COVER May-June 03
03-06-03
16:52
™ÂÏ›‰·1
ISSN 0377-2551
ETO™ 2003
ª¿ÈÔ˜ - πÔ‡Ó ÈÔ˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 3
∞¡∞™∫O¶∏™∂π™ OÚÁ·ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ì „˘¯È·ÙÚÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙ· ·È‰È¿: Ë ‰ÈÂÚ‡ÓËÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ
REVIEW ARTICLES 167
D. Protagoras-Lianos
∂Ӊ›ÍÂȘ ÂÎÙ¤ÏÂÛ˘ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Ù˘ ·Ó·ÓÔ‹˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·
176
ª. ªÔ˘ÛÙ¿ÎË
M. Moustaki
Eƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ ∂͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜
ORIGINAL ARTICLES 185
∂. ∫·Ú·ÓÙ·Ó¿, ™. ∫ˆÛÙ·Ú›‰Ô˘, ∞. ∫·Ï·ÓÙ˙‹˜, ∞. °È·ÓÓÔ‡ÏÈ·
ºÔÚ›· Neisseria meningitidis Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜: ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È ¯·Ú·ÎÙËÚÈÛÙÈο ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ
Indications for pulmonary function testing in childhood
Extrapulmonary symptoms of Mycoplasma pneumoniae infections E. Karantana, S. Kostaridou, A. Kalantzis, A. Giannoulia
188
π. ¶·˘ÏÔÔ‡ÏÔ˘, ∂. ∞ÏÂÍ¿Ó‰ÚÔ˘, °. ¢·›ÎÔ˜, ∂. ¶ÂÙÚ›‰Ô˘, ∞. ¶¿ÁηÏË, ª. £ÂÔ‰ˆÚ›‰Ô˘, µ. ™˘ÚÈÔÔ‡ÏÔ˘
Neisseria meningitidis carriage in schoolchildren: risk factors and characteristics of isolated strains I. Pavlopoulou, E. Alexandrou, G. Daikos, E. Petridou, A. Pangalis, M. Theodoridou, V. Syriopoulou
¶AI¢IATPIKH
●
TOMO™ 66
●
TEYXO™ 3
●
¡. ¶ÚˆÙ·ÁfiÚ·-§È·ÓÔ‡
Organic disorders with psychiatric symptomatology in children: investigation by the paediatrician
§ÂÌÊÒÌ·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∂ÌÂÈÚ›· 10 ¯ÚfiÓˆÓ
195
º. ∞ı·Ó·ÛÈ¿‰Ô˘, £. ∆Ú·ÁÈ·ÓÓ›‰Ë˜, £. ¶··ÁˆÚÁ›Ô˘, µ. ∫·ÏÔ‡ÙÛË, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡, ª. ™Ù¿ÌÔ˘, ¢. ∫·ÙÚÈÔ‡
§È›‰È· Î·È ÏÈÔÚˆÙ½Ó˜ ÔÚÔ‡ ·È‰ÈÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η
Lymphomas in childhood. Ten years’ experience F. Athanassiadou, T. Tragiannidis, T. Papageorgiou, V. Kaloutsi, M. Hatzistilianou, M. Stamou, D. Katriou
202
Serum lipids and lipoproteins in epileptic children receiving antiepileptic drugs
∫. ∞. µÔ‡‰Ú˘, ∞. ™Î·Ú‰Ô‡ÙÛÔ˘, ª. ™ÂÚ‚ÈÙ˙fiÁÏÔ˘, ™. ¢‹ÌÔ˘, ∂. ∞. µ·ÁÈ¿ÎÔ˘
K. Voudris, A. Skardoutsou, M. Servitzoglou, S. Dimou, E. Vagiakou
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
May - June 2 0 0 3 . V o l u m e 6 6 . N o 3
May-June 03
03-06-03
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M¿ÈÔ˜ - IÔ‡Ó ÈÔ˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
CASE REPORTS
EN¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™ ™‡Ó‰ÚÔÌÔ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÛÙÔÓ ‡ÓÔ Û˘Óԉ¢fiÌÂÓÔ ·fi Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË
208
E. Alexopoulos, A. Kaditis, V. Mikraki, E. Kostadima, N. Skenteris, K. Gourgoulianis
∂. ∞ÏÂÍfiÔ˘ÏÔ˜, ∞. ∫·‰›Ù˘, µ. ªÈÎÚ¿ÎË, ∂. ∫ˆÛÙ·‰‹Ì·, ¡. ™ÎÂÓÙ¤Ú˘, ∫. °Ô˘ÚÁÔ˘ÏÈ¿Ó˘
∂ÙÂÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË ˆ˜ ÚÔ¤¯ÔÓ Û‡Ìو̷ ¯ÚfiÓÈ·˜ ÈÁÌÔÚ›Ùȉ·˜
211
215
CURRENT ISSUES
∂¶π∫∞πƒ∞ £∂ª∞∆∞ 223
SPECIAL ARTICLE
∂π¢π∫O ∞ƒ£ƒO 232
™˘Ó¯›˙ÔÓÙ·È
A case of diabetes mellitus presented in the journal “∂ÚÌ‹˜ Ô §fiÁÈÔ˜”, 1814 D. Karaberopoulos
¢. ∫·Ú·ÌÂÚfiÔ˘ÏÔ˜
¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
Probiotics, prebiotics, synbiotics: recent data I. Charoniti, M. Mavrokosta, E. Kokori
π. ÷ڈӛÙË, ª. ª·˘ÚfiΈÛÙ·, ∂. ∫fiÎÔÚË
¶·ÚÔ˘Û›·ÛË ÂÚ›ÙˆÛ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÙÔ ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” ÙÔ˘ 1814
Clinical heterogeneity in facioscapulohumeral muscular dystrophy (FSHMD). Report of two cases and review of the literature H. Fryssira, S. Amenta, K. Kekou, S. Youroukos, P. Manta, C. Metaxotou
E. ºÚ˘Û›Ú·, ™. ∞̤ÓÙ·, ∫. ∫¤ÎÔ˘, ™. °ÈÔ˘ÚÔ‡ÎÔ˜, ¶. ª·ÓÙ¿, ∞. ªÂٷ͈ÙÔ‡
¶ÚÔ‚ÈÔÙÈο, Ú‚ÈÔÙÈο, Û˘Ì‚ÈÔÙÈο: ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ
Unilateral intermittent blepharoptosis as an urgent symptom of chronic sinusitis G. Pardalos, S. Mouskou, D. Zafiriou, V. Aivazis
°. ¶·Ú‰·Ïfi˜, ™. ªÔ‡ÛÎÔ˘, ¢. ∑·ÊÂÈÚ›Ô˘, µ. ∞˚‚¿˙˘
∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ÛÙËÓ ÚÔÛˆÔˆÌÔ‚Ú·¯ÈfiÓÈÔ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (FSHMD). ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜
Obstructive sleep apnoea syndrome accompanied by nocturnal enuresis
236
NEWS FROM THE INTERNET
Continued
May - June 2 0 0 3 . V o l u m e 6 6 . N o 3
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M¿ÈÔ˜ - πÔ‡Ó ÈÔ˜ 2003 . ∆fiÌÔ˜ 66 . ∆‡¯Ô˜ 3
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
Continuation of table of contents
LITERATURE ABSTRACTS
¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶O ∆∏ µπµ§πO°ƒ∞ºπ∞ ∞ÓÙÈ‚ÈÔÙÈο ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ÛÙ· ·È‰È¿
194
Glasziou PP, Del Mar CB, Sanders SL, Hayem M Greek translation: F. Hantzi
Glasziou PP, Del Mar CB, Sanders SL, Hayem M ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ºˆÙÂÈÓ‹ ÷ÓÙ˙‹
¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ η΋˜ ¤Î‚·Û˘ Î·È ÔʤÏË ·fi Ù· ·ÓÙÈ‚ÈÔÙÈο Û ·È‰È¿ Ì ÔÍ›· ̤ÛË ˆÙ›Ùȉ·
Antibiotics for acute otitis media in children
201
Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomized trial Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I Greek translation: F. Hantzi
Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ºˆÙÂÈÓ‹ ÷ÓÙ˙‹
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xi
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xv
Abbreviations
May - June 2 0 0 3 . V o l u m e 6 6 . N o 3
May-June 03
03-06-03
16:55
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M¿ÈÔ˜ - πÔ‡Ó ÈÔ˜ 2003
. ∆fiÌÔ˜
66
. ∆‡¯Ô˜
3
¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜
Bimonthly Publication The Official Journal of the Hellenic Paediatric Society
EΉfiÙ˘ K. °ÚÈ‚¤·˜
Publisher K. Griveas
I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28
Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28
TËÏ.: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
Tel.: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ¢È¢ı˘ÓÙ‹˜ : ™. ÷˚‰¿˜ M¤ÏË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : °. µ·ÚÏ¿Ì˘ : ª. ∏Ï›· : π. ¶··‰¿ÙÔ˜ : ¡. ¶··‰fiÔ˘ÏÔ˜ : ™. ¶ÔÏ˘¯ÚÔÓÔÔ‡ÏÔ˘ : ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ : ∫. ™ÙÂÊ·Ó›‰Ë˜ : ª. ∆ÛÔÏÈ¿ : ™. ºˆÙfiÔ˘ÏÔ˜
Scientific President Editor Members
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ I. K·Ú·‚Ú¿ÓÔ˘
Manuscript Editing
EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘
English Editing S. Nakou
∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: 210-7771 140 / 210-7771 663, Fax: 210-7758 354
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Publishing Coordinator
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20
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03-06-03
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™ÂÏ›‰·5
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Â›Ó·È Ë ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜, Ô˘ ‰È·Ó¤ÌÂÙ·È ÛÙ· ̤ÏË Ù˘. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÂÈÛÙËÌÔÓÈÎÔ‡ ¤ÚÁÔ˘ Î·È ÙË Û˘Ó¯‹ ÂÓË̤ڈÛË ÙˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. ÕÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜). 2. ∞Ó·ÛÎÔ‹ÛÂȘ. 3. µÚ·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. 4. ∂Ú¢ÓËÙÈΤ˜ ÌÂϤÙ˜. 5. ∂ÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ. 6. ∂›Î·ÈÚ· ı¤Ì·Ù·. 7. £¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÔÚÁ¿ÓˆÛ˘ ˘Á›·˜. 8. ∫ÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ. 9. ™‡ÓÙÔÌ· Ó¤·. 10. µÚ·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. 11. ∂ÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË. 12. ¶ÂÚÈÏ‹„ÂȘ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. 13. ∞Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘Ó‰ڛˆÓ Î·È ÂÈÛÙËÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ 14. ∞Ó·ÊÔÚ¤˜ Î·È ÎÚÈÙÈ΋ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ Î·ıÒ˜ Î·È ¿ÚıÚ· Ì ›ηÈÚ· ı¤Ì·Ù· ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜. ∂›Û˘, ÌÔÚ› Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ·ÚÔ˘ÛÈ·Ûı› ÛÙÔ ÂÙ‹ÛÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ·ÚÔ˘ÛÈ¿ÛÂˆÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜ Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™ÙȘ ÂÚÁ·Û›Â˜ Ì ›ηÈÚ· ı¤Ì·Ù· Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÂÙ·È ÛÙËÓ ÚÒÙË ÛÂÏ›‰· Ë ÚfiıÂÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÁÈ· ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. ∏ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ù˘ ·Ô‰Ô¯‹˜ Ù˘ Ù·¯Â›·˜ ‰ËÌÔÛ›Â˘Û˘. µ. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋”. ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚË-
Á›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ∫·ıÒ˜ Î·È fiÙÈ ÙËÚ‹ıËÎ·Ó ÔÈ Ô‰ËÁ›Â˜ ÁÈ· ÙË ÊÚÔÓÙ›‰· ÂÈÚ·Ì·Ùfi˙ˆˆÓ ÙÔ˘ ∂ıÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ ÀÁ›·˜ ÙˆÓ ∏¶∞ (DHEW Publication, NIH, 80-23). ™ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ¤¯Ô˘Ó ÂÁÎÚÈı› ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ “¶·È‰È·ÙÚÈ΋” Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∏ ¶∞π¢π∞∆ƒπ∫∏ ÚÔÙ›ÓÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÈÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals) Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ JAMA 1997;277:927-934 http://jama.ama-assn.org/info/auinst_req.html OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Excel, ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 30 ËÌÂÚÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ‰‡Ô (2) Ë̤Ú˜. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏÌ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı› ÂÓÙfi˜ ÂÍ·Ì‹ÓÔ˘, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜
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May-June 03
03-06-03
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A4 (21x29.7 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È ÂÚÈıÒÚÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2,5 cm ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ‚Ú·¯‡˜ Ù›ÙÏÔ˜, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘. H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ·: ·. ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 2000-3000 ϤÍÂȘ. ‚. ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ Û 1500-2500 ϤÍÂȘ. Á. ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000-1500 ϤÍÂȘ. ‰. ÙȘ ÂÈÛÙÔϤ˜ Û 250-500 ϤÍÂȘ. ™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ) ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË, e-mail Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·. ¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. £· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 200 ϤÍÂȘ, fï˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ∏ ÂÚ›ÏË„Ë ÙˆÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË ÛÙȘ ÂÍ‹˜ ·Ú·ÁÚ¿ÊÔ˘˜: ÂÈÛ·ÁˆÁ‹, ̤ıÔ‰ÔÈ, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘ÌÂÚ¿ÛÌ·Ù·. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓÔ Û ÂÈÛ·ÁˆÁ‹ (background), ̤ıÔ‰ÔÈ (methods), ·ÔÙÂϤÛÌ·Ù· (results) Î·È Û˘ÌÂÚ¿ÛÌ·Ù· (conclusions). H ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÛÙ· ÂÏÏËÓÈο. T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ. K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·-
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Ô̤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. ∂›Û˘, Ú¤ÂÈ Ì ÏÂÙÔ̤ÚÂȘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ ·Ó¿Ï˘Û˘ Î·È ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜. TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional-™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ JAMA 1986;255:2329-2339. ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ, Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ. BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Î·È ÛÙȘ ÂÈÛÙÔϤ˜. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors/Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JAMA 1997;277:927-934), http://jama.amaassn.org/info/auinst_req.html. OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus (List of Journals Indexed in Index Medicus, http://www.nlm.nih.gov).
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¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”. T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ∞ÓÙˆÓ›Ô˘ ¢, ª¿Ú· Ã, °È·ÓÓ¿ÙÔ˘ Ã. ∂Ì‚fiÏÈ·: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1999;59:272-279. Proesmans W. Bartter syndrome and its neonatal variant. Eur J Pediatr 1997;156:669-679. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19. Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: ÷ڷϷ̛‰Ë˜ π, ¶··‰fiÔ˘ÏÔ˜ ∞. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·ÈÌ›· [¶ÂÚ›ÏË„Ë]. 36Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1998 5-7 πÔ˘Ó›Ô˘; ¶¿ÊÔ˜, ∫‡ÚÔ˜; 1998. ÛÂÏ. 199. Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356. II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 29-
31; New York: International Society of Chemotherapy; 1963. p. 484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¶··‰fiÔ˘ÏÔ˜ Ã.. ∏ ıÂڷ›· ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡. [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the elderly’s access and utilization [dissertation]. St. Louis (Mo): Washington Univ.; 1995. ¶›Ó·Î˜ Î·È EÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜, ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, Î.Ï.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο. ¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. ∂ÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜. 2. ¢‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜. 3. 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜. 4. ™ÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂÚÈÏ·Ì‚¿ÓÂÈ: ·. Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜, ‚. fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), Á. ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›·, ‰. fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›·. 5. ¶ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 6. ∫·Ù¿ÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 7. ∫›ÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 8. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢). 9. µÈ‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·). 10. ¶›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó. 11. ∂ÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó. 12. ∆›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
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Paediatriki 2003;66:167-175
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OÚÁ·ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ì „˘¯È·ÙÚÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙ· ·È‰È¿: Ë ‰ÈÂÚ‡ÓËÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ ¡. ¶ÚˆÙ·ÁfiÚ· - §È·ÓÔ‡
Organic disorders with psychiatric symptomatology in children: investigation by the paediatrician D. Protagoras - Lianos
¶ÂÚ›ÏË„Ë: ∏ ‰È¿ÁÓˆÛË Ù˘ ˘ÔΛÌÂÓ˘ ÔÚÁ·ÓÈ΋˜ ÓfiÛÔ˘ ÛÙÔ ·È‰› Ì „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÛÙËÚ›˙ÂÙ·È ÛÙË ‰ÈÂÍÔ‰È΋ „˘¯È·ÙÚÈ΋ Î·È ·È‰È·ÙÚÈ΋ ÂͤٷÛË. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈο „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· Î·È ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â˘Ú‡ Ê¿ÛÌ· ‰È·Ù·Ú·¯ÒÓ Û˘ÌÂÚÈÊÔÚ¿˜. ¶·È‰È¿ Ì ÔÚÁ·ÓÈο ÓÔÛ‹Ì·Ù· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È ÈÔ ÂÈÚÚ‹ Û ‰˘ÛÌÂÓ›˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÛÙȘ ÙÔÍÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ „˘¯ÔÙÚfiˆÓ Ê·Ú̿ΈÓ. ∆Ô ·ÚfiÓ ¿ÚıÚÔ ·ÚÔ˘ÛÈ¿˙ÂÈ ·Ó·ÛÎfiËÛË ÙˆÓ ÔÚÁ·ÓÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ÌÔÚ› Ó· ÂΉËψıÔ‡Ó Ì „˘¯È·ÙÚÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ÛÙ· ·È‰È¿, ηıÒ˜ Î·È ÙˆÓ ÛËÌ·ÓÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ·È‰È·ÙÚÈ΋˜ ÎÏÈÓÈ΋˜ ÂͤٷÛ˘.
Abstract: The diagnosis of underlying organic disease in children with psychiatric symptoms is based on a thorough psychiatric and paediatric examination. In most cases, there are no specific psychiatric symptoms and the patients may present with a wide range of behavioural disorders. Children with organic brain disease are more susceptible both to unfavourable environmental factors and to the toxic side effects of psychotropic medications. This article presents a review of organic diseases in children which may present with psychiatric symptoms and outlines the significant elements of the paediatric clinical examination.
§¤ÍÂȘ ÎÏÂȉȿ: ÔÚÁ·ÓÈ΋ „˘¯È·ÙÚÈ΋ ‰È·Ù·Ú·¯‹, ÌÂÙ·‚ÔÏÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ó¢ÚÔ„˘¯È·ÙÚÈ΋, Ó¢ÚÔÂÎÊ˘ÏÈÛÙÈο.
Key words: organic psychiatric disorder, metabolic encephalopathy, neuropsychiatry, neurodegenerative disorder.
∂ÈÛ·ÁˆÁ‹ ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ù¿ ηÈÚÔ‡˜ ‰È·Ù·Ú·¯¤˜ Û˘Ó·ÈÛıËÌ¿ÙˆÓ Î·È Û˘ÌÂÚÈÊÔÚ¿˜ (1). ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, Ù· ÚÔ‚Ï‹Ì·Ù· Â›Ó·È ‹È·, ÂÓÒ Û·ÓÈfiÙÂÚ· ÏËÚÔ‡Ó Ù· Ù˘Èο ÎÚÈÙ‹ÚÈ· ÁÈ· ¿Á¯Ô˜, ηٿıÏÈ„Ë, ‰È·Ù·Ú·¯‹ ‰È·ÁˆÁ‹˜ ‹ „‡¯ˆÛË (2). ŸÙ·Ó ÔÈ ÁÔÓ›˜ ·Ú·ÙËÚ‹ÛÔ˘Ó ÛÙÔ ·È‰› ÙÔ˘˜ ·ÏÏ·Á‹ ÚÔÛˆÈÎfiÙËÙ·˜, Ë ÔÔ›· ÂËÚ¿˙ÂÈ ·ÚÓËÙÈο ÙË Û¯ÔÏÈ΋ ›‰ÔÛË, ÙȘ ÎÔÈÓˆÓÈΤ˜ Û¯¤ÛÂȘ ‹ ÙËÓ ·˘ÙÔÂ͢ËÚ¤ÙËÛ‹ ÙÔ˘, Û˘¯Ó¿ ·Â˘ı‡ÓÔÓÙ·È ÚÒÙ· ÛÙÔÓ ·È‰›·ÙÚÔ. ¶ÔÏÏ¿ ÓÔÛ‹Ì·Ù· Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ Û˘Óԉ‡ÔÓÙ·È ·fi „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ÙÔ ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÔÚÁ·ÓÈ΋˜ ÓfiÛÔ˘. ™·ÓÈfiÙÂÚ·, fï˜, Ù· „˘¯È·ÙÚÈο Û˘-
ÌÙÒÌ·Ù· ÌÔÚ› Ó· ÚÔËÁËıÔ‡Ó ÙˆÓ ¿ÏÏˆÓ Î·Ù¿ ÔÏÏÔ‡˜ Ì‹Ó˜ ‹ ¯ÚfiÓÈ· (3-7). O Goodman (5) ·Ú·ÏÏËÏ›˙ÂÈ ÙËÓ „˘¯È΋ ‰È·Ù·Ú·¯‹ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ËÏÂÎÙÚÔÓÈÎÔ‡ ˘ÔÏÔÁÈÛÙ‹ (∏À). ŸÙ·Ó Ô ∏À ‰˘ÛÏÂÈÙÔ˘ÚÁ›, ˘¿Ú¯Ô˘Ó ÙÚÂȘ Èı·Ó¤˜ ÂÍËÁ‹ÛÂȘ: ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛˆÛÙ¿, ÂÚȤ¯ÂÈ ÂÏ·Ùو̷ÙÈÎfi ÚfiÁÚ·ÌÌ· ‹ ˘¿Ú¯ÂÈ ‚Ï¿‚Ë ÛÙ· ËÏÂÎÙÚÔÓÈο ΢ÎÏÒÌ·Ù¿ ÙÔ˘. ∆ÚÂȘ ·ÚfiÌÔȘ ÂÚÌËÓ›˜, ÌÂÌÔӈ̤Ó˜ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi, Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ Û ÂÚ›ÙˆÛË „˘¯È·ÙÚÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙÔ ·È‰›: ÙÔ ÎÔÈÓˆÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÂÈ‚¿ÏÏÂÈ ÛÙÔ ·È‰› ··ÈÙ‹ÛÂȘ Ô˘ ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ ‰˘Ó·ÙfiÙËÙ¤˜ ÙÔ˘, ¤¯ÂÈ ‰È‰·¯Ù› ‰˘ÛÏÂÈÙÔ˘ÚÁÈÎÔ‡˜ ÙÚfiÔ˘˜ Û˘ÌÂÚÈÊÔÚ¿˜ ‹ ˘¿Ú¯ÂÈ ÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë ÙˆÓ Ó¢ÚÒÓˆÓ. ™‡Ìʈӷ Ì ÙÔ “¢È·ÁÓˆÛÙÈÎfi ™Ù·ÙÈÛÙÈÎfi ∂Á¯ÂÈÚ›‰ÈÔ IV” Ù˘ ∞ÌÂÚÈηÓÈ΋˜ æ˘¯È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜
∞’ ¶·È‰È·ÙÚÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
1st Department of Paediatrics, “Aghia Sophia” Children’s Hospital, Athens
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(DSM IV), Ë ‰È¿ÁÓˆÛË ÔÚÁ·ÓÈÎÔ‡ „˘¯È·ÙÚÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÌÔÚ› Ó· ÙÂı› fiÙ·Ó ˘¿Ú¯Ô˘Ó “·Ô‰Â›ÍÂȘ ·fi ÙË Ê˘ÛÈ΋ ÂͤٷÛË, ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‹ ÙÔ ÈÛÙÔÚÈÎfi ÁÈ· ÂȉÈÎfi ÔÚÁ·ÓÈÎfi ·Ú¿ÁÔÓÙ·, Ô ÔÔ›Ô˜ ÎÚ›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ·ÈÙÈÔÏÔÁÈ΋ Û¯¤ÛË Ì ÙË ‰È·Ù·Ú·¯‹” (8). ™Ù· Ï·›ÛÈ· ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ ÛÙËÓ ∞ÁÁÏ›·, Û ÏÈÁfiÙÂÚÔ ·fi 10% ÙˆÓ ·È‰ÈÒÓ Ì „˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Ê˘ÛÈÔÏÔÁÈÎfi ÓÔËÙÈÎfi ËÏ›ÎÔ ‚Ú¤ıËΠÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë ÂÁÎÂÊ¿ÏÔ˘ (5). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË, Ë Î·Ù¿ÏÏËÏË È·ÙÚÈ΋ ·ÁˆÁ‹ Î·È Ë ·Ú·ÔÌ‹ Û ÂȉÈÎÔ‡˜ ÂÓ‰¤¯ÂÙ·È Ó· ·ÔÙÚ¤„ÂÈ ‹ Ó· ÌÂÙÚÈ¿ÛÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ·Ûı¤ÓÂÈ·˜. ∞ÎfiÌË Î·È fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ıÂڷ›·, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÁÂÓÂÙÈ΋ Û˘Ì‚Ô˘Ï¢ÙÈ΋, ÂÓË̤ڈÛË ÁÈ· ÙËÓ ÚfiÁÓˆÛË Î·È Î·Ù¿ÏÏËÏË „˘¯ÔÎÔÈÓˆÓÈ΋ ÛÙ‹ÚÈÍË. ™ÙË ÌÂϤÙË ·˘Ù‹ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÔÚÁ·ÓÈΤ˜ ·Èٛ˜ „˘¯È·ÙÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, Ù· ÛÙÔȯ›· ÙÔ˘ ÈÛÙÔÚÈÎÔ‡, Ù˘ ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ÂͤٷÛ˘, ηıÒ˜ Î·È ÔÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌÔ‡ÓÙ·È, ÚÔÎÂÈ̤ÓÔ˘ Ó· Ô‰ËÁËı› Ô ·È‰›·ÙÚÔ˜ ÛÙËÓ ÔÚı‹ ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. OÚÁ·ÓÈΤ˜ ·Èٛ˜ „˘¯È·ÙÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ∞. ∂Ó‰ÔÁÂÓ‹ ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· ™Ù· ÓÔÛ‹Ì·Ù· ·˘Ù¿, ÙÔ ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ ¤ÏÏÂÈÌÌ· ÂÓ˙‡ÌÔ˘ Ô‰ËÁ› ÛÂ Û˘ÛÛÒÚ¢ÛË ·ıÔÏÔÁÈÎÒÓ ÚÔ˚fiÓÙˆÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ‹ Ê˘ÛÈÔÏÔÁÈÎÒÓ Ô˘ÛÈÒÓ Û ·ıÔÏÔÁÈ΋ Û˘ÁΤÓÙÚˆÛË ÛÙÔ˘˜ ÈÛÙÔ‡˜. ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ˘fiÛÙڈ̷ ÁÈ· „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÛÙÔÓ ·ÛıÂÓ‹ (3-7). ∏ οı ̛· ÓfiÛÔ˜ Â›Ó·È Û¿ÓÈ·, ·ÏÏ¿ Ë ·ıÚÔÈÛÙÈ΋ ÙÔ˘˜ Û˘¯ÓfiÙËÙ· ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È ÂÚ›Ô˘ 1:2000 (9). OÈ ‚·ÚȤ˜ ÌÔÚʤ˜ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙË ‚ÚÂÊÈ΋ ‹ ÓËȷ΋ ËÏÈΛ· Ì ϋÚË ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ™Â ¿ÙÔÌ· Ì ÌÂÚÈ΋ ¤ÏÏÂÈ„Ë ÂÓ˙‡ÌÔ˘ ‹ Û ı‹Ï· ÊÔÚ›˜ Ê˘ÏÔÛ‡Ó‰ÂÙˆÓ ÓÔÛËÌ¿ÙˆÓ, ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ·, ÙËÓ ÂÊ˂›· ‹ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹. ∆fiÙÂ, Ù· Û˘ÌÙÒÌ·Ù· Û˘¯Ó¿ Â›Ó·È ‹È· ‹ ÚÔηÏÔ‡ÓÙ·È ÌfiÓÔ Û ηٷÛÙ¿ÛÂȘ ÌÂÙ·‚ÔÏÈ΋˜ ·ÔÚÚ‡ıÌÈÛ˘, fiˆ˜ ˘ÚÂÙfi˜, ÓËÛÙ›·, ÏÔÈÌÒÍÂȘ ‹ ηٷӿψÛË ÌË ·ÓÂÎÙÒÓ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ. ∆· „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÌÔÚ› Ó· ˘ÂÚÈÛ¯‡Ô˘Ó ‹ Ó· ÚÔËÁÔ‡ÓÙ·È ÙˆÓ ¿ÏÏˆÓ Î·È, ÙfiÙÂ, Ë ‰È¿ÁÓˆÛË Â›Ó·È ‰˘Û¯ÂÚ‹˜. OÈ ÈÔ Û˘¯Ó¤˜ ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Â›Ó·È Ë Â˘ÂÚÂıÈÛÙfiÙËÙ·, Ë ‰È¤ÁÂÚÛË, Ë ÂÈıÂÙÈÎfiÙËÙ· Î·È Ë ·ÚÔÚÌËÙÈÎfiÙËÙ· ‹, ·ÓÙÈı¤Ùˆ˜, Ë ·Ê‡ÛÈÎË ·ıËÙÈÎfiÙËÙ·. ∂Ó›ÔÙÂ, ˘¿Ú¯ÂÈ ÂÈÎfiÓ· „‡¯ˆÛ˘ (3-7,10-12). ™ÙÔ ÓÔËÙÈÎfi ÙÔ̤·, ÙÔ ·È‰› ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ÚÔԉ¢ÙÈο ÂȉÂÈÓÔ‡ÌÂÓÔ ¤ÏÏÂÈÌÌ· ÚÔ-
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ÛÔ¯‹˜, ¤ÎÙˆÛË ÌÓ‹Ì˘, ÌÂȈ̤ÓÔ ÏÂÍÈÏfiÁÈÔ, ηÎfi ÚÔÛ·Ó·ÙÔÏÈÛÌfi ÛÙÔ ¯ÒÚÔ Î·È ÔÙÈÎÔ-ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∆· Û˘ÌÙÒÌ·Ù· ÂÓ‰¤¯ÂÙ·È Ó· ÂÚÌËÓ¢ÙÔ‡Ó ·Ú¯Èο ˆ˜ ·Ï¤˜ ‰È·Ù·Ú·¯¤˜ ÚÔÛÔ¯‹˜ ‹ Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜. ™Â ·È‰È¿ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Ë ‰È·Ù·Ú·¯‹ Û˘ÌÂÚÈÊÔÚ¿˜ Û˘¯Ó¿ ·Ô‰›‰ÂÙ·È ÛÙÔ ÁÓˆÛÙÈÎfi ¤ÏÏÂÈÌÌ·. ∂Ó›ÔÙÂ, ÔÈ ÚÒÙ˜ ÂΉËÏÒÛÂȘ Â›Ó·È ÔÍ›˜, Ì ηٿıÏÈ„Ë ‹ „‡¯ˆÛË. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ, ÔÈ ·ÛıÂÓ›˜ ÓÔÛËχÔÓÙ·È ·Ú¯Èο Û „˘¯È·ÙÚÈο ÙÌ‹Ì·Ù· (13). ™Ù· ÂÈ̤ÚÔ˘˜ ÓÔÛ‹Ì·Ù·, ÔÚÈṲ̂ӷ „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ··ÓÙÒÓÙ·È ÈÔ Û˘¯Ó¿, ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈÎÔ› Ê·ÈÓfiÙ˘ÔÈ Û˘ÌÂÚÈÊÔÚ¿˜ (4). ¶·Ú¿ÏÏËÏ· Ì ÙȘ ÚÔԉ¢ÙÈΤ˜ ·ÏÏ·Á¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÁÓˆÛÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, Ë ÛËÌ·ÓÙÈÎfiÙÂÚË ¤Ó‰ÂÈÍË Èı·ÓÔ‡ ÌÂÙ·‚ÔÏÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Â›Ó·È Ë ÂÌÊ¿ÓÈÛË Ó¢ÚÔÏÔÁÈÎÒÓ Û˘Ìو̿وÓ, fiˆ˜ ‰È·Ù·Ú·¯¤˜ ÔÌÈÏ›·˜ (‰˘Û·ÚıÚ›·, ·ÏÏ·Á‹ ¯ÚÔÈ¿˜ Ù˘ ʈӋ˜, ÙÚ·˘ÏÈÛÌfi˜), ÙÚfiÌÔ˜ ¯ÂÚÈÒÓ, ¤ÎÙˆÛË fiÚ·Û˘ ‹ ·ÎÔ‹˜, ·ıÔÏÔÁÈο ˘Ú·ÌȉÈο ‹ Â͈˘Ú·ÌȉÈο ÛËÌ›· (3-7,10-12). ™ÙË Û˘Ó¤¯ÂÈ· ·Ó·Ê¤ÚÔÓÙ·È Ù· Û˘¯ÓfiÙÂÚ· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Ô˘ ÌÔÚ› Ó· ÂΉËψıÔ‡Ó Ì „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÂÊ‹‚Ô˘˜. °È· ÙËÓ ÂÚÈÁÚ·Ê‹ Ù˘ Ï‹ÚÔ˘˜ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, Ô ·Ó·ÁÓÒÛÙ˘ ÌÔÚ› Ó· ·Ó·ÙÚ¤ÍÂÈ ÛÙË Û¯ÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· (3,6,7,9). ÀÂÚ·Ì̈ÓÈ·ÈÌ›·: ∏ ÈÔ Û˘¯Ó‹ ‰È·Ù·Ú·¯‹ Â›Ó·È ÙÔ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ¤ÏÏÂÈÌÌ· ÙÚ·ÓÛηڂ·Ì˘Ï¿Û˘ Ù˘ ÔÚÓÈı›Ó˘. ∫ÔÚ›ÙÛÈ· ÊÔÚ›˜ Î·È ·ÁfiÚÈ· Ì ˘ÔÏÂÈÌÌ·ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÓ˙‡ÌÔ˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÔÍ›˜, ‰È·Ï›ԢÛ˜ ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÏÔÈÌÒÍÂȘ ‹ ηٷӿψÛË ÌÂÁ¿Ï˘ ÔÛfiÙËÙ·˜ Ï¢ÎÒÌ·ÙÔ˜ (46,9,13,14). GM2 Á·ÁÁÏÈÔÛ›‰ˆÛË, ÌÔÚÊ‹ Ó·ÓÈ΋ ‹ ÂÓËϛΈÓ: OÈ „˘¯È·ÙÚÈΤ˜ ÂΉËÏÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Â˘ÂÚÂıÈÛÙfiÙËÙ· Î·È ÂÈıÂÙÈÎfiÙËÙ·, ηٿıÏÈ„Ë ‹ ÓÔËÙÈ΋ ¤ÎÙˆÛË (4-6,9). ¡fiÛÔ˜ Nieman-Pick Ù‡Ô˘ C: ∏ ·È‰È΋ ÌÔÚÊ‹ ÂΉËÏÒÓÂÙ·È Ì ¤ÎÙˆÛË Û¯ÔÏÈ΋˜ ›‰ÔÛ˘ Î·È Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, Ë ÔÔ›· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Ì‹Ó˜ ·ÚÁfiÙÂÚ·. ∏·ÙÔÛÏËÓÔÌÂÁ·Ï›· ‰ÂÓ ˘¿Ú¯ÂÈ Û fiϘ ÙȘ ÂÚÈÙÒÛÂȘ (4-6,9). ¡fiÛÔ˜ Wilson: ∆· 2/3 ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙Ô˘Ó „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÂÓÒ ÛÙÔ 1/5 ÙˆÓ ·ÛıÂÓÒÓ ·ÔÙÂÏÔ‡Ó ÙÔ ÌÔÓ·‰ÈÎfi ·Ú¯ÈÎfi Û‡Ìو̷. ¶ÔÏÏÔ› ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÓÔÛËÏ¢Ù› Û „˘¯È·ÙÚÈο ÙÌ‹Ì·Ù· ÚÈÓ ‰È·ÁÓˆÛÙ› Ë ÓfiÛÔ˜. ∆· ÈÔ Û˘¯Ó¿ ÚÔ‚Ï‹Ì·Ù· Â›Ó·È Ë Â˘ÂÚÂıÈÛÙfiÙËÙ· Î·È Ë ÂÈıÂÙÈÎfiÙËÙ·, Ë Î·Ù¿ıÏÈ„Ë Î·È Ë ÓÔËÙÈ΋ ¤ÎÙˆÛË (4,15,16). OÌÔ΢ÛÙÈÓÔ˘Ú›·: OÈ ÌÈÛÔ› ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó
May-June 03
03-06-03
16:55
™ÂÏ›‰·169
¶·È‰È·ÙÚÈ΋ 2003;66:167-175
„˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù·. ™˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯ÂÈ Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜ ۈ̷ÙÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ Î·È ‹È· ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË (4-6). ¡fiÛÔ˜ Sanfilippo: OÈ Ù‡ÔÈ µ Î·È C ¤¯Ô˘Ó ‹È· ÔÚ›· Î·È Û˘¯Ó¿ ÂΉËÏÒÓÔÓÙ·È ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ· Ì ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ÂÈıÂÙÈÎfiÙËÙ· Î·È ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘. ∆· ·‰Ú¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ ÂÓ›ÔÙÂ Â›Ó·È ‰È·ÎÚÈÙÈο Î·È Ù· Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ·ÚÁfiÙÂÚ· (4-6). ∫ËÚÔÂȉ‹˜ ÏÈÔÊÔ˘ÛΛӈÛË: ∏ ÓfiÛÔ˜ Batten Ì ÓÔËÙÈ΋ ¤ÎÙˆÛË Î·È ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ Û ËÏÈΛ· 6 ÂÙÒÓ. ∏ ÔÙÈ΋ Ô͇ÙËÙ· ÂËÚ¿˙ÂÙ·È ÓˆÚ›˜ ÛÙËÓ ÔÚ›· (4). ¡fiÛÔ˜ Tay Sachs: ∏ ÓfiÛÔ˜ ÌÔÚ› Ó· ÂΉËψı› Û ¿ÙÔÌ· fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ. 懯ˆÛË ·Ó·Ê¤ÚÂÙ·È Û 30-50% ·ÛıÂÓÒÓ Ì ÙÔÓ Ù‡Ô ÂÓËϛΈÓ, Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ·Ú¯›˙ÂÈ ÛÙËÓ ÂÊ˂›·. ™˘¯Ó¿ Ù›ıÂÙ·È Ï·Óı·Ṳ̂ÓË ‰È¿ÁÓˆÛË Û¯È˙ÔÊÚ¤ÓÈ·˜ (4-6,17). º˘ÏÔÛ‡Ó‰ÂÙË ·‰ÚÂÓÔÏ¢ÎÔ‰˘ÛÙÚÔÊ›· (∞§¢): ∂›Ó·È Û¯ÂÙÈο Û˘¯Ó‹ ‰È·Ù·Ú·¯‹ (1:20.000 ÁÂÓÓ‹ÛÂȘ), Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Û ·ÁfiÚÈ· ËÏÈΛ·˜ 610 ÂÙÒÓ. ∏ ÌÔÚÊ‹ Ì ¤Ó·ÚÍË ÛÙËÓ ÂÊ˂›· ¤¯ÂÈ ÈÔ ‹È· ÔÚ›·. ¶·ÚÔ˘ÛÈ¿˙ÂÈ ·Ó¿ÚÎÂÈ· ÂÈÓÂÊÚȉ›ˆÓ, Ó¢ÚÔÏÔÁÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ηÈ, Û ÔÛÔÛÙfi 56%, „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù·. ∏ „‡¯ˆÛË ÌÔÚ› Ó· ÚÔËÁËı› ÙˆÓ ¿ÏÏˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·Ù¿ ÔÏÏÔ‡˜ Ì‹Ó˜. ∞Ó·‰ÚÔÌÈο, Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ∞§¢ Ù‡Ô˘ ÂÓËÏ›ÎˆÓ ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ë ·ÏÏ·Á‹ Ù˘ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÂÌÊ·Ó›ÛÙËÎ·Ó ÛÙËÓ ·È‰È΋ ËÏÈΛ· ‹ ÙËÓ ÂÊ˂›· Î·È ·Ô‰fiıËÎ·Ó Û ¿ÏÏ· ·›ÙÈ·. ™Ù· 2/3 ÙˆÓ ·ÛıÂÓÒÓ ‰È·ÈÛÙÒÓÂÙ·È ‚ÈÔ¯ËÌÈο ·Ó¿ÚÎÂÈ· ÂÈÓÂÊÚȉ›ˆÓ, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ¿ÓÙ· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· (4,18). OÍ›· ‰È·ÏÂ›Ô˘Û· ÔÚÊ˘Ú›·: ∞ÔÙÂÏ› Û¿ÓÈ· ‰È·Ù·Ú·¯‹ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÔÚÊ˘ÚÈÓÒÓ, Ë ÔÔ›· ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÎÔÚ›ÙÛÈ·. ¶·ÚÔ˘ÛÈ¿˙ÂÈ Ôͤ· ÂÂÈÛfi‰È· „‡¯ˆÛ˘, Ì ÈÛÙÔÚÈÎfi Û˘¯ÓÒÓ ·ÓÂÍ‹ÁËÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ (4). ªÂÙ·¯ÚˆÌ·ÙÈ΋ Ï¢ÎÔ‰˘ÛÙÚÔÊ›·: ∏ Ó·ÓÈ΋ ÌÂÙ·¯ÚˆÌ·ÙÈ΋ Ï¢ÎÔ‰˘ÛÙÚÔÊ›· ÂÌÊ·Ó›˙ÂÙ·È Û ËÏÈΛ· 6-10 ÂÙÒÓ, Ì ÓÔËÙÈ΋ ¤ÎÙˆÛË, Ì›ˆÛË Û¯ÔÏÈ΋˜ ›‰ÔÛ˘ Î·È ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿. ¡Â˘ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ (4,9). µ. ¢È·Ù·Ú·¯¤˜ ÂÓ‰ÔÎÚÈÓÒÓ ·‰¤ÓˆÓ ™˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Ë ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘. ¡ÔÛ‹Ì·Ù· ı˘ÚÂÔÂȉԇ˜: ∞ÛıÂÓ›˜ Ì ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û‡Á¯˘ÛË, ¿Á¯Ô˜ ‹ Î·È „‡¯ˆÛË. ™ÙÔÓ ˘Ôı˘ÚÂÔÂȉÈÛÌfi ··ÓÙ¿Ù·È ‚Ú·‰˘„˘¯ÈÛÌfi˜ Î·È ÂÓ›ÔÙ ηٿıÏÈ„Ë (7,10). ∂ÓÙÔ‡ÙÔȘ, Ë Û˘¯ÓfiÙËÙ· ÓÔÛËÌ¿ÙˆÓ ı˘ÚÂÔÂȉԇ˜ ‰ÂÓ Â›Ó·È ·˘ÍË̤ÓË ÛÙÔÓ „˘¯È·ÙÚÈÎfi ÏËı˘ÛÌfi. °È·
Paediatriki 2003;66:167-175
ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ‰ÂÓ ıˆÚÔ‡Ó ·Ó·Áη›Ô ÙÔÓ Û¯ÂÙÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ·Ô˘Û›· ÎÏÈÓÈ΋˜ ˘Ô„›·˜, ÂÓÒ ¿ÏÏÔÈ ÙÔÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û˘ÛÙËÌ·ÙÈο (19,20). ÕÙÔÌ· Ì ·˘ÙÔ¿ÓÔÛË ı˘ÚÂÔÂȉ›Ùȉ·, Û˘Ó‹ıˆ˜ Û ηٿÛÙ·ÛË Â˘ı˘ÚÂÔÂȉÈÛÌÔ‡, ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó „˘¯È·ÙÚÈ΋ ‰È·Ù·Ú·¯‹ ÛÙ· Ï·›ÛÈ· ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Hashimoto, Ë ÔÔ›· ·Ô‰›‰ÂÙ·È Û ‚Ï¿‚Ë Ó¢ÚÒÓˆÓ Ì ·˘ÙÔ¿ÓÔÛÔ Ì˯·ÓÈÛÌfi. ™ÙË ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÁÚ¿ÊÔÓÙ·È ‰¤Î· ÂÚÈÙÒÛÂȘ ıËϤˆÓ, ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·ÚÔ˘Û›·˙·Ó Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù·, fiˆ˜ Û·ÛÌÔ‡˜, ÂÓÒ fiϘ ›¯·Ó ÛÙËÓ ÔÚ›· ·ıÔÏÔÁÈÎfi ∏∂° Î·È ·˘ÍË̤ÓÔ Ï‡Έ̷ ÛÙÔ ∂¡À. ∏ ‰È·Ù·Ú·¯‹ ·˘Ù‹ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Û ·ÁˆÁ‹ Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (21-24). ¡fiÛÔ˜ Cushing: ™˘Ó‹ıˆ˜ ˘¿Ú¯Ô˘Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÛËÌ›· ÛÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Â˘ÂÚÂıÈÛÙfiÙËÙ·, ηٿıÏÈ„Ë Î·È Â‡ÎÔÏË ÎfiˆÛË (7). ÀÂÚÚÔÏ·ÎÙÈÓ·ÈÌ›·: ∂ÎÙfi˜ ·fi Ù· Ê˘ÛÈο Û˘ÌÙÒÌ·Ù· (Á˘Ó·ÈÎÔÌ·ÛÙ›·, Á·Ï·ÎÙfiÚÚÔÈ·), ÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ¿Á¯Ô˜, ηٿıÏÈ„Ë Î·È ÂÈıÂÙÈÎfiÙËÙ· (25). ÀÂÚ·Ó‰ÚÔÁÔÓÈÛÌfi˜: O ˘ÂÚ·Ó‰ÚÔÁÔÓÈÛÌfi˜ ÛÙ· ı‹Ï· ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ı‡ÌÔ˘ ‹ Ì ÂΉ‹ÏˆÛË Û¯È˙ÔÊÚ¤ÓÂÈ·˜ Û ÓÂfiÙÂÚË ËÏÈΛ· (›‰È·˜ Ì ·˘Ù‹ ÙˆÓ ·ÁÔÚÈÒÓ). Œ¯ÂÈ ÛËÌÂȈı› ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ·fi ÔÚÌÔÓÈ΋ ·ÁˆÁ‹ Ì ·ÓÙÈÛ˘ÏÏËÙÈο (26,27). ¢È·Ù·Ú·¯¤˜ ·Ú·ı˘ÚÂÔÂȉÒÓ ·‰¤ÓˆÓ: ∏ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Û¯ÂÙ›˙ÂÙ·È Ì ÔÍ›· Û‡Á¯˘ÛË ‹ ¯ÚfiÓȘ ·ÏÏ·Á¤˜ ÚÔÛˆÈÎfiÙËÙ·˜, ‰˘ÛÎÔϛ˜ Û˘ÁΤÓÙÚˆÛ˘ Î·È ¤ÏÏÂÈ„Ë ÚˆÙÔ‚Ô˘Ï›·˜, Ô˘ ·Ó·ÛÙÚ¤ÊÔÓÙ·È Ì ÙË ‰ÈfiÚıˆÛË Ù˘ ËÏÂÎÙÚÔÏ˘ÙÈ΋˜ ‰È·Ù·Ú·¯‹˜. ∏ ˘Ô·Û‚ÂÛÙÈ·ÈÌ›· ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ÔÍ›· Û‡Á¯˘ÛË (·ÎfiÌË Î·È ·Ô˘Û›· ÙÂÙ·Ó›·˜), Â¿Ó Ë ÙÒÛË ÙˆÓ ÂȤ‰ˆÓ ·Û‚ÂÛÙ›Ô˘ Â›Ó·È ·fiÙÔÌË. ∏ ‚·ıÌÈ·›· ÙÒÛË ÚÔηÏ› ÈÔ ‹È˜ ·ÏÏ·Á¤˜ ÚÔÛˆÈÎfiÙËÙ·˜ Î·È ÁÓˆÛÙÈο ÂÏÏ›ÌÌ·Ù·, Ù· ÔÔ›· ‰ÂÓ ·Ôηı›ÛÙ·ÓÙ·È ¿ÓÙ· ÌÂÙ¿ ·fi ÙËÓ Â·Ó·ÊÔÚ¿ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂȤ‰ˆÓ (10). °. ∫¿ÎˆÛË ÎÂÊ·Ï‹˜ (28-30) ∏ ÂÌÊ¿ÓÈÛË „˘¯È·ÙÚÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ·fi οΈÛË Ù˘ ÎÂÊ·Ï‹˜ ÂÍ·ÚÙ¿Ù·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ·ÓÙÈÎÂÈÌÂÓÈ΋ ‚·Ú‡ÙËÙ· Ù˘ οΈÛ˘ Â›Ó·È Ô Î‡ÚÈÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙÔ˘˜ ÚÒÙÔ˘˜ ÙÚÂȘ Ì‹Ó˜ ÌÂÙ¿ ÙÔ Û˘Ì‚¿Ó, ÂÓÒ ·È‰È¿ Ì ‚·Ú‡ÙÂÚ˜ ηÎÒÛÂȘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Î·È ÈÔ ÓˆÚ›˜. ™ÙËÓ ÔÍ›· ÂÚ›Ô‰Ô ·Ó¿ÚÚˆÛ˘ ÌÔÚ› Ó· ÂΉËÏÒÓÂÙ·È ¿Á¯Ô˜ ηÈ, ÛÙË Û˘Ó¤¯ÂÈ·, ηٿıÏÈ„Ë (‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘ Î·È fiÚÂ͢, ·¿ıÂÈ·, ¢ÂÚÂıÈÛÙfiÙËÙ·, ÂÓÔ¯¤˜,
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™ÂÏ›‰·170
¶·È‰È·ÙÚÈ΋ 2003;66:167-175
·˘ÙÔÎÙÔÓÈÎfi˜ ȉ·ÛÌfi˜). ªÂÙ¿, ÙÔ Ê¿ÛÌ· Èı·ÓÒÓ ·ÏÏ·ÁÒÓ Û˘ÌÂÚÈÊÔÚ¿˜ Î˘Ì·›ÓÂÙ·È ·fi ‹È· ÎÔÈÓˆÓÈ΋ ·‰È·ÎÚÈÛ›· ¤ˆ˜ ‚›·È˜ ÂÈı¤ÛÂȘ. ¶ÂÚÈÁÚ¿ÊÂÙ·È ‰È·ÎÚÈÙfi Û‡Ó‰ÚÔÌÔ ·ÚfiÌÔÈÔ Ì ÙÔ “Û‡Ó‰ÚÔÌÔ ÌÂوȷ›Ô˘ ÏÔ‚Ô‡”, ÙÔ ÔÔ›Ô ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÚÔÚÌËÙÈÎfiÙËÙ·, Û˘Ó·ÈÛıËÌ·ÙÈΤ˜ ÂÎÚ‹ÍÂȘ Î·È ·ÒÏÂÈ· ÎÔÈÓˆÓÈÎÒÓ ·Ó·ÛÙÔÏÒÓ (.¯. Á‰‡ÓÂÙ·È ‹ ·˘Ó·Ó›˙ÂÙ·È ‰ËÌÔÛ›ˆ˜). ∆· ı‡Ì·Ù· οΈÛ˘ ÎÂÊ·Ï‹˜ ‰ËÏÒÓÔ˘Ó ÈÔ Û˘¯Ó¿ ¯·ÌËÏ‹ ·˘ÙÔÂÎÙ›ÌËÛË, ÌÔÓ·ÍÈ¿ Î·È ‰˘ÛÎÔϛ˜ ÚÔÛ·ÚÌÔÁ‹˜, Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜. ∂Ó›ÔÙÂ, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÌÙÒÌ·Ù· ÂÓ·ÓÙȈÙÈ΋˜ ‰È·Ù·Ú·¯‹˜ ‹ ‰È·Ù·Ú·¯‹˜ Ù˘ ‰È·ÁˆÁ‹˜. ∏ ÚÔ¸¿Ú¯Ô˘Û· ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ‹ ‰È·Ù·Ú·¯‹ ‰È·ÁˆÁ‹˜ Úԉȷı¤ÙÂÈ ÁÈ· ·Ù˘¯‹Ì·Ù· Î·È ÌÔÚ› Ó· ÂȉÂÈÓˆı› ÌÂÙ¿ ·fi ·˘Ù¿. ∆Ô ıÂÙÈÎfi ÈÛÙÔÚÈÎfi „˘¯È·ÙÚÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ›Û˘ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÚÔ‚ÏËÌ¿ÙˆÓ. ªÂÙ¿ ·fi ¤ÍÈ Ì‹Ó˜ ÌÂÈÒÓÂÙ·È Ë Û¯ÂÙÈ΋ ÛËÌ·Û›· Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ οΈÛ˘ Î·È ·˘Í¿ÓÂÈ Ô ÚfiÏÔ˜ ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ∏ Û¯¤ÛË ‰ÂÓ Â›Ó·È ·Ï‹, ‰ÈfiÙÈ ÔÈ ·ÏÏ·Á¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È Û ·È‰·ÁˆÁÈο ÛÊ¿ÏÌ·Ù· (.¯. ˘ÂÚÚÔÛÙ·Û›·). ¶ÚÔÔÙÈ΋ ÌÂϤÙË ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ 60% ÙˆÓ ·È‰ÈÒÓ Ì ÚÔ¸¿Ú¯ÔÓÙ· ÎÔÈÓˆÓÈο ÚÔ‚Ï‹Ì·Ù·, ÂÓÒ Û 14% ÙˆÓ ·È‰ÈÒÓ ·fi ÂÚÈ‚¿ÏÏÔÓ ÂχıÂÚÔ Ù¤ÙÔÈˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ (5). ¢. ŸÁÎÔÈ ÂÁÎÂÊ¿ÏÔ˘ (7,10,31,32) æ˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÂΉËÏÒÓÔÓÙ·È ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ÌÈÛÔ‡˜ ·ÛıÂÓ›˜ Ì fiÁÎÔ ÂÁÎÂÊ¿ÏÔ˘, ·ÏÏ¿ Û˘Ó‹ıˆ˜ Û˘Óԉ‡ÔÓÙ·È ·fi ¿ÏÏ· Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›·. OÈ fiÁÎÔÈ ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì „˘¯ˆÛÈο Û˘ÌÙÒÌ·Ù·, ÂÓÒ ÙÔ˘ ÌÂوȷ›Ô˘ ÏÔ‚Ô‡ ÌÔÚ› ·Ú¯Èο Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ·ÏÏ·Á‹ ÚÔÛˆÈÎfiÙËÙ·˜, ÁÓˆÛÙÈο ÂÏÏ›ÌÌ·Ù· Î·È ·Ú·Í›·. ∏ ηٿıÏÈ„Ë ÌÔÚ› Ó· Û˘Óԉ‡ÂÈ Î¿ı ¯ÚfiÓÈÔ ÓfiÛËÌ·, ÂȉÈο fiÙ·Ó ˘¿Ú¯ÂÈ ·›ÛıËÌ· ηÎÔ˘¯›·˜ Î·È ¤ÎÙˆÛË ÏÂÈÙÔ˘ÚÁ›·˜. ŸÙ·Ó Ù· Û˘ÌÙÒÌ·Ù· ηٿıÏȄ˘ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ÎÂÊ·Ï·ÏÁ›Â˜ Î·È Â̤ÙÔ˘˜ ¯ˆÚ›˜ ¿ÏÏ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ÂÙÈÎfi, Û˘ÓÈÛÙ¿Ù·È Ó¢ÚÔÏÔÁÈ΋ Î·È Èı·ÓÒ˜ Ó¢ÚÔ·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÂÚÈÙÒÛÂȘ ηı˘ÛÙÂÚË̤Ó˘ ‰È¿ÁÓˆÛ˘ fiÁÎÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‹ ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Û ·È‰È¿ ÌÂ Û˘ÓÔ‰¿ „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· Î·È ‰˘ÛÎÔϛ˜ ÛÙË Û¯ÔÏÈ΋ ›‰ÔÛË ‹ ÌÂ Û˘ÌÙÒÌ·Ù· Ô˘ ÂÛÊ·Ï̤ӷ ·Ô‰fiıËÎ·Ó Û „˘¯ÔÏÔÁÈο ·›ÙÈ·, fiˆ˜ ȉÈfiÌÔÚÊË ÛÙ¿ÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ¿ÏÁË ÛÙ· ¿ÎÚ·. ŸÙ·Ó Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË (ÂÓ›ÔÙ Ì ηı˘ÛÙ¤ÚËÛË ÌËÓÒÓ ‹ ÂÙÒÓ), ›¯Â ·Ó·Ù˘¯ı› Ë Ï‹Ú˘ ÂÈÎfiÓ· Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, ÙÔÓ›˙ÂÙ·È Ë ·Ó·ÁηÈfiÙËÙ· ÂÚÈÔ‰È΋˜ ·ÓÂͤٷÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ (33).
170
Paediatriki 2003;66:167-175
∂. ∂ÈÏË„›· (7,10,34) ŸÙ·Ó ÙÔ ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ Ôͤ· ÂÂÈÛfi‰È· ÔÚÁ‹˜ ‹ ·ÓÈÎÔ‡, Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ë Èı·ÓfiÙËÙ· ÂÈÏË„›·˜ ÎÚÔÙ·ÊÈÎÔ‡ ÏÔ‚Ô‡. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÂÂÈÛÔ‰›Ô˘ Î·È ÛÙË ÌÂÙ·ÎÚÈÙÈ΋ Ê¿ÛË, ÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ Â›Ó·È ‰È·Ù·Ú·Á̤ÓÔ, Ë ‚›·ÈË Û˘ÌÂÚÈÊÔÚ¿ Â›Ó·È ÛÙÂÚÂfiÙ˘Ë Î·È ¿ÛÎÔË, ÂÓÒ Û˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ˘ÓËÏ›· Î·È ·ÌÓËÛ›· ÙÔ˘ Û˘Ì‚¿ÓÙÔ˜. ∏ ÂÈÏÂÁ̤ÓË ÂÛÙȷ΋ ÂÈÏË„›· ÙÔ˘ ÌÂوȷ›Ô˘ ÏÔ‚Ô‡ ÌÔÚ› Ó· ÂΉËÏÒÓÂÙ·È Ì ÂÈʈӋ̷ٷ Î·È ÔÈΛϘ ·ıÔÏÔÁÈΤ˜ ÎÈÓ‹ÛÂȘ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÎÏ·ÛÈÎfi ¯·Ú·ÎÙ‹Ú· Û·ÛÌÒÓ. ™Â ·È‰È¿ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, ˘¿Ú¯ÂÈ Èı·ÓfiÙËÙ· Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ˆ˜ ·ÚÂÓ¤ÚÁÂÈ· ÙˆÓ Ê·Ú̿ΈÓ. ™Ù. °ÂÓÂÙÈο Û‡Ó‰ÚÔÌ· ŸÙ·Ó Ë „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Û˘Ó˘¿Ú¯ÂÈ Ì „˘¯È·ÙÚÈÎfi Úfi‚ÏËÌ·, Ë Û˘¯ÓfiÙËÙ· ΢ÙÙ·ÚÔÁÂÓÂÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Â›Ó·È 3%, Êı¿ÓÔÓÙ·˜ ÙÔ 10% Û ÂÚÈÙÒÛÂȘ ÚÒÈÌ˘ Û¯È˙ÔÊÚ¤ÓÂÈ·˜ (35,36). ∏ ‰È¿ÁÓˆÛË Ù˘ ÁÂÓÂÙÈ΋˜ ·ÓˆÌ·Ï›·˜ ÂÈÙÚ¤ÂÈ ÛÙÔÓ ·È‰›·ÙÚÔ Ó· ÂÎÙÈÌ‹ÛÂÈ ÙÔ ÁÂÓÂÙÈÎfi ˘fiÛÙڈ̷ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·È‰ÈÔ‡, Ó· ÂϤÁÍÂÈ ÁÈ· Û˘ÓÔ‰¿ ÚÔ‚Ï‹Ì·Ù·, Ó· ÚԂϤ„ÂÈ ÙËÓ ÔÚ›· ηÈ, Èı·ÓÒ˜, Ó· ‰È·ÁÓÒÛÂÈ ËÈfiÙÂÚ˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ Û ¿ÏÏ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∆· ÈÔ Û˘¯Ó¿ ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ· Ì ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ê·ÈÓfiÙ˘Ô Û˘ÌÂÚÈÊÔÚ¿˜ Â›Ó·È Ù· ·ÎfiÏÔ˘ı· (35,37,38): ™‡Ó‰ÚÔÌÔ Down: ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Û ÌÈÎÚ‹ ËÏÈΛ·, ÏfiÁˆ ¯·Ú·ÎÙËÚÈÛÙÈÎÔ‡ ۈ̷ÙÈÎÔ‡ Ê·ÈÓÔÙ‡Ô˘. ™Â Û‡ÁÎÚÈÛË Ì ¿ÏÏ· ·È‰È¿ Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Â›Ó·È ÈÔ ÎÔÈÓˆÓÈο, ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ‰È·Ù·Ú·¯ÒÓ ı‡ÌÔ˘ Î·È „‡¯ˆÛ˘, ·ÏÏ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÈÔ Û˘¯Ó¿ Û‡Ó‰ÚÔÌÔ ÂÏÏÂÈÌÌ·ÙÈ΋˜ ÚÔÛÔ¯‹˜. ™‡Ó‰ÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘ Ã: ∂›Ó·È Ë ÈÔ Û˘¯Ó‹ ÎÏËÚÔÓÔÌÈ΋ ·ÈÙ›· ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ (1:1250 ÁÂÓÓ‹ÛÂȘ ·ÚÚ¤ÓˆÓ). ¡ÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Ë ‚·Ú‡ÙËÙ· Ù˘ ÔÔ›·˜ ÔÈΛÏÏÂÈ, ˘¿Ú¯ÂÈ Û fiÏÔ˘˜ ÙÔ˘˜ ¿ÚÚÂÓ˜ Î·È ÛÙ· ÌÈÛ¿ ÂÙÂÚfi˙˘Á· ı‹Ï·. º·ÈÓÔÙ˘Èο, Ù· ·ÁfiÚÈ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·Ï·ÚfiÙËÙ· ·ÚıÚÒÛˆÓ, ÌÂÁ¿ÏÔ˘˜ fiÚ¯ÂȘ, ÌÂÁ¿ÏË ÁÓ¿ıÔ Î·È Âͤ¯ÔÓÙ· ·ÊÙÈ¿. ∏ Û˘ÌÂÚÈÊÔÚ¿ ÙˆÓ ·ÛıÂÓÒÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÊÙˆ¯‹ ‚ÏÂÌÌ·ÙÈ΋ ·ʋ, ·ÔÊ˘Á‹ ÎÔÈÓˆÓÈÎÒÓ Â·ÊÒÓ, ÛÙÂÚÂÔÙ˘›Â˜, ÂÌÌÔÓ¤˜, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Î·È ÂÎÚ‹ÍÂȘ ı˘ÌÔ‡. ™‡Ó‰ÚÔÌÔ Williams: ∆· ·È‰È¿ ·˘Ù¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÚÔۈ›Ô, ÎÔÓÙfi ·Ó¿ÛÙËÌ·, Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Î·È ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·. Œ¯Ô˘Ó ηϿ ·ÓÂÙ˘Á̤ÓÔ ÂÎÊÚ·ÛÙÈÎfi ÏfiÁÔ, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Î·È ¿Á¯Ô˜.
