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

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Τριμηνιαία έκδοση της Ελληνικής Παιδιατρικής Εταιρείας

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<ul><li><p>1 CURRENT ISSUE</p><p> : ;. , . , . </p><p>: 20 . 21 , . - , , . -. 51 . . , ., (reassortment) . , 51 - . - . , - - . , , , . , - 51.</p><p> : , , .</p><p>Avian flu: a new pandemic threat?</p><p>M. Tsolia, I. Logotheti, A. Konstantopoulos </p><p>Abstract: During the course of the 20th century the world experienced three influenza pandemics.Today, at the dawn of the 21st century the emergence of a new pandemic seems inevitable. In recentyears, an increasing number of epidemics caused by high pathogenicity avian influenza viruses haveoccurred, mainly in Asian countries but also in other parts of the world. The current widespreaddissemination of H5N1 avian virus in wild and domestic birds in Asia is unprecedented and has causedglobal concern. What is more troubling is the fact that this virus has been transmitted from birds tohumans causing disease and death. Although human-to-human transmission is known to haveoccurred, the virus cannot be transmitted between humans with great efficiency. However, it mayacquire this capacity either by reassortment with a human strain or through adaptive mutations. In thiscase, the H5N1 strain will cause explosive global spread and a new influenza pandemic will occur. Aneffort should be made by governments and poultry producers to improve biosecurity and conducteducation programmes with a view to restriction of the spread of avian influenza. An operationalpandemic plan should be available in every country and an adequate amount of antiviral medicationstockpiled. Immunization will be the most effective way to reduce the impact of a pandemic andresearchers are currently trying to develop a vaccine against the H5N1 strain. </p><p>Key words: Influenza, avian influenza, pandemic.</p><p> , . . </p><p>A: 5, . , .. 171 23e-mail: giannalogotheti@yahoo.gr</p><p>2nd Paediatric Clinic,University of Athens, P. &amp; A. Kyriakou ChildrensHospital</p><p>Correspondence:Logotheti Ioanna5 Lykeias Str., N. Smyrni, 171 23, Athense-mail:giannalogotheti@yahoo.gr</p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 1</p></li><li><p> , , - , . -, , , . - 20 - , , - o (1-3). 21 , - . H5N1, - (3-6). - , . , . 51 , . - , - - .</p><p> 8 - RNA, - 10 . - - () () ( 1) (1-3) . -</p><p> - - . - - , - . </p><p> ,, C. C . , H N. - 16 9 . - , , , , . , , -, . , - . 144 (16 x 9) - - . - - , (2,3). , </p><p> 1. . T (2).</p><p>O </p><p> 2</p><p>RNA </p><p>2 . .</p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 2</p></li><li><p>3 </p><p> , - . , , - .</p><p> , - . - -. - - (antigenic drift) (1-3). (antigenicshift) () / (), . , - (1-3).</p><p> . - , - . , (reassortant) (3). 8 - . - - 8 , - -, (reassortment), - . , - . - - -, -</p><p> , - .</p><p> ( ) - (6). - -, . - , 5 . - - , , ( 1). </p><p> - - . - - . </p><p> 20 - . , - - . </p><p> 2006;69:1-9</p><p> 1. </p><p>, </p><p>1995, 77</p><p>1997, 51</p><p>1999, 92</p><p>2003, 51</p><p>2003, 77</p><p>2003, H9N2</p><p>2004, 51</p><p>2004, 51</p><p>2004, 73</p><p>2004, 107</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 3</p></li><li><p>4 . .</p><p> , , (2,4). - (1918) 11. - 20 - (5). - 1957, - 22, 1968, 32. 1918 ., - - (reassortment) (7). - 32, , 11 . , , 32, 11 . </p><p> 1957 1968, 1918 - (reassortment) (7). - 11 1918 Taubeneberger , 8 - - (8). - , . </p><p> 1918 (9). , - . 100 -</p><p>. , - - (9). - , . , - , - . , - - . - , (7). </p><p> 51 </p><p> , . - - (10). , - , , . - , - . - - , . - - - 5 , 7, </p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 4</p></li><li><p>5 </p><p> (high patho-genicity avian influenza, HPAI). </p><p> 1997, (HPAI) . . - - 1878 , - - , (6). ... - , . </p><p> 7 - . </p><p> , , . -. </p><p> - 51 (11-13). - . 51 - 1996. 1997 - -. 18 </p><p> 2006;69:1-9</p><p> 2. . (reassortment) 8 . - - . (5).</p><p> (51)</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 5</p></li><li><p>6 . .</p><p> 6 . - 1,6 - . ., 51 , , - - . 2003 , (11,13). - -, . 2003 - , . - , -, , , , , , -, ( -), , - (15). 51 - . - 51 , , (6). </p><p> - - 51 - (5). 