6? Se

1
6? Seµ?????? ?????, ??e?t????t?? ?a? ??e?ßas????
?s????p?a???µ?t??? 28-29 Septeµß???? 2012?
s?µas?a t?? ?p??at??a?µ?a? st??? ??????µ?????

• ?????a?? ?. ?ap?????
• ??d??e??µe??? ?ef??????a?
• ?ef???????? ?a? ?etaµ?s?e?t??? ???t??
• ?a?ep?st?µ?a?? Ge???? ??s???µe?? ?at???

2
?p??at??a?µ?a

• ?a ???? lt136 meq/lt
• ?a ???? 130-135 mEq/lt ?p?a
• ?a ???? 120-129 mEq/lt µ?t??a
• ?a ???? lt 120 mEq/lt ßa???

3
???t? ?????a

• ?te???e??? ?µ?da µe ????? ?a?a?t???st??? t??
  ??????????? ta?t?t?ta, ? ?p??a de?
  a?t??at?pt???e? t? ß???????? ?at?stas?
• pre elderly
  (µes????e?) 45-64
• young old persons/elderly
  (??????µ????) 65-74
• old persons / old
  (?pe?????e?) 75-84
• oldest- old persons/very elderly (ßa?? ???a?)
  gt85

4
?p?d?µ??????a ?p??at??a?µ?a?

• ?p?te?e? t? s????te?? ??e?t????t??? d?ata?a?? p??
  pa?at??e?ta? se ??s??e??µe???? as?e?e?? (1-5)
  s???????
• ?? p?s?st? pa???s???e? µe???? d?a??µa?s? ?a?
  f???e? µ???? t? 42,6
• ? d?a??µa?s? t?? p?s?st?? ?fe??eta?
• St? d?af??et??? e?t?µ?s? ap? t? ?at???? p??s?p???
• St? s????t?ta a?µ??????? t?? as?e???

Al-Salman J et al. West J Med 2002 176 173-176
Upadhyay A. et al, AJM,2006 119 (7A)530-535
5
S??s? ?p??at??a?µ?a? p?? ?a? ?at? t?? ??s??e?a
?p?pt?s? ?p??at??a?µ?a? ()
?a???sa st?? e?sa????
?t??e?sa st? ??s??e?a
S?????
6
?p?pt?s? ?p??at??a?µ?a? st??? ??????µ?????
??s??e??µe????

• St??? ??????µ????? ??s??e??µe???? as?e?e?? t?
  p?s?st? f???e? ?a? t? 18-24

7
?p?d?µ??????a ?p??at??a?µ?a? se ??s??e??µe????
a?????a µe t?? ?????a
8
?p?d?µ??????a ?p??at??a?µ?a? ??s??e??µe???
as?e??? a?????a µe t?? ?????a ?a? t? f???
9
?µ???stas?a Na ?a? ?dat??

• ?as??eta? ?at? ????? ???? se 3 µ??a??sµ???
• St?? pa?a???? ?a? d??s? t?? a?t?d?????t????
  ??µ????
• St? ?ef???? ?e?t?????a ?a? ??a??t?ta t?? ?ef???
  ??a a?a??s? ?a? s?µp????s? t?? ?????
• St? a?s??µa t?? d??a?

10
??t?d?????t??? ??µ??? (ADH)

• ????apept?d??
• ?a???eta? st?? pa?a?????a?? ?a? ?pe??pt??? p????a
  t?? ?p??a??µ?? ?a? ape?????eta? st?? ?p?s??? ??ß?
  t?? ?p?f?s??

11
??????t?ta ?? e????sµa ??a ape?e?????s? ADH

• ?e??µ??? a?t???a?? p?es? ? µe??µ???? d?ast????
  ?????f???? ????? a?µat??
• ??e??sµ?? tase??p?d????? a??t???? t???? ?a?
  ?a??t?d???? ???p??
• ?pe?e?????s? ADH

12
Osµ?t???t?ta ?? e????sµa ??a ape?e?????s? t?? ADH
13
???s? t?? ADH
14
???a a?t?a p?? ep??e????? t?? ?????s? ADH

• ???e??? e?e??sµata (a???s?)
• ?a?t?a (a???s?)
• ???f??a f??µa?a, e?d??? st??? ??????µ?????,
  ep??e????? t?? ?????s? t?? ADH