May-June 03
03-06-03
16:55
™ÂÏ›‰·171
¶·È‰È·ÙÚÈ΋ 2003;66:167-175
™‡Ó‰ÚÔÌÔ Prader-Willi: O ÎÏÈÓÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ·¯˘Û·ÚΛ·, ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÎÚ˘„ÔÚ¯›·, ˘ÔÏ·ÛÙÈο ÁÂÓÓËÙÈο fiÚÁ·Ó·, ÌÈÎÚ¿ ¯¤ÚÈ· Î·È fi‰È·. ™ÙÔ ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ˘ÔÙÔÓ›· ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, ÔÏ˘Ê·Á›· ·fi ÙË ÓËȷ΋ ËÏÈΛ· Î·È Î·ı˘ÛÙ¤ÚËÛË „˘¯ÔÎÈÓËÙÈ΋˜ ·Ó¿Ù˘Í˘. ∆· ¿ÙÔÌ· Ì ۇӉÚÔÌÔ Prader-Willi ¤¯Ô˘Ó ÔÚȷ΋ ‹ ‹ÈÔ˘ ‚·ıÌÔ‡ ¯·ÌËÏ‹ ÓÔËÌÔÛ‡ÓË. ∆· ÈÔ Û˘¯Ó¿ ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â›Ó·È ÂÌÌÔÓ¤˜, ΢ڛˆ˜ Ì ÙÔ Ê·ÁËÙfi, ηıÒ˜ Î·È ÂÂÈÛfi‰È· ÂÈıÂÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜. ™‡Ó‰ÚÔÌÔ Turner: ∏ ÌÂÚÈ΋ ‹ Ï‹Ú˘ ¤ÏÏÂÈ„Ë ÂÓfi˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à ÂΉËÏÒÓÂÙ·È Ì ÙÔÓ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ê·ÈÓfiÙ˘Ô: ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ȉÈfiÌÔÚÊÔ ÚÔۈ›Ô, ÙÂÚ‡ÁÈÔ ÙÚ·¯‹ÏÔ˘, Ê·Ú‰‡˜ ıÒڷη˜ Î·È ÎÔÓÙfi ٤ٷÚÙÔ ÌÂٷοÚÈÔ. ∏ ÓÔËÌÔÛ‡ÓË Â›Ó·È Û˘Ó‹ıˆ˜ ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·, ·ÏÏ¿ ÔÈ Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Â›Ó·È Û˘¯Ó¤˜. ¶ÔÏϤ˜ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ù¿ıÏÈ„Ë, ¿Á¯Ô˜ Î·È ‰˘ÛÎÔÏ›· ÛÙȘ ÎÔÈÓˆÓÈΤ˜ Û¯¤ÛÂȘ. ∞ÁfiÚÈ· Ì ηڢfiÙ˘Ô ÃÃÀ ‹ Û‡Ó‰ÚÔÌÔ Klinefelter: ∂›Ó·È „ËÏÔ›, Ì ‰˘Û·Ó¿ÏÔÁ· Ì·ÎÚÈ¿ fi‰È·, ÌÈÎÚÔ‡˜ fiÚ¯ÂȘ Î·È Á˘Ó·ÈÎÔÌ·ÛÙ›·. ¶ÔÏÏÔ› ¤¯Ô˘Ó ¯·ÌËÏfi ÏÂÎÙÈÎfi ËÏ›ÎÔ ÓÔËÌÔÛ‡Ó˘ Î·È ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó¿ÁÓˆÛË. ∂›Ó·È ·ıËÙÈÎÔ› ÛÙȘ Û¯¤ÛÂȘ ÌÂ Û˘ÓÔÌËÏ›ÎÔ˘˜, ÔÈ ÔÔ›ÔÈ Û˘¯Ó¿ ÙÔ˘˜ ÂÈÙ›ıÂÓÙ·È. ∞ÁfiÚÈ· Ì ηڢfiÙ˘Ô ÃÀÀ: ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi „ËÏfi ·Ó¿ÛÙËÌ· Î·È ¤ÓÙÔÓË ·ÎÌ‹ ηٿ ÙËÓ ÂÊ˂›·. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·ı˘ÛÙ¤ÚËÛË ÙÔ˘ ÏfiÁÔ˘, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Î·È ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿, ÂÓÒ ÛÙËÓ ÂÊ˂›· ÌÔÚ› Ó· ‰È·ÁÓˆÛÙ› ‰È·Ù·Ú·¯‹ ‰È·ÁˆÁ‹˜. ¶·È‰È¿ Ì Ó¢ÚÔ˚ӈ̿وÛË: Œ¯Ô˘Ó ÓÔËÌÔÛ‡ÓË ÛÙ· ¯·ÌËÏ¿ Ê˘ÛÈÔÏÔÁÈο fiÚÈ·, ÂÓÒ Ù· ÌÈÛ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Î·È ‰È·Ù·Ú·¯‹ ÚÔÛÔ¯‹˜. ∑. §ÔÈÌÒÍÂȘ OÈ ·ÎfiÏÔ˘ı˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ∫¡™ ÌÔÚ› Ó· ÂΉËψıÔ‡Ó ·Ú¯Èο Ì „˘¯ÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ (7,10,39). ÀÔÍ›· ÛÎÏËÚ˘ÓÙÈ΋ ·ÓÂÁÎÂÊ·Ï›Ùȉ·: ¶ÚfiÎÂÈÙ·È ÁÈ· Ï·Óı¿ÓÔ˘Û·, ÚÔԉ¢ÙÈ΋ ÊÏÂÁÌÔÓ‹ Ô˘ ·ÎÔÏÔ˘ı› ÙËÓ ÈÏ·Ú¿ ‹ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ ÈÏ·Ú¿˜. ∂ΉËÏÒÓÂÙ·È Ì ·¸Ó›·, ÂÓ·ÓÙȈÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿, ÂÎÚ‹ÍÂȘ ı˘ÌÔ‡ Î·È ·Ú·ÈÛı‹ÛÂȘ. ¡Â˘ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù·, fiˆ˜ Û·ÛÌÔ› Î·È ·Ù·Í›·, ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ·ÚÁfiÙÂÚ· ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘. ∂ÚËÙÈ΋ ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ·: ∫·Ù¿ ÙÔ Ô͇ ÂÂÈÛfi‰ÈÔ, Ù· 9/10 ÙˆÓ ·ÛıÂÓÒÓ ¤¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜, ·Ú·ÈÛı‹ÛÂȘ ‹ „‡¯ˆÛË. ™˘Ó‹ıˆ˜ ˘¿Ú¯ÂÈ ˘ÚÂÙfi˜, Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· Î·È ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ∂ÈÏÔΤ˜ ÌÈÎÚԂȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜: ª›· ·fi ÙȘ ÈÔ Û˘¯Ó¤˜ ÂÈÏÔΤ˜ Â›Ó·È Ë ·ÒÏÂÈ· ·ÎÔ‹˜, Ë ÔÔ›· ÂÓ‰¤¯ÂÙ·È Ó· ÂΉËψı› Ì ‰È·Ù·Ú·¯¤˜ ÔÌÈ-
Paediatriki 2003;66:167-175
Ï›·˜ Î·È Û˘ÌÂÚÈÊÔÚ¿˜. ªÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜ ‹ Î·È Ì‹Ó˜ ÌÂÙ¿ ÙË ÓfiÛÔ, ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ Î·È ÁÓˆÛÙÈο ÂÏÏ›ÌÌ·Ù·. °ÂÓÈο, fï˜, Ë ÚfiÁÓˆÛË Â›Ó·È Â˘ÓÔ˚΋ ÛÙ· ·È‰È¿ Ô˘ ‰ÂÓ Â›¯·Ó Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ™‡Ó‰ÚÔÌÔ ¯ÚfiÓÈ·˜ ÎfiˆÛ˘: ™˘Ó‹ıˆ˜ ·Ú¯›˙ÂÈ Ì ÔÍ›· Ïԛ̈ÍË (ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË ‹ ÁÚ›Ë). ∞ÎÔÏÔ˘ı› ·›ÛıËÌ· ÎfiˆÛ˘ Î·È ÌÂȈ̤Ó˘ ·ÓÙÔ¯‹˜, Ô˘ ÂÌÔ‰›˙ÂÈ ÙȘ ηÓÔÓÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Î·È ‰È·ÚΛ >6 Ì‹Ó˜. ™˘Óԉ‡ÂÙ·È ·fi ÔÏÏ·Ï¿ Û˘ÌÙÒÌ·Ù· Î·È Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Â¿Ó ÏËÚÔ› Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ Î·È ¶ÚfiÏ˄˘ ∞ÛıÂÓÂÈÒÓ ÙˆÓ ∏¶∞ (40). OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ¿Û¯Ô˘Ó ·fi ‰È·Ù·Ú·¯¤˜ ‡ÓÔ˘ (·¸Ó›· ‹ ˘ÓËÏ›·), ‰˘ÛÎÔÏ›· Û˘ÁΤÓÙÚˆÛ˘ Ù˘ ÚÔÛÔ¯‹˜ ‹ ¤¯Ô˘Ó fiÏ· Ù· Û˘ÌÙÒÌ·Ù· ηٿıÏȄ˘ (Û ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ·fi ¿ÙÔÌ· Ì ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, fiˆ˜ Ë Î˘ÛÙÈ΋ ›ÓˆÛË). ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó Ù· „˘¯Èο ÚÔ‚Ï‹Ì·Ù· Â›Ó·È ·ÈÙ›· ‹ ›وÛË ÙˆÓ ÛˆÌ·ÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹ Â¿Ó ˘¿Ú¯ÂÈ ÎÔÈÓfi˜ ·ÈÙÈÔÏÔÁÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. ™‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (AIDS): ¶·È‰È¿ Ì AIDS Î·È ÚÔÛ‚ÔÏ‹ ÙÔ˘ ∫¡™ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰È·Ù·Ú·¯¤˜ ÌÓ‹Ì˘ Î·È ÚÔÛÔ¯‹˜, ·fiÛ˘ÚÛË Î·È ·˘ÍË̤ÓË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÌÂÙ·‚ÏËÙfiÙËÙ·. ∏. ∞˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (7,41) ¶·È‰È·ÙÚÈΤ˜ ·˘ÙÔ¿ÓÔÛ˜ Ó¢ÚÔ„˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÛÙÚÂÙfiÎÔÎÎÔ (Pediatric autoimmune neuropsychiatric disorders associated with streptococcus - PANDAS): ∂ΉËÏÒÓÂÙ·È Ì ȉÂÔ„˘¯·Ó·ÁηÛÙÈ΋ ‰È·Ù·Ú·¯‹. ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ·ÔÙÂÏÔ‡Ó: ·) Ë ·ÚÔ˘Û›· ȉÂÔ„˘¯·Ó·ÁηÛÙÈ΋˜ ‰È·Ù·Ú·¯‹˜ ‹ ÙÈÎ, ‚) Ë ¤Ó·ÚÍË ÌÂٷ͇ ËÏÈΛ·˜ 3 ÂÙÒÓ Î·È ÂÊ˂›·˜, Á) Ë ·ÈÊÓ›‰È· ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, Ë ÔÚ›· Ì ˘Ê¤ÛÂȘ Î·È ‰Ú·Ì·ÙÈΤ˜ ÂÍ¿ÚÛÂȘ, ‰) Ë ¯ÚÔÓÔÏÔÁÈ΋ Û¯¤ÛË ÙˆÓ ÂÍ¿ÚÛÂˆÓ Ì ÙË ÛÙÚÂÙÔÎÔÎÎÈ΋ Ïԛ̈ÍË Î·È Â) Ù· ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤Í·ÚÛ˘ (ÙÈÎ, ¯ÔÚ›·, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·). ∞fi ÌÂϤÙ˜ Ì ÌÈÎÚÔ‡˜ ·ÚÈıÌÔ‡˜ ·ÛıÂÓÒÓ ÚÔ·ÙÂÈ fiÙÈ ÂÚ›Ô˘ 10% ÙˆÓ ·È‰ÈÒÓ Ì ȉÂÔÏË„›Â˜ Î·È „˘¯·Ó·ÁηÛÌÔ‡˜ ÌÔÚ› Ó· ¿Û¯ÂÈ ·fi PANDAS. ™˘ÓÈÛÙ¿Ù·È ÚÔʇϷÍË Ì ÂÓÈÎÈÏ›ÓË, fiˆ˜ ÌÂÙ¿ ·fi ÚÂ˘Ì·ÙÈÎfi ˘ÚÂÙfi, ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË ÏËÚÔÊÔڛ˜ ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÚfiÁÓˆÛË. ∂Ú˘ıËÌ·Ù҉˘ χÎÔ˜: ¶·È‰È¿ Ì ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ Ô˘ ¤¯ÂÈ ÚÔÛ‚¿ÏÂÈ ÙÔ ∫¡™ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÔÍ›· Û‡Á¯˘ÛË ‹ „‡¯ˆÛË, ÚÔÙÔ‡ ÂÌÊ·ÓÈÛÙÔ‡Ó Ù· ¿ÏÏ· Ó¢ÚÔÏÔÁÈο Î·È Û˘ÛÙËÌ·ÙÈο Û˘ÌÙÒÌ·Ù· Ù˘ ÓfiÛÔ˘ (42,43). £. ∆ÔÍÈο ·›ÙÈ· (12,32) º·ÚÌ·ÎÔÏÔÁÈο ·›ÙÈ·: ¶ÔÏÏ¿ Ê¿Ú̷η ÌÔÚ›
171
May-June 03
03-06-03
16:55
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¶·È‰È·ÙÚÈ΋ 2003;66:167-175
Ó· ÚÔηϤÛÔ˘Ó „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ˆ˜ ·ÚÂÓ¤ÚÁÂÈ¿ ÙÔ˘˜ ‹ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÛÙ¤ÚËÛ˘. ∞fi ÙËÓ ·È‰È·ÙÚÈ΋ Ê·ÚÌ·ÎÔÏÔÁ›· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·ÓÙȯÔÏÈÓÂÚÁÈο, ·ÓÙÈÂÈÏËÙÈο, ‚·Ú‚ÈÙÔ˘ÚÈο, ‚ÂÓ˙ԉȷ˙›Ó˜, ·ÓÙ·ÁˆÓÈÛÙ¤˜ ‚-˘Ô‰Ô¯¤ˆÓ, ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÈÛÔÓÈ·˙›‰Ë, ÌÂÙÚÔÓȉ·˙fiÏË, ÙÚÈÌÂıÔÚ›ÌË-ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË Î·È ¿ÏÏ·. ∫·Ù¿¯ÚËÛË Ô˘ÛÈÒÓ: ™Â ÂÊ‹‚Ô˘˜ Ì ۯÈ˙ÔÊÚ¤ÓÂÈ·, Û˘¯Ó¿ Û˘Ó˘¿Ú¯ÂÈ ¯Ú‹ÛË ··ÁÔÚÂ˘Ì¤ÓˆÓ Ô˘ÛÈÒÓ. ŸÙ·Ó Ô ¯Ú‹ÛÙ˘ ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ Ô˘Û›·˜, ·˘Í¿ÓÂÈ Ë Èı·ÓfiÙËÙ· Ó· ˘¿Ú¯ÂÈ ÚˆÙÔ·ı¤˜ „˘¯È·ÙÚÈÎfi Úfi‚ÏËÌ·. ∏ ÂıÈÛÙÈ΋ Ô˘Û›· ‰Ú· ˆ˜ ÚÔÎÏËÙÈÎfi˜ Î·È ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. π. ¡Â˘ÚÔ·Ó·Ù˘ÍÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ ∏ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ „˘¯È·ÙÚÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Â›Ó·È 2-3 ÊÔÚ¤˜ ·˘ÍË̤ÓË Û ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Ì ¯·ÌËÏfi ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹/Î·È ÂÚÈÁÂÓÓËÙÈΤ˜ ÂÈÏÔΤ˜, fiˆ˜ Ë ·ÓÔÍ›· (44). ∏ ̤ÛË ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Û ·È‰È¿ Ì ۯÈ˙ÔÊÚ¤ÓÂÈ· Â›Ó·È ¯·ÌËÏfiÙÂÚË Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ (45). ∂›Û˘, ÛÙËÓ ·ÂÈÎfiÓÈÛË ÂÁÎÂÊ¿ÏÔ˘ ·Ú·ÙËÚÂ›Ù·È ÈÔ Û˘¯Ó¿ ‰È‡ڢÓÛË ÎÔÈÏÈÒÓ Û ۯÈ˙ÔÊÚÂÓÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÂÚÈÁÂÓÓËÙÈÎÒÓ ÂÈÏÔÎÒÓ (46). ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ì ‚‚·ÚË̤ÓÔ ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ „˘¯È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù· Î·È ¤ÙÛÈ Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘˜ ÔÊ›ÏÂÙ·È Û ·ÏÏËÏ›‰Ú·ÛË ‚Ï¿‚˘ ÙÔ˘ ∫¡™ Ì ÁÂÓÂÙÈÎÔ‡˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (47,48). ∏ ¯Ú‹ÛË ÔÈÓÔÓ‡̷ÙÔ˜, ÓÈÎÔÙ›Ó˘, οÓÓ·‚˘, ÎÔη˝Ó˘ ‹ ·ÓÙÈηٷıÏÈÙÈÎÒÓ, ·ÓÙÈÂÈÏËÙÈÎÒÓ Î·È ·ÓÙÈ„˘¯ˆÛÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·fi ÙË ÌËÙ¤Ú· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ‰È·Ù·Ú·¯ÒÓ Ù˘ „˘¯ÔÎÈÓËÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙÔ ·È‰›. OÈ ÌÂϤÙ˜ ¤¯Ô˘Ó Ï¿‚ÂÈ ˘’ fi„ÈÓ ÙÔ˘˜ ÔÏÏÔ‡˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ˘¿Ú¯Ô˘Ó Û ٤ÙÔȘ ÂÚÈÙÒÛÂȘ (49). ™ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ·È‰ÈÒÓ Ì „˘¯È·ÙÚÈο Û˘ÌÙÒÌ·Ù· ·Ó·Ê¤ÚÔÓÙ·È ÈÔ Û˘¯Ó¿ ·ÔÎÏ›ÛÂȘ ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË, ΢ڛˆ˜ ηı˘ÛÙ¤ÚËÛË ÛÙË ‚¿‰ÈÛË Î·È ÛÙËÓ ÂͤÏÈÍË ÙÔ˘ ÏfiÁÔ˘. ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ‰È·Ù·Ú·Á̤ÓË ·Ó¿Ù˘ÍË ÙÔ˘ ∫¡™ ı· ÌÔÚÔ‡Û ӷ ·ÔÙÂÏ› ÎÔÈÓfi ˘fiÛÙڈ̷ ÁÈ· Ù· ‰‡Ô Ê·ÈÓfiÌÂÓ· (48,50). OÈ ÂÏ¿ÛÛÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Ê˘ÛÈο ÂÏÏ›ÌÌ·Ù· Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ÔÛÔÛÙfi <4% ÙÔ˘ ÏËı˘ÛÌÔ‡. ¶·Ú·‰Â›ÁÌ·Ù· ·˘ÙÒÓ Â›Ó·È Ô ˘ÂÚÙÂÏÔÚÈÛÌfi˜, Ë ÌÔÓ‹Ú˘ Ù˘¯‹ Ù˘ ·Ï¿Ì˘, Ë ıÔψً ˘ÂÚÒ· Î.Ï. ™Â ·È‰È¿ Ì ÔÈΛϷ ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜ (˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ÂÏÏÂÈÌÌ·ÙÈ΋ ÚÔÛÔ¯‹, ‰È·Ù·Ú·¯‹ ‰È·ÁˆÁ‹˜, „‡¯ˆÛË), ÔÈ ÂÏ¿ÛÛÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ··ÓÙÒ-
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ÓÙ·È ÈÔ Û˘¯Ó¿ Û ۇÁÎÚÈÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (51,52). ™Â ÚÔÔÙÈ΋ ÌÂϤÙË ·È‰ÈÒÓ Û ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· „˘¯È·ÙÚÈ΋ ÓfiÛÔ (ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi, ÚÔ‚ÏËÌ·ÙÈÎfi ÂÚÈ‚¿ÏÏÔÓ), Ë Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ „˘¯È·ÙÚÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙËÓ ÂÊ˂›· ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË ÛÙ· ·È‰È¿ Ì ≥2 ÂÏ¿ÛÛÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ (52). ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ·˘Ù¤˜ ÛËÌ·ÙÔ‰ÔÙÔ‡Ó ‰È·ÎÚÈÙÈΤ˜ ·Ó·Ù˘ÍȷΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ∫¡™ Ô˘ Úԉȷı¤ÙÔ˘Ó, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÁÈ· „˘¯È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·. ∫ÏÈÓÈ΋ ·È‰È·ÙÚÈ΋ ÂͤٷÛË πÛÙÔÚÈÎfi ∆· ·ÎfiÏÔ˘ı· ÛÙÔȯ›· ·fi ÙÔ ÈÛÙÔÚÈÎfi ˘Ô‰ËÏÒÓÔ˘Ó ÙËÓ Èı·Ó‹ ‡·ÚÍË ÔÚÁ·ÓÈ΋˜ ‰È·Ù·Ú·¯‹˜ (3-7,9-11): ·) ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi (Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, ÌÂÙ·‚ÔÏÈο ‹ ¿ÏÏ· ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù·, ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Û·ÛÌÔ›, ·˘ÙfiÌ·Ù˜ ·Ô‚ÔϤ˜, ı¿Ó·ÙÔÈ Û ·È‰È΋ ËÏÈΛ·, ·ÈÌÔÌÈÍ›·, „˘¯È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·), ‚) ÌËÙ¤Ú· Ì AIDS, Á) ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi (ÂÈÏÔΤ˜ ·ËÛ˘, ÙÔÎÂÙÔ‡, ÂÚÈÁÂÓÓËÙÈ΋˜ ÂÚÈfi‰Ô˘, ÚÔˆÚfiÙËÙ·), ‰) „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË (ηı˘ÛÙÂÚ‹ÛÂȘ, ÂȉÈο ÛÙÔ ‚¿‰ÈÛÌ·, ÏfiÁÔ˘ Î·È ÛÙËÓ ÎÔÈÓˆÓÈÎfiÙËÙ·, ¿Ù˘Ë ·Ó¿Ù˘ÍË), Â) ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi (¤ÓÙÔÓÔÈ ¤ÌÂÙÔÈ ‹ ‰È·Ù·Ú·¯¤˜ Û˘Ó›‰ËÛ˘ ÚÔηÏÔ‡ÌÂÓ· ·ÓÂÈÏËÌ̤ӈ˜ ·fi ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ, ÓËÛÙ›· ‹ ‰È·ÈÙËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ·Û˘Ó‹ıÈÛÙË ÔÛÌ‹ ۈ̷ÙÈÎÒÓ ÂÎÎÚ›ÛˆÓ, Û·ÛÌÔ› ‹ ¿ÏÏ· Ó¢ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù·) Î·È ÛÙ) ÁÂÓÈÎfi Â›Â‰Ô ÏÂÈÙÔ˘ÚÁ›·˜ (˘ÓËÏ›· ‹ ·¸Ó›·, ÚÔԉ¢ÙÈ΋ ·ÒÏÂÈ· ‰ÂÍÈÔÙ‹ÙˆÓ ·˘ÙÔÂ͢ËÚ¤ÙËÛ˘, ·fiÛ·ÛË ÚÔÛÔ¯‹˜, ¤ÎÙˆÛË ÌÓ‹Ì˘, ÌÂȈ̤ÓÔ ÏÂÍÈÏfiÁÈÔ Ì ·ÎfiÏÔ˘ıË Ì›ˆÛË Ù˘ Û¯ÔÏÈ΋˜ ›‰ÔÛ˘, ηÎfi˜ ÚÔÛ·Ó·ÙÔÏÈÛÌfi˜ ÛÙÔ ¯ÒÚÔ Î·È ÔÙÈÎÔ-ÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹, ‰È·Ù·Ú·¯¤˜ ÔÌÈÏ›·˜ - ‰˘Û·ÚıÚ›·, ·ÏÏ·Á‹ ¯ÚÔÈ¿˜ Ù˘ ʈӋ˜, ÙÚ·˘ÏÈÛÌfi˜, ¤ÎÙˆÛË fiÚ·Û˘ ‹ ·ÎÔ‹˜). ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙ· ·ÌÈÁÒ˜ „˘¯È·ÙÚÈο ÓÔÛ‹Ì·Ù·, Ë Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ ÂËÚ¿˙ÂÈ ‰˘ÛÌÂÓÒ˜ ÙË Û¯ÔÏÈ΋ ÚfiÔ‰fi ÙÔ˘, ·ÏÏ¿ ·˘Ùfi Û˘Ó‹ıˆ˜ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÎÙˆÛË ÙˆÓ ‰ÂÍÈÔÙ‹ÙˆÓ Î·ı’ ·˘Ù‹ (·Ó¿ÁÓˆÛË, ÁÚ·Ê‹, ÁÓˆÛÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜), fiˆ˜ ÛÙȘ ÔÚÁ·ÓÈΤ˜ „˘¯ÒÛÂȘ. ∞ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ∆· ·ÎfiÏÔ˘ı· ÛËÌ›· ÌÔÚ› Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ‡·ÚÍË ÔÚÁ·ÓÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜ (3-7,911,51,52): ·) ۈ̷ÙÔÌÂÙÚÈο (ÛËÌ·ÓÙÈ΋ ·fiÎÏÈÛË ·fi ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÁÈ· ·Ó¿ÛÙËÌ· Î·È ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜), ‚) ȉÈfiÌÔÚÊÔ ÚÔۈ›Ô, Á) ‰ÈfiÁΈÛË ı˘ÚÂÔÂȉԇ˜, ‰) ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË (‰·ÎÙ‡ÏÈÔ˜ Kaiser Fleischer, ÂӉ›ÍÂȘ ·˘ÍË̤Ó˘ ÂÓ‰ÔÎÚ·Óȷ΋˜ ›ÂÛ˘ ÛÙË ‚˘ıÔÛÎfiËÛË, ¤ÎÙˆÛË ÔÙÈ΋˜ Ô͇ÙËÙ·˜, Ì›ˆÛË ÔÙÈÎÒÓ Â‰›ˆÓ, ÔÈΛϘ
May-June 03
03-06-03
16:55
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¶·È‰È·ÙÚÈ΋ 2003;66:167-175
·ıÔÁÓˆÌÔÓÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·), Â) ΢ÎÏÔÊÔÚÈÎfi (‰È·Ù·Ú·¯¤˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ûʇ͈Ó), ÛÙ) ÎÔÈÏÈ¿ (‰ÈfiÁΈÛË ‹·ÙÔ˜ ‹ ÛÏËÓfi˜), ˙) Â͈ÙÂÚÈο ÁÂÓÓËÙÈο fiÚÁ·Ó· (‰È·Ù·Ú·¯‹ ÛÂÍÔ˘·ÏÈ΋˜ ˆÚ›Ì·ÓÛ˘), Ë) ·ÓˆÌ·Ï›Â˜ ÛÎÂÏÂÙÔ‡ ‹ ‰¤ÚÌ·ÙÔ˜, ı) ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË (‚¿‰ÈÛÌ·, ÈÛÔÚÚÔ›·, Û˘ÓÙÔÓÈÛÌfi˜, ÂÁÎÂÊ·ÏÈΤ˜ Û˘˙˘Á›Â˜, ÏfiÁÔ˜/ÔÌÈÏ›·, ·ÎÔ‹, Ì˘˚΋ ÈÛ¯‡˜, Ì˘˚Îfi˜ ÙfiÓÔ˜, ·ÎÔ‡ÛȘ ÎÈÓ‹ÛÂȘ-ÙÚfiÌÔ˜, ‰˘ÛÎÈÓËÛ›·, ·ıÔÏÔÁÈο ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο, ·ÈÛıËÙÈÎfiÙËÙ·-ÂÏ¿ÛÛÔÓ· Ó¢ÚÔÏÔÁÈο ÛËÌ›·) Î·È È) Ì›˙ÔÓ˜ ‹ ÂÏ¿ÛÛÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜. ∂ÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·Ï¤˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· ·Ó›¯Ó¢ÛË ÓÔÛËÌ¿ÙˆÓ Û ¿ÙÔÌ· ¯ˆÚ›˜ ÔÚÁ·ÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Î·È ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋ ˘Ô„›· (3-7,9-11,55). ·) ∞ÓȯÓ¢ÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ: °ÂÓÈ΋ ·›Ì·ÙÔ˜, ∆∫∂, ÁÂÓÈ΋ Ô‡ÚˆÓ, ÁÏ˘Îfi˙Ë ·›Ì·ÙÔ˜, ÈÔÓÙfiÁÚ·ÌÌ·, Ô˘ÚÈÎfi Ô͇, Ô˘Ú›· Î·È ÎÚ·ÙÈÓ›ÓË, ÂÍÂÙ¿ÛÂȘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÏÈ›‰È·, CPK (54-56), ÂÍÂÙ¿ÛÂȘ ÏÂÈÙÔ˘ÚÁ›·˜ ı˘ÚÂÔÂȉԇ˜. ‚) ¢È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ÔÈ Ôԛ˜ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ·Ó¿ÏÔÁ· Ì ٷ ÎÏÈÓÈο ÛÙÔȯ›·. i) ÃÚˆÌÔÛˆÌÈ΋ ·Ó¿Ï˘ÛË Î·È ÂͤٷÛË ÁÈ· ‡ıÚ·˘ÛÙÔ Ã Û ÂÚÈÙÒÛÂȘ Ì æ∫∫, ·ıÔÁÓˆÌÔÓÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È Ê·ÈÓfiÙ˘Ô Û˘ÌÂÚÈÊÔÚ¿˜ ‹ ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ii) ∫˘ÙÙ·ÚÔÁÂÓÓËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, fiÙ·Ó ˘¿Ú¯Ô˘Ó Ê˘ÛÈο Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ‹/Î·È æ∫∫. iii) ∂ͤٷÛË ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ÁÈ· ÙÔÍÈΤ˜ Ô˘Û›Â˜, fiÔ˘ ÂӉ›ÎÓ˘Ù·È. iv) ŒÏÂÁ¯Ô˜ ÁÈ· Ó¢ÚÔÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜: ·›Ì· (p∏, ·Ì̈ӛ·, ·ÌÈÓÔͤ·, Á·Ï·ÎÙÈÎfi Ô͇, ˘ÚÔÛÙ·Ê˘ÏÈÎfi Ô͇, ηÚÓÈÙ›ÓË, ÏÈ·Ú¿ Ôͤ· Ôχ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘, ÛÂÚÔ˘ÏÔÏ·ÛÌ›ÓË), o‡Ú·: (ÔÚÁ·ÓÈο Ôͤ·, ·ÌÈÓÔͤ·, ‚ÂÓÓÔÔÏ˘Û·Î¯·Ú›Ù˜, ÔÏÈÁÔ۷ί·Ú›Ù˜, ¯·ÏÎfi˜). v) ∆· ·Ú·¿Óˆ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÈÔ ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÂÍÂÙ¿ÛÂȘ, fiˆ˜ ÂÍÂÙ¿ÛÂȘ ∂¡À (57), ÂÓ˙˘Ì·ÙÈΤ˜ ÌÂϤÙ˜ ‰ÂÈÁÌ¿ÙˆÓ ·fi ‚ÈÔ„›·, ·Ó¿Ï˘ÛË DNA. Á) ¡Â˘ÚÔ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂϤÙ˜: ∂Ӊ›ÎÓ˘ÓÙ·È fiÙ·Ó ˘¿Ú¯Ô˘Ó Ó¢ÚÔÏÔÁÈο ÛËÌ›· ‹ ˘Ô„›· ÂÎÊ˘ÏÈÛÙÈ΋˜ ÓfiÛÔ˘ (19,58,59). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÚÔÛʤÚÂÈ ÂÚÈÛÛfiÙÂÚ· ·fi ÙËÓ ˘ÔÏÔÁÈÛÙÈ΋, ÂȉÈο ÁÈ· ÓÔÛ‹Ì·Ù· Ù˘ Ï¢΋˜ Ô˘Û›·˜ Î·È fiÁÎÔ˘˜. ™ÙËÓ ·È‰È΋ Û¯È˙ÔÊÚ¤ÓÂÈ· ‰È·ÈÛÙÒÓÂÙ·È ÚÔԉ¢ÙÈ΋ ‰È‡ڢÓÛË ÎÔÈÏÈÒÓ Î·È Ì›ˆÛË ÔÏÈÎÔ‡ fiÁÎÔ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∞ÛıÂÓ›˜ Ì Ó¢ÚÔÁÂÓ‹ ·ÓÔÚÂÍ›· ¤¯Ô˘Ó Ì›ˆÛË Ê·È¿˜ Î·È Ï¢΋˜ Ô˘Û›·˜, Ë
Paediatriki 2003;66:167-175
ÔÔ›· ·Ôηı›ÛÙ·Ù·È ÌfiÓÔ ÌÂÚÈÎÒ˜ ÌÂÙ¿ ·fi ÙËÓ ·Ó¿ÎÙËÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. OÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ PET, SPECT, MRS, Â›Ó·È ·ÎfiÌË Î˘Ú›ˆ˜ ÂÚ¢ÓËÙÈο ÂÚÁ·Ï›·. ‰) ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· (60): ∆Ô ∏∂° Â›Ó·È ‰È·ÁÓˆÛÙÈÎfi Û ÂÚÈÙÒÛÂȘ ÂÈÏË„›·˜. ™Â ÔÚÁ·ÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ ∫¡™, ÔÈ ÂȉÈΤ˜ ‹ ÌË-ÂȉÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÌÔÚ› Ó· ÚÔÛʤÚÔ˘Ó ÂÈÚfiÛıÂÙ˜ ÏËÚÔÊÔڛ˜. ∫ÔÈÓˆÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ ŸÙ·Ó ‰È·ÈÛÙÒÓÔ˘Ì ÙËÓ ‡·ÚÍË ÔÚÁ·ÓÈÎÔ‡ ÚÔ‚Ï‹Ì·ÙÔ˜, ‰ÂÓ ÌÔÚԇ̠¿ÓÙ· Ó· ˘Ôı¤ÛÔ˘Ì fiÙÈ ·˘Ùfi ¢ı‡ÓÂÙ·È ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙËÓ „˘¯È·ÙÚÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·. ∏ ÔÚ›· ÙÔ˘ ·È‰ÈÔ‡ ÂËÚ¿˙ÂÙ·È Î·È ·fi ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. À¿Ú¯Ô˘Ó ‰‡Ô ÌÔÓ٤Ϸ ÂÚÌËÓ›·˜ (5). ™‡Ìʈӷ Ì ÙÔ ¤Ó·, ÙÔ ÔÚÁ·ÓÈÎfi ÓfiÛËÌ· ηıÈÛÙ¿ ÙÔ ·È‰› ÈÔ ÂÈÚÚ¤˜ ·ÎfiÌË Û ÎÔÈÓ¿ ‰˘ÛÌÂÓ‹ ÎÔÈÓˆÓÈο Û˘Ì‚¿ÓÙ·. ∂Ô̤ӈ˜, Ì ۈÛÙ‹ ÂÚÈ‚·ÏÏÔÓÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ÌÔÚ› Ó· ·ÔÙÚ·Ô‡Ó, Û οÔÈÔ ‚·ıÌfi, Ù· „˘¯È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·. ™‡Ìʈӷ Ì ÙÔ ¿ÏÏÔ ÌÔÓÙ¤ÏÔ, ÔÈ ‚ÈÔÏÔÁÈΤ˜ ‰ÈÂÚÁ·Û›Â˜ Î·È Ù· „˘¯ÔÏÔÁÈο Ê·ÈÓfiÌÂÓ· ÂÍÂÏ›ÛÛÔÓÙ·È ·ÓÂÍ¿ÚÙËÙ·. ÕÚ·, ÌÂÚÈο ¿ÙÔÌ· Ì ÔÚÁ·ÓÈÎfi Úfi‚ÏËÌ· ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó „˘¯Ô·ıÔÏÔÁ›·, ·ÎfiÌË Î·È Î¿Ùˆ ·fi ÙȘ ÈÔ Â˘ÓÔ˚Τ˜ ÎÔÈÓˆÓÈΤ˜ Û˘Óı‹Î˜. ªÂ ·˘Ù‹ ÙËÓ ÚÔÛ¤ÁÁÈÛË, ·ÔʇÁÔ˘Ì ÙËÓ ÂÓÔ¯ÔÔ›ËÛË ÙˆÓ ‹‰Ë ٷϷȈÚËÌ¤ÓˆÓ ÁÔÓ¤ˆÓ. À¿Ú¯ÂÈ Î·È Ì›· ÙÚ›ÙË ÚÔÛ¤ÁÁÈÛË, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÔÚÈṲ̂ӷ ¿ÙÔÌ· Ì ÔÚÁ·ÓÈ΋ ‰È·Ù·Ú·¯‹ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Î·È „˘¯È΋ ‰È·Ù·Ú·¯‹ ÔÚÁ·ÓÈο ÚÔηıÔÚÈṲ̂ÓË. £· ˘ÔÛÙÔ‡Ó fï˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÂȉڿÛÂȘ, ÔÈ Ôԛ˜ Â›Ó·È Î·Ïfi Ó· ÚÔÛ¯ıÔ‡Ó, Ô‡Ùˆ˜ ÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈËıÔ‡Ó ÔÈ Èı·ÓfiÙËÙ˜ ¯ÚfiÓÈ·˜ „˘¯Ô·ıÔÏÔÁ›·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ô ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ·›ÍÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó›¯Ó¢ÛË „˘¯ÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÙÔ˘, ÛÙË ‰È¿ÁÓˆÛË Èı·Ó‹˜ ÔÚÁ·ÓÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Î·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ ˆ˜ ̤ÏÔ˜ ‰ÈÂÈÛÙËÌÔÓÈ΋˜ ÔÌ¿‰·˜. ∂Âȉ‹ Û˘¯Ó¿ ˘¿Ú¯ÂÈ ‰È·¯ÚÔÓÈ΋ ÌÂÙ·‚ÏËÙfiÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ÂÈÛËÌ·›ÓÂÙ·È Ë ·Ó·ÁηÈfiÙËÙ· Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Â·ÓÂͤٷÛ˘ ÙÔ˘ ·ÛıÂÓ‹. ∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙÒ ÙÔÓ Î‡ÚÈÔ ¢ËÌ‹ÙÚË µ·˚fiÔ˘ÏÔ Î·È ÙËÓ Î˘Ú›· ∂‡Ë ∆ÛÂÏ·Ï›‰Ô˘-µ·˚ÔÔ‡ÏÔ˘ ÁÈ· ÙȘ ¯Ú‹ÛÈ̘ ·Ú·ÙËÚ‹ÛÂȘ ÙÔ˘˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1. £ˆÌ·˝‰Ô˘ §, ™Ù¤ÓÔ˘ ∞, °ÚÈ‚¿ÎË ª, ª·ÎԇϷ Ã. ∞Ó›¯Ó¢ÛË ‰È·Ù·Ú·¯ÒÓ Û˘ÌÂÚÈÊÔÚ¿˜ ·fi ÙÔÓ ·È‰›·ÙÚÔ [ÂÚ›ÏË„Ë]. 2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¶·È‰Ô„˘¯È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜
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51. Sanders RD, Keshavan MS. Physical and neurologic examinations in neuropsychiatry. Semin Clin Neuropsychiatry 2002;7:18-29. 52. Pine DS, Shaffer D, Schonfeld IS, Davies M. Minor physical anomalies: modifiers of environmental risks for psychiatric impairment? J Am Acad Child Adolesc Psychiatry 1997;36:395-403. 53. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry 2001;40 (Suppl):4-23. 54. Blumensohn R, Yoran-Hegesh R, Golubchik P, Mester R, Fluhr H, Hermesh H et al. Elevated serum creatine kinase activity in adolescent psychiatric inpatients on admission. Int Clin Psychopharmacol 1998;13:269-272. 55. Crayton JW, Meltzer HY. Serum creatine phosphokinase activity in psychiatrically hospitalized children. Arch Gen Psychiatry 1976;33:679-681. 56. Hermesh H, Stein D, Manor I, Shechtmann T, Blumensohn R, Meged S et al. Serum creatine kinase levels in untreated hospitalized adolescents during acute psychosis. J Am Acad Child Adolesc Psychiatry 2002;41:1045-1053. 57. Hoffmann GF, Surtees RA, Wevers RA. Cerebrospinal fluid investigations for neurometabolic disorders. Neuropediatrics 1998;29:59-70. 58. Gordon E. Neuroimaging in neuropsychiatry. Semin Clin Neuropsychiatry 2002;7:42-53. 59. Hendren RL, De Backer I, Pandina GJ. Review of neuroimaging studies of child and adolescent psychiatric disorders from the past 10 years. J Am Acad Child Adolesc Psychiatry 2000;39:815-828. 60. Hughes JR. A review of the usefulness of the standard EEG in psychiatry. Clin Electroencephalogr 1996;27:35-39.
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Paediatriki 2003;66:176-184
REVIEW ARTICLE
∂Ӊ›ÍÂȘ ÂÎÙ¤ÏÂÛ˘ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Ù˘ ·Ó·ÓÔ‹˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ª. ªÔ˘ÛÙ¿ÎË
Indications for pulmonary function testing in childhood M. Moustaki
¶ÂÚ›ÏË„Ë: OÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ù˘ ·Ó·ÓÔ‹˜ ·ÔÙÂÏÔ‡Ó ÔχÙÈÌ· ÂÚÁ·Ï›· ÂÎÙ›ÌËÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÊÂÓfi˜ ÌÂÓ ·ÛıÂÓÒÓ Ì ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù·, ·ÊÂÙ¤ÚÔ˘ ‰Â ‰È·ÊfiÚˆÓ ÔÌ¿‰ˆÓ ÏËı˘ÛÌÔ‡ Ì ÛÎÔfi ÙËÓ ÂÍ·ÁˆÁ‹ ÂȉËÌÈÔÏÔÁÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ¯Ú‹ÛÈÌˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ Ì¤ÙÚˆÓ ÚfiÏ˄˘. OÈ ‰ÔÎÈ̷ۛ˜ ·Ó·ÓÔ‹˜ Ô˘ Û˘ÓËı¤ÛÙÂÚ· ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙ· ·È‰È¿ ›ӷÈ, ηٿ Êı›ÓÔ˘Û· ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜, Ë ÛÈÚÔ̤ÙÚËÛË, Ë Ì¤ÙÚËÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ Î·È ¯ˆÚËÙÈÎÔÙ‹ÙˆÓ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ÏËı˘ÛÌÔÁÚ·Ê›·˜ ‹ Ù˘ ‰È¿¯˘Û˘, Ë ‰È¿¯˘ÛË ÙÔ˘ CO Î·È ÙÔ ÂÎÓÂfiÌÂÓÔ ¡O. ™ÙËÓ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÚÈÁÚ¿ÊÔÓÙ·È ÔÈ ÂӉ›ÍÂȘ ÂÎÙ¤ÏÂÛ˘ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ ·˘ÙÒÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜ Î·È ÁÈ· ÙË ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ.
Abstract: Pulmonary function testing is a valuable tool for the assessment of respiratory function of children being evaluated for either diagnostic or epidemiological purposes, aiming to establish the disease diagnosis or meaningful preventive measures respectively. The lung function tests most commonly used, in descending order of frequency, are: spirometry, measurement of lung volumes and capacities by using body plethysmography or gas dilution techniques, carbon monoxide diffusing capacity and exhaled nitric oxide measurement. The purpose of this review is to describe the indications for the above mentioned tests in childhood for the categorization, staging and monitoring of lung disease.
§¤ÍÂȘ ÎÏÂȉȿ: Ó¢ÌÔÓÈΤ˜ ‰ÔÎÈ̷ۛ˜, Ó¢ÌÔÓÈÎÔ› fiÁÎÔÈ, ÛÈÚÔ̤ÙÚËÛË, ‰È¿¯˘ÛË CO, ÂÎÓÂfiÌÂÓÔ ¡O.
Key words: lung function testing, lung volumes, spirometry, carbon monoxide diffusing capacity, exhaled NO.
∂ÈÛ·ÁˆÁ‹ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ, ÔÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ù˘ ·Ó·ÓÔ‹˜ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·Ï¿ ̤ıÔ‰Ô ÌÂϤÙ˘ Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ Ù˘ ·Ó·ÓÔ‹˜, ·ÏÏ¿ Î·È ÂÚÁ·ÏÂ›Ô ÂÎÙ›ÌËÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÊÂÓfi˜ ÌÂÓ ·ÛıÂÓÒÓ Ì ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù·, ·ÊÂÙ¤ÚÔ˘ ‰Â ‰È·ÊfiÚˆÓ ÔÌ¿‰ˆÓ ÏËı˘ÛÌÔ‡ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ÂȉËÌÈÔÏÔÁÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ¯Ú‹ÛÈÌˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ Ì¤ÙÚˆÓ ÚfiÏ˄˘. ∏ ‰˘Ó·ÙfiÙËÙ· ÂÎÙ¤ÏÂÛ˘ ηϋ˜ ÔÈfiÙËÙ·˜ ·Ó·Ó¢ÛÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ, Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ ÙˆÓ ∂ÈÛÙËÌÔÓÈÎÒÓ ¶Ó¢ÌÔÓÔÏÔÁÈÎÒÓ
∂Ù·ÈÚÂÈÒÓ, ÚÔ¸Ôı¤ÙÂÈ ÙËÓ Î·Ï‹ Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰ÈÔ‡, Ë ÔÔ›· Ê·›ÓÂÙ·È fiÙÈ ÁÈ· ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ‰˘Ó·Ù‹ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ (1,2). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ë ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂÛÙÈ¿˙ÂÙ·È ÛÙȘ ÂӉ›ÍÂȘ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÛÙ· ·È‰È¿ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜, ηıÒ˜ Û ÌÈÎÚfiÙÂÚ· ·È‰È¿ Â›Ó·È ÂÊÈÎÙ‹ Ë ÂÎÙ¤ÏÂÛË ÔÚÈÛÌ¤ÓˆÓ ‰ÔÎÈÌ·ÛÈÒÓ Î·È Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ Á›ÓÂÙ·È ÛÙ· Ï·›ÛÈ· ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ. ∏ ‰ÈÂÓ¤ÚÁÂÈ· ÛËÌ·ÓÙÈÎÔ‡ ·ÚÈıÌÔ‡ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Û ·È‰È¿, ÙËÓ ÙÂÏÂ˘Ù·›· ÂÈÎÔÛ·ÂÙ›·, η٤ÛÙËÛ ‰˘Ó·Ù‹ ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÙȘ ÂӉ›ÍÂȘ ÂÎÙ¤ÏÂÛ˘ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Ù˘ ·Ó·ÓÔ‹˜
µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
2nd Paediatric Department of University of Athens “P. & A. Kyriakou” Children’s Hospital, Athens
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ÛÙ· ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ›Ù ·fi ÚˆÙÔ·ı‹ ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù·, ›Ù ·fi ÓÔÛ‹Ì·Ù· Ô˘ ‰Â˘ÙÂÚÔ·ıÒ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. OÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ù˘ ·Ó·ÓÔ‹˜ ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ÏfiÁÔ˘˜: ·) ‰È·ÁÓˆÛÙÈÎÔ‡˜ (¯·Ú·ÎÙËÚÈÛÌfi˜ Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘, ÂÓ›Û¯˘ÛË ‹ ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË, ÔÛÔÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, ·ÍÈÔÏfiÁËÛË Ù˘ ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ ‰È·ÁÓˆÛÙÈÎÒÓ ‹ ıÂڷ¢ÙÈÎÒÓ ÂÂÌ‚·ÙÈÎÒÓ ÌÂıfi‰ˆÓ Î·È ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜), ‚) ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ (·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘, ÂÎÙ›ÌËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ·ÁˆÁ‹, ηıÔÚÈÛÌfi˜ Ù˘ ‰È¿ÚÎÂÈ·˜ Î·È ÙÔ˘ ›‰Ô˘˜ Ù˘ ·ÁˆÁ‹˜) Î·È Á) ÂȉËÌÈÔÏÔÁÈÎÔ‡˜ (ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÔÌ¿‰ˆÓ ÏËı˘ÛÌÔ‡ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ, Ì ÛÎÔfi ÙËÓ ÂÊ·ÚÌÔÁ‹ ̤ÙÚˆÓ ÚfiÏ˄˘). ∂Ӊ›ÍÂȘ ÛÈÚÔ̤ÙÚËÛ˘ °È· ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ ÂӉ›ÍÂˆÓ ˘ÂÓı˘Ì›˙ÂÙ·È fiÙÈ Ë ÛÈÚÔ̤ÙÚËÛË Î·Ù·ÁÚ¿ÊÂÈ ÙÔÓ fiÁÎÔ ÙÔ˘ ·¤Ú· Ô˘ ÂÈÛÓ¤ÂÈ Î·È ÂÎÓ¤ÂÈ ÙÔ ¿ÙÔÌÔ Û ۯ¤ÛË Ì ÙÔ ¯ÚfiÓÔ. OÈ Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ·Ú¿ÌÂÙÚÔÈ Â›Ó·È (3,4): ·) Ë ‚›·ÈË ˙ˆÙÈ΋ ¯ˆÚËÙÈÎfiÙËÙ· (FVC), Ô˘ ÈÛÔ‰˘Ó·Ì› Ì ÙÔÓ fiÁÎÔ ÙÔ˘ ·¤Ú· ÙÔÓ ÔÔ›Ô ÙÔ ÂÍÂÙ·˙fiÌÂÓÔ ¿ÙÔÌÔ ÂÎÓ¤ÂÈ, ·ÊÔ‡ ¤¯ÂÈ ÚÔËÁËı› Ë ÈÔ ‚·ıÈ¿ ÂÈÛÓÔ‹, ‚) Ô ‚›·È· ÂÎÓÂfiÌÂÓÔ˜ fiÁÎÔ˜ ÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ Ù˘ ÂÎÓÔ‹˜ (FEV1), Á) Ô ÏfiÁÔ˜ FEV1/FVC. ∏ ·Ú¿ÌÂÙÚÔ˜ ·˘Ù‹ ÂÎÊÚ¿˙ÂÈ ÙÔ ÏfiÁÔ ÙÔ˘ fiÁÎÔ˘ Ô˘ ÂÎÓ¤ÂÙ·È ÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ Ù˘ ÂÎÓ¢ÛÙÈ΋˜ ÚÔÛ¿ıÂÈ·˜ ÚÔ˜ ÙÔÓ fiÁÎÔ Ô˘ ÂÎÓ¤ÂÙ·È ÛÙÔ Û‡ÓÔÏÔ Ù˘ ÚÔÛ¿ıÂÈ·˜. ™Ù· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ·Ó·Ì¤ÓÂÙ·È fiÙÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ˘ fiÁÎÔ˘ ÂÎÓ¤ÂÙ·È ‚›·È· ÙÔ ÚÒÙÔ ‰Â˘ÙÂÚfiÏÂÙÔ Ù˘ ÂÎÓÔ‹˜, ‰) Ë ÂÎÓ¢ÛÙÈ΋ ÚÔ‹ Ô˘ ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙËÓ ÂÎÓÔ‹ ÙÔ˘ 25-75% ÙÔ˘ fiÁÎÔ˘ Ù˘ ˙ˆÙÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ Î·È Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ Ù˘ ‚·ÙfiÙËÙ·˜ ÙˆÓ ÌÈÎÚÒÓ ·ÂÚ·ÁˆÁÒÓ Î·È Â) Ë Ì¤ÁÈÛÙË ÂÎÓ¢ÛÙÈ΋ ÚÔ‹ Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙË Ì¤ÁÈÛÙË ÙÈÌ‹ Ù˘ ÚÔ‹˜ ηٿ ÙËÓ ÂÎÓÔ‹, Ë ÔÔ›· ÌÂÙÚ¿Ù·È Î·È Ì ÙÔ ·Ïfi ÚÔfiÌÂÙÚÔ. ∞Ó Ë ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, fiˆ˜ ÂÎÙÈÌ¿Ù·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÛÈÚÔ̤ÙÚËÛ˘, ‰ÂÓ Â›Ó·È ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ - ÁÈ· ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË - ÔÚ›ˆÓ, ÙfiÙ ٷ Â˘Ú‹Ì·Ù· Â›Ó·È Û˘Ì‚·Ù¿ Ì Ó¢ÌÔÓÔ¿ıÂÈ· ·ÔÊÚ·ÎÙÈÎÔ‡, ÂÚÈÔÚÈÛÙÈÎÔ‡ ‹ ÌÈÎÙÔ‡ Ù‡Ô˘. ∏ ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì›ˆÛË ÙˆÓ ÚÔÒÓ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Ì›ˆÛË Ù˘ FVC, Ì ·ÔÙ¤ÏÂÛÌ· Ô ÏfiÁÔ˜ FEV1/FVC Ó· ˘ÔÏ›ÂÙ·È ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡, ÌÂ Û˘ÓÔ‰fi ·‡ÍËÛË Ù˘ ÎԛϷÓÛ˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ù˘ η̇Ï˘ ÚÔ‹˜-fiÁÎÔ˘ (∂ÈÎfiÓ˜ 1, 2, 3). ∏ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È
Paediatriki 2003;66:176-184
·fi ·Ó¿ÏÔÁË Ì›ˆÛË Ù˘ ÚÔ‹˜ Û ۯ¤ÛË Ì ÙÔÓ fiÁÎÔ, Ì ·ÔÙ¤ÏÂÛÌ· Ô ÏfiÁÔ˜ FEV1/FVC Ó· ·Ú·Ì¤ÓÂÈ Ê˘ÛÈÔÏÔÁÈÎfi˜ ‹ Î·È ·˘ÍË̤ÓÔ˜ (∂ÈÎfiÓ· 4). ∏ ÌÈÎÙÔ‡ Ù‡Ô˘ ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì›ˆÛË ÚÔ‹˜ Î·È fiÁÎÔ˘, Û ·Ó·ÏÔÁ›· Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÔÈÔ ÛÙÔÈ¯Â›Ô ˘ÂÚ¤¯ÂÈ (ÙÔ ·ÔÊÚ·ÎÙÈÎfi ‹ ÙÔ ÂÚÈÔÚÈÛÙÈÎfi). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, › ˘Ô„›·˜ ÌÈÎÙÔ‡ Ù‡Ô˘ ÓÔÛ‹Ì·ÙÔ˜ Û˘ÓÈÛÙ¿Ù·È ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Ì ÏËı˘ÛÌÔÁÚ·Ê›·, fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È ·Ú·Î¿Ùˆ ÛÙË Û¯ÂÙÈ΋ ÂÓfiÙËÙ·. π‰È·›ÙÂÚË Â›Ó·È Ë Û˘Ì‚ÔÏ‹ Ù˘ ÛÈÚÔ̤ÙÚËÛ˘ ÛÙ· ·È‰È¿ Ì ¿ÛıÌ·. ™Ù· ·È‰È¿ ·˘Ù¿, Ë ÛÈÚÔ̤ÙÚËÛË Â›Ó·È ·Ó¿ÏÔÁ˘ ÛËÌ·Û›·˜ Ì ÙË Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û ˘ÂÚÙ·ÛÈÎÔ‡˜ ·ÛıÂÓ›˜ ‹ ÙÔ˘ ۷ί¿ÚÔ˘ Û ‰È·‚ËÙÈÎÔ‡˜. ∏ ÛÈÚÔ̤ÙÚËÛË ‰ÂÓ ı¤ÙÂÈ Ê˘ÛÈο ÙË ‰È¿ÁÓˆÛË, ·ÏÏ¿ ηٷ‰ÂÈÎÓ‡ÂÈ ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÔÊÚ·ÎÙÈ΋ ‹ ÂÚÈÔÚÈÛÙÈ΋ ÓfiÛÔ. ™ÙÔ ¿ÛıÌ· ·Ú·ÙËÚÂ›Ù·È ÌÂȈ̤ÓÔ˜ FEV1, Ô ÏfiÁÔ˜ FEV1/FVC Î·È Ë ÚÔ‹ ÛÙÔ˘˜ ÌÈÎÚÔ‡˜ ·ÂÚ·ÁˆÁÔ‡˜ (FEF 25-75%). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë ÛÈÚÔ̤ÙÚËÛË Û˘ÓÈÛÙ¿Ù·È Û fiÏ· Ù· ·È‰È¿ Ì ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ‹/Î·È ÛËÌÂÈÔÏÔÁ›· ¿ÛıÌ·ÙÔ˜. π‰È·›ÙÂÚË Â›Ó·È Ë Û˘Ì‚ÔÏ‹ Ù˘ Û ·È‰È¿ Ì ¿Ù˘· Û˘ÌÙÒÌ·Ù·, fiˆ˜ .¯. ›ÌÔÓÔ ‚‹¯·. ∞Ó Û ¤Ó· ·È‰› Ì ˘Ô„›· ¿ÛıÌ·ÙÔ˜ Ë ÛÈÚÔ̤ÙÚËÛË Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ÂÚÈÔÚÈÛÙÈ΋˜ ÓfiÛÔ˘ (ÌÂȈ̤ÓÔ˜ FEV1, ÌÂȈ̤ÓË FVC Î·È Ê˘ÛÈÔÏÔÁÈÎfi˜ ÏfiÁÔ˜ FEV1/FVC), Û˘ÓÈÛÙ¿Ù·È ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙˆÓ Ó¢ÌfiÓˆÓ Ì ÏËı˘ÛÌÔÁÚ·Ê›·, ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘, ‰È¿¯˘ÛË, ηıÒ˜ Î·È ÁÂÓÈÎfiÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ (‰ÔÎÈÌ·Û›· ȉÚÒÙ·, ·ÂÈÎÔÓÈÛÙÈÎfi˜ Flow
8 6 4 2 0 -2 -4 -6 -1
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∂ÈÎfiÓ· 1. º˘ÛÈÔÏÔÁÈ΋ η̇ÏË ÚÔ‹˜-fiÁÎÔ˘ ηٿ ÙËÓ ÂÎÓÔ‹ Î·È ÙËÓ ÂÈÛÓÔ‹.
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Volume ∂ÈÎfiÓ· 2. ∂ÎÓ¢ÛÙÈ΋ η̇ÏË ÚÔ‹˜-fiÁÎÔ˘ Ì ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ·fiÊÚ·ÍË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó¿ÏÔÁÔ˘ ‚·ıÌÔ‡ ÎԛϷÓÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ù˘ ÂÎÓ¢ÛÙÈ΋˜ η̇Ï˘. ∂ÈÛÓ¢ÛÙÈ΋ η̇ÏË Ê˘ÛÈÔÏÔÁÈ΋.
¤ÏÂÁ¯Ô˜ Ó¢ÌfiÓˆÓ Î.Ï.) ÁÈ· Ó· ÙÂı› Ë ‰È¿ÁÓˆÛË. ™Â ·È‰È¿ Ì ˘Ô„›· ¿ÛıÌ·ÙÔ˜ Î·È ÛÈÚÔÌÂÙÚÈ΋ ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ, Û˘ÓÈÛÙ¿Ù·È ÁÈ· ÂȂ‚·›ˆÛË - Ë ‰ÔÎÈÌ·Û›· ·Ó·ÛÙÚ„ÈÌfiÙËÙ·˜ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ (5). ∞‡ÍËÛË Î·Ù¿ 12% ÙÔ˘ FEV1, 20 ÏÂÙ¿ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Û·Ï‚Ô˘Ù·ÌfiÏ˘ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘, ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË, ηıÒ˜ Î·È ÙËÓ ·ÓÙ·fiÎÚÈÛ‹ Ù˘ ÛÙÔ˘˜ ‚2 ‰ÈÂÁ¤ÚÙ˜. ∏ ·‡ÍËÛË ÙÔ˘ FEV1 Â›Ó·È Ë Û˘¯ÓfiÙÂÚ· ·ÍÈÔÏÔÁÔ‡ÌÂÓË ÌÂÙ·‚ÔÏ‹ ηٿ ÙË ‰ÔÎÈÌ·Û›· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡. ªÔÚ›, ›Û˘, Ó· ·ÍÈÔÏÔÁËı› ·‡ÍËÛË Ù˘ PEFR ηٿ 12-15% ‹ Ù˘ FEF25-75% ηٿ 25-30%, ·Ó Î·È ÂȉÈο Ë ÙÂÏÂ˘Ù·›· ‰ÂÓ ·ÔÙÂÏ› ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË ÔÍ›·˜ ÌÂÙ·‚ÔÏ‹˜ ηıÒ˜ ÂËÚ¿˙ÂÙ·È ·fi ÙȘ Û˘ÓÔ‰¤˜ ÌÂÙ·‚ÔϤ˜ Ù˘ FVC (6). ∏ ‰ÔÎÈÌ·Û›· ·ÓÙÈÛÙÚÂÙfiÙËÙ·˜ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÛÙ· ·È‰È¿ Ì ¿ÛıÌ· Ô˘ ‰ÂÓ ¤¯Ô˘Ó ¤ÓÙÔÓ· Û˘Ú›ÙÙÔ˘Û· ·Ó·ÓÔ‹, Ë ÂÍ¿ÏÂÈ„Ë Ù˘ ÔÔ›·˜ ÂȂ‚·ÈÒÓÂÈ ÙËÓ ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ·ÁˆÁ‹, ηıÈÛÙÒÓÙ·˜ ÂÚÈÙÙ‹ ÛÙË Ê¿ÛË ·˘Ù‹ ÙË ÛÈÚÔ̤ÙÚËÛË. ™Â ·È‰È¿ Ì ÈÛÙÔÚÈÎfi ÂÓ‰ÂÈÎÙÈÎfi ¿ÛıÌ·ÙÔ˜, ·ÏÏ¿ Ê˘ÛÈÔÏÔÁÈ΋ ÛÈÚÔ̤ÙÚËÛË, Û˘ÓÈÛÙ¿Ù·È Ë ÂÎÙ¤-
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Volume ∂ÈÎfiÓ· 3. ∂ÎÓ¢ÛÙÈ΋ η̇ÏË ÚÔ‹˜-fiÁÎÔ˘ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·fiÊÚ·ÍË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ó¿ÏÔÁÔ˘ ‚·ıÌÔ‡ ÎԛϷÓÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ù˘ ÂÎÓ¢ÛÙÈ΋˜ η̇Ï˘. ∂ÈÛÓ¢ÛÙÈ΋ η̇ÏË Ê˘ÛÈÔÏÔÁÈ΋.
ÏÂÛË ÛÈÚÔ̤ÙÚËÛ˘ ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ (7,8), ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÂÌÂÈÚÈ΋˜ ıÂڷ›·˜. ∫·Ù¿ ÙË ‰ÔÎÈÌ·Û›· ·˘Ù‹, Á›ÓÂÙ·È ÛÈÚÔ̤ÙÚËÛË ‰È·‰Ô¯Èο ÚÈÓ Î·È ÌÂÙ¿ ·fi ÂÈÛÓÔ‹ ÈÛÙ·Ì›Ó˘ ‹ ÌÂÙ·¯ÔÏ›Ó˘. ∆· ·È‰È¿ Ì ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ·ÂÚ·ÁˆÁÒÓ ·Ó·Ì¤ÓÂÙ·È Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ‚ÚÔÁ¯fiÛ·ÛÌÔ Î·È ÙÒÛË ÙÔ˘ FEV1 ηٿ 20% ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË 225 ÌÔÓ¿‰ˆÓ ÌÂÙ·¯ÔÏ›Ó˘. ∏ ÌÂÙ·‚ÔÏ‹ Ùo˘ FEV1 Â›Ó·È Ô Û˘¯ÓfiÙÂÚ· ·ÍÈÔÏÔÁÔ‡ÌÂÓÔ˜ ‰Â›ÎÙ˘ ηٿ ÙË ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘. ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ Ë ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ÙÂÏÂ˘Ù·›· Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ηıÒ˜ ÔÈ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηϤÛÔ˘Ó ·ÚÔ‰Èο ˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÙˆÓ ·ÂÚ·ÁˆÁÒÓ (8,9). ™Â ·È‰È¿ ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ¿ÛıÌ·ÙÔ˜ ÌfiÓÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¿ÛÎËÛ˘, Û˘ÓÈÛÙ¿Ù·È Ë ÂÎÙ¤ÏÂÛË ‰ÔÎÈÌ·Û›·˜ ¿ÛÎËÛ˘ Ì ÙË ¯Ú‹ÛË ÂÚÁÔÌÂÙÚÈÎÔ‡ Ô‰ËÏ¿ÙÔ˘ ‹ ‰È·‰ÚfiÌÔ˘. °È· ÙËÓ ÂÎÙ¤ÏÂÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ·˘Ù‹˜ ··ÈÙÂ›Ù·È ¿ÛÎËÛË ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· 6 ÏÂÙ¿, Û ڢıÌfi Ô˘ Ó· ÚÔηÏ› ·‡ÍËÛË ÙˆÓ ÛʇÍÂˆÓ Û 80% ÙÔ˘ ̤ÁÈÛÙÔ˘ - ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ - ηډȷÎÔ‡ Ú˘ıÌÔ‡. ∏ ̤ÁÈÛÙË ÙÒÛË ÙÔ˘ FEV1
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Volume ∂ÈÎfiÓ· 4. ∏ ÂÎÓ¢ÛÙÈ΋ η̇ÏË ÂÚÈÔÚÈÛÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Â›Ó·È ÌÈÎÚfiÙÂÚË Û ̤ÁÂıÔ˜ ·fi ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Ê˘ÛÈÔÏÔÁÈ΋, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÙ·È ÙÔ Û¯‹Ì· Ù˘.
·Ú·ÙËÚÂ›Ù·È 5-15 ÏÂÙ¿ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ¿ÛÎËÛ˘. ¶ÙÒÛË ÙÔ˘ FEV1 >15% Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ¿ÛıÌ·ÙÔ˜ ÌÂÙ¿ ·fi ¿ÛÎËÛË (4). ™ËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ Ù˘ ÛÈÚÔ̤ÙÚËÛ˘ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘. ∏ ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÛÈÚÔ̤ÙÚËÛË Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ¤ÁηÈÚË ‰È·›ÛÙˆÛË Âȉ›ӈÛ˘ ‹ ‚ÂÏÙ›ˆÛ˘ Ù˘ ÓfiÛÔ˘ Î·È ÙÚÔÔÔ›ËÛ˘ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜, ·ÏÏ¿ Î·È ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÚfiÛÊ·ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÁˆÁ‹. ∏ ÂÎÙ¤ÏÂÛË ÛÈÚÔ̤ÙÚËÛ˘ ÂÚÈÔ‰Èο, Ì ÛÎÔfi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÙËÓ ·Ó¿ÏÔÁË ÙÚÔÔÔ›ËÛË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜, ÂÈ‚¿ÏÏÂÙ·È Î·È ÛÙ· ·È‰È¿ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ. ∏ ÛÈÚÔ̤ÙÚËÛË ‰È¢ÎÔχÓÂÈ ÙË Ï‹„Ë ÛˆÛÙÒÓ ıÂڷ¢ÙÈÎÒÓ ·ÔÊ¿ÛÂˆÓ ÙfiÛÔ Û ÂÚÈfi‰Ô˘˜ ¤Í·ÚÛ˘ Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜, fiÛÔ Î·È Î·Ù¿ ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ ÂÚÈÔ‰ÈÎfi ¤ÏÂÁ¯Ô ÙˆÓ ·ÛıÂÓÒÓ. ™Ù· ÚÒÈÌ· ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘, ÔÈ ·ÓˆÌ·Ï›Â˜ ·ÊÔÚÔ‡Ó ÛÙÔ˘˜ ÌÈÎÚÔ‡˜ ·ÂÚ·ÁˆÁÔ‡˜ (10) Î·È ·ÎÔÏÔ˘ı› Ì›ˆÛË ÙÔ˘ ÏfiÁÔ˘ FEV1/FVC. ŸÌˆ˜, ηٿ ÙËÓ ÂͤÏÈÍË Î·È ÙËÓ ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË Ù˘ ÓfiÛÔ˘, Ô ÏfiÁÔ˜ FEV1/FVC
·ӤگÂÙ·È ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‹ Î·È ·˘Í¿ÓÂÙ·È, ‰ÈfiÙÈ ÔÈ ÈÓÒ‰ÂȘ ÌÂÙ·‚ÔϤ˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· ÚÔÛı¤ÙÔ˘Ó ¯·Ú·ÎÙËÚÈÛÙÈο ÂÚÈÔÚÈÛÙÈ΋˜ ÓfiÛÔ˘ ÛÙËÓ ·Ú¯Èο ÂÎÊÚ·˙fiÌÂÓË ˆ˜ ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ. ∏ ÂÎÙ¤ÏÂÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ‰È¢ÎÔχÓÂÈ ÙËÓ ·Ó›¯Ó¢ÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı· ˆÊÂÏËıÔ‡Ó ·fi ÙË Ï‹„Ë ÂÈÛÓÂfiÌÂÓˆÓ ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÒÓ (11). ™Â ·È‰È¿ Ì ‚ÚÔÁ¯ÂÎٷۛ˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙÈÔÏÔÁ›·, Û˘ÓÈÛÙ¿Ù·È Ë ÂÚÈÔ‰È΋ ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÛÈÚÔ̤ÙÚËÛË. ™Ù· ·Ú¯Èο ÛÙ¿‰È·, ÂȉÈο fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÂÓÙÔÈṲ̂Ó˜ ‚ÚÔÁ¯ÂÎٷۛ˜, Ë ÛÈÚÔ̤ÙÚËÛË Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈ΋ (12). ™Â Âȉ›ӈÛË Ù˘ ÓfiÛÔ˘, ·Ú·ÙËÚÂ›Ù·È Ì›ˆÛË ÙÔ˘ FEV1 Î·È ÙÔ˘ ÏfiÁÔ˘ FEV1/FVC, ÌÂÙ·‚ÔϤ˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È Î·È ·fi ÙÒÛË ÙÔ˘ FVC Â¿Ó ‰ÂÓ ÂÈÙ¢¯ı› ÈηÓÔÔÈËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜. ™ÈÚÔ̤ÙÚËÛË Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Î·È Û ·È‰È¿ Ì ‰È¿ÌÂÛË Ó¢ÌÔÓÔ¿ıÂÈ· (13), ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô Ù˘. ™˘Ó‹ıˆ˜, ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË ÙÔ˘ ÏfiÁÔ˘ FEV1/FVC Î·È ÙÔ˘ ÏfiÁÔ˘ FEF2575%/∆LC Û ·ÛıÂÓ›˜ Ô˘ Â›Ó·È ‰˘Ó·Ù‹ Ë Ì¤ÙÚËÛË Ù˘ ÔÏÈ΋˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ Ì ÏËı˘ÛÌÔÁÚ·Ê›·. ∂ÈÛËÌ·›ÓÂÙ·È, fï˜, fiÙÈ ‰ÂÓ ·ÔÙÂÏ› ÏÂÈÙÔ˘ÚÁÈ΋ ‰ÔÎÈÌ·Û›· ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ÂÓ›Û¯˘ÛË Ù˘ ‰È¿ÁÓˆÛ˘ ‹ ÁÈ· ÙË ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ‰È¿ÌÂÛË Ó¢ÌÔÓÔ¿ıÂÈ·, ÔÈ ÔÔ›ÔÈ, ·ÓÙ›ıÂÙ·, ı· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û˘¯Ó¿ Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ‰È¿¯˘Û˘ ÙÔ˘ CO (DLCO). ™ÈÚÔ̤ÙÚËÛË Û˘ÓÈÛٿٷÈ, ›Û˘, Û ·ÛıÂÓ›˜ ÌÂ Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù· Ô˘ ÂÈÓ¤ÌÔÓÙ·È ÚˆÙÔ·ıÒ˜ ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·, fiˆ˜ ÓfiÛÔÈ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ (14,15). ™Â ·˘ÙÔ‡˜, Ë ÛÈÚÔ̤ÙÚËÛË ÌÔÚ› Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ‹ Ó· ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈο ÓfiÛÔ˘ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘. ∂Âȉ‹ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ÚÔÛ‚¿ÏÏÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ Ô ‰È¿ÌÂÛÔ˜ ÈÛÙfi˜, ÂͤٷÛË ÂÎÏÔÁ‹˜ ηٿ ÙË ‰È¿ÁÓˆÛË, ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÔÙÂÏ› Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ‰È¿¯˘Û˘ ÙÔ˘ CO (DLCO) (14,15). OÈ ÂӉ›ÍÂȘ ÛÈÚÔ̤ÙÚËÛ˘ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù˜ Û ·ÛıÂÓ›˜ Ì ÓÔÛ‹Ì·Ù· ÙˆÓ ÔÔ›ˆÓ ÔÈ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ ·ÊÔÚÔ‡Ó ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. ∆· ‰Â‰Ô̤ӷ, fï˜, Ô˘ ˘¿Ú¯Ô˘Ó ·fi ÙȘ ̤¯ÚÈ Û‹ÌÂÚ· ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ı· ‰ÈηÈÔÏÔÁÔ‡Û·Ó ÙËÓ ÂÎÙ¤ÏÂÛË Ù˘ ÛÈÚÔ̤ÙÚËÛ˘ Û ·ÛıÂÓ›˜ Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· (16,17), ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (18), ÛÎÔÏ›ˆÛË (19) Î·È ·¯˘Û·ÚΛ· (20). ™Â ·È‰È¿ Ì ÛÔ‚·Ú‹ ÛÎÔÏ›ˆÛË (>50Ô), ȉÈÔ·ı‹ ‹ ‰Â˘ÙÂÚÔ·ı‹, ·Ú·ÙËÚÂ›Ù·È Ì›ˆÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ fiÁÎÔ˘, Ë ÔÔ›· Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ ‚·ıÌÔ‡ ΢ÚÙfiÙËÙ·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∞ÔÙ¤ÏÂÛÌ· Ù˘ Ì›ˆÛ˘ ÙÔ˘ fiÁÎÔ˘ Â›Ó·È Î·È Ë Ì›ˆÛË ÙˆÓ ÚÔÒÓ, ÔÈ ÙÈ̤˜ ÙˆÓ ÔÔ›ˆÓ, fï˜,
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·Ó ‰ÈÔÚıˆıÔ‡Ó ˆ˜ ÚÔ˜ ÙÔÓ fiÁÎÔ ÙˆÓ Ó¢ÌfiÓˆÓ, Â›Ó·È Ê˘ÛÈÔÏÔÁÈΤ˜. ∂›Ó·È, ›Û˘, ÁÓˆÛÙfi fiÙÈ ÂÓ‹ÏÈΘ Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ Ó¢ÌÔÓÔ¿ıÂÈ· Ì ‚¿ÛË Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÛÈÚÔ̤ÙÚËÛ˘. ∏ ÂÈ‚¿Ú˘ÓÛË ·˘Ù‹ ·Ô‰›‰ÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙËÓ ·Ó¿Ù˘ÍË Ó¢ÌÔÓÈ΋˜ ›ÓˆÛ˘ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·ӷϷ̂·ÓfiÌÂÓˆÓ ÂÂÈÛÔ‰›ˆÓ ÔͤԘ ıˆÚ·ÎÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ˘ÔÙÚÔÈ·˙Ô˘ÛÒÓ ÏÔÈÌÒÍÂˆÓ Î·È ·ÁÁÂÈ·ÎÒÓ ÂÌÊÚ¿ÎÙˆÓ, ·ÊÂÙ¤ÚÔ˘ ‰Â ÛÙËÓ ˘ÔÏÂÈfiÌÂÓË ·Ó¿Ù˘ÍË ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ·È‰È¿ Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›· ¤‰ÂÈÍ·Ó ·ÔÙÂϤÛÌ·Ù· ÛÈÚÔ̤ÙÚËÛ˘ ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ Û 40%, Ì ·ÓÙÈÛÙÚÂÙfiÙËÙ· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈÎÔ‡ Û 80% ÂÚ›Ô˘ ÂÍ ·˘ÙÒÓ. ∞Ó Î·È Ù· ̤¯ÚÈ ÛÙÈÁÌ‹˜ ‰Â‰Ô̤ӷ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ, Ì ‰Â‰Ô̤ÓË ÙËÓ ·ÏfiÙËÙ· ÂÎÙ¤ÏÂÛ˘ Ù˘ ÛÈÚÔ̤ÙÚËÛ˘, ı· ‹Ù·Ó ÛÎfiÈÌË Ë ÂÚÈÔ‰È΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Ì ÛÈÚÔ̤ÙÚËÛË Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ‰È¿¯˘Û˘ CO (DLCO) Û ·˘Ù¿ ÌÂ Â˘Ú‹Ì·Ù· Ó¢ÌÔÓÔ¿ıÂÈ·˜ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘. ∆· ‰Â‰Ô̤ӷ Â›Ó·È ÈÔ ÂÚÈÔÚÈṲ̂ӷ Û ·ÛıÂÓ›˜ Ì Ì›˙ÔÓ· ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›·, ηıÒ˜ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· Û Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ (21) Ô˘ ˘Ô‰ËÏÒÓÔ˘Ó ÌÈÎÚ‹ ÂÈ‚¿Ú˘ÓÛË ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ Î·È Û ÌÈÎÚfi ·ÚÈıÌfi ·È‰ÈÒÓ fiÔ˘ ÌÂÏÂÙ‹ıËÎÂ Ë Â›‰Ú·ÛË Ù˘ ¤ÎÙ˘Í˘ ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÌÂÙ¿ ·fi ÌÂÙ¿ÁÁÈÛË ÚÈÓ Î·È ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÔ‡ (22). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÛÈÚÔ̤ÙÚËÛË Û ·È‰È¿ Ì Ì›˙ÔÓ· ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· ÛÙËÓ ·ÚÔ‡Û· Ê¿ÛË ÌÔÚ› Ó· Á›ÓÂÈ ÌfiÓÔ ÛÙ· Ï·›ÛÈ· ÎÏÈÓÈ΋˜ ¤Ú¢ӷ˜. ∆· ϤÔÓ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ÂÌÊ¿ÓÈÛ˘ Ó¢ÌÔÓÔ¿ıÂÈ·˜ Û˘ÓËı¤ÛÙÂÚ· ÂÚÈÔÚÈÛÙÈÎÔ‡ Î·È Û·ÓÈfiÙÂÚ· ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ - ÛÙ· ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, fiÙ·Ó ·˘Ù‹ Á›ÓÂÙ·È Û ÙÂÏÈο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘ (18,23). ∞˘Ù‹ Ë ·˘ÍËÙÈ΋ Ù¿ÛË Û˘Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ηٿ ÙÔ ÔÔ›Ô ¤ÁÈÓÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û˘Û¯¤ÙÈÛË Ô˘ ·Ó¿ÁÂÈ ÛÙËÓ ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÛÙ· ·È‰È¿ ·˘Ù¿ ÏfiÁˆ Ù˘ ÚÔËÁËı›۷˜ ¯ÔÚ‹ÁËÛ˘ ÙÔÍÈÎÒÓ Ê·Ú̿ΈÓ. ¶·ÚfiÙÈ Ù· Â˘Ú‹Ì·Ù· ·fi ÙË ÛÈÚÔ̤ÙÚËÛË ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, Ê·›ÓÂÙ·È fiÙÈ Ë ÂÚÈÔ‰È΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÛÈÚÔ̤ÙÚËÛË ı· ‚ÔËı‹ÛÂÈ ÛÙË Ï‹„Ë ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ ÁÈ· ·ÔÊ˘Á‹ ÂÚ·ÈÙ¤Úˆ ÂÈ‚¿Ú˘ÓÛ˘.
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™ËÌ·ÓÙÈ΋ Â›Ó·È Ë Û˘Ì‚ÔÏ‹ Ù˘ ÛÈÚÔ̤ÙÚËÛ˘ Î·È Û ÂÚÈÙÒÛÂȘ ˘Ô„›·˜ ·fiÊڷ͢ ÙˆÓ ·ÓÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ (24). °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Û˘ÓÈÛÙ¿Ù·È Ë Î·Ù·ÁÚ·Ê‹ Î·È Ù˘ ÂÈÛÓ¢ÛÙÈ΋˜ η̇Ï˘ ÚÔ‹˜ fiÁÎÔ˘ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Á›ÓÂÙ·È ÛÈÚÔ̤ÙÚËÛË ÁÈ· ÚÒÙË ÊÔÚ¿, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û˘¯Ó¤˜ ÎÏÈÓÈΤ˜ ÂÎÊÚ¿ÛÂȘ Ù˘ ·fiÊڷ͢ ÙˆÓ ·ÓÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ Â›Ó·È Ô ‚‹¯·˜ ‹ Ë Û˘ÚÚ›ÙÔ˘Û· ·Ó·ÓÔ‹, Û˘ÌÙÒÌ·Ù· fï˜ Ô˘ Â›Ó·È ÂÓ‰ÂÈÎÙÈο Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜. ™Â ÂÚ›ÙˆÛË ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, ·Ó¿ÏÔÁ· Ì ÙÔ Â›Â‰Ô Ù˘ ·fiÊڷ͢, ÙÚÔÔÔÈÂ›Ù·È ÙÔ Û¯‹Ì· Ù˘ ÂÈÛÓ¢ÛÙÈ΋˜ ‹ Î·È Ù˘ ÂÎÓ¢ÛÙÈ΋˜ η̇Ï˘ ÚÔ‹˜ fiÁÎÔ˘ (∂ÈÎfiÓ˜ 5, 6). ∂Ӊ›ÍÂȘ ÏËı˘ÛÌÔÁÚ·Ê›·˜ ∏ ÏËı˘ÛÌÔÁÚ·Ê›· ÂÈÙÚ¤ÂÈ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ (RV, ERV, TV, IRV) Î·È ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ¯ˆÚËÙÈÎÔÙ‹ÙˆÓ (∆LC, VC, FRC, IC), ÂÓÒ Ì ÙË ÛÈÚÔ̤ÙÚËÛË Â›Ó·È ÂÊÈÎÙ‹ ÌfiÓÔ Ë Ì¤ÙÚËÛË Ù˘ VC Î·È ÙˆÓ ˘Ô‰È·ÈÚ¤ÛÂˆÓ Ù˘ ERV, TV, IRV Î·È IC (25) (∂ÈÎfiÓ· 7). O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ˘fiÏÔÈˆÓ ÙÚÈÒÓ ÌÂÁÂıÒÓ (RV, FRC, TLC) ÚÔ¸Ôı¤ÙÂÈ ÙË Ì¤ÙÚËÛË ÙÔ˘ RV (˘ÔÏÂÈfiÌÂÓÔ˘ fiÁÎÔ˘), Ô ÔÔ›Ô˜ ‰ÂÓ ÂÎÓ¤ÂÙ·È ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ηÈ, ÂÔ̤ӈ˜, ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ì ÙË ÛÈÚÔ̤ÙÚËÛË. ∏ ÂÎÙ¤ÏÂÛË ÏËı˘ÛÌÔÁÚ·Ê›·˜ Û˘Ó‹ıˆ˜ Â›Ó·È ‰˘Ó·Ù‹ Û ·È‰È¿ ËÏÈΛ·˜ >8 ÂÙÒÓ, ¯ˆÚ›˜ ÙÔ fiÚÈÔ ·˘Ùfi Ó· Â›Ó·È ·fiÏ˘ÙÔ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ‰˘Ó·ÙfiÙËÙ· ÂÎÙ¤ÏÂÛ˘ Ù˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ‰ÔÎÈÌ·Û›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙË Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ Ô‰ËÁÈÒÓ. ™Â ·ÓÙ›ıÂÛË, fï˜, Ì ÙË ÛÈÚÔ̤ÙÚËÛË, ‰ÂÓ ·ÔÙÂÏ› ÂͤٷÛË ÚÔ˘Ù›Ó·˜ Û ·ÛıÂÓ›˜ Ì ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù·. ∞ÓÙ›ıÂÙ·, ÂӉ›ÎÓ˘Ù·È Û ÂÈÏÂÁ̤ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¤¯ÂÈ ÚÔËÁËı› ÛÈÚÔ̤ÙÚËÛË Î·È ··ÈÙÂ›Ù·È ÏÂÙÔÌÂÚ¤ÛÙÂÚË ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ ‹ ۷ʤÛÙÂÚË ‰È¿ÁÓˆÛ‹ Ù˘ fiÙ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÛÈÚÔ̤ÙÚËÛ˘ ‰ÂÓ Â›Ó·È Ì ۷ʋÓÂÈ· ÂÓÈÛ¯˘ÙÈο Ù˘ ‰È¿ÁÓˆÛ˘ Ô˘ ¤¯ÂÈ ÙÂı› Ì ٷ ÎÏÈÓÈο Î·È Ù· ˘fiÏÔÈ· ÂÚÁ·ÛÙËÚȷο ÎÚÈÙ‹ÚÈ·. ∆¤ÙÔȘ ÂÚÈÙÒÛÂȘ Û˘Ó·ÓÙÒÓÙ·È Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ ·Ó·Ó¢ÛÙÈο ÓÔÛ‹Ì·Ù· Î·È Û ·˘ÙÔ‡˜ Ì ÌÈÎÙÔ‡ Ù‡Ô˘ ÚÔ‚Ï‹Ì·Ù· (ÂÚÈÔÚÈÛÙÈÎÔ‡ Î·È ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘). °ÂÓÈο, Ë ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ˜ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ (ÚˆÙÔ·ı‹˜ ‹ ‰Â˘ÙÂÚÔ·ı‹˜) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ì›ˆÛË ÙfiÛÔ Ù˘ VC Ô˘ ηٷÁÚ¿ÊÂÙ·È Ì ÙË ÛÈÚÔ̤ÙÚËÛË, fiÛÔ Î·È Ù˘ TLC Ô˘ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ì ÙËÓ ÏËı˘ÛÌÔÁÚ·Ê›·. ∞Ó¿ÏÔÁ·, fï˜, Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘, Ô ¤Ó·˜ ‰Â›ÎÙ˘ ÌÔÚ› Ó· ˘ÂÚÙÂÚ› ÙÔ˘ ¿ÏÏÔ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Û ·ÛıÂÓ›˜ ÌÂ
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∂ÈÎfiÓ· 5. ∂ȉˆÌ¤ÓË ÂÈÛÓ¢ÛÙÈ΋ η̇ÏË ÌÂ Û˘ÓÔ‰fi Ê˘ÛÈÔÏÔÁÈ΋ ÂÎÓ¢ÛÙÈ΋ η̇ÏË ÚÔ‹˜-fiÁÎÔ˘, ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÌÂÙ·‚·ÏÏfiÌÂÓ˘ Â͈ıˆÚ·ÎÈ΋˜ ·fiÊڷ͢ ÙˆÓ ·ÓÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ (.¯. ‰ÈfiÁΈÛË ı˘ÚÂÔÂȉԇ˜, ·Ú¿Ï˘ÛË ÊˆÓËÙÈÎÒÓ ¯ÔÚ‰ÒÓ).
˘Ô„›· ÓÔÛ‹Ì·ÙÔ˜ ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ ¯ˆÚ›˜ Û·Ê‹ Â˘Ú‹Ì·Ù· ·fi ÙË ÛÈÚÔ̤ÙÚËÛË, Û˘ÓÈÛÙ¿Ù·È Ë ÏÂÙÔÌÂÚ¤ÛÙÂÚË Î·Ù·ÁÚ·Ê‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ fiÁÎˆÓ Î·È ¯ˆÚËÙÈÎÔÙ‹ÙˆÓ Ì ÏËı˘ÛÌÔÁÚ·Ê›·. ™Â ·ÛıÂÓ›˜ Ì ÌÈÎÙÔ‡ Ù‡Ô˘ ÚÔ‚Ï‹Ì·Ù· (·ÔÊÚ·ÎÙÈÎÔ‡ Î·È ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘) Â›Ó·È ‰˘Ó·ÙfiÓ Ì ÙË ÛÈÚÔ̤ÙÚËÛË Ó· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Û·ÊÒ˜ ÙÔ ·ÔÊÚ·ÎÙÈÎfi Úfi‚ÏËÌ·, ÂÓÒ ÙÔ ÂÚÈÔÚÈÛÙÈÎfi ÛÙÔÈ¯Â›Ô Ù˘ ÓfiÛÔ˘ Ó· ÌËÓ ·ÔηχÙÂÙ·È. ™Â ·ÛıÂÓ›˜ Ô˘ ˘¿Ú¯ÂÈ ÎÏÈÓÈ΋ ˘Ô„›· Û˘Ó‡·Ú͢ Î·È ÂÚÈÔÚÈÛÙÈÎÔ‡ ÛÙÔÈ¯Â›Ô˘, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ TLC ı· ‰È¢ÎÔχÓÂÈ ÙË ‰ÈÂÚ‡ÓËÛË ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ı· ·ÍÈÔÏÔÁËıÔ‡Ó fi¯È ÌfiÓÔ ÔÈ ·ıÔÏÔÁÈο ¯·ÌËϤ˜ ÙÈ̤˜, ·ÏÏ¿ Î·È ÔÈ ÌË ·Ó·ÌÂÓfiÌÂÓ˜ Ê˘ÛÈÔÏÔÁÈΤ˜ ÁÈ· ·ÛıÂÓ‹ Ì ·ÔÎÏÂÈÛÙÈο ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ (25) (¶›Ó·Î·˜ 1). ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ FRC, ÂÎÙfi˜ ·fi ÙËÓ ÏËı˘ÛÌÔÁÚ·Ê›·, ÌÔÚ› Ó· Á›ÓÂÈ Î·È Ì ÙË Ì¤ıÔ‰Ô ‰È¿Ï˘Û˘ ÙˆÓ ·ÂÚ›ˆÓ ËÏ›Ô˘ ‹ ·˙ÒÙÔ˘ (multiple-breath gas dilution). ∂ÈÛËÌ·›ÓÂÙ·È, ˆÛÙfiÛÔ, fiÙÈ Û ·ÛıÂÓ›˜ Ì ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ÓfiÛÔ ˘ÔÂÎÙÈÌ¿Ù·È Ë FRC, ‰ÈfiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÂÚÈÔÚ›˙ÂÙ·È ÛÙȘ ÂÚÈÔ¯¤˜ ÙˆÓ Ó¢ÌfiÓˆÓ Ô˘ Â›Ó·È Û ·ʋ Ì ÙÔ ÛÙfiÌ· Î·È ‰ÂÓ ˘ÔÏÔÁ›˙ÂÙ·È Ô fiÁÎÔ˜ ÙÔ˘ ·¤Ú· Ô˘ Â›Ó·È ÂÁÎψ‚ÈṲ̂ÓÔ˜ (26).
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∂ÈÎfiÓ· 6. ∂ȉˆÌ¤ÓË ÂÈÛÓ¢ÛÙÈ΋ Î·È ÂÎÓ¢ÛÙÈ΋ η̇ÏË ÚÔ‹˜-fiÁÎÔ˘, ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÛÙ·ıÂÚ‹˜ ·fiÊڷ͢ ÙˆÓ ·ÓÒÙÂÚˆÓ ·ÂÚ·ÁˆÁÒÓ (.¯. ÛÙ¤ÓˆÛË ÙÚ·¯Â›·˜).
∂Ӊ›ÍÂȘ ‰È¿¯˘Û˘ CO O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ‰È¿¯˘Û˘ ·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ Ô͢ÁfiÓÔ˘ ·fi ÙËÓ Î˘„ÂÏ›‰· ÛÙ· Ó¢ÌÔÓÈο ÙÚȯÔÂȉ‹. °È· ÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Ô˘ ·Ú¤¯ÂÈ Ë ‰È¿¯˘ÛË ÙÔ˘ CO ηÈ, ÂÔ̤ӈ˜, ÙˆÓ ÂӉ›ÍÂÒÓ Ù˘, ˘ÂÓı˘Ì›˙ÂÙ·È Ë Â͛ۈÛË ÙˆÓ Roughton Î·È Forster (27) ÁÈ· ÙË ‰È¿¯˘ÛË: 1/DLCO = 1/Dm + 1/ıVc. H ·Ú¿ÌÂÙÚÔ˜ Dm Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÈÊ¿ÓÂÈ· Î·È ÙÔ ¿¯Ô˜ Ù˘ ΢„ÂÏȉÈ΋˜ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÙËÓ ÂÈÊ¿ÓÂÈ· Î·È ÙÔ ¿¯Ô˜ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÙÔ ¿¯Ô˜ Ù˘ ÛÙÈ‚¿‰·˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÙË Ê˘ÛÈ΋ ‰È·¯˘ÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ CO ‰È·Ì¤ÛÔ˘ Ù˘ ΢„ÂÏȉÈ΋˜ ÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÂÚ˘ıÚÔ‡ ·ÈÌÔÛÊ·ÈÚ›Ô˘ Î·È ÙÔ˘ ÂÛˆÙÂÚÈÎÔ‡ ÙÔ˘ ÂÚ˘ıÚÔ‡ ·ÈÌÔÛÊ·ÈÚ›Ô˘. ∏ ·Ú¿ÌÂÙÚÔ˜ ı Â›Ó·È Ô Û˘ÓÙÂÏÂÛÙ‹˜ Ù˘ ¯ËÌÈ΋˜ Û˘ÁÁ¤ÓÂÈ·˜ ÙÔ˘ CO Ì ÙËÓ Hb Î·È Vc Â›Ó·È Ô fiÁÎÔ˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙ· Ó¢ÌÔÓÈο ÙÚȯÔÂȉ‹. ∞fi ÙËÓ ·Ú·¿Óˆ Â͛ۈÛË Â›Ó·È Ê·ÓÂÚ¿ Ù· ·ÎfiÏÔ˘ı· (28-31): ÓÔÛ‹Ì·Ù· Ô˘ ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ·Ú·Ì¤ÙÚÔ˘ Dm, fiˆ˜ Ë Ó¢ÌÔÓÈ΋ ›ÓˆÛË, Ô‰ËÁÔ‡Ó ÛÂ Û˘ÓÔ‰fi Ì›ˆÛË Ù˘ DLCO. ∏ ·Ú¿ÌÂÙÚÔ˜ ı
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ª¤ÁÈÛÙË ÂÈÛÓÔ‹
IRV IC TLC
◊ÚÂÌË ÂÈÛÓÔ‹ VC TV ◊ÚÂÌË ÂÎÓÔ‹ ERV
FRC ª¤ÁÈÛÙË ÂÎÓÔ‹ RV
RV
∂ÈÎfiÓ· 7. ¶Ó¢ÌÔÓÈÎÔ› fiÁÎÔÈ Î·È ·ÓÙ›ÛÙÔȯ˜ ¯ˆÚËÙÈÎfiÙËÙ˜ Ô˘ ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ì ÙËÓ ÏËı˘ÛÌÔÁÚ·Ê›·.
ÂËÚ¿˙ÂÙ·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ı¤ÛÂˆÓ ‰¤ÛÌ¢Û˘ Î·È ·fi ÙÔÓ ·ÓÙ·ÁˆÓÈÛÌfi O2 Î·È CO ÁÈ· ÙË Û‡Ó‰ÂÛ‹ ÙÔ˘˜ Ì ÙȘ ı¤ÛÂȘ ·˘Ù¤˜. ∏ DLCO ·Ó·Ì¤ÓÂÙ·È ÌÂȈ̤ÓË fiÙ·Ó ÔÈ ı¤ÛÂȘ ‰¤ÛÌ¢Û˘ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜, fiˆ˜ Û ÂÚ›ÙˆÛË ·Ó·ÈÌ›·˜, ηıÒ˜ Î·È fiÙ·Ó ÌÂÈÒÓÂÙ·È Ë Û˘ÁÁ¤ÓÂÈ· ÙÔ˘ O2 ÚÔ˜ ÙȘ ı¤ÛÂȘ ‰¤ÛÌ¢Û˘ ÏfiÁˆ ¯·ÌËÏ‹˜ ›ÂÛ˘, fiˆ˜ .¯. Û ÌÂÁ¿ÏÔ ˘„fiÌÂÙÚÔ. ∏ Ì›ˆÛË, ›Û˘, ÙÔ˘ ÙÚȯÔÂȉÈÎÔ‡ fiÁÎÔ˘ ·›Ì·ÙÔ˜ Vc, Ë ÔÔ›· Û˘Ì‚·›ÓÂÈ .¯. Û Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹, ÂÌʇÛËÌ· ‹ ›ÓˆÛË ÏfiÁˆ ·fiÊڷ͢ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ, ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Û˘ÓÔ‰fi ÂÏ¿ÙÙˆÛË ÙÔ˘ DLCO. ∏ ·Ú·¿Óˆ Â͛ۈÛË, ›Û˘, ÂÍËÁ› ·Ó¿ÏÔÁ· ÙËÓ ·‡ÍËÛË Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÔÏ˘Î˘ÙÙ·Ú·ÈÌ›·, Û ÓÔÛ‹Ì·Ù· Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÂÓ‰Ô΢„ÂÏȉÈ΋ ·ÈÌÔÚÚ·Á›·, fiˆ˜ Ó¢ÌÔÓÈ΋ ·ÈÌÔÛȉ‹ÚˆÛË ‹ ÎÔÎÎȈ̿وÛË Wegener, ηıÒ˜ Î·È Û ÓÔÛ‹Ì·Ù· Ì ·˘ÍË̤ÓË ÚÔ‹ ·›Ì·ÙÔ˜ ÛÙËÓ Ó¢ÌÔÓÈ΋ ΢ÎÏÔÊÔÚ›·, fiˆ˜ Û ‰È·Ê˘Á‹ ·›Ì·ÙÔ˜ ·fi ÙËÓ ·ÚÈÛÙÂÚ‹ ÛÙË ‰ÂÍÈ¿ ΢ÎÏÔÊÔÚ›·. ∞fi Ù· ·ÓˆÙ¤Úˆ Á›ÓÂÙ·È Ê·ÓÂÚfi fiÙÈ Ë ÂÎÙ¤ÏÂÛË Ù˘ ‰ÔÎÈÌ·Û›·˜ ÁÈ· ηٷÁÚ·Ê‹ Ù˘ DLCO ÂӉ›ÎÓ˘Ù·È Û ÓÔÛ‹Ì·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ÂΉËψı› Ó¢ÌÔÓÈ΋ ›ÓˆÛË ‹ Ì›ˆÛË ÙÔ˘ ÙÚȯÔÂȉÈÎÔ‡ fiÁÎÔ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ‰ÔÎÈÌ·Û›· ‰È¿¯˘Û˘ Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Û ·ÛıÂÓ›˜ ÌÂ
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˘Ô„›· ‰È¿ÌÂÛ˘ Ó¢ÌÔÓÔ¿ıÂÈ·˜. ∏ Ì›ˆÛË Ù˘ DLCO ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ·ÔÙÂÏ› ȉȷ›ÙÂÚ· ÚÒÈÌÔ Â‡ÚËÌ· Ô˘ ÚÔËÁÂ›Ù·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ Î·È ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ (32). ™Â ÂÓ‹ÏÈΘ, Ì¿ÏÈÛÙ·, ÌÂÚÈÎÔ› Û˘ÓÈÛÙÔ‡Ó ÙËÓ ÂÎÙ¤ÏÂÛË ‚ÈÔ„›·˜ Ó‡ÌÔÓ· Û ·ÛıÂÓ›˜ Ì ‰‡ÛÓÔÈ· Î·È Ê˘ÛÈÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη fiÙ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ·ÔÊÚ·ÎÙÈ΋˜ ÓfiÛÔ˘ Î·È Ë DLCO Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi ÙÔ 50% ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡. °È· Ù· ·È‰È¿ ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔÈ¯Ë Û‡ÛÙ·ÛË. O ÚÔÛ‰ÈÔÚÈÛÌfi˜, fï˜, Ù˘ DLCO Â›Ó·È ··Ú·›ÙËÙÔ˜ Î·È ÛÙ· ·È‰È¿ Ì ˘Ô„›· ‰È¿ÌÂÛ˘ Ó¢ÌÔÓÔ¿ıÂÈ·˜, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘. ™˘ÓÈÛٿٷÈ, ›Û˘, Ë ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘ Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ DLCO, ÔÈ ÌÂÙ·‚ÔϤ˜ Ù˘ ÔÔ›·˜ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ ÁÈ· ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜. ªÂ ‚¿ÛË Ù· ‰Â‰Ô̤ӷ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, Ë DLCO Â›Ó·È ÛÎfiÈÌÔ Ó· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Î·È ÛÙ· ·È‰È¿ Ì ۷ÚÎÔ›‰ˆÛË (33), ·ÎfiÌË Î·È Û ·˘Ù¿ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙÔ ÛÙ¿‰ÈÔ π, ÙÔ ÔÔ›Ô ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·ÎÙÈÓÔÏÔÁÈο ·fi Ê˘ÛÈÔÏÔÁÈÎfi Ó¢ÌÔÓÈÎfi ·Ú¤Á¯˘Ì· Î·È Û˘ÓÔ‰fi ˘Ï·›· ·‰ÂÓ›Ùȉ·. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ DLCO ¤¯ÂÈ, ›Û˘, ı¤ÛË Î·È Û ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ
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ÔÛÙÒÓ, ȉȷ›ÙÂÚ· fiÙ·Ó ·˘Ù‹ ¤ÁÈÓ Û ÙÂÏÈο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘, ηıÒ˜ Î·È Û ·È‰È¿ Ì ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›·. ∂Ӊ›ÍÂȘ ̤ÙÚËÛ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O ∆Ô ÂÓ‰ÔÁÂÓ¤˜ ¡O ·Ú¿ÁÂÙ·È ·fi ÙËÓ L-·ÚÁÈÓ›ÓË Ì ÙË ‰Ú¿ÛË ÙÚÈÒÓ ÈÛÔÌÂÚÒÓ ÙˆÓ Û˘ÓıÂÙ·ÛÒÓ ÙÔ˘ ¡O (¡OS). ∆Ô ÈÛÔÌÂÚ¤˜ ¡OS2 Ê·›ÓÂÙ·È fiÙÈ Â¿ÁÂÙ·È ·fi ÙȘ ΢ÙÔΛÓ˜ (34) Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË ÊÏÂÁÌÔÓÒ‰Ë ‰È·‰Èηۛ· ηÈ, ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë ‰Ú·ÛÙËÚÈfiÙËÙ¿ ÙÔ˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÊÏÂÁÌÔÓ‹ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ. °È· ÚÒÙË ÊÔÚ¿ ÙÔ 1991, ÔÈ Gustafsson Î·È Û˘Ó ‰È·›ÛÙˆÛ·Ó ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ¡O ÛÙËÓ ·ÓıÚÒÈÓË ·Ó·ÓÔ‹ (35). ŒÎÙÔÙÂ, ·ÚÎÂÙÔ› ÂÚ¢ÓËÙ¤˜ ·Ú·Ù‹ÚËÛ·Ó ˘„ËÏ¿ ›‰· ¡O Û ·ÛıÂÓ›˜ Ì ¿ÛıÌ· (36-38). ™ÙË Ì¤ÙÚËÛË ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O, ·Ú¯Èο, ‰fiıËΠȉȷ›ÙÂÚË ÛËÌ·Û›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¿ÛıÌ·, ‰ÈfiÙÈ ÂÓÒ Ë ÛÈÚÔ̤ÙÚËÛË ·ÔÙÂÏ› ‰Â›ÎÙË Ù˘ ·fiÊڷ͢ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, Ë Ì¤ÙÚËÛË ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O ·ÔÙÂÏ› ‰Â›ÎÙË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ, Ë ÔÔ›· ÛÙ· ·Ú¯Èο ÛÙ¿‰È· ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ¯ˆÚ›˜ Û˘ÓÔ‰fi ·fiÊÚ·ÍË. ∆· ›‰· ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O Â›Ó·È Ê˘ÛÈÔÏÔÁÈο ‹ ¯·ÌËÏ¿ Û ÌË ·ÛıÌ·ÙÈο ·È‰È¿ Ì ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ Ó¢ÌÔÓÈ΋ ÓfiÛÔ, fiˆ˜ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ Î·È Û‡Ó‰ÚÔÌÔ ‰˘ÛΛÓËÙˆÓ ÎÚÔÛÛÒÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ë Ì¤ÙÚËÛË ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O ÂӉ›ÎÓ˘Ù·È Û ·È‰È¿ Ì ˘Ô„›· ¿ÛıÌ·ÙÔ˜, ÚÈÓ ÙËÓ ¤Ó·ÚÍË ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÁˆÁ‹˜, fiÙ·Ó ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· ÁÈ· ÙË ‰È¿ÁÓˆÛË. ∞ÓÙ›ıÂÙ·, fï˜, ·Ú¿ ÙÔÓ ·Ú¯ÈÎfi ÂÓıÔ˘ÛÈ·ÛÌfi, Ù· ›‰· ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O ‰ÂÓ Ê·›ÓÂÙ·È fiÙÈ ·ÔÙÂÏÔ‡Ó Î·Ù¿ÏÏËÏÔ ‰Â›ÎÙË ·Ú·ÎÔÏÔ‡ıËÛ˘ ·È‰ÈÒÓ Ì ¿ÛıÌ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÂÈÛÓÂfiÌÂÓ· ‹ Û˘ÛÙËÌ·ÙÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÌÂϤÙ˜, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ›‰· ÂÎÓÂfiÌÂÓÔ˘ ¡O ‰ÂÓ Û˘Û¯ÂÙ›˙ÔÓÙ·È ÈηÓÔÔÈËÙÈο Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜ (˘ÂÚ·ÓÙȉڷÛÙÈÎfiÙËÙ· ·ÂÚ·ÁˆÁÒÓ ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ Ì ÌÂÙ·¯ÔÏ›ÓË ‹ ÈÛÙ·Ì›ÓË, ˈÛÈÓfiÊÈÏ· Ù˘¤ÏˆÓ) ÛÙÔ˘˜ ·ÛıÌ·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ˘fi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌËÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ·ÛÊ·Ï‹˜ ‰Â›ÎÙ˘ Ì›ˆÛ˘ Ù˘ ‰fiÛ˘ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Ê·ÚÌ¿ÎˆÓ Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÂÏÂÁ¯ı› Ù· Û˘ÌÙÒÌ·Ù·. ªÂ Ù· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ‰ÂÓ Â›Ó·È, ›Û˘, ÂÊÈÎÙfi Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙ› ÙÔ ·ÙÔÈÎfi ·fi ÙÔ ÌË ·ÙÔÈÎfi ¿ÛıÌ· Ì ‚¿ÛË Ù· ›‰· ÙÔ˘ ÂÎÓÂfiÌÂÓÔ˘ ¡O.
