔÓÙ·È ·fi ÌË ÂȉÈÎÂ˘Ì¤ÓË ÔÌ¿‰· (5). ™Â fi,ÙÈ ·ÊÔÚ¿ ÛÙËÓ ¤Î‚·ÛË, ÛÙË ÌÂϤÙË ·˘Ù‹, ÔÈ ı¿Ó·ÙÔÈ ‹Ù·Ó ÂÚÈÛÛfiÙÂÚÔÈ ÛÙËÓ ÔÌ¿‰· ÌÂÙ·ÊÔÚÒÓ ÙÔ˘ ∂∫∞µ (13/54 ¤Ó·ÓÙÈ 6/46), ÂÓÒ Ë ·ÚÔ˘Û›· Ó¢ÚÔÏÔÁÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜ ‹Ù·Ó ·ÚfiÌÔÈ· ÛÙȘ 2 ÔÌ¿‰Â˜ (3/54 ¤Ó·ÓÙÈ 2/40). ŒÙÛÈ, Ë “ηχÙÂÚË” ÌÂÙ·ÊÔÚ¿ Ê·›ÓÂÙ·È Ó· ÌË Û˘Ó‰˘¿˙ÂÙ·È, Û ·˘Ù‹ ÙË ÌÂϤÙË, Ì ηχÙÂÚË ¤Î‚·ÛË. ŸÌˆ˜, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÚÔ-

Paediatriki 2003;66:37-41

ÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ¤Î‚·Û˘ ÔˆÛ‰‹ÔÙ Ϸ̂¿ÓÂÙ·È ˘’ fi„ÈÓ Ë ·Ú¯È΋ ‚·Ú‡ÙËÙ·, ÂÎÙ›ÌËÛË Ë ÔÔ›· ‰ÂÓ ¤ÁÈÓ ÛÙË ÌÂϤÙË Ì·˜. ∏ ÂÓÙ‡ˆÛ‹ Ì·˜ Â›Ó·È fiÙÈ Ù· ·È‰È¿ Ô˘ ÌÂٷʤÚıËÎ·Ó ·fi ÙÔ ∂∫∞µ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ·. ∂›Û˘, ‰ÂÓ ¤¯Ô˘Ó ηٷÁÚ·Ê› Ù· ÂÚÈÛÙ·ÙÈο Ô˘ η٤ÏËÍ·Ó Î·Ù¿ ÙË ÌÂÙ·ÊÔÚ¿. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂÙ·ÊÔÚ¿ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ Â›Ó·È ¤Ó· ÛËÌ·ÓÙÈÎfi ÎÔÌÌ¿ÙÈ ÛÙËÓ Â›ÁÔ˘Û· ·È‰È·ÙÚÈ΋ Ú¿ÍË. ∏ ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ·˘ÙÒÓ ÛÙÔÓ ÚÒÙÔ ÛÙ·ıÌfi ÌÂÙ·ÊÔÚ¿˜, Ë ÛÙ·ıÂÚÔÔ›ËÛË Î·È Ë Î·Ï‹ ÔÚÁ¿ÓˆÛË Ù˘ ÌÂÙ·ÊÔÚ¿˜ ÛÙÔ Î¤ÓÙÚÔ ÂΛÓÔ Ô˘ ı· ÌÔÚ› Ó· ·Ú¿Û¯ÂÈ ÔÏÔÎÏËڈ̤ÓË ÂÚ›ı·Ï„Ë Â›Ó·È ÎÂÊ·Ï·È҉˘. ∏ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ Î·È Ë ÛÙ·ıÂÚÔÔ›ËÛ‹ ÙÔ˘˜ ı· Á›ÓÂÈ Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ÚÔÂÙÔÈÌ·Û›· Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÊÔÚ¿˜, ·ÔÙÂÏÔ‡ÌÂÓË ·fi ÚÔÛˆÈÎfi ÂÎ·È‰Â˘Ì¤ÓÔ ÁÈ’ ·˘Ù‹. ªÂÙ·ÊÔÚ¤˜ Ô˘ Á›ÓÔÓÙ·È ·fi ÔÌ¿‰Â˜ ¯ˆÚ›˜ ÙËÓ ··ÈÙÔ‡ÌÂÓË ÂÌÂÈÚ›· ÌÔÚ› Ó· ¤¯Ô˘Ó ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÔÚ›· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ. ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È Ë ÂÓË̤ڈÛË ÙÔ˘ ΤÓÙÚÔ˘ ˘Ô‰Ô¯‹˜, Ë ÂÈÏÔÁ‹ ÙÔ˘ ÔÔ›Ô˘ ı· ‚·ÛÈÛÙ› ÛÙȘ ‰˘Ó·ÙfiÙËÙ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÂÚ›ÙˆÛ˘ (.¯. Â¿Ó ˘¿Ú¯ÂÈ Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÌ‹Ì·, ª∂£), ÒÛÙ ӷ ·ÔÊ¢¯ıÔ‡Ó ¿ÛÙԯ˜ ÌÂÙ·ÎÈÓ‹ÛÂȘ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Macrae DJ. Paediatric intensive care transport. Arch Dis Child 1994;71:175-178.

2. Pon S, Notterman DA. ∏ ÔÚÁ¿ÓˆÛË ÂÓfi˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÙ·ÊÔÚÒÓ ÂÓÙ·ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÁÈ· ·È‰È¿. Pediatr Clin North Am 1993;40:325-3529 (ÌÂÙ·ÊÚ·Ṳ̂ÓÔ).

3. ªÈÏ¿Ï˘ ¢, ∫·Ú·Ì›Ó˘ ∞. ªÂÙ·Ù˘¯È·Î¿ ª·ı‹Ì·Ù· ∂›ÁÔ˘Û·˜ ¶ÚÔÓÔÛÔÎÔÌÂȷ΋˜ π·ÙÚÈ΋˜ 1995;134-163.

4. American Academy of Pediatrics. Guidelines for air and ground transportation of pediatric patients. Pediatrics 1986;78:943-950.

5. Edge WE, Kanter RK, Weigle CGM, Walsh RF. Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 1992;20:117-124.

6. British Paediatric Association. The care of critically ill children. Report of the multidisciplinary working party on paediatric intensive care. London: BPA; 1993.

7. Henning R. Emergency transport of critically ill children: stabilization before departure. Med J Aust 1992;156:117-124. ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢ËÌ‹ÙÚÈÔ˜ °ÎÈÒÓ˘ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ & §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·

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¶·È‰È·ÙÚÈ΋ 2003;66:42-46

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Paediatriki 2003;66:42-46

ORIGINAL ARTICLE

∞ÍÈÔÏfiÁËÛË Ù˘ ÎÂÊÚÔ˙›Ï˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜1, OÌ¿‰· ªÂϤÙ˘2

Evaluation of cefprozil in the treatment of streptococcal tonsillo-pharyngitis in children A. Constantopoulos1, Study Group2

¶ÂÚ›ÏË„Ë: §fiÁˆ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·ÔÙ˘¯›·˜ Ù˘ ıÂÚ·›·˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Ì ÙËÓ ÂÓÈÎÈÏ›ÓË fiÛÔ Î·È ÙȘ Ì·ÎÚÔÏ›‰Â˜, ÔÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ÎÂÚ‰›˙Ô˘Ó Û˘Ó¯Ҙ ¤‰·ÊÔ˜ Û·Ó ıÂÚ·›· ÂÎÏÔÁ‹˜ Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË, Ì›· ÓÂfiÙÂÚË ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·, ¯ÔÚËÁ‹ıËΠ۠5175 ·ÛıÂÓ›˜ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜, ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ì ÂÍ·ÈÚÂÙÈο ·ÔÙÂϤÛÌ·Ù·. ∫ÏÈÓÈ΋ ›·ÛË ·Ú·ÙËÚ‹ıËΠ۠ÔÛÔÛÙfi 89,3% ÙˆÓ ·ÛıÂÓÒÓ, Ì ·Ú¿ÏÏËÏ· ˘„ËÏ¿ ÔÛÔÛÙ¿ Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂÚ·›· (98,2%) Î·È ¯·ÌËÏ¿ ÔÛÔÛÙ¿ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ (4%) Î·È ·ÏÏ·Á‹˜ Ù˘ ıÂÚ·›·˜ (2,6%). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Û˘ÌʈÓÔ‡Ó ·fiÏ˘Ù· Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÌÂÏÂÙÒÓ ·fi ͤÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÎÂÊÚÔ˙›ÏË Â›Ó·È Ì›· ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ·ÛÊ·Ï‹˜ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜.

Abstract: Due to the increased incidence of clinical failure following oral penicillin and macrolides treatment, cephalosporins are continuously gaining ground as an alternative therapy of streptococcal tonsillo-pharyngitis. In the present study, cefprozil a novel oral cephalosporin, was administered to 5175 patients aged 3-18 years old, in several parts of Greece, with clinical evidence of streptococcal tonsillo-pharyngitis having excellent results. Cure based on clinical evidence was observed in 89.3% of patients, with concurrent high rates of compliance to the treatment (98.2%), low rates of adverse events (4%) and even lower rate of switch to other therapy (2.6%). These results are in full accordance with those of previous studies, indicating that cefprozil is an effective and safe choice for the treatment of streptococcal tonsillo-pharyngitis.

§¤ÍÂȘ ÎÏÂȉȿ: ·È‰›, ÛÙÚÂÙfiÎÔÎÎÔ˜, Ïԛ̈ÍË, ÎÂÊÚÔ˙›ÏË, ıÂÚ·›·, ·Ì˘Á‰·Ï›Ùȉ·.

Key words: child, streptococcus, infection, cefprozil, treatment, tonsillitis.

∂ÈÛ·ÁˆÁ‹ ∏ ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· ÚÔηÏÂ›Ù·È ·fi ÙÔÓ ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ Ù˘

ÔÌ¿‰·˜ ∞ (˘ÔÁfiÓÔ ÛÙÚÂÙfiÎÔÎÎÔ) Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·. ∂›Ó·È, fï˜, ȉȷ›ÙÂÚ· Û˘¯Ó‹ ÛÙ· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏

1 ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ

1 Professor of Pediatrics, University of Athens

2 ª. ∞ÁÁÂÏ¿Î˘, ¢. ∞ÁÁÂÏfiÔ˘ÏÔ˜, ª. ∞ÚÁ˘Ú¿Î˘, ∂. ∞Ú¯ÈÙÂÎÙÔÓ›‰Ô˘, ª. ∞Ú¯ÔÓÙ›‰Ô˘, ™. ∞˘ÏˆÓ›Ù˘, ¢. µÈ‰¿Î˘, ∫. µÔ˘ÎÂÏ¿ÙÔ˘, °. µÚ˘ÒÓ˘, §. °·Ï¿Ó˘, ª. °È·ÓӷΛ‰Ô˘, ¡. °Î·Ì›Ï˘, ¶. °Ô˘Ú‰Ô˘¿Ú˘, ™. °Ú‡ÏÏ˘, ∫. ¢·ÓÂÏ¿ÙÔ˘, ∞. ¢È‰¿ÁÁÂÏÔ˜, °. ¢Ô‡‚Ú˘, ™. ¢ÚfiÛ˘, ∂. ∂Ï¢ıÂÚÈ¿‰Ô˘, °. ∑ÂÚ‚¿˜, Ã. ∑Ô˘Á·Ó¤ÏË, ∫. £ÂÚÌfi˜, Œ. π·Îˆ‚›‰Ô˘, ∞. ∫·ÎÔÁÈ¿ÓÓË, °. ∫·ÏÔÁÂÚfiÔ˘ÏÔ˜, °. ∫·ÂÙ·Ó¿Î˘, ¶. ∫·Ú·ÁÈ¿ÓÓ˘, ™. ∫·Ú·ÛÙ·Ì¿Ù˘, ∫. ∫ÔÚÒÓË-¶··ÓÙˆÓ›Ô˘, ¢. ∫·Û·¿Î˘, ¢. ∫·ÙÛÈοÚË, º. ∫·ÙÛÈԇϷ, ¢. ∫ψÛÙÔÔ‡ÏÔ˘, ∂. ∫fiÎÎÔÚË, ∞. ∫ÔÏÈÔ¿ÓÔ˘, ™. ∫fiÚÚ·, ∫. ∫ÔÙÛÈÒÓË, ∞. ∫Ô˘ÎfiÁÈ·, º. ∫Ô˘ÁÈ¿ÓÔ˜, ∫. ∫Ô‡ÚÙ˘, °. ∫ÚÔÎȉ¿˜, §. ∫˘Ú·ÓÔ‡‰Ë, ∂. ∫˘ÚÈ·ÎÔ‡, ∂. ∫˘Ú›ÙÛË, ∞. §ËÌÓ·›Ô˘, ∞. §˘ÎÔ˘Ú›ÓÔ˘, ∏. ª¿Ì·Ï˘, Ã. ª·ÓÙ¿, °. ª·ÚΤÙÔ˜, ª. ª·ÈÙ›ÓË, ∂. ª·ÙÛԇη-¶··ÓÈÎÔÏ¿Ô˘, °. ª·˘Ú¿Î˘, §. ªËÙÚfiÔ˘ÏÔ˜, π. ªÈ۷ϤÌ˘, §. ªÈÏ¿Ï˘, ∞. ªÔ˘Ú¿ÓÙ·-º·ÏÔ‡ÙÛÔ˘, ∞. ¡Èfi˙·, ∫. ¡Ù·Ïԇη˜, ƒ. ¡ÙÈÔ‡‰Ë-∞¯ÙÛfiÁÏÔ˘, ¶. ¡ÙÔ‡ÚÌ·, ª. ¶¿ÓÔ˘, ∂. ¶··‰ËÌËÙÚ›Ô˘, ∂. ¶··ı·Ó·Û›Ô˘, π. ¶··˚ˆ¿ÓÓÔ˘, ∞. ¶··ÓÙˆÓ›Ô˘, ¶. ¶›ÛÎÔÔ˜, π. ¶ÔÏ›ÙÛÔ˜, ∑. ¶ÔÏ˘¯ÚÔÓ›‰Ô˘, ¡. ¶Ô˘Ï·ÓÙ˙¿˜, ∫. ƒ¿Ù˘, ∞. ™·Î·Ï›‰Ô˘, ∂. ™·Ú·¿Ú˘, Ÿ. ™È‰ËÚÔÔ‡ÏÔ˘, ¢. ™ÔÏÔ‡ÎÔ˜, π. ™ÙÂÚÁ›‰Ë˜, ∞. ™Ù˘ÏÈ·Ó¿ÎË, ¢. ™˘Ìˆӛ‰Ë˜, ¢. ∆·Ï›‰Ë˜, ¢. ∆˙¿Ï·˜, °. ∆Û·Áη‰fiÔ˘ÏÔ˜, π. ∆Û·ÎÓ¿ÎË-ª·ÓˆÏ¿ÎË, ∫. ∆ÛÂÚÏÂÓÙ¿ÎË, °. ∆ÛÔÏ¿˜, °. ∆˘¯¿Ï·˜, ª. ÷ÈÚ¤Ù˘, ∫. ÷ω·ÈÔÔ‡ÏÔ˘-¶Ú¤ÓÙ˙·, ¶. ÷ÏÂÏ‹, º. ÷ÏÈÒÙ˘, π. ÷ڈӛÙË, ∂. ÷ÛÈÒÙÔ˘-∆Ô˘Ú›ÎË, ∂. ÷Ù˙Ë·ı·Ó·ÛÈ¿‰Ô˘, ∞. ÃÚËÛÙ¿ÎÔ˘, ¶. ÃÚ˘ÛfiÌ·ÏÏÔ˘

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JAN-FEB-03

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14:37

™ÂÏ›‰·43

¶·È‰È·ÙÚÈ΋ 2003;66:42-46

‰È¿ÁÓˆÛ‹ Ù˘ Ù›ıÂÙ·È Ì ·ÛÊ¿ÏÂÈ· Ì ÙËÓ ·ÔÌfiÓˆÛË ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, ÂÓÒ ·ÍÈfiÈÛÙ· ·ÔÙÂϤÛÌ·Ù· ‰›ÓÂÈ Î·È Ë Ù·¯Â›· ̤ıÔ‰Ô˜ ·Ó›¯Ó¢Û˘ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (1). ™ÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË, ¿ÓÙˆ˜, Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ ÙË ‚Ô‹ıÂÈ· Ù¤ÙÔÈˆÓ Ù¯ÓÈÎÒÓ. ™ÙȘ Ï›ÛÙ˜ ÂÚÈÙÒÛÂȘ, Ë ‰È¿ÁÓˆÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ù›ıÂÙ·È ·fi ÛÙÔȯ›· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Î·È ÂȂ‚·ÈÒÓÂÙ·È Ì ηÏÏȤÚÁÂÈ· ÂȯڛÛÌ·ÙÔ˜, ÂÓÒ Ë ıÂÚ·›· ¯ÔÚËÁÂ›Ù·È ÂÌÂÈÚÈο. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ Ì ·ÓÙÈ‚ÈÔÙÈο ·ÔÛÎÔ› ·ÊÂÓfi˜ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ˆ‰ÒÓ ÂÈÏÔÎÒÓ Ô˘ Â›Ó·È ‰˘ÓËÙÈο ÛÔ‚·Ú¤˜ (.¯. ÂÚÈ·Ì˘Á‰·ÏÈÎfi ·fiÛÙËÌ·), ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ÌË ˘ˆ‰ÒÓ ÂÈÏÔÎÒÓ (.¯. ÚÂ˘Ì·ÙÈÎfi˜ ˘ÚÂÙfi˜) (2). ∏ 10‹ÌÂÚË ¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘ ·ÔÙÂÏ› ÙËÓ ÎÏ·ÛÈ΋ ıÂÚ·›· ÁÈ· ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· (1). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· ·ÔÙ˘¯›· Ù˘ ÂÓÈÎÈÏ›Ó˘ Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ (1). ∏ ·ÔÙ˘¯›· ·˘Ù‹ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ·fi ÙÔÓ ÛÙÚÂÙfiÎÔÎÎÔ, ·ÏÏ¿ ·Ô‰›‰ÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ ÛÙËÓ ·ÚÔ˘Û›· ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ê¿Ú˘ÁÁ· ÌÈÎÚÔ‚›ˆÓ Ô˘, ¯ˆÚ›˜ Ó· Â›Ó·È ·ıÔÁfiÓ·, ·Ú¿ÁÔ˘Ó ¤Ó˙˘Ì· (‚-Ï·ÎÙ·Ì¿Û˜) Ô˘ ‰È·ÛÔ‡Ó Î·È ·‰Ú·ÓÔÔÈÔ‡Ó ÙËÓ ÂÓÈÎÈÏ›ÓË (Ê·ÈÓfiÌÂÓÔ ‚·ÎÙËÚȷ΋˜ ·ÚÂÌ‚ÔÏ‹˜) (1,3). ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ÂÓÈÎÈÏ›ÓË, ÔÈ Ì·ÎÚÔÏ›‰Â˜ Ô˘ ·Ó¤Î·ıÂÓ ·ÔÙÂÏÔ‡Û·Ó ÙËÓ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË Û ÂÚ›ÙˆÛË ·ÏÏÂÚÁ›·˜ ÛÙȘ ‚-Ï·Îٿ̘, ¤¯Ô˘Ó Úfi‚ÏËÌ· ·ÓÙÔ¯‹˜ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, Ô˘ Û ÌÂÚÈΤ˜ ¯ÒÚ˜ Â›Ó·È Ôχ ÛÔ‚·Úfi. ∏ ·ÓÙÔ¯‹ ·˘Ù‹ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÛËÌ·ÓÙÈο Â›‰· (38%) Î·È ÛÙËÓ ∂ÏÏ¿‰· Î·È ·ÊÔÚ¿ ÛÙȘ ·Ï·ÈfiÙÂÚ˜ (ÂÚ˘ıÚÔÌ˘Î›ÓË), ·ÏÏ¿ Î·È ÛÙȘ ÓÂfiÙÂÚ˜ Ì·ÎÚÔÏ›‰Â˜ (ÚÔÍÈıÚÔÌ˘Î›ÓË, ÎÏ·ÚÈıÚÔÌ˘Î›ÓË, ·˙ÈıÚÔÌ˘Î›ÓË) (4).

OÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Â›Ó·È ÂÍ›ÛÔ˘ ‰Ú·ÛÙÈΤ˜ Ì ÙËÓ ÂÓÈÎÈÏ›ÓË ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, ¯ˆÚ›˜ fï˜ Ó· ‰È·ÛÒÓÙ·È ·fi ÙȘ Ï·ÎÙ·Ì¿Û˜ ÙˆÓ Û·ÚÔÊ‡ÙˆÓ ÙÔ˘ Ê¿Ú˘ÁÁ·. À¿Ú¯Ô˘Ó ÔÏϤ˜ ÌÂϤÙ˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ô˘ ‰Â›¯ÓÔ˘Ó ˘ÂÚÔ¯‹ ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ ¤Ó·ÓÙÈ Ù˘ ÂÓÈÎÈÏ›Ó˘ ÛÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁ›Ùȉ· (1). ∏ ÎÂÊÚÔ˙›ÏË Â›Ó·È Ì›· Ó¤· ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·. Œ¯ÂÈ Â˘Ú‡ ·ÓÙÈÌÈÎÚÔ‚È·Îfi Ê¿ÛÌ· ηχÙÔÓÙ·˜ ÂÍ›ÛÔ˘ ηϿ Gram(+) Î·È Gram(-) ·ıÔÁfiÓ· Ù˘ ηıËÌÂÚÈÓ‹˜ ÎÏÈÓÈ΋˜ Ú¿Í˘. ∂ÌÊ·Ó›˙ÂÈ ÌÂÁ¿ÏË ‰Ú·ÛÙÈÎfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (MIC90 ≤0,032 mg/l) (4). ÃÔÚËÁÔ‡ÌÂÓË ·fi ÙÔ ÛÙfiÌ· ¤¯ÂÈ ÂÍ·ÈÚÂÙÈο Ê·Ú-

Paediatriki 2003;66:42-46

Ì·ÎÔÎÈÓËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο: ¿ÚÈÛÙË ‚ÈԉȷıÂÛÈÌfiÙËÙ· Î·È ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌÔÚ› Ó· ¯ÔÚËÁËı› Ì›· ‹ ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜, ÁÂÁÔÓfi˜ Ô˘ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙË ıÂÚ·›· (5,6). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó: ·) Ë ÂÎÙ›ÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ÎÂÊÚÔ˙›Ï˘ Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, ‚) Ë ÂÎÙ›ÌËÛË Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ÎÂÊÚÔ˙›Ï˘ Î·È Á) Ë ÂÎÙ›ÌËÛË Ù˘ Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ ıÂÚ·¢ÙÈÎfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË ÂÚÈÏ‹ÊıËÎ·Ó ·ÛıÂÓ›˜ ËÏÈΛ·˜ 3-18 ÂÙÒÓ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ı· ÌÔÚÔ‡Û ӷ ¯ÔÚËÁËı› ıÂÚ·›· Â͈ÓÔÛÔÎÔÌÂȷο Ì ·ÓÙÈ‚ÈÔÙÈÎfi ·fi ÙÔ ÛÙfiÌ·. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ·ÛıÂÓÒÓ ·fi ÙË ÌÂϤÙË ·ÔÙ¤ÏÂÛ·Ó: ·) ÁÓˆÛÙ‹ ·ÏÏÂÚÁ›· ÛÙËÓ ÎÂÊÚÔ˙›ÏË Î·È ÁÂÓÈÎfiÙÂÚ· ÛÙȘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ‹ ÛÙȘ ÂÓÈÎÈϛӘ ÏfiÁˆ Èı·Ó‹˜ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÏÏÂÚÁ›·˜, ‚) Ë Ù·˘Ùfi¯ÚÔÓË Ï‹„Ë Î·È ¿ÏÏÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ‹ Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 7 Ë̤Ú˜ ÚÈÓ ÙË Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË Î·È Á) Ë ·ÚÔ˘Û›· ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÔÔÈ·Û‰‹ÔÙ ʇÛ˘ (Û˘ÁÁÂÓÔ‡˜, È·ÙÚÔÁÂÓÔ‡˜ ‹ ÔÊÂÈÏfiÌÂÓ˘ Û ˘ÔΛÌÂÓË ÓfiÛÔ). ™ÙËÓ ·Ú¯È΋ Â›ÛÎÂ„Ë ÁÈÓfiÙ·Ó ·ÍÈÔÏfiÁËÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (¶›Ó·Î·˜ 1) Î·È ·ÔÊ·ÛÈ˙fiÙ·Ó Â¿Ó Ë fiÏË ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô ·ÛıÂÓ‹˜ ‹Ù·Ó ηٿÏÏËÏÔ˜ ÁÈ· Û˘ÌÌÂÙÔ¯‹ ÛÙË ÌÂϤÙË, ÂÏ¿Ì‚·Ó ·ÁˆÁ‹ Ì ÎÂÊÚÔ˙›ÏË 30 mg/kg/24ˆÚÔ ÁÈ· 10 Ë̤Ú˜. ∏ Û˘ÓÔÏÈ΋ ËÌÂÚ‹ÛÈ· ‰ÔÛÔÏÔÁ›· ¯ÔÚËÁÔ‡ÓÙ·Ó Û ‰‡Ô ‰fiÛÂȘ (·Ó¿ 12ˆÚÔ), ›Ù ˘fi ÙË ÌÔÚÊ‹ ÂӷȈڋ̷ÙÔ˜ ›Ù ˘fi ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ÙˆÓ 500 mg. ∏ ̤ÁÈÛÙË ÂÈÙÚÂfiÌÂÓË ‰ÔÛÔÏÔÁ›· ‹Ù·Ó 1 g/24ˆÚÔ. ™Â ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·, 5-8 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, Ï·Ì‚¿ÓÔÓÙ·Ó ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÔÚ›· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙËÓ Ù˘¯fiÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Ù˘ ÓfiÛÔ˘ ‹ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ·fi ÙË ıÂÚ·›·. ªÂ ‚¿ÛË Ù· ÛÙÔȯ›· ·fi ÙËÓ ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·, ‰ÈÓfiÙ·Ó Î·È Ô ¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ ¤Î‚·Û˘ Ù˘ ıÂÚ·›·˜: ·) ÿ·ÛË: Ï‹Ú˘ ·Ô‰ÚÔÌ‹ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ Ù˘ Ïԛ̈͢, ‚) µÂÏÙ›ˆÛË: Ì›ˆÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ‹/Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÛËÌ›ˆÓ Î·È Á) ∞ÔÙ˘¯›·: ÔÚȷ΋ ·Ô‰ÚÔÌ‹, ÂÈÌÔÓ‹ ‹ Âȉ›ӈÛË ÙˆÓ Û˘Ìو̿وÓ. ¶·Ú¿ÏÏËÏ·, ηٿ ÙËÓ ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Ï·Ì‚¿ÓÔÓÙ·Ó ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙË Û˘ÌÌfiÚʈÛË ÛÙË ıÂÚ·›·, ÙËÓ Èı·Ó‹ ·ÏÏ·Á‹ Ù˘ ıÂÚ·›·˜, ηıÒ˜ Î·È ÙÔ˘˜ ÏfiÁÔ˘˜ Ô˘ ÙËÓ ˘·ÁfiÚÂ˘Û·Ó.

43

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™ËÌÂÈÒÓÂÙ·È fiÙÈ fiÔ˘ ·Ó·Ê¤ÚÂÙ·È Ô fiÚÔ˜ Û˘ÌÌfiÚʈÛË ÛÙË ıÂÚ·›·, ¤¯ÂÈ ÔÚÈÛÙ› ‰ÈÂıÓÒ˜ fiÙÈ Ô ¿ÚÚˆÛÙÔ˜ Ï·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 80% Ù˘ Û˘ÓÔÏÈ΋˜ ıÂÚ·›·˜.

∞ÔÙÂϤÛÌ·Ù· ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 89 ÂÚ¢ÓËÙ¤˜ ·fi ·ÚÎÂÙ¿ ̤ÚË Ù˘ ∂ÏÏ¿‰·˜, ÌÂ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi 5175 ·ÛıÂÓÒÓ. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 6,5±3,3 ¯ÚfiÓÈ· (‰È¿ÌÂÛË ËÏÈΛ·: 6 ¯ÚfiÓÈ·). ¶Ï‹Úˆ˜ ·ÍÈÔÏÔÁ‹ÛÈÌÔÈ ‹Ù·Ó 5087 ·ÛıÂÓ›˜. ™˘ÓÔÏÈο, ›·ÛË Ì ‚¿ÛË ÙȘ ÚԉȷÁڷʤ˜ Ù˘ ÌÂϤÙ˘ ÂÌÊ¿ÓÈÛ ÙÔ 89,3%, ‚ÂÏÙ›ˆÛË ÙÔ 9,2% Î·È ·ÔÙ˘¯›· ÙÔ 1,5% ÙˆÓ ·ÍÈÔÏÔÁ‹ÛÈÌˆÓ ·ÛıÂÓÒÓ (∂ÈÎfiÓ· 1). ∆Ô ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂÚ·›· ‹Ù·Ó Ôχ ÌÈÎÚfi (1,8%), fï˜ Ë Â›ÙˆÛË Ù˘ ÌË Û˘ÌÌfiÚʈÛ˘ ÛÙËÓ ¤Î‚·ÛË Ù˘ ıÂÚ·›·˜ ‹Ù·Ó Ôχ ÛËÌ·ÓÙÈ΋.

OÈ ‰È·ÊÔÚ¤˜ Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ŒÙÛÈ, ÛÙËÓ ÂÚ›ÙˆÛË ÌË Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂÚ·›· ÙÔ ÔÛÔÛÙfi ›·Û˘ ‹Ù·Ó ·ÚÎÂÙ¿ οو ·fi ÙÔ 50% Î·È Ô ˘ÔÏÔÁÈ˙fiÌÂÓÔ˜ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· “fi¯È Ï‹ÚË ›·ÛË” (‚ÂÏÙ›ˆÛË+·ÔÙ˘¯›·) ‹Ù·Ó 12,9 (95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘: 8,0-20,9). ∂Ô̤ӈ˜, Â¿Ó ÏË-

ÊıÔ‡Ó ˘’ fi„ÈÓ ÌfiÓÔ Ù· ¿ÙÔÌ· Ô˘ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂÚ·›·, ÙÔ ÔÛÔÛÙfi Ù˘ ›·Û˘ ‹Ù·Ó ·ÎfiÌË ˘„ËÏfiÙÂÚÔ (90,2%). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ˘Ô¯ÒÚËÛÂ Ô ˘ÚÂÙfi˜, Ë Ì¤ÛË ÙÈÌ‹ ‹Ù·Ó 2,39±0,82 Ë̤Ú˜, ÂÓÒ ÙfiÛÔ Ë ‰È¿ÌÂÛË fiÛÔ Î·È Ë ÂÈÎÚ·ÙÔ‡Û· ÙÈÌ‹ ‹Ù·Ó Ë ‰Â‡ÙÂÚË Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (¶›Ó·Î·˜ 2). ∏ ·ÓÙ›ÛÙÔÈ¯Ë Ì¤ÛË ÙÈÌ‹ ÁÈ· ÙËÓ ˘Ô¯ÒÚËÛË ÙˆÓ ÏÔÈÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó 2,92±1,22, ÂÓÒ Ë ‰È¿ÌÂÛË ‹Ù·Ó Ë ÙÚ›ÙË Î·È Ë ÂÈÎÚ·ÙÔ‡Û· ÙÈÌ‹ ‹Ù·Ó Ë ‰Â‡ÙÂÚË Ë̤ڷ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (¶›Ó·Î·˜ 3). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Ù˘ ÏÔÈÌÒ͈˜ ‹Ù·Ó ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· (44 ·ÛıÂÓ›˜, ÔÛÔÛÙfi 0,86%). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ Û˘Óԉ¢fiÙ·Ó, ¿ÓÙˆ˜, ·fi ·ÏÏ·Á‹ ÛÙË ıÂÚ·›·. ∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ıÂÚ·›· ÂÌÊ·Ó›ÛÙËÎ·Ó Û 204 ·ÛıÂÓ›˜ (4%) Î·È ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ Û ‰È¿ÚÚÔÈ· Î·È Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi Û ¤ÌÂÙÔ. OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ‰ÂÓ ‹Ù·Ó Û˘Ó‹ıˆ˜ ÛÔ‚·Ú¤˜ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ÏÈÁfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÌÈÛÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó Î¿ÔÈ· ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ¿ÏÏ·Í·Ó ÙÂÏÈο

¶›Ó·Î·˜ 1. ™ÙÔȯ›· Ô˘ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÙˆÓ ·ÛıÂÓÒÓ ™˘ÌÙÒÌ·Ù· ¶ÔÓfiÏ·ÈÌÔ˜ ¢˘ÛηٷÔÛ›· ¶ÔÓÔΤʷÏÔ˜ ƒ›ÁÔ˜ ∫ÔÈÏÈ·Îfi ¿ÏÁÔ˜ £ÂÚÌÔÎÚ·Û›· Ì·Û¯¿Ï˘

BÂÏÙ›ˆÛË 9,2%

™˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 82% 60,8% 48,1% 46,9% 32,5% Ô 38,9 C

∞ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË

¶ÔÛÔÛÙfi

°ÂÓÈ΋ ηٿÛÙ·ÛË ÂËÚ·Ṳ̂ÓË ¢‡ÛÙÚÔÔ ª¤ÁÂıÔ˜ ·Ì˘Á‰·ÏÒÓ ‰ÈÔÁΈ̤ÓÔ ∂›¯ÚÈÛÌ· ∂Ú˘ıÚfiÙ˘ ∂Í›‰ÚˆÌ· ∞˘ÙÈ¿-̇ÙË-Ï·ÈÌfi˜ Û˘Ì‚·Ù¿ Ì ·Ì˘Á‰·Ï›Ùȉ· (‰ÂÓ ˘‹Ú¯Â ‚‹¯·˜, ÚÈÓ›ÙȘ, ˆÙ›ÙȘ, ÂÈÂÊ˘Î›ÙȘ Î.¿.)

∞ÔÙ˘¯›· 1,5%

32,3% 20,1% 71,1% 76,8% 97,4% 53,7%

92,2%

100% ∞ÔÙ˘¯›· 80% 60% BÂÏÙ›ˆÛË 40% 20%

ÿ·ÛË 89,3% ∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙÈ·›· ηٷÓÔÌ‹ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ·ÁˆÁ‹˜.

44

ÿ·ÛË

0% ™˘ÌÌfiÚʈÛË

ªË Û˘ÌÌfiÚʈÛË

∂ÈÎfiÓ· 2. ÷ڷÎÙËÚÈÛÌfi˜ ·ÁˆÁ‹˜ ·Ó¿ÏÔÁ· Ì ÙË Û˘ÌÌfiÚʈÛË ÛÙË Ï‹„Ë ÙÔ˘ Ê·ÚÌ¿ÎÔ˘.

JAN-FEB-03

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¶·È‰È·ÙÚÈ΋ 2003;66:42-46

Paediatriki 2003;66:42-46

¶›Ó·Î·˜ 2. ÃÚÔÓÈ΋ ÛÙÈÁÌ‹ ÙÒÛ˘ ÙÔ˘ ˘ÚÂÙÔ‡

∏̤ڷ ÙÒÛ˘ ˘ÚÂÙÔ‡

1 2 3 4 5 6+

™‡ÓÔÏÔ ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ ™‡ÓÔÏÔ ÌË ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ °ÂÓÈÎfi Û‡ÓÔÏÔ

™˘¯ÓfiÙËÙ·

¶ÔÛÔÛÙfi Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ··ÓÙËı¤ÓÙˆÓ (%)

496 2118 1638 310 26 11

10,8% 46,1% 35,6% 6,7% 0,6% 0,2%

4599 576 5175

100%

¶›Ó·Î·˜ 3. ÃÚÔÓÈ΋ ÛÙÈÁÌ‹ ˘Ô¯ÒÚËÛ˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ™˘¯ÓfiÙËÙ·

¶ÔÛÔÛÙfi Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ··ÓÙËı¤ÓÙˆÓ (%)

∏̤ڷ ˘Ô¯ÒÚËÛ˘ 1 ÙˆÓ ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ 2 3 4 5 6 7 8

353 1491 1474 679 340 93 30 15

7,9% 33,3% 32,9% 15,2% 7,6% 2,1% 0,7% 0,3%

™‡ÓÔÏÔ ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ ™‡ÓÔÏÔ ÌË ·ÓÙ·ÔÎÚÈı¤ÓÙˆÓ °ÂÓÈÎfi Û‡ÓÔÏÔ

4475 700 5175

100%

ÙË ıÂÚ·›· ÂÍ·ÈÙ›·˜ ·˘Ù‹˜. ™˘ÓÔÏÈο, ·ÏÏ·Á‹ ıÂÚ·›·˜ ÁÈ· fiϘ ÙȘ ·Èٛ˜ ¤ÁÈÓ Û 130 ·ÛıÂÓ›˜ (2,6%). ∞Ó Î·È ‰ÂÓ ¤ÁÈÓ·Ó Î·ÏÏȤÚÁÂȘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, Ù· Â˘Ú‹Ì·Ù· ÛÙËÓ ∂ÈÎfiÓ· 2 ‰Â›¯ÓÔ˘Ó fiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ·Ì˘Á‰·Ï›Ùȉ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ¢È·ÊÔÚÂÙÈο, Â¿Ó ÂÚfiÎÂÈÙÔ ÁÈ· ÈÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜, ‰ÂÓ ı· ‰È·ÈÛÙˆÓfiÙ·Ó ‰È·ÊÔÚ¿ Û ·ÛıÂÓ›˜ Ì η΋ Û˘ÌÌfiÚʈÛË. ™˘˙‹ÙËÛË ∏ ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· Â›Ó·È Ì›· Û˘¯Ó‹ ¿ıËÛË Ù˘ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏ ·Ú·‰ÔÛȷ΋ ıÂÚ·›· Ì ÂÓÈÎÈÏ›ÓË ¤¯ÂÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÔÙ˘¯›·˜ Î·È ˘ÔÙÚÔÒÓ, ·Ú¿ ÙË ‰Ú·ÛÙÈÎfiÙËÙ¿ Ù˘ ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ (1). ∂ÈϤÔÓ, ÔÈ Ì·ÎÚÔÏ›‰Â˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂÚ·›·, ¤¯Ô˘Ó ÛÔ‚·Úfi Úfi‚ÏËÌ· ·ÓÙÔ¯‹˜ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘, Ô˘ ·ÊÔÚ¿ ÙfiÛÔ ÛÙ· ·Ï·ÈfiÙÂÚ· fiÛÔ Î·È ÛÙ· ÓÂfiÙÂÚ· ̤ÏË ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ·ÓÙÈ‚ÈÔÙÈÎÒÓ (4). ∞ÓÙ›ıÂÙ·, ÔÈ ÎÂÊ·ÏÔÛÔÚ›Ó˜ Â›Ó·È ‰Ú·ÛÙÈΤ˜ ¤Ó·ÓÙÈ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ fiˆ˜ Î·È Ë ÂÓÈÎÈÏ›ÓË, ÂÓÒ ÛÙÂÚÔ‡ÓÙ·È ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·˘Ù‹ ÂÌÊ·Ó›˙ÂÈ (‰È¿Û·ÛË ·fi ‚-Ï·ÎÙ·Ì¿Û˜, η΋ Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋). π‰È·›ÙÂÚ· Ë ÎÂÊÚÔ˙›ÏË, Ì›· ÓÂfiÙÂÚË ÎÂÊ·ÏÔÛÔÚ›ÓË Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ·, ¤¯ÂÈ ÌÂÁ¿ÏË ‰Ú·ÛÙÈ-

ÎfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘. ™Â ÌÂϤÙ˜ Û˘ÁÎÚÈÙÈΤ˜ Î·È ÌË ¤‰ÂÈÍ ÂÍ·ÈÚÂÙÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Û ÔÈÎÈÏ›· ÏÔÈÌÒ͈Ó, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ (5,6). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Û ‰ÔÛÔÏÔÁ›· 30 mg/kg/24ˆÚÔ Û ·ÛıÂÓ›˜ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, ¤Ù˘¯Â ˘„ËÏfi ÔÛÔÛÙfi ÎÏÈÓÈ΋˜ ›·Û˘ (89,3%). ™ËÌÂÈÒÓÂÙ·È, Â›Û˘, fiÙÈ Ô ¯ÚfiÓÔ˜ ̤¯ÚÈ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡ Î·È ÙˆÓ ÏÔÈÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹Ù·Ó ÌÈÎÚfi˜, Ì ÙÔ Ï›ÛÙÔ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ó· ˘Ô¯ˆÚ› ‹‰Ë ·fi ÙË ‰Â‡ÙÂÚË Ë̤ڷ Ù˘ ıÂÚ·›·˜, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ Ù·¯Â›· ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›·. ∆Ô ÔÛÔÛÙfi ·˘Ùfi (89,3%) ‹Ù·Ó ·ÎfiÌË ˘„ËÏfiÙÂÚÔ (90,2%) ·Ó Ï·Ì‚¿ÓÔÓÙ·Ó ˘’ fi„ÈÓ ÌfiÓÔ ÔÈ ·ÛıÂÓ›˜ Ô˘ Û˘ÌÌÔÚÊÒıËÎ·Ó ÛÙË ıÂÚ·›·. To ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Û˘ÌÌfiÚʈÛ˘ ÛÙË ıÂÚ·›· Ô˘ ·Ú·ÙËÚ‹ıËΠ̠ÙËÓ ÎÂÊÚÔ˙›ÏË ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Î·È Ô˘ ·ÔÙÂÏ› Ô˘ÛÈ·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÎÏÈÓÈ΋ ÂÈÙ˘¯›· Ù˘ ıÂÚ·›·˜, Ú¤ÂÈ Ó· ·Ô‰Ôı› ·ÊÂÓfi˜ ÛÙÔ ·Ïfi ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Ù˘ ÎÂÊÚÔ˙›Ï˘, ·ÊÂÙ¤ÚÔ˘ ÛÙÔ ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Ô˘ ·Ú·ÙËÚ‹ıËηÓ. ∞Í›˙ÂÈ Ó· ÙÔÓÈÛÙ› ÙÔ È‰È·›ÙÂÚ· ¯·ÌËÏfi ÔÛÔÛÙfi ·ÏÏ·Á‹˜ Ù˘ ıÂÚ·›·˜ Ô˘ ηٷÁÚ¿ÊËΠÛÙËÓ ·ÚÔ‡Û·

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ÌÂϤÙË, Ô˘ ‹Ù·Ó Û˘Ó¿ÚÙËÛË ÙfiÛÔ Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ fiÛÔ Î·È Ù˘ ·ÛÊ¿ÏÂÈ·˜ Ù˘ ıÂÚ·›·˜, fiˆ˜ ·˘Ù‹ ÂÎÊÚ¿ÛÙËΠ̠ÙÔ ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ë ·ÛÊ¿ÏÂÈ· Ù˘ ÎÂÊÚÔ˙›Ï˘ Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› Û ÔÏϤ˜ ÌÂϤÙ˜, Û˘ÁÎÚÈÙÈΤ˜ Î·È ÌË. ŒÙÛÈ, .¯. ÔÈ µrook Î·È Û˘Ó (7) Û ̛· Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË Ì ÂÚ˘ıÚÔÌ˘Î›ÓË ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙfi ›·Û˘ 90% Ì ÙËÓ ÎÂÊÚÔ˙›ÏË, ÂÓÒ ÙÔ ÔÛÔÛÙfi ‚·ÎÙËÚÈÔÏÔÁÈ΋˜ ÂÎÚ›˙ˆÛ˘ ÙÔ˘ ˘ÔÁfiÓÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ ÛÙËÓ ›‰È· ÌÂϤÙË ¤Êı·Û ÙÔ 95% ¤Ó·ÓÙÈ ÌfiÏȘ 74% Ì ÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË. ™Â Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË, Â›Û˘, ÙˆÓ Milatovic Î·È Û˘Ó, Ë ÎÂÊÚÔ˙›ÏË ‹Ù·Ó ·ÓÒÙÂÚË Ù˘ ÂÓÈÎÈÏ›Ó˘ ÙfiÛÔ Û ÎÏÈÓÈÎfi fiÛÔ Î·È Û ‚·ÎÙËÚÈÔÏÔÁÈÎfi Â›Â‰Ô (8). ™Â Ì›· ¿ÏÏË ÌÂϤÙË, Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ ›¯Â Ù· ›‰È· ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ÎÂÊ·ÎÏfiÚË Ô˘ ¯ÔÚËÁ‹ıËΠ3 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Î·È ÙËÓ ÂÚ˘ıÚÔÌ˘Î›ÓË Ô˘ ¯ÔÚËÁ‹ıËΠ4 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ (9). ∏ ·ÓÒÙÂÚË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ÎÂÊÚÔ˙›Ï˘, Û ÂÚÈÙÒÛÂȘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜, Ô‰‹ÁËÛ ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ Ó· Û˘˙ËÙÔ‡Ó ÙÔ ÂӉ¯fiÌÂÓÔ ·Ó·ıÂÒÚËÛ˘ Ù˘ ıÂÚ·›·˜ ÂÎÏÔÁ‹˜ ÁÈ· ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·. ™ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÙÔ Î‡ÚÈÔ Âȯ›ÚËÌ· ˘¤Ú Ù˘ ÂÓÈÎÈÏ›Ó˘ Â›Ó·È ÙÔ ¯·ÌËÏfi ÎfiÛÙÔ˜ Ù˘ ıÂÚ·›·˜. ∂¿Ó, fï˜, ÏËÊı› ˘’ fi„ÈÓ ÙÔ “ÎÚ˘Êfi” ÎfiÛÙÔ˜ Ô˘ ÂÚÈÎÏ›ÂÈ Ì›· ·ÔÙ˘¯›· Ù˘ ıÂÚ·›·˜ (Ó¤· È·ÙÚÈ΋ Â›Û΄Ë, Ó¤Ô ·ÓÙÈ‚ÈÔÙÈÎfi, ÙÚÒÛË ÙÔ˘ ·ÚÔ˘˜ ÙÔ˘ È·ÙÚÔ‡, ·Ô˘Û›· ·fi Û¯ÔÏ›Ô-‰Ô˘ÏÂÈ¿ Î.Ï.), ηıÒ˜ Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÌÂÁ¿ÏË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ì ÙË ¯Ú‹ÛË ‚Ú·¯¤ˆÓ (5 ÌÂÚÒÓ) Û¯ËÌ¿ÙˆÓ, Ë “Ï¿ÛÙÈÁÁ· ›Ûˆ˜ Á›ÚÂÈ ÙÂÏÈο ÚÔ˜ ÙÔ Ì¤ÚÔ˜ ÙˆÓ ÎÂÊ·ÏÔÛÔÚÈÓÒÓ” (10). ∏ ·ÚÔ‡Û· ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ë ÎÂÊÚÔ˙›ÏË ¯ÔÚËÁÔ‡ÌÂÓË Û ·È‰È¿ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜ ÂÌÊ·Ó›˙ÂÈ ÌÂÁ¿ÏË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ô˘ Û˘Ó‰˘¿˙ÂÙ·È Ì ¯·ÌËÏfi ÔÛÔÛÙfi ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ Î·È ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Û˘ÌÌfiÚʈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ. ªÂ ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿, Ë ÎÂÊÚÔ˙›ÏË Ú¤ÂÈ

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Ó· ıˆÚÂ›Ù·È Û·Ó Ì›· ·ÍÈfiÈÛÙË Î·È ·ÛÊ·Ï‹˜ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÚÂÙÔÎÔÎÎÈ΋˜ Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Pichichero ME, Casey JR, Mayes T, Francis AB, Marsocci SM, Murphy AM et al. Penicillin failure in streptococcal tonsillopharyngitis: causes and remedies. Pediatr Infect Dis J 2000;19:917-923.

2. Kaplan EL. The resurgence of group A streptococcal infections and their sequelae. Eur J Clin Microbiol Infect Dis 1991;10:55-57.

3. Brook I. ∆he role of beta-lactamase producing bacteria and bacterial interference in streptococcal tonsillitis. Int J Antimicrob Agents 2001;17:439-442.

4. Syrogiannopoulos GA, Grivea IN, Fitoussi F, Doit C, Katopodis GD, Bingen E et al. High prevalence of erythromycin resistance of Streptococcus pyogenes in Greek children. Pediatr Infect Dis J 2001;20:863-868.

5. Barriere SL. Review of in vitro activity, pharmacokinetic characteristics, safety, and clinical efficacy of cefprozil, a new oral cephalosporin. Ann Pharmacother 1993;27: 1082-1089.

6. Wiseman LR, Benfield P. Cefprozil. A review of its antibacterial activity, pharmacokinetic properties, and therapeutic potential. Drugs 1993;45:295-317.

7. Brook I, Aronovitz GH, Pichichero ME. Open-label, parallel-group, multicenter, randomized study of cefprozil versus erythromycin in children with group A streptococcal pharyngitis/tonsillitis. Clin Ther 2001;23: 1889-1900.

8. Milatovic D, Adam D, Hamilton H, Materman E. Cefprozil versus penicillin V in the treatment of streptococcal tonsillopharyngitis. Antimicrob Agents Chemother 1993; 37:1620-1623.

9. Aronovitz G. Treatment of upper and lower respiratory tract infections: Clinical trials with cefprozil. Pediatr Infect Dis J 1998;17 (8 Suppl):S83-S88.

10. ∞dam D, Scholz H, Helmerking M. Short-course antibiotic treatment of 4782 culture-proven cases of group A streptococcal tonsillopharyngitis and incidence of poststreptococcal sequelae. J Infect Dis 2000;182:509-516.

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-11-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 10-12-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

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Paediatriki 2003;66:47-51

CASE REPORT

ÀÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Û ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I °. ∆Ú›Ì˘1, ª. ªÔÛ¯fi‚Ë1, ∏. ∫·Ú·Ó›Î·˜2, ª. ∫·Ó¿ÚÈÔ˘3, ∞. ƒ·ÊÙÔÔ‡ÏÔ˘4, º. ∆˙ˆÚÙ˙¿ÙÔ˘ - ™Ù·ıÔÔ‡ÏÔ˘1

Subacute vertebral osteomyelitis in a child with type I diabetes mellitus G. Trimis1, M. Moschovi1, I. Karanikas2, M. Kanariou3, A. Raftopoulou4, F. Tzortzatou - Stathopoulou1

¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ 14 ÂÙÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I Î·È Â›ÌÔÓÔ ¿ÏÁÔ˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ·fi ÌËÓfi˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÂÚÈÔ¯‹ ¤ıÂÛ ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜. ¢È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ¤ıÂÛ ÙË ‰È¿ÁÓˆÛË ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ˘ÏÈÎÔ‡ Ù˘ ‚ÈÔ„›·˜ ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. OÈ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ ˘Ô¯ÒÚËÛ·Ó ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹. ∆Ô ÂӉȷʤÚÔÓ ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙË Û¿ÓÈ· ÂΉ‹ÏˆÛË ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Û ·È‰› Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤Ï·ÛË Ù˘ ÂÚ›ÙˆÛ˘.