????? ???s?µ?p????µe?a f??µa?a p?? ???s?µ?p?????ta? ap? t??? ??????µ????? ?a? ep??e????? t?? ?????s? ADH ????? ???s?µ?p????µe?a f??µa?a p?? ???s?µ?p?????ta? ap? t??? ??????µ????? ?a? ep??e????? t?? ?????s? ADH ????? ???s?µ?p????µe?a f??µa?a p?? ???s?µ?p?????ta? ap? t??? ??????µ????? ?a? ep??e????? t?? ?????s? ADH
????t???1 ???f??? (????? d?s?)1 ?p??ef????1 ?????f?sfaµ?d?1 ???ß??taµ?d?2 ?????p??paµ?d?2 ?S?F2 ???????3 ???f??? (?aµ??? d?s?)3 ?????d???3 G???????t???e?d?3 ???pe??d???3 S?sp?at???3 ?a?ßaµa?ep???3 ?????4 ?????????4 ?eµe??????????4 G??µp????d?4 ??????t??? t?? a??????4 ???µp?ast???4 ?e????f????????4
1a????e? t?? ?????s? t?? ADH, 2a????e? t?? a?tap????s? t?? ?ef????? s????a????, 3µe???e? t?? ?????s? t?? ADH, 4µe???e? t?? a?tap????s? t?? ?ef????? s????a????, ?S?Fµ? ste??e?d? a?t?f?e?µ???d? f??µa?a 1a????e? t?? ?????s? t?? ADH, 2a????e? t?? a?tap????s? t?? ?ef????? s????a????, 3µe???e? t?? ?????s? t?? ADH, 4µe???e? t?? a?tap????s? t?? ?ef????? s????a????, ?S?Fµ? ste??e?d? a?t?f?e?µ???d? f??µa?a 1a????e? t?? ?????s? t?? ADH, 2a????e? t?? a?tap????s? t?? ?ef????? s????a????, 3µe???e? t?? ?????s? t?? ADH, 4µe???e? t?? a?tap????s? t?? ?ef????? s????a????, ?S?Fµ? ste??e?d? a?t?f?e?µ???d? f??µa?a
15
S??d??µ? ?p??sf???? ?????s?? ??t?d?????t????
??µ???? (SIADH)

• ??a???st??? ???t???a ??a t? S??d??µ? ?p??sf????
  ?????s?? ??t?d?????t???? ??µ????
• ???ta????? ??a???st??? ???t???a
• ?e??µ??? d?ast??? ?sµ?t???t?ta e????tt????? ?????
  (lt270 mOsm/kg H2O)
• ?p??sf??? s?µp????s? t?? ?????(gt100 mOsm/kg H2O)
• ??????? e????a?µ?a
• ????? s?????t??s? Na ????? ??t? ap? ?a???????
  s?????e? p??s????? ?dat?? ?a? ??at??
• ?p??s?a ep??ef??d?a???, ???e?e?d????, ?p?f?s?a???
  ? ?ef????? ß??ß?? ? p??sfat?? ????? d?????t????
• ?e?te?e???ta ???t???a
• ??ata?a?µ??? d???µas?a f??t?s?? µe ?e?? (ad??aµ?a
  ap?ß???? t??????st?? t?? 90 t?? f??t?s?? µe 20
  mg/kgS? ?e??? se 4 ??e? ?/?a? ad??aµ?a a?a??s??
  t?? ????? µe ?sµ?t???t?ta lt100 mosm/kg
• ?p?peda ADH st? p??sµa a???µ??a d?sa?????a se
  s??s? µe t?? ?sµ?t???t?ta t?? p??sµat??
• ?? s?µa?t??? d?????s? t?? Na t?? p??sµat?? µe
  t?? ??pt??? t?? ?????, a??? ße?t??s? µet? t??
  pe?????sµ? t?? ?dat??

16
?pe?e?????s? ADH st??? ??????µ?????