51 , - . </p><p> 51 (14). - . , -</p><p> - 3300 5 150 -, 142 - . - 142 - - 74 - 52% (15). -o . - -, (14,16). - (17). , - , . . </p><p> , , 51 - - - . - , - - - - (5). - - . - - - . </p><p> , , - . , - ,</p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 6</p></li><li><p>7 </p><p> . - - , - - - (10,11,13,16).</p><p>, - 51 . - , - . (16). , - , , . 51 . - 51 . - (16). , - , . , - - . </p><p> - - -. - ( -) 2. -, 51 . oseltamivir (Tamiflu) zanamivir(Relenza) -. , -</p><p> . 51 - - - , - - (18). - . </p><p> - , . Tamiflu - Relenza -. , , - Tamiflu. - , -, (19,20). - 12 , . , - , , . , - . , - , , . , - - . </p><p> - - , - . - - - (20). </p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 7</p></li><li><p>8 . .</p><p>, . </p><p> 10 51 ..., (19). - - , - . - - - - . - , . . , - - -. , - (adjuvants) (20,21) - . </p><p> 300 , - (19). . - - , - - (22). , , , - - . </p><p>, - . - -</p><p> , , . . . - , - - - . </p><p>1. Treanor G. Influenza virus. In: Mandell GL, BennettJE, Dolin R (eds). Mandel, Douglas and Bennett'sPrinciples and practice of infectious diseases. 5thedition. Churchill Livingstone, Philadelphia, 2000:1823-1849.</p><p>2. Laver WG, Bischofberger N, Webster RG. Disarm-ing flu viruses. Sci Am 1999;280:78-87.</p><p>3. Osterhaus A. H5N1: the lessons to be learned. In:Zambon MC, ed. United Kingdom: Advances in in-fluenza. Blackwell Science; 1999. p. 11-17.</p><p>4. Laver G, Garman E. Virology. The origin and controlof pandemic influenza. Science 2001;293:1776-1777.</p><p>5. Hien TT, De Jong M, Farrar J. Avian influenza - AChallenge to global health care structures. N Engl JMed 2004;351:2363-2365.</p><p>6. Perez DR, Sorrell EM, Donis RO. Avian influenza:an omnipresent pandemic threat. Pediatr Infect DisJ 2005;24 (11 Suppl):S208-S216. </p><p>7. Belshe RB. The Origins of Pandemic Influenza -lessons from the 1918 Virus. N Eng J Med 353;21:2209-2211.</p><p>8. Taubenberger JK, Reid AH, Lourens RM, Wang R,Jin G, Fanning TG. Characterization of the 1918 in-fluenza virus polymerase genes. Nature 2005;437:889-893.</p><p>9. Tumpey TM. Basler CF, Aguilar PV, Zeng H,Solorzano A, Swayne DE et al. Characterization ofthe reconstructed 1918 Spanish influenza pandemicvirus. Science 2005;310:77-80.</p><p>10. Centers for Disease Control and Prevention Influen-za (flu): information about Avian influenza andAvian influenza A [Internet]. 2005: Webpage:http://www.cdc.gov/flu.</p><p>11. Macfarlane JT, Lim WS. Bird flu and pandemic flu.BMJ 2005;331:975-976.</p><p>12. Monto AS. The threat of an avian influenza pan-demic. N Eng J Med 2005;352:323-325.</p><p>13. Stohr K. Avian influenza and pandemics-Researchneeds and opportunities. N Eng J Med 2005;352:405-407.</p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 8</p></li><li><p>9 </p><p>14. Beigel JH, Farrar J, Han AM, Hayden FG, Hyer R, deJong MD et al; Writing Committee of the WorldHealth Organization (WHO) Consultation on Hu-man Influenza A/H5. Avian influenza A (H5N1) in-fections in humans. N Eng J Med 2005;353:1374-1385.</p><p>15. World Health Organization. Cumulative number ofconfirmed human cases of avian influenza A H5N1.[Internet, Webpage] www.who.int/csr/disease/avian_influenza/country/cases_table_2005_12_30/en/index.html </p><p>16. Webster R, Hulse D Controlling avian flu at thesource. Nature 2005;435:415-416.</p><p>17. Ungchusak K, Auewarakul P, Dowell SF, Kitphati R,Auwanit W, Puthavathana P et al. Probable person-to-person transmission of avian influenza A(H5N1). N Eng J Med 2005;352:333-340.</p><p>18. Le QM, Kiso M, Someya K, Sakai YT, Nguyen TH,Nguyen KH et al. Isolation of drug resistant H5N1virus. Nature 2005;437:1108.</p><p>19. Fleming D. Influenza pandemics and Avian flu. BMJ2005;331:1066-1069.</p><p>20. Check E. Avian flu special: is this our best shot? Na-ture 2005;437:404-406.</p><p>21. Wood JM, Robertson JS. From lethal virus to life-sav-ing vaccine: developing inactivated vaccines for pan-demic influenza. Nat Rev Microbiol 2004;2:842-847. </p><p>22. Hoffmann E, Neumann G, Kawaoka Y, Hobom G,Webster RG. A DNA transfection system for gener-ation of influenza A virus from eight plasmids. ProcNatl Acad Sci USA 2000;97:6108-6113. </p><p>23. Reichert TA. Preparing for the next influenza pan-demic: lessons from multinational data. Pediatr In-fect Dis J 2005;24(11 Suppl):S228-S231. </p><p> 2006;69:1-9</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 9</p></li><li><p>10 REVIEW ARTICLE</p><p>Director of Pediatric Nephrology, Children'sHospital of Pittsburghand the University of Pittsburgh School of Medicine</p><p>Correspondence: Demetrius Ellis, M.D.Children's Hospital of Pittsburgh3705 Fifth AvenuePittsburgh, PA 15213e-mail: ellisd@chp.edu</p><p> 2006;69:10-17</p><p>Evaluation and management of hypertensivecrisis in childhood D. Ellis</p><p>Abstract: Hypertensive crisis is relatively uncommon in the paediatric age group and many emer-gency departments are poorly prepared to manage children with this potentially lethal disorder. Thisreview provides guidelines aimed at facilitating the evaluation and management of children with thisdisorder.