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Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·1

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1

°Ú›Ë ÙˆÓ ÙËÓÒÓ: ·ÂÈÏ‹ ÌÈ·˜ Ó¤·˜ ·Ó‰ËÌ›·˜; ª. ∆ÛÔÏÈ¿, π. §ÔÁÔı¤ÙË, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜

¶ÂÚ›ÏË„Ë: ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 20Ô‡ ·ÈÒÓ· Ë ·ÓıÚˆfiÙËÙ· ‰ÔÎÈÌ¿ÛÙËΠ·fi ÙÚÂȘ ·Ó‰Ë̛˜ ÁÚ›˘. ™ÙËÓ ·˘Á‹ ÙÔ˘ 21Ô˘ ·ÈÒÓ·, Ë ÂÌÊ¿ÓÈÛË ÌÈ·˜ Ó¤·˜ ·Ó‰ËÌ›·˜ ÌÔÈ¿˙ÂÈ ·Ó·fiÊ¢ÎÙË. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ¤Ó·˜ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ÂȉËÌÈÒÓ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ ÂΉËÏÒÓÔÓÙ·È Î˘Ú›ˆ˜ ÛÙȘ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜, ηıÒ˜ Î·È Û ¿ÏÏ· ̤ÚË ÙÔ˘ ÎfiÛÌÔ˘. ∞˘Ù¤˜ ÚÔηÏÔ‡ÓÙ·È ·fi ÈÔ‡˜ Ô˘ ¤¯Ô˘Ó ·˘ÍË̤ÓË ÏÔÈÌÔÁfiÓÔ ‰‡Ó·ÌË Î·È ÚÔηÏÔ‡Ó ˘„ËÏ‹˜ ·ıÔÁÔÓÈÎfiÙËÙ·˜ ÁÚ›Ë ÛÙ· ÙËÓ¿. π‰È·›ÙÂÚË ·ÓËÛ˘¯›· ¤¯ÂÈ ÚÔηϤÛÂÈ Ë Â˘Ú›· ÂÍ¿ψÛË ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘ ∏5¡1 Û ¿ÁÚÈ· Î·È ÔÈÎfiÛÈÙ· ÙËÓ¿ ÛÙËÓ ∞Û›·. ∆Ô Û٤ϯԘ ·˘Ùfi ÌÔÚ› Ó· ÌÂÙ·‰Ôı› ·fi Ù· ÙËÓ¿ ÛÙÔÓ ¿ÓıÚˆÔ Î·È Ó· ÚÔηϤÛÂÈ Ïԛ̈ÍË Î·È ı¿Ó·ÙÔ. ∞Ó Î·È ¤¯ÂÈ ·Ú·ÙËÚËı› ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ, Ê·›ÓÂÙ·È fiÙÈ ÙÔ Û٤ϯԘ ·˘Ùfi ‰ÂÓ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› ‡ÎÔÏ· ÌÂٷ͇ ·ÓıÚÒˆÓ. øÛÙfiÛÔ, ÌÔÚ› Ó· ·ÔÎÙ‹ÛÂÈ ÙËÓ ÈηÓfiÙËÙ· ·˘Ù‹ Ì ·Ó¿ÌÈÍË Î·È ·ÓÙ·ÏÏ·Á‹ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ÙÔ˘ ˘ÏÈÎÔ‡ (reassortment) Ì ÙÔ ÁÂÓÂÙÈÎfi ˘ÏÈÎfi ·ÓıÚÒÈÓÔ˘ ÛÙÂϤ¯Ô˘˜ ‹ Ì ‰È·‰Ô¯ÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ. ™Â ·˘Ù‹Ó ÙËÓ ÂÚ›ÙˆÛË, ÙÔ Û٤ϯԘ ∏5¡1 ı· ÂÍ·ψı› Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Î·È ı· ÂΉËψı› ÌÈ· Ó¤· ·Ó‰ËÌ›·. °È· Ó· ÂÚÈÔÚÈÛÙ› Ë ÂÍ¿ψÛË ÙÔ˘ ÈÔ‡ Â›Ó·È ··Ú·›ÙËÙË Ë Û˘ÓÙÔÓÈṲ̂ÓË ÚÔÛ¿ıÂÈ· ÙˆÓ Î˘‚ÂÚÓ‹ÛÂˆÓ ·ÏÏ¿ Î·È fiÛˆÓ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ÂÎÙÚÔÊ‹ ÙËÓÒÓ ÒÛÙ ӷ ÂÊ·ÚÌÔÛıÔ‡Ó Ù· ηٿÏÏËÏ· ÂÎ·È‰Â˘ÙÈο ÚÔÁÚ¿ÌÌ·Ù· Î·È Ó· ‚ÂÏÙȈı› Ë ‚ÈÔÏÔÁÈ΋ ·ÛÊ¿ÏÂÈ·. ∫¿ı ¯ÒÚ· Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ¤Ó· Û¯¤‰ÈÔ ·ÓÙÈÌÂÙÒÈÛ˘ ÌÈ·˜ ÂӉ¯fiÌÂÓ˘ ·Ó‰ËÌ›·˜, fiˆ˜ Â›Û˘ Î·È ·fiıÂÌ· ÈηÓÒÓ ÔÛÔÙ‹ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ Ó· ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ ÏËı˘ÛÌÔ‡. √ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜, fï˜, ÁÈ· Ó· ÂÚÈÔÚÈÛÙ› Ë ·Ó‰ËÌ›·, ·Ú·Ì¤ÓÂÈ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜. ™‹ÌÂÚ·, Á›ÓÂÙ·È ÂÓÙ·ÙÈ΋ ÂÚ¢ÓËÙÈ΋ ÚÔÛ¿ıÂÈ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ÛÙÂϤ¯Ô˘˜ ∏5¡1.

µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. Î·È ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: §ÔÁÔı¤ÙË πˆ¿ÓÓ· §˘Î›·˜ 5, ¡. ™Ì‡ÚÓË, ∆.∫. 171 23 e-mail: giannalogotheti@yahoo.gr

§¤ÍÂȘ ÎÏÂȉȿ: °Ú›Ë, ÁÚ›Ë ÙËÓÒÓ, ·Ó‰ËÌ›·.

Avian flu: a new pandemic threat? M. Tsolia, I. Logotheti, A. Konstantopoulos

Abstract: During the course of the 20th century the world experienced three influenza pandemics. Today, at the dawn of the 21st century the emergence of a new pandemic seems inevitable. In recent years, an increasing number of epidemics caused by high pathogenicity avian influenza viruses have occurred, mainly in Asian countries but also in other parts of the world. The current widespread dissemination of H5N1 avian virus in wild and domestic birds in Asia is unprecedented and has caused global concern. What is more troubling is the fact that this virus has been transmitted from birds to humans causing disease and death. Although human-to-human transmission is known to have occurred, the virus cannot be transmitted between humans with great efficiency. However, it may acquire this capacity either by reassortment with a human strain or through adaptive mutations. In this case, the H5N1 strain will cause explosive global spread and a new influenza pandemic will occur. An effort should be made by governments and poultry producers to improve biosecurity and conduct education programmes with a view to restriction of the spread of avian influenza. An operational pandemic plan should be available in every country and an adequate amount of antiviral medication stockpiled. Immunization will be the most effective way to reduce the impact of a pandemic and researchers are currently trying to develop a vaccine against the H5N1 strain.

2nd Paediatric Clinic, University of Athens, “P. & A. Kyriakou” Children’s Hospital Correspondence: Logotheti Ioanna 5 Lykeias Str., N. Smyrni, 171 23, Athens e-mail: giannalogotheti@yahoo.gr

Key words: Influenza, avian influenza, pandemic.

¶·È‰È·ÙÚÈ΋ 2006;69:1-9


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·2

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ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.

∂ÈÛ·ÁˆÁ‹

O Èfi˜ Ù˘ ÁÚ›˘ Ó¢ڷÌÈÓȉ¿ÛË

∫¿ı ¯ÚfiÓÔ, ηٿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜, ÂÌÊ·Ó›˙ÔÓÙ·È ÂȉËÌÈΤ˜ ÂÍ¿ÚÛÂȘ ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘ Ô˘ ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ÛÙÔÓ ÏËı˘ÛÌfi, ȉȷ›ÙÂÚ· ÛÙȘ ¢·ı›˜ ÔÌ¿‰Â˜. √ Èfi˜ Ù˘ ÁÚ›˘ ÌÔÚ›, fï˜, Ó· ÚÔηϤÛÂÈ Î·È ·Ó‰Ë̛˜ ηٿ ÙȘ Ôԛ˜ Ë ÓÔÛËÚfiÙËÙ· Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ı·Ó¿ÙˆÓ ·˘Í¿ÓÔÓÙ·È ‰Ú·Ì·ÙÈο, ·ÎfiÌË Î·È ÌÂٷ͇ Ó¤ˆÓ Î·È ˘ÁÈÒÓ ·ÙfïÓ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 20Ô‡ ·ÈÒÓ· Ë ·ÓıÚˆfiÙËÙ· ‰ÔÎÈÌ¿ÛÙËΠ·fi ÙÚÂȘ ·Ó‰Ë̛˜ ÁÚ›˘, ÔÈ Ôԛ˜ ÚÔοÏÂÛ·Ó ÂÚÈÛÛfiÙÂÚÔ˘˜ ı·Ó¿ÙÔ˘˜ ·fi ÔÔÈ·‰‹ÔÙ ¿ÏÏË Ê˘ÛÈ΋ ‹ ÚÔηÏÔ‡ÌÂÓË ·fi ÙÔÓ ¿ÓıÚˆÔ Î·Ù·ÛÙÚÔÊ‹, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ÙˆÓ ‰‡Ô ·ÁÎoÛÌ›ˆÓ ÔÏ¤ÌˆÓ (1-3). ™ÙËÓ ·˘Á‹ ÙÔ˘ 21Ô˘ ·ÈÒÓ·, Ë Ì¿¯Ë Ì ÙÔÓ Èfi ·˘Ùfi Û˘Ó¯›˙ÂÙ·È Ì ÛÎÔfi ÙËÓ ·ÔÙÚÔ‹ ÌÈ·˜ Ó¤·˜ ·Ó‰ËÌ›·˜. π‰È·›ÙÂÚË ·ÓËÛ˘¯›· ¤¯ÂÈ ‰ËÌÈÔ˘ÚÁËı› Á‡Úˆ ·fi ÙËÓ Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ·Ó‰ËÌ›·˜ ·fi ÙÔ Û٤ϯԘ H5N1, Ô˘ Û‹ÌÂÚ· ÂÓ‰ËÌ› ÛÙ· ÙËÓ¿ Û ÔÏϤ˜ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜ (3-6). ∏ ‰ÈÂıÓ‹˜ ÂÈÛÙËÌÔÓÈ΋ ÎÔÈÓfiÙËÙ· ÂÎÊÚ¿˙ÂÈ ÙË ‚‚·ÈfiÙËÙ· fiÙÈ ÌÈ· Ó¤· ·Ó‰ËÌ›· ÁÚ›˘ ı· ÂΉËψı› ÛÙÔ ÚÔÛ¯¤˜ ̤ÏÏÔÓ, ‰ÂÓ Â›Ó·È fï˜ ‰˘Ó·Ùfi Ó· ÚÔ‚ÏÂÊı› Ô ·ÎÚÈ‚‹˜ ¯ÚfiÓÔ˜ ¤Ó·ÚÍ‹˜ Ù˘. ∞fi ÙfiÙ Ô˘ ÂÌÊ·Ó›ÛÙËΠÙÔ Û٤ϯԘ ·˘Ùfi Î·È Ì¤¯ÚÈ Û‹ÌÂÚ·, ¤¯Ô˘Ó ÂΉËψı› ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ÓfiÛÔ˘ ·fi ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜ Ì ÛËÌ·ÓÙÈ΋ ıÓËÙfiÙËÙ·. ∆Ô Û٤ϯԘ ∏5¡1 ‰ÂÓ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› ‡ÎÔÏ· ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ Î·È ÁÈ· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ‰ÂÓ ¤¯ÂÈ ÚÔ·„ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÈ· Ó¤· ·Ó‰ËÌ›·. √È Ì˯·ÓÈÛÌÔ› Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÌÈ·˜ ·Ó‰ËÌ›·˜, Ù· ÛËÌÂÚÈÓ¿ ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ÔÈ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌÔÛıÔ‡Ó ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ·Ú·Î¿Ùˆ.

√ Èfi˜ Ù˘ ÁÚ›˘ Î·È ÔÈ ·ÓÙÈÁÔÓÈΤ˜ ÙÔ˘ ÌÂÙ·‚ÔϤ˜ √ Èfi˜ Ù˘ ÁÚ›˘ ·Ó‹ÎÂÈ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ÔÚıÔÌ˘ÍÔ˚ÒÓ Î·È ·ÔÙÂÏÂ›Ù·È ·fi 8 ÙÌ‹Ì·Ù· ÌÔÓ‹˜ ¤ÏÈη˜ RNA, Ô˘ ÂÚȤ¯Ô˘Ó ÙȘ ÁÂÓÂÙÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· 10 ÚˆÙ½Ó˜. √ Èfi˜ ÂÚÈ‚¿ÏÏÂÙ·È ·fi ‰ÈÛÙڈ̷ÙÈÎfi ÏÈȉȷÎfi ÂÚ›‚ÏËÌ· ·fi ÙÔ ÔÔ›Ô ÚÔÛÂ΂¿ÏÏÔ˘Ó ˆ˜ ·Î›‰Â˜ ÔÈ ÁÏ˘ÎÔÚˆÙ½Ó˜ ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›ÓË (∏) Î·È Ó¢ڷÌÈÓȉ¿ÛË (¡) (∂ÈÎfiÓ· 1) (1-3) . ∏ ·È¶·È‰È·ÙÚÈ΋ 2006;69:1-9

ıÂ̤ÏÈÔ˜ Ô˘Û›· ÚˆÙ½ÓË ÙÔ˘ ˘Ú‹Ó· Î·È ÔÏ˘ÌÂÚ¿Û˜

·ÈÌÔÛ˘ÁÎÔÏÏËÙ›ÓË RNA

ÚˆÙ½ÓË ª2

∂ÈÎfiÓ· 1. √ Èfi˜ Ù˘ ÁÚ›˘. TÚÔÔÔÈË̤ÓË ·fi (2).

ÌÔÛ˘ÁÎÔÏÏËÙ›ÓË Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙËÓ ÚÔÛÎfiÏÏËÛË Û ÌfiÚÈ· ÛÈ·ÏÈÎÔ‡ ÔͤԘ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÁÏ˘ÎÔÚˆÙ½Ó˜ Î·È ÁÏ˘ÎÔÏÈ›‰È· ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∏ Ó¢ڷÌÈÓȉ¿ÛË ‰È¢ÎÔχÓÂÈ ÙË ‰Ú¿ÛË Ù˘ ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›Ó˘ Î·È ÂÈÚfiÛıÂÙ·, ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ÈÔ‡ ·fi ÙÔ Î‡ÙÙ·ÚÔ. √È ÈÔ› Ù˘ ÁÚ›˘ ‰È·ÎÚ›ÓÔÓÙ·È Û هÔ˘˜ ∞, µ, C. ∆· ÛÙÂϤ¯Ë C ‰ÂÓ ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ·. ∆· ÛÙÂϤ¯Ë Ù‡Ô˘ ∞ Â›Ó·È ·˘Ù¿ Ô˘ ÚÔηÏÔ‡Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· Î·È Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û ˘ÔÙ‡Ô˘˜, ·Ó¿ÏÔÁ· Ì ÙȘ ÂÈÊ·ÓÂȷΤ˜ ÁÏ˘ÎÔÚˆÙ½Ó˜ H Î·È N. À¿Ú¯Ô˘Ó 16 Ù‡ÔÈ ∏ Î·È 9 ¡. √È ˘fiÙ˘ÔÈ ∞ ÚÔÛ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ·fi ÙÔÓ ¿ÓıÚˆÔ, Ù· ÙËÓ¿ Î·È ‰È¿ÊÔÚ· ˙Ò·, fiˆ˜ ¯Ô›ÚÔ˘˜, ¿ÏÔÁ·, ÊÒÎȘ Î·È Ê¿Ï·ÈÓ˜. ∆· ÙËÓ¿ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÛÙÂϤ¯Ë fiÏˆÓ ÙˆÓ ˘ÔÙ‡ˆÓ ∏ Î·È ¡, ÂÓÒ Ù· ıËÏ·ÛÙÈο, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È ÔÈ ¿ÓıÚˆÔÈ, ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ˘ÔÙ‡ˆÓ. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ù· ÙËÓ¿ ıˆÚÔ‡ÓÙ·È fiÙÈ Â›Ó·È Ô Ê˘ÛÈÎfi˜ ÍÂÓÈÛÙ‹˜ Ù˘ ÁÚ›˘ ∞. √È 144 (16 x 9) ‰˘Ó·ÙÔ› Û˘Ó‰˘·ÛÌÔ› ÙˆÓ Ù‡ˆÓ ∏ Î·È ¡ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ó· ΢ÎÏÔÊÔÚ› ÛÙ· ¿ÁÚÈ· ÙËÓ¿ ¤Ó·˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ˘ÔÙ‡ˆÓ ÙˆÓ ÈÒÓ ·˘ÙÒÓ. ∆· ¿ÁÚÈ· ÌÂÙ·Ó·ÛÙ¢ÙÈο ÙËÓ¿ ÈÛÙ‡ÂÙ·È fiÙÈ ·ÔÙÂÏÔ‡Ó ÙË ‰ÂÍ·ÌÂÓ‹ ÁÈ· ÙË ÌÂÙ¿‰ÔÛË Ù˘ Ïԛ̈͢ Û ηÙÔÈΛ‰È· ÙËÓ¿, ¯Ô›ÚÔ˘˜ ‹ ·ÓıÚÒÔ˘˜ (2,3). ∞ÓÙ›ıÂÙ· Ì ٷ ÛÙÂϤ¯Ë Ù‡Ô˘ ∞, Ù· ÛÙÂϤ¯Ë


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·3

3

°Ú›Ë ÙˆÓ ÙËÓÒÓ

ÙÔ˘ Ù‡Ô˘ µ ¤¯Ô˘Ó ÛÙ·ıÂÚ¤˜ ∏ Î·È ¡, ‰ÂÓ ‰È·ÈÚÔ‡ÓÙ·È Û ˘ÔÙ‡Ô˘˜ Î·È ÚÔÛ‚¿ÏÏÔ˘Ó ÌfiÓÔ ÙÔÓ ¿ÓıÚˆÔ. ∂Ó‰¤¯ÂÙ·È fï˜, Ó· ˘¿Ú¯Ô˘Ó ·ÓÙÈÁÔÓÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ÙÔ ¤Ó· Û٤ϯԘ ÛÙÔ ¿ÏÏÔ, fiˆ˜ Î·È ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ÛÙÂϯÒÓ ÁÚ›˘ ∞ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙÔÓ ›‰ÈÔ ˘fiÙ˘Ô. √È ÈÔ› Ù˘ ÁÚ›˘ ˘Ê›ÛÙ·ÓÙ·È ·ÓÙÈÁÔÓÈΤ˜ ÌÂÙ·‚ÔϤ˜ Î·È ‰ÂÓ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ˆ˜ ÔÈΛÔÈ ·fi ÙÔ ·ÓÔÛÈ·Îfi Û‡ÛÙËÌ·, Ì ·ÔÙ¤ÏÂÛÌ· Ô ¿ÓıÚˆÔ˜ Ó· ·Ú·Ì¤ÓÂÈ Â˘¿ÏˆÙÔ˜ ÛÙË Ïԛ̈ÍË ÁÈ· fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘. √È ·ÓÙÈÁÔÓÈΤ˜ ·˘Ù¤˜ ÌÂÙ·‚ÔϤ˜ Á›ÓÔÓÙ·È Ì ‰‡Ô ÙÚfiÔ˘˜. √ ÚÒÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰È·‰Ô¯ÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ Ô˘ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂͤÏÈÍË ÙÔ˘ ÈÔ‡ Î·È ·ÔÙÂÏÔ‡Ó ÙËÓ ÂÏ¿ÛÛÔÓ· ·ÓÙÈÁÔÓÈ΋ ÌÂÙ·‚ÔÏ‹ (antigenic drift) (1-3). √ ‰Â‡ÙÂÚÔ˜ ÙÚfiÔ˜ ·Ú·ÙËÚÂ›Ù·È Ôχ ÈÔ Û¿ÓÈ· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÌÈ·˜ Ì›˙ÔÓÔ˜ ·ÓÙÈÁÔÓÈ΋˜ ÌÂÙ·‚ÔÏ‹˜ (antigenic shift) Ù˘ ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›Ó˘ (∏) ‹/Î·È Ù˘ Ó¢ڷÌÈÓȉ¿Û˘ (¡), ÒÛÙ ӷ ÂÌÊ·Ó›˙ÂÙ·È ¤Ó· Ó¤Ô ÌfiÚÈÔ ∏ ‹ Î·È ¡ Î·È Ó· ÚÔ·ÙÂÈ Ó¤Ô˜ ˘fiÙ˘Ô˜. ™ÙËÓ ÙÂÏÂ˘Ù·›· ·˘Ù‹ ÂÚ›ÙˆÛË, Ô ÏËı˘ÛÌfi˜ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Â›Ó·È Â˘¿ÏˆÙÔ˜ ·ÊÔ‡ ‰ÂÓ ‰È·ı¤ÙÂÈ ·ÓÙÈÛÒÌ·Ù· ηٿ ÙˆÓ Ó¤ˆÓ ·˘ÙÒÓ ∏ Î·È ¡ Î·È ÌÔÚ› Ó· ÚÔ·„ÂÈ ·Ó‰ËÌ›· (1-3). ªÈ· Ì›˙ˆÓ ·ÓÙÈÁÔÓÈ΋ ÌÂÙ·‚ÔÏ‹ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· Á›ÓÂÈ ‰È· ̤ÛÔ˘ ·ÏÒÓ ÁÂÓÂÙÈÎÒÓ ÌÂÙ·ÏϿ͈Ó. ªÈ· ÙfiÛÔ ‰Ú·ÛÙÈ΋ ÌÂÙ·ÌfiÚʈÛË ÙÔ˘ ÈÔ‡ ÂÓ‰¤¯ÂÙ·È Ó· Ú·ÁÌ·ÙÔÔÈËı› Ì ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÌÂٷ͇ ‰‡Ô ‰È·ÊÔÚÂÙÈÎÒÓ ÛÙÂϯÒÓ ÁÚ›˘, fiÙ·Ó ÌÔχÓÔ˘Ó Ù·˘Ùfi¯ÚÔÓ· Ù· ·ÙÙ·Ú· ÂÓfi˜ ÍÂÓÈÛÙ‹. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ·Ú¿ÁÂÙ·È Û٤ϯԘ Ô˘ ÂÚȤ¯ÂÈ ÌÈÎÙfi ÁÂÓÂÙÈÎfi ˘ÏÈÎfi (reassortant) (3). ŒÓ· ‹ ÂÚÈÛÛfiÙÂÚ· ·fi Ù· 8 ÙÌ‹Ì·Ù· ÙÔ˘ ÛÙÂϤ¯Ô˘˜ ·˘ÙÔ‡ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ ¤Ó· ·Ú¯ÈÎfi Û٤ϯԘ Î·È Ù· ˘fiÏÔÈ· ·fi ÙÔ ¿ÏÏÔ. ∏ ηٷÓÔÌ‹ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘ Û 8 ÙÌ‹Ì·Ù·, ÙÔ Î·ı¤Ó· ·fi Ù· ÔÔ›· ÂÚȤ¯ÂÈ ÙȘ ÏËÚÔÊÔڛ˜ ÁÈ· ÌÈ· ‹ ‰‡Ô ÚˆÙ½Ó˜, ¢ÓÔ› ÙËÓ ·Ó¿ÌÈÍË Î·È ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ÙÌËÌ¿ÙˆÓ ·˘ÙÒÓ (reassortment), ÌÂٷ͇ ‰‡Ô ‰È·ÊÔÚÂÙÈÎÒÓ ÛÙÂϯÒÓ fiÙ·Ó ÌÔχÓÔ˘Ó Ù·˘Ùfi¯ÚÔÓ· ÙÔ ›‰ÈÔ Î‡ÙÙ·ÚÔ. ∂¿Ó ÙÔ ÛÙ¤Ï��¯Ô˜ Ô˘ ÚÔ·ÙÂÈ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÂÈ ÙÔÓ ¿ÓıÚˆÔ Î·È Ó· ÌÂÙ·‰›‰ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ÙÔÓ ¤Ó·Ó ÛÙÔÓ ¿ÏÏÔ, ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÔÈ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· Ó· ÂΉËψı› ÌÈ· Ó¤· ·Ó‰ËÌ›·. ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠfiÙÈ ·Ó‰ËÌ›· ÁÚ›˘ ÌÔÚ› Ó· ÚÔ·„ÂÈ Î·È Ì ¤Ó·Ó ‰Â‡ÙÂÚÔ Ì˯·ÓÈÛÌfi, fiÙ·Ó ¤Ó· Û٤ϯԘ Ô˘ Û˘Ó‹ıˆ˜ ÚÔÛ‚¿Ï-

ÏÂÈ Ù· ÙËÓ¿, ·ÔÎÙ‹ÛÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· ÚÔÛ‚¿ÏÂÈ Î·È ÙÔÓ ¿ÓıÚˆÔ. ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ÔÈÎfiÛÈÙ· ÙËÓ¿ (fiÚÓÈı˜ Î·È Á·ÏÔԇϘ) ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÈÔ‡˜ ÁÚ›˘ Ô˘ ¤¯Ô˘Ó ÙÔ ‰˘Ó·ÌÈÎfi Ó· ÚÔÛ‚¿ÏÔ˘Ó Î·È ÙÔÓ ¿ÓıÚˆÔ (6). ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÌÂÚÈο ÔÈÎfiÛÈÙ· ÙËÓ¿ ‰ÚÔ˘Ó ˆ˜ ·Ê·Ó›˜ ÔÏÏ·Ï·ÛÈ·ÛÙ¤˜ ÛÙÂϯÒÓ ÁÚ›˘ Ì ‰˘Ó·ÌÈÎfi Ó· ÚÔηϤÛÔ˘Ó ·Ó‰ËÌ›·, ¯ˆÚ›˜ Ó· ÂΉËÏÒÓÔ˘Ó Û˘ÌÙÒÌ·Ù·. ¶·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏÔ‡Ó ÔÈ ¿Ș, ÔÈ Ôԛ˜ ʤÚÔ˘Ó ÈÔ‡˜ ÁÚ›˘ Ì ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›ÓË ∏5 ¯ˆÚ›˜ ÔÈ ›‰È˜ Ó· ÓÔÛÔ‡Ó. ∞ÚÎÂÙ¿ ÚfiÛÊ·Ù· ·Ú·‰Â›ÁÌ·Ù· ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ô ¿ÓıÚˆÔ˜ ÌÔÚ› Ó· ÚÔÛ‚ÏËı› ·fi ÛÙÂϤ¯Ë ÈÒÓ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ Î·È ÂÔ̤ӈ˜, Ô ÚfiÏÔ˜ ÙÔ˘ ·ÓıÚÒÔ˘ ˆ˜ ÍÂÓÈÛÙ‹ Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ˘ÔÛÙËÚ›ÍÂÈ ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ÛÙÂϯÒÓ ÁÚ›˘, ‰ÂÓ Ú¤ÂÈ Ó· ˘ÔÙÈÌ¿Ù·È (¶›Ó·Î·˜ 1). ∆Ô Û˘Ì¤Ú·ÛÌ· ·fi fiÛ· ÂϤ¯ıËÛ·Ó ·Ú·¿Óˆ Â›Ó·È fiÙÈ Ë ‰ËÌÈÔ˘ÚÁ›· ÛÙÂϯÒÓ ÁÚ›˘ ÈηÓÒÓ Ó· ÚÔηϤÛÔ˘Ó ·Ó‰ËÌ›· Â›Ó·È ÌÈ· ‰È·‰Èηۛ· Ô˘ ··ÈÙ› ·ÚÎÂÙfi ¯ÚfiÓÔ Î·È ÂÚÓ¿ ·fi ÔÏÏ¿ ‰È·‰Ô¯Èο ÛÙ¿‰È·. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ¤¯ÂÈ ÚÔËÁËı› ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ˘ÔÙ‡ˆÓ ‹ ÛÙÂϯÒÓ ÙÔ˘ ÈÔ‡ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó Û ‰È¿ÊÔÚ· ˙ˆÈο ›‰Ë Ù·˘Ùfi¯ÚÔÓ·.

√È ÚÔËÁÔ‡ÌÂÓ˜ ·Ó‰Ë̛˜ ÁÚ›˘ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ 20Ô‡ ·ÈÒÓ· ÂΉËÏÒıËÎ·Ó ÙÚÂȘ ·Ó‰Ë̛˜ ÁÚ›˘. ™ÙȘ ·Ó‰Ë̛˜ ·˘Ù¤˜ ¤¯Ô˘Ó ‰Ôı› ‰È·ÊÔÚÂÙÈο ÔÓfiÌ·Ù·, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÙfiÔ ÛÙÔÓ ÔÔ›Ô Î¿ı ÊÔÚ¿ Ê·ÈÓfiÙ·Ó Ó· ·Ú¯›˙ÂÈ Ë ·Ó‰ËÌ›·. ™‹ÌÂÚ· ıˆÚÂ›Ù·È ¶›Ó·Î·˜ 1. ¶·Ú·‰Â›ÁÌ·Ù· ÚfiÛÊ·ÙˆÓ ÂȉËÌÈÒÓ ÁÚ›˘ ÛÙ· ÙËÓ¿ Ì ÌÂÙ¿‰ÔÛË ÛÙÔÓ ¿ÓıÚˆÔ ŒÙÔ˜, ÃÒÚ·

πfi˜

1995, ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ

∏7¡7

1997, ÃÔÓÁÎ ∫ÔÓÁÎ

∏5¡1

1999, ÃÔÓÁÎ ∫ÔÓÁÎ

∏9¡2

2003, ÃÔÓÁÎ ∫ÔÓÁÎ

∏5¡1

2003, √ÏÏ·Ó‰›·

∏7¡7

2003, ÃÔÓÁÎ ∫ÔÓÁÎ

H9N2

2004, µÈÂÙÓ¿Ì

∏5¡1

2004, ∆·˚Ï¿Ó‰Ë

∏5¡1

2004, ∫·Ó·‰¿˜

∏7¡3

2004, ∞›Á˘ÙÔ˜

∏10¡7 ¶·È‰È·ÙÚÈ΋ 2006;69:1-9


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·4

4

ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.

ÂÚÈÛÛfiÙÂÚÔ Èı·Ófi fiÙÈ fiϘ ÚÔ‹Ïı·Ó ·fi ÙËÓ ∫›Ó·, fiÔ˘ ¿ÓıÚˆÔÈ, ÙËÓ¿ Î·È ¯Ô›ÚÔÈ Û˘Á¯ÚˆÙ›˙ÔÓÙ·È (2,4). ∏ ÚÒÙË ‹Ù·Ó Ë ·Ó‰ËÌ›· Ù˘ πÛ·ÓÈ΋˜ ÁÚ›˘ (1918) Î·È ÔÊÂÈÏfiÙ·Ó ÛÙÔÓ ˘fiÙ˘Ô ∏1¡1. ∏ ·Ó‰ËÌ›· ·˘Ù‹ ‹Ù·Ó Ë ÛÔ‚·ÚfiÙÂÚË Î·È ÈÔ Î·Ù·ÛÙÚÔÊÈ΋ ÂȉËÌ›· ÏÔÈÌÒ‰Ô˘˜ ÓfiÛÔ˘ Ô˘ ÂΉËÏÒıËΠÛÙË ÓÂfiÙÂÚË ·ÓıÚÒÈÓË ÈÛÙÔÚ›· Î·È ÛÙÔ›¯ÈÛ ÙË ˙ˆ‹ Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 20 ÂηÙÔÌ̇ÚÈ· ·ÓıÚÒÔ˘˜ (5). √È ‰‡Ô ÂfiÌÂÓ˜ ·Ó‰Ë̛˜ ‹Ù·Ó ·˘Ù¤˜ Ù˘ ∞ÛÈ·ÙÈ΋˜ ÁÚ›˘ ÙÔ 1957, ·fi ÙÔ Û٤ϯԘ ∏2¡2, Î·È Ù˘ ÁÚ›˘ ÙÔ˘ ÃÔÓÁÎ ∫ÔÓÁÎ ÙÔ 1968, Ô˘ ÚÔÎÏ‹ıËΠ·fi ÙÔ Û٤ϯԘ ∏3¡2. √È ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ·Ó‰Ë̛˜ ‹Ù·Ó ËÈfiÙÂÚ˜ ·fi ·˘Ù‹Ó ÙÔ˘ 1918 Î·È ÚÔοÏÂÛ·Ó ÂÚ› ÙÔ ¤Ó· ÂηÙÔÌ̇ÚÈÔ ı·Ó¿ÙÔ˘˜ Ë Î·ıÂÌ›·. ™‹ÌÂÚ·, ÈÛÙ‡ÂÙ·È fiÙÈ Î·È ÛÙȘ ‰‡Ô ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ Ù· ÛÙÂϤ¯Ë Ô˘ ÙȘ ÚÔοÏÂÛ·Ó ÚÔ‹Ïı·Ó ·fi ·Ó¿ÌÈÍË Î·È ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ (reassortment) ÌÂٷ͇ ·ÓıÚÒÈÓˆÓ ÛÙÂϯÒÓ Î·È ÛÙÂϯÒÓ ÙˆÓ ÙËÓÒÓ (7). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ΢ÎÏÔÊÔÚ› ΢ڛˆ˜ Ô ˘fiÙ˘Ô˜ ∏3¡2, Ô˘ Û˘Ó¤¯È˙ ӷ ˘Ê›ÛÙ·Ù·È ÂÏ¿ÛÛÔÓ˜ ·ÓÙÈÁÔÓÈΤ˜ ÌÂÙ·‚ÔϤ˜, Î·È ÏÈÁfiÙÂÚÔ Ô ∏1¡1 ηıÒ˜ Î·È ÙÔ Û٤ϯԘ µ. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, Ù· ÂÌ‚fiÏÈ· ÁÚ›˘ οı ¯ÚfiÓÔ, ÂÚȤ¯Ô˘Ó ÙÚ›· ÛÙÂϤ¯Ë ÈÒÓ ÁÚ›˘ ∏3¡2, ∏1¡1 Î·È µ. ™Â ·ÓÙ›ıÂÛË Ì ÙȘ ·Ó‰Ë̛˜ ÙÔ˘ 1957 Î·È ÙÔ˘ 1968, ·˘Ù‹ ÙÔ˘ 1918 ‰ÂÓ ÚÔ‹Ïı ·fi ·Ó¿ÌÈÍË Î·È ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ (reassortment) ÌÂٷ͇ ‰‡Ô ÛÙÂϯÒÓ (7). ∏ ÚfiÛÊ·ÙË ·Ó¿Ï˘ÛË ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÙÔ˘ ÛÙÂϤ¯Ô˘˜ ∏1¡1 Ù˘ ÁÚ›˘ ÙÔ˘ 1918 ·fi ÙÔ˘˜ Taubeneberger Î·È Û˘Ó, ¤‰ÂÈÍ fiÙÈ Î·È Ù· 8 ÁÔÓ›‰È· ÙÔ˘ ÈÔ‡ ÌÔÈ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ Ì ÛÙÂϤ¯Ë ÁÚ›˘ ÙËÓÒÓ ·Ú¿ Ì ÛÙÂϤ¯Ë Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¿ÏÏ· ˙ˆÈο ›‰Ë ‹ ÙÔÓ ¿ÓıÚˆÔ (8). ∆Ô Â‡ÚËÌ· ·˘Ùfi ‰Â›¯ÓÂÈ fiÙÈ Î¿ÔÈÔ Û٤ϯԘ ÙˆÓ ÙËÓÒÓ ÌfiÚÂÛ ӷ ÚÔÛ‚¿ÏÂÈ ÙÔ˘˜ ·ÓıÚÒÔ˘˜ Î·È Ó· ÚÔÛ·ÚÌÔÛÙ› Û ·˘ÙÔ‡˜, ÒÛÙ ӷ ÌÔÚ› Ó· ÌÂÙ·‰›‰ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ. ™ËÌ·ÓÙÈÎfiÙ·ÙÔ Â›Ù¢ÁÌ· Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ·ÔÙ¤ÏÂÛÂ Ë ÚfiÛÊ·ÙË ·Ó·Û‡ÛÙ·ÛË ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘ ÙÔ˘ 1918 ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Î·È ÙÒÚ· ÙÔ Û٤ϯԘ ‚Ú›ÛÎÂÙ·È ÛÙË ‰È¿ıÂÛË ÙˆÓ ÂÚ¢ÓËÙÒÓ ÁÈ· ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘ÛË (9). ∏ ̤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙË Û ΢ÙÙ·ÚÔηÏÏȤÚÁÂȘ ηıÒ˜ Î·È Û ˙Ò· ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ, ¤‰ÂÈÍ fiÙÈ ÙÔ Û٤ϯԘ ·˘Ùfi ¤¯ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ÌÔÓ·‰ÈΤ˜ ȉÈfiÙËÙ˜. ∏ ı·Ó·ÙËÊfiÚÔ˜ ‰Ú¿ÛË ÙÔ˘ ÛÙ· ÔÓÙ›ÎÈ· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 100 ÊÔÚ¤˜ ˘„ËÏfiÙÂÚË Û ۇÁÎÚÈÛË Ì ¿ÏÏÔ˘˜ ÈÔ‡˜ ÁÚ›¶·È‰È·ÙÚÈ΋ 2006;69:1-9

˘. ∫·Ù¿ ‰Â‡ÙÂÚÔ ÏfiÁÔ, Ô Èfi˜ ·˘Ùfi˜ ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· ÂÓÂÚÁÔÔÈ› ÌfiÓÔ˜ ÙÔ˘ ÙËÓ ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›ÓË ÙÔ˘ ̤ۈ Ù˘ ‰Ú¿Û˘ Ù˘ Ó¢ڷÌÈÓȉ¿Û˘ (9). ∏ Û˘Ó¯È˙fiÌÂÓË ÌÂϤÙË ı· ·˘Í‹ÛÂÈ ÙȘ ÁÓÒÛÂȘ Ô˘ Û‹ÌÂÚ· ¤¯Ô˘Ì ۯÂÙÈο Ì ÙÔÓ ÙÚfiÔ Ô˘ ‰Ú· ÙÔ Û٤ϯԘ ·˘Ùfi Î·È ÚÔηÏ› ÛÔ‚·Ú‹ ÓfiÛÔ, Î·È ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ¡¤ÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ·˘ÙÔ› Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙË ‰Ú¿ÛË ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÌÔÚÔ‡Ó ÙÒÚ· Ó· ÌÂÏÂÙËıÔ‡Ó ˆ˜ ıÂÚ·›˜ Ô˘ ÂÓ‰¤¯ÂÙ·È Ó· ÌÂÈÒÛÔ˘Ó ÙË ıÓËÙfiÙËÙ· Ù˘ ÁÚ›˘ Û ÂÚ›ÙˆÛË ·Ó‰ËÌ›·˜. ∏ ÚfiÛÊ·ÙË ÌÂϤÙË ÙˆÓ ÛÙÂϯÒÓ ÁÚ›˘ Ô˘ ÚÔοÏÂÛ·Ó ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ ·Ó‰Ë̛˜, ηٿÊÂÚ ӷ ÚÔÛ‰ÈÔÚ›ÛÂÈ ÛËÌ·ÓÙÈΤ˜ ÁÂÓÂÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ Â›Ó·È ··Ú·›ÙËÙ˜ ÒÛÙ ٷ ÛÙÂϤ¯Ë ÙˆÓ ÙËÓÒÓ Ó· ÌÔÚÔ‡Ó Ó· ÌÂÙ·‰›‰ÔÓÙ·È Â‡ÎÔÏ· ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜. √È ÁÓÒÛÂȘ ·˘Ù¤˜ Î·È ÂΛӘ Ô˘ ı· ·ÔÎÙËıÔ‡Ó ·fi ÙË Û˘Ó¯È˙fiÌÂÓË ¤Ú¢ӷ, ı· ÌÔÚ¤ÛÔ˘Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂͤÏÈ͢ ÙˆÓ ÈÒÓ ÙˆÓ ÙËÓÒÓ Î·È ÛÙËÓ Úfi‚ÏÂ„Ë ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ·Ó‰ËÌ›·˜ (7).

∏ ·ÂÈÏ‹ ÌÈ·˜ Ó¤·˜ ·Ó‰ËÌ›·˜ ·fi ÙÔ Û٤ϯԘ ∏5¡1 Ù˘ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ Ÿˆ˜ ·Ó·Ê¤ÚıËΠ·Ú·¿Óˆ, Ù· ˘‰Úfi‚È· Î·È ÌÂÙ·Ó·ÛÙ¢ÙÈο ÙËÓ¿ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ Ê˘ÛÈÎÔ‡˜ ÍÂÓÈÛÙ¤˜ ÙˆÓ ÈÒÓ Ù˘ ÁÚ›˘ Ù‡Ô˘ ∞ Î·È Û˘¯Ó¿ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÛÙÂϤ¯Ë Ô˘ Û˘Ó‹ıˆ˜ ¤¯Ô˘Ó ¯·ÌËÏ‹ ÏÔÈÌÔÁfiÓÔ ‰‡Ó·ÌË. √È ÈÔ› ÁÚ›˘ ÔÏÏ·Ï·ÛÈ¿˙ÔÓÙ·È ÛÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· ÙˆÓ ÙËÓÒÓ Î·È ·Ô‚¿ÏÏÔÓÙ·È Ì ٷ ÎfiÚ·Ó· ÛÙÔ ÓÂÚfi ÚÔηÏÒÓÙ·˜ ¤Ó·Ó ·ÎÏÔ ÂÓÙÂÚÔ-ÛÙÔÌ·ÙÈ΋˜ ÌÂÙ¿‰ÔÛ˘ (10). ∞fi Ù· ˘‰Úfi‚È· ÙËÓ¿, ÔÈ ÈÔ› Ù˘ ÁÚ›˘ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÌÂÙ·‰›‰ÔÓÙ·È Û ¿ÏÏ· ›‰Ë ÙËÓÒÓ, fiˆ˜ ÔÈ fiÚÓÈı˜ ‹ ÔÈ Á·ÏÔԇϘ, ·ÏÏ¿ Î·È Û ıËÏ·ÛÙÈο. ∏ ‚·Ú‡ÙËÙ· Ù˘ Ïԛ̈͢ ÛÙ· Ô˘ÏÂÚÈο ÔÈΛÏÏÂÈ ·fi ‹È· ‹ Î·È ·Û˘Ìو̷ÙÈ΋ ¤ˆ˜ ÛÔ‚·Ú‹, ÂÓÒ ÌÂÚÈΤ˜ ÊÔÚ¤˜ Ë Ïԛ̈ÍË Â›Ó·È ı·Ó·ÙËÊfiÚÔ˜. ¶ÚÔÛ‚¿ÏÏÂÙ·È Û˘Ó‹ıˆ˜ ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· ·ÏÏ¿ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ÚÔÛ‚ÏËı› Î·È ÙÔ ·Ó·Ó¢ÛÙÈÎfi, fiˆ˜ Û˘Ì‚·›ÓÂÈ Ì ٷ ıËÏ·ÛÙÈο. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Ù· ÙËÓ¿ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÛÙÂϤ¯Ë ÈÒÓ ÁÚ›˘ Ì ÂÈÊ·ÓÂȷΤ˜ ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›Ó˜ ∏5 ΢ڛˆ˜, ·ÏÏ¿ Î·È ∏7, Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË ÏÔÈÌÔÁfiÓÔ ‰‡Ó·ÌË Î·È ÚÔηÏÔ‡Ó


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·5

5

°Ú›Ë ÙˆÓ ÙËÓÒÓ

¶ÙËÓ¿

ÕÓıÚˆÔ˜ ¡¤Ô˜ Èfi˜ Ô˘ ÌÂÙ·‰›‰ÂÙ·È ÛÙÔÓ ¿ÓıÚˆÔ

∫‡ÙÙ·ÚÔ Ô˘ ¤¯ÂÈ ÌÔÏ˘Óı› Ù·˘Ùfi¯ÚÔÓ· Î·È ·fi ÙÔ˘˜ ‰‡Ô ÈÔ‡˜ ∞ÓıÚÒÈÓÔ Û٤ϯԘ ÁÚ›˘ ∞

¡¤Ô Û٤ϯԘ Ì ÌÈÎÙfi ÁÂÓÂÙÈÎfi ˘ÏÈÎfi

¶ÙËÓ¿ ÌÂ ÁÚ›Ë ∞ (∏5¡1)

∫‡ÙÙ·ÚÔ ¯Ô›ÚÔ˘ Ô˘ ¤¯ÂÈ ÌÔÏ˘Óı› Ù·˘Ùfi¯ÚÔÓ· Î·È ·fi ÙÔ˘˜ ‰‡Ô ÈÔ‡˜

¡¤Ô Û٤ϯԘ Ì ÌÈÎÙfi ÁÂÓÂÙÈÎfi ˘ÏÈÎfi

ÃÔ›ÚÔ˜ ∂ÈÎfiÓ· 2. ¢ËÌÈÔ˘ÚÁ›· ÂÓfi˜ ÛÙÂϤ¯Ô˘˜ ÈÔ‡ ÁÚ›˘ Ì ‰˘Ó·ÌÈÎfi Ó· ÚÔηϤÛÂÈ ·Ó‰ËÌ›·. ∏ ·Ó¿ÌÈÍË Î·È ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ (reassortment) ÌÂٷ͇ ·ÓıÚÒÈÓˆÓ ÛÙÂϯÒÓ ÈÔ‡ ÁÚ›˘ Î·È ÛÙÂϯÒÓ Ô˘ ÚÔÛ‚¿ÏÏÔ˘Ó Ù· ÙËÓ¿ ‰È¢ÎÔχÓÂÙ·È ·fi ÙË ‰È·›ÚÂÛË ÙÔ˘ ÁÂÓÒÌ·ÙÔ˜ ÙÔ˘ ÈÔ‡ Ù˘ ÁÚ›˘ ∞ Û 8 ÙÌ‹Ì·Ù· Î·È ÌÔÚ› Ó· Û˘Ì‚Â› ηٿ ÙË ‰È¿ÚÎÂÈ· Ù·˘Ùfi¯ÚÔÓ˘ Ïԛ̈͢ ÂÓfi˜ ΢ÙÙ¿ÚÔ˘ Î·È Ì ٷ ‰‡Ô ÛÙÂϤ¯Ë. ∏ Ù·˘Ùfi¯ÚÔÓË ·˘Ù‹ Ïԛ̈ÍË ÌÔÚ› Ó· Û˘Ì‚Â› ÛÙÔ˘˜ ¯Ô›ÚÔ˘˜ - ÔÈ ÔÔ›ÔÈ ÌÔÚÔ‡Ó Ó· ÚÔÛ‚ÏËıÔ‡Ó Î·È ·fi ·ÓıÚÒÈÓÔ Èfi Î·È ·fi Èfi ÙˆÓ ÙËÓÒÓ - ‹ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜. ∆ÚÔÔÔÈË̤ÓË ·fi (5).

˘„ËÏ‹˜ ·ıÔÁÔÓÈÎfiÙËÙ·˜ ÁÚ›Ë ÙˆÓ ÙËÓÒÓ (high patho-genicity avian influenza, HPAI). ¶ÚÈÓ ·fi ÙÔ 1997, ÂÈÎÚ·ÙÔ‡ÛÂ Ë ¿Ô„Ë fiÙÈ ÔÈ ˘„ËÏ‹˜ ·ıÔÁÔÓÈÎfiÙËÙ·˜ ÈÔ› ÁÚ›˘ ÙˆÓ ÙËÓÒÓ (HPAI) ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÚÔÛ‚¿ÏÔ˘Ó ÙÔ˘˜ ·ÓıÚÒÔ˘˜ ‰ÈfiÙÈ ˘¿Ú¯Ô˘Ó ÂÚÈÔÚÈÛÌÔ› Û ÌÔÚÈ·Îfi Â›Â‰Ô Ô˘ ‰ÂÓ ÂÈÙÚ¤Ô˘Ó ÙËÓ ÌÂÙ¿‰ÔÛË ·fi Ù· ÙËÓ¿ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜. ∫È ·˘Ùfi ÁÈ·Ù› ÔÈ ¿ÓıÚˆÔÈ ¤¯Ô˘Ó ˘ԉԯ›˜ ÁÈ· ·ÓıÚÒÈÓÔ˘˜ ÈÔ‡˜ Î·È Ù· ÙËÓ¿ ‰È·ı¤ÙÔ˘Ó ˘ԉԯ›˜ ÁÈ· ÙÔ˘˜ ÈÔ‡˜ ÙˆÓ ÙËÓÒÓ. ∏ ÂΉ‹ÏˆÛË ÂȉËÌÈÒÓ ÁÚ›˘ ˘„ËÏ‹˜ ·ıÔÁÔÓÈÎfiÙËÙ·˜ ÛÙ· ÙËÓ¿ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1878 ˆ˜ “·ÓÒÏË ÙˆÓ ÙËÓÒÓ”, ·ÏÏ¿ ‰ÂÓ Â›¯Â ˘¿ÚÍÂÈ ÔÙ¤ ¤Ó‰ÂÈÍË fiÙÈ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜, ·Ó Î·È ˘‹ÚÍ·Ó ·ÚÎÂÙ¤˜ ¢ηÈڛ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔÏÏ·ÏÒÓ ÂȉËÌÈÎÒÓ ÂÍ¿ÚÛÂˆÓ ÛÙ· ÙËÓ¿ Ô˘ ¤¯Ô˘Ó ηٷÁÚ·Ê› ÛÙËÓ ÈÛÙÔÚ›· (6). √ÚÔÏÔÁÈΤ˜ fï˜ ÌÂϤÙ˜ ÛÙËÓ ∂˘ÚÒË Î·È ÙȘ ∏.¶.∞. ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ˘‹ÚÍ ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜, Ì ‰È·ÊfiÚÔ˘˜ ˘ÔÙ‡Ô˘˜ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ. ∂Í·›ÚÂÛË ÛÙ· fiÛ· ·Ó·Ê¤ÚıËηÓ

ÈÔ ¿Óˆ ˘‹ÚÍ Â›Û˘ Ë ÌÂÙ¿‰ÔÛË ÛÙÂϯÒÓ Ì ·ÈÌÔÛ˘ÁÎÔÏÏËÙ›ÓË ∏7 Ô˘ ÚÔοÏÂÛ·Ó ÂÈÂÊ˘Î›Ùȉ· Û ·ÓıÚÒÔ˘˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Èı·Ófiٷٷ ÏfiÁˆ Î·È ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ÙÚfiÔ˘ ˙ˆ‹˜, ¤¯ÂÈ ·˘ÍËı› Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÂȉËÌÈÒÓ ÁÚ›˘ ÛÙ· ÙËÓ¿. √È ÂȉË̛˜ ·˘Ù¤˜ ¤¯Ô˘Ó ÙÂÚ¿ÛÙȘ ÔÈÎÔÓÔÌÈΤ˜ Û˘Ó¤ÂȘ Î·È Ï‹ÙÙÔ˘Ó ÛÔ‚·Ú¿ ÙȘ ÔÈÎÔÓƠ̂˜ ÙˆÓ ¯ˆÚÒÓ ÛÙȘ Ôԛ˜ ÂΉËÏÒÓÔÓÙ·È. π‰È·›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ Ë ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓÔ ‰È¿‰ÔÛË ÙÔ˘ ÛÙÂϤ¯Ô˘˜ ∏5¡1 ÛÙ· ¿ÁÚÈ· ÙËÓ¿ Î·È Ù· Ô˘ÏÂÚÈο Û ÔÏϤ˜ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜ (11-13). Èڛ˜ ÚÔËÁÔ‡ÌÂÓÔ Â›Ó·È Â›Û˘ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Èfi˜ ·˘Ùfi˜ ·¤ÎÙËÛ ÙËÓ ÈηÓfiÙËÙ· Ó· ÌÂÙ·‰›‰ÂÙ·È ·fi Ù· Ô˘ÏÂÚÈο ÛÙÔÓ ¿ÓıÚˆÔ. √ Èfi˜ ∏5¡1 Ê·›ÓÂÙ·È fiÙÈ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÓÔÙÈÔ·Ó·ÙÔÏÈ΋ ∫›Ó· fiÔ˘ ‰È·ÈÛÙÒıËÎÂ Ë ·ÚÔ˘Û›· ÙÔ˘ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1996. ∆Ô 1997 ÚÔοÏÂÛ ÌÂÁ¿ÏË ÂȉËÌ›· ÛÙ· Ô˘ÏÂÚÈο ÛÙÔ ÃÔÓÁÎ ∫ÔÓÁÎ Î·È ÁÈ· ÚÒÙË ÊÔÚ¿ ‰È·ÈÛÙÒıËΠÌÂÙ¿‰ÔÛË Û ·ÓıÚÒÔ˘˜. ∫·Ù·ÁÚ¿ÊËÎ·Ó 18 ÂÚÈÙÒÛÂȘ ·fi ÙȘ ¶·È‰È·ÙÚÈ΋ 2006;69:1-9


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·6

6

ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.

Ôԛ˜ ÔÈ 6 ‹Ù·Ó ı·Ó·ÙËÊfiÚ˜. ∏ ¯ÒÚ· ·˘Ù‹ ‹Ù·Ó Û ı¤ÛË Ó· Ï¿‚ÂÈ ¿ÌÂÛ· ̤ÙÚ· ı·Ó·ÙÒÓÔÓÙ·˜ 1,6 ÂηÙÔÌ̇ÚÈ· Ô˘ÏÂÚÈο Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÏÂÁ¯ı› Ï‹Úˆ˜ Ë ÂȉËÌ›·. ∂ÎÙfi˜ ·fi ÙË ı·Ó¿ÙˆÛË ÙˆÓ ÙËÓÒÓ ÂÊ·ÚÌfiÛÙËÎ·Ó Ù·˘Ùfi¯ÚÔÓ· Î·È ·˘ÛÙËÚ¿ ÚÔÏËÙÈο ̤ÙÚ·. ¢˘ÛÙ˘¯Ò˜, ·ÚfiÌÔÈ· ̤ÙÚ· ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ùfi Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Û ¿ÏϘ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜ Ì ·ÔÙ¤ÏÂÛÌ· ÔÈ ÈÔ› ∏5¡1 Ó· ΢ÎÏÔÊÔÚÔ‡Ó ÛÙ· ÙËÓ¿, ȉȷ›ÙÂÚ· ÛÙȘ ¿Ș Î·È ÛÙȘ ¯‹Ó˜, Î·È Ó· ÌÔÚÔ‡Ó Ó· ˘Ê›ÛÙ·ÓÙ·È ÁÂÓÂÙÈ΋ Î·È ·ÓÙÈÁÔÓÈ΋ ÂͤÏÈÍË Î·È Ó· ÂÂÎÙ›ÓÔ˘Ó ÙË ÁˆÁÚ·ÊÈ΋ ÙÔ˘˜ ηٷÓÔÌ‹ Î·È ÙÔ Â‡ÚÔ˜ ÙˆÓ ÍÂÓÈÛÙÒÓ ÙÔ˘˜ ÔÔ›Ô˘˜ ÌÔÚÔ‡Ó Ó· ÚÔÛ‚¿ÏÔ˘Ó. ŒÙÛÈ ÙÔ 2003 Ô Èfi˜ ÂÌÊ·Ó›ÛÙËÎÂ Î·È ¿ÏÈ Û ¿ÁÚÈ·, Â͈ÙÈο Î·È ÔÈÎfiÛÈÙ· ÙËÓ¿ ÛÂ Ê˘ÛÈο ¿Úη ÙÔ˘ ÃÔÓÁÎ ∫ÔÓÁÎ (11,13). ∂ΉËÏÒıËÎ·Ó Ì¿ÏÈÛÙ· Î·È ‰‡Ô ÎÚÔ‡ÛÌ·Ù· Û ·ÓıÚÒÔ˘˜, ·fi Ù· ÔÔ›· ÙÔ ¤Ó· ‹Ù·Ó ı·Ó·ÙËÊfiÚÔ. ∞fi ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2003 ¤¯ÂÈ ÛËÌÂȈı› Ë ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÈÛÙÔÚ›· ÂȉËÌÈ΋ ¤ÎÚËÍË ÁÚ›˘ ÛÙ· ÙËÓ¿, ÛÙȘ ·ÛÈ·ÙÈΤ˜ ΢ڛˆ˜ ¯ÒÚ˜. ∂ȉË̛˜ ¤¯Ô˘Ó ÛËÌÂȈı› ÛÙÔ µÈÂÙÓ¿Ì, ÙËÓ ∆·˚Ï¿Ó‰Ë, ÙËÓ πÓ‰ÔÓËÛ›·, ÙËÓ ∫·ÌfiÙ˙Ë, ÙÔ §¿Ô˜, ÙË ª·Ï·ÈÛ›·, ÙËÓ ∫›Ó·, ÙËÓ ∫ÔÚ¤· Î·È ÙËÓ π·ˆÓ›·, ÙË ƒˆÛ›· (‰˘ÙÈ΋ ™È‚ËÚ›· Î·È ∫·˙·ÎÛÙ¿Ó), ÙËÓ ∆Ô˘ÚΛ·, ÙË ƒÔ˘Ì·Ó›· Î·È ÙËÓ ∫ÚÔ·Ù›· (15). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙÒÓ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ÛÙÂϤ¯Ë ∏5¡1 ¤¯Ô˘Ó ·ÔÎÙ‹ÛÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· ÚÔÛ‚¿ÏÔ˘Ó Î·È Ù· ıËÏ·ÛÙÈο. ™ÙËÓ ∆·˚Ï¿Ó‰Ë ·Ú·ÙËÚ‹ıËΠÈfi˜ ÁÚ›˘ ∏5¡1 Û ¯Ô›ÚÔ˘˜ Û ‰‡Ô ·ÁÚÔÎÙ‹Ì·Ù·, Û ٛÁÚÂȘ Î·È ÏÂÔ·Ú‰¿ÏÂȘ Û ¤Ó· ˙ˆÔÏÔÁÈÎfi ΋Ô, ηıÒ˜ Î·È Û Á¿Ù˜ ÛÙËÓ ›‰È· ¯ÒÚ· (6). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ù· ÌÂÙ·Ó·ÛÙ¢ÙÈο ˘‰Úfi‚È· ÙËÓ¿ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÍ¿ψÛË ÙˆÓ ÈÒÓ ∏5¡1 ·ÊÔ‡ ÌÔÚÔ‡Ó Ó· ‰È¢ÎÔχÓÔ˘Ó ÙË ÌÂÙ¿‰ÔÛ‹ ÙÔ˘˜ ÛÙÔ˘˜ ˘‰Ô‚ÈfiÙÔÔ˘˜ Î·È ¤ÙÛÈ Ó· ÙË ÌÂٷʤÚÔ˘Ó ·fi ÙÔ ¤Ó· ̤ÚÔ˜ Ù˘ Á˘ ÛÙÔ ¿ÏÏÔ (5). ∂¿Ó Ù· ÛÙÂϤ¯Ë ∏5¡1 ÚÔÛ·ÚÌÔÛıÔ‡Ó Ï‹Úˆ˜ ÛÙ· ˘‰Úfi‚È· ÙËÓ¿, ÙfiÙÂ Ë Ë ÁˆÁÚ·ÊÈ΋ ÂÍ¿ψۋ ÙÔ˘˜ ı· ÂÂÎÙ·ı› ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ Î·È Ë ·ÂÈÏ‹ Ù˘ ·Ó‰ËÌ›·˜ ı· ·˘ÍËı›. ¶ÂÚÈÙÒÛÂȘ ÁÚ›˘ ∏5¡1 Û ·ÓıÚÒÔ˘˜ ¤¯Ô˘Ó ÛËÌÂȈı› Û ·ÚÎÂÙ¤˜ ·fi ÙȘ ·Ú·¿Óˆ ¯ÒÚ˜ (14). ∏ ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ ¤ÁÈÓ Û ¿ÙÔÌ· Ô˘ ›¯·Ó Â·Ê‹ Ì ÌÔÏ˘Ṳ̂ӷ Ô˘ÏÂÚÈο ̤ۈ ÂÈÛÓÔ‹˜ ÌÔÏ˘ÛÌ¤ÓˆÓ ÛÙ·ÁÔÓȉ›ˆÓ ·fi Ù· Ô˘ÏÂÚÈο ‹ Ù· ÎfiÚ·Ó¿ ÙÔ˘˜ ‹ ηٿ ÙËÓ ·Ú·Û΢‹ ÙÚÔÊ‹˜. µ¤‚·È·, Ë ÌÂÙ¿‰ÔÛË ·fi Ù· ÙËÓ¿ ÛÙÔÓ ¿ÓıÚˆÔ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿¶·È‰È·ÙÚÈ΋ 2006;69:1-9

ÓÈÔ Ê·ÈÓfiÌÂÓÔ ·Ó ÏËÊı› ˘ã fi„ÈÓ fiÙÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ηٷÁÚ·Ê› 3300 ÂȉË̛˜ ÙÔ˘ ÈÔ‡ ∏5 ÛÙ· ÙËÓ¿ Î·È 150 ÂηÙÔÌ̇ÚÈ· ¤¯Ô˘Ó ÊÔÓ¢ı›, ÂÓÒ ¤¯Ô˘Ó ÛËÌÂȈı› ÌfiÏȘ 142 ÂÚÈÙÒÛÂȘ ÛÙÔÓ ¿ÓıÚˆÔ. ∏ ÓfiÛÔ˜ ¤¯ÂÈ Î·È ˘„ËÏ‹ ıÓËÙfiÙËÙ· ·ÊÔ‡ ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 142 ÂÚÁ·ÛÙËÚȷο ÂȂ‚·ÈˆÌ¤ÓˆÓ ÂÚÈÙÒÛÂˆÓ ÛËÌÂÈÒıËÎ·Ó 74 ı¿Ó·ÙÔÈ ·Ó‚¿˙ÔÓÙ·˜ ÙË ıÓËÙfiÙËÙ· ÛÙÔ 52% (15). √ ı¿Ó·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Â¤Ú¯ÂÙ·È ÏfiÁˆ Ó¢ÌÔÓ›·˜ Î·È ÔÏ˘oÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ªÂÙ¿‰ÔÛË ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ÂÚÁ·ÛÙËÚȷο, ıˆÚÂ›Ù·È fï˜ ۯ‰fiÓ ‚¤‚·ÈË (14,16). ¶·Ú·ÙËÚ‹ıËÎ·Ó Û˘ÁÎÂÓÙÚÒÛÂȘ ÂÚÈÛÙ·ÙÈÎÒÓ Û ÌÂÚÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ ηıÒ˜ Î·È ÌÈ· ÂÚ›ÙˆÛË ÌÂÙ¿‰ÔÛ˘ ·fi ÙÔ ¿ÚÚˆÛÙÔ ·È‰› ÛÙË ÌËÙ¤Ú· ÙÔ˘ (17). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜, ˘‹ÚÍ ÛÙÂÓ‹ Â·Ê‹ ¯ˆÚ›˜ ÚÔÊ˘Ï¿ÍÂȘ Î·È Û η̛· ÂÚ›ÙˆÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÌÂÙ¿‰ÔÛË Ì ÌÈÎÚ¿ ÛÙ·ÁÔÓ›‰È·, ‰ËÏ·‰‹ ·ÂÚÔÁÂÓ‹˜. ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› ÌÂÙ¿‰ÔÛË Û ȷÙÚÔÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ·ÎfiÌË Î·È Û ÂÚÈÙÒÛÂȘ fiÔ˘ Ù· ̤ÙÚ· ÚÔʇϷ͢ ‹Ù·Ó ÂÏÏÈ‹. º·›ÓÂÙ·È ÂÔ̤ӈ˜ fiÙÈ, ÚÔ˜ ÙÔ ·ÚfiÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ, Ô Èfi˜ ∏5¡1 ‰ÂÓ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› ·ÔÙÂÏÂÛÌ·ÙÈο ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ Î·È ÂÔ̤ӈ˜ ‰ÂÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Ó‰ËÌ›·. ªÔÚ› fï˜ Ô Èfi˜ Ó· ·ÔÎÙ‹ÛÂÈ ÙËÓ ÈηÓfiÙËÙ· ·˘Ù‹ ·Ó¿ ¿Û· ÛÙÈÁÌ‹, ̤ۈ ÌÈ·˜ ÚÔԉ¢ÙÈ΋˜ ‰È·‰Èηۛ·˜ ÚÔÛ·ÚÌÔÛÙÈÎÒÓ ÁÂÓÂÙÈÎÒÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ‹ Ì ·ÓÙ·ÏÏ·Á‹ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ¤Ó· Û٤ϯԘ ·ÓıÚÒÈÓÔ˘ ÈÔ‡ ÁÚ›˘ (5). ∏ ‰È·‚›ˆÛË ÙˆÓ ·ÓıÚÒˆÓ ˘fi Û˘Óı‹Î˜ Û˘Á¯ÚˆÙÈÛÌÔ‡ ÎÔÓÙ¿ Û Ô˘ÏÂÚÈο Î·È ¯Ô›ÚÔ˘˜ ÛÙȘ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂΉ‹ÏˆÛ˘ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ ·˘ÙÔ‡. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô Èfi˜ ηٷÛÙ› ÈηÓfi˜ Ó· ÌÂÙ·‰›‰ÂÙ·È Ù·¯¤ˆ˜ ·fi ¿ÓıÚˆÔ Û ¿ÓıÚˆÔ ÌÔÚ› Ó· ‰È·‰Ôı› Û ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Î·È Ó· ÚÔÎÏËı› ·Ó‰ËÌ›·.

¶ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÌÈ·˜ ·Ó‰ËÌ›·˜ ∞ÚÎÂÙ¤˜ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È Ë ¯ÒÚ· Ì·˜, ¤¯Ô˘Ó ‹‰Ë ‰È·ÌÔÚÊÒÛÂÈ Û¯¤‰ÈÔ ·ÓÙÈÌÂÙÒÈÛ˘ ÌÈ·˜ ÂӉ¯fiÌÂÓ˘ ·Ó‰ËÌ›·˜ ÁÚ›˘. ∫¿ÙÈ Ù¤ÙÔÈÔ fï˜, ‰ÂÓ Â›Ó·È ÂÊÈÎÙfi Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ ÎfiÛÌÔ˘ Ô˘ ‹‰Ë ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÛÔ‚·Ú¿ ÎÔÈÓˆÓÈο,


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·7

7

°Ú›Ë ÙˆÓ ÙËÓÒÓ

ÔÈÎÔÓÔÌÈο ‹ ÔÏÈÙÈο ÚÔ‚Ï‹Ì·Ù·. ∏ ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙËÓ ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó‰ËÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ì¤ÙÚ· ÚÔʇϷ͢ ηٿ Ù˘ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘, ÙËÓ ‡·ÚÍË ‰È·ı¤ÛÈÌˆÓ ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÙËÓ ·Ó¿Ù˘ÍË ÂÓfi˜ ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ (10,11,13,16). ™‹ÌÂÚ·, ÚÔÙÂÚ·ÈfiÙËÙ· Ú¤ÂÈ Ó· ‰Ôı› ÛÙË Ï‹„Ë Ì¤ÙÚˆÓ Ô˘ ı· ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÁÚ›˘ ∏5¡1 ÛÙ· ÙËÓ¿. ∆Ô ¤ÚÁÔ fï˜ ·˘Ùfi Â›Ó·È È‰È·›ÙÂÚ· ‰‡ÛÎÔÏÔ, Â¿Ó ÏËÊıÔ‡Ó ˘ã fi„ÈÓ ÔÈ Û˘Óı‹Î˜ Ô˘ ÂÈÎÚ·ÙÔ‡Ó ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜. ∆· ̤ÙÚ· Ô˘ ˘ÈÔıÂÙ‹ıËÎ·Ó ÛÙÔ ÃÔÓÁÎ ∫ÔÓÁÎ ·ÔÙÂÏÔ‡Ó ·Ú¿‰ÂÈÁÌ· ÚÔ˜ Ì›ÌËÛË ·ÏÏ¿ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ ÎfiÛÙÔ˜ Î·È ··ÈÙÔ‡Ó ˘„ËÏfi Â›Â‰Ô ÔÚÁ¿ÓˆÛ˘ Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ (16). ™Â ÔÏϤ˜ ·ÛÈ·ÙÈΤ˜ ¯ÒÚ˜, ÔÈ ÌÂÁ¿Ï˜ ÙËÓÔÙÚÔÊÈΤ˜ ÌÔÓ¿‰Â˜ Û˘Ó˘¿Ú¯Ô˘Ó Ì ÌÈÎÚÔ‡˜ ·Ú·ÁˆÁÔ‡˜, ÔÏϤ˜ ·ÁÚÔÙÈΤ˜ ÔÈÎÔÁ¤ÓÂȘ ÂÎÙÚ¤ÊÔ˘Ó Ô˘ÏÂÚÈο ÛÙËÓ ·˘Ï‹ ÙÔ˘˜, ÂÓÒ Û˘Á¯ÚfiÓˆ˜ ˙ˆÓÙ·Ó¿ Ô˘ÏÂÚÈο ‰È·ÎÈÓÔ‡ÓÙ·È ÛÙȘ ·ÁÔÚ¤˜. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ÙËÓÒÓ Ì ·‰Ú·ÓÔÔÈË̤ÓÔ Èfi ∏5¡1 Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓÔ Ì¤ÙÚÔ. ∆· ÂÌ‚fiÏÈ· Ô˘ ˘¿Ú¯Ô˘Ó Û‹ÌÂÚ· ηٿ ÙÔ˘ ∏5¡1 ÁÈ· Ù· ÙËÓ¿ ·ÔÙÚ¤Ô˘Ó ÙËÓ ÂΉ‹ÏˆÛË Û˘ÌÙˆÌ¿ÙˆÓ ·ÏÏ¿ fi¯È Î·È ÙËÓ ˘ÔÎÏÈÓÈ΋ Ïԛ̈ÍË. √ Èfi˜ Û˘Ó¯›˙ÂÈ Ó· ·Ô‚¿ÏÏÂÙ·È Î·È Ë Ïԛ̈ÍË ÌÔÚ› Ó· ÌÂÙ·‰›‰ÂÙ·È ·fi ·Û˘Ìو̷ÙÈο ÙËÓ¿ (16). Œ¯ÂÈ Â›Û˘ ÂÎÊÚ·Ûı› Ô Êfi‚Ô˜, fiÙÈ Ì ÙË ¯Ú‹ÛË ÙÔ˘˜ ¢ÓÔÂ›Ù·È Ë ÂÈÏÔÁ‹ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔ˘˜ ÈÔ‡˜ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó, ¤ÙÛÈ ÒÛÙ ӷ ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ Ïԛ̈͢ ÛÙ· ›‰È· Ù· ÙËÓ¿ ‹ Û ¿ÏÏ· ›‰Ë. ∂Í¿ÏÏÔ˘, Ì·˙È΋ ı·Ó¿ÙˆÛË ¿ÁÚÈˆÓ ÙËÓÒÓ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂȯÂÈÚËı› ‰ÈfiÙÈ ı· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ Ì›˙ÔÓ· ÔÈÎÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Î·È ‰ÂÓ Â›Ó·È ·Ô‰ÂÎÙ‹ ·fi ÔÏÏÔ‡˜ ‰ÈÂıÓ›˜ ÔÚÁ·ÓÈÛÌÔ‡˜. ∏ ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó‰ËÌ›·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ‡·ÚÍË ‰È·ı¤ÛÈÌˆÓ Â·ÚÎÒÓ ÔÛÔÙ‹ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ Ê·Ú̿ΈÓ. ∆· ·Ï·ÈfiÙÂÚ· ·ÓÙÈÁÚÈÈο Ê¿Ú̷η Â›Ó·È ÔÈ ·‰·Ì·ÓÙ¿Ó˜ (·Ì·ÓÙ·‰›ÓË Î·È ÚÈÌ·ÓÙ·‰›ÓË) Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ÚˆÙ½ÓË ª2. ¢˘ÛÙ˘¯Ò˜, Ù· ÛÙÂϤ¯Ë ∏5¡1 Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙËÓ ∞Û›· ‰ÂÓ Â›Ó·È Â˘·›ÛıËÙ· ÛÙ· Ê¿Ú̷η ·˘Ù¿. ∆· ÓÂfiÙÂÚ· ·ÓÙÈÁÚÈÈο Ê¿Ú̷η Â›Ó·È ÙÔ oseltamivir (Tamiflu) Î·È zanamivir (Relenza) Ô˘ ‰ÚÔ˘Ó ˆ˜ ·Ó·ÛÙÔÏ›˜ Ù˘ Ó¢ڷÌÈÓȉ¿Û˘. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi, ÂÌÔ‰›˙ÂÙ·È Ë Â›ÛÔ‰Ô˜ ÙÔ˘ ÈÔ‡ ÛÙÔ Î‡ÙÙ·ÚÔ Î·È Ë ·ÂÏ¢ı¤-

ÚˆÛ‹ ÙÔ˘ ·fi ·˘Ùfi. √È ÈÔ› ∏5¡1 Â›Ó·È Â˘·›ÛıËÙÔÈ ÛÙÔ˘˜ ·ÓÙÈ-ÈÈÎÔ‡˜ ·˘ÙÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÔÈ ÔÔ›ÔÈ Â›Ó·È Î·Ù¿ÏÏËÏÔÈ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÌÈ·˜ ·Ó‰ËÌ›·˜, ·ÚfiÏÔ Ô˘ ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ ÂÈÛËÌ·›ÓÔ˘Ó ÙËÓ ÂÚÈÁÚ·Ê‹ ·ÓıÂÎÙÈÎfiÙËÙ·˜ Î·È Û ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›· Ê·ÚÌ¿ÎˆÓ (18). ∞˜ ÛËÌÂȈı› fiÙÈ Î·Ó¤Ó· ·fi Ù· Ê¿Ú̷η ·˘Ù¿ ‰ÂÓ ¤¯ÂÈ ÂÁÎÚÈı› ÁÈ· ¯ÔÚ‹ÁËÛË Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜. ∆· Ê¿Ú̷η ·˘Ù¿ ı· Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ıÂÚ·›· Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÚÒÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È fi¯È ˆ˜ ÚÔʇϷÍË, ‰ÈfiÙÈ Ë Ú·ÎÙÈ΋ ·˘Ù‹ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜. ∆Ô Tamiflu ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ ÛÙfiÌ· Î·È ¤ÙÛÈ Â›Ó·È ÈÔ Â‡ÎÔÏÔ Ó· ¯ÚËÛÈÌÔÔÈËı› Û ۇÁÎÚÈÛË Ì ÙÔ Relenza Ô˘ ΢ÎÏÔÊÔÚ› Û ÌÔÚÊ‹ ÛÎfiÓ˘ ÁÈ· ÂÈÛÓÔ¤˜. ¶ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È Ë ∂ÏÏ¿‰·, ¤¯Ô˘Ó ‹‰Ë ·Ú·ÁÁ›ÏÂÈ ÛÙË ‚ÈÔÌ˯·Ó›· οÔȘ ÔÛfiÙËÙ˜ ·ÓÙÈÁÚÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È Î˘Ú›ˆ˜ ÙÔ˘ Tamiflu. ∏ ·Ú·ÁˆÁ‹ ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ, ÈηÓÒÓ Ó· ηχ„Ô˘Ó Ì¤ÚÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡, ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈο ÂÌfi‰È· (19,20). ∏ ·Ú·Û΢‹ ÙÔ˘˜ Â›Ó·È ·ÚÎÂÙ¿ ÔχÏÔÎË Î·È ··ÈÙÔ‡ÓÙ·È 12 ÂÚ›Ô˘ Ì‹Ó˜, ÂÓÒ ÙÔ ÎfiÛÙÔ˜ Â›Ó·È ÌÂÁ¿ÏÔ. ª¤¯ÚÈ Û‹ÌÂÚ·, Ë ¯Ú‹ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÙËÓ ∂˘ÚÒË, ‹Ù·Ó Ôχ ÂÚÈÔÚÈṲ̂ÓË. ŒÙÛÈ, Ë ‚ÈÔÌ˯·Ó›· ���ÂÓ Â›Ó·È Û ı¤ÛË Ó· ·Ú·Û΢¿ÛÂÈ ÙÂÚ¿ÛÙȘ ÔÛfiÙËÙ˜ Û ‚Ú·¯‡ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Ó· ·ÓÙÂÂͤÏıÂÈ ÛÙȘ ·Ó¿ÁΘ ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ Û˘ÓfiÏÔ˘. ŒÓ· ¿ÏÏÔ ˙‹ÙËÌ· Ô˘ Ù›ıÂÙ·È, Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂÏ¿¯ÈÛÙ˜ ÌfiÓÔ ¯ÒÚ˜ ·Ú¿ÁÔ˘Ó ·ÓÙÈÁÚÈÈο Ê¿Ú̷η Î·È Û ÂÚ›ÙˆÛË ·Ó‰ËÌ›·˜ ÚÔÙÂÚ·ÈfiÙËÙ· ı· ‰Ôı›, ÂӉ¯Ô̤ӈ˜, ÛÙËÓ ÂÁ¯ÒÚÈ· ηٷӿψÛË Î·È fi¯È ÛÙȘ ÂÍ·ÁˆÁ¤˜. ∆¤ÏÔ˜, ‰ÂÓ Â›Ó·È ·ÎÚÈ‚Ò˜ ÁÓˆÛÙfi fiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈο ı· Â›Ó·È Ù· Ê¿Ú̷η ·˘Ù¿ ÁÈ· ÙÔÓ Èfi Ù˘ ·Ó‰ËÌ›·˜ Î·È fiÛÔ ÌÂÁ¿ÏÔ˜ Ô Î›Ó‰˘ÓÔ˜ ·Ó¿Ù˘Í˘ ·ÓÙÔ¯‹˜. ∞Ó Î·È Ù· ·ÓÙÈ-ÈÈο Ê¿Ú̷η ÌÔÚÔ‡Ó ÚÔÛˆÚÈÓ¿ Ó· ‚ÔËı‹ÛÔ˘Ó, ÙÔ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi ̤ÛÔ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÌÈ·˜ ÂӉ¯fiÌÂÓ˘ ·Ó‰ËÌ›·˜ Â›Ó·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜. ∏ Ù¯ÓÈ΋ Ù˘ ·Ó¿ÛÙÚÔÊ˘ ÁÂÓÂÙÈ΋˜ Ô˘ ·Ó·Ù‡¯ıËΠٷ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÂÈÙÚ¤ÂÈ Û‹ÌÂÚ· ÛÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÙÔÓ Â‡ÎÔÏÔ ¯ÂÈÚÈÛÌfi ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÙÔ˘ ÈÔ‡ Î·È ÙË ÁÚ‹ÁÔÚË ‰ËÌÈÔ˘ÚÁ›· ÂÓfi˜ ÛÙÂϤ¯Ô˘˜ ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Ô˘ ı· ¤¯ÂÈ ÙËÓ ÂÈı˘ÌËÙ‹ ÁÂÓÂÙÈ΋ Û‡ÓıÂÛË (20). ¶·Ú¿ÁÂÙ·È Ì ÙÔÓ ÙÚfiÔ ¶·È‰È·ÙÚÈ΋ 2006;69:1-9


Pediatr Jan-Feb 06 final allges

27-01-06

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ª. ∆ÛÔÏÈ¿ Î·È Û˘Ó.