• ?a ep?peda t?? ADH st? p??sµa a?e???s???ta?
  a???µ??a se ?at? ta ???a ???e?? ??????µ?????
• Se s?????e? a??????? a???µ???? ?sµ?t???t?ta? t??
  p??sµat?? ?? ??????µ???? ?a e???????? µe?a??te??
  p?s?t?ta ADH s?????t??? µe ?e?te???? as?e?e??

Johnson AG et al, J Am Geriatr 1994 42 (4)
399-404 Froklis VV et al , Arch Gerontol Geriatr
1999 29 (3)193-214
17
S????t?ta SIADH st??? ??????µ?????
18
?d??pa??? SIADH st??? ??????µ?????

• ?????pte? ?t? pa?at??e?ta? s??d??µ? ap??sf????
  ?????s?? a?t?d?????t???? ??µ???? st???
  ??????µ????? s????te?a se s??s? µe t???
  ?e?te????, ????? ?a ?p???e? p??fa??? a?t?a
• ?? s??d??µ? ?e??e?ta? ?d??pa??? ?a? e???e? t??
  a??pt??? ?p??at??a?µ?a? µe ? ????? s???p?????ta
  pa?????ta

19
??at?µ???? µetaß???? t?? ?ef??? µe t?? ?????a

• ?e??s? t?? ß????? t?? ?ef??? (300 gr ?at? t?? 9?
  de?aet?a t?? ???? se s??s? µe 400 gr ?at? t??
  ?????a t?? 40 et??
• ?e??s? t?? µe?????? ?at? 10 30 st?? ?????a
  t?? 80 et??
• ?? pa?ap??? µetaß???? ?fe????ta? ?at? ????? ????
  st?? spe??aµat?s??????s? st?? ep?fa?e?a??
  st??ß?da t?? f?????, ? ?p??a e??a? lt5 st??
  ?????a t?? 40 ?a? f???e? st?10-30 st?? ?????a
  t?? 80 et??

20
???p?? µetaß???? t?? ?ef??? µe t?? ?????a

• ???µes? ???s? µe d????s? µ?????tt???? ?a? ?????
  f?e?µ???d?? ??tt????
• ?t??f?a t?? s????a???? µe ap?t??esµa t?? e?f???s?
  t?? ep???????
• ?e??s? t?? a???µ??, t?? µ????? ?a? t?? ????? t??
  s????a????
• ?a????s? t?? a?t????????
• ??a ta pa?ap??? ?d????? se a?t?st???e?
  ?e?t???????? µetaß????

21
?e??s? µe?????? ?ef??? µe t?? ?????a
??at?µ? ?ef???
???a??te???
?e?te???
22
Spe??aµat?s??????s? µe t?? ?????a
23
?e?t???????? µetaß???? µe t?? ?????a

• ??ata?a??? st? d?at???s? t?? ??e?ßas????
  ?s????p?a?
• ??ata?a??? st? ?µ???stas?a t?? ??e?t????t??
• ??ata?a??? st? s?µp????s? t?? ?????
• ??ata?a??? st?? a?a??s? t?? ?????
• Se s??d?asµ? µe
• ?e??s? t?? spe??aµat???? d????s??
• ?e??s? t?? a?tap????s?? t?? ????f???? s????a????
  st?? ADH

24
??s??µa d??a?

• ?e t?? ?????a t? a?s??µa d??a? aµß???eta?,
  ?e????? p?? e???e? t?? ?at?stas? af?d?t?s?? ?a?
  µe???e? t?? p??a??t?ta a??pt???? ?p??at??a?µ?a?

25
??at?µ???? µetaß???? p?????s?? t?? ?????a? e?t??
?ef???

• Se ???e?? e?????e? t? ?d?? e??a? t? 55-65 t??
  s???????? s?µat???? ß?????
• ??????s?? t?? ?????a? µe???eta? ? a?a????a
  ?d??f???? (?.?. µ?e?) p??? ?d??f?ß??? ?st???
  (?.?. ?st?, ??p??)
• ?a pa?ap??? d?µ???????? p???p???se?? ??a a??pt???
  ?p??at??a?µ?a? st??? ??????µ?????

26
?s????p?a ?at???? st??? ??????µ?????
SIADH
??ata?a?? d??a?
?ef???? ???a?s?
?p??at??a?µ?a
?pe??at??a?µ?a
27
??? eµfa?????? ?? ??????µ???? ??????? ??d???
?p??at??a?µ?a
S???p?????sa pa??????a
Fa?µa?e?t??? a????

• ?e?t???????? µetaß????

??at?µ???? µetaß????
??a?t?t???? s????e?e?
??ata?a?? ?µ???stat???? µ??a??sµ??
??????? ??d??? ?p??at??a?µ?a
28
??t?a ?p??at??a?µ?a? st??? ??????µ?????
????? a?t?a ?p??at??a?µ?a? st??? ??????µ????? ????? a?t?a ?p??at??a?µ?a? st??? ??????µ????? ????? a?t?a ?p??at??a?µ?a? st??? ??????µ?????
?e??µ??? ????? Na s?µat?? F?s???????? ????? Na s?µat?? (pe??sse?a ?dat??) ????µ??? ????? Na s?µat??
Te?a??d??? d?????t??? (gt50 t?? pe??pt?se??) ?ef???? ap??e?a ??at?? ??s?? Addison ?µet??, d??????e? ?aµ??? p??s???? d?a??t?? (?.?. ?d???? d?a?ta) ?aµ??? ?sµ?t??? s?t?s? µe ?????ast???? s????a S??d??µ? ap??sf???? ?????s?? a?t?d?????t???? ??µ???? ?p????e?e?d?sµ?? ??ep???e?a ????????t???e?d?? ?????e??? p???d???a ??????s? ?p?t???? d?a??µ?t?? S?µf???t??? ?a?d?a?? a?ep???e?a ?pat??? ?????s? ?ef??s??? s??d??µ? ?ef???? a?ep???e?a
29
????pa?a???t??? ?p??at??a?µ?a

• Sta p?a?s?a d?e?e???s?? ??a t?? ?a??te??
  a?t?µet?p?s?, d?ap?st????e ?t? ta a?t?a t??
  ?p??at??a?µ?a? st??? ??????µ????? µp??e? ?a e??a?
  p??? ap? ??a a??µ? ?a? st? 50 t?? pe??pt?se??

????µ?? as?e???
????µ?? a?t???
30
Te?a??d??? d?????t???-?p??at??a?µ?a- ??????µ????

• ?p?te???? t? s?????ste?? a?t?? p?? s?µß??e? se
  µ?a p???pa?a???t??? ?p??at??a?µ?a, e?? a?t??eta
  spa???te?a ?a s??a?t??e? ?? t? µ??ad??? a?t?? t??
  d?ata?a??? a?t??
• ? ?p??at??a?µ?a ap? ta ?e?a??d??? d?????t???
  p??sß???e? e?????te?a t??? ??????µ?????, t??
  ???a??e? ?a? as?e?e?? µe ?aµ??? s?µat??? ß????
• ?a?a?t????eta? ap? ??????? eµf???s? µet? t??
  ??a??? t?? fa?µ???? (pe??p?? 2 eßd?µ?de?) ?a?
  s?et??? ??????? ?fes? µet? t? d?a??p? t??.
• St??? ??????µ????? ta ?e?a??d??? d?????t???
  p???a???? a?s??t? µe??s? t?? ???a?s?? e?e??????
  ?dat?? se s?????s? µe µ????te?e? ?????e?, a??µ?
  ?a? ?ta? de? ??e? d?ap?st??e? ?p??at??a?µ?a st??
  e??ast???a?? ??e???.

31
Te?a??d??? st??? ??????µ?????
32
F??µa?a ?a? ?p??at??a?µ?a(1)

• F??µa?a p?? ep??e????? t?? ?µ???stas? Na ?a?
  ?dat??
• ??????t???
• Te?a??d???
• ??dapaµ?d?
• ?µ?????d?
• ??????t??? t?? a??????

33
F??µa?a ?a? ?p??at??a?µ?a(2)

• F??µa?a p?? ep??e????? t?? ?µ???stas? µ??? t??
  ?dat??

????µ??? ?p??a?aµ??? pa?a???? ADH ??t??ata???pt??? ?????????? a?t??ata???pt??? (aµ?t??pt?????, p??t??pt?????, des?p?aµ???) ??d???? a?ast??e?? epa?ap??s????? t?? se??t?????? ??ast??e?? t?? µ???aµ?????e?d?s?? ??t?????s??? f??µa?a Fa????e?a???e? (?e????da????, t??f?????pe?a????) ???t???fa????e? (a??pe??d???) ??t?ep???pt??? f??µa?a ?a?ßaµa?ep??? ,???a?ßa?ep??? ?a?p????? ??t??? ??t??a???????? pa?????te? ???a??e?d? t?? vinca (ß?????st???, ß??p?ast???) ?a?????a p?at???? (s?sp?at???, ?a?ß?p?at???) ?????f?sfaµ?d?, µe?fa????, ?f?sfaµ?d? ???f??a (µe??t?e??t?, ??te?fe???? ?a? ?eßaµ?????, pe?t?stat???, µ?????????? a?t?s?µata) ?p??e?d? ????µ??? ?p??a?aµ??? pa?a???? ADH ??t??ata???pt??? ?????????? a?t??ata???pt??? (aµ?t??pt?????, p??t??pt?????, des?p?aµ???) ??d???? a?ast??e?? epa?ap??s????? t?? se??t?????? ??ast??e?? t?? µ???aµ?????e?d?s?? ??t?????s??? f??µa?a Fa????e?a???e? (?e????da????, t??f?????pe?a????) ???t???fa????e? (a??pe??d???) ??t?ep???pt??? f??µa?a ?a?ßaµa?ep??? ,???a?ßa?ep??? ?a?p????? ??t??? ??t??a???????? pa?????te? ???a??e?d? t?? vinca (ß?????st???, ß??p?ast???) ?a?????a p?at???? (s?sp?at???, ?a?ß?p?at???) ?????f?sfaµ?d?, µe?fa????, ?f?sfaµ?d? ???f??a (µe??t?e??t?, ??te?fe???? ?a? ?eßaµ?????, pe?t?stat???, µ?????????? a?t?s?µata) ?p??e?d?
???s??s? t?? d??s?? t?? ADH ??t?ep???pt??? f??µa?a ?a?ßaµa?ep???, ?aµ?t?????? ??t?d?aß?t??? f??µa?a ?????p??paµ?d?, t??ß??taµ?d? ??t??a???????? pa?????te? ???????t???? pa?????te? (?F ?????f?sfaµ?d?) ?? ste??e?d? a?t?f?e?µ???d? f??µa?a ?pa?at?p???t?s? t?? ?sµ?st?t? ??t??ata???pt??? ?e??afa???? ??t?ep???pt??? f??µa?a ?a?ßaµa?ep???
34
F??µa?a s????? ???s?? ?? spa???te?a a?t?a
?p??at??a?µ?a?

• ??t??pe?tas???
• ??ast??e?? µetat?ept???? e???µ?? t??
  a??e??te?s????
• ?µ???d?p???
• ???s?sfa????? (?F)
• 3,4-?e???e?ed????µe???aµfetaµ??? (ecstasy)
• A?t?ß??t???
• ???µe??p??µ?/s???faµe???a????
• S?p??f???as???
• ?ef?pe?a????/s???ßa?t?µ?
• ??t?a????µ???
• ?µ??da????, ????a???d?, p??pafa?????
• Te?f??????
• ??ast??e?? a?t??a? p??t?????
• ???µ????pt???
• ?e???p?ess???
• ?t?????et???
• F?????a??e????af?a
• ???p??p????

35
?p??at??a?µ?a e? fa?µ????

• ?e? µp??e? ?a p??ß?ef?e? ? a??pt??? ? µ?
  ?p??at??a?µ?a? ap? ??a fa?µa?e?t??? s?e?asµa
• ??a?t?ta? ap? t? s???p?????sa pa??????a ?a?
  ?????? ap? t? ?ef???? ?e?t?????a
• Mp??e? ?a e??a? ?a? ? p??t? e?d???s? ?ef?????
  d?s?e?t?????a?

Burkhardt H et al J Nephrol 2005 18 (2)166-173
36
??????? e????a

• St??? ??????µ?????, ?p?? ?a? st? ?e???? p????sµ?
  ? ??????? e????a e?a?t?ta? ap?
• ?? ßa??t?ta t?? d?ata?a???
• ??? ta??t?ta e??at?stas??
• ??d?p???? d?af??? st??? ??????µ?????
• S?????ste?? ßa??? d?ata?a??
• S?ßa??te?a s?µpt?µata ?a? s?µe?a

37
S?µpt?µata ?a? s?µe?a

• ?efa?a???a
• S????s?
• Spasµ??
• G??s?a??? d?ata?a???
• ??ata?a??? t?? µ??µ??
• ??ata?a??? st? ß?d?s?
• ???a????
• ??µa
• ?fe????ta? st? ??d?µa t?? e??efa????? ??tt????,
  ?ta? ? d?ata?a?? e??a? ??e?a

38
?at??µata ???? ?p??at??a?µ?a?

• S?et????ta? µe
• ??? d?ata?a??? ß?d?s??
• ??? ata??a
• ??? ?ste?p???s?
• ?aµß????? ???a
• St? ?s???
• St?? a????a t?? µ???a??? ?st??
• ?p????? ?a a?apt?????? ?a? se ?p?a ?p??at??a?µ?a

39
?ste?p???s? ?a? ?p??at??a?µ?a

• ?p??at??a?µ?a

????µ??? ?ste???ast??? d?ast????t?ta
?e??µ??? ?ste?ß?ast??? d?ast????t?ta
?e??s? ?st???? p????t?ta?
40
?ste???ast??? d?ast????t?ta se pe??aµat???
µ??t??? SIADH
Verbalis JG et al, J Bone Min Res 2010 25
(3)554-563
41
?ste?p???s? ap? ?p??at??a?µ?a se pe??aµat???a
Verbalis JG et al, J Bone Min Res 2010 25
(3)554-563
42
?p???e??a ?a? ?p??at??a?µ?a st??? ??????µ?????

• ?a?at??e?ta? pt?s? t?? de??t? µ??a? s?µat?? (BMI)
  se ?p??at??a?µ????? ??s??e??µe???? ??????µ?????
• ?e d?af????? ???µ?- ?a? ?p?- ?at??a?µ????
  as?e?e?? s?et??? µe ?????? pa?????te? ??????
  (a?ß??µ???, a?µ?sfa?????)
• ? pt?s? t?? BMI p??a??? ?fe??eta? st? st???s?
  ?dat?? p?? efa?µ??eta? ??a t?? a?t?µet?p?s? t??
  ?p??at??a?µ?a?

43
??????s? t?? ?p??at??a?µ?a? st??? ??????µ?????

• ????µ??? ??s???t?ta
• ?a?atetaµ??? e?de??µe?? ??s??e?a
• ?a??ste??µ??? ap??at?stas?
• ????µ??? ???t?t?ta
• ?s? ßa??te?? ? d?ata?a?? st?? e?sa????, t?s?
  ft???te?? ? p?????s?

44
T??t?t?ta ?a? ?p??at??a?µ?a

• Se Na ???? lt 125 mEq/lt
• ????µ??? ???t?t?ta ?at? t? ??s??e?a
• ????µ??? µ???et? ???t?t?ta
• ????µ??? pe?taet? ???t?t?ta
• ??????a ded?µ??a ?s????? ?a? st?? ?p?a
  ?p??at??a?µ?a

45
Waikar SS et al Am J Med 2009 122857-865
46
??s? ep?de????eta? ? p?????s? ap? t??
?p??at??a?µ?a
Waikar SS et al Am J Med 2009 122857-865
47
?pa?a?t?t? ? d?????s? t?? Na
Waikar SS et al Am J Med 2009 122857-865
48
?p??at??a?µ?a ?a? ?a?d?a?? a?ep???e?a

• ?t?s? Na ???? ?at? 3 meq/lt
• St??? ??????µ????? µe ?a?d?a?? a?ep???e?a, ?
  ?p??at??a?µ?a ap?te?e? d?sµe?? pa?????ta, a??µ?
  ?a? e?? ? s?st????? ?e?t?????a t?? µ???a?d???
  e??a? ??a??p???t???

????s? ???t?t?ta? st? ??s???µe?? ?at? 19,5
????s? ???t?t?ta? ?at? 10 st?? ?µes? µet?pe?ta
pe???d?
49
?p??at??a?µ?a ?a? ??st?? ??s??e?a?

• ????µ??? ??st?? ??s??e?a? ?a? pe???a???? as?e???
  µe ?p??at??a?µ?a ??a?t? e?e???? µe a???µ??? ?
  f?s???????? Na ???? se 6µ???a?a ?a? et?s?a ß?s?

50
???s??? st?? ?p??at??a?µ?a !
51
??t?µet?p?s?

• ??t?µet?p?s? t?? ?e?es??????? pa?????ta (?.?.
  d?a??p? ?pe?????? fa?µ????)
• S??t???t??? µ?t?a
• ?e?????sµ?? ?dat??
• ??????s? ?p??t???? d?a??µ?t?? ?p? a?st???
  pa?a???????s?
• ?e?te?e? e?d???? ?e?ape?e?

52
?apt??e?

• ??ta????st?? ?p?d????? a?t?d?????t???? ??µ????
• ?????a?µ??? ? ?pe????a?µ??? ?p??at??a?µ?a
• ???????? a?t?µet?p?s? ??e?a? ? ?????a?
  ?p??at??a?µ?a?
• ??s?st? ?p?t??p?? 68 7?µ??e? µet? t? d?a??p?
• ?a?e????e?e? se ?????s? ?pat??

53
??ep???µ?te? d??se?? ßapta???
???pe? ?a? p?te ?a ??ß??? ?? ??????µ????
ßapt??e?

• S????????a
• ????st?µ?a
• ???a
• ????????a
• ????d???a
• ?pat??ef???? s??d??µ? (se as?e?? µe ?????s?)
• ?e ße?t???eta? ? ???t?t?ta ep? ?a?d?a???
  a?ep???e?a?

54

• St??? ??????µ????? µe ?p??at??a?µ?a e?a??a?t???
  a???? µe pe?????sµ??e? a?ep???µ?te? e????e?e?
• ??at?- ? ?????-???t???e?d?
• 10 mg ?d?????t?????? ?µe??s???

55
S????????ta?

• ? ?p??at??a?µ?a e??a? ? s????te?? ??e?t????t???
  d?ata?a?? p?? d?ap?st??eta? st??? ??????µ?????,
  e?d??? s a?t??? p?? ??s??e???ta?
• F?s????????? d?µ???? ?a? ?e?t???????? µetaß????
  p?? s?µßa????? e?a?t?a? ???a?s?? st?? ?p????aµ?
  ?a? t??? ?ef???? d?µ???????? p??d???es? ??a
  ?p??at??a?µ?a
• St??? ??????µ????? pa?at??e?ta? ?d??pa???
  s??d??µ? ap??sf???? ?????s?? a?t?d?????t????
  ??µ????
• ?? ??????µ???? eµfa?????? ?st?p???s? ?a?
  ?at??µata e?a?t?a? t?? ?p??at??a?µ?a?
• ? ?p??at??a?µ?a ap?te?e? pa?????ta p??
  ep?de????e? t?? p?????s? t?? ??????µ????, ?? p???
  t? ??s???t?ta, t?? ?µ??e? ??s??e?a? ?a? t?
  ???t?t?ta

56
S????????ta?

• ? d?????s? t?? Na ße?t???e? t? p??sd???µ?
  ep?ß??s?? se as?e?e?? µe ?a?d?a?? a?ep???e?a ?a?
  ???????????? as?e?e??
• ? a?t?µet?p?s? t?? s?µpt?µat???? ?p??at??a?µ?a?
  pe???aµß??e? st???s? ?dat??, ??????s? ?p??t????
  d?a??µ?t?? ?a? ??p??e? f???? ????????t???e?d?
• ? ??????s? a?ta????st?? t?? ?p?d????? t??
  a?t?d?????t???? ??µ???? µp??e? ?a p???a????
  a???s? t?? ep?p?d?? Na ????, ?µ?? aµf?sß?te?ta?
  ? ???s? t??? e?a?t?a? t?? a?ep???µ?t?? e?e??e???

57
Na ????
58
???a??st? ??a t?? p??s??? sa?