Abstract: A case of a 14 year-old boy with type I diabetes mellitus and persistent pain in the spine of one month’s duration is described. A magnetic resonance imaging of vertebral column was performed and the patient was initially considered to have lymphoma. The diagnosis of twelfth thoracic vertebrae osteomyelitis was established by transcutaneous biopsy. Staphylococcus aureus was isolated from the culture of the biopsy material. The manifestations of the disease resolved after antibiotic treatment. Subacute vertebral osteomyelitis is a rare condition, even in a child with diabetes mellitus, and the diagnosis is often overlooked initially.

§¤ÍÂȘ ÎÏÂȉȿ: ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, ÔÛÙÂÔÌ˘ÂÏ›ÙȘ, ۷ί·Ú҉˘ ‰È·‚‹Ù˘.

Key words: spine, osteomyelitis, diabetes mellitus.

∂ÈÛ·ÁˆÁ‹ ∏ ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ˘ÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Û˘Á¯¤ÂÙ·È ÔÏϤ˜ ÊÔÚ¤˜ Ì ·˘Ù‹ ÙˆÓ Î·ÎÔ‹ıˆÓ fiÁΈÓ, fiˆ˜ ÙÔ Ï¤Ìʈ̷, ÙÔ ÔÛÙÂÔÛ¿ÚΈ̷, ÙÔ Û¿ÚΈ̷ Ewing’s, ÙÔ ËˆÛÈÓfiÊÈÏÔ ÎÔÎΛˆÌ· Î·È ·ÓÙ›ÛÙÚÔÊ· (1). ∏ ÈÔ Â˘·›ÛıËÙË ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Â›Ó·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) Ì ¢·ÈÛıËÛ›· 98%, fï˜ Ë ÂȉÈÎfiÙËÙ¿ Ù˘ ‰ÂÓ Â›Ó·È ·ÓÙ›ÛÙÔÈ¯Ë Î·È ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 75% (2). °È· ÙËÓ Â‰Ú·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ··ÈÙÂ›Ù·È ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ ‹, Â› ·ÔÙ˘¯›·˜, ·ÓÔȯً ‚ÈÔ„›· (3). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ 14 ÂÙÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ I Ô˘ ·ÚÔ˘Û›·Û Â›-

ÌÔÓÔ ¿ÏÁÔ˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ·fi ÌËÓfi˜. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÂÚÈÔ¯‹˜ ¤ıÂÛ ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜. ªÂ ÙË ‚Ô‹ıÂÈ· ‰È·‰ÂÚÌÈ΋˜ ‚ÈÔ„›·˜ ‰È·ÁÓÒÛıËΠÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ˘ÏÈÎÔ‡ Ù˘ ‚ÈÔ„›·˜ ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. OÈ ÂΉËÏÒÛÂȘ Ù˘ ÓfiÛÔ˘ ˘Ô¯ÒÚËÛ·Ó ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹.

¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 1 ªÔÓ¿‰· ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜, A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 µ’ OÚıÔ‰È΋ ∫ÏÈÓÈ΋ 3 ∞ÓÔÛÔÏÔÁÈÎfi ∆Ì‹Ì· 4 ∆Ì‹Ì· ∫ÏÈÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜

“Agia Sophia” Children’s Hospital, Athens 1 Hematology-Oncology Unit, 1st Pediatric Clinic of University of Athens 2 2nd Orthopedic Clinic 3 Department of Immunology 4 Department of Clinical Microbiology

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 14 ÂÙÒÓ ·Ú·¤ÌÊıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì ÙËÓ ˘fiÓÔÈ· ÏÂÌÊÒÌ·ÙÔ˜ ÛÙÔ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ. ∏ Èı·Ó‹ ·˘Ù‹ ‰È¿ÁÓˆÛË Ù¤ıËΠ·fi ÙËÓ MRI Ù˘ ıˆÚ·ÎÔ-ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, ÛÙËÓ ÔÔ›· ˘Ô‚Ï‹ıËÎÂ

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Ô ·ÛıÂÓ‹˜ ÁÈ·Ù› ·ÚÔ˘Û›·˙ Â›ÌÔÓÔ ¿ÏÁÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ ·fi ÌËÓfi˜.

O ·ÛıÂÓ‹˜ Â›Ó·È ÙÔ ‰Â‡ÙÂÚÔ ·È‰› ÙÂÙÚ·ÌÂÏÔ‡˜ ÔÈÎÔÁ¤ÓÂÈ·˜ Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÂÙ·È ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ I ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 7 ÂÙÒÓ, Ô ÔÔ›Ô˜ Ú˘ıÌ›˙ÂÙ·È ÌÂÙÚ›ˆ˜ Ì ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ ÈÓÛÔ˘Ï›Ó˘ Î·È ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹ (ÙÈ̤˜ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜: 200-350 mg/dl, ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË HbA1c: 9,5-11%, ÙÂÏÂ˘Ù·›· ÙÈÌ‹: 9,6%). OÈ ÂÓԯϋÛÂȘ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË ÍÂΛÓËÛ·Ó ÚÔ ÌËÓfi˜, ÌÂÙ¿ ·fi ¤ÓÙÔÓË ¿ÛÎËÛË. O ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·ÛÂ, Â›Û˘, ˘„ËÏfi ˘ÚÂÙfi ̤¯ÚÈ 40ÔC Ù· ÙÚ›· ÚÒÙ· 24ˆÚ·, Ô˘ ·Ô‰fiıËΠ۠ÈÔÁÂÓ‹ Ïԛ̈ÍË. §fiÁˆ ÚÔԉ¢ÙÈ΋˜ Âȉ›ӈÛ˘ ÙÔ˘ ¿ÏÁÔ˘˜, ¤ÁÈÓ ÔÚıÔ‰È΋ ÂÎÙ›ÌËÛË ÙËÓ ¤ÌÙË Ë̤ڷ Ù˘ ÓfiÛÔ˘. ∏ ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË Î·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜, fiÔ˘ Ë ÌÔÚÊÔÏÔÁ›· ÙˆÓ ÛÔÓ‰‡ÏˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋, ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ıÏ¿Û˘ Ì˘ÒÓ. ™˘ÛÙ‹ıËΠ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ Î·È ·˘ÛÙËÚ‹ ηٿÎÏÈÛË Û ·ÓÙ·ÏÁÈ΋ ı¤ÛË ÁÈ· 15 Ë̤Ú˜. ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ÙÔ ¿ÏÁÔ˜ ·ÚÔ˘Û›·Û ۯÂÙÈ΋ ‡ÊÂÛË. ™ÙË Û˘Ó¤¯ÂÈ·, fï˜, ·ÚÔ˘ÛÈ¿ÛÙËΠ‰Ú·Ì·ÙÈ΋ Âȉ›ӈÛË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÂÌÔ‰›˙ÔÓÙ·È ÔÈ ·Ϥ˜ ÎÈÓ‹ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡. ŒÁÈÓ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Ì MRI Î·È ‰È·ÈÛÙÒıËΠÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ì ·ÓÒÌ·ÏÔ ÂÚ›ÁÚ·ÌÌ· Ù˘ ÚfiÛıÈ·˜ Î·È Î¿Ùˆ ·Ú˘Ê‹˜ ·˘ÙÔ‡, Ë ÔÔ›· ‰ËÌÈÔ˘ÚÁÔ‡Û ÙËÓ ÂÓÙ‡ˆÛË ‰È·‚ÚÒÛÂˆÓ Î·È ÏÈÁfiÙÂÚÔ Û˘ÌÈÂÛÙÈÎÔ‡ ηٿÁÌ·ÙÔ˜. ∆·˘Ùfi¯ÚÔÓ·, ·ÂÈÎÔÓÈ˙fiÙ·Ó Ì¿˙· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ¤ÚÈÍ ÙÔ˘ ÛÔÓ‰‡ÏÔ˘, Ë ÔÔ›· ·ÚÔ˘Û›·˙ ÌÈÎÚ‹ Â¤ÎÙ·ÛË ÚÔ˜ Ù· οو ¤ÌÚÔÛıÂÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘ (∂ÈÎfiÓ· 1). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ¤ıÂÙ·Ó ÙËÓ ˘fiÓÔÈ· ‰ÈËıËÙÈ΋˜ ÂÍÂÚÁ·Û›·˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘, Ë ÔÔ›· ÂӉ¯Ô̤ӈ˜ ÔÊÂÈÏfiÙ·Ó Û ϤÌʈ̷.

O ·ÛıÂÓ‹˜ ·Ú·¤ÌÊıËΠÛÙËÓ ÎÏÈÓÈ΋ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Èı·Ó‹˜ ηÎÔ‹ıÂÈ·˜. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠ¤ÓÙÔÓË Â˘·ÈÛıËÛ›· ÛÙËÓ Î·ÙÒÙÂÚË ıˆÚ·ÎÈ΋ Î·È ·ÓÒÙÂÚË ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÂ Û˘ÓÔ‰fi Ì˘˚Îfi Û·ÛÌfi. ∆Ô ¿ÏÁÔ˜ ÂÈÙÂÈÓfiÙ·Ó Î·Ù¿ ÙȘ ÎÈÓ‹ÛÂȘ ο̄˘ Î·È ¤ÎÙ·Û˘ ÙÔ˘ ÎÔÚÌÔ‡. ∆Ô ÛËÌÂ›Ô Laseque ‹Ù·Ó ÂÓÙfiÓˆ˜ ıÂÙÈÎfi ¿Ìʈ. ∞fi ÙËÓ ÂͤٷÛË ÙˆÓ ˘fiÏÔÈˆÓ Û˘ÛÙËÌ¿ÙˆÓ ‰ÂÓ ÂÓÙÔ›ÛÙËÎ·Ó ¿ÏÏ· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ·˘ÍË̤ÓÔÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂: 85 mm, CRP: 50 mg/L, ÊÂÚÚÈÙ›ÓË:

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196 ng/ml, LDH: 497 IU/L, Cu: 150 Ìg/dl), ÂÓÒ Ë ÁÂÓÈ΋ ·›Ì·ÙÔ˜ (Ht: 42,9%, Hb: 14,2 g/dl, WBC: 8200/Ìl, PLT: 268.000/Ìl) Î·È Ô ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. O ¤ÏÂÁ¯Ô˜ ÁÈ· Ê˘Ì·Ù›ˆÛË Î·È ‚ÚԢΤÏψÛË ·¤‚Ë ·ÚÓËÙÈÎfi˜. ™ÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· Ù˘ ÂÚÈÔ¯‹˜ ·ÂÈÎÔÓ›ÛÙËÎÂ Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Ì χÛË Î·Ù¿ ÙÔ ÚfiÛıÈÔ Î¿Ùˆ ¯Â›ÏÔ˜ ·˘ÙÔ‡. ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ Ì Ù¯ӋÙÈÔ ¤‰ÂÈÍ ·˘ÍË̤ÓË Î·ı‹ÏˆÛË ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ÛÙÔÓ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ. ∏ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÙÂı› ‰È¿ÁÓˆÛË, ÚÔÁÚ·ÌÌ·Ù›ÛÙËΠ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÛÔÓ‰‡ÏÔ˘ ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ. ∆Ô ·È‰› Ù¤ıËΠ۠·˘ÛÙËÚ‹ ηٿÎÏÈÛË, Û ·ÓÙ·ÏÁÈ΋ ı¤ÛË Î·È ÙÔ˘ ¯ÔÚËÁ‹ıËΠÈÛ¯˘Ú‹ ·Ó·ÏÁËÙÈ΋ ·ÁˆÁ‹. ¶·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË, fï˜ ÙËÓ Ù¤Ù·ÚÙË Ë̤ڷ ÓÔÛËÏ›·˜ ÂÌÊ¿ÓÈÛ ˘ÚÂÙfi ̤¯ÚÈ 39oC Ì ڛÁÔ˜, ¯ˆÚ›˜ Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. ™ÙËÓ Î·ÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜ Ô˘ ÂÏ‹ÊıË ·ÔÌÔÓÒıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÙÂ˚ÎÔÏ·Ó›ÓË 800 mg/24ˆÚÔ:2 (̤ÁÈÛÙË ‰fiÛË), ÎÂÊÔÙ·Í›ÌË 150 mg/kg/24ˆÚÔ:3 Î·È ·ÌÈηۛÓË 15 mg/kg/24ˆÚÔ:2 ÂÓ‰ÔÊÏ‚›ˆ˜. O ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛ ÂÓÙfi˜ 36

∂ÈÎfiÓ· 1. ª·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ù˘ ıˆÚ·ÎÔ-ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ¢È·ÎÚ›ÓÂÙ·È Ë ÛÊËÓÔÂȉ‹˜ ·Ú·ÌfiÚʈÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Î·È Ë ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙·, Ë ÔÔ›· ·ÚÔ˘ÛÈ¿˙ÂÈ Â¤ÎÙ·ÛË ÚÔ˜ Ù· οو ¤ÌÚÔÛıÂÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘.

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ˆÚÒÓ Î·È ÙËÓ ÂfiÌÂÓË Ë̤ڷ ¤ÁÈÓÂ Ë ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ÙÔ˘ ÚÔۂ‚ÏË̤ÓÔ˘ ÛÔÓ‰‡ÏÔ˘. ∞fi ÙËÓ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÂͤٷÛË ÙÔ˘ ˘ÏÈÎÔ‡ ‚ÈÔ„›·˜ ‰È·ÈÛÙÒıËΠÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· (ÂÈÎfiÓ· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜), ÛÙÔ ¿ÌÂÛÔ ·Ú·Û··ÛÌ· ‹Ù·Ó ÔÚ·ÙÔ› Gram(+) ÎfiÎÎÔÈ Û ۈÚÔ‡˜, ÂÓÒ ÛÙËÓ Î·ÏÏȤÚÁÂÈ· ‰Â›ÁÌ·ÙÔ˜ ·fi ÙÔ ›‰ÈÔ ˘ÏÈÎfi ·Ó·Ù‡¯ıËΠ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Ô˘ ·ÚÔ˘Û›·˙ ÙËÓ ›‰È· ¢·ÈÛıËÛ›· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô Û٤ϯԘ Ô˘ ·ÔÌÔÓÒıËΠÛÙÔ ·›Ì·. ™˘ÁÎÂÎÚÈ̤ӷ, ÙÔ Û٤ϯԘ ‹Ù·Ó ·ÓıÂÎÙÈÎfi ÛÙËÓ ÔÍ·ÎÈÏÏ›ÓË, ÙËÓ ÎÂÊ·ÏÂÍ›ÓË Î·È ÙËÓ ÎÂÊÔ˘ÚÔÍ›ÌË, ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙÔ ÛÙË ÁÂÓÙ·ÌÈΛÓË Î·È ÙËÓ ·ÌÈηۛÓË Î·È Â˘·›ÛıËÙÔ ÛÙËÓ ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË, ÙÔ ÊÔ˘ÛȉÈÎfi Ô͇, ÙËÓ ÎÏÈÓ‰·Ì˘Î›ÓË, ÙËÓ ÙÂ˚ÎÔÏ·Ó›ÓË Î·È ÙË ‚·ÓÎÔÌ˘Î›ÓË. ™‡Ìʈӷ Ì ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù·, Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Î·È ·ÔÊ·Û›ÛÙËÎÂ Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ Ì ÙÂ˚ÎÔÏ·Ó›ÓË Î·È ·ÌÈηۛÓË. ∆Ô ¿ÏÁÔ˜ ˘Ô¯ÒÚËÛ ı·̷ÙÈο ÂÓÙfi˜ 5 ËÌÂÚÒÓ Î·È ÙÔ ·È‰› ¿Ú¯ÈÛ ӷ ÎÈÓËÙÔÔÈÂ›Ù·È Ì ÙË ‚Ô‹ıÂÈ· ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ·. ™˘Á¯ÚfiÓˆ˜, ˘‹ÚÍ ‚ÂÏÙ›ˆÛË ÛÙÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂: 30 mm, CRP: 4 mg/L, ÊÂÚÚÈÙ›ÓË: 60 ng/ml, LDH: 240 IU/L, Cu: 50 Ìg/dl). ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÔÏÔÎÏËÚˆı› Ô ¤ÏÂÁ¯Ô˜, ¤ÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ÂÚÈÔ¯‹, fiÔ˘ ÂȂ‚·ÈÒıËÎÂ Ë ÔÛÙÂÔÏ˘ÙÈ΋ ÂÍÂÚÁ·Û›· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ Î·È Ë ·Ô˘Û›· ‚Ï¿‚˘ ÙˆÓ ·ÔʇÛÂˆÓ Î·È ÙÔ˘ Ì˘ÂÏÈÎÔ‡ ۈϋӷ, ÂÓÒ ¿ÏϘ ÂÛٛ˜ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ·ÔÎÏ›ÛÙËÎ·Ó Ì ÔÏfiÛˆÌÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Á¿ÏÏÈÔ. §fiÁˆ Ù˘ ÌÈÎÚÔ‚È·ÈÌ›·˜, ¤ÁÈÓ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ fiÔ˘ ‰ÂÓ ·ÓȯÓ‡ıËÎ·Ó Â΂ϷÛÙ‹ÛÂȘ. ∆· ·ÓÙÈÛÒÌ·Ù· ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈο, ÔÈ ÙÈ̤˜ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÛÙÔÓ ÔÚfi ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜, ÂÓÒ ÔÈ ˘ÔÔÌ¿‰Â˜ Ig3 Î·È Ig4 ‹Ù·Ó ¯·ÌËϤ˜: Ig3: 20 mg/dl (º∆: 28-141 mg/dl) Î·È Ig4: 25 mg/dl (º∆: 40-184 mg/dl). ∏ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, fiˆ˜ Î·È Ë ‰ÔÎÈÌ·Û›· DHR (dihydrorhodamine 123 fluorescence test) Ì ‰È¤ÁÂÚÛË ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ, Ë ÔÔ›· ÂϤÁ¯ÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÂÓ˙‡ÌˆÓ ÙÔ˘˜ Ô˘ ·ÛÎÔ‡Ó ÌÈÎÚÔ‚ÈÔÎÙfiÓÔ ‰Ú¿ÛË, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜.

O ·ÛıÂÓ‹˜ ÂÍ‹Ïı ·ÊÔ‡ Û˘ÌÏ‹ÚˆÛ 28 Ë̤Ú˜ ÂÓ‰ÔÊϤ‚È·˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ Î·È ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋˜ ·ÁˆÁ‹˜. ¢ÂÓ ·ÚÔ˘Û›·˙ η̛· ÂÓfi¯ÏËÛË ÛÙËÓ ¿Û¯Ô˘Û· ÂÚÈÔ¯‹ Î·È Â›¯Â ·Ó·Ù‡ÍÂÈ ÈηÓÔÔÈËÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ·. ™˘ÓÂÛÙ‹ıË Ë Û˘Ó¤¯ÈÛË Ù˘ ·ÁˆÁ‹˜ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Ì ÊÔ˘ÛȉÈÎfi Ô͇ 20 mg/kg/24ˆÚÔ:3 Î·È ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊÔÌÂıÔÍ·˙fiÏË 10 mg/kg/ 24ˆÚÔ:2 ÁÈ· ¿ÏϘ 8 ‚‰ÔÌ¿‰Â˜ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙË-

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Úȷο. ¢‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ¤ÁÈÓ Ӥ· MRI ÛÙË ıˆÚ·ÎÔ-ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, fiÔ˘ ·Ú·ÙËÚ‹ıËΠÂÍ¿ÏÂÈ„Ë Ù˘ ·Ú·ÛÔÓ‰˘ÏÈ΋˜ Ì¿˙·˜, ·ÏÏ¿ ·Ú·ÌÔÓ‹ ÙˆÓ ‰È·‚ÚÒÛÂˆÓ ÛÙÔÓ ‰ˆ‰¤Î·ÙÔ ıˆÚ·ÎÈÎfi ÛfiÓ‰˘ÏÔ, ÛÙ¤ÓˆÛË ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ÌÂÛ·ÚıÚ›Ô˘ ‰È·ÛÙ‹Ì·ÙÔ˜, ηٷÛÙÚÔÊ‹ ÙÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ Î·È Â¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙËÓ ¿Óˆ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘, fiÔ˘ ·Ú·ÙËÚ‹ıËÎ·Ó Â›Û˘ ‰È·‚ÚÒÛÂȘ (∂ÈÎfiÓ· 2). OÈ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ ·Ú¤ÌÂÓ·Ó ¯·ÌËÏÔ› (∆∫∂: 22 mm, CRP: <3,4 mg/L). ™˘ÓÂÛÙ‹ıË Ù·ÎÙÈ΋ ÔÚıÔ‰È΋ Î·È Ó¢ÚÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÙËÓ ÚfiÏË„Ë ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ. ™˘˙‹ÙËÛË ∏ ÔÛÙÂÔÌ˘ÂÏ›ÙȘ, ÂȉÈο ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, Â›Ó·È Û¿ÓÈ· Î·È Ë ‰È¿ÁÓˆÛ‹ Ù˘ - ÛÙÔ ‹ÌÈÛ˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ - ηı˘ÛÙÂÚ› ÂÚÈÛÛfiÙÂÚÔ ·fi ¤Ó· Ì‹Ó·, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηı˘ÛÙÂÚ› Ë ¤Ó·ÚÍË ·ÁˆÁ‹˜ Î·È Ó· ÂÈ‚·Ú‡ÓÂÙ·È Ë ÚfiÁÓˆÛË (4). ¶·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ Û ¿ÙÔÌ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 50 ÂÙÒÓ, Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ¿ÚÚÂÓÔ˜ ʇÏÔ˘, Ì οÔÈÔ ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· fiˆ˜ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·, ¯ÚfiÓÈ· Ï‹„Ë ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ηÎÔ‹ıÂÈ·, ·ÏÎÔÔÏÈÛÌfi, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ‹ ÚÔËÁËı›۷ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË (4,5). ∆Ô Â›ÌÔÓÔ

∂ÈÎfiÓ· 2. ¡¤· Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ›‰È· ÂÚÈÔ¯‹ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÂÙ¿ ·fi 2 Ì‹Ó˜. ¢È·ÈÛÙÒÓÂÙ·È ·Ú·ÌÔÓ‹ ÙˆÓ ‰È·‚ÚÒÛÂˆÓ ÛÙÔ ÛÒÌ· ÙÔ˘ ‰ˆ‰¤Î·ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘, ·Ú·ÙËÚÂ›Ù·È fï˜ ηٷÛÙÚÔÊ‹ ÙÔ˘ ηÙÒÙÂÚÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ Î·È ‰È¿‚ÚˆÛË Ù˘ ¿Óˆ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ∏ ·Ú·ÛÔÓ‰˘ÏÈ΋ Ì¿˙· ¤¯ÂÈ ÂÍ·ÏÂÈÊı›.

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¿ÏÁÔ˜ Î·È Ë Â˘·ÈÛıËÛ›· Û ÂÓÙÔÈṲ̂ÓÔ ÛËÌÂ›Ô Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, fiÙ·Ó Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (∆∫∂, CRP), ı¤ÙÔ˘Ó ˆ˜ Èı·ÓfiÙÂÚË ‰È¿ÁÓˆÛË ÙËÓ ÔÍ›· ‹ ˘ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·. O ˘ÚÂÙfi˜ Î·È Ë Ï¢ÎÔ΢ÙÙ¿ÚˆÛË fiÙ·Ó Û˘Ó˘¿Ú¯Ô˘Ó ˘ÔÛÙËÚ›˙Ô˘Ó ÙË ‰È¿ÁÓˆÛË, fï˜ Ë ·Ô˘Û›· ÙÔ˘˜ ‰ÂÓ ÙËÓ ·ÔÎÏ›ÂÈ. ∂› ·‰˘Ó·Ì›·˜ ‰È¿ÎÚÈÛ˘ ÌÂٷ͇ ÊÏÂÁÌÔÓ‹˜ Î·È Î·ÎÔ‹ıÂÈ·˜ Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ MRI ÛÙËÓ ÂÚÈÔ¯‹, ··ÈÙÂ›Ù·È ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· Ù˘ ÔÛÙÈ΋˜ ‚Ï¿‚˘ ˘fi ·ÍÔÓÈÎfi ÙÔÌÔÁÚ¿ÊÔ, ÂÓÒ Â› ·ÔÙ˘¯›·˜ Á›ÓÂÙ·È ·ÓÔȯً ‚ÈÔ„›· (3,5). ∏ Û˘ÓËı¤ÛÙÂÚË ÂÓÙfiÈÛË ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË Â›Ó·È Ë ÔÛÊ˘Ô˚ÂÚ‹ ÌÔ›Ú· (60%) Î·È ·ÎÔÏÔ˘ı› Ë ıˆÚ·ÎÈ΋ (33%) Î·È Ë ·˘¯ÂÓÈ΋ (7%) (5). OÈ ˘‡ı˘ÓÔÈ ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ›ӷÈ, ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, Ô ÂȉÂÚÌÈÎfi˜ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘, Ô ‚-·ÈÌÔÏ˘ÙÈÎfi˜ ÛÙÚÂÙfiÎÔÎÎÔ˜ Ù˘ ÔÌ¿‰·˜ µ, Ô ÛÙÚÂÙfiÎÔÎÎÔ˜ viridans Î·È ÙÔ ÎÔÏÔ‚·ÎÙËÚ›‰ÈÔ. ª˘ÎËÙÈ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ˆ˜ Û˘ÓÔ‰fi ·›ÙÈÔ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Â›Ó·È Û·ÓÈfiÙ·ÙÔÈ (4,6). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Û˘ÓÙËÚËÙÈ΋ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ (75-85%), Ì ÂÓ‰ÔÊϤ‚È· ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÁÈ· 4-6 ‚‰ÔÌ¿‰Â˜ ηÈ, ·ÎÔÏÔ‡ıˆ˜, ·ÁˆÁ‹ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ¢ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· ÙË ‰È¿ÚÎÂÈ· Ù˘ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÁˆÁ‹˜ (2 ˆ˜ 8 ‚‰ÔÌ¿‰Â˜) (6,7). ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ¿Û¯Ô˘Û·˜ ÂÚÈÔ¯‹˜ Ì ÙË ‚Ô‹ıÂÈ· ÔÚıÔ‰ÈÎÔ‡ ÎˉÂÌfiÓ· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ó¢ÚÔÏÔÁÈ΋˜ Û˘Ó‰ÚÔÌ‹˜ (6). ø˜ ÎÚÈÙ‹ÚÈÔ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ıÂÚ·›· ıˆÚÂ›Ù·È Ë ·ÔηٿÛÙ·ÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÛÙÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ Â›Ó·È Ë ∆∫∂ Î·È Ë CRP. ™Â ÔÚÈṲ̂ӷ ΤÓÙÚ·, ÔÈ ·ÚÓËÙÈΤ˜ ÙÈ̤˜ ·˘ÙÒÓ ÙˆÓ ‰ÂÈÎÙÒÓ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ‰È·ÎÔ‹˜ Ù˘ ıÂÚ·›·˜ (7). ∂› ·ÔÙ˘¯›·˜ ÙˆÓ ·ÓˆÙ¤Úˆ ıÂÚ·¢ÙÈÎÒÓ Ì¤ÙÚˆÓ, ·ÎÔÏÔ˘ı› ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ηı·ÚÈÛÌfi˜ Ù˘ ÚÔۂ‚ÏË̤Ó˘ ÂÚÈÔ¯‹˜ (3,6). ∏ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·Ó·Ì¤ÓÂÙ·È Û 3-6 Ì‹Ó˜ (8). ∏ ËÏÈΛ· οو ÙˆÓ 40 ÂÙÒÓ, Ë ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ÛˆÛÙ‹ ·ÎÈÓËÙÔÔ›ËÛË, Ë ¤ÁηÈÚË ¤Ó·ÚÍË ·ÁˆÁ‹˜ Î·È Ë ÁÚ‹ÁÔÚË ÙÒÛË ÙˆÓ ‰ÂÈÎÙÒÓ ÊÏÂÁÌÔÓ‹˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÔÊ˘Á‹ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ (4,5). ∏ ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Â›Ó·È Û¿ÓÈ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·, ·ÎfiÌ· Î·È Û ¿ÙÔÌ· Ì ·˘ÍË̤ÓÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Â›Ó·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘. ™˘Ó‹ıˆ˜, ¯ÚÂÈ¿˙ÔÓÙ·È ·ÚÎÂÙ¤˜ ‰ÂηÂٛ˜ ̤¯ÚÈ Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ÔÈ ÚÔ¸Ôı¤ÛÂȘ ÂÁηٿÛÙ·Û˘ Ì›·˜ ÙfiÛÔ ÛÔ‚·Ú‹˜

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Ïԛ̈͢ Û ‰È·‚ËÙÈο ¿ÙÔÌ·. ∆¤ÙÔÈÔÈ ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·, Ë ÂÚÈÊÂÚÈ΋ Ó¢ÚÔ¿ıÂÈ· Î·È ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ˘ÂÚÏ·Û›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È Ë ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ·ÁÁ›ˆÓ ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜, Ì Â·ÎfiÏÔ˘ıÔ ÙË ‰ËÌÈÔ˘ÚÁ›· ÌÈÎÚÔıÚfiÌ‚ˆÓ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ·Ó¿Ù˘ÍË ÌÈÎÚÔ‚›ˆÓ (9). ∆Ô Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ¢ԉÒÓÂÙ·È Û ÈÛÙÔ‡˜ Ì ÊÙˆ¯‹ ·ÁÁ›ˆÛË, fiˆ˜ Â›Ó·È Ù· ÔÛÙ¿. OÈ Û˘¯ÓfiÙÂÚ˜ ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ··ÓÙÒÓÙ·È ÛÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Â›Ó·È Ë ·Ó·ÛÙÔÏ‹ Ù˘ ÌÈÎÚÔ‚ÈÔÎÙfiÓÔ˘ ‰Ú¿Û˘ ÙˆÓ ÂÓ˙‡ÌˆÓ ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Î·È Ë ‰È·Ù·Ú·¯‹ Ù˘ ÈηÓfiÙËÙ¿˜ ÙÔ˘˜ ÁÈ· Ê·ÁÔ΢ÙÙ¿ÚˆÛË (10). ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, Â›Û˘, ¤¯ÂÈ ·Ú·ÙËÚËı› ÙÒÛË Ù˘ IgG ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ‹ ¯·ÌËϤ˜ ÙÈ̤˜ ÔÚÈÛÌ¤ÓˆÓ ˘ÔÔÌ¿‰ˆÓ Ù˘ Î·È ·‡ÍËÛË Ù˘ IgA Î·È Ù˘ IgM ÛÙÔÓ ÔÚfi. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ·ÓÔÛ›·, ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Ì›ˆÛË ÙÔ˘ ÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÙˆÓ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÒÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û ÔÚÈṲ̂ÓÔ˘˜ Ì·ÎÚÔ¯ÚfiÓÈÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ (11). ∏ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÌÔÚ› Ó· ÚÔÎÏËı› ·ÈÌ·ÙÔÁÂÓÒ˜, Ô˘ Â›Ó·È Î·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ, ·fi ‰È·ÙÈÙÚ·›ÓÔÓ ÙÚ·‡Ì· ‹ ηٿ Û˘Ó¤¯ÂÈ· ÈÛÙÔ‡. O Û˘ÓËı¤ÛÙÂÚÔ˜ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ Ô‰fi ÌÂÙ¿‰ÔÛ˘, Â›Ó·È Ô ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜. ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, fï˜, ¤¯ÂÈ ·Ú·ÙËÚËı› ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚÈÓÈ΋˜ ÊÔÚ›·˜ Î·È ÌÈÎÚÔ‚È·ÈÌ›·˜ ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·Ú¿ÁÔÓÙ·. ∏ Û˘¯ÓfiÙËÙ· ·ÔÈÎÈÛÌÔ‡ ÙÔ˘ ÚÈÓÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ·ÛıÂÓ›˜ Ì ÌË ÈηÓÔÔÈËÙÈ΋ Ú‡ıÌÈÛË Ù˘ ÓfiÛÔ˘, fiˆ˜ ·˘Ù‹ ·ÔÙ˘ÒÓÂÙ·È Û ÙÈ̤˜ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ Î·È ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c) (12). º·›ÓÂÙ·È fiÙÈ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÈηÓfiÙËÙ· ÙˆÓ ÂÓ˙‡ÌˆÓ ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Ó· ηٷÛÙÚ¤ÊÔ˘Ó ÂÓ‰Ô΢ÙÙ¿ÚÈ· Ù· ÛÙÂϤ¯Ë ÙÔ˘ ‚·ÎÙËÚȉ›Ô˘. ∂›Û˘, Ù· ÏÂÌÊÔ·ÙÙ·Ú¿ ÙÔ˘˜ ‰ÂÓ ‰ÈÂÁ›ÚÔÓÙ·È Â·ÚÎÒ˜ in vitro ·fi ÙÔ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎfi ·ÓÙÈÁfiÓÔ (11,12). ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·ÛıÂÓ‹ Ì·˜, Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÛÔÓ‰‡ÏÔ˘ ¤ÁÈÓ ·ÈÌ·ÙÔÁÂÓÒ˜. ∏ ÂӉ¯fiÌÂÓË Î¿ÎˆÛË ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË Î·Ù¿ ÙËÓ ¿ÛÎËÛË, Ì ÙȘ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÁÁ›ˆÛË, ÙË Ó¤ÎÚˆÛË ÙÔ˘ ÔÛÙÔ‡ Î·È ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÔÎÈÓÒÓ Ô˘ ÚÔοÏÂÛÂ, ¢fi‰ˆÛ ÙËÓ ÂÛÙȷ΋ ÚfiÎÏËÛË ÌÈÎÚԂȷ΋˜ ÊÏÂÁÌÔÓ‹˜. ∞ÎÔÏÔ‡ıˆ˜, ÂÍÂÏ›¯ıËÎÂ Ë Ïԛ̈ÍË ÛÙÔÓ ÛfiÓ‰˘ÏÔ, Ë ÔÔ›· ÏfiÁˆ Ù˘ ·˘ÛÙËÚ‹˜ ηٿÎÏÈÛ˘ Î·È Ù˘ ÈÛ¯˘Ú‹˜ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜ ‰È¤‰Ú·Ì ˘ÔÎÏÈÓÈο ÙÔ ÚÒÙÔ 20‹ÌÂÚÔ. ¶ÚÔԉ¢ÙÈο, Ë ÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›· ÚÔοÏÂÛ ‰È‹ıËÛË ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ̤ÚÔ˘˜ ÙÔ˘

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ÛÔÓ‰˘ÏÈÎÔ‡ ÛÒÌ·ÙÔ˜ Î·È ‰ËÌÈÔ˘ÚÁ›· ·ÔÛÙËÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ ·Ú·ÛÔÓ‰˘ÏÈο. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ‡·ÚÍË ·ÚÙËÚÈÔÊÏ‚ˆ‰ÒÓ ÎfiÏˆÓ Ì ‚Ú·‰Â›· ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙË ÌÂÙ¿Ê˘ÛË ÙÔ˘ ÛÔÓ‰‡ÏÔ˘, ÏËÛ›ÔÓ Ù˘ ÂÈÊ˘Ûȷ΋˜ Ͽη˜, ÌÂÈÒÓÂÈ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ·fi Ù· Ï¢ÎÔ·ÙÙ·Ú·, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ·ÔÛÙËÌ¿ÙˆÓ (13). ∏ ¤ÍÔ‰Ô˜ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· ÚÔοÏÂÛ ÙÔ ‰Â‡ÙÂÚÔ ÂÌ‡ÚÂÙÔ ÂÂÈÛfi‰ÈÔ. ªÂÙ·ÁÂÓ¤ÛÙÂÚ·, Ë ÊÏÂÁÌÔÓ‹ ÂÂÎÙ¿ıËΠ̤ۈ ÙÔ˘ ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘ ÛÙÔÓ Î·ÙÒÙÂÚÔ ÛfiÓ‰˘ÏÔ, ÁÈ’ ·˘Ùfi ÛÙË ‰Â‡ÙÂÚË MRI ·ÂÈÎÔÓ›˙ÂÙ·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ÚÒÙÔ˘ ÔÛÊ˘˚ÎÔ‡ ÛÔÓ‰‡ÏÔ˘. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜, ÏËÓ ÙÔ˘ ÎÏÂÈÛÙÔ‡ ÙÚ·‡Ì·ÙÔ˜, Ô˘ Û˘Ó¤‚·Ï·Ó ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ˘ÔÍ›·˜ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ‹Ù·Ó Ë Ì¤ÙÚÈ· Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ ÛÙÔÓ ÔÚfi, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙȘ ÙÈ̤˜ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c) Î·È ÔÈ ¯·ÌËϤ˜ ÙÈ̤˜ ÙˆÓ ˘ÔÙ¿ÍÂˆÓ Ig3 Î·È Ig4. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ë ‰ÈËıËÙÈ΋ ÂÍÂÚÁ·Û›· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ ÚÔηÏ› ¤ÓÙÔÓÔ ‰È·ÊÔÚԉȷÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· ÌÂٷ͇ ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ Î·È Î·ÎÔ‹ıÔ˘˜ ÓÔÛ‹Ì·ÙÔ˜. ∏ ˘ÔÍ›· ÔÛÙÂÔÌ˘ÂÏ›ÙȘ Û ·È‰È¿ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ·Ó Î·È Â›Ó·È Û¿ÓÈ·, Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÁÓˆÛÙÈ΋ ÛΤ„Ë. ∏ Û˘ÓÂÎÙ›ÌËÛË ÙÔ˘ ·ÙÔÌÈÎÔ‡ ·Ó·ÌÓËÛÙÈÎÔ‡ Î·È ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Ù˘ ·ÚÔ‡Û·˜ ÓfiÛÔ˘ Î·È Î˘Ú›ˆ˜ Ë ‰ÈÂÓ¤ÚÁÂÈ· ‰È·‰ÂÚÌÈ΋˜ ‹ ·ÓÔȯً˜ ‚ÈÔ„›·˜ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· Ó· ÙÂÎÌËÚȈı› Ë ‰È¿ÁÓˆÛË. ŒÙÛÈ ı· ÏËÊıÔ‡Ó Ù· ·Ó·Áη›· ıÂÚ·¢ÙÈο ̤ÙÚ· Ì ÙË ÌÈÎÚfiÙÂÚË ‰˘Ó·Ù‹ ηı˘ÛÙ¤ÚËÛË, ¯ˆÚ›˜ Ó· ÚÔηÏÂ›Ù·È ·‰ÈηÈÔÏfiÁËÙË ·ÓËÛ˘¯›· ÛÙÔÓ ·ÛıÂÓ‹ Î·È ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ Î·È Ó· ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ¿ÛÎÔ˜ ÔÏ˘‰¿·Ó˜ ÂÍÂÙ¿ÛÂȘ.

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3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

of diagnosis with MR imaging. Radiology 1991;180:533539.

Mader JT, Ortiz M, Calhoun JH. Update on the diagnosis and management of osteomyelitis. Clin Podiatr Med Surg 1996;13:701-724.

Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997;79:874-880.

Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis 2001;33: 527-532.

Carek PJ, Dickerson LM, Sack JL. Diagnosis and management of osteomyelitis. Am Fam Physician 2001; 63:2413-2420.

Song KM, Sloboda JF. Acute hematogenous osteo myelitis in children. J Am Acad Orthop Surg 2001;9:166-175.

Rasool MN. Primary subacute haematogenous osteomyelitis in children. J Bone Joint Surg Br 2001;83:93-98.

DeFeo WT, Jay RM. Osteomyelitis associated with peripheral vascular disease secondary to diabetes mellitus.

J Foot Surg 1976;15:159-165.

Dziatkowiak H, Kowalska M, Denys A. Phagocytic and bactericidal activity of granulocytes in diabetic children.

Diabetes 1982;31:1041-1043.

Gorus FK, Vandewalle CL, Winnock F, Lebleu F, Keymeulen B, Van der Auwera B et al. Increased prevalence of abnormal immunoglobulin M, G, and A concentrations at clinical onset of insulin-dependent diabetes mellitus: a registry-based study. The Belgian Diabetes Registry. Pancreas 1998;16:50-59.

Tuazon CU, Perez A, Kishaba T, Sheagren JN. Staphylococcus aureus among insulin-injecting diabetic patients. An increased carrier rate. JAMA 1975;231:1272.

Whalen JL, Parke WW, Mazur JM, Stauffer ES. The intrinsic vasculature of developing vertebral end plates and its nutritive significance to the intervertebral discs. J Pediatr Orthop 1985;5:403-410.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Cottias P, Tomeno B, Anract P, Vinh TS, Forest M. Subacute osteomyelitis presenting as a bone tumour. A review of 21 cases. Int Orthop 1997;21:243-248.

2. Erdman WA, Tamburro F, Jayson HT, Weatherall PT, Ferry KB, Peshock RM. Osteomyelitis: characteristics and pitfalls

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÈÒÚÁÔ˜ ∆Ú›Ì˘ ∏Ï›· ∑ÂÚ‚Ô‡ 72, ∆.∫. 111 44, ∞ı‹Ó·

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Paediatriki 2003;66:52-54

CASE REPORT

™˘Ó‡·ÚÍË ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Î·È ÓfiÛÔ˘ Gilbert: ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ª. OÈÎÔÓfiÌÔ˘, π. ∆Û¿ÙÚ·, ª. ∞ı·Ó·Û›Ô˘ - ªÂÙ·Í¿

Co-existence of hereditary spherocytosis and Gilbert’s syndrome: a case report M. Economou, I. Tsatra, M. Athanassiou - Metaxa

¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË Ó·ڋ˜ ·ÛıÂÓÔ‡˜ Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Î·È ÓfiÛÔ˘ Gilbert. ∏ ÓfiÛÔ˜ Gilbert, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ·fi ÂÂÈÛfi‰È· ηÏÔ‹ıÔ˘˜ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚ‹ ÎÏÈÓÈ΋ ÛËÌ·Û›· ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·. øÛÙfiÛÔ, Û ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ ÚÔηÏ› ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÊÔÚÙ›Ô˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ÂÈÙ›ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ Û¯ËÌ·ÙÈÛÌÔ‡ ¯ÔÏÔÏ›ıˆÓ Î·È Ô‰ËÁ› Û ‰È·ÊÔÚԉȷÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ·ÛıÂÓÔ‡˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È.

Abstract: A case of hereditary spherocytosis and Gilbert’s syndrome co-existence in a young girl is described. Gilbert’s syndrome, characterized by episodes of mild unconjugated hyperbilirubinaemia, is of limited importance in normal individuals. In cases of chronic hemolysis, however, co-existence of the syndrome may lead to a combined effect in producing high levels of bilirubin and increase the risk of gallstone formation. Additionally, it may result in diagnostic problems, as in the case described below.

§¤ÍÂȘ ÎÏÂȉȿ: ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ÓfiÛÔ˜ Gilbert, ¤ÌÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·, ¯ÚfiÓÈ· ·ÈÌfiÏ˘ÛË, ¯ÔÏÔÏÈı›·ÛË.

Key words: hereditary spherocytosis, Gilbert’s syndrome, unconjugated hyperbilirubinaemia, chronic haemolysis, gallstones.

∂ÈÛ·ÁˆÁ‹ ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ¤ÌÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ÔÊ›ÏÂÙ·È Â›Ù Û ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ ·Û‡Ó‰ÂÙ˘ (¤ÌÌÂÛ˘) ¯ÔÏÂÚ˘ıÚ›Ó˘, ›Ù Û ÌÂȈ̤ÓË Ë·ÙÈ΋ ÚfiÛÏË„Ë ‹ Û‡Ó‰ÂÛË ·˘Ù‹˜ (1). ∏ ·ÈÌfiÏ˘ÛË Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· ˘ÂÚ·Ú·ÁˆÁ‹˜ Ù˘ ¤ÌÌÂÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ì›· ·fi ÙȘ Û˘ÓËı¤ÛÙÂÚ· ··ÓÙÒÌÂÓ˜ Û˘ÁÁÂÓ›˜ ·ÈÌÔÏ˘ÙÈΤ˜ ·Ó·È̛˜ Â›Ó·È Ë ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË (hereditary spherocytosis, HS). ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ÌÂȈ̤ÓË Û‡Ó‰ÂÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, Ë ÓfiÛÔ˜ Gilbert ıˆÚÂ›Ù·È Ë ˘‡ı˘ÓË ‰È·Ù·Ú·¯‹ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ (2,3). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ì ÙËÓ ÂÍ·›ÚÂÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘, ‰È·Ê¤ÚÂÈ ÛÙȘ ‰‡Ô ÚÔ·Ó·ÊÂÚı›Û˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, Ë Û˘Ó‡·ÚÍË ·˘ÙÒÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ‰È·ÊÔÚԉȷÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù· (4-6), fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ Ó·ڋ˜ ·ÛıÂÓÔ‡˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 12 ÂÙÒÓ Ì ÁÓˆÛÙ‹ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Ô˘ ‰È·ÁÓÒÛÙËΠÛÙ· Ï·›ÛÈ· ‰ÈÂÚ‡ÓËÛ˘ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜ Û ËÏÈΛ· 4 ÂÙÒÓ. ∏ ‰È¿ÁÓˆÛË Â›¯Â ÙfiÙ ÙÂı› Ì ‚¿ÛË ÙËÓ ·Ó‡ÚÂÛË ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, ÙÔÓ ·˘ÍË̤ÓÔ ·ÚÈıÌfi ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ Î·È ÙËÓ ÂÏ·Ùو̤ÓË ˆÛ̈ÙÈ΋ ·ÓÙ›ÛÙ·ÛË ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ. ◊‰Ë ·fi ÙÔÓ ·Ú¯ÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ›¯Â ‰È·ÈÛÙˆı› ˘ÂÚ˯ÔÁÚ·ÊÈο Ë ·ÚÔ˘Û›· ¯ÔÏÔÏ›ıˆÓ ÛÙË ¯ÔÏˉfi¯Ô ·ÛÙË. ∆Ô ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi Ù˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂχıÂÚÔ. ∫·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÙÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘, Ë ·ÛıÂÓ‹˜ ‹Ù·Ó Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÌfiÓÔÓ ‹È· ÛÏËÓÔÌÂÁ·Ï›· (ÂÚ›Ô˘ 2 cm) Î·È ÈÎÙÂÚÈ΋ ¯ÚÔÈ¿ ‰¤ÚÌ·ÙÔ˜ Î·È ÂÈÂÊ˘ÎfiÙˆÓ. ¢È·ÙËÚÔ‡Û ÈηÓÔÔÈËÙÈο Â›‰· ·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È ·ÈÌ·ÙÔÎÚ›ÙË (Hb ~13,2 g/dl, Ht ~40%) Ì ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ‰ÈÎÙ˘ÔÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ

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

1st Pediatric Clinic of Aristotelion University, “Ippokration” General Hospital, Thessaloniki

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(ÂÚ›Ô˘ 3%) Î·È Ì¤ÙÚÈ· ·‡ÍËÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ (6,5 mg/dl), ¤ÌÌÂÛ˘ ηٿ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (5,5 mg/dl). ™Â ËÏÈΛ· 11 ÂÙÒÓ, ÏfiÁˆ ÂΉ‹ÏˆÛ˘ ¤ÓÙÔÓˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ¯ÔÏÔÏÈı›·Û˘ (ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜, ‰˘Û„›·˜, Ó·˘Ù›·˜, ÂÌ¤ÙˆÓ Î·È ·ÒÏÂÈ·˜ ‚¿ÚÔ˘˜), ·ÔÊ·Û›ÛÙËÎÂ Ë ‰ÈÂÓ¤ÚÁÂÈ· ¯ÔÏÔ΢ÛÙÂÎÙÔÌ‹˜ Ì ٷ˘Ùfi¯ÚÔÓË ÛÏËÓÂÎÙÔÌ‹. øÛÙfiÛÔ, Ë ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ‰ÂÓ ·ÔηٷÛÙ¿ıËΠÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÛÏ‹Ó· (ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË 4,3 mg/dl, ¤ÌÌÂÛË ¯ÔÏÂÚ˘ıÚ›ÓË 3,45 mg/dl). ™Ù· Ï·›ÛÈ· Ù˘ ÂÎ Ó¤Ô˘ ‰ÈÂÚ‡ÓËÛ˘ Ù˘ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ·ÔÎÏ›ÛÙËÎÂ Ë Èı·ÓfiÙËÙ· Ê·ÚÌ·ÎÔÁÂÓÔ‡˜ ·Ó·ÛÙÔÏ‹˜ Û‡Ó‰ÂÛ˘ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ηıÒ˜ Î·È Ë ·ÚÔ˘Û›· ÂÈÎÔ˘ÚÈÎÔ‡ ÛÏ‹Ó· Ô˘ ı· ÌÔÚÔ‡Û ӷ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·ÓÙÈÚÚÔÔ‡ÌÂÓË ‹È· ·ÈÌfiÏ˘ÛË. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (SGOT, SGPT, ÁGT, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÔÏÈο Ï¢ÎÒÌ·Ù·, ÏÂ˘ÎˆÌ·Ù›Ó˜ Î·È ÛÊ·ÈÚ›Ó˜) ‹Ù·Ó, Â›Û˘, Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ‰ÔÎÈÌ·Û›· ̤ÙÚËÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÓËÛÙ›·˜ Î·È ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÙÚÔÊ‹˜ ¤‰ÂÈÍ ÙÈ̤˜ ¤ÌÌÂÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ 3,5 Î·È 2,3 mg/dl, ·ÓÙ›ÛÙÔȯ·. ªÂ ÙËÓ ÈÛ¯˘Ú‹, ϤÔÓ, ˘Ô„›· Ù˘ ÓfiÛÔ˘ Gilbert, ˙ËÙ‹ıËÎÂ Ë Ú·ÁÌ·ÙÔÔ›ËÛË ·Ó¿Ï˘Û˘ DNA Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR) ÛÙËÓ π·ÙÚÈ΋ ™¯ÔÏ‹ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, fiÔ˘ Î·È ·ÓȯÓ‡ıËΠ۠ÔÌÔ˙˘ÁˆÙ›· Ë ‰È·ÌfiÚʈÛË ∞(∆∞)7∆∞∞, Ë ÔÔ›· ÂÓ¤¯ÂÙ·È ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ŒÎÙÔÙÂ, Ë ·ÛıÂÓ‹˜, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÛˆÛÙ‹ ‰È·ÙÚÔÊÈ΋ ·ÁˆÁ‹, ·Ú·Ì¤ÓÂÈ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÌfiÓÔ ÂÚÈÛÙ·Ûȷο ˘›ÎÙÂÚÔ. ™˘˙‹ÙËÛË ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Â›Ó·È Ë Û˘¯ÓfiÙÂÚË Û˘ÁÁÂÓ‹˜ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· ÔÊÂÈÏfiÌÂÓË Û ‰È·Ù·Ú·¯‹ Ù˘ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÌÂ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 1:2000 ÛÙË µÔÚÂÈÔ‰˘ÙÈ΋ ∂˘ÚÒË Î·È ÙË µfiÚÂÈ· ∞ÌÂÚÈ΋ (7). ∏ ‚ÈÔ¯ËÌÈ΋ ‚¿ÛË Ù˘ ÓfiÛÔ˘ Û˘Ó›ÛÙ·Ù·È Û ·ÏÏ·Á‹ Ù˘ ‰ÔÌ‹˜ ÙÔ˘ ΢ÙÙ·ÚÔÛÎÂÏÂÙÔ‡ Ù˘ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÏfiÁˆ ‚Ï¿‚˘ ‰ÔÌÈÎÒÓ ÚˆÙÂ˚ÓÒÓ fiˆ˜ Â›Ó·È Ë ÛÂÎÙÚ›ÓË, Ë ·Ó΢ڛÓË ‹, Û·ÓÈfiÙÂÚ·, Ë ÚˆÙ½ÓË 4.2 (1,8). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ‰È·Ù·Ú·¯‹˜ Â›Ó·È Ë ·ÒÏÂÈ· ÙÔ˘ Û¯‹Ì·ÙÔ˜ ÙÔ˘ ÂÚ˘ıÚÔ΢ÙÙ¿ÚÔ˘, Ì ÌÂÙ·ÙÚÔ‹ ·˘ÙÔ‡ ·fi ·ÌÊ›ÎÔÈÏÔ ‰›ÛÎÔ Û ÛÊ·ÈÚÔ·ÙÙ·ÚÔ Î·È ·ÎfiÏÔ˘ıË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÛÙÔ ÛÏ‹Ó·. ∏ HS ÎÏËÚÔÓÔÌÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ÂÓÒ Ë ÌÂÙ·‚›‚·ÛË Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ¯·Ú·ÎÙ‹Ú· Â›Ó·È Û·ÓÈfiÙÂÚË (9).