·˘Ùfi, ÙÔ Ó¤Ô Û٤ϯԘ ÈÔ‡ Ô˘ ÛÙË Û˘Ó¤¯ÂÈ· ηÏÏÈÂÚÁÂ›Ù·È Û ·‚Á¿ ÁÈ· Ì·˙È΋ ·Ú·ÁˆÁ‹. ™‹ÌÂÚ· ¤¯Ô˘Ó ۯ‰ȷÛÙ› ÙÔ˘Ï¿¯ÈÛÙÔÓ 10 ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÂÌ‚ÔÏ›ˆÓ ηٿ ÙÔ˘ ∏5¡1 Û ‰È¿ÊÔÚ˜ ¯ÒÚ˜ Î·È ÛÙȘ ∏.¶.∞., fiÔ˘ ¤¯ÂÈ ‹‰Ë ÍÂÎÈÓ‹ÛÂÈ Ë ‰ÈÂÍ·ÁˆÁ‹ ÔÚÈÛÌ¤ÓˆÓ ·fi ·˘Ù¤˜ (19). ¶ÈÛÙ‡ÂÙ·È fiÙÈ ·ÎfiÌË ÎÈ ·Ó Ô Èfi˜ Ô˘ ı· ÚÔηϤÛÂÈ ÙËÓ ·Ó‰ËÌ›· Â›Ó·È Î¿ˆ˜ ‰È·ÊÔÚÂÙÈÎfi˜ ·fi ·˘ÙfiÓ Ô˘ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›Ô˘, ı· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÚfiÌÔÈÔ˜ Î·È ÙÔ ÂÌ‚fiÏÈÔ ·Ó·Ì¤ÓÂÙ·È fiÙÈ ı· ·Ú¤¯ÂÈ Î¿ÔÈ· ÚÔÛÙ·Û›·. ∏ ·Ú·ÁˆÁ‹ ÂÌ‚ÔÏ›ˆÓ Û˘Ó·ÓÙ¿ ÚÔ‚Ï‹Ì·Ù· ‰ÈfiÙÈ Ë ‰È·‰Èηۛ· Â›Ó·È ¯ÚÔÓÔ‚fiÚ· Î·È Ì ÙȘ ˘¿Ú¯Ô˘Û˜ Û˘Óı‹Î˜ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ú·Û΢‹ ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ÈηÓÒÓ Ó· ηχ„Ô˘Ó ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡. ∞Ó·˙ËÙÔ‡ÓÙ·È Û‹ÌÂÚ· ‰È¿ÊÔÚ˜ Ù¯ÓÈΤ˜ ‚ÂÏÙ›ˆÛ˘ Ù˘ ÈηÓfiÙËÙ·˜ Î·È Ù˘ Ù·¯‡ÙËÙ·˜ ·Ú·ÁˆÁ‹˜, fiˆ˜ Â›Ó·È Ë ¯Ú‹ÛË Î˘ÙÙ·ÚÔηÏÏÈÂÚÁÂÈÒÓ ·ÓÙ› ÙˆÓ ·‚ÁÒÓ. Œ¯ÂÈ ‚ÚÂı› fiÙÈ ÁÈ· Ó· ˘¿ÚÍÂÈ ÈÛ¯˘Ú‹ ·ÓÔÛȷ΋ ·¿ÓÙËÛË ··ÈÙÔ‡ÓÙ·È ‰‡Ô ‰fiÛÂȘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Û οı ¿ÙÔÌÔ. ™‹ÌÂÚ· fï˜, Á›ÓÔÓÙ·È ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÂÌ‚ÔÏ›Ô˘ Ô˘ ı· ÂÚȤ¯ÂÈ ˙ˆÓÙ·Ófi ÂÍ·ÛıÂÓË̤ÓÔ Û٤ϯԘ Î·È ¤ÙÛÈ ı· Â›Ó·È ·ÚÎÂÙ‹ Ì›· ÌfiÓÔ ‰fiÛË. ªÂÏÂÙ¿Ù·È Â›Û˘, Ë ¯Ú‹ÛË ·ÓÔÛÔÂÓÈÛ¯˘ÙÒÓ (adjuvants) (20,21) Ô˘ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ·ÓÔÛȷ΋ ·¿ÓÙËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Ô˘ ‰ÔÎÈÌ¿˙ÔÓÙ·È Û‹ÌÂÚ·. ™‹ÌÂÚ· Ë ‰˘Ó·ÙfiÙËÙ· Ù˘ ‚ÈÔÌ˯·Ó›·˜ ÁÈ· ·Ú·ÁˆÁ‹ ÂÌ‚ÔÏ›Ô˘ ÁÚ›˘ ‰ÂÓ ÍÂÂÚÓ¿ Ù· 300 ÂηÙÔÌ̇ÚÈ· ‰fiÛÂȘ ÙÔÓ ¯ÚfiÓÔ, ÂÓÒ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Û ÂÚ›ÙˆÛË ·Ó‰ËÌ›·˜ ı· ··ÈÙËıÔ‡Ó ‰ÈÛÂηÙÔÌ̇ÚÈ· ‰fiÛÂȘ (19). ∏ ‚ÈÔÌ˯·Ó›· ‰ÈÛÙ¿˙ÂÈ Ó· ÂÂÓ‰‡ÛÂÈ Ù· ÙÂÚ¿ÛÙÈ· ÎÂÊ¿Ï·È· Ô˘ ··ÈÙÔ‡ÓÙ·È Ì ·‚¤‚·ÈË ÛÙÔ Ì¤ÏÏÔÓ ÙË ˙‹ÙËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ. ¶ÚÔÙ›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Ë ¯Ú‹ÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ Ù˘ Û˘ÓËıÈṲ̂Ó˘ ÁÚ›˘ ı· Ú¤ÂÈ Û fiϘ ÙȘ ¯ÒÚ˜ Ó· ·˘ÍËı› Î·È Ó· ˘ÈÔıÂÙËıÔ‡Ó Ú·ÎÙÈΤ˜ ÁÂÓÈÎÂ˘Ì¤Ó˘ ¯Ú‹Û˘ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ÒÛÙÂ Ë ‚ÈÔÌ˯·Ó›· Ó· ·Ó·Ù‡ÍÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·Ú¿ÁÂÈ ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ (22). ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, Â¿Ó ÚÔ·„ÂÈ ·Ó‰ËÌ›·, ı· ÌÔÚ¤ÛÂÈ Ó· ·Ú·¯ı› ·ÓÙ› ÙÔ˘ ÙÚȉ˘Ó¿ÌÔ˘, ÙÔ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Ù˘ ·Ó‰ËÌ›·˜ Û ÔÛfiÙËÙ˜ ÈηӤ˜ Ó· ηχ„Ô˘Ó ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÂΉ‹ÏˆÛË ÌÈ·˜ Ó¤·˜ ·Ó‰ËÌ›·˜ ÁÚ›˘ ıˆÚÂ›Ù·È ÛÙȘ ̤Ú˜ Ì·˜ ‚¤‚·ÈË ÙËÓ ÚÔÛ¯‹ ÂÓÙ·ÂÙ›·. √È ·ÛÈ·ÙÈΤ˜ ΢ڛˆ˜ ¯ÒÚ˜ ı· Ú¤ÂÈ Ó· Ï¿‚Ô˘Ó Ù· ··Ú·›Ù˶·È‰È·ÙÚÈ΋ 2006;69:1-9

Ù· ̤ÙÚ· Ô˘ ı· Ô‰ËÁ‹ÛÔ˘Ó ÛÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ, Ì ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÙÚfiˆÓ ÂÎÙÚÔÊ‹˜ ÙÔ˘˜ Î·È ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ·ÁÔÚÒÓ, ηıÒ˜ Î·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ·˘ÛÙËÚ‹˜ ÂȉËÌÈÔÏÔÁÈ΋˜ ÂÈÙ‹ÚËÛ˘. ¢Â›ÁÌ·Ù· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È Î·È ·fi Ù· ˘‰Úfi‚È· ÙËÓ¿ ÒÛÙ ӷ ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ë ÂͤÏÈÍË ÙˆÓ ÈÒÓ ÁÚ›˘. ŸÏ˜ ÔÈ ¯ÒÚ˜ ÔÊ›ÏÔ˘Ó Ó· ·Ó·Ù‡ÍÔ˘Ó ¤Ó· ÂȯÂÈÚËÛÈ·Îfi Û¯¤‰ÈÔ ·ÓÙÈÌÂÙÒÈÛ˘ ÌÈ·˜ ·Ó‰ËÌ›·˜ ÁÚ›˘. £· Ú¤ÂÈ Ó· ‰Ôı› ‚¿ÚÔ˜ ÛÙË Ï‹„Ë Ì¤ÙÚˆÓ ÚÔʇϷ͢ ·fi ÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘, ÛÙËÓ ‡·ÚÍË ‰È·ı¤ÛÈÌˆÓ ·ÔıÂÌ¿ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Î·È ÛÙËÓ ÚÔÌ‹ıÂÈ· Â·ÚÎÒÓ ÔÛÔÙ‹ÙˆÓ ÂÌ‚ÔÏ›Ô˘ ηٿ Ù˘ ÁÚ›˘ ÙˆÓ ÙËÓÒÓ fiÙ·Ó ·˘Ùfi ·Ú·¯ı›.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Treanor G. Influenza virus. In: Mandell GL, Bennett JE, Dolin R (eds). Mandel, Douglas and Bennett's Principles and practice of infectious diseases. 5th edition. Churchill Livingstone, Philadelphia, 2000: 1823-1849. 2. Laver WG, Bischofberger N, Webster RG. Disarming flu viruses. Sci Am 1999;280:78-87. 3. Osterhaus A. H5N1: the lessons to be learned. In: Zambon MC, ed. United Kingdom: Advances in influenza. Blackwell Science; 1999. p. 11-17. 4. Laver G, Garman E. Virology. The origin and control of pandemic influenza. Science 2001;293:1776-1777. 5. Hien TT, De Jong M, Farrar J. Avian influenza - A Challenge to global health care structures. N Engl J Med 2004;351:2363-2365. 6. Perez DR, Sorrell EM, Donis RO. Avian influenza: an omnipresent pandemic threat. Pediatr Infect Dis J 2005;24 (11 Suppl):S208-S216. 7. Belshe RB. The Origins of Pandemic Influenza lessons from the 1918 Virus. N Eng J Med 353;21: 2209-2211. 8. Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG. Characterization of the 1918 influenza virus polymerase genes. Nature 2005;437: 889-893. 9. Tumpey TM. Basler CF, Aguilar PV, Zeng H, Solorzano A, Swayne DE et al. Characterization of the reconstructed 1918 Spanish influenza pandemic virus. Science 2005;310:77-80. 10. Centers for Disease Control and Prevention Influenza (flu): information about Avian influenza and Avian influenza A [Internet]. 2005: Webpage: http://www.cdc.gov/flu. 11. Macfarlane JT, Lim WS. Bird flu and pandemic flu. BMJ 2005;331:975-976. 12. Monto AS. The threat of an avian influenza pandemic. N Eng J Med 2005;352:323-325. 13. Stohr K. Avian influenza and pandemics-Research needs and opportunities. N Eng J Med 2005;352: 405-407.


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14. Beigel JH, Farrar J, Han AM, Hayden FG, Hyer R, de Jong MD et al; Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5. Avian influenza A (H5N1) infections in humans. N Eng J Med 2005;353:13741385. 15. World Health Organization. Cumulative number of confirmed human cases of avian influenza A H5N1. [Internet, Webpage] www.who.int/csr/disease/ avian_influenza/country/cases_table_2005_12_30/ en/index.html 16. Webster R, Hulse D Controlling avian flu at the source. Nature 2005;435:415-416. 17. Ungchusak K, Auewarakul P, Dowell SF, Kitphati R, Auwanit W, Puthavathana P et al. Probable personto-person transmission of avian influenza A (H5N1). N Eng J Med 2005;352:333-340.

18. Le QM, Kiso M, Someya K, Sakai YT, Nguyen TH, Nguyen KH et al. Isolation of drug resistant H5N1 virus. Nature 2005;437:1108. 19. Fleming D. Influenza pandemics and Avian flu. BMJ 2005;331:1066-1069. 20. Check E. Avian flu special: is this our best shot? Nature 2005;437:404-406. 21. Wood JM, Robertson JS. From lethal virus to life-saving vaccine: developing inactivated vaccines for pandemic influenza. Nat Rev Microbiol 2004;2:842-847. 22. Hoffmann E, Neumann G, Kawaoka Y, Hobom G, Webster RG. A DNA transfection system for generation of influenza A virus from eight plasmids. Proc Natl Acad Sci USA 2000;97:6108-6113. 23. Reichert TA. Preparing for the next influenza pandemic: lessons from multinational data. Pediatr Infect Dis J 2005;24(11 Suppl):S228-S231.

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REVIEW ARTICLE

Evaluation and management of hypertensive crisis in childhood Director of Pediatric Nephrology, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine Correspondence: Demetrius Ellis, M.D. Children's Hospital of Pittsburgh 3705 Fifth Avenue Pittsburgh, PA 15213 e-mail: ellisd@chp.edu

D. Ellis

Abstract: Hypertensive crisis is relatively uncommon in the paediatric age group and many emergency departments are poorly prepared to manage children with this potentially lethal disorder. This review provides guidelines aimed at facilitating the evaluation and management of children with this disorder. Key words: Hypertension, paediatrics, hypertensive crisis, hypertensive emergencies.

Abbreviations BP HTN

blood pressure hypertension

Introduction Normal blood pressure (BP) levels differ by age, gender and height; accordingly no single BP level defines hypertension (HTN) in all children. Updated BP norms and definitions of HTN in children are provided in the latest of four comprehensive reports (1). HTN is generally defined as the average of three manually obtained systolic BP and/or diastolic BP measurements being ≥95th percentile for age, gender and height. There are several recent reviews of hypertensive crisis in adults (2-8), but the clinical approach to this topic has been rarely addressed for the paediatric age group (9,10). For purposes of this review, hypertensive crisis is a syndrome classified as either a) hypertensive emergency if there are clinical manifestations of ongoing organ injury, or, b) hypertensive urgency if there are no acute clinical symptoms and evidence for end-organ damage is minimal or absent. The implication is that the former requires immediate reduction in BP, while in the latter BP reduction may take place over hours or days. Although the large majority of children who present in the emergency department with hypertensive crisis have BP above the 99th percentile, hypertensive crisis is not strictly defined by absolute BP levels. In the absence of known preexisting renal disorder, which often predisposes to hypertensive crisis, the possibility must be considered of previously unrecognized cardiac and endocrino¶·È‰È·ÙÚÈ΋ 2006;69:10-17

logic aetiologies of HTN, which may strongly influence the therapeutic choice for individuals in the emergency department. This brief report describes a practical clinical approach to the diagnosis and immediate management of the child presenting with hypertensive crisis, which may be facilitated by means of an algorithm, along with a table of potentially useful agents and dosage guidelines suitable for the paediatric age group. The goal of therapy is to prevent the catastrophic consequences of this potentially lethal disorder.

Symptoms and signs Unlike adults, in whom hypertensive crises usually occur in individuals with known and often severe preexisting HTN, in children the discovery of HTN is often made at the time of presentation with a hypertensive crisis. Symptoms of HTN in children depend on the acute nature of the development of HTN as well as on the magnitude of the BP elevation. Hence, in a child with chronic HTN secondary to renal artery stenosis, mild to moderate HTN is usually well tolerated whereas the same BP level may cause severe headache or seizures in a child with acute glomerulonephritis. Similarly children with cardiac outlet obstruction or cardiomyopathy may become symptomatic despite mild HTN. The most common symptoms of HTN in the majority of older children who present in the emergency department are those of hypertensive encephalopathy, namely headache, nausea, vomiting, mental confusion, blurred vision, agitation or frank seizures. Other manifestations


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Hypertensive crisis in childhood

may include cerebral infarction, intracerebral or retinal haemorrhage, congestive heart failure, acute pulmonary oedema (with shortness of breath), acute renal insufficiency, and microangiopathic haemolytic anaemia. Less common sequelae of hypertensive crisis in children include myocardial infarction and aortic dissection. Newborns and infants with severe hypertension may present with congestive heart failure, hypertensive retinopathy, respiratory distress, apnoea or cyanosis, extreme irritability, hypotonia, convulsions or coma. Vomiting, diarrhoea and failure to thrive may be among the chronic manifestations of hypertension in the younger age group.

Causes of hypertensive crisis Table 1 lists the main causes of hypertensive crisis in children. Renal disorders predominate and these include renovascular hypertension (including renal artery stenosis and aortic coarctation), accelerated HTN in children with renal failure and fluid overload together with pre-existing HTN, acute glomerulonephritis, haemolytic-uremic syndrome and other renal parenchymal disorders. Less common causes are vasculitis, head injury and phaeochromocytoma.

Pathophysiology of hypertensive emergencies The ability to maintain almost constant perfusion to an organ over a wide range of mean arterial pressures ranging from 60-150 mmHg is known as autoregulation of blood flow. This process is mediated by multiple neurohumoral mechanisms which affect vascular resistance, and is particularly effective and well guarded in the cerebral and renal circulations. Chronic HTN leads to compensatory, functional and structural changes in arterial vessels, which maintain perfusion to these organs while protecting against injury that may otherwise result from organ hyperperfusion due to HTN (11). When the systemic BP surpasses the compensatory limits of autoregulation, arterial injury, such as fibrinoid necrosis and organ ischaemia, may follow (5, 12). Conversely when the BP is suddenly reduced below the new steady state limits of compensation, ischaemic injury may

be enhanced, particularly in individuals with structural hypertensive arterial changes. Most children with hypertensive emergencies do not have structural vascular lesions and are, therefore, less susceptible to organ ischaemia after lowering of the BP. Conversely, the lack of adaptive responses in children with an acute and rapid rise in BP may predispose to symptoms at BP levels which may not be gauged as being sufficiently high to produce such symptoms.

Evaluation of hypertensive emergencies The algorithm shown in the Figure may facilitate the clinical assessment and management of the symptomatic child with hypertensive emergency. A similar approach may be applied in the child with hypertensive urgency, in which case the Table 1. Causes of hypertensive crisis ñ Abrupt increase in blood pressure in children with chronic hypertension (most common in those with renal disorders or on dialysis) ñ Renovascular hypertension, including renal artery stenosis, partial arterial thrombosis especially in neonates with umbilical arterial lines, aortic coarctation ñ Parenchymal renal disease (polycystic kidney disease, vasculitis, acute glomerulonephritis, hemolytic uraemic syndrome, renal scarring associated with pyelonephritis or reflux nephropathy) ñ Renin-secreting tumour (Wilm's tumour, nephroblastomatosis, Drash syndrome) ñ Ingestion of drugs (sympathomimetic agents [cocaine, amphetamines, phencyclidine hydrochloride, lysergic acid diethylamide, diet pills], tricyclic antidepressants, anabolic steroids, chlorpromazine, oral contraceptives, erythropoietin, cyclosporine, monoamine oxidase inhibitors, corticosteroids, nonsteroidal anti-inflammatory agents) ñ Acute withdrawal of antihypertensive drugs (clonidine or centrally acting agents and ‚-antagonists) ñ Ingestion of tyramine in conjunction with use of a monoamine oxidase-inhibitor ñ Cushing's syndrome, syndrome of apparent mineralocorticoid excess, or glucocorticoid-excess states ñ Phaeochromocytoma, neuroblastoma or ganglioneuroma ñ Head injury, brain tumours, increased intracranial pressure ñ Autonomic hyperactivity in patient with GuillainBarre or other spinal-cord syndromes ñ Porphyria ñ Hypercalcaemia ¶·È‰È·ÙÚÈ΋ 2006;69:10-17


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Figure. Hypertensive crisis management guidelines.

time course needed to obtain the diagnostic studies or to implement therapeutic measures can be prolonged. Initial evaluation includes inspection of the optic fundi for hypertensive arterial changes, mental status and neurologic assessment, and careful cardiac, pulmonary and abdominal examination to uncover cardiac dysfunction, pulmonary oedema or masses. Physical examination should include auscultation for carotid and ab¶·È‰È·ÙÚÈ΋ 2006;69:10-17

dominal bruits along with assessment of pulses in the radial, femoral and pedal arteries, and BP measurement in both the upper and lower extremities. These examinations, together with inspection of the skin for café au lait spots, striae, adenoma sebaceum or malar rash, may provide clues as to the aetiology of HTN. The medical history may indicate pre-existing renal disorders, urinary tract infections, or other infectious illnesses which may be associated with renal involvement, such as acute


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glomerulonephritis. A history of illicit or prescribed drug use which may precipitate or aggravate pre-existing HTN may be helpful. Urinalysis and measurement of BUN, serum creatinine, electrolytes, calcium, phosphorus, magnesium and uric acid may provide evidence of renal involvement. Because anti-hypertensive therapy may alter plasma levels of renin, cortisol and aldosterone, as well as urinary VMA excretion, in undiagnosed cases, these measurements should be obtained before administering anti-hypertensive drugs. A plasma toxicology screen may be useful in children with suspected substance abuse. Chest X-ray and EKG or echocardiogram should also be done as early as possible. Once the BP improves, children with severe encephalopathy or focal neurologic deficit may be escorted by an emergency department physician to the radiology department, where computerized cranial tomography may be done to diagnose or eliminate thrombotic or haemorrhagic events.

General principles of management There have been no controlled clinical trials of treatment of hypertensive emergencies or hypertensive urgencies in children. A review of multiple adult studies failed to produce statistical superiority of any single therapeutic agent and the outcome was not uniform between studies (6). Experience is accruing from clinical trials on adults with hypertensive emergencies of the calcium channel inhibitor lacidipine or the ·1adrenergic receptor blocker urapidil, administered for specific indications (6,13). However, it is the author's opinion that the newer vascular dopamine receptor agonist (DA1), fenoldopam (14) shows the most promise, particularly in replacing intravenous nitroprusside in children with renal dysfunction. Employment of the newer agents may be more appropriate for hypertensive emergencies due to disorders not frequently encountered in childhood, such as atherosclerotic cerebrovascular and renal arterial disease, HTN associated with pregnancy, or aortic dissection. Hence, reliance on older agents is still preferred. As a general rule agents with a short duration of action are employed, so that if BP reduction is gauged as excessive, the effect can be quickly reversed by stopping the agent and/or administering normal saline. A major long-term objective

is to assure compliance with antihypertensive therapy during follow-up (7,8). The goal of emergency therapy is to achieve a gradual decrease in systolic and diastolic BP to near the 99th percentile, or to reduce the mean arterial pressure (one third of the pulse pressure difference added to the diastolic BP) by 25%. With such reduction in BP over a period of minutes or hours the symptoms and signs of hypertension tend to improve or resolve. Further lowering in BP may be effected more slowly over several days or weeks in such a way that the BP remains below the 90th percentile for age, gender and height percentile (1).

Choice of oral vs. intravenous therapy in hypertensive crisis In general, if a renal aetiology for the HTN can be readily ascertained and the child is capable of swallowing, the initial therapy in the emergency department may consist of oral agents. If the aetiology of HTN cannot be established, the initial agent could be intravenous hydrallazine, with oral or trans-dermal clonidine as an adjunctive agent. If HTN persists, the child is admitted to the intensive care unit (ICU) where more powerful parenteral agents may be urgently administered and BP can be monitored continuously and directly through an intra-arterial transducer. A list of antihypertensive agents and the recommended dosages for children with hypertensive crisis are shown in Table 2. Specific disorders such phaeochromocytoma or drug-induced HTN from catecholamine excess (cocaine intoxication, monoamine oxidase inhibitor crisis) may be managed with an alpha adrenergic blocker such as phentolamine, while avoiding initial use of beta blockers which may potentiate the alpha adrenergic action of catecholamines. Intravenous diuretics may be very useful as adjunctive agents in the case of congestive heart failure in disorders accompanied by fluid overload, such as acute glomerulonephritis.

Oral agents used to manage hypertensive crisis Assuming that the child does not have severe neurological symptoms and is capable of ¶·È‰È·ÙÚÈ΋ 2006;69:10-17


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Table 2. Pharmacologic management of hypertensive crisis in infants and in children Action

Agents (trade names)

Dose

Route

Comments

Vasodilator

Hydrallazine (Apresoline, others)

0.1-0.2 mg/kg (maximum 20 mg/dose)

IV

Administer at <0.2 mg/kg/minute; onset 5-20 minutes; lower dose can be repeated after 5-20 minutes. Duration is 2-6 hours. Can cause reflex tachycardia. Available in 20 mg/ml ampoule.

Minoxidil (Loniten)

0.1-0.2 mg/kg (maximum 50 mg/day)

Oral

Onset ≤30 minutes; maximum effect @ 2-8 hours; long duration of effect, once daily dosing, contraindicated in phaeochromocytoma.

Diazoxide (Hyperstat)

1-3 mg/kg (maximum 150 mg dose)

IV push

Administer IV push over 10-30 seconds, maximum effect within 5 minutes, can be repeated after 5 minutes, duration of effect 3-12 hours. Available in 300 mg/30 ml ampule. Alternative dosage is 1 mg/kg every 5-15 minutes until BP control is achieved.

Sodium nitroprusside (Nipride)

0.25-8 mcg/kg/min

IV drip

Administer by continuous infusion only; onset within 2 minutes, duration <10 minutes. Start at 0.25 mcg/kg/minute and increase dose by 25% every 5-10 minutes until BP control is obtained. Obtain thiocyanate levels if used for more than 48 hours; protect from light. Available in 50 mg/ 5 ml vial.

Labetalol (Normodyne, Trandate)

0.2-0.5 mg/kg/dose (maximum 1mg/kg)

IV

Administer IV over 2-3 minutes; onset 2-5 minutes; maximum effect in 5-15 minutes, duration 2-4 hours; lower dose can be doubled and repeated at 15 minute intervals x 2; can also be given at same dose by IV infusion over 1 hr. Avoid if child has history of asthma / bronchospasm. Contraindicated in congestive heart failure, sinus tachycardia, heart block. Available as 5 mg/ml.

Clonidine (Catapres)

5-10 mcg/kg/day (maximum 25 mcg/kg/day)

Oral

Divide dose and administer q 6-12 hours. Also available in transdermal formulation. Avoid in cerebrovascular disorders. May cause agitation, insomnia, drowsiness, rebound hypertension after rapid withdrawal.

Esmolol (Brevibloc)

Loading dose: IV drip 500 mcg/kg IV, then use as continuous infusion 50-250 mcg/kg/min

Adrenergic alpha and beta blocking agents

Use for postoperative hypertension; administer loading dose over 1 minute; followed by continuous infusion; onset: beta blockade occurs in 2-10 minutes; duration 10-30 minutes (short). Contraindicated in congestive heart failure, sinus tachycardia, heart block. continued...

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Hypertensive crisis in childhood

Table 2. Pharmacologic management of hypertensive crisis in infants and in children Action

Agents (trade names)

Dose

Route

Comments

Isradipine (DynaCirc)

0.2-0.9 mg/kg/day (maximum 0.6 mg/kg/day)

Oral

Available in capsules (2.5 and 5 mg) and in liquid formulation (1 mg/mL). May cause tachycardia or congestive heart failure.

Nifedipine (Procardia, others)

0.2-0.5 mg/kg (Initial dose should not exceed 0.25 mg/kg)

Oral

Swallow whole, or bite capsule and swallow, or remove liquid from capsule with syringe; not effective by sublingual route (actual effect due to swallowing the drug with subsequent rapid oral absorption); initial dose can be repeated once within 30 minutes. Onset of effect within 1-5 minutes after bite and swallow, contraindicated in patients with heart disease; available in 10 and 20 mg capsules.

Nicardipine (Cardene IV)

1 mcg/kg/min (maximum 5 mcg/kg/min)

IV drip

Onset 10 minutes; duration 2-6 hours; available as 2.5 mg/ml

Alpha-adrenergic blocker

Phentolamine (Regitine)

0.05-0.1 mg/kg/dose IV (maximum 5 mg)

Diagnostic test for phaeochromocytoma. Onset immediate; maximum effect in 2 minutes, duration 30 minutes; available in 5 mg vial.

ACE inhibitors

Enalaprilat

5-10 mcg/kg/dose

Administer undiluted over 5 minutes; onset ≤15 minutes; maximum effect in 1 hour; duration 4-6 hours. Severe hypotension can occur in sodium or volume depleted patients. Use lower dosages in neonates.

Calcium-channel blocking agents

swallowing medications, the use of oral medication may be limited to children with hypertensive emergencies or urgencies associated with known or suspected renal disorders. Short-acting nifedipine is currently a very popular drug for use in this situation. Unlike adults, where studies show that the use of this agent may be associated with a precipitous fall in BP and increased risk of myocardial infarction, stroke and death (15), data on children indicate that use of nifedipine is safe and effective (16, 17). However, both the clinical situation and the initial dose may modify safety. Guidelines for avoidance of the use of short acting nifedipine in children include: 1. Congestive heart failure, presence of myocardial ischaemia, after cardiac arrest, severe left ventricular hypertrophy, left ventricular outflow obstruction, or cardiac arrhythmia. 2. Acute hypertension with high cardiac out-

IV

put states, such as sickle cell crisis or other chronic anaemias. 3. Cyanotic heart disease. 4. Hypovolaemic states including children with anasarca, those undergoing acute diuresis, or those with acute haemorrhage. 5. Acute hypertension associated with severe pain. The BP should be reassessed after administration of appropriate analgesics such as morphine. 6. Acute central nervous system injury. 7. Children receiving large dosages of beta blockers, such as atenolol or labetolol. 8. Infants less than one year of age. In the absence of such conditions, orthostatic hypotension is usually avoided when the starting dose of nifedipine is 0.2 to 0.25 mg/kg body weight. Although it is often given sublingually, very little of the agent is actually absorbed via the oral mucosa. Thus, if the entire 10 mg nifedipine ¶·È‰È·ÙÚÈ΋ 2006;69:10-17


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D. Ellis

capsule is to be used the “bite and swallow” method is recommended. If lesser amounts are needed, the contents of the 10 mg capsule are drawn into a 1 mL graded syringe and the portion needed (0.034 mL = 1 mg) may be administered orally so as to speed up gastrointestinal uptake and onset of action. This dose may be repeated once within 30 minutes. All subsequent dosages should not exceed 0.5 mg/kg body weight, with a maximum of 10 mg, and the frequency of administration may be every 4-6 hours. Close BP monitoring is mandatory and such children should not ambulate after receiving the medication unless they are completely free of orthostatic hypotension, dizziness or mental disturbances. Minoxidil is an alternative oral agent, with properties of smooth arterial muscle relaxation (leading to vasodilation), which may be effective in overcoming hypertensive emergencies. Close BP monitoring and avoidance of ambulation is recommended after its use also.

Intravenous agents used to manage hypertensive crisis In children who are unable to take oral shortacting nifedipine or minoxidil, or in those with severe neurological symptoms, intravenous medications are preferred. Diozoxide is rarely used for this purpose because of unpredictable or precipitous drops in BP. Hydrallazine has become less popular because of the common sideeffects of flushing, tachycardia, nausea and headache, although it is still useful in the emergency department setting. With more severe or refractory symptomatic HTN more potent intravenous medications are indicated. In all instances in which intravenous medications other than hydrallazine are administered, the child should have an arterial line inserted for BP monitoring. In addition co-administered medications must be reviewed for possible synergism or drug interaction, which may exacerbate adverse effects of antihypertensive agents. The most useful parenteral agents in children include sodium nitroprusside (9,18,19), nicardipine (20-22), and labetalol (23,24); esmolol may be a preferred drug for use in infants (9,23,25,26). These agents may be given as a constant infusion and have an onset of action of less than 5 minutes. Generally, these medications should be started with the lower dosages and increased stepwise by ¶·È‰È·ÙÚÈ΋ 2006;69:10-17

25% every 5-10 minutes until the desired BP is reached. Sodium nitroprusside may be the initial intravenous agent in any child presenting with hypertensive emergency, with the exception of closed head injury or suspected high intracranial pressure. With long-term use of this agent, accumulation of its metabolic end products, comprising cyanide and thiocyanate, may cause nausea, vomiting, neurological symptoms, hypothyroidism, dyspnoea and metabolic acidosis. Nicardipine may be more suitable for use in individuals with renal insufficiency who are unable to excrete these metabolites effectively. Less frequently, nicardipine may also be given as mini-boluses. Fenoldopan is a newer agent which is also effective and uniquely suitable for managing HTN in the case of renal insufficiency (5,6,14). Esmolol, labetalol (23,24) and enlaprilat (10,27) may be particularly useful in infants. Esmolol can be given by constant infusion while all three agents can be administered on an intermittent basis. Intravenous labetalol is particularly useful in the management of HTN after transplantation, associated with cyclosporine or tacrolimus given in conjunction with glucocorticoids. It can also be administered as an infusion over 1-hr. As with esmolol and other beta blockers, labetalol should be avoided or be used with caution in children with reactive airway disease, and with consideration of other contraindications to their use (Table 2). Infants are particularly susceptible to enalaprilat-induced inhibition of angiotensin II, and may develop significant reduction in renal blood flow and glomerular filtration rate. Hence, enalaprilat (IV enalapril) should be used with caution in infants with known or suspected renal artery stenosis. However, this agent may be used to manage renovascular HTN due to microthrombi associated with intubation of the umbilical vessels.

Acknowledgements My gratitude to Dr. Bill McGhee and for confirming the paediatric drug dosages shown in Table 2, and to Mrs. Anne Spence who aided in the preparation of the algorithm.

References 1. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the


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2.

3. 4.

5. 6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114:555-576. Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Neph 1998; 133-142. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000;356:411-417. Vidt DG. Emergency room management of hypertensive urgencies and emergencies. J Clin Hypertens 2001;3:158-164. Elliott WJ. Hypertensive emergencies. Crit Care Clin 2001;17:435-451. Cherney D, Straus S. Management of patients with hypertensive urgencies and emergencies. J Gen Intern Med 2002;17:937-945. Phillips RA, Greenblatt J, Krakoff LR. Hypertensive emergencies: Diagnosis and management. Prog Cardiovasc Dis 2002;45:33-48. Mansoor GA, Frishman WH. Comprehensive management of hypertensive emergencies and urgencies. Heart Dis 2002;4:358-371. Fivush B, Neu A, Furth S. Acute hypertensive crisis in children: emergencies and urgencies. Curr Opin Pediatr 1996;9:233-236. Adelman RD, Coppo R, Dillon MJ. The emergency management of severe hypertension. Pediatr Nephrol 2000;14:422-427. Traon AP, Costes-Salon MC, Galinier M, Fourcade J, Larrue V. Dynamics of cerebral blood flow autoregulation in hypertensive patients. J Neurol Sci 2002;195:139-144. Kase CS. Hypertensive vascular disease and cerebral microcirculation. Neurologia 1999;14 (Suppl 2): S22-S30. Alijotas-Reig J, Bove-Farre I, de Cabo-Frances F, Angles-Coll R. Effectiveness and safety of prehospital urapidil for hypertensive emergencies. Am J Emerg Med 200;19:130-133. Tumlin JA, Dunbar LM, Oparil S, Buckalew V, Ram CV, Mathur V, et al. Fenoldopam, a dopamine agonist, for hypertensive emergency: a multicenter randomized trial. Fenoldopam Study Group. Acad Emerg Med 2000;7:653-662. Grosssman E, Messerli FH, Grodzicki T, Kowey P.

16.

17.

18.

19.

20.

21.

22.

23. 24.

25.

26.

27.

Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 1996;276:13281331. Egger DW, Deming DD, Hamada N, Perkin RM, Sahney S. Evaluation of the safety of short-acting nifedipine in children with hypertension. Pediatr Nephrol 2002;17:35-40. Blaszak RT, Savage JA, Ellis EN. The use of shortacting nifedipine in pediatric patients with hypertension. J Pediatr 2001;139:34-37. Gordillo Paniagua G, Velasquez Jones L, Martini R, Valdez Bolanos E. Sodium nitroprusside treatment of severe arterial hypertension in children. J Pediatr 1975;87:799-802. Luderer JR, Hayes AH Jr, Dubnsky O, Cerlin CM. Long-term administration of sodium nitroprusside in childhood. J Pediatr 1977;91:490-491. Treluyer JM, Hubert P, Jouvet P, Couderc S, Cloup M. Intravenous nicardipine in hypertensive children. Eur J Pediatr 1993;152:712-714. Flynn JT, Mottes TA, Brophy PD, Kershaw DB, Smoyer WE, Bunchman TE. Intravenous nicardipine for treatment of severe hypertension in children. J Pediatr 2001;139:38-43. Michael J, Groshong T, Tobias JD. Nicardipine for hypertensive emergencies in children with renal disease. Pediatr Nephrol 1998;12:40-42. Sinaiko AR. Treatment of hypertension in children. Pediatr Nephrol 1994;6:603-660. Bunchman TE, Lynch RE, Wood EG. Intravenously administered labetalol for treatment of hypertension in children. J Pediatr 1992;120:140-144. Trippel DL, Wiest DB, Gillette PC. Cardiovascular and antiarrhythmic effects of esmolol in children. J Pediatr 1991;119:142-147. Wiest DB, Garner SS, Uber WE, Sade RM. Esmolol for the management of pediatric hypertension after cardiac operations. J Thorac Cardiovasc Surg 1998; 115:890-897. Hirschl MM, Binder M, Bur A, Herkner H, Brunner M, Mullner M, et al. Clinical evaluation of different doses of intravenous enalaprilat in patients with hypertensive crisis. Arch Intern Med 1995;155:22172223.

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∞¡∞™∫√¶∏™∏

REVIEW ARTICLE

∏ Â›‰Ú·ÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ Î·È Ô ÚfiÏÔ˜ ÙˆÓ ·ÈˆÚÔ‡ÌÂÓˆÓ ÛˆÌ·Ùȉ›ˆÓ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ· ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., ¡ÔÛÔÎÔÌÂ›Ô ¶··ÁˆÚÁ›Ô˘ £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: ÷ϤÌ˘ ∑·¯·Ú›·˜ ™. ∫·Ú·Ù˙¿ 25 ∫·Ï·Ì·ÚÈ¿ ∆.∫. 551 32, £ÂÛÛ·ÏÔÓ›ÎË E-mail: zaxosped@hol.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 07-06-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 30-09-2005

∑. ÷ϤÌ˘, °. µ·ÚÏ¿Ì˘

¶ÂÚ›ÏË„Ë: ∏ ·¤ÚÈ· Ú‡·ÓÛË (·ÙÌÔÛÊ·ÈÚÈÎÔ› Ú‡ÔÈ) Î·È Î˘Ú›ˆ˜ Ù· ·ÈˆÚÔ‡ÌÂÓ· ۈ̷ٛ‰È· Ô˘ ·ÓȯÓ‡ÔÓÙ·È ÛÙÔ Ó¤ÊÔ˜ ÙˆÓ ÌÂÁ·ÏÔ˘fiÏÂˆÓ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù·, ÂÌÊ¿ÓÈÛË Î·ÚΛÓÔ˘ ·ÏÏ¿ Î·È Î·Ú‰È·Î¿ ÚÔ‚Ï‹Ì·Ù·, ÙfiÛÔ Û ÂÓ‹ÏÈΘ fiÛÔ Î·È Û ·È‰È¿, Û ‚·ıÌfi Ô˘ Ó· ıˆÚÔ‡ÓÙ·È ˘‡ı˘Ó· ÁÈ· ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· Û ÂÚÈfi‰Ô˘˜ ·˘ÍË̤Ó˘ ·ÙÌÔÛÊ·ÈÚÈ΋˜ Ú‡·ÓÛ˘. ™ÙÔ ¿ÚıÚÔ ·˘Ùfi Á›ÓÂÙ·È Û‡ÓÙÔÌË ·Ó·ÛÎfiËÛË ÙˆÓ ÂȉڿÛÂˆÓ ÙˆÓ ·ÈˆÚÔ‡ÌÂÓˆÓ ÛˆÌ·Ùȉ›ˆÓ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi, Ì ¤ÌÊ·ÛË ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ·. ∂ȉÈ΋ ÂÈÛ‹Ì·ÓÛË Á›ÓÂÙ·È ÁÈ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ‰È·ÙÚ¤¯Ô˘Ó Ù· ·È‰È¿, Ù· ÔÔ›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÔÚÈṲ̂Ó˜ ‰˘Ó·ÙfiÙËÙ˜ ·˘ÙÔÚÔÛÙ·Û›·˜. ∆· ϤÔÓ ÂÈΛӉ˘Ó· ·ÈˆÚÔ‡ÌÂÓ· ۈ̷ٛ‰È· Â›Ó·È Ù· ÌÈÎÚ¿ (ƒª2,5) Î·È Ù· Ôχ ÌÈÎÚ¿ ÂÈÛÓ‡ÛÈÌ· (ƒª0,1), ηıÒ˜ Â›Ó·È ‰È·Ï˘Ù¿, ÌÂٷʤÚÔÓÙ·È Â‡ÎÔÏ· ·fi ÙȘ ΢„ÂÏ›‰Â˜ ÛÙË ÁÂÓÈ΋ ΢ÎÏÔÊÔÚ›· Î·È ¤¯Ô˘Ó ·¢ı›·˜ ‰Ú¿ÛË Û ‰È¿ÊÔÚ· fiÚÁ·Ó· Î·È ÛÙËÓ Î·Ú‰È¿, fiÔ˘ ÚÔηÏÔ‡Ó ·ÚÚ˘ı̛˜, ‰È·Ù·Ú·¯¤˜ Ù˘ Â·Ó·fiψÛ˘, ‚Ú·‰˘Î·Ú‰›·, ·ÁÁÂÈÔÛ‡Û·ÛË ·ÎfiÌË Î·È ¤ÌÊÚ·ÁÌ·. ∏ ·¢ı›·˜ ‰Ú¿ÛË ÙÔ˘˜ ÛÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÈΛӉ˘Ó˜ Ù·¯˘Î·Ú‰›Â˜, ̤¯ÚÈ Î·È ÈÓȉÈÛÌfi. ∆· Ì·ÎÚÔÊ¿Á· ÙˆÓ Î˘„ÂÏ›‰ˆÓ, ÌÂÙ¿ ÙËÓ Ê·ÁÔ·ÙÙˆÛË ÙˆÓ ·ÈˆÚÔ‡ÌÂÓˆÓ ÛˆÌ·Ùȉ›ˆÓ, ÂÎÎÚ›ÓÔ˘Ó Î˘ÙÔΛÓ˜, ÔÈ Ôԛ˜ -ÌÂٷ͇ ¿ÏψÓ- ÚÔηÏÔ‡Ó ·‡ÍËÛË Ù˘ ÂÓ‰ÔıËÏ›Ó˘ (∂∆-1) ÛÙÔ ·›Ì·, Ì ·ÔÙ¤ÏÂÛÌ· ·ÁÁÂÈÔÛ‡Û·ÛË, ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Î·È ÂÌÊÚ¿ÁÌ·ÙÔ˜. ∆· ·È‰È¿ Â›Ó·È ÈÔ Â˘·›ÛıËÙ· ÛÙËÓ ·¤ÚÈ· Ú‡·ÓÛË, Ì·˙› Ì ÙÔ˘˜ ˘ÂÚ‹ÏÈΘ, ÙÔ˘˜ ¯ÚfiÓÈÔ˘˜ Ó¢ÌÔÓÔ·ı›˜ Î·È ÙÔ˘˜ ηډÈÔ·ı›˜, ÂÓÒ ÚfiÛÊ·Ù· ·Ó·Ê¤ÚıËΠ·ÎfiÌË Î·È ÂÓ‰ÔÌ‹ÙÚÈÔ˜ ı¿Ó·ÙÔ˜ ÂÌ‚Ú‡ˆÓ. §¤ÍÂȘ ÎÏÂȉȿ: ∞¤ÚÈ· Ú‡·ÓÛË, ·ÈˆÚÔ‡ÌÂÓ· ۈ̷ٛ‰È·, ηډȷÁÁÂÈ·Îfi Û‡ÛÙËÌ·.

The effect of air pollution and the effects of fine particulate matter on the circulatory system 4th Pediatric Clinic of the Aristotle University, Papageorgiou Hospital, Thessaloniki Correspondence: Chalemis Zacharias 25, S. Karatza Str., Kalamaria 551 32, Thessaloniki E-mail: zaxosped@hol.gr Date of submission: 07-06-2005 Date of approval: 30-09-2005

Z. Chalemis, G. Varlamis

Abstract: Inhaled air pollutants and especially ambient air particulate matter (PM) have been identified as causing respiratory problems, cancer and heart disease, in both adults and children, even to the extent that increased mortality is observed in periods of increased PM air pollution. Here a brief review is made of PM and its effects in humans, with emphasis on the cardiovascular system. Special emphasis has been given to the dangers in childhood, when the mechanisms of autoprotection are less well developed. The most dangerous particles are the “fine” (aerodynamic diameter <2.5 Ìm, PM2.5) and the “ultrafine” (aerodynamic diameter <0.1 Ìm, PM0.1) particles, as they are solvable, can be transmitted easily into the circulation and exert immediate action on various systems, including the heart. In the cardiovascular system they may cause arrhythmias, exacerbation of ST-segment, bradycardia, arterial vasoconstriction even myocardial infarction. The direct effect on the autonomic nervous system can lead to dangerous tachycardia or even inidism. When alveolar macrophages are exposed to PM produce cytokines, which promote increase of the levels of endothelin-1 (ET-1) in the blood. This results in vasoconstriction, a rise in blood pressure and increased risk of coronary heart disease and myocardial infarction. Children, the elderly and patients with chronic cardiovascular disease are the groups most sensitive to air pollution, but recently even intrauterine fetal death has been reported. Key words: Air pollution, particulate matter, cardiovascular system.

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∏ Â›‰Ú·ÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi

∂ÈÛ·ÁˆÁ‹ ∏ Û¯¤ÛË ÙˆÓ ·ÈˆÚÔ‡ÌÂÓˆÓ ÛˆÌ·Ùȉ›ˆÓ ÙÔ˘ ·¤Ú· ÛÙËÓ ·ıÔÏÔÁ›· ÓfiÛˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÙÔ˘ ηÚΛÓÔ˘ ÙÔ˘ Ó‡ÌÔÓ· ¤¯ÂÈ ·Ô‰Âȯı› Â‰Ò Î·È ·ÚÎÂÙ¿ ¯ÚfiÓÈ· (1-4). ∆ËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› Ô ÚfiÏÔ˜ ÙÔ˘˜ Î·È Û ·ı‹ÛÂȘ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙfiÛÔ Ì ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜, fiÛÔ Î·È Ì ÂÈÚ·Ì·ÙÈΤ˜ ÂÚÁ·Û›Â˜ (5-7), ÛÙȘ Ôԛ˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ë ·‡ÍËÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ Û¯ÂÙ›˙ÂÙ·È Ì ·‡ÍËÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜, ÙˆÓ ÂÈÛ·ÁˆÁÒÓ Û ÓÔÛÔÎÔÌ›· Î·È Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ·fi ηډȷÁÁÂȷο ·›ÙÈ·. ∫¿ı ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ Î·È Î¿ı fiÏË ¤¯ÂÈ ÙË ‰È΋ Ù˘ ÔÈÎÈÏ›· Ú‡ˆÓ. ŒÙÛÈ ÔÈ ı¿Ó·ÙÔÈ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·¤ÚÈ· Ú‡·ÓÛË ‰È·Ê¤ÚÔ˘Ó ÛÙȘ ‰È¿ÊÔÚ˜ ÛÙ·ÙÈÛÙÈΤ˜ (2-7).

∂›‰Ë ۈ̷Ùȉ›ˆÓ ∆· ∞ȈÚÔ‡ÌÂÓ· ™ˆÌ·Ù›‰È· (∞™), Ù· ÔÔ›· ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ˆ˜ Particulate Matter (PM), Â›Ó·È ÛÙÂÚ¿ ‹ ˘ÁÚ¿ ۈ̷ٛ‰È· (ÛÙ·ÁÔÓ›‰È·), Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ‰È·ÛÔÚ¿ ÛÙËÓ ·ÙÌfiÛÊ·ÈÚ· Î·È Î·Ï‡ÙÔ˘Ó Â˘Ú‡ Ê¿ÛÌ· ÌÂÁÂıÒÓ, Ì ·ÂÚÔ‰˘Ó·ÌÈ΋ ‰È¿ÌÂÙÚÔ d ·fi <0,1 Ìm ̤¯ÚÈ >100 Ìm. ∞ÔÙÂÏÔ‡ÓÙ·È ·fi Ì›ÁÌ· ÚÔ˚fiÓÙˆÓ Î·‡ÛˆÓ, ‚·Ú¤ˆÓ ÌÂÙ¿ÏψÓ, ¯ËÌÈÎÒÓ ·Ï¿ÙˆÓ Î·È ‚ÈÔÏÔÁÈÎÒÓ ˘ÏÈÎÒÓ fiˆ˜ ÌÈÎÚfi‚È·, ÈÔ› Î·È ÂÓ‰ÔÙÔ͛Ә (8). ∏ ¯ËÌÈ΋ ÙÔ˘˜ Û‡ÛÙ·ÛË ‰È·Ê¤ÚÂÈ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÁ‹ ÂÎÔÌ‹˜ ÙÔ˘˜. ¢È·ÎÚ›ÓÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ ·) Û “·Ó¿ÈÙ·”, Ì ÌÂÁ¿ÏÔ Ì¤ÁÂıÔ˜ (>10 Ìm) Î·È ÌÈÎÚfi ¯ÚfiÓÔ ·ÈÒÚËÛ˘, Ô˘ ηٷÎÚ·ÙÔ‡ÓÙ·È ·fi ÙÔÓ ÚÈÓÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î·È ‰ÂÓ ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi, ‚) Û “·Ó·Ó‡ÛÈÌ·” (coarce, PM10 2,5-10 Ìm), Ù· ÔÔ›· ·Ó¿ÏÔÁ· Ì ÙË ¯ËÌÈ΋ ÙÔ˘˜ Û‡ÛÙ·ÛË ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ·ÛıÌ·ÙÈΤ˜ ÎÚ›ÛÂȘ, ̤¯ÚÈ Î·ÚΛÓÔ ÙÔ˘ Ó‡ÌÔÓ·, Á) Û “ÏÂÙ¿” ‹ “ÌÈÎÚ¿” (fine PM2,5 <2,5 Ìm) Î·È ‰) Û “Ôχ ÏÂÙ¿” ‹ “Ôχ ÌÈÎÚ¿” (ultrafine PM0,1 <0,1 Ìm) ۈ̷ٛ‰È·. √È ‰‡Ô ÙÂÏÂ˘Ù·›Â˜ ηÙËÁÔڛ˜ ۈ̷Ùȉ›ˆÓ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙȘ ‚Ï¿‚˜ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ·, ηıÒ˜ Â›Ó·È ‰È·Ï˘Ù¿ Î·È ·fi ÙȘ ΢„ÂÏ›‰Â˜ ÌÂٷʤÚÔÓÙ·È ·¢ı›·˜ ÛÙË ÁÂÓÈ΋ ΢ÎÏÔÊÔÚ›· (8). ∆· ÈÔ ÂÈΛӉ˘Ó· ∞™ Â›Ó·È ÙÔ˘ ÌÔχ‚‰Ô˘ (·fi ‚ÂÓ˙›Ó˜ Ì ·ÓÙÈÎÚÔÙÈο), ÙÔ˘ ·ÌÈ¿ÓÙÔ˘ (˘ÏÈο ÊÚ¤ÓˆÓ ·˘ÙÔÎÈÓ‹ÙˆÓ) ηıÒ˜ Î·È ÛˆÌ·Ù›‰È· ¯ËÌÈÎÒÓ ·Ï¿ÙˆÓ Î·È ¿ÏÏˆÓ ÌÂÙ¿ÏÏˆÓ ·fi ‰Â˘ÙÂÚÔÁÂÓ›˜ ¯ËÌÈΤ˜ ·ÓÙȉڿÛÂȘ. ÕÏÏ· ÙÔÍÈο ∞™

Â›Ó·È ·˘Ù¿ Ô˘ ÂÚȤ¯Ô˘Ó ηÚÎÈÓÔÁfiÓÔ˘˜ ÔÏ˘·ÚˆÌ·ÙÈÎÔ‡˜ ˘‰ÚÔÁÔÓ¿ÓıڷΘ. √È ËÁ¤˜ Ú‡·ÓÛ˘ Ù˘ ·ÙÌfiÛÊ·ÈÚ·˜ Ì ∞™ Â›Ó·È ÔÈ ‚ÈÔÌ˯·Ó›Â˜ (ÙÛÈÌÂÓÙÔ·Ú·ÁˆÁ‹˜, Ï·ÙÔÌ›·, ÂÚÁÔÛÙ¿ÛÈ· ·Ú·ÁˆÁ‹˜ ËÏÂÎÙÚÈÎÔ‡ Ú‡̷ÙÔ˜, ¯·Ï˘‚Ô˘ÚÁ›·), ÔÈ ÎÂÓÙÚÈΤ˜ ıÂÚÌ¿ÓÛÂȘ ÔÈÎÈÒÓ Î·È ÔÏ˘Î·ÙÔÈÎÈÒÓ, ÔÈ ÂÍ·ÙÌ›ÛÂȘ ·˘ÙÔÎÈÓ‹ÙˆÓ, Ë ÙÚÈ‚‹ ÂÏ·ÛÙÈÎÒÓ Î·È Ë ÛÎfiÓË ÙÔ˘ ‰¿ÊÔ˘˜. ∫˘ÚÈfiÙÂÚË ËÁ‹ ·ÛÙÈÎÒÓ Ú‡ˆÓ Â›Ó·È Ù· ·˘ÙÔΛÓËÙ· (ÔÛÔÛÙfi ·fi 46,7-64,3%) Î·È Ë Î·‡ÛË ÂÙÚÂÏ·›Ô˘ (ÔÛÔÛÙfi 8,4-28%) (9).

∞ÙÌÔÛÊ·ÈÚÈÎÔ› Ú‡ÔÈ √È Î˘ÚÈfiÙÂÚÔÈ ·ÙÌÔÛÊ·ÈÚÈÎÔ› Ú‡ÔÈ Â›Ó·È ÙÔ ‰ÈÔÍ›‰ÈÔ ÙÔ˘ ı›Ԣ (SO2, ηÙ' ÂÍÔ¯‹Ó ‚ÈÔÌ˯·ÓÈÎfi˜ Ú‡Ô˜), Ù· ·˙ˆÍ›‰È·, Ô˘ ‰È·ÎÚ›ÓÔÓÙ·È Û ÓÈÙÚÈο ÔÍ›‰È· (NOx) Î·È ‰ÈÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ (NO2) Î·È Â›Ó·È Î˘Ú›ˆ˜ ÚÔ˚fiÓÙ· η‡ÛˆÓ, ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη (C√, ÚÔ˚fiÓ Î·‡ÛÂˆÓ Â›Û˘), Ë Ù¤ÊÚ· (ÂÚȤ¯ÂÈ ÔÍ›‰È· ÌÂÙ¿ÏÏˆÓ ·fi η‡ÛË ÏÈÁÓ›ÙË ÁÈ· ·Ú·ÁˆÁ‹ ËÏÂÎÙÚÈÎÔ‡ Ú‡̷ÙÔ˜), ÔÈ ˘‰ÚÔÁÔÓ¿ÓıڷΘ (∏C, ·fi ·ÙÂÏ‹ η‡ÛË ·˘ÙÔÎÈÓ‹ÙˆÓ) Î·È ÙÔ fi˙ÔÓ (O3, ÚÔ˚fiÓ ÊˆÙÔ¯ËÌÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙËÓ ·ÙÌfiÛÊ·ÈÚ· ·fi NOx, O2 Î·È ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›·). √ ηı¤Ó·˜ ·fi ÙÔ˘˜ Ú‡Ô˘˜ ·˘ÙÔ‡˜ ¤¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ Â›‰Ú·ÛË ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi (¶›Ó·Î·˜ 1).

∞Ó·Ó¢ÛÙÈÎfi ∏ Û¯¤ÛË ÙˆÓ ·ÙÌÔÛÊ·ÈÚÈÎÒÓ Ú‡ˆÓ Î·È ÙˆÓ ∞™ Ì ·ı‹ÛÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ¤¯ÂÈ ÌÂÏÂÙËı› Î·È ÂÚÈÁÚ·Ê› ‰ÈÂÍÔ‰Èο. ∆· ÌÂÁ·Ï‡ÙÂÚ· ∞™ Ô˘ ηٷÎÚ·ÙÔ‡ÓÙ·È ÛÙÔÓ ÚÈÓÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, ÙËÓ ÙÚ·¯Â›· Î·È ÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜ ÚÔηÏÔ‡Ó ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, ÙÚ·¯ÂÈ›Ùȉ·, ¯ÚfiÓÈ· ‚ÚÔÁ¯›Ùȉ· Î·È ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·. √È ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜ fiˆ˜ SO2, NOx, O3 Î·È ·ÏÏÂÚÁÈÔÁfiÓ· ۈ̷ٛ‰È· ÚÔηÏÔ‡Ó ¿ÛıÌ· Î·È ¯ÚfiÓȘ ·ÔÊÚ·ÎÙÈΤ˜ Ó¢ÌÔÓÔ¿ıÂȘ, ÂÓÒ ÙÔ ‚ÂÓ˙fiÏÈÔ, Ô ·Ì›·ÓÙÔ˜ Î·È ¿ÏÏ· ‚·Ú¤· ̤ٷÏÏ· ÚÔηÏÔ‡Ó Î·ÚΛÓÔ ÙÔ˘ Ó‡ÌÔÓ· (∂ÈÎfiÓ· 1) (1). ∆· ۈ̷ٛ‰È· Ì ‰È¿ÌÂÙÚÔ <10 Ìm ‰ÈÂÈÛ‰‡Ô˘Ó ÛÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi Î·È ÚÔηÏÔ‡Ó ›ÓˆÛË Î·È ‰ËÌÈÔ˘ÚÁ›· ÎÔÎÎȈ̿وÓ. ∆· ÌÈÎÚ¿ (<2,5 Ìm) Î·È Ù· Ôχ ÌÈÎÚ¿ ∞™ (<0,1 Ìm) Â›Ó·È Î·È Ù· ÈÔ ÂÈΛӉ˘Ó·, ÁÈ·Ù› ·ÊÂÓfi˜ ‰ÈÂÈÛ‰‡Ô˘Ó ·¢ı›·˜ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ‰ÚÔ˘Ó Û ‰È¿ÊÔÚ· fiÚÁ·Ó·, ·ÊÂÙ¤ÚÔ˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ¶·È‰È·ÙÚÈ΋ 2006;69:18-24


Pediatr Jan-Feb 06 final allges

27-01-06

15:34

™ÂÏ›‰·20

20

∑. ÷ϤÌ˘, °. µ·ÚÏ¿Ì˘

¶›Ó·Î·˜ 1. ∞ÙÌÔÛÊ·ÈÚÈÎÔ› Ú‡ÔÈ, ËÁ‹ ÚÔ¤Ï¢Û˘ Î·È Â›‰Ú·ÛË ÛÙËÓ ˘Á›· (46) ƒ‡ÔÈ µÂÓ˙fiÏÈÔ µ·Ú¤· ̤ٷÏÏ· ñ ·ÚÛÂÓÈÎfi ñ ο‰ÌÈÔ ñ ÌfiÏ˘‚‰Ô˜ ñ ˘‰Ú¿ÚÁ˘ÚÔ˜ ñ ÓÈΤÏÈÔ ¢ÈÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ Ÿ˙ÔÓ

¢ÈÔÍ›‰ÈÔ ÙÔ˘ ı›Ԣ ∞ȈÚÔ‡ÌÂÓ· ۈ̷ٛ‰È·

∫‡ÚÈ· ËÁ‹

™˘Ó¤ÂȘ

∞˘ÙÔΛÓËÙ· ÃËÌÈ΋ ‚ÈÔÌ˯·Ó›· µÈÔÌ˯·Ó›· ∞˘ÙÔΛÓËÙ·

∫·ÚΛÓÔ˜ ¶ÚÔÛ‚ÔÏ‹ ∫¡™ ∫·ÚΛÓÔ˜ µÏ¿‚˜ ÂÙÈÎÔ‡ µÏ¿‚˜ ∫¡™

∞˘ÙÔΛÓËÙ· ∫·‡ÛÂȘ ¡√x ·fi ·˘ÙÔΛÓËÙ· +√2 + ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· ∫·‡ÛÂȘ ∫·‡ÛÂȘ µÈÔÌ˯·Ó›·

µÏ¿‚˜ ·Ó·Ó¢ÛÙÈÎÔ‡

‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ ÙˆÓ Î˘„ÂÏ›‰ˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ‚Ú¤ıËÎ·Ó ·˘ÍË̤ÓÔÈ ÔÈ “‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜”, fiˆ˜ Ë CRP Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ηıÒ˜ Î·È ‰È¿ÊÔÚ˜ ΢ÙÔΛÓ˜ Î·È Ô TNF, Ô˘ ÂÎÎÚ›ÓÔÓÙ·È ·fi Ù· ÂÓÂÚÁÔÔÈË̤ӷ Ì·ÎÚÔÊ¿Á· (8,10).

∫·Ú‰È·ÁÁÂÈ·Îfi Î·È ∞˘ÙfiÓÔÌÔ ¡Â˘ÚÈÎfi ™‡ÛÙËÌ· ∂ȉËÌÈÔÏÔÁÈΤ˜ ¤Ú¢Ó˜ ¤¯Ô˘Ó ·ԉ›ÍÂÈ ÙË Û˘Û¯¤ÙÈÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ Ì ÙË ÓÔÛË-

µÏ¿‚˜ ·Ó·Ó¢ÛÙÈÎÔ‡ ÕÛıÌ·, ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ∂Ï¿ÙÙˆÛË ·ÓÙ›ÛÙ·Û˘ Û ÏÔÈÌÒÍÂȘ µÏ¿‚˜ ·Ó·Ó¢ÛÙÈÎÔ‡ ∫·ÚΛÓÔ˜ µÏ¿‚˜ ·Ó·Ó¢ÛÙÈÎÔ‡ µÏ¿‚˜ ηډȷÁÁÂÈ·ÎÔ‡ µÚÂÊÈ΋ ıÓËÛÈÌfiÙËÙ·

ÚfiÙËÙ· Î·È ÙË ıÓËÛÈÌfiÙËÙ· ·fi ·ı‹ÛÂȘ ÙÔ˘ ηډÈÔ·Ó·Ó¢ÛÙÈÎÔ‡ ·ÏÏ¿ Î·È ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (11). ∏ ·¢ı›·˜ ›ÛÔ‰Ô˜ ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ÛˆÌ·Ùȉ›ˆÓ ·fi ÙȘ ΢„ÂÏ›‰Â˜ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ·›Ì·ÙÔ˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·ÛÔÚ¿ Î·È ÙË ‰Ú¿ÛË ÙÔ˘˜ Û ‰È¿ÊÔÚ· fiÚÁ·Ó· (‹·Ú, ÓÂÊÚÔ›, ı˘ÚÂÔÂȉ‹˜ ·‰¤Ó·˜, ÛÈÂÏÔÁfiÓÔÈ, ÛÙfiÌ·¯Ô˜) (10), ÂÓÒ ·Ú·ÙËÚ‹ıËΠfiÙÈ ÚÔηÏÔ‡ÓÙ·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·˘ÙfiÓÔÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ·ÔÙ¤ÏÂÛÌ· Ù·¯˘Î·Ú‰›· ‹ ‚Ú·‰˘Î·Ú‰›·, ·ÁÁÂÈÔÛ‡Û·ÛË, ηډȷΤ˜ ·ÚÚ˘ı̛˜ ·ÎfiÌË Î·È Î·Ú‰È·Îfi ¤ÌÊÚ·ÁÌ· ‹ ÌfiÓÔ

ƒÈÓ›Ùȉ· - Ï·Ú˘ÁÁ›Ùȉ· ∆· ÌÂÁ¿Ï· ۈ̷ٛ‰È· Û˘ÁÎÚ·ÙÒÓÙ·È ÛÙË Ì‡ÙË, ÙÔÓ Ê¿Ú˘ÁÁ· Î·È ÙÔÓ Ï¿Ú˘ÁÁ·. ∆· ‰È·Ï˘Ù¿ ·¤ÚÈ· (SO2) ·ÔÚÚÔÊÒÓÙ·È ·fi ÙÔ ·ÓÒÙÂÚÔ ·Ó·Ó¢ÛÙÈÎfi Î·È ÚÔηÏÔ‡Ó Ô›‰ËÌ· Î·È ˘ÂÚ¤ÎÎÚÈÛË ‚ϤÓÓ˘.

ƒÈÓÈ΋ ÎÔÈÏfiÙËÙ· º¿Ú˘ÁÁ·˜ §¿Ú˘ÁÁ·˜

∆Ú·¯ÂÈ›Ùȉ· - ‚ÚÔÁ¯›Ùȉ· - ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ™ˆÌ·Ù›‰È· ‰È·Ì¤ÙÚÔ˘ >10 Ìm Û˘ÁÎÚ·ÙÒÓÙ·È Î·È ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi ÙÔ˘˜ ÎÚÔÛÛÔ‡˜. ªÈÎÚfiÙÂÚ· ۈ̷ٛ‰È· Û˘ÁÎÚ·ÙÒÓÙ·È ÛÙ· ‚ÚÔÁ¯ÈfiÏÈ·. §ÈÁfiÙÂÚÔ ‰È·Ï˘Ù¿ ·¤ÚÈ· ‰ÈÂÈÛ‰‡Ô˘Ó ‚·ı‡ÙÂÚ·.

∆Ú·¯Â›· µÚfiÁ¯ÔÈ

ÕÛıÌ· Î·È ¯ÚfiÓÈ· ·ÔÊÚ. Ó¢ÌÔÓÔ¿ıÂÈ· ∞ÏÏÂÚÁÈÔÁfiÓ· Î·È ÂÚÂıÈÛÙÈΤ˜ Ô˘Û›Â˜ ÂÓ·ÔÙ›ıÂÓÙ·È ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ÚÔηÏÒÓÙ·˜ ¯ÚfiÓȘ ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ. ∫·ÚΛÓÔ˜ ∫·ÚÎÈÓÔÁfiÓ· ۈ̷ٛ‰È· (·Ì›·ÓÙÔ˜, ÔÏ˘Î˘ÎÏÈÎÔ› ·ÚˆÌ·ÙÈÎÔ› ˘‰ÚÔÁÔÓ¿ÓıڷΘ) ÂȉÚÔ‡Ó ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ÚÔηÏÒÓÙ·˜ ÌÂÙ·ÏÏ¿ÍÂȘ Î·È Î·ÎÔ‹ıË ÂÍ·ÏÏ·Á‹. ¢È¿ÌÂÛË ÓfiÛÔ˜ ™ˆÌ·Ù›‰È· <10 Ìm Î·È ›Ó˜ Êı¿ÓÔ˘Ó ÛÙ· ÙÂÏÈο ‚ÚÔÁ¯ÈfiÏÈ· Î·È ÙȘ ΢„ÂÏ›‰Â˜ Î·È ‰ÈÂÈÛ‰‡Ô˘Ó ÛÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi ÚÔηÏÒÓÙ·˜ ›ÓˆÛË Î·È ‰ËÌÈÔ˘ÚÁ›· ÎÔÎÎȈ̿وÓ.

µÚÔÁ¯ÈfiÏÈ· ∫˘„ÂÏ›‰Â˜

∂ÈÎfiÓ· 1. ∂·ÁÁÂÏÌ·ÙÈο ÓÔÛ‹Ì·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. √È ·Ó·ÙÔÌÈΤ˜ ı¤ÛÂȘ ÙÔ˘˜ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·, ·Ú·‰Â›ÁÌ·Ù· ÙˆÓ Û˘ÓËı¤ÛÙÂÚˆÓ ÛˆÌ·Ùȉ›ˆÓ-·ÈÙ›ˆÓ Î·È Ë ·ıÔÊ˘ÛÈÔÏÔÁÈ΋ ÙÔ˘˜ ‰Ú¿ÛË (∆ÚÔÔÔÈË̤ÓÔ ·fi: William S Beckett, MD N Engl J Med 2000;342:406-412)(1). ¶·È‰È·ÙÚÈ΋ 2006;69:18-24


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∏ Â›‰Ú·ÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi

‰È·Ù·Ú·¯¤˜ Ù˘ Â·Ó·fiψÛ˘ (12-18). ¶Èı·ÓÔÏÔÁÂ›Ù·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ÙfiÓÔ˘ ÙÔ˘ Ó¢ÌÔÓÔÁ·ÛÙÚÈÎÔ‡ Ó‡ÚÔ˘ (14), ¯ˆÚ›˜ Ó· ·ÔÎÏ›ÂÙ·È Â›Û˘ Ë ·¢ı›·˜ ‰Ú¿ÛË ÙˆÓ ∞™ ÛÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·, Ë ÔÔ›· ÚÔηÏ› ¢ÂÚÂıÈÛÙfiÙËÙ· ÙˆÓ Î·Ú‰È·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÈÓÒÓ Î·È ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹ Ù·¯˘Î·Ú‰›Â˜, ̤¯ÚÈ Î·È Û ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ (14-18) (∂ÈÎfiÓ· 2).

∞›Ì· ∞‡ÍËÛË Ù˘ ËÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÌÂÙ¿ ·fi ÂÈÛÓÔ‹ ·ÂÚ›ˆÓ Ú‡ˆÓ ›¯Â ·Ú·ÙËÚËı› ·fi ∂˘Úˆ·›Ô˘˜ ÂÚ¢ÓËÙ¤˜ Û ÂÓ‹ÏÈΘ ·fi ÙÔ 1985 (19). ∏ ÊÏÂÁÌÔÓ҉˘ ‰ÈÂÚÁ·Û›·, Ô˘ ¤¯ÂÈ ·ÊÂÙËÚ›· ÙÔ˘˜ Ó‡ÌÔÓ˜ Ì ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÔÎÈÓÒÓ (IL-1-beta, IL-6) Î·È TNF-alfa

¶ÚÔ¿ÁÔ˘Ó ÌÈ· Û˘ÛÙËÌ·ÙÈ΋ ·¿ÓÙËÛË stress ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡

·fi Ù· Ì·ÎÚÔÊ¿Á·, ÌÂÙ¿ ·fi ÂÈÛÓÔ‹ ∞™, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Â˘ÓÔ› ÙËÓ ·Ó¿Ù˘ÍË ·ıËڈ̷ÙÈÎÒÓ ‚Ï·‚ÒÓ Î·È ÙËÓ ·‡ÍËÛË Ù˘ CRP ÙÔ˘ ÔÚÔ‡, ¯ˆÚ›˜ Ó· ÂËÚ¿˙ÔÓÙ·È ÔÈ ÙÈ̤˜ ÙˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ÔÚÔ‡ (20). ¶·Ï·ÈfiÙÂÚ˜, ·ÏÏ¿ Î·È ÚfiÛÊ·Ù˜ ÌÂϤÙ˜, ¤¯Ô˘Ó ·ԉ›ÍÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ Î˘ÙÔÎÈÓÒÓ Ì ÌÂÙ·‚ÔϤ˜ ÛÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÂÚ˘ıÚÒÓ Î·È Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙÔ ·›Ì·, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÌÂÙ·‚ÔϤ˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, Ì ÛËÌ›· ‰È·Ù·Ú·¯‹˜ Ù˘ ËÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ·›Ì·ÙÔ˜ (·‡ÍËÛË ÈÓˆ‰ÔÁfiÓÔ˘ Ï¿ÛÌ·ÙÔ˜) (21,22) Î·È ÂÔ̤ӈ˜ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÈÛ¯·ÈÌÈÎÒÓ ‚Ï·‚ÒÓ (19-23).