™Â ÂÚÈÔÚÈṲ̂ÓÔ, fï˜, ·ÚÈıÌfi ÌÂÏÂÙÒÓ Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ, ‰È·ÈÛÙÒıËÎ·Ó ˘„ËÏfiÙÂÚ· ›‰· ÂÎÓÂfiÌÂÓÔ˘ ¡O ÛÙÔ˘˜ ·ÙÔÈÎÔ‡˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ·ÙÔÈÎÔ‡˜ ·ÛıÂÓ›˜. ∂Ô̤ӈ˜, Â›Ó·È Èı·ÓfiÓ ÛÙÔ Ì¤ÏÏÔÓ ÙÔ ÂÎÓÂfiÌÂÓÔ ¡O Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ Ê·ÈÓÔÙ‡ˆÓ ÙÔ˘ ·È‰ÈÎÔ‡ ¿ÛıÌ·ÙÔ˜ (39). ∆· ›‰· ÙÔ˘ ÚÈÓÈÎÔ‡ ¡O Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÍË̤ӷ Û ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· (39). ∞ÓÙ›ıÂÙ·, ¯·ÌËÏ¿ ›‰· ÚÈÓÈÎÔ‡ ¡O ·Ú·ÙËÚÔ‡ÓÙ·È Û ·ÛıÂÓ›˜ Ì ڈÙÔ·ı‹ ‰˘ÛÎÈÓËÛ›· ÎÚÔÛÛÒÓ, ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ Î·È ÔÍ›· ‹ ¯ÚfiÓÈ· ÈÁÌÔÚ›Ùȉ·. ™Â ·ÛıÂÓ›˜ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ ‹ ‰˘ÛΛÓËÙÔ˘˜ ÎÚÔÛÛÔ‡˜ ¤¯Ô˘Ó ·Ú·ÙËÚËı› ¯·ÌËÏ¿ ›‰· ÚÈÓÈÎÔ‡ ¡O Î·È fiÙ·Ó ÔÈ ·Ú·ÚÚ›ÓÈÔÈ ÎfiÏÔÈ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎÔ›, ÌÂ Û˘Ó¤ÂÈ· Ù· ¯·ÌËÏ¿ ›‰· Ó· ÌËÓ ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ÛÂ Û˘Ó˘¿Ú¯Ô˘Û· ·fiÊÚ·ÍË ÙˆÓ ·Ú·ÚÚÈÓ›ˆÓ Î·È Û˘ÓÔ‰fi ÈÁÌÔÚ›Ùȉ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ, ˘¿Ú¯ÂÈ ·ÏÏËÏÔÂÈÎ¿Ï˘„Ë ÙˆÓ ÂȤ‰ˆÓ Ì ·˘Ù¿ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Û ˘ÁÈ‹ ¿ÙÔÌ·, fiÛÔ Î·È Û ¿ÏϘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ. ∞ÓÙ›ıÂÙ·, ·ÚfiÌÔÈ· ·ÏÏËÏÔÂÈÎ¿Ï˘„Ë ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ì ‰˘ÛÎÈÓËÛ›· ÙˆÓ ÎÚÔÛÛÒÓ Î·È ¿ÏÏˆÓ ÔÌ¿‰ˆÓ ·ÛıÂÓÒÓ ‹ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·ÙfïÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ù· ›‰· ÙÔ˘ ÚÈÓÈÎÔ‡ ¡O ·ÔÙÂÏÔ‡Ó ·ÚÎÂÙ¿ ÈηÓÔÔÈËÙÈÎfi ‰Â›ÎÙË ‰È·ÏÔÁ‹˜ (40) ÙˆÓ ·È‰ÈÒÓ Ì ÎÏÈÓÈ΋ ˘Ô„›· Ù˘ ÓfiÛÔ˘, ÛÙ· ÔÔ›· ı· ··ÈÙËı› ÂÓ‰Âϯ¤ÛÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙˆÓ ÎÚÔÛÛÒÓ Î·È ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Ì ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÛÈÚÔ̤ÙÚËÛË ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚ· ÂÓ‰ÂÈÎÓ˘fiÌÂÓË ÂͤٷÛË Û ·È‰È¿ Ì ÓÔÛ‹Ì·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÛÙ· ÔÔ›· ··ÈÙÂ›Ù·È Ë ÂÎÙ›ÌËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™Â ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·È‰ÈÒÓ ··ÈÙÂ›Ù·È ÂÚ·ÈÙ¤Úˆ ÏÂÈÙÔ˘ÚÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·Ó·ÓÔ‹˜ Ì ÂÎÙ›ÌËÛË Ù˘ ‰È·¯˘ÙÈ΋˜ ÈηÓfiÙËÙ·˜ Ù˘ ΢„ÂÏȉÔÙÚȯÔÂȉÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ‹ ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ fiÁÎˆÓ Î·È ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ¯ˆÚËÙÈÎÔًوÓ. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÚÈÓÈÎÔ‡ ¡O ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ ÂÚÁ·ÏÂ›Ô ‰È·ÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ˘Ô„›· ‰˘ÛΛÓËÙˆÓ ÎÚÔÛÛÒÓ, ÂÓÒ ÙÔ ÂÎÓÂfiÌÂÓÔ ¡O ÁÈ· ÎÏÈÓÈÎÔ‡˜ ÏfiÁÔ˘˜ Û˘ÓÈÛÙ¿Ù·È Û ·ÛıÂÓ›˜ ÌÂ Û˘ÌÙÒÌ·Ù· ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·ÂÚ·ÁˆÁÒÓ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÛÈÚÔ̤ÙÚËÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. American Thoracic Society. Standardization of spirometry: 1994 update. Am Rev Respir Dis 1994;143:1215-1223. 2. ∫·ÙÛ·Ú‰‹˜ Ã. §ÂÈÙÔ˘ÚÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ó¢ÌfiÓˆÓ ÛÙ· ·È‰È¿. ¶ÓÂ‡ÌˆÓ 1987;1:82-89. 3. American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis 1991;144:1202-1218.
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
∂͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜ ∂. ∫·Ú·ÓÙ·Ó¿1, ™. ∫ˆÛÙ·Ú›‰Ô˘2, ∞. ∫·Ï·ÓÙ˙‹˜3, ∞. °È·ÓÓÔ‡ÏÈ·2
Extrapulmonary symptoms of Mycoplasma pneumoniae infections E. Karantana1, S. Kostaridou2, A. Kalantzis3, A. Giannoulia2
¶ÂÚ›ÏË„Ë: ∫·Ù·ÁÚ¿ÊÔÓÙ·È 114 ÂÚÈÙÒÛÂȘ Ïԛ̈͢ ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ 31 Ì Â͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ, Ì ‹ ¯ˆÚ›˜ Û˘ÌÌÂÙÔ¯‹ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. ∞Ó·ÊÂÚfiÌ·ÛÙ Û 10 ÂÚÈÙÒÛÂȘ Ì ÂΉËÏÒÛÂȘ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi, Û 6 Ì ‰ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ, 5 Ì ÂΉËÏÒÛÂȘ ·fi ÙÔ Ì˘ÔÛÎÂÏÂÙÈÎfi Û‡ÛÙËÌ·, 4 Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ηÈ, Ù¤ÏÔ˜, Û 6 ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ∫¡™. ∏ ‰È¿ÁÓˆÛË Ù¤ıËΠ̠ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi IgG Î·È IgM ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜ Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡. £Âڷ›· ¤Ï·‚·Ó ÔÈ 20 ·fi ÙÔ˘˜ 31 ·ÛıÂÓ›˜, Ë ÔÚ›· ÙˆÓ ÔÔ›ˆÓ ÂÍÂÏ›¯ıËΠÔÌ·Ï¿.
Abstract: This is a presentation of 114 cases of Mycoplasma pneumoniae infection, 31 of which had extrapulmonary symptoms, with or without respiratory tract involvement. These include 10 cases with gastrointestinal tract symptoms, 6 with skin involvement, 5 with symptoms related to muscles and joints, 4 of blood anomalies and 6 cases with central nervous system symptoms. The diagnosis was established using immunofluorescence techniques. Treatment was administered to 20 of the 31 patients and the course of the disease was satisfactory.
§¤ÍÂȘ ÎÏÂȉȿ: Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜, Ì˘ÂÏ›Ùȉ·, ·ÚıÚ›Ùȉ·, ÂÍ¿ÓıËÌ·, ·ÁÁÂÈ›Ùȉ·.
Key words: Mycoplasma pneumoniae infection, myelitis, arthropathy, brainstem syndrome, exanthem, vasculitis.
∂ÈÛ·ÁˆÁ‹ OÈ Â͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜ ·ÔÙÂÏÔ‡Ó ‰È·ÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ·È‰›·ÙÚÔ, ȉȷ›ÙÂÚ· fiÙ·Ó ·Ô˘ÛÈ¿˙Ô˘Ó Ù· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ÂÓÒ Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂȉÈÎÒÓ ·ÓÙÈۈ̿وÓ. OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ‰È·ÎÚ›ÓÔÓÙ·È Û ·˘Ù¤˜ ·fi ÙÔ ·ÓÒÙÂÚÔ Î·È Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi, ηıÒ˜ Î·È Û ÂΛӘ Ô˘ ÂÌϤÎÔ˘Ó ¿ÏÏ· Û˘ÛÙ‹Ì·Ù·. ∞fi ÙÔ ·ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·, Ë Ì˘ÎÔÏ·ÛÌ·ÙÈ΋ Ïԛ̈ÍË ÌÔÚ› Ó· ÂΉËψı› ˆ˜ Ê·Ú˘ÁÁ›ÙȘ, ÔÍ›· ̤ÛË ˆÙ›ÙȘ, ·Ì˘Á‰·Ï›ÙȘ, ÂÓÒ ·fi ÙÔ Î·ÙÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi, ÂÎÙfi˜ ·fi ÙËÓ Ó¢ÌÔÓ›· Ô˘ Â›Ó·È Î·È Ë ÛËÌ·ÓÙÈÎfiÙÂÚË ÂΉ‹ÏˆÛË, ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› ˆ˜
Ï·Ú˘ÁÁÔÙÚ·¯ÂÔ‚ÚÔÁ¯›ÙȘ, ‚ÚÔÁ¯›ÙȘ ‹ ‚ÚÔÁ¯ÈÔÏ›ÙȘ (1). OÈ Â͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜ Â›Ó·È ·Û˘Ó‹ıÈÛÙ˜, ¯ˆÚ›˜ Ó· Â›Ó·È ‰˘Ó·Ùfi Ó· ηıÔÚÈÛÙ› ÙÔ ·ÎÚÈ‚¤˜ ÔÛÔÛÙfi Î·È ÙÔ ÎÏÈÓÈÎfi ‡ÚÔ˜ ·˘ÙÒÓ. Œ¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÙÒÛÂȘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜, Û˘Ó‰ÚfiÌÔ˘ StevensJohnson, ÂÚÈηډ›Ùȉ·˜, Ì˘Ôηډ›Ùȉ·˜, Ë·Ù›Ùȉ·˜, ÂÁÎÂÊ·Ï›Ùȉ·˜, ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ·˜ Î·È Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (2).
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶.°.¡. “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ ¡›Î·È·-¶ÂÈÚ·È¿˜ 2 A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 O˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶.°.¡. “°. °ÂÓÓËÌ·Ù¿˜”, ∞ı‹Ó·
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∫·Ù¿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ 1996 ¤ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ 1997, ηÙÂÁÚ¿ÊËÛ·Ó 114 ÂÚÈÙÒÛÂȘ Ì˘ÎÔÏ·ÛÌ·ÙÈ΋˜ Ïԛ̈͢, 31 ÂÎ ÙˆÓ ÔÔ›ˆÓ (25,4%) Ì Â͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ (∂ÈÎfiÓ· 1). ™Â 16 ·fi ·˘Ù¤˜ ÙȘ 31 1 Paediatric Clinic of “Agios Panteleimon” General Hospital, Nikea-Piraeus 2 1st Paediatric Clinic of Athens University, “Agia Sophia” Children’s Hospital, Athens 3 Urology Clinic of “G. Gennimatas” General Hospital, Athens
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ÂÚÈÙÒÛÂȘ, ÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi. ∏ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ Î˘Ì·ÈÓfiÙ·Ó ·fi 9 Ì‹Ó˜ ¤ˆ˜ 12 ¤ÙË (̤ÛË ËÏÈΛ·: 6 ¤ÙË), ÂÓÒ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ Ê‡ÏÔ, 15 ·ÛıÂÓ›˜ ‹Ù·Ó ¿ÚÚÂÓ˜ Î·È 16 ı‹ÏÂȘ. OÈ Â͈Ó¢ÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ ÂÌÊ·Ó›ÛÙËÎ·Ó 1-30 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ, ‰ËÏ·‰‹ ̤۷ ÛÙÔ ‰È¿ÛÙËÌ· ÙˆÓ ÚÒÙˆÓ 20 ËÌÂÚÒÓ, ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÓfiÛÔ˘, ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó. ∞ÊÔÚÔ‡Û·Ó ‰Â: ·) Û ÂΉËÏÒÛÂȘ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· Û 10 ÂÚÈÙÒÛÂȘ (8,7%) (΢ڛˆ˜ Ó·˘Ù›·, ¤ÌÂÙÔ, ‰È¿ÚÚÔÈ· Î·È ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜). ŒÓ· ·È‰› ÂÌÊ¿ÓÈÛ ·ÈÌ·Ù¤ÌÂÛË, ÂÓÒ Û ‰‡Ô ‰È·ÈÛÙÒıËΠ‹È· ÙÚ·ÓÛ·ÌÈÓ·ÈÌ›· (ÙÈ̤˜ SGPT: 100-200 u/dl). ‚) Û ‰ÂÚÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Û 6 ÂÚÈÙÒÛÂȘ (5,3%) (Ù‡Ô˘ ÂÏ¿ÛÛÔÓÔ˜ ÔχÌÔÚÊÔ˘ ÂÚ˘ı‹Ì·ÙÔ˜ Û 2 ·È‰È¿ Î·È Û‡Ó‰ÚÔÌÔ Stevens-Johnson Û 3 ·È‰È¿). ™Â Ì›· ÂÚ›ÙˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Stevens-Johnson ÛËÌÂÈÒıËÎ·Ó ÙÚÂȘ ˘ÔÙÚÔ¤˜ ÌÈÎÚfiÙÂÚ˘ ‚·Ú‡ÙËÙ·˜ ·fi ÙËÓ ·Ú¯È΋, ÔÈ Ôԛ˜ ·ÚÔ˘Û›·Û·Ó ‡ÊÂÛË ÌÂÙ¿ ·fi ÔÏÈÁÔ‹ÌÂÚË per os ¯ÔÚ‹ÁËÛË ÎÔÚÙÈ˙fiÓ˘. Á) Û ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Û 4 ÂÚÈÙÒÛÂȘ (3,5%). ◊È· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· ·ÚÔ˘ÛÈ¿ÛÙËΠ۠¤Ó· ·È‰› ¯ˆÚ›˜ Ó· Û˘Óԉ‡ÂÙ·È ·fi ‚·ÚÈ¿ Ó¢ÌÔÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ Ì˘ÎÔÏ·ÛÌ·ÙÈ΋˜ Ïԛ̈͢, ÂÓÒ ÔÈ „˘¯ÚÔÛ˘ÁÎÔÏÏËÙ›Ó˜ ‹Ù·Ó ıÂÙÈΤ˜. £ÚÔÌ‚ÔÂÓ›· ÂΉËÏÒıËΠ۠‰‡Ô ÂÚÈÙÒÛÂȘ (·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ: 5000 Îί Î·È 7000 Îί). ŒÓ· ·È‰› ÂÌÊ¿ÓÈÛ ÂÙ¤¯ÂȘ, Âί˘ÌÒÛÂȘ, ÚÈÓÔÚÚ·Á›· Î·È Ô˘ÏÔÚÚ·Á›·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÎÚ›ıËΠ·Ó·Áη›· Ë ¯ÔÚ‹ÁËÛË Á-ÛÊ·ÈÚ›Ó˘. ∂›Û˘, ÛËÌÂÈÒıËÎÂ Î·È Ì›· ÂÚ›ÙˆÛË ‚·ÚÈ¿˜ Ô˘‰ÂÙÂÚÔÂÓ›·˜ (·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ Ô˘‰ÂÙÂÚfiÊÈψÓ: 400), Ô˘ fï˜ ‰ÂÓ ÂÓÂÏ¿ÎË ·fi οÔÈ· Ïԛ̈ÍË. ™ÙȘ ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ÂÚÈÙÒÛÂȘ ¤ÁÈÓ ϋÚ˘ ¤ÏÂÁ¯Ô˜ ËÎÙÈÎfiÙËÙ·˜, ηıÒ˜ Î·È ¤ÏÂÁ¯Ô˜ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÒÛÙ ӷ ·ÔÎÏÂÈÛÙÔ‡Ó ÓÔÛ‹Ì·Ù· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·ÚfiÌÔÈ· ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ‰) ÛÂ Ì˘ÔÛÎÂÏÂÙÈΤ˜ ÂΉËÏÒÛÂȘ Û 5 ÂÚÈÙÒÛÂȘ (4,4%) (·ÚıÚ›Ùȉ· Û 2 ·È‰È¿, ·ÚıÚ·ÏÁ›Â˜ Û 1 Î·È Ì˘ÔÛ›Ùȉ· Û 2 ·È‰È¿). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ ÚÔ˜ ·ÔÎÏÂÈÛÌfi ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ. ∂Ï‹ÊıËÛ·Ó ∞¡∞, RA-TEST, Anti DNA, pANCA, ·ÓÙÈËÎÙÈÎfi ÙÔ˘ χÎÔ˘ Î·È ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Î·Ú‰ÈÔÏÈ›Ó˘ IgG-IgM, fiÔ˘ Ù· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ·ÚÓËÙÈο.
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™‡ÓÔÏÔ ÂÚÈÙÒÛÂˆÓ ∂͈Ó¢ÌÔÓÈΤ˜ Ì˘ÎÔÏ·ÛÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ∂ÈÎfiÓ· 1. ™˘ÁÎÂÓÙÚˆÙÈ΋ ·Ó¿Ï˘ÛË Â͈Ó¢ÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜.
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Â) Û Ó¢ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Û 6 ÂÚÈÙÒÛÂȘ (5,3%). ∞Ó·Ï˘ÙÈÎfiÙÂÚ·, ¤Ó· ·ÁfiÚÈ ËÏÈΛ·˜ ‰‡Ô ÂÙÒÓ, ·ÚÔ˘Û›·Û ¿ÚÂÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÁˆÓ›·˜ ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ηıÒ˜ Î·È ¿ÚÂÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ˘. ∂›¯Â ÚÔËÁËı›, ÚÔ ‰ÂηÂÓıË̤ÚÔ˘, Ó¢ÌÔÓ›· ÂÓÙÔÈṲ̂ÓË ÛÙÔÓ ·ÚÈÛÙÂÚfi οو ÏÔ‚fi. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÓÙÔ›ÛÙËΠ¤ÌÊÚ·ÎÙÔ Ù˘ ̤Û˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÚÙËÚ›·˜ (ÊÏÔÈfi˜ Î·È Ï¢΋ Ô˘Û›· Ù˘ ‰ÂÍÈ¿˜ ‚ÚÂÁÌ·ÙÈ΋˜ ¯ÒÚ·˜). ∂Ï‹ÊıËÛ·Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Î·Ú‰ÈÔÏÈ›Ó˘ Î·È ‹Ù·Ó ·ÚÓËÙÈο. ŒÏÂÁ¯Ô˜ ÁÈ· ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ· ‰ÂÓ ¤ÁÈÓÂ. ™Â Ì›· ÂÚ›ÙˆÛË ÂΉËÏÒıËΠÂÁÎÂÊ·Ï›Ùȉ· Ì ‰‡Ô ÂÂÈÛfi‰È· ÂÛÙÈ·ÎÒÓ Û·ÛÌÒÓ, ·‰˘Ó·Ì›· Î·È ‰˘Û¯ÚËÛÙ›· ·ÚÈÛÙÂÚÔ‡ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚÔ˘. ™ÙÔ ∂¡À ‚Ú¤ıËÎ·Ó Î‡ÙÙ·Ú· 23 Îί, χΈ̷ 17 mg/dl Î·È Û¿Î¯·ÚÔ 59 mg/dl. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ¤‰ÂÈÍ ÙÚÂȘ ˘¤Ú˘ÎÓ˜ ÂÛٛ˜ ÛÙÔ ‰ÂÍÈfi ÂÁÎÂÊ·ÏÈÎfi ËÌÈÛÊ·›ÚÈÔ, ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ ‚·ÛÈÎÒÓ Á·ÁÁÏ›ˆÓ, ÔÈ Ôԛ˜ ·Ô‰fiıËÎ·Ó Û ‚Ï¿‚˜ ÏfiÁˆ ·ÁÁÂÈ›Ùȉ·˜. OÈ ¿ÏϘ Ù¤ÛÛÂÚȘ ÂÚÈÙÒÛÂȘ ·ÊÔÚÔ‡Û·Ó Û ·È‰È¿ Ì ·ÈıÔ˘ÛÈ·›· Ó¢ڛÙȉ·, ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÈÏ›ÁÁÔ˘, Ì›· ÂÚ›ÙˆÛË Û˘Ó‰ÚfiÌÔ˘ Guilain-Barre Î·È Ì›· ÂÚ›ÙˆÛË ·ÚÂÁÎÂÊ·ÏÈÙȉÈ΋˜ ·Ù·Í›·˜. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ó¢ÚÔÏÔÁÈÎÒÓ ÂΉËÏÒÛÂˆÓ ‰ÂÓ ˘‹ÚÍ·Ó Ó¢ÚÔÏÔÁÈο ηٿÏÔÈ· (¶›Ó·Î·˜ 1). ∏ ‰È¿ÁÓˆÛË Ù˘ Ì˘ÎÔÏ·ÛÌ·ÙÈ΋˜ Ïԛ̈͢ Ù¤ıËΠ̠ÙË Ì¤ıÔ‰Ô ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ Ì ¤ÏÂÁ¯Ô IgG Î·È πgM ·ÓÙÈۈ̿وÓ, Ì ÙÂÙÚ·Ï·ÛÈ·ÛÌfi ‹ ˘ÔÙÂÙÚ·Ï·ÛÈ·ÛÌfi ÙÔ˘ Ù›ÙÏÔ˘ ÌÂٷ͇ ÔÍ›·˜ Ê¿Û˘ Î·È ·Ó¿ÚÚˆÛ˘ ‹ Ù›ÙÏÔ >1/512. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ, Ë Ì¤ÛË ÙÈÌ‹ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‹Ù·Ó Ã=12.200 Îί. ™ÙË Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›·, Ô Ù‡Ô˜ ‹Ù·Ó ÔÏ˘ÌÔÚÊÔ˘ÚËÓÈÎfi˜, ÂÓÒ Ë ∆∫∂ ‹Ù·Ó Ã=36,7 mm (5-73 mm) Î·È Ë CRP Ã=37,1 mg/l (3,2-258 mg/l). ™ÙÔ 64% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÚÔËÁ‹ıËΠ‹ Û˘Ó˘‹ÚÍ Ó¢ÌÔÓ›· ‹ ·ÎfiÌ· ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. £Âڷ›· ¯ÔÚËÁ‹ıËΠ۠20 ·ÛıÂÓ›˜ (71%), ˆ˜ › ÙÔ Ï›ÛÙÔÓ Ì ÎÏ·ÚÈıÚÔÌ˘Î›ÓË. ∏ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ÔÌ·Ï‹, ·Ú¿ ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ‚Ú·‰Â›· ·Ó¿ÚÚˆÛË (2,3) Î·È ¯·Ú·ÎÙËÚ›ÛÙËΠ·fi Ï‹ÚË ·ÔηٿÛÙ·ÛË ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ Û˘ÛÙËÌ¿ÙˆÓ, ¯ˆÚ›˜ ÛÙÔȯ›· ˘ÔÏÂÈÌÌ·ÙÈ΋˜ ÓfiÛÔ˘. ŒÓÙÂη ·fi ÙÔ˘˜ 31 ·ÛıÂÓ›˜ ›¯·Ó Ï¿‚ÂÈ ·ÁˆÁ‹ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÁÈ· ‰È¿ÛÙËÌ· ÂÚ›Ô˘ 5-7 ËÌÂÚÒÓ.
™˘˙‹ÙËÛË ™ÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ Â͈Ó¢ÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ÂÌϤÎÔÓÙ·È ÔÏÏ·ÏÔ› Ì˯·ÓÈÛÌÔ›, fiˆ˜ ¤ÎÙ·ÛË Ù˘ ÌfiÏ˘ÓÛ˘, ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ Î·È È‰ÈfiÙ˘Ë ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÙÔ˘ ÍÂÓÈÛÙ‹ (4). OÈ ÂΉËÏÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ Â›Ó·È ÙfiÛÔ Û˘¯Ó¤˜. ™˘Ì‚·›ÓÔ˘Ó 1-21 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ, ÂÓÒ Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ ÚÔËÁÂ›Ù·È Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (3). ∏ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ·fi ÙÔ ∫¡™, fiˆ˜ ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›ÙȘ (5) (Ô˘ Â›Ó·È Î·È Ë ÈÔ Û˘¯Ó‹), ÂÁοÚÛÈ· Ì˘ÂÏ›ÙȘ ‹ Ó¢ڛÙȘ (6), Û‡Ó‰ÚÔÌÔ ·Ó¿ÏÔÁÔ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜, Û‡Ó‰ÚÔÌÔ Guilain-Barre, „‡¯ˆÛË Î·È ÂÁÎÂÊ·ÏÈÎfi ¤ÌÊÚ·ÎÙÔ, ·ÓÙÈÛÙÔȯ› Û ÔÛÔÛÙfi 0,1% ÙˆÓ ÓÔÛÔ‡ÓÙˆÓ, ·ÏÏ¿ Î·È Ì¤¯ÚÈ 7%
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¶›Ó·Î·˜ 1. ¶ÔÛÔÛÙÈ·›· ·Ó¿Ï˘ÛË Â͈Ó¢ÌÔÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜ °·ÛÙÚÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ 10/114 (8,7%) (·ÏÏËÏÔÂÈÎ¿Ï˘„Ë Û˘ÌÙˆÌ¿ÙˆÓ ) ¡·˘Ù›·-¤ÌÂÙÔÈ 6/114 ¢È¿ÚÚÔȘ 4/114 ∫ÔÈÏÈ·Îfi ¿ÏÁÔ˜ 4/114 ∞ÈÌ·Ù¤ÌÂÛË 1/114 ∏·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· 2/114 ¢ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ 6/114 (5,3%) ¶ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· 2/114 Stevens-Johnson 3/114 ∞ÈÌÔÚÚ·ÁÈÎfi ÎËÏȉԂϷÙȉ҉˜ ÂÍ¿ÓıËÌ· 1/114 ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ 4/114 (3,5%) ∞ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· 1/114 £ÚÔÌ‚ÔÂÓ›· 2/114 O˘‰ÂÙÂÚÔÂÓ›· 1/114 ª˘ÔÛÎÂÏÂÙÈΤ˜ ÂΉËÏÒÛÂȘ 5/114 (4,4%) ∞ÚıÚ›Ùȉ· 2/114 ∞ÚıÚ·ÏÁ›Â˜ 1/114 ª˘ÔÛ›ÙȘ 1/114 ¡Â˘ÚÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ 6/114 (5,3%) ŒÌÊÚ·ÎÙÔ Ì¤Û˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÚÙËÚ›·˜ 1/114 ∂ÁÎÂÊ·Ï›ÙȘ 1/114 ∞ÈıÔ˘ÛÈ·›· Ó¢ڛÙȘ 2/114 Guilain-Barre 1/114 ¶·ÚÂÁÎÂÊ·ÏÈÙȉÈ΋ ·Ù·Í›· 1/114
ÙˆÓ ÓÔÛËÏ¢fiÌÂÓˆÓ Ì Ó¢ÌÔÓÈ΋ ÓfiÛÔ. ∏ ıÓËÙfiÙËÙ· ¤¯ÂÈ ÂÎÙÈÌËı› Û 10%. ™Â fiÛÔ˘˜ ÂÈ‚ÈÒÛÔ˘Ó, Ë ·ÔηٿÛÙ·ÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Â›Ó·È ‚Ú·‰Â›· Î·È ÙÔ 1/3 ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ‚·ÚÈ¿ ˘ÔÏÂÈÌÌ·ÙÈ΋ ÓfiÛÔ (7,8), ÁÂÁÔÓfi˜ Ô˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÈÛ¯‡ÂÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ηıÒ˜ Ë ÔÚ›· ÙÔ˘˜ ‹Ù·Ó ÔÌ·Ï‹ Î·È Ë ·Ó¿ÚÚˆÛË Ï‹Ú˘, ¯ˆÚ›˜ ÛÙÔȯ›· ˘ÔÏÂÈÌÌ·ÙÈ΋˜ ÓfiÛÔ˘. ŸÛÔÓ ·ÊÔÚ¿ ÛÙ· ¿ÏÏ· Û˘ÛÙ‹Ì·Ù·, Ì˘·ÏÁ›Â˜ Î·È ·ÚıÚ·ÏÁ›Â˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯Ó¿ (15-45%), Û‡Ìʈӷ Ì ٷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ηıÒ˜ Î·È ÛËÌ›· ¿Ù˘Ë˜ ·ÚıÚ›Ùȉ·˜ (ÌÔÓÔ·ÚıÚ›ÙȘ ‹ ÌÂÙ·Ó·ÛÙ¢ÙÈ΋ ·ÚıÚ›ÙȘ ‹ ÔÏ˘·ÚıÚ›ÙȘ Ì ÚÔÛ‚ÔÏ‹ ÌÂÁ¿ÏˆÓ ·ÚıÚÒÛˆÓ) (9-10). OÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Û˘Ó‹ıˆ˜ Â›Ó·È ‹È˜, Ì ÈÔ ÛËÌ·ÓÙÈ΋ ÙËÓ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, Ì ·‡ÍËÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ „˘¯ÚÔÛ˘ÁÎÔÏÏËÙÈÓÒÓ, ıÂÙÈ΋ Coomps Î·È ·‡ÍËÛË ÙˆÓ ¢∂∫. §ÈÁfiÙÂÚÔ Û˘¯Ó¤˜ Â›Ó·È Ë Ì˘ÂÏÈ΋ ·Ï·Û›·, Ë ıÚÔÌ‚ÔÂÓ›· ηÈ, ÂÍ·ÈÚÂÙÈο Û¿ÓÈ·, Ë ‰È¿¯˘ÙË ÂÓ‰Ô·ÁÁÂȷ΋ ‹ÍË. ¢‡Ô ÌÔÚʤ˜ ‰ÂÚÌ·ÙÈÎÒÓ ÂΉËÏÒÛÂˆÓ Û˘Ó‰˘¿˙ÔÓÙ·È Ì Ïԛ̈ÍË ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜: ÙÔ ÔχÌÔÚÊÔ ÂÚ‡ıËÌ· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Stevens-Johnson, ÂÓÒ Û‡Ìʈӷ Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ‹È˜ ‰ÂÚÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ ÌÔÚ› Ó· ÊÙ¿ÛÔ˘Ó ÙÔ 30% Û ·ÛıÂÓ›˜ Ì ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, Ë Û˘Ìو̷ÙÔÏÔÁ›· Â›Ó·È ËÈfiÙÂÚË, Ì Â̤ÙÔ˘˜, ‰È¿ÚÚÔȘ Î·È ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÂÓÒ Û¿ÓÈ· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Û˘ÌÙÒÌ·Ù· ·ÁÎÚ·ÙÈ΋˜ Î·È Ë·ÙÈ-
Paediatriki 2003;66:185-187
΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, ηıÒ˜ Î·È ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÂÙÈÎfi. ∆¤ÏÔ˜, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂΉËÏÒÛÂȘ ·fi Ù· ÓÂÊÚ¿, Ì ÙË ÌÔÚÊ‹ ‰È¿ÌÂÛ˘ ÓÂÊÚ›Ùȉ·˜ ‹ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜, ηıÒ˜ Î·È ÂÚÈÙÒÛÂȘ ·ÚÔ‰È΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ∏ ÙÂÏÂ˘Ù·›·, ÌÔÚ› Ó· ÂÚÌËÓ‡ÛÂÈ ÙË Ì·ÎÚ¿ ÂÚ›Ô‰Ô ·Ú·ÌÔÓ‹˜ ÙÔ˘ Ì˘ÎÔÏ¿ÛÌ·ÙÔ˜ Ù˘ Ó¢ÌÔÓ›·˜ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi ÌÂÙ¿ ÙËÓ ‡ÊÂÛË ÙˆÓ Û˘Ìو̿وÓ, ηıÒ˜ Î·È ÙËÓ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ·, Ù·˘Ùfi¯ÚÔÓ· ‹ ·Ì¤Ûˆ˜ ÌÂÙ¿, Ïԛ̈͢ ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÈÔ‡˜ Î·È ‚·ÎÙËÚ›‰È· (11). µÈ‚ÏÈÔÁÚ·Ê›· 1. Stevens D, Swift PG, Johnston PG, Kearney PJ, Corner BD, Burman D. Mycoplasma pneumoniae infections in children. Arch Dis Child 1978;53:38-42. 2. Cassell GH, Cole BC. Mycoplasmas as agents of human disease. N Engl J Med 1981;304:80-89. 3. Lehtokoski-Lehtiniemi E, Koskiniemi ML. Mycoplasma pneumoniae encephalitis: a severe entity in children. Pediatr Infect Dis J 1989;8:651-653. 4. Tjhie JH, van Kuppeveld FJ, Roosendaal R, Melchers WJ, Gordijn R, MacLaren DM et al. Direct PCR enables detection of Mycoplasma pneumoniae in patients with respiratory tract infections. J Clin Microbiol 1994;32:11-16. 5. Koskiniemi M, Rautonen J, Lehtokoski-Lehtiniemi E, Vaheri A. Epidemiology of encephalitis in children: a 20-year survey. Ann Neurol 1993;29:492-497. 6. Mills RW, Schoolfield L. Acute transverse myelitis associated with Mycoplasma pneumoniae infection: a case report and review of the literature. Pediatr Infect Dis J 1992;11:228-231. 7. Nishimura M, Saida T, Kuroki S, Kawabata T, Obayashi H, Saida K et al. Post-infectious encephalitis with antigalactocerebroside antibody subsequent to Mycoplasma pneumoniae infection. J Neurol Sci 1996;140:91-95. 8. Pellegrini M, O’Brien TJ, Hoy J, Sedal L. Mycoplasma pneumoniae infection associated with an acute brainstem syndrome. Acta Neurol Scand 1996;93:203-206. 9. Perez C, Mendoza H, Hernandez R, Valcayo A, Guarch R. Leukocytoclastic vasculitis and polyarthritis associated with Mycoplasma pneumoniae infection. Clin Infect Dis 1997;25:154-155. 10. Cimolai N, Malleson P, Thomas E, Middleton PJ. Mycoplasma pneumoniae associated arthropathy: confirmation of the association by determination of the antipolypeptide IgM response. J Rheumatol 1989;16:1150-1152. 11. Liakopoulou-Tsisipi T. §ÔÈÌÒÍÂȘ ·fi Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ¶·È‰È·ÙÚÈΤ˜ £Âڷ¢ÙÈΤ˜ ∂ÓËÌÂÚÒÛÂȘ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ 1995;1:47-51. ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-09-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 31-01-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ∫·Ú·ÓÙ·Ó¿ ∞Á. ¢ËÌ‹ÙÚÈÔ˘ 28, ∆.∫. 166 73, µÔ‡Ï· - ∞ÙÙÈ΋˜ E-mail: ankalant@otenet.gr
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Paediatriki 2003;66:188-194
ORIGINAL ARTICLE
ºÔÚ›· Neisseria meningitidis Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜: ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È ¯·Ú·ÎÙËÚÈÛÙÈο ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ π. ¶·˘ÏÔÔ‡ÏÔ˘1, ∂. ∞ÏÂÍ¿Ó‰ÚÔ˘2, °. ¢·›ÎÔ˜3, ∂. ¶ÂÙÚ›‰Ô˘2, ∞. ¶¿ÁηÏË2, ª. £ÂÔ‰ˆÚ›‰Ô˘1, µ. ™˘ÚÈÔÔ‡ÏÔ˘1
Neisseria meningitidis carriage in schoolchildren: risk factors and characteristics of isolated strains I. Pavlopoulou1, E. Alexandrou2, G. Daikos3, E. Petridou2, A. Pangalis2, M. Theodoridou1, V. Syriopoulou1
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ Ù˘ ›وÛ˘ Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ù˘ ÊÔÚ›·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, ηıÒ˜ Î·È Ë ÂÚÈÁÚ·Ê‹ ÙˆÓ ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ. ∂Ï‹ÊıËÛ·Ó Î·ÏÏȤÚÁÂȘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·fi 554 ·È‰È¿ ·È‰ÈÎÒÓ ÛÙ·ıÌÒÓ, ‰ËÌÔÙÈÎÒÓ Î·È Á˘ÌÓ·Û›ˆÓ Ù˘ ∞ı‹Ó·˜, ËÏÈΛ·˜ 2-19 ÂÙÒÓ. ¶ÚÔËÁÔ˘Ì¤Óˆ˜ Û˘ÌÏËÚÒıËΠ·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ·ÊÔÚÔ‡Û Û ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÊÔÚ›·. ∏ ¢·ÈÛıËÛ›· ÙˆÓ ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ Û ÎÔÈÓ¿ ·ÓÙÈÌÈÎÚԂȷο ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ÙË Ì¤ıÔ‰Ô E-test, Ë Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘˜ Û ÔÚÔ-ÔÌ¿‰Â˜ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠̤ıÔ‰Ô Û˘ÁÎfiÏÏËÛ˘, ÂÓÒ Ë ÁÂÓÂÙÈ΋ ÙÔ˘˜ Û˘ÁÁ¤ÓÂÈ· Ì ËÏÂÎÙÚÔÊfiÚËÛË ·ÏÏfiÌÂÓÔ˘ ‰›Ô˘ (PFGE). °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ·Î¤ÙÔ STATA. N. meningitidis ·ÔÌÔÓÒıËΠ·fi ÙÔÓ Ê¿Ú˘ÁÁ· 22 ·È‰ÈÒÓ (3,97%). ∏ ÏÂÈÔ„ËÊ›· ·Ó‹Î ÛÙȘ ÔÚÔ-ÔÌ¿‰Â˜ C (31,8%) Î·È B (22,7%). ŸÏ· Ù· ÛÙÂϤ¯Ë ‚Ú¤ıËÎ·Ó Â˘·›ÛıËÙ· ÛÙËÓ ÎÂÊÙÚÈ·ÍfiÓË, ÚÈÊ·ÌÈΛÓË Î·È ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË, 5 ‚Ú¤ıËÎ·Ó ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙ· ÛÙËÓ ÂÓÈÎÈÏ›ÓË (22,7%) Î·È 1 ·ÚÔ˘Û›·Û ϋÚË ·ÓÙÔ¯‹ ÛÙËÓ ÎÔÙÚÈÌÔÍ·˙fiÏË (4,5%). ∏ ÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË 16 ÛÙÂϯÒÓ Ì PFGE ·ÔÎ¿Ï˘„ 6 ‰È·ÊÔÚÂÙÈΤ˜ ÂÈÎfiÓ˜ ËÏÂÎÙÚÔÊfiÚËÛ˘. ™ÙÔ ›‰ÈÔ Û¯ÔÏÂ›Ô ·Ú·ÙËÚ‹ıËÎÂ Û˘ÁΤÓÙÚˆÛË ·È‰ÈÒÓ Ì ›‰È· PFGE ÂÈÎfiÓ·, ÂÓÒ ÛÙÔÓ ›‰ÈÔ ÎÏÒÓÔ ‚Ú¤ıËÎ·Ó ÛÙÂϤ¯Ë ·fi ‰È·ÊÔÚÂÙÈΤ˜ ÔÚÔ-ÔÌ¿‰Â˜. ™ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË, Ë ÌfiÓË ÌÂÙ·‚ÏËÙ‹ Ô˘ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È ÛËÌ·ÓÙÈο Ì ÙË ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ‹Ù·Ó Ë ËÏÈΛ·
Abstract: The aim of this study was to determine the prevalence of carriage of N. meningitidis strains in Greek schoolchildren and to identify associated risk factors. Oropharyngeal swabs were cultivated from a total of 554 children aged 2 to 19 years attending nurseries and primary and secondary schools in Athens. A questionnaire with questions including parameters possibly associated with meningococcal carriage was completed by the children’s parents. Susceptibilities of the isolates to antimicrobial agents were determined by E-test. Isolate serogrouping was performed by slide agglutination and their relatedness was tested by pulsed field gel electrophoresis (PFGE). Data were analyzed using the statistical package STATA. Twenty-two (3.97%) children were identified as meningococcal carriers. The majority of isolates belonged to serogroups C (31.8%) and B (22.7%). All were sensitive to ceftriaxone, rifampicin and chloramphenicol, one was resistant to cotrimoxazole (4.5%) and 5 intermediately resistant to penicillin (22.7%). DNA analysis of 16 isolates revealed 6 distinct PFGE patterns. Clusters with an identical PFGE pattern were noted in the same school. More than one serogroup were included in the same clonal group. On multivariate logistic regression analysis, age >12 years was the only variable to remain independently associated with the carrier state (OR: 7.96; 95% CI: 2.24-28.33; p<0.001). In conclusion, the N. meningitidis carriage rate among Greek schoochildren increases with age.
1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 ∞’ ¶ÚÔ·È‰Â˘ÙÈ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, “§·˚Îfi” °ÂÓÈÎfi ¡ÔÛÔÎÔÌ›Ô, ∞ı‹Ó·
1 1st Paediatric Clinic of University of Athens “Agia Sophia” Children’s Hospital, Athens 2 Microbiological Laboratory “Agia Sophia” Children’s Hospital, Athens 3 1st Academic Clinic of Pathology, University of Athens “Laiko” General Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2003;66:188-194
Paediatriki 2003;66:188-194
¿Óˆ ÙˆÓ 12 ÂÙÒÓ (OR: 7,96, 95% CI: 2,24-28,33, p<0,001). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ËÏÈΛ·, ÂÓÒ ÔÈ Û˘¯ÓfiÙÂÚ˜ ÔÚÔ-ÔÌ¿‰Â˜ ÛÙËÓ ·ÙÚ›‰· Ì·˜ Â›Ó·È ÔÈ C Î·È µ. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÛÙÔÓ ›‰ÈÔ ÎÏÒÓÔ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ÔÚÔ-ÔÌ¿‰Â˜ ˘Ô‰ËÏÒÓÂÈ fiÙÈ, οو ·fi ÙËÓ ›ÂÛË ÂÈÏÔÁ‹˜, Á›ÓÔÓÙ·È ÌÂÙ·ÙÚÔ¤˜ ÛÙ· ˘Â‡ı˘Ó· ÁÈ· ÙȘ ÔÚÔ-ÔÌ¿‰Â˜ ÁÔÓ›‰È·. ∆· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÔ˘Ó ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ì·˙ÈÎÒÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÙÔ Û˘Ó‰Â‰Â̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙË ¯ÒÚ· Ì·˜.
The predominant serogroups in our geographic region are C and B. The inclusion of more than one serogroup within the same clonal group suggests switching of capsular genes. These findings have implications for future immunization with conjugate vaccines.
§¤ÍÂȘ ÎÏÂȉȿ: ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ·È‰È¿, ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘.
Key words: meningococcal carriage, schoolchildren, risk factors.
∂ÈÛ·ÁˆÁ‹ ∏ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ·Ú·Ì¤ÓÂÈ ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙ· ·È‰È¿, ·Ú¿ ÙȘ ‚ÂÏÙȈ̤Ó˜ ÌÂıfi‰Ô˘˜ ÂÚÁ·ÛÙËÚȷ΋˜ ‰È¿ÁÓˆÛ˘ Î·È ıÂڷ›·˜. ∏ Û˘Ó‹ı˘ ËÁ‹ ‰È·ÛÔÚ¿˜ Ù˘ Ïԛ̈͢ Â›Ó·È ÔÈ ·Û˘Ìو̷ÙÈÎÔ› ÊÔÚ›˜. ∏ ›وÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÊÔÚ›·˜ ÔÈΛÏÏÂÈ. ∂›Ó·È ¯·ÌËÏ‹ ÛÙ· ÌÈÎÚ¿ ·È‰È¿ (<2%), ˘„ËÏfiÙÂÚË ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÙÔ˘˜ Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ (5-15%) Î·È ·ÚÎÂÙ¿ ˘„ËÏ‹ Û ¿ÙÔÌ· Ô˘ ‰È·‚ÈÔ‡Ó ÛÂ Û˘Óı‹Î˜ Û˘Á¯ÚˆÙÈÛÌÔ‡, fiˆ˜ ȉڇ̷ٷ Î·È ÛÙÚ·Ùfi‰· (~50%) (1-3). ∏ ÊÔÚ›· N. meningitidis ‰Ú· ·ÓÔÛÔÔÈËÙÈο, Ì ·ÔÙ¤ÏÂÛÌ·, ‰‡Ô ÂÚ›Ô˘ ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ·ÔÈÎÈÛÌfi ÙÔ˘ ·ÙfiÌÔ˘, Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔÓ ÔÚfi ÂȉÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÔÚÔ-ÔÌ¿‰·˜. ø˜ ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÊÔÚ›·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Ë ÚÔËÁËı›۷ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙÔ ÂÓÂÚÁËÙÈÎfi ‹ ·ıËÙÈÎfi οÓÈÛÌ·, ÙÔ ¿ÚÚÂÓ Ê‡ÏÔ Î·È ÙÔ ¯·ÌËÏfi ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô (2,4,5). ™‡Ìʈӷ Ì ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, fiÙ·Ó ÙÔ ÔÛÔÛÙfi ÊÔÚ›·˜ ·fi Û˘ÁÎÂÎÚÈ̤ÓË ÔÚÔ-ÔÌ¿‰· ˘Âڂ› ÙÔ 20% Û ̛· ÎÔÈÓfiÙËÙ·, ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ÂȉËÌ›·˜, Û˘Ó‹ıˆ˜ ·fi ÙËÓ ›‰È· ÔÚÔ-ÔÌ¿‰·. ŒÌÊ·ÛË, fï˜, ı· Ú¤ÂÈ Ó· ‰Ôı› ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÏϤ˜ ÂȉË̛˜ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ηٷÁÚ¿ÊÔÓÙ·È fi¯È Û ÂÚÈfi‰Ô˘˜ ˘„ËÏ‹˜ ÊÔÚ›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡, ·ÏÏ¿ fiÙ·Ó ˘¿Ú¯ÂÈ Ù·¯Â›· ·‡ÍËÛË ÙÔ˘ Ú˘ıÌÔ‡ Ù˘ Û ¿ÙÔÌ· Ô˘ ‰ÂÓ ‹Ù·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ·ÔÈÎÈṲ̂ӷ ηÈ, ηٿ Û˘Ó¤ÂÈ·, ‰ÂÓ Â›¯·Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ ˘Â‡ı˘Ó˘ ÁÈ· ÙËÓ ÂȉËÌ›· ÔÚÔ-ÔÌ¿‰·˜ (6). ™ÙËÓ ∂ÏÏ¿‰·, Ë N. meningitidis Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· Ù˘ ÌÈÎÚԂȷ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ ÛÙ· ·È‰È¿, Ì ˘ÔÏÔÁÈ˙fiÌÂÓË Ì¤ÛË ÂÙ‹ÛÈ· ›وÛË 7,5 ÂÚÈÙÒÛÂȘ ·Ó¿ 100.000 ·È‰È¿ ËÏÈΛ·˜ <14 ÂÙÒÓ, ÛÙËÓ Â-
ÚÈÔ¯‹ Ù˘ ∞ı‹Ó·˜ (7). ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ·ÊÔÚ¿ Û ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ, ÂÓÒ Ì›· ¿ÏÏË ÔÌ¿‰· Ô˘ ÚÔÛ‚¿ÏÏÂÙ·È Û˘¯Ó¿ Â›Ó·È ÔÈ ¤ÊË‚ÔÈ (8). ∞fi ÙÔ 1995 ¤¯ÂÈ ÛËÌÂȈı› Ì›· Û˘Ó¯È˙fiÌÂÓË ·‡ÍËÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘, ÔÊÂÈÏfiÌÂÓ˘ ΢ڛˆ˜ ÛÙËÓ ÔÚÔ-ÔÌ¿‰· µ, ÂÓÒ ÙÔ 1997 Ë ÔÚÔ-ÔÌ¿‰· Ô˘ ·ÔÌÔÓˆÓfiÙ·Ó Û˘¯ÓfiÙÂÚ· ‹Ù·Ó Ë C. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ô ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˜ µ ·ÔÌÔÓÒÓÂÙ·È ÛÙÔ 58% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÛÙËÓ ·ÙÚ›‰· Ì·˜. ∏ ·‡ÍËÛË ·˘Ù‹ Ù˘ ›وÛ˘ ÔÊ›ÏÂÙ·È ÂÓ Ì¤ÚÂÈ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ηٷÁÚ·Ê‹˜ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ·fi ÙÔ ∂ıÓÈÎfi ∫¤ÓÙÚÔ ∞Ó·ÊÔÚ¿˜ ªËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ·ÏÏ¿ Î·È ÛÙËÓ Â›ÛÔ‰Ô Ó¤ˆÓ ÛÙÂϯÒÓ ÛÙË ¯ÒÚ· Ì·˜, ·Ú¯Èο Ì ʷÈÓfiÙ˘Ô C:2a:P1.2.P1.5 (ÎÏÒÓÔ˜ ET-37) Î·È ÚfiÛÊ·Ù· Ì ʷÈÓfiÙ˘Ô B:2a:P1.2 (ÎÏÒÓÔ˜ ET-15) (9,10). ™Â ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜, Ô˘ ·ÊÔÚÔ‡Û·Ó Û ÛÙÚ·ÙÈÒÙ˜, ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È ÌÂÙ·Ó¿ÛÙ˜, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÔÛÔÛÙ¿ ÊÔÚ›·˜ 25%, 5,8% Î·È 13%, ·ÓÙ›ÛÙÔȯ· (11,12). ª¤¯ÚÈ ÚfiÛÊ·Ù·, Ë ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÂÚÈÂÏ¿Ì‚·Ó ÂÌ‚ÔÏÈ·ÛÌfi Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÔÌ¿‰ˆÓ-ÛÙfi¯ˆÓ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÛÙȘ ηٿ ÙfiÔ˘˜ ÂȉË̛˜, ηıÒ˜ Î·È ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ÛÙÚ·ÙȈÙÒÓ Ì ÙÔ ‰È·ı¤ÛÈÌÔ ÛÙË ¯ÒÚ· Ì·˜ ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ ¤Ó·ÓÙÈ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ A+C. ∂ÓÙÔ‡ÙÔȘ, Ë Â˘Ú›· ·Ô‰Ô¯‹ ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰È¿ÙÚˆÓ, ·ÏÏ¿ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ÙÔ˘ Ó¤Ô˘ Û˘˙¢Á̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤Ó·ÓÙÈ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ C, ÙÔ ÔÔ›Ô Î˘ÎÏÔÊfiÚËÛ ÛÙË ¯ÒÚ· Ì·˜ ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 2001, Ô‰‹ÁËÛ ÛÙËÓ ÔÏÔ¤Ó· ·˘Í·ÓfiÌÂÓË ›ÂÛË ÛÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Ó· ÂÚÈÏËÊı› ÙÔ ÂÌ‚fiÏÈÔ ·˘Ùfi ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ, ·Ú¿ ÙÔ ˘„ËÏfi ÙÔ˘ ÎfiÛÙÔ˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ›وÛ˘ Ù˘ ÊÔÚ›·˜ N. meningitidis Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ∞ı‹Ó·˜, ηıÒ˜ Î·È Ë ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ô˘
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™ÂÏ›‰·190
¶·È‰È·ÙÚÈ΋ 2003;66:188-194
Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÊÔÚ›·. ∂›Û˘, ÂÚÈÁÚ¿ÊÔÓÙ·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ Î·È Û˘˙ËÙÂ›Ù·È Ë Èı·Ó‹ ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì·˜ ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ì·˙ÈÎÒÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÙÔ Û˘Ó‰Â‰Â̤ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙË ¯ÒÚ· Ì·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó Û˘ÓÔÏÈο 580 ·È‰È¿ ËÏÈΛ·˜ 2-19 ÂÙÒÓ, Ù· ÔÔ›· ‹Ù·Ó Ì·ıËÙ¤˜ ·È‰ÈÎÒÓ ÛÙ·ıÌÒÓ, ‰ËÌÔÙÈÎÒÓ Î·È Á˘ÌÓ·Û›ˆÓ Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ΤÓÙÚÔ˘ Ù˘ ∞ı‹Ó·˜. ™ÙÔ˘˜ ÁÔÓ›˜ ÙˆÓ Ì·ıËÙÒÓ ·ÔÛÙ¿ÏıËΠÂÓËÌÂÚˆÙÈÎfi ÛËÌ›ˆÌ·, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ˙ËÙ‹ıËΠ·fi ·˘ÙÔ‡˜ Ó· Û˘ÌÏËÚÒÛÔ˘Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ, ÙÔ ÔÔ›Ô ÂÚÈÂÏ¿Ì‚·Ó ÂÚˆÙ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Û·Ó Û ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·È‰ÈÒÓ, fiˆ˜ ËÏÈΛ·, ʇÏÔ, ÂıÓÈÎfiÙËÙ·, ηıÒ˜ Î·È ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÚÔËÁËı›۷ ÈÔÁÂÓ‹ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÙÔÓ ÚÔËÁÔ‡ÌÂÓÔ Ì‹Ó·, οÓÈÛÌ· Î·È ÌÔÚʈÙÈÎfi Â›Â‰Ô ÙˆÓ ÁÔÓ¤ˆÓ, ‰Â›ÎÙË ‰È·‚›ˆÛ˘ (·ÚÈıÌfi˜ ·ÙfiÌˆÓ ÛÙÔ Û›ÙÈ, ·ÚÈıÌfi˜ ‰ˆÌ·Ù›ˆÓ ÛÈÙÈÔ‡), ÌËÙÚÈÎfi ıËÏ·ÛÌfi Î·È ÂÌ‚ÔÏÈ·ÛÌfi Ì ÔÏ˘Û·Î¯·ÚȉÈÎfi ‹ Û˘Ó‰Â‰Â̤ÓÔ ·ÓÙÈÌËÓÈÁÁÈÙȉÔÎÔÎÎÈÎfi ÂÌ‚fiÏÈÔ. ∂Ï‹ÊıËÛ·Ó Î·ÏÏȤÚÁÂȘ Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜ ·fi ÙÔ˘˜ Ì·ıËÙ¤˜ ÛÙȘ Ù¿ÍÂȘ ÙÔ˘˜, ·fi ÙÔÓ ›‰ÈÔ È·ÙÚfi, ÛÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙÔÓ ¡Ô¤Ì‚ÚÈÔ 2000 ¤ˆ˜ ÙÔÓ ºÂ‚ÚÔ˘¿ÚÈÔ 2001. ∞ÔÌfiÓˆÛË ÌÈÎÚÔ‚›Ô˘: ∆· ‰Â›ÁÌ·Ù· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜, Ù· ÔÔ›· Ï·Ì‚¿ÓÔÓÙ·Ó Ì ‚·Ì‚·ÎÔÊfiÚÔ ÛÙÂÈÏÂfi, ηÏÏÈÂÚÁÔ‡ÓÙ·Ó Û ÛÔÎÔÏ·ÙÔ‡¯Ô ¿Á·Ú ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ‚·ÓÎÔÌ˘Î›ÓË, ÎÔÏÈÌ˘Î›ÓË Î·È ÓÂÔÌ˘Î›ÓË (VCN). ∆· ÙÚ˘‚Ï›· Ô Âˆ¿˙ÔÓÙ·Ó ÛÙÔ˘˜ 35 C Û 5% CO2 ÁÈ· 2 Ë̤Ú˜ Î·È Ë Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÁÈÓfiÙ·Ó Ì ÙȘ Û˘Ó‹ıÂȘ ÌÈÎÚÔ‚ÈÔÏÔÁÈΤ˜ Ù¯ÓÈΤ˜. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ¢·ÈÛıËÛ›·˜ (MIC) ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙËÓ ÂÓÈÎÈÏ›ÓË, ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË, ÚÈÊ·ÌÈΛÓË, ÎÂÊÙÚÈ·ÍfiÓË Î·È ÙÚÈÌÂıÔÚ›ÌË/ ÛÔ˘ÏÊ·ÌÂıÔÍ·˙fiÏË ÁÈÓfiÙ·Ó Ì ÙË Ì¤ıÔ‰Ô ∂-test Û Mueller-Hinton ¿Á·Ú Ì 5% HB. ∆· ÛÙÂϤ¯Ë ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ·ÓıÂÎÙÈο, ÌÂÙÚ›ˆ˜ ¢·›ÛıËÙ· Î·È Â˘·›ÛıËÙ· ÛÙËÓ ÂÓÈÎÈÏ›ÓË, Â¿Ó Ë MIC ‹Ù·Ó ≥1 Ìg/ml, 0,125-0,5 Ìg/ml Î·È <0,125 Ìg/ml, ·ÓÙ›ÛÙÔȯ·. ∞ÓıÂÎÙÈο ÛÙËÓ ÎÔÙÚÈÌÔÍ·˙fiÏË, ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË Î·È ÚÈÊ·ÌÈΛÓË ÔÚ›ÛÙËÎ·Ó Ù· ÛÙÂϤ¯Ë Ì MIC ≥2 Ìg/ml, ≥2 Ìg/ml Î·È ≥4 Ìg/ml, ·ÓÙ›ÛÙÔȯ· (13). ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÔÚÔ-ÔÌ¿‰·˜: ∏ ηٿٷÍË ÙˆÓ ÛÙÂϯÒÓ Û ÔÚÔ-ÔÌ¿‰Â˜ A, B, C, D, Y Î·È W135 ÁÈÓfiÙ·Ó Ì ÌÔÓÔ- ‹ ÔÏ˘ÎψÓÈÎÔ‡˜ ÔÚÔ‡˜ Ì ÙË Ì¤ıÔ‰Ô Ù˘ Û˘ÁÎfiÏÏËÛ˘, Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹ (Biotec Laboratories Ltd, Suffolk, United Kingdom). ™ÙȘ ·ÔÈ˘ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÁÈÓfiÙ·Ó ·Ó·Î·ÏÏȤÚÁÂÈ· Î·È ÌÂÙ¿ Ù· ÛÙÂϤ¯Ë Ê˘Ï¿ÛÛÔÓÙ·Ó ÛÙÔ˘˜ -70ÔC ̤¯ÚÈ Ó· Á›ÓÂÈ Ë ÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË. ∏ÏÂÎÙÚÔÊfiÚËÛË ·ÏÏfiÌÂÓÔ˘ ‰›Ô˘: ∏ ÁÂÓÂÙÈ΋ Û˘ÁÁ¤ÓÂÈ· ÙˆÓ ÛÙÂϯÒÓ ÂÍÂÙ¿ÛÙËΠ̠ËÏÂÎÙÚÔÊfiÚËÛË Û ·ÏÏfiÌÂÓÔ Â‰›Ô ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÌÂÙ¿ ·fi ηٿÙÌËÛË Ì ÙȘ ÂÚÈÔÚÈÛÙÈΤ˜ ÂÓ‰ÔÓÔ˘ÎÏ¿Û˜ NotI Î·È SfiI, fiˆ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÚÔËÁÔ‡ÌÂÓ· (14). ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË: ∏ ÂÂÍÂÚÁ·Û›· ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘
190
Paediatriki 2003;66:188-194
ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ·Î¤ÙÔ STATA. ∏ Û˘Û¯¤ÙÈÛË Î·ıÂÓfi˜ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ͯˆÚÈÛÙ¿ Û ۯ¤ÛË Ì ÙË ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ¤ÁÈÓ Ì ÙÔ ¯2. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Ó· Â›Ó·È Î·Ó›˜ ÊÔÚ¤·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÁÈ· ηı¤Ó· ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ͯˆÚÈÛÙ¿, ˘ÔÏÔÁ›ÛÙËΠ̠ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. OÈ ÌÂÙ·‚ÏËÙ¤˜ ÂΛӘ Ô˘ ÛÙË ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ‚Ú¤ıËΠӷ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ÛÂ Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ 10%, ·Ó·Ï‡ıËÎ·Ó ÂÚ·ÈÙ¤Úˆ Ì ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘.
∞ÔÙÂϤÛÌ·Ù· º·Ú˘ÁÁÈÎfi ›¯ÚÈÛÌ· ÂÏ‹ÊıË ·fi 554 Ì·ıËÙ¤˜ (Û ۇÓÔÏÔ 580 ·È‰ÈÒÓ) ËÏÈΛ·˜ 2-19 ÂÙÒÓ (̤ÛË ËÏÈΛ·: 10 ¤ÙË, SD: ±4 ¤ÙË), ÔÈ ÔÔ›ÔÈ Â¤ÛÙÚ„·Ó Û˘ÌÏËڈ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ (ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜: 95,5%). ¶ÔÛÔÛÙfi 3,97% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Ì·ıËÙÒÓ (22/554) ‚Ú¤ıËΠӷ Â›Ó·È ÊÔÚ¤·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘. ∞fi Ù· 349 ·È‰È¿ ËÏÈΛ·˜ <12 ÂÙÒÓ, ÌfiÓÔ 3 ‚Ú¤ıËÎ·Ó Ó· Â›Ó·È ÊÔÚ›˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ (0,86%). ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ, ÙÔ ÔÛÔÛÙfi Ù˘ ÊÔÚ›·˜ ·˘Í‹ıËΠÛËÌ·ÓÙÈο Û 9,27% (19/205, p<0,0001). ∆· ÔÛÔÛÙ¿ ÊÔÚ›·˜ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ʇϷ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο (13/272 ·ÁfiÚÈ· Î·È 9/282 ÎÔÚ›ÙÛÈ· ÊÔÚ›˜) (¶›Ó·Î·˜ 1). ∏ ÚÔËÁËı›۷ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Ë ÚfiÛÊ·ÙË Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÒÓ ‚Ú¤ıËÎ·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È ·ÓÙ›ÛÙÚÔÊ· Ì ÙË ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ (p=0,004 Î·È p=0,06, ·ÓÙ›ÛÙÔȯ·). ∆· ·È‰È¿ Ì ·˘ÍË̤ÓÔ ‰Â›ÎÙË ‰È·‚›ˆÛ˘ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· Â›Ó·È ÊÔÚ›˜ (p=0,064). ∏ ÊÔÚ›· N. meningitidis ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ·ıËÙÈÎfi οÓÈÛÌ·, ÙËÓ ÂıÓÈÎfiÙËÙ·, ÙÔ ıËÏ·ÛÌfi ‹ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ì ÔÏ˘Û·Î¯·ÚȉÈÎfi A+C ‹ ÌÂ Û˘Ó‰Â‰Â̤ÓÔ C ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘. ∆Ô ÔÛÔÛÙfi ÊÔÚ›·˜ ‚Ú¤ıËΠ¯·ÌËÏfiÙÂÚÔ Û ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÁÔÓ›˜ ›¯·Ó ·ÓÂÈÛÙËÌȷ΋ ÌfiÚʈÛË, Û˘ÁÎÚÈÙÈο Ì ٷ ·È‰È¿ ÂÎÂ›ÓˆÓ Ô˘ ‰ÂÓ Â›¯·Ó (p=0,049). O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (OR), ηıÂÓfi˜ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ͯˆÚÈÛÙ¿, Ù˘ Èı·ÓfiÙËÙ·˜ ¶›Ó·Î·˜ 1. ºÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ Î·È ÙËÓ ÂıÓÈÎfiÙËÙ· ªÂÙ·‚ÏËÙ‹
ºÔÚ›· (¡·È/fi¯È)
%
p
3/346 19/186
0,89 9,2
<0,0001
∏ÏÈΛ· ≤12¤ÙË >12¤ÙË º‡ÏÔ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ· ∂ıÓÈÎfiÙËÙ· ŒÏÏËÓ·˜ ∞ÏÏÔ‰·fi˜
13/259 9/273
4,7 3,1
0,339
20/491 2/41
3,9 4,6
0,812
™‡ÓÔÏÔ
22/532
3,97
May-June 03
03-06-03
16:55
™ÂÏ›‰·191
¶·È‰È·ÙÚÈ΋ 2003;66:188-194
Paediatriki 2003;66:188-194
Ó· Â›Ó·È ¤Ó· ·È‰› ÊÔÚ¤·˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ™ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË, ÌfiÓÔ Ë ËÏÈΛ· ·Ú¤ÌÂÈÓ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘. ŒÙÛÈ, Ë ËÏÈΛ· ¿Óˆ ÙˆÓ 12 ÂÙÒÓ ‚Ú¤ıËΠӷ ·˘Í¿ÓÂÈ, ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ 8 ÊÔÚ¤˜, ÙËÓ Èı·ÓfiÙËÙ· Ó· Â›Ó·È ¤Ó· ·È‰› ÊÔÚ¤·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, Û˘ÁÎÚÈÙÈο Ì ¤Ó· ·È‰› ËÏÈΛ·˜ <12 ÂÙÒÓ (¶›Ó·Î·˜ 3). ŸÏ· Ù· ÛÙÂϤ¯Ë ‚Ú¤ıËÎ·Ó Â˘·›ÛıËÙ· ÛÙËÓ ÎÂÊÙÚÈ·ÍfiÓË, ÙË ÚÈÊ·ÌÈΛÓË Î·È ÙË ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË. ªfiÓÔ 1 Û٤ϯԘ ‚Ú¤ıËΠ·ÓıÂÎÙÈÎfi ÛÙËÓ ÎÔÙÚÈÌÔÍ·˙fiÏË (4,5%) Î·È 5 ̤ÙÚÈ· ¢·›ÛıËÙ· ÛÙËÓ ÂÓÈÎÈÏ›ÓË (22,7%). ∞fi Ù· ·ÔÌÔÓˆı¤ÓÙ· ÛÙÂϤ¯Ë, 1 ·Ó‹Î ÛÙËÓ ÔÚÔ-ÔÌ¿‰· ∞ (4,5%), 5 ÛÙËÓ ÔÚÔ-ÔÌ¿‰· µ (22,7%), 7 ÛÙËÓ ÔÚÔ-ÔÌ¿‰· C (31,8%), 1 ÛÙËÓ ÔÚÔ-ÔÌ¿‰· D (4,5%) Î·È 3 ÛÙËÓ ÔÚÔ-ÔÌ¿‰· W135 (13,7%). ¶¤ÓÙ ÛÙÂϤ¯Ë (22,7%) ‹Ù·Ó ÌË Ù˘ÔÔÈ‹ÛÈÌ·. ∏ ÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË 16 ÛÙÂϯÒÓ Ì ËÏÂÎÙÚÔÊfiÚËÛË ·ÏÏfiÌÂÓÔ˘ ‰›Ô˘ ·ÔÎ¿Ï˘„ 6 ‰È·ÊÔÚÂÙÈΤ˜ ÂÈÎfiÓ˜ ËÏÂÎÙÚÔÊfiÚËÛ˘. OÎÙÒ ·fi Ù· ÛÙÂϤ¯Ë ›¯·Ó fiÌÔÈ· ÂÈÎfiÓ· Î·È Î·Ù·Ù¿¯ÙËÎ·Ó ÛÙËÓ ÔÌ¿‰· a, 2 ÛÙÂϤ¯Ë ÛÙËÓ ÔÌ¿‰· b, 2 ÛÙÂϤ¯Ë ÛÙËÓ ÔÌ¿‰· c Î·È 2 ÛÙÂϤ¯Ë ÛÙËÓ ÔÌ¿‰· d. ∆· ˘fiÏÔÈ· 2 ÛÙÂϤ¯Ë ›¯·Ó ÙÔ Î·ı¤Ó· ‰È·ÊÔÚÂÙÈΤ˜ ËÏÂÎÙÚÔÊÔÚËÙÈΤ˜ ÂÈÎfiÓ˜ Ô˘ ‰ÂÓ ¤ÌÔÈ·˙·Ó Ô‡Ù ÌÂٷ͇ ÙÔ˘˜, Ô‡Ù Ì η̛· ·fi ÙȘ ÚÔËÁÔ‡ÌÂÓ˜. ∆¤ÛÛÂÚ· ·fi Ù· ÛÙÂϤ¯Ë ‰ÂÓ ‹Ù·Ó ˙ˆÓÙ·Ó¿ ÙË ÛÙÈÁÌ‹ Ù˘ ÁÂÓÂÙÈ΋˜ ·Ó¿Ï˘Û˘ Î·È 2 ‰ÂÓ ¤‰ˆÛ·Ó η̛· ËÏÂÎÙÚÔÊÔÚËÙÈ΋ ÂÈÎfiÓ· (¶›Ó·Î·˜ 4). ∆· ÛÙÂϤ¯Ë ÙˆÓ ÊÔÚ¤ˆÓ Û˘ÁÎÚ›ıËÎ·Ó Ì 4 ÛÙÂϤ¯Ë ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ (2 ·Ó‹Î·Ó ÛÙË ÔÚÔ-ÔÌ¿‰· µ Î·È 2 ÛÙËÓ ÔÚÔ-ÔÌ¿‰· C), Ù˘¯·›· ÂÈÏÂÁ̤ӷ, Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ·È‰ÈÒÓ Ì ÌËÓÈÁÁ›Ùȉ·, Ù· ÔÔ›· ÓÔÛËχıËÎ·Ó ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÓÔÛÔÎÔÌÂ›Ô Î·Ù¿ ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· ÛÙÂϤ¯Ë ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ó‹Î·Ó ÛÙȘ ÔÚÔ-ÔÌ¿‰Â˜ B Î·È C, ›¯·Ó Ù· ›‰È· ‰·ÎÙ˘ÏÈο ·ÔÙ˘ÒÌ·Ù· Ì ٷ ÛÙÂϤ¯Ë ÙˆÓ
ÊÔÚ¤ˆÓ Ô˘ ·Ó‹Î·Ó ÛÙȘ ÔÌ¿‰Â˜ ËÏÂÎÙÚÔÊfiÚËÛ˘ a Î·È b, ·ÓÙ›ÛÙÔȯ· (∂ÈÎfiÓ· 1). ™˘˙‹ÙËÛË ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·Ú¤¯Ô˘Ó ÏËÚÔÊÔڛ˜ ÁÈ· ÙË ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, ηıÒ˜ Î·È ÁÈ· Ù· ÁÔÓÔÙ˘Èο Î·È Ê·ÈÓÔÙ˘Èο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÛÙÂϯÒÓ Neisseria meningitidis ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÈÔ¯‹. O ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÊÔÚ¤ˆÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Î·È ÙÔ Û¯ÂÙÈο ÌÈÎÚfi ̤ÁÂıÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ÌÂÏÂÙ‹ıËÎÂ, ÂÚÈÔÚ›˙Ô˘Ó ÙË ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÛÙË ¯¿Ú·ÍË ÛÙÚ·ÙËÁÈ΋˜ ∂ıÓÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∂Ì‚ÔÏÈ·ÛÌÔ‡. ¶·Ú’ fiÏ· ·˘Ù¿, ·Ó Û˘Ó‰˘·ÛÙÔ‡Ó ÌÂ Â˘Ú‹Ì·Ù· ·fi ¿ÏϘ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜, ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈÌ· ÛÙË Ï‹„Ë ·fiÊ·Û˘ Û¯ÂÙÈο Ì ÙÔ Ì·˙ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi ÔÚÈÛÌ¤ÓˆÓ Â˘·ıÒÓ ÔÌ¿‰ˆÓ ÏËı˘ÛÌÔ‡ Ì ÙÔ Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ÙÔ ÔÔ›Ô Î˘ÎÏÔÊÔÚ› ÛÙËÓ ∂ÏÏ¿‰· Â‰Ò Î·È ¤Ó· ¯ÚfiÓÔ. O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ÔÛÔÛÙÔ‡ Ù˘ ÊÔÚ›·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Û ‰È·ÊÔÚÂÙÈΤ˜ ÔÌ¿‰Â˜ ÏËı˘ÛÌÔ‡ Û ̛· ‰Â‰Ô̤ÓË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Â›Ó·È ‰‡ÛÎÔÏÔ˜, ‰ÈfiÙÈ ÌÔÚ› Ó· ÂËÚ·ÛÙ› ·fi ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ¿ÙÔÌÔ, ÙÔ ‚·ÎÙËÚ›‰ÈÔ Î·È ÙËÓ Ù¯ÓÈ΋ Ù˘ ‰ÂÈÁÌ·ÙÔÏË„›·˜. ∏ ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÛÙȘ ∏.¶.∞ Î·È ÛÙȘ ÌË ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜ ·Ó·Ê¤ÚÂÙ·È ÌÂٷ͇ 5-10% (14). ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, ÙÔ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÊÔÚ›·˜ (5-15%) ‚Ú›ÛÎÂÙ·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ, ÂÓÒ ÙÔ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·Ú·ÙËÚÂ›Ù·È ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ (50/100.000) Î·È ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ· (5/100.000) (3). ∞fi ÙÔ˘˜ 554 Ì·ıËÙ¤˜ Ô˘ ÙÂÏÈο ¤Ï·‚·Ó ̤ÚÔ˜ ÛÙË ÌÂϤÙË Ì·˜, ÙÔ 3,97% ‚Ú¤ıËΠӷ Â›Ó·È ÊÔÚ¤·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘,
¶›Ó·Î·˜ 2. ºÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘: ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ªÂÙ·‚ÏËÙ‹
ºÔÚ›· ¡·È Ÿ¯È
™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜)
∏ÏÈΛ· >12 ¤ÙË ∞ÏÏÔ‰·fi˜ ¶ÚÔËÁËı›۷ Ïԛ̈ÍË §‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ¢Â›ÎÙ˘ Û˘ÁηÙÔ›ÎËÛ˘ >1 ∫¿ÓÈÛÌ· (¤Ó·˜ ÁÔÓ¤·˜) ∫¿ÓÈÛÌ· (Î·È ÔÈ ‰‡Ô ÁÔÓ›˜) ªfiÚʈÛË ¶·Ó/ÌÈÔ (¤Ó·˜ ÁÔÓ¤·˜) ¶·Ó/ÌÈÔ (Î·È ÔÈ ‰‡Ô ÁÔÓ›˜) £ËÏ·ÛÌfi˜ ≥3 Ì‹Ó˜ <3 Ì‹Ó˜ ∂Ì‚ÔÏÈ·ÛÌfi˜
19 2 4 1 15 11 7
186 41 263 112 248 190 166
4 2
131 150
0,48 (0,16-1,46) 0,21 (0,47-0,92)
0,196 0,039
10 7 3
184 244 42
1,13 (0,37-3,39) 0,60 (0,19-1,92) 1,84 (0,52-6,48)
0,827 0,387 0,341
11,78 1,20 0,23 0,18 2,45 2,55 1,86
(3,44-40,32) (0,27-5,30) (0,08-0,68) (0,24-1,34) (0,98-6,12) (0,80-8,15) (0,53-6,45)
p <0,0001 0,812 0,008 0,094 0,054 0,115 0,331
191
May-June 03
03-06-03
16:55
™ÂÏ›‰·192
¶·È‰È·ÙÚÈ΋ 2003;66:188-194
Paediatriki 2003;66:188-194
¶›Ó·Î·˜ 3. ºÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜: ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ªÂÙ·‚ÏËÙ‹
¢ÈÔÚıˆÌ¤ÓÔ˜ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜
95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜
p
7,96 0,45 0,46 1,29
2,24-28,33 0,13-1,58 0,049-4,38 0,48-3,46
0,001 0,214 0,500 0,614
0,68 0,42
0,21-2,23 0,09-1,98
0,528 0,275
∏ÏÈΛ· >12 ¤ÙË ¶ÚÔËÁËı›۷ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË ¶ÚfiÛÊ·ÙË Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ¢Â›ÎÙ˘ Û˘ÁηÙÔ›ÎËÛ˘ >1 ªfiÚʈÛË ÁÔÓ¤ˆÓ ¶·ÓÂÈÛÙ‹ÌÈÔ (¤Ó·˜ ÁÔÓ¤·˜) ¶·ÓÂÈÛÙ‹ÌÈÔ (Î·È ÔÈ ‰‡Ô ÁÔÓ›˜)
¶›Ó·Î·˜ 4. OÚÔ-ÔÌ¿‰Â˜ Î·È ÂÈÎfiÓ˜ ËÏÂÎÙÚÔÊfiÚËÛ˘ ÙˆÓ ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ∞/· ÛÙÂϤ¯Ô˘˜
OÌ¿‰· ËÏÂÎÙÚÔÊfiÚËÛ˘
OÚÔ -ÔÌ¿‰·
™¯ÔÏÂ›Ô (Ù¿ÍË)
1 5 17 18 19 11 21 22
a a a a a a a a
NG C C B C NG C B
9 10
b b
D C
™3 (∆7) ™3 (∆7)
6 20
c c
NG W135
™3 (∆8) ™3 (c8)
4 8
d d
W135 A
™3 (∆9) ™3 (∆10)
2 3
DP DP
B W135
™2 (∆1) ™3 (∆11)
13 14 15 16
ND ND ND ND
NG C B B
™3 (∆12) ™3 (∆9) ™3 (∆13) ™3 (∆4)
7 12
ND ND
C NG
™3 (∆10) ™2 (∆1)
™2 ™3 ™3 ™3 ™3 ™3 ™3 ™3
(∆1) (∆2) (∆3) (∆2) (∆4) (∆3) (∆5) (∆6)
NG: ÌË ÔÌ·‰ÔÔÈÔ‡ÌÂÓÔ DP: ͯˆÚÈÛÙ‹ ËÏÂÎÙÚÔÊÔÚËÙÈ΋ ÂÈÎfiÓ· ND: ‰ÂÓ ¤ÁÈÓÂ
ÔÛÔÛÙfi ÂÏ·ÊÚ¿ ¯·ÌËÏfiÙÂÚÔ ·fi ÂΛÓÔ Ô˘ ›¯Â ·Ó·ÊÂÚı› Û ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ∂ÏÏ¿‰· (11). ¶·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ËÏÈΛ·, Ô ˘„ËÏfi˜ ‰Â›ÎÙ˘ Û˘ÁηÙÔ›ÎËÛ˘, ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô ÙˆÓ ÁÔÓ¤ˆÓ Î·È Ë ÚÔËÁÔ‡ÌÂÓË ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÊÔÚ›· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Î·È ÛÙËÓ ∂ÏÏ¿‰·, fiˆ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ·fi ÙË µfiÚÂÈ· ∂˘ÚÒË (14,15). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Ë ÚÔËÁËı›۷ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È ·ÓÙ›ÛÙÚÔÊ· Ì ÙË ÊÔÚ›·, ÂÓÒ Ë Û˘Û¯¤ÙÈÛË Ì ÙÔ ·ıËÙÈÎfi οÓÈÛÌ· ‰ÂÓ ÂȂ‚·ÈÒıËÎÂ,
192
fiˆ˜ Û ¿ÏϘ ÌÂϤÙ˜ (11). O ÚÔËÁËı›˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÔÏ˘Û·Î¯·ÚȉÈÎfi A+C ‹ Û˘Ó‰˘·Ṳ̂ÓÔ C ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ‰ÂÓ Ê¿ÓËΠӷ ÂËÚ¿˙ÂÈ ÙË ÊÔÚ›·. ∞Í›˙ÂÈ, fï˜, Ó· ÛËÌÂȈı› fiÙÈ ÙÔ Û˘ÓÔÏÈÎfi ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‹Ù·Ó ¯·ÌËÏfi (8,1%). O ÌfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ·Ú¤ÌÂÈÓ ӷ Û¯ÂÙ›˙ÂÙ·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ì ÙË ÊÔÚ›· Î·È ÛÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË, ‹Ù·Ó Ë ËÏÈΛ· ¿Óˆ ÙˆÓ 12 ÂÙÒÓ. O ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÛÙÂϯÒÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ô˘ ÂÍÂÙ¿ÛÙËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙËÓ ÂÍ·ÁˆÁ‹ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏ›ÓË ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÈÔ¯‹. ∆Ô ÔÛÔÛÙfi ÙˆÓ ÛÙÂϯÒÓ Ù˘ ÌÂϤÙ˘ Ô˘ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ÂӉȿÌÂÛË ·ÓÙÔ¯‹ ÛÙËÓ ÂÓÈÎÈÏ›ÓË (22,7%) ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÂΛÓÔ Ô˘ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙËÓ ›‰È· ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ (∆. ∆˙·Ó·Î¿ÎË, ∂ıÓÈÎfi ∫¤ÓÙÚÔ ∞Ó·ÊÔÚ¿˜ ªËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›·). ∆Ô ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·ÓÙÔ¯‹˜ ÛÙËÓ ÂÓÈÎÈÏ›ÓË ÙˆÓ ÛÙÂϯÒÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Èı·ÓfiÓ Ó· ·ÔÙÂÏ› ˘ÂÚÂÎÙ›ÌËÛË Î·È Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ 3 ·fi Ù· 5 ÛÙÂϤ¯Ë Ì ÂӉȿÌÂÛË ·ÓÙÔ¯‹ ›¯·Ó Ù·˘ÙfiÛËÌË ËÏÂÎÙÚÔÊÔÚËÙÈ΋ ÂÈÎfiÓ· Î·È ·ÔÌÔÓÒıËÎ·Ó ·fi Ì·ıËÙ¤˜ ÙÔ˘ ›‰ÈÔ˘ Û¯ÔÏ›Ԣ, ÁÂÁÔÓfi˜ Ô˘ Èı·ÓÔÏÔÁ› ‰È·ÛÔÚ¿ ÙÔ˘ ›‰ÈÔ˘ ·ÓıÂÎÙÈÎÔ‡ ÎÏÒÓÔ˘ ·fi ·È‰› Û ·È‰›. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ÛÙÂϯÒÓ Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·Ó‹Î ÛÙËÓ ÔÚÔ-ÔÌ¿‰· C (31,8%) Î·È B (22,7%). ∏ ÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ·ÏÏfiÌÂÓÔ Â‰›Ô ¤‰ÂÈÍ ÔÈÎÈÏÔÌÔÚÊ›· ÌÂٷ͇ ÙˆÓ ÛÙÂϯÒÓ, ·Ú’ fiÏÔ Ô˘ ·Ú·ÙËÚ‹ıËÎÂ Û˘ÁΤÓÙÚˆÛË ÛÙÂϯÒÓ Ì ٷ˘ÙfiÛËÌË ÂÈÎfiÓ· ËÏÂÎÙÚÔÊfiÚËÛ˘ Û ¤Ó· ·fi Ù· Û¯ÔÏ›·. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÛÙÔÓ ›‰ÈÔ ÎÏÒÓÔ ·Ú·ÙËÚ‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ÔÚÔ-ÔÌ¿‰Â˜, ÁÂÁÔÓfi˜ Ô˘ Èı·ÓfiÓ ˘Ô‰ËÏÒÓÂÈ ÌÂÙ·ÙÚÔ¤˜ ÛÙ· ˘Â‡ı˘Ó· ÁÈ· ÙȘ ÔÚÔ-ÔÌ¿‰Â˜ ÁÔÓ›‰È·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ 3 ·fi ÙÔ˘˜ ÊÔÚ›˜ ‹Ù·Ó ÂÌ‚ÔÏÈ·Ṳ̂ÓÔÈ Ì ÂÌ‚fiÏÈÔ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘. ™Â 2 ·fi Ù· 3 ÛÙÂϤ¯Ë ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ (ÛÙÂϤ¯Ë 9 Î·È 22) (¶›Ó·Î·˜ 4), Ë ÌÂÙ·ÙÚÔ‹ ÙˆÓ ÁÔÓȉ›ˆÓ Â›Ó·È Èı·Ófi Ó· ¤ÁÈÓ ηÙfiÈÓ ›ÂÛ˘ ÂÈÏÔÁ‹˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi. ∏ ÌÂÙ·ÙÚÔ‹ ÙˆÓ
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727.5 679,0 630,5 585,0 533,5 485,0 436,5 388,0 339,5 291,0 242,5 194,0 145,5 97,0 48,5 ∂ÈÎfiÓ· 1. ∏ÏÂÎÙÚÔÊfiÚËÛË Û ·ÏÏfiÌÂÓÔ Â‰›Ô (PFGE) ÌÂÙ¿ ·fi ηٿÙÌËÛË Ì ÙËÓ ÂÚÈÔÚÈÛÙÈ΋ ÂÓ‰ÔÓÔ˘ÎÏ¿ÛË Sfi I ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ 9 ÛÙÂϯÒÓ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘. Ï, lambda ladder, ÛًϘ 1,2,3,5 Î·È 6: ·ÓÙÈÚÔÛˆÂ˘ÙÈο ÛÙÂϤ¯Ë ·fi ÊÔÚ›˜ Ì ÂÈÎfiÓ· ËÏÂÎÙÚÔÊfiÚËÛ˘ Ô˘ ·Ó‹ÎÂÈ ÛÙȘ ÔÌ¿‰Â˜ c, d, b, c Î·È a, ·ÓÙ›ÛÙÔȯ· (¶›Ó·Î·˜ 4). ™Ù‹Ï˜ 4, 7, 8 Î·È 9: Ù˘¯·›· ÂÈÏÂÁ̤ӷ ÛÙÂϤ¯Ë ·ÛıÂÓÒÓ Ì ÌËÓÈÁÁ›Ùȉ·, ηٿ ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô. ¡· ÛËÌÂȈı› fiÙÈ Ù· ÛÙÂϤ¯Ë ÙˆÓ ·È‰ÈÒÓ Ì ÌËÓÈÁÁ›Ùȉ· Î·È ÙˆÓ ÊÔÚ¤ˆÓ ¤¯Ô˘Ó Ù·˘ÙfiÛËÌÔ ‰·ÎÙ˘ÏÈÎfi ·ÔÙ‡ˆÌ· (ÛًϘ 3, 4, 9 Î·È ÛًϘ 6, 7, 8). ∆· ÛÙÂϤ¯Ë ·fi ÙȘ ÛًϘ 3, 4 Î·È 9 ·Ó‹ÎÔ˘Ó ÛÙËÓ ÔÚÔ-ÔÌ¿‰· C, ÂÓÒ Ù· ÛÙÂϤ¯Ë ·fi ÙȘ ÛًϘ 6, 7 Î·È 8 ·Ó‹ÎÔ˘Ó ÛÙËÓ ÔÚÔ-ÔÌ¿‰· B.
