t t st e e

1
? ????? t?? ???-???t???? st?? ?e??????????
???µ??e?? ????? ???a!!

• ?a?as?e?? 7 ?e?eµß???? 2007 (?????sa ?a?ed???a)
• 13.15 13.45 ????e??
• ???ed?e?? ?. ?a??a?t??
• T?µa ? ????? t?? ???-???t???? st?? ?e??????????
  ???µ??e??
• ?µ???t?? G. ?pa?t?p?????
• 10o ?a?e?????? S???d??? ?e?????????? ???µ??e??
• ????a 7 - 9 ?e?eµß???? 2007
• ?e??d??e?? Divani Caravel

?a????t?? Ge?????? ?. ?pa?t?p???????e????t??
?a?ep?st?µ?a??? ??T Ge????? ??s???µe??? ???
2
?a µ????ß?a ?a? ? ?????p??
???? ???a µ????ß?a e??a? pa?????a
????? µ????ß?a e??a? d???t??? pa?????a
Ta pe??ss?te?a µ????ß?a de? e??a? pa?????a
3
?? ???a?? t?? ?????da?
Gustafsson B 1985.The future of germ-free
research. Alan R. Liss. New York
4
?????ß?a?? f??t?a ???te????? ep?fa?e???

• ?a?? ??te?? 1014
• ???µa 1012
• ???p?? 1010
• St?µa 1010
• ??t? 1010
• F?????a? 1010

5
? a?ae??ß?a f?s???????? ?????da

• T?s?
• d??µa
• pa?? ??te??
• ???p??

• S??s? a?ae??ß??? ae??ß?a
• 11
• 10001
• 101

6
? ???e ?????p?? ??e? t?? d??? t?? µ??ad???
s?????? ßa?t???d???

• ??tta?a a????p???? s?µat?? 1013
• ?a?t???a st? a????p??? s?µa 1014
• ? ?????da t?? e?t???? /??p????? 400 e?d? (30 -
  40 e?d? 99 )
• ?e???? ßa?t???a e??a? pe?ast???
• ?a pe??ss?te?a e??a? µ???µa
• ??s???a a????e? ? f?s???????? ?????da st???
  ???e??

7
? f?s???????? ?????da Mims C et al. Medical
Microbiology Textbook. 2004.
8
?? ??te?? ?? p??? ???µ??e??

• ?? ??te?? e??a? µ?a µe???? d?a????st???
  ep?f??e?a (interface), p?? ?e?t????e? ??
  f?a?µ?? ??a t??? µ???????a??sµ??? ?a? t?? e?d?-
  ?a? e??- t????e? t???
• 150 sq.m.
• ?µßad?? ???e??d?? 70 sq. m BSA 1.8 sq.m.
• F?a?µ?? µeta?? pe??ß?????t?? ?a? ???a??sµ??
• GALT (Gut Associated Lymphocytic Tissue )
  a?t?p??s?pe?e? t? µe?a??te?? ?eµf???tta????
  s?st?µa t?? ???a??sµ??

9
? f?s???????? ?????da a????e?

• ?e t?? ??µ?????? µetaß???? ?a? t?? a??pt???
• Ge???t???? s????a? ???a??? ?a? ?a?a?t?ß??????
• ?e t?? ???s? a?t?ß??t???? ? ep????? a??e?t????
  ?????da?
• ?pe?a??pt??? Candida st? st?µa ?a? st?? ???p?
• Clostridium difficile (????t?da s?et???µe?? µe
  t?? ???? a?t?ß??t????)
• ?e t?? ap??t?s? ???? ???a??sµ??
• ?e??????ta ap? t?? ?e???t??? s????a t?? µ?t??a?
  