∂Ó‰ÔıËÏ›ÓË-1 ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·¤‰ÂÈÍ·Ó ÙËÓ ¤ÓÙÔÓË ·ÁÁÂÈÔÛ‡Û·ÛË Û ˘ÁÈ‹ ¿ÙÔÌ· ÌÂÙ¿ ·fi

∂ÈÛÓÂfiÌÂÓ· ۈ̷ٛ‰È· ÂÚÈ‚¿ÏÏÔÓÙÔ˜

∞·ÓÙ‹ÛÂȘ ∫¡™

 ∫·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ·

¢È·Î‡Ì·ÓÛ˘ ηډȷ΋˜  Ù˘ Û˘¯ÓfiÙËÙ·˜

¢È¤ÁÂÚÛË Â˘·›ÛıËÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜

 ÕÓÔÈ·  ‚ÚÔÁ¯fiÛ·ÛÌÔ˜

ÁÚ‹ÁÔÚ˜ & ÂÈfiϷȘ ·Ó·ÓÔ¤˜

ºÏÂÁÌÔÓ‹ ÛÙÔÓ Ó‡ÌÔÓ· ÙÔ˘  ∞ÓÙ›‰Ú·ÛË Ó¢ÌÔÓÔÁ·ÛÙÚÈÎÔ‡ ÛÙË Î·Ú‰È¿

™¯¤ÛË Ã·ÌËÏ‹˜

 Û˘¯ÓfiÙËÙ·˜ /

Ù˘  ¢È·Î‡Ì·ÓÛË Î·Ú‰È·Î‹˜ Û˘¯ÓfiÙËÙ·˜

˘„ËÏ‹ Û˘¯ÓfiÙËÙ·

˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ Ù˘  ¶ÂÚÈÔ¯‹ ‰È·Î‡Ì·ÓÛ˘ Ù˘ ηډ. Û˘¯ÓfiÙËÙ·˜ ∆·¯˘·ÚÚ˘ıÌ›· & ∫ÔÈÏÈ·Îfi˜ ÈÓȉÈÛÌfi˜

 ™˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓ‹

µÚ·‰˘·ÚÚ˘ı̛˜

∂ÈÎfiÓ· 2. ÀÔıÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ì ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ÂÈÛÓÂfiÌÂÓ· ۈ̷ٛ‰È· ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË Ó¢ÚÈ΋ Ú‡ıÌÈÛË Ù˘ ηډȿ˜ (∆ÚÔÔÔÈË̤ÓÔ ·fi Stone PH and Godleski JJ, Am Heart J 1999;138:804-807)(13). ¶·È‰È·ÙÚÈ΋ 2006;69:18-24


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∑. ÷ϤÌ˘, °. µ·ÚÏ¿Ì˘

ÂÈÛÓÔ‹ ۈ̷Ùȉ›ˆÓ ƒª2,5 Î·È fi˙ÔÓÙÔ˜ √3 (24,25). ™Â ·˘Ù‹Ó ÂÓÔ¯ÔÔÈÂ›Ù·È Ô Ì˯·ÓÈÛÌfi˜ ·Ú·ÁˆÁ‹˜ ÌÈ·˜ ÈÛ¯˘ÚfiÙ·Ù˘ ·ÁÁÂÈÔÛ˘Û·ÛÙÈ΋˜ Ô˘Û›·˜, Ù˘ ÂÓ‰ÔıËÏ›Ó˘-1 (∂∆-1). ∞Ó¿ÏÔÁÔ˜ Ì˯·ÓÈÛÌfi˜ ·Ú·ÁˆÁ‹˜ Ù˘ ∂∆-1 ·Ú·ÙËÚ‹ıËΠ۠ηÓÈÛÙ¤˜ (26). ™‡Ìʈӷ Ì ÙÔÓ Ì˯·ÓÈÛÌfi ·˘ÙfiÓ, ÔÈ ÂχıÂÚ˜ Ú›˙˜ ¿Óıڷη Î·È √2, Ô˘ ÂÚȤ¯ÔÓÙ·È Û ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔÓ ÂÈÛÓÂfiÌÂÓÔ Î·Ófi, ·ÔÙÂÏÔ‡Ó ÙÔÓ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ·. ∞˘Ù¤˜ ‰ÚÔ˘Ó ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· Î·È ·ÊÂÓfi˜ ÂȉÚÔ‡Ó ·ÚÓËÙÈο ÛÙË ‚ÈԉȷıÂÛÈÌfiÙËÙ· Ù˘ L-·ÚÁÈÓ›Ó˘, ·ÊÂÙ¤ÚÔ˘ ·Ô‰ÔÌÔ‡Ó ÙÔ Û˘ÓÙÈı¤ÌÂÓÔ ¡√, οÓÔÓÙ¿˜ ÙÔ ÌË ‰È·ı¤ÛÈÌÔ ÚÔ˜ ·ÁÁÂÈԉȷÛÙÔÏ‹. ¶·Ú¿ÏÏËÏ· ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙÔ ¤Ó˙˘ÌÔ Û˘ÓıÂÙ¿ÛË Ù˘ ÚÔÛÙ·Î˘ÎÏ›Ó˘, ÚÔηÏÒÓÙ·˜ ¤ÙÛÈ ÙË Ì›ˆÛË Ù˘ Û˘ÓÙÈı¤ÌÂÓ˘ ÚÔÛÙ·Î˘ÎÏ›Ó˘, Ô˘ Â›Ó·È ÚÔÛٷ٢ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, Ì ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ Î·È ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰Ú¿ÛË (26). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Â›Ó·È Ë ·Ú·ÁˆÁ‹ ∂∆-1, Ô˘ ÚÔηÏ› ·ÁÁÂÈÔÛ‡Û·ÛË (27). Œ¯ÂÈ ‚ÚÂı› ÂÍ¿ÏÏÔ˘, fiÙÈ Ë ÂÈÛÓÔ‹ ƒª2,5 ÚÔηÏ› Û˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓÒ‰Ë ‰ÈÂÚÁ·Û›· Î·È ·Ú·ÁˆÁ‹ ΢ÙÔÎÈÓÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·Ú·ÁˆÁ‹ Î·È ‰Ú¿ÛË ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ, ÔÈ Ôԛ˜ Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ ÂÓÂÚÁÔÔÈÔ‡Ó ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ·Ú·ÁˆÁ‹˜ Ù˘ ∂∆-1 Ì ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤ÓË ·ıËÚÔÁ¤ÓÂÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Î·È Ù˘ ·ÔÚÙ‹˜. ∆Ô ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ·ÁÁ›ˆÓ ·ÔÙÂÏ› ÙÔÓ ·Ô‰¤ÎÙË ‚Ï·ÙÈÎÒÓ ÂȉڿÛÂˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘, ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘. √È ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› (˘¤ÚÙ·ÛË, ˘��ÚÏÈȉ·ÈÌ›·, οÓÈÛÌ·, stress) ÚÔηÏÔ‡Ó “ÂÓ‰ÔıËÏȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·” Ì ‰È¿ÊÔÚÔ˘˜ ‚ÈÔ¯ËÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜, ÎÔÈÓ‹ ηٿÏËÍË ÙˆÓ ÔÔ›ˆÓ Â›Ó·È ·) Ë ·˘ÍË̤ÓË ÂÓ‰Ô΢ÙÙ¿ÚÈ· Û˘ÛÛÒÚ¢ÛË ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ Î·È ‚) Ë ·‡ÍËÛË ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ·Û‚ÂÛÙ›Ô˘. ∏ ÂÓ‰ÔıËÏȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ÙÔ ·Ú¯ÈÎfi ‚ÈÔ¯ËÌÈÎfi ÁÂÁÔÓfi˜, Ô˘ Ô‰ËÁ› ÛÙËÓ ·Ó¿Ù˘ÍË ˘ÂÚÏ·ÛÙÈÎÒÓ ·ÏÏ·ÁÒÓ Î·È ·ıËڈ̿وÛ˘ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Î·È ¿ÏÏˆÓ ·ÚÙËÚÈÒÓ (27). Œ¯ÂÈ ·Ô‰Âȯı› Â›Û˘ Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÌÂÙ¿ ·fi ÌÂÚÈΤ˜ ÒÚ˜ ̤¯ÚÈ Î·È Ë̤Ú˜ ÂÈÛÓÔ‹˜ ۈ̷Ùȉ›ˆÓ ƒª2,5 (28).

ƒ‡·ÓÛË Î·È ·È‰› ∆· ·È‰È¿ Â›Ó·È ÈÔ Â˘·›ÛıËÙ· ÛÙËÓ Â›‰Ú·ÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ¶·È‰È·ÙÚÈ΋ 2006;69:18-24

ÂÓ‹ÏÈΘ, ‰ÈfiÙÈ Ô Ì˯·ÓÈÛÌfi˜ ‚ÏÂÓÓÔÎÚÔÛÛˆÙ‹˜ οı·ÚÛ˘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÈıËÏ›Ô˘ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ù˘ ÚÔÛ¯ÔÏÈ΋˜ ‹ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ - ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ÏÔÈÌÒÍÂˆÓ ‹ Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚԉȿıÂÛ˘ - Â›Ó·È ‰È·Ù·Ú·Á̤ÓÔ˜. ∏ ‚Ï¿‚Ë ÂΉËÏÒÓÂÙ·È Ì ‰È·Ù·Ú·¯‹ Ù˘ ¤ÎÎÚÈÛ˘ Î·È ·ÔÌ¿ÎÚ˘ÓÛ˘ Ù˘ ‚ϤÓÓ˘, ÏfiÁˆ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ÎÚÔÛÛÒÓ (29,30). ∞˘Ùfi ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù· ۈ̷ٛ‰È· Ó· ‰ÈÂÈÛ‰‡Ô˘Ó ‚·ı‡ÙÂÚ· ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi ‰¤Ó‰ÚÔ. ∆· ·È‰È¿, Â›Û˘, ÂÚÓÔ‡Ó ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ¤Íˆ ·fi ÙÔ Û›ÙÈ, ÎÈÓÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ Î·È ÈÔ ¤ÓÙÔÓ·, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÂÚÈÛÛfiÙÂÚË ˘¤ÚÓÔÈ·, ÂÓÒ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·Ó·ÁÓˆÚ›ÛÔ˘Ó Â‡ÎÔÏ· ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶·Ú¿ÏÏËÏ·, ÂÍ·ÈÙ›·˜ ÙÔ˘ ¯·ÌËÏfiÙÂÚÔ˘ ·Ó·ÛÙ‹Ì·Ùfi˜ ÙÔ˘˜, ‚Ú›ÛÎÔÓÙ·È ÏËÛȤÛÙÂÚ· ÛÙÔ ¤‰·ÊÔ˜, fiÔ˘ ÔÚÈṲ̂ÓÔÈ Ú‡ÔÈ Â›Ó·È Û˘ÁÎÂÓÙڈ̤ÓÔÈ Î·È ÙÔ˘˜ ·Ó·Ó¤Ô˘Ó Â˘ÎÔÏfiÙÂÚ· (31). ™Ù· ÌÈÎÚ¿ ·È‰È¿ Â›Ó·È ÌÂȈ̤ÓË Ë ¯˘ÌÈ΋ ·ÓÔÛ›·, Î·È ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi ·ÓÙÈÚÚÔÂ›Ù·È ÌfiÓÔ ÌÂÚÈÎÒ˜ ·fi ÙËÓ Î˘ÙÙ·ÚÈ΋ ·ÓÔÛ›·. ŸÙ·Ó ÂÎÙ›ıÂÓÙ·È Û ˘„ËÏ‹ ·ÙÌÔÛÊ·ÈÚÈ΋ Ú‡·ÓÛË, Ù· Ì·ÎÚÔÊ¿Á· ÂÍ·ÓÙÏÔ‡ÓÙ·È ÛÙË ‰¤ÛÌ¢ÛË ÙˆÓ ÏÂÙÒÓ ÌÔÚ›ˆÓ ÛÎfiÓ˘, Ì ·ÔÙ¤ÏÂÛÌ· Ù· ·È‰È¿ Ó· Á›ÓÔÓÙ·È ÏÈÁfiÙÂÚÔ ·ÓıÂÎÙÈο Û ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ·ÏÏ¿ Î·È Û ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ ηÚΛÓÔ˘ (32,33). √È Ì¤¯ÚÈ Û‹ÌÂÚ· ÌÂϤÙ˜ Î·È ÂÈÚ·Ì·ÙÈΤ˜ ÂÚÁ·Û›Â˜ ·Ó·Ê¤ÚÔÓÙ·È Î˘Ú›ˆ˜ Û ÂÓ‹ÏÈΘ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÌÂÏÂÙ‹ıËÎÂ Ë Â›ÙˆÛË Ù˘ ‚Ú·¯˘¯ÚfiÓÈ·˜ ¤ÎıÂÛ‹˜ ÙÔ˘˜ Û ∞™. ∏ ‰ÈÂıÓ‹˜ ‚È‚ÏÈÔÁÚ·Ê›· Â›Ó·È Ôχ ÊÙˆ¯‹ Û ·Ó¿ÏÔÁ˜ ÌÂϤÙ˜ Û ·È‰È¿ Î·È Ôχ ÂÚÈÛÛfiÙÂÚÔ Ì ̷ÎÚÔ¯ÚfiÓÈ· ¤ÎıÂÛ‹ ÙÔ˘˜ Û ‚‚·ÚË̤ÓÔ ÂÚÈ‚¿ÏÏÔÓ (30,32). ∏ ÚfiÛÊ·ÙË Û˘Û¯¤ÙÈÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ Ì ÌÂÙ·ÏÏ¿ÍÂȘ, ·È‰ÈÎfi ηÚΛÓÔ ·ÏÏ¿ Î·È Ì ÂÓ‰ÔÌ‹ÙÚÈÔ ı¿Ó·ÙÔ, ηıÈÛÙ¿ ÙËÓ fiÏË ˘fiıÂÛË ¿ÎÚˆ˜ ·ÓËÛ˘¯ËÙÈ΋ (33,35). ™Â ÌÈ· ÂÚÈÔ¯‹ Ù˘ ¶Ôψӛ·˜ Ì Ôχ ˘„ËÏ‹ Ú‡·ÓÛË, ÙË ™ÈÏÂÛ›·, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ·fi ·ÓÙÔ‡ (36,37). ™ÙȘ ™Î·Ó‰ÈÓ·‚ÈΤ˜ ¯ÒÚ˜ ÌÂϤÙ˜ Û˘Û¯¤ÙÈÛ·Ó ÙËÓ ÂÈÛÓÔ‹ η˘Û·ÂÚ›ˆÓ ·˘ÙÔÎÈÓ‹ÙˆÓ Ì ÏÂÌÊÒÌ·Ù·, Ï¢¯·ÈÌ›· Î·È fiÁÎÔ˘˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (38), ÂÓÒ ÛÙË µÚ·˙ÈÏ›· ÂÚ¢ÓËÙ¤˜ ·¤‰ÂÈÍ·Ó fiÙÈ Ë ÂÈÛÓÔ‹ ÌÔÏ˘Ṳ̂ÓÔ˘ ·¤Ú·, ȉ›ˆ˜ ·fi ÌË Î·Ó›ÛÙÚȘ ÌËÙ¤Ú˜, ‹Ù·Ó ·ÈÙ›· ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘, ÏfiÁˆ Û¯ËÌ·ÙÈÛÌÔ‡ ÌÂı·ÈÌÔÛÊ·ÈÚ›Ó˘ Î·È ·ÓıÚ·Î˘Ï·ÈÌÔÛÊ·ÈÚ›Ó˘ (35). ªÂϤÙ˜ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Î·Ù¿ ηÈÚÔ‡˜ ÛÙË ¯ÒÚ· Ì·˜, ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜ ÛÙËÓ Â›‰Ú·ÛË


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15:34

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23

∏ Â›‰Ú·ÛË Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ ÛÙÔ Î˘ÎÏÔÊÔÚÈÎfi

∞ȈÚÔ‡ÌÂÓ· ™ˆÌ·Ù›‰È· (∞™) 8.

ª·ÎÚÔÊ¿Á· ¶¡∂Àª√¡ø¡ 9.

∞¡™

΢ÙÔΛÓ˜

∫˘ÎÏÔÊÔÚÈÎfi

EÓ‰Ôı‹ÏÈÔ (∂∆-1)

∆·¯˘Î·Ú‰›·

∞πª∞ ¶ËÎÙÈÎÔ› Ì˯·ÓÈÛÌÔ›

∞ıËڈ̿وÛË

∂ªºƒ∞°ª∞

10.

11.

∂ÈÎfiÓ· 3. ™¯ËÌ·ÙÈÎfi ‰È¿ÁÚ·ÌÌ· Ù˘ ‰Ú¿Û˘ ÙˆÓ ∞™ ÛÙ· ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·. 12.

Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ÙˆÓ ·È‰ÈÒÓ (39,40). ∆· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ·Ó·Ê¤ÚÔÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ¿ÛıÌ·ÙÔ˜, ¯ÚfiÓÈ·˜ ‚ÚÔÁ¯›Ùȉ·˜ Î·È ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (41-44). §fiÁˆ Ù˘ ·ÁÎÔÛÌÈfiÙËÙ·˜ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù˘ ·¤ÚÈ·˜ Ú‡·ÓÛ˘ Î·È ÙˆÓ ÂÈÙÒÛˆÓ, fi¯È ÌfiÓÔ ÛÙËÓ ˘Á›· ·ÏÏ¿ ·ÎfiÌË Î·È ÛÙȘ ÔÈÎÔÓƠ̂˜ ÙˆÓ ÎÚ·ÙÒÓ ÙÔ˘ ÎfiÛÌÔ˘, ÙÔ ı¤Ì· ı· Â›Ó·È ¿ÓÙ· Â›Î·ÈÚÔ ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜ (45).

µÈ‚ÏÈÔÁÚ·Ê›· 1. Beckett WS. Occupational respiratory diseases. [Review article]. N Engl J Med 2000;342:406-413. 2. Dockery DW, Pope CA 3rd, Xu X, Spengler JD, Ware JH, Fay ME et al. An association between air pollution and mortality in six U.S. cities. N Engl J Med 1993;329:1753-1759. 3. Pope CA 3rd, Burnett RT, Thun MJ, Calle EE, Krewski D, Ito K. et al. Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. JAMA 2002;287:1132-1141. 4. Beeson LW, Abbey DE, Knutsen SF. Long-term concentrations of ambient air pollutants and incident lung cancer in California adults: results from the AHSMOG study. Adventist Health Study on Smog. Environ Health Perspect 1998;106:813-823. 5. Schwartz J. Air pollution and Hospital admissions for heart disease in eight U.S. counties. Epidemiology 1999;10:17-22. 6. Samet JM, Dominici F, Curriero FC, Coursac I, Zeger SL. Fine particulate air pollution and mortality in 20 U.S. cities, 1987-1994. N Engl J Med 2000; 343:1742-1749. 7. Touloumi G, Katsouyanni K, Zmirou D, Schwartz J, Spix C, de Leon AP et al. Short-term effects of ambient oxidant exposure on mortality: a combined analysis within the APHEA project. Air Pollution

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∑. ÷ϤÌ˘, °. µ·ÚÏ¿Ì˘

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¶·È‰È·ÙÚÈ΋ 2006;69:18-24

Atkinson RW. Daily concentrations of air pollution and plasma fibrinogen in London. Occup Environ Med 2000;57:818-822. Seaton A, Soutar A, Crawford V, Elton R, McNerlan S, Cherrie J et al. Particulate air pollution and the blood. Thorax 1999;54:1027-1032. Brook RD, Brook JR, Urch B, Vincent R, Rajagopalan S, Silverman F. Inhalation of fine particulate air pollution and ozone causes acute arterial vasoconstriction in healthy adults. Circulation 2002;105:1534-1536. Bouthillier L, Vincent R, Goegan P, Adamson IY, Bjarnason S, Stewart M et al. Acute effects of inhaled urban particles and ozone: lung morphology, macrophage activity, and plasma endothelin-1. Am J Pathol 1998;153:1873-1884. Southorn PA, Powis G. Free radicals in medicine. II. Involvement in human disease. Mayo Clin Proc 1988;93:390-408. ƒ¿ÌÔ˜ ∫., ∫Ô‡ÏÈ·˜ °. √ ÚfiÏÔ˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÛÙË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ. 1Ë ¤Î‰. £ÂÛÛ·ÏÔÓ›ÎË: ∂Ή. ºÈÏÒÙ·˜; 1997. Û. 71. Peters A, Dockery DW, Muller JE, Mittleman MA. Increased particulate air pollution and the triggering of myocardial infarction. Circulation 2001;103:28102815. Pedersen M. Ciliary activity and pollution. Lung. 1990;168 (Suppl):S368-S376. Houtmeyers E, Gosselink R, Gayan-Ramirez G, Decramer M. Regulation of mucociliary clearance in health and disease. Eur Respir J 1999;13:1177-1188. ∆Û›ÙÔ˘Ú· ™. ¶·È‰È΋ ˘Á›· Î·È ÂÚÈ‚¿ÏÏÔÓ. ªËӇ̷ٷ ·fi ÙÔ Û˘Ó¤‰ÚÈÔ Ù˘ ∂˘Úˆ·˚΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ (ESSOP). ¶·È‰È·ÙÚÈ΋ 1995:90-91. Matorova NI. Evaluation of health changes in children under environmental hazards. Med Tr Prom Ekol 2003;3:19-23. Ha EH, Lee JT, Kim H, Hong YC, Lee BE, Park HS et al. Infant susceptibility of mortality to air pollution in Seoul, South Korea. Pediatrics 2003;111:284-290. Feychting M, Svensson D, Ahlbom A. Exposure to motor vehicle exhaust and childhood cancer. Scand J Work Environ Health 1998;24:8-11. Pereira LA, Loomis D, Conceicao GM, Braga AL, Arcas RM, Kishi HS et al. Association between air pollution and intrauterine mortality in Sao Paulo, Brazil. Environ Health Perspect 1998;106:325-329.

36. Perera FP, Hemmimki K, Gryzbowska E, Motykiewicz G, Michalska J, Santella RM et al. Molecular and genetic damage in humans from environmental pollution in Poland. Nature 1992;360:256-258. 37. Rusin M, Butkiewicz D, Malusecka E, Zborek A, Harasim J, Czyzewski K et al. Molecular epidemiological study of non-small-cell lung cancer from an environmentally polluted region of Poland. Br J Cancer 1999;80:1445-1452. 38. Raaschou-Nielsen O, Hertel O, Thomsen BL, Olsen JH. Air pollution from traffic at the residence of children with cancer. Am J Epidemiol 2001;153:433-443. 39. ™˘¯ÏÂÙ›‰Ë˜ §, ¢·ÛηÏÔÔ‡ÏÔ˘ ∂, ∆ÛÈfiÙÛÈÔ˜ π, ÃψÚfi˜ ¢, µÏ·¯ÔÁÈ¿ÓÓ˘ ∂, ∑ÈÒÌ·˜ π Î·È Û˘Ó. ∏ Â›‰Ú·ÛË Ù˘ Ú‡·ÓÛ˘ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ÙˆÓ ·È‰ÈÒÓ. ∂ÏÏËÓ π·ÙÚ 1994;60:210-218. 40. ª·Ì˙ÔÚ›‰Ô˘ ∞, ¶·ÈÔÓ›‰Ë˜ ∞, ™·Ì·Ú¿˜ ∫. ∞ÙÌÔÛÊ·ÈÚÈ΋ Ú‡·ÓÛË: ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡. ∏ ηٿÛÙ·ÛË ÛÙË £ÂÛÛ·ÏÔÓ›ÎË. ¶·È‰È·ÙÚ ÃÚÔÓ 1993;20:173-186. 41. Gourgoulianis KI, Brelas N, Hatziparasides G, Papayianni M, Molyvdas PA. The influence of altitude in bronchial asthma. Arch Med Res 2001;32:429-431. 42. Priftis K, Panagiotopoulou-Gartagani P, TapratziPotamianou P, Zachariadi-Xypolita A, Sagriotis A, Saxoni-Papageorgiou P. Hospitalizations for childhood asthma in Athens, Greece, from 1978 to 2000. Pediatr Allergy Immunol 2005;16:82-85. 43. Anthracopoulos M, Karatza A, Liolios E, Triga M, Triantou K, Priftis K. Prevalence of asthma among schoolchildren in Patras, Greece: three surveys over 20 years. Thorax 2001;56:569-571. 44. Mihailidou H, Paspalaki P, Skalidaki M, Katakis E, Smyrnaki P, Mantzouranis E. Decreasing morbidity of childhood asthma by regular outpatient followup, in Crete. Minerva Pediatr 2004;56:197-206. 45. Haines A, McMichael AJ, Epstein PR. Environment and health: Global climate change and health. CMAJ 2000;163:729-734. 46. ∂˘Úˆ·˚΋ ∂ÈÙÚÔ‹ ∫·ı·ÚÔ‡ ∞¤Ú· ÁÈ· ÙȘ ¶fiÏÂȘ Ù˘ ∂˘ÚÒ˘ - Swiss Participation in European Research Programmes. APHEA 2: Short-term effects of air pollution on health - A European approach to methodology, dose response assessment and evaluation of public health significance. [Abstract, Internet]. Webpage: http://www.sbf.admin.ch/htm/ services/publikationen/international/frp/euabstracts/html/fp/fp4/env97.0477.html.


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ORIGINAL ARTICLE

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À¿Ú¯ÂÈ ‹ fi¯È ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D Û ·È‰È¿ Î·È Ó¤Ô˘˜ ̤¯ÚÈ 18 ¯ÚfiÓˆÓ ÛÙËÓ ∂ÏÏ¿‰·; ¢. §··ÙÛ¿Ó˘1, A. MÔ˘Ï¿˜2, B. XÔϤ‚·˜2, ¶. ™Ô˘Î¿ÎÔ˜3, Z. ¶··‰ÔÔ‡ÏÔ˘ - KÔ˘ÏÔ˘Ì‹1, Õ. X¿ÏÏ·2

¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: H ÂÔ¯‹ Î·È ÔÈ ·ÏÏ·Á¤˜ ÛÙÔÓ ÙÚfiÔ ˙ˆ‹˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤ÎıÂÛË ÙÔ˘ ·ÓıÚÒÔ˘ ÛÙÔÓ ‹ÏÈÔ, Ô˘ Â›Ó·È ··Ú·›ÙËÙÔ˜ ÁÈ· ÙË Û‡ÓıÂÛË ‚ÈÙ·Ì›Ó˘ D ÛÙÔ ‰¤ÚÌ·. ¶·È‰È¿ Î·È ¤ÊË‚ÔÈ Ì ·˘ÍË̤ÓÔ Ú˘ıÌfi ÔÛÙÈÎÔ‡ ·Ó·Û¯ËÌ·ÙÈÛÌÔ‡ ·ÔÙÂÏÔ‡Ó ÏËı˘ÛÌfi ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂÌÊ¿ÓÈÛË ·ÓÂ¿ÚÎÂÈ·˜ ‚ÈÙ·Ì›Ó˘ D. ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ: ¢Â›ÁÌ· 210 ÎÏÈÓÈο ˘ÁÈÒÓ ·È‰ÈÒÓ 3 ¤ˆ˜ 18 ¯ÚfiÓˆÓ, ηٷٿ¯ıËÎ·Ó Û ÙÚÂȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜ (√Ì¿‰· I: 3-10, √Ì¿‰· II: 11-14 Î·È √Ì¿‰· III: 15-18 ¯ÚfiÓˆÓ). §‹„Ë ‰ÂÈÁÌ¿ÙˆÓ ¤ÁÈÓ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Î·È Î·ÏÔηÈÚÈÓÔ‡˜ Ì‹Ó˜ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ·Û‚ÂÛÙÈÔÙÚfiˆÓ ÔÚÌÔÓÒÓ, ·Û‚ÂÛÙ›Ô˘, ʈÛÊÔÚÈÎÒÓ Î·È ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘. ∞ÔÙÂϤÛÌ·Ù·: TÔ 47% ÙˆÓ ·ÙfiÌˆÓ ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ Â›¯·Ó Â›‰· 25OHD <10 ng/ml ÙÔÓ ¯ÂÈÌÒÓ·, ÂÓÒ Ù· ÔÛÔÛÙ¿ ÛÙȘ ËÏÈ˘ 3-14 ¯ÚfiÓˆÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ· (13-14%). TÔ Î·ÏÔη›ÚÈ fiÏÔÈ Â›¯·Ó 25OHD>10 ng/ml. ∏ Û˘¯ÓfiÙËÙ· ˘Ô‚Èٷ̛ӈÛ˘ D ‹Ù·Ó ·ÎfiÌË ˘„ËÏfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ· 15-18 ¯ÚfiÓˆÓ Î·È Û˘Ó‰˘·˙fiÙ·Ó Ì ¯·ÌËÏfiÙÂÚ· Â›‰· ʈÛÊÔÚÈÎÒÓ ÙÔÓ ¯ÂÈÌÒÓ· (¯ÂÈÌ.: 1,19±0,03, ηÏ.: 1,39±0,03 mmol/l, p<0,001). ™ÙË ÌÂÁ·Ï‡ÙÂÚË ËÏÈÎȷ΋ ÔÌ¿‰·, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ 24,25(OH)2D ÙÔÓ ¯ÂÈÌÒÓ· ‹Ù·Ó ηٿ Ù· 2/3 ¯·ÌËÏfiÙÂÚ˜ ·fi ÙÔ˘ ηÏÔηÈÚÈÔ‡ (0,73±0,10 ¤Ó·ÓÙÈ 2,41±0,20 ng/ml, p<0,001). √È ‚ÈÔ¯ËÌÈÎÔ› ‰Â›ÎÙ˜ ÔÛÙÈ΋˜ ·Ú·ÁˆÁ‹˜ ÔÛÙÂÔηÏÛ›Ó˘ (OC) Î·È ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (ALP), ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔÈ ÛÙ· ÎÔÚ›ÙÛÈ· Ù˘ ÔÌ¿‰·˜ III, ÁÈ· ¯ÂÈÌÒÓ· Î·È Î·ÏÔη›ÚÈ ·ÓÙ›ÛÙÔȯ· (OC: 5,8±0,3 ¤Ó·ÓÙÈ 8,7±0,6 Î·È 4,6±0,3 ¤Ó·ÓÙÈ 7,3±0,5 ng/ml, p<0,001, ALP: 108±5 ¤Ó·ÓÙÈ 212±28 Î·È 116±7 ¤Ó·ÓÙÈ 248±31 IU/l, p<0,001). ™˘ÌÂÚ¿ÛÌ·Ù·: ™ÙËÓ ∂ÏÏ¿‰·, ÔÈ Ó¤ÔÈ 15-18 ¯ÚfiÓˆÓ ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfi ΛӉ˘ÓÔ ·ÓÂ¿ÚÎÂÈ·˜ ‚ÈÙ·Ì›Ó˘ D ÙÔÓ ¯ÂÈÌÒÓ·. EÌÏÔ˘ÙÈÛÌfi˜ Ì ‚ÈÙ·Ì›ÓË D ÙÚÔÊÒÓ fiˆ˜ ÙÔ Á¿Ï· Î·È ÌÂÚÈο ·Ó·„˘ÎÙÈο ı· ‚ÔËıÔ‡Û Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ·˘ÙÔ‡ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘.

1 ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋, TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ 2 EÚÁ·ÛÙ‹ÚÈÔ ¶·È‰È·ÙÚÈ΋˜, TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ 3 √ÚıÔ‰È΋ KÏÈÓÈ΋, I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ AÏÏËÏÔÁÚ·Ê›·: AÓ. K·ıËÁ‹ÙÚÈ· ÕÓÓ· X¿ÏÏ· TÔ̤·˜ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ I·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ T.K. 451 10, Iˆ¿ÓÓÈÓ· E-mail: achalla@cc.uoi.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 03-09-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-11-2005

§¤ÍÂȘ ÎÏÂȉȿ: ∞ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D, ·È‰È¿ Î·È ¤ÊË‚ÔÈ.

Is there or not vitamin D deficiency in children and adolescents in Greece? D. Lapatsanis1, A. Moulas2, V. Cholevas2, P. Soukakos3, Z. Papadopoulou1, A. Challa2

Abstract Background: Season and changes in the way of living significantly modify exposure to the sun, which is important for vitamin D synthesis in the skin. Children and adolescents who have high bone turnover may comprise a high-risk population for vitamin D deficiency. Methods: A sample of 210 clinically healthy children aged 3 to 18 years, were assigned into three age groups: 3-10, 11-14 and 15-18 years of age. Blood samples were taken during winter and summer for determining calciotropic hormones, calcium, phosphate (Pi) and biochemical markers of bone synthesis. Results: The 47% of the subjects aged 15-18 years, and 13-14% of the 3-14 years, had 25OHD levels <10 ng/ml in the winter. In the summer all had 25OHD>10 ng/ml. The prevalence of hypovitaminosis D was higher in the older girls, accompanied by lower Pi concentrations in the winter (win.: 1.19±0.03, sum.: 1.39±0.03 mmol/l, p<0.001). The 24,25(OH)2D levels in the older subjects were lower by 2/3 in the winter than in the summer (0.73±0.10 vs 2.41±0.20 ng/ml, p<0.001). The biochemical markers of bone synthesis, osteocalcin (OC) and total alkaline phosphatase (ALP) were significantly lower in the older girls in both winter and summer, respectively (OC: 5.8±0.3 vs

1 Department of Paediatrics, Medical School, University of Ioannina 2 Laboratory of Paediatrics, Medical School, University of Ioannina 3 Department of Orthopedics, Medical School, University of Ioannina Correspondence: Anna Chala Department of Paediatrics, Medical School, University of Ioannina 451 10, Ioannina E-mail: achalla@cc.uoi.gr Date of submission: 03-09-2004 Date of approval: 28-11-2005

¶·È‰È·ÙÚÈ΋ 2006;69:25-36


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¢. §··ÙÛ¿Ó˘ Î·È Û˘Ó.

8.7±0.6 and 4.6±0.3 vs 7.3±0.5 ng/ml, p<0.001; ALP: 108±5 vs 212±28 and 116±7 vs 248±31 IU/l, p<0.001). Conclusions: In Greece young people aged 15-18 years, are at increased risk of vitamin D deficiency during the winter. Vitamin D supplementation of milk and popular beverages would be of help in counteracting this.

Key words: Vitamin D deficiency, children and adolescents.

∂ÈÛ·ÁˆÁ‹ ∏ ÛËÌ·Û›· ÙˆÓ ËÏÈ·ÎÒÓ ·ÎÙ›ÓˆÓ ÛÙÔÓ Û¯ËÌ·ÙÈÛÌfi Ù˘ ‚ÈÙ·Ì›Ó˘ D ·Ó·ÁÓˆÚ›ÛÙËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1919 fiÙ·Ó ÔÈ Huldschinki Î·È Û˘Ó. ¤Ù˘¯·Ó ›·ÛË ÙÔ˘ Ú·¯ÈÙÈÛÌÔ‡ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· (1). ∏ ‡·ÚÍË ÌÈ·˜ ÏÈÔ‰È·Ï˘Ù‹˜ Ô˘Û›·˜, Ô˘ ·ÚÁfiÙÂÚ· ÔÓÔÌ¿ÛÙËΠ‚ÈÙ·Ì›ÓË D Î·È Ô˘ ÌÔÚÔ‡Û ӷ ıÂÚ·‡ÛÂÈ ÙÔÓ Ú·¯ÈÙÈÛÌfi ¤ÁÈÓ ÁÓˆÛÙ‹ ·fi ÙÔ˘˜ Mellanby Î·È Û˘Ó. ÙÔ 1919 (2). ∏ ÂÌÊ¿ÓÈÛË Ú·¯ÈÙÈÛÌÔ‡ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜ ÁÈ· ÚÒÙË ÊÔÚ¿ ·Ó·Ê¤ÚıËΠ̠ÙËÓ ¤Ó·ÚÍË Ù˘ ‚ÈÔÌ˯·ÓÈ΋˜ Â·Ó¿ÛÙ·Û˘ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 17Ô˘ ·ÈÒÓ·. ∏ Û˘¯ÓfiÙËÙ· Ú·¯ÈÙÈÛÌÔ‡ ÛÙ· ·È‰È¿ Ô˘ ηÙÔÈÎÔ‡Û·Ó ÛÙ· ·Ó‹ÏÈ· Û›ÙÈ· Î·È ‰ÚfiÌÔ˘˜ Ù˘ µfiÚÂÈ·˜ ∂˘ÚÒ˘ Î·È ∞ÌÂÚÈ΋˜ ·Ó¤Ú¯ÔÓÙ·Ó ÛÙÔ 90% (3). ™ÙȘ ‰ÂηÂٛ˜ ÙÔ˘ 1930 Î·È 1940 Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÚÔÊÒÓ Î·È Á¿Ï·ÙÔ˜ Ì ‚ÈÙ·Ì›ÓË D ¤ÁÈÓ ‰ËÌÔÊÈÏ‹˜. ªÂÙ¿ ÙÔ 1960 ¿Ú¯ÈÛ·Ó Ó· ÂÚ¢ÓÒÓÙ·È Î·È Ó· Á›ÓÔÓÙ·È Î·Ù·ÓÔËÙÔ› ÔÈ Ì˯·ÓÈÛÌÔ› ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÛÙÔ ‹·Ú (25-˘‰ÚÔÍ˘Ï›ˆÛË) Î·È ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ (1·-˘‰ÚÔÍ˘Ï›ˆÛË) ·ÏÏ¿ Î·È ÔÈ ‰Ú¿ÛÂȘ Ù˘, ÒÛÙ ӷ ÌÔÚÔ‡Ó Ó· ·Ó··Ú¿ÁÔÓÙ·È Î·È ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ (4,5). ∂ÎÙfi˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D Û ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, ˘fi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ·fi ÙÔ ¤ÓÙÂÚÔ, ÙËÓ Â·Ó·ÚÚfiÊËÛ‹ ÙÔ˘ ÛÙ· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ· Î·È ÙË ÌÂÙ¿ÏψÛË ÙˆÓ ÔÛÙÒÓ (6). ™Ù· Ó‹È·, ‚Ú¤ÊË Î·È ·È‰È¿ ̤¯ÚÈ ÙËÓ ÂÓËÏÈΛˆÛË, fiÔ˘ ˘¿Ú¯ÂÈ Û˘Ó¯‹˜ ·‡ÍËÛË ÙÔ˘ ÛÎÂÏÂÙÔ‡, Ë ‚ÈÙ·Ì›ÓË D Î·È Ë Â¿ÚÎÂÈ¿ Ù˘ ·ÔÎÙÔ‡Ó È‰È·›ÙÂÚË ÛËÌ·Û›·. ™Â ·˘Ù¤˜ ÙȘ ËÏÈ˘ Î·È Ï›ÁÔ ÌÂÙ¿, ·ÔÎÙ¿Ù·È Ë Ì¤ÁÈÛÙË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· Ô˘ fiÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È ÙfiÛÔ Î·Ï‡ÙÂÚ· ÁÈ· ÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹ (7,8,9). ∞Ó Î·È Ë ∂ÏÏ¿‰· Â›Ó·È ¯ÒÚ· Ì ÌÂÁ¿ÏË ËÏÈÔÊ¿ÓÂÈ·, Ì›· ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÚÈÓ ·fi 35 ¯ÚfiÓÈ· ·Ó¤ÊÂÚ ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ D ÛÙ· Ó‹È· (10). ∞fi ÙfiÙ fiÏ· Ù· ÂÌÔÚÈο ¶·È‰È·ÙÚÈ΋ 2006;69:25-36

Á¿Ï·Ù· ÁÈ· ‚Ú¤ÊË ÂÌÏÔ˘Ù›ÛÙËÎ·Ó Ì ‚ÈÙ·Ì›ÓË D (40 IU/100 ml) Î·È Ù· ÎÏÈÓÈο ÛËÌ›· ÙÚÔÊÈÎÔ‡ Ú·¯ÈÙÈÛÌÔ‡ ۯ‰fiÓ ÂÍ·Ê·Ó›ÛÙËÎ·Ó ·fi Ù· Ó‹È·. ™Ù· ∂ÏÏËÓfiÔ˘Ï· ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 3 ÂÙÒÓ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È Û˘ÛÙËÌ·ÙÈο ‚ÈÙ·Ì›ÓË D Î·È ÔÈ ÙÚÔʤ˜ ÛÙËÓ ∂ÏÏ¿‰· ‰ÂÓ ÂÌÏÔ˘Ù›˙ÔÓÙ·È Ì ‚ÈÙ·Ì›ÓË D. √È ˙ˆÈÎÔ› ÔÚÁ·ÓÈÛÌÔ› ÌÔÚÔ‡Ó Ó· ·ÔÎÙ‹ÛÔ˘Ó ÙÔ 90%-100% Ù˘ ‚ÈÙ·Ì›Ó˘ D Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ·fi ÙËÓ ¤ÎıÂÛ‹ ÙÔ˘˜ ÛÙËÓ ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· (6). ŸÌˆ˜, Ë ÂÔ¯‹, Ô ÙÚfiÔ˜ ˙ˆ‹˜ (‰È·ÌÔÓ‹ Î·È ÂÚÁ·Û›· ÁÈ· ÔÏϤ˜ ÒÚ˜ Û ÎÏÂÈÛÙÔ‡˜ ¯ÒÚÔ˘˜) ηıÒ˜ Î·È Ë Â˘Ú›· ¯Ú‹ÛË ÙˆÓ ·ÓÙÈËÏÈ·ÎÒÓ Ô˘ÛÈÒÓ, Â¤‰Ú·Û·Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·ÓÂ·Ú΋ ÌÂÙ·ÙÚÔ‹ Ù˘ ÚÔ‚ÈÙ·Ì›Ó˘ D ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Û ‰Ú·ÛÙÈ΋ ‚ÈÙ·Ì›ÓË D. ∂›Û˘, ÔÈ Û˘Ó‹ıÂȘ ‰È·ÙÚÔÊ‹˜ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÁÈ· ÙËÓ Â·Ú΋ ‹ ÌË ÚfiÛÏË„Ë ‚ÈÙ·Ì›Ó˘ D. ∏ ·Ó·Áη›· ÔÛfiÙËÙ· ‚ÈÙ·Ì›Ó˘ D Ì ÙËÓ ÙÚÔÊ‹ ÔÈΛÏÂÈ ÌÂٷ͇ ÙˆÓ ¯ˆÚÒÓ ·ÏÏ¿ Î·È ÌÂٷ͇ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ. ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ Û˘ÓÈÛÙ¿ 400 ‰ÈÂıÓ›˜ ÌÔÓ¿‰Â˜ (IU) ËÌÂÚËÛ›ˆ˜ ÁÈ· Ó‹È·, ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ (11). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› Ë Â¿ÚÎÂÈ· ‹ ÌË Ù˘ ‚ÈÙ·Ì›Ó˘ D Û ¤Ó· ·ÓÙÈÚÔÛˆ¢ÙÈÎfi ‰Â›ÁÌ· ÎÏÈÓÈο ˘ÁÈÒÓ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ, Ô˘ ηÙÔÈÎÔ‡Ó ÛÙË ‚ÔÚÂÈÔ‰˘ÙÈ΋ ∂ÏÏ¿‰· ÙËÓ Î·ÏÔηÈÚÈÓ‹ Î·È ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ™ÙË Û˘Ó¤¯ÂÈ·, ¤ÁÈÓ ÚÔÛ¿ıÂÈ· Ó· Û˘Û¯ÂÙÈÛıÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ Î·È ÙËÓ ÂÔ¯‹ ÙÔ˘ ¤ÙÔ˘˜ Î·È Ì ‚ÈÔ¯ËÌÈÎÔ‡˜ ‰Â›ÎÙ˜ ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘.

ÀÏÈÎfi Î·È ª¤ıÔ‰ÔÈ ¢Â›ÁÌ· ·fi 210 ·È‰È¿ ËÏÈΛ·˜ 3 ̤¯ÚÈ 18 ÂÙÒÓ Ô˘ ‰ÂÓ Â›¯·Ó ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ÔÛÙÈ΋˜ Î·È Ë·ÙÈ΋˜ ÓfiÛÔ˘ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÙË ÌÂϤÙË Î·È ¯ˆÚ›ÛıËÎ·Ó Û ÙÚÂȘ ÔÌ¿‰Â˜: ™ÙËÓ ÔÌ¿‰· π (¡ 75) ‹Ù·Ó ·È‰È¿ ËÏÈΛ·˜ 3-10 ÂÙÒÓ, ÛÙËÓ ÔÌ¿‰· ππ (¡ 49) 11-14 ¯ÚfiÓˆÓ Î·È ÛÙËÓ ÔÌ¿‰· πππ (¡ 86) 15-18 ¯ÚfiÓˆÓ. ∆· ÌÈÛ¿ ·È‰È¿ ·fi οı ÔÌ¿‰· ÌÂÏÂÙ‹ıËÎ·Ó ÙË ¯ÂÈÌÂÚÈÓ‹


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·27

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µÈÙ·Ì›ÓË D Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜

ÂÚ›Ô‰Ô (ºÂ‚ÚÔ˘¿ÚÈÔ - ª¿ÚÙÈÔ) Î·È Ù· ˘fiÏÔÈ· ÙË ıÂÚÈÓ‹ ÂÚ›Ô‰Ô (™Â٤̂ÚÈÔ - √ÎÙÒ‚ÚÈÔ). ∆Ô ÛÙ¿‰ÈÔ Ù˘ ÂÊ˂›·˜ ηٿ Tanner ÛÙ· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ πππ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ÚÔÛÂÎÙÈ΋ ÂͤٷÛË ÙˆÓ ‰Â˘ÙÂÚÔÁÂÓÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ʇÏÔ˘ Î·È ÙˆÓ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ (12). ™ÙËÓ ÔÌ¿‰· πππ ÙÔ ¯ÂÈÌÒÓ·, 11 ·È‰È¿ ‹Ù·Ó ÛÙ·‰›Ô˘ πππ ÚÔ˜ IV, 12 ÛÙÔ ÛÙ¿‰ÈÔ IV Î·È 22 ÛÙÔ ÛÙ¿‰ÈÔ IV ÚÔ˜ V, ÂÓÒ ÙÔ Î·ÏÔη›ÚÈ 7 ·È‰È¿ ‹Ù·Ó ÛÙÔ ÛÙ¿‰ÈÔ πππ ÚÔ˜ IV, 18 ÛÙÔ ÛÙ¿‰ÈÔ IV Î·È 16 ÛÙÔ ÛÙ¿‰ÈÔ IV ÚÔ˜ V. ∆· ·È‰È¿ ÛÙȘ ÔÌ¿‰Â˜ ππ Î·È πππ ¤ÈÓ·Ó Îfiη-ÎfiÏ· ÂÓ›ÔÙÂ Î·È ‰ÂÓ ¤Î·Ó·Ó Û˘ÛÙËÌ·ÙÈ΋ ¯Ú‹ÛË ÔÈÓÔÓÂ˘Ì·Ùˆ‰ÒÓ ÔÙÒÓ. √È ·Ú¿ÌÂÙÚÔÈ Ô˘ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙÔÓ ÔÚfi ‹Ù·Ó ·Û‚¤ÛÙÈÔ ÔÚÔ‡ (Ca), ·ÓfiÚÁ·ÓÔ˜ ʈÛÊfiÚÔ˜ (Pi), ÔÏÈ΋ ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË (ÔÏÈ΋ ALP), ÔÛÙÂÔηÏÛ›ÓË (OC), ÔÈ ÙÚÂȘ ·ÚÈÔÈ ÌÂÙ·‚Ôϛ٘ Ù˘ ‚ÈÙ·Ì›Ó˘ D [25OHD, 24,25 (√∏)2D Î·È 1,25 (√∏)2D] Î·È ÙÔ Î·Ú‚Ô͢ÙÂÏÈÎfi ¿ÎÚÔ Ù˘ ·Ú·ıÔÚÌfiÓ˘ (C-PTH). ∆· ·Ôı¤Ì·Ù· Ù˘ ‚ÈÙ·Ì›Ó˘ D ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ÂÎÙÈÌ‹ıËÎ·Ó ·fi ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ 25√∏D ÛÙÔÓ ÔÚfi. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ D ıˆڋıËΠfiÙ·Ó Ù· Â›‰· Ù˘ 25OHD ÛÙÔÓ ÔÚfi ‚Ú¤ıËÎ·Ó Ó· Â›Ó·È ÌÈÎÚfiÙÂÚ· ·fi 10 ng/ml Î·È ·ÓÂ¿ÚÎÂÈ·, fiÙ·Ó Ë ÙÈÌ‹ Ù˘ 25OHD ‹Ù·Ó ÌÂٷ͇ 10-20 ng/ml (13). To Ca ÙÔ˘ ÔÚÔ‡ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ÙËÓ ÙÈÙÏÔ‰ÔÙÈ΋ ÌÈÎÚÔ̤ıÔ‰Ô ÙÔ˘ ÔÚÁ¿ÓÔ˘ Calcette, Model 4008, Precision Systems Inc, MA, ∏.¶.∞. √ ·ÓfiÚÁ·ÓÔ˜ ʈÛÊfiÚÔ˜ ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ʈÙÔÌÂÙÚÈ΋ ̤ıÔ‰Ô (14). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÔÏÈ΋˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ¤ÁÈÓ Ì ʈÙÔÌÂÙÚÈ΋ ̤ıÔ‰Ô ÎÈÓËÙÈ΋˜, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ·ÓÙȉڷÛÙ‹ÚÈ· Ù˘ Elitech Diagnostics, Sees, France. √È ÚÔÛ‰ÈÔÚÈÛÌÔ› ÙÔ˘ ηڂÔ͢ÙÂÏÈÎÔ‡ ¿ÎÚÔ˘ Ù˘ ·Ú·ıÔÚÌfiÓ˘ (C-PTH) Î·È Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ ¤ÁÈÓ·Ó Ì ڷ‰ÈÔ·ÓÔÛÔÏÔÁÈΤ˜ ÌÂıfi‰Ô˘˜ (RIA) ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ·ÓÙȉڷÛÙ‹ÚÈ· ·fi ÙËÓ Incstar Co, ∏.¶.∞. √È ÌÂÙ·‚Ôϛ٘ Ù˘ ‚ÈÙ·Ì›Ó˘ D [25(OH)D, 24,25 (OH)2D Î·È 1,25(√∏)2D] ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì Ù¯ÓÈΤ˜ Ô˘ ·Ó·Ù‡¯ıËÎ·Ó ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ·fi ÙÔ˘˜ ªÔ˘Ï¿ Î·È Û˘Ó (15). ∆ÚÔÔÔÈ‹ıËÎ·Ó ·fi ‹‰Ë ˘¿Ú¯Ô˘Û˜ ÌÂıfi‰Ô˘˜ ÙˆÓ Shepard Î·È Û˘Ó (1979) Î·È Reinhardt Î·È Û˘Ó (1984) ·ÍÈÔÔÈÒÓÙ·˜ ·Ú¿ÏÏËÏ· Î·È ÓÂfiÙÂÚ˜ Ù¯ÓÈΤ˜ ˘ÁÚ‹˜ ¯ÚˆÌ·ÙÔÁÚ·Ê›·˜ ˘„ËÏ‹˜ ›ÂÛ˘ (HPLC) ÁÈ· ÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÌÂٷ͇ ÙÔ˘˜ (16,17). MÂÙ¿ ÙËÓ Âί‡ÏÈÛË ·fi

ÙÔÓ ÔÚfi Î·È ÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙÔ˘˜, ÔÈ ÌÂÙ·‚Ôϛ٘ Ù˘ 25(OH)D Î·È 24,25(OH)2D ÛÙË Û˘Ó¤¯ÂÈ· ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì ڷ‰ÈÔ·ÓÔÛÔÏÔÁÈ΋ ̤ıÔ‰Ô (RIA) ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ‰ÂÛÌ¢ÙÈ΋ ÚˆÙ½ÓË (DBP) ·ÓıÚÒÔ˘ Î·È Ù˘ 1,25(√∏)2D Ì RIA ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÚˆÙÂ˚ÓÈÎfi ˘Ô‰Ô¯¤· ·fi ı‡ÌÔ ·‰¤Ó· ÌfiÛ¯Ô˘.

™Ù·ÙÈÛÙÈ΋ ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Û ˘ÔÏÔÁÈÛÙ‹, Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ StatView Ù˘ SAS Institute Inc. ∏ Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ¤ÁÈÓ Ì Student's t-test Î·È ÙËÓ Ì¤ıÔ‰Ô Ù˘ ·Ó¿Ï˘Û˘ Ù˘ ÌÂÙ·‚ÏËÙfiÙËÙ·˜ ηٿ Ì›· ‰È‡ı˘ÓÛË (ANOVA). °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ fiÚˆÓ ÌÂٷ͇ ¯ÂÈÌÒÓ· Î·È Î·ÏÔηÈÚÈÔ‡ ÛÙËÓ ›‰È· ÔÌ¿‰· ·È‰ÈÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ paired t-test Ì fiÚÈÔ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÙÔ 5%. √È Û˘ÓÙÂÏÂÛÙ¤˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ˘ÔÏÔÁ›ÛÙËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô Ù˘ ÁÚ·ÌÌÈ΋˜ Û˘ÌÌÂÙ·‚ÔÏ‹˜ (linear regression).

∞ÔÙÂϤÛÌ·Ù· ∫·È ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ù· Â›‰· Ù˘ 25OHD ÛÙÔÓ ÔÚfi ‚Ú¤ıËÎ·Ó ¯·ÌËÏfiÙÂÚ· ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô Û ۇÁÎÚÈÛË Ì ÙË ıÂÚÈÓ‹ (¶›Ó·Î·˜ 1). √ ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ ÙÈÌÒÓ ·ÓÙ›ÛÙÔȯ· ‹Ù·Ó 18,5±1,3 ¤Ó·ÓÙÈ 29,8±1,8 ng/ml (p<0,01) ÁÈ· ÙËÓ ÔÌ¿‰· π, 21,0±1,9 ¤Ó·ÓÙÈ 26,6±1,4 ng/ml (p<0,05) ÁÈ· ÙËÓ ÔÌ¿‰· ππ, Î·È 12,7±0,9 ¤Ó·ÓÙÈ 27,7±1,3 ng/ml (p<0,01) ÁÈ· ÙËÓ ÔÌ¿‰· πππ. √È ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÔ¯ÒÓ ‹Ù·Ó ÈÔ ¤Î‰ËϘ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ (ÔÌ¿‰· πππ). ∂›Û˘, ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô ÛÙ· ·È‰È¿ Ù˘ ÙÚ›Ù˘ ÔÌ¿‰·˜ Ù· Â›‰· Ù˘ 25OHD ‚Ú¤ıËÎ·Ó Ó· Â›Ó·È Ôχ ¯·ÌËÏfiÙÂÚ· (p<0,01) ·fi ÙˆÓ ¿ÏÏˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (¶›Ó·Î·˜ 1). TÔ Î·ÏÔη›ÚÈ ÔÈ Ì¤ÛÔÈ fiÚÔÈ fiÏˆÓ ÙˆÓ ÔÌ¿‰ˆÓ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙÔ˘˜ (¶›Ó·Î·˜ 1).

¶›Ó·Î·˜ 1. TÔ ËÏÈÎÈ·Îfi ‡ÚÔ˜, Ô ·ÚÈıÌfi˜ (N) Î·È ÔÈ Ì¤Û˜ ÙÈ̤˜ (±SEM) ÛÙÔÓ ÔÚfi ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D [25OHD, 24,25(OH)2D Î·È 1,25(OH)2D] Î·È Ù˘ ·Ú·ıÔÚÌfiÓ˘ (C-PTH) ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ¯ÚfiÓˆÓ, Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ¯ÂÈÌÒÓ· (X) Î·È Î·ÏÔη›ÚÈ (K) ∏ÏÈÎÈ·Îfi ‡ÚÔ˜ (¯ÚfiÓÈ·)

N

25OHD (ng/ml)

24,25(OH)2D (ng/ml)

1,25(OH)2D (pg/ml)

C-PTH (ng/ml)

3-10

X: 43 K: 32

18,5±1,3c 29,4±1,8**

1,31±0,12c 2,17±0,19+

23,0±1,9 26,9±1,9

0,73±0,07a 0,70±0,07

11-14

X: 22 K: 27

21,0±1,9e 26,6±1,4*

1,47±0,17c 1,79±0,16c

25,8±3,4 32,4±3,0a

0,74±0,04a 0,80±0,14

15-18

X: 45 K: 41

12,7±0,9d 27,7±1,3**

0,73±0,10d 2,41±0,20+,d

26,7±1,5 25,7±1,9b

0,47±0,06b 0,60±0,06

*p<0,05, **p<0,01, +p<0,001: Û ۇÁÎÚÈÛË Ì ÙȘ ÙÈ̤˜ ÙÔ˘ ¯ÂÈÌÒÓ· a vs bp<0,05, cvs dp<0,01, dvs ep<0,001: Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ ¶·È‰È·ÙÚÈ΋ 2006;69:25-36


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

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∏ÏÈΛ· (¤ÙË)

∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Ù˘ 25OHD ÛÙÔÓ ÔÚfi Ì ÙËÓ ËÏÈΛ· Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ 3-18 ¯ÚfiÓˆÓ, ÁÈ· ÙÔÓ ¯ÂÈÌÒÓ· Î·È ÙÔ Î·ÏÔη›ÚÈ Ì·˙› (N=209, R=-0,23, p<0,001). ¶·È‰È·ÙÚÈ΋ 2006;69:25-36

ÛÙËÓ ÔÌ¿‰· πππ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ ·' fi,ÙÈ ÛÙȘ ÔÌ¿‰Â˜ ππ Î·È π (0,73±0,10 ¤Ó·ÓÙÈ 1,47±0,17 Î·È 1,31±0,12 ng/ml, p<0,01), ·ÏÏ¿ ÌÂÁ·Ï‡ÙÂÚ˜ ÙÔ Î·ÏÔη›ÚÈ (2,41±0,20 ¤Ó·ÓÙÈ 1,79±0,16, p<0,01 Î·È 2,17±0,19 ng/ml). πÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÛÙÔÓ ÔÚfi Ù˘ 25OHD Î·È Ù˘ 24,25(√∏)2D ‚Ú¤ıËΠ۠fiÏ· Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Î·È ÁÈ· ÙȘ ‰‡Ô ÂÔ¯¤˜ (R=0,61 p<0,001). A˘Ù‹ Ë Û˘Û¯¤ÙÈÛË ‹Ù·Ó ÈÛ¯˘ÚfiÙÂÚË ÙÔÓ ¯ÂÈÌÒÓ· R=0,68, p<0,0001) ·' fi,ÙÈ ÙÔ Î·ÏÔη›ÚÈ (R=0,37, p<0,001) (∂ÈÎfiÓ· 2). ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ Ù˘ 1,25 ‰È˘‰ÚÔ͢‚ÈÙ·Ì›Ó˘ D [1,25(OH)2D] ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÔ¯ÒÓ Î·È ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 1). ª›· Û¯ÂÙÈο ÌÈÎÚ‹ ‰È·ÊÔÚ¿ ·Ú·ÙËÚ‹ıËΠÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ππ Î·È πππ ˆ˜ ÚÔ˜ ÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ ÌÂÙ·‚ÔÏ›ÙË ÙÔ Î·ÏÔη›ÚÈ (32,4±3,0 ¤Ó·ÓÙÈ 25,7±1,9 pg/ml, p<0,05). √È ÙÈ̤˜ Ù˘ C-PTH ÛÙÔÓ ÔÚfi ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÔ¯ÒÓ Û fiϘ ÙȘ ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 1). ∆ÔÓ ¯ÂÈÌÒÓ·, Ù· Â›‰· Ù˘ CPTH ‚Ú¤ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ¯·ÌËÏfiÙÂÚ· ÛÙÔ˘˜ Ó¤Ô˘˜ Ù˘ ÔÌ¿‰·˜ πππ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ ÙˆÓ ÔÌ¿‰ˆÓ π Î·È ππ (0,47±0,06 ¤Ó·ÓÙÈ 0,73±0,07 Î·È 0,74±0,04 ng/ml, p<0,05). √È ÙÈ̤˜ ÙÔ˘ Ca ÛÙÔÓ ÔÚfi Î˘Ì·›ÓÔÓÙ·Ó ÛÂ Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÁÈ· ÙȘ ‰‡Ô ÂÔ¯¤˜ Î·È ÛÙȘ ÙÚÂȘ ˘fi ÌÂϤÙË ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 2). ªÂÚÈΤ˜ ‰È·ÊÔÚ¤˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÔ¯ÒÓ ÛÙËÓ ÔÌ¿‰· π (2,43±0,3 ÙÔÓ ¯ÂÈÌÒÓ· ¤Ó·ÓÙÈ 2,28±0,08 mml/L ÙÔ Î·ÏÔη›ÚÈ, p<0,01) Î·È ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ π Î·È ππ ÙÔ Î·ÏÔη›ÚÈ (2,28±0,08 ¤Ó·ÓÙÈ 2,40±0,03 mml/L, p<0,01).

24,25(OH)2 D (ng/mL)

250HD (ng/mL)

∆Ë ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô, ÙÔ 47% ÙˆÓ ÂÊ‹‚ˆÓ ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ Â›¯·Ó ÙÈ̤˜ 25OHD <10 ng/ml, ÂÓÒ ÁÈ· Ù· ·È‰È¿ ÙˆÓ ÔÌ¿‰ˆÓ π Î·È ππ Ë ÂηÙÔÛÙÈ·›· ·Ó·ÏÔÁ›· ‹Ù·Ó 14% Î·È 13% ·ÓÙ›ÛÙÔȯ·. ∂ÈϤÔÓ, Ô ·ÚÈıÌfi˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ì ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D ÛÙËÓ ÔÌ¿‰· πππ, ‹Ù·Ó ‰ÈÏ¿ÛÈÔ˜ ·' fi,ÙÈ ÙˆÓ ·ÁÔÚÈÒÓ, ÂÓÒ Ë Î·Ù·ÓÔÌ‹ ÛÙȘ ¿ÏϘ ‰‡Ô ÔÌ¿‰Â˜ ‹Ù·Ó ›ÛË ÁÈ· Ù· ‰‡Ô ʇϷ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ηÏÔηÈÚÈÔ‡ fiÏ· Ù· ·È‰È¿ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó Â›‰· 25OHD ¿Óˆ ·fi 10 ng/ml. ŸÌˆ˜, Û fiϘ ÙȘ ÔÌ¿‰Â˜, ¤Ó· ÔÛÔÛÙfi ·È‰ÈÒÓ Ô˘ ‹Ù·Ó 15%, 9,4% Î·È 21% ÁÈ· ÙȘ ÔÌ¿‰Â˜ π, ππ Î·È πππ ·ÓÙ›ÛÙÔȯ·, ›¯·Ó Û˘ÁÎÂÓÙÚÒÛÂȘ Ô˘ Î˘Ì·›ÓÔÓÙ·Ó ÌÂٷ͇ 10 Î·È 20 ng/ml. °È· ÙÔÓ ¯ÂÈÌÒÓ·, ·˘Ù¿ Ù· ÔÛÔÛÙ¿ ·Ó¤Ú¯ÔÓÙ·Ó Û 37%, 35% Î·È 33% ·ÓÙ›ÛÙÔȯ·. ªÂ ÙË ¯ÚÔÓÔÏÔÁÈ΋ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜, ·Ú·ÙËÚ‹ıËΠ̛· Ù¿ÛË Ì›ˆÛ˘ ÙˆÓ ÙÈÌÒÓ Ù˘ 25OHD ÛÙÔÓ ÔÚfi ÁÈ· ¯ÂÈÌÒÓ· Î·È Î·ÏÔη›ÚÈ (∂ÈÎfiÓ· 1). √È Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ 24,25 ‰È˘‰ÚÔ͢‚ÈÙ·Ì›Ó˘ D [24,25(OH)2D] Î·È ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·ÚÔ˘Û›·Û·Ó Âԯȷ΋ ‰È·Î‡Ì·ÓÛË ·Ú¿ÏÏËÏ· Ì ·˘Ù‹ Ù˘ 25OHD. √ ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ ÙÈÌÒÓ ‹Ù·Ó 1,31±0,12 ÙÔÓ ¯ÂÈÌÒÓ· ¤Ó·ÓÙÈ 2,17±0,19 ng/ml ÙÔ˘ ηÏÔηÈÚÈÔ‡ (p<0,001) ÛÙËÓ ÔÌ¿‰· π, 1,47±0,17 ¤Ó·ÓÙÈ 1,79±0,19 ng/ml ÛÙËÓ ÔÌ¿‰· ππ Î·È 0,73±0,10 ¤Ó·ÓÙÈ 2,41±0,20 ng/ml (p<0,001), ÛÙËÓ ÔÌ¿‰· πππ (¶›Ó·Î·˜ 1). Ÿˆ˜ Î·È Ì ÙËÓ 25OHD Ë ‰È·ÊÔÚ¿ ÌÂٷ͇ ÂÔ¯ÒÓ ‹Ù·Ó ÈÔ ÂÌÊ·Ó‹˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ (¶›Ó·Î·˜ 1). °È· ÙËÓ 24,25(√∏)2D ‰È·ÊÔÚ¤˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Û¯ÂÙÈο Ì ÙȘ ÙÈ̤˜ Î·È ÁÈ· ÙȘ ‰‡Ô ÂÔ¯¤˜ (¶›Ó·Î·˜ 1). √È ÙÈ̤˜ ÙÔÓ ¯ÂÈÌÒÓ·

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∂ÈÎfiÓ· 2. ™˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Ù˘ 25OHD Î·È Ù˘ 24,25(OH)2D ÛÙÔÓ ÔÚfi Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ 3-18 ¯ÚfiÓˆÓ, ÙÔÓ ¯ÂÈÌÒÓ· (N=102, R=0,68, p<0,0001) Î·È ÙÔ Î·ÏÔη›ÚÈ (N=87, R=0,37, p<0,001).


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

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29

µÈÙ·Ì›ÓË D Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜

√È Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ·ÓfiÚÁ·ÓˆÓ ʈÛÊÔÚÈÎÒÓ (Pi) ÛÙÔÓ ÔÚfi ‹Ù·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· Î·È ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 2). ŸÌˆ˜, ÔÈ ¤ÊË‚ÔÈ Ù˘ ÔÌ¿‰·˜ πππ ›¯·Ó ÙÈ̤˜ ʈÛÊfiÚÔ˘ ÛÙÔÓ ÔÚfi ÙÔÓ ¯ÂÈÌÒÓ· ÌÈÎÚfiÙÂÚ˜ ·fi ÙˆÓ ·È‰ÈÒÓ ÙˆÓ ¿ÏÏˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (1,26±0,03 ¤Ó·ÓÙÈ 1,45±0,06 mmol/L, p<0,05). ™ÙËÓ ›‰È· ÔÌ¿‰· ÙÔ Î·ÏÔη›ÚÈ, ÔÈ ÙÈ̤˜ ÙÔ˘ Pi ‚Ú¤ıËÎ·Ó Ó· Â›Ó·È „ËÏfiÙÂÚ˜ ·fi ÙÔÓ ¯ÂÈÌÒÓ· (1,39±0,03 ¤Ó·ÓÙÈ 1,26±0,03 mmol/L, p<0,01) (¶›Ó·Î·˜ 2). ∏ Ì›ˆÛË ÙˆÓ ÙÈÌÒÓ ÙÔÓ ¯ÂÈÌÒÓ· ‚Ú¤ıËΠӷ Â›Ó·È ÈÔ ¤Î‰ËÏË ÛÙ· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-18 ÂÙÒÓ (1,19±0,03 ¤Ó·ÓÙÈ 1,39±0,03 mmol/L, p<0,001) ·' fi,ÙÈ ÛÙ· ·ÁfiÚÈ· (1,29±0,06 ¤Ó·ÓÙÈ 1,39±0,03 mmol/L), ÂÓÒ ‰ÂÓ ‚Ú¤ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ ÙÔ˘ Pi ÛÙÔÓ ÔÚfi ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ÙÔ Î·ÏÔη›ÚÈ (¶›Ó·Î·˜ 3). ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ Pi ÛÙÔÓ ÔÚfi Î·È ÁÈ· Ù· ‰‡Ô ʇϷ ÙˆÓ ·È‰ÈÒÓ 3-18 ÂÙÒÓ (∂ÈÎfiÓ· 3). ∆· Â›‰· Ù˘ ÔÏÈ΋˜ ALP ÛÙÔÓ ÔÚfi ÛÙËÓ ÔÌ¿‰· ππ ‹Ù·Ó ˘„ËÏfiÙÂÚ· ·fi ÙˆÓ ¿ÏÏˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Î·È Ë ‰È·ÊÔÚ¿ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÔ Î·ÏÔη›ÚÈ, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2. √ ·ÓÙ›ÛÙÔȯԘ ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ ÙÈÌÒÓ ÙÔ Î·ÏÔη›ÚÈ ‹Ù·Ó 264±30 ¤Ó·ÓÙÈ 187±17 IU/L, p<0,05 ÛÙËÓ ÔÌ¿‰· π Î·È 180±18 IU/L, p<0,01 ÛÙËÓ ÔÌ¿‰· πππ Î·È ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂԯȷ΋ ‰È·Î‡Ì·ÓÛË. √È ÙÈ̤˜ Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ ÛÙÔÓ ÔÚfi Ù˘ ÔÌ¿‰·˜ πππ ‚Ú¤ıËÎ·Ó ¯·ÌËÏfiÙÂÚ˜ ·fi ÂΛӘ Ù˘ ÔÌ¿‰·˜ ππ Î·È ÛÙȘ ‰‡Ô ÂÔ¯¤˜ (7,0±0,4 ¤Ó·ÓÙÈ 9,4±1,2, p<0,05 ÙÔÓ ¯ÂÈÌÒÓ· Î·È 5,9±0,3 ¤Ó·ÓÙÈ 12,7±1.2 ng/ml, p<0,001 ÙÔ Î·ÏÔη›ÚÈ), ÂÓÒ ·fi Ù˘ ÔÌ¿‰·˜ π, ÌfiÓÔ ÙÔ Î·ÏÔη›ÚÈ (5,9±0,3 ¤Ó·ÓÙÈ 10,3±1,0 ng/ml, p<0,001) (¶›Ó·Î·˜ 2).

™ÙȘ ‰‡Ô ÚÒÙ˜ ÔÌ¿‰Â˜ ·È‰ÈÒÓ, ‰È·ÊÔÚ¤˜ ·Ú·ÙËÚ‹ıËÎ·Ó Î·È ÌÂٷ͇ ÙˆÓ ÂÔ¯ÒÓ fiÔ˘ ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ˜ ÙÔÓ ¯ÂÈÌÒÓ· ·fi ÂΛӘ ÙÔ˘ ηÏÔηÈÚÈÔ‡ (7,5±0,7 ¤Ó·ÓÙÈ 10,3±1,0 ng/ml, p<0,01 ÛÙËÓ ÔÌ¿‰· π Î·È 9,4±1,2 ¤Ó·ÓÙÈ 12,7±1,2 ng/ml, p<0,01 ÛÙËÓ ÔÌ¿‰· ππ) (¶›Ó·Î·˜ 2). £ÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ Î·È Ù˘ ÔÏÈ΋˜ ALP ÛÙÔÓ ÔÚfi ·Ú·ÙËÚ‹ıËΠÛÙ· ·È‰È¿ Î·È ÙˆÓ ÙÚÈÒÓ ÔÌ¿‰ˆÓ ËÏÈΛ·˜ 3-18 ÂÙÒÓ Î·È ÁÈ· ÙȘ ‰‡Ô ÂÔ¯¤˜ (R=0,35, p<0,001) (∂ÈÎfiÓ· 4). ¢È·ÊÔÚ¤˜ ÛÙȘ ÙÈ̤˜ ÌÂÚÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ÛÙÔ˘˜ Ó¤Ô˘˜ 15-18 ÂÙÒÓ, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 3. √È ÙÈ̤˜ ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ÔÛÙÒÓ (ÔÏÈ΋ ALP Î·È ÔÛÙÂÔηÏÛ›ÓË) ‚Ú¤ıËÎ·Ó ¯·ÌËÏfiÙÂÚ˜ ÛÙ· ÎÔÚ›ÙÛÈ· ·' fi,ÙÈ ÛÙ· ·ÁfiÚÈ· ÙË ¯ÂÈÌÂÚÈÓ‹ Î·È ÙË ıÂÚÈÓ‹ ÂÚ›Ô‰Ô (¶›Ó·Î·˜ 3). √È ·ÓÙ›ÛÙÔȯÔÈ Ì¤ÛÔÈ fiÚÔÈ ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÏÈ΋˜ ALP ‹Ù·Ó 108±48 ¤Ó·ÓÙÈ 212±28 IU/L p<0,001 ÙÔÓ ¯ÂÈÌÒÓ· Î·È 116±7 ¤Ó·ÓÙÈ 248±39 IU/L p<0,001 ÙÔ Î·ÏÔη›ÚÈ (¶›Ó·Î·˜ 3). √ ̤ÛÔ˜ fiÚÔ˜ ÙˆÓ ÙÈÌÒÓ Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ ‚Ú¤ıËΠ5,8±0,3 ¤Ó·ÓÙÈ 8,7±0,6 ng/ml p<0,001 ÁÈ· ÙÔÓ ¯ÂÈÌÒÓ· Î·È 4,6±0,3 ¤Ó·ÓÙÈ 7,3±0,5 ng/ml p<0,001 ÁÈ· ÙÔ Î·ÏÔη›ÚÈ (¶›Ó·Î·˜ 3). ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ÁÈ· ÙÔ˘˜ Ó¤Ô˘˜ ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ÌÂÙ·‚Ôϛ٘ Ù˘ ‚ÈÙ·Ì›Ó˘ D, C-PTH Î·È Ca (¶›Ó·Î·˜ 3). ™ÙËÓ ÔÌ¿‰· III, Û ·ÙÔÌÈÎfi Â›‰Ô, ÙÔ 61% ÙˆÓ ÎÔÚÈÙÛÈÒÓ Â›¯·Ó ÙÈ̤˜ 25√HD ÛÙÔÓ ÔÚfi ÌÈÎÚfiÙ��Ú˜ ·fi 10 ng/ml ¤Ó·ÓÙÈ ÙÔ˘ 35% ÙˆÓ ·ÁÔÚÈÒÓ, ÂÓÒ Ù¤ÙÔȘ ‰È·ÊÔÚ¤˜ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó 700

2,0

600 500 ALP (IU/L)

Pi ÔÚÔ‡ ( mmol/L)

1,8 1,6 1,4

400 300

1,2

200

1,0

100

0,8

0 2

4

6

8

10 12 14 ∏ÏÈΛ· (¤ÙË)

16

18

20

∂ÈÎfiÓ· 3. ™˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÙÔ˘ ʈÛÊfiÚÔ˘ (Pi) ÛÙÔÓ ÔÚfi Ì ÙËÓ ËÏÈΛ· Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ 3-18 ¯ÚfiÓˆÓ ÁÈ· ÙÔÓ ¯ÂÈÌÒÓ· Î·È ÙÔ Î·ÏÔη›ÚÈ Ì·˙› (N=159, R=0,18, p<0,02).

0

5

10 15 20 √ÛÙÂÔηÏÛ›ÓË (ng/mL)

25

∂ÈÎfiÓ· 4. ™˘Û¯¤ÙÈÛË ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÛÙÔÓ ÔÚfi Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Î·È Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ 3-18 ¯ÚfiÓˆÓ ÁÈ· ¯ÂÈÌÒÓ· Î·È Î·ÏÔη›ÚÈ Ì·˙› (N=138, R=0,35, p<0,0001). ¶·È‰È·ÙÚÈ΋ 2006;69:25-36


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·30

30

¢. §··ÙÛ¿Ó˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 2. OÈ Ì¤Û˜ ÙÈ̤˜ ÛÙÔÓ ÔÚfi (±SEM) ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (Ca), ʈÛÊÔÚÈÎÒÓ (Pi), ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (ALP) Î·È ÔÛÙÂÔηÏÛ›Ó˘ (OC) ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ¯ÚfiÓˆÓ, Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ¯ÂÈÌÒÓ· (X) Î·È Î·ÏÔη›ÚÈ (K) ∏ÏÈÎÈ·Îfi ‡ÚÔ˜ (¯ÚfiÓÈ·)

Ca (mmol/L)

Pi (mmol/L)

ALP (IU/L)

OC (ng/ml)

3-10

X: K:

2,43±0,03 2,28±0,08**,c

1,45±0,06d 1,35±0,06

203±10 187±17a

7,5±0,7 10,3±1,0**,d

11-14

X: K:

2,35±0,05 2,35±0,03

1,45±0,06a 1,39±0,06

240±37 264±30b,c

9,4±1,2a 12,7±1,2**,d

15-18

X: K:

2,43±0,03 2,40±0,03d

1,26±0,03b,e 1,39±0,03+

156±15 180±18d

7,0±0,4b 5,9±0,3e

**p<0,01, +p<0,001: Û ۇÁÎÚÈÛË Ì ÙȘ ÙÈ̤˜ ÙÔ˘ ¯ÂÈÌÒÓ· a vs bp<0,05, cvs dp<0,01, dvs ep<0,001: Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ

ÛÙ· ·È‰È¿ ÙˆÓ ÔÌ¿‰ˆÓ π Î·È ππ. ∂›Û˘, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ Pi ÛÙÔÓ ÔÚfi ÛÙ· ÎÔÚ›ÙÛÈ· Ù˘ ÔÌ¿‰·˜ πππ ‚Ú¤ıËÎ·Ó ¯·ÌËÏfiÙÂÚ˜ ÙÔÓ ¯ÂÈÌÒÓ· ·' fi,ÙÈ ÙÔ Î·ÏÔη›ÚÈ (1,19±0,03 ¤Ó·ÓÙÈ 1,39±0,03 mmol/L, p<0,001).

