VOL15_ISSUE4_OCT_DEC_2003 by SAN PUBLICATIONS

Ôüìïò 15, Ôåý÷ïò 4, Oêôþâñéïò - ÄåêÝìâñéïò 2003

ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 15, Ôåý÷ïò 4, Ïêôþâñéïò - ÄåêÝìâñéïò 2003, Volume 15, Number 4, Ïctober - December 2003

ÅñåõíçôéêÜ Üñèñá 158

Á. Ãêßêáò, Ð. ÐåñäéêÜêç: ÄéáôñïöéêÝò óõíÞèåéåò êáé ðáñÜãïíôåò óõó÷Ýôéóçò ôùí åöÞâùí ëõêåéáêÞò çëéêßáò

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Ä. ÂÞíç, ×. Æáâüò, Ì. ÂåíéæÝëïò: ÅíõäÜôùóç ðáéäéþí ìå Þðéá Ýùò ìÝôñéá áöõäÜôùóç ëüãù åìÝôùí óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò

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Á. ÐáðïõôóéäÜêçò: ÐñïáãùíéóôéêÞ éáôñéêÞ åîÝôáóç ðáéäéþí êé åöÞâùí Eðáéíåèåßóåò Åëåýèåñåò Áíáêïéíþóåéò

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Å. Èçñáßïò, Í. ÃéáìáëÜêçò, Å. Ëýêïõ, Ì. Ðýëëç, Ã. ÌðÝëïò, ×. Ïéêïíïìïðïýëïõ, Å. ÌùñáÀôçò: ËåéôïõñãéêÞ äéáóýíäåóç êáé óõíåñãáóßá ôïõ ðñïóùðéêïý ôùí ÊÝíôñùí Õãåßáò ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò

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Ä. Æþãáò, Â. Æþãá, ×. Ôóéþëçò, Ó. Ðáíáãéùôßäïõ, É. ÔóéÜëéïò, Ê. Äéáìáíôüðïõëïò, Í. Åëåõèåñßïõ: Åêôßìçóç ôçò áíáãêáéüôçôáò æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óå KÝíôñï ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò Áíáóêüðçóç

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Î. ÁëáôóÜêç, Ê. Óïõëéþôçò, Ã. Êõñéüðïõëïò: Ï ñüëïò ôùí ãåíïóÞìùí öáñìÜêùí óôéò ÷þñåò ôïõ Ï.Ï.Ó.Á. êáé óôçí ÅëëÜäá ÃñÜììá óôïí Åíäüôç

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

204

Ã.I. Ôóßñïò, Ä.Ê. Êáëïãåñüðïõëïò: ÊïéíÝò äõóëåéôïõñãßåò óôçí åêðáßäåõóç ôùí Ãåíéêþí/Ïéêïãåíåéáêþí Éáôñþí ÅëëÜäïò êáé ÌåãÜëçò Âñåôáíßáò Íåêñïëïãßá

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É. Ìïýæáò: Óôç ÌíÞìç ôïõ ÊáèçãçôÞ É. Âëá÷ïíéêïëÞ

ISSN 1105-7432

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ Ôá÷. Ãñáöåßï Ê. Ä. Áèçíþí Áñéèìüò ¢äåéáò 451/91

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

Cited in Index Copernicus Recognised by the Ministry of Health and Welfare

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 15, Number 4, 158-165, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 158-165, 2003

ÄéáôñïöéêÝò óõíÞèåéåò êáé ðáñÜãïíôåò óõó÷Ýôéóçò ôùí åöÞâùí ëõêåéáêÞò çëéêßáò Á. Ãêßêáò1, Ð. ÐåñäéêÜêç2

Ðåñßëçøç Óêïðüò: Ç êáôáãñáöÞ äéáôñïöéêþí óõíçèåéþí ôùí åöÞâùí ëõêåéáêÞò çëéêßáò êáé ç äéåñåýíçóç áõôþí óå ó÷Ýóç ìå ôçí êáôÜóôáóç èñÝøçò êáé äéÜöïñïõò êïéíùíéêï-äçìïãñáöéêïýò ðáñÜãïíôåò. Ðëçèõóìüò ìåëÝôçò-ÌÝèïäïò: ÌåëåôÞèçêå ôõ÷áßï äåßãìá 513 ìáèçôþí/ôñéþí Ëõêåßïõ, ôñéþí äéáöïñåôéêþí ðåñéï÷þí: ìéáò áóôéêÞò, ìéáò çìéáóôéêÞò íçóéþôéêÞò êáé ìéáò áãñïôéêÞò ðåñéï÷Þò. Óõìðëçñþèçêå åñùôçìáôïëïãßï ðïõ áöïñïýóå ôá êïéíùíéêï-äçìïãñáöéêÜ ÷áñáêôçñéóôéêÜ êáé ôéò äéáôñïöéêÝò óõíÞèåéåò (ëÞøç ðñïãåýìáôïò êáé óõíïðôéêü éóôïñéêü óõ÷íüôçôáò êáôáíÜëùóçò ôñïößìùí). ÌåôñÞèçêå ôï ýøïò, âÜñïò êáé ìå âÜóç ôï ÄÌÓ êáôáôÜ÷èçêáí óå õðÝñâáñá/ðá÷ýóáñêá (14,4%) êáé öõóéïëïãéêÜ Üôïìá. ÁðïôåëÝóìáôá: Ôï 29,4% ôùí åöÞâùí ðáñáëåßðïõí ôï ðñùéíü ôïõò, ìå õøçëüôåñï ðïóïóôü óôïõò õðÝñâáñïõò/ðá÷ýóáñêïõò (41,9% Ýíáíôé 27.3%, p=0,011). Åðßóçò, ç ðáñÜëåéøç ðñùéíïý âñÝèçêå íá ó÷åôßæåôáé ìå ôçí çëéêßá, ôï åêðáéäåõôéêü åðßðåäï ôïõ ðáôÝñá êáé ôçí ðåñéï÷Þ. Ôï 78% ôùí åöÞâùí êáôáíáëþíïõí äéÜöïñá óíáêò óôï äéÜëåéììá. Ìéêñü Þôáí ôï ðïóïóôü êáèçìåñéíÞò êáôáíÜëùóçò ëá÷áíéêþí (27%) êáé ó÷åôéêÜ ìÝôñéï ôùí öñïýôùí (60%). Óå ðïóïóôü 44% êáôáíáëþíïõí êñÝáò ôïõëÜ÷éóôïí 3 ö/åâä. Ìüíï ôï 37% êáôáíáëþíïõí 2 ö/åâä üóðñéá êáé 27% øÜñéá. Óôçí åôïéìáóßá ôïõ öáãçôïý ÷ñçóéìïðïéåßôáé êõñßùò ôï åëáéüëáäï. Ôï ãÜëá êáôáíáëþíåôáé êáèçìåñéíÜ óå ðïóïóôü 91%. ÁíáøõêôéêÜ êáé æá÷áñþäç êáôáíáëþíïíôáé óõ÷íÜ áðü ôï 7080% ôùí åöÞâùí. Ôá áãüñéá êáôáíáëþíïõí óõ÷íüôåñá êñÝáò, øÜñéá, áëëáíôéêÜ, áíáøõêôéêÜ, ïéíïðíåõìáôþäç. Ôá êïñßôóéá õðåñÝ÷ïõí óôçí êáôáíÜëùóç ëá÷áíéêþí êáé öñïýôùí. Ç áíþôåñç åêðáßäåõóç ôùí ãïíÝùí ó÷åôßæåôáé ìå óõ÷íüôåñç êáôáíÜëùóç êñÝáôïò êáé ìå ìéêñüôåñá ðïóïóôÜ êáôáíÜëùóçò áíáøõêôéêþí êáé ïéíïðíåõìáôùäþí. Óôéò áóôéêÝò ðåñéï÷Ýò ãßíåôáé óõ÷íüôåñç êáôáíÜëùóç ëá÷áíéêþí, êñÝáôïò, áëëáíôéêþí êáé ìéêñüôåñç êáôáíÜëùóç áíáøõêôéêþí, ïéíïðíåõìáôùäþí óå ó÷Ýóç ìå ôéò ëéãüôåñï áóôéêïðïéçìÝíåò. ÓõìðåñÜóìáôá: Ïé äéáôñïöéêÝò óõíÞèåéåò ôùí åöÞâùí ëõêåéáêÞò çëéêßáò áðïêëßíïõí óå óçìáíôéêü âáèìü áðü ôïí åíäåäåéãìÝíï ôñüðï äéáôñïöÞò. Ïé ãåíéêÝò ôÜóåéò áõôþí ðáñåêêëßíïõí ðåñéóóüôåñï ðñïò ôï äéáôñïöéêü ðñüôõðï äõôéêïý ôýðïõ. Óçìáíôéêïß ðáñÜãïíôåò ðïõ ó÷åôßæïíôáé ìå ôéò åíäåäåéãìÝíåò ç ìÞ äéáôñïöéêÝò óõíÞèåéåò åßíáé ôï öýëï, ç êáôÜóôáóç èñÝøçò, ôï ìïñöùôéêü åðßðåäï ôùí ãïíÝùí, ç ãåùãñáöéêÞ ðåñéï÷Þ êáé ï âáèìüò áóôéêïðïéçóÞò ôçò.

ÅðéìåëçôÞò Â, ÊÝíôñï Õãåßáò Óáëáìßíáò, 2Äéåõèýíôñéá ÊÝíôñïõ Õãåßáò Áóôñïõò

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ÅéóáãùãÞ Ôéò ôåëåõôáßåò äåêáåôßåò óôçí ÅëëÜäá ðáñáôçñåßôáé áõîçìÝíç åðßðôùóç ôùí êáñäéáããåéáêþí íïóçìÜôùí, ôçò ðá÷õóáñêßáò êáé ïñéóìÝíùí íåïðëáóéþí, ãåãïíüò ôï ïðïßï ó÷åôßæåôáé óå ìåãÜëï âáèìü ìå ôïí óýã÷ñïíï ôñüðï äéáôñïöÞò ôùí ÅëëÞíùí1-3. Ç ðáñáäïóéáêÞ ÅëëçíéêÞ äéáôñïöÞ (ðñïôåéíüìåíç áðü ôçí ÐÏÕ ùò ðñüôõðï äéáôñïöÞò), ç ïðïßá ÷áñáêôçñßæåôáé áðü õøçëÞ êáôáíÜëùóç öñïýôùí, ëá÷áíéêþí, ïóðñßùí, åëáéüëáäïõ, øùìéïý êáé ÷áìçëÞ êáôáíÜëùóç êñÝáôïò, öáßíåôáé íá ìåôáâÜëëåôáé ðñïò ìßá äßáéôá äõôéêïý ôýðïõ ìå ìåéùìÝíç êáôáíÜëùóç ëá÷áíéêþí, ïóðñßùí êáé áõîçìÝíç êáôáíÜëùóç êñÝáôïò4,5. ÁõôÝò ïé áëëáãÝò áöïñïýí êõñßùò íåáñïýò åíÞëéêåò6. Óôç äéáìüñöùóç ôùí äéáôñïöéêþí ðñïôýðùí óçìáíôéêü ñüëï ðáßæåé ç åöçâéêÞ çëéêßá êáôÜ ôçí ïðïßá, åêôüò ôùí Üëëùí áëëáãþí ðïõ óõìâáßíïõí, ïé äéáôñïöéêÝò óõíÞèåéåò ËÝîåéò êëåéäéÜ: ÄéáôñïöéêÝò óõíÞèåéåò, êáôÜóôáóç èñÝøçò, êïéíùíéêï-äçìïãñáöéêïß ðáñÜãïíôåò, åöçâåßá ÕðïâëÞèçêå: 15 MáÀïõ 2002 ÅðáíõðïâëÞèçêå: 7 Ïêôùâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 20 Íïååìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: ÁñéóôïöÜíçò Ãêßêáò, Ãáâñéçëßäïõ 6, Áíù ÐáôÞóéá, ÁèÞíá, Ô.Ê. 11141, Ôçë.: (210) 2286830, e-mail:argikas@internet.gr