• ?p????sµ?? µe Gram(-) t?? e?t???? ?a? t??
  a??te??? a?ap?e?st???? se ??s???µe?a????
  a???st???
• ?etaf??? µ????ß??? ap? p?s???te? ( C. difficile,
  MRSA, VRE ??p)

10
?? µa? e?d?af??e? ? f?s???????? ?????da
µp??e? ?a µa? ???e? ?a? ?a?? !

• ??t?stas? st?? ap????sµ?
• ??ta????sµ?? µe ta pa?????a ??a ???? ?a? t??f?
• ????s? ßa?t????????? ?a? ?????????
  (a?t?µ????ß?a??? ??s?e?), p?? p??f???ss??? ap?
  t?? a??pt??? pa???????
• ?a?a???? ß?taµ???? ? st? ??te??
• S??e??? a?t??????? d???e?s?
• ???p???s? t?? a??s?a??? s?st?µat?? ??a?t?
  pa???????
• ?a ?µ?t??pe?a neisseriaceae µa? p??f???ss??? ap?
  t?? Neisseria meningitidis

11
?? ß?apt???? ep?d??se?? t?? µetaß???? t??
e?te????? ?????da?

• ???s? a?t?ß??t????
• ?d??e? se
• T??at? t?? e?a?s??t?? e?te????? ?????da?
• ?d??e? se
• ?pe?a??pt??? a??e?t???? ste?e??? Clostridium
  difficile
• ?d??e? se
• pa?a???? t?????? C. difficile
• ?d??e? se
• ???????a, ?e?d?µeµß?a??d? ????t?da

• Te?ape?a
• stop ta ?pe????a a?t?ß??t???
• metronidazole ? vancomycin ?.?.
• ?p??at?stas? µe epa?af??? t?? f?s?????????
  ?????da?
• ???ß??t???

12
?? ??te?? ?a? ?? ???µ??e??

• Beau
• 1? pe????af? MOF sta µ?sa t?? 1970
• ?p??es? ?t? t? ??te?? e????eta? ??a t? MOF
• ?a p??t?????a ??a t?? ??e??? t?? ???µ??e?? de?
  pe?????sa? t?? ???µ??e??
• ?? e?d??e?e?? ???µ??e?? ????a? s????te?e? ap? t??
  e???e?e??
• ? p??? t?? ???µ??e?? ?ta? sta?e?? t? ??te??
• ? f?????a? ap?????eta? µe pa?????a GNB ap? t?
  ??te??
• ??e?µ???a ap? e?s??f?s? VAP
• ????????a??sµ?? ap? t? ??te?? ? p?????ta t???
  d?aµetat??e?ta? st? a?µa

13
?? ??te?? st??? ßa??? p?s???te?

• ? ?e?t?????a f?a?µ?? ?ata??e?ta? st??? ßa???
  p?s???te?
• ?? ????e? at??f??? a? de? ????? t??f??? e????sµa
• ?? ??te?? e??a? e?a?s??t? st?? ?s?a?µ?a
• ?e???eta? ? ?e?t?????a e?te????tt???? ?a?
  ?eµf???tt????
• ?? ??te??
• ??a µe???? µ??a µ???????a??sµ?? ?a? ??a e????t?
  d?a????st??? t????µa
• ?? µe???? apa???e?tet? ap?st?µa t?? ???a??sµ??
  
• ? µ??a?? p?? ?d??e? se MOF
• SDD s?ed??st??e ?a ?pe??e??se? a?t? t? p??ß??µa
• ??at??e? t?? ?p?????sa ?????da ?a? ?atast???e? ta
  PP-GNB

14
???ß??t??? - ???sµ??

• ???te? µ???????a??sµ?? ?? ?p???? ?ta?
  ????????ta? se epa???? p?s?t?te? ?fe???? t??
  ??e?a t?? ?e??st?.
• 2001
• ???a??sµ?? ???f?µ?? ?a? Ge????a? t?? ???µ????
  ?????
• ? ?a???sµ??? ???a??sµ?? ??e?a?
• ??e?e????? t?? ap?pt?s?
• ?p??e????? t??
• fa????tta???? ?e?t?????a
• pa?a???? a??s?sfa??????
• ????s? ??tta???????
• ?e????????? t?? µ????ß?a??? t????e?