™˘˙‹ÙËÛË ∏ ·ÚÔ‡Û· ÌÂϤÙË ‰Â›¯ÓÂÈ fiÙÈ ·ÎfiÌË Î·È Û ¯ÒÚ˜ Ì ÌÂÁ¿ÏË ËÏÈÔÊ¿ÓÂÈ· fiˆ˜ Ë ∂ÏÏ¿‰·, ÛËÌ·ÓÙÈ΋ ·Ó·ÏÔÁ›· ·È‰ÈÒÓ ËÏÈΛ·˜ 3-14 ÂÙÒÓ (14%) ·ÏÏ¿ ΢ڛˆ˜ Ó¤ˆÓ ËÏÈΛ·˜ 15-18 ÂÙÒÓ (47%) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D (<10 ng/ml) ηٿ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ·fi ¿ÏϘ Â˘Úˆ·˚Τ˜ Î·È ÌÂÛÔÁÂȷΤ˜ ¯ÒÚ˜. OÈ Ala Houhala Î·È Û˘Ó (18) ·fi ÙË ºÈÓÏ·Ó‰›· ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÙÔ 22,4% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 11-17 ÂÙÒÓ ·ÚÔ˘Û›·Û·Ó ˘Ô‚Èٷ̛ӈÛË D (25OHD <5 ng/ml) ηı' fiÏË ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¤ÙÔ˘˜ Û ۇÁÎÚÈÛË Ì ÙÔ 16,8% ÙˆÓ ·È‰ÈÒÓ 610 ÂÙÒÓ Î·È ÙÔ 7,5% ·È‰ÈÒÓ ËÏÈΛ·˜ 2-5 ¯ÚfiÓˆÓ. ™Â Ì›· ·ÛÙÈ΋ ÂÚÈÔ¯‹ Ù˘ ‚fiÚÂÈ·˜ °·ÏÏ›·˜ ‚Ú¤ıËΠfiÙÈ ÛÙÔ 24% ÙˆÓ ·È‰ÈÒÓ ËÏÈΛ·˜ 10-17 ÂÙÒÓ ÔÈ ÙÈ̤˜ ÔÚÔ‡ Ù˘ 25OHD ‹Ù·Ó ¯·ÌËÏfiÙÂÚ˜ ·fi 6 ng/ml (19). ∞fi Ì›· ÔÌ¿‰· Ì·ıËÙÒÓ ÛÙÔÓ §›‚·ÓÔ ËÏÈΛ·˜ 10-16 ÂÙÒÓ ÙÔ 52% (65% ÙÔÓ ¯ÂÈÌÒÓ· Î·È 40% ÙÔ Î·ÏÔη›ÚÈ) ›¯·Ó Â›‰· 25OHD ÛÙÔÓ ÔÚfi οو ·fi 10 ng/ml (20). ™Â Ì›· ÔÌ¿‰· ·È‰ÈÒÓ ËÏÈΛ·˜ 7-10 ÂÙÒÓ Ô˘ ηÙÔÈÎÔ‡Û·Ó ÛÙË ÓÔÙÈÔ·Ó·ÙÔÏÈ΋ πÛ·Ó›· Ù· Â›‰· 25OHD ÛÙÔÓ ÔÚfi ÙÔ˘˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·, ‹Ù·Ó οو ·fi 12 ng/ml Î·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·fi ·˘Ù¿ Î˘Ì·›ÓÔÓÙ·Ó ÌÂٷ͇ 12 Î·È 20 ng/ml (21). ™ÙË µÚÂÙ·Ó›·, ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ §ÔÓ‰›ÓÔ˘, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ˘·Û‚¶·È‰È·ÙÚÈ΋ 2006;69:25-36

ÛÙÈ·ÈÌ›· ‹ Ú·¯ÈÙÈÛÌfi ‹Ù·Ó ËÏÈΛ·˜ οو ÙˆÓ ÙÚÈÒÓ ‹ ¿Óˆ ÙˆÓ 10 ÂÙÒÓ (22). ¶·ÚfiÌÔÈ· Î·È ÛÙËÓ KÔÂÁ¯¿ÁË (¢·Ó›·), ÔÈ ËÏÈ˘ ·È‰ÈÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó Ú·¯ÈÙÈÛÌfi ‹Ù·Ó 0,5-4 Î·È 9-15 ¯ÚfiÓÈ· (23). ∂›Û˘, ·Ó·Ê¤ÚÔÓÙ·È Î·È ÌÂÁ¿Ï· ÔÛÔÛÙ¿ ·È‰ÈÒÓ ÌÂÙ·Ó·ÛÙÒÓ Ì ˘Ô‚Èٷ̛ӈÛË D, ·ÚfiÙÈ ¤¯Ô˘Ó ÁÂÓÓËı› Î·È ˙Ô˘Ó ÛÙË ¢·Ó›·. ∞˘Ù¿ ·Ó¤Ú¯ÔÓÙ·È Û 46% Î·È 81% ·ÓÙ›ÛÙÔȯ·, ÁÈ· ÙȘ ËÏÈ˘ 0-8 Î·È 9-16 ¯ÚfiÓˆÓ (24). ™ÙȘ H.¶.A., fiÔ˘ ÙÚÔʤ˜ fiˆ˜ ÙÔ Á¿Ï· Î·È Ù· ‰ËÌËÙÚȷο (cereals) Â›Ó·È ÂÌÏÔ˘ÙÈṲ̂Ó˜ Ì ‚ÈÙ·Ì›ÓË D, Ú·¯ÈÙÈÛÌfi˜ ·Ó·Ê¤ÚÂÙ·È Ó· ··ÓÙ¿Ù·È ÛÙȘ ËÏÈ˘ 0,4-4,5 ¯ÚfiÓˆÓ Î·È Î˘Ú›ˆ˜ Û ·ÊÚÈηÓÈ΋˜ ηٷÁˆÁ‹˜ ·È‰È¿ Ô˘ Â›Û˘ ›¯·Ó ıËÏ¿ÛÂÈ ÁÈ· Ì·ÎÚ‡ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ¯ˆÚ›˜ Û˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ D (25). ™ÙË ÌÂϤÙË ÙˆÓ πˆ·ÓÓ›ÓˆÓ, Ë ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ÌÈÎÚfiÙÂÚˆÓ Î·È ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·È‰ÈÒÓ ÌÔÚ› Ó· ·Ô‰Ôı› Û ‰È·ÊÔÚ¤˜ Û˘ÌÂÚÈÊÔÚ¿˜ ˆ˜ ÚÔ˜ ÙË ‰È·ÙÚÔÊ‹ Î·È ÙÔÓ ÙÚfiÔ ‰È·‚›ˆÛ˘. ∆· ÌÂÁ¿Ï· ·È‰È¿ ·ÔʇÁÔ˘Ó Ó· Ï·Ì‚¿ÓÔ˘Ó ÚˆÈÓfi ‹ ÙÚÒÓ ÙÚÔʤ˜ Ù·¯Â›·˜ ·Ú·Û΢‹˜ (fast food) Î·È ÏÈÁfiÙÂÚ· Á·Ï·ÎÙÔÎÔÌÈο, ÂÓÒ ÙȘ ÈÔ ÔÏϤ˜ ÒÚ˜ ‰È·Ì¤ÓÔ˘Ó ÛÙÔ Û›ÙÈ ‹ ÎÈÓÔ‡ÓÙ·È Û ÎÏÂÈÛÙÔ‡˜ ¯ÒÚÔ˘˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Û¯ÔÏÈÎÔ‡ ¤ÙÔ˘˜ (™Â٤̂ÚÈÔ˜ - πÔ‡ÓÈÔ˜), ΢ڛˆ˜ ‰È·Ì¤ÓÔ˘Ó ÂÓÙfi˜ ÙÔ˘ Û¯ÔÏ›Ԣ Î·È ÙÔ˘ ÛÈÙÈÔ‡ ÌÂÏÂÙÒÓÙ·˜ Â› ÒÚ˜ ÁÈ· Ó· ÚÔÂÙÔÈÌ·ÛıÔ‡Ó ÁÈ· ÙȘ ÂÈÛ·ÁˆÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÛÙ· ¶·ÓÂÈÛÙ‹ÌÈ·. ∞ÎfiÌË Î·È ÁÈ· ÙË ‰È·ÛΤ‰·Û‹ ÙÔ˘˜ ÂÈϤÁÔ˘Ó ÎÏÂÈÛÙÔ‡˜ ¯ÒÚÔ˘˜, ηıÒ˜ Û' ·˘Ù‹ ÙËÓ ËÏÈΛ· ÙÔ˘˜ ÂÏ·ÂÈ Ë Ó˘¯ÙÂÚÈÓ‹ ˙ˆ‹ ÂÚÈÛÛfiÙÂÚÔ. ∞ıÏËÙÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙÔ ‡·ÈıÚÔ Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜ Û ·˘Ù¤˜ ÙȘ ËÏÈ˘, ȉ›ˆ˜ ÛÙ· ÎÔÚ›ÙÛÈ·, ÂÔ̤ӈ˜ Ë ¤ÎıÂÛË ÛÙÔÓ ‹ÏÈÔ Û·Ó›˙ÂÈ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ∞fi Ù· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ê·›ÓÂÙ·È fiÙÈ Ù· ıÂÚÈÓ¿ ·Ôı¤Ì·Ù· Ù˘


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·31

31

µÈÙ·Ì›ÓË D Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜

¶›Ó·Î·˜ 3. OÈ Ì¤Û˜ ÙÈ̤˜ (±SEM) ËÏÈΛ·˜ Î·È ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ÛÙÔÓ ÔÚfi ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (Ca), ÙˆÓ ÊˆÛÊÔÚÈÎÒÓ (Pi), Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (ALP), Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ (OC), ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D Î·È Ù˘ ·Ú·ıÔÚÌfiÓ˘ (C-PTH) Û ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ ¯ÂÈÌÒÓ· Î·È Î·ÏÔη›ÚÈ XÂÈÌÒÓ·

K·ÏÔη›ÚÈ

AÁfiÚÈ·

KÔÚ›ÙÛÈ·

AÁfiÚÈ·

KÔÚ›ÙÛÈ·

N

21

24

19

22

HÏÈΛ· (¯ÚfiÓÈ·)

16,5±0,2

16,9±0,2

16,0±0,2

16,4±0,2

Ca (mmol/L)

2,43±0,03

2,45±0,03

2,38±0,03

2,43±0,03

Pi (mmol/L)

1,29±0,06

1,19±0,03a

1,39±0,03

1,39±0,03b

ALP (IU/L)

212±28

108±48*

248±39

116±7*

OC (ng/ml)

8,7±0,6

5,8±0,3*

7,3±0,5

4,6±0,3*,d

25OHD (ng/ml)

13,4±15a

12,4±1,2a

28,4±0,2b

26,7±1,5b

0,7±0,1

2,8±0,3

2,2±0,3b

27,0±2,1

23,4±1,3

23,2±2,2

24,0±1,8

0,6±0,1

0,6±0,1

0,5±0,1

0,5±0,1

24,25(OH)2D (ng/ml)

0,7±0,1

1,25(OH)2D (pg/ml) C-PTH (ng/ml)

a

,c

a

b

*p<0,001: Û‡ÁÎÚÈÛË ÌÂٷ͇ ·ÁÔÚÈÒÓ Î·È ÎÔÚÈÙÛÈÒÓ ÙËÓ ›‰È· ÂÔ¯‹ a vs bp<0,001, cvs dp<0,02: Û‡ÁÎÚÈÛË ÌÂٷ͇ ÂÔ¯ÒÓ ÁÈ· ÙÔ ›‰ÈÔ Ê‡ÏÔ

25OHD ‰ÂÓ Â·ÚÎÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Ù˘ ‚ÈÙ·Ì›Ó˘ D ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ·ÓÙËÏȷΤ˜ Îڤ̘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÔ Î·ÏÔη›ÚÈ ÂÚÈÔÚ›˙Ô˘Ó ÙËÓ Û‡ÓıÂÛË Ù˘ ‰ÂÚÌ·ÙÈ΋˜ ‚ÈÙ·Ì›Ó˘ D, ÂÔ̤ӈ˜ ‰ÂÓ ·ÔÎÏ›ÂÙ·È Ó· Â›Ó·È Û˘Ó˘‡ı˘Ó˜ ÁÈ· ÙËÓ ˘Ô‚Èٷ̛ӈÛË D (26). ∞ÓÙ›ıÂÙ·, Ù· ·È‰È¿ ËÏÈΛ·˜ 3-14 ÂÙÒÓ ÙÔÓ ¯ÂÈÌÒÓ· Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜ ÛÙÔÓ ‹ÏÈÔ ·' fi,ÙÈ Ù· ·È‰È¿ ËÏÈΛ·˜ 15-18 ÂÙÒÓ. ¶·Ú¿ ÙË ÌÂÁ¿ÏË ÛËÌ·Û›· Ù˘ Ï‹„˘ ÙÔ˘ Á¿Ï·ÙÔ˜ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· (8), ÛÙ· Û¯ÔÏ›· ÙˆÓ ∏.¶.∞. ˘¿Ú¯ÂÈ Ë Ù¿ÛË Ó· ÂÈÙÚ¤Ô˘Ó ÔÙ¿ Ì ¯·ÌËÏ‹ ÂÚÈÂÎÙÈÎfiÙËÙ· Û Ca Î·È Û¯Â‰fiÓ Î·ıfiÏÔ˘ Á¿Ï·. ¶·ÚfiÌÔÈ· ηٿÛÙ·ÛË ˘¿Ú¯ÂÈ Î·È ÛÙËÓ ∂ÏÏ¿‰·. ∆· ÙÚfiÊÈÌ· ÛÙËÓ ∂ÏÏ¿‰· Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ÙˆÓ Á·Ï¿ÙˆÓ (ÂÎÙfi˜ ·fi Ù· Á¿Ï·Ù· ÁÈ· Ù· ‚Ú¤ÊË) ‰ÂÓ ÂÌÏÔ˘Ù›˙ÔÓÙ·È Ì ‚ÈÙ·Ì›ÓË D. ¶ÚfiÛÊ·Ù· ¿Ú¯ÈÛÂ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÔÚÈÛÌ¤ÓˆÓ Á·Ï¿ÙˆÓ Ì ‚ÈÙ·Ì›ÓË D, ·ÏÏ¿ Ë ÂÚÈÂÎÙÈÎfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È ¯·ÌËÏ‹. ŒÓ· ·È‰› ÛÙËÓ ∂ÏÏ¿‰·, ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 3 ÂÙÒÓ, ÁÈ· Ó· ¿ÚÂÈ 400 IU ‚ÈÙ·Ì›Ó˘ D ËÌÂÚËÛ›ˆ˜ Ú¤ÂÈ Ó· ›ÓÂÈ 1,5-2 Ï›ÙÚ· ·fi ÙÔ ÂÌÏÔ˘ÙÈṲ̂ÓÔ Á¿Ï·. ™Â ¿ÏϘ ‰˘ÙÈΤ˜ ¯ÒÚ˜ ÂÎÙfi˜ ÙÔ˘ Á¿Ï·ÙÔ˜ Î·È ¿ÏϘ ÙÚÔʤ˜ fiˆ˜ Ë Ì·ÚÁ·Ú›ÓË, ÂÌÏÔ˘Ù›˙ÔÓÙ·È Ì ‚ÈÙ·Ì›ÓË D. ™ÙÔÓ §›‚·ÓÔ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÔ˘ Á¿Ï·ÙÔ˜ Ì ‚ÈÙ·Ì›ÓË D ‰ÂÓ Â›Ó·È ˘Ô¯ÚˆÙÈÎfi˜ (20) Î·È ÛÙËÓ ∂ÏÏ¿‰· ηÌÈ¿ ·fi ÙȘ ÙÚÔʤ˜ ‰ÂÓ ÂÌÏÔ˘Ù›˙ÂÙ·È Ì ‚ÈÙ·Ì›ÓË D. ∂Ô̤ӈ˜ ÂÌÏÔ˘ÙÈÛÌfi˜ ÙˆÓ Á·Ï¿ÙˆÓ Ì Â·Ú΋ ÔÛfiÙËÙ· ‚ÈÙ·Ì›Ó˘ D ‹/Î·È ·Û‚ÂÛÙ›-

Ô˘, ηıÒ˜ Î·È Ë ›ÂÛË ÚÔ˜ Ù· Û¯ÔÏ›· Ó· ÚÔÛı¤ÛÔ˘Ó ÛÙ· ÚÔ˚fiÓÙ· ΢ÏÈΛԢ Á·Ï·ÎÙÔÎÔÌÈο (Á¿Ï·, ÁÈ·Ô‡ÚÙÈ) ÂÎÙfi˜ ·fi ·Ó·„˘ÎÙÈο ÔÙ¿ ˘„ËÏÒÓ ıÂÚÌ›‰ˆÓ, Èı·ÓfiÓ Ó· Û˘Ì‚¿ÏÔ˘Ó ÛÙÔ Ó· ·ÔÎÙ‹ÛÔ˘Ó Ù· ·È‰È¿ Î·È ÔÈ Ó¤ÔÈ ÌÂÁ·Ï‡ÙÂÚË ÔÛÙÈ΋ Ì¿˙·. ∞˘Ùfi ı· ¤¯ÂÈ Î·Ï‡ÙÂÚ˜ ÚÔÔÙÈΤ˜ ÁÈ· ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ Î·È Î˘Ú›ˆ˜ ÁÈ· ÙȘ Á˘Ó·›Î˜ Ô˘ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÔÛÙÂÔfiÚˆÛË. ∆ÂÏÂ˘Ù·›·, ¤¯ÂÈ ÚÔÙ·ı› Ë È‰¤· ÂÌÏÔ˘ÙÈÛÌÔ‡ Ì ‚ÈÙ·Ì›ÓË D Î·È ¿ÏÏˆÓ ÔÙÒÓ, fiˆ˜ ÙÔ ·Ô‚Ô˘Ù˘ÚˆÌ¤ÓÔ Á¿Ï· Î·È Ë ÔÚÙÔηϿ‰· (9). TÔ ÙÂÏÂ˘Ù·›Ô ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ Î·È Ù· ¿ÙÔÌ· Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ‹ ‰˘Û·ÓÂÍ›· ÛÙË Á·Ï·ÎÙfi˙Ë, ·ÓÙÈηıÈÛÙÒÓÙ·˜ ÙÔ Á¿Ï· ˆ˜ ËÁ‹ ‚ÈÙ·Ì›Ó˘ D. ª›· ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ ∂ÏÏ¿‰· ÙˆÓ ª·ÓÈÔ‡ Î·È Û˘Ó (27), ‚ڋΠfiÙÈ ÌfiÓÔ ÙÔ 48,4% ÙˆÓ ·ÁÔÚÈÒÓ Î·È ÙÔ 42,7% ÙˆÓ ÎÔÚÈÙÛÈÒÓ ËÏÈΛ·˜ 10-15 ¯ÚfiÓˆÓ Â›¯·Ó ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ·Û‚ÂÛÙ›Ô˘ ¿Óˆ ·fi ÙÔ 80% Ù˘ Û˘ÓÈÛÙÒÌÂÓ˘. ∂›Û˘, ÔÈ MϤÙÛ· Î·È Û˘Ó (28) ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ Â›¯·Ó ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ‚ÈÙ·Ì›Ó˘ D οو ÙˆÓ 10 Ìg/Ë̤ڷ (400 IU/Ë̤ڷ). ∏ ˘Ô‚Èٷ̛ӈÛË D Úԉȷı¤ÙÂÈ Û ÔÛÙÈ΋ ‚Ï¿‚Ë Î·È Î·ıÈÛÙ¿ ÙÔÓ ÏËı˘ÛÌfi ÂÈÚÚÂ‹ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ú·¯ÈÙÈÛÌÔ‡ ‹ ÔÛÙÂÔÌ·Ï¿Î˘ÓÛ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (29). ªÂϤÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ÂÊ‹‚Ô˘˜ Î·È ÂÓ‹ÏÈΘ ‰È·ÈÛÙÒÓÔ˘Ó ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ D Û˘¯Ó¿ Û ¿ÙÔÌ· Ó·ڋ˜ ËÏÈΛ·˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ· (13). ™ÙË ÓÔÙÈÔ‰˘ÙÈ΋ ∂˘ÚÒË Ë ˘Ô‚Èٷ̛ӈÛË D ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙfi 40% Û Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ ¶·È‰È·ÙÚÈ΋ 2006;69:25-36


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·32

32

¢. §··ÙÛ¿Ó˘ Î·È Û˘Ó.

ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô (30). ∞fi ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË Ê·›ÓÂÙ·È fiÙÈ Ù· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-18 ÂÙÒÓ ÚԉȷٛıÂÓÙ·È Ó· ·Ó·Ù‡ÍÔ˘Ó ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D ÙÔÓ ¯ÂÈÌÒÓ·, ‡ÚËÌ· Ô˘ ·Ó·Ê¤ÚÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (18,31). ™ÙË ™·Ô˘‰È΋ ∞Ú·‚›· ·fi ÙÔ˘˜ 21 Û˘Ìو̷ÙÈÎÔ‡˜ ÂÊ‹‚Ô˘˜ (ËÏÈΛ·˜ 10-15 ÂÙÒÓ) Ì ڷ¯ÈÙÈÛÌfi ÔÈ 20 ‹Ù·Ó ÎÔ¤Ï˜ (32). ∆· Â›‰· Ù˘ 24,25(√∏)2D ÛÙÔÓ ÔÚfi ·ÚÔ˘Û›·Û·Ó Âԯȷ΋ ‰È·Î‡Ì·ÓÛË fiˆ˜ Î·È Ë 25OHD, ÂÓÒ ·Ú·ÙËÚ‹ıËΠÈÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ 25OHD Î·È 24,25(√∏)2D ÛÙÔÓ ÔÚfi, Ë ÔÔ›· ‹Ù·Ó ÈÛ¯˘ÚfiÙÂÚË ÙÔÓ ¯ÂÈÌÒÓ·. ∞Ó Î·È Ô Ê˘ÛÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ Ù˘ 24,25(√∏)2D Â›Ó·È ·Û·Ê‹˜, Ë ÛËÌ·Û›· Ù˘ ÛÙË ÌÂÙ¿ÏψÛË ÙˆÓ ÔÛÙÒÓ ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ (33). ™Â Ó¤Ô˘˜ ËÏÈΛ·˜ 15-18 ÂÙÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÌÂÏÂÙ‹ıËÎÂ Ë Î˘ÎÏÔÊÔÚ›· ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ 24,25(√∏)2D, ‚Ú¤ıËΠηٿ Ù· ‰‡Ô ÙÚ›Ù· ¯·ÌËÏfiÙÂÚË ÙÔÓ ¯ÂÈÌÒÓ· ·' fi,ÙÈ ÙÔ Î·ÏÔη���ÚÈ Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ Î¿ÔÈ· ÛËÌ·Û›·. ∞˘Ùfi ‰ÂÓ ¤¯ÂÈ ÂÈÛËÌ·Óı› ·fi ¿ÏϘ ÌÂϤÙ˜. √È ÙÈ̤˜ Ù˘ 1,25(√∏)2D ÛÙÔÓ ÔÚfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÙÚÈÒÓ ÔÌ¿‰ˆÓ. ¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ·Ó·Ê¤ÚÔÓÙ·È Î·È ·fi ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜ (34,35). √È ÌÂÁ·Ï‡ÙÂÚ˜ ÙÈ̤˜ Ù˘ 1,25(√∏)2D ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ηÏÔηÈÚÈÔ‡, ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 11-14 ¯ÚfiÓˆÓ, ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È ÛÙË ÌÂÁ·Ï‡ÙÂÚË Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ (34,36). √È Û˘ÁÎÂÓÙÚÒÛÂȘ ·Û‚ÂÛÙ›Ô˘ ÛÙÔÓ ÔÚfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‚Ú¤ıËÎ·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. √È ÙÈ̤˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÛÙÔÓ ÔÚfi ‹Ù·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ. ŸÌˆ˜, Ù· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ̤Û˜ ÙÈ̤˜ ¯·ÌËÏfiÙÂÚ˜ ÙÔÓ ¯ÂÈÌÒÓ· ·' fi,ÙÈ ÙÔ Î·ÏÔη›ÚÈ, ÂÓÒ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÙÔ ›‰ÈÔ ÛÙ· ·ÁfiÚÈ·. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ·fi ÙËÓ ÎÂÓÙÚÈ΋ ∂˘ÚÒË ¤¯Ô˘Ó ·Ó·Ê¤ÚÂÈ Âԯȷ΋ ‰È·Î‡Ì·ÓÛË ÙÔ˘ Pi ÔÚÔ‡ Ì ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÙÔ Î·ÏÔη›ÚÈ (37). OÈ Round Î·È Û˘Ó (1973) ·Ó·Ê¤ÚÔ˘Ó ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ ʈÛÊÔÚÈÎÒÓ ÛÙ· ÎÔÚ›ÙÛÈ· ·' fi,ÙÈ ÛÙ· ·ÁfiÚÈ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 13 ÂÙÒÓ, ·ÏÏ¿ ‰ÂÓ ‰È·›ÛÙˆÛ·Ó Âԯȷ΋ ‰È·ÊÔÚ¿ ÙÔ˘ Pi Û ·È‰È¿ ËÏÈΛ·˜ 7-17 ÂÙÒÓ (38). ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· Ù· ·È‰È¿ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ËÏÈΛ·˜ 3-14 ¯ÚfiÓˆÓ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ¯·ÌËϤ˜ ÙÈ̤˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÛÙÔÓ ÔÚfi ÙÔÓ ¯ÂÈÌÒÓ· Û˘Ó˘‹Ú¯·Ó Ì ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ 25√∏D. ∂Ô̤ӈ˜, Û ·˘Ù‹ ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· ÌÔÚ› Ó· ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ë ‚ÈÔ¯ËÌÈ΋ ¤ÏÏÂÈ„Ë ¶·È‰È·ÙÚÈ΋ 2006;69:25-36

‚ÈÙ·Ì›Ó˘ D ÌÔÚ› Ó· ¤¯ÂÈ ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË ÛÙÔÓ ÛÎÂÏÂÙfi. ∞Ó Î·È ÌÂÚÈΤ˜ ÌÂϤÙ˜, Ô˘ ÚÔÛ¿ıËÛ·Ó Ó· Û˘Û¯ÂÙ›ÛÔ˘Ó Ù· Â›‰· Ù˘ 25OHD ÛÙÔÓ ÔÚfi Ì ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ‹ ÙÔÓ ÔÛÙÈÎfi ·Ó·Û¯ËÌ·ÙÈÛÌfi Û ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ, ·Ú·Ù‹ÚËÛ·Ó ÌÈÎÚ‹ ‹ ηıfiÏÔ˘ ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË ÛÙÔÓ ÛÎÂÏÂÙfi, ‰ÂÓ ÌfiÚÂÛ·Ó Î·È Ó· ÙÔ ·ÔÎÏ›ÛÔ˘Ó (39,40). ¶·Ú·Ù‹ÚËÛ·Ó fï˜, fiÙÈ ÙÔ ‡„Ô˜ ·ÌÊÔÙ¤ÚˆÓ ÙˆÓ Ê‡ÏˆÓ Ì ¯·ÌËϤ˜ ÙÈ̤˜ 25OHD ÛÙÔÓ ÔÚfi ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ·, ‚Ú¤ıËΠÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ·fi ÂΛÓÔ ÙˆÓ ·È‰ÈÒÓ Ù˘ ›‰È·˜ ËÏÈΛ·˜ Ì Â¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ ÙÔÓ ¯ÂÈÌÒÓ·. E›Û˘, ÔÈ Oliveri Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó ¯·ÌËÏ‹ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· Û Ó·ڤ˜ ÎÔ¤Ï˜ Ì ¯·ÌËϤ˜ ÙÈ̤˜ 25OHD ÛÙÔÓ ÔÚfi ÙÔÓ ¯ÂÈÌÒÓ· Î·È ¯·ÌËÏ‹ ÚfiÛÏË„Ë ·Û‚ÂÛÙ›Ô˘ ¯ˆÚ›˜ ·˘Ùfi Ó· ·Ú·ÙËÚÂ›Ù·È ÛÙ· ·ÁfiÚÈ· (39). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ Ì¤Û˜ ÙÈ̤˜ ÙˆÓ ÂÈ¤‰ˆÓ ÔÛÙÂÔηÏÛ›Ó˘ ‚Ú¤ıËÎ·Ó ¯·ÌËÏfiÙÂÚ˜ ÙÔÓ ¯ÂÈÌÒÓ· ·' fi,ÙÈ ·˘Ù¤˜ ÙÔ˘ ηÏÔηÈÚÈÔ‡ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÙˆÓ ÌÈÎÚfiÙÂÚˆÓ ËÏÈÎÈÒÓ. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÂÔ¯ÒÓ ÛÙ· Â›‰· Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Û fiϘ ÙȘ ÔÌ¿‰Â˜. øÛÙfiÛÔ, Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ‰È·ÎÚ›ÓÔ˘ÌÂ Ù˘¯fiÓ ÂÈÙÒÛÂȘ Ù˘ ·ÓÂ¿ÚÎÂÈ·˜ ‚ÈÙ·Ì›Ó˘ D ÛÙËÓ ÔÛÙÈ΋ Û‡ÓıÂÛË Î·È ÙȘ ·ÏÏ·Á¤˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ·‡ÍËÛË ÏfiÁˆ ËÏÈΛ·˜. ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ô ÔÛÙÈÎfi˜ ·Ó·Û¯ËÌ·ÙÈÛÌfi˜ ÛÙȘ ËÏÈ˘ 15-18 ¯ÚfiÓˆÓ ‹Ù·Ó ¯·ÌËÏfiÙÂÚÔ˜ ÛÙ· ÎÔÚ›ÙÛÈ· ·' fi,ÙÈ ÛÙ· ·ÁfiÚÈ·. √È Asknes Î·È Aarskog (1982) ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÈ ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙ· ÎÔÚ›ÙÛÈ· 11 ÂÙÒÓ Î·È ÛÙ· ·ÁfiÚÈ· 13 ¯ÚfiÓˆÓ (41). ™Ù· ÎÔÚ›ÙÛÈ·, ÛÙ·ıÂÚ‹ Ì›ˆÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ ·Ú·ÙËÚÂ›Ù·È ·fi ÙÔ ‰Â‡ÙÂÚÔ Ì¤¯ÚÈ ÙÔ Ù¤Ù·ÚÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÊ˂›·˜ Î·È ÛÙ· ·ÁfiÚÈ· ·fi ÙÔ ÙÚ›ÙÔ Ì¤¯ÚÈ ÙÔ ¤ÌÙÔ. √È Round Î·È Û˘Ó (1973) ·Ó·Ê¤ÚÔ˘Ó ·‡ÍËÛË Ù˘ ALP ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 13-14 ¯ÚfiÓˆÓ Ô˘ ‹Ù·Ó ÌÈÎÚfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ· (38). ªÂ›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÏÈ΋˜ ALP ÙÔ˘ ÔÚÔ‡ ·Ó·Ê¤ÚıËΠÁÈ· ·ÌÊfiÙÂÚ· Ù· ʇϷ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 14 ÂÙÒÓ. ™Ù· ·È‰È¿ ˘fi ÌÂϤÙË, Ù· Â˘Ú‹Ì·Ù· Û˘ÌʈÓÔ‡Ó Ì ·˘Ù¿ ÚÔËÁÔ‡ÌÂÓˆÓ ÌÂÏÂÙÒÓ Ì ÙȘ ÙÈ̤˜ Ù˘ ALP Ó· Â›Ó·È ˘„ËÏfiÙÂÚ˜ ÛÙȘ ËÏÈ˘ 11-14 ¯ÚfiÓˆÓ Î·È Ó· ÌÂÈÒÓÔÓÙ·È ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (15-18 ÂÙÒÓ). √È ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ Ô˘ ‚Ú¤ıËÎ·Ó ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ù˘ ÌÂϤÙ˘ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È ÛÙËÓ ÚÒÈÌË Ì›ˆÛË ÛÙ· ÎÔÚ›ÙÛÈ· Û˘ÁÎÚÈÙÈο Ì ٷ ·ÁfiÚÈ·.


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·33

33

µÈÙ·Ì›ÓË D Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜

¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó Î·È Ì ÙËÓ ÔÛÙÂÔηÏÛ›ÓË. ª›· ÈÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ‚Ú¤ıËΠÌÂٷ͇ ÔÛÙÂÔηÏÛ›Ó˘ Î·È ÔÏÈ΋˜ ALP, ·ÊÔ‡ Î·È ÔÈ ‰‡Ô Â›Ó·È ‚ÈÔ¯ËÌÈÎÔ› ‰Â›ÎÙ˜ Ù˘ ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘. ∞˘Ù‹ Ë ·Ú·Ù‹ÚËÛË ¤¯ÂÈ ÂÈÛËÌ·Óı› Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ Û ÂÓ‹ÏÈΘ Î·È ·È‰È¿ ËÏÈΛ·˜ 7-18 ÂÙÒÓ (42,43). ∫·È ÔÈ ‰‡Ô ‰Â›ÎÙ˜ ÁÈ· ¯ÂÈÌÒÓ· Î·È Î·ÏÔη›ÚÈ ·Ú·¤ÌÔ˘Ó Û ¯·ÌËÏfiÙÂÚÔ ÔÛÙÈÎfi ·Ó·Û¯ËÌ·ÙÈÛÌfi Î·È ¯·ÌËÏfi Ú˘ıÌfi ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘ ÛÙ· ÎÔÚ›ÙÛÈ·. ∞˘Ù¿ Ù· Â˘Ú‹Ì·Ù· Û˘ÌʈÓÔ‡Ó Ì ÚfiÛÊ·ÙË ÌÂϤÙË Ô˘ ¤‰ÂÈÍ fiÙÈ Ë Ì¤ÛË ËÏÈΛ· Ù˘ ̤ÁÈÛÙ˘ Û˘ÛÛÒÚ¢Û˘ Ca ÛÙËÓ ‹‚Ë Â›Ó·È Ù· 14 ¤ÙË ÁÈ· Ù· ·ÁfiÚÈ· Î·È ÛÙ· 12,5 ¤ÙË ÁÈ· Ù· ÎÔÚ›ÙÛÈ· (44). ∂›Û˘, ÂÎÙÈÌÔ‡Ó fiÙÈ, ηٿ ÚÔÛ¤ÁÁÈÛË, ÙÔ 26% ÙÔ˘ Ca ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÔÎÙ¿Ù·È ÛÙ· ‰‡Ô ¯ÚfiÓÈ· Ù˘ Ù·¯Â›·˜ ÛÎÂÏÂÙÈ΋˜ ·‡ÍËÛ˘. √È ˘„ËϤ˜ ·Ó·ÏÔÁ›Â˜ Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÔÛÙÈÎÒÓ ÌÂÙ¿ÏÏˆÓ ÛÙËÓ ‹‚Ë ‰Â›¯ÓÔ˘Ó fiÙÈ ¤Ó· ·ÍÈfiÏÔÁÔ ÎÏ¿ÛÌ· Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÂÙ¿ÏÏˆÓ ÙÔ˘ ÔÛÙÔ‡ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙ· Ï›Á· ¯ÚfiÓÈ· Ù˘ ÂÊ˂›·˜. √È ˘„ËϤ˜ ·Ó·ÏÔÁ›Â˜ ηٷÎÚ¿ÙËÛ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙËÓ ‹‚Ë ÌÔÚÔ‡Ó Ó· ÂÈÙ¢¯ıÔ‡Ó Ì ·‡ÍËÛË Ù˘ ‰È·ÈÙËÙÈ΋˜ ÚfiÛÏ˄˘, ηıÒ˜ Î·È Ì ÙËÓ Â·Ú΋ ·ÔÚÚfiÊËÛË Î·È Î·Ù·ÎÚ¿ÙËÛË. ∆Ô ‰Â‡ÙÂÚÔ ÂÍ·ÚÙ¿Ù·È Î·Ù¿ ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ·fi ÙËÓ Â¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D. °Ú·ÌÌÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ‚Ú¤ıËÎÂ Î·È ÌÂٷ͇ ÙÔ˘ ‰Â›ÎÙË ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘, Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ Î·È ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ 1,25(OH)2D ÛÙÔÓ ÔÚfi. °ÓˆÛÙfi Â›Ó·È fiÙÈ Ë Î·ÏÛÈÙÚÈfiÏË ÚÔ¿ÁÂÈ ÙË Û‡ÓıÂÛË Ù˘ ÔÛÙÂÔηÏÛ›Ó˘ Î·È ·Ó·Ê¤ÚÂÙ·È fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜, ˘¿Ú¯ÂÈ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Î·ÏÛÈÙÚÈfiÏ˘ Î·È ÔÛÙÂÔηÏÛ›Ó˘ (45). ∂›Û˘ ÛÙËÓ ÂÊ˂›· ·Ó·Ê¤ÚÂÙ·È Û˘Û¯¤ÙÈÛË Î·È ÌÂٷ͇ ηÏÛÈÙÚÈfiÏ˘ Î·È Û˘ÁΤÓÙÚˆÛ˘ ·Û‚ÂÛÙ›Ô˘ ÛÙÔÓ ÛÎÂÏÂÙfi ‹ ·‡ÍËÛ˘ Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ (36). £ÂˆÚËÙÈο, Ê·›ÓÂÙ·È fiÙÈ Ù· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂÚÌËÓ¢ıÔ‡Ó ˆ˜ Û¯¤ÛË ÂÈ¤‰ˆÓ ηÏÛÈÙÚÈfiÏ˘ Î·È ÔÛÙÈ΋˜ Ì¿˙·˜, Èı·ÓfiÓ ÏfiÁˆ Ù˘ Â›‰Ú·Û‹˜ Ù˘ ÛÙËÓ ·ÔÚÚfiÊËÛË Î·È Î·Ù·ÎÚ¿ÙËÛË ÙÔ˘ Ca ÛÙÔ ÛÒÌ·. ªÂϤÙ˜ ÌÂÙ·-·Ó¿Ï˘Û˘ ÈÛÔ˙˘Á›ˆÓ ·Û‚ÂÛÙ›Ô˘ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ·ÔÚÚfiÊËÛË Î·È Ë Î·Ù·ÎÚ¿ÙËÛË Ca ÛÙÔ ÛÒÌ· Â›Ó·È ˘„ËÏfiÙÂÚ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜ Î·È ÛÙ· ‰‡Ô ʇϷ (46). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙËÓ C-PTH ÌÂٷ͇ ÙˆÓ ÂÔ¯ÒÓ Î·È ÛÙȘ 3 ÔÌ¿‰Â˜ ·È‰ÈÒÓ Î·È ÔÈ ÙÈ̤˜

‚Ú¤ıËÎ·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·, Ì ÌÈÎÚfiÙÂÚ˜ ÙÈ̤˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÌÂÁ¿ÏˆÓ ·È‰ÈÒÓ (15-18 ÂÙÒÓ). ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó ·‡ÍËÛË Ù˘ PTH Û ·È‰È¿ Ì ˘Ô‚Èٷ̛ӈÛË D (20). ™ËÌ·ÓÙÈ΋ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂÈ¤‰ˆÓ ÛÙÔÓ ÔÚfi 25√HD Î·È ƒ∆∏ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ·ÁfiÚÈ· ÂÊ‹‚Ô˘˜ (47). ∆¤ÙÔÈ· Û˘Û¯¤ÙÈÛË ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛÙ· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· Â›‰· Ù˘ C-PTH ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÙËÓ ·ÔÎÏ›ÛÔ˘Ó ˆ˜ ¢·›ÛıËÙÔ ‰Â›ÎÙË ·ÓÂ¿ÚÎÂÈ·˜ ‚ÈÙ·Ì›Ó˘ D. √‡Ù ÌÔÚ› Ó· ·ÁÓÔËı› fiÙÈ ÂÓ‰¤¯ÂÙ·È Ó· ˘¿Ú¯Ô˘Ó ÎÏÈÓÈο ·ÍÈÔÏÔÁ‹ÛÈ̘ ÂÈÙÒÛÂȘ ·fi ÙËÓ ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D. ∂Ó‰¤¯ÂÙ·È Ó· ˘¿Ú¯ÂÈ ¤Ó·˜ Ô˘‰fi˜ ÁÈ· Ù· Â›‰· Ù˘ 25OHD, οو ·fi ÙÔÓ ÔÔ›Ô ÌÔÚ› Ó· ÂËÚ¿˙ÔÓÙ·È Ù· Â›‰· C-PTH. ™Â ÌÂÙ·-ÂÌÌËÓÔ·˘ÛȷΤ˜ Á˘Ó·›Î˜ Ô Ô˘‰fi˜ ·˘Ùfi˜ ·Ó·Ê¤ÚÂÙ·È Ó· Î˘Ì·›ÓÂÙ·È ÛÙ· 3044 ng/ml Î·È Â›Û˘ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ‚·ıÌfi ·ÔÚÚfiÊËÛ˘ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (48,49). ™Ù· ·È‰È¿ ·˘Ùfi˜ Ô Ô˘‰fi˜ ‰ÂÓ ¤¯ÂÈ ˘ÔÏÔÁÈÛı› ·ÏÏ¿ Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È ·ÚÎÂÙ¿ ¯·ÌËÏfiÙÂÚ·. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ·ÎfiÌË Î·È Û ÌÈ· ËÏÈfiÏÔ˘ÛÙË ¯ÒÚ· fiˆ˜ Ë ∂ÏÏ¿‰·, ÔÈ Ó¤ÔÈ ËÏÈΛ·˜ 15-18 ¯ÚfiÓˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÌÒÓ· ¤¯Ô˘Ó ·Ó¿ÁÎË Ï‹„˘ ‚ÈÙ·Ì›Ó˘ D, ·ÊÔ‡ Ù· ·Ôı¤Ì·Ù· Û ‚ÈÙ·Ì›ÓË D ÙÔ˘ ηÏÔηÈÚÈÔ‡ ‰ÂÓ Â·ÚÎÔ‡Ó. ∆· ÎÔÚ›ÙÛÈ· ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ ·ÔÙÂÏÔ‡Ó ÈÔ Â˘·›ÛıËÙÔ ÏËı˘ÛÌfi ·ÚfiÙÈ ‰ÂÓ ¤¯Ô˘Ó ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ Ù˘ ÂÓ‰˘Ì·Û›·˜ fiˆ˜ ÛÙȘ ÌÔ˘ÛÔ˘ÏÌ·ÓÈΤ˜ ¯ÒÚ˜, Ô Î›Ó‰˘ÓÔ˜ ‰Â Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÁÈ· ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ∫·Ù¿ fiÛÔÓ ˘¿Ú¯Ô˘Ó Ì·ÎÚÔ¯ÚfiÓȘ ÂÈÙÒÛÂȘ Â› Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ ÙÔ˘˜ ‰ÂÓ ÌÔÚ› Ó· ÂȂ‚·Èˆı› ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ·ÏÏ¿ ‰ÂÓ ÌÔÚ› Î·È Ó· ·ÁÓÔËı›, ÂȉÈο Ì ¯·ÌËϤ˜ ÙÈ̤˜ ‰ÂÈÎÙÒÓ ÔÛÙÈ΋˜ Û‡ÓıÂÛ˘ ÙË ¯ÂÈÌÂÚÈÓ‹ ÂÚ›Ô‰Ô. ∂›Û˘, ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ¤¯Ô˘Ó ‰È·ÈÛÙˆı› ÂÚ¢ÓËÙÈο Î·È ¿ÏϘ ‰Ú¿ÛÂȘ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÂÎÙfi˜ ·fi ·˘Ù‹ ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ (50). ŒÙÛÈ, Ù˘¯fiÓ ÂÈÙÒÛÂȘ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ D ÛÙÔÓ ¿ÓıÚˆÔ Ì¿ÏÏÔÓ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛı›. √È ÈÔ Û˘ÓËıÈṲ̂Ó˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ÔÊ›ÏÔÓÙ·È Û ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· fiˆ˜ Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ I, Ë ÚÂ˘Ì·ÙÔÂȉ‹˜ ·ÚıÚ›Ùȉ· Î·È Ë ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÔÚÔ‡Û·Ó Ó· ÚÔÏËÊıÔ‡Ó Û ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ¤·ÈÚÓ·Ó ¶·È‰È·ÙÚÈ΋ 2006;69:25-36


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1,25(OH)2D ·fi ÙËÓ ·Ú¯‹ Ù˘ ˙ˆ‹˜ ÙÔ˘˜ (51,52,53). √È Hypponen Î·È Û˘Ó (2001) Û ̛· ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË, ‚Ú‹Î·Ó fiÙÈ Ù· ·È‰È¿ Ô˘ ¤·ÈÚÓ·Ó 2000 IU ‚ÈÙ·Ì›Ó˘ D ·fi ÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜ Ì›ˆÓ·Ó ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ I ηٿ 80% (54). ÀÂÚÙ·ÛÈÎÔ› ·ÛıÂÓ›˜ Ô˘ ÂÎÙ¤ıËÎ·Ó Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· (UVB) ÁÈ· ÌÂÚÈÎÔ‡˜ Ì‹Ó˜ Î·È ·‡ÍËÛ·Ó Ù· Â›‰· Ù˘ ΢ÎÏÔÊÔÚÔ‡Û·˜ 25OHD, ‚Ú¤ıËÎ·Ó Ó· ÌÂÈÒÓÔ˘Ó ÙË Û˘ÛÙÔÏÈ΋ Î·È ‰È·ÛÙÔÏÈ΋ ›ÂÛ‹ ÙÔ˘˜ Û·Ó Ó· ¤·ÈÚÓ·Ó ·ÓÙÈ˘ÂÚÙ·ÛÈ΋ ·ÁˆÁ‹, ÂÓÒ ‰ÂÓ Û˘Ó¤‚·ÈÓ ÙÔ ›‰ÈÔ Ì ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ ·‡ÍËÛ·Ó ÙËÓ 25OHD (55). ª¤Ûˆ Ì˯·ÓÈÛÌÒÓ Ô˘ ‰ÚÔ˘Ó ·ÚÓËÙÈο ÛÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ Î˘ÙÙ¿ÚˆÓ ‹ Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ·fiÙˆÛ˘, Ë ‚ÈÙ·Ì›ÓË D ÌÔÚ› Ó· ÂËÚ¿˙ÂÈ Î·È Ì¿ÏÈÛÙ· ·ÔÙÂÏÂÛÌ·ÙÈο ÙËÓ Î˘ÙÙ·ÚÈ΋ ·‡ÍËÛË, ÚÔÛٷهÔÓÙ·˜ ¤ÙÛÈ ·fi ÌÂÚÈÎÔ‡˜ Ù‡Ô˘˜ ηÚΛÓÔ˘ (56). ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰‡Ô ‰ÂηÂٛ˜, ÂÚ¢ÓËÙ¤˜ ÂȂ‚·›ˆÛ·Ó ·ÏÈfiÙÂÚ˜ ·Ú·ÙËÚ‹ÛÂȘ fiÙÈ ¿ÓıÚˆÔÈ ·fi ÙȘ H.¶.A. Î·È ÙËÓ E˘ÚÒË Ô˘ ˙Ô‡Û·Ó Û ˘„ËÏfi ÁˆÁÚ·ÊÈÎfi Ï¿ÙÔ˜ ‹ ‰ÂÓ ÂÎÙ›ıÂÓÙÔ ·ÚÎÂÙ¿ Û UVB ·ÎÙÈÓÔ‚ÔÏ›·, ‚Ú›ÛÎÔÓÙ·Ó Û ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ı·Ó¿ÙÔ˘ ·fi ηÚΛÓÔ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ÙÔ˘ ÚÔÛÙ¿ÙË Î·È ÙÔ˘ Ì·ÛÙÔ‡ (57). ™˘ÓÂÒ˜, Ô ÂÌÏÔ˘ÙÈÛÌfi˜ Ì ÈηÓÔÔÈËÙÈ΋ ÔÛfiÙËÙ· ‚ÈÙ·Ì›Ó˘ D ÙˆÓ Á·Ï¿ÙˆÓ Î·È ÙˆÓ ¿ÏÏˆÓ ·Ú·ÁÒÁˆÓ Á¿Ï·ÙÔ˜ Î·È ÛÙËÓ ∂ÏÏ¿‰· Û›ÁÔ˘Ú· ı· Â›Ó·È Â˘ÂÚÁÂÙÈÎfi˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Huldschinsky K. Heilung von Rachitis durch Kunstliche Hohensonne. Dtsch Med Wochenschr 1919; 45:712-713. 2. Mellanby E. An experimental investigation of rickets. Lancet 1919;1:407-412. 3. Holick MF. McCollum Award Lecture, 1994: vitamin D - new horizons for the 21st century. Am J Clin Nutr 1994;60:619-630. 4. Ponchon G, DeLuca HF. The role of the liver in the metabolism of vitamin D. J Clin Invest 1969;48: 1273-1279. 5. Fraser DR, Kodicek E. Unique biosynthesis by kidney of a biologically active vitamin D metabolite. Nature 1970;228:764-766. 6. Holick MF. Vitamin D: the underappreciated Dlightful hormone that is important for skeletal and cellular health. Curr Opin Endocrinol Diabetes 2002;9:87-98. 7. Bonjour JP, Theintz G, Buchs B, Slosman D, Rizzoli R. Critical years and stages of puberty for spinal and femoral bone mass accumulation during adoles¶·È‰È·ÙÚÈ΋ 2006;69:25-36

cence. J Clin Endocrinol Metab. 1991;73:555-563. 8. Tucker KL. Does milk intake in childhood protect against later osteoporosis? Am J Clin Nutr 2003;77: 10-11. 9. Tangpricha V, Koutkia P, Rieke SM, Chen TC, Perez AA, Holick MF. Fortification of orange juice with vitamin D: a novel approach for enhancing vitamin D nutritional health. Am J Clin Nutr 2003;77:14781483. 10. Lapatsanis P, Deliyanni V, Doxiadis S. Vitamin D deficiency rickets in Greece. J Pediatr 1968;73:195-202. 11. Holick MF. Vitamin D requirements for humans of all ages: New increased requirements for women and men 50 years and older. Osteoporosis 1998; 8 (Suppl):S24-S29. 12. Tanner JM, Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity and weight velocity and the stages of puberty. Arch Dis Child 1976;51:170-179. 13. Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone 2002;30:771-777. 14. Challa A, Bevington A, Angier CM, Asbury AJ, Preston CJ, Russell RG. A technique for the measurement of orthophosphate in human erythrocytes and some studies of its determinants. Clin Sci 1985;69:429-434. 15. Moulas A, Challa A, Lapatsanis D. Method of quantitative determination of the main metabolites of vitamin D [25OHD, 24,15(OH)2D and 1,25(OH)2D] in the same sample of serum or plasma. Ostoun (Athens) 1996;7:17-24. 16. Shepard RM, Horst RL, Hamstra AJ, DeLuca HF. Determination of vitamin D and its metabolites in plasma from normal and anephric man. Biochem J 1979;182:55-69. 17. Reinhardt T∞, Horst RL, Orf JW, Hollis BW. A microassay for 1,25-dihydroxyvitamin D not requiring high performance liquid chromatography: application to clinical studies. J Clin Endocrinol Metab 1984;58:91-98. 18. Ala-Houhala M, Parviainen MT, Pyykko K, Visakorpi JK. Serum 25-hydroxyvitamin D levels in Finnish children aged 2 to 17 years. Acta Paediatr Scand 1984;73:232-236. 19. Zeghoud F, Delaveyne R, Rehel P, Chalas J, Garabédian M, Odiévre M. Vitamine D et maturation pubertaire. Intérêt et tolérance d'une supplémentation vitaminique D en période hivernale. Arch Pediatr 1995;2:221-226. 20. El-Hajj Fuleihan G, Nabulsi M, Choucair M, Salamoun M, Hajj-Shahine G, Kizirian A, Tannous R. Hypovitaminosis D in healthy schoolchildren. Pediatrics 2001;107(4):E53. 21. Docio S, Riancho JA, Pérez A, Olmos JM, Amado JA, Conzalez-Macias J. Seasonal deficiency of vitamin D in children: a potential target for osteoporosis-preventing strategies? J Bone Miner Res 1998; 13:544-548. 22. Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Arch Dis


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Child 2004;89:781-784. 23. Pedersen P, Michaelsen KF, Molgaard C. Children with nutritional rickets referred to hospitals in Copenhagen during a 10-year period. Acta Paediatr 2003;92:87-90. 24. Glerup H, Rytter L, Mortensen L, Nathan E. Vitamin D deficiency among immigrant children in Denmark. Eur J Pediatr 2004;163:272-273. 25. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr 2004;80(Suppl):1697S-705S. 26. Matsuoka LY, Ide L, Wortsman J, MacLaughlin JA, Holick MF. Sunscreens suppress cutaneous vitamin D3 synthesis. J Clin Endocrinol Metab 1987;64:11651168. 27. Manios Y, Babaroutsi E, Bletsa M, Rammata M, Sidossis S, Yannakoulia M, Sidossis LS. Physical Activity, calcium intake and bone mineral density in a semi-representative sample of Greek pupils and adults [Abstract]. 2nd Congress of the European Chapter of the American College of Nutrition; 2002 November 15-16; Athens, Greece. 28. Bletsa M, Babaroutsi E, Sidossis S, Manios Y, Sidossis LS. Prevalence of osteopenia and osteoporosis in Greece [Abstract]. 2nd Congress of the European Chapter of the American College of Nutrition; 2002 November 15-16; Athens, Greece. 29. Parfitt AM. Osteomalacia and related disorders. In: Metabolic Bone Disease and Clinically Related Disorders 2nd ed. Avioli LV and Krane SM eds. Philadelphia: WB Saunders: 1990. p. 329-396. 30. McKenna MJ. Differences in vitamin D status between countries in young adults and the elderly. Am J Med 1992;93:69-77. 31. Lehtonen-Veromaa M, Mottonen T, Irjala K, Karkkainen M, Lamberg-Allardt C, Hakola P, Viikari J. Vitamin D is low and hypovitaminosis D common in healthy 9-to 15-year old Finnish girls. Eur J Clin Nutr 1999;53:746-751. 32. Narchi H, El Jamil M, Kulaylat N. Symptomatic rickets in adolescence. Arch Dis Child 2001;84:501-503. 33. Ornoy A, Goodwin D, Edelstein S. 24,25-Dihydroxyvitamin D is a metabolite of vitamin D essential for bone formation. Nature 1978;276:517-519. 34. Chesney RW, Rosen JF, Hamstra AJ, Smith C, Mahaffey K, DeLuca HF. Absence of seasonal variation in serum concentrations of 1,25-dihydroxyvitamin D despite a rise in 25-hydroxyvitamin D in summer. J Clin Endocrinol Metab 1981;53:139-142. 35. Taylor AF, Norman ME. Vitamin D metabolite levels in normal children. Pediatr Res 1984;18:886-890. 36. Ilich JZ, Badenhop NE, Jelic T, Clairmont AC, Nagode LA, Matkovic V. Calcitriol and bone mass accumulation in females during puberty. Calcif Tissue Int 1997;61:104-109. 37. Douglas AS, Miller MH, Reid DM, Hutchison JD, Porter RW, Robins SP. Seasonal differences in biochemical parameters of bone remodeling. J Clin Pathol 1996;49:284-289. 38. Round JM. Plasma calcium, magnesium, phosphorus and alkaline phosphatase levels in normal British

schoolchildren. Brit Med J 1973;3:137-140. 39. Oliveri MB, Wittich A, Mautalen C, Chaperon A, Kizlansky A. Peripheral bone mass is not affected by winter vitamin D deficiency in children and young adults from Ushuaia. Calcif Tissue Int 2000; 67: 220-224. 40. Kristinsson JO, Valdimarsson O, Sigurdsson G, Franzson L, Olafsson I, Steingrimsdottir L. Serum 25-hydroxyvitamin D levels and bone mineral density in 16-20-year-old girls. Lack of association. J Intern Med 1998;243:381-388. 41. Aksnes L, Aarskog D. Plasma concentrations of vitamin D metabolites in puberty: Effect of sexual maturation and implications for growth. J Clin Endocrinol Metab 1982;55:94-101. 42. Mora S, Pitukcheewanont P, Kaufman FR, Nelson JC, Gilsanz V. Biochemical markers of bone turnover and the volume and the density of bone in children at different stages of sexual development. J Bone Miner Res 1999;14:1664-1667. 43. Seydewitz HH, Henschen M, Kuhnel W, Brandis M. Pediatric reference ranges for osteocalcin measured by the Immulite analyzer. Clin Chem Lab Med 2001;39:980-982. 44. Bailey DA, Martin AD, McKay HA, Whiting S, Mirwald R. Calcium accretion in girls and boys during puberty: A longitudinal analysis. J Bone Miner Res 2000;15:2245-2250. 45. Price PA, Baukol SA. 1,25-Dihydroxyvitamin D3 increases synthesis of the vitamin K-dependent bone protein by osteosarcoma cells. J Biol Chem 1980;255:11660-11665. 46. Matkovic V. Calcium metabolism and calcium requirements during skeletal modeling and consolidation of bone mass. Am J Clin Nutr 1991;54 (1 Suppl): S245-S260. 47. Guillemant J, Cabrol S, Allemandou A, Peres G, Guillemant S. Vitamin D-dependent seasonal variation of PTH in growing male adolescents. Bone 1995;17:513-516. 48. Dawson-Hughes B, Harris SS, Dallal GE. Plasma calcidiol, season, and serum parathyroid hormone concentrations in healthy elderly men and women. Am J Clin Nutr 1997;65:67-71. 49. Heaney RP, Dowell MS, Hale CA, Bendich A. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr 2003;22:142-146. 50. DeLuca HF, Cantorna MP. Vitamin D: its role and uses in immunology. FASEB J 2001;15:2579-2585. 51. Mathieu C, Waer M, Laureys J. Rutgeerts O, Bouillon R. Prevention of autoimmune diabetes in NOD mice by 1,25 dihydroxyvitamin D3. Diabetologia 1994;37:552-558. 52. Cantorna MT, Hayes CE, DeLuca HF. 1,25-Dihydroxyvitamin D3 reversibly blocks the progression of relapsing encephalomyelitis, a model of multiple sclerosis. Proc Natl Acad Sci USA 1996;93:7861-7864. 53. Cantorna MT, Hayes CE, DeLuca HF. 1,25 Dihydroxyvitamin D3 inhibits the progression of arthritis in murine models of human arthritis. J Nutr 1998; 128:68-72. ¶·È‰È·ÙÚÈ΋ 2006;69:25-36


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¢. §··ÙÛ¿Ó˘ Î·È Û˘Ó.

54. Hyppönen E, Läärä E, Reunanen A, Järvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet 2001;358: 1500-1503. 55. Krause R, Buhring M, Hopfenmuller W, Holick MF, Sharma AM. Ultraviolet B and blood pressure. Lancet 1998;352:709-710

¶·È‰È·ÙÚÈ΋ 2006;69:25-36

56. Holick MF. Vitamin D: importance in the prevention of cancers, type I diabetes, heart disease, and osteoporosis. Am J Clin Nutr 2003;79:362-371. 57. Grant WB. An estimate of premature cancer mortality in the U.S. due to inadequate doses of solar ultraviolet-B radiation. Cancer 2002;94:1867-1875.


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ORIGINAL ARTICLE

37

¡ÔÛËÚfiÙËÙ· Î·È ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ‚ÚԢΤÏψÛ˘ ÛÙËÓ ∂ÏÏ¿‰· ª. ª·˘ÚfiΈÛÙ·, ∂. °·Ï·Ó¿Î˘

¶ÂÚ›ÏË„Ë: ¶·Ú¿ Ù· ̤ÙÚ· ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘, Ë ‚ÚԢΤÏψÛË ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÓ‰ËÌ› Û ÔÏϤ˜ ÂÚÈÔ¯¤˜ ÙÔ˘ ÎfiÛÌÔ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·Ó·ÛÎÔ‹ıËÎ·Ó ÔÈ Ì·ÎÚÔ¯ÚfiÓȘ Ù¿ÛÂȘ Ù˘ ÓÔÛËÚfiÙËÙ·˜ ÛÙËÓ ∂ÏÏ¿‰· ηٿ ÙËÓ 25ÂÙ›· 1979-2003, Ì ¤ÌÊ·ÛË ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi, Î·È Ì ‚¿ÛË Ù· ‰Â‰Ô̤ӷ Ù˘ ∂ıÓÈ΋˜ ™Ù·ÙÈÛÙÈ΋˜ ÀËÚÂÛ›·˜ Î·È ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜. ∫·Ù¿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980, Ë Â›ÙˆÛË ÂÌÊ¿ÓÈÛ ÛÙ·‰È·Î‹ Ì›ˆÛË, fï˜ ÛÙ· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990, ·Ú·ÙËÚ‹ıËÎÂ Ó¤Ô ·˘ÍËÙÈÎfi ·̷. ∏ ̤ÛË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ ‹Ù·Ó 4,38 ‰Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· Î·È 7,76 ÓÔÛËÏ›˜ / 100.000 ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ / ¤ÙÔ˜. ∆Ô 11,2% ÙˆÓ ÓÔÛËÏÂÈÒÓ ·ÊÔÚÔ‡Û ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 14 ÂÙÒÓ, Ì ̤ÛË ÙÈÌ‹ 5,08 ÓÔÛËÏ›˜ / 100.000 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ / ¤ÙÔ˜. ™Ù· ·È‰È¿ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·. ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ʇϷ ηٿ ÙË ‚ÚÂÊÈ΋ Î·È ÙË ÓËȷ΋ ËÏÈΛ·, fï˜ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, Ë ÓfiÛÔ˜ ÚÔÛ¤‚·ÏÂ Û˘¯ÓfiÙÂÚ· Ù· ·ÁfiÚÈ·. ∏ ÓfiÛÔ˜ ‹Ù·Ó Ôχ ÈÔ Û˘¯Ó‹ ÛÙËÓ ◊ÂÈÚÔ Î·È ÙË £Ú¿ÎË Î·È ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ Û ÓËÛȈÙÈΤ˜ Î·È ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜. √È ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÏÏËÓÈΤ˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ ·Ù˘›· Î·È ÙËÓ ÔÈÎÈÏÔÌÔÚÊ›· ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÂÈÌÔÓ‹ Î·È Ë ÚfiÛÊ·ÙË ·Ó·˙ˆ‡ÚˆÛË Ù˘ ‚ÚԢΤÏψÛ˘ ÂÈ‚¿ÏÏÔ˘Ó ¤ÏÂÁ¯Ô ÙˆÓ ˙ÒˆÓ ÂÎÙÚÔÊ‹˜ Î·È Ù˘ ·Ú·Û΢‹˜ Î·È ‰È¿ıÂÛ˘ ÙˆÓ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ, ηıÒ˜ Î·È ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÔÈÎÔÁÂÓÂÈÒÓ Ì ¿Û¯ÔÓ Ì¤ÏÔ˜. √È ÁÈ·ÙÚÔ› ÛÙËÓ ∂ÏÏ¿‰· ÔÊ›ÏÔ˘Ó Ó· ÛΤÊÙÔÓÙ·È ÙË ‚ÚԢΤÏψÛË Û ·ÛıÂÓ›˜ Ì ¿Ù˘˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Î·È È‰È·›ÙÂÚ· Û ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜ Î·È Û ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ ∆Ô̤·˜ ªËÙ¤Ú·˜-¶·È‰ÈÔ‡, ∆Ì‹Ì· π·ÙÚÈ΋˜ ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ ∆.£. 2208, T.K. 710 03 ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ ∂-mail: egalanak@med.uoc.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-01-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-10-2005

§¤ÍÂȘ ÎÏÂȉȿ: µÚԢΤÏψÛË, Â·ÁÁÂÏÌ·ÙÈΤ˜ ÓfiÛÔÈ, ÙÚÔÊÈÌÔÁÂÓ›˜ ÓfiÛÔÈ, ˙ˆÔ·ÓıÚˆÔÓfiÛÔÈ.

Morbidity and clinical manifestations of brucellosis in Greece M. Mavrokosta, E. Galanakis

Abstract: Despite the preventive efforts, brucellosis remains endemic in many areas worldwide. ∆he long-term morbidity of the disease in Greece was investigated in the present study, with an emphasis on childhood morbidity. The study was based on the data reported from 1979 through 2003 by the Greek National Statistical Service and in the relevant published studies. During the 1980s, brucellosis presented with a decrease in morbidity, but a reemergence was observed in the mid 1990s. The average annual incidence was 4.38 reported cases and 7.76 admissions / 100,000 population. Among the hospitalized patients, 11,2% were children aged less than 14 years, and average annual incidence was calculated at 5.08 admissions / 100,000 child population. The morbidity in childhood and adolescence increased with age. Male and female infants and toddlers were equally affected, but males presented with a considerably higher morbidity during late childhood and adolescence. Endemic areas were identified, mainly in Northern Greece. The lowest incidence rates were observed in the islands and in urban areas. The protean clinical manifestations of brucellosis were confirmed in the Greek published studies. The persistence and the recent reemergence of brucellosis in Greece stress the need of animal control and pasteurization of milk and dairy products, and of screening the families of index cases. Physicians should think of brucellosis when caring for patients who reside in or have traveled to endemic areas and who present with atypical manifestations.

Paediatric Department, General University Hospital of Heraklion, Crete Correspondence: Emmanouil Galanakis School of Medicine, Mother-Child Department University of Crete P.O. Box 2208, 710 03, Heraklion, Crete ∂-mail: egalanak@med.uoc.gr Date of submission: 10-01-2005 Date of approval: 14-10-2005

Key words: Brucellosis, endemic areas, Greece, occupational diseases, food-borne diseases, zoonotic diseases.

¶·È‰È·ÙÚÈ΋ 2006;69:37-44


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38

ª. ª·˘ÚfiΈÛÙ·, ∂. °·Ï·Ó¿Î˘

∏ ‚ÚԢΤÏψÛË, ·ÏÈfiÙÂÚ· ÁÓˆÛÙ‹ Î·È ˆ˜ ÌÂÏÈÙ·›Ô˜ ˘ÚÂÙfi˜ (1), Â›Ó·È ˙ˆÔ·ÓıÚˆÔÓfiÛÔ˜ ÂÓ‰ËÌÈ΋ Û ÔÏÏ¿ ÛËÌ›· ÙÔ˘ ÎfiÛÌÔ˘, fiˆ˜ Û ¯ÒÚ˜ Ù˘ §·ÙÈÓÈ΋˜ ∞ÌÂÚÈ΋˜, Ù˘ ∞ÊÚÈ΋˜, Ù˘ ª¤Û˘ ∞Ó·ÙÔÏ‹˜ Î·È Û ¯ÒÚ˜ Ù˘ ªÂÛÔÁ›Ԣ, fiˆ˜ Ë °·ÏÏ›·, Ë πÙ·Ï›·, Î·È Ë ∂ÏÏ¿‰· (1-9). ∞fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960, Ë Û˘ÛÙËÌ·ÙÈ΋ ÚfiÏË„Ë Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ‡ÊÂÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Û ˙Ò· Î·È ·ÓıÚÒÔ˘˜, ·ÎfiÌË Î·È ÙËÓ ÂÍ¿ÏÂÈ„Ë Ù˘ ÓfiÛÔ˘ Û ·ÚÎÂÙ¤˜ ¯ÒÚ˜, fiˆ˜ ÔÈ ÛηӉÈÓ·‚ÈΤ˜, Ë ªÂÁ¿ÏË µÚÂÙ·Ó›·, Ë ∂Ï‚ÂÙ›·, Î·È Ë ∫‡ÚÔ˜, Ô˘ ıˆÚÔ‡ÓÙ·È ÂχıÂÚ˜ ‚ÚԢΤÏψÛ˘ (3). ∏ ‚ÚԢΤÏψÛË ·ÔÙÂÏÔ‡Û ·fi ·ÏÈ¿ ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ ÛÙËÓ ∂ÏÏ¿‰· (8-21). ¶·Ú¿ ÙËÓ ·Ó·ÌÊ›‚ÔÏË ¿ÓÔ‰Ô ÙÔ˘ ˘ÁÂÈÔÓÔÌÈÎÔ‡ ÂÈ¤‰Ô˘ Î·È ·Ú¿ Ù· ̤ÙÚ· Ô˘ ¤¯Ô˘Ó ÏËÊı›, Ë ÓfiÛÔ˜ ‰ÂÓ ¤¯ÂÈ ÂÍ·Ê·ÓÈÛı› fiˆ˜ ·ÏÏÔ‡. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó·ÛÎfiËÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Ù˘ ‚ÚԢΤÏψÛ˘ ÛÙËÓ ∂ÏÏ¿‰· ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ì ¤ÌÊ·ÛË ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi.

ÓÔÛËÏÂÈÒÓ ÙÔ˘ ›‰ÈÔ˘ ·ÛıÂÓÔ‡˜. ∆· ÏÂÔÓÂÎÙ‹Ì·Ù¿ Ù˘ Â›Ó·È fiÙÈ Â¤ÙÚ„ ÙËÓ ·Ó·Ï˘ÙÈ΋ ÌÂϤÙË ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ʇÏÔ, ËÏÈΛ· Î·È ÁˆÁÚ·ÊÈÎfi ‰È·Ì¤ÚÈÛÌ·, ¿Ú· Î·È ÙÔÓ ·‰Úfi ¤ÛÙˆ ˘ÔÏÔÁÈÛÌfi ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÂÈÙÒÛÂˆÓ Ù˘ ÓfiÛÔ˘. ø˜ ÏËı˘ÛÌfi˜ Ù˘ ¯ÒÚ·˜ ıˆڋıËΠÂΛÓÔ˜ Ù˘ ·ÔÁÚ·Ê‹˜ ÙÔ˘ 1991 (Û‡ÓÔÏÔ ÏËı˘ÛÌÔ‡: 10.259.000, ·È‰È¿ 0-14 ÂÙÒÓ: 1.974.867), Ô˘ ·ÔÙÂÏ› Î·È ÙÔÓ ÂӉȿÌÂÛÔ ÏËı˘ÛÌfi ÁÈ· ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ô˘ ηχÙÂÙ·È ·fi ÙË ÌÂϤÙË (24). ∏ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ¤ÁÈÓ Ì ÙȘ ϤÍÂȘ-ÎÏÂȉȿ “‚ÚԢΤÏÏ·”, “‚ÚԢΤÏψÛË”, Î·È “ÌÂÏÈÙ·›Ô˜ ˘ÚÂÙfi˜” ÛÙȘ ËÏÂÎÙÚÔÓÈΤ˜ ‚¿ÛÂȘ π∞∆ƒ√∆∂∫ ÁÈ· Ù· ÂÏÏËÓÈο ‰ËÌÔÛȇ̷ٷ Î·È PubMed ÁÈ· Ù· ‰ÈÂıÓ‹. ∂ÈϤÔÓ, ¤ÁÈÓ ·Ó·ÛÎfiËÛË ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ π·ÙÚÈ΋, ∞گ›· ∂ÏÏËÓÈ΋˜ π·ÙÚÈ΋˜, ¢ÂÏÙ›ÔÓ ∂ÏÏËÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜, ¶·È‰È·ÙÚÈ΋, ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜, ∞گ›· ∞ã ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ Î·È ¶·È‰È·ÙÚÈο ÃÚÔÓÈο. ∆¤ÏÔ˜, ·Ó·ÛÎÔ‹ıËÎ·Ó Ù· Ú·ÎÙÈο ÙˆÓ ¶·ÓÂÏÏ‹ÓÈˆÓ ¶·È‰È·ÙÚÈÎÒÓ ™˘Ó‰ڛˆÓ ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 1988-2003. ∏ ·Ó·‰ÚÔÌÈ΋ ʇÛË Ù˘ ÌÂϤÙ˘ ‰ÂÓ Â¤ÙÚ„ ÙËÓ ÂÍ·ÎÚ›‚ˆÛË Ù˘ ÔÚıfiÙËÙ·˜ Ù˘ ‰È¿ÁÓˆÛ˘. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË ·ÚÔ˘ÛÈ¿˙ÂÈ ‰˘ÛÎÔϛ˜, ÏfiÁˆ ÙˆÓ Û˘¯Ó¿ ¿Ù˘ˆÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÓfiÛÔ˘ Î·È ÂÈϤÔÓ Â›Ó·È Â˘ÓfiËÙÔ fiÙÈ Î·Ù¿ ÙË ÌÂÁ¿ÏË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ô˘ ηχÙÂÙ·È ·fi ÙË ÌÂϤÙË, Ë ÂÚÁ·ÛÙËÚȷ΋ ÂȂ‚·›ˆÛË ¤ÁÈÓ Û ‰È·ÊÔÚÂÙÈο ÂÚÁ·ÛÙ‹ÚÈ· Î·È Ì ÌÂıfi‰Ô˘˜ ÔÈΛÏ˘ ·ÍÈÔÈÛÙ›·˜ (2-8,25-26).

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ

∞ÔÙÂϤÛÌ·Ù·

¶ÚfiÎÂÈÙ·È ÁÈ· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË, Ù· ‰Â‰Ô̤ӷ Ù˘ ÔÔ›·˜ ÛÙËÚ›¯ıËÎ·Ó ·ÊÂÓfi˜ ÛÙ· ÂÙ‹ÛÈ· ‰ÂÏÙ›· Ù˘ ∂ıÓÈ΋˜ ™Ù·ÙÈÛÙÈ΋˜ ÀËÚÂÛ›·˜ Ù˘ ∂ÏÏ¿‰·˜ (∂™À∂) Î·È ÛÙ· ‰È·ı¤ÛÈÌ· ÛÙÔȯ›· ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ ∂ȉÈÎÒÓ §ÔÈÌÒÍÂˆÓ (∫∂∂§) ÁÈ· ÙÔ 25ÂÙ¤˜ ‰È¿ÛÙËÌ· 19792003, Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ ·Ó·ÛÎfiËÛË Ù˘ Û¯ÂÙÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜. ∞fi ÙÔÓ Û˘Ó‰˘·ÛÌfi ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ∂™À∂ (22) Î·È ÙÔ˘ ∫∂∂§ (23) ηٷÁÚ¿ÊËÎ·Ó Ù· ‰Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· ‚ÚԢΤÏψÛ˘ ÛÙȘ ¢È¢ı‡ÓÛÂȘ Î·È Ù· ∆Ì‹Ì·Ù· ÀÁÈÂÈÓ‹˜ ÙˆÓ ¡ÔÌ·Ú¯ÈÒÓ ÁÈ· fiÏË ÙË ¯ÒÚ·, ·ÓÂÍ·Úًو˜ ÂÈÛ·ÁˆÁ‹˜ Û ÓÔÛÔÎÔÌ›Ô. ™ÙËÓ ∂ÏÏ¿‰· οı ÎÚÔ‡ÛÌ· ‚ÚԢΤÏψÛ˘ ÔÊ›ÏÂÈ Ó· ‰ËÏÒÓÂÙ·È ·fi ÙÔÓ ÁÈ·ÙÚfi, ÂÚÁ·ÛÙËÚÈ·Îfi ‹ ÎÏÈÓÈÎfi, Ô˘ ‰È·ÁÈÁÓÒÛÎÂÈ ÙË ÓfiÛÔ, ˆÛÙfiÛÔ Ë ‰‹ÏˆÛË ·˘Ù‹ Û˘¯Ó¿ ·Ú·Ï›ÂÙ·È Î·È Ô Ú·ÁÌ·ÙÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Â›Ó·È ·ÚÎÂÙ¿ ÌÂÁ·Ï‡ÙÂÚÔ˜, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ ÂÈÛËÌ·Óı› Î·È Û ¿ÏϘ ¯ÒÚ˜ (2,4-5). ø˜ ÂÎ ÙÔ‡ÙÔ˘, ·˘Ù‹ Ë Î·Ù·ÁÚ·Ê‹ Â͢ËÚÂÙ› ÙËÓ ÂÈÛÎfiËÛË ÙˆÓ Ì·ÎÚÔ¯ÚfiÓÈˆÓ Ù¿ÛÂˆÓ Ì¿ÏÏÔÓ, ·Ú¿ ÙÔÓ ·ÎÚÈ‚‹ ˘ÔÏÔÁÈÛÌfi Ù˘ Â›ÙˆÛ˘ Ù˘ ÓfiÛÔ˘. ∞fi Ù· ‰ÂÏÙ›· Ù˘ ∂™À∂ ηٷÁÚ¿ÊËÎ·Ó ÔÌÔ›ˆ˜, ÔÈ ÓÔÛËÏ›˜ ÁÈ· ‚ÚԢΤÏψÛË Ô˘ ¤ÁÈÓ·Ó Û fiÏ· Ù· ÓÔÛËÏ¢ÙÈο ȉڇ̷ٷ Ù˘ ¯ÒÚ·˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô 19801997, ηıÒ˜ ‰ÂÓ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› Ù· ·ÓÙ›ÛÙÔȯ· ‰Â‰Ô̤ӷ ÁÈ· Ù· ¤ÙË ÌÂÙ¿ ÙÔ 1997. ∆· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ·˘Ù‹˜ Ù˘ ηٷÁÚ·Ê‹˜ Â›Ó·È fiÙÈ ‰ÂÓ ÂÚÈÏ¿Ì‚·Ó ٷ ÎÚÔ‡ÛÌ·Ù· Ô˘ ıÂÚ·‡ıËÎ·Ó ÂÎÙfi˜ ÓÔÛËÏ¢ÙÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ Î·È fiÙÈ ÙÔ ›‰ÈÔ ÎÚÔ‡ÛÌ· ÌÔÚ› Ó· ηٷÌÂÙÚËı› ÂÚÈÛÛfiÙÂÚ˜ ·fi 1 ÊÔÚ¤˜, ÛÙËÓ ÂÚ›ÙˆÛË ÔÏÏ·ÏÒÓ

™ÙËÓ ∂ÈÎfiÓ· 1 ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÙ‹ÛÈ· ηٷÓÔÌ‹ ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ 11.240 ‰Ëψı¤ÓÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ‚ÚԢΤÏψÛ˘ ηٿ Ù· ¤ÙË 19792003. ∞fi ÙËÓ ∂ÈÎfiÓ· ηٷ‰ÂÈÎÓ‡ÂÙ·È ÛÙ·‰È·Î‹ Ì›ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù¿ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 Î·È Ó¤· ·‡ÍËÛË ·fi Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 Ô˘ ‰È‹ÚÎÂÛ Â› ·ÚÎÂÙ¿ ¤ÙË. ŒÙÛÈ, Ù· ‰Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· ηٿ ÙË ‰ÈÂÙ›· 1999-2000 ¤ÊÙ·Ó·Ó ÛÙ· Â›‰· Ù˘ ‰ÈÂÙ›·˜ 1983-1984. ∏ ̤ÛË Â›ÙˆÛË ‹Ù·Ó 4,38 ‰Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· / 100.000 ÏËı˘ÛÌÔ‡ / ¤ÙÔ˜. ™ÙÔ ‰È¿ÛÙËÌ· 1980-1997 ηٷÁÚ¿ÊËÎ·Ó Û˘ÓÔÏÈο 14.811 ÓÔÛËÏ›˜ ÁÈ· ‚ÚԢΤÏψÛË ÛÙËÓ ∂ÏÏ¿‰·. √È 9.545 ·ÊÔÚÔ‡Û·Ó ¿Ó‰Ú˜ Î·È ÔÈ 5.266 Á˘Ó·›Î˜ (·Ó·ÏÔÁ›· ·Ó‰ÚÒÓ-Á˘Ó·ÈÎÒÓ 1,81:1). √ ·ÚÈıÌfi˜ ÙˆÓ ÓÔÛËÏÂÈÒÓ ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó 1.660, ‰ËÏ·‰‹ 11,2% ÙÔ˘ Û˘ÓfiÏÔ˘ ηٿ ÙË ¯ÚÔÓÈ΋ ·˘Ù‹ ÂÚ›Ô‰Ô. ∏ ̤ÛË Û˘¯ÓfiÙËÙ· ÓÔÛËÏÂÈÒÓ ‹Ù·Ó 7,76 ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È 5,08 ÁÈ· Ù· ·È‰È¿ 0-14 ÂÙÒÓ. ∏ ÓÔÛËÚfiÙËÙ· ·fi ‚ÚԢΤÏψÛË ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰·, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô 1980-1997 ηٷÁÚ¿ÊËÎ·Ó 4 ÓÔÛËÏ›˜ ÓÂÔÁÓÒÓ Î·È 46 ‚ÚÂÊÒÓ ËÏÈΛ·˜ 1-11

∂ÈÛ·ÁˆÁ‹

¶·È‰È·ÙÚÈ΋ 2006;69:37-44


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∏ ‚ÚԢΤÏψÛË ÛÙËÓ ∂ÏÏ¿‰·

¢Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· ‚ÚԢΤÏψÛ˘

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ŒÙÔ˜ ∂ÈÎfiÓ· 1. ¢Ëψı¤ÓÙ· ÎÚÔ‡ÛÌ·Ù· ‚ÚԢΤÏψÛ˘ ηٿ ÙËÓ ÂÚ›Ô‰Ô 1979-2003 ÁÈ· fiϘ ÙȘ ËÏÈ˘ Î·È ÁÈ· ÙÔ Û‡ÓÔÏÔ Ù˘ ∂ÏÏ¿‰·˜.

ÌËÓÒÓ. ™ÙȘ ÌÈÎÚ¤˜ ËÏÈ˘, Ë ÓÔÛËÚfiÙËÙ· ÙˆÓ ‰˘Ô Ê‡ÏˆÓ ‰ÂÓ ·ÚÔ˘Û›·˙ ·ÍÈÔÛËÌ›ˆÙ˜ ‰È·ÊÔÚ¤˜. ŸÌˆ˜, ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ Î·È ÌÂÙ¿, Ô ·ÚÈıÌfi˜ ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ·˘Í¿ÓÂÙ·È Î˘Ú›ˆ˜ ÛÙ· ·ÁfiÚÈ·, Ô˘ ÛÙËÓ ÂÊ˂›· ÓÔÛÔ‡Ó Û¯Â‰fiÓ 3 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚÔ ·’ fi,ÙÈ Ù· ÎÔÚ›ÙÛÈ·. ™ÙÔÓ ¶›Ó·Î· 2 Î·È ÛÙËÓ ∂ÈÎfiÓ· 2, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ÓÔÛËÏ›˜ ·ÛıÂÓÒÓ / 100.000 ÏËı˘ÛÌÔ‡ / ¤ÙÔ˜ ÛÙ· ÁˆÁÚ·ÊÈο ‰È·ÌÂÚ›ÛÌ·Ù· Ù˘ ∂ÏÏ¿‰Ô˜ ηٿ ÙÔ ‰È¿ÛÙËÌ· 1980-1997. ∏ ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹ ÙˆÓ ÓÔÛËÏ¢fiÌÂÓˆÓ ·ÛıÂÓÒÓ ÛÙËÚ›˙ÂÙ·È ÛÙÔÓ ÙfiÔ ÓÔÛËÏ›·˜ Î·È fi¯È ÛÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜. ™ÙÔÓ ¶›Ó·Î· 3 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ·Û˘Ó‹ıÈÛÙ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ‚ÚԢΤÏψÛ˘ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ÛÙË ¯ÒÚ· Ì·˜ ·fi ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ Î·È ÙȘ ¶›Ó·Î·˜ 1. ¡ÔÛËÏ›˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ÁÈ· ‚ÚԢΤÏψÛË Î·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1980-1997 ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· Î·È ÙÔ Ê‡ÏÔ ∏ÏÈÎȷ΋ ÔÌ¿‰·

™‡ÓÔÏÔ

0-4 ÂÙÒÓ 5-9 ÂÙÒÓ 10-14 ÂÙÒÓ 15-19 ÂÙÒÓ ™‡ÓÔÏÔ 0-19 ÂÙÒÓ

317 470 873 1026 2686

ÕÚÚÂÓ˜ £‹ÏÂȘ ∞Ó·ÏÔÁ›· ∞/£ 182 294 571 760 1.807

135 176 302 266 879

1,35/1 1,67/1 1,89/1 2,86/1 2,06/1

·Ó·ÎÔÈÓÒÛÂȘ. ™‡Ìʈӷ Ì ٷ ‰ÂÏÙ›· Ù˘ ∂™À∂, 22 ı¿Ó·ÙÔÈ ·Ô‰fiıËÎ·Ó ÛÙË ÓfiÛÔ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô 1980-1997.

™˘˙‹ÙËÛË ∏ Ú·ÁÌ·ÙÈ΋ ÓÔÛËÚfiÙËÙ· Ù˘ ‚ÚԢΤÏψÛ˘ Û ˙Ò· Î·È ·ÓıÚÒÔ˘˜ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙË, ηıÒ˜ Û˘¯Ó¿ Ë ‰‹ÏˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Â›Ó·È ÂÏÏÈ‹˜ (2,4). ∆· ÚÔÁÚ¿ÌÌ·Ù· ÚfiÏ˄˘ ÛÙËÚ›˙ÔÓÙ·È ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ˙ÒˆÓ, ÛÙȘ ÚÔÊ˘Ï¿ÍÂȘ ηٿ ÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ¤ÎıÂÛË, Î·È ÛÙËÓ Î·Ù¿ÏÏËÏË ·Ú·Û΢‹ ÙÔ˘ Á¿Ï·ÎÙÔ˜, ÙˆÓ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ Î·È ¿ÏÏˆÓ ‰˘ÓËÙÈο ÌÔÏ˘ÛÌ·ÙÈÎÒÓ ÙÚÔÊ›ÌˆÓ (3,9). ™Â ·ÚÎÂÙ¤˜ ¯ÒÚ˜, Ì ٷ ̤ÙÚ· ·˘Ù¿ Ë ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ·fi ÂÓ‰ËÌÈ΋ ‹ Â·ÁÁÂÏÌ·ÙÈ΋ Û ÓfiÛÔ ÙˆÓ Ù·ÍȉȈÙÒÓ. ∞fi Ù· 6 ÁÓˆÛÙ¿ ̤ÏË ÙÔ˘ Á¤ÓÔ˘˜ Brucella, (B. melitensis, B. abortus, B. suis, B. canis, B. neotomae Î·È B. ovis), ÌfiÓÔ Ù· 4 ÚÒÙ· ¤¯Ô˘Ó ÎÏÈÓÈ΋ ÛËÌ·Û›· ÁÈ· ÙÔÓ ¿ÓıÚˆÔ (2). ™ÙËÓ ∂ÏÏ¿‰·, ÙÔ Û¯Â‰fiÓ ·ÔÎÏÂÈÛÙÈο ·ıÔÁfiÓÔ Â›‰Ô˜ ÁÈ· ÙÔÓ ¿ÓıÚˆÔ Â›Ó·È Ë B. melitensis. §ÔÈÌÒÍÂȘ ·fi B. abortus ·Ó·Ê¤ÚÔÓÙ·È Û·ÓÈfiٷٷ, Î·È ·ÎfiÌË Î·È Ë ‡·ÚÍ‹ ÙÔ˘˜ ÛÙË ¯ÒÚ· Ì·˜, ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ Û˘˙‹ÙËÛ˘ (5,27-32). ∏ ¶·È‰È·ÙÚÈ΋ 2006;69:37-44


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ª. ª·˘ÚfiΈÛÙ·, ∂. °·Ï·Ó¿Î˘

¶›Ó·Î·˜ 2. ¡ÔÛËÏ›˜ ÁÈ· ‚ÚԢΤÏψÛË Î·Ù¿ ÁˆÁÚ·ÊÈÎfi ‰È·Ì¤ÚÈÛÌ· ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1980-1997 ¢È·Ì¤ÚÈÛÌ· ◊ÂÈÚÔ˜ £Ú¿ÎË ¶ÂÏÔfiÓÓËÛÔ˜ ª·Î‰ÔÓ›· £ÂÛÛ·Ï›· §ÔÈ‹ ™ÙÂÚ¿ Î·È ∂‡‚ÔÈ· ∫Ú‹ÙË ¶ÂÚÈʤÚÂÈ· ¶ÚˆÙ¢ԇÛ˘ πfiÓÈÔÈ ¡‹ÛÔÈ ¡‹ÛÔÈ ∞ÈÁ·›Ô˘ °ÂÓÈÎfi Û‡ÓÔÏÔ

¡ÔÛËÏ¢ı¤ÓÙ˜ ·ÛıÂÓ›˜

¶ÏËı˘ÛÌfi˜ (·ÔÁÚ·Ê‹ 1991)

¡ÔÛËÏ›˜ ·Ó¿ 100.000 ÏËı˘ÛÌÔ‡/¤ÙÔ˜

1.166 968 2.269 4.472 1.338 2.123 403 1.366 86 132 14.323

339.728 338.005 1.086.935 2.236.019 734.846 1.260.945 540.054 3.072.922 193.734 456.712 10.259.900

19,1 15,9 11,6 11,1 10,1 9,35 4,14 2,47 2,46 1,61 7,76

‚ÚԢΤÏψÛË ÚÔÛ‚¿ÏÏÂÈ Û˘¯ÓfiÙÂÚ· ÙȘ ÔÌ¿‰Â˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· ÙˆÓ ˙ÒˆÓ (12, 33-36), Î·È ¤ÙÛÈ Ú¤ÂÈ Ó· ÂÚÌËÓ¢ı› Î·È Ë ·˘ÍË̤ÓË ÚÔÛ‚ÔÏ‹ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·ÁÔÚÈÒÓ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ∏ ›‰È· ÓÔÛËÚfiÙËÙ· ÙˆÓ ‰‡Ô Ê‡ÏˆÓ ÛÙ· ‚Ú¤ÊË Î·È Ù· Ó‹È·, ÚÔÊ·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ Û ·˘Ù¤˜ ÙȘ ËÏÈ˘ Ì ÌÔÏ˘Ṳ̂ÓÔ Á¿Ï· Ì¿ÏÏÔÓ, ·Ú¿ Ì ¿ÌÂÛË Â·Ê‹ Ì ˙Ò· (37-38). ™ÙË ¯ÒÚ· Ì·˜ ¤¯Ô˘Ó ·Ó·ÊÂÚı��› ÂÓ‰ÔÔÈÎÔÁÂÓÂȷΤ˜ ÂȉË̛˜ Û ÎÔÈÓfiÙËÙ˜ ÎÙËÓÔÙÚfiÊˆÓ (34,39) ηıÒ˜ Î·È ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ‰È·Ï·ÎÔ˘ÓÙȷο Î·È Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi (31,37,40). √È Û˘Ó‹ıÂȘ ÂΉËÏÒÛÂȘ Ù˘ ‚ÚԢΤÏψÛ˘ ÛÙÔÓ ¿ÓıÚˆÔ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ˘ÚÂÙfi, ·ÓÔÚÂÍ›·, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ‡ÎÔÏË ÎfiˆÛË, ÂÊ›‰ÚˆÛË, ·ÚıÚ·ÏÁ›Â˜ ‹ Î·È ·ÚıÚ›Ùȉ·, ÎÂÊ·Ï·ÏÁ›·, Ì˘·ÏÁ›Â˜, Ë·ÙÔ-ÛÏËÓÔÌÂÁ·Ï›·, Î·È ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· (2-4). øÛÙfiÛÔ, Ë ÓfiÛÔ˜ Â›Ó·È ÁÓˆ-

ÛÙ‹ ÁÈ· ÙËÓ ÈηÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÔÔÈÔ˘‰‹ÔÙ ۯ‰fiÓ ÔÚÁ¿ÓÔ˘ Î·È Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ë ÂÓÙ˘ˆÛȷ΋ ÔÏ˘ÌÔÚÊ›· ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ‰ÈηÈÔÏÔÁ› ÙÔÓ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ˆ˜ “ÚˆÙÂ˚΋˜” ÓfiÛÔ˘. Ÿˆ˜ ÚÔ·ÙÂÈ ·fi ÙÔÓ ¶›Ó·Î· 3, ÔÈ ÂÏÏËÓÈΤ˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ ÔÏ˘ÌÔÚÊ›· ·˘Ù‹ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Û ·È‰È¿ Î·È Û ÂÓ‹ÏÈΘ. ∏ ıÓËÙfiÙËÙ· ˘‹ÚÍ ¯·ÌËÏ‹ ÁÈ· ÙË ¯ÒÚ· Ì·˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÌÂϤÙ˘. ø˜ ΢ÚÈfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ıˆÚÂ›Ù·È Ë ÂÓ‰Ôηډ›Ùȉ· (41-42). ™Ù· ˙Ò· Ë ‚ÚԢΤÏψÛË ÚÔηÏ› ¯ÚfiÓÈ· Ïԛ̈ÍË, ·˘ÙfiÌ·Ù˜ ·Ô‚ÔϤ˜ Î·È ÛÙÂÈÚfiÙËÙ·. ∆Ô ÂÌ‚fiÏÈÔ µ19 Ô˘ Á›ÓÂÙ·È ÛÙ· ‚ÔÔÂȉ‹ ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ÌfiÓÔ ·fi ÙË B. abortus Î·È ÙÔ ÂÌ‚fiÏÈÔ Rev-1 ÁÈ· ÙË B. melitensis Ô˘ Á›ÓÂÙ·È ÛÙ· ·ÈÁÔÚfi‚·Ù· ‰ÂÓ ¤¯ÂÈ ÌÂÏÂÙËı› ÛÙ· ‚ÔÔÂȉ‹ (2,9,33). ∏ ÂÎÚ›˙ˆÛË Ù˘ ÓfiÛÔ˘ ÛÙ· ‚ÔÔÂȉ‹ ¤¯ÂÈ ÂÈÙ¢¯ı› Û ·ÚÎÂÙ¤˜ ¯ÒÚ˜, ÂÓÒ, ·ÓÙ›ıÂÙ·, Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂϤÁ¯Ô˘ ÛÙ· ·ÈÁÔÚfi‚·Ù·

¶›Ó·Î·˜ 3. ∞Û˘Ó‹ıÈÛÙ˜ ÂΉËÏÒÛÂȘ ‚ÚԢΤÏψÛ˘ Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙËÓ ∂ÏÏ¿‰· ∂ÓÙfiÈÛË

∂ΉËÏÒÛÂȘ Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙËÓ ∂ÏÏ¿‰·

¡Â˘ÚÈÎfi Û‡ÛÙËÌ·

∫ÂÊ·Ï·ÏÁ›· (34,47), ÌËÓÈÁÁ›Ùȉ· (29,39,47-52), ˘ÔÙÚÔÈ¿˙Ô˘Û· ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ· (42,53), ÂÁÎÂÊ·ÏÈÎfi ·fiÛÙËÌ· (29), ÚÈ˙›Ùȉ· (12,54), ÂÚÈÊÂÚÈ΋ Ó¢ÚÔ¿ıÂÈ· (13,21,48), ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Ó‡ÚÔ˘ (39), ÈۯȷÏÁ›· (55), „˘¯ÈΤ˜ ‰È·Ù·Ú·¯¤˜ (34,55) πÚȉÔ΢ÎÏ›Ùȉ· (39) ¶ÂÚÈηډ›Ùȉ· (41), ÂÓ‰Ôηډ›Ùȉ· (42) ¶Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ (29) √Í›· ÎÔÈÏ›· (57), ·ÛΛÙ˘ (58), ¯ÔÏÔ΢ÛÙ›Ùȉ· (57), Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Û ¤‰·ÊÔ˜ ·ÏÎÔÔÏÈ΋˜ Ë·ÙÔ¿ıÂÈ·˜ (59), Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ (60) √ÛÙÂÔÌ˘ÂÏ›Ùȉ· (60, 61), ÛÔÓ‰˘Ï›Ùȉ· (62) √Ú¯›Ùȉ· (35), ÔÚ¯ÂÔÂȉȉ˘Ì›Ùȉ· (44,56,63-65), ÚÔÛÙ·Ù›Ùȉ· (55) ∞Ó·ÈÌ›·, Ô˘‰ÂÙÂÚÔÂÓ›·, ÏÂÌÊÔÂÓ›·, ıÚÔÌ‚ÔÂÓ›· (21,29,39,66), ·Ó΢ÙÙ·ÚÔÂÓ›· (67-68), Ï¢¯·ÈÌÔÂȉ‹˜ ·ÓÙ›‰Ú·ÛË, ˈÛÈÓÔÊÈÏ›·, ÌÔÓÔ΢ÙÙ¿ÚˆÛË (39,68), ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ (39,69) §Ô›ÌˆÍË ÓÂÔÁÓÔ‡ (31,37,40) ∂Ì‡ËÌ· ‚Ú·Á¯È·Î‹˜ ·ÛÙ˘ (70), ·fiÛÙËÌ· Ì·ÛÙÔ‡ (71), ÂÍ¿ÓıËÌ· (29), ÂÈÎfiÓ· ÚÂ˘Ì·ÙÔÂȉԇ˜ ·ÚıÚ›Ùȉ·˜ (60)

∞ÈÛıËÙ‹ÚÈ· ∫·Ú‰È¿ ∞Ó·Ó¢ÛÙÈÎfi ¶ÂÙÈÎfi √ÛÙ¿ Î·È ·ÚıÚÒÛÂȘ √˘ÚÔÔÈÔÁÂÓÓËÙÈÎfi ∞ÈÌÔÔÈËÙÈÎfi

∫‡ËÛË ÕÏϘ ÂÓÙÔ›ÛÂȘ

¶·È‰È·ÙÚÈ΋ 2006;69:37-44


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·41

41

∏ ‚ÚԢΤÏψÛË ÛÙËÓ ∂ÏÏ¿‰·

£Ú¿ÎË 15,9

ª·Î‰ÔÓ›· 11,1 ◊ÂÈÚÔ˜ 19,1‰

£ÂÛÛ·Ï›· 10,1

§ÔÈ‹ ™ÙÂÚ¿ Î·È ∂‡‚ÔÈ· 9,35 πfiÓÈÔÈ ¡‹ÛÔÈ ¶ÂÚÈÊ. 2,46 ¶ÚˆÙ¢ԇÛ˘ ¶ÂÏÔfiÓÓËÛÔ˜ 2,47 11,6

¡‹ÛÔÈ ∞ÈÁ·›Ô˘ 1,61

∫Ú‹ÙË 4,14

∂ÈÎfiÓ· 2. ¡ÔÛËÏ›˜ ÁÈ· ‚ÚԢΤÏψÛË ·Ó¿ 100.000 ÏËı˘ÛÌÔ‡, ·Ó¿ ¤ÙÔ˜ ÛÙ· ÂÈ̤ÚÔ˘˜ ÁˆÁÚ·ÊÈο ‰È·ÌÂÚ›ÛÌ·Ù· Ù˘ ∂ÏÏ¿‰Ô˜ ηٿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 1980-1997.

¤¯Ô˘Ó ÂÚÈÔÚÈṲ̂ÓË ÂÈÙ˘¯›· (3,31). ™ÙËÓ ∂ÏÏ¿‰· Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ‚ÔÔÂȉÒÓ Î·È ÙˆÓ ·ÈÁÔÚÔ‚¿ÙˆÓ ËÏÈΛ·˜ οو ÙÔ˘ ¤ÙÔ˘˜ ¿Ú¯ÈÛ ·fi ÙÔ 1975 (8,9). ∆Ô ÚfiÁÚ·ÌÌ· ·˘Ùfi ·ÓÙÈηٷÛÙ¿ıËΠÙÔ 1994 ·fi ÙÔÓ ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÙˆÓ ÌÔÏ˘ÛÌ¤ÓˆÓ ˙ÒˆÓ (5-6, 8,33), ˆÛÙfiÛÔ ·fi ÙÔ 1997 Î·È ÌÂÙ¿, ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì Rev-1 ηıÈÂÚÒıËΠ¿ÏÈ, ÛÙËÓ ËÂÈÚˆÙÈ΋ ÙÔ˘Ï¿¯ÈÛÙÔÓ ∂ÏÏ¿‰· Î·È ¤¯ÂÈ ÚÔÁÚ·ÌÌ·ÙÈÛÙ› Ó· ‰È·ÚΤÛÂÈ ¤ˆ˜ Î·È ÙÔ 2004, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙȘ Ô‰ËÁ›Â˜ Ù˘ ∂˘Úˆ·˚΋˜ ∫ÔÈÓfiÙËÙ·˜ (5). ™ÙȘ ÂÚÈÔ¯¤˜ ÌÈÎÚfiÙÂÚ˘ Â›ÙˆÛ˘, fiˆ˜ Â›Ó·È Ë ÓËÛȈÙÈ΋ ∂ÏÏ¿‰·, ÂÍ·ÎÔÏÔ˘ı› Ë Ù·ÎÙÈ΋ ÙÔ˘ ÔÚÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ ÙˆÓ ˙ÒˆÓ Î·È Ù˘ ÛÊ·Á‹˜ ÙˆÓ ÓÔÛÔ‡ÓÙˆÓ (5). Ÿˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ ∂ÈÎfiÓ· 1, Ë ÓÔÛËÚfiÙËÙ· ÛÙÔÓ ¿ÓıÚˆÔ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ˙ÒˆÓ (9). ∫·È ÔÈ ‰‡Ô ÂÌÊ·Ó›˜ ˘Ê¤ÛÂȘ Ù˘ Â›ÙˆÛ˘, ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 Î·È ÌÂÙ¿ ÙÔ 2000, ·ÎÔÏÔ˘ıÔ‡Ó ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ˙ÒˆÓ Î·È Ë ·‡ÍËÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌÂÙ¿ ÙÔ 1995 ·ÎÔÏÔ˘ı› ÙËÓ ·Ó·ÛÙÔÏ‹ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ¶ÚfiÛÊ·ÙË ·Ó·˙ˆ‡ÚˆÛË Ù˘ ÓfiÛÔ˘ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÛÙË ª¿ÏÙ· Î·È ÛÙÔ √Ì¿Ó (3). ∂› ÙÔ˘ ·ÚfiÓÙÔ˜, η̛· ÂÚÈÔ¯‹ ÛÙËÓ ∂ÏÏ¿‰· ‰ÂÓ ¤¯ÂÈ ÎËÚ˘¯ı› ÂχıÂÚË ‚ÚԢΤÏψÛ˘ (5) Î·È ÚÔÊ·ÓÒ˜ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ·ÎfiÌË ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ÁÈ· ÙËÓ Â›Ù¢ÍË ·˘ÙÔ‡ ÙÔ˘ ÛÎÔÔ‡. ∂ÎÙfi˜ ·fi ÙË ÁˆÁÚ·ÊÈ΋, ·Ú·ÙËÚÂ›Ù·È Î·È Âԯȷ΋ ηٷÓÔÌ‹ Ù˘ ÓfiÛÔ˘, ÌÂ

ÂÍ¿ÚÛÂȘ ηٿ ÙËÓ ÂÚ›Ô‰Ô Á·Ï·ÎÙÔ·Ú·ÁˆÁ‹˜ (29,44). √ ¤ÏÂÁ¯Ô˜ fiÏˆÓ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È ··Ú·›ÙËÙÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Û οı ÁÓˆÛÙfi ÎÚÔ‡ÛÌ· ÌÔÚ› Ó· ·ÓÙÈÛÙÔÈ¯Ô‡Ó ·ÚÎÂÙ¿ ·‰È¿ÁÓˆÛÙ· (45-46). ∞Í›˙ÂÈ Ó· ˘ÔÁÚ·ÌÌÈÛÙ› fiÙÈ ÙÔ ÚÔÛÂÎÙÈÎfi ÈÛÙÔÚÈÎfi, ηٿ ηÓfiÓ·, ·Ó·‰ÂÈÎÓ‡ÂÈ È‰È·›ÙÂÚË Û¯¤ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ˙Ò· (16,28) Î·È fiÙÈ Û˘ÓÂÒ˜ Ô Î›Ó‰˘ÓÔ˜ ÌfiÏ˘ÓÛ˘ ·fi Ù· Á·Ï·ÎÙÔÎÔÌÈο Ô˘ ‰È·ÎÈÓÔ‡ÓÙ·È ÛÙÔ ÂÌfiÚÈÔ Â›Ó·È ·ÌÂÏËÙ¤Ô˜. °È· ÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ¤¯ÂÈ ·Ú·Û΢·ÛÙ› ̤¯ÚÈ Û‹ÌÂÚ· οÔÈÔ ÈηÓÔÔÈËÙÈÎfi ÂÌ‚fiÏÈÔ (2,3), ÌÔÏÔÓfiÙÈ ·ÚÎÂÙ¿ ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› (3,43). ∞fi ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÚÔ·ÙÂÈ fiÙÈ Î·Ù¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ë ‚ÚԢΤÏψÛË ·ÔÙÂÏÔ‡Û ˘ÔÏÔÁ›ÛÈÌÔ Úfi‚ÏËÌ· ˘Á›·˜ ÛÙËÓ ∂ÏÏ¿‰·. ŒÓ· ·ÍÈfiÏÔÁÔ ÔÛÔÛÙfi ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ·ÊÔÚÔ‡Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜. ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ ı· Á›ÓÂÈ ÂÊÈÎÙ‹ ÌfiÓÔ Ì ÙËÓ Â·ÁÚ‡ÓËÛË Î·È ÙˆÓ ÁÈ·ÙÚÒÓ Î·È ÙˆÓ ÎÙËÓÈ¿ÙÚˆÓ. ∆Ô ·Ú¿‰ÂÈÁÌ· ¿ÏÏˆÓ ¯ˆÚÒÓ ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Ë ‚ÚԢΤÏψÛË ÌÔÚ› Ó· ÂÍ·ÏÂÈÊı› Ï‹Úˆ˜ Î·È ·fi ÙËÓ ∂ÏÏ¿‰·. Œˆ˜ ÙfiÙÂ, Ë ÓfiÛÔ˜ ÂÈ‚¿ÏÏÂÙ·È Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ¿Ù˘ˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ, Î·È Ì¿ÏÈÛÙ· Û ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Vassalo DJ. The saga of brucellosis: controversy over credit for linking Malta fever with goats’ milk. Lancet 1996;348:804-808. 2. Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21:283-290. 3. Corbel MJ. Brucellosis: an overview. Emerg Infect Dis 1997;3:213-221. 4. Sauret JM, Vilissova N. Human brucellosis. J Am Board Fam Pract 2002;15:401-406. 5. Taleski V, Zerva L, Kantardjiev T, Cvetnic Z, ErskiBiljic M, Nikolovski B et al. An overview of the epidemiology and epizootology of brucellosis in selected countries of Central and Southeast Europe. Vet Microbiol 2002;90:147-155. 6. ∫·ÓÛÔ˘˙›‰Ô˘-∫·Ó·ÎÔ‡‰Ë ∞. µÚÔ˘ÎÂÏÏÒÛÂȘ. ¢ÂÏÙ›ÔÓ ∂ÏÏËÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ 1997; 42:37-41. 7. K·ÓÛÔ˘˙›‰Ô˘ A, ª‹Ùη ™, ¢·ÓÈËÏ›‰Ë˜ µ. ∂›‰Ë Î·È ‚ÈfiÙ˘ÔÈ ‚ÚÔ˘ÎÂÏÏÒÓ Ô˘ ·ÔÌÔÓÒıËÎ·Ó ·fi ·ÓıÚÒÔ˘˜. ¢ÂÏÙ›ÔÓ ∂ÏÏËÓÈ΋˜ ªÈÎÚÔ‚ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ 1996;41:598-602. 8. ∫·ÓÛÔ˘˙›‰Ô˘-∫·Ó·ÎÔ‡‰Ë ∞. µÚԢΤÏψÛË. ªÈ· ÓfiÛÔ˜ Ô˘ Û˘Ó¯›˙ÂÈ Ó· ·ÔÙÂÏ› Úfi‚ÏËÌ· ÛÙËÓ ∂ÏÏ¿‰·. π·ÙÚÈ΋ 1998;73:371-376. 9. Minas A, Minas M, Stournara A, Tselepidis S. The “effects” of Rev-1 vaccination of sheep and goats on ¶·È‰È·ÙÚÈ΋ 2006;69:37-44


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ª. ª·˘ÚfiΈÛÙ·, ∂. °·Ï·Ó¿Î˘

10.

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18. 19.

20.

21.

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38. ÷Ù˙ËÁˆÚÁ›Ô˘ ™, ÷ÚÈÛÔÔ‡ÏÔ˘ ¢, ÷ڷϷÌ›‰Ô˘ ∞, √ÈÎÔÓÔÌ›‰Ô˘ ¡, ™·ÚfiÁÏÔ˘ ∞, ºÂÛ·Ù›‰Ô˘ ª. ¶Ú·ÎÙÈο 40Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2002, πÔ‡ÓÈÔ˜ 21-23; £ÂÛÛ·ÏÔÓ›ÎË: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 2002:308. 39. Tsolia M, Drakonaki S, Messaritaki A, Farmakakis T, Kostaki M, Tsapra H, Karpathios T. Clinical features, complications and treatment outcome of childhood brucellosis in central Greece. J Infect 2002;44:257-262. 40. ™·Ú·Ê›‰Ë˜ ∫, ¢ÚfiÛÔ˘-∞Á·Î›‰Ô˘ µ, ¡ÈÎÔÏ·˚‰Ë˜ ¡, ¡Ô‡ÙÛÈ· Ã, ¶Â¯ÏÈ‚¿ÓË ∂, ∫ÚÂÌÂÓfiÔ˘ÏÔ˜ °. ™˘ÁÁÂÓ‹˜ ‚ÚԢΤÏψÛË: ¶ÂÚÈÁÚ·Ê‹ ÌÈ·˜ ÂÚ›ÙˆÛ˘. ¶Ú·ÎÙÈο 41Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2003, πÔ‡ÓÈÔ˜ 13-15; £ÂÛÛ·ÏÔÓ›ÎË: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 2003:176. 41. ™ÙÚ·Ù¿ÎÔ˜ π, ¡ÙÔ˘Ú¿Î˘ ™¶, ª·˘ÚÔÁÈ·ÓÓ¿ÎË ∞, ∫Ô˘ÏÔ‡Ú˘ ¶, ÷Ù˙ËÁÈ¿ÓÓ˘ ™π. √Í›· ÂÚÈηډ›Ùȉ· ˆ˜ ÚÒÙË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË ÔÍ›·˜ ‚ÚԢΤÏψÛ˘. π·ÙÚÈ΋ 2001;80:526-529. 42. §È·Î¿ÎÔ˜ ¢, ™·ÎÂÏÏ·Ú›‰Ë˜ ¡, µÏ¿¯Ô˜ ¶ Î·È Û˘Ó. µÚԢΤÏψÛȘ ÂÎ B. melitensis ÌÂÙ¿ ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›ÙȉԘ Î·È ÂÓ‰Ôηډ›ÙȉԘ Â› ¿ÚÚÂÓÔ˜ ËÏÈΛ·˜ 14 ÂÙÒÓ. π·ÙÚÈ΋ 1973;23:262. 43. Hadjichristodoulou C, Voulgaris P, Toulieres L, Babalis T, Manetas S, Goutziana G et al. Tolerance of the human brucellosis vaccine and the intradermal reaction test for brucellosis. EurJ Clin Microbiol Infect Dis 1994;13:129-134. 44. ¡ÙÂÏ‹˜ π, ªÔ˘ÚÓ¿˙Ô˜ ∏, √‡· µ, ¡Ù·ÓfiÔ˘ÏÔ˜ ™, ¶··ÁˆÚÁ›Ô˘ ∞, ¶·Ú‰¿Ï˘ °, ªÚÈ¿Ó·˜ §. ¶Ú·ÎÙÈο 29Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ π·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2003, ª¿ÈÔ˜ 20-24; ∞ı‹Ó·: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ; 2003:169. 45. ¡ÙÔ‡ÚÔ˜ £, ¢Ô‡Ì·ÏË ∂, ™È·Ó¿‚· √, °·Ï·Ó¿Î˘ ∂. ∞ÓȯÓ¢ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Brucella Û ÏËı˘ÛÌÔ‡˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ¶Ú·ÎÙÈο 40Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2002, πÔ‡ÓÈÔ˜ 2123; £ÂÛÛ·ÏÔÓ›ÎË: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 2002:238. 46. °·Ï·Ó¿Î˘ ∂, ∆Û›Úη ∞, ∞ÁÁÂÏfiÔ˘ÏÔ˜ ∂, °ÎÔÏÔÁοÓË ∞, §··ÙÛ¿Ó˘ ¶, ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ ∑. ∏ ÂȉËÌÈÔÏÔÁ›· Ù˘ ‚ÚԢΤÏψÛ˘ ÛÙ· ·È‰È¿ Ù˘ µ¢ ∂ÏÏ¿‰Ô˜. ¶Ú·ÎÙÈο 38Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2000, πÔ‡ÓÈÔ˜ 16-18; ∫ˆ˜: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 2000:80. 47. ™ÈÔ‡Ú·˜ π, ¶ÂÚ¿Î˘ ∞, ∆Û·ÎÚ‹˜ ∞, ∫ˆÓÛÙ·Óٷο΢ ∂, ª·ÓÈ¿Ù˘ ∞. ¡Â˘ÚÔ‚ÚԢΤÏψÛË Ì ÂΉËÏÒÛÂȘ ˘ÔÍ›·˜ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜ Î·È ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜. ∂Ê·ÚÌÔṲ̂ÓË ∫ÏÈÓÈ΋ ªÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ∂ÚÁ·ÛÙËÚȷ΋ ¢È·ÁÓˆÛÙÈ΋ 1991;6:137-140. 48. ª·ÚÌÔ˘Ó¿ÎË π, §È·ÎÔÔ‡ÏÔ˘ £, ™Ê·ÎÈ·Ófi˜ °, ¶··Â˘·ÁÁ¤ÏÔ˘ µ, ∫·Ú·ÌԇϷ ∞. ¡Â˘ÚÔ‚ÚԢΤÏψÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·- ¶ÂÚÈÁÚ·Ê‹ ‰‡Ô ÂÚÈÙÒÛˆÓ. ¶Ú·ÎÙÈο 37Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 1999, ª¿ÈÔ˜ 28-30; £ÂÛÛ·ÏÔÓ›ÎË: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 1999:75. 49. §¤ÎÎÔ˘ ∞, ªϛη˜ ∞, ¢·Ó›Î·˜ ¢, ™È¿ÁÎÚ˘ ¢, ™Ù·Ú¿Î˘ π, §·ÌÚÔÔ‡ÏÔ˘-∫·Ú·Ù˙¿ Ã. ¡Â˘ÚÔ‚ÚԢΤÏψÛË. ¶Ú·ÎÙÈο 7Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ™˘Ó‰ڛԢ ¶·ıÔÏÔÁ›·˜; 2001, √ÎÙÒ‚ÚÈÔ˜ 16-20; ∞ı‹Ó·: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·ıÔÏÔÁ›·˜; 2001:38.

50. ¢·ÛηϿ΢ ∂, ∫·ÏÔÁ‹ÚÔ˘ µ, ¶··Â˘·ÁÁ¤ÏÔ˘ µ. µÚÔ˘Î¤ÏˆÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ¶Ú·ÎÙÈο 38Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2000 πÔ‡ÓÈÔ˜ 16-18; ∫ˆ˜: ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›·; 2000:81. 51. ∫·ÓÈÎÏ›‰Ë˜ ¶, £ÂÔ‰ˆÚ›‰Ô˘ ª, ∞‰¿Ì ∂, ∑Ô˘ÌÔ˘Ï¿Î˘ ¢. ªËÓÈÁÁ›Ùȉ· ·fi ‚ÚԢΤÏÏ·. ¶·È‰È·ÙÚÈ΋ 1981;44:441-443. 52. ª·˙ÌÔÚ›‰Ô˘ ∞, ¶··¯Ú‹ÛÙÔ˘ º, ª·Ï·Î¿-∑·ÊÂÈÚ›Ô˘ ∫. ¶ÂÚ›ÙˆÛË ÌËÓÈÁÁ›Ùȉ·˜ ·fi µÚԢΤÏÏ·: ÔÚÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË. ¶·È‰È·ÙÚÈο ÃÚÔÓÈο 1992; 19:49-52. 53. ™Ù·˘ÚÈÓ¿‰Ë˜ X, ∫Ô˘ÎÔ˘ÙÛ¿Î˘ ¶, ª·˝ÏË ∞, ª·ÚηÓÙÒÓË ∞, ∆ÛÔ˘Î¿ÙÔ˘ £, §È¿Ë-∞‰·Ì›‰Ô˘ °. ÀÔÙÚÔÈ¿˙Ô˘Û· ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ· ·fi µÚԢΤÏÏ·. ¶·È‰È·ÙÚÈ΋ 1989;52:181-187. 54. °ÂˆÚÁ·Î¿Î˘ °, ∫Ú¤ÌÌ˘ ¢, ∆ÛÈfiÙÚ·˜ ™. ªËÓÈÁÁÔÌ˘ÂÏ›Ùȉ· ÌÂÙ¿ ÚÈ˙›Ùȉ·˜ ·fi ‚ÚԢΤÏψÛË. π·ÙÚÈ΋ 1988; 54:311-313. 55. ªÔ‡Ú· ¶, ∫Ô˘ÓÙÔ‡Ú·˜ π, ™Î¤Ó‰ÚÔ˜ ¶, ∆Û¿·˜ ∞, ∆Û¿·˜ °. In vivo Â›‰Ú·ÛË Ù˘ ÈÛÔÚÈÓÔÛ›Ó˘ ÛÙÔ Û‡ÛÙËÌ· ÙˆÓ ÌÔÓÔ‡ÚËÓˆÓ-Ì·ÎÚÔÊ¿ÁˆÓ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ·ÓÂÓÂÚÁfi ‚ÚԢΤÏψÛË. °·ÏËÓfi˜ 1999;41:153-165. 56. ¡Ùfi‚·˜ ∞, ∑¤ÁÁÔ˜ ¡, ™Ù·Ù‹Ú˘ ∫, ∆Ô‡Ï˘ °. √Ú¯ÂÔÂȉȉ˘Ì›ÙȘ Â› ÔÍ›·˜ ‚ÚÔ˘ÎÂÏÏÒÛˆ˜. ¶Ú·ÎÙÈο 29Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ π·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; ∞ı‹Ó·: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ; 2003:172. 57. Andriopoulos P, Tsironi M, Asimakopoulos G. Acute abdomen due to Brucella melitensis. Scand J Infect Dis 2003;35:204-205. 58. ÃÚ‹ÛÙÔ˘ §, ¡Ù·Ï¤ÎÔ˜ °, ∆ÛÈ¿ÓÔ˜ ∂, ªÔ˘Ú·ÓÙ¿˜ ∂. ∞ÛΛÙ˘. ∞Û˘Ó‹ı˘ ÂΉ‹ÏˆÛË ÌÂÏÈÙ·›Ô˘ ˘ÚÂÙÔ‡. π·ÙÚÈ΋ 1995;67:77-79. 59. ¶··ÓÈÎÔÏ¿Ô˘ π™, ¡ÙÔ˘Ú¿Î˘ ™¶, ¶··‰ËÌËÙÚfiÔ˘ÏÔ˜ µÃ, ¶ÂÙÚ¿ÎË ∫, ÷Ù˙ËÁÈ¿ÓÓ˘ ™π. §Ô›ÌˆÍË ·fi Brucella abortus Û ·ÛıÂÓ‹ Ì ·ÏÎÔÔÏÈ΋ Ë·ÙÔ¿ıÂÈ·. ∞گ›· ∂ÏÏËÓÈ΋˜ π·ÙÚÈ΋˜; 2000; 17:612-615. 60. ¶··‰ËÌËÙÚ›Ô˘ Ã, ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜ π, ¡ÈÎÔÏ¿Ô˘ ∞, ª·ÓÔ‡ÛÔ˜ √. ªÂÏÈÙ·›Ô˜ ˘ÚÂÙfi˜. ∫ÏÈÓÈÎÔÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ 40 ÂÚÈÙÒÛÂˆÓ Ì ¤ÌÊ·ÛË ÛÙȘ ÎÏÈÓÈΤ˜ ·Ù˘›Â˜. ¡ÔÛÔÎÔÌÂȷο ÃÚÔÓÈο 1985;47:5-12. 61. ∆ÛÈÎڛη˜ £, ∆Ú˘ÊˆÓ›‰Ë˜ ¶, ºÈÏfiΈÛÙ·˜ °, ∫·Ú˘ÒÙ˘ ∞, ™·ÚËÁÈ¿ÓÓ˘ ∂, ∆ۿΈӷ˜ ∞. ªÂÏÈÙÔÎÔÎÎÈ΋ ÔÛÙÂÔÌ˘ÂÏÈ΋ ‚Ï¿‚Ë. Materia Medica Greca 1985;13:201-204. 62. ª·‡ÚË ∞, ªÂÛÛ·ÚÈÙ¿ÎË ∞, ∫·‚·˙·Ú¿Î˘ ∂. ™ÔÓ‰˘Ï›Ùȉ· Û ·È‰› Ì ‚ÚԢΤÏψÛË. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1999;11:56-58. 63. ¶·ÓÙ·˙‹˜ ∞, ¶·ÙÛ¿Ú˘ ™, ª·ÓÙÔ‡Ó·˜ ¢, ¢ËÌËÙÚÈ¿‰Ë˜ Ã, ∆ۿΈӷ˜ £. √Í›· ÔÚ¯ÂÔÂȉȉ˘Ì›Ùȉ· Û·Ó ÚˆÙ·Ú¯È΋ ÂΉ‹ÏˆÛË ‚ÚԢΤÏψÛ˘. °·ÏËÓfi˜ 1987;29:425-428. 64. ∫·ÏοÓË ª, ∞Ó‰ÚÈfiÔ˘ÏÔ˜ ¶, ¢ÈÔÓ˘ÛÔÔ‡ÏÔ˘ ª, ÃÚÈÛÙÔÊ‹ ∞. ∂ÓÙÔÈṲ̂ÓË ‚ÚԢΤÏψÛË - ‰‡Ô ÂÚÈÙÒÛÂȘ ÔÚ¯ÂÔÂȉȉ˘Ì›Ùȉ·˜ Î·È ÌÔÓÔ·ÚıÚ›Ùȉ·˜. ∂Ê·ÚÌÔṲ̂ÓË ∫ÏÈÓÈ΋ ªÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ∂ÚÁ·ÛÙËÚȷ΋ ¢È·ÁÓˆÛÙÈ΋ 2000;5:89-93. 65. Papatsoris AG, Mpadra FA, Karamouzis MV, Frangides CY. Endemic brucellar epididymo-orchitis: ¶·È‰È·ÙÚÈ΋ 2006;69:37-44


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a 10-year experience. Int J Infect Dis 2002; 6:309-313. 66. Galanakis E, Makis A, Bourantas K, Papadopoulou Z. Interleukin-3 and interleukin-4 in childhood brucellosis. Infection 2002;30:33-34. 67. ∆Û·Ù·Ï¿˜ ∫, ÷ÏÎÈ¿ ¶, ∫·Ú·ÎÔÏÈfi˜ ∞, ∆ÛÈÎڛη˜ £, ™ÈÓ¿ÎÔ˜ ∑. µ·Ú›· ·Á΢ÙÙ·ÚÔÂÓ›· ·fi ‚ÚԢΤÏψÛË. ∂ÏÏËÓÈ΋ π·ÙÚÈ΋ 1989;55:208-211. 68. °·Ï·Ó¿Î˘ ∂, ªÔ˘Ú¿ÓÙ·˜ ∫§, ∫ÂÊ·ÏÏËÓÔ‡ ∞, ∫·ÎÔÛ›ÌÔ˜ °, §··ÙÛ¿Ó˘ ¶¢. ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ‚ÚԢΤÏψÛ˘ ÙˆÓ ·È‰ÈÒÓ. ¶·È‰È·ÙÚÈ΋ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 1994;6:146-151. 69. Benecos P, Spingou T, Galanakis E, Lapatsanis PD.

¶·È‰È·ÙÚÈ΋ 2006;69:37-44

Thrombocytopenic purpura secondary to brucellosis. Eur J Pediatr 1998;157:698. 70. Apostolova E, Papadopoulos V, Leptidou-Kerestetzi T. Branchial cyst empyema due to Brucella melitensis infection as a form of focal Brucellosis. J Infect 2002;44:271. 71. ∆ÛÈÚÒÓË ª, ∞Ó‰ÚÈfiÔ˘ÏÔ˜ ¶, ∫·ÏοÓË ª, µÔ˘Ó¿Û˘ ∞, ¡ÙÔÚÔ‚›ÙÛ· Ã, ¢ÈÔÓ˘ÛÔÔ‡ÏÔ˘ ª, ¶ÂÚȉ›ÎË ª. ∞fiÛÙËÌ· Ì·ÛÙÔ‡ ÔÊÂÈÏfiÌÂÓÔ Û Brucella melitensis. ¶Ú·ÎÙÈο 29Ô˘ ¶·ÓÂÏÏ‹ÓÈÔ˘ π·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ; 2003, ª¿ÈÔ˜ 20-24; ∞ı‹Ó·: π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ; 2003:169.


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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

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∆˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π: ·ÛıÂÓ‹˜ Ì ¤ÓÙ ¯ÚfiÓÈ· ·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ıÂÚ·›·˜ ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘ - ™·‚‚ÔÔ‡ÏÔ˘1, ™. ∫·Ú‡‰· - ∫·‚·ÏÈÒÙË1, ∂. ÷Ù˙Ë·ÓÙÂÏ‹˜1, ∂. ∑·ÊÂÈÚÈ¿‰Ô˘2, ∫. ºˆÙÈ¿‰Ô˘3, ¡. ∫Ô˙¤Ë˜4, ∫. ¶·ÙÛÈ·Ô‡Ú·5, ™. ªÔ‡ÛÈÔ˘1, E. Holme6, ∫. ª·Ï·Î¿ - ∑·ÊÂÈÚ›Ô˘1, º. ∫·Ó·ÎÔ‡‰Ë - ∆۷ηϛ‰Ô˘1

¶ÂÚ›ÏË„Ë: ∏ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π ‹ Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· (√ªπª 276700) Â›Ó·È Û¿ÓÈÔ ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ÓfiÛËÌ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ Ù˘ÚÔÛ›Ó˘ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÊÔ˘Ì·Ú˘Ï·ÎÂÙÔÍÂÈ΋ ˘‰ÚÔÏ¿ÛË (fumaryloacetoacetate hydrolase, FAH) Î·È ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÙÔ ‹·Ú (ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ·fi ‚ÚÂÊÈÎ��� ËÏÈΛ·, ÂÍÂÏÈÛÛfiÌÂÓË Ë·ÙÈ΋ ΛÚÚˆÛË, Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ), ÙÔ˘˜ ÓÂÊÚÔ‡˜ (Û‡Ó‰ÚÔÌÔ Fanconi) Î·È Ù· ÂÚÈÊÂÚÈο Ó‡ڷ (ÎÚ›ÛÂȘ ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜ Ù‡Ô˘ ÔÚÊ˘Ú›·˜). ¶·ıÔÁÓˆÌÔÓÈ΋ ÁÈ· ÙËÓ ¿ıËÛË Â›Ó·È Ë ·ÚÔ˘Û›· ÛÔ˘ÎÈÓ˘Ï·ÎÂÙfiÓ˘ ÛÙÔ Ï¿ÛÌ· ‹ ÛÙ· Ô‡Ú·. ∏ Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· Â›Ó·È ÙÔ ÎÏËÚÔÓÔÌÈÎfi ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ· Ì ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ Î·È Ì¤¯ÚÈ ÚfiÙÈÓÔ˜, Ë ÌfiÓË ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ‹Ù·Ó Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È Ë ÌÂȈ̤ÓË ‰È·ÈÙËÙÈ΋ ÚfiÛÏË„Ë Ê·ÈÓ˘Ï·Ï·Ó›Ó˘ Î·È Ù˘ÚÔÛ›Ó˘. ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂÚ·›·˜ Ì NTBC [2-(2nitro 4 -trifluoromethylbenzoyl)-1,3-cyclohexanedione] Û ·ÛıÂÓ›˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ 1 ¤¯ÂÈ ·˘Í‹ÛÂÈ ı·̷ÙÈο ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ Ì ·Ú¿ÏÏËÏË Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜, ÒÛÙ ۋÌÂÚ· Ó· ÂÓÙ¿ÛÛÂÙ·È ÛÙË ıÂÚ·›· ÚÒÙ˘ ÁÚ·ÌÌ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘. ¶ÂÚÈÁÚ¿ÊÂÙ·È ŒÏÏËÓ·˜ ·ÛıÂÓ‹˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π Ô˘ ‰È·ÁÓÒÛÙËΠ۠ËÏÈΛ· 5 ÌËÓÒÓ Î·È ÛÙÔÓ ÔÔ›Ô ¯ÔÚËÁ‹ıËΠNTBC, ·Ú¿ÏÏËÏ· Ì ÙËÓ ÂȉÈ΋ ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹. ª›· ‚‰ÔÌ¿‰· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ÙÔ ‚Ú¤ÊÔ˜ ·ÚÔ˘Û›·Û ÂÓÙ˘ˆÛȷ΋ ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË Î·È ÔÈ ‚ÈÔ¯ËÌÈÎÔ› ·Ú¿ÌÂÙÚÔÈ Ù˘ Ë·ÙÈ΋˜ ÙÔ˘ ÏÂÈÙÔ˘ÚÁ›·˜ Â·Ó‹Ïı·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. ™‹ÌÂÚ·, ¤ÓÙ ¯ÚfiÓÈ· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Ì NTBC, Ô ·ÛıÂÓ‹˜ ‚Ú›ÛÎÂÙ·È Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ·' fi,ÙÈ ÁÓˆÚ›˙Ô˘ÌÂ, ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂÚ›ÙˆÛË Ù˘ÚÔÛÈÓ·ÈÌ›·˜ Ù‡Ô˘ π ÛÙËÓ ∂ÏÏ¿‰· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì NTBC.

1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., °. ¡. £ÂÛÛ·ÏÔӛ΢ “πÔÎÚ¿ÙÂÈÔ” 2 ∞ÎÙÈÓÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, °. ¡. £ÂÛÛ·ÏÔӛ΢ “πÔÎÚ¿ÙÂÈÔ” 3 ∆Ì‹Ì· ¢È·ÙÚÔÊ‹˜, °. ¡. £ÂÛÛ·ÏÔӛ΢ “πÔÎÚ¿ÙÂÈÔ” 4 √Êı·ÏÌÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °. ¡. £ÂÛÛ·ÏÔӛ΢ “πÔÎÚ¿ÙÂÈÔ” 5 ¶·ıÔÏÔÁÔ-AÓ·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, °. ¡. £ÂÛÛ·ÏÔӛ΢ “πÔÎÚ¿ÙÂÈÔ”, 6 Dept. of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden AÏÏËÏÔÁÚ·Ê›·: ¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘™·‚‚ÔÔ‡ÏÔ˘ µÈÔ¯ËÌÈÎfi-ªÂÙ·‚ÔÏÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ∞’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ∞.¶.£. °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛ/ӛ΢ “πÔÎÚ¿ÙÂÈÔ” ∫ˆÓ/fiψ˜ 49 T.K. 546 42, £ÂÛÛ·ÏÔÓ›ÎË ∂-mail: persefon@med.auth.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 21-03-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 28-11-2005

§¤ÍÂȘ ÎÏÂȉȿ: ∆˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π, Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›·, ıÂÚ·›·, NTBC.

Five years effective therapy of a patient with tyrosinaemia type I without transplantation P. Augoustides - Savvopoulou1, S. Karyda - Kavalioti1, E. Hatzipantelis1, ∂. Zafeiriadou2, K. Fotiadou3, N. Kozeis4, K. Patsiaoura5, S. Moussiou1, E. Holme6, K. Malaka - Zafeiriou1, F. Kanakoudi - Tsakalidou1

Abstract: Tyrosinaemia type I or hepatorenal tyrosinaemia (OMIM 276700) is a rare autosomal recessive inborn error of tyrosine metabolism caused by deficiency of fumarylacetoacetate hydrolase (FAH) and involving mainly the liver (acute liver failure in infancy, cirrhosis, hepatocellular carcinoma), kidneys (renal Fanconi syndrome) and peripheral nerves (porphyria-like crises). The presence of succinylacetone in plasma or urine is diagnostic for this disorder. Tyrosinaemia type I is the inborn error of metabolism with the highest incidence of hepatocellular carcinoma and till relatively recently, the only treatment for this disorder was liver transplantation in combination with dietary restriction of phenylalanine and tyrosine. Treatment with NTBC (2-(2-nitro-4trifluoromethylbenzoyl)-1,3-cyclohexanedione) has greatly increased survival and has reduced the need for liver transplantation during early childhood establishing NTBC as first-line treatment for patients with tyrosinemia type I. We present a Greek boy with hepatorenal tyrosinaemia who was diagnosed at the age of 5 months and immediately started on a regimen of NTBC in parallel with the dietary therapy indicated in this disorder. Significant clinical improvement with normalization of liver function tests was apparent after one week of treatment. Currently, after five years treatment

1 1st Paediatric Clinic of Aristotle University, “Ippokration” General Hospital Thessaloniki 2 Laboratory of Radiology, “Ippokration” General Hospital Thessaloniki 3 Department of Nutrition, “Ippokration” General Hospital Thessaloniki 4 Department of Ophtalmology, “Ippokration” General Hospital Thessaloniki 5 Laboratory of Pathology, “Ippokration” General Hospital Thessaloniki 6 Dept. of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden

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Correspondence: P. Augoustides-Savvopoulou Biochemistry-Metabolism Laboratory 1st Paediatric Clinic of Aristotle University “Ippokration” General Hospital Thessaloniki 49, Konstantinoupoleos Str., 546 42, Thessaloniki ∂-mail: persefon@med.auth.gr Date of submission: 21-03-2005 Date of approval: 28-11-2005

¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

with NTBC, the patient is in excellent clinical condition. As far as we are aware, he is the first tyrosinaemia type I patient on a therapeutic regimen of NTBC in Greece.

Key words: ∆yrosinaemia type I, therapy, NTBC, hepato-renal.

∂ÈÛ·ÁˆÁ‹ ∏ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π ‹ Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· (√ªπª 276700) Â›Ó·È Û¿ÓÈÔ (1:100.000-120.000 ÁÂÓÓ‹ÛÂȘ) ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ÓfiÛËÌ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ Ù˘ÚÔÛ›Ó˘ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÓÂ¿ÚÎÂÈ· ˘‰ÚÔÏ¿Û˘ ÙÔ˘ ÊÔ˘Ì·Ú˘Ï·ÎÂÙÔÍÂÈÎÔ‡ ÔͤԘ (fumarylacetate hydrolase-FAH), ¤Ó˙˘ÌÔ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È ·fi ÁÔÓ›‰ÈÔ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔ ¯ÚˆÌfiۈ̷ 15q23-q25 (1). ¶ÚÔÛ‚¿ÏÏÔÓÙ·È Î˘Ú›ˆ˜ ÙÔ ‹·Ú (ÂÍÂÏÈÛÛfiÌÂÓË Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ΛÚÚˆÛË, Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ), ÔÈ ÓÂÊÚÔ› (ÓÂÊÚÈ΋ ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë, ˘ÔʈÛÊ·Ù·ÈÌÈ΋ Ú·¯›Ùȉ·) Î·È Ù· ÂÚÈÊÂÚÈο Ó‡ڷ (Ó¢ÚÔÏÔÁÈÎfi Û‡Ó‰ÚÔÌÔ Ù‡Ô˘ ÔÚÊ˘Ú›·˜). ∞fi Ù· ÎÏËÚÔÓÔÌÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, Ë Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘. ª¤¯ÚÈ ÙÔ 1980, Ë ÌfiÓË

·ÓÙÈÌÂÙÒÈÛË Ù˘ Ù˘ÚÔÛÈÓ·ÈÌ›·˜ π ‹Ù·Ó Ë ÌÂȈ̤ÓË ‰È·ÈÙËÙÈ΋ ÚfiÛÏË„Ë Ê·ÈÓ˘Ï·Ï·Ó›Ó˘ Î·È Ù˘ÚÔÛ›Ó˘ Î·È ÌÂÙ¿ ·fi ÙÔ 1980, ÚÔÛÙ¤ıËÎÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (1-5). ∂·Ó¿ÛÙ·ÛË ÛÙË ıÂÚ·›· Ù˘ ÓfiÛÔ˘ ·ÔÙ¤ÏÂÛÂ Ë ·Ó·Î¿Ï˘„Ë Ù˘ ‰Ú¿Û˘ ÌÈ·˜ ÙÚÈÎÂÙfiÓ˘, ÙÔ˘ NTBC (2-(2-nitro 4 -trifluoromethylbenzoyl)1,3-cyclohexanedione) ÛÙÔ ÌÂÙ·‚ÔÏÈÎfi ÌÔÓÔ¿ÙÈ Ù˘ Ù˘ÚÔÛ›Ó˘ (∂ÈÎfiÓ· 1) (1,2,5-9). ∏ ™Ô˘Ë‰È΋ ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÙˆÓ Lindstedt Î·È Û˘Ó (ÔÌ¿‰· ÙÔ˘ Gothenburg), ‹Ù·Ó ÔÈ ÚÒÙÔÈ Ô˘ ·Ú·Ù‹ÚËÛ·Ó ÙȘ ıÂÚ·¢ÙÈΤ˜ ȉÈfiÙËÙ˜ ÙÔ˘ NTBC Û ·ÛıÂÓ›˜ Ì Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· ÙÔ 1991 (8). ¶ÂÚÈÁÚ¿ÊÂÙ·È ŒÏÏËÓ·˜ ·ÛıÂÓ‹˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· π, Ô ÔÔ›Ô˜ Â‰Ò Î·È ¤ÓÙ ¯ÚfiÓÈ·, ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÂÈÙ˘¯Ò˜ Ì NTBC. ∞' fi,ÙÈ ÁÓˆÚ›˙Ô˘ÌÂ, Â›Ó·È Ô ÚÒÙÔ˜ ·ÛıÂÓ‹˜ Ì Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· ÛÙËÓ ∂ÏÏ¿‰· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì NTBC. ∆˘ÚÔÛ›ÓË

4-˘‰ÚÔÍ˘Ê·ÈÓ˘ÏÔÁ·Ï·ÎÙÈÎfi Ô͇

4-˘‰ÚÔÍ˘Ê·ÈÓ˘ÏÔ˘ÚÔ˘‚ÈÎfi Ô͇ ·Ó·ÛÙÔÏ‹ ·fi NTBC ÔÌÔÁÂÓÙÈÛÈÎfi Ô͇

ÛÔ˘ÎÈÓ˘ÏÔ·ÎÂÙÔÍÂÈÎfi Ô͇

̷ϸÏÔ·ÎÂÙÔÍÂÈÎfi Ô͇ ∆ÔÍÈÎÔ› ÌÂÙ·‚Ôϛ٘

ÛÔ˘ÎÈÓ˘ÏÔ·ÎÂÙfiÓË

ÊÔ˘Ì·Ú˘ÏÔ·ÎÂÙÔÍÂÈÎfi Ô͇ ∆˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π

‰-·ÌÈÓÔÏ‚ԢÏÈÓÈÎfi Ô͇

ÊÔ˘Ì·ÚÈÎfi Ô͇ Î·È ·ÎÂÙÔÍÂÈÎfi Ô͇ ÔÚÊÔ¯ÔÏÈÓÔÁfiÓÔ

∂ÈÎfiÓ· 1. ªÂÙ·‚ÔÏÈÎfi ÌÔÓÔ¿ÙÈ Ù˘ ·Ô‰fiÌËÛ˘ Ù˘ Ù˘ÚÔÛ›Ó˘, fiÔ˘ Ê·›ÓÔÓÙ·È ÔÈ ÙÔÍÈÎÔ› ÌÂÙ·‚Ôϛ٘, ÙÔ ÛËÌÂ›Ô ·Ú¤Ì‚·Û˘ ÙÔ˘ NTBC Î·È ÙÔ ÛËÌÂ›Ô ·Ó·ÛÙÔÏ‹˜ Ù˘ Û˘ÓıÂÙ¿Û˘ ÙÔ˘ ÔÚÊÔ¯ÔÏÈÓÔÁfiÓÔ˘ (‹ 5-∞§∞ ˘‰Ú·Ù¿Û˘) ·fi ÙË ÛÔ˘ÎÈÓ˘Ï·ÎÂÙfiÓË (·fi Holme Î·È Lindstedt, Clinics in Liver Disease 2000;4:806). ¶·È‰È·ÙÚÈ΋ 2006;69:45-51


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£ÂÚ·›· Ù˘ÚÔÛÈÓ·ÈÌ›·˜ Ù‡Ô˘ π

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶ÚfiÎÂÈÙ·È ÁÈ· ·ÁfiÚÈ ËÏÈΛ·˜ 5 ÌËÓÒÓ, Ô˘ ÂÈÛ‹Ïı ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÏfiÁˆ ÂÎÛÂÛËÌ·Ṳ̂Ó˘ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·˜, ‰˘ÛÙÚÔÊ›·˜ Î·È ·ÈÌÔÚÚ·ÁÈ΋˜ ‰È¿ıÂÛ˘. ∂›Ó·È ÙÔ 2Ô ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ ÌÂ Û˘ÁÁ¤ÓÂÈ· 4Ô˘ ‚·ıÌÔ‡. ∆Ô Ì·È¢ÙÈÎfi Î·È ÂÚÈÁÂÓÓËÙÈÎfi ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂχıÂÚ·. ∞fi ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ·ÈÌÔÚÚ·Á›· ·fi ÙÔ ÔÌÊ·ÏÈÎfi ÎÔÏfi‚ˆÌ· ÙË 10Ë Ë̤ڷ ˙ˆ‹˜, Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ K. ∞fi ÙÔÓ 3Ô Ì‹Ó· ˙ˆ‹˜ ·Ú·ÙËÚ‹ıËΠ˘ÔÏÂÈfiÌÂÓË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË. ªÂ Èı·Ó‹ ‰È¿ÁÓˆÛË “·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜” ¯ÔÚËÁ‹ıËΠ˘Ô·ÏÏÂÚÁÈÎfi Á¿Ï·. ∆ÔÓ 4Ô Ì‹Ó· ˙ˆ‹˜, ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÚÔÛÙ¤ıËÎ·Ó ‚ÏÂÓÓÔ·ÈÌ·ÙËÚ¤˜ ÎÂÓÒÛÂȘ. ∞ÎÔÏÔ‡ıËÛ ·ÏÏ·Á‹ Ù˘ ‰È·ÙÚÔÊ‹˜ Û Á¿Ï· Ï‹ÚÔ˘˜ ˘‰ÚfiÏ˘Û˘ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ¯ˆÚ›˜ η̛· ‚ÂÏÙ›ˆÛË. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ∫ÏÈÓÈ΋ Ì·˜, ¯·Ú·ÎÙËÚÈÛÙÈ΋ ‹Ù·Ó Ë ¤ÓÙÔÓË ‰˘ÛÙÚÔÊ›· (‚¿ÚÔ˜, Ì‹ÎÔ˜ Î·È ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ <3Ë ÂηÙÔÛÙÈ·›· ı¤ÛË) ÂÓÒ ‰È·ÈÛÙÒıËΠˆ¯ÚfiÙËÙ·, ÛÙÔÌ·Ù›Ùȉ· Î·È ·Ú¿ÙÚÈÌÌ·. ∏ ÎÔÈÏÈ¿ ‹Ù·Ó ÌÂÙˆÚÈṲ̂ÓË, Ì „ËÏ·ÊËÙfi ÛÎÏËÚfi ‹·Ú Î·È ÛÏ‹Ó· 8 Î·È 5 cm οو ·fi Ù· Ï¢ÚÈο ÙfiÍ· ·ÓÙ›ÛÙÔȯ·. ∏ ÂͤٷÛË ÙˆÓ ˘ÔÏÔ›ˆÓ Û˘ÛÙËÌ¿ÙˆÓ Î·ıÒ˜ Î·È Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ‹Ù·Ó ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∞fi ÙÔÓ ÚÒÙÔ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ‰È·ÈÛÙÒıËÎ·Ó ıÚÔÌ‚ÔÂÓ›·, ·Ó·ÈÌ›·, ˘ÔÁÏ˘Î·ÈÌ›·, ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Î·È Ù˘ ¯ÔÏÂÚ˘ı˘Ú›Ó˘, ̤ÙÚÈ· ·‡ÍËÛË Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘, ¯·ÌËÏ¿ Â›‰· ʈÛÊÒÚÔ˘, ÛËÌ·ÓÙÈ΋ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Î·È Ù˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ Î·È Ôχ ˘„ËÏ¿ Â›‰· ·-ÊÂÙÔÚˆÙ½Ó˘ ÔÚÔ‡ (¶›Ó·Î·˜ 1). ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ¤‰ÂÈÍ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ‹·ÙÔ˜ Ì ·‰Ú‹ ˯ԉÔÌ‹, ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ Ì ÔÌÔÈÔÁÂÓ‹ ˯ԉÔÌ‹ Î·È ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Î·È ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ Ì ·˘ÍË̤ÓË Ë¯ÔÁ¤ÓÂÈ·. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· (CT) ÎÔÈÏ›·˜ ¤‰ÂÈÍ ÔÏ˘Ô˙Ò‰Ë ·ÂÈÎfiÓÈÛË ÙÔ˘ ‹·ÙÔ˜, ÛÏËÓÔÌÂÁ·Ï›·, ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ÓÂÊÚÒÓ Î·È ·Ô˘Û›· ÏÂÌÊ·‰¤ÓˆÓ, ÂÓÒ ÛÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ÎÔÈÏ›·˜ ‰È·ÈÛÙÒıËΠÂÈÎfiÓ· ΛÚÚˆÛ˘ ‹·ÙÔ˜ Ì ÔÏÏ·ÏÔ‡˜ ·Ó·ÁÂÓÓËÙÈÎÔ‡˜ fi˙Ô˘˜ ÂÓÙfi˜ ·˘ÙÔ‡, ¯ˆÚ›˜ ÛÙÔȯ›· Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ (∂ÈÎfiÓ˜ 2· Î·È 2‚). ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ‚ÈÔ„›·˜ ‹·ÙÔ˜ ÂȂ‚·›ˆÛ ÙË ‰È¿ÁÓˆÛË Ù˘

¶›Ó·Î·˜ 1. ∞ÔÙÂϤÛÌ·Ù· ·Ú¯ÈÎÔ‡ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘ ∞›Ì· ∞ÈÌÔÛÊ·ÈÚ›ÓË (g/dl, Ê.Ù.: 9,5-11 ) ∞ÈÌÔÂÙ¿ÏÈ· (k/ml, Ê.Ù.: 150-300) ƒ∆ (sec) PTT (sec) ∞ÏÎ. ʈÛÊ·Ù¿ÛË (U/L, Ê.Ù.: 1-3 x ÂÓËϛΈÓ) SGOT (U/L, Ê.Ù.: 20-40) SGPT (U/L, Ê.Ù.: 20-40) ÃÔÏÂÚ˘ıÚ›ÓË ÔÏ. (mg/dl, Ê.Ù.: 0,1-0,5) (Ìmol/L, Ê.Ù.: 1,71-8,55) ÁGT (mU/L, Ê.Ù.: 6-26) ºˆÛÊfiÚÔ˜ (mg/dl, Ê.Ù.: 3,5-5,5) (Ìmol/L, Ê.Ù.: 1,71-8,55) ·-ÊÂÙÔÚˆÙ½ÓË (ng/ml, Ê.Ù. <12) ∆˘ÚÔÛ›ÓË (Ìmol/L, Ê.Ù.: 50-130) (mg/dl, Ê.Ù.: 0,90-2,35) ªÂıÂÈÔÓ›ÓË (Ìmol/L, Ê.Ù.: 20-50) (mg/dl, Ê.Ù.: 0,45-0,95) º·ÈÓ˘Ï·Ï·Ó›ÓË (Ìmol/L, Ê.Ù.: 40-120) (mg/dl, Ê.Ù.: 0,07- 0,20)

9,8 83 17,7/12 74.4/36 1677 152 80 2,2 37,62 199 2,1 1,03 151000 354 6,41 220 3,28 193 0,318

ΛÚÚˆÛ˘ (∂ÈÎfiÓ· 3). ¶·Ú¿ÏÏËÏ· Ì ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, ¤ÁÈÓ ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· CMV, EBV, HBV, HAV, HCV Î·È ÙÔÍÔÏ¿Û̈ÛË Ì ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· Î·È ¤ÏÂÁ¯Ô˜ ÁÈ· ÎÏËÚÔÓÔÌÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·. √ ÔÛÔÙÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ·ÌÈÓÔͤˆÓ ÛÙÔ Ï¿ÛÌ· ¤‰ÂÈÍ ˘„ËÏ¿ Â›‰· Ù˘ÚÔÛ›Ó˘, ÌÂıÂÈÔÓ›Ó˘, Ê·ÈÓ˘Ï·Ï·Ó›Ó˘, ÂÓ‰ÂÈÎÙÈο Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Î·È ÂÎÛÂÛËÌ·Ṳ̂ÓË ÁÂÓÈÎÂ˘Ì¤ÓË ·ÌÈÓÔÍÔ˘Ú›· Ô˘ Û˘ÓËÁÔÚÔ‡Û ÁÈ· Û‡Ó‰ÚÔÌÔ Fanconi. √ ¤ÏÂÁ¯Ô˜ Ù˘ ÓÂÊÚÈ΋˜ ÛˆÏËÓ·Úȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ¤‰ÂÈÍ οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·, ÂÓÒ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·Û‚ÂÛÙÈÔ˘Ú›· ‹ ʈÛÊ·ÙÔ˘Ú›· ‹ ÁÏ˘ÎÔ˙Ô˘Ú›·. ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ ·ÌÈÓÔͤˆÓ Û˘ÓËÁÔÚÔ‡Û·Ó ÁÈ· Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ I Î·È Ë ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒıËΠ̠ÙËÓ ÂͤٷÛË ÁÈ· ÔÚÁ·ÓÈο Ôͤ· Ô‡ÚˆÓ Ô˘ ·ÔÎ¿Ï˘„ ÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ÛÔ˘ÎÈÓ˘Ï·ÎÂÙfiÓ˘. ∏ ¯·ÌËÏ‹ ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ Û˘ÓıÂÙ¿Û˘ ÙÔ˘ ÔÚÊÔ¯ÔÏÈÓÔÁfiÓÔ˘ (PBGS) ÛÙ· ÂÚ˘ıÚ¿ ·ÈÌÔÛÊ·›ÚÈ·, Ë ·‡ÍËÛË ÙÔ˘ ‰-·ÌÈÓÔÏ‚ԢÏÈÓÈÎÔ‡ ÔͤԘ ÛÙ· Ô‡Ú· Î·È Ë ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ÛÔ˘ÎÈÓ˘Ï·ÎÂÙfiÓ˘ ÛÙÔ Ï¿ÛÌ· ÂÓ›Û¯˘Û·Ó ÂÈϤÔÓ ÙË ‰È¿ÁÓˆÛË Ù˘ Ë·ÙÔÓÂÊÚÈ΋˜ Ù˘ÚÔÛÈÓ·ÈÌ›·˜ ¶·È‰È·ÙÚÈ΋ 2006;69:45-51


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¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

∂ÈÎfiÓ· 2. ∞ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηٿ ÙË ‰È¿ÁÓˆÛË, fiÔ˘ Ê·›ÓÂÙ·È Ë ÔÏ˘Ô˙҉˘ ˘Ê‹ ÙÔ˘ ‹·ÙÔ˜ Û ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· 2·) Î·È Û ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI - gradient echo) 2‚).

(¶›Ó·Î·˜ 2). √ ¤ÏÂÁ¯Ô˜ ÙÔ˘ DNA ÙÔ˘ ·ÛıÂÓ‹ ·ÂÎ¿Ï˘„ ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙËÓ ÌÂÙ¿ÏÏ·ÍË Met 1 Val ÛÙÔ ÚÒÙÔ ÂÍfiÓÈÔ ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Έ‰ÈÎÔÔÈ› ÙÔ ¤Ó˙˘ÌÔ FAH. ™ÙÔÓ ˘fiÏÔÈÔ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Ô˘ ·ÎÔÏÔ‡ıËÛÂ, ÔÈ Ù·¯‡ÙËÙ˜ ·ÁˆÁÈÌfiÙËÙ·˜ ÓÂ‡ÚˆÓ ¤‰ÂÈÍ·Ó Â˘Ú‹Ì·Ù· ‹È·˜ ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜, ÂÓÒ Ê˘ÛÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· ¤‰ÂÈÍ·Ó Ë ‚˘ıÔÛÎfiËÛË, Ë ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË Ì ۯÈÛÌÔÂȉ‹ Ï˘¯Ó›·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ Î·È Ë ·ÎÙÈÓÔÁÚ·Ê›· Ì·ÎÚÒÓ ÔÛÙÒÓ. ªÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, Ô ·ÛıÂÓ‹˜ Ù¤ıËΠ۠ÂȉÈ΋ ‰›·ÈÙ· ÂÚÈÔÚÈṲ̂Ó˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ÚˆÙ½ÓË, Ù˘ÚÔÛ›ÓË Î·È Ê·ÈÓ˘Ï·Ï·Ó›ÓË. ∆·˘Ùfi¯ÚÔÓ· ÍÂΛÓËÛ ·ÁˆÁ‹ Ì NTBC ·fi ÙÔ ÛÙfiÌ·, 1 mg/kg/24ˆÚÔ Û ‰‡Ô ‰fiÛÂȘ, Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ ™Ô˘Ë‰È΋˜ ÔÌ¿‰·˜. ∏ ·¿ÓÙËÛË ÛÙË ıÂÚ·›· Ì NTBC ‹Ù·Ó ÂÓÙ˘ˆÛȷ΋. ª›· ‚‰ÔÌ¿‰· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜, ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ Î·È Ù˘ fiÚÂ͢ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ÎÔÈÏÈ¿ ÙÔ˘ ‹Ù·Ó ̷Ϸ΋ Î·È ÙÔ ‹·Ú „ËÏ·ÊËÙfi 5 cm οو ·fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ (Ì›ˆÛË Î·Ù¿ 3 cm), ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙÔÓ ·ÈÌ·ÙÔÏÔÁÈÎfi, ‚ÈÔ¯ËÌÈÎfi Î·È ÌÂÙ·‚ÔÏÈÎfi ¶·È‰È·ÙÚÈ΋ 2006;69:45-51

¤ÏÂÁ¯Ô ›¯·Ó ‚ÂÏÙȈı› ÂÓÙ˘ˆÛȷο (¶›Ó·Î·˜ 2). π‰È·›ÙÂÚË ÂÓÙ‡ˆÛË ¤Î·ÓÂ Ë ÌÂÁ¿ÏË ÙÒÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘. ŒÍÈ Ì‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, Ô ·ÛıÂÓ‹˜ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, Ë ÛˆÌ·ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ÙÔ˘ ·Ó¿Ù˘ÍË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ (‚¿ÚÔ˜, Ì‹ÎÔ˜, ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÛÙËÓ 50Ë ÂηÙÔÛÙÈ·›· ı¤ÛË), ÂÓÒ ÙÔ „ËÏ·ÊËÙfi ̤ÁÂıÔ˜ ÙÔ˘ ‹·ÙÔ˜ ÌÂÈÒıËΠÛÙ· 4 cm οو ·fi ÙÔ Ï¢ÚÈÎfi ÙfiÍÔ. √ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ‹·ÙÔ˜ Î·È Ë ‚ÈÔ„›· ‹·ÙÔ˜ Ô˘ ¤ÁÈÓ·Ó ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô, ¤‰ÂÈÍ·Ó ·Ú·ÌÔÓ‹ ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ·ÏÏ¿ ¯ˆÚ›˜ ÛËÌ›· ηÎÔ‹ıÂÈ·˜. ™‹ÌÂÚ·, ¤ÓÙ ¯ÚfiÓÈ· ·fi ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, Ô ·ÛıÂÓ‹˜ Û˘Ó¯›˙ÂÈ ÙËÓ ›‰È· ·ÁˆÁ‹, Ë ÁÂÓÈ΋ ÙÔ˘ ηٿÛÙ·ÛË ·Ú·Ì¤ÓÂÈ ¿ÚÈÛÙË, Ë ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È Ô ·Ó·Ù˘ÍÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈο Î·È ÙÔ ‹·Ú ۯ‰fiÓ ·„ËÏ¿ÊËÙÔ (1 cm). ™ÙÔÓ ¶›Ó·Î· 2 Ê·›ÓÂÙ·È Ë Ï‹Ú˘ ·ÔηٿÛÙ·ÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ™ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ ‹·ÙÔ˜ (CT spiral) Ô˘ ¤ÁÈÓ ÙÔ 2Ô Î·È 3Ô ¯ÚfiÓÔ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈÎfiÓ·˜ ÙÔ˘ ‹·ÙÔ˜ (∂ÈÎfiÓ· 4).


