Παιδιατρική | Τόμος 71 • Τεύχος 2 • Μάρτιος - Απρίλιος 2008

Pediatri Mar-Apr 08

10-04-08

12:30

¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜ M¤ÏË ™. ∞Ó‰ÚÔÓ›ÎÔ˘ ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ∂. °·Ï·Ó¿Î˘ §. £ˆÌ·˝‰Ô˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ ™. K›ÙÛÈÔ˘-∆˙¤ÏË ∞. ¶··‰ÔÔ‡ÏÔ˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿ ÀÔ‚ÔÏ‹ ∂ÚÁ·ÛÈÒÓ e-mail: hps@ath.forthnet.gr √‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜: http://www.e-child.gr/Instructions_ to_Authors_GR.pdf ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ M. ¡·ÙÛÔ˘Ï›‰Ô˘ EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘ EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜ E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶ÈÂÚ›·˜ 1∞ 144 51 MÂÙ·ÌfiÚʈÛË TËÏ.: 210 87 78 810 Fax: 210 87 78 822 I‰ÈÔÎÙ‹Ù˘ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889

ISSN 0377-2551

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¶·È‰È·ÙÚÈ΋ ∆fiÌÔ˜ 71 ñ ∆‡¯Ô˜ 2 ñ ª¿ÚÙÈÔ˜-∞Ú›ÏÈÔ˜ 2008

¶ÂÚȯfiÌÂÓ· ∞¡∞™∫O¶∏™∂π™ 87 Paediatric liver transplantation: historical notes G. C. Sotiropoulos, S. Nadalin, A. Radtke, H. Lang 92 Childhood obesity – ∞ public health crisis across the European Union A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso 96 Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity M. Ponce-Rivera, D. Fuentes-Lugo

141 ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿: ÂÌÂÈÚ›· 15 ÂÙÒÓ Û ¤Ó· ΤÓÙÚÔ Ÿ. µÚ¿ÓË, ª. ¶·ÓÙÈΛ‰Ô˘, °. ÿÌ‚ÚÈÔ˜, π. •˘ÓÈ¿˜, µ. ¢ÂÌÂÚÙ˙›‰Ô˘, ∫. ∫¿ÓÙ˙ÈÔ˘, ∞. ª·˘ÚÔ˘‰‹, ¢. ∆·ÎÔ‡‰·˜, £. ¶··ÛÙ·‡ÚÔ˘, ∫. ™‡ÚÔÁÏÔ˘ 148 √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ µ. ∆ÛÈ¿ÓÙÔ˘, ∞. ∫·Úfi΢, ∂. ¶¿‚Ë, °. ∫˘ÚÈfiÔ˘ÏÔ˜ ¶ƒ∞∫∆π∫√ £∂ª∞ 157 ¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ÁÈ· ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ ∞. ∫·Ê¿ÙÔ˜

105 µ·ÛÈΤ˜ Ù¯ÓÈΤ˜ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ ÛÙË ‰È¿ÁÓˆÛË ·È‰È·ÙÚÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜

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162 Recurrent Respiratory Papillomatosis: case report and literature review D. A. Nunez

123 ∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ E. ∫Ô‡ÛÙ·, ∞. ¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘† ∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™ 128 ∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·È‰È¿ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ª. ¶··‰ÔÔ‡ÏÔ˘, ™. ¡ÙÔ˘Ì¿, ∫. ∫›ÙÛÈÔ˜, ¡. ∫·‰fiÁÏÔ˘, ∫. ∫ÒÛÙ·, π. ∆ÛÈÔ‡Ú˘ 135 ªÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi Èfi Epstein-Barr Î·È ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË, ∞. ºÏ¤‚·, µ. ∞ÓÙ¿ÚË, ∞. ¶·˘Ï›ÙÔ˘-∆ÛÈfiÓÙÛË, ª. ªÔÛÎÔÊ›‰Ë˜, °. µ·ÚÏ¿Ì˘

165 ∫§π¡π∫√ ∫√Àπ∑ ¶. ™ËÊÈ·ÓÔ‡, ∫. ºˆÙ›Ô˘, ∫. ™ÎÈ·‰¿˜, ∫. ¶··Á·ÚÔ˘Ê¿Ï˘ ∂¶I∫∞πƒ√ £Eª∞ 166 ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞ 171 ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ 2008 E. °·Ï·Ó¿Î˘ ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ 173 ™‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ ‰È·‰›ÎÙ˘Ô ∫. ™ÙÂÊ·Ó›‰Ë˜

Pediatri Mar-Apr 08

08-04-08

11:51

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Bimonthly Publication of the Greek Paediatric Society

Paediatriki

President A. Constantopoulos Editorial Board Editor-in-Chief C. Stefanidis Members S. Andronikou P. Augoustides-Savvopoulou A. Vazeou-Gerasimidi G. Varlamis ∂. Galanakis L. Thomaidou M. Kanariou ∂. Katsarou-Pectasides A. Kattamis S. Kitsiou-Tzeli ∞. Papadopoulou N. Papadopoulos A. Siamopoulou-Mavridou M. Tsolia Manuscript submission e-mail: hps@ath.forthnet.gr Instructions to authors: http://www.e-child.gr/paediatriki/ iae.pdf Manuscript Editing Greek Editing M. Natsoulidou English Editing S. Nakou Publisher K. Griveas Publishing Coordinator SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822 Owner Greek Paediatric Society© 92 Michalakopoulou St. GR - 115 28, Athens Tel.: +30 210 7771 140 +30 210 7771 663 Fax: +30 210 7758 354 e-mail: hps@ath.forthnet.gr Annual Subscription All foreign countries: US $ 50

Volume 71 ñ Number 2 ñ March-April 2008

Contents REVIEW ARTICLES 87 Paediatric liver transplantation: historical notes G. C. Sotiropoulos, S. Nadalin, A. Radtke, H. Lang 92 Childhood obesity – ∞ public health crisis across the European Union A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso 96 Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity M. Ponce-Rivera, D. Fuentes-Lugo 105 Basic techniques of molecular biology and their applications in the diagnosis of childhood diseases S. Megremis, A. Pampanos 116 New aspects of infant nutrition C. Costalos 123 Indications for administering growth hormone to children and adolescents E. Kousta, A. Papathanassiou, C. Hadjiathanassiou† ORIGINAL ARTICLES 128 Final height of children with growth hormone deficiency who received replacement treatment M. Papadopoulou, S. Douma, ∫. ∫itsios, ¡. ∫adoglou, ∫. ∫osta, π. Tsiouris 135 Study of the immunophenotype of peripheral blood lymphocyte subsets in children with Epstein-Barr virus and cytomegalovirus infection: association with outcome ∂. Papadopoulou-Alataki, ∞. Fleva, V. Antari, ∞. Pavlitou-∆siontsi, ª. Moskofidis, G. Varlamis

141 Liver transplantation in children: 15 years experience in one center O. Vrani, ª. Pantikidou, G. Imvrios, π. Xinias, V. Demertzidou, ∫. ∫antziou, ∞. Mavroudi, D. Takoudas, T. Papastaurou, ∫. Spyroglou 148 Economic evaluation of new vaccines against varicella, serogroup C meningococcus and pneumococcus V. ∆siantou, ∞. ∫arokis, ∂. Pavi, G. ∫yriopoulos PRACTICAL ISSUE 157 Childhood and adolescent nutrition for promoting health and growth and preventing chronic diseases ∞. ∫afatos CASE REPORT 162 Recurrent Respiratory Papillomatosis: case report and literature review D. A. Nunez 165 CLINICAL QUIZ P. Sifianou, ∫. Fotiou, ∫. Skiadas, ∫. Papagaroufalis CURRENT ISSUE 166 National Immunization Programme PAEDIATRIC NEWS IN BRIEF 171 National Immunization Programme 2008 E. Galanakis NEWS FROM THE INTERNET 173 Paediatric news in brief at the internet C. Stefanidis

Pediatri Mar-Apr 08

07-04-08

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™À¡∆∞∫∆π∫∏ E¶π∆ƒ√¶∏

EDITORIAL BOARD

¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘

Editor-in-Chief

∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ∞ı‹Ó·

Constantinos Stefanidis, Athens

∂ȉÈÎÔ› ™˘ÓÙ¿ÎÙ˜

Section Editors

™Ù¤ÏÏ· ∞Ó‰ÚfiÓÈÎÔ˘, ¡ÂÔÁÓÔÏÔÁ›·, πˆ¿ÓÓÈÓ·

Stella Andronikou, Neonatology, Ioannina

¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, MÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, £ÂÛÛ·ÏÔÓ›ÎË

Persefoni Avgoustides-Savvopoulou, Metabolic Disorders, Thessaloniki

∞Ó‰ÚÈ·Ó‹ µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë, ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·, ∞ı‹Ó·

Andriani Vazaiou-Gerasimidi, Endocrinology, Athens

°ÂÒÚÁÈÔ˜ µ·ÚÏ¿Ì˘, ∫·Ú‰ÈÔÏÔÁ›·, £ÂÛÛ·ÏÔÓ›ÎË

George Varlamis, Cardiology, Thessaloniki

∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, ∏ıÈ΋ Î·È ¢ÂÔÓÙÔÏÔÁ›·, ∏Ú¿ÎÏÂÈÔ

Emmanouil Galanakis, Ethics and Deontology, Heraklion

§ˆÚ¤ÙÙ· £ˆÌ·˚‰Ô˘, ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, ∞ı‹Ó·

Loretta Thomaidou, Developmental Pediatrics, Athens

ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ÓÔÛÔÏÔÁ›·, ∞ı‹Ó·

Maria Kanariou, Immunology, Athens

∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ¡Â˘ÚÔÏÔÁ›·, ∞ı‹Ó·

Eustathia Katsarou-Pektasides, Neurology, Athens

∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·, ∞ı‹Ó·

Antonis Kattamis, Haematology - √ncology, Athens

™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË, °ÂÓÂÙÈ΋, ∞ı‹Ó·

Sophia Kitsiou-Tzeli, Genetics, Athens

∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· - ¢È·ÙÚÔÊ‹, ∞ı‹Ó·

Alexandra Papadopoulou, Gastroenterology - Nutrition, Athens

¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏÔÁ›· - ¶Ó¢ÌÔÓÔÏÔÁ›·, ∞ı‹Ó·

Nicos Papadopoulos, Allergology - Pneumonology, Athens

∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, ƒÂ˘Ì·ÙÔÏÔÁ›·, πˆ¿ÓÓÈÓ·

Antigoni Siamopoulou-Mavridou, Rheumatology, Ioannina

ª·Ú›˙· ∆ÛÔÏÈ¿, §ÔÈ̈ÍÈÔÏÔÁ›·, ∞ı‹Ó·

Marisa Tsolia, Infectious Diseases, Athens

ª¤ÏË Ù˘ ¢ÈÂıÓÔ‡˜ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ ñ Members of the International Editorial Board Alexis Arzimanoglou, Paris, France

Peter Hoyer, Essen, Germany

Ellis D. Avner, Milwaukee, USA

Jan Janda, Prague, Czech Republic

Swati Bhave, New Delhi, India

Jan Kimpen, Ultrecht, Netherlands

Alberto Bissot, Panama, Panama

Craig B. Langman, Chicago, USA

David Branski, Jerusalem, Israel

John Manis, Boston, USA

Francesco Chiarelli, Chieti, Italy

Manuel Moya, Alicante, Spain

Chok-Wan Chan, Hong Kong, China

Hugh O'Brodovich, Toronto, Canada

Denis Daneman, Toronto, Canada

Ross Petty, Vancouver, Canada

Jochen Ehrich, Hannover, Germany

Willem Proesmans, Leuven, Belgium

Demetrius Ellis, Pittsburgh, USA

Jose Ramet, Antwerp, Belgium

Yoshikatsu Eto, Tokyo, Japan

Nikolai Shabalov, St. Petersburg, Russia

Richard N. Fine, Stony Brook, USA

Alan Sinaiko, Minneapolis, USA

Margaret C. Fisher, Philadelphia, USA

Nick J. Spencer, Coventry, UK

Raif Geha, Boston, USA

Alfred Tenore, Udine, Italy

Adenike Grange, Lagos, Nigeria

Alkis Togias, Bethesda, USA

Judith G. Hall, Vancouver, Canada

Eva Tsalikian, Iowa City, USA

Patricia Hamilton, London, UK

Catherine Weil-Olivier, Paris, France

Enver Hasanoglu, Ankara, Turkey

Max Zach, Graz, Austria

Christer Holmberg, Helsinki, Finland

Zheng-Yan Zhao, Hangzhou, China

Lewis B. Holmes, Boston, USA

Johannes Zschocke, Heidelberg, Germany

v

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07-04-08

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REVIEW ARTICLE

87

Paediatric liver transplantation: historical notes G. C. Sotiropoulos1,2, S. Nadalin2, A. Radtke1,2, H. Lang1,2 Abstract: Liver transplantation (LT) is now a standard treatment for children with end-stage liver disease, with very good 1- and 5-year survival rates, which have been achieved through the constant improvement of surgical techniques and clinical management, and use of new immunosuppressive drugs. The indications for LT in infants and children include acute liver failure, chronic liver failure with pruritus, complications of cholestasis and failure to thrive. In young children the most common liver disease leading to transplantation is biliary atresia, which accounts for at least 50% of all LTs in children and is characterized by the failure of the bile ducts to develop normally and drain bile from the liver. Although the majority of transplanted children enjoy an excellent quality of life, there are still many possible complications, including short-term primary non-function, vascular and biliary problems, bowel perforation, severe rejection, infection, hypertension with long-term renal impairment, chronic rejection, de novo autoimmunity, lymphoproliferative disease and cancer, most of which are related to anti-rejection drug toxicity. This paper focuses on the historical development of surgical techniques in the era of paediatric LT. Key words: Liver transplantation, paediatric transplant programme, split liver, living donor liver

1 Department of General, Abdominal and Transplant Surgery, University Hospital, Johannes Gutenberg University Mainz, Germany 2 Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany Correspondence: Georgios C. Sotiropoulos sotiropoulos@ach.klinik. uni-mainz.de Klinik für Allgemein-, Abdominal- und Transplantationschirurgie, Klinikum der Johannes Gutenberg Universität Mainz, Langenbeckstraße 1, 55131 Mainz, Germany

transplantation, split techniques, liver insufficiency, liver failure, biliary atresia.

Introduction Paediatric liver transplantation (LT) is an established method of treatment for patients with end-stage liver failure. Its mortality has decreased dramatically since its first description, thanks to new strategies for immunosuppression, new surgical techniques (1,2), and the improved overall condition of the patients prior to transplantation. The introduction of the splitliver (SL) techniques has dramatically improved the problem of organ shortage (3,4).

Full-Size LT The first clinical attempt at liver replacement was made by Starzl on March 1st, 1963 on a 3 year-old child who had developed end-stage liver disease from biliary atresia, but “he bled to death as we worked desperately to stop the haemorrhage. The operation could not be completed” (5). This attempt was followed in 1963 by transplantation of livers into four adult patients, who all died from pulmonary embolism, after otherwise successful transplants. Starzl performed the next eight LTs in infants and children (6) all of whom survived surgery, but four died after 2-6 months from sepsis. This series of fatal complications was attributed to inadequate immunosuppression, followed by rejection. Between March 1963 and July 1976, 111 LTs were performed at the University of Colorado, but with a 1-year survival rate of only 28%. Such poor results were attributed to technical and medical problems (80%)

and acute rejection (20%) (7). From July 1976 to December 1977, following technical and diagnostic improvements the paediatric 1-year survival rate doubled from 34 to 62%. Based on these improved results, the development of other LT centres was undertaken.

In Europe, the first attempt at LT was made on a 10 month-old child with biliary atresia on June 6th, 1968 in Cambridge, UK, by Sir Roy Calne. As with Starzl’s first attempt, the child died during surgery. The first successful LT in Europe was performed by Otte et al. on March 17th, 1971 on a 17 month-old boy with biliary atresia. The recovery was uneventful until the child developed acute rejection, which was reversed by steroids, but he died 7 weeks after transplantation from massive intrathoracic bleeding caused by a liver biopsy (8). Following this case, as in the USA, there was a long-term moratorium before the LT programme was finally resumed in 1984. The four children transplanted that year are still alive, including the first patient who received a reduced liver graft and who is currently, worldwide, the longest survivor with her original cut-down liver (9).

All the early LT patients were treated with a drug regimen that had been developed for kidney grafts, namely azathioprine and steroids, sometimes with the addition of antilymphocyte globulins. Because of inadequate immunosuppression, long-term survival was observed in less than one third of patients. At the beginning of the 1980s, the introduction of cyclosporine led to a ¶·È‰È·ÙÚÈ΋ 2008;71:87-91

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G. C. Sotiropoulos et al.

Figure 1a. Adult split liver transplantation Right versus left liver split for an adult recipient, 3-dimensional reconstruction. Right graft segments 5-8 (green), left graft segments 1-4 (brown). RHV-right hepatic vein (blue), MHV-middle hepatic vein (yellow), LHV-left hepatic vein (red).

Figure 1b. Adult split liver transplantation Right versus left liver split for an adult recipient, 3-dimensional reconstruction of the hepatic veins. The line of division lies exactly over the MHV-middle hepatic vein (yellow). RHV-right hepatic vein (blue), LHV-left hepatic vein (red).

significant increase of graft and patient survival rates.

In March 1980, the liver trials with cyclosporine A immunosuppression began in Denver. Twelve patients entered the study between March and September 1980, of whom 11 lived for one year or longer (10).

In October 1986 representatives of the eight centres in Europe and the USA with experience of at least 20 paediatric LTs (i.e., Boston, Brussels, Cambridge, Dallas, Hannover, Minneapolis, Pittsburgh and Los Angeles) met for an update on the status of paediatric LT: long-term (>1 year) patient survival had reached 57-83%; all centres were using cyclosporine-based primary immunosuppression; the major indications biliary atresia being the most frequent - were already clearly delineated.

Since the implementation of LT for end-stage liver disease there has been a strong disparity between organ demand and the cadaveric donor supply for children.

This initially resulted in a pre-transplant mortality for

children on the waiting list for LT of around 25%, which was disproportionably high compared with that of adult patients (11). The problem of size mismatch and the different epidemiology of paediatric donorship and terminally diseased children were responsible for the disparity (12). This stimulated the development of technical innovations, based on the segmental anatomy of the liver, which facilitated transplanting parts of a large cadaveric donor liver into smaller recipients: i.e. reduced size LT, split LT and living donor LT.

Reduced size liver transplantation (RSLT) The first step in solving the size mismatch problem was the introduction of reduced-size techniques.

With this approach, after harvesting the liver from a cadaver donor, liver resection is performed on the back table to tailor the size of the graft to that of one single recipient. The remaining resected liver tissue is discarded. In paediatric RSLT either the left lateral

Figure 1c. Adult split liver transplantation Left liver graft segments 1-4 for an adult recipient, 3-dimensional reconstruction. The right-sided border of the MHV-middle hepatic vein (yellow) can be seen exposed on the transection surface. All tributaries from segments 5 and 8 are exposed at their confluence with the MHV trunk. RHV-right hepatic vein (blue), LHV-left hepatic vein (red).

Figure 1d. Adult split liver transplantation Right liver graft segments 5-8 for an adult recipient, 3-dimensional reconstruction. The left-sided border of the MHV-middle hepatic vein (yellow) can be seen exposed on the transection surface. All tributaries from segments 4a and 4b are exposed at their confluence with the MHV trunk. RHV-right hepatic vein (blue), LHV-left hepatic vein (red).

Paediatriki 2008;71:87-91

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Paediatric liver transplantation

Figure 2a. Pediatric split liver transplantation Left lateral liver split for a child, 3-dimensional reconstruction of the hepatic vein anatomy. Graft segments 2-3 (brown), remnant segments 1,4-8 (green), RHV-right hepatic vein (blue), MHVmiddle hepatic vein (yellow), LHV-left hepatic vein (red).

segment (Couinaud's segments II-III) or the full left lobe (Couinaud's segments II-IV) is usually retained.

The technique as originally described by Bismuth and Houssin (13) was validated in the late 1980s and later became standard practice worldwide with 1-year survival rates of about 80% (14-18).

Although RSLT increases the number of paediatric donor organs, it does not increase the total number of organs available for LT, and indeed, it is actually disadvantageous to the adult recipient pool, which is continuously growing (19).

Split liver transplantation (SLT) The disadvantage of RSLT, namely, a discarded liver segment, was solved by the introduction of split liver techniques. SLT evolved from the RSLT and was first described by Pichlmayr (20). This technique allowed the preparation of two split grafts by dividing all vascular and biliary structures and parenchyma for the benefit of two recipients, one recipient receiving a right lobe graft, and the other receiving either a left lobe (segments 2-4, Figure 1) or left lateral segment

Figure 2c. Pediatric split liver transplantation Left lateral graft (segments 2-3) including LHV-left hepatic vein (red) for a child, 3-dimensional reconstruction. RHV-right hepatic vein (blue), MHV-middle hepatic vein (yellow) remained with the remnant liver.

Figure 2b. Pediatric split liver transplantation Left lateral liver split for a child, 3-dimensional reconstruction of the hepatic veins. The line of division lies exactly over the LHV-left hepatic vein (red). Main tributaries of the MHV-middle hepatic vein (yellow) draining segments IVa/IVb in the remnant liver are preserved. RHV-right hepatic vein (blue).

graft (segments 2-3, Figure 2). Usually the right lobe is transplanted into an adult and the left lobe or the left lateral segment into a child. In 1989, Pichlmayr and colleagues were the first to report the transplantation of one donor liver into two recipients (20,21). The first series was reported by Broelsch and co-workers at the University of Chicago (22) and in the early 1990s the technique was further validated (23-25).

Technically, SLT is a complex procedure that can be performed in two ways, ex situ or in situ, both of which require precise knowledge of the liver anatomy and extensive experience with liver resection techniques and all the technical modalities of liver graft implantation. Unfortunately, the wider application of the split technique is still hindered by the lack of experience and unwillingness of some centres to split every suitable donor liver (26). Recent comprehensive studies confirm that SLTs generally lead to less favourable results for individual recipients, but they

Figure 2d. Pediatric split liver transplantation Remnant liver (segments 1,4-8) including RHV-right hepatic vein (blue) and MHV-middle hepatic vein (yellow) after retrieval of a left lateral liver graft (segments 2-3) including LHV-left hepatic vein (red) for a child, 3-dimensional reconstruction. ¶·È‰È·ÙÚÈ΋ 2008;71:87-91

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also result in more individuals deriving the benefit of LT. While initially holding great promise and being adopted as standard policy by many paediatric transplant centres, early experience demonstrated a higher incidence of technical complications and decreased graft and patient survival rates in recipients of right lobe grafts. Unfortunately, relevant extensive, detailed data on this issue are not yet available.

Living donor liver transplantation (LDLT) The development of LDLT in the USA and Europe has been driven by the shortage of donor organs in spite of the use of innovative techniques for cadaveric LT, such as RSLT and SLT (27). In Japan, where organ procurement from brain-dead donors was not legal until recently, LDLT was the only option.

LDLT was first reported by Raia et al. in two patients in 1989 (28). Both recipients died shortly after the procedure of medical complications, but lived long enough for the technical feasibility of the procedure to be established. This was soon followed by a report from Strong et al. in Australia, where the first successful LT of a child using its mother's left lobe was performed in July 1989 (29). Even before the initial reports by Raia and Strong, an extensive ethical appraisal of the concept of LDLT was in progress at the University of Chicago, where clinical ethicists and transplant physicians convened a yearlong series of seminars and discussions open to the entire university community (30). The introduction of LDLT required a balance between the presumed benefits of an elective transplant for the recipient and the risk of morbidity or even mortality from LDLT for the donor. At the outset the main ethical problems the Chicago group had to deal with for the introduction of paediatric LDLT were the principle of equipoise and the principle of coercion (30,31). A proposal derived from these meetings was submitted to the institutional review board and a successful LDLT was performed in November 1989 by Dr. Broelsch, who subsequently initiated the systematic use of LDLT for children with end-stage liver disease (32). Between November 1989 and July 1996, 100 LDLTs were performed, with 1-year patient and graft survival rates of 88% and 72%, respectively. Similar results were reproduced worldwide, confirming the effectiveness of the procedure (33,34).

LDLT has several advantages for the child and for the transplant population as a whole. First, it increases the number of organs directly available for the paediatric population. Second, most recipients receive their transplants on an elective basis and thus should incur lower morbidity and mortality rates and decreased overall cost. Third, the minimal cold ischaemia time Paediatriki 2008;71:87-91

and the use of healthy donors may contribute to the absence of primary non-function. The application of LDLT for children with end-stage liver disease had a profound impact on organ waiting list times and decreased waiting list mortality markedly (35). Paediatric LDLT is now accepted therapy for children throughout the world and frequently accounts for 50% or more of all paediatric LTs performed at regional referral centres (35).

Despite the impressive results of LDLT, considerable debate persists concerning donor safety. The risks to the donor include those associated with invasive pre-surgical testing and with the surgical procedure. These risks are accepted by the potential donors in exchange for the knowledge that the child's life may be saved without the uncertainty of the cadaveric waiting list. The most recent donor outcomes from multiple centres have been excellent (36-38).

The development of segmental hepatic grafts has expanded the supply of size-appropriate organs, allowing children who otherwise would have died on the waiting list the opportunity to undergo LT. Recently the association between graft type, recipient age and graft survival has been better defined: among children <3 years of age, LDLT provides superior graft survival compared to RLT and SLT. In older children it appears that cadaveric organs may offer a better outcome (39,40). While RLT and SLT grafts produce an overall inferior outcome in the national experience, they remain an important and necessary tool in paediatric centre armamentarium. They provide appropriately sized grafts for children with no suitable living donor and for those for whom no cadaveric paediatric donor is available, and they can yield an excellent outcome in experienced centres. It is apparent that the technical complexities and perioperative events surrounding these procedures have a significant impact on the outcome. This emphasizes the importance of experience, attention to continued technical refinement, and judicious selection of appropriate donors for specific recipients.

References 1. Kim JS, Grotelüschen R, Mueller T, Ganschow R, Bicak T, Wilms C, et al. Pediatric transplantation: the Hamburg experience. Transplantation 2005;79:1206-1209.

2. Burdelski MM, Rogiers X. What lessons have we learned in pediatric liver transplantation? J Hepatol 2005;42:28-33.

3. Rogiers X, Malagfi M, Gawad K, Jauch KW, Olausson M, Knoefel WT, et al. In situ splitting of cadaveric livers. The ultimate expansion of a limited donor pool. Ann Surg 1996;224:331-339.

4. Ringe B, Burdelski M, Rodeck B, Pichlmayr R. Experience with partial liver transplantation in Hannover. Clin Transpl 1990;4:135-144.

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5. Starzl TE. The Puzzle People: Memoirs of a Transplant Surgeon. Pittsburgh, Pennsylvania: University of Pittsburgh Press; 1992.

6. Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, et al. Orthotopic homotransplantation of the human liver. Ann Surg 1968;168:392-415.

7. Starzl TE, Koep LJ, Halgrimson CG, Hood J, Schroter GP, Porter KA, et al. Fifteen years of clinical liver transplantation. Gastroenterology 1979;77:375-388.

8. Otte JB. History of pediatric liver transplantation. Where are we coming from? Where do we stand? Pediatr Transplant 2002;6:378-387.

9. Otte JB, de Ville de Goyet J, Sokal E, Alberti D, Moulin D, de Hemptinne B, et al. Size reduction of the donor liver is a safe way to alleviate the shortage of size-matched organs in pediatric liver transplantation. Ann Surg 1990;211:146-157.

10. Starzl TE, Klintmalm GB, Porter KA, Iwatsuki S, Schröter GP. Liver transplantation with use of cyclosporin a and prednisone. N Engl J Med 1981;305:266-269.

11. Malagfi M, Rogiers X, Broelsch CE. Reduced-size hepatic allografts. Annu Rev Med 1995;46:507-512.

12. Emond JC, Whitington PF, Thistlethwaite JR, Alonso EM, Broelsch CE. Reduced-size orthotopic liver transplantation: use in the management of children with chronic liver disease. Hepatology 1989;10:867-872.

13. Bismuth H, Houssin D. Reduced-sized orthotopic liver graft in hepatic transplantation in children. Surgery 1984; 95:367-370.

14. Strong R, Ong TH, Pillay P, Wall D, Balderson G, Lynch S. A new method of segmental orthotopic liver transplantation in children. Surgery 1988;104:104-107.

15. Broelsch CE, Emond JC, Thistlethwaite JR, Whitington PF, Zucker AR, Baker AL, et al. Liver transplantation, including the concept of reduced-size liver transplants in children. Ann Surg 1988;208:410-420.

16. Broelsch CE, Emond JC, Thistlethwaite JR, Rouch DA, Whitington PF, Lichtor JL. Liver transplantation with reduced-size donor organs. Transplantation 1988;45:519-524.

17. Ringe B, Pichlmayr R, Burdelski M. A new technique of hepatic vein reconstruction in partial liver transplantation.

Transpl Int 1988;1:30-35.

18. Ong TH, Lynch SV, Pillay SP, Balderson GA, Wall DR, Shepherd R, et al. Reduced-size orthotopic liver transplantation in children: an experience with seven cases. Transplant Proc 1989;21:2443-2444.

19. Busuttil RW, Goss JA. Split liver transplantation. Ann Surg 1999;229:313-321.

20. Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. [Transplantation of a donor liver to 2 recipients (splitting transplantation)--a new method in the further development of segmental liver transplantation]. Langenbecks Arch Chir 1988;373:127-130.

21. Pichlmayr R, Bretschneider HJ, Kirchner E, Ringe B, Lamesch P, Gubernatis G, et al. [Ex situ operation on the liver. A new possibility in liver surgery]. Langenbecks Arch Chir 1988;373:122-126.

22. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg 1990; 212: 368-375.

23. Bismuth H, Morino M, Castaing D, Gillon MC, Descorps Declere A, Saliba F, et al. Emergency orthotopic liver transplantation in two patients using one donor liver. Br J Surg 1989;76:722-724.

24. Otte JB, de Ville de Goyet J, Alberti D, Balladur P, de Hemptinne B. The concept and technique of the split liver in clinical transplantation. Surgery 1990;107:605-612.

25. Otte JB, de Ville de Goyet J, Reding R, Van Obbergh L, Veyckemans F, Carlier MA, et al. Pediatric liver transplantation: from the full-size liver graft to reduced, split, and living related liver transplantation. Pediatr Surg Int 1998; 13:308-318.

26. Colledan M, Segalin A, Spada M, Lucianetti A, Corno V, Gridelli B. Liberal policy of split liver for pediatric liver transplantation. A single centre experience. Transpl Int 2000;13:S131-133.

27. Trotter JF, Wachs M, Everson GT, Kam I. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002;346:1074-1082.

28. Raia S, Nery JR, Mies S. Liver transplantation from live donors. Lancet 1989;2:497.

29. Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y, Balderson GA. Successful liver transplantation from a living donor to her son. N Engl J Med 1990;322:1505-1507.

30. Singer PA, Siegler M, Whitington PF, Lantos JD, Emond JC, Thistlethwaite JR, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321:620-622.

31. Singer PA, Lantos JD, Whitington PF, Broelsch CE, Siegler M. Equipoise and the ethics of segmental liver transplantation. Clin Res 1988;36:539-545.

32. Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite JR, Stevens L, et al. Liver transplantation in children from living related donors. Surgical techniques and results. Ann Surg 1991;214:428-437.

33. Reding R, de Goyet Jde V, Delbeke I, Sokal E, Jamart J, Janssen M, et al. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts. J Pediatr 1999;134: 280-286.

34. Inomata Y, Tanaka K, Uemoto S, Asonuma K, Egawa H, Kiuchi T, et al. Living donor liver transplantation: an 8year experience with 379 consecutive cases. Transplant Proc 1999;31:381.

35. Emond JC, Heffron TG, Kortz EO, Gonzalez-Vallina R, Contis JC, Black DD, et al. Improved results of living-related liver transplantation with routine application in a pediatric program. Transplantation 1993;55:835-840.

36. Renz JF, Roberts JP. Long-term complications of living donor liver transplantation. Liver Transpl 2000;6:S73-76.

37. Lo CM. Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers.

Transplantation 2003;75:S12-15.

38. Nadalin S, Heuer M, Wallot M, Auth M, Schaffer R, Sotiropoulos GC, et al. Paediatric acute liver failure and transplantation: the University of Essen experience.

Transpl Int. 2007;20:519-527.

39. Emond JC. Living donor liver transplantation in children: what to recommend? Am J Transplant 2004;4:293-294.

40. Abt PL, Rapaport-Kelz R, Desai NM, Frank A, Sonnad S, Rand E, et al. Survival among pediatric liver transplant recipients: impact of segmental grafts. Liver Transpl 2004;10: 1287-1293.

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REVIEW ARTICLE

Childhood obesity – A public health crisis across the European Union Primary / Secondary Care Group of the European Academy of Paediatrics

A. J. Nicholson, S. Del Torso, A. Hadjipanyidis, D. Van Esso

Correspondence: Alf Nicholson alf.nicholson@maile.hse.ie Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland

has become the primary paediatric health issue in the EU. It is known that some 10% of children are either overweight or obese, and that obesity worldwide, apart from in sub-Saharan Africa, has reached epidemic proportions, with a threefold or more rise in most European countries since the 1980s (1,2,14,18). The main causes of the obesity epidemic are clear - overeating, especially of foods rich in fats, extracted sugars or refined starches, and a progressive decline in physical activity. The management of this epidemic depends on the successful motivation of people to eat less, to eat healthier foods and to exercise more, all of which are difficult to achieve in societies where fruit and vegetables are less available than high-fat processed foods, and where exercise no longer plays a regular part in most people’s lives. Management of childhood obesity is time-consuming, frustrating, difficult and expensive (18). Adult obesity is the strongest predictor of childhood obesity; if both parents are obese, the chance of their child being obese increases tenfold.

Breast feeding exerts a small protective effect against obesity. Television viewing is important, as it is known that for each additional hour of television watched at 5 years of age, the risk of adult obesity rises by 8% (7,8,18). Long-term increase or decrease in activity levels will influence whether a child becomes obese.

Studies have implicated inactivity, with over 4 hours TV or computer use, and consumption of takeaway foods more than twice weekly and fizzy drinks in the rising rates of obesity. Prevention of obesity will occur only if there are fundamental changes in society, involving the production and availability of cheap healthy foods, urban planning to ensure that people exercise more, education about eating, beginning in schools, and a global code to promote only healthy food and drink to children and adolescents. The vast majority of obese children have primary obesity due to a disturbed energy balance. A very small percentage (5%) have a genetic cause for their obesity, and only very rarely are hormonal causes found.

Abstract: In the past, a fat child meant a healthy child, but in the last decade, excessive fatness or obesity

Key words: Childhood obesity, epidemiology, management, prevention.

The definition of childhood obesity The Body Mass Index (BMI) is the most practical measure of obesity and it is used in growth monitoring to assess fatness. The BMI charts for boys and girls (Tables 1 and 2) show the recommended International Obesity Task Force cut-off points for obesity and overweight in children. These correspond to the adult definitions of overweight (BMI >25) and obesity (BMI >30) at age 18 years. Rapid changes in BMI can occur during normal growth. The BMI is recommended as a practical estimate of overweight in children and adolescents, but it needs to be interpreted with caution as it is not a direct measure of adiposity.

For epidemiological purposes overweight should be defined as BMI greater than or equal to the 85th centile of the 1990 reference data, and obesity as BMI greater than or equal to the 95th centile of the 1990 reference data.

The international epidemic of childhood obesity The definitions of overweight and obesity in children differ between epidemiological studies, Paediatriki 2008;71:92-95

making comparisons of cross-sectional data difficult. The rates have increased threefold over 25 years in the USA and fourfold over 18 years in Egypt (see the international childhood obesity map) (1,2).

Consequences of childhood obesity Childhood obesity is a multisystem disease with potentially devastating consequences. It causes hypertension, dyslipidaemia, increased blood clotting tendency, endothelial dysfunction and hyperinsulinism. Type 2 diabetes mellitus, once virtually unknown in adolescence, is largely attributable to childhood obesity (4). A prediabetic state of glucose intolerance and insulin resistance appears to be highly prevalent among severely obese children irrespective of ethnic group.

Type 2 diabetes is almost entirely attributable to the childhood obesity epidemic, although hereditary and life-style factors affect individual risk.

Pulmonary complications include sleep-disordered breathing (sleep apnoea), asthma and exercise intolerance. The development of exercise intolerance in an obese child can limit physical activity and thus lead to further weight gain.

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Table 1. Complications of obesity

Table 2. Tests to be considered in obesity

Short-term

Long-term

Poor self-esteem/depression Asthma Sleep apnoea Type 2 diabetes mellitus Orthopaedic problems (e.g. slipped epiphysis) Hypertension/ high cholesterol Early puberty/ polycystic ovaries Gallstones

Persistence of obesity Social stigmatisation Sleep apnoea Type 2 diabetes mellitus Osteoarthritis Hypertension/ high cholesterol Menstrual irregularities/ hirsutism Gallstones

Childhood obesity, of course, has substantial psychosocial consequences, and overweight children can develop a negative self-image at as early as 5 years of age, while obese adolescents show diminishing degrees of self-esteem associated with sadness, loneliness and risk-taking behaviour (3,15).

Causes of childhood obesity Genetic causes In 1997, two massively obese Pakistani children of consanguineous parents were found to have a mutation in the gene encoding leptin and since then five genetic mutations causing obesity have been identified, all presenting in childhood (5,6).

Prader-Willi syndrome (PWS) is a rare cause of obesity, with a deletion of chromosome 15 and features of a voracious appetite, poor linear growth, small hands and genitalia and dysmorphic features.

Progress has been made in mapping the genetic loci of PWS but the molecular cause of this obesity syndrome has not yet been identified.

Thus, single gene defects account for a very small fraction of human obesity and predisposition to obesity appears to be related to a complex interaction between at least 250 obesity-associated genes.

Physical activity A lifestyle characterized by a lack of physical activity and excessive television viewing has been shown to be associated with childhood obesity. Among children from Mexico City, the risk of obesity decreased by 10% for each hour of moderate to vigorous physical activity and increased by 12% for each hour per day of television viewing.

Television viewing Television viewing is thought to promote weight gain not only by displacing physical activity but also by increasing energy intake (7,8). Children tend to passively consume excessive amounts of energy-dense

Secondary causes of obesity are exceedingly rare; most obesity is what is termed simple obesity, and no investigations are required.

- Short stature/hypertension/striae - morning and evening cortisol levels (to exclude Cushings disease) - Short stature/goitre/hip pain - thyroid function tests , hip X-ray to exclude slipped capital femoral epiphysis - Small hands and feet/voracious appetite - karyotype, FISH (Prader-Willi syndrome) - Excessive thirst/increased urine output - fasting + 2 hour blood sugar levels, glucose tolerance test (Diabetes) - Hirsutism/obesity/absence of periods - blood testosterone level, ultrasound scan of ovaries showing numerous cysts (polycystic ovary syndrome)

foods while watching television. Furthermore, television advertising could adversely influence dietary patterns at other times throughout the day. Screen time for children of over 2 years should be limited to no more than 1 to 2 hours per day (18).

Diet Children who were bottle fed appear to be at greater risk of obesity later in childhood than those who were breast fed (9).

Sugar-sweetened soft drinks have been the subject of several studies, which have shown that the total energy intake was 10% greater among children who consumed soft drinks than in those who did not (18). Increasing portion sizes are also a factor. Fast food typically incorporates potentially adverse dietary factors including saturated fat, a high glycaemic index, high energy density and, increasingly, large portion size. A large fast food meal could contain 2,200 kcal, which, at 85 kcal per mile, would require a full Marathon to burn off.

Breakfast skipping, snacking and eating out (in particular at fast food establishments) are all associated with obesity (18). The ‘traffic light diet’, recommended for consumption by children in the age-group 6 to 12 years, consists of low energy, high nutrient foods such as fruit and vegetables (green), moderate energy foods (orange) and high energy foods (red). ‘Green’ foods may be eaten often, ‘orange’ foods in moderation and ‘red’ foods should be eaten sparingly (10,18).

Family factors Parent-child interactions and the home environment can affect the risk of developing obesity. Traditional family meals tend to decrease television viewing and improve dietary quality; the child takes a diet with less saturated and trans fats, less fried foods, lower glycaemic load, more fibre, fewer soft drinks and more fruit and vegetables. ¶·È‰È·ÙÚÈ΋ 2008;71:92-95

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Prevention and treatment Prevention and treatment ultimately involves eating less and exercising more. Most efforts to reduce obesity in children have used family-based or schoolbased approaches and only in severe cases are pharmacological and surgical treatments considered. Following a review of randomised controlled trials, Ebstein et al. (10) concluded, somewhat soberly, that most interventions to treat childhood obesity are marked by only small changes in weight or BMI and very high rates of subsequent relapse.

School-based interventions have been oriented towards prevention of obesity, targeting all children. The Pathways programme (12), for American Indian children at high risk of type 2 diabetes and cardiovascular disease, aimed to reduce dietary fat consumption and increase physical activity. This 3-year programme produced a significant decrease in fat consumption and a trend towards increased physical activity but the BMI did not differ between children in the intervention and the control schools at the end of the programme. The Planet Earth trial (11) focussed largely on changing the school environment over two school years to include reduced television viewing, increased physical activity, decreased fat intake, increased fruit and vegetable intake, altered class curricula and extensive education of families. In this trial there was a significant reduction in obesity in girls (absolute risk 0.47, CI 0.24-0.93), with trends in the same direction in boys, although not reaching statistical significance. The authors reported that the effect observed was largely attributable to observed reductions in television viewing.

Most children managed in the community will have simple obesity with no underlying medical cause and without comorbidity. Treatment should be offered when the obese child and family are willing to make the necessary life-style changes. For children who are overweight and most children who are obese, weight maintenance is an acceptable goal (13). Weight maintenance can only be achieved by sustained behavioural changes, including healthier eating, an increase in physical activity to a minimum of 30 minutes per day and reduction of physical inactivity (e.g., watching television or playing computer games) to less than 2 hours per day. Particular attention should be given to methods for increasing physical activity in adolescents (18).

Suggestions for parents Suggestions for increasing physical activity: - any increase in activity will help, - aim for simple changes at first, such as walking, cycling and using stairs rather than lifts, - develop an active life-style for the whole family, Paediatriki 2008;71:92-95

- encourage active play that is enjoyable and do all you can to keep exercise fun, - decrease TV viewing and other sedentary activities, - schedule unstructured free playtime on a daily basis.

Dietary suggestions: - a balanced, varied diet for the whole family, - serve meals at regular times; avoid ‘grazing’ and TV snacks, - serve smaller portions, - avoid snacks as rewards or treats, - offer healthy snacks (e.g., fruit) as alternatives to sweets, chocolates, potato crisps, biscuits and cakes, - use less energy dense food (e.g., semi-skimmed milks and low fat spreads), - provide whole foods that take time to eat (e.g., fruits and wholemeal bread), - promote low calorie drinks (preferably water), - ensure at least five portions of fruit and vegetables per day, - grill, boil or bake foods rather than frying them, - “Eat to live, don’t live to eat”, - pare down the amount of ‘junk’ food in the house, - comfort with attention, listening and hugs instead of food.

The perfect meal plan Modern families may rarely sit down to a meal all together, and one major suggestion is to bring back the traditional family meal; the perfect meal plan entails: - firstly turn off the TV, - involve children in the cooking process, - switch mobile phones to silent, - make sure that everyone sits down together at the table, - serve the plates from a central location to ensure control over portion sizes, - the meal should last at least 20 minutes, - share the positive events of the day, - be mindful while eating of the colour, texture and smell of the food, - make dessert a continuation of the meal and not something too special, - substitute fruit for dessert at times, - parents, not children, should be responsible for food decision making, - limit soft drink consumption.

Drug treatment for obesity Drug treatment is not recommended for children under 12 years, and in adolescence it is only

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recommended in situations where there are medical complications (orthopaedic complications or sleep apnoea) or severe psychological issues arising from the obesity. Medication used as part of a structured life-style modification produces an average weight loss of 5 to 10%, which typically reaches a plateau at 4 to 6 months of treatment, and weight regain is common after the drug is withdrawn (16,18). Prescribing should be made by a specialist multidisciplinary team. The drugs used are orlistat and sibutramine and they are generally used for a 6-12 month trial with regular reviews of effectiveness, adverse effects and adherence. Sibutramine is an appetite suppressant and orlistat works as a reversible lipase inhibitor (18). Drug treatment may be used to help the adolescent maintain weight loss as well as to continue to lose weight. Four experimental drugs have produced weight loss in small studies involving children with special conditions, specifically, metformin in obese adolescents with insulin resistance, octeotride for hypothalamic obesity, growth hormone in Prader-Willi syndrome and leptin for congenital leptin deficiency (17).

Bariatric surgery for obesity Surgery is generally not recommended for children and adolescents and constitutes, at best, a last resort for severely obese adolescents. Exceptional circumstances in which surgery might be considered are when the BMI is >40, or when in the case of a significant complication, such as hypertension or type 2 diabetes that could be improved by weight loss, all appropriate non-surgical measures have failed or when they are receiving intensive care.

Key points to remember - Obesity is now the commonest chronic condition affecting children across the EU. - Obesity is due to an imbalance between energy consumption and energy expenditure. Obese children do not have low energy needs.

- Family support is necessary for treatment to succeed.

- Generally the aim of treatment is to help children and adolescents to maintain their weight.

- In younger children the main impact of obesity is social and emotional rather than medical.

- A medical cause for obesity is more likely in children who are both short and obese for age.

- Most children are not obese because of an underlying medical problem, but rather as a result of their life-style.

- Weight reduction or stabilization goals should always be kept reasonable.

- The major calorie culprits are high-fat fast food, large portions and sugar-containing soft drinks.

- If a child is at risk of obesity due to family history, the earlier the modifications (e.g., reducing TV time) the better.

References 1. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 2001;286:2845-2848.

2. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360: 473-482.

3. Strauss RS. Childhood obesity and self-esteem. Paediatrics 2000;105:e15.

4. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Eng J Med 2002;346:802-810.

5. Montague CT, Farooqi IS, Whitehead JP, Soos MA, Rau H, Wareham NJ, et al. Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature 1997; 387:903-908.

6. Farooqi IS, O’Rahilly S. Recent advances in the genetics of severe childhood obesity. Arch Dis Child 2000;83:31-34.

7. Robinson TN. Does television cause childhood obesity?

JAMA 1998;279: 959-960.

8. Robinson TN. Reducing children’s television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282:1561-1567.

9. Ludwig DS, Peterson KE, Gortmaker SL. Causes of obesity.

Lancet 2001;357:1978-1979.

10. Epstein LH, Roemmich JN, Raynor HA. Behavioral therapy in the treatment of pediatric obesity. Pediatr Clin North Am 2001;48:981-993.

11. Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001;323: 1029-1032.

12. Lohman TG, Going S, Stewart D, et al. The effect of Pathways obesity prevention study on body composition in American children. FASEB J 2001;15:A1093.

13. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev 2003;(3):CD001872.

14. Wiegand S, Maikowski U, Blankenstein O, Biebermann H, Tarnow P, Grüters A. Type 2 diabetes and impaired glucose tolerance in European children and adolescents with obesity - a problem that is no longer restricted to minority groups. Eur J Endocrinol 2004;151:199-206.

15. Sabin MA, Ford AL, Holly JM, Hunt LP, Crowne EC, Shield JP. Characterisation of morbidity in a UK, hospital based, obesity clinic. Arch Dis Child 2006;91:126-130.

16. Glazer G. Long-term pharmacotherapy of obesity 2000: a review of efficacy and safety. Arch Intern Med 2001;161: 1814-1824.

17. Farooqi IS, Jebb SA, Langmack G, Lawrence E, Cheetham CH, Prentice AM, et al. Effects of recombinant leptin therapy in a child with congenital leptin deficiency. N Eng J Med 1999;341:879-884.

18. Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120:S254-S288. ¶·È‰È·ÙÚÈ΋ 2008;71:92-95

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Use of the new World Health Organization growth standards in the prevention of childhood overweight and obesity Facultad de Ciencias de la Salud, Universidad Autonoma del Carmen, Ciudad del Carmen, Campeche, Mexico Correspondence: Daniel Fuentes-Lugo daniel.fuentes@mac.com Facultad de Ciencias de la Salud, Universidad Autonoma del Carmen, Ciudad del Carmen, Mexico

M. Ponce-Rivera, D. Fuentes-Lugo Abstract: The prevalence of overweight and obesity in young children continues to rise in most parts of the world. Obese children have a significantly higher risk of becoming obese adults, which underlines the importance of adequate growth monitoring from early ages. Different international references for growth assessment are currently being used by paediatricians in most countries. This review examines the differences between the Centers for Disease Control (CDC) growth reference and the new World Health Organization (WHO) growth standards for children of less than five years when used as diagnostic tools for the detection of excess weight. It also includes preliminary results from a retrospective study conducted in a cohort of 300 healthy children from a paediatric clinic in Mexico evaluating differences in overweight prevalence depending on the growth reference employed. Results showed a higher prevalence of overweight and obesity with WHO standards than with the CDC reference in children from 1 through 5 years of age, independent of gender, in agreement with other studies. Use of the new WHO growth standards is emphatically encouraged for both routine clinical practice and epidemiological research, in order to avoid potential pitfalls and inaccuracies when monitoring child growth and to detect childhood overweight and obesity effectively. The new WHO standards provide a unique opportunity for redesigning child overweight surveillance and prevention programmes so that they become more useful for detection and decision making and less complicated for gathering epidemiological data.

Key words: Childhood obesity, childhood overweight, growth reference, growth standard.

Childhood globesity: understanding the magnitude of the problem Overweight and obesity have achieved global acknowledgement during the past decade. Excess body weight is now considered one of the most important risk factors contributing to the overall burden of disease. Worldwide, around 1.2 billion adults are classified as being overweight, of which 312 million are considered obese (1). The prevalence of obesity has reached alarming levels, affecting both developed and developing countries and all socioeconomic groups, irrespective of age, sex or ethnicity. If effective preventive measures are not implemented soon, this public health problem will continue to expand to the extent that it will become out of control. For example, it is estimated that in the US by 2015, 75% of adults will be overweight, of which more than half will be obese (2).

Concerning childhood obesity, around 10% of children in the world have some degree of overweight and over 22 million children under the age of 5 are already obese (3). The prevalence of overweight is dramatically higher in the economically developed regions, but it is also rising significantly in most other parts of the world. In developing nations, childhood obesity is most prevalent in the wealthier sections of the populaPaediatriki 2008;71:96-104

tion. However, it is also increasing among the urban poor in these countries, possibly due to their exposure to westernized diets. The prevalence of childhood overweight in America is currently above 20%, reaching up to 40% in the case of the US and Mexico. In Europe, the number of children who are overweight is expected to rise by 1.3 million children per year, with more than 300,000 of them becoming obese each year (4).

By 2010 it is estimated that 26 million children in European countries will be overweight, including 6.4 million who will be obese (5). Such rapid changes in the numbers of obese children within a relatively stable population indicate that genetic factors are not the primary reason for change, although they play a role that is yet to be precisely determined.

Childhood obesity is usually associated with complications that include diabetes types 1 and 2 (6,7), insulin resistance, atherosclerosis (8,9), hypertension, dyslipidaemia, polycystic ovary disease, kidney disease (10) and fatty liver among many others (11). Children with body mass index (BMI) and waist circumference exceeding the established normal values are at increased risk for metabolic syndrome when they reach adulthood (12,13). A higher BMI during

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childhood is also associated with an increased risk for coronary heart disease (CHD) in adulthood (14) and this association appears to be stronger in boys than in girls and to increase with age in both sexes (15).

In addition, excess body weight appears to be an important risk factor for some cancers. A systematic review compared associations between 20 cancer types and BMI (16). Their results show that a higher BMI is associated with an increased risk of thyroid, renal and colon cancers, oesophageal adenocarcinoma, multiple myeloma, leukaemia and non-Hodgkin lymphoma in both sexes, rectal cancer and malignant melanoma in men, and gallbladder, pancreas, endometrial and postmenopausal breast cancers in women.

Several theories have been formulated to account for the obesity epidemic. Clearly, the main causes are overeating and lack of physical activity. However, it is of paramount importance to identify all the risk factors that predispose an individual to become obese (17).

There appears to be a direct causal relationship between childhood overweight and maternal pre-pregnancy body size, maternal smoking during pregnancy (18), early weaning (19), rapid growth (20) and children’s use of television and media, while breastfeeding appears to have a protective effect against overweight (21). Further studies are needed to elucidate the exact mechanisms by which these factors influence childhood adiposity, for example, its relationship with socioeconomic status (22). Some authors have claimed that, although clinically irrelevant, temperament may be slightly related to overweight and rapid early weight gain in infants (23). Others have proposed that a high early protein intake, particularly from dairy products, increases obesity risk (24,25). Some studies suggest that sleep deprivation may influence weight through effects on appetite, physical activity, and thermoregulation (26). Short sleep duration appears independently associated with weight gain in younger age groups (27).

Unfortunately, to date, scientific evidence regarding risk factors for childhood obesity is still insufficient, with much of the literature being of limited quality, inconclusive and contradictory (28).

There is strong evidence to suggest a direct relationship between weight status in childhood and eventual adult obesity, but many studies are based on cross-sectional data or have relatively long periods of time between measurements. It is now accepted that obesity in adolescence is highly predictive of obesity in adulthood. Therefore, an important next step will be to identify those young children at greatest risk of developing obesity in adolescence, and to intervene before chronic overweight is established during early childhood. Children who are found to be overweight

at least once at ages 24, 36 or 54 months during the preschool period are 5 times more likely to be overweight at age 12 years than those who are below the 85th percentile for BMI at all three of the preschool ages. The longer a child remains in the lower range of normal BMI, the less likelihood there is that the child will become overweight by early adolescence (29).

Adequate detection of overweight and obesity in childhood Not long ago, a fat child meant a healthy child, and the concept of “bigger is better” was widely accepted by parents, paediatricians and caregivers. Such a point of view belongs to the past, however (30), and at present, child obesity is one of the most evident, yet most neglected public health problems in the world. Although the problem is well recognized, most obesity prevention measures worldwide have been small, timid and ineffective to halt the epidemic (31). Arguably, ‘globesity’ might have been detectable earlier if a prescriptive reference had been available 20 years ago, and even now the first problem that needs to be addressed is agreement of a definition of true obesity. Some of the contradictory childhood obesity rates seen in the literature are a direct consequence of using different criteria to define overweight and obesity. The main purposes for defining overweight and obesity are to predict health risks and to provide comparisons between populations. For practical reasons, the definitions have usually been based on anthropometry, but regardless of which definition is used, the increasing rates have highlighted the relevance of the problem (32).

Obesity is defined as an excess of body fat or adipose tissue. It is actually fat and not weight which is associated with all the comorbid conditions. Measuring fat is not as straightforward as measuring weight; therefore weight, rather than adiposity, is the usual clinical marker for identifying obesity. Although body weight tends to be associated with adiposity, weight alone is an insufficient measure of obesity by itself, because it is correlated with height (33). To avoid this limitation, a number of measures of weight in relation to height have been devised over the years. The simplest and most frequently used are weight-for-height and the BMI. BMI is a practical indirect measure of adiposity, although the relationship changes according to age, sex and ethnicity, but also degree of fatness. A child’s BMI can be compared with a reference data set and be converted into a Z-score. A BMI Z-score of 0 is equivalent to the median or 50th percentile value, a Z-score of +2.00 is approximately equivalent to the 98th percentile and a Z-score of +2.85 is >99th percentile.

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is optimal for assessing adiposity on a single occasion, it is not necessarily the best scale for measuring change in adiposity, as the within-child variability over time depends on the child’s level of adiposity (34).

Use of BMI index charts during a paediatric health supervision visit increases physician recognition of overweight patients better than height-for-weight charts (35). Regrettably, BMI charts are not routinely used (36) and due to ineffective detection not all children with overweight receive either a formal diagnosis or treatment (37). A study conducted among public and private practice paediatricians in the US revealed that they identified overweight in only 27% of children with BMI at the 85th-94.9th percentile and up to 86% with a BMI at or above the 95th percentile (38). Rate recognition by physicians increased as the severity of obesity increased. US paediatricians may not use BMI charts because they recognize obesity empirically when they see it, at least when the BMI is above the 95th percentile. However, they may overlook excess weight in children with BMI at the 85th-94th percentile, perhaps because these children seem fairly normal.

Adequate growth and weight gain should concern not only paediatricians and child caretakers but also parents (39). One study showed that parents of younger children were significantly more likely to underestimate overweight (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate weight, nor was accuracy associated with parental education or socieconomic status.

Parental recognition of childhood overweight may be improved with BMI screening and feedback (40).

Growth references versus growth standards: which should be used?

Growth references are a fundamental tool for the interpretation of anthropometric data. Classifying a child as overweight or obese assumes that such a child is comparable to the reference population, so choosing the right tool for proper detection is mandatory (41). In the US, reference growth charts based on nationally representative surveys have been produced since 1977. An expert committee recommended their use for children and adolescents, with the 95th BMI percentile for age and sex (or BMI 30 kg/m2) as the cutoff points for overweight and the 85th percentile as “at risk of overweight” for screening purposes. The fact that the committee decided not to use the term ‘obese’, which they associated with excess fat rather than weight, has lead to some confusion (42).

In May 2000 the US Centers for Disease Control (CDC) released new growth charts to replace the 1977 NCHS reference. The CDC-2000 charts were based Paediatriki 2008;71:96-104

on five nationally representative surveys conducted between 1963 and 1994. This reference, currently used in about 100 countries, is based on data from several samples of children from a single country and suffers from a number of technical drawbacks that makes it inadequate for monitoring growth in early childhood. A survey reported that CDC-2000 is the growth reference most commonly used worldwide.

Another interesting fact from this international study is that most paediatricians prefer using percentiles rather than Z-scores (43). The use of Z-scores offers advantages over the use of percentiles; for instance, when conducting epidemiological studies, Z-scores allow easier comparison between growth references.

In the late 1990s, the International Obesity Task Force (IOTF) determined that although BMI was not ideal as a measure of adiposity, it could be used to define overweight and obesity in children and adolescents. IOTF recommended cutoff points based on age-specific values that project to the adult cutoff points of 25 kg/m2 for overweight and 30 kg/m2 for obesity. Using data collected between 1963 and 1993 from six different populations (Great Britain, Brazil, the Netherlands, Hong Kong, Singapore and USA) IOTF published their reference curves in 2000 (44).

These are useful mainly for epidemiological research, since children and adolescents can only be categorized as non-overweight or overweight/obese. Since the adult cutoff points of BMI 25 and 30 may not be universally applicable, the IOTF curves are inappropriate for some child populations. A number of reports have shown that these cutoff points substantially underestimate the prevalence of childhood obesity in different settings (45). In short, the IOTF reference appears to be a less adequate tool for detecting overweight and obesity in clinical practice compared with methods based on percentiles or Z-scores.

WHO 2006 Child Growth Standards The WHO 2006 Child Growth Standards are the product of a long systematic process which started in the early 1990s. They are based for the first time on a prospective, prescriptive, international sample of infants selected to represent optimum growth (46). The WHO Multicenter Growth Reference Study (MGRS) was designed to provide data that describe how children should grow from birth to five years under optimal environmental conditions, rather than describing their growth in a particular time and place, and therefore, they can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding (47).

The MGRS was carried out from July 1997 to

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Table 1. Body mass index (BMI) cutoff values for overweight from the IOTF, CDC-2000 and WHO-2006 growth standards in children aged 2 to 5 years

Age (years)

IOTF BMI 25 Kg/m2 Boys Girls

CDC 2000 +2 S.D. Boys Girls

WHO 2006 +2 S.D. Boys Girls

2 2.5 3 3.5 4 4.5 5

18.41 18.30 17.89 17.69 17.55 17.47 17.42

20.14 19.38 18.86 18.55 18.43 18.48 18.69

18.9 18.6 18.4 18.2 18.2 18.2 18.3

18.02 17.76 17.56 17.40 17.28 17.19 17.15

December 2003 as a population-based study covering the cities of Davis, California, USA; Muscat, Oman; Oslo, Norway; and Pelotas, Brazil, together with selected affluent neighborhoods of Accra, Ghana and South Delhi, India. The WHO combined a longitudinal follow-up from birth to 24 months with a crosssectional component of children aged 18-71 months.

The study population lived under socioeconomic conditions favourable to growth. The individual inclusion criteria were: no known health or environmental constraints to growth, mothers willing to follow MGRS feeding recommendations (exclusive or predominant breast-feeding for at least 4 months, introduction of complementary foods by 6 months of age, and continued breast-feeding to at least 12 months of age), no maternal smoking before and after delivery, single term birth and absence of significant morbidity (48). Prior to their release, the standards were field-tested in four countries: Argentina, Italy, Maldives and Pakistan (49).

One important feature of the WHO standards to bear in mind is that it makes breast-feeding the biological norm and establishes the breast-fed infant as the normative growth model (50). The previous references were based mostly on the growth pattern of artificially-fed children. The WHO-2006 standards demonstrate that healthy children from around the world who are raised in healthy environments and follow recommended feeding practices have similar patterns of growth. This indicates that the same potential for growth should be expected in any country.

It also implies that deviations from this ideal growth pattern must be assumed to reflect adverse conditions that require correction (51).

Since there are substantial differences in methodology, cutoff values and selected population between the various growth references, it is expected that significant changes would be found when one reference is compared to another, even if they are from the same country. For instance, the CDC-2000 reference under-

19.80 19.31 19.01 18.89 18.93 19.10 19.39

18.7 18.5 18.4 18.4 18.5 18.7 18.8

estimates the weight-for-height Z-scores of individual children compared to the 1977 NCHS reference, both of which are references derived from American children. A child classified as close to +3 Z-score using the 1977 NCHS reference will be just below +2 Z-score when the CDC 2000 reference is applied (52).

Few studies have compared the 1977 NCHS criteria for defining overweight or obesity with the CDC2000 reference curves and the IOTF alternative set of cutoff points. In younger children, the IOTF curves gave significantly lower estimates for the prevalence of obesity. One study involving 258 Italian children (average age 4.8 years) found that the CDC -2000 reference led to a significantly higher prevalence of obesity in both males and females when compared to the growth charts of the IOTF (53). BMI cutoff points from the CDC and IOTF have relatively high specificity, but lower sensitivity, meaning that children with normal weight are unlikely to be wrongly labelled, but overweight and obese children may be missed. Detecting a child with overweight depends basically on which reference and which cutoff value is used, and this clearly represents a major problem (Tables 1 and 2).

When CDC-2000 reference curves are compared with the new WHO-2006 standards, significant differences are found that vary by age group, growth Table 2. Body mass index (BMI) cutoff values for obesity from IOTF and WHO-2006 growth standards in children aged 2 to 5 years

Age (years)

IOTF BMI 25 Kg/m2 Boys Girls

WHO 2006 +3 S.D. Boys Girls

2 2.5 3 3.5 4 4.5 5

20.09 19.80 19.57 19.39 19.29 19.26 19.30

20.6 20.2 20.0 19.8 19.9 20.0 20.3

19.81 19.55 19.36 19.23 19.15 19.12 19.17

20.6 20.4 20.3 20.4 20.6 20.8 21.1

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Mean weight-for-age Z-scores 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 -0.8

NCHS CDC WHO

Table 3. Prevalence of overweight (including obesity) using weight-for-height Z-scores from the CDC-2000 growth reference and WHO-2006 growth standards during the first year of life

Birth 1 year 0

1

2

3

4

5 6 7 8 Age (months)

9

indicator and Z-score curve. The main differences in weight-for-age Z-score curves occur during infancy (Graph 1). Regarding weight-for-length Z-score curves for boys, estimates of overweight and obesity are higher when based on the WHO standards (54).

The change in the shape of the curves is probably due to issues related to study design and the characteristics of the sample, as well as differences in the type of feeding. The CDC used samples of less than 100 infants per age group during the first six months; consequently, the CDC-2000 curves probably fail to capture the rapid and changing rate of weight gain in early infancy. The WHO-2006 standard is based on a much larger sample size (428 boys and 454 girls) and shorter measurement intervals.

These design characteristics allowed the WHO curves to capture rapidly changing patterns of growth in early infancy.

Comparison of weight-for-length and weight-forheight chart shows that CDC-2000 children were generally heavier than those included in the WHO2006 sample. The BMI-for-age curves are dramatically different, partly reflecting obesity in the US sample. This flaw makes the CDC-2000 weight-forheight curves inadequate for monitoring obesity from 100 cm onwards. In addition, the pattern of

0% 2.25%

0.59% 0%

3% 2.25%

z-BMI for girls (n=133) 1

1 WHO 2006

0.5

CDC 2000

0

WHO 2006

0.5 Z

CDC 2000

0 -0.5

-0.5 2

3

4

5

Age Graph 2. WHO Growth Standard versus CDC Growth Reference.

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0% 2.39%

lower centiles of the CDC weight-for-length chart below 53 cm may reflect peculiarities of the birth registry data used to design the CDC curves (55). In summary, the CDC-2000 charts provide a growth reference rather than a prescriptive standard, such as the WHO-2006.

Based on this rationale, a retrospective study was conducted in a cohort of healthy children from a single paediatric clinic in Mexico City in order to assess differences between the CDC-2000 reference and the new WHO-2006 standards (56). Among the main outcomes examined were differences in estimated overweight/obesity prevalence. From the files with complete weight and height records from birth up to five years of age, 300 children (167 boys and 133 girls) were randomly selected. Children with a history of chronic disease were excluded. Weight-for-age, height-for-age, weight-for-height and BMI percentiles and Z-scores were obtained at 0, 12, 24, 36, 48 and 60 months of age (±2 months). To classify children with overweight or obesity, Z-score values of +2.00 S.D. and +3.00 S.D. respectively, were used.

Anova regression analysis was performed to compare the curves from birth to five years of age derived from the two reference instruments.

Using weight-for-height as an anthropometric marker, the results showed a relatively low prevalence of overweight in the complete cohort between the first and second years of age with both references, although the prevalence using the WHO-2006 standards was significantly different from that obtained

z-BMI for boys (n=167)

-1

Girls WHO CDC +2 S.D. +2 S.D.

10 11 12

Graph 1. WHO Growth Standard versus CDC-2000 and NCHS1977 Growth References (adapted from references 52 and 54).

Z

Boys WHO CDC +2 S.D. +2 S.D.

-1

2

3

4

5

Age Graph 3. WHO Growth Standard versus CDC Growth Reference.

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WHO 2006 CDC 2000

12 10

7 5

8

% 4

% 6

3

4

2

2

1

0

WHO 2006 CDC 2000

6

0 2

3 4 Age (years)

5

2

3 4 Age (years)

5

Graph 4. Prevalence of overweight/obesity in boys (BMI Zscore=/>2.0) (n=167).

Graph 5. Prevalence of overweight/obesity in girls (BMI Zscore=/>2.0) (n=133).

with the CDC-2000 reference (1.33% versus 0.66% overweight). The main differences in the weight-forheight Z-score were observed from 12 to 36 months of age. At 1 year of age, differences were found for the boys but not the girls (Table 3). The prevalence of overweight increased markedly at age 4-5, but with significant differences between CDC and WHO scores regardless of gender.

It was not possible to compare Z-BMI curves between the two references during the first two years because such data is not included in the CDC-2000 growth curves. When BMI Z-score was used to identify overweight (+2.0) and obesity (+3.0), there were statistically significant differences between the two references (p<0.001) for both boys and girls from 2 to 5 years of age. Although the median values of the BMI Z-score were within the normal weight range with both references, the WHO-2006 curve pattern was always above the CDC curve pattern for both boys and girls from age 2 years to 5 years (Graphs 2 and 3). In addition, the prevalence of overweight and obesity using WHO standards was higher than the prevalence found when CDC growth references were used (Graphs 4 and 5). Furthermore, as pointed out elsewhere, the weight-for-height Z-score proved to be of lesser sensitivity in detecting overweight accurately when compared to the BMI Z-score, with both references (p<0.001).

Final comments The shift to the new WHO standards provides a unique opportunity not only to monitor linear growth, but also to redesign surveillance programmes so that they are more useful for problem detection and decision making, and less complicated for gathering epidemiological data (57). The WHO standards would set a markedly lower standard for weight gain beyond 4 months of age, and could thus support efforts to avoid future childhood obesity (58). However, there is evidence that they might not be appropriate for use across all populations, and specifically some populations in Asia (59) and Africa (60). One study conducted in refugee camps in Algeria, Kenya and Bangladesh showed important differences in the weight-for-height cutoff points used for defining acute malnutrition between those obtained from the WHO standards and those derived from the NCHS reference. The WHO standards apparently resulted in a higher measured prevalence of severe acute malnutrition. For such reasons, assessment of the new WHO growth standards in different populations and environments is recommended. Compared to previous international references they appear to be more accurate and easier to interpret. In addition, last year WHO published a second set of standards that include head circumference-for-age, arm circumference-for-age, triceps and subscapular skinfold-forage, and new international growth standards for the screening, surveillance and monitoring of school-age children and adolescents (61-63), all available at the WHO website.

Prevention is perhaps the only effective way to stop this childhood obesity epidemic, and the first step for proper prevention, is proper detection. The WHO 2006 standards were created basically for that purpose.

The authors agree with others who suggest that all the demographic surveys should now be derived using the

Table 4. Prevalence of overweight (including obesity) using body mass index (BMI) Z-scores from the CDC-2000 growth reference and WHO-2006 growth standards Age (years)

Boys WHO CDC

Girls WHO CDC

2 3 4 5

3.58% 7.77% 11.97% 11.36%

3% 6.76% 5.26% 6.76%

0% 4.18% 7.77% 8.97%

0.75% 4.50% 4.50% 3.75%

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WHO standards (64). Perhaps in the future technological advances will allow a more direct assessment of adiposity than BMI, and new charts will need to be created (65). Currently, there are few reports in the literature of studies assessing the level of body fat in childhood (66-68) and only one that has actually produced body fat reference curves for children aged older than five (69).

There is a marked mismatch between the public health importance of childhood obesity and the number and quality of studies conducted so far to assess preventive interventions (70,71). There is an urgent need for well-designed intervention studies to demonstrate the long-term effectiveness of preventive strategies that would provide a basis for evidence-based recommendations (72,73). In Europe, a series of initiatives and actions have been launched in recent years, one of which is the creation of national centres for collecting country-specific data to back up concrete strategies for future policy building (74). In the US, the new National Children’s Study will seek information on enviromental risks and individual susceptibility factors for obesity, among other diseases. This will be conducted in a cohort of 100,000 US born children, which will be followed from conception to 21 years of age. Environmental exposures will be assessed repeatedly during pregnancy and throughout childhood in the children’s homes, schools and communities. Chemical assays will be performed by the CDC and banks of biological and genetic material and environmental samples will be collected. Recruitment started in 2007 at 7 sites and will be extended to 105 sites across the US (75). Unfortunately, it will be a long time before preliminary results are available. In the meantime, until all these studies start to answer some of the numerous questions regarding childhood obesity, it would be advisable to promote physical activity and healthy eating habits among children and to encourage adequate monitoring of growth and weight gain from early infancy.

References 1. Maziak W, Ward KD, Stockton MB. Childhood obesity: are we missing the big picture? Obes Rev 2008;9:35-42.

2. Wang Y, Beydoun MA. The obesity epidemic in the United States-gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev 2007;29:6-28.

3. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes 2006;1:11-25.

4. Jackson-Leach R, Lobstein T. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 1. The increase in the prevalence of child obesity in Europe is itself increasing. Int J Pediatr Obes 2006;1:26-32.

Paediatriki 2008;71:96-104

5. Kosti RI, Panagiotakos DB. The epidemic of obesity in children and adolescents in the world. Cent Eur J Public Health 2006;14:151-159.

6. Knip M, Reunanen A, Virtanen SM, Nuutinen M, Viikari J, Akerblom HK. Does the secular increase in body mass in children contribute to the increasing incidence of type 1 diabetes? Pediatr Diabetes 2008 [Epub ahead of print].

7. Jones KL. Role of obesity in complicating and confusing the diagnosis and treatment of diabetes in children. Pediatrics 2008;121:361-368.

8. Freedman DS, Patel DA, Srinivasan SR, Chen W, Tang R, Bond MG, et al. The contribution of childhood obesity to adult carotid intima-media thickness: the Bogalusa Heart Study. Int J Obes (Lond) 2008 [Epub ahead of print].

9. Beauloye V, Zech F, Tran HT, Clapuyt P, Maes M, Brichard SM. Determinants of early atherosclerosis in obese children and adolescents. J Clin Endocrinol Metab 2007;92:3025-3032.

10. Wang Y, Chen X, Klag MJ, Caballero B. Epidemic of childhood obesity: implications for kidney disease. Adv Chronic Kidney Dis 2006;13:336-351.

11. Nathan BM, Moran A. Metabolic complications of obesity in childhood and adolescence: more than just diabetes.

Curr Opin Endocrinol Diabetes Obes 2008;15:21-29.

12. Sun SS, Liang R, Huang TT, Daniels SR, Arslanian S, Liu K, et al. Childhood obesity predicts adult metabolic syndrome: the Fels Longitudinal Study. J Pediatr 2008;152:191-200.

13. Morrison JA, Friedman LA, Wang P, Glueck CJ. Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. J Pediatr 2008;152:201-206.

14. Celermajer DS, Ayer JG. Childhood risk factors for adult cardiovascular disease and primary prevention in childhood. Heart 2006;92:1701-1706.

15. Baker JL, Olsen LW, So/ rensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood.

N Engl J Med 2007;357:2329-2337.

16. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569-578.

17. Reilly JJ, Ness AR, Sherriff A. Epidemiological and physiological approaches to understanding the etiology of pediatric obesity: finding the needle in the haystack. Pediatr Res 2007;61:646-652.

18. Oken E, Levitan EB, Gillman MW. Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis. Int J Obes (Lond) 2008;32:201-210.

19. Sloan S, Gildea A, Stewart M, Sneddon H, Iwaniec D. Early weaning is related to weight and rate of weight gain in infancy. Child Care Health Dev 2008;34:59-64.

20. Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life--a systematic review.

Obes Rev 2005;6:143-154.

21. Buyken AE, Karaolis-Danckert N, Remer T, Bolzenius K, Landsberg B, Kroke A. Effects of breastfeeding on trajectories of body fat and BMI throughout childhood. Obesity (Silver Spring) 2008;16:389-395.

22. Shrewsbury V, Wardle J. Socioeconomic status and adiposity in childhood: a systematic review of cross-sectional studies 1990-2005. Obesity (Silver Spring) 2008;16:275-284.

23. Niegel S, Ystrom E, Vollrath ME. Is difficult temperament related to overweight and rapid early weight gain in

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·103

103

Prevention of childhood overweight and obesity

infants? A prospective cohort study. J Dev Behav Pediatr 2007;28: 462-466.

24. Ong KK, Emmett PM, Noble S, Ness A, Dunger DB; ALSPAC Study Team. Dietary energy intake at the age of 4 months predicts postnatal weight gain and childhood body mass index. Pediatrics 2006;117:e503-e508.

25. Günther AL, Remer T, Kroke A, Buyken AE. Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Am J Clin Nutr 2007;86:1765-1772.

26. Al Mamun A, Lawlor DA, Cramb S, O'Callaghan M, Williams G, Najman J. Do childhood sleeping problems predict obesity in young adulthood? Evidence from a prospective birth cohort study. Am J Epidemiol 2007;166:1368-1373.

27. Chen X, Beydoun MA, Wang Y. Is sleep duration associated with childhood obesity? A systematic review and metaanalysis. Obesity (Silver Spring) 2008;16:265-274.

28. Hawkins SS, Law C. A review of risk factors for overweight in preschool children: a policy perspective. Int J Pediatr Obes 2006;1:195-209.

29. Nader PR, O'Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, et al. Identifying risk for obesity in early childhood.

Pediatrics 2006;118:e594-e601.

30. Weaver LT. Rapid growth in infancy: balancing the interests of the child. J Pediatr Gastroenterol Nutr 2006;43:428-432.

31. Wofford LG. Systematic review of childhood obesity prevention. J Pediatr Nurs 2008;23:5-19.

32. Sweeting HN. Measurement and definitions of obesity in childhood and adolescence: a field guide for the uninitiated. Nutr J 2007;6:32.

33. De Onis M. The use of anthropometry in the prevention of childhood overweight and obesity. Int J Obes Relat Metab Disord 2004;28:S81-S85.

34. Cole TJ, Faith MS, Pietrobelli A, Heo M. What is the best measure of adiposity change in growing children: BMI, BMI %, BMI z-score or BMI centile? Eur J Clin Nutr 2005; 59:419-425.

35. Gilbert MJ, Fleming MF. Use of enhanced body mass index charts during the pediatric health supervision visit increases physician recognition of overweight patients. Clin Pediatr (Phila) 2007;46:689-697.

36. Perrin EM, Flower KB, Ammerman AS. Body mass index charts: useful yet underused. J Pediatr 2004;144:455-460.

37. Dorsey KB, Wells C, Krumholz HM, Concato JC. Diagnosis, evaluation, and treatment of childhood obesity in pediatric practice. Arch Pediatr Adolesc Med 2005;159:632-638.

38. Barlow SE, Bobra SR, Elliott MB, Brownson RC, HaireJoshu D. Recognition of childhood overweight during health supervision visits: Does BMI help pediatricians?

Obesity (Silver Spring) 2007;15:225-232.

39. Golan M. Parents as agents of change in childhood obesity-from research to practice. Int J Pediatr Obes 2006;1:66-76.

40. West DS, Raczynski JM, Phillips MM, Bursac Z, Heath Gauss C, Montgomery BE. Parental Recognition of Overweight in School-age Children. Obesity (Silver Spring) 2008;16:630-636.

41. Ogden CL. Defining overweight in children using growth charts. Md Med 2004;5:19-21.

42. Wang Y, Moreno LA, Caballero B, Cole TJ. Limitations of the current world health organization growth references for children and adolescents. Food Nutr Bull 2006;27:S175-S188.

43. De Onis M, Wijnhoven TM, Onyango AW. Worldwide practices in child growth monitoring. J Pediatr 2004;144: 461-465.

44. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-1243.

45. Serra-Majem L, Ribas-Barba L, Pérez-Rodrigo C, Ngo J, Aranceta J. Methodological limitations in measuring childhood and adolescent obesity and overweight in epidemiological studies: does overweight fare better than obesity?

Public Health Nutr 2007;10:1112-1120.

46. De Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J. The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food Nutr Bull 2004;25:S15-S26.

47. WHO Multicentre Growth Reference Study Group. Reliability of anthropometric measurements in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:38-46.

48. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl 2006;450:76-85.

49. Onyango AW, de Onis M, Caroli M, Shah U, Sguassero Y, Redondo N, et al. Field-testing the WHO child growth standards in four countries. J Nutr 2007;137:149-152.

50. WHO Multicentre Growth Reference Study Group.

Breastfeeding in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:16-26.

51. Garza C. New growth standards for the 21st century: a prescriptive approach. Nutr Rev 2006;64:S55-S59.

52. De Onis M, Onyango AW. The Centers for Disease Control and Prevention 2000 growth charts and the growth of breastfed infants. Acta Paediatr 2003;92:413-419.

53. Vidal E, Carlin E, Driul D, Tomat M, Tenore A. A comparison study of the prevalence of overweight and obese Italian preschool children using different reference standards.

Eur J Pediatr 2006;165:696-700.

54. De Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr 2007;137:144-148.

55. De Onis M, Onyango AW, Borghi E, Garza C, Yang H; WHO Multicentre Growth Reference Study Group. Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutr 2006;9:942-947.

56. Ponce M, Blanco A, Reyes H, Lfipez C, Fuentes D. Utilidad de las nueva curvas de crecimiento de la OMS para la de~os menores de cinteccifin del sobrepeso y obesidad en nin ~ co anos. Pediaãtrika 2007;27(4):48.

57. Garza C, de Onis M. Rationale for developing a new international growth reference. Food Nutr Bull 2004; 25:S5-S14.

58. Wright C, Lakshman R, Emmett P, Ong K. Implications of adopting the WHO 2006 Child Growth Standard in the UK: two prospective cohort studies. Arch Dis Child 2007 [Epub ahead of print].

59. Hui LL, Schooling CM, Cowling BJ, Leung SS, Lam TH, Leung GM. Are universal standards for optimal infant growth appropriate? Evidence from a Hong Kong Chinese birth cohort. Arch Dis Child 2007 [Epub ahead of print].

60. Seal A, Kerac M. Operational implications of using 2006 ¶·È‰È·ÙÚÈ΋ 2008;71:96-104

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·104

104

M. Ponce-Rivera, D. Fuentes-Lugo

World Health Organization growth standards in nutrition programmes: secondary data analysis. BMJ 2007;334:733.

61. Butte NF, Garza C, de Onis M. Evaluation of the feasibility of international growth standards for school-aged children and adolescents. J Nutr 2007;137:153-157.

62. De Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007;85:660-667.

63. Butte NE, Garza C, de Onis M. Evaluation of the feasibility of international growth standards for school-aged children and adolescents. Food Nutr Bull 2006;27:S169-S174.

64. Deshmukh PR, Dongre AR, Gupta SS, Garg BS. Newly developed WHO growth standards: implications for demographic surveys and child health programs. Indian J Pediatr 2007;74:987-990.

65. Wells JC, Fewtrell MS. Is body composition important for paediatricians? Arch Dis Child 2008;93:168-172.

66. Williams J, Wake M, Campbell M. Comparing estimates of body fat in children using published bioelectrical impedance analysis equations. Int J Pediatr Obes 2007;2:174-179.

67. Burdette HL, Whitaker RC, Hall WC, Daniels SR. Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age. Am J Clin Nutr 2006;83:550-558.

68. Cleary J, Daniells S, Okely AD, Batterham M, Nicholls J. Predictive validity of four bioelectrical impedance equations in determining percent fat mass in overweight and obese children. J Am Diet Assoc 2008;108:136-139.

Paediatriki 2008;71:96-104

69. McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM. Body fat reference curves for children. Int J Obes (Lond) 2006; 30:598-602.

70. Isganaitis E, Levitsky LL. Preventing childhood obesity: can we do it? Curr Opin Endocrinol Diabetes Obes 2008;15:1-8.

71. Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K. Recommendations for prevention of childhood obesity. Pediatrics 2007;120:S229-S253.

72. Connelly JB, Duaso MJ, Butler G. A systematic review of controlled trials of interventions to prevent childhood obesity and overweight: a realistic synthesis of the evidence.

Public Health 2007;121:510-517.

73. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120:S164-S192.

74. Fussenegger D, Pietrobelli A, Widhalm K. Childhood obesity: political developments in Europe and related perspectives for future action on prevention. Obes Rev 2008;9:76-82.

75. Landrigan PJ, Trasande L, Thorpe LE, Gwynn C, Lioy PJ, D'Alton ME, et al. The National Children's Study: a 21-year prospective study of 100,000 American children. Pediatrics 2006;118:2173-2186.

Pediatri Mar-Apr 08

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∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ∞Ó‰Ú¤·˜ ¶¿Ì·ÓÔ˜ apampanos@yahoo.com ∂ÚÁ·ÛÙ‹ÚÈÔ π·ÙÚÈ΋˜ °ÂÓÂÙÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ÈڤÌÂÈÔ ∂Ú¢ÓËÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·

§¤ÍÂȘ ÎÏÂȉȿ: °ÂÓÂÙÈ΋, ÌÔÚȷ΋ ‰È¿ÁÓˆÛË, ·È‰È·ÙÚÈ΋.

Basic techniques of molecular biology and their applications in the diagnosis of childhood diseases S. Megremis, ∞. Pampanos Abstract: All the techniques applied in molecular biology focus on the characterization, isolation and manipulation of the molecular components of the cell. These components include DNA, which is the repository of genetic information, RNA and proteins. Genes are the functional units of the DNA, specifying the structure of proteins. There are about 24,000 protein-coding genes in the human genome as estimated by the Human Genome Project. Most of the molecular tests that are used in clinical diagnosis screen multiple genes for specific and/or non-specific mutations. Nowadays, a vast variety of genetic tests are available for use by clinicians in order to obtain diagnostic and prognostic information. Most of these tests are feasible because of the capability of the DNA double helix to denature and anneal or hybridize. In this review some of the basic molecular diagnostic techniques are presented, such as the polymerase chain reaction, DNA sequencing, DHPLC, and the southern and northern blotting techniques.

Key words: Genetics, molecular diagnostics, paediatrics.