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

Ôüìïò 15, Ôåý÷ïò 4, 2003

ìáôïëïãßïõ ðïõ óõìðëÞñùóáí Åëëçíåò ìáèçôÝò Ëõêåßùí, çëéêßáò 15-18 åôþí (ÌÇ=16,4±0,9 Ýôç), ôñéþí ðåSummary ñéï÷þí ôçò ÅëëÜäáò: ìéÜò áóôéêÞò, ìéÜò Aim: To investigate the usual food habits of high school adolescents in relation çìéáóôéêÞò íçóéþôéêçò êáé ìéÜò êáôåto nutritional status and socio-demographic factors. Method and Participants: The random sample of 513 high school students from three geographic areas : îï÷Þí áãñïôéêÞò ðåñéï÷Þò. ÅðéëÝ÷èç(A) urban/city, (B) urban/town island and (C) rural/village was studied. They êå ôõ÷áßï äåßãìá 513 áôüìùí, áðü completed a questionnaire concerning socio-demographic characteristics and äýï ó÷ïëåßá. áíÜ ðåñéï÷Þ. Óõãêåêñéìfood habits (having breakfast, snacking and frequency of consumption of speìÝíá ôïí ðëçèõóìü ìåëÝôçò ìáò ôïí cific foodstuffs). Height and weight was measured and divided into overweight áðïôåëïýóáí 143 (28%) ìáèçôÝò/ôñéåò (14.4%) and normal on the basis of BMI. Results: Approximately 29% of the sample skipped breakfast, of which a greater proportion was overweight (41.9% Ëõêåßùí Ãáëáôóßïõ (ÁèÞíá), 172 vs 27.3%, p=0.011). Breakfast skipping was related to age, parents education, (33,5%) ôçò Óáëáìßíáò êáé 198 (38,5%) geographic area and level of urbanization. Seventy eight percent of adolescents ôïõ ¢óôñïõò Êõíïõñßáò. Ç Ýñåõíá äéåconsume a break snack. Daily consumption of vegetables was low(27%), and of îÞ÷èç ôïí Áðñßëéï 2000. fruits relatively moderate (60%). A proportion of 44% consumed meat at least Óôï åéäéêÜ äéáìïñöùìÝíï åñùôçthree times a week. 37% adolescents ate vegetables twice a week and 27% fish (more frequently in island areas). The use of olive oil in the preparation of ìáôïëüãéï õðÞñ÷áí åñùôÞóåéò ðïõ food was more frequent in rural areas. 91% consumed milk daily. 70-80% áöïñïýóáí óôéò äéáôñïöéêÝò óõíÞèåéåò frequently consumed soft drinks and sugary foods. Boys consume the most ó÷åôéêÝò ìå ôç ëÞøç ðñùéíïý, ôç êámeat, sausages, fish, refreshments and alcohol. Girls eat more fruit and vegetaôáíÜëùóç äéáöüñùí óíÜêò åíäéÜìåóá bles. An increase in the consumption of meat and a decrease in soft drinks and ðñéí ôï ìåóçìåñéáíü êáé ôç óõ÷íüôçalcohol, was noted if the level of parental education was higher. In urban higher/ med!ium areas the consumption of vegetables, meat and sausages is higher ôá êáôáíÜëùóçò ôùí åîÞò åðéëåãìÝand that of soft drinks and alcohol lower. Conclusion: The food habits of íùí ôñïößìùí: ÷üñôá/óáëÜôåò, öñïýadolescents are to a great degree healthy. They are shaped by a diet of healthy ôá/÷õìïß, êñÝáò, ãÜëá, øÜñéá, áëëánutrition. However they have the tendency to follow a western type diet. The íôéêÜ, üóðñéá, øùìß, ëÜäé, áíáøõêôémain related factors to food habits are: obesity, educational level of parents, êÜ, ïéíïðíåõìáôþäç, ãëõêßóìáôá êáé geographic area and level of urbanisation. Key words: Food habits, nutritional status, socio-demographic factors, adolesêáñõêåýìáôá. Åðßóçò ðåñéëáìâÜíïíôáí cents. åñùôÞóåéò ó÷åôéêÝò ìå ôá êïéíùíéêï1 2 äçìïãñáöéêÜ ÷áñáêôçñéóôéêÜ üðùò: ç Health Centre of Salamis, Health Centre of Astros çëéêßá, ôï öýëï, ç åêðáßäåõóç êáé ôï ðïõ åãêáèßóôáíôáé åßíáé êáèïñéóôéêÝò ãéá ôçí åðÜããåëìá ôùí ãïíÝùí (Ðßíáêáò É). åíÞëéêç æùÞ. Ãé’áõôü ç åãêáôÜóôáóç ôïõ åíäåÓôï óýíïëï ôïõò ìåôñÞèçêå ôï ýøïò, âÜñïò äåéãìÝíïõ ôñüðïõ äéáôñïöÞò áðáéôåß ðáñåìâÜ- êáé õðïëïãßóôçêå ï Äåßêôçò ÌÜæáò Óþìáôïò óåéò Þäç áðü áõôÞ ôçí çëéêßá, ïé ïðïßåò Ý÷åé (ÄÌÓ). Ïé Ýöçâïé ìå ÄÌÓ ³85ç – 95ç åêáôïáðïäåé÷èåß üôé åßíáé áðïôåëåóìáôéêÝò7, áöïý ðñù- óôéáßá èÝóç ãéá ôçí çëéêßá, ôï öýëï êáé ôç ëåõêÞ ôßóôùò Ý÷ïõí áðïôõðùèåß ïé äéáôñïöéêÝò ôïõò öõëÞ, ÷áñáêôçñßóôçêáí ùò õðÝñâáñïé êáé áõôïß óõíÞèåéåò. Óôïí åëëçíéêü ÷þñï ïé ó÷åôéêÝò ìåëÝ- ìå ÄÌÓ ³95ç ðá÷ýóáñêïé. Áõôüò ï äéá÷ùñéóìüò ôåò åßíáé ðåñéïñéóìÝíåò êáé áöïñïýí êõñßùò ðáé- Ýãéíå ìå âÜóç ôç ìåëÝôç NHANES (National Health and Nutrition Examination Surveys) ÉÉÉ äéÜ óôçí Ýíáñîç ôçò åöçâåßáò8. Ìå âÜóç áõôÜ ôá äåäïìÝíá óêïðüò ìáò Þôáí ôùí ÇÐÁ9. ÊáôáôÜ÷èçêáí óå äýï ïìÜäåò: 1) ôùí ç êáôáãñáöÞ ôùí äéáôñïöéêþí óõíçèåéþí ôùí õðÝñâáñùí/ðá÷ýóáñêùí êáé 2) ôùí öõóéïëïãéåöÞâùí, çëéêßáò 15-18 åôþí, êáé ç äéåñåýíçóç êþí åöÞâùí. Ç áíÜëõóç ôùí äåäïìÝíùí Ýãéíå óå ðñïóùáõôþí óå ó÷Ýóç ìå ôï öýëï, ôçí êáôÜóôáóç èñÝøçò, ôç ãåùãñáöéêÞ ðåñéï÷Þ (ëáìâÜíïíôáò õðü- ðéêü çëåêôñïíéêü õðïëïãéóôÞ ìå ôç ÷ñÞóç ôïõ øç êáé ôï âáèìü áóôéêïðïßçóçò), ôçí åêðáßäåõ- óôáôéóôéêïý ðñïãñÜììáôïò SPSS. Ãéá ôïí ðñïóäéïñéóìü ôùí óôáôéóôéêÜ óçìáíôéêþí äéáöïñþí óç êáé ôçí åñãáóéáêÞ êáôÜóôáóç ôùí ãïíÝùí. óôéò äéáôñïöéêÝò óõíÞèåéåò ìåôáîý äéáöüñùí êáôçãïñéþí ÷ñçóéìïðïéÞèçêå ç äïêéìáóßá ÷² (Pearson chi-square), êáèþò êáé ç äïêéìáóßá t-test. Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò To åðßðåäï óôáôéóôéêÞò óçìáíôéêüôçôáò êáèïñßÏé ðëçñïöïñßåò óõëëÝ÷èçêáí ìÝóù åñùôç- óôçêå óôï p<0,05. Food habits and related factors of high shcool adolescents. Gikas A1, Perdikaki P2

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

Ðßíáêáò É. ÄçìïãñáöéêÜ ÷áñáêôçñéóôéêÜ ôùí ìáèçôþí/ôñéþí Ëõêåßïõ ðïõ Ýëáâáí ìÝñïò óôç ìåëÝôç Çëéêßá (Ýôç) 15-15,9 16-16.9 17-18 Öýëï Áãüñéá Êïñßôóéá Ðåñéï÷Þ ÁèÞíá (áóôéêÞ) Óáëáìßíá (çìéáóôéêÞ) Áóôñïò (áãñïôéêÞ) Åêðáßäåõóç ðáôÝñá ÂáóéêÞ ÌÝóç Áíþôåñç/áíþôáôç Åêðáßäåõóç ìçôÝñáò ÂáóéêÞ ÌÝóç Áíþôåñç/áíþôáôç Åñãáóßá ôïõ ðáôÝñá Åëåýèåñïò åðáããåëìáôßáò Äçìüóéïò õðÜëëçëïò Éäéùôéêüò õðÜëëçëïò Óõíôáîéïý÷ïò Åñãáæüìåíç ìçôÝñá Íáé ¼÷é

Áñéèìüò

Ðïóïóôü

198 166 149

38,6% 32,4% 29,0%

243 270

47,4% 52,6%

143 172 198

27,9% 33,5% 38,6%

240 146 120

47,4% 28,9% 23,9%

250 180 62

50,8% 36,6% 12,6%

215 115 152 22

42,7% 22,8% 30,2% 4,4%

160 345

31,7% 68,3%

ÁðïôåëÝóìáôá Ðá÷ýóáñêïé Þôáí 12 Ýöçâïé 2,3%. ÕðÝñâáñïé/ðá÷ýóáñêïé: 74 (14,4%), 54 áãüñéá 22,2% êáé 20 êïñßôóéá 7,4% (p<0,0001).

1) ËÞøç ç ìç ðñùéíïý êáé êáôáíÜëùóç äéáöüñùí óíÜêò óôï äéÜëåéììá Ðñùéíü áíÝöåñáí üôé ëáìâÜíïõí ôï 70,6% (n=362) ôùí åñùôçèÝíôùí. Ôï 61% êáôáíáëþíïõí ãéá ðñùéíü êõñßùò ãÜëá êáé ìüíï ôï 9,6% ðåñéëáìâÜíïõí óôï ãåýìá ôïõò ôñïöÝò üðùò äçìçôñéáêÜ, áõãü, öñïýôï ç ÷õìü. ÃåíéêÜ, üóïí áöïñÜ ôçí êáôáíÜëùóç ãÜëáêôïò áõôÞ åßíáé êáèçìåñéíÞ óå ðïóïóôü 91%, ìå ðñïôßìçóç óôï óïêïëáôïý÷ï 47%. Ðïóïóôü 29,4% (n=151) ôùí åöÞâùí áíÝöåñáí üôé ðáñáëåßðïõí ôï ðñùéíü ôïõò, ÷ùñßò äéáöïñÝò ìåôáîý ôùí äýï öýëùí. Ôï ðïóïóôü áõôü áõîáíüôáí ìå ôçí çëéêßá (1ç–3ç Ëõêåßïõ, 25,6% Ýíáíôé 35,3%, p=0.047). Õøçëüôå160

ñïò åðéðïëáóìüò ðáñÜëåéøçò ðñùéíïý âñÝèçêå óôïõò åöÞâïõò ìå ðáôåñÜäåò êáôþôåñïõ åêðáéäåõôéêïý åðéðÝäïõ (35% Ýíáíôé 27,4% Ýíáíôé 21,7%, p=0,026) êáé óôïõò åöÞâïõò ôçò áãñïôéêÞò ðåñéï÷Þò (35,4% Ýíáíôé 29,7% Ýíáíôé 21%, p=0,016). To åêðáéäåõôéêü åðßðåäï ôçò ìçôÝñáò êáèþò êáé ç åñãáóéáêÞ áðáó÷üëçóç ôùí äýï ãïíÝùí äåí âñÝèçêáí íá ó÷åôßæïíôáé ìå ôçí ðáñÜëåéøç ðñùéíïý. ÓáöÞò Þôáí ç äéáöïñÜ ìåôáîý õðÝñâáñùí/ðá÷ýóáñêùí êáé öõóéïëïãéêþí áôüìùí (41.9% Ýíáíôé 27.3%, p=0.011). Ðïóïóôü 78% êáôáíáëþíåé äéÜöïñá óíÜêò êáôÜ ôç äéÜñêåéá ôïõ äéáëåßììáôïò, üðïõ ôá áãüñéá õðåñÝ÷ïõí Ýíáíôé ôùí êïñéôóéþí (86,4% Ýíáíôé 70,4%, p<0,0001). Áð’áõôïýò ôï 31% ðñïôéìÜ óÜíôïõéôò, 18% ôõñüðéôá, 9% êñïõáóÜí, 4,5% ðßíåé áíáøõêôéêü ç êáöÝ, åíþ ôï 15,5% äåí åßíáé óôáèåñü êáé ðñïôéìÜ äéÜöïñá óíÜêò. Oé Ýöçâïé ôùí áóôéêþí ðåñéï÷þí êáôáíáëþíïõí óõ÷íüôåñá óÜíôïõéôò åíþ ôçò áãñïôéêÞò ðåñéï÷Þò ðñïôéìïýí ôçí ôõñüðéôá.