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£ÂÚ·›· Ù˘ÚÔÛÈÓ·ÈÌ›·˜ Ù‡Ô˘ π

¶›Ó·Î·˜ 2. ¶·Ú¿ÌÂÙÚÔÈ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ıÂÚ·›·˜ Ì NTBC Û‡Ìʈӷ Ì ÙÔ ÂȉÈÎfi ÚˆÙfiÎÔÏÏÔ ÙˆÓ ™Ô˘Ë‰ÒÓ Û˘ÓÂÚÁ·ÙÒÓ ¶·Ú·ÎÔÏÔ‡ıËÛË

¢È¿ÚÎÂÈ· ıÂÚ·›·˜ ∞›Ì· PBG synthase, ÂÚ˘ıÚ¿ ™Ô˘ÎÈÓ˘Ï·ÎÂÙfiÓË, Ï¿ÛÌ· ·-ÊÂÙÔÚˆÙ½ÓË, ÔÚfi˜ ∆˘ÚÔÛ›ÓË, Ï¿ÛÌ· º·ÈÓ˘Ï·Ï·Ó›ÓË Ï¿ÛÌ· ªÂıÂÈÔÓ›ÓË, Ï¿ÛÌ· √‡Ú· ‰-·ÌÈÓÔÏ‚ԢÏÈÓÈÎfi Ô͇ ™Ô˘ÎÈÓ˘Ï·ÎÂÙfiÓË

∏Ì. ÚˆÙÔÎfiÏÏÔ˘ ∏̤Ú˜

¶ÚÔNTBC 000214

+1 ‚‰.

+1Ì

000225

12Ì

+24Ì

+36Ì

+48Ì

+ 60Ì

000317 010217 020217

030217

040217

050217

ªÔÓ¿‰Â˜

∆È̤˜ ·Ó·ÊÔÚ¿˜

Nkat/g Hb

0,58-1,25

0,03

1,05

0,8

0,72

0,6

0,67

0,75

0,69

Ìg/ml

<0,4

42

7,8

2,5

<0,1

<0,1

<0,1

<0,1

<0,1

Ìmol/L

<12

151000

51000

26400

100

21

19

20

15

Ìmol/L

50-130

354

136

121

335

479

450

657

550

Ìmol/L

40-120

193

30

46

55

55

92

68

63

Ìmol/L

20-50

220

22

38

18

19

28

15

15

0-3

160

6,7

6,3

8,1

3

5,5

6,3

3,6

<1

320

<1

<1

<1

<1

<1

<1

<1

<1

330

<1

<1

<1

<1

<1

<1

<1

31,9

46,1

50,7

50,2

46,9

47,1

48,1

mmol/mol ÎÚ·ÙÈÓ›Ó˘ mmol/mol ÎÚ·ÙÈÓ›Ó˘ ™Ô˘ÎÈÓ˘ÏÔ·ÎÂÙÔÍÂÈÎfi mmol/mol Ô͇ ÎÚ·ÙÈÓ›Ó˘ NBTC, ÔÚfi˜ Ìmol/L

∏ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÚÈÓ ·fi 50 ¯ÚfiÓÈ· Î·È Â›Ó·È ·fi Ù· ÈÔ Î·Ï¿ ÙÂÎÌËÚȈ̤ӷ ÎÏËÚÔÓÔÌÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (1). ∆Ô ‹·Ú Â›Ó·È ÙÔ Î‡ÚÈÔ fiÚÁ·ÓÔ Ô˘ ÚÔÛ‚¿ÏÏÂÙ·È ÛÙËÓ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ 1 Î·È Û ‰ÈÂıÓ‹ ÌÂϤÙË, 69% ÙˆÓ ı·Ó¿ÙˆÓ ·Ô‰fiıËÎ·Ó ÛÙËÓ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ·ÈÌÔÚÚ·Á›· Î·È 16% ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ

(10). ™‡Ìʈӷ Ì ÙÔ˘˜ van Spronsen Î·È Û˘Ó, ‚·ÛÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙË ‚·Ú‡ÙËÙ· Î·È ÚfiÁÓˆÛË Ù˘ ¿ıËÛ˘ Â›Ó·È Ë ËÏÈΛ· ¤Ó·Ú͢ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (10). √ ·ÛıÂÓ‹˜ Ì·˜ ÚÔÛ‹Ïı Ì ÙËÓ Ù˘È΋ ‚·ÚÈ¿ ÂÈÎfiÓ· Ù˘ ÔÍ›·˜ Ë·ÙÔÓÂÊÚÈ΋˜ Ù˘ÚÔÛÈÓ·ÈÌ›·˜, Û ËÏÈΛ· 5 ÌËÓÒÓ, Ì ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘, ¤ÓÙÔÓË ‰˘ÛÙÚÔÊ›·, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ì ΛÚÚˆÛË, ˘ÂÚÙ˘ÚÔÛÈÓ·ÈÌ›·, ˘ÂÚÌÂıÂÈÔÓÈÓ·ÈÌ›·, ÁÂÓÈÎÂ˘Ì¤ÓË ·ÌÈÓÔÍÔ˘Ú›· Î·È ˘„ËÏ¿ Â›‰· ÛÔ˘ÎÈÓ˘Ï·ÎÂÙfiÓ˘ ÛÙ· Ô‡Ú·.

∂ÈÎfiÓ· 3. µÈÔ„›· ‹·ÙÔ˜ ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜: ¶˘Ï·›Ô ‰È¿ÛÙËÌ· Ì ¤ÓÙÔÓË ›ÓˆÛË Î·È ˘ÂÚÏ·Û›· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ (ÙÚ›¯ÚˆÌË Masson x 200).

∂ÈÎfiÓ· 4. Spiral CT ‹·ÙÔ˜ 3 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜, fiÔ˘ Û˘ÁÎÚÈÙÈο Ì ÙȘ ÂÈÎfiÓ˜ 2‚ Î·È 2‚ ·Ú·ÙËÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈÎfiÓ·˜ - fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÔÌÔÈÔÁ¤ÓÂÈ· - ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜.

™˘˙‹ÙËÛË

¶·È‰È·ÙÚÈ΋ 2006;69:45-51


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·50

50

¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

™ÙÔ˘˜ ·ÛıÂÓ›˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ 1, ‰È·Ù·Ú¿ÛÛÂÙ·È Î˘Ú›ˆ˜ Ë Û˘ÓıÂÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‹·ÙÔ˜ Ì Ôχ ·Ú·ÙÂٷ̤ÓÔ˘˜ ¯ÚfiÓÔ˘˜ ÚÔıÚÔÌ‚›Ó˘ Î·È ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘, ÂÓÒ Ù· Â›‰· ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Î·È ¯ÔÏÂÚ˘ıÚ›Ó˘ ÌÔÚ› Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈο ‹ Ï›ÁÔ ·˘ÍË̤ӷ, ÁÂÁÔÓfi˜ Ô˘ ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙÔÓ ‰ÈÎfi Ì·˜ ·ÛıÂÓ‹ (1). ∆· Ôχ ˘„ËÏ¿ Â›‰· Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘ Û˘Ó‹ıˆ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ηıÒ˜ Î·È Ù· ˘„ËÏ¿ Â›‰· Ù˘ ÌÂıÂÈÔÓ›Ó˘, ·Ú¿ÁˆÁÔ Ù˘ ÔÔ›·˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙË ¯·Ú·ÎÙËÚÈÛÙÈ΋ Ì˘Úˆ‰È¿ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı˘Ì›˙ÂÈ ‚Ú·Ṳ̂ÓÔ Ï¿¯·ÓÔ. ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ Ù· Â›‰· ·-ÊÂÙÔÚˆÙ›Ó˘ ÛÙË ‰È¿ÁÓˆÛË ‹Ù·Ó Ôχ ˘„ËÏ¿ Î·È Û˘ÌʈÓÔ‡Û·Ó Ì ٷ ·ÂÈÎÔÓÈÛÙÈο Î·È ·ıÔÏÔÁÔ-·Ó·ÙÔÌÈο Â˘Ú‹Ì·Ù· ÙÔ˘ ‹·ÙÔ˜. ∏ ˘ÔÁÏ˘Î·ÈÌ›· Ô˘ ·Ú·ÙËÚ‹ıËΠÂ›Û˘ ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜, ·Ô‰›‰ÂÙ·È ÛÙË ‚·ÚÈ¿ Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ÛÙËÓ ˘ÂÚÙÚÔÊ›· Ù˘ ÂÓ‰ÔÎÚÈÓÔ‡˜ ÌÔ›Ú·˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ Ù˘ÚÔÛÈÓ·ÈÌ›· 1 (1). ª¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ‚ÚÂı› ÂÚÈÛÛfiÙÂÚ˜ ·fi 34 ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ÁÔÓ›‰ÈÔ Ô˘ Έ‰ÈÎÔÔÈ› ÙÔ ¤Ó˙˘ÌÔ FAH. √ ¤ÏÂÁ¯Ô˜ ÙÔ˘ DNA ÙÔ˘ ·ÛıÂÓ‹ Ì·˜ ·ÔÎ¿Ï˘„ ÔÌÔ˙˘ÁˆÙ›· ÁÈ· ÙËÓ ÌÂÙ¿ÏÏ·ÍË Met 1 Val ÛÙÔ ÚÒÙÔ ÂÍÒÓÈÔ ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Έ‰ÈÎÔÔÈ› ÙÔ ¤Ó˙˘ÌÔ FAH. ∏ ÌÂÙ¿ÏÏ·ÍË ·˘Ù‹, Ô˘ Â›Ó·È ÌÂÙ¿ÏÏ·ÍË “Ì ϿıÔ˜ ÓfiËÌ·” (missense), ÂÈʤÚÂÈ ‰È·Ù·Ú·¯‹ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ÚˆÙÂ˚ÓÈ΋˜ Û‡ÓıÂÛ˘ (ÙÔ˘ ÂÓ˙‡ÌÔ˘) (1,12). §fiÁˆ ÙˆÓ ÊÙˆ¯ÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ‰È·ÈÙËÙÈ΋˜ ıÂÚ·›·˜ Î·È Ù˘ ˘„ËÏ‹˜ ıÓËÛÈÌfiÙËÙ·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ (10-15% ·ÎfiÌË Î·È Û ȉ·ÓÈΤ˜ Û˘Óı‹Î˜), Ë ·Ó·Î¿Ï˘„Ë Ù˘ ‰Ú¿Û˘ ÙÔ˘ NTBC ıˆڋıËΠÂ·Ó¿ÛÙ·ÛË ÛÙË ıÂÚ·›· Ù˘ Ù˘ÚÔÛÈÓ·ÈÌ›·˜ Ù‡Ô˘ 1. ∆Ô Ê¿ÚÌ·ÎÔ ÌÂÏÂÙ‹ıËΠ·Ú¯Èο ·fi ÙÔ ∂ÚÁ·ÛÙ‹ÚÈÔ ∆ÔÍÈÎÔÏÔÁ›·˜ Zeneca Central Toxicology Laboratory ÛÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ Û·Ó ˙È˙·ÓÈÔÎÙfiÓÔ, ·ÏÏ¿ ÛÙȘ ÙÔÍÈÎÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Û Â›Ì˘Â˜, ·Ú·ÙËÚ‹ıËΠfiÙÈ ÙÔ 80% ÂÌÊ¿ÓÈÛ·Ó ÔÊı·ÏÌÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÏfiÁˆ ÂÓ·fiıÂÛ˘ ÎÚ˘ÛÙ¿ÏÏˆÓ Ù˘ÚÔÛ›Ó˘ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ ¯ÈÙÒÓ·. ∏ ÈÛ¯˘Ú‹ ·Ó·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÙÔ˘ NTBC ÛÙËÓ 4-˘‰ÚÔ͢ Ê·ÈÓ˘ÏÔ˘ÚÔ˘‚È΋ ‰ÈÔ͢ÁÂÓ¿ÛË (HPPD), Ô˘ Â›Ó·È ÙÔ ÚÒÙÔ ¤Ó˙˘ÌÔ ÛÙÔ ÌÂÙ·‚ÔÏÈÎfi ÌÔÓÔ¿ÙÈ Ù˘ Ù˘ÚÔÛ›Ó˘, ·ԉ›¯ÙËÎÂ Î·È Û ·ÓıÚÒÈÓÔ Ë·ÙÈÎfi ÈÛÙfi (7). ∆Ô ÛÎÂÙÈÎfi ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ NTBC ‚·Û›˙ÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·Ó·ÛÙÔÏ‹ ÙÔ˘ ÂÓ˙‡ÌÔ˘ HPPD ÌÂÈÒÓÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÙÔÍÈÎÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ô˘ ·Ú¿ÁÔÓÙ·È ÌÂÙ¿ ·fi ¶·È‰È·ÙÚÈ΋ 2006;69:45-51

ÙÔ HPPD Ì ÌfiÓË Â›ÙˆÛË Ù· ·˘ÍË̤ӷ Â›‰· Ù˘ÚÔÛ›Ó˘ Ô˘ ‰ÂÓ ıˆÚÂ›Ù·È Ì›˙ÔÓ Úfi‚ÏËÌ· Û ·ÛıÂÓ›˜ Ô˘ ‹‰Ë ‚Ú›ÛÎÔÓÙ·È Û ‰›·ÈÙ· ÌÂȈ̤Ó˘ ÚfiÛÏ˄˘ Ù˘ÚÔÛ›Ó˘ (∂ÈÎfiÓ· 1). ŒÙÛÈ, ÙÔ 1991 ¯ÔÚËÁ‹ıËΠÙÔ NTBC ÁÈ· ÚÒÙË ÊÔÚ¿ Û ‚Ú¤ÊÔ˜ 2 ÌËÓÒÓ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ 1 Î·È ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (7). ∆· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÂÓÙ˘ˆÛȷο Î·È ¿ÌÂÛ· ÙfiÛÔ Û ÎÏÈÓÈÎfi fiÛÔ Î·È Û ‚ÈÔ¯ËÌÈÎfi Â›Â‰Ô Î·È Ë ¯ÔÚ‹ÁËÛË NTBC Û 4 ·ÎfiÌ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ 2-7 ¯ÚÔÓÒÓ Â›¯Â ÂÍ›ÛÔ˘ ηϿ ·ÔÙÂϤÛÌ·Ù·. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ÂÌÊ¿ÓÈÛ·Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÛÙ·‰È·Î‹ ÙÒÛË Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘. ªÂÙ¿ ·fi ÙË ‰ËÌÔÛ›Â˘ÛË ÙˆÓ ÚÒÙˆÓ ·˘ÙÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ‰ÈÂÍ‹¯ıË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ·fi ÙË ÛԢˉÈ΋ ÔÌ¿‰· ÙÔ˘ Gothenburg, Ô˘ Û˘ÓÙfiÓÈÛ ÙfiÛÔ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ fiÛÔ Î·È ÙË Ì¤ÙÚËÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ Î·È ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Û ÎÔÈÓ‹ ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ Gothenburg. ™ÙÔ ÚˆÙfiÎÔÏÏÔ ·˘Ùfi Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ¿Óˆ ·fi 300 ·ÛıÂÓ›˜, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÛÛfiÙÂÚÔÈ ·fi 100 Ï·Ì‚¿ÓÔ˘Ó NTBC ÁÈ· ¿Óˆ ·fi 5 ¯ÚfiÓÈ· (9). ªÂÙ¿ ·fi 9 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙÔ ÚˆÙfiÎÔÏÏÔ, ÔÈ Holme Î·È Lindstedt ·Ó·ÎÔ›ÓˆÛ·Ó fiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏÏ· ÂÚÈÛÙ·ÙÈο Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ ÛÙ· ¿ÙÔÌ· ÛÙ· ÔÔ›· ÍÂΛÓËÛ·Ó ·ÁˆÁ‹ ¤ÁηÈÚ·, ÂÎÙfi˜ ·fi ‰‡Ô ·ÛıÂÓ›˜ (1%) Ô˘ ÂÌÊ¿ÓÈÛ·Ó Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ ÚÈÓ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 2 ¯ÚfiÓˆÓ, Ô ¤Ó·˜ ·fi ·˘ÙÔ‡˜ ηٿ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ∞ÓÙ›ıÂÙ·, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηı˘ÛÙÂÚË̤ÓË ıÂÚ·›· Ì NTBC, ıˆÚÔ‡Ó fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜ Î·È ı· Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌ¿Ù·È Ì ÙÔÓ Ê·ÈÓfiÙ˘Ô Î·È ÙË ÁÂÓÈ΋ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË Î¿ı ·ÛıÂÓ‹. ∂ÈϤÔÓ, ηӤӷ˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì NTBC ‰ÂÓ ÂÌÊ¿ÓÈÛ Ó¢ÚÔÏÔÁÈΤ˜ ÎÚ›ÛÂȘ Ù‡Ô˘ ÔÚÊ˘Ú›·˜, Ô˘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ ‰Ú·Ì·ÙÈ΋ Î·È ‰˘ÓËÙÈο ı·Ó·ÙËÊfiÚ· ÂÈÏÔ΋ Ù˘ Ù˘ÚÔÛÈÓ·ÈÌ›·˜. √È ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ‹Ù·Ó ÂÏ¿¯ÈÛÙ˜, ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙËÓ ÂÌÊ¿ÓÈÛË ıÔÏÂÚfiÙËÙ·˜ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ ÏfiÁˆ ÂÓ·fiıÂÛ˘ ÎÚ˘ÛÙ¿ÏÏˆÓ Ù˘ÚÔÛ›Ó˘ (9). ∏ ¯ÔÚ‹ÁËÛË NTBC ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘ ¤ÁÈÓ ۇÌʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ÙˆÓ ™Ô˘Ë‰ÒÓ ÂÚ¢ÓËÙÒÓ. ∏ ıÂÚ·›· ÍÂΛÓËÛ ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ÙË ‰È¿ÁÓˆÛË Û ËÏÈΛ· 5 ÌËÓÒÓ, Ë ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó ÂÓÙ˘ˆÛȷ΋, ÂÓÒ Ù·


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

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51

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Â›‰· Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘ Â·Ó‹Ïı·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÌÂÙ¿ ·fi ¤Ó·Ó ¯ÚfiÓÔ ıÂÚ·›·˜. √ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰‡Ô Î·È ÙÚ›· ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ¤‰ÂÈÍ ۷ʋ ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÂÈÎfiÓ·˜. √ ·ÛıÂÓ‹˜ Ì·˜ ‰ÂÓ ¤¯ÂÈ ÂÌÊ·Ó›ÛÂÈ Ó¢ÚÔÏÔÁÈΤ˜ ÎÚ›ÛÂȘ Ù‡Ô˘ ÔÚÊ˘Ú›·˜, ÁÂÁÔÓfi˜ Ô˘ Û˘ÓËÁÔÚ› fiÙÈ ÙÔ NTBC ÚÔÛٷهÂÈ ·fi ·˘Ù‹ ÙËÓ ÂÈÏÔ΋ Î·È ÂÈϤÔÓ, ‰ÂÓ ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ Î·Ì›· ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ·fi ÙË ıÂÚ·›· ̤¯ÚÈ Û‹ÌÂÚ·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÂÎÙfi˜ ·fi ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (Ô˘ ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜), ÛÙfi¯Ô˜ Ù˘ ‰›·ÈÙ·˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì NTBC Â›Ó·È Ë ‰È·Ù‹ÚËÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ Ù˘ÚÔÛ›Ó˘ οو ·fi 500 Ìmol/L, ÁÈ· Ó· ÚÔÏËÊı› Ë ÂÓ·fiıÂÛË ÎÚ˘ÛÙ¿ÏÏˆÓ Î˘ÛÙ›Ó˘ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹. √È ÂÓ·Ôı¤ÛÂȘ Ù˘ÚÔÛ›Ó˘ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ·›ÛıËÌ· η‡ÛÔ˘ Î·È ‰·ÎÚ‡ÚÚÔÈ·, ÁÈ' ·˘Ùfi ÔÈ ·ÛıÂÓ›˜ Ô˘ ·›ÚÓÔ˘Ó NTBC ı· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÔÓÙ·È ÔÊı·ÏÌÔÏÔÁÈο Û ٷÎÙ¿ ‰È·ÛÙ‹Ì·Ù· (·Ó¿ ÙÚ›ÌËÓÔ) Ì ۯÈÛÌÔÂȉ‹ Ï˘¯Ó›·. √ ·ÛıÂÓ‹˜ Ì·˜ ‰ÂÓ ·ÚÔ˘Û›·ÛÂ Û˘Ìو̷ÙÔÏÔÁ›· Ô‡Ù ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÛÙȘ ÂÚÈÔ‰ÈΤ˜ ÔÊı·ÏÌÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È Ô ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ‰ÂÓ Â›Ó·È ·ÚÎÂÙfi˜ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ÔÚÈÛÙÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÁÈ· ÙËÓ ·ÔÙÚÂÙÈ΋ ‰Ú¿ÛË ÙÔ˘ NTBC ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ ÛÙ· ·È‰È¿ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ÔÌ¿‰· ÙÔ˘ Gothenburg, ÌÂÏÂÙ¿Ù·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ NTBC ·fi ÙËÓ ÔÌ¿‰· ÙÔ˘ Quebec, ÏfiÁˆ ÙˆÓ È‰È·›ÙÂÚˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÚ¢ÓÒÓÙ·È ÂΛ (3). ∂›Ó·È ·Ó·Áη›· Ë Û˘ÌÌÂÙÔ¯‹ fiÏˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì Ë·ÙÔÓÂÊÚÈ΋ Ù˘ÚÔÛÈÓ·ÈÌ›· ÛÙ· ÚˆÙfiÎÔÏÏ· ıÂÚ·›·˜ Î·È ·Ú·ÎÔÏÔ‡ıËÛ˘, ÁÈ· ÙË Û˘ÏÏÔÁ‹ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚˆÓ ÏËÚÔÊÔÚÈÒÓ ÁÈ· ÙË ÓfiÛÔ Î·È ÙË Ì·ÎÚÔ¯ÚfiÓÈ· Â›‰Ú·ÛË ÙÔ˘ NTBC. ∏ ·Ó¿Ù˘ÍË Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘, Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÔÓÙÈÎÒÓ Ì ·ÓÂ¿ÚÎÂÈ· FAH ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¯ÔÚËÁ‹ıËΠNTBC, ·ÔÙÂÏ› ·fi‰ÂÈÍË fiÙÈ ÔÈ ·ÛıÂÓ›˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ π ˘fi ·ÁˆÁ‹ Ì NTBC ı· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÂÓ¿ ÁÈ· Ù˘¯fiÓ ·Ó¿Ù˘ÍË Î·ÚΛÓÔ˘ (1,13). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ì¤¯ÚÈ Û‹ÌÂÚ· ¿ÚÈÛÙË ÎÏÈÓÈ΋ Î·È ÂÚÁ·ÛÙËÚȷ΋ ÔÚ›· ÙÔ˘ ·ÛıÂÓ‹ Ì·˜ ÂÓÈÛ¯‡Ô˘Ó Ù· ·ÈÛÈfi‰ÔÍ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ÁÈ· Ù· ıÂÚ·¢ÙÈο ·ÔÙÂϤÛÌ·Ù· ÙÔ˘

NTBC Û ·ÛıÂÓ›˜ ÌÂ Ù˘ÚÔÛÈÓ·ÈÌ›· Ù‡Ô˘ 1. º·›ÓÂÙ·È fiÙÈ Î·ıÔÚÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ Î·Ï‹ ÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Ì ·Ú·ÎÔÏÔ‡ıËÛË ‚¿ÛÂÈ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÚˆÙÔÎfiÏÏÔ˘ Ù˘ ÔÌ¿‰·˜ ÙÔ˘ Gothenburg, Ô˘ ÚÔ¸Ôı¤ÙÂÈ Î·Ï‹ Û˘ÓÂÚÁ·Û›· ÙˆÓ ‰È·ÊfiÚˆÓ ÂȉÈÎÒÓ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Mitchell G, Grompe M, Lambert M, Tanguay R. Hypertyrosinemia. In: Scriver RC, Beaudet A, Sly WS, Valle D eds. The Metabolic and Molecular Bases of Inherited Disease. 8th ed. New York: McGrawHill; 2001. p. 1777-1806. 2. Russo PA, Mitchell GA, Tanguay RM. Tyrosinemia: a review. Pediatr Dev Pathol 2001;4(3):212-221. 3. Paradis K. Tyrosinemia: the Quebec experience. Clin Invest Med 1996;19:311-316. 4. Holme E, Lindstedt S. Tyrosinaemia type I and NTBC (2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione). J Inherit Metab Dis 1998;21:507-517. 5. Wijburg FA, Reitsma WC, Slooff MJ, van Spronsen FJ, Koetse HA, Reijngoud DJ et al. Liver transplantation in tyrosinaemia type I: the Groningen experience. J Inherit Metab Dis 1995;18:115-118. 6. Holme E, Lindstedt S. Diagnosis and management of tyrosinemia type I. Curr Opin Pediatr 1995;7:726-732. 7. Lock EA, Ellis MK, Gaskin P, Robinson M, Auton TR, Provan WM et al. From toxicological problem to therapeutic use: the discovery of the mode of action of 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC), its toxicology and development as a drug. J Inher Metab Dis 1998;21:498-506. 8. Lindstedt S, Holme E, Lock EA, Hjalmarson O, Strandvik B. Treatment of hereditary tyrosinemia type I by inhibition of 4-hydroxyphenylpyruvate dioxygenase. Lancet 1992;340:813-817. 9. Holme E, Lindstedt S. Nontransplant treatment of tyrosinemia. Clin Liver Dis 2000;4:805-814. 10. van Spronsen FJ, Thomasse Y, Smit GP, Leonard JV, Clayton PT, Fidler V et al. Hereditary tyrosinemia type I: a new clinical classification with difference in prognosis on dietary treatment. Hepatology 1994; 20: 1187-1191. 11. ∆ÛÈ·Ú¿˙Ë-™Ù¿ÌÔ˘ ª, §·Ê·˙¿Ó˘ µ, ™·‚‚ÔÔ‡ÏÔ˘-∞˘ÁÔ˘ÛÙ›‰Ô˘ ¶, Sewell A, Berger Rª, ¶·ÈÔÓ›‰Ë˜ ∞. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∆˘ÚÔÛÈÓ·ÈÌ›·˜ Ù‡Ô˘ π. ¶·È‰È·ÙÚ µ ∂ÏÏ¿‰·˜ 1997;9:257-261. 12. Bergeron A, D'Astous M, Timm DE, Tanguay RM. Structural and functional analysis of missense mutations in fumarylacetoacetate hydrolase, the gene deficient in hereditary tyrosinemia type 1. J Biol Chem. 2001;276:15225-15231. 13. Grompe M, Overturf K, Al-Dhalimy M, Finegold. Therapeutic trials in the murine model of hereditary tyrosinemia type I: A progress report. J Inherit Metab Dis 1998;21:518-531. ¶·È‰È·ÙÚÈ΋ 2006;69:45-51


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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

Schimke ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›·. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ 1 ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 2 ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 3 ∞ÓÔÛÔÏÔÁÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 4 ¡ÂÊÚÔ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∆Ì‹Ì·, ¡ÔÛÔÎÔÌÂ›Ô “∂˘·ÁÁÂÏÈÛÌfi˜”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ŒÏÂÓ· ºÚ˘Û›Ú· ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∆.∫. 115 27, ∞ı‹Ó· E-mail: efrysira@cc.uoa.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-11-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 21-09-2005

1 Medical Genetics Laboratory, University of Athens, “Aghia Sophia” Children's Hospital, Athens 2 Department of Paediatric Nephrology, “Aghia Sophia” Children's Hospital, Athens 3 Department of Immunology, “Aghia Sophia” Children's Hospital, Athens 4 Department of Renal Pathology, “Evaggelismos” General Hospital, Athens Correspondence: Helen Fryssira Medical Genetics Laboratory, Choremio Research Laboratory, “Aghia Sophia” Children's Hospital, 115 27, Athens E-mail: efrysira@cc.uoa.gr Date of submission: 15-11-2004 Date of approval: 21-09-2005

¶·È‰È·ÙÚÈ΋ 2006;69:52-58

™. æÒÓË1, ∂. °ÂˆÚÁ¿ÎË2, ∞. ∫·fiÁÈ·ÓÓ˘2, ∞. ™·Ï·‚Ô‡Ú·3, ª. ∫·Ó¿ÚÈÔ˘3, º. ™fiÙÛÈÔ˘4, Œ. ºÚ˘Û›Ú·1

¶ÂÚ›ÏË„Ë:∏ ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›· Ù‡Ô˘ Schimke (Schimke immuno-osseous dysplasia SIOD, Online Mendelian Inheritance In Man, website: http://www.ncbi.nlm.nih.gov/htbinpost/OMIM; OMIM:242900) Â›Ó·È Û¿ÓÈÔ ÁÂÓÂÙÈÎfi ÓfiÛËÌ· Ô˘ ÎÏËÚÔÓÔÌÂ›Ù·È Ì ˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·, ÙÔ ÔÔ›Ô ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÛÔÓ‰˘ÏÔ-ÂÈÊ˘Ûȷ΋ ‰˘ÛÏ·Û›·, ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÂÏ·Ùو̷ÙÈ΋ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· Î·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ê·ÈÓfiÙ˘Ô Ì ‰˘Û·Ó¿ÏÔÁÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ÙÚÈÁˆÓÈÎfi ÚfiÛˆÔ, ·ÔÛÙÚÔÁÁ˘ÏÂ̤ÓË Ì‡ÙË Î·È ˘Âگڈ̷ÙÈΤ˜ ÎËÏ›‰Â˜ ÛÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ·. ∆Ô ˘‡ı˘ÓÔ ÁÔÓ›‰ÈÔ ¤¯ÂÈ ¯·ÚÙÔÁÚ·ÊËı› ÚfiÛÊ·Ù·. ∏ SIOD Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ÔÛÙÈ΋˜ ‰˘ÛÏ·Û›·˜, ηıÒ˜ Û˘Ó‰˘¿˙ÂÙ·È Ì ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË, ÏfiÁˆ ÛÔ‚·Ú‹˜ ‚Ï¿‚˘ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ Î·È ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÓÂÊÚÒÓ. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 3 ÂÙÒÓ, ÙÔ ÔÔ›Ô ÚÔÛ‹Ïı ÏfiÁˆ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Î·È ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜. §¤ÍÂȘ ÎÏÂȉȿ: Schimke ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›·, ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, ȉȿ˙ÔÓ ÚÔÛˆ›Ô.

Schimke immuno-osseous dysplasia. Case report and review of the literature S. Psoni1, H. Georgaki2, A. Kapogiannis2, A. Salavoura3, M. Kanariou3, F. Sotsiou4, H. Fryssira1

Abstract: Schimke immuno-osseous dysplasia (SIOD) [(Schimke immuno-osseous dysplasia SIOD, Online Mendelian Inheritance In Man, website: http://www.ncbi.nlm.nih.gov/htbinpost/OMIM; OMIM:242900)] is a rare autosomal recessive disorder characterized by spondyloepiphyseal dysplasia, renal failure, defective cellular immunity and distinct phenotype with disproportionate short stature, triangular face, bulbous nose and abdominal pigmented spots. The responsible gene has been mapped recently. SIOD must be included in the differential diagnosis of cases with growth retardation and osseous dysplasia, as the prognosis can be poor, because of severe damage of the cellular immunity and renal insult. A case of a three year-old boy with short stature and proteinuria, characteristic features in this condition, is described. Key words: Schimke immuno-osseous dysplasia, proteinuria, dysmorphic features.

™˘ÓÙÔÌÔÁڷʛ˜ √ªπª SIOD ∂∫∞ KO¶ ª™ ¶∫ ∂£ µ™ À™ PHA FSGS

Online Mendelian inheritance in man Schimke immuno-osseous dysplasia ∂Ó‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ·Ó¿Ù˘Í˘ ∫˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ª‹ÎÔ˜ ÛÒÌ·ÙÔ˜ ¶ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ∂ηÙÔÛÙÈ·›· ı¤ÛË µ¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ⁄„Ô˜ ÛÒÌ·ÙÔ˜ Phytohemagglutinin Focal segmental glomerular sclerosis (ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË)

G-CSF

Granulocyte-colony stimulating factor (‰ÈÂÁÂÚÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ·ÔÈÎÈÒÓ ÙˆÓ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ) GM-CSF Granulocyte-monocyte-colony stimulating factor (‰ÈÂÁÂÚÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ·ÔÈÎÈÒÓ ÙˆÓ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ-ÌÔÓÔ΢ÙÙ¿ÚˆÓ)

∂ÈÛ·ÁˆÁ‹ ∏ ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›· Ù‡Ô˘ Schimke (Schimke immuno-osseous dysplasia - SIOD, √ªπª: 242900) Â›Ó·È Ì›· Û¿ÓÈ· ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ ÎÏËÚÔÓÔÌÂ›Ù·È ÌÂ


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Schimke ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›·

˘ÔÏÂÈfiÌÂÓÔ ·˘ÙÔۈ̷ÙÈÎfi ¯·Ú·ÎÙ‹Ú·. √Ê›ÏÂÙ·È Û ÌÂÙ¿ÏÏ·ÍË ÂÓfi˜ Ú˘ıÌÈÛÙÈÎÔ‡ ÁÔÓȉ›Ô˘ Ô˘ ·Ó·Î·Ï‡ÊıËΠÚfiÛÊ·Ù· Î·È ¤¯ÂÈ Û¯¤ÛË Ì ÙËÓ ·Ó·‰ÈÔÚÁ¿ÓˆÛË Ù˘ ¯ÚˆÌ·Ù›Ó˘ (chromatin remodelling) (1). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÂÚÈÏ·Ì‚¿ÓÂÈ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Ê·ÈÓfiÙ˘Ô, ÛÔÓ‰˘ÏÔÂÈÊ˘Ûȷ΋ ‰˘ÛÏ·Û›· Ì Â·ÎfiÏÔ˘ıÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, ‰È·Ù·Ú·¯‹ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ Î·È ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘ (2). ¢È·¯ˆÚ›˙ÂÙ·È ·‰Ú¿ Û ‰‡Ô Ù‡Ô˘˜: ·) ‚ÚÂÊÈÎfi˜ Ù‡Ô˜, Ì ηı˘ÛÙ¤ÚËÛË ÂÓ‰ÔÌ‹ÙÚÈ·˜ ·Ó¿Ù˘Í˘, ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÚÒÈÌË ıÓËÛÈÌfiÙËÙ· Î·È ıÓËÙfiÙËÙ· Î·È ‚) ÂÊË‚ÈÎfi˜ Ù‡Ô˜ (8-13 ¤ÙË), Ô˘ ¤¯ÂÈ ËÈfiÙÂÚË ÎÏÈÓÈ΋ ‰È·‰ÚÔÌ‹, Ì ÚÔ˚Ô‡Û· ÓÂÊÚÈ΋ ‚Ï¿‚Ë, ·Ó·ÛÙÔÏ‹ ·‡ÍËÛ˘ ηٿ ÙËÓ ÂÊ˂›· Î·È ÌÂÁ·Ï‡ÙÂÚË ÂÈ‚›ˆÛË (3). ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 3 ÂÙÒÓ Ì ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ÙÔ ÂÍ·ÈÚÂÙÈο Û¿ÓÈÔ ·˘Ùfi ÁÂÓÂÙÈÎfi ÓfiÛËÌ·, ÂÓÒ Á›ÓÂÙ·È ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î·È ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜.

¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 3 ÂÙÒÓ ÚÔÛ‹Ïı ÛÙÔ ¶·È‰ÔÓÂÊÚÔÏÔÁÈÎfi ∆Ì‹Ì· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ηÙfiÈÓ ·Ú·ÔÌ‹˜ ·fi Â͈ÙÂÚÈÎfi È·ÙÚfi ÁÈ· ¤ÏÂÁ¯Ô ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. ™˘Á¯ÚfiÓˆ˜, fï˜, ·Ú·ÙËÚ‹ıËΠ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È Î¿ÔÈ· ȉȷ›ÙÂÚ· ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ·Ú·¤ÌÊıËΠÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË ÛÙÔ È·ÙÚÂ›Ô °ÂÓÂÙÈ΋˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ÚÒÙÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, ÌË Û˘ÁÁÂÓÒÓ ÌÂٷ͇ ÙÔ˘˜ Î·È Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi. ∆Ô ÌÈÎÚfiÙÂÚÔ ·‰ÂÏÊ¿ÎÈ ÙÔ˘ ‹Ù·Ó ˘ÁȤ˜. ∞fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·Ó·Ê¤ÚÂÙ·È fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ (28Ë Â‚‰ÔÌ¿‰·) ›¯Â ‰È·ÈÛÙˆı› ˘ÂÚ˯ÔÁÚ·ÊÈο ÔÏÈÁÔ¸‰Ú¿ÌÓÈÔ. √ ·ÛıÂÓ‹˜ ÁÂÓÓ‹ıËΠ̠ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÙËÓ 36Ë Â‚‰ÔÌ¿‰· Ù˘ ΢‹Ûˆ˜, ÏfiÁˆ ∂∫∞ (‚¿ÚÔ˜ Á¤ÓÓËÛ˘: 2000 g), ÂÓÒ Ù· ˘fiÏÔÈ· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· ‹Ù·Ó ÛÙ· ηÙÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (ª™: 48 cm Î·È ¶∫: 32,5 cm ÛÙËÓ 3Ë ∂£). ™Â ËÏÈΛ· 37 ËÌÂÚÒÓ ·ÚÔ˘Û›·Û ԢÚÔÏԛ̈ÍË. √ ¤ÏÂÁ¯Ô˜ Ô˘ ·ÎÔÏÔ‡ıËÛ ¤‰ÂÈÍ ΢ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË 4Ô˘-5Ô˘ ‚·ıÌÔ‡ ‰ÂÍÈ¿ Î·È 2Ô˘ ‚·ıÌÔ‡ ·ÚÈÛÙÂÚ¿, ÁÈ· ÙËÓ ÔÔ›· ¤Ï·‚ ¯ËÌÂÈÔÚÔʇϷÍË. ∞fi ÙÔÓ 8Ô Ì‹Ó· ·Ú·ÙËÚ‹ıËΠ‚Ú·¯˘ÛˆÌ›· (À™: 63 cm, <3Ë E£), ÂÓÒ ÙÔ µ™ Î·È Ë ¶∫ ·Ú¤ÌÂÓ·Ó ÛÙËÓ 3Ë ∂£. ™Â ËÏÈΛ· 1,5 ¤ÙÔ˘˜, ÏfiÁˆ ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜,

¤ÁÈÓ ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜, Ô ÔÔ›Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∆ÔÓ ÙÂÏÂ˘Ù·›Ô ¯ÚfiÓÔ ·Ó·Ê¤ÚÔÓÙ·Ó Â›Û˘ Û˘¯Ó¿ ÂÂÈÛfi‰È· ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È ÏÔÈÌÒÍÂˆÓ ·Ó·Ó¢ÛÙÈÎÔ‡. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Û ËÏÈΛ· 3 ÂÙÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ µ™ ‹Ù·Ó 10.700 g (3Ë-10Ë ∂£), ÙÔ À™ ‹Ù·Ó 81 cm (3Ë ∂£) Î·È Ë ¶∫ ‹Ù·Ó 47 cm (<3Ë ∂£). º·ÈÓÔÙ˘Èο, ·ÚÔ˘Û›·˙ ÙÚÈÁˆÓÈÎfi Û¯‹Ì· ÚÔÛÒÔ˘, ÂÌ‚¿ı˘ÓÛË ÔÊı·ÏÌÒÓ, ‹ÈÔ Ô›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ, ÚÔ¤¯Ô˘Û· ̇ÙË Ì ¢Ú›· Á¤Ê˘Ú· Î·È Ï·Ù‡ ·ÎÚÔÚÚ›ÓÈÔ, ıÔψً ˘ÂÚÒ· Î·È Ì·ÎÚ‡ ÏÂÙfi ¿Óˆ ¯Â›ÏÔ˜. √ ·˘¯¤Ó·˜ ‹Ù·Ó ÎÔÓÙfi˜, Ô ÎÔÚÌfi˜ ‚Ú·¯‡˜ ΢ÏÈÓ‰ÚÈÎfi˜ (barrel chest) Î·È Ë ÎÔÈÏ›· ÚÔ¤¯Ô˘Û·. ∂›¯Â ÔÛÊ˘˚΋ ÏfiÚ‰ˆÛË Î·È ÌÈÎÚ‹ ‰˘Û·Ó·ÏÔÁ›· ÎÔÚÌÔ‡-¿ÎÚˆÓ (∂ÈÎfiÓ˜ 1, 2). ™ÙÔ ‰¤ÚÌ· ÂÌÊ¿ÓÈ˙ ˘Âگڈ̷ÙÈΤ˜ ÎËÏ›‰Â˜, ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ Î·È ‰È·ÊfiÚÔ˘ Û¯‹Ì·ÙÔ˜, ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó›˜ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÎÔÈÏ›·˜ (∂ÈÎfiÓ· 3). ∆Ô ÓÔËÙÈÎfi Â›Â‰Ô ‹Ù·Ó Ôχ ηÏfi, ÂÓÒ Ë ÊˆÓ‹ ‹Ù·Ó ˘„›Û˘¯ÓË (high pitched voice). ∞fi ÙÔÓ ·Ú¯ÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, Ë ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ¤‰ÂÈÍ ‹È· ÏÂÌÊÔÂÓ›· Î·È Ï¢ÎÔÂÓ›·: §Â˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·: 4x103/ÌL, Ô˘‰ÂÙÂÚfiÊÈÏ·: 46%, ÏÂÌÊÔ·ÙÙ·Ú·: 36%, ÌÔÓÔ·ÙÙ·Ú·: 8%, ¿Ù˘· ÏÂÌÊÔ·ÙÙ·Ú·: 10%. √ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜, ÂÎÙfi˜ ·fi ÙËÓ ÂÏ·ÊÚ¿ ·˘ÍË̤ÓË ¯ÔÏËÛÙÂÚfiÏË: 255 mg/dL. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÈÛÙÒıËÎÂ, ÂÎÙfi˜ Ù˘ ∫√¶, ÌÈÎÚÔÛÎÔÈ΋ ·ÈÌ·ÙÔ˘Ú›· (Ì ‰È·Î˘Ì¿ÓÛÂȘ Ù˘ ٿ͈˜ ÙˆÓ 10-30 ÂÚ˘ıÚÒÓ Î·Ù¿ ÔÙÈÎfi ‰›Ô) Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·. ∆Ô Ï‡Έ̷ Ô‡ÚˆÓ 24ÒÚÔ˘ ‹Ù·Ó 1,2 g. §fiÁˆ ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ¤ÁÈÓ ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜: 1) ¿ÎÚ·˜ ¯ÂÈÚfi˜, Ô˘ ¤‰ÂÈÍ fiÙÈ Ë ÔÛÙÈ΋ ËÏÈΛ· Û˘Ì‚¿‰È˙ Ì ÙË ¯ÚÔÓÔÏÔÁÈ΋. 2) ·fi ÙÔÓ ÏÔÈfi ÛÎÂÏÂÙfi ·Ú·ÙËÚ‹ıËΠÌÈÎÚfi ‡„Ô˜ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ Ì ‚Ú·¯‡ÙÂÚÔ ÙÔ Ô›ÛıÈÔ ÙÌ‹Ì· ·˘ÙÒÓ, ÚfiÛıÈ· οو ÁˆÓ›ˆÛË ÙÔ˘ √2 ÛÔÓ‰‡ÏÔ˘, ˘ÔÏ·Û›· Ï·ÁÔÓ›ˆÓ, ·ÓˆÌ·Ï›· Ù˘ ·Ú˘Ê‹˜ Ù˘ ÎÔÙ‡Ï˘ Î·È ÙÔ˘ ¿Óˆ ¯Â›ÏÔ˘˜ ÙˆÓ ÌÂٷʇÛÂˆÓ ˆ˜ Î·È ·ÓÂ·Ú΋˜ Û¯ËÌ·ÙÈÛÌfi˜ ÙˆÓ ÂÈʇÛÂˆÓ ÙˆÓ ÌËÚÈ·›ˆÓ ÔÛÙÒÓ (∂ÈÎfiÓ˜ 4, 5, 6). §fiÁˆ Ù˘ ∫√¶ ¤ÁÈÓ ·ÓÈÔ‡Û· ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Ô˘ ¤‰ÂÈÍ ‚ÂÏÙ›ˆÛË Ù˘ ·ÏÈÓ‰ÚfiÌËÛ˘. √ ÂÓ‰ÔÎÚÈÓÔÏÔÁÈÎfi˜ Â·Ó¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍ ˘ÂÚÌÂÙÚˆ›· Î·È ·ÛÙÈÁÌ·ÙÈÛÌfi. §fiÁˆ ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÂÛÙ¿ÏËÛ·Ó ‚ÏÂÓÓÔÔÏ˘Û·Î¯·Ú›Ù˜ Ô‡ÚˆÓ Ô˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎÔ›. √ ηڢfiÙ˘Ô˜ ‹Ù·Ó 46,ÃÀ, Ê˘ÛÈÔÏÔÁÈÎÔ‡ ¿ÚÚÂÓÔ˜. §fiÁˆ ÙˆÓ ¶·È‰È·ÙÚÈ΋ 2006;69:52-58


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

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¶·È‰È·ÙÚÈ΋ 2006;69:52-58

™. æÒÓË Î·È Û˘Ó.

∂ÈÎfiÓ· 1. º·›ÓÂÙ·È ÙÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ· ÙÔ˘ ·ÛıÂÓ‹, ÙÔ È‰ÈfiÌÔÚÊÔ ÚÔÛˆ›Ô, Ô Â˘Ú‡˜ ıÒڷη˜, Ë ÔÛÊ˘˚΋ ÏfiÚ‰ˆÛË, Ë ÚÔ¤¯Ô˘Û· ÎÔÈÏ›· Î·È Ù· ÌÂÁ¿Ï· ¯¤ÚÈ·.

∂ÈÎfiÓ· 2. ¶·Ú·ÙËÚÂ›Ù·È Ë ÔÛÊ˘˚΋ ÏfiÚ‰ˆÛË, Ô Î˘ÏÈÓ‰ÚÈÎfi˜ ıÒڷη˜ Î·È Ù· ÌÂÁ¿Ï· ¯¤ÚÈ·.

Û˘¯ÓÒÓ ÏÔÈÌÒÍÂˆÓ ¤ÁÈÓÂ Î·È Ï‹Ú˘ ·ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜: ·) √ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ·ÔÎ¿Ï˘„ ÛÔ‚·Ú‹ Ì›ˆÛË ÙˆÓ CD4 T ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ·‡ÍËÛË ÙˆÓ ˘Ô‰Ô¯¤ˆÓ TCRÁ‰ (CD4: 18%, CD3TCRÁ‰: 14% ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ <7,5). √È ‰Â›ÎÙ˜ ÙˆÓ µ ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ ·Ú¤ÌÂÈÓ·Ó ·ÓÂËÚ¤·ÛÙÔÈ, fiˆ˜ Â›Û˘ Î·È ÔÈ ‰Â›ÎÙ˜ ‰ÈÂÁ¤ÚÛˆ˜-ÂÓÂÚÁÔÔÈ‹Ûˆ˜. ‚) ™ÙȘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÔÚÔ‡ ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ IgG ÎÏ¿ÛÌ·ÙÔ˜: IgG: 521 mg/dl (Ê.Ù. 7001622). Á) ∆¤ÏÔ˜, ¤ÁÈÓÂ Î·È ‰È¤ÁÂÚÛË Î·ÏÏȤÚÁÂÈ·˜ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì ÙË ÌÈÙÔÁfiÓÔ Ô˘Û›· PHA Ë ÔÔ›· ¤‰ÂÈÍ ÛÙÔÓ ·ÛıÂÓ‹: 16.870 bits Ú·‰ÈÂÓ¤ÚÁÂÈ·˜ Î·È ÛÙÔÓ Ì¿ÚÙ˘Ú·: 110.650 bits Ú·‰ÈÂÓ¤ÚÁÂÈ·˜ (Ê.Ù. 60.000-150.000), ‰ËÏ·‰‹ ·Ú·ÙËÚ‹ıËΠÂÚ›Ô˘ ‰¤Î· ÊÔÚ¤˜ ¯·ÌËÏfiÙÂÚË ·¿ÓÙËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ۯ¤ÛË Ì ÙÔÓ Ì¿ÚÙ˘Ú·. ∂Ô̤ӈ˜, ÂȂ‚·ÈÒıËΠÛÙÔÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ Ë Ôχ ¯·ÌËÏ‹ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, ȉ›ˆ˜ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∏ ÁÂÓÈ΋ Ô‡ÚˆÓ ·Ó¿ ‰È·ÛÙ‹Ì·Ù· ¤‰ÂȯÓ 10-15 ÂÚ˘ıÚ¿ ηٿ ÔÙÈÎfi ‰›Ô, ÛÂÈÚ·Ì·ÙÈ΋˜ ÚÔ¤Ï¢Û˘, Î·È Ï‡Έ̷ (+), ÂÓÒ Û Â·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ Ï¢ÎÒÌ·ÙÔ˜ Ô‡ÚˆÓ

24ÒÚÔ˘, Ë ÙÈÌ‹ ÙÔ˘ Î˘Ì·ÈÓfiÙ·Ó ·fi 1,2 ¤ˆ˜ 1,5 g/24ˆÚÔ. ŒÏÂÁ¯Ô˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ¤‰ÂÈÍÂ: ۿί·ÚÔ: 80 mg/dl, ÔÏÈο Ï¢ÎÒÌ·Ù·: 5,4 g/dl, ÏÂ˘ÎˆÌ·Ù›ÓË: 3,4 g/dl, ¯ÔÏËÛÙÂÚ›ÓË: 218 mg/dl, ÙÚÈÁÏ˘ÎÂÚ›‰È·: 136 mg/dl, HDL: 62 mg/dl, LDL: 119 mg/dl, Ô˘Ú›·: 28 mg/dl, ÎÚ·ÙÈÓ›ÓË: 0,4 mg/dl, Ô˘ÚÈÎfi Ô͇: 3,6 mg/dl, SGOT: 48 mg/dl, SGPT: 17 mg/dl, ÁGT: 19 mg/dl, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË: 185 IU/dl, K+:4,1 mmoll/l, Na+:140 mmol/l, Cl-: 109 mmol/l, Ca oÏÈÎfi: 9 mg/dl, P: 4,2 mg/dl, Mg: 1,7 mg/dl. ¶ÚÔÁÚ·ÌÌ·Ù›ÛÙËΠ‚ÈÔ„›· ÓÂÊÚÔ‡, Ë ÔÔ›· ¤‰ÂÈÍ ÚÈÎÓˆÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ 68% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ Î·È ÂÓ·Ôı¤ÛÂȘ C3 ÛÙ· ·ÚÙËÚ›‰È· Î·È ÛÙËÓ Î¿„· ÙÔ˘ Bowman, Â˘Ú‹Ì·Ù· ·Ú¯fiÌÂÓ˘ ÂÛÙȷ΋˜ ÙÌËÌ·ÙÈ΋˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ (FSGS) (∂ÈÎfiÓ· 7). §fiÁˆ ÙˆÓ ÎÏÈÓÈÎÒÓ, ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ SIOD. °È· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ ÂÛÙ¿ÏË ‰Â›ÁÌ· ·›Ì·ÙÔ˜ ÛÙȘ ∏¶∞ ÁÈ· ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA ÛÙÔ ·È‰› Î·È ÛÙÔ˘˜ ÁÔÓ›˜. ∆· ÚÒÙ· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÂȂ‚·ÈˆÙÈο ÁÈ· ·ÚÔ˘Û›· ÂÙÂÚfi˙˘Á˘ ÌÂÙ¿ÏÏ·Í˘ 1736C>T, Ô˘ ·ÓȯÓ‡ıËΠÛÙÔ ÂÍÒÓÈÔ 11 ÙÔ˘ ÁÔÓȉ›Ô˘ SMARCAL1, Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ¿ÌÂÛÔ˘


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∂ÈÎfiÓ· 3. ¶ÚÔ¤¯Ô˘Û· ÎÔÈÏ›· Î·È ÌÂÏ·Á¯ÚˆÌ·ÙÈΤ˜ ÎËÏ›‰Â˜.

ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ·ÏÏËÏÔ˘¯›·˜ DNA (direct sequencing). √ ·Ù¤Ú·˜ Â›Ó·È ÂÙÂÚÔ˙˘ÁÒÙ˘ ÁÈ· ÙËÓ ›‰È· ÌÂÙ¿ÏÏ·ÍË. ∏ ÂͤٷÛË ‚Ú›ÛÎÂÙ·È ·ÎfiÌË Û ÂͤÏÈÍË ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ¿ÏÏ·Í˘ Î·È ÛÙÔ ·ÏÏËÏfiÌÔÚÊÔ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÌËÙ¤Ú·. ∏ ıÂÚ·›· ÙÔ˘ ·È‰ÈÔ‡ ̤¯ÚÈ Û‹ÌÂÚ· Â›Ó·È Û˘Ìو̷ÙÈ΋ Î·È ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Û˘ÛÙËÌ·ÙÈο ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ·Ó¿Ù˘Í˘ ‰Â˘ÙÂÚÔ·ıÒÓ ÂÈÏÔÎÒÓ.

™˘˙‹ÙËÛË ∏ ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›· Ù‡Ô˘ Schimke (Schimke immuno-osseous dysplasia, SIOD, √ªπª: 242900) ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1974 ·fi ÙÔÓ Schimke Û ¤Ó· ÎÔÚ›ÙÛÈ 6 ÂÙÒÓ Ô˘ ·ÚÔ˘Û›·˙ ÛÔÓ‰˘ÏÔÂÈÊ˘Ûȷ΋ ‰˘ÛÏ·Û›·, ÂÍÂÏÈÛÛfiÌÂÓË ÓÂÊÚÈ΋ ÓfiÛÔ, ÂӉ›ÍÂȘ ‰È·Ù·Ú·Á̤Ó˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ Î·È ·˘ÍË̤ÓË ·Ô‚ÔÏ‹ 6-ıÂÈÈ΋˜ ¯ÔÓ‰ÚÔ˚Ù›Ó˘ ÛÙ· Ô‡Ú· (2). §fiÁˆ ·˘ÙÔ‡ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ Â˘Ú‹Ì·ÙÔ˜, ıˆڋıËΠfiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ó¤Ô Ù‡Ô ‚ÏÂÓÓÔÔÏ˘Û·Î¯·Ú›‰ˆÛ˘, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ·ÚÁfiÙÂÚ· ‰ÂÓ Â·ÏËı‡ÙËÎÂ. ∆Ô 1991, ÔÈ Spranger Î·È Û˘Ó ÂÚȤÁÚ·„·Ó ¿ÏϘ ¤ÓÙ ·ÚfiÌÔȘ ÂÚÈÙÒÛÂȘ, ¯ˆÚ›˜ ·Ó›¯Ó¢ÛË ÌÂÙ·‚ÔÏÈÙÒÓ ÛÙ· Ô‡Ú·, ÂÓÒ Ô Spranger ‹Ù·Ó ·˘Ùfi˜ Ô˘ ¤‰ˆÛ ÙÔ fiÓÔÌ· SIOD ÛÙË ‰È·Ù·Ú·¯‹ (4). √Ê›ÏÂÙ·È Û ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ SMARCAL 1 (SW1/SNF2-related matrix-associated actindependent regulator of chromatin, sub-family alike 1), ÙÔ ÔÔ›Ô Îˆ‰ÈÎÔÔÈ› Ì›· Ú˘ıÌÈÛÙÈ΋ ÚˆÙ½ÓË Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Â·Ó·‰fiÌËÛË ÙÔ˘ ÓÔ˘ÎÏÂÔÛÒÌ·ÙÔ˜ (5). ∏ Â·Ó·‰fiÌËÛË ·˘Ù‹ ·Ú·ÙËÚÂ›Ù·È Û˘Ó‹ıˆ˜ ηٿ ÙË ÁÔÓȉȷ΋ Ú‡ıÌÈÛË, fiˆ˜ ÙÔÓ ·Ó·‰ÈÏ·ÛÈ·ÛÌfi, ÙÔÓ ·Ó·Û˘Ó‰˘·ÛÌfi, ÙË ÌÂı˘Ï›ˆÛË Î·È ÙËÓ ÂȉÈfiÚıˆ-

∂ÈÎfiÓ· 4. ∞ÎÙÈÓÔÁÚ·Ê›· ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘. ¶·Ú·ÙËÚÂ›Ù·È ÌÈÎÚfi ‡„Ô˜ ÛÔÓ‰˘ÏÈÎÒÓ ÛˆÌ¿ÙˆÓ, ÂȉÈο ÛÙÔ Ô›ÛıÈÔ Ì¤ÚÔ˜ ·˘ÙÒÓ. ¶ÚfiÛıÈ· οو ÁˆÓ›ˆÛË ÙÔ˘ √2.

ÛË ÙÔ˘ DNA. Œ¯ÂÈ ÚfiÛÊ·Ù· ¯·ÚÙÔÁÚ·ÊËı› ÛÙË ı¤ÛË 2q34-q36 Î·È ¤¯Ô˘Ó ÌÂÏÂÙËı› ·ÚÎÂÙ¤˜ ÌÂÙ·ÏÏ¿ÍÂȘ (1). ∏ ‡·ÚÍË ·ÚÎÂÙÒÓ Î·È ‰È·ÊfiÚˆÓ ÂȉÒÓ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔ ›‰ÈÔ ÁÔÓ›‰ÈÔ Ê·›ÓÂÙ·È fiÙÈ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ÎÏÈÓÈ΋ ÔÈÎÈÏÔÌÔÚÊ›· Î·È ÙËÓ ËÏÈΛ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ∏ ‡·ÚÍË ·ÚÂÚÌËÓ‡ÛÈÌ˘ (missense) ÌÂÙ¿ÏÏ·Í˘ ‚ÔËı¿ ÛÙË ‰È·Ù‹ÚËÛË Î¿ÔÈ·˜ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ SMARCAL1 ÁÔÓȉ›Ô˘ Î·È Ô‰ËÁ› Û ËÈfiÙÂÚË ÓfiÛÔ (ÂÊË‚ÈÎfi˜ Ù‡Ô˜), Û ·ÓÙ›ıÂÛË Ì ÙȘ ·ÓÂÚÌËÓ‡ÛÈ̘ (nonsense), Ï·ÈÛÈÔÙÚÔÔÔÈËÙÈΤ˜ (frameshift) ‹ ÌÂÙ·ÏÏ¿ÍÂȘ Ì·Ù›ÛÌ·ÙÔ˜ (splicing) Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÈÔ ÛÔ‚·Ú‹ Î·È ÂȉÂÈÓÔ‡ÌÂÓË ÔÚ›· (‚ÚÂÊÈÎfi˜ Ù‡Ô˜) (1,5). ∏ ·Ó›¯Ó¢ÛË ÛÙÔÓ ·ÛıÂÓ‹ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ Ù˘ ·ÚÂÚÌËÓ‡ÛÈÌ˘ ÌÂÙ¿ÏÏ·Í˘ 1736C>T Ô‰ËÁ› Û ·ÓÙÈηٿÛÙ·ÛË ÂÓfi˜ ·ÌÈÓÔͤԘ (S579L) ÛÙËÓ ¶·È‰È·ÙÚÈ΋ 2006;69:52-58


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∂ÈÎfiÓ· 5. ∞ÎÙÈÓÔÁÚ·Ê›· ÏÂοÓ˘-ÈÛ¯›ˆÓ. ¶·Ú·ÙËÚÂ›Ù·È ˘ÔÏ·Û›· Ï·ÁÔÓ›ˆÓ, ·ÓˆÌ·Ï›· Ù˘ ·Ú˘Ê‹˜ Ù˘ ÎÔÙ‡Ï˘.

ÚˆÙ½ÓË SMARCAL1. ∂›Ó·È Ë ‰Â‡ÙÂÚË ÊÔÚ¿ Ô˘ ·ÓȯÓ‡ÂÙ·È Ë Û˘ÁÎÂÎÚÈ̤ÓË ÌÂÙ¿ÏÏ·ÍË Û ·ÛıÂÓ‹ Ì SIOD (5). ∂Âȉ‹ ÙÔ ÓfiÛËÌ· Â›Ó·È ˘ÔÏÂÈfiÌÂÓÔ, Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚ˜ ‰È·ÊÔÚÂÙÈΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ ›‰ÈÔ ÁÔÓ›‰ÈÔ. Œˆ˜ ÙÒÚ· ‰ÂÓ ¤¯ÂÈ ·ÓȯÓ¢ı› Ë ‰Â‡ÙÂÚË ÌÂÙ¿ÏÏ·ÍË, Ô˘ ˘Ô¯ÚˆÙÈο Ú¤ÂÈ Ó·

∂ÈÎfiÓ· 6. ∞ÓÂ·Ú΋˜ Û¯ËÌ·ÙÈÛÌfi˜ ÙˆÓ ÂÈʇÛÂˆÓ Î·È ÙˆÓ ÌÂٷʇÛÂˆÓ ÙˆÓ ÌËÚÈ·›ˆÓ ÔÛÙÒÓ. ¶·È‰È·ÙÚÈ΋ 2006;69:52-58

∂ÈÎfiÓ· 7. µÈÔ„›· ÓÂÊÚÔ‡. ∞ÂÈÎÔÓ›˙ÂÙ·È ¤Ó· Û›ڷ̷ Ô˘ Û˘ÌʇÂÙ·È Ì ÙËÓ Î¿„· ÙÔ˘ Bowman Î·È ¤Ó· Ì ÚÈÎÓˆÙÈ΋ ÛÎÏ‹Ú˘ÓÛË. ∆· Ô˘ÚÔÊfiÚ· ÛˆÏËÓ¿ÚÈ· ÂÌÊ·Ó›˙Ô˘Ó ÂÛٛ˜ ·ÙÚÔÊ›·˜ Î·È ·ıÚÔ›ÛÂȘ ·ÔÊÔÏȉˆÌ¤ÓˆÓ ΢ÙÙ¿ÚˆÓ.

ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÌËÙ¤Ú·. °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ‰ÂÓ ÌÔÚ› Ó· Á›ÓÂÈ Ï‹Ú˘ Úfi‚ÏÂ„Ë Ù˘ ÎÏÈÓÈ΋˜ ¤ÎÊÚ·Û˘ ÛÙÔ ·È‰›. ∏ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓË. ∫·Ù¿ Ì›· ˘fiıÂÛË, Ù· ÁÔÓ›‰È· Ô˘ ÂËÚ¿˙ÔÓÙ·È ·fi ÙȘ ÌÂÙ·ÏÏ¿ÍÂȘ ÙÔ˘ SMARCAL1 Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË Î·È ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ¯ÔÓ‰ÚÔ΢ÙÙ¿ÚˆÓ, ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ›Ûˆ˜ ÙˆÓ ÌÂÏ·ÓÔ΢ÙÙ¿ÚˆÓ, ÂÓÒ ÌÂÚÈο ·fi ·˘Ù¿ ›Ûˆ˜ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙË Û˘ÓÙ‹ÚËÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ Î·È ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜. ø˜ ÚÔ˜ Ù· ÏÂÌÊÔ·ÙÙ·Ú·, ÈÛÙ‡ÂÙ·È fiÙÈ ˘¿Ú¯ÂÈ Î¿ÔÈ· ·ÓˆÌ·Ï›· ÛÙË ‰È·ÊÔÚÔÔ›ËÛË Î·È ‰È·ÏÔÁ‹ ÙˆÓ ∆΢ÙÙ¿ÚˆÓ ÛÙÔÓ ı‡ÌÔ ·‰¤Ó·, ÏfiÁˆ ·ÔÙ˘¯›·˜ Û‡Ó‰ÂÛ˘ ÙÔ˘ DNA ηٿ ÙȘ ·Ó·Î·Ù·Ù¿ÍÂȘ ÁÔÓȉ›ˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Ê˘ÛÈÔÏÔÁÈο Û ·˘Ù‹ ÙË ‰È·‰Èηۛ· (1). ™˘˙ËÙ›ٷÈ, Â›Û˘, Ë ˘fiıÂÛË fiÙÈ Ë ÓÂÊÚÈ΋ ‚Ï¿‚Ë Â›Ó·È ‰Â˘ÙÂÚÔÁÂÓ¤˜ Ê·ÈÓfiÌÂÓÔ, ÔÊÂÈÏfiÌÂÓÔ ÛÙËÓ ÂÏ·Ùو̷ÙÈ΋ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›·, Ë ÔÔ›· Úԉȷı¤ÙÂÈ Û ÏÔÈÌÒÍÂȘ Î·È ·ÎÔÏÔ‡ıˆ˜ Û ÂÓ·fiıÂÛË ·ÓÔÛÔÛ˘ÌÏÂÁÌ¿ÙˆÓ ÛÙÔÓ ÓÂÊÚÈÎfi ÈÛÙfi (1). ™Â ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ ·Ú·ÙËÚÂ›Ù·È ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›·, ÏfiÁˆ ·ÏÏÔ›ˆÛ˘ ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Â˘ıÚ·˘ÛÙfiÙËÙ· ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Î·È ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘¤ÚÙ·ÛË Î·È ÙËÓ ˘ÂÚÏÈȉ·ÈÌ›· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÓÂÊÚÈ΋ ‚Ï¿‚Ë (6,7). ªÂ›˙ÔÓ· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ SIOD ·ÔÙÂÏÔ‡Ó Ë ·Ó·ÛÙÔÏ‹ Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, Ë ·ÓÂ¿ÚÎÂÈ· Ù˘ ∆ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜, Ë ÚÔԉ¢ÙÈο ÂÍÂÏÈÛÛfiÌÂÓË ÓÂÊÚÔ¿ıÂÈ·, ÔÈ ˘Âگڈ̷ÙÈΤ˜ ÎËÏ›‰Â˜ ÛÙÔÓ ÎÔÚÌfi Î·È Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜. √È ÌÔÚÊÔÏÔÁÈΤ˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈΤ˜,


Pediatr Jan-Feb 06 final allges

27-01-06

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Schimke ·ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›·

¶›Ó·Î·˜ 1. ªÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛÒÔ˘ 1. ∂Ì‚¿ı˘ÓÛË ÔÊı·ÏÌÒÓ 2. ªÈÎÚ¤˜ ‚ÏÂÊ·ÚÈΤ˜ Û¯ÈṲ̂˜ 3. ÷ÌËÏ‹ Î·È Â˘Ú›· ÚÈÓÈ΋ Á¤Ê˘Ú· 4. ∞ÔÛÙÚÔÁÁ˘ÏÂ̤ÓÔ ·ÎÚÔÚÚ›ÓÈÔ 5. ªÈÎÚÔ‰ÔÓÙ›· 6. ª·ÎÚ‡ ¿Óˆ ¯Â›ÏÔ˜ 7. À„›Û˘¯ÓË ÊˆÓ‹ (high pitched voice) 8. ∂Ûٛ˜ ıÔÏÂÚfiÙËÙ·˜ ÛÙÔÓ ÎÂÚ·ÙÔÂȉ‹ ¯ÈÙÒÓ· 9. §ÂÙ¿ Ì·ÏÏÈ¿

fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Î·È ‰È·ÈÛÙÒıËÎ·Ó Î·È ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜ (∂ÈÎfiÓ˜ 1, 2, 3) (8). ∆· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÂȂ‚·ÈÒÓÔ˘Ó ÙË ÛÔÓ‰˘ÏÔÂÈÊ˘Ûȷ΋ ‰˘ÛÏ·Û›· (ˆÔÂȉ›˜ ÔÈÛı›ˆ˜ ÂÈ‰ˆÌ¤ÓÔÈ ÛfiÓ‰˘ÏÔÈ, ˘ÔÏ·ÛÙÈ΋ ‡ÂÏÔ˜, ·ÓÒ̷Ϙ ÎÂʷϤ˜ ÌËÚÈ·›ˆÓ, ÔÛÙÂÔÂÓ›·, ıˆÚ·ÎÈ΋ ·ʈÛË) (∂ÈÎfiÓ˜ 4, 5, 6). ∏ ÚˆÙÂ˚ÓÔ˘Ú›· Ô˘ ·ÚÔ˘Û›·˙Â Ô ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘, ‹Ù·Ó ÛËÌ·ÓÙÈ΋ Î·È Ë ˘ÔΛÌÂÓË ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ô ÈÛÙÔÏÔÁÈÎfi˜ ·˘Ùfi˜ Ù‡Ô˜ Û˘¯Ó¿ Ô‰ËÁ› Û ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. √È ·ÁÁÂȷΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, ÚÔ‚¿ÏÏÔ˘Ó Ì ÎÂÊ·Ï·ÏÁ›Â˜ Ù‡Ô˘ ËÌÈÎÚ·Ó›·˜ ‹ Ì ·ÚÔ‰Èο ‹ Î·È ÌfiÓÈÌ· ÈÛ¯·ÈÌÈο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È· (6,8-10). ∏ MRI ·Ó·‰ÂÈÎÓ‡ÂÈ ÂÍÂÏÈÛÛfiÌÂÓ˜ ·ÏÏÔÈÒÛÂȘ Ù˘ Ï¢΋˜ Ô˘Û›·˜, Û˘Ì‚·Ù¤˜ Ì ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›·, ηıÒ˜ Â›Û˘ Î·È ÂÚÈÔ¯¤˜ ΢ÛÙÈ΋˜ ·ÏÏÔ›ˆÛ˘ (ÂÁÎÂÊ·ÏÔÌ·Ï¿Î˘ÓÛË ÌÂ Û˘Ó¤ÂÈ· οÔȘ ÊÔÚ¤˜ ÙË ÓÔË-

ÙÈ΋ ¤ÎÙˆÛË), ˆ˜ ÚÔ˚fiÓ ÂͤÏÈ͢ ÙÔ˘ ÈÛ¯·ÈÌÈÎÔ‡ ÂÌÊÚ¿ÎÙÔ˘ (3,7). ™·ÓÈfiÙÂÚ˜ ÂΉËÏÒÛÂȘ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ê·ÈÓfiÌÂÓ· ·˘ÙÔ·ÓÔÛ›·˜, fiˆ˜ ÂÓÙÂÚÔ¿ıÂÈ·, ·Ó·ÈÌ›·-ıÚÔÌ‚Ô΢ÙÙÔÂÓ›· Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÂ Ì˘ÂÏÈ΋ ·Ï·Û›· Î·È ·‡ÍËÛË ÙÔ˘ Ù›ÙÏÔ˘ ·ÓÙÈʈÛÊÔÏÈȉÈÎÒÓ Î·È ·ÓÙÈÁÏÈ·‰ÈÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (6,11). ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ Û ‚Ï¿‚Ë Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜, ÂÓÒ ÂÓ›ÔÙ ÛËÌÂÈÒÓÂÙ·È Î·È ˘ÔÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· (9). √ ·ÛıÂÓ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÂÚ›ÙˆÛ˘ ·ÚÔ˘Û›·Û Ì›ˆÛË ÙÔ˘ IgG ÎÏ¿ÛÌ·ÙÔ˜ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ. ∆Ô Â›‰Ô˜ Ù˘ ·ÓÂ¿ÚÎÂÈ·˜ ÙˆÓ ∆ ΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Ù˘ÈÎfi Ù˘ SIOD, ηıÒ˜ ·ÚÔ˘Û›·Û Ì›ˆÛË ÙˆÓ CD4+ Î·È CD3+/CD4+, ˘ÂÚ¤ÎÊÚ·ÛË ÙˆÓ Á‰ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ CD3 T ΢ÙÙ¿ÚˆÓ Î·È ÂÏ·Ùو̤ÓË ·ÓÙ·fiÎÚÈÛË Ù˘ ηÏÏȤÚÁÂÈ·˜ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û ∆-ÂȉÈΤ˜ ÌÈÙÔÁfiÓ˜ Ô˘Û›Â˜ (9). ∞fi ÙËÓ ÔÌ¿‰· ÙˆÓ µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÂÈÒÓÔÓÙ·È ÌfiÓÔ Ù· µ ÏÂÌÊÔ·ÙÙ·Ú· Ô˘ ÂÍ·ÚÙÒÓÙ·È ·fi Ù· ∆ ÏÂÌÊÔ·ÙÙ·Ú·. ∆· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ·Ú·Ì¤ÓÔ˘Ó Î·È ·˘Ù¿ ·ÓÂËÚ¤·ÛÙ· (9). ¶Ú¤ÂÈ Ó· ÛËÌÂȈı›, fï˜, fiÙÈ Ë ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·, ·Ó Î·È ÌÔÚ› Ó· Â›Ó·È ÛÔ‚·Ú‹ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘, ‰ÂÓ Î˘Úȷگ› ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ·Ú¿ ÌfiÓÔ ÌÂÙ¿ ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓıÂÎÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ (6,9). ∏ ÚfiÁÓˆÛË Â›Ó·È Î·Î‹. √È ÂÈÏÔΤ˜, fiˆ˜ Ë ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ë Ì˘ÂÏÈ΋ ·Ï·Û›·, ÔÈ ÛÔ‚·Ú¤˜ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ Î·È Ù·

¶›Ó·Î·˜ 2. ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·ÓÔÛÔ-ÔÛÙÈ΋˜ ‰˘ÛÏ·Û›·˜ Ù‡Ô˘ Schimke ¶·ı‹ÛÂȘ Ì ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È ÓÂÊÚÈ΋ Û˘ÌÌÂÙÔ¯‹

¶·ı‹ÛÂȘ Ì ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·

™. Jeune (asphyxiating thoracic dystrophy) µÚ·¯˘ÌÂÛÔÌÂÏ›· Ì ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· (brachymesomelia-renal dysplasia) ™. ªainzer-Saldino

∞ÓÂ¿ÚÎÂÈ· ‰Â·ÌÈÓ¿Û˘-·‰ÂÓÔÛ›Ó˘ ™. ÌÂÙ·Ê˘Ûȷ΋˜ ‰˘ÛÏ·Û›·˜‰˘Û·ÔÚÚfiÊËÛË˜Ô˘‰ÂÙÂÚÔÂÓ›·˜ ÀÔÏ·Û›· ¯fiÓ‰ÚˆÓÙÚȯˆÙÔ‡ ÎÂÊ·Ï‹˜ (cartilage-hair hypoplasia)

¡ÂÊÚÔÛÈ·Ï›‰ˆÛË (‹ ÛÈ·Ï›‰ˆÛË Ù‡Ô˘ ππ) ™. Wolkott-Rallison

¢˘ÛÏ·Û›· ıÒÚ·ÎÔ˜ ·fi ÙË Á¤ÓÓËÛË

∞ӈ̷ϛ˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Î·È ÔÙÈÎÔ‡ Ó‡ÚÔ˘

∞ÎÙÈÓÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÌÂÙ·Ê˘Ûȷ΋˜ ‰˘ÛÏ·Û›·˜, ‰È·Ù·Ú·¯‹ ΢Ù. ·ÓÔÛ›·˜, ÏÂÙ¿, ·Ú·È¿ Î·È ·ԯڈ̷ÙÈṲ̂ӷ Ì·ÏÏÈ¿

ªÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ· ¶ÚÒÈÌË ÂÌÊ¿ÓÈÛË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË

¶·ı‹ÛÂȘ Ì ÔÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, ÓÂÊÚÈ΋ Û˘ÌÌÂÙÔ¯‹ Î·È ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ· ∞ÓÔÛÔ-ÔÛÙÈ΋ ‰˘ÛÏ·Û›· Ù‡Ô˘ Schimke ¶·È‰È·ÙÚÈ΋ 2006;69:52-58


Pediatr Jan-Feb 06 final allges

27-01-06

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™. æÒÓË Î·È Û˘Ó.