Paediatriki 2003;66:52-54

∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÂÙÂÚÔÁ¤ÓÂÈ·: ·fi ÙËÓ ·Û˘Ìو̷ÙÈ΋ ÊÔÚ›· ̤¯ÚÈ ÙËÓ ÂΉ‹ÏˆÛË ‚·ÚÈ¿˜ ·Ó·ÈÌ›·˜ ÂÍ·ÚÙÒÌÂÓ˘ ·fi ÌÂÙ·ÁÁ›ÛÂȘ Î·È Û˘Óԉ¢fiÌÂÓ˘ ·fi ÛÏËÓÔÌÂÁ·Ï›· Î·È ›ÎÙÂÚÔ. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, Ë ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·˙ ‹È· HS, Ì ·ÓÙÈÚÚÔÔ‡ÌÂÓË ·ÈÌfiÏ˘ÛË ¯ˆÚ›˜ Û˘ÓÔ‰fi ·Ó·ÈÌ›·. ∏ ‰ËÌÈÔ˘ÚÁ›· ¯ÔÏÔÏ›ıˆÓ, Ô˘ ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÓfiÛÔ˘, ‹Ù·Ó ‹‰Ë ·ÚÔ‡Û· ÛÙË ÌÈÎÚ‹ ·ÛıÂÓ‹ ηٿ ÙÔ ¯ÚfiÓÔ ‰È¿ÁÓˆÛ˘ Ù˘ HS. ∏ ¯ÔÏÔÏÈı›·ÛË Â›Ó·È ›Ûˆ˜ Ë ÌfiÓË ¤Ó‰ÂÈÍË ÁÈ· ‰ÈÂÓ¤ÚÁÂÈ· ÛÏËÓÂÎÙÔÌ‹˜ Û ·ÛıÂÓ›˜ Ì HS ‹È·˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜, ÌÂÙ¿ ÙËÓ ÔÔ›· ·Ó·Ê¤ÚÂÙ·È ÎÏÈÓÈ΋ ›·ÛË, ‰ËÏ·‰‹ ˘Ô¯ÒÚËÛË Ù˘ ·Ó·ÈÌ›·˜ Î·È ÙÔ˘ ÈÎÙ¤ÚÔ˘ Û ÔÛÔÛÙfi 100% (9). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ˆÛÙfiÛÔ, Ë ·Ó·ÌÂÓfiÌÂÓË ›·ÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎÂ. ∞ÊÔ‡ ·ÔÎÏ›ÛÙËÎ·Ó Ù· ˘fiÏÔÈ· Èı·Ó¿ ·›ÙÈ· ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, Ù¤ıËÎÂ Ë ˘Ô„›· Û˘Ó‡·Ú͢ Ù˘ ÓfiÛÔ˘ Gilbert Î·È ·ÔÊ·Û›ÛÙËÎÂ Ë Ú·ÁÌ·ÙÔÔ›ËÛË Ù˘ ÂÌÂÈÚÈ΋˜ ‰ÔÎÈÌ·Û›·˜ ̤ÙÚËÛ˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÌÂÙ¿ ·fi ÓËÛÙ›· Î·È ·fi ¯ÔÚ‹ÁËÛË ÙÚÔÊ‹˜ (9), ÂÓÒ Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Ù¤ıËΠÙÂÏÈο Ì ÙË Ì¤ıÔ‰Ô ·Ó¿Ï˘Û˘ DNA. H ÓfiÛÔ˜ Gilbert ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ UDP-ÁÏ˘ÎÔ˘ÚÔÓ˘Ï-ÙÚ·ÓÛÊÂÚ¿Û˘ 1 ÛÙÔ ¯ÚˆÌfiۈ̷ 2q37 (ÂÍfiÓÈ· 1-5 ‹ ÂÎÎÈÓËÙ‹˜ TATAAbox), Ì ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ô˘ÚȉÈÓÔ-‰ÈʈÛÊÔÓÈ΋ ÁÏ˘ÎÔ˘ÚÔÓÈ΋ ÙÚ·ÓÛÊÂÚ¿ÛË Î·È ·ÎfiÏÔ˘ıË ·Ó·ÛÙÔÏ‹ Û‡Ó‰ÂÛ˘ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ (9). ∏ Û˘¯ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ ÔÈΛÏÏÂÈ Û ‰È¿ÊÔÚ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ·fi 3-36%, ·Ó¿ÏÔÁ· Ì ÙË Ê˘Ï‹ Î·È ÙÔ Ê‡ÏÔ (2,3,11-13). O ÙÚfiÔ˜ ÎÏËÚÔÓÔÌÈ΋˜ ÌÂÙ·‚›‚·Û˘ Â›Ó·È Ô ·˘ÙÔۈ̷ÙÈÎfi˜ ÂÈÎÚ·ÙÒÓ, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓÔ˜ ·fi ·ÙÂÏ‹ ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ·. ∏ ÓfiÛÔ˜ Gilbert ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏ› Ê˘ÛÈÔÏÔÁÈ΋ ·Ú·ÏÏ·Á‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ÎÏÈÓÈο ·fi ÂÂÈÛfi‰È· ηÏÔ‹ıÔ˘˜ ¤ÌÌÂÛ˘ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›·˜, ΢ڛˆ˜ Û ηٷÛÙ¿ÛÂȘ ÓËÛÙ›·˜. ∂ÓÒ ÛÙ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Ë ÎÏÈÓÈ΋ ÛËÌ·Û›· Ù˘ ÓfiÛÔ˘ Â›Ó·È ÌÈÎÚ‹, Û ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ ÚÔηÏ› ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÊÔÚÙ›Ô˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, ÂÈÙ›ÓÔÓÙ·˜ ¤ÙÛÈ ÙÔÓ Î›Ó‰˘ÓÔ Û¯ËÌ·ÙÈÛÌÔ‡ ¯ÔÏÔÏ›ıˆÓ (7,14). ∏ ÂÈ‚¿Ú˘ÓÛË ·˘Ù‹ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› fi¯È ÌfiÓÔ ÛÂ Û˘Ó‡·ÚÍË Ù˘ ÓfiÛÔ˘ Ì ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ·ÏÏ¿ Î·È Ì ¿ÏϘ ÌÔÚʤ˜ ÎÏËÚÔÓÔÌÈ΋˜ (‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ¤ÏÏÂÈ„Ë G6PD) ‹ Â›ÎÙËÙ˘ ¯ÚfiÓÈ·˜ ·ÈÌfiÏ˘Û˘ (·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·) (7,15). ™Â οı ÂÚ›ÙˆÛË, Ô ·È‰›·ÙÚÔ˜ Ô˘ ·Ú·ÎÔÏÔ˘ı› ¤Ó·Ó ·ÛıÂÓ‹ Ì ¯ÚfiÓÈ· ·ÈÌfiÏ˘ÛË, ·ÏÏ¿ Î·È ·˘Ùfi˜ Ô˘ ‰ÈÂÚÂ˘Ó¿ ¤Ó·Ó ·ÛıÂÓ‹ Ì ¯ÔÏÔÏÈı›·ÛË,

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ı· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ηٿ ÓÔ˘ ÙËÓ Èı·ÓfiÙËÙ· Û˘Ó‡·Ú͢ Î·È ·ÏÏËÏÂ›‰Ú·Û˘ Ù˘ ¯ÚfiÓÈ·˜ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ Ì ÙË ÓfiÛÔ Gilbert. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿ ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ∂ÚÁ·ÛÙËÚ›Ô˘ Ù˘ ∞’ ¶·ıÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÁÈ· ÙË ÌÔÚȷ΋ ÂȂ‚·›ˆÛË Ù˘ ÓfiÛÔ˘ Gilbert.

10.

11.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Becker P, Lux S. Disorders of the red cell membrane. In: Nathan DG, Oski FA, editors. Hematology of infancy and childhood. 4th ed. Philadelphia: W.B. Saunders Company; 1993. p. 529-633.

2. Borlak J, Thum T, Landt O, Erb K, Hermann R. Molecular diagnosis of a familial nonhemolytic hyperbilirubinemia (Gilbert’s syndrome) in healthy subjects. Hepatology 2000;32:792-795.

3. Burchell B, Hume R. Molecular genetic basis of Gilbert’s syndrome. J Gastroenterol Hepatol 1999;14:960-966.

4. Berk PD, Blaschke TF. Detection of Gilbert’s syndrome in patients with hemolysis. Ann Intern Med 1972;77:527-531.

5. Katz ME, Weinstein IM. Extreme hyperbilirubinemia in a patient with hereditary spherocytosis, Gilbert’s syndrome, and obstructive jaundice. Am J Med Sci 1978;275:373-379.

6. Sharma S, Vukelja SJ, Kadakia S. Gilbert’s syndrome coexisting with and masking hereditary spherocytosis. Ann Hematol 1997;74:287-289.

7. del Giudice EM, Perrotta S, Nobili B, Specchia C, d’Urzo G, Iolascon A. Coinheritance of Gilbert syndrome increases the risk for developing gallstones in patients with hereditary spherocytosis. Blood 1999;94:2259-2262.

8. Palek J, Jarolim P. Clinical expression and laboratory detection of red blood cell membrane protein mutations.

Semin Hematol 1993;30:249-283.

9. Palek J, Jarolim P. Red cell membrane disorders. In:

54

12.

13.

14.

15.

Hoffman R, Benz EJ, Shattil SJ, Furil B, Cohen HJ, Silberstein LE, editors. Hematology. Basic Principles and Practice. 2nd ed. Churchill Livingstone Inc; 1995. p. 667709.

Monaghan G, Ryan M, Seddon R, Hume R, Burchell B. Genetic variation in bilirubin UDP-glucurononyltransferase gene promoter and Gilbert’s syndrome. Lancet 1996;347:578-581.

Rudenski AS, Halsall DJ. Genetic testing for Gilbert’s syndrome: how useful is it in determining the cause of jaundice? Clin Chem 1998;44:1604-1609.

Beutler E, Gelbart T, Demina A. Racial variability in the UDPglucuronosyltransferase 1 (UGT1A1) promoter: a balanced polymorphism for regulation of bilirubin metabolism? Proc Natl Acad Sci USA 1998;95:8170-8174. ∆Û¤˙Ô˘ ∞, ∆˙¤ÙË ª, ∫›ÙÛÈÔ˘ ™, °·ÏÏ¿ ∞, ∫·‚·˙·Ú¿Î˘ ∂, ÷Ù˙ˉËÌԇϷ ∞ Î·È Û˘Ó. ™‡Ó‰ÚÔÌÔ Gilbert: ÁÔÓÔÙ˘È΋ ·Ó¿Ï˘ÛË Î·È Û˘Û¯¤ÙÈÛË Ì ÙÔ Ê·ÈÓfiÙ˘Ô Û ·È‰ÈÎfi ÏËı˘ÛÌfi. ¶·È‰È·ÙÚÈ΋ 2000;63:21-26.

Berk PD, Berman MD, Blitzer BL, Chretien P, Martin JF, Scharschmidt BF et al. Effect of splenectomy on hepatic bilirubin clearance in patients with herediatry spherocytosis: implications for the diagnosis of Gilbert’s syndrome. J Lab Clin Med 1981;98:37-45.

Sampietro M, Lupica L, Perrero L, Comino A, Martinez di Montemuros F, Cappellini MD et al. The expression of UDPglucuronosyltransferase gene is a major determinant of bilirubin level in heterozygous beta-thalassaemia and in G6PD deficiency. Br J Haematol 1997;99:437-439.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-06-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 22-10-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ªÈÚ¿ÓÙ· ∞ı·Ó·Û›Ô˘ ∞Á. ™ÔÊ›·˜ 30, ∆.∫. 546 22, £ÂÛÛ·ÏÔÓ›ÎË E-mail: marina@med.auth.gr

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Paediatriki 2003;66:55-57

CASE REPORT

¶·ÚÔ˘Û›· ·ÚÔ‰ÈÎÔ‡ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ Û ·È‰› Ì ÓfiÛÔ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ª. §ÈıÔÍÔÔ‡ÏÔ˘, ª. ∞ı·Ó·Û›Ô˘, Ã. ∆۷ηϛ‰Ë˜, µ. ∞˚‚¿˙˘

Presentation of lupus anticoagulant in a child caused by cat scratch disease: a case report M. Lithoxopoulou, M. Athanasiou, C. Tsakalidis, V. Aivazis

¶ÂÚ›ÏË„Ë: ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ·ÔÙÂÏ› Ì›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÏÔÈÌÒ‰Ë ÓfiÛÔ Ô˘ ¤¯ÂÈ ˆ˜ ·›ÙÈÔ ÙË Bartonella henselae Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ô›‰ËÌ· Î·È ¿ÏÁÔ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ. ¶ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ ·È‰È¿ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ. ™˘Ó‹ıˆ˜ ÚÔηÏ› ÏÂÌÊ·‰ÂÓ›Ùȉ· Ô˘ Â›Ó·È ¯ÚfiÓÈ· Î·È ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ô˘ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ηÈ, ˆ˜ Û˘ÓÔ‰fi Û‡Ìو̷ Ù˘ Ïԛ̈͋˜ ÙÔ˘, Ù˘¯·›· ·Ó‡ÚÂÛË ·Ú¿Ù·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·ƒTT) ÏfiÁˆ ·ÚÔ˘Û›·˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ (LA) ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·.

Abstract: Cat scratch disease is a self-limited infectious disease characterized by edema and pain in the lymph nodes caused by Bartonella henselae. Most patients are children and young adults. Usual symptoms are chronic or regional lymphadenopathy, malaise, anorexia and fever. We describe a patient with regional lymphadenopathy and transient prolonged activated partial thromboplastine time associated with lupus anticoagulant caused by cat scratch disease. This was found during the preoperative tests.

§¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜, bartonella henselae, ÏÂÌÊ·‰ÂÓ›Ùȉ·, ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘, ¯ÚfiÓÔ˜ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘.

Key words: cat scratch disease, bartonella henselae, chronic lymphadenopathy, lupus anticoagulant, activated partial thromboplastine time.

∂ÈÛ·ÁˆÁ‹ ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ·ÔÙÂÏ› Ì›· ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÏÔÈÌÒ‰Ë ÓfiÛÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ô›‰ËÌ· Î·È ¿ÏÁÔ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (ÂÚÈÔ¯È΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÏÂÌÊ·‰ÂÓ›Ùȉ·) Î·È ÔÈÎÈÏ›· ÎÔÈÓÒÓ Û˘ÓÔ‰ÒÓ Û˘ÌÙˆÌ¿ÙˆÓ fiˆ˜ ηÎÔ˘¯›·, ÎfiˆÛË, ·ÓÔÚÂÍ›·, Â̤ÙÔ˘˜, ÎÂÊ·Ï·ÏÁ›·, Ê·Ú˘ÁÁ›Ùȉ·, ˘ÚÂÙfi ‹ Î·È ÛÔ‚·ÚfiÙÂÚˆÓ fiˆ˜ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ÛÏËÓÔÌÂÁ·Ï›·, ηıÒ˜ Î·È ·ÚÔ‰ÈÎfi ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· ÙÔ˘ ÎÔÚÌÔ‡ Î·È ¿ÏÏ· (1-4). ™˘Ó‹ıˆ˜ ÚÔηÏ› ÏÂÌÊ·‰ÂÓ›Ùȉ· Ô˘ Â›Ó·È ¯ÚfiÓÈ· Î·È ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. ÕÙ˘· Â˘Ú‹Ì·Ù· Â›Ó·È Ë ÂÈÂÊ˘Î›Ùȉ·, Ë ÚÔˆÙÈ·›· ·‰ÂÓ›Ùȉ·, Ë ÂÁÎÂÊ·Ï›Ùȉ·, Ë ¿ÚÂÛË ÎÚ·ÓÈ·ÎÒÓ Ó‡ڈÓ, Ë ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ, Ë ÔÛÙÂ-

ÔÌ˘ÂÏ›Ùȉ·, Ë Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, ÙÔ Ô˙҉˜ ÂÚ‡ıËÌ·, ÙÔ ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· Î·È Ë Ó¢ÌÔÓ›· (2,5). ∏ ÚÒÙË ·Ó·ÊÔÚ¿ Î·È ÂÚÈÁÚ·Ê‹ Ù˘ ÓfiÛÔ˘ ¤ÁÈÓ ·fi ÙÔÓ Henri Parinaud ÙÔ 1889, ÂÓÒ Ô Robert Debre ÙÔ 1931 ·Ó·ÁÓÒÚÈÛ fiÙÈ Ë Á¿Ù· ·ÔÙÂÏ› ÙÔÓ ÂӉȿÌÂÛÔ ÍÂÓÈÛÙ‹ Î·È ¤‰ˆÛ ÙËÓ ÔÓÔÌ·Û›· ÛÙË ÓfiÛÔ. ∏ Bartonella henselae ˆ˜ ·›ÙÈÔ Ù˘ ÓfiÛÔ˘, Ô˘ ÌÂÙ·‰›‰ÂÙ·È ·fi ¤ÓÙÔÌÔ ÛÙË Á¿Ù·, Ë ÔÔ›· Î·È ·ÔÙÂÏ› ÙË ‰ÂÍ·ÌÂÓ‹ Ù˘ ÓfiÛÔ˘, ·Ó·ÁÓˆÚ›ÛÙËΠÙÔ 1993 (4,5). ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë ÂÌÊ¿ÓÈÛË ·Ú·ÙÂٷ̤ÓÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·ƒ∆∆) ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ (LA) Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·fi ÏÔÈÌÒÍÂȘ, ÈÔÁÂÓ›˜, ÚˆÙÔ˙ˆÈΤ˜, Ê˘Ì·Ù›ˆÛË

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

1st Pediatric Clinic of Aristotelion University of Thessaloniki “Ippokration” General Hospital, Thessaloniki

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(3-5), ÓfiÛÔ ÙÔ˘ Lyme, ηÎÔ‹ıÂȘ, (ÌÔÓ‹ÚË fiÁÎÔ, Ï¢¯·È̛˜, ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù·), Ï‹„Ë Ê·ÚÌ¿ÎˆÓ (Ê·ÈÓÔıÂÈ·˙›Ó˜, ÚÔη˚Ó·Ì›‰Ë, ¯ÏˆÚÔıÂÈ·˙›Ó˜, ·ÓÙÈÛ˘ÏÏËÙÈο), ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÚÂ˘Ì·ÙÈο ÓÔÛ‹Ì·Ù· (™∂§, ƒ∞, Û‡Ó‰ÚÔÌÔ Sjogren, ‰ÂÚÌ·ÙÔÌ˘ÔÛ›Ùȉ·/ÔÏ˘Ì˘ÔÛ›Ùȉ·, „ˆÚÈ·ÛÈ΋ ·ÚıÚ›Ùȉ·, ·ÁÎ˘ÏˆÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·) ‹ Ó· ·ÔÙÂÏ› Ù˘¯·›Ô ‡ÚËÌ· ÛÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ (6-8). ∆Ô ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ (LA) ·ÔÙÂÏ› ¤Ó·Ó Â›ÎÙËÙÔ ·Ó·ÛÙÔϤ· ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ‹Í˘. ∞Ó‹ÎÂÈ Ì·˙› Ì ٷ ·ÓÙÈηډÈÔÏÈÈÓÈο ·ÓÙÈÛÒÌ·Ù· Î·È Ù· ÂȉÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ Ô˘‰¤ÙÂÚˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ, ÛÙ· ·ÓÙÈʈÛÊÔÏÈȉÈο ·ÓÙÈÛÒÌ·Ù· (9-12), in vitro ‰Â, ÚÔηÏÔ‡Ó ·Ú¿Ù·ÛË Û˘Ó‹ıˆ˜ ÙÔ˘ ·PTT. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ô˘ ·ÚÔ˘Û›·Û ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi ÓfiÛÔ ·Ì˘¯‹˜ Ó˘¯ÈÒÓ Á¿Ù·˜ Î·È Ù˘¯·›· ·Ó‡ÚÂÛË ·Ú·ÙÂٷ̤ÓÔ˘ ·ƒTT ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ ·ÓÙÈËÎÙÈÎÔ‡ ÙÔ˘ χÎÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 9 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÏfiÁˆ ÙÚ·¯ËÏÈ΋˜ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜, ȉ›ˆ˜ ·ÚÈÛÙÂÚ¿. ∏ ÓfiÛÔ˜ ÂÌÊ·Ó›ÛÙËΠ̠˘ÚÂÙfi Î·È ‰ÈfiÁΈÛË ÙÚ·¯ËÏÈÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ (block) ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÙÚ·¯ËÏÈ΋ ¯ÒÚ·, ¯ˆÚ›˜ ¿ÏÏ· Û˘ÓÔ‰¿ Û˘ÌÙÒÌ·Ù·. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: Hb: 12,3 g/dl, Ht: 38%, ÏÂ˘Î¿: 8900/mm3 (¶: 64%, §: 28%, ª: 7%), ·ÈÌÔÂÙ¿ÏÈ·: 368.000/mm3, ∆∫∂: 45 mm ÙËÓ 1Ë ÒÚ· Î·È CRP: 33,4 mg/dl. O ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Û˘Ó‹ıˆÓ ÈÒÓ, fiˆ˜ ÙÔ˘ Epstein Barr, Cytomegalovirus, Herpes simple, Parvo B19, Coxsackie B1-B5, ηıÒ˜ Î·È ÁÈ· ÙÔÍfiÏ·ÛÌ· ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ∆¤ÏÔ˜, Ë mantoux ‹Ù·Ó ·ÚÓËÙÈ΋. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. O ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜ ¿Ìʈ ¤‰ÂÈÍ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÙÚ·¯ËÏÈ΋ ¯ÒÚ· Û˘ÚÚ¤ÔÓÙ˜ ÏÂÌÊ·‰¤Ó˜ Ì ÂÏ·Ùو̤ÓË Ë¯ÔÁ¤ÓÂÈ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ‚Ú›ÛÎÔÓÙ·Ó Û ًÍË. ¶·ÚfiÌÔÈ·˜ ˘Ê‹˜ ÏÂÌÊ·‰¤Ó˜ ˘‹Ú¯·Ó ÛÙËÓ ·ÚˆÙȉÈ΋ Î·È ÛÙË ‰ÂÍÈ¿ Ï¿ÁÈ· ÙÚ·¯ËÏÈ΋ ¯ÒÚ·. ∆Ô Ì˘ÂÏfiÁÚ·ÌÌ· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. §ÂÙÔÌÂÚ¤ÛÙÂÚË Ï‹„Ë ÈÛÙÔÚÈÎÔ‡ ·ÔÎ¿Ï˘„ ÙËÓ ‡·ÚÍË Á¿Ù·˜ ÛÙÔ Û›ÙÈ ÙÔ˘ ·ÛıÂÓ‹. ¢‹ÁÌ·Ù· ‹ ·Ì˘¯¤˜ ÛÙ· ¿ÎÚ· ÙÔ˘ ·ÛıÂÓ‹ ‰ÂÓ ·Ú·ÙËÚ‹ıËηÓ. ªÂ ÙËÓ ˘fiÓÔÈ· Ù˘ ÓfiÛÔ˘ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ ¤ÁÈÓ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Bartonella henselae, Ô ÔÔ›Ô˜ ¤‰ÂÈÍ IgM ·ÓÙÈÛÒÌ·Ù· ıÂÙÈο 1:20 Î·È IgG >1:256. O Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó Ô ›‰ÈÔ˜ ηÈ

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ÌÂÙ¿ ·fi 15 Ë̤Ú˜.

O ·ÛıÂÓ‹˜ Ù¤ıËΠ۠ıÂÚ·›· Ì ·ÌÔÍÈÎÈÏÏ›ÓË Û ‰fiÛË 80 mg/kg ·fi ÙÔ ÛÙfiÌ· ÁÈ· 10 Ë̤Ú˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ÎÂÊÙÚÈ·ÍfiÓË 100 mg/kg ÂÓ‰ÔÊÏ‚›ˆ˜ ÁÈ· 10 Ë̤Ú˜, ¯ˆÚ›˜ ‚ÂÏÙ›ˆÛË, Ì Ӥ· ‰ÈfiÁΈÛË ÏÂÌÊ·‰¤ÓˆÓ Ù˘ Ì·Û¯·ÏÈ·›·˜ ¯ÒÚ·˜ Î·È ÌË ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡. ∞ÔÊ·Û›ÛÙËÎÂ Ë ·Ê·›ÚÂÛË Î·È Ë ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó·, ‚Ú¤ıËΠÌÂÁ¿ÏË ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ (·PTT) 31”/59” (‡ÚÔ˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÁÈ· ·ƒTT: 30”-37”), ÂÓÒ Ô ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ Î·È Ù· ·ÈÌÔÂÙ¿ÏÈ· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆· Â›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ππ, VIII, IX, XI, XII ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο, ÂÓÒ ‚Ú¤ıËΠ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ (LA) ıÂÙÈÎfi, Ë ·ÚÔ˘Û›· ÙÔ˘ ÔÔ›Ô˘ ÂȂ‚·ÈÒıËΠ̠ÙË ‰ÔÎÈÌ·Û›· dRVVT (dilute Russell’s viper venom time) 35”/70”. ∆· ·ÓÙÈηډÈÔÏÈÈÓÈο ·ÓÙÈÛÒÌ·Ù· (APC) ‚Ú¤ıËÎ·Ó ·ÚÓËÙÈο. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍ Ï‹Úˆ˜ ηٷÚÁË̤ÓË ·Ú¯ÈÙÂÎÙÔÓÈ΋ ·fi ÙËÓ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ÂÈıËÏÈÔÂȉÒÓ ÎÔÎÎÈˆÌ¿ÙˆÓ Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË, ÂÓÒ Á‡Úˆ ·fi ÙË Ó¤ÎÚˆÛË ·Ú·ÙËÚ‹ıËÎ·Ó ÂÈıËÏÈÔÂȉ‹ ÈÛÙÈÔ·ÙÙ·Ú·, ηıÒ˜ Î·È ÔÏ˘‡ÚËÓ· ÁÈÁ·ÓÙÔ·ÙÙ·Ú·. OÈ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ¯ÚÒÛÂȘ ÁÈ· ̇ÎËÙ˜ Î·È Ì˘ÎÔ‚·ÎÙËÚ›‰È· ‹Ù·Ó ·ÚÓËÙÈΤ˜. ∏ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÈÛÙÔÚÈÎfi, ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÓfiÛÔ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·È‰ÈÔ‡ ‚ÂÏÙÈÒıËΠÌÂÙ¿ ·fi ‰¤Î· Ë̤Ú˜, ÂÓÒ Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· (·PTT: 31”/31,5” Î·È LA(-) ·ÚÓËÙÈÎfi) ·ÔηٷÛÙ¿ıËÎ·Ó ÌÂÙ¿ ·fi 2 Ì‹Ó˜, ¯ˆÚ›˜ Ô ·ÛıÂÓ‹˜ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÔÔÈÔ‰‹ÔÙ ۇÌو̷ ‹ Ó· Ï¿‚ÂÈ ÂȉÈ΋ ıÂÚ·›·. ™˘˙‹ÙËÛË Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ë ÂÌÊ¿ÓÈÛË ·Ú¿Ù·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ ·ƒTT ÛÙ· ·È‰È¿ ÏfiÁˆ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ LA Â›Ó·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ‰È΋ Î·È Î·ÏÔ‹ı˘ Î·È Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ·fi ÏÔÈÌÒÍÂȘ ‹ Ó· ·ÔÙÂÏ› Ù˘¯·›Ô ‡ÚËÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ (6-8). ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜, Ë ·Ó‡ÚÂÛË Ù˘ ·Ú¿Ù·Û˘ ÙÔ˘ ·ƒ∆∆ ‹Ù·Ó Ù˘¯·›·, ÛÙ· Ï·›ÛÈ· ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÈÛÙÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ‰ÈÔÁΈ̤ÓÔ˘ ÏÂÌÊ·‰¤Ó·, ÏfiÁˆ Ù˘ ÓfiÛÔ˘ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜, Ë ÔÔ›· ÂȂ‚·ÈÒıËΠ̠ÙËÓ ·Ó‡ÚÂÛË ÛÙÔÓ ÔÚfi ÙÔ˘ ·ÛıÂÓÔ‡˜

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IgM Î·È IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Bartonella henselae. ∏ ·ÓˆÙ¤Úˆ ‰È¿ÁÓˆÛË Ù¤ıËΠÌÂÙ¿ ·fi ÙÔÓ ÏÂÙÔÌÂÚ‹ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ô ÔÔ›Ô˜ ·¤ÎÏÂÈÛ ÙËÓ Î·ÎÔ‹ıË ‰ÈfiÁΈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ Î·È Î˘Ú›ˆ˜ ·fi ÙË ÏÂÙÔÌÂÚ‹ Ï‹„Ë ÈÛÙÔÚÈÎÔ‡, Ë ÔÔ›· ·ÔÎ¿Ï˘„ ÙËÓ ‡·ÚÍË Î·ÙÔÈΛ‰ÈÔ˘ ˙ÒÔ˘ (Á¿Ù·˜) ÛÙÔ Û›ÙÈ ÙÔ˘ ·ÛıÂÓ‹. ∏ ÓfiÛÔ˜ ·fi ·Ì˘¯‹ Ó˘¯ÈÒÓ Á¿Ù·˜ Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË. ∆Ô 30% ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÂÌÊ·‰¤Ó˜ Û ÔÏÏ·Ϥ˜ ı¤ÛÂȘ. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÂӉ›ÎÓ˘Ù·È Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜, ÂÓÒ ¿ÏÏÔÈ Û˘ÁÁÚ·Ê›˜ Û˘ÓÈÛÙÔ‡Ó ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Û ÂÚ›ÙˆÛË ·Ú·ÙÂÈÓfiÌÂÓÔ˘ ˘ÚÂÙÔ‡ (2,3,13). ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ ¯ÔÚËÁ‹ıËΠʷÚ̷΢ÙÈ΋ ·ÁˆÁ‹ ÏfiÁˆ ÙÔ˘ ·Ú·ÙÂÈÓfiÌÂÓÔ˘ ˘ÚÂÙÔ‡ Î·È Ù˘ Ó¤·˜ ÂÌÊ¿ÓÈÛ˘ ‰ÈÔÁΈ̤ÓÔ˘ ÏÂÌÊ·‰¤Ó· (ÛÙË Ì·Û¯·ÏÈ·›· ¯ÒÚ·). ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍÂ Â˘Ú‹Ì·Ù· ÌË ÂȉÈÎÒÓ ·ÏÏÔÈÒÛˆÓ, ηıÒ˜ Î·È ÔÏÏ·Ï¿ ÂÈıËÏÈÔÂȉ‹ ÎÔÎÎÈÒÌ·Ù· Ì ÎÂÓÙÚÈ΋ Ó¤ÎÚˆÛË, fiˆ˜ ¿ÏψÛÙ ·Ó·ÌÂÓfiÙ·Ó (1,2,14). ∏ Ù˘¯·›· ·Ó‡ÚÂÛË ÙÔ˘ ·Ú·ÙÂٷ̤ÓÔ˘ ·ƒ∆∆ ÛÙÔÓ ÚÔÂÁ¯ÂÈÚËÙÈÎfi ¤ÏÂÁ¯Ô ÌÂÙ¿ ·fi ÏÂÙÔÌÂÚ‹ ‰ÈÂÚ‡ÓËÛË ‚Ú¤ıËΠfiÙÈ ÔÊÂÈÏfiÙ·Ó ÛÙËÓ ‡·ÚÍË Î˘ÎÏÔÊÔÚÔ‡ÓÙÔ˜ LA. £ÂˆÚ‹Û·Ì fiÙÈ Ë ·ÚÔ˘Û›· ÙÔ˘ LA Û ¤Ó· ·È‰› Ô˘ ‰ÂÓ ÂÌÊ¿ÓÈ˙ ·ÈÌÔÚÚ·ÁÈΤ˜ ÂΉËÏÒÛÂȘ ‹ ıÚÔÌ‚ÒÛÂȘ, ‹Ù·Ó ·ÚÔ‰È΋ Î·È Î·ÏÔ‹ı˘, ÔÊÂÈÏfiÌÂÓË ÛÙË Ïԛ̈ÍË ÙÔ˘ ·ÛıÂÓ‹ ·fi ÙË Bartonella henselae. ™ÙËÚÈ˙fiÌÂÓÔÈ ÛÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ (4,6,8,11,12), ÚÔ¯ˆÚ‹Û·Ì ÛÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÏÂÌÊ·‰¤Ó· ·Ú¿ ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ·ƒ∆∆, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚËı› ·ÈÌÔÚÚ·Á›· ‹ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ÂԇψÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙ· ·È‰È¿ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËı› ·Ú¿Ù·ÛË ÙÔ˘ ·ƒ∆∆, Ë ÔÔ›· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË, ·ÏÏ¿ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‡·Ú͢ LA (6,8,11,12). ∆Ô LA, o Â›ÎÙËÙÔ˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ‹Í˘, Â›Ó·È Û˘Ó‹ıˆ˜ ·ÚÔ‰ÈÎfi Ì ηÏÔ‹ıË ÔÚ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Joseph R Lex. Catscratch disease. Medicine Journal 2001;2:8.

2. Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to “Rochalimaea henselae” antigen in suspected

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cat-scratch disease. Lancet 1992;339:1443-1445.

3. Margileth AM. Antibiotic therapy for catscratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J 1992;11:474-478.

4. Eckart P, Tournade G, Amiour M, Guillot M, Courtheoux P, Rousselot P. Maladie des griffes du chat de presentation pseudotumorale. Arch Pediatr 2001;8:393-396.

5. Carithers HA. Cat-scratch disease. An overview based on a study of 1200 patients. Am J Dis Child 1985;139:1124-1133.

6. OÈÎÔÓfiÌÔ˘ ª, ∫Ô‡ÛË ∞, ∆Û¿ÙÚ· π, °·Ú˘›‰Ô˘ µ, ∞ı·Ó·Û›Ô˘-ªÂÙ·Í¿ ª. ¶·ÚÔ‰ÈÎfi ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·: ÂÚÈÁÚ·Ê‹ ÙÂÛÛ¿ÚˆÓ ÂÚÈÙÒÛˆÓ. ¶·È‰È·ÙÚÈ΋ 2002;65:77-80.

7. ªale C, Lechner K, Eichinger S, Kyrle PA, Kapiotis S, Wank H et al. Clinical significance of lupus anticoagulants in children. J Pediatr 1999;134:199-205.

8. Lee MT, Nardi MA, Hadzi-Nesic J, Karpatkin M. Transient hemorrhagic diathesis associated with an inhibitor of prothrombin with lupus anticoagulant in a 1ó year-old girl: report of a case and review of literature. Am J Hematol 1996;51:307-314.

9. Hoffman R, Benz EJ, Shattil SJ, Furil B, Cohen HJ, eds.

Inhibitors of blood coagulation. In: Hematology. Basic Principles and Practice. 2nd ed. Churchill Livingstone Inc; 1995. p. 1746-1755.

10. Seaman DE, Londino AV Jr, Kwoh CK, Medsger TA Jr, Manzi S. Antiphospholipid antibodies in pediatric systemic lupus erythematosus. Pediatrics 1995;96:1040-1045.

11. Manco-Johnson MJ, Nuss R, Key N, Moertel C, Jacobson L, Meech S et al. Lupus anticoagulant and protein S deficiency in children with postvaricella purpura fulminans or thrombosis. J Pediatr 1996;128:319-323.

12. Manco-Johnson MJ. Antiphospholipid antibodies in children. Semin Thromb Hemost 1998;24:591-598.

13. Adal KA, Cockerell CJ, Petri WA Jr. Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea. N Engl J Med 1994;330:1509-1515.

14. Infectious Diseases and Immunization Committee, Canadian Pediatric Society. CPS: Cat scratch disease: diagnosis and management. Paediatr Child Health 1997;2:275-278.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-08-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª. §ÈıÔÍÔÔ‡ÏÔ˘ µ·Û. °ÂˆÚÁ›Ô˘ 24, ∆.∫. 546 40, £ÂÛÛ·ÏÔÓ›ÎË

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CURRENT ISSUES

ŒÎ‚·ÛË ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∞. ª·ÓÔ˘Ú¿, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘

Outcome of newborns conceived by in vitro fertilization A. Manoura, C. Giannakopoulou

¶ÂÚ›ÏË„Ë: ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÂÚ›Ô˘ ÂÓ‹ÓÙ· ¯ÈÏÈ¿‰Â˜ ·È‰È¿ ÁÂÓÓÈÔ‡ÓÙ·È Î¿ı ¯ÚfiÓÔ Ì ÙË Ì¤ıÔ‰Ô Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘. ∂›ÎÔÛÈ ¯ÚfiÓÈ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ÚÒÙÔ˘ “·È‰ÈÔ‡ ÙÔ˘ ۈϋӷ” ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ÂÚˆÙËÌ·ÙÈο ˆ˜ ÚÔ˜ ÙËÓ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ù¯ÓÔÏÔÁ›·˜. ∆· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ Á¤ÓÓËÛ˘ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹, ÚÔˆÚfiÙËÙ·˜, ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, Ô˘ ÊÙ¿ÓÂÈ ÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ Î˘‹ÛÂˆÓ Ô˘ ¤¯Ô˘Ó ÚÔ¤ÏıÂÈ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË. ¢È·ÊÔÚ¤˜ ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌËÙ¤ÚˆÓ Û˘Ì‚¿ÏÏÔ˘Ó, Â›Û˘, ÛÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ¤Î‚·ÛË. ∆· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÂȉÈο ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È Â›Û˘ ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘Í‹ ÙÔ˘˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋, ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜. ∏ Â·Ó·ÙÔÔı¤ÙËÛË ÛÙË Ì‹ÙÚ· ‰‡Ô, ÙÔ ·ÓÒÙÂÚÔ, ÂÌ‚Ú‡ˆÓ, Ì ÚÔÔÙÈ΋ ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ÙËÓ ÙÔÔı¤ÙËÛË ÂÓfi˜ ÌfiÓÔ “ηϋ˜ ÔÈfiÙËÙ·˜” ‚ÈÒÛÈÌÔ˘ ÂÌ‚Ú‡Ô˘, ı· ‚ÂÏÙÈÒÛÂÈ Î·Ù¿ Ôχ ÙËÓ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘.

Abstract: During the last years, almost fifty thousand children are born every year after in vitro fertilization. Twenty years after the birth of the first baby conceived by in vitro fertilization, many questions concerning the outcome of these children remain unanswered. Pregnancies achieved after in vitro fertilization bear an increased risk for prematurity, low birth weight, perinatal mortality and delivery by cesarean section compared with pregnancies after spontaneous conception.

Adverse outcome is mainly due to the high frequency of multiple pregnancies, which reach one third of in vitro fertilization pregnancies. Differences in maternal characteristics also contribute to this adverse outcome. Children conceived by in vitro fertilization are at higher risk of neurological sequelae, especially cerebral palsy, which is also mainly due to the high frequency of multiple gestations. Physical growth is within normal range while congenital malformations do not seem to be higher. Two-embryo transfer policy and, in the near future, the effective selection and transfer of one viable embryo will improve the outcome of children born after in vitro fertilization.

§¤ÍÂȘ ÎÏÂȉȿ: Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ôχ‰˘ÌË Î‡ËÛË.

Key words: in vitro fertilization, multiple pregnancy.

∂ÈÛ·ÁˆÁ‹ ¶ÂÚÈÛÛfiÙÂÚ· ·fi ›ÎÔÛÈ ¯ÚfiÓÈ· ¤¯Ô˘Ó ÂÚ¿ÛÂÈ ·fi ÙË Á¤ÓÓËÛË ÙÔ˘ ÚÒÙÔ˘ “̈ÚÔ‡ ÙÔ˘ ۈϋӷ” (1). ∞fi ÙfiÙÂ, ÔÈ Ì¤ıÔ‰ÔÈ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··-

Ú·ÁˆÁ‹˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ, ¤¯Ô˘Ó ‰ÒÛÂÈ ÙË ¯·Ú¿ Ù˘ ·fiÎÙËÛ˘ ÂÓfi˜ ·È‰ÈÔ‡ Û ÔÏÏ¿ ˙¢Á¿ÚÈ· Ì ÚÔ‚Ï‹Ì·Ù· ˘ÔÁÔÓÈÌfiÙËÙ·˜. ¶·Ú¿ÏÏËÏ·, fï˜, ¤¯Ô˘Ó ÂÁ›ÚÂÈ Î·È

¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘

Department of Neonatology of University of Crete

58

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·59

¶·È‰È·ÙÚÈ΋ 2003;66:58-64

ÔÏÏÔ‡˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË Î·È ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ù˘ Ù¯ÓÔÏÔÁ›·˜. ªÂ ÙËÓ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ·ÚÎÂÙ¿ ÛÙ¿‰È· Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ˘ÂÚˉԇÓÙ·È, ·ÊÔ‡ Ë ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË Á›ÓÂÙ·È ·Ú¯Èο in vitro. ∆· ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙȘ Èı·Ó¤˜ ÂȉڿÛÂȘ ÛÙÔ ¤Ì‚Ú˘Ô, ·˘Ù‹˜ Ù˘ ·Ú¤Ì‚·Û˘ ÛÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ‰È·‰Èηۛ˜ Ù˘ ÁÔÓÈÌÔÔ›ËÛ˘, ‰ÂÓ ¤¯Ô˘Ó ··ÓÙËı› ·ÎfiÌ·. ∏ ·Ó·ÛÎfiËÛË ·˘Ù‹ ÛÎÔfi ¤¯ÂÈ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ù· ¿ÌÂÛ· ÂÚÈÁÂÓÓËÙÈο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î·È Ó· Û˘ÓÔ„›ÛÂÈ ÙÔ˘˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡˜ Ô˘ ˘¿Ú¯Ô˘Ó Û‹ÌÂÚ· Û¯ÂÙÈο Ì ÙËÓ ·ÒÙÂÚË ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ∆¯ÓÔÏÔÁ›· ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ ∏ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ÛÙËÚ›˙ÂÙ·È ÛÙË Û˘ÏÏÔÁ‹ ˆ·Ú›ˆÓ Î·È ÛÙËÓ ÙÔÔı¤ÙËÛ‹ ÙÔ˘˜, Ì·˙› Ì ηٿÏÏËÏ· ÂÂÍÂÚÁ·Ṳ̂ÓÔ Û¤ÚÌ·, Û ‰ÔÎÈÌ·ÛÙÈÎfi ۈϋӷ ‹ ÙÚ˘‚Ï›· Ì ηٿÏÏËÏÔ ıÚÂÙÈÎfi ˘ÏÈÎfi, ÒÛÙ ӷ Á›ÓÂÈ Ë ÁÔÓÈÌÔÔ›ËÛË. ™ÙË Û˘Ó¤¯ÂÈ·, ·ÎÔÏÔ˘ı› ÂÌʇÙ¢ÛË ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ ÛÙË Ì‹ÙÚ· (2). ∞Ú¯Èο, ‰ÂÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ê¿Ú̷η ÚfiÎÏËÛ˘ ˆÔÚÚËÍ›·˜, ‰È·ÈÛÙÒıËΠfï˜ fiÙÈ Ë Ì¤ıÔ‰Ô˜ Ì ϋ„Ë ˆ·Ú›Ô˘ ·fi Á˘Ó·›Î· ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÁÂÓÓËÙÈÎfi ·ÎÏÔ ·ÚÔ˘Û›·˙ ÔÏÏ¿ Ú·ÎÙÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÌÈÎÚfi ÔÛÔÛÙfi ÂÈÙ˘¯›·˜. ™‹ÌÂÚ·, ÁÈ· ÙË Ï‹„Ë ˆ·Ú›ˆÓ, Á›ÓÂÙ·È Î·Ù¿ ηÓfiÓ· Ê·Ú̷΢ÙÈ΋ ‰È¤ÁÂÚÛË ÙˆÓ ˆÔıËÎÒÓ. ∂ͤÏÈÍË Ù˘ ÎÏ·ÛÈ΋˜ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ·ÔÙÂÏ› Ë ÙÔÔı¤ÙËÛË ÂÓfi˜ ÌfiÓÔ ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘ ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ· ÙÔ˘ ˆ·Ú›Ô˘ (ICSH) ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÏÈÁÔ·ÛıÂÓÔÛÂÚÌ›·˜. ∏ ηٿ„˘ÍË ÂÌ‚Ú‡ˆÓ Û ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÁÔÓÈÌÔÔ›ËÛ˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÁÈ· ʇϷÍË ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ (2). ∏ ¯ÚËÛÈÌÔÔ›ËÛË ‰È·ÊfiÚˆÓ ÔÚÌÔÓÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ÁÈ· ÙËÓ ÚfiÎÏËÛË ˆÔÚÚËÍ›·˜, Ë Èı·ÓfiÙËÙ· ‚Ï¿‚˘ ÙÔ˘ ˆ·Ú›Ô˘ ηٿ ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ï‹„˘ ÙÔ˘ ‹ ηٿ ÙËÓ Â·Ó·ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ÛÙË Ì‹ÙÚ·, Ë ¯Ú‹ÛË Î·ÏÏÈÂÚÁËÙÈÎÒÓ ˘ÏÈÎÒÓ Ô˘ Èı·ÓfiÓ ¤¯Ô˘Ó οÔÈ· Â›‰Ú·ÛË ÛÙÔ ·Ó·Ù˘ÛÛfiÌÂÓÔ ¤Ì‚Ú˘Ô, ηıÒ˜ Î·È Ë Î·Ù¿„˘ÍË ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ÂÌ‚Ú‡ˆÓ ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ·ÓËÛ˘¯›Â˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ·˘Ù¤˜ ÙȘ ÌÂıfi‰Ô˘˜ (3,4). ¶·Ú¿ÏÏËÏ·, Ë ÚÔÛ¿ıÂÈ· ·‡ÍËÛ˘ ÙˆÓ ÔÛÔÛÙÒÓ Â›Ù¢Í˘ ÂÁ΢ÌÔÛ‡Ó˘ ÌÂÙ¿ ·fi ¤Ó· ·ÎÏÔ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ Â·Ó·ÙÔÔı¤ÙËÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ÂÌ‚Ú‡ˆÓ ÛÙË Ì‹ÙÚ·. ∏ Ú·ÎÙÈ΋ ·˘Ù‹ ›¯Â Û·Ó