˘Â‡ı˘ÓˆÓ ÁÈ· ÙȘ ÔÚÔ-ÔÌ¿‰Â˜ ÁÔÓȉ›ˆÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È ÛÙÔ ·ÚÂÏıfiÓ, ·Ú’ fiÏÔ Ô˘ Ë ÎÏÈÓÈ΋ ÛËÌ·Û›· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡ ‰ÂÓ Â›Ó·È ·Ôχو˜ ÁÓˆÛÙ‹ (16). ∂›Ó·È ¿ÓÙˆ˜ Èı·Ófi, Ì ÙËÓ ·˘ÍË̤ÓË ·ÓÔÛ›· Ù˘ ÎÔÈÓfiÙËÙ·˜ Ô˘ ı· ÂÈÙ‡¯ÂÈ Ô Ì·˙ÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜, Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ·ÚfiÌÔÈÔÈ Ì˯·ÓÈÛÌÔ› ‰È·Ê˘Á‹˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÈÏÔÁ‹ ÛÙÂϯÒÓ Ô˘ ı· ·ÔÈΛÛÔ˘Ó Î·È ÌÔÚ› Ó· ÚÔÎÏËıÔ‡Ó ÂȉË̛˜ ·fi ÔÚfiÙ˘Ô˘˜ Ô˘ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· ˘¿Ú¯ÔÓÙ· ÂÌ‚fiÏÈ·. ∂ÈϤÔÓ, ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÚÔ·ÙÂÈ fiÙÈ ÔÈ ÔÚÔ-ÔÌ¿‰Â˜ Ô˘ Û˘¯ÓfiÙÂÚ· ·ÔÈΛ˙Ô˘Ó ÙÔ Ê¿Ú˘ÁÁ· Â›Ó·È ›‰È˜ Ì ÙȘ ÔÚÔ-ÔÌ¿‰Â˜ Ô˘ ÚÔηÏÔ‡Ó ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋ ÓfiÛÔ ÛÙËÓ ∂ÏÏ¿‰· (9,10). ∂ÈÚfiÛıÂÙ·, Ù· ÛÙÂϤ¯Ë ÙˆÓ ·ÛıÂÓÒÓ ‚Ú¤ıËÎ·Ó ÁÂÓÂÙÈο Ù·˘ÙfiÛËÌ· Ì ÛÙÂϤ¯Ë ÊÔÚ¤ˆÓ. ŒÙÛÈ, ÂÊfiÛÔÓ Ë Î‡ÚÈ· ËÁ‹ ÌÂÙ¿‰ÔÛ˘ ·ıÔÁfiÓˆÓ ÛÙÂϯÒÓ Â›Ó·È ÔÈ ·Û˘Ìو̷ÙÈÎÔ› ÊÔÚ›˜, Ì ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ÊÔÚ›·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘, ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ¯ÔÚ‹ÁËÛË ¯ËÌÂÈÔÚÔʇϷ͢ ÁÈ· ÙËÓ ÂÍ¿ÏÂÈ„Ë Ù˘ ÊÔÚ›·˜ ‰ÂÓ ·ÔÙÂÏ› ¿ÓÙ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÙÚfiÔ ÚfiÏË-
„˘ Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘. Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ù· Û˘Ó‰Â‰Â̤ӷ ÂÌ‚fiÏÈ· ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔ˘˜ ‚ÏÂÓÓÔÁfiÓÔ˘˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ÊÔÚ›·˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÌ¿‰·˜ C (16,17). ∂¿Ó ÏËÊı› ˘’ fi„ÈÓ fiÙÈ Ë ÔÚÔÔÌ¿‰· C ·ÓÙÈÚÔۈ‡ÂÈ ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙfiÛÔ Ù˘ ÊÔÚ›·˜, fiÛÔ Î·È Ù˘ ÓfiÛÔ˘, Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ·Ó·Ì¤ÓÂÙ·È Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙËÓ Â›ÙˆÛË Ù˘ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ÛÙËÓ ∂ÏÏ¿‰·. ∏ ·Ô˘Û›· ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÁÈ· fiϘ ÙȘ ÔÌ¿‰Â˜ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÂÈ‚¿ÏÏÂÈ ÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË Ù˘ ‰˘Ó·ÌÈ΋˜ Ù˘ ÊÔÚ›·˜, ·ÏÏ¿ Î·È Ù˘ ÓfiÛÔ˘, Ì ÛÎÔfi ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ÚfiÏË„Ë. ∂ÈϤÔÓ, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ˘¿Ú¯ÂÈ Û˘Ó¯‹˜ ÂȉËÌÈÔÏÔÁÈ΋ ÂÈÙ‹ÚËÛË ÙˆÓ ÌËÓÈÁÁÈÙȉÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·È ÛÙËÓ ∂ÏÏ¿‰·, Ì ÛÎÔfi ÙË ‰È·ÌfiÚʈÛË ÛÙÚ·ÙËÁÈ΋˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ٷ ‹‰Ë ˘¿Ú¯ÔÓÙ· ÂÌ‚fiÏÈ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Caugant DA, Hoiby EA, Rosenqvist E, Froholm LO, Selander RK. Transmission of Neisseria meningitidis among asymptomatic military recruits and antibody analysis. Epidemiol Infect 1992;109:241-253. 2. Stephens DS. Uncloaking the meningococcus: dynamics of carriage and disease. Lancet 1999;353:941-943. 3. Cartwright K. Meningococcal carriage and disease. In: Cartwright K, editor. Meningococcal disease. 1st edition. Chichester, UK: John Wiley and Sons; 1995. p. 114-146. 4. Stuart JM, Cartwright KA, Robinson PM, Noah ND. Effect of smoking on meningococcal carriage. Lancet 1989;2:723725. 5. Caugant DA, Hoiby EA, Magnus P, Scheel O, Hoel T, Bjune G et al. Asymptomatic carriage of Neisseria meningitidis in a randomly sampled population. J Clin Microbiol 1994;32:323-330. 6. Apicella MA. Neisseria meningitidis. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 5th edition. London: Churchill Livingstone; 2000. p. 2228-2241. 7. Tsolia M, Theodoridou M, Tzanakaki G, Kalabalikis P, Vrani E, Mostrou G et al. A population-based multicenter study of invasive meningococcal disease in children in the area of Athens. The 18th Annual Meeting of the European Society for Paediatric Infectious Diseases; 2000 May 3-5; Noordwijk, The Netherlands: 2000. abstr. 0-6. 8. Theodoridou M, Pavlopoulou ID, Stamatiadis D, Mostrou G, Pangalis A, Papaevangelou V et al. Acute bacterial meningitis in Greek children: a 15-year overview. The 18th Annual Meeting of the European Society for Paediatric Infectious Diseases; 2000 May 3-5; Noordwijk, The Netherlands: 2000. abstr. 55. 9. ∂ȉËÌÈÔÏÔÁÈÎfi ¢ÂÏÙ›Ô §ÔÈ̈‰ÒÓ ¡ÔÛËÌ¿ÙˆÓ ∂ÏÏ¿‰Ô˜. ªËÓÈ·›· ŒÎ‰ÔÛË ÙÔ˘ ∂ıÓÈÎÔ‡ ∫¤ÓÙÚÔ˘ ∂ȉËÌÈÔÏÔÁÈ΋˜ ¶·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ¶·Ú¤Ì‚·Û˘ (∂∫∂¶∞¶) ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ ¶ÚfiÓÔÈ·˜ 1999;2:81-82.
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10. Kremastinou J, Tzanakaki G, Kansouzidou A, Pagalis A, Danielides V, Kouppari G et al. Recent emergence of serogroup C meningococcal disease in Greece. FEMS Immunol Med Microbiol 1999;23:49-55. 11. Kremastinou J, Blackwell C, Tzanakaki G, Kallergi C, Elton R, Weir D. Parental smoking and carriage of Neisseria meningitidis among Greek schoolchildren. Scand J Infect Dis 1994;26:719-723. 12. Kremastinou J, Tzanakaki G, Velonakis E, Voyiatzi A, Nickolaou A, Elton RA et al. Carriage of Neisseria meningitides and Neisseria lactamica among ethnic Greek schoolchildren from Russian immigrant families in Athens. FEMS Immunol Med Microbiol 1999;23:13-20. 13. Breakpoints in in-vitro antibiotic sensitivity testing. Report by a working party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 1988;21:701-710. 14. Broome CV. The carrier state: Neisseria meningitidis. J Antimicrob Chemother 1986;18 (Suppl A):S25-S34.
15. Fitzpatrick PE, Salmon RL, Hunter PR, Roberts RJ, Palmer SR. Risk factors for carriage of Neisseria meningitidis during an outbreak in Wales. Emerg Infect Dis 2000;6:65-69. 16. Ala’Aldeen DA, Neal KR, Ait-Tahar K, Nguyen-Van-Tam JS, English A, Falla TJ et al. Dynamics of meningococcal longterm carriage among university students and their implications for mass vaccination. J Clin Microbiol 2000;38:2311-2316. 17. Zhang Q, Choo S, Everard J, Jennings R, Finn A. Mucosal immune responses to meningococcal group C conjugate and group A and C polysaccharide vaccines in adolescents. Infect Immun 2000;68:2692-2697. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-08-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 17-02-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆ¿ÓÓ· ¶·˘ÏÔÔ‡ÏÔ˘ ºÂȉ›Ô˘ 25, ∆.∫. 155 62, ÃÔÏ·ÚÁfi˜, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∞ÓÙÈ‚ÈÔÙÈο ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ÛÙ· ·È‰È¿1 ™ÎÔfi˜: ∏ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· Â›Ó·È Ì›· ·fi ÙȘ ÈÔ ÎÔÈÓ¤˜ ÓfiÛÔ˘˜ Ù˘ ‚ÚÂÊÈ΋˜ Î·È ·È‰È΋˜ ËÏÈΛ·˜. ∏ ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ÔÈΛÏÏÂÈ ·fi 31% ÛÙËÓ OÏÏ·Ó‰›· ¤ˆ˜ 98% ÛÙȘ ∏¶∞ Î·È ÙËÓ ∞˘ÛÙÚ·Ï›·. O ÛÎÔfi˜ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ë ·ÔÙ›ÌËÛË ÙˆÓ Û˘ÓÂÂÈÒÓ Ù˘ ¯Ú‹Û˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙ· ·È‰È¿ Ì ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∂ÍÂÙ¿ÛÙËÎ·Ó ÂÓ‰ÂϯҘ ÙÔ Cochrane Controlled Trials Register, ÙÔ Medline, ÙÔ Index Medicus (ÚÔ ÙÔ˘ 1965) Î·È ÔÈ Î·Ù¿ÏÔÁÔÈ ÙˆÓ ·Ó·ÊÔÚÒÓ ÙˆÓ ¿ÚıÚˆÓ ·fi ÙÔ 1958 ¤ˆ˜ ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 2000. ∫ÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ·ÔÙ¤ÏÂÛ·Ó Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ·È‰ÈÒÓ Ì ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, ÛÙȘ Ôԛ˜ Û˘ÁÎÚ›ıËÎ·Ó ·ÓÙÈÌÈÎÚԂȷο Ê¿Ú̷η Ì placebo. ∞fi ÙÚÂȘ ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÎÚÈÙ¤˜, ÂÎÙÈÌ‹ıËÎÂ Ë ÔÈfiÙËÙ· ÙˆÓ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌÒÓ Î·È ÂÍ‹¯ıËÛ·Ó ÏËÚÔÊÔڛ˜. ∞ÔÙÂϤÛÌ·Ù·: ¢¤Î· ÌÂϤÙ˜ ‹Ù·Ó ηٿÏÏËϘ, ·ÏÏ¿ ÌfiÓÔ ÂÙ¿ ÌÂϤÙ˜ ÌÂ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi 2202 ·È‰ÈÒÓ, ÂÚÈ›¯·Ó ÛËÌ›· ¤Î‚·Û˘ Ô˘ ·Ó·Ê¤ÚÔÓÙ·Ó ÛÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹. ∏ ÔÈfiÙËÙ· Ù˘ ÌÂıÔ‰ÔÏÔÁ›·˜ ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ‹Ù·Ó ÁÂÓÈο ˘„ËÏ‹. ŸÏ˜ ÔÈ ÌÂϤÙ˜ ‹Ù·Ó ·fi ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜. ™‡Ìʈӷ Ì ÙȘ ÌÂϤÙ˜, ÂÓÒ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÍ·Ûı¤ÓËÛË ÙÔ˘ fiÓÔ˘ Û 24 ÒÚ˜, ÛÙÔ 28% (95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜: 15% ¤ˆ˜ 38%) ˘‹ÚÍ ÂÍ·Ûı¤ÓËÛË ÙÔ˘ fiÓÔ˘ Û 2-7 Ë̤Ú˜. ∂ÊfiÛÔÓ ÙÔ 80% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ ı· ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ ‡ÊÂÛË ·˘ÙfiÌ·Ù· ̤¯ÚÈ ·˘Ùfi ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ì ‚¿ÛË Ù· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ Û˘Ó¿ÁÂÙ·È fiÙÈ Ë ·fiÏ˘ÙË ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÓÔ˘ ı· ·ÊÔÚ¿ ÛÙÔ 5% ‹ fiÙÈ Â-
194
Ú›Ô˘ 17 ·ÛıÂÓ›˜ ı· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ·ÓÙÈ‚ÈÔÙÈο ÚÔÎÂÈ̤ÓÔ˘ Ó· ÚÔÏËÊı› Û 1 ·È‰› Ë ÂÈÌÔÓ‹ ÙÔ˘ fiÓÔ˘ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 2 Ë̤Ú˜. ¢ÂÓ ‰È·ÈÛÙÒıËΠη̛· ›‰Ú·ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙ· ÚÔ‚Ï‹Ì·Ù· ·ÎÔ‹˜ Ô˘ ÚÔÎÏ‹ıËÎ·Ó ·fi ÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, fiˆ˜ ηٷÁÚ¿ÊËΠ·fi ÙËÓ Â·ÎfiÏÔ˘ıË Ù˘Ì·ÓÔÌÂÙÚ›·. øÛÙfiÛÔ, ·ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠‰‡Ô ÌfiÓÔ ÌÂϤÙ˜ Î·È Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ‹Ù·Ó ÂÏÏÈ‹˜. ™ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ÌÂϤÙ˜ ·Ú·ÙËÚ‹ıËÎ·Ó Ï›Á˜ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜: Ì›· ÌfiÓÔ ÂÚ›ÙˆÛË Ì·ÛÙÔÂȉ›Ùȉ·˜, Ô˘ ÂÌÊ·Ó›ÛÙËΠÛÙËÓ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠¯ÔÚ‹ÁËÛË ÂÓÈÎÈÏ›Ó˘. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·ÓÙÈ‚ÈÔÙÈο ÚÔÛʤÚÔ˘Ó ÌÈÎÚfi fiÊÂÏÔ˜ ÛÙËÓ ÔÍ›· ̤ÛË ˆÙ›Ùȉ· ÛÙ· ·È‰È¿. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ·˘ÙfiÌ·Ù· ‡ÊÂÛË, ÙÔ fiÊÂÏÔ˜ ı· Ú¤ÂÈ Ó· Û˘ÁÎÚÈı› Ì ÙȘ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ∏ ıÂڷ›· Ì ·ÓÙÈ‚ÈÔÙÈο ÌÔÚ› Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ Ì·ÛÙÔÂȉ›Ùȉ·˜ Û ÏËı˘ÛÌÔ‡˜ Ô˘ ·˘Ù‹ Â›Ó·È Û˘¯ÓfiÙÂÚË.
1 Glasziou PP, Del Mar CB, Sanders SL, Hayem M Antibiotics for acute otitis media in children The Cochrane Library, Issue 4, 2002. Oxford: Update Software
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ORIGINAL ARTICLE
§ÂÌÊÒÌ·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∂ÌÂÈÚ›· 10 ¯ÚfiÓˆÓ º. ∞ı·Ó·ÛÈ¿‰Ô˘1, £. ∆Ú·ÁÈ·ÓÓ›‰Ë˜1, £. ¶··ÁˆÚÁ›Ô˘1, µ. ∫·ÏÔ‡ÙÛË2, ª. ÷Ù˙ËÛÙ˘ÏÈ·ÓÔ‡1, ª. ™Ù¿ÌÔ˘1, ¢. ∫·ÙÚÈÔ‡1
Lymphomas in childhood. Ten years’ experience F. Athanassiadou1, T. Tragiannidis1, T. Papageorgiou1, V. Kaloutsi2, M. Hatzistilianou1, M. Stamou1, D. Katriou1
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÎÏÈÓÈ΋ ·ÚÔ˘Û›·ÛË Î·È Ù· ıÂڷ¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ·È‰ÈÒÓ Ì Hodgkin (HD) Î·È ÌË Hodgkin ϤÌʈ̷ (NHL) Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÎÏÈÓÈ΋ ÙË ‰ÂηÂÙ›· 1992-2002. ÀÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 38 ·È‰È¿ ËÏÈΛ·˜ 2 ¤ˆ˜ 15 ¯ÚfiÓˆÓ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ٷ ÚˆÙfiÎÔÏÏ· LSA2-L2, BFM Î·È ÙÔ ˘‚ÚȉÈÎfi ÚˆÙfiÎÔÏÏÔ COPP/ABVD. °È· οı ·È‰› ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙÔ˘ ʇÏÔ˘, Ù˘ ËÏÈΛ·˜, ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È ÙÔ˘ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË Û ÚÒÙË ‡ÊÂÛË (event free survival - EFS) Î·È Ë Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ (overall survival - OS) ˘ÔÏÔÁ›ÛÙËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô Kaplan-Meier. ∞fi Ù· 38 ·È‰È¿, 16 (42,1%) Ù·ÍÈÓÔÌ‹ıËÎ·Ó ˆ˜ HD, ÂÓÒ 22 ·È‰È¿ (57,9%) ˆ˜ NHL. ∆· 27 ‹Ù·Ó ·ÁfiÚÈ· (71,1%) Î·È Ù· 11 ÎÔÚ›ÙÛÈ· (28,9%). ∏ ̤ÛË ËÏÈΛ· ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 9 ¯ÚfiÓÈ· (9±6,04). ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÚԤ΢„·Ó Ù· ÂÍ‹˜: 26 ·fi Ù· 38 ·È‰È¿ ›¯·Ó ·ÚÈıÌfi Ï¢ÎÒÓ <10.000/mm3 (68,4%), 28/38 Hb >10 g/dL (73,7%), 10/38 LDH >1000 U/L (26,3%) Î·È 7/38 ›¯·Ó ∆∫∂ >100 mm (18,4%). ∞fi Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ηٷÁÚ¿ÊËΠ˘ÚÂÙfi˜ Û ÔÛÔÛÙfi 39,5%, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ÛÙÔ 42,1% Î·È Ó˘¯ÙÂÚÈÓÔ› ȉÚÒÙ˜ ÛÙÔ 26,3% ÙˆÓ ·È‰ÈÒÓ. ∏·ÙÔÛÏËÓÔÌÂÁ·Ï›· (>3 cm) ›¯Â ÙÔ 36,8%, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ÙÔ 76,3%, ‰ÈfiÁΈÛË ÙˆÓ ·‰¤ÓˆÓ ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÙÔ 73,7% Î·È ÙˆÓ ÔÈÛıÔÂÚÈÙÔÓ·˚ÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ ÙÔ 26,3%. ∏ ηٷÓÔÌ‹ ηٿ ÛÙ¿‰È· ‹Ù·Ó Ë ÂÍ‹˜: ÛÙÔ ÛÙ¿‰ÈÔ I ·Ó‹Î ÙÔ 7,9% (3 ·È‰È¿), ÛÙÔ II ÙÔ 52,6% (20 ·È‰È¿), ÛÙÔ III ÙÔ 31,6% (12 ·È‰È¿) Î·È ÛÙÔ IV ÙÔ 7,9%
Abstract: This is a study of children with Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL), admitted to the paediatric clinic during the period 1992-2002. The study includes 38 children aged between 2 and 15 years with lymphoma, treated with the protocols LSA2-L2, BFM and COPP/ABVD. The sex of the children and age at diagnosis, clinical and laboratory data at admission and the findings on radiological and histological investigation were evaluated. Event free survival (EFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Sixteen of the 38 children (42.1%) were diagnosed as HD and 22 (57.9%) as NHL. Twentyseven children (71.1%) were males and 11 (28.9%) females, and their mean age at admission was 9 years (9±6.04). Laboratory findings at admission showed that 68.4% had WBC <10.000/mm3, 73.7% had Hb >10 g/dL, 26.3% had LDH >1000 U/L and 18.4% had ESR >100 mm. Fever was documented in 39.5%, weight loss in 42.1% and night sweats in 26.3%. Hepatosplenomegaly (>3 cm) was found in 36.8%, and cervical, mediastinal, and retroperitoneal lymphadenopathy in 76.3%, 73.7% and 26.3% respectively. The disease was staged at: stage I 7.9%, stage II 52.6%, stage III 31.6% and stage IV 7.9%. Half of the children with HD were aged >10 years while 72.7% with NHL were aged between 5 and 10 years. Boys constituted 77.3% of the children with NHL and 62.5% of those with HD. Fever was present in 56.3% of those with HD and 27.3% of those with NHL. EFS at the first remission was 77.05% (±6.58%) and OS 91.27% (±4.36%). EFS in correlation to the type of lymphoma was 71.79% (±11.58%) for HD and 79.6% (±8.02%) for
1 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢ 2 ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢
1 2nd Paediatric Clinic of Aristotelion University, Thessaloniki 2 Laboratory of Clinical Pathology of Aristotelion University, Thessaloniki
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(3 ·È‰È¿). ∆· ÌÈÛ¿ ·È‰È¿ Ì HD (50%) ‹Ù·Ó ËÏÈΛ·˜ >10 ¯ÚfiÓˆÓ, ÂÓÒ ÙÔ 72,7% ÙˆÓ NHL ‹Ù·Ó ËÏÈΛ·˜ 5-10 ¯ÚfiÓˆÓ. ∆Ô 77,3% ÙˆÓ NHL ‹Ù·Ó ·ÁfiÚÈ·, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÙˆÓ HD ‹Ù·Ó 62,5%. ¶˘ÚÂÙfi ›¯Â ÙÔ 56,3% ÙˆÓ HD, ¤Ó·ÓÙÈ 27,3% ÙˆÓ NHL. ªÂ ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù· 4,8 ¤ÙË, Ë EFS Û ÚÒÙË ‡ÊÂÛË Â›Ó·È 77,05% (±6,58%) Î·È Ë OS 91,27% (±4,36%). ∏ ·Ó¿Ï˘ÛË Ù˘ Èı·ÓfiÙËÙ·˜ EFS Û ۯ¤ÛË Ì ÙÔÓ Ù‡Ô ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ Â›Ó·È 71,79% (±11,58%) ÁÈ· Ù· ·È‰È¿ Ì HD, ¤Ó·ÓÙÈ 79,6% (±8,02%) ÁÈ· ÂΛӷ Ì NHL. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 16 ·È‰ÈÒÓ Ì HD Î·È ÙˆÓ 22 Ì NHL, ˘ÔÙÚÔ›·Û·Ó 5 Î·È 5 ·È‰È¿, ·ÓÙ›ÛÙÔȯ·. ∞fi ·˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ÚÔ·ÙÂÈ fiÙÈ Ë OS Î·È Ë EFS, Ì ٷ Û‡Á¯ÚÔÓ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ·, ηٷÁÚ¿ÊËÎ·Ó Û ϋÚË ·ÓÙÈÛÙÔȯ›· Ì ٷ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ. ™˘ÁÎÚÈÙÈο ÚÔ·ÙÂÈ Î·Ï‡ÙÂÚË ¤Î‚·ÛË ÁÈ· Ù· ·È‰È¿ Ì NHL, Ô˘ ÔÊ›ÏÂÙ·È Èı·ÓfiÓ ÛÙËÓ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Ô˘ ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ¤ÁηÈÚË ÚÔۤϢÛË, ‰È¿ÁÓˆÛË Î·È ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË.
NHL. Relapses occurred in 5/16 and 5/22 children with HD and NHL respectively. In conclusion, the OS and EFS in this group of children were equivalent to those treated with modern chemotherapy protocols reported in the international bibliography. Comparing HD and NHL, better outcome for children with NHL was noted, possibly due to more timely admission, diagnosis and start of treatment.
§¤ÍÂȘ ÎÏÂȉȿ: ÓfiÛÔ˜ Hodgkin, ÌË Hodgkin ϤÌʈ̷, ÂÈ‚›ˆÛË ÂχıÂÚË ÓfiÛÔ˘, ·È‰È΋ ËÏÈΛ·.
Key words: Hodgkin disease, non-Hodgkin lymphoma, event free survival, childhood.
∂ÈÛ·ÁˆÁ‹ ∆· ÏÂÌÊÒÌ·Ù· ·ÔÙÂÏÔ‡Ó ÙÔ ÙÚ›ÙÔ Î·Ù¿ Û˘¯ÓfiÙËÙ· ηÎfiËı˜ ÓfiÛËÌ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÌÂÙ¿ ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· Î·È ÙÔ˘˜ ÚˆÙÔ·ı›˜ fiÁÎÔ˘˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÓÙÈÚÔۈ‡ÔÓÙ·˜ ÂÚ›Ô˘ ÙÔ 10-15% ÙˆÓ Î·ÎÔËıÂÈÒÓ (1). ¢È·ÎÚ›ÓÔÓÙ·È ÛÙ· ÌË Hodgkin ÏÂÌÊÒÌ·Ù· (NHL) Î·È ÛÙ· Hodgkin ÏÂÌÊÒÌ·Ù· (HD). ∆· NHL ÂÌÊ·Ó›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· Û ۯ¤ÛË Ì ٷ HD ÛÙËÓ ·È‰È΋ ËÏÈΛ· (·Ó·ÏÔÁ›· 3/2), ÂÓÒ Ë Î·Ù·ÓÔÌ‹ ÛÙ· ‰‡Ô ʇϷ Â›Ó·È 3:1 Ì ˘ÂÚÔ¯‹ ÙˆÓ ·ÁÔÚÈÒÓ (1-3). ∆· NHL ·ÔÙÂÏÔ‡Ó Î·ÎfiËı˜ ÓfiÛËÌ· ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ (ÏÂÌÊ·‰¤Ó˜ ‹ Â͈ÏÂÌÊ·‰ÂÓÈο fiÚÁ·Ó·). ∞ÓÙÈÚÔÛˆÂ‡Ô˘Ó ÂÚ›Ô˘ ÙÔ 7-10% ÙˆÓ Î·ÎÔ‹ıˆÓ ÓÔÛËÌ¿ÙˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (2,4,5). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ NHL Â›Ó·È ˘„ËÏfiÙÂÚË ÛÙËÓ ∞ÊÚÈ΋, ÁÂÁÔÓfi˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ Burkitt ÛÙËÓ ÂÚÈÔ¯‹, ÙÔ ÔÔ›Ô Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙÔÓ Èfi Epstein-Barr (EBV) Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 95% (2,4,6). ∞ÓÙ›ıÂÙ·, ÛÙËÓ ∂˘ÚÒË Î·È ÛÙË µfiÚÂÈ· ∞ÌÂÚÈ΋, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ NHL Â›Ó·È ∆ ‹ µ (ÌË Burkitt) ΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ Î·È ÌfiÓÔ ÙÔ 10-15% ʤÚÂÈ ÙÔ Á¤ÓˆÌ· ÙÔ˘ EBV (5). °ÂÓÂÙÈÎÔ› ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË ÙˆÓ NHL Â›Ó·È ÔÈ ÎÏËÚÔÓÔÌÈΤ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ Wiskott-Aldrich, Ë ·Ù·Í›· ÙËÏ·ÁÁÂÈÂÎÙ·Û›· Î·È ÙÔ Ê˘ÏÔÛ‡Ó‰ÂÙÔ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ, ηıÒ˜ Î·È ÔÈ Â›ÎÙËÙ˜ ·ÓÔÛÔ·Ó¿ÚÎÂȘ, fiˆ˜ Ë ·ÓÔ-
ÛÔηٷÛÙÔÏ‹ Ô˘ ·ÎÔÏÔ˘ı› ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ‹ ÙÔ˘ ‹·ÙÔ˜ (1,2). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Úԉȷı¤ÙÔ˘Ó ÛÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ NHL Â›Ó·È Ë ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÔÚÈṲ̂ÓÔÈ ÈÔ› fiˆ˜ Ô EBV Î·È Ô Èfi˜ Ù˘ ›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (HIV). ∏ ÓfiÛÔ˜ ÙÔ˘ Hodgkin ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÚÔԉ¢ÙÈ΋, ·ÓÒ‰˘ÓË ‰ÈfiÁΈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ, Û˘¯ÓfiÙÂÚ· Ù˘ ÙÚ·¯ËÏÈ΋˜ ¯ÒÚ·˜. ∏ ÓfiÛÔ˜ ·Ú¯Èο ÚÔÛ‚¿ÏÏÂÈ ¤Ó· ÌÔÓ‹ÚË ÏÂÌÊ·‰¤Ó· ‹ ÔÌ¿‰· ÏÂÌÊ·‰¤ÓˆÓ, ÂÓÒ Û ÚÔ¯ˆÚË̤ÓÔ ÛÙ¿‰ÈÔ ÌÔÚ› Ó· ÂÈÓ¤ÌÂÙ·È Î·È fiÚÁ·Ó·. ∏ η̇ÏË Û˘¯ÓfiÙËÙ·˜ ·ÚÔ˘ÛÈ¿˙ÂÈ Ì›· ·È¯Ì‹ Û ËÏÈΛ· 15-35 ÂÙÒÓ Î·È Ì›· ‰Â‡ÙÂÚË Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (>50 ¯ÚfiÓÈ·) (1,4,7). ™ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ÓfiÛÔ˘ ÂÓ¤¯ÔÓÙ·È ·ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÂÓÒ ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Û ¿ÙÔÌ· Ì ÓÔÛ‹Ì·Ù· fiˆ˜ Ô Û˘ÛÙËÌ·ÙÈÎfi˜ ÂÚ˘ıËÌ·Ù҉˘ χÎÔ˜ (™∂§), Ë ÚÂ˘Ì·ÙÔÂȉ‹˜ ·ÚıÚ›Ùȉ· Î·È Ë ·Ù·Í›· ÙËÏ·ÁÁÂÈÂÎÙ·Û›· (1,7,8). ∂›Û˘, Ô EBV ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ HD, ·ÊÔ‡ ÌÂϤÙ˜ ·¤‰ÂÈÍ·Ó ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ EBV ÛÙ· ·ÙÙ·Ú· ReedSternberg Ì ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ (PCR), Û ÔÛÔÛÙfi Ô˘ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 60% ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ·Ú·Û΢·ÛÌ¿ÙˆÓ ·È‰ÈÒÓ Ì HD.
196
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÀÏÈÎfi Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 38 ·È‰È¿ ËÏÈΛ·˜ 2-15 ÂÙÒÓ Ì ϤÌʈ̷, Ù· ÔÔ›· ÓÔÛËχÙËÎ·Ó ÛÙË µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£. ÙÔ ¯ÚÔÓÈÎfi
May-June 03
03-06-03
16:55
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¶·È‰È·ÙÚÈ΋ 2003;66:195-201
‰È¿ÛÙËÌ· ·fi ÙÔÓ πÔ‡ÏÈÔ 1992 ˆ˜ ÙÔÓ πÔ‡ÏÈÔ 2002 Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ٷ ÚˆÙfiÎÔÏÏ· LSA2-L2, BFM Î·È ÙÔ ˘‚ÚȉÈÎfi COPP/ABVD. °È· οı ·È‰› ¤ÁÈÓ ηٷÁÚ·Ê‹ ÙÔ˘ ʇÏÔ˘, Ù˘ ËÏÈΛ·˜, ÙˆÓ ÎÏÈÓÈÎÒÓ (Ë·ÙÔÌÂÁ·Ï›·, ÛÏËÓÔÌÂÁ·Ï›·, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ‰ÈfiÁΈÛË ·‰¤ÓˆÓ ÌÂÛÔıˆÚ·Î›Ô˘/ÎÔÈÏ›·˜, ˘ÚÂÙfi˜, Ó˘ÎÙÂÚÈÓÔ› ȉÚÒÙ˜, ·ÒÏÂÈ· ‚¿ÚÔ˘˜) Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ (ÁÂÓÈ΋ ·›Ì·ÙÔ˜, Á·Ï·ÎÙÈ΋ ‰Â¸‰ÚÔÁÂÓ¿ÛË, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ∆∫∂, ÊÂÚÚÈÙ›ÓË) ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ηıÒ˜ Î·È Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘ Î·È ÙÔ˘ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ÓfiÛÔ˘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ¤ÁÈÓ Ì ٷ ÎÚÈÙ‹ÚÈ· Ann Arbor ÁÈ· Ù· ·È‰È¿ ÛÙ· ÔÔ›· ‰È·ÁÓÒÛÙËΠHD, ÂÓÒ Ì ٷ ÎÚÈÙ‹ÚÈ· Murphy ÁÈ· ÂΛӷ Ì NHL. ∏ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË Û ÚÒÙË ‡ÊÂÛË (event free survival EFS) Î·È Ë Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ (overall survival OS) ˘ÔÏÔÁ›ÛÙËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô Kaplan-Meier, Ì ̤ÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù· 4,8 ¤ÙË Î·È Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙȘ ÎÏÈÓÈΤ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ηٷÁÚ¿ÊËηÓ. ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· Î·È ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ·Î¤ÙÔ SPSS.
∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 38 ·È‰È¿ Ô˘ ÓÔÛËχÙËηÓ, 16 (42,1%) Ù·ÍÈÓÔÌ‹ıËÎ·Ó ÛÙËÓ HD, ÂÓÒ 22 (57,9%) ÛÙ· NHL. ∆· 27 (71,1%) ‹Ù·Ó ·ÁfiÚÈ· Î·È Ù· 11 (28,9%) ÎÔÚ›ÙÛÈ·. ∏ ̤ÛË ËÏÈΛ· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‹Ù·Ó 9 ¯ÚfiÓÈ· (9±6,04). ∆Ô 60,5% ÙˆÓ ·È‰ÈÒÓ Â›¯Â ËÏÈΛ· 5-10 ¯ÚfiÓˆÓ Î·È ÙÔ 31,5% ›¯Â ËÏÈΛ· >10 ¯ÚfiÓˆÓ. ∞fi ÙË Û˘Û¯¤ÙÈÛË ÙÔ˘ Ù‡Ô˘ ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ Ì ÙËÓ ËÏÈΛ· ÚԤ΢„ fiÙÈ ÛÙËÓ HD ÙÔ 50% ÙˆÓ ·È‰ÈÒÓ Â›¯Â ËÏÈΛ· >10 ¯ÚfiÓˆÓ Î·È ÙÔ 43,8% 5-10 ¯ÚfiÓˆÓ, ÂÓÒ ÛÙ· NHL ÙÔ 18,2% ‹Ù·Ó ËÏÈΛ·˜ >10 ¯ÚfiÓˆÓ Î·È ÙÔ 72,7% 5-10 ¯ÚfiÓˆÓ. ∞fi Ù· ·È‰È¿ Ì HD, ÙÔ 62,5% ‹Ù·Ó ·ÁfiÚÈ· (10 ·È‰È¿), ÂÓÒ ÛÙ· ·È‰È¿ Ì NHL ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ‹Ù·Ó 77,3% (17 ·È‰È¿). ∞fi Ù· 38 ·È‰È¿, ÙÔ 68,4% (26 ·È‰È¿) ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ›¯Â ·ÚÈıÌfi Ï¢ÎÒÓ <10.000/mm3 Î·È ÙÔ 23,7% 10.000-25.000/mm3. ∏ ÙÈÌ‹ Ù˘ Hb ÛÙÔ 73,7% ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó >10 g/dL Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÛÙÔ 71,1% ÙˆÓ ·È‰ÈÒÓ Î˘Ì·ÈÓfiÙ·Ó ·fi 100.000-450.000/mm3, ÂÓÒ ÛÙÔ 10,5% ‹Ù·Ó >450.000/mm3. ∞˘ÍË̤ÓË LDH >1000 U/L ›¯Â ÙÔ 26,3%, ÊÂÚÚÈÙ›ÓË >150 ng/dl ÙÔ 23,7% Î·È ALP >250 U/L ÙÔ 63,2% ÙˆÓ ·È‰ÈÒÓ. ∞fi Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙÔ 36,8% (10 ·È‰È¿) ÂÌÊ¿ÓÈ˙ ˷ÙÔÛÏËÓÔÌÂÁ·Ï›· (>3 cm), ÙÔ 76,3% (29 ·È‰È¿) ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÙÔ 73,7% (28 ·È‰È¿) ‰ÈÔÁΈ̤ÓÔ˘˜ ÏÂÌÊ·‰¤Ó˜ ÌÂÛÔıˆÚ·Î›Ô˘ Î·È ÙÔ 26,3% (10 ·È‰È¿) ÔÈÛıÔÂÚÈÙÔÓ·˚ÎÔ‡˜. ¶˘ÚÂÙfi ·ÚÔ˘Û›·˙ ÙÔ 39,5% (15 ·È‰È¿), ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ÙÔ 42,1% (16 ·È‰È¿) Î·È Ó˘ÎÙÂÚÈÓÔ‡˜ ȉÚÒÙ˜ ÙÔ 26,3% ÙˆÓ ·È‰ÈÒÓ. ™‡Ìʈӷ Ì ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË, 12 ·fi Ù· 16 ·È‰È¿, ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË ‹Ù·Ó HD, Ù·ÍÈÓÔÌ‹ıËÎ·Ó ÛÙÔÓ Ù‡Ô Ù˘ Ô˙Ò‰Ô˘˜ ÛÎÏ‹Ú˘ÓÛ˘
Paediatriki 2003;66:195-201
(75%) Î·È 4 Û ÂΛÓÔÓ Ù˘ ÌÈÎÙ‹˜ ΢ÙÙ·ÚÔ‚Ú›ıÂÈ·˜ (25%). ∞fi Ù· ·È‰È¿ Ì NHL, ÙÔ 54,5% (12 ·È‰È¿) Ù·ÍÈÓÔÌ‹ıËΠÛÙ· ÏÂÌÊÔ‚Ï·ÛÙÈο ÏÂÌÊÒÌ·Ù·, ÙÔ 41% ÛÙ· ·‰È·ÊÔÚÔÔ›ËÙ· (·fi ÌÈÎÚ¿ ·ÙÙ·Ú· ¯ˆÚ›˜ ÂÓÙÔÌ‹) Burkitt/ÌË Burkitt, ÂÓÒ, Ù¤ÏÔ˜, 1 ·È‰› Ì Ki-1 ϤÌʈ̷ Ù·ÍÈÓÔÌ‹ıËΠÛÙ· ·ÓÔÛÔ‚Ï·ÛÙÈο ‹ ÈÛÙÈÔ΢ÙÙ·ÚÈο (ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ‹Ù·Ó 4,5%) (∂ÈÎfiÓ· 1). ∏ ηٷÓÔÌ‹ ηٿ ÛÙ¿‰ÈÔ ‹Ù·Ó Ë ÂÍ‹˜: ÛÙ¿‰ÈÔ I 7,9% (3 ·È‰È¿), ÛÙ¿‰ÈÔ II 52,6% (20 ·È‰È¿), ÛÙ¿‰ÈÔ III 31,6% (12 ·È‰È¿) Î·È ÛÙ¿‰ÈÔ IV 7,9% (3 ·È‰È¿). ∞fi ÙË Û˘Û¯¤ÙÈÛË ÙÔ˘ Ù‡Ô˘ ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ï¢ÎÒÓ ‰ÂÓ ÚԤ΢„ η̛· Ô˘ÛÈ·ÛÙÈ΋ ‰È·ÊÔÚ¿, ·ÊÔ‡ ÙÔ 68,8% ÙˆÓ ·È‰ÈÒÓ Ì HD ›¯Â ·ÚÈıÌfi <10.000/mm3, ¤Ó·ÓÙÈ ÔÛÔÛÙÔ‡ 68,2% ÙˆÓ ·È‰ÈÒÓ Ì NHL. ∞ÓÙ›ıÂÙ·, ·Ó·ÈÌ›· (Hb <10 g/dL) ··ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ì NHL, ·ÊÔ‡ ‚Ú¤ıËΠÛÙÔ 36,4% (8 ·È‰È¿) Ì NHL, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ì HD ‹Ù·Ó 12,5% (2 ·È‰È¿). ∞˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ (>450.000/mm3) ‚Ú¤ıËΠ۠4 ·È‰È¿ Ì HD (25%), ÂÓÒ Û ηӤӷ ·È‰› Ì NHL. ∏ ÙÈÌ‹ Ù˘ LDH ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‚Ú¤ıËΠӷ ¤¯ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ NHL, ·ÊÔ‡ 9 ·È‰È¿ Ì NHL (40,9%) ·ÚÔ˘Û›·˙·Ó ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ (>1000 U/L). ∞ÓÙ›ıÂÙ·, Ë ∆∫∂ Ê·›ÓÂÙ·È fiÙÈ ·ÚÔ˘ÛÈ¿˙ÂÈ ·‡ÍËÛË (>100 mm) Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ì HD, ·ÊÔ‡ ‹Ù·Ó ·˘ÍË̤ÓË ÛÙÔ 31,3% ·˘ÙÒÓ, ¤Ó·ÓÙÈ ÔÛÔÛÙÔ‡ 9,1% ÙˆÓ ·È‰ÈÒÓ Ì NHL. ∏ ÙÈÌ‹ Ù˘ ALP ‹Ù·Ó ·˘ÍË̤ÓË ÛÙÔ 68,8% ÙˆÓ ·È‰ÈÒÓ Ì HD, ¤Ó·ÓÙÈ 59,1% ÙˆÓ ·È‰ÈÒÓ Ì NHL (¶›Ó·Î·˜ 1). ∞fi Ù· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÚԤ΢„ fiÙÈ ˘ÚÂÙfi ›¯Â ÙÔ 56,3% (9 ·È‰È¿) ÙˆÓ ·È‰ÈÒÓ Ì HD Î·È ÙÔ 60
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¶·È‰È·ÙÚÈ΋ 2003;66:195-201
Paediatriki 2003;66:195-201
27,3% ÂÎÂ›ÓˆÓ Ì NHL (6 ·È‰È¿). ¡˘ÎÙÂÚÈÓÔ‡˜ ȉÚÒÙ˜ ·ÚÔ˘Û›·˙·Ó 5 ·È‰È¿ ·fi οı ÔÌ¿‰·. ∞ÒÏÂÈ· ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ·ÚÔ˘Û›·˙ ÙÔ 37,5% Ì HD (6 ·È‰È¿) Î·È ÙÔ 45,5% Ì NHL (10 ·È‰È¿). ™˘ÌÌÂÙÔ¯‹ ÙˆÓ ÔÈÛıÔÂÚÈÙÔÓ·˚ÎÒÓ ÏÂÌÊ·‰¤ÓˆÓ ·ÚÔ˘Û›·˙ ÙÔ 25% Ì HD (4 ·È‰È¿), ¤Ó·ÓÙÈ 27,3% Ì NHL (6 ·È‰È¿). ∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ›¯Â ÙÔ 75% Ì HD (12 ·È‰È¿), ¤Ó·ÓÙÈ 77,3% ÙˆÓ ·È‰ÈÒÓ Ì NHL (17 ·È‰È¿). ™˘ÌÌÂÙÔ¯‹ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ‚Ú¤ıËΠÛÙÔ 93,8% ÙˆÓ ·È‰ÈÒÓ Ì HD (15 ·È‰È¿), ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ Ì NHL ‹Ù·Ó 59,1% (13 ·È‰È¿) (¶›Ó·Î·˜ 2). ∆· ·È‰È¿ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ٷ ÚˆÙfiÎÔÏÏ· LSA2-L2, BFM Î·È ÙÔ ˘‚ÚȉÈÎfi ÚˆÙfiÎÔÏÏÔ COPP/ABVD, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô. ∞fi Ù· 38 ·È‰È¿ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ¯ËÌÂÈÔıÂڷ›·, 10 (26,3%) ˘ÔÙÚÔ›·Û·Ó ÂÎ ÙˆÓ ÔÔ›ˆÓ 5 Ì HD (29,4%) Î·È 5 Ì NHL (23,8%), ÂÓÒ Î·Ù¤ÏËÍ·Ó 4 ·È‰È¿ ÂÎ ÙˆÓ ÔÔ›ˆÓ 3 Ì NHL (13,6%). ∞fi ·˘Ù¿, 2 η٤ÏËÍ·Ó Î·Ù¿ ÙË Ê¿ÛË Ù˘ Û˘ÓÙ‹ÚËÛ˘ Î·È 1 ÛÙË Ê¿ÛË ÂÊfi‰Ô˘ Ù˘ ıÂڷ›·˜. ∞fi Ù· ·È‰È¿ Ì HD, η٤ÏËÍ 1 ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ ‰‡Ô ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË. ∏ ÂÎÙ›ÌËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ (overall survival) Î·È Ù˘ ÂÈ‚›ˆÛ˘ ¯ˆÚ›˜ ÓfiÛÔ Û ÚÒÙË ‡ÊÂÛË (event-free survival) ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ÙË Ì¤ıÔ‰Ô Kaplan-Meier, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙÔ˘ ÛÙ·ıÂÚÔ‡ ÛÊ¿ÏÌ·ÙÔ˜ (standard error) Î·È 95% ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ ·ÍÈÔÈÛÙ›·˜ (confidence interval). ∏ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÓfiÛÔ Û ÚÒÙË ‡ÊÂÛË ˘ÔÏÔÁ›ÛÙËΠ·fi ÙËÓ ËÌÂÚÔÌËÓ›· Ù˘ ‰È¿ÁÓˆÛ˘ ̤¯ÚÈ ÙËÓ ËÌÂÚÔÌËÓ›· Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËΠ˘ÔÙÚÔ‹, ·ÔÙ˘¯›· Ï‹ÚÔ˘˜ ‡ÊÂÛ˘, ı¿Ó·ÙÔ˜ ‹ ·Ó¿Ù˘ÍË ‰Â‡ÙÂÚÔ˘ ÓÂÔÏ¿ÛÌ·ÙÔ˜. ∏ EFS Û ÚÒÙË ‡ÊÂÛË Â›Ó·È 77,05% (±6,58%) Î·È Ë OS 91,27% (±4,36%). ∏ ·Ó¿Ï˘ÛË Ù˘ Èı·ÓfiÙËÙ·˜ EFS Û ۯ¤ÛË Ì ÙÔÓ Ù‡Ô ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ ‹Ù·Ó 71,79% (±11,58%) ÁÈ· ÙËÓ HD, ¤Ó·ÓÙÈ 79,6% (±8,02%) ÁÈ· Ù· ·È‰È¿ Ì NHL. ∏ Èı·ÓfiÙËÙ· EFS Ì ‚¿ÛË ÙËÓ ËÏÈΛ· ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ËÏÈΛ·˜ <10 ¯ÚfiÓˆÓ ‹Ù·Ó
79,78% (±7,9%), ÂÓÒ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ËÏÈΛ· >10 ¤ÙË ‹Ù·Ó 82,39% (±11,22%), ‰È·ÊÔÚ¿ Ô˘ ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. H EFS ›¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Û ۯ¤ÛË Ì ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È ‹Ù·Ó 95,12% (±4,73%) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ π Î·È II ÛÙ·‰›Ô˘, ÂÓÒ ÌÂȈÓfiÙ·Ó ÛÙÔ 50% (±26,87%) ÁÈ· ÂΛÓÔ˘˜ πππ Î·È IV ÛÙ·‰›Ô˘. ∏ Èı·ÓfiÙËÙ· EFS ÙˆÓ ·È‰ÈÒÓ Ì ‹ ¯ˆÚ›˜ ˘ÚÂÙfi ‹Ù·Ó 67,46 (±11,49%) Î·È 83,35% (±7,52%) ·ÓÙ›ÛÙÔȯ·, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,01). ∂›Û˘, Ë Èı·ÓfiÙËÙ· EFS ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‹ ¯ˆÚ›˜ ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‹Ù·Ó 60,73% (±10,95%) Î·È 90,59% (±6,31%) ·ÓÙ›ÛÙÔȯ·, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,01). ∞fi Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÚԤ΢„ fiÙÈ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¯·ÌËÏ¿ ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· Ë EFS ‹Ù·Ó 87,9% (±6,53%), ÂÓÒ ÁÈ· ÂΛÓÔ˘˜ Ì ·˘ÍË̤ӷ ‹Ù·Ó 63,11% (±13,85%), ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ ÁÈ· ÙËÓ ÙÈÌ‹ Ù˘ Hb, fiÔ˘ ·Ú·ÙËÚ‹Û·Ì fiÙÈ Ë EFS ‹Ù·Ó 56,3% (±15,94%) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¯·ÌËÏ‹ Hb Î·È ¤ÊÙ·Ó ÛÙÔ 83,74% (±6,53%) ÁÈ· ÂΛÓÔ˘˜ Ì Hb >10 g/dL, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,01). ∆¤ÏÔ˜, Ë Èı·ÓfiÙËÙ· EFS ÛÙ· ·È‰È¿ Ì ‹ ¯ˆÚ›˜ ÛÏËÓÔÌÂÁ·Ï›· ‹Ù·Ó 51,53% (±11,79%) Î·È 95,59% (±4,31%) ·ÓÙ›ÛÙÔȯ·, ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ø˜ ÚÔ˜ ÙËÓ Â›ÙˆÛË ÙÔ˘ ÈÛÙÔÏÔÁÈÎÔ‡ Ù‡Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì NHL ÛÙËÓ ÚfiÁÓˆÛË, ÙÔ ÏÂÌÊÔ‚Ï·ÛÙÈÎfi ϤÌʈ̷ ›¯Â ÙËÓ Î·Ï‡ÙÂÚË ÚfiÁÓˆÛË Ì Èı·ÓfiÙËÙ· EFS 92,8% (±6,83%), ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÁÈ· Ù· ·È‰È¿ Ì ·‰È·ÊÔÚÔÔ›ËÙÔ Ï¤Ìʈ̷ ‹Ù·Ó 63% (±20,31%). ∞fi Ù· ·È‰È¿ Ì HD, ηχÙÂÚË ÚfiÁÓˆÛË Â›¯·Ó ÂΛӷ Ì ÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô Ù˘ Ô˙Ò‰Ô˘˜ ÛÎÏ‹Ú˘ÓÛ˘, fiÔ˘ Ë EFS ‹Ù·Ó 78,25% (±13,32%), ÂÓÒ ÛÙÔÓ Ù‡Ô Ù˘ ÌÈÎÙ‹˜ ΢ÙÙ·ÚÔ‚Ú›ıÂÈ·˜ ÙÔ ÔÛÔÛÙfi ‹Ù·Ó 59,75% (±20,46%). ™˘˙‹ÙËÛË ∆· ÏÂÌÊÒÌ·Ù· Hodgkin Î·È ÌË, ·ÔÙÂÏÔ‡Ó ‰È·ÊÔÚÂÙÈΤ˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, Ì ‰È·ÊÔÚÂÙÈ΋ ÎÏÈÓÈ΋ Î·È ‚ÈÔÏÔÁÈ΋ Û˘ÌÂÚÈÊÔÚ¿, ‰È·ÊÔÚÂÙÈ΋
¶›Ó·Î·˜ 1. ¢È·ÊÔÚ¤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÛÙ· ·È‰È¿ Ì HD Î·È NHL 3
HD NHL
WBC <10.000/mm
Hb >10 g/dL
PLT >450.000/mm3
LDH >1000 U/L
∆∫∂ >100 mm
ALP >250 U/L
68,8% 68,2%
87,5% 63,6%
25% 0
7% 40,9%
31,3% 9,1%
68,8% 59,1%
¶›Ó·Î·˜ 2. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·È‰ÈÒÓ Ì HD Î·È NHL
HD NHL
198
¶˘ÚÂÙfi˜
∞ÒÏÂÈ· ‚¿ÚÔ˘˜
π‰ÚÒÙ˜
∆Ú·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·
56,3% 27,3%
37,5% 45,5%
31% 22%
75% 77,3%
May-June 03
03-06-03
16:55
™ÂÏ›‰·199
¶·È‰È·ÙÚÈ΋ 2003;66:195-201
΢ÙÙ·ÚÈ΋ ÚԤϢÛË, ÂÓÙfiÈÛË Î·È ·ÚÔ˘Û›· ΢ÙÙ·ÚÔÁÂÓÂÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ (¶›Ó·Î·˜ 3). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙˆÓ NHL ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÚˆÙÔ·ı‹ ÂÓÙfiÈÛ‹ ÙÔ˘˜. ∂ÌÊ·Ó›˙ÔÓÙ·È Ì ÔÈΛϘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Î·È Û˘¯Ó¿ Ë ÓfiÛÔ˜ Â›Ó·È ÁÂÓÈÎÂ˘Ì¤ÓË Î·Ù¿ ÙË ‰È¿ÁÓˆÛË, ·ÊÔ‡ Ù· NHL ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ‰È¿¯˘Ù· Î·È ˘„ËÏ‹˜ ηÎÔ‹ıÂÈ·˜ (1,4). ™˘¯Ó¤˜ Â›Ó·È Â›Û˘ Î·È ÔÈ ·ÔÌ·ÎÚ˘Ṳ̂Ó˜ ÌÂÙ·ÛÙ¿ÛÂȘ. ¶ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ NHL ÛÙ· ·È‰È¿ Â›Ó·È ∆-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ Â›Ó·È 5% (9). ∏ ηٷÓÔÌ‹ ÙˆÓ NHL ÛÙ· ·È‰È¿ Ì ‚¿ÛË ÙÔÓ ÈÛÙÔÏÔÁÈÎfi ÙÔ˘˜ Ù‡Ô Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 4. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÚˆÙÔ·ıÔ‡˜ ÂÓÙfiÈÛ˘ ÛÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ Î·È ÛÙËÓ ÎÔÈÏÈ¿ Â›Ó·È ÂÚ›Ô˘ Ù·˘ÙfiÛËÌË (30-40%) Î·È ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙÔÓ ÈÛÙÔÏÔÁÈÎfi Ù‡Ô (2,5,9). ™Â ·È‰È¿ Ì ÏÂÌÊÔ‚Ï·ÛÙÈÎfi ϤÌʈ̷ (΢ڛˆ˜ ∆-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘), Ë ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ˆ˜ Ì¿˙· ÛÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 50-70%, ÂÓÒ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ·Ó‹Ïı ÛÙÔ 75%, Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ÙÚ·¯ËÏÈ΋˜ ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·˜ (2,10). ∞ÓÙ›ıÂÙ·, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·‰È·ÊÔÚÔÔ›ËÙÔ NHL (Burkitt/non Burkitt) ‹ µ ΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ Â›Ó·È Û˘¯ÓfiÙÂÚË Ë ·Ó‡ÚÂÛË ÎÔÈÏȷ΋˜ Ì¿˙·˜ (7090%) Î·È ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÂÁÎÔÏ·ÛÌÔ‡ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ >6 ¯ÚfiÓˆÓ (9-11). ÕÏϘ Û·ÓÈfiÙÂÚ˜ ÚˆÙÔ·ı›˜ ÂÓÙÔ›ÛÂȘ ·ÔÙÂÏÔ‡Ó ÙÔ ‰¤ÚÌ· Î·È Ô ˘Ô‰fiÚÈÔ˜ ÈÛÙfi˜, Ô ı˘ÚÂÔÂȉ‹˜ ·‰¤Ó·˜, ÔÈ ÓÂÊÚÔ›, ÂÓÒ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ Î·È ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (2,12,13). ∞ÓÙ›ıÂÙ·, ÛÙËÓ HD Ë Û˘¯ÓfiÙÂÚË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ·ÓÒ‰˘ÓË ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 75-90% Î·È ·ÊÔÚ¿ ΢ڛˆ˜ ÛÙÔ˘˜ ÙÚ·¯ËÏÈÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜ ÛÙÔ 6080%, ÂÓÒ ·fi Ù· ‰Â‰Ô̤ӷ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ·Ó‹Ïı ÛÙÔ 76,5%. OÈ ·‰¤Ó˜ Â›Ó·È ·ÓÒ‰˘ÓÔÈ, ˘fiÛÎÏËÚÔÈ, ‰ÂÓ Û˘ÌʇÔÓÙ·È Ì ÙÔ˘˜ Á‡Úˆ ÈÛÙÔ‡˜ Î·È ‰ÂÓ ÊÏÂÁÌ·›ÓÔ˘Ó (8,14). ¢ÈfiÁΈÛË ÙˆÓ ·‰¤ÓˆÓ ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ 60% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ (ÙÔ ÔÛÔÛÙfi ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‹Ù·Ó 88,2%, ÂÓÒ ÁÈ· Ù· NHL 61,9%). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ÔÈ Ì¿˙˜ ÛÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ‹ Ù˘ ¿Óˆ ÎÔ›Ï˘ ÊϤ‚·˜ Î·È Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ÛÙËÓ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ·. O ÛÏ‹Ó·˜ ‚Ú›ÛÎÂÙ·È ‰ÈÔÁΈ̤ÓÔ˜ Û ÔÛÔÛÙfi 6070% Î·È ÙÔ ‹·Ú ÛÙÔ 20-40% (8,14,15). ∆Ô ‚·ÛÈÎfi ‰È·ÁÓˆÛÙÈÎfi ÈÛÙÔÏÔÁÈÎfi ‡ÚËÌ· Â›Ó·È Ë ·Ó‡ÚÂÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Reed-Sternberg, Ù· ÔÔ›· Â›Ó·È ÌÂÁ¿Ï· ·ÙÙ·Ú· Ì ‰‡Ô ˘Ú‹Ó˜. OÈ ÈÛÙÔ·ıÔÏÔÁÈÎÔ› Ù‡ÔÈ Ù˘ ÓfiÛÔ˘ ÙÔ˘ Hodgkin, ηıÒ˜ Î·È Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ÛÙ· ·È‰È¿ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 5.
Paediatriki 2003;66:195-201
ªÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó ÁÂÓÈο Û˘ÌÙÒÌ·Ù· fiˆ˜ ˘ÚÂÙfi˜, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ >10% ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÍ¿ÌËÓÔ, ȉÚÒÙ˜, ·‰˘Ó·Ì›· Î·È Î·Ù·‚ÔÏ‹. ∂›Ó·È, fï˜, Û˘¯ÓfiÙÂÚ· ÛÙËÓ HD, ·ÊÔ‡ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ 30% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Û˘ÌʈÓ› Ì ٷ ‰Â‰Ô̤ӷ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ·ÊÔ‡ Ù· ·Ú·¿Óˆ Û˘ÌÙÒÌ·Ù· ‚Ú¤ıËÎ·Ó Û ÔÛÔÛÙfi Ô˘ Î˘Ì¿ÓıËΠ·fi 30-50%. O ··Ú·›ÙËÙÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓÂÊÚÈ΋˜ Î·È Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ÙÔ Ì˘ÂÏfiÁÚ·ÌÌ· Î·È ÙËÓ ÔÛÙÂÔÌ˘ÂÏÈ΋ ‚ÈÔ„›·, ÙËÓ Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ∂¡À, ÙËÓ ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È ÙÔÓ ÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô (1,4,8). ™Ù· ÏÂÌÊÒÌ·Ù· Â›Ó·È Û˘¯ÓfiÙÂÚË Ë Ï¢ÎÔ΢ÙÙ¿ÚˆÛË Î·È Ë ·Ó·ÈÌ›· Î·È Û¿ÓÈ· Û˘Ó˘¿Ú¯ÂÈ ıÚÔÌ‚ÔÂÓ›· (16). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Û˘ÌʈÓÔ‡Ó Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÌÂϤÙ˘, ÂÊfiÛÔÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÛË Â›¯Â ÙÔ 31,6% (WBC >10.000/mm3) Î·È ·Ó·ÈÌ›· ÙÔ 26,3% ÙˆÓ ·È‰ÈÒÓ. ∆Ô ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ NHL Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi ÙÔ ÛÙ¿‰ÈÔ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË Î·È ·fi ÙÔ ÚˆÙfiÎÔÏÏÔ ıÂڷ›·˜ Î·È Î˘Ì·›ÓÂÙ·È ·fi 50-80%, ÂÓÒ Ë EFS ·fi 75-90% ¶›Ó·Î·˜ 3. ¢È·ÊÔÚ¤˜ ÌÂٷ͇ Ù˘ HD Î·È Ù˘ NHL HD ¶ÚԤϢÛË Î˘ÙÙ¿ÚˆÓ ∂ÓÙÔÈṲ̂ÓË ÓfiÛÔ˜ ∂¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘ ªÂÛÔıˆÚ¿ÎÈÔ ∫ÔÈÏ›· ™˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ÃÚˆÌÔÛˆÌÈΤ˜ ÌÂÙ·ı¤ÛÂȘ
NHL
∞‰È¢ÎÚ›ÓÈÛÙË µ ‹ ∆-·ÙÙ·Ú· ™˘¯Ó¿ ™¿ÓÈ· ∂ȯÒÚÈÔ˘˜ ∞ÔÌ·ÎÚ˘Ṳ̂ÓÔ˘˜ ™˘¯Ó¿ ™¿ÓÈ· ™¿ÓÈ· ™˘¯Ó¿ ™˘¯Ó¿
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¶›Ó·Î·˜ 4. IÛÙÔÏÔÁÈÎÔ› Ù‡ÔÈ Î·È Û˘¯ÓfiÙËÙ· ÙˆÓ NHL πÛÙÔÏÔÁÈÎfi˜ Ù‡Ô˜
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§ÂÌÊÔ‚Ï·ÛÙÈÎfi πÛÙÈÔ΢ÙÙ·ÚÈÎfi ∞‰È·ÊÔÚÔÔ›ËÙÔ (Burkitt, ÌË Burkitt) ÕÏÏ·
∆ ·ÙÙ·ÚÔ, ¿ˆÚÔ ÚÔ µ µ, ÌË ∆, ÌË µ ·ÙÙ·ÚÔ
30-40% 10-15%
µ ·ÙÙ·ÚÔ
40-50% 5%
¶›Ó·Î·˜ 5. πÛÙÔÏÔÁÈÎÔ› Ù‡ÔÈ Î·È Û˘¯ÓfiÙËÙ· Ù˘ HD πÛÙÔÏÔÁÈÎfi˜ Ù‡Ô˜ §ÂÌÊÔ΢ÙÙ·ÚÈÎfi˜ Ù‡Ô˜ O˙҉˘ ÛÎÏËÚ˘ÓÙÈÎfi˜ ªÈÎÙ‹˜ ΢ÙÙ·ÚÔ‚Ú›ıÂÈ·˜ §ÂÌÊÔÂÓÈÎfi˜
™˘¯ÓfiÙËÙ· 5-15% 40-60% 15-30% <5%
199
May-June 03
03-06-03
16:55
™ÂÏ›‰·200
¶·È‰È·ÙÚÈ΋ 2003;66:195-201
(2,3,17). OÈ ˘ÔÙÚÔ¤˜ Â›Ó·È ÚÒÈ̘ ÛÙ· B-NHL, ÂÓÒ ·ÓÙ›ıÂÙ· fi„È̘ ÛÙ· T-NHL (1). ™Ù· ·È‰È¿ Ì HD, Ë Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 8095% Î·È Ë EFS ·fi 70-90% (3,18,19). ∞fi Ù· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ ÚԤ΢„ fiÙÈ Ë EFS Û ÚÒÙË ‡ÊÂÛË ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ 38 ·È‰ÈÒÓ Ì ϤÌʈ̷ Â›Ó·È 77,05% (±6,58%) Î·È Ë OS 91,27% (±4,36%). ∏ ·Ó¿Ï˘ÛË Ù˘ Èı·ÓfiÙËÙ·˜ EFS Û ۯ¤ÛË Ì ÙÔÓ Ù‡Ô ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ Â›Ó·È 71,79% (±11,58%) ÁÈ· ÙËÓ HD, ¤Ó·ÓÙÈ 79,6% (±8,02%) ÁÈ· Ù· NHL, ÁÂÁÔÓfi˜ Ô˘ ¤Ú¯ÂÙ·È Û ·ÓÙ›ıÂÛË Ì ٷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ÌfiÓÔ ˆ˜ ÚÔ˜ Ù· ÏÂÌÊÒÌ·Ù· Hodgkin. ∏ η΋ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· ÙˆÓ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ì HD Î·È Ë ¯·ÌËÏfiÙÂÚË - Û ۯ¤ÛË Ì ÙË ‚È‚ÏÈÔÁÚ·Ê›· - EFS ÔÊ›ÏÔÓÙ·È ÛÙÔ ÚÔ¯ˆÚË̤ÓÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ηٿ ÙË ‰È¿ÁÓˆÛË. ∂›Ó·È ÁÓˆÛÙfi, ÂÍ¿ÏÏÔ˘, fiÙÈ ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ ÏÂÌÊÒÌ·ÙÔ˜ ηٿ ÙË ‰È¿ÁÓˆÛË ·ÔÙÂÏ› ÙÔÓ ÛÔ˘‰·ÈfiÙÂÚÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË, Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Î·È Û˘ÌʈÓ› ·fiÏ˘Ù· Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ·ÊÔ‡ ÚԤ΢„ fiÙÈ Ë EFS fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙË ‰È¿ÁÓˆÛË ‹Ù·Ó 95,12% (±4,73%) ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ I Î·È II ÛÙ·‰›Ô˘, ÂÓÒ ÌÂȈÓfiÙ·Ó ÛÙÔ 50% (±26,87%) ÁÈ· ÂΛÓÔ˘˜ πππ Î·È IV ÛÙ·‰›Ô˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÚÔ·ÙÂÈ fiÙÈ Ì ٷ Û‡Á¯ÚÔÓ· ıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· Ë OS Î·È Ë EFS ηٷÁÚ¿ÊËÎ·Ó Û ϋÚË ·ÓÙÈÛÙÔȯ›· Ì ٷ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ÂÓÒ ÛËÌ·ÓÙÈÎfi Â›Ó·È Â›Û˘ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·Ú·ÙËÚÂ›Ù·È Î·Ï‡ÙÂÚË ¤Î‚·ÛË ÁÈ· Ù· ·È‰È¿ Ì NHL. ∞˘Ùfi ÔÊ›ÏÂÙ·È Èı·ÓÒ˜ ÛÙËÓ ·ÚÔ˘Û›· ÎÏÈÓÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ Ô˘ ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ¤ÁηÈÚË ÚÔۤϢÛË, ‰È¿ÁÓˆÛË Î·È ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË, Û ·ÓÙ›ıÂÛË Ì ٷ ·È‰È¿ Ì HD, Ù· ÔÔ›· ηٿ ÙË ‰È¿ÁÓˆÛË Â›Ó·È ˘„ËÏÔ‡ ÛÙ·‰›Ô˘. ™˘ÓÂÒ˜, ·ÔÙÂÏ› ‚·ÛÈÎfi ̤ÏËÌ· Î·È Â˘ı‡ÓË ÙˆÓ ·È‰È¿ÙÚˆÓ ·ÈÌ·ÙÔÏfiÁˆÓ, Ô˘ Â›Ó·È Î·È ˘Â‡ı˘ÓÔÈ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È ÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ, Ó· ÂÈÛËÌ¿ÓÔ˘Ó ÙËÓ ·Í›· Ù˘ ¤ÁηÈÚ˘ ·Ú·ÔÌ‹˜ ·È‰ÈÒÓ Ì ‰ÈÔÁΈ̤ÓÔ˘˜ ÏÂÌÊ·‰¤Ó˜ ‹ ÌÂ Û˘ÌÙÒÌ·Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÏÂÌÊˆÌ¿ÙˆÓ Û ÂȉÈΤ˜ ·È‰È·ÙÚÈΤ˜ ÌÔÓ¿‰Â˜, ·ÊÔ‡ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ηٿ ÙË ‰È¿ÁÓˆÛË ·ÔÙÂÏ› ÙÔ ÎÚ›ÛÈÌÔ ÛËÌÂ›Ô ÁÈ· ÙËÓ Â˘ÓÔ˚΋ ÚfiÁÓˆÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Lanzkowsky P. Pediatric haematology and oncology. 3rd ed. New York: University Press; 2000. 2. Shad A, Magrath I. Malignant non-Hodgkin’s lymphoma in children. In: Pizzo PA, Poplack DG, editors. Principles and practices of pediatric oncology. Philadelphia: LippincottRaven; 1997. p. 545-587. 3. Zhao G, Boysen CD, Brown EF, Hassanein KM, Holmes FF,
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 22-10-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 21-02-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: º·Ó‹ ∞ı·Ó·ÛÈ¿‰Ô˘ ™Ù. ∫˘ÚȷΛ‰Ë 1, ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞, £ÂÛÛ·ÏÔÓ›ÎË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ η΋˜ ¤Î‚·Û˘ Î·È ÔʤÏË ·fi Ù· ·ÓÙÈ‚ÈÔÙÈο Û ·È‰È¿ Ì ÔÍ›· ̤ÛË ˆÙ›Ùȉ·1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ÔÈ· ·fi Ù· ·È‰È¿ Ì ÔÍ›· ̤ÛË ˆÙ›Ùȉ· ¤¯Ô˘Ó ΛӉ˘ÓÔ Î·Î‹˜ ¤Î‚·Û˘ Î·È Ó· ÂÎÙÈÌËı› Û ·˘Ù¿ Ë ˆÊ¤ÏÂÈ· ·fi Ù· ·ÓÙÈ‚ÈÔÙÈο. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠ‰Â˘ÙÂÚÔÁÂÓ‹˜ ·Ó¿Ï˘ÛË ÙˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÂÏÂÁ¯fiÌÂÓˆÓ ÚÔÔÙÈÎÒÓ ÌÂÏÂÙÒÓ. ∏ ÌÂϤÙË ‰ÈÂÍ‹¯ıË ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÂÚ›ı·Ï„Ë. ™˘ÌÌÂÙ›¯·Ó 315 ·È‰È¿ ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 10 ÂÙÒÓ, ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠ·ÓÙÈ‚ÈÔÙÈÎfi, ¿ÌÂÛ· ‹ ηı˘ÛÙÂÚË̤ӷ (Ï‹„Ë ÌÂÙ¿ ·fi 72 ÒÚ˜, Â¿Ó ‹Ù·Ó ··Ú·›ÙËÙÔ). ¶ÚÔÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ‚Ú·¯˘ÚfiıÂÛÌ˘ ¤Î‚·Û˘ ·ÔÙ¤ÏÂÛÂ Ë ÂÌÊ¿ÓÈÛË ÂÂÈÛÔ‰›Ô˘ ·ÓËÛ˘¯›·˜ ‹ Ó˘¯ÙÂÚÈÓ‹˜ ·Ó·ÛٿوÛ˘ ¤ˆ˜ ÙÚÂȘ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ Â›ÛÎÂ„Ë ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔ ÁÈ·ÙÚfi. ∞ÔÙÂϤÛÌ·Ù·: ∏ ÂΉ‹ÏˆÛË ·ÓËÛ˘¯›·˜ ̤¯ÚÈ ÙËÓ ÙÚ›ÙË Ë̤ڷ ‹Ù·Ó ÈÔ Èı·Ó‹ ÛÙ· ·È‰È¿ Ô˘ ÙËÓ ÚÒÙË Ë̤ڷ ÂÌÊ¿ÓÈ˙·Ó ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 4,5, 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜: 2,3 ¤ˆ˜ 9,0), Â̤ÙÔ˘˜ (2,6, 1,3 ¤ˆ˜ 5,0) Î·È ‚‹¯· (2,0, 1,1 ¤ˆ˜ 3,8). ∏ ÂÌÊ¿ÓÈÛË Ó˘¯ÙÂÚÈÓ‹˜ ·Ó·ÛٿوÛ˘ ̤¯ÚÈ ÙËÓ ÙÚ›ÙË Ë̤ڷ ‹Ù·Ó ÈÔ Èı·Ó‹ ÛÙ· ·È‰È¿ Ì ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· (2,4, 1,2 ¤ˆ˜ 4,8), Â̤ÙÔ˘˜ (2,1, 1,1 ¤ˆ˜ 4,0), ‚‹¯· (2,3, 1,3 ¤ˆ˜ 4,2) Î·È ˆÙfiÚÚÔÈ· (2,1, 1,2 ¤ˆ˜ 3,9). ™Ù· ·È‰È¿ Ì ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· ‹ Â̤ÙÔ˘˜, Ë ÂΉ‹ÏˆÛË ·ÓËÛ˘¯›·˜ ̤¯ÚÈ ÙËÓ ÙÚ›ÙË Ë̤ڷ ‹Ù·Ó ÏÈÁfiÙÂÚÔ Èı·Ó‹ ÌÂÙ¿ ·fi ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ (32% ÛÙËÓ ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ¤Ó·ÓÙÈ 53% ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË, ¯2=4,0 (p=0,045) (¯ÚÂÈ¿ÛÙËΠӷ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó 5 ·È‰È¿). ∞Ó¿ÏÔÁ· ‹Ù·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Î·È ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ·Ó·ÛٿوÛË Î·-
2 Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ó‡¯Ù·˜ (26% ¤Ó·ÓÙÈ 59%, ¯ =9,3 (p=0,002) (¯ÚÂÈ¿ÛÙËΠӷ ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó 3 ·È‰È¿). ™Ù· ·È‰È¿ Ô˘ ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· ‹ Â̤ÙÔ˘˜, Ë ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ ‰ÂÓ ‰È·ÊÔÚÔÔ›ËÛ ÛËÌ·ÓÙÈο ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ·ÓËÛ˘¯›·˜ (15% ¤Ó·ÓÙÈ 19%, ¯2=0,74, p=0,39) ‹ Ó˘¯ÙÂÚÈÓ‹˜ ·Ó·ÛٿوÛ˘ ̤¯ÚÈ ÙËÓ ÙÚ›ÙË Ë̤ڷ (20% ¤Ó·ÓÙÈ 27%, ¯2=1,6, p=0,20). ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘‹Ú¯Â ÂÈÚfiÛıÂÙ· ‚‹¯·˜, Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ‰ÂÓ ‚ÂÏÙ›ˆÛÂ, ›Û˘, ÛËÌ·ÓÙÈο ÙËÓ ÚfiÁÓˆÛË Ù˘ ÓfiÛÔ˘. ™˘ÌÂÚ¿ÛÌ·Ù·: ™Ù· ·È‰È¿ Ì ̤ÛË ˆÙ›Ùȉ·, ¯ˆÚ›˜ fï˜ ˘ÚÂÙfi ‹ Â̤ÙÔ˘˜, Ë ıÂڷ›· Ì ·ÓÙÈ‚ÈÔÙÈο ÚÔÛ¤ÊÂÚ ÌÈÎÚfi fiÊÂÏÔ˜. ∂›Û˘, Ë Èı·ÓfiÙËÙ· η΋˜ ¤Î‚·Û˘ Ù˘ ÓfiÛÔ˘ Û ·˘Ù¿ Ù· ·È‰È¿ ‹Ù·Ó ÌÈÎÚ‹.