™˘ÓÙÔÌÔÁڷʛ˜: PCR dNTP ddNTP QRT PCR RFLP VNTR STR DHPLC

Polymerase Chain Reaction diNucleotideTriPhosphatase didiNucleotideTriPhosphatase Quantitative Real Time PCR Restriction Fragment Length Polymorphism Variable Number Tandem Repeat Short Tandem Repeat Denaturant High Performance Liquid Chromatography

∂ÈÛ·ÁˆÁ‹ - πÛÙÔÚÈ΋ ∞Ó·‰ÚÔÌ‹ ∏ °ÂÓÂÙÈ΋ ‚·Û›˙ÂÙ·È ÛÙȘ ÁÓÒÛÂȘ Ù˘ π·ÙÚÈ΋˜ Î·È Ù˘ µÈÔÏÔÁ›·˜ Î·È ÂȯÂÈÚ› Ó· ‰ÒÛÂÈ ··ÓÙ‹ÛÂȘ Û ÂÚˆÙ‹Ì·Ù· fiÛÔÓ ·ÊÔÚ¿

Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital, Athens, Greece Correspondence: Andreas Pampanos apampanos@yahoo.com Medical Genetics Laboratory, University of Athens, Choremio Research Laboratory, “Aghia Sophia” Children’s Hospital Thivon & Levadias St., 115 27, Athens, Greece

ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ù˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Î·È Ù˘ ‚ÈÔÔÈÎÈÏfiÙËÙ·˜. √ fiÚÔ˜ ÁÂÓÂÙÈ΋ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ ÕÁÁÏÔ ÁÂÓÂÙÈÛÙ‹ Bateson ÙÔ 1905 (1). ∂›ÛËÌ·, ·Ù¤Ú·˜ Ù˘ ÁÂÓÂÙÈ΋˜ ıˆÚÂ›Ù·È Ô ªendel, Ô ÔÔ›Ô˜ ÙÔ 1865 ‰È·Ù‡ˆÛ ÙÔ˘˜ ÓfiÌÔ˘˜ Ô˘ ʤÚÔ˘Ó ÙÔ fiÓÔÌ¿ ÙÔ˘ (2). ∏ ·Ï‹ıÂÈ·, fï˜, Â›Ó·È fiÙÈ ÙÔ ˙‹ÙËÌ· Ù˘ ÌÂÙ·‚›‚·Û˘ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ·fi ÁÂÓÈ¿ Û ÁÂÓÈ¿ ¤¯ÂÈ ··Û¯ÔÏ‹ÛÂÈ ÙÔÓ ¿ÓıÚˆÔ ·fi ÙËÓ ·Ú¯·ÈfiÙËÙ·. °È· ·Ú¿‰ÂÈÁÌ·, ÔÈ ·Ú¯·›ÔÈ µ·‚˘ÏÒÓÈÔÈ ÁÓÒÚÈ˙·Ó fiÙÈ ÁÈ· Ó· ·Ú·¯ı› ηÚfi˜ Û ÊÔÈÓÈÎfi‰ÂÓÙÚ· ¤ÚÂ ӷ ÌÂÙ·ÊÂÚı› Á‡ÚË ·fi ¿ÚÚÂÓ· Ê˘Ù¿ ÛÙÔ˘˜ ‡ÂÚÔ˘˜ ÙˆÓ ıËÏ˘ÎÒÓ Ê˘ÙÒÓ (1). ™ÙËÓ ·Ú¯·›· ¶·È‰È·ÙÚÈ΋ 2008;71:105-115

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106

™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜

∂ÏÏ¿‰·, Ô ¶˘ı·ÁfiÚ·˜ ‰È·Ù‡ˆÛ ÙËÓ ˘fiıÂÛË fiÙÈ Ë ˙ˆ‹ ÍÂÎÈÓ¿ Ì ÙËÓ ·Ó¿ÌÂÈÍË ·ÚÛÂÓÈÎÒÓ Î·È ıËÏ˘ÎÒÓ ÛÂÚÌ¿ÙˆÓ (1). ∆ÔÓ 4o ·ÈÒÓ· .Ã., Ô ∞ÚÈÛÙÔÙ¤Ï˘ ˘ÔÛÙ‹ÚÈÍ fiÙÈ Ô Î¿ı ÁÔÓ¤·˜ Û˘Ì‚¿ÏÏÂÈ ÛÙË ÌÂÙ·ÊÔÚ¿ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜ (1). ™ÙȘ ·Ú¯¤˜ ÙÔ˘ 19Ô˘ ·ÈÒÓ·, Ô °¿ÏÏÔ˜ Ê˘ÛÈÔ‰›Ê˘ Lamarck ˘ÔÛÙ‹ÚÈÍ fiÙÈ Ù· Â›ÎÙËÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÎÏËÚÔÓÔÌÔ‡ÓÙ·È (3), ÂÓÒ ÙÔ 1859 Ô Darwin ÙfiÓÈÛ ÙË ÛËÌ·Û›· ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ù˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ ÛÙË ÌÂϤÙË Ù˘ ÂͤÏÈ͢ ÙˆÓ ÂȉÒÓ (1). §›Á· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, ÙÔ 1865, Ô Mendel ‰ËÌÔÛȇÂÈ ÙȘ ıˆڛ˜ ÙÔ˘. ∆Ô 1903 ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ Ù· ¯ÚˆÌÔÛÒÌ·Ù· Â›Ó·È ÊÔÚ›˜ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ (1), ÂÓÒ ÙÔ 1910 Ô Morgan ÂÎÙÈÌ¿ fiÙÈ Ù· ÁÔÓ›‰È· ÂÓÙÔ›˙ÔÓÙ·È ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù· (4). ∆Ô DNA ·Ú¯Èο ÔÓÔÌ¿ÛÙËΠÓÔ˘ÎϽÓË Î·È ·Ó·Î·Ï‡ÊıËΠ·fi ÙÔÓ Meischer ÙÔ 1867 (4), ·ÏÏ¿ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÁÂÁÔÓfi˜ Û˘ÓÙÂÏÂ›Ù·È ÙÔ 1953, fiÙ·Ó ÔÈ Watson Î·È Crick ÚÔÙ›ÓÔ˘Ó ÙÔ ÌÔÓÙ¤ÏÔ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ ÙÔ˘ DNA (4,5), ÂÓÒ ÙÔ 1956 ÔÈ Tjio Î·È Levan ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ¯ÚˆÌÔÛˆÌ¿ÙˆÓ ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È 46 (1). ∞fi ÙfiÙÂ Ë ÂͤÏÈÍË Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ Î·È ÁÂÓÂÙÈ΋˜ Â›Ó·È Ù¤ÙÔÈ·, ÒÛÙ ӷ ıˆÚÂ›Ù·È ϤÔÓ ‰Â‰Ô̤ÓË Ë ¯Ú‹ÛË ÙˆÓ ÌÂıfi‰ˆÓ ÙÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË. ∏ ÂÈÏÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙË ÌÔÚȷ΋ ‰È¿ÁÓˆÛË ÌÈ·˜ ÁÂÓÂÙÈ΋˜ ·Ûı¤ÓÂÈ·˜ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ Ì˯·ÓÈÛÌfi Ô˘ ÚÔηÏ› ÙËÓ ›‰È· ÙË ÓfiÛÔ. ™Ùfi¯Ô˜ ÙÔ˘ ¿ÚıÚÔ˘ Â›Ó·È Ë ·Ó·ÊÔÚ¿ ÛÙȘ ‚·ÛÈÎfiÙÂÚ˜ ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ ·Ó¿Ï˘Û˘ DNA, ÔÈ Ôԛ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ Â› ÙÔ Ï›ÛÙÔÓ ÛÙË ‰È¿ÁÓˆÛË ÁÂÓÂÙÈÎÒÓ ÓfiÛˆÓ Î·È ·Ó‹ÎÔ˘Ó ϤÔÓ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ·È‰È·ÙÚÈÎÒÓ ˘ÔÂȉÈÎÔÙ‹ÙˆÓ (¶›Ó·Î·˜ 1).

∆Ô ‰ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚Îfi Ô͇ (DNA) ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ÎÏËÚÔÓÔÌÈΤ˜ ÏËÚÔÊÔڛ˜ ÌÂÙ·‚È‚¿˙ÔÓÙ·È ·fi οı ·ÙÙ·ÚÔ ÛÙ· ı˘Á·ÙÚÈο ÙÔ˘, ηٿ ÙËÓ Î˘ÙÙ·ÚÈ΋ ‰È·›ÚÂÛË, ‰È·Ì¤ÛÔ˘ ÙˆÓ ÁÔÓȉ›ˆÓ. ◊‰Ë, ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ ÂÈÎÔÛÙÔ‡ ·ÈÒÓ·, ÔÈ ÂÈÛÙ‹ÌÔÓ˜ ıˆÚÔ‡Û·Ó ‰Â‰Ô̤ÓÔ fiÙÈ Ù· ÁÔÓ›‰È· ‚Ú›ÛÎÔÓÙ·È ÛÙ· ¯ÚˆÌÔÛÒÌ·Ù·, Ù· ÔÔ›· ÙfiÙ ‹Ù·Ó ÁÓˆÛÙ¿ ˆ˜ ÓËÌ·ÙÔÂȉ›˜ ‰Ô̤˜ ÙÔ˘ ˘Ú‹Ó· ÙˆÓ Â˘Î·Ú˘ˆÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Á›ÓÔÓÙ·È ÔÚ·Ù¿ fiÙ·Ó ÙÔ Î‡ÙÙ·ÚÔ ·Ú¯›˙ÂÈ Ó· ‰È·ÈÚ›ٷÈ. ªÂ ÙËÓ ¿ÚÔ‰Ô ‰Â ÙÔ˘ ¯ÚfiÓÔ˘ Î·È Ì ÙËÓ ÂͤÏÈÍË ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ó·Ï‡ÛÂˆÓ ÂȂ‚·ÈÒıËΠfiÙÈ Ù· ¯ÚˆÌÔÛÒÌ·Ù· ·ÔÙÂÏÔ‡ÓÙ·È ·fi DNA Î·È ÚˆÙ½Ó˜. ∞Ú¯Èο, ÔÈ ÂÈÛÙ‹ÌÔÓ˜ ‰˘ÛÎÔχÔÓÙ·Ó Ó· ‰Â¯ÙÔ‡Ó ÙÔ Ì·ÎÚ‡ ·˘Ùfi ÔÏ˘ÌÂÚ¤˜ ˘ÏÈÎfi Ô˘ ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 4 ÌfiÓÔ Â›‰Ë ˘ÔÔÌ¿‰ˆÓ, ˆ˜ ÁÂÓÂÙÈÎfi ˘ÏÈÎfi, ÏfiÁˆ Ù˘ Ê·ÈÓÔÌÂÓÈ΋˜ ·ÏfiÙËÙ·˜ Ù˘ ¯ËÌ›·˜ ÙÔ˘. ∆Ô 1953, fï˜, ÔÈ J. Watson & F. Crick Paediatriki 2008;71:105-115

¶›Ó·Î·˜ 1. ∂Ӊ›ÍÂȘ ·Ó¿Ï˘Û˘ DNA ÃÚfiÓÔ˜ DNA ·Ó¿Ï˘Û˘

∂Ӊ›ÍÂȘ (·Ú·‰Â›ÁÌ·Ù·)

¶ÚÔÁÂÓÓËÙÈο

ñ ¢È¿ÁÓˆÛË Î‡ËÛ˘ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (.¯. ÈÛÙÔÚÈÎfi Ì˘˚΋˜ ‰˘ÛÙÚÔÊ›·˜ Duchenne) ¡ÂÔÁÓ¿ - µÚ¤ÊË ñ ∂Ȃ‚·›ˆÛË ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ (.¯. Ê·ÈÓfiÙ˘Ô˜ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ Ì ıÂÙÈÎfi ÙÂÛ٠ȉÚÒÙ·) ¶·È‰È¿ ñ ¢ÈÂÚ‡ÓËÛË ÓÔËÙÈ΋˜ ˘ÛÙ¤ÚËÛ˘ (.¯. ·ÔÎÏÂÈÛÌfi˜ Û˘Ó‰ÚfiÌÔ˘ ¢ıÚ·‡ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ Ã) ñ ∂Ȃ‚·›ˆÛË ‰È¿ÁÓˆÛ˘ ÓÔÛ‹Ì·ÙÔ˜ Ì ¤Ó·ÚÍË ÂΉËÏÒÛÂˆÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (.¯ Ì˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne) ∂Ó‹ÏÈΘ ñ ŒÏÂÁ¯Ô˜ ÊÔÚ¤ˆÓ (.¯. ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ΢ÛÙÈ΋˜ ›ÓˆÛ˘) ñ ¶ÚÔÛ˘Ìو̷ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ (ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ηÚΛÓÔ˘ Ì·ÛÙÔ‡/ˆÔıËÎÒÓ) ñ ∂Ȃ‚·›ˆÛË ‰È¿ÁÓˆÛ˘ ÓÔÛ‹Ì·ÙÔ˜ Ì ¤Ó·ÚÍË ÂΉËÏÒÛÂˆÓ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (.¯. ÓfiÛÔ˜ Huntington)

(4,5) ˘¤‚·Ï·Ó Û ·Ó¿Ï˘ÛË ÂÚ›ıÏ·Û˘ ·ÎÙ›ÓˆÓ Ã (Ù¯ÓÈ΋ ηıÔÚÈÛÌÔ‡ ÙÚÈۉȿÛÙ·Ù˘ ·ÙÔÌÈ΋˜ ‰ÔÌ‹˜ ÙˆÓ ÌÔÚ›ˆÓ) ÙÔ ‰ÂÔ͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚Îfi Ô͇ (DNA) ·Ô‰›‰ÔÓÙ¿˜ ÙÔ˘ ÙË ‰›ÎψÓË ÂÏÈÎÔÂȉ‹ ÌÔÚÊ‹, ‰›ÓÔÓÙ·˜ ¤ÙÛÈ ·¿ÓÙËÛË Û ÂÚˆÙ‹Ì·Ù· ÙÔ˘ Ù‡Ô˘: ‰˘Ó·ÙfiÙËÙ· ·ÎÚÈ‚Ô‡˜ ·ÓÙÈÁÚ·Ê‹˜ ÙˆÓ 2 ÎÏÒÓˆÓ Î·È ÌÂÙ·ÊÔÚ¿ ÏËÚÔÊÔÚÈÒÓ, ˘fi ¯ËÌÈ΋ ÌÔÚÊ‹, ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡. ∏ ¤Ó·ÚÍË Ù˘ Û‡ÓıÂÛ˘ ÙÔ˘ DNA, fiˆ˜ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ, Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÛÙȘ ÏÂÁfiÌÂÓ˜ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ (replication forks) ˘fi ÙËÓ ·ÚÔ˘Û›· ÂȉÈÎÒÓ ÂÓ·ÚÎÙ‹ÚÈˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ·Ó·ÁÓˆÚ›˙Ô˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ DNA ÛÙȘ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ·ԉȷٿÛÛÔ˘Ó ÙÔÈο ÙÔ˘˜ 2 ÎÏÒÓÔ˘˜ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜. √È ÚÔ·ÙÔÓÙ˜ ÂÎÙÂıÂÈ̤ÓÔÈ ÌÔÓÔ› ÎÏÒÓÔÈ ·Ú·Ì¤ÓÔ˘Ó ·Ó¤·ÊÔÈ Î·È ÏÂÈÙÔ˘ÚÁÔ‡Ó ˆ˜ ÂÎÌ·Á›· ÁÈ· ÙÔ Û¯ËÌ·ÙÈÛÌfi Û˘ÌÏËڈ̷ÙÈÎÒÓ ÎÏÒÓˆÓ DNA (∂ÈÎfiÓ˜ 1· Î·È 1‚) ˘fi ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÂÓ˙‡ÌÔ˘ DNA ÔÏ˘ÌÂÚ¿ÛË Î·È ¿ÓÙÔÙ ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË 5ã→3ã. ∆· ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÙȘ ÁÂÓÂÙÈΤ˜ ÙÔ˘˜ Ô‰ËÁ›Â˜, Ù· ÁÔÓ›‰È¿ ÙÔ˘˜, ̤ۈ Ù˘ ÌÂÙ·ÁÚ·Ê‹˜ Î·È Ù˘ ÌÂÙ¿ÊÚ·Û˘, ¤ÙÛÈ ÒÛÙÂ Ë ÚÔ‹ ÙˆÓ ÁÂÓÂÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ Ó· Â›Ó·È ¿ÓÙ· Ë ÂÍ‹˜: DNA→RNA→¶ÚˆÙ½Ó˜. ∆Ô RNA ‰È·‰Ú·Ì·Ù›˙ÂÈ Î˘Ú›ˆ˜ ÙÔ ÚfiÏÔ ÂÓfi˜ ÌÂÛ¿˙ÔÓÙ· (∂ÈÎfiÓ· 2). ∫·Ù¿ Û˘Ó¤ÂÈ·, Ù· ÁÔÓ›‰È· ‰ÂÓ Â›Ó·È Ù›ÔÙ ¿ÏÏÔ ·fi ÙȘ ıÂÌÂÏÈÒ‰ÂȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ÌÔÓ¿‰Â˜ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ οı ˙ÒÓÙÔ˜ ÔÚÁ·ÓÈÛÌÔ‡ Ô˘ ηٷϷ̂¿ÓÔ˘Ó ¤Ó·Ó ÂȉÈÎfi ÙfiÔ-ı¤ÛË (locus) ¿Óˆ Û οı ¯ÚˆÌfiۈ̷. ∏ ‰ÔÌ‹ ÙÔ˘ οıÂ

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·107

107

ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË

∞ÊÂÙËÚ›· ·ÓÙÈÁÚ·Ê‹˜

∞ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜

1

5ã ¢›Îψӷ DNA 3ã

∫·Ù‡ı˘ÓÛË Ù˘ ‰È¯¿Ï·˜ 2

3ã 5㠢ȿÓÔÈÍË Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ Ì ÙË ‚Ô‹ıÂÈ· ÂÓ·ÚÎÙ‹ÚÈˆÓ ÂÎÌ·Á›ˆÓ

¢È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜

0,1 Ìm

5ã

3ã

3ã

5ã

0,1 Ìm

ªÔÓfiÎψӷ DNA ÂÎÌ·Á›·, ¤ÙÔÈÌ· ÁÈ· ÙË Û‡ÓıÂÛË DNA

3

∂ÈÎfiÓ· 1‚. ∞ÓÙÈÁÚ·Ê‹ DNA. ∂ȉÈΤ˜ ÂÓ·ÚÎÙ‹ÚȘ ÚˆÙ½Ó˜ ·Ó·ÁÓˆÚ›˙Ô˘Ó Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ DNA ÛÙȘ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÙÔÈο ·ԉȷٿÛÛÔ˘Ó ÙÔ˘˜ 2 ÎÏÒÓÔ˘˜ Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜. √È ÚÔ·ÙÔÓÙ˜ ÌÔÓÔ› ÎÏÒÓÔÈ ‰‡Ó·ÓÙ·È Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ˆ˜ ÂÎÌ·Á›· ·ÓÙÈÁÚ·Ê‹˜ ÙÔ˘ DNA.

∂ÈÎfiÓ· 1·. ™‡ÓıÂÛË DNA ÛÙȘ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ (replication forks). ∏ÏÂÎÙÚÔÓÈ΋ ÌÈÎÚÔʈÙÔÁÚ·Ê›· ¯ÚˆÌÔÛÒÌ·ÙÔ˜ ¢ηڢˆÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘, ÛÙÔ ÔÔ›Ô ÔÈ ‰È¯¿Ï˜ ·ÓÙÈÁÚ·Ê‹˜ ÌÂÙ·ÎÈÓÔ‡ÓÙ·È ÚÔ˜ ·ÓÙ›ıÂÙ˜ ηÙ¢ı‡ÓÛÂȘ ÍÂÎÈÓÒÓÙ·˜ ·fi ÔÏÏ·Ϥ˜ ·ÊÂÙËڛ˜ ·ÓÙÈÁÚ·Ê‹˜.

ÁÔÓȉ›Ô˘ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ Î·È ·ÔÙÂÏÂ›Ù·È ·fi ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ·ÏÏËÏÔ˘¯›Â˜, ÁÓˆÛÙ¤˜ ˆ˜ ÂÛfiÓÈ· (introns), ÂÓ·ÏÏ·ÛÛfiÌÂÓ˜ Ì Έ‰ÈÎÔÔÈÔ‡Û˜ ·ÏÏËÏÔ˘¯›Â˜, Ù· ÂÍfiÓÈ· (exons). ™˘Ó‹ıˆ˜, Ù· ÂÍfiÓÈ· Â›Ó·È ‚Ú·¯‡ÙÂÚ· ·fi Ù· ÈÓÙÚfiÓÈ· Î·È Ë ÂÚÈÔ¯‹ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È Û˘¯Ó¿ ·ÓÙÈÚÔÛˆ‡ÂÈ ÌfiÓÔ ¤Ó· ÌÈÎÚfi ÔÛÔÛÙfi ÙÔ˘ ÂοÛÙÔÙ ÁÔÓȉ›Ô˘ (∂ÈÎfiÓ· 3). ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰ÔÌ‹ Î·È Ê˘ÛÈο ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ οı ÁÔÓȉ›Ô˘ ¤¯Ô˘Ó ÔÈ ˘ÔÎÈÓËÙ¤˜ (promoters).

¶˘Ú‹Ó·˜

¶ÚfiÎÂÈÙ·È ÁÈ· ·ÏÏËÏÔ˘¯›Â˜ DNA ÛÙȘ Ôԛ˜ ÚÔÛ‰¤ÓÂÙ·È Ë RNA ÔÏ˘ÌÂÚ¿ÛË ÚÔÙÔ‡ ·Ú¯›ÛÂÈ ÙË ÌÂÙ·ÁÚ·Ê‹ ÙÔ˘ DNA Û RNA. ∆Ô ÁÔÓȉ›ˆÌ· ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡ Â›Ó·È fiϘ ÔÈ ÎÏËÚÔÓÔÌ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ Î·È Îˆ‰ÈÎÔÔÈÂ›Ù·È ÛÙÔ DNA. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÂÎÙÈÌ‹ÛÂȘ, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· ¤¯ÂÈ Ì¤ÁÂıÔ˜ ÂÚ›Ô˘ 3 ‰ÈÛÂηÙÔÌ̇ÚÈ· ‚¿ÛÂȘ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ 20.000-25.000 ÁÔÓ›‰È· (6). ∏ ÁÔÓȉȷ΋ ˘ÎÓfiÙËÙ· ÂÓfi˜ ÁÔÓȉÈÒÌ·ÙÔ˜ Â›Ó·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÁÔÓȉ›ˆÓ ·Ó¿ ¤Ó· ÂηÙÔÌ̇ÚÈÔ ‚¿ÛÂȘ (megabase, Mb).

πÓÙÚfiÓÈ·

∂ÍfiÓÈ·

DNA

°ÔÓ›‰ÈÔ

MÂÙ·ÁÚ·Ê‹

¶ÚˆÙÔÁÂÓ¤˜ RNA ÌÂÙ¿ÁÚ·ÊÔ

¶ÚÔÛı‹ÎË 5' ηχÙÚ·˜ Î·È Ô˘Ú¿˜ ÔÏ˘ ∞

∫·Ï‡ÙÚ· RNA ∞∞∞∞ ™˘ÚÚ·Ê‹ RNA m RNA

∞∞∞∞ EÍ·ÁˆÁ‹

m RNA

∞∞∞∞ MÂÙ¿ÊÚ·ÛË

∫˘ÙÙ·ÚfiÏ·ÛÌ·

¶ÚˆÙ½ÓË

∂ÈÎfiÓ· 2. ∏ ÚÔ‹ ÁÂÓÂÙÈÎÒÓ ÏËÚÔÊÔÚÈÒÓ ·fi DNA Û ÚˆÙ½ÓË. ™¯ËÌ·ÙÈ΋ ·Ó··Ú¿ÛÙ·ÛË ÙˆÓ ÛÙ·‰›ˆÓ Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· Ó· ÂÎÊÚ·Ûı› Ë ÁÂÓÂÙÈ΋ ÏËÚÔÊÔÚ›·. ™Ù· ¢ηڢˆÙÈο ·ÙÙ·Ú· ÙÔ ·Ú¯ÈÎfi ÌfiÚÈÔ ÙÔ˘ RNA ÂÚȤ¯ÂÈ ÈÓÙÚfiÓÈ· Ù· ÔÔ›· ·Ê·ÈÚÔ‡ÓÙ·È Ì ÌÈ· ÂÓ˙˘ÌÈο Î·Ù·Ï˘fiÌÂÓË ·ÓÙ›‰Ú·ÛË Û˘ÚÚ·Ê‹˜. ∞fi ÙȘ ÌÂÙ·ÙÚÔ¤˜ ·˘Ù¤˜ ·Ú¿ÁÂÙ·È mRNA, ÙÔ ÔÔ›Ô ÌÂٷʤÚÂÙ·È ·fi ÙÔÓ ˘Ú‹Ó· ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·, fiÔ˘ Î·È ÌÂÙ·ÊÚ¿˙ÂÙ·È Û ÚˆÙ½ÓË. ¶·È‰È·ÙÚÈ΋ 2008;71:105-115

Pediatri Mar-Apr 08

10-04-08

12:42

™ÂÏ›‰·108

108

™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜

™ËÌÂ›Ô ÂÎΛÓËÛ˘ ÌÂÙ·ÁÚ·Ê‹˜ Û RNA -1

πÓÙÚfiÓÈÔ

TGA-Έ‰ÈÎfiÓÈÔ ÙÂÚÌ·ÙÈÛÌÔ‡ ÌÂÙ¿ÊÚ·Û˘ tga

Ṳ̂ӷ Ì ٤ÙÔÈÔ ÙÚfiÔ, ÒÛÙ ӷ ·Ô‰›‰Ô˘Ó ÂÚ›Ô˘ 6 Ìg DNA ·fi 200 Ìl ÂÚÈÊÂÚÈÎÔ‡ ÔÏÈÎÔ‡ ·›Ì·ÙÔ˜ Ì ·ÓÙÈËÎÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ -fiˆ˜ EDTAÎ·È Ì¤¯ÚÈ 50 Ìg DNA ·fi Ù· ÂÈıËÏȷο ·ÙÙ·Ú· Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Ô˘ ÂÚȤ¯ÔÓÙ·È Û 200 Ìl ÛȤÏÔ˘ (13).

∂ÍfiÓÈÔ

∂ÈÎfiÓ· 3. ∆˘ÈÎfi ÁÔÓ›‰ÈÔ Â˘Î·Ú˘ˆÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘. ∫¿ı ÁÔÓ›‰ÈÔ ·ÔÙÂÏÂ›Ù·È ·fi Έ‰ÈÎÔÔÈÔ‡Û˜ (ÂÍÒÓÈ·) Î·È ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜ (ÂÛfiÓÈ· ‹ ÈÓÙÚfiÓÈ·).

H ÁÔÓȉȷ΋ ˘ÎÓfiÙËÙ· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ Â›Ó·È Û¯Â‰fiÓ 12-15 ÁÔÓ›‰È·/ÌÂÁ·‚¿ÛË (7). √È ‰ÈÂÚÁ·Û›Â˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÂȉÈfiÚıˆÛ˘ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ οı ΢ÙÙ¿ÚÔ˘ Û¿ÓÈ· ·ÔÙ˘Á¯¿ÓÔ˘Ó Î·È ¤ÙÛÈ ‰È·ÙËÚÂ›Ù·È Ë ÓÔ˘ÎÏÂÔÙȉÈ΋ ÙÔ˘ ·ÏÏËÏÔ˘¯›· ÛÙ·ıÂÚ‹. ∂Ó›ÔÙÂ, fï˜, ‰‡Ó·Ù·È Ó· ·Ú·ÙËÚËıÔ‡Ó ÓÔ˘ÎÏÂÔÙȉÈΤ˜ ·ÏÏ·Á¤˜, ÛËÌÂȷΤ˜ ‹ ÌË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Ô‰ËÁԇ̷ÛÙ Û ۇÓıÂÛË ·ıÔÏÔÁÈÎÒÓ ÚˆÙÂ˚ÓÒÓ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÙË ÌË Ê˘ÛÈÔÏÔÁÈ΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ·Ú·ÁÒÁÔ˘ ÙÔ˘ ÁÔÓȉ›Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. √ÔÈ·‰‹ÔÙ ٤ÙÔÈ· ·ÏÏ·Á‹ ηÏÂ›Ù·È ÌÂÙ¿ÏÏ·ÍË. ∂ÓÙÔ‡ÙÔȘ, ÛËÌÂȷΤ˜ ·ÏÏ·Á¤˜ Û ÁÔÓ›‰ÈÔ, ÔÈ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ó Â›ÙˆÛË ÛÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ Έ‰ÈÎÔÔÈÔ‡Û·˜ ÚˆÙ½Ó˘, ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ÔÏ˘ÌÔÚÊÈÛÌÔ› ‹ ÔÏ˘ÌÔÚÊÈΤ˜ ı¤ÛÂȘ. ªÂÙ·ÏÏ¿ÍÂȘ ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ ÛÙȘ Έ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜ ÙˆÓ ÁÔÓȉ›ˆÓ, ·ÏÏ¿ Î·È Û ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜, Ì ٷ ›‰È· ·ÔÙÂϤÛÌ·Ù· (8). OÈ Î˘ÚÈfiÙÂÚÔÈ Ù‡ÔÈ ÌÂÙ·ÏÏ¿ÍÂˆÓ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2.

∞ÔÌfiÓˆÛË DNA ∏ ÂͤٷÛË ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÚÔ¸Ôı¤ÙÂÈ Û ÚÒÙË Ê¿ÛË ÙËÓ ÂÍ·ÁˆÁ‹ Î·È ·ÔÌfiÓˆÛË ÙÔ˘ DNA (ÁÂÓˆÌÈÎÔ‡, ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ ‹ ÈÈÎÔ‡) ·fi ÂÚÈÊÂÚÈÎfi ·›Ì· ‹ ¿ÏÏÔ˘˜ ÈÛÙÔ‡˜, Ì ÛÎÔfi ÙÔ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ ·fi Ù· ˘fiÏÔÈ· Û˘ÛÙ·ÙÈο ÙˆÓ Î˘ÙÙ¿ÚˆÓ (ÚˆÙ½Ó˜, ÏÈ›‰È·, RNA, Î.Ï.). √È ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË Ì˯·ÓÈ΋ ıÚ·‡ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ, ÒÛÙ ӷ ·ÓÔ›ÍÔ˘Ó Ì ÙË ¯Ú‹ÛË ‰È¿ÊÔÚˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ Î·È ÂÓ˙‡ÌˆÓ, Ì ÛÎÔfi ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (9-11). À¿Ú¯Ô˘Ó ‰‡Ô ̤ıÔ‰ÔÈ ·ÔÌfiÓˆÛ˘ DNA ·fi ÂÚÈÊÂÚÈÎfi ·›Ì· ‹ ·fi ‰È¿ÊÔÚÔ˘˜ ÈÛÙÔ‡˜, Ë Ì¤ıÔ‰Ô˜ ÙÔ˘ NaCl (10) Î·È Ë ¯Ú‹ÛË ÙˆÓ ÂÌÔÚÈο ‰È·ı¤ÛÈÌˆÓ ‘kits’, Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ϤÔÓ ÂÚÈÛÛfiÙÂÚÔ ÏfiÁˆ Ù˘ ˘ÂÚÔ¯‹˜ ÙÔ˘˜ Û ٷ¯‡ÙËÙ· (ÂÚ›Ô˘ 25 ÏÂÙ¿, ¤Ó·ÓÙÈ ‰‡Ô ËÌÂÚÒÓ ÛÙË Ì¤ıÔ‰Ô ÙÔ˘ NaCl) (12) Î·È Ù˘ ηı·ÚfiÙËÙ·˜ ÙÔ˘ ÂÍ·ÁfiÌÂÓÔ˘ DNA. ∆· ÂÌÔÚÈο ‰È·ı¤ÛÈÌ· kits Â›Ó·È Û¯Â‰È·Paediatriki 2008;71:105-115

AÓ¿Ï˘ÛË Î·È ÌÂϤÙË ÙÔ˘ DNA ∞Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ (Polymerase Chain Reaction, PCR) ∏ ̤ıÔ‰Ô˜ ·Ó·Î·Ï‡ÊıËΠÙÔ 1987 ·fi ÙÔÓ Mullis (14), Ô ÔÔ›Ô˜ ‚Ú·‚‡ÙËΠ̠Nobel ÙÔ 1995, Î·È ·ÔÛÎÔ› ÛÙÔÓ ÂÎıÂÙÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi ÌÈÎÚÒÓ ÙÌËÌ¿ÙˆÓ DNA Ì ÙË ¯Ú‹ÛË Û˘ÓıÂÙÈÎÒÓ ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉ›ˆÓ (ÂÎÎÈÓËÙ¤˜-primers) Î·È ıÂÚÌÔ·ÓıÂÎÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ (15-17). √ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ·ÊÔÚ¿ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂÚÈÔ¯¤˜ DNA Ô˘ ÌÔÚ› Ó· ÂÚȤ¯Ô˘Ó ›Ù ¤Ó· ·Ïfi ÁÔÓ›‰ÈÔ ‹ ̤ÚÔ˜ ·˘ÙÔ‡ ‹ ÌË Îˆ‰ÈÎÔÔÈÔ‡Û˜ ÂÚÈÔ¯¤˜, ÌÂÁ¤ıÔ˘˜ ̤¯ÚÈ 10.000 ‚¿ÛÂȘ (bp) (18-21). ∏ Ù¯ÓÈ΋ PCR ‚·Û›˙ÂÙ·È ÛÙËÓ ÂÓ˙˘Ì·ÙÈ΋ ÎψÓÔÔ›ËÛË ÙÔ˘ ÁÂÓˆÌÈÎÔ‡ ˘ÏÈÎÔ‡, ¯ˆÚ›˜ ÙË ¯Ú‹ÛË ˙ÒÓÙˆÓ ÔÚÁ·ÓÈÛÌÒÓ fiˆ˜ ∂. coli ‹ ̇ÎËÙ˜ (14-17). ∏ ̤ıÔ‰Ô˜ ÂÊ·ÚÌfi˙ÂÙ·È Â˘Ú‡Ù·Ù· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È ÙË ‚ÈÔÏÔÁÈ΋ ¤Ú¢ӷ ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚ› Ó· ÂÓÙÔ›ÛÂÈ ÌÈ· Û˘ÁÎÂÎÚÈ̤ÓË ·ÏÏËÏÔ˘¯›· DNA ‹ RNA Û ÔÔÈÔ‰‹ÔÙ ˘fi ÂͤٷÛË ÎÏÈÓÈÎfi ‰Â›ÁÌ· (22). ∫Ï·ÛÈο ·Ú·‰Â›ÁÌ·Ù· Â›Ó·È ÔÈ ÁÂÓÂÙÈΤ˜ ·ı‹ÛÂȘ ÁÓˆÛÙÒÓ ÌÔÓÔÁÔÓȉȷÎÒÓ ‹ ÔÏ˘ÁÔÓȉȷÎÒÓ ÓÔÛËÌ¿ÙˆÓ, fiÔ˘ Ì PCR ·ÓȯÓ‡ÂÙ·È Ë ÌÂÙ·‚ÔÏ‹ ¤ÛÙˆ Î·È ÌÈ·˜ ÌfiÓÔ ‚¿Ûˆ˜ Î·È ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÔÌfi˙˘Á˜ ‹ ÂÙÂÚfi˙˘Á˜ ηٷÛÙ¿ÛÂȘ, Î·Ù·Ï˘ÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÂÍÂÏÈÎÙÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ (¶›Ó·Î·˜ 3). ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi, ηı›ÛÙ·Ù·È ÂÊÈÎÙfi˜ Ô ÚÔÁÂÓÓËÙÈÎfi˜, ·fi ·ÌÓÈ·Îfi ˘ÁÚfi (23) ‹ ¯ÔÚȷΤ˜ Ï¿¯Ó˜ (24,25), ηıÒ˜ Î·È Ë ÚÔÂÌÊ˘Ù¢ÙÈ΋ ‰È¿ÁÓˆÛË ·fi ‚Ï·ÛÙÔ·ÛÙË (26) ‹ ÔÏÈÎfi ۈ̿ÙÈÔ (27). ¶›Ó·Î·˜ 2. ∆‡ÔÈ ÌÂÙ·ÏÏ¿ÍÂˆÓ 1. ∂ÏÏ›„ÂȘ ‹ ‰ÈÏ·ÛÈ·ÛÌÔ› ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÂÍÔÓ›ˆÓ ÂÓfi˜ ÁÔÓȉ›Ô˘.

2. ªÂÙ·ÏÏ¿ÍÂȘ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ˘ÔÎÈÓËÙ‹.

3. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ‰È·‰Èηۛ· ÙÔ˘ Ì·Ù›ÛÌ·ÙÔ˜.

4. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ·ÏÏ¿˙Ô˘Ó ÙÔ Ï·›ÛÈÔ ·Ó¿ÁÓˆÛ˘ (frameshifts).

5. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó Îˆ‰ÈÎfiÓÈÔ ÙÂÚÌ·ÙÈÛÌÔ‡ (nonsense mutation).

6. ªÂÙ·ÏÏ¿ÍÂȘ Ô˘ ·ÏÏ¿˙Ô˘Ó ¤Ó· ·ÌÈÓÔ͇ Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÚˆÙ½Ó˘ Ì ¤Ó· ¿ÏÏÔ (missense mutation).

7. MÂÙ·ÏÏ¿ÍÂȘ Ô˘, ÂÓÒ ·ÏÏ¿˙Ô˘Ó ÙÔ Îˆ‰ÈÎfiÓÈÔ ÂÓfi˜ ·ÌÈÓÔͤԘ, ‰ÂÓ ·ÏÏ¿˙Ô˘Ó ÙÔ ·ÌÈÓÔ͇ Ô˘ Έ‰ÈÎÔÔÈÂ›Ù·È (silent mutation).

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·109

109

ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË

£¤ÚÌ·ÓÛË ÁÈ· ÙÔ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ÎÏÒÓˆÓ

À‚ÚȉÈÛÌfi˜ ÙˆÓ ÂÎÎÈÓËÙÒÓ

+DNA ÔÏ˘ÌÂÚ¿ÛË +dNTPs

¢›ÎψÓÔ DNA

™Ù¿‰ÈÔ 2

™Ù¿‰ÈÔ 1

™Ù¿‰ÈÔ 3

1Ô˜ ·ÎÏÔ˜ ∂ÈÎfiÓ· 4. ∏ ‚·ÛÈ΋ ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ Ù˘ PCR. ∏ ‚·ÛÈ΋ ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ PCR, fiˆ˜ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ·ÎÏÔ˘. √È ‰‡Ô ·Ï˘Û›‰Â˜ DNA ·ԉȷٿÛÛÔÓÙ·È (ÛÙ¿‰ÈÔ 1) Î·È Ô Î¿ı ÂÎÎÈÓËÙ‹˜ ÚÔÛÎÔÏÏ¿Ù·È ÛÙÔ Û˘ÌÏËڈ̷ÙÈÎfi ÙÔ˘ ÎÏÒÓÔ (ÛÙ¿‰ÈÔ 2). √È ÂÎÎÈÓËÙ¤˜ ÂÈÌË·ÓÔÓÙ·È Ì ÙË ‰Ú¿ÛË Ù˘ DNA ÔÏ˘ÌÂÚ¿Û˘ ·ÓÙÈÁÚ¿ÊÔÓÙ·˜ ÙËÓ ÂÚÈÔ¯‹ ÛÙfi¯Ô ÙÔ˘ DNA (ÛÙ¿‰ÈÔ 3).

∏ ¯Ú‹ÛË Ù˘ PCR ÂӉ›ÎÓ˘Ù·È Â›Û˘ ÛÙË ‰È¿ÁÓˆÛË ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ‰ÈfiÙÈ Ë Â˘·ÈÛıËÛ›· Ù˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·ÎfiÌ· Î·È ·fi ·˘Ù‹ ÙˆÓ ·ÓÔÛÔÂÓ˙˘Ìȶ›Ó·Î·˜ 3. ¶·Ú·‰Â›ÁÌ·Ù· ÎÏËÚÔÓÔÌÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ‰‡Ó·ÓÙ·È Ó· ‰È·ÁÓˆÛıÔ‡Ó Ì PCR ñ A˘ÙÔۈ̷ÙÈÎfi˜ EÈÎÚ·ÙËÙÈÎfi˜

∫ˆ‰ÈÎfi˜ PubMed

¶ÔÏ˘Î˘ÛÙÈ΋ ÓfiÛÔ˜ ÙˆÓ ÓÂÊÚÒÓ ¡fiÛÔ˜ ÙÔ˘ Huntington ª˘ÔÙÔÓÈ΋ ‰˘ÛÙÚÔÊ›· √˙҉˘ ÛÎÏ‹Ú˘ÓÛË ∫ÒʈÛË DFN∞5 ÀÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· ƒÂÙÈÓÔ‚Ï¿Ûو̷

OMIM 600666 OMIM 143100 OMIM 160900 OMIM 191100 OMIM 608798 √ªπª 44010 OMIM 180200

ñ ∞˘ÙÔۈ̷ÙÈÎfi˜ YÔÏÂÈfiÌÂÓÔ˜ ™˘ÁÁÂÓ¤˜ ÓÂÊÚˆÙÈÎfi Û‡Ó‰ÚÔÌÔ ∫˘ÛÙÈ΋ ›ÓˆÛË ¡Â˘ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· DFNB1 µ ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· º·ÈÓ˘ÏÔÎÂÙÔÓÔ˘Ú›· ™‡Ó‰ÚÔÌÔ Usher 1 ŒÏÏÂÈ„Ë 21-˘‰ÚÔÍ˘Ï¿Û˘ NfiÛÔ˜ Tay-Sachs ¡fiÛÔ˜ Gaucher ™‡Ó‰ÚÔÌÔ Bloom ¡ˆÙÈ·›· Ì˘˚΋ ·ÙÚÔÊ›· (SMA)

∫ˆ‰ÈÎfi˜ PubMed √ªπª 600995 √ªπª 219700 √ªπª 220290 √ªπª 141900 √ªπª 261600 OMIM 276900 OMIM 201910 OMIM 272800 OMIM 230800 OMIM 210900 OMIM 253300

ñ à º˘ÏÔÛ‡Ó‰ÂÙÔ˜ ∫ˆ‰ÈÎfi˜ PubMed ™‡Ó‰ÚÔÌÔ Â‡ıÚ·˘ÛÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ à OMIM 300624 ¡ÂÊÚÔÏÈı›·ÛË OMIM 310468 ∞ÈÌÔÊÈÏ›· ∞/µ √ªπª 306700/ 306900 ª˘˚΋ ‰˘ÛÙÚÔÊ›· Duchenne √ªπª 310200 ª˘˚΋ ‰˘ÛÙÚÔÊ›· Becker √ªπª 300376 ∞¯ÚˆÌ·ÙÔ„›· ÂÚ˘ıÚÔ‡-Ú·Û›ÓÔ˘ (‰·ÏÙÔÓÈÛÌfi˜) √ªπª 303900 X Ê˘ÏÔÛ‡Ó‰ÂÙË È¯ı‡·ÛË √ªπª 607602 Ã Ê˘ÏÔÛ‡Ó‰ÂÙË ·Á·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· √ªπª 300300 ŒÏÏÂÈ„Ë ÁÏ˘Îfi˙˘ 6 ʈÛÊ·Ù¿Û˘ ·Ê˘‰ÚÔÁÔÓ¿Û˘ √ªπª 305900

ÎÒÓ ÌÂıfi‰ˆÓ (Elisa) (28) Î·È ··ÈÙÂ›Ù·È ÂÏ¿¯ÈÛÙÔ ÁÂÓÂÙÈÎfi ˘ÏÈÎfi ÙÔ˘ ·ıÔÁfiÓÔ˘ ·ÈÙ›Ô˘ (¤Ó· ÌfiÓÔ ·ÓÙ›ÁÚ·ÊÔ), ÒÛÙ ӷ ÌË ‚·Û›˙ÂÙ·È Ë ‰È¿ÁÓˆÛË ÛÙËÓ ‡·ÚÍË ‹ ÌË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘ (¶›Ó·Î·˜ 4). ∏ PCR ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â›Û˘ ÛÙËÓ ·Ó›¯Ó¢ÛË ·ÏÏËÏÔ˘¯ÈÒÓ ÁÔÓȉÈÒÌ·ÙÔ˜ ÈÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Ì ηÎÔ‹ıÂȘ fiÁÎÔ˘˜ ‹ ÛÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ÔÁÎÔÁÔÓ›‰È· ‹/Î·È ÔÁÎÔηٷÛÙ·ÏÙÈο ÁÔÓ›‰È· (¶›Ó·Î·˜ 4). ∏ ·ÓÙ›‰Ú·ÛË Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÛÙÔ ıÂÚÌÈÎfi ΢ÎÏÔÔÈËÙ‹, Ô ÔÔ›Ô˜ ·˘ÍÔÌÂÈÒÓÂÈ ÙË ıÂÚÌÔÎÚ·Û›· Ù˘ ·ÓÙ›‰Ú·Û˘, Ì ÛÎÔfi ÙË ‰È·‰Ô¯È΋ ·ԉȿٷÍË Î·È ˘‚ÚȉÔÔ›ËÛË Ù˘ ‰ÈÏ‹˜ ¤ÏÈη˜ DNA. H ·ÓÙ›‰Ú·ÛË PCR ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚ›· ÛÙ¿‰È· (∂ÈÎfiÓ˜ 4 Î·È 5): 1. AԉȿٷÍË ÙÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ (template denaturation) Û ˘„ËÏ‹ ıÂÚÌÔÎÚ·Û›· (94ÔC-96ÔC) Ì ‰È¿ÚÎÂÈ· ÂÓfi˜ ÏÂÙÔ‡.

2. ™‡Ó‰ÂÛË (annealing) ÙˆÓ ÂÎÎÈÓËÙÒÓ Ì ÙȘ Û˘ÌÏËڈ̷ÙÈΤ˜ ÙÔ˘˜ ·ÏÏËÏÔ˘¯›Â˜ ÛÙÔ DNA Û ıÂÚÌÔÎÚ·Û›· ÌÂٷ͇ 37ÔC-70ÔC Û˘Ó‹ıˆ˜ ÁÈ· ¤Ó· ÏÂÙfi.

3. ∂ÈÌ‹Î˘ÓÛË ÙˆÓ ˘‚ÚȉÈÛÌ¤ÓˆÓ ÂÎÎÈÓËÙÒÓ (primer extension), Ë ÔÔ›· Á›ÓÂÙ·È Û ıÂÚÌÔÎÚ·Û›·

¶›Ó·Î·˜ 4. ¶·Ú·‰Â›ÁÌ·Ù· Â›ÎÙËÙˆÓ ÓÔÛËÌ¿ÙˆÓ Ô˘ ‰‡Ó·ÓÙ·È Ó· ‰È·ÁÓˆÛıÔ‡Ó Ì PCR §ÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· ÕÚıÚÔ ∞Ó·ÊÔÚ¿˜ πfi˜ ÙÔ˘ Epstein-Barr (EBV) 49 ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ (CMV) 50 πfi˜ ·ÏÔ‡ ¤ÚËÙÔ˜ (HSV) 51 πfi˜ ÙˆÓ ·ÓıÚˆ›ÓˆÓ ıËÏˆÌ¿ÙˆÓ (HPV) 28 ª˘ÎÔ‚·ÎÙ‹ÚÈÔ Ê˘Ì·Ù›ˆÛ˘ 29 ¡ÂÔϷۛ˜ ∫ˆ‰ÈÎfi˜ PubMed √ÁÎÔηٷÛÙ·ÏÙÈο ÁÔÓ›‰È· BRCA1/ √ªπª 113705/ BRCA2 600185 P53 √ªπª 191170 MYC √ªπª 190080 RAS √ªπª 190020 ¶·È‰È·ÙÚÈ΋ 2008;71:105-115

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™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜

¢È·¯ˆÚÈÛÌfi˜ ÙˆÓ ÎÏÒÓˆÓ ÙÔ˘ DNA Î·È ÚÔÛı‹ÎË ÂÎÎÈÓËÙÒÓ

¢È·¯ˆÚÈÛÌfi˜ ÙˆÓ ÎÏÒÓˆÓ ÙÔ˘ DNA Î·È ÚÔÛı‹ÎË ÂÎÎÈÓËÙÒÓ

™‡ÓıÂÛË DNA

™‡ÓıÂÛË DNA

DNA ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉÈÎÔ› ÂÎÎÈÓËÙ¤˜ ¢›ÎψÓÔ DNA

1Ô˜ ·ÎÏÔ˜ (·Ú¿ÁÂÈ 2 ‰›Îψӷ ÌfiÚÈ· DNA)

2Ô˜ ·ÎÏÔ˜ (·Ú¿ÁÂÈ 4 ‰›Îψӷ ÌfiÚÈ· DNA)

∂ÈÎfiÓ· 5. √ ÚÒÙÔ˜ Î·È ‰Â‡ÙÂÚÔ˜ ·ÎÏÔ˜ ÌÈ·˜ ·ÓÙ›‰Ú·Û˘ PCR. ∫·Ù¿ ÙÔÓ 1Ô Î‡ÎÏÔ Ù˘ ·ÓÙ›‰Ú·Û˘ ·Ú¿ÁÔÓÙ·È 2 ‰›Îψӷ ÌfiÚÈ· DNA, ηٿ ÙÔ 2Ô Î‡ÎÏÔ 4 ‰›Îψӷ ÌfiÚÈ· DNA, ηٿ ÙÔÓ 3Ô Î‡ÎÏÔ 16 Î.Ô.Î.

72ÔC ÁÈ· ¤Ó· ÂÚ›Ô˘ ÏÂÙfi. ∆· ÙÚ›· ·˘Ù¿ ÛÙ¿‰È· ·ÔÙÂÏÔ‡Ó ¤Ó·Ó ·ÎÏÔ Ù˘ ·ÓÙ›‰Ú·Û˘. ªÈ· Û˘ÓËıÈṲ̂ÓË PCR ·ÔÙÂÏÂ›Ù·È ·fi 25-30 ·ÎÏÔ˘˜. ™ÙÔ Ù¤ÏÔ˜ οı ·ÎÏÔ˘, ÙÔ ÚÔ˚fiÓ Ù˘ ÂÈÌ‹Î˘ÓÛ˘ ÙÔ˘ οı ÂÎÎÈÓËÙ‹ ı· ·ÔÙÂϤÛÂÈ -‡ÛÙÂÚ· ·fi ·ԉȿٷÍË- ÙÔ ˘fiÛÙڈ̷ ÙÔ˘ ¿ÏÏÔ˘ ÂÎÎÈÓËÙ‹. ∏ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÔÈÎÈÏ›· ·Ú·ÏÏ·ÁÒÓ, fiˆ˜ nested PCR, ARMS PCR, QRT-PCR Ì ÙË ıÂÌÂÏÈÒ‰Ë ·Ú¯‹ Ù˘ ÌÂıfi‰Ô˘ Ó· ·Ú·Ì¤ÓÂÈ Ë ›‰È· (14,17,24). ∏ÏÂÎÙÚÔÊfiÚËÛË ÚÔ˚fiÓÙˆÓ PCR Û ‹Îو̷ ·Á·Úfi˙˘ ∏ ̤ıÔ‰Ô˜ Â›Ó·È Û˘ÌÏËڈ̷ÙÈ΋ Ù˘ PCR, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏÂÁ¯ı› Ë ÂÈÙ˘¯›· Ù˘ (29). ∆· ÚÔ˚fiÓÙ· Ù˘ ·ÓÙ›‰Ú·Û˘ PCR ËÏÂÎÙÚÔÊÔÚÔ‡ÓÙ·È Û ‹Îو̷ ·Á·Úfi˙˘ (∂ÈÎfiÓ· 6). ∏ ·Á·Úfi˙Ë Â›Ó·È ¤Ó· ÁÚ·ÌÌÈÎfi ÔÏ˘ÌÂÚ¤˜, Û˘ÛÙ·ÙÈÎfi ÙÔ˘ ¿Á·Ú, Ô˘ ¤¯ÂÈ ÙËÓ Ù¿ÛË Ó· Û¯ËÌ·Ù›˙ÂÈ ËÎÙÒÌ·Ù·, Ë ÂÚÈÂÎÙÈÎfiÙËÙ· ÙÔ˘ ÔÔ›Ô˘ ÂÈϤÁÂÙ·È Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ıÚ·˘ÛÌ¿ÙˆÓ DNA Ô˘ ı· ‰È·¯ˆÚÈÛıÔ‡Ó. ∆· ÚÔ˚fiÓÙ· Ù˘ PCR ËÏÂÎÙÚÔÊÔÚÔ‡ÓÙ·È ÛÙÔ ‹Îو̷ Ì·˙› Ì ÂȉÈ΋ ¯ÚˆÛÙÈ΋ (loading dye) Î·È Î·Ù¿ ÙÔ ‰È·¯ˆÚÈÛÌfi ‚¿ÊÔÓÙ·È Ì ‚ÚˆÌÈÔ‡¯Ô ·Èı›‰ÈÔ, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· ÚfiÛ‰ÂÛ˘ ÌÂٷ͇ ÙˆÓ ‚¿ÛÂˆÓ ÙÔ˘ DNA (29). ∆· ‰È·ÊÔÚÂÙÈο ıÚ·‡ÛÌ·Ù· DNA, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¤¯Ô˘Ó ·ÚÓËÙÈÎfi ÊÔÚÙ›Ô, ηÙ¢ı‡ÓÔÓÙ·È ÚÔ˜ ÙÔ ıÂÙÈÎfi fiÏÔ Ì ٷ¯‡ÙËÙ· Ô˘ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙˆÓ ÏÔÁ·Ú›ıÌˆÓ ÙÔ˘ ÌÔÚÈ·ÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘, ÔÈ ˙ÒÓ˜ ÙÔ˘ DNA Á›ÓÔÓÙ·È ÔÚ·Ù¤˜ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· (∂ÈÎfiÓ· 6).

Paediatriki 2008;71:105-115

°È· Ó· Â›Ó·È ‰˘Ó·Ù‹ Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÚÔ˚fiÓÙÔ˜, ËÏÂÎÙÚÔÊÔÚÂ›Ù·È ·Ú·Ïϋψ˜ Î·È ¤Ó· Ì›ÁÌ· ıÚ·˘ÛÌ¿ÙˆÓ DNA ÁÓˆÛÙÔ‡ ÌÂÁ¤ıÔ˘˜. ªÂ ÙË Ì¤ıÔ‰Ô PCR ÌÔÚÔ‡Ó Â›Û˘ Ó· ·ÓȯÓ¢ıÔ‡Ó Î·È ÔÈ ÔÈΛÏÔ˘ ·ÚÈıÌÔ‡ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜

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∂ÈÎfiÓ· 6. ∏ÏÂÎÙÚÔÊfiÚËÛË ARMS-PCR Û ‹Îو̷ ·Á·Úfi˙˘. ¢Â›ÁÌ·Ù· ˘fi ÂͤٷÛË Û˘ÁÎÚÈÓfiÌÂÓ· Ì ·ıÔÏÔÁÈÎfi ‰Â›ÁÌ·. ª¿ÚÙ˘Ú·˜ ÌÂÁ¤ıÔ˘˜ ·ÏÏËÏÔ˘¯ÈÒÓ: 100 bp ladder ·: ˙ÒÓË ÂϤÁ¯Ô˘ ÙˆÓ ˘fi ÂͤٷÛË ‰ÂÈÁÌ¿ÙˆÓ, ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÂÈÙ˘¯Ë̤Ó˘ ·ÓÙ›‰Ú·Û˘ (Û ÂÚ›ÙˆÛË ·Ô˘Û›·˜ Ù˘, Ë ·ÓÙ›‰Ú·ÛË ‰ÂÓ ‹Ù·Ó ÂÈÙ˘¯‹˜), ‚: ˙ÒÓË ·ıÔÏÔÁÈ΋˜ ·ÏÏËÏÔ˘¯›·˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ıÂÙÈÎfi ÎÔÓÙÚfiÏ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ËÏÂÎÙÚÔÊfiÚËÛË, Ë ·ÓÙ›‰Ú·ÛË Â›Ó·È ÂÈÙ˘¯‹˜ Î·È Î·Ó¤Ó· ‰Â›ÁÌ· ‰ÂÓ Ê¤ÚÂÈ ÌÂÙ¿ÏÏ·ÍË.

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ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË

·ÏÏËÏÔ˘¯›Â˜ (Variable Number of Tandem Repeats, VNTRs), Ì‹ÎÔ˘˜ 14-100 ‚¿ÛˆÓ. ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi ÌÈ· ÎÂÓÙÚÈ΋ ·ÏÏËÏÔ˘¯›· Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi ¤Ó·Ó ·ÚÈıÌfi Ù·˘ÙfiÛËÌˆÓ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ·ÏÏËÏÔ˘¯ÈÒÓ, ÔÈ Ôԛ˜ ÔÚÁ·ÓÒÓÔÓÙ·È Û ÔÌ¿‰Â˜ (Ì ·ÚÈıÌfi Â·Ó¿Ï˄˘ 4 ¤ˆ˜ 40 ÊÔÚ¤˜). ∞˘Ù¤˜ ÔÈ ÔÌ¿‰Â˜ ‚Ú›ÛÎÔÓÙ·È Û fiÏ· Ù· ¯ÚˆÌÔÛÒÌ·Ù· Î·È ÎÏËÚÔÓÔÌÔ‡ÓÙ·È Î·È ·fi ÙÔ˘˜ ‰‡Ô ÁÔÓ›˜.

OÈ VNTRs ¯ˆÚ›˙ÔÓÙ·È Û ‰‡Ô ηÙËÁÔڛ˜ Ì ‚¿ÛË ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜: 1) ÛÙȘ Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (minisatellites) Î·È 2) ÛÙȘ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (microsatellites).

OÈ Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΘ ·ÏÏËÏÔ˘¯›Â˜ ·ÔÙÂÏÔ‡ÓÙ·È ·fi 10-100 bp Î·È ·Ó¢ڛÛÎÔÓÙ·È Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 1000 ÂÚÈÔ¯¤˜ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜. ™˘Û¯ÂÙ›˙ÔÓÙ·È Ì ¯ÚˆÌÔÛˆÌÈΤ˜ ÂÚÈÔ¯¤˜, ÔÈ Ôԛ˜ Â›Ó·È ÂÈÚÚÂ›˜ Û ıÚ˘ÌÌ·ÙÈÛÌÔ‡˜, fiˆ˜ ÙÂÏÔÌÂÚ›‰È·, ÂÓÒ ‚Ú›ÛÎÔÓÙ·È ÎÔÓÙ¿ Û ÛËÌ›· ÌÂÙ·ı¤ÛÂˆÓ (30). ∂ÈÚÔÛı¤Ùˆ˜, ÔÈ ÂÚÈÔ¯¤˜ Ô˘ ηχÙÔÓÙ·È ·fi Ì›ÓÈ-‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ Â›Ó·È ÔÈ ÂÚÈÛÛfiÙÂÚÔ ·ÛÙ·ı›˜ ÛÙÔ ·ÓıÚÒÈÓÔ ÁÔÓȉ›ˆÌ· (31). ∏ ¯·ÚÙÔÁÚ¿ÊËÛ‹ ÙÔ˘˜ ‚Ô‹ıËÛ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙË ÁÂÓÂÙÈ΋ Ù·˘ÙÔÔ›ËÛË (DNA fingerprint) Ô˘ Â›Ó·È ··Ú·›ÙËÙË ÛÙËÓ È·ÙÚÔ‰ÈηÛÙÈ΋ Î·È Â›Û˘ ÛÙË ‰È¿ÁÓˆÛË ÁÂÓÂÙÈÎÒÓ ·ı‹ÛÂˆÓ Ô˘ ÔÊ›ÏÔÓÙ·È Û ÌË Ê˘ÛÈÔÏÔÁÈÎfi ·Ó·‰ÈÏ·ÛÈ·ÛÌfi ÙÔ˘ DNA (ÔÏ˘ÌÔÚÊÈÛÌÔ› ·ÚÈıÌÔ‡ ·ÓÙÈÁÚ¿ÊˆÓ - copy number variation) (32). √È ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ (microsatellite or Small Tandem Repeats, STRs) ·ÔÙÂÏÔ‡ÓÙ·È ·fi 100-200 ‚¿ÛÂȘ. ∂ÎÙÈÌ¿Ù·È fiÙÈ ÔÈ ÌÈÎÚÔ‰ÔÚ˘ÊÔÚÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ˘‡ı˘Ó˜ ÁÈ· ÙËÓ ÚfiÎÏËÛË ÓfiÛÔ˘, ·ÏÏ¿ ·ÔÙÂÏÔ‡Ó ÂÍ·ÈÚÂÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ Ù·˘ÙÔÔ›ËÛË ÂÓfi˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ ‹ ÌÈ·˜ ÁÂÓÂÙÈ΋˜ ı¤Û˘ Î·È ‚Ú›ÛÎÔ˘Ó ÂÊ·ÚÌÔÁ‹ ÛÙË ¯·ÚÙÔÁÚ¿ÊËÛË ÁÔÓȉ›ˆÓ Î·È ÛÙoÓ ¤ÏÂÁ¯Ô ·ÙÚfiÙËÙ·˜ (33) (∂ÈÎfiÓ· 7). ∞Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Ù˘ ÚˆÙÔÙ·ÁÔ‡˜ ‰ÔÌ‹˜ ÙÔ˘ DNA (Sequencing) ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· ÂÓfi˜ ÙÌ‹Ì·ÙÔ˜ DNA (.¯. ÁÔÓ›‰ÈÔ), ÂÈÙÚ¤ÔÓÙ·˜ ¤ÙÛÈ ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ (34,35). ∆Ô ÙÌ‹Ì· Ô˘ ·Ó·Ï‡ÂÙ·È ·ԉȷٿÛÛÂÙ·È Î·È ÏÂÈÙÔ˘ÚÁ› ˆ˜ Ì‹ÙÚ· ÛÙËÓ ÔÔ›· ˘‚Úȉ›˙ÂÙ·È ¤Ó·˜ ÂÎÎÈÓËÙ‹˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÍÂÎÈÓ‹ÛÂÈ Ë ÂÓ˙˘Ì·ÙÈ΋ ÂÈÌ‹Î˘ÓÛË Ù˘ ÂÚÈÔ¯‹˜-ÛÙfi¯Ô˘. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Â›Ó·È Ë Ú·ÁÌ·ÙÔÔ›ËÛË ·ÓÙ›‰Ú·Û˘, Û‡ÓıÂÛ˘ ·ÓÙÈÁÚ¿ÊˆÓ ÙÔ˘ ȉ›Ô˘ ÌÔÓfiÎψÓÔ˘ DNAÌ‹ÙÚ·, Ì ÙË ¯Ú‹ÛË 4 ddNTPs, ηı¤Ó· ·fi Ù· ÔÔ›· ʤÚÂÈ Û‹Ì·ÓÛË Ì ‰È·ÊÔÚÂÙÈ΋ ÊıÔÚ›˙Ô˘Û· ¯ÚˆÛÙÈ΋. ∆Ô ÚÔ˚fiÓ Ù˘ ·ÓÙ›‰Ú·Û˘ ‰È·¯ˆÚ›˙ÂÙ·È Ì οıÂÙË ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·ÎÚ˘Ï·Ì›‰Ë˜ ηÈ

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F

Human paternity analysis using NICETM probe 33.6 ∂ÈÎfiÓ· 7. ŒÏÂÁ¯Ô˜ ·ÙÚfiÙËÙ·˜ Ì ¯Ú‹ÛË ÙˆÓ VNTRs. M=MËÙ¤Ú·, F= ¶·Ù¤Ú·˜, C= ¶·È‰›. ∫¿ı ˙ÒÓË ·ÓÙÈÚÔÛˆ‡ÂÈ ÌÈÎÚÔ-‰ÔÚ˘ÊÔÚÈΤ˜ ı¤ÛÂȘ (microsatellites). ™Â οı ı¤ÛË ·ÓÙÈÛÙÔÈ¯Ô‡Ó 2 ·ÏÏËÏfiÌÔÚÊ·. º·›ÓÔÓÙ·È ÔÈ ÌÈÎÚÔ-‰ÔÚ˘ÊÔÚÈΤ˜ ı¤ÛÂȘ Ô˘ ¤¯Ô˘Ó ÎÏËÚÔÓÔÌËı› ·fi ÙÔÓ Î¿ı ÁÔÓ¤· (ÎfiÎÎÈÓ· ‚¤ÏË-ı¤ÛÂȘ Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È ·fi ÙÔÓ ·Ù¤Ú·, ÌϤ ‚¤ÏË-ı¤ÛÂȘ Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È ·fi ÙË ÌËÙ¤Ú·).

‰‡Ó·Ù·È Ó· ·ÓȯÓ¢ı› Ì ‰¤ÛÌË ÊˆÙfi˜ laser (36-39). ∏ ·ÓÙ›‰Ú·ÛË Ï·Ì‚¿ÓÂÈ ¯ÒÚ· Û ıÂÚÌÈÎfi ΢ÎÏÔÔÈËÙ‹ (40). ∫·Ù¿ ̤ÛÔ fiÚÔ ··ÈÙÔ‡ÓÙ·È 30-35 ·ÎÏÔÈ, ¤ÙÛÈ ÒÛÙ ӷ ‰È·ÛÊ·ÏÈÛı› Ë ·Ú·ÁˆÁ‹ Â·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ ·ÓÙÈÁÚ¿ÊˆÓ (∂ÈÎfiÓ· 8). ∏ ¢·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ Sequencing Â›Ó·È Ù¤ÙÔÈ· ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó›¯Ó¢ÛË ·ÏÏ·Á‹˜ ·ÎfiÌË Î·È ÌÈ·˜ ÌfiÓÔ ‚¿Û˘ ÛÙËÓ ˘fi ÌÂϤÙË ·ÏÏËÏÔ˘¯›·. ¶ÚfiÎÂÈÙ·È ‰ËÏ·‰‹ ÁÈ· ÌÈ· ÂÍ·ÈÚÂÙÈο ¯Ú‹ÛÈÌË Ù¯ÓÈ΋, Ë ÔÔ›· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û ÔÔÈÔ‰‹ÔÙ ÁÂÓÂÙÈÎfi ÓfiÛËÌ·, ÂÊfiÛÔÓ ÁÓˆÚ›˙Ô˘Ì ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÓÔ˘ÎÏÂÔÙȉÈ΋ ·ÏÏËÏÔ˘¯›· Ù˘ ÂÚÈÔ¯‹˜-ÛÙfi¯Ô˘.

A

C

A

T

C (g>a) A

T

C

C

C

∂ÈÎfiÓ· 8. ∞Ó¿Ï˘ÛË Ù˘ ·ÏÏËÏÔ˘¯›·˜ Ù˘ ÚˆÙÔÙ·ÁÔ‡˜ ‰ÔÌ‹˜ ÙÔ˘ DNA (Sequencing). ¶·Ú·ÙËÚÂ›Ù·È ·ÓÙÈηٿÛÙ·ÛË ÁÔ˘·Ó›Ó˘ ·fi ·‰ÂÓ›ÓË. ¶·È‰È·ÙÚÈ΋ 2008;71:105-115

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·112

112

™. ªÂÁÚ¤Ì˘, ∞. ¶¿Ì·ÓÔ˜

6 5

8,248

7

4,612 4,412

mV 8

3,944

ªÂÚÈο ·fi Ù· ÂηÙÔÓÙ¿‰Â˜ ·Ú·‰Â›ÁÌ·Ù· ÁÂÓÂÙÈÎÒÓ ·ı‹ÛˆÓ, fiÔ˘ Ë Ù¯ÓÈ΋ ·˘Ù‹ ‚Ú›ÛÎÂÈ ÂÊ·ÚÌÔÁ‹ ÁÈ· ÙË ‰È¿ÁÓˆÛË, Â›Ó·È Ë Î˘ÛÙÈ΋ ›ÓˆÛË, Ë Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, ÙÔ Û‡Ó‰ÚÔÌÔ Rett, ÔÈ ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ, Ë Ô˙҉˘ ÛÎÏ‹Ú˘ÓÛË Î·È Ë ÓfiÛÔ˜ Wilson (41,42).

4

∞ԉȷٷÎÙÈ΋ ¯ÚˆÌ·ÙÔÁÚ·Ê›· ˘ÁÚ‹˜ Ê¿Û˘ (Denaturing High Performance Liquid Chromatography, DHPLC) ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÂÍ·ÈÚÂÙÈο ·ÍÈfiÈÛÙÔ Û‡ÛÙËÌ· ·Ó›¯Ó¢Û˘ ÌÂÙ·ÏÏ¿ÍÂˆÓ Î·È Û˘Á¯ÚfiÓˆ˜ ÁÚ‹ÁÔÚÔ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈ‹ÛÂÈ ÙÔÓ ¤ÏÂÁ¯Ô ÂÓfi˜ ‰Â›ÁÌ·ÙÔ˜ Û 6 ÏÂÙ¿. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÛÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ 24ÒÚÔ˘ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› Ô ¤ÏÂÁ¯Ô˜ ÂÚ›Ô˘ 240 ‰ÂÈÁÌ¿ÙˆÓ. ∏ Ù¯ÓÈ΋ DHPLC ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÔ‡ DNA ‹ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏϿ͈Ó, fiˆ˜ ÂÓı¤ÛˆÓ, ÂÏÏ›„ˆÓ, ·ÓÙÈηٷÛÙ¿ÛˆÓ, ÛËÌÂÈ·ÎÒÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ (SNPs) Î·È ‰È·‰Ô¯ÈÎÒÓ Â·Ó·Ï‹„ÂˆÓ (∂ÈÎfiÓ· 9). √ ÂÓÙÔÈÛÌfi˜ ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì¤Ûˆ Ù˘ ·Ó›¯Ó¢Û˘ ÂÙÂÚÔ‰ÈÌÂÚÒÓ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÏfiÁˆ ÌË Û˘ÌÏËڈ̷ÙÈÎÒÓ ‚¿ÛÂˆÓ ÛÙÔ ˘fi ÌÂϤÙË ÙÌ‹Ì· ÙÔ˘ DNA. ∂ÈÚÔÛı¤Ùˆ˜, ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› ‰È·¯ˆÚÈÛÌfi˜ Ì ‚¿ÛË ÙÔ Ì‹ÎÔ˜ (fragment analysis), ÙËÓ ·Ó¿Ï˘ÛË Î·È ÙÔÓ Î·ı·ÚÈÛÌfi ÔÏÈÁÔÓÔ˘ÎÏÂÔÙȉ›ˆÓ (Ôligonucleotide purification and analysis). ∏ ¢·ÈÛıËÛ›· Ù˘ ·Ó›¯Ó¢Û˘ ÌÂÙ·ÏÏ¿ÍÂˆÓ Î·È Ë ·ÎÚ›‚ÂÈ· ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ·ÁÁ›˙ÂÈ ÙÔ 100%, ÂÓÒ Ë ÂÏ¿¯ÈÛÙË ÔÛfiÙËÙ· ÙˆÓ ·ÓÙȉڷÛÙËÚ›ˆÓ Î·È ÙÔ ¯·ÌËÏfi ÎfiÛÙÔ˜ ÙÔ˘˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÔÊ˘Á‹ ¯Ú‹Û˘ ÂÈΛӉ˘ÓˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ, ηıÈÛÙÔ‡Ó ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÌÈ· ·fi ÙȘ ϤÔÓ ‰È·‰Â‰Ô̤Ó˜ Ù¯ÓÈΤ˜ ÌÔÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘. ÷ڷÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ DHPLC ·ÔÙÂÏ› Ë ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙ· 2 ÁÔÓ›‰È· Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙÔÓ Î·ÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ Î·È ÙˆÓ ˆÔıËÎÒÓ, BRCA1 Î·È BRCA2 (43,44). ª¤ıÔ‰ÔÈ ˘‚ÚȉÔÔ›ËÛ˘: Southern Blotting Î·È Northern Blotting ∆Ô Ê·ÈÓfiÌÂÓÔ Ù˘ ˘‚ÚȉÔÔ›ËÛ˘, ‰ËÏ·‰‹ Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ÂÓfi˜ ÌÔÓfiÎψÓÔ˘ ÌÔÚ›Ô˘ ÓÔ˘ÎÏÂ˚ÎÔ‡ ÔͤԘ Ó· Û¯ËÌ·Ù›˙ÂÈ ‰›ÎψÓË ¤ÏÈη Ì ¤Ó· ¿ÏÏÔ ÌÔÓfiÎψÓÔ ÌfiÚÈÔ, ·ÔÙÂÏ› ÙË ‚¿ÛË ÁÈ· ÔÏϤ˜ Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙfiÛÔ ÛÙË ÌÔÚȷ΋ ‰È¿ÁÓˆÛË, fiÛÔ Î·È ÛÙË ÁÂÓÂÙÈ΋ Ì˯·ÓÈ΋. ªÂٷ͇ ·˘ÙÒÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ Ù¯ÓÈΤ˜ Southern Î·È NÔrthern Blot.

Southern Blotting ∏ ̤ıÔ‰Ô˜ ÙÔ˘ Southern Blotting ‹Ú ÙÔ fiÓÔÌ¿ Ù˘ ·fi ÙÔÓ Edwin Southern Î·È ÌÔÚ› Ó· ‰È·¯ˆÚ›Paediatriki 2008;71:105-115

3 2 1 0 -1 2

3

4

5

6

7

min

∂ÈÎfiÓ· 9. ŒÏÂÁ¯Ô˜ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ì ÙË Ì¤ıÔ‰Ô DHPLC. DHPLC: ∞ԉȷٷÎÙÈ΋ Ãڈ̷ÙÔÁÚ·Ê›· ÀÁÚ‹˜ º¿Û˘. ™‡ÁÎÚÈÛË ‰Â›ÁÌ·ÙÔ˜ ˘fi ÂͤٷÛË (Ú¿ÛÈÓÔ) Ì ·ıÔÏÔÁÈÎfi ‰Â›ÁÌ· (ηʤ) ˆ˜ ÛËÌÂ›Ô ·Ó·ÊÔÚ¿˜. ∏ ηÌ‡ÏË Ô˘ ˘Ô‰ÂÈÎÓ‡ÂÙ·È ·Ô ÙÔ ‚¤ÏÔ˜ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ¤ÎÏÔ˘ÛË ÙˆÓ ÂÙÂÚÔ‰ËÌÂÚÒÓ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÏfiÁˆ Ù˘ ˘¿Ú¯Ô˘Û·˜ ÌÂÙ¿ÏÏ·Í˘.

ÛÂÈ, Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜, Û˘ÁÎÂÎÚÈ̤ӷ ÙÌ‹Ì·Ù· ÁÂÓˆÌÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ¤Ó· Ì›ÁÌ· ÔÏÏÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÙÌËÌ¿ÙˆÓ (45). ∆Ô ÚÔ˜ ·Ó¿Ï˘ÛË DNA (.¯. ÙÔ DNA ÂÓfi˜ ÔÚÁ·ÓÈÛÌÔ‡) Âˆ¿˙ÂÙ·È Ì ÙË ¯Ú‹ÛË ÂÚÈÔÚÈÛÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘. °È· ¤Ó·Ó ÔÚÁ·ÓÈÛÌfi Ì ۇÓıÂÙÔ ÁÔÓȉ›ˆÌ·, ·˘Ù‹ Ë ¤„Ë ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÂηÙÔÌ̇ÚÈ· ‰È·ÊÔÚÂÙÈο ÚÔ˚fiÓÙ· ÎÔ‹˜ (ÎÏ¿ÛÌ·Ù· ÂÚÈÔÚÈÛÌÔ‡). ∆· ÚÔ˚fiÓÙ· Ù˘ ¤„˘ ‰È·¯ˆÚ›˙ÔÓÙ·È Ì ËÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·Á·Úfi˙˘. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘ ÙÔ ‹Îو̷ ÂÎÙ›ıÂÙ·È Û ˘ÂÚÈÒ‰Ë ·ÎÙÈÓÔ‚ÔÏ›· Î·È ÙÔ DNA ·ÂÈÎÔÓ›˙ÂÙ·È ˆ˜ Û˘Ó¯fiÌÂÓË Ù·ÈÓ›·. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÔ˘Ó ÂÌÊ·Ó‹ Ù· ‰È·ÊÔÚÂÙÈο ıÚ·‡ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ¤„Ë, ÌÂٷʤÚÔÓÙ·È Û ıÂÙÈο ÊÔÚÙÈṲ̂ÓË ÌÂÌ‚Ú¿ÓË Ó¿ÈÏÔÓ ‹ ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘. ¶ÚÈÓ Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÊÔÚ¿˜, ÙÔ ‹Îو̷ ·Ú·Ì¤ÓÂÈ Û ·ÏηÏÈÎfi ‰È¿Ï˘Ì· ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ԉȷٷ¯ı› ÙÔ DNA Î·È Ó· Á›ÓÂÈ ÌÔÓfiÎψÓÔ. ∆Ô Ê›ÏÙÚÔ ÛÙË Û˘Ó¤¯ÂÈ· ˘‚Úȉ›˙ÂÙ·È Ì ÛËÌ·Ṳ̂ÓÔ˘˜ ·ÓȯÓÂ˘Ù¤˜ Ô˘ ʤÚÔ˘Ó ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ ˘fi ‰ÈÂÚ‡ÓËÛË ÁÔÓȉ›Ô˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ ÌÔÓfiÎψÓÔ DNA Ù˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÁÔÓȉ›Ô˘ Ó· ÛËÌ·›ÓÂÙ·È Î·È ¿Ú· Ó· ·ÓȯÓ‡ÂÙ·È. ∆ÂÏÈο, Ë ÊˆÙÔÁÚ¿ÊËÛË Ì ÊÈÏÌ ·ÎÙ›ÓˆÓ Ã ·ÔηχÙÂÈ Ù· ÛËÌ·Ṳ̂ӷ ıÚ·‡ÛÌ·Ù· (45) (∂ÈÎfiÓ· 10). ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÌÔÚÔ‡Ó Ó· ·ÓȯÓ¢ıÔ‡Ó Î˘Ú›ˆ˜ ÌÔÚȷΤ˜ ‚Ï¿‚˜ Ô˘ ·ÏÏÔÈÒÓÔ˘Ó ÙÔ Ì‹ÎÔ˜ ÂÓfi˜ ÙÌ‹Ì·ÙÔ˜ DNA (.¯. ÂÏÏ›ÌÌ·Ù·, ‰ÈÏ·ÛÈ·ÛÌÔ›), ·ÏÏ¿ fi¯È ÛËÌÂȷΤ˜ ÌÂÙ·ÏÏ¿ÍÂȘ . ∆Ë ÌÂÁ·Ï‡ÙÂÚË ›Ûˆ˜ ·Í›· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›¯Â Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Southern Blotting ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÔÏ˘ÌÔÚÊÈÛÌÒÓ ÌÂÁ¤ıÔ˘˜ ÎÏ·ÛÌ¿ÙˆÓ ÂÚÈÔÚÈÛÌÔ‡ (RFLP: Ê˘ÛÈÔÏÔÁÈο ÎÏËÚÔÓÔÌÔ‡ÌÂÓ˜

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·113

113

ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË

∏ÏÂÎÙÚÔÊfiÚËÛË Û ‹Îو̷ ·Á·Úfi˙˘

¶¤„Ë Ì ÂÚÈÔÚÈÛÙÈο ¤Ó˙˘Ì·

°ÂÓˆÌÈÎfi DNA £Ú·‡ÛÌ·Ù· DNA ∞ԉȿٷÍË µ¿ÚÔ˜ ∆˙¿ÌÈ

÷ÚÙÔÂÙÛ¤Ù˜

º‡ÏÏ· ¯·ÚÙÈÔ‡ Whartman 3MM ÂÌÔÙÈṲ̂ӷ Û ‰È¿Ï˘Ì· 2xSSC

ªÂÌ‚Ú¿ÓË ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘ ÷ÚÙ› Whartman 3MM ¢È¿Ï˘Ì· 20xSSC

¶‹Îو̷ ·Á·Úfi˙˘ ∆˙¿ÌÈ

°¤Ê˘Ú·

ªÂÌ‚Ú¿ÓË ºÈÏÌ ∂ÎχÛÂȘ

À‚ÚȉÈÛÌfi˜ Ì ȯÓËıÂÙË̤ÓÔ ·ÓȯÓÂ˘Ù‹+

∞˘ÙÔÚ·‰ÈÔÁÚ·Ê›·

∂ÈÎfiÓ· 10. ∏ ̤ıÔ‰Ô˜ Southern Blotting. AÚ¯‹ Ù˘ ÌÂıfi‰Ô˘ ÌÂÙ·ÊÔÚ¿˜ ηٿ Southern ÛÂ Û˘Ó‰˘·ÛÌfi Ì ˘‚ÚȉÈÛÌfi Ì ȯÓËıÂÙË̤ÓÔ ·ÓȯÓÂ˘Ù‹.

ÔÈÎÈÏÔÌÔÚʛ˜ ÎÔÓÙ¿ ÛÙÔÓ ˘fi ÌÂϤÙË ÁÂÓÂÙÈÎfi ÙfiÔ, ÔÈ Ôԛ˜ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÂÓfi˜ ÓÔÛÔÁfiÓÔ˘ ÁÔÓȉ›Ô˘, ·ÎfiÌ· Î·È fiÙ·Ó ‰ÂÓ ÌÔÚ› Ó· ·ÓȯÓ¢ı› Ë Û˘ÁÎÂÎÚÈ̤ÓË ÌÔÚȷ΋ ‰È·Ù·Ú·¯‹) (46). ªÂ ÙËÓ ·Ó·Î¿Ï˘„Ë, fï˜, ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ÓÂfiÙÂÚˆÓ ÌÔÚÈ·ÎÒÓ Ù¯ÓÈÎÒÓ, ÙÔ Southern Blotting Û·Ó›ˆ˜ ϤÔÓ ¯ÚËÛÈÌÔÔÈ›ٷÈ, ÂÎÙfi˜ ·fi οÔȘ ÂÚÈÙÒÛÂȘ ∂˘ıÚ·‡ÛÙÔ˘ Ã.

Northern Blotting ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ·Ó›¯Ó¢ÛË Û˘ÁÎÂÎÚÈ̤ÓÔ˘ RNA ·fi ¤Ó· Ì›ÁÌ· ‰È·ÊÔÚÂÙÈÎÒÓ RNAs. ∞Ú¯Èο ÏfiÁˆ ·Ó·ÏÔÁ›·˜ Î·È ÔÌÔÈfiÙËÙ·˜ Ù˘ ÌÂıfi‰Ô˘ Ì ÙÔ Southern µlotting Î·È Ì ¯ÈÔ˘ÌÔÚÈÛÙÈ΋ ‰È¿ıÂÛË Ù˘ ·‰fiıË ÙÔ fiÓÔÌ· Northern µlotting, ÌÈ· ÔÓÔÌ·Û›· Ô‡ ÙÂÏÈο ÂÈÎÚ¿ÙËÛ ‰ÈÂıÓÒ˜. ∆Ô ˘fi ÂͤٷÛË ‰Â›ÁÌ· RNA ˘Ê›ÛÙ·Ù·È ÂÂÍÂÚÁ·Û›· ÌÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ¯ËÌÈΤ˜ Ô˘Û›Â˜ (.¯. ÊÔÚÌ·Ï‰Â˛‰Ë), ÂÈÙ˘Á¯¿ÓÔÓÙ·˜ ÙËÓ ·ԉȿٷÍË ÙˆÓ ‰Â˘ÙÂÚÔÙ·ÁÒÓ ‰ÔÌÒÓ ÙÔ˘. T· ‰È·ÊÔÚÂÙÈο ÌfiÚÈ· RNA ÙÔ˘ Ì›ÁÌ·ÙÔ˜, ‰È·¯ˆÚ›˙ÔÓÙ·È Ì ËÏÂÎÙÚÔÊfiÚËÛË Ì ‚¿ÛË ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ Î·È ÌÂٷʤÚÔÓÙ·È Û ʛÏÙÚÔ ÓÈÙÚÔ΢ÙÙ·Ú›Ó˘. ™ÙË Û˘Ó¤¯ÂÈ·, ÙÔ Ê›ÏÙÚÔ ÂÎÙ›ıÂÙ·È Û ÛËÌ·Ṳ̂ÓÔ ÂÎÎÈÓËÙ‹ DNA (probe) Î·È ˘fiÎÂÈÙ·È Û ڷ‰ÈÔ·˘ÙÔÁÚ·Ê›·. ∏ Ù¯ÓÈ΋ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú‡Ù·Ù· ÁÈ· ÙË ÌÂϤÙË Ù˘ ¤ÎÊÚ·Û˘ ÂÓfi˜ ÏËı˘ÛÌÔ‡ mRNA Û ‰È·-

ÊÔÚÂÙÈο ÛÙ¿‰È· ·Ó¿Ù˘Í˘ ÙˆÓ ˘fi ÌÂϤÙË ÈÛÙÒÓ (.¯. mRNA ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ‚-ÛÊ·ÈÚ›Ó˘) (47,48).