2) Óõ÷íüôçôåò êáôáíÜëùóçò åðéëåãìÝíùí ôñïößìùí êáé ç ó÷Ýóç ôïõò ìå äéÜöïñåò ðáñáìÝôñïõò Ëá÷áíéêÜ (÷üñôá Þ óáëÜôåò) êáôáíáëþíïõí êáèçìåñéíÜ ðåñßðïõ ôï 27% ôùí åöÞâùí, ôï 44% óå óõ÷íüôçôá 3-5 öïñÝò ôçí åâäïìÜäá åíþ ôï 29% óðÜíéá ç ðïôÝ. Ïðùò öáßíåôáé óôïí ðßíáêá ÉÉ ó÷åôéêÜ ìåãáëýôåñï åßíáé ôá ðïóïóôü ôùí êïñéôóéþí, ðïõ êáôáíáëþíïõí êáèçìåñéíÜ ëá÷áíéêÜ, óå ó÷Ýóç ìå ôùí áãïñéþí. Åðßóçò, óõ÷íüôåñç åßíáé ç êáèçìåñéíÞ êáôáíÜëùóç ëá÷áíéêþí óôéò áóôéêÝò ðåñéï÷Ýò óå ó÷Ýóç ìå ôçí áãñïôéêÞ (31% Ýíáíôé 26% Ýíáíôé 19%, p=0,015). To ðïóïóôü êáèçìåñéíÞò êáôáíÜëùóçò öñïýôùí ç ÷õìþí Þôáí ðåñßðïõ 60% êáé áõôþí ìå óõ÷íüôçôá 3-5 ö/åâä 28%. Äéáðéóôþèçêå üôé ôá êïñßôóéá êáôáíáëþíïõí ðéï óõ÷íÜ öñïýôá/÷õìïýò óå ó÷Ýóç ìå ôá áãüñéá. ÓçìáíôéêÝò åßíáé ïé äéáöïñÝò ìåôáîý ôùí äýï öýëùí êáé óôçí êáôáíÜëùóç êñåáôéêþí, áíáøõêôéêþí êáé áëêïïëïý÷ùí ðïôþí. Ïóðñéá êáôáíáëþíïõí: 2 ö/åâä ôï 37%, 1 ö/åâä ôï 35% êáé óðÜíéá Þ ðïôÝ ôï 27%. Ç êáôáíÜëùóç êñÝáôïò åßíáé ðéï óõ÷íÞ óôïõò åöÞâïõò ìå ðáôåñÜäåò áíþôåñçò/Üôçò åêðáßäåõóçò (Ðßíáêáò ÉÉÉ). Ðáñüìïéá óõó÷Ýôéóç äéáðéóôþíåôáé êáé üóïí áöïñÜ ôçí åêðáßäåõóç ôçò ìçôÝñáò (p=0,034). ÃåíéêÜ ïé Ýöçâïé êáôáíáëþíïõí êñÝáò óå óõ÷íüôçôá: 4% êáèçìåñéíÜ, 40% 3-5 ö/åâä êáé 43% 1-2 ö/åâä.

Ôüìïò 15, Ôåý÷ïò 4, 2003

Á. Ãêßêáò, Ð. ÐåñäéêÜêç Ðßíáêáò ÉÉ. Óõ÷íüôçôåò êáôáíÜëùóçò ôñïößìùí, äéáöïñÝò ìåôáîý ôùí äýï öýëùí ÊÜèå ìÝñá

×üñôá/ÓáëÜôåò Öñïýôá/×õìïß Ïóðñéá ÊñÝáò ÁëëáíôéêÜ ØÜñéá ÁíáøõêôéêÜ ÆÜ÷áñç/Ãëõêßóì. Áëêïïëïý÷á Êáñõêåýìáôá

3-5 öïñÝò/åâä

2 öïñÝò/åâä

1 öïñÜ/åâä

Óõ÷íÜ

ÓðÜíéá-ÐïôÝ

Á %

Ê %

Á %

Ê %

Á %

Ê %

Á %

Ê %

Á %

Ê %

Á %

Ê %

21 59 ¯ 5 19 ¯ 38 26 13 27

28 61 ¯ 3 11 ¯ 12 33 2 13

46 25 ¯ 44 ¯ ¯ ¯ ¯ ¯ ¯

45 30 ¯ 37 ¯ ¯ ¯ ¯ ¯ ¯

¯ ¯ 39 47 29 33 ¯ ¯ ¯ ¯

¯ ¯ 35 53 18 21 ¯ ¯ ¯ ¯

¯ ¯ 34 ¯ 21 36 ¯ ¯ ¯ ¯

¯ ¯ 37 ¯ 21 43 ¯ ¯ ¯ ¯

¯ ¯ ¯ ¯ ¯ ¯ 41 50 34 46

¯ ¯ ¯ ¯ ¯ ¯ 45 48 17 44

33 16 27 4 31 31 21 24 53 27

27 9 28 7 50 37 43 19 81 43

0,044 0,048 ÍS 0,026 0,000 0,011 0,000 NS 0,000 0,000

NS= Ìç óçìáíôéêÞ äéáöïñÜ, Á: Áãüñéá, Ê: Êïñßôóéá

ÓçìáíôéêÞ Þôáí ç äéáöïñÜ óôçí óõ÷íüôçôá êáôáíÜëùóçò êñÝáôïò ìåôáîý áóôéêþí ðåñéï÷þí êáé áãñïôéêÞò ðåñéï÷Þò (Ðßíáêáò IV). Åðßóçò, üðùò ðáñïõóéÜæåôáé óôïí ðßíáêá ïé Ýöçâïé ôùí áóôéêþí ðåñéï÷þí êáôáíáëþíïõí åîßóïõ óõ÷íüôåñá êáé áëëáíôéêÜ. ØÜñéá êáôáíáëþíïõí: óôï 27% 2ö/åâä, óôï 39% 1ö/åâä êáé óå óçìáíôéêü âáèìü (34%) óðÜíéá ç ðïôÝ. Åßíáé ðñïöáíÝò üôé ç óõ÷íüôåñç êáôáíÜëùóç ãßíåôáé óôçí íçóéþôéêç ðåñéï÷Þ. ÁíáøõêôéêÜ êáôáíáëþíïõí êáèçìåñéíÜ ðåñßðïõ ôï 25%, óõ÷íÜ ôï 42% êáé óðÜíéá ôï 20%. Ôá áãüñéá áñêåôÜ óõ÷íüôåñá óå ó÷Ýóç ìå ôá êïñßôóéá. Ïé Ýöçâïé ìå ãïíåßò áíþôåñçò/Üôçò åêðáßäåõóçò êáôáíáëþíïõí óå ìéêñüôåñï âáèìü áíáøõêôéêÜ (ðáôÝñá p=0,021, ìçôÝñáò p=0,004). Ç êáôáíÜëùóç áëêïïëïý÷ùí ðïôþí ãßíåôáé óå êáèçìåñéíÞ âÜóç óôï 6% ôùí åöÞâùí, óõ÷íÜ óôï 26%, óðÜíéá 45% êáé êáèüëïõ óôï 23%. ÁöïñÜ êõñßùò ôá áãüñéá (p<0,0001) åíþ ðáñÜë-

ëçëá ó÷åôßæåôáé ìå ôçí êáôþôåñç åêðáßäåõóç ôùí ãïíÝùí (p=0,001, p=0,001) êáé ôçí ãåùãñáöéêÞ ðåñéï÷Þ (p<0,0001), êáèþò êáé ôï õðåñâÜëëïí âÜñïò/ðá÷õóáñêßá (p=0,014). Óôçí åôïéìáóßá ôïõ öáãçôïý ÷ñçóéìïðïéåßôáé êõñßùò ôï åëáéüëáäï, óðÜíéá óðïñÝëáéï ç âïýôõñï. Ôá ðïóïóôÜ áðïêëåéóôéêÞò êáôáíÜëùóçò ôïõ åëáéüëáäïõ Þôáí: áóôéêÞ ðåñéï÷Þ 85%, çìéáóôéêÞ 89%, áãñïôéêÞ 97% (p=0,001). Ïé Ýöçâïé êáôáíáëþíïõí ÷ùñéÜôéêï øùìß óå ìåãáëýôåñï ðïóïóôü (63%), Üóðñï 25%, ìáýñï 11%. ÊáôÜ ìÝóï üñï êáôáíáëþíïõí 1,73 öÝôåò øùìß áíÜ ãåýìá ìå ìåãáëýôåñç êáôáíÜëùóç áðü ôïõò åöÞâïõò ôçò áãñïôéêÞò ðåñéï÷Þò (p=0,016). Ðïóïóôü 10% ôùí åñùôçèÝíôùí áíÝöåñáí üôé ôñþíå ?3ö/ åâä óå fast food êáé ôï 39% óå óõ÷íüôçôá 1-2 ö/ åâä. Ôá áãüñéá óõ÷íüôåñá áðü ôá êïñßôóéá (p<0,0001). Ïóïí áöïñÜ ôç óõó÷Ýôéóç óõ÷íïôÞôùí êáôáíÜëùóçò ôñïößìùí ìå ôçí åñãáóéáêÞ êáôÜ-

Ðßíáêáò ÉÉÉ. Óõ÷íüôçôåò êáôáíÜëùóçò ôñïößìùí óå ó÷Ýóç ìå ôï åêðáéäåõôéêü åðßðåäï ôïõ ðáôÝñá ÊÜèå ìÝñá Â % ×üñôá/ÓáëÜôåò Öñïýôá/×õìïß Ïóðñéá ÊñÝáò ÁëëáíôéêÜ ØÜñéá ÁíáøõêôéêÜ Áëêïïëïý÷á

Ì Á % %

23 27 29 57 60 64 – 3 4 7 13 19 12 – 29 27 16 7 6 5

3-5 öïñÝò/åâä 2 öïñÝò/åâä Â %

Ì Á % %

46 42 47 30 29 27 – 34 46 51 – – – –

1 öïñÜ/åâä

Óõ÷íÜ

ÓðÜíéá-ÐïôÝ

Â Ì Á % % %

– – 35 46 24 35 – –

– – 36 32 39 — 22 23 20 37 35 43 – –

– – – – – – 46 43 41 33 22 12

36 57 20 28

39 39 28 30

32 13 28 6 45 35 25 61

29 11 33 4 34 30 30 72

24 NS 9 NS 22 NS 3 0,006 40 NS 27 NS 57 0.021 83 0,001

NS=Mç óçìáíôéêÞ äéáöïñÜ, B: ÂáóéêÞ, Ì: ÌÝóç, Á: Áíþôåñç/ÁíùôÜôç

161

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

Ðßíáêáò IV. ÄéáöïñÝò óôéò óõ÷íüôçôåò êáôáíÜëùóçò ôñïößìùí ìåôáîý ãåùãñáöéêþí ðåñéï÷þí ÊÜèå ìÝñá A % ×üñôá/ÓáëÜôåò Öñïýôá/×õìïß Ïóðñéá ÊñÝáò ÁëëáíôéêÜ ØÜñéá ÁíáøõêôéêÜ Áëêïïëïý÷á