1 Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomized trial BMJ 2002;325:22
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ORIGINAL ARTICLE
§È›‰È· Î·È ÏÈÔÚˆÙ½Ó˜ ÔÚÔ‡ ·È‰ÈÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η ∫. ∞. µÔ‡‰Ú˘1, ∞. ™Î·Ú‰Ô‡ÙÛÔ˘2, ª. ™ÂÚ‚ÈÙ˙fiÁÏÔ˘2, ™. ¢‹ÌÔ˘3, ∂. ∞. µ·ÁÈ¿ÎÔ˘4
Serum lipids and lipoproteins in epileptic children receiving antiepileptic drugs K. Voudris1, A. Skardoutsou2, M. Servitzoglou2, S. Dimou3, E. Vagiakou4
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó›¯Ó¢ÛË ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÏÈȉ›ˆÓ, ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ÛÙÔÓ ÔÚfi ÂÈÏËÙÈÎÒÓ ·È‰ÈÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ¯ÚfiÓÈ· ÌÔÓÔıÂڷ›· Ì ٷ ·ÓÙÈÂÈÏËÙÈο ʿ̷η ηڂ·Ì·˙›ÓË, ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ‹ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË. ™Â Û‡ÁÎÚÈÛË ÌÂ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Ì¿ÚÙ˘Ú˜, ·˘ÍË̤ӷ ›‰· ÛÙÔÓ ÔÚfi Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (TC), Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ˘„ËÏ‹˜ (HDL-C) Î·È ¯·ÌËÏ‹˜ (LDL-C) ˘ÎÓfiÙËÙ·˜ Î·È ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ∞-π (ApoA-I) Î·È µ (ApoB) ‰È·ÈÛÙÒıËÎ·Ó ÌfiÓÔ ÛÙ· ·È‰È¿ Ô˘ ÂÏ¿Ì‚·Ó·Ó ηڂ·Ì·˙›ÓË Î·È Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, ÂÓÒ ‰ÂÓ ‚Ú¤ıËΠÌÂÙ·‚ÔÏ‹ ÛÙ· ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ (∆G) Î·È Ù˘ ÏÈÔÚˆÙ½Ó˘ a [Lp(a)] Û η̛· ·fi ÙȘ ÔÌ¿‰Â˜. ¢ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÏÈȉ›ˆÓ, ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ ÔÚÔ‡ Î·È Ù˘ ‰È¿ÚÎÂÈ·˜ ıÂڷ›·˜ ·ÊÂÓfi˜, Î·È ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ô˘ÛÈÒÓ ÛÙÔÓ ÔÚfi ·ÊÂÙ¤ÚÔ˘. OÈ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ ÛÙ· ·È‰È¿ Ì ÂÈÏË„›·, Ù· ÔÔ›· Â›Ó·È Û ¯ÚfiÓÈ· ÌÔÓÔıÂڷ›· Ì ٷ ÌÂÏÂÙËı¤ÓÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η.
Abstract: The aim of this study was to evaluate changes in serum lipids, lipoproteins and apolipoproteins in children with epilepsy on longterm antiepileptic drug monotherapy with carbamazepine, sodium valproate, or phenobarbital. In comparison to controls taking no medication, significantly increased levels of serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A-I (ApoA-I) and apolipoprotein B (ApoB) were found in children receiving carbamazepine and phenobarbital, but not in those on sodium valproate. No group showed significantly increased levels of serum triglycerides (TG) or lipoprotein a [Lp(a)]. The changes in the serum lipids profile did not correlate with either drug plasma concentrations or the duration of treatment. The possibility of such changes must be considered in all children with epilepsy on long-term antiepileptic drug monotherapy with carbamazepine and phenobarbital.
§¤ÍÂȘ ÎÏÂȉȿ: ÏÈ›‰È·, ÏÈÔÚˆÙ½Ó˜, ·ÔÏÈÔÚˆÙ½Ó˜, ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, ·È‰È΋ ÂÈÏË„›·.
Key words: lipids, lipoproteins, apolipoproteins, antiepileptic drugs, epilepsy.
™˘ÓÙÔÌÔÁڷʛ˜ TC ∆G HDL-C LDL-C
OÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË ∆ÚÈÁÏ˘ÎÂÚ›‰È· ÃÔÏËÛÙÂÚfiÏË ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÃÔÏËÛÙÂÚfiÏË ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ
1 ¡Â˘ÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 2 µ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 3 µÈÔ¯ËÌÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· 4 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶. °. ¡ÔÛÔÎÔÌÂ›Ô “°. °ÂÓÓËÌ·Ù¿˜”, ∞ı‹Ó·
202
ApoA-I ApoB Lp(a) ª™
¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ∞ÔÏÈÔÚˆÙ½ÓË ∞-π ∞ÔÏÈÔÚˆÙ½ÓË µ §ÈÔÚˆÙ½ÓË a ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿
1 Neurology Department, “P. & A. Kyriakou” Children’s Hospital, Athens 2 2nd Paediatric Clinic of University of Athens, “P. & A. Kyriakou” Children’s Hospital, Athens 3 Department of Biochemistry, “P. & A. Kyriakou” Children’s Hospital, Athens 4 Department of Microbiology, “G. Gennimatas” Peripheral General Hospital, Athens
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¶·È‰È·ÙÚÈ΋ 2003;66:202-207
∂ÈÛ·ÁˆÁ‹ ªÂÙ·‚ÔϤ˜ ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ, ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ ÔÚÔ‡ Û ¿ÙÔÌ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η ¤¯Ô˘Ó ‰È·ÈÛÙˆı› Û ‰È¿ÊÔÚ˜ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ (1-11). ™˘¯Ó¿, ÔÈ ·ÛıÂÓ›˜ ÂÏ¿Ì‚·Ó·Ó Ù·˘Ùfi¯ÚÔÓ· ÔÏÏ¿ ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η Î·È Ë ÂӉ¯fiÌÂÓË Â›‰Ú·ÛË ÌÂÌÔӈ̤ÓÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ Î·È ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ÛÙÔÓ ÔÚfi ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÏÂÁ¯ı›. OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› ΢ڛˆ˜ Û ÂÓ‹ÏÈΘ, ·ÏÏ¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·ÚfiÌÔȘ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› Î·È ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi, ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Ó ÛÙ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η Ù˘ ÌÂϤÙ˘ Ì·˜, Ì ·Ó¿ÏÔÁ· ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ÔÚÔ‡ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·Î˘Ì¿ÓÛÂȘ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ·ÏÏ¿ Î·È ÌÂٷ͇ ‰È·ÊfiÚˆÓ Ï·ÒÓ Î·È ‰È·ÊÔÚÂÙÈÎÒÓ ÏËı˘ÛÌÒÓ (12). Œ¯ÂÈ ·Ó·ÊÂÚı›, ›Û˘, fiÙÈ ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÔÈÔÙÈ΋ Î·È ÔÛÔÙÈ΋ ›‰Ú·ÛË ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ÔÚÔ‡ (10). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰È·›ÛÙˆÛË Èı·Ó‹˜ ›‰Ú·Û˘ Ù˘ ¯ÚfiÓÈ·˜ ÌÔÓÔıÂڷ›·˜ Ì ٷ Û˘¯ÓfiÙÂÚ· ¯ÔÚËÁÔ‡ÌÂÓ· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η (ηڂ·Ì·˙›ÓË, ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ‹ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË) ÛÙ· ›‰· ÔÚÔ‡ Ù˘ TC, ÙˆÓ ∆G, Ù˘ HDL-C, Ù˘ LDL-C, Ù˘ ApoA-I, Ù˘ ApoB Î·È Ù˘ Lp(a) ÛÙ· ·È‰È¿ Ì ÂÈÏË„›· ÛÙË ¯ÒÚ· Ì·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 151 ÂÈÏËÙÈο ·È‰È¿, Ù· ÔÔ›· ¯ˆÚ›ÛÙËÎ·Ó Û 3 ÔÌ¿‰·˜ ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ ÙÔ˘ ·ÓÙÈÂÈÏËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ Ô˘ ÂÏ¿Ì‚·Ó·Ó. ∂Í‹ÓÙ· ¤ÓÙ ·È‰È¿ (32 ·ÁfiÚÈ·, 33 ÎÔÚ›ÙÛÈ·) ‹Ù·Ó Û ÌÔÓÔıÂڷ›· Ì ηڂ·Ì·˙›ÓË, 48 (22 ·ÁfiÚÈ·, 26 ÎÔÚ›ÙÛÈ·) Ì ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ Î·È 38 (18 ·ÁfiÚÈ·, 20 ÎÔÚ›ÙÛÈ·) Ì ʷÈÓÔ‚·Ú‚ÈÙ¿ÏË. ∏ ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÏ¿Ì‚·Ó·Ó ηڂ·Ì·˙›ÓË ‹Ù·Ó ÌÂٷ͇ 2 Î·È 13,5 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 8,5 ¤ÙË), ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ 2 ¤ˆ˜ 14 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 8,8 ¤ÙË) Î·È ÂÎÂ›ÓˆÓ Ô˘ ÂÏ¿Ì‚·Ó·Ó Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÌÂٷ͇ 6 ÌËÓÒÓ Î·È 4 ÂÙÒÓ (‰È¿ÌÂÛË ËÏÈΛ·: 2,4 ¤ÙË). ŸÏ· Ù· ·È‰È¿ ˘Ô‚Ï‹ıËÎ·Ó Û ϋÚË ÎÏÈÓÈ΋ ÂͤٷÛË, ÂÓÒ ÂÏ‹ÊıË ·fi ÙÔ˘˜ ÁÔÓ›˜ Ï‹Ú˜ ·ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∞ÔÎÏ›ÛÙËÎÂ Ë ·ÚÔ˘Û›· ¿ÏÏÔ˘ ÓÔÛ‹Ì·ÙÔ˜, Ë Ï‹„Ë ¿ÏÏˆÓ Ê·ÚÌ¿ÎˆÓ Î·È Ë ‡·ÚÍË ıÂÙÈÎÔ‡ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÚÒÈÌ˘ ·ıËڈ̿وÛ˘. ŸÏ· Ù· ·È‰È¿ ‚Ú›ÛÎÔÓÙ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· 6 Ì‹Ó˜ ÛÙËÓ ›‰È· ·ÓÙÈÂÈÏËÙÈ΋ Ê·Ú̷΢ÙÈ΋ ÌÔÓÔıÂڷ›·. ™Â fiÏ· Ù· ·È‰È¿ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙÔÓ ÔÚfi Ù· ›‰· Ù˘ TC Î·È ÙˆÓ TG. ™Â 76 ·È‰È¿, ·fi Ù· ÔÔ›· 28 (13 ·ÁfiÚÈ·, 15 ÎÔÚ›ÙÛÈ·) ÂÏ¿Ì‚·Ó·Ó ηڂ·Ì·˙›ÓË, 24 (12 ·ÁfiÚÈ·, 12 ÎÔÚ›ÙÛÈ·) ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ Î·È 24 (11 ·ÁfiÚÈ·, 13 ÎÔÚ›ÙÛÈ·) Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ù· ›‰· Ù˘ LDL-C, HDL-C Î·È Lp(a) Î·È Û 85 ·È‰È¿, ·fi Ù· ÔÔ›· 32 (16
Paediatriki 2003;66:202-207
·ÁfiÚÈ·, 16 ÎÔÚ›ÙÛÈ·) ‹Ù·Ó Û ÌÔÓÔıÂڷ›· Ì ηڂ·Ì·˙›ÓË, 28 (13 ·ÁfiÚÈ·, 15 ÎÔÚ›ÙÛÈ·) Ì ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ Î·È 25 (12 ·ÁfiÚÈ·, 13 ÎÔÚ›ÙÛÈ·) Ì ʷÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ù· ›‰· Apo∞-I Î·È Apoµ. ∆· Â˘Ú‹Ì·Ù· Û˘ÁÎÚ›ıËÎ·Ó Ì ÂΛӷ ˘ÁÈÒÓ ·È‰ÈÒÓ ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘. ∆· ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜, Ù· ÔÔ›· ÂÏ‹ÊıËÛ·Ó ÚˆÈÓ‹ ÒÚ· ÌÂÙ¿ ·fi 12ˆÚË ÓËÛÙ›·, Ê˘Ï¿ÛÛÔÓÙ·Ó ÌÂÙ¿ ÙÔ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ÔÚÔ‡ Û ıÂÚÌÔÎÚ·Û›· -40ÔC Î·È ÔÈ ÌÂÙÚ‹ÛÂȘ Á›ÓÔÓÙ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÚÒÙˆÓ Â‚‰ÔÌ¿‰ˆÓ ·fi ÙËÓ ·ÈÌÔÏË„›·. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ¤ÁÈÓ Ì ÂÓ˙˘ÌÈ΋ ¯ÚˆÌ·ÙÔÌÂÙÚÈ΋ ̤ıÔ‰Ô Û ·Ó·Ï˘Ù‹ Hitachi 704 Û ıÂÚÌÔÎÚ·Û›· 30ÔC Î·È Ì ÔÚfiÙ˘Ô˘˜ Ù˘ Boehringer Mannheim. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ HDL-C ¤ÁÈÓ ÛÙÔ ˘ÂÚΛÌÂÓÔ ÛÙÚÒÌ· ÌÂÙ¿ ·fi ηٷÎÚ‹ÌÓÈÛË ÙˆÓ VLDL Î·È LDL-C Ì ʈÛÊÔÚÔ‚ÔÏÊÚ·ÌÈÎfi Ô͇ Î·È Ì·ÁÓ‹ÛÈÔ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ApoA-I Î·È ApoB ¤ÁÈÓ Ì ·ÓÔÛÔıÔψÛÈÌÂÙÚÈ΋ ̤ıÔ‰Ô SPIA (Serum Protein Immunoassay). ∏ Lp(a) ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ, ›Û˘, Ì ·ÓÔÛÔıÔψÛÈÌÂÙÚÈ΋ ̤ıÔ‰Ô ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÓÂÊÂÏfiÌÂÙÚÔ Behring. ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ LDL-C ˘ÔÏÔÁ›ÛÙËΠ·fi ÙÔÓ Ù‡Ô ÙˆÓ Friedwald Î·È Û˘Ó. °È· ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÛÙ·ÙÈÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ t (t-test) Î·È Mann Whitney Î·È ÔÈ Û˘Û¯ÂÙ›ÛÂȘ ηٿ Pearson Î·È Spearman. ∆È̤˜ p<0,05 ıˆڋıËÎ·Ó ˆ˜ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜.
∞ÔÙÂϤÛÌ·Ù· ∆· ›‰· ÛÙÔÓ ÔÚfi ÙˆÓ TC, LDL-C Î·È HDL-C ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ Û ۇÁÎÚÈÛË Ì ÂΛӷ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÌfiÓÔ ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·È‰ÈÒÓ ˘fi ·ÁˆÁ‹ Ì ηڂ·Ì·˙›ÓË Î·È Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË (¶›Ó·Î˜ 1 Î·È 2) (∂ÈÎfiÓ˜ 1 Î·È 2). ∞ÓÙ›ıÂÙ·, ÛÙ· ›‰· ÙˆÓ TG ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Û η̛· ·fi ÙȘ ÔÌ¿‰Â˜. ∆· ›‰· Ù˘ Lp(a) ÛÙÔÓ ÔÚfi ·˘Í‹ıËÎ·Ó Û fiϘ ÙȘ ÔÌ¿‰Â˜ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ·ÏÏ¿ Ë ‰È·ÊÔÚ¿ ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∆· ›‰· Ù˘ Apo∞-I Î·È Apoµ ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÌfiÓÔ ÛÙ· ·È‰È¿ Ô˘ ÂÏ¿Ì‚·Ó·Ó ηڂ·Ì·˙›ÓË Î·È Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË (¶›Ó·Î·˜ 3) (∂ÈÎfiÓ· 3). ¢ÂÓ ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙȘ ·ÓˆÙ¤Úˆ ·Ú·Ì¤ÙÚÔ˘˜ ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ, ÌÔÏÔÓfiÙÈ ÔÈ Ì¤Û˜ ÙÈ̤˜ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÔÚÔ‡ ÙˆÓ TC, LDLC, HDL-C, Apo∞-I Î·È Apoµ ‹Ù·Ó ÈÔ ·˘ÍË̤Ó˜ ÛÙ· ·ÁfiÚÈ· ÛÙËÓ ÔÌ¿‰· Ù˘ ηڂ·Ì·˙›Ó˘ Î·È ÛÙ· ÎÔÚ›ÙÛÈ· ÛÙËÓ ÔÌ¿‰· Ù˘ Ê·ÈÓÔ‚·Ú‚ÈÙ¿Ï˘. ™Â η̛· ·fi ÙȘ ÔÌ¿‰Â˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‰ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ÏÈȉ›ˆÓ, ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ Î·È Ù˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ıÂڷ›·˜ ·ÊÂÓfi˜ Î·È ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ô˘ÛÈÒÓ ÛÙÔ ·›Ì· ·ÊÂÙ¤ÚÔ˘. ™˘˙‹ÙËÛË OÈ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÏÈȉ›ˆÓ, ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ ıˆÚÔ‡ÓÙ·È ˆ˜ ·ÚÈÔÈ
203
May-June 03
03-06-03
16:55
™ÂÏ›‰·204
¶·È‰È·ÙÚÈ΋ 2003;66:202-207
Paediatriki 2003;66:202-207
·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ·ıËڈ̿وÛ˘ ηÈ, Û˘ÁÎÂÎÚÈ̤ӷ, Ù· ˘„ËÏ¿ ›‰· TC Î·È LDL-C Û¯ÂÙ›˙ÔÓÙ·È ıÂÙÈο Ì ÙÔÓ Î›Ó‰˘ÓÔ ·ıËڈ̿وÛ˘, ÂÓÒ Ù· ˘„ËÏ¿ ›‰· HDL-C ·ÚÓËÙÈο (13). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ TC Î·È Ù˘ LDL-C Î·È Ë ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ HDLC ÛÙÔÓ ÔÚfi ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ˘Ô¯ÒÚËÛË Ù˘ ·ıËڈ̿وÛ˘ Î·È Û ÂÏ¿ÙÙˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ Î·È Ù˘ ÓÔÛËÚfiÙËÙ·˜ Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔ ·›Ì·, ÌÔÏÔÓfiÙÈ Ù· Â˘Ú‹Ì·Ù· ÔÈΛÏÏÔ˘Ó Î·È Û ÌÂÚÈΤ˜ ÌÂϤÙ˜ Â›Ó·È ·ÓÙÈÊ·ÙÈο (1-11). ∏ ·È‰È΋ ÂÈÏË„›· ··ÈÙ› Û˘¯Ó¿ Ì·ÎÚÔ¯ÚfiÓÈ· ·ÁˆÁ‹ Ì ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÌÂÌÔӈ̤ӷ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi. ∏ ηڂ·Ì·˙›ÓË, Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· Ê¿Ú̷η ÚÒÙ˘ ÂÈÏÔÁ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘.
∞‡ÍËÛË Ù˘ TC, Ù˘ HDL-C Î·È Ù˘ LDL-C ÛÙÔÓ ÔÚfi Û ·ÛıÂÓ›˜ Ì ÂÈÏË„›· ˘fi ıÂڷ›· Ì ηڂ·Ì·˙›ÓË, fiˆ˜ ‚Ú¤ıËÎÂ Î·È ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ¤¯ÂÈ ‰È·ÈÛÙˆı› Î·È Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (4,8). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ù· ›‰· ÙˆÓ TG ‰ÂÓ ÌÂÙ·‚Ï‹ıËÎ·Ó ÛËÌ·ÓÙÈο ÛÙ· ·È‰È¿ Ì ϋ„Ë Î·Ú‚·Ì·˙›Ó˘, fiˆ˜ ¤¯ÂÈ ·Ó·ÊÂÚı› Î·È ÛÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (2,11). ∏ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Ë ÔÔ›· ¤¯ÂÈ ·ÚfiÌÔȘ ·ÁˆÁÈΤ˜ ȉÈfiÙËÙ˜ Ì ÙËÓ Î·Ú‚·Ì·˙›ÓË, ÚÔηÏ› ·ÚfiÌÔȘ ‰È·Ù·Ú·¯¤˜ ÛÙ· ÏÈ›‰È· Î·È ÛÙȘ ÏÈÔÚˆÙ½Ó˜ ÙÔ˘ ÔÚÔ‡ (1,2,4). ∆· ‰Â‰Ô̤ӷ ÁÈ· ÙÔÓ ·ıÔÁÂÓÂÙÈÎfi Ì˯·ÓÈÛÌfi ÙˆÓ ÌÂÙ·‚ÔÏÒÓ ·˘ÙÒÓ ‰ÂÓ Â›Ó·È ÙÂÏ›ˆ˜ ÍÂοı·Ú·. ∏ ηڂ·Ì·˙›ÓË Î·È Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È Â¿ÁÔÓÙ·˜ Ù· Ë·ÙÈο ÌÈÎÚÔÛˆÌȷο ¤Ó˙˘Ì· Î·È ÚÔηÏÔ‡Ó ÌÂÙ·‚ÔϤ˜ ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ, Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘, ÙˆÓ ÏÈȉ›ˆÓ, Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È ¿ÏÏˆÓ Â͈ÁÂÓÒÓ Ê·Ú̿ΈÓ
¶›Ó·Î·˜ 1. ∂›Â‰· TC Î·È TG ÔÚÔ‡ Û ·ÛıÂÓ›˜ Î·È Ì¿ÚÙ˘Ú˜ º¿Ú̷η ñ ∫·Ú‚·Ì·˙›ÓË ª¿ÚÙ˘Ú˜ ñ µ·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ª¿ÚÙ˘Ú˜ ñ º·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ª¿ÚÙ˘Ú˜
∞ÚÈıÌfi˜ ·È‰ÈÒÓ
TC (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
TG (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
65 71 48 70 38 56
211,7±33,8 152,2±33,9 158,3±35,2 151,8±34,9 201,7±25,9 148,1±29,1
<0,01
108,5±37,0 104,8±42,9 96,5±42,5 105,1±42,3 87,8±32,6 84,1±37,2
ª™
ª™ <0,01
ª™ ª™
250
200 ÃÔÏËÛÙÂÚfiÏË (mg/dl) 150
∆ÚÈÁÏÈÎÂÚ›‰È· (mg/dl)
100
50
0
›ÓË ˜1 Ù˘Ú ·Ì·˙ ª¿Ú K·Ú‚
ÚÔ˚Îfi µ·Ï ÈÔ Ó¿ÙÚ
Ë ˜2 ˜3 ‚ÈÙ¿Ï Ù˘ÚÂ Ù˘Ú Ԃ·Ú ª¿Ú ª¿Ú º·ÈÓ
∂ÈÎfiÓ· 1. ª¤ÛË ÙÈÌ‹ ÙˆÓ ÂȤ‰ˆÓ Ù˘ TC Î·È ÙˆÓ TG Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜.
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¶›Ó·Î·˜ 2. ∂›Â‰· HDL-C, LDL-C Î·È Lp(a) ÔÚÔ‡ Û ·ÛıÂÓ›˜ Î·È Ì¿ÚÙ˘Ú˜ º¿Ú̷η
∞ÚÈıÌfi˜ ·È‰ÈÒÓ
ñ ∫·Ú‚·Ì·˙›ÓË ª¿ÚÙ˘Ú˜ ñ µ·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ª¿ÚÙ˘Ú˜ ñ º·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ª¿ÚÙ˘Ú˜
28 42 24 40 24 36
HDL-C (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
LDL-C (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
Lp(a) (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
61,2±13,2 51,3±15,7 51,1±11,5 51,8±15,3 54,5±13,0 43,0±15,1
<0,01
125,1±25,2 108,8±28,1 98,4±18,1 109,2±28,4 124,0±32,6 104,5±27,2
<0,05
17,8±20,1 14,8±17,3 17,6±18,2 15,1±17,5 18,5±18,1 12,3±22,0
ª™
ª™ <0,01
ª™ <0,05
ª™ ª™
140 120 HDL-C (mg/dl)
100 80
LDL-C (mg/dl)
60 Lp(a) (mg/dl) 40 20 10
›ÓË ·Ì·˙ K·Ú‚
˜1 Ù˘Ú ª¿Ú
ÚÔ˚Îfi µ·Ï ÈÔ Ó¿ÙÚ
˜2 Ù˘Ú ª¿Ú
Ë ‚ÈÙ¿Ï Ô‚·Ú º·ÈÓ
˜3 Ù˘Ú ª¿Ú
∂ÈÎfiÓ· 2. ª¤ÛË ÙÈÌ‹ ÙˆÓ ÂȤ‰ˆÓ Ù˘ HDL-C, LDL-C Î·È Lp(a) Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜.
Ô˘ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È ·fi Ù· ¤Ó˙˘Ì· ·˘Ù¿. ∆· ·ÓÙÈÂÈÏËÙÈο ·˘Ù¿ Ê¿Ú̷η ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙË ¯ÔÏËÛÙÂÚfiÏË Î·È Ù· ¿ÏÏ· ÏÈ›‰È· ÛÙȘ ı¤ÛÂȘ Û‡Ó‰ÂÛ˘ Ì ÙÔ Ë·ÙÈÎfi ΢ÙÙfi¯ÚˆÌ· ƒ450, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘˜ (8,9). O Ì˯·ÓÈÛÌfi˜ ·˘Ùfi˜, fï˜, ‰ÂÓ ıˆÚÂ›Ù·È ·ÚÎÂÙfi˜ ÁÈ· Ó· ÂÍËÁ‹ÛÂÈ ÙËÓ ·‡ÍËÛË ÙˆÓ ÏÈȉ›ˆÓ, ·ÊÔ‡ ¿ÏÏ· Ê¿Ú̷η, fiˆ˜ Ë ÚÈÊ·ÌÈΛÓË Ô˘ Â›Ó·È ÂÓ˙˘ÌÈÎfi˜ ·ÁˆÁ¤·˜, ‰ÂÓ ÚÔηÏÔ‡Ó ·Ó¿ÏÔÁË ·‡ÍËÛË. ÕÏÏÔ ¤Ó˙˘ÌÔ Ô˘ ¿ÁÂÙ·È ·fi Ù· ·ÓÙÈÂÈÏËÙÈο Â›Ó·È ÙÔ ˘‰ÚÔ͢ÌÂı˘Ï-ÁÏÔ˘Ù·Ú˘ÏÔ Û˘Ó¤Ó˙˘ÌÔ ∞, Ô˘ ηٷχÂÈ ÙË Û‡ÓıÂÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘. ∏ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Î·È Ë Î·Ú‚·Ì·˙›ÓË ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ·‡ÍËÛË - ¤ˆ˜ Î·È ‰ÈÏ·ÛÈ·ÛÌfi - ÙÔ˘ Ë·ÙÈÎÔ‡ ˘‰ÚÔ͢ÌÂı˘Ï-ÁÏÔ˘Ù·Ú˘ÏÔ Û˘ÓÂÓ˙‡ÌÔ˘ ∞, ηٷϋÁÔÓÙ·˜ Û ·˘ÍË̤ÓË Û‡ÓıÂÛË ¯ÔÏËÛÙÂÚfiÏ˘. ÕÏÏÔ˜ Ì˯·ÓÈÛÌfi˜, Ô˘ ›Ûˆ˜ ı· ÌÔÚÔ‡Û ӷ ÂÍËÁ‹ÛÂÈ ÙȘ ÌÂÙ·‚ÔϤ˜ ÙˆÓ ÏÈȉ›ˆÓ Û ÂÚÈÙÒÛÂȘ ¯ÔÚ‹ÁËÛ˘ Ê·ÚÌ¿ÎˆÓ Ì ·ÁˆÁÈ΋ ‰Ú¿ÛË, fiˆ˜ Â›Ó·È Ë Î·Ú‚·Ì·˙›ÓË Î·È Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, Â›Ó·È ÔÈ ÔÚÌÔÓÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Î·Ù¿ ÙË ¯ÚfiÓÈ· ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹. ∏ Ì›ˆÛË Ù˘ Âχ-
ıÂÚ˘ ı˘ÚÔ͛Ӣ Î·È Ù˘ ıÂÈÈ΋˜ ‰Â¸‰ÚÔÂÈ·Ó‰ÚÔÛÙÂÚfiÓ˘ Â›Ó·È ·fi ÙȘ ΢ÚÈfiÙÂÚ˜ ÔÚÌÔÓÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ÂÓ˙˘ÌÈ΋ ·ÁˆÁ‹. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ÔÚÌÔÓÒÓ ·˘ÙÒÓ Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤ÓË ÛÙ¿ıÌË ÏÈȉ›ˆÓ ÛÙÔÓ ÔÚfi. Ÿˆ˜ ‚Ú¤ıËΠÙfiÛÔ ÛÙËÓ ·ÚÔ‡Û·, fiÛÔ Î·È Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜, ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ‰ÂÓ ÌÂÙ·‚¿ÏÏÂÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔÓ ÔÚfi (2,4,7,9,11). ∞˘Ùfi ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ‚·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ‰ÂÓ ¤¯ÂÈ Â·ÁˆÁÈΤ˜ ȉÈfiÙËÙ˜ Î·È Ë Î‡ÚÈ· Ô‰fi˜ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ Â›Ó·È Ë Û‡˙¢͋ ÙÔ˘ Ì ÙÔ ÁÏ˘ÎÔ˘ÚÔÓÈÎfi Ô͇ Î·È Ë ‚-ÔÍ›‰ˆÛË. £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, fï˜, fiÙÈ Û¿ÓÈ· ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ Î·È ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ Î·È, ΢ڛˆ˜, Ù˘ TC, ÙˆÓ TG Î·È Ù˘ LDL-C, Ì ·‰È¢ÎÚ›ÓÈÛÙÔ Ì˯·ÓÈÛÌfi (8). ∆· ˘„ËÏ¿ ›‰· Lp(a) ıˆÚÔ‡ÓÙ·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ·ıËÚÔÁ¤ÓÂÛ˘ Î·È ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, ÂÂȉ‹ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ·fiÊÚ·ÍË ÙˆÓ ÌÈÎÚÒÓ ·ÁÁ›ˆÓ ÂÍ·ÈÙ›·˜
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¶›Ó·Î·˜ 3. ∂›Â‰· ApoA-I Î·È ApoB ÔÚÔ‡ Û ·ÛıÂÓ›˜ Î·È Ì¿ÚÙ˘Ú˜ º¿Ú̷η ñ ∫·Ú‚·Ì·˙›ÓË ª¿ÚÙ˘Ú˜ ñ µ·ÏÚÔ˚Îfi Ó¿ÙÚÈÔ ª¿ÚÙ˘Ú˜ ñ º·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ª¿ÚÙ˘Ú˜
∞ÚÈıÌfi˜ ·È‰ÈÒÓ
ApoA-I (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
ApoB (mg/dl) (ª¤ÛË ÙÈÌ‹)
p
32 35 28 34 25 26
192,1±27,2 131,2±43,9 142,9±39,2 131,7±42,9 156,9±27,7 128,1±39,3
<0,01
101,3±27,7 74,8±17,9 84,5± 26,1 75,2±17,4 99,7±23,61 72,2±17,2
<0,01
ª™ <0,01
ª™ <0,01
250
200
150
ApoA-I (mg/dl)
100
ApoB (mg/dl)
50
0 ›ÓË ·Ì·˙ ‚ Ú · K
˜1 Ù˘Ú ª¿Ú
ÚÔ˚Îfi µ·Ï ÈÔ Ó¿ÙÚ
˜2 Ù˘Ú ª¿Ú
Ë ‚ÈÙ¿Ï Ô‚·Ú º·ÈÓ
˜3 Ù˘Ú ª¿Ú
∂ÈÎfiÓ· 3. ª¤ÛË ÙÈÌ‹ ÙˆÓ ÂȤ‰ˆÓ Ù˘ ApoA-I Î·È ApoB Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Î·È ÛÙÔ˘˜ Ì¿ÚÙ˘Ú˜.
ÙˆÓ ·ÓÙÈÈÓˆ‰ÔÏ˘ÙÈÎÒÓ È‰ÈÔÙ‹ÙˆÓ ÙÔ˘˜. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ·Ó Î·È Ë Lp(a) ·˘Í¿ÓÂÙ·È Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·È‰ÈÒÓ, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÙ·È Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ›‰Ô. À¿Ú¯Ô˘Ó ÌfiÓÔ ‰‡Ô ÚÔËÁÔ‡ÌÂÓ˜ ·ÚfiÌÔȘ ÌÂϤÙ˜. ™ÙËÓ ÚÒÙË ÌÂϤÙË ‰ÂÓ ‚Ú¤ıËΠӷ ÂËÚ¿˙ÔÓÙ·È Ù· ›‰· Ù˘ Lp(a) (8), ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÌÂϤÙË ‚Ú¤ıËΠ·˘ÍË̤ÓË Û fiϘ ÙȘ ÔÌ¿‰Â˜, ÌÔÏÔÓfiÙÈ Ë ·‡ÍËÛË ·˘Ù‹ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÌfiÓÔ ÛÙ· ·È‰È¿ Ì ϋ„Ë Ê·ÈÓÔ‚·Ú‚ÈÙ¿Ï˘ (11). ∏ ·ÁˆÁ‹ ÙˆÓ Ë·ÙÈÎÒÓ ÌÈÎÚÔÛˆÌÈ·ÎÒÓ ÂÓ˙‡ÌˆÓ ·fi ÙËÓ Î·Ú‚·Ì·˙›ÓË Î·È ÙËÓ Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË ÌÔÚ› Ó· ıˆÚËı› ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ·‡ÍËÛË ·˘Ù‹ (9), ·ÏÏ¿ Â›Ó·È ¿ÁÓˆÛÙÔ˜ Ô Ì˯·ÓÈÛÌfi˜ ÁÈ· ÙËÓ ·‡ÍËÛË Ù˘ Lp(a) Ì ÙË Ï‹„Ë ÙÔ˘ ‚·ÏÚÔ˚ÎÔ‡ Ó·ÙÚ›Ô˘. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ÂӉ¯Ô̤ӈ˜ ı· ‰ÒÛÔ˘Ó ·¿ÓÙËÛË Û ·˘Ùfi ÙÔ ÂÚÒÙËÌ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙ· ›‰· ÙˆÓ ·ÔÏÈÔÚˆÙÂ˚ÓÒÓ, ˘¿Ú¯Ô˘Ó ÌfiÓÔ Ï›Á˜ ÌÂϤÙ˜ (1,7,11). ªÔÏÔ-
206
ÓfiÙÈ Ù· ›‰· Ù˘ HDL-C Î·È Ù˘ LDL-C ÛÙÔÓ ÔÚfi Û˘¯Ó¿ ·Ó·Ê¤ÚÔÓÙ·È ·˘ÍË̤ӷ Û ¿ÙÔÌ· Ô˘ Ï·Ì‚¿ÓÔ˘Ó Â·ÁˆÁÈο ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, ÔÈ ApoA-I Î·È ApoB, Ô˘ ·ÔÙÂÏÔ‡Ó Î·È ÙȘ ·ÚȘ ÚˆÙ½Ó˜ ÙˆÓ HDL-C Î·È HDL-C ·ÓÙ›ÛÙÔȯ·, Û¿ÓÈ· ‚Ú›ÛÎÔÓÙ·È ÂËÚ·Ṳ̂Ó˜, fiˆ˜ ‰È·ÈÛÙÒıËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË (1). ∂›Ó·È Èı·Ófi Ë Â·ÁˆÁ‹ ÙˆÓ ÌÈÎÚÔÛˆÌÈ·ÎÒÓ ÂÓ˙‡ÌˆÓ ·fi ÙËÓ Î·Ú‚·Ì·˙›ÓË Î·È ÙË Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË Ó· ÚÔηÏ› ·˘ÍË̤ÓË Ë·ÙÈ΋ Û‡ÓıÂÛË Ù˘ ApoA-I Î·È ApoB. Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Ù· ¿ÙÔÌ· Ì ¯ÚfiÓÈ· ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ¤¯Ô˘Ó ÁÂÓÈο ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (14). ∫·ıÒ˜ ÈÛÙ‡ÂÙ·È fiÙÈ Ù· ·˘ÍË̤ӷ ›‰· Ù˘ HDL-C ÌÂÈÒÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (13), Ë ·Ó·ÊÂÚfiÌÂÓË ÌÂȈ̤ÓË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Û ÂÈÏËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ Û ·‡ÍËÛË Ù˘ HDL-C (4,8). ŸÌˆ˜, Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ıˆÚ› fiÙÈ Ù· ·˘ÍË̤ӷ Ëϛη TC/HDL-C Î·È LDL-C/HDL-C ›ӷÈ
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 08-07-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ∞. µÔ‡‰Ú˘ ¡Â˘ÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, £Ë‚ÒÓ & §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó· E-mail: kvoudris@otenet.gr
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CASE REPORT
™‡Ó‰ÚÔÌÔ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÛÙÔÓ ‡ÓÔ Û˘Óԉ¢fiÌÂÓÔ ·fi Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË ∂. ∞ÏÂÍfiÔ˘ÏÔ˜, ∞. ∫·‰›Ù˘, µ. ªÈÎÚ¿ÎË, ∂. ∫ˆÛÙ·‰‹Ì·, ¡. ™ÎÂÓÙ¤Ú˘, ∫. °Ô˘ÚÁÔ˘ÏÈ¿Ó˘
Obstructive sleep apnoea syndrome accompanied by nocturnal enuresis E. Alexopoulos, A. Kaditis, V. Mikraki, E. Kostadima, N. Skenteris, K. Gourgoulianis
¶ÂÚ›ÏË„Ë: ∏ Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË ıˆÚÂ›Ù·È ÂÈÏÔ΋ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÙÔ˘ ‡ÓÔ˘, ÂÂȉ‹ Û˘¯Ó¿ ˘Ô¯ˆÚ› ÌÂÙ¿ ·fi ·Ì˘Á‰·ÏÂÎÙÔÌ‹ Î·È ·‰ÂÓÔÂȉÂÎÙÔÌ‹, ÔÈ Ôԛ˜ ·ÔÛÎÔÔ‡Ó ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ‚·ÙfiÙËÙ·˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·ÂÚ·ÁˆÁÔ‡. øÛÙfiÛÔ, ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ̤¯ÚÈ Û‹ÌÂÚ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, Ë ˘Ô¯ÒÚËÛË Ù˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ Èı·ÓÔÏÔÁ‹ıËΠ·fi ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Î·È ‰ÂÓ ÙÂÎÌËÚÈÒıËΠ̠ÔÏ˘Î·Ù·ÁÚ·ÊÈ΋ ÌÂϤÙË ‡ÓÔ˘ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ì˘Á‰·ÏÂÎÙÔÌ‹/·‰ÂÓÔÂȉÂÎÙÔÌ‹. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 9 ÂÙÒÓ Ì ÈÛÙÔÚÈÎfi ηı’ ¤ÍÈÓ ÚÔ¯·ÏËÙÔ‡ Î·È ÚˆÙÔ·ıÔ‡˜ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘, Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ÔÔ›Ô˘ ˘Ô¯ÒÚËÛ·Ó ÌÂÙ¿ ·fi Û˘Ó‰˘·Ṳ̂ÓË ·Ì˘Á‰·ÏÂÎÙÔÌ‹ Î·È ·‰ÂÓÔÂȉÂÎÙÔÌ‹. ¶ÔÏ˘·Ú·ÌÂÙÚÈ΋ ÌÂϤÙË ‡ÓÔ˘ Ô˘ ¤ÁÈÓ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË ·Ó¤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ. ∂Í·ÈÙ›·˜ Ù˘ Èı·Ó‹˜ Û˘Û¯¤ÙÈÛ˘ Ù˘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ Ì ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ, ÏÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È Û fiÏ· Ù· ·È‰È¿ Ô˘ ÚÔÛÎÔÌ›˙ÔÓÙ·È ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÓÔ‡ÚËÛ˘. £Âڷ›· Ù˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÙÔ˘ ‡ÓÔ˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ˘Ô¯ÒÚËÛË Ù˘ ÂÓÔ‡ÚËÛ˘.
Abstract: A causative link between nocturnal enuresis and obstructive sleep apnoea (OSA) in children has been suggested, since bedwetting frequently improves or resolves completely after adenotonsillectomy for the relief of upper airway obstruction. However, in the patients reported in the paediatric literature, the improvement of sleepdisordered breathing was not assessed by comparing preoperative and postoperative polysomnography findings. This is a report of a child with a long history of snoring and primary nocturnal enuresis whose symptoms ceased following adenotonsillectomy for OSA. Polysomnograms performed before and after the surgical procedure demonstrated appreciable improvement in the sleep pattern. Since nocturnal enuresis has been associated with sleepdisordered breathing, questions regarding respiratory symptoms during sleep should be asked in children undergoing an evaluation for bedwetting. Treatment of OSA may contribute to resolution of enuresis.
§¤ÍÂȘ ÎÏÂȉȿ: ·ÔÊÚ·ÎÙÈ΋ ¿ÓÔÈ· ÙÔ˘ ‡ÓÔ˘, ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ, Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË, ·Ì˘Á‰·ÏÂÎÙÔÌ‹, ·‰ÂÓÔÂȉÂÎÙÔÌ‹.
Key words: obstructive sleep apnoea syndrome, sleep disordered breathing, nocturnal enuresis, adenoidectomy, tonsillectomy.
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Pediatric and Respiratory Medicine Clinic of University of Thessalia Department of Pediatric Respiratory Medicine and Laboratory for the Study of Sleep and Breathing Disorders, University Hospital of Larissa
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¶·È‰È·ÙÚÈ΋ 2003;66:208-210
∂ÈÛ·ÁˆÁ‹ Œ¯ÂÈ ‰È·Ù˘ˆı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Ë ¿Ô„Ë fiÙÈ Î¿ÔȘ ÂÚÈÙÒÛÂȘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ ·ÔÙÂÏÔ‡Ó ÂÈÏÔ΋ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÙÔ˘ ‡ÓÔ˘ (1,2). ∏ ı¤ÛË ·˘Ù‹, fï˜, ‰ÂÓ ÛÙËÚ›˙ÂÙ·È Û ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, ·ÏÏ¿ ÛÙË ‚ÂÏÙ›ˆÛË ‹ Î·È Ï‹ÚË ˘Ô¯ÒÚËÛË Ù˘ ÂÓÔ‡ÚËÛ˘ ÌÂÙ¿ ÙË ıÂڷ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ ÙÔ˘ ‡ÓÔ˘ (™∞∞À) (3-5). øÛÙfiÛÔ, ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ̤¯ÚÈ Û‹ÌÂÚ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ¤¯ÂÈ Á›ÓÂÈ ÔÏ˘Î·Ù·ÁÚ·ÊÈ΋ ÌÂϤÙË ‡ÓÔ˘ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ì˘Á‰·ÏÂÎÙÔÌ‹/·‰ÂÓÔÂȉÂÎÙÔÌ‹, ÂÓÒ Ë ˘Ô¯ÒÚËÛË ÙÔ˘ ™∞∞À Èı·ÓÔÏÔÁ‹ıËΠ·fi ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ÚÔ¯·ÏËÙfi, ·Ó‹Û˘¯Ô ‡ÓÔ, ™∞∞À Î·È ÚˆÙÔ·ı‹ Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË, Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ÔÔ›Ô˘ Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ÔÏ˘Î·Ù·ÁÚ·ÊÈ΋˜ ÌÂϤÙ˘ ‚ÂÏÙÈÒıËÎ·Ó ÌÂÙ¿ ÙË Û˘Ó‰˘·Ṳ̂ÓË ·Ì˘Á‰·ÏÂÎÙÔÌ‹/ ·‰ÂÓÔÂȉÂÎÙÔÌ‹. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 9 ÂÙÒÓ ÚÔÛÎÔÌ›ÛÙËΠÛÙÔ ÁÂÓÈÎfi ·È‰È·ÙÚÈÎfi È·ÙÚ›Ô, ηıÒ˜ ·ÚÔ˘Û›·˙ ڈÙÔ·ı‹ Ó˘ÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË Û¯Â‰fiÓ Î¿ı ‚Ú¿‰˘. OÈ ÁÔÓ›˜ ·Ó¤ÊÂÚ·Ó ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 3,5 ÂÙÒÓ. ∆· Û˘ÌÙÒÌ·Ù· ÂÚÈÂÏ¿Ì‚·Ó·Ó ˘ÓËÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜, ·Ó·ÓÔ‹ ·fi ÙÔ ÛÙfiÌ· ÙfiÛÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ fiÛÔ Î·È Î·Ù¿ ÙËÓ ÂÁÚ‹ÁÔÚÛË, ˯ËÚfi ÚÔ¯·ÏËÙfi οı ‚Ú¿‰˘ Î·È ¿ÓÔȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘. ¶ÚfiÛÊ·ÙË ÚÔÛ¿ıÂÈ· ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ Ì ÙÚÔÔÔ›ËÛË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ ‰ÂÓ Â›¯Â ·ÔÙ¤ÏÂÛÌ·. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÈÛÙÒıËÎ·Ó ÛÙÔÌ·ÙÈ΋ ·Ó·ÓÔ‹ Î·È ˘ÂÚÙÚÔÊÈΤ˜ ·Ì˘Á‰·Ï¤˜ Ô˘ ·¤ÊÚ·ÛÛ·Ó Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ÙËÓ Â›ÛÔ‰Ô ÙÔ˘ ÛÙÔÌ·ÙÔÊ¿Ú˘ÁÁ·. ¶Ï¿ÁÈ· ·ÎÙÈÓÔÁÚ·Ê›· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ· Ì ÙÔ ÛÙfiÌ· ·ÓÔÈÎÙfi ·Ó¤‰ÂÈÍ ̤ÙÚÈÔ˘ ‚·ıÌÔ‡ ˘ÂÚÙÚÔÊ›· ÙˆÓ ·‰ÂÓÔÂȉÒÓ Â΂ϷÛÙ‹ÛˆÓ, ÂÓÒ Ô ˘fiÏÔÈÔ˜ ÎÏÈÓÈÎfi˜ Î·È ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ·¤ÎÏÂÈÛ ¿ÏÏ· ÔÚÁ·ÓÈο ·›ÙÈ· ÛÙ· ÔÔ›· ı· ÌÔÚÔ‡Û ӷ ·Ô‰Ôı› Ë ÂÓÔ‡ÚËÛË. ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠÔÏ˘·Ú·ÌÂÙÚÈ΋ ÌÂϤÙË ‡ÓÔ˘ Ì ˘ÔÏÔÁÈÛÙÈÎfi Û‡ÛÙËÌ· (Alice 4, Respironics, Mariette, GA), ÛÙËÓ ÔÔ›· ηٷÁÚ¿ÊËÎÂ Ë ÚÔ‹ ÙÔ˘ ·¤Ú· ·fi ÙË Ì‡ÙË Î·È ÙÔ ÛÙfiÌ·, ÔÈ ÎÈÓ‹ÛÂȘ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ Î·È ÎÔÈÏÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜, Ô ÎÔÚÂÛÌfi˜ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ, Ë Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· Î·È Ë ·ÏÏ·Á‹ Ù˘ ı¤Û˘ ÙÔ˘ ÛÒÌ·ÙÔ˜. ∂ÈϤÔÓ, ¤ÁÈÓÂ Î·È ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈ΋ ηٷÁÚ·Ê‹ ÁÈ· ÛÙ·‰ÈÔÔ›ËÛË ÙÔ˘ ‡ÓÔ˘. ø˜
Paediatriki 2003;66:208-210
·ÔÊÚ·ÎÙÈ΋ ¿ÓÔÈ· ÙÔ˘ ‡ÓÔ˘ ÔÚ›ÛÙËÎÂ Ë ‰È·ÎÔ‹ Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú· ·fi ÙË Ì‡ÙË Î·È ÙÔ ÛÙfiÌ· ‰È¿ÚÎÂÈ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·Ó·Ó¢ÛÙÈÎÒÓ Î‡ÎψÓ, Ì ٷ˘Ùfi¯ÚÔÓË Î·Ù·ÁÚ·Ê‹ ÎÈÓ‹ÛÂˆÓ Ù˘ ÎÔÈÏÈ¿˜. ø˜ ·ÔÊÚ·ÎÙÈ΋ ˘fiÓÔÈ· ıˆڋıËÎÂ Ë ÂÏ¿ÙÙˆÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ 50% Ù˘ ÚÔ‹˜ ÙÔ˘ ·¤Ú· ·fi ÙË Ì‡ÙË Î·È ÙÔ ÛÙfiÌ·, Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ·Ú¿‰Ô͢ ·Ó·ÓÔ‹˜ Î·È ·ÔÎÔÚÂÛÌfi Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ 4% (6). ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∆Ô ·È‰› ˘Ô‚Ï‹ıËΠ۠·Ì˘Á‰·ÏÂÎÙÔÌ‹ Î·È ·‰ÂÓÔÂȉÂÎÙÔÌ‹. ∏ ˘ÓËÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜ Î·È ÔÈ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ¿ÓÔȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ ˘Ô¯ÒÚËÛ·Ó Ï‹Úˆ˜, ÂÓÒ ÙÔ ÚÔ¯·ÏËÙfi ‚ÂÏÙÈÒıËΠÛËÌ·ÓÙÈο. ∆Ô ·È‰› ·ÚÔ˘Û›·Û ÌfiÓÔ ÙÚ›· ÂÂÈÛfi‰È· Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ ÛÙȘ ÚÒÙ˜ ‰‡Ô ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Î·È Â›Ó·È ÂχıÂÚÔ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 18 Ì‹Ó˜. ŒÁÈÓ Ӥ· ÔÏ˘·Ú·ÌÂÙÚÈ΋ ÌÂϤÙË ‡ÓÔ˘ 6 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™˘˙‹ÙËÛË ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ Û ·È‰È¿ Ì ·ÔÊÚ·ÎÙÈ΋ ¿ÓÔÈ· ÛÙÔÓ ‡ÓÔ ·Ó·Ê¤ÚÔ˘Ó ÂÚÈÙÒÛÂȘ Ì ӢÎÙÂÚÈÓ‹ ÂÓÔ‡ÚËÛË (2,3). OÈ Swift Î·È Û˘Ó ·Ó¤ÊÂÚ·Ó 3 ·È‰È¿ Ì ™∞∞À Î·È ÂÓÔ‡ÚËÛË, ÛÙÔ ¤Ó· ·fi Ù· ÔÔ›· Ë ÂÓÔ‡ÚËÛË ˘Ô¯ÒÚËÛ ÌÂÙÂÁ¯ÂÈÚËÙÈο (4). ª›· ÈÔ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ Î·È Ù˘ ·fiÊڷ͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·ÂÚ·ÁˆÁÔ‡ ¤¯ÂÈ ·ÚÔ˘ÛÈ·ÛÙ› ·fi ÙÔ˘˜ Weider Î·È Û˘Ó (5). ¶ÂÚÈÁÚ¿ÊÔ˘Ó ÙËÓ ÂÌÂÈÚ›· ÙÔ˘˜ ·fi 115 ·ÛıÂÓ›˜ ËÏÈΛ·˜ 3-19 ÂÙÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ·Ì˘Á‰·ÏÂÎÙÔÌ‹ ‹ ·‰ÂÓÔÂȉÂÎÙÔÌ‹ Ì ÔÈΛϘ ÂӉ›ÍÂȘ. ¶·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ó˘ÎÙÒÓ Ì ÂÓÔ˘ÚËÙÈο ÂÂÈÛfi‰È· ηٿ 66% ¤Ó· Ì‹Ó· ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Î·È Î·Ù¿ 76% ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿. ™Â 3 ·fi Ù· 11 ·È‰È¿ Ô˘ ¶›Ó·Î·˜ 1. ∞ÔÙÂϤÛÌ·Ù· ÔÏ˘Î·Ù·ÁÚ·ÊÈÎÒÓ ÌÂÏÂÙÒÓ ¶ÚÈÓ ÙËÓ ªÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Â¤Ì‚·ÛË ™‡ÓÔÏÔ ·ÓÔÈÒÓ ™‡ÓÔÏÔ ˘ÔÓÔÈÒÓ ™‡ÓÔÏÔ ·ÔÎÔÚÂÛÌÒÓ >4% ∞π (‰Â›ÎÙ˘ ·ÓÔÈÒÓ) ∞∏π (‰Â›ÎÙ˘ ·ÓÔÈÒÓ-˘ÔÓÔÈÒÓ) DI (‰Â›ÎÙ˘ ·ÔÎÔÚÂÛÌÒÓ) ∂Ï¿¯ÈÛÙÔ SaO2 ÃÚfiÓÔ˜ ‡ÓÔ˘ Ì SaO2 <95% ÃÚfiÓÔ˜ ‡ÓÔ˘ Ì SaO2 <90% ÃÚfiÓÔ˜ ‡ÓÔ˘ Ì SaO2 <85%
12 41 57 1,5/ÒÚ· 6,6/ÒÚ· 7,1/ÒÚ· 82% 32 min 6 min 0,5 min
4 7 12 0,5/ÒÚ· 1,5/ÒÚ· 1,6/ÒÚ· 93% 1,5 min 0 min 0 min
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¤ÁÈÓ ÔÏ˘Î·Ù·ÁÚ·ÊÈ΋ ÌÂϤÙË ‡ÓÔ˘ ÚÔÂÁ¯ÂÈÚËÙÈο ‚Ú¤ıËΠ™∞∞À. ∏ ÂÓÔ‡ÚËÛË ˘Ô¯ÒÚËÛÂ Î·È ÛÙ· 3 ·È‰È¿ ÌÂÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∏ ˘¤ÚÌÂÙÚË ·Ú·ÁˆÁ‹ Ô‡ÚˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘ ¤¯ÂÈ ÚÔÙ·ı› ˆ˜ ¤Ó·˜ ·fi ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÂÌÊ¿ÓÈÛË Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ (8). ∆· ÂÂÈÛfi‰È· Ù˘ ·ÔÊÚ·ÎÙÈ΋˜ ¿ÓÔÈ·˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÚÓËÙÈ΋ ÂÓ‰ÔıˆÚ·ÎÈ΋ ›ÂÛË, ·˘ÍË̤ÓË ÊÏ‚È΋ ÂÈÛÙÚÔÊ‹, ‰È¿Ù·ÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÎfiÏÔ˘ Î·È ¤ÎÎÚÈÛË ÎÔÏÈÎÔ‡ Ó·ÙÚÈÔ‰ÈÔ˘ÚËÙÈÎÔ‡ ÂÙȉ›Ô˘. ∏ ˘ÔÍ·ÈÌ›· Ô˘ Û˘¯Ó¿ Û˘Óԉ‡ÂÈ ÙȘ ¿ÓÔȘ, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÁÁÂÈÔÛ‡Û·ÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ Î·È ÌÔÚ› ›Û˘ Ó· Ô‰ËÁ‹ÛÂÈ Û ‰È¿Ù·ÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÎfiÏÔ˘. ∆Ô ÎÔÏÈÎfi Ó·ÙÚÈÔ‰ÈÔ˘ÚËÙÈÎfi ÂÙ›‰ÈÔ Â˘Ô‰ÒÓÂÈ ÙËÓ ·Ô‚ÔÏ‹ Ó·ÙÚ›Ô˘ ·fi ÙÔÓ ÓÂÊÚfi Î·È ·˘Í¿ÓÂÈ ÙÔÓ fiÁÎÔ ÙˆÓ Ô‡ÚˆÓ (9,10). ÀÔ¯ÒÚËÛË Ù˘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ÛÙ· ·È‰È¿ Ì ‰È·ÏÂ›Ô˘Û· ·fiÊÚ·ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·ÂÚ·ÁˆÁÔ‡ ÌÂÙ¿ ·fi ıÂڷ›· Ì ÚÈÓÈÎfi ÂÎӤʈ̷ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (11) Î·È ÛÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ Ì ™∞∞À ÌÂÙ¿ ·fi ÂÊ·ÚÌÔÁ‹ Û˘Ó¯ԇ˜ ıÂÙÈ΋˜ ›ÂÛ˘ ·fi ÙË Ì‡ÙË (nasal CPAP) (12). OÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ ‰ÂÓ Â›Ó·È ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Ù˘ Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘. ŸÙ·Ó fï˜ ˘¿Ú¯Ô˘Ó, ·ÔÙÂÏÔ‡Ó ·Ú¿ÁÔÓÙ· Ô˘ Û˘Ó‹ıˆ˜ ÌÔÚ› ‡ÎÔÏ· Ó· ‰ÈÔÚıˆı›. §ÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi ÁÈ· Ù˘¯fiÓ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜ ÛÙÔÓ ‡ÓÔ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ·fi fiÏ· Ù· ·È‰È¿ Ô˘ ÚÔÛÎÔÌ›˙ÔÓÙ·È ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Ó˘ÎÙÂÚÈÓ‹˜ ÂÓÔ‡ÚËÛ˘ Î·È ÂÊfiÛÔÓ ÚÔ·ÙÔ˘Ó ÂӉ›ÍÂȘ Èı·ÓÔ‡ ™∞∞À, ı· Ú¤ÂÈ Ó· ÙÂÎÌËÚÈÒÓÂÙ·È Ë ‰È¿ÁÓˆÛË Ì ÔÏ˘·Ú·ÌÂÙÚÈ΋ ÌÂϤÙË Î·È Ó· ·ÎÔÏÔ˘ı› ıÂڷ›·. ∏ ‚ÂÏÙ›ˆÛË ÙÔ˘ ™∞∞À Û˘¯Ó¿ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ˘Ô¯ÒÚËÛË Ù˘ ÂÓÔ‡ÚËÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea
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syndrome. Pediatrics 2002;109:704-712. 2. Guilleminault C, Winkle R, Korobkin R, Simmons B. Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr 1982;139:165-171. 3. Richardson MA, Seid AB, Cotton RT, Benton C, Kramer M. Evaluation of tonsils and adenoids in sleep apnea syndrome. Laryngoscope 1980;90:1106-1110. 4. Swift AC. Upper airway obstruction, sleep disturbance and adenotonsillectomy in children. J Laryngol Otol 1988;102:419-422. 5. Weider DJ, Sateia MJ, West RP. Nocturnal enuresis in children with upper airway obstruction. Otolaryngol Head Neck Surg 1991;105:427-432. 6. American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med 1996;153:866-878. 7. Goh DY, Galster P, Marcus CL. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med 2000;162:682-686. 8. Neveus T, Lackgren G, Tuvemo T, Hetta J, Hjalmas K, Stenberg A. Enuresis - background and treatment. Scand J Urol Nephrol 2000;206 (Suppl):S1-S44. 9. Krieger J, Follenius M, Sforza E, Brandenberger G, Peter JD. Effects of treatment with nasal continuous positive airway pressure on atrial natriuretic peptide and arginine vasopressin release during sleep in patients with obstructive sleep apnoea. Clin Sci 1991;80:443-449. 10. Warley AR, Stradling JR. Abnormal diurnal variation in salt and water excretion in patients with obstructive sleep apnoea. Clin Sci 1988;74:183-185. 11. Demain JG, Goetz DW. Pediatric adenoidal hypertrophy and nasal airway obstruction: reduction with aqueous nasal beclomethasone. Pediatrics 1995;95:355-364. 12. Kramer NR, Bonitati AE, Millman RP. Enuresis and obstructive sleep apnea in adults. Chest 1998;114:634-637.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 22-10-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ÌÌ·ÓÔ˘‹Ï ∞ÏÂÍfiÔ˘ÏÔ˜ ÃÚ˘ÛÔÛÙfiÌÔ˘ ™Ì‡ÚÓ˘ 2, ¶ÂÚÈÔ¯‹ ™Ù·ıÌÔ‡ ∆.∫. 412 23, §¿ÚÈÛ· E-mail: ealexop@yahoo.com
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CASE REPORT
∂ÙÂÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË ˆ˜ ÚÔ¤¯ÔÓ Û‡Ìو̷ ¯ÚfiÓÈ·˜ ÈÁÌÔÚ›Ùȉ·˜ °. ¶·Ú‰·Ïfi˜, ™. ªÔ‡ÛÎÔ˘, ¢. ∑·ÊÂÈÚ›Ô˘, µ. ∞˚‚¿˙˘
Unilateral intermittent blepharoptosis as an urgent symptom of chronic sinusitis G. Pardalos, S. Mouskou, D. Zafiriou, V. Aivazis
¶ÂÚ›ÏË„Ë: H ›ÎÙËÙË ÙÒÛË ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ ÛÙ· ·È‰È¿ ¯ÚÂÈ¿˙ÂÙ·È ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË, ÁÈ·Ù› Û˘Ó‹ıˆ˜ ‰ËÏÒÓÂÈ ÛÔ‚·Ú‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂ȉÈÎfiÙÂÚ·, Ë ‚ÏÂÊ·ÚfiÙˆÛË ˆ˜ ÚÔ¤¯ÔÓ Û‡Ìو̷ ÂÈÏÔ΋˜ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜, ·Ó Î·È Û¿ÓÈ· ÛÙ· ·È‰È¿, Ú¤ÂÈ ¿ÓÙÔÙ ӷ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ÁÈ·Ù› Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÔÙÂÏ› ÚÒÈÌÔ Û‡Ìو̷ ÔÍ›·˜ ÊÏÂÁÌÔÓ‹˜ ‹ ÌÂÌÔӈ̤ÓÔ Û‡Ìو̷ ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ ËÏÈΛ·˜ 13 ÂÙÒÓ Ì ÂÙÂÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË ·ÚÈÛÙÂÚ¿, ÏfiÁˆ ¤ÎÙ·Û˘ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎfiÏˆÓ ÛÙÔ˘˜ ·Ú·Î›ÌÂÓÔ˘˜ ÈÛÙÔ‡˜ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘ Î·È ›ÂÛ˘ ÙÔ˘ ÎÏ¿‰Ô˘ ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ Ó‡ÚÔ˘ Ô˘ Ó¢ÚÒÓÂÈ ÂÎÏÂÎÙÈο ÙÔÓ ·ÓÂÏÎÙ‹Ú· Ì˘ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘.
Abstract: Acquired blepharoptosis in childhood demands special attention because it usually indicates a potentially serious neurologic disorder. In particular, blepharoptosis as an urgent symptom of complicated sinusitis, although rare in children, must be included in the differential diagnosis because it may constitute an early sign of acute inflammation or an isolated sign of chronic inflammation of the orbit. The case is reported of a 13-year-old girl with unilateral intermittent blepharoptosis of the left upper lid due to intraorbital extension of chronic sinusitis with pressure on the oculomotor nerve branch which supplies only the inferior levator palpebrae muscle.
§¤ÍÂȘ ÎÏÂȉȿ: ‚ÏÂÊ·ÚfiÙˆÛË, ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·, ¿ÚÂÛË ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘.
Key words: blepharoptosis, sinusitis, paresis of the inferior levator palpebrae muscle.
∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· ·ÔÙÂÏ› Û˘¯Ófi Úfi‚ÏËÌ· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË Î·È ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·fi οÔÈÔ ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ÚÈÓ›Ùȉ·˜ ÈÔÁÂÓÔ‡˜ ‹ ·ÏÏÂÚÁÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∏ ¯ÚfiÓÈ· ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· Â›Ó·È Û·ÓÈfiÙÂÚË Î·È ‰ËÏÒÓÂÈ Û˘Ó‹ıˆ˜ ÙËÓ ‡·ÚÍË ÙÔÈ΋˜ (·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· ÚÈÓÔÊ¿Ú˘ÁÁ· Î.¿.) ‹ ÁÂÓÈÎÂ˘Ì¤Ó˘ ‰È·Ù·Ú·¯‹˜ (‰˘ÛÎÈÓËÛ›· ÎÚÔÛÛÒÓ, ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Î.¿.), Ë ÔÔ›· ‰È¢ÎÔχÓÂÈ ÙËÓ ÂÈÌÔÓ‹ Ù˘ ÊÏÂÁÌÔÓ‹˜ (1). OÈ ÂÈÏÔΤ˜ ÙˆÓ ·Ú·ÚÚÈÓÔÎÔÏ›ÙȉˆÓ Â›Ó·È Û¯ÂÙÈο Û¿ÓȘ, ·ÏÏ¿ Ë ·ÚÔ˘Û›· ÙÔ˘˜ Î·È È‰›ˆ˜ Ë Â¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÂÓ‰ÔÎÚ·Óȷο, ÌÔÚ› Ó· Â›Ó·È ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ (1-3). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ·È‰ÈÔ‡ Ì ÂÙÂ-
ÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË ·ÚÈÛÙÂÚ¿ ÏfiÁˆ ¤ÎÙ·Û˘ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎfiÏˆÓ ÛÙÔ˘˜ ·Ú·Î›ÌÂÓÔ˘˜ ÈÛÙÔ‡˜ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘ Î·È ›ÂÛ˘ ÙÔ˘ ÎÏ¿‰Ô˘ ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ Ó‡ÚÔ˘ Ô˘ Ó¢ÚÒÓÂÈ ÂÎÏÂÎÙÈο ÙÔÓ ·ÓÂÏÎÙ‹Ú· Ì˘ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘. ∏ ÂÈÏÔ΋ ·˘Ù‹ Â›Ó·È Û¿ÓÈ· (4-6), ȉȷ›ÙÂÚ· ÛÙ· ·È‰È¿ (7). ¢ÂÓ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙȘ Û˘Ó‹ıÂȘ ÂÈÏÔΤ˜ ÙˆÓ ·Ú·ÚÚÈÓÔÎÔÏ›ÙȉˆÓ (1-3) Î·È ·Ó·Ê¤ÚÂÙ·È ÌfiÓÔ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ‚ÏÂÊ·ÚfiÙˆÛ˘ ˆ˜ Û¿ÓÈÔ ·›ÙÈÔ ÚfiÎÏËÛ‹˜ Ù˘ (8,9).
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£. “πÔÎÚ¿ÙÂÈÔ” °.¶.¡. £ÂÛÛ·ÏÔӛ΢
1st Paediatric Clinic of Aristotelion University “Ippokration” General Hospital, Thessaloniki
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 13 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÏfiÁˆ ÂÙÂÚfiÏ¢Ú˘ ‰È·ÏÂ›Ô˘Û·˜ ‚ÏÂÊ·ÚfiÙˆÛ˘ ·ÚÈÛÙÂÚ¿ ·fi ÂÓıË̤ÚÔ˘.
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May-June 03
03-06-03
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¶·È‰È·ÙÚÈ΋ 2003;66:211-214
∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ, ÂÓÒ ·fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·ÍÈÔÛËÌ›ˆÙË ‹Ù·Ó Ë ·Ó·ÊÔÚ¿ 4 ÂÂÈÛÔ‰›ˆÓ ÈÁÌÔÚ›Ùȉ·˜ ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÍ¿ÌËÓÔ. ∆· ÂÂÈÛfi‰È· ·˘Ù¿ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ·fi ÚÈÓÈ΋ Û˘ÌÊfiÚËÛË Î·È ÌÂوȷ›· ÎÂÊ·Ï·ÏÁ›·. ∏ ‰È¿ÁÓˆÛË Ù˘ ÈÁÌÔÚ›Ùȉ·˜ ¿Ìʈ ÂȂ‚·ÈÒıËΠ·ÎÙÈÓÔÏÔÁÈο ÛÙ· 3 ·fi Ù· 4 ÂÂÈÛfi‰È·. ÃÔÚËÁ‹ıËΠ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ per os ÁÈ· 10 Ë̤Ú˜ Î·È ÙȘ Ù¤ÛÛÂÚȘ ÊÔÚ¤˜, Ì ‰È·ÊÔÚÂÙÈÎfi οı ÊÔÚ¿ ·ÓÙÈ‚ÈÔÙÈÎfi Î·È ÚfiÛηÈÚË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘Ìو̿وÓ. ∞ӷʤÚÂÙ·È, ›Û˘, fiÙÈ Ì ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÈÁÌÔÚ›Ùȉ·˜ ηٿ Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· ÂÂÈÛfi‰È·, ·ÚÔ˘ÛÈ¿ÛÙËÎÂ Î·È ÂÙÂÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË ·ÚÈÛÙÂÚ¿, Ë ÔÔ›· ÂÈÙÂÈÓfiÙ·Ó Ì ÙËÓ ÚfiÔ‰Ô Ù˘ Ë̤ڷ˜ Î·È ‚ÂÏÙȈÓfiÙ·Ó ‹ ÂÍ·ÏÂÈÊfiÙ·Ó Ì ÙËÓ Î·Ù¿ÎÏÈÛË. ∆Ô Û‡Ìو̷ ·˘Ùfi ‰È‹ÚÎÂÛ ϛÁ˜ Ë̤Ú˜ Î·È ÙȘ ‰‡Ô ÊÔÚ¤˜ Î·È ·Ô‰fiıËΠÛÙËÓ ÈÁÌÔÚ›Ùȉ·, ÁÈ·Ù› ÂÍ·Ï›ÊıËΠϋڈ˜ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜. ∏ ·ÛıÂÓ‹˜ ‹Ù·Ó Û ηϋ ηٿÛÙ·ÛË ÌÂÙ¿ ÙÔ ÙÂÏÂ˘Ù·›Ô, ÚÔ ‰ÈÌ‹ÓÔ˘, ÂÂÈÛfi‰ÈÔ ÈÁÌÔÚ›Ùȉ·˜, ·Ó ÂÍ·ÈÚ¤ÛÔ˘Ì οÔȘ ÂÍ¿ÚÛÂȘ ‹È·˜ ÚÈÓÈ΋˜ Û˘ÌÊfiÚËÛ˘ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·Ó Â˘Î·ÈÚȷο Ì ÙÔÈο ·ÔÛ˘ÌÊÔÚËÙÈο. ¶¤ÓÙ Ë̤Ú˜ ÚÔ Ù˘ ÂÈÛ·ÁˆÁ‹˜ Ù˘ ·ÚÔ˘ÛÈ¿ÛÙËΠͷӿ ‚ÏÂÊ·ÚfiÙˆÛË ·ÚÈÛÙÂÚ¿ Ì ٷ ›‰È· ‰È·Ï›ÔÓÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ›ٷÛ˘ Ì ÙËÓ ÚfiÔ‰Ô Ù˘ Ë̤ڷ˜ Î·È ˘Ô¯ÒÚËÛ˘ Ì ÙËÓ Î·Ù¿ÎÏÈÛË, ·ÏÏ¿ ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ¿ÏÏˆÓ Û˘Ìو̿وÓ, fiˆ˜ ηٷÚÚÔ‹˜, ¤ÓÙÔÓ˘ ÚÈÓÈ΋˜ Û˘ÌÊfiÚËÛ˘, ÎÂÊ·Ï·ÏÁ›·˜ ‹ ˘ÚÂÙÔ‡. ¢ÂÓ ·Ó·Ê¤ÚÔÓÙ·Ó, ›Û˘, ¿ÏÏ· ÔÊı·ÏÌÈο ÂÓԯϋ̷ٷ, fiˆ˜ fiÓÔ˜, ÂÚ˘ıÚfiÙËÙ·, ‰·ÎÚ‡ÚÚÔÈ·, ‰Èψ›· ‹ ÚfiÛÊ·ÙÔ˜ ÙÚ·˘Ì·ÙÈÛÌfi˜. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ¤‰ÂÈÍ ̛· Ê˘ÛÈÔÏÔÁÈ΋, ηٿ Ù· ¿ÏÏ·, ¤ÊË‚Ë Ì ηϋ ·Ó¿Ù˘ÍË, ıÚ¤„Ë Î·È ÁÂÓÈ΋ ηٿÛÙ·ÛË. ¶·Ú·ÙËÚ‹ıËΠÙÒÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ ÂÚ›Ô˘ 5 mm, ¯ˆÚ›˜ Ô›‰ËÌ·, ÂÚ˘ıÚfiÙËÙ· ‹ ¿ÏÁÔ˜. ∏ Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ ÔÊı·ÏÌÔÎÈÓËÙÈÎÒÓ ÓÂ‡ÚˆÓ ¤‰ÂÈÍ ¿ÚÂÛË ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ‚ÏÂÊ¿ÚÔ˘ Ô˘ Ó¢ÚÒÓÂÙ·È ·fi ÎÏ¿‰Ô ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡, ÂÓÒ ÔÈ ˘fiÏÔÈÔÈ Ì‡Â˜ Ô˘ Ó¢ÚÒÓÔÓÙ·È ÙfiÛÔ ·fi ¿ÏÏÔ˘˜ ÎÏ¿‰Ô˘˜ ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ (¤Ûˆ, ¿Óˆ Î·È Î¿Ùˆ ÔÚıfi˜, οو ÏÔÍfi˜, ÛÊÈÁÎÙ‹Ú·˜ Ù˘ ÎfiÚ˘ Î·È ·ÎÙÈÓˆÙfi˜ Ì˘˜), fiÛÔ Î·È ·fi ÙÔ ÙÚÔ¯ÈÏÈ·Îfi (¿Óˆ ÏÔÍfi˜) Î·È ÙÔ ··ÁˆÁfi (¤Íˆ ÔÚıfi˜) ¢ڤıËÛ·Ó Ê˘ÛÈÔÏÔÁÈÎÔ›. º˘ÛÈÔÏÔÁÈο ‹Ù·Ó Ù· Â˘Ú‹Ì·Ù· Î·È ·fi ÙËÓ ˘fiÏÔÈË Ó¢ÚÔÏÔÁÈ΋ Î·È ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË, fiˆ˜ ›Û˘ Î·È ·fi ÙËÓ ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÚÈÓÔÊ¿Ú˘ÁÁ·, ÏËÓ Ù˘ ·ÚÔ˘Û›·˜ ‹È·˜ ÔÈÛıÔÚÈÓÈ΋˜ ¤ÎÎÚÈÛ˘ Ô˘ Û˘ÓËÁÔÚÔ‡Û ˘¤Ú Ù˘ ÈÁÌÔÚ›Ùȉ·˜. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ÂÚÈÂÏ¿Ì‚·ÓÂ
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Ï‹ÚË ·ÈÌ·ÙÔÏÔÁÈÎfi, ‚ÈÔ¯ËÌÈÎfi, ÔÚÔÏÔÁÈÎfi, ·ÓÔÛÔÏÔÁÈÎfi, ·ÏÏÂÚÁÈÔÏÔÁÈÎfi Î·È Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ Î·È Ë Mantoux ‹Ù·Ó ·ÚÓËÙÈ΋. O ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, ÏËÓ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒÚ·ÎÔ˜, ÂÚÈÔÚ›ÛÙËΠÛÙËÓ MRI ÂÁÎÂÊ¿ÏÔ˘ ÁÈ· ηχÙÂÚË Â˘ÎÚ›ÓÂÈ·. ∏ ÙÂÏÂ˘Ù·›· ¤‰ÂÈÍ ÊÏÂÁÌÔÓ‹ fiÏˆÓ ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎÔÈÏÔًوÓ, ȉȷ›ÙÂÚ· ÙˆÓ ËıÌÔÂȉÒÓ Î˘„ÂÏÒÓ, Ì ÂÈÎfiÓ· ·Ó·Î·Ù·Û΢‹˜ ÙÔ˘ ÔÛÙÔ‡ (bone remodeling), Ô˘ ·ÔÙÂÏ› ÂÓ‰ÂÈÎÙÈÎfi ‡ÚËÌ· ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ (∂ÈÎfiÓ· 1). ∂ÈϤÔÓ, ·Ú·ÙËÚ‹ıËΠ›ÂÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ¤Ûˆ ÔÚıÔ‡ ÔÊı·ÏÌÈÎÔ‡ Ì˘fi˜ ÂÍ·ÈÙ›·˜ Ù˘ ÂÓÙÔÓfiÙÂÚ˘ ÊÏÂÁÌÔÓ‹˜ ÚÔ˜ ÙÔ ¤Ûˆ ÙÔ›¯ˆÌ· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘ (∂ÈÎfiÓ· 2). ∞˘Ù¿ Ù· Â˘Ú‹Ì·Ù· Ù˘ ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·Ú·ÚÚ›ÓÈˆÓ ÎÔÈÏÔÙ‹ÙˆÓ Ì ¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙÔÓ ÔÊı·ÏÌÈÎfi ÎfiÁ¯Ô, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ·ÔÎÏÂÈÛÌfi ¿ÏÏˆÓ ·ÈÙ›ˆÓ ‚ÏÂÊ·ÚfiÙˆÛ˘ (ÙÚ·‡Ì·, fiÁÎÔÈ, Ì˘·Ûı¤ÓÂÈ·, Û. Horner), ÂÓ›Û¯˘Û·Ó ÙËÓ ·Ú¯È΋ ˘fiÓÔÈ· Ù˘ ¿ÚÂÛ˘ ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ ÏfiÁˆ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ·Ú·Î›ÌÂÓˆÓ ÈÛÙÒÓ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘ Î·È ›ÂÛ˘ ÙÔ˘ ÎÏ¿‰Ô˘ ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ Ó‡ÚÔ˘ Ô˘ Ó¢ÚÒÓÂÈ ÙÔÓ ÂÓ ÏfiÁˆ Ì˘. ŒÙÛÈ, Ë ·ÛıÂÓ‹˜ Ù¤ıËΠ۠ÂÓ‰ÔÊϤ‚È· ·ÁˆÁ‹ Ì ÎÏÈÓ‰·Ì˘Î›ÓË ÁÈ· 7 Ë̤Ú˜, ·ÓÙÈ-ÈÛÙ·ÌÈÓÈ΋ ·ÁˆÁ‹ per os Î·È ÚÈÓÈΤ˜ ÂÓÛÙ·Ï¿ÍÂȘ ·ÔÛ˘ÌÊÔÚËÙÈÎÒÓ. ∆ÚÂȘ Ë̤Ú˜ ÌÂÙ¿ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, Ë ‚ÏÂÊ·ÚfiÙˆÛË ˘Ô¯ÒÚËÛ ϋڈ˜ Î·È Ë ·ÛıÂÓ‹˜ ÂÍ‹Ïı ÙËÓ 8Ë Ë̤ڷ Ì ԉËÁ›Â˜ ÁÈ· Û˘Ó¤¯ÈÛË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ per os ÁÈ· 7 ·ÎfiÌË Ë̤Ú˜. ™ÙÔÓ Ù·ÎÙÈÎfi ·ӤÏÂÁ¯Ô ÌÂÙ¿ ·fi 2, 4 Î·È 6 Ì‹Ó˜, Ë ·ÛıÂÓ‹˜ ‹Ù·Ó ÙÂÏ›ˆ˜ ηϿ, ¯ˆÚ›˜ ηӤӷ ÂÂÈÛfi‰ÈÔ ‚ÏÂÊ·ÚfiÙˆÛ˘ ‹ ¿ÏÏ· Û˘ÌÙÒÌ·Ù·. ™˘˙‹ÙËÛË ∏ ›ÎÙËÙË ÙÒÛË ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘, ·Ó Î·È Û¿ÓÈ· ÛÙ· ·È‰È¿, ··ÈÙ› ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË, ÁÈ·Ù› ‰ËÏÒÓÂÈ Ó¢ÚÈ΋ ‹/Î·È Ì˘˚΋ ÔÊı·ÏÌÔÎÈÓËÙÈ΋ ‰È·Ù·Ú·¯‹, Ë ÔÔ›· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÂÓ‰ÔÎÚ·ÓȷΤ˜ ‹ ÂÓ‰ÔÎÔÁ¯ÈΤ˜ ‚Ï¿‚˜ (ÙÚ·‡Ì·, ÊÏÂÁÌÔÓ‹, fiÁÎÔÈ), Ì˘Ô¿ıÂȘ (‚·ÚÈ¿ Ì˘·Ûı¤ÓÂÈ·, Ì˘ÔÛ›Ùȉ·) ‹ ¿ÏϘ ηٷÛÙ¿ÛÂȘ (Û. Horner, ·ÏÏ·ÓÙ›·ÛË, ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·) (8,9). ∏ ÂÙÂÚfiÏ¢ÚË ‰È·ÏÂ›Ô˘Û· ‚ÏÂÊ·ÚfiÙˆÛË Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ·ÛıÂÓÔ‡˜, Ì ÙÔ ÂÈ‚·Ú˘Ì¤ÓÔ ÚfiÛÊ·ÙÔ ÈÛÙÔÚÈÎfi ÙˆÓ Û˘¯ÓÒÓ ÈÁÌÔÚ›ÙȉˆÓ ηÈ, ȉȷ›ÙÂÚ·, Ë ·ÚÔ˘Û›· ·ÚfiÌÔÈ·˜ ÛËÌÂÈÔÏÔÁ›·˜ ηٿ ÙË ‰È·‰ÚÔÌ‹ ÙˆÓ ‰‡Ô ÙÂÏÂ˘Ù·›ˆÓ ÂÂÈÛÔ‰›ˆÓ ÈÁÌÔÚ›Ùȉ·˜ Ô˘ ˘Ô¯ÒÚËÛ Ì ÙËÓ ·ÓÙÈ‚ÈÔÙÈ΋ ıÂڷ›·, ¤ıÂÙ·Ó ÙËÓ ˘fiÓÔÈ· ¤ÎÙ·Û˘ Ù˘ ·Ú·ÚÚ›ÓÈ·˜
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∂ÈÎfiÓ· 1. MRI ÂÁÎÂÊ¿ÏÔ˘, ∆1 ·ÎÔÏÔ˘ı›· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÛÎÈ·ÛÙÈÎÔ‡: ÊÏÂÁÌÔÓ‹ ·ÌÊfiÙÂÚˆÓ ÙˆÓ ËıÌÔÂȉÒÓ Î˘„ÂÏÒÓ ÛÙÔÓ ÔÊı·ÏÌÈÎfi ÎfiÁ¯Ô Ì ÂÈÎfiÓ· ·Ó·Î·Ù·Û΢‹˜ ÙÔ˘ ÔÛÙÔ‡ (bone remodeling).