Paediatriki 2003;66:58-64

·ÔÙ¤ÏÂÛÌ· ÙË ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Ì ·ÚÓËÙÈΤ˜ Û˘Ó¤ÂȘ ÛÙËÓ ÚfiÁÓˆÛË ÙˆÓ ÓÂÔÁÓÒÓ. ¶Ôχ‰˘Ì˜ ΢‹ÛÂȘ ∆· Ôχ‰˘Ì· ÓÂÔÁÓ¿ ÛÙÔÓ ¿ÓıÚˆÔ ·ÔÙÂÏÔ‡Ó Ê˘ÛÈÔÏÔÁÈο ÙÔ 2-3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (5). ∏ Û˘¯ÓfiÙËÙ· ‰›‰˘Ì˘ ·ËÛ˘ ·Ó·Ê¤ÚÂÙ·È 1/80, ÙÚ›‰˘Ì˘ 1/6400, ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˘ Ù¿Í˘ Ôχ‰˘Ì˜ ΢‹ÛÂȘ, Ë Û˘¯ÓfiÙËÙ· ÌÂÈÒÓÂÙ·È ÂÎıÂÙÈο. ∏ Ôχ‰˘ÌË Î‡ËÛË Â›Ó·È Û˘Ó‹ıˆ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· ÁÔÓÈÌÔÔ›ËÛ˘ ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ˆ·Ú›ˆÓ (‰ÈˆÔÁÂÓ‹ ‰›‰˘Ì·) (6). ∏ ‰È·›ÚÂÛË ÂÓfi˜ ÁÔÓÈÌÔÔÈË̤ÓÔ˘ ˆ·Ú›Ô˘ Û ‰‡Ô ·ÓÔÌÔÈfiÙ˘· ¤Ì‚Ú˘· (ÌÔÓÔˆÔÁÂÓ‹) ·ÔÙÂÏ› ¤Ó·Ó ¿ÏÏÔ Ì˯·ÓÈÛÌfi ‰ËÌÈÔ˘ÚÁ›·˜ ‰È‰‡ÌˆÓ. ∏ Û˘¯ÓfiÙËÙ· ÌÔÓÔˆÔÁÂÓÔ‡˜ ‰›‰˘Ì˘ ·ËÛ˘ Â›Ó·È 3,5 ÛÙȘ 1000 ÁÂÓÓ‹ÛÂȘ Î·È Â›Ó·È Û¯ÂÙÈο ÛÙ·ıÂÚ‹ ·ÁÎfiÛÌÈ· (7). ∞ÓÙ›ıÂÙ·, Ë Û˘¯ÓfiÙËÙ· ‰ÈˆÔÁÂÓÔ‡˜ ‰›‰˘Ì˘ ·ËÛ˘ Î˘Ì·›ÓÂÙ·È ·fi 4 ¤ˆ˜ 50 ÛÙȘ 1000 ÁÂÓÓ‹ÛÂȘ Î·È ÂËÚ¿˙ÂÙ·È ·fi ÙË Ê˘Ï‹, ·fi Ì›· ÔÈÎÔÁÂÓÂȷ΋ ÚԉȿıÂÛË Ô˘ ÌÂٷʤÚÂÙ·È ·fi ÙË ÌËÙ¤Ú·, ·fi ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜, ÙÔÓ ÙfiÎÔ, ÙË ‰È·ÙÚÔÊ‹ ‹ ÙËÓ ÂÔ¯‹ ÙÔ˘ ¯ÚfiÓÔ˘. OÈ ÔχÙÔΘ ÌËÙ¤Ú˜ ¤¯Ô˘Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ‰›‰˘ÌË Î‡ËÛË, ηıÒ˜ Î·È ÔÈ Á˘Ó·›Î˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Ì ÙË Ì¤ÁÈÛÙË Û˘¯ÓfiÙËÙ· ÛÙ· 37 ¯ÚfiÓÈ· (7). ∆· ÌÔÓÔˆÔÁÂÓ‹ ‰›‰˘Ì· ·ÔÙÂÏÔ‡Ó ÙÔ 10-18% ÙˆÓ ˙ÒÓÙˆÓ ‰È‰‡ÌˆÓ (8). ∏ ÂÚÈÁÂÓÓËÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤Ó˜ Î·È Ë Èı·ÓfiÙËÙ· ÂÚÈÁÂÓÓËÙÈÎÔ‡ ı·Ó¿ÙÔ˘ Â›Ó·È 2,5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ·fi Ù· ‰ÈˆÔÁÂÓ‹ (9). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ Ì›· ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∏ ·‡ÍËÛË ·˘Ù‹ ·Ô‰›‰ÂÙ·È Î·Ù¿ ÙÔ ¤Ó· ÙÚ›ÙÔ ÂÚ›Ô˘ ÛÙËÓ ÚÔ˜ Ù· ¿Óˆ ÌÂÙ·ÙfiÈÛË Ù˘ ̤Û˘ ËÏÈΛ·˜ ÙˆÓ ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ Î·È Î·Ù¿ Ù· ‰‡Ô ÙÚ›Ù· ÛÙËÓ Â˘Ú›· ¯Ú‹ÛË ÙˆÓ ÌÂıfi‰ˆÓ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ (5). ∏ ıÂÚ·›· ·ÓˆÔÚÚËÎÙÈÎÒÓ Á˘Ó·ÈÎÒÓ Ì ʷÚ̷΢ÙÈο Û΢¿ÛÌ·Ù· Â·ÁˆÁ‹˜ ˆÔÚÚËÍ›·˜ Û¯ÂÙ›˙ÂÙ·È Ì ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ Ôχ‰˘Ì˘ ·ËÛ˘ Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ê¿ÚÌ·ÎÔ Î·È ÙË ‰fiÛË. ∏ ÎÈÙÚÈ΋ ÎÏÔÌÈÊ·›ÓË Î·È ¿ÏÏ· ·ÓÙÈ-ÔÈÛÙÚÔÁfiÓ· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ‰›‰˘Ì˘ ·ËÛ˘ Û 10% Î·È ÙÚ›‰˘Ì˘ ·ËÛ˘ Û 1%, ÂÓÒ Û ıÂÚ·›· ÌÂ Û˘Ì‚·ÙÈο Û¯‹Ì·Ù· ÁÔÓ·‰ÔÙÚÔÈÓÒÓ, Ô Î›Ó‰˘ÓÔ˜ Ôχ‰˘Ì˘ ·ËÛ˘ Â›Ó·È ÂÚ›Ô˘ 25% (3). ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘, Ô Î›Ó‰˘ÓÔ˜ Ôχ‰˘Ì˘ ·ËÛ˘ ·˘Í¿ÓÂÙ·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ Ô˘ Â·Ó·ÙÔÔıÂÙÔ‡ÓÙ·È ÛÙË Ì‹ÙÚ·. OÚÈṲ̂ӷ ΤÓÙÚ· ıˆÚÔ‡Ó fiÙÈ Ë ÂÌʇÙ¢ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ

59

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14:37

™ÂÏ›‰·60

¶·È‰È·ÙÚÈ΋ 2003;66:58-64

·˘Í¿ÓÂÈ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ Ù˘ ÌÂıfi‰Ô˘. øÛÙfiÛÔ, ¤¯ÂÈ ‰Âȯı› fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ˆ·Ú›ˆÓ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Î·È fiÙÈ Ë ÂÌʇÙ¢ÛË ÙÚÈÒÓ ·ÓÙ› ‰‡Ô ˆ·Ú›ˆÓ ‰ÂÓ ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÔÛÔÛÙfi ÙˆÓ Î˘‹ÛÂˆÓ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È (3). ∏ Û˘¯ÓfiÙËÙ· Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Û ÂÚÈÙÒÛÂȘ ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ Â›Ó·È 2030%, ÂÓÒ ÙÔ 30-40% ÙˆÓ ÌˆÚÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÂÙ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ÚÔ¤Ú¯ÔÓÙ·È ·fi Ôχ‰˘Ì˜ ΢‹ÛÂȘ (5). OÈ ‰›‰˘Ì˜ ΢‹ÛÂȘ ¤¯Ô˘Ó ·˘ÍËı› ÛÙȘ ∏¶∞ ·fi 1,8% ÙÔ 1971 Û 2,7% ÙÔ 1997 (8). ¶ÂÚÈÛÛfiÙÂÚÔ ÂÓÙ˘ˆÛȷ΋ Â›Ó·È Ë ·‡ÍËÛË ÙˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ Ù¿Í˘ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ∆· ÙÚ›‰˘Ì· ÓÂÔÁÓ¿, ·fi 296 ·Ó¿ 1 ÂηÙÔÌ̇ÚÈÔ ˙ÒÓÙˆÓ ÁÂÓÓ‹ÛÂˆÓ ÙÔ 1971, ¤ÊÙ·Û·Ó ÙȘ 1584 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1997, Ù· ÙÂÙÚ¿‰˘Ì· ·fi 13 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1971 ¤ÊÙ·Û·Ó ÙȘ 144 ÙÔ 1996, ÂÓÒ Ù· ÂÓÙ¿‰˘Ì· ·fi 3,8 ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÙÔ 1971 ¤ÊÙ·Û·Ó ÙȘ 20,8 ÙÔ 1996 (8). ¶ÚfiÁÓˆÛË ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∆· ÓÂÔÁÓ¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó, ÁÂÓÈο, ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ Á¤ÓÓËÛ˘ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹, ÚÔˆÚfiÙËÙ·˜, ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ Î·È ÂÚÈÁÂÓÓËÙÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (3,5,10,11). ™Â ÌÂϤÙË Ô˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ 4298 ΢‹ÛÂȘ Î·È 5539 ÓÂÔÁÓ¿ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ ‚Ú¤ıËΠfiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ‹Ù·Ó 31,9%, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÚÈÁÂÓÓËÙÈÎÒÓ ı·Ó¿ÙˆÓ ‹Ù·Ó 1,8% Î·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ Ì ËÏÈΛ· ·ËÛ˘ ÌÈÎÚfiÙÂÚË ÙˆÓ 33 ‚‰ÔÌ¿‰ˆÓ ‹Ù·Ó 4,8%, Û ·ÓÙ›ıÂÛË Ì 13,2%, 0,8% Î·È 1,1% ·ÓÙ›ÛÙÔȯ· ÁÈ· Ù· ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (11). ™Â ¿ÏÏË ÌÂÁ¿ÏË ÌÂϤÙË ·fi ÙË ™Ô˘Ë‰›·, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ ‚Ú¤ıËΠ30,3% ÛÙȘ ΢‹ÛÂȘ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Û ·ÓÙ›ıÂÛË Ì ÙÔ 6,3% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ÷ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‰È·ÈÛÙÒıËΠÛÙÔ 27,4%, Û ۯ¤ÛË Ì ÙÔ 6,3% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5). ¶Èı·Ófi ›ӷÈ, ˆÛÙfiÛÔ, fiÙÈ ÛÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÙˆÓ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ Û˘Ì‚¿ÏÏÂÈ Î·È ÙÔ ¿Á¯Ô˜, ÙfiÛÔ ÙˆÓ ÁÔÓ¤ˆÓ fiÛÔ Î·È ÙˆÓ ÁÈ·ÙÚÒÓ, ÁÈ· ÂÈÙ˘¯‹ ¤Î‚·ÛË Ù˘ ·ËÛ˘ fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, Ô˘ Ô‰ËÁ› Û ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Ì ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË Î·ÈÛ·ÚÈ΋ ÙÔÌ‹ ÛÙȘ 36 Ì 37 ‚‰ÔÌ¿‰Â˜ (3,10). ™ËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ‚Ú¤ıËÎ·Ó Î·È ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· Ô˘ ‹Ù·Ó 8,2ò, ÂÓÒ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ‹Ù·Ó 6,6ò (5). ∏ ‰˘ÛÌÂÓ¤ÛÙÂÚË ·˘Ù‹ ¤Î‚·ÛË ¤¯ÂÈ ·Ô‰Ôı› Û ÌÂ-

60

Paediatriki 2003;66:58-64

Á¿ÏÔ ‚·ıÌfi ÛÙÔ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Ì ٷ ·˘ÍË̤ӷ ÚÔ‚Ï‹Ì·Ù· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (5,12). øÛÙfiÛÔ, Ê·›ÓÂÙ·È fiÙÈ Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Û˘ÓÙÂÏÔ‡Ó ÛÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ·˘Ù‹ ¤Î‚·ÛË, ·ÊÔ‡ ‰È·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË ¤¯ÂÈ ‚ÚÂı› Î·È Û ÓÂÔÁÓ¿ ·fi ·Ϥ˜ ΢‹ÛÂȘ (3,13,14). ·. ¶ÚfiÁÓˆÛË ÓÂÔÁÓÒÓ ·fi ·Ϥ˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ·Ó··Ú·ÁˆÁ‹˜ ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó Û˘ÁÎÚ›ÓÂÈ ÙËÓ ¤Î‚·ÛË ÓÂÔÁÓÒÓ ·fi ·Ϥ˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ·Ó··Ú·ÁˆÁ‹˜ Ì ÂΛÓË ÓÂÔÁÓÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÌʈÓÔ‡Ó fiÙÈ Ù· ÓÂÔÁÓ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ‰È·ÙÚ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· ÚfiˆÚÔ ÙÔÎÂÙfi Î·È ÁÈ· ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (4,5,10,15). ¶·Ú’ fiÏÔ Ô˘ ¤Ó· ̤ÚÔ˜ ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ·Ô‰›‰ÂÙ·È ÛÙ· ‰È·ÊÔÚÂÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ Á˘Ó·ÈÎÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, ÚˆÙÔÙfiΘ), ·ÎfiÌ· Î·È fiÙ·Ó Á›ÓÂÈ ÂÍÔÌÔ›ˆÛË ÙˆÓ ÔÌ¿‰ˆÓ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙÔÓ ÙfiÎÔ Ù˘ ÌËÙ¤Ú·˜, Ë ‰È·ÊÔÚ¿ ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ Û ۯ¤ÛË Ì ÂΛӷ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë ·Ú·Ì¤ÓÂÈ (4,5,15-17). ∂›Ó·È Èı·Ófi fiÙÈ Ë ˘ÔΛÌÂÓË ·ÈÙ›· Ù˘ ˘ÔÁÔÓÈÌfiÙËÙ·˜ Î·È Ë Ê·Ú̷΢ÙÈ΋ ‰È¤ÁÂÚÛË ÙˆÓ ˆÔıËÎÒÓ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Î‚·ÛË (3,4,18). ∂ÓÈÛ¯˘ÙÈÎfi Ù˘ ¿Ԅ˘ ·˘Ù‹˜ Â›Ó·È fiÙÈ Û ΢‹ÛÂȘ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÌÂÙ¿ ·fi ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÙÔÔı¤ÙËÛË ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘, fiÔ˘ ˘¿Ú¯ÂÈ Û˘Ó‹ıˆ˜ ·Ó‰ÚÈ΋ ÛÙÂÈÚfiÙËÙ· ÂÓÒ ÔÈ Á˘Ó·›Î˜ Â›Ó·È ˘ÁÈ›˜, Ô Î›Ó‰˘ÓÔ˜ ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡, ηıÒ˜ Î·È ÙÔ Ì¤ÛÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Â›Ó·È ·ÚfiÌÔÈ· Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4,19,20). ‚. ¶ÚfiÁÓˆÛË Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ÙÚfiÔ Û‡ÏÏ˄˘, Û˘Óԉ‡ÔÓÙ·È ·fi ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Ù˘ ÌËÙ¤Ú·˜ Î·È ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ. OÈ ÂÈÏÔΤ˜ ·fi ÏÂ˘Ú¿˜ Ù˘ ÂÁ·Ԣ ÂÌÊ·Ó›˙ÔÓÙ·È 3-7 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· Û ÂÚ›ÙˆÛË Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ ·’ fi,ÙÈ ÛÙȘ ÌÔÓ‹ÚÂȘ ΢‹ÛÂȘ (6). ∆Ô ÔÛÔÛÙfi ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ Â›Ó·È ·˘ÍË̤ÓÔ (6). ∏ ÚÔˆÚfiÙËÙ· Î·È ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ·ÔÙÂÏÔ‡Ó ÙȘ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ ÙˆÓ ÓÂÔÁÓÒÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ¶ÚfiˆÚÔ˜ ÙÔÎÂÙfi˜ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ 20-50% ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, ÂÓÒ ÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ‰È‰‡ÌˆÓ Î·È ¿Óˆ ·fi ÙÔ 90% ÙˆÓ ÙÚ›‰˘ÌˆÓ Î·È ÙÂÙÚ¿‰˘ÌˆÓ ÁÂÓÓÈ¤Ù·È Ì ‚¿ÚÔ˜

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·61

¶·È‰È·ÙÚÈ΋ 2003;66:58-64

ÌÈÎÚfiÙÂÚÔ ÙˆÓ 2500 g (7,8). O ΛӉ˘ÓÔ˜ Á¤ÓÓËÛ˘ Ôχ ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ ÓÂÔÁÓÔ‡ (<1500 g) Â›Ó·È 68% ÁÈ· Ù· ‰›‰˘Ì·, ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Î›Ó‰˘ÓÔ ÛÙȘ ÌÔÓ‹ÚÂȘ ΢‹ÛÂȘ (0,71,6%) (6,8). ∏ ÓÔÛËÚfiÙËÙ· ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ôχ‰˘ÌˆÓ Î·È ·ÏÒÓ Î˘‹ÛˆÓ, ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡ (6,7,21). O ΛӉ˘ÓÔ˜ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ‚Ú¤ıËΠ0,2%, 1,3% Î·È 7,6% Û ·Ϥ˜, ‰›‰˘Ì˜ Î·È ÙÚ›‰˘Ì˜ ΢‹ÛÂȘ, ·ÓÙ›ÛÙÔȯ· (21,22). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ·˘ÍË̤ÓË Î˘Ú›ˆ˜ ÛÙ· ÌÔÓÔˆÔÁÂÓ‹ ‰›‰˘Ì· (7). ∏ ıÓËÛÈÌfiÙËÙ· Â›Ó·È Ôχ ·˘ÍË̤ÓË ÛÙ· ÓÂÔÁÓ¿ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. ™Ù· ‰›‰˘Ì· ÓÂÔÁÓ¿, Ë ıÓËÛÈÌfiÙËÙ· Â›Ó·È Ù¤ÛÛÂÚȘ Ì ¤ÓÙ ÊÔÚ¤˜ ·˘ÍË̤ÓË Û ۯ¤ÛË Ì ٷ ÓÂÔÁÓ¿ ·ÏÒÓ Î˘‹ÛˆÓ, ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÙÚ›‰˘Ì· ÓÂÔÁÓ¿, Ë ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· ÂÙ·Ï·ÛÈ¿˙ÂÙ·È (7,22). ™ÙËÓ ·‡ÍËÛË ·˘Ù‹ Û˘ÓÙÂÏÔ‡Ó Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡, ÚÔÂÎÏ·Ì„›·˜, ÚfiÙˆÛ˘ ÔÌÊ·Ï›‰·˜ Î·È ¿ÏÏˆÓ ÂÈÏÔÎÒÓ. ¶¤Ú· ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ·˘Ù¿ Ô˘ ·ÊÔÚÔ‡Ó ÛÙ· ÓÂÔÁÓ¿ Ôχ‰˘Ì˘ ·ËÛ˘ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ÙÚfiÔ Û‡ÏÏ˄˘, ÁÈ· ÙËÓ ÔÌ¿‰· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· ·Ó Ë ‰È·‰Èηۛ· ˘Ô‚ÔËıÔ‡ÌÂÓ˘ ·Ó··Ú·ÁˆÁ‹˜ ÂÈ‚·Ú‡ÓÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ ÚfiÁÓˆÛË. ™Â Û‡ÁÎÚÈÛË Ì ٷ ÓÂÔÁÓ¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë, Ù· ÓÂÔÁÓ¿ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ ÁÂÓÓÈÔ‡ÓÙ·È ·fi ÌËÙ¤Ú˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È ÚˆÙÔÙfiΘ, ·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ì·È¢ÙÈÎÒÓ ÂÈÏÔÎÒÓ (23). øÛÙfiÛÔ, ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÌʇÙ¢ÛË ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÌ‚Ú‡ˆÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ÌÔÓÔˆÔÁÂÓÒÓ ‰È‰‡ÌˆÓ Ô˘ ¤¯Ô˘Ó Î·È ÙË ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË. ªÂ ‚¿ÛË ÙÔ ÛÎÂÙÈÎfi ·˘Ùfi, ı· ÂÚ›ÌÂÓ ›Ûˆ˜ ηÓ›˜ ‚ÂÏÙȈ̤ÓË ¤Î‚·ÛË ÙˆÓ ‰È‰‡ÌˆÓ ·fi ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹ Û ۯ¤ÛË Ì ·˘Ù¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ª›· ÚfiÛÊ·ÙË ÌÂϤÙË ‰Â›¯ÓÂÈ ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (24). OÚÈṲ̂ÓÔÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÚfiˆÚˆÓ ÙÔÎÂÙÒÓ, ηıÒ˜ Î·È ÓÂÔÁÓÒÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÛÙËÓ ÔÌ¿‰· ÙˆÓ Ôχ‰˘ÌˆÓ ÓÂÔÁÓÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (25,26). OÈ ÂÚÈÛÛfiÙÂÚÔÈ, fï˜, Û˘ÌʈÓÔ‡Ó fiÙÈ Ë ÓÂÔÁÓÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÁÈ· Ù· ÓÂÔÁÓ¿ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Û ۯ¤ÛË Ì ·˘Ù¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (5,11,27).

Paediatriki 2003;66:58-64

™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ∏ Â›ÙˆÛË ÙˆÓ Û˘ÁÁÂÓÒÓ Î·È ¯ÚˆÌÔÛˆÌÈ·ÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÌÂÙ¿ ·fi ÙËÓ ÎÏ·ÛÈ΋ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î˘Ì·›ÓÂÙ·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÌÂٷ͇ 2% Î·È 2,5%, ÔÛÔÛÙ¿ Ô˘ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ·˘Ù¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÁÈ· ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (4,10,28,29). ™Â ÚfiÛÊ·ÙË ÌÂϤÙË, ˆÛÙfiÛÔ, ·Ó·Ê¤ÚÂÙ·È ‰ÈÏ¿ÛÈÔ˜ ΛӉ˘ÓÔ˜ ÌÂÈ˙fiÓˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ (30). OÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜, ÂÍ¿ÏÏÔ˘, ·Ó·Ê¤ÚÔ˘Ó Ì›· ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÌÂÙ¿ıÂÛ˘ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ, ·ÙÚËÛ›·˜ ÔÈÛÔÊ¿ÁÔ˘ Î·È ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ ·˘Ù¿ (3,5,31,32). µ¤‚·È·, Ú¤ÂÈ Ó· Ï¿‚ÂÈ Î·Ó›˜ ˘’ fi„ÈÓ ÙÔ˘ fiÙÈ ˘¿Ú¯ÂÈ Î·Ï‡ÙÂÚË ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ·˘ÍË̤ÓË ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ‰È·ÎÔ‹˜ ·˘ÙÒÓ ÙˆÓ Î˘‹ÛÂˆÓ Û ÂÚ›ÙˆÛË ‰È·›ÛÙˆÛ˘ οÔÈ·˜ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜, ηıÒ˜ Î·È ·˘ÍË̤ÓÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. øÛÙfiÛÔ, Ë ·Ó‡ÚÂÛË - Û ÚfiÛÊ·ÙË ÌÂϤÙË - ‰ÈÏ¿ÛÈ·˜ Û˘¯ÓfiÙËÙ·˜ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔÈËÛ˘, ·ÎfiÌ· Î·È fiÙ·Ó ÌÂÏÂÙÒÓÙ·È ·È‰È¿ ÌfiÓÔ ·fi ·Ϥ˜ ΢‹ÛÂȘ Î·È Á›ÓÂÈ ÂÍÔÌÔ›ˆÛË ÙˆÓ ÔÌ¿‰ˆÓ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ Î·È ¿ÏÏÔ˘˜ Èı·ÓÔ‡˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰È·ÙËÚ› ÙËÓ ·ÓËÛ˘¯›· Ô˘ ˘¿Ú¯ÂÈ ˆ˜ ÚÔ˜ ÙÔÓ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È ‰ËÌÈÔ˘ÚÁ› ÙËÓ ·Ó¿ÁÎË ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˘ (30). ∞Ó¿ÏÔÁ· ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ÎÏ·ÛÈ΋ Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ·Ó·Ê¤ÚÔÓÙ·È Î·È ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ηٿ„˘Í˘ ÂÌ‚Ú‡ˆÓ (3,4,33). ªÂÁ·Ï‡ÙÂÚ˜ ·ÓËÛ˘¯›Â˜ ÂÁ›ÚÔ˘Ó ÔÈ ÓÂfiÙÂÚ˜, ÂÚÈÛÛfiÙÂÚÔ ÂÂÌ‚·ÙÈΤ˜ Ù¯ÓÈΤ˜ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ë ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ¤Á¯˘ÛË ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘. ™ÙË Ì¤ıÔ‰Ô ·˘Ù‹, ÔÈ Ì˯·ÓÈÛÌÔ› ÂÈÏÔÁ‹˜ ηٿ ·ÓÒÌ·ÏˆÓ ÛÂÚÌ·ÙÔ˙ˆ·Ú›ˆÓ Î·È ˆ·Ú›ˆÓ ˘ÂÚˉԇÓÙ·È, ÔÈ ·˘ÍË̤ÓÔÈ ¯ÂÈÚÈÛÌÔ› ÌÔÚ› Ó· ÂÈʤÚÔ˘Ó Ì˯·ÓÈ΋ ‹ ¯ËÌÈ΋ ‚Ï¿‚Ë ÛÙÔ ˆ¿ÚÈÔ Ì ·ÔÙ¤ÏÂÛÌ· ‰È·Ù·Ú·¯‹ ÛÙË Ì›ˆÛË Î·È ÙË Ì›ÙˆÛË, ÂÓÒ Ë ¤ÎıÂÛË Û ÔÈΛÏÔ˘˜ ¯ËÌÈÎÔ‡˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ (4,34,35). ¶·Ú’ fiÏÔ Ô˘ Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ÁÂÓÓËı› Ì ·˘Ù‹ ÙË Ì¤ıÔ‰Ô Â›Ó·È Û¯ÂÙÈο ÌÈÎÚfi˜, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ̤¯ÚÈ ÙÒÚ· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ (4,19,35,36). ∫·È ÛÙË Ì¤ıÔ‰Ô ·˘Ù‹, fï˜, ˘¿Ú¯Ô˘Ó ÂÚ¢ÓËÙ¤˜ Ô˘ ·Ó·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (30). ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜, Ê·›ÓÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓˆÌ·ÏÈÒÓ, ÙfiÛÔ ÙˆÓ ÛˆÌ·ÙÈÎÒÓ

61

JAN-FEB-03

14-05-03

14:37

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¶·È‰È·ÙÚÈ΋ 2003;66:58-64

fiÛÔ Î·È ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ʇÏÔ˘, Â›Ó·È ·˘ÍË̤ÓË Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (0,83% ¤Ó·ÓÙÈ 0,19-0,23% ÁÈ· ÙȘ ·ÓˆÌ·Ï›Â˜ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ʇÏÔ˘, 0,36% ¤Ó·ÓÙÈ 0,07% ÁÈ· ÙȘ ·ÓˆÌ·Ï›Â˜ ·˘ÙfiÛˆÌˆÓ ¯ÚˆÌÔۈ̿وÓ) (4,20,37). O ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Èı·Ó¿ Û¯ÂÙ›˙ÂÙ·È Ì ·˘Ù‹ ηı·˘Ù‹ ÙË ‰È·‰Èηۛ· ÁÔÓÈÌÔÔ›ËÛ˘, ¯ˆÚ›˜ Ó· ·ÔÎÏ›ÂÙ·È Ì›· ·˘ÍË̤ÓË Â›ÙˆÛË ¯ÚˆÌÔÛˆÌÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ ÛÙ· ÛÂÚÌ·ÙÔ˙ˆ¿ÚÈ· ·ÓÙÚÒÓ Ì Úfi‚ÏËÌ· ÁÔÓÈÌfiÙËÙ·˜ (4,20). æ˘¯Ôۈ̷ÙÈ΋ ÂͤÏÈÍË - ∞ÒÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ∏ ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË ‚Ú¤ıËΠ·Ó¿ÏÔÁË Ì ·˘Ù‹ ÙˆÓ ·È‰ÈÒÓ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4). ŸÙ·Ó ÌÂÏÂÙÒÓÙ·È Û·Ó ÂÓÈ·›· ÔÌ¿‰·, Ù· ·È‰È¿ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ÂÌÊ·Ó›˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÂȉÈο ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË (38). øÛÙfiÛÔ, ÙÔ Â‡ÚËÌ· ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙÔ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ, ÂÓÒ Ù· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ·Ϥ˜ ΢‹ÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÏ·ÊÚ¿ ·˘ÍË̤ÓÔ, ·ÏÏ¿ fi¯È ÛËÌ·ÓÙÈÎfi ÛÙ·ÙÈÛÙÈο, ÔÛÔÛÙfi Ó¢ÚÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ (38). ∂Ô̤ӈ˜, Ê·›ÓÂÙ·È fiÙÈ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ „˘¯Ôۈ̷ÙÈ΋ ÙÔ˘˜ ÂͤÏÈÍË, Ù· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Â›Ó·È Ì¤Û· ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ· (3,4). ∞Ó¿ÏÔÁË Â›Ó·È Î·È Ë ·Ó¿Ù˘ÍË Î·È Ë „˘¯oۈ̷ÙÈ΋ ÂͤÏÈÍË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÂÚÈÛÛfiÙÂÚÔ ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô Ù˘ ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋˜ ÙÔÔı¤ÙËÛ˘ ÛÂÚÌ·ÙÔ˙ˆ·Ú›Ô˘ (ISCI) (35). ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¤Ì‚Ú˘· Ô˘ ηٷ„‡¯ıËÎ·Ó Î·È Û˘ÓÙËÚ‹ıËηÓ, ‰ÂÓ ¤¯Ô˘Ó ‚ÚÂı› ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙËÓ „˘¯Ôۈ̷ÙÈ΋ ÂͤÏÈÍË Û ۯ¤ÛË Ì ·È‰È¿ Ê˘ÛÈÔÏÔÁÈ΋˜ Û‡ÏÏ˄˘ ‹ ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË “ÊÚ¤ÛΈӔ ÂÌ‚Ú‡ˆÓ (39). ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ, ηıÒ˜ Î·È Ë Û¯¤ÛË ÁÔÓ¤ˆÓ-·È‰ÈÒÓ ¤¯ÂÈ ÌÂÏÂÙËı› Î·È Û˘ÁÎÚÈı› Ì ·È‰È¿ ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë. ∏ ÔÈfiÙËÙ· Ù˘ ÁÔÓÈ΋˜ ÊÚÔÓÙ›‰·˜ Î·È Ë ·ÏÏËÏÂ›‰Ú·ÛË ÁÔÓ¤ˆÓ-·È‰ÈÔ‡ ‚Ú¤ıËΠ·ÓÒÙÂÚË ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (3,4). OÈ ÌËÙ¤Ú˜ ÙˆÓ ·È‰ÈÒÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘Ó·ÈÛıËÌ·ÙÈο ‰Â̤Ó˜ Ì ٷ ·È‰È¿ ÙÔ˘˜, ÔÈ ·Ù¤Ú˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÛÙËÓ ·Ó·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ Î·È ÔÈ Û¯¤ÛÂȘ ÁÔÓ¤ˆÓ-·È‰ÈÒÓ Â›Ó·È ·ÓÒÙÂÚ˜ Û ۇÁÎÚÈÛË Ì ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ì ·È‰› ˘ÈÔıÂÙË̤ÓÔ ‹ ·È‰› ·fi Ê˘ÛÈÔÏÔÁÈ΋ Û‡ÏÏË„Ë (4,40). ™Â ·Ï·ÈfiÙÂÚË ÌÂϤÙË Â›¯Â ·Ó·ÊÂÚı› ·˘ÍË̤ÓÔ ÔÛÔÛÙfi Ó¢ÚÔÂÎÙÔ‰ÂÚÌÈÎÒÓ fiÁÎˆÓ Û ·È‰È¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (41). ¡ÂfiÙÂÚ˜ ÌÂϤ-

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Ù˜, ˆÛÙfiÛÔ, ‰ÂÓ ¤‰ÂÈÍ·Ó ·‡ÍËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó¿Ù˘Í˘ ηÎÔ‹ıÂÈ·˜ Û ·˘Ù¿ Ù· ·È‰È¿, Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5,42). øÛÙfiÛÔ, ÂÂȉ‹ Ô Î·ÚΛÓÔ˜ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈÔ˜, ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ÙÂÎÌËÚÈˆÌ¤ÓˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜, ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·È‰ÈÒÓ (5,42). ™˘ÌÂÚ¿ÛÌ·Ù· ∂›ÎÔÛÈ ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÚÒÙË ÂÈÙ˘¯Ë̤ÓË Î‡ËÛË ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË, ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ÚÔ‚ÏËÌ·ÙÈÛÌÔ› Î·È ·ÓËÛ˘¯›Â˜ ÁÈ· ÙÔ˘˜ Èı·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ÎÚ‡‚ÂÈ Ë ˘ÂÚΤڷÛË ÔÏÏÒÓ ÛÙ·‰›ˆÓ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘. ∫¿ı ¯ÚfiÓÔ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹ 50.000 ·È‰È¿ (37). ∞fi ·˘Ù¿, ¤Ó· Û¯ÂÙÈο ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (ÂÚ›Ô˘ 30%) ÁÂÓÓÈÔ‡ÓÙ·È ÚfiˆÚ· ‹ Ì ÌÈÎÚfi ‚¿ÚÔ˜ (ÂÚ›Ô˘ 27%) Û ۯ¤ÛË Ì 6,3% Î·È 4,6% ·ÓÙ›ÛÙÔȯ·, ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (5). ∏ ÔÏÔ¤Ó· ¢ڇÙÂÚË ÂÊ·ÚÌÔÁ‹ Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤¯ÂÈ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·‡ÍËÛË ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·È ÙˆÓ ÓÂÔÁÓÒÓ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘. ¶ÚfiÛÊ·ÙË ÌÂϤÙË ·Ô‰›‰ÂÈ ÙÔ 45% Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ οو ·fi 1250 g Î·È ÙÔ 50% Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÁÂÓÓ‹ÛÂˆÓ Û ËÏÈΛ· ·ËÛ˘ οو ÙˆÓ 35 ‚‰ÔÌ¿‰ˆÓ ÛÙ· ÓÂÔÁÓ¿ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (43). ∆Ô Î‡ÚÈÔ ·›ÙÈÔ ÁÈ· Ù· ‰˘ÛÌÂÓ¤ÛÙÂÚ· ·˘Ù¿ ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÔÈ Ôχ‰˘Ì˜ ΢‹ÛÂȘ Ô˘ ÊÙ¿ÓÔ˘Ó ÛÙÔ ¤Ó· ÙÚ›ÙÔ ÙˆÓ Î˘‹ÛÂˆÓ ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (5,44). ¢È·ÊÔÚ¤˜ ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌËÙ¤ÚˆÓ Û˘Ì‚¿ÏÏÔ˘Ó, Â›Û˘, ÛÙ· ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÚÔˆÚfiÙËÙ·˜ Î·È ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ (5). ∏ ·‡ÍËÛË ÙˆÓ Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Â›Ó·È È·ÙÚÔÁÂÓ‹˜ Î·È ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÛÙË ıÂÚ·›· Ì ʷÚ̷΢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÚfiÎÏËÛ˘ ˆÔÚÚËÍ›·˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Â·Ó·ÙÔÔı¤ÙËÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ¤Ó· ÂÌ‚Ú‡ˆÓ ÛÙË Ì‹ÙÚ·, Û ̛· ÚÔÛ¿ıÂÈ· ·‡ÍËÛ˘ ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈÙ˘¯›·˜ Ù˘ ÌÂıfi‰Ô˘. øÛÙfiÛÔ, ÔÏϤ˜ ÂÚÁ·Û›Â˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÂÌʇÙ¢ÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi ‰‡Ô ÂÌ‚Ú‡ˆÓ ‰ÂÓ ·˘Í¿ÓÂÈ Ù· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜, ÂÓÒ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÙÚ›‰˘Ì˘ ·ËÛ˘ (22,45,46). ∞Ó¿Ï˘ÛË ÂÚÈÛÛfiÙÂÚˆÓ ·fi 44.000 ·ÎÏˆÓ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ¤‰ÂÈÍ fiÙÈ Ë ÌÂÙ·ÊÔÚ¿ ‰‡Ô ·ÓÙ› ÙÚÈÒÓ ÂÌ‚Ú‡ˆÓ ÌÂÈÒÓÂÈ ÙÔ ÔÛÔÛÙfi ÙÚ›‰˘Ì˘ ·ËÛ˘ ·fi 6% Û 0,4%, ¯ˆÚ›˜ ‰È·ÊÔÚ¿ ÛÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·ËÛ˘ (5). ªÂ ‚¿ÛË ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ ˘ÔÏÔÁ›ÛÙËΠfiÙÈ Ë ÛÙÚ·ÙËÁÈ΋ ÌÂÙ·ÊÔÚ¿˜ ‰‡Ô ÂÌ‚Ú‡ˆÓ ı· Ì›ˆÓ ÙËÓ Â›ÙˆÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·Ú¿Ï˘Û˘ ·fi 1,69% Û 0,89% (22,47). ™Â ÔÏϤ˜ ¯ÒÚ˜, Û‹ÌÂÚ·, ·ÊÔ‡ ¤ÁÈÓ·Ó Î·Ù·ÓÔËÙ¤˜ ÔÈ Û˘Ó¤ÂȘ Ù˘ ·‡ÍËÛ˘ ÙˆÓ

JAN-FEB-03

14-05-03

14:37

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Ôχ‰˘ÌˆÓ ΢‹ÛÂˆÓ Î·È ¤ÁÈÓ ·ÓÙÈÏËÙfi fiÙÈ Ë ÂÈÙ˘¯›· Ù˘ Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ‰ÂÓ ÎÚ›ÓÂÙ·È ÌfiÓÔ ·fi Ù· ÔÛÔÛÙ¿ ÂÈÙ˘¯Ô‡˜ ÂÁ΢ÌÔÛ‡Ó˘, ·ÏÏ¿ ΢ڛˆ˜ ·fi ÙËÓ ˘Á›· ÙˆÓ ·È‰ÈÒÓ Ô˘ ¤Ú¯ÔÓÙ·È ÛÙÔÓ ÎfiÛÌÔ, Û˘ÓÈÛÙ¿Ù·È Ë ÂÌ‚Ú˘ÔÌÂÙ·ÊÔÚ¿ ‰‡Ô ÙÔ Ôχ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ (5,44). ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ ÌÂıfi‰ˆÓ ηٿ„˘Í˘ Î·È Ê‡Ï·Í˘ ÙˆÓ ÁÔÓÈÌÔÔÈËÌ¤ÓˆÓ ˆ·Ú›ˆÓ Î·È Ë Â›Ù¢ÍË ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ÙÚfiˆÓ ÂÈÏÔÁ‹˜ “ηϋ˜ ÔÈfiÙËÙ·˜” ‚ÈÒÛÈÌˆÓ ÂÌ‚Ú‡ˆÓ ı· ÂÈÙÚ¤„Ô˘Ó ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ ÙËÓ Î·ıȤڈÛË Ù˘ ÛÙÚ·ÙËÁÈ΋˜ Â·Ó·ÙÔÔı¤ÙËÛ˘ ÂÓfi˜ ÌfiÓÔ ÂÌ‚Ú‡Ô˘, Ô˘ ¯ˆÚ›˜ Ó· ÂËÚ¿ÛÂÈ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯Ô‡˜ ÂÁ΢ÌÔÛ‡Ó˘, ı· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ·fi Â͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË (44). µÈ‚ÏÈÔÁÚ·Ê›· 1. Steptoe PC, Edwards RG. Birth after reimplantation of a human embryo [letter]. Lancet 1978;2:366.

2. ª·ÓÙ˙·‚›ÓÔ˜ £, ∫·Ó¿Î·˜ ¡. ∂͈ۈ̷ÙÈ΋ ÁÔÓÈÌÔÔ›ËÛË Î·È ÓÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ˘Ô‚ÔËıÔ‡ÌÂÓË ·Ó··Ú·ÁˆÁ‹. ∂ÊË‚ °˘Ó ∞Ó· ∂ÌÌËÓ 1998;10:106-116.

3. Buitendijk SE. Children after in vitro fertilization. An overview of the literature. Int J Technol ∞ssess Health Care 1999;15:52-65.

4. Tarlatzis BC, Grimbizis G. Pregnancy and child outcome after assisted reproduction techniques. Hum Reprod 1999;14 (1 Suppl):231-244.

5. Bergh T, Ericson A, Hillensjo T, Nygren KG, Wennerholm UB. Deliveries and children born after in vitro fertilisation in Sweden 1982-95: a retrospective cohort study. Lancet 1999;354:1579-1582.

6. The ESHRE Capri Workshop Group. Multiple gestation and pregnancy. Hum Reprod 2000;15:1856-1864.

7. Revenis ME, Johnson LA. Multiple gestations. In: Avery GB, Fletcher MA, MacDonald MG, editors. Neonatology: Patholophysiology and Management of the Newborn. 4th ed. Philadelphia: JB Lippincott Co; 1994. p. 417-426.

8. Warner µB, Kiely JL, Donovan EF. Multiple births and outcome. Clin Perinatol 2000;27:347-361.

9. Kochenour NK. Obstetric management of multiple gestation. In: Fanaroff AA, Martin RJ, editors. NeonatalPerinatal Medicine: Diseases of the fetus and infant. 6th ed.

St. Louis: Mosby-Year book Inc; 1997. p. 289-294.

10. D’Souza SW, Rivlin E, Cadman J, Richards B, Buck P, Lieberman BA. Children conceived by in vitro fertilization after fresh embryo transfer. Arch Dis Child 1997;76:F70F74.

11. Dhont M, De Sutter P, Ruyssinck G, Martens G, Bekaert A. Perinatal outcome of pregnancies after assisted reproduction: a case-control study. Am J Obstet Gynecol 1999;181:688-695.

12. Lancaster B, on behalf of Australian in vitro fertilization collaborative group. High incidence of preterm deliveries and early losses in pregnancy after in vitro fertilization. BMJ 1985;291:1160-1163.

13. Doyle P, Beral V, Maconochie N. Preterm delivery, low birth

Paediatriki 2003;66:58-64

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

weight and small-for-gestational-age in liveborn singleton babies resulting from in vitro fertilization. Hum Reprod 1992;7:425-428.

Tanbo T, Dale PO, Lunde O, Moe N, Abyholm T. Obstetric outcome in singleton pregnancies after assisted reproduction. Obstet Gynecol 1995;86:188-192.

Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731-737.

Tan SL, Doyle P, Campbell S, Beral V, Rizk B, Brinsden P et al. Obstetric outcome of in vitro fertilization pregnancies compared with normally conceived pregnancies. Am J Obstet Gynecol 1992;167:778-784.

Wang JX, Clark AM, Kirby CA, Philipson G, Petrucco O, Anderson G et al. The obstetric outcome of singleton pregnancies following in vitro fertilization/gamete intrafallopian transfer. Hum Reprod 1994;9:141-146. de Mouzon J, Allali F, Bachelot A. Results of the French multicenter study comparing babies born after IVF and after natural conception [abstracts]. 14th Annual Meeting of the ESHRE; 1998 June; Goteborg; Hum Reprod 1998 (Abstract book);13:107-108.

Wennerholm UB, Bergh C, Hamberger L, Nilsson L, Reismer E, Wennergren M et al. Obstetric and perinatal outcome of pregnancies following intracytoplasmic sperm injection. Hum Reprod 1996;11:1113-1119.

Bonduelle M, Camus M, De Vos A, Straessen C, Tournaye H, Van Assche E et al. Seven years of intracytoplasmic sperm injection and follow-up of 1987 subsequent children.

Hum Reprod 1999;14 (1 Suppl):243-264.

Petterson B, Nelson KB, Watson L, Stanley F. Twins, triplets, and cerebral palsy in births in Western Australia in the 1980s. BMJ 1993;307:1239-1243.

Fisk NM, Trew G. Two’s company, three’s a crowd for embryo transfer. Lancet 1999;354:1572-1573.

Kessler I, Lancet M, Borenstein R, Steinmetz A. The problem of the older primipara. Obstet Gynecol 1980;56:165-169.

Fitzsimmons BP, Bebbington MW, Fluker MR. Perinatal and neonatal outcomes in multiple gestations: assisted reproduction versus spontaneous conception. Am J Obstet Gynecol 1998;179:1162-1167.

Daniel Y, Ochshorn Y, Fait G, Geva E, Bar-Am A, Lessing JB. Analysis of 104 twin pregnancies conceived with assisted reproductive technologies and 193 spontaneously conceived twin pregnancies. Fertil Steril 2000;74:683-689.

Lambalk CB, van Hoof M. Natural versus induced twinning and pregnancy outcome: a Dutch nationwide survey of primiparous dizygotic twin deliveries. Fertil Steril 2001;75:731-736.

Bernasko J, Lunch L, Lapinski R, Berkowitz RL. Twin pregnancies conceived by assisted reproductive techniques: maternal and neonatal outcomes. Obstet Gynecol 1997;89:368-372.

ASRM/SART. Assisted Reproductive technology in the United States and Canada: 1993 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. Fertil Steril

63

JAN-FEB-03

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14:37

™ÂÏ›‰·64

¶·È‰È·ÙÚÈ΋ 2003;66:58-64

1995;64:13-21.

29. de Mouzon J, Lancaster P. World collaborative report on in vitro fertilization, preliminary data for 1995. J Assist Reprod Genet 1997;14S:251-265.

30. Hansen M, Kurinczuk JJ, Bower C, Webb S. The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization. N Engl J Med 2002;346:725-730.

31. Beral V, Doyle P. MRC Working Party on children conceived by in vitro fertilisation. Births in Great Britain resulting from assisted conception, 1978-87. BMJ 1990;300:1229-1233.

32. Lancaster PA. Congenital malformations after in vitro fertilization. Lancet 1987;2:1392-1393.

33. Sutcliffe AG, D’Souza SW, Cadman J, Richards B, McKinlay IA, Lieberman B. Minor congenital anomalies, major congenital malformations and development in children conceived from cryopreserved embryos. Hum Reprod 1995;10:3332-3337.

34. Bonduelle M, Wilikens A, Buysse A, Van Assche E, Wisanto A, Devroey P et al. Prospective follow-up study of 877 children born after intracytoplasmic sperm injection (ICSI) with ejaculated epididymal and testicular spermatozoa and after replacement of cryopreserved embryos obtained after ICSI. Hum Reprod 1996;11 (4 Suppl):131-155.

35. Sutcliffe AG, Taylor B, Saunders K, Thornton S, Lieberman BA, Grudzinskas JG. Outcome in the second year of life after in vitro fertilization by intracytoplasmic sperm injection: a UK case-control study. Lancet 2001;357:2080-2084.

36. Wennerholm UB, Bergh C, Hamberger L, Lundin K, Nilsson L, Wikland M et al. Incidence of congenital malformations in children born after ICSI. Hum Reprod 2000;15:944-948.

37. Nielsen J, Wohlert M. Chromosome abnormalities found among 34910 newborn children: results from a 13-year incidence study in Arhus, Denmark. Hum Genet 1991; 87:81-83.

38. Stromberg B, Dahlquist G, Ericson A, Finnstrom O, Koster M, Stjernqvist K. Neurological sequelae in children after in vitro fertilisation: a population-based study. Lancet 2002;359:461-465.

39. Wennerholm UB, Albertsson-Wikland K, Bergh C,

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Paediatriki 2003;66:58-64

40.

41.

42.

43.

44.

45.

46.

47.

Hamberger L, Niklasson A, Nilsson L et al. Postnatal growth and health in children born after cryopreservation as embryos. Lancet 1998;351:1085-1090.

Golombok S, Brewaeys A, Cook R, Giavazzi MT, Guerra D, Mantovani A et al. The European study of assisted reproduction families: family functioning and child development. Hum Reprod 1996:11:2324-2331.

White L, Giri N, Vowels MR, Lancaster PA. Neuroectodermal tumours in children born after assisted conception. Lancet 1990;336:1577.

Doyle P, Bunch KJ, Beral V, Draper GJ. Cancer incidence in children conceived with assisted reproduction technology.

Lancet 1998;352:452-453.

Tough SC, Greene CA, Svenson LW, Belik J. Effects of in vitro fertilization on low birth weight, preterm delivery, and multiple birth. J Pediatr 2000;136:618-622.

Hazekamp J, Bergh C, Wennerholm UB, Hovatta O, Karlstrom PO, Selbing A. Avoiding multiple pregnancies in ART: consideration of new strategies. Hum Reprod 2000;15:1217-1219.

Staessen C, Janssenswillen C, Van den Abbeel E, Devroey P, Van Steirteghem AC. Avoidance of triplet pregnancies by elective transfer of two good quality embryos. Hum Reprod 1993;8:1650-1653.

Vauthier-Brouzes D, Lefebvre G, Lesourd S, Gonzales J, Darbois Y. How many embryos should be transferred in in vitro fertilization? A prospective randomized study. Fertil Steril 1994;62:339-342.

Blickstein I, Weissman A. Estimating the risk of cerebral palsy after assisted conceptions. N Engl J Med 1999;341:1313-1314.

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-04-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-09-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37, ∆.∫. 713 05, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘

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µƒ∞µ∂Àª∂¡∏ ∂ƒ°∞™π∞

Paediatriki 2003;66:65-81

AWARD-WINNING ARTICLE

ªÂϤÙË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (Multi Drug Resistance, MDR) ‰È¿ ÙÔ˘ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ÔÍ›· Ï¢¯·ÈÌ›· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜* ¶. ∆˙ÒÚÙ˙Ë1, ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘ - ∞Ó‰ÚÔ˘Ï·Î¿ÎË1, π. ¶. ¶·Ó·ÁÈÒÙÔ˘1, ∫. ∆Û›ÙÛÈη˜1, K. ™ÙÂÊ·Ó¿ÎË2, ™. ÷˚‰¿˜1

Evaluation of the immunocytochemical expression of P-170 in acute leukemias of childhood* P. Tzortzi1, S. Polychronopoulou - Androulakaki1, J. P. Panagiotou1, K. Tsitsikas1, K. Stefanaki2, S. Haidas1

¶ÂÚ›ÏË„Ë: ∏ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂÚ·›· ·ÔÙÂÏ› Ì›· ·fi ÙȘ ΢ÚÈfiÙÂÚ˜ ·Èٛ˜ ıÂÚ·¢ÙÈ΋˜ ·ÔÙ˘¯›·˜ ÛÙ· ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· ÂÓËÏ›ÎˆÓ Î·È ·È‰ÈÒÓ. ¶ÔÏÏÔ› Ì˯·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜, ·ÏÏ¿ Ô ÈÔ ·ÓÙÈÚÔÛˆ¢ÙÈÎfi˜ Î·È Î·Ï¿ ÌÂÏÂÙË̤ÓÔ˜ Â›Ó·È ·˘Ùfi˜ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘. ∆Ô ÁÔÓ›‰ÈÔ ·˘Ùfi Έ‰ÈÎÔÔÈ› Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÙËÓ ƒ-170, Ô˘ ‰Ú· ˆ˜ ·ÓÙÏ›·, ÌÂٷʤÚÔÓÙ·˜ ÙÔÓ Î¿ı ʷÚ̷΢ÙÈÎfi, ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ, ηٷÚÁÒÓÙ·˜ ¤ÙÛÈ ÙË ‚Ï·ÙÈ΋ Â›‰Ú·ÛË Ù˘ ¯ËÌÂÈÔıÂÚ·¢ÙÈ΋˜ Ô˘Û›·˜ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ. ∆ËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ ·ÎÔÏÔ‡ıËÛ·Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜, ΢ڛˆ˜ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ™ÙËÓ ·È‰È΋ ËÏÈΛ·, Ë ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ·Ó·˙ËÙ‹ıËΠηْ ÂÍÔ¯‹Ó ÛÙËÓ ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÂÓÒ Ôχ Ï›Á˜ ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Ô˘ Â›Ó·È Î·È Ë ÂÈÎÚ·Ù¤ÛÙÂÚË ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶Ôχ ÏÈÁfiÙÂÚ˜ ·Ó·Ê¤ÚÔÓÙ·È Î·È ÛÙÔ˘˜ ‰‡Ô Ù‡Ô˘˜ Ï¢¯·ÈÌ›·˜ Û ‰È·ÊÔÚÂÙÈΤ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ (.¯. ‰È¿ÁÓˆÛË Î·È ˘ÔÙÚÔ‹). ™ÎÔfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ Ë ·ÔÙ‡ˆÛË Ù˘ ·ÚÔ˘Û›·˜ ‹ ÌË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô ∞ƒ∞∞ƒ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Î·È Ù˘ ÔÍ›·˜ ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ë ÚÔÁÓˆÛÙÈ΋ Ù˘ ı¤ÛË ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ. ªÂÏÂÙ‹ıËηÓ

Abstract: The multidrug resistant (MDR) phenotype has been suggested as a major cause of treatment failure in hematologic malignancies.