∂›ÏÔÁÔ˜ ™ÙȘ ̤Ú˜ Ì·˜ Ù· ÂÚÁ·ÛÙ‹ÚÈ· ªÔÚȷ΋˜ °ÂÓÂÙÈ΋˜ ÚÔÛʤÚÔ˘Ó ÌÈ· ÔÈÎÈÏ›· ‰È·ÁÓˆÛÙÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ·Ó¿Ï˘Û˘ DNA. ∏ ¿ÌÂÛË ·Ó¿Ï˘ÛË ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ Â›Ó·È ‰È·ı¤ÛÈÌË ÁÈ· ÏËıÒÚ· ÁÂÓÂÙÈÎÒÓ ·ı‹ÛÂˆÓ Î·È Î·ıÈÛÙ¿ ‰˘Ó·Ù‹ ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ Û ¿Û¯ÔÓÙ˜, ÙËÓ ÚÔÛ˘Ìو̷ÙÈ΋ ‰È¿ÁÓˆÛË Û ¿ÙÔÌ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓÔ ÓfiÛËÌ·, ÙËÓ ·Ó›¯Ó¢ÛË ÊÔÚ¤ˆÓ Î·È ÙËÓ ÚÔÁÂÓÓËÙÈ΋ ‹ ÙËÓ ÚÔÂÌÊ˘Ù¢ÙÈ΋ ÁÂÓÂÙÈ΋ ‰È¿ÁÓˆÛË. °È· Ù· ÌÔÓÔÁÔÓȉȷο ÓÔÛ‹Ì·Ù·, fiÔ˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó›¯Ó¢ÛË ÌÂÙ·ÏϿ͈Ó, ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÂÓÂÙÈÎÔ› ‰Â›ÎÙ˜, ÒÛÙ ӷ ÚÔ‚ÏÂÊı› Ë ÎÏËÚÔÓÔÌÈ΋ ÌÂÙ·‚›‚·ÛË, ·Ú·‰Â›ÁÌ·ÙÔ˜ ¯¿ÚÈÓ ÛÙÔ Û‡Ó‰ÚÔÌÔ Marfan Î·È ÛÙË Ó¢ÚÔ˚ӈ̿وÛË Ù‡Ô˘ 1. ∂›Ó·È Â›Û˘ ÛËÌ·ÓÙÈÎfi fiÙÈ ‰Â›ÁÌ·Ù· DNA ÌÔÚÔ‡Ó Ó· Û˘ÓÙËÚËıÔ‡Ó ÁÈ· ·ÂÚÈfiÚÈÛÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÌÂÏÏÔÓÙÈο ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. √È ÛËÌÂÚÈÓ¤˜ ‰˘Ó·ÙfiÙËÙ˜ ·ÍÈfiÈÛÙ˘ ·Ó¿Ï˘Û˘ ÙˆÓ ÁÔÓȉ›ˆÓ οı ·ÙfiÌÔ˘, ηıÒ˜ Î·È ÔÈ ·ÏÌ·ÙÒ‰ÂȘ ÚfiÔ‰ÔÈ Ù˘ ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÌÂÙ·ÏÏ¿ÍÂˆÓ Û¯ÂÙÈο ÁÚ‹ÁÔÚ· Î·È Ì ÔÏÔ¤Ó· ÌÈÎÚfiÙÂÚÔ ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜, ‰ÈηÈÔÏÔÁÔ‡Ó ÙË ‰È‡ڢÓÛË Ù˘ ÌÔÚȷ΋˜ ‰È·ÁÓˆÛÙÈ΋˜. ŒÙÛÈ, Ô ·È‰›·ÙÚÔ˜ ηÙ¢ı‡ÓÂÈ ÙȘ ÔÈÎÔÁ¤ÓÂȘ ¶·È‰È·ÙÚÈ΋ 2008;71:105-115

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Ì ÙÔ ÁÂÓÂÙÈÎfi Úfi‚ÏËÌ· ÛÙȘ ηٿÏÏËϘ ˘ËÚÂۛ˜ ÎÏÈÓÈ΋˜ Î·È ÌÔÚȷ΋˜ ÁÂÓÂÙÈ΋˜, ÒÛÙ ÂÁη›Úˆ˜ Î·È ˘‡ı˘Ó· Ó· ÂÓËÌÂÚÒÓÔÓÙ·È ÁÈ· ÙȘ ‰˘Ó·ÙfiÙËÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÙÔ˘˜ ÚÔÛÊÂÚıÔ‡Ó ÛÙ· Ï·›ÛÈ· Ù˘ ÌÔÚȷ΋˜ ‰È¿ÁÓˆÛ˘.

µÈ‚ÏÈÔÁÚ·Ê›· 1. DNA From The Beginning.org [Webpage, Internet]. Cold Spring Harbor Laboratory; 2002: http://www.dnaftb.org/ 2. πÛÙÔÚ›· Ù˘ ∆¯ÓÔÏÔÁ›·˜. ªÂ ·ÚÂ΂¿ÛÂȘ ÛÂ Û˘Ó·Ê‹ ÁÂÁÔÓfiÙ· Ô˘ ÂËÚ¤·Û·Ó ÙËÓ ÂÈÛÙ‹ÌË, ÙËÓ Ù¯ÓÔÏÔÁ›· Î·È ÙÔÓ ÔÏÈÙÈÛÌfi. [Webpage, Internet]. Styl. G. Frangopoulos; 2007: http://www.sfrang.com/historia/ 3. π∞™¶π™ π‰Â҉˜ ∞™ÎÏËÈ·Îfi ¶¿ÚÎÔ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ [Webpage, Internet]. ∞ÛÎÏËÈ·Îfi ¶¿ÚÎÔ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ; 2006: http://panacea. med.uoa.gr/ 4. Morgan TH. Chromosomes and Heredity. The American Naturalist 1910;44:449-496. [Internet] Electronically Scholarly Publishing. Webpage: http://www.esp.org/foundations/ 5. History of Genetics: the Discovery of the Watson-Crick Model of DNA from World of Genetics 2005-2006. Thomson Gale, a part of the Thomson Corporation. [Webpage, Internet]. http://www.bookrags.com/research/history-ofgenetics-the-discovery-o-wog/ 6. International Human Genome Sequencing Consortium.

Finishing the euchromatic sequence of the human genome.

Nature 2004;431 (7011):931-45.

7. Watson JD, Balker TA, Bell SP, Gann A, Levine M, Losick R. Molecular Biology of the Gene, 5th ed. Benjamin Cummings, Pearson Education & Cold Spring Harbor Laboratory Press; 2004.

8. Read A, Donnai D. New Clinical Genetics. Scion Publishing Ltd.; 2007.

9. Böyum A. Isolation of mononuclear cells and granulocytes from human blood. Isolation of mononuclear cells by one centrifugation, and of granulocytes by combining centrifugation and sedimentation at 1 g. Scand J Clin Lab Invest Suppl. 1968;97:77-89.

10. Hoopes BC, McClure WR. Studies on the selectivity of DNA precipitation by spermine. Nucleic Acids Res. 1981; 9:5493-5504.

11. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res. 1988;16:1215.

12. Wolff RK, Frazer KA, Jakler RK, Lanser MJ, Pitts LH, Cox DR. Analysis of chromosome 22 deletions in neurofibromatosis type 2-related tumors. Am J Hum Genet. 1992; 51:478-485.

13. Birren B, Green ED, Klapholz S, Myers RM, Roskams J, editors. Genome Analysis: A Laboratory Manual. Vol. 1: Analyzing DNA. Cold Spring Harbor Laboratory Press; 1997.

14. Mullis KB, Faloona FA. Specific synthesis of DNA in vitro via a polymerase-catalyzed chain reaction. Methods Enzymol. 1987;155:335-350.

15. Abramson RD. Thermostable DNA polymerases. In: Innes MA, Gelfand DH, Sninsky JJ, editors. PCR strategies. San Diego: Academic Press; 1995. p. 39-55.

16. Bej AK, Mahbubani MH. Thermostable DNA polymerases for in vitro DNA amplifications. In: Griffen HG, Griffen Paediatriki 2008;71:105-115

AM, editors. PCR Technology, Current Innovations. Florida: CRC Press, Inc., Boca Raton; 1994. p. 219-237.

17. Mullis KB. The unusual origin of the polymerase chain reaction. Sci Am. 1990;262:56-61, 64-65.

18. Barnes WM. PCR amplification of up to 35-kb DNA with high fidelity and high yield from lambda bacteriophage templates. Proc Natl Acad Sci USA. 1994;91:2216-2220.

19. Cheng S, Chang SY, Gravitt P, Respess R. Long PCR. Nature 1994;369:684-685.

20. Cheng, S, Fockler C, Barnes WM, Higuchi R. Effective amplification of long targets from cloned inserts and human genomic DNA. Proc Natl Acad Sci USA 1994;91:56955699.

21. Li YY, Hengstenberg C, Maisch B. Whole mitochondrial genome amplification reveals basal level multiple deletions in mtDNA of patients with dilated cardiomyopathy.

Biochem Biophys Res Commun. 1995;210:211-218.

22. Chelly J, Kahn A. RT-PCR and mRNA quantitation. In: Mullis DB, Ferre F, Gibbs R, editors. The Polymerase Chain Reaction. Boston: Birkhäuser; 1994. p. 97-109.

23. Moatter T, Khilji Z, Murad F, Munim S. Analysis of amniotic fluid specimens for common chromosome disorders using interphase fluorescence in situ hybridization. J Pak Med Assoc. 2007;57:189-192.

24. Nagel HTC, Knegt AC, Kloosterman MD, Wildschut HIJ, Leschot NJ, Vandenbussche FPHA. Prenatal diagnosis in the Netherlands, 1991-2000: Number of invasive procedures, indications, abnormal results and terminations of pregnancy. Prenat Diagn. 2007;27:251-257.

25. Caughey AB, Hopkins LM, Norton ME. Chorionic villus sampling compared with amniocentesis and the difference in the rate of pregnancy loss. Obstet Gynecol. 2006;108: 612-616.

26. Kokkali G, Traeger-Synodinos J, Vrettou C, Stavrou D, Jones GM, Cram DS, et al. Blastocyst biopsy versus cleavage stage biopsy and blastocyst transfer for preimplantation genetic diagnosis of beta-thalassaemia: a pilot study.

Hum Reprod. 2007;22:1443-1449.

27. Miny P, De Geyter Ch, Holzgreve W. New options in prenatal and preimplantation diagnosis of genetic disorders.

Ther Umsch. 2006;63:703-709.

28. Yoshida T, Sano T, Kanuma T, Owada N, Sakurai S, Fukuda T, et al. Quantitative real-time polymerase chain reaction analysis of the type distribution, viral load, and physical status of human papillomavirus in liquid-based cytology samples from cervical lesions. Int J Gynecol Cancer.

2008;18:121-127.

29. Liu KT, Su WJ, Perng RP. Clinical utility of polymerase chain reaction for diagnosis of smear-negative pleural tuberculosis. J Chin Med Assoc. 2007;70:148-151.

30. Du J, Zhu Y, Shanmugam A, Kenter AL. ∞nalysis of immunoglobulin Sgamma3 recombination breakpoints by PCR: implications for the mechanism of isotype switching.

Nucleic Acids Res. 1997;25:3066-3073.

31. Edwards A, Hammond HA, Jin L, Caskey CT, Chakraborty R. Genetic variation at five trimeric and tetrameric tandem repeat loci in four human population groups. Genomics.

1992;12:241-253.

32. Redon R, Ishikawa S, Fitch KR, Feuk L, Perry GH, Andrews TD, et al. Global variation in copy number in the human genome. Nature. 2006;444:444-454.

33. Li YC, Korol AB, Fahima T, Beiles A, Nevo E. Microsatellites:

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·115

115

ªÔÚȷ΋ ‚ÈÔÏÔÁ›· ÛÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË

genomic distribution, putative functions and mutational mechanisms: a review. Mol Ecol. 2002;11:2453-2465.

34. Kessler C. The digoxigenin:anti-digoxigenin (DIG) technology--a survey on the concept and realization of a novel bioanalytical indicator system. Mol Cell Probes. 1991;5: 161-205.

35. Saiki RK, Gelfand DH, Stoffel S, Scharf SJ, Higuchi R, Horn GT, et al. Primer-directed enzymatic amplification of DNA with a thermostable DNA polymerase. Science.

1988;239:487-491.

36. Sanger F, Nicklen S, Coulson AR. DNA sequencing with chain-terminating inhibitors. Proc Natl Acad Sci USA. 1977;74:5463-5467.

37. Maxam AM, Gilbert W. A new method for sequencing DNA. Proc Natl Acad Sci USA. 1977;74:560-564.

38. Zimmermann J, Voss H, Schwager C, Stegemann J, Ansorge W. Automated Sanger dideoxy sequencing reaction protocol. FEBS Lett. 1988;233:432-436.

39. Mardis ER, Roe BA. Automated methods for singlestranded DNA isolation and dideoxynucleotide DNA sequencing reactions on a robotic workstation. Biotechniques. 1989;7:840-850.

40. Oste CC. PCR Instrumentation: Where Do We Stand? In: Mullis K, Ferré F, Gibbs RA, editors. The Polymerase Chain Reaction. Boston: Birkhäuser; 1994. p. 165-173.

41. Wilson RK, Chen C, Avdalovic N, Burns J, Hood L. Development of an automated procedure for fluorescent DNA sequencing. Genomics. 1990;6:626-634.

42. Koop BF, Wilson RK, Chen C, Halloran N, Sciammis R, Hood L, et al. Sequencing reactions in microtiter plates.

Biotechiques. 1990;9:32, 34-37.

43. Konstantopoulou I, Rampias T, Ladopoulou A, Koutsodontis G, Armaou S, Anagnostopoulos T, et. al. Greek BRCA1 and BRCA2 mutation spectrum: two BRCA1 mutations account for half the carriers found among high-risk breast/ovarian cancer patients. Breast Cancer Res Treat.

2008;107:431-441.

44. Lim KS, Naviaux RK, Haas RH. Quantitative mitochondrial DNA mutation analysis by denaturing HPLC. Clin Chem. 2007;53:1046-1052.

45. Southern EM. Detection of specific sequences among DNA fragments separated by gel electrophoresis. J Mol Biol.

1975;98:503-517.

46. Harper P. Practical Genetic Counselling. 5th ed. London: Reed Educational and Professional Publishing Ltd; 1998.

47. Kingston HM. ABC of Clinical Genetics. 3rd ed. London: BMJ Books; 2002.

48. Wahl GM, Meinkoth JL, Kimmel AR. Northern and Southern blots. Methods Enzymol. 1987;152:572-581.

49. Prichard MN, Daily SL, Jefferson GM, Perry AL, Kern ER. A rapid DNA hybridization assay for the evaluation of antiviral compounds against Epstein-Barr virus. J Virol Methods. 2007;144:86-90.

50. Caliendo AM, Ingersoll J, Fox-Canale AM, Pargman S, Bythwood T, Hayden MK, et al. Evaluation of real-time PCR laboratory-developed tests using analyte-specific reagents for cytomegalovirus quantification. J Clin Microbiol. 2007;45:1723-1727.

51. Strick LB, Wald A. Diagnostics for herpes simplex virus: is PCR the new gold standard? Mol Diagn Ther. 2006;10:17-28.

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REVIEW ARTICLE

¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¶ÂÚÈÊÂÚÂÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ “∞ÏÂÍ¿Ó‰Ú·” ∞ıËÓÒÓ AÏÏËÏÔÁÚ·Ê›·: Ã. ∫ÒÛÙ·ÏÔ˜ ccostalos@yahoo.gr ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “∞ÏÂÍ¿Ó‰Ú·” ∞ıËÓÒÓ

Ã. ∫ÒÛÙ·ÏÔ˜ ¶ÂÚ›ÏË„Ë: ∏ ÚÔÛ¿ıÂÈ· Ì›ÌËÛ˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ô‰‹ÁËÛ Û ÛÔ‚·Ú¿ Ï¿ıË ÎÈ ·˘Ùfi ‰ÈfiÙÈ Ë Û‡ÛÙ·ÛË ÙÔ˘ ·ÓıÚˆ›ÓÔ˘ Á¿Ï·ÎÙÔ˜ ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ‹ Î·È ÂÍ¿ÏÏÔ˘ Ë ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ·’ fi,ÙÈ ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ÂȯÂÈÚ› Ó· Ú›ÍÂÈ ÌÈ· ÎÚÈÙÈ΋ Ì·ÙÈ¿ Û ÔÚÈṲ̂ӷ ÓÂfiÙÂÚ· Û˘ÛÙ·ÙÈο ÙÔ˘ ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï·, fiˆ˜ Â›Ó·È Ù· ÓÔ˘ÎÏÂÔÙ›‰È·, Ù· ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, Ë ÁÏÔ˘Ù·Ì›ÓË, Ë ·ÚÁÈÓ›ÓË, Ë Î·ÚÓÈÙ›ÓË, Ô Û›‰ËÚÔ˜, Ù· Ú‚ÈÔÙÈο, Ù· ÚÔ‚ÈÔÙÈο Î·È Ù· Á¿Ï·Ù· ˘„ËÏ‹˜ ıÚÂÙÈ΋˜ ·Í›·˜. ∞fi ÙË Û˘˙‹ÙËÛË ÚÔ·ÙÂÈ fiÙÈ ÁÈ· ÔÚÈṲ̂Ó˜ Ô˘Û›Â˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ÛÙÔȯ›· Ô˘ Ó· ‰ÈηÈÔÏÔÁÔ‡Ó ÙËÓ ÚÔÛı‹ÎË ÙÔ˘˜. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÔÔÈ·‰‹ÔÙ ÙÚÔÔÔ›ËÛË ˆ˜ ÚÔ˜ ÙË Û‡ÓıÂÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Á·Ï¿ÙˆÓ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ ¤ÂÈÙ· ·fi ÂÓ‰Âϯ›˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, Ì ÛÙfi¯Ô fi¯È ÌfiÓÔ Ù˘¯fiÓ ‚Ú·¯˘ÚfiıÂÛÌÔ fiÊÂÏÔ˜, ·ÏÏ¿ Î·È ÙËÓ Â˘ÓÔ˚΋ Â›ÙˆÛË ÂÓfi˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÙÚÔÊÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙË ÓÔËÙÈ΋ ÂͤÏÈÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜, ηıÒ˜ Î·È Û ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ÂÓËÏ›ÎÔ˘ ˙ˆ‹˜. §¤ÍÂȘ ÎÏÂȉȿ: ¢È·ÙÚÔÊ‹ ‚Ú¤ÊÔ˘˜, ÓÔ˘ÎÏÂÔÙ›‰È·, ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ·, ÁÏÔ˘Ù·Ì›ÓË, ·ÚÁÈÓ›ÓË, ηÚÓÈÙ›ÓË, Û›‰ËÚÔ˜, Ú‚ÈÔÙÈο, ÚÔ‚ÈÔÙÈο, Á¿Ï·Ù· ˘„ËÏ‹˜ ‰È·ÙÚÔÊÈ΋˜ ·Í›·˜.

New aspects of infant nutrition Neonatal Unit, Alexandra Regional General Hospital, Athens, Greece Correspondence: C. Costalos ccostalos@yahoo.gr Neonatal Unit, Alexandra Regional General Hospital, Athens, Greece

C. Costalos Abstract: Efforts to imitate human milk for feeding the infant led to serious miscalculations of the levels of supplementation needed, with resultant dangers. As the exact content of human milk is difficult to estimate due to its wide fluctuations, only limited information can be deduced from measurement of the levels of specific components of human milk. In addition, there may be possible differences in bioavailability and substances other than components of human milk may be needed to achieve the desired effect. This article provides a critical review of these factors, which include nucleotides, polyunsaturated fatty acids, glutamine, arginine, carnitine, iron, prebiotics, probiotics and high energy formulae. Following discussion of these nutrients, it is concluded that for some of them there is insufficient data to justify their use and that there may even be potential dangers from their inclusion.

Independent scientific bodies should evaluate any proposed modification of infant formulae beyond the established standards before permission is given for introduction of such products into the market.

It is important that such research considers not only the short-term effects of the nutrients on growth, but also safety aspects and the possibility of evaluating long-term effects on neurodevelopmental achievement and the incidence of chronic diseases.

Key words: Infant nutrition, nucleotides, polyunsaturated fatty acids, glutamine, arginine, carnitine, iron, prebiotics, probiotics, high energy formulae.

∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Á›Ó·Ì ̿ÚÙ˘Ú˜ ÌÈ·˜ ÌÂÙ·ÛÙÚÔÊ‹˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜. EÓÒ ·Ï·ÈfiÙÂÚ· Ô Î‡ÚÈÔ˜ ÛÙfi¯Ô˜ ηٿ ÙËÓ ·Ú·Û΢‹ ÂÓfi˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‹Ù·Ó Ë ·ÚÔ¯‹ ÛˆÛÙ‹˜ ÔÛfiÙËÙ·˜ Î·È ·Ó·ÏÔÁ›·˜ ÌÂÁ·ÏÔÌÔÚÈ·ÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, Û‹ÌÂÚ· Ë ¤Ú¢ӷ ·ԂϤÂÈ ÛÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙÔ˘ Á¿Ï·ÎÙÔ˜ Ì ÂȉÈο Û˘ÛÙ·ÙÈο Ù˘ ÙÚÔÊ‹˜, Ù· ÔÔ›· ·ÓȯÓ‡ÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ηÈ, ÂÎÙfi˜ ·fi ÙȘ ηı·Ú¿ ‰È·ÙÚÔÊÈΤ˜ ÙÔ˘˜ ·Í›Â˜, ÂËÚ¿˙Ô˘Ó ÙË ÁÂÓÈÎfiÙÂÚË ˘Á›· ÙÔ˘ ·È‰ÈÔ‡. ŒÙÛÈ, Ë ‰È·›ÛÙˆÛË Ù˘ Paediatriki 2008;71:116-122

·ÚÔ˘Û›·˜ ÛÙÔ ·ÓıÚÒÈÓÔ Á¿Ï· ·Ú¯Èο Ù˘ Ù·˘Ú›Ó˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ, ÙˆÓ Ú‚ÈÔÙÈÎÒÓ, ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ, Ù˘ ÁÏÔ˘Ù·Ì›Ó˘, Ù˘ ·ÚÁÈÓ›Ó˘ Ô‰‹ÁËÛ ÛÙËÓ ÚÔÛı‹ÎË ÙˆÓ Ô˘ÛÈÒÓ ·˘ÙÒÓ ÛÙ· ÙÚÔÔÔÈË̤ӷ Á¿Ï·Ù·. ¶·Ú¿ ÙȘ ÊÈÏfiÙÈ̘ ÚÔÛ¿ıÂȘ, ηӤӷ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ÌÔÚ› Ó· ¤¯ÂÈ ÙȘ ȉÈfiÙËÙ˜ ÙÔ˘ ·ÓıÚˆ›ÓÔ˘, ÎÈ ·˘Ùfi ÁÈ·Ù› Ë Û‡ÓıÂÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ‹, ·ÏÏ¿ ÌÂÙ·‚¿ÏÏÂÙ·È Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. ŒÙÛÈ, Â›Ó·È ‰‡ÛÎÔÏÔ˜ Ô ·ÎÚÈ‚‹˜ ˘ÔÏÔÁÈÛÌfi˜

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·117

117

¢È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜

Ù˘ ··ÈÙÔ‡ÌÂÓ˘ ÔÛfiÙËÙ·˜ ÁÈ· οı ÛÙÔȯ›Ô. ∏ ‚ÈԉȷıÂÛÈÌfiÙËÙ· ÂÍ¿ÏÏÔ˘ Î·È Ë Â›‰Ú·ÛË ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ Ô˘ÛÈÒÓ ÌÔÚ› Ó· Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ·’ fi,ÙÈ ÛÙÔ Í¤ÓÔ Á¿Ï·. ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ï‹ıÔ˜ ÔÚÌÔÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÔÚ› Ó· ¢ԉÒÓÔ˘Ó ‹ Ó· ÂÚÈÔÚ›˙Ô˘Ó ÙË ‰Ú¿ÛË ÌÈ·˜ Û˘ÁÎÂÎÚÈ̤Ó˘ Ô˘Û›·˜, ÁÂÁÔÓfi˜ Ô˘ ‰ÂÓ Û˘Ì‚·›ÓÂÈ Ì ÙÔ Í¤ÓÔ Á¿Ï·. ™ÙËÓ Ú¿ÍË ·ԉ›¯ıËΠfiÙÈ Ù· ÔÏ˘‰È·ÊËÌÈ˙fiÌÂÓ· ÔʤÏË ÁÈ· ÔÏϤ˜ Ô˘Û›Â˜ Â›Ó·È ·Ó‡·ÚÎÙ· ‹ ÛÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ÙˆÛË ÔÚȷο, ÂÓÒ ˘¿Ú¯Ô˘Ó Î·È Î›Ó‰˘ÓÔÈ ·fi ÙËÓ ·ÓÂͤÏÂÁÎÙË ¯Ú‹ÛË ÙÔ˘˜. ™ÙË Û˘Ó¤¯ÂÈ· ı· ÚÔÛ·ı‹ÛÔ˘Ì ӷ οÓÔ˘Ì ÌÈ· ·ÓÙÈÎÂÈÌÂÓÈ΋ ·ÍÈÔÏfiÁËÛË Î¿ı ÌÈ·˜ ·fi ·˘Ù¤˜ ÙȘ Ô˘Û›Â˜.

¡Ô˘ÎÏÂÔÙ›‰È· (¡∫) ∞ÔÙÂÏÔ‡Ó Úfi‰ÚÔ̘ Ô˘Û›Â˜ ÙÔ˘ RNA Î·È ÙÔ˘ DNA. £ÂˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÛÙËÓ ·‡ÍËÛË Î·È ÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ÂÙÈÎÔ‡, ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜, ÛÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡, ÛÙË Ì›ˆÛË Ù˘ Á·ÛÙÚÂÓÙÂÚ›Ùȉ·˜ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÁÂÓÈÎfiÙÂÚ·, ηıÒ˜ Î·È ÛÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË (1). ∞. ∂›‰Ú·ÛË ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÙÈÎÔ‡ £ÂÙÈ΋ Â›‰Ú·ÛË ÙˆÓ ¡∫ ÛÙÔ ÂÙÈÎfi ‚Ú¤ıËΠ۠ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ÔÓÙ›ÎÈ· Ô˘ ¤Ï·‚·Ó 2 ÙÚÔʤ˜, ÂÎ ÙˆÓ ÔÔ›ˆÓ Ë Ì›· ÂÚÈ›¯Â ¡∫ Î·È Ë ¿ÏÏË ‰ÂÓ ÂÚÈ›¯Â ηıfiÏÔ˘ ¡∫. ™ÙËÓ Ú¿ÍË, fï˜, ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ó¤Ó· Á¿Ï· Ô˘ Ó· ÌËÓ ÂÚȤ¯ÂÈ Î·ıfiÏÔ˘ ¡∫. ∂›Û˘, ÂÓÒ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÔÓÙÈÎÒÓ Ô˘ ¤Ï·‚ Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ÓÔ˘ÎÏÂÔÙ›‰È· ·Ú·ÙËÚ‹ıËΠÌÂÁ·Ï‡ÙÂÚË ·‡ÍËÛË Ù˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ÂÓÙ¤ÚÔ˘, ÂÓÒ ·Ú·‰fi͈˜ Û ÚˆÙ½ÓË ‰ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ‰È·ÊÔÚ¿ ÛÙÔ Ì¤ÛÔ Î·È ÙÔ ÙÂÏÈÎfi ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ (2). ŒÙÛÈ, ¯ÚÂÈ¿˙ÔÓÙ·È ÂÈϤÔÓ ÌÂϤÙ˜ ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ ·Ú·¿Óˆ. µ. ∂ÓÙÂÚÈ΋ ¯ÏˆÚ›‰· ∂˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ¡∫ ·Ó·Ê¤ÚÔÓÙ·È Û ÌÈ· ÌÂϤÙË, fiÔ˘ Û˘ÁÎÚ›ıËΠÌÈ· ÔÌ¿‰· ÓÂÔÁÓÒÓ Ô˘ ¤·ÈÚÓ Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ¡∫ Ì ¿ÏÏË Ô˘ ¤·ÈÚÓ Á¿Ï· ¯ˆÚ›˜ ¡∫. ∏ ÌÂϤÙË ÂÚÈ›¯Â ÌÈÎÚfi ·ÚÈıÌfi Û˘ÌÌÂÙ¯fiÓÙˆÓ ¯ˆÚ›˜ ÛˆÛÙ‹ Ù˘¯·ÈÔÔ›ËÛË. ¢ÂÓ ‚Ú¤ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔÓ ·fiÏ˘ÙÔ ·ÚÈıÌfi ÙˆÓ ·ÔÈÎÈÒÓ ÙˆÓ ÌÈÎÚÔ‚›ˆÓ ÛÙ· ÎfiÚ·Ó·. ªfiÓÔ fiÙ·Ó ¤ÁÈÓ ۇÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÔÛÔÛÙÒÓ Î¿ı ÌÈÎÚÔ‚›Ô˘ ÛÙ· ÎfiÚ·Ó· ‚Ú¤ıËΠοÔÈ· ‰È·ÊÔÚ¿ (3). ™Ù· ›‰È· Û˘ÌÂÚ¿ÛÌ·Ù· ηٷϋÁÂÈ Î·È ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË (4).

°. ∂›‰Ú·ÛË ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi ∞Ó Î·È ·Ó·Ê¤ÚıËΠ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ Î˘ÙÙ¿ÚˆÓ (¡∫ cells) Î·È ˘„ËÏfiÙÂÚÔÈ Ù›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜ Î·È Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi ÛÙÔ˘˜ 2 Ì‹Ó˜ ˙ˆ‹˜ Û ‚Ú¤ÊË Ô˘ ¤Ï·‚·Ó Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì ¡∫, ‰ÂÓ ˘‹Ú¯Â η̛· ‰È·ÊÔÚ¿ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ÌËÓÒÓ (5) Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÂ›Û˘ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ‹ ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ¢. ¢È¿ÚÚÔÈ·-ÏÔÈÌÒÍÂȘ ∞Ó Î·È ÔÈ ÚÒÙ˜ ÌÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó Î·Ï‡ÙÂÚË ÂԇψÛË ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÌÂÙ¿ ·fi ÚÔÎÏËÙ‹ ‚Ï¿‚Ë (2) ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ¡∫, ÎÏÈÓÈ΋ ÌÂϤÙË Û ·È‰È¿ ‰ÂÓ ¤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ‰È¿ÚÚÔÈ·˜ Î·È ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· οı ÂÂÈÛÔ‰›Ô˘. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÂ›Û˘ ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ Î·È ÙÔ˘ ηو٤ÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ù˘ ·Ú·ÌÔÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (6). ∂. ∂›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ ·‡ÍËÛË ªÈ· ÌÂϤÙË ¤‰ÂÈÍ ηχÙÂÚË ·ÓÙÈÚÚÔÈÛÙÈ΋ ·‡ÍËÛË Û ÙÂÏÂÈfiÌËÓ· Ì ÂÓ‰ÔÌ‹ÙÚÈ· ηı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ (7) ÌÂÙ¿ ÙË Ï‹„Ë ¡∫. ÕÏϘ ÌÂϤÙ˜ ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ·˘Ù‹ ÙËÓ ¿Ô„Ë (8,9). À„ËϤ˜ ‰fiÛÂȘ ¡∫ ‚Ú¤ıËΠfiÙÈ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó·Ó¢ÛÙÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (10). ¢È΋ Ì·˜ Ù˘¯·ÈÔÔÈË̤ÓË Ù˘ÊÏ‹ ÌÂϤÙË ‰ÂÓ ¤‰ÂÈÍ Â›‰Ú·ÛË ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ ÛÙËÓ ·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ˘‰·Ù·ÓıÚ¿ÎˆÓ Ô‡ÙÂ Î·È Ì›ˆÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ÂÓÙÂÚÔ·ıÔÁfiÓˆÓ ÛÙ· ÎfiÚ·Ó· (11). ªÈ· Èı·Ó‹ ÂÍ‹ÁËÛË Ù˘ ÌË ·Ó‡ÚÂÛ˘ ıÂÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ ›Ûˆ˜ Ó· Â›Ó·È fiÙÈ Ë ÌÂϤÙË ‰ÂÓ ÂÚÈÂÏ¿Ì‚·Ó Â·Ú΋ ·ÚÈıÌfi ÓÂÔÁÓÒÓ Ì ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘ÛÙÚÔÊ›·, Ù· ÔÔ›·, ηٿ ÙË ÁÓÒÌË Ì·˜, ı· ˆÊÂÏÔ‡ÓÙ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ ÚÔÛı‹ÎË ÙˆÓ ÓÔ˘ÎÏÂÔÙȉ›ˆÓ.

¶ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· (¶∞§√) ∞ÔÙÂÏÔ‡Ó Úfi‰ÚÔ̘ Ô˘Û›Â˜ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, ÚÔÛÙ·Î˘ÎÏ›Ó˘, ıÚÔÌ‚ÔÍ¿Ó˘, Ï¢ÎÔÙÚÈÂÓ›ˆÓ Î·È ıˆÚÔ‡ÓÙ·È ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÓÂÔÁÓÈÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ù˘ ÔÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ¶·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Ó¢ÚÈÎÒÓ Û˘Ó¿„ÂˆÓ (12-14). ∂ȉÚÔ‡Ó, Â›Û˘, ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi, ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË, ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÔÛÙÒÓ (15). ∞Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ ÚÒÙÔ˘ ‰ÈÏÔ‡ ‰ÂÛÌÔ‡ ·fi ÙÔ ÌÂı˘ÏÈÎfi ¿ÎÚÔ ‰È·ÎÚ›ÓÔÓÙ·È Û ˆ-3 Î·È ˆ-6. ¶·È‰È·ÙÚÈ΋ 2008;71:116-122

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·118

118

Ã. ∫ÒÛÙ·ÏÔ˜

∆· ΢ÚÈfiÙÂÚ· Â›Ó·È ÙÔ ·Ú·¯È‰ÔÓÈÎfi Î·È ÙÔ 22-ÂÍ·ÓÔ˚Îfi Ô͇ (DHA). ∞ÔÙÂÏÔ‡Ó Û˘ÛÙ·ÙÈÎfi Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, Ë ÔÔ›· Â›Ó·È Â˘·ı‹˜ Û ÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘. ÀÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ¶∞§√ ·˘Í¿ÓÂÈ ÙËÓ ·ÈÌfiÏ˘ÛË ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÂÈÙ›ÓÂÈ ÙËÓ ˘ÂÚÔÍÈ΋ ‚Ï¿‚Ë ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ÙË ÊˆÙÔÙÔÍÈ΋ ‚Ï¿‚Ë ÙˆÓ Ú·‚‰›ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Úԉȷı¤ÙÔÓÙ·˜ ›Ûˆ˜ Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ¯ÚfiÓÈ·˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜ (ö), ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜ (¡∂∫), ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ (∞¶) (16). ¶ÚfiˆÚ· Ô˘ ¤Ï·‚·Ó ȯı˘¤Ï·ÈÔ Â›¯·Ó ¯·ÌËÏfiÙÂÚË ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜ (17). ∞˘Ùfi ÔÊÂÈÏfiÙ·Ó Û ·ÚÂÌfi‰ÈÛË ·fi Ù· ˆ-3 ÏÈ›‰È· Ù˘ ÌÂÙ·ÙÚÔ‹˜ ÙÔ˘ ÏÈÓÔÏÂ˚ÎÔ‡ ÔͤԘ Û ·Ú·¯È‰ÔÓÈÎfi. ªÂ ‚¿ÛË ·˘Ù¿, Ë ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜ ÚÔÙ›ÓÂÈ Ë ÔÛfiÙËÙ· ÙÔ˘ DHA ÛÙÔ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· Ó· ÌËÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 0,5% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ Ï›Ô˘˜ Î·È Ë ÂÚÈÂÎÙÈÎfiÙËÙ· Û ∞∞ Ó· Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ›ÛË Ì ·˘Ù‹ ÙÔ˘ DHA (18). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚ˜ ‚ÈÔÌ˯·Ó›Â˜ ·Ú·Û΢‹˜ ‚ÚÂÊÈÎÒÓ Á·Ï¿ÙˆÓ ÚÔÛı¤ÙÔ˘Ó ¶∞§√ ÛÙ· ÚÔ˚fiÓÙ· ÙÔ˘˜. Œ¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÌÂϤÙ˜ ÙfiÛÔ Û ÚfiˆÚ· fiÛÔ Î·È Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ ηٿ ÙË ‚ÚÂÊÈ΋ ÂÚ›Ô‰Ô Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Â›Ó·È ·ÓÙÈÊ·ÙÈο. £· ÛÙ·¯˘ÔÏÔÁ‹ÛÔ˘Ì ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜.

ªÂϤÙ˜ Û ÚfiˆÚ· ÓÂÔÁÓ¿ ªÂÁ¿ÏË ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË Ô˘ Û˘ÌÂÚȤϷ‚ 11 ÌÂϤÙ˜ ¤‰ÂÈÍ fiÙÈ Ë ÚÔÛı‹ÎË ¶∞§√ Û ÚfiˆÚ· ‰ÂÓ Â›¯Â η̛· ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Î·È ÓÔËÙÈ΋ ÂͤÏÈÍ‹ ÙÔ˘˜ (19). √È ÌÂϤÙ˜ ‰ÂÓ ÂÚÈÂÏ¿Ì‚·Ó·Ó fï˜ ÓÂÔÁÓ¿ Ì ÂÍ·ÈÚÂÙÈο ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘. ÕÏÏË Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ Ë ÚÔÛı‹ÎË ¶∞§√ ÛÙË ‰È·ÙÚÔÊ‹ ÚÔÒÚˆÓ Ô‰‹ÁËÛ Û ηχÙÂÚË ·Ó¿Ù˘ÍË Û ‚¿ÚÔ˜ Î·È Ì‹ÎÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ÌËÓÒÓ. ∆· ·ÁfiÚÈ· Ù˘ ÌÂϤÙ˘ ›¯·Ó ÛÙÔ˘˜ 18 Ì‹Ó˜ ˙ˆ‹˜ ˘„ËÏfiÙÂÚÔ ÓÔËÙÈÎfi ‰Â›ÎÙË Û ۯ¤ÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (20). ÕÏÏË ÌÂϤÙË ¤‰ÂÈÍ ¿ÏÈ fiÙÈ ÚfiˆÚ· Ô˘ ¤Ï·‚·Ó ¶∞§√ ›¯·Ó ÛÙË ‰ÈÔÚıˆÌ¤ÓË ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ ˘„ËÏfiÙÂÚÔ˘˜ ‰Â›ÎÙ˜ ÓÔËÌÔÛ‡Ó˘ Û‡Ìʈӷ Ì ÙËÓ Îϛ̷η Bayley (21). ªÂϤÙ˜ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ √È ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó Û ÙÂÏÂÈfiÌËÓ· ¤‰ÂÈÍ·Ó ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·. ªÂÁ¿ÏË ·Ó·ÛÎfiËÛË Ô˘ ÂÚÈÂÏ¿Ì‚·Ó 10 ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÂÓ ¤‰ÂÈÍ ηӤӷ fiÊÂÏÔ˜ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ (22). ™Â ¿ÏPaediatriki 2008;71:116-122

ÏË ·Ó·ÛÎfiËÛË ¿ÏÈ ‚Ú¤ıËΠfiÙÈ Ô ÂÌÏÔ˘ÙÈÛÌfi˜ Ì ¶∞§√ ›¯Â ıÂÙÈ΋ ‰Ú¿ÛË ÛÙËÓ ÔÙÈ΋ Ô͇ÙËÙ· ÓÂÔÁÓÒÓ ÛÙÔ 2Ô Ì‹Ó· ˙ˆ‹˜ (23). À¿Ú¯ÂÈ, fï˜, Î·È ÌÂϤÙË Ô˘ ‰Â›¯ÓÂÈ ¯ÂÈÚfiÙÂÚË ÓÔËÙÈ΋ ¤Î‚·ÛË ÛÙËÓ ËÏÈΛ· ÙˆÓ 39 ÌËÓÒÓ Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ (24). Ÿˆ˜ ·Ó·Ê¤ÚÂÈ Ë Fewtrell (25), ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ÏfiÁÔ˘˜, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ¿Óˆ ÛÙ· ¶∞§√ Â›Ó·È ·ÓÙÈÊ·ÙÈο, Â›Ó·È ÔÈ ÂÍ‹˜: ·) √È ÂÏ¿¯ÈÛÙ˜ ·Ó·Áη›Â˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ¤˜. ‚) ∏ Û¯¤ÛË 18:ˆ-3/18:ˆ6 ÛÙ· ¯ÔÚËÁÔ‡ÌÂÓ· ¶∞§√ Î·È Ë ÚÔ¤ÏÂ˘Û‹ ÙÔ˘˜ ÔÈΛÏÏÂÈ. Á) ∏ ¯ÔÚËÁÔ‡ÌÂÓË ÔÛfiÙËÙ·, Â›Û˘, ÔÈΛÏÏÂÈ. ‰) ¢ÂÓ ˘¿Ú¯Ô˘Ó, Ù¤ÏÔ˜, Ì·ÎÚfi¯ÚÔÓ˜ ÌÂϤÙ˜ Û¯ÂÙÈο Ì ÙËÓ ¤Î‚·ÛË ÙˆÓ ˘fi ÌÂϤÙË ·È‰ÈÒÓ. ∞fi Ù· ·Ú·¿Óˆ Ê·›ÓÂÙ·È fiÙÈ ·˘Ù¿ Ô˘ ˆÊÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ¶∞§√ Â›Ó·È Ù· Ôχ ÚfiˆÚ· ÓÂÔÁÓ¿, Ù· ÔÔ›· ¤¯Ô˘Ó Î·È Ù· ¯·ÌËÏfiÙÂÚ· ·Ôı¤Ì·Ù· ÙˆÓ ÏÈ·ÚÒÓ ·˘ÙÒÓ ÔͤˆÓ ηٿ ÙË Á¤ÓÓËÛË. ∏ ·Ó·ÁηÈfiÙËÙ· ¯ÚËÛÈÌÔÔ›ËÛ‹˜ ÙˆÓ ¶∞§√ ÛÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ̤ÓÂÈ Ó· ·Ô‰Âȯı›.

°ÏÔ˘Ù·Ì›ÓË ∞ÔÙÂÏ› ËÁ‹ ÂÓ¤ÚÁÂÈ·˜ ÁÈ· Ù· ÂÓÙÂÚÔ·ÙÙ·Ú· Î·È ·Ú¤¯ÂÈ ¿˙ˆÙÔ ÁÈ· ÙË Û‡ÓıÂÛË ·ÌÈÓÔͤˆÓ Ô˘ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÂÓÙÂÚÔ΢ÙÙ¿ÚˆÓ, ÙËÓ ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘, ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡ (26). ¶ÚfiˆÚ· Û ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ô˘ ¤Ï·‚·Ó ÂÏ¿¯ÈÛÙË ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Ô˘ ‹Ù·Ó ÂÌÏÔ˘ÙÈṲ̂ÓË Ì ÁÏÔ˘Ù·Ì›ÓË Â›¯·Ó ¯·ÌËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ÛË„·ÈÌ›·˜ Î·È ·˘ÍË̤ÓË ·ÓÔ¯‹ ÂÓÙÂÚÈ΋˜ ÙÚÔÊ‹˜ (27). ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÁÏÔ˘Ù·Ì›Ó˘ ·ÌÊÈÛ‚ËÙÂ›Ù·È Û ·ı‹ÛÂȘ, fiˆ˜ Û‡Ó‰ÚÔÌÔ ÙÔ˘ ‚Ú·¯¤Ô˜ ÂÓÙ¤ÚÔ˘, ÊÏÂÁÌÔÓÒ‰Ë ÂÓÙÂÚÔ¿ıÂÈ· Î·È ·ÎÙÈÓÈ΋ ‚Ï¿‚Ë ÙÔ˘ ÂÓÙ¤ÚÔ˘ (28), ÂÓÒ ÌÂϤÙ˜ Û ÓÂÔÁÓ¿ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯Ú‹ÛË Ù˘ ‰ÂÓ ÌÂÈÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÏÔÈÌÒÍÂˆÓ Î·È ¡∂∫, ·ÏÏ¿ Ô‡ÙÂ Î·È Ô‰ËÁ› Û ηχÙÂÚË ·ÓÔ¯‹ ÂÓÙÂÚÈ΋˜ ÙÚÔÊ‹˜ (29,30). ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È Î·È Èı·Ó‹ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ ÁÏÔ˘Ù·Ì›Ó˘ ‹ ÙÔ˘ ÁÏÔ˘Ù·ÌÈÎÔ‡, Ô˘ ·ÔÙÂÏ› ·Ú¿ÁˆÁfi Ù˘, ÛÙÔ ∫¡™. ∏ ÁÏÔ˘Ù·Ì›ÓË, Ù¤ÏÔ˜, ÌÔÚ› Ó· ·Ú¤Ì‚ÂÈ ·ÚÓËÙÈο ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ¿ÏÏˆÓ ·ÌÈÓÔͤˆÓ (31). ∞ÚÁÈÓ›ÓË ∂›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Û‡ÓıÂÛË ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘, ÙËÓ ÂÓÙÂÚÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹, ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡, ÙËÓ ·Ú·ÁˆÁ‹ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (32). ∏ ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ·ÛıÂÓ›˜ ÓÔÛËÏ¢fiÌÂÓÔ˘˜ Û ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰· ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË (33). ¶ÚfiˆÚ· Ô˘ ·Ó¤Ù˘Í·Ó ¡∂∫ ›¯·Ó ¯·ÌËÏfiÙÂÚ· Â›‰· ·ÚÁÈÓ›Ó˘ ·›Ì·ÙÔ˜ (34) Û ۯ¤ÛË Ì ̿ÚÙ˘Ú˜. ∆Ô ·ÌÈÓÔ͇ ·˘Ùfi ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ù˘

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·119

119

¢È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜

ÁÏ˘Îfi˙˘, ¤¯ÂÈ ÈÛÙ·ÌÈÓÈ΋ ‰Ú¿ÛË (35), ÂÓÒ ·˘Í¿ÓÂÈ ÙË Û‡ÓıÂÛË ÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÓÂ·ÓfiÚıˆÙÔ ÛËÙÈÎfi ÛÔÎ (36).

∫·ÚÓÈÙ›ÓË ∂›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÔÍ›‰ˆÛË ÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· ÌÈÙÔ¯fiÓ‰ÚÈ· Î·È ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ·ÎÂÙ˘ÏÈˆÌ¤ÓˆÓ ÚÔ˚fiÓÙˆÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (37). ¡ÂfiÙÂÚ˜ ÌÂϤÙ˜ ·ÌÊÈÛ‚ËÙÔ‡Ó ÙË ¯ÚËÛÈÌfiÙËÙ¿ Ù˘ (38), ÂÓÒ ÔÚÈṲ̂ÓÔÈ ıˆÚÔ‡Ó fiÙÈ ÌÔÚ› Î·È Ó· ‚Ï¿ÙÂÈ ·Ó ¯ÔÚËÁËı› Û ·˘ÍË̤ÓË ‰fiÛË (39). ™›‰ËÚÔ˜ ∂ÌÔ‰›˙ÂÈ ÙËÓ ·ÔÚÚfiÊËÛË „¢‰·ÚÁ‡ÚÔ˘ Î·È ¯·ÏÎÔ‡ ·fi ÙÔ ÂÙÈÎfi. ∂›Ó·È ÈÛ¯˘Úfi ÔÍÂȉˆÙÈÎfi Î·È ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÔÍÂȉˆÙÈ΋ ‚Ï¿‚Ë. ™Â ÂÓ‹ÏÈΘ ˘¿Ú¯ÂÈ ¿ÌÂÛË Û¯¤ÛË ÌÂٷ͇ ·ÔıÂÌ¿ÙˆÓ Ûȉ‹ÚÔ˘ Î·È Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ (40). ™Â ÌÂϤÙË ·fi ÙË ™Ô˘Ë‰›· Û ‚Ú¤ÊË ËÏÈΛ·˜ 4-9 ÌËÓÒÓ Ì Â·Ú΋ ·Ôı¤Ì·Ù· Ûȉ‹ÚÔ˘, Ë ¯ÔÚ‹ÁËÛË ÂÈϤÔÓ Ûȉ‹ÚÔ˘ ·fi ÙÔ ÛÙfiÌ· Ô‰‹ÁËÛ Û ÌÂȈ̤ÓË ·‡ÍËÛË ÂȘ Ì‹ÎÔ˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ. ∂›Û˘, Ù· ‚Ú¤ÊË ÂÌÊ¿ÓÈÛ·Ó, Û˘ÁÎÚÈÙÈο Ì ̿ÚÙ˘Ú˜, ˘„ËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ‰È¿ÚÚÔÈ·˜ Î·È ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (41). ¶Ú‚ÈÔÙÈο ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÎÙfi˜ ·fi ÙȘ ¿ÏϘ ÙÔ˘ ȉÈfiÙËÙ˜ ÂÓÈÛ¯‡ÂÈ ÂÈϤÔÓ ÙËÓ ¿Ì˘Ó· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ̤ۈ Ù˘ ¢ÂÚÁÂÙÈ΋˜ ÙÔ˘ ‰Ú¿Û˘ ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ÙÔ˘ ÓÂÔÁÓÔ‡, ÂÓÒ ·Ú¿ÏÏËÏ· ÌÂÈÒÓÂÈ ÙËÓ ÂΉ‹ÏˆÛË ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ (42). ª¤ÚÔ˜ Ù˘ ¢ÓÔ˚΋˜ ÙÔ˘ ‰Ú¿Û˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· Á·Ï·ÎÙÔ-ÔÏÈÁÔ۷ί·Úȉ›ˆÓ, Ù· ÔÔ›· ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ bifidobacteria Î·È Á·Ï·ÎÙÔ‚·Î›ÏÏˆÓ ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ (43). ŒÙÛÈ, ηıÈÂÚÒıËÎÂ Ô fiÚÔ˜ «Ú‚ÈÔÙÈο», Ô˘ ˘Ô‰ËÏÒÓÂÈ ÔÚÈṲ̂ӷ ›‰Ë ˘‰·Ù·ÓıÚ¿ÎˆÓ Ê˘ÙÈ΋˜ ÚÔ¤Ï¢Û˘ Ô˘ ‰ÂÓ ‰È·ÛÒÓÙ·È ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ, ·ÏÏ¿ Êı¿ÓÔ˘Ó ·Ó·ÏÏÔ›ˆÙ· ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, fiÔ˘ ÚÔ¿ÁÔ˘Ó ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ÂÓÙÂÚÈ΋˜ ¯ÏˆÚ›‰·˜ Ì ¢ÓÔ˚Τ˜ Û˘Ó¤ÂȘ ÁÈ· ÙÔÓ ÍÂÓÈÛÙ‹ (44). À¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· ›‰Ë Ú‚ÈÔÙÈÎÒÓ, Ì ΢ÚÈfiÙÂÚ· Ù· ÊÚÔ˘ÎÙÔ-ÔÏÈÁÔ۷ί·Ú›‰È· (º√™), Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ê˘Ù¿ .¯. Ì·Ó¿Ó·, Ú·‰›ÎÈ·, ÛÈÙ¿ÚÈ, ÎÚÂÌ̇‰È·, Î·È Ù· Á·Ï·ÎÙÔ-ÔÏÈÁÔ۷ί·Ú›‰È· (°√™) Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ Á¿Ï· (45). √È ‚ÈÔÌ˯·Ó›Â˜ ·È‰ÈÎÒÓ ÙÚÔÊÒÓ ·Ú‹Á·Á·Ó ÚÔÛ·ÚÌÔṲ̂ӷ ÚÔ˜ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÔÓÙ· Ì›ÁÌ· º√™ Î·È °√™ Ô˘ ÌÈÌÔ‡ÓÙ·È ÙË ÌÔÚȷ΋ ‰ÔÌ‹ ÙˆÓ ÔÏÈÁÔ۷ί·Úȉ›ˆÓ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ (46). ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ Ì›ÁÌ·ÙÔ˜ ·˘ÙÔ‡ ÙfiÛÔ Û ÙÂÏÂÈfiÌËÓ· (47,48) fiÛÔ Î·È Û ÚfiˆÚ· ÓÂÔÁÓ¿ (49,50) ‹Ù·Ó ηϿ ·ÓÂÎÙ‹ Î·È Û˘Óԉ‡ÙËΠ·fi ·˘ÍË̤ÓË ·Ó¿Ù˘ÍË

bifidobacteria ÛÙÔ ·¯‡ ¤ÓÙÂÚÔ, Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ì ηٷÛÙÔÏ‹ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ·ıÔÁfiÓˆÓ ÂÓÙÂÚÔ‚·ÎÙËÚȉ›ˆÓ. ¶·Ú¿ÏÏËÏ·, Ô ·ÚÈıÌfi˜ ÙˆÓ ÎÂÓÒÛÂˆÓ Î·È Ë Û‡ÛÙ·ÛË ÙˆÓ ÎÔÚ¿ÓˆÓ, fiˆ˜ Î·È ÙÔ pH, ·ÚÔÌÔ›·˙·Ó Ì ÂΛӷ ÓÂÔÁÓÒÓ Ô˘ ÙÚ¤ÊÔÓÙ·Ó Ì ÌËÙÚÈÎfi Á¿Ï·. ¶ÚfiÛÊ·Ù·, ·Ó·Ê¤ÚıËÎÂ Î·È Â˘ÓÔ˚΋ ‰Ú¿ÛË ÙˆÓ Ú‚ÈÔÙÈÎÒÓ ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ (51). ∞Ó Î·È Ù· Ú‚ÈÔÙÈο ·ÎfiÌ· ‰ÂÓ ıˆÚÔ‡ÓÙ·È ·fiÏ˘Ù· ·ÛÊ·Ï‹, ı· Ú¤ÂÈ Ó· ‰›ÓÔÓÙ·È Ì ÚÔÛÔ¯‹ ÂȉÈο Û ÚfiˆÚ· ‹ ‰˘ÛÙÚÔÊÈο ÓÂÔÁÓ¿ ÁÈ·Ù› ÌÔÚ› Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ¤„Ë Î·È ÙËÓ ·ÔÚÚfiÊËÛË Ï›Ô˘˜ Î·È ˘‰·Ù·ÓıÚ¿ÎˆÓ ·fi ÙÔ ¤ÓÙÂÚÔ (52).

¶ÚÔ‚ÈÔÙÈο ∂›Ó·È ˙ÒÓÙ˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› Ô˘ ¯ÔÚËÁÔ‡ÌÂÓÔÈ Û Â·ÚΛ˜ ÔÛfiÙËÙ˜ ÚÔ¿ÁÔ˘Ó ÙËÓ ˘Á›· ÙÔ˘ ÍÂÓÈÛÙ‹. ∆· ÂÚÈÛÛfiÙÂÚÔ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Â›Ó·È Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Î·È bifidobacteria, Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈο Î·È ÛÙÔ ¤ÓÙÂÚÔ ‚ÚÂÊÒÓ Ô˘ ·›ÚÓÔ˘Ó ÌËÙÚÈÎfi Á¿Ï·. ∏ ·ÚÔ˘Û›· ÙÔ˘˜ ÛÙÔ ¤ÓÙÂÚÔ Î·Ù·ÛÙ¤ÏÏÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ·ıÔÁfiÓˆÓ ÌÈÎÚÔ‚›ˆÓ, ÌÂÈÒÓÂÈ ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ÙËÓ ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Û ·ÏÏÂÚÁÈÔÁfiÓ· (53,54). ¶ÚÔ‚ÈÔÙÈο ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· Û Á·ÛÙÚÂÓÙÂÚ›Ùȉ· ·fi ROTA Èfi (55), ÛÙË ‰È¿ÚÚÔÈ· ·fi ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ (56), ÛÙËÓ ÚfiÏË„Ë ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ (57) Î·È ÈÔ ÚfiÛÊ·Ù· ÛÙËÓ ÚfiÏË„Ë Ù˘ ¡∂∫ Û ÚfiˆÚ· ÓÂÔÁÓ¿ (58,59). °È· Ù· ÚÔ‚ÈÔÙÈο ··ÈÙÔ‡ÓÙ·È ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜. ¶·ÚÂÓ¤ÚÁÂȘ ·Ó·Ê¤ÚÔÓÙ·È Ôχ Û¿ÓÈ· ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Á·Ï·ÎÙÔ‚¿ÎÈÏÏˆÓ Î·È ˙˘ÌÔ̇ÎËÙˆÓ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û˘ÛÙËÌ·ÙÈΤ˜ ÏÔÈÌÒÍÂȘ, ÂȉÈο Û ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ¿ÙÔÌ·, ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË (Á·Ï·ÎÙÔ‚¿ÎÈÏÏÔÈ Ô˘ ·Ú¿ÁÔ˘Ó Á·Ï·ÎÙÈÎfi Ô͇), ÌÂÙ·ÊÔÚ¿ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÚÔ˜ ¿ÏÏ· ÌÈÎÚfi‚È·, ÌÂ Û˘Ó¤ÂÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ (60,61). ™˘Ì‚ÈÔÙÈο ŒÓ· ÌÂÈÔÓ¤ÎÙËÌ· ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ Â›Ó·È fiÙÈ ¤¯Ô˘Ó ‚Ú·¯Â›· ‰Ú¿ÛË, ÌÂ Û˘Ó¤ÂÈ· Ó· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Î·ıËÌÂÚÈÓ¿ .∏ ÚÔÛı‹ÎË Ú‚ÈÔÙÈÎÒÓ ÛÙ· ÚÔ‚ÈÔÙÈο ·˘Í¿ÓÂÈ ÙÔ ¯ÚfiÓÔ ‰Ú¿Û˘ ÙÔ˘˜ ÎÈ ¤ÙÛÈ ‰ÂÓ ··ÈÙÂ›Ù·È Û˘¯Ó‹ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ (62). ∏ ¯Ú‹ÛË ÙÔ˘˜, fï˜, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ÙÂÎÌËÚȈı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. °¿Ï·Ù· ·˘ÍË̤Ó˘ ıÚÂÙÈ΋˜ ·Í›·˜ ∏ ÂÓ‰ÔÌ‹ÙÚÈ· ‰˘ÛÙÚÔÊ›·, ·ÏÏ¿ Î·È Ë Î·Î‹ ıÚ¤„Ë Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ ÎÚ›ÛÈÌÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜, ÌÔÚ› Ó· ¤¯ÂÈ ÛÔ‚·Úfiٷ٘ Û˘Ó¤ÂȘ ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋ Î·È ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜ (63,64). H Û˘¯ÓfiÙËÙ· ÂÓ‰ÔÌ‹ÙÚÈ·˜ ‰˘ÛÙÚÔÊ›·˜ Û ¶·È‰È·ÙÚÈ΋ 2008;71:116-122

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ÓÂÔÁÓ¿ Ì Ôχ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Êı¿ÓÂÈ Î·È ÙÔ 30%. ªÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘ÔÛÈÙ›˙ÔÓÙ·È Î·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÏfiÁˆ Ù˘ ÏËıÒÚ·˜ ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·Ù¿ ÙË ÓÔÛËÏ›· ÙÔ˘˜ Û ÂÓÙ·ÙÈ΋ ÌÔÓ¿‰·, ÌÂ Û˘Ó¤ÂÈ· Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ‰˘ÛÙÚÔÊÈο ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô (65). ŒÙÛÈ ÙÔ ‚¿ÚÔ˜ ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ÛÙË ÛˆÛÙ‹ Û›ÙÈÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. ∆· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Ù·¯Â›· ·Ó·ÏËڈ̷ÙÈ΋ ·‡ÍËÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË Û ÂÏÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿ Ô‰ËÁ› Û ηχÙÂÚË ÓÔËÙÈ΋ ÂͤÏÈÍË (66,67). À¿Ú¯ÂÈ, fï˜, Î·È Ë ¿Ô„Ë fiÙÈ Ù·¯Â›· ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÌÔÚ› Ó· Úԉȷı¤ÛÂÈ Û ¯ÚfiÓÈ· ηډȷÁÁÂȷ΋ ÓfiÛÔ, ˘¤ÚÙ·ÛË, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2 Î·È ÔÛÙÂÔfiÚˆÛË ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (68). ªÈ· ÌÂÁ¿ÏË ·Ó·ÛÎfiËÛË ‰ÂÓ ¤‰ÂÈÍ ηӤӷ fiÊÂÏÔ˜ ˆ˜ ÚÔ˜ ÙË ÛˆÌ·ÙÈ΋ Î·È æ∫ ÂͤÏÈÍË (69). ∞fi Ù· ·Ú·¿Óˆ Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ÛÙÔ ı¤Ì· Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ÓÂÔÁÓÔ‡ ··ÈÙÂ›Ù·È Û‡ÓÂÛË Î·È ÚÔÛÔ¯‹ ÛÙËÓ ˘ÈÔı¤ÙËÛË Ó¤ˆÓ ·Ú¯ÒÓ. Àfi ·˘Ùfi ÙÔ Ó‡̷, Ë ESPGHAN Âͤ‰ˆÛ ԉËÁ›Â˜ Ô˘ ÂÈÛËÌ·›ÓÔ˘Ó fiÙÈ “Ë ·Ï‹ ·ÚÔ˘Û›· ÌÈ·˜ Ô˘Û›·˜ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ‰ÂÓ ‰ÈηÈÔÏÔÁ› ÙËÓ ·˘ÙfiÌ·ÙË ÚÔÛı‹ÎË Ù˘ ÛÙÔ Û˘ÓıÂÙÈÎfi Á¿Ï·, ¯ˆÚ›˜ ÚÔËÁÔ˘Ì¤Óˆ˜ Ó· ‰È·ÈÛÙˆı› fi¯È ÌfiÓÔ ÙÔ ‚Ú·¯˘ÚfiıÂÛÌÔ, ·ÏÏ¿ Î·È ÙÔ Ì·ÎÚÔÚfiıÂÛÌÔ fiÊÂÏÔ˜ Ô˘ ·ÔʤÚÂÈ ÛÙÔÓ ·Ó·Ù˘ÛÛfiÌÂÓÔ ÔÚÁ·ÓÈÛÌfi” (70).

µÈ‚ÏÈÔÁÚ·Ê›· 1. Carver JD. Dietary nucleotides: effects on the immune and gastrointestinal systems. Acta Paediatr Suppl 1999;88:83-88.

2. Uauy R, Stringel G, Thomas R, Quan R. Effect of dietary nucleosides on growth and maturation of the developing gut in the rat. J Pediatr Gastroenterol Nutr 1990;10:497-503.

3. Gil A, Corral E, Martinez A, Molina JA. Effects of the addition of nucleotides to an adapted milk formula on the microbial pattern of feces in at term newborn infants. Clin Nutr Gastroenterol 1986;1:127-132.

4. Balmer SE, Hanvey LS, Wharton BA. Diet and faecal flora in the newborn: nucleotides. Arch Dis Child Fetal Neonatal Ed 1994;70:F137-F140.

5. Carver JD, Pimentel B, Cox WI, Barness LA. Dietary nucleotide effects upon immune function in infants. Pediatrics 1991;88:359-363.

6. Brunser O, Espinoza J, Araya M, Cruchet S, Gil A. Effect of dietary nucleotide supplementation on diarrhoeal disease in infants. Acta Paediatr 1994;83:188-191.

7. Cosgrove M, Davies DP, Jenkins HR. Nucleotide supplementation and the growth of term small for gestational age infants. Arch Dis Child Fetal Neonatal Ed 1996;74:F122-F125.

8. Carver JD, Walker WA. The role of nucleotides in human nutrition. J Nutr Biochem 1995;6:58-72.

9. Yu VY. The role of dietary nucleotides in neonatal and infant nutrition. Singapore Med J 1998;39:145-150.

Paediatriki 2008;71:116-122

10. Yau KI, Huang CB, Chen W, Chen SJ, Chou YH, Huang FY, et al. Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastroenterol Nutr 2003;36:37-43.

11. ™ÎÔ˘Ù¤ÚË µ, ∫ÒÛÙ·ÏÔ˜ Ã, ™Â‚·ÛÙÈ¿‰Ô˘ ™, °·‚Ú›ÏË ™, ¢·ÓÂÏ¿ÙÔ˘ ∫, µÔÁÈ·Ù˙‹ ∞, Î·È Û˘Ó. ∏ Â›‰Ú·ÛË ÂÓfi˜ ÂÌÏÔ˘ÙÈṲ̂ÓÔ˘ Ì ÓÔ˘ÎÏÂÔÙ›‰È· Á¿Ï·ÙÔ˜ ÛÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ÚÔÒÚˆÓ ÓÂÔÁÓÒÓ. ¶·È‰È·ÙÚÈ΋ 2002;65:52-56.

12. Litman BJ, Mitchell DC. A role for phospholipid polyunsaturation in modulating membrane protein function.

Lipids 1996;31:S193-S197.

13. Neuringer M, Jeffrey BG. Visual development: Neural basis and new assessment methods. J Pediatr 2003;143:S87-S95.

14. Mitchell DC, Niu SL, Litman BJ. DHA-rich phospholipids optimize G-Protein-coupled signaling. J Pediatr 2003:143: S80-S86.

15. Calder PC. ˆ3 Polyunsaturated Fatty Acids, Inflammation and Immunity. In: ∏amazaki T, Okuyama H, editors. Fatty Acids and Lipids - New Findings. World Rev Nutr Diet.

Basel: Karger; 2001. p. 109-116.

16. Jensen CL, Heird WC. Lipids with an emphasis on longchain polyunsaturated fatty acids. Clin Perinatol 2002; 29:261-281, vi.

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

18. Koletzko B, Baker S, Cleghorn G, Neto UF, Gopalan S, Hernell O, et al. Global standard for the composition of infant formula: recommendations of an ESPGHAN coordinated international expert group. J Pediatr Gastroenterol Nutr 2005;41:584-599.

19. Simmer K, Patole S. Longchain polyunsaturated fatty acid supplementation in preterm infants. Cohrane Review. The Cohrane Library. Issue 3. Chichester: Wiley; 2004.

20. Fewtrell MS, Abbott RA, Kennedy K, Singhal A, Morley R, Caine E, et al. Randomized, double-blind trial of longchain polyunsaturated fatty acid supplementation with fish oil and borage oil in preterm infants. J Pediatr 2004;144: 471-479.

21. Clandinin M, VanAerde J, Antonson D, Lim M, Stevens D, Merkel K, et al. Formulas with docosahexaenoic acid (DHA) and arachidonic acid (AA) promote better growth and development scores in very-low-birth-weight infants (VLBW). Pediatr Res 2002;51:187A-188A. 22. Simmer K. Longchain polyunsaturated fatty acid supplementation in infants born at term. Cochrane Review. The Cochrane Library. Issue 4. Oxford: Update Software; 2004.

23. SanGiovanni JP, Berkey CS, Dwyer JT, Colditz GA. Dietary essential fatty acids, long-chain polyunsaturated fatty acids, and visual resolution acuity in healthy fullterm infants: a systematic review. Early Hum Dev 2000;57:165-188.

24. Auestad N, Scott DT, Janowsky JS, Jacobsen C, Carroll RE, Montalto MB, et al. Visual, cognitive, and language assessments at 39 months: a follow-up study of children fed formulas containing long-chain polyunsaturated fatty acids to 1 year of age. Pediatrics 2003;112:e177-183.

25. Fewtrell MS. Long-Chain Polyunsaturated Fatty Acids in Early Life: Effects on Multiple Health Outcomes. Lucas A, Sampson HA, editors. Primary Prevention by Nutrition Intervention in Infancy and Childhood. Nestlé Nutr Workshop Ser Pediatr Program. Nestec Ltd., Vevey/S Karger AG, Basel, 2006, vol 57. p. 203-221.

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·121

121

¢È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜

26. Souba WW. Intestinal glutamine metabolism and nutrition. J Nutr Biochem 1993;4:2-9.

27. Neu J, De Marco V, Weiss M.Glutamine supplementation in low-birth-weight infants: mechanisms of action. J Parenter Enteral Nutr 1999;23:S49-S51.

28. Buchman AL. Glutamine: commercially essential or conditionally essential? A critical appraisal of the human data.

Am J Clin Nutr 2001;74:25-32.

29. Tubman TR, Thompson SW, McGuire W. Glutamine supplementation to prevent morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2005;(1): CD001457.

30. Burrin DG, Shulman RJ, Langston C, Storm MC. Supplemental alanylglutamine, organ growth, and nitrogen metabolism in neonatal pigs fed by total parenteral nutrition.

JPEN J Parenter Enteral Nutr 1994;18:313-319.

31. Garlick PJ. Assessment of the safety of glutamine and other amino acids. J Nutr 2001;131:2556S-2561S. 32. Daly JM, Reynolds J, Thom A, Kinsley L, Dietrick-Gallagher M, Shou J, et al. Immune and metabolic effects of arginine in the surgical patient. Ann Surg 1988;208:512-523.

33. Efron D, Barbul A. Role of arginine in immunonutrition. J Gastroenterol 2000;35:20-23.

34. Becker RM, Wu G, Galanko JA, Chen W, Maynor AR, Bose CL, et al. Reduced serum amino acid concentrations in infants with necrotizing enterocolitis. J Pediatr 2000;137:785-793.

35. Vosatka RJ, Kashyap S, Trifiletti RR. Arginine deficiency accompanies persistent pulmonary hypertension of the newborn. Biol Neonate 1994;66:65-70.

36. Thiemermann C, Vane J. Inhibition of nitric oxide synthesis reduces the hypertension induced by bacterial lipopolysaccharides in the rat in vivo. Eur J Pharmacol 1990;182: 591-595.

37. Schmidt-Sommerfeld E, Penn D. Carnitine and total parenteral nutrition of the neonate. Biol Neonate 1990;58;81-88.

38. Cairns PA, Stalker DJ. Carnitine supplementation of parenterally fed neonates. Cochrane Database Syst Rev 2000; (4):CD000950.

39. Borum PR. Should carnitine be added to parenteral nutrition solutions? Nutr Clin Prac 2000;15:153-154.

40. Lönnerdal B, Hernell O. Iron, zinc, copper and selenium status of breast-fed infants and infants fed trace element fortified milk-based infant formula. Acta Paediatr 1994;83: 367-373.

41. Dewey KG, Domellöf M, Cohen RJ, Landa Rivera L, Hernell O, Lönnerdal B. Iron supplementation affects growth and morbidity of breast-fed infants: results of a randomized trial in Sweden and Honduras. J Nutr 2002;132:32493255.

42. Kunz C, Rudloff S, Baier W, Klein N, Strobel S. Oligosaccharides in human milk: structural, functional, and metabolic aspects. Annu Rev Nutr 2000;20:699-722.

43. Fanaro S, Chierici R, Guerrini P, Vigi V. Intestinal microflora in early infancy: composition and development.

Acta Paediatr Suppl 2003;91:48-55.

44. Gibson GR, Roberfroid MB. Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics. J Nutr 1995;125:1401-1412.

45. Veereman-Wauters G. Application of prebiotics in infant foods. Br J Nutr 2005;93:S57-S60.

46. Fanaro S, Boehm G, Garssen J, Knol J, Mosca F, Stahl B, et al. Galacto-oligosaccharides and long-chain fructo-oligo-

saccharides as prebiotics in infant formulas: a review. Acta Paediatr Suppl 2005;94:22-26.

47. Moro G, Minoli I, Mosca M, Fanaro S, Jelinek J, Stahl B, et al. Dosage-related bifidogenic effects of galacto- and fructooligosaccharides in formula-fed term infants. J Pediatr Gastroenterol Nutr 2002;34:291-295.

48. Knol J, Van der Linde EGM, Wells JCK, Böckler HM. An infant formula containing prebiotics changes the intestinal microflora of term infants. J Pediatr Gastroenterol Nutr 2003;36:566.

49. Boehm G, Lidestri M, Casetta P, Jelinek J, Negretti F, Stahl B, et al. Supplementation of a bovine milk formula with an oligosaccharide mixture increases counts of faecal bifidobacteria in preterm infants. Arch Dis Child Fetal Neonatal Ed 2002;86:F178-F181.

50. Kapiki A, Costalos C, Oikonomidou C, Triantafyllidou A, Loukatou E, Petrohilou V. The effect of a fructo-oligosaccharide supplemented formula on gut flora of preterm infants. Early Hum Dev 2007;83:335-339.

51. Moro G, Arslanoglu S, Stahl B, Jelinek J, Wahn U, Boehm G. A mixture of prebiotic oligosaccharides reduces the incidence of atopic dermatitis during the first six months of age. Arch Dis Child 2006;91:814-819.

52. Koletzko B, Baker S, Cleghorn G, Neto UF, Gopalan S, Hernell O, et al. Global standard for the composition of infant formula: recommendations of an ESPGHAN coordinated international expert group. J Pediatr Gastroenterol Nutr 2005;41:584-599.

53. Isolauri E, Sütas Y, Kankaanpää P, Arvilommi H, Salminen S. Probiotics: effects on immunity. Am J Clin Nutr 2001; 73:444S-450S. 54. Neu J, Bernstein H. Update on host defense and immunonutrients. Clin Perinatol 2002;29:41-64.

55. Majamaa H, Isolauri E, Saxelin M, Vesikari T. Lactic acid bacteria in the treatment of acute rotavirus gastroenteritis.

J Pediatr Gastroenterol Nutr 1995;20:333-338.

56. Arvola T, Laiho K, Torkkeli S, Mykkänen H, Salminen S, Maunula L, et al. Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study. Pediatrics 1999;104:e64.

57. Prescott SL, Macaubas C, Smallacombe T, Holt BJ, Sly PD, Holt PG. Development of allergen-specific T-cell memory in atopic and normal children. Lancet 1999;353:196-200.

58. Lin HC, Su BH, Chen AC, Lin TW, Tsai CH, Yeh TF, et al.

Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. Pediatrics 2005;115:1-4.

59. Bin-Nun A, Bromiker R, Wilschanski M, Kaplan M, Rudensky B, Caplan M. Oral probiotics prevent necrotizing enterocolitis in very low birth weight neonates. J Pediatr 2005;147:192-196.

60. Szajewska H, Setty M, Mrukowicz J, Guandalini S. Probiotics in gastrointestinal diseases in children: hard and notso-hard evidence of efficacy. J Pediatr Gastroenterol Nutr 2006;42:454-475.

61. Yamashiro Y, Castaneda C, Davidson G, Gibson G, Penna FJ, Mack D, et al. Biotherapeutic and nutraceutical agents:Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2004;39:S596-S600.

62. Rastall RA, Maitin V. Prebiotics and synbiotics: towards the next generation. Cur Opin Biotechnol 2002;13:490-496. ¶·È‰È·ÙÚÈ΋ 2008;71:116-122

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·122

122

Ã. ∫ÒÛÙ·ÏÔ˜

63. Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ 1998;317:1481-1487.

64. Hack M, Schluchter M, Cartar L, Rahman M, Cuttler L, Borawski E. Growth of very low birth weight infants to age 20 years. Pediatrics 2003;112:e30-38.

65. Dusick AM, Poindexter BB, Ehrenkranz RA, Lemons JA. Growth failure in the preterm infant: can we catch up?

Semin Perinatol 2003;27:302-310.

66. Latal-Hajnal B, von Siebenthal K, Kovari H, Bucher HU, Largo RH. Postnatal growth in VLBW infants: significant association with neurodevelopmental outcome. J Pediatr 2003;143:163-170.

Paediatriki 2008;71:116-122

67. Hack M, Weissman B, Borawski-Clark E. Catch-up growth during childhood among very low-birth-weight children.

Acta Pediatr Adolesc Med 1996;150:1122-1129.

68. Barker DJ, Eriksson JG, Forsén T, Osmond C. Fetal origins of adult disease: strength of effects and biological basis. Int J Epidemiol 2002;31:1235-1239.

69. ∂hrenkranz RA. Cohrane Database Syst Rev 2005;15; CD004696.

70. ESPGHAN Committee on Nutrition, Aggett PJ, Agostoni C, Axelsson I, De Curtis M, Goulet O, et al. Feeding preterm infants after hospital discharge: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006;42:596-603.

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123

∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ E. ∫Ô‡ÛÙ·, ∞. ¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘† ¶ÂÚ›ÏË„Ë: ª¤¯ÚÈ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980, Ë ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) ›¯Â ¯ÚËÛÈÌÔÔÈËı› ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙË ıÂÚ·›· ·È‰ÈÒÓ Ì ÛÔ‚·Ú‹ ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÊÂÈÏfiÌÂÓË Û ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD). ∏ GHD ·ÊÔÚ¿ Û˘Ó‰˘·ÛÌfi ÎÏÈÓÈÎÒÓ, ·ÎÙÈÓÔÏÔÁÈÎÒÓ, ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÔÚÌÔÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. ∏ ÂÈÏÔÁ‹ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ, ÛÙ· ÔÔ›· ı· Á›ÓÔ˘Ó ‰È·ÁÓˆÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¤ÎÎÚÈÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ÚÔ¸Ôı¤ÙÂÈ ÙË ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Î·È Î˘Ú›ˆ˜ ÙÔ˘ ‰È·ÁÚ¿ÌÌ·ÙÔ˜ ·‡ÍËÛ˘. ∏ ıÂÚ·›· Ì G∏ ÛÙ· ·È‰È¿ Ì GHD Ô‰ËÁ› Û ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È Â›Ó·È ‰˘Ó·Ùfi Ó· ÊÙ¿ÛÔ˘Ó ÛÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Â¿Ó Ë ıÂÚ·›· ·Ú¯›ÛÂÈ ÂÁη›Úˆ˜. E›Û˘, ÂÎÙfi˜ ·fi ÙÔ ‡„Ô˜, Ë GH ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi, ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· Î·È ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ·ÚÂÓ¤ÚÁÂȘ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 20 ÂÙÒÓ, ÔÈ ÂӉ›ÍÂȘ ¤¯Ô˘Ó ÂÂÎÙ·ı› Î·È ¤¯ÂÈ ÂÁÎÚÈı› Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÛÙ· ÎÔÚ›ÙÛÈ· Ì ۇӉÚÔÌÔ Turner Î·È Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È Û‡Ó‰ÚÔÌÔ Prader-Willi. ™ÙȘ ∏¶∞ Î·È ÙȘ ¯ÒÚ˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ ¤¯ÂÈ ÂÁÎÚÈı› Ë ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Û ·È‰È¿ ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË GH Û ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ¤¯ÂÈ ÂÁÎÚÈı› ÌfiÓÔ ÛÙȘ ∏¶∞. ∏ ıÂÚ·›· fï˜ ÛÙ· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ¤¯ÂÈ ÂÁÎÚÈı› ÛÙË ¯ÒÚ· Ì·˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ÂÂÎÙ·ı› Ë ¯Ú‹ÛË Ù˘ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ Î·È ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ GHD. ∏ ıÂÚ·›· Ì GH Â›Ó·È ÌÈ· ·ÎÚÈ‚‹ ıÂÚ·›· Î·È ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·.

∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó· AÏÏËÏÔÁÚ·Ê›·: ∂ϤÓË ∫Ô‡ÛÙ· lkousta@otenet.gr ™. ∞Ú‚·ÓÈÙ¿ÎË 6 ∆.∫. 491 00, ∫¤Ú΢ڷ

§¤ÍÂȘ ÎÏÂȉȿ: ∞˘ÍËÙÈ΋ ÔÚÌfiÓË, ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Û‡Ó‰ÚÔÌÔ ∆urner, Û‡Ó‰ÚÔÌÔ Prader-Willi, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·.

Indications for administering growth hormone to children and adolescents ∂. Kousta, A. Papathanassiou, C. Hadjiathanassiou† Abstract: Recombinant growth hormone (GH) was used exclusively for the treatment of children with severe growth retardation due to GH deficiency (GHD) up until the end of the 1980’s. GHD is characterized by a combination of clinical, radiological, metabolic and hormonal abnormalities. The selection of cases for whom there is a need to proceed to stimulation tests requires accurate auxological data and correct interpretation of the growth curve. GH treatment in children with GHD leads to acceleration of growth velocity and, if treatment is started early enough, to a final height within the normal range. Treatment with GH improves not only the height, but also body composition, by decreasing fat mass and increasing bone density, without significant side effects. During the last 20 years, the indications for treatment with GH have been expanded and its use has been approved for girls with Turner syndrome and for children with chronic renal failure and Prader-Willi syndrome. In the USA and some countries of the EU, GH treatment is approved for children born small for gestational age. Treatment for idiopathic short stature has been approved only in the USA. These indications have not been approved in Greece. Over the last few years its use has been extended to adolescents and adults with severe GH deficiency. GH treatment is an expensive therapy and regular monitoring of its use needs to be made in specialised centres.

Department of Endocrinology, “P. & A. Kyriakou” Children’s Hospital, Athens Correspondence: Eleni Kousta lkousta@otenet.gr 6, Sp. ∞rvanitaki St., 491 00, Corfu, Greece

Key words: Growth hormone, growth hormone deficiency, Tyrner syndrome, Prader-Willi syndrome, chronic renal failure.

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E. ∫Ô‡ÛÙ· Î·È Û˘Ó.

ÚÔÂÚ¯fiÌÂÓË ·fi ·ÓıÚÒÈÓÔ ÈÛÙfi ˘fiÊ˘Û˘, Ë ¯Ú‹ÛË Ù˘ ÔÔ›·˜ fï˜ ‰È·ÎfiËΠÏfiÁˆ Ù˘ ·ÈÙÈÔÏÔÁÈ΋˜ Û˘Û¯¤ÙÈÛ‹˜ Ù˘ Ì ÙË ÓfiÛÔ Creutzfeldt-Jakob, ÌÈ· Û¿ÓÈ· ı·Ó·ÙËÊfiÚÔ, ÛÔÁÁÔÂȉ‹ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ∏ ·Ú·ÁˆÁ‹ ‚ÈÔÛ˘ÓıÂÙÈ΋˜ GH Ô‰‹ÁËÛ ÛÙËÓ Â˘Ú‡ÙÂÚË ¯Ú‹ÛË Ù˘ GH. M¤¯ÚÈ Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980, Ë GH ¯ÚËÛÈÌÔÔÈ‹ıËΠ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙË ıÂÚ·›· ·È‰ÈÒÓ Ì ÛÔ‚·Ú‹ ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘, ÔÊÂÈÏfiÌÂÓË Û GHD. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 20 ÂÙÒÓ, ÔÈ ÂӉ›ÍÂȘ ¤¯Ô˘Ó ÂÂÎÙ·ı› Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ Û‡Ó‰ÚÔÌÔ Turner (1), ÙË ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (2) Î·È ÙÔ Û‡Ó‰ÚÔÌÔ Prader-Willi (3). H GH ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·ÎfiÌË Û ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ (Small for Gestational Age - SGA) (4). ∏ ¤Ó‰ÂÈÍË ·˘Ù‹ ¤¯ÂÈ ÂÁÎÚÈı› Û ∞ÌÂÚÈ΋ Î·È ∂˘ÚÒË Î·È ÛÙËÓ ∂ÏÏ¿‰· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔÓ ∂√º Î·È ÙÔ ∫∂™À Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ˘ÔÁÚ·Ê‹˜. ∞ÎfiÌ·, Ë GH ¤¯ÂÈ ¯ÔÚËÁËı› Û ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (Idiopathic Short Stature - ISS) (5). ™ÙȘ ∏¶∞ ¤¯ÂÈ ‰Ôı› ¤ÁÎÚÈÛË ÌfiÓÔ Û ¤Ó· Û··ÛÌ· Î·È ÚÔ˜ ÙÔ ·ÚfiÓ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ ÛÙ· ·È‰È¿ ·˘Ù¿ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ ÛÙ· Ï·›ÛÈ· ÂÚ¢ÓËÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ. ª¤¯ÚÈ ÚfiÛÊ·Ù·, ÛÙ· ·È‰È¿ Ì GHD ÁÈÓfiÙ·Ó ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ÂÚÈfi‰Ô˘ ·Ó¿Ù˘Í˘. ∆ÒÚ·, Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Â·Ó¤ÏÂÁ¯Ô˜ Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ GH ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂÚ·›·˜ ηٿ ÙË Û‡ÁÎÏÂÈÛË ÙˆÓ ÂÈʇÛˆÓ, ȉȷÈÙ¤Úˆ˜ ÙˆÓ ·È‰ÈÒÓ Ì Ôχ ¯·ÌËϤ˜ ÙÈ̤˜ GH Î·È Ì ·ıÔÏÔÁÈ΋ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ˘fiÊ˘Û˘ (ÌÈÎÚfi ‡„Ô˜, ¤ÎÙÔË ˘fiÊ˘ÛË) ‹ ÈÛÙÔÚÈÎfi fiÁÎÔ˘ ‹ ·ÎÙÈÓÔ‚ÔÏ›·˜. ™Â fiÛÔ˘˜ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ¯·ÌËÏ‹˜ ¤ÎÎÚÈÛ˘ GH Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙˆÓ ÂÓËϛΈÓ, Û˘ÓÈÛÙ¿Ù·È Û˘Ó¤¯ÈÛË Ù˘ ıÂÚ·›·˜ Ì ‰ÔÛÔÏÔÁ›· ÂÓËϛΈÓ, ÏfiÁˆ ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ÂÈÙÒÛÂˆÓ Ù˘ ÛÔ‚·Ú‹˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹. ∫¿ÔÈÔÈ ÂÚ¢ÓËÙ¤˜ Û˘ÓÈÛÙÔ‡Ó ÙË Û˘Ó¤¯ÈÛË Ù˘ ıÂÚ·›·˜ ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ÁÈ· οÔÈÔ ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙË Û‡ÁÎÏÂÈÛË ÙˆÓ ÂÈʇÛˆÓ, ÏfiÁˆ Ù˘ ıÂÙÈ΋˜ Â›‰Ú·Û˘ ÛÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (6). ∏ ıÂÚ·›· Ì GH ¯ÚÂÈ¿˙ÂÙ·È Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·. ∆Ô ÎfiÛÙÔ˜ Ù˘ ıÂÚ·›·˜ Â›Ó·È ÌÂÁ¿ÏÔ, ȉȷ›ÙÂÚ· ÛÙ· ·È‰È¿ Ì ۇӉÚÔÌÔ Turner, ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È È‰ÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, Ù· ÔÔ›· ¯ÚÂÈ¿˙ÔÓÙ·È ÌÂÁ·Ï‡ÙÂÚË ‰fiÛË GH. ∂ÈϤÔÓ, ÚÈÓ ·ÔÊ·ÛÈÛÙ› Ë ıÂÚ·›· Ì GH, Ú¤ÂÈ ¤Ú· ·fi ÙËÓ Â˘ÓÔ˚΋ Â›‰Ú·ÛË Ù˘ ıÂÚ·›·˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Ó· ÏËÊıÔ‡Ó ˘fi„Ë „˘¯ÔÎÔÈÓˆÓÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È Ë Ù˘¯fiÓ ·ÚÓËÙÈ΋ Â›ÙˆÛË Ù˘ ıÂÚ·›·˜ ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·fi ÙȘ ηıËÌÂÚÈÓ¤˜ ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ. ¶·ÚfiÏÔ Ô˘ ÙÔ ¯·Paediatriki 2008;71:123-127

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· GHD ñ ™ËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ηı˘ÛÙ¤ÚËÛË ‡„Ô˘˜ (<3 SD) ñ ⁄„Ô˜ <1,5 SD οو ·fi ÙÔ ‡„Ô˜-ÛÙfi¯Ô ñ ⁄„Ô˜ <-2 SD Î·È Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ <1 SD οو ·fi ÙÔ Ì¤ÛÔ fiÚÔ ÙÔÓ ÚÔËÁÔ‡ÌÂÓÔ ¯ÚfiÓÔ (‹ -0,5 SD ÁÈ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ) ñ ™Â ·È‰È¿ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡„Ô˘˜, ÙÒÛË Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ <1,5 SD Â› 2 ¯ÚfiÓÈ· ñ ™ËÌ›· ÂÓ‰ÔÎÚ·Óȷ΋˜ ‚Ï¿‚˘ ‹ ÔÏÏ·Ï‹˜ ˘ÔÊ˘Ûȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ñ ™˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· ¤ÏÏÂȄ˘ GH ÛÙÔ ÓÂÔÁÓfi (˘ÔÁÏ˘Î·ÈÌ›·, ÌÈÎÚfi ¤Ô˜)

ÌËÏfi ·Ó¿ÛÙËÌ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÌÔÚ› Ó· ÂÈ‚·Ú‡ÓÂÈ „˘¯ÔÏÔÁÈο οÔÈ· ·È‰È¿, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› Î·È ‰ÂÓ Â›Ó·È ·fi fiÏÔ˘˜ ·Ô‰ÂÎÙ‹ Ë Â˘ÓÔ˚΋ Â›‰Ú·ÛË Ù˘ ıÂÚ·›·˜ Ì GH ÛÙÔÓ „˘¯ÈÛÌfi ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ.