∂ÈÎfiÓ· 2. MRI ÂÁÎÂÊ¿ÏÔ˘, ∆2 ·ÎÔÏÔ˘ı›·: ›ÂÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ¤Ûˆ ÔÚıÔ‡ ÔÊı·ÏÌÈÎÔ‡ Ì˘fi˜ ÏfiÁˆ Ù˘ ¤ÓÙÔÓ˘ ÊÏÂÁÌÔÓ‹˜ ÙˆÓ ËıÌÔÂȉÒÓ Î˘„ÂÏÒÓ ÚÔ˜ ÙÔ ¤Ûˆ ÙÔ›¯ˆÌ· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘.
ÊÏÂÁÌÔÓ‹˜ ÚÔ˜ ÙÔÓ ÔÊı·ÏÌÈÎfi ÎfiÁ¯Ô Î·È ÙËÓ ÚfiÎÏËÛË ‚ÏÂÊ·ÚfiÙˆÛ˘. ∏ ˘fiÓÔÈ· Ù˘ ÂÓ‰ÔÎÔÁ¯È΋˜ ‚Ï¿‚˘ ÂÓÈÛ¯‡ıËΠ·fi ÙÔ Â‡ÚËÌ· Ù˘ ÌÂÌÔӈ̤Ó˘ ¿ÚÂÛ˘ ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘, ÁÈ·Ù› Ô Ì˘˜ ·˘Ùfi˜ Ó¢ÚÒÓÂÙ·È ·fi ÙÔÓ ¿Óˆ ÎÏ¿‰Ô ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ Ó‡ÚÔ˘ Ô˘ ÔÚ‡ÂÙ·È ÂÍ·Ú¯‹˜ ÂÓÙfi˜ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘. ∆· ˘fiÏÔÈ· ÔÊı·ÏÌÔÎÈÓËÙÈο Ó‡ڷ ‹Ù·Ó ·ÓÂËÚ¤·ÛÙ·, fiˆ˜ Ê˘ÛÈÔÏÔÁÈ΋ ‹Ù·Ó Î·È Ë ÏÔÈ‹ Ó¢ÚÔÏÔÁÈ΋ Î·È ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË. ∞ÚÓËÙÈÎfi ÛËÌÂ›Ô ·ÔÙ¤ÏÂÛÂ Ë ·Ô˘Û›· ¤ÓÙÔÓ˘ ÎÏÈÓÈ΋˜ ÛËÌÂÈÔÏÔÁ›·˜ Î·È Â˘ÚËÌ¿ÙˆÓ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜, ÏËÓ Ì›·˜ ‹È·˜ ÔÈÛıÔÚÚÈÓÈ΋˜ ¤ÎÎÚÈÛ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ‰ÈÂÓÂÚÁ‹ıËΠÏËÚ¤ÛÙÂÚÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ÂÛÙÈ¿ÛÙËΠ΢ڛˆ˜ ÛÙËÓ MRI ÂÁÎÂÊ¿ÏÔ˘ ÁÈ· ηχÙÂÚË Â˘ÎÚ›ÓÂÈ·. ∆· Â˘Ú‹Ì·Ù· Ù˘ ¯ÚfiÓÈ·˜ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜ Ì ¤ÎÙ·ÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÛÙÔ˘˜ ÔÊı·ÏÌÈÎÔ‡˜ ÎfiÁ¯Ô˘˜, Ô˘ ‹Ù·Ó ÂÓÙÔÓfiÙÂÚË ·ÚÈÛÙÂÚ¿, ÂÓ›Û¯˘Û·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ¿ÚÂÛ˘ ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ ÏfiÁˆ ÂÓ‰ÔÎÔÁ¯È΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È Ë ‰È¿ÁÓˆÛË ÙÂÎÌËÚÈÒıËΠ·fi ÙËÓ ˘Ô¯ÒÚËÛË Ù˘ ‚ÏÂÊ·ÚfiÙˆÛ˘ ۯ‰fiÓ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ Î·È ÙË ÌË Â·ÓÂÌÊ¿ÓÈÛ‹ Ù˘ ÁÈ· 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·ÔıÂڷ›·. OÈ ÂÈÏÔΤ˜ ÙˆÓ ·Ú·ÚÚÈÓÔÎÔÏ›ÙȉˆÓ Â›Ó·È Û¯ÂÙÈο Û¿ÓȘ Û‹ÌÂÚ·, ÏfiÁˆ Ù˘ ¢Ú›·˜ ¯Ú‹Û˘ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ. ∏ ·ÚÔ˘Û›· ÙÔ˘˜, fï˜, ÌÔÚ› Ó· Â›Ó·È ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ ÙÔ˘ ·ÛıÂ-
ÓÔ‡˜. OÈ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÏÔΤ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ Â¤ÎÙ·ÛË Ù˘ ·Ú·ÚÚ›ÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ ÚÔ˜ ÙÔÓ ÔÊı·ÏÌÈÎfi ÎfiÁ¯Ô (΢ÙÙ·Ú›Ùȉ·, ÚfiÙˆÛË ÙÔ˘ ‚ÔÏ‚Ô‡, Ó¢ڛÙȉ· ÙÔ˘ ÔÙÈÎÔ‡ Ó‡ÚÔ˘), ÙËÓ ÂÓ‰ÔÎÚ¿ÓÈ· ÎÔÈÏfiÙËÙ· (ÂÁÎÂÊ·ÏÈÎfi ·fiÛÙËÌ·, ıÚfiÌ‚ˆÛË ÙÔ˘ ÛËÚ·ÁÁÒ‰Ô˘˜ ÎfiÏÔ˘, ÌËÓÈÁÁ›Ùȉ·) Î·È Ù· ÔÛÙ¿ Ù˘ ÂÚÈÔ¯‹˜ (ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, ˘ÔÂÚÈÔÛÙÈÎfi ·fiÛÙËÌ·) (1-3). ∏ ÂͿψÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Á›ÓÂÙ·È Â›Ù Ì ÙËÓ ·Â˘ı›·˜ ‰È¿‚ÚˆÛË ÙÔ˘ ÔÛÙÔ‡, ›Ù ‰È·Ì¤ÛÔ˘ ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ÔÛÙÔ‡ (3,10). ∏ ‚ÏÂÊ·ÚfiÙˆÛË ˆ˜ ÂÈÏÔ΋ Ù˘ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜ ÏfiÁˆ ¤ÎÙ·Û˘ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÂÓ‰ÔÎÔÁ¯Èο Â›Ó·È Û¿ÓÈ· Î·È ÔÊ›ÏÂÙ·È Û ¿ÚÂÛË ‹ ·Ú¿Ï˘ÛË ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘, Ô ÔÔ›Ô˜ Ó¢ÚÒÓÂÙ·È ·fi ÙÔÓ ¿Óˆ ÎÏ¿‰Ô ÙÔ˘ ÎÔÈÓÔ‡ ÎÈÓËÙÈÎÔ‡ Ó‡ÚÔ˘ (4-7). ∏ ÔÚ›· ÙÔ˘ Ó‡ÚÔ˘ ·˘ÙÔ‡ Â›Ó·È ÂÍ·Ú¯‹˜ ÂÓ‰ÔÎÔÁ¯È΋ Î·È Ó¢ÚÒÓÂÈ ÂÈϤÔÓ Î·È ÙÔÓ ¿Óˆ ÔÚıfi Ì˘. ™˘ÁÎÂÎÚÈ̤ӷ, ÚÒÙ· ‰›‰ÂÈ ÎÏ¿‰Ô˘˜ Ô˘ Ó¢ÚÒÓÔ˘Ó ÙÔÓ ¿Óˆ ÔÚıfi Ì˘, ÛÙË Û˘Ó¤¯ÂÈ· ÔÚ‡ÂÙ·È Î¿Ùˆ ·fi ·˘ÙfiÓ Î·È, ·ÎÔÏÔ˘ıÒÓÙ·˜ ·Á·ÏË ÔÚ›·, Êı¿ÓÂÈ Ì¤¯ÚÈ ÈÔ ¿Óˆ ·fi ÙÔÓ ¿Óˆ ÔÚıfi Ì˘ fiÔ˘ Î·È ‰›ÓÂÈ ÙÔ˘˜ ÙÂÏÈÎÔ‡˜ ÎÏ¿‰Ô˘˜ Ô˘ Ó¢ÚÒÓÔ˘Ó ÙÔÓ ·ÓÂÏÎÙ‹Ú· Ì˘ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘. O ÎÏ¿‰Ô˜ ·˘Ùfi˜, ‰ËÏ·‰‹, ‚Ú›ÛÎÂÙ·È ÂÚÈÔÚÈṲ̂ÓÔ˜ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ÔÊı·ÏÌÔÎÈÓËÙÈÎÔ‡˜ Ì˘˜. ∞˘Ù¤˜ ÔÈ ÛÙÂÓ¤˜ ·Ó·ÙÔÌÈΤ˜ Û¯¤ÛÂȘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÚÒÈÌÔ ÂÁÎψ‚ÈÛÌfi ÙÔ˘ Ó‡ÚÔ˘ Û ÂÚ›ÙˆÛË ÂÓ‰ÔÎÔÁ¯È΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÂÍÔ›‰ËÛ˘ ÙˆÓ ·Ú·Î›ÌÂÓˆÓ Ì˘ÒÓ. ∆ÂÏÈÎfi
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·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÈÂÛÙÈÎÒÓ Â› ÙÔ˘ Ó‡ÚÔ˘ ‰˘Ó¿ÌÂˆÓ Â›Ó·È Ë ¿ÚÂÛË ‹ ·Ú¿Ï˘ÛË ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ Î·È Ë ÙÒÛË ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ (7). ™ÙËÓ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ‚Ú¤ıËΠ·ÚfiÌÔÈ· ÂÚ›ÙˆÛË, ÂÓÒ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÂÏ¿¯ÈÛÙ˜ ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ ·Ó¿ÏÔÁ˜ ÙÔ˘ ·ÚfiÓÙÔ˜ ÂÚÈÛÙ·ÙÈÎÔ‡ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ (4,6). ™Â Ì›· ÂÎÙÂÓ‹ ÌÂϤÙË 113 ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ Ì ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÎfiÁ¯Ô˘ ÏfiÁˆ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜, ‰È·ÈÛÙÒıËÎ·Ó ÌfiÓÔ 3 ÂÚÈÙÒÛÂȘ ÌÂÌÔӈ̤Ó˘ ‚ÏÂÊ·ÚfiÙˆÛ˘ (5). ∂Ú¢ÓÒÓÙ·˜ ÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ‚Ú¤ıËΠ·ÚfiÌÔÈ· ÂÚ›ÙˆÛË ‰ËÌÔÛÈÂ˘Ì¤ÓË Ô˘ Ó· ·ÊÔÚ¿ Û ·È‰È¿, ÂÓÒ ‚Ú¤ıËΠ̛· ÌfiÓÔ ‰ËÌÔÛ›Â˘ÛË ÌÂÌÔӈ̤ÓÔ˘ ÂÚÈÛÙ·ÙÈÎÔ‡ Ô˘ ·ÊÔÚÔ‡Û Û ¤ÊË‚Ô. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ô˘ ·ÚÔ˘Û›·˙ ‹Ù·Ó ·ÚfiÌÔÈ· Ì ÂΛÓË Ù˘ ·ÚÔ‡Û·˜ ·ÛıÂÓÔ‡˜, ÏËÓ fï˜ Ë ‚ÏÂÊ·ÚfiÙˆÛ‹ ÙÔ˘ ‹Ù·Ó ÌfiÓÈÌË Î·È ÚÔ›¯Â Ô ¤ÓÙÔÓÔ˜ ÔÊı·ÏÌÈÎfi˜ fiÓÔ˜ (7). ∏ ·¿ÓÙËÛË ÛÙËÓ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ·˘ÙÔ‡ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂÈÙ˘¯‹˜ (7), fiˆ˜ Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË, ÂÓÒ ·¤Ù˘¯Â Û 2 ÂÚÈÙÒÛÂȘ ÂÓËÏ›ÎˆÓ Ô˘ ¯ÚÂÈ¿ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈ΋ ‰È¿ÓÔÈÍË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·Ú·ÚÚ›ÓÈÔ˘ ÎfiÏÔ˘ Ì ÈηÓÔÔÈËÙÈο, ÙÂÏÈÎÒ˜, ·ÔÙÂϤÛÌ·Ù· (4,6). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ‚ÏÂÊ·ÚfiÙˆÛË ˆ˜ ÚÔ¤¯ÔÓ Û‡Ìو̷ ÂÈÏÔ΋˜ ·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ·˜, ·Ó Î·È Û¿ÓÈ· ÛÙ· ·È‰È¿, Ú¤ÂÈ ¿ÓÙÔÙ ӷ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË, ÁÈ·Ù› Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·ÔÙÂÏ› ÚÒÈÌÔ Û‡Ìو̷ ÔÍ›·˜ ÊÏÂÁÌÔÓ‹˜ ‹ ÌÂÌÔӈ̤ÓÔ Û‡Ìو̷ ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘. ∞˘Ùfi ÚÔ·ÙÂÈ ·fi ÙȘ ÛÙÂÓ¤˜ ·Ó·ÙÔÌÈΤ˜ Û¯¤ÛÂȘ Ù˘ ÔÚ›·˜ ÙÔ˘ Ó‡ÚÔ˘ Ô˘ Ó¢ÚÒÓÂÈ ÙÔÓ ·ÓÂÏÎÙ‹Ú· Ì˘ ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘ ‰È·Ì¤ÛÔ˘ ÙˆÓ ÔÊı·ÏÌÔÎÈÓËÙÈÎÒÓ Ì˘ÒÓ Î·È ÙÔÓ ÚÒÈÌÔ ÂÁÎψ‚ÈÛÌfi ÙÔ˘ Û ÂÚ›ÙˆÛË ÂÓ‰ÔÎÔÁ¯È΋˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÂÍÔ›‰ËÛ˘ ÙˆÓ ·Ú·Î›ÌÂÓˆÓ Ì˘ÒÓ. ∞˘Ù¤˜ ÔÈ ÈÂÛÙÈΤ˜ ‰˘Ó¿ÌÂȘ › ÙÔ˘ Ó‡ÚÔ˘ ¤¯Ô˘Ó Û·Ó Â·-
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ÎfiÏÔ˘ıÔ ÙËÓ ¿ÚÂÛË ‹ ·Ú¿Ï˘ÛË ÙÔ˘ ·ÓÂÏÎÙ‹Ú· Ì˘fi˜ Î·È ÙËÓ ÙÒÛË ÙÔ˘ ¿Óˆ ‚ÏÂÊ¿ÚÔ˘, fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚ›ÙˆÛË. ∏ Û˘Ó‰˘·Ṳ̂ÓË ıÂڷ›· Ù˘ ÈÁÌÔÚ›Ùȉ·˜ Ê·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ Î·Ï‡ÙÂÚÔ ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Nash D, Wald E. Sinusitis. Pediatr Rev 2001;22:111-117. 2. Wagenmann M, Naclerio RM. Complications of sinusitis. J Allergy Clin Immunol 1992;90:552-554. 3. Stankiewicz JA, Newell DJ, Park AH. Complications of inflammatory diseases of the sinuses. Otolaryngol Clin North Am 1993;26:639-655. 4. Stefanis L, Przedborski S. Isolated palsy of the superior branch of the oculomotor nerve due to chronic erosive sphenoid sinusitis. J Clin Neuroophthalmol 1993;13:229231. 5. Pogosov VS, Akopian RG, Davudov KhSh, El’kun GB. Rhinogenous inflammatory diseases of the orbit. Vestn Otorinolaringol 1996;14-17. 6. Chotmongkol V, Chainunsamit S. Superior branch palsy of the oculomotor nerve caused by acute sphenoid sinusitis. J Med Assoc Thai 1999;82:410-413. 7. Coker SB, Ros SP. Ptosis associated with sinusitis. Pediatr Neurol 1996;14:62-63. 8. Weiss AH. The swollen and droopy eyelid. Signs of systemic disease. Pediatr Clin North Am 1993;40:789-804. 9. Olitsky SE, Nelson LB. Abnormalities of the lids: ptosis. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders Co; 2000. p. 1909. 10. Jabor MA, Amedee RG. Orbital complications of sinusitis. J La State Med Soc 1997;149:105-108.
∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 01-11-2002 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÚËÁfiÚ˘ ¶·Ú‰·Ïfi˜ §‡ÙÚ· 3, ∆.∫. 546 40, £ÂÛÛ·ÏÔÓ›ÎË E-mail: pargr@med.auth.gr
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∂¡¢π∞º∂ƒOÀ™∞ ¶∂ƒπ¶∆ø™∏
Paediatriki 2003;66:215-222
CASE REPORT
∫ÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ÛÙËÓ ÚÔÛˆÔˆÌÔ‚Ú·¯ÈfiÓÈÔ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (FSHMD). ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ E. ºÚ˘Û›Ú·1, ™. ∞̤ÓÙ·1, ∫. ∫¤ÎÔ˘1, ™. °ÈÔ˘ÚÔ‡ÎÔ˜2, ¶. ª·ÓÙ¿3, ∞. ªÂٷ͈ÙÔ‡1
Clinical heterogeneity in facioscapulohumeral muscular dystrophy (FSHMD). Report of two cases and review of the literature H. Fryssira1, S. Amenta1, K. Kekou1, S. Youroukos2, P. Manta3, C. Metaxotou1
¶ÂÚ›ÏË„Ë: ∏ ÚÔÛˆÔ-ˆÌÔ-‚Ú·¯ÈfiÓÈÔ˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (FSHMD) Â›Ó·È Ì›· Ì˘Ô¿ıÂÈ· Ô˘ ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ÙÔÓ ·˘ÙÔۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ÙÚfiÔ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Û‡ÌÌÂÙÚË, ÚÔԉ¢ÙÈ΋ ·‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘, Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Î·È ÙˆÓ ¿Óˆ ¿ÎÚˆÓ. ∏ ÓfiÛÔ˜ ÔÊ›ÏÂÙ·È ÛÙÔ 95% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û ÂÏÏ›„ÂȘ ÙˆÓ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ·ÏÏËÏÔ˘¯ÈÒÓ D4Z4 ÛÙËÓ ÂÚÈÔ¯‹ q35 ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 4. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Û Ôχ ÌÈÎÚ‹ ËÏÈΛ·, ÛÙȘ Ôԛ˜ Û˘Ó˘‹Ú¯Â ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ‚·ÚËÎÔ˝·, ˆ˜ ·ÎÚ·›Â˜ ÂÚÈÙÒÛÂȘ ‚·Ú¤ˆ˜ Ê·ÈÓÔÙ‡Ô˘. ∫·È ÛÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ, Ë ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA ÂȂ‚·›ˆÛ ÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË.
Abstract: Facioscapulohumeral muscular dystrophy (FSHMD) is a myopathy which is transmitted by autosomal dominant inheritance. It is characterized clinically by asymmetric and progressive weakness of the facial, shoulder-girdle and upper arm muscles. The disease is caused by the size reduction of a polymorphic repeat array D4Z4 on locus 4q35. ∆wo cases of children are presented with severe early onset muscular weakness, co-existing mental retardation and deafness which represent an unusual side of the disease spectrum. In both cases the clinical diagnosis was confirmed by molecular analysis.
§¤ÍÂȘ ÎÏÂȉȿ: ÚÔÛˆÔ-ˆÌÔ-‚Ú·¯ÈfiÓÈÔ˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, ÌÔÚȷ΋ ‰È¿ÁÓˆÛË, ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ‚·ÚËÎÔ˝·.
Key words: FSHMD, molecular diagnosis, mental retardation, deafness.
™˘ÓÙÔÌÔÁڷʛ˜
∂ÈÛ·ÁˆÁ‹ ∏ ÚÔÛˆÔ-ˆÌÔ-‚Ú·¯ÈfiÓÈÔ˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· (FSHMD, OMIM 158900) ÎÏËÚÔÓÔÌÂ›Ù·È Ì ·˘Ùoۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú· Î·È Â›Ó·È Ë ÙÚ›ÙË ÈÔ Û˘¯Ó‹ Ì˘Ô¿ıÂÈ·. ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ ˘ÔÏÔÁ›˙ÂÙ·È Û 1 ·Ó¿ 20.000, ÂÓÒ Ë ‰ÈÂÈÛ‰˘ÙÈÎfiÙËÙ· Â›Ó·È 90% ÛÙËÓ ËÏÈΛ· ÙˆÓ 20 ¯ÚfiÓˆÓ (1,2). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÚÔԉ¢ÙÈ΋, ·Û‡ÌÌÂÙÚË ·‰˘Ó·Ì›· Î·È ·ÙÚÔÊ›· ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘, Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Î·È ÙˆÓ ¿Óˆ ¿ÎÚˆÓ, fiˆ˜ ¿ÏψÛÙ ʷ›ÓÂÙ·È ·fi ÙËÓ ÔÓÔÌ·Û›· Ù˘ (3,4). ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÚÔÛ‚¿ÏÏÔÓÙ·È Î·È ÔÈ
FSHMD OMIM DNA ∫¡™ ∏∫° ∏ª° CPK ∫b AvrII BlnI EcoRI
}
¶ÚÔÛˆÔˆÌÔ‚Ú·¯ÈfiÓÈÔ˜ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· On line Mendelian inheritance in man ¢ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚Îfi Ô͇ ∫ÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ∏ÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ∏ÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· ∫Ú·ÙÈÓÔʈÛÊÔÚÈ΋ ÎÈÓ¿ÛË ∫ÈÏÔ‚¿ÛÂȘ ¶ÂÚÈÔÚÈÛÙÈο ¤Ó˙˘Ì·
1 ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 ¡Â˘ÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, “∞ÈÁÈÓ‹ÙÂÈÔ” ¡ÔÛÔÎÔÌ›Ô, ∞ı‹Ó·
1 Medical Genetics, Athens University, “Aghia Sophia” Children’s Hospital, Choremio Research Laboratory, ∞thens 2 1st Paediatric Department of Athens University, “Aghia Sophia” Children’s Hospital, Athens 3 Neurology Department of Athens University, “Aeginition” Hospital, Athens
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ÎÔÈÏÈ·ÎÔ›, ÔÈ ÂÎÙ›ÓÔÓÙ˜ Ù· οو ¿ÎÚ· Î·È ÔÈ Ì‡Â˜ Ù˘ ˘ÂÏÈ΋˜ ˙ÒÓ˘. À¿Ú¯ÂÈ ·ÍÈÔÛËÌ›ˆÙË ÎÏÈÓÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ· ·ÎfiÌ· Î·È ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· (5). ∆Ô 1990, Ë ˘Â‡ı˘ÓË ÂÚÈÔ¯‹ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ ¯·ÚÙÔÁÚ·Ê‹ıËΠÌÂÙ¿ ·fi ·Ó¿Ï˘ÛË Û‡Ó‰ÂÛ˘ ÛÙËÓ ˘ÔÙÂÏÔÌÂÚÈ΋ ÂÚÈÔ¯‹ ÙˆÓ Ì·ÎÚÒÓ ÛÎÂÏÒÓ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 4 (4q35), fiÔ˘ Ô ·ÓȯÓÂ˘Ù‹˜ p13∂-11 ·Ó·ÁÓˆÚ›˙ÂÈ ¤Ó· ȉȷ›ÙÂÚ· ÔÏ˘ÌÔÚÊÈÎfi ıÚ·‡ÛÌ· ∂coRI (6-9). ∏ ‰È¿ÁÓˆÛË, Û‹ÌÂÚ·, ÂȂ‚·ÈÒÓÂÙ·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ ËÏÈΛ·˜ 10 Î·È 15 ¯ÚfiÓˆÓ ·ÓÙ›ÛÙÔȯ·, Ì ·Û˘Ó‹ıÈÛÙË ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Ù˘ FSHMD Î·È ÚÒÈÌË ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ™ÎÔfi˜ Ù˘ ÂÚÈÁÚ·Ê‹˜ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ·˘ÙÒÓ Â›Ó·È ·ÊÂÓfi˜ ÌÂÓ Ó· ÙÔÓ›ÛÂÈ ÙÔ Â˘Ú‡ÙÂÚÔ ÎÏÈÓÈÎfi Ê¿ÛÌ· Ù˘ FSHMD, ȉ›ˆ˜ fiÙ·Ó Ë ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Â›Ó·È Û Ôχ ÌÈÎÚ‹ ËÏÈΛ·, ·ÊÂÙ¤ÚÔ˘ ‰Â Ó· ‰Â›ÍÂÈ ÙË ÌÂÁ¿ÏË Û˘Ì‚ÔÏ‹ Ù˘ ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜ ÛÙË ‰È¿ÁÓˆÛË, ÛÙËÓ ÚÔÛ˘Ìو̷ÙÈ΋ ·Ó›¯Ó¢ÛË ÊÔÚ¤ˆÓ Î·È ÛÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ¶ÂÚ›ÙˆÛË ÚÒÙË ∫ÔÚ›ÙÛÈ ËÏÈΛ·˜ 10 ¯ÚfiÓˆÓ ÚÔÛ‹Ïı ÁÈ· ¤ÏÂÁ¯Ô ‚·ÚÈ¿˜ ÓÔËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ Î·È ·‰˘Ó·Ì›·˜ ÛÙË ‚¿‰ÈÛË. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ÌÔÓ·‰ÈÎfi ·È‰› ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, ÌË Û˘ÁÁÂÓÒÓ ÌÂٷ͇ ÙÔ˘˜. ™ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ¤Ó·˜ ‰Â‡ÙÂÚÔ˜ ÂÍ¿‰ÂÏÊÔ˜ ·fi ÙÔÓ ·Ù¤Ú· Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ¤Ó·˜ ı›Ԙ Ô˘ ›¯Â ÂÌÊ·Ó›ÛÂÈ Û·ÛÌÔ‡˜ Î·È Î·ı˘ÛÙ¤ÚËÛË ÏfiÁÔ˘. °ÂÓÓ‹ıËΠÙÂÏÂÈfiÌËÓË Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ Èۯȷ΋˜ ÚÔ‚ÔÏ‹˜ Î·È Ë ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ ·Ó·ÊÂÚfiÙ·Ó ÂχıÂÚË. ∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 3250 g. ◊‰Ë ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ·Ú·ÙËÚ‹ıËΠ··ı¤˜ ÚÔÛˆÂ›Ô Î·È ˘ÔÙÔÓ›·. ™Â ËÏÈΛ· 20 ÌËÓÒÓ ÂÈÛ‹¯ıË ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙËÓ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ÏfiÁˆ ÛÔ‚·Ú‹˜ ηı˘ÛÙ¤ÚËÛ˘ ÛÙ· ÛÙ¿‰È· ·Ó·Ù˘Íȷ΋˜ ÂͤÏÈ͢ - οıÈÛ Û ËÏÈΛ· 12 ÌËÓÒÓ, ÂÚ¿ÙËÛ Û ËÏÈΛ· 20 ÌËÓÒÓ Î·È ‰ÂÓ Â›¯Â ·ÎfiÌ· ·Ó·Ù‡ÍÂÈ ÏfiÁÔ Î·È ÎÔÈÓˆÓÈÎfiÙËÙ·. ™ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠfiÙÈ ÂÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ·È‰› ˘ÔÙÔÓÈÎfi Ì ··ı¤˜ ÚÔÛˆÂ›Ô Ô˘ ‰ÂÓ ¯·ÌÔÁÂÏÔ‡Û ‡ÎÔÏ·, ¤ÎÏ·ÈÁ ¯ˆÚ›˜ Ó· Û˘ÛÒÓÙ·È ÔÈ Ì‡Â˜ ÙÔ˘ ÚÔÛÒÔ˘ Î·È Â›¯Â ÛÈÂÏfiÚÚÔÈ·. ¢ÂÓ Â›¯Â ÈÓȉÈÛÌÔ‡˜ ÁÏÒÛÛ·˜. ∆· ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÂÎχÔÓÙ·Ó Ê˘ÛÈÔÏÔÁÈο. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ (·ÈÌ·ÙÔÏÔÁÈÎfi˜, ‚ÈÔ¯ËÌÈÎfi˜, ÌÂÙ·‚ÔÏÈÎfi˜, ·ÓÔÛÔÏÔÁÈÎfi˜) ‹Ù·Ó ÌË ‰È·ÁÓˆÛÙÈÎfi˜, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë CPK Î·È Ë ·Ï‰ÔÏ¿ÛË ‹Ù·Ó ÂÏ·ÊÚÒ˜ ·˘ÍË̤Ó˜. ∏ ÌÂϤÙË ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∏ ‚˘ıÔÛÎfiËÛË, Ë ˘ÔÏÔÁÈÛÙÈ-
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΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ ·ÎÔfiÁÚ·ÌÌ· ÂχıÂÚÔ˘ ‰›Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ™Â ËÏÈΛ· 5 ¯ÚfiÓˆÓ ÂÚ›Ô˘ ¤ÁÈÓ ·ӤÏÂÁ¯Ô˜ ÙÔ˘ ·È‰ÈÔ‡. ∂Í·ÎÔÏÔ˘ıÔ‡Û ӷ ÂÌÊ·Ó›˙ÂÈ ‚·ÚÈ¿ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, ÁÂÓÈÎÂ˘Ì¤ÓË ˘ÔÙÔÓ›·, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ Ì˘˜ ÙÔ˘ ÚÔÛÒÔ˘ Î·È Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘. À‹Ú¯·Ó, ›Û˘, ÛÈÙÈÛÙÈο ÚÔ‚Ï‹Ì·Ù· ÏfiÁˆ ‰˘ÛÎÔÏÈÒÓ ÛÙËÓ Î·Ù¿ÔÛË. ¢ÂÓ ÌÈÏÔ‡Û ÈηÓÔÔÈËÙÈο (¤ÏÂÁ 10-12 ϤÍÂȘ). ∂›¯Â ÂȉÂÈÓÔ‡ÌÂÓË ‰˘ÛÎÔÏ›· ÛÙË ‚¿‰ÈÛË Î·È ÏfiÚ‰ˆÛË ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ∂›¯Â, ›Û˘, ·Ú¯›ÛÂÈ Ó· ·Ú·ÙËÚÂ›Ù·È ·‰˘Ó·Ì›· ·Ó¿‚·Û˘ Îϛ̷η˜ Î·È ‚¿‰ÈÛË ÛÙȘ ̇Ù˜ ÙˆÓ Ô‰ÈÒÓ. ™ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË, ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó ÛÙËÓ 75Ë ∂.£. Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÛÙËÓ 50Ë ∂.£. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ‰˘ÛÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ·ÓˆÌ·Ï›Â˜ ·fi ÙÔ ‰¤ÚÌ·. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎÂ Ì˘ÔÙÔÓÈÎfi Ê·ÈÓfiÌÂÓÔ, Ô‡Ù ÙÚfiÌÔ˜, ˘‹Ú¯Â fï˜ ÂÁÁ‡˜ Î·È ¿ˆ ÁÂÓÈÎÂ˘Ì¤ÓË Ì˘˚΋ ·‰˘Ó·Ì›·. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜, ÂÎÙfi˜ Ù˘ CPK Ô˘ ‹Ù·Ó 900 U/l (º.∆. ̤¯ÚÈ 140) Î·È Ù˘ ·Ï‰ÔÏ¿Û˘ Ô˘ ‹Ù·Ó 35 U/l (º.∆. ̤¯ÚÈ 16). ∏ ÙÈÌ‹ Ù˘ ηÚÓÈÙ›Ó˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. O ÔÊı·ÏÌÔÏÔÁÈÎfi˜ Î·È ·ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÍ·ÎÔÏÔ˘ıÔ‡Û·Ó Ó· Â›Ó·È ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ‚ÈÔ„›· ‰ÂÏÙÔÂȉԇ˜ ·ÔÎ¿Ï˘„ ‹È˜, ÌË ‰È·ÁÓˆÛÙÈΤ˜ ÈÛÙÔ·ıÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘. ™ÙÔ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· ·Ú·ÙËÚ‹ıËÎ·Ó ‹È˜ ·ÏÏÔÈÒÛÂȘ Ì˘Ô·ıËÙÈ΋˜ ‰ÈÂÚÁ·Û›·˜. ∏ Ù·¯‡ÙËÙ· ·ÁˆÁ‹˜ ÓÂ‡ÚˆÓ ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. µ¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Î¿ÔÈ·˜ ÌÔÚÊ‹˜ Ì˘Ô¿ıÂÈ·˜ Ì·˙› Ì ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ô˘ ı· ÌÔÚÔ‡Û ӷ Á›ÓÂÈ ÏfiÁˆ Ù˘ Û˘Ó‡·Ú͢ Ì˘Ô¿ıÂÈ·˜ Ì ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‹Ù·Ó ÌÂٷ͇ Û˘ÁÁÂÓÔ‡˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ Î·È ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜, ‰È·ÁÓÒÛÂȘ Ô˘ ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ·fi Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·. ™ÙËÓ ÙÂÏÂ˘Ù·›· ÎÏÈÓÈ΋ ÂͤٷÛË, Û ËÏÈΛ· 10 ÂÙÒÓ, ›¯Â ÂÎÛÂÛËÌ·Ṳ̂ÓË Âȉ›ӈÛË Ù˘ ÎÈÓËÙÈ΋˜ Î·È ÓÔËÙÈ΋˜ ÂͤÏÈ͢. ◊Ù·Ó Î·ıËψ̤ÓË Û ·Ó·ËÚÈÎfi ·Ì·Í›‰ÈÔ Î·È Â›¯Â ¤Î‰ËÏË ÏfiÚ‰ˆÛË Î·È Î˘ÊÔÛÎÔÏ›ˆÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Ì ÚÔ‚ÔÏ‹ Ù˘ ˆÌÔÏ¿Ù˘. ∆Ô ÛÙfiÌ· ·Ú¤ÌÂÓ ·ÓÔÈÎÙfi Ì ÛÈÂÏfiÚÚÔÈ· Î·È ‰ÂÓ ÂÈÎÔÈÓˆÓÔ‡Û Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ (∂ÈÎfiÓ˜ 1 Î·È 2). ¶ÂÚ›ÙˆÛË ‰Â‡ÙÂÚË ∞ÁfiÚÈ ËÏÈΛ·˜ 15 ¯ÚfiÓˆÓ ÚÔÛ‹Ïı ÏfiÁˆ Ì˘˚΋˜ ·‰˘Ó·Ì›·˜, ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ Î·È ‚·ÚËÎÔ˝·˜. ◊Ù·Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∆Ô ‰Â‡ÙÂÚÔ ·È‰› ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi ·ÁfiÚÈ. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi
May-June 03
03-06-03
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¶·È‰È·ÙÚÈ΋ 2003;66:215-222
·Ó·ÊÂÚfiÙ·Ó ÂχıÂÚÔ. °ÂÓÓ‹ıËΠ̠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ·ÓÒÌ·Ï˘ ı¤Û˘, ÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË Î‡ËÛË, ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÔ›·˜ Ë ÌËÙ¤Ú· ‰ÂÓ ÓfiÛËÛÂ, ‰ÂÓ ÂÎÙ¤ıËΠ۠ÂÌ‚Ú˘ÔÙÔÍÈο Ê¿Ú̷η ‹ ÛËÌ·ÓÙÈ΋ ‰fiÛË ·ÎÙÈÓÔ‚ÔÏ›·˜. ∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ‹Ù·Ó 3 kg. ∏ ÎÈÓËÙÈ΋ ÙÔ˘ ÂͤÏÈÍË ‹Ù·Ó ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ - οıÈÛ Û ËÏÈΛ· 7 ÌËÓÒÓ Î·È ÂÚ¿ÙËÛ Û ËÏÈΛ· 14 ÌËÓÒÓ. ™ÙËÓ ËÏÈΛ· ÙˆÓ 2 ¯ÚfiÓˆÓ, ‹Ù·Ó ‹Û˘¯Ô ·È‰›, Ì ÌÂÁ¿ÏÔ ·ÚÓËÙÈÛÌfi Î·È ‰ÂÓ Â›¯Â ·Ó¿Ù˘ÍË ÙÔ˘ ÏfiÁÔ˘. ™Â ·ÎÔfiÁÚ·ÌÌ· Ô˘ ¤ÁÈÓ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ¯ÚfiÓˆÓ, ‚Ú¤ıËΠÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ‚·ÚËÎÔ˝· ·ÌÊÔÙÂÚfiÏ¢ڷ. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ¤ÁÈÓ ÙfiÙ Ì ·ÈÌ·ÙÔÏÔÁÈÎfi, ‚ÈÔ¯ËÌÈÎfi, ÌÂÙ·‚ÔÏÈÎfi, ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô ÂÁÎÂÊ¿ÏÔ˘ Ì ̷ÁÓËÙÈÎfi Û˘ÓÙÔÓÈÛÌfi, ∏∂° Î·È Î·Ú˘fiÙ˘Ô ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ÙÈÌ‹ Ù˘ CPK Î˘Ì·ÈÓfiÙ·Ó ·fi 240-460 U/l. ∆Ô ·È‰› ¿Ú¯ÈÛ ÚfiÁÚ·ÌÌ· ÂȉÈ΋˜ ·ÁˆÁ‹˜ Î·È ÏÔÁÔıÂڷ›·˜ ÏfiÁˆ Ù˘ ‚·ÚËÎÔ˝·˜ Î·È Ù˘ ÂÓÙÔÓfiÙ·Ù˘ ‰˘Û·ÚıÚ›·˜. ™ÙËÓ ËÏÈΛ· ÙˆÓ 10 ¯ÚfiÓˆÓ, ÚÔÛÙ¤ıËΠÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ‰˘ÛÎÔÏ›· ÛÙË ‚¿‰ÈÛË, ·‰˘Ó·Ì›· ·Ó¿‚·Û˘ Îϛ̷η˜ Î·È ·Ó¤ÁÂÚÛ˘ ·fi ÙËÓ Î·ıÈÛÙ‹ ÛÙËÓ fiÚıÈ· ı¤ÛË. ∆· ÙÂÏÂ˘Ù·›· 3 ¯ÚfiÓÈ· ›¯Â ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙÔ˘, ȉ›ˆ˜ ÙÔ˘ ÏfiÁÔ˘ (·Ú¿ ÙË ÏÔÁÔıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË) Î·È Ù˘ ‚¿‰ÈÛ˘. ∂›Û˘, ¿Ú¯ÈÛ ӷ ÂÌÊ·Ó›˙ÂÈ Î·È ‰˘ÛÎÔÏ›· ÛÙË Ì¿ÛËÛË. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, ÛÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, ÂÎÙfi˜ ·fi ÙË ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË Î·È ÙË ‚·ÚËÎÔ˝·, ·Ú·ÙËÚ‹ıËΠÌÂÁ¿ÏË ·‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘, ¤ÏÏÂÈ„Ë ¤ÎÊÚ·Û˘ Ì ÙÒÛË ÙÔ˘ οو ¯Â›ÏÔ˘˜ Î·È ÛÈÂÏfiÚÚÔÈ·. À‹Ú¯Â ·ÙÚÔÊ›· Î·È ÛËÌ·ÓÙÈ΋ ·‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Î·È ËÈfiÙÂÚË
∂ÈÎfiÓ· 1. O ·ÛıÂÓ‹˜ Ù˘ ÚÒÙ˘ ÂÚ›ÙˆÛ˘ ηıËψ̤ÓÔ˜ Û ·Ó·ËÚÈ΋ ηڤÎÏ·. ∂›Ó·È ¤Î‰ËÏË Ë Î˘ÊÔÛÎÔÏ›ˆÛË Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Î·È Ë ÚÔ¤ÙÂÈ· Ù˘ ˆÌÔÏ¿Ù˘.
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ÙˆÓ Ì˘ÒÓ Ù˘ ˘ÂÏÈ΋˜ ˙ÒÓ˘ Î·È ÙˆÓ Ì˘ÒÓ ÙˆÓ ¿ÎÚˆÓ. ¶·Ú·ÙËÚ‹ıËΠ„¢‰Ô¸ÂÚÙÚÔÊ›· ÙˆÓ Á·ÛÙÚÔÎÓËÌÈÒÓ, ·ÏÏ¿ Î·È ·ÍÈÔÛËÌ›ˆÙË ÏfiÚ‰ˆÛË Ù˘ ÔÛÊ˘˚΋˜ ÌÔ›Ú·˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ Î·È ·Û‡ÌÌÂÙÚË ÙÂÚ˘ÁÔÂȉ‹˜ ˆÌÔÏ¿ÙË (∂ÈÎfiÓ˜ 3 Î·È 4). ∞fi ÙËÓ ˘fiÏÔÈË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË, Ù· ÙÂÓfiÓÙÈ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÂÎχÔÓÙ·Ó Ê˘ÛÈÔÏÔÁÈο. O ÔÊı·ÏÌÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËΠÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ ÙÈÌ‹˜ Ù˘ CPK. ∆Ô ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ· ¤‰ÂÈÍ ‰È¿¯˘Ù˜ ·ÏÏÔÈÒÛÂȘ Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘. Ÿˆ˜ Ê·›ÓÂÙ·È ·fi ÙËÓ ÂÚÈÁÚ·Ê‹ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È Ë ÂÏ·ÊÚÒ˜ ·˘ÍË̤ÓË CPK Û˘ÓËÁÔÚÔ‡Û·Ó ˘¤Ú Ù˘ ÚÔÛˆÔ-ˆÌÔ‚Ú·¯ÈÔÓ›Ô˘ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÔÚȷ΋ ·Ó¿Ï˘ÛË ∏ ‰È¿ÁÓˆÛË Î·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ ÚÔÛˆÔ-ˆÌÔ‚Ú·¯ÈÔÓ›Ô˘ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ ÂȂ‚·ÈÒıËΠÂÚÁ·ÛÙËÚȷο Ì ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA. ∞ÔÌÔÓÒıËΠDNA ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÙˆÓ ·ÛıÂÓÒÓ Î·È ÌÂÏÂÙ‹ıËΠ̠ÙËÓ Ù¯ÓÈ΋ Southern blotting, ÌÂÙ¿ ·fi ‰ÈÏ‹ ÂÒ·ÛË Ì ٷ ÂÚÈÔÚÈÛÙÈο ¤Ó˙˘Ì· EcoRI Î·È ∞vrII. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi ‰È·ÈÛÙÒıËÎÂ Â¿Ó ÔÈ ÂÏÏ›„ÂȘ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙËÓ ÂÚÈÔ¯‹ 4q35 Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ÓfiÛËÌ· ‹ ·fi Ì›· ÔÌfiÏÔÁË ÂÚÈÔ¯‹ ÛÙÔ ¯ÚˆÌfiۈ̷ 10 (10q26), ÙÔ ÔÔ›Ô ‰ÂÓ Û˘Óԉ‡ÂÙ·È Ì ·ıÔÏÔÁÈÎfi Ê·ÈÓfiÙ˘Ô. °È· ÙÔÓ ˘‚ÚȉÈÛÌfi ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ô ·ÓȯÓÂ˘Ù‹˜ p13∂11 (ÚÔÛÊÔÚ¿ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ °ÂÓÂÙÈ΋˜ ÙÔ˘ Sylvius Lab, Leiden). ∏ Û‹Ì·ÓÛË ¤ÁÈÓ Ì ÌË Ú·‰ÈÂÓÂÚÁfi ÙÚfiÔ Î·È ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ Û‡ÛÙËÌ· Û‹Ì·ÓÛ˘ Î·È ·Ó›¯Ó¢Û˘ Ì ‰ÈÁÔÍÈÁÂÓ›ÓË (Roche). ∆· ·ÔÙÂϤÛÌ·Ù· Î·È ÛÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ ¤‰ÂÈÍ·Ó ÙÔ ›‰ÈÔ ıÚ·‡ÛÌ·, fiˆ˜ Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 5. ¢ËÏ·‰‹, ·Ú·ÙËÚ‹ıËΠfiÙÈ ˘‹Ú¯Â ıÚ·‡ÛÌ· ÂÚ›Ô˘ 7 kb ÌÂÙ¿ ·fi ‰ÈÏ‹ ÂÒ·ÛË Ì ٷ ¤Ó˙˘Ì· EcoRI Î·È ∞vrII.
∂ÈÎfiÓ· 2. O ·ÛıÂÓ‹˜ Ù˘ ÚÒÙ˘ ÂÚ›ÙˆÛ˘ Ì ·ÓÔȯÙfi ÛÙfiÌ· Î·È ÛÈÂÏfiÚÚÔÈ·.
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∂ÈÎfiÓ˜ 3 Î·È 4. ¢Â‡ÙÂÚË ÂÚ›ÙˆÛË. º·›ÓÔÓÙ·È Ù· ·ÎÔ˘ÛÙÈο ‚·ÚËÎÔ˝·˜, Ë ·‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘ Î·È Ë ·Û‡ÌÌÂÙÚË ÙÂÚ˘ÁÔÂȉ‹˜ ˆÌÔÏ¿ÙË.
™˘˙‹ÙËÛË ∏ FSHMD ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ÁÂÓÂÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ·. ∏ ÂÙÂÚÔÁ¤ÓÂÈ· Â›Ó·È ¤Î‰ËÏË ·ÎfiÌ· Î·È ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· (5,10). ∞ӷʤÚÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÂÚ›ÙˆÛË ÌÔÓÔ˙˘ÁˆÙÈÎÒÓ ‰È‰‡ÌˆÓ Ì ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· ÛÙËÓ ¤ÎÊÚ·ÛË (1). ¶·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ ‰ÂÓ ¤¯ÂÈ ·ÔÌÔÓˆı› ̤¯ÚÈ Û‹ÌÂÚ· ÙÔ ˘Â‡ı˘ÓÔ ÁÈ· ÙË ÓfiÛÔ ÁÔÓ›‰ÈÔ (9,11,12). ™ÙÔ 95% ÙˆÓ ·Û¯fiÓÙˆÓ ·ÓȯÓ‡ÔÓÙ·È ÂÏÏ›„ÂȘ ·ӷϷ̂·ÓfiÌÂÓˆÓ ·ÏÏËÏÔ˘¯ÈÒÓ, Ô˘ ÔÓÔÌ¿˙ÔÓÙ·È D4Z4 Î·È ¤¯Ô˘Ó ̤ÁÂıÔ˜ 3,3 kb (13). §fiÁˆ ÙˆÓ ÂÏÏ›„ˆÓ, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·Ó·Î·Ù·Ù¿ÍÂȘ ÛÙËÓ ÙÂÏÔÌÂÚÈ΋ ÂÚÈÔ¯‹ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 4. A˘Ù¤˜ ¤¯Ô˘Ó ˆ˜ Û˘Ó¤ÂÈ· ÌÂÙ·‚ÔÏ‹ ¤ÎÊÚ·Û˘ Î·È ·ÏÏ·Á‹ ÛÙË ÌÂÙ·ÁÚ·ÊÈ΋ ÈηÓfiÙËÙ· ÁÂÈÙÔÓÈÎÒÓ ÛÙËÓ ÂÚÈÔ¯‹ ·˘Ù‹ ÁÔÓȉ›ˆÓ Ì ÙÔ Ì˯·ÓÈÛÌfi Ù˘ “›‰Ú·Û˘ ı¤Û˘” (positional effect). ∞˘Ùfi ıˆÚÂ›Ù·È Û‹ÌÂÚ· Ô Èı·ÓfiÙÂÚÔ˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ FSHMD (6-9,14). ∏ ·Ó›¯Ó¢ÛË ÙˆÓ ÂÏÏ›„ÂˆÓ Á›ÓÂÙ·È Ì ÙËÓ Ù¯ÓÈ΋ ÙÔ˘ Southern blot, Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÂÚÈÔÚÈÛÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ EcoRI Î·È ÙÔ˘ ·ÓȯÓÂ˘Ù‹ p13-11 (5). ™˘ÁÎÂÎÚÈ̤ӷ, ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·ÓȯÓ‡ÂÙ·È ıÚ·‡ÛÌ· ≤35 kb, ÂÓÒ ÛÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi ÏËı˘ÛÌfi ·˘Ùfi ÙÔ ıÚ·‡ÛÌ· ÔÈΛÏÏÂÈ Û ̤ÁÂıÔ˜ ·fi 35 kb ̤¯ÚÈ 300 kb (15). ªÂ ÙÔÓ ›‰ÈÔ ÙÚfiÔ, ·ÓȯÓ‡ÔÓÙ·È ÔÌfiÏÔÁ˜ ·ÏÏËÏÔ˘¯›Â˜ ÂÎÙfi˜ ·fi ÙÔ ¯ÚˆÌfiۈ̷ 4 Î·È ÛÙÔ ¯ÚˆÌfiۈ̷ 10, ÁÂÁÔÓfi˜ Ô˘ ÛÙÔ ·ÚÂÏıfiÓ ‰ËÌÈÔ˘ÚÁÔ‡Û ‰È·ÁÓˆÛÙÈÎfi Úfi‚ÏËÌ· (13). ŒÓ· ÂÚÈÔÚÈÛÙÈÎfi ¤Ó˙˘ÌÔ, ÙÔ BlnI (‹
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AvRII), ·Ó·ÁÓˆÚ›˙ÂÈ ·ÔÎÏÂÈÛÙÈο ÙÔ ÙÌ‹Ì· ÌfiÓÔ ÛÙÔ ¯ÚˆÌfiۈ̷ 10 Î·È fi¯È ÛÙÔ 4. ŒÙÛÈ, ‰ÈÏ‹ ÂÒ·ÛË Ì ٷ ‰‡Ô ÂÚÈÔÚÈÛÙÈο ¤Ó˙˘Ì· (∂coRI-BlnI ‹ AvrII) ÂÈÙÚ¤ÂÈ ÙÔÓ ‰È·¯ˆÚÈÛÌfi Î·È ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ıÚ·‡ÛÌ·ÙÔ˜ ÛÙÔ ¯ÚˆÌfiۈ̷ 4, ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ·ÍÈÔÈÛÙ›· Ù˘ ·Ó¿Ï˘Û˘ (9,19). ªÂÙ¿ ÙËÓ ·Ó·Î¿Ï˘„Ë Ù˘ ÌÔÚȷ΋˜ ‚Ï¿‚˘, ¤¯Ô˘Ó Á›ÓÂÈ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ÁÈ· ÙÔ Û˘Û¯ÂÙÈÛÌfi ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ıÚ·‡ÛÌ·ÙÔ˜ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (16,17). Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ fiÛÔ ÈÔ ÌÈÎÚfi Â›Ó·È ÙÔ ıÚ·‡ÛÌ·, ‰ËÏ·‰‹ ÌÂÁ¿Ï˜ ÂÏÏ›„ÂȘ, ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Û˘Ó‰¤ÔÓÙ·È Ì ‚·Ú‡ÙÂÚÔ Ê·ÈÓfiÙ˘Ô Î·È Û˘ÌÌÂÙÔ¯‹ ·fi ÙÔ ∫¡™ (18). OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ÂÌÊ·Ó›˙Ô˘Ó Û˘Ó‹ıˆ˜ ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ÂÈÏË„›·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û˘ÁÁÂÓ‹ ·ÁÂÓÂÛ›· ÙˆÓ ÚÔÛˆÈÎÒÓ Ó‡ڈÓ, ÙË ÓˆÙÈ·›· Ì˘˚΋ ·ÙÚÔÊ›·, ÙËÓ ÔÏ˘Ì˘ÔÛ›Ùȉ·, ÙË ˙ˆÓÈ·›· Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, ÙË Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Ù‡Ô˘ Becker, ÙȘ ÌÈÙÔ¯ÔÓ‰ÚȷΤ˜ Ì˘Ô¿ıÂȘ, ÙÔ Û‡Ó‰ÚÔÌÔ Moebius Î·È ÙË Û˘ÁÁÂÓ‹ Ì˘ÔÙÔÓÈ΋ ‰˘ÛÙÚÔÊ›· (3,5). ∫·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È, Ë ‰È¿ÁÓˆÛË ‚·Û›ÛÙËΠÙfiÛÔ ÛÙ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù·, fiÛÔ Î·È ÛÙË ÌÔÚȷ΋ ·Ó¿Ï˘ÛË, fiÔ˘ ·ÓȯÓ‡ıËΠÙÔ ÌÈÎÚfiÙÂÚÔ ıÚ·‡ÛÌ· Ô˘ ·Ó·Ê¤ÚÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· (7,5 kb). ∞˘Ùfi Û˘ÌʈÓ› Ì ÙË ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Î·È ÙËÓ ÚÒÈÌË ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (4,9,17,19,20). ∏ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÔÈΛÏÏÂÈ. ∏ ·‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ Û˘Ó‹ıˆ˜ Á›ÓÂÙ·È ·ÓÙÈÏËÙ‹ ηٿ
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∫ϛ̷η ÌÂÁ¤ıÔ˘˜ 2
∂/∞
∂
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48,5 kb 38,4 kb 33,5 kb 29,9 kb 24 kb
17 kb 15 kb
12 kb 11 kb 10 kb 10 kb
9 kb
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7 kb
6 kb ∂ÈÎfiÓ· 5. ∞Ó›¯Ó¢ÛË: ·) ıÚ·‡ÛÌ·ÙÔ˜ ÂÚ›Ô˘ 10 kb ÌÂÙ¿ ·fi ÂÒ·ÛË Ì ÙÔ ¤Ó˙˘ÌÔ ∂coRI (∂) Î·È ‚) ıÚ·‡ÛÌ·ÙÔ˜ ÂÚ›Ô˘ 7 kb ÌÂÙ¿ ·fi ‰ÈÏ‹ ÂÒ·ÛË Ì ٷ ¤Ó˙˘Ì· ∂coRI/AvrII (E/A) ÛÙÔ ÚÒÙÔ ÂÚÈÛÙ·ÙÈÎfi. ∫ϛ̷η ÌÂÁ¤ıÔ˘˜ 1:1 kb ladder (BRL), Îϛ̷η ÌÂÁ¤ıÔ˘˜ 2:Ï Cut mix (Biolabs).
ÙÔ Ù¤ÏÔ˜ Ù˘ ÚÒÙ˘ ‹ ÛÙË ‰Â‡ÙÂÚË ‰ÂηÂÙ›· ˙ˆ‹˜. ™Â ÔÛÔÛÙfi 15% ÙˆÓ ÂÚÈÙÒÛÂˆÓ FSHªD, Ù· Û˘ÌÙÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ÚÒÙË ÂÓÙ·ÂÙ›· Î·È Û˘Ó‹ıˆ˜ ·˘Ùfi ˘Ô‰ËÏÒÓÂÈ Î·ÈÓÔ‡ÚÈ· ÌÂÙ¿ÏÏ·ÍË Î·È ‚·Ú‡ÙÂÚË ÓfiÛËÛË (4,5). ∏ ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÛÙËÓ ÚÒÙË ÂÚ›ÙˆÛË ‹Ù·Ó ÚÈÓ ÙÔ˘˜ 20 Ì‹Ó˜ ˙ˆ‹˜, ÂÓÒ ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË ‹Ù·Ó Ù· 3 ¯ÚfiÓÈ·. ∫·È Ù· ‰‡Ô ÂÚÈÛÙ·ÙÈο Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ›¯·Ó ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ™Â ÔÈÎÔÁÂÓ›˜ ÂÚÈÙÒÛÂȘ, Ë ÓfiÛËÛË Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂÏ·ÊÚ‡ÙÂÚË. ™Â ·È‰È¿ Ì ÚÔÛˆÈ΋ ‰ÈÏËÁ›· (·‰˘Ó·Ì›· Ó· ÛÊ˘Ú›ÍÔ˘Ó, ÂÍ·Ê¿-
ÓÈÛË ÚÈÓÔ¯ÂÈÏÈÎÒÓ ·˘Ï¿ÎˆÓ, ·‰˘Ó·Ì›· Û‡ÁÎÏÂÈÛ˘ ‚ÏÂÊ¿ÚˆÓ Î·È, ÁÂÓÈÎfiÙÂÚ·, ·‰˘Ó·Ì›· ¤ÎÊÚ·Û˘ ÚÔÛÒÔ˘), Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA ÁÈ· FSHMD (5). ∆· Û˘ÌÙÒÌ·Ù· ·Ú¯›˙Ô˘Ó Û˘Ó‹ıˆ˜ Ì ·‰˘Ó·Ì›· Î·È ·ÙÚÔÊ›· ÙˆÓ Ì˘ÒÓ Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Î·È ÙÔ˘ ÚÔÛÒÔ˘ Î·È ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ Ì˘ÒÓ Ù˘ ˘ÂÏÈ΋˜ ˙ÒÓ˘. ∞Ó, fï˜, Ë ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Á›ÓÂÈ ·fi ÙÔ˘˜ ̇˜ Ù˘ ˘ÂÏÈ΋˜ ˙ÒÓ˘, ı· Ú¤ÂÈ Ó· ÙÂı› ˘fi ·ÌÊÈÛ‚‹ÙËÛË Ë ‰È¿ÁÓˆÛË Ù˘ FSHMD (2). ŸÙ·Ó ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÚÔÛˆÈ΋ ‰ÈÏËÁ›·, Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ÌfiÓÔ ·Ó ˘¿Ú¯Ô˘Ó Î·È ¿ÏÏ· ¿Û¯ÔÓÙ· ̤ÏË ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Û˘ÌÌÂÙÔ¯‹ ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘ (4). ¢ÂÓ ÚÔÛ‚¿ÏÏÔÓÙ·È ÔÈ Ì·ÛËÙ‹Ú˜, ÔÈ ÔÊı·ÏÌÔÎÈÓËÙÈÎÔ›, ÔÈ ÁψÛÛÈÎÔ› Î·È ÔÈ Ê·Ú˘ÁÁÈÎÔ› ̇˜. ∏ ·‰˘Ó·Ì›· ÙÔ˘ ÚÔÛÒÔ˘ ÌÔÚ› Ó· Â›Ó·È Ôχ ÂÏ·ÊÚÈ¿ Î·È Ó· ·Ú·ÙËÚÂ›Ù·È ÌfiÓÔ Ì›· ÌÈÎÚ‹ ·Û˘ÌÌÂÙÚ›· ÛÙËÓ ¤ÎÊÚ·ÛË. O ÈÔ ÛÔ‚·Ú¿ ÚÔۂ‚ÏË̤ÓÔ˜ Ì˘˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ô ˆÌÔÏ·ÙÈ·›Ô˜, ÁÂÁÔÓfi˜ Ô˘ Ô‰ËÁ› ÛÙȘ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÙÂÚ˘ÁÔÂȉ›˜ ˆÌÔÏ¿Ù˜, Ô˘ ‹Ù·Ó ÂÌÊ·Ó›˜ Î·È ÛÙ· ‰‡Ô ÂÚÈÛÙ·ÙÈο Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘. ∞ÎÔÏÔ˘ıÔ‡Ó, Û ÛÂÈÚ¿ ÚÔÛ‚ÔÏ‹˜, Ô Ì›˙ˆÓ ıˆÚ·ÎÈÎfi˜ Î·È Ô ‰ÂÏÙÔÂȉ‹˜ (2,5). ∏ ·Û˘ÌÌÂÙÚ›· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ Ì˘ÒÓ Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘ Â›Ó·È Î·ÓfiÓ·˜ Î·È Û˘Ó‹ıˆ˜ ÚÔÛ‚¿ÏÏÂÙ·È ÚÒÙ· ÙÔ ‰ÂÍÈfi ÙÌ‹Ì·. ™˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È ·Û˘ÌÌÂÙÚ›· Î·È ÛÙËÓ ÚÔÛ‚ÔÏ‹ ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘. ∏ Û˘ÌÌÂÙÚÈ΋ ·‰˘Ó·Ì›· Î·È ·ÙÚÔÊ›· ÛÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Â›Ó·È ·Û˘Ó‹ı˘ Î·È ··ÈÙÂ›Ù·È ÌÂÁ¿ÏË ÚÔÛÔ¯‹ ÚÈÓ ÙÂı› Ë ‰È¿ÁÓˆÛË Ù˘ FSHMD (4). ∏ ÓfiÛÔ˜ ¤¯ÂÈ ·Ó·fiÊ¢ÎÙ· ÂÍÂÏÈÎÙÈÎfi ¯·Ú·ÎÙ‹Ú·, Ì ڢıÌfi Ô˘ ÔÈΛÏÏÂÈ Î·È Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁÔ˜ Ù˘ ËÏÈΛ·˜ ¤Ó·Ú͢ ÙˆÓ Û˘Ìو̿وÓ. ™¿ÓÈ·, ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó ÂÚ›Ô‰ÔÈ ÛÙ·ÛÈÌfiÙËÙ·˜. ∫·Ù¿ ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ ÚÔÛ‚¿ÏÏÔÓÙ·È ÔÈ ÎÔÈÏÈ·ÎÔ› Î·È ÔÈ ÂÎÙ›ÓÔÓÙ˜ ÙÔÓ ¿ÎÚÔ fi‰· ̇˜ (2). ∞‰˘Ó·Ì›· ÙˆÓ Ì˘ÒÓ Ù˘ ˘¤ÏÔ˘ Î·È ÙˆÓ ¿Óˆ ¿ÎÚˆÓ ÌÔÚ› Ó· Û˘Ì‚Â› Û ÔÔÈ·‰‹ÔÙ ÛÙÈÁÌ‹, ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ·‰˘Ó·Ì›·˜ ÙˆÓ Ì˘ÒÓ Ù˘ ˆÌÈ΋˜ ˙ÒÓ˘. ™˘Û¿ÛÂȘ Î·È „¢‰Ô¸ÂÚÙÚÔÊ›· ÙˆÓ Ì˘ÒÓ Ù˘ Á·ÛÙÚÔÎÓËÌ›·˜ ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó, ÂÓÒ ÛÔ‚·Ú¤˜ Î·È ÁÂÓÈÎÂ˘Ì¤Ó˜ Û˘Áο̄ÂȘ ·ÔÎÏÂ›Ô˘Ó ÙË ‰È¿ÁÓˆÛË. ∏ „¢‰Ô¸ÂÚÙÚÔÊ›· Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙÔÓ ‰Â‡ÙÂÚÔ ·ÛıÂÓ‹ Ù˘ ÌÂϤÙ˘, ˘Ô‰ËÏÒÓÂÈ fiÙÈ ·˘Ùfi Â›Ó·È Û‡ÓËı˜, ȉ›ˆ˜ fiÙ·Ó Ë FSHMD ·Ú¯›˙ÂÈ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ‰ÂÓ Ú¤ÂÈ Ó· Û˘Á¯¤ÂÙ·È Ì ÙË Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Ù‡Ô˘ Becker (21). °ÂÓÈÎÒ˜, Ë FSHMD ‰ÂÓ ÚÔÛ‚¿ÏÏÂÈ ÙÔÓ Î·Ú‰È·Îfi Ì˘. ª˘ÔηډÈÔ¿ıÂÈ· ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È Û η̛· ÌÂϤÙË fiÔ˘ Á›ÓÂÙ·È Û˘Û¯¤ÙÈÛË Ê·ÈÓfiÙ˘Ô˘-ÁÔÓfiÙ˘Ô˘ Î·È ‰ÂÓ Ê·›ÓÂÙ·È Ó· ·Ó‹ÎÂÈ ÛÙ· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· Ù˘
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ÓfiÛÔ˘. ™Â ÌÈÎÚfi ÔÛÔÛÙfi (5%) ÌÔÚ› Ó· ÚÔÎÏËıÔ‡Ó ‰È·Ù·Ú·¯¤˜ ·ÁˆÁÈÌfiÙËÙ·˜ ‹ ·ÚÚ˘ı̛˜ (22). ¢ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ì˘˚΋˜ ·‰˘Ó·Ì›·˜ Î·È Ù˘ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ηډȷÎÔ‡ Ì˘fi˜. ¶·Ú’ fiÏ· ·˘Ù¿, Û˘ÓÈÛÙ¿Ù·È ÂÙ‹ÛÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫°. ∫·È ÔÈ ‰‡Ô ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰ÂÓ Â›¯·Ó Â˘Ú‹Ì·Ù· ·fi ÙÔ Î˘ÎÏÔÊÔÚÈÎfi. ¶·Ú·ÙËÚÂ›Ù·È ‚·ÚËÎÔ˝· Ó¢ÚÔ·ÈÛıËÙËÚÈ·ÎÔ‡ Ù‡Ô˘, Ë ÔÔ›· ÌÔÚ› Ó· ÂÂÎÙ·ı› Û fiϘ ÙȘ Û˘¯ÓfiÙËÙ˜ Î·È Â›Ó·È ÂÍÂÏÈÎÙÈ΋. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÁÓˆÛË Ù˘ ‚·ÚËÎÔ˝·˜, Ë ÔÔ›· ÌÔÚ› Ó· ÂÎÏËÊı› Ï·Óı·Ṳ̂ӷ ˆ˜ ¯·ÌËÏfi ÓÔËÙÈÎfi ›‰Ô, ˘¿Ú¯ÂÈ Î·ı˘ÛÙ¤ÚËÛË, fiˆ˜ Ê¿ÓËÎÂ Î·È ÛÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË. ∞ÎÔÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û οı ÂÚ›ÙˆÛË FSHMD Ô˘ ‰È·ÁÈÁÓÒÛÎÂÙ·È ÛÙËÓ ÚÒÙË ·È‰È΋ ËÏÈΛ· (5). OÈ Brouwer Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ‚·ÚËÎÔ˝·, ȉ›ˆ˜ ÛÙȘ ˘„ËϤ˜ Û˘¯ÓfiÙËÙ˜, ·Ú·ÙËÚÂ›Ù·È Û¯Â‰fiÓ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì FSHMD (23). ¶ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ‚·ÚËÎÔ˝·˜ Û ÂÚÈÙÒÛÂȘ FSHMD Ì ¤Ó·ÚÍË ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ‰ÂÓ Â›Ó·È Û˘¯ÓfiÙÂÚË ·fi ÂΛÓË ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ËÏÈΛ· ¤Ó·Ú͢, Ë ‰È¿ÚÎÂÈ· Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, Ô ‚·ıÌfi˜ Ù˘ Ì˘˚΋˜ ·‰˘Ó·Ì›·˜ ÙÔ˘ ÚÔÛÒÔ˘, ·ÏÏ¿ Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ıÚ·‡ÛÌ·ÙÔ˜ ‰ÂÓ ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ‚·ıÌfi Ù˘ ‚·ÚËÎÔ˝·˜ (24). ∞ÌÊÈ‚ÏËÛÙÚÔÂȉÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· Ì ÙÚȯÔÂȉÈ΋ ÙËÏ·ÁÁÂÈÂÎÙ·Û›·, ÌÈÎÚÔ·Ó¢ڇÛÌ·Ù· Î·È ·ÔÊÚ¿ÍÂȘ ÙÚȯÔÂȉÒÓ ·ÁÁ›ˆÓ (ÓfiÛÔ˜ Coats) ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙËÓ FSHMD (25). OÈ Shapiro Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÊı·ÏÌÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì·˙› Ì ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË ÛÙ· ˘fiÏÔÈ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È ¯Ú‹ÛÈÌ· ˆ˜ ÚÔ˜ ÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË (26). ∂Âȉ‹ Ë ÓfiÛÔ˜ Coats ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·, ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË Ë ·Ú·ÎÔÏÔ‡ıËÛË Ì ‚˘ıÔÛÎfiËÛË. ∏ ÚÒÈÌË ‰È¿ÁÓˆÛ‹ Ù˘ ÌÔÚ› ÛÙ· ·Ú¯fiÌÂÓ· ÛÙ¿‰È· Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘, Ì ÎÚ˘ÔËÍ›· Î·È ÊˆÙÔËÍ›· ÙˆÓ ‰È¢ڢÛÌ¤ÓˆÓ ·ÁÁ›ˆÓ. ∂Âȉ‹ Ù· Â˘Ú‹Ì·Ù· ·fi ÙËÓ ·ÎÔ‹ Î·È ÙËÓ fiÚ·ÛË ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ¿, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÚÔÛ˘Ìو̷ÙÈÎfi ¤ÏÂÁ¯Ô, ȉ›ˆ˜ › ·Ô˘Û›·˜ Ì˘˚΋˜ ·‰˘Ó·Ì›·˜ (9). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì FSHMD, ÁÂÓÈο, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓÂ˘Ì·ÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ Â›Ó·È ÂÚ›Ô˘ 2% Î·È Û¿ÓÈ· Û˘Óԉ‡ÂÙ·È ·fi ÂÈÏË„›· (18,27,28). ™ÙÔ˘˜ ¿Û¯ÔÓÙ˜, fï˜, Ì ÚÒÈÌË ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓÂ˘Ì·ÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 20%. ™ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ‰‡Ô ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È. ∂ÂÈÛfi‰È· Û·ÛÌÒÓ ‰ÂÓ ¤¯Ô˘Ó ̤¯ÚÈ ÙÒÚ· ·Ú·ÙËÚËı› ÛÙÔ˘˜ ‰‡Ô ·ÛıÂÓ›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘.
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∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ù· ›‰· Ù˘ CPK Î˘Ì·›ÓÔÓÙ·È ·fi Ê˘ÛÈÔÏÔÁÈο ¤ˆ˜ ·˘ÍË̤ӷ. ¶·Ú’ fiÏ· ·˘Ù¿, Û¿ÓÈ· ÊÙ¿ÓÔ˘Ó ÙÔ ÂÓÙ·Ï¿ÛÈÔ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË, Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏÏ· Ó¢ÚÔÌ˘˚ο ÓÔÛ‹Ì·Ù·. ∏ ̤ÙÚËÛË Ù˘ CPK Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Û·Ó ÚÔÛ˘Ìو̷ÙÈÎfi test. ™˘Ó‹ıˆ˜ ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË Ì ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ÓfiÛÔ˘ Î·È Ë ÙÈÌ‹ Ù˘ ÌÂÈÒÓÂÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜ (2). ∆Ô ∏ª° Û˘¯Ó¿ ‰Â›¯ÓÂÈ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ Î·È ¯·ÌËÏÔ‡ ‡ÚÔ˘˜ ÔÏ˘Ê·ÛÈο ‰˘Ó·ÌÈο. ∏ ÎÈÓËÙÈ΋ Î·È Ë ·ÈÛıËÙÈ΋ ·ÁˆÁÈÌfiÙËÙ· ÙˆÓ ÓÂ‡ÚˆÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ (2). ∆Ô ∏ª° Î·È ÛÙ· ‰‡Ô ·È‰È¿ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó ·ıÔÏÔÁÈÎfi. ∏ ‚ÈÔ„›· Ì˘fi˜ Â›Ó·È ÂȂ‚ÏË̤ÓË, ·ÏÏ¿ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ÔÈÎÈÏÔÌÔÚÊ›· ÌÂ Â˘Ú‹Ì·Ù· Û˘¯Ó¿ ÌË ÂȉÈο, Û˘Ó‹ıˆ˜ Ì˘Ô·ıËÙÈÎÔ‡ Ù‡Ô˘. ¶·Ú·ÙËÚÂ›Ù·È ÌÂÁ¿ÏË ‰È·ÊÔÚÔÔ›ËÛË ÛÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ, Ì ÂÓ‰Ô·ÙÙˆÛË ÙˆÓ ˘Ú‹ÓˆÓ Î·È ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ÂÓ‰ÂÈÎÙÈ΋ Ì˘Ô¿ıÂÈ·˜. ºÏÂÁÌÔÓÒ‰Ë ÌÔÓÔ˘ÚËÓÈο ·ÙÙ·Ú· ‰È·ÈÛÙÒÓÔÓÙ·È Û ·È‰È¿ ËÏÈΛ·˜ <2 ¯ÚfiÓˆÓ (2). ∞Ó¢ڛÛÎÔÓÙ·È ÔÏϤ˜ ˘ÂÚÙÚÔÊÈΤ˜, fiˆ˜ Î·È ·ÙÚÔÊÈΤ˜, ÌÈÎÚ¤˜, ÁˆÓÈÒ‰ÂȘ Ì˘˚Τ˜ ›Ó˜ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó Û‡Á¯˘ÛË Ì ‚Ï¿‚Ë Ó¢ÚÔÁÂÓÔ‡˜ Ù‡Ô˘. À¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ·ÛıÂÓÒÓ Ì ӈÙÈ·›· Ì˘˚΋ ·ÙÚÔÊ›· Ù‡Ô˘ FSHªD, Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙˆÓ ÔÔ›ˆÓ ÔÌÔÈ¿˙ÂÈ ÙfiÛÔ Ì ÙËÓ ÂÈÎfiÓ· ÙˆÓ ·Û¯fiÓÙˆÓ Ì FSHMD, Ô˘ ‰ËÌÈÔ˘ÚÁ› ·ÌÊÈ‚ÔÏ›· ÁÈ· ÙÔ ·Ó ÔÈ ‰‡Ô ÔÓÙfiÙËÙ˜ Â›Ó·È ‰È·ÊÔÚÂÙÈΤ˜. ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ¤‰ÂÈÍ·Ó fiÙÈ ·Ú·ÙËÚÂ›Ù·È ÛˆÌ·ÙÈÎfi˜ ̈۷˚ÎÈÛÌfi˜ ÛÙÔ 40% ÙˆÓ ÂÚÈÙÒÛˆÓ, ›Ù ÛÙÔ˘˜ ·ÛıÂÓ›˜ ›Ù ÛÙÔ˘˜ ·Û˘Ìو̷ÙÈÎÔ‡˜ ÁÔÓ›˜ (29). ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ, ÔÛÔÛÙfi 10-20% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌÊ·Ó›˙ÂÈ ·‰˘Ó·Ì›· ‚¿‰ÈÛ˘ Û ËÏÈΛ· ÂÚ›Ô˘ 40 ÂÙÒÓ Î·È Î·Ù·Ï‹ÁÂÈ Û ·Ó·ËÚÈ΋ ηڤÎÏ·. ¶ÚÔÛ˘Ìو̷ÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ‰È·ÁÓˆÛÙÔ‡Ó Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ· Î·È ·ÔÙÂÏÔ‡Ó ÙÔ 30% ÙˆÓ ÔÈÎÔÁÂÓÒÓ ÂÚÈÙÒÛÂˆÓ (2,4,5,17). º·›ÓÂÙ·È fiÙÈ Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÚfiÌÔÈ· Ì ÙÔÓ ¿Û¯ÔÓÙ· ÁÔÓ¤·. ¢ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› ·Ó ÛÙÔ ÓfiÛËÌ· ·Ú·ÙËÚÂ›Ù·È ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ “›Û¢Û˘ ‹ ÚÒÈÌ˘ ¤ÎÊÚ·Û˘” Û οı ÂfiÌÂÓË ÁÂÓÈ¿ (30). ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÁÂÓÈο ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÔÓÙ·È Ë ÂÈ‚›ˆÛË Î·È Ë ·Ó··Ú·ÁˆÁ‹ (2,3), ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÂÙ·È ı·Ó·ÙËÊfiÚ· ¤Î‚·ÛË Û ‰‡Ô ÔÈÎÔÁ¤ÓÂȘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÔÊÂÈÏfiÌÂÓË ÛÙËÓ FSHMD (31,32). Ÿˆ˜ Î·È Û ¿ÏÏÔ˘˜ Ù‡Ô˘˜ Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜, ‰ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ıÂڷ›·. ™˘ÓÈÛٿٷÈ
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¿ÛÎËÛË ¯ˆÚ›˜ ˘ÂÚ‚ÔÏ‹ ηÈ, ÂȉÈÎfiÙÂÚ·, ·ÔÊ˘Á‹ ·Û΋ÛÂˆÓ ÙÔ˘ Ù‡Ô˘ body building (2). ™‹ÌÂÚ· ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· ÚÔÛ˘Ìو̷ÙÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ Southern blot ·Ó¿Ï˘ÛË, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔÓ ·ÓȯÓÂ˘Ù‹ p13-11, ‰ËÌÈÔ‡ÚÁËÛ ¤Ó·Ó ·ÍÈfiÏÔÁÔ ÌÔÚÈ·Îfi ¤ÏÂÁ¯Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ FSHMD. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ıÚ·‡ÛÌ· ÌÈÎÚfiÙÂÚÔ ·fi 35 kb, ·˘Ùfi˜ Ô ¤ÏÂÁ¯Ô˜ ¤¯ÂÈ Â˘·ÈÛıËÛ›· ÂÚ›Ô˘ 95%, ÂÓÒ Ë ÂÍÂȉ›Î¢ÛË ÏËÛÈ¿˙ÂÈ ÙÔ 100% (19). Œ¯ÂÈ ‚ÔËı‹ÛÂÈ ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Î·È ÛÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙˆÓ ·Û¯fiÓÙˆÓ ÌÂÙ¿ ·fi ¯ÚfiÓÈ· ·ÌÊ›‚ÔÏ˘ ‰È¿ÁÓˆÛ˘. ¶ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Û ÔÈÎÔÁ¤ÓÂȘ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi FSHMD, ·Ú¿ ÙȘ ·ÓÙÈÌÂÙˆÈ˙fiÌÂÓ˜ Ú·ÎÙÈΤ˜ ‰˘ÛÎÔϛ˜ (33). ªÂ ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ·Ó·Ì¤ÓÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ÚÔÛ¿ıÂÈ· ·ÔÌfiÓˆÛ˘ Î·È ÎψÓÔÔ›ËÛ˘ ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ FSHMD Î·È ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ‰Ú¿Û˘ ÙÔ˘. ∞˘Ùfi ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË ÙÔ˘ ·ıÔÁÂÓÂÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ù˘ ÓfiÛÔ˘ Î·È ı· ÂÓÈÛ¯‡ÛÂÈ ÙËÓ ·ÍÈÔÈÛÙ›· Ù˘ ÌÔÚȷ΋˜ ‰È¿ÁÓˆÛ˘ (9). µÈ‚ÏÈÔÁÚ·Ê›· 1. Tawil R, Storvick D, Feasby TE, Weiffenbach B, Griggs RC. Extreme variability of expression in monozygotic twins with FSH muscular dystrophy. Neurology 1993;43:345-348. 2. Lunt PW, Harper PS. Genetic counselling in facioscapulohumeral muscular dystrophy. J Med Genet 1991;28:655-664. 3. Eggers S, Zatz M. How the magnitude of clinical severity and recurrence risk affects reproductive decisions in adult males with different forms of progressive muscular dystrophy. J Med Genet 1998;35:189-195. 4. Padberg GW, Lunt PW, Koch M, Fardeau M. Diagnostic criteria for facioscapulohumeral muscular dystrophy. Neuromuscul Disord 1991;1:231-234. 5. Jardine PE, Koch MC, Lunt PW, Maynard J, Bathke KD, Harper PS et al. De novo facioscapulohumeral muscular dystrophy defined by DNA probe p13E-11(D4F104S1). Arch Dis Child 1994;71:221-227. 6. Wijmenga C, Frants RR, Brouwer OF, Moerer P, Weber JL, Padberg GW. Location of facioscapulohumeral muscular dystrophy gene on chromosome 4. Lancet 1990;336:651653. 7. Upadhyaya M, Lunt PW, Sarfarazi M, Broadhead W, Daniels J, Owen M et al. DNA marker applicable to presymptomatic and prenatal diagnosis of facioscapulohumeral disease. Lancet 1990;336:1320-1321. 8. Wijmenga C, Padberg GW, Moerer P, Wiegant J, Liem L, Brouwer OF et al. Mapping of facioscapulohumeral muscular dystrophy gene to chromosome 4q35-qter by multipoint linkage analysis and in situ hybridization. Genomics 1991;9:570-575. 9. Upadhyaya M, Lunt PW, Sarfarazi M, Broadhead W, Daniels J, Owen M et al. A closely linked DNA marker for facioscapulohumeral disease on chromosome 4q. J Med
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Genet 1991;28:665-671. 10. Padberg GW, Frants RR, Brouwer OF, Wijmenga C, Bakker E, Sandkuijl LA. Facioscapulohumeral muscular dystrophy in the Dutch population. Muscle Nerve 1995;2:S81-S84. 11. Ding H, Beckers MC, Plaisance S, Marynen P, Collen D, Belayew A. Characterization of a double homeodomain protein (DUX1) encoded by a cDNA homologous to 3.3 kb dispersed repeated elements. Hum Mol Genet 1998;7:1681-1694. 12. van Deutekom JC, Lemmers RJ, Grewal PK, van Geel M, Romberg S, Dauwerse HG et al. Identification of the first gene (FRG1) from the FSHD region on human chromosome 4q35. Hum Mol Genet 1996;5:581-590. 13. Lemmers RJ, van der Maarel SM, van Deutekom JC, van der Wielen MJ, Deidda G, Dauwerse HG et al. Inter- and intrachromosomal sub-telomeric rearrangements on 4q35: implications for facioscapulohumeral muscular dystrophy (FSHD) aetiology and diagnosis. Hum Mol Genet 1998;7:1207-1214. 14. Sarfarazi M, Wijmenga C, Upadhyaya M, Weiffenbach B, Hyser C, Mathews K et al. Regional mapping of facioscapulohumeral muscular dystrophy gene on 4q35: combined analysis of an international consortium. Am J Hum Genet 1992;51:396-403. 15. Bakker E, Van der Wielen MJ, Voorhoeve E, Ippel PF, Padberg GW, Frants RR et al. Diagnostic, predictive, and prenatal testing for facioscapulohumeral muscular dystrophy: diagnostic approach for sporadic and familial cases. J Med Genet 1996;33:29-35. 16. Ricci E, Galluzzi G, Deidda G, Cacurri S, Colantoni L, Merico B et al. Progress in the molecular diagnosis of facioscapulohumeral muscular dystrophy and correlation between the number of KpnI repeats at the 4q35 locus and clinical phenotype. Ann Neurol 1999;45:751-757. 17. Lunt PW, Jardine PE, Koch MC, Maynard J, Osborn M, Williams M et al. Correlation between fragment size at D4F104S1 and age at onset or at wheelchair use, with a possible generational effect, accounts for much phenotypic variation in 4q35-facioscapulohumeral muscular dystrophy (FSHD). Hum Mol Genet 1995;4:951-958. 18. Funakoshi M, Goto K, Arahata K. Epilepsy and mental retardation in a subset of early onset 4q35facioscapulohumeral muscular dystrophy. Neurology 1998;50:1791-1794. 19. Upadhyaya M, Maynard J, Rogers MT, Lunt PW, Jardine P, Ravine D et al. Improved molecular diagnosis of facioscapulohumeral muscular dystrophy (FSHD): validation of the differential double digestion for FSHD. J Med Genet 1997;34:476-479. 20. Van Deutekom JC, Wijmenga C, van Tienhoven EA, Gruter AM, Hewitt JE, Padberg GW et al. FSHD associated DNA rearrangements are due to deletions of integral copies of a 3.2 kb tandemly repeated unit. Hum Mol Genet 1993;2:2037-2042. 21. Reardon W, Temple IK, Harwood G, Baraitser M. Atypical facioscapulohumeral muscular dystrophy - a counselling dilemma. Clin Genet 1991;39:172-177. 22. Laforet P, de Toma C, Eymard B, Becane HM, Jeanpierre M,
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 05-09-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 12-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ŒÏÂÓ· ºÚ˘Û›Ú· ª·ÎÚ˘Ó›ÙÛ·˜ 16, ∆.∫. 115 22, ∞ÌÂÏfiÎËÔÈ, ∞ı‹Ó· E-mail: efrysira@cc.uoa.gr
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CURRENT ISSUES
¶ÚÔ‚ÈÔÙÈο, Ú‚ÈÔÙÈο, Û˘Ì‚ÈÔÙÈο: ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ π. ÷ڈӛÙË, ª. ª·˘ÚfiΈÛÙ·, ∂. ∫fiÎÔÚË
Probiotics, prebiotics, synbiotics: recent data I. Charoniti, M. Mavrokosta, E. Kokori
¶ÂÚ›ÏË„Ë: ∏ ·ÓıÚÒÈÓË ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰· Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË ‰È·Ù‹ÚËÛË Î·È ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜. ∏ ÙÚÔÔÔ›ËÛ‹ Ù˘ Û ̛· ¢ÓÔ˚ÎfiÙÂÚË ÁÈ· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi Û‡ÛÙ·ÛË ¤¯ÂÈ ÂÈÎÂÓÙÚÒÛÂÈ ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÈÛÙËÌfiÓˆÓ ˘Á›·˜. ∏ ÌÂÙ·‚ÔÏ‹ Ù˘ ÌÔÚ› Ó· ÂÈÙ¢¯ı› ›Ù Ì ÙË ¯ÔÚ‹ÁËÛË ˙ÒÓÙˆÓ ‚·ÎÙËÚ›ˆÓ, ÌÂÙ·‚ÔÏÈο ÂÓÂÚÁÒÓ, Ô˘ ÌÔÚÔ‡Ó Ó· Êı¿ÓÔ˘Ó ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ ·Ó·ÏÏÔ›ˆÙ· ·fi ÙË ‰Ú¿ÛË ÙˆÓ ÂÓ˙‡ÌˆÓ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (ÚÔ‚ÈÔÙÈο), ›Ù Ì ÙË ¯ÔÚ‹ÁËÛË ÌË ÂÙÒÓ ˘‰·Ù·ÓıÚ¿ÎˆÓ Ô˘ ·ÔÙÂÏÔ‡Ó ÂÎÏÂÎÙÈÎfi ˘fiÛÙڈ̷ ÁÈ· Û˘ÁÎÂÎÚÈ̤ӷ ›‰Ë ‚·ÎÙËÚ›ˆÓ Ì ȉÈfiÙËÙ˜ ˆÊ¤ÏÈ̘ ÁÈ· ÙÔÓ ÍÂÓÈÛÙ‹ (Ú‚ÈÔÙÈο), ›Ù ٤ÏÔ˜ Ì ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ú·¿Óˆ (Û˘Ì‚ÈÔÙÈο). ∏ ÙÚÔÔÔ›ËÛË Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜ ‚Ú›ÛÎÂÈ ÂÊ·ÚÌÔÁ‹ Û ÔÏϤ˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·, fiˆ˜ Û ‰È·ÚÚÔ˚ο Û‡Ó‰ÚÔÌ· ÔÈΛÏ˘ ·ÈÙÈÔÏÔÁ›·˜, ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔ˘˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È Î·Ù·ÛÙ¿ÛÂȘ Ì ˘ÂÚ·Ó¿Ù˘ÍË ·ıÔÁfiÓˆÓ ÌÈÎÚÔ‚›ˆÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘.