ÂÁÎÂÊ·ÏÈο ¤ÌÊÚ·ÎÙ·, ·ÔÙÂÏÔ‡Ó ÙȘ ·Èٛ˜ ı·Ó¿ÙÔ˘. ∏ ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ Î·È È‰›ˆ˜ Ô ‚ÚÂÊÈÎfi˜ Ù‡Ô˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì IUGR, ¤¯ÂÈ Û˘Ó‹ıˆ˜ ‚·ÚÈ¿ ÂÍÂÏÈÛÛfiÌÂÓË ÔÚ›· Î·È ÌÈÎÚfiÙÂÚË ÂÈ‚›ˆÛË. ∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È ¤Ó· ÛËÌÂ›Ô ÔÚfiÛËÌÔ, ÁÈ·Ù› ·fi ÂΛ Î·È ÌÂÙ¿ Ë ÂͤÏÈÍË Ù˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ Â›Ó·È ÈÔ ÁÚ‹ÁÔÚË, Ì ·Ú¿ÏÏËϘ ÂÈÏÔΤ˜ ÏfiÁˆ Ù˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ (1,6). ∏ ÛÂÈÚ¿ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ Â›Ó·È: ·Ó·ÛÙÔÏ‹ ·‡ÍËÛ˘, ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, ·˘ÍË̤ÓË Â˘·ÈÛıËÛ›· ÛÙȘ ÏÔÈÌÒÍÂȘ Ô˘ ηٷϋÁÂÈ Û ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ Ì ‰˘ÛÌÂÓ‹ ¤Î‚·ÛË. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 2, ÂÚÈÏ·Ì‚¿ÓÂÈ Î·Ù·ÛÙ¿ÛÂȘ fiÔ˘ ·Ú·ÙËÚÔ‡ÓÙ·È: ·) ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ì ÓÂÊÚÈ΋ Û˘ÌÌÂÙÔ¯‹ Î·È ‚) ÓÔÛ‹Ì·Ù· Ô˘ Û˘Ó‰˘¿˙Ô˘Ó ÛÎÂÏÂÙÈΤ˜ ‰˘ÛϷۛ˜ Ì ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÏÂÈÌÌ·. ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ Ù¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ ·ÓÔÛÔ-ÔÛÙÈ΋˜ ‰˘ÛÏ·Û›·˜ Ù‡Ô˘ Schimke, ÁÈ·Ù› ‹Ù·Ó Ë ÌfiÓË ÓfiÛÔ˜ ÌÂ Û˘ÌÌÂÙÔ¯‹ ·fi Ù· ÔÛÙ¿, ÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÙÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ·. ∏ ÓÂÊÚÈ΋ ‚Ï¿‚Ë Â›Ó·È ·ÓıÂÎÙÈ΋ ÛÙË ıÂÚ·›· Ì ÛÙÂÚÔÂȉ‹ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈο Î·È ÙÂÏÈο, ÌÂÙ¿ ÙËÓ ÂÁηٿÛÙ·ÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ô ·ÛıÂÓ‹˜ Ô‰ËÁÂ›Ù·È ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∏ ÏÔÈ‹ ıÂÚ·›· Â›Ó·È ˘ÔÛÙËÚÈÎÙÈ΋, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ·Ó·ÎÔ‹˜ Ù˘ ÂÍÂÏÈÎÙÈ΋˜ ÔÚ›·˜ Ù˘ ÓfiÛÔ˘. °È· ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› ıÂÚ·¢ÙÈο G-CSF, GM-CSF, ÂÚ˘ıÚÔÔÈËÙ›ÓË, ÌÂÙ·ÁÁ›ÛÂȘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ, ÂÓÒ ¯ÔÚËÁÂ›Ù·È ·ÓÙÈ˘ÂÚÙ·ÛÈ΋, ·ÓÙÈÏÈȉ·ÈÌÈ΋ ·ÁˆÁ‹ Î·È ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÌÈÎÚԂȷ΋, fiÔ˘ ¯ÚÂÈ¿˙ÂÙ·È (6). √È ·ÁÁÂȷΤ˜ ‰È·Ù·Ú·¯¤˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·ÓÙÈËÎÙÈο, ·ÈÌÔÚÚÂÔÏÔÁÈο Î·È Î·Ù¿ Ù˘ ËÌÈÎÚ·Ó›·˜ Ê¿Ú̷η (6,7). ∆ÂÏÂ˘Ù·›·, ·Ó·Ê¤ÚÂÙ·È ÂÈÙ˘¯Ë̤ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Û ̛· ÂÚ›ÙˆÛË SIOD Ô˘ ›¯Â ÂÌÊ·Ó›ÛÂÈ Ì˘ÂÏÈ΋ ·Ï·Û›·. ™ÙË Û˘Ó¤¯ÂÈ· ¤ÁÈÓÂ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Î·È ·Ú·ÙËÚ‹ıËΠ‚ÂÏÙ›ˆÛË Ù˘ ·ÈÌ·ÙÔÏÔÁÈ΋˜, ·ÓÔÛÔÏÔÁÈ΋˜ Î·È ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (12). øÛÙfiÛÔ, ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙË, ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈıÌÔ‡ ÂÚÈÙÒÛˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ıÔ‡Ó Û·Ê¤ÛÙÂÚ· Û˘ÌÂÚ¿ÛÌ·Ù·. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙÔ˘ ˘ÔÏÂÈfiÌÂÓÔ˘ ·˘ÙÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Î·È Ë ÌÔÚȷ΋ ·Ó¿Ï˘ÛË DNA Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÛÙË ÁÂÓÂÙÈ΋ ηıÔ‰‹ÁËÛË, Ë ÔÔ›· ¶·È‰È·ÙÚÈ΋ 2006;69:52-58

Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ·Ó›¯Ó¢ÛË ÊÔÚ¤ˆÓ Î·È ÛÙË ‰˘Ó·ÙfiÙËÙ· ÚÔÁÂÓÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ·Û¯fiÓÙˆÓ.

∂˘¯·ÚÈÛٛ˜ £ÂṲ́˜ ¢¯·ÚÈÛٛ˜ ÛÙÔÓ Assistant Professor C.F. Boerkoel ·fi ÙÔ ∆Ì‹Ì· ªÔÚȷ΋˜ °ÂÓÂÙÈ΋˜ ÙÔ˘ ∞ÓıÚÒÔ˘ ÙÔ˘ Baylor College of Medicine, USA.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Lou S, Lamfers P, McGuire N, Boerkoel CF. Longevity in Schimke immuno-osseous dysplasia. J Med Genet 2002;39:922-925. 2. Schimke RN, Horton WA, King CR, Martin NL. Chondroitin-6-sulfate mucopoly-saccharidosis in conjunction with lymphopenia, defective cellular immunity and the nephrotic syndrome. Birth Defects Orig Artic Ser 1974;10:258-266. 3. Sigurdardorttir S, Myers SM, Woodworth JM, Raymond GV. Mental retardation and seizure disorder in Schimke immunoosseous dysplasia. Am J Med Genet 2000;90:294-298. 4. Spranger J, Hinkel GK, Stoss H, Thoenes W, Wargowski D, Zepp F. Schimke immuno-osseous dysplasia: a newly recognized multisystem disease. J Pediatr 1991;119:64-72. 5. Boerkoel CF, Takashima H, John J, Yan J, Stankiewicz P, Rosenbarker L et al. Mutant chromatin remodeling protein SMARCAL1 causes Schimke immuno-osseous dysplasia. Nat Genet 2002;30:215-220. 6. Boerkoel CF, O'Neill S, Andre JL, Benke PJ, Bogdanovic R, Bulla M et al. Manifestations and treatment of Schimke immuno-osseous dysplasia: 14 new cases and a review of the literature. Eur J Pediatr 2000;159:1-7. 7. Schmidt B, Christen HJ, Herkenrath P, Benz-Bohm G, Muller-Berghaus J, Querfeld U. Cerebral complications in Schimke immuno-osseous dysplasia. Eur J Pediatr 1997;156:789-791. 8. Ludman MD, Cole DE, Crocker JF, Cohen MM Jr. Schimke immuno-osseous dysplasia: case report and review. Am J Med Genet 1993;47:793-796. 9. Saraiva JM, Dinis A, Resende C, Faria E, Gomes C, Correia AJ et al. Schimke immuno-osseous dysplasia: case report and review of 25 patients. J Med Genet 1999;36:786-789. 10. Tylki-Szymanska A, Pyrkosz A, Krajewska-Walasek M, Michalkiewicz J, Kowalska A, Rokicki D. Schimke immuno-osseous dysplasia: two cases. Pediatr Radiol 2003;33:216-218. 11. Stormon M, Friedman J, King S, Cutz E, Furuya KN. An unusual case of diarrhea in schimke immuno-osseous dysplasia. J Pediatr Gastroenterol Nutr 2002;35:369-371. 12. Petty EM, Yanik GA, Hutchinson RJ, Alter BP, Schmalstieg FC, Levine JE et al. Successful bone marrow transplantation in a patient with Schimke immunoosseous dysplasia. J Pediatr 2000;137:882-886.


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PRACTICAL ISSUE

59

H ÛËÌ·Û›· ÙÔ˘ ÂϤÁ¯Ô˘ Ù˘ fiÚ·Û˘ ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ Î·È Û¯ÔÏÈ΋ ËÏÈΛ· ÛÙÔ ÚˆÙÔ‚¿ıÌÈÔ ·È‰È·ÙÚÈÎfi È·ÙÚÂ›Ô ∞. •ÂηϿÎË, π. ∞ÓÙˆÓÈ¿‰Ô˘ - ∫Ô˘Ì¿ÙÔ˘

¶ÂÚ›ÏË„Ë: ∞‰È¿ÁÓˆÛÙ· ÚÔ‚Ï‹Ì·Ù· fiÚ·Û˘ Û ·È‰È¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ¤Ó· Ï‹ıÔ˜ Û˘ÓÂÂÈÒÓ. √È ÈÔ ÛËÌ·ÓÙÈΤ˜ Â›Ó·È Ë ·Ì‚Ï˘ˆ›· Î·È Ù· ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ·fi‰ÔÛË ÛÙÔ Û¯ÔÏ›Ô. ∏ ÂÎÙ›ÌËÛË Ù˘ fiÚ·Û˘ ÔÊ›ÏÂÈ Ó· Â›Ó·È Ì¤ÚÔ˜ Ù˘ Ù·ÎÙÈ΋˜ ·È‰È·ÙÚÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘. ∫·Ù¿ÏÏËÏ· ·ÓȯÓ¢ÙÈο ÂÚÁ·Ï›· (screening tests) ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ fiÚ·Û˘ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ‰È¿ÊÔÚ˜ ËÏÈ˘.

¢È‡ı˘ÓÛË ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜, πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ AÏÏËÏÔÁÚ·Ê›·: π. ∞ÓÙˆÓÈ¿‰Ô˘-∫Ô˘Ì¿ÙÔ˘ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·” ∆.∫. 115 27, ∞ı‹Ó· E-mail: inchild@otenet.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 28-01-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 21-09-2005

§¤ÍÂȘ ÎÏÂȉȿ ¶·È‰È¿, ¤ÏÂÁ¯Ô˜ fiÚ·Û˘, ·Ì‚Ï˘ˆ›·.

The importance of vision tests in pre-school and school age children in the primary paediatric setting A. Xekalaki, I. Antoniadou - Koumatou

Abstract: Undetected vision problems in children can lead to a variety of adverse consequences. The most serious of these are amblyopia and inadequate school performance. Vision assessment should be carried out as part of the regular paediatric examination. Screening tests for vision need to be appropriate for the various ages of children. Key words Children, vision screening, amblyopia.

Department of Social Paediatrics, Institute of Child Health, Athens Correspondence: I. Antoniadou-Koumatou Institute of Child Health “Aghia Sofia” Children's Hospital 115 27, Athens, Greece E-mail: inchild@otenet.gr Date of submission: 28-01-2005 Date of approval: 21-09-2005

∏ ÚÔÛ¿ıÂÈ· ¤ÁηÈÚ˘ ·Ó›¯Ó¢Û˘ ÚÔ‚ÏËÌ¿ÙˆÓ fiÚ·Û˘ ¤¯ÂÈ ÍÂÎÈÓ‹ÛÂÈ Â‰Ò Î·È ¤Ó·Ó ·ÈÒÓ· ÂÚ›Ô˘. ∆Ô ÚÒÙÔ ·ÓȯÓ¢ÙÈÎfi ÂÚÁ·ÏÂ›Ô ÂÊ·ÚÌfiÛÙËΠÙÔ 1899 (1). ™ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜ ÂÌÊ·Ó›ÛÙËÎ·Ó ÔÏϤ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÚÔ‚ÏËÌ¿ÙˆÓ fiÚ·Û˘ (2), ·ÏÏ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1960 ÛËÌÂÈÒÓÂÙ·È ÌÈ· ·ÏÌ·Ù҉˘ ·‡ÍËÛË Ù˘ ÚÔÛ¿ıÂÈ·˜ Û˘Ì‚·Ù‹ Ì ÙËÓ «¤ÎÚËÍË» ÙˆÓ ÂÊ·ÚÌÔÁÒÓ ÙˆÓ ·ÓȯÓ¢ÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÂΛÓË ÙËÓ ÂÚ›Ô‰Ô. TÔ ·ÚfiÓ ¿ÚıÚÔ ¤¯ÂÈ ÛÙfi¯Ô Ó· ··ÓÙ‹ÛÂÈ Û ÙÚÂȘ ‚·ÛÈΤ˜ ÂÚˆÙ‹ÛÂȘ: ñ °È·Ù› ¤¯ÂÈ ÛËÌ·Û›· Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË ·ÓˆÌ·ÏÈÒÓ ÛÙËÓ fiÚ·ÛË Î·È Ì¿ÏÈÛÙ· Û Ôχ ÌÈÎÚ‹ ËÏÈΛ·; ñ ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÂÍ·ÛÊ·Ï›˙ÂÈ Î·Ï‡ÙÂÚÔ ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·, ‰ËÏ·‰‹ ηχÙÂÚË fiÚ·ÛË; ñ ªÂ ÔÈÔ «ÂÚÁ·Ï›Ի ÌÔÚ› Ô ÚˆÙÔ‚¿ıÌÈÔ˜ Â·ÁÁÂÏÌ·Ù›·˜ ˘Á›·˜ Ó· ÂϤÁÍÂÈ ·ÍÈfiÈÛÙ· ÙËÓ ÔÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡;

√ÚfiÛËÌÔ ÁÈ· ÙËÓ Î·Ù·ÓfiËÛË Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ Ù˘ fiÚ·Û˘ ·ÔÙ¤ÏÂÛ·Ó ÔÈ ÂÚÁ·Û›Â˜ ÙˆÓ Ó¢ÚÔ‚ÈÔÏfiÁˆÓ. ∏. Hubel Î·È T.M. Wiesel (¡fiÌÂÏ π·ÙÚÈ΋˜ 1981) (3), ÔÈ ÔÔ›ÔÈ Î·Ù¤‰ÂÈÍ·Ó ÙÔÓ ˘„ËÏfi ‚·ıÌfi Ï·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÔÙÈÎÔ‡ ÊÏÔÈÔ‡ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ÙË ÛËÌ·Û›· Ù˘ ‡·Ú͢ Î·È Ù˘ ÔÈÎÈÏ›·˜ ÙˆÓ ÔÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∏ ÚÒÈÌË ‰È¿ÁÓˆÛË ·ÓˆÌ·ÏÈÒÓ ÛÙËÓ fiÚ·ÛË ¤¯ÂÈ ˆ˜ ÛÙfi¯Ô, fi¯È ÌfiÓÔ ÙËÓ ÚfiÏË„Ë Ù˘ ·Ì‚Ï˘ˆ›·˜, ·ÏÏ¿ Î·È ÙˆÓ ‰Â˘ÙÂÚÔÁÂÓÒÓ Û˘ÓÂÂÈÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙ· ÌÈÎÚ¿ ·È‰È¿ Ì ̷ÎÚÔ¯ÚfiÓÈ· ·‰È¿ÁÓˆÛÙ· ÚÔ‚Ï‹Ì·Ù· fiÚ·Û˘ (.¯. ÚÔ‚Ï‹Ì·Ù· Û˘ÌÂÚÈÊÔÚ¿˜, Â›‰ÔÛ˘ ÛÙÔ Û¯ÔÏÂ›Ô ÎÏ.). ŒÙÛÈ, Ù· ™˘ÛÙ‹Ì·Ù· ÀÁ›·˜ ·ÚÎÂÙÒÓ ¯ˆÚÒÓ ˘ÈÔı¤ÙËÛ·Ó Î·È ÂÊ¿ÚÌÔÛ·Ó ÚÔÁÚ¿ÌÌ·Ù· ¤ÁηÈÚ˘ ·Ó›¯Ó¢Û˘ ÚÔ‚ÏËÌ¿ÙˆÓ fiÚ·Û˘ (screening) ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏ ÂÎÙ›ÌËÛË Ù˘ ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜ fï˜, Û Ôχ ÌÈÎÚ¿ Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÌË Û˘ÓÂÚÁ¿ÛÈÌ· ·È‰È¿ ¶·È‰È·ÙÚÈ΋ 2006;69:59-64


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∞. •ÂηϿÎË, π. ∞ÓÙˆÓÈ¿‰Ô˘-∫Ô˘Ì¿ÙÔ˘

¤¯ÂÈ ‰˘ÛÎÔϛ˜, Î·È ¤ÙÛÈ, ÔÈ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ̤ıÔ‰ÔÈ Û˘¯Ó¿ ·ÏÏ¿˙Ô˘Ó ÛÙËÓ ÚÔÛ¿ıÂÈ· Ó· ·˘ÍËı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜. ™‹ÌÂÚ·, ¯ÒÚ˜ Ô˘ ¤¯Ô˘Ó Û˘ÛÙËÌ·ÙÈο ÂÊ·ÚÌfiÛÂÈ ÌÂıfi‰Ô˘˜ screening ÁÈ· ÙËÓ fiÚ·ÛË (∏¶∞, ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ, ™Î·Ó‰ÈÓ·‚Èο ÎÚ¿ÙË) Û˘Ó¯›˙Ô˘Ó Ó· ÂÈÛËÌ·›ÓÔ˘Ó ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù¤ÙÔÈˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ (fiˆ˜ Ô ÙÚfiÔ˜ ÂÊ·ÚÌÔÁ‹˜ Î·È Ë Î·ıÔÏÈÎfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜) Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÚÔ‚Ï‹Ì·Ù· ÛÙË Û¯¤ÛË ÎfiÛÙÔ˘˜/·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ (4-9). ∏ ÂÌÂÈÚ›· ·˘ÙÒÓ ÙˆÓ ¯ˆÚÒÓ ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ Ë Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È Ë ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ÌÂÈÒÓÔ˘Ó ÛËÌ·ÓÙÈο ÙËÓ Â›ÙˆÛË Ù˘ ·Ì‚Ï˘ˆ›·˜ (1,21,32), ¤ÙÛÈ Û η̛· ·fi ·˘Ù¤˜ ÙȘ ¯ÒÚ˜ ‰ÂÓ ¤¯ÂÈ Î·Ù·ÚÁËı› Ô Ì·˙ÈÎfi˜ ÚÔÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÚÔ‚Ï‹Ì·Ù· fiÚ·Û˘ ·ÚfiÏÔ Ô˘ Û˘Ó¯Ҙ ·Ó·˙ËÙÔ‡ÓÙ·È ÙÚfiÔÈ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚ˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ (2,9-13). ™ÙËÓ ∂ÏÏ¿‰·, ÂÓÒ ˘¿Ú¯ÂÈ ıÂÛÌÔıÂÙË̤ÓË Ú·ÎÙÈ΋ ÁÈ· ¤ÏÂÁ¯Ô fiÚ·Û˘ (ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· Ù· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ Î·È Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ̤ۈ ÙÔ˘ ∞ÙÔÌÈÎÔ‡ ¢ÂÏÙ›Ô˘ ÀÁ›·˜ ÙÔ˘ ª·ıËÙ‹), ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ù¿ÏÏËÏÔ ÂÚÁ·ÏÂ›Ô Ô˘ Ó· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ·fi ÚˆÙÔ‚¿ıÌÈÔ˘˜ Â·ÁÁÂÏ̷ٛ˜ ˘Á›·˜.

¶fiÛÔ ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ ·Ì‚Ï˘ˆ›·˜; ∞Ì‚Ï˘ˆ›· Â›Ó·È Ë ÂÏ·Ùو̤ÓË ÔÙÈ΋ Ô͇ÙËÙ· ÛÙÔ ¤Ó· ‹ Î·È ÛÙ· ‰‡Ô Ì¿ÙÈ·. £ÂˆÚÂ›Ù·È ÌÈ· ‰È·Ù·Ú·¯‹ ·Ó·Ù˘ÍÈ·ÎÔ‡ ¯·Ú·ÎÙ‹Ú· Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ «Â˘·›ÛıËÙË-ÎÚ›ÛÈÌË» ÂÚ›Ô‰Ô ÙÔ˘ Ì·ÙÈÔ‡ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ê˘ÛÈÔÏÔÁÈ΋˜ fiÚ·Û˘, ÁÂÁÔÓfi˜ Ô˘ ·ÔÙ¤ÏÂÛÂ Î·È ÙËÓ ÚˆÙ·Ú¯È΋ ·ÈÙ›· ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ·ÓˆÌ·ÏÈÒÓ Ù˘ fiÚ·Û˘ (3,32). ™˘Ó‹ıÂȘ ·Èٛ˜ ·Ì‚Ï˘ˆ›·˜ Â›Ó·È Ô Î·Ù·ÚÚ¿ÎÙ˘, Ô ÛÙÚ·‚ÈÛÌfi˜, Ë ÙÒÛË ÙÔ˘ ‚ÏÂÊ¿ÚÔ˘, Ë ÛËÌ·ÓÙÈ΋ ·ÓÈÛÔÌÂÙÚˆ›· (28) Î·È ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ™ÙÔÓ ÛÙÚ·‚ÈÛÌfi ÔÊ›ÏÔÓÙ·È ÂÚ›Ô˘ ÙÔ 48% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·Ì‚Ï˘ˆ›·˜, ÂÓÒ ÛÙȘ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ 20% (32). ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ‰È·ıÏ·ÛÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Â›Ó·È Ôχ ˘„ËÏfiÙÂÚË ·fi ·˘Ù‹ ÙÔ˘ ÛÙÚ·‚ÈÛÌÔ‡. ∏ ÂÌÊ¿ÓÈÛË Ù˘ ·Ì‚Ï˘ˆ›·˜ Û˘Ó‰¤ÂÙ·È Ì ÔÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û Ôχ ÌÈÎÚ‹ ËÏÈΛ·. ∞Ó ÔÈ ›‰È˜ ·ÓˆÌ·Ï›Â˜ ·ÚÔ˘ÛÈ·¶·È‰È·ÙÚÈ΋ 2006;69:59-64

ÛÙÔ‡Ó ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6-8 ÂÙÒÓ Û˘Ó‹ıˆ˜ ‰ÂÓ ÚÔ·ÙÂÈ ·Ì‚Ï˘ˆ›· (32). ŒÙÛÈ, Û ·Ì‚Ï˘ˆ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó ÔÈ ‰È·ıÏ·ÛÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (Ì˘ˆ›·-˘ÂÚÌÂÙÚˆ›·-·ÛÙÈÁÌ·ÙÈÛÌfi˜), Ë ·ÓÈÛÔÌÂÙÚˆ›· (ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ ÛÙË ‰È·ıÏ·ÛÙÈ΋ ÈηÓfiÙËÙ· ÌÂٷ͇ ÙˆÓ ‰‡Ô Ì·ÙÈÒÓ) ‹ Ë ·Ó¿Ù˘ÍË ÛÙÚ·‚ÈÛÌÔ‡. ∏ ·ÍÈÔÏfiÁËÛ‹ ÙÔ˘˜ fï˜, ÛÙ· Ôχ ÌÈÎÚ¿ ·È‰È¿ ¤¯ÂÈ Î·È ÌÈ· ÚfiÛıÂÙË ÛËÌ·Û›·. ∫·ıÒ˜ Ù· ·È‰È¿ ÌÂÁ·ÏÒÓÔ˘Ó, ·ÏÏ¿˙ÂÈ Ë ‰È·ıÏ·ÛÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ Ì·ÙÈÔ‡. ∆Ô Ì¤ÁÂıÔ˜ ÙÔ˘ Ì·ÙÈÔ‡ ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ̤¯ÚÈ Ù· 3 ¯ÚfiÓÈ· ˙ˆ‹˜, ÂÓÒ Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÛÙË Û˘Ó¤¯ÂÈ· ÂÏ·ÙÙÒÓÂÙ·È. ªÂ ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÈηÓÔÔÈËÙÈ΋˜ fiÚ·Û˘, ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÚÈfi‰Ô˘ Ù˘ ÁÚ‹ÁÔÚ˘ ·‡ÍËÛ˘, ·ÏÏ¿˙ÂÈ ÙÔ ·ÍÔÓÈÎfi Ì‹ÎÔ˜ Î·È Ì¤ÁÂıÔ˜ ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ô Ê·Îfi˜ ÙÔ˘ Ì·ÙÈÔ‡ ·ÏÏ¿˙ÂÈ ÁˆÌÂÙÚ›· (emmetropization). ¶ÂÈÚ¿Ì·Ù· Û ˙Ò· ¤‰ÂÈÍ·Ó fiÙÈ Ë ÂͤÏÈÍË ·˘Ù‹ ‰ÂÓ ÚÔ·ÙÂÈ ·Ó ÙÔ Ì¿ÙÈ ‰ÂÓ ‰¤¯ÂÙ·È Èηӿ ÔÙÈο ÂÚÂı›ÛÌ·Ù· (32). ∂Í·ÈÙ›·˜ Ù˘ ÌÂÁ¿Ï˘ ÂÙÂÚÔÁ¤ÓÂÈ·˜ ÙˆÓ ·ÈÙ›ˆÓ Ô˘ ÚÔηÏÔ‡Ó ·Ì‚Ï˘ˆ›·, ÙˆÓ ‰È·ÊÔÚÒÓ ÛÙË ‰È¿ÚÎÂÈ· Î·È ÙÔ Â›‰Ô˜ Ù˘ ıÂÚ·›·˜, ÙÔ˘ ‚·ıÌÔ‡ Ù˘ Û˘ÌÌfiÚʈÛ˘ ÙÔ˘ ·ÛıÂÓ‹ Î·È ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ¿ ÙË ıÂÚ·›· ·Ú·ÎÔÏÔ‡ıËÛ˘ (follow-up), ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ ‰ÂÓ Â›Ó·È Â‡ÎÔÏ· Û˘ÁÎÚ›ÛÈ̘ ˆ˜ ÚÔ˜ ÙÔ ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ¶¿ÓÙˆ˜ ·Ó·Ê¤ÚÂÙ·È ‚ÂÏÙ›ˆÛË Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÙˆÓ ·È‰ÈÒÓ Û ÔÛÔÛÙfi 41%-96% (ÚÔÔÙÈΤ˜ ÌÂϤÙ˜) Î·È Û ÔÛÔÛÙfi 40%95% (·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜) (32). ™ËÌ·ÓÙÈÎfi Â›Û˘, Â›Ó·È ÙÔ Û˘Ì¤Ú·ÛÌ· ÌÂÚÈÎÒÓ ÌÂÏÂÙÒÓ fiÙÈ Ë ÂÈÙ˘¯›· Ù˘ ıÂÚ·›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Û ÌÈÎÚ‹ ËÏÈΛ·. ŒÙÛÈ, Ê·›ÓÂÙ·È fiÙÈ ·˘Í¿ÓÂÙ·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜ Û ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 3 ÂÙÒÓ. √ Ú˘ıÌfi˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂÚ·›·˜ ÂÏ·ÙÙÒÓÂÙ·È ÌÂÙ¿ Ù· 5 ¯ÚfiÓÈ· ˙ˆ‹˜, ÂÓÒ Û ·È‰È¿ 12 ÂÙÒÓ Â›Ó·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋ (32). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ ·Ì‚Ï˘ˆ›·˜ ȉȷ›ÙÂÚ· Û ËÏÈΛ· <5 ¯ÚfiÓˆÓ ÌÔÈ¿˙ÂÈ Ó· ¤¯ÂÈ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙËÓ Î·Ï‹ fiÚ·ÛË, ÂÊfiÛÔÓ Ë ıÂÚ·›· Â›Ó·È ‰˘ÛÎÔÏfiÙÂÚË Î·È ÙÂÏÈο ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ screening fiÚ·Û˘ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Ì ÛÙfi¯Ô ÙË Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·Ì‚Ï˘ˆ›·˜ Ê·›ÓÂÙ·È ·fi Ù· ‰‡Ô ·Ú·Î¿Ùˆ ·Ú·‰Â›ÁÌ·Ù·. ∏ ™Ô˘Ë‰›· ‰È·ı¤ÙÂÈ ¤Ó· ÂÈıÂÙÈÎfi ·ÓȯÓ¢ÙÈÎfi ÚfiÁÚ·ÌÌ· Ì Â·Ó·Ï·Ì‚·ÓfiÌÂÓ· screening tests ·fi ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ̤¯ÚÈ ÙËÓ ËÏÈΛ·


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·61

61

H ÛËÌ·Û›· ÙÔ˘ ÂϤÁ¯Ô˘ Ù˘ fiÚ·Û˘

ÙˆÓ 10 ¯ÚfiÓˆÓ. ªÈ· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÛÙËÓ ËÏÈΛ· ÙˆÓ 10 ÂÙÒÓ, Ë Â›ÙˆÛË (prevalence) Ù˘ ·Ì‚Ï˘ˆ›·˜ ‹Ù·Ó 0,03% -Ôχ ÌÈÎÚfiÙÂÚË ·fi ÙÔ 3% ¿ÏÏˆÓ ÌÂÏÂÙÒÓ Â›ÙˆÛ˘ Ù˘ ·Ì‚Ï˘ˆ›·˜ Û ÏËı˘ÛÌÔ‡˜ Ô˘ ‰ÂÓ ˘fiÎÂÈÓÙ·È ÛÂ Û˘ÛÙËÌ·ÙÈÎfi screening. ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ÛÙÔ πÛÚ·‹Ï ¤‰ÂÈÍ·Ó fiÙÈ Ë Â›ÙˆÛË Ù˘ ·Ì‚Ï˘ˆ›·˜ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 8 ÂÙÒÓ Ô˘ ›¯·Ó ÂÏÂÁ¯ı› Ì screening Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· ‹Ù·Ó 1% Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙÔ 2,6% Û ËÏÈÎȷΤ˜ ʤÙ˜ Ô˘ ‰ÂÓ Â›¯·Ó ˘ÔÛÙ› ·ÓȯÓ¢ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ (32).

∞ÓȯÓ¢ÙÈο ÂÚÁ·Ï›· ÂϤÁ¯Ô˘ ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜ (ÔÙfiÙ˘·) °È· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÂÓfi˜ ‚Ú¤ÊÔ˘˜ ‹ ÂÓfi˜ ÌÈÎÚÔ‡ ·È‰ÈÔ‡ Â›Ó·È ÛËÌ·ÓÙÈΤ˜ ÔÈ Û¯ÂÙÈΤ˜ ÏËÚÔÊÔڛ˜ ·fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Î·È ÔÈ ·Ó·ÊÂÚfiÌÂÓ˜ Û¯ÂÙÈΤ˜ ·ÓËÛ˘¯›Â˜ ÙˆÓ ÁÔÓ¤ˆÓ. ∂›Û˘, ÛËÌ·ÓÙÈο Â›Ó·È Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Ê˘ÛÈ΋˜ ÂͤٷÛ˘ fiˆ˜ Ë Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹ (red reflex) Û ‚Ú¤ÊË ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË Î·Ù·ÚÚ¿ÎÙË ‹ Ë ‰ÔÎÈÌ·Û›· Î¿Ï˘„˘ ‹ ÙÔ Hirschberg test ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË ÛÙÚ·‚ÈÛÌÔ‡. ™Â ·È‰È¿ fï˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ ÙÚÈÒÓ ¯ÚfiÓˆÓ, Ô ¤ÏÂÁ¯Ô˜ Ù˘ ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜ Û˘ÌÏËÚÒÓÂÙ·È Ì ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÙÔ˘ ·È‰ÈÔ‡. °È· ÙÔÓ ÛÎÔfi ·˘Ùfi ¯ÚËÛÈÌÔÔÈÂ›Ù·È ¤Ó· ÂÚÁ·ÏÂ›Ô (ÙÂÛÙ fiÚ·Û˘) Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ÔÔ›Ô˘ ‰È·ÈÛÙÒÓÂÙ·È ·Ó ÙÔ ·È‰› ¤¯ÂÈ ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ÔÙÈ΋ Ô͇ÙËÙ·. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ÂÚÁ·Ï›Ԣ ÔÊ›ÏÂÈ Ó· Û˘ÌÌÔÚÊÒÓÂÙ·È Ì ÔÚÈṲ̂ӷ ÎÚÈÙ‹ÚÈ·. ∞Ó fï˜ ˙ËÙ‹ÛÔ˘Ì ·fi ¤Ó· ·È‰› ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ó· ·Ó·ÁÓˆÚ›ÛÂÈ Î·È Ó· ÔÓÔÌ¿ÛÂÈ Û‡Ì‚ÔÏ· Ô˘ ˘¿Ú¯Ô˘Ó ¿Óˆ Û ¤Ó· ÙÂÛÙ fiÚ·Û˘ ÁÈ· Ó· ‰È·ÈÛÙÒÛÔ˘Ì fiÛÔ Î·Ï¿ ‚ϤÂÈ, ˘Ôı¤ÙÔ˘Ì fiÙÈ Û οı ÂÍÂÙ·˙fiÌÂÓÔ ¿ÙÔÌÔ, ÚÔ¸¿Ú¯Ô˘Ó ÂÍ›ÛÔ˘ fiϘ ÔÈ ··Ú·›ÙËÙ˜ ÁÓˆÛÙÈΤ˜, ·ÓÙÈÏËÙÈΤ˜, ÂÈÎÔÈÓˆÓȷΤ˜ Î·È ÔÊı·ÏÌÔÎÈÓËÙÈΤ˜ ÈηÓfiÙËÙ˜. ∫·È ÂÂȉ‹ ·˘Ùfi ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÈÛ¯‡ÂÈ ÂÍ›ÛÔ˘ ÁÈ· fiÏ· Ù· ·È‰È¿ Î·È È‰È·›ÙÂÚ· ÁÈ· Ù· ÌÈÎÚfiÙÂÚ·, ÙÔ ÔÔÈÔ‰‹ÔÙ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ÙÂÛÙ ¯¿ÓÂÈ ÙËÓ ÂȉÈÎfiÙËÙ¿ ÙÔ˘. ¶Ú¿ÁÌ· Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ‰ÔÎÈÌ·Û›·˜ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ú·ÁÌ·ÙÈ΋ ÔÙÈ΋ Ô͇ÙËÙ· ÙÔ˘ ·È‰ÈÔ‡, ·ÏÏ¿ ÙËÓ ˘ÔÂÎÙÈÌ¿ ÂÍ·ÈÙ›·˜ ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·ÊÔÚÒÓ.

ŒÓ· ηٿÏÏËÏÔ ÙÂÛÙ fiÚ·Û˘ ı· Ú¤ÂÈ Ó· ¤¯ÂÈ ˘„ËÏ‹ ÂȉÈÎfiÙËÙ· (ÌÈÎÚfi ÔÛÔÛÙfi „¢‰Ò˜ ıÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ó· ÌÂÙÚ¿ÂÈ ÌfiÓÔ ÔÙÈ΋ Ô͇ÙËÙ·) Î·È ˘„ËÏ‹ ¢·ÈÛıËÛ›· (ÌÈÎÚfi ÔÛÔÛÙfi „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ‰ËÏ·‰‹ Ó· ·ÓȯÓ‡ÂÈ Î·È ÌÈÎÚ¤˜ ÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜). ∏ ·fi‰ÔÛË ÙÔ˘ ÔÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (visual performance) ÂÍ·ÚÙ¿Ù·È ·fi: 1. ¶ÔÏϤ˜ ÔÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ fiˆ˜ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ·, ÙËÓ Â˘·ÈÛıËÛ›· ·ÓÙ›ıÂÛ˘, ÙËÓ ·ÓÙ›ÏË„Ë ¯ÚˆÌ¿ÙˆÓ, ÙËÓ ÚÔÛ·ÚÌÔÁ‹ ÛÙÔ Êˆ˜ Î·È ÛÙÔ ÛÎÔÙ¿‰È, ÙË ‰ÈfiÊı·ÏÌË fiÚ·ÛË. 2. ¶ÔÏϤ˜ ÔÙÈÎÔ-ÓÔËÙÈΤ˜ ‰˘Ó·ÙfiÙËÙ˜, fiˆ˜ ÙËÓ ·ÓÙÈÏËÙÈÎfiÙËÙ· ÙÔ˘ ¯ÒÚÔ˘ Î·È ÙˆÓ Û¯ËÌ¿ÙˆÓ, ÙËÓ ÔÙÈ΋ ÌÓ‹ÌË Î·È 3. ∆Ș ÔÊı·ÏÌÔ-ÎÈÓËÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜. ™ÙȘ ¯ÒÚ˜ ÙÔ˘ ‰˘ÙÈÎÔ‡ ÎfiÛÌÔ˘ Ô˘ ÂÊ·ÚÌfi˙ÔÓÙ·È screening test fiÚ·Û˘ ·fi ÙȘ ÚˆÙÔ‚¿ıÌȘ ˘ËÚÂۛ˜ ˘Á›·˜, ¤¯ÂÈ ÏËÊı› ̤ÚÈÌÓ· ÒÛÙ ٷ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· ÂÚÁ·Ï›· Ó· ÙËÚÔ‡Ó ÙȘ ‰ÈÂıÓ›˜ Û˘ÛÙ¿ÛÂȘ ηٷÛ΢‹˜ ÔÙÔÙ‡ˆÓ Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ÙÂÛÙ Ó· ÂÎÊÚ¿˙ÂÈ ÔÙÈ΋ Ô͇ÙËÙ· Î·È fi¯È ÁÓˆÛÙÈ΋ ÈηÓfiÙËÙ·. ¢ÈÂıÓÒ˜ (32), ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÔÏÏ¿ ÙÂÛÙ (ȉ›ˆ˜ ÁÈ· ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·) Ô˘ ›¯·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜ (22) (.¯. ÛÙË ‰È¿Ù·ÍË ÙˆÓ ¯·Ú·ÎÙ‹ÚˆÓ, ÙËÓ ·fiÛÙ·ÛË ÌÂٷ͇ ÙÔ˘˜, ÙÔÓ ÙÚfiÔ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘˜ ÎÏ.). √ÙfiÙ˘ÔÈ Ô˘ ¤¯Ô˘Ó ¢ڤˆ˜ ¯ÚËÛÈÌÔÔÈËı› ‰ÈÂıÓÒ˜ Â›Ó·È ÙÔ Kay Picture Test, ÙÔ Sheridan Gardirer Test, ÙÔ Stycar Test ÙÔ Cambridge Crowded Cards, ÙÔ Snellen Test, ÙÔ Sonksen-Silver Acuity System Test (SSAS), Ù· test Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó LEA ¯·Ú·ÎÙ‹Ú˜ ÎÏ. ∏ ‰ÈÂÚ‡ÓËÛË Ù˘ Û¯ÂÙÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ (14,22-25) ¤‰ÂÈÍ fiÙÈ ÛÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ˘¿Ú¯ÂÈ ‰ÈÂıÓÒ˜ Ë Ù¿ÛË ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‰ÔÎÈ̷ۛ˜ Ù‡Ô˘ «Ù·ÈÚÈ¿ÛÌ·ÙÔ˜» ‹ «Ù·‡ÙÈÛ˘» (matching test) fiˆ˜ Â›Ó·È ÙÔ SSAS ‹ ÌÂÚÈο ·fi Ù· LEA tests. °È· Ù· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÂÛÙ fiÚ·Û˘ Ì ·ÚÈıÌÔ‡˜, Ô˘ fï˜ ÏËÚÔ‡Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ÚÔ¸Ôı¤ÛÂȘ ηٷÛ΢‹˜. ™ÙȘ ˘ËÚÂۛ˜ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜ ÛÙËÓ ∂ÏÏ¿‰· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·Ú·‰ÔÛȷο 3 ÔÙfiÙ˘· (‰‡Ô ÁÈ· ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ÙÔ ÙÂÛÙ Ì ۯ‹Ì·Ù· Î·È ÙÔ «E» test Î·È ¤Ó· ÁÈ· ÙËÓ Û¯ÔÏÈ΋ ËÏÈΛ· Ì ·ÚÈıÌÔ‡˜). ∆· ·È‰È¿ ÂÍÂÙ¿˙ÔÓÙ·È ·fi ·fiÛÙ·ÛË 5 ̤ÙÚˆÓ Î·È ÙÔ˘˜ ˙ËÙÂ›Ù·È Ó· ·Ó·ÁÓˆÚ›ÛÔ˘Ó Î·È Ó· ÔÓÔÌ¿ÛÔ˘Ó ÙÔÓ ˙ËÙÔ‡ÌÂÓÔ ¯·Ú·ÎÙ‹Ú·. ¶·È‰È·ÙÚÈ΋ 2006;69:59-64


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·62

62

∞. •ÂηϿÎË, π. ∞ÓÙˆÓÈ¿‰Ô˘-∫Ô˘Ì¿ÙÔ˘

∫ÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ·ÓȯÓ¢ÙÈÎÒÓ ÂÚÁ·Ï›ˆÓ (ÔÙÔÙ‡ˆÓ) ∫¿ı ÙÂÛÙ fiÚ·Û˘ ÁÈ· ·È‰È¿ ı· Ú¤ÂÈ Ó· ÏËÚÔ› ÔÚÈṲ̂ӷ ÎÚÈÙ‹ÚÈ· Ô˘ Ó· ÙÔ Î¿ÓÔ˘Ó Î·Ù¿ÏÏËÏÔ ÁÈ· ¯Ú‹ÛË ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ËÏÈÎȷ΋ ÔÌ¿‰· (33). ŒÙÛÈ: ∞) ¶ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· √ÔÈÔ‰‹ÔÙ ÙÂÛÙ fiÚ·Û˘ ÁÈ· ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ı· Ú¤ÂÈ Ó· ÂÍ·ÛÊ·Ï›˙ÂÈ fiÙÈ: 1. ∆Ô ·È‰› ηٷϷ‚·›ÓÂÈ ÙÔ ˘ÏÈÎfi Î·È ÙË ‰È·‰Èηۛ· ÙÔ˘ ÙÂÛÙ. 2. ¢ÈÂÁ›ÚÂÙ·È ÙÔ Î›ÓËÙÚÔ, Ë ÚÔÛÔ¯‹ Î·È Ë Û˘ÓÂÚÁ·Û›· ÙÔ˘ ·È‰ÈÔ‡. 3. ∆Ô ·È‰› ÌÔÚ› ‡ÎÔÏ· Ó· «‰Â›ÍÂÈ» ÛÙÔÓ ÂÍÂÙ·ÛÙ‹ fiÙÈ Â›‰Â ÙÔ ˙ËÙÔ‡ÌÂÓÔ. 4. ∆Ô ÙÂÛÙ Â›Ó·È “ÂȉÈÎfi”, ‰ËÏ·‰‹ ÌÂÙÚ¿ ÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ·ÓÂÍ·Úًو˜ ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ (.¯. ·Ó·Ù˘ÍÈ·ÎÒÓ ‰È·ÊÔÚÒÓ). °È· Ó· Û˘Ì‚·›ÓÂÈ ·˘Ùfi ı· Ú¤ÂÈ: 1. ∆· ۇ̂ÔÏ· ÙÔ˘ ÙÂÛÙ Ó· Â›Ó·È Û·Ê‹. ¢ÂÓ ı· Ú¤ÂÈ ‰ËÏ·‰‹ Ó· Ì·ÓÙ‡ÂÈ ÙÔ ·È‰› (¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ¿ÏϘ ÓÔËÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜) ·fi ÙÔ ·‰Úfi ÂÚ›Ô˘ “ÁÓˆÛÙfi ÂÚ›ÁÚ·ÌÌ·”. 2. ∏ Ù·˘ÙÔÔ›ËÛË ÙˆÓ Û˘Ì‚fiÏˆÓ ÙÔ˘ ÙÂÛÙ Ó· ÌËÓ Â›Ó·È ‰‡ÛÎÔÏË ÒÛÙ ӷ ÌËÓ ÂÍ·ÚÙ¿Ù·È ·fi ·Ó·Ù˘ÍȷΤ˜ ‰˘Ó·ÙfiÙËÙ˜. 3. ∏ ‰˘Ó·ÙfiÙËÙ· Ó· ‰È·ÎÚ›ÓÂÈ ÙÔ ·È‰› ¤Ó· ۇ̂ÔÏÔ ˆ˜ ͯˆÚÈÛÙfi ·fi ¿ÏÏ· ۇ̂ÔÏ· Ô˘ ˘¿Ú¯Ô˘Ó ‰›Ï· ÙÔ˘, ·Ó·Ù‡ÛÛÂÙ·È ÚÔԉ¢ÙÈο Î·È Û ÌÂÚÈο ·È‰È¿, fi¯È ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ¯ÚfiÓˆÓ. ŸÛÔ ÈÔ ÎÔÓÙ¿ Â›Ó·È ÙÔÔıÂÙË̤ӷ Ù· ۇ̂ÔÏ· ÙÔ ¤Ó· Û ۯ¤ÛË Ì ÙÔ ¿ÏÏÔ, ÙfiÛÔ ÈÔ ‰‡ÛÎÔÏÔ˜ Á›ÓÂÙ·È Ô ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘˜ ·fi Ù· ÌÈÎÚ¿ ·È‰È¿. ∞˘Ùfi ¤¯ÂÈ Û¯¤ÛË Ì ÙÔÓ ·Ú¿ÁÔÓÙ· Û˘Á¯ÚˆÙÈÛÌÔ‡ (14) (crowding factor) fiÚÔ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ Û¯ÂÙÈΤ˜ Ì ÔÙfiÙ˘· ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜. ŒÙÛÈ, Ô Û˘Á¯ÚˆÙÈÛÌfi˜ ÔÏÏÒÓ Û˘Ì‚fiÏˆÓ Û ÛÂÈÚ¿ Û ¤Ó· ÙÂÛÙ fiÚ·Û˘, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÛÊ¿ÏÌ·Ù· ÛÙË Ì¤ÙÚËÛË Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÛÙ· Ôχ ÌÈÎÚ¿ ·È‰È¿. ¢È·ÛÙ·˘ÚˆÌ¤Ó˜ ÌÂϤÙ˜ (22) ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ Ë ÔÙÈ΋ Ô͇ÙËÙ· ˘ÂÚÂÎÙÈÌ¿Ù·È fiÙ·Ó ‰Â›¯ÓÔÓÙ·È Í¯ˆÚÈÛÙ¿ ۇ̂ÔÏ· ·' fi,ÙÈ fiÙ·Ó ‰Â›¯ÓÔÓÙ·È ÂÚÈÛÛfiÙÂÚ· ۇ̂ÔÏ· Û ÛÂÈÚ¿ (crowding phenomenon). ∆· ÙÂÛÙ Ù‡Ô˘ “Ù·ÈÚÈ¿ÛÌ·ÙÔ˜” (matching test) Ê·›ÓÂÙ·È fiÙÈ ÏËÚÔ‡Ó Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·. ™Ù· ÙÂÛÙ ·˘Ù¿ ˙ËÙÈ¤Ù·È ·fi ÙÔ ·È‰›, Ô˘ ‚Ú›ÛÎÂÙ·È Û ·fiÛÙ·ÛË 3 ̤ÙÚˆÓ ·fi ÙÔÓ ÂÍÂÙ·ÛÙ‹, Ó· ÎÔÈÙ¿ÍÂÈ ÙÔ ˙ËÙÔ‡ÌÂÓÔ Û‡Ì‚ÔÏÔ ¶·È‰È·ÙÚÈ΋ 2006;69:59-64

Î·È Ó· ÙÔ ‰Â›ÍÂÈ ÛÙË Û˘Ó¤¯ÂÈ· ¿Óˆ Û ÌÈ· οÚÙ· Ô˘ ‚Ú›ÛÎÂÙ·È ÌÚÔÛÙ¿ ÙÔ˘ Î·È Ë ÔÔ›· ʤÚÂÈ fiÏ· Ù· ÂÍÂÙ·˙fiÌÂÓ· ۇ̂ÔÏ·. ¢ÂÓ ÙÔ˘ ˙ËÙÈ¤Ù·È Ó· ·Ó·ÁÓˆÚ›ÛÂÈ Î·È Ó· ÔÓÔÌ¿ÛÂÈ ÙÔ Û‡Ì‚ÔÏÔ ·ÏÏ¿ ÌfiÓÔ Ó· ÙÔ “Ù·ÈÚÈ¿ÍÂÈ”. ™Â οı ÙÂÛÙ ˘¿Ú¯Ô˘Ó οÚÙ˜ ÁÈ· ÙÔÓ ‰ÈfiÊı·ÏÌÔ ‹ ÂÙÂÚfiÊı·ÏÌÔ ¤ÏÂÁ¯Ô Ù˘ ÎÔÓÙÈÓ‹˜ Î·È Ì·ÎÚÈÓ‹˜ fiÚ·Û˘. ∆ËÓ Î·Ù·ÏÏËÏfiÙËÙ· ·˘ÙÒÓ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ “Ù·ÈÚÈ¿ÛÌ·ÙÔ˜” ÁÈ· ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· ¤¯Ô˘Ó ÚÔÛ·ı‹ÛÂÈ Ó· ‰Â›ÍÔ˘Ó ÔÏϤ˜ ÌÂϤÙ˜. √È Sonksen et al (22) ÂÊ¿ÚÌÔÛ·Ó matching test Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∏ ÌÂϤÙË ·˘Ù‹ ‰›ÓÂÈ ¯Ú‹ÛÈÌ· ÛÙÔȯ›· ÁÈ· Ù· ÙÂÛÙ Ù‡Ô˘ “Ù·ÈÚÈ¿ÛÌ·ÙÔ˜”, fiˆ˜: 1. ∏ ÂͤٷÛË Ù˘ ‰ÈfiÊı·ÏÌ˘ fiÚ·Û˘ Â›Ó·È ¯Ú‹ÛÈÌË Û ·È‰È¿ <4 ÂÙÒÓ. ¶Ôχ ÌÈÎÚfi ÔÛÔÛÙfi ·È‰ÈÒÓ ı· ¤¯Ô˘Ó Ì›˙ÔÓ Úfi‚ÏËÌ· fiÚ·Û˘ ÛÙÔ ¤Ó· Ì¿ÙÈ, ·Ó Ë ‰ÈfiÊı·ÏÌË fiÚ·ÛË Â›Ó·È Î·Ï‹. ŒÙÛÈ, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· ·Ú·ÂÌÊıÔ‡Ó ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô ·Ó ‰ÂÓ ‰Â¯ÙÔ‡Ó ÙË ÌÔÓfiÊı·ÏÌË ÂͤٷÛË. ∆Ô ·Ú·¿Óˆ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÁÈ·Ù› fiÛÔ ÌÈÎÚfiÙÂÚÔ Â›Ó·È ÙÔ ·È‰›, ÙfiÛÔ ‰˘ÛÎÔÏfiÙÂÚ· ‰¤¯ÂÙ·È ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘ Ì·ÙÈÔ‡. 2. ŒÓ· ÔÛÔÛÙfi ·È‰ÈÒÓ Î¿ÓÂÈ “Ù·›ÚÈ·ÛÌ·” ÛÙËÓ ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ÙÂÛÙ, ·ÏÏ¿ fiÙ·Ó Ô ÂÍÂÙ·ÛÙ‹˜ ·ÔÌ·ÎÚ‡ÓÂÙ·È ÛÙ· 3 ̤ÙÚ· ‰ÂÓ ÌÔÚ› Ó· ÙÔ Î·Ù·Ê¤ÚÂÈ. ÿÛˆ˜ ·˘Ùfi ¤¯ÂÈ Û¯¤ÛË Ì ÙÔ fiÙÈ Î·Ù¿ ÙËÓ ÚÔÂÙÔÈÌ·Û›· ‰Â›¯ÓÂÙ·È ¤Ó·-¤Ó· ۇ̂ÔÏÔ ·fi ÙÔ ÂÎ·È‰Â˘ÙÈÎfi Ê˘ÏÏ¿‰ÈÔ. ∂ÓÒ ÛÙËÓ ·fiÛÙ·ÛË ÙˆÓ 3 Ì. ÙÔ ÙÂÛÙ ¤¯ÂÈ 5 ۇ̂ÔÏ· ÛÙË ÛÂÈÚ¿. ÿÛˆ˜ fï˜, Ó· ¤¯ÂÈ Ó· οÓÂÈ Ì ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÈÔ ÌÈÎÚ¿ ·È‰È¿ ‰ÂÓ ÌÔÚÔ‡Ó Ó· Û˘ÁÎÂÓÙÚˆıÔ‡Ó fiÙ·Ó Ô ÂÍÂÙ·ÛÙ‹˜ Â›Ó·È Ì·ÎÚÈ¿. 3. ™Â οı ËÏÈΛ· Ë ‰ÈfiÊı·ÏÌË fiÚ·ÛË ‰È·ÈÛÙÒıËΠηχÙÂÚË ·fi ÙË ÌÔÓfiÊı·ÏÌË Ì ÙË ‰È·ÊÔÚ¿ Ó· ÌÂÈÒÓÂÙ·È Î·ıÒ˜ ÌÂÁ·ÏÒÓÂÈ Ë ËÏÈΛ·. √È ÂÚ¢ÓËÙ¤˜ Û˘Ì¤Ú·Ó·Ó fiÙÈ Ë Û˘ÌÌÔÚʈÙÈÎfiÙËÙ· ÛÙÔ ÙÂÛÙ Â›Ó·È Î·Ï‹ ÁÈ· Ù· ·È‰È¿ ËÏÈΛ·˜ 2,5-6 ¯ÚfiÓˆÓ Î·È ÙÔ Î·ıÈÛÙ¿ ηٿÏÏËÏÔ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÔÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ. √ ¯ÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ Â›Û˘, ÙÔ Î¿ÓÂÈ Û˘Ì‚·Ùfi Ì ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ËÏÈ˘. µ) ™¯ÔÏÈ΋ ËÏÈΛ· ∆Ô ‚·ÛÈÎfi ÙÂÛÙ Â›Ó·È ÙÔ ÁÚ·ÌÌÈÎfi ÙÂÛÙ Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤ÓÙ ۇ̂ÔÏ· Û οı ÛÂÈÚ¿ ÙÔ˘ ÙÂÛÙ (26). µ·ÛÈ΋ ηٷÛ΢·ÛÙÈ΋ ÚÔ¸fiıÂÛË Â›Ó·È: 1. √È ·ÔÛÙ¿ÛÂȘ ÌÂٷ͇ ÙˆÓ Û˘Ì‚fiÏˆÓ Ó· Â›Ó·È ›Û˜ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ οıÂ Û˘Ì‚fiÏÔ˘ ·˘Ù‹˜ Ù˘ ÛÂÈÚ¿˜. 2. ∏ ·fiÛÙ·ÛË ÌÂٷ͇ ÙˆÓ ÛÂÈÚÒÓ ÙÔ˘ ÙÂÛÙ


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

™ÂÏ›‰·63

63

H ÛËÌ·Û›· ÙÔ˘ ÂϤÁ¯Ô˘ Ù˘ fiÚ·Û˘

Ó· Â›Ó·È ›ÛË Ì ÙÔ ‡„Ô˜ ÙˆÓ Û˘Ì‚fiÏˆÓ Ù˘ ηÙÒÙÂÚ˘ ÛÂÈÚ¿˜. ∞˘Ùfi Á›ÓÂÙ·È ÒÛÙÂ Ô ·Ú¿ÁÔÓÙ·˜ Û˘Á¯ÚˆÙÈÛÌÔ‡ Ó· ‰È·ÙËÚÂ›Ù·È ÛÙ·ıÂÚfi˜. ŒÙÛÈ ÙÔ ÙÂÛÙ ·›ÚÓÂÈ ÌÈ· ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÌÔÚÊ‹ Ô˘ ÌÔÈ¿˙ÂÈ Ó· ÛÙÂÓ‡ÂÈ ÚÔ˜ Ù· οو (ηٷÚÚ¿ÎÙ˘). ∆· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· ÈÛ¯‡Ô˘Ó Î·È ÁÈ· Ù· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· ÙÂÛÙ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÎÔÓÙÈÓ‹˜ fiÚ·Û˘. ™‡Ìʈӷ Ì ٷ ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·, Ù· ÔÙfiÙ˘· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ∂ÏÏ¿‰· ÛÙÔ˘˜ ÚˆÙÔ‚¿ıÌÈÔ˘˜ ¯ÒÚÔ˘˜ ˘Á›·˜ Â›Ó·È ·Î·Ù¿ÏÏËÏ· ÚÔ˜ ¯Ú‹ÛË ‰ÈfiÙÈ: ∞/ ¶ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·: ∆Ô ÔÙfiÙ˘Ô Ì ۯ‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·: 1. ¢ÂÓ Â›Ó·È ÙÂÛÙ “Ù·ÈÚÈ¿ÛÌ·ÙÔ˜” (matching test). 2. À¿Ú¯ÂÈ Û·Ê‹˜ Û˘Û¯¤ÙÈÛË Ì ·Ó·Ù˘ÍȷΤ˜ ‰˘Ó·ÙfiÙËÙ˜ (ÙÔ ·È‰› Ú¤ÂÈ Ó· ÔÓÔÌ¿˙ÂÈ ÙÔ Û‡Ì‚ÔÏÔ). 3. ∆· ۇ̂ÔÏ· ¤¯Ô˘Ó ·‰Úfi ÂÚ›ÁÚ·ÌÌ· Ô˘ ·Ú·¤ÌÔ˘Ó Ù· ·È‰È¿ Û ‰È·ÊÔÚÂÙÈο ·ÓÙÈΛÌÂÓ· Î·È Ô‰ËÁÔ‡Ó ÙÔÓ ÂÍÂÙ·ÛÙ‹ “Ó· ÂÚ¿ÛÂÈ ÙÔ ÙÂÛÙ” ηÙ' ÂÎÙ›ÌËÛË. 4. ¢›ÓÂÙ·È ·fi ·fiÛÙ·ÛË 5 ̤ÙÚˆÓ. Œ¯ÂÈ ‰Âȯı› fiÙÈ fiÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë ·fiÛÙ·ÛË, ÙfiÛÔ ÏÈÁfiÙÂÚÔ Û˘ÌÌÔÚÊÒÓÔÓÙ·È Ù· ·È‰È¿ (22). ∂ÈϤÔÓ, Ë ·fiÛÙ·ÛË ÙˆÓ 5 ̤ÙÚˆÓ Â›Ó·È ··ÁÔÚ¢ÙÈ΋ ÁÈ· ÙȘ ‰Â‰Ô̤Ó˜ ‰È·ÛÙ¿ÛÂȘ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ È·ÙÚ›ˆÓ. 5. ¢ÂÓ Û˘Óԉ‡ÂÙ·È ·fi Û·Ê›˜ Ô‰ËÁ›Â˜ ¯Ú‹Û˘ Ô˘ Ó· ÔÚ›˙Ô˘Ó ÙÔ ÛËÌÂ›Ô ·Ú·ÔÌ‹˜ Û ÂȉÈÎfi ÙfiÛÔ ÌÂÙ¿ ·fi ÙËÓ ÂͤٷÛË Ù˘ ÎÔÓÙÈÓ‹˜ fiÛÔ Î·È Ù˘ Ì·ÎÚÈÓ‹˜ fiÚ·Û˘. µ/ ™¯ÔÏÈ΋ ËÏÈΛ·: ∆Ô ÔÙfiÙ˘Ô Ì ÙÔ˘˜ ·ÚÈıÌÔ‡˜ ÁÈ· ¯Ú‹ÛË ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ·: 1. ¢ÂÓ ÏËÚÔ› ÙȘ ‰ÈÂıÓ›˜ Û˘ÛÙ¿ÛÂȘ ηٷÛ΢‹˜ ÔÙÔÙ‡ˆÓ fiˆ˜ ·Ó·Ê¤ÚıËÎ·Ó ÛÙ· ÎÚÈÙ‹ÚÈ· (ÙÂÛÙ Ù‡Ô˘ “ηٷÚÚ¿ÎÙË”). 2. ¢›ÓÂÙ·È ·fi ·fiÛÙ·ÛË 5 ̤ÙÚˆÓ (··ÁÔÚ¢ÙÈ΋ ÁÈ· ¯ÒÚÔ˘˜ ˘Á›·˜, .¯. È·ÙÚ›·). 3. ¢ÂÓ Û˘Óԉ‡ÂÙ·È Û˘Ó‹ıˆ˜ ·fi Ô‰ËÁ›Â˜ ¯Ú‹Û˘ Ô˘ Ó· ÔÚ›˙Ô˘Ó Î·È ÙÔ ÛËÌÂ›Ô ·Ú·ÔÌ‹˜ Û ÂȉÈÎfi. ™ÙËÓ ∂ÏÏ¿‰· ‰ÂÓ ˘¿Ú¯ÂÈ ÙÂÛÙ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÎÔÓÙÈÓ‹˜ fiÚ·Û˘ Û ¯ÒÚÔ˘˜ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο ÏÔÈfiÓ, Ì ‚¿ÛË ÙË ÛËÌ·Û›· Ù˘ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ ÛËÌ·ÓÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÔÙÈ΋˜ ÈηÓfiÙËÙ·˜, ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ Î·È ÙËÓ ¤ÏÏÂÈ„Ë Î·Ù¿ÏÏËÏÔ˘ ·ÓȯÓ¢ÙÈÎÔ‡ ÂÚÁ·Ï›Ԣ ÛÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· ˘Á›·˜, ‰È·ÌÔÚÊÒÓÂÙ·È

Ë ·Ó¿ÁÎË ‡·Ú͢/·Ó·˙‹ÙËÛ˘ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÙÂÛÙ fiÚ·Û˘ ηٿÏÏËÏˆÓ ÁÈ· ¯Ú‹ÛË ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ Î·È Û¯ÔÏÈ΋ ËÏÈΛ· ÙfiÛÔ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÎÔÓÙÈÓ‹˜ fiÛÔ Î·È Ù˘ Ì·ÎÚÈÓ‹˜ fiÚ·Û˘. ∆¤ÙÔÈ· ÙÂÛÙ fiÚ·Û˘ ΢ÎÏÔÊÔÚÔ‡Ó Â˘Ú¤ˆ˜ Û ¯ÒÚ˜ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ∏ ÂÈÏÔÁ‹ fï˜ ÙÔ˘ ηٿÏÏËÏÔ˘ ÙÂÛÙ fiÚ·Û˘, ·ÏÏ¿ Î·È Ë ·fiÎÙËÛ‹ ÙÔ˘ (ÌfiÓÔ Î·ÙfiÈÓ ·Ú·ÁÁÂÏ›·˜) ·ÔÙÂÏ› Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ÚˆÙÔ‚¿ıÌÈÔ Â·ÁÁÂÏÌ·Ù›· ˘Á›·˜ Ô˘ ÂÚÁ¿˙ÂÙ·È ÛÙËÓ ∂ÏÏ¿‰·.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Appelboom TM. A history of vision screening. J Sch Health 1985;55:138-141. 2. Hartmann EE, Dobson V, Hainline L, Marsh-Tootle W, Quinn GE, Ruttum MS, et al. Preschool vision screening: summary of a Task Force report. Behalf of the Maternal and Child Health Bureau and the National Eye Institute Task Force on Vision Screening in the Preschool Child. Pediatrics 2000;106: 1105-1161. 3. The Official Website of the Nobel Foundation. The 1981 Prize in Physiology or Medicine. [Webpage, Internet]. The Nobel Assembly of Karolinska Institutet. www.nobel.se/medicine/laureates/1981/press.html. 4. Snowdon SK, Stewart Brown SL. Preschool vision screening [Executive Summary]. Health Technol Assess 1997;1:1-83. 5. Stewart-Brown SL, Snowdon SK. Evidence base dilemmas in preschool vision screening. Arch Dis Child 1998;78:406-407. 6. Moseley MJ. Preschool vision screening: a recent report calls for a halt [Commentary]. Br J Opthalmol 1998;82:722-723. 7. Rahi JS, Dezateux C. The future of preschool vision screening services in Britain [Editorials]. BMJ 1997; 315:1247-1248. 8. Ciner EB, Schmidt PP, Orel-Bixler D, Dobson V, Maguire M, Cyert L, et al. Vision screening of preschool children: evaluating the past, looking toward the future. Optom Vis Sci 1998;75:571-584. 9. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screening in pediatric practice: A study from the pediatric research in office setting (PROS) Network. Pediatrics 1992;89:834-838. 10. Newman DK, Hitchcock A, McCarthy H, KeastButler J, Moore AT. Preschool vision screening: outcome of children referred to the hospital eye service. Br J Ophthalmol 1996;80:1077-1082. 11. Preslan MW, Novak A. Baltimore Vision Screening Project. Ophthalmology 1996;103:105-109. 12. Bolger PG, Stewart-Brown SL, Newcombe E, Starbuck A. Vision screening in preschool children: comparison of orthoptists and clinical medical officers as primary screeners. BMJ 1997;303:1291-1294. 13. Yang YF. Visual acuity testing in schools: what needs to be done [Paper]. BMJ 1996;313:1053. 14. Hall DBM, ed. Health for all children. Report of the ¶·È‰È·ÙÚÈ΋ 2006;69:59-64


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∞. •ÂηϿÎË, π. ∞ÓÙˆÓÈ¿‰Ô˘-∫Ô˘Ì¿ÙÔ˘

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¶·È‰È·ÙÚÈ΋ 2006;69:59-64

third joint working party on child Health Surveillance. 3rd ed. Oxford: Oxford University Press; 1996. p. 164. AAP Policy statement: Eye examination and Vision screening in infants, children and young adults. Pediatrics 1996;98:153-157. Polnay L, Hull D, eds. Community Paediatrics, 2nd ed. London: Churchill Livingstone, 1993 American Optometric Association. Pediatric eye and vision examination. Reference guide for clinicians. Prepared by the American Optometric Association Consensus Approved by the AOA Board of Trustees. 1994 June 23, 2nd ed. 1997. ∫Ô˘ÛÔ˘Ú‹ ª, ∆˙ˆÚÙ˙¿ÙÔ˘ °, ™ÌÒÎÔ˘ ¢, °ÎÈÒÓ˘ ¢, ¡ÈÎÔÏ¿Ô˘-¶·Ó·ÁÈÒÙÔ˘ ∞. ∞ÍÈÔÏfiÁËÛË Ù˘ ·Ú¯fiÌÂÓ˘ ÚˆÙÔ‚¿ıÌÈ·˜ ÂÚ›ı·Ï„˘ Û ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. 4Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ «ÀÁ›· Î·È ¶ÔÈfiÙËÙ· ∑ˆ‹˜»: ŸÚ·Ì· Î·È Âȉ›ˆÍË ÁÈ· ÙÔ ·È‰› ÙÔ˘ ¢ËÌÔÙÈÎÔ‡ ™¯ÔÏ›Ԣ. ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ 1992;12. ∆۷ӿη˜ π, ƒÔËÏ›‰Ë˜ ª, ÷Ù˙ËÌȯ·‹Ï ∞, £Ò‰Ë˜ ™, µ¿ÚÓ·Ï˘ ¶, ∫·ÚÔ‡˙·˜ π. ∏ ÛËÌ·Û›· ÙˆÓ ÚÔÏËÙÈÎÒÓ ÂϤÁ¯ˆÓ ÛÙ· ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. ¶·È‰È·ÙÚÈ΋ 1986;49:154-164. ¶Ï·Ù‹˜ √, ™ÎÔ‡ÊË ∂. ¶ÚÔÏËÙÈ΋ ÂͤٷÛË ·È‰ÈÒÓ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Û ·ÁÚÔÙÈ΋ ÂÚÈÔ¯‹. 18Ô ∂Ù‹ÛÈÔ ¶·ÓÂÏÏ‹ÓÈÔ π·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. π·ÙÚÈ΋ ∂Ù·ÈÚ›· ∞ıËÓÒÓ 1991;519. ¶·Ó·ÁȈÙfiÔ˘Ïo˜ ∆. ÀÁ›· ÛÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· [EÌÂÈÚÈ΋ ŒÚ¢ӷ]. ÿ‰Ú˘Ì· ∂Ú¢ÓÒÓ ÁÈ· ÙÔ ¶·È‰›, ∞ı‹Ó· 1991. Salt AT, Sonksen PM, Wade A, Jayatunga R. The maturation of linear acuity and compliance with the Sonksen-Silver Acuity System in young children. Dev Med Child Neurol 1995;37:505-514. Jayatunga R, Sonksen PM, Bhide, A, Wade A. Measures of acuity in primary-school children and their

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ability to detect minor errors of vision. Dev Med Child Neurology 1995;37:515-527. Hered RW, Murphy S, Clancy M. Comparison of the HOTV and LEA Symbols charts for preschool vision screening. J Ophthalmic Nurs Technol 1997; 16:68-73. Wade AM, Ades AE, Salt AT, Jayatunga R, Sonksen PM. Age-related standards for ordinal data: modeling the changes in visual acuity form 2 to 9 years of age. Stat Med 1995;15,14(3):257-266. Lea Huvärinen MD. Precision Vision. Instruction Manual for vision testing products. http://www.leatest.sgic.fi ‹ http://med-apos.bu.edu/leaweb/index. html. 2001; p. 4. Newman, East MM. Preschool vision screening: negative predictive value for amblyopia. Br J Opthalmol 1999;83:676-679. Simons K. Preschool vision screening: rationale, methodology, and outcome. Surv Ophthalmol 1996; 41:3-30. Morad Y, Werker E, Nemet P. Visual acuity tests using chart, line and single optotype in healthy amblyopic children. J AAPOS 1999;3:94-97. Fern KD, Manny RE. Visual acuity of the preschool child: a review. Am J Optom Physiol Opt 1986;63: 319-345. Kohler L. Early detection and screening evaluation of preventive programmes. Pediatriki 1983;46 (Suppl):S337-S341. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Screening for Visual Impairment in Children Younger than Age 5 Years. Systematic Evidence Review for the U.S. Preventive Services Task Force. May 2004. Lindstedt E. What is a vision test. Presented Oct 26th 1991 at the opening of the Eva Lindstedt Early Intervention Programme at the Eye Clinic-Santa Casa Hospital-SaoPaulo, Brazil.


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∏ ·Í›· Ù˘ ÂͤٷÛ˘ Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ Û ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ∞. ¡ÈÎÔÏ·˝‰Ô˘, °. ∆ÛfiÏ·˜

¶ÂÚ›ÏË„Ë: ∏ ÂͤٷÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ Û˘ÓÈÛÙ¿Ù·È Û fiÏ· Ù· ÓÂÔÁÓ¿ Î·È Ù· ‚Ú¤ÊË. ∆Ô Û‡ÓÙÔÌÔ ·˘Ùfi ¿ÚıÚÔ ·ÔÛÎÔ› ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ÂӉ›ÍÂˆÓ Î·È Ù˘ Ù¯ÓÈ΋˜ Ô˘ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ÛˆÛÙ‹ ‰ÈÂÓ¤ÚÁÂÈ· ·˘Ù‹˜ Ù˘ ÂͤٷÛ˘, ηıÒ˜ Â›Û˘ Î·È ÙˆÓ ÂӉ›ÍÂˆÓ ÁÈ· ‰È·ÛÙÔÏ‹ Ù˘ ÎfiÚ˘, ·ÏÏ¿ Î·È ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ηıÈÛÙÔ‡Ó ·Ó·Áη›· ÙËÓ ·Ú·ÔÌ‹ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ. §¤ÍÂȘ ÎÏÂȉȿ: ƒfi‰ÈÓË ·ÓÙ·‡ÁÂÈ·, ·ÓˆÌ·Ï›Â˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, ¤ÏÂÁ¯Ô˜ fiÚ·Û˘, ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË.

¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ, ¶ÂÈÚ·È¿˜ AÏÏËÏÔÁÚ·Ê›·: °ÂÒÚÁÈÔ˜ ∆ÛfiÏ·˜ ¶¿ÚÓËıÔ˜ 32, ∆.∫. 190 13, ™·ÚˆÓ›‰· ∞ÙÙÈ΋˜ E-mail: geotsol@otenet.gr ∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-09-2004 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 13-04-2005

Red reflex examination in newborn babies and infants as a basic part of the physical examination A. Nikolaidou, G. Tsolas

Abstract: The red reflex examination is recommended for all newborn babies and infants. This article describes the indications for and the technique of performing this examination, including the indications for dilation of the pupils before examination and the indications for referral to an ophthalmologist. Key words: Red reflex, retinal abnormalities, vision screening, eye examination.