∞ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD) ∏ GHD ÛÙ· ·È‰È¿ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÔ Û˘Ó‰˘·ÛÌfi ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Ù· ÔÔ›· ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Û ÌÈÎÚfi ‹ ÌÂÁ¿ÏÔ ‚·ıÌfi ·Ó¿ÏÔÁ· Ì ÙËÓ Ï‹ÚË ‹ ÌÂÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ‹ ÌË ¤ÎÎÚÈÛË ‰Ú·ÛÙÈ΋˜ GH ‹ ÂÏ¿ÙÙˆÛË ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (IGFs) (7). ∏ ‰È¿ÁÓˆÛË Ù˘ GHD ÛÙËÓ ·È‰È΋ ËÏÈΛ· Â›Ó·È ¤Ó· ‰‡ÛÎÔÏÔ ı¤Ì·, ‰ÈfiÙÈ Ë ¤ÎÎÚÈÛË Ù˘ GH ÛÙ· ·È‰È¿ ηχÙÂÈ ¤Ó· Û˘Ó¯¤˜ Ê¿ÛÌ·, ÙÔ ÔÔ›Ô ÂÎÙ›ÓÂÙ·È ·fi Ù· fiÚÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ¤ˆ˜ ÙË Ì¤ÙÚÈ· ·ÓÂ¿ÚÎÂÈ· ¤ÎÎÚÈÛ˘ (ÌÂÌÔӈ̤ÓË GHD) ̤¯ÚÈ ÙË ÛÔ‚·Ú‹ ·ÓÂ¿ÚÎÂÈ· (fiˆ˜ Û˘Ì‚·›ÓÂÈ Û ÔÏÏ·Ï‹ ˘ÔÊ˘Ûȷ΋ ·ÓÂ¿ÚÎÂÈ· ‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ ˘Ôı·Ï·ÌÈÎÔ‡ ÂÎÏ˘ÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·) ‹ Ï‹ÚË ¤ÏÏÂÈ„Ë (·¿ÏÂÈ„Ë ÁÔÓȉ›Ô˘ Ù˘ GH). ™˘Ó‹ıˆ˜, ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘ÛÎÔÏ›· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ ‘ÎÏ·ÛÈ΋˜’, Ï‹ÚÔ˘˜ GHD, fï˜ Ë ·Ó·ÁÓÒÚÈÛË Ù˘ ÔÌ¿‰·˜ ÙˆÓ ·È‰ÈÒÓ, Ù· ÔÔ›·, ÂÓÒ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÚȷ΋ ‰È·Ù·Ú·¯‹ ÛÙËÓ ¤ÎÎÚÈÛË Ù˘ GH, ı· ÂˆÊÂÏËıÔ‡Ó ·fi ÙË ¯ÔÚ‹ÁËÛ‹ Ù˘, ·Ú·Ì¤ÓÂÈ ÌÈ· ÚfiÎÏËÛË (8,9). ¶ÚfiÛÊ·Ù·, ηıÈÂÚÒıËÎ·Ó ÎÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ‰ÈÂıÓ‹ ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË GHD, Ù· ÔÔ›· ‚·Û›˙ÔÓÙ·È Û ·ÍÈÔÏfiÁËÛË Ù˘ ·‡ÍËÛ˘, ηıÒ˜ Î·È ÙÔ˘ ¿ÍÔÓ· GH-IGF. ∆· ÎÏÈÓÈο Î·È ·˘ÍÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· ¤ÏÏÂȄ˘ GH ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ GH ÂÎÎÚ›ÓÂÙ·È Î·Ù¿ ÒÛÂȘ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘. ∂Ô̤ӈ˜, Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ GH ÛÙÔ Ï¿ÛÌ·, ¯ˆÚ›˜ Ó· ÚÔËÁËı› ‰È¤ÁÂÚÛË, ‰ÂÓ ¤¯ÂÈ ‰È·ÁÓˆÛÙÈ΋ ·Í›· Î·È ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈ›ٷÈ. °È· ÙË ‰È¿ÁÓˆÛË Ù˘ GHD ··ÈÙÂ›Ù·È Ì¤ÁÈÛÙË ·ÓÙ·fiÎÚÈÛË GH (peak) οو ·fi Ù· fiÚÈ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ (GH <10 ng/ml) Û ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘. ™ÎÔfi˜ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ Â›Ó·È Ó·

Pediatri Mar-Apr 08

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∂Ӊ›ÍÂȘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘

Û˘ÌÏËÚÒÛÔ˘Ó ÙËÓ ÎÏÈÓÈ΋ ˘Ô„›· Ù˘ GHD Û ٤ÙÔÈÔ ‚·ıÌfi, ÒÛÙ ӷ ÌÂȈıÔ‡Ó ÛÙÔ ÂÏ¿¯ÈÛÙÔ „¢‰Ò˜ ıÂÙÈΤ˜ ‹ „¢‰Ò˜ ·ÚÓËÙÈΤ˜ ‰È·ÁÓÒÛÂȘ (10). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ IGF-1, Â¿Ó ¤¯Ô˘Ó ·ÔÎÏÂÈÛı› ¿ÏϘ ·Èٛ˜ (Ë·ÙÔ¿ıÂÈ·, ¯ÚfiÓÈ· ·Ó·ÈÌ›·, Î.Ï.), ‚ÔËı¿ ÛÙË ‰È¿ÁÓˆÛË Û ·È‰› Ì ÈÛÙÔÚÈÎfi Î·È Î·Ì‡ÏË ·Ó¿Ù˘Í˘ Ô˘ ı¤ÙÔ˘Ó ÙËÓ ˘Ô„›· GHD. ¶ÚÔËÁÔ˘Ì¤Óˆ˜, Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛıÔ‡Ó Î·Ù·ÛÙ¿ÛÂȘ, fiˆ˜ Ô ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, ¯ÚfiÓÈ· Û˘ÛÙËÌ·ÙÈο ÓÔÛ‹Ì·Ù·, ÙÔ Û‡Ó‰ÚÔÌÔ Turner Î·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ™ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ GHD ÛÙ· ·È‰È¿ ÌÔÚ› Â›Û˘ Ó· ‚ÔËı‹ÛÂÈ Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ù˘ ˘fiÊ˘Û˘, Ì ÙËÓ ÔÔ›· ÌÔÚ› Ó· ‰È·ÁÓˆÛı› Ë ˘ÔÏ·Û›· ÙÔ˘ ÚÔÛı›Ô˘ ÏÔ‚Ô‡ Ù˘ ˘fiÊ˘Û˘, Ë ÂÎÙÔ›· ÙÔ˘ ÔÈÛı›Ô˘ ÏÔ‚Ô‡, Ë ·ÁÂÓÂÛ›· ÙÔ˘ Ì›Û¯Ô˘, ηıÒ˜ Î·È ¿ÏϘ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∏ ·ÍÈÔÈÛÙ›· ÙˆÓ Ê·ÚÌ·ÎÔÏÔÁÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ‰È¤ÁÂÚÛ˘ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ¤ÎÎÚÈÛ˘ GH ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ (11). ™ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ ÔÏ˘ÎÂÓÙÚÈÎÒÓ ÌÂÏÂÙÒÓ Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¯ÔÚËÁ‹ıËΠıÂÚ·›· Ì GH, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ôχ Ï›Á˜ ·ÍÈfiÈÛÙ˜ ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ Î·È Ó· Á›ÓÂÈ ÚÔÛ¿ıÂÈ· Ó· ηıÔÚÈÛıÔ‡Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÁÈ· ÙȘ ‰È¿ÊÔÚ˜ ËÏÈ˘ (12,13).

H ÂÙ·ÈÚ›· ¤Ú¢ӷ˜ GH (Growth Hormone Research Society) ¤¯ÂÈ ÂΉÒÛÂÈ Î·Ù¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È ÙË ıÂÚ·›· Ù˘ GHD ÛÙ· ·È‰È¿ (14). ŒÓ· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÔÂÓ‰ÔÎÚÈÓÔÏfiÁˆÓ ·ÎÔÏÔ˘ı› ·˘Ù¤˜ ÙȘ Ô‰ËÁ›Â˜, ·ÚfiÙÈ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ·ÔÎÏ›ÛÂȘ ÛÙȘ ‰È¿ÊÔÚ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ (15,16). ∏ ıÂÚ·›· Ì G∏ Ô‰ËÁ› Û ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηÈ, Â¿Ó Ë ıÂÚ·›· ·Ú¯›ÛÂÈ ÂÁη›Úˆ˜, Û ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. ÃÚÂÈ¿˙ÂÙ·È ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË Ù˘ ‰fiÛ˘ Ì ÙËÓ ËÏÈΛ·, ÒÛÙ ÙÔ ·È‰› Ó· ‚Ú›ÛÎÂÙ·È ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· Ù˘ ηÌ‡Ï˘ ·‡ÍËÛ˘ Î·È Ó· ÂÈÙ‡¯ÂÈ ÙÔ ÁÂÓÂÙÈÎÒ˜ ·Ó·ÌÂÓfiÌÂÓÔ ·Ó¿ÛÙËÌ·. ∏ ıÂÚ·›· Ì GH, ¤Ú· ·fi ÙÔ ‡„Ô˜, ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË (body composition), ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi, ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· Î·È ·˘Í¿ÓÔÓÙ·˜ ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·. Œ¯ÂÈ Â›Û˘ ¢ÂÚÁÂÙÈΤ˜ ÌÂÙ·‚ÔÏÈΤ˜ ÂȉڿÛÂȘ: ÌÂÈÒÓÂÈ ÙÔ ÏfiÁÔ Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÚÔ˜ ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË. ∏ ‰fiÛË Ù˘ ıÂÚ·›·˜ Î˘Ì·›ÓÂÙ·È ·fi 0,15 ¤ˆ˜ 0,30 mg/Kg/‚‰ÔÌ¿‰·, Û ηıËÌÂÚÈÓ¤˜ ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ. ¶·ÚfiÏÔ Ô˘ Ë ıÂÚ·›· Ì GH Ô‰ËÁ› Û ·‡ÍËÛË ÙÔ˘ IGF-1, ÙÔ ÔÔ›Ô ¤¯ÂÈ ÌÈÙÔÁfiÓÔ ‰Ú¿ÛË, ‰ÂÓ ¤¯ÂÈ ·Ú·ÙËÚËı› ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ·Ó¿Ù˘ÍË Î·ÎÔ‹ıÂÈ·˜ ÛÙ· ·È‰È¿ Ô˘ ·›ÚÓÔ˘Ó ÙË ıÂÚ·-

›· (17). Œ¯Ô˘Ó ·Ó·ÊÂÚı› Û¿ÓÈ· ηÏÔ‹ı˘ ÂÓ‰ÔÎÚ·Óȷ΋ ˘¤ÚÙ·ÛË, ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·, ÂÈÊ˘ÛÈÔÏ›ÛıËÛË Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘, Âȉ›ӈÛË Ù˘ ÛÎÔÏ›ˆÛ˘ Î·È Á˘Ó·ÈÎÔÌ·ÛÙ›· (17).

™‡Ó‰ÚÔÌÔ Turner ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È 1/2.500 1/3.000 ÁÂÓÓ‹ÛÂȘ ÎÔÚÈÙÛÈÒÓ (1). T· ÎÔÚ›ÙÛÈ· ·˘Ù¿, ·Ú¿ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÂÓ‰ÔÁÂÓ‹ ¤ÎÎÚÈÛË GH, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, Ë ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ÔÔ›Ô˘ Â›Ó·È Èı·ÓfiÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋. ¢È¿ÊÔÚÔÈ Ì˯·ÓÈÛÌÔ› ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›, fiˆ˜: ÂÏ·Ùو̤ÓË ‚ÈÔ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ GH, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ¿ÍÔÓ· IGF, ÌÔÓÔۈ̛· ÙÔ˘ Ã-¯ÚˆÌÔÛÒÌ·ÙÔ˜ (·Ô˘Û›· ÙÔ˘ ÁÔÓȉ›Ô˘ SHOX, Ô˘ ηıÔÚ›˙ÂÈ ÙÔ ·Ó¿ÛÙËÌ· Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ Ã) Î·È Èı·ÓfiÓ Î·È Ë Ï‹Ú˘ ·ÓÂ¿ÚÎÂÈ· ÔÈÛÙÚÔÁfiÓˆÓ Î·Ù¿ ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· (1,18). ∂Âȉ‹ ‰ÂÓ ˘¿Ú¯ÂÈ GHD, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÔÈ ·ÛıÂÓ›˜ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË G∏. ∆Ô ‡„Ô˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ۇӉÚÔÌÔ Turner Ú¤ÂÈ Ó· ÚÔ‚¿ÏÏÂÙ·È ÛÙ· ÂȉÈο ‰È·ÁÚ¿ÌÌ·Ù· ·‡ÍËÛ˘ (19). ∏ ¯ÔÚ‹ÁËÛË GH Û ·È‰È¿ Ô˘ ¿Ú¯ÈÛ·Ó ÙË ıÂÚ·›· ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-13 ÂÙÒÓ Ô‰ËÁ› Û ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ·fi 3 ¤ˆ˜ 12 cm (1,20,21). H ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂÚ·›· Ì GH, fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, Â›Ó·È Î·Ï‡ÙÂÚË fiÛÔ ÓˆÚ›ÙÂÚ· ·Ú¯›˙ÂÈ Ë ıÂÚ·›· (20,22). ∏ ıÂÚ·›· Ì GH Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ Ôχ ηϿ ·ÓÂÎÙ‹, Ë Î·ÏÔ‹ı˘ ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË Î·È Ë ‹È· ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Ô˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Â›Ó·È ·Ó·ÛÙÚ¤„È̘, ·ÏÏ¿ Ë ÂÌÊ¿ÓÈÛË Ì¤Û˘ ˆÙ›Ùȉ·˜ Î·È Ë ·Ó¿ÁÎË ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ (ÛÙ· ·˘ÙÈ¿, ÙË Ì‡ÙË Î·È ÙÔ Ï¿Ú˘ÁÁ·) ·Ó·Ê¤ÚÂÙ·È Û˘¯ÓfiÙÂÚË ÛÙ· ·È‰È¿ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· Ì GH (1,20). √È Ì·ÎÚÔÚfiıÂÛ̘ ÂÈÙÒÛÂȘ Ù˘ ıÂÚ·›·˜ Ì G∏, fiÛÔÓ ·ÊÔÚ¿ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· Î·È ÙÔ ÌÂÙ¤ÂÈÙ· ΛӉ˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ‰È·‚‹ÙË Ù‡Ô˘ 2 Û ÎÔÚ›ÙÛÈ· Ì ۇӉÚÔÌÔ Turner, ‰ÂÓ Â›Ó·È ·ÎfiÌ· Ï‹Úˆ˜ ÁÓˆÛÙ¤˜ (1). ÃÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÔ˘Ó ÂÚÈÛÛfiÙÂÚ˜ Ì·ÎÚÔÚfiıÂÛ̘ ÌÂϤÙ˜, Ì ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÁÈ· Ó· ÂÍ·¯ıÔ‡Ó ÔÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·. ∏ ÂÈÎÚ·ÙÔ‡Û· ¿Ô„Ë Â›Ó·È Ó· ¯ÔÚËÁÂ›Ù·È G∏ Û οı ·È‰› Ì ۇӉÚÔÌÔ Turner (1). ∏ Û˘Ó‹ı˘ ‰fiÛË Â›Ó·È 0,30-0,35 mg/Kg/‚‰ÔÌ¿‰·. ∏ ıÂÚ·›· Û˘Ó‰˘¿˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÔÈÛÙÚÔÁfiÓˆÓ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ. ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (á∞) ∆Ô ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ· ÛÙ· ·È‰È¿ Ì á∞. H ·ÈÙÈÔÏÔÁ›· ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È ·ÊÔÚ¿ ÙfiÛÔ ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ¿ÍÔÓ· GH-πGF-1, fiÛÔ Î·È ¶·È‰È·ÙÚÈ΋ 2008;71:123-127

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E. ∫Ô‡ÛÙ· Î·È Û˘Ó.

ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ‰È·Ù·Ú·¯¤˜ Ù˘ ıÚ¤„˘ (23,24). ∂Âȉ‹ ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÂ¿ÚÎÂÈ·, ·ÏÏ¿ ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ GH, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÔÈ ·ÛıÂÓ›˜ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘ ÚÈÓ ·fi ÙË ¯ÔÚ‹ÁËÛË G∏. ∏ ıÂÚ·›· Ì GH, Â¿Ó ‰Ôı› ÓˆÚ›˜, ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ Î·È ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÚÂÓ¤ÚÁÂȘ (2,23,24). ∏ ıÂÚ·›· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔ 1996 Î·È ¯ÔÚËÁÂ›Ù·È Û ·ÛıÂÓ›˜ Ì á∞ ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜ ÚÔÙÂÏÈÎÔ‡ Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ∏ ıÂÚ·›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û fiÛÔ ‰˘Ó·ÙfiÓ ÌÈÎÚfiÙÂÚË ËÏÈΛ·, ÂÊfiÛÔÓ Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÂÌÊ·Ó›˙ÂÈ ÙÒÛË, Ë ÔÔ›· ‰ÂÓ ÔÊ›ÏÂÙ·È Û ·ÓÂ·Ú΋ ıÚ¤„Ë ‹ ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ‰fiÛË Ù˘ GH ÛÙË Ã¡∞ Â›Ó·È 0,35 mg/Kg/‚‰ÔÌ¿‰·.

™‡Ó‰ÚÔÌÔ Prader-Willi ¶ÚfiÎÂÈÙ·È ÁÈ· Û¿ÓÈÔ ÁÂÓÂÙÈÎfi Û‡Ó‰ÚÔÌÔ (Û˘¯ÓfiÙËÙ· 1/10.000-15.000), ÙÔ ÔÔ›Ô ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÒÏÂÈ· Ù˘ ÁÔÓȉȷ΋˜ ¤ÎÊÚ·Û˘ Ù˘ ÂÚÈÔ¯‹˜ 15q11-q13 ÙÔ˘ ·ÙÚÈÎÔ‡ ·ÏÏËÏfiÌÔÚÊÔ˘ ·ÔÙ˘ˆÌ¤ÓÔ˘ ÁÔÓȉ›Ô˘ (imprinted gene) Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÂÚÊ·Á›·, ·¯˘Û·ÚΛ·, ˘ÔÁÔÓ·‰ÈÛÌfi, ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È GHD ÔÊÂÈÏfiÌÂÓË Û ˘Ôı·Ï·ÌÈ΋ ‰È·Ù·Ú·¯‹ (3,25). ∏ ıÂÚ·›· Ì GH ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘, ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Î·È ¤¯ÂÈ È‰È·›ÙÂÚ· ¢ÂÚÁÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË, ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙÔ ÏÈÒ‰Ë ÈÛÙfi Î·È ·˘Í¿ÓÔÓÙ·˜ ÙË Ì˘˚΋ Ì¿˙· (3,25). ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,25 mg/Kg/‚‰ÔÌ¿‰·. ¶ÚfiÛÊ·Ù· ·Ó·Ê¤ÚıËÎ·Ó ·ÈÊÓ›‰ÈÔÈ ı¿Ó·ÙÔÈ, ΢ڛˆ˜ ·fi ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ˘Ô·ÂÚÈÛÌfi Û ·È‰È¿ Ì ÙÔ Û‡Ó‰ÚÔÌÔ, Ù· ÔÔ›· ÂÏ¿Ì‚·Ó·Ó ıÂÚ·›· Ì GHØ ·ÚfiÏÔ Ô˘ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› Ë Û˘Û¯¤ÙÈÛË Ù˘ ıÂÚ·›·˜ Ì GH, ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÙ·È ÚÔÛÂÎÙÈÎfi˜ ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁÈÎfi˜ Î·È ·Ó·Ó¢ÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (26). ÕÏϘ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ¯ÔÚËÁÂ›Ù·È GH Û ·È‰È¿, ÔÈ Ôԛ˜ fï˜ ‰ÂÓ ¤¯Ô˘Ó ¿ÚÂÈ ¤ÁÎÚÈÛË ÛÙË ¯ÒÚ· Ì·˜ ¶·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÌÈÎÚfiۈ̷ ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ (Small for Gestational Age, SGA) ¶ÂÚ›Ô˘ 10% ÙˆÓ ·È‰ÈÒÓ Ì SGA (‚¿ÚÔ˜ ‹/Î·È Ì‹ÎÔ˜ <2 SD) ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ 2 ÚÒÙˆÓ ÂÙÒÓ Ù˘ ˙ˆ‹˜, Ì ·ÔÙ¤ÏÂÛÌ· ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È ¯·ÌËÏfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (ÂÚ›Ô˘ 1 SD οو ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘) (27). ™Â ·È‰È¿ 2-4 ÂÙÒÓ Ì SGA, Ù· ÔÔ›· ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÂÈÙ¿¯˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ Î·È ¤¯Ô˘Ó ‡„Ô˜ <-2,5 SD (‹ Û ·È‰È¿ Ì SGA ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 4 ÂÙÒÓ Ì ‡„Ô˜ <-2 SD), Û˘ÓÈÛÙ¿Ù·È Ó· Ï·Ì‚¿ÓÔ˘Ó ıÂÚ·›· Ì GH Paediatriki 2008;71:123-127

(27). ∏ ¯ÔÚ‹ÁËÛË GH ‚ÂÏÙÈÒÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ Î·È ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ (4). §fiÁˆ ÙˆÓ Â˘ÓÔ˚ÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ˆ˜ ÚÔ˜ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ıÂÚ·›·˜, ·Ó Î·È Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ, ¤¯ÂÈ ‹‰Ë ÂÁÎÚÈı› Ë ıÂÚ·›· Û ·˘Ù¿ Ù· ·È‰È¿ Û ∞ÌÂÚÈ΋ Î·È ∂˘ÚÒË Î·È ÛÙËÓ ∂ÏÏ¿‰· ¤¯ÂÈ ÂÁÎÚÈı› ·fi ÙÔÓ ∂√º Î·È ÙÔ ∫∂™À Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ˘ÔÁÚ·Ê‹˜. √È Ì·ÎÚÔÚfiıÂÛ̘, fï˜, ÌÂÙ·‚ÔÏÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ıÂÚ·›·˜ Ì GH, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ÙËÓ ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· Û ·˘Ù¿ Ù· ·È‰È¿, Â›Ó·È ·ÎfiÌË ˘fi ÌÂϤÙË. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,25 mg/Kg/‚‰ÔÌ¿‰·. ¶·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (Idiopathic Short Stature, ISS) T· ·È‰È¿ Ì ȉÈÔ·ı¤˜ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (<2,25 SD) Â›Ó·È ÌÈ· ÂÙÂÚÔÁÂÓ‹˜ ÔÌ¿‰·, Ù· ÂÚÈÛÛfiÙÂÚ· ·fi ·˘Ù¿ (·ÏÏ¿ fi¯È fiÏ·) ‰ÂÓ ÊÙ¿ÓÔ˘Ó ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ∏ ıÂÚ·›· Ì GH ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÂÈÙ·¯‡ÓÂÈ ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘, Â¿Ó ‰Ôı› ÓˆÚ›˜, ȉ›ˆ˜ ÛÙËÓ ·Ú¯‹ Ù˘ ıÂÚ·›·˜ Î·È ‚ÂÏÙÈÒÓÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ηٿ 4-7 cm, Û οÔȘ, ·ÏÏ¿ fi¯È Û fiϘ ÙȘ ÌÂϤÙ˜ (5). T· ̤¯ÚÈ Û‹ÌÂÚ· ·ÔÙÂϤÛÌ·Ù·, ·ÚfiÙÈ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ıÂÚ·›· Ì GH Â›Ó·È ·ÛÊ·Ï‹˜ ÛÙ· ·È‰È¿ ·˘Ù¿, Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (5). ™ÙȘ ∏¶∞ ¤¯ÂÈ ‰Ôı› ¤ÁÎÚÈÛË ÌfiÓÔ Û ¤Ó· Û··ÛÌ·. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, Ë ¯ÔÚ‹ÁËÛË GH ÛÙ· ·È‰È¿ ·˘Ù¿ Â›Ó·È ˘fi ÌÂϤÙË Î·È ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛÙ· Ï·›ÛÈ· ÂÚ¢ÓËÙÈÎÒÓ ÚˆÙÔÎfiÏψÓ. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË Â›Ó·È 0,30 mg/Kg/‚‰ÔÌ¿‰·. ÕÏϘ ÂÚÈÙÒÛÂȘ ¯ÔÚ‹ÁËÛ˘ GH H GH ¤¯ÂÈ Â›Û˘ ¯ÔÚËÁËı› Ì ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· Û ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ˘ÂÚÏ·Û›· ÂÈÓÂÊÚȉ›ˆÓ (28) Î·È Û ·È‰È¿ Ì ÈÓÔ΢ÛÙÈ΋ ÓfiÛÔ (29), Ë ¯Ú‹ÛË Ù˘, fï˜, Û ·˘Ù¿ Ù· ·È‰È¿ ·ÎfiÌË ÌÂÏÂٿٷÈ.

GHD Û ÂÓ‹ÏÈΘ ∞ÊÔÚ¿ ÂÚ›Ô˘ 200 ·ÛıÂÓ›˜ ·Ó¿ 1.000.000. ∏ ıÂÚ·›· ¯ÔÚËÁÂ›Ù·È Û ·ÛıÂÓ›˜ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÓÂ¿ÚÎÂÈ·, ‰ËÏ·‰‹ Ì ̤ÁÈÛÙË ·¿ÓÙËÛË GH ÛÙË ‰ÔÎÈÌ·Û›· ˘ÔÁÏ˘Î·ÈÌ›·˜, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÈÓÛÔ˘Ï›Ó˘ <3 ng/ml. ∏ ¤ÏÏÂÈ„Ë GH ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Ô‰ËÁ› Û ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ·, ÂÏ·Ùو̤ÓË ¿ÏÈÔ Ì¿˙· (lean body mass), ÂÏ·Ùو̤ÓË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, ·˘ÍË̤ÓË Î·Ú‰È·ÁÁÂȷ΋ ÓÔÛËÚfiÙËÙ· Î·È ÂËÚ·Ṳ̂ÓË ÔÈfiÙËÙ· ˙ˆ‹˜, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË GH ‚ÂÏÙÈÒÓÂÈ ÙË ÛˆÌ·ÙÈ΋ Û‡ÛÙ·ÛË Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ (30). ∏ ‰fiÛË Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î˘Ì·›ÓÂÙ·È ·fi 0,15-0,3 mg/Ë̤ڷ, Ì ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË, Ô˘ ηıÔÚ›˙ÂÙ·È ·fi Ù· Â›‰· ÙÔ˘ IGF-1 (30).

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BÈ‚ÏÈÔÁÚ·Ê›· 1. Sybert VP, McCauley E. Turner's syndrome. N Engl J Med 2004;351:1227-1238.

2. Vimalachandra D, Hodson EM, Willis NS, Craig JC, Cowell C, Knight JF. Growth hormone for children with chronic kidney disease. Cochrane Database Syst Rev 2006;3: CD003264.

3. Burman P, Ritzén EM, Lindgren AC. Endocrine dysfunction in Prader-Willi syndrome: a review with special reference to GH. Endocr Rev 2001;22:787-799.

4. Ong K, Beardsall K, de Zegher F. Growth hormone therapy in short children born small for gestational age. Early Hum Dev 2005;81:973-980.

5. Cuttler L. Safety and efficacy of growth hormone treatment for idiopathic short stature. J Clin Endocrinol Metab 2005; 90:5502-5504.

6. Saggese G, Baroncelli GI, Vanacore T, Fiore L, Ruggieri S, Federico G. Indications and strategies for continuing GH treatment during transition from late adolescence to early adulthood in patients with GH deficiency: the impact on bone mass. J Endocrinol Invest 2004;27:596-602.

7. Sizonenko ƒC, Clayton ƒE, Cohen ƒ, Hintz RL. Tanaka T, Laron Z. Diagnosis and management of growth hormone deficiency in childhood and adolescence. Part 1: diagnosis of growth hormone deficiency. Growth Horm IGF Res 2001;11:137-165.

8. Rosenfeld RG, Albertsson-Wikland K, Cassorla F, Frasier SD, Hasegawa Y, Hintz RL, et al. Diagnostic controversy: the diagnosis of childhood growth hormone deficiency revisited. J Clin Endocrinol Metab 1995;80:1532-1540.

9. Van den Broeck J, Arends N, Hokken-Koelega A. Growth response to recombinant human growth hormone (GH) in children with idiopathic growth retardation by level of maximum GH peak during GH stimulation tests. Horm Res 2000;53:267-273.

10. Hindmarsh PC, Swift PG. An assessment of growth hormone provocation tests. Arch Dis Child 1995;72:362-368.

11. Gandrud LM, Wilson DM. Is growth hormone stimulation testing in children still appropriate? Growth Horm IGF Res 2004;14:185-194.

12. Carel JC, Tresca JP, Letrait ª, Chaussain JL, Lebouc Y, Job JC, et al. Growth hormone testing for the diagnosis of growth hormone deficiency in childhood: a population register-based study. J Clin Endocrinol Metab 1997;82: 2117-2121.

13. Ghigo E, Bellone J, Aimaretti G, Bellone S, Loche S, Cappa M, et al. Reliability of provocative tests to assess growth hormone secretory status. Study in 472 normally growing children. J Clin Endocrinol Metab 1996;81:3323-3327.

14. Growth Hormone Research Society. Consensus guidelines for the diagnosis and treatment of growth hormone (GH) deficiency in childhood and adolescence: summary statement of the GH Research Society. GH Research Society. J Clin Endocrinol Metab 2000;85:3990-3993.

15. Frasier SD. Editorial: the diagnosis and treatment of childhood and adolescent growth hormone deficiency--consensus or confusion? J Clin Endocrinol Metab 2000;85:39883989.

16. Juul A, Bernasconi S, Clayton PE, Kiess W, DeMuinckKeizer Schrama S; Drugs and Therapeutics Committee of the European Society for Paediatric Endocrinology (ESPE). European audit of current practice in diagnosis and treatment of childhood growth hormone deficiency.

Horm Res 2002;58:233-241.

17. Bowlby DA, Rapaport R. Safety and efficacy of growth hormone therapy in childhood. Pediatr Endocrinol Rev 2004;2 Suppl 1:68-77.

18. Rao E, Weiss B, Fukami M, Rump A, Niesler B, Mertz A, et al. Pseudoautosomal deletions encompassing a novel homeobox gene cause growth failure in idiopathic short stature and Turner syndrome. Nat Genet 1997;16:54-63.

19. Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child 1985;60:932-935.

20. Stephure DK; Canadian Growth Hormone Advisory Committee. Impact of growth hormone supplementation on adult height in turner syndrome: results of the Canadian randomized controlled trial. J Clin Endocrinol Metab 2005;90:3360-3366.

21. Baxter L, Bryant J, Cave CB, Milne R. Recombinant growth hormone for children and adolescents with Turner syndrome. Cochrane Database Syst Rev 2007;(1):CD003887.

22. Ranke MB, Lindberg A, Ferrãandez Long as ã A, Darendeliler F, Albertsson-Wikland K, Dunger D, et al. Major determinants of height development in Turner syndrome (TS) patients treated with GH: analysis of 987 patients from KIGS. Pediatr Res 2007;61:105-110.

23. Mahan JD, Warady BA; the Consensus Committee. Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement. Pediatr Nephrol 2006;21:917-930.

24. Stefanidis CJ, Klaus G. Growth of prepubertal children on dialysis. Pediatr Nephrol. 2007;22:1251-1259.

25. Goldstone AP. Prader-Willi syndrome: advances in genetics, pathophysiology and treatment. Trends Endocrinol Metab 2004;15:12-20.

26. Eiholzer U. Deaths in children with Prader-Willi syndrome. A contribution to the debate about the safety of growth hormone treatment in children with PWS. Horm Res 2005;63:33-39.

27. Clayton PE, Cianfarani S, Czernichow P, Johannsson G, Rapaport R, Rogol A. Management of the child born small for gestational age through to adulthood: a consensus statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society. J Clin Endocrinol Metab 2007;92:804-810.

28. Gallagher MP, Levine LS, Oberfield SE. A review of the effects of therapy on growth and bone mineralization in children with congenital adrenal hyperplasia. Growth Horm IGF Res 2005;15 Suppl A:S26-30.

29. Hardin DS, Ferkol T, Ahn C, Dreimane D, Dyson M, Morse M, et al. A retrospective study of growth hormone use in adolescents with cystic fibrosis. Clin Endocrinol (Oxf) 2005;62:560-566.

30. Drake WM, Howell SJ, Monson JP, Shalet SM. Optimizing gh therapy in adults and children. Endocr Rev 2001;22: 425-450.

¶·È‰È·ÙÚÈ΋ 2008;71:123-127

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ORIGINAL ARTICLE

∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·È‰È¿ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ 1. °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °¶¡£ 2. ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, °ÂÓÈÎfi ¡ÔÛÔÎoÌÂ›Ô ∫ÈÏΛ˜ 3. ∞’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, πÔÎÚ¿ÙÂÈÔ °¶¡£ AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›Ó· ∫ÒÛÙ·, konstantinakosta@yahoo.gr °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °¶¡£

ª. ¶··‰ÔÔ‡ÏÔ˘1, ™. ¡ÙÔ˘Ì¿2, ∫. ∫›ÙÛÈÔ˜3, ¡. ∫·‰fiÁÏÔ˘3, ∫. ∫ÒÛÙ·1, π. ∆ÛÈÔ‡Ú˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Û ·È‰È¿ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GH) Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·Ó·Û˘Ó‰˘·Ṳ̂ÓË GH Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 72 ·È‰È¿ (25 ÚÔÂÊË‚Èο) Ì ÌÂÌÔӈ̤ÓË (61/72) ‹ Û˘Ó‰˘·Ṳ̂ÓË (11/72) ·ÓÂ¿ÚÎÂÈ· GH, Ô˘ ‰È·ÁÓÒÛÙËΠÌÂÙ¿ ·fi ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ GH Ì ‰ÔÎÈ̷ۛ˜ ‰È¤ÁÂÚÛ˘. ∆· ·È‰È¿ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì GH sc, 3, 6 ‹ 7 ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜. ¶ÚÔÛ‰ÈÔÚ›ÛÙËΠÁÈ· οı ·È‰› ÙÔ ‡„Ô˜-ÛÙfi¯Ô˜. ∫·Ù·ÁÚ¿ÊËÎ·Ó Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È ·ÎÔÏÔ‡ıˆ˜ ·Ó¿ ÂÍ¿ÌËÓÔ ÙÔ ‡„Ô˜ Û fiÚıÈ· ı¤ÛË, Ë ÔÛÙÈ΋ ËÏÈΛ·, Ô ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ·‡ÍËÛ˘ Î·È ÙÔ ÛÙ¿‰ÈÔ ÂÓ‹‚ˆÛ˘. ∞ÔÙÂϤÛÌ·Ù·: ∏ ‰È·ÊÔÚ¿ Ù˘ ̤Û˘ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÛÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜ Û ۯ¤ÛË Ì ٷ ÚÔ ·˘Ù‹˜ Â›‰· ‹Ù·Ó 1,3. ™ÙÔ ‡„Ô˜-ÛÙfi¯Ô ¤ÊÙ·Û·Ó 23 ·È‰È¿ (32%). À‹Ú¯Â ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙÔ ·Ú¯ÈÎfi ‡„Ô˜, ÙÔ ‡„Ô˜-ÛÙfi¯Ô Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ ·Ó¿ ‚‰ÔÌ¿‰·, ÂÓÒ ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂÚ·›·˜, ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂÚ·›·˜, ÙÔ Ê‡ÏÔ Î·È ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ıÂÚ·›·˜. ∆· ·È‰È¿ ÌÂ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÂ¿ÚÎÂÈ· ÔÚÌÔÓÒÓ Î¤Ú‰ÈÛ·Ó ÂÚÈÛÛfiÙÂÚÔ ‡„Ô˜ Ì ÙË ıÂÚ·›· Û ۯ¤ÛË Ì ÂΛӷ Ì ÌÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· GH. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯ÔÚ‹ÁËÛË GH ·ÔÙÂÏ› ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂÚ·›· ÁÈ· ·È‰È¿ Ì ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ÔÊÂÈÏfiÌÂÓÔ Û ·ÓÂ¿ÚÎÂÈ· ·˘Ù‹˜. ∆Ô ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÛÙ· ·È‰È¿ ·˘Ù¿ Ê·›ÓÂÙ·È ˆ˜ ηıÔÚ›˙ÂÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ ‡„Ô˜-ÛÙfi¯Ô Î·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ GH ·Ó¿ ‚‰ÔÌ¿‰·.

§¤ÍÂȘ ÎÏÂȉȿ: A˘ÍËÙÈ΋ ÔÚÌfiÓË, ‹‚Ë, Û˘Ó‰˘·Ṳ̂ÓË ·ÓÂ¿ÚÎÂÈ· ÔÚÌÔÓÒÓ, ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ‡„Ô˜-ÛÙfi¯Ô˜.

Final height of children with growth hormone deficiency who received replacement treatment 1. 3rd Paediatric Department, Aristotle University of Thessaloniki, Hippokration General Hospital of Thessaloniki 2. Paediatric Department, General Hospital of Kilkis 3. 1st Department of Internal Medicine, Hippokration General Hospital of Thessaloniki Correspondence: ∫onstantina Kosta, konstantinakosta@yahoo.gr 3rd Paediatric Department, Aristotle University of Thessaloniki, Hippokration General Hospital of Thessaloniki

M. Papadopoulou1, S. Douma2, K. Kitsios3, N. Kadoglou3, K. Kosta1, I. Tsiouris1 Abstract Background: The aim of the study was the evaluation of the final height of children with Growth Hormone (GH) deficiency treated with recombinant GH, and of the factors related to their final height.

Methods: Seventy two children (25 prepubertal) with isolated (61/72) or combined (11/72) GH deficiency, diagnosed after measurement of GH following stimulation tests with clonidin or insulin, were monitored. The children were treated with 3, 6 or 7 weekly subcutaneous injections of recombinant GH. The target height (TH) was calculated for each child. Height, bone age, growth velocity and pubertal stage were recorded at the beginning of treatment and every 6 months. Final height was defined as the height at the time of the complete fusion of the epiphyses observed in a plain X-ray of the hand and wrist.

Results: The difference in the SDS of the mean final height before and after GH treatment was 1.3. Twenty three children (32%) reached the TH. The final height was associated statistically with the initial height, the TH and the number of weekly injections, while no relationship was observed with the age at the beginning of treatment, the duration of treatment, the growth velocity during the first year of treatment or the sex of the child. Children with combined hormone deficiency gained more height than those with isolated GH deficiency, but they also had a greater TH. Conclusions: GH replacement therapy is beneficial for children with small height due to deficiency of the hormone. The final height in these children appears to be highly predictable by the TH and the number of GH injections given weekly.

Key words: Growth hormone, puberty, combined hormone deficiency, final height, target height.

Paediatriki 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·129

129

AÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘

∂ÈÛ·ÁˆÁ‹ ∏ ·ÓıÚÒÈÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) Â›Ó·È Ë Î‡ÚÈ· ‰Ú·ÛÙÈ΋ ÔÚÌfiÓË Ô˘ ÚÔ¿ÁÂÈ ÙËÓ ·‡ÍËÛË ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ȉ›ˆ˜ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ (1). ∏ GH Â›Ó·È ·Ó·‚ÔÏÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÚÔ¿ÁÂÈ ÙËÓ ·‡ÍËÛË fiÏˆÓ ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜. √È ‰Ú¿ÛÂȘ Ù˘ Â›Ó·È ·) ¿ÌÂÛ˜ ÌÂÙ·‚ÔÏÈΤ˜ Ô˘ ‰È¢ÎÔχÓÔ˘Ó ÙËÓ ·‡ÍËÛË ÙˆÓ Ì˘ÒÓ Î·È ÙËÓ ÂÍÔÈÎÔÓfiÌËÛË Ù˘ ÁÏ˘Îfi˙˘ Î·È ‚) ·˘ÍËÙÈΤ˜ ÛÙÔ ÛÎÂÏÂÙfi. ∏ ·‡ÍËÛË ÙÔ˘ ÛÎÂÏÂÙÔ‡ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÛÙȘ ÂÈʇÛÂȘ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ Î·È Ë Â›‰Ú·ÛË ·˘Ù‹ ‰È·ÎfiÙÂÙ·È Ì ÙË Û‡ÁÎÏÈÛË ÙˆÓ ÂÈʇÛˆÓ. ∏ GH ‰Ú· ÛÙÔ Û˘˙¢ÎÙÈÎfi ¯fiÓ‰ÚÔ, fiÔ˘ ‰ÈÂÁ›ÚÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ¯ÔÓ‰ÚÔ΢ÙÙ¿ÚˆÓ ·ÊÂÓfi˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÈÓÛÔ˘ÏÈÓoÌfiÚÊˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁÔÓÙˆÓ (IGF). √ ÈÓÛÔ˘ÏÈÓfiÌÔÚÊÔ˜ ·Ú¿ÁÔÓÙ·˜ π (IGF-1) ‰ÈÂÁ›ÚÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Î·È ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ¯ÔÓ‰ÚÔ΢ÙÙ¿ÚˆÓ. ∏ ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÂΉËÏÒÓÂÙ·È ˆ˜: ·) ¯·ÌËÏfi ·Ó¿ÛÙËÌ· (2,5 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ (SDS) οو ·fi ÙÔ Ì¤ÛÔ fiÚÔ ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ), ‚) ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÔÛÙÒÓ, Á) ¯·ÌËÏ‹ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ Î·È ‰) ¯·ÌËÏ‹ ¤ÎÎÚÈÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ‰È¤ÁÂÚÛ˘. ™Â ·È‰È¿ Ì ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, ¯ÔÚËÁÂ›Ù·È ıÂÚ·¢ÙÈο ‚ÈÔÛ˘ÓıÂÙÈ΋ GH Ô˘ ·Ú¿ÁÂÙ·È Ì ÙË Ì¤ıÔ‰Ô ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ DNA. ∏ ¯ÔÚ‹ÁËÛË Á›ÓÂÙ·È Ì ÙË ÌÔÚÊ‹ ˘Ô‰ÔÚ›ˆÓ ÂÓ¤ÛˆÓ. ∏ ‚ÈÔÛ˘ÓıÂÙÈ΋ GH ·Ú·Û΢¿ÛÙËΠ·Ú¯Èο ÙÔ 1979, ·ÏÏ¿ ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ·fi ÙÔ 1985, ÔfiÙÂ Î·È ·ÓÙÈηٿÛÙËÛ ÙËÓ و̷ÙÈ΋ ·˘ÍËÙÈ΋ ÔÚÌfiÓË Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·fi ÙÔ 1957. ∏ ıÂÚ·›· ·ÔÛÎÔ› ÛÙÔ Ó· ÂÈÙ¢¯ı› ÙÂÏÈÎfi ‡„Ô˜ ̤۷ ÛÙ· Ï·›ÛÈ· ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˘˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ˘ ÛÙÔ Ê‡ÏÔ. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Û ·È‰È¿ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ùfi. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 72 ·È‰È¿, 43 ·ÁfiÚÈ· Î·È 29 ÎÔÚ›ÙÛÈ·, Ì ¯·ÌËÏfi ·Ó¿ÛÙËÌ· Î·È ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Ô˘ ¤Ï·‚·Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH) ¯ÔÚËÁÔ‡ÌÂÓË ˘Ô‰fiÚÈ·. ∆· 61 ›¯·Ó ÌÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È Ù· 11 Û˘Ó‰˘·Ṳ̂ÓË. ∂ȉÈÎfiÙÂÚ·: 6 ·È‰È¿, 4 ·ÁfiÚÈ· Î·È 2 ÎÔÚ›ÙÛÈ·, ›¯·Ó ·ÓÂ¿ÚÎÂÈ· ı˘ÚÔ͛Ӣ (∆4), 1 ·ÁfiÚÈ Â›¯Â ·ÓÂ¿ÚÎÂÈ· ∆4 Î·È ÙÂÛÙÔÛÙÂÚfiÓ˘, 1 ÎÔÚ›ÙÛÈ Â›¯Â ·ÓÂ¿ÚÎÂÈ· ∆4 Î·È ÔÈÛÙÚÔÁfiÓˆÓ, 1 ·ÁfiÚÈ Â›¯Â ·ÓÂ¿ÚÎÂÈ· ∆4 Î·È ¿ÔÈÔ ‰È·‚‹ÙË Î·È 2 ÎÔÚ›ÙÛÈ· ·Ó˘ÔÊ˘ÛÈÛÌfi ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁËı¤ÓÙ˜ ÂÁÎÂÊ·ÏÈÎÔ‡˜ fiÁÎÔ˘˜. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ ‹Ù·Ó 11,6±2,9 ¤ÙË Î·È Î·Ù¿ ÙÔ ¤Ú·˜ ·˘Ù‹˜ 16,2±1,6. ∞ÓıÚˆÔÌÂÙÚÈΤ˜ ÌÂÙÚ‹ÛÂȘ Á›ÓÔÓÙ·Ó Ì ·Ó·ÛÙËÌfiÌÂÙÚÔ Harpenden

ÛÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È ·Ó¿ ÂÍ¿ÌËÓÔ Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ¿ Ù˘. ∏ ̤ÙÚËÛË ÙÔ˘ ‡„Ô˘˜ οı ·È‰ÈÔ‡ ÁÈÓfiÙ·Ó Û fiÚıÈ· ı¤ÛË Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÛËÌÂȈÓfiÙ·Ó ÛÙȘ ηÌ‡Ï˜ ·‡ÍËÛ˘ ÙˆÓ Tanner Î·È Whitehouse ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ (∂£). ¶ÚÔÛ‰ÈÔÚÈ˙fiÙ·Ó Ô ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ·‡ÍËÛ˘ (∂ƒ∞). √ ∂ƒ∞ ‹ height velocity Â›Ó·È Ë ‰È·ÊÔÚ¿ ÙÔ˘ ‡„Ô˘˜ Û ¤Ó· ¯ÚfiÓÔ. ¶ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ·fi ÙÔ ËÏ›ÎÔ Ù˘ ‰È·ÊÔÚ¿˜ ÙÔ˘ ‡„Ô˘˜ ·Ó¿ÌÂÛ· Û ‰‡Ô ÌÂÙÚ‹ÛÂȘ ‰È· ÙÔ˘ ¯ÚfiÓÔ˘ Ô˘ ÌÂÛÔÏ¿‚ËÛÂ Î·È ÂÎÊÚ¿˙ÂÙ·È Û cm/¤ÙÔ˜. ∆Ô ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ˘ÔÏÔÁ›˙ÂÙ·È ·ÎÚÈ‚Ò˜ Ì ÙÔ ‰Âη‰ÈÎfi ËÌÂÚÔÏfiÁÈÔ. √È ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ‡„Ô˘˜ Î·È ÙÔ˘ ∂ƒ∞ ÙÔ˘ οı ·È‰ÈÔ‡ ÂÎÊÚ¿ÛÙËÎ·Ó Û ‰Â›ÎÙ˜ ÛÙ·ıÂÚ‹˜ ·fiÎÏÈÛ˘ (Standard Deviation Score, SDS) Ì ‚¿ÛË ÙË ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ·. √ ‰Â›ÎÙ˘ ·˘Ùfi˜ ‰Â›¯ÓÂÈ fiÛ˜ ·ÎÚÈ‚Ò˜ ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ ·fi ÙÔ Ì¤ÛÔ fiÚÔ ‚Ú›ÛÎÂÙ·È ÙÔ ‡„Ô˜ ‹ ¿ÏÏË Ì¤ÙÚËÛË ÙÔ˘ ·È‰ÈÔ‡. √ ‰Â›ÎÙ˘ ·˘Ùfi˜ ˘ÔÏÔÁ›˙ÂÙ·È ·fi ÙÔÓ Ù‡Ô: SDS=(X-XÌÙ) / SD, fiÔ˘ Ã: ‡„Ô˜ (‹ ¿ÏÏË Ì¤ÙÚËÛË ÙÔ˘ ·È‰ÈÔ‡), ÃÌÙ: Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ‡„Ô˘˜ (·fi ›Ó·Î˜) Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ ÙÔ˘ ·È‰ÈÔ‡ Î·È SD: Ë ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË Ù˘ ›‰È·˜ ËÏÈΛ·˜ (2). ∂›Û˘, ˘ÔÏÔÁ›ÛÙËΠÙÔ ‡„Ô˜-ÛÙfi¯Ô˜ (target height, TH) ÁÈ· Ó· ÂÏÂÁ¯ı› ·Ó ÙÔ ÙÂÏÈÎfi ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ ‚Ú›ÛÎÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ‰˘Ó·ÌÈÎÔ‡ ÙÔ˘. ∆Ô TH ˘ÔÏÔÁ›˙ÂÙ·È ·Ó ÛÙÔ Ì¤ÛÔ ‡„Ô˜ ÙˆÓ ÁÔÓ¤ˆÓ ÚÔÛÙÂıÔ‡Ó 6,5 cm, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ·ÁfiÚÈ, ‹ ·Ê·ÈÚÂıÔ‡Ó 6,5 cm, ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÎÔÚ›ÙÛÈ. °ÈÓfiÙ·Ó ˘ÔÏÔÁÈÛÌfi˜ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Î·È ·Ó¿ ¤ÙÔ˜, Û‡Ìʈӷ Ì ÙÔÓ ¿ÙÏ·ÓÙ· TWRUS. ∂›Û˘, ÁÈÓfiÙ·Ó ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ÂÊ˂›·˜ ηٿ Tanner ÛÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Î·È ·Ó¿ ÂÍ¿ÌËÓÔ. ¶ÚÔÂÊË‚ÈÎfi ıˆÚ›ÙÔ Î¿ı ÎÔÚ›ÙÛÈ ¯ˆÚ›˜ „ËÏ·ÊËÙfi Ì·˙ÈÎfi ·‰¤Ó· Î·È Î¿ı ·ÁfiÚÈ Ì fiÁÎÔ fiÚ¯ÂˆÓ <4 ml. ∆Ô Ì¤ÁÂıÔ˜ ÙˆÓ fiÚ¯ÂˆÓ ÂÎÙÈÌ‹ıËΠ̠ÔگȉfiÌÂÙÚÔ Prader. ø˜ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ıˆڋıËΠÙÔ ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ¯ÂÈÚÒÓ ‰È·ÈÛÙˆÓfiÙ·Ó Ï‹Ú˘ Û‡ÁÎÏÈÛË ÙˆÓ ÂÈʇÛÂˆÓ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ™Â οı ·È‰› ÂÎÙÈÌ‹ıËÎÂ Ë ¤ÎÎÚÈÛË GH ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ‰È¤ÁÂÚÛ˘ Ì ÎÏÔÓȉ›ÓË ‹ ‰È·Ï˘Ù‹ ÈÓÛÔ˘Ï›ÓË Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ GH Û ¯ÚfiÓÔ˘˜ 0, 15, 30, 45, 60, 90, 120 min. ¶·ıÔÏÔÁÈ΋ ıˆÚ›ÙÔ ÙÈÌ‹ GH <10 ng/ml Ô˘ ÂȂ‚·ÈˆÓfiÙ·Ó Û ‰Â‡ÙÂÚË ‰ÔÎÈÌ·Û›· ÂÓÙfi˜ ÂÓfi˜ ÌËÓfi˜. °È· ÙÔÓ ¤ÏÂÁ¯Ô ¤Ó·Ú͢ Ù˘ ÂÊ˂›·˜ ÁÈÓfiÙ·Ó ‰ÔÎÈÌ·Û›· LHRH Ì ÚÔÛ‰ÈÔÚÈÛÌfi ÙÈÌÒÓ LH, FSH Û ¯ÚfiÓÔ˘˜ 0, 30, 60 min. ŒÓ·ÚÍË Ù˘ ÂÊ˂›·˜ ıˆÚ›ÙÔ ÙÈÌ‹ LH >15 IU/L (3). ∂›Û˘, ÁÈÓfiÙ·Ó ‰ÔÎÈÌ·Û›· TRH ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ TSH (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ TSH: 0,4-4 ÌπU/ml) Û ¯ÚfiÓÔ˘˜ 0, 30, 60 min Î·È Ù˘ ∆4 Û ¯ÚfiÓÔ 0 (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ∆4: 5,6-12 Ìg/dl). ∞Ó¿ ÂÍ¿ÌËÓÔ ÁÈÓfiÙ·Ó ¤ÏÂÁ¯Ô˜ ÁÏ˘Îfi˙˘ ÔÚÔ‡, ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c%), ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (TSH, T3, T4), ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ÛÙ· ·È‰È¿ Ô˘ Ë ÂÊ˂›· ›¯Â ÍÂÎÈÓ‹ÛÂÈ. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË √È ÔÛÔÙÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ Û˘ÓÔ„›ÛÙËÎ·Ó ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ̤ÛÔ˘˜ fiÚÔ˘˜ Î·È Ù˘ÈΤ˜ ·ÔÎÏ›ÛÂȘ (standard deviation). °È· ÙË Û‡ÁÎÚÈÛË ‰‡Ô Ì¤ÛˆÓ fiÚˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· ηٿ Student’s t-test. ¶·Ú¿ÏÏËÏ· ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ Î·ÓÔÓÈÎfiÙËÙ· ÙˆÓ ÌÂÙ·‚ÏËÙÒÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙË ‰ÔÎÈÌ·Û›· ηٿ Shapiro-Wilk, fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·fiÎÏÈÛË ·fi ÙËÓ Î·ÓÔÓÈÎfiÙËÙ· Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ¶·È‰È·ÙÚÈ΋ 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·130

130

ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 1. µ·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηٿ ÙËÓ ¤Ó·ÚÍË ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ ∞ÛıÂÓ›˜

ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)

º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ⁄„Ô˜-ÛÙfi¯Ô˜ (∆∏) (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)

72 (43 ¿ÚÚÂÓ·, 29 ı‹Ï·) 11,59±2,95 -2,5±0,84 9,49±3,02 -0,74±1,05 -0,77±0,74 -0,91±0,9 -0,66±0,91

ª¤ÁÈÛÙË ÙÈÌ‹

∂Ï¿¯ÈÛÙË ÙÈÌ‹

16,06 -0,51 14,10

3,23 -5,78 1,50

1,83 1,05 1,3 1,54

-4,73 -2,21 -3,36 -2,51

SDS: standard deviation score, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ

··ÈÙ‹ıËΠÔÔÈ·‰‹ÔÙ ÌÂÙ·ÙÚÔ‹ ÙˆÓ ÌÂÙ·‚ÏËÙÒÓ. ∞Ú¯Èο, Ë Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ Ì ÙȘ ¿ÏϘ ηÙËÁÔÚÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ ÂÍÂÙ¿ÛÙËΠ̠ÙÔ Û˘ÓÙÂÏÂÛÙ‹ Û˘Û¯¤ÙÈÛ˘ ηٿ Pearson, ÂÓÒ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Û¯¤Û˘ ʇÏÔ˘ Î·È ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ô Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ ηٿ Spearman. ∂Ê·ÚÌfiÛÙËΠÔÏ˘·Ú·ÁÔÓÙÈ΋ ÁÚ·ÌÌÈ΋ ·ÏÈÓ‰ÚfiÌËÛË ÁÈ· Ó· ÂÍÂÙ·ÛÙ› Ë Û˘ÓÔÏÈ΋ Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ Ì ¿ÏÏÔ˘˜ ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ™’ fiϘ ÙȘ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ, ÙÔ Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ÔÚ›ÛÙËΠˆ˜ 0,05 Î·È ·ÌÊ›Ï¢ÚÔ. √È ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ ÂÊ·ÚÌfiÛÙËÎ·Ó Ì ٷ ÛÙ·ÙÈÛÙÈο ·Î¤Ù· SPSS 13.0 Î·È STATA.

∞ÔÙÂϤÛÌ·Ù· ∆· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂÚ·›·˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο ÛÙÔÓ ¶›Ó·Î· 2. ¢È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÌÂ: ÙÔ ·Ú¯ÈÎfi ‡„Ô˜, ÙÔ ‡„Ô˜ÛÙfi¯Ô˜, ÙÔ ‡„Ô˜ Ù˘ ÌËÙ¤Ú·˜, ÙÔ ‡„Ô˜ ÙÔ˘ ·Ù¤Ú· Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ ·Ó¿ ‚‰ÔÌ¿‰· (¶›Ó·Î·˜ 3). ¢ÂÓ ‚Ú¤ıËÎÂ Û˘Û¯¤ÙÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙÔ Ê‡ÏÔ, ÙË ‰È¿ÚÎÂÈ· ıÂÚ·›·˜ Î·È ÙËÓ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ (height velocity) ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂÚ·›·˜. ªÂ ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÁÚ·ÌÌÈ΋˜

·ÏÈÓ‰ÚfiÌËÛ˘, ÂÍÂÙ¿ÛÙËÎÂ Ë Û¯¤ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë Ù· ‚·ÛÈο ÙÔ˘˜ ¯·Ú·ÎÙËÚÈÛÙÈο. ∆ÂÏÈο, ‰È·ÌÔÚÊÒıËΠ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi ÌÔÓÙ¤ÏÔ ·Ó¿Ï˘Û˘, Ì ÙÔ ÔÔ›Ô ÌÔÚ› Ó· ÚÔ‚ÏÂÊı› ÙÔ 38,7% (R2adj= 0,387) ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜. ∞fi ÙËÓ ·Ú·¿Óˆ ·Ó¿Ï˘ÛË ÚÔ·ÙÂÈ fiÙÈ ÙÔ ‡„Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ Ì GH, Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÓ¤ÛÂˆÓ Â‚‰ÔÌ·‰È·›ˆ˜, ÙÔ ‡„Ô˜ Ù˘ ÌËÙ¤Ú·˜ fiÛÔ Î·È ÙÔ˘ ·Ù¤Ú· ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÂÓfi˜ ·ÙfiÌÔ˘ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘. ™ÙË Û˘Ó¤¯ÂÈ· ÌÂÏÂÙ‹ıËÎ·Ó ˆ˜ ͯˆÚÈÛÙ‹ ˘ÔÔÌ¿‰· Ù· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ÙË ıÂÚ·›· ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘. ∆· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο ÛÙÔ˘˜ ¶›Ó·Î˜ 4 Î·È 5. ∆Ô ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÛÙ· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ÚÈÓ ·fi ÙËÓ ‹‚Ë Â›Ó·È ÌÈÎÚfiÙÂÚÔ Û ۯ¤ÛË Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘ (p=0,037). ∆Ô ·ÔÙ¤ÏÂÛÌ· ·˘Ùfi, fï˜, Ê·›ÓÂÙ·È Ó· ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Î·È ÙÔ ·Ú¯ÈÎfi ‡„Ô˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ÚÈÓ ·fi ÙËÓ ‹‚Ë ‹Ù·Ó ÌÈÎÚfiÙÂÚÔ (p=0,016). ŸÙ·Ó Û˘ÁÎÚ›ıËÎÂ Ë ‰È·ÊÔÚ¿ Ù˘ ̤Û˘

¶›Ó·Î·˜ 2. ∞ÔÙÂϤÛÌ·Ù· ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ∞ÛıÂÓ›˜ (¡=72)

ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)

ª¤ÁÈÛÙË ÙÈÌ‹

∂Ï¿¯ÈÛÙË ÙÈÌ‹

∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂÚ·›·˜ (Height Velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂÚ·›·˜ (¤ÙË)

-1,23±1,02

1,22

-5,08

6,26±4,95 16,16±1,61 1,3±0,97 -0,47±0,91 0,47±0,11 6,57±1,23 4,64±2,75

19,00 19,27 4,46 1,75 0,80 7,00 14,81

-1,99 12,44 -0,88 -3,70 0,27 3,00 1,10

SDS: standard deviation score, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ, ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS) Paediatriki 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·131

131

AÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘

¶›Ó·Î·˜ 3. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Û ·ÛıÂÓ›˜ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ¶·Ú¿ÁÔÓÙ˜ ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) TH (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)

∆ÂÏÈÎfi ·Ó¿ÛÙËÌ· ™˘Û¯¤ÙÈÛË p r=0,474 r=0,265

<0,01 0,024

r=0,384 r=0,51 r=0,394 r=0,434

<0,01 <0,001 <0,01 <0,001

SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ

Ù˘È΋˜ ·fiÎÏÈÛ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜-·Ú¯ÈÎÔ‡ ‡„Ô˘˜ (¢ height SDS), ·˘Ù‹ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ 2 ˘ÔÔÌ¿‰Â˜ (p=0,9). ∆· ·ÓˆÙ¤Úˆ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 6. ªÈ· ¿ÏÏË ˘ÔÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËΠͯˆÚÈÛÙ¿ ‹Ù·Ó Ù· ·È‰È¿ Ì ¤ÏÏÂÈ„Ë Î·È ¿ÏÏˆÓ ÔÚÌÔÓÒÓ ÏËÓ Ù˘ ·˘ÍËÙÈ΋˜. ∆Ô ¢ height ÛÙ· ·È‰È¿ ·˘Ù¿ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ›¯·Ó ÌÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (p=0,001), ·Ó Î·È ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ 2 ·˘Ù¤˜ ˘ÔÔÌ¿‰Â˜ (p=0,091). ∆· ·ÓˆÙ¤Úˆ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 7.

™˘˙‹ÙËÛË ∏ ̤ÛË Ù˘È΋ ·fiÎÏÈÛË ÙÔ˘ ‡„Ô˘˜ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (HtSDS) ‹Ù·Ó -2,5, ÂÓÒ Ë Ì¤ÛË Ù˘È΋ ·fiÎÏÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ (FHSDS) ‹Ù·Ó -1,22. ∏ ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ‚ÂÏÙ›ˆÛ ۷ÊÒ˜ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ, ·Ó Î·È ÌfiÓÔ 23 ·È‰È¿ (32%) ¤ÊÙ·Û·Ó ÙÔ ‡„Ô˜-ÛÙfi¯Ô (TH). ¶·È‰È¿ Ì ȉÈÔ·ı‹ ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GHD) ‹ ˘ÔÊ˘ÛÈÛÌfi Ô˘ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ıÂÚ·›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó FHSDS ÌÂٷ͇

-4 Î·È -6 (4). ™Â ÌÈ· ÛÂÈÚ¿ ·fi ·Ó¿ÏÔÁ˜ ÂÚÁ·Û›Â˜ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÌÂٷ͇ 1995 Î·È 2006, ÙÔ FHSDS ·Ó·Ê¤ÚÂÙ·È ÌÂٷ͇ -0,4 Î·È -2,0 (5-13). ™Â ÌÂϤÙ˜ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÌÂٷ͇ 1981 Î·È 1989, ÙÔ FHSDS ·Ó·Ê¤ÚÂÙ·È ÌÂٷ͇ -1,75 Î·È -3,0 (14-20). ∆· Ùˆ¯fiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ·Ï·ÈfiÙÂÚˆÓ ·˘ÙÒÓ ÌÂÏÂÙÒÓ ÔÊ›ÏÔÓÙ·È ÛÙË ¯Ú‹ÛË ÚÈÓ ·fi ÙÔ 1985 Ù˘ و̷ÙÈ΋˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηıÒ˜ Î·È ÛÙË ıÂÚ·›· Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ì 3 ÌfiÓÔ ÂÓ¤ÛÂȘ GH ‚‰ÔÌ·‰È·›ˆ˜. ∏ ¿ÚÈÛÙË ‰fiÛË Ù˘ GH ¤¯ÂÈ ÔÚÈÛı› ÛÙȘ 0,3-0,6 πU/kg/‚‰ÔÌ¿‰· ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (21). ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜, Ë ¤ÎÎÚÈÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ·˘Í¿ÓÂÙ·È Î·È Û˘ÓÂÒ˜ ı· Ú¤ÂÈ Ë ‰fiÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ó· ·Ó·ÚÔÛ·ÚÌfi˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ (22). √È Ranke Î·È Butendandt (1989) (19) ηıÒ˜ Î·È Ë ÌÂϤÙË KIGS (20,23) ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ FHSDS Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÓ¤ÛÂˆÓ GH. ∞˘Ùfi ‰È·ÈÛÙÒıËÎÂ Î·È ÛÙË ‰È΋ Ì·˜ ÌÂϤÙË, ÛÙËÓ ÔÔ›· 6 ·È‰È¿ ¤Î·Ó·Ó 3 ÌfiÓÔ ÂÓ¤ÛÂȘ ‚‰ÔÌ·‰È·›ˆ˜, ÂÓÒ 66 ·È‰È¿ ·ÎÔÏÔ‡ıËÛ·Ó Û¯‹Ì· 6 ‹ 7 ÂÓ¤ÛÂˆÓ Â‚‰ÔÌ·‰È·›ˆ˜. ∂ÓÙÔ‡ÙÔȘ, Û¯‹Ì·Ù· Ì ÂÚÈÛÛfiÙÂÚ˜ Ù˘ ÌÈ·˜ ¤ÓÂÛ˘ ËÌÂÚËÛ›ˆ˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÚÔÛʤÚÔ˘Ó ÌÂÁ·Ï‡ÙÂÚÔ fiÊÂÏÔ˜ (24). √ ·Ú¿ÁÔÓÙ·˜ Ô˘ ‚Ú¤ıËΠӷ ¤¯ÂÈ ÙËÓ ÈÛ¯˘ÚfiÙÂÚË Û˘Û¯¤ÙÈÛË Ì ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‹Ù·Ó ÛÙË ÌÂϤÙË Ì·˜ ÙÔ ‡„Ô˜-ÛÙfi¯Ô˜ (·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ) (T∏). ∏ Û˘Û¯¤ÙÈÛË ·˘Ù‹ ¤¯ÂÈ ·Ó·ÊÂÚı› Î·È Û ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (12,14,19,20,23,25). º·›ÓÂÙ·È ÙÂÏÈο ˆ˜ ÙÔ ÁÂÓÂÙÈÎfi ‰˘Ó·ÌÈÎfi Â›Ó·È ·˘Ùfi Ô˘ Û ÌÂÁ¿ÏÔ ‚·ıÌfi ηıÔÚ›˙ÂÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ∂›Û˘, ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Û˘Û¯ÂÙ›ÛÙËΠÛÙË ÌÂϤÙË Ì·˜ Î·È Ì ÙÔ ‡„Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ (12,26). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ Ù˘ ÌË ·Ó‡ÚÂÛ˘ ÛÙË ÌÂϤÙË Ì·˜ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Î·È ‰È¿ÚÎÂÈ·˜ ıÂÚ·›·˜. ™ÙË ÌÂϤÙË KIGS (20,23) ˘‹ÚÍ ÔÚȷ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ‰˘Ô

¶›Ó·Î·˜ 4. µ·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·ÛıÂÓÒÓ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ¤Ó·ÚÍË ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ ηٿ ÙËÓ ÚÔÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜

ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)

º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS)

25 (11 ¿ÚÚÂÓ·, 14 ı‹Ï·) 8,4±2,39 -2,89±1,08 6,32±2,64 -0,855±1,45 -0,9±0,78 -1,06±1,05 -0,76±0,89

ª¤ÁÈÛÙË ÙÈÌ‹

∂Ï¿¯ÈÛÙË ÙÈÌ‹

10,99 -0,51 10,10

3,23 -5,78 1,50

1,83 1,01 1,11 1,51

-4,73 -2,21 -3,36 -2,21

SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height) ¶·È‰È·ÙÚÈ΋ 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·132

132

ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 5. ∞ÔÙÂϤÛÌ·Ù· ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì ·ÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ¤Ó·ÚÍË ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ ηٿ ÙËÓ ÚÔÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜ (¡=25)

ª¤ÛÔ˜ fiÚÔ˜ (ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË)

ª¤ÁÈÛÙË ÙÈÌ‹

∂Ï¿¯ÈÛÙË ÙÈÌ‹

∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂÚ·›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-TH (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂÚ·›·˜ (¤ÙË)

-1,56±1,3

1,22

-5,08

5,93±4,66 15,36±1,8 1,32±1,37 -0,66±1,2 0,54±0,13 6,08±1,68 6,97±3,13

17,97 18,1 4,46 1,75 0,80 7,00 14,81

-0,37 12,44 -0,88 -3,70 0,35 3,00 2,72

SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS)

·˘ÙÒÓ ·Ú·Ì¤ÙÚˆÓ (Ú=0,06) Î·È ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‰È·ÊÔÚ¿˜ ÙÂÏÈÎÔ‡-·Ú¯ÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ (¢ height) Î·È Ù˘ ‰È¿ÚÎÂÈ·˜ ıÂÚ·›·˜ (p=0,001). ∂ȯÂÈÚÒÓÙ·˜ Û‡ÁÎÚÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ‹‚˘ Î·È ·˘ÙÒÓ Ô˘ ÍÂΛÓËÛ·Ó ÌÂÙ¿, ‰È·ÈÛÙÒıËΠˆ˜ ÙÔ ¢ height ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÛÙȘ ‰‡Ô ˘ÔÔÌ¿‰Â˜ (p=0,9). ∆· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ÚÔÂÊË‚Èο ›¯·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ·Ú¯ÈÎfi ‡„Ô˜ (p=0,016) Î·È ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ÙÂÏÈÎfi ‡„Ô˜ (p=0,037) Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ·ÁˆÁ‹ ηٿ ÙËÓ ÂÊ˂›·. ∆Ô fiÊÂÏÔ˜ ·fi ÙË ıÂÚ·›·, fiˆ˜ ·ÓÙÈηÙÔÙÚ›˙ÂÙ·È ÛÙÔ ÎÂÚ‰Ëı¤Ó ·Ó¿ÛÙËÌ·, ‹Ù·Ó ÙÔ ›‰ÈÔ ÛÙȘ ‰‡Ô ·˘Ù¤˜ ˘ÔÔÌ¿‰Â˜. ∂ÓÙÔ‡ÙÔȘ, ÙÔ 54% ÙˆÓ ·È‰ÈÒÓ Ì ¤Ó·ÚÍË ıÂÚ·›-

·˜ ÚÔÂÊË‚Èο Êı¿ÓÂÈ ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô, ÂÓÒ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÁÈ· Ù· ·È‰È¿ Ì ¤Ó·ÚÍË ıÂÚ·›·˜ ηٿ ÙËÓ ÂÊ˂›· Â›Ó·È ÌfiÏȘ 18,4% (13,27). £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, ˆÛÙfiÛÔ, fiÙÈ Ù· ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÚÈÓ ·fi ÙËÓ ÂÊ˂›· ‹Ú·Ó ıÂÚ·›· ÁÈ· ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Û ˘„ËÏfiÙÂÚË ‰fiÛË Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ÍÂΛÓËÛ·Ó ıÂÚ·›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜ (p<0,001 Î·È p=0,001). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È ˆ˜ ÛÙÔ Û‡ÓÔÏÔ, ÌfiÓÔ Ù· 23 ·fi Ù· 72 ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó (32%) ¤ÊÙ·Û·Ó ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô (∆∏). ™Â 47 ·fi Ù· 72 ·È‰È¿, Ë ‹‚Ë Â›¯Â ‹‰Ë ÍÂÎÈÓ‹ÛÂÈ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ 80-85% Ù˘ ·‡ÍËÛ˘ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÚÈÓ ·fi ÙËÓ ‹‚Ë Î·È ¤ÙÛÈ Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ¤¯·Û·Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·,

¶›Ó·Î·˜ 6. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ Â›‰Ú·Û˘ Ù˘ ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÛÙËÓ ÚÔÂÊË‚È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ∞ÛıÂÓ›˜ (¡=72)

¶ÚÔÂÊË‚È΋ ËÏÈΛ·

∂ÊË‚È΋ ËÏÈΛ·

p

AÚÈıÌfi˜ - º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂÚ·›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜( SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂÚ·›·˜ (¤ÙË)

25 (11 ¿ÚÚÂÓ·, 14 ı‹Ï·) 8,4±2,39 -2,89±1,08 6,32±2,64

47 (32 ¿ÚÚÂÓ·, 15 ı‹Ï·) 13,29±1,39 -2,29±0,59 11,18±1,43

-0,855±1,45 -0,9±0,78 -1,06±1,05 -0,76±0,89 -1,56±1,3

-0,67±0,76 -0,7±0,71 -0,83±0,82 -0,6±0,93 -1,04±0,79

0,56 0,29 0,30 0,48 0,037

5,93±4,66 15,36±1,8 1,32±1,37 -0,66±1,2 0,54±0,13 6,08±1,68 6,97±3,13

6,43±5,14 16,58±1,34 1,28±0,69 -0,36±0,71 0,43±0,09 6,83±0,82 3,4±1,42

0,69 0,005 0,9 0,26 0,001 0,044 <0,001

0,01 <0,001 0,016 <0,001

SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS) Paediatriki 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·133

133

AÓÂ¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘

¶›Ó·Î·˜ 7. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ Â›‰Ú·Û˘ Ù˘ ıÂÚ·›·˜ ˘ÔηٿÛÙ·Û˘ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË Û ·È‰È¿ ÌÂ Û˘Ó‰˘·Ṳ̂ÓË Î·È ·È‰È¿ Ì ÌÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· GH ∞ÛıÂÓ›˜ (¡=72)

∞ÓÂ¿ÚÎÂÈ· ÔÏÏ·ÏÒÓ ÔÚÌÔÓÒÓ

ªÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· GH

p

º‡ÏÔ ∏ÏÈΛ· ¤Ó·Ú͢ GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ (SDS) √ÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË GH (¤ÙË) ∞Ú¯ÈÎfi ‡„Ô˜ ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ· (SDS) ∆∏ ‡„Ô˜ (SDS) ⁄„Ô˜ ÌËÙ¤Ú·˜ (SDS) ⁄„Ô˜ ·Ù¤Ú· (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS) ∆·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ıÂÚ·›·˜ (height velocity) (SDS) ∏ÏÈΛ· ‰È·ÎÔ‹˜ GH (¤ÙË) ¢ height (SDS) ∆ÂÏÈÎfi ‡„Ô˜ (SDS)-∆∏ (SDS) ¢ÔÛÔÏÔÁ›· GH (IU/kgr/‚‰ÔÌ¿‰·) ∞ÚÈıÌfi˜ ÂÓ¤ÛˆÓ/‚‰ÔÌ¿‰· ¢È¿ÚÎÂÈ· ıÂÚ·›·˜ (¤ÙË)

11 (6 ¿ÚÚÂÓ·, 5 ı‹Ï·) 10,26±3,38 -2,91±0,78 7,17±3,71

61 (37 ¿ÚÚÂÓ·, 24 ı‹Ï·) 11,83±2,82 -2,42±0,83 9,91±2,71

NS 0,1 0,075 0,005

-0,52±1,05 -0,183±1,02 -0,5±1,41 0,08±0,87 -0,75±1,18

-0,77±1,05 -0,88±0,63 -0,98±0,78 -0,79±0,86 -1,31±0,97

0,47 0,003 0,29 0,003 0,091

6,62±4,71 16,8±1,07 2,17±1,1 -0,56±1,01 0,52±0,14 6±1,73 6,55±3,2

6,19±5,03 16,04±1,67 1,14±0,87 -0,45±0,9 0,46±0,11 6,67±1,11 4,29±2,54

0,79 0,15 0,001 0,71 0,14 0,24 0,011

SDS: standard deviation, GH: ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ∆∏: ·Ó·ÌÂÓfiÌÂÓÔ ÁÈ· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‡„Ô˜, ÚÔÛ·ÚÌÔṲ̂ÓÔ ÛÙÔ Ê‡ÏÔ (target height), NS: non significant, ¢ height: ÙÂÏÈÎfi ‡„Ô˜ (SDS)-·Ú¯ÈÎfi ‡„Ô˜ (SDS)

ÏfiÁˆ ηı˘ÛÙ¤ÚËÛ˘ ÛÙËÓ ·Ó·˙‹ÙËÛË ÂÍÂȉÈÎÂ˘Ì¤Ó˘ ·Ú¤Ì‚·Û˘ (28-30). ªÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË, Ù· ·È‰È¿ ‚ÂÏÙÈÒÓÔ˘Ó ÙÔÓ ÂÙ‹ÛÈÔ Ú˘ıÌfi ·‡ÍËÛ˘ ηٿ 2 ÊÔÚ¤˜ Û ۯ¤ÛË Ì ÂΛÓÔÓ ÚÈÓ ·fi ÙË ıÂÚ·›·. ŸÛÔ ÌÈÎÚfiÙÂÚÔ Â›Ó·È ÙÔ ·È‰›, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ÂÈÙ˘Á¯¿ÓÂÈ Ì ÙËÓ ¤ÁηÈÚË ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜. ∏ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ıÂÚ·›·˜ Â›Ó·È Û˘Ó‹ıˆ˜ Î·È Ë Ì¤ÁÈÛÙË Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ GH (27). ∏ ÌË ·Ó‡ÚÂÛË ÛÙË ÌÂϤÙË Ì·˜ Û˘Û¯¤ÙÈÛ˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙËÓ Ù·¯‡ÙËÙ· ·‡ÍËÛ˘ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ıÂÚ·›·˜ ÔÊ›ÏÂÙ·È Èı·ÓÒ˜ ÛÙË ÌÂÁ¿ÏË Û¯ÂÙÈο ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜. ™˘ÁÎÚ›ÓÔÓÙ·˜ Ù· ·È‰È¿ Ì ÔÏÏ·Ï‹ ·ÓÂ¿ÚÎÂÈ· ÔÚÌÔÓÒÓ Ì ÂΛӷ Ì ÌÂÌÔӈ̤ÓË ·ÓÂ¿ÚÎÂÈ· GH, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÛÙȘ 2 ˘ÔÔÌ¿‰Â˜, fiˆ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È Û ¿ÏϘ ÌÂϤÙ˜ (12,31). ∆Ô 45,5% ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ¤ÊÙ·Û ÛÙÔ ‡„Ô˜-ÛÙfi¯Ô. ∂ÓÙÔ‡ÙÔȘ, ÙÔ ¢ height ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ (p=0,001) ÛÙ· ·È‰È¿ Ì ÔÏÏ·Ï‹ ·ÓÂ¿ÚÎÂÈ· ÔÚÌÔÓÒÓ, Ù· ÔÔ›· Ê·›ÓÂÙ·È Ó· ˆÊÂÏ‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ıÂÚ·›· (13). £· Ú¤ÂÈ Ó· ÛËÌÂȈı›, ˆÛÙfiÛÔ, fiÙÈ Ë ·ÚÔ‡Û· ÔÌ¿‰· ÙˆÓ 11 ·È‰ÈÒÓ Ì ·ÓÂ¿ÚÎÂÈ· ÔÏÏÒÓ ÔÚÌÔÓÒÓ ·ÚÔ˘Û›·˙ ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË SDS ÁÈ· ÙÔ TH Û ۯ¤ÛË ÌÂ

Ù· ·È‰È¿ Ì ÌÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηÈ, Û˘ÓÂÒ˜, ˘‹Ú¯Â ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙÔ ÁÂÓÂÙÈο ηıÔÚÈṲ̂ÓÔ ·Ó¿ÛÙËÌ·. ∞·ÈÙ›ٷÈ, ÂÔ̤ӈ˜, ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ·È‰ÈÒÓ ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ·ÛÊ·ÏÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ . ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, ηıÒ˜ Î·È ¿ÏÏˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÌÂÏÂÙÒÓ ‰ÈÂıÓÒ˜, ‰Â›¯ÓÔ˘Ó ÌÈ· Û·Ê‹ ‚ÂÏÙ›ˆÛË ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Ì ÙË ¯Ú‹ÛË Ù˘ ‚ÈÔÛ˘ÓıÂÙÈ΋˜ GH 6 ‹ 7 ÊÔÚ¤˜ ‚‰ÔÌ·‰È·›ˆ˜, Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË 3 ‰fiÛÂˆÓ Ô˘ ·ÔÙÂÏÔ‡ÛÂ Û˘Ó‹ıË Ú·ÎÙÈ΋ ÛÙÔ ·ÚÂÏıfiÓ. ∂ÓÙÔ‡ÙÔȘ, ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÈηÓÔÔÈËÙÈÎfi ÁÈ· fiÏÔ˘˜ ÙÔ˘ ·ÛıÂÓ›˜ Î·È È‰›ˆ˜ ÁÈ· ÂΛÓÔ˘˜ Ô˘ ÍÂΛÓËÛ·Ó ÙËÓ ·ÁˆÁ‹ Û¯ÂÙÈο ·ÚÁ¿. ∏ ‚ÂÏÙ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ηٿ ÙËÓ ÂÊ˂›· Ê·›ÓÂÙ·È Ó· ··ÈÙ› ÌÈ· ·‡ÍËÛË Î·Ù¿ 50% ÂÚ›Ô˘ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ‰fiÛ˘ ÚÈÓ ·fi ÙËÓ ‹‚Ë. ∆¤ÏÔ˜, ‰ÂÓ ı· Ú¤ÂÈ Ó· ·Ú·‚ϤÂÈ Î·Ó›˜ ÙÔ ÚfiÏÔ Ô˘ ·›˙ÂÈ ÙÔ ÁÂÓÂÙÈÎfi ‰˘Ó·ÌÈÎfi ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Hindmarsh PC, Dattani MT. Use of growth hormone in children. Nat Clin Pract Endocrinol Metab 2006;2:260-268.

2. ÃÈÒÙ˘ ¢, ∆ÛÈÊÙ‹˜ °, ÷Ù˙ËÛ˘ÌÂÒÓ ª, ª·ÓÈ¿ÙËÃÚËÛÙ›‰Ë ª, ∫Ú›ÎÔ˜ •, ¢¿ÎÔ˘-µÔ˘ÙÂÙ¿ÎË ∞. ∞Ó¿ÛÙËÌ· Î·È ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ÂÏÏËÓÔ·›‰ˆÓ ËÏÈΛ·˜ 0-18 ÂÙÒÓ (2001-2002): Û‡ÁÎÚÈÛË Ì ‰Â‰Ô̤ӷ ÌÂϤÙ˘ ÙÔ˘ 19781979. ¢ÂÏÙ›Ô ∞ã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋˜ 2003;50:136-156.

3. Cavallo A, Richards GE, Busey S, Michaels SE. A simplified ¶·È‰È·ÙÚÈ΋ 2008;71:128-134

Pediatri Mar-Apr 08

07-04-08

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™ÂÏ›‰·134

134

ª. ¶··‰ÔÔ‡ÏÔ˘ Î·È Û˘Ó.

gonadotrophin-releasing hormone test for precocious puberty. Clin Endocrinol (Oxf) 1995;42:641-646.

4. Wit JM, Kamp GA, Rikken B. Spontaneous growth and response to growth hormone treatment in children with growth hormone deficiency and idiopathic short stature.

Pediatr Res 1996;39:295-302.

5. De Angelis R, di Natale B, Lukezic M, Bozzato N, Mora C, Pozzobon G, Vigano G, Chiumello G. Final height in idiopathic growth hormone deficient children after optimized rhGH treatment [abstract]. Horm Res 1997;48:149.

6. Barsanti S, Saggese G. Final height in children with growth hormone deficiency treated with recombinant growth hormone (abstract). Horm Res 1997;48:151.

7. Brämswig JH, Schlösser H, Kiese K. Final height in children with growth hormone deficiency. Horm Res 1995;43:126-128.

8. De Luca F, Maghnie M, Arrigo T, Lombardo F, Messina MF, Bernasconi S. Final height outcome of growth hormone-deficient patients treated since less than five years of age. Acta Paediatr 1996;85:1167-1171.

9. Coste J, Letrait M, Carel JC, Tresca JP, Chatelain P, Rochiccioli P, et al. Long-term results of growth hormone treatment in France in children of short stature: population, register based study. BMJ 1997;315:708-713.

10. Cacciari E, Cicognani A, Pirazzoli P, Zucchini S, Salardi S, Balsamo A, et al. Final height of patients treated for isolated GH deficiency: examination of 83 patients. Eur J Endocrinol 1997 Jul;137:53-60.

11. Thomas M, Massa G, Bourguignon JP, Craen M, De Schepper J, de Zegher F, et al. Final height in children with idiopathic growth hormone deficiency treated with recombinant growth hormone: the Belgian experience. Horm Res 2001;55:88-94.

12. Karavanaki K, Kontaxaki C, Maniati-Christidi M, Petrou V, Dacou-Voutetakis C. Growth response, pubertal growth and final height in Greek children with growth hormone (GH) deficiency on long-term GH therapy and factors affecting outcome. J Pediatr Endocrinol Metab 2001;14:397-405.

13. Reiter EO, Price DA, Wilton P, Albertsson-Wikland K, Ranke MB. Effect of growth hormone (GH) treatment on the near-final height of 1258 patients with idiopathic GH deficiency: analysis of a large international database. J Clin Endocrinol Metab 2006;91:2047-2054.

14. Burns EC, Tanner JM, Preece MA, Cameron N. Final height and pubertal development in 55 children with idiopathic growth hormone deficiency, treated for between 2 and 15 years with human growth hormone. Eur J Pediatr 1981;137:155-164.

15. Lenko HL, Leisti S, Perheentupa J. The efficacy of growth hormone in different types of growth failure. An analysis of 101 cases. Eur J Pediatr 1982;138:241-249.

16. Joss E, Zuppinger K, Schwarz HP, Roten H. Final height of patients with pituitary growth failure and changes in growth variables after long term hormonal therapy. Pediatr Res 1983;17:676-679.

17. Job JC, Joab N, Toublanc JE, Canlorbe P. Résultats à terme des traitments par l’hormone de croissance humaine. Arch Fr Pediatr 1984;41:477-482.

18. Hibi I, Tanaka T, Tanae A, Kagawa J, Hashimoto N,

Paediatriki 2008;71:128-134

Yoshizawa A, et al. The influence of gonadal function and the effect of gonadal suppression treatment on final height in growth hormone (GH)-treated GH-deficient children. J Clin Endocrinol Metab 1989;69:221-226.

19. Ranke MB, Butenandt O. Idiopathic growth hormone deficiency: final height to treatment with growth hormone and effects of puberty and sex steroids. In: Frisch H, Zaron Z, editors. Induction of puberty in hypopituitarism.

Serono Symposia Review No. 16. Rome: Ares-Serono Symposia; 1988. p. 84-89.

20. Ranke MB, Guilbaud O. Growth response in prepubertal children with idiopathic growth hormone deficiency during the first two years of treatment with human growth hormone. Analysis of the Kabi Pharmacia International Growth Stydy. Acta Paediatr Scand Suppl 1991;379:109115.

21. Radetti G, D’Addato G, Gatti D, Bozzola M, Adami S. Influence of two different GH dosage regimens on final height, bone geometry and bone strength in GH-deficient children. Eur J Endocrinol 2006;154:479-482.

22. Ranke MB, Price DA, Albertsson-Wikland K, Maes M, Lindberg A. Factors determining pubertal growth and final height in growth hormone treatment of idiopathic growth hormone deficiency. Analysis of 195 Patients of the Kabi Pharmacia International Growth Study. Horm Res 1997;48:62-71.

23. Ranke MB, Guilbaud O, Lindberg A, Cole T. Prediction of the growth response in children with various growth disorders treated with growth hormone: analyses of data from the Kabi Pharmacia International Growth Study. International Board of the Kabi Pharmacia International Growth Study. Acta Paediatr Suppl 1993;82 Suppl 391:82-88.

24. Hakeem V, Hindmarsh PC, Brook CG. Intermittent versus continuous administration of growth hormone treatment.

Arch Dis Child 1993;68:783-784.

25. Hilczer M, Smyczy‹ska J, Lewi‹ski A. Parentally-adjusted deficit of height as a prognostic factor of the effectiveness of growth hormone (GH) therapy in children with GH deficiency. Neuro Endocrinol Lett 2006;27:149-152.

26. Chen YD, Shu SG, Chi CS. Growth response and final height in growth hormone-deficient patients treated with biosynthetic growth hormone. Acta Paediatr Taiwan 2001;42:291-296.

27. Bajpai A, Kabra M, Gupta AK, Menon PS. Growth pattern and skeletal maturation following growth hormone therapy in growth hormone deficiency: factors influencing outcome. Indian Pediatr 2006;43: 593-599.

28. Frisch H, Birnbacher R. Final height and pubertal development in children with growth hormone deficiency after long-term treatment. Horm Res 1995;43:132-134.

29. August GP, Julius JR, Blethen SL. Adult height in children with growth hormone deficiency who are treated with biosynthetic growth hormone: the National Cooperative Growth Study experience. Pediatrics 1998;102:512-516.

30. Saggese G, Federico G, Barsanti S. Growth Hormone Deficiency. In: Hindmarsh PC, editor. Current Indications for Growth Hormone Therapy. Endocr Dev. Basel, Karger, 1999, vol 1, pp 55-67.

31. Severi F. Final height in children with growth hormone deficiency. Horm Res 1995;43:138-140.

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135

ªÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Û ·È‰È¿ Ì Ïԛ̈ÍË ·fi Èfi Epstein-Barr Î·È ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Î·È Û˘Û¯¤ÙÈÛË Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË1, ∞. ºÏ¤‚·2, µ. ∞ÓÙ¿ÚË1, ∞. ¶·˘Ï›ÙÔ˘-∆ÛÈfiÓÙÛË2, ª. ªÔÛÎÔÊ›‰Ë˜3, °. µ·ÚÏ¿Ì˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ë ÌÂϤÙË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì ۇӉÚÔÌÔ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ (™§ª) ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ Ïԛ̈͢, ηıÒ˜ Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘ Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 26 ·È‰È¿ Ì ™§ª, Ì ̤ÛÔ fiÚÔ ËÏÈΛ·˜ 6,6±3,5 ¤ÙË. ¶·Ú·ÎÔÏÔ˘ı‹ıËÎÂ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÔÚ›· Î·È ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÛÏËÓfi˜, ̤ÙÚËÛË ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ÚÔÛ‰ÈÔÚÈÛÌfi ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ, Á-GT, ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgG, IgA, IgM) Î·È ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ, ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD3+, CD3+/CD4+, CD3+/CD8+), µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (CD19+) Î·È Ê˘ÛÈÎÒÓ Î˘ÙÙ·ÚÔÎÙfiÓˆÓ (CD3-/CD16+56+) ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ·fi 3-6 Ì‹Ó˜. ∞ÔÙÂϤÛÌ·Ù·: ∆Ô 69% ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·˙ Ïԛ̈ÍË ·fi Èfi Epstein-Barr (EBV), ÂÓÒ ÙÔ 31% ·fi ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi (CMV). ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ IgM Î·È ·‡ÍËÛË ÙˆÓ IgG ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ·Ú¿ÏÏËÏË ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË. ∏ ÛÏËÓÔÌÂÁ·Ï›·, Ë ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË Î·È Ë ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ˘Ô¯ÒÚËÛ·Ó ÛËÌ·ÓÙÈο. ∏ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ΢ڛˆ˜ Ù˘ IgM, ·ÔηٷÛÙ¿ıËÎÂ. ∫·Ù¿ ÙËÓ ÔÍ›· Ïԛ̈ÍË, Ù· CD3+/CD8+ ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË, Ì ÂÏ¿ÙÙˆÛË ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+, ÂÓÒ Ù· CD19+ Î·È Ù· CD3+/CD4+ ‹Ù·Ó ÂÏ·Ùو̤ӷ. ™ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, Ù· CD3+ Î·È CD3+/CD8+ ·ÚÔ˘Û›·˙·Ó ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË, ÂÓÒ Ù· CD3+/CD4+, Ù· CD19+ Î·È Ô ÏfiÁÔ˜ CD4+/CD8+ ·ÚÔ˘Û›·˙·Ó ·‡ÍËÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ∆· CD3+/CD8+ ∆ ÏÂÌÊÔ·ÙÙ·Ú· ·ÔÙÂÏÔ‡Ó ÙËÓ Î˘ÙÙ·ÚÔÙÔÍÈ΋ ∆ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ·¿ÓÙËÛË ÛÙ· EBV Î·È CMV ·ÓÙÈÁfiÓ· Î·È Ë Ì›ˆÛ‹ ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ‡ÊÂÛË Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜. ∞fi ÙË ÌÂϤÙË ÚÔ·ÙÂÈ Ë ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì ™§ª Ô˘ ¯ÚÔÓ›˙ÂÈ.

1 ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË 2 ∂ÚÁ·ÛÙ‹ÚÈÔ ∞ÓÔÛÔÏÔÁ›·˜πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË 3 ªÈÎÚÔ‚ÈÔÏÔÁÈÎfiµÈÔ¯ËÌÈÎfi-πÔÏÔÁÈÎfi ∆Ì‹Ì·, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ∂˘ÊËÌ›· ¶··‰ÔÔ‡ÏÔ˘∞Ï·Ù¿ÎË efiala@otenet.gr °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô “¶··ÁˆÚÁ›Ô˘”, ¶ÂÚÈÊÂÚÂȷ΋ Ô‰fi˜ ¡. ∂˘Î·Ú›·, ∆.∫. 564 03, £ÂÛÛ·ÏÔÓ›ÎË

§¤ÍÂȘ ÎÏÂȉȿ: ∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜, EBV, CMV Ïԛ̈ÍË, ÎÏÈÓÈ΋ ¤Î‚·ÛË.

Study of the immunophenotype of peripheral blood lymphocyte subsets in children with Epstein-Barr virus and cytomegalovirus infection: association with outcome E. Papadopoulou-Alataki1, A. Fleva2, V. Antari1, A. Pavlitou-Tsiontsi2, M. Moskofidis3, G. Varlamis1 Abstract Background: The purpose of this study was to identify the immunophenotype of children with infectious mononucleosis during the acute phase of the disease and convalescence and to investigate its association with the disease outcome.

Methods: A study was made of 26 children aged 6.6±3.5 years, affected by infectious mononucleosis. The clinical presentation, spleen size, peripheral blood count, anti-virus specific antibodies, levels of SGOT, SGPT, Á-GT, IgG, IgA and IgM, and immunophenotype of blood T, B and NK cells were studied during the acute phase and 3-6 months later.

Results: Of the 26 children, 69% were infected by Epstein-Barr virus (EBV) and 31% by cytomegalovirus (CMV). At 3-6 month reevaluation a significant decrease in IgM and an increase in IgG antivirus antibodies were observed, and the splenomegaly, lymphocytosis and high initial levels of SGOT were restored to normal. At the time of onset of symptoms, the CD3+/CD8+ cells were considerably increased, CD19+ and CD3+/CD4+ percentages were low and a marked lowering of the CD4+/CD8+ ratio was observed. At reevaluation, CD3+ and CD3+/CD8+ were lower, while CD3+/CD4+, CD19+ cells and the CD4+/CD8+ ratio were significantly increased.

Conclusions: The increase in CD3+/CD8+ cells represents the cytotoxic response to the proliferation of EBV and CMV antigens, and may be related with the remission of symptoms. Immunophenotyping of peripheral blood could be helpful in the follow-up of children with persistent infectious mononucleosis.

1 4th Department of Paediatrics, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki 2 ImmunologyHistocompatibility Laboratory, Papageorgiou General Hospital, Thessaloniki 3 MicrobiologicalBiochemical-Virological Department, Papageorgiou General Hospital, Thessaloniki Correspondence: Efimia Papadopoulou-Alataki efiala@otenet.gr Papageorgiou General Hospital, Ring road, 564 03, ¡. Efkarpia, Thessaloniki, Greece

Key words: Immunophenotype, EBV, CMV infection, clinical outcome. ¶·È‰È·ÙÚÈ΋ 2008;71:135-140

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∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.

™˘ÓÙÔÌÔÁڷʛ˜ EBV CMV ™§ª §ª SGOT SGPT Á-GT CD3+ CD3+/CD4+ CD3+/CD8+ CD19+ CD3-/16+56+

πfi˜ Epstein-Barr ªÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ ™‡Ó‰ÚÔÌÔ §ÔÈÌÒ‰Ô˘˜ ªÔÓÔ˘Ú‹ÓˆÛ˘ §ÔÈÌ҉˘ ªÔÓÔ˘Ú‹ÓˆÛË OÍ·ÏÔÍÈ΋ ÙÚ·ÓÛ·ÌÈÓ¿ÛË ¶˘ÚÔÛÙ·Ê˘ÏÈ΋ ÙÚ·ÓÛ·ÌÈÓ¿ÛË Á-ÁÏÔ˘Ù·Ì˘ÏÔÙÚ·ÓÛÊÂÚ¿ÛË flÚÈÌ· ∆ ÏÂÌÊÔ·ÙÙ·Ú· Ì TCR ˘Ô‰Ô¯¤· µÔËıËÙÈο ∆ ÏÂÌÊÔ·ÙÙ·Ú· ∫·Ù·ÛÙ·ÏÙÈο/΢ÙÙ·ÚÔÙÔÍÈο ∆ ÏÂÌÊÔ·ÙÙ·Ú· µ ÏÂÌÊÔ·ÙÙ·Ú· º˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· (NK)

∂ÈÛ·ÁˆÁ‹ ∏ §ÔÈÌ҉˘ ªÔÓÔ˘Ú‹ÓˆÛË (§ª) Â›Ó·È ¤Ó· ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚÂÙfi, Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ· Î·È ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·. ∞Ó Î·È Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÔÊ›ÏÔÓÙ·È ÛÙÔÓ Èfi Epstein-Barr (EBV), ÏÔÈÌÒÍÂȘ ·fi ¿ÏÏ· ·›ÙÈ·, fiˆ˜ Ô ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô˜ (CMV), Ô ÂÚËÙÔ˚fi˜ 6 (HSV), Ô Èfi˜ Ù˘ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ (HIV), ÔÈ ·‰ÂÓÔ˚Ô›, Ô Èfi˜ Ù˘ ÂÚ˘ıÚ¿˜, Ô Èfi˜ Parvo µ19, ÔÈ ÈÔ› Ù˘ Ë·Ù›Ùȉ·˜ ∞ Î·È µ, ÙÔ ÙÔÍfiÏ·ÛÌ·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚfiÌÔÈ· ÎÏÈÓÈ΋ Î·È ·ÈÌ·ÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Î·È ÚÔηÏÔ‡Ó ÙÔ Û‡Ó‰ÚÔÌÔ Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ (™§ª) (1-3). ∏ ‰È¿ÁÓˆÛË Ù˘ ÚfiÛÊ·Ù˘ Ïԛ̈͢ ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ Ù¿Í˘ IgM. ∂ȉÈο ÁÈ· ÙÔÓ EBV, Ë ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙˆÓ Î·„ȉÈÎÒÓ, ÚÒÈÌˆÓ Î·È ˘ÚËÓÈÎÒÓ ·ÓÙÈÁfiÓˆÓ ˘Ô‚ÔËıÔ‡Ó ÙË ‰È¿ÁÓˆÛË. ∏ ·ÚÔ˘Û›· ·ÓÙÈη„ȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Ë ·Ô˘Û›· ·ÓÙÈ˘ÚËÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ÂÓ‰ÂÈÎÙÈΤ˜ Ù˘ ÔÍ›·˜ Ïԛ̈͢, ‰ÈfiÙÈ Ù· EBV ·ÓÙÈ˘ÚËÓÈο ·ÓÙÈÛÒÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿ÚÚˆÛ˘ (4,5). ∏ ÔÍ›· §ª Â›Ó·È Û˘Ó‹ıˆ˜ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÓfiÛÔ˜ (6). øÛÙfiÛÔ, Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ ηٷϋÁÂÈ Û ¯ÚfiÓÈ· ÂÓÂÚÁfi Ïԛ̈ÍË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÔÙÚÔ¤˜ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È Ùˆ¯‹ ÚfiÁÓˆÛË (7,8). ∞ÔÙÂÏ› ÌÈ· ÛÔ‚·Ú‹ ·Ûı¤ÓÂÈ· Ì ¿ÁÓˆÛÙË ·ıÔÁ¤ÓÂÈ· Ô˘ ÂÈ̤ÓÂÈ ¿Óˆ ·fi 3-6 Ì‹Ó˜ ¤ˆ˜ Î·È ¯ÚfiÓÈ·, ÂÓÒ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Î·È Û ¿ÙÔÌ· Ì ηϋ ·ÓÔÛÔÏÔÁÈ΋ ηٿÛÙ·ÛË (911). ∂ÈϤÔÓ, Û ·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÙˆÓ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ë EBV Ïԛ̈ÍË Ô‰ËÁ› Û˘¯Ó¿ Û ¯ÚfiÓÈ· ÂÓÂÚÁfi Ïԛ̈ÍË Ì Èı·Ó‹ ÂͤÏÈÍË Û ηÎÔ‹ıÂÈ· ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡. ™Â ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜, Ë §ª ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ÂÈıÂÙÈ΋ ÔÚ›· Ì ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ÂÈÏÔΤ˜ (7,12,13). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó·˙‹ÙËÛË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Î·È ÌÂÙ¿ ÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ ÏÔ›Paediatriki 2008;71:135-140

̈͢, ηıÒ˜ Î·È Ë ‰ÈÂÚ‡ÓËÛË Ù˘ Û¯¤Û˘ ÙÔ˘˜ Ì ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË Î·È ÙËÓ ÂÁηٿÛÙ·ÛË ·ÓÔÛ›·˜.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 26 ·ÛıÂÓ›˜, 15 ·ÁfiÚÈ· Î·È 11 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 2-14 ÂÙÒÓ, Ì ̤ÛÔ fiÚÔ ËÏÈΛ·˜ 6,6±3,5 ¤ÙË. √È ·ÛıÂÓ›˜ ÓÔÛËχıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÙÒÓ 2005-2006 Î·È ÏËÚÔ‡Û·Ó Ù· ÂÍ‹˜ ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·: ·) ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÚ›· ·fi Ù· ·Ú·Î¿Ùˆ: ˘ÚÂÙfi˜, Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·, ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÛÏËÓÔÌÂÁ·Ï›·, ÙÚ·ÓÛ·ÌÈÓ·Û·ÈÌ›· Î·È ‚) ıÂÙÈο IgM ·ÓÙÈÛÒÌ·Ù· ˆ˜ ÚÔ˜ EBV ‹ CMV. √ ¤ÏÂÁ¯Ô˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ¿ÏÏˆÓ ·ÈÙ›ˆÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙÔ ™§ª (ÂÚËÙÔ˚Ô‡ 6, Parvo B19, ·‰ÂÓÔ˚Ô‡ Î·È ÙÔÍÔÏ¿ÛÌ·ÙÔ˜) ·¤‚Ë ·ÚÓËÙÈÎfi˜. ∫·Ó¤Ó·˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ‰ÂÓ Â›¯Â ÁÓˆÛÙ‹ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ· ‹ ·ÓÔÛÔηٷÛÙÔÏ‹. √ ÛÎÔfi˜ Ù˘ ÌÂϤÙ˘ ÂÍËÁ‹ıËΠÛÙÔ˘˜ ÁÔÓ›˜ Î·È fiÏÔÈ ÔÈ ÁÔÓ›˜ ¤‰ˆÛ·Ó ÁÚ·Ù‹ Û˘ÁηٿıÂÛË ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘. ™Â fiÏ· Ù· ·È‰È¿ ¤ÁÈÓ ÎÏÈÓÈ΋ ÂͤٷÛË Î·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ÎÏÈÓÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, ηıÒ˜ Î·È ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÛÏËÓfi˜. ∆· ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜, ·Ó¿ÏÔÁ· Ì ÙÔ ·›ÙÈÔ Ù˘ Ïԛ̈͢: Ë Ì›· ÔÌ¿‰· ÂÚÈÂÏ¿Ì‚·Ó 18 ·È‰È¿ Ô˘ ›¯·Ó ıÂÙÈο EBV IgM ·ÓÙÈÛÒÌ·Ù· Î·È Ë ¿ÏÏË ÂÚÈÂÏ¿Ì‚·Ó 8 ·È‰È¿ Ô˘ ›¯·Ó ıÂÙÈο CMV IgM ·ÓÙÈÛÒÌ·Ù·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·ÓÂ: ÁÂÓÈ΋ ·›Ì·ÙÔ˜, SGOT, SGPT, Á-GT, ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ IgG, IgA, IgM Î·È ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô ∆, µ Î·È ¡∫ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆ÚÂȘ ¤ˆ˜ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿, ¤ÁÈÓ ÂÎÙ›ÌËÛË Ù˘ ÎÏÈÓÈ΋˜ ÔÚ›·˜ Î·È Â·Ó¿ÏË„Ë ÙÔ˘ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡ ÂϤÁ¯Ô˘. ∏ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ IgG ¤Ó·ÓÙÈ ÙÔ˘ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô‡, ÙÔ˘ ·‰ÂÓÔ˚Ô‡ Î·È ÙÔ˘ ÙÔÍÔÏ¿ÛÌ·ÙÔ˜ (Toxoplasma gondii) ¤ÁÈÓ ÔÛÔÙÈο, Ë ‰Â ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ IgM ¤ÁÈÓ ÔÈÔÙÈο Ì ÙË ÌÈÎÚÔۈ̷Ùȉȷ΋ ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô (MEIA, Axsym, Abbott). ∏ ·Ó›¯Ó¢ÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ IgG Î·È IgM ¤Ó·ÓÙÈ ÙÔ˘ η„ȉÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ EBV (EBVVCA IgG/IgM, Virotech), ÙÔ˘ HSV (HSV-IgG/IgM, Virotech) Î·È ÙÔ˘ Parvo µ19 (Parvovirus B19 IgG/IgM, Focus) ¤ÁÈÓ·Ó Ì ÙËÓ ¤ÌÌÂÛË ·ÓÔÛÔÂÓ˙˘ÌÈ΋ ̤ıÔ‰Ô (Elisa). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ (CD3+, CD3+/CD4+, CD3+/CD8+, CD19+, CD3-/CD16+56+, ÏfiÁÔ˘ CD4+/CD8+) ¤ÁÈÓ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Û ·Ó·Ï˘Ù‹ Epics Elite ESP, Coulter Î·È Ì ÙË ¯Ú‹ÛË ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù˘ ÂÙ·ÈÚ›·˜ Beckman Coulter, Immunotech. ∏ ÔÛÔÙÈ΋ ̤ÙÚËÛË ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (IgG, IgA Î·È πgM) Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̠ÙË ÓÂÊÂÏÔÌÂÙÚÈ΋ ̤ıÔ‰Ô ÛÙÔÓ ·Ó·Ï˘Ù‹ Beckman Immage ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ·ÓÙȉڷÛÙ‹ÚÈ· Ù˘ ÂÙ·ÈÚ›·˜ Beckman Coulter. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÛÙ·ÙÈÛÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ SPSS 11.0. ∏ ‰È·‰Èηۛ· ÛÙ·ÙÈÛÙÈ΋˜ ·Ó¿Ï˘Û˘ ÂÚÈÂÏ¿Ì‚·Ó ˘ÔÏÔÁÈÛÌfi ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ Ù˘ ̤Û˘ ÙÈÌ‹˜ (mean) Î·È Ù˘ Ù˘È΋˜ ·fiÎÏÈÛ˘ (SD). ∏ Û‡ÁÎÚÈÛË ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ ·È‰ÈÒÓ ¤ÁÈÓ Ì t-test. √ Û¯ÂÙÈÎfi˜ Û˘ÓÙÂÏÂÛÙ‹˜ Pearson ˘ÔÏÔÁ›ÛıËΠÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘ÛË Ù˘ Û˘Û¯¤ÙÈÛ˘ ÌÂٷ͇ ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ Î·È ÙˆÓ ¿ÏÏˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ø˜ fiÚÈÔ ÛÙ·ÙÈÛÙÈ΋˜ ÛËÌ·ÓÙÈÎfiÙËÙ·˜ ıˆڋıËÎÂ Ë ÙÈÌ‹ p<0,05.

∞ÔÙÂϤÛÌ·Ù· ∞fi Ù· 26 ·È‰È¿ Ù˘ ÌÂϤÙ˘, Ù· 18 ›¯·Ó EBV Ïԛ̈ÍË, ÂÓÒ Ù· ˘fiÏÔÈ· ›¯·Ó CMV Ïԛ̈ÍË. √

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·137

137

∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ·È‰ÈÒÓ Ì EBV Î·È CMV Ïԛ̈ÍË

CD3+

72% 23%

CD3+/CD4+ CD3+/CD8+ CD19+ NK

26% 8%

82%

38% 49%

18%

9% 10%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% √Í›· Ïԛ̈ÍË ∂·Ó¤ÏÂÁ¯Ô˜ ∂ÈÎfiÓ· 1. ª¤Û˜ ÙÈ̤˜ ˘ÔÏËı˘ÛÌÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ÛÙËÓ ÔÍ›· Ïԛ̈ÍË Î·È ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô.

¯ÚfiÓÔ˜ ÓÔÛËÏ›·˜ Î˘Ì·ÈÓfiÙ·Ó ·fi 3 ¤ˆ˜ Î·È 10 Ë̤Ú˜. √ ˘ÚÂÙfi˜ ‹Ù·Ó ÙÔ Û‡Ìو̷ Ô˘ ·ÚÔ˘Û›·˙·Ó fiÏ· Ù· ·È‰È¿ Î·È ·ÔÙ¤ÏÂÛ ÙËÓ Î‡ÚÈ· ·ÈÙ›· ÚÔÛ¤Ï¢Û˘. ∆ËÓ ÎÏ·ÛÈ΋ ÎÏÈÓÈ΋ ÙÚÈ¿‰· (˘ÚÂÙfi˜, ÏÂÌÊ·‰ÂÓ›Ùȉ· Î·È Ê·Ú˘ÁÁÔ·Ì˘Á‰·Ï›Ùȉ·) ·ÚÔ˘Û›·Û ÙÔ 65% ÙˆÓ ·È‰ÈÒÓ. √›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ ‰È·ÈÛÙÒıËΠÛÙÔ 23%, ·fiÊÚ·ÍË ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ 23%, ÂÍ¿ÓıËÌ· 11%, ÂÚÈηډ›Ùȉ· 11%, ÂÓÒ Ó¢ÌÔÓ›·, ·ÁÎÚ·ٛÙȉ· Î·È ·Ó΢ÙÙ·ÚÔÂÓ›· ·fi ¤Ó· ·È‰› ·ÓÙ›ÛÙÔȯ·. ŸÏ· Ù· ·È‰È¿ Ù˘ ÌÂϤÙ˘ ·ÚÔ˘Û›·Û·Ó ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ ¿Óˆ ·fi Ù· ·ÓÒÙÂÚ· fiÚÈ· ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘˜, Û‡Ìʈӷ Ì ÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô. ∆Ô Ì¤ÁÂıÔ˜ ÙÔ˘ ÛÏËÓfi˜ ‹Ù·Ó 11,5±1,9 cm ÛÙËÓ ÔÌ¿‰· EBV Î·È 9,8±1,8 cm ÛÙËÓ ÔÌ¿‰· CMV (p=0,04). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ‚Ú¤ıËΠfiÙÈ ÙÔ 77% ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ÔÛÔÛÙfi ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ >50% ÙˆÓ Û˘ÓÔÏÈÎÒÓ Ï¢ÎÒÓ Î·È ·fiÏ˘ÙÔ ·ÚÈıÌfi ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ >5000, ÂÓÒ ÛÙÔ 54% ‚Ú¤ıËÎ·Ó ¿Ù˘· ÏÂÌÊÔ·ÙÙ·Ú· Û ÔÛÔÛÙfi 4-29% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ™ÙÔ 81% ‰È·ÈÛÙÒıËΠ·‡ÍËÛË Ù˘ SGOT Î·È Ù˘ SGPT. √È Ì¤Û˜

ÙÈ̤˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ ¿Ù˘ˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ÀÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ̛· Ù¿ÍË ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ·ÚÔ˘Û›·Û ÙÔ 69% ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ IgM 53% Î·È ÛÙËÓ IgG 16%. ∞fi ÙËÓ ·ÓÔÛÔÊ·ÈÓÔÙ˘È΋ ·Ó¿Ï˘ÛË ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜, ÚԤ΢„ fiÙÈ ÙÔ 58% ÙˆÓ ·È‰ÈÒÓ ÂÌÊ¿ÓÈ˙ ·‡ÍËÛË ÙˆÓ CD3+ (̤ÛÔ˜ fiÚÔ˜ >80%), ÙÔ 46% ÂÏ¿ÙÙˆÛË ÙˆÓ CD3+/CD4+ Î·È ÙÔ 58% ÂÏ¿ÙÙˆÛË ÙˆÓ CD19+ (ηÙÒÙÂÚË ÙÈÌ‹ 1,9%). ™Â fiÏ· Ù· ·È‰È¿ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ Ì ۇÁ¯ÚÔÓË ÂÏ¿ÙÙˆÛË ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Ô˘ Î˘Ì·ÈÓfiÙ·Ó ·fi 0,12 ¤ˆ˜ Î·È 1. ∫·Ó¤Ó· ·È‰› ‰ÂÓ Â›¯Â ·ıÔÏÔÁÈ΋ ÙÈÌ‹ ÙˆÓ CD3-/CD16+56+. ∞fi ÙË Û‡ÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ ÙˆÓ ·Ú·¿Óˆ ·Ú·Ì¤ÙÚˆÓ ‰ÂÓ ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ·È‰ÈÒÓ Ì EBV Ïԛ̈ÍË Î·È CMV Ïԛ̈ÍË Î·Ù¿ ÙËÓ ÔÍ›· Ê¿ÛË (¶›Ó·Î·˜ 2). ∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, fiÏ· Ù· ·È‰È¿ ‹Ù·Ó ÂχıÂÚ· Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·ÚÔ˘Û›·˙·Ó Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ IgM Î·È ·‡ÍËÛË ÙˆÓ IgG ·ÓÙÈ-ÈÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÏËÓ Ì›·˜ ·ÛıÂÓÔ‡˜, Ù˘ ÔÔ›·˜ Ë ·Ó¿ÚÚˆÛË ‰È‹ÚÎÂÛ 8 Ì‹Ó˜. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ, Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ (8,7±1,4 cm) ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË (p<0,001), Û ۇÁÎÚÈÛË Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Ù˘ ÔÍ›·˜ Ïԛ̈͢. √È Ì¤Û˜ ÙÈ̤˜ Ù˘ ÂηÙÔÛÙÈ·›·˜ ·Ó·ÏÔÁ›·˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (47±10%), ÙÔ˘ ·fiÏ˘ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (3817±1136/Ìl), Ù˘ IgM (1±0,4 g/L) ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ¯·ÌËÏfiÙÂÚ˜ (p<0,001), ÂÓÒ ÔÈ Ì¤Û˜ ÙÈ̤˜ Ù˘ IgG (11,4±3,1 g/L) Î·È Ù˘ IgA (1,7±1 g/L) ‰ÂÓ Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜. √È Ì¤Û˜ ÙÈ̤˜ ÙˆÓ CD3+ (72±5%), ÙˆÓ CD3/+CD8+ (26±6%) ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ (p<0,001), ÂÓÒ ÙˆÓ CD3+/CD4+ (38±7%) Î·È CD19+ (18,37±12,7%) ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤Ó˜. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ·ÍÈÔÛËÌ›ˆÙË ÌÂÙ·‚ÔÏ‹ ÛÙ· ¡∫ ·ÙÙ·Ú· (∂ÈÎfiÓ· 1). ∏ ̤ÛË ÙÈÌ‹ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ (1,55±0,6) ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô Û ۇÁÎÚÈÛË Ì Ù˘ ÔÍ›·˜ Ïԛ̈͢ (p<0,001) (∂ÈÎfiÓ· 2). ∏ ‰ÔÎÈÌ·Û›· Pearson ¤‰ÂÈÍ fiÙÈ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘

¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ·ÈÌ·ÙÔÏÔÁÈÎÔ› Î·È Ë·ÙÈÎÔ› ‰Â›ÎÙ˜ ÙˆÓ ·È‰ÈÒÓ Ì ™§ª ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹

∞ÛıÂÓ›˜ ∏ÏÈΛ· (¤ÙË) ÃÚfiÓÔ˜ ÓÔÛËÏ›·˜ (Ë̤Ú˜) §Â˘Î¿ (Î/Ìl) §ÂÌÊÔ·ÙÙ·Ú· (%) ÕÙ˘· ÏÂÌÊÔ·ÙÙ·Ú· (%) SGPT (U/L) SGOT (U/L)

™‡ÓÔÏÔ

EBV Ïԛ̈ÍË

CMV Ïԛ̈ÍË

p

26 6,6±3,5 6,2±1,9 15.917±7.130 57,1±10,31 14,6±7,17 147±130 110±84,38

18 7±3,6 6,3±1,8 14.828±6.008 56,51±10,3 14,37±7,15 173±160 124±96

8 5,7±3,1 6±2,4 18.366±9.159 58,42±10,3 15,25±8,3 84±51 77,14±27,5

ª™ ª™ ª™ ª™ ª™ ª™ ª™

ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ¶·È‰È·ÙÚÈ΋ 2008;71:135-140

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·138

138

∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.

¶›Ó·Î·˜ 2. ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ Î·È ˘ÔÏËı˘ÛÌÔ› ∆ Î·È µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·ÛıÂÓÒÓ Ì ™§ª ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹

IgG (g/L) IgA (g/L) IgM (g/L) CD3+ (%) CD3+/CD4+ (%) CD3+/CD8+ (%) CD19+ (%) CD3-/CD16+56+ (%) CD4+/CD8+

™‡ÓÔÏÔ

EBV Ïԛ̈ÍË

CMV Ïԛ̈ÍË

p

13±3,9 2,1±1,3 2,2±0,9 82±9 22,9±10,6 48,5±15,5 7,7±4,9 9,4±3,7 0,4±0,3

13,5±4,1 2,1±1,1 2,2±0,9 78,6±10,2 22,3±10,1 47,8±14,3 7,8±4,3 9,3±3,2 0,5±0,3

12,1±3,3 2,2±1,7 2,15±1,04 81,1±6,5 24,2±12,5 49,9±17,5 7,4±6,2 9,4±4,9 0,4±0,2

ª™ ª™ ª™ ª™ ª™ ª™ ª™ ª™ ª™

ª™: ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi

ÙÔ˘ ™§ª ÛÙÔ 69% ÙˆÓ ·È‰ÈÒÓ, Û˘¯ÓfiÙËÙ· ¯·ÌËÏfiÙÂÚË ·fi ÙÔ 85-90% ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Û ÂÓ‹ÏÈΘ (3). ∏ ̤ÛË ËÏÈΛ· ÓfiÛËÛ˘ ‹Ù·Ó 6,6 ¤ÙË, 4

3

2 CD4+/CD8+

ÛÏËÓfi˜ ›¯Â ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ CD3+/CD8+ ÏÂÌÊÔ·ÙÙ·Ú· Î·È ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔ ÏfiÁÔ CD4+/CD8+. ªÂٷ͇ Ù˘ IgA Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ ‚Ú¤ıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË, ÂÓÒ ·ÚÓËÙÈ΋ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ IgA Î·È ÙˆÓ CD3+/CD4+ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Î·È ÈÛ¯˘Ú¿ ıÂÙÈ΋ Ì ٷ CD3+/CD8+. ∏ IgG ›¯Â ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ IgA Î·È Ù· CD3+/CD8+ (¶›Ó·Î·˜ 3). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ô˘ Â·ÓÂϤÁ¯ıËηÓ, ÙÚ›· ·È‰È¿ (‰‡Ô ·ÁfiÚÈ· Î·È ¤Ó· ÎÔÚ›ÙÛÈ) ËÏÈΛ·˜ 9-11 ÂÙÒÓ, ·ÚÔ˘Û›·˙·Ó ηٷ‚ÔÏ‹ Î·È ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ·. ∆· ‰‡Ô ·fi ·˘Ù¿ ›¯·Ó Ïԛ̈ÍË ·fi EBV Î·È ·¤ÎÙËÛ·Ó ·ÓÔÛ›· 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÔÍ›· Ê¿ÛË. ™ÙÔ ÙÚ›ÙÔ ·È‰›, ÎÔÚ›ÙÛÈ, Ì CMV Ïԛ̈ÍË, Ë ÂÁηٿÛÙ·ÛË ·ÓÔÛ›·˜ ηı˘ÛÙ¤ÚËÛÂ, Ì ÂÈÌÔÓ‹ ÙˆÓ ·ÓÙÈ-CMV IgM ·ÓÙÈÛˆÌ¿ÙˆÓ Â› 8 Ì‹Ó˜, ÙˆÓ ÔÔ›ˆÓ Ô Ù›ÙÏÔ˜ ÛÙ·‰È·Î¿ ÌˉÂÓ›ÛÙËÎÂ Î·È ·Ú·ÙËÚ‹ıËΠÂÈÎÚ¿ÙËÛË ÙˆÓ ·ÓÙÈ-CMV IgG ·ÓÙÈۈ̿وÓ. ∆ËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ÙÔ˘˜ ÂÈÎfiÓ· ¯·Ú·ÎÙ‹ÚÈ˙ Â›ÌÔÓË ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË (>50%), ηıÒ˜ Î·È ·ÚÔ˘Û›· ¿Ù˘ˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Â› 3 Ì‹Ó˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ¤‰ÂÈÍ fiÙÈ ÛÙËÓ ÔÍ›· Ê¿ÛË Ù· ‰‡Ô ·È‰È¿ Ì EBV Ïԛ̈ÍË Î·È ÙÔ ¤Ó· ·È‰› Ì CMV Ïԛ̈ÍË Â›¯·Ó ˘„ËÏ¿ CD3+/CD8+: 40%, 70% Î·È 70% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ô ÏfiÁÔ˜ CD4+/CD8+ ‹Ù·Ó ¯·ÌËÏfi˜: 0,5, 0,15 Î·È 0,23 ·ÓÙ›ÛÙÔȯ·. ™ÙÔ ·È‰› Ì ÙË CMV Ïԛ̈ÍË, Ô ÏfiÁÔ˜ CD4+/CD8+ ·Ú¤ÌÂÈÓ <1 ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 8 ÌËÓÒÓ.

1

0

-1

™˘˙‹ÙËÛË ™ÙË ÌÂϤÙË Ì·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ì ÔÍ›· EBV Î·È CMV Ïԛ̈ÍË ·ÚÔ˘Û›·Û·Ó ·‡ÍËÛË ÙˆÓ CD8+ ∆ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ù· ÔÔ›· ÂÏ·ÙÙÒıËÎ·Ó ·Ú¿ÏÏËÏ· Ì ÙËÓ ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË. ∞Ó¿ÏÔÁ˜ ÌÂϤÙ˜, ·Ó·ÊÔÚÈο Ì ÙÔÓ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿ÚÚˆÛ˘, Â›Ó·È Ôχ ÂÚÈÔÚÈṲ̂Ó˜ Î·È ·ÊÔÚÔ‡Ó ÌfiÓÔ ÙÔÓ EBV (14,15). √ EBV ·ÔÙ¤ÏÂÛ ·›ÙÈÔ Paediatriki 2008;71:135-140

√Í›· Ïԛ̈ÍË

∂·Ó¤ÏÂÁ¯Ô˜

∂ÈÎfiÓ· 2. ¢È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ (ÔÚÈ˙fiÓÙÈ· ÁÚ·ÌÌ‹ ÂÓÙfi˜ ÙˆÓ ·Ú·ÏÏËÏÔÁÚ¿Ì̈Ó) ÛÙÔ˘˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ̤ÙÚËÛ˘. TÔ 1o Î·È 3o ÙÂÙ·ÚÙËÌfiÚÈÔ (25% Î·È 75% ÙˆÓ ·Ú·ÙËÚ‹ÛˆÓ) ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ÙËÓ ¿Óˆ Î·È Î¿Ùˆ ÏÂ˘Ú¿ ÙÔ˘ ·Ú·ÏÏËÏÔÁÚ¿ÌÌÔ˘. √È ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ Ô˘ ÚÔ‚¿ÏÏÔ˘Ó ÂÎÙfi˜ ÙÔ˘ ·Ú·ÏÏËÏÔÁÚ¿ÌÌÔ˘ ‰ËÏÒÓÔ˘Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+.

Pediatri Mar-Apr 08

07-04-08

16:23

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139

∞ÓÔÛÔÊ·ÈÓfiÙ˘Ô˜ ·È‰ÈÒÓ Ì EBV Î·È CMV Ïԛ̈ÍË

ȉȷÈÙ¤Úˆ˜ ¯·ÌËÏ‹ Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ó·ÊÂÚfiÌÂÓË Û ¿ÏϘ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë Ïԛ̈ÍË Â›Ó·È Û˘¯ÓfiÙÂÚË Û ÂÊ‹‚Ô˘˜ Î·È Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ ˘„ËÏÒÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ ÔÌ¿‰ˆÓ (16), ηıÒ˜ Î·È Û ËÏÈ˘ 10-19 ÂÙÒÓ, ȉ›ˆ˜ Û ÎÏÂÈÛÙÔ‡˜ ÏËı˘ÛÌÔ‡˜ ÛÙÚ·ÙȈÙÈÎÒÓ Î·È ÊÔÈÙËÙÒÓ (17). ™Â ¿ÙÔÌ· ¯·ÌËÏÔ‡ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂÈ¤‰Ô˘ Î·È Û ÙÚÔÈΤ˜ Î·È ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜, Ë Ïԛ̈ÍË Â›Ó·È Û·ÓÈfiÙÂÚË Î·È ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ Û ÌÈÎÚ‹ ·È‰È΋ ËÏÈΛ· ˆ˜ ·Û˘Ìو̷ÙÈ΋ (9,18). √ CMV ˘‹ÚÍ ·ÍÈÔÛËÌ›ˆÙÔ ·›ÙÈÔ ™§ª, ηıÒ˜ ÚÔÛ¤‚·Ï 8 ·fi Ù· 26 ·È‰È¿ Ù˘ ÌÂϤÙ˘. ŸÌˆ˜, ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÍ·¯ıÔ‡Ó Û¯ÂÙÈο ·ÍÈfiÈÛÙ· Û˘ÌÂÚ¿ÛÌ·Ù· ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Ì CMV Î·È EBV Ïԛ̈ÍË, ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ‰Â›ÁÌ·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ. ø˜ ÚÔ˜ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÔÈ ÂΉËÏÒÛÂȘ Â›Ó·È ÌÂÓ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜, ·ÏÏ¿ fi¯È ÂȉÈΤ˜, fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È Î·È ·ÏÏÔ‡ (19). ŸÏ· Ù· ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÚÔ˘Û›·Û·Ó ˘ÚÂÙfi Î·È ÛÏËÓÔÌÂÁ·Ï›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ïԛ̈͢. ∆· Û˘ÌÙÒÌ·Ù· ·˘Ù¿ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·fi Ù· ·ÓÙ›ÛÙÔȯ· (84% Î·È 64%) Û ·Ó¿ÏÔÁË ÌÂϤÙË (14). ŸÛÔÓ ·ÊÔÚ¿ ÙȘ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ÎÏÈÓÈΤ˜ ÂÈÏÔΤ˜, Ë ·fiÊÚ·ÍË ÙˆÓ ·ÓÒÙÂÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ ÂÌÊ·Ó›ÛÙËΠ۠Ôχ ÏÈÁfiÙÂÚ· ·È‰È¿ (23%) ÛÙË ÌÂϤÙË Ì·˜ Û ۇÁÎÚÈÛË Ì ٷ ·È‰È¿ (64%) Ù˘ ·ÓˆÙ¤Úˆ ÌÂϤÙ˘, ÂÓÒ ÙÔ Ô›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ ·Ú·ÙËÚ‹ıËΠÛÙÔ ›‰ÈÔ ÂÚ›Ô˘ ÔÛÔÛÙfi (23% Î·È 29% ·ÓÙ›ÛÙÔȯ·). ¶Ï‹Ú˘ ·Ó¿ÚÚˆÛË ·Ú·ÙËÚ‹ıËΠ۠¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 3-6 ÌËÓÒÓ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ, ÂÎÙfi˜ ·fi Ì›· ·ÛıÂÓ‹, ÁÂÁÔÓfi˜ Ô˘ ‰È·Ê¤ÚÂÈ ·fi ÙȘ ÌÂϤÙ˜ Û ÂÓ‹ÏÈΘ, fiÔ˘ Ë ‰È¿ÚÎÂÈ· ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi 6 Ì‹Ó˜ (19,20). ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi, ÔÈ ÂÓ‹ÏÈΘ Ì¿ÏÏÔÓ ·Ú·Ì¤ÓÔ˘Ó ÌÂÙ·‰ÔÙÈÎÔ›, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ ÂÈÌÔÓ‹ ÙÔ˘ ˘„ËÏÔ‡ ∂µV DNA ÊÔÚÙ›Ô˘ ÛÙÔ Û›ÂÏfi ÙÔ˘˜ (21). §ÂÌÊÔ΢ÙÙ¿ÚˆÛË ·Ú·ÙËÚ‹ıËΠÛÙÔ 77% ÙˆÓ ·È‰ÈÒÓ Û ۇÁÎÚÈÛË Ì ÙÔ 32% Î·È ÙÔ 85% ¿ÏÏˆÓ ÌÂÏÂÙÒÓ Û ÂÓ‹ÏÈΘ (3,22). ∞‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ ‰È·ÈÛÙÒıËÎÂ Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿ Ù˘ ‰È΋˜

Ì·˜ ÌÂϤÙ˘ (80%) Û ۇÁÎÚÈÛË Ì ÙÔ 59% ·Ó¿ÏÔÁ˘ ÌÂϤÙ˘ (14). ÀÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ΢ڛˆ˜ IgM Ù¿Í˘, ·Ú·ÙËÚ‹ıËΠÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì·˜. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ïԛ̈͢ ÚÔ·ÙÂÈ fiÙÈ Ù· CD3+ ‹Ù·Ó ·˘ÍË̤ӷ ÛÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ, ‡ÚËÌ· Ô˘ Û˘ÌʈÓ› Ì ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (9,22). ∆Ô 50% ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ·ÚÔ˘Û›·Û ȉȷ›ÙÂÚË Ì›ˆÛË ÙˆÓ CD3+/CD4+ Î·È ÙˆÓ CD19+, Û ·ÓÙ›ıÂÛË Ì ÌÂϤÙË ÂÓËϛΈÓ, fiÔ˘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·ÍÈÔÛËÌ›ˆÙË ÌÂÙ·‚ÔÏ‹ (22). ∫·Ó¤Ó· ·È‰› ‰ÂÓ ·ÚÔ˘Û›·Û ÌÂÙ·‚ÔÏ‹ ÛÙ· Ê˘ÛÈο ΢ÙÙ·ÚÔÎÙfiÓ· ¡∫, fiˆ˜ ‰È·ÈÛÙÒıËÎÂ Î·È ·fi ÙÔ˘˜ Weisberger Î·È Û˘Ó. (23), ÂÓÒ ·ÓÙ›ıÂÙ· ÔÈ Williams Î·È Û˘Ó. (22) ·Ó¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ Â›‰· ¡∫ ΢ÙÙ¿ÚˆÓ Û ÂÓ‹ÏÈΘ Ì ÔÍ›· §ª. ™Â fiÏ· Ù· ·È‰È¿, ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙˆÓ CD3+/CD8+ (̤ÛË ÙÈÌ‹: 48,5%). ¶Èı·Ófiٷٷ, Ù· CD3+/CD8+ Û˘ÓÈÛÙÔ‡Ó Ù· ÂÓÂÚÁÔÔÈË̤ӷ ∆ ÏÂÌÊÔ·ÙÙÙ·Ú· Ô˘ ÌÔÚÊÔÏÔÁÈο ÔÚ›˙ÔÓÙ·È ˆ˜ ‘¿Ù˘·’ ÏÂÌÊÔ·ÙÙ·Ú· Î·È ·ÔÙÂÏÔ‡Ó ¤ˆ˜ Î·È ÙÔ 50% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡ ÏËı˘ÛÌÔ‡ (20). ∏ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ ÛÙËÓ ÔÍ›· Ïԛ̈ÍË Û ÂÓ‹ÏÈΘ ÂÈÛËÌ·›ÓÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (20,22,24,25). ∆· CD3+/CD8+, ˆ˜ Ô Î˘Ú›·Ú¯Ô˜ ˘ÔÏËı˘ÛÌfi˜ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ·›˙Ô˘Ó ÚˆÙ·Ú¯ÈÎfi ÚfiÏÔ ÛÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡. ∞ÛÎÔ‡Ó Î˘ÙÙ·ÚÔÙÔÍÈ΋ ‰Ú¿ÛË ¤Ó·ÓÙÈ ÙˆÓ ÚÔÛ‚ÏËı¤ÓÙˆÓ ·fi ÙÔÓ Èfi µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‰ÈηÈÔÏÔÁÒÓÙ·˜ Èı·ÓÒ˜ ÙËÓ ÙÒÛË ÙˆÓ CD19+ Ô˘ ‰È·ÈÛÙÒıËΠÛÙË ÌÂϤÙË Ì·˜. ∏ ·Ú·ÙËÚÔ‡ÌÂÓË Î˘ÙÙ·ÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ CD3+/CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·Ú·ÙËÚÂ›Ù·È Î·È Û ¿ÏϘ ÏÔÈÌÒÍÂȘ, fiˆ˜ ÛÙËÓ ∏IV Î·È ÙËÓ HCV Ïԛ̈ÍË. øÛÙfiÛÔ, ÛÙË §ª Ù· CD3+/CD8+ ¤¯Ô˘Ó Ê·ÈÓfiÙ˘Ô CD45R0+/ CD45RA-, Û˘Ì‚·Ùfi Ì ∆ ÌÓËÌÔÓÈο ·ÙÙ·Ú· ·Ú¿ Ì ·Úı¤Ó· ∆ ÏÂÌÊÔ·ÙÙ·Ú· (20). ™Â fiÏ· Ù· ·È‰È¿, Ô ÏfiÁÔ˜ CD4+/CD8+ ‹Ù·Ó ÂÏ·Ùو̤ÓÔ˜ (0,12-1), ÁÂÁÔÓfi˜ ·Ó·ÌÂÓfiÌÂÓÔ ·fi ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ CD3+/CD8+ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‡ÚËÌ· Ô˘ Û˘ÌʈÓ› Ì ÙÔ˘˜ Weisberger Î·È Û˘Ó. (0,1-0,9) (23) Î·È Lima Î·È Û˘Ó. (0,11-1,23) (25).

¶›Ó·Î·˜ 3. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ ÙˆÓ ∆, µ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+, ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÛÏËÓfi˜ Î·È ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ

ª¤ÁÂıÔ˜ ÛÏËÓfi˜ SGOT SGPT Á-GT IgG IgA IgM

CD3+

CD4+

CD8+

CD19+

NK

CD4/CD8

0,97 -0,08 0,03 -0,41* 0,22 0,18 -0,24

-0,44 -0,19 -0,24 -0,26 -0,06 -0,42* -0,31

0,52** 0,06 0,36 0,16 0,47* 0,50** 0,38

-0,75 -0,04 -0,11 0,23 -0,1 -0,2 0,03

0,18 -0,01 0,07 0,05 0,21 0,19 -0,26

-0,5** -0,08 -0,21 -0,19 -0,37 -0,48* -0,39*

IgA 0,32 0,48* 0,58* 0,51** 0,48* 0,21

∆· ‰Â‰Ô̤ӷ ‰›ÓÔÓÙ·È ˆ˜ Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ (r). T· p ·Ó·Ê¤ÚÔÓÙ·È fiÙ·Ó Â›Ó·È ÛËÌ·ÓÙÈο (*p<0,05, **p<0,001) ¶·È‰È·ÙÚÈ΋ 2008;71:135-140

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·140

140

∂. ¶··‰ÔÔ‡ÏÔ˘-∞Ï·Ù¿ÎË Î·È Û˘Ó.

∫·Ù¿ ÙÔÓ Â·Ó¤ÏÂÁ¯Ô, Ë Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ·È‰ÈÒÓ ·ÚÔ˘Û›·Û ›·ÛË. ¶·Ú·ÙËÚ‹ıËΠÙÒÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ CD3+/CD8+ Î·È Â¿ÓÔ‰Ô˜ ÙˆÓ CD3+/CD4+, CD19+ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+. ∏ ÎÏÈÓÈ΋ ›·ÛË Û˘Ì‚¿‰È˙ Ì ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ‰ÂÈÎÙÒÓ. ¢È·ÈÛÙÒıËΠfiÙÈ Ù· CD3+/CD8+ ›¯·Ó ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ÛÏËÓÔÌÂÁ·Ï›·, ηıÒ˜ Î·È Ì ÙȘ IgG Î·È IgA. ™Â ÙÚ›· ·fi Ù· 26 ·È‰È¿, Ë ÎÏÈÓÈ΋ ·ÔηٿÛÙ·ÛË Î·ı˘ÛÙ¤ÚËÛ ¤ˆ˜ Î·È 8 Ì‹Ó˜, ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÔÔ›ˆÓ ÔÈ ÏfiÁÔÈ CD4+/CD8+ ·Ú¤ÌÂÓ·Ó ¯·ÌËÏÔ›. ∫·ı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿ÚÚˆÛ˘ ̤¯ÚÈ Î·È 18 Ì‹Ó˜, Ë ÔÔ›· ‰ÂÓ Û˘Ó‰¤ÂÙ·È fï˜ Ì ٷ ·˘ÍË̤ӷ Â›‰· ÙˆÓ CD3+/CD8+, ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏÏË ÌÂϤÙË (15). ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ·Ú¿Ù·ÛË Ù˘ Ïԛ̈͢ ‰ÂÓ ÔÊ›ÏÂÙ·È ÛÙÔ ·˘ÍË̤ÓÔ ÈÈÎfi ÊÔÚÙ›Ô, ·ÏÏ¿ ÛÙËÓ ÂËÚ·Ṳ̂ÓË ·ÓÔÛȷ΋ ηٿÛÙ·ÛË ÙÔ˘ ÍÂÓÈÛÙ‹ (20). ™˘ÌÂÚ·ÛÌ·ÙÈο, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ô˘ ÌÂÏÂÙ‹Û·Ì ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ EBV Î·È Ù˘ CMV Ïԛ̈͢ ··ÓÙÔ‡Ó Ì ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏË ·‡ÍËÛË ÙˆÓ CD3+/CD8+. ∏ ‡ÊÂÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ù˘ ÔÍ›·˜ Ïԛ̈͢ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ¢Ú›·˜ ΢ÙÙ·ÚÔÙÔÍÈ΋˜ ∆ ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ (CTL) ·¿ÓÙËÛ˘ ÛÙ· ·ÓÙÈÁfiÓ· ÙÔ˘ ÈÔ‡. ™˘ÓÂÒ˜, Ë ÂÎÙ›ÌËÛË ÙÔ˘ ·ÓÔÛÔÊ·ÈÓfiÙ˘Ô˘ Î·È ÙÔ˘ ÏfiÁÔ˘ CD4+/CD8+ Â›Ó·È ¯Ú‹ÛÈÌË ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ Ì ¯ÚfiÓÈ· EBV ‹ CMV Ïԛ̈ÍË.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Jenson HB. Epstein-Barr Virus. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics. 17th edition. Saunders; 2004. p. 1062-1066.

2. American Academy of Pediatrics. Epstein-Barr Virus Infections. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edition. p. 286-288.

3. Ventura KC, Hudnall SD. Hematologic differences in heterophile-positive and heterophile negative infectious mononucleosis. Am J Hematol 2004;76:315-318.

4. Koch HG, Harms E. Infektionen mit dem Epstein-Barr Virus. Deutsches Arzteblatt 1995;92:7-17.

5. Okay TS, Del Negro GM, Yamamoto L, Raiz Junior R. Detection of EBV-DNA in serum samples of an immunosuppressed child during a three years follow-up: association of clinical and PCR data with active infection. Rev Inst Med Trop Sao Paulo 2005;47:99-102.

6. Sitki-Green D, Covington M, Raab-Traub N. Compartmentalization and transmission of multiple Epstein-Barr virus strains in asymptomatic carriers. J Virol 2003;77: 1840-1847.

7. Kano K, Yamada Y, Sato Y, Arisaka O, Ono Y, Ueda Y. Glomerulonephritis in a patient with chronic active Epstein-Barr virus infection. Pediatr Nephrol 2005;20:89-92.

8. Roth DE, Jones A, Smith L, Lai R, Preiksaitis J, Robinson J. Severe chronic active Epstein-Barr virus infection mimicPaediatriki 2008;71:135-140

19.

20.

21.

22.

23.

24.

25.

king steroid-dependent inflammatory bowel disease. Pediatr Infect Dis J 2005;24:261-264.

Sugaya N, Kimura H, Hara S, Hoshino Y, Kojima S, Morishima T, et al. Quantitative analysis of Epstein-Barr virus (EBV)-specific CD8+ T cells in patients with chronic active EBV infection. J Infect Dis 2004;190:985-988.

Yuge A, Kinoshita E, Moriuchi M, Ohno Y, Haga H, Moriuchi H. Persistent hepatitis associated with chronic active Epstein-Barr virus infection. Pediatr Infect Dis J 2004; 23:74-76.

Okano M, Kawa K, Kimura H, Yachie A, Wakiguchi H, Maeda A, et al. Proposed guidelines for diagnosing chronic active Epstein-Barr virus infection. Am J Hematol 2005;80:64-69.

Hara S, Hoshino Y, Naitou T, Nagano K, Iwai M, Suzuki K, et al. Association of virus infected-T cell in severe hepatitis caused by primary Epstein-Barr virus infection. J Clin Virol 2006;35:250-256.

Jenson HB. Acute complications of Epstein-Barr virus infectious mononucleosis. Curr Opin Pediatr 2000;12: 263-268.

Chan CW, Chiang AK, Chan KH, Lau AS. Epstein-Barr virus-associated infectious mononucleosis in Chinese children. Pediatr Infect Dis J 2003;22:974-978.

Novitskii VV, Urazova OI, Naslednikova IO, Pomogaeva AP, Syusina LV. Subpopulation composition of peripheral blood lymphocytes in children with infectious mononucleosis. Bull Exp Biol Med 2002;134:57-59.

Grotto I, Mimouni D, Huerta M, Mimouni M, Cohen D, Robin G, et al. Clinical and Laboratory presentation of EBV positive infectious mononucleosis in young adults.

Epidemiol Infect 2003;131:683-689.

Ebell MH. Epstein-Barr virus infectious mononucleosis.

Am Fam Physician 2004;70:1279-1287.

Cohen JI. Epstein-Barr virus infection. New Engl J Med 2000;343:481-492.

Rea TD, Russo JE, Katon W, Ashley RL, Buchwald DS. Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract 2001;14:234-242.

Cameron B, Bharadwaj M, Burrows J, Fazou C, Wakefield D, Hickie I, et al; Dubbo Infection Outcomes Study. Prolonged illness after infectious mononucleosis is associated with altered immunity but not with increased viral load. J Infect Dis 2006;193:664-671.

Fafi-Kremer S, Morand P, Brion JP, Pavese P, Baccard M, Germi R, et al. Long-term shedding of infectious EpsteinBarr virus after infectious mononucleosis. J Infect Dis 2005;191:985-989.

Williams H, Macsween K, McAulay K, Higgins C, Harrison N, Swerdlow A, et al. Analysis of immune activation and clinical events in acute infectious mononucleosis. J Infect Dis 2004;190:63-71.

Weisberger J, Cornfield D, Gorczyca W, Liu Z. Down-regulation of pan-T-cell antigens, particularly CD7, in acute infectious mononucleosis. Am J Clin Pathol 2003;120:49-55.

Ohga S, Nomura A, Takada H, Hara T. Immunological aspects of Epstein-Barr virus infection. Crit Rev Oncol Hematol 2002;44:203-215.

Lima M, Teixeira Mdos A, Queirfis ML, Santos AH, Gonçalves C, Correia J, et al. Immunophenotype and TCRVbeta repertoire of peripheral blood T-cells in acute infectious mononucleosis. Blood Cells Mol Dis 2003;30:1-12.

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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞

ORIGINAL ARTICLE

141

ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿: ÂÌÂÈÚ›· 15 ÂÙÒÓ Û ¤Ó· ΤÓÙÚÔ Ÿ. µÚ¿ÓË1, ª. ¶·ÓÙÈΛ‰Ô˘1, °. ÿÌ‚ÚÈÔ˜2, π. •˘ÓÈ¿˜1, µ. ¢ÂÌÂÚÙ˙›‰Ô˘1, ∫. ∫¿ÓÙ˙ÈÔ˘1, ∞. ª·˘ÚÔ˘‰‹1, ¢. ∆·ÎÔ‡‰·˜2, £. ¶··ÛÙ·‡ÚÔ˘1, ∫. ™‡ÚÔÁÏÔ˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏) ÛÙ· ·È‰È¿ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ıÂÚ·›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÌË ·Ó·ÛÙÚ¤„ÈÌ˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ·Ó·ÊÔÚ¿ Ù˘ ÂÌÂÈÚ›·˜ Ì·˜ ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∞fi ÙÔ 1990 ̤¯ÚÈ Û‹ÌÂÚ·, 16 ·ÛıÂÓ›˜ Ù˘ °’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜, ËÏÈΛ·˜ 6 ÌËÓÒÓ ¤ˆ˜ 13 ÂÙÒÓ, ˘Ô‚Ï‹ıËÎ·Ó Û ª∏. ∞fi Ù· ·È‰È¿ ·˘Ù¿, 9 ›¯·Ó ·ÙÚËÛ›· Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, 2 ÔÍ›· Ë·ÙÈ΋ Ó¤ÎÚˆÛË ÌÂÙ¿ ÙË ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ, 1 Û‡Ó‰ÚÔÌÔ Alagille, 1 ÂÓ‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ÌË Û˘Ó‰ÚÔÌÈÎÔ‡ Ù‡Ô˘, 1 ÓfiÛÔ ÙÔ˘ Wilson, 1 ÚˆÙÔ·ı‹ ˘ÂÚÔÍ·ÏÔ˘Ú›· Î·È 1 Ë·ÙÔ‚Ï¿Ûو̷. ¢¤Î· ·È‰È¿ ˘Ô‚Ï‹ıËÎ·Ó Û ª∏ ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£ Î·È Ù· ˘fiÏÔÈ· Û ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ∆ÚÂȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ¤ÁÈÓ·Ó ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ‰fiÙË Î·È 13 ·fi و̷ÙÈÎfi ‰fiÙË. ŒÍÈ ·È‰È¿ ¤Ï·‚·Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ΢ÎÏÔÛÔÚ›ÓË, MMF Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È 7 ·È‰È¿ tacrolimus ·ÓÙ› ΢ÎÏÔÛÔÚ›Ó˘. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 16 ·È‰È¿ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË, 3 η٤ÏËÍ·Ó ÙÔÓ ÚÒÙÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi Ì‹Ó·. ∞fi Ù· ˘fiÏÔÈ· Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠¤ˆ˜ Û‹ÌÂÚ·, 3 ·ÚÔ˘Û›·Û·Ó ÔÍ›· Î·È 1 ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶¤ÓÙ ·È‰È¿ ÂÌÊ¿ÓÈÛ·Ó Ïԛ̈ÍË ·fi CMV, 5 ·fi EBV, 2 Ïԛ̈ÍË ·fi HSV, 2 ·fi Èfi Parvo µ19, 1 ·fi Èfi Coxsackie Î·È 1 ·fi Candida albicans. ∂›Û˘, ¤Ó· ·È‰› ·ÚÔ˘Û›·Û ·ÈÌÔÚÚ·Á›· ÙÔ˘ ·ÓÒÙÂÚÔ˘ °∂™ Î·È ¤Ó· ·ÚÔ˘Û›·Û ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ∏ ¤Î‚·ÛË ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ‹Ù·Ó ηϋ, Ì ηϋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÂÎÙfi˜ ·fi ÙËÓ ÂÚ›ÙˆÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ÙË ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ Ô˘ ¯ÚÂÈ¿ÛÙËΠӤ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÔÚ›· Î·È ¤Î‚·ÛË ·È‰ÈÒÓ Ì Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Û¯ÂÙÈο ηϋ Ì ÙËÓ ÚÔ¸fiıÂÛË Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ·.

1 °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 2 ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ AÏÏËÏÔÁÚ·Ê›·: ∫ÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘ klspirog@med.auth.gr °’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞¶£, πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ∫ˆÓÛÙ·ÓÙÈÓÔ˘fiψ˜ 49 ∆.∫. 546 39, £ÂÛÛ·ÏÔÓ›ÎË

§¤ÍÂȘ ÎÏÂȉȿ: ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·È‰È¿.

Liver transplantation in children: 15 years experience in one center O. Vrani1, M. Pantikidou1, G. Imvrios2, I. Xinias1, V. Demertzidou1, K. Kantziou1, A. Mavroudi1, D. Takoudas2, T. Papastaurou1, K. Spyroglou1 Abstract Background: Liver transplantation (LT) is the only treatment for children with irreversible liver failure. This is a report of the follow-up of a series of 16 children who underwent LT. Methods: Since 1990, 16 patients of the 3rd Paediatric Clinic of the Hippocration General Hospital of Thessaloniki, aged 6 months to 13 years, underwent LT. Nine children presented initially with extrahepatic biliary atresia, 2 with acute liver failure following toxic mushroom ingestion, 1 with Alagille syndrome, 1 with non-syndromic intrahepatic biliary paucity, 1 with Wilson’s disease, 1 with primary hyperoxaluria and 1 with hepatoblastoma. Ten children underwent LT in the Organ Transplantation Unit of the Aristotle University of Thessaloniki and the others in various medical centers in other countries. Three transplants came from living-related donors and 13 from deceased donors. Six children went under immunosuppressive treatment with cyclosporine, MMF and corticosteroids and seven with tacrolimus, MMF and corticosteroids.

Results: Three of the 16 children died within the first month after transplantation due to post-transplant complications, and eleven have survived. Three children presented with acute rejection and one with chronic organ rejection, which was successfully managed. Five children developed CMV infection, 5 EBV infection, 2 HSV infection, 2 Parvo B19 virus and 1 Candida Albicans infection. One child had upper GI haemorrhage and one presented with small biliary paucity. The outcome was satisfactory in most cases, with good graft function, except in the case of the patient with small biliary paucity, who required retransplantation.

Conclusions: The long-term clinical course of children following LT is good, provided that they are monitored in specialized centres.

1. 3rd Department of Paediatrics, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece 2. Department of Surgery, Organ Transplantation Unit, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece Correspondence: ∫leomenis Spyroglou klspirog@med.auth.gr 3rd Department of Paediatrics, Aristotle University, Hippokration General Hospital of Thessaloniki 49 Konstantinoupoleos St., 546 39, Thessaloniki, Greece

Key words: Liver transplantation, children. ¶·È‰È·ÙÚÈ΋ 2008;71:141-147

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142

Ÿ. µÚ¿ÓË Î·È Û˘Ó.

∂ÈÛ·ÁˆÁ‹ ∏ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏) Ú·ÁÌ·ÙÔÔÈ‹ıËΠÙÔ 1963 ·fi ÙÔÓ Starzl (1) ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ ∫ÔÏÔÚ¿ÓÙÔ Û ·È‰› 3 ÂÙÒÓ Ô˘ ¤·Û¯Â ·fi ·ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. √ ·ÛıÂÓ‹˜ ·˘Ùfi˜ η٤ÏËÍ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Â¤Ì‚·Û˘ ÏfiÁˆ ·ıÚfi·˜ ·ÈÌÔÚÚ·Á›·˜. ∆¤ÛÛÂÚ· ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·fi ÙÔÓ ›‰ÈÔ È·ÙÚfi Ë ÚÒÙË ÂÈÙ˘¯‹˜ ª∏ Û ¤Ó· Ó‹ÈÔ 18 ÌËÓÒÓ Ì Ë·ÙÔ‚Ï¿Ûو̷, ÙÔ ÔÔ›Ô Â¤˙ËÛ ÁÈ· 400 Ë̤Ú˜ (2). ∆ËÓ ›‰È· ÂÚ›Ô‰Ô ¿Ú¯ÈÛÂ Ë ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ Ù˘ ª∏ Î·È ÛÙËÓ ∂˘ÚÒË Ì ˘„ËÏ¿, fï˜, ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜ ηٿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›·, Ô˘ ¤ÊÙ·Ó·Ó ÙÔ 60-70% (3,4). ŒÎÙÔÙÂ, Ë ‚ÂÏÙ›ˆÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È Ë ·Ó¿Ù˘ÍË Ó¤ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ, ÙÔ ÔÔ›Ô Û‹ÌÂÚ·, ÛÙ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ·, ÍÂÂÚÓ¿ ÙÔ 90% ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙË ¯ÚfiÓÈ· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ÙÔ 70% ÛÙËÓ ÔÍ›·, ÂÓÒ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË (10-15 ¤ÙË) ÍÂÂÚÓ¿ ÙÔ 80% (5-8). ª¿ÏÈÛÙ·, ÏfiÁˆ ÙˆÓ Ôχ ηÏÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÂÎÙ¿ıËÎ·Ó ÁÚ‹ÁÔÚ· Î·È ÔÈ ÂӉ›ÍÂȘ Ù˘, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÌÊ·ÓÈÛÙ› ¤Ó‰ÂÈ· ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ë ÔÔ›· ÂÚÈfiÚÈ˙ ÙËÓ ÔÚıÔÙÔÈ΋ ª∏ ÛÙ· ·È‰È¿. ™ËÌ·ÓÙÈ΋ ÒıËÛË ÛÙËÓ Â¤ÎÙ·ÛË ÙˆÓ ª∏, ȉ›ˆ˜ Û ‚Ú¤ÊË Î¿Ùˆ ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ Î·È ‚¿ÚÔ˘˜ οو ÙˆÓ 10 kg, ¤‰ˆÛ·Ó ÔÈ Ù¯ÓÈΤ˜ Ù˘ ÙÌËÌ·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (split liver) Î·È Ù˘ ÌÂıfi‰Ô˘ ÂÏ·ÙÙÒÛˆ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (reduced size), ηıÒ˜ Â›Û˘ Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ‰fiÙË. ∏ ̤ıÔ‰Ô˜ ÂÏ·ÙÙÒÛˆ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1984 Û ·È‰› ·fi ÙÔ˘˜ Bismuth Î·È Houssin (9). ∆Ô 1989 ÔÈ Pichlmayr Î·È Û˘Ó. (10) ·Ó·ÎÔ›ÓˆÛ·Ó ÙËÓ ÚÒÙË ÂÈÙ˘¯Ë̤ÓË ÙÌËÌ·ÙÈ΋ ª∏, ÂÓÒ ÔÈ ÚÒÙ˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ˆÓÙ·Ófi ‰fiÙË ÂÚÈÁÚ¿ÊÔÓÙ·È ·fi ÙÔ˘˜ Broelsch Î·È Û˘Ó. (11). ™‹ÌÂÚ·, Ë ª∏ ÛÙ· ·È‰È¿ ·ÔÙÂÏ› ıÂÚ·›· ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ¤Ó‰ÂÈÍË -fiˆ˜ ηÎÔ‹ıÂÈ· ÂÎÙfi˜ ‹·ÙÔ˜, Û˘ÁÎÂÎÚÈ̤Ó˜ ÓÂÔϷۛ˜ ÙÔ˘ ‹·ÙÔ˜, fiˆ˜ ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷- ‹ ·ÎfiÌË Û˘Óı‹Î˜ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡, Ô˘ Ó· ÌËÓ ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÙË Û˘ÌÌfiÚʈÛË Ì ٷ ÚˆÙfiÎÔÏÏ· Ù˘ ·ÁˆÁ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (12). ™ÙË ¯ÒÚ· Ì·˜ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ Û ·È‰È¿ ·fi ÙÔ 1990, ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£, ÂÓÒ ·Ú¿ÏÏËÏ· ÙÔ ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏÔÁÈÎfi ∆Ì‹Ì· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ¤¯ÂÈ ·ÔÎÔÌ›ÛÂÈ ÛËÌ·ÓÙÈ΋ ÂÌÂÈÚ›· ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË 16 ·È‰ÈÒÓ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ë·Paediatriki 2008;71:141-147

¶›Ó·Î·˜ 1. ¢ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È ·›ÙÈ· ª∏ ∏ÏÈΛ· ª¤ÛË 5 ¤ÙË (6 Ì‹Ó˜ - 13 ¤ÙË) <1 ¤ÙÔ˘˜ 3 1-6 ÂÙÒÓ 9 7-13 ÂÙÒÓ 4 º‡ÏÔ ∞ÁfiÚÈ· 8 ∫ÔÚ›ÙÛÈ· 8 ∞›ÙÈ· ∞ÙÚËÛ›· Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ 9 √Í›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÌÂÙ¿ ÙË ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ 2 ∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË (Û‡Ó‰ÚÔÌÔ Alagille, ÌË Û˘Ó‰ÚÔÌÈÎÔ‡ Ù‡Ô˘) 2 ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (ÓfiÛÔ˜ Wilson, ÚˆÙÔ·ı‹˜ ˘ÂÚÔÍ·ÏÔ˘Ú›·) 2 ŸÁÎÔÈ ‹·ÙÔ˜ (Ë·ÙÔ‚Ï¿Ûو̷) 1

ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÛÙ· ÔÔ›· ÙÂÏÈÎÒ˜ Ù¤ıËΠ¤Ó‰ÂÈÍË ÁÈ· ª∏. ¶·ÚÔ˘ÛÈ¿˙Ô˘Ì ٷ ·›ÙÈ· Ô˘ Ô‰‹ÁËÛ·Ó ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÙȘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÌÂıfi‰Ô˘˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, ÙËÓ ¤Î‚·Û‹ Ù˘, ηıÒ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ÌÂÙ¿ ÙË ª∏.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∞fi ÙÔ 1990 ̤¯ÚÈ Û‹ÌÂÚ·, 16 ·È‰È¿ (8 ·ÁfiÚÈ· Î·È 8 ÎÔÚ›ÙÛÈ·) ˘Ô‚Ï‹ıËÎ·Ó Û ª∏, 10 ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£ Î·È 6 Û ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ∆· ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ Î·È Ù· ·›ÙÈ· Ô˘ Ô‰‹ÁËÛ·Ó Û ª∏, ηıÒ˜ Î·È Ë ÔÛÔÛÙÈ·›· ·Ó·ÏÔÁ›· ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Î·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ ·ÔÙÂÏ› ÙÔ ÚÒÙÔ ÛÂ Û˘¯ÓfiÙËÙ· ·›ÙÈÔ. ∞ÎÔÏÔ˘ıÔ‡Ó Ë ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË (Û‡Ó‰ÚÔÌÔ Alagille, ÌË Û˘Ó‰ÚÔÌÈ΋ ˘ÔÏ·Û›· ÂÓ‰ÔË·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ), Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (ÓfiÛÔ˜ Wilson, ÚˆÙÔ·ı‹˜ ˘ÂÚÔÍ·ÏÔ˘Ú›·) ηÈ

ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· 13%

ŸÁÎÔÈ ‹·ÙÔ˜ 5%

∞ÙÚËÛ›· 56%

∂Ó‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË 13%

√Í›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· 13% ∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙÈ·›· ·Ó·ÏÔÁ›· ÙˆÓ ·ÈÙÈÒÓ Ô˘ Ô‰‹ÁËÛ·Ó Û ª∏ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜.

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·143

143

ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿

Ë ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÌÂÙ¿ ·fi ‚ÚÒÛË ÙÔÍÈÎÒÓ Ì·ÓÈÙ·ÚÈÒÓ, ηÈ, Ù¤ÏÔ˜, ÔÈ fiÁÎÔÈ ÙÔ˘ ‹·ÙÔ˜. ∞fi Ù· 9 ·È‰È¿ Ì ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ, 3 ›¯·Ó ˘Ô‚ÏËı› Û Â¤Ì‚·ÛË Kasai (Ë·ÙÔ˘ÏÔÂÓÙÂÚÔ·Ó·ÛÙfïÛË) ÚÈÓ ·fi ÙË ª∏ Û ËÏÈΛ· 1, 2 Î·È 4 ÌËÓÒÓ. ™Â 2 ·È‰È¿ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÂ¤Ì‚·ÛË Kasai Ù‡Ô˘ II, ηٿ ÙËÓ ÔÔ›· ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÂÓÙÂÚÔÛÙÔÌ›· ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ ·Ú¤Ì‚·Û˘ ̤ۈ ·˘Ù‹˜ ÛÙË ¯ÔÏÔÂÙÈ΋ ·Ó·ÛÙfïÛË, Î·È Û ¤Ó· ·È‰› Kasai Ù‡Ô˘ I. ™Â fiÏ· Ù· ·È‰È¿, ÚÈÓ ·fi ÙË ª∏, Ù·ÍÈÓÔÌ‹ıËÎÂ Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· ηٿ Child-Pugh (9). ŒÓ· ·È‰› ‹Ù·Ó ÛÙ·‰›Ô˘ ∞, 7 ÛÙ·‰›Ô˘ µ, Î·È 8 ÛÙ·‰›Ô˘ C. ™Â 3 ·È‰È¿ ‰fiÙ˘ ‹Ù·Ó Ë ÌËÙ¤Ú·, ·fi ÙËÓ ÔÔ›· ÂÏ‹ÊıËÛ·Ó Ù· ÙÌ‹Ì·Ù· II & III ÙÔ˘ ‹·ÙÔ˜. ™Ù· ˘fiÏÔÈ· 13 ·È‰È¿ ÙÔ ÌfiÛ¯Â˘Ì· ÚÔÂÚ¯fiÙ·Ó ·fi و̷ÙÈÎfi ‰fiÙË. ™Â 7 ÂÚÈÙÒÛÂȘ Ô ‰fiÙ˘ ‹Ù·Ó ·È‰›, ÂÓÒ Û 6 ¯ÚËÛÈÌÔÔÈ‹ıËΠÌfiÛ¯Â˘Ì· ·fi ÂÓ‹ÏÈη ‰fiÙË. ∞fi ·˘Ù¤˜ ÙȘ 6 ÂÚÈÙÒÛÂȘ, ÛÙȘ 4 ÂÊ·ÚÌfiÛÙËÎÂ Ë Ù¯ÓÈ΋ split liver, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ù· ÙÌ‹Ì·Ù· ππ & πππ ÙÔ˘ ‹·ÙÔ˜, ÂÓÒ Ô ‰ÂÍÈfi˜ ÏÔ‚fi˜ ÌÂÙ·ÌÔۯ‡ıËΠ۠ÂÓ‹ÏÈη Ï‹ÙË, Î·È ÛÙȘ ¿ÏϘ 2 ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Â›Û˘ Ù· ÙÌ‹Ì·Ù· ππ & πππ, ÁÈ· ÙÔ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ÔÔ›ˆÓ, fï˜, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ù¯ÓÈ΋ reduced-size, ηٿ ÙËÓ ÔÔ›· ÙÔ ÂÓ·ÔÌÂ›Ó·Ó ÙÌ‹Ì· ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È ÌË ¯ÚËÛÈÌÔÔÈ‹ÛÈÌÔ. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÈ ·ÛıÂÓ›˜ ·Ú¤ÌÂÈÓ·Ó Û˘Ó‰Â‰Â̤ÓÔÈ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ÁÈ· 24 ¤ˆ˜ 48 ÒÚ˜ Î·È ‚Ú›ÛÎÔÓÙ·Ó ˘fi ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ÔÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜, ÌÂÙ·‚ÔÏÈΤ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, Ë ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Î·È ÔÈ ÏÔÈÌÒÍÂȘ. ø˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁ‹ıËΠ·Ú¯ÈÎÒ˜ methylprednizolone (2 mg/kg IV) Î·È ·ÎÔÏÔ‡ıˆ˜ prednizolone (0,2 mg/kg, per os), ÛÂ Û˘Ó‰˘·ÛÌfi Ì mycophenolate mofetil/ MMF (CellCept) Î·È Î˘ÎÏÔÛÔÚ›ÓË (Neoral) Û 6 ·È‰È¿, ÂÓÒ Û 7 ·È‰È¿, ·ÓÙ› Ù˘ ΢ÎÏÔÛÔÚ›Ó˘, ¯ÔÚËÁ‹ıËΠFK506/ tacrolimus (Prograf).

∞ÔÙÂϤÛÌ·Ù· ∆Ú›· ·È‰È¿ η٤ÏËÍ·Ó ÙÔÓ ÚÒÙÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi Ì‹Ó· ·fi ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜: ¤Ó· ·fi ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, ¤Ó· ·fi ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ Î·È ¤Ó· ·fi ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∞fi Ù· 13 ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ıԇ̠¤ˆ˜ Û‹ÌÂÚ·, 4 ÂÌÊ¿ÓÈÛ·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ̤ÛÔ fiÚÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘˜ 25,7 Ì‹Ó˜ ÌÂÙ¿ ÙË ª∏. ™Ù· ‰‡Ô ·È‰È¿ Ù· ÂÂÈÛfi‰È· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÈÙ˘¯Ò˜ Ì ÒÛÂȘ ÎÔÚÙÈ˙fiÓ˘. ™Ù· ˘fiÏÔÈ· ‰‡Ô ··ÈÙ‹ıËΠ¯ÔÚ‹ÁËÛË ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈÎÔ‡ ÔÚÔ‡ (ATG), ÏfiÁˆ ·ÓıÂÎÙÈÎfiÙËÙ·˜ Ù˘ ·ÔÚÚÈÙÈ΋˜ ‰È·‰Èηۛ·˜ ÛÙ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ™ÙË Ì›· ÂÚ›ÙˆÛË Ë ·ÓÙ›ÛÙ·ÛË ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÔÊ›ÏÂÙÔ ÛÙÔ fiÙÈ Ô ‰fiÙ˘ ‹Ù·Ó Û˘Ì‚·Ù‹˜ Î·È fi¯È ›‰È·˜ ÔÌ¿‰·˜ ·›Ì·ÙÔ˜. √ ·ÛıÂÓ‹˜ ·˘Ùfi˜ ·ÚÔ˘Û›·Û ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ÔÔ›· fï˜ ÌÂÙÚÈ¿ÛÙËΠ̠·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ·fi ΢ÎÏÔÛÔÚ›ÓË Û tacrolimus. ∆ÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÎÚ›ıËΠ··Ú·›ÙËÙË Û 3 Û˘ÓÔÏÈο ·ÛıÂÓ›˜. ™ÙÔ˘˜

¶›Ó·Î·˜ 2. ∂ÈÏÔΤ˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·Ù¿ ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ∂ÈÏÔ΋ §Ô›ÌˆÍË ñ CMV ñ EBV ñ Parvo B19 ñ HSV1,2 ñ Coxsackie ñ Candida albicans ∞fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜ ∞ÈÌÔÚÚ·Á›· ·ÓÒÙÂÚÔ˘ °∂™ ÀÂÚÔ˘Úȯ·ÈÌ›· ∂Í·Ê¿ÓÈÛË ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ

∞ÚÈıÌfi˜ ·ÛıÂÓÒÓ 5 5 2 2 1 1 4 1 1 1

2 ¤ÁÈÓ ·ÏÏ·Á‹ ÙÔ˘ Û¯‹Ì·ÙÔ˜ ·fi cyclosporine Û tacrolimus, ÂÍ·ÈÙ›·˜ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ ÛÙË Ì›· ÂÚ›ÙˆÛË -Ë ÔÔ›· ‰ÈÂÁÓÒÛıË Ì ÎÏÂÈÛÙ‹ ‚ÈÔ„›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜-, Î·È ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÛÙËÓ ¿ÏÏË. ∏ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÂΉËÏÒıËΠ̠·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ Î·È ÂÏ¿ÙÙˆÛË ÙÔ˘ GFR ηٿ ÙË Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ÌÂϤÙË. ∆¤ÏÔ˜, Û ¤Ó· ·È‰› Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·ÏÏ·Á‹ ·fi tacrolimus Û ΢ÎÏÔÛÔÚ›ÓË, ÏfiÁˆ ·Ú¯fiÌÂÓ˘ ·ÁÎÚ·ٛÙȉ·˜. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙȘ ÏÔÈÌÒÍÂȘ (¶›Ó·Î·˜ 2), ·ÓȯÓ‡ıËÎ·Ó Î˘Ú›ˆ˜ ÔÈ ÈÔ› CMV, EBV Î·È Parvo µ19 Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). ∂›Û˘, 2 ·È‰È¿ ·ÚÔ˘Û›·Û·Ó Ïԛ̈ÍË ·fi HSV, 1 ·fi Coxsackie Î·È 1 ·fi Candida albicans. √È ÏÔÈÌÒÍÂȘ ·˘Ù¤˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ÂÈÙ˘¯Ò˜ Ì ÂÏ¿ÙÙˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÙË ¯ÔÚ‹ÁËÛË gancyclovir, acyclovir ‹ amphotericin B. ªÈÎÚԂȷ΋ Ïԛ̈ÍË ‰ÂÓ ÂÌÊ¿ÓÈÛ ηӤӷ˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜. ÕÏϘ ÂÈÏÔΤ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, ‹Ù·Ó Á·ÛÙÚÔÚÚ·Á›· Î·È ˘ÂÚÔ˘Úȯ·ÈÌ›·. ∆¤ÏÔ˜, ¤Ó·˜ ·ÛıÂÓ‹˜ ÂÌÊ¿ÓÈÛ ÓfiÛÔ ÂÍ·Ê¿ÓÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ‡ÛÙÂÚ· ·fi ‰È·‰Ô¯ÈΤ˜ ÏÔÈÌÒÍÂȘ ·fi ÙÔ˘˜ ÈÔ‡˜ Parvo B19, CMV Î·È EBV ηٿ ÙËÓ ÚÒÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô, Ë ÔÔ›· Ô‰‹ÁËÛ Û ΛÚÚˆÛË Î·È ˘Ï·›· ˘¤ÚÙ·ÛË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¯ÚÂÈ·ÛÙ› Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â fi,ÙÈ ·ÊÔÚ¿ ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË, ¤ÍÈ ·È‰È¿ ¤¯Ô˘Ó Û‹ÌÂÚ· ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ¿Óˆ ·fi ÙËÓ 50‹ ÂηÙÔÛÙÈ·›· ı¤ÛË Ì ‚¿ÛË ÙȘ ηÌ‡Ï˜ ·Ó¿Ù˘Í˘, 2 ÌÂٷ͇ 50‹˜ Î·È 25˘ ∂£ Î·È Ù· ˘fiÏÔÈ· οو ·fi ÙË 10Ë ∂£. ∆· ·È‰È¿ Ô˘ ‚Ú›ÛÎÔÓÙ·È ¿Óˆ ·fi ÙËÓ 50‹ ∂£ ˘Ô‚Ï‹ıËÎ·Ó ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ËÏÈ˘ ·fi 3 ¤ˆ˜ 8 ÂÙÒÓ Î·È ‚Ú›ÛÎÔÓÙ·Ó ÛÙȘ ›‰È˜ ∂£ ÚÈÓ ·fi ÙË ª∏. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ‡„Ô˜, 7 ·È‰È¿ ‚Ú›ÛÎÔÓÙ·È Û‹ÌÂÚ· ¿Óˆ ·fi ÙË 50‹ ∂£, ÂÓÒ 6 ¤¯Ô˘Ó ‡„Ô˜ ›ÛÔ ‹ οو ·fi ÙËÓ 10Ë ∂£. ∆· ·È‰È¿ ¶·È‰È·ÙÚÈ΋ 2008;71:141-147

Pediatri Mar-Apr 08

07-04-08

16:23

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144

Ÿ. µÚ¿ÓË Î·È Û˘Ó.

Ô˘ Û‹ÌÂÚ· Â›Ó·È ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 10 ÂÙÒÓ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ›‰È· ∂£ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ÚÈÓ ·fi ÙË ª∏, ‰ËÏ·‰‹ Ë ·Ó¿Ù˘Í‹ ÙÔ˘˜ ‰ÂÓ ÂËÚ¿ÛÙËΠ·fi ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹. √ ÚÒÙÔ˜ ·ÛıÂÓ‹˜ Ô˘ ˘Ô‚Ï‹ıËΠ۠ª∏ Û ËÏÈΛ· 6 ÌËÓÒÓ, ÚÈÓ ·fi 15 ¯ÚfiÓÈ·, ÛÙÔ ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ ÙÔ˘ πÔÎÚ·Ù›Ԣ ÂÈ‚ÈÒÓÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ·, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ۈ̷ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË Î·È ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Î¿ı 6 Ì‹Ó˜ ÛÙËÓ °ã ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋.

™˘˙‹ÙËÛË ∏ ª∏ ÛÙ· ·È‰È¿ ·ÔÙÂÏ› Û‹ÌÂÚ· ıÂÚ·›· ÚÔ˘Ù›Ó·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ‰›ÓÔÓÙ·˜ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÈ‚›ˆÛ˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ì ÓÔÛ‹Ì·Ù· Ô˘ ÚÔËÁÔ˘Ì¤Óˆ˜ ‹Ù·Ó ı·Ó·ÙËÊfiÚ·. ∆· ÓÔÛ‹Ì·Ù· Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ª∏ Î·È ÙÔ ÔÛÔÛÙfi Ô˘ ηٷϷ̂¿ÓÔ˘Ó ‰ÈÂıÓÒ˜ ·ÂÈÎÔÓ›˙ÔÓÙ·È ÛÙËÓ ∂ÈÎfiÓ· 2. ™‡Ìʈӷ Ì ÙÔ ¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô ¢È¿ıÂÛ˘ √ÚÁ¿ÓˆÓ, Ë ·ÙÚËÛ›· ÙˆÓ Â͈Ë·ÙÈÎÒÓ ¯ÔÏËÊfiÚˆÓ Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÈÙ›·, ÂÚ›Ô˘ 50%, ÛÙȘ ‰ËÌÔÛȇÛÂȘ fiÏˆÓ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ. ª¿ÏÈÛÙ·, ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÊÙ¿ÓÂÈ ÙÔ 76% ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ ∞ÌÂÚÈ΋ (8). ÕÏϘ ·ı‹ÛÂȘ ÔÈ Ôԛ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Â›Ó·È Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Î·È Ë ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË. ∞fi Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Û˘¯ÓfiÙÂÚ· Â›Ó·È Ë ÓfiÛÔ˜ ÙÔ˘ Wilson, Ë ·ÓÂ¿ÚÎÂÈ· ·1·ÓÙÈıÚ˘„›Ó˘, Ë Ù˘ÚÔÛÈÓ·ÈÌ›· Î·È Ë ·ÈÌԯڈ̿وÛË. ¢ÈÂıÓÒ˜, ÔÛÔÛÙfi ÂÚ›Ô˘ 11% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ë ÔÔ›· Ô‰ËÁ› Û ª∏, ÂÍ·ÈÙ›·˜ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, Ê·ÚÌ¿ÎˆÓ ‹ ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ. √È ÌË ¯ÂÈÚÔ˘ÚÁÈο ÂÍ·ÈÚ¤ÛÈÌÔÈ fiÁÎÔÈ ÙÔ˘ ‹·ÙÔ˜ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ÁÈ· ª∏ Û ÔÛÔÛÙfi 2% (6,7,12,13). ∞fi Ù· ÂÚÈÛÙ·ÙÈο Ì·˜, ·Ó Î·È Ô ·ÚÈıÌfi˜ Â›Ó·È ÌÈÎÚfi˜, Ù· ·›ÙÈ· ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ·˘Ù¿ Ô˘ ¤¯Ô˘Ó ‹‰Ë ‰ËÌÔÛÈ¢ı› ·fi ¿ÏÏ· ΤÓÙÚ·. ∏ ‰˘Û·ÔÚÚfiÊËÛË ÙÔ˘ Ï›Ô˘˜ Î·È ÙˆÓ ÏÈÔ‰È·Ï˘ÙÒÓ ‚ÈÙ·ÌÈÓÒÓ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·ÓÂ·Ú΋ ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ Î·È ÂÔ̤ӈ˜ ‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘. •ÂÎÈÓÒÓÙ·˜ ¤ÁηÈÚ· ÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô, Ë ÔÌ¿‰· ÙˆÓ ÂȉÈÎÒÓ È·ÙÚÒÓ ÌÔÚ› Ó· ÂÈÎÂÓÙÚˆı› ·Ú¯Èο ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ô˘ Â›Ó·È ÂËÚ·Ṳ̂ÓË ÏfiÁˆ Ù˘ ‰˘Û·ÔÚÚfiÊËÛ˘ (14). ∏ ‚ÂÏÙ›ˆÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ·ÛıÂÓÔ‡˜ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ ÂÈÙ˘¯›·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ηıÒ˜ Ë ‚ÂÏÙ›ˆÛË ·˘Ù‹ ÌÂÙ·ÊÚ¿˙ÂÙ·È Û Ì›ˆÛË ÙˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ Î·È ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È Û˘ÓÔÏÈο Û ηχÙÂÚË ÂÈ‚›ˆÛË ÌÂÙ¿ Paediatriki 2008;71:141-147

∫˘ÛÙÈ΋ ›ÓˆÛË 2% ŸÁÎÔÈ 2% ∞˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· 2% ¡ÂÔÁÓÈ΋ Ë·Ù›Ùȉ· 3% ¶ÚˆÙÔ·ı‹˜ ¯ÔÏ·ÁÁÂÈ›Ùȉ· 5% ∂Ó‰ÔË·ÙÈ΋ ˘ÔÏ·Û›· 6% ∫ÂÚ·˘ÓÔ‚fiÏÔ˜ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· 11%

ÕÏÏ· 12% ∞ÙÚËÛ›· ¯ÔÏËÊfiÚˆÓ 44%

ªÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· 13%

∂ÈÎfiÓ· 2. ∞›ÙÈ· ª∏ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ÈÂıÓÒ˜ (¢ÈÂıÓ¤˜ ¢›ÎÙ˘Ô ¢È¿ıÂÛ˘ √ÚÁ¿ÓˆÓ) (41).

ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (15). ª¿ÏÈÛÙ·, Û ÌÈ· ÛÂÈÚ¿ ·ÛıÂÓÒÓ Ì ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÂÂÈÁfiÓÙˆ˜ Û ª∏, ·ÚÓËÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‹Ù·Ó Ë ÌÈÎÚ‹ ËÏÈΛ·, Ë ÔÔ›· Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ (16). ™ÙË ‰È΋ Ì·˜ ÛÂÈÚ¿, 4 ·È‰È¿ ›¯·Ó ÛËÌ·ÓÙÈ΋ ‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘ ηٿ ÙËÓ ·Ú·ÔÌ‹ ÙÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∆· ·È‰È¿ ·˘Ù¿ ˘Ô‚Ï‹ıËÎ·Ó ÛÙËÓ Î·Ù¿ÏÏËÏË ‰È·ÙÚÔÊÈ΋ ˘ÔÛÙ‹ÚÈÍË, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ë̤ڷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ Ó· ¤¯ÂÈ ·˘ÍËı› ηٿ 20-30%. ∏ ηϋ ۈ̷ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÛÙfi¯Ô ÁÈ· ÙÔ˘˜ È·ÙÚÔ‡˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·È‰ÈÒÓ Ì ª∏. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ó·ÛÙÚ¤„ÂÈ ÙË ÛÙ·ÛÈÌfiÙËÙ· Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Ô˘ ÚÔ¸‹Ú¯Â ÏfiÁˆ Ù˘ ÓfiÛÔ˘, ÂÓÒ Ê˘ÛÈÔÏÔÁÈ΋ Â›Ó·È Î·È Ë ÓÂ˘Ì·ÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ (17,18). ∂ÓÙÔ‡ÙÔȘ, ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ˆ˜ ÌÔÚ› Ó· ˘¿Ú¯Ô˘Ó ÁÓˆÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ·ÏÏ¿ Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ ·Ó¿Ù˘Í˘ ÌÂÙ¿ ÙË ª∏ (19). ™ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ¢ı‡ÓÔÓÙ·È Û˘ÁηٷϤÁÔÓÙ·È Ë ÚÔÂÁ¯ÂÈÚËÙÈ΋ ηٿÛÙ·ÛË, Ë ·Ú·ÙÂٷ̤ÓË ÓÔÛËÏ›· Î·È Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹, ΢ڛˆ˜ Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∏ Ú·ÎÙÈ΋ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ‰ÈÂıÓÒ˜ -Î·È ·fi ÂÌ¿˜- Ì Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù·, Â›Ó·È Ë Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ Ù·¯‡ÙÂÚË Ì›ˆÛË Î·È ‰È·ÎÔ‹ Ù˘ ÎÔÚÙÈ˙fiÓ˘ (20-24). ∆Ô ÌÂÁ¿ÏÔ Úfi‚ÏËÌ· ÛÙË ª∏ Â›Ó·È fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ˘Ô„‹ÊÈˆÓ ·È‰ÈÒÓ ˘ÂÚ‚·›ÓÂÈ Î·Ù¿ Ôχ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ·Ó¿ÁÎË

Pediatri Mar-Apr 08

07-04-08

16:23

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145

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ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙËÓ ¤ÏÏÂÈ„Ë و̷ÙÈÎÒÓ ‰ÔÙÒÓ ÌÈÎÚ‹˜ ËÏÈΛ·˜ ÚÔοÏÂÛ ÙËÓ ·Ó·˙‹ÙËÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ËÁÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ¢‡Ô ÂÁ¯ÂÈÚËÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ÚÔÛʤÚÔ˘Ó ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·, Â›Ó·È Ë Ï‹„Ë ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‰È·›ÚÂÛË Û ‰‡Ô ÏÂÈÙÔ˘ÚÁÈο ÙÌ‹Ì·Ù· ÙÔ˘ و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÓ‹ÏÈη ‰fiÙË, ÒÛÙ ӷ ÌÂÙ·ÌÔÛ¯Â˘ı› Û ‰‡Ô Ï‹Ù˜ (11,25). √È Ì¤ıÔ‰ÔÈ ·˘Ù¤˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ïfi ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ Ï‹ÙË Î·È ¤¯Ô˘Ó ϤÔÓ Î·ıÈÂÚˆı› ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ (26-30). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÂȂ‚·ÈÒÓÂÈ ÌÈ· ÌÂÁ¿ÏË ÌÂÙ·-·Ó¿Ï˘ÛË, Ë ÔÔ›· ‰Â›¯ÓÂÈ fiÙÈ Ë ÂÈ‚›ˆÛË Â›Ó·È Î·Ï‡ÙÂÚË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ‡ÛÙÂÚ· ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Û˘ÁÎÚÈÙÈο Ì ·˘Ù‹ ·fi و̷ÙÈÎfi ‰fiÙË, ·ÊÂÓfi˜ ‰ÈfiÙÈ ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÂÈ‚·Ú‡ÓÔ˘Ó ÙË ÁÂÓÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË ·Ó·Ì¤ÓÔÓÙ·˜ و̷ÙÈÎfi ÌfiÛ¯Â˘Ì· Î·È ·ÊÂÙ¤ÚÔ˘ ÁÈ·Ù› ÔÈ ¯ÚfiÓÔÈ ıÂÚÌ‹˜ Î·È „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Â›Ó·È ÌÈÎÚfiÙÂÚÔÈ (31). ∂ÓÙÔ‡ÙÔȘ, ı· Ú¤ÂÈ Ó· ÂÈϤÁÔÓÙ·È Ôχ ÚÔÛÂÎÙÈο ÔÈ ˘Ô„‹ÊÈÔÈ ˙ÒÓÙ˜ ‰fiÙ˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÂÍ·ÈÙ›·˜ ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÛÙÔ ‰fiÙË ÌÂÙ¿ ÙËÓ Ë·ÙÂÎÙÔÌ‹ (.¯. ¯ÔÏfiÚÚÔÈ·, ıÚfiÌ‚ˆÛË ˘Ï·›·˜ ‹ Û‡ÛÙÔÈ¯Ë Ó¢ÌÔÓÈ΋ Û˘ÏÏÔÁ‹), ·ÏÏ¿ Î·È Ù˘ ıÓËÛÈÌfiÙËÙ·˜ ·ÎfiÌË, Ë ÔÔ›·, fï˜, Â›Ó·È ÂÍ·ÈÚÂÙÈο ÌÈÎÚ‹ (0,01%). ªÂ ÙË Û˘Ó¯fiÌÂÓË ·‡ÍËÛË ÙˆÓ ˘Ô„ËÊ›ˆÓ ÁÈ· ª∏ -ηıÒ˜ Ì ÙËÓ ·‡ÍËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ‰È¢ڇÓıËÎ·Ó Î·È ÔÈ ÂӉ›ÍÂȘ Ù˘-, ÚԤ΢„ ¤Ó· ·ÎfiÌË ˙‹ÙËÌ·: Ë ÛˆÛÙ‹ ¯Ú‹ÛË ÙˆÓ ‰È·ÙÈı¤ÌÂÓˆÓ ÔÚÁ¿ÓˆÓ. ŸÙ·Ó ¿Ú¯ÈÛ ӷ ÂÊ·ÚÌfi˙ÂÙ·È Ë ª∏, Ë ‰È¿ıÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÁÈÓfiÙ·Ó Ì ‚¿ÛË ÙÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜. °Ú‹ÁÔÚ·, fï˜, ¤ÁÈÓ ·ÈÛıËÙ‹ Ë ·Ó¿ÁÎË ‡·Ú͢ ÂÓfi˜ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ı· ηıfiÚÈ˙ ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ. ∏ ·ÍÈÔÏfiÁËÛË ‚·Û›ÛÙËΠÛÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ηٿ Child-Turcotte-Pugh Î·È ÛÙȘ Ù˘¯fiÓ Û˘Ó˘¿Ú¯Ô˘Û˜ ÂÈÏÔΤ˜ Ù˘, fiˆ˜ ·ÛΛÙ˘, ÎÈÚÛÔÚÚ·Á›· ‹ Ë·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ (32). ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ ÛÙËÓ ∂˘ÚÒË -Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£- Î·È ÛÙËÓ ∞˘ÛÙÚ·Ï›·, Û˘Ó¯›˙Ô˘Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ·˘Ùfi ÙÔ Û‡ÛÙËÌ·. ™ÙȘ ∏¶∞ ÂÈÛ‹¯ıË ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ 2002 ¤Ó· Ó¤Ô Û‡ÛÙËÌ·, ÙÔ ÔÔ›Ô ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË ÌË ‰ÈÂÓ¤ÚÁÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÙÔ ÏÂÁfiÌÂÓÔ MELD (Model for End-Stage Liver Disease) ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È PELD (Pediatric End-Stage Liver Disease) ÁÈ· Ù· ·È‰È¿. ∆Ô ·Ó ·˘Ùfi ÙÔ Û‡ÛÙËÌ· Á›ÓÂÈ Î·ıÔÏÈο ·Ô‰ÂÎÙfi ·fi ÙË ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÎÔÈÓfiÙËÙ·, ̤ÓÂÈ Ó· ·Ô‰Âȯı› ÛÙÔ Ì¤ÏÏÔÓ (33,34). √È ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ ÛËÌ·ÓÙÈ΋ ÂÈ-

ÏÔ΋ Ù˘ ª∏ ÌÂÙ¿ ÙË ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È Î·Ù¿ ÙȘ ÚÒÙ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ Ë̤Ú˜. ∆ËÓ ÚÒÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Î˘ÚÈ·Ú¯Ô‡Ó ÔÈ ÌÈÎÚԂȷΤ˜ ÏÔÈÌÒÍÂȘ, ÂÓÒ ÂÚ›Ô˘ 2 ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ·fi ̇ÎËÙ˜. ™ÙË Û˘Ó¤¯ÂÈ·, ÌÂÙ¿ ÙȘ 6 ‚‰ÔÌ¿‰Â˜ Î·È ÁÈ· fiÏË ÙË ‰È¿ÚÎÂÈ· ˙ˆ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÈÎÚ·Ù› Ô Î›Ó‰˘ÓÔ˜ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÏÏÔ› ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó ¯ËÌÂÈÔÚÔʇϷÍË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∆· ·ÓÙÈ‚ÈÔÙÈο Î·È Ù· ·ÓÙÈÌ˘ÎËÙÈ·ÛÈο ‰È·ÎfiÙÔÓÙ·È ÌÂÚÈΤ˜ ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â¿Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ Ïԛ̈͢, ÂÓÒ Ù· ·ÓÙÈ-ÈÈο ¤¯Ô˘Ó ı¤ÛË ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜. √È ÈÔ Û˘¯ÓÔ› ÈÔ› Â›Ó·È Ô CMV, o EBV, ÔÈ ·‰ÂÓÔ˚Ô› Î·È Ô RSV (35). √ EBV Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi˜ Èfi˜, ηıÒ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈ΋ ÓfiÛÔ (post transplant lymphoproliferative disease, PTLD) (36). ™‡Ìʈӷ Ì ٷ ÂÚÈÛÙ·ÙÈο Ì·˜, Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË ¤¯Ô˘Ó ÔÈ ÈÔ› EBV Î·È CMV Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ô Parvo B19, Ô HSV1,2, Ô Coxsackie Î·È Ë Candida albicans. ∂ÎÙfi˜ ·fi ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙË ÓÔÛËÚfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ ÌÂÙ¿ ÙË ª∏ Â›Ó·È ÔÈ ÂÈÏÔΤ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, fiˆ˜ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (Neoral, Prograf), Ë Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, Ë ÔÛÙÂÔfiÚˆÛË Î·È Ë Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜ (37-39). ∏ ‰È·Ù‹ÚËÛË Î·Ï‹˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ï·Ì‚¿ÓÂÙ·È ÛÔ‚·Ú¿ ˘fi„Ë ÛÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ∆· ÓÂfiÙÂÚ· Ê¿Ú̷η, mycophenolate mofetil (CellCept) Î·È Ù· ÈÔ ÚfiÛÊ·Ù· mycophenolate sodium (Myfortic) Î·È sirolimus (Rapamycin), Ù· ÔÔ›· ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ¤‰ˆÛ·Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÔÈ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ Û ÌÈÎÚfiÙÂÚ˜ ‰fiÛÂȘ, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ÙÔ˘˜ (40-43). ∞fi Ù· ÂÚÈÛÙ·ÙÈο Ì·˜, 1 ·È‰›, ÙÔ ÔÔ›Ô Ï¿Ì‚·Ó ΢ÎÏÔÛÔÚ›ÓË ÁÈ· ¤Ó· ¤ÙÔ˜, ·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ ÙÔ˘ ÔÚÔ‡ Î·È ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ∞ÓÙÈÌÂÙˆ›ÛÙËΠ·Ú¯ÈÎÒ˜ Ì Ì›ˆÛË Ù˘ ‰fiÛ˘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Û tacrolimus. ™Â ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÔÈ ÔÔ›ÔÈ Â›Ó·È Èı·Ófi Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ˘ÔÙÚÔ‹ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ª∏, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ‰ÂÓ ÎÈÓ‰˘Ó‡ÂÈ ·fi ˘ÔÙÚÔ‹ Ù˘ ÚˆÙ·Ú¯È΋˜ ÓfiÛÔ˘. ∏ ·Ú·Ù‹ÚËÛË ·˘Ù‹ ÂȂ‚·ÈÒÓÂÙ·È Î·È ·fi Ù· ηχÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ (44). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ª∏ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË ÌfiÓË ‰È·ı¤ÛÈÌË ıÂÚ·›· Û ·È‰È¿ Ì ÌË ·Ó·ÛÙÚ¤„ÈÌË ¶·È‰È·ÙÚÈ΋ 2008;71:141-147

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Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÏÂÈ¿‰· ÓÔÛËÌ¿ÙˆÓ, Ù· ÔÔ›· ÛÙÔ ·ÚÂÏıfiÓ ‹Ù·Ó ‰‡ÛÎÔÏÔ Ó· ÂÏÂÁ¯ıÔ‡Ó Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó. ∏ ηϋ Û˘ÓÂÚÁ·Û›· Ù˘ ÔÌ¿‰·˜ ÂȉÈÎÒÓ (¯ÂÈÚÔ˘ÚÁÒÓ, ·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏfiÁˆÓ, ·È‰Ô„˘¯È¿ÙÚˆÓ, ÓÔÛËÏ¢ÙÚÈÒÓ, ÎÔÈÓˆÓÈÎÒÓ ÏÂÈÙÔ˘ÚÁÒÓ) Ì ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ıÂÌÂÏÈÒ‰Ô˘˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ÔÌ·Ï‹ ÔÚ›· ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. √È ÌÂÏÏÔÓÙÈΤ˜ ÂÍÂÏ›ÍÂȘ ÛÙË ¯Ú‹ÛË ÂÙÂÚÔÌÔÛ¯Â˘Ì¿ÙˆÓ ‹ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ηıÒ˜ Î·È ÔÈ È‰ÈfiÙËÙ˜ Ô˘ ‰È·Ê·›ÓÔÓÙ·È ÛÙ· ‚Ï·ÛÙÔ·ÙÙ·Ú·, ›Ûˆ˜ ÂÚÈÔÚ›ÛÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó·Ì¤ÓÔ˘Ó Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Starzl TE, Marchioro TL, Vonkaulla KN, Hermann G, Brittain RS, Waddell WR. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963;117:659-676.

2. Starzl TE. History of Liver and Other Splanchnic Organ Transplantation. In: Busutill RW, Klintmalm GB, editors.

Transplantation of the Liver. Philadelphia, Pa: W.B. Saunders; 1996. p. 3-22.

3. Otte JB. History of pediatric liver transplantation. Where are we coming from? Where do we stand? Pediatr Transplant 2002;6:378-387.

4. Alagille D. History of pediatric liver transplantation in Europe. Acta Gastroenterol Belg 2004;67:172-175.

5. Schafer DF. Liver transplantation. Looking back, looking forward. In: Maddrey WC, Schiff ER, Sorrell MF, editors.

Transplantation of the Liver. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2001.

6. Busuttil RW, Farmer DG, Yersiz H, Hiatt JR, McDiarmid SV, Goldstein LI, et al. Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience. Ann Surg 2005;241:905-916.

7. Lee WS, McKiernan P, Kelly DA. Etiology, outcome and prognostic indicator of childhood fulminant hepatic failure in the United Kingdom. J Pediatr Gastroenterol Nutr 2005;40:575-581.

8. Kelly DA. Current results and evolving indications for liver transplantation in children. J Pediatr Gastroenterol Nutr 1998;27:214-221.

9. Bismuth H, Houssin D. Reduced-size orthotopic liver graft in hepatic transplantation in children. Surgery 1984;95: 367-372.

10. Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. [Transplantation of a donor liver to 2 recipients (splitting transplantation) -- a new method in the further development of segmental liver transplantation]. Langenbecks Archiv Chir 1988;373:127-130.

11. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants. Ann Surg 1990;212: 368-375.

12. Dhawan A, Cheeseman P, Mieli-Vergani G. Approaches to acute liver failure in children. Pediatr Transplant 2004;8: 584-588.

13. Kelly DA. Liver Transplantation. In: Walker WA et al, editors. Pediatric Gastrointestinal Disease. Philadelphia, Pa: BC Decker; 2000. p. 1272-1290.

Paediatriki 2008;71:141-147

14. Tiao GM, Alonso M, Bezerra J, Yazigi N, Heubi J, Balisteri W, et al. Liver transplantation in children younger than 1 year - the Cincinnati experience. J Pediatr Surg 2005;40: 268-273.

15. Kelly DA. Nutritional factors affecting growth before and after liver transplantation. Ped Transplant 1997;1:80-84.

16. Nadalin S, Heuer M, Wallot M, Auth M, Schaffer R, Sotiropoulos GC, et al. Paediatric acute liver failure and transplantation: the University of Essen experience.

Transpl Int 2007;20:519-527.

17. Holt RI, Broide E, Buchanan CR, Miell JP, Baker AJ, Mowat AP, et al. Orthotopic liver transplantation reverses the adverse nutritional changes of end-stage liver disease in children. Am J Clin Nutr 1997;65:534-542.

18. Burdelski M, Nolkemper D, Ganschow R, Sturm E, Malago M, Rogiers X, et al. Liver transplantation in children: long-term outcome and quality of life. Eur J Pediatr 1999; 158:S34-S42.

19. Van Mourik ID, Beath SV, Brook GA, Cash AJ, Mayer AD, Buckels JA, et al. Long term nutritional and neurodevelopmental outcome of liver transplantation in infants aged less than 12 months. J Pediatr Gastroenterol Nutr 2000;30: 269-275.

20. Bartosh SM, Thomas SE, Sutton MM, Brady LM, Whitington PF. Linear growth after pediatric liver transplantation.

J Pediatr 1999;135: 624-631.

21. Melter M, Briscoe DM. Challenges after pediatric transplantation. Semin Nephrol 2000; 20:199-208.

22. Ramaccioni V, Soriano HE, Arumugam R, Klish WJ. Nutritional aspects of chronic liver disease and liver transplantation in children. J Pediatr Gastroenterol Nutr 2000; 30:361-367.

23. Viner RM, Forton JT, Cole TJ, Clark IH, Noble-Jamieson G, Barnes ND. Growth of long-term survivors of liver transplantation. Arch Dis Child 1999;80:235-240.

24. Reding R, Gras J, Sokal E, Otte JB, Davies HF. Steroid-free liver transplantation in children. Lancet 2003;362:2068-2070.

25. Magee JC, Bucuvalas JC, Farmer DG, Harmon WE, Hulbert-Shearon TE, Mendeloff EN. Pediatric transplantation.

Am J Transplant 2004;4:54-71.

26. Lfipez-Santamaria M, de Vicente E, Gaãmez M, Murcia M, Leal N, Hernandez F, et al. Pediatric living donor liver transplantation. Transplant Proc 2003;35:1808-1809.

27. Takada Y, Tanaka K. Living related liver transplantation.

Transplant Proc 2004;36:271-273.

28. Chen CL, Concejero A, Wang CC, Wang SH, Lin CC, Liu YW, et al. Living donor liver transplantation for biliary atresia: a single-center experience with first 100 cases. Am J Transplant 2006;6:2672-2679.

29. Hattori H, Higuchi Y, Tsuji M, Inomata Y, Uemoto S, Asonuma K, et al. Living-related liver transplantation and neurological outcome in children with fulminant hepatic failure. Transplantation 1998;65:686-692.

30. Yersiz H, Renz JF, Farmer DG, Hisatake GM, McDiarmid SV, Busuttil RW. One hundred in situ split-liver transplantations: a single-center experience. Ann Surg 2003;238:496-505.

31. Austin MT, Feuer ID, Chari RS, Gorden DL, Wright JK, Pinson CW. Survival after pediatric liver transplantation.

Why does living donation offer an advantage? Arch Surg 2005;140:465-470.

32. Sundaram SS, Alonso EM, Whitington PF. Liver transplantation in neonates. Liver Transpl 2003;9:783-788.

Pediatri Mar-Apr 08

08-04-08

11:32

™ÂÏ›‰·147

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ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙ· ·È‰È¿

33. Graziadei I. Liver transplantation organ allocation between Child and MELD. Wien Med Wochenschr 2006;156: 410-415.

34. Evrard V, Otte JB, Sokal E, Rochet JS, Haccourt F, Gennari F, et al. Impact of surgical and immunological parameters in pediatric liver transplantation: a multivariate analysis in 500 consecutive recipients of primary grafts. Ann Surg 2004; 239:272-280.

35. Brown RS, Kumar KS, Russo MW, Kinkhabwala M, Rudow DL, Harren P, et al. Model for end-stage liver disease and Child-Turcotte-Pugh score as predictors of pretransplantation disease severity, posttransplantation outcome, and resource utilization in United Network for Organ Sharing status 2A patients. Liver Transpl 2002;8:278-284.

36. Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR. Fever in liver transplant recipients: changing spectrum of etiologic agents. Clin Infect Dis 1998;26:59-65.

37. Guthery SL, Heubi JE, Bucuvalas JC, Gross TG, Ryckman FC, Alonso MH, et al. Determination of risk factors for Epstein-Barr virus-associated posttransplant lymphoproliferative disorder in pediatric liver transplant recipients using objective case ascertainment. Transplantation 2003;75: 987-993.

38. Kling K, Lau H, Colombani P. Biliary complications of liv-

ing related pediatric liver transplant patients. Pediatr Transplant 2004;8:178-184.

39. Araz C, Pirat A, Torgay A, Zeyneloglu P, Arslan G. Early postoperative complications of pediatric liver transplantation: experience at one center. Transplant Proc 2004;36: 214-217.

40. Reding R. Tacrolimus in pediatric liver transplantation.

Pediatr Transplant 2002;6:447-451.

41. Nobili V, Comparcola D, Sartorelli MR, Diciommo V, Marcellini M. Mycophenolate mofetil in pediatric liver transplant patients with renal dysfunction: preliminary data. Pediatr Transplant 2003;7:454-457.

42. Evans HM, McKiernan PJ, Kelly DA. Mycophenolate mofetil for renal dysfunction after pediatric liver transplantation. Transplantation 2005;79:1575-1580.

43. Mahadevan SBK, Beath SV, Davids P, Lloyd C, James C, van Mourik IDM, et al. Safety and efficacy of Sirolimus in children following chronic rejection and/or nephrotoxicity post intestinal transplant (Itx) and liver transplantation (LTx). J Pediatr Gastroenterol Nutr 2004;39:S152.

44. Bucuvalas JC, Ryckman FC. Long-term outcome after liver transplantation in children. Pediatr Transplant 2002;6:30-36.

45. United Network for Organ Sharing [Webpage, Internet]. http://www.unos.org/

¶·È‰È·ÙÚÈ΋ 2008;71:141-147

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ORIGINAL ARTICLE

√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ 1 ∆Ô̤·˜ √ÈÎÔÓÔÌÈÎÒÓ Ù˘ ÀÁ›·˜, ∂ıÓÈ΋ ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ 2 ∂Ù·ÈÚÈΤ˜ ÀÔı¤ÛÂȘ, Wyeth Hellas A.E.B.E. AÏÏËÏÔÁÚ·Ê›·: µ·ÛÈÏÈ΋ ∆ÛÈ¿ÓÙÔ˘ vtsiantou@nsph.gr ∆Ô̤·˜ √ÈÎÔÓÔÌÈÎÒÓ Ù˘ ÀÁ›·˜, ∂ıÓÈ΋ ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ §ÂˆÊ. ∞ÏÂÍ¿Ó‰Ú·˜ 196 ∆.∫. 115 21, ∞ı‹Ó·

µ. ∆ÛÈ¿ÓÙÔ˘1, ∞. ∫·Úfi΢2, ∂. ¶¿‚Ë1, °. ∫˘ÚÈfiÔ˘ÏÔ˜1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∆· ÂÌ‚fiÏÈ· ·ÔÙÂÏÔ‡Ó ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÂÚÁ·Ï›· ÚˆÙÔÁÂÓÔ‡˜ ÚfiÏ˄˘. øÛÙfiÛÔ, ÔÈ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓ˜ ·Ó¿ÁΘ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ˘˜ ÂÚÈÔÚÈṲ̂ÓÔ˘˜ ÔÈÎÔÓÔÌÈÎÔ‡˜ fiÚÔ˘˜, ÂÈ‚¿ÏÏÔ˘Ó ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙȘ ·ÔÊ¿ÛÂȘ ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ·Ó·‰Â›ÍÂÈ ÙË Û˘Ì‚ÔÏ‹ Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÛÙÔÓ Â˘·›ÛıËÙÔ ÙÔ̤· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ Î·È ÂÌ‚ÔÏÈ·ÛÌÔ‡. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ŒÁÈÓÂ Û˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË ÂÈÛÙËÌÔÓÈÎÒÓ ¿ÚıÚˆÓ Ô˘ ·ÊÔÚÔ‡Ó Û ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÌ‚ÔÏ›ˆÓ ηٿ ÙËÓ ÂÚ›Ô‰Ô 1999-2006. ø˜ ·Ú¯È΋ ËÁ‹ ‡ÚÂÛ˘ ¿ÚıÚˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ËÏÂÎÙÚÔÓÈ΋ ‚È‚ÏÈÔı‹ÎË PubMed. ∞ÔÙÂϤÛÌ·Ù·: ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ ‰ËÌÔÛȇÙËÎ·Ó ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÚÈÓ ·fi ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ‹ ÌË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ. ∫·Ù¿ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÙÔ˘˜ ÌÂÏÂÙ‹ıËÎ·Ó fiÏ· Ù· Èı·Ó¿ ÛÂÓ¿ÚÈ· Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ‰Â›ÎÙË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·fi ‰È¿ÊÔÚ˜ ·Ó·Ï˘ÙÈΤ˜ ÚÔÔÙÈΤ˜. ™˘ÌÂÚ¿ÛÌ·Ù·: ∞Ó Î·È ÔÏϤ˜ ·fi ÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ‰ÂÓ ‹Ù·Ó ¿ÓÙÔÙ ‹ ·Ôχو˜ ¢ÓÔ˚Τ˜ ÁÈ· ÙËÓ ¿ÌÂÛË ¤ÓÙ·ÍË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÙ· ∂ıÓÈο ¶ÚÔÁÚ¿ÌÌ·Ù· ∂Ì‚ÔÏÈ·ÛÌÒÓ, ÂÓ Î·ÈÚÒ, ÔÈ ¯ÒÚ˜ ÚÔ¤‚ËÎ·Ó ÛÙËÓ ¤ÓÙ·Í‹ ÙÔ˘˜, ·ÊÔ‡ ·ÍÈÔÏfiÁËÛ·Ó ·fi ÎÔÈÓÔ‡ ÙÔ˘˜ ‰Â›ÎÙ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜, ÙËÓ ·ÓËÛ˘¯›· ÙÔ˘ ÎÔÈÓÔ‡ Î·È ÙÔ ÎÔÈÓˆÓÈÎfi Î·È ÔÈÎÔÓÔÌÈÎfi ÊÔÚÙ›Ô Ù˘ ÓfiÛÔ˘. √È ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Û˘Ó¤‚·Ï·Ó ÛÙËÓ ÙÂÎÌËÚȈ̤ÓË ·ÔÙ›ÌËÛË ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÛÙÚ·ÙËÁÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡.

§¤ÍÂȘ ÎÏÂȉȿ: √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË, ÂÌ‚fiÏÈ·, ·ÓÂÌ¢ÏÔÁÈ¿, ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˜ Ù‡Ô˘ C, Ó¢ÌÔÓÈfiÎÔÎÎÔ˜.

Economic evaluation of new vaccines against varicella, serogroup C meningococcus and pneumococcus 1 Department of Health Economics, National School of Public Health 2 Corporate Affairs, Wyeth Hellas S.A. Correspondence: Vasiliki Tsiantou vtsiantou@nsph.gr Health Economics Sector, National School of Public Health 196, Alexandras Avenue 115 21, Athens, Greece

V. Tsiantou1, A. Karokis2, E. Pavi1, G. Kyriopoulos1 Abstract Background: Vaccines are one of the most important tools for the primary prevention of infectious diseases. Decisions on the inclusion of new vaccines in the National Immunization Schedule need to address competing priorities, which stem from the lack of health care resources and the growing health care needs of the population. The objective of this study is to highlight the importance of economic evaluation in the sensitive field of immunization programs and vaccines.

Methods: A systematic review of papers on the economic evaluation of new vaccines published in scientific journals between 1999 and 2006 was conducted through PubMed. Results: In the majority of the health care systems of developed countries, ex ante economic evaluations were published, which evaluated all the possible scenarios and factors influencing the cost-effectiveness ratio of the vaccines before their introduction.

Conclusions: Economic evaluations were not always clearly in favour of the introduction of new vaccines into the vaccination schedules. However, countries usually adopted the vaccines for inclusion in the National Immunization Schedules after assessing additional parameters, such as the mortality and morbidity ratios, the economic and social burden of disease and the anxiety of the population regarding the risk of infection.

Key words: Economic evaluation, vaccines, varicella, serogroup meningococcus, pneumococcus vaccination.

∂ÈÛ·ÁˆÁ‹ ∆· ÂÌ‚fiÏÈ· ·ÔÙÂÏÔ‡Ó Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÂÚÁ·Ï›· ÁÈ· ÙËÓ ÚˆÙÔÁÂÓ‹ ÚfiÏË„Ë ÙˆÓ ÓÔPaediatriki 2008;71:148-156

ÛËÌ¿ÙˆÓ, Û˘ÓÂÈÛʤÚÔÓÙ·˜ ıÂÙÈο ÛÙË ‰ËÌfiÛÈ· ˘Á›· Î·È ÙËÓ ÔÈÎÔÓÔÌÈ΋ ˙ˆ‹. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Ô‰ËÁ› ÛÙË Ì›ˆÛË ‹ ·ÎfiÌ· Î·È ÛÙËÓ

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√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ

ÂÎÚ›˙ˆÛË ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÛÙËÓ ÂÍÔÈÎÔÓfiÌËÛË ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ˘ÁÂÈÔÓÔÌÈÎÒÓ ·Ó·ÁÎÒÓ (1). ∫·Ù¿ Û˘Ó¤ÂÈ·, ÂÎÙfi˜ ·fi ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÛÊ¿ÏÂÈ¿ ÙÔ˘˜ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Î·È Ë ÔÈÎÔÓÔÌÈ΋ ÙÔ˘˜ ·Ô‰ÔÙÈÎfiÙËÙ·. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘. ∏ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· Û‡ÓÔÏÔ Ù¯ÓÈÎÒÓ, ÙÔ ÔÔ›Ô ÂÎÙÈÌ¿ ÙË Û¯ÂÙÈ΋ ·Í›· ·˘ÙÒÓ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜, Û˘ÁÎÚ›ÓÔÓÙ·˜ ‰È·ÊÔÚÂÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Î·È ÂΛÓË ÙÔ˘ ÌË ÂÌ‚ÔÏÈ·ÛÌÔ‡ (2,3). ∏ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Û˘Ì‚¿ÏÏÂÈ ÛÙË Ï‹„Ë ÌÈ·˜ ·fiÊ·Û˘, fiÙ·Ó Ú¤ÂÈ Ó· Á›ÓÂÈ ÈÂÚ¿Ú¯ËÛË ÚÔÙÂÚ·ÈÔÙ‹ÙˆÓ (3) Î·È ÂÓÈÛ¯‡ÂÈ ÙËÓ ÔÚıÔÏÔÁÈ΋ ηٷÓÔÌ‹ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ Û¿ÓÈˆÓ fiÚˆÓ. √È ÚÒÙ˜ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÂÌÊ·Ó›ÛÙËÎ·Ó ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 (4). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ô ·ÚÈıÌfi˜ ÙÔ˘˜ ·˘Í‹ıËÎÂ, Ë ÔÈfiÙËÙ¿ ÙÔ˘˜ ‚ÂÏÙÈÒıËÎÂ Î·È Ù· ÌÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì¤Ûˆ Ù˘ ¤Î‰ÔÛ˘ ηÙ¢ı˘ÓÙ‹ÚÈˆÓ Ô‰ËÁÈÒÓ (guidelines). ∆ÂÏÈο, Ë Ê·ÚÌ·ÎÔÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÂÓÙ¿¯ıËΠÛÙË ‰È·‰Èηۛ· Ï‹„˘ ·ÔÊ¿ÛÂˆÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜ ÔÏÏÒÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ¯ˆÚÒÓ. √ ÙÔ̤·˜ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Â›Ó·È È‰È·›ÙÂÚ· ¢·›ÛıËÙÔ˜ ‰ÈfiÙÈ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ Ù¤ÙÔÈ·˜ ·Ú¤Ì‚·Û˘ ‰ÂÓ Â›Ó·È ¿ÌÂÛ· ÔÚ·Ù¿. ∂ÈϤÔÓ, ÔÏÏ¿ ·fi Ù· Ó¤· ÂÌ‚fiÏÈ· ·ÊÔÚÔ‡Ó ·Ûı¤ÓÂȘ ÔÈ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ó ·˘ÍË̤ÓË ıÓËÙfiÙËÙ·, ·ÏÏ¿ ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· ÛÙÔÓ ÏËı˘ÛÌfi, Ì ·ÔÙ¤ÏÂÛÌ· Ë ¯ÚËÛÈÌfiÙËÙ¿ ÙÔ˘˜ Î·È Ë Û˘Ì‚ÔÏ‹ ÙÔ˘˜ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘Á›·˜ ÙÔ˘ ÏËı˘ÛÌÔ‡ Û˘¯Ó¿ Ó· ˘ÔÙÈÌ¿Ù·È ‹ Î·È Ó· ·ÌÊÈÛ‚ËÙÂ›Ù·È (4,5). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ó· ·Ó·‰Â›ÍÂÈ ÙË ÛËÌ·Û›· Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÛÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÛÙÔÓ Â˘·›ÛıËÙÔ ÙÔ̤· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘, ÌÂÏÂÙÒÓÙ·˜ Ù· Ó¤· ÂÌ‚fiÏÈ· ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜, ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C Î·È ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘, ÁÈ·Ù› ·˘Ù¿ ·ÂÈÎÔÓ›˙Ô˘Ó Î·Ï‡ÙÂÚ· ÙÔ ‰›ÏËÌÌ· Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÔÈ ˘‡ı˘ÓÔÈ Î·Ù¿ ÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ ÁÈ· ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ fiÚˆÓ. ∆· ÂÌ‚fiÏÈ· ·˘Ù¿ ÚfiÛÊ·Ù· ÂÓÙ¿¯ıËÎ·Ó ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ Ù˘ ∂ÏÏ¿‰·˜. ∏ ˘„ËÏ‹ ÙÈÌ‹ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó¿ÁÎË ¤ÓÙ·Í‹˜ ÙÔ˘˜ ÛÙÔ ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ¿ÛÎËÛË ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ ÔÏÈÙÈ΋˜ Â›Ó·È ÌÂÚÈο ·fi Ù· ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ÂÚÈϤÎÔ˘Ó ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ ÙË ‰È·‰Èηۛ· Ï‹„˘ ·ÔÊ¿ÛˆÓ.

ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ÃÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Ì¤ıÔ‰Ô˜ Ù˘ ·Ó·ÛÎfiËÛ˘ ÂÈÛÙËÌÔÓÈÎÒÓ ¿ÚıÚˆÓ Ì ÙË ¯Ú‹ÛË Ù˘ Ì˯·Ó‹˜ ·Ó·˙‹ÙËÛ˘ Ù˘ ËÏÂÎÙÚÔÓÈ΋˜ ‚È‚ÏÈÔı‹Î˘ PubMed (www.pubmed.com). ø˜ ϤÍÂȘ ÎÏÂȉȿ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ fiÚÔÈ: economic evaluation, vaccines, pharmacoeconomic studies, cost-effectiveness of vaccines, varicella vaccine, meningococcal vaccine, pneumococcus vaccine Î·È Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ. ∂ÈϤ¯ÙËÎ·Ó Ù· ¿ÚıÚ· Ô˘ ·ÊÔÚÔ‡Û·Ó ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ÂÌ‚ÔÏ›ˆÓ. ∆· ¿ÚıÚ· Ô˘ ·ÓÙÏ‹ıËÎ·Ó ·ÊÔÚÔ‡Û·Ó ÙËÓ ÂÚ›Ô‰Ô 1999-2006 Î·È Ë ÁÏÒÛÛ· Û˘ÁÁÚ·Ê‹˜ ‹Ù·Ó Ë ·ÁÁÏÈ΋. ∂ÈϤÔÓ, Ú·ÁÌ·ÙÔÔÈ‹ıËΠ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·˙‹ÙËÛË ‰ËÌÔÛȇÛÂˆÓ ÛÙ· ÂÈÛÙËÌÔÓÈο ÂÚÈÔ‰Èο Ù· ÔÔ›· ηÙÂÍÔ¯‹Ó ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ı¤Ì· Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Î·È ÙˆÓ ÂÌ‚ÔÏ›ˆÓ, fiˆ˜ Ù·: Vaccines, The Lancet, Journal of Infectious Diseases, Health Economics, Pharmacoeconomics Î·È Pediatrics. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ªÂ ÙÔÓ fiÚÔ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË (economic evaluation) ÔÚ›˙ÂÙ·È Ë Û˘ÁÎÚÈÙÈ΋ ·ÔÙ›ÌËÛË ÂÓ·ÏÏ·ÎÙÈÎÒÓ ıÂÚ·¢ÙÈÎÒÓ ‹ ÚÔÏËÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ (6). ™ÎÔfi˜ Ù˘ Â›Ó·È Ó· ÂÓÙÔ›ÛÂÈ, Ó· ÌÂÙÚ‹ÛÂÈ Î·È Ó· ÂÎÙÈÌ‹ÛÂÈ ÙÔ ÎfiÛÙÔ˜ Î·È Ù· ÔʤÏË Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂοÛÙÔÙ ÚÔÁÚ¿ÌÌ·ÙÔ˜. ¢Â›¯ÓÂÈ, ¤ÙÛÈ, ÔÈÔ ÚfiÁÚ·ÌÌ· ÚÔÛʤÚÂÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‰˘Ó·Ùfi fiÊÂÏÔ˜ Ì ÙÔ ÌÈÎÚfiÙÂÚÔ ‰˘Ó·Ùfi ÎfiÛÙÔ˜. ∏ ∂ÈÎfiÓ· 1 ‰Â›¯ÓÂÈ Ù· Èı·Ó¿ ÛÂÓ¿ÚÈ· Ù˘ Û¯¤Û˘ ÎfiÛÙÔ˘˜-·ÔÙÂϤÛÌ·ÙÔ˜ Û ÌÈ· Ó¤· ·Ú¤Ì‚·ÛË ˘Á›·˜ Î·È ÙȘ ·ÓÙ›ÛÙÔȯ˜ ·ÔÊ¿ÛÂȘ. ∫·Ù¿ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ, ÙÔ ÎfiÛÙÔ˜ ‰È·ÎÚ›ÓÂÙ·È Û ÙÚÂȘ ηÙËÁÔڛ˜. ∆Ô ¿ÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜ ·ÊÔÚ¿ ‰·¿Ó˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ Ô˘ Â›Ó·È Û¯ÂÙÈΤ˜ Ì ÙËÓ ·Ûı¤ÓÂÈ· (Ê¿Ú̷η, ÂÍÂÙ¿ÛÂȘ, Î.Ù.Ï.) ‹ Ì ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, fiˆ˜ Â›Ó·È Ë ÙÈÌ‹ ·ÁÔÚ¿˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ÔÈ ‰·¿Ó˜ ¯ÔÚ‹ÁËÛ˘ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Èı·ÓÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. ∆Ô ¿ÌÂÛÔ ÌË È·ÙÚÈÎfi ÎfiÛÙÔ˜ ·ÊÔÚ¿ ȉȈÙÈΤ˜ ÏËڈ̤˜ Î·È Ù· ¤ÍÔ‰· ÌÂٷΛÓËÛ˘ ÙÔ˘ ·ÛıÂÓ‹ ÚÔ˜ Î·È ·fi ÙÔ ÓÔÛÔÎÔÌ›Ô. √È ‰·¿Ó˜ ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ·ÔÙÂÏÔ‡Ó ÎfiÛÙÔ˜ ÌfiÓÔ ÁÈ· ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹ Î·È ÙËÓ ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘. ∆Ô ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ·ÒÏÂÈ· ·Ú·ÁˆÁÈÎfiÙËÙ·˜ ÏfiÁˆ ·Ô˘Û›·˜ ‹ ÌÂȈ̤Ó˘ ÈηÓfiÙËÙ·˜ ÂÍ·ÈÙ›·˜ Ù˘ ·Ûı¤ÓÂÈ·˜ Î·È ÛÙËÓ ·ÒÏÂÈ·

¶ÂÚÈÔ¯‹ ∞ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÈÎÚfiÙÂÚÔ ÎfiÛÙÔ˜. °›ÓÂÙ·È ‰ÂÎÙ‹

∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ¯ÂÈÚfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÈÎÚfiÙÂÚÔ ÎfiÛÙÔ˜. ∏ ·fiÊ·ÛË ‰ÂÓ Â›Ó·È ÍÂοı·ÚË.

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∞¶√∆∂§∂™ª∞ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÂÁ·Ï‡ÙÂÚÔ ÎfiÛÙÔ˜. ∏ ·fiÊ·ÛË ‰ÂÓ Â›Ó·È + ÍÂοı·ÚË ∫√™∆√™ ¶ÂÚÈÔ¯‹ µ ∏ ·Ú¤Ì‚·ÛË Ô‰ËÁ› Û ¯ÂÈÚfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ì ÌÂÁ·Ï‡ÙÂÚÔ ÎfiÛÙÔ˜. ∞ÔÚÚ›ÙÂÙ·È

∂ÈÎfiÓ· 1. ™ÂÓ¿ÚÈ· ÎfiÛÙÔ˘˜-·ÔÙÂϤÛÌ·ÙÔ˜ ÌÈ·˜ Ó¤·˜ ·Ú¤Ì‚·Û˘ ˘Á›·˜ Î·È ÔÈ ·ÓÙ›ÛÙÔȯ˜ ·ÔÊ¿ÛÂȘ. ¶·È‰È·ÙÚÈ΋ 2008;71:148-156

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·150

150

µ. ∆ÛÈ¿ÓÙÔ˘ Î·È Û˘Ó.

·Ú·ÁˆÁÈÎfiÙËÙ·˜, ¯ÚfiÓÔ˘ Î·È ÂÈÛÔ‰‹Ì·ÙÔ˜ ÙˆÓ Û˘ÁÁÂÓÒÓ Î·È Ê›ÏˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÊÚÔÓÙ›ÛÔ˘Ó ÙÔÓ ·ÛıÂÓ‹ (2,3). ∆Ô ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ıˆÚÂ›Ù·È Î·È ÎÔÈÓˆÓÈÎfi ÎfiÛÙÔ˜, ηıÒ˜ ·Ó·Ê¤ÚÂÙ·È Û ÔÈÎÔÓÔÌÈΤ˜ ·ÒÏÂȘ Ù˘ ÎÔÈÓˆÓ›·˜. ∏ ÚÔÔÙÈ΋ Ù˘ ÌÂϤÙ˘ ηıÔÚ›˙ÂÈ ÔȘ ‰·¿Ó˜ ı· ÂÚÈÏËÊıÔ‡Ó Û ÌÈ· ÌÂϤÙË Î·È ı· ·Ó·Ï˘ıÔ‡Ó (2,6). ∏ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ ÂÚÈÏ·Ì‚¿ÓÂÈ fiϘ ÙȘ ηÙËÁÔڛ˜ ÎfiÛÙÔ˘˜ Î·È Û˘Ó˘ÔÏÔÁ›˙ÂÈ fiÏ· Ù· ÔʤÏË, ÂÓÒ ·Ú¿ÏÏËÏ· ıˆÚÂ›Ù·È Î·Ù·ÏÏËÏfiÙÂÚË ÁÈ· ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ·ÓÔÛÔÔ›ËÛ˘ ÏfiÁˆ Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜, Ë ÔÔ›· ¤¯ÂÈ ıÂÙÈΤ˜ ÂÈÙÒÛÂȘ Û fiÏÔ ÙÔÓ ÏËı˘ÛÌfi (7,8). √È Ù¯ÓÈΤ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Â›Ó·È ÔÈ ·ÎfiÏÔ˘ı˜ (1-3,7-9): 1. ∞Ó¿Ï˘ÛË ÂÏ·¯ÈÛÙÔÔ›ËÛ˘ ÎfiÛÙÔ˘˜. √È ÂÓ·ÏÏ·ÎÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û˘ÁÎÚ›ÓÔÓÙ·È ÌfiÓÔ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, ÂÊfiÛÔÓ ¤¯Ô˘Ó ·ԉ‰ÂÈÁ̤ӷ ›‰È· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ÒÛÙ ӷ ÂÈÏÂÁ› Ë ÊıËÓfiÙÂÚË ·fi ·˘Ù¤˜.

2. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜. ∞ÔÙÈÌ¿ ÙfiÛÔ ÙÔ ÎfiÛÙÔ˜ fiÛÔ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ÓÔÌÈÛÌ·ÙÈΤ˜ ÌÔÓ¿‰Â˜ Î·È ·ÍÈÔÏÔÁ› ·Ó ÌÈ· ·Ú¤Ì‚·ÛË ˘Á›·˜ ·Í›˙ÂÈ Ó· ¯ÚËÌ·ÙÔ‰ÔÙËı›.

3. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜. ∂›Ó·È Ë Û˘¯ÓfiÙÂÚ· ÂÊ·ÚÌÔ˙fiÌÂÓË Ù¯ÓÈ΋, fiÔ˘ ÙÔ ÎfiÛÙÔ˜ ·ÔÙÈÌ¿Ù·È Û ÓÔÌÈÛÌ·ÙÈΤ˜ ÌÔÓ¿‰Â˜ Î·È Ù· ÔʤÏË ÛÂ Ê˘ÛÈΤ˜ ÌÔÓ¿‰Â˜ ·Ú·ÁfiÌÂÓÔ˘ ¤ÚÁÔ˘, fiˆ˜ ¤ÙË ˙ˆ‹˜ Ô˘ ÛÒ˙ÔÓÙ·È ‹ ÂÚÈÛÙ·ÙÈο Ô˘ ·ÔÙÚ¤ÔÓÙ·È.

4. ∞Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-¯ÚËÛÈÌfiÙËÙ·˜. ∂‰Ò ÙÔ fiÊÂÏÔ˜ ÌÂÙÚ¿Ù·È ˆ˜ Û˘Ó‰˘·ÛÌfi˜ ·Ú¿Ù·Û˘ Ù˘ ÂÈ‚›ˆÛ˘ Î·È ‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜. ∞˘Ù‹ Ë ÚÔÛ¤ÁÁÈÛË Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË ÁÈ· ÙȘ ·ÚÂÌ‚¿ÛÂȘ ˘Á›·˜ Ô˘ ·Ú¿ÁÔ˘Ó ÔʤÏË fi¯È ÌfiÓÔ fiÛÔÓ ·ÊÔÚ¿ ÙË ıÓËÛÈÌfiÙËÙ·, ·ÏÏ¿ Î·È ÙË ÓÔÛËÚfiÙËÙ·. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C ∏ ÌËÓÈÁÁ›Ùȉ· Â›Ó·È ÌÈ· ÊÏÂÁÌÔÓ‹ ÙˆÓ ÌËÓ›ÁÁˆÓ Ô˘ ÂÚÈÎÏÂ›Ô˘Ó ÙÔÓ ÂÁΤʷÏÔ Î·È ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÚÔηÏÂ›Ù·È ·fi ‚·ÎÙ‹ÚÈ· ‹ ÈÔ‡˜. ¶¤ÓÙ ÔÚfiÙ˘ÔÈ ÙÔ˘ ‚·ÎÙËÚ›Ô˘ Neisseria meningitidis (A, B, C, Y Î·È W-135) ÚÔηÏÔ‡Ó ÂÚÈÛÛfiÙÂÚ· ·fi ÙÔ 90% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ ÌËÓÈÁÁ›Ùȉ·˜ ·ÁÎÔÛÌ›ˆ˜ (10). ™‡Ìʈӷ Ì ÙÔÓ ¶·ÁÎfiÛÌÈÔ √ÚÁ·ÓÈÛÌfi ÀÁ›·˜ (¶√À), ÔÈ Ù‡ÔÈ ∞ Î·È C Â›Ó·È ÔÈ Î‡ÚȘ ·Èٛ˜ Ù˘ ÂȉËÌÈ΋˜ ÌËÓÈÁÁ›Ùȉ·˜. Èڛ˜ ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹, ÂÚÈÛÛfiÙÂÚ· ·fi ÙÔ 50% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù·Ï‹ÁÔ˘Ó Û ı¿Ó·ÙÔ. ∞ÎfiÌ· fï˜ Î·È Ì ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È Î·Ù¿ÏÏËÏË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹, ÂÚ›Ô˘ 5-10% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Î·Ù·Ï‹ÁÔ˘Ó Û ı¿Ó·ÙÔ, ÂÓÒ ÂÚ›Ô˘ ÙÔ 15-20% fiÛˆÓ ÂÈ‚ÈÒÓÔ˘Ó ˘ÔʤÚÔ˘Ó ·fi Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, fiˆ˜ ÎÒʈÛË Î·È ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ∆Ô Ó¤Ô Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C, ÚÔÛʤÚÂÈ ÚÔÛÙ·Û›· ÌfiÓÔ ¤Ó·ÓÙÈ ·˘ÙÔ‡ ÙÔ˘ Ù‡Ô˘ (11,12). ™ÙËÓ ∂ÏÏ¿‰·, Ë Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ÂÁÎÚ›ıËΠÙÔ ™Â٤̂ÚÈÔ ÙÔ˘ 2000, Ì ‰ÂÛ̇ÛÂȘ ÁÈ· ‰ÈÂÚ‡ÓËÛË Ù˘ ·Ó·ÁηÈfiÙËÙ·˜ ·Ó·ÌÓËÛÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÁÈ· Û˘ÛÙËÌ·ÙÈ΋ ˘Ô‚ÔÏ‹ ÛÙÔȯ›ˆÓ ·Ó·ÊÔÚÈο Ì ÙȘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (13). ™ÙÔÓ ¶›Ó·Î· 1 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ‚·ÛÈο ÛÙÔȯ›· ÙˆÓ ÔÈÎÔÓÔÌÈÎÒÓ ·ÍÈÔÏÔÁ‹ÛÂˆÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÂÌ‚ÔÏ›Ô˘. ∏ Ù¯ÓÈ΋ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ΢ڛˆ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠ‹Ù·Ó Ë ·Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Ë ·Ó¿Ï˘ÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ˘fi ÙËÓ ÚÔÔÙÈ΋ Ù˘ ÎÔÈÓˆÓ›·˜ Î·È ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ. √È Û˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘ ‹Ù·Ó Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ›‰È˜ Û fiϘ Paediatriki 2008;71:148-156

ÙȘ ¯ÒÚ˜ Ô˘ ‰ÈÂÓ‹ÚÁËÛ·Ó Ù¤ÙÔȘ ÌÂϤÙ˜ Î·È ·ÊÔÚÔ‡Û·Ó Î˘Ú›ˆ˜, ÂÓ·ÏÏ·ÎÙÈΤ˜ ÂÈÏÔÁ¤˜ Û¯ÂÙÈο Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ‰fiÛˆÓ. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ, ÂÓÒ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Ë ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ô‰ËÁÔ‡Û Û ÂÈÏÔÁ¤˜ ÚÔÁÚ·ÌÌ¿ÙˆÓ Ì›·˜ ‰fiÛ˘, Ù· ÎÏÈÓÈο ‰Â‰Ô̤ӷ Â¤‚·ÏÏ·Ó ÙËÓ ˘ÈÔı¤ÙËÛË ÛÙÚ·ÙËÁÈÎÒÓ 2 Û˘Ó 1 ‰fiÛÂˆÓ ÛÙ· ÂÚÈÛÛfiÙÂÚ· Û˘ÛÙ‹Ì·Ù· ˘Á›·˜. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ªÂ ÙÔÓ fiÚÔ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ ÓfiÛÔ˜ ÔÚ›˙ÂÙ·È ÌÈ· ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙÔ ‚·ÎÙ‹ÚÈÔ Streptococcus pneumoniae. ™Ù· ÓÔÛ‹Ì·Ù· ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ‰ÈÂÈÛ‰˘ÙÈΤ˜ ÏÔÈÌÒÍÂȘ, fiˆ˜ ‚·ÎÙËÚÈ·ÈÌ›·, ÌËÓÈÁÁ›Ùȉ· Î·È ‚·ÎÙËÚÈ·ÈÌÈ΋ Ó¢ÌÔÓ›·. √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ ÚÔηÏ› Â›Û˘ ÌË ‰ÈÂÈÛ‰˘ÙÈΤ˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ·Ûı¤ÓÂȘ, fiˆ˜ Ë Ì¤ÛË ˆÙ›Ùȉ· (10). √ Ó¢ÌÔÓÈfiÎÔÎÎÔ˜ Â›Ó·È Î‡ÚÈ· ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·ÁÎÔÛÌ›ˆ˜ Î·È Â˘ı‡ÓÂÙ·È ÁÈ· ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 1 ÂηÙÔÌ̇ÚÈÔ ı·Ó¿ÙÔ˘˜ Û ‚Ú¤ÊË Î·È ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ (18). ™ÙËÓ ∂ÏÏ¿‰·, Ë Â›ÙˆÛË Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ Û ·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ Â›Ó·È 43-100 ·Ó¿ 100.000 ·È‰È¿, ÔÛÔÛÙfi ˘„ËÏfiÙÂÚÔ ·fi ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜. ∆· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ·ÓÂÏÏ‹ÓÈ·˜ ÌÂϤÙ˘ ¤‰ÂÈÍ·Ó fiÙÈ ÛÙ· ·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ, 88% ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙÔ˘˜ ÔÚfiÙ˘Ô˘˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ∂ÓÒ ÁÈ· Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÌÂÈÒÓÂÙ·È ÛÙÔ 50% (19). ∂ÈϤÔÓ, ÙÔ ÂÌ‚fiÏÈÔ ÚÔÛٷهÂÈ ¤Ó·ÓÙÈ Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È Ù˘ Ó¢ÌÔÓ›·˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙÔ˘˜ ÔÚfiÙ˘Ô˘˜, ÔÈ ÔÔ›ÔÈ ÂÚȤ¯ÔÓÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ. ™ÙÔÓ ¶›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ‚·ÛÈο ÛÙÔȯ›· ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘. ∏ ·Ó¿Ï˘ÛË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Ë ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ Ù˘ ·Ó¿Ï˘Û˘ Â›Ó·È Ù· ·ÚÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ. √ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ∏ ·ÓÂÌ¢ÏÔÁÈ¿ Â›Ó·È ¤Ó· ÓfiÛËÌ· Ì ÌÂÁ¿ÏË ÌÂÙ·‰ÔÙÈÎfiÙËÙ· Î·È Â˘Ú‡ Ê¿ÛÌ· ÂÈÏÔÎÒÓ. ŸÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë ËÏÈΛ· ÓfiÛËÛ˘ ÙfiÛÔ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È. ∂›Û˘, ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ·Ó ÌÈ· ¤ÁÎ˘Ô˜ ÓÔÛ‹ÛÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ‹ ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ÙÚÈÌ‹ÓÔ˘ ·ËÛ˘. ™‡Ìʈӷ Ì ¤Ú¢Ó˜ ÂÚ›Ô˘ ÙÔ 90% ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È Èı·Ófi Ó· ÚÔÛ‚ÏËı› ·fi ÙË ÓfiÛÔ (10). ∆Ô ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ·ıÔÁfiÓÔ˘˜ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ ·ÓÔÛ›·˜ Ô˘ ÚÔÛʤÚÂÈ ÙÔ ÂÌ‚fiÏÈÔ ‰ÂÓ ¤¯ÂÈ ·ÎfiÌ· ÂÍ·ÎÚÈ‚ˆı›, ·ÏÏ¿ Ë ÂÌÂÈÚ›· ·fi ¿ÏÏ· ÂÌ‚fiÏÈ· ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ‰Â›¯ÓÂÈ fiÙÈ Ë ·ÓÔÛ›· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ô‰ËÁ› Û ‹Ș ·ÓÙȉڿÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î¿ÔÈ· ÂÍ·Óı‹Ì·Ù· ‹ ÂΉ‹ÏˆÛË ˘ÚÂÙÔ‡. ™·ÓÈfiÙÂÚ· ÂÌÊ·Ó›˙ÔÓÙ·È ÛÔ‚·ÚfiÙÂÚ˜ ·ÓÙȉڿÛÂȘ fiˆ˜ ÂÁÎÂÊ·Ï›Ùȉ˜, Ó¢ÌÔÓ›·, Û·ÛÌÔ› ·ÎfiÌË Î·È ı¿Ó·ÙÔ˜. ∆Ô Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÌ‚fiÏÈÔ ÂӉ›ÎÓ˘Ù·È ÁÈ· ÂÓÂÚÁËÙÈ΋ ·ÓÔÛÔÔ›ËÛË ÂÓ·ÓÙ›ÔÓ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Û ¿ÙÔÌ· Ô˘ Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘˜ ·fi ÙË ÓfiÛÔ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ (13,30). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù› ÔÏϤ˜ ·Ó·Ï‡ÛÂȘ ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ¤Ó·ÓÙÈ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. √È ‚·ÛÈÎfiÙÂÚ˜ ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3.

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¶›Ó·Î·˜ 1. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜

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∞ÁÁÏ›· 2002 (14)

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¢È¿ÊÔÚ˜ ÛÙÚ·ÙËÁÈΤ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ô˘ ‰È¤ÊÂÚ·Ó ÛÙÔÓ ÙÚfiÔ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘ Î·È ÛÙËÓ ËÏÈΛ· ¤Ó·Ú͢ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡

∂Ï‚ÂÙ›· 2003 (15)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜

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∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·

1. ∂Ì‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ 2 ‰fiÛÂˆÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘ 4. ∂Ì‚ÔÏÈ·ÛÌfi˜ ̤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜

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∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜

1. ∂Ì‚ÔÏÈ·ÛÌfi˜ ̤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 3. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘

1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Ë Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ˘„ËÏ‹ 2. °È· ÙȘ ËÏÈ˘ 1-4 ÂÙÒÓ, Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Á›ÓÂÙ·È ·fi ÙÔ˘˜ ÁÂÓÈÎÔ‡˜ È·ÙÚÔ‡˜ 3. °È· ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (5-17 ÂÙÒÓ), Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ fiÙ·Ó Á›ÓÂÙ·È ÛÙ· Û¯ÔÏ›· 1. ÀÔı¤ÙÔÓÙ·˜ ÂÌ‚ÔÏÈ·ÛÙÈ΋ Î¿Ï˘„Ë 80% Î·È ·ÚÈıÌfi ÁÂÓÓ‹ÛÂˆÓ 80.000, Ë ¤ÓÙ·ÍË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ 2. ∏ ÛÙÚ·ÙËÁÈ΋ 3 ‰fiÛÂˆÓ ÂÈÙ˘Á¯¿ÓÂÈ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ fiÊÂÏÔ˜ ÁÈ· ÙËÓ ˘Á›· 1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ô˘ Á›ÓÂÙ·È Ì¤¯ÚÈ ÙËÓ ‡ÊÂÛË Ù˘ ÂȉËÌ›·˜ Â›Ó·È Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ 2. ∞fi ÙȘ ÛÙÚ·ÙËÁÈΤ˜ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Ë ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Â›Ó·È ·˘Ù‹ Ù˘ Ì›·˜ ‰fiÛ˘, ·Ó Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ‹Ù·Ó Ï›ÁÔ ÂÚÈÔÚÈṲ̂ÓË Û ۯ¤ÛË Ì ÙȘ ˘fiÏÔÈ˜ ÛÙÚ·ÙËÁÈΤ˜ 1. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ·ÓÔÛÔÔ›ËÛ˘ Â›Ó·È Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 1 ‰fiÛ˘ 2. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÎÏÈÓÈο Â›Ó·È Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ 3 ‰fiÛˆÓ

∞ÔÙÂϤÛÌ·Ù· √È ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ Ù‡Ô˘ C, ·ÏÏ¿ Î·È Ù· ‰È·ı¤ÛÈÌ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ¿Ԅ˘ fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋. ∆Ô ÂÌ‚fiÏÈÔ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ηıÒ˜ ÚÔηÏ› ¿ÌÂÛË ÚÔÛÙ·Û›· ÛÙ· ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ·ÏÏ¿ Î·È ¤ÌÌÂÛË ÚÔÛÙ·Û›· ̤ۈ Ù˘ ÂÏ¿ÙÙˆÛ˘ Ù˘ ‰È·ÛÔÚ¿˜ ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ (36). ¢ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÚÂÓ¤ÚÁÂȘ, ÁÂÁÔÓfi˜ Ô˘ ı· ‰ËÌÈÔ˘ÚÁÔ‡Û ÌÂÁ·Ï‡ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ Î·È ÂÈϤÔÓ ÎfiÛÙÔ˜ ÁÈ· ÙË ÛÙÚ·ÙËÁÈ΋ ·ÓÔÛÔÔ›ËÛ˘. ª¿ÏÈÛÙ·, fiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘, ÙfiÛÔ Î·Ï‡ÙÂÚ· Ù· ·ÔÙÂϤÛÌ·Ù·, ηıÒ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì·ÎÚÔ¯ÚfiÓÈ· Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÔÏϤ˜ ¯ÒÚ˜ ·ÔÊ¿ÛÈÛ·Ó Ó· ÂÓÙ·¯ı› ÙÔ ÂÓ ÏfiÁˆ ÂÌ‚fiÏÈÔ ÛÙ· Ù·ÎÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÂÌ‚ÔÏÈ·ÛÌÔ‡.

1 2

√È ex ante ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘1 ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ·Ó Î·È ÙÔ ÂÌ‚fiÏÈÔ Â›Ó·È Ôχ ‰Ú·ÛÙÈÎfi Î·È ÌÂÈÒÓÂÈ ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘, ˆÛÙfiÛÔ, Ì ÙȘ ‰Â‰Ô̤Ó˜ ÙÈ̤˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Ë Â˘Ú›· ¯Ú‹ÛË ÙÔ˘ ‰ÂÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ¿ÓÙÔÙ ˆ˜ ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋. √È ex post2 ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ ¤‰ÂÈÍ·Ó fiÙÈ ·Ó ÏËÊı› ˘fi„Ë Ë Â›‰Ú·ÛË Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜, ÙfiÙÂ Ë ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ (36). øÛÙfiÛÔ, Ù· ¤ÌÌÂÛ· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÔÓÙ·È Ê·ÓÂÚ¿ Ì·ÎÚÔ¯ÚfiÓÈ· Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ÌÔÚÔ‡Ó Ó· Û˘Ó˘ÔÏÔÁÈÛÙÔ‡Ó ÛÙȘ ex ante ÔÈÎÔÓÔÌÈΤ˜ ·ÍÈÔÏÔÁ‹ÛÂȘ. ™ÙȘ ∏¶∞ ÙÔ ÂÙ·‰‡Ó·ÌÔ Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î˘ÎÏÔÊfiÚËÛ ÙÔ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 2000 Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ÔÈ ¤ÌÌÂÛ˜ ÂȉڿÛÂȘ ÙÔ˘ Ì·˙ÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó›˜. ™˘ÁÎÂÎÚÈ̤ӷ, ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂÈÒıËÎ·Ó ÔÈ ÏÔÈÌÒÍÂȘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÙÔ˘˜ ÔÚfiÙ˘Ô˘˜

ªÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÚÈÓ ·fi ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ˘ÏÔÔ›ËÛË Ù˘ ·Ú¤Ì‚·Û˘. ªÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÌÂÙ¿ ÙË Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÙËÓ ˘ÏÔÔ›ËÛË Ù˘ ·Ú¤Ì‚·Û˘.

¶·È‰È·ÙÚÈ΋ 2008;71:148-156

Pediatri Mar-Apr 08

09-04-08

10:37

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¶›Ó·Î·˜ 2. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜

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¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜

™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜

∞ÔÙÂϤÛÌ·Ù·

2001 ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, Kaiser ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ™‡ÛÙËÌ· ÀÁ›·˜ Permanente, Oakland ∫·ÏÈÊfiÚÓÈ·, ∏¶∞ (20)

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ Û ‚Ú¤ÊË (2-15 ÌËÓÒÓ) Î·È ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì›·˜ ‰fiÛ˘ Û ·È‰È¿ 2-5 ÂÙÒÓ 2. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜

1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÌÔÚ› Ó· ÌÂÙ·‚¿ÏÂÈ ÙËÓ ÂȉËÌÈÔÏÔÁ›· Ù˘ ÓfiÛÔ˘ 2. ∞ÎfiÌ· ÌÔÚ› Ó· ·Ô‰Âȯı› ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·Ó¿ÏÔÁ· Ì ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡

2003 ∫·Ó·‰¿˜ (21)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜

1. ∆·ÎÙÈÎfi˜ ∂Ì‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ 2. ŒÎÙ·ÎÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 3. ŒÎÙ·ÎÙÔ˜ 2 ‰fiÛÂˆÓ 4. ŒÎÙ·ÎÙÔ˜ 1 ‰fiÛ˘

1. ¶ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Â›Ó·È Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. øÛÙfiÛÔ, Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ı· Â›Ó·È ÈÔ ·Ô‰ÔÙÈÎfi˜ ÁÈ· ÙËÓ ÎÔÈÓˆÓ›·, ·Ó Ë ÙÈÌ‹ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÌÂȈı› ÛÙ· $30/‰fiÛË

2003 √ÏÏ·Ó‰›· (22)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜

1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜

1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ ÌÂÁ¿ÏÔ ·ÚÈıÌfi Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·È Ó· ÌÂÈÒÛÂÈ ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙË ÓÔÛËÚfiÙËÙ· 2. √ ‰Â›ÎÙ˘ ÎfiÛÙÔ˘˜- ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ‰ÂÓ Â›Ó·È Â˘ÓÔ˚Îfi˜ (83.226 – ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È), ÁÈ’ ·˘Ùfi ÚÔÙ›ÓÂÙ·È Ó· ÌËÓ ÂÓÙ·¯ı› ÙÔ ÂÌ‚fiÏÈÔ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi

2003 °ÂÚÌ·Ó›· (23)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∞ÛÊ·ÏÈÛÙÈο ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∆·Ì›·, ∫ÔÈÓˆÓ›·

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‚ÚÂÊÒÓ Î·È ·È‰ÈÒÓ ÌÈÎÚfiÙÂÚ· ÙˆÓ 2 ÂÙÒÓ 2. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜

1. ∞fi ÙËÓ ÚÔÔÙÈ΋ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ ÙÔ ÂÌ‚fiÏÈÔ ÂÍÔÈÎÔÓÔÌ› 51,1% ÙˆÓ ‰··ÓÒÓ ÙÔ˘ 2. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋

2004 πÛ·Ó›· (24)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∫ÔÈÓˆÓ›·

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ‚ÚÂÊÒÓ ËÏÈΛ·˜ 6 ‚‰ÔÌ¿‰ˆÓ-7 ÌËÓÒÓ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ

1. ∏ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘ ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ı· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË ıÓËÛÈÌfiÙËÙ· Î·È ÙË ÓÔÛËÚfiÙËÙ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË ÛÙ· ·È‰È¿ 2. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ <5 ÂÙÒÓ Â›Ó·È ·Ô‰ÔÙÈÎfi˜ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÛÎÔÈ¿ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙË ÛÎÔÈ¿ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜

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ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Ì›ˆÛË Ô˘ Î˘Ì·ÈÓfiÙ·Ó ÛÙÔ 80% ÂÚ›Ô˘ ÛÙ· ·È‰È¿ οو ÙˆÓ 2 ÂÙÒÓ (20), ÂÓÒ ÂÈϤÔÓ, ηٷÁÚ¿ÊËΠÂÏ¿ÙÙˆÛË ÙˆÓ ‰ÈÂÈÛ‰˘ÙÈÎÒÓ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·Ù¿ 54% Û ¿ÙÔÌ· 2039 ÂÙÒÓ, ηٿ 25% Û ¿ÙÔÌ· 40-64 ÂÙÒÓ Î·È Î·Ù¿ 39% Û ¿ÙÔÌ· ¿Óˆ ÙˆÓ 65 ÂÙÒÓ (37). ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ‹Ù·Ó Ë Ì›ˆÛË Ù˘ ·ÓÙÈÌÈÎÚԂȷ΋˜ ·ÓÙÔ¯‹˜, ηıÒ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ù· ÛÙÂϤ¯Ë Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Á›ÓÂÙ·È ‰‡ÛÎÔÏË Ë ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ Î·È Ë Èı·ÓfiÙËÙ· ÂÈÏÔÎÒÓ Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË (20). ∆Ô 2006 ‰ËÌÔÛȇÙËΠÌÈ· ÌÂϤÙË ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ Ó¢ÌÔÓÈÔÎÔÎÎÈÎÔ‡ ÂÌ‚ÔÏ›Ô˘, Ë ÔÔ›· ‚·Û›ÛÙËΠ۠ÛÙÔȯ›· ·fi ÙËÓ ÂÓÙ·ÂÙ‹ ÂÌÂÈÚ›· Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÛÙȘ ∏¶∞ (22).

Paediatriki 2008;71:148-156

∏ ex ante ÌÂϤÙË ÎfiÛÙÔ˘˜-·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÂÎÙÈÌÔ‡Û fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ ı· ÎfiÛÙÈ˙ 176.000 ‰ÔÏ¿ÚÈ· ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È, fiÙ·Ó ˘ÔÏÔÁÈ˙fiÙ·Ó ÌfiÓÔ ÙÔ ¿ÌÂÛÔ È·ÙÚÈÎfi ÎfiÛÙÔ˜, ÂÓÒ ·Ó Û˘Ó˘ÔÏÔÁÈ˙fiÙ·Ó ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È ÙÔ ÌË È·ÙÚÈÎfi ¿ÌÂÛÔ ÎfiÛÙÔ˜, ÙfiÙ ÙÔ ÂÌ‚fiÏÈÔ ı· ÎfiÛÙÈ˙ 80.000 ‰ÔÏ¿ÚÈ· ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È. ∆· ÛÙÔȯ›· Ô˘ ÚԤ΢„·Ó ·fi ÙËÓ ÂÓÙ·ÂÙ‹ ¯Ú‹ÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ Â¤‰Ú·ÛÂ Î·È ÛÙ· ÌË ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ÛÙ· ÔÔ›· ·ÚÔ˘ÛÈ¿ÛÙËΠ̛ˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Ù˘ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋˜ ÓfiÛÔ˘ Ô˘ ¤ÊÙ·Û ÙÔ 68%. µ¿ÛÂÈ ·˘ÙÒÓ ÙˆÓ ÛÙÔȯ›ˆÓ ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È ˘ÔÏÔÁ›ÛÙËΠÛÙ· 7.500 ‰ÔÏ¿ÚÈ·. ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Û¯ÂÙÈο Ì ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ‰ÂÓ

Pediatri Mar-Apr 08

07-04-08

16:23

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153

√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ

¶›Ó·Î·˜ 2. (Û˘Ó¤¯ÂÈ·) ÃÒÚ· Î·È ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜

ª¤ıÔ‰Ô˜

2004 ∞˘ÛÙÚ·Ï›· (25)

¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜

™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜

∞ÔÙÂϤÛÌ·Ù·

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜

1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ Û 4 ‰fiÛÂȘ

1. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È ·Û‡ÌÊÔÚË 2. ∆Ô ÎfiÛÙÔ˜ ·Ó¿ DALY Â›Ó·È ÛÙ· ˘„ËÏfiÙÂÚ· Â›‰· Û˘ÁÎÚÈÙÈο Ì ÙÔ fiÚÈÔ Ô˘ ÂÈÙÚ¤Ô˘Ó ÔÈ Î·Ù¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ Ù˘ ∞˘ÛÙÚ·Ï›·˜

2005 ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ (26)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∂ıÓÈÎfi ™‡ÛÙËÌ· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÀÁ›·˜

∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ Û ·È‰È¿

™˘Ó˘ÔÏÔÁ›˙ÔÓÙ·˜ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙÔ ÂÌ‚fiÏÈÔ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜

2005 πÙ·Ï›· (27)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›·, ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 3 ‰fiÛÂˆÓ 2. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜

1. ∞fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ ÂÍÔÈÎÔÓÔÌÔ‡ÓÙ·È 52–/·ÛıÂÓ‹ 2. ∞fi ÙËÓ ÚÔÔÙÈ΋ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ ÂÍÔÈÎÔÓÔÌÔ‡ÓÙ·È 23–/·ÛıÂÓ‹ 3. ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ÙÔ ÂÌ‚fiÏÈÔ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Î·È ı· Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏËÊı› ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ

2006 ¡ÔÚ‚ËÁ›· (28)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜™ÙÔÓ ˘ÔÏÔÁÈÛÌfi 1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÎfiÛÙÔ˘˜ 4 ‰fiÛÂˆÓ Î·È ∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ - Û˘ÓÂÎÙÈÌ‹ıËÎ·Ó ÙÔ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÃÚËÛÈÌfiÙËÙ·˜ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È 3 ‰fiÛÂˆÓ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜

1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ 4 ‰fiÛÂˆÓ ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, Û‡Ìʈӷ Ì ÙȘ ÚÔ¸Ôı¤ÛÂȘ Ô˘ ı¤ÙÂÈ Ë ¡ÔÚ‚ËÁ›·, ·ÎfiÌ· ÎÈ ·Ó Û˘Ó˘ÔÏÔÁÈÛÙÔ‡Ó ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Î·È ÔÈ ÂÈÙÒÛÂȘ Ù˘ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ 2. ∞Ó ÙÔ Û¯‹Ì· ÙˆÓ 3 ‰fiÛÂˆÓ Â›Ó·È ÂÍ›ÛÔ˘ ‰Ú·ÛÙÈÎfi, fiˆ˜ ·˘Ùfi ÙˆÓ 4, ÙfiÙÂ Ë ÛÙÚ·ÙËÁÈ΋ Â›Ó·È ·Ô‰ÔÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ (cost saving) ·Ó Û˘Ó˘ÔÏÔÁÈÛÙ› Î·È ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜

2006 ∏¶∞ (29)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜∫ÔÈÓˆÓ›· ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜

ªÂ ‰Â‰Ô̤ӷ Ù· ÛÙÔȯ›· Ù˘ Â›‰Ú·Û˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙ· ÌË ÂÌ‚ÔÏÈ·Ṳ̂ӷ ¿ÙÔÌ·, ¤ÂÈÙ· ·fi 5 ¯ÚfiÓÈ· ¯Ú‹Û˘, ÙÔ ÎfiÛÙÔ˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È $7.500 ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È. ∏ ·Ó·ÏÔÁ›· ·˘Ù‹ Â›Ó·È Î·Ù¿ Ôχ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ ·Ú¯È΋ Ô˘ ‹Ù·Ó $80.000 ·Ó¿ ¤ÙÔ˜ ˙ˆ‹˜ Ô˘ ÛÒ˙ÂÙ·È

∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÌÈÎÚfiÙÂÚ· ÙˆÓ 23 ÌËÓÒÓ

Â›Ó·È È‰È·›ÙÂÚ· ÂÓı·ÚÚ˘ÓÙÈο Û¯ÂÙÈο Ì ÙËÓ ÔÈÎÔÓÔÌÈ΋ ·Ô‰ÔÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Î·È ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙËÓ ÂÍÔÈÎÔÓfiÌËÛË fiÚˆÓ. ∂ȉÈÎfiÙÂÚ·, ÛÙȘ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›·, Ë ÂÊ·ÚÌÔÁ‹ ÂÓfi˜ ·ÓÔÛÔÔÈËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Û fiÏ· Ù· ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜, ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ÂıÓÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ ˘Á›·˜, ‰ÂÓ Â›Ó·È Û η̛· ÂÚ›ÙˆÛË ÂˆÊÂÏ‹˜. ∞fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋, fiÔ˘ Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜, Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·Ô‰ÔÙÈο (38). øÛÙfiÛÔ Ë ‰Ú·ÛÙÈÎfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Â›Ó·È ÈηÓÔÔÈËÙÈ΋ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Î·È ÙˆÓ ı·Ó¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Î·È ¤ÌÌÂÛ· Ì ·˘Ù‹. ™˘ÁÎÂÎÚÈ̤ӷ,

ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙȘ ∏¶∞ ÌÂÙ¿ ·fi 4 ¯ÚfiÓÈ· ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ·ÁÔÚ¿, ¤‰ÂÈÍ fiÙÈ ÔÈ ı¿Ó·ÙÔÈ ÂÍ·ÈÙ›·˜ Ù˘ ÓfiÛÔ˘ ÌÂÈÒıËÎ·Ó ·fi 145 Û 66 ηْ ¤ÙÔ˜ (39). ∏ ·ÓÂÌ¢ÏÔÁÈ¿ Â›Ó·È ÌÈ· ÓfiÛÔ˜ Ô˘ ÂÈʤÚÂÈ ÌÂÁ¿ÏË ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÛÙËÓ ÎÔÈÓˆÓ›·, ΢ڛˆ˜ ÏfiÁˆ ÙÔ˘ ¤ÌÌÂÛÔ˘ ÎfiÛÙÔ˘˜. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÈηÈÔÏÔÁ› ÂÓ Ì¤ÚÂÈ ÙËÓ ·fiÊ·ÛË ÔÏÏÒÓ ¯ˆÚÒÓ Ó· ÂÂÓ‰‡ÛÔ˘Ó ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∂ÈϤÔÓ, ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ Â›Ó·È Î·È Ô Î·ıÔÚÈÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Ô‰ËÁ› Û ÌË ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ Ù·Ì›ˆÓ ‹ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘ Â›Ó·È È‰È·›ÙÂÚ· ¢ÓÔ˚ο, ·Ó Ë ÔÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË ‰ÈÂÍ¿ÁÂÙ·È ˘fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋ (40). ¶·È‰È·ÙÚÈ΋ 2008;71:148-156

Pediatri Mar-Apr 08

07-04-08

16:23

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154

µ. ∆ÛÈ¿ÓÙÔ˘ Î·È Û˘Ó.