Abstract: Human gut microflora play a significant role in the maintenance and promotion of the health of the host and scientists in the field of health have shown great interest in modifying gut microflora towards a more beneficial composition. Alteration of the gut microflora can be achieved by the ingestion of either live, metabolically active bacteria able to reach the colon intact through the action of the small intestine enzymes (probiotics), nondigestible carbohydrates which act as substrates to a limited number of bacteria beneficial to the host (prebiotics), or a combination of pro- and prebiotics (synbiotics). Modification of gut microflora has been applied with encouraging results in several clinical conditions such as various diarrhoeal illnesses, inflammatory bowel disease and conditions associated with bacterial overgrowth.
§¤ÍÂȘ ÎÏÂȉȿ: ÚÔ‚ÈÔÙÈο, Ú‚ÈÔÙÈο, Û˘Ì‚ÈÔÙÈο.
Key words: probiotics, prebiotics, synbiotics.
∂ÈÛ·ÁˆÁ‹ ∏ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ˘Á›·˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ™ÙȘ ˆÊ¤ÏÈ̘ ÏÂÈÙÔ˘ÚÁ›Â˜ Ù˘ ·Ó‹ÎÔ˘Ó Ë ·ÚÂÌfi‰ÈÛË ·Ó¿Ù˘Í˘ ‚Ï·‚ÂÚÒÓ ‚·ÎÙËÚȉ›ˆÓ, Ë Û˘ÌÌÂÙÔ¯‹ Û ·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜, Ë Û˘Ì‚ÔÏ‹ ÛÙË Ì›ˆÛË ÂÓÙÂÚÈ΋˜ ‰È¿Ù·Û˘ ÏfiÁˆ ·ÂÚ›ˆÓ, Ë ‚ÂÏÙ›ˆÛË Ù˘ ¤„˘ Î·È Ù˘ ·ÔÚÚfiÊËÛ˘ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, ηıÒ˜ Î·È Ë Û‡ÓıÂÛË ‚ÈÙ·ÌÈÓÒÓ (1). ∏ Ê˘ÛÈÔÏÔÁÈ΋ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ÛÙÔÓ ¿ÓıÚˆÔ ÂÚÈÔÚ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, ÙÔ ÔÔ›Ô ·ÔÈΛ˙ÂÙ·È Ì ÂÚÈÛÛfiÙÂÚ· ·fi 1012 ·ÂÚfi‚È· Î·È ˘Ô¯ÚˆÙÈο ·Ó·ÂÚfi‚È· Gram(-)
Î·È Gram(+) ‚·ÎÙ‹ÚÈ· ·Ó¿ ÁÚ·ÌÌ¿ÚÈÔ ÂÓÙÂÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. ∞fi Ù· 400 ›‰Ë Ô˘ Û˘Ì‚ÈÒÓÔ˘Ó, Ù· 30-40 ·ÔÙÂÏÔ‡Ó ÙÔ 99% Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜. ∆· ·Ó·ÂÚfi‚È· ˘ÂÚÙÂÚÔ‡Ó Î·Ù¿ Ôχ ÙˆÓ ·ÂÚfi‚ÈˆÓ (ÁÈ· οı 1000 ·Ó·ÂÚfi‚È· ·ÓÙÈÛÙÔȯ› 1 ·ÂÚfi‚ÈÔ ‚·ÎÙ‹ÚÈÔ) (2). ™Ù· ÂÈÎÚ·ÙÔ‡ÓÙ· ·Ó·ÂÚfi‚È· ›‰Ë ·Ó‹ÎÔ˘Ó Ù· Bacteroides spp, bifidobacteria, propionibacteria Î·È clostridia. ªÂٷ͇ ÙˆÓ ·ÂÚfi‚ÈˆÓ Î˘ÚÈ·Ú¯Ô‡Ó Ù· enterobacteria Î·È Î˘Ú›ˆ˜ Ù· escherichia coli Î·È enterococci (2). O ·ÔÈÎÈÛÌfi˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·Ú¯›˙ÂÈ ÙȘ ÚÒÙ˜ ÒÚ˜ Ù˘ ˙ˆ‹˜, ·fi ÙËÓ Î·Ù¿ÔÛË ÎÔÏÈÎÒÓ ˘ÁÚÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÙÔÎÂÙÔ‡ Ì ‚·ÎÙ‹ÚÈ· ÙÔ˘
A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, ∫Ú‹ÙË
1st Paediatric Clinic Venizelion General Hospital of Heraklion, Crete
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May-June 03
03-06-03
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¶·È‰È·ÙÚÈ΋ 2003;66:223-231
ÎfiÏÔ˘ Î·È Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ÂÚÈÔ¯‹˜ Ù˘ ÌËÙ¤Ú·˜ ‹ ·fi ‚·ÎÙ‹ÚÈ· ÙÔ˘ ÂÓ‰ÔÓÔÛÔÎÔÌÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Û ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ (2,3). ∂ÎÙfi˜ ·fi ÙÔÓ Ù‡Ô ÙÔ˘ ÙÔÎÂÙÔ‡, ÚfiÏÔ ÛÙË Û‡ÛÙ·ÛË Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜ ¤¯ÂÈ Î·È Ë Û›ÙÈÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ (4). ™Â ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË, ΢ÚÈ·Ú¯Ô‡Ó Ù· bifidobacteria. ™Â ‚Ú¤ÊË Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹, Ë ÌÈÎÚԯψڛ‰· Â›Ó·È ÈÔ ÂÚ›ÏÔÎË, ·ÔÙÂÏÔ‡ÌÂÓË ·fi bifidobacteria, ‚·ÎÙËÚÈÔÂȉ‹, ÎψÛÙËÚ›‰È· Î·È ÛÙÚÂÙfiÎÔÎÎÔ˘˜ (5,6). OÈ ‰È·ÊÔÚ¤˜ Ô˘ ˘¿Ú¯Ô˘Ó Û¯ÂÙ›˙ÔÓÙ·È Ì ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ Á·ÛÙÚ›Ùȉ·˜ ÛÙ· ıËÏ¿˙ÔÓÙ· ‚Ú¤ÊË. §›Á· ÂÈϤÔÓ ‚·ÎÙ‹ÚÈ· ÚÔÛÙ›ıÂÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂfiÌÂÓˆÓ ‰‡Ô ¯ÚfiÓˆÓ Ù˘ ˙ˆ‹˜, ÒÛÙÂ Ë ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ÌÂÙ¿ ÙËÓ ËÏÈΛ· ·˘Ù‹ Ó· ÔÌÔÈ¿˙ÂÈ Ì ÂΛÓË ÙÔ˘ ÂÓËÏ›ÎÔ˘ (7). ∆Ô ÔÈÎÔÛ‡ÛÙËÌ· ÙÔ˘ ÂÓÙ¤ÚÔ˘, οو ·fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, ‰È·ÙËÚÂ›Ù·È Û¯ÂÙÈο ÛÙ·ıÂÚfi ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘ ·ÓıÚÒÔ˘ (7). O ÛËÌ·ÓÙÈÎfi˜ ÚfiÏÔ˜ ÙˆÓ ‚·ÎÙËÚ›ˆÓ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙË ‰È·Ù‹ÚËÛË Î·È ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› ·fi ·ÚÎÂÙ¿ ·ÏÈ¿. ∆Ô ÂӉȷʤÚÔÓ ÙˆÓ ÂÈÛÙËÌfiÓˆÓ ·fi ÓˆÚ›˜ ÛÙÚ¿ÊËΠ۠ÚÔÛ¿ıÂȘ ÙÚÔÔÔ›ËÛ˘ Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜, ÒÛÙ ӷ ·˘ÍËı› Ô ·ÚÈıÌfi˜ ‹ Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ÔÌ¿‰ˆÓ ‚·ÎÙËÚ›ˆÓ Ì ȉÈfiÙËÙ˜ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ˘Á›·. ™Â ·˘Ùfi ÙÔ ÛËÌÂ›Ô ÂÈÛ¿ÁÂÙ·È Ë È‰¤· ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, ÙˆÓ Ú‚ÈÔÙÈÎÒÓ Î·È ÙˆÓ Û˘Ì‚ÈÔÙÈÎÒÓ, Ô˘ Â›Ó·È ÁÓˆÛÙ¿ ˆ˜ ÚfiÛıÂÙ· ÙÚÔÊÒÓ. ¶ÚÔ‚ÈÔÙÈο ∆· ÚÔ‚ÈÔÙÈο Â›Ó·È ‰È·ÙÚÔÊÈο Û˘ÌÏËÚÒÌ·Ù· ·fi ˙ÒÓÙ˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Ô˘ ·ÛÎÔ‡Ó ˆÊ¤ÏÈÌË ‰Ú¿ÛË ÛÙÔÓ ÍÂÓÈÛÙ‹, ÌÂÙ·‚¿ÏÏÔÓÙ·˜ ÙË Û‡ÛÙ·ÛË Î·È ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÌÈÎÚԯψڛ‰·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ (8). °È· Ó· ıˆÚËı› ¤Ó·˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi˜ fiÙÈ ·Ó‹ÎÂÈ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, Ú¤ÂÈ Ó· ÏËÚÔ› Ù· ÎÚÈÙ‹ÚÈ· Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. OÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÚÔ‚ÈÔÙÈο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ¶ÚfiÎÂÈÙ·È Î˘Ú›ˆ˜ ÁÈ· Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔ˘˜ Î·È bifidobacteria Ô˘ Û˘Ó‹ıˆ˜ ·Ú¿ÁÔ˘Ó Î·Ù¿ ÙË ˙‡ÌˆÛ‹ ÙÔ˘˜ Á·Ï·ÎÙÈÎfi Ô͇. ∆Ô ·Ô¶›Ó·Î·˜ 1. ∫ÚÈÙ‹ÚÈ· ÚÔ‚ÈÔÙÈÎÒÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÌÏËÚˆÌ¿ÙˆÓ ∆· ÚÔ‚ÈÔÙÈο Ú¤ÂÈ: ñ Ó· ·ÛÎÔ‡Ó ˆÊ¤ÏÈÌË ‰Ú¿ÛË ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ñ Ó· ÌËÓ Â›Ó·È ÙÔÍÈο Î·È ·ıÔÁfiÓ· ñ Ó· ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ‚ÈÒÛÈÌˆÓ Î˘ÙÙ¿ÚˆÓ ñ Ó· ‰È·ÙËÚÔ‡Ó ÙȘ ȉÈfiÙËÙ¤˜ ÙÔ˘˜ ηٿ ÙȘ ‰È·‰Èηۛ˜ ·Ôı‹Î¢Û˘, ‰È·Ù‹ÚËÛ˘ Î·È ¯Ú‹Û˘ ñ Ó· Â›Ó·È ‰˘Ó·Ùfi Ó· ·Ó··Ú·¯ıÔ‡Ó Û ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ (‚ÈÔÌ˯·ÓÈ΋ ·Ó··Ú·ÁˆÁ‹)
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Ù¤ÏÂÛÌ· Ù˘ ‰Ú¿Û˘ ÙÔ˘˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Û٤ϯԘ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Ô˘ ¯ÔÚËÁÂ›Ù·È (9). ™ÙȘ ȉÈfiÙËÙ¤˜ ÙÔ˘˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È: ·) Ë ·‡ÍËÛË Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙȘ ÏÔÈÌÒÍÂȘ ÙÔ˘ ÂÙÈÎÔ‡, ‚) Ë ‰È¤ÁÂÚÛË Ù˘ ·ÓÔÛ›·˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, Á) Ë ‰È·Ù‹ÚËÛË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ıÂڷ›·˜, ‰) Ë ‚ÂÏÙ›ˆÛË Ù˘ ¤„˘ Î·È Â) Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ‰˘Û·ÓÂÍ›·˜ ÛÙË Ï·ÎÙfi˙Ë. ¶Èı·Ó¿ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ Î·È Ù˘ ·Ì̈ӛ·˜ ÛÙÔ ·›Ì· Î·È ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ ÙˆÓ Î·ÎÔËıÂÈÒÓ ÙÔ˘ ÂÙÈÎÔ‡ (10). O ·ÚÈÔ˜ Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ıˆÚÂ›Ù·È Ô “·ÓÙ·ÁˆÓÈÛÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜” (10). O fiÚÔ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ó· ÂÚÈÁÚ¿„ÂÈ ÙË ‰È·‰Èηۛ· ÚÔÛÎfiÏÏËÛ˘ ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ÛÙÔÓ ÂÓÙÂÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î·È, ̤ۈ ·˘Ù‹˜, ÙËÓ ·ÚÂÌfi‰ÈÛË Ù˘ ÚÔÛÎfiÏÏËÛ˘ ¿ÏÏˆÓ ‚·ÎÙËÚ›ˆÓ, Èı·Ó¿ ·ıÔÁfiÓˆÓ, ÏfiÁˆ ηٿÏ˄˘ ÙˆÓ ı¤ÛÂˆÓ ÚÔÛÎfiÏÏËÛ˘. ÕÏÏÔÈ Ì˯·ÓÈÛÌÔ› ‰Ú¿Û˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ‚·ÎÙËÚÈÔÎÙfiÓˆÓ Ô˘ÛÈÒÓ (11) Î·È ÙËÓ ÂÓ›Û¯˘ÛË ‹ ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛ›·˜ ÙÔ˘ ÍÂÓÈÛÙ‹ (·Ú·ÁˆÁ‹ ·ÓÙÈۈ̿وÓ, ÂÓÂÚÁÔÔ›ËÛË ·ÓÙȉڿÛÂˆÓ Î·ı˘ÛÙÂÚË̤Ó˘ ˘ÂÚ¢·ÈÛıËÛ›·˜, ›ٷÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÔÓÔ‡ÚËÓˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ, ‰È¤ÁÂÚÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÈÓÙÂÚÊÂÚfiÓ˘, IL-1a Î·È TNF-a) (12). ∆· bifidobacteria Ê·›ÓÂÙ·È fiÙÈ ·ÛÎÔ‡Ó ÙË ‰Ú¿ÛË ÙÔ˘˜ ̤ۈ ·Ú·ÁˆÁ‹˜ Ô˘ÛÈÒÓ ·Ó·ÛÙ·ÏÙÈÎÒÓ Ù˘ ·Ó¿Ù˘Í˘ ¿ÏÏˆÓ ‚·ÎÙËÚ›ˆÓ, ·ÏÏ¿ Î·È Ì¤Ûˆ ·Ú·ÁˆÁ‹˜ ÈÛ¯˘ÚÒÓ ÔͤˆÓ, Ù· ÔÔ›· ·ÛÎÔ‡Ó ÙË ‚·ÎÙËÚÈÔÎÙfiÓÔ ¶›Ó·Î·˜ 2. ™˘Ó‹ıË ÚÔ‚ÈÔÙÈο Lactobacilli L. acidophilus L. casei L. deibrueckii subsp. bulgrius L. reuteri L. cellobiosus L. curvarus L. fermentum L. plantarum Gram positive cocci Lactococcus lactis subsp. cremoris Streptococcus salivaris subsp. thermophilus Enterococcus faecium S. diaacetylactis S. intermedius Bifidobacteria B. bifidum B. adolescentis B. animalis B. infantis B. longum B. thermophilum
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‰Ú¿ÛË ÙÔ˘˜ ̤ۈ Ì›ˆÛ˘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ pH (13). ™Â fi,ÙÈ ·ÊÔÚ¿ ÙȘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ˜, Ù· ÚÔ‚ÈÔÙÈο Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÔ˘Ó ÙË ‰È¿ÚÎÂÈ· Î·È ÙË ‚·Ú‡ÙËÙ· ·˘ÙÒÓ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‹ ·ÎfiÌË Î·È Ó· ÚÔÏ¿‚Ô˘Ó ÙËÓ ÂΉ‹ÏˆÛ‹ ÙÔ˘˜. ™˘ÁÎÂÎÚÈ̤ӷ, Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯ÂÈ ·Ô‰ÂȯÙ› Ô ÛËÌ·ÓÙÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ Lactobacillus rhamnosus GG ÛÙË ıÂÙÈ΋ ¤Î‚·ÛË Ù˘ ‰È¿ÚÚÔÈ·˜ ·fi Èfi Rota ÛÙ· ‚Ú¤ÊË (1417). ™Â Ì›· ÚfiÛÊ·ÙË, ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙËÓ ∂˘ÚÒË Î·È ¤Ï·‚·Ó ̤ÚÔ˜ ·È‰È¿ ËÏÈΛ·˜ ·fi 1-36 ÌËÓÒÓ Ì ÔÍ›· ‰È¿ÚÚÔÈ·, ¯ÔÚËÁ‹ıËΠÎÔÈÓfi ËÏÂÎÙÚÔÏ˘ÙÈÎfi ‰È¿Ï˘Ì· Î·È ËÏÂÎÙÚÔÏ˘ÙÈÎfi ‰È¿Ï˘Ì· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì Lactobacillus rhamnosus GG. ™Ù· ·È‰È¿ Ô˘ ¤Ï·‚·Ó ÙÔ ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì Lactobacillus rhamnosus GG ËÏÂÎÙÚÔÏ˘ÙÈÎfi ‰È¿Ï˘Ì· Î·È ÂȉÈο Û ·˘Ù¿ Ô˘ ¤·Û¯·Ó ·fi Ïԛ̈ÍË ·fi Èfi Rota, Ë ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÈÒıËΠÛËÌ·ÓÙÈο (58±28 ÒÚ˜ ÛÙ· ·È‰È¿ Ì ÙÔ ÂÌÏÔ˘ÙÈṲ̂ÓÔ ‰È¿Ï˘Ì· Î·È 76±36 ÒÚ˜ ÛÙ· ·È‰È¿ Ì ÙÔ ÎÔÈÓfi ËÏÂÎÙÚÔÏ˘ÙÈÎfi ‰È¿Ï˘Ì·) (18,19). O Lactobacillus GG Ê·›ÓÂÙ·È fiÙÈ ÌÂÈÒÓÂÈ Î·È ÙÔ Ú˘ıÌfi ·Ô‚ÔÏ‹˜ ÙÔ˘ ÈÔ‡ Rota ÛÙ· ÎfiÚ·Ó· ηÈ, ¿Ú·, fiÙÈ ÂÚÈÔÚ›˙ÂÈ ÙË ÌÂÙ¿‰ÔÛ‹ ÙÔ˘ (20). ™Â ¿ÏϘ ÌÂϤÙ˜, fiÔ˘ ÙÔ ·›ÙÈÔ ÙˆÓ ‰È·ÚÚÔÈÒÓ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È, ÚÔ‚ÈÔÙÈο Ô˘ ¤¯Ô˘Ó ÌÂÈÒÛÂÈ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Â›Ó·È, ÂÎÙfi˜ ÙÔ˘ Lactobacillus rhamnosus GG, Ô Enterococcus faecium SF68 (21), Ô Saccharomyces boulardii (22) Î·È Ô Lactobacillus reuteri (20). O Lactobacillus acidophilus Ê·›ÓÂÙ·È fiÙÈ ÌÂÈÒÓÂÈ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÙˆÓ ÌÈÎÚÔ‚È·ÎÒÓ Á·ÛÙÚÂÓÙÂÚ›ÙȉˆÓ (23). À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ Û˘Û¯ÂÙ›˙Ô˘Ó ÙË ¯ÔÚ‹ÁËÛË ÚÔ‚ÈÔÙÈÎÔ‡ Ì ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ‰È¿ÚÚÔÈ·˜ ÙˆÓ Ù·ÍȉȈÙÒÓ (24,25), ηıÒ˜ Î·È ÙËÓ ÂÎÚ›˙ˆÛË ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ fiˆ˜ Ë Salmonella Î·È ÙÔ Campylobacter ·fi ÙÔ ¤ÓÙÂÚÔ ¯ÚfiÓÈˆÓ ÊÔÚ¤ˆÓ (26,27). ∏ ˘ÔÙÚÔÈ¿˙Ô˘Û· ÂÓÙÂÚ›Ùȉ· ·fi Cl. difficile Ê·›ÓÂÙ·È, ›Û˘, Ó· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ¯ÔÚ‹ÁËÛË Ï·ÎÙÔ‚¿ÎÈÏÏˆÓ (28). ∞ÔÙÂÏÂÛÌ·ÙÈο ÚÔ‚ÈÔÙÈο ÛÙËÓ ÚfiÏË„Ë Ù˘ ‰È¿ÚÚÔÈ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ٷ ·ÓÙÈ‚ÈÔÙÈο ıˆÚÔ‡ÓÙ·È Ô Lactobacillus rhamnosus GG Î·È Ô Saccharomyces boulardii (29). ™Â ‰ÈÏ‹-Ù˘ÊÏ‹ ÌÂϤÙË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ·È‰È¿ Ô˘ ÂÏ¿Ì‚·Ó·Ó ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ë ¯ÔÚ‹ÁËÛË Lactobacillus rhamnosus GG Ì›ˆÛ ÙËÓ Â›ÙˆÛË ÙˆÓ ¯·Ï·ÚÒÓ ÎÂÓÒÛÂˆÓ ·fi 42% Û 17% (30). ∏ ¯ÔÚ‹ÁËÛË ÚÔ‚ÈÔÙÈÎÒÓ ¤¯ÂÈ ÂÚÈÔÚÈṲ̂ӷ ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ÂÎÚ›˙ˆÛË ÙÔ˘ H. Pylori, ·Ú’ fiÏÔ Ô˘ Û in vitro ÌÂϤÙ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› ·ÓÙ·ÁˆÓÈÛÙÈ΋ Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ H. Pylori Î·È ÛÙÂϯÒÓ Lactobacillus (31).
Paediatriki 2003;66:223-231
∆· ÚÔ‚ÈÔÙÈο ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Ì ÂÈÙ˘¯›· Û ÂÓËÏ›ÎÔ˘˜ ÛÙË ıÂڷ›· Ù˘ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ ·fi ÌÂıÔÙÚÂÍ¿ÙË (32), Ù˘ ·ÎÙÈÓÈ΋˜ ÂÓÙÂÚ›Ùȉ·˜ (33) Î·È ÛÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯ÚfiÓÈ·˜ ‰È¿ÚÚÔÈ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ AIDS (34). º·›ÓÂÙ·È fiÙÈ ¤¯Ô˘Ó ¢ÂÚÁÂÙÈ΋ ›‰Ú·ÛË fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ÓÂÔÁÓ¿ ¿Û¯ÔÓÙ· ·fi ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· Î·È ·ÏÏÂÚÁÈ΋ ÎÔÏ›Ùȉ·, ηıÒ˜ Î·È Û ·È‰È¿ Ì ΢ÛÙÈ΋ ›ÓˆÛË (35). ™Â fi,ÙÈ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ¯Ú‹ÛË ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ÛÙȘ ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔ˘˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ù· ·ÔÙÂϤÛÌ·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚÎÂÙfi ÂӉȷʤÚÔÓ. OÈ Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Ê·›ÓÂÙ·È fiÙÈ ·Ó·ÎÔ˘Ê›˙Ô˘Ó fi¯È ÌfiÓÔ ·fi ÙȘ ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ˘ÂÚ·Ó¿Ù˘ÍË ‚·ÎÙËÚ›ˆÓ, ·ÏÏ¿ Î·È ·fi ÙȘ Â͈ÂÓÙÂÚÈΤ˜ ÂÈÏÔΤ˜, fiˆ˜ Ë ·ÚıÚ›Ùȉ· (35,36). ∏ ¯ÔÚ‹ÁËÛË Saccharomyces boulardii Û ·È‰È¿ Ì ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ÂÓÂÚÁfi ÓfiÛÔ Crohn ¤Ù˘¯Â ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ÎÂÓÒÛÂˆÓ Î·È Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘, Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ Ô˘ ‰ÂÓ ¤Ï·‚·Ó ÚÔ‚ÈÔÙÈÎfi (37). ∆· ÚÔ‚ÈÔÙÈο Ê·›ÓÂÙ·È Ó· Â›Ó·È ÙÔ ›‰ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο Ì ÙË ÌÂÛ·Ï·˙›ÓË ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ‡ÊÂÛ˘ ÛÙË ÓfiÛÔ Crohn Î·È ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ˘ÔÙÚÔÒÓ (38). ™Â fi,ÙÈ ¤¯ÂÈ Û¯¤ÛË Ì ÙË ‰˘Û·ÓÂÍ›· ÛÙË Ï·ÎÙfi˙Ë, Ô Lactobacillus acidophilus Ê·›ÓÂÙ·È fiÙÈ ‚ÂÏÙÈÒÓÂÈ Ù· Û˘ÌÙÒÌ·Ù·, ̤ۈ ·Ú·ÁˆÁ‹˜ ‚-Á·Ï·ÎÙÔÛȉ¿Û˘ (39). ∆· ÚÔ‚ÈÔÙÈο ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· ÛÙËÓ ÚfiÏË„Ë, ·ÏÏ¿ Î·È ÛÙË ıÂڷ›· ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓfiÛˆÓ (40). ∏ ‰Ú¿ÛË ÙÔ˘˜ ÔÈΛÏÏÂÈ. ∂ÓÈÛ¯‡Ô˘Ó ÙÔÓ ‚ÏÂÓÓÔÁfiÓÈÔ ÊÚ·ÁÌfi ÙÔ˘ ÂÓÙ¤ÚÔ˘ (41) Î·È ·ÓÙÈÛÙÚ¤ÊÔ˘Ó ÙËÓ ·˘ÍË̤ÓË ‰È·ÂÚ·ÙfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ô˘ ·Ú·ÙËÚÂ›Ù·È Û˘¯Ó¿ Û ·ÛıÂÓ›˜ Ì ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· (42). ∂›Û˘, ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ÂȉÈ΋, ÂÈÙÂÏÔ‡ÌÂÓË Ì¤Ûˆ IgA, ·¿ÓÙËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘, Ô˘ Û˘¯Ó¿ Â›Ó·È ÂÏÏÂÈÌÌ·ÙÈ΋ ÛÙÔ˘˜ ·Ú·¿Óˆ ·ÛıÂÓ›˜ (42). ∆¤ÏÔ˜, ÌÂÈÒÓÔ˘Ó ÙËÓ ÚÔηÏÔ‡ÌÂÓË ·fi ÙËÓ ·ÏÏÂÚÁ›· ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË, ̤ۈ ·Ú·ÁˆÁ‹˜ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÔÎÈÓÒÓ, fiˆ˜ Ë ÈÓÙÂÚÏ¢ΛÓË 10 Î·È Ô ÌÂÙ·ÙÚÂÙÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‚ (41). O˘ÛÈ·ÛÙÈο, Ù· ÚÔ‚ÈÔÙÈο ·ÔÙÚ¤Ô˘Ó ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ Ù‡Ô˘ 2 (TH2) Î·È ‰È·‰Ú·Ì·Ù›˙Ô˘Ó Ú˘ıÌÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ÙÔÈ΋, ·ÏÏ¿ Î·È ÙË Û˘ÛÙËÌ·ÙÈ΋ ÂΉ‹ÏˆÛË ÊÏÂÁÌÔÓ‹˜ ÏfiÁˆ ¤ÎıÂÛ˘ Û ·ÏÏÂÚÁÈÔÁfiÓ· ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ (43). ™ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Ù· ·Ú·¿Óˆ ·Ô‰ÂÈÎÓ‡ÔÓÙ·È Ì¤Û· ·fi ÌÂϤÙ˜, fiÔ˘ Ë ¯ÔÚ‹ÁËÛË ÚÔ‚ÈÔÙÈÎÒÓ Û ÂÁ·Ԣ˜ ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ·ËÛ˘ Î·È Û ÓÂÔÁÓ¿ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Ì›ˆÛ ÛËÌ·ÓÙÈο ÙËÓ ÂΉ‹ÏˆÛË ·ÙÔ›·˜ (44). O ÚfiÏÔ˜ ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ÛÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ¯ÔÏËÛÙÂÚfiÏ˘ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÙÂÎÌËÚȈ̤ÓÔ˜, ·ÏÏ¿ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó ÙËÓ
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¢ÓÔ˚΋ ›‰Ú·Û‹ ÙÔ˘˜, ȉȷ›ÙÂÚ· ÛÙ· ›‰· Ù˘ LDL (45). ∆· ÚÔ‚ÈÔÙÈο Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÔ˘Ó ÙË ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Î·È ÙÔ˘ Ì·ÁÓËÛ›Ô˘ fiÙ·Ó ÚÔÛÙ›ıÂÓÙ·È Û Á¿Ï·Ù·. ∂›Û˘, ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ·Ú·ÁˆÁ‹ ‚ÈÙ·ÌÈÓÒÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ µ Î·È ÙÔ˘ Ê˘ÏÏÈÎÔ‡ ÔͤԘ (46). O Lactobacillus GG ¤¯ÂÈ Î·Ù·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÛÙË ‚·ÎÙËÚȷ΋ ÂÓ˙˘ÌÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ∏ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ¤¯ÂÈ Û˘Ó‰Âı› Ì ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ÂÓ˙‡ÌˆÓ ‚-ÁÏ˘ÎÔ˘ÚÔÛȉ¿‰Ë˜, ‚-ÁÏ˘ÎÔÓȉ¿Û˘, ÓÈÙÚÔÚ‰ԢÎÙ¿Û˘ Î·È ·˙ˆÙÔÚ‰ԢÎÙ¿Û˘, Ù· ÔÔ›· ıˆÚÂ›Ù·È fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È¤ÁÂÚÛË ÚÔηÚÎÈÓÔÁfiÓˆÓ Ô˘ÛÈÒÓ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ. ∂›Û˘, Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ Î·È Ô‰ËÁÔ‡Ó Û ηÚÎÈÓÔÁ¤ÓÂÛË (46). ∏ ¯Ú‹ÛË ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÎfiÛÌÔ, Û ·È‰È¿ Ì ‰È·ÚÚÔ˚ο Û‡Ó‰ÚÔÌ·, ˆ˜ ̤ÚÔ˜ ÙˆÓ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, ›Ûˆ˜ ÚÔÛʤÚÂÈ ÔχÙÈÌË ‚Ô‹ıÂÈ· Û ·˘Ùfi ÙÔ ÙÂÚ¿ÛÙÈÔ Úfi‚ÏËÌ· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜. ◊‰Ë, ÛÙȘ Û˘ÛÙ¿ÛÂȘ Ù˘ ¶·ÁÎfiÛÌÈ·˜ OÚÁ¿ÓˆÛ˘ ÀÁ›·˜ (WHO) ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯Ú‹Û˘ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ¯Ú‹ÛË ÚÔ‚ÈÔÙÈÎÒÓ fiˆ˜ ÔÈ Lactobacilli rhamnosus Î·È plantarum. ∆· ÚÔ‚ÈÔÙÈο ÚÔÛÙ›ıÂÓÙ·È Û Á¿Ï·Ù·, ‰È¿ÊÔÚ· ›‰Ë ÁÈ·Ô˘ÚÙÈÔ‡, Ù˘ÚÈ¿, ÚÔÊ‹Ì·Ù· Î·È ·ÁˆÙ¿. ™ÙËÓ π·ˆÓ›·, ÚˆÙÔfiÚÔ ¯ÒÚ· ÛÙËÓ ·Ú·Û΢‹ ÔÚÁ·ÓÈÎÒÓ ÚÔ˚fiÓÙˆÓ, ÁÈ· Ó· ıˆÚËı› οÔÈÔ ÚÔ˚fiÓ ÚÔ‚ÈÔÙÈ΋ ÙÚÔÊ‹, ı· Ú¤ÂÈ Ó· ÂÚȤ¯ÂÈ ˙ˆÓÙ·ÓÔ‡˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Û ÔÛfiÙËÙ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 107/g ‹ ml ÚÔ˚fiÓÙÔ˜ (47). ¶·Ú·Ì¤ÓÂÈ, fï˜, ·‰È¢ÎÚ›ÓÈÛÙÔ ·ÎfiÌË ÙÔ ÂÏ¿¯ÈÛÙÔ ÔÛfi ÙˆÓ ÚÔÛÙÈı¤ÌÂÓˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, ηıÒ˜ Î·È Ô È‰·ÓÈÎfi˜ ¯ÚfiÓÔ˜ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜, ÒÛÙ ӷ ˘¿ÚÍÂÈ Â˘ÂÚÁÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ™‹ÌÂÚ·, Ù›ÓÂÈ Ó· ÂÈÎÚ·Ù‹ÛÂÈ Ë ¿Ô„Ë fiÙÈ Û˘ÁΤÓÙÚˆÛË ÌÈÎÚfiÙÂÚË ·fi 105 ˙ˆÓÙ·ÓÒÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ·Ó¿ g ‹ ml ÚÔ˚fiÓÙÔ˜ ‰ÂÓ Â›Ó·È ÈηӋ Ó· ·Ú¿ÁÂÈ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ·, ·Ó Î·È Ë È‰·ÓÈ΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ÚÔ‚ÈÔÙÈÎÔ‡ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ Û٤ϯԘ Ô˘ ¯ÚËÛÈÌÔÔÈ›ٷÈ, ηıÒ˜ Î·È Ì ÙÔ Â›‰Ô˜ Ù˘ ÙÚÔÊ‹˜ ÛÙËÓ ÔÔ›· ÂÓۈ̷ÙÒÓÂÙ·È (47). ™ÙÔ ÂÌfiÚÈÔ Î˘ÎÏÔÊÔÚÔ‡Ó Ì ÙË ÌÔÚÊ‹ ÛÎfiÓ˘, ÔÏÙÔ‡, Ù·ÌϤٷ˜, ο„Ô˘Ï·˜, ˘ÁÚÔ‡ ÂӷȈڋ̷ÙÔ˜ Î·È ÛÚ¤È. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â˘Ú‡Ù·Ù· ÛÙËÓ ÎÙËÓÔÙÚÔÊ›·, ·ÏÏ¿ ÛÙ·‰È·Î¿ ηıÈÂÚÒÓÔÓÙ·È Î·È ˆ˜ Û˘ÌÏËÚÒÌ·Ù· ÛÙËÓ ·ÓıÚÒÈÓË ‰È·ÙÚÔÊ‹. ¶¿ÓÙˆ˜, ¯ÚÂÈ¿˙ÔÓÙ·È ·ÎfiÌË ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÁÂÓÈ΢ٛ Ë ¯Ú‹ÛË ÙÔ˘˜ ˆ˜ ·ÛÊ·Ï‹ ‰È·ÙÚÔÊÈο Û˘ÌÏËÚÒÌ·Ù·. ¶ÚÔ‚Ï‹Ì·Ù· ËÁ¿˙Ô˘Ó ·fi ÙËÓ ·ÓÔÌÔÈÔÌÔÚÊ›· ÙˆÓ ÌÂÏÂÙÒÓ, ·fi ÙÔ ÁÂÁÔ-
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Ófi˜ fiÙÈ Û˘¯Ó¿ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÓÙÔÈÛÙÔ‡Ó ÔÈ ÏËı˘ÛÌÔ› ÙˆÓ Â͈ÁÂÓÒ˜ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, ÏfiÁˆ ‡·Ú͢ ›‰ÈˆÓ ‹ ·Ú·Ï‹ÛÈˆÓ ÂÓ‰ÔÁÂÓÒÓ ÏËı˘ÛÌÒÓ, ηıÒ˜ Î·È ·fi ÙÔ fiÙÈ ·Ô‚¿ÏÏÔÓÙ·È Ù·¯‡Ù·Ù· ·fi ÙÔÓ ÔÚÁ·ÓÈÛÌfi (̤۷ Û ÂÚ›Ô˘ Ô¯ÙÒ Ë̤Ú˜ ¤ˆ˜ Ï›Á˜ ‚‰ÔÌ¿‰Â˜) ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜. ∆· ÚÔ‚Ï‹Ì·Ù· Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi ÙËÓ Î·Ù¿ÔÛË ˙ÒÓÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, ˘ÂÚÛÎÂÏ›˙Ô˘Ó Û οÔÈÔ ‚·ıÌfi Ù· Ú‚ÈÔÙÈο, Ô˘Û›Â˜ ÌË ˙ÒÛ˜, ÔÈ Ôԛ˜ ·ÔÙÂÏÔ‡Ó ˘fiÛÙڈ̷ ÁÈ· ÙËÓ ˘ÂÚ·Ó¿Ù˘ÍË Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ‚·ÎÙËÚÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ô˘ ‹‰Ë ˘¿Ú¯Ô˘Ó ÛÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÙÔ˘ ÍÂÓÈÛÙ‹ Î·È ·ÛÎÔ‡Ó Â˘ÂÚÁÂÙÈ΋ ‰Ú¿ÛË. ¶Ú‚ÈÔÙÈο ™˘ÛÙ·ÙÈο ÙˆÓ ÙÚÔÊÒÓ, fiˆ˜ Ê˘ÙÈΤ˜ ›Ó˜, Û‡ÓıÂÙ˜ ÚˆÙ½Ó˜, ÌË ÂÙÔ› ˘‰·Ù¿ÓıڷΘ (ÔÏÈÁÔÎ·È ÔÏ˘Û·Î¯·Ú›Ù˜) Î·È ÔÚÈṲ̂ӷ ÏÈ›‰È·, Ô˘ ‰ÂÓ ˘fiÎÂÈÓÙ·È Û ÂÓ˙˘ÌÈ΋ ‰È¿Û·ÛË ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ Î·È Êı¿ÓÔ˘Ó ·Ó·ÏÏÔ›ˆÙ· ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ıÚ¤„Ë ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘. ∞ӷʤÚÔÓÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ “ÙÚÔÊ‹ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘”. ∏ “ÙÚÔÊ‹ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘” ·ÔÙÂÏ› ˘fiÛÙڈ̷ ÁÈ· Ù· ‚·ÎÙËÚ›‰È· ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, Ù· ÔÔ›· ‰È·ÛÒÓÙ·˜ ÙËÓ, ÙÚÔÊÔ‰ÔÙÔ‡Ó ÙÔÓ ÔÚÁ·ÓÈÛÌfi Ì ··Ú·›ÙËÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Î·È ÂÓ¤ÚÁÂÈ·. ™˘ÓÈÛÙ¿Ù·È Ó· ·Ú¤¯ÂÙ·È ÙÔ 10% ÙˆÓ ËÌÂÚ‹ÛÈˆÓ ıÂÚÌ›‰ˆÓ Î·È ÙÔ 20% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ fiÁÎÔ˘ Ù˘ ËÌÂÚ‹ÛÈ·˜ ‰È·ÙÚÔÊ‹˜ Ì ÙË ÌÔÚÊ‹ “Ù˘ ÙÚÔÊ‹˜ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘” (48). ∆· ÂÚÈÛÛfiÙÂÚ· Û˘ÛÙ·ÙÈο “Ù˘ ÙÚÔÊ‹˜ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘” ·ÔÙÂÏÔ‡Ó ˘fiÛÙڈ̷ ÌË ÂȉÈ΋˜ ˙‡ÌˆÛ˘ ·fi ‰È·ÊÔÚÂÙÈο ›‰Ë ‚·ÎÙËÚ›ˆÓ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ·˘ÏÔ‡, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÂÓ›ÔÙÂ Î·È ·ıÔÁfiÓˆÓ ÛÙÂϯÒÓ. ™˘ÛÙ·ÙÈο “Ù˘ ÙÚÔÊ‹˜ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘” Ô˘ ·ÔÙÂÏÔ‡Ó ·ÔÎÏÂÈÛÙÈÎfi ˘fiÛÙڈ̷ ÂȉÈ΋˜ ÂÓ˙˘ÌÈ΋˜ ‰È¿Û·Û˘ ·fi ˆÊ¤ÏÈÌ· ÁÈ· ÙÔÓ ÔÚÁ·ÓÈÛÌfi ‚·ÎÙ‹ÚÈ·, fiˆ˜ lactobacilli Î·È bifidobacteria, ηٷٿÛÛÔÓÙ·È ÛÙ· Ú‚ÈÔÙÈο. ∆· Ú‚ÈÔÙÈο Â›Ó·È ÌË ÂÙÒÌÂÓ· ÙÚÔÊÈο Û˘ÛÙ·ÙÈο Ô˘ ÂËÚ¿˙Ô˘Ó Â˘ÂÚÁÂÙÈο ÙÔÓ ÍÂÓÈÛÙ‹, ÚÔ¿ÁÔÓÙ·˜ ÙËÓ ·‡ÍËÛË Î·È ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÂÎÏÂÎÙÈο ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÚÈÔÚÈṲ̂ÓÔ˘ ·ÚÈıÌÔ‡ “ˆÊ¤ÏÈ̈Ӕ ‚·ÎÙËÚ›ˆÓ Ô˘ ‹‰Ë ·ÔÈÎÔ‡Ó ÙÔ ¤ÓÙÂÚÔ, Û˘ÓÙÂÏÒÓÙ·˜ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘Á›·˜ ÙÔ˘ ÍÂÓÈÛÙ‹ (49). ™ÙËÓ ÏÂÈÔ„ËÊ›· ÙÔ˘˜ ÚfiÎÂÈÙ·È ÁÈ· ˘‰·Ù¿ÓıڷΘ ÌÈÎÚ‹˜ ·Ï˘Û›‰·˜ Ô˘ ‰ÂÓ ‰È·ÛÒÓÙ·È ·fi Ù· ¤Ó˙˘Ì· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Î·È ÂΛӷ Ù˘ „ËÎÙÚÔÂȉԇ˜ ·Ú˘Ê‹˜ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ηÏÔ‡ÓÙ·È ÌË ÂÙÔ› ÔÏÈÁÔ۷ί·Ú›Ù˜ (50). °È· Ó· ¯·Ú·ÎÙËÚÈÛÙ›, ÂÔ̤ӈ˜, ¤Ó· Û˘ÛÙ·ÙÈÎfi
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Ù˘ ÙÚÔÊ‹˜ ˆ˜ Ú‚ÈÔÙÈÎfi ı· Ú¤ÂÈ: ·) Ó· ÌËÓ ˘‰ÚÔχÂÙ·È, Ô‡Ù ӷ ·ÔÚÚÔÊ¿Ù·È ·fi ÙÔ ·ÓÒÙÂÚÔ ÙÌ‹Ì· ÙÔ˘ ÂÙÈÎÔ‡, ‚) Ó· ·ÔÙÂÏ› ÂÎÏÂÎÙÈÎfi ˘fiÛÙڈ̷ ÁÈ· ÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ‚·ÎÙËÚ›ˆÓ Ô˘ ¤¯Ô˘Ó ¢ÂÚÁÂÙÈ΋ ‰Ú¿ÛË ÛÙÔÓ ÍÂÓÈÛÙ‹ Î·È Á) Ó· ÌÔÚ› Ó· ÌÂÙ·‚¿ÏÂÈ ÙË ÌÈÎÚԯψڛ‰· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÚÔ˜ Ì›· ÏÂÔÓÂÎÙÈÎfiÙÂÚË, ÁÈ· ÙËÓ ˘Á›· ÙÔ˘ ÍÂÓÈÛÙ‹, Û‡ÛÙ·ÛË (10,48,49). ∞·ÓÙÒÓÙ·È ÛÙÔ ÎÚÂÌ̇‰È, ÙËÓ ·ÁÎÈÓ¿Ú·, Ù· Û·Ú¿ÁÁÈ·, Ù· Ú·‰›ÎÈ· Î·È ÛÙË Ì·Ó¿Ó·. OÈ È‰ÈfiÙËÙ¤˜ ÙÔ˘˜ ÂÍ·ÚÙÒÓÙ·È ·fi ÙË ¯ËÌÈ΋ ÙÔ˘˜ ‰ÔÌ‹, ÙÔ ÌÔÚÈ·Îfi ÙÔ˘˜ ‚¿ÚÔ˜ Î·È ·fi ÙÔ ÔÛÔÛÙfi ÌÔÓÔ۷ί·ÚÈÙÒÓ Î·È ‰È۷ί·ÚÈÙÒÓ Ô˘ ÂÚȤ¯Ô˘Ó (10). ∏ ¢ÓÔ˚΋ ÁÈ· ÙÔÓ ÍÂÓÈÛÙ‹ ‰Ú¿ÛË ÙÔ˘˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì¤Ûˆ ÚÔ·ÁˆÁ‹˜ Ù˘ ·Ó¿Ù˘Í˘ ÙˆÓ ˆÊ¤ÏÈÌˆÓ ‚·ÎÙËÚ›ˆÓ, ̤ۈ ‰Ú·ÛÙËÚÈÔÔ›ËÛ˘ ·˘ÙÒÓ ‹ ̤ۈ Û˘Ó‰˘·ÛÌÔ‡ ÙˆÓ ·Ú·¿Óˆ ‰Ú¿ÛˆÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ¤Ú¢Ó˜ ÁÈ· Ù· Ú‚ÈÔÙÈο ηÙ¢ı‡ÓÔÓÙ·È ÚÔ˜ ÙËÓ ·Ó¿Ù˘ÍË Ô˘ÛÈÒÓ Ô˘ ·ÔÙÂÏÔ‡Ó ˘fiÛÙڈ̷ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ·Ú¿ÁÔ˘Ó Á·Ï·ÎÙÈÎfi Ô͇, ÏfiÁˆ ÙˆÓ Â˘ÂÚÁÂÙÈÎÒÓ È‰ÈÔÙ‹ÙˆÓ Ô˘ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ·˘ÙÔ› ÁÈ· ÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi. ¶·Ú’ fiÏ· ·˘Ù¿, ›Ûˆ˜ οÔȘ ÌÂÏÏÔÓÙÈΤ˜ ÌÂϤÙ˜ Ó· Û˘ÌÂÚÈÏ¿‚Ô˘Ó Î·È Ô˘Û›Â˜ Ô˘ ı· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÚÂÌfi‰ÈÛË Ù˘ ·Ó¿Ù˘Í˘ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ. ŒÓ· Ù¤ÙÔÈÔ ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› Ë Ô˘Û›· cellobiose, Ë ÔÔ›· ·Ô‰Â›¯ÙËΠfiÙÈ ÌÂÈÒÓÂÈ ÙË ÏÔÈÌÔÁfiÓÔ ‰‡Ó·ÌË Ù˘ Listeria monocytoges (51). ∆· Û˘Ó‹ıË Ú‚ÈÔÙÈο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3. OÈ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ ·ÔÙÂÏÔ‡Ó Ì›· ÌÂÁ¿ÏË Î·ÙËÁÔÚ›· Ê˘ÛÈÎÒÓ ÔÏÈÁÔ۷ί·ÚÈÙÒÓ. ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÏÈÁÔÌÂÚ‹ Ù˘ ÊÚÔ˘ÎÙfi˙˘ Ô˘, ·Ó¿ÏÔÁ· Ì ÙÔÓ ‚·ıÌfi ÔÏ˘ÌÂÚÈÛÌÔ‡ ÙÔ˘˜, ‰È·ÎÚ›ÓÔÓÙ·È ÛÙËÓ ÈÓÔ˘Ï›ÓË (‚·ıÌfi˜ ÔÏ˘ÌÂÚÈÛÌÔ‡ 2-60) Î·È ÛÙËÓ ÔÏÈÁÔÊÚÔ˘ÎÙfi˙Ë (̤ÛÔ˜ ‚·ıÌfi˜ ÔÏ˘ÌÂÚÈÛÌÔ‡ 4) (52,53). ∞fi ÔÏϤ˜ ÌÂϤÙ˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› fiÙÈ Ë ÈÓÔ˘Ï›ÓË Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi Ù· Ú·‰›ÎÈ·, ·˘Í¿ÓÂÈ ÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÙˆÓ bifidobacteria Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÌË Â˘ÓÔ˚ÎÒÓ ÁÈ· ÙÔÓ ¿ÓıÚˆÔ ‚·ÎÙËÚ›ˆÓ (52-55). OÈ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ Â›Ó·È Ù· ϤÔÓ ÌÂÏÂÙË̤ӷ ˆ˜ Û‹ÌÂÚ· Ú‚ÈÔÙÈο. ∞ÔÙÂÏÔ‡Ó ÂȉÈÎfi ˘fiÛÙڈ̷ ÁÈ· Ù· bifidobacteria, Ù· ÔÔ›· fiÙ·Ó ˙˘ÌÒÓÔ˘Ó ÙÔ˘˜ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜, ÙÔ Î¿ÓÔ˘Ó Û ‚¿ÚÔ˜ ÙˆÓ bacteroides, clostridia Î·È coliforms. ∞˘Ùfi ˘ÔÛÙËÚ›˙ÂÙ·È Î·È ·fi Ù· ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ηÏÏÈÂÚÁÂÈÒÓ ÙˆÓ Gibson Î·È Wang (55), ÔÈ ÔÔ›ÔÈ Î·ÏÏȤÚÁËÛ·Ó, ÛÂ Û˘Óı‹Î˜ ÂÏÂÁ¯fiÌÂÓÔ˘ pH, bifidobacterium infantis, e. coli Î·È c. perfingens, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ˆ˜ ˘fiÛÙڈ̷ ÔÏÈÁÔÊÚÔ˘ÎÙfi˙Ë. ∆Ô bifidobacterium infantis ·Ó·Ù‡¯ıËΠ۠‚¿ÚÔ˜
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¶›Ó·Î·˜ 3. ™˘Ó‹ıË Ú‚ÈÔÙÈο ºÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ [ÔÏÈÁÔÊÚÔ˘ÎÙfi˙Ë, ÈÓÔ˘Ï›ÓË Î·È Û˘ÓıÂÙÈÎÔ› ˘‰·Ù¿ÓıڷΘ (Neosugar)] °·Ï·ÎÙÔÔÏÈ۷ί·Ú›Ù˜ §·ÎÙÔ˘Ïfi˙Ë §·ÎÙÈÙfiÏË
ÙˆÓ ˘ÔÏÔ›ˆÓ. ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ in vitro ÌÂÏÂÙÒÓ ÙˆÓ ·Ú·¿Óˆ ÂÚ¢ÓËÙÒÓ Â·ÏËı‡ÙËÎ·Ó ·fi in vivo ÌÂϤÙ˜ (56). ∏ ÂȉÈÎfiÙËÙ· ·˘Ù‹ ÙˆÓ bifidobacteria ÚÔ˜ ÙÔ˘˜ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ ÈÛÙ‡ÂÙ·È fiÙÈ ÔÊ›ÏÂÙ·È ÛÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· ·Ú¿ÁÔ˘Ó ‚-ÊÚÔ˘ÎÙÔÛȉ¿ÛË. ∏ ·Ó·ÛÙÔÏ‹ Ù˘ ·Ó¿Ù˘Í˘ ‚·ÎÙËÚ›ˆÓ, fiˆ˜ clostridia, e. coli Î·È ÔÏÏÒÓ ¿ÏÏˆÓ ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ, fiˆ˜ listeria, shigella, salmonella Î·È v. Cholerae, ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ‚·ÎÙËÚÈÔÎÙfiÓˆÓ Ô˘ÛÈÒÓ ·fi Ù· bifidobacteria (57,58). ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ ·ÔÙÂÏÔ‡Ó ÂȉÈÎfi ˘fiÛÙڈ̷ ÁÈ· ÙËÓ ÂÎÏÂÎÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ bifidobacteria ¤¯ÂÈ ·Ô‰ÂȯÙ› Î·È ·fi ¿ÏϘ ÌÂϤÙ˜, fiÔ˘ ˘ÁÈ›˜ ÂıÂÏÔÓÙ¤˜, fiÙ·Ó ÂÏ¿Ì‚·Ó·Ó 3x5 g ÊÚÔ˘ÎÙÔÔÏÈ۷ί·ÚÈÙÒÓ ·Ó¿ Ë̤ڷ, ·‡ÍËÛ·Ó Ù· bifidobacteria ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘˜ ·fi 6% ¤ˆ˜ 22%. ™Â ÚfiÛÊ·Ù· ‰ËÌÔÛÈÂ˘Ì¤ÓË ÌÂϤÙË (59) ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÔ˘ Á¿Ï·ÎÙÔ˜ ‚ÚÂÊÒÓ Ì ̛ÁÌ· Á·Ï·ÎÙÔ- Î·È ÊÚÔ˘ÎÙÔÔÏÈ۷ί·ÚÈÙÒÓ Â˘ÓÔ› ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ bifidobacteria Î·È ÙˆÓ lactobacilli, Ì ÙÚfiÔ ‰ÔÛÔÂÍ·ÚÙÒÌÂÓÔ Î·È ¯ˆÚ›˜ ·ÚÂÓ¤ÚÁÂȘ. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÙÔÓÈÛÙ› fiÙÈ ÌÂϤÙ˜ Û ÂÓ‹ÏÈΘ (60,61), ·ÏÏ¿ Î·È Û ÂÈÚ·Ì·Ùfi˙ˆ· (62,63) Û˘ÁÎÏ›ÓÔ˘Ó ÛÙÔ fiÙÈ Ë ·Ó¿Ù˘ÍË ÙˆÓ bifidobacteria Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ÚÔ¸¿Ú¯Ô˘Û·˜ Û˘ÁΤÓÙÚˆÛ˘ bifidobacteria ÛÙÔ ¤ÓÙÂÚÔ, ÂÓÒ fiÙ·Ó ·˘Ù¿ ·Ô˘ÛÈ¿˙Ô˘Ó ·fi ÙËÓ ·Ú¯È΋ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰·, Ë Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË Ú‚ÈÔÙÈÎÒÓ Â›Ó·È ÂÓÙÂÏÒ˜ ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋. OÈ ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ Ê·›ÓÂÙ·È fiÙÈ ·ÛÎÔ‡Ó Â˘ÓÔ˚΋ ›‰Ú·ÛË ÛÙËÓ ·ÔÚÚfiÊËÛË ÈfiÓÙˆÓ fiˆ˜ Ô Û›‰ËÚÔ˜, ÙÔ ·Û‚¤ÛÙÈÔ Î·È ÙÔ Ì·ÁÓ‹ÛÈÔ, ̤ۈ Ù˘ ·Ú·ÁˆÁ‹˜ - ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓ˙˘ÌÈ΋˜ ÙÔ˘˜ ˙‡ÌˆÛ˘ - ÏÈ·ÚÒÓ ÔͤˆÓ ‚Ú·¯Â›·˜ ·Ï‡ÛÔ˘ Î·È Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ. º·›ÓÂÙ·È, ›Û˘, fiÙÈ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎÔ› ÛÙË Ì›ˆÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÙÔ˘ ÔÚÔ‡, ÛÙË Ì›ˆÛË ÂÓ·fiıÂÛ˘ Ï›Ô˘˜ ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ, ÏfiÁˆ Èı·ÓÒ˜ Ù˘ ÙÚÔÔÔ›ËÛ˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ Ï›Ô˘˜. OÈ ·Ú·¿Óˆ ıˆڛ˜ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ÙÂÎÌËÚ›ˆÛË. ¶¿ÓÙˆ˜, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÙfiÛÔ Ë ÈÓÔ˘Ï›ÓË, fiÛÔ Î·È Ë ÔÏÈÁÔÊÚÔ˘ÎÙfi˙Ë ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙȘ ‚ÈÔÌ˯·Ó›Â˜ ÙÚÔÊ›ÌˆÓ Â˘Ú‡Ù·Ù·. ∏ ¯Ú‹ÛË ÙÔ˘˜
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Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙˆÓ ÙÚÔÊÒÓ Û ‰È·ÈÙËÙÈΤ˜ ›Ó˜, ÛÙË Ì›ˆÛË Ù˘ ıÂÚÌȉÈ΋˜ ·Í›·˜ ÙÔ˘˜ Î·È ÛÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ‰˘Ó·ÙÔÙ‹ÙˆÓ ÙˆÓ ÙÚÔÊ›ÌˆÓ Ó· ·˘Í¿ÓÔ˘Ó ÙÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÙˆÓ ˆÊ¤ÏÈÌˆÓ ‚·ÎÙËÚ›ˆÓ ÛÙÔ ¤ÓÙÂÚÔ ·˘ÙÒÓ Ô˘ ηٷӷÏÒÓÔ˘Ó ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ÙÚÔʤ˜. ∏ ηٷӿψÛË ÔÏÈÁÔÊÚÔ˘ÎÙfi˙˘ Û˘ÓÙÂÏ› Î·È ÛÙËÓ Î·Ï‡ÙÂÚË ÛÙÔÌ·ÙÈ΋ ˘ÁÈÂÈÓ‹, ηıÒ˜ ÈÛÙ‡ÂÙ·È fiÙÈ ÌÂÈÒÓÂÈ ÙËÓ ÙÂÚˉfiÓ·. ª›· ¿ÏÏË ÛËÌ·ÓÙÈ΋ ÔÌ¿‰· ÔÏÈÁÔ۷ί·ÚÈÙÒÓ Â›Ó·È ÔÈ Á·Ï·ÎÙÔÔÏÈ۷ί·Ú›Ù˜. OÈ Á·Ï·ÎÙÔÔÏÈ۷ί·Ú›Ù˜ Ê˘ÛÈÔÏÔÁÈο ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È Û ·˘ÙÔ‡˜ ·Ô‰›‰ÂÙ·È Ë ‰È·ÊÔÚÂÙÈ΋ ¯ÏˆÚ›‰· ÙÔ˘ ÂÙÈÎÔ‡ ÙˆÓ ıËÏ·˙fiÓÙˆÓ ‚ÚÂÊÒÓ (64). ™‹ÌÂÚ·, Â›Ó·È ‰˘Ó·Ù‹ Î·È Ë ‚ÈÔÌ˯·ÓÈ΋ ·Ú·Û΢‹ ÙÔ˘˜. OÈ ÔÏÈÁÔ۷ί·Ú›Ù˜ Î·È ÔÈ Û‡ÌÏÔÎÔÈ ˘‰·Ù¿ÓıڷΘ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ·ÔÙÂÏÔ‡Ó ÙÔ ÙÚ›ÙÔ Û ÔÛfiÙËÙ· ÛÙÂÚÂfi Û˘ÛÙ·ÙÈÎfi ÙÔ˘, ÌÂÙ¿ ÙÔ Ï›Ô˜ Î·È ÙË Ï·ÎÙfi˙Ë (65). ∏ Û˘ÁΤÓÙÚˆÛ‹ ÙÔ˘˜ ÛÙÔ ‡·Ú ·Ó¤Ú¯ÂÙ·È ÂÚ›Ô˘ Û 22 g/L Î·È ÛÙÔ ÒÚÈÌÔ Á¿Ï· Û 12 g/L (65). OÈ ÔÏÈÁÔ۷ί·Ú›Ù˜ Â›Ó·È Û‡ÓıÂÙ· ۿί·Ú· Âӈ̤ӷ Ì ÌfiÚÈ· Ï·ÎÙfi˙˘ ÛÙÔ ·Ó·ÁˆÁÈÎfi ÙÔ˘˜ ¿ÎÚÔ Î·È ÌfiÚÈ· ÊÔ˘Îfi˙˘ ‹ ÛÈ·ÏÈÎÔ‡ ÔͤԘ ÛÙÔ ÌË ·Ó·ÁˆÁÈÎfi ÙÔ˘˜ ¿ÎÚÔ. OÈ Û‡ÌÏÔÎÔÈ ˘‰·Ù¿ÓıڷΘ Â›Ó·È Î·È ·˘ÙÔ› Û‡ÓıÂÙ· ۿί·Ú·, Ô˘ fï˜ Â›Ó·È Âӈ̤ӷ Ì ڈÙ½Ó˜, ÏÈ›‰È· ‹ ¿ÏÏ· ÌfiÚÈ·, Û ‰Ô̤˜ Ô˘ ηÏÔ‡ÓÙ·È ÁÏ˘ÎÔÚˆÙ½Ó˜, ÁÏ˘ÎÔÏÈ›‰È·, ÁÏ˘ÎÔ˙·ÌÈÓÔÁÏ˘Î¿Ó˜, ‚ÏÂÓÓ›Ó˜ (mucins) Î.¿. Œ¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ÔÈ ÔÏÈÁÔ۷ί·Ú›Ù˜ Î·È ÔÈ Û‡ÌÏÔÎÔÈ ˘‰·Ù¿ÓıڷΘ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÚfiÏÔ˘˜ ÎÏÂȉȿ ÛÙËÓ ¿Ì˘Ó· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ÂÓ·ÓÙ›ÔÓ ·ıÔÁfiÓˆÓ ‚·ÎÙËÚ›ˆÓ, ÈÒÓ Î·È ·Ú·Û›ÙˆÓ. ™˘ÁÎÂÎÚÈ̤ӷ, Ù· ‚·ÎÙ‹ÚÈ· Ô˘ ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙÔÓ ÂÓÙÂÚÈÎfi ·˘Ïfi ÁÈ· Ó· ·Û΋ÛÔ˘Ó ÙËÓ ·ıÔÁfiÓÔ ‰Ú¿ÛË ÙÔ˘˜ ı· Ú¤ÂÈ Ó· ÚÔÛÎÔÏÏËıÔ‡Ó ÛÙÔÓ ÂÓÙÂÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ. ∏ ÚÔÛÎfiÏÏËÛË Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Û ı¤ÛÂȘ˘Ô‰Ô¯Â›˜ ÙˆÓ ÏÂÎÙÈÓÒÓ ÙˆÓ ‚·ÎÙËÚ›ˆÓ. ∞˘Ù¤˜ ÔÈ ı¤ÛÂȘ-˘Ô‰Ô¯Â›˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Û˘Ó›ÛÙ·ÓÙ·È ·fi ÁÏ˘ÎÔÚˆÙ½Ó˜ Î·È ÁÏ˘ÎÔÏÈ›‰È· Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ ÂÓÙÂÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ÙˆÓ ÔÔ›ˆÓ ÙÔ ÔÏÈÁÔ۷ί·ÚÈÎfi ÙÌ‹Ì· ÚÔ¤¯ÂÈ Ì¤Û· ÛÙÔÓ ÂÓÙÂÚÈÎfi ·˘Ïfi. OÈ ÔÏÈÁÔ۷ί·Ú›Ù˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ·ÔÙÂÏÔ‡Ó ÔÌfiÏÔÁ˜ ‰Ô̤˜ ÙˆÓ ÔÏÈÁÔ۷ί·ÚÈÙÒÓ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ ÂÓÙÂÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ÕÚ·, ÌÔÚÔ‡Ó Ó· Û˘Ó‰¤ÔÓÙ·È Ì ٷ ‚·ÎÙ‹ÚÈ· Î·È Ó· ÂÌÔ‰›˙Ô˘Ó Ì ·˘Ùfi ÙÔÓ ÙÚfiÔ ÙË Û‡Ó‰ÂÛË ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ∞ÔÙÂÏÔ‡Ó, ηٿ Ì›· ¤ÓÓÔÈ·, ‰fiψ̷ ÙˆÓ ‚·ÎÙËÚ›ˆÓ, ÒÛÙ ӷ ·Ó·¯·ÈÙ›˙ÂÙ·È Ë ·ıÔÁfiÓÔ˜ ‰Ú¿ÛË ÙÔ˘˜. ªÂ ÙÔÓ ·Ú·¿Óˆ ÙÚfiÔ ¤¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ·Ó·ÛÙ¤ÏÏÂÙ·È Ë ‰Ú¿ÛË ÙÔ˘ ÂÓÙÂÚÔÙÔÍÈÓÔÁfiÓÔ˘ (66) Î·È ÙÔ˘ ÂÓÙÂÚÔ·ÈÌÔÚÚ·ÁÈÎÔ‡ e. coli (67), ÙÔ˘ v. cholerae (66), ÙÔ˘ streptococcus pneumoniae (68),
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ÙÔ˘ haemophilus influenzae (68), Ù˘ shigella dysenteriae (69), ÙÔ˘ clostridium difficile (70) Î·È ÙÔ˘ campylobacter jejuni (71), ÂÓÒ Ë ¤Ú¢ӷ ÔÏÔ¤Ó· Î·È ·Ó·‰ÂÈÎÓ‡ÂÈ Ó¤· ·ıÔÁfiÓ·, Ë ‰Ú¿ÛË ÙˆÓ ÔÔ›ˆÓ ·Ó·ÛÙ¤ÏÏÂÙ·È ·fi ÙÔ˘˜ ÔÏÈÁÔ۷ί·Ú›Ù˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜. ªÂ ·ÚfiÌÔÈÔ ÙÚfiÔ ·Ó·ÛÙ¤ÏÏÂÙ·È Ë ‰Ú¿ÛË ÙÔ˘ ÈÔ‡ Rota, ̤ۈ Ì›·˜ ÁÏ˘ÎÔÚˆÙ½Ó˘, Ù˘ Ï·ÎÙÔÚÔÛÎÔÏÏËÙ›Ó˘ (72). OÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ÔÏÈÁÔ۷ί·ÚÈÙÒÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÌÂÙ·‚¿ÏÏÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ›‰ÈÔ˘ Á‡̷ÙÔ˜ (73) ηÈ, ›Û˘, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ËÌÂÚ‹ÛÈ· ‰È·Î‡Ì·ÓÛË (73). ∆Ô ÌËÙÚÈÎfi Á¿Ï· Ù˘ ÚÒÙ˘ ‚‰ÔÌ¿‰·˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi ¤¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ Û‡ÛÙ·ÛË ÔÏÈÁÔ۷ί·ÚÈÙÒÓ ·fi ÂΛÓË ÙˆÓ ÂfiÌÂÓˆÓ ÌËÓÒÓ (74). °›ÓÂÙ·È Ê·ÓÂÚfi fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÚÔÛٷهÂÈ ·fi ÏÔÈÌÒÍÂȘ ·fi Ôχ ÓˆÚ›˜, ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, fiÙ·Ó ÔÈ ¿ÏÏÔÈ Ì˯·ÓÈÛÌÔ› ¿Ì˘Ó·˜ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ·Ó·Ù˘¯ı› Û ÈηÓÔÔÈËÙÈÎfi ‚·ıÌfi. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ηٷ‚¿ÏÏÔÓÙ·È ÚÔÛ¿ıÂȘ ·Ú·Û΢‹˜ Ú‚ÈÔÙÈÎÒÓ Ì ۇÛÙ·ÛË ·ÚfiÌÔÈ· Ì ·˘Ù‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, ·ÊÔ‡ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÙˆÓ Á·Ï¿ÙˆÓ Ì Ú‚ÈÔÙÈο ¤¯ÂÈ ·Ú¯›ÛÂÈ Ó· Á›ÓÂÙ·È Ú¿ÍË. ∏ ¯Ú‹ÛË, fï˜, ÙˆÓ Ú‚ÈÔÙÈÎÒÓ ÂÂÎÙ›ÓÂÙ·È Î·È ¤Ú· ·fi Ù· ‚ÚÂÊÈο Á¿Ï·Ù·. ∫¿ı ¯ÚfiÓÔ ·Ú¿ÁÔÓÙ·È, Ì ÂÓ˙˘Ì·ÙÈΤ˜ ‰È·‰Èηۛ˜, ÔÏÏ¿ Ó¤· Ú‚ÈÔÙÈο. °È· Ó· ηٷٷ¯ı› ÛÙ· Ú‚ÈÔÙÈο Ì›· ‚ÈÔÌ˯·ÓÈο ·Ú·ÁfiÌÂÓË Ô˘Û›·, ı· Ú¤ÂÈ Ó· ÂΉËÏÒÓÂÈ Î·Ï‹ Û˘Û¯¤ÙÈÛË ÙˆÓ in vitro Î·È in vivo ȉÈÔÙ‹ÙˆÓ Ù˘ Î·È Ó· ÏËÚÔ› Ì›· ÛÂÈÚ¿ ·fi ÎÚÈÙ‹ÚÈ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰ÂÓ Â›Ó·È ÂÊÈÎÙfi οı Ӥ· ˘Ô„‹ÊÈ· Ô˘Û›· Ó· ÂϤÁ¯ÂÙ·È Î·È Û ÌÂϤÙ˜ Û ·ÓıÚÒÔ˘˜. ¢Ò‰Âη ηÙËÁÔڛ˜ Ô˘ÛÈÒÓ Ì Ú‚ÈÔÙÈΤ˜ ȉÈfiÙËÙ˜ ¤¯Ô˘Ó ·Ú·¯ı› ‚ÈÔÌ˯·ÓÈο. OÈ Ô˘Û›Â˜ ·˘Ù¤˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 4. OÈ ÂÚÈÛÛfiÙÂÚ˜ Û˘ÓÙ›ıÂÓÙ·È ·fi ·ÏÔ‡˜ ˘‰·Ù¿ÓıڷΘ, fiˆ˜ Ë ÛÔ˘ÎÚfi˙Ë Î·È Ë Ï·ÎÙfi˙Ë ‹ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÏÂÁ¯fiÌÂÓË ˘‰ÚfiÏ˘ÛË ·Ì‡ÏÔ˘ ‹ ¿ÏÏˆÓ ÔÏ˘Û·Î¯·ÚÈÙÒÓ (67). ∏ Ï·ÎÙfi˙Ë ·ÔÙÂÏ› ÚÒÙË ‡ÏË ÁÈ· ÙËÓ ·Ú·Û΢‹ ÙˆÓ Á·Ï·ÎÙÔÔÏÈ۷ί·ÚÈÙÒÓ, Ù˘ Ï·ÎÙÔ˘Ïfi˙˘ Î·È Ù˘ Ï·ÎÙÔÛÔ˘ÎÚfi˙˘. ∆· Ú‚ÈÔÙÈο ÌÔÚÔ‡Ó Ó· ÂÓۈ̷وıÔ‡Ó Û ÚÔÊ‹Ì·Ù·, ÁÏ˘Î›ÛÌ·Ù·, Ì·ÚÌÂÏ¿‰Â˜, ·ÁˆÙ¿, ÛÔÎÔÏ¿Ù˜, ˙˘Ì·ÚÈο, Û¿ÏÙÛ˜ Î·È Û Á·Ï·ÎÙÔÎÔÌÈο ÚÔ˚fiÓÙ· (67). OÈ ÏËı˘ÛÌÔ› Ô˘ Ê·›ÓÂÙ·È fiÙÈ ˆÊÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ¯Ú‹ÛË ÙˆÓ Ú‚ÈÔÙÈÎÒÓ Â›Ó·È ·˘ÙÔ› Ì ÚÔ¸¿Ú¯Ô˘Û˜ ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ bifidobacteria ÛÙÔÓ ·˘Ïfi ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ¶ÚfiÎÂÈÙ·È ÁÈ· ËÏÈÎȈ̤ÓÔ˘˜, ·ÛıÂÓ›˜ Ì ‰È¿ÚÚÔÈ· ·fi Ï‹„Ë ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ·ÛıÂÓ›˜ Ì Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, Ì ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÚfiˆÚ· ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ
May-June 03
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¶·È‰È·ÙÚÈ΋ 2003;66:223-231
¶›Ó·Î·˜ 4. ∫·ÙËÁÔڛ˜ Ô˘ÛÈÒÓ Ì Ú‚ÈÔÙÈΤ˜ ȉÈfiÙËÙ˜ Ô˘ ¤¯Ô˘Ó ·Ú·¯ı› ‚ÈÔÌ˯·ÓÈο °·Ï·ÎÙÔÔÏÈÁÔ۷ί·Ú›Ù˜ §·ÎÙÔ˘Ïfi˙Ë §·ÎÙÔÛÔ˘ÎÚfi˙Ë ºÚÔ˘ÎÙÔÔÏÈÁÔ۷ί·Ú›Ù˜ ¶·Ï·ÙÈÓfi˙Ë - ÔÏÈÁÔ۷ί·Ú›Ù˜ °Ï˘ÎÔ˙˘ÏÔÛÔ˘ÎÚfi˙Ë ª·ÏÙÔÔÏÈÁÔ۷ί·Ú›Ù˜ πÛÔÌ·ÏÙÔÔÏÈÁÔ۷ί·Ú›Ù˜ ∫˘ÎÏÔ‰ÂÍÙÚ›Ó˜ °ÂÓÙÈÔÔÏÈÁÔ۷ί·Ú›Ù˜ OÏÈÁÔ۷ί·Ú›Ù˜ ÙÔ˘ ηÚÔ‡ Ù˘ ÛfiÁÈ·˜ •˘ÏÔÔÏÈÁÔ۷ί·Ú›Ù˜
ÂΉ‹ÏˆÛ˘ ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜. ¶¿ÓÙˆ˜, fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È Ì ÙËÓ ÚfiÛÏË„Ë ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, ÙÔ Â˘ÂÚÁÂÙÈÎfi ÙÔ˘˜ ·ÔÙ¤ÏÂÛÌ· ۯ‰fiÓ ÂÍ·ÓÙÏÂ›Ù·È ÛÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ Ï‹„˘ ÙÔ˘˜. ™Â ·ÓÂÈÏËÌ̤Ó˜ ÌÂϤÙ˜ ¤¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ÔÈ ÏËı˘ÛÌÔ› ÙˆÓ bifidobacteria ·ӤگÔÓÙ·È ÛÙ· ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ ›‰· Û 7-8 Ë̤Ú˜ ¤ˆ˜ 3-4 ‚‰ÔÌ¿‰Â˜. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂÁÈÛÙÔÔÈËı› Ë Â˘ÓÔ˚΋ ‰Ú¿ÛË ÚÔ‚ÈÔÙÈÎÒÓ Î·È Ú‚ÈÔÙÈÎÒÓ, ÔÈ ÂÚ¢ÓËÙ¤˜ ÂÍÂÙ¿˙Ô˘Ó ÙË Û˘Ó‰˘·Ṳ̂ÓË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜. ∞fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÌÂٷ͇ ÙÔ˘˜ Û˘Ó‰˘·ÛÌÔ‡˜ ¤¯Ô˘Ó ÚÔ·„ÂÈ Ù· Û˘Ì‚ÈÔÙÈο. ™˘Ì‚ÈÔÙÈο ¶Ú‚ÈÔÙÈο Î·È ÚÔ‚ÈÔÙÈο ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi. ∆· ˙ˆÓÙ·Ó¿ ÌÈÎÚԂȷο ÚfiÛıÂÙ· (ÚÔ‚ÈÔÙÈο) ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂȉÈο Û˘ÛÙ·ÙÈο (Ú‚ÈÔÙÈο) ÁÈ· ÙËÓ ·Ó¿Ù˘Í‹ ÙÔ˘˜ (3,10). ∆· Û˘Ó‹ıË ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Û˘Ì‚ÈÔÙÈο Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 5. O Û˘Ó‰˘·ÛÌfi˜ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÚÔ‚ÈÔÙÈÎÔ‡ ÔÚÁ·ÓÈÛÌÔ‡ Î·È ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÏÂÔÓÂÎÙ‹Ì·Ù· ÛÙÔÓ ÍÂÓÈÛÙ‹ Ô˘ ÚÔÛʤÚÔ˘Ó ÙfiÛÔ Ô ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi˜ fiÛÔ Î·È Ù· Ú‚ÈÔÙÈο. ™˘ÁÎÂÎÚÈ̤ӷ, Ô Û˘Ó‰˘·ÛÌfi˜ Ê·›ÓÂÙ·È fiÙÈ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ˙ÒÓÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙ· ‰È·ÙÚÔÊÈο Û˘ÌÏËÚÒÌ·Ù·, Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ·Ú¿Ù·ÛË ÛÙË ‰È¿ÚÎÂÈ· ˙ˆ‹˜ ÙÔ˘˜. ∂›Û˘, ·˘Í¿ÓÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‚·ÎÙËÚ›ˆÓ Ô˘ Êı¿ÓÔ˘Ó ˙ˆÓÙ·Ó¿ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‹‰Ë ˘·Ú¯fiÓÙˆÓ Û˘Ì‚ÈÔÙÈÎÒÓ ‚·ÎÙËÚ›ˆÓ. ∂ÓÂÚÁÔÔÈ› ÌÂÙ·‚ÔÏÈο Ù· Â͈ÁÂÓÒ˜ ¯ÔÚËÁÔ‡ÌÂÓ·, ·ÏÏ¿ Î·È Ù· ‚·ÎÙ‹ÚÈ· Ô˘ ÚÔ¸¿Ú¯Ô˘Ó ˆ˜ ÙÌ‹Ì· Ù˘ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ∏ ÙÂÏÂ˘Ù·›· ·˘Ù‹ ‰Ú¿ÛË ÎÚ›ÓÂÙ·È ˆ˜ Ë Ï¤ÔÓ ÛËÌ·ÓÙÈ΋, ηıÒ˜ ÌfiÓÔ Ù· ÂÓÂÚÁ¿ ÌÂÙ·‚ÔÏÈο ‚·ÎÙ‹ÚÈ· ÌÔÚÔ‡Ó Ó· ·Û΋ÛÔ˘Ó ˆÊ¤ÏÈÌË ‰Ú¿ÛË ÛÙÔÓ ÍÂÓÈÛÙ‹. ™˘Ì‚ÈÔÙÈο ˘¿Ú¯Ô˘Ó ΢ڛˆ˜ Û ·Ú¿ÁˆÁ· Á¿Ï·ÎÙÔ˜ Ô˘ ¤¯Ô˘Ó ˘ÔÛÙ› ˙‡ÌˆÛË.