However, there is a complexity of MDR mechanisms. Perhaps the best understood mechanism of multidrug resistance involves that of the P-170 glycoprotein (P-gp), one membrane transporter protein which is responsible for transporting chemotoxic agents out of the malignant cells. Encoded by the MDR-1 gene, P-gp acts as an efflux pump, excreting chemotherapeutic agents from cells, before they can exert their cytotoxic effect. Several prospective studies have attempted to evaluate the clinical relevance of P-170 in childhood acute leukemia. In our study, P-170 expression was evaluated in 57 children with acute lymphoblastic leukemia (ALL) (49 on diagnosis and 8 on relapse) and in 13 children with acute non lymphoblastic leukemia (ANLL) (8 on diagnosis and 5 on relapse), diagnosed between 1 January 1996 and 31 July 1999. Bone marrow was examined immunocyto-chemically (APAAP technique) with three monoclonal antibodies of P-170 (JSB-1, C219 and MRK16). P-170 positive expression (P-170+) was found in 18/49 patients with ALL at initial diagnosis (36.7%) and in 5/8 patients at relapse (62.5%), while in patients with ANLL, P-170 positive expression was found in 5/8 at diagnosis (62.5%) and 2/5 at relapse (40%). In the ALL group with P170 positive at diagnosis complete remission (CR) was achieved in 16/18 (88.9%) patients, and 2/18 (11.1%) died, while in the ALL group with P-170

¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 1 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-OÁÎÔÏÔÁ›·˜ 2 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ

“Agia Sophia” Children’s Hospital, Athens 1 Department of Pediatric Hematology-Oncology 2 Laboratory of Clinical Pathology

* µ’ ÈڤÌÂÈÔ Œ·ıÏÔ 38Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 2000

* 2nd “Choremeio” Award 38th Panhellenic Pediatric Meeting, 2000

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ÚÔÔÙÈο 57 ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Î·È 13 Ì ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (OM§§), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó ÛÙo ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1/1/1996 ¤ˆ˜ 31/7/1999 Î·È ÛÙ· ÔÔ›· ·ÎÔÏÔ˘ı‹ıËΠÔÌÔÈÔÁÂÓÒ˜ ÙÔ ·Ó¿ÏÔÁÔ Ì ÙÔ ÓfiÛËÌ· ıÂÚ·¢ÙÈÎfi ÚˆÙfiÎÔÏÏÔ (ALL-BFM ’95 Î·È AML-BFM ’93) ÁÈ· ÙËÓ O§§ Î·È ÙËÓ Oª§§, ·ÓÙ›ÛÙÔȯ·. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ (57), ÔÈ 49 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË. ∞fi ·˘ÙÔ‡˜, 3 ˘ÔÙÚÔ›·Û·Ó Î·È Ì·˙› Ì ¿ÏÏÔ˘˜ 5 ·Ï·ÈfiÙÂÚÔ˘˜ ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ì O§§ Û ˘ÔÙÚÔ‹ (Û‡ÓÔÏÔ 8). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ì Oª§§ (13), 8 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË. ∞fi ·˘ÙÔ‡˜, 2 ˘ÔÙÚÔ›·Û·Ó Î·È Ì·˙› Ì ¿ÏÏÔ˘˜ 3 ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Ì Oª§§ Û ˘ÔÙÚÔ‹ (Û‡ÓÔÏÔ 5). OÈ ‰È¿ÌÂÛÔÈ ¯ÚfiÓÔÈ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 24 Ì‹Ó˜ Î·È 18 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÁÈ· ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙËÓ ˘ÔÙÚÔ‹ ‹Ù·Ó 28,5 Ì‹Ó˜ Î·È 26 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ∂ȯڛÛÌ·Ù· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂÏÂÙ‹ıËÎ·Ó ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο (∞ƒ∞∞ƒ Ù¯ÓÈ΋) Ì ÙË ¯Ú‹ÛË ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ƒ-170 (JSB-1, C219 Î·È MRK16). ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÌÔÓ·‰È΋ ‚È‚ÏÈÔÁÚ·ÊÈο Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú·, Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÌË ·Ó›¯Ó¢Û˘ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ¯2 ÙÂÛÙ. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ, ıÂÙÈ΋ ¤ÎÊÚ·ÛË ÛÙËÓ ƒ-170 ·ÓȯÓ‡ıËΠ۠ÔÛÔÛÙfi 52,6%. ∂ÓÓ¤· ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ıÂÙÈÎfiÙËÙ· Î·È ÛÙ· ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·. ∆· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 86,6% ÁÈ· ÙÔ JSB1, 80% ÁÈ· ÙÔ C219 Î·È 63,3% ÁÈ· ÙÔ MRK16. ∂ȉÈÎfiÙÂÚ·, ÁÈ· ÙȘ ÂÈ̤ÚÔ˘˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ: ™Â 18/49 ·ÛıÂÓ›˜ (36,7%) Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È Û 5/8 ·ÛıÂÓ›˜ (62,5%) ηٿ ÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ‚Ú¤ıËΠ۠5/8 (62,5%), ÂÓÒ ÛÙËÓ ˘ÔÙÚÔ‹ Û 2/5 (40%). ™Â Û¯¤ÛË Ì ÙËÓ ÔÚ›· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ: ·) ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ170 ηٿ ÙË ‰È¿ÁÓˆÛË (18), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠16/18 ·ÛıÂÓ›˜ (88,9%), ÂÓÒ 2/18 (11,1%) η٤ÏËÍ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹). ∞ÓÙ›ıÂÙ·, ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (31), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠27/31 ·ÛıÂÓ›˜ (87,1%), 1/31 (3,2%) ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹, ÂÓÒ 3/31 (9,7%) η٤ÏËÍ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô). ‚) ™ÙËÓ

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negative at diagnosis complete remission (CR) was achieved in 27/31 (87.1%) patients, 1/31 relapsed and 3/31 (9.7%) died. In the ALL group with P-170 positive at relapse complete remission (CR) was achieved in 2/5 (40%) patients, 1/5 (20%) relapsed and 2/5 (40%) died, while in the ALL group with P170 negative at relapse, complete remission (CR) was achieved in 3/3 (100%) patients. In the ANLL group with P-170 positive expression at diagnosis, complete remission was achieved in 3/5 (60%) patients, while 2/5 (40%) died, due to uncontrolled disease. In the ANLL group with P-170 negative at diagnosis 2/3 (66.6%) patients relapsed, and 1/3 (3.3%) died during the induction phase. In the ANLL group with P-170 positive expression at relapse complete remission was achieved in 2/2 (100%) patients, while in the ANLL group with P-170 negative at relapse 3/3 (100%) patients entered into complete remission. In the total population of our study, 30 out of 67 patients (52.6%) expressed the MDR protein. We found 26 (86.6%) cases positive for JSB-1, 24 (80%) for C219 and 19 (63.3%) for MRK16. Increased P-170 expression was more frequently found in patients with ALL at relapse than at initial diagnosis, while in patients with ANLL increased P-170 expression was found on both diagnosis and relapse. In the ALL group, P-170(+) at relapse was associated with a shorter remission rate (40%) and shorter median survival (40%) compared with P-170(-) expression (the percentages were 100% and 0% respectively). In the ANLL group, P-170 positive at diagnosis was associated with a shorter median survival (40%) compared with P-170 negative expression (33.3%).

In our study the correlation between P-170 expression and age, WBC count, karyotype, sex and FAB morphology in childhood acute leukemia was not found statistically significant, perhaps due to the relatively small number of patients and the limited follow-up period. P-170 expression seems insufficient so far, to fully explain all patterns of resistance. However, determination of the P-gp status in the leukaemic blasts at diagnosis and relapse may be used as an additional prognostic factor.

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ÔÌ¿‰· Ù˘ Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (5), Ï‹Ú˘ ‡ÊÂÛË ·Ú·ÙËÚ‹ıËΠ۠3/5 ·ÛıÂÓ›˜ (60%), ÂÓÒ ı¿Ó·ÙÔ˜ Â‹Ïı Û 2/5 (40%) (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹). ™ÙËÓ ÔÌ¿‰· Ù˘ Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (3), 2/3 (66,6%) ·ÚÔ˘Û›·Û·Ó ˘ÔÙÚÔ‹, ÂÓÒ 1/3 (33,3%) η٤ÏËÍ (ÛÙËÓ ¤ÊÔ‰Ô). Á) ™ÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (5), 2/5 ·ÛıÂÓ›˜ (40%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· ‰È¿ÌÂÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘˜ 15 Ì‹Ó˜, 1/5 (20%) ·ÚÔ˘Û›·Û ˘ÔÙÚÔ‹, ÂÓÒ 2/5 ·ÛıÂÓ›˜ (40%) ·‚›ˆÛ·Ó. ∞ÓÙ›ıÂÙ·, ÛÙËÓ ÔÌ¿‰· Ù˘ O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (3), 3/3 (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 26, 30 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· Î·È Ù¤ÏÔ˜, ‰) ÛÙËÓ ÔÌ¿‰· Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (2), 2/2 ·ÛıÂÓ›˜ (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 20 Î·È 25 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ÔÌ¿‰· Ù˘ Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ (3), 3/3 (100%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û 2Ë Ï‹ÚË ‡ÊÂÛË ÁÈ· 20, 26 Î·È 38 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ™˘ÌÂÚ·ÛÌ·ÙÈο: ·) ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÂÊfiÛÔÓ Ù· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ¤Ó· ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷, ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈΤ˜ ·ÔÎÏ›ÛÂȘ ηٿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ Û ıÂÙÈο ‰Â›ÁÌ·Ù·. ™ÙÔ ˘fi ÌÂϤÙË ˘ÏÈÎfi ‚Ú¤ıËΠfiÙÈ ÙÔ JSB-1 ¤¯ÂÈ Û¯ÂÙÈ΋ ‹ ·fiÏ˘ÙË ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ηı’ fiÛÔÓ ÙÔ ÔÛÔÛÙfi ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘ ‹Ù·Ó 86,6% ¤Ó·ÓÙÈ 80% ÙÔ˘ C219 Î·È 63,3% ÙÔ˘ MRK16. ‚) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Û ÔÛÔÛÙfi 36,7%, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËΠۯ‰fiÓ ‰ÈÏ¿ÛÈÔ (62,5%). Á) ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ·Ú·ÙËÚ‹ıËΠ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Û ۯ¤ÛË Ì ÙËÓ O§§ (62,5%). ∫·Ù¿ ÙËÓ ˘ÔÙÚÔ‹, ·Ú·ÙËÚ‹ıËΠÂ›Û˘ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (40%). ‰) OÈ ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%). Â) OÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË (40%) Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜

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Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·). ¶·Ú’ fiÙÈ ‰È·Ê·›ÓÂÙ·È ÂÎ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÂϤÙ˘ Ë ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈ΋ ÛËÌ·Û›· Ô˘ ÂÓ¤¯ÂÈ Ë ·ÚÔ˘Û›· Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ O§§ Î·È Oª§§ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, Èı·ÓfiÓ ÏfiÁˆ ÙÔ˘ ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜, ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô, ÙÔ Ê‡ÏÔ, ÙËÓ Î·Ù¿ FAB ÌÔÚÊÔÏÔÁ›·, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi Ï¢ÎÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙÔÓ Î·Ú˘fiÙ˘Ô. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú· ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹, ·Ó Î·È ‰ÂÓ Â›Ó·È ÈηÓfi˜ Ó· ÂÚÌËÓ‡ÛÂÈ fiÏÔ˘˜ ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·ÚÌ·ÎÔ·ÓÙÔ¯‹˜, ˆÛÙfiÛÔ, ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ÂÈϤÔÓ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË Ù˘ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘. §¤ÍÂȘ ÎÏÂȉȿ: ÔÏÏ·Ï‹ Ê·ÚÌ·ÎÔ·ÓÙÔ¯‹, ƒ-ÁÏ˘ÎÔÚˆÙ½ÓË, ÔÍ›· Ï¢¯·ÈÌ›·, ·È‰È΋ ËÏÈΛ·, ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·, ∞ƒ∞∞ƒ.

Key words: MDR, P-glycoprotein, childhood, ALL, ANLL, immunocytochemistry, APAAP.

∂ÈÛ·ÁˆÁ‹ O ηÚΛÓÔ˜ ÛÙÔÓ ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi, ·Ó Î·È Û¯ÂÙÈο Û¿ÓÈÔ ÓfiÛËÌ·, ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË ‰Â‡ÙÂÚË ÛÂ Û˘¯ÓfiÙËÙ· ·ÈÙ›· ı·Ó¿ÙÔ˘ ÌÂÙ¿ ·fi Ù· ·Ù˘¯‹Ì·Ù· (1). ∏ ÂÙ‹ÛÈ· Â›ÙˆÛË ÙÔ˘ ηÚΛÓÔ˘ ÛÙȘ ËÏÈ˘ ¤ˆ˜ 5 ÂÙÒÓ ·Ó·Ê¤ÚÂÙ·È Û 150 Ӥ˜ ÂÚÈÙÒÛÂȘ, ÂÓÒ ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (5-14 ÂÙÒÓ) Â›Ó·È 90-100 Ӥ˜ ÂÚÈÙÒÛÂȘ ·Ó¿ 1.000.000 ·È‰È¿, ·ÓÙÈÛÙÔ›¯ˆ˜. ∞fi ÙÔ Û‡ÓÔÏÔ ·˘Ùfi, ÙÔ ¤Ó· ÙÚ›ÙÔ ÂÚ›Ô˘ ·ÊÔÚ¿ ÛÙȘ ÔÍ›˜ Ï¢¯·È̛˜ Î·È Û˘¯ÓfiÙÂÚ· ÛÙȘ ÔÍ›˜ ÏÂÌÊÔ‚Ï·ÛÙÈΤ˜ (1-4). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÔÈ Ó¤Â˜ ÂÈÙ‡ÍÂȘ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛÔÏÔÁ›·˜, Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ù˘ ÁÂÓÂÙÈ΋˜ ‚Ô‹ıËÛ·Ó ·ÊÂÓfi˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ηÚÎÈÓÔÁ¤ÓÂÛ˘, ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Î·Ï‡ÙÂÚË Ù·ÍÈÓfiÌËÛË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·ÎÔËıÂÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (1). ™ËÌ·ÓÙÈΤ˜ ·Ú¿ÌÂÙÚÔÈ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÂÓfi˜ ηÎÔ‹ıÔ˘˜ ΢ÙÙ¿ÚÔ˘, Ô˘ ηٿ οÔÈÔ ÙÚfiÔ ÌÔÚÔ‡Ó Ó· ÚÔ‰ÈοÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘, ‰ËÏ·‰‹ ÙËÓ Èı·ÓfiÙËÙ· ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ó· ·ÓÙ·ÔÎÚÈı› ÈηÓÔÔÈËÙÈο ÛÙË ıÂÚ·›· Î·È Ó· ·Ú·Ì›ÓÂÈ ÛÂ Û˘Ó¯‹ Ï‹ÚË ‡ÊÂÛË ‹ fi¯È, ›ӷÈ: ·) Ô Ú˘ıÌfi˜ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘, ‚) Ë ‰˘Ó·ÙfiÙËÙ· Î·È Ë Ù·¯‡ÙËÙ· ‰È·ÛÔÚ¿˜ ÙÔ˘, Á) Ë ·˘ÍË̤ÓË ‹ ÂÏ·Ùو̤ÓË ·Ú¯È΋ ·ÓÙ·fiÎÚÈÛ‹ ÙÔ˘ ÛÙ· ¯ÔÚËÁÔ‡ÌÂÓ· ¯ËÌÂÈÔıÂÚ·¢ÙÈο Î·È ‰) Ë ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÛÙ· Ê¿Ú̷η ·˘Ù¿ ηٿ ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ (5). ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·È‰ÈÒÓ Ì ηÚΛÓÔ

¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ·. OÈ Ï¢¯·È̛˜, ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Î·È ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋, ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 ·fi ÂÈ‚›ˆÛË Ù˘ Ù¿Í˘ ÙÔ˘ 70% Î·È 50% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÚÈÓ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ÔÈ ÙÈ̤˜ ·˘Ù¤˜ ‹Ù·Ó ÛÙ·ıÂÚ¿ οو ÙÔ˘ 10% (2). ™‹ÌÂÚ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ 2 ÛÙ· 3 ·È‰È¿ Ì ηÎfiËı˜ ÓÂfiÏ·ÛÌ· ı· Ù‡¯Ô˘Ó Ì·ÎÚ¿˜ ÂÈ‚›ˆÛ˘ ÂχıÂÚ˘ ÓfiÛÔ˘, ÂÓÒ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· ÌÈÛ¿ ı· ıÂÚ·¢ıÔ‡Ó. £ÂˆÚÂ›Ù·È fiÙÈ ÙÔÓ 21Ô ·ÈÒÓ· ÌÂٷ͇ ÙˆÓ ÂÓËÏ›ÎˆÓ ËÏÈΛ·˜ 20-29 ÂÙÒÓ, 1/1000 ı· ¤¯ÂÈ ıÂÚ·¢ı› ·fi οÔÈ· ηÎÔ‹ıÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (4). ¶·Ú¿ ÙË ÌÂÁ¿ÏË ÚfiÔ‰Ô fï˜ Ô˘ ¤¯ÂÈ ÛËÌÂȈı› ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙË ıÂÚ·›· ÙˆÓ ·È‰ÈÒÓ Ì Ï¢¯·ÈÌ›·, ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·˘ÙÒÓ Û˘Ó¯›˙ÂÈ Ó· ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ·fi ÙËÓ ·Ú¯È΋ ÂÈÛ·ÁˆÁ‹ Û ‡ÊÂÛË. ∞˘Ùfi Û ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·Ô‰›‰ÂÙ·È ÛÙËÓ ÂÁÁÂÓ‹ ‹ Â›ÎÙËÙË ·ÓÙÔ¯‹ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú· ÛÙÔ˘˜ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ·ÎfiÌ· Î·È ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜, ÔfiÙ ¤¯Ô˘Ì ÎÏÈÓÈ΋ ÂÍ·Ê¿ÓÈÛË Ù˘ ÓfiÛÔ˘, ıˆÚËÙÈο, ·Ú·Ì¤ÓÂÈ ¤Ó·˜ ·ÚÈıÌfi˜ ηÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ, Ô˘ ·ÔÙÂÏ› ÙËÓ ÂÔÓÔÌ·˙fiÌÂÓË ÂÏ¿¯ÈÛÙË ˘ÔÏÂÈÌÌ·ÙÈ΋ ÓfiÛÔ (minimal residual disease, MRD), Ù· ÔÔ›· ÏfiÁˆ ·ÓÙÔ¯‹˜ ÛÙË ıÂÚ·›·, ÂÈ‚ÈÒÓÔ˘Ó Î·È Â˘ı‡ÓÔÓÙ·È ÙÂÏÈο ÁÈ· ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (5). ∏ ·Ó¿Ù˘ÍË Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ‰ÚÔ˘Ó ÌÂÌÔӈ̤ӷ

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‹ ÛÂ Û˘Ó‰˘·ÛÌfi (1). ∂ÓÔ¯ÔÔÈËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ıˆÚÔ‡ÓÙ·È: ·) Ë ‰˘Ó·ÙfiÙËÙ· in vivo “·fiÎÚ˘„˘” ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ÂÚÈÔ¯¤˜-“ÎÚËÛʇÁÂÙ·” ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ·fi fiÔ˘ ‰È·Ê‡ÁÔ˘Ó ÙˆÓ ˘„ËÏÒÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÙˆÓ ¯ÔÚËÁÔ˘Ì¤ÓˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (.¯. Ô ÂÁΤʷÏÔ˜ Î·È Ô ÓˆÙÈ·›Ô˜ Ì˘ÂÏfi˜ Ì ÙȘ ÂÚÈ‚¿ÏÏÔ˘Û˜ Ì‹ÓÈÁÁ˜ ·ÔÙÂÏÔ‡Ó ÎÏ·ÛÈο ·Ú·‰Â›ÁÌ·Ù· “Î·Ù·Ê˘Á›Ô˘” ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÏfiÁˆ ÙÔ˘ ˘¿Ú¯ÔÓÙÔ˜ ·ÈÌ·ÙÔÂÁÎÂÊ·ÏÈÎÔ‡ ÊÚ·ÁÌÔ‡, ÙÔÓ ÔÔ›Ô ‰È·ÂÚÓÔ‡Ó Ù· ¯ËÌÂÈÔıÂÚ·¢ÙÈο Ê¿Ú̷η ÌfiÓÔ Û Ôχ ˘„ËϤ˜ ‰fiÛÂȘ). ‚) ÙÔ Ì¤ÁÂıÔ˜ Ù˘ Ï¢¯·ÈÌÈ΋˜ Ì¿˙·˜ (ÌÂÁ¿ÏË Ï¢¯·ÈÌÈ΋ Ì¿˙· ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· Â›ÎÙËÙ˘ ·Ó¿Ù˘Í˘ ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜). Á) Ë ·ÚÔ˘Û›· ÂÓ‰ÔÁÂÓÔ‡˜ ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (multi drug resistance, MDR). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÔÈ ÌÂÁ¿Ï˜ Ï¢¯·ÈÌÈΤ˜ Ì¿˙˜ ÂÚȤ¯Ô˘Ó ·ÙÙ·Ú· ‹‰Ë ·ÓıÂÎÙÈο Û ÔÌ¿‰Â˜ ΢ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ì¿ÏÈÛÙ· ÛÂ Û˘¯ÓfiÙËÙ· 1/1.000.000 ·ÙÙ·Ú· (de novo Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹, ıˆڛ· ÙˆÓ Goldie-Goldman). ‰) Ë ·Ó¿Ù˘ÍË ÔÏ˘Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ οو ·fi ÙËÓ ›ÂÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Î˘ÙÙ·ÚÔÛÙ·ÙÈÎÒÓ (Â›ÎÙËÙË Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹), ÁÂÁÔÓfi˜ Ô˘ ηıÔÚ›˙ÂÙ·È Î·È ·fi ȉÈÔÛ˘ÛÙ·ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ (6). ∆· ηÎÔ‹ıË Î‡ÙÙ·Ú· ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ó· ·Ó·Ù‡ÛÛÔ˘Ó Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ·Ú·Î¿ÌÙÔ˘Ó ÙËÓ ÙÔÍÈ΋ ÁÈ· ·˘Ù¿ ‰Ú¿ÛË Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ ̤ۈ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ‹ ÙÚÔÔÔ›ËÛ˘ Ù˘ ‰Ú¿Û˘ Ì›·˜ ÛÂÈÚ¿˜ ÁÔÓȉ›ˆÓ (6-9). OÈ ÈÔ ÁÓˆÛÙ¤˜ Ô‰Ô› ·Ó¿Ù˘Í˘ ·fi Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú· Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙ· ¯ËÌÂÈÔıÂÚ·¢ÙÈο ›ӷÈ: ·) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘, Ô˘ Ô‰ËÁ› ÛÙËÓ ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ì›·˜ ÁÏ˘ÎÔÚˆÙ½Ó˘, Ù˘ ƒ-170, Ô˘ ‰ÚÒÓÙ·˜ ˆ˜ ·ÓÙÏ›· ÌÂٷʤÚÂÈ ÙÔ Ê¿ÚÌ·ÎÔ ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηٷÚÁÂ›Ù·È Ë ÙÔÍÈ΋ ‰Ú¿ÛË ÙÔ˘ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ. ‚) OÈ ÌÂÙ·‚ÔϤ˜ ÛÙËÓ ·fiÙˆÛË, ‰ËÏ·‰‹ ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ Î˘ÙÙ·ÚÈÎfi ı¿Ó·ÙÔ (˘ÂÚ¤ÎÊÚ·ÛË ‹ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ ƒ-53 ‹ ÙÔ˘ µcl-2 ÁÔÓȉ›Ô˘). Á) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ‹ Ë ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ MRP ÁÔÓȉ›Ô˘, Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ 10q24 ¯ÚˆÌfiۈ̷, Ì ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ MRP ÚˆÙ½Ó˘ (multidrug resistance associated protein), Ë ÔÔ›· ÌÂٷʤÚÂÈ Ì›· ÌÂÁ¿ÏË ÔÈÎÈÏ›· ÚÔ˚fiÓÙˆÓ, fiˆ˜ ÏÈÔÊÈÏÈο ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈο Ê¿Ú̷η Ô˘ ‰ÚÔ˘Ó Ì¤Ûˆ ATP-ÂÍ·ÚÙÒÌÂÓˆÓ Ì˯·ÓÈÛÌÒÓ.

Paediatriki 2003;66:65-81

‰) OÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘-S-ÙÚ·ÓÛÊÂÚ¿Û˘, ΢ڛˆ˜ ˘fi ÙËÓ ¤ÓÓÔÈ· Ù˘ ·‡ÍËÛ˘ Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ¿˜ Ù˘. ∆· ·˘ÍË̤ӷ ΢ÙÙ·ÚÈο Â›‰· ÁÏÔ˘Ù·ıÂÈfiÓ˘ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ·Ô‰fiÌËÛË ÙˆÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ ·fi Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú·. Â) ∏ ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÙÔÔ˚ÛÔÌÂÚ¿Û˘ ππ, Ì ·ÔÙ¤ÏÂÛÌ· ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÛÙfi¯ˆÓ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔÓ ˘Ú‹Ó·. ÛÙ) ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ LRP ÁÔÓȉ›Ô˘, Ô˘ ‰ڿ˙ÂÙ·È ÛÙÔ 16p42 ¯ÚˆÌfiۈ̷, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ Ù˘ LRP ÚˆÙ½Ó˘ (LRP - lung resistance related protein), Ë ÔÔ›· ‚Ú›ÛÎÂÙ·È ÛÙÔ˘˜ fiÚÔ˘˜ Ù˘ ˘ÚËÓÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È ÂËÚ¿˙ÂÈ ÙËÓ ˘ÚËÓÈ΋ Û˘ÁΤÓÙÚˆÛË ÙˆÓ Ê·Ú̿ΈÓ. ∂ȉÈÎfiÙÂÚ·, Ë ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (MDR-1) Â›Ó·È Ô ÈÔ ·ÓÙÈÚÔÛˆ¢ÙÈÎfi˜ Î·È ÈÔ Î·Ï¿ ÌÂÏÂÙË̤ÓÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (MDR). ∆Ô MDR-1 ÁÔÓ›‰ÈÔ ‚Ú›ÛÎÂÙ·È ÛÙÔ Ì·ÎÚ‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 7. ∞ӷχÛÂȘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÙÔ˘ ·ÓıÚÒÔ˘ ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯Ô˘Ó ‰‡Ô ÁÔÓ›‰È·, Ù· MDR-1 Î·È MDR-2, Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÛÙÂÓ¿ Î·È Îˆ‰ÈÎÔÔÈÔ‡Ó ÔÌfiÏÔÁ˜ ÌÂÌ‚Ú·ÓÈΤ˜ ÚˆÙ½Ó˜. ∞Ó Î·È Ù· ‰‡Ô ÔÓÔÌ¿˙ÔÓÙ·È MDR ÁÔÓ›‰È· ÏfiÁˆ ÙˆÓ ‰ÔÌÈÎÒÓ ÙÔ˘˜ ÔÌÔÈÔًوÓ, ˆÛÙfiÛÔ, ÌfiÓÔ ÙÔ MDR-1 ¤¯ÂÈ Û˘Ó‰Âı› ̤¯ÚÈ Û‹ÌÂÚ· Ì ÙËÓ ÔÏÏ·Ï‹ Ê·Ú̷΢ÙÈ΋ ·ÓÙÔ¯‹. ∏ ‰Ú¿ÛË Ù˘ ÚˆÙ½Ó˘ ÙÔ˘ MDR2 ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹, fï˜ ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ MDR (6,7,10). ∆Ô MDR-1 ÁÔÓ›‰ÈÔ Îˆ‰ÈÎÔÔÈ›, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, ÙËÓ ƒ-170, Ì›· ÁÏ˘ÎÔÚˆÙ½ÓË ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ 170.000 dalton, Ô˘ ÂÚÈÁÚ¿ÊËΠÙÔ 1976 ·fi ÙÔ˘˜ Juliano Î·È Ling (6,7). ∆Ô ·Ú¯ÈÎfi ƒ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ·ÁÁÏÈ΋ ϤÍË permeability, Ô˘ ÛËÌ·›ÓÂÈ ‰È·ÂÚ·ÙfiÙËÙ·, ÁÈ·Ù› Ë ƒ-170 ‰Ú· ˆ˜ ·ÓÙÏ›·, ÌÂٷʤÚÔÓÙ·˜ ÙÔ Ê¿ÚÌ·ÎÔ ‹ ÔÔÈÔÓ‰‹ÔÙ ¿ÏÏÔ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙÔ ÂÛˆÙÂÚÈÎfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛÙÔÓ ÂÚÈ‚¿ÏÏÔÓÙ· ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ.

OÈ FÔgÔ Î·È Û˘Ó (6) ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÁÔÓ›‰ÈÔ MDR1 ÂÎÊÚ¿˙ÂÙ·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ·ÙÙ·Ú· ÂÈÓÂÊÚȉ›ˆÓ, ÓÂÊÚÒÓ, ‹·ÙÔ˜, ¯ÔÏËÊfiÚˆÓ ·ÁÁ›ˆÓ, ÂÓÙ¤ÚÔ˘, Ï·ÎÔ‡ÓÙ·, ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ·ÈÌÔÔÈËÙÈÎÒÓ ·Ú¯¤ÁÔÓˆÓ Î˘ÙÙ¿ÚˆÓ. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ Û ÔÏÏ¿ ¿ÏÏ· fiÚÁ·Ó· Â›Ó·È ¯·ÌËÏfiÙÂÚË ‹ ·Ó‡·ÚÎÙË. ∏ ƒ-170 ‚Ú›ÛÎÂÙ·È ÛÙË ÌÂÌ‚Ú¿ÓË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÏÂÈÙÔ˘ÚÁ› Û·Ó ·ÓÙÏ›·, Ô˘ ÚÔÛٷهÂÈ Ù· ·ÙÙ·Ú· ·fi ‰È¿ÊÔÚ˜ ÙÔÍÈΤ˜ Ô˘Û›Â˜, .¯. Ê¿Ú̷η, ÚÔ˚fiÓÙ· ·ÏηÏÔÂȉÒÓ Î.¿. ™Ù· Ê˘ÛÈÔÏÔÁÈο ÂÈÓÂÊÚ›‰È· ‚Ú›ÛÎÂÙ·È ÛÙȘ ΢ÙÙ·ÚÈΤ˜

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ÌÂÌ‚Ú¿Ó˜ Î·È ‰Ú· Û·Ó ÂÓ‰Ô΢ÙÙ·ÚÈÎfi˜ ÌÂÙ·ÊÔÚ¤·˜ ÁÈ· ÂȉÈο ÚÔ˚fiÓÙ·, .¯. ÛÙÂÚÔÂȉ‹. ∂›Û˘, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË MDR ÁÔÓȉ›ˆÓ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÁ΢ÌÔÛ‡ÓË. O Ê˘ÛÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ Ù˘ ÁÏ˘ÎÔÚˆÙ½Ó˘ ƒ-170 ÂÓÙ›ÓÂÙ·È Û ·ÙÙ·Ú· ÔÚÁ¿ÓˆÓ Ì ÂÓ‰ÔÎÚÈÓ‹ Î·È Â͈ÎÚÈÓ‹ ÌÔ›Ú·, .¯. ¯ÔÏ‹, ÂÁÁ‡˜ ÛˆÏËÓ¿ÚÈ· ÓÂÊÚÒÓ, ÂÈÓÂÊÚ›‰È· Î.¿. ∆¤ÏÔ˜, ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ ƒ-170 ·ÓȯÓ‡ÔÓÙ·È ÛÙ· 2/3 ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (µ Î·È ∆) Î·È ÌÔÓÔ΢ÙÙ¿ÚˆÓ Î·È ÂÚ›Ô˘ ÛÙÔ 1/3 ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ (10). ™Â ÌÂÙ·ÏÏ¿ÍÂȘ ‹ Û ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘ ÛÙÔ Î·ÎfiËı˜ ·ÙÙ·ÚÔ, Ë ·Ú·ÁˆÁ‹ Ù˘ ƒ-170 ÚˆÙ½Ó˘ ·˘Í¿ÓÂÙ·È. ∂Ô̤ӈ˜, ÛÙȘ ÂÚÈÙÒÛÂȘ ηÎÔËıÂÈÒÓ, Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ170 Èı·Ó¿ ÈÛ¯˘ÚÔÔÈ› Ù· ·ÙÙ·Ú· ¤Ó·ÓÙÈ Ù˘ ¯ËÌÂÈÔıÂÚ·›·˜ (ê£), ÚÔÛ‰›‰ÂÈ ÌÂÁ·Ï‡ÙÂÚË ·ÓÙÔ¯‹ ÛÙ· ¯ËÌÂÈÔıÂÚ·¢ÙÈο Ê¿Ú̷η Î·È ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ ·Ú·ÙËÚÂ›Ù·È fi¯È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ʿÚ̷η Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜, ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ÌË Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÙÂÙÚ·¯ÏˆÚ›‰ÈÔ ÙÔ˘ ¿Óıڷη, ÌÂÙ¿ ·fi

Paediatriki 2003;66:65-81

ËÏÂÎÙÚÔÛfiÎ ‹ Â›‰Ú·ÛË ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡ stress (10-13). ∞fi ÔÏϤ˜ ‰ÈÂıÓ›˜ ÌÂϤÙ˜ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Ë ·Ó¿Ù˘ÍË, ̤ۈ ‚ÈÔ¯ËÌÈÎÒÓ Ì˯·ÓÈÛÌÒÓ, ·ÓÙ›ÛÙ·Û˘ ‹ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›ÛÙ·Û˘ ÙˆÓ Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ΢ÙÙ·ÚÔÛÙ·ÙÈο Ê¿Ú̷η, fiˆ˜ .¯. ÛÙ· ·ÏηÏÔÂȉ‹ ·Ú¿ÁˆÁ· Ù˘ Vinca Rosea ‹ ÛÙ· ·Ú¿ÁˆÁ· Ù˘ ÂÈÔ‰ÔÊ˘ÏÏÔÙÔ͛Ӣ. ∆· ΢ÙÙ·ÚÔÛÙ·ÙÈο ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÌÂٷ͇ ÙˆÓ ‚·ÛÈÎÒÓ ·ÓÙÈÏ¢¯·ÈÌÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Ë ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÚÔ˜ ·˘Ù¿ ıˆÚÂ›Ù·È ˆ˜ ‚·ÛÈ΋ ·ÈÙ›· ˘ÔÙÚÔ‹˜, ÂȉÈÎfiÙÂÚ· ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ Î·ÎÔËıÂÈÒÓ (13,14). ªÂ ‚¿ÛË ÏÔÈfiÓ ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ MDR, Ù· ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈο Ê¿Ú̷η ¤¯Ô˘Ó ¯ˆÚÈÛÙ› Û ‰‡Ô ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·Ó Û¯ÂÙ›˙ÔÓÙ·È ‹ fi¯È Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜. ™˘ÁÎÂÎÚÈ̤ӷ: ·) ™Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Ê¿Ú̷η (˘‰ÚfiÊÔ‚·) ÂÓÙ¿ÛÛÔÓÙ·È ÔÈ ·Óıڷ΢ÎϛӘ, Ù· ·ÏηÏÔÂȉ‹ Ù˘ Vinca, ÔÈ ÂÈÔ‰ÔÊ˘ÏÏÔÙÔ͛Ә Î·È ÔÈ Ù·Í¿Ó˜. ‚) ™Ù· ÌË Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Ê¿Ú̷η (˘‰ÚfiÊÈÏ·) ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜,

∂ÈÎfiÓ· 1·. ∞ÏÁfiÚÈıÌÔ˜ 49 ·ÛıÂÓÒÓ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È 8 ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹.

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ÔÈ ·ÓÙÈÌÂÙ·‚Ôϛ٘, Ù· ·Ú¿ÁˆÁ· Ï·Ù›Ó·˜ Î·È Ë ÚÔηڂ·˙›ÓË (14). ∏ ¤Ú¢ӷ Û‹ÌÂÚ·, ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο, Û˘Ó¯›˙ÂÙ·È ÂÓÙ·ÙÈο, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌ‹ÛÂÈ ÙȘ Û˘Ó¤ÂȘ ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂÈ¤‰ˆÓ Ù˘ ƒ-170 Û ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ηÎÔ‹ıˆÓ ÓÔÛËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÓËϛΈÓ. °È· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ, ÔÈ Ôԛ˜ ÌÂÙÚÔ‡Ó Â›Ù ÙËÓ ¤ÎÊÚ·ÛË ÙˆÓ ÁÔÓȉ›ˆÓ MDR (ÔÈÔÙÈÎfi˜ ¤ÏÂÁ¯Ô˜) ‹ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ (ÔÛÔÙÈÎfi˜ ¤ÏÂÁ¯Ô˜) (9,11,13, 14). ∆¤ÙÔȘ ̤ıÔ‰ÔÈ Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜: i) ∏ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ ÁÔÓȉ›ˆÓ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ Û Â›Â‰Ô RNA (Northern blot, RT-PCR) Î·È Ô In situ ˘‚ÚȉÈÛÌfi˜. OÈ Ì¤ıÔ‰ÔÈ ·˘Ù¤˜, ·Ú’ fiÙÈ Â›Ó·È Â˘·›ÛıËÙ˜, ‰ÂÓ ·ÓȯÓÂ‡Ô˘Ó ÙË ‰˘ÓËÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ›Ûˆ˜ ÂËÚ¿˙ÔÓÙ·È ·fi ·Ó¿ÌÂÈÍË ÌË Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ ÛÙÔÓ ˘fi ¤ÏÂÁ¯Ô Ï¢¯·ÈÌÈÎfi ÏËı˘ÛÌfi. ii) §ÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜. OÈ ‰ÔÎÈ̷ۛ˜ ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙË Ì¤ÙÚËÛË Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‹ Ù˘ ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÔÚÈÛÌ¤ÓˆÓ ÂÓ˙‡ÌˆÓ ‹, Ù¤ÏÔ˜, ÛÙË ‰Ú¿ÛË ÔÚÈÛÌ¤ÓˆÓ Ô˘ÛÈÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÙÚÔÔÔÈËÙ¤˜ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜. ∂›Û˘, Ë Î˘ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Ì ÙË ¯Ú‹ÛË ÊıÔÚȈ̤Ó˘ ¯ÚˆÛÙÈ΋˜ (dye rhodamine 123) ¯ÚË-

Paediatriki 2003;66:65-81

ÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·Ú·ÁfiÓÙˆÓ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ( ƒ-170, MRP). £· Ú¤ÂÈ Â‰Ò Ó· ÙÔÓÈÛÙ› fiÙÈ ÔÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Û˘¯Ó¿ ÌÂÙÚÔ‡Ó ÙÔ ·ÔÙ¤ÏÂÛÌ· ÔÏÏ·ÏÒÓ Ì˯·ÓÈÛÌÒÓ ·Ó¿Ù˘Í˘ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ MDR ÙˆÓ Î˘ÙÙ¿ÚˆÓ (.¯. Ë rhodamine 123 ·Ó·ÁÓˆÚ›˙ÂÙ·È ˆ˜ ÌÂÙ·ÊÂÚfiÌÂÓË ·fi ‰‡Ô ÚˆÙ½Ó˜, ÙËÓ ƒ-170 Î·È ÙËÓ MRP) Î·È fi¯È ÌÂÌÔӈ̤ӷ. ™ÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË, ·ÓÙ›ıÂÙ·, ÔÈ Ì¤ıÔ‰ÔÈ ·Ó›¯Ó¢Û˘ ÚˆÙÂ˚ÓÒÓ Ì¤Ûˆ Ù˘ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜ Â›Ó·È ·ÏÔ‡ÛÙÂÚ˜, ¢ÎÔÏfiÙÂÚ˜ Î·È Ù·¯‡ÙÂÚ˜. °È’ ·˘ÙÔ‡˜ ÙÔ˘˜ ÏfiÁÔ˘˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂÈϤ¯ıËÎÂ Ë ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›· ˆ˜ ̤ıÔ‰Ô˜ ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË Ù˘ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙ· Ï¢¯·ÈÌÈο ·ÙÙ·Ú·. iii) ∏ ·Ó›¯Ó¢ÛË ÙˆÓ ·Ú·ÁfiÌÂÓˆÓ ÚˆÙÂ˚ÓÒÓ Û ÌÔÚÈ·Îfi Â›Â‰Ô (Western blot). °È· ÙȘ ÌÂıfi‰Ô˘˜ ·˘Ù¤˜ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Ìʈӛ· ÁÈ· ÙÔ ÔÈÔ Â›Â‰Ô ıÂÙÈÎfiÙËÙ·˜ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ MDR Ê·ÈÓfiÙ˘Ô˘. ™Â Â›Â‰Ô ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜, Ù· ·ÔÙÂϤÛÌ·Ù· ÂÍ·ÚÙÒÓÙ·È ·fi: ·) ÙÔ Â›‰Ô˜ ÙÔ˘ ·ÓÙÈÛÒÌ·ÙÔ˜, ‚) ÙË ‰È·‰Èηۛ· ÌÔÓÈÌÔÔ›ËÛ˘ Î·È Á) Ù· Â›‰· ıÂÙÈ΋˜ ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ. ™‹ÌÂÚ·, ¤¯Ô˘Ì ÛÙË ‰È¿ıÂÛ‹ Ì·˜ ‰È¿ÊÔÚ· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÚˆÙÂ˚ÓÒÓ Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜. ∂ȉÈÎfiÙÂÚ· ÁÈ· ÙËÓ ϤÔÓ ÁÓˆÛÙ‹ ÚˆÙ½ÓË, ÙËÓ ƒ-170, ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ÂÈ̤ÚÔ˘˜ ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·

∂ÈÎfiÓ· 1‚. ∞ÏÁfiÚÈıÌÔ˜ 8 ·ÛıÂÓÒÓ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È 5 ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹.

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¶›Ó·Î·˜ 1. ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂϤÁ¯ıËÎ·Ó Û ·È‰È¿ Ì O§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘

º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÛÙÔ ·›Ì· ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB

∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË

ŒÎÊÚ·ÛË Ù˘ P-170

∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË ≤100 x 109/L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ / (Common) T-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ∞¤Ù˘¯·Ó ¢ÂÓ ¤ÁÈÓ £ÂÙÈ΋ ∞ÚÓËÙÈ΋

Ô˘ ÙËÓ ·ÓȯÓ‡ԢÓ. ∞fi ·˘Ù¿, ¿ÏÏ· ·ÓȯÓÂ‡Ô˘Ó ÂÈÊ·ÓÂÈ·ÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘, fiˆ˜ Ù· ªR∫16, ªR∫-17, VIC2, 4E2 (Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· ¤¯Ô˘Ó ÌÂÁ¿ÏË ÂȉÈÎfiÙËÙ·), ÂÓÒ ¿ÏÏ· ·ÓȯÓÂ‡Ô˘Ó Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘, fiˆ˜ ÙÔ JSB-1 (¤¯ÂÈ ÌÂÁ¿ÏË ÂȉÈÎfiÙËÙ·), ÙÔ C219 Î·È ÙÔ C494 (12,15). °È· ÙËÓ ·‡ÍËÛË Ù˘ ¢·ÈÛıËÛ›·˜ Î·È Ù˘ ÂȉÈÎfiÙËÙ·˜ Ù˘ ÌÂıfi‰Ô˘ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·ÓÙÈÛÒÌ·Ù· Ô˘ ·Ó·ÁÓˆÚ›˙Ô˘Ó ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘ ƒ-170 ÚˆÙ½Ó˘. ∆· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· JSB-1, C219 Î·È MPK16 Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂٷ͇ ÙˆÓ ÂÈÎÚ·Ù¤ÛÙÂÚˆÓ ÁÈ· ÙËÓ ·Ó›¯ÓÂ˘Û‹ Ù˘ (16-18). ∆Ô ÚÒÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ô˘ ÌÂÏÂÙ‹ıËΠ‹Ù·Ó ÙÔ C219, ¤Ó· IgG-2a ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ Î˘ÙÙ¿ÚˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙË doxorubicine, ‚ÈÓÎÚÈÛÙ›ÓË Î.¿. ∞Ó·ÁÓˆÚ›˙ÂÈ ¤Ó· ÌÈÎÚfi ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Â›ÙÔÔ ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∞ÓÙȉڿ Î·È Ì ٷ ‰‡Ô ÚˆÙÂ˚ÓÈο ·Ú¿ÁˆÁ· MDR-1 Î·È MDR-2, ¯ˆÚ›˜ Ó· Â›Ó·È ÂȉÈÎfi ÁÈ· οÔÈÔ ·fi Ù· ‰‡Ô. ∆Ô ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ JSB-1 Â›Ó·È ¤Ó· IgG-1 ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·ÓÙÈ ·ÓıÂÎÙÈÎÒÓ ÛÙËÓ ÎÔϯÈΛÓË Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·ÁÓˆÚ›˙ÂÈ ¤Ó· ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Â›ÙÔÔ Ù˘ ƒ-170, ÙfiÛÔ Û ·ÓıÚÒÈÓ· ·ÙÙ·Ú·, fiÛÔ Î·È Û ηÎÔ‹ıË Î‡ÙÙ·Ú· ÂÈÚ·Ì·Ùfi˙ˆˆÓ.

OÈ Tsuruo Î·È Û˘Ó ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÛÙË ÌÂϤÙË ÙÔ˘˜ ÙÔ ªP∫16, ·ÓıÚÒÈÓÔ ÂȉÈÎfi ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ì ÌÂÁ¿ÏË ¯ËÌÈ΋ Û˘ÁÁ¤ÓÂÈ· ÁÈ· ÙÔ MDR1 (16). ∂›Ó·È ¤Ó· ·Óٛۈ̷ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ¤Ó·-

72

O§§ ‰È¿ÁÓˆÛË

O§§ ˘ÔÙÚÔ‹

29 (59,1%) 20 (40,8%) 31 (63,3%) 18 (36,7%) 37 (75,5%) 12 (24,5%) 46 (93,8%) 3 (6,2%) 44 (89,8%) 5 (10,2%) 35 (71,4%) 12 (24,5%) 2 (4,1%) 44 (89,8%) / (35) (71,5%) 5 (10,2%) 18 (36,7%) 4 (8,1%) 3 (6,2%) 9 (18,4%) 15 (30,6%) 18 (36,7%) 39 (63,3%)

6 (75%) 2 (25%) 0 (0%) 8 (100%) 6 (75%) 2 (25%) 8 (100%) 0 (0%) 7 (87,5%) 1 (12,5%) 6 (75%) 2 (25%) 0 (0%) 7 (87,5%) / (6) (75%) 1 (12,5%) 2 (25%) 2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 5 (62,5%) 3 (37,5%)

ÓÙÈ ·ÓıÂÎÙÈÎÒÓ Û doxorubicine ·ÓıÚÒÈÓˆÓ Ï¢¯·ÈÌÈÎÒÓ Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·ÁÓˆÚ›˙ÂÈ ¤Ó·Ó Â͈ÙÂÚÈÎfi ÂÈÊ·ÓÂÈ·Îfi Â›ÙÔÔ. ∞ÓÙ›ıÂÙ· Ì ÙÔ C219, ‰ÂÓ ·ÓÙȉڿ Ì ÙÔ ÚˆÙÂ˚ÓÈÎfi ·Ú¿ÁˆÁÔ ÙÔ˘ MDR-2. ™ÎÔfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛÂ: ·) Ë ·Ó·˙‹ÙËÛË Ù˘¯fiÓ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂÚ·›·, ̤ۈ Ù˘ ·Ó‡ÚÂÛ˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ÚˆÙ½Ó˘ ƒ-170 Ì ÌÂıfi‰Ô˘˜ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜ Û ÛÂÈÚ¿ Ó¤ˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ì O§§ Î·È Oª§§ ÛÙË Ê¿ÛË Ù˘ ·Ú¯È΋˜ ‰È¿ÁÓˆÛ˘ ‹ Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ Î·È ‚) Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ì ÙËÓ ·ÓÙ·fiÎÚÈÛË ÛÙË ¯ËÌÂÈÔıÂÚ·›· Î·È ÙËÓ ¤Î‚·ÛË ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ÚÔÔÙÈ΋˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 67 ·ÛıÂÓ›˜ Ì ÔÍ›· Ï¢¯·ÈÌ›·, 38 ·ÁfiÚÈ· Î·È 29 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 14 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 6 ¤ÙË), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÛÙÔ ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1/1/1996 ¤ˆ˜ 31/7/1999. ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ÌÂÏÂÙ‹ıËÎ·Ó 57 ·ÛıÂÓ›˜ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Î·È 13 Ì ÔÍ›· ÌË ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (Oª§§). ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§, 49 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË Î·È 8 ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔ›·Û·Ó, 3 ·Ó‹Î·Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ 49 ·ÛıÂÓÒÓ, ÂÓÒ 5 ·Ï·ÈfiÙÂÚÔÈ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘, ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (Û‡ÓÔÏÔ ·ÛıÂÓÒÓ ÔÌ¿‰·˜ O§§ Û ˘ÔÙÚÔ‹: 8). OÈ ‰‡Ô ÔÌ¿‰Â˜

JAN-FEB-03

14-05-03

14:37

™ÂÏ›‰·73

¶·È‰È·ÙÚÈ΋ 2003;66:65-81

Paediatriki 2003;66:65-81

¶›Ó·Î·˜ 2. ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂϤÁ¯ıËÎ·Ó Û ·È‰È¿ Ì OM§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘

º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ FAB

∫·Ú˘fiÙ˘Ô˜

∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· MR HR M1 M2 M3 M5 M7 º˘ÛÈÔÏÔÁÈÎfi˜ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ¢ÂÓ ¤ÁÈÓÂ

ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ (‰È¿ÁÓˆÛ˘-˘ÔÙÚÔ‹˜), Ë ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1·. ∞ÓÙ›ÛÙÔȯ·, ·ÛıÂÓ›˜ Ì OM§§, 8 ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ ÛÙËÓ ÔÌ¿‰· Ù˘ ˘ÔÙÚÔ‹˜ ÂÚÈÏ‹ÊıËÛ·Ó 2/8 Ô˘ ˘ÔÙÚÔ›·Û·Ó Î·È ÔÈ 3 ·Ï·ÈfiÙÂÚÔÈ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ Î·Ù¿ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ (Û‡ÓÔÏÔ ·ÛıÂÓÒÓ ÔÌ¿‰·˜ OM§§ Û ˘ÔÙÚÔ‹: 5). OÈ ‰‡Ô ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ (‰È¿ÁÓˆÛ˘-˘ÔÙÚÔ‹˜), Ë ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ê·›ÓÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1‚. ∏ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙËÚ›¯ıËΠÛÙÔÓ ÌÔÚÊÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ÙˆÓ Ì˘ÂÏÈÎÒÓ ÂȯÚÈÛÌ¿ÙˆÓ, ÙËÓ Î·Ù¿ FAB Ù·ÍÈÓfiÌËÛË Î·È ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ Î·È Î˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ.