¶›Ó·Î·˜ 3. ªÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ÃÒÚ· Î·È ª¤ıÔ‰Ô˜ ¯ÚfiÓÔ˜ ‰ÈÂÍ·ÁˆÁ‹˜

¶ÚÔÔÙÈ΋ ·Ó¿Ï˘Û˘/ ÀÔÏÔÁÈÛÌfi˜ ÎfiÛÙÔ˘˜

™˘ÁÎÚÈÓfiÌÂÓ˜ ÛÙÚ·ÙËÁÈΤ˜

∞ÔÙÂϤÛÌ·Ù·

1999 ∞˘ÛÙÚ·Ï›· (31)

∞Ó¿Ï˘ÛË ∂ıÓÈÎfi ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 2. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ·ÓÂÌ¢ÏÔÁÈ¿ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· 3. ™˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ·Ú·¿Óˆ 4. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜

1. ∏ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 2. ¶ÈÔ ‰Ú·ÛÙÈ΋ ÛÙÚ·ÙËÁÈ΋ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ûı¤ÓÂÈ·˜ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ (ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ), ·ÏÏ¿ ‰ÂÓ ‹Ù·Ó ÔÈÎÔÓÔÌÈο ·Ô‰ÔÙÈ΋

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∞Ó¿Ï˘ÛË ∫ÔÈÓˆÓ›·, ∫fiÛÙÔ˘˜™‡ÛÙËÌ· ÀÁ›·˜ ∞ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜

1. ªË ÂÌ‚ÔÏÈ·ÛÌfi˜ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÓÔÛ‹ÛÂÈ ·fi ·ÓÂÌ¢ÏÔÁÈ¿ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ· 4. ™˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô ·Ú·¿Óˆ

1. ∆Ș ηχÙÂÚ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ›¯Â Ë ÛÙÚ·ÙËÁÈ΋ ÙÔ˘ ÌÈÎÙÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, ·ÏÏ¿ ‰ÂÓ ‹Ù·Ó ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙË ÛÎÔÈ¿ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 2. ∞fi ÙËÓ ÔÙÈ΋ Ù˘ ÎÔÈÓˆÓ›·˜, Ë ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÛÙÚ·ÙËÁÈ΋ ‹Ù·Ó ·˘Ù‹ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ËÏÈΛ· ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ 3. ∏ ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÌfiÓÔ ÙˆÓ ÂÊ‹‚ˆÓ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ÌfiÓÔ ·fi ÙËÓ ÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜

2003 ∞ÁÁÏ›·√˘·Ï›· (33)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜ÃÚËÛÈÌfiÙËÙ·˜

∫ÔÈÓˆÓ›·, ™‡ÛÙËÌ· ÀÁ›·˜

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ‚ÚÂÊÒÓ 2. ŒÎÙ·ÎÙÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ 2-11 ÂÙÒÓ 3. ∂Ì‚ÔÏÈ·ÛÌfi˜ ÂÊ‹‚ˆÓ ¿Óˆ ÙˆÓ 11 ÂÙÒÓ

1. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ÂÊ‹‚ˆÓ Â›Ó·È Ô ÈÔ ·ÛÊ·Ï‹˜ Î·È Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·fi ÙËÓ ÚÔÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 2. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ‚ÚÂÊÒÓ Â›Ó·È ·›ı·ÓÔ Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜

2004 πÙ·Ï›· (34)

∞Ó¿Ï˘ÛË ∫fiÛÙÔ˘˜√ʤÏÔ˘˜

∫ÔÈÓˆÓ›·, ™‡ÛÙËÌ· ÀÁ›·˜

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ 1-2 ÂÙÒÓ (Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ‰È·ÊÔÚÂÙÈο Â›‰· ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ (1-2 ÂÙÒÓ) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (ÙÔ ÔÔ›Ô ı· ‰È·ÚÎÔ‡Û ٷ 5 ÚÒÙ· ¤ÙË Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘) 3. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ·È‰ÈÒÓ ËÏÈΛ·˜ (1-2 ÂÙÒÓ) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤Ó· ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (ÙÔ ÔÔ›Ô ı· ‰È·ÚÎÔ‡Û ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘)

1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· ¤¯ÂÈ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÓÔÛËÚfiÙËÙ· ÏfiÁˆ ·ÓÂÌ¢ÏÔÁÈ¿˜. ∆· ÌÂÁ·Ï‡ÙÂÚ· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È fiÙ·Ó ÙÔ ÔÛÔÛÙfi Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ Â›Ó·È 90% 2. ∆Ô ÛÂÓ¿ÚÈÔ ÙÔ˘ Ù·ÎÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ÔÛÔÛÙfi ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ 90%, Â›Ó·È ·Ô‰ÔÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜, ÙfiÛÔ ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ ÚÔÔÙÈ΋, fiÛÔ Î·È ·fi ÙËÓ ÚÔÔÙÈ΋ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ˘Á›·˜ 3. ŸÛÔ ÌÂÈÒÓÂÙ·È ÙÔ Â›Â‰Ô Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ Î¿Ï˘„˘ ÙfiÛÔ ÏÈÁfiÙÂÚÔ ·Ô‰ÔÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ Á›ÓÂÙ·È ÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÔ‡. ¶·ÚfiÏ· ·˘Ù¿ ·ÎfiÌ· Î·È ÛÙÔ ¯ÂÈÚfiÙÂÚÔ ÛÂÓ¿ÚÈÔ ÙÔ ÂÌ‚fiÏÈÔ ·Ú·Ì¤ÓÂÈ ·ÔÙÂÏÂÛÌ·ÙÈÎfi ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜

2006 πÛ·Ó›· (35)

Dynamic model ∫ÔÈÓˆÓ›·, ∞ÛÊ·ÏÈÛÙÈο ∆·Ì›·

1. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÁÈ· ·È‰È¿ 1-2 ÂÙÒÓ Î·È 2. ∆·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÌ‚ÔÏÈ·ÛÌfi ·ÙfiÌˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (catch-up program)

1. √ Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤¯ÂÈ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙË ÓÔÛËÚfiÙËÙ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÓÂÌ¢ÏÔÁÈ¿. ª¿ÏÈÛÙ· ·fi ÎÔÈÓˆÓÈ΋ ÛÎÔÈ¿ Ë ÛÙÚ·ÙËÁÈ΋ ·˘Ù‹ ÂÌÊ·Ó›˙ÂÙ·È È‰È·›ÙÂÚ· ·Ô‰ÔÙÈ΋ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ›Ù ÏËÊı› ˘fi„Ë ÙÔ ¤ÌÌÂÛÔ ÎfiÛÙÔ˜ ›Ù fi¯È 2. ∞fi ÙË ÛÎÔÈ¿ ÙˆÓ ·ÛÊ·ÏÈÛÙÈÎÒÓ ÊÔÚ¤ˆÓ, Ô Ù·ÎÙÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ıˆÚÂ›Ù·È ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ˆ˜ ÚÔ˜ ÙÔ ÎfiÛÙÔ˜ ·Ó Î·È ·˘Í¿ÓÂÙ·È Ï›ÁÔ ÙÔ ÎfiÛÙÔ˜

Paediatriki 2008;71:148-156

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·155

155

√ÈÎÔÓÔÌÈ΋ ·ÍÈÔÏfiÁËÛË Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ

√ ¶√À Û˘ÓÈÛÙ¿ ÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ¯ÒÚ˜ fiÔ˘ Ë ·ÓÂÌ¢ÏÔÁÈ¿ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Î·È Ù˘ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋˜ ηٿÛÙ·Û˘ Ù˘ ¯ÒÚ·˜. ª¤¯ÚÈ ÙÔ 2004 ÙÔ ÂÌ‚fiÏÈÔ Î˘ÎÏÔÊÔÚÔ‡Û ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ Î·È ÔÚÈṲ̂Ó˜ ·fi ·˘Ù¤˜ ÙÔ Â›¯·Ó ÂÓÙ¿ÍÂÈ ÛÙÔÓ Ù·ÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (40).

™˘˙‹ÙËÛË ∆· ÚÔÁÚ¿ÌÌ·Ù· ·ÓÔÛÔÔ›ËÛ˘ Â›Ó·È ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË ÁÈ· ÙË Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜, Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ÙÔ˘ ÎfiÛÙÔ˘˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ٷ ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·. ∏ ·fiÊ·ÛË ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÂÓfi˜ ÂÌ‚ÔÏ›Ô˘ ÛÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÌÈ·˜ ¯ÒÚ·˜ Ï·Ì‚¿ÓÂÙ·È ‚¿ÛÂÈ ÂȉËÌÈÔÏÔÁÈÎÒÓ, ÔÈÎÔÓÔÌÈÎÒÓ, ÔÏÈÙÈÎÒÓ Î·È ÎÔÈÓˆÓÈÎÒÓ ÎÚÈÙËÚ›ˆÓ. ∏ Ù¯ÓÈ΋ Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘, ·Ó Î·È ·ÊÔÚ¿ Ì›· ÌfiÓÔ ÏÂ˘Ú¿ ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜, Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ÏfiÁˆ ·ÊÂÓfi˜ Ù˘ Û·ÓÈfiÙËÙ·˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÔÈÎÔÓÔÌÈÎÒÓ fiÚˆÓ Î·È ·ÊÂÙ¤ÚÔ˘ ÙˆÓ ·˘Í·ÓfiÌÂÓˆÓ ˘ÁÂÈÔÓÔÌÈÎÒÓ ·Ó·ÁÎÒÓ. øÛÙfiÛÔ, ÔÈ ÌÂϤÙ˜ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÙÔ ÌÔÓ·‰ÈÎfi ÎÚÈÙ‹ÚÈÔ Ï‹„˘ ·ÔÊ¿ÛˆÓ. ∞˘Ùfi Á›ÓÂÙ·È ÈÔ Î·Ù·ÓÔËÙfi ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ Ó¤ˆÓ ÂÌ‚ÔÏ›ˆÓ. ∞Ó Î·È ·fi ÔÈÎÔÓÔÌÈ΋˜ ÏÂ˘Ú¿˜ ÔÈ Û˘ÁÎÂÎÚÈ̤Ó˜ ·ÚÂÌ‚¿ÛÂȘ ‰ÂÓ ‹Ù·Ó ¿ÓÙÔÙ ÔÈ ϤÔÓ ·Ô‰ÔÙÈΤ˜, ·fi È·ÙÚÈ΋˜ ·fi„ˆ˜ ‹Ù·Ó ȉȷ›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È ¤ÙÛÈ, ÌÔÚÔ‡Û·Ó Ó· ηıËÛ˘¯¿ÛÔ˘Ó ¤Ó· ÌÂÁ¿ÏÔ ÙÌ‹Ì· ÙÔ˘ ÏËı˘ÛÌÔ‡ Ô˘ ·ÓËÛ˘¯Ô‡Û ÁÈ· ·˘Ù¿ Ù· ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·. µÂ‚·›ˆ˜, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÈÎÔÓÔÌÈÎÒÓ ·ÍÈÔÏÔÁ‹ÛÂˆÓ ‰ÂÓ Ì¤ÓÔ˘Ó ·ÓÂÎÌÂÙ¿ÏÏÂ˘Ù·. ∞ÓÙ›ıÂÙ· Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂÈÏÔÁ‹ Ù˘ ·Ô‰ÔÙÈÎfiÙÂÚ˘ ÛÙÚ·ÙËÁÈ΋˜ ·ÓÔÛÔÔ›ËÛ˘ Î·È ÛÙÔÓ Û¯Â‰È·ÛÌfi ÙˆÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ·ÚÂÌ‚¿ÛˆÓ. ∆· ‚·ÛÈο ÂÚˆÙ‹Ì·Ù· ÛÙ· ÔÔ›· ÔÈ ‰È·ÌÔÚʈ٤˜ Ù˘ ÔÏÈÙÈ΋˜ ˘Á›·˜ ηÏÔ‡ÓÙ·È Ó· ··ÓÙ‹ÛÔ˘Ó ÚÈÓ Ï¿‚Ô˘Ó ÔÔÈ·‰‹ÔÙ ·fiÊ·ÛË Â›Ó·È (41): 1. √È ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔÔ›ËÛ˘ ı· ÌÂÈÒÛÔ˘Ó ÙËÓ Â›ÙˆÛË Ù˘ ÓfiÛÔ˘; 2. ¶ÔÈÔ Â›Ó·È ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ fiÊÂÏÔ˜ ÁÈ· ÙËÓ ˘Á›·; 3. ™Â fiÛÔ ¯ÚfiÓÔ ı· Á›ÓÔ˘Ó ÂÌÊ·Ó‹ ·˘Ù¿ Ù· ÔʤÏË; 4. ¶fiÛÔ ÎÔÛÙ›˙ÂÈ Ë ÛÙÚ·ÙËÁÈ΋ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÔÈÔ ÙÔ ÎfiÛÙÔ˜ Ô˘ ·ÔÙÚ¤ÂÙ·È; 5. ∆· ·ÔÙÂϤÛÌ·Ù· ·Ú·Ì¤ÓÔ˘Ó ›‰È·, ·Ó ·ÏÏ¿ÍÔ˘Ó Î¿ÔȘ ·fi ÙȘ ·Ú·Ì¤ÙÚÔ˘˜; 6. ¶ÔÈÔ˜ Â›Ó·È Ô ·Ô‰ÂÎÙfi˜ ‰Â›ÎÙ˘ ÎfiÛÙÔ˘˜·ÔÙÂϤÛÌ·ÙÔ˜ ÁÈ· Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÌ‚ÔÏÈ·ÛÌÔ‡; √˘ÛÈ·ÛÙÈο ÔÈ ˘‡ı˘ÓÔÈ Ï‹„˘ ·ÔÊ¿ÛˆÓ

Ú¤ÂÈ Ó· ÛÙ·ıÌ›ÛÔ˘Ó Î·È Ó· Û˘Ì‚È‚¿ÛÔ˘Ó ÙÔ˘˜ ÂȉËÌÈÔÏÔÁÈÎÔ‡˜, ÔÈÎÔÓÔÌÈÎÔ‡˜, ÎÔÈÓˆÓÈÎÔ‡˜ Î·È ÔÏÈÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÒÛÙ ӷ Ï¿‚Ô˘Ó ÙËÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·Ô‰ÔÙÈ΋ Î·È ÎÔÈÓˆÓÈο ·Ô‰ÂÎÙ‹ ·fiÊ·ÛË.

∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠Ôχ ÁÈ· ÙËÓ ÔχÙÈÌË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙËÓ ·Ó·˙‹ÙËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ -ÂȉÈο fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÂÌ‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜- ÙÔÓ Î. ∫ˆÙÛfiÔ˘ÏÔ ¡›ÎÔ, Health Economics Manager ÛÙËÓ ÂÙ·ÈÚ›· GlaxoSmithCline.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Jefferson T. Do vaccines make best use of available resources? (in other words are they cost-effective?). Vaccine 1999;17:S69-S73.

2. Van Damme P, Beutels P. Economic evaluation of vaccination. Pharmacoeconomics 1996;9:8-15.

3. Ess SM, Szucs TD. Economic evaluation of immunization strategies. Clin Infect Dis 2002;35:294-297.

4. Spier R, Jefferson TO, Demicheli V. An editorial policy statement: Submission of economic evaluation of vaccines.

[Editorial]. Vaccine 2002;20:1693-1695.

5. Kimman TG, Boot HJ, Berbers GA, Vermeer-de Bondt PE, Ardine de Wit G, de Melker HE. Developing a vaccination evaluation model to support evidence-based decision making on national immunization programs. Vaccine 2006;24: 4769-4778.

6. Drummond MF, O’ Brien BJ, Stoddart GL, Torrance G. ª¤ıÔ‰ÔÈ ÔÈÎÔÓÔÌÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ ˘Á›·˜. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∫ÚÈÙÈ΋. 2002.

7. Szucs TD. Health economic research on vaccinations and immunisation practices - an introductory primer. Vaccine 2005;23:2095-2103.

8. Chabot I, Goetghebeur MM, Gregoire JP. The societal value of universal childhood vaccination. Vaccine 2004;22: 1992-2005.

9. Szucs ∆. Cost-benefits of vaccination programmes. Vaccine 2000;18:S49-S51.

10. ¶···Ó·ÁÈÒÙÔ˘ π, ∫˘ÚÈ·˙ÔÔ‡ÏÔ˘-¢·Ï·˝Ó· µ. π·ÙÚÈ΋ ÌÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ÈÔÏÔÁ›·. £ÂÛÛ·ÏÔÓ›ÎË: ∂ΉfiÛÂȘ University Studio Press. 2001.

11. Wyeth Hellas [Webpage, Internet]. £ÂÚ·¢ÙÈ΋ ÂÓfiÙËÙ·: ªËÓÈÁÁ›Ùȉ·. http://www.wyeth.gr/th_areas/th_area_main. asp?th_ar_id=32 12. World Health Organization [Webpage, Internet]. Meningitis. http://www.who.int/topics/meningitis/en 13. ∂ıÓÈÎfi˜ √ÚÁ·ÓÈÛÌfi˜ º·Ú̿ΈÓ, ∂√º [Webpage, Internet]. http://www.eof.gr 14. Trotter CL, Edmunds WJ. Modelling cost-effectiveness of meningococcal serogroup C conjugate vaccination campaign in England and Wales. BMJ 2002;324:809.

15. Ruedin HJ, Ess S, Zimmermann HP, Szucks T. Invasive meningococcal and pneumococcal disease in Switzerland: cost-utility analysis of different vaccine strategies. Vaccine 2003;21:4145-4152.

16. Welte R, Van den Dobbelsteen G, Bos JM, de Melker H, van Alphen L, Spanjaard L, et al, Economic evaluation of meningococcal serogroup C conjugate vaccination programmes in The Netherlands and its impact on decisionmaking. Vaccine 2004;23:470-479. ¶·È‰È·ÙÚÈ΋ 2008;71:148-156

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µ. ∆ÛÈ¿ÓÙÔ˘ Î·È Û˘Ó.

17. De Wals P, Nguyen VH, Erickson LJ, Guay M, Drapeau J, St-Laurent J. Cost-effectiveness of immunization strategies for the control of serogroup C meningococcal disease. Vaccine 2004;22:1233-1240.

18. Beutels P, Thiry N, Van Damme P. Convincing or confusing? Economic evaluations of childhood pneumococcal conjugate vaccination - a review (2002-2006). Vaccine 2007; 25:1355-1367.

19. Zissis NP, Syriopoulou V, Kafetzis D, Daikos GL, Tsilimingaki A, Galanakis E, et al. Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae causing invasive infections and acute otitis media in children. Eur J Pediatr 2004;163:364-368.

20. Black S, Lieu TA, Ray GT, Capra A, Shinefield HR. Assessing costs and cost effectiveness of pneumococcal disease and vaccination within Kaiser Permanente. Vaccine 2000; 19:S83-S86.

21. De Wals P, Petit G, Erickson LJ, Guay M, Tam T, Law B, et al. Benefits and costs of immunization of children with pneumococcal conjugate vaccine in Canada. Vaccine 2003;21:3757-3764.

22. Bos JM, Rumke H, Welte R, Postma MJ. Epidemiologic impact and cost-effectiveness of universal infant vaccination with a 7-valent conjugated pneumococcal vaccine in the Netherlands. Clin Ther 2003;25:2614-2630.

23. Claes C, Schulenburg JM Graf von der. Cost effectiveness of pneumococcal vaccination for infants and children with the conjugate vaccine PnC-7 in Germany. Pharmacoeconomics 2003;21:587-600.

24. Asensi F, De Jose M, Lorente M, Moraga F, Ciuryla V, Arikian S, et al. A pharmacoeconomic evaluation of sevenvalent pneumococcal conjugate vaccine in Spain. Value Health 2004;7:36-51.

25. Butler JR, McIntyre P, MacIntyre CR, Gilmour R, Howarth AL, Sander B. The Cost- Effectiveness of pneumococcal conjugate vaccination in Australia. Vaccine 2004;22:1138-1149.

26. McIntosh ED, Conway P, Willingham J, Hollingsworth R, Lloyd A. Pneumococcal pneumonia in the UK - how herd immunity affects the cost-effectiveness of 7-valent pneumococcal conjugate vaccine (PCV). Vaccine 2005;23:1739-1745.

27. Marchetti M, Colombo GL. Cost-effectiveness of universal pneumococcal vaccination for infants in Italy. Vaccine 2005;23:4565-4576.

28. Wisloff T, Abrahamsen T, Bergsaker MA, Lovoll O, Moller P, Pedersen MK, et al. Cost effectiveness of adding 7-valent pneumococcal conjugate (PCV-7) vaccine to the Norwegian childhood vaccination program. Vaccine 2006;24: 5690-5699.

Paediatriki 2008;71:148-156

29. Ray GT, Whitney CG, Fireman BH, Ciuryla V, Black SB. Cost-effectiveness of pneumococcal conjugate vaccine: evidence from the first 5 years of use in the United States incorporating herd effects. Pediatr Infect Dis J 2006;25:494-501.

30. GlaxoSmithCline [Webpage, Internet]. Varilrix http://emc. medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=9453 31. Scuffham PA, Lowin AV, Burgess MA. The cost-effectiveness of varicella vaccine programs for Australia. Vaccine 1999;18:407-415.

32. Brisson M, Edmunds WJ. The cost-effectiveness of varicella vaccination in Canada. Vaccine 2002;20:1113-1125.

33. Brisson M, Edmunds WJ. Varicella vaccination in England and Wales: cost-utility analysis. Arch Dis Child 2003;88: 862-869.

34. Coudeville L, Paree F, Lebrun T, Sailly J. The value of varicella vaccination in healthy children: cost-benefit analysis of the situation in France. Vaccine 1999;17:142-151.

35. Lenne X, Diez Domingo J, Gil A, Ridao M, Lluch J, Dervaux B. Economic evaluation of varicella vaccination in Spain: results from a dynamic model. Vaccine 2006;24: 6980-6989.

36. Trotter CL, Edmunds WJ. Reassessing the cost-effectiveness of meningococcal serogroup C conjugate (MCC) vaccines using a transmission dynamic model. Med Decis Making 2006;26:38-47.

37. McIntosh ED, Conway P, Willingham J, Hollingsworth R, Lloyd A. Pneumococcal pneumonia in the UK - how herd immunity affects the cost-effectiveness of 7-valent pneumococcal conjugate vaccine (PCV). Vaccine 2005;23: 1739-1745.

38. Diez Domingo J, Ridao M, Latour J, Ballester A, Morant A. A cost benefit analysis of routine varicella vaccination in Spain. Vaccine 1999;17:1306-1311.

39. Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med 2005;352:450-458.

40. Rentier B, Gershon AA; European Working Group on Varicella. Consensus: varicella vaccination of healthy children - a challenge for Europe. Pediatr Infect Dis J 2004;23: 379-389.

41. Welte R, Trotter CL, Edmunds WJ, Postma MJ, Beutels P. The role of economic evaluation in vaccine decision making: focus on meningococcal group C conjugate vaccine.

Pharmacoeconomics 2005;23:855-874.

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¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ÁÈ· ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ ∞. ∫·Ê¿ÙÔ˜ ¶ÂÚ›ÏË„Ë: ∏ ÂȉËÌÈ΋ ¤Í·ÚÛË Ù˘ ·È‰È΋˜ ·¯˘Û·ÚΛ·˜ ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 ̤¯ÚÈ Û‹ÌÂÚ· ηıÈÛÙ¿ ·Ó·Áη›· ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Î·È ÙˆÓ ÁÔÓÈÒÓ ÁÈ· ÙË ÛˆÛÙ‹ ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ. ∏ ÂÓË̤ڈÛË ·˘Ù‹ ı· ‚ÔËı‹ÛÂÈ ÛÙËÓ ·ÔÊ˘Á‹ ÙÚÔÊ›ÌˆÓ ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜, ÁÈ· ·Ú¿‰ÂÈÁÌ· ·Ù¿Ù˜ ÙÛÈ˜ Ì 530 kcal/100 ÁÚ·Ì., ÌÈÛÎfiÙ· Ì ÛÔÎÔÏ¿Ù· Ì 524 kcal/100 ÁÚ·Ì. Î·È ¯·ÌËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο. ∆· ÙÚfiÊÈÌ· ·˘Ù¿ ÚÔÛʤÚÔ˘Ó ÂÏ¿¯ÈÛÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Ô˘ Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜. ∆· ··Ú·›ÙËÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο ÂÍ·ÛÊ·Ï›˙ÔÓÙ·È fiÙ·Ó Ï·Ì‚¿ÓÔÓÙ·È ÔÈ Û˘ÓÈÛÙÒÌÂÓ˜ ÌÂÚ›‰Â˜ ·fi ηıÂÌÈ¿ ·fi ÙȘ 5 ηÙËÁÔڛ˜ ÙÚÔÊ›ÌˆÓ Î·È Î·Ù·Ó¤ÌÔÓÙ·È Û 3 ·ÚÈ· Î·È 2 ÌÈÎÚfiÙÂÚ· ÂӉȿÌÂÛ· Á‡̷ٷ. ∞·ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÚÔÛ¿ıÂÈ· ÂΠ̤ÚÔ˘˜ ÙˆÓ ÁÔÓÈÒÓ, ÒÛÙ ӷ ¤¯Ô˘Ó Ù· ·È‰È¿ 2-3 Á‡̷ٷ ÙËÓ Â‚‰ÔÌ¿‰· Ì ÌÈÎÚ¿ ÏÈ·Ú¿ „¿ÚÈ·, 2-8 ÌÂÚ›‰Â˜ Ï·¯·ÓÈÎÒÓ ËÌÂÚËÛ›ˆ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, 2-5 ÊÚÔ‡Ù· ÙËÓ Ë̤ڷ, 2-3 ÌÂÚ›‰Â˜ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ, ÂÏ¿¯ÈÛÙÔ ÎfiÎÎÈÓÔ ÎÚ¤·˜ Î·È Î·ıfiÏÔ˘ ÂÂÍÂÚÁ·Ṳ̂ÓÔ ÎÚ¤·˜ (.¯. ˙·ÌfiÓ). ∆Ô ·Ú¿‰ÂÈÁÌ· ÙˆÓ ÁÔÓÈÒÓ ¯ˆÚ›˜ ÏfiÁÈ· Â›Ó·È Ô Î·Ï‡ÙÂÚÔ˜ ÙÚfiÔ˜ ‰È‰·Ûηϛ·˜ (ÛÙËÓ ¿ÛÎËÛË Î·È ÛÙÔ Ê·ÁËÙfi). ∏ ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ, ‚·ÛÈṲ̂ÓË ÛÙÔÓ ·Ú·‰ÔÛÈ·Îfi ÙÚfiÔ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ∂ÏÏ‹ÓˆÓ Ì·˙› Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ 2-3 ÒÚ˜ ¤ÓÙÔÓ˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ηıËÌÂÚÈÓ¿, ı· ÂÍ·ÛÊ·Ï›ÛÂÈ ¿ÚÈÛÙË ·Ó¿Ù˘ÍË Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ.

∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ∞ÓÙÒÓ˘ ∫·Ê¿ÙÔ˜ kafatos@med.uoc.gr ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘

§¤ÍÂȘ ÎÏÂȉȿ: ¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ, ·Ó¿Ù˘ÍË, ·¯˘Û·ÚΛ·, ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·, ıÚÂÙÈο Û˘ÛÙ·ÙÈο, ۈ̷ÙÈ΋ ¿ÛÎËÛË.

Childhood and adolescent nutrition for promoting health and growth and preventing chronic diseases A. Kafatos Abstract: Paediatric obesity has been increasing since the 1980s in an epidemic mode. Due to this fact, it has become necessary to provide information for paediatricians and parents about the diet appropriate for growth and avoidance of obesity of children. The primary target should be the elimination of foods of high energy density and low nutrient content (e.g., chips, chocolate biscuits) from the diet of children, with emphasis on the traditional Greek diet. The intake of essential nutrients is ensured when children consume the recommended portions from each of the 5 categories of foods, and when these portions are distributed between 3 main and 2 smaller intermediate meals on a daily basis. Particular effort is required on the part of the parents to ensure that children consume 2-3 portions of small oily fish per week, 2-8 portions of vegetables daily, depending on age, and 2-5 portions of fruits and 2-3 portions of dairy products on a daily basis. The best way of teaching children about diet and physical activity is for parents to set an example by practising these habits themselves at home. The adoption of the traditional Greek diet, low in saturated fat and high in olive oil, vegetables, fruit and legumes, with at least 2-3 hours of daily intense physical activity will ensure excellent growth and development of the children and help in the prevention of chronic diseases.

Division of Preventive Medicine and Nutrition, Faculty of Medicine, University of Crete Correspondence: Antonis Kafatos kafatos@med.uoc.gr Division of Preventive Medicine and Nutrition, Faculty of Medicine, University of Crete

Key words: Childhood nutrition, growth, obesity, chronic diseases, nutrients, physical activity.

∏ Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ ÚÔ¸Ôı¤ÙÂÈ ÙË Ï‹„Ë ÂÚ›Ô˘ 50 ··Ú·›ÙËÙˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÛÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ËÌÂÚ‹ÛȘ ÔÛfiÙËÙ˜ ·fi ÙȘ ÙÚÔʤ˜ ÁÈ· ÙË Û‡ÓıÂÛË ÙˆÓ ‰È·ÊfiÚˆÓ ÈÛÙÒÓ. ∞ÓÂ·Ú΋˜ Ï‹„Ë ÂÓfi˜ ‹ ÂÚÈÛÛfiÙÂÚˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ‹ ˘ÂÚ‚ÔÏÈ΋ Ï‹„Ë ¿ÏÏˆÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜ ÛÙË ıÚ¤„Ë Î·È ÙËÓ

·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡. °È’ ·˘Ùfi, οı ·È‰È·ÙÚÈ΋ ÂͤٷÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎÙ›ÌËÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·È‰ÈÔ‡. ∏ ÂÎÙ›ÌËÛË ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÈ (1): 1. ÎÏÈÓÈ΋ ÂͤٷÛË ÁÈ· ÛËÌ›· ·ÓÂ·ÚÎÔ‡˜ ıÚ¤„˘ ‹ ÙÔÍÈ΋ Â›‰Ú·ÛË ·fi ˘ÂÚ‚ÔÏÈ΋ Ï‹„Ë ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, 2. ۈ̷ÙÔÌÂÙÚÈΤ˜ ÌÂÙÚ‹ÛÂȘ (‚¿ÚÔ˜, Ì‹ÎÔ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:157-161

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∞. ∫·Ê¿ÙÔ˜

‹ ·Ó¿ÛÙËÌ·, ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜, ÂÚ›ÌÂÙÚÔ˜ ̤Û˘, ÏÂοÓË Î·È ‚Ú·¯›ÔÓ· Î·È ÔÚÈṲ̂Ó˜ ‰ÂÚÌ·ÙÈΤ˜ Ù˘¯¤˜) Î·È Û‡ÁÎÚÈÛË Ì ηٿÏÏËϘ ηÌ‡Ï˜ ·Ó¿Ù˘Í˘, 3. ‰È·ÈÙËÙÈÎfi ÈÛÙÔÚÈÎfi Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Ï‹„˘ ÙÚÔÊ›ÌˆÓ ·fi οı ηÙËÁÔÚ›· ̤۷ Û ÌÈ· ‚‰ÔÌ¿‰· (¤ÓÙ ηÙËÁÔڛ˜ ÙÚÔʛ̈Ó, ηıÒ˜ Î·È ·Ó·„˘ÎÙÈο, ÁÏ˘Î¿, snacks, Ê·ÁËÙ¿ ·fi Ù·¯˘ÂÛÙÈ·ÙfiÚÈ·), ȉȷÈÙÂÚfiÙËÙ˜ ÛÙË ‰È·ÙÚÔÊ‹, .¯. Ê˘ÙÔÊ·Á›· ‹ ·fiÏ˘ÙË Ê˘ÙÔÊ·Á›·. ∆Ô ‰È·ÈÙÔÏfiÁÈÔ ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ ÂÈÎÔÛÈÙÂÙÚ·ÒÚÔ˘ ‰›ÓÂÈ ÙȘ ÔÛfiÙËÙ˜ Ê·ÁËÙÔ‡ Î·È ÌÔÚ› Ó· ·Ó·Ï˘ı› Û ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û‡Ìʈӷ Ì ËÏÂÎÙÚÔÓÈ΋ ‚¿ÛË ÙÚÔʛ̈Ó, 4. ÂÎÙ›ÌËÛË Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ (›‰Ô˜, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ‹ ·‰Ú¿ÓÂÈ·˜, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ηıÈÛÙÈ΋˜ ÂÚÁ·Û›·˜ ÛÙÔ˘˜ ˘ÔÏÔÁÈÛÙ¤˜ ‹ ÙËÏÂfiÚ·ÛË, Î.Ù.Ï.), ‰È¿ÚÎÂÈ· ‡ÓÔ˘, ηıÒ˜ Î·È Ì¤ÙÚËÛË Ù˘ ηډÈÔ·Ó·Ó¢ÛÙÈ΋˜ ·ÓÙÔ¯‹˜, 5. ‚ÈÔ¯ËÌÈ΋ ÂÎÙ›ÌËÛË ıÚ¤„˘ ÁÈ· ÎÏÈÓÈΤ˜ Î·È ˘ÔÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ·ÓÂ·ÚÎÔ‡˜ ıÚ¤„˘ (.¯. ·ÈÌÔÛÊ·ÈÚ›ÓË, ·ÈÌÔÛÊ·ÈÚÈÓÈÎÔ› ‰Â›ÎÙ˜, ÊÂÚÚÈÙ›ÓË, Ê˘ÏÏÈÎfi Ô͇ Î·È µ12, ηıÒ˜ Î·È ¿ÏϘ ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›· ÛÙÔ ·›Ì·), 6. ·ÓÔÛÔ‚ÈÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ù˘ ¯˘ÌÈ΋˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È ÛÙÂÓ¿ Ì ÙË ıÚ¤„Ë ÙÔ˘, 7. ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Ë ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ÙÔ DEXA, ηıÔÚ›˙Ô˘Ó Ì ·ÎÚ›‚ÂÈ· ÙË Û‡ÓıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ ÛÂ Ì˘˚΋ Ì¿˙·, ÔÏÈÎfi Ï›Ô˜ Î·È ÔÛÙÈ΋ Ì¿˙·. ¶Ï¤ÔÓ Â‡¯ÚËÛÙË Î·È ÏÈÁfiÙÂÚÔ ‰··ÓËÚ‹ Â›Ó·È Ë ‚ÈÔËÏÂÎÙÚÈ΋ ·ÁˆÁÈÌfiÙËÙ· ÁÈ· ÙË Û‡ÓıÂÛË ÙÔ˘ ÛÒÌ·ÙÔ˜. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ ı· ÂÚÈÔÚÈÛÙԇ̠ÛÙȘ Û˘ÛÙ¿ÛÂȘ Û ÙÚfiÊÈÌ· Î·È ıÚÂÙÈο Û˘ÛÙ·ÙÈο, ÒÛÙ ӷ ÂÈÙ‡¯ÂÈ ÙÔ ·È‰› ¿ÚÈÛÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË. √ ¶›Ó·Î·˜ 1 ‰›ÓÂÈ ÙȘ ÂÓÂÚÁÂȷΤ˜ ·Ó¿ÁΘ ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ËÏÈΛ· Î·È Ê‡ÏÔ, ηıÒ˜ Î·È ÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÔÛfiÙËÙ˜ ÙˆÓ ‚·ÛÈÎÒÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ (2-5). °È· ¤Ó· ·È‰› 5 ÂÙÒÓ, ÙÔ 50% ÂÚ›Ô˘ Ù˘ ÂÓ¤ÚÁÂÈ·˜ Ô˘ Ï·Ì‚¿ÓÂÙ·È Î·ıËÌÂÚÈÓ¿ ηχÙÂÈ ÙȘ ·Ó¿ÁΘ ÙÔ˘ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ÙÔ 5% Íԉ‡ÂÙ·È ÛÙËÓ ÂȉÈ΋ ‰˘Ó·ÌÈ΋ ÂÓ¤ÚÁÂÈ· Ù˘ ·ÔÚÚfiÊËÛ˘, ȉȷ›ÙÂÚ· ÙˆÓ ÚˆÙÂ˚ÓÒÓ, Î·È ÙȘ ·Ó¿ÁΘ ÁÈ· ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘˜. ∆Ô 25% ÂÚ›Ô˘ Ù˘ ÂÓ¤ÚÁÂÈ·˜ Íԉ‡ÂÙ·È ÁÈ· ̤ÙÚÈ· Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÙÔ 12% ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ÈÛÙÒÓ Î·È ÂÚ›Ô˘ 7% ¯¿ÓÂÙ·È ÛÙ· ÎfiÚ·Ó· (6). °È· ÙËÓ ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ·È‰ÈÔ‡ ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË Â›Ó·È Ë ¤ÁÎ˘Ô˜ Paediatriki 2008;71:157-161

Ó· ¤¯ÂÈ ¿ÚÈÛÙË ‰È·ÙÚÔÊ‹ Ì ·ÔÊ˘Á‹ ÙˆÓ ÙÔÍÈÎÒÓ Ô˘ÛÈÒÓ, fiˆ˜ ÙÔ ¿ÌÂÛÔ Î·È ¤ÌÌÂÛÔ Î¿ÓÈÛÌ·, Î·È ÙˆÓ ÔÈÓÔÓÂ˘Ì·Ùˆ‰ÒÓ ÔÙÒÓ (7). ™ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, Ë ¤ÁÎ˘Ô˜ Ú¤ÂÈ Ó· ÚÔÂÙÔÈÌ·Ûı› ÁÈ· ÂÈÙ˘¯‹ ıËÏ·ÛÌfi. ∂ÈÙ˘¯‹˜ ıËÏ·ÛÌfi˜ ÛËÌ·›ÓÂÈ ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ÁÈ· 6 Ì‹Ó˜ Î·È Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ̤¯ÚÈ ÙÔ 12Ô Ì‹Ó· Ì ÚÔԉ¢ÙÈ΋ ÚÔÛı‹ÎË ¿ÏÏˆÓ ÙÚÔÊÒÓ. ∆Ô ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Î·È ÔÈ ÁÈ·ÙÚÔ› ÛÙ· Ì·ÈÂ˘Ù‹ÚÈ· ‰ÂÓ ı· Ú¤ÂÈ Ó· ÂÈÙÚ¤Ô˘Ó ÛÙÔ˘˜ ·ÓÙÈÚÔÛÒÔ˘˜ ÙˆÓ ·È‰ÈÎÒÓ ÙÚÔÊÒÓ Ó· ‰›ÓÔ˘Ó ‰ÒÚ· ÛÙȘ ÌËÙ¤Ú˜ Ô‡Ù ӷ ‰Ôı› ͤÓÔ Á¿Ï· Ì ÌÈÌÂÚfi ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. ∏ ¯ÔÚ‹ÁËÛË ÌÈÌÂÚÔ‡ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ıËÏ·ÛÌÔ‡ ·ÔÎÏ›ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ıËÏ·ÛÌÔ‡. √ ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ¤¯ÂÈ ÔÏÏ¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÁÂÏ·‰ÈÓÔ‡ Á¿Ï·ÙÔ˜, ·ÏÏ¿ ΢ڛˆ˜ ÂÏ·ÙÙÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÌÂÏÏÔÓÙÈ΋˜ ·¯˘Û·ÚΛ·˜ Î·È fiÏˆÓ ÙˆÓ Û˘ÓÔ‰ÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ (˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜, ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 2 Î·È ·˘ÍË̤ÓÔ˘ ΛӉ˘ÓÔ˘ Û ÔÚÈṲ̂ÓÔ˘˜ ηÚΛÓÔ˘˜, Î.¿.). ªÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ú¤ÂÈ Ó· ·Ú¯›ÛÂÈ ÚÔԉ¢ÙÈ΋ ÂÈÛ·ÁˆÁ‹ fiÏˆÓ ÙˆÓ ÙÚÔÊÒÓ ÛÙË ‰È·ÙÚÔÊ‹ ÙˆÓ ·È‰ÈÒÓ Î·È Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ̤¯ÚÈ ÙÔ 12Ô Ì‹Ó·. ∏ ηıËÌÂÚÈÓ‹ ‰È·ÙÚÔÊ‹ ÙÔ˘ ·È‰ÈÔ‡ ıˆÚÂ›Ù·È ¿ÚÈÛÙË fiÙ·Ó ÂÚȤ¯ÂÈ ÙÚfiÊÈÌ· Î·È ·fi ÙȘ 5 ηÙËÁÔڛ˜ ÙˆÓ ÙÚÔÊ›ÌˆÓ Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2 (8). √È ··Ú·›ÙËÙ˜ ÌÂÚ›‰Â˜ Î·È ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ·˘Ùfi ÙÔÓ ›Ó·Î·. ∏ ÂÈÏÔÁ‹ ÙˆÓ ··Ú·›ÙËÙˆÓ ÌÂÚ›‰ˆÓ ÁÈ· οı ËÏÈΛ· ·fi fiϘ ÙȘ ηÙËÁÔڛ˜ ÙÚÔÊ›ÌˆÓ Î·ıËÌÂÚÈÓ¿ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙË Ï‹„Ë fiÏˆÓ ÙˆÓ ··Ú·›ÙËÙˆÓ ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ ÛÙȘ Û˘ÓÈÛÙÒÌÂÓ˜ ÔÛfiÙËÙ˜. ∆· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ¿ÚÈÛÙ˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÂÊ‹‚Ô˘ Â›Ó·È Ù· ·ÎfiÏÔ˘ı· (9): 1. ¶ÔÈÎÈÏ›· ÛÙË ‰È·ÙÚÔÊ‹ Ì ÂÈÏÔÁ‹ ÙÚÔÊ›ÌˆÓ Î·ıËÌÂÚÈÓ¿ ·’ fiϘ ÙȘ 5 ηÙËÁÔڛ˜ Ô˘ ı· ηٷӤÌÔÓÙ·È Û ÙÚ›· ·ÚÈ· Á‡̷ٷ Î·È 2-3 ÌÈÎÚfiÙÂÚ· ÂӉȿÌÂÛ·, .¯. Ï›ÁÔ „ˆÌ›, Ù˘Ú›, ÊÚÔ‡ÙÔ, ÁÈ·Ô‡ÚÙÈ, ¤Ó· ηÚfiÙÔ, ÌÈ· ÓÙÔÌ¿Ù·, Î.¿. (¶›Ó·Î·˜ 2).

2. ¡· ÌËÓ ÚÔÛÙ›ıÂÙ·È Î·ıfiÏÔ˘ ·Ï¿ÙÈ Î·È ˙¿¯·ÚË Ô‡Ù ηٿ ÙÔ Ì·Á›ÚÂÌ· Ô‡Ù ηٿ ÙÔ ÛÂÚ‚›ÚÈÛÌ·.

3. ¡· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·ÔÎÏÂÈÛÙÈο ·ÁÓfi ·Úı¤ÓÔ ÂÏ·ÈfiÏ·‰Ô ηٿ ÚÔÙ›ÌËÛË ˆÌfi Î·È Î·ıfiÏÔ˘ Ì·ÚÁ·Ú›Ó˜, ÛÔڤϷÈÔ, ‚Ô‡Ù˘ÚÔ ‹ ¿ÏÏ· ˙ˆÈο Î·È Ê˘ÙÈο Ï›Ë.

4. ¡· ÌËÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÂÍÂÚÁ·Ṳ̂ӷ ÙÚfiÊÈÌ· Ì Ï‹ıÔ˜ ÚfiÛıÂÙˆÓ Ô˘ÛÈÒÓ, fiˆ˜ ÂÂÍÂÚÁ·Ṳ̂ӷ ÎÚ¤·Ù· (·ÏÏ·ÓÙÈο, ˙·ÌfiÓ, ÏÔ˘Î¿ÓÈη, Î.¿.), ÌÈÛÎfiÙ·, ÛÔÎÔÏ¿Ù˜, ¤ÙÔÈ̘ ·È‰ÈΤ˜ ÙÚÔʤ˜, ·Ù·Ù¿ÎÈ·, Á·Úȉ¿ÎÈ·, ÎÚÔ˘·Û¿Ó, Î.¿. ¡· ·ÔʇÁÔÓÙ·È Ù· Ù·¯˘ÂÛÙÈ·ÙfiÚÈ· ÁÈ·Ù› Ù· Ê·ÁËÙ¿ ÙÔ˘˜ Â›Ó·È ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È ¤¯Ô˘Ó

Pediatri Mar-Apr 08

07-04-08

16:23

™ÂÏ›‰·159

159

¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ

¶›Ó·Î·˜ 1. §ÈÔ‰È·Ï˘Ù¤˜ µÈٷ̛Ә

µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·

µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·

µÚ¤ÊË ¶·È‰È¿ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·

∏ÏÈΛ· (¤ÙË)

∂Ó¤ÚÁÂÈ· (kcal)

¶ÚˆÙ½ÓË (g)

µÈÙ·Ì›ÓË ∞ (Ìg RE)

µÈÙ·Ì›ÓË D (Ìg)

µÈÙ·Ì›ÓË ∂ (mg ·-TE)

0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18

650 850 1300 1800 2500 3000 2200 2200

13 14 16 24 45 59 46 44

400 500 300 400 600 900 600 700

5 5 5 5 5 5 5 5

4 5 6 7 11 15 11 15

∏ÏÈΛ· (¤ÙË)

µÈÙ·Ì›ÓË C (mg)

0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18

40 50 40 45 45 75 50 65

0,2 0,3 0,5 0,6 0,9 1,2 0,9 1,0

∏ÏÈΛ· (¤ÙË)

∞Û‚¤ÛÙÈÔ (mg)

ºÒÛÊÔÚÔ˜ (mg)

0-6 7-12 1-3 4-8 9-13 14-18 9-13 14-18

210 270 500 800 1300 1300 1300 1300

µÈÙ·Ì›ÓË ∫ (Ìg) 2 2,5 30 55 60 75 60 75

À‰ÚÔ‰È·Ï˘Ù¤˜ µÈٷ̛Ә £ÂÈ·Ì›ÓË ƒÈ‚ÔÊÏ·‚›ÓË ¡È·Û›ÓË µÈÙ·Ì›ÓË µ6 º˘ÏÏÈÎfi µÈÙ·Ì›ÓË µ12 (mg) (mg) (mgNE) (mg) √͇ (Ìg) (Ìg)

100 275 460 500 1250 1250 1250 1250

0,3 0,4 0,5 0,6 0,9 1,3 0,9 1,0

2 4 6 8 12 16 12 14

0,1 0,3 0,5 0,6 1,0 1,3 1,0 1,2

π¯ÓÔÛÙÔȯ›· ª·ÁÓ‹ÛÈÔ ™›‰ËÚÔ˜ 梉¿ÚÁ˘ÚÔ˜ (mg) (mg) (mg) 30 75 80 130 240 410 240 360

0,27 11 7 10 8 11 8 15

2 3 3 5 8 11 8 9

65 80 150 200 300 400 400 400

0,4 0,5 0,9 1,2 1,8 2,4 1,8 2,4

πÒ‰ÈÔ (Ìg)

™ÂÏ‹ÓÈÔ (Ìg)

110 130 90 90 120 150 120 150

15 20 20 30 40 55 40 55

¶ËÁ¤˜: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997). Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998). Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001).

ÌÂÁ¿ÏË ÔÛfiÙËÙ· ÏÈÒÓ Î·È È‰È·›ÙÂÚ· ÎÔÚÂṲ̂ÓÔ˘ Ï›Ô˘˜, ηıÒ˜ Î·È Ôχ ·Ï¿ÙÈ Î·È ÔÏÏ‹ ˙¿¯·ÚË.

5. ¡· ·ÔʇÁÔÓÙ·È ·Ó·„˘ÎÙÈο Ô˘ ÂÚȤ¯Ô˘Ó ÌfiÓÔ ˙¿¯·ÚË (˘„ËÏfi ÁÏ˘Î·ÈÌÈÎfi ÊÔÚÙ›Ô), ηıÒ˜ Î·È ¯˘ÌÔ› ÊÚÔ‡ÙˆÓ Ì ·ÌÊ›‚ÔÏË ÂÚÈÂÎÙÈÎfiÙËÙ· Ê˘ÛÈÎÔ‡ ¯˘ÌÔ‡. ¶ÚÔÙÂÚ·ÈfiÙËÙ· Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ù· ÊÚÔ‡Ù· Î·È ÌÂÙ¿ Ô ÊÚ¤ÛÎÔ˜ ¯˘Ìfi˜ ÊÚÔ‡ÙˆÓ (Ù· ÊÚÔ‡Ù· ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚÔ ÁÏ˘Î·ÈÌÈÎfi ÊÔÚÙ›Ô ·fi ÙÔ˘˜ ÊÚ¤ÛÎÔ˘˜ ¯˘ÌÔ‡˜ ÊÚÔ‡ÙˆÓ).

6. ¡· ÚÔÙÈÌÒÓÙ·È ÈÛÙÔÔÈË̤ӷ ‚ÈÔÏÔÁÈο ÚÔ˚fiÓÙ·.

7. ¡· ‰›ÓÂÙ·È ÚÔÙÂÚ·ÈfiÙËÙ· Û „¿ÚÈ Î·È ı·Ï·ÛÛÈÓ¿ Ì 3-4 Á‡̷ٷ ÙËÓ Â‚‰ÔÌ¿‰·, ΢ڛˆ˜ ÌÈÎÚ¿ ÏÈ·Ú¿ „¿ÚÈ·, ÒÛÙ ӷ Ï·Ì‚¿ÓÔÓÙ·È Ù· ··Ú·›ÙËÙ· ˆ-3 ÏÈ·Ú¿ Ôͤ· Î·È Ë ‚ÈÙ·Ì›ÓË D. ∞ÎÔÏÔ˘ıÔ‡Ó Ù·

Ô˘ÏÂÚÈο Î·È Û·ÓÈfiÙÂÚ· ÙÔ ÎfiÎÎÈÓÔ ÎÚ¤·˜ (ÌÔÛ¯¿ÚÈ, ηÙÛ›ÎÈ, ·ÚÓ›, ¯ÔÈÚÈÓfi). ∆· fiÛÚÈ· Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯Ó¿.

8. ¡· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯Ó¿ ·Ó¿Ï·ÙÔÈ ÍËÚÔ› ηÚÔ›, ΢ڛˆ˜ ηڇ‰È·, 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·.

9. ∏ ¿ÚÈÛÙË ‰È·ÙÚÔÊ‹ Ú¤ÂÈ Ó· Û˘Ó‰˘¿˙ÂÙ·È Ì ηıËÌÂÚÈÓ‹ ̤ÙÚÈ· ÚÔ˜ ¤ÓÙÔÓË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ÁÈ· 2 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÒÚ˜. ∞ÎfiÌË Î·È Ô ıËÏ·ÛÌfi˜ ÚÔÛʤÚÂÈ ÂÚÈÛÛfiÙÂÚË ÛˆÌ·ÙÈ΋ ¿ÛÎËÛË ÛÙÔ ‚Ú¤ÊÔ˜, ÁÈ·Ù› Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ¿ÚÂÈ ÙÔ Á¿Ï· ·fi ÙË ÌËÙ¤Ú· Û ·ÓÙ›ıÂÛË Ì ÙÔ ÌÈÌÂÚfi Ô˘ ·‰ÂÈ¿˙ÂÈ Ôχ ÁÚ‹ÁÔÚ· Î·È Â‡ÎÔÏ·.

10. ¡· ÂÎÙ›ıÂÙ·È ÙÔ ‚Ú¤ÊÔ˜ Î·È ÙÔ ·È‰› ÛÙÔÓ ‹ÏÈÔ Ì Á˘ÌÓ¿ ¯¤ÚÈ· Î·È fi‰È· ÁÈ· 10-30 ÏÂÙ¿ ηıËÌÂÚÈÓ¿. ªÂ ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ‹ÏÈÔ˘ ·Ú¿ÁÂÙ·È Ë ¶·È‰È·ÙÚÈ΋ 2008;71:157-161

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∞. ∫·Ê¿ÙÔ˜

¶›Ó·Î·˜ 2. ∫·ıËÌÂÚÈÓ¤˜ ·Ó¿ÁΘ Û ÌÂÚ›‰Â˜ ·fi οı ÔÌ¿‰· ÙÚÔÊ›ÌˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙÔ Â›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜* √Ì¿‰Â˜ ÙÚÔʛ̈Ó

¶ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· 2-6 ¤ÙË

™¯ÔÏÈ΋ ËÏÈΛ· 7-12 ¤ÙË

∂ÊË‚È΋ ËÏÈΛ· 13-18 ¤ÙË

°·Ï·ÎÙÔÎÔÌÈο °¿Ï· °È·Ô‡ÚÙÈ ∆˘Ú›

2-3

2-3

3

ñ Õ·¯Ô ‹ ¯·ÌËÏfi Û ÏÈ·Ú¿ Á¿Ï· ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ. ñ ∞ÔÊ˘Á‹ Ù˘ ˘ÂÚηٷӿψÛ˘ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ.

¢ËÌËÙÚȷο æˆÌ› ¢ËÌËÙÚȷο ª·Î·ÚfiÓÈ·, Ú‡˙È ∞ڷο˜, ·Ù¿Ù˜, ηϷÌfiÎÈ

3-6

5-9

6-10

ñ ∆Ô Ì·‡ÚÔ „ˆÌ› Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ ·fi ÙÔ Ï¢Îfi. ñ ∆· ÈÙ˘ÚÔ‡¯· ‹ ÔÏÈ΋˜ ·Ï¤Ûˆ˜ ‰ËÌËÙÚȷο, ηÛÙ·Ófi Ú‡˙È Î·È Ì·Î·ÚfiÓÈ· ÔÏÈ΋˜ ·Ï¤Ûˆ˜ Â›Ó·È ÚÔÙÈÌfiÙÂÚ·.

§·¯·ÓÈο øÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ Ê˘ÏÏÒ‰Ë Ï·¯·ÓÈο (Ú·‰›ÎÈ·, Ì·ÚÔ‡ÏÈ, Û·Ó¿ÎÈ Î.Ï.) ∫›ÙÚÈÓ· Ï·¯·ÓÈο (ηÚfiÙÔ, ÎÔ˘ÓÔ˘›‰È, ÓÙÔÌ¿Ù· Î.¿.) º·ÛÔÏ¿ÎÈ· Ú¿ÛÈÓ·, Ì¿ÌȘ, ÌÂÏÈÙ˙¿Ó˜ Î.¿.

2-5

4-7

5-8

ñ ∆· Ï·¯·ÓÈο Ó· ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·È Î›ÙÚÈÓ· Î·È Ú¿ÛÈÓ·, ˆÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ.

ºÚÔ‡Ù· ª‹ÏÔ, Ì·Ó¿Ó·, ÔÚÙÔοÏÈ, ·¯Ï¿‰È Î.Ï. ºÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÊÚÔ‡Ù· Ì·ÁÂÈÚÂ̤ӷ ‹ ÊÚÔ‡Ù· ÎÔÓÛ¤Ú‚·˜ Ã˘Ìfi˜ ÊÚÔ‡ÙˆÓ

2-3

3-4

3-5

ñ ™Ù· ÊÚÔ‡Ù· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ÊÚ¤ÛÎÔÈ ¯˘ÌÔ›, ·ÏÏ¿ Â›Ó·È ÚÔÙÈÌfiÙÂÚ· Ù· ÊÚ¤Ûη ÊÚÔ‡Ù·. ñ Ã˘ÌÔ› ÊÚÔ‡ÙˆÓ ¯ˆÚ›˜ ÚÔÛÙÈı¤ÌÂÓË ˙¿¯·ÚË.

1

1-2

2

∫Ú¤·˜-∞˘Á¿-æ¿ÚÈ-∫ÔÙfiÔ˘ÏÔŸÛÚÈ·-•ËÚÔ› ηÚÔ› ∫Ú¤·˜ æ¿ÚÈ £·Ï·ÛÛÈÓ¿ ∫ÔÙfiÔ˘ÏÔ ŸÛÚÈ· ∞˘Áfi •ËÚÔ› ηÚÔ›

ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜

ñ ∫ÔÙfiÔ˘ÏÔ: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ æ¿ÚÈ-ı·Ï·ÛÛÈÓ¿: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ŸÛÚÈ·: 2-3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ∫fiÎÎÈÓÔ ÎÚ¤·˜: 1-2 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ¡· ·Ê·ÈÚÂ›Ù·È ÙÔ ÔÚ·Ùfi Ï›Ô˜ ·fi Ù· Ô˘ÏÂÚÈο Î·È ÙÔ ÎÚ¤·˜. ñ ó ÌÂÚ›‰· Û˘ÎÒÙÈ (40 ÁÚ.) 1 ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰·. ñ ∞˘Áfi ۯ‰fiÓ Î¿ı ̤ڷ. ñ •ËÚÔ› ηÚÔ›: .¯. 2-3 ηڇ‰È· οı ‰Â‡ÙÂÚË Ì¤Ú· (ÙÚÈÌ̤ӷ ¿Óˆ ·fi ÌÈ· ÊÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÌÈ· Îڤ̷ ÁÈ· Ù· ÌÈÎÚ¿ ·È‰È¿).

√Ì¿‰Â˜ ÙÚÔÊ›ÌˆÓ & ̤ÁÂıÔ˜ ÌÂÚ›‰·˜ °·Ï·ÎÙÔÎÔÌÈο

1 ÌÂÚ›‰· = 1 ÊÏÈÙ˙. Á¿Ï·, 40 ÁÚ. Ù˘Ú›, 1 ÊÏÈÙ˙. ÁÈ·Ô‡ÚÙÈ

∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 12 ıÚÂÙÈο Û˘ÛÙ·ÙÈο.

¢ËÌËÙÚȷο

1 ÌÂÚ›‰· = 1 ʤٷ „ˆÌ›, 1 ÊÏÈÙ˙. ‰ËÌËÙÚȷο (ÎÔÚÓ ÊϤÈΘ), ó ÊÏÈÙ˙. ̷ηÚfiÓÈ·, ÈÏ¿ÊÈ, Ì·ÁÂÈÚÂ̤ӷ, ó ÊÏÈÙ˙. ·Ù¿Ù˜ Ì·ÁÂÈÚÂ̤Ó˜

∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 14 ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ ÈÓÒÓ.

§·¯·ÓÈο

1 ÌÂÚ›‰· = 1 ÊÏÈÙ˙. Ê˘ÏÏÒ‰Ë, ˆÌ¿ Ï·¯·ÓÈο (Ú·‰›ÎÈ·, Ì·ÚÔ‡ÏÈ, ∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 27 ıÚÂÙÈο Û˘ÛÙ·ÙÈο. Û·Ó¿ÎÈ Î.Ï.), ó ÊÏÈÙ˙. ˆÌ¿ ‹ Ì·ÁÂÈÚÂ̤ӷ Ï·¯·ÓÈο (Ê·ÛÔÏ¿ÎÈ· Ú¿ÛÈÓ·, ηÚfiÙ·, Ì¿ÌȘ, ÓÙÔÌ¿Ù·, ·Ú·Î¿˜, ηϷÌfiÎÈ, ÎÔÏÔ·ıÈ Î.¿.), 3/4 ÊÏÈÙ˙. ·ÏÂṲ̂ӷ Ï·¯·ÓÈο Û ÛÔ‡· ‹ ¯˘Ìfi˜ Ï·¯·ÓÈÎÒÓ

ºÚÔ‡Ù·

1 ÌÂÚ›‰· = 1 ÌÂÙÚ›Ô˘ ÌÂÁ¤ıÔ˘˜ Ì‹ÏÔ, Ì·Ó¿Ó·, ÔÚÙÔοÏÈ, ·¯Ï¿‰È Î.Ï., ó ÊÏÈÙ˙. ÊÚÔ˘ÙÔÛ·Ï¿Ù· ‹ ÊÚÔ‡Ù· Ì·ÁÂÈÚÂ̤ӷ ‹ ÊÚÔ‡Ù· ÎÔÓÛ¤Ú‚·˜, 3/4 ÊÏÈÙ˙. ¯˘Ìfi˜ ÊÚÔ‡ÙˆÓ, 3/4 ÊÏÈÙ˙. ÍËÚ¿ ÊÚÔ‡Ù·

∫Ú¤·˜-∞˘Á¿-æ¿ÚÈ- 1 ÌÂÚ›‰· = 85 ÁÚ. ÎÚ¤·˜, ÎÔÙfiÔ˘ÏÔ, 85 ÁÚ. „¿ÚÈ, ı·Ï·ÛÛÈÓ¿, ∫ÔÙfiÔ˘ÏÔ-ŸÛÚÈ·ó ÊÏÈÙ˙. fiÛÚÈ·, 1/3 ÊÏÈÙ˙. ÍËÚÔ› ηÚÔ›, •ËÚÔ› ηÚÔ› 2 ÎÔ˘Ù·ÏȤ˜ Ù˘ ÛÔ‡·˜ ÛfiÚÔÈ (.¯. ËÏÈfiÛÔÚÔÈ), 1 ·˘Áfi *∆Ô ÊÏÈÙ˙¿ÓÈ Â›Ó·È ¯ˆÚËÙÈÎfiÙËÙ·˜ 240 ml

Paediatriki 2008;71:157-161

∏ ηÙËÁÔÚ›· ·˘Ù‹ ‰›ÓÂÈ 27 ıÚÂÙÈο Û˘ÛÙ·ÙÈο.

™˘¯ÓfiÙÂÚË Î·Ù·Ó¿ÏˆÛË ÌÈÎÚÒÓ ÏÈ·ÚÒÓ „·ÚÈÒÓ, ÔÛÚ›ˆÓ Î·È ·Ó¿Ï·ÙˆÓ ÍËÚÒÓ Î·ÚÒÓ.

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¢È·ÙÚÔÊ‹ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ

··Ú·›ÙËÙË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‚ÈÙ·Ì›ÓË D. ∞fi Ù· ÏÈ·Ú¿ „¿ÚÈ· ÙÔ ·È‰› ·›ÚÓÂÈ ÙfiÛÔ ÙË ‚ÈÙ·Ì›ÓË D fiÛÔ Î·È Ù· ··Ú·›ÙËÙ· ˆ-3 ÏÈ·Ú¿ Ôͤ·. ¢Â‰Ô̤Ó˘ Ù˘ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ù˘ ¯ÒÚ·˜ Ì·˜, ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÙÚfiÊÈÌ· ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È Ó· ÚÔÙÈÌÒÓÙ·È ÙÚfiÊÈÌ· ˘„ËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›·. °È’ ·˘Ùfi Ë ÂÓ¤ÚÁÂÈ· ·fi ÏÈ·Ú¿ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙÔ 35% Ù˘ Û˘ÓÔÏÈ΋˜ ÂÓ¤ÚÁÂÈ·˜ ËÌÂÚËÛ›ˆ˜. ∆Ô ˘fiÏÔÈÔ ı· Â›Ó·È 55-65% ·fi Û‡ÓıÂÙÔ˘˜, ΢ڛˆ˜, ˘‰·Ù¿ÓıڷΘ, ÂÓÒ ÙÔ 10-20% Ó· ÚÔ¤Ú¯ÂÙ·È ·fi ÚˆÙ½Ó˜. ∆· ÏÈ·Ú¿ ı· Ú¤ÂÈ Û¯Â‰fiÓ ÂÍ’ ÔÏÔÎÏ‹ÚÔ˘ Ó· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÏ·ÈfiÏ·‰Ô, ÂÓÒ ¤Ó· ÌÈÎÚfi ̤ÚÔ˜, 1-2 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ, ·fi ˆ-3 ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÛÔ˘ („¿ÚÈ·) ‹ 5-6 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ ·fi ·-ÏÈÓÔÓÂÏÈÎfi Ô͇ (ηڇ‰È·, ¿ÁÚÈ· ¯fiÚÙ·, fiÛÚÈ·, Î.¿.). ∆· ˆ-6 ÏÈ·Ú¿ Ôͤ· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÛÔڤϷȷ, ÍËÚÔ‡˜ ηÚÔ‡˜, fiÛÚÈ· Î·È ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó Ù· 6-10 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ. ∞˘Ùfi Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈÙ¢¯ı›, fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·ıfiÏÔ˘ ÛÔڤϷȷ (8). ∆Ô ÎÔÚÂṲ̂ÓÔ Ï›Ô˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ Ù· 15-20 ÁÚ·ÌÌ¿ÚÈ· ÙËÓ Ë̤ڷ. √ ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È ÙÔ˘ Â›‰Ԣ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ηıÒ˜ Î·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ ··ÈÙÔ‡ÌÂÓˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ·Ó·ÁÎÒÓ ı· ‰ÔıÔ‡Ó Û ¿ÏÏÔ ¿ÚıÚÔ, ηıÒ˜ Â›Û˘ Î·È Ô ÙÚfi-

Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ.

µÈ‚ÏÈÔÁÚ·Ê›· 1. ∫·Ê¿ÙÔ˜ ∞°, §·Ì·‰¿ÚÈÔ˜ ¢. ∆ÂÏÂ˘Ù·›Â˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ÎÏÈÓÈ΋ ‰È·ÙÚÔÊ‹ Î·È ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ‰È·ÙÚÔÊ‹˜. ∆Ì‹Ì· π·ÙÚÈ΋˜, ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘. ∏Ú¿ÎÏÂÈÔ: 1990.

2. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academy of Sciences; 1997.

3. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington DC: Food and Nutrition Board, Institute of Medicine, National Academy Press; 1998.

4. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. National Academy of Sciences; 2000.

5. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc National Academy of Sciences; 2001.

6. Williams SR. Nutrition and Diet Therapy. 8th ed. St Louis: Mosby Publishing Co.; 1997.

7. ¢È·ÙÚÔÊ‹ ÁÈ· ¶ÚÔ·ÁˆÁ‹ Ù˘ ˘Á›·˜ Î·È ÚfiÏË„Ë ÙˆÓ ¯ÚfiÓÈˆÓ ·ÛıÂÓÂÈÒÓ. ∏Ú¿ÎÏÂÈÔ: ∆À¶√∫ƒ∂∆∞ ∞µ∂; πÔ‡ÏÈÔ˜ 2007.

8. Kafatos A, Codrington CA. Nutrition and diet for healthy lifestyles in Europe: the ‘Eurodiet’ Project. Public Health Nutr.1999;2:327-328.

9. ∫·Ê¿ÙÔ˜ ∞°. ÀÁ›·, ‰È·ÙÚÔÊ‹ Î·È ·Ó¿Ù˘ÍË ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜. ∫Ú‹ÙË: ¡Ô̷گȷ΋ ∞˘ÙÔ‰ÈÔ›ÎËÛË Ã·Ó›ˆÓ; 2004.

¶·È‰È·ÙÚÈ΋ 2008;71:157-161

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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏

CASE REPORT

Recurrent Respiratory Papillomatosis: case report and literature review Academic Unit of Otolaryngology, North Bristol NHS Trust, Southmead Hospital, Correspondence: D. A. Nunez d.a.nunez@bristol.ac.uk Academic Unit of Otolaryngology, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, United Kingdom

D. A. Nunez Abstract: Juvenile onset recurrent respiratory papillomatosis (RRP) is a rare but potentially life threatening disease caused by Human papilloma virus (HPV) infection, primarily HPV types 6 and 11. It typically presents in children with an onset at 3-4 years. The incidence estimates vary widely, but in Europe a rate of approximately 3.5 cases per million is reported. The vocal folds are the commonest site of involvement. Dysphonia and/or stridor are the main clinical features of respiratory papillomatosis. A typical case in a 3 year-old boy is presented. Laryngoscopy to visualise the larynx is required to arrive at the diagnosis. The mainstay of treatment is surgical resection using the CO2 laser or the laryngeal microshaver (microdebrider) under micro-laryngoscopic control. It is not unusual for a typical case to require 3 surgical interventions a year over a period of several years. In more aggressive cases adjuvant treatment is indicated, which includes systemic interferon and intra-lesional Cidofovir. Fatality is associated with loss of the airway, distal spread into the lungs or malignant transformation. An overview of the clinical condition and current treatment is presented.

Key words: Larynx, papilloma, Human papilloma virus 6, Human papilloma virus 11, voice disorders.

Case Report A 3 year-old boy presented to his paediatrician with a 4-month history of a persistent hoarse voice, with no history of preceding upper respiratory tract infection or trauma. He had no dysphagia or dyspnoea. His single mother reported that he was her first child, delivered normally at full term when she was 19 years old, after an uncomplicated pregnancy and delivery.

On examination he was apyrexial and not distressed, and he was not jaundiced. He weighed 15 kg and was 105 cm tall. There was no stridor or cyanosis, his respiratory rate was 24 per minute, the trachea was central and the chest clear on auscultation. There were no abnormal heart sounds. Anterior rhinoscopy and oral cavity examination were normal.

He was referred to an otolaryngologist who undertook a micro-laryngoscopic examination.

The laryngoscopic appearance is as illustrated in the clinical photograph (Figure 1).

Discussion Figure 1 shows a larynx of grossly abnormal appearance, in stark contrast to the appearance of the normal larynx, Figure 2. The mucosa of the vocal folds and vestibular folds is oedematous and polypoid in keeping with the typical appearance of widespread laryngeal papillomatosis. This pattern of presentation is to be distinguished from the single solitary often pedunculated upper aeroPaediatriki 2008;71:162-164

digestive tract papilloma. The latter is more common and often presents in the oropharynx arising from the soft palate, uvula or palatopharyngeal arches. Excision is usually curative.

The laryngeal papilloma is the commonest benign neoplasm of the larynx (1). Laryngeal involvement when widespread, as demonstrated in this case, is not easily cured and the condition is known as recurrent laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP). The term RRP is to be preferred because while the larynx at the level of the vocal cords (glottis) is the site predominantly affected, the papillomata may extend above and below this level into the trachea and bronchi. RRP is an uncommon condition with a bimodal peak age incidence of 3-5 years in children and in the third decade in adults (2). The distribution of age of onset has lead to the condition being sub-classified as juvenile onset RRP or adult onset RRP. RRP can be life threatening because of airway compromise, especially in children, or due to malignant degeneration (3). The reported prevalence of juvenile onset laryngeal papillomatosis is lower in Europe (approximately 3.5 per million) than in the US (4.3 per 100,000) (4,5). The presenting features are hoarseness and stridor (2). Males and females are equally affected in childhood but in the adult onset disease males are more commonly affected in the ratio of 2-4 to 1 (6,7).

The Human papilloma (wart) virus (HPV) is

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Figure 1.

Figure 2.

the causative agent for RRP, and specifically HPV subtypes 6 and 11 (8). There are reports that HPV 11 laryngeal disease is more aggressive, with a greater predilection for relapse and malignant degeneration (9). Malignant degeneration is usually associated with other cofactors such as tobacco use (10), or irradiation, which was an early therapy for RRP, however some cases undergo malignant change in the absence of any known cofactors (11). HPV subtypes 6 and 11 are not associated with a high risk of malignant change, in contrast to other subtypes such as 16 and 18, which have been established as causative agents of cancer of the uterine cervix (12,13). In the head and neck region high risk types of HPV have been isolated, predominantly from cancers of the oral cavity and oropharynx but also from the larynx. The degree of positivity, depending on the identification method, varies between 0% and 75% (14). This is in contrast to uterine cervical invasive squamous cell carcinoma, where the level of positivity is 86-94% (15). It would therefore seem that HPV has a causative role only in certain anatomical sites in the head and neck or in particular subgroups of patients.

The mechanism of HPV transmission is uncertain but vertical materno-fetal transmission is the most favoured route. This is supported by the 231-fold increase in risk of juvenile onset recurrent respiratory papillomatosis in children born to mothers with cervical condoylomata (16). The birth canal is not the only route of transmission, as Armbruster-Moraes and colleagues demonstrated that HPV DNA can be isolated in amniotic fluid aspirates from women who had clinical and slot hybridisation evidence of cervical papilloma, providing evidence of in-utero transmission (17). This can explain the failure of Caesarean section to abolish the development of juvenile onset laryngeal papilloma disease (18,19).

The presence of HPV6 and/or 11 is not in itself sufficient to cause the development of laryngeal papillomatosis, as up to 25% of histologically normal larynges are positive for HPV6 and 11 DNA (20). Restricted host immune response is believed to play a role.

The mainstay of treatment is surgery. Microlaryngoscopy provides the opportunity not only for tissue diagnosis by biopsy but also for excision of the papillomata. The surgeon must exercise caution in the pursuit of disease eradication in order to avoid damage to the laryngeal structure and thus irreversible impairment of laryngeal function. Stenosis and webbing of the anterior glottis can leave the patient with the same symptoms that the therapy is intended to treat, namely a restricted airway and a life-long hoarse voice. A CO2 laser beam controlled by a micromanipulator gives the surgeon microscopic guided accuracy in the control of papilloma excision. The 10,600 nm wavelength CO2 provides the advantage of haemostasis and this is the technique most widely used for treatment of laryngeal papillomata in the UK (21). A number of other laser types are also used, including the potassium titanyl phosphate laser delivered by a flexible fibre that facilitates treatment of papillomata in the tracheobronchial tree (1).

A recent survey of members of American Society of Paediatric Otolaryngologists demonstrated the popularity of the laryngeal shaver (microdebrider) (22). This is a sleeved rotating blade with continuous saline irrigation and suction allowing for almost bloodless removal of laryngeal papillomata.

RRP is a difficult condition to treat in many patients and in some patients it follows a relentless course requiring multiple surgeries with only short intervals between treatment schedules when the patient is clinically free of disease. This is due to the difficulty ¶·È‰È·ÙÚÈ΋ 2008;71:162-164

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of eradicating the papilloma virus, which is present even in normal appearing laryngeal tissue of the affected patients (19). For this reason a number of adjuvant treatments have been tried and put into use with the aim of reducing the relapse rate. Alpha interferon and indole-3-carbinol are two popular adjuvant therapies but they are not always effective (1,22). Intra-lesional Cidofovir is gaining in popularity because of the good early results obtained with this antimetabolite by some clinicians in controlling the disease (23). Photodynamic therapy is also under investigation (24). The launch of a highly efficacious HPV vaccine that targets HPV 6 and 11 in addition to 16 and 18 (25) offers the potential to eradicate this disease for future generations.

References 1. Derkay CS. Recurrent respiratory papillomatosis. Laryngoscope 2001;111:57-69.

2. Quiney RE, Hall D, Croft CB. Laryngeal papillomatosis: analysis of 113 patients. Clin Otolaryngol Allied Sci 1989;14:217-225.

3. Zarod AP, Rutherford JD, Corbitt G. Malignant progression of laryngeal papilloma associated with human papilloma virus type 6 (HPV-6) DNA. J Clin Pathol 1988;41:280283.

4. Silverberg MJ, Thorsen P, Lindeberg H, Ahdieh-Grant L, Shah KV. Clinical course of recurrent respiratory papillomatosis in Danish children. Arch Otolaryngol Head Neck Surg 2004;130:711-716.

5. Derkay CS. Task force on recurrent respiratory papillomas.

A preliminary report. Arch Otolaryngol Head Neck Surg 1995;121:1386-1391.

6. Lindeberg H, Elbro/ nd O. Laryngeal papillomas: clinical aspects in a series of 231 patients. Clin Otolaryngol Allied Sci 1989;14:333-342.

7. Capper JW, Bailey CM, Michaels L. Squamous papillomas of the larynx in adults. A review of 63 cases. Clin Otolaryngol 1983;8:109-119.

8. Terry RM, Lewis FA, Griffiths S, Wells M, Bird CC. Demonstration of human papillomavirus types 6 and 11 in juvenile laryngeal papillomatosis by in-situ DNA hybridization. J Pathol 1987;153:245-248.

9. Rimell FL, Shoemaker DL, Pou AM, Jordan JA, Post JC, Ehrlich GD. Pediatric respiratory papillomatosis: prognostic role of viral typing and cofactors. Laryngoscope 1997; 107:915-918.

10. Kashima HK, Mounts P, Shah K. Recurrent respiratory papillomatosis. Obstet Gynecol Clin North Am 1996;23:699706.

11. Lindeberg H, Elbro/ nd O. Malignant tumours in patients

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with a history of multiple laryngeal papillomas: the significance of irradiation. Clin Otolaryngol Allied Sci 1991;16: 149-151.

12. Zur Hausen H. Human papillomaviruses in the pathogenesis of anogenital cancer. Virology 1991;184:9-13.

13. Zur Hausen H. Papillomaviruses in human cancer. Appl Pathol 1987;5:19-24.

14. McKaig RG, Baric RS, Olshan AF. Human papillomavirus and head and neck cancer: epidemiology and molecular biology. Head Neck 1998;20:250-265.

15. Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a metaanalysis update. Int J Cancer. 2007 Aug 1;121(3):621-632.

16. Silverberg MJ, Thorsen P, Lindeberg H, Grant LA, Shah KV. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet Gynecol 2003;101:645-652.

17. Armbruster-Moraes E, Ioshimoto LM, Lea~o E, Zugaib M. Presence of human papillomavirus DNA in amniotic fluids of pregnant women with cervical lesions. Gynecol Oncol 1994;54:152-158.

18. Shah K, Kashima H, Polk BF, Shah F, Abbey H, Abramson A. Rarity of cesarean delivery in cases of juvenile-onset respiratory papillomatosis. Obstet Gynecol 1986;68:795-799.

19. Abramson AL, Steinberg BM, Winkler B. Laryngeal papillomatosis: clinical, histopathologic and molecular studies.

Laryngoscope 1987;97:678-685.

20. Nunez DA, Astley SM, Lewis FA, Wells M. Human papilloma viruses: a study of their prevalence in the normal larynx. J Laryngol Otol 1994;108:319-320.

21. Tasca RA, McCormick M, Clarke RW. British Association of Paediatric Otorhinolaryngology members experience with recurrent respiratory papillomatosis. Int J Pediatr Otorhinolaryngol 2006;70:1183-1187.

22. Schraff S, Derkay CS, Burke B, Lawson L. American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy. Arch Otolaryngol Head Neck Surg 2004;130:10391042.

23. Naiman AN, Ayari S, Nicollas R, Landry G, Colombeau B, Froehlich P. Intermediate-term and long-term results after treatment by cidofovir and excision in juvenile laryngeal papillomatosis. Ann Otol Rhinol Laryngol 2006;115:667-672.

24. Shikowitz MJ, Abramson AL, Freeman K, Steinberg BM, Nouri M. Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results.

Laryngoscope 1998;108:962-967.

25. Ault KA; Future II Study Group. Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. Lancet. 2007;369:1861-1868.

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“¡¤Ô ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (2008)” ™ÙȘ 4/12/2007 Û˘Ó‹Ïı ÛÙËÓ ∞ı‹Ó· (¢È‡ı˘ÓÛË ¢ËÌfiÛÈ·˜ ÀÁ›·˜) Ë ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ (∂∂∂) ÁÈ· Ó· ·Ó·ıˆڋÛÂÈ ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ (∂¶∂) Î·È Ó· ÚÔÙ›ÓÂÈ ÔÚÈṲ̂Ó˜ ·ÏÏ·Á¤˜ Û‡Ìʈӷ Ì ÙȘ ÙÚ¤¯Ô˘Û˜ ÂȉËÌÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ Ù˘ ¯ÒÚ·˜, ÙȘ ‰ÈÂıÓ›˜ Ù¿ÛÂȘ Î·È ÙËÓ Î˘ÎÏÔÊÔÚ›· Ó¤ˆÓ, Ôχ ÛËÌ·ÓÙÈÎÒÓ ÁÈ· ÙË ¢ËÌfiÛÈ· ÀÁ›· ∂Ì‚ÔÏ›ˆÓ. ªÂÙ¿ ·fi ÂÈÛٷ̤ÓË ÌÂϤÙË ÙˆÓ ÚÔ·Ó·ÊÂÚı¤ÓÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Î·È ÂÎÙÂÓ‹ Û˘˙‹ÙËÛË ÌÂٷ͇ ÙˆÓ ÌÂÏÒÓ Ù˘ ∂ÈÙÚÔ‹˜ Â› ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·˘ÙÒÓ ‰È·ÌÔÚÊÒıËΠÙÔ Ó¤Ô ∂¶∂, ÙÔ ÔÔ›Ô ¤ÁÈÓ ·Ô‰ÂÎÙfi ·fi ÙËÓ ÔÏÈÙÈ΋ ËÁÂÛ›· ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜, fiˆ˜ ·ÎÚÈ‚Ò˜ ÚÔÙ¿ıËÎÂ. √È ·ÏÏ·Á¤˜ Ô˘ ¤ÁÈÓ·Ó ÛÙÔ ∂¶∂ Û˘ÓÔ„›˙ÔÓÙ·È ˆ˜ ÂÍ‹˜: 1. ∂Ì‚fiÏÈÔ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÂÙ¿ÓÔ˘, ÎÔηÙË (DTaP). ¶ÚÔÛÙ›ıÂÙ·È Ì›· ÂÈϤÔÓ ‰fiÛË ÛÙËÓ ËÏÈΛ· 11-12 ÂÙÒÓ Ì ÙÔ Û··ÛÌ· TdaP (‚Ϥ ÂÂÍ‹ÁËÛË 2·, 2‚).

2. ∂Ì‚fiÏÈÔ ·ÓÂÌ¢ÏÔÁÈ¿˜ (Var). ¶ÚÔÛÙ›ıÂÙ·È 2Ë ‰fiÛË ÛÙËÓ ËÏÈΛ· 4-6 ÂÙÒÓ.

3. ∂Ì‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚÒÈÓˆÓ ıËÏˆÌ¿ÙˆÓ (Human Papilloma Virus ‹ HPV). ¶ÚÔÛÙ›ıÂÙ·È Ó¤Ô ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ HPV Ô˘ Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ ÁÈ· Ù· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ ‹ ̤¯ÚÈ 26 ÂÙÒÓ, ÂÊfiÛÔÓ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (‚Ϥ ÂÂÍ‹ÁËÛË 9 Î·È ÙË Û¯ÂÙÈ΋ ÂÁ·ÎÏÈÔ Ô˘ ¶›Ó·Î·˜ 1. ÕÙÔÌ· Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÛÔ‚·Ú¤˜ Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ ñ ªÈÎÚ¿ ·È‰È¿ ¿Óˆ ÙˆÓ 2 ÂÙÒÓ Î·È ÂÓ‹ÏÈΘ >60 ÂÙÒÓ. ñ ÕÙÔÌ· ÌÂ Û˘ÁÁÂÓ›˜ ·ÓÙÈۈ̷ÙÈΤ˜ ·ÓÂ¿ÚÎÂȘ (΢ڛˆ˜ ¤ÏÏÂÈ„Ë Ù˘ IgG2). ñ ÕÙÔÌ· Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ Èfi HIV. ñ ÕÙÔÌ· Ì Â›ÎÙËÙË ·ÓÔÛÔηٷÛÙÔÏ‹, ÂÍ·ÈÙ›·˜ ÓÔÛ‹Ì·ÙÔ˜ ‹ ıÂÚ·›·˜ ‹ ¿ÏÏ˘ (ÂÎÙfi˜ ÙÔ˘ HIV) ÈÔÁÂÓÔ‡˜ Ïԛ̈͢. ñ ÕÙÔÌ· Ì ÌÂÈÔÓÂÎÙÈ΋ ÛÏËÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‹ ·ÛÏËÓ›· .¯. Ì ‰ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ, Ì ˘ÂÚÛÏËÓÈÛÌfi, Ì ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙÔ˘ ÛÏ‹Ó·. ñ ÕÙÔÌ· Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ñ ÕÙÔÌ· Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ñ ÕÙÔÌ· Ì ¯ÚfiÓÈ· Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ·. ñ ÕÙÔÌ· Ì ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ. ñ ÕÙÔÌ· Ì ‰È·Ê˘Á‹ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ ·fi Û˘ÁÁÂÓ›˜ ‹ Â›ÎÙËÙ˜ ·Èٛ˜.

Paediatriki 2008;71:166-170

¶›Ó·Î·˜ 2. ¶·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ê˘Ì·ÙÈ΋ ÌfiÏ˘ÓÛË/Ê˘Ì·Ù›ˆÛË ñ ªÂÙ·Ó¿ÛÙ˜ ·fi ¯ÒÚ˜ Ì ˘„ËÏfi ‹ ̤ÛÔ ‰Â›ÎÙË ÂÓ‰ËÌÈÎfiÙËÙ·˜. ñ ∫·Ù·˘ÏÈÛÌÔ› ·ıÈÁÁ¿ÓˆÓ Î·È ¿ÏÏˆÓ ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ Ô˘ ˙Ô˘Ó ÛÂ Û˘Óı‹Î˜ ÔÌ·‰È΋˜ ‰È·‚›ˆÛ˘. ñ ¶·È‰È¿ Ì Mantoux (-) ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ÔÔ›ˆÓ ˘¿Ú¯ÂÈ ¿ÙÔÌÔ ÌÂ Ê˘Ì·Ù›ˆÛË (ıÂÙÈο Ù‡ÂÏ·). ñ ¡ÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ Èfi HIV (fi¯È ‚Ú¤ÊË Û˘Ìو̷ÙÈο ÁÈ· AIDS). ñ ¡ÂÔÁÓ¿, ÛÙÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ ÙˆÓ ÔÔ›ˆÓ ˘¿Ú¯ÂÈ ¿ÙÔÌÔ ÌÂ Ê˘Ì·Ù›ˆÛË (ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È Î·Ù¿ ÙË Á¤ÓÓËÛË).

·ÊÔÚ¿ ÙÔ ÂÌ‚fiÏÈÔ ·˘Ùfi ÛÙË ÛÙ‹ÏË Ù˘ ¢ËÌfiÛÈ·˜ ÀÁ›·˜).

4. ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ Ë·Ù›Ùȉ·˜ ∞ (Hep A). ¶ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙ· ··Ú·›ÙËÙ· ϤÔÓ ÂÌ‚fiÏÈ· ÙÔ˘ ∂¶∂ ·fi ÙÔ 12Ô Ì‹Ó· Î·È ÌÂÙ¿ (‚Ϥ ÂÂÍ‹ÁËÛË 10) Î·È Û˘Ó¯›˙ÂÈ Ó· Á›ÓÂÙ·È ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 3). °È· ÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ, Ô˘ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂¶∂ ËÏÈΛ·, ˘¿Ú¯Ô˘Ó ÂȉÈο ¯ÚÔÓԉȿÁÚ·ÌÌ·Ù· (¶›Ó·Î˜ 5 Î·È 6) Ì ÙȘ Û¯ÂÙÈΤ˜ ÂÂÍËÁ‹ÛÂȘ. ∆Ô Ó¤Ô ∂¶∂, fiˆ˜ ‰È·ÌÔÚÊÒıËΠÁÈ· ÙÔ 2008, Û˘ÓÔ„›˙ÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1 Î·È ÛÙÔ˘˜ ¶›Ó·Î˜ 5 Î·È 6. ∏ ∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ √ ¶Úfi‰ÚÔ˜: ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ∞Ó‰Ú¤·˜ ∆· ̤ÏË: µÈÔÏ¿ÎË ª., £ÂÔ‰ˆÚ›‰Ô˘ ª., ∫·Ó·ÎÔ‡‰Ë-∆۷ηϛ‰Ô˘ º., ∫·ÊÂÙ˙‹˜ ¢., ∫¯·ÁÈ·‰¿Î˘ °., ∫‡ÚÏÂÛË ∞., ™¿Ï· °., ™ÙÚ·ÙËÁ¿Î˘ ª., ™˘ÚÈÔÔ‡ÏÔ˘ µ., ÃÚÔ‡ÛÔ˜ °. ∏ °Ú·ÌÌ·Ù¤·˜: ™ˆÙ‹Ú¯Ô˘ ∞. ¶›Ó·Î·˜ 3. ∂Ӊ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ ∏·Ù›Ùȉ·˜ ∞ Û ¯ÒÚ˜ Ì ¯·ÌËÏ‹ Î·È Ì¤ÛË ÂÓ‰ËÌÈÎfiÙËÙ· ñ ∆·ÍȉÈÒÙ˜. ñ ∂·ÁÁÂÏ̷ٛ˜ ˘Á›·˜. ñ ∂·ÁÁÂÏ̷ٛ˜ ‰È·Î›ÓËÛ˘ ÙÚÔʛ̈Ó. ñ ¶ÚÔÛˆÈÎfi È‰Ú˘Ì¿ÙˆÓ. ñ ¶ÚÔÛˆÈÎfi ηı·ÚÈfiÙËÙ·˜ ‰ËÌfiÛÈˆÓ Î·È È‰ÈˆÙÈÎÒÓ ÂÎ·È‰Â˘ÙÈÎÒÓ È‰Ú˘Ì¿ÙˆÓ. ñ ∫ÏÂÈÛÙÔ› ÏËı˘ÛÌÔ›*. ñ √ÌÔÊ˘ÏfiÊÈÏÔÈ - ∆ÔÍÈÎÔÌ·Ó›˜. ñ ÕÙÔÌ· Ì ¯ÚfiÓÈ· Ïԛ̈ÍË Ì ÙÔÓ Èfi Ù˘ ∏µ. * ‚Ϥ ˘ÔÛËÌ›ˆÛË ¶›Ó·Î· 4

Pediatri Mar-Apr 08

07-04-08

17:43

™ÂÏ›‰·167

167

∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ

∂£¡π∫√ ¶ƒ√°ƒ∞ªª∞ ∂ªµ√§π∞™ªø¡ - ÃÚÔÓԉȿÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ ÁÈ· ¶·È‰È¿ Î·È ∂Ê‹‚Ô˘˜

°¤ÓÓËÛË

∏ÏÈΛ· ∂Ì‚fiÏÈÔ

Hep B1·

1 ÌËÓfi˜

2 ÌËÓÒÓ

4 ÌËÓÒÓ

6 ÌËÓÒÓ

Hep B1‚ (1-2 ‰fiÛÂȘ)

12 ÌËÓÒÓ

15 ÌËÓÒÓ

18 ÌËÓÒÓ

24 ÌËÓÒÓ

4-6 ÂÙÒÓ

11-12 ÂÙÒÓ

13-18 ÂÙÒÓ

Hep B

∏·Ù›Ùȉ·˜ µ (∏ep µ)1

¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘,

Hep B1Á

Hep B

DTaP

DTaP

Hep B DTaP

Hep B (fiϘ ÔÈ ‰fiÛÂȘ) DTaP

D∆aP2·,2‚

DTaP

2

∫ÔηÙË (D∆aP)

¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV(IPV)3

IPV

IPV

AÈÌfiÊÈÏÔ˘ Ù‡Ô˘ µ4

Hib

Hib

MËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ C (MCC)5

MCC

MCC

¶Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ (PCV)6

PCV

PCV

IPV Hib

IPV

Hib MCC

PCV

PCV (PPV)6·

PCV

πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR)7

MMR

MMR

AÓÂÌ¢ÏÔÁÈ¿˜ (Var)8

Var

Var HPV ÎÔÚ›ÙÛÈ· 12-15 ÂÙ.

3 ‰fiÛÂȘ

πfi˜ ∞ÓıÚÒÈÓˆÓ £ËÏˆÌ¿ÙˆÓ (∏PV)9 ∏·Ù›Ùȉ·˜ A (Hep A)10 º˘Ì·Ù›ˆÛ˘ (BCG)11 °Ú›˘ (πNFL)12

Hep A (2 ‰fiÛÂȘ) Mantoux11·

Mantoux

BCG

Mantoux11‚

π¡FL (ÂÙËÛ›ˆ˜)

∂ÈÎfiÓ· 1. ÃÚÔÓԉȿÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜.

------ ∆· ÂÌ‚fiÏÈ· οو ·fi ÙË ‰È·ÎÂÎÔÌ̤ÓË ÁÚ·ÌÌ‹ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· ÂÈÏÂÎÙÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi (‚Ϥ ÂÂÍËÁ‹ÛÂȘ Ù˘ ∂ÈÎfiÓ·˜ 1). ∂‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡. ™ÙËÓ ·Ú¤ÓıÂÛË ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ‰fiÛÂȘ ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ô˘ Á›ÓÔÓÙ·È Û’ ·˘Ùfi ÙÔ Â‡ÚÔ˜ ËÏÈÎÈÒÓ, fiÙ·Ó Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›·. ∆Ô Â‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÔÓÔ‰‡Ó·Ì· ‹ ÔÏ˘‰‡Ó·Ì· (Û˘Ó‰˘·Ṳ̂ӷ) ÂÌ‚fiÏÈ· ‹/Î·È Û˘Ó‰˘·ÛÌfi˜ ÌÔÓÔ‰‡Ó·ÌˆÓ-Û˘Ó‰˘·Ṳ̂ӈÓ. ∂‡ÚÔ˜ ËÏÈÎÈÒÓ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ fiÙ·Ó ·˘Ùfi˜ ‰ÂÓ ¤¯ÂÈ ÚÔËÁËı› ηٿ ÙÔ Û˘ÓÈÛÙÒÌÂÓÔ Û¯‹Ì· ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ· Î·È ÙȘ ‰fiÛÂȘ (‚Ϥ ÂÂÍËÁ‹ÛÂȘ ¶ÈÓ¿ÎˆÓ 5 Î·È 6).

∂ÂÍËÁ‹ÛÂȘ ∂ÈÎfiÓ·˜ 1 1. HepB = ∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ∏·Ù›Ùȉ·˜ µ.

1·. ∏ 1Ë ‰fiÛË ÙÔ˘ HepB ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÌfiÓÔÓ fiÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ÊÔÚ¤·˜ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ (HBsAg) ‹ fiÙ·Ó Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ÊÔÚ¤·˜ ‹ fi¯È. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ·Ó·ÁηÛÙÈο Ë 1Ë ‰fiÛË ÙÔ˘ HepB ¯ÔÚËÁÂ›Ù·È ˆ˜ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ.

1‚. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ë 1Ë ‰fiÛË ¯ÔÚËÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘ÓÔÏÈο 4 ‰fiÛÂȘ ·ÓÙ› ÁÈ· 3 ‰fiÛÂȘ (Ë 2Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó· Î·È Ë 3Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2Ô˘ Ì‹Ó·). ∆Ô ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ 1˘ Î·È 2˘ ηıÒ˜ Î·È 2˘ Î·È 3˘ ‰fiÛ˘ Â›Ó·È 4 ‚‰ÔÌ¿‰Â˜. ∆Ô ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ ÚÔÙÂÏÂ˘Ù·›·˜ (3˘) Î·È ÙÂÏÂ˘Ù·›·˜ (4˘) ‰fiÛ˘ ÙÔ˘ ‚·ÛÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Â›Ó·È 8-16 ‚‰ÔÌ¿‰Â˜ Î·È ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÓˆÚ›ÙÂÚ· ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 24 ‚‰ÔÌ¿‰ˆÓ (6 ÌËÓÒÓ). ¶ƒ√™√Ã∏! ™Â ÂÚ›ÙˆÛË Ô˘ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ ¯ÔÚËÁËı› ˆ˜ Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ, Ô ÁÈ·ÙÚfi˜ Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ fiÙÈ Ù· Û˘Ó‰˘·Ṳ̂ӷ ÂÌ‚fiÏÈ· ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ 6Ë Â‚‰ÔÌ¿‰· Ù˘ ˙ˆ‹˜. ∂Ô̤ӈ˜, ÙÔ ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· Ô˘ ÌÂÛÔÏ·‚› ·fi ÙË Á¤ÓÓËÛË, Ô˘ ¯ÔÚËÁÂ›Ù·È ÙÔ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ, Â›Ó·È 6 ‚‰ÔÌ¿‰Â˜ ·ÓÙ› 1 Ì‹Ó·˜. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ 1Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, Û’ fiÏ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ, ÊÔÚ¤ˆÓ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘, Î·È Ì¤Û· ÛÙȘ ÚÒÙ˜ 12 ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¯ÔÚËÁÔ‡ÓÙ·È 0,5 ml ˘ÂÚ¿ÓÔÛ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÁÈ· ∏·Ù›Ùȉ· µ. ∏ ¤ÓÂÛË Á›ÓÂÙ·È Û ‰È·ÊÔÚÂÙÈÎfi ̤ÚÔ˜ ·’ ·˘Ùfi Ô˘ ¤ÁÈÓ (‹ ı· Á›ÓÂÈ) ÙÔ ÂÌ‚fiÏÈÔ. ŸÏ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi ÌËÙ¤Ú˜ ÊÔÚ›˜ Î·È ‹Ú·Ó ÙÔ ÂÌ‚fiÏÈÔ Î·È ÙËÓ ˘ÂÚ¿ÓÔÛË ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ (HBsAg) Î·È ·ÓÙÈÛÒÌ·Ù· (·ÓÙÈ-HBs) ÛÙËÓ ËÏÈΛ· ÙˆÓ 9 ¤ˆ˜ 15 ÌËÓÒÓ. ŸÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Â›Ó·È ‹ fi¯È ÊÔÚ¤·˜ ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ηٿ ÙÔÓ ÙÔÎÂÙfi Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·Ô‰ÂȯÙ› fiÙÈ ‰ÂÓ Â›Ó·È, ·fi ÙË 2Ë ‰fiÛË Î·È ¤ÂÈÙ· ·ÎÔÏÔ˘ıÂ›Ù·È ÙÔ Û¯‹Ì· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ô˘ ÈÛ¯‡ÂÈ ÁÈ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ Ô˘ ‰ÂÓ Â›Ó·È ÊÔÚ›˜ ÙÔ˘ HbsAg, ‰ËÏ·‰‹ ·ÁÓÔÂ›Ù·È Ë 1Ë ‰fiÛË.

1Á. ŸÙ·Ó Ë ÌËÙ¤Ú· Â›Ó·È ·ÚÓËÙÈ΋ ÁÈ· ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ, Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ (‰‡Ô ·Ú¯ÈΤ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:166-170

Pediatri Mar-Apr 08

07-04-08

168

17:43

™ÂÏ›‰·168

∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ

Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰ˆÓ Î·È ÌÈ· ÙÚ›ÙË Û ËÏÈΛ· 6-18 ÌËÓÒÓ Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ·fi ÙË 2Ë ‰fiÛË 8-16 ‚‰ÔÌ¿‰Â˜ Î·È fi¯È ÓˆÚ›ÙÂÚ· ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ).

2. DTaP = ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÔ˘ ÙÂÙ¿ÓÔ˘, ÙÔ˘ ÎÔηÙË Ô˘ ÂÚȤ¯ÂÈ Ù· ÙÔÍÔÂȉ‹ (‹ ·ÙÔ͛Ә) ÙÔ˘ ÎÔÚ˘ÓÔ‚·ÎÙËÚȉ›Ô˘ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ Î·È ÙÔ˘ ÎψÛÙËÚȉ›Ô˘ ÙÔ˘ ÙÂÙ¿ÓÔ˘ Î·È ÌfiÓÔ ·ÓÙÈÁfiÓ· Ù˘ µ. pertussis (fi¯È ÔÏfiÎÏËÚÔ ÙÔ ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi ÓÂÎÚfi, fiˆ˜ Ù· ·Ï·ÈfiÙÂÚ· “ÔÏÔ΢ÙÙ·ÚÈο” ÂÌ‚fiÏÈ·), ÁÈ’ ·˘Ùfi Î·È Î·ÏÂ›Ù·È “·Î˘ÙÙ·ÚÈÎfi” ηٿ ÙÔ˘ ÎÔηÙË (acellular pertussis ‹ ·P) ÂÌ‚fiÏÈÔ.

2·. TdaP = ∂Ì‚fiÏÈÔ Î·Ù¿ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜, ÙÔ˘ ÙÂÙ¿ÓÔ˘, ÙÔ˘ ÎÔηÙË, Ì ÌÈÎÚfiÙÂÚË ‰fiÛË ‰ÈÊıÂÚÈÙÈ΋˜ ·ÙÔ͛Ӣ. ™ÙË ¯ÒÚ· Ì·˜ ÂÚȤ¯ÂÈ Î·È IPV Î·È ‰‡Ó·Ù·È Ó· ¯ÔÚËÁËı› ̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ. ∆Ô TdaP Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÁÈ· Â·Ó·ÏËÙÈ΋ ‰fiÛË ÛÙËÓ ËÏÈΛ· ÙˆÓ 11-12 ÂÙÒÓ ‹ Î·È ·ÚÁfiÙÂÚ· (̤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 64 ÂÙÒÓ) ηٿ ÚÔÙ›ÌËÛË fiÙ·Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ·ÔÎÙ¿Ù·È ÓÂÔÁ¤ÓÓËÙÔ. ™˘ÓÈÛÙ¿Ù·È Ó· ·¤¯ÂÈ 5 ¯ÚfiÓÈ· ·fi ÙÔ DTaP ‹ ÙÔ ∆d ÁÈ· ÏÈÁfiÙÂÚ˜ ÙÔÈΤ˜ ·ÓÙȉڿÛÂȘ, ÌÔÚ› fï˜ Ó· ¯ÔÚËÁËı› Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· Î·È ‰‡Ô ÂÙÒÓ. ∂¿Ó ‰ÂÓ Î˘ÎÏÔÊÔÚ› ÙÔ TdaP ÌfiÓÔ ÙÔ˘ (¯ˆÚ›˜ IPV) ¯ÔÚËÁÂ›Ù·È ÙÔ Td ÂÓËϛΈÓ. √È ˘fiÏÔÈ˜ ‰fiÛÂȘ ı· Â›Ó·È Î¿ı 10 ¯ÚfiÓÈ· Ì Td ÂÓËϛΈÓ.

2‚. Td = ∂Ì‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÙÂÙ¿ÓÔ˘ Î·È Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ Ì ÌÈÎÚfiÙÂÚË ‰fiÛË ‰ÈÊıÂÚÈÙÈ΋˜ ·ÙÔ͛Ӣ. ™˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È Î¿ı 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ TdaP ÛÙËÓ ÂÊË‚È΋ ËÏÈΛ·. ∆Ô ÂÌ‚fiÏÈÔ ÙÔ˘ ÙÂÙ¿ÓÔ˘ ÌÔÚ› Ó· Á›ÓÂÙ·È ‰È· ‚›Ô˘ Ì ·ÛÊ¿ÏÂÈ·.

3. IPV = ∂Ó¤ÛÈÌÔ ÂÓÈÛ¯˘Ì¤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜.

4. Hib = ™˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘ Ù‡Ô˘ ‚. ∂¿Ó Ë ÚˆÙ½ÓË Û‡˙¢Í˘ Â›Ó·È Ë PRP-OMP (ÚˆÙÂ˚ÓÈÎfi Û‡ÌÏÂÁÌ· Ù˘ Â͈ÙÂÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘), ÙfiÙÂ Ë 3Ë ·fi ÙȘ 3 ·Ú¯ÈΤ˜ ‰fiÛÂȘ ÌÔÚ› Ó· ·Ú·ÏËÊı› Î·È ÙÔ Û¯‹Ì· Ó· Â›Ó·È (2Ô˜, 4Ô˜ Î·È 12Ô˜-15Ô˜ Ì‹Ó·˜).

5. MCC = ™˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÌËÓÈÁÁÈÙȉfiÎÔÎÎÔ˘ ÔÚÔÔÌ¿‰·˜ C. ™˘ÓÈÛÙ¿Ù·È Ë ¤Ó·ÚÍË ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ËÏÈΛ· 2 ÌËÓÒÓ Î·È ·ÎÔÏÔ˘ıÂ›Ù·È Û¯‹Ì· 3 ‰fiÛÂˆÓ - ÔÈ 2 ÚÒÙ˜ ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 2 ÌËÓÒÓ Î·È Â·Ó·ÏËÙÈ΋ ‰fiÛË Û ËÏÈΛ· 15-18 ÌËÓÒÓ. ™Â ÂÚ›ÙˆÛË ¤Ó·Ú͢ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Û ËÏÈΛ· >12 ÌËÓÒÓ, ·ÎÔÏÔ˘ıÂ›Ù·È Û¯‹Ì· 1 ‰fiÛ˘.

6. PCV = ¡ÂÎÚfi, Û˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi, ÂÙ·‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ Ù˘ Ó¢ÌÔÓ›·˜ (Ó¢ÌÔÓÈfiÎÔÎÎÔ˘). ™˘ÓÈÛÙ¿Ù·È Û’ fiÏ· Ù· ·È‰È¿ ËÏÈΛ·˜ 2-23 ÌËÓÒÓ. ∏ ÙÂÏÂ˘Ù·›· ‰fiÛË (4Ë) Á›ÓÂÙ·È Û ËÏÈΛ· ≥12 ÌËÓÒÓ. ∆Ô ÂÌ‚fiÏÈÔ ÌÔÚ› Ó· Á›ÓÂÈ Î·È Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Î·È È‰È·›ÙÂÚ· Û ¿ÙÔÌ· Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (‚Ϥ ˘ÔÛËÌÂÈÒÛÂȘ 6,7 ÛÙÔ ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ¶›Ó·Î˜ 5 Î·È 6). ™ÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË, ÔÈ Â·Ó·ÏËÙÈΤ˜ ‰fiÛÂȘ ÌÔÚ› Ó· Á›ÓÔÓÙ·È Î·È Ì ÙÔ 23‰‡Ó·ÌÔ ÔÏ˘Û·Î¯·ÚȉÈÎfi ÌË Û˘˙¢Á̤ÓÔ ÂÌ‚fiÏÈÔ (PPV).

6·. PPV = ªË Û˘˙¢Á̤ÓÔ, ÔÏ˘Û·Î¯·ÚȉÈÎfi ÂÌ‚fiÏÈÔ (23‰‡Ó·ÌÔ) ηٿ ÙÔ˘ ÛÙÚÂÙfiÎÔÎÎÔ˘ Ù˘ Ó¢ÌÔÓ›·˜ (Ó¢ÌÔÓÈÔÎfiÎÎÔ˘). ™˘ÓÈÛÙ¿Ù·È ÁÈ· Â·Ó·ÏËÙÈΤ˜ ‰fiÛÂȘ Û ·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÔ‚·Ú‹ Ó¢ÌÔÓÈÔÎÔÎÎÈ΋ Ïԛ̈ÍË (¶›Ó·Î·˜ 1), ÂÎÙfi˜ ·fi ˘ÁÈ‹ ‚Ú¤ÊË Î·È ·È‰È¿ ËÏÈΛ·˜ 2-23 ÌËÓÒÓ.

7. MMR = ∂Ì‚fiÏÈÔ Ô˘ ÂÚȤ¯ÂÈ ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Ù˘ ÈÏ·Ú¿˜, ·ÚˆÙ›Ùȉ·˜ Î·È ÂÚ˘ıÚ¿˜. ÃÔÚËÁÂ›Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-15 ÌËÓÒÓ. ™˘ÓÈÛÙ¿Ù·È 2Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ·, ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. √ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÈ ·Ó ¤ÁÈÓ ‹ fi¯È Ë 2Ë ‰fiÛË Î·È ·Ó fi¯È ¯ÔÚËÁÂ›Ù·È Ë 2Ë ‰fiÛË Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·.

8. Var = ∂Ì‚fiÏÈÔ Ô˘ ÂÚȤ¯ÂÈ ˙ÒÓÙ· ÂÍ·ÛıÂÓË̤ÓÔ Èfi Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜. ÃÔÚËÁÂ›Ù·È Û’ fiÏ· Ù· ·È‰È¿ ÛÙËÓ ËÏÈΛ· ÙˆÓ 1218 ÌËÓÒÓ (ηٿ ÚÔÙ›ÌËÛË ÌÂÙ¿ ÙÔ 15Ô Ì‹Ó·), ·ÏÏ¿ Î·È Û’ ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ·, ÂÊfiÛÔÓ ÙÔ ¿ÙÔÌÔ ‰ÂÓ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ. ™˘ÓÈÛÙ¿Ù·È 2Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÔÔÈ·‰‹ÔÙ ¿ÏÏË ËÏÈΛ· ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. √ ·È‰›·ÙÚÔ˜ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÈ ·Ó ¤ÁÈÓ ‹ fi¯È Ë 2Ë ‰fiÛË Î·È ·Ó fi¯È ¯ÔÚËÁÂ›Ù·È Ë 2Ë ‰fiÛË Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·.

9. HPV = ∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚÒÈÓˆÓ ıËψ̿وÓ. ™‡Ìʈӷ Ì ٷ ̤¯ÚÈ ÛÙÈÁÌ‹˜ ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ, ÌÔÚ› Ó· ¯ÔÚËÁËı› ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 9-26 ÂÙÒÓ. ™ÙË ¯ÒÚ· Ì·˜ Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ, ·ÏÏ¿ Î·È Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-26 ÂÙÒÓ, Â¿Ó ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·ÛÙ› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (¯ˆÚ›˜ Ó· ‰È·ÛÊ·Ï›˙ÂÙ·È Ë ÚÔʇϷ͋ ÙÔ˘˜, Â¿Ó ‹‰Ë ¤¯Ô˘Ó ÌÔÏ˘Óı› ·fi Ù‡Ô ÙÔ˘ ÈÔ‡ Ô˘ ÂÚȤ¯ÂÙ·È ÛÙÔ ÂÌ‚fiÏÈÔ, ȉȷ›ÙÂÚ· ·Ó ¤¯Ô˘Ó ·ÏÏ¿ÍÂÈ 3-4 ÛÂÍÔ˘·ÏÈÎÔ‡˜ Û˘ÓÙÚfiÊÔ˘˜). ™ÙË ¯ÒÚ· Ì·˜ ΢ÎÏÔÊÔÚÔ‡Ó ‰‡Ô ÂÌ‚fiÏÈ·. ∆Ô ¤Ó· Â›Ó·È ‰È‰‡Ó·ÌÔ Î·È ÙÔ ¿ÏÏÔ ÙÂÙÚ·‰‡Ó·ÌÔ. ∫·È Ù· ‰‡Ô ÂÌ‚fiÏÈ· ÂÚȤ¯Ô˘Ó Ù· ÔÁÎÔÁfiÓ· ÛÙÂϤ¯Ë 16 Î·È 18. ∆Ô ÙÂÙÚ·‰‡Ó·ÌÔ ÂÚȤ¯ÂÈ ÂÈϤÔÓ ‰‡Ô ·ÎfiÌ· Ù‡Ô˘˜ ÈÒÓ (6 Î·È 11), Ô˘ ·ÛÎÔ‡Ó ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË Î·Ù¿ ÙˆÓ ıËÏˆÌ¿ÙˆÓ (ÎÔÓ‰˘ÏˆÌ¿ÙˆÓ). ∆Ô ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Î·È ÁÈ· Ù· ‰‡Ô ÂÌ‚fiÏÈ· ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ. °È· ÌÂÓ ÙÔ ‰È‰‡Ó·ÌÔ, ÔÈ ‰fiÛÂȘ Â›Ó·È 0-1-6 Ì‹Ó˜, ÂÓÒ ÁÈ· ÙÔ ÙÂÙÚ·‰‡Ó·ÌÔ Â›Ó·È 0-2-6 Ì‹Ó˜. ™Â ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ÙËÚËı› ÙÔ ·ÎÚÈ‚¤˜ ¯ÚÔÓԉȿÁÚ·ÌÌ·, Ô ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· Û˘Ó¯›ÛÂÈ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi, ¯ˆÚ›˜ Ó· ¯¿ÓÔÓÙ·È ÔÈ ÚÔËÁÔ‡ÌÂÓ˜ ‰fiÛÂȘ. ∆¤ÏÔ˜, Ë Û˘Á¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Ì ¿ÏÏ· ÂÌ‚fiÏÈ· ¤¯ÂÈ ·Ô‰Âȯı› ̤¯ÚÈ ÛÙÈÁÌ‹˜ ·ÛÊ·Ï‹˜ ÌfiÓÔ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ∏·Ù›Ùȉ·˜ µ.

10. Hep A = ∞‰Ú·ÓÔÔÈË̤ÓÔ ÔÏÔ΢ÙÙ·ÚÈÎfi ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ∏·Ù›Ùȉ·˜ ∞. ÃÔÚËÁÂ›Ù·È Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ· ¿Óˆ ÙÔ˘ ÂÓfi˜ (1) ¤ÙÔ˘˜ Û 2 ‰fiÛÂȘ, Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 6 ÌËÓÒÓ, ηıÒ˜ Î·È Û fiϘ ÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∏·Ù›Ùȉ· ∞ (¶›Ó·Î·˜ 3).

11. BCG = ∑ˆÓ ÂÍ·ÛıÂÓË̤ÓÔ ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ Ê˘Ì·Ù›ˆÛ˘. ™‡Ìʈӷ Ì ÙȘ ÚfiÛÊ·Ù˜ Ô‰ËÁ›Â˜ Ù˘ ¢ÈÂıÓÔ‡˜ ŒÓˆÛ˘ ηٿ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Î·È Ù˘ ¶·ÁÎfiÛÌÈ·˜ √ÚÁ¿ÓˆÛ˘ ÀÁ›·˜, Ë ¯ÒÚ· Ì·˜ ‰ÂÓ ÏËÚÔ› ÙȘ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· ÙË ‰È·ÎÔ‹ ÙÔ˘ ·ÓÙÈÊ˘Ì·ÙÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡, Ô ÔÔ›Ô˜ ÂÍ·ÎÔÏÔ˘ı› Ó· Á›ÓÂÙ·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ. π‰È·›ÙÂÚË ¤ÌÊ·ÛË Ú¤ÂÈ Ó· ‰Ôı› ΢ڛˆ˜ ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 2). ¶·Ú¿ÏÏËÏ·, Û˘ÓÈÛÙ¿Ù·È Ì·˙ÈÎfi˜ ÚÔÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux ÛÙȘ ËÏÈ˘ 1, 4-6 ÂÙÒÓ (ÚÈÓ ·fi ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ì BCG, 11·) Î·È ÛÙ· ·ÓÂÌ‚ÔÏ›·ÛÙ· ·È‰È¿, ÛÙËÓ ËÏÈΛ· 11-12 ÂÙÒÓ (fiÙ·Ó Á›ÓÂÙ·È Ë ÂÎÙ›ÌËÛË Ù˘ ÂÌ‚ÔÏÈ·ÛÙÈ΋˜ ÙÔ˘˜ Î¿Ï˘„˘, 11‚).

12. INFL = ∞‰Ú·ÓÔÔÈË̤ÓÔ ÔÏÔ΢ÙÙ·ÚÈÎfi ‹ ·Î˘ÙÙ·ÚÈÎfi (ÙÌËÌ·ÙÈÎfi) ÂÌ‚fiÏÈÔ Î·Ù¿ Ù˘ ÁÚ›˘ Ô˘ Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÂÙËÛ›ˆ˜, Û 1 ‰fiÛË Î·È Û ËÏÈΛ· ¿Óˆ ·fi 6 ÌËÓÒÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ ÁÈ· ·È‰È¿ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ Ó· ÓÔÛ‹ÛÔ˘Ó ÛÔ‚·Ú¿ ·fi ÁÚ›Ë (¶›Ó·Î·˜ 4). ¶·È‰È¿ οو ÙˆÓ 8 ÂÙÒÓ Ô˘ ı· ÂÌ‚ÔÏÈ·ÛıÔ‡Ó ÁÈ· ÚÒÙË ÊÔÚ¿ ı· ¿ÚÔ˘Ó 2 ‰fiÛÂȘ ÂÌ‚ÔÏ›Ô˘ (0,25 ml <3 ÂÙÒÓ Î·È 0,5 ml ≥3 ÂÙÒÓ) Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 4 ‚‰ÔÌ¿‰ˆÓ.

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¶›Ó·Î·˜ 4. ∂Ӊ›ÍÂȘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ηٿ Ù˘ ÁÚ›˘ ¶·ÚÔ˘Û›· ÂÓfi˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‹ ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù·: ñ ÕÛıÌ· ‹ ¿ÏϘ ¯ÚfiÓȘ Ó¢ÌÔÓÔ¿ıÂȘ. ñ ∫·Ú‰È·Î‹ ÓfiÛÔ˜ Ì ÛÔ‚·Ú¤˜ ηډÈÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜. ñ ∞ÓÔÛÔηٷÛÙÔÏ‹ (ÂÍ·ÈÙ›·˜ ÓÔÛ‹Ì·ÙÔ˜ ‹ ıÂÚ·›·˜). ñ ¢ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ˜ (Î·È ¿ÏϘ ·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ). ñ ¶·È‰È¿ Ô˘ ·›ÚÓÔ˘Ó ·ÛÈÚ›ÓË Ì·ÎÚÔ¯ÚfiÓÈ· (.¯. ÓfiÛÔ˜ Kawasaki) ÁÈ· Ó· ÂÏ·ÙÙˆı› Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Û˘Ó‰ÚfiÌÔ˘ Reye ÌÂÙ¿ ·fi ÁÚ›Ë. ñ ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ‹ ¿ÏÏÔ ¯ÚfiÓÈÔ ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ·. ñ ÃÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ·. ñ ∫ÏÂÈÛÙÔ› ÏËı˘ÛÌÔ›*. ñ ∂·ÁÁÂÏ̷ٛ˜ ˘Á›·˜. ñ ∂·ÁÁÂÏ̷ٛ˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì Ô˘ÏÂÚÈο**. ñ ÕÙÔÌ· ËÏÈΛ·˜ 60 ÂÙÒÓ Î·È ¿Óˆ. * ¶ÚÔÛˆÈÎfi Î·È ÂÛˆÙÂÚÈÎÔ› ÛÔ˘‰·ÛÙ¤˜ Á˘ÌÓ·Û›ˆÓ-Ï˘Î›ˆÓ, ÛÙÚ·ÙȈÙÈÎÒÓ Î·È ·ÛÙ˘ÓÔÌÈÎÒÓ Û¯ÔÏÒÓ, ÂȉÈÎÒÓ Û¯ÔÏ›ˆÓ ‹ Û¯ÔÏÒÓ, ÙÚfiÊÈÌÔÈ Î·È ÚÔÛˆÈÎfi È‰Ú˘Ì¿ÙˆÓ Î.¿. ** √ Èfi˜ Ù˘ ÁÚ›˘ ÙˆÓ Ô˘ÏÂÚÈÎÒÓ Î·ÓÔÓÈο ‰ÂÓ ÚÔηÏ› ÓfiÛËÛË ÛÙÔÓ ¿ÓıÚˆÔ. ∂›Ó·È ‰˘Ó·ÙfiÓ fï˜, Û ÂÚ›ÙˆÛË Û˘ÏÏԛ̈͢ Ì ÙÔÓ Èfi Ù˘ ÁÚ›˘ ÙˆÓ ·ÓıÚÒˆÓ, Ó· ÚÔ·„ÂÈ ÌÂÙ·ÏÏ·Á̤ÓÔ˜ Èfi˜ Ô˘ Ó· ÚÔÛ‚¿ÏÏÂÈ Î·È ÙÔÓ ¿ÓıÚˆÔ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Û˘ÓÈÛÙ¿Ù·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ·ÙfiÌˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì Ô˘ÏÂÚÈο.

∂›Û˘, Û˘ÓÈÛÙ¿Ù·È ÂÙ‹ÛÈÔ˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ fiÏˆÓ ÙˆÓ ˘ÁÈÒÓ ·ÙfiÌˆÓ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ Î·È ÙˆÓ ·ÙfiÌˆÓ Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘, ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜. ™Â ÂÚ›ÙˆÛË ·ÏÏ·Á‹˜ ÙˆÓ ÂȉËÌÈÔÏÔÁÈÎÒÓ Û˘ÓıËÎÒÓ (.¯. ÂȉËÌ›·, ·Ó‰ËÌ›·) ÔÈ Û˘ÛÙ¿ÛÂȘ ·ÏÏ¿˙Ô˘Ó. ŸÏ· Ù· ·È‰È¿ Ú¤ÂÈ Ó· ÂÈÛΤÙÔÓÙ·È ÙÔ ÁÈ·ÙÚfi ÙÔ˘˜ ÛÙËÓ ËÏÈΛ· ÙˆÓ 11-12 ÂÙÒÓ (Ù¤ÏÔ˜ ‰ËÌÔÙÈÎÔ‡, ¤Ó·ÚÍË ÊÔ›ÙËÛ˘ ÛÙÔ Á˘ÌÓ¿ÛÈÔ), ÒÛÙ ӷ Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ Ù˘ ÂÌ‚Ô-

ÏÈ·ÛÙÈ΋˜ ÙÔ˘˜ Î¿Ï˘„˘ Î·È Î·Ù·ÁÚ·Ê‹ Ù˘ ÛÙËÓ ÂȉÈ΋ ÛÂÏ›‰· ÙÔ˘ ·ÙÔÌÈÎÔ‡ ‚È‚ÏÈ·Ú›Ô˘ ˘Á›·˜. ∫¿ı ÛÔ‚·Ú‹ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ô˘ ÂÈÛËÌ·›ÓÂÈ Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È ÛÙÔÓ ∂√º (Ó· Û˘ÌÏËÚÒÓÂÙ·È Ë Î›ÙÚÈÓË Î¿ÚÙ·). ™ÙÔ˘˜ ¶›Ó·Î˜ 5 Î·È 6 Û˘ÓÔ„›˙ÂÙ·È ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· Ù· ·È‰È¿ Ô˘ ηı˘ÛÙ¤ÚËÛ·Ó Ó· ÂÌ‚ÔÏÈ·ÛÙÔ‡Ó.

¶›Ó·Î·˜ 5. ¶ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 6 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ËÏÈΛ· ∂Ì‚fiÏÈÔ

∏·Ù›Ùȉ·˜ µ (Hep B) ¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘, ∫ÔηÙË (D∆aP)Ç ¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV3 ∞ÈÌfiÊÈÏÔ˘ Ù‡Ô˘ ‚ (Hib)4 ªËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C (MCC)5 ¶Ó¢ÌÔÓÈoÎfiÎÎÔ˘ (7‰‡Ó·ÌÔ) (PCV)6 πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR)7 ∞ÓÂÌ¢ÏÔÁÈ¿˜ (Var)8 ∏·Ù›Ùȉ·˜ ∞ (Hep ∞)9 º˘Ì·Ù›ˆÛ˘ (BCG)10 º˘Ì·ÙÈÓ·ÓÙ›‰Ú·ÛË11 (Mantoux) °Ú›˘ (INFL)12

1Ë ‰fiÛË ËÌ/Ó›·

2Ë ‰fiÛË 1Ë-2Ë ËÌ/Ó›· ‰fiÛË1

3Ë ‰fiÛË 2Ë-3Ë ËÌ/Ó›· ‰fiÛË1

4Ë ‰fiÛË 3Ë-4Ë ËÌ/Ó›· ‰fiÛË1

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5Ë ‰fiÛË 4Ë-5Ë ËÌ/Ó›· ‰fiÛË1

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∂ıÓÈ΋ ∂ÈÙÚÔ‹ ∂Ì‚ÔÏÈ·ÛÌÒÓ

¶›Ó·Î·˜ 6. ¶ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÁÈ· ·È‰È¿ ËÏÈΛ·˜ 7-18 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ·fi ÙÔ ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ËÏÈΛ· ∂Ì‚fiÏÈÔ

∏·Ù›Ùȉ·˜ µ (Hep B) ¢ÈÊıÂÚ›Ùȉ·˜, ∆ÂÙ¿ÓÔ˘ (Td) Tdap ¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ IPV ªËÓÈÁÁÈÙȉÔÎfiÎÎÔ˘ C (MCC) πÏ·Ú¿˜, ¶·ÚˆÙ›Ùȉ·˜, ∂Ú˘ıÚ¿˜ (MMR) ∞ÓÂÌ¢ÏÔÁÈ¿˜ (Var) πfi˜ ∞ÓıÚÒÈÓˆÓ £ËÏˆÌ¿ÙˆÓ (HPV)13 ∏·Ù›Ùȉ·˜ ∞ (Hep ∞) °Ú›˘ (INFL)

1Ë ‰fiÛË ËÌ/Ó›·

2Ë ‰fiÛË 1Ë-2Ë ËÌ/Ó›· ‰fiÛË1

3Ë ‰fiÛË 2Ë-3Ë ËÌ/Ó›· ‰fiÛË1

4 ‚‰.

4 ‚‰.

3 ÌËÓ.

6 ÌËÓ.

4 ‚‰.

4 ‚‰.

4 ‚‰.

8 ‚‰.

4-8 ‚‰.

6 ÌËÓ.

4Ë ‰fiÛË 3Ë-4Ë ËÌ/Ó›· ‰fiÛË1 6 ÌËÓ.

5 ¯ÚfiÓÈ· 6 ÌËÓ.

4-5 ÌËÓ.

ÀÔÛËÌÂÈÒÛÂȘ/ÂÂÍËÁ‹ÛÂȘ ÙˆÓ ¶ÈÓ¿ÎˆÓ 5 Î·È 6 1. ÃÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙËÓ ÚÔËÁÔ‡ÌÂÓË ‰fiÛË.

2. ∏ 5Ë ‰fiÛË ÌÔÚ› Ó· ·Ú·ÏËÊı› fiÙ·Ó Ë 4Ë Á›ÓÂÈ ÌÂÙ¿ ÙÔ 4Ô ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Û˘Ó¯›˙ÂÙ·È Ì Td. To TdaP Á›ÓÂÙ·È Û ̛· ‰fiÛË ÛÙËÓ ÂÊ˂›·, ηٿ ÚÔÙ›ÌËÛË Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 5 ÂÙÒÓ ·fi ÙÔ Td. (µÏ¤ ÂÂÍËÁ‹ÛÂȘ 2·, 2‚ ÛÙËÓ ∂ÈÎfiÓ· 1).

3. ÃÔÚËÁÔ‡ÓÙ·È 4 ‰fiÛÂȘ IPV. 4. °›ÓÂÙ·È Û 2 ‰fiÛÂȘ Û ¿ÙÔÌ· ≤12 ÌËÓÒÓ ‹ Û 1 ‰fiÛË ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿. ∂¿Ó Á›ÓÂÈ Î¿Ï˘„Ë ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ì 2 ‰fiÛÂȘ Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 12 ÌËÓÒÓ, ÙfiÙ Á›ÓÂÙ·È , ÌÂÙ¿ ÙÔ 1Ô ¤ÙÔ˜, Î·È Ì›· Â·Ó·ÏËÙÈ΋ ‰fiÛË. ¢ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ηٿ ÙÔ˘ ·ÈÌfiÊÈÏÔ˘, Û ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 5 ÂÙÒÓ, Ì ÂÍ·›ÚÂÛË ¿ÙÔÌ· Ô˘ ·Ó‹ÎÔ˘Ó Û ÔÌ¿‰Â˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ¿ÙÔÌ· Ì ÛÏËÓÂÎÙÔÌ‹ ‹ ÏÂÈÙÔ˘ÚÁÈ΋ ·ÛÏËÓ›·.

5. ∂¿Ó Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Û ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 12 ÌËÓÒÓ, ¯ÔÚËÁÂ›Ù·È Ì›· ÌfiÓÔ ‰fiÛË MCC. ∂¿Ó ÔÈ ÚÒÙ˜ 2 ‰fiÛÂȘ ¤ÁÈÓ·Ó Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 12 ÌËÓÒÓ Á›ÓÂÙ·È Ì›· 3Ë ‰fiÛË.

6. ∂¿Ó Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 7 ÌËÓÒÓ, ¯ÔÚËÁÔ‡ÓÙ·È 4 ‰fiÛÂȘ ÙÔ˘ PCV ηٿ ÙÔ Û¯‹Ì· Ô˘ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1 (Ë 4Ë ‰fiÛË Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ). ∂¿Ó Ë ¤Ó·ÚÍË Á›ÓÂÈ ÌÂٷ͇ 12Ô˘ Î·È 23Ô˘ Ì‹Ó·, ¯ÔÚËÁÔ‡ÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰Â˜. ∂¿Ó Ë ¤Ó·ÚÍË Á›ÓÂÈ ·fi ÙÔÓ 24Ô Ì‹Ó· Î·È ÌÂÙ¿, ÛÙ· ˘ÁÈ‹ ·È‰È¿ ¯ÔÚËÁÂ›Ù·È Ì›· ÌfiÓÔ ‰fiÛË. ™Ù· ·ÓÔÛÔηٷÛÙ·Ï̤ӷ Î·È Û’ ·˘Ù¿ Ô˘ ·Ó‹ÎÔ˘Ó ÁÂÓÈο ÛÙȘ ÔÌ¿‰Â˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ó¢ÌÔÓÈÔÎÔÎÎÈΤ˜ ÏÔÈÌÒÍÂȘ (¶›Ó·Î·˜ 1) ¯ÔÚËÁÔ‡ÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 6-8 ‚‰ÔÌ¿‰Â˜.

7. ∏ 2Ë ‰fiÛË ÙÔ˘ MMR Û˘ÓÈÛÙ¿Ù·È Ó· Á›ÓÂÙ·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ. ∂¿Ó fï˜ Ë ¤Ó·ÚÍË ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Á›ÓÂÈ Û’ ·˘Ù‹ ÙËÓ ËÏÈΛ·, Ë 2Ë ‰fiÛË ÌÔÚ› Ó· Á›ÓÂÈ Û‡ÓÙÔÌ· Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 8 ‚‰ÔÌ¿‰Â˜.

8. ŸÙ·Ó Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ηٿ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ Á›ÓÂÈ Û ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 12 ÂÙÒÓ Û˘ÓÈÛÙÒÓÙ·È 2 ‰fiÛÂȘ Ì ÌÂÛԉȿÛÙËÌ· 2 ÌËÓÒÓ.

9. µÏ¤ ÂÂÍ‹ÁËÛË 10 ÛÙËÓ ∂ÈÎfiÓ· 1.

10,11. µÏ¤ ÂÂÍ‹ÁËÛË 11 (11·, 11‚) ÛÙËÓ ∂ÈÎfiÓ· 1.

12. µÏ¤ ÂÂÍ‹ÁËÛË 12 ÛÙËÓ ∂ÈÎfiÓ· 1.

13. ªfiÓÔ ÁÈ· ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 15-26 ÂÙÒÓ Ô˘ ‰ÂÓ ÂÌ‚ÔÏÈ¿ÛÙËÎ·Ó ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ· (‚Ϥ ÂÂÍ‹ÁËÛË 9 ÛÙËÓ ∂ÈÎfiÓ· 1).

Paediatriki 2008;71:166-170

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08-04-08

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™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞

171

∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ 2008 ∂. °·Ï·Ó¿Î˘

¶ÚÈÓ ·fi Ï›Á˜ ‚‰ÔÌ¿‰Â˜ ·Ó·ÎÔÈÓÒıËΠ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜ ÙÔ “¡¤Ô ∂ıÓÈÎfi ¶ÚfiÁÚ·ÌÌ· ∂Ì‚ÔÏÈ·ÛÌÒÓ” (À1.°.¶.158238, 23 π·Ó. 2008) Ì ÙȘ Û¯ÂÙÈΤ˜ ÁÓˆÌÔ‰ÔÙ‹ÛÂȘ Ù˘ ∂ıÓÈ΋˜ ∂ÈÙÚÔ‹˜ ∂Ì‚ÔÏÈ·ÛÌÒÓ. ∏ ·fiÊ·ÛË Û˘Óԉ‡ÂÙ·È ·fi ¶›Ó·Î˜ Ì ¯ÚÔÓԉȷÁÚ¿ÌÌ·Ù· ‚·ÛÈÎÔ‡ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Î·È ÂÌ‚ÔÏÈ·ÛÌÔ‡ ·È‰ÈÒÓ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı› ÛÙË Û˘ÓÈÛÙÒÌÂÓË ËÏÈΛ·. ∞Ó·Ï˘ÙÈΤ˜ √‰ËÁ›Â˜ Â›Ó·È ‰È·ı¤ÛÈ̘ ÛÙËÓ ˘Ô˘ÚÁÈ΋ ·fiÊ·ÛË ÙÔ˘ ÀÀÎ∫∞ Î·È ÛÙËÓ ÈÛÙÔÛÂÏ›‰· ÙÔ˘ (www.mohaw.gr → ÛÙÔ ·‡ÚÈÔ → ·Ó·ÎÔÈÓÒÛÂȘ-ÂÁ·ÎÏÈÔÈ) ηıÒ˜ Î·È ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘ ¶∞π¢π∞∆ƒπ∫∏™. ™ÙÔ Ó¤Ô ÂıÓÈÎfi ÚfiÁÚ·ÌÌ· ÂÌ‚ÔÏÈ·ÛÌÒÓ ¤¯Ô˘Ó Á›ÓÂÈ ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ ÛÙ·: ∂Ì‚fiÏÈÔ ÙÔ˘ ÈÔ‡ ÙˆÓ ·ÓıÚˆ›ÓˆÓ ıËψ̿وÓ. ¡¤Ô, ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ ÂÌ‚fiÏÈÔ. ™˘ÓÈÛÙ¿Ù·È Û ÎÔÚ›ÙÛÈ· ËÏÈΛ·˜ 12-15 ÂÙÒÓ Î·È Û ÎÔÚ›ÙÛÈ· Î·È Á˘Ó·›Î˜ 15-26 ÂÙÒÓ, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı›. ™ÙËÓ ∂ÏÏ¿‰· ΢ÎÏÔÊÔÚÔ‡Ó ¤Ó· ‰È‰‡Ó·ÌÔ (3 ‰fiÛÂȘ, 0-1-6 Ì‹Ó˜) Î·È ¤Ó· ÙÂÙÚ·‰‡Ó·ÌÔ (3 ‰fiÛÂȘ, 0-2-6 Ì‹Ó˜). ∂Ì‚fiÏÈÔ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜: ÚÔÛı‹ÎË ‰Â‡ÙÂÚ˘ ‰fiÛ˘. ∏ 1Ë ‰fiÛË ¯ÔÚËÁÂ›Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 12-18 ÌËÓÒÓ (ηٿ ÚÔÙ›ÌËÛË ÌÂÙ¿ ÙÔ 15Ô Ì‹Ó·), ·ÏÏ¿ Î·È Û οı ¿ÏÏË ËÏÈΛ·, ÂÊfiÛÔÓ ÙÔ ¿ÙÔÌÔ ‰ÂÓ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ. ∏ 2Ë ‰fiÛË Û˘ÓÈÛÙ¿Ù·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 4-6 ÂÙÒÓ, ·ÏÏ¿ Î·È Û οı ¿ÏÏË ËÏÈΛ·, ·ÚΛ Ó· ·¤¯ÂÈ 2 Ì‹Ó˜ ·fi ÙËÓ 1Ë ‰fiÛË. ∂Ì‚fiÏÈÔ Ù˘ Ë·Ù›Ùȉ·˜ ∞. ™˘ÓÈÛÙ¿Ù·È ÁÈ· fiÏ· Ù· ·È‰È¿ ¿Óˆ ÙÔ˘ 1 ¤ÙÔ˘˜. ÃÔÚËÁÂ›Ù·È ÛÂ

AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘

ÔÔÈ·‰‹ÔÙ ËÏÈΛ· ¿Óˆ ÙÔ˘ 1 ¤ÙÔ˘˜ Û 2 ‰fiÛÂȘ Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 6 ÌËÓÒÓ. ∂Ì‚fiÏÈÔ ‰ÈÊıÂÚ›Ùȉ·˜-ÙÂÙ¿ÓÔ˘-ÎÔηÙË ÁÈ· ÂÊ‹‚Ô˘˜. ∂ÈÛ·ÁˆÁ‹ ÙÔ˘ ∆daP ÁÈ· Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ ¿Óˆ ÙˆÓ 11 ÂÙÒÓ. ∆Ô TdaP ÂÚȤ¯ÂÈ ÌÈÎÚfiÙÂÚË ‰fiÛË ÙÔÍÔÂȉԇ˜ Ù˘ ‰ÈÊıÂÚ›Ùȉ·˜ ·fi ÙÔ DTaP. ∆· ÂÌ‚fiÏÈ· TdaP Ô˘ ‰È·Ù›ıÂÓÙ·È ÛÙËÓ ∂ÏÏ¿‰· ÂÚȤ¯Ô˘Ó Î·È IPV Î·È ¯ÔÚËÁÂ›Ù·È ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÂÙÒÓ. ™˘ÓÈÛÙ¿Ù·È 1 Â·Ó·ÏËÙÈ΋ ‰fiÛË TdaP ÛÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ ‹ Î·È ·ÚÁfiÙÂÚ· (¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 64 ÂÙÒÓ), ηٿ ÚÔÙ›ÌËÛË fiÙ·Ó ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ˘¿Ú¯ÂÈ ÓÂÔÁ¤ÓÓËÙÔ. ™˘ÓÈÛÙ¿Ù·È ÌÂÛԉȿÛÙËÌ· 5 ÂÙÒÓ ·fi ÙÔ DTaP ‹ ÙÔ Td ÁÈ· ÏÈÁfiÙÂÚ˜ ÙÔÈΤ˜ ·ÓÙȉڿÛÂȘ, ÌÔÚ› fï˜ Ó· ¯ÔÚËÁËı› Î·È Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 2 ÂÙÒÓ. ∂¿Ó ‰ÂÓ ‰È·Ù›ıÂÙ·È ÙÔ TdaP ÌfiÓÔ ÙÔ˘ (¯ˆÚ›˜ IPV) ¯ÔÚËÁÂ›Ù·È ÙÔ Td ÂÓËϛΈÓ. √È ˘fiÏÔÈ˜ ‰fiÛÂȘ Á›ÓÔÓÙ·È Ì Ì Td ÂÓËÏ›ÎˆÓ ·Ó¿ 10ÂÙ›·. ∂Ì‚fiÏÈÔ Ù˘ Ë·Ù›Ùȉ·˜ µ. ªËÙ¤Ú· HBsAg(+), ‰ËÏ·‰‹ ÊÔÚ¤·˜ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ ‹ ÌËÙ¤Ú· Ì ¿ÁÓˆÛÙË Î·Ù¿ÛÙ·ÛË HBsAg: Ô ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 4 ‰fiÛÂȘ: Ë 1Ë Á›ÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË (ˆ˜ ÌÔÓÔ‰‡Ó·ÌÔ ÂÌ‚fiÏÈÔ, ÔÏ˘‰‡Ó·Ì· ‰ÂÓ ¯ÔÚËÁÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ 6Ë Â‚‰ÔÌ¿‰· ˙ˆ‹˜) Ë 2Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó·, Ë 3Ë ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2Ô˘ Ì‹Ó· Î·È Ë 4Ë ÛÙÔ˘˜ 6-18 Ì‹Ó˜ ˙ˆ‹˜ (ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· ÌÂٷ͇ 1˘-2˘ Î·È 2˘-3˘ ‰fiÛ˘: 4 ‚‰ÔÌ¿‰Â˜ Î·È ÌÂٷ͇ 3˘4˘ ‰fiÛ˘: 8 ‚‰ÔÌ¿‰Â˜). ™Â fiÏ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ HBsAg(+) ¯ÔÚËÁ›ٷÈ, ·Ú¿ÏÏËÏ· Ì ÙËÓ 1Ë ‰fiÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, ˘ÂÚ¿ÓÔÛË ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ë·Ù›Ùȉ·˜ µ (0,5 ml, ÛÙȘ 12 ÚÒÙ˜ ¶·È‰È·ÙÚÈ΋ 2008;71:171-172

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PAEDIATRIC NEWS IN BRIEF ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û ‰È·ÊÔÚÂÙÈÎfi ÛËÌÂ›Ô ·fi ÙÔ ÂÌ‚fiÏÈÔ). ∆· ·È‰È¿ ·˘Ù¿ Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· HBsAg Î·È ·ÓÙÈ-HBs ÛÙËÓ ËÏÈΛ· ÙˆÓ 9-15 ÌËÓÒÓ. ∞Ó Î·Ù¿ ÙÔÓ ÙÔÎÂÙfi Ë ÌËÙ¤Ú· Â›Ó·È ¿ÁÓˆÛÙÔ ·Ó Â›Ó·È ‹ fi¯È ÊÔÚ¤·˜ HBsAg Î·È ·ÎÔÏÔ‡ıˆ˜ ·Ô‰Âȯı› fiÙÈ ‰ÂÓ Â›Ó·È, ÙfiÙ ÙÔ ÓÂÔÁÓfi ·ÎÔÏÔ˘ı› ÙÔ Û¯‹Ì· ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÁÈ· Ù· ÓÂÔÁÓ¿ ÌËÙ¤ÚˆÓ HBsAg(-), ‰ËÏ·‰‹ ·ÁÓÔÂ›Ù·È Ë 1Ë ‰fiÛË. ªËÙ¤Ú· HBsAg(-): o ‚·ÛÈÎfi˜ ÂÌ‚ÔÏÈ·ÛÌfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ 3 ‰fiÛÂȘ (ÌÂÛԉȿÛÙËÌ· 6-8

Paediatriki 2008;71:171-172

‚‰ÔÌ¿‰ˆÓ ÌÂٷ͇ 1˘ Î·È 2˘ ‰fiÛ˘ Î·È Ë 3Ë ÛÙÔ˘˜ 6-18 Ì‹Ó˜, Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 8 ‚‰ÔÌ¿‰ˆÓ ·fi ÙË 2Ë ‰fiÛË). ∂Ì‚fiÏÈÔ ÁÈ· ÙË ÁÚ›Ë. ∂Í·ÎÔÏÔ˘ı› Ó· Û˘ÓÈÛÙ¿Ù·È ÌfiÓÔ Û ÔÌ¿‰Â˜ ÏËı˘ÛÌÔ‡ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, Û 1 ‰fiÛË ÂÙËÛ›ˆ˜. ™Â ·È‰È¿ οو ÙˆÓ 8 ÂÙÒÓ Ô˘ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿ Á›ÓÔÓÙ·È 2 ‰fiÛÂȘ ÂÌ‚ÔÏ›Ô˘ (<3 ÂÙÒÓ: 0,25 ml, ≥3 ÂÙÒÓ: 0,5 ml) Ì ÂÏ¿¯ÈÛÙÔ ÌÂÛԉȿÛÙËÌ· 4 ‚‰ÔÌ¿‰ˆÓ.

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™‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ ‰È·‰›ÎÙ˘Ô ∫. ™ÙÂÊ·Ó›‰Ë˜ ™ÙȘ ̤Ú˜ Ì·˜, ¤Ó·˜ ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ‰ËÌÔÛȇÛÂˆÓ Ì·˜ ηٷÎχ˙ÂÈ. ∫¿ÔȘ ·fi ·˘Ù¤˜ ÌÔÚ› Ó· ¤¯Ô˘Ó ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ì·˜ Ú¿ÍË. ªÂÚÈΤ˜ ÌÔÚ› Ó· Ì·˜ ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì Û¿ÓÈ· ÚÔ‚Ï‹Ì·Ù·. ŸÌˆ˜ Ë ÚfiÛ‚·ÛË Û ·˘Ù¤˜ ÙȘ Ӥ˜ ÏËÚÔÊÔڛ˜ ÌÔÚ› Ó· Â›Ó·È ‰˘Û¯ÂÚ‹˜ Î·È Ô ¯ÚfiÓÔ˜ Ì·˜ ÁÈ· ÏÂÙÔÌÂÚ‹ ÂÓË̤ڈÛË ÂÚÈÔÚÈṲ̂ÓÔ˜. ŒÙÛÈ, ÚfiÛÊ·Ù· ¤ÁÈÓ ȉȷ›ÙÂÚ· ‰ËÌÔÊÈÏ‹˜ Ë Û˘ÓÔÙÈ΋ ·ÚÔ˘Û›·ÛË ÙˆÓ ‚·ÛÈÎÒÓ ÛÙÔȯ›ˆÓ ÚfiÛÊ·ÙˆÓ ‰ËÌÔÛȇۈÓ. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÛÙ‹ÏË ÙˆÓ “™‡ÓÙÔÌˆÓ ¶·È‰È·ÙÚÈÎÒÓ ¡¤ˆÓ” ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ·Ú·Ì¤ÓÂÈ Ë ÚÒÙË ÚÔÙ›ÌËÛË ÙˆÓ ·Ó·ÁÓˆÛÙÒÓ. ∞ÚÎÂÙ¤˜ ÈÛÙÔÛÂÏ›‰Â˜ ÛÙÔ ‰È·‰›ÎÙ˘Ô ÂÚȤ¯Ô˘Ó ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ·fi ÚfiÛÊ·Ù· ¿ÚıÚ·. ª¿ÏÈÛÙ· ÔÏϤ˜ ÊÔÚ¤˜ ÛÙ¤ÏÓÔÓÙ·È Î·È Ì ËÏÂÎÙÚÔÓÈο ÌËӇ̷ٷ Ù· Û‡ÓÙÔÌ· ·È‰È·ÙÚÈο Ó¤· ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜, Û˘Ó‹ıˆ˜ ¯ˆÚ›˜ ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË. ŒÁÈÓ ÂÈÏÔÁ‹ ÙÂÛÛ¿ÚˆÓ ÈÛÙÔÛÂÏ›‰ˆÓ, ÔÈ Ôԛ˜ ¤¯Ô˘Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ÂÈÛΤ„ÂˆÓ Î·È ÂÚȤ¯Ô˘Ó ÏËÚÔÊÔڛ˜ Ô˘ ÂÏ›˙ˆ fiÙÈ ı· Û·˜ ÂӉȷʤÚÔ˘Ó.

AÏÏËÏÔÁÚ·Ê›·: ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜ stefanid@hol.gr ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ∞ıËÓÒÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

∏ ÈÛÙÔÛÂÏ›‰· “Pediatric News” - http://www.pediatricnews.com/issues ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ÌËÓÈ·›Â˜ ‰ËÌÔÛȇÛÂȘ ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÙ¿ ÂÙÒÓ. ªÈ· ÏËıÒÚ· ·fi ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ·Ú¤¯ÔÓÙ·È ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜. ∂›Û˘, ˘¿Ú¯Ô˘Ó ȉȷ›ÙÂÚ· ¯Ú‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·, ÂÌ‚ÔÏÈ·ÛÌÔ‡˜, ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÂÊ‹‚Ô˘ Ì ·¯˘Û·ÚΛ· Î·È ÁÈ· ¿ÏÏ· Û˘Ó‹ıË ÚÔ‚Ï‹Ì·Ù·. π‰È·›ÙÂÚË ·Ó·ÊÔÚ¿ Á›ÓÂÙ·È ÛÙÔ ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ, Ô˘ ÚÈÓ ·fi 10 ¯ÚfiÓÈ· ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·È‰›·ÙÚÔÈ ‰ÂÓ ›ÛÙ¢·Ó fiÙÈ Â›Ó·È Úfi‚ÏËÌ· ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ·. ™‹ÌÂÚ· ·Ó·Ê¤ÚÂÙ·È fiÙÈ ‰È·ÈÛÙÒÓÂÙ·È ÛÙÔ 2-9% ÙˆÓ ÂÊ‹‚ˆÓ, ·Ó¿ÏÔÁ· Ì ÙÔÓ ÔÚÈÛÌfi Ô˘ ¯ÚËÛÈÌÔÔÈ›ٷÈ. ∆Ô 8% ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ÙÔ 44% ÙˆÓ ·¯‡Û·ÚÎˆÓ ÂÊ‹‚ˆÓ ·ÚÔ˘ÛÈ¿ÛÂÈ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi. ∆· ÛÙÔȯ›· ·˘Ù¿ Â›Ó·È ·ÓËÛ˘¯ËÙÈο, ÂÂȉ‹ Ë ·¯˘Û·ÚΛ· ÛÙȘ ̤Ú˜ Ì·˜ ¤¯ÂÈ ¿ÚÂÈ ÂȉËÌÈ΋ ‰È¿ÛÙ·ÛË. ∂›Û˘, ÙÔÓ›˙ÂÙ·È Ë ÛËÌ·Û›· Ù˘ ̤ÙÚËÛ˘ Ù˘ ÂÚÈ̤ÙÚÔ˘ Ù˘ ÎÔÈÏÈ¿˜. ™Â ÚfiÛÊ·ÙË ÈÙ·ÏÈ΋ ÌÂϤÙË (Maffeis C. Î·È Û˘Ó., J Pediatr 2008;152:207-213) ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ·¯‡Û·Úη ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Â›¯·Ó 13 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ¤¯Ô˘Ó ‰‡Ô ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ. ∆· ˘¤Ú‚·Ú· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÂÁ·Ï‡ÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË Â›¯·Ó 7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ. ∆¤ÏÔ˜, Ù· ˘¤Ú‚·Ú· ·È‰È¿ Ì ÂÚ›ÌÂÙÚÔ ÎÔÈÏ›·˜ ÌÈÎÚfiÙÂÚË ·fi ÙËÓ 90Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ.

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¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√ ∏ ÈÛÙÔÛÂÏ›‰· “Medscape Pediatrics” - http://www.medscape.com/pediatrics ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û¯ÔÏÈ·Ṳ̂Ó˜ ÂÚÈÏ‹„ÂȘ ÚfiÛÊ·ÙˆÓ ‰ËÌÔÛȇۈÓ, ·fi„ÂȘ ÂȉÈÎÒÓ, ÂÓËÌÂÚˆÙÈο ¿ÚıÚ· Ì ÂÚˆÙ‹ÛÂȘ ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛ‹ Û·˜. ∞ÚÎÂÙ¿ ÂӉȷʤÚÔÓ Â›Ó·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁ›· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÈÓÔÌ˘·ÏÁ›·˜ ÛÙ· ·È‰È¿. ∂ÓÒ ·Ï·ÈfiÙÂÚ· ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ·fi Ì˘ÔÛÎÂÏÂÙÈÎÔ‡˜ fiÓÔ˘˜, ·Ó¿ÏÔÁÔ˘˜ ¿ÏÏˆÓ ÚÂ˘Ì·ÙÈÎÒÓ ·ı‹ÛˆÓ, Û‹ÌÂÚ· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ÈÓÔÌ˘·ÏÁ›· ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚÔ Ô˘‰fi fiÓÔ˘ Û ۯ¤ÛË Ì ٷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·. ∞˘Ùfi ÔÊ›ÏÂÙ·È Û ·ıÔÏÔÁÈ΋ ÂÂÍÂÚÁ·Û›· ÙÔ˘ fiÓÔ˘ ÛÙÔÓ ÂÁΤʷÏÔ Î·È ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi (Clauw DJ, J Clin Rheumatol 2007;13:102-109). ŒÙÛÈ ÂÍËÁÂ›Ù·È Î·È Ë ıÂÚ·¢ÙÈ΋ ·ÔÙ˘¯›· ÙˆÓ ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ. ª¿ÏÈÛÙ· ÚfiÛÊ·Ù· ·Ó·Ê¤ÚÔÓÙ·È ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· Ì ÙË ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ Â·Ó·ÚfiÛÏ˄˘ (dual receptor reuptake inhibitors) (Rooks DS, Curr Opin Rheumat 2007;19:111-117). ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ·È‰È¿ Ì ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÙÚÔ¤˜ ÌÂÙ¿ ·fi ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ì ·È‰È¿ Ì ıÂÚ·›· Û˘ÓÙ‹ÚËÛ˘ Ì Ú‰ÓÈ˙ÔÏfiÓË Û ‰fiÛË ÌÈÎÚfiÙÂÚË ·fi 0.6 mg/kg/48ˆÚÔ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ô˘ Ì ٷ ÚÒÙ· Û˘ÌÙÒÌ·Ù· Ù˘ ›ˆÛ˘ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠηıËÌÂÚÈÓ¿ 5 mg Ú‰ÓÈ˙ÔÏfiÓ˘ ÁÈ· 7 ̤Ú˜ ·ÚÔ˘Û›·Û·Ó Û·ÓÈfiÙÂÚ· (18% Û ۯ¤ÛË Ì 48%) ˘ÔÙÚÔ¤˜ Û ۯ¤ÛË Ì ٷ ·È‰È¿ Ô˘ ‹Ú·Ó ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ (Abeyagunawardena AS, Trompeter RS, Arch Dis Child 2008;93:226-228).

∏ ÈÛÙÔÛÂÏ›‰· “Pediatrics Jwatch” - http://pediatrics.jwatch.org/ ∏ ÂΉÔÙÈ΋ ÔÌ¿‰· ÙˆÓ ‰¤Î· ÁÓˆÛÙÒÓ ∞ÌÂÚÈηÓÒÓ Î·ıËÁËÙÒÓ ·È‰È·ÙÚÈ΋˜ ÂÈϤÁÂÈ Î·È Û¯ÔÏÈ¿˙ÂÈ ÂӉȷʤÚÔÓÙ· ¿ÚıÚ·, Ô˘ ÛÙ¤ÏÓÔÓÙ·È Î·ıËÌÂÚÈÓ¿ Ì ËÏÂÎÙÚÔÓÈο ÌËӇ̷ٷ ÛÙÔ˘˜ Û˘Ó‰ÚÔÌËÙ¤˜. H ÂÈÏÔÁ‹ ÙˆÓ ¿ÚıÚˆÓ Â›Ó·È ÂÍ·ÈÚÂÙÈ΋ Î·È Ù· ı¤Ì·Ù· ÂӉȷʤÚÔÓÙ·. ™Â ÂÓÙ·ÂÙ‹ Û˘Á¯ÚÔÓÈ΋ ÌÂϤÙË 2.216 ÂÊ‹‚ˆÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ¤ÊË‚ÔÈ Ô˘ ¤ÙÚˆÁ·Ó ηıËÌÂÚÈÓ¿ ÚˆÈÓfi ›¯·Ó ¯·ÌËÏfiÙÂÚÔ˘˜ ‰Â›ÎÙ˜ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ Û ۯ¤ÛË Ì ÂΛÓÔ˘˜ Ô˘ ÛÔÚ·‰Èο ›¯·Ó ÚfiÁÂ˘Ì· (Timlin MT Î·È Û˘Ó., Pediatrics 2008;121: e638). ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ·Ú¿ÏË„Ë ÙÔ˘ ÚˆÈÓÔ‡ Û˘Û¯ÂÙ›˙ÂÙ·È Paediatriki 2008;71:173-175

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Ì ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ÂÊ‹‚ˆÓ, οÙÈ Ô˘ ·fi ·ÏÈ¿ ‹Ù·Ó ÁÓˆÛÙfi, fï˜ ÔÙ¤ ‰ÂÓ Â›¯Â ÂÈÛÙËÌÔÓÈο ÙÂÎÌËÚȈı›. ∂ӉȷʤÚÔÓ Â›¯Â Î·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙË ÛËÌ·Û›· Ù˘ ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ‹Í˘ Û ÂÊ‹‚Ô˘˜ Ì ·ıÔÏÔÁÈ΋ ÌËÓÔÚÚ·Á›· (Kulp JL Î·È Û˘Ó., J Pediatr Adolesc Gynecol 2008;21:27), fiˆ˜ Î·È ÙÔ ¿ÚıÚÔ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‚ÚÂÊÒÓ Ì Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ¯ˆÚ›˜ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ê¿Ú̷η Ô˘ ÂÏ·ÙÙÒÓÔ˘Ó ÙË Á·ÛÙÚÈ΋ Ô͇ÙËÙ· (Hassall E, J Pediatr 2008;152:301).

∏ ÈÛÙÔÛÂÏ›‰· “Pediatric Linx” - http://www.mdlinx.com/pediatriclinx/ ™ÙËÓ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ì›· ηıËÌÂÚÈÓ‹ ÂÓÙ¿ÏÂÙË Â›Û΄‹ Ù˘ ·ÚΛ ÁÈ· ÙËÓ ÂÓË̤ڈۋ Û·˜. ™Â ·˘Ù¿ Ù· ¤ÓÙ ÏÂÙ¿ ÂÓÙÔ›ÛÙËÎ·Ó ÂӉȷʤÚÔÓÙ· ÛÙÔȯ›· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·È‰ÈÔ‡ Ì ÙÚ·¯ËÏÈ΋ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· ÙËÓ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ·ÓÙÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ¤ÊË‚ÔÈ ÙËÓ ·¯˘Û·ÚΛ·, ÁÈ· ÙËÓ Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÁÈ· ÙËÓ Â›‰Ú·ÛË Ù˘ ÌÔ˘ÛÈ΋˜ ÛÙÔ ¿Á¯Ô˜ ÙˆÓ ·È‰ÈÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÂÂÌ‚¿ÛÂȘ. √È ÏËÚÔÊÔڛ˜ ·˘Ù¤˜ ‹Ù·Ó ·ÚÎÂÙ¿ Û˘ÓÔÙÈΤ˜ Î·È ‹Ù·Ó ··Ú·›ÙËÙË Ë ·Ó¿ÁÓˆÛË ÙˆÓ ¿ÚıÚˆÓ. ŒÙÛÈ Ù· ¤ÓÙ ÏÂÙ¿ ¤ÊÙ·Ó·Ó ÌfiÓÔ ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÂӉȷÊÂÚfiÓÙˆÓ ıÂÌ¿ÙˆÓ Î·È ¯ÚÂÈ¿ÛÙËΠÂÚÈÛÛfiÙÂÚË ÒÚ· ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘˜.

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∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ √ ‰È·ÁÓˆÛÙÈÎfi˜ ¯ÂÈÚÈÛÌfi˜ ÂÚÈÏ¿Ì‚·Ó ÙËÓ ·Ê‡ÓÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÓfi˜ ÂÂÈÛÔ‰›Ô˘ Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ‰È·ÎÔ‹ ÙÔ˘. ∞˘Ùfi Â›Ó·È ÙÔ Î‡ÚÈÔ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· ÙȘ ηÏÔ‹ıÂȘ Ì˘ÔÎÏÔӛ˜ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (∫ªÀ¡), ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ô˘ ·ÔÙÂÏ› ÙË ‰È¿ÁÓˆÛË ÛÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË. √È ∫ªÀ¡ ÂÚÈÁÚ¿ÊËÎ·Ó ·fi ÙÔ˘˜ Coulter Î·È Allen ÙÔ 1982 (1). ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi Ì˘ÔÎÏÔÓÈο ÙÈÓ¿ÁÌ·Ù· (jerks) Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ·fi ÙȘ ÚÒÙ˜ ̤Ú˜ Ù˘ ˙ˆ‹˜ (1Ë ˆ˜ Î·È 16Ë Ì¤Ú·) (2), Û˘Ì‚·›ÓÔ˘Ó ÌfiÓÔ Î·Ù¿ ÙÔÓ ‡ÓÔ Î·È ÛÙ·Ì·ÙÔ‡Ó Ì ÙËÓ ·Ê‡ÓÈÛË. √È Ì˘ÔÎÏÔӛ˜ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢Ú˜ Î·È ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ Ù· ¿Óˆ, ·ÏÏ¿ Î·È Ù· οو ¿ÎÚ·. ¢È·ÚÎÔ‡Ó Ï›Á· ‰Â˘ÙÂÚfiÏÂÙ· ˆ˜ Î·È 20 ÏÂÙ¿ Î·È ÌÔÚ› Ó· Â·Ó·Ï·Ì‚¿ÓÔÓÙ·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÙÔ 24ˆÚÔ. ∂ÌÊ·Ó‹˜ ÂÎÏ˘ÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ, ¤Ú·Ó ÙÔ˘ ‡ÓÔ˘, ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜, ˆÛÙfiÛÔ, Û ϛÁ˜ ÂÚÈÙÒÛÂȘ ¤¯ÂÈ ·Ó·ÊÂÚı› Ë ÚfiÎÏËÛË ÂÂÈÛÔ‰›ˆÓ Ì ÙÔ ıfiÚ˘‚Ô ‹ Ì ÙÔ Ê¿ÛÎȈ̷ ‹ Ì ÙÔ ÎÔ‡ÓËÌ· ÙÔ˘ ÓÂÔÁÓÔ‡. ∆· ÂÂÈÛfi‰È· ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ÛÔÚ·‰ÈÎfi ¯·Ú·ÎÙ‹Ú·, ˘¿Ú¯Ô˘Ó fï˜ ‰ËÌÔÛȇÛÂȘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘˜ ÂÓfi˜ ÂÚÈÛÙ·ÙÈÎÒÓ ÛÙËÓ ›‰È· ÔÈÎÔÁ¤ÓÂÈ· (3). ∏ Ó¢ÚÔÊ˘ÛÈÔÏÔÁÈ΋ ‚¿ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Â›Ó·È ·Û·Ê‹˜. ∞˘Ùfi Ô˘ ¤¯ÂÈ Á›ÓÂÈ ÁÓˆÛÙfi, Ì ÙË ‚Ô‹ıÂÈ· ÔÏ˘ÁÚ·Ê‹Ì·ÙÔ˜ ‡ÓÔ˘, Â›Ó·È fiÙÈ Ù· ÂÂÈÛfi‰È· Û˘Ì‚·›ÓÔ˘Ó ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‹ÚÂÌÔ˘ ‡ÓÔ˘ (quiet sleep) ÙˆÓ ÓÂÔÁÓÒÓ (4), Ô˘ ·ÔÙÂÏ› ÙÔ ÈÛÔ‰‡Ó·ÌÔ ÙÔ˘ NREM (Non Rapid Eye Movement) ‡ÓÔ˘ ÙˆÓ ÂÓËϛΈÓ. ∞fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ù· ÂÂÈÛfi‰È· ·Ú·Ì¤ÓÔ˘Ó ˆ˜ ÙÔ˘˜ 3 Ì‹Ó˜ ˙ˆ‹˜ Î·È ˘Ô¯ˆÚÔ‡Ó ÛÙË Û˘Ó¤¯ÂÈ·. √ ¯ÚfiÓÔ˜ ·˘Ùfi˜ Û˘Ì›ÙÂÈ Ì ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÛÙ·‰›ˆÓ ÙÔ˘ ‡ÓÔ˘ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Î·È ÙË ÛÙ·‰È·Î‹ ÂÌÊ¿ÓÈÛË ÙˆÓ Ê¿ÛÂˆÓ ‡ÓÔ˘ REM (Rapid Eye Movement) Î·È NREM, Û ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ Ê¿ÛÂˆÓ ÙÔ˘ ÂÓÂÚÁÔ‡ (active) Î·È ‹ÚÂÌÔ˘ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ (5). ∆Ô Â‡ÚËÌ· ·˘Ùfi

Paediatriki 2008;71:165,176

·Ô‰›‰ÂÙ·È Û ÚÔÛˆÚÈÓ‹ ·ÓˆÚÈÌfiÙËÙ· Ù˘ ÔÚÁ¿ÓˆÛ˘ ÙÔ˘ ‡ÓÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó ‰ËÌÔÛȇÛÂȘ Ô˘ ·Ó·Ê¤ÚÔ˘Ó Û ÔÚÈṲ̂ӷ ‚Ú¤ÊË ÂÈÌÔÓ‹ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ̤¯ÚÈ Î·È ÙËÓ ËÏÈΛ· ÙˆÓ 10 ÌËÓÒÓ, ¯ˆÚ›˜ fï˜ ÂÈÙÒÛÂȘ ÛÙË „˘¯ÔÎÈÓËÙÈ΋ ÙÔ˘˜ ÂͤÏÈÍË. √È ∫ªÀ¡ Û˘Á¯¤ÔÓÙ·È Û˘¯Ó¿ Ì Û·ÛÌÔ‡˜, ·ÎfiÌ· Î·È Ì status epilepticus, ÌÔÏÔÓfiÙÈ ‰ÂÓ ÚfiÎÂÈÙ·È ÁÈ· ÂÈÏËÙÈÎfi Ê·ÈÓfiÌÂÓÔ (6). ∏ ·Ó·ÁÓÒÚÈÛ‹ ÙÔ˘˜ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ·Ó·›ÙÈ·˜ ·ÓËÛ˘¯›·˜ ÙˆÓ ÁÔÓ¤ˆÓ, Ù˘ ·‰ÈηÈÔÏfiÁËÙ˘ Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÂÍÂÙ¿ÛˆÓ, ·ÏÏ¿ ΢ڛˆ˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·Ú̿ΈÓ, Ù· ÔÔ›· ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ˘ÚÔ‰fiÙËÛË Ó¤ˆÓ ÂÂÈÛÔ‰›ˆÓ (6). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó Ì ‚‚·ÈfiÙËÙ· ∫ªÀ¡ ÔÈ Ì˘ÔÎÏÔӛ˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ÚÒÈÌË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ Î·Ù¿ ÙÔÓ ‡ÓÔ, ˘Ô¯ˆÚÔ‡Ó Ì ÙËÓ ·Ê‡ÓÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ‰ÂÓ Û˘Óԉ‡ÔÓÙ·È ·fi ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÂÈÏËÙÈÎÒÓ ÂÎÊÔÚÙ›ÛˆÓ. ∂ÊfiÛÔÓ ÏËÚÔ‡ÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ‰ÂÓ Ú¤ÂÈ Ó· ‰Ôı› Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÛÙÔ ÓÂÔÁÓfi Ô‡Ù ¯ÚÂÈ¿˙ÂÙ·È Ó· ˘Ô‚ÏËı› Û ÂÚ·ÈÙ¤Úˆ ‰È·ÁÓˆÛÙÈÎfi ¤ÏÂÁ¯Ô.

µÈ‚ÏÈÔÁÚ·Ê›· 1. Coulter DL, Allen RJ. Benign neonatal sleep myoclonus. Arch Neurol 1982;39:191-192.

2. ParÔ-Panjan D, Neubauer D. Benign neonatal sleep myoclonus: experience from the study of 38 infants.

Eur J Paediatr Neurol 2008;12:14-18.

3. Cohen R, Shuper A, Straussberg R. Familial benign neonatal sleep myoclonus. Pediatr Neurol 2007;36: 334-337.

4. Di Capua M, Fusco L, Ricci S, Vigevano F. Benign neonatal sleep myoclonus: clinical features and videopolygraphic recordings. Mov Disord 1993;8:191-194.

5. °ÈˆÛ·Ê¿Ù ª, ™ËÊÈ·ÓÔ‡ ¶. º˘ÛÈÔÏÔÁ›· Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‡ÓÔ˘ ÛÙ· ·È‰È¿. π·ÙÚÈ΋ 1984;46:4-15.

6. Egger J, Grossmann G, Auchterlonie IA. Benign sleep myoclonus in infancy mistaken for epilepsy. BMJ 2003;326:975-976.

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4-6 ∞ÚÈÏ›Ô˘ 2008

2Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ¡ÂÔÁÓÔÏÔÁ›·˜ ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· Î·È ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶ÂÚÈÁÂÓÓËÙÈ΋˜ π·ÙÚÈ΋˜ ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress ∆ËÏ.: 0030-210-7499300 Fax: 0030-210-7705752 E-mail: info@neonatology2008.gr Website: http://www.neonatology2008.gr

∞›ÁÏË ∑·›Ԣ, ∞ı‹Ó·

5 ∞ÚÈÏ›Ô˘ 2008

ªÂÙÂÎ·È‰Â˘ÙÈ΋ ∏ÌÂÚ›‰· ¶·È‰È·ÙÚÈο ∂›ÁÔÓÙ· & µ·ÛÈ΋ ˘ÔÛÙ‹ÚÈÍË ∑ˆ‹˜ ¢ÈÔÚÁ¿ÓˆÛË: π·ÙÚÈÎfi˜ ™‡ÏÏÔÁÔ˜ ∞ıËÓÒÓ Î·È ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ¶ÏËÚÔÊÔڛ˜: ∞Ó·ÛÙ¿ÛÈÔ˜ ¢. ÷Ù˙‹˜ ∆ËÏ.: 0030-210-7488686 Website: www.isathens.gr

∞›ıÔ˘Û· ∂ΉËÏÒÛÂˆÓ π·ÙÚÈÎÔ‡ ™˘ÏÏfiÁÔ˘ ∞ıËÓÒÓ, ∞ı‹Ó·

19 ∞ÚÈÏ›Ô˘ 2008

6Ë ∂ÈÛÙËÌÔÓÈ΋ ∏ÌÂÚ›‰· ∂˘ÚˆÎÏÈÓÈ΋˜ ¶·›‰ˆÓ “™‡Á¯ÚÔÓ· ¶·È‰È·ÙÚÈο £¤Ì·Ù·” ¶ÏËÚÔÊÔڛ˜: Firstevent TËÏ.: 0030-210-8228950 Fax: 0030-210-8228901 E-mail: info@firstevent.gr

•ÂÓÔ‰Ô¯Â›Ô “Royal Olympic”, ∞ı‹Ó·

30 ∞ÚÈÏ›Ô˘1 ª·˝Ô˘ 2008

TRANSMED 16 - European Mediterranean Congress about Mother & Child Health Contact: Kamel Bargaoui Tel.: 33-607-686-118 Fax: 33-143-839-985 E-mail: Kamel@medicom-international.com

Syracusa, Italy

3-6 ª·˝Ô˘ 2008

Pediatric Academic Societies' 2008 Annual Meeting Contact: Meeting Organiser Tel.: 281-419-0052 Fax: 281-419-0082 E-mail: info@pas-meeting.org

Honolulu, HI, United States

5-11 ª·˝Ô˘ 2008

XXIth European Society of Pediatric Neurosurgery (ESPN) Meeting Contact: Meeting Organiser E-mail: info@espn2008.org

Montreux, Switzerland

9-11 ª·˝Ô˘ 2008

13Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘ÌfiÛÈÔ √ÚıÔ·È‰È΋˜ ¶·›‰ˆÓ ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ÃÂÈÚÔ˘ÚÁÈ΋˜ √ÚıÔ·È‰È΋˜ & ∆Ú·˘Ì·ÙÔÏÔÁ›·˜ ∆Ì‹Ì· √ÚıÔ·È‰È΋˜ ¶·›‰ˆÓ ¶ÏËÚÔÊÔڛ˜: ∫∂°ª ∆Ô˘ÚÈÛÙÈΤ˜ & ™˘Ó‰ÚȷΤ˜ ∂ȯÂÈÚ‹ÛÂȘ ∞∂ - Congress World - ª. ¶···Ó·ÁÈÒÙÔ˘ TËÏ.: 0030-210-7210052, 7210001 Fax: 0030-210-7210051 E-mail: info@congress@goldair.gr

•ÂÓÔ‰Ô¯Â›Ô “Olympian Village Aldemar”, ™Î·Êȉȿ

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10 ª·˝Ô˘ 2008

7Ë ∏ÌÂÚ›‰· ∞Ó¿Ó˄˘ «∏ ∞Ó¿ÓË„Ë ÛÙ· ·È‰È¿» ¢ÈÔÚÁ¿ÓˆÛË: ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ ∞ıËÓÒÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡» ∂ÈÎÔÈÓˆÓ›·: ¶·ÙÚ›ÙÛÈ· ªfiÓÔ˘ ∆ËÏ.: 210-7798033 & 2132009443

∞ÌÊÈı¤·ÙÚÔ “∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ¶··‰¿ÙÔ˜”, °. ¡. ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”

15-17 ª·˝Ô˘ 2008

9th Congress of the European Society for •ÂÓÔ‰Ô¯Â›Ô Pediatric Dermatology “Hilton”, ∞ı‹Ó· ¢ÈÔÚÁ¿ÓˆÛË: ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ & ∂˘Úˆ·˚΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ¶ÏËÚÔÊÔڛ˜: Erasmus - ¶ËÓÂÏfiË ªËÙÚÔÁÈ¿ÓÓË Tel.: 0030-210-7257693 Fax: 0030-210-7257532 E-mail: info@espd2008.com

2-4 πÔ˘Ó›Ô˘ 2008

Perinatal Medicine 2008 Contact: Kate Melton Tel.: 02-0-89-798-300 Fax: 02-0-89-796-700 E-mail: kmelton@hamptonmedical.com

Harrogate, England, United Kingdom

13-15 πÔ˘Ó›Ô˘ 2008

46Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: AC&C International ∆ËÏ.: 0030-210-6889130 Fax: 0030-210-6844777 E-mail: pedcongress@acnc.gr Website:www.pediatric-congress.gr

COREXPO ∂ÎıÂÛÈ·Îfi ∫¤ÓÙÚÔ ∫¤Ú΢ڷ˜, ∫¤Ú΢ڷ

19-21 πÔ˘Ó›Ô˘ 2008

NHS 2008 - Beyond Newborn Hearing Screening: Infant and Childhood Hearing in Science and Clinical Practice Contact: Meeting Organiser Tel.: 39-0-498-601-818 Fax: 39-0-498-602-389 E-mail: meet@meetandwork.com

Cernobbio, Italy

11-14 √ÎÙˆ‚Ú›Ô˘ 2008

2008 National Conference & Exhibition of the American Academy of Pediatrics Contact: PediaLink Customer Service Tel.: 866-843-2271 E-mail: csc@aap.org / kidsdocs@aap.org

Boston, MA, United States

23-26 √ÎÙˆ‚Ú›Ô˘ 2008

31st Congress of the Union of Middle-Eastern & Mediterranean Pediatric Societies Contact: Prof. Ahmed Sahloul Essoussi Tel.: +216.73.219494/221411 Fax: +216.73.224899 E-mail: sahloulessoussi@ms.tn

Tunis, Tunisia

24-28 √ÎÙˆ‚Ú›Ô˘ 2008

2nd Congress of the European Academy of Paediatrics - EAP Contact: KENES International Tel: +41 22 908 0488 Fax: +41 22 732 2850 Email: paediatrics@kenes.com Website: www.kenes.com/paediatrics

Nice, France