Department of Pediatrics, “Aghios Panteleimon” General Hospital of Nikea, Piraeus Correspondence: Georgios Tsolas 32 Parnithos Str., 190 13, Saronida, Attica E-mail: geotsol@otenet.gr Date of submission: 17-09-2004 Date of approval: 13-04-2005

∂ÈÛ·ÁˆÁ‹ OÈ ÔÊı·ÏÌÔ› ·ÔÙÂÏÔ‡Ó fi¯È ÌfiÓÔ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ·ÈÛıËÙ‹ÚÈÔ fiÚÁ·ÓÔ, ·ÏÏ¿ Ù·˘Ùfi¯ÚÔÓ· ÙÔ ·Ú¿ı˘ÚÔ ÁÈ· ÙËÓ ÂͤٷÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂›Ó·È, Â›Û˘, ÁÓˆÛÙfi fiÙÈ ÂΉËÏÒÛÂȘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜, ȉȷ›ÙÂÚ˘ Ì¿ÏÈÛÙ· ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜, ·Ó¢ڛÛÎÔÓÙ·È Î·È Û ·ÚÎÂÙ¿ Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù·. ∂Ô̤ӈ˜, Ë ÂͤٷÛË ÙˆÓ ÔÊı·ÏÌÒÓ, ÏÔÁÈ˙fiÌÂÓË ˆ˜ ̤ÚÔ˜ Ù˘ Ê˘ÛÈ΋˜ ÂͤٷÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÛÙËÌ¿ÙˆÓ, ·ÔÎÙ¿ ͯˆÚÈÛÙ‹ ÛËÌ·Û›· Î·È ÔÊ›ÏÂÈ Ó· Á›ÓÂÙ·È ‹‰Ë ·fi ÙËÓ ÚÒÙË Â›ÛÎÂ„Ë ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ (1-4). ™‡Ìʈӷ Ì ÙËÓ ÙÚ¤¯Ô˘Û· ÔÏÈÙÈ΋ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ (5), Û˘ÓÈÛÙ¿Ù·È ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË ÁÈ· Ù· ‚Ú¤ÊË Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ì›·˜ ÂͤٷÛ˘ ̤۷ ÛÙ· ÚÒÙ· ‰‡Ô ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜. O “·ÓȯÓ¢ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ fiÚ·Û˘”

(vision screening) Î·È Ë ÔÊı·ÏÌÔÏÔÁÈ΋ ÂͤٷÛË Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ‰È·ÛÙÚ‚ÏÒÓÔ˘Ó ‹ ·ÚÂÌÔ‰›˙Ô˘Ó ÙÔÓ Û¯ËÌ·ÙÈÛÌfi Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÙÈÎÔ‡ ÂȉÒÏÔ˘, ÁÂÁÔÓfi˜ Ô˘ ı· ÌÔÚÔ‡Û ӷ Ô‰ËÁ‹ÛÂÈ Û ·ÓÂ·Ú΋ Û¯ÔÏÈ΋ Â›‰ÔÛË, ÂÊfiÛÔÓ ÙÔ Úfi‚ÏËÌ· Â›Ó·È ·ÌÊÔÙÂÚfiÏ¢ÚÔ, ÂÓÒ ÛÙȘ ϤÔÓ ÛÔ‚·Ú¤˜ ÂÚÈÙÒÛÂȘ ¤ˆ˜ Î·È Û Ï‹ÚË ·ÒÏÂÈ· Ù˘ fiÚ·Û˘ ÙÔ˘ ·È‰ÈÔ‡. ¶·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Ô Î·Ù·ÚÚ¿ÎÙ˘, ÙÔ ÁÏ·‡ÎˆÌ·, ÙÔ ÚÂÙÈÓÔ‚Ï¿Ûو̷, ÔÈ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÔÊı·ÏÌÈÎÒÓ Ì˘ÒÓ Î·È ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÓfiÛÔÈ Ì ÂΉËÏÒÛÂȘ ·fi ÙÔ˘˜ ÔÊı·ÏÌÔ‡˜, ı· ÌÔÚÔ‡Û·Ó Ó· ·Ó·ÁÓˆÚÈÛÙÔ‡Ó Ì ÚÔÛÂÎÙÈ΋ ÂͤٷÛË, ÙËÓ ÔÔ›· - Û ÌÂÁ¿ÏÔ ‚·ıÌfi - ÔÊ›ÏÂÈ Ó· Â›Ó·È Û ı¤ÛË Ó· Ú·ÁÌ·ÙÔÔÈ‹ÛÂÈ Ô ›‰ÈÔ˜ Ô ·È‰›·ÙÚÔ˜. ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ÚÔÙ›ÓÂÈ fiÙÈ Ë ÔÊı·ÏÌÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ‚ÚÂÊÒÓ Î·È ÙˆÓ ÓË›ˆÓ ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô (5): ·) ÙˆÓ ‚ÏÂÊ¿ÚˆÓ Î·È ÙˆÓ ÔÊı·ÏÌÈÎÒÓ ÎfiÁ¯ˆÓ, ‚) ÙÔ˘ ÚfiÛıÈÔ˘ ¶·È‰È·ÙÚÈ΋ 2006;69:65-68


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∞. ¡ÈÎÔÏ·˝‰Ô˘, °. ∆ÛfiÏ·˜

ÙÌ‹Ì·ÙÔ˜ ÙˆÓ ÔÊı·ÏÌÒÓ (ÂÈÂÊ˘ÎfiÙ·˜, ÎÂÚ·ÙÔÂȉ‹˜), Á) Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙˆÓ ÔÊı·ÏÌÈÎÒÓ Ì˘ÒÓ, ‰) Ù˘ ÈÛÔÚÚÔ›·˜ ÙˆÓ ÔÊı·ÏÌÈÎÒÓ Ì˘ÒÓ, Â) ÙˆÓ ÎÔÚÒÓ Î·È ÛÙ) Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜. ªÂ ÙËÓ ·Ó·˙‹ÙËÛË, ÂȉÈÎfiÙÂÚ·, Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, Ë ÔÔ›· ·ÔÙÂÏ› ‚·ÛÈÎfi ÙÌ‹Ì· Ù˘ ÂͤٷÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ÙÔ˘ ‚Ú¤ÊÔ˘˜, ·ÓȯÓ‡ÔÓÙ·È ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô›ÛıÈÔ˘ ‰È·ÌÂÚ›ÛÌ·ÙÔ˜ ÙÔ˘ ÔÊı·ÏÌÔ‡ ‹ ıÔÏÂÚfiÙËÙ˜ ηٿ Ì‹ÎÔ˜ ÙÔ˘ ÔÙÈÎÔ‡ ¿ÍÔÓ·, fiˆ˜ Â›Ó·È Ô Î·Ù·ÚÚ¿ÎÙ˘, Ë ·‰È·Ê¿ÓÂÈ· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ‹ ÙÔ ÚÂÙÈÓÔ‚Ï¿Ûو̷ (6). ™ÙË Û˘Ó¤¯ÂÈ· ·Ó·Ï‡ÔÓÙ·È ÙfiÛÔ Ë Ù¯ÓÈ΋ ‰ÈÂÓ¤ÚÁÂÈ·˜ Ù˘ ÂͤٷÛ˘ Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, fiÛÔ Î·È Ë ·Í›· Ù˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ÛÔ‚·ÚÒÓ ÔÊı·ÏÌÈÎÒÓ ÓfiÛˆÓ. ∂ÈÎfiÓ· 1. º˘ÛÈÔÏÔÁÈ΋ Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ·.

∆¯ÓÈ΋ ÂͤٷÛ˘ Î·È ·ÍÈÔÏfiÁËÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ∏ Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ·, ÁÓˆÛÙ‹ Î·È ˆ˜ ‰ÔÎÈÌ·Û›· ÙÔ˘ Bruckner (Bruckner test), ‚·Û›˙ÂÙ·È ÛÙÔ ·Ó·ÎÏÒÌÂÓÔ Â› ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ʈ˜ ÙÔ˘ ÔÊı·ÏÌÔÛÎÔ›Ô˘ ÌÂÙ¿ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ̤۷ ÛÙÔ Ì¿ÙÈ. ∏ Ï‹„Ë ÂͤڢıÚ˘ ·ÓÙ·Ó¿ÎÏ·Û˘ ÙÔ˘ ʈÙfi˜ Ì ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ‰Â›¯ÓÂÈ Ô˘ÛÈ·ÛÙÈο ÙËÓ ‡·ÚÍË Î·ı·ÚÔ‡ ÎÂÚ·ÙÔÂȉԇ˜, Ê·ÎÔ‡ Î·È ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ (7) (∂ÈÎfiÓ· 1). ∏ ÂͤٷÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È Û ۯÂÙÈο ÛÎÔÙÂÈÓfi ¯ÒÚÔ, ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë Ì¤ÁÈÛÙË ‰˘Ó·Ù‹ Ì˘‰Ú›·ÛË Ù˘ ÎfiÚ˘, ÂÓÒ ·Ú¿ÏÏËÏ· ·˘Í¿ÓÂÙ·È Î·È Ë Â˘·ÈÛıËÛ›· ÙˆÓ Ì·ÙÈÒÓ ÙÔ˘ ÂÍÂÙ·ÛÙ‹. ∫Ú·ÙÒÓÙ·˜ ÙÔ ÔÊı·ÏÌÔÛÎfiÈÔ ÎÔÓÙ¿ ÛÙÔ Ì¿ÙÈ Î·È ÂÛÙÈ¿˙ÔÓÙ·˜ ÛÙËÓ ÎfiÚË, Ô ÂÍÂÙ·ÛÙ‹˜ ÂÈÛÎÔ› Î·È Ù· ‰‡Ô Ì¿ÙÈ· ÙÔ˘ ·È‰ÈÔ‡ ·fi ·fiÛÙ·ÛË 30-45 cm ·fi ÙÔ ‰ÈÎfi ÙÔ˘ ÚfiÛˆÔ. ∏ ÂͤٷÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ·ÚÓËÙÈ΋ fiÙ·Ó Ë ·ÓÙ·‡ÁÂÈ· Â›Ó·È Û˘ÌÌÂÙÚÈ΋ Î·È ÈÛfiÙÈÌË Î·È ÛÙ· ‰‡Ô Ì¿ÙÈ·. ™˘ÓÂÒ˜, fiÙ·Ó Ë Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ· Â›Ó·È Û˘ÌÌÂÙÚÈ΋ Û ¤ÓÙ·ÛË Î·È ·fi ÙÔ˘˜ ‰‡Ô ÔÊı·ÏÌÔ‡˜, ÙfiÙÂ Ë fiÚ·ÛË Â›Ó·È Èı·Ófiٷٷ Ê˘ÛÈÔÏÔÁÈ΋ Î·È ÌÔÚ› Ì ‚‚·ÈfiÙËÙ· Ó· ·ÔÎÏÂÈÛÙ› ÔÔÈ·‰‹ÔÙÂ Û˘ÁÁÂÓ‹˜ ·Ó·ÙÔÌÈ΋ ·ÓˆÌ·Ï›· ‹ ¿ÏÏË ·ıÔÏÔÁÈ΋ ηٿÛÙ·ÛË Ô˘ Âȉڿ ÛÙËÓ ÔÌ·Ï‹ ·Ó·ÙÔÌ›· Ù˘ ÂÚÈÔ¯‹˜, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ÙÔ ÚÂÙÈÓÔ‚Ï¿Ûو̷, ÙÔ ÔÔ›Ô Î·Ï‡ÙÂÈ Ì¤ÚÔ˜ Ù˘ ÎfiÚ˘. ∂›Û˘, ·ÔÎÏ›ÔÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜, ÙÔ˘ Ê·ÎÔ‡ Î·È ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ·ı‹ÛÂȘ, ÔÈ Ôԛ˜ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÂËÚ¿˙Ô˘Ó ÙËÓ fiÚ·ÛË ¶·È‰È·ÙÚÈ΋ 2006;69:65-68

‰ÂÓ ·ÓȯÓ‡ÔÓÙ·È Ì ÙËÓ ·Ï‹ ÂÈÛÎfiËÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, fiˆ˜ Ë ÂÚ›ÙˆÛË ‰˘ÛÙÚÔÊ›·˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜. OÈ ÛÎÔÙÂÈÓ¤˜ ÎËÏ›‰Â˜ ̤۷ ÛÙË Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ·, ÔÔÈ·‰‹ÔÙ ·Û˘ÌÌÂÙÚ›· ÛÙËÓ ¤ÓÙ·ÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÊı·ÏÌÒÓ, ·ÓÙÂÏ‹˜ ·Ô˘Û›· Ù˘ ·fi ÙÔ ¤Ó· Ì¿ÙÈ ‹ ·ÚÔ˘Û›· Ï¢΋˜ ·ÓÙ·Ó¿ÎÏ·Û˘, ˘Ô‰ËÏÒÓÔ˘Ó ˘ÔΛÌÂÓË ·ıÔÏÔÁ›· ηٿ ÙÔÓ ÔÙÈÎfi ¿ÍÔÓ· Î·È ÂÈ‚¿ÏÏÔ˘Ó ÙËÓ ¿ÌÂÛË ·Ú·ÔÌ‹ ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ÔÊı·ÏÌ›·ÙÚÔ (∂ÈÎfiÓ˜ 2 Î·È 3). ∞fi Ù· ·Ú·¿Óˆ ηı›ÛÙ·Ù·È Û·Ê‹˜ Ë ÙÂÚ¿ÛÙÈ· ÛËÌ·Û›· Ù˘ ÂͤٷÛ˘ Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Ë ÔÔ›· Ì¿ÏÈÛÙ· ı· Ú¤ÂÈ Î·Ù¿ ‰È·ÛÙ‹Ì·Ù· Ó· Â·ÓÂÍÂÙ¿˙ÂÙ·È ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ·ÎfiÌË Î·È fiÙ·Ó ¤¯ÂÈ ıˆÚËı› Ê˘ÛÈÔÏÔÁÈ΋ ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô. ÕÏψÛÙÂ, ÔÈ ÂȉÈÎÔ› ÂÊÈÛÙÔ‡Ó ÙËÓ ÚÔÛÔ¯‹ ˆ˜ ÚÔ˜ ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÛÔ‚·ÚÒÓ ·ı‹ÛˆÓ, fiˆ˜ ÙÔ˘ ÚÂÙÈÓÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ηٷÚÚ¿ÎÙË, Ë ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÔÔ›ˆÓ Â›Ó·È Ô˘ÛÈ·ÛÙÈ΋˜ ÛËÌ·Û›·˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË ‰È¿ÛˆÛË Ù˘ fiÚ·Û˘, ÔÚÈṲ̂Ó˜ ‰Â ÊÔÚ¤˜ Î·È ÁÈ' ·˘Ù‹ ηı·˘Ù‹ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ªÔÏÔÓfiÙÈ ÛÙ· ‚Ú¤ÊË ÔÈ ÎfiÚ˜ ‰È·ÛÙ¤ÏÏÔÓÙ·È Â‡ÎÔÏ· ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÔÈΛÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÛÔÚ·‰Èο ¤¯Ô˘Ó ηٷÁÚ·Ê› ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi Ù· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Ì˘‰ÚÈ·ÙÈο Û΢¿ÛÌ·Ù·, ÙfiÛÔ Ù· Û˘Ì·ıËÙÈÎÔÌÈÌËÙÈο, fiˆ˜ Ë Ê·ÈÓ˘ÏÂÊÚ›ÓË, fiÛÔ Î·È Ù· ·ÓÙȯÔÏÈÓÂÚÁÈο, fiˆ˜ Ë ˘‰ÚԯψÚÈ΋ ΢ÎÏÔÂÓÙÔÏ¿ÙË Î·È Ë ÙÚÔÈη̛‰Ë. ™ÙȘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡,


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∂ͤٷÛË Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜

∂ÈÎfiÓ· 3. §Â˘ÎÔÎÔÚ›·.

∂ÈÎfiÓ· 2. ∫·Ù·ÚÚ¿ÎÙ˘.

ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, Ë ÔÍ›· ÎÓ›‰ˆÛË, ηıÒ˜ Î·È Ë ‰ÂÚÌ·Ù›Ùȉ· ÂÍ Â·Ê‹˜ (8-12). ¶·Ú' fiÏ· ·˘Ù¿, Ë ‰È·ÛÙÔÏ‹ Ù˘ ÎfiÚ˘ ÙˆÓ ÌÈÎÚÒÓ ·È‰ÈÒÓ ·ÔÙÂÏ› ‰È·‰Èηۛ· ÚÔ˘Ù›Ó·˜ Â‰Ò Î·È ÔÏÏ¿ ¯ÚfiÓÈ· ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·È‰Ô-ÔÊı·ÏÌÔÏÔÁÈο È·ÙÚ›·, ¯ˆÚ›˜ Ó· ·Ú·ÙËÚÔ‡ÓÙ·È ÙfiÛÔ Û˘¯Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ηıÈÛÙÒÓÙ·˜ ·˘Ù‹ ÙË ‰È·‰Èηۛ· ·ÛÊ·Ï‹, fiÙ·Ó Á›ÓÂÙ·È Û ¯ÒÚÔ ÔÚÁ·ÓˆÌ¤ÓÔ˘ È·ÙÚ›Ԣ, Û ‚Ú¤ÊË, ·ÎfiÌË Î·È Û ÓÂÔÁÓ¿ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ ‰‡Ô ‚‰ÔÌ¿‰ˆÓ. ∆¤ÏÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, ·˘Ù¿ ÂÍÂÙ¿˙ÔÓÙ·È ÂÓÒ ·ÎfiÌË ÓÔÛËχÔÓÙ·È ÛÙË ªÔÓ¿‰· ¡ÂÔÁÓÒÓ, Ô‡Ùˆ˜ ÒÛÙÂ Ë Ì˘‰Ú›·ÛË Ó· Â›Ó·È Û¯ÂÙÈÎÒ˜ ·ÛÊ·Ï‹˜, ·ÎfiÌË Î·È Û ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·È‰ÈÒÓ. ∏ ÚÔ·Ó·ÊÂÚı›۷ ÔÏÈÙÈ΋ ÛÙԯ‡ÂÈ ÛÙË Û‡ÓÙ·ÍË Î·Ù¢ı˘ÓÙ‹ÚÈˆÓ Ô‰ËÁÈÒÓ-Û˘ÛÙ¿ÛˆÓ, ‚·ÛÈÛÌ¤ÓˆÓ ÙfiÛÔ ÛÙË ÁÓÒÛË fiÛÔ Î·È ÛÙËÓ ›ڷ Ô˘ ¤¯ÂÈ ·ÔÎÙËı› Û¯ÂÙÈο Ì ÙÔ ı¤Ì· Ù˘ ÔÊı·ÏÌÔÏÔÁÈ΋˜ ÂͤٷÛ˘ ÓÂÔÁ¤ÓÓËÙˆÓ Î·È ÌÈÎÚÒÓ ‚ÚÂÊÒÓ, ÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈËı› Ô Î›Ó‰˘ÓÔ˜ ·fi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ‰È¿ÁÓˆÛ˘ ·ÂÈÏËÙÈÎÒÓ - ÁÈ· ÙËÓ fiÚ·ÛË ‹ Î·È ÙË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡ - ηٷÛÙ¿ÛˆÓ.

™˘ÛÙ¿ÛÂȘ ·) ŸÏ· Ù· ‚Ú¤ÊË ı· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÛÙËÓ ÂͤٷÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ η-

Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÚÒÙˆÓ ÌËÓÒÓ Ù˘ ˙ˆ‹˜ ÙÔ˘˜ ·fi ÙÔÓ ·È‰›·ÙÚÔ ‹ ¿ÏÏÔ È·ÙÚfi ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜, Èı·Ófiٷٷ ÁÂÓÈÎfi È·ÙÚfi, Ô ÔÔ›Ô˜ fï˜ ı· ¤¯ÂÈ ÂÎ·È‰Â˘ı› ηٿÏÏËÏ·. ∏ ÂͤٷÛË ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È Û ÛÎÔÙÂÈÓfi ¯ÒÚÔ, ÒÛÙ ӷ ÌÂÁÈÛÙÔÔÈÂ›Ù·È Ë Ì˘‰Ú›·ÛË Ù˘ ÎfiÚ˘ Î·È Ó· ·˘Í¿ÓÂÙ·È Ë Â˘·ÈÛıËÛ›· ÙˆÓ Ì·ÙÈÒÓ ÙÔ˘ ÂÍÂÙ·ÛÙ‹. ∏ ÂͤٷÛË Á›ÓÂÙ·È Î·Ù¿ ÙÔÓ ÎÏ·ÛÈÎfi ÌÔÓfiÊı·ÏÌÔ ÙÚfiÔ, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÔÊı·ÏÌÔÛÎfiÈÔ, ÙÔ ÔÔ›Ô Ô ÂÍÂÙ·ÛÙ‹˜ ÎÚ·Ù¿ ÎÔÓÙ¿ ÛÙÔ Ì¿ÙÈ ÙÔ˘ Î·È Û ·fiÛÙ·ÛË ·fi Ù· Ì¿ÙÈ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ fiÛÔ ÂÚ›Ô˘ ÙÔ Ì‹ÎÔ˜ ÂÓfi˜ ‚Ú·¯›ÔÓ·. ‚) ∆Ô ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂͤٷÛ˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ·ÚÓËÙÈÎfi ‹ Ê˘ÛÈÔÏÔÁÈÎfi fiÙ·Ó Ë ·ÓÙ·Ó¿ÎÏ·ÛË Î·È ·fi Ù· ‰‡Ô Ì¿ÙÈ· Â›Ó·È Û˘ÌÌÂÙÚÈ΋ Î·È ÈÛÔ‰‡Ó·ÌË Û ¯ÚÒÌ·, ¤ÓÙ·ÛË Î·È Î·ı·ÚfiÙËÙ· Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ıÔÏÂÚfiÙËÙ˜ ‹ Ï¢Τ˜ ÎËÏ›‰Â˜ ̤۷ ÛÙÔ ‰›Ô Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ οı ÔÊı·ÏÌÔ‡, Ô‡Ù ‚‚·›ˆ˜ Ï¢΋ ·ÓÙ·Ó¿ÎÏ·ÛË ·fi ÙËÓ ÎfiÚË (Ï¢ÎÔÎÔÚ›·). Á) ∆Ô ıÂÙÈÎfi ‹ ·ıÔÏÔÁÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂͤٷÛ˘ (·Û˘ÌÌÂÙÚ›· ÛÙËÓ ¤ÓÙ·ÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, ‰È·ÊÔÚ¿ ÛÙÔ ¯ÚÒÌ· ‹ ÙË ‰È·‡ÁÂÈ· ‹, Ù¤ÏÔ˜, ·ÒÏÂÈ· ‹ Ï¢΋ ·ÓÙ·Ó¿ÎÏ·ÛË) ı· Ú¤ÂÈ, ̤۷ Û ‡ıÂÙÔ ¯ÚfiÓÔ, Ó· ‰ÈÂÚÂ˘Ó¿Ù·È ÂÚ·ÈÙ¤Úˆ: i) ›Ù Ì Â·Ó¤ÏÂÁ¯Ô Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, 15 ÂÚ›Ô˘ ÏÂÙ¿ ÌÂÙ¿ ÙËÓ ÂÓÛÙ¿Ï·ÍË ÛÙÔ Î¿ı ̿ÙÈ Ì˘‰ÚÈ·ÙÈÎÔ‡ ÎÔÏÏ˘Ú›Ô˘ (ÙÚÔÈη̛‰Ë <1% ‹ Ì›ÁÌ· ÙÚÔÈη̛‰Ë˜ <1% Î·È Ê·ÈÓ˘ÏÂÊÚ›Ó˘ 2,5% ‹ Ì›ÁÌ· ΢ÎÏÔÂÓÙÔÏ¿Ù˘ 0,25% Î·È Ê·ÈÓ˘ÏÂÊÚ›Ó˘ 2,5%), ‰Â‰Ô̤ÓÔ˘ fiÙÈ, ·ÎfiÌË Î·È ÛÂ Ê˘ÛÈÔÏÔÁÈ΋ fiÚ·ÛË, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ô˘ÛÈ¿˙ÂÈ Ë Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ· („¢‰Ò˜ ıÂÙÈ΋ ‰ÔÎÈÌ·Û›·), ȉ›ˆ˜ ¶·È‰È·ÙÚÈ΋ 2006;69:65-68


Pediatr Jan-Feb 06 final allges

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™ÂÏ›‰·68

68

∞. ¡ÈÎÔÏ·˝‰Ô˘, °. ∆ÛfiÏ·˜

fiÙ·Ó ‰ÂÓ ÂÛÙÈ¿˙ÂÙ·È ÙÔ ‚ϤÌÌ· ÛÙË ÊˆÙÂÈÓ‹ ËÁ‹, ÂÓÒ ·ÓÙÈı¤Ùˆ˜ Ô˘‰¤ÔÙ ˘¿Ú¯ÂÈ „¢‰Ò˜ ·ÚÓËÙÈ΋ ‰ÔÎÈÌ·Û›· Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜, ii) ›Ù Ì ÙËÓ ·Ú·ÔÌ‹ ÙÔ˘ ·È‰ÈÔ‡ Û ¤ÌÂÈÚÔ ·È‰Ô-ÔÊı·ÏÌ›·ÙÚÔ, Ô ÔÔ›Ô˜ - ÂÎÙfi˜ ÙˆÓ ¿ÏÏˆÓ - ı· ÚԂ› Î·È Û ÂͤٷÛË ÙÔ˘ ‚˘ıÔ‡ Ì ¤ÌÌÂÛË ÔÊı·ÏÌÔÛÎfiËÛË ÌÂÙ¿ ·fi Ì˘‰Ú›·ÛË Ù˘ ÎfiÚ˘ ÙÔ˘ ÔÊı·ÏÌÔ‡. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi ·Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ ÔÏÏ¿ ·fi Ù· ÚÔ·Ó·ÊÂÚı¤ÓÙ· Ì˘‰ÚÈ·ÙÈο ÎÔÏχÚÈ· ΢ÎÏÔÊÔÚÔ‡Ó Ì ÙȘ ·Ú·¿Óˆ ·Ó·ÁÚ·ÊfiÌÂÓ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙȘ ∏.¶.∞. Î·È Û ¿ÏϘ ¯ÒÚ˜ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ¶ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙË ¯ÒÚ· Ì·˜, Â›Ó·È ¯Ú‹ÛÈÌÔ Ó· ÁÓˆÚ›˙Ô˘Ì fiÙÈ ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ ·Ú·›ˆÛË ÙˆÓ ˘·Ú¯fiÓÙˆÓ ÎÔÏÏ˘Ú›ˆÓ. ‰) ∏ Ï‹„Ë ÏÂÙÔÌÂÚÔ‡˜ ÎÏËÚÔÓÔÌÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ı· Ú¤ÂÈ ¿ÓÙ· Ó· ÚÔËÁÂ›Ù·È Ù˘ ÎÏÈÓÈ΋˜ ÂͤٷÛ˘, Ì ÛÎÔfi ÙËÓ ·ÔÎ¿Ï˘„Ë ÔÈÎÔÁÂÓÒÓ ÓfiÛˆÓ ‹ ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛˆÓ, fiˆ˜ Ë ÚÔˆÚfiÙËÙ·, Ô˘ ÂȉÚÔ‡Ó ÛÙÔ˘˜ ÔÊı·ÏÌÔ‡˜. ŒÙÛÈ, ‚Ú¤ÊË Ô˘ ·Ó‹ÎÔ˘Ó Û ηÙËÁÔÚ›· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ÁÈ· ·Ú¿‰ÂÈÁÌ· ÌÂ Û˘ÁÁÂÓ›˜ ¿Û¯ÔÓÙ˜ ·fi ÚÂÙÈÓÔ‚Ï¿Ûو̷ ‹ Û˘ÁÁÂÓ‹ ηٷÚÚ¿ÎÙË ‹ Û˘ÁÁÂÓ‹ ‰˘ÛÏ·Û›· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ‹ Î·È ¿ÏϘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ‹ ÙÔ˘ Ê·ÎÔ‡, ı· Ú¤ÂÈ ÂÍ·Ú¯‹˜ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ÂͤٷÛË Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ηÙfiÈÓ Ì˘‰ÚÈ¿Ûˆ˜ ‹ Ó· ÂÍÂÙ¿˙ÔÓÙ·È Î·Ù¢ı›·Ó ·fi ¤ÌÂÈÚÔ ·È‰Ô-ÔÊı·ÏÌ›·ÙÚÔ. Â) µÚ¤ÊË Ì Ï¢ÎÔÎÔÚ›· ÛÙÔ ¤Ó· ‹ Î·È Ù· ‰‡Ô Ì¿ÙÈ·, ηıÒ˜ Î·È ·˘Ù¿ ÛÙ· ÔÔ›· ·Ô˘ÛÈ¿˙ÂÈ Ë Úfi‰ÈÓË ·ÓÙ·‡ÁÂÈ·, ı· Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ·Ì¤Ûˆ˜ Û ¤ÌÂÈÚÔ ·È‰Ô-ÔÊı·ÏÌ›·ÙÚÔ.

™˘ÌÂÚ¿ÛÌ·Ù· ∏ ÂͤٷÛË Ù˘ Úfi‰ÈÓ˘ ·ÓÙ·‡ÁÂÈ·˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ·ÔÙÂÏ› ‚·ÛÈÎfi ̤ÚÔ˜ Ù˘ Ê˘ÛÈ΋˜ ÂͤٷÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ÙÔ˘ ‚Ú¤ÊÔ˘˜, ηıÒ˜ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ÔÊı·ÏÌÈÎÒÓ ·ı‹ÛÂˆÓ Ô˘ ı¤ÙÔ˘Ó Û ÛÔ‚·Úfi ΛӉ˘ÓÔ ÙËÓ fiÚ·ÛË, ·ÏÏ¿ ÂÓ›ÔÙÂ Î·È ÙËÓ ›‰È· ÙË ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡. ∏ ÂͤٷÛË ·˘Ù‹ ı· Ú¤ÂÈ Ó·

¶·È‰È·ÙÚÈ΋ 2006;69:65-68

Á›ÓÂÙ·È - fi¯È ÌfiÓÔ Ì›· ÊÔÚ¿ - ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·È‰›·ÙÚÔ, Ô ÔÔ›Ô˜ ÔÊ›ÏÂÈ Ó· Â›Ó·È ÂÍÔÈÎÂȈ̤ÓÔ˜ Ì ÙËÓ ÔÚı‹ Î·È Û˘ÓÂ‹ ‰ÈÂÓ¤ÚÁÂÈ¿ Ù˘.

∂˘¯·ÚÈÛٛ˜ OÈ ÊˆÙÔÁڷʛ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ ·Ú¯Â›Ô Ù˘ ΢ڛ·˜ ∫ˆÓÛÙ·ÓÙ›Ó·˜ µÏ¿¯Ô˘, ∂ÈÌÂÏ‹ÙÚÈ·˜ ∞' Ù˘ OÊı·ÏÌÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ÙË�� ÔÔ›· Î·È Â˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Calhoun JH. Consultation with the specialist. Eye examinations in infants and children. Pediatr Rev 1997;18:28-31. 2. Mills MD. The eye in childhood. Am Fam Physician 1999;60:907-916. 3. Olitsky SE, Nelson LB. Common ophthalmologic concerns in infants and children. Pediatr Clin North Am 1998;45:993-1012. 4. Curnyn KM, Kaufman LM. The eye examination in the pediatrician's office. Pediatr Clin North Am 2003;50:25-40. 5. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. Eye examination and vision screening in infants, children, and young adults. Pediatrics 1996;98:153-157. 6. American Academy of Pediatrics, Section on Ophthalmology. Red reflex examination in infants. Pediatrics 2002;109:980-981. 7. Tongue AC, Cibis GW. Bruckner test. Ophthalmology 1981;88:1041-1044. 8. Ogut MS, Bozkurt N, Ozek E, Birgen H, Kazokoglu H, Ogut M. Effects and side effects of mydriatic eyedrops in neonates. Eur J Ophthalmol 1996;6:192-196. 9. Fraunfelder FT. Pupil dilation using phenylephrine alone or in combination with tropicamide. Ophthalmology 1999;106:4. 10. Gaynes BI. Monitoring drug safety; cardiac events in routine mydriasis. Optom Vis Sci 1998;75:245-246. 11. Resano A, Esteve C, Fernandez Benitez M. Allergic contact blepharoconjunctivitis due to phenylephrine eye drops. J Investig Allergol Clin Immunol 1999; 9:55-57. 12. Boukhman MP, Maibach HI. Allergic contact dermatitis from tropicamide ophthalmic solution. Contact Dermatitis 1999;41:47-48.


Pediatr Jan-Feb 06 final allges

27-01-06

15:35

∂π™∏°∏™∏

™ÂÏ›‰·69

RECOMMENDATION

69

∂ÈÛ‹ÁËÛË ÁÈ· ¯ÔÚ‹ÁËÛË Synagis ÁÈ· ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV) EÈ̤ÏÂÈ·: Dr ™ÔÊ›· ¶ÂÙÌÂ˙¿ÎË ¶·È‰›·ÙÚÔ˜-¡ÂÔÁÓÔÏfiÁÔ˜ À‡ı˘ÓË ª∂¡ ¡ÂÔÁÓÒÓ ª·È¢ÙËÚ›Ô˘ “ªËÙ¤Ú·”

∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›·

Recommendation on administration of Palivizumab (Synagis) for the prevention of disease caused by respiratory syncytial virus (RSV) Hellenic Society of Neonatology

Abstract: The aim of this article is to make recommendations about the use of Palivizumab (Synagis) for the disease caused by respiratory syncytial virus (RSV), according to the literature accessible to the Hellenic Society of Neonatology at the present time. RSV is the main cause of lower respiratory tract infection in the first two years of life. Seventy per cent of infants are infected during their first year of life and 95% by the end of their second year. Of those infected, 15-22% will present with bronchiolitis, pneumonitis or pneumonia, and 0.5-2% will need hospitalization. The mortality from RSV ranges between 0.5-3.5% (1,2). Reinfection occurs in 50% of infants. The presentation of RSV is seasonal, differing between countries. In Greece it is reported mainly from November until March. The infants at highest risk are premature infants ≤28 weeks of gestation, with or without chronic bronchopulmonary disease (BPD), or more mature infants with BPD, congenital heart disease or immunodeficiencies. Synagis is a monoclonal antibody against RSV. The prophylactic administration of Synagis at a dose of 15 mg/kg i.m. during the season of RSV infection has been reported to reduce the rates of hospitalization for RSV infections by 55%. According to this information, Synagis is recommended for the following groups: a) Infants ≤2 years of age with BPD, if they have been on treatment in the last 6 months before the start of the RSV season. b) Premature infants without BPD, if they have been born at: 1. gestational age ≤28 weeks and are aged <1 year during the RSV season 2. gestational age 29-32 weeks and are aged <6 months during the RSV season 3. gestational age 33-35 weeks, if they have additional risk factors and are aged <6 months during the RSV season. c) Infants with congenital heart disease, with or without cyanosis, if they are aged <1 year, or if they need surgery or hospitalization during the RSV season. Also infants with cardiomyopathies, if they are aged <1 year of age during the RSV season. d) Infants with immunodeficiencies.

™ÎÔfi˜ Ù˘ ÂÈÛËÁ‹Ûˆ˜ ·˘Ù‹˜ Â›Ó·È Ó· ηıÔÚÈÛÙÔ‡Ó ÔÈ ÂӉ›ÍÂȘ ÁÈ· ÙË ¯Ú‹ÛË ÙÔ˘ Synagis ÁÈ· ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV) ‚¿ÛÂÈ Ù˘ ÚÔÛÈÙ‹˜ Û ̷˜ ‚È‚ÏÈÔÁÚ·Ê›·˜. √ RSV (·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜) Â›Ó·È Ë Î˘ÚÈfiÙÂÚË ·ÈÙ›· Ïԛ̈͢ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÁÈ· Ù· 2 ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜. ¶ÂÚ›Ô˘ 70% ÙˆÓ ·È‰ÈÒÓ ÌÔχ-

∏ÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 27-06-2005 ∏ÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-09-2005

Editor: Dr Sofia Petmezaki Paediatrician-Neonatologist Head of Neonatal ICU, “Mitera” Maternity Clinic Date of submission: 27-06-2005 Date of approval: 15-09-2005

ÓÔÓÙ·È ÛÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜ Î·È 95% ı· ¤¯Ô˘Ó ÚÔÛ‚ÏËı› ̤¯ÚÈ ÙÔÓ 2Ô ¯ÚfiÓÔ ˙ˆ‹˜. ∞fi ·˘Ù¿, 15-22% ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ‚ÚÔÁ¯›Ùȉ·, Ó¢ÌÔÓ›Ùȉ·, Ó¢ÌÔÓ›·, ÂÓÒ 0,5-2% ı· ¯ÚÂÈ·ÛÙ› ÂÈÛ·ÁˆÁ‹ Û ÓÔÛÔÎÔÌ›Ô. ∆Ô ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ ·fi RSV Î˘Ì·›ÓÂÙ·È ·fi 0,53,5% (1,2). ∂·Ó·ÌfiÏ˘ÓÛË ÌÔÚ› Ó· Û˘Ì‚Â› ÛÙÔ 50% ÙˆÓ ·È‰ÈÒÓ (2). √ RSV ¤¯ÂÈ Âԯȷ΋ ÂÌÊ¿ÓÈÛË. ∏ ÂÔ¯‹ ¶·È‰È·ÙÚÈ΋ 2006;69:69-71


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‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ™ÙËÓ ∂ÏÏ¿‰· ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ÌÂٷ͇ ¡ÔÂÌ‚Ú›Ô˘ Î·È ª·ÚÙ›Ô˘. ¶Ï¤ÔÓ ÂÈÚÚÂ‹ ÁÈ· ÛÔ‚·Ú‹ ÓfiÛËÛË ·fi ÙÔÓ RSV ›ӷÈ: - Ù· ÚfiˆÚ· Î·È Î˘Ú›ˆ˜ ÂΛӷ Ô˘ ÂͤگÔÓÙ·È ·fi ÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ÙËÓ ÂÔ¯‹ Ù˘ ¤Í·ÚÛ˘ ÙÔ˘ ÈÔ‡ - ·È‰È¿ Ì ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ, .¯. ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (B¶¢), ΢ÛÙÈ΋ ›ÓˆÛË, ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË - ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· - ·È‰È¿ Ì ÚˆÙÔ·ı‹ ‹ ‰Â˘ÙÂÚÔ·ı‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ - ·È‰È¿ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ - ·È‰È¿ Ì Ó¢ÚÔÌ˘˚΋ ÓfiÛÔ (3) ∂ÈϤÔÓ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÓfiÛËÛË ·fi RSV ›ӷÈ: (2,4) - ŒÍÔ‰Ô˜ ·fi ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, ÚÈÓ ‹ ηٿ ÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ RSV - ¶·ÚÔ˘Û›· ¿ÏÏˆÓ ·‰ÂÏÊÒÓ - Û˘Á¯ÚˆÙÈÛÌfi˜ - ∞Ó ËÁ·›ÓÂÈ Û ‚ÚÂÊÔÓËÈ·Îfi ÛÙ·ıÌfi - ∞Ó ÚÔ¤Ú¯ÂÙ·È ·fi Ôχ‰˘ÌË Î‡ËÛË - ∞Ó ÚfiÎÂÈÙ·È Ó· ¯ÂÈÚÔ˘ÚÁËı› ÁÈ· ηډÈÔ¿ıÂÈ· - ¡Â˘ÚÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ - ªÂÁ¿ÏË ·fiÛÙ·ÛË ·fi ÓÔÛÔÎÔÌÂ›Ô (·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ·) - ¶·ıËÙÈÎfi οÓÈÛÌ· - ÷ÌËÏfi ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô £ÂÚ·¢ÙÈο, ÛÙË ÓfiÛËÛË ·fi RSV ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ÂÎÙfi˜ ·fi Ù· ÎÔÈÓ¿ ̤ÙÚ· ·ÔÊ˘Á‹˜ ‰È·ÛÔÚ¿˜ ÏÔÈÌÒÍÂˆÓ (χÛÈÌÔ ¯ÂÚÈÒÓ, Ì¿ÛΘ, ·ÔÊ˘Á‹ Û˘Á¯ÚˆÙÈÛÌÔ‡) Î·È ‚ÚÔÁ¯Ô‰È·ÛÙ·ÏÙÈο, ÛÙÂÚÔÂȉ‹, O2, πgGIV, ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ηϿ ·ÔÙÂϤÛÌ·Ù·. ¶ÚÔÏËÙÈο, ¯ÔÚËÁ‹ıËΠÂȉÈ΋ RSV IgGIV, ·ÏÏ¿ ··ÈÙ›ÙÔ IV ÌfiÓÔ ¯ÔÚ‹ÁËÛË, ÂÌÊ¿ÓÈÛ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÙˆÓ ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ Î·È ÂÓ›ÔÙ ·Ú·ÙËÚ‹ıËÎÂ Î·È ‚·Ú‡ÙÂÚË ÓfiÛËÛË Û Â·Ó·ÌfiÏ˘ÓÛË ÛÙ· ·È‰È¿ Ô˘ ›¯·Ó Ï¿‚ÂÈ RSV IgGIV (2). ∆Ô 1998, ÙÔ FDA Â¤ÙÚ„ ÙË ¯Ú‹ÛË Ù˘ palivizumab (Synagis) ÁÈ· ÚfiÏË„Ë ÌfiÏ˘ÓÛ˘ ·fi ÙÔÓ RSV. ∏ ¯Ú‹ÛË ÙÔ˘ Synagis Ì›ˆÛ ηٿ 55% ÙËÓ ·Ó¿ÁÎË ÁÈ· ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÁÈ· Ïԛ̈ÍË ·fi RSV (5). ™Ù· ÚfiˆÚ· ¯ˆÚ›˜ B¶¢, ÙÔ ÔÛÔÛÙfi Ì›ˆÛ˘ ‹Ù·Ó 78% ÂÓÒ Û ·˘Ù¿ Ì B¶¢ ‹Ù·Ó 39% (1). ∆Ô Synagis Â›Ó·È ÂÍ·ÓıÚˆÔÔÈË̤ÓÔ ÌÔÓÔ¶·È‰È·ÙÚÈ΋ 2006;69:69-71

ÎψÓÈÎfi ·Óٛۈ̷ ÂÓ·ÓÙ›ÔÓ Ù˘ F-ÁÏ˘ÎÔÚˆÙ½Ó˘ ÙÔ˘ RSV. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ Synagis ˘ÂÚÙÂÚ› Ù˘ RSV IgGIV, ‰ÈfiÙÈ ·‰›¯ıË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ÛÙËÓ ÚfiÏË„Ë, Â›Ó·È Â‡ÎÔÏË ÛÙËÓ ¯ÔÚ‹ÁËÛ‹ Ù˘, ‰ÂÓ ¤¯ÂÈ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ ÙˆÓ ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ Î·È Â›Û˘, ‰‡Ó·Ù·È Ó· ¯ÔÚËÁËı› Û˘Á¯ÚfiÓˆ˜ Ì ÂÌ‚fiÏÈ· Ì ˙ÒÓÙ˜ ÈÔ‡˜ .¯. ªªR (6,7). ∆o Synagis ¯ÔÚËÁÂ›Ù·È πª Û ‰fiÛË 15 mg/kg ·Ó¿ Ì‹Ó· Û maximum 5 ‰fiÛÂȘ, ÛÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ RSV. ™Â ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ¯ÔÚ‹ÁËÛË Î·È ÛÙÔÓ 2Ô ¯ÚfiÓÔ ˙ˆ‹˜, ÛÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ ÈÔ‡ (4). ™˘ÌÂÚ·ÛÌ·ÙÈο, ‚¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ, Ë ∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ÂÈÛËÁÂ›Ù·È ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Synagis: ·) ™Â ·È‰È¿ ≤2 ÂÙÒÓ, ·Ó ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· Ó¢ÌÔÓÔ¿ıÂÈ· (µ¶¢) Î·È Ï·Ì‚¿ÓÔ˘Ó ıÂÚ·›· ÁÈ' ·˘Ù‹, ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 6 Ì‹Ó˜ ÚÈÓ ÙËÓ ¤Í·ÚÛË ÙÔ˘ RSV. ‚) ™Â ÚfiˆÚ· ¯ˆÚ›˜ µ¶¢ ·Ó ›ӷÈ: 1. ∏.∫. ≤28 ‚‰. Î·È ÙËÓ ÂÔ¯‹ Ù˘ ¤Í·ÚÛ˘ ÙÔ˘ RSV Â›Ó·È ËÏÈΛ·˜ ≤1 ¤ÙÔ˘˜, 2. ∏.∫. 29-32 ‚‰. Î·È ÙËÓ ÂÔ¯‹ Ù˘ ¤Í·ÚÛ˘ ÙÔ˘ RSV Â›Ó·È ËÏÈΛ·˜ <6 ÌËÓÒÓ, 3. ∏.∫. 33-35 ‚‰. ·Ó Û˘Ó˘¿Ú¯Ô˘Ó ÂÈϤÔÓ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·Ó ÙËÓ ÂÔ¯‹ Ù˘ ¤Í·ÚÛ˘ ÙÔ˘ RSV Â›Ó·È ËÏÈΛ·˜ <6 ÌËÓÒÓ. Á) ™Â Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Ì ·ÈÌÔ‰˘Ó·ÌÈο ÛËÌ·ÓÙÈ΋ ·ÓˆÌ·Ï›·, Ì ΢¿ÓˆÛË ‹ ÌË, ·Ó Â›Ó·È <1 ¤ÙÔ˘˜ ÛÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ RSV. ∂›Û˘, ÛÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Ô˘ ÚfiÎÂÈÙ·È Ó· ¯ÂÈÚÔ˘ÚÁËıÔ‡Ó ‹ ¯ÚÂÈ¿˙ÔÓÙ·È ÓÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë ÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ RSV, fiˆ˜ Â›Û˘ Û ηډÈÔÌ˘Ô¿ıÂȘ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ıÂÚ·›· Û ‚Ú¤ÊË ËÏÈΛ·˜ <1 ¤ÙÔ˘˜ ÙËÓ ÂÔ¯‹ ¤Í·ÚÛ˘ ÙÔ˘ RSV (8). ‰) ™Â ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ‹ Â›ÎÙËÙË ‰È·Ù·Ú·¯‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. √È Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙȘ ∏¶∞ (4), IÛ·Ó›· (1), πÙ·Ï›· (5), µÚÂÙ·Ó›· (3), ∂˘ÚÒË (6), ∫·Ó·‰¿˜ (7), °ÂÚÌ·Ó›· (9), §·ÙÈÓÈ΋ ∞ÌÂÚÈ΋ (2), √ÏÏ·Ó‰›· (10), ¶Ôψӛ· (11), √˘ÁÁ·Ú›· (12).

µÈ‚ÏÈÔÁÚ·Ê›· 1. Spanish Consensus Committee: Prevention of Respiratory Syncytial Virus Infection in Spain. Pediatric Infectious Diseases Journal en Espan~ ol, Octubre 1999. 2. Azar P, Broglia B, Miceli INP, Parga L, Castillo S, Edwin A et al. Guidelines for the use of Palivizumab


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3. 4.

5.

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in the prevention of RSV disease. A consensus opinion. Pediatrics in Review en Espan~ ol, Abril 2000; 21(2):62-68. U.K. Guidelines for the use of Synagis. Document issued by Abbott U.K., 1999. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Prevention of Respiratory Syncytial Virus Infections: Indications for the use of Palivizumab and Update on the use of RSV-IGIV. Pediatrics 1998; 102(5):1211-1216. Giovannini M, Giuffre L, Marini A, Rondini G, Rossi G, Salvioli GP. Respiratory Syncytial Virus Infections in children. State of the Art. Neonatologica 1999;13(2):89-92. Carbonell-Estrany X, Giuffre L, Kimpen Jan LL, Adan D, Calenius H, Devlieger H et al. Guidelines for the use of Synagis® (Palivizumab), a Humanised Monoclonal Antibody for the prevention of Respiratory Syncytial Virus (RSV) Disease in High Risk Infants. A consensus opinion. Supplement to Infections in Medicine, December 1999;16(G):29-33. A joint statement of the Canadian Paediatric Society and the Fetus and Newborn Committee. Palivizumab and respiratory syncytial virus immune globulin intravenously for the prophylaxis of respiratory syncytial virus infection in high risk infants. Paediatrics and Child Health 1999;4(7):474-480.

8. Tulloh R, Marsh M, Blackburn M, Casey F, Lennen W, Weller P et al. Recommendations for the use of Palivizumab as prophylaxis against respiratory syncytial virus in infants with congenital cardiac disease. Cardiol Young 2003;13(5):420-423. 9. Prophylaxis of RSV Infections with immunoglobulin. Statement / report of the German Society of Pediatric Infectology. Coordinator Prof. Dr. J. Foster. Monatsschrift Kinderheilkunde, October 1999;971-972. 10. Duiverman EJ, Lafeber HN, Hartwig N. The standpoint of the pediatric pulmonary diseases, neonatology and infectious diseases divisions of the Pediatric Association of the Netherlands (NVK) regarding the indication in children for the use of Palivizumab. Groningen, 21 September 2001. 11. The National Consultant for Pediatrics and the National Consultant for Neonatology. Guidelines for the Prevention of Respiratory Syncytial Virus (RSV) Infections in High Risk Infants. Prepared by P. Januszewicz et al. Warszawa 2000. 12. Pinter S, Adamovich K, Hajdu J, Katona M, Megyeri P, Nobilis A et al. Professional Guidelines for the use of SYNAGISTM (Palivizumab) for the Prevention of Respiratory Syncytial Virus Infections in Infants, 15 December 1999.

¶·È‰È·ÙÚÈ΋ 2006;69:69-71


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∫§π¡π∫O ∫OÀπ∑ ∞. µ·˙·›Ô˘, ¡. ºÈÔÏÈÙ¿Î˘, ∞. ¶··‰ÔÔ‡ÏÔ˘

∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: ∞. ¶··‰ÔÔ‡ÏÔ˘ E-mail: papadop5@otenet.gr

∞ÁfiÚÈ 11 ÂÙÒÓ ÂÈÛ‹¯ıË ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÏfiÁˆ ηٷ‚ÔÏ‹˜ Î·È ‰ÂηÙÈ΋˜ ˘ÚÂÙÈ΋˜ ΛÓËÛ˘ ·fi 15Ë̤ÚÔ˘ Î·È ‹È·˜ ÂÈÁ·ÛÙÚ·ÏÁ›·˜ ·fi 6Ì‹ÓÔ˘. ∞ÙÔÌÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ·Ó·ÌÓËÛÙÈÎfi ÂχıÂÚÔ. ∞��� ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË Î·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ‰ÂÓ ÚԤ΢„·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· ¤Ú·Ó Ù˘ ˆ¯ÚfiÙËÙ·˜. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÚԤ΢„·Ó Ù· ·Ú·Î¿Ùˆ: ∏b: 7,3g/dl, Ht: 25,5%, MCV: 56,7, RDW: 19, WBC: 9.900 (N: 46%, L: 26%, M:11% ), PLT: 849.000, ∆∫∂: 118 ¯ÈÏ./1Ë ÒÚ·, CRP: 129 mg/L, Fe ÔÚÔ‡: 15Ìg/dl, ÊÂÚÚÈÙ›ÓË: 22 ng/ml (º™ 20-250 ng/ml), ªayer ÎÔÚ¿ÓˆÓ: ·ÚÓËÙÈ΋. BÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜: ÎÊ. ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÁÏÔÈ·‰›Ó˘, ÚÂÙÈÎÔ˘Ï›Ó˘, ÂÓ‰ÔÌ˘˝Ô˘: ·ÚÓËÙÈο, ·˘ÙÔ·ÓÙÈÛÒÌ·Ù·, ·ÙÙ·Ú· χÎÔ˘, Ra test: ·ÚÓËÙÈο, VMA, · - ÊÂÙÔÚˆÙ½ÓË: ·ÚÓËÙÈο, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜: IgG: 2050 mg/dl (↑), IgA: 460 mg;dl (↑), C3: 231 mg/dl (↑). ¢ÂÚÌ·ÙÔ·ÓÙ›‰Ú·ÛË Mantoux (-). ∞ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜: ∞/· ıÒÚ·ÎÔ˜, U/S ÎÔÈÏ›·˜, ‚·ÚÈÔ‡¯Ô˜ ‰È¿‚·ÛË ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘: fiÏ· ÎÊ. CT ÎÔÈÏ›·˜: Î.Ê. ª˘ÂÏfiÁÚ·ÌÌ·: ŸÏ˜ ÔÈ Î˘ÙÙ·ÚÈΤ˜ ÛÂÈÚ¤˜ ·ÚÔ‡Û˜. EÚ˘ıÚ¿ ÛÂÈÚ¿ ˆÚÈÌ¿˙ÂÈ Ì ÌÈÎÚÔ-ÔÚıÔ‚Ï·ÛÙÈÎfi ¯·Ú·ÎÙ‹Ú·, ÛȉËÚ·Ôı‹Î˜ ÎÂÓ¤˜. °·ÛÙÚÔÛÎfiËÛË: ÛÔ‚·Ú‹

Á·ÛÙÚ›Ùȉ· - ‰ˆ‰Âη‰·ÎÙ˘Ï›Ùȉ· Î·È ·Ó‡ÚÂÛË Helicobacter pylori ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Î·È ÙÔ CLO test Ì ηϋ ·Ú¯ÈÙÂÎÙÔÓÈ΋ ÙˆÓ Ï·¯ÓÒÓ ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘. ∆Ô ·È‰› ÂÍ‹Ïı Ì ‰È¿ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË Fe (Hb ÂÍfi‰Ô˘: 9 g/dl) Î·È ·ÁˆÁ‹ ÂÎÚ›˙ˆÛ˘ ÙÔ˘ Helicobacter pylori.

∂·ÓÂͤٷÛË ÌÂÙ¿ 45 Ë̤Ú˜ ∆Ô ·È‰› ÚÔÛ‹Ïı ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ Â·Ó¤ÏÂÁ¯Ô. ∏ ÂÈÁ·ÛÙÚ·ÏÁ›· ›¯Â Ï‹Úˆ˜ ˘Ô¯ˆÚ‹ÛÂÈ, fï˜ ÙÔ ·È‰› ·ÚÔ˘Û›·Û ‹ÈÔ ‚‹¯·. ∞fi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ‚Ú¤ıËΠÌfiÓÔ ‹È· ˆ¯ÚfiÙËÙ·. ∞fi ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÚԤ΢„·Ó Ù· ·Ú·Î¿Ùˆ: ∏b:10g/dl, ∆∫∂ >100 mm/1Ë ÒÚ·, CRP >100 mg/L. §fiÁˆ ÙÔ˘ ‚‹¯·, ÙÔ ·È‰› ˘Ô‚Ï‹ıËΠ۠Ӥ· ·/· ıÒÚ·ÎÔ˜: ‰È‡ڢÓÛË ÌÂÛÔıˆÚ·Î›Ô˘ (ÂÈÎfiÓ· 1), CT ıÒÚ·ÎÔ˜: Ì¿˙· ÛÙÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ (ÂÈÎfiÓ· 2), MIBG ·ÚÓËÙÈÎfi ÁÈ· Ó¢ÚÔ‚Ï¿Ûو̷, ÂͤٷÛË Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ÁÈ· ÔÍ¿ÓÙÔ¯· (-), ‰ÂÚÌ·ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÁÈ· ¿Ù˘· (-), Ì˘ÎÔ‚·ÎÙËÚ›‰È· VMA, HVA (-). ∏ ‰È‡ڢÓÛË ÙÔ˘ Ô›ÛıÈÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÛÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË ÔÊ›ÏÂÙ·È ÛÂ: 1. §¤Ìʈ̷ 2. ¡Â˘ÚÔ‚Ï¿Ûو̷ 3. ¡fiÛÔ Castelman 4. ∆Âڿو̷ 5. ∫˘ÛÙÈÎfi ‡Áڈ̷

∂ÈÎfiÓ· 1.

∂ÈÎfiÓ· 2. CT ıÒÚ·ÎÔ˜: ∂ÍÂÚÁ·Û›· ÛÙÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ, ‰ÂÍÈ¿ Ù˘ ̤Û˘ ÁÚ·ÌÌ‹˜. ÕÚ¯ÂÙ·È ÂÚ›Ô˘ ·fi ÙÔ ‡„Ô˜ Ù˘ ÌÂÛfiÙËÙÔ˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÎfiÏÔ˘ Î·È ÚÔ˜ Ù· ¿Óˆ ÂÎÙ›ÓÂÙ·È Ì¤¯ÚÈ ÙÔ ‡„Ô˜ Ù˘ ÙÚfiȉԘ. ¢È·ÛÙ¿ÛÂȘ: 6 x 5 cm.

∏ ·¿ÓÙËÛË ·ÎÔÏÔ˘ı› ÛÙË ÛÂÏ›‰· 76 ¶·È‰È·ÙÚÈ΋ 2006;69:72,76


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¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜ - ∞ÏÏÂÚÁÈÔÏfiÁÔ˜

∞ÏÏÂÚÁ›Â˜, ˘ÂÚ¢·ÈÛıËۛ˜ Î·È ¿ÛıÌ· ÛÙÔ ÛÙfi¯·ÛÙÚÔ Ù˘ “ÕÓÔÈ͢” http://www.allergyped.gr

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µ' ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ¡›ÎÔ˜ ¶··‰fiÔ˘ÏÔ˜ E-mail: ngp@allergy.gr

∏ ÕÓÔÈÍË Â›Ó·È Ì›· ·ÛÙÈ΋ ÂÙ·ÈÚ›· ÌË ÎÂÚ‰ÔÛÎÔÈÎÔ‡ ¯·Ú·ÎÙ‹Ú·, Ô˘ ÛÙfi¯Ô ¤¯ÂÈ Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ Î·Ù·ÔϤÌËÛË ÙˆÓ ·ÏÏÂÚÁÈÒÓ Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ̤ۈ Ù˘ ÂÓË̤ڈÛ˘, Ù˘ ÂÎ·›‰Â˘Û˘, Ù˘ ÎÔÈÓˆÓÈ΋˜ ·ÚÔ˘Û›·˜ Î·È Ù˘ ¤Ú¢ӷ˜. H ·ÚÔ˘Û›· Ù˘ ÕÓÔÈ͢ ÂÚÈÏ·Ì‚¿ÓÂÈ ‰Ú¿ÛÂȘ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÙfïÓ, Î·È ÂȉÈο ÙˆÓ ·È‰ÈÒÓ Ô˘ ¿Û¯Ô˘Ó ·fi ·ÏÏÂÚÁ›Â˜, ˘ÂÚ¢·ÈÛıËۛ˜ Î·È ¿ÛıÌ·, fiˆ˜ ÛÂÌÈÓ¿ÚÈ· Î·È ËÌÂÚ›‰Â˜ ÛÂ Û˘ÓÂÚÁ·Û›· ÌÂ Â˘Úˆ·˚Τ˜ ÔÚÁ·ÓÒÛÂȘ, (EFA), Î·È ÂÚ¢ÓËÙÈο ‰›ÎÙ˘· (GA2LEN) Î·È ÂΉËÏÒÛÂȘ Ì ÂÎ·È‰Â˘ÙÈÎfi ÂÚȯfiÌÂÓÔ, fiˆ˜ ÙËÓ ¶·ÁÎfiÛÌÈ· ∏̤ڷ ÕÛıÌ·ÙÔ˜. √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ Ù˘ ÕÓÔÈ͢ ·ÔÙÂÏ› ‚·ÛÈÎfi ÂÚÁ·ÏÂ›Ô ÂÈÎÔÈÓˆÓ›·˜ Ì ٷ ̤ÏË Ù˘. ∂ÎÙfi˜ ·fi ÙËÓ ÂÏÏËÓÈ΋ ¤Î‰ÔÛË, Ì Ï‹Ú˜ ÂÚȯfiÌÂÓÔ, ˘¿Ú¯ÂÈ Î·È Ë ·ÁÁÏÈ΋, Ô˘ ¤¯ÂÈ ÂÚÈÏËÙÈÎfi ¯·Ú·ÎÙ‹Ú·. ∆Ô Î‡ÚÈÔ ‚¿ÚÔ˜ Ù˘ ÈÛÙÔÛÂÏ›‰·˜ ‰›ÓÂÙ·È ÛÙËÓ ÏËÚÔÊfiÚËÛË ÛÙÔ Â˘Ú‡ ‰›Ô Ù˘ ·ÏÏÂÚÁÈÔÏÔÁ›·˜, Ì ÏÔ‡ÛÈÔ ÂÓËÌÂÚˆÙÈÎfi ˘ÏÈÎfi Û¯ÂÙÈο Ì ٷ ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, Ô‰ËÁ›Â˜ ÚÔʇϷ͢ Î·È ÚfiÏ˄˘ ηıÒ˜ Î·È ¯Ú‹ÛÈ̘ Û˘Ì‚Ô˘Ï¤˜ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÙfiÌˆÓ Ì ·ÏÏÂÚÁ›Â˜ Î·È ¿ÛıÌ·. À¿Ú¯Ô˘Ó Â›Û˘ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙȘ ÂΉËÏÒÛÂȘ Ù˘ ÔÚÁ¿ÓˆÛ˘. ∞ÈÛıËÙÈο Ô ÙfiÔ˜ Â›Ó·È fiÌÔÚÊÔ˜ Î·È Ë Î›ÓËÛË ·Ó¿ÌÂÛ· ÛÙȘ ÂÓfiÙËÙ˜ ·ÚfiÛÎÔÙË.

º§√°∞ - ™˘Ó¯‹˜ ºÚÔÓÙ›‰· ÁÈ· ÙÔ ·È‰› - http://www.floga.org.gr µ·ÛÈṲ̂ÓÔ˜ ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÂıÂÏÔÓÙÈÛÌÔ‡, Ë ºÏfiÁ· Â›Ó·È Û‡ÏÏÔÁÔ˜ ÌË-ÎÂÚ‰ÔÛÎÔÈÎÔ‡ ¯·Ú·ÎÙ‹Ú· ÁÔÓ¤ˆÓ ·È‰ÈÒÓ Ì ÓÂÔÏ·ÛÌ·ÙÈ΋ ·Ûı¤ÓÂÈ·. ∆Ô ‰›Ô ‰Ú¿Û˘ Â›Ó·È Ë ˘ÔÛÙ‹ÚÈÍË ¿Û˘ ʇÛˆ˜ Î·È Ë Û˘Ì·Ú¿ÛÙ·ÛË ÙˆÓ ·È‰ÈÒÓ Ô˘ ¿Û¯Ô˘Ó ·fi ηÚΛÓÔ. ∆Ô ¤ÚÁÔ ÙÔ˘ Û˘ÏÏfiÁÔ˘, Ô ÔÔ›Ô˜ ÌÂÙÚ¿ 20 ¯ÚfiÓÈ· ·ÚÔ˘Û›·˜, ·ÊÔÚ¿ ·ÚÂÌ‚¿ÛÂȘ Î·È ÂÈÛËÁ‹ÛÂȘ Û ·ÚÌfi‰È˜ ·Ú¯¤˜ Ù˘ ÔÏÈÙ›·˜, ÂÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙȘ Ӥ˜ ıÂÚ·›˜ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÂÈÛÙËÌÔÓÈο ΤÓÙÚ·, ËÌÂÚ›‰Â˜ Î·È ÂΉËÏÒÛÂȘ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ‰˘Ó·Ù‹ È·ÙÚÈ΋, „˘¯È΋ Î·È ÎÔÈÓˆÓÈ΋ ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Î·È ÙË ÁÂÓÈÎfiÙÂÚË Â˘·ÈÛıËÙÔÔ›ËÛË ÛÙȘ ¢·ı›˜ ·˘Ù¤˜ ÔÌ¿‰Â˜. ∂ÈϤÔÓ, Ë ºÏfiÁ· ‰Ú·ÛÙËÚÈÔÔÈÂ›Ù·È Î·È ÁÈ· ÙËÓ ÔÈÎÔÓÔÌÈ΋ ÂÓ›Û¯˘ÛË ÙˆÓ ·‰‡Ó·ÌˆÓ ÔÌ¿‰ˆÓ, ̤ۈ È·ÙÚÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·È Î·Ï‡ÙÔÓÙ·˜ ÙȘ ‚·ÛÈΤ˜ ·Ó¿ÁΘ ‰È·‚›ˆÛ˘. ¶·È‰È·ÙÚÈ΋ 2006;69:73-75


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√ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ ÙÔ˘ Û˘ÏÏfiÁÔ˘ ºÏfiÁ· Â›Ó·È ·ÚÎÂÙ¿ ·Ïfi˜ ÛÙËÓ ÏÔ‹ÁËÛË Î·È ÏÈÙfi˜ ÛÙÔ ÂÚȯfiÌÂÓÔ, Ì ٤ÛÛÂÚȘ ıÂÌ·ÙÈΤ˜ ηÙËÁÔڛ˜. ¶ÂÚȤ¯ÂÈ ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ˘˜ ÙÚfiÔ˘˜ Î·È Ù· ̤۷ Ì ٷ ÔÔ›· ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ Î·È Ó· Û˘ÓÂÈÛʤÚÂÈ ÔÈÎÔÓÔÌÈο Ô Î·ı ÂӉȷÊÂÚfiÌÂÓÔ˜.

ºπ§√π ∆√À ¶∞π¢π√À - °›Ó ÎÈ ÂÛ‡ Ê›ÏÔ˜ - http://www.filoitoupediou.gr/ √È º›ÏÔÈ ÙÔ˘ ¶·È‰ÈÔ‡ Â›Ó·È ¤Ó· ÊÈÏ·ÓıÚˆÈÎfi ÌË ÎÂÚ‰ÔÛÎÔÈÎfi ۈ̷ÙÂ›Ô Ì ·ÓÙÈΛÌÂÓÔ ÙËÓ ÚÔÛÙ·Û›· Î·È ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Ô˘ ›Ù ·ÓÙÈÌÂÙˆ›˙ÂÈ ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜, ›Ù ÌÂÁ·ÏÒÓÂÈ Û ÌÔÓÔÁÔÓÂ˚΋ ÔÈÎÔÁ¤ÓÂÈ·, ›Ù Û ›‰Ú˘Ì·, ›Ù ·ÓÙÈÌÂÙˆ›˙ÂÈ ÁÂÓÈÎfiÙÂÚ· ÎÔÈÓˆÓÈο, „˘¯ÔÏÔÁÈο Î·È ÔÈÎÔÓÔÌÈο ÚÔ‚Ï‹Ì·Ù·. ∞ÒÙÂÚÔ˜ ÛÙfi¯Ô˜ ÙÔ˘ ۈ̷Ù›Ԣ Â›Ó·È Ë Û˘Ì‚ÔÏ‹, Ì οı ̤ÛÔ, ÛÙËÓ ÔÌ·Ï‹ ÂͤÏÈÍË Î·È „˘¯ÔÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ. °È· ÙÔÓ ÛÎÔfi ·˘Ùfi, ÙÔ ÛˆÌ·ÙÂ›Ô ‰›ÓÂÈ ¤ÌÊ·ÛË ÛÙËÓ ·Í›· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ˆ˜ ÙÔ È‰·ÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡. ∏ ‰Ú¿ÛË ÙÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ‰ÈÔÚÁ¿ÓˆÛË ÊÈÏ·ÓıÚˆÈÎÒÓ ÂΉËÏÒÛˆÓ, Û˘Ó·˘ÏÈÒÓ, bazaar, Î·È ÂÎı¤ÛÂˆÓ ¿ÓÙ· Ì Â›ÎÂÓÙÚÔ ÙÔ ·È‰›. ™Ù· ÌÂÏÏÔÓÙÈο ÙÔ˘ Û¯¤‰È· ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÔÏÔÎÏ‹ÚˆÛË ¶·È‰ÈÎÔ‡ ™Ù·ıÌÔ‡ ÁÈ· ÙË ÛÙ¤Á·ÛË ·È‰ÈÒÓ ·Ó‡·ÓÙÚˆÓ ÌËÙ¤ÚˆÓ, ¤ÚÁÔ Ô˘ ‚Ú›ÛÎÂÙ·È Û ÂͤÏÈÍË. √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ º›ÏÔÈ ÙÔ˘ ¶·È‰ÈÔ‡ ÂÎÙfi˜ ·fi ÙȘ ‚·ÛÈΤ˜ ÂÓfiÙËÙ˜ Ì ÏËÚÔÊÔÚÈ·Îfi ΢ڛˆ˜ ÂÚȯfiÌÂÓÔ, ÚÔÛʤÚÂÈ Î·È ·ÓÔȯً ÁÚ·ÌÌ‹ ÂÈÎÔÈÓˆÓ›·˜ Ì ηı ÂӉȷÊÂÚfiÌÂÓÔ ÁÈ· ÙËÓ ·ÚÔ¯‹ Û˘Ì‚Ô˘ÏÒÓ Î·È ˘ԉ›ÍˆÓ. Œ¯ÂÈ ÌÔÓÙ¤ÚÓÔ Û¯Â‰È·ÛÌfi Û ˙ˆËÚ¿ ¯ÚÒÌ·Ù· Î·È Â‡ÎÔÏË ÏÔ‹ÁËÛË. ∏ ηÙËÁÔÚ›· “∂ΉËÏÒÛÂȘ” ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È Â‡ÎÔÏË Ì˯·Ó‹ ·Ó·˙‹ÙËÛ˘ ÙˆÓ ÂΉËÏÒÛÂˆÓ Ô˘ ¤¯Ô˘Ó Ï¿‚ÂÈ ¯ÒÚ· ÛÙÔ ·ÚÂÏıfiÓ ÂÓÒ ÂÓËÌÂÚÒÓÂÙ·È Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·.

¶¡√∏ - ∞Ó¿Û· ·Ó·ÎÔ‡ÊÈÛ˘ ÁÈ· Ù· ·È‰È¿ - http://www.pnoe.gr/ ∏ ¶¡√∏ - º›ÏÔÈ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ¶·È‰ÈÔ‡ Â›Ó·È ¤Ó· ۈ̷ÙÂ›Ô ÌË ÎÂÚ‰ÔÛÎÔÈÎÔ‡ ¯·Ú·ÎÙ‹Ú·, Ì ¤‰Ú· ÙËÓ ∂ÏÏ¿‰· ÙÔ ÔÔ›Ô È‰Ú‡ıËΠÙÔ 1991 ·fi ÁÔÓ›˜, ·È‰È¿ÙÚÔ˘˜ Î·È Ê›ÏÔ˘˜ ÂıÂÏÔÓÙ¤˜. ™Ùfi¯Ô˜ ÙÔ˘ Â›Ó·È Ô È·ÙÚÈÎfi˜ ÂÍÔÏÈÛÌfi˜ ÙˆÓ ªÔÓ¿‰ˆÓ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ·È‰ÈÒÓ Î·È ÓÂÔÁÓÒÓ, Ë ÔÈÎÔÓÔÌÈ΋ ÂÓ›Û¯˘ÛË Î·È ËıÈ΋ Û˘Ì·Ú¿ÛÙ·ÛË ÙˆÓ ÁÔÓ¤ˆÓ Ù· ·È‰È¿ ÙˆÓ ÔÔ›ˆÓ ÓÔÛËχÔÓÙ·È Û ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜, Ë ·ÔηٿÛÙ·ÛË ÙˆÓ ›‰ÈˆÓ ÙˆÓ ·È‰ÈÒÓ fiÙ·Ó ‚ÁÔ˘Ó ·fi ÙËÓ ∂ÓÙ·ÙÈ΋ ÁÈ· ÙȘ ηχÙÂÚ˜ Û˘Óı‹Î˜ ‰È·‚›ˆÛ˘. ∂ÈϤÔÓ, ÂÎÙfi˜ ·fi Ù· ·È‰È¿-·ÛıÂÓ›˜, Ë ‰Ú¿ÛË ÙÔ˘ ۈ̷Ù›Ԣ ÂÂÎÙ›ÓÂÙ·È Î·È Û ı¤Ì·Ù· ÂÎ·›‰Â˘Û˘ Î·È ÂÈÌfiÚʈÛ˘ ÙÔ˘ È·ÙÚÈÎÔ‡, ÓÔÛËÏ¢ÙÈÎÔ‡ Î·È ·Ú·˚·ÙÚÈÎÔ‡ ÚÔÛˆÈÎÔ‡ ÙˆÓ ªÔÓ¿‰ˆÓ. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÂηÂÓÙ·ÂÙÔ‡˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘, ÙÔ ÛˆÌ·ÙÂ›Ô ¤¯ÂÈ Ú·ÁÌ·ÙÔÔÈ‹ÛÂÈ ÛÂÈÚ¿ ‰Ú¿ÛˆÓ, fiˆ˜ ÛÂÌÈÓ¿ÚÈ·

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∫·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋˜ ∞Ó¿Ó˄˘ (Ì·Ï¿ÍÂȘ, ÊÈÏ› Ù˘ ˙ˆ‹˜) Ù· ÔÔ›· Á›ÓÔÓÙ·È ·fi ÂÎ·È‰Â˘Ì¤ÓÔ˘˜ ÁÈ·ÙÚÔ‡˜ Û ÂȉÈο ‰È·ÌÔÚʈ̤ÓÔ˘˜ ¯ÒÚÔ˘˜ ·ÏÏ¿ Î·È Û ۯÔÏ›·, Á˘ÌÓ·ÛÙ‹ÚÈ· Î·È ÂȯÂÈÚ‹ÛÂȘ. ∆· Ì·ı‹Ì·Ù· Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÂÙ·È Ë Û˘Ó¯‹ Â·Ê‹ Ì ÙÔ ·ÓÙÈΛÌÂÓÔ. ™ÙË Û¯ÂÙÈ΋ ÛÂÏ›‰· ÙÔ˘ ‰ÈÎÙ˘·ÎÔ‡ ÙfiÔ˘ ˘¿Ú¯ÂÈ Î·È Ë ÊfiÚÌ· ÂΉ‹ÏˆÛ˘ ÂӉȷʤÚÔÓÙÔ˜ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÛÙÔ ÚfiÁÚ·ÌÌ·. √ ‰ÈÎÙ˘·Îfi˜ ÙfiÔ˜ ¶¡√∏ ÚÔÛʤÚÂÈ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙȘ ‰Ú¿ÛÂȘ ÙÔ˘ ۈ̷Ù›Ԣ ÛÙÔ ·ÚÂÏıfiÓ, fiˆ˜ ÂΉËÏÒÛÂȘ, ËÌÂÚ›‰Â˜, ÂÍÔÏÈÛÌfi È·ÙÚÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ ÂÓÒ ·Ó·Ê¤ÚÔÓÙ·È Î·È Ù· ÌÂÏÏÔÓÙÈο Û¯¤‰È·. √ ۯ‰ȷÛÌfi˜ Â›Ó·È ÌÔÓÙ¤ÚÓÔ˜ Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙ· ÓÂÔÁÓ¿, ÂÓÒ Û οı ÂÓfiÙËÙ· Â›Ó·È ÂÌÊ·Ó¤˜ ÙÔ ÌfiÙÔ ÙÔ˘ ۈ̷Ù›Ԣ ŒÓ· ¶·È‰› ˙ËÙ¿ ÙË µÔ‹ıÂÈ¿ Û·˜.

ª·Ú›· ¶··Ê›ÏË °È· ÏËÚÔÊÔڛ˜: www.euran.com ªaria Papafili For information: www.euran.com

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CLINICAL QUIZ ∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏

™ÙÔ ·È‰› ¤ÁÈÓ ‚ÈÔ„›· ‰È¿ ÏÂÙ‹˜ ‚ÂÏfiÓ˘ (FNA) ˘fi ÙËÓ Î·ıÔ‰‹ÁËÛË ·ÍÔÓÈÎÔ‡ ÙÔÌÔÁÚ¿ÊÔ˘, Ë ÔÔ›· ‰ÂÓ Â›¯Â ‰È·ÁÓˆÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÁÈ’ ·˘Ùfi Î·È ˘Ô‚Ï‹ıËΠ۠ıˆÚ·ÎÔÙÔÌ‹ Î·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË Ù˘ Ì¿˙·˜ ·fi ÙÔ ÌÂÛÔıˆÚ¿ÎÈÔ. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ¤‰ÂÈÍ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ¡fiÛÔ Castleman ÌÈÎÙÔ‡ Ù‡Ô˘. ªÂÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË ÙÔ ·È‰› ‰ÂÓ ·ÚÔ˘Û›·Û ηӤӷ Úfi‚ÏËÌ·. ∏ ÓfiÛÔ˜ Castleman Â›Ó·È ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈ΋ ‰È·Ù·Ú·¯‹ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜. ∂ΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ 4Ë ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ Î·È Û¿ÓÈ· ÛÙ· ·È‰È¿. ∏ ÓfiÛÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ‰‡Ô ÌÔÚʤ˜: ÙËÓ ÂÓÙÔÈṲ̂ÓË Î·È ÙËÓ ÔÏ˘ÂÛÙÈ΋ Î·È ÈÛÙÔÏÔÁÈο Ì ÙÚÂȘ Ù‡Ô˘˜: ÙÔÓ ˘·ÏÈÓÔ·ÁÁÂÈÒ‰Ë ÙÔÓ Ï·ÛÌ·ÙÔ΢ÙÙ·ÚÈÎfi Î·È ÙÔÓ ÌÈÎÙfi Ù‡Ô. ∏ ÂÓÙÔÈṲ̂ÓË ÌÔÚÊ‹ (85%) ¯·Ú·ÎÙËÚ›˙ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÌÈ· ·ÚÁ¿ ·˘Í·-

ÓfiÌÂÓË Ì¿˙· Ô˘ ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ (Û ·ÓÙ›ıÂÛË Ì ÙÔ ÙÂڿو̷ Ô˘ ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Ì¤ÛÔ Î·È ÙÔ Ï¤Ìʈ̷ Î·È ÙÔ Î˘ÛÙÈÎfi ‡Áڈ̷ Ô˘ ÂÓÙÔ›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙÔ ÚfiÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ), ÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ· ‹ ÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÏÂÌÊ·‰¤Ó˜. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ı· Ú¤ÂÈ Ó· Á›ÓÂÈ Â›Û˘ ·fi ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷ Î·È ÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ fiÁÎÔ˘˜ Ó¢ÚÔÂ͈‰ÂÚÌÈ΋˜ ÚÔ¤Ï¢Û˘. ∏ ÎÏÈÓÈ΋ ÔÚ›· Â›Ó·È ‹È· Ì ·ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔÓ ˘ÚÂÙfi, ÙË ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·, ÙËÓ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ÙÔ˘˜ ·˘ÍË̤ÓÔ˘˜ ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜. ∏ ÚfiÁÓˆÛË ÌÂÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË Â›Ó·È Î·Ï‹. ∏ ÔÏ˘ÂÛÙȷ΋ ÌÔÚÊ‹ ··ÓÙ¿Ù·È Û fiÁÎÔ˘˜ Ì ÔÏÏ·Ϥ˜ ÂÓÙÔ›ÛÂȘ, ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈο Î·È ¤¯ÂÈ ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË, ηıÒ˜ ÌÔÚ› Ó· ÂÈϷΛ Ì ηÎÔ‹ıÂȘ ‹ ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Parez N, Bader-Meunier B, Roy CC, Dommergues JP. Paediatric Castleman disease: report of seven cases and review of the literature. Eur J Pediatr. 1999 Aug;158(8):631-7.

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2. Salisbury JR. Castleman's disease in childhood and adolescence: report of a case and review of literature. Pediatr Pathol. 1990;10(4):609-15.


Παιδιατρική | Τόμος 69 • Τεύχος 1 • Ιανουάριος - Φεβρουάριος 2006