OÈ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Î·È OM§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 1 Î·È 2, ·ÓÙ›ÛÙÔȯ·.

OÈ ·ÛıÂÓ›˜ Ì O§§ ¤Ï·‚·Ó ÔÌÔÈÔÁÂÓÒ˜ ÙÔ °ÂÚÌ·ÓÈÎfi ™˘ÓÂÚÁ·ÙÈÎfi £ÂÚ·¢ÙÈÎfi ¶ÚˆÙfiÎÔÏÏÔ ALL-BFM ’95 Î·È ‰È·¯ˆÚ›ÛÙËÎ·Ó Û ÔÌ¿‰Â˜: ·) ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (MR) (31) Î·È ‚) ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (HR) (25). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ÂÊ·ÚÌfiÛÙËΠÔÌÔÈÔÁÂÓÒ˜ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ™˘ÓÂÚÁ·ÙÈÎfi °ÂÚÌ·ÓÈÎfi £ÂÚ·¢ÙÈÎfi ¶ÚˆÙfiÎÔÏÏÔ AML-BFM ’93.

O ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ·fi ÙË ‰È¿ÁÓˆÛË Î˘Ì·›ÓÂÙ·È ·fi 6 Ì‹Ó˜ ¤ˆ˜ 3,5 ¯ÚfiÓÈ· (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 24 Ì‹Ó˜), ÂÓÒ ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ ·fi 5 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 18 Ì‹Ó˜). O ‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜ ˘ÔÙÚÔ‹˜ ·fi ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 19 Ì‹Ó˜ ÁÈ· ÙËÓ ÔÌ¿‰· Ù˘ O§§ Î·È 26 Ì‹Ó˜ ÁÈ· ÙËÓ ÔÌ¿‰· Ù˘ OM§§. O ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ˘ÔÙÚÔ‹ Î˘Ì·›ÓÂÙ·È ·fi 2 ¤ˆ˜ 27 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 28,5 Ì‹Ó˜) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Î·È ·fi 11 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì OM§§. ø˜ Ì¿ÚÙ˘Ú˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó 13 ·È‰È¿ Ì ¿ÏÏ· ηÏÔ‹ıË ‹ ÌË ·ÈÌ·ÙÔÏÔÁÈο ηÎÔ‹ıË ÓÔÛ‹Ì·Ù·, ÛÙ· ÔÔ›· ˘‹Ú¯Â ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (ªO). ∞Ó·Ï˘ÙÈÎfiÙÂ-

OM§§ ‰È¿ÁÓˆÛË

OM§§ ˘ÔÙÚÔ‹

4 (50%) 4 (50%) 3 (37,5%) 5 (62,5%) 2 (25%) 3 (37,5%) 1 (12,5%) 1 (12,5%) 1 (12,5%) 2 (25%) 1 (12,5%) 1 (12,5%) 4 (50%)

5 (100%) 0 (0%) 0 (0%) 5 (100%) 2 (40%) 2 (40%) 1 (20%) 0 (0%) 0 (0%) 2 (40%) 1 (20%) 1 (20%) 1 (20%)

Ú·, 3 ·ÛıÂÓ›˜ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È Ì˘ÂÏÈ΋ ‰È‹ıËÛË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ıÂÙÈÎÔ› Ì¿ÚÙ˘Ú˜, ÂÓÒ 3 ·ÛıÂÓ›˜ Ì ˘ÔÏ·ÛÙÈ΋ ·Ó·ÈÌ›·, 2 Ì ·Ó·ÈÌ›· Fanconi, 2 Ì ȉÈÔ·ı‹ ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ Î·È 3 Ì Ԣ‰ÂÙÂÚÔÂÓ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ·ÚÓËÙÈÎÔ› Ì¿ÚÙ˘Ú˜. ∂ÈϤÔÓ, ˆ˜ ıÂÙÈο ‰Â›ÁÌ·Ù· ·Ó·ÊÔÚ¿˜ (controls) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Î˘ÙÙ·ÚÈο ÂȯڛÛÌ·Ù· ·fi Ê˘ÛÈÔÏÔÁÈÎfi ‹·Ú, ÂÓÒ ˆ˜ ·ÚÓËÙÈο ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰Â›ÁÌ·Ù· Ì˘ÂÏÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·ÛıÂÓÒÓ, ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛÙËΠ∞ƒ∞∞ƒ: ·) ¯ˆÚ›˜ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ·Óٛۈ̷ ‹ ‚) Ì ·Óٛۈ̷ ÌË ‰È·ÛÙ·˘ÚÔ‡ÌÂÓÔ Ì ÙË Ï¢΋ ÛÂÈÚ¿ (·Óٛۈ̷ ¤Ó·ÓÙÈ Ù˘ ΢ÙÙ·ÚÔÎÂÚ·Ù›Ó˘ Î·È Ù˘ ‰ÂÛÌ›Ó˘). ∏ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÌÂÏÂÙ‹ıËΠ̠ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘-·ÓÙÈ-·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (∞ƒ∞∞ƒ) (16,18) Û ΢ÙÙ·ÚÈο ÂȯڛÛÌ·Ù· (cytospins) ·fi Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ, ̤ۈ ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ: JSB-1, (YLEM, code: MCF 404), C219 (Centocor WH29) Î·È MRK16 (KAMIYA BIOMEDICAL, MC-012). ∞fi οı ·ÛıÂÓ‹ ÌÂÏÂÙ‹ıËÎ·Ó 3 ‰Â›ÁÌ·Ù· ÁÈ· οı ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷, ·Ó¿ Ê¿ÛË Ù˘ ÓfiÛÔ˘ (‰È¿ÁÓˆÛË-˘ÔÙÚÔ‹). ∏ Ù¯ÓÈ΋ ·˘Ù‹ Â›Ó·È ·ÍÈfiÈÛÙË, Ù·¯Â›· Î·È ÔÈÎÔÓÔÌÈ΋ ˆ˜ ̤ıÔ‰Ô˜ ÚÔ˘Ù›Ó·˜ ÁÈ· ¤Ó· ·ÈÌ·ÙÔÏÔÁÈÎfi ÂÚÁ·ÛÙ‹ÚÈÔ. µÈ‚ÏÈÔÁÚ·ÊÈο ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË ÁÈ· ‰Â›ÁÌ·Ù· Ì ÌÈÎÚfi Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ΢ÙÙ¿ÚˆÓ (<105), Ù· ÔÔ›· Â›Ó·È ‰‡ÛÎÔÏÔ ‹ ·‰‡Ó·ÙÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó Ì ¿ÏϘ ÌÂıfi‰Ô˘˜. ∆Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ Â›Ó·È fiÙÈ ÌÔÚ› Ó· ‰È·ÎÚ›ÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û ÌÂÌÔӈ̤ÓÔ˘˜ ¢‰È¿ÎÚÈÙÔ˘˜ ÌÔÚÊÔÏÔÁÈο ÏËı˘ÛÌÔ‡˜. ¶·Ú¿ÏÏËÏ·, Ù· ÂȯڛÛÌ·Ù· ÌÂÏÂÙ‹ıËÎ·Ó Î·È Ì ¯ÚÒÛË Giemsa. ∏ ̤ıÔ‰Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÂÍ‹˜ ÛÙ¿‰È·: i) ™Â ‰Â›ÁÌ· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Á›ÓÂÙ·È ‰È·¯ˆÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì Ficoll-Hypaque (density 1.077, Seromed), Ê˘ÁÔΤÓÙÚËÛË Û 1800 ÛÙÚÔʤ˜ ÁÈ· 20 ÏÂÙ¿, Ì ÛÎÔfi ÙÂÏÈ΋ Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÌÔÓÔ‡ÚËÓˆÓ Î˘ÙÙ¿ÚˆÓ 10x106 ·ÙÙ·Ú·/ÌL. ii) ª¤ÚÔ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ Ê˘ÁÔÎÂÓÙÚÂ›Ù·È ÂÎ Ó¤Ô˘ ÛÙË Ê˘ÁfiÎÂÓÙÚÔ Cytospin (Shandon) Û 400 ÛÙÚÔʤ˜ ÁÈ· 3 ÏÂÙ¿, Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ΢ÙÙ·ÚÈÎÒÓ ÂȯÚÈÛÌ¿ÙˆÓ

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∂È‚›ˆÛË

JAN-FEB-03

∂ÈÎfiÓ· 2. £ÂÙÈ΋ ÂÈÊ·ÓÂȷ΋ ¤ÎÊÚ·ÛË Ù˘ P-170.

¶·Ú·ÎÔÏÔ‡ıËÛË (Ì‹Ó˜) ∂ÈÎfiÓ· 4. ∫·Ì‡ÏË ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ì O§§.

∂ÈÎfiÓ· 3. πÛ¯˘Ú¿ ıÂÙÈ΋ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÌÂÌ‚Ú·ÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ P-170. Ì ÙË ÌÔÚÊ‹ cytospin, Ù· ÔÔ›· ·ÔÍËÚ·›ÓÔÓÙ·È ÛÙÔÓ ·ÙÌÔÛÊ·ÈÚÈÎfi ·¤Ú· ÁÈ· 3 ÒÚ˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÌÔÓÈÌÔÔÈÔ‡ÓÙ·È Û Ì›ÁÌ· ·ÎÂÙfiÓ˘-ÌÂı·ÓfiÏ˘ 1:1 ÁÈ· 90’’ Û ıÂÚÌÔÎÚ·Û›· ‰ˆÌ·Ù›Ô˘. ∫·ÙfiÈÓ, ÌÂٷʤÚÔÓÙ·È Û buffer TBS (tris-buffersaline), Ô˘ Â›Ó·È 1/10 ‰È·Ï‡Ì·ÙÔ˜ 0.5 ª Tris -HCL Ì p∏ 6 Û 0.15 ª Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ÁÈ· 5 ÚÒÙ· ÏÂÙ¿. iii) ™ÙË Û˘Ó¤¯ÂÈ·, Ù· ‰Â›ÁÌ·Ù· ÙÔÔıÂÙÔ‡ÓÙ·È ÛÙÔ˘˜ Ï·ÛÙÈÎÔ‡˜ ı·Ï·ÌÔ‡˜-coverplates ÙÔ˘ Ì˯·Ó‹Ì·ÙÔ˜ Sequenza Ù˘ ÂÙ·ÈÚ›·˜ Shandon Î·È Âˆ¿˙ÔÓÙ·È Ì 0,20 ml ‰È·Ï‡Ì·ÙÔ˜ ÚˆÙÔÁÂÓÔ‡˜ ·ÓÙÈÛÒÌ·ÙÔ˜ anti-P glycoprotein 170 Ì buffer TBS Û ·Ú·›ˆÛË 1:30, Û ˘ÁÚfi ı¿Ï·ÌÔ ÁÈ· 30 ÚÒÙ· ÏÂÙ¿. iv) ∆· ‰Â›ÁÌ·Ù· ÍÂϤÓÔÓÙ·È ÙÚÂȘ ÊÔÚ¤˜ (6 ÏÂÙ¿) Ì buffer TBS Î·È ÛÙË Û˘Ó¤¯ÂÈ· Âˆ¿˙ÔÓÙ·È Ì 0,20 ml ¤ÙÔÈÌÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ÔÏ˘‰‡Ó·ÌÔ˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ·ÓÙÈÛÒÌ·ÙÔ˜ goat anti-mouse ÁÈ· 10 ÚÒÙ· ÏÂÙ¿. v) ªÂÙ¿ ·fi Ó¤Ô Í¤Ï˘Ì·, Âˆ¿˙ÔÓÙ·È Ì 0,20 ml ·ÓÔÛÔÛ˘ÌϤÁÌ·ÙÔ˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ÁÈ· 10 ÚÒÙ· ÏÂÙ¿. vi) ∞ÊÔ‡ ÍÂÏ˘ıÔ‡Ó ÂÎ Ó¤Ô˘ ÁÈ· 6 ÚÒÙ· ÏÂÙ¿, Âˆ¿˙ÔÓÙ·È Ì 0,25 ml ¯ÚˆÌÔÁfiÓÔ˘ ÁÈ· 20 ÏÂÙ¿. vii) •ÂϤÓÔÓÙ·È ¿ÏÈ ÁÈ· 6 ÚÒÙ· ÏÂÙ¿ Î·È ÂÓ Û˘Ó¯›·

74

Ù· ‰Â›ÁÌ·Ù· ‚¿ÊÔÓÙ·È Ì 0,25 ml ·ÈÌ·ÙÔÍ˘Ï›Ó˘ Mayer’s (LIPSHAW IMMUNON, No 407050). viii) ∆¤ÏÔ˜, ·ÊÔ‡ ÍÂÏ˘ıÔ‡Ó Ì ·oÛÙ·Á̤Óo ÓÂÚfi, ÙÔÔıÂÙÂ›Ù·È Â› ÙÔ˘ ˘ÏÈÎÔ‡ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÂÈÎ·Ï˘ÙÚ›‰·, Ô˘ Û˘ÁÎÔÏÏ¿Ù·È Ì ‰È·Ê·Ó¤˜ ˘ÏÈÎfi. ∆· ‰Â›ÁÌ·Ù· ÌÂÏÂÙ‹ıËÎ·Ó Û ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ ·fi ‰‡Ô ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÌÂÏÂÙËÙ¤˜, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ÁÓÒÚÈ˙·Ó ÙË Ê¿ÛË ÂϤÁ¯Ô˘ Ù˘ ÓfiÛÔ˘. ™Â οı ‰Â›ÁÌ· ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ë ·Ó·ÏÔÁ›· ÙˆÓ ıÂÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ë ¤ÓÙ·ÛË Ù˘ ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘˜, ηıÒ˜ Î·È Ë ÌÔÚÊÔÏÔÁ›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì ¯ÚÒÛË Giemsa. ø˜ ıÂÙÈο ÛÙËÓ P-170 ÚˆÙ½ÓË Î‡ÙÙ·Ú· ıˆڋıËÎ·Ó ÂΛӷ Ô˘ ‚¿ÊÙËÎ·Ó ¤ÓÙÔÓ· ÎfiÎÎÈÓ· (∂ÈÎfiÓ· 2), ÂÓÒ ·ÚÓËÙÈο ÂΛӷ Ô˘ ‰ÂÓ ‚¿ÊÙËηÓ. ø˜ ıÂÙÈο ıˆڋıËÎ·Ó Ù· ‰Â›ÁÌ·Ù· ÛÙ· ÔÔ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ 1% ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÚÔÛÏ¿Ì‚·Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷. ™Â οıÂ Ì˘ÂÏÈÎfi Â›¯ÚÈÛÌ· ÂϤÁ¯ÔÓÙ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 1000 ·ÙÙ·Ú· ·fi ‰‡Ô ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·Ú·ÙËÚËÙ¤˜.

2 ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ¯ ÙÂÛÙ. ªÂÏÂÙ‹ıËÎÂ Ë Û˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ MDR Ê·ÈÓÔ̤ÓÔ˘ ̤ۈ Ù˘ ·Ó›¯Ó¢Û˘ Ù˘ ƒ-170 Ì ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ Î·È ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Ï¢¯·ÈÌ›· (ËÏÈΛ·, ʇÏÔ, ·ÚÈıÌfi˜ Ï¢ÎÒÓ, ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜, ηڢfiÙ˘Ô˜, ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘).

∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 49 ·È‰È¿ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, 3 ˘ÔÙÚÔ›·Û·Ó (Û ‰È¿ÛÙËÌ· 4, 17 Î·È 23 ÌËÓÒÓ ·fi ÙË ‰È¿ÁÓˆÛË, ·ÓÙ›ÛÙÔȯ·), 3 η٤ÏËÍ·Ó (2 ÚÒÈÌÔÈ ı¿Ó·ÙÔÈ) Î·È Ù· ˘fiÏÔÈ· 43 ‚Ú›ÛÎÔÓÙ·È Û Ï‹ÚË ÚÒÙË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 5 ¤ˆ˜ 46 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜

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¶›Ó·Î·˜ 3. ∞ÔÙÂϤÛÌ·Ù· ¤ÎÊÚ·Û˘ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹

O§§ ‰È¿ÁÓˆÛË O§§ ˘ÔÙÚÔ‹

JSB-1+

JSB-1-

C219+

C219-

MPK16+

MPK16-

15/49 30,6% 4/8 50%

34/49 69,4% 4/8 50%

12/49 24,5% 5/8 62,5%

37/49 75,5% 3/8 37,5%

11/49 22,5% 2/8 25%

38/49 77,5% 6/8 75%

¶›Ó·Î·˜ 4. ∞ÔÙÂϤÛÌ·Ù· ¤ÎÊÚ·Û˘ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹

Oª§§ ‰È¿ÁÓˆÛË Oª§§ ˘ÔÙÚÔ‹

JSB-1+

JSB-1-

C219+

C219-

MPK16+

MPK16-

5/8 62,5% 2/5 40%

3/8 37,5% 3/5 60%

5/8 62,5% 2/5 40%

3/8 37,5% 3/5 60%

4/8 50% 2/5 40%

4/8 50% 3/5 60%

¶›Ó·Î·˜ 5. ŒÎÊÚ·ÛË Ù˘ MDR ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜

O§§ ‰È¿ÁÓˆÛË O§§ ˘ÔÙÚÔ‹ Oª§§ ‰È¿ÁÓˆÛË Oª§§ ˘ÔÙÚÔ‹

MDR+

MDR-

18/49 (36,7%) 5/8 (62,5%)

31/49 (63,9%) 3/8 (37,5%)

5/8 (62,5%) 2/5 (40%)

3/8 (37,5%) 3/5 (60%)

¯ÚfiÓÔ˜: 26 Ì‹Ó˜). ∞fi Ù· 3 Ô˘ ˘ÔÙÚÔ›·Û·Ó, 2 η٤ÏËÍ·Ó Û 2 Î·È 3 Ì‹Ó˜ ·fi ÙËÓ ˘ÔÙÚÔ‹ ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÙÔ ÙÚ›ÙÔ ·Ú·Ì¤ÓÂÈ Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 10 Ì‹Ó˜ (∂ÈÎfiÓ· 1·). ∞fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ ÛÙËÓ ˘ÔÙÚÔ‹, 3 η٤ÏËÍ·Ó (1 ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜), ÂÓÒ ÔÈ ¿ÏÏÔÈ 2 ‚Ú›ÛÎÔÓÙ·È Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 19 ¤ˆ˜ 38 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 27 Ì‹Ó˜). ∏ ηÌ‡ÏË ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 4 (Kaplan-Meier cumulative event-free survival). ∞fi ÙÔ˘˜ 8 ·ÛıÂÓ›˜ Ì OM§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙË ‰È¿ÁÓˆÛË, 2 ˘ÔÙÚÔ›·Û·Ó (Û ‰È¿ÛÙËÌ· 12 Î·È 26 ÌËÓÒÓ ·fi ÙË ‰È¿ÁÓˆÛË, ·ÓÙ›ÛÙÔȯ·), 3 η٤ÏËÍ·Ó (2 ÚÒÈÌÔÈ ı¿Ó·ÙÔÈ) Î·È ÔÈ ˘fiÏÔÈÔÈ 3 ‚Ú›ÛÎÔÓÙ·È Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 16 ¤ˆ˜ 29 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜). OÈ 2 ·ÛıÂÓ›˜ Ô˘ ˘ÔÙÚÔ›·Û·Ó ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 16 Î·È 20 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ∆¤ÏÔ˜, Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÌfiÓÔ ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘, ‚Ú›ÛÎÔÓÙ·È Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 20 ¤ˆ˜ 36 Ì‹Ó˜ (‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜: 26 Ì‹Ó˜) (∂ÈÎfiÓ· 1‚). ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 210 ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ, ˘‹Ú¯·Ó Û˘ÓÔÏÈο 110 ıÂÙÈο ‰Â›ÁÌ·Ù· (52,3%).

∂ÓÓ¤· ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ıÂÙÈÎfiÙËÙ· Î·È ÛÙ· ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·. ∂› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ, Ù· ÔÛÔÛÙ¿ ıÂÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó 86,6% ÁÈ· ÙÔ JSB-1, 80% ÁÈ· ÙÔ C219 Î·È 63,3% ÁÈ· ÙÔ MRK16. ∆Ô ÔÛÔÛÙfi ıÂÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙ· ‰Â›ÁÌ·Ù¿ Ì·˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 11% ¤ˆ˜ 82%. ∏ ¤ÓÙ·ÛË Ù˘ ıÂÙÈÎfiÙËÙ·˜ ‰È·ÎÚ›ıËΠ۠‹È·, ̤ÙÚÈ· Î·È ¤ÓÙÔÓË. ∂›¯·Ì ¤ÓÙÔÓË ÂÚ˘ıÚ‹ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÌÂÌ‚Ú·ÓÈ΋ ·ÓÙ›‰Ú·ÛË (∂ÈÎfiÓ· 3) Ì ٷ JSB-1 Î·È C219, ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· Ô˘, fiˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, ·ÓȯÓÂ‡Ô˘Ó Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÔ‡˜ ÂÈÙfiÔ˘˜ Ù˘ ƒ-170 Î·È ¤ÓÙÔÓË ÂÚ˘ıÚ‹ ÂÈÊ·ÓÂȷ΋ ÌÂÌ‚Ú·ÓÈ΋ ·ÓÙ›‰Ú·ÛË Ì ªR∫16 ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ô˘, fiˆ˜ Â›Û˘ ¤¯ÂÈ ·Ó·ÊÂÚı›, ·ÓȯÓ‡ÂÈ ÂÈÊ·ÓÂÈ·Îfi Â›ÙÔÔ Ù˘ ƒ-170. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤ÎÊÚ·Û˘ οı ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Î·È Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 3 Î·È 4, ·ÓÙ›ÛÙÔȯ·. ™Â 18/49 (36,7%) ·ÛıÂÓ›˜ Ì O§§ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ Û 5/8 (62,5%) ÛÙËÓ ˘ÔÙÚÔ‹ (¶›Ó·Î·˜ 5). ™Â 5/8 (62,5%) ·ÛıÂÓ›˜ Ì Oª§§ ‚Ú¤ıËΠ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙË ‰È¿ÁÓˆÛË, ÂÓÒ Û 2/5 (40%) ÛÙËÓ ˘ÔÙÚÔ‹ (¶›Ó·Î·˜ 5). ™ÙË ‰È¿ÁÓˆÛË: ·) ·fi ÙÔ˘˜ 18 ·ÛıÂÓ›˜ Ì O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (11,1%) ·‚›ˆÛ·Ó (1 ÛÙËÓ ¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹), ÂÓÒ 16 (88,9%) ÂÈÛ‹¯ıËÛ·Ó Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË, ‚) ·fi ÙÔ˘˜ 31 ·ÛıÂÓ›˜ Ì O§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 1 (3,6%) ˘ÔÙÚÔ›·ÛÂ, 3 (9,7%) η٤ÏËÍ·Ó (1 ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜) Î·È 27 (87,1%) ÂÈÛ‹¯ıËÛ·Ó Û ÚÒÙË Ï‹ÚË ‡ÊÂÛË, Á) ·fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (40%) ·‚›ˆÛ·Ó (1 ÛÙËÓ

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¶›Ó·Î·˜ 6. ™˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR Ì ÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ ÛÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘

ñ O§§ ‰È¿ÁÓˆÛË (49) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ ÀÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ ñ O§§ ˘ÔÙÚÔ‹ (8) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ 2Ë ˘ÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ

MDR+

%

MDR-

%

18/49 16/18 1/18 0/18 2/18

36,7% 88,9% 5,5% 0% 11,1%

31/49 27/31 1/31 1/31 3/31

63,9% 87,1% 3,2% 3,2% 9,7%

5/8 2/5 0/5 1/5 2/5

62,5% 40% 0% 20% 40%

3/8 3/3 0/3 0/3 0/3

37,5% 100% 0% 0% 0%

¶›Ó·Î·˜ 7. ™˘Û¯¤ÙÈÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR Ì ÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì OM§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘

ñ OM§§ ‰È¿ÁÓˆÛË (8) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ ÀÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ ñ OM§§ ˘ÔÙÚÔ‹ (5) ™‡ÓÔÏÔ ·ÛıÂÓÒÓ ⁄ÊÂÛË ¶ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜ 2Ë ˘ÔÙÚÔ‹ ™‡ÓÔÏÔ ı·Ó¿ÙˆÓ

MDR+

%

MDR-

%

5/8 3/5 1/5 0/5 2/5

62,5% 60% 20% 0% 40%

3/8 0/3 1/3 2/3 1/3

37,5% 0% 33,3% 66,6% 33,3%

2/5 2/2 0/2 0/2 0/2

40% 100% 0% 0% 0%

3/5 3/3 0/3 0/3 0/3

60% 100% 0% 0% 0%

¤ÊÔ‰Ô Î·È 1 Û Ôχ ÚÒÈÌË ˘ÔÙÚÔ‹), ÂÓÒ 3 (60%) ÂÌÊ¿ÓÈÛ·Ó Ï‹ÚË ‡ÊÂÛË Î·È ‰) ·fi ÙÔ˘˜ 3 ·ÛıÂÓ›˜ Ì Oª§§ Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ170, 2 (66,6%) ˘ÔÙÚÔ›·Û·Ó Î·È 1 η٤ÏËÍ (ÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜) (¶›Ó·Î·˜ 6 Î·È 7). ™ÙËÓ ˘ÔÙÚÔ‹: ·) ·fi ÙÔ˘˜ 5 ·ÛıÂÓ›˜ Ì O§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170, 2 (40%) ·‚›ˆÛ·Ó, 1 (20%) ˘ÔÙÚÔ›·Û ÂÎ Ó¤Ô˘, ÂÓÒ 2 (40%) ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 19 Î·È 27 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·, ‚) Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì O§§ (100%) Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 26, 30 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·, Á) Î·È ÔÈ 2 ·ÛıÂÓ›˜ Ì Oª§§ (100%) Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 20 Î·È 26 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· Î·È ‰) Î·È ÔÈ 3 ·ÛıÂÓ›˜ Ì Oª§§ (100%) Ì ·ÚÓËÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÂÈÛ‹¯ıËÛ·Ó Î·È ·Ú·Ì¤ÓÔ˘Ó Û ‰Â‡ÙÂÚË Ï‹ÚË ‡ÊÂÛË ÁÈ· 20, 26 Î·È 36 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ· (¶›Ó·Î·˜ 6 Î·È 7). ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È ÛÙÔ˘˜ ¶›Ó·Î˜ 8 Î·È 9, ·ÓÙ›ÛÙÔȯ·.

76

∆· ÔÛÔÛÙ¿ fiÏˆÓ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹ ‚Ú¤ıËÎ·Ó ·˘ÍË̤ӷ, ۯ‰fiÓ ‰ÈÏ¿ÛÈ·, Û˘ÁÎÚÈÙÈο Ì ÂΛӷ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170. ¶·Ú’ fiÏ· ·˘Ù¿, ÏfiÁˆ ÙÔ˘ Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ‰ËÏ·‰‹ ÙÔ Ê‡ÏÔ, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÙÔÓ Î·Ú˘fiÙ˘Ô, ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô Î·È ÙËÓ ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 8 Î·È 9). ™˘˙‹ÙËÛË ∏ ÂͤÏÈÍË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ï¢¯·ÈÌ›·˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Û˘ÓÙÂϤÛÙËΠ̤۷ ·fi Ì›· ‰È·‰ÚÔÌ‹ ÔÏÏÒÓ ‰ÂηÂÙÈÒÓ. ∆Ô 1945 ·Ó·ÁÓˆÚ›ÛÙËÎÂ Ë ÓfiÛÔ˜ ˆ˜ È·ÙÚÈÎfi Úfi‚ÏËÌ· Î·È ÌfiÏȘ ÙÔ 1975 ¿Ú¯ÈÛ ӷ ‰È·Ê·›ÓÂÙ·È Ë Èı·ÓfiÙËÙ· Ú·ÁÌ·ÙÈ΋˜ ›·Û˘ Ì ÙËÓ ·Ó¿Ù˘ÍË ÈÔ ÂÈıÂÙÈÎÒÓ Î·È ÂÓÙ·ÙÈÎÔÔÈËÌ¤ÓˆÓ ıÂÚ·¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ (2,4,6). ∂ÈϤÔÓ, ÔÈ Ó¤Â˜ ÂÈÙ‡ÍÂȘ ÛÙÔÓ ÙÔ̤· Ù˘ ·ÓÔÛÔÏÔÁ›·˜, Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ù˘ ÁÂÓÂÙÈ΋˜

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¶›Ó·Î·˜ 8. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÌÂٷ͇ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ¤ÎÊÚ·Û˘ Ù˘ MDR ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘

º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB

∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË

ŒÎÊÚ·ÛË Ù˘ ƒ-170

∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË 9 ≤100 x 10 /L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ (Common) T-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ∞¤Ù˘¯·Ó ¢ÂÓ ¤ÁÈÓÂ

MDR+

MDR-

P

11 (22,5%) 7 (14,3%) 10 (20,4%) 8 (16,3%) 14 (28,5%) 4 (8,2%) 18 (36,7%) 0 (0%) 17 (34,7%) 1 (2%) 10 (20,4%) 6 (12,4%) 2 (4,1%) 16 (10) (32,6%) 2 (4,1%) 10 (20,4%) 0 (0%) 2 (4,1%) 2 (4,1%) 4 (8,2%) 18 (36,7%)

18 (36,7%) 13 (26,5%) 21 (42,9%) 10 (20,4%) 23 (46,8%) 8 (16,3%) 28 (57,1%) 3 (6,2%) 27 (55,1%) 4 (8,2%) 25 (50,7%) 6 (12,4%) 0 (0%) 29 (24) (59,2%) 2 (4,1%) 8 (16,3%) 4 (8,2%) 1 (2%) 7 (14,3%) 11 (22,4%) 31 (63,3%)

0,075

Ô˘ ‚Ô‹ıËÛ·Ó ·ÊÂÓfi˜ ÛÙËÓ Î·Ù·ÓfiËÛË Ù˘ ηÚÎÈÓÔÁ¤ÓÂÛ˘, ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Î·Ï‡ÙÂÚË Ù·ÍÈÓfiÌËÛË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·ÎÔËıÂÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, fi¯È ÌfiÓÔ Û ÂÌÂÈÚÈ΋ ·ÏÏ¿ Î·È Û ·ÈÙÈÔÏÔÁË̤ÓË ‚¿ÛË, Û˘ÓÙ¤ÏÂÛ·Ó ÙÂÏÈο ÛÙË ÛËÌÂÚÈÓ‹ ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÓÙ·ÂÙÔ‡˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ Ì ÔÍ›· Ï¢¯·ÈÌ›·. ¶·Ú¿ Ù·‡Ù·, ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·ÙËÚÂ›Ù·È ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ ·ÎfiÌ· Î·È ÛÙȘ Ï¢¯·È̛˜ Ô˘ ηıÔÚ›˙ÔÓÙ·È ˆ˜ ÂӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ (ÂÚ›Ô˘ 20%), ÂÓÒ Ôχ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ ÂÍ·ÎÔÏÔ˘ı› Ó· ·Ú·Ì¤ÓÂÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ∂ÈϤÔÓ, fiÛÔÓ ·ÊÔÚ¿ ÛÙË Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, ·Ú¿ ÙËÓ ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ ‹‰Ë Û˘ÓÙÂÏÂÛÙ›, Ù· ÙÚ¤¯ÔÓÙ· ıÂÚ·¢ÙÈο ÚˆÙfiÎÔÏÏ· ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÈ‚›ˆÛË Ù˘ ٿ͈˜ ÙÔ˘ 40% ¤ˆ˜ 60%. ™˘ÓÂÒ˜, Â›Ó·È Ê˘ÛÈÎfi Ó· ÂÁ›ÚÔÓÙ·È ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ˆ˜ ÚÔ˜ Ù· ·›ÙÈ· ·ÔÙ˘¯›·˜ Ù˘ ıÂÚ·›·˜ (1,2,13,19,20). ¶ÔÏ˘¿ÚÈı̘ ÌÂϤÙ˜ ۯ‰ȿÛÙËÎ·Ó Ì ÛÎÔfi ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ıÂÚ·¢ÙÈ΋˜ ·ÔÙ˘¯›·˜ Î·È ÙËÓ ·Ó·˙‹ÙËÛË Ó¤ˆÓ ·Ú·ÁfiÓÙˆÓ ‹ ·Ú·Ì¤ÙÚˆÓ Ô˘, ÂÚÈÏ·Ì‚·ÓfiÌÂÓÔÈ ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ı· ¤ÚÈ¯Ó·Ó Êˆ˜ Û ˘‡ı˘ÓÔ˘˜ ÁÈ· ÙË Ê·Ú̷΢ÙÈ΋ ·ÔÙ˘¯›· Ì˯·ÓÈÛÌÔ‡˜ (‚ÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ¿Ì˘Ó·˜ ÙˆÓ Î·ÎÔ‹ıˆÓ ΢ÙÙ¿ÚˆÓ) (17,18,20,21). ªÂٷ͇ ÙˆÓ ÔÈÎ›ÏˆÓ ·Ú·ÁfiÓÙˆÓ, Ù· ÙÂÏ¢-

0,255 0,063 0,063 0,062 0,099

0,277 0,031

0,168

Ù·›· ¯ÚfiÓÈ· ȉȷ›ÙÂÚ· ¤¯ÂÈ ÌÂÏÂÙËı› ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ·Ó¿Ù˘Í˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Û Â›Â‰Ô Î˘Ú›ˆ˜ ÂÚÁ·ÛÙËÚÈ·Îfi. ø˜ ΢ÚÈfiÙÂÚÔ˜ Ì˯·ÓÈÛÌfi˜ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ ıˆÚÂ›Ù·È Ë ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ MDR-1 ÁÔÓȉ›Ô˘, Ô˘ ·ÓȯÓ‡ÂÙ·È Ì¤Ûˆ Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÁÏ˘ÎÔÚˆÙ½Ó˘, Ë ÔÔ›· ›Ûˆ˜ Â›Ó·È ·ÚÔ‡Û· ÛÙËÓ ·Ú¯‹ Î·È ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜ ‹ ÛÙȘ ˘ÔÙÚÔ¤˜ Ù˘ ÓfiÛÔ˘ (12,19,20,22-24). ∆Ô 1990, ÔÈ Kuwazuru Î·È Û˘Ó ‰ËÌÔÛ›Â˘Û·Ó 3 ÌÂϤÙ˜ Û ÂÓ‹ÏÈÎÔ˘˜ ·ÛıÂÓ›˜ Ì O§§, 11 Ì ¯ÚfiÓÈ· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Î·È 25 Ì ∆-O§§, fiÔ˘ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ C219 ÁÈ· ÙËÓ Ù˘¯fiÓ ·Ó›¯Ó¢ÛË Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜.

OÈ ÂÓ ÏfiÁˆ ÂÚ¢ÓËÙ¤˜ ·¤‰ÂÈÍ·Ó Û˘Û¯¤ÙÈÛË Ù˘ ·ÚÔ˘Û›·˜ ƒ-170 Î·È Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘, Ô˘ ÂΉËÏÒÓÂÙ·È Â›Ù ˆ˜ ÌË ·Ú¯È΋ ·¿ÓÙËÛË ÛÙË ıÂÚ·›· (·ÓıÂÎÙÈ΋ ÓfiÛÔ˜), ›Ù Ì ˘ÔÙÚÔ‹. ªÂ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ÂÈÛËÌ·›ÓÔ˘Ó ÙËÓ ÎÏÈÓÈ΋ ÛËÌ·Û›· ÙÔ˘ ªDR Ê·ÈÓÔ̤ÓÔ˘ (25-27). ™ÙË Û˘Ó¤¯ÂÈ·, ÌÂϤÙ˜ Û ·È‰È¿ Ì O§§ Ô˘ ÚÔÛ‰ÈfiÚÈ˙·Ó ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Ì ÌÔÚȷΤ˜ ÌÂıfi‰Ô˘˜ Û ‰È¿ÊÔÚ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘, ¤‰ÂÈÍ·Ó fiÙÈ ˘¿Ú¯ÂÈ ·Ó·ÏÔÁÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ·˘ÍË̤ӷ ÔÛ¿ ƒ170 Î·È Ù˘ ·˘ÍË̤Ó˘ ·ÓÙÔ¯‹˜ ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙË Ãª£, ÙfiÛÔ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, fiÛÔ Î·È ÛÙËÓ ‡ÊÂÛË, ÛÙËÓ ˘ÔÙÚÔ‹ Î·È ÛÙË

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¶·È‰È·ÙÚÈ΋ 2003;66:65-81

Paediatriki 2003;66:65-81

¶›Ó·Î·˜ 9. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÌÂٷ͇ ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ù˘ ¤ÎÊÚ·Û˘ Ù˘ MDR, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ηٿ ÙËÓ ˘ÔÙÚÔ‹

º‡ÏÔ OÌ¿‰· ÎÈÓ‰‡ÓÔ˘ ∏ÏÈΛ· ∞ÚÈıÌfi˜ Ï¢ÎÒÓ ÛÙË ‰È¿ÁÓˆÛË ∞ÚÈıÌfi˜ ‚Ï·ÛÙÒÓ ÙËÓ 8Ë Ë̤ڷ ªÔÚÊÔÏÔÁ›· ηٿ FAB

∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ∫˘ÙÙ·ÚÔÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË

∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ӉȿÌÂÛÔ˘ ÎÈÓ‰‡ÓÔ˘ À„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ 1-10 ¤ÙË <1 ¤ÙÔ˘˜ ‹ >10 ¤ÙË 9 ≤100 x 10 /L >100 x 109/L ≤1 x 109/L >1 x 109/L L1 L2 L3 µ-O§§ (Common) ∆-O§§ º˘ÛÈÔÏÔÁÈ΋ ÀÂÚ‰ÈÏÔÂȉÈÛÌfi˜ ∂ÏÏ›ÌÌ·Ù· ¢ÂÓ ¤ÁÈÓÂ

ŒÎÊÚ·ÛË Ù˘ ƒ-170

‰Â‡ÙÂÚË ‡ÊÂÛË (11,19,28). ∞ÎÔÏÔ‡ıËÛ·Ó, fï˜, ‰‡Ô ÌÂϤÙ˜ Ô˘ ‰ÂÓ ¤‰ÂÈÍ·Ó ÎÏÈÓÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙËÓ ÎÏÈÓÈ΋ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ (30,31). ™ÙËÓ ÚÒÙË ¯ÚËÛÈÌÔÔÈ‹ıËΠÌfiÓÔ ÙÔ MPK16 ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Û 19 ·ÛıÂÓ›˜ ̠Ϣ¯·ÈÌ›·, ÂÎ ÙˆÓ ÔÔ›ˆÓ 5 ›¯·Ó O§§, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÌÂÏÂÙ‹ıËÎÂ Ë ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û 141 ·ÛıÂÓ›˜ Ì O§§ Î·È Û 27 Ì Oª§§ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜. ªÂ ÛÎÔfi ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ Â›‰Ú·Û˘ Ù˘ MDR ÛÙËÓ ÚfiÁÓˆÛË Ù˘ O§§ Î·È Ù˘ Oª§§ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Û ‰È·ÊÔÚÂÙÈΤ˜ Ê¿ÛÂȘ Ù˘ ÓfiÛÔ˘ (‰È¿ÁÓˆÛË-˘ÔÙÚÔ‹), ÌÂÏÂÙ‹Û·Ì ÚÔÔÙÈο ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Ì ÙËÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ̤ıÔ‰Ô ∞ƒ∞∞ƒ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· (JSB-1, MRK16, C219) Û 57 ·ÛıÂÓ›˜ Ì O§§ (49 ÛÙË ‰È¿ÁÓˆÛË Î·È 8 Û ˘ÔÙÚÔ‹) Î·È Û 13 ·ÛıÂÓ›˜ Ì Oª§§ (8 ÛÙË ‰È¿ÁÓˆÛË Î·È 5 Û ˘ÔÙÚÔ‹), Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Î·È ıÂÚ·‡ÙËÎ·Ó Ì ·Ó¿ÏÔÁ· (ALL-BFM ’95 Î·È AML-BFM ’93) ıÂÚ·¢ÙÈο ÚˆÙfiÎÔÏÏ· ÛÙÔ ∆Ì‹Ì· Ì·˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. µÚ¤ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ170 (ۯ‰fiÓ ‰ÈÏ¿ÛÈÔ) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ÛÙËÓ ˘ÔÙÚÔ‹ (62,5%), ÂÓÒ ‰ÂÓ ıˆڋıËÎÂ Â˘Î·Ù·ÊÚfiÓËÙÔ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈÎfiÙËÙ·˜ Ù˘ ƒ170 ηٿ ÙË ‰È¿ÁÓˆÛË (36,7%) (de novo MDR). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÙfiÛÔ ÛÙËÓ ˘ÔÙÚÔ‹ (40%), fiÛÔ Î·È ÛÙË ‰È¿ÁÓˆÛË (62,5%), ¢-

78

MDR+

MDR-

P

4 (50%) 1 (12,5%) 0 (0%) 5 (62,5%) 4 (50%) 1 (12,5%) 5 (62,5%) 0 (0%) 4 (50%) 1 (12,5%) 4 (50%) 1 (12,5%) 0 (0%) 4 (50%) 1 (12,5%) 2 (25%) 2 (25%) 0 (0%) 1 (12,5%) 5 (62,5%)

2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 2 (25%) 1 (12,5%) 3 (37,5%) 0 (0%) 3 (37,5%) 0 (0%) 2 (25%) 1 (12,5%) 0 (0%) 3 (37,5%) 0 (0%) 0 (0%) 0 (0%) 1 (12,5%) 2 (25%) 3 (37,5%)

0,48 0,5 0,157 0,993 0,157 0,147

0,48 0,034

0,48

Ú‹Ì·Ù· Ô˘ Û˘ÌʈÓÔ‡Ó Ì ÂΛӷ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ (29-35).

OÈ Herweijer Î·È Û˘Ó ·Ó›¯ÓÂ˘Û·Ó ˘„ËÏfiÙÂÚË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û 5 ·fi ÙÔ˘˜ 9 ·ÛıÂÓ›˜ Ì ∆O§§ Î·È Û 2 Ì µ-O§§ Î·È Î·Ù¤ÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ÌÔÚ› Ó· ‚ÚÂı› Û fiÏÔ˘˜ ÙÔ˘˜ ˘ÔÙ‡Ô˘˜ ÙˆÓ Ï¢¯·ÈÌÈÒÓ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ‚Ú¤ıËΠ۠20/52 ·ÛıÂÓ›˜ Ì µ-O§§ Î·È Û 3/5 ·ÛıÂÓ›˜ Ì ∆-O§§ (17). ∂ӉȷʤÚÔ˘Û˜ Â›Ó·È ÔÈ ÌÂϤÙ˜ ÙˆÓ Pirker Î·È Û˘Ó Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ MDR1 ÁÔÓȉ›Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ‚Ú·¯‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ‡ÊÂÛË, ÂÈ‚›ˆÛË ÂχıÂÚË ÓfiÛÔ˘ Î·È ÙÂÏÈ΋ ÂÈ‚›ˆÛË (32), ηıÒ˜ Î·È ÙˆÓ Goasguen JE Î·È Û˘Ó, ÔÈ ÔÔ›ÔÈ ‚Ú‹Î·Ó ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ (73%) ÙˆÓ ·ÛıÂÓÒÓ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó (32%) (30). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi (40%) ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%), Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·). ∂›Û˘, ÔÈ ·ÛıÂÓ›˜ Ì Oª§§ Ì ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (40%) ıÓËÙfiÙËÙ·˜, Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%) (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿).

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¶ÈÛÙ‡ÂÔ˘Ì fiÙÈ ÏfiÁˆ ÙÔ˘ Û¯ÂÙÈο ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ ƒ-170 Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô, ÙÔ Ê‡ÏÔ, ÙËÓ Î·Ù¿ FAB ÌÔÚÊÔÏÔÁ›·, ÙÔÓ Î·Ú˘fiÙ˘Ô, ÙËÓ ËÏÈΛ·, ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ÔÌ¿‰· ÎÈÓ‰‡ÓÔ˘, ÁÂÁÔÓfi˜ Ô˘ ÂÈÛËÌ·›ÓÂÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ (33,35,36). ∂›Û˘, Èı·Ó¿ ÁÈ· ÙÔÓ ›‰ÈÔ ÏfiÁÔ, ·Ú’ fiÙÈ ‰È·Ê·›ÓÂÙ·È Ë ‰˘ÛÌÂÓ‹˜ ÚÔÁÓˆÛÙÈ΋ Â›‰Ú·ÛË Ù˘ ·ÚÔ˘Û›·˜ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ÛÙËÓ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Ì O§§ Î·È Oª§§ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ˘ÔÙÚÔ‹, ÙÔ‡ÙÔ ‰ÂÓ ‰È·ÈÛÙÒıËΠ̠ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· (¶›Ó·Î·˜ 8 Î·È 9). ∆¤ÏÔ˜, ·ÓÙ›ıÂÙ· Ì ÙÔ˘˜ Filipits Î·È Û˘Ó (1997) Î·È den Boer Î·È Û˘Ó (1997), ÔÈ ÔÔ›ÔÈ ·Ó·Ê¤ÚıËÎ·Ó Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙȘ ‰˘ÛÎÔϛ˜ ÙˆÓ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈÎÒÓ ÌÂıfi‰ˆÓ ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ÔÛÔÛÙÔ‡ Â·Ó·ÏË„ÈÌfiÙËÙ·˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·˘Í‹ıËÎÂ Ë Â˘·ÈÛıËÛ›· Î·È Ë ÂȉÈÎfiÙËÙ· Ù˘ ∞ƒ∞∞ƒ Ù¯ÓÈ΋˜: ·) Ì ÙË ¯Ú‹ÛË ‰ÂÈÁÌ¿ÙˆÓ ·Ó·ÊÔÚ¿˜ οı ÊÔÚ¿ Ô˘ ÚÔÛ‰ÈÔÚÈ˙fiÙ·Ó Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 Û οÔÈÔÓ ·ÛıÂÓ‹, ÒÛÙ ӷ ÌËÓ ˘¿Ú¯Ô˘Ó „¢‰Ò˜ ıÂÙÈο ‹ „¢‰Ò˜ ·ÚÓËÙÈο ‰Â›ÁÌ·Ù·, ηıÒ˜ Î·È ‚) Ì ÙË Û˘Ìʈӛ· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌÂٷ͇ ÙˆÓ ·ÓÂÍ¿ÚÙËÙˆÓ ·Ú·ÙËÚËÙÒÓ. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·Ó›¯Ó¢Û˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙË ¯Ú‹ÛË ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘ ÂÓfi˜ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ. ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÌÔÓ·‰È΋ Ô˘ ¯ÚËÛÈÌÔÔÈ› ÙÚ›· ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ۠Ϣ¯·ÈÌÈο ·ÙÙ·Ú·. ™ÙÔ ˘fi ÌÂϤÙË ˘ÏÈÎfi ‚Ú¤ıËΠfiÙÈ ÙÔ JSB-1 ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170. ∆Ô ÔÛÔÛÙfi ıÂÙÈÎfiÙËÙ¿˜ ÙÔ˘ ‹Ù·Ó 86,6%, ¤Ó·ÓÙÈ 80% ÙÔ˘ C219 Î·È 63,3% ÙÔ˘ MRK16. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O§§ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ170 ÛÙËÓ ˘ÔÙÚÔ‹ (62,5%) Û ۯ¤ÛË Ì ÙË ‰È¿ÁÓˆÛË, ÂÓÒ ‰ÂÓ ıˆÚÂ›Ù·È Î·ıfiÏÔ˘ Â˘Î·Ù·ÊÚfiÓËÙÔ ÙÔ ÔÛÔÛÙfi Ù˘ ıÂÙÈÎfiÙËÙ·˜ Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË (36,7%) (de novo MDR). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Oª§§ ‚Ú¤ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¤ÎÊÚ·Û˘ Ù˘ ƒ-170, ÙfiÛÔ ÛÙË ‰È¿ÁÓˆÛË (62,5%), fiÛÔ Î·È ÛÙËÓ ˘ÔÙÚÔ‹ (40%).

OÈ ·ÛıÂÓ›˜ Ì O§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙËÓ ˘ÔÙÚÔ‹, ·ÚÔ˘Û›·Û·Ó ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi (40%) ÂÈÛ·ÁˆÁ‹˜ Û ‡ÊÂÛË Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%) Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (100% Î·È 0%, ·ÓÙ›ÛÙÔȯ·).

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OÈ ·ÛıÂÓ›˜ Ì Oª§§ Ô˘ ›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ (40%) Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ Â›¯·Ó ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË Ù˘ ƒ-170 (33,3%) (ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿). ∞fi ÙȘ ̤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ηıÒ˜ Î·È ·Ô ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÂÈÛËÌ·›ÓÂÙ·È fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ηÈ, ̤ۈ ·˘Ù‹˜, Ù˘ MDR ÛÙ· Ï¢¯·ÈÌÈο ·ÙÙ·Ú· ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈηÚÎÈÓÈÎÒÓ Ê·Ú̿ΈÓ, ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó·Ó ·ÎfiÌË ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∏ ÌÂϤÙË Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 Ì ÙË ¯Ú‹ÛË ÙÚÈÒÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈۈ̿وÓ, fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Â›Ó·È Û¯ÂÙÈο ÚÔÛÈÙ‹, ·Ú·ÁÒÁÈÌË Î·È ·ÍÈfiÈÛÙË ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ MDR. ∂›Ó·È ‚¤‚·È· ÁÓˆÛÙfi fiÙÈ Ë ·ÚÔ˘Û›· Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂÚ·›· Â›Ó·È ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi Ê·ÈÓfiÌÂÓÔ. ªÂϤÙ˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Ì ÙË ¯Ú‹ÛË Î·Ù¿ÏÏËÏˆÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÚÔ˘Û›·˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË ¯ËÌÂÈÔıÂÚ·›·, Â›Ó·È ·Ó¿ÁÎË Ó· ÚÔÁÚ·ÌÌ·ÙÈÛÙÔ‡Ó ÛÙÔ ¿ÌÂÛÔ Ì¤ÏÏÔÓ. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ Ì¤¯ÚÈ ÙÒÚ· ÌÂϤÙ˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ƒ-170 ·ÊÔÚÔ‡Ó Û ÌÈÎÚÔ‡˜ ·ÚÈıÌÔ‡˜ ·ÛıÂÓÒÓ, ıˆÚԇ̠fiÙÈ Ë ÌÂÙ·-·Ó¿Ï˘ÛË ÛÙËÓ ÔÔ›· ı· Û˘ÌÂÚÈÏËÊıÔ‡Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ı· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ì¤¯ÚÈ Û‹ÌÂÚ· ¢ÚËÌ¿ÙˆÓ ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ÔÏÏ·Ï‹˜ Ê·Ú̷΢ÙÈ΋˜ ·ÓÙÔ¯‹˜ (Multi Drug Resistance, MDR) ÙˆÓ Ï¢¯·ÈÌÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ¤Ó·ÓÙÈ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ¯ËÌÂÈÔıÂÚ·¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∆· Û˘ÌÂÚ¿ÛÌ·Ù· Ì›·˜ Ù¤ÙÔÈ·˜ ÌÂϤÙ˘, ÌÂÙ·ÊÂÚfiÌÂÓ· ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË, ı· ¤¯Ô˘Ó ÌÂÙ¿ ‚‚·ÈfiÙËÙ·˜ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ ̠Ϣ¯·ÈÌ›·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Ditter L, Li FP. Epidemiology of cancer in childhood. In: Nathan DG, Oski FA. Hematology of infancy and childhood.