</p><p>Key words: Hypertension, paediatrics, hypertensive crisis, hypertensive emergencies. </p><p>Abbreviations</p><p>BP blood pressureHTN hypertension</p><p>Introduction</p><p>Normal blood pressure (BP) levels differ byage, gender and height; accordingly no single BPlevel defines hypertension (HTN) in all children.Updated BP norms and definitions of HTN inchildren are provided in the latest of four com-prehensive reports (1). HTN is generally definedas the average of three manually obtained sys-tolic BP and/or diastolic BP measurements being95th percentile for age, gender and height. </p><p>There are several recent reviews of hyperten-sive crisis in adults (2-8), but the clinical ap-proach to this topic has been rarely addressedfor the paediatric age group (9,10). For purpos-es of this review, hypertensive crisis is a syn-drome classified as either a) hypertensive emer-gency if there are clinical manifestations of on-going organ injury, or, b) hypertensive urgencyif there are no acute clinical symptoms and evi-dence for end-organ damage is minimal or ab-sent. The implication is that the former requiresimmediate reduction in BP, while in the latterBP reduction may take place over hours or days.Although the large majority of children whopresent in the emergency department with hy-pertensive crisis have BP above the 99th per-centile, hypertensive crisis is not strictly definedby absolute BP levels.</p><p>In the absence of known preexisting renaldisorder, which often predisposes to hyperten-sive crisis, the possibility must be considered ofpreviously unrecognized cardiac and endocrino-</p><p>logic aetiologies of HTN, which may strongly in-fluence the therapeutic choice for individuals inthe emergency department. This brief report de-scribes a practical clinical approach to the diag-nosis and immediate management of the childpresenting with hypertensive crisis, which maybe facilitated by means of an algorithm, alongwith a table of potentially useful agents anddosage guidelines suitable for the paediatric agegroup. The goal of therapy is to prevent the cat-astrophic consequences of this potentially lethaldisorder. </p><p>Symptoms and signs</p><p>Unlike adults, in whom hypertensive crisesusually occur in individuals with known and of-ten severe preexisting HTN, in children the dis-covery of HTN is often made at the time of pre-sentation with a hypertensive crisis. Symptomsof HTN in children depend on the acute natureof the development of HTN as well as on themagnitude of the BP elevation. Hence, in a childwith chronic HTN secondary to renal arterystenosis, mild to moderate HTN is usually welltolerated whereas the same BP level may causesevere headache or seizures in a child with acuteglomerulonephritis. Similarly children with car-diac outlet obstruction or cardiomyopathy maybecome symptomatic despite mild HTN. </p><p>The most common symptoms of HTN in themajority of older children who present in theemergency department are those of hyperten-sive encephalopathy, namely headache, nausea,vomiting, mental confusion, blurred vision, ag-itation or frank seizures. Other manifestations</p><p>Pediatr Jan-Feb 06 final allges 27-01-06 15:34 10</p></li><li><p>11Hypertensive crisis in childhood</p><p>may include cerebral infarction, intracerebral orretinal haemorrhage, congestive heart failure,acute pulmonary oedema (with shortness ofbreath), acute renal insufficiency, and microan-giopathic haemolytic anaemia. Less commonsequelae of hypertensive crisis in children in-clude myocardial infarction and aortic dissec-tion. Newborns and infants with severe hyper-tension may present with congestive heart fail-ure, hypertensive retinopathy, respiratory dis-tress, apnoea or cyanosi...</p></li></ul>

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