Paediatriki 2003;66:223-231
¶›Ó·Î·˜ 5. ™˘Ó‹ıË Û˘Ì‚ÈÔÙÈο Bifidobacteria Î·È ÊÚÔ˘ÎÙÔÔÏÈ۷ί·Ú›Ù˜ Lactobacilli Î·È Ï·ÎÙÈÙfiÏË Bifidobacteria Î·È Á·Ï·ÎÙÔÔÏÈ۷ί·Ú›Ù˜
™˘ÌÂÚ¿ÛÌ·Ù· ™ÙȘ Ë̤Ú˜ Ì·˜ ‰›ÓÂÙ·È ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚË ÛËÌ·Û›· ÛÙË Û‡ÛÙ·ÛË Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜. ∏ ηٿÏÏËÏË ÙÚÔÔÔ›ËÛ‹ Ù˘ ÌÔÚ› Ó· ·ÔʤÚÂÈ Â˘ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ˘Á›·. OÈ ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ Î·È Ú·ÎÙÈΤ˜ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰·. ∞˘Ùfi ÌÔÚ› Ó· ÂÈÙ¢¯ı› ›Ù Ì ÙËÓ ÚfiÛÏË„Ë Î·Ù¿ÏÏËÏˆÓ ˙ÒÓÙˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ (ÚÔ‚ÈÔÙÈο), ›Ù Ì ÙËÓ ÚfiÛÏË„Ë ÂȉÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ·ÔÙÂÏÔ‡Ó ÙÔ ÌÂÙ·‚ÔÏÈÎfi ÙÔ˘˜ ˘fiÛÙڈ̷ (Ú‚ÈÔÙÈο) ‹, Ù¤ÏÔ˜, Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÙˆÓ ·Ú·¿Óˆ (Û˘Ì‚ÈÔÙÈο). ŸÏ˜ ÔÈ ·Ú·¿Óˆ Ô˘Û›Â˜ Î·È ÂȉÈο Ù· Û˘Ì‚ÈÔÙÈο ÌÔÚÔ‡Ó Ó· ·Û΋ÛÔ˘Ó Â˘ÓÔ˚΋ ‰Ú¿ÛË ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, fiˆ˜ ‰È¿ÊÔÚ· ‰È·ÚÚÔ˚ο Û‡Ó‰ÚÔÌ·, ÊÏÂÁÌÔÓÒ‰ÂȘ ÓfiÛÔÈ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È Î·Ù·ÛÙ¿ÛÂȘ fiÔ˘ Ë ˘ÂÚ·Ó¿Ù˘ÍË ·ıÔÁfiÓˆÓ ÌÈÎÚÔ‚›ˆÓ Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜ Â›Ó·È ‰˘ÓËÙÈο ÂÈΛӉ˘ÓË (ÂÎÙÂٷ̤ӷ ÂÁη‡Ì·Ù·, ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi stress, ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÚÁ¿ÓˆÓ, Û‡Ó‰ÚÔÌÔ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘) (57). ∏ ·ÚˆÁ‹ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Â›Ó·È ÔχÙÈÌË ÛÙËÓ ÙÂÎÌËÚ›ˆÛË ÙˆÓ ·ÏÏ·ÁÒÓ Ô˘ ÂÈʤÚÂÈ Ë ¯Ú‹ÛË ÙˆÓ ·Ú·¿Óˆ ·Ó·ÊÂÚfiÌÂÓˆÓ Ô˘ÛÈÒÓ ÛÙËÓ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ÙÔ˘ ·ÓıÚÒÔ˘. ∏ ÚfiÔ‰fi˜ Ù˘ Ì Ӥ˜ ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ ı· ·ÓÔ›ÍÂÈ Èı·Ó¿ ÙÔÓ ‰ÚfiÌÔ Ù˘ ¢Ú›·˜ ¯Ú‹Û˘ ÙÔ˘˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Hill MJ. The normal gut bacterial flora. In: Hill MJ, editor. Role of gut bacteria in human toxicology and pharmacology. London: Taylor and Francis; 1995. p. 3-17. 2. Nord CE, Kager L. The normal flora of the gastrointestinal tract. Neth J Med 1984;27:249-252. 3. Mandar R, Mikelsaar M. Transmission of mother’s microflora to the newborn at birth. Biol Neonate 1996;69:30-35. 4. Orrhage ∫, Nord CE. Factors controlling the bacterial colonization of the intestine in breastfed infants. Acta Paediatr 1999;88 (Suppl):S47-S57. 5. Lundequist B, Nord CE, Winberg J. The composition of the faecal microflora in breastfed and bottle fed infants from birth to eight weeks. Acta Paediatr Scand 1985;74:45-51. 6. Kleessen B, Bunke H, Tovar K, Noack J, Sawatzki G. Influence of two infant formulas and human milk on the development of the faecal flora in newborn infants. Acta Paediatr 1995;84:1347-1356. 7. Midtvedt AC, Carlstedt-Duke B, Midtvedt T. Establishment of a mucin-degrading intestinal microflora during the first two years of human life. J Pediatr Gastroenterol Nutr 1994;18:321-326.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 06-02-2002 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-03-2003 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆ¿ÓÓ· ÷ڈӛÙË A’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ, ∫Ú‹ÙË
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SPECIAL ARTICLE
¶·ÚÔ˘Û›·ÛË ÂÚ›ÙˆÛ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÙÔ ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” ÙÔ˘ 1814 ¢. ∫·Ú·ÌÂÚfiÔ˘ÏÔ˜
A case of diabetes mellitus presented in the journal “∂ÚÌ‹˜ Ô §fiÁÈÔ˜”, 1814 D. Karaberopoulos
¶ÂÚ›ÏË„Ë: ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚ›ÙˆÛË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ·fi ÙÔÓ È·ÙÚfi πˆ¿ÓÓË ∞Û¿ÓË (17901850) ÛÙÔ ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” (µÈ¤ÓÓË 1814, ÛÂÏ. 117-123). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë Î·Ù¿ÛÙ·ÛË Ó¤Ô˘ ËÏÈΛ·˜ 14 ÂÙÒÓ Î·È Î·Ù·ÁÚ¿ÊÔÓÙ·È ÔÈ Û‡Á¯ÚÔÓ˜ ÁÓÒÛÂȘ ÁÈ· ÙË ÓfiÛÔ. ø˜ ıÂڷ›· ÚÔÙ›ÓÂÙ·È ÏÂ˘ÎˆÌ·ÙÔ‡¯Ô˜ ‰›·ÈÙ· Î·È ¯ÔÚ‹ÁËÛË ÊˆÛÊfiÚÔ˘, Ì›· Ó¤· ÚfiÙ·ÛË ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜. ™ÙÔ ¿ÚıÚÔ ÂÈÛ¿ÁÂÙ·È ÛÙËÓ ÂÏÏËÓÈ΋ È·ÙÚÈ΋ ÔÚÔÏÔÁ›· Ô fiÚÔ˜ “۷ί·Ú҉˘ ‰È·‚‹Ù˘”.
Abstract: A case of diabetes mellitus was presented by doctor John Assanis (1790-1850) in the journal “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” (Wien 1814, p. 117123). The condition of a fourteen year-old adolescent is described and updated information for the disease is recorded. A new proposal for treatment is recommended, consisting of a protein diet and phosphorus as medication. In the article the term “diabetes mellitus” is introduced into the Greek medical terminology.
§¤ÍÂȘ ÎÏÂȉȿ: ۷ί·Ú҉˘ ‰È·‚‹Ù˘, ¡ÂÔÂÏÏËÓÈÎfi˜ ¢È·ÊˆÙÈÛÌfi˜, ʈÛÊfiÚÔ˜.
Key words: diabetes mellitus, Enlightenment, phosphorus.
¶·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÚ›ÙˆÛË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, Ô˘ ‰ËÌÔÛȇıËΠÙÔ 1814 ÛÙÔ ·ÍÈfiÏÔÁÔ ÚÔ·ӷÛÙ·ÙÈÎfi ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜”. ∆Ô ÂÚÈÔ‰ÈÎfi ·˘Ùfi, ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ ¿ÚıÚˆÓ, ÂÚÈÂÏ¿Ì‚·ÓÂ Î·È È·ÙÚÈο ı¤Ì·Ù·, ‰ÈfiÙÈ ‰ÂÓ Î˘ÎÏÔÊÔÚÔ‡Û·Ó, ηٿ ÙËÓ ÂÈÛ‹Ì·ÓÛË ÙÔ˘ ÂΉfiÙË ÙÔ˘, ÂÏÏËÓÈο È·ÙÚÈο ÂÚÈÔ‰Èο, fiˆ˜ Û˘Ó¤‚·ÈÓ ÛÙȘ Â˘Úˆ·˚Τ˜ ÁÏÒÛÛ˜ (1). ™˘ÁÁڷʤ·˜ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ¿ÚıÚÔ˘ ‹Ù·Ó Ô ÂÎ ∫ÂÊ·ÏÏËÓ›·˜ ηٷÁfiÌÂÓÔ˜ È·ÙÚfi˜ πˆ¿ÓÓ˘ ∞Û¿Ó˘ (2) (1790-1850), Ô ÔÔ›Ô˜ ÛÔ‡‰·Û π·ÙÚÈ΋ Î·È ª·ıËÌ·ÙÈο ÛÙËÓ ¶¿‰Ô‚·, ÙË µÈ¤ÓÓË Î·È ÙÔ ¶·Ú›ÛÈ Î·È Â›¯Â ‰ËÌÔÛȇÛÂÈ Â›Û˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” (3) ¿ÚıÚÔ Ì ٛÙÏÔ “∞¿ÓÙËÛȘ ÂȘ ÙËÓ ÂÚ› ÙÔ˘ µÚÔÓÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂÚÒÙËÛÈÓ”, ÙÔ ÔÔ›Ô ·Ó·ÊÂÚfiÙ·Ó ÛÙÔ ıÂڷ¢ÙÈÎfi Û‡ÛÙËÌ· ÙÔ˘ ÕÁÁÏÔ˘ È·ÙÚÔ‡ John Brown (1735-1788). ∂›Û˘, ›¯Â ÌÂÙ·ÊÚ¿ÛÂÈ ·fi ÙËÓ ÈÙ·ÏÈ΋ ÁÏÒÛÛ· ÙÔ ‚È‚Ï›Ô ÁÈ· ÙÔ˘˜ ÂÚÈÔ‰ÈÎÔ‡˜ ˘ÚÂÙÔ‡˜, fiˆ˜ ÔÓÔÌ·˙fiÙ·Ó ÙfiÙÂ Ë ÂÏÔÓÔÛ›·, Ì ٛÙÏÔ: “¶ÂÚ› ÙÔ˘ ·ÚÌԉȈ٤ÚÔ˘ ÙÚfiÔ˘ ÂȘ ÙÔ Ó· ÂÌÔ‰›˙ˆÓÙ·È ·È ˘ÔÛÙÚÔÊ·› ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ ˘ÚÂÙÒÓ ·ÊÔ‡ ‹‰Ë ÎÔÒÛÈ Ì ÙËÓ Î›Ó·Ó
‰È·ÙÚÈ‚‹ ¶¤ÙÚÔ˘ ƒÔ˘‚›ÓÔ˘. ªÂÙ·ÊÚ·Ûı›۷ ÂÎ ÙÔ˘ πÙ·ÏÈÎÔ‡ ˘fi πˆ¿ÓÓË ∞Û¿ÓË. ∂Ó ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiÏÂÈ, ÂÎ Ù˘ ∆˘ÔÁÚ·Ê›·˜ ∫. ∞. ∫ÔÏÔÓ¤ÏÏÔ˘, 1841”. ∂ÈϤÔÓ, Ô È·ÙÚfi˜ ¡ÈÎfiÏ·Ô˜ ¶›ÎÎÔÏÔ˜ (1792-1865), ηıËÁËÙ‹˜ ÛÙËÓ πfiÓÈÔ ∞η‰ËÌ›·, ·ÊȤڈÛ ÛÙÔÓ πˆ¿ÓÓË ∞Û¿ÓË ÙÔ ‚È‚Ï›Ô Ô˘ ÌÂÙ¤ÊÚ·ÛÂ Î·È Âͤ‰ˆÛ ÛÙËÓ ∫¤Ú΢ڷ ÙÔ 1824 “ƒÂÓ¿ÙÔ˘ ∫·ÚÙÂÛ›Ô˘, §fiÁÔ˜ ÂÚ› ÌÂıfi‰Ô˘ ÙÔ˘ Ô‰ËÁÂ›Ó Î·ÏÒ˜ ÙÔÓ ÓÔ‡Ó Î·È ˙ËÙÂ›Ó ÙËÓ ·Ï‹ıÂÈ·Ó ÂȘ Ù·˜ ÂÈÛÙ‹Ì·˜”. O πˆ¿ÓÓ˘ ∞Û¿Ó˘ ·ÛÎÔ‡Û ÙËÓ È·ÙÚÈ΋ ÛÙÔ π¿ÛÈÔ Ù˘ ªÔω·‚›·˜ Î·È ¤ÛÙÂÈÏ ÛÙÔÓ ÕÓıÈÌÔ °·˙‹, ÂΉfiÙË ÙÔ˘ ÚÔ·ӷÛÙ·ÙÈÎÔ‡ ÂÚÈÔ‰ÈÎÔ‡ “∂ÚÌ‹˜ Ô §fiÁÈÔ˜”, ÙÔ ¿ÚıÚÔ Û¯ÂÙÈο Ì ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÂ Ó¤Ô ËÏÈΛ·˜ 14 ÂÙÒÓ Î·È ÙȘ Ӥ˜ ıÂڷ¢ÙÈΤ˜ ÙÔ˘ ÚÔÛ¿ıÂȘ (4). ™ÙÔ ÚÒÙÔ Ì¤ÚÔ˜ ÙÔ˘ ¿ÚıÚÔ˘, Ô πˆ¿ÓÓ˘ ∞Û¿Ó˘ ·Ú·ı¤ÙÂÈ ÙȘ Û‡Á¯ÚÔÓ˜ ÁÓÒÛÂȘ ÁÈ· ÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ‰›‰ÔÓÙ·˜ Ì¿ÏÈÛÙ· Î·È ÙÔÓ ÔÚÈÛÌfi ÙÔ˘: “¢È·‚‹Ù˘ ϤÁÂÙ·È ·Ú¿ ÙˆÓ ÓÔÛÔÏfiÁˆÓ Ë ˘ÂÚ‚ÔÏÈ΋ ¤ÎÚ˘ÛȘ Ô‡ÚÔ˘˜, ÌÂÙ¿ ‰›„˘ ·Û‚¤ÛÙÔ˘, Ôڤ͈˜ ·Ï‹ÛÙÔ˘, Î·È Ì·Ú·ÛÌÔ‡”. ™ËÌÂÈÒÓÂÈ fiÙÈ ÙÔ 1778 ·Ó·Î·Ï‡ÊıËΠ·fi ÙÔÓ “∫·ÓϤȔ
¢ÈÂıÓ¤˜ πÔÎÚ¿ÙÂÈÔ ÿ‰Ú˘Ì· Ù˘ ∫ˆ, ∞ı‹Ó·
International Hippocratic Foundation of Kos, Athens
232
Neohellenic
May-June 03
03-06-03
16:55
™ÂÏ›‰·233
¶·È‰È·ÙÚÈ΋ 2003;66:232-235
(William Cullen, 1710-1790) ÛÙ· Ô‡Ú· ÙˆÓ ‰È·‚ËÙÈÎÒÓ “Ë ÂÌÂÚȯÔ̤ÓË Û¿Î¯·ÚȘ” Î·È fiÙÈ ÙÔ 1803 Ë “ÂÓÙÂÏÂÛÙ¤Ú· ·Ó¿Ï˘ÛȘ ÙÔ˘ Ô‡ÚÔ˘˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ” ¤‰ÂÈÍ ˆ˜ “‰ÂÓ ˘¿Ú¯ÂÈ Ô˘Ú›· Ì‹Ù ԢÚÈÎfiÓ Ô͇”. ∞ÎfiÌË, ·Ó·Ê¤ÚÂÈ fiÙÈ “ÔÈ Î‡ÚÈÔÈ ∆ÂÓ¿Ú Î·È ¢Ô˘Ô˘¸ÙÚ¤Ó ¤Î·Ì·Ó Ó¤·˜ Û˘˙ËÙ‹ÛÂȘ Î·È ÂÍÂÙ¿ÛÂȘ ÂȘ ÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙËÓ” (5) Î·È ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ “˙ˆÙÈ΋˜ ‰È·›Ù˘”, ‰ËÏ. ˙ˆÈ΋˜, fiˆ˜ ·ÔηÏÂ›Ù·È Ë ÏÂ˘ÎˆÌ·ÙÔ‡¯Ô˜. ∂ÈÛËÌ·›ÓÂÙ·È fiÙÈ Ô fiÚÔ˜ “۷ί·Ú҉˘ ‰È·‚‹Ù˘” ηٷÁÚ¿ÊÂÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙËÓ ÂÏÏËÓÈ΋ È·ÙÚÈ΋ ÔÚÔÏÔÁ›· Èı·ÓfiÓ ÂΛÓË ÙËÓ ÂÔ¯‹ (1814). O ∞Û¿Ó˘ ÛËÌÂÈÒÓÂÈ fiÙÈ “fiÙ·Ó ÔÈ ‰È·‚ËÙÈÎÔ› ÙÚÒÁˆÛÈ ÌfiÓÔÓ ˙ˆÙÈο (˙ˆÈο) Ê·ÁËÙ¿, ÙÔ Ô‡ÚÔ˜ ·˘ÙÒÓ ÂÓÙfi˜ ÔÏ›ÁÔÓ ÌÂÙ·ÏÏ¿ÙÙÂÈ ÙËÓ Â·˘ÙÔ‡ ʇÛÈÓ”. ™¯ÂÙÈο Ì ÙËÓ ·ÈÙ›· ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, ·Ó·Ê¤ÚÂÈ ÙËÓ ˘fiıÂÛË ÙÔ˘ ∂Ú¿ÛÌÔ˘ ¢·Ú‚›ÓÔ˘ (Erasmus Darwin, 1731-1802), ·Ù¤Ú· ÙÔ˘ ÁÓˆÛÙÔ‡ Ê˘ÛÈÔ‰›ÊË Ù˘ ÂÍÂϛ͈˜ ÙˆÓ ÂȉÒÓ ∫·ÚfiÏÔ˘ ¢·Ú‚›ÓÔ˘, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ÔÊ›ÏÂÙ·È ÛÙËÓ “ÔÈÛıfi‰ÚÔÌÔÓ Î›ÓËÛÈÓ ÙˆÓ ¯˘ÏÔÊfiÚˆÓ ·ÁÁ›ˆÓ”. øÛÙfiÛÔ, Ô ∞Û¿Ó˘ ‰È·Ù˘ÒÓÂÈ Î·È ÙË ‰È΋ ÙÔ˘ ¿Ô„Ë ÛËÌÂÈÒÓÔÓÙ·˜ Û¯ÂÙÈο fiÙÈ “ÂȘ Â̤ fï˜ Ê·›ÓÂÙ·È Â˘ÛÙÔ¯ÒÙÂÚÔÓ ÙÔ Ó· ˘ÔÙÂı› Ë ·ÙÔÓ›· Î·È Ù¤ÏÔ˜ Ë ÂÓÙÂÏ‹˜ ·Ú·Ï˘Û›· ÙˆÓ ¯˘ÏÔÊfiÚˆÓ ·ÁÁ›ˆÓ, ÂÓÒ Ù· Ï˘ÌÊ·ÙÈο ÙÔ˘ Ô˘ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÁÁ›· ·˘Í¿ÓÔ˘ÛÈÓ ÙËÓ ÂÓ¤ÚÁÂÈ·Ó ·˘ÙÒÓ” (6). O fiÚÔ˜ “¯˘ÏÔÊfiÚ·” ·ÁÁ›· Â›Ó·È ÁÈ· Ù· ÌÂÛÂÓÙÂÚÈο ÏÂÌÊ·ÁÁ›·, ÂÍ Ô˘ Î·È Ô fiÚÔ˜ “¯˘ÏÔÊfiÚÔ˜ ‰ÂÍ·ÌÂÓ‹” Ô˘ ·Ú¤ÌÂÈÓÂ. ∞ÎfiÌË, ·Ó·Ê¤ÚÂÈ fiÙÈ Ê¿ÚÌ·ÎÔ Û ·˘Ù‹ ÙËÓ “·Ú·Ï˘Û›·Ó” ÙˆÓ ¯˘ÏÔÊfiÚˆÓ ·ÁÁ›ˆÓ Â›Ó·È Ï¤ÔÓ Ô ÊˆÛÊfiÚÔ˜, ÁÈ’ ·˘Ùfi ÙÔÓ›˙ÂÈ Ì ¤ÌÊ·ÛË fiÙÈ “‰¤Ó Ú¤ÂÈ Ï¤ÔÓ Ó· ·ÂÏÈ˙fiÌÂı·”. ∫·È Û˘ÌÏËÚÒÓÂÈ fiÙÈ “fiÛÙȘ ÂÈı˘Ì› Ï›ÔÓ·˜ ȉ¤·˜ Ù˘ Ù ÂÚÈÁÚ·Ê‹˜ Î·È ıÂڷ›·˜ ¿¯ÚÈ ÙÔ˘ Ó‡Ó Ì·Ù·›ˆ˜ ÂÓÂÚÁÔ˘Ì¤Ó˘, ·˜ ·Ó·ÁÓÒÛÂÈ ÙÔÓ ¶¤ÙÚÔ ºÚ¿ÓÎ Î·È Ù·˜ ÌÔÓÔÁÚ·Ê›·˜”. ∞˜ ÛËÌÂȈı› fiÙÈ Ô “¶¤ÙÚÔ˜ ºÚ¿ÓΔ (Peter Frank, 1745-1821), ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, fiÚÈÛ ÙÔ 1794 ÙÔÓ ¿ÔÈÔ ‰È·‚‹ÙË Î·È ¤ÁÚ·„ ̛· ÔχÙÔÌË Ú·ÁÌ·Ù›· ÛÙË ıÂڷ¢ÙÈ΋ “De curandis hominum morbis epitome”, Ô˘ ¿Ú¯ÈÛ ӷ ÂΉ›‰ÂÙ·È ÙÔ 1792 Î·È Û˘Ó¯›ÛÙËΠ̤¯ÚÈ ÙÔ 1821 (7). ∂›Ó·È Èı·Ófi Ô ∞Û¿Ó˘ Ó· ÂÓÓÔ› ·˘Ù‹ Ì ÙÔÓ fiÚÔ “ÌÔÓÔÁÚ·Ê›·”. ™ËÌÂÈÒÓÔ˘Ì fiÙÈ ÛÙÔ ‚È‚Ï›Ô ÙÔ˘ Fourcroy AF, Ô˘ ÌÂÙ¤ÊÚ·ÛÂ Ô £ÂÔ‰fiÛÈÔ˜ ∏ÏÈ¿‰Ë˜, ÌÓËÌÔÓ‡ÔÓÙ·È ÔÈ ·Ú·ÙËÚ‹ÛÂȘ ÙÔ˘ Peter Frank ÁÈ· ÙË ÁÏ˘ÎÈ¿ Á‡ÛË ÙˆÓ Ô‡ÚˆÓ ÙˆÓ ‰È·‚ËÙÈÎÒÓ (8). ™‡Ìʈӷ Ì ÙÔÓ ¡ÈÎ. ∫ˆÛÙ‹, Ô ÊˆÛÊfiÚÔ˜ ·fi ÙÔ 1751 ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÂÛˆÙÂÚÈÎÒ˜ ˆ˜ Ê¿ÚÌ·ÎÔ Û ‰È¿ÊÔÚ˜ ·ı‹ÛÂȘ (9). O ∞Ó·ÛÙ¿ÛÈÔ˜ °ÂˆÚÁÈ¿‰Ë˜ ·Ó·Ê¤ÚÂÈ fiÙÈ Ô ‰È·‚‹Ù˘ ÔÓÔÌ¿˙ÂÙ·È Î·Ù¿ ÙÔÓ ∞ϤͷӉÚÔÓ ∆Ú·ÏÏÈ·-
Paediatriki 2003;66:232-235
ÓfiÓ “‰È¿ÚÚÔÈ· ÂȘ Ô‡Ú·, Î·È ¿ıÔ˜ ‰›„·ÎÔÓ Î·È ‡‰ÂÚÔ˜ ›˜ ·Ì›‰·” (10). ª¿ÏÈÛÙ·, Ô ÙÂÏÂ˘Ù·›Ô˜ fiÚÔ˜ “‡‰ÂÚÔ˜ ÂȘ ·Ì›‰·” ÌÓËÌÔÓ‡ÂÙ·È Î·È ·fi ÙÔÓ £ˆÌ¿ ª·Ó‰·Î¿ÛË ÙÔ 1757 (11). ¶ÚÒÙË ÂÚÈÁÚ·Ê‹ Ù˘ ÓÔÛÔÏÔÁÈ΋˜ ÔÓÙfiÙËÙ·˜ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ¤¯ÂÈ Á›ÓÂÈ ·fi ÙÔÓ È·ÙÚfi ∞ÚÂÙ·›Ô, Ô ÔÔ›Ô˜ ÂÈϤÔÓ ÂÍËÁ› fiÙÈ ‰fiıËΠÛÙËÓ ¿ıËÛË ·˘Ù‹ Ô fiÚÔ˜ “‰È·‚‹Ù˘” ·fi ÙÔ Ú‹Ì· ‰È·‚·›Óˆ (12). ™˘ÁÎÂÎÚÈ̤ӷ, ÙÔ Î›ÌÂÓÔ Û ÓÂÔÂÏÏËÓÈ΋ ·fi‰ÔÛË ¤¯ÂÈ ˆ˜ ·ÎÔÏÔ‡ıˆ˜: “ŸÙ·Ó Ë ¤ÓÙÔÓË ·˘Ù‹ ·›ÛıËÛË (ÏËÚfiÙËÙ·˜) Êı¿ÛÂÈ ÛÙÔ ¿ÎÚÔ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ Ù˘ ·ÛÙˆ˜, ÔÈ ·ÛıÂÓ›˜ ·Ì¤Ûˆ˜ Ô˘ÚÔ‡Ó. °È’ ·˘Ùfi ÙÔÓ ÏfiÁÔ ÔÓÔÌ¿ÛıËΠ‰È·‚‹Ù˘ Ë ¿ıËÛË, ÂÂȉ‹ ÌÔÈ¿˙ÂÈ Ì ‰È·‚‹ÙË, ηı’ fiÙÈ Ù· ˘ÁÚ¿ ‰ÂÓ ·Ú·Ì¤ÓÔ˘Ó ÛÙÔ ÛÒÌ· ·Ú¿ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔ ·ÓıÚÒÈÓÔ ÛÒÌ· ˆ˜ ‰È·‚¿ıÚË (Îϛ̷η, ÛοϷ) ̤ۈ Ù˘ ÔÔ›·˜ ÂͤگÔÓÙ·È”. ™ÙÔ ‰Â‡ÙÂÚÔ Ì¤ÚÔ˜ Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘, Ô È·ÙÚfi˜ ∞Û¿Ó˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi, “ÙËÓ πÛÙÔÚ›· Ù˘ π·ÙÚÈ΋˜ ÂÈÛΤ„ˆ˜” fiˆ˜ ÙÔ ·ÔηÏ›, ÂÓfi˜ Ó¤Ô˘ ËÏÈΛ·˜ 14 ÂÙÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ∞ӷʤÚÂÈ fi,ÙÈ Â›¯Â ÚÔËÁËı› ÚÈÓ ·Ó·Ï¿‚ÂÈ ÙË ıÂڷ›· ÙÔ˘ ·ÛıÂÓÔ‡˜. ™ËÌÂÈÒÓÂÈ fiÙÈ Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ‰È·‚‹ÙË ¿Ú¯ÈÛ·Ó ·ÈÊÓȉ›ˆ˜ ÚÈÓ ·fi Ù¤ÛÛÂÚȘ Ì‹Ó˜, ÙÔ ¢ÂΤ̂ÚÈÔ ÙÔ˘ 1813, Ì “Û˘Ó¯›˜ ÏÂÈÔı˘Ì›·˜ Î·È ÎÒÏÈη˜”. °È· ‰‡Ô Ì‹Ó˜ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó ·fi È·ÙÚÔ‡˜, ÔÈ ÔÔ›ÔÈ ÙÔ˘ ¤‰ÈÓ·Ó “·ÓıÂÏÌÈÓÙÈο” Ê¿Ú̷η “ÂÂȉ‹ ÂÓfiÌÈ˙ÔÓ ÙÔ ¿ıÔ˜ ÛΈÏÈÎ҉˜, Ï‹Ó Ì·Ù·›ˆ˜ ηıfiÙÈ Ì‹Ù ¤ÏÌȘ ÔÙ¤ ÂÊ¿ÓË, Ì‹Ù ٷÈÓ›·”. ∫·È Û˘Ó¯›˙ÂÈ Ô ∞Û¿Ó˘ fiÙÈ “ÌÂÙ¿ Ù·‡Ù· ¿Ú¯ÈÛ·Ó Ù· ÙÔ˘ ‰È·‚‹ÙÔ˘ ÛËÌ›·” Î·È fiÙÈ ¤Î·Ó ·Ó¿Ï˘ÛË ÙˆÓ Ô‡ÚˆÓ Î·È ‰È·›ÛÙˆÛ ÙËÓ ‡·ÚÍË Ù˘ ۷ί·ÚÔ˘Ú›·˜, “Ë ÙÔ˘ Ô‡ÚÔ˘˜ ·Ó¿Ï˘ÛȘ ·¤‰ÂÈÍ ÙËÓ Û¿Î¯·ÚÈÓ ¿ÊıÔÓÔÓ”. ∂ÈÛËÌ·›ÓÂÈ fiÙÈ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó “fiÏ· Ù· È·ÙÚÈο fiÛ· ̤¯ÚÈ ÙÔ‡‰Â Ë Ù¤¯ÓË ˘·ÁÔÚ‡ÂÈ”. ª¿ÏÈÛÙ·, ˘ÔÁÚ·ÌÌ›˙ÂÈ fiÙÈ ÔÈ ÁÔÓ›˜ ·Â˘ı‡ÓıËÎ·Ó Î·È ÛÙÔ˘˜ È·ÙÚÔ‡˜ Ù˘ µÈ¤ÓÓ˘, ÔÈ ÔÔ›ÔÈ ‰˘ÛÙ˘¯Ò˜ ıÂÒÚËÛ·Ó ·ıÂÚ¿Â˘ÙË ÙË ÓfiÛÔ Ì ·ÔÙ¤ÏÂÛÌ·, fiˆ˜ Á›ÓÂÙ·È ÛÙȘ ·Ó›·Ù˜ ÂÚÈÙÒÛÂȘ Ô˘ ÔÈ ÁÔÓ›˜ ÚÔÛÙÚ¤¯Ô˘Ó ÛÙÔ˘˜ ÁfiËÙ˜ Î·È ÛÙȘ Ì·Á›˜, Î·È ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ “ηٿ ÙÔ Û‡ÓËı˜, Ë ·Ó›Û¯˘ÚÔ˜ π·ÙÚÈ΋ ·Ú¯ÒÚËÛ ÙË ÁÔËÙ›·. ∫·È Ô Ù·Ï·›ˆÚÔ˜ Ó¤Ô˜ ˘¤ÂÛÂÓ ÂȘ Ù·˜ ¯Â›Ú·˜ ÙˆÓ ÁÚ·˚‰›ˆÓ Î·È Ù˘ Ì·Á›·˜ ·˘ÙÒÓ”. ™ÙË Û˘Ó¤¯ÂÈ·, ÂÚÈÁÚ¿ÊÂÈ ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Ó¤Ô˘ Î·È Ù· Â˘Ú‹Ì·Ù· ·fi ÙË Ê˘ÛÈ΋ ÂͤٷÛË, fiÔ˘ ·Ú·Ù‹ÚËÛ “·ÙÚÔÊ›· ÔÏÔÌÂÏ‹˜, ‰¤ÚÌ· ÍËÚfiÓ, ÛÎÏËÚfiÓ Î·È Ú˘Ùȉ҉˜ ÂÍ Ô‡ ¤ÈÙ Ì ÙËÓ ÙÚÈ‚‹Ó ·Ï¢Ú҉˘ ÎfiÓȘ, Ë ÁÏÒÛÛ·, Ô Ê¿Ú˘ÁÍ, fiÏË Ë ÌÂÌ‚Ú¿ÓË ÍËÚÔÙ¿ÙË, ‰›„· Î·È Â›Ó· Û˘Ó¯‹˜ Î·È ·‰È¿ÎÔÔ˜. ∆Ô ¯ÚÒÌ· ˘fiÏ¢ÎÔÓ Î·È ÁÏ˘Î‡, Ô ÛÊ˘ÁÌfi˜ Ù·¯‡˜”. ∏ ÔÛfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ ÁÚ¿ÊÂÈ fiÙÈ ‹Ù·Ó 24 Ï›ÙÚ·, ÙÚÈÏ¿ÛÈ· ·’ fi,ÙÈ ¤ÈÓÂ. ∏ ÎÔÈÏÈ¿ ‹Ù·Ó “ÊÔ˘ÛΈ̤ÓË”
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Ì “·‰˘Ó·Ì›· ÛÙ· ¿ÎÚ·” Î·È Â›¯Â ‰˘ÛÎÔÈÏÈfiÙËÙ· Î·È ÛÎÏËÚ¿ ÎfiÚ·Ó· “Âͤ‚·ÈÓÔÓ ‰È¿ ÙÔ˘ ÎÏ˘ÛÙËÚ›Ô˘”. ¶ÚÔÛı¤ÙÂÈ fiÙÈ Û˘ÁÎÏ‹ıËΠȷÙÚÈÎfi Û˘Ì‚Ô‡ÏÈÔ, Ô˘ ÙÔ ·ÔηÏ› “π·ÙÚÈ΋ Û˘Ó¤Ï¢ÛȘ”, ÛÙÔ ÔÔ›Ô ÚfiÙÂÈÓÂ, ÛÙËÚÈ˙fiÌÂÓÔ˜ “ÛÙËÓ ÂÈηۛ·Ó” ÂÓfi˜ ÊËÌÈṲ̂ÓÔ˘ È·ÙÚÔ‡ Ù˘ ¶·˘˝·˜, Ó· ‰ÔÎÈÌ·ÛÙ› ÛÙÔÓ ·ÛıÂÓ‹ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, “ÂÛˆÙÂÚÈÎÒ˜”, ¤Ó· Ó¤Ô Ê¿ÚÌ·ÎÔ, “Ô ÊˆÛÊfiÚÔ˜” “·Ó·Ï˘fiÌÂÓÔ˜ ÂȘ ÙÔÓ ıÂÈÈÎfiÓ ·Èı¤Ú·”. H ıÂڷ›· ı· Û˘Óԉ‡ÂÙ·È Ì ۯÂÙÈ΋ ˙ˆÈ΋ ‰›·ÈÙ· Î·È ı· ÚÔÛʤÚÂÙ·È ˆ˜ “ηıËÌÂÚÈÓfiÓ ÔÙfiÓ ÙÔ ˘‰ÚfiÁ·ÏÔÓ”, ‰ÈfiÙÈ fiˆ˜ ÛËÌÂÈÒÓÂÈ “ηٿ ÙËÓ ÂÌ‹Ó ÂÈηۛ·Ó Ë ÙˆÓ ÎÂÓˆÙÈÎÒÓ Î·Ù¿¯ÚËÛȘ Ó· ¤ÚÚÈ„Â Ù· ıÚÂÙÈο ·ÁÁ›· ÂȘ ·ÙÔÓ›·Ó”. ∏ Ó¤· ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÙÔ˘ Ó·ÓÈÎÔ‡ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ì ÙÔÓ ÊˆÛÊfiÚÔ ‰È‹ÚÎÂÛ 2 Î·È Ï¤ÔÓ Ì‹Ó˜ (15 ∞ÚÈÏ›Ô˘ 1814 ¤ˆ˜ 24 πÔ˘Ó›Ô˘ 1814), ÂÓÒ ·Ú¿ÏÏËÏ· Û˘Óԉ¢fiÙ·Ó ·fi ÙÚÈ„›Ì·Ù· ÙÔ˘ Ï›Ô˘˜ ‰È¿ Ó· ·Ú·ÎˆÏ˘ı› Ô Â͈ÙÂÚÈÎfi˜ “ÂÎÚÔÊÈÛÌfi˜”, Ë ¿‰ËÏÔ˜ ‰È·ÓÔ‹. π‰È·›ÙÂÚ· ÙÔÓ›˙ÂÈ fiÙÈ Û˘Ó¤ÛÙËÛ ÙË “Á·Ï·ÎÙÔÙÚÔÊ›·”, ÂÂȉ‹ Ô Ó·Úfi˜ ·ÛıÂÓ‹˜ ›¯Â ·ÈÛı·Óı› ÎÔÚÂÛÌfi ·fi ÙÔ ÎÚ¤·˜. ™ËÌÂÈÒÓÂÈ fiÙÈ Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ Ô ·ÛıÂÓ‹˜ ÙÔ˘ ›¯Â ¿ÚÂÈ ‚¿ÚÔ˜, Ë ÔÛfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ ÌÂȈÓfiÙ·Ó, ÙÔ ¯ÚÒÌ· Î·È Ë ÔÛÌ‹ ÙˆÓ Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈ΋, “Ë fiÚÂÍȘ Î·È Ë ‰›„· ÌÂÙÚȈٿÙË. ∆Ô ‰¤ÚÌ· Ì·Ï·ÎfiÓ, Ï›ÔÓ. ∂Ó›ÔÙ ›‰ÚˆÓ ÂȘ fiÏÔÓ ÙÔ ÛÒÌ·” Î·È fiÙÈ Â›¯Â “·¯‡ÓË ÙfiÛÔÓ fiÛÔÓ ‹ÙÔÓ Úfi Ù˘ ÓfiÛÔ˘”. ∆¤ÏÔ˜, ÂÚÈÁÚ¿ÊÂÈ ÙËÓ Î·Ù¿ÏËÍË ÙÔ˘ ·ÛıÂÓ‹, Ô˘ Û˘Ó¤‚Ë (ÙÔÓ πÔ‡ÏÈÔ ÙÔ˘ 1814) ηٿ ÙË ‰È·ÌÔÓ‹ ÙÔ˘ ÛÙËÓ ÂÍÔ¯‹. ∞ӷʤÚÂÈ fiÙÈ Ô Ó·Úfi˜ ·ÛıÂÓ‹˜ “ÂÛ˘Á¯›ÛıË ‰È¿ ÙËÓ ‰›·ÈÙ¿Ó ÙÔ˘ Ì ÙËÓ ÌËÙ¤Ú· ÙÔ˘, ÒÛÙ ‰ÂÓ ‹ıÂÏ ηْ Ô˘‰¤Ó· ÙÚfiÔÓ Ó· ηٷÂÈÛı› Ó· Ê¿ÁË Ì‹Ù ӷ ›Ë ‰‡Ô ÔÏÔÎÏ‹ÚÔ˘˜ Ë̤ڷ˜” Î·È ·Ú·‚·›ÓÔÓÙ·˜ ÙË ‰›·ÈÙ· Ô˘ ÙÔ˘ ›¯Â Û˘ÛÙËı›, ·ÚÔ˘Û›·ÛÂ Û˘Ó¯›˜ Â̤ÙÔ˘˜ Î·È ÎÔÈÏȷο ¿ÏÁË. ∆ËÓ ÙÚ›ÙË Ë̤ڷ ÙˆÓ ÛÔ‚·ÚÒÓ Û˘Ìو̿وÓ, fiÙ·Ó ÚÔÛÎÏ‹ıËÎÂ Ô È·ÙÚfi˜ ∞Û¿Ó˘, ›¯·Ó ·Ú¯›ÛÂÈ ‹‰Ë, fiˆ˜ ÁÚ¿ÊÂÈ, Ù· ÛËÌ›· ÙÔ˘ ı·Ó¿ÙÔ˘. øÛÙfiÛÔ, ·Ú·ÙËÚ› fiÙÈ “ÙÔ ÂÚ›ÂÚÁÔÓ Â›Ó·È fiÙÈ ÂȘ ·˘Ù¿˜ Ù·˜ ÙÚ›˜ ÙÂÏÂ˘Ù·›·˜ Ë̤ڷ˜ ÙÔ Ô‡ÚÔ˜ ‹ÙÔÓ ÂȘ ÂÏ·¯›ÛÙËÓ ÔÛfiÙËÙ·, ÂÚ˘ıÚfiÓ Î·È Ì ÔÛÌ‹Ó ‚·Ú›·Ó ·Ì̈ÓÈ·ÎÔ‡”. ∫·È ηٷϋÁÂÈ ˆ˜, ·Ó Î·È ‹ıÂÏ ӷ οÓÂÈ ÓÂÎÚÔÙÔÌ‹ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ÂÚÈÙÒÛˆ˜, ÙËÓ ·¤Ê˘Á “ÁÓˆÚ›˙ˆÓ ÙËÓ ÎÔÈÓ‹Ó ‰ÂÈÛȉ·ÈÌÔÓ›·Ó Î·È ·¤¯ıÂÈ·Ó” ÙÔ˘ Ï·Ô‡ ÚÔ˜ ÙȘ ÓÂÎÚÔÙÔ̤˜. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÁÈ· ÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÏϤ˜ Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜, Ô˘ ηٷÁÚ¿ÊÔÓÙ·È Î·È Û ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ‚È‚Ï›·, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ·fi ÙÔÓ ¢ÈÔÓ‡ÛÈÔ ¶‡ÚÚÔ (13), Ô ÔÔ›Ô˜ ÂÈϤÔÓ ·Ú·ı¤ÙÂÈ Î·È Û¯ÂÙÈÎfi ∞ÊÔÚÈÛÌfi ÙÔ˘ πÔ-
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ÎÚ¿ÙÔ˘˜ (ÙÌ‹Ì· 4ÔÓ, 83) “°ÈÁÓÒÌÂÓÔÓ Ôχ Ô‡ÚÔ˜ ÙËÓ Ó‡ÎÙ·, ‰ËÏÔ› ÌÈÎÚ¿Ó ÙËÓ ˘Ô¯ÒÚËÛÈÓ”, Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙÔ ·Ú¯·›Ô ΛÌÂÓÔ “O‡ÚËÛȘ Ó‡ÎÙˆÚ ÔÏÏ‹ ÁÈÓÔ̤ÓË, ÛÌÈÎÚ‹Ó ÙËÓ ˘Ô¯ÒÚËÛÈÓ ÛËÌ·›ÓÂÈ” Î·È Èı·ÓfiÓ Ó· ·Ó·Ê¤ÚÂÙ·È ÛÙÔÓ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË. OÌÔ›ˆ˜, Ô §. ¢. ÃÚ‹ÛÙÔ‚ÈÙ˙ ÛÙ· “¡¤· Ê¿Ú̷η” ÁÈ· ÙÔÓ ‰È·‚‹ÙË ·Ó·ÁÚ¿ÊÂÈ Ù· ·ÎfiÏÔ˘ı·: “Ȉ‰ÔÊfiÚÌÈÔÓ, „›ÓË, ÂÙfiÓ·È, Ó¿ÙÚÈÔÓ ÛÂÈÚ·˚ÎfiÓ, Ó·Ú‰ÈÎfi˜ „¢‰¿ÚÁ˘ÚÔ˜, Ô͇ Á·Ï·ÎÙÈÎfiÓ, ıÂÈ҉˜ ·Û‚¤ÛÙÈÔÓ” (14). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙÔ Î›ÌÂÓÔ ÙÔ˘ È·ÙÚÔ‡ πˆ¿ÓÓË ∞Û¿ÓË Î·Ù·¯ˆÚ›˙ÂÙ·È Ë Û˘Ìو̷ÙÔÏÔÁ›· ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ÛÂ Ó¤Ô ËÏÈΛ·˜ 14 ÂÙÒÓ, Ë ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹ Ì ÏÂ˘ÎˆÌ·ÙÔ‡¯Ô ÙÚÔÊ‹ Î·È Ì›· ÚÔÛ¿ıÂÈ· ıÂڷ¢ÙÈ΋˜ ‰ÔÎÈÌ‹˜ ÂÓfi˜ Ó¤Ô˘ Ê·ÚÌ¿ÎÔ˘, ÙÔÓ “ʈÛÊfiÚÔÓ, ·ÏÂÍÈÊ¿ÚÌ·ÎÔÓ Ù˘ ÊÚÈÎÒ‰Ô˘˜ Î·È ·ÓÈ¿ÙÔ˘ ۯ‰fiÓ ÓfiÛÔ˘, ÙÔ˘ ‰È·‚‹ÙÔ˘”. ∞ÎfiÌË, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÛÙÔ ÂÚÈÔ‰ÈÎfi “∂ÚÌ‹˜ Ô §fiÁÈÔ˜” ηٷÁÚ¿ÊÔÓÙ·È Û‡Á¯ÚÔÓ˜ ÂÈÛÙËÌÔÓÈΤ˜ È·ÙÚÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ·Ó·ÁÓˆÛÙÒÓ ÙÔ˘, Û ̛· ÂÚ›Ô‰Ô Ô˘ ‰ÂÓ Î˘ÎÏÔÊÔÚÔ‡Û ÂȉÈÎfi ÂÏÏËÓÈÎfi È·ÙÚÈÎfi ÂÚÈÔ‰ÈÎfi. ∆¤ÏÔ˜, Û ·˘Ù‹ ÙËÓ ÂÚÁ·Û›· ÙÔ˘ È·ÙÚÔ‡ πˆ¿ÓÓË ∞Û¿ÓË ·Ó·ÁÚ¿ÊÔÓÙ·È, ›Ûˆ˜ ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙÔ ÓÂÔÂÏÏËÓÈÎfi ÏÂÍÈÏfiÁÈÔ, ÔÈ fiÚÔÈ “۷ί·Ú҉˘ ‰È·‚‹Ù˘”, “‰È·‚ËÙÈÎfi˜” Î·È “ÌÔÓÔÁÚ·Ê›·”, ÔÈ ÔÔ›ÔÈ, ˆÛÙfiÛÔ, ·Ô‰›‰ÔÓÙ·È Ì¤¯ÚÈ ÙÒÚ· Û ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ‚È‚Ï›· (15). µÈ‚ÏÈÔÁÚ·Ê›· Î·È ™ËÌÂÈÒÛÂȘ 1. ∂ÚÌ‹˜ Ô §fiÁÈÔ˜. ∂Ó µÈ¤ÓÓË, ÂÎ Ù˘ Ù˘ÔÁÚ·Ê›·˜ ÙÔ˘ πˆ. µ·ÚıÔÏ. ∆˙‚ÂΛԢ, 1817, ·ӷهˆÛË ∂Ù·ÈÚ›· ∂ÏÏËÓÈÎÔ‡ §ÔÁÔÙ¯ÓÈÎÔ‡ ∞Ú¯Â›Ô˘, ∞ı‹Ó·; 1989. ÛÂÏ. 578: “ …ÂÂȉ‹ ·ÎfiÌË ‰ÂÓ ÂÊı¿Û·ÌÂÓ ÂȘ ÙÔÓ ‚·ıÌfiÓ ÂΛÓÔÓ Ù˘ ·È‰Â›·˜, ηı fiÓ ÂÌÔÚÔ‡ÌÂÓ Ó· ¤¯ˆÌÂÓ ÂοÛÙ˘ ÂÈÛÙ‹Ì˘ ȉ›·Ó ÂÊËÌÂÚ›‰·Ó, ˆ˜ ¤¯Ô˘ÛÈ Ù· ÛÔÊ¿ Ù˘ ‰˘ÙÈ΋˜ ∂˘ÚÒ˘ ¤ıÓË, ·Ó·Áη˙fiÌÂı· Ó· ÂΉ›‰ˆÌÂÓ ‰È· ÙÔ˘ §.[ÔÁ›Ô˘] ∂.[ÚÌÔ‡] ·Ó fi,ÙÈ ‹ıÂÏ ʤÚÂÈ ˆÊ¤ÏÂÈ·Ó ÂȘ ÙÔ Á¤ÓÔ˜…”. 2. ∆ÛÈÙÛ¤Ï˘ ∏. ∫ÂÊ·ÏÏËÓȷο Û‡ÌÌÈÎÙ·. ∆fiÌÔ˜ ∞’: ∞ı‹Ó·; 1904. ÛÂÏ. 33-34. 3. ∂ÚÌ‹˜ Ô §fiÁÈÔ˜. µÈ¤ÓÓË; 1811, ÛÂÏ. 91-95, 111-118. ∂ӉȷʤÚÔÓ ¤¯ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÛÙÔ ¿ÚıÚÔ ·˘Ùfi ηٷÁÚ¿ÊÂÙ·È Ô fiÚÔ˜ “‰ÈÂÁÂÚÛÈÌfiÙ˘” Î·È ÂÈÛ¿ÁÂÙ·È ÛÙËÓ ÂÏÏËÓÈ΋ ÔÚÔÏÔÁ›·. µÏ. ™ÙÂÊ. ∫Ô˘Ì·ÓÔ‡‰Ë˜. ™˘Ó·ÁˆÁ‹ Ó¤ˆÓ Ϥ͈Ó. ∞ı‹Ó·; 1900. ∞Ó·Ù‡ˆÛË ∂ÚÌ‹˜: ∞ı‹Ó·; 1980. ÛÂÏ. 288. 4. ∂ÚÌ‹˜ Ô §fiÁÈÔ˜. µÈ¤ÓÓË; 1814. ÛÂÏ. 117-123. 5. O Thenar Luis (1777-1857) ‹Ù·Ó °¿ÏÏÔ˜ ¯ËÌÈÎfi˜ Î·È Ê·ÚÌ·ÎÔÔÈfi˜ Î·È Ô Dupuytren Guillaume (1777-1835) ‰È¿ÛËÌÔ˜ °¿ÏÏÔ˜ ¯ÂÈÚÔ˘ÚÁfi˜, Ô˘ ÌÂٷ͇ ¿ÏÏˆÓ ·Ó·Ê¤ÚÂÙ·È ˆ˜ Ô ÚÒÙÔ˜ Ô˘ ıÂÚ¿Â˘Û ·Ó‡ڢÛÌ· Î·È Â›Ó·È ÁÓˆÛÙfi˜ Î·È ·fi ÙÔ Î¿Ù·ÁÌ· ¡Ù˘Ô˘˚ÙÚ¤Ó, Ô˘ ÂÚȤÁÚ·„ ÙÔ 1812. µÏ. ∂ÌÌ·ÓÔ˘‹Ï ∂. πÛÙÔÚ›· Ù˘ º·Ú̷΢ÙÈ΋˜. ∞ı‹Ó·È; 1948. ÛÂÏ. 415 Î·È Garrison F. An Introduction to the
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¡∂∞ ∞¶O ∆O ¢π∞¢π∫∆ÀO
∂π™∞°ø°π∫O ™∏ª∂πøª∞ ∫ÔÚ›Ó· ¶ÚÔ‡ÓÙ˙Ô˘ - ∫·ÛÛÈÔ‡
∞Á·ËÙÔ› Û˘Ó¿‰ÂÏÊÔÈ, ∆Ô ÂÚÈÔ‰ÈÎfi “¶·È‰È·ÙÚÈ΋” Ì¿˜ ¤¯ÂÈ ÛËÌ·‰¤„ÂÈ fiÏÔ˘˜ ÙÔ˘˜ ·Ï·ÈfiÙÂÚÔ˘˜ Î·È ·ÔÙÂÏ› ÛËÌÂ›Ô ·Ó·ÊÔÚ¿˜ ÁÈ· ÙÔ˘˜ Ó¤Ô˘˜ ·È‰È¿ÙÚÔ˘˜. Œ¯ÂÈ ÙË ‰‡Ó·ÌË ÙÔ˘ ÎÏ·ÛÈÎÔ‡ Î·È ÙÔÓ ÚÔÛ·Ó·ÙÔÏÈÛÌfi ÙÔ˘ ÛÙÔ Ó¤Ô. ™Â ·˘Ùfi ÙÔ Ù‡¯Ô˜ ÂÁηÈÓÈ¿˙Ô˘Ì ̛· Ó¤· ÛÂÏ›‰· Ô˘ ϤÁÂÙ·È “¡¤· ·fi ÙÔ ¢È·‰›ÎÙ˘Ô”. ∂›Ó·È Ì›· ÛÂÏ›‰· Ô˘ ı· ÂÚÈÏ·Ì‚¿ÓÂÈ ÂӉȷʤÚÔÓÙ· Ó¤· Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È ÌÂϤÙ˜ ÂÓÙÂÏÒ˜ ÚfiÛÊ·Ù˜, ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ÚÈÓ ·ÎfiÌË ‰ËÌÔÛÈ¢ıÔ‡Ó ÛÙ· ·ÓÙ›ÛÙÔȯ· ÂÚÈÔ‰Èο. £· ÂÚÈÏ·Ì‚¿ÓÂÈ, ›Û˘, ÏËÚÔÊÔڛ˜ ÁÈ· ÈÛÙÔÛÂÏ›‰Â˜ Î·È ËÏÂÎÙÚÔÓÈΤ˜ ‰È¢ı‡ÓÛÂȘ Ì ·ÓÙÈΛÌÂÓÔ ÙËÓ ¶·È‰È·ÙÚÈ΋. ∏ ÂÈ̤ÏÂÈ· Ù˘ ÛÂÏ›‰·˜ ı· Â›Ó·È Â˘ı‡ÓË ÙˆÓ: ∫. ¶ÚÔ‡ÓÙ˙Ô˘-∫·ÛÛÈÔ‡ (¶·È‰È¿ÙÚÔ˘), ¡›ÎÔ˘ ¶··‰fiÔ˘ÏÔ˘ (∞ÏÏÂÚÁÈÔÏfiÁÔ˘) Î·È ª·Ú›·˜ ∏Ï›· (¶·È‰È¿ÙÚÔ˘-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˘). ™˘ÓÂÚÁ¿Ù˜ Ù˘ ÛÂÏ›‰·˜ ı· Â›Ó·È Î·È ·È‰›·ÙÚÔÈ Ì ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ‰È·‰›ÎÙ˘Ô. ∞˘Ù‹ ÙËÓ ÂÔ¯‹, ÙÔ ÂӉȷʤÚÔÓ fiÏÔ˘ ÙÔ˘ ÎfiÛÌÔ˘ Â›Ó·È ÛÙÚ·Ì̤ÓÔ ÛÙËÓ ÂȉËÌ›· ÙÔ˘ ™Ô‚·ÚÔ‡ OͤԘ ∞Ó·Ó¢ÛÙÈÎÔ‡ ™˘Ó‰ÚfiÌÔ˘ (™O∞™). ™Â ·˘Ùfi ÙÔ Ù‡¯Ô˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ì ÙȘ ÙÂÏÂ˘Ù·›Â˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ. £ÂˆÚÔ‡ÌÂ, fï˜, ¯Ú¤Ô˜ Ì·˜ ÚÈÓ ¿Ì ÛÙȘ ÏËÚÔÊÔڛ˜, Ó· ·ÔÙ›ÛÔ˘Ì ÊfiÚÔ ÙÈÌ‹˜ ÛÙÔÓ π·ÙÚfi-ÕÓıÚˆÔ Carlo Urbani. O Carlo Urbani ‹Ù·Ó 46 ÂÙÒÓ Î·È ·Ù¤Ú·˜ 3 ·È‰ÈÒÓ. ◊Ù·Ó ÂȉÈÎfi˜ ÛÙ· ÌÂÙ·‰ÔÙÈο ÓÔÛ‹Ì·Ù· Î·È ¤ı·Ó ÛÙȘ 29 ª·ÚÙ›Ô˘ 2003 ÛÙÔ ∞ÓfiÈ, fiÔ˘ ÂÚÁ·˙fiÙ·Ó Û·Ó ÂÎÚfiÛˆÔ˜ ÙÔ˘ WHO Û ÚÔÁÚ¿ÌÌ·Ù· ‰ËÌfiÛÈ·˜ ˘Á›·˜. O Carlo Urbani ‹Ù·Ó Ô ÚÒÙÔ˜ ÁÈ·ÙÚfi˜ Ô˘ ·Ú·Ù‹ÚËÛ ÙËÓ È‰È·ÈÙÂÚfiÙËÙ· Ù˘ Ó¤·˜ ·Ûı¤ÓÂÈ·˜ Û ¤Ó·Ó ∞ÌÂÚÈηÓfi ÂȯÂÈÚËÌ·Ù›·, Û ¡ÔÛÔÎÔÌÂ›Ô ÙÔ˘ ∞ÓfiÈ. ÿÚË Û ·˘Ù‹ ÙËÓ ÚÒÈÌË ·Ó·ÁÓÒÚÈÛË Ù˘ ÓfiÛÔ˘, ÂÓÂÚÁÔÔÈ‹ıËΠÔχ ÁÚ‹ÁÔÚ· Ô ·ÁÎfiÛÌÈÔ˜ Ì˯·ÓÈÛÌfi˜ ÂÈÙ‹ÚËÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÏËÊıÔ‡Ó ¤ÁηÈÚ· ̤ÙÚ· ·Ó·ÎÔ‹˜ Ù˘ ÂͿψÛ˘ Ù˘ ÓfiÛÔ˘ Î·È Ë ÂȉËÌ›· ÛÙÔ ∞ÓfiÈ ÙÒÚ· Ó· ÂϤÁ¯ÂÙ·È. O Carlo Urbani ‹Ú ÙÔ Ù˘¯›Ô Ù˘ π·ÙÚÈ΋˜ ·fi ÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ Ù˘ ∞ÁÎfiÓ· ÛÙËÓ πÙ·Ï›· Î·È ¤Î·Ó ÌÂÙ·Ù˘¯È·Î¤˜ ÛÔ˘‰¤˜ ÛÙËÓ ÂÏÔÓÔÛ›· Î·È Ù· ·Ú·ÛÈÙÈο ÓÔÛ‹Ì·Ù·. ◊Ù·Ó ÂȉÈÎfi˜ ÙÚÔÈÎÒÓ ÓfiÛˆÓ ÛÙ· ·È‰È¿. ∂›Û˘, ‹Ù·Ó ¶Úfi‰ÚÔ˜ ÙˆÓ “°È·ÙÚÒÓ ¯ˆÚ›˜ Û‡ÓÔÚ·” Ù˘ πÙ·Ï›·˜. O ı¿Ó·Ùfi˜ ÙÔ˘ Û˘ÁÎÏfiÓÈÛ ÙËÓ ·ÁÎfiÛÌÈ· È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ· Î·È Â·Ó¤ÊÂÚ ÛÙË Û˘Ó›‰ËÛË fiÏˆÓ Ì·˜ ·Í›Â˜ Ô˘ Ú¤ÂÈ Ó· ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔÓ ÁÈ·ÙÚfi: ÚÔۋψÛË ÛÙÔ Î·ı‹ÎÔÓ, ·ÓȉÈÔÙ¤ÏÂÈ·, ·˘ÙÔı˘Û›·, ·ÓıÚˆÈÛÌfi˜. ™ÙËÓ ÙÂÏÂ˘Ù·›· “Ú¿ÍË ÙÔ˘ ‰Ú¿Ì·ÙÔ˜” ÚÔÛ¤ÊÂÚ ÙËÓ ˘¤ÚÙ·ÙË ı˘Û›·: ∆∏ ∑ø∏ ∆OÀ. ∆Ë ÛËÌÂÚÈÓ‹ ÂÔ¯‹, ·ÁÎfiÛÌÈ·, ¤¯Ô˘Ó ÂÎÏ›„ÂÈ ÔÈ ËÁ¤Ù˜ Î·È Ù· ÚfiÙ˘· Û fiÏ· Ù· ›‰·. O Carlo Urbani Â›Ó·È Ô ÈÔ Û‡Á¯ÚÔÓÔ˜ “º¿ÚÔ˜” Û fiÏË ÂΛÓË ÙË ÛÂÈÚ¿ ÙˆÓ ·ÓıÚÒˆÓ Ù˘ πÛÙÔÚ›·˜ Ù˘ π·ÙÚÈ΋˜ Ô˘ ʈٛ˙Ô˘Ó ÙÔ ‰‡Û‚·ÙÔ ÌÔÓÔ¿ÙÈ ÙÔ˘ ∞ÓıÚˆÈÛÌÔ‡. ¢ÂÓ ı· ͯ·ÛÙ› ÔÙ¤ ÁÈ·Ù›, ÁÈ· Ó· ı˘ÌËıÔ‡ÌÂ Î·È ÙÔÓ ÔÈËÙ‹, “fiÏÔ ÙÔ ÛÎÔÙ¿‰È ÙÔ˘ ÎfiÛÌÔ˘ ‰ÂÓ ÌÔÚ› Ó· Û‚‹ÛÂÈ ÙÔ Êˆ˜ ÂÓfi˜ ÌÈÎÚÔ‡ ÎÂÚÈÔ‡”. ¶fiÛÔ Ì¿ÏÏÔÓ ÂÓfi˜ “º¿ÚÔ˘”.
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¡∂∞ ™Ô‚·Úfi O͇ ∞Ó·Ó¢ÛÙÈÎfi ™‡Ó‰ÚÔÌÔ (™O∞™) - Severe Acute Respiratory Syndrome (SARS) ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
∆Ô ™Ô‚·Úfi O͇ ∞Ó·Ó¢ÛÙÈÎfi ™‡Ó‰ÚÔÌÔ (Severe Acute Respiratory Syndrome - SARS) ÚˆÙÔÂÌÊ·Ó›ÛÙËΠÛÙËÓ ∫›Ó· ÚÈÓ ·fi Ï›ÁÔ˘˜ Ì‹Ó˜. Œ¯Ô˘Ó ÚÔ˜ ÙÔ ·ÚfiÓ ÚÔÛ‚ÏËı› ÙÔ˘Ï¿¯ÈÛÙÔÓ 2600 ¿ÙÔÌ·, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÂÚ›Ô˘ 100 ¤¯Ô˘Ó Âı¿ÓÂÈ. ¶˘Ú‹Ó˜ Ù˘ ÂȉËÌ›·˜ Â›Ó·È Ë ∫›Ó·, ÙÔ ÃÔÓÁÎ-∫ÔÓÁÎ, Ë ™ÈÁηԇÚË Î·È ÙÔ µÈÂÙÓ¿Ì, ·ÏÏ¿ ¤Ó·˜ ‰Â‡ÙÂÚÔ˜ ı‡Ï·Î·˜ ¤¯ÂÈ ‰ËÌÈÔ˘ÚÁËı› ÛÙÔÓ ∫·Ó·‰¿ Î·È ÛÙȘ ∏.¶.∞. ·fi ¿ÙÔÌ· Ô˘ ÚÔÛ‚Ï‹ıËÎ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù·ÍȉÈÒÓ ÛÙËÓ Õˆ ∞Ó·ÙÔÏ‹. ∆Ô Û‡Ó‰ÚÔÌÔ ·ÚÔ˘ÛÈ¿˙ÂÈ ·Ú¯Èο ˘„ËÏfi ˘ÚÂÙfi Î·È ÁÂÓÈο Û˘ÌÙÒÌ·Ù· (Ì˘·ÏÁ›Â˜, ÎÂÊ·Ï·ÏÁ›·, ηÎÔ˘¯›·), ÁÈ· Ó· ÂÌÊ·Ó›ÛÂÈ 2-7 Ë̤Ú˜ ·ÚÁfiÙÂÚ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ΢ڛˆ˜ ÍËÚfi ‚‹¯· Î·È ÛÙ·‰È·Î¿ ÂȉÂÈÓÔ‡ÌÂÓË ‰‡ÛÓÔÈ· Ô˘ ÌÔÚ› Ó· ÊÙ¿ÛÂÈ Ì¤¯ÚÈ ÙÔ ÛËÌÂ›Ô Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. O ¯ÚfiÓÔ˜ ÂÒ·Û˘ ÙÔ˘ ÏÔÈÌÔÁfiÓÔ˘ ·Ú¿ÁÔÓÙ· Â›Ó·È 2-10 Ë̤Ú˜. O ÙÚfiÔ˜ ÌÂÙ¿‰ÔÛ˘ Ê·›ÓÂÙ·È Ó· Á›ÓÂÙ·È Ì ÛÙ·ÁÔÓ›‰È·, ¯ÚÂÈ¿˙ÂÙ·È fï˜ Û¯ÂÙÈο ÛÙÂÓ‹ ·ʋ Ì ÙÔÓ ·ÛıÂÓ‹: Â›Ó·È ÛËÌ·ÓÙÈÎfi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ È·ÙÚÒÓ Ô˘ ÓÔÛ‹Ï¢·Ó ¿Û¯ÔÓÙ˜ ·fi SARS. ∆Ô ·›ÙÈÔ Ù˘ ÓfiÛÔ˘ ÌÔÈ¿˙ÂÈ Ó· Â›Ó·È ¤Ó·˜ Ó¤Ô˜ Èfi˜ ÎÔÚfiÓ·, ·Ó Î·È Û˘Û¯ÂÙ›ÛÂȘ ¤¯Ô˘Ó Á›ÓÂÈ Î·È Ì ÌÂÙ·Ó¢ÌÔÓÔ˚fi Î·È ·Ú·Ì˘ÍÔ˚fi. °›ÓÔÓÙ·È ÌÂÁ¿Ï˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ‰È·ÁÓˆÛÙÈÎÔ‡ ÙÂÛÙ, ·Ú¿ÏÏËÏ· Ì ÙËÓ ÂȂ‚·›ˆÛË ÙÔ˘ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ ıÂڷ›· Â›Ó·È ·ÏÒ˜ ˘ÔÛÙËÚÈÎÙÈ΋. ∏ ¶OÀ Û˘ÛÙ‹ÓÂÈ ÙËÓ ·ÔÊ˘Á‹ Ù·ÍȉÈÒÓ ÚÔ˜ ÙȘ ÂÚÈÔ¯¤˜ Ô˘ ¤¯Ô˘Ó ÏËÁ›.
ŒÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
∏ ¤ÁηÈÚË ¯ÔÚ‹ÁËÛË ÚÔÊ˘Ï·ÎÙÈ΋˜ ıÂڷ›·˜ ÁÈ· ÙÔ ¿ÛıÌ· Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈο ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ¯ÔÚ‹ÁËÛË. ∞Ó Î·È ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ÛÙÔ ·ÚÂÏıfiÓ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ‰˘Ó·ÙfiÙËÙ· ‚ÂÏÙ›ˆÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙ· ·È‰È¿ Ì ÙË ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙÔ˘ ¯ÚfiÓÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, Ë ÌÂϤÙË START, Ù˘ ÔÔ›·˜ ÙÔ ÚÒÙÔ Ì¤ÚÔ˜ ‰ËÌÔÛȇıËΠÛÙȘ 29-03-2003 ÛÙÔ Lancet, ·ÔÙÂÏ› ÙË ÌÂÁ·Ï‡ÙÂÚË Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Û¯ÂÙÈο Ì ÙË ıÂڷ›· ÙÔ˘ ¿ÛıÌ·ÙÔ˜, ÂÚÈÏ·Ì‚¿ÓÔÓÙ·˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 7000 ·ÛıÂÓ›˜, fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ START ¤‰ÂÈÍ·Ó fiÙÈ ¿ÙÔÌ· Ì ‹ÈÔ Â›ÌÔÓÔ ¿ÛıÌ·, Ô˘ ›¯Â ‰È·ÁÓˆÛÙ› ÏÈÁfiÙÂÚÔ ·fi 2 ¯ÚfiÓÈ· Î·È ¤Ï·‚·Ó ‚Ô˘‰ÂÛÔÓ›‰Ë ÂÈϤÔÓ ¿ÏÏˆÓ ıÂÚ·ÂÈÒÓ, ›¯·Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Û fiϘ ۯ‰fiÓ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÓfiÛÔ˘. º·›ÓÂÙ·È fiÙÈ Ù· ÚÒÙ· ¯ÚfiÓÈ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ Â›Ó·È Ôχ ÛËÌ·ÓÙÈο ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ‰›ÓÂÈ ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ· ÛÙÔ ÚfiÏÔ ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘. Lancet 2003;361:1071-1076
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µÚ·¯‡ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÁÈ· Ë·Ù›Ùȉ· µ ÛÙ· ·È‰È¿ ¢‹ÌËÙÚ· §È·ÓÔ‡, ¶·È‰›·ÙÚÔ˜
∆˘¯·ÈÔÔÈË̤ÓË Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ¤Ó· “‚Ú·¯‡” Û¯‹Ì· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ Ë·Ù›Ùȉ·˜ µ (3 ‰fiÛÂȘ Û ¯ÚfiÓÔ 0, 10 Î·È 21 Ë̤Ú˜) ‰ËÌÈÔ˘ÚÁ› ÚÔÛٷ٢ÙÈο ·ÓÙÈÛÒÌ·Ù· (antiHBs) Ù·¯‡ÙÂÚ· ·’ fiÙÈ ÙÔ ÎÏ·ÛÈÎfi Û¯‹Ì· (3 ‰fiÛÂȘ Û ¯ÚfiÓÔ 0, 1 Î·È 6 Ì‹Ó˜), ÂÓÒ Ô ‚·ıÌfi˜ ·ÓÔÛÔÏÔÁÈ΋˜ ÚÔÛÙ·Û›·˜ Î·È ÛÙ· ‰‡Ô Û¯‹Ì·Ù· Â›Ó·È Ô ›‰ÈÔ˜ ÌÂÙ¿ ·fi 1 ¯ÚfiÓÔ. ™˘ÓÂÒ˜, ÙÔ ‚Ú·¯‡ ·˘Ùfi Û¯‹Ì· ı· ÌÔÚÔ‡Û ӷ ¯ÔÚËÁËı› Û ·È‰È¿ Ô˘ ÚfiÎÂÈÙ·È Ó· Ù·Íȉ¤„Ô˘Ó Û ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜ Î·È ‰ÂÓ Â›¯·Ó ·Ú΋ ¯ÚfiÓÔ ÁÈ· Ó· Û˘ÌÏËÚÒÛÔ˘Ó ÙÔ ÎÏ·ÛÈÎfi ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‹ ÚfiÎÂÈÙ·È Ó· Ï¿‚Ô˘Ó ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜. Pediatr Int 2002;44:663-665
∏§∂∫∆ƒO¡π∫∂™ ¢π∂À£À¡™∂π™ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ - www.aap.org ∏ ÈÛÙÔÛÂÏ›‰· Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ ·ÔÙÂÏ› ÛËÌÂ›Ô ·Ó·ÊÔÚ¿˜. ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÈÔ ÚfiÛÊ·Ù· ·È‰È·ÙÚÈο Ó¤·, ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ٷ ÚÔÙÂÈÓfiÌÂÓ· Û¯‹Ì·Ù· ÂÌ‚ÔÏÈ·ÛÌÒÓ, ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ÂÎÛÙÚ·Ù›˜ Ô˘ ÔÚÁ·ÓÒÓÂÈ Ë ∞η‰ËÌ›·, ‰ÂÏÙ›· Ù‡Ô˘, ÏËÚÔÊÔڛ˜ ÁÈ· ÁÔÓ›˜, ÂȉÈΤ˜ ÂΉfiÛÂȘ Î·È ¿ÏÏ·. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔÈ Ô‰ËÁ›Â˜ Â›Ó·È ÏÈÙ¤˜, Û˘ÁÎÂÎÚÈ̤Ó˜ Î·È ‰ÔÌË̤Ó˜, ¤ÙÛÈ ÒÛÙ ÌÔÚ› ηÓ›˜ ‡ÎÔÏ· Ó· ÙȘ ÌÂٷʤÚÂÈ, ·ÊÔ‡ ÙȘ ÌÂÙ·ÊÚ¿ÛÂÈ, ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÙÔ˘ Ú·ÎÙÈ΋. °È· ÙÔ˘˜ ÓÂfiÙÂÚÔ˘˜, ˘¿Ú¯Ô˘Ó ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ¢ηÈڛ˜ ·Ó‡ÚÂÛ˘ ÂÚÁ·Û›·˜ ÛÙȘ ∏.¶.∞., ˘ÔÙÚÔʛ˜ Î.Ï. ¶·Ú¤¯ÔÓÙ·È, ›Û˘, ‰ˆÚÂ¿Ó Ì·ı‹Ì·Ù· Û˘Ó¯È˙fiÌÂÓ˘ ·È‰È·ÙÚÈ΋˜ Âη›‰Â˘Û˘ on-line, links ÁÈ· Ù· ÂÚÈÔ‰Èο Ù˘ ∞η‰ËÌ›·˜, fiˆ˜ ÙÔ Pediatrics Î·È ÙÔ Pediatrics in Review Î·È ÔÏÏ¿ ¿ÏÏ·. ∞Í›˙ÂÈ Ó· ÙÔ ÂÚÈÏ¿‚ÂÙ ÛÙ· favorites! PediatricLinx.com - www.pediatriclinx.com °È· fiÛÔ˘˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ̤ÓÔ˘Ó ›Ûˆ Ô‡Ù ̛· ‚‰ÔÌ¿‰· ÛÙËÓ ÂÓË̤ڈۋ ÙÔ˘˜, ÙÔ PediatricLinx ›Ûˆ˜ Ó· ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ χÛË. ∏ ÔÌ¿‰· ·˘Ù‹˜ Ù˘ ÈÛÙÔÛÂÏ›‰·˜ ·Ô‰ÂÏÙÈÒÓÂÈ ÙÔ Û‡ÓÔÏÔ Û¯Â‰fiÓ ÙˆÓ ÂÈÛÙËÌÔÓÈÎÒÓ ÂÚÈÔ‰ÈÎÒÓ ·È‰È·ÙÚÈ΋˜ Î·È Û¯ÂÙÈ˙fiÌÂÓˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Î·È ·Ú·ı¤ÙÂÈ ÙÔÓ Ù›ÙÏÔ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù·, Ì ڢıÌfi ·Ó·Ó¤ˆÛ˘ 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ŒÙÛÈ, ÌÔÚ› ηÓ›˜ Ó· Ú›¯ÓÂÈ Ì›· Ì·ÙÈ¿ ÛÙÔÓ ÙÂÚ¿ÛÙÈÔ ·˘Ùfi fiÁÎÔ ÙˆÓ ÏËÚÔÊÔÚÈÒÓ Î·È, Â¿Ó Î¿ÙÈ ÙÔÓ ÂӉȷʤÚÂÈ È‰È·›ÙÂÚ·, Ó· Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ ‰È·‰ÈÎÙ˘·Îfi ÙfiÔ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÚÈÔ‰ÈÎÔ‡, fiÔ˘ ˘¿Ú¯ÂÈ Ë Ï‹Ú˘ ÂÚ›ÏË„Ë Î·È, ›Ù ‰ˆÚÂ¿Ó Â›Ù ̤ۈ Û˘Ó‰ÚÔÌ‹˜, ÙÔ Ï‹Ú˜ ¿ÚıÚÔ. ¢›ÓÂÙ·È, ›Û˘, Ë ‰˘Ó·ÙfiÙËÙ· Ó· ÁÚ·ÊÙ› οÔÈÔ˜ Û˘Ó‰ÚÔÌËÙ‹˜ ÛÙÔ newsletter ·˘ÙÔ‡ ÙÔ˘ ÙfiÔ˘, ÔfiÙ fiϘ ÔÈ ·Ú·¿Óˆ ÏËÚÔÊÔڛ˜ ηٷÊı¿ÓÔ˘Ó Ì ÙÔ ËÏÂÎÙÚÔÓÈÎfi Ù·¯˘‰ÚÔÌ›Ô. ¶ÚÔÛÔ¯‹! O ÙfiÔ˜ ·˘Ùfi˜ ·Â˘ı‡ÓÂÙ·È ÛÙÔ˘˜ ·ÔÊ·ÛÈṲ̂ÓÔ˘˜ Î·È ‰È„·Ṳ̂ÓÔ˘˜ ÁÈ· ÁÓÒÛË Û˘Ó·‰¤ÏÊÔ˘˜.
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5Ë ∏ÌÂÚ›‰· ¶·È‰È·ÙÚÈ΋˜ ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ “Oͤ· Î·È ÃÚfiÓÈ· ¡Â˘ÚÔÏÔÁÈο ¶ÚÔ‚Ï‹Ì·Ù·” ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ¶ÏËÚÔÊÔڛ˜: ∞Ó·ÛÙ¿ÛÈÔ˜ ÷Ù˙‹˜ ª.∂.£. ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∆ËÏ. & fax: 210-74 88 686
∞ı‹Ó·
8-12 πÔ˘Ó›Ô˘ 2003
15th European Immunology Congress ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ∞ÓÔÛÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: Amphitrion Holidays ∆ËÏ.: +3 210-900 6000 Fax: +3 210-9249 836 E-mail: congress@amphitrion.gr
ƒfi‰Ô˜
12-14 πÔ˘Ó›Ô˘ 2003
“2nd Caring in the skies” ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress ∆ËÏ.: +3 210-7499 300 Fax: +3 210-7705 752 E-mail: siav@triaenatours.gr
∞ı‹Ó·
12-15 πÔ˘Ó›Ô˘ 2003
8th Congress of the European Hematology Association ¶ÏËÚÔÊÔڛ˜: Eurocongres Conference Management Tel.: +31 20 679 3411 Fax: +31 20 673 7306 E-mail: eha2003@eurocongres.com
Lyon, France
13-15 πÔ˘Ó›Ô˘ 2003
41Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: C & C International S.A. ∆ËÏ.: 210 - 68 89 100 Fax: 210 - 68 44 777 E-mail: pediatric2003@cnc.gr
ƒfi‰Ô˜
16-17 πÔ˘Ó›Ô˘ 2003
2nd International Medical and Genetic Congress on Schwachman Diamond Syndrome ¶ÏËÚÔÊÔڛ˜: ¢Ú ∂ϤÓË æÈ¿¯Ô˘-Leonard E-mail: epsiachou@hotmail.com
Toronto, Canada
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12-18 πÔ˘Ï›Ô˘ 2003
Ãπà Congress of the International Society on Thrombosis and Haemostasis ¶ÏËÚÔÊÔڛ˜: Concorde Services Tel.: +44 20 8743 3106 Fax: +44 20 8743 1010 E-mail: isth-programme@concorde-uk.com
Birmingham, UK
12-13 ™ÂÙÂÌ‚Ú›Ô˘ 2003
Erasmus Workshop on Molecular Therapeutics in Acute Leukemia ¶ÏËÚÔÊÔڛ˜: Erasmus Workshop Leukemia Tel.: +31 (0)10 4087669 Fax: +31 (0)10 4089462 E-mail: info@emco.fgg.eur.nl Website: www.eur.nl/fgg/emco
Rotterdam, The Netherlands
18-21 ™ÂÙÂÌ‚Ú›Ô˘ 2003
28th UMEMPS Congress Secretariat: Dr S. Afif - Pr. M. Oumlil Tel. & Fax: +212 22 22 6386 E-mail: smpcasa@wanadoo.net.ma
Marrakech, Morocco
20-23 ¡ÔÂÌ‚Ú›Ô˘ 2003
14th European Congress on Pediatric and Neonatal Intensive Care Astir Palace Hotel ¶ÏËÚÔÊÔڛ˜: ZITA Congress E-mail: grasimosk@zita-congress.gr
∞ı‹Ó·
10-13 πÔ˘Ó›Ô˘ 2004
9th Congress of the European Geneva, Hematology Association Switzerland ¶ÏËÚÔÊÔڛ˜: Eurocongres Conference Management Tel.: +31 20 679 3411 Fax: +31 20 673 7306 E-mail: eha2004@eurocongres.com Website: www.eurocongres.com/eha2004
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™YNTOMO°PAºIE™
ABBREVIATIONS
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
AIDS
Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜
AMP, ADP, ATP
ÌÔÓÔ-, ‰È-, ÙÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË
ATPase cal CSF ‹ ENY CNS ‹ ∫¡™ cm CoA cmÑ cm2 cAMP ÆC CRP DNA ECG ‹ ∏∫° EEG ‹ ∏∂° ELISA ESR ‹ ∆∫∂ EDTA g Hct Hb HLA
ÙÚÈʈÛÊ·Ù¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ ıÂÚÌ›‰· ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂηÙÔÛÙfi Û˘Ó¤Ó˙˘ÌÔ ∞ ΢‚ÈÎfi ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ΢ÎÏÈÎfi AMP ‚·ıÌfi˜ KÂÏÛ›Ô˘ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‰ÂÔ͢ÚÈ‚Ô˙ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤Ó˙˘ÌÔ-Û˘Ó‰¤Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù·¯‡ÙËÙ· ηıÈ˙‹Ûˆ˜ ÂÚ˘ıÚÒÓ Âı˘ÏÂÓԉȷÌÈÓÔÙÂÙÚ·ÔÍÂ˚Îfi Ô͇ ÁÚ·ÌÌ¿ÚÈo ·ÈÌ·ÙÔÎÚ›Ù˘ ·ÈÌÔÛÊ·ÈÚ›ÓË ·ÓÙÈÁfiÓÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜
Ig ICU ‹ ª∂£ IU i.m. ‹ ∂.ª. i.p. ‹ ∂.¶. i.v. ‹ ∂.º. L log mol ªW ‹ MB MCH MCV mRNA m min n N NS ‹ ª™ Ôsm % PCR pH PCO2 PO2 p
·ÓÔÛÔÛÊ·ÈÚ›ÓË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚ο ÂÓ‰ÔÊϤ‚È· Ï›ÙÚÔ(·) ÏÔÁ¿ÚÈıÌÔ˜ ÁÚ·ÌÌÔÌfiÚÈÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ̤ÛË ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÚ˘ıÚÒÓ Ì¤ÛÔ˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ ·ÁÁÂÏÈÔÊfiÚÔ˜ RNA ̤ÙÚÔ ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÙÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·
acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability
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™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·
by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) giga- (10 ) mega-(10 ) kilo- (10 ) hecto(10 ) deca (10 ) deci (10 ) centi- (10 ) milli(10 ) micro (10 ) nano (10 ) pico (10 ) femto (10 ) atto (10 ) 9
6
3
2
1
-1
-2
-3
-6
-9
-12
-15
-18
xvi
Combining prefixes T G M k h da d c m Ì n p f a