5th ed. Philadelphia: W.B. Saunders Company; 1998. p.

1071-1091.

2. Niemeyer CM, Sally SE. Acute lymphoblastic leukemia. In: Nathan DG, Oski FA. Hematalogy of infancy and childhood.

5th ed. Philadelphia: W.B. Saunders Company; 1998. p.

1245-1285.

3. Grier ∏E, Sivin πC. Myeloid leukemia, myelodysplasia and myeloproliferative diseases in children. In: Nathan DG, Oski FA. Hematology of infancy and childhood. 5th ed.

Philadelphia: W.B. Saunders Company; 1998. p. 12861321.

79

JAN-FEB-03

14-05-03

14:38

™ÂÏ›‰·80

¶·È‰È·ÙÚÈ΋ 2003;66:65-81

4. ÷˚‰¿˜ ™. ÀÔÛÙËÚÈÎÙÈ΋ ıÂÚ·›· ·È‰ÈÒÓ Ì ÓÂÔÏ·ÛÌ·ÙÈο ÓÔÛ‹Ì·Ù·. ¢ÂÏÙ›Ô ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ∞ıËÓÒÓ 1990;40:212-234.

5. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘-∞Ó‰ÚÔ˘Ï·Î¿ÎË ™. ¶ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ Î·È Û‡Á¯ÚÔÓ· ıÂÚ·¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∂›Î·ÈÚ· ¶·È‰È·ÙÚÈο £¤Ì·Ù·. ∆fiÌÔ˜ ¶ÂÚ·ÁÌ¤ÓˆÓ 6Ô˘ ™ÂÌÈÓ·Ú›Ô˘ µ’ ¶·ıÔÏÔÁÈÎÔ‡ ∆Ô̤· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” 1994;77-85.

6. Chan HS, DeBoer G, Haddad G, Gallie BL, Ling V. Multidrug resistance in pediatric malignancies. Hematol Oncol Clin North Am 1995;9:275-317.

7. Hall AG, Cattan AR. Drug resistance mechanisms in leukemia. Baillieres Clin Haematol 1991;4:655-679.

8. Dalton WS. Mechanisms of drug resistance in hematologic malignacies. Semin Hematol 1997;34 (Suppl 5):1-8.

9. List FA. Non-P-glucoprotein drug export mechanisms of multidrug resistance. Semin Hematol 1997;34 (Suppl 5):20-24.

10. Damiani D, Michieli M, Michelutti A, Geromin A, Raspadori D, Fanin R et al. Expression of multidrug resistance gene (MDR-1) in human normal leukocytes. Haematologica 1993;78:12-17.

11. Marie JP, Legrand O, Perrot JY, Chevillard S, Huet S, Robert J. Measuring multidrug resistance expression in human malignancies: elaboration of consensus recommendations. Semin Hematol 1997;34 (Suppl 5):63-71.

12. Scheper RJ, Bulte JW, Brakkee JG, Quak JJ, van der Schoot E, Balm AJ et al. Monoclonal antibody JBS-1 detects a highly conserved epitope on the P-glycoprotein associated with multi-drug-resistance. Int J Cancer 1988;42:389-394.

13. Lowenberg B, Sonneveld P. Resistance to chemotherapy in acute leukemia. Curr Opin Oncol 1998;10:31-35.

14. Malayeri R, Filipits M, Suchomel RW, Zochbauer S, Lechner K, Pirker R. Multidrug resistance in leukemias and its reversal. Leuk Lymphoma 1996;23:451-458.

15. Hegewisch-Becker S, Hossfeld DK. The MDR phenotype in hematologic malignancies: prognostic relevance and future perspectives. Ann Hematol 1996;72:105-117.

16. Cordell JL, Falini B, Erber WN, Ghosh AK, Abdulaziz Z, MacDonald S at al. Immunoenzymatic labeling of monoclonal antibodies using immune complexes of alkaline phosphatase and monoclonal anti-alkaline phosphatase (APAAP complexes). The J Histochem Cytochem 1984;32:219-229.

17. Broxterman HJ, Pinedo HM, Kuiper CM, van der Hoeven JJ, de Lange P et al. Immunohistochemical detection of Pglycoprotein in human tumor cells with a low degree of drug resistance. Int J Cancer 1989;43:340-343.

18. 8Ô ™ÂÌÈÓ¿ÚÈÔ ‰ÂÈÎÙÒÓ Î·ÚΛÓÔ˘. ∂ÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË Î·È ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË. ∞ı‹Ó·; 1995.

19. Rothenberg ML, Mickley LA, Cole DE, Balis FM, Tsuruo T, Poplack DG et al. Expression of the MDR-1/P-170 gene in patients with acute lymphoblastic leukemia. Blood 1989;74:1388-1392.

20. Goasguen JE, Dossot JM, Fardel O, Le Mee F, Le Gall E, Leblay R et al. Expression of the multidrug resistanceassociated P-glycoprotein (P-170) in 59 cases of de novo

80

Paediatriki 2003;66:65-81

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

acute lymphoblastic leukemia: prognostic implications.

Blood 1993;81:2394-2398.

Musto P, Melillo L, Lombardi G, Matera R, di Giorgio G, Carotenuto M. High risk of early resistant relapse for leukaemic patients with presence of multidrug resistance associated P-glycoprotein positive cells in complete remission. Br J Haematol 1991;77:50-57.

Wood P, Burgess R, MacGregor A, Yin JA. P-glycoprotein expression on acute myeloid leukaemia blast cells at diagnosis predicts response to chemotherapy and survival.

Br J Haematol 1994;87:509-514.

Campos L, Guyotat D, Archimbaud E, Calmard-Oriol P, Tsuruo T, Troncy J et al. Clinical significance of multidrug resistance P-glycoprotein expression on acute nonlymphoblastic leukemia cells at diagnosis. Blood 1992;79: 473-480.

Martinez A, San Miguel JF, Valverde B, Barez A, Moro MJ, Carcia-Marcos MA et al. Functional expression of MDR-1 in acute myeloid leukemia: correlation with the clinicalbiological, immunophenotypical, and prognostic disease characteristics. Ann Hematol 1997;75:81-86. ∫uwazuru Y, Yoshimura A, Hanada S, Ichikawa M, Saito T, Uozumi K et al. Expression of the multidrug transporter, Pglycoprotein, in chronic myelogenous leukaemia cells in blast crisis. Br J Haematol 1990;74:24-30.

Kuwazuru Y, Yoshimura A, Hanada S, Utsunomiya A, Makino T, Ishibashi K et al. Expression of the multidrug transporter, P-glycoprotein, in acute leukemia cells and correlation to clinical drug resistance. Cancer 1990;66: 868-672.

Kuwazuru Y, Hanada S, Furukawa T, Yoshimura A, Sumizawa T, Utsunomiya A et al. Expression of Pglycoprotein in adult T-cell leukemia cells. Blood 1990;76:2065-2070.

O’Meara A, Imamura A, Johnson P, Ball R, Rooney S, Kierce B et al. Reactivity of P-glycoprotein monoclonal antibodies in childhood cancers. Oncology 1992;49:203-208. den Boer ML, Pieters R, Kazemier KM, Rottier MM, Zwaan CM, Kaspers GJ et al. Relationship between major vault protein/lung resistance protein, multidrug resistanceassociated protein, P-glycoprotein expression, and drug resistance in childhood leukemia. Blood 1998;91:20922098.

Goasguen JE, Lamy T, Bergeron C, Ly Sunaram B, Mordelet E, Gorre G et al. Multifactiorial drug-resistance phenomenon in acute leukemias: impact of P170-MDR1, LRP56 protein, glutathione-transferases and metallothio-nein systems on clinical outcome. Leuk Lymphoma 1996; 23:567-576.

ItÔ À, Tanimoto M, Kumazawa T, Okumura M, Morishima Y, Ohno R et al. Increased P-glycoprotein expression and multidrug-resistant gene (MDR1) amplification are infrequently found in fresh acute leukemia cells. Cancer 1989;63:1534-1539. ªarie JP, Zittoun R, Siki B. Multidrug resistance (MDR-1) gene expression in adult acute leukemia: correlation with treatment outcome and in vitro drug sensitivity. Blood 1990;78:586-590.

Pirker R, Wallner J, Geissler K, Linkesch W, Haas OA, Bettelheim P et al. MDR1 gene expression and treatment

JAN-FEB-03

14-05-03

14:38

™ÂÏ›‰·81

¶·È‰È·ÙÚÈ΋ 2003;66:65-81

Paediatriki 2003;66:65-81

outcome in acute myeloid leukemia. J Natl Cancer Inst 1991;83:708-712.

34. Michieli M, Damiani D, Geromin A, Michelutti A, Fanin R, Raspadori D et al. Overexpression of multidrug resistanceassociated p170-glycoprotein in acute non-lymphocytic leukemia. Eur J Haematol 1992;48:87-92.

35. Willman CL. The prognostic significance of the expression and function of multifdrug resistance transporter proteins in acute myeloid leukemia: studies of the Southwest Oncology Group Leukemia Research Program. Semin Hematol

1997;34 (5 Suppl):25-33.

36. Dhooge C, Moerloose B, Laureys G, Kint J, Ferster A, De Bacquer D et al. P-glycoprotein is an independent prognostic factor predicting relapse in childhood acute lymphoblastic leukaemia: results of a 6-year prospective study. Br J Haematol 1999;105:676-683.

¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶·Ó·ÁÈÒÙ· ∆˙ÒÚÙ˙Ë ¶Ï·Ù·ÈÒÓ 7, ÷˚‰¿ÚÈ, ∆.∫. 124 61, ∞ı‹Ó·

¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂›‰· ÙÔ˘ ·Ó·ÛÙÔϤ· ·1-ÚˆÙÂ˚Ó¿ÛË Ù˘ ÂÏ·ÛÙ¿Û˘ ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú· ÓÂÔÁ¤ÓÓËÙˆÓ Ì ԢÚÔÏԛ̈ÍË1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÚ¢ÓËı› ·Ó Ô ·Ó·ÛÙÔϤ·˜ ·1-ÚˆÙÂ˚Ó¿ÛË Ù˘ ÂÏ·ÛÙ¿Û˘ (∂-·1-PI) ÛÙÔÓ ÔÚfi Î·È Ù· Ô‡Ú· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Û·Ó ¤Ó·˜ ‰È·ÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÛÙ· ÓÂÔÁÓ¿. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÙÚ‹ıËÎ·Ó Ì ·ÓÔÛÔÚÔÛ‰ÈÔÚÈÛÌfi Ù· Â›‰· ∂-·1-PI ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú·: ·) Û 23 ÓÂÔÁÓ¿ Ì ԢÚÔÏԛ̈ÍË, ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È 72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ‚) Û 10 “Ê˘ÛÈÔÏÔÁÈο” ÓÂÔÁÓ¿, Ì ‹È· ÚÔ‚Ï‹Ì·Ù·, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Û·Ó Ì¿ÚÙ˘Ú˜ Î·È Á) Û 15 ÓÂÔÁÓ¿ Ì ÂȂ‚·ÈˆÌ¤ÓË Û‹„Ë. ∞ÔÙÂϤÛÌ·Ù·: ∆· Â›‰· Ï¿ÛÌ·ÙÔ˜ ÙÔ˘ ∂-·1-PI ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ Ì ԢÚÔÏԛ̈ÍË Î·È ÙˆÓ “Ê˘ÛÈÔÏÔÁÈÎÒÓ”. ∆· Â›‰· fï˜ Ù˘ ∂-·1-PI ÛÙ· Ô‡Ú· ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙ· ÓÂÔÁÓ¿ Ì ԢÚÔÏԛ̈ÍË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ. ª›· ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ ∂-·1-PI ÛÙ· Ô‡Ú· ·Ú·ÙËÚ‹ıËΠ72 ÒÚ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ۯ‰fiÓ Û fiÏ· Ù· ÓÂÔÁÓ¿, ÂÎÙfi˜ ·fi 2 ÓÂÔÁÓ¿ ÛÙ· ÔÔ›· Ë Ïԛ̈ÍË ‹Ù·Ó Â›ÌÔÓË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ∂-·1-PI ÛÙ· Ô‡Ú· ÛÙÔ Â›Â‰Ô ·ÔÎÔ‹˜ (cutoff

level) ÙˆÓ 48 Ìg/l ›¯Â ¢·ÈÛıËÛ›· 83%, ÂȉÈÎfiÙËÙ· 90%, ıÂÙÈ΋ ÚÔ‚ÏÂÙÈ΋ ·Í›· 95% Î·È Ì›· ·ÚÓËÙÈ΋ ÚÔ‚ÏÂÙÈ΋ ·Í›· 69% ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÛÙ· ÓÂÔÁÓ¿. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·˘ÍË̤ӷ Â›‰· ÛÙ· Ô‡Ú· ÙÔ˘ ∂-·1-PI Ê·›ÓÂÙ·È Ó· Â›Ó·È ¤Ó· ¯Ú‹ÛÈÌÔ ‰È·ÁÓˆÛÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙȘ ÓÂÔÁÓÈΤ˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ, ·ÎfiÌË Î·È ÛÙ· ÓÂÔÁÓ¿ Ô˘ ·›ÚÓÔ˘Ó ·ÓÙÈ‚›ˆÛË Î·È Èı·Ó¿ ¤Ó·˜ ÔχÙÈÌÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ·ÔÙ˘¯›· Ù˘ ıÂÚ·›·˜.

1 Bakakos P, Messaritaki A, Mandyla H, Nicolaidou P, Anagnostakis D Plasma and urine elastase alpha-1-proteinase inhibitor levels in neonatal urinary tract infection Biol Neonate 2002;81:109-112

™‡ÚÔ˜ ºˆÙfiÔ˘ÏÔ˜ ¶·È‰›·ÙÚÔ˜-¡ÂÔÁÓÔÏfiÁÔ˜ ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ µ’ ª∂¡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”

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∂π¢π∫O ∞ƒ£ƒO

Paediatriki 2003;66:82-88

SPECIAL ARTICLE

¢ËÌfiÛÈ· ˘Á›·: Á¤Ê˘Ú· ÂÈÚ‹Ó˘* ¶. ¢. §··ÙÛ¿Ó˘

Public health: a bridge for peace* P. D. Lapatsanis

¶ÂÚ›ÏË„Ë: “∫·› â› Áɘ ÂåÚ‹ÓË” ‰È·ÎËÚ‡ÛÛÂÙ·È ÛÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ. OÈ “ÌÂÁ¿ÏÔÈ” Ù˘ Á˘ ·Û¿˙ÔÓÙ·È ÙÔ ÙÚÔ¿ÚÈÔ: “∫·› â› Áɘ fiÏÂÌÔ˜”. ∏ ÙÚÔÌÔÎÚ·Ù›· ¤¯ÂÈ ÛËÌÂÈÒÛÂÈ Ú·Á‰·›· ·‡ÍËÛË Î·È Â˘ÓÔÂ›Ù·È Ë ·Ó¿Ù˘Í‹ Ù˘ ÛÙȘ ¯ÒÚ˜ Ô˘ ˘¿Ú¯ÂÈ ÔÏÈÙÈ΋ ·ÛÙ¿ıÂÈ· Î·È ¿ÓÈÛË Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂıÓÈÎÔ‡ ÏÔ‡ÙÔ˘. O ÛÎÔfi˜ ÙÔ˘ ÙÚÔÌÔÎÚ·ÙÈÎÔ‡ ÎÙ˘‹Ì·ÙÔ˜ Â›Ó·È Ó· ÚÔηϤÛÂÈ ıÏ›„Ë, ·ÓÈÎfi Î·È Û‡Á¯˘ÛË ÛÙËÓ ÎÔÈÓˆÓ›·. ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ¤Ó· Úfi‚ÏËÌ· ‰˘ÛÂ›Ï˘ÙÔ, ‰ÈfiÙÈ ÔÈ ÙÚÔÌÔÎÚ¿Ù˜ ¤¯Ô˘Ó ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÛÙfi¯Ô. O ÛÙÚ·ÙËÁfi˜ Col. Powell ÚÔÊËÙÈο ·Ó¤ÊÂÚ ÛÙÔ ∫ÔÁÎÚ¤ÛÔ ÙˆÓ ∏¶∞ (ª¿ÈÔ˜ 2001): “∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ÙÔ ÛÎÔÙÂÈÓfi ÎÔÌÌ¿ÙÈ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘. ∂›Ó·È Ï˘ËÚfi, ·ÏÏ¿ ¤ÙÛÈ Â›Ó·È. ŒÓ· ̤ÚÔ˜ ÙÔ˘ ÎfiÛÌÔ˘ ·Û¯ÔÏÂ›Ù·È Ì ÙËÓ ÙÚÔÌÔÎÚ·Ù›·”. ∂›¯·Ó ·Ú¤ÏıÂÈ ÌfiÓÔ ÙÚÂȘ Ì‹Ó˜ ·fi ÙËÓ ÔÌÈÏ›· ÙÔ˘ Col. Powell, fiÙ·Ó Â‹Ïı ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÛÙË ¡. ÀfiÚÎË. ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È Ì›· ηٿÛÙ·ÛË Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È, ·ÏÏ¿ ‰ÂÓ ÂÍÔ˘‰ÂÙÂÚÒÓÂÙ·È. ∏ ‰ËÌfiÛÈ· ˘Á›· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó· ·fi Ù· Ô˘ÛÈÒ‰Ë Ì¤ÙÚ· ηٿ Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜. ∏ ÈÛÙÔÚ›· ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ‰Â›¯ÓÂÈ Ò˜ ·Ó·Ù‡¯ıËÎÂ Ë ÙÚÔÌÔÎÚ·Ù›·. ∏ ¯ÒÚ· ·˘Ù‹ Â› 200 ¯ÚfiÓÈ· ›¯Â ÛÙÚ·ÙËÁÈ΋ ÛËÌ·Û›· ÁÈ· ÙȘ ·˘ÙÔÎÚ·ÙÔڛ˜. ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó, ÙÔ 1970, ¤ÁÈÓ ÙÔ Ì‹ÏÔ Ù˘ ¤ÚȉԘ ÌÂٷ͇ ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. OÈ ÎÔÌÌÔ˘ÓÈÛÙ¤˜ ÂÎıÚfiÓÈÛ·Ó ÙÔ ‚·ÛÈϤ· ™·¯ ÙÔ 1973 Î·È ÙÔ 1978 ‰ËÌÈÔ˘ÚÁ‹ıËΠÎÔÌÌÔ˘ÓÈÛÙÈ΋ ‰ÈÎÙ·ÙÔÚ›· Ô˘ Ô‰‹ÁËÛ Û ̷˙ÈΤ˜ ÂÎÙÂϤÛÂȘ ÙÔ˘ ·ÊÁ·ÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. OÈ ∏¶∞, ÔÈ Ôԛ˜ ˘ÔÛÙ‹ÚÈ˙·Ó ÙÔ ¶·ÎÈÛÙ¿Ó, ‰ËÌÈÔ‡ÚÁËÛ·Ó ·ÓÙ›ÛÙ·ÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó. ∆Ô 1989, Ô Úfi‰ÚÔ˜ °ÎÔÚÌ·ÙÛfiÊ ·Ó·ÁοÛÙËΠӷ ÙÂÏÂÈÒÛÂÈ ·˘ÙfiÓ ÙÔÓ ¯ÚfiÓÈÔ fiÏÂÌÔ.

Abstract: The last decades the hymn of the church “a peace over the land” is not praised but the hymn “a war over the land” is embraced.

Terrorism thrives in countries with varying degrees of state failure. The purpose of the terroristic hit is to produce panic, confusion, and grief in the society.

The terrorists will not be easy to eradicate from the society because such is the nature of terrorism. The General Colin Powell reported in the US senate in May 2001 that “Terrorism is part of the dark side of globalisation. However, sadly, it is part of doing business in the world”. His words were to prove prophetic because on Tuesday September 11, 2001, terrorism raised a threat on human life. Public health could be one of the important measures against terrorism. The history of Afghanistan reveals how the terrorism has been developed. For almost 200 years the country was a strategic spot for empires. The Russian-Iranian axis with US were against the Taliban (2001). Afghanistan people could be a little cynical to western politicians who promised peace to the Afghans. Afghanistan and Pakistan are both at the lowest level of child health care. Life-expectancy for men is 45.3 and women 47.2 (1999). Infant mortality rate per 1000 live births is 165; mortality rate in under 5 year-old is 257ò; adult illiteracy 74%, malnutrition 70% while use of betterment water service is 13%. Concerning the Middle East crisis it is obvious that both communities will support revenge as a normal and acceptable strategy. C. Bellamy noted that “Israelis and Palestinians teach their children to use terrorism increasing their acceptance of violence as a method

OÌ. ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ, πˆ¿ÓÓÈÓ·

Em. Professor of Pediatrics University of Ioannina Medical School, Ioannina

* ∞Ó·ÎÔÈÓÒıËΠÛÙË 12Ë ∂ÈÛÙËÌÔÓÈ΋ ∂Ή‹ÏˆÛË ¶·È‰È·ÙÚÈ΋˜, ™Â٤̂ÚÈÔ˜ 2002, πˆ¿ÓÓÈÓ·

* It was presented in the 12th Pediatric Scientific Conference, September 2002, Ioannina

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∆· ̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ Ù˘ ¢‡Û˘ ·Ó¤ÊÂÚ·Ó ÂÏ¿¯ÈÛÙ· ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ì ·ÔÙ¤ÏÂÛÌ· Ë ¯ÒÚ· Ó· ÂÁηٷÏÂÈÊı› ÛÙÔÓ fiÏÂıÚÔ. OÈ ∆·ÏÈÌ¿Ó, ˘ÔÛÙËÚÈ˙fiÌÂÓÔÈ ·fi ÙÔ ¶·ÎÈÛÙ¿Ó, η٤Ϸ‚·Ó ÙËÓ ÂÍÔ˘Û›· Î·È ·ÓÙÈη٤ÛÙËÛ·Ó ÙÔ 1995 ÙÔ ÎÔÌÌÔ˘ÓÈÛÙÈÎfi ηıÂÛÙÒ˜ Ì ¤Ó·Ó ÚÔÈÎÈṲ̂ÓÔ, ·ÏÏ¿ ÂÍÙÚÂÌÈÛÙ‹ ÈÛÏ·ÌÈÛÙ‹ (Wahhabism).

O ¿ÍÔÓ·˜ ƒˆÛ›·˜-πÚ¿Ó Ì·˙› Ì ÙȘ ∏¶∞ ‹Ù·Ó ÂÓ·ÓÙ›ÔÓ ÙˆÓ ∆·ÏÈÌ¿Ó. OÈ ˘ÔÛ¯¤ÛÂȘ ÙˆÓ ÔÏÈÙÈÎÒÓ ÙÔ˘ ‰˘ÙÈÎÔ‡ ÎfiÛÌÔ˘ ÁÈ· ÂÈÚ‹Ó¢ÛË ÛÙËÓ ÂÚÈÔ¯‹ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ΢ÓÈÛÌfi ·fi ÙÔ˘˜ ∞ÊÁ·ÓÔ‡˜.

O ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘ ηٿ ÙÔ ¤ÙÔ˜ 1999 ÁÈ· ÙÔ˘˜ ¿Ó‰Ú˜ ‹Ù·Ó 45,3 ¯ÚfiÓÈ· Î·È ÁÈ· ÙȘ Á˘Ó·›Î˜ 47,2. ∏ ÓÂÔÁÓÈ΋ ıÓËÛÈÌfiÙËÙ· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 165ò, ÂÓÒ ÛÙȘ ∏¶∞ ÛÙÔ 7ò. ∆Ô ÔÛÔÛÙfi ÙˆÓ ·Ó·ÏÊ¿‚ËÙˆÓ ÛÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ·Ó¤Ú¯ÂÙ·È ÛÙÔ 64% Î·È ÛÙȘ ∏¶∞ ÛÙÔ 1%. O ˘ÔÛÈÙÈÛÌfi˜ ÛÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ ·Ó¤Ú¯ÂÙ·È Û 70% ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È 0% ÛÙËÓ ∞ÌÂÚÈ΋. ∫·ı·Úfi, fiÛÈÌÔ ÓÂÚfi Â›Ó·È ‰È·ı¤ÛÈÌÔ ÛÙÔ 13% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ 100% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ∞ÌÂÚÈ΋˜. ™Â ¤Ó· ÙÌ‹Ì· Ù˘ ∆¯ÂÚ¿Ó˘, Ë ·ÚÔ¯‹ ÓÂÚÔ‡ ‰È·ÎfiÙÂÙ·È 12 ÒÚ˜ ÙËÓ Â‚‰ÔÌ¿‰·. ∞ÍȈ̷ÙÔ‡¯ÔÈ ÙÔ˘ ¶·ÎÈÛÙ¿Ó ·Ó¤ÊÂÚ·Ó fiÙÈ ÏfiÁˆ ÍËÚ·Û›·˜ ˘‹ÚÍ·Ó ·ÒÏÂȘ 1,2 ‰ÈÛÂηÙÔÌÌ˘Ú›ˆÓ ‰ÔÏ·Ú›ˆÓ ∞ÌÂÚÈ΋˜ ÂÎ ÙˆÓ ·ÁÚÔÙÈÎÒÓ Î·ÏÏÈÂÚÁÂÈÒÓ. ™¯Â‰fiÓ ÌÈÛfi ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ÛÙÔÓ Ï·Ó‹ÙË Ì·˜ ‰ÂÓ ¤¯Ô˘Ó Â¿ÚÎÂÈ· ·ÚÔ¯‹˜ ÓÂÚÔ‡ Î·È ·Ó ‰ÂÓ ÏËÊıÔ‡Ó Ì¤ÙÚ·, ÙÔ 2025 ÙÔ 35% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ ı· ¤¯ÂÈ Ï›·Ó ÌÂȈ̤ÓË ·ÚÔ¯‹ ÓÂÚÔ‡ (ۯ‰fiÓ 2,8 ‰ÈÛÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ). ∏ ÌÂȈ̤ÓË ·ÚÔ¯‹ ÓÂÚÔ‡ ‰ËÌÈÔ˘ÚÁ› ÎÔÈÓˆÓÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ Âڋ̈ÛË Î·È Èı·ÓÒ˜ “ÌÂÙ·Ó¿ÛÙ˜ ‡‰·ÙÔ˜”. ∆Ô 1998, Ë ¤ÎıÂÛË ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ OÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜ ·Ó·Ê¤ÚÂÈ fiÙÈ ··ÈÙÔ‡ÓÙ·È 10 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÙÔ ¯ÚfiÓÔ ÁÈ· Ó· ÂÊԉȷÛÙ› fiÏÔ˜ Ô ÏËı˘ÛÌfi˜ Ù˘ Á˘ Ì ηı·Úfi ÓÂÚfi. ∞˘Ùfi ÙÔ ÎfiÛÙÔ˜ ÈÛÔ‰˘Ó·Ì› Ì ÙÔ 1/10 ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ÍÔ‰Â‡Ô˘Ó ÔÈ ∂˘Úˆ·›ÔÈ ÁÈ· ·ÏÎÔÔÏÔ‡¯· ÔÙ¿ ‹ Ì ÙÔ ‹ÌÈÛ˘ ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ηٷӷÏÒÓÔ˘Ó ∞ÌÂÚÈηÓÔ› Î·È ∂˘Úˆ·›ÔÈ Î¿ı ¯ÚfiÓÔ ÁÈ· ˙ˆÔÙÚÔʤ˜ ÙˆÓ Î·ÙÔÈΛ‰ÈˆÓ ˙ÒˆÓ ÙÔ˘˜. ∞fi ÙËÓ ÎÚ›ÛË ÛÙË ª¤ÛË ∞Ó·ÙÔÏ‹ Ê·›ÓÂÙ·È fiÙÈ ÙfiÛÔ ÔÈ πÛÚ·ËÏÈÓÔ› fiÛÔ Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ıˆÚÔ‡Ó ÙËÓ Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·Ùfi˜ ÙÔ˘˜ ÂÊÈÎÙ‹ Ì ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ú¿ÍÂˆÓ ÂΉ›ÎËÛ˘ Î·È ‚›·˜.

O ‰È¢ı˘ÓÙ‹˜ Ù˘ UNICEF C. Bellamy ·Ó¤ÊÂÚ fiÙÈ ÔÈ πÛÚ·ËÏÈÓÔ› Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ‰È‰¿ÛÎÔ˘Ó ÛÙ· ·È‰È¿ ÙÔ˘˜ ÙËÓ ÙÚÔÌÔÎÚ·Ù›· ˆ˜ ̤ıÔ‰Ô Â›Ï˘Û˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘˜. OÈ Î˘‚ÂÚÓ‹ÛÂȘ Ù˘ ∂Ó. ∂˘ÚÒ˘ Î·È ÙˆÓ ∏¶∞ Ô˘ ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ Â›Ó·È ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÂÈÚ‹Ó˘ ÛÙÔÓ ÎfiÛÌÔ, Ú¤ÂÈ Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó ÒÛÙ ÌÂÙ¿ ÙËÓ Î·Ù¿·˘ÛË ÙˆÓ Â¯ıÚÔÚ·ÍÈÒÓ Ó· ÂÈÌÂÏËıÔ‡Ó ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜, ‰ÈfiÙÈ Ô ¿Ì·¯Ô˜ ÏËı˘ÛÌfi˜

Paediatriki 2003;66:82-88

for resolving problems”. In old days there was one Herod but nowadays there are many. Christ will not be born again but he continues to suffer in the Middle East on behalf of innocent civilian victims who die in the street, bus, school or their houses.

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Â›Ó·È Ù·Ï·ÈˆÚË̤ÓÔ˜, ηÎÔÔÈË̤ÓÔ˜ Î·È ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜. O Benjamin Disraeli ·Ó·Ê¤ÚÂÈ ÙÔ 1877 fiÙÈ “Ë ˘Á›· ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È Ë Ú·ÁÌ·ÙÈ΋ ıÂÌÂÏ›ˆÛ˘ Ù˘ Â˘Ù˘¯›·˜ Î·È Ù˘ ‰‡Ó·Ì˘ ÁÈ· Ì›· ·ÓÂÍ¿ÚÙËÙË ÔÏÈÙ›·”. ∆ËÓ ÂÔ¯‹ Ô˘ ÁÂÓÓ‹ıËÎÂ Ô ÃÚÈÛÙfi˜ ˘‹Ú¯Â ¤Ó·˜ ∏Ú҉˘. ™‹ÌÂÚ·, Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ô˘ ˘ÈÔıÂÙÔ‡Ó ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ Î·È ÌÂıÔ‡Ó ·fi ÙÔ ·›Ì· ÙˆÓ ÛÊ·ÁÒÓ Î·È ÙȘ ÊÔÓÈΤ˜ ÂÎÚ‹ÍÂȘ. O ÃÚÈÛÙfi˜ ›Ûˆ˜ ‰ÂÓ ı· Í·Ó·ÁÂÓÓËı›, ·ÏÏ¿ ÂÍ·ÎÔÏÔ˘ı› Ó· ÛÙ·˘ÚÒÓÂÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ ÔϤÌÔ˘, ÛÙÔ ÚfiÛˆÔ ·ıÒˆÓ ı˘Ì¿ÙˆÓ Ô˘ ·Ê‹ÓÔ˘Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÓÔ‹ ÙÔ˘˜ ÛÙÔ ‰ÚfiÌÔ, ÛÙÔ ÏˆÊÔÚ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô ‹ οو ·fi ÙË ‚ÔÌ‚·Ú‰ÈṲ̂ÓË ÛÙ¤ÁË ÙÔ˘ ÛÈÙÈÔ‡ ÙÔ˘˜. §¤ÍÂȘ ÎÏÂȉȿ: ‰ËÌfiÛÈ· ˘Á›·, ÂÈÚ‹ÓË, ÙÚÔÌÔÎÚ·Ù›·.

Key words: public health, peace, terrorism.

“∫·› â› Áɘ ÂåÚ‹ÓË” ‰È·ÎËÚ‡ÛÛÂÙ·È ÛÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ Ù˘ °¤ÓÓËÛ˘ ÙÔ˘ £Â·ÓıÚÒÔ˘.

OÈ “ÌÂÁ¿ÏÔÈ” fï˜ Ù˘ Á˘ ·Û¿˙ÔÓÙ·È ÙÔ ÙÚÔ¿ÚÈÔ “∫·› â› Áɘ fiÏÂÌÔ˜” (1). ∆· ÎÚÔ‡ÛÌ·Ù· ÙˆÓ ÙÚÔÌÔÎÚ·ÙÈÎÒÓ ÎÙ˘ËÌ¿ÙˆÓ ¤¯Ô˘Ó ·˘ÍËı› Û ¯ÒÚ˜ Ì ÔÏÈÙÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ ·ÛÙ¿ıÂÈ· fiˆ˜ Ë ∞ÏÁÂÚ›·, ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë µfiÚÂÈ· πÚÏ·Ó‰›·, ÙÔ πÚ¿Î, Ë ∫ÔÏÔÌ‚›·, Ë ¶·Ï·ÈÛÙ›ÓË Î·È ÙÔ ™Ô˘‰¿Ó. ∞˘Ù¤˜ ÔÈ ¯ÒÚ˜ ‰È·ÎÚ›ÓÔÓÙ·È Î·È ÁÈ· ÙËÓ ¿ÓÈÛË Î·Ù·ÓÔÌ‹ ÙÔ˘ ÂıÓÈÎÔ‡ ÏÔ‡ÙÔ˘.

O Pillar, ·Ú¯ËÁfi˜ Ù˘ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈ΋˜ ÔÚÁ¿ÓˆÛ˘ ÙˆÓ ∏¶∞, Ô ÔÔ›Ô˜ ‹Ù·Ó ·Ú¯ËÁfi˜ Ù˘ CIA (Central Intelligence Agency), ÛÙÔ ‚È‚Ï›Ô “∏ ÙÚÔÌÔÎÚ·Ù›· Î·È Ë Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Ù˘ ∞ÌÂÚÈ΋˜” ÈÛ¯˘Ú›˙ÂÙ·È fiÙÈ Ë ÙÚÔÌÔÎÚ·Ù›· ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Î·È fi¯È Ì ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈο ̤ÙÚ· fiˆ˜ ‰Èψ̷ٛ·, ·Ú·ÓÔÌ›·, ÛÙÚ·ÙȈÙÈ΋ ‚›· Î·È ÔÈÎÔÓÔÌÈÎfi ÂÌ¿ÚÁÎÔ (2). ∞˘Ù¿ ÎÚ›ÓÔÓÙ·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈο Î·È ‰ÂÓ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ‡ÊÂÛË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜. ¢ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È ‰Èı‡Ú·Ì‚ÔÈ Î·È Ê·ÓÊ·ÚÔÓÈÛÌÔ›. O ÛÙÚ·ÙËÁfi˜ Col. Powell ÚÔÊËÙÈο ·Ó¤ÊÂÚ ÛÙËÓ ÔÌÈÏ›· ÙÔ˘ ÙÔÓ ª¿ÈÔ ÙÔ˘ 2001 ÛÙÔ ∫ÔÁÎÚ¤ÛÔ: “∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ÙÔ ÛÎÔÙÂÈÓfi ÎÔÌÌ¿ÙÈ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘. ∂›Ó·È Ï˘ËÚfi, ·ÏÏ¿ ¤ÙÛÈ Â›Ó·È. ŒÓ· ̤ÚÔ˜ ÙÔ˘ ÎfiÛÌÔ˘ ·Û¯ÔÏÂ›Ù·È Ì ÙËÓ ÙÚÔÌÔÎÚ·Ù›·”. ∏ ÙÚÔÌÔÎÚ·Ù›· ·ÔÙÂÏ› ‰˘ÛÂ›Ï˘ÙÔ Úfi‚ÏËÌ·, ηıÒ˜ ÔÈ ÙÚÔÌÔÎÚ¿Ù˜ ‰È·ı¤ÙÔ˘Ó ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÛÙfi¯Ô Î·È ÂÓÂÚÁÔ‡Ó Ì ÚÔÛÂÎÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜. ∂›Û˘, Ô ¯ÚfiÓÔ˜ Î·È Ô ÙfiÔ˜ Ì›·˜ ÙÚÔÌÔÎÚ·ÙÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ηıÔÚ›˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ·fi ÙÔ˘˜ ‰Ú¿ÛÙ˜. ŒÙÛÈ, ÔÔÈÔ‰‹ÔÙ ̤ÙÚÔ ·ÛÊ¿ÏÂÈ·˜ Û ·ÂÚÔÏ¿Ó· ‹ ·ÂÚÔ‰ÚfiÌÈ·, fiˆ˜ ÛÙÚ·ÙȈÙÈΤ˜ ‰˘Ó¿ÌÂȘ, Â›Ó·È ·ÓÂ·ÚΤ˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÙÚÔÌÔÎÚ·ÙÒÓ. ∆Ô ÙÚÔÌÔÎÚ·ÙÈÎfi ÎÙ‡ËÌ· ÚÔηÏ› „˘¯ÔÏÔÁÈ-

ο ÙÚ·‡Ì·Ù·, ıÏ›„Ë, ·ÓÈÎfi Î·È Û‡Á¯˘ÛË (3). ∏ ÙÚÔÌÔÎÚ·Ù›· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÈÙÈ΋˜ Î·È ÎÔÈÓˆÓÈ΋˜ ·ÏÏ·Á‹˜. ªÂÙ¿ ÙÔ ıÏÈ‚ÂÚfi ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ 2001 ÛÙË ¡. ÀfiÚÎË, Ë Â͈ÙÂÚÈ΋ ·ÌÂÚÈηÓÈ΋ ÔÏÈÙÈ΋ ÛÙËÚ›¯ÙËΠÛÙË ÛÙÚ·ÙȈÙÈ΋ ÈÛ¯‡ Î·È ¯ÚËÛÈÌÔÔ›ËÛ ÙË ÁÏÒÛÛ· Ù˘ ·ÓÙÂΉ›ÎËÛ˘. O ªÔ˘˜ ˙‹ÙËÛ ·fi fiÏ· Ù· ÔÏÈÙÈṲ̂ӷ ÎÚ¿ÙË Ó· Û˘ÓÂÚÁ·ÛÙÔ‡Ó ÁÈ· Ó· ÂΉÈÒÍÔ˘Ó ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÙÔ˘˜ ∆·ÏÈÌ¿Ó, ÔÈ ÔÔ›ÔÈ ›Ûˆ˜ ¤¯Ô˘Ó ÚÔηϤÛÂÈ ÎfiˆÛË ÛÙÔ Ï·fi ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. ∏ Ù·ÎÙÈ΋ ·˘Ù‹ ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ ÌË ÔÚı‹. OÈ ∞ÌÂÚÈηÓÔ› ÏËÛÌfiÓËÛ·Ó ÙËÓ È·ÙÚÈ΋ Î·È ÙË ‰ËÌfiÛÈ· ˘Á›·, ÔÈ Ôԛ˜ ·›˙Ô˘Ó ¤Ó·Ó ¤ÌÌÂÛÔ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÂÈÚ‹Ó˘ Î·È ÙË ÛÙ·ıÂÚfiÙËÙ· Û ¯ÒÚ˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ‰È¿Ï˘ÛË Î·È Î·Ù¿ÙˆÛË. ∏ ‰ËÌfiÛÈ· ˘Á›· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÙÔ Î·Ï‡ÙÂÚÔ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈÎfi ̤ÙÚÔ Ô˘ ·ÎfiÌË, fï˜, ‰ÂÓ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı›. ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó ‰ÂÓ Â›Ó·È ÔÌÔÈÔÁÂÓ¤˜ ÎÚ¿ÙÔ˜. Œ¯ÂÈ 22 ÂηÙÔÌ̇ÚÈ· ÏËı˘ÛÌfi Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ∆·˙›ÎÔ˘˜, O˘˙Ì¤ÎÔ˘˜ Î·È ¶·ÛÙÔ‡Ó˜. OÈ ∆·ÏÈÌ¿Ó ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ˘˜ ¶·ÛÙÔ‡Ó˜. ∏ ÚfiÛÊ·ÙË ÈÛÙÔÚ›· ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ‰Â›¯ÓÂÈ fiÙÈ ‹Ù·Ó Ì›· ¯ÒÚ· ÂÈÚÚÂ‹˜ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜, ‰ÈfiÙÈ Â› ‰‡Ô ·ÈÒÓ˜ ‹Ù·Ó ÛÙÚ·ÙËÁÈ΋ ı¤ÛË ÁÈ· ·˘ÙÔÎÚ·ÙÔڛ˜ Û ·ÎÌ‹ ‹ ·Ú·ÎÌ‹. ∆Ô 1970, ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ¤ÁÈÓ ÙÔ Ì‹ÏÔ Ù˘ ¤ÚȉԘ ÌÂٷ͇ ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ∆Ô 1973, ÔÈ ÎÔÌÌÔ˘ÓÈÛÙ¤˜ ÂÎıÚfiÓÈÛ·Ó ÙÔ ‚·ÛÈϤ· ™·¯. ∆Ô 1978 ¤ÁÈÓ ÎÔÌÌÔ˘ÓÈÛÙÈ΋ ‰ÈÎÙ·ÙÔÚ›·, Ë ÔÔ›· Ô‰‹ÁËÛ Û ̷˙ÈΤ˜ ÂÎÙÂϤÛÂȘ ÙÔ˘ ·ÊÁ·ÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. OÈ ∏¶∞ Ô˘ ˘ÔÛÙ‹ÚÈ˙·Ó ÙÔ ¶·ÎÈÛÙ¿Ó ‰ËÌÈÔ‡ÚÁËÛ·Ó ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ·ÓÙ›ÛÙ·ÛË. ∞˘Ù‹ Ë ¯ÚfiÓÈ· Û‡ÚÚ·ÍË ·Ó¿ÁηÛ ÙÔ 1989 ÙÔÓ Úfi‰ÚÔ °ÎÔÚÌ·ÙÛfiÊ Ó· ÙÂÚÌ·Ù›ÛÂÈ ÙÔÓ fiÏÂÌÔ. ∆·

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̤۷ Ì·˙È΋˜ ÂÓË̤ڈÛ˘ Ù˘ ¢‡Û˘ ·Ó¤ÊÂÚ·Ó ÂÏ¿¯ÈÛÙ· ÁÈ· ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, ÌÂ Û˘Ó¤ÂÈ· Ë ¯ÒÚ· Ó· ÂÁηٷÏÂÈÊı› ÛÙÔÓ fiÏÂıÚÔ. ™ÎÔÙÒıËÎ·Ó 1,5 ÂηÙÔÌ̇ÚÈÔ Ôϛ٘, ÂÓÒ 6 ÂηÙÔÌ̇ÚÈ· ‹Ú·Ó ÙÔ ‰ÚfiÌÔ Ù˘ ÚÔÛÊ˘ÁÈ¿˜ ÚÔ˜ ÙÔ πÚ¿Ó Î·È ÙÔ ¶·ÎÈÛÙ¿Ó. ŒÓ·˜ ÙÚÔÌÂÚfi˜ ÂÌʇÏÈÔ˜ fiÏÂÌÔ˜ ·Ó·Ù‡¯ıËΠÛÙËÓ ÂÚÈÔ¯‹ ·fi ÙËÓ ·ÓÙÈ·Ú¿ıÂÛË ÙˆÓ ∏¶∞ Î·È Ù˘ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ∆Ô 1995, ÔÈ ∆·ÏÈÌ¿Ó ˘ÔÛÙËÚÈ˙fiÌÂÓÔÈ ·fi ÙÔ ¶·ÎÈÛÙ¿Ó, ‹Ú·Ó ÙËÓ ÂÍÔ˘Û›· Î·È ·ÓÙÈη٤ÛÙËÛ·Ó ÙÔ ÎÔÌÌÔ˘ÓÈÛÙÈÎfi ηıÂÛÙÒ˜ ·fi ¤Ó·Ó ÚÔÈÎÈṲ̂ÓÔ, ·ÏÏ¿ ÂÍÙÚÂÌÈÛÙ‹ πÛÏ·ÌÈÛÙ‹ (Wahhabism). ∆Ô 2001, ÔÈ ∏¶∞ ˘ÔÛÙËÚÈ˙fiÌÂÓ˜ ·fi ÙË ƒˆÛ›· Î·È ÙÔ πÚ¿Ó, ‰ËÌÈÔ‡ÚÁËÛ·Ó ¤Ó·Ó ¿ÍÔÓ· ηٿ ÙˆÓ ∆·ÏÈÌ¿Ó. ∂·Ó¤ÊÂÚ·Ó ÙÔÓ ‚·ÛÈÏÈ¿ ™·¯ Û ËÏÈΛ· 86 ÂÙÒÓ. OÈ ÔÏÈÙÈÎÔ› Ù˘ ¢‡Û˘ ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÎÏ‹ÛÛÔÓÙ·È fiÙ·Ó Ô ÏËı˘ÛÌfi˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È Î˘ÓÈÎfi˜ ÁÈ· ÙËÓ ÂÈÚ‹ÓË Ô˘ ÙÔ˘˜ ÂÁÁ˘‹ıËηÓ. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ OÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜, Ë ¯ÒÚ· ·˘Ù‹ ¤¯ÂÈ Ôχ ¯·ÌËÏfi Â›Â‰Ô ÊÚÔÓÙ›‰·˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜, η٤¯ÔÓÙ·˜ ÙËÓ 173Ë ı¤ÛË Û ۇÓÔÏÔ 191 ¯ˆÚÒÓ. ™ÙÔ ¶·ÎÈÛÙ¿Ó Î·È ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, ÙÔ Â›Â‰Ô ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ ‚Ú›ÛÎÂÙ·È ÛÙÔ Î·ÙÒÙ·ÙÔ Â›‰Ô, ‰ËÏ·‰‹ ·ÎfiÌË ¯·ÌËÏfiÙÂÚ· Î·È ·fi ÙË ™·¯¿Ú· Ù˘ ∞ÊÚÈ΋˜. ∆Ô 1999, Ô ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘ ÁÈ· ÙÔ˘˜ ¿Ó‰Ú˜ ‹Ù·Ó Ù· 45,3 ¯ÚfiÓÈ· Î·È ÁÈ· ÙȘ Á˘Ó·›Î˜ Ù· 47,2. ™ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, 165/1000 ·È‰È¿ Âı·›ÓÔ˘Ó Î·Ù¿ ÙË Á¤ÓÓËÛË, ÂÓÒ ÛÙËÓ ∞ÌÂÚÈ΋ 7/1000. ™Ù· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 5 ÂÙÒÓ, Âı·›ÓÔ˘Ó 257/1000 Î·È 8/1000 ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙȘ ∏¶∞, ·ÓÙ›ÛÙÔȯ·. ™ÙȘ ËÏÈ˘ ¿Óˆ ÙˆÓ 15 ÂÙÒÓ, ÙÔ 64% ÙˆÓ ∞ÊÁ·ÓÒÓ Â›Ó·È ·Ó·ÏÊ¿‚ËÙÔÈ, ÂÓÒ ÛÙȘ ∏¶∞ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ·Ó¤Ú¯ÂÙ·È ÌfiÏȘ Û 1%. O ˘ÔÛÈÙÈÛÌfi˜ ÛÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È 70% Î·È 0% ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙËÓ ∞ÌÂÚÈ΋, ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Î·ı·Úfi Î·È fiÛÈÌÔ ÓÂÚfi ·Ú¤¯ÂÙ·È ÛÙÔ 13% ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ 100% ÙˆÓ ∞ÌÂÚÈηÓÒÓ (3). ∆Ô Û‡ÛÙËÌ· ˘Á›·˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó Û¯Â‰fiÓ Î·Ù¤ÚÚ¢Û ٷ ÙÂÏÂ˘Ù·›· ‰‡Ô ¯ÚfiÓÈ·. ∏ ÍËÚ·Û›· Î·È Ô fiÏÂÌÔ˜ ÚÔοÏÂÛ·Ó ÌÂÙ·Ó¿ÛÙ¢ÛË ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó Î·È ÙÔ πÚ¿Ó. ¢‡Ô ÂηÙÔÌ̇ÚÈ· ∞ÊÁ·ÓÔ› ÎÈÓ‹ıËÎ·Ó ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó Î·È 1.500.000 ÛÙÔ πÚ¿Ó. ªÂ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ‚ÔÌ‚·Ú‰ÈÛÌÒÓ, ¯ÈÏÈ¿‰Â˜ ¿ÓıÚˆÔÈ ¤Ê˘Á·Ó ÚÔ˜ ÙÔ ¶·ÎÈÛÙ¿Ó, ÙÔ πÚ¿Ó Î·È ¿ÏϘ ÁÂÈÙÔÓÈΤ˜ ¯ÒÚ˜. ∆Ô ÌÂÙ·Ó·ÛÙ¢ÙÈÎfi ·̷ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙ· ÔÎÙÒ ÂηÙÔÌ̇ÚÈ·. O ÏÈÌfi˜ ‹‰Ë Ì·ÛÙ›˙ÂÈ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙÔ˘ ÏËı˘ÛÌÔ‡. ∫¿Ùˆ ·fi ·˘Ù¤˜ ÙȘ Û˘Óı‹Î˜, ηӤӷ ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈÎfi ̤ÙÚÔ ‰ÂÓ ÚfiÎÂÈÙ·È Ó· ·Ô‰ÒÛÂÈ. ¶Ú¤ÂÈ Ó· ‚ÚÂıÔ‡Ó ÙÚfiÔÈ

Paediatriki 2003;66:82-88

‚Ô‹ıÂÈ·˜ ÙˆÓ ÏËı˘ÛÌÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ΛӉ˘ÓÔ (populations at risk), ·Ú¿ ̤ıÔ‰ÔÈ ÙÈ̈ڛ·˜.

O Lafeet Afridi, ·ÍȈ̷ÙÔ‡¯Ô˜ ÙÔ˘ ¶·ÎÈÛÙ¿Ó, ·Ó¤ÊÂÚ fiÙÈ Ë ¢‡ÛË Ú¤ÂÈ Ó· ÎÙ›ÛÂÈ Û¯ÔÏ›· Î·È ÓÔÛÔÎÔÌ›· ÙÔ Ù·¯‡ÙÂÚÔ, ‰ÈfiÙÈ ÔÈ Û˘Ì·ıÔ‡ÓÙ˜ ÚÔ˜ ÙÔ˘˜ ∆·ÏÈÌ¿Ó ı· Ï¿‚Ô˘Ó Ì¤ÚÔ˜ ÛÙÔÓ fiÏÂÌÔ Î·È ı· Á›ÓÔ˘Ó ÂÈÚ·Ù¤˜ (3). ∆Ô ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È ÙÔ ı‡Ì· ÙˆÓ Î˘‚ÂÚÓ‹ÛÂˆÓ Ô˘ ı¤ÏÔ˘Ó Ó· ηٷÔÏÂÌ‹ÛÔ˘Ó ÙËÓ ÙÚÔÌÔÎÚ·Ù›·. ∏ ÔÏÈÙÈ΋ ÙˆÓ ‰˘ÙÈÎÒÓ ‰˘Ó¿ÌÂˆÓ Ú¤ÂÈ Ó· Â›Ó·È Ì·ÎÚÔ¯ÚfiÓÈ· Î·È Ó· ¤¯ÂÈ ÙÚÈÏ‹ ηÙ‡ı˘ÓÛË: ˘Á›·, ·Ó¿Ù˘ÍË Î·È ·ÓıÚÒÈÓ· ‰ÈηÈÒÌ·Ù·. ∞˘Ù¿ Ú¤ÂÈ Ó· ·ÔÙÂÏÔ‡Ó ÙÔ ÛÙÚ·ÙËÁÈÎfi ÎÏÂȉ› Ù˘ ¢‡Û˘. ∏ Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Â›Ó·È Û˘Ó‹ıˆ˜ ‚Ú·¯˘ÚfiıÂÛÌË Î·È ÂÛÙÈ¿˙ÂÙ·È ÛÙȘ ¿ÌÂÛ˜ ÔÏÈÙÈΤ˜ Î·È ÛÙÚ·ÙȈÙÈΤ˜ ÂȉÈÒÍÂȘ. ™ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó, Ù· ∏ӈ̤ӷ ŒıÓË ¤ÛÙÚ„·Ó fiÏË ÙËÓ ÚÔÛÔ¯‹ Û ¤Ó· ÚfiÛˆÔ Î·È ›ÂÛ·Ó ÙÔ˘˜ ∆·ÏÈÌ¿Ó Ó· ·Ú·‰ÒÛÔ˘Ó ÙÔÓ Osama Bin Laden. ∞ÁÓfiËÛ·Ó ÙȘ ÂȉڿÛÂȘ ÛÙËÓ ˘Á›· Î·È ·¤Ù˘¯·Ó ÛÙËÓ ¿Ù·ÍË Ù˘ ÙÚÔÌÔÎÚ·Ù›·˜.

OÈ ‰˘ÙÈΤ˜ ‰˘Ó¿ÌÂȘ Ú¤ÂÈ Ó· ȤÛÔ˘Ó ÙÔ˘˜ ¢ÈÂıÓ›˜ OÚÁ·ÓÈÛÌÔ‡˜ Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔÓ ¿Û¯ÔÓÙ· ÏËı˘ÛÌfi. ¶·Ú¿ÏÏËÏ·, Ú¤ÂÈ Ó· ÌÂÚÈÌÓ‹ÛÔ˘Ó ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ (Â¿ÚÎÂÈ· fiÛÈÌÔ˘ ÓÂÚÔ‡, ·ÔÊ˘Á‹ ÍËÚ·Û›·˜ Î.Ï.). O ¶·ÁÎfiÛÌÈÔ˜ OÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ (¶OÀ) ¤ÛÙÂÈÏ 10.000 ÙfiÓÔ˘˜ ÛÈÙ¿ÚÈ ÁÈ· ÙÔ˘˜ ÌÂÙ·Ó¿ÛÙ˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· ∆Ú¿Â˙·, ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ 2001 ÛÙȘ ∏¶∞ ı· ¤¯ÂÈ ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÔÈÎÔÓÔÌ›· ÙˆÓ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ ¯ˆÚÒÓ. ∫·Ù¿ ÙÔÓ Devaragan, ı· Âı¿ÓÔ˘Ó 20.000-40.000 ÂÚÈÛÛfiÙÂÚ· ·È‰È¿, ÂÓÒ ÂÚ›Ô˘ 10 ÂηÙÔÌ̇ÚÈ· ÂÈϤÔÓ ¿ÓıÚˆÔÈ ı· ˙‹ÛÔ˘Ó Ì ¤Ó· ‰ÔÏ¿ÚÈÔ ÙËÓ Ë̤ڷ. OÈ ˘Ô·Ó¿Ù˘ÎÙ˜ ¯ÒÚ˜ ı· ÂÚÈÔÚ›ÛÔ˘Ó ÙȘ ‰·¿Ó˜ ÁÈ· ÙË ‰ËÌfiÛÈ· ˘Á›·, ‰ËÏ·‰‹ ÙË ‰·¿ÓË ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· Aids, Ê˘Ì·Ù›ˆÛË, ÂÏÔÓÔÛ›· Î·È ÌËÙÚÈ΋ ˘Á›·. ∂Ô̤ӈ˜, ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÚÔοÏÂÛ ÌÂÁ·Ï‡ÙÂÚË ÔÈÎÔÓÔÌÈ΋ ‰˘ÛÙ˘¯›· ÛÙȘ ÊÙˆ¯¤˜ ·’ fiÙÈ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜.

O ¶OÀ ˘ÔÏÔÁ›˙ÂÈ fiÙÈ ÙÔ 2005 ı· ¤¯ÂÈ ÂÍ·Ê·ÓÈÛÙ› Ë ÔÏÈÔÌ˘ÂÏ›Ùȉ· ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È ÛÙÔ ¶·ÎÈÛÙ¿Ó. ∫·È ÔÈ ‰‡Ô ¯ÒÚ˜ ÛËÌ›ˆÛ·Ó ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô ÛÙË Ì›ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜. ªÂÙ¿ ÙËÓ Â›ıÂÛË Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘ ÛÙË ¡. ÀfiÚÎË ÙˆÓ ∏¶∞, 1,5 ÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÌÂÙ·Ó¿ÛÙÂ˘Û·Ó ÛÙ· Û‡ÓÔÚ· ÙÔ˘ ¶·ÎÈÛÙ¿Ó, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÙÔ 20% ‹Ù·Ó ·È‰È¿. §fiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÌË ÂÌ‚ÔÏÈ·ÛÌ¤ÓˆÓ ·È‰ÈÒÓ, ·Ó·Ì¤ÓÂÙ·È ÂȉËÌ›· ÈÏ·Ú¿˜ Î·È ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙÔ ¶·ÎÈÛÙ¿Ó.

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™ÂÏ›‰·86

¶·È‰È·ÙÚÈ΋ 2003;66:82-88

∆Ô ™Â٤̂ÚÈÔ ÙÔ˘ 2001 ›¯Â ÚÔÁÚ·ÌÌ·ÙÈÛÙ› Ì·˙ÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙ· ·È‰È¿ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó, Ô ·ÚÈıÌfi˜ ÙˆÓ ÔÔ›ˆÓ ÛÙËÓ ËÏÈΛ· οو ÙˆÓ 5 ÂÙÒÓ ·Ó¤Ú¯ÂÙ·È Û 5 ÂηÙÔÌ̇ÚÈ·. §fiÁˆ ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ‚ÔÌ‚·Ú‰ÈÛÌÒÓ, Ù· ·È‰È¿ ÌÂÙ·ÎÈÓ‹ıËÎ·Ó ·fi Ù· ·ÛÙÈο ΤÓÙÚ· ÚÔ˜ ÙȘ ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜. ŒÙÛÈ ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÓÙÔÈÛÙÔ‡Ó Î·È Ó· ÂÌ‚ÔÏÈ·ÛÙÔ‡Ó. ª¤¯ÚÈ ÙÔ ™Â٤̂ÚÈÔ ÙÔ˘ 2000, ·Ó·Ê¤ÚıËÎ·Ó 9 ÂÚÈÙÒÛÂȘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Î·È 50 ÛÙÔ ¶·ÎÈÛÙ¿Ó. ¡¤· ÂıÓÈ΋ Ë̤ڷ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÚÔÁÚ·ÌÌ·Ù›ÛÙËÎÂ Ë 8Ë ¡ÔÂÌ‚Ú›Ô˘ 2001, ȉȷ›ÙÂÚ· ÁÈ· Ù· ·È‰È¿ ÙˆÓ ÌÂÙ·Ó·ÛÙÒÓ Ô˘ ‹Ù·Ó ÛÙ· Û‡ÓÔÚ· Ì ÙÔ ¶·ÎÈÛÙ¿Ó. ™ÙȘ ·Ú¯¤˜ ÙÔ˘ OÎÙˆ‚Ú›Ô˘ 2001 ‰È·Ù¤ıËÎ·Ó ·fi ÙË UNICEF 35 ÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÁÈ· ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó.

O ¶OÀ ·Ó¤ÊÂÚ fiÙÈ Ù· ÔÈÎÔÓÔÌÈο ÎÂÊ¿Ï·È· ‹Ù·Ó ÌÈÎÚ¿ ÁÈ· Ó· ηχ„Ô˘Ó ÙȘ ·Ó¿ÁΘ ˘Á›·˜ Î·È ÂÈ‚›ˆÛ˘ ÙˆÓ ·È‰ÈÒÓ. O Kofi Annan ÂÂÛ‹Ì·Ó fiÙÈ ¯ÚÂÈ¿˙ÔÓÙ·È 854 ÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÁÈ· Ó· ‚ÔËı‹ÛÔ˘Ó 7,5 ÂηÙÔÌ̇ÚÈ· ∞ÊÁ·ÓÔ‡˜ ÁÈ· 6 Ì‹Ó˜ (4). ∆· ∏ӈ̤ӷ ŒıÓË ‰È·›ÛÙˆÛ·Ó fiÙÈ ÌÂÙ¿ ·fi 23 ¯ÚfiÓÈ· ÂÌfiÏÂÌ˘ ηٿÛÙ·Û˘ Î·È 3 ¯ÚfiÓÈ· ÌÂÁ¿Ï˘ ÍËÚ·Û›·˜, ÔÈ Û˘Óı‹Î˜ ˙ˆ‹˜ ¤¯Ô˘Ó ÂȉÂÈÓˆı› ÛÙËÓ ÂÚÈÔ¯‹. ªÂÙ¿ ·fi ÙÔ ÎÙ‡ËÌ· Ù˘ 11˘ ™ÂÙÂÌ‚Ú›Ô˘, ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÙÔ˘ OÎÙˆ‚Ú›Ô˘ 2001, ¤Êı·Ó·Ó ÛÙË ∫·ÌÔ‡Ï 218 ÙfiÓÔÈ ÛÈÙ·ÚÈÔ‡. ∏ ÌÂÁ¿ÏË ÍËÚ·Û›· ÚÔοÏÂÛ ·Ûı¤ÓÂÈ· ÙÔ˘ ‹·ÙÔ˜, Ë ÔÔ›· ‹Ù·Ó ı·Ó·ÙËÊfiÚÔ˜. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ ¶OÀ, ÙÔ 1999 ÂηÙfi ¿ÙÔÌ· ¤ı·Ó·Ó ·fi ·˘Ù‹ ÙË ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ Î·È 400 ·ÎfiÌ· ÚÔÛ‚ϋıËÛ·Ó. ∫·Ù¿ ÙËÓ ÍËÚ·Û›· ÙÔ˘ 1970 ·Ó·Ê¤ÚıËΠfiÙÈ Ë ÓfiÛÔ˜ ÚÔηÏ› ·fiÊÚ·ÍË ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ Î·Ù·Ó¿ÏˆÛË „ˆÌÈÔ‡ ÙÔ ÔÔ›Ô ¤¯ÂÈ ·Ó·ÌÂȯı› Ì ÛfiÚÔ˘˜ ËÏÈÔÙÚÔ›Ô˘. ∞˘Ùfi ÙÔ Â›‰Ô˜ „ˆÌÈÔ‡ ηٷӷÏÒÓÂÙ·È ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Û ÂÚ›Ô‰Ô ÍËÚ·Û›·˜. ∆Ô ËÏÈÔÙÚfiÈÔ, Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÍËÚ·Û›·˜, ÂÚȤ¯ÂÈ ˘ÚÔÏȉ›ÓË Ô˘ Â›Ó·È ·ÏηÏÔÂȉ¤˜ Î·È ‚Ú›ÛÎÂÙ·È Î·È ÛÙÔ Á¿Ï· ÙˆÓ ·ÁÂÏ¿‰ˆÓ, ÙˆÓ ÚÔ‚¿ÙˆÓ Î.Ï., ·ÊÔ‡ ·˘Ùfi ·ÔÙÂÏ› ‚·ÛÈ΋ ÙÚÔÊ‹ ÙˆÓ ˙ÒˆÓ Î·Ù¿ ÙËÓ ÍËÚ·Û›·. ∆Ô 1975, ¿ÏÈ ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó ÚÔÛ‚ϋıËÛ·Ó ·fi ÙË ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜ “Charmac” 7.200 οÙÔÈÎÔÈ Ì¤Û· Û 2 ¯ÚfiÓÈ·. ∏ ¤ÏÏÂÈ„Ë ÁÓÒÛ˘ ·˘Ù‹˜ Ù˘ ·ÈÙ›·˜ ÚÔηÏ› ˘„ËÏ‹ ıÓËÛÈÌfiÙËÙ· Î·È ‰˘ÛÙÚÔÊ›·, fiˆ˜ ÙÔ Kwashorkor. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÙÚÔÊ‹˜ Î·È Ë ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÛfiÚˆÓ ÙÔ˘ ËÏÈÔÙÚÔ›Ô˘ ·fi ÙÔ „ˆÌ› Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓfiÛÔ˘. º˘ÛÈο, fiϘ ÔÈ ÂÓ¤ÚÁÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ¤ÁηÈÚ·. ∆ÔÓ OÎÙÒ‚ÚÈÔ 2001, ‚ÈÔÏfiÁÔÈ ‹Á·Ó ÛÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó

86

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Ó· ÂϤÁÍÔ˘Ó ÙÔ „ˆÌ› ÙˆÓ ·ÓıÚÒˆÓ Î·È ÙÔ Á¿Ï· ÙˆÓ ·ÁÂÏ¿‰ˆÓ (4). ∏ ¤ÏÏÂÈ„Ë ÙÔ˘ ÓÂÚÔ‡ ÛÙË ÁË Ì·˜ Â›Ó·È Î·Ù·ÛÙÚÔÊÈ΋ Î·È Á›ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ¤Î‰ËÏË Û ÂÚÈfi‰Ô˘˜ ÍËÚ·Û›·˜. À¿Ú¯Ô˘Ó ÔÏϤ˜ ¯ÒÚ˜ Ô˘ ˘ÔʤÚÔ˘Ó ·fi ÍËÚ·Û›· fiˆ˜ ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë µfiÚÂÈ· ∞ÊÚÈ΋, Ë µfiÚÂÈ· ∫›Ó·, Ë πÓ‰›·, ÙÔ πÚ¿Ó, Ë ∫ÂÓÙÚÈ΋ ∞ÌÂÚÈ΋, Ë ª¤ÛË ∞Ó·ÙÔÏ‹, Ë ¡fiÙÈ· ∫ÔÚ¤·, ÙÔ ¶·ÎÈÛÙ¿Ó Î·È Ë ™·¯¿Ú·. ™Â ¤Ó· ÙÌ‹Ì· Ù˘ ∆¯ÂÚ¿Ó˘, Ë ·ÚÔ¯‹ ÓÂÚÔ‡ ‰È·ÎfiÙÂÙ·È Ì›· Ë̤ڷ ÙËÓ Â‚‰ÔÌ¿‰· ÁÈ· 12 ÒÚ˜. ∞ÍȈ̷ÙÔ‡¯ÔÈ ÙÔ˘ ¶·ÎÈÛÙ¿Ó ·Ó¤ÊÂÚ·Ó fiÙÈ ÏfiÁˆ Ù˘ ÍËÚ·Û›·˜ ηٷÁÚ¿ÊËÎ·Ó ·ÒÏÂȘ 1,2 ‰ÈÛÂηÙÔÌÌ˘Ú›ˆÓ ‰ÔÏ·Ú›ˆÓ ·fi ÙȘ ·ÁÚÔÙÈΤ˜ ηÏÏȤÚÁÂȘ. ™ÙÔ ªÂÍÈÎfi Î·È ÙÔ ¡fiÙÈÔ ∆¤Í·˜, Ù· ·Ôı¤Ì·Ù· ÓÂÚÔ‡ Â›Ó·È ¯·ÌËÏ¿ ÌÂ Û˘Ó¤ÂÈ· ÔÈ ·ÁÚfiÙ˜ Ó· ¤¯Ô˘Ó Úfi‚ÏËÌ· ·Ú‰Â‡Ûˆ˜ ÙˆÓ ÎÙËÌ¿ÙˆÓ ÙÔ˘˜, ÔfiÙ ‰·Ó›˙ÔÓÙ·È ÓÂÚfi ·fi ÙÔ ∆¤Í·˜. ∞ÎfiÌË Î·È ÔÈ fiÏÂȘ ÙÔ˘ ªÂÍÈÎÔ‡ Ô˘ Û˘ÓÔÚÂ‡Ô˘Ó Ì ÙÔ ∆¤Í·˜ ¤¯Ô˘Ó Úfi‚ÏËÌ· ÏÂÈ„˘‰Ú›·˜. ŒÓ· ÍËÚfi ηÏÔη›ÚÈ ÛÙËÓ ∫ÂÓÙÚÈ΋ ∞ÌÂÚÈ΋ ÚÔοÏÂÛ ÙËÓ ·ÒÏÂÈ· ÙˆÓ ·ÁÚÔÙÈÎÒÓ ÂÈÛÔ‰ËÌ¿ÙˆÓ Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 50% Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 700.000 ·ÁÚÔÙÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ. ™ÙȘ ·Ú·¿Óˆ 10 ¯ÒÚ˜, ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÌÈÛfi ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ˘ÔʤÚÔ˘Ó ·fi ·ÓÂ¿ÚÎÂÈ· ·ÚÔ¯‹˜ ÓÂÚÔ‡. ∞Ó ‰ÂÓ ÏËÊıÔ‡Ó Î·Ù¿ÏÏËÏ· ̤ÙÚ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ ¤ÙÔ˜ 2025 ÙÔ 35% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ (ÂÚ›Ô˘ 2,8 ‰ÈÛÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ) ı· ·ÓÙÈÌÂÙˆ›˙ÂÈ Úfi‚ÏËÌ· ÏÂÈ„˘‰Ú›·˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÎÔÈÓˆÓÈ΋ Î·È ÔÈÎÔÓÔÌÈ΋ Âڋ̈ÛË ÙˆÓ ÂÚÈÔ¯ÒÓ Ô˘ Ï‹ÙÙÔÓÙ·È ·fi ÙËÓ ÍËÚ·Û›· Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ·̷ÙÔ˜ “ÌÂÙ·Ó·ÛÙÒÓ ‡‰·ÙÔ˜”. ªfiÓÔ ÙÔ 3% ÙÔ˘ ÓÂÚÔ‡ Ù˘ Á˘ Â›Ó·È ÊÚ¤ÛÎÔ, ÂÓÒ ÙÔ ÂÚÈÛÛfiÙÂÚÔ ‰ÂÓ Â›Ó·È ‰È·ı¤ÛÈÌÔ ÂÂȉ‹ Â›Ó·È ÂÁÎψ‚ÈṲ̂ÓÔ Û ˘‰·ÙÔı‹Î˜ ÙˆÓ ¿ÁˆÓ. ∏ ·Ó·ÏÔÁ›· ÊÚ¤ÛÎÔ˘ ÓÂÚÔ‡ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙË ÁË ·ÓÙÈÛÙÔȯ› Û ó ÎÔ˘Ù·Ï¿ÎÈ ÙÔ˘ ÁÏ˘ÎÔ‡ ·Ó¿ 100 L ÓÂÚÔ‡ (5). ∞˘Ùfi ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÏÈÙÈΤ˜ ·ÓÙÈ·Ú·ı¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ÎÚ·ÙÒÓ ÁÈ· ÙÔ ÓÂÚfi ÙˆÓ ÔÙ·ÌÒÓ Î·È ÙˆÓ ˘‰¿ÙÈÓˆÓ ·ÔıËÎÒÓ. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÙÈ·Ú¿ıÂÛË ÌÂٷ͇ ÙˆÓ fiÏÂˆÓ ÙˆÓ πÓ‰ÈÒÓ ·Ó¿ÁηÛ ÙËÓ Î˘‚¤ÚÓËÛË Ó· ηıÈÂÚÒÛÂÈ ‰ÈηÛÙ‹ÚÈ· ÓÂÚÔ‡ ÁÈ· Ó· Ú˘ıÌ›˙ÔÓÙ·È ÔÈ ‰È·ÊÔÚ¤˜ ÙÔ˘˜. ™ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó, Ë ÏÂÈ„˘‰Ú›· Î·È Ë ÍËÚ·Û›· ÚÔοÏÂÛ·Ó ÙË ı·Ó·ÙËÊfiÚÔ ÓfiÛÔ ÙÔ˘ ‹·ÙÔ˜. ∏ Ì›ˆÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ ÓÂÚÔ‡ ÚÔÎÏ‹ıËΠ·fi ÔÏϤ˜ ·Èٛ˜, fiˆ˜ Ë Ù·¯Â›· ·‡ÍËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ȉ›ˆ˜ ÛÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë ˘ÂÚ‚ÔÏÈ΋ ¿ÓÙÏËÛË ÙˆÓ ·ÔıËÎÒÓ ÓÂÚÔ‡, ÔÈ Î·Ù·Û΢¤˜ ˘‰·ÙÔÊÚ·ÎÙÒÓ Î·È ·ÔıËÎÒÓ ÓÂÚÔ‡, Ë ˘ÂÚ‚ÔÏÈ΋ ηٷӿψÛË ÙÔ˘ ÓÂÚÔ‡ Î·È ÔÈ ·ÏÏ·Á¤˜ ÙÔ˘ Îϛ̷ÙÔ˜.

JAN-FEB-03

14-05-03

17:18

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¶·È‰È·ÙÚÈ΋ 2003;66:82-88

∂ÎÙfi˜ ·fi ÙËÓ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÓÂÚÔ‡, ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ·ÔÙÂÏ› Î·È Ë ‰È·Ù‹ÚËÛË Ù˘ ÔÈfiÙËÙ¿˜ ÙÔ˘. ∆Ô ‰È·ı¤ÛÈÌÔ ÓÂÚfi ÌÔÚ› Ó· ÂÈÌÔχÓÂÙ·È Ì ·ÓıÚÒÈÓ· ÎfiÚ·Ó·, Ô‡Ú·, ·ıÔÁfiÓÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜, ‚ÈÔÌ˯·ÓÈο ·fi‚ÏËÙ·, È·ÙÚÈο Î·È ÎÙËÓÈ·ÙÚÈο Ê¿Ú̷η Î·È Ê¿Ú̷η Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙˆÓ ÏÔÈÌÒÓ, fiˆ˜ ÂÓÙÔÌÔÎÙfiÓ·, Ê¿Ú̷η ÁÈ· ·ÚÔ˘Ú·›Ô˘˜, ÔÓÙÈÎÔ‡˜ Î.Ï. ™ÙÔ ª·ÁÎÏ·ÓÙ¤˜, ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 1/3 Ù˘ ¯ÒÚ·˜ ·ÓÙÈÌÂÙˆ›˙ÂÈ ÛÔ‚·Úfi Úfi‚ÏËÌ· ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÓÂÚÔ‡ ·fi ·ÚÛÂÓÈÎfi. ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ·ÚÛÂÓÈÎfi Ô˘ ÂÚȤ¯ÂÙ·È ÛÙÔ ÓÂÚfi ÚÔÊ˘Ï¿ÛÛÂÈ ÌÂÓ ÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ·fi ÓÔÛ‹Ì·Ù· Ô˘ ÌÂÙ·‰›‰ÔÓÙ·È ·fi ÙÔ ÓÂÚfi, fiˆ˜ .¯. ¯ÔϤڷ, Ù‡ÊÔ Î·È Ë·Ù›Ùȉ· ∞, ÛÎÔÙÒÓÂÈ ‰Â 500 ¯ÈÏÈ¿‰Â˜ ηÙÔ›ÎÔ˘˜ Ù˘ ¯ÒÚ·˜ οı ¯ÚfiÓÔ (5). ¢È¿ÊÔÚ˜ χÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÏÂÈ„˘‰Ú›·˜ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÈfiÙËÙ·˜ ÙÔ˘ ÓÂÚÔ‡ Ú¤ÂÈ Ó· ÚÔÙ·ıÔ‡Ó. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÔÙ·ÌÔ› ÂϤÁ¯ÔÓÙ·È ·fi ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ¯ÒÚ˜. ŒÙÛÈ Â›Ó·È ˙ˆÙÈÎfi, Ì ÂıÓÈΤ˜ Û˘Ìʈӛ˜ Î·È ‰ÈÂıÓ›˜ Û˘Ì‚¿ÛÂȘ, Ó· ηٷÓÂÌËı› ÙÔ ÓÂÚfi ÌÂٷ͇ ÙˆÓ ÂӉȷÊÂÚfiÌÂÓˆÓ ¯ˆÚÒÓ. ∆Ô 1998, Ë ¤ÎıÂÛË ÙÔ˘ ¶OÀ ·Ó¤ÊÂÚ fiÙÈ ··ÈÙÔ‡ÓÙ·È 10 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ÙÔ ¯ÚfiÓÔ ÁÈ· Ó· ÂÊԉȷÛÙ› fiÏÔ˜ Ô ÏËı˘ÛÌfi˜ Ù˘ Á˘ Ì ˘ÁÈÂÈÓfi Î·È Î·ı·Úfi ÓÂÚfi. ∆Ô ÎfiÛÙÔ˜ ·˘Ùfi ÈÛÔ‰˘Ó·Ì› Ì ÙÔ 1/10 ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ÍÔ‰Â‡Ô˘Ó ÔÈ ∂˘Úˆ·›ÔÈ ÁÈ· ·ÏÎÔÔÏÔ‡¯· ÔÙ¿, Ì ÙÔ ÔÛfi Ô˘ ÍÔ‰Â‡Ô˘Ó ÁÈ· ·ÁˆÙ¿ ‹ Ì ÙÔ ‹ÌÈÛ˘ ÙˆÓ ¯ÚËÌ¿ÙˆÓ Ô˘ ‰··ÓÔ‡Ó ∞ÌÂÚÈηÓÔ› Î·È ∂˘Úˆ·›ÔÈ Î¿ı ¯ÚfiÓÔ ÁÈ· ÙÚÔʤ˜ ÙˆÓ Î·ÙÔÈΛ‰ÈˆÓ ˙ÒˆÓ ÙÔ˘˜. ∏ Ó¤· Ù¿ÍË Ú·ÁÌ¿ÙˆÓ Ê·›ÓÂÙ·È fiÙÈ Ô‰‹ÁËÛ ÙÔÓ ¿ÓıÚˆÔ Ó· Á›ÓÂÈ ÂÚÈÛÛfiÙÂÚÔ ˙ˆfiÊÈÏÔ˜ Î·È ÏÈÁfiÙÂÚÔ ÊÈÏ¿ÓıÚˆÔ˜. ∆Ô ÌÈÎÚfi ÎfiÛÙÔ˜ ¯ÚËÌ¿ÙˆÓ ÌÔÚ› Ó· Â›Ó·È Ë ÚÒÙË ÂÓ¤ÚÁÂÈ· ÁÈ· ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Î·ı·ÚÔ‡ Î·È ˘ÁÈÂÈÓÔ‡ ÓÂÚÔ‡ ÛÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ Ï·Ó‹ÙË Ì·˜. ∆· ∂ӈ̤ӷ ŒıÓË ÔÚÁ·ÓÒÓÔ˘Ó ÙÔ 2003 ÙÔ “¢ÈÂıÓ¤˜ ŒÙÔ˜ ºÚ¤ÛÎÔ˘ ¡ÂÚÔ‡”. ∂›Ó·È ÛËÌ·ÓÙÈÎfi, ÔÈ Î˘‚ÂÚÓ‹ÛÂȘ ÙˆÓ ÎÚ·ÙÒÓ, Ó· ÌËÓ ÂÚÈÔÚÈÛÙÔ‡Ó Û ÔÚ¿Ì·Ù· Î·È ıˆÚËÙÈο Ï¿Ó· ÁÈ· ηı·Úfi ÓÂÚfi, ·ÏÏ¿ Ó· ÂÊ·ÚÌfiÛÔ˘Ó Ì¤ÙÚ· Ú·ÎÙÈο Î·È ·ÔÙÂÏÂÛÌ·ÙÈο ÁÈ· ÙËÓ Â›Ù¢ÍË ·˘ÙÔ‡ ÙÔ˘ ÛÙfi¯Ô˘ (5). ™‡Ìʈӷ Ì ‰ËÌÔÛÎfiËÛË ÙÔ˘ CNN (∞Ú›ÏÈÔ˜ 2002), ÔÈ ∞ÌÂÚÈηÓÔ›, ‰˘ÛÙ˘¯Ò˜, ÈÛÙÂ‡Ô˘Ó fiÙÈ Ë ∞ÌÂÚÈ΋ Â›Ó·È ÈÛ¯˘ÚfiÙÂÚË ÌÂÙ¿ ÙËÓ 11Ë ™ÂÙÂÌ‚Ú›Ô˘, ÂÓÒ ÙÔ 90% ‰¤¯ÂÙ·È fiÙÈ ¿ÏÏ·Í·Ó “Ù· ¿ÓÙ· ÁÈ· ¿ÓÙ·”. ∆Ô 60% Ù¿ÛÛÂÙ·È ˘¤Ú ÙÔ˘ ÔϤÌÔ˘ Î·È ÙÔ 75% ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ÔÈ ∏¶∞ Ú¤ÂÈ Ó· ÛÙ›ÏÔ˘Ó ÛÙÚ·Ù‡̷ٷ ÂÓ·ÓÙ›ÔÓ ÙÔ˘ πÚ¿Î ÁÈ· Ó· ·Ó·ÙÚ¤„Ô˘Ó ÙÔÓ ™·ÓÙ¿Ì ÃÔ˘ÛÂ˝Ó (6). ∞fi ÙËÓ ÎÚ›ÛË ÛÙË ª¤ÛË ∞Ó·ÙÔÏ‹ Ê·›ÓÂÙ·È fiÙÈ ÙfiÛÔ ÔÈ πÛÚ·Ëϛ٘ fiÛÔ Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ıˆ-

Paediatriki 2003;66:82-88

ÚÔ‡Ó ÙËÓ Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·Ùfi˜ ÙÔ˘˜ ÂÊÈÎÙ‹ Ì ÙËÓ ÂΉ›ÎËÛË Î·È ÙË ‚›· (7). ™‡Ìʈӷ Ì ÙËÓ ¿Ô„Ë ÙˆÓ È·ÙÚÒÓ ÁÈ· Ù· ·ÓıÚÒÈÓ· ‰ÈηÈÒÌ·Ù·, ÔÈ ‰‡Ô ÎÔÈӈӛ˜ ¤¯Ô˘Ó ÂÈÛ¤ÏıÂÈ Û ¤Ó·Ó ·ÎÏÔ ·ÏÏËÏÔÂÍfiÓÙˆÛ˘. ¶ÏËÚÔÊÔڛ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÓÔÛÔÎÔÌÂȷο ·˘ÙÔΛÓËÙ· ÙˆÓ ¶·Ï·ÈÛÙÈÓ›ˆÓ Ô˘ ›¯·Ó ÂÏÂÁ¯ı› ·fi ÙȘ ŒÓÔϘ ¢˘Ó¿ÌÂȘ ÙÔ˘ πÛÚ·‹Ï ˘ÚÔ‚ÔÏ‹ıËÎ·Ó Î·È ÙÔ ϋڈ̿ ÙÔ˘˜ ÊÔÓ‡ıËÎÂ. ∂ÈÛÙÔϤ˜ ·fi È·ÙÚÔ‡˜ ÙˆÓ ∏¶∞, ÙÔ˘ Eӈ̤ÓÔ˘ µ·ÛÈÏ›Ԣ Î·È ÙÔ˘ πÛÚ·‹Ï ÚÔ˜ ÙÔ ÂÚÈÔ‰ÈÎfi Lancet, Ô˘ ‰ËÌÔÛȇıËÎ·Ó ÛÙÔ ¿ÚıÚÔ Ì ٛÙÏÔ “Failure to address the health toll of Middle East crisis”, ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ ÓÔÛÔÎÔÌÂȷο ·˘ÙÔΛÓËÙ· ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·fi ÙÔ˘˜ ¶·Ï·ÈÛÙ›ÓÈÔ˘˜ ˆ˜ ·˘ÙÔΛÓËÙ· ·˘ÙÔÎÙÔÓ›·˜ Ô˘ ¤ÊÂÚ·Ó ¿ÚÚˆÛÙ· ·È‰È¿ ‹ ÓÂÎÚÔ‡˜ ÙÔÔıÂÙË̤ÓÔ˘˜ Û ÂÎÚËÎÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜, Ì ÛÎÔfi Ó· ·Ú·Ï·Ó‹ÛÔ˘Ó ÙȘ ŒÓÔϘ ¢˘Ó¿ÌÂȘ ÙÔ˘ πÛÚ·‹Ï ÁÈ· Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ηÌÈο˙È ÂÓ·ÓÙ›ÔÓ πÛÚ·ËÏÈÓÒÓ ÔÏÈÙÒÓ (7). ¶·Ï·ÈÛÙÈÓÈ·Îfi ·ÛıÂÓÔÊfiÚÔ Ì ÂÎÚËÎÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Î·È ‚fî˜ ·ÔÂÈÚ¿ıËΠӷ ·ÂÈÏ‹ÛÂÈ ÙË ˙ˆ‹ ÙÔ˘ Colin Powell ÙÔ ‚Ú¿‰˘ Ù˘ ·Ê›ÍÂÒ˜ ÙÔ˘ ÛÙÔ πÛÚ·‹Ï Û‡Ìʈӷ Ì ÙË Ì·ÚÙ˘Ú›· ÙÔ˘ Ô‰ËÁÔ‡ ÙÔ˘ ·ÛıÂÓÔÊfiÚÔ˘, fiˆ˜ ÂÈÛËÌ·›ÓÂÈ ÛÙËÓ ÂÈÛÙÔÏ‹ ÙÔ˘ Ô ª.

Lauer ·fi ÙÔ Cleveland ÙˆÓ ∏¶∞ (8). À¿Ú¯Ô˘Ó Û·Ê›˜ ÂӉ›ÍÂȘ fiÙÈ ˘‹Ú¯Â ¤ÏÏÂÈ„Ë ÙÚÔʛ̈Ó, ÓÂÚÔ‡ Î·È ËÏÂÎÙÚÈÎÔ‡ Ú‡̷ÙÔ˜ Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ ÛÙË ‰ËÌfiÛÈ· ˘Á›·. OÈ ËÏÂÎÙÚÈΤ˜ ÂÁηٷÛÙ¿ÛÂȘ Ô˘ ηٷÛ΢¿ÛÙËÎ·Ó ÛÙË ÏˆÚ›‰· Ù˘ °¿˙·˜ ÙÔ 1993 ÛÙÔ›¯ÈÛ·Ó 4,5 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰ÔÏ¿ÚÈ· ∞ÌÂÚÈ΋˜ Î·È ¤¯Ô˘Ó ˘ÔÛÙ› ÙÂÚ¿ÛÙȘ ˙ËÌȤ˜.

O Carrol Bellamy, ‰È¢ı˘ÓÙ‹˜ Ù˘ Unicef, ·Ó¤ÊÂÚ fiÙÈ ÔÈ πÛÚ·ËÏÈÓÔ› Î·È ÔÈ ¶·Ï·ÈÛÙ›ÓÈÔÈ ‰È‰¿ÛÎÔ˘Ó ÛÙ· ·È‰È¿ ÙÔ˘˜ ÙËÓ ÙÚÔÌÔÎÚ·Ù›· ˆ˜ ̤ıÔ‰Ô Â›Ï˘Û˘ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘˜. OÈ Î˘‚ÂÚÓ‹ÛÂȘ Ù˘ ∂Ó. ∂˘ÚÒ˘ Î·È ÙˆÓ ∏¶∞, ÔÈ Ôԛ˜ ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ Â›Ó·È ÌÂÛÔÏ·‚ËÙ¤˜ Ù˘ ÂÈÚ‹Ó˘ ÛÙÔÓ ÎfiÛÌÔ, Ú¤ÂÈ Ó· ÎÈÓËÙÔÔÈËıÔ‡Ó, ÒÛÙ ÌÂÙ¿ ÙËÓ Î·Ù¿·˘ÛË ÙˆÓ Â¯ıÚÔÚ·ÍÈÒÓ Ó· ÂÈÌÂÏËıÔ‡Ó ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Ô˘ ‰ÂÓ Â›Ó·È ÔÏ˘Ù¤ÏÂÈ·, ·ÏÏ¿ ÂÈ‚¿ÏÏÂÙ·È ‰ÈfiÙÈ Ô ¿Ì·¯Ô˜ ÏËı˘ÛÌfi˜ Â›Ó·È Ù·Ï·ÈˆÚË̤ÓÔ˜, ηÎÔÔÈË̤ÓÔ˜ Î·È ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˜.

O Benjamin Disraeli ÙÔ 1877 ·Ó¤ÊÂÚ fiÙÈ “∏ ˘Á›· ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È Ë Ú·ÁÌ·ÙÈ΋ ıÂÌÂÏ›ˆÛ˘ Ù˘ Â˘Ù˘¯›·˜ Î·È Ù˘ ‰‡Ó·Ì˘ ÁÈ· Ì›· ·ÓÂÍ¿ÚÙËÙË ÔÏÈÙ›·”. ∆ËÓ ÂÔ¯‹ Ô˘ ÁÂÓÓ‹ıËÎÂ Ô ÃÚÈÛÙfi˜ ˘‹Ú¯Â ÌfiÓÔ ¤Ó·˜ ∏Ú҉˘. ™‹ÌÂÚ· Ê·›ÓÂÙ·È fiÙÈ ˘¿Ú¯Ô˘Ó ÔÏÏÔ› Ô˘ Û˘ÌÂÚÈʤÚÔÓÙ·È Û·Ó Ó· ¤¯Ô˘Ó ̤۷ ÙÔ˘˜ ÙÔÓ ∏ÚÒ‰Ë Î·È ÌÂıÔ‡Ó ·fi ÙÔ ·›Ì· ÙˆÓ ÛÊ·ÁÒÓ Î·È ·fi ÙÔ ıfiÚ˘‚Ô ÙˆÓ ÊÔÓÈÎÒÓ ÂÎڋ͈Ó. O ÃÚÈÛÙfi˜ ›Ûˆ˜ Ó· ÌËÓ Í·Ó·ÁÂÓÓËı›,

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¶·È‰È·ÙÚÈ΋ 2003;66:82-88

·ÏÏ¿ ÂÍ·ÎÔÏÔ˘ı› Ó· ÛÙ·˘ÚÒÓÂÙ·È ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÈÔ¯¤˜ ÔϤÌÔ˘, ÛÙÔ ÚfiÛˆÔ ÙˆÓ ·ıÒˆÓ ı˘Ì¿ÙˆÓ Ô˘ ·Ê‹ÓÔ˘Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÓÔ‹ ÛÙÔ ‰ÚfiÌÔ, ÛÙÔ ÏˆÊÔÚ›Ô, ÛÙÔ Û¯ÔÏÂ›Ô ‹ οو ·fi ÙË ‚ÔÌ‚·Ú‰ÈṲ̂ÓË ÛÙ¤ÁË ÙÔ˘ ÛÈÙÈÔ‡ ÙÔ˘˜ (1).

O ¶OÀ, ÔÈ ÌË ÎÚ·ÙÈΤ˜ ÔÚÁ·ÓÒÛÂȘ, Ë ∂ӈ̤ÓË ∂˘ÚÒË Î·È Ë ¢ÈÂıÓ‹˜ ∆Ú¿Â˙· Ú¤ÂÈ Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·Ó·Û˘ÁÎÚfiÙËÛË Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ¿ÓıÚˆÔÈ Âı·›ÓÔ˘Ó ÂÚ›Ô˘ Û ËÏÈΛ· 47 ÂÙÒÓ, ÂÓÒ ¤Ó· ÛÙ· Ù¤ÛÛÂÚ· ·È‰È¿ Âı·›ÓÂÈ ÛÙ· ¤ÓÙ ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘. ∆ÚÂȘ ¯ÈÏÈ¿‰Â˜ ¿ÓıÚˆÔÈ ÛÎÔÙÒıËÎ·Ó Û ¤Ó· ¯ÚfiÓÔ ·fi ÙȘ Ó¿ÚΘ Î·È ·ÚÎÂÙÔ› ¤ÌÂÈÓ·Ó ·Ó¿ËÚÔÈ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ηıÂÛÙÒÙÔ˜ ÙˆÓ ∆·ÏÈÌ¿Ó, ‰ÂÓ ·Ú¯fiÙ·Ó È·ÙÚÈ΋ ÊÚÔÓÙ›‰· ÛÙȘ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ Î·È ¤ÙÛÈ ÛËÌÂÈÒıËΠ˘„ËÏ‹ ÌËÙÚÈ΋ ıÓËÛÈÌfiÙËÙ·. ™ËÌ·ÓÙÈ΋ ÚÔÙÂÚ·ÈfiÙËÙ· ·ÔÙÂÏ›, Â›Û˘, Ë È·ÙÚÈ΋ ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ Î·È Ì ̤ÙÚ· ÚfiÏ˄˘ ·fi Ù· ÌÂÙ·‰È‰fiÌÂÓ· ÓÔÛ‹Ì·Ù·. ∏ ·Ó·‚¿ıÌÈÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ ÙÔ˘ ∞ÊÁ·ÓÈÛÙ¿Ó ı· ¯ÚÂÈ·ÛÙ› 5-10 ¯ÚfiÓÈ·. ∂›Ó·È ÁÓˆÛÙfi ·fi ÚÔËÁÔ‡ÌÂÓ˜ Û˘ÁÎÚÔ‡ÛÂȘ fiˆ˜ Ù˘ ªÔ˙·Ì‚›Î˘, ÙÔ˘ ∫ÔÛfi‚Ô˘ Î.Ï. fiÙÈ Ë ÊıËÓ‹ Â¤Ó‰˘ÛË ˘Á›·˜ Â›Ó·È ÛÊ¿ÏÌ·. ŒÓ· ·ÈÛÈfi‰ÔÍÔ Ì‹Ó˘Ì· ·fi ÙÔ ∞ÊÁ·ÓÈÛÙ¿Ó Â›Ó·È fiÙÈ Î·ı‹ÎÔÓÙ· ÀÔ˘ÚÁÔ‡ ÀÁ›·˜ ·Ó¤Ï·‚Â Ë Suhaila Seddiqui ¯ÂÈÚÔ˘ÚÁfi˜ ·fi ÙËÓ ∫·ÌÔ‡Ï. ∏ ‰È¿ÛˆÛË ·ÓıÚÒˆÓ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Â›Ó·È ËıÈ΋ Î·È ÂÈÙ·ÎÙÈ΋ ·Ó¿ÁÎË ÁÈ· fiÏÔ ÙÔÓ ÎfiÛÌÔ. ∏ Â¤Ó‰˘ÛË ÛÙËÓ ˘Á›· ›Ûˆ˜ ·Ô‰Âȯı› fiÙÈ Â›Ó·È Ë ·ÛʷϤÛÙÂÚË Â¤Ó‰˘ÛË ÁÈ· ÙËÓ ÂÈÚ‹ÓË. ∫·Ù¿ ÙÔÓ °ÂÚÌ·Ófi Obermann “Don’t try to be God, just work hard to be Human”, ‰ËÏ·‰‹ “ÌËÓ ÚÔÛ·ı›˜ Ó· Á›ÓÂȘ £Âfi˜, ÂÚÁ¿ÛÔ˘ ÛÎÏËÚ¿ Ó· Â›Û·È ºÈÏ¿ÓıÚˆÔ˜” (9). ∏ ‰ËÌfiÛÈ· ˘Á›· Â›Ó·È ¤Ó· Ó¤Ô ÂÚÁ·ÏÂ›Ô ÁÈ· ÙËÓ Â͈ÙÂÚÈ΋ ÔÏÈÙÈ΋ Î·È ÁÈ· Ù· ·ÓÙÈÙÚÔÌÔÎÚ·ÙÈο ̤ÙÚ·. ∂ÍÔ˘‰ÂÙÂÚÒÓÔÓÙ·˜ ÙËÓ ›ӷ, ÙÔ ÏÈÌfi, ÙȘ ·ÚÚÒÛÙȘ, ÙË ÊÙÒ¯ÂÈ· Î·È ÙËÓ ÎÔÈÓˆÓÈ΋ ·ÔÌfiÓˆÛË ÌÔÚ› Ó· ÂÈÙ¢¯ı› ηχÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· ·fi ÙȘ ‚fî˜, Ù· ·ÂÚÔÏ¿Ó·, ÙȘ ÂȉÈΤ˜ ‰˘Ó¿ÌÂȘ Î·È ÙËÓ ·ÔÌfiÓˆÛË. ∏ ·ÛÊ¿ÏÂÈ· Ù˘ Á˘ ı· ÂÈÙ¢¯ı› ηχÙÂÚ· Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ÛÙ·ıÂÚÒÓ Î·È ÈÛ¯˘ÚÒÓ ÎÔÈÓˆÓÈÒÓ. ∏

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‰ËÌfiÛÈ· ˘Á›·, ÙÔÓ 21Ô ·ÈÒÓ·, Â›Ó·È Ì¤ÚÔ˜ Ù˘ ·ÁÎÔÛÌÈÔÔ›ËÛ˘ ηٿ ÙËÓ ÂχıÂÚË ·ÁÔÚ¿ ‹ ¤¯ÂÈ ·ÁÎÔÛÌÈfiÙËÙ·, ‰ËÏ·‰‹ ÔÈÎÔ˘ÌÂÓÈÎfiÙËÙ·, ηٿ ÙË ¯ÚÈÛÙÈ·ÓÈ΋ ¿Ô„Ë. ∞˘Ù‹ Ë ·Ó¿ÁÎË Ù˘ ·ÁÎÔÛÌÈfiÙËÙ·˜ Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ ‰ÂÓ Â›¯Â ÂÈÛËÌ·Óı› Ì ÙfiÛË ¤ÌÊ·ÛË Û ηӤӷ ÚÔËÁÔ‡ÌÂÓÔ ·ÈÒÓ·. ÃÚÂÈ¿˙ÂÙ·È fï˜ ÂÍÂȉ›Î¢ÛË, Û˘Ì·Ú¿ÛÙ·ÛË Î·È ‰Ú¿ÛË Â› Ù˘ ÎÔÈÓˆÓÈ΋˜ Î·È ÔÏÈÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÁÈ· Ó· ‚ÂÏÙȈı› Ë ‰ËÌfiÛÈ· ˘Á›· Û fiÏÔ ÙÔÓ ÏËı˘ÛÌfi Ù˘ Á˘. ∏ ∂ӈ̤ÓË ∂˘ÚÒË, Û‡Ìʈӷ Ì ÙÔ ÚfiÁÚ·ÌÌ· Ô˘ ı· ÂÊ·ÚÌfiÛÂÈ ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 2003, ¤Î·Ó ÙÔ ÚÒÙÔ ‚‹Ì· ÁÈ· Ó· ‚ÂÏÙȈı› Ë ‰ËÌfiÛÈ· ˘Á›· Û fiÏÔ ÙÔÓ ÎfiÛÌÔ. §Â›ÂÈ, fï˜, Ô ÂÛÙÈ·ÛÌfi˜, Ë Û˘ÁÎÂÎÚÈ̤ÓË ‚Ô‹ıÂÈ· Î·È Ë ÔÏÈÙÈ΋ ‚Ô‡ÏËÛË. ∏ ‰ËÌfiÛÈ· ˘Á›· Â›Ó·È ¤Ó· ̤ÙÚÔ Ô˘ ˘ÔÙÈÌ‹ıËΠ·fi ÙËÓ ·ÁÎÔÛÌÈÔÔÈË̤ÓË ·ÛÊ¿ÏÂÈ· ÙÔ˘ Ï·Ó‹ÙË Ì·˜. ∏ ·ÚÔ¯‹ ηϋ˜ ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÁÈ· fiÏÔ ÙÔÓ ÏËı˘ÛÌfi ÙÔ˘ Ï·Ó‹ÙË Ú¤ÂÈ Ó· Á›ÓÂÈ Ë µ›‚ÏÔ˜ ÙÔ˘ 21Ô˘ ·ÈÒÓ·, Â¿Ó ı¤ÏÔ˘Ì ӷ Ú·ÁÌ·ÙÔÔÈËı› ÙÔ ÂÎÎÏËÛÈ·ÛÙÈÎfi ÙÚÔ¿ÚÈÔ (10) “∫·› â› Áɘ ÂåÚ‹ÓË”. µÈ‚ÏÈÔÁÚ·Ê›· 1. ™ÙÂÊ·ÓÔÔ‡ÏÔ˘ ∞. ∫·È Â› Á˘ fiÏÂÌÔ˜. ∂ÛÙ›·; 2001, 24 ¢ÂÎÂÌ‚Ú›Ô˘.

2. Pillar PR. Terrorism and US foreign policy Washington: Brookings Institution; 2001.

3. Horton R. Public health: a neglected counter terrorist measure. Lancet 2001;358:1112-1113.

4. Ahmad K. Health and safety of Afghans hangs in the balance. Lancet 2001;358:1069-1070.

5. Nor any drop to drink [Editorial]. Lancet 2001;358:1025.

6. ÕÏÏ·Í·Ó “Ù· ¿ÓÙ· ÁÈ· ¿ÓÙ·” ÈÛÙÂ‡Ô˘Ó ÔÈ ∞ÌÂÚÈηÓÔ›. ∂ÛÙ›·; 2002, 2 ∞ÚÈÏ›Ô˘.

7. Failure to address the health toll of the Middle East crisis [Editorial]. Lancet 2002;359:1261.

8. Lauer MS. Health toll of the Middle East crisis. Lancet 2002;359:1860-1861.

9. Obermann K. More life for Lifeline. Lancet 2001;358:2174.

10. ∫·ÈÓ‹ ¢È·ı‹ÎË: ∫·Ù¿ §Ô˘Î¿Ó ∂˘·ÁÁ¤ÏÈÔ (2,14).

HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 23-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-11-2002 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶¤ÙÚÔ˜ §··ÙÛ¿Ó˘ ∞ÛÎÏËÈÔ‡ 44, ∆.∫. 114 71, ∞ı‹Ó·