15
???????? ep?d??se?? t?? ???ß??t????

• ?e??????
• t?? s????t?ta ?a? ßa??t?ta t?? s???? st???
  a???st??? ??T ?a? ?e??????????
• ta s?µpt?µata t?? e?e????st?? e?t????
• t?? e?d???se?? t?? at?p???? e???µat?? sta pa?d??
  
• ???f???ss??? ? µe?????? t?? d??????e? ap?
  rotavirus, Clostridium difficile
• ????a????
• ?p?????s? t?? s?µpt?µ?t?? t?? f?e?µ???d??? ??s??
  t?? e?t????
• ???f???ss??? ap? ?p?t??p??
• t?? e?d???se?? t?? e???d??? ????t?da?

16
??eß??t???- ???sµ??

• S???et?? µ? µetaß?????µe??? ap? t?? ???a??sµ?
  ?dat????a?e?
• ap?te???? t??f? ??a ta s???at??????ta,
  ?µ?t??pe?a, ?f???µa ßa?t???a- p??ß??t??? t??
  ???a??sµ?? (?????? ??a ta Bifidobacterium spp)
• ????????, f????t?-?????sa??a??d?a ?a?
  ?a?a?t?sa??a??d?a
• ta ?a?? p?eß??t??? de? p?pt??ta? st?? a??te??
  pept??? s????a, a??? µetaß??????ta? st? ?????

GIBSON et al. 1995
17
??eß??t???

• ???s???? f????t??? -?????sa??a??d??? -FOS-
  (15g/d)
• a???se t?? a???µ? t?? bifidobacteria t?? ??p?????
  ?at? 10- f???? ?a? µe??se t?? a???µ? t??
  Clostridia Enterobacteria
• ?p?fe??? d??s? t??? st?? ?e??st?
• µp??e? ?a e??a? ap?t??esµa ?atast???? t??
  a??pt???? t?? ß?aße??? ? ? d???e?s? a??pt???? t??
  f?????? µ???????a??sµ?? (????a t??
  lactobacilli ?a? bifidobacteria)
• ?e??t?? p?eß??t???? ????s? t?? ap???t??
  a???µ?? t?? bifidobacteria / ?µe??s?a
  p??s??f?e?sa d?s?
• J. Nutr. 137 830S837S, 2007.

HAYAKAWA k et al. Microb Ecology Health Dis1990
18
S????? ???ß??t???

• Lactobacilli
• L. acidophilus
• L. casei
• L. delbrueckii subsp Bulgaricus
• L. reuteri
• L. brevis
• L. cellobiosus
• L. curvatus
• L. fermentum
• L. plantarum
• L. rhamnosus
• L. salivarius

• Bifidobacteria
• B. Bifidum
• B. Infantis
• B. Longum
• B. Thermophilum
• B. Adolescentes
• Streptococcus
• Lactis
• Salivarius subsp thermophilus
• Yeasts
• Saccharomyces boulardii
• S. cerevisiae

19
S????? ??eß??t??? S?µß??t???

• ??eß??t???
• Fructo-oligosaccharides (FOS)
• Inulin
• Galacto-oligosaccharides (GOS)
• Lactulose
• Lactilol

• S?µß??t???
• Bifidobacteria FOS
• Lactobacilli lactilol
• Bifidobacteria GOS

20
(No Transcript)
21
(No Transcript)
22
S?µß??t??? ???- ??e- ß??t???
Synbiotic 2000 Forte
23
?a?a?t???st??? t?? p??ß??t????

• Sta?e??t?ta ep?ß??s?
• ep??e????ta? ap? t?? s?????e? ap????e?s??,
  pa?a?????, epe?e??as?a?, µetaf????, ??????
  pa?aµ???? st? ??f?
• ? ?????? ep?ß??s?? st? ??f? p?????e? ap? 3-6
  eßd?µ?de?
• 12 µ??e? ??a ta ????? ???as?a p??ß??t???
• ??af???? µeta?? t?? pa?a????? ?a? t?? pa?t?d??
  t?? ?d??? pa?a?????
• 1-450 e?at?µµ???a ??tta?a
• 1 - 8 d?af??et??? ste???? µ?sa st? ?d?? p?????

24
?p?de??e?????- ??e- S??- ß??t???????????
efa?µ????
??a?µa ?ete??e???t???? ???µ??e?? ??e?a
pa???eat?t?da ?etaµ?s?e?s? ?pat?? Antibiotic-Assoc
iated Diarrhea Enteral Tube Feeding
25
BENEFITS OF SYNBIOTIC 2000FORTE IN CRITICALLY ILL
TRAUMA-PATIENTS Early Results of a Randomized
Controlled Trial- 2005

• Katerina Kotzampassi, Evagellos J. Giamarellos
  Bourboulis, Antonios Voudouris, Pantelis
  Kazamias, Efthimios Eleftheriadis

Critically Ill Trauma Patients 35
Synbiotic2000Forte Group 30 Placebo Group 15
days No Differences in Baseline Values
26
CRITICALLY ILL TRAUMA-PATIENTS PCT CRP
MDATNFa
Open bars synbiotic group. Closed bars placebo
group p0.05, p0.01,
p0.001
K.Kotzabassi et al 2005
27
SYNBIOTIC 2000FORTE CRITICALLY ILL
TRAUMA-PATIENTS
K.Kotzabassi et al 2005
28
SYNBIOTIC 2000FORTE CRITICALLY ILL
TRAUMA-PATIENTS

• Conclusion
• Synbiotic 2000Forte in critically ill ventilated
  multiple trauma patients seems to exert
• beneficial effects in respect to infection and
  sepsis rates, and
• to improve the patients response, reducing thus
  the duration of ventilatory support and intensive
  care treatment.

K.Kotzabassi et al 2005
29
Early EN supply of Fiber and Lactobacilli vs
standard PN after major abdominal surgery

• PRCT in 3 groups of patients
• Standard PN or fiber-free EN (C)
• Fiber-containing EN with living Lactobacilli
  (LL)
• Fiber-containing EN with heat-killed Lact. (KL)
• Main endpoints
• infection rates
• duration of antibiotic therapy
• length of hospital stay
• side-effects of nutrition

Rayes N et al. Nutrition 2002 18 609-15
30
?ete??e???t???? ???µ??e?? ?e????e? epeµß?se??
?????a? ENLactobacilli
GR gastric resection PR pancreatic resection
Rayes N. Nutrition 2002 18609
31
Early EN supply of Fiber and Lactobacilli vs
standard PN after major abdominal surgery
16
14
12
p .01
p .04
10
Controls (n30)
8
F LL (n30)
6
F KL (n30)
4
2
0
Pts Pneumonia (n) (n)
Hospital Duration of antibiotic therpy (d)
infected
LOS
Rayes N et al. Nutrition 2002 18 609-15
32
?ete??e???t???? ???µ??e?? ?e????e? epeµß?se??
?????a?
Dx Colorectal Ca, Gastroesoph Ca, Panc Ca,
Crohns, Ulcerative Colitis, Diverticular
disease, AAA, malignant disease
McNaught et al Gut 200251827
33
Bacterial Infection Rates After
Pylorus-preserving Pancreatoduodenectomy

• Group A (n40)
• 1 ?µ??a pre 8 ?µ??e? post- Synbiotic 2000
• Group B (n40)
• 1 ?µ??a pre 8 ?µ??e? post- ?????sa??a??te?

• Group A Group B
• ?µ. µe a?t?ß??t??? 2 5 10 14
• ???µ??e?? 5/40 (12.5) 16/40 (40)
• plt0.005 plt0.015

N. Rayes et al Effect of Enteral Nutrition and
Synbiotics on Bacterial Infection Rates After
Pylorus-preserving PancreatoduodenectomyA
Randomized, Double-blind Trial. Ann Surg
2007246 3641
34
?a?????? ????f???? ?a? s?µß??t??? ap? t?? ??st?da
L. casei strain Shirota B.breve strain Yakult
galactooligosaccharides
Group A 2wks post Group B 2 wks pre- post
G. Sugawara et al Perioperative Synbiotic
Treatment to Prevent Postoperative Infectious
Complications in Biliary Cancer Surgery. A
Randomized Controlled Trial Surg 2006244
706714
35
????d?? ????t?da-???e?t?µ?- ?p?t??p?????sa
f?e?µ??? t?? s???? t?? e??e?? (relapsing
pouchitis) VSL3

• 40 as?e?e?? µet? 1 µ??a ?e?ape?a µe rifaximin, 2
  g/day ciprofloxacin 1 g/day ? ?fes?
  t??a??p???s?
• 20 as?e?e?? Placebo
• 20 as?e?e?? VSL3
• 8 p??ß??t??? (Lactobacillus casei, Lactobacillus
  plantarum, Lactobacillus acidophilus,
  Lactobacillus delbrueckii subsp. Bulgaricus,
  Bifidobacterium longum, Bifidobacterium
  brevis,Bifidobacterium infantis, Streptococcus
  salivarius subsp. Thermophilus)
• 4 pa??ta t?? 450 e?. t?? ?µ??a (VSL
  Pharmaceuticals Inc., Fort Lauderdale,FL, USA)
• ?a?a???????s? ??a 9 µ??e?
• ?µ?da placebo
• ?p?t??p? 8 st??? 2 µ??e?, 7 st??? 3 ?a? 5 st???
  4
• ?µ?da VSL3
• ?p?t??p? 3. ?? 17 ????? ?p?t??p?, ?p?t??p?asa? 4
  µ??e? µet? t? p??a? t?? µe??t??

P. Gionchetti et al Probiotics for the treatment
of postoperative complications following
intestinal surgery. Best Practice Research
Clinical Gastroenterology 2003 17 821831
36
Early jejunal nutrition with combined pre- and
pro- biotics in acute pancreatitis

• Prospective, randomized, double-blind
• Plasma amylase gt 200, CRP gt150 and Glasgow score
  3
• Randomized to receive live 109 lactobacillus
  plantarum 299 with oat fiber or heat inactivated
  L. plantarum and oat fiber for seven days, BID
  for 7 days
• Study terminated after enrolling 45 patients
  because of compelling differences between the two
  groups

Olah A. et al. Br. J Surg 2002, 89, 1103
37
Early jejunal nutrition with combined pre-and
probiotics in acute pancreatitis

• assessed by aspiration cultures

Olah A. et al. Br. J Surg 2002, 89, 1103
38
Early jejunal nutrition with combined pre-and
probiotics in acute pancreatitis

• Authors conclusions lactobacillus plantarum 299
  was effective in reducing pancreatic sepsis and
  the number of surgical interventions.
• But
• Methodological flaws
• Small sample
• failure to report randomization method
• no power calculation
• no defined primary endpoint and a lack of
  analysis by intention to treat
• ? whether microbiological specimens obtained from
  all patients with pancreatic necrosis and whether
  sampling was always done prior to antibiotic
  treatment.
• Concomitant use of antibiotics in 3 patients for
  reasons other than infected pancreatic necrosis

39
Probiotic Prophylaxis in Patients with Severe
Acute Pancreatitis

• Double-blind, placebo-controlled randomised
  multicenter trial in which patients will be
  randomly allocated to a multispecies probiotic
  preparation (Ecologic 641) or placebo it will be
  performed in 15 Dutch Hospitals
• The study-product is administered twice daily
  through a nasojejunal tube for 28 days or until
  discharge
• Inclusion criteria adult patients with a first
  onset of predicted severe acute pancreatitis
  Imrie criteria 3 or more, CRP 150 mg/L or more,
  APACHE II score 8 or more
• Exclusion criteria post-ERCP pancreatitis,
  malignancy, infection/sepsis caused by a second
  disease, intra-operative diagnosis of
  pancreatitis and use of probiotics during the
  study
• The study-product administration starts within 72
  hours after onset of abdominal pain
• Primary endpoint total number of infectious
  complications
• Secondary endpoints mortality, necrosectomy,
  antibiotic resistance, hospital stay and adverse
  events
• A sample size of 200 patients was calculated to
  demonstrate that probiotic prophylaxis reduces
  the proportion of patients with infectious
  complications from 50 to 30, with alpha 0.05
  and power 80

Besselink MG, et al. BMC Surg. 2004 412. 41
40
L. Plantarum 299 Liver Transplantation

• Prospective, randomized placebo-controlled
• N95 12 days
• Std TF SBD 48 infection
• 15 g fiber TF placebo 34 infection
• 15 g fiber TF probiotic 13 infection
• P0.017
• Selective Bowel Decontamination with broad
  spectrum ATB and antifungals

Rayes N et al. Transplantation 2002 74123
41
Pre- and Probiotics After Liver Transplantation
(RDBT)
plt0.05
Rayes et al. Am J Transplantation 2005 5125
42
Antibiotic-Associated Diarrhea (AAD)

• Affects as many as 30 of patients
• Alteration in normal intestinal flora from
  excessive use of broad-spectrum ATB
• Numerous pathogenic bacteria can be responsible
  for AAD
• Clostridium difficile - most common isolated
  pathogen

43
Recurrent C. Difficile Colitis

• 168 patients w/ C. diff.
• 2 g Vanco/day S. boulardii
• 16.7 recurrence with probiotic/ATB vs. 50 with
  ATB alone
• Surawicz CM et al. Clin Infec Dis 2000 311012

• 124 patients w/ C. diff.
• Std antibiotic Saccharomyces boulardii
• 34.6 recurrence with S. boulardii vs. 63.7 with
  placebo
• McFarland et al. JAMA 19942711913

44
AAD non C. difficile related
probiotics or placebo given with ATB
45
???ß??t??? ?a? s?t?s? µe ??te???? s????a
46
???ß??t??? - ?sf??e?a

• Ge???? ?e?????ta? asfa?? p?????ta
• Generally regarded as safe (GRAS)
• ??ep???µ?te? e????e?e?
• A???s? t?? a????? t?? e?t????
• Sp???a
• ?p??e? ?a p???a??s??? ???µ??? se a???st??? µe
  s??-??s???t?ta
• ??e?µ???a (Lactobacillus)
• ?????ß?a?µ?a (S boulardii, L rhamnosus)
• ???a??e??t?da(Lactobacillus)
• ??d??a?d?t?da (lactobacilli)
• ?p?st?µa (Saccharomyces cerevisiae)
• ?a ?f??? p??pe? ?a a?t????p??? t??? ???d?????

47
??s?????a

• ?e? ?p?????? saf? das??????? s??µata
• ? ?µe??s?a d?s? ?a? ? d????e?a ??????s??
  ep??e??eta? ap? t? e?d??/ st??e???, ?a? ap? t?
  µ??f? t?? s?e??sµat??.
• ?a p??ß??t??? d?af?????
• st?? a?t??? p?? eµfa?????? se ????? pe??ß?????
• st?? p??s????t??? t??? ??a??t?ta st? ep??????
• ?a? st?? ap????sµ? t?? G?S,
• st?? pa?a???? ßa?t????????? ??p

48
T?µata asfa??st???? taµe???

• ?e? ?p?????? ?a????st???? d?at??e?? ??a t?? ???s?
  t???
• Ge???? ?e?????ta? asfa?? p?????ta
• Generally regarded as safe (GRAS)
• ?p?s?µ? ???s? ??a p?????? ? ?e?ape?a
• Ga???a ????da (S. Bulardii), Ge?µa??a (E.Coli
  Nielsen 1917)
• ?e? ?a??pt??ta? ap? ta asfa??st??? taµe?a ep?
  t?? pa???t?? ???s?µ?p?????ta? sa? d?at??f???
  s?µp????µata

49
S?µp??asµa

• ? ???s? t?? p??ß??t???? st??? ?e??????????? ?a?
  st??? ßa??? p?s???te? ????st??? ?p?s?eta? p????!.
• ?e?t??????
• t??? de??te? f?e?µ????
• t?? s????t?ta eµf???s?? ???µ??e??
• t?? d????e?a ??s??e?a?
• t? ????? ????? a?t?ß??t????
• ?pa?t???ta? d?p??? t?f???, e?e???µe?e? µe placebo
  µe??te?, ??a t?? ep?ßeßa??s? t??
  ap?te?esµat???t?ta? e??? ??ast?? e?d???
  p??ß??t????
• The Role of Synbiotics in Reducing Post-Operative
  Infections in Patients Undergoing Cardiac
  Surgery A Pilot Study. Beth Israel Medical
  Center ClinicalTrials.gov IdentifierNCT00164099.
  End of recruiting patients 30/10/07

50
? f?s???????? ?????da
A New Year Greeting After an article by Mary J.
Marples in Scientific American, January, 1969
On this day tradition allots to taking
stock of our lives, my greetings to all of
you, Yeasts, Bacteria, Viruses,
Aerobics and Anaerobics A Very Happy New
Year to all for whom my ectoderm is
as Middle-Earth to me. For creatures your
size I offer a free choice of habitat,
so settle yourselves in the zone that
suits you best, in the pools of my pores or
the tropical forests of arm-pit and
crotch, in the deserts of my fore-arms,
or the cool woods of my scalp. Build
colonies I will supply adequate warmth
and moisture, the sebum and lipids you
need, on condition you never do me
annoy with your presence, but behave as
good guests should, not rioting into acne
or athlete's-foot or a boil..
W.H. Auden
A New Year Greeting After an article by Mary J.
Marples in Scientific American, January,
1969 ??t? t? µ??a ? pa??d?s? ?pa???e?e?
?a s?ed??s??µe t?? ???? µa? ????? se ????? sa?
µ???te?, ßa?t???a, ??? ?e??ß?a ?a?
??ae??ß?a e?t???sµ???? ? ???? ?????? Se ?????
??a ?e????? p?? t? e??de?µa µ?? e??a? t?
d?a????st??? µeta?? µa? G?a d?µ??????µata t??
µe?????? sa? p??sf??? µ?a e?e??e?? ep?????
?at????a? ??a ?a ß??e?te?te st? ???? p?? sa?
p?e? ?a??te?a, st?? ?da??de?aµe??? t?? p???? µ??
? sta t??p??? d?s? t?? µas?a???, ?a? t??
pe??????, st?? e??µ??? t?? p??e?? ? sta ???a
d?s? t?? ?efa???? µ?? ???te ap????e? Ta sa?
e?asfa???? epa??? ?e?µ???as?a ?a? ???as?a, t?
sµ??µa ?a? ta ??p?d?a p?? ??e???este, µe t??
p???p??es? ?t? p?t? de? ?a µe e????e?te µe t??
pa???s?a sa? ?a? ?a s?µpe??f??este ?p?? p??pe?
?a s?µpe??f????ta? ?? ?a??? f????e???µe??? ?????
e?t??p?? p??? a?µ? ? p?da???a ? d?????a
W.H. Auden
51
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