Ç %

ÁÃ %

31 26 19 57 61 56 — 6 4 4 19 21 7 — 20 21 30 8 4 6

3-5 öïñÝò/åâä Á %

Ç ÁÃ % %

35 47 51 31 28 29 — 45 43 33 — — — —

2 öïñÝò/åâä Á %

Ç %

34 46 28 18

— — 39 45 23 41 — —

1 öïñÜ/åâä

ÁÃ %

Á Ç ÁÃ % % %

39 57 21 21

— — 35 35 36 — 19 18 26 47 36 37 — —

Óõ÷íÜ Á %

ÓðÜíéá-ÐïôÝ

Ç ÁÃ % %

Á %

— — — — — — 41 37 48 19 19 36

34 12 31 3 34 35 39 73

Ç ÁÃ % % 27 11 26 8 38 23 42 77

30 15 25 6 46 42 22 58

p 0,015 NS ÍS 0,033 0,002 0,000 0,001 0,000

NS=Ìç óçìáíôéêÞ äéáöïñÜ, Á: ÁóôéêÞ (ÁèÞíá), Ç: ÇìéáóôéêÞ (Óáëáìßíá), ÁÃ: ÁãñïôéêÞ (Áóôñïò)

óôáóç ôùí ãïíÝùí äåí äéáðéóôþèçêáí óçìáíôéêÝò äéáöïñÝò. Ó÷åôéêÜ ìå ôçí êáôÜóôáóç èñÝøçò âñÝèçêå üôé ôá õðÝñâáñá/ðá÷ýóáñêá Üôïìá êáôáíáëþíïõí óõ÷íüôåñá áíáøõêôéêÜ (p=0,024) êáé áëêïïëïý÷á ðïôÜ (p=0,014) óå ó÷Ýóç ìå ôá öõóéïëïãéêÜ (Ðßíáêáò V). Ïé óõ÷íüôçôåò êáôáíÜëùóçò ôùí õðïëïßðùí ôñïößìùí äåí ó÷åôßæïíôáé ìå ôï õðåñâÜëëïí âÜñïò/ðá÷õóáñêßá. ÅóôéÜæïíôáò óôçí ó÷Ýóç ìåôáîý åñãáóßáò ôçò ìçôÝñáò êáé ðá÷õóáñêßáò, âñÝèçêå üôé ôï ðïóïóôü õðÝñâáñùí/ðá÷ýóáñêùí áãïñéþí ìåôáîý áõôþí ìå åñãáæüìåíïé ìçôÝñá Þôáí õøçëüôåñï óå ó÷Ýóç ìå áõôþí ìå ìç åñãáæüìåíç ìçôÝñá (27% Ýíáíôé 20%), äéáöïñÜ ç ïðïßá üìùò äåí åßíáé óôáôéóôéêÜ óçìáíôéêç. Ôá áíôßóôïé÷á ðïóïóôÜ ìåôáîý ôùí êïñéôóéþí Þôáí ðáñüìïéá (7,2% Ýíáíôé 7,6%).

ÓõæÞôçóç Óôçí ðáñïýóá åñãáóßá ìåëåôÞèçêáí ïé äéáôñïöéêÝò óõíÞèåéåò ôùí åöÞâùí ëõêåéáêÞò çëéêßáò ïé ïðïßåò äåí Ý÷ïõí ìåëåôçèåß åðáñêþò óôç ÷þñá ìáò. ÁñêåôÜ óõ÷íÜ, ìå óêïðü ôçí ðéï áîéüðéóôç ìåëÝôç ôùí äéáôñïöéêþí óõíçèåéþí ÷ñçóéìïðïéåßôáé ç ìåèüäïò êáôáãñáöÞò ôçò óõ÷íüôçôáò êáôáíÜëùóçò ôñïößìùí óå óõíäõáóìü ìå ôç ìÝèïäï çìåñÞóéïõ ðïóïôéêïý ðñïóäéïñéóìïý ôùí ôñïößìùí 8,10. ËáìâÜíïíôáò õðüøéí ôéò äõóêïëßåò åöáñìïãÞò ôçò ôåëåõôáßáò ìåèüäïõ êáé ôéò äéáêõìÜíóåéò áðü ìÝñá óå ìÝñá ôçò äßáéôáò ôùí óõììåôå÷üíôùí êáèþò êáé ôéò åðï÷éáêÝò åðéäñÜóåéò ó’ áõôÞí11 åðéëÝîáìå íá óõëëÝîïõìå ôéò ó÷åôéêÝò ðëçñïöïñßåò – ðïõ áöïñïýóáí ôéò äéáôñïöéêÝò óõíÞèåéåò ôùí åöÞâùí – ÷ñçóéìïðïéþíôáò ôï åñùôçìáôïëüãéï åâäïìáäéáßáò óõ÷íüôçôáò

Ðßíáêáò V. ÄéáöïñÝò óôéò óõ÷íüôçôåò êáôáíÜëùóçò ôñïößìùí ìåôáîý öõóéïëïãéêþí êáé õðÝñâáñùí/ðá÷ýóáñêùí åöÞâùí ÊÜèå ìÝñá

×üñôá/ÓáëÜôåò Öñïýôá/×õìïß Ïóðñéá ÊñÝáò ÁëëáíôéêÜ ØÜñéá ÁíáøõêôéêÜ Ãëõêßóìáôá Áëêïïëïý÷á Êáñõêåýìáôá

3-5 öïñÝò/åâä

2 öïñÝò/åâä

1 öïñÜ/åâä

ÓðÜíéá-ÐïôÝ

Ö %

Õ/Ð %

Ö %

Õ/Ð %

Ö %

Õ/Ð %

Ö Õ/Ð % %

25 61 – 4 16 – 23 31 5 18

46 27 – 40 – – – – – –

43 30 – 41 – – – – – –

– – 36 43 23 26 – – – –

– – 42 41 30 34 – – – –

– – 36 7 21 41 – – – –

– – 32 11 22 30 – – – –

– – – – – – 43 48 25 46

29 12 28 6 40 33 34 21 70 36

22 53 – 5 10 – 34 20 14 24

NS=Ìç óçìáíôéêÞ äéáöïñÜ, Ö: Áôïìá ìå öõóéïëïãéêü âÜñïò, Õ/Ð: ÕðÝñâáñá/ðá÷ýóáñêá

162

Óõ÷íÜ

Ö Õ/Ð % %

– – – – – – 43 57 31 41

35 NS 17 NS 26 ÍS 2 NS 38 NS 36 NS 23 0.024 23 NS 55 0.014 35 NS

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

êáôáíÜëùóçò ôñïößìùí ôï ïðïßï áðïôåëåß ìßá áðïäåêôÞ ìÝèïäïò ãéá ðáñüìïéåò åðéäçìéïëïãéêÝò ìåëÝôåò6,12. Áðü ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò äéáðéóôþíåôáé üôé ðåñßðïõ ôï 29% ôùí åöÞâùí ðáñáëåßðïõí ôï ðñùéíü ôïõò, ðáñüôé áõôü áðïôåëåß Ýíá óçìáíôéêü ãåýìá ôçò çìÝñáò. Ôï ðïóïóôü áõôü óõãêñéíüìåíï ìå áíÜëïãá ðïóïóôÜ åöÞâùí, ßäéáò çëéêßáò, Üëëùí áíåðôõãìÝíùí ÷ùñþí öáßíåôáé íá åßíáé áðü ôá õøçëüôåñá. Óå ìåëÝôåò áðü Üëëåò ÷þñåò (Iáðùíßá, Íïñâçãßá, Ïëëáíäßá, ÇÐÁ) ï åðéðïëáóìüò ðáñÜëåéøçò ðñùéíïý êõìáßíåôáé áðü 18-30%13-16. Ïé äéáðéóôþóåéò ìáò üôé ç ðáñÜëåéøç ðñùéíïý óõó÷åôßæåôáé èåôéêÜ ìå ôçí çëéêßá êáé áñíçôéêÜ ìå ôï åêðáéäåõôéêü åðßðåäï ôïõ ðáôÝñá êáé ôï âáèìü áóôéêïðïßçóçò ôçò ðåñéï÷Þò ðïõ äéáìÝíïõí ïé Ýöçâïé óõìâáäßæåé ìå ôá äåäïìÝíá ôçò äéåèíÞò âéâëéïãñáößáò. Ç áðïöõãÞ ôïõ ðñùéíïý Ý÷åé óõó÷åôéóèåß ìå áõîÞìÝíï êßíäõíï ðá÷õóáñêßáò16, ç ïðïßá ó÷Ýóç åðéâåâáéþíåôáé êáé óôçí ìåëÝôç ìáò, áðïäåéêíýïíôáò ôçí óçìáóßá áõôïý ôïõ ãåýìáôïò. Åßíáé óçìáíôéêü ï Ýöçâïò íá îåêéíÜåé ôçí åíÞëéêç æùÞ ôïõ ìå õãéåéíÝò óõíÞèåéåò üðùò ç êáíïíéêÞ ëÞøç ðñùéíïý. Ïðùò äåß÷íïõí êáé ôá åõñçìáôÜ ìáò áñêåôÜ óõ÷íÞ åßíáé, óôçí åöçâåßá, ç êáôáíÜëùóç äéáöüñùí óíáêò êáé ðñü÷åéñùí öáãçôþí (fast foods) ôá ïðïßá, ùò ãíùóôüí, êáëýðôïõí ìåãÜëï ðïóïóôü ôçò çìåñÞóéáò åíÝñãåéáò êáé Ý÷ïõí ìåéùìÝíç èñåðôéêÞ áîßá. Óå áíôßèåóç ìå ôéò ïäçãßåò õãéåéíÞò äéáôñïöÞò, ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò äåß÷íïõí üôé ìüíï ôï 27% ôùí åöÞâùí êáôáíáëþíïõí êáèçìåñéíÜ ëá÷áíéêÜ, ðïóïóôü ôï ïðïßï åßíáé áñêåôÜ ìéêñü ãéá ôá ÅëëçíéêÜ ðáñáäïóéáêÜ äéáôñïöéêÜ äåäïìÝíá êáé ðïëý êïíôÜ ìå áõôþí ôùí Äõôéêï-Åõñùðáéêþí ÷ùñþí10,12. Ìðïñåß ôï ðïóïóôü êáèçìåñéíÞò êáôáíÜëùóçò öñïýôùí óôïõò åöÞâïõò ìáò, íá äéáôçñåßôáé óå ó÷åôéêÜ õøçëüôåñá åðßðåäá óå ó÷Ýóç ìå ôùí Üëëùí ÷ùñþí ôçò ÊåíôñéêÞò êáé Âüñåéáò Åõñþðçò, áëëÜ ãéá ôá äéêÜ ìáò äåäïìÝíá åßíáé åíäåéêôéêü ôçò áíåðáñêïýò êáôáíÜëùóçò öñïýôùí áðü Ýíá óçìáíôéêü ðïóïóôü åöÞâùí. Ôá üóðñéá öáßíåôáé íá ìÞí áðïôåëïýí óçìáíôéêÞ ðçãÞ ðñüóëçøçò ðñùôåúíþí, ãéá ôïí óýã÷ñïíï Ýöçâï, áðïäåéêíýïíôáò Ýôóé ç ìåßùóç êáôáíáëùóÞò ôïõò áðïôåëåß ìßá áðü ôéò âáóéêÝò ìåôáâïëÝò ðïõ õðÝóôç ç ðáñáäïóéáêÞ ÅëëçíéêÞ äéáôñïöÞ. ÁíôéèÝôùò ôï êñÝáò êáé ôá áëëáíôéêÜ,

Ôüìïò 15, Ôåý÷ïò 4, 2003

âÜóåé ôùí ó÷åôéêÜ õøçëþí ðïóïóôþí êáôáíÜëùóçò, áðïôåëïýí ìßá áðü ôéò óçìáíôéêüôåñåò ðçãÝò ðñùôåéíþí, ðáñåêêëßíïíôáò Ýôóé ðñïò ôç äßáéôá äõôéêïý ôýðïõ. Åíþ ç ó÷åôéêÜ ìÝôñéá êáôáíÜëùóç øáñéþí áðü ôïõò åöÞâïõò ìáò ßóùò íá óõìâÜëëåé óôçí êáëýôåñç äéáôñïöéêÞ éóïññïðßá. Ç çìåñÞóéá êáôáíÜëùóç åëáéüëáäïõ, ùò Ýíá áðü ôá âáóéêÜ ÷áñáêôçñéóôéêÜ ôçò ðáñáäïóéáêÞò äéáôñïöÞò, öáßíåôáé íá äéáôçñåßôáé óôç óõíôñéðôéêÞ ðëåéïøçößá ôùí åöÞâùí êáé ôùí ïéêïãåíåéþí ôïõò. Ôá áðïôåëÝóìáôá ìáò äåß÷íïõí üôé ôá áíáøõêôéêÜ êáé ôá æá÷áñþäç êáôáíáëþíïíôáé óõ÷íÜ (áðü ôï 70-80% ôùí åöÞâùí), ôá ïðïßá ðñïêáëïýí áíåðáñêÞ ðñüóëçøç åíäåäåéãìÝíçò ôñïöÞò ðëïýóéá óå õäáôÜíèñáêåò, öõôéêÝò ßíåò êáé é÷íïóôïé÷åßá. Oóïí áöïñÜ ôá ïéíïðíåõìáôþäç óïâáñüôåñï ãßíåôáé ôï ðñüâëçìá áí ôï äïýìå êáé áðü ôçí êïéíùíéêÞ ôïõ ðëåõñá (åèéóìüò, áéôßá áôõ÷çìÜôùí êáé ôñáõìáôéóìþí ê.ëð.). Ìå âÜóç ôá äåäïìÝíá ôçò ðáñïýóáò ìåëÝôçò, äéáðéóôþíåôáé üôé áðü ôïõò óçìáíôéêüôåñïõò ðáñÜãïíôåò ðïõ ó÷åôßæïíôáé ìå ôéò äéáôñïöéêÝò óõíÞèåéåò åßíáé ôï öýëï. Öáßíåôáé üôé ïé åðéëïãÝò ôùí êïñéôóéþí ó÷åôéêÜ ìå ôçí êáôáíÜëùóç ëá÷áíéêþí, öñïýôùí, êñåáôéêþí, áíáøõêôéêþí êáé ïéíïðíåõìáôùäþí åßíáé ðéï õãéåéíÝò. ÁõôÝò ïé äéáöïñÝò ìåôáîý ôùí äýï öýëùí Ý÷ïõí äéáðéóôùèåß êáé óå Üëëåò ìåëÝôåò, åëëçíéêÝò17 êáé îÝíåò10,12,15. Ðñïöáíþò ôá áãüñéá åßíáé ðéï åðéññåðåßò óôïõò äéáôñïöéêïýò “ðåéñáóìïýò”, ßóùò êáé ãé´áõôü ôï ðïóïóôü õðÝñâáñùí/ðá÷ýóáñêùí åßíáé áñêåôÜ ìåãáëýôåñï. Ó’áõôü óõìâÜëëïõí êáé ïé óýã÷ñïíïé ðïëéôéóìéêïß ðáñÜãïíôåò ïé ïðïßïé åðéâÜëëïõí, óôï ãõíáéêåßï öýëï, áõóôçñüôåñïõò ðåñéïñéóìïýò óå èÝìáôá ðïõ ó÷åôßæïíôáé ìå ôçí åìöÜíéóç. Ôï õðåñâÜëëïí âÜñïò êáé ç ðá÷õóáñêßá, åêôüò ìå ôçí ðáñÜëåéøç ðñùéíïý, ó÷åôßæïíôáé êáé ìå ôçí óõ÷íüôåñç êáôáíÜëùóç áíáøõêôéêþí êáé ïéíïðíåõìáôùäþí - áðïôåëÝóìáôá ôá ïðïßá óõìöùíïýí ìå ôá åõñÞìáôá Üëëùí ìåëÝôþí18,19 – êáé åßíáé åíäåéêôéêÜ ôùí äéáéôçôéêþí ðáñåêôñïðþí ðïõ õðüêåéíôáé ïé ðá÷ýóáñêïé Ýöçâïé. Ôï üôé äåí õðÜñ÷åé ðëÞñçò ôáýôéóç ìå ôá áðïôåëÝóìáôá Üëëùí ìåëåôþí ðïõ áöïñïýí ð.÷. ôçí êáôáíÜëùóç êñÝáôïò, áëëáíôéêþí êáé ãëõêéóìÜôùí, ðñïöáíþò ïöåßëåôáé óôçí áäõíáìßá ôçò ìåëÝôçò ìáò íá ðñïóêïìßóåé ðïóïôéêÜ óôïé÷åßá ðïõ áöïñïýí ôçí óýóôáóç ôçò äßáéôáò, áäõíáìßá ç ïðïßá áðáé163

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôåß íá åßìáóôå åðéöõëáêôéêïß óôçí åñìçíåßá ôùí áñíçôéêþí áðïôåëåóìÜôùí óõó÷Ýôéóçò ìåôáîý êáôÜóôáóçò èñÝøçò êáé êáôáíÜëùóçò ïñéóìÝíùí ôñïößìùí. Ïóïí áöïñÜ ôï åêðáéäåõôéêü åðßðåäï ôùí ãïíÝùí (ðáñÜ ôçí ìç äéáðßóôùóç óçìáíôéêþí äéáöïñþí) öáßíåôáé üôé óôéò ïéêïãÝíåéåò ìå áíþôåñï åêðáéäåõôéêü åðßðåäï ôùí ãïíÝùí ïé ôÜóåéò åßíáé ðñïò ôçí äéáôÞñçóç ðéï õãéåéíþí äéáôñïöéêþí óõíçèåßùí ó÷åôéêÜ ìå ôçí êáôáíÜëùóç ïóðñßùí, ëá÷áíéêþí, øáñéþí, áíáøõêôéêþí êáé ïéíïðíåõìáôùäþí ðáñÜ ôçí ó÷åôéêÜ óõ÷íüôåñç êáôáíÜëùóç êñÝáôïò. Ó’ áõôü ßóùò íá óõìâÜëëåé ç êáëýôåñç åíçìÝñùóç ãéá ôç äéáôñïöÞ. Ïðùò äéáðéóôþíåôáé óôçí ìåëÝôç ìáò, ïé Ýöçâïé ðïõ äéáìÝíïõí óôéò áóôéêÝò ðåñéï÷Ýò áêïëïõèïýí óõ÷íüôåñá ôéò ìç åíäåäåéãìÝíåò óõíÞèåéåò ùò ðñïò ôçí êáôáíÜëùóç êñÝáôïò, áëëáíôéêþí êáé øùìéïý óå ó÷Ýóç ìå ôéò ëéãüôåñï áóôéêïðïéçìÝíåò. Áõôü áðïäåéêíýåé ôç óçìáíôéêÞ èÝóç ðïõ êáôÝ÷åé ç êáôáíÜëùóç êñÝáôïò óôï óýã÷ñïíï ôñüðï äéáôñïöÞò. ÅíäéáöÝñïí ðáñïõóéÜæïõí ïé äéáöïñÝò óôçí êáôáíÜëùóç ëá÷áíéêþí ìåôáîý ôùí ôñéþí ðåñéï÷þí üðïõ óôçí áãñïôéêÞ ðåñéï÷Þ ç êáôáíÜëùóç Þôáí ëéãüôåñï óõ÷íÞ. H åîÞãçóç ðïõ ìðïñïýìå íá äþóïõìå ó’áõôü ôï åýñçìá åßíáé üôé ðéèáíþò ïöåßëåôáé óôo ãåãïíüò üôé ç ðëåéïøçößá ôùí åöÞâùí ðïõ äéáìÝíïõí óôéò ëéãüôåñï áóôéêïðïéçìÝíåò ðåñéï÷Ýò áíÞêïõí óå ïéêïãÝíåéåò ìå ÷áìçëüôåñï êïéíùíéêï-ïéêïíïìéêü åðéðÝäï – üðùò äéáðéóôþíåôáé êáé óôçí ðáñïýóá ìåëÝôç ôï ïðïßï ùò ãíùóôüí åðéäñÜ áñíçôéêÜ óôéò äéáôñïöéêÝò åðéëïãÝò ôùí åöÞâùí6. Óôçí ýðáñîç óçìáíôéêþí äéáöïñþí ó÷åôéêþí ìå ôçí óõ÷íüôçôá êáôáíÜëùóçò øáñéþí êáé åëáéüëáäïõ ìåôáîý ôùí ðåñéï÷þí ðñïöáíþò óõìâÜëëïõí ïéêïíïìéêïß êáé ðáñáäïóéáêïß ðáñÜãïíôåò. ¼ëá áõôÜ äåß÷íïõí ôçí ðïëõðáñáãïíôéêÞ åðßäñáóç óôéò äéáôñïöéêÝò óõíÞèåéåò ôùí åöÞâùí êáé ãåíéêüôåñá ïëüêëçñïõ ôïõ ðëçèõóìïý. ÓõìðåñáóìáôéêÜ, ìðïñïýìå íá ðïýìå üôé ïé äéáôñïöéêÝò óõíÞèåéåò ôùí åöÞâùí ëõêåéáêÞò çëéêßáò áðïêëßíïõí óå óçìáíôéêü âáèìü áðü ôïí åíäåäåéãìÝíï ôñüðï äéáôñïöÞò. Ôá âáóéêÜ ÷áñáêôçñéóôéêÜ ôçò ðáñáäïóéáêÞò ÅëëçíéêÞò äéáôñïöÞò Ý÷ïõí ìåôáâëçèåß, óôçí ðëåéïøçößá ôùí åöÞâùí, êáé ïé ãåíéêÝò ôÜóåéò áõôþí ðáñåêêëßíïõí ðåñéóóüôåñï ðñïò ôï äéáôñïöéêü ðñüôõðï äõôéêïý ôýðïõ. Óçìáíôéêïß ðáñÜãïíôåò ðïõ ó÷åôßæïíôáé ìå ôéò åíäåäåéãìÝíåò ç ìÞ äéáôñïöéêÝò óõíÞ164

Á. Ãêßêáò, Ð. ÐåñäéêÜêç

èåéåò åßíáé ôï öýëï, ç èñåðôéêÞ êáôÜóôáóç, ôï ìïñöùôéêü åðßðåäï ôùí ãïíÝùí, ç ãåùãñáöéêÞ ðåñéï÷Þ êáé ï âáèìüò áóôéêïðïéçóÞò ôçò. Ìå áõôÜ ôá äåäïìÝíá êáé óå óõíäõáóìü ìå ôçí áýîçóç ôçò åðßðôùóçò ôùí íïóçìÜôùí öèïñÜò óôïí Åëëçíéêü ðëçèõóìü1-3, ôçí ßäéá óôéãìÞ ðïõ óôéò Üëëåò áíáðôõãìÝíåò ÷þñåò õðÜñ÷åé ìåßùóç, ôï äéáôñïöéêü æÞôçìá áíáäåéêíýåôáé óå ìåßæïí ðñüâëçìá. Óçìáíôéêü ñüëï óôçí êáôáãñáöÞ êáé åí óõíå÷åßá ðáñÝìâáóç ãéá âåëôßùóç ôùí äéáôñïöéêþí óõíçèåéþí ôùí åöÞâùí êáèþò êáé ïëüêëçñïõ ôïõ Åëëçíéêïý ðëçèõóìïý ìðïñïýí íá äéáäñáìáôßóïõí ôá ÊÝíôñá Õãåßáò ôá ïðïßá èá ëÜâïõí õðüøéí ôéò üðïéåò éäéáéôåñüôçôåò ôçò ðåñéï÷Þò åõèýíçò ôïõò. Âéâëéïãñáöéá 1. Chimonas ET. The treatment of coronary heart disease: an update. Part 2: Mortality trends and main causes of death in the Greek population. Curr Med Res Opin, 17:27-33, 2001. 2. Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obes Metab Disord, 20:488492, 1996. 3. Ðåôñßäïõ Å, Ôñé÷üðïõëïò Ä. Åðéäçìéïëïãßá êáé áéôéïëïãßá êáêïÞèùí íåïðëáóéþí. Áñ÷åßá ÅëëçíéêÞò ÉáôñéêÞò, 13:252-273, 1996. 4. Trichopoulu A, Katsouyanni K, Gnardellis C. The traditional Greek diet. Eur J Clin Nutr, 47(suppl 1):76-81, 1993. 5. Trichopoulu A, Efstadhiadis P. Changes in nutrition patterns and health indications at the population level in Greece. Am J Clin Nutr, 49:1042-1047, 1989. 6. Ðáðáåõóôáèßïõ Á, ÂáóéëÜêïõ Ô, Ôñé÷ïðïýëïõ Á. ÄéáôñïöéêÝò ãíþóåéò êáé óôÜóåéò óðïõäáóôþí ôïõ ÔÅÉ ÁèÞíáò. ÉáôñéêÞ, 75:232-237, 1999. 7. Lionis C, Kafatos A, Vlachonikolis J, Vakaki M, Tzortzi M, Petraki A. The effects of health education intervention program among Cretan adolescents. Prev Med, 20:685-699, 1991. 8. ËõäÜêç Å, ÊáöÜôïò Á, ÊïõíÜëç Ä, ÁðïóôïëÜêç É. ÄéáéôçôéêÝò óõíÞèåéåò, öõóéêÞ äñáóôçñéüôçôá êáé ëéðßäéá ïñïý ðá÷ýóáñêùí ðáéäéþí çëéêßáò 12-14 ÷ñïíþí. ÐáéäéáôñéêÞ, 57:330-347, 1994. 9. Rosner B, Prineas R, Loggie J, Daniels SR. Percentiles for body mass index in U.S. children 5 to 17 years of age. J Pediatr, 132:211222, 1998 10. Paulus D, Saint-Remy A, Jeanjean M. Dietary

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18.

19.

Nutritional status and food intake in adolescents living in Western Europe. Eur J Clin Nutr, 54(suppl 1):41-46, 2000. Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United States from 1965-1991. Am J Clin Nutr, 67:7489-7565, 1998. Çassapidou MN, Fotiadou E. Dietary intakes and food habits of adolescents in Northern Greece. Int J Food Sci Nutr, 52:109-116, 2001. Nicklas TA, Yang SJ, Baranowski T, Zakeri I, Berenson G. Eating patterns and obesity in children. The Bogalusa Heart Study. Am J Prev Med, 25:9-16, 2003. Gillis LJ, Kennedy LC, Gillis AM, Bar-Or O. Relationship between juvenile obesity, dietary energy and fat intake and physical activity. Int J Obes Relat Metab Disord, 26:458-463, 2002.

ÌÉÁ ÓÇÌÁÍÔÉÊÇ ÅÉÄÇÓÇ Ðñüóöáôá åíçìåñùèÞêáìå üôé ôï ðåñéïäéêü THE EUROPEAN JOURNAL OF GENERAL PRACTICE óõìðåñéëÞöèçêå óôç âÜóç äåäïìÝíùí ôïõ PAPMED & MED LINE. To site ôïõ Ðåñéïäéêïý áõôïý åßíáé:

http://www.ejgp.com

165

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ä. ÂÞíç êáé óõí

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 15, Number 4, 166-171, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 166-171, 2003

ÅíõäÜôùóç ðáéäéþí ìå Þðéá Ýùò ìÝôñéá áöõäÜôùóç ëüãù åìÝôùí óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò Ä. ÂÞíç1, ×. Æáâüò2, Ì. ÂåíéæÝëïò3

Ðåñßëçøç Óêïðüò: Ïé Ýìåôïé åßíáé Ýíá óõ÷íü óýìðôùìá êáôÜ ôçí ïîåßá ãáóôñåíôåñßôéäá êáé ðïëëÝò öïñÝò äõíáôüí íá åßíáé ç ìüíç Þ ç åíáñêôÞñéá åêäÞëùóç. Ç ðáñïýóá áíáäñïìéêÞ ìåëÝôç äéåñåõíÜ ôçí áíôéìåôþðéóç ðáéäéþí ìå ðñïåîÜñ÷ïí óýìðôùìá åìÝôïõò, óå êÝíôñï õãåßáò áãñïôéêÞò ðåñéï÷Þò êáé áíé÷íåýåé ôçí ïñèüôçôá, ôéò ðáñáëåßøåéò êáé ôá ëÜèç ôùí êëéíéêþí óôçí áîéïëüãçóç êáé áíôéìåôþðéóç ôïõ óõìðôþìáôïò. Áóèåíåßò-ìÝèïäïò: 93 ðáéäéÜ, çëéêßáò 3 ìçíþí Ýùò 6 åôþí, ðñïóÞëèáí óôï êÝíôñï õãåßáò ãéá åìÝôïõò êáé Þðéá Ýùò ìÝôñéá áöõäÜôùóç êáé ÷ùñßóèçêáí óå äýï ïìÜäåò. Ç ïìÜäá Á ðåñéåëÜìâáíå 45 ðáéäéÜ ðïõ ðñïóÞëèáí êáôÜ ôï ðñùéíü ùñÜñéï êáé ç ïìÜäá Â 48 ðáéäéÜ ðïõ ðñïóÞëèáí óôç äéÜñêåéá ôçò åöçìåñßáò. ÁðïôåëÝóìáôá: Ç åíäïöëÝâéá èåñáðåßá ðñïôéìÞèçêå êõñßùò óôá ðáéäéÜ ôçò ïìÜäáò Â (P=0,015). 33 áðü 42 (78,6%) ðáéäéÜ ôçò ïìÜäáò Á ðïõ áíôéìåôùðßóèçêáí per os, åíõäáôþèçêáí óôï êÝíôñï õãåßáò, åíþ ìüíï 14 áðü ôá 36 (38,9%) ðáéäéÜ ôçò ïìÜäáò Â åíõäáôþèçêáí per os óôï êÝíôñï õãåßáò (P=0,0004). 3 áðü 42 (7,1%) ðáéäéÜ ôçò ïìÜäáò Á êáé 11 áðü 36 (30,6%) ðáéäéÜ ôçò ïìÜäáò Â ðïõ Ýëáâáí per os åíõäÜôùóç åðáíÞëèáí óôï ðñþôï 24ùñï (P=0,027). ÁíôéåìåôéêÜ ÷ïñçãÞèçêáí óå 9 (18,75%) ðáéäéÜ áðü ôçí ïìÜäá Â êáé óå êáíÝíá ðáéäß ôçò ïìÜäáò Á (P=0,004). ÓõìðåñÜóìáôá: Ó÷åäüí üëá ôá ðáéäéÜ ìå åìÝôïõò êáé Þðéá Ýùò ìÝôñéá áöõäÜôùóç äýíáíôáé íá áíôéìåôùðéóèïýí ìå per os åíõäÜôùóç, ìéá áðïôåëåóìáôéêÞ êáé öèçíÞ èåñáðåßá. Ç per os åíõäÜôùóç äåí ÷ñçóéìïðïéåßôáé áêüìç üðùò ðñÝðåé áðü ôïõò êëéíéêïýò. Ïé éáôñïß ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò ðñÝðåé íá åîïéêåéùèïýí ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ãéá per os åíõäÜôùóç êáé áðïöõãÞ áíôéåìåôéêþí.

Ðáéäßáôñïò, 2Åéäéêåõüìåíïò éáôñüò, 3Ä/íôÞò ÃåíéêÞò ÉáôñéêÞò, ÊÝíôñï Õãåßáò Ãüííùí Íïìïý ËÜñéóáò

166

ÅéóáãùãÞ Ùò ïîåßá ãáóôñåíôåñßôéäá ïñßæåôáé ç äéáññïúêÞ íüóïò ôá÷åßáò Ýíáñîçò ìå Þ ÷ùñßò óõíïäÜ óõìðôþìáôá üðùò íáõôßá, Ýìåôïé, ðõñåôüò êáé/Þ êïéëéáêü Üëãïò. ÐáñÜ ôï ãåãïíüò üôé ç Ýìöáóç ôçò íüóïõ âñßóêåôáé óôá äéáññïúêÜ åðåéóüäéá ïé Ýìåôïé ìðïñïýí åðßóçò íá åßíáé Ýíá óçìáíôéêü óôïé÷åßï ôçò íüóïõ Þ êáé ç ìüíç åêäÞëùóç. Ïé éïß êáé êõñßùò ïé Rota éïß Ý÷ïõí ìåôáôïðßóåé ôçí åðßðôùóç ôçò íüóïõ óôïõò ÷åéìåñéíïýò ìÞíåò, áöïý åßíáé ðëÝïí ïé êýñéïé õðåýèõíïé ôçò ëïéìþäïõò ãáóôñåíôåñßôéäáò óôïí áíáðôõãìÝíï êüóìï (70-80% óôçí ÁìåñéêÞ) óôéò ìéêñÝò çëéêßåò1,2. Óêïðüò ôçò ðáñïýóáò áíáäñïìéêÞò åñãáóßáò Þôáí íá ðñïóäéïñéóèåß ï ôñüðïò áíôéìåôþðéóçò ôçò áöõäÜôùóçò áðü ãáóôñåíôåñßôéäá, ìå ðñïåîÜñ÷ïí óýìðôùìá ôïõò åìÝôïõò, ôüóï êáôÜ ôç äéÜñêåéá ôïõ ðñùéíïý ùñáñßïõ üóï êáé óôçí åöçìåñßá êáé íá óõãêñéèïýí ËÝîåéò êëåéäéÜ: Ýìåôïò, áöõäÜôùóç, per os, iv, áíôéåìåôéêÜ, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: 4 Íïåìâñßïõ 2002 ÅðáíõðïâëÞèçêå: 3 Öåâñïõáñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 7 Ïêôùâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Ìé÷áÞë ÂåíéæÝëïò, ÊÝíôñï Õãåßáò Ãüííùí, 400 04, Ãüííïé ËÜñéóáò, Tçë. (24950) 31200, Fax. (24950) 31585, e-mail: czavos@hotmail.com

Ä. ÂÞíç êáé óõí

Ôüìïò 15, Ôåý÷ïò 4, 2003

ãá ìå ôçí þñá ðñïóÝëåõóÞò ôïõò. Ç ïìÜäá Á ðåñéåëÜìâáíå 45 ðáéäéÜ ðïõ ðñïóÞëèáí óôï êÝíôñï õãåßáò êáôÜ ôï ðñùéíü ùñÜñéï, åíþ ç ïìÜäá Â ðåñéåSummary ëÜìâáíå 48 ðáéäéÜ ðïõ ðñïóÞëèáí Aim: Vomiting in the course of acute gastroenteritis constitutes a frequent symptom and many times it can be the sole or preliminary manifestation. The óôçí åöçìåñßá. Ôá ðáéäéÜ óôï ðñùéíü study investigates the management of children with vomiting as principal sympùñÜñéï áíôéìåôùðßóèçêáí êõñßùò áðü tom, at a rural health centre and reveal the accuracy, negligence and faults of ðáéäßáôñï êáé áðü ãåíéêïýò éáôñïýò, clinicians in assesing and coping with this symptom. Patients and Method: 93 åíþ óôéò åöçìåñßåò áðü éáôñïýò üëùí children, aged between 3 months and 6 years, were refered to our health centre ôùí âáèìßäùí. Ïé ðáñÜìåôñïé ðïõ êáwith vomiting and mild to moderate dehydration. They were divided into two groups. Group A consisted of 45 children that were referred in the morning, and ôáãñÜöçêáí ãéá êÜèå ïìÜäá ÷ùñéóôÜ group B comprised 48 children that came during the shift. Results: Intravenous Þôáí ï ôñüðïò êáé ï ôüðïò åíõäÜôùtherapy was preferred mainly in group B (P=0.015). 33 out of 42 (78.6%) orally óçò, ï âáèìüò áöõäÜôùóÞò ôïõò4, ç rehydrated children of group A were treated at the health centre, whereas only õðïôñïðÞ ôùí åìÝôùí êáôÜ ôçí åíõ14 out of 36 (38.9%) children of group B received oral therapy at the health äÜôùóç óôï êÝíôñï õãåßáò, ç åðáíácentre (P=0.0004). 3 out of 42 (7.1%) of group A and 11 out of 36 (30.6%) of group B that were treated orally revisited the health centre in the first 24 hours ðñïóÝëåõóÞ ôïõò ôï åðüìåíï äéÞìåñï post treatment (P=0.004). Conclusion: Almost all children who suffer mild to ãéá åììïíÞ ôùí óõìðôùìÜôùí êáé ç moderate dehydration due to vomiting can be managed orally, which is an ÷ïñÞãçóç áíôéåìåôéêþí. Ç óýãêñéóç effective and inexpensive option. Per os rehydration is not employed, as it ôùí ðñïáíáöåñèÝíôùí ðáñáìÝôñùí should be by clinicians. Primary health care doctors should be familiar with the ìåôáîý ôùí äýï ïìÜäùí Ýãéíå ìå ôç general guidelines for oral rehydration and the avoidance of antiemetics. Key words: vomit, rehydration, per os, iv, antiemetics, primary health care. ÷ñÞóç ôçò áêñéâïýò äïêéìáóßáò 1 2 Fisher’s. Óôáôéóôéêþò óçìáíôéêÞ èåùHealth Centre of Salamis, Health Centre of Astros ñÞèçêå ç äéáöïñÜ üôáí ôï P<0,05. ¸ãéíå áíôéðáñáâïëÞ ôùí åõñçìÜôùí ôá åõñÞìáôá. Åðßóçò äéåñåõíÞèçêå ï êáôáëëçëü- ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ôùí äéåèíþí ïñãáôåñïò ôñüðïò êáé ôüðïò ÷ïñÞãçóçò áðü ôïõ óôü- íéóìþí êáé ìå ôç äéåèíÞ âéâëéïãñáößá. ìáôïò (per os) åíõäÜôùóçò êáé ôá áßôéá ôõ÷üí áðïôõ÷ßáò ôçò óôçí ðáñå÷üìåíç ðñùôïâÜèìéá öñïíôßäá õãåßáò áðü ôá êÝíôñá õãåßáò. ÁðïôåëÝóìáôá Rehydration of children with mild to moderate dehydration due to vomiting in primary health care D. Vini, C. Zavos, M. Venizelos

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò Ôï ðëçèõóìü ìåëÝôçò áðåôÝëåóáí üëá ôá ðáéäéÜ (n=93) çëéêßáò 3 ìçíþí Ýùò 6 åôþí ðïõ ðñïóÞëèáí óôï êÝíôñï õãåßáò ôçí ðåñßïäï ÌÜéïò – Áýãïõóôïò 2002 ãéá åìÝôïõò êáé Þðéá Ýùò ìÝôñéá áöõäÜôùóç óôá ðëáßóéá ïîåßáò ãáóôñåíôåñßôéäáò. Óå üóá ðáéäéÜ Þôáí äõíáôüí (äéüôé åîáéôßáò ôçò áöõäÜôùóçò ïñéóìÝíá ðáéäéÜ äåí åß÷áí äéïýñçóç áñ÷éêÜ) ãéíüôáí êáôÜ ôçí ðñïóÝëåõóÞ ôïõò ðñïóäéïñéóìüò åéäéêïý âÜñïõò ïýñùí ìå stick þóôå íá õðÜñ÷åé êïéíü óçìåßï áíáöïñÜò ãéá ôçí åêôßìçóç ôçò áöõäÜôùóçò. Óôá ðáéäéÜ ðïõ áíÝöåñáí ùò ìïíáäéêü óýìðôùìá åìÝôïõò (1-2) ãéíüôáí åîÝôáóç ôùí ïýñùí ìå ôáéíßá áíß÷íåõóçò áêåôüíçò ãéá áðïêëåéóìü áñ÷üìåíçò äéáâçôéêÞò êåôïîÝùóçò. Ôá ðáéäéÜ ÷ùñßóôçêáí óå äýï ïìÜäåò áíÜëï-

Ç ðëåéïøçößá (n=75) ôùí ðñïóåñ÷ïìÝíùí ðáéäéþí ÷áñáêôçñßóèçêå ùò Þðéá áöõäáôùìÝíá êáé óôéò äýï ïìÜäåò. Ùò ðñþôçò ãñáììÞò åíõäÜôùóç êáé óôéò 2 ïìÜäåò åðéëÝ÷èçêå áõôÞ áðü ôïõ óôüìáôïò. ÊáôÜ ôï ðñùéíü ùñÜñéï (ïìÜäá Á) üëá ôá ðáéäéÜ ìå Þðéá áöõäÜôùóç åíõäáôþèçêáí per os, áöïý ðñïçãÞèçêå óôÝñçóç õãñþí ìßáò þñáò óôï êÝíôñï õãåßáò. ÊáôÜ ôï áðïãåõìáôéíü ùñÜñéï (ïìÜäá Â) 3 áðü ôá 48 ðáéäéÜ áíôéìåôùðßóèçêáí ìå iv ÷ïñÞãçóç õãñþí (Ðßíáêáò É). Óôï ÷ñïíéêü äéÜóôçìá ôçò óôÝñçóçò õãñþí óõíõðïëïãéæüôáí êáé ç þñá êáôÜ ôçí ïðïßá ïé ãïíåßò áíÝöåñáí üôé åß÷å óçìåéùèåß ï ôåëåõôáßïò Ýìåôïò ìÝ÷ñé ôçí ðñïóÝëåõóÞ ôïõò óôï êÝíôñï õãåßáò. Åðßóçò, üëá ôá ðáéäéÜ ôçò ïìÜäáò Â ðïõ ÷áñáêôçñßóôçêáí ùò ìåôñßùò áöõäáôùìÝíá (n=9) áíôéìåôùðßóèçêáí ìå åíäïöëÝâéá áíáðëÞñùóç õãñþí, åíþ ìüíï 3 ðáéäéÜ ôçò ïìÜäáò Á Ýëáâáí åíäïöëÝâéá áãùãÞ (P=0,0045). ÅðåéäÞ óå ïñéóìÝíåò ðåñéðôþóåéò ôá êñéôÞñéá äéá÷ùñéóìïý ôçò Þðéáò 167

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ä. ÂÞíç êáé óõí

Ðßíáêáò É. Óýãêñéóç åíõäÜôùóçò (per os êáé iv) ôùí áóèåíþí ôùí äýï ïìÜäùí ÏìÜäá Á (n=45) ¹ðéá áöõäÜôùóç ÌÝôñéá áöõäÜôùóç Óýíïëï ÅíõäÜôùóç per os óôï êÝíôñï õãåßáò ÅíõäÜôùóç per os óôï óðßôé ÕðïôñïðÞ óõìðôùìÜôùí ÅðáíÞëèáí ôï åðüìåíï 24ùñï ×ïñÞãçóç áíôéåìåôéêþí

ÏìÜäá Â (n=48)

ÓôáôéóôéêÞ ÄéáöïñÜ

Per os

(P)

36 6 42 33 9 3 3 0

0 3 3 ...* ... 0 0 9

36 0 36 14 22 7 11 0,004

3 9 12 ... ... 0 0

>0,05 0,0045 0,015 0,0004 >0,05 0,027

* Ç åîåôáæüìåíç ðáñÜìåôñïò äåí áöïñÜ óôçí êáôçãïñßá áõôÞ

áðü ôç ìÝôñéá áöõäÜôùóç åßíáé äõóäéÜêñéôá óõãêñßèçêå ôï óýíïëï ôùí ðåñéóôáôéêþí óôéò 2 ïìÜäåò êáé êáôáãñÜöçêå óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ (P=0,015) óå üôé áöïñÜ ôçí õðåñßó÷õóç ôçò åíäïöëÝâéáò èåñáðåßáò óôçí ïìÜäá Â (Ðßíáêáò 1). Óôçí ïìÜäá Á, 33 áðü ôá 42 (78,6%) ðáéäéÜ ðïõ áíôéìåôùðßóèçêáí ìå per os ÷ïñÞãçóç õãñþí åíõäáôþèçêáí óôï êÝíôñï õãåßáò. Áíôßèåôá, ìüíï 14 áðü ôá 36 (38,9%) ðáéäéÜ ôçò ïìÜäáò Â åíõäáôþèçêáí per os óôï êÝíôñï õãåßáò (P=0,0004), åíþ ç ðëåéïøçößá áõôþí Ýëáâå ôçí åíõäÜôùóç óôï óðßôé. Áðü ôá ðáéäéÜ ðïõ Üñ÷éóáí óôáäéáêÞ åíõäÜôùóç per os, ìåôÜ áðü ôçí ùñéáßá óôÝñçóç õãñþí, õðïôñïðßáóáí 3 (7,1%) óôçí ïìÜäá Á êáé 7 (19,4%) óôçí ïìÜäá Â, ÷ùñßò ùóôüóï ç äéáöïñÜ áõôÞ íá åßíáé óôáôéóôéêþò óçìáíôéêÞ. Ôá ðáéäéÜ áõôÜ áíôéìåôùðßóèçêáí ìå iv ÷ïñÞãçóç ùò åðüìåíï âÞìá. Ôï åðüìåíï 24ùñï åðáíÞëèáí ìå Þðéá áöõäÜôùóç 3 áðü ôá 42 (7,1%) ðáéäéÜ ðïõ Ýëáâáí per os åíõäÜôùóç áðü ôçí ïìÜäá Á êáé 11 áðü ôá 36 (30,6%) ðáéäéÜ áðü ôçí ïìÜäá Â, äéáöïñÜ ðïõ Þôáí óôáôéóôéêþò óçìáíôéêÞ (P=0,027). ¼ëá ôá ðáéäéÜ ðïõ åðáíÞëèáí åß÷áí åíõäáôùèåß óôï óðßôé ìå ïäçãßåò. ÊáíÝíá áðü ôá ðáéäéÜ ðïõ åíõäáôþèçêáí óôï êÝíôñï õãåßáò (per os Þ iv) äåí åðáíÞëèå. ÁíôéåìåôéêÜ ÷ïñçãÞèçêáí óå 9 (18,75%) ðáéäéÜ áðü ôçí ïìÜäá Â êáé óå êáíÝíá ðáéäß ôçò ïìÜäáò Á (P=0,004) (Ðßíáêáò É).

ÓõæÞôçóç Ïé Ýìåôïé ùò ðñïåîÜñ÷ïí óýìðôùìá ïîåßáò ãáóôñåíôåñßôéäáò åßíáé ßóùò áðü ôá ðëÝïí èïñõâþäç ãéá ôïõò ãïíåßò áëëÜ êáé ãéá ôïõò éáôñïýò. 168

Ôï ãåãïíüò áõôü äéêáßùò êáèéóôÜ ôïí Ýëåã÷ï ôùí åìÝôùí ùò ðñÜîç ðñþôçò ðñïôåñáéüôçôáò, áöïý Ýíá ðáéäß ðïõ áäõíáôåß íá êñáôÞóåé õãñÜ áðü ôï óôüìá èá áöõäáôùèåß ðïëý ãñÞãïñá. Áõôüò åßíáé êáé Ýíáò áðü ôïõò ëüãïõò ðïõ ðïëëÝò öïñÝò êáôá÷ñçóôéêÜ ðñïôéìÜôáé ç iv ÷ïñÞãçóç õãñþí áêüìç êáé óå ðåñéðôþóåéò Þðéáò Þ ìÝôñéáò áöõäÜôùóçò ôüóï óå ÅëëçíéêÝò üóï êáé óå äéåèíåßò ìåëÝôåò3-5. ÌåëÝôç ôçò Á´ ÐáíåðéóôçìéáêÞò ÊëéíéêÞò Áèçíþí óå ðáéäéÜ Ýùò 3 ÷ñüíùí ðïõ íïóçëåýèçêáí ãéá ïîåßá ãáóôñåíôåñßôéäá Ýäåéîå üôé óôï 52% ôùí ðåñéðôþóåùí ÷ïñçãÞèçêáí õãñÜ åíäïöëåâßùò ÷ùñßò íá õðÜñ÷åé Ýíäåéîç6, åíþ áðü ôçí ÁìåñéêáíéêÞ âéâëéïãñáößá ðñïêýðôåé üôé ïé éáôñïß ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò äåí ãíùñßæïõí ôéò äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò ãéá ôçí åíõäÜôùóç1,7. Óôçí åñãáóßá ìáò äéåñåõíÞèçêå ôï êáôÜ ðüóï Þôáí äõíáôÞ ç åíõäÜôùóç per os ðáéäéþí ìå Þðéïõ Ýùò ìÝôñéïõ âáèìïý áöõäÜôùóç åíþ óõíå÷ßæïíôáí ïé Ýìåôïé. Ï ôñüðïò åíõäÜôùóçò êáé ï õðïëïãéóìüò ôùí ÷ïñçãïýìåíùí õãñþí áðü ôï óôüìá óôçñßæïíôáí óôçí åêôßìçóç ôïõ âáèìïý áöõäÜôùóçò, üðùò áõôüò ðñïÝêõðôå áðü ôï éóôïñéêü êáé ôçí êëéíéêÞ åîÝôáóç. Ôï 80% ôùí ðáéäéþí ôçò ïìÜäáò Á êáé ôï 81,25% ôçò ïìÜäáò Â áîéïëïãÞèçêå ùò Þðéá áöõäáôùìÝíï. ÅðåéäÞ ç êáôÜôáîç ôïõ âáèìïý áöõäÜôùóçò åßíáé áñêåôÜ õðïêåéìåíéêÞ7, æçôÞèçêáí üëá ôá óôïé÷åßá ôïõ éóôïñéêïý (Ýíáñîç, äéÜñêåéá, áñéèìüò êáé óõ÷íüôçôá åìÝôùí/äéáññïéþí). Ç æýãéóç ôïõ ðáéäéïý êáé ç äéáöïñÜ Â.Ó. ðñéí êáé ìåôÜ ôçí Ýíáñîç ôùí óõìðôùìÜôùí áðåäåß÷èçóáí ó÷åôéêÜ õðïêåéìåíéêÝò ùò óôïé÷åßá áîéïëüãçóçò, åíþ áõôü ðïõ ôåëéêÜ ÷ñçóßìåõóå ùò áíôéêåéìåíéêüôåñï êñéôÞñéï óôá ðåñéóóüôåñá ðáéäéÜ Þôáí ç ýðáñîç Þ ìç äéïýñçóçò êáé ôï áõîç-

Ôüìïò 15, Ôåý÷ïò 4, 2003

Ä. ÂÞíç êáé óõí

ìÝíï åéäéêü âÜñïò ïýñùí. ÌåôÜ ôçí áîéïëüãçóç ôçò áöõäÜôùóçò õðïëïãßæïíôáí ôá õãñÜ ðïõ Ýðñåðå íá ÷ïñçãçèïýí ãéá ôçí áíáðëÞñùóç ôùí õðáñ÷üíôùí áðùëåéþí, óýìöùíá ìå ôéò óõóôÜóåéò ôùí äéåèíþí ïñãáíéóìþí.7 Óôéò ðåñéðôþóåéò Þðéáò áöõäÜôùóçò ÷ïñçãÞóáìå 50mL/kg âÜñïõò óþìáôïò (Â.Ó.) äéáëýìáôïò ãëõêüæçò/çëåêôñïëõôþí óõí ôéò óõíå÷éæüìåíåò áðþëåéåò ðïõ ôõ÷üí õðÞñ÷áí êáé ïé ïðïßåò ðñïóôßèïíôáí, áöïý ãéíüôáí ðñþôá åêôßìçóç ôçò åíõäÜôùóçò êÜèå 2 þñåò. ÊÜèå äéáññïúêÞ êÝíùóç áíáðëçñùíüôáí ìå 10 mL õãñþí/kg Â.Ó., åíþ êÜèå Ýìåôïò ìå 2 mL/kg Þ áíÜëïãá ìå ôïí üãêï ôïõ åìÝôïõ. Ïé óõóôÜóåéò ãéá ôç äéÜñêåéá ôïõ ÷ñüíïõ áíáðëÞñùóçò åßíáé 4 þñåò. Óôç äéêÞ ìáò ìåëÝôç ðáñáôçñÞèçêå åðéìÞêõíóç ôïõ ÷ñïíéêïý áõôïý äéáóôÞìáôïò Ýùò êáé 6 þñåò, ëüãù äõóêïëßáò ôùí ãïíÝùí ùò ðñïò ôç ÷ïñÞãçóç Þ êáé Üñíçóçò ôùí ðáéäéþí ëüãù ãåýóçò. Ç ÷ïñÞãçóç ôïõ äéáëýìáôïò Ýãéíå áðü ôïõò ãïíåßò åíôüò ôïõ ÷þñïõ ôïõ êÝíôñïõ õãåßáò óå 33 áðü 45 (73,3%) ðáéäéÜ ôçò ïìÜäáò Á êáé óå 14 áðü 48 (29,17%) ðáéäéÜ ôçò ïìÜäáò Â, õðü ôçí åðßâëåøç íïóçëåõôéêïý ðñïóùðéêïý êáé åðïðôåßá ôïõ éáôñïý. Ôï äéÜëõìá ÷ïñçãïýôáí ìå óýñéããá 5 mL Þ êïõôáëÜêé, áñ÷éêÜ êÜèå 15-20 ëåðôÜ åíþ óôáäéáêÜ ôá äéáóôÞìáôá ðýêíùíáí êÜèå 1-2 ëåðôÜ. Ìå áõôüí ôïí ôñüðï ï ìÝóïò üñïò ôïõ ÷ïñçãïýìåíïõ äéáëýìáôïò Ýöèáíå ôá 200 mL/h, ðïóü ðïõ áíôáðïêñßíåôáé óôéò óõóôÜóåéò ãéá 150300 mL/h. Ç ÷ïñÞãçóç îåêéíïýóå ìåôÜ áðü óôÝ-

ñçóç õãñþí ìéáò þñáò. Óôá ðáéäéÜ ìå ìÝôñéá áöõäÜôùóç, ç ÷ïñÞãçóç õãñþí per os ãéíüôáí ðÜíôïôå ìÝóá óôï êÝíôñï õãåßáò, åíþ ôï ðïóü ôùí ÷ïñçãïýìåíùí õãñþí ãéá ôçí áíáðëÞñùóç õðïëïãéæüôáí óå 100 mL/ kg Â.Ó. Ôï äéÜëõìá ðïõ ÷ïñçãÞèçêå (Almora) ðåñéÝ÷åé 30 mEq/L Na+ êáé åßíáé ôï äéÜëõìá ìå ôç ÷áìçëüôåñç ðåñéåêôéêüôçôá Na+ áðü áõôÜ ðïõ êõêëïöïñïýí óôï åìðüñéï (Ðßíáêáò ÉÉ). Ç ðåñéåêôéêüôçôá ôùí äéáëõìÜôùí óå Na+ êáé ç ùóìùôéêüôçôÜ ôïõò åßíáé óçìåßï áíôéêñïõüìåíùí áðüøåùí. Ç ÅõñùðáúêÞ Åôáéñßá ÐáéäéáôñéêÞò Ãáóôñåíôåñïëïãßáò êáé ÄéáôñïöÞò óõíéóôÜ ôç ÷ñÞóç äéáëõìÜôùí ðïõ ðåñéÝ÷ïõí 60 mEq/L Na+ óôéò áíáðôõãìÝíåò ÷þñåò, åîáéôßáò ôïõ êéíäýíïõ õðåñíáôñéáéìßáò üôáí áõôÜ ôá äéáëýìáôá ðåñéÝ÷ïõí õøçëüôåñåò óõãêåíôñþóåéò êáé ëáìâÜíïíôáé áðü êáëÜ óéôéóìÝíá ðáéäéÜ.1 Ç ðñïôåéíüìåíç ùóìùôéêüôçôá åßíáé ìåôáîý 200-250 mOsm/L êáé åßíáé ðñïôéìüôåñï ôï äéÜëõìá íá ðåñéÝ÷åé ñýæé 50 g/L áíôß ãéá ãëõêüæç (Ðßíáêáò ÉÉ). Óå ðïëëÝò ðåñéðôþóåéò ïé ãïíåßò åß÷áí Þäç ÷ïñçãÞóåé ðïôÜ ôýðïõ cola Þ åõñùðáúêü ôóÜé, áëëÜ êáé ïé ïäçãßåò áðü ôïõò éáôñïýò óå ðïóïóôü 60% ðåñéåëÜìâáíáí óõóôÜóåéò ãéá ÷ñÞóç ôÝôïéùí äéáëõìÜôùí. ÔÝôïéïõ åßäïõò ðïôÜ åßíáé ëÜèïò íá óõóôÞíïíôáé äéüôé: á) Ý÷ïõí ÷áìçëÞ óõãêÝíôñùóç çëåêôñïëõôþí êáé äõíáôüí íá ïäçãÞóïõí óå õðïíáôñéáéìßá, êáé â) åßíáé õðåñôïíéêÜ (ëüãù õøçëïý õäáôáíèñáêéêïý öïñôßïõ), åðé-

Ðßíáêáò ÉÉ. Óýíèåóç ïñèþò Þ ëáíèáóìÝíùò ÷ñçóéìïðïéïýìåíùí õãñþí ãéá åíõäÜôùóç ÄéÜëõìá Ïñèþò: ÐÏÕ/Unicef Almora Orisel Soparyx Rizolyte ElectroRice ËáíèáóìÝíùò: Gatorade ×õìüò ìÞëïõ Æùìüò êñÝáôïò Æùìüò êüôáò Cola ÔóÜé (÷ùñßò æÜ÷áñç)

ÕäáôÜíèñáêåò (g/L)

Na+ (mEq/L)

K+ (mEq/L)

ÂÜóç(mEq/L) (äéôôáíèñáêéêü/êéôñéêü)

Ùóìùôéêüôçôá (mOsm/L)

20 (ãëõêüæç) 20 (ãëõêüæç) 20 (ãëõêüæç) 30 (ñõæÜëåõñï) 30 (Üìõëï ñõæéïý) 30 (Üìõëï ñõæéïý)

90 35 60 60 60 60

20 13,5 25 20 20 20

30 18 10 10 10 10

310 Äåí áíáöÝñåôáé 269 140 200 140

330

3 110-248 140-250

32 2,5-17 1,5-8

0 5 5

700 300-400 380-500

1,7 0

0,1 0

13 0

550 0

46 (ãëõêüæç, öñïõêôüæç, óïõêñüæç) 60 (ãëõêüæç, öñïõêôüæç) 0 0 110 (ãëõêüæç, öñïõêôüæç) 0

169

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

äåéíþíïíôáò ôç äéÜññïéá (Ðßíáêáò ÉÉ). Ïé Ýìåôïé õðïôñïðßáóáí óå 3 ðáéäéÜ ôçò ïìÜäáò Á êáé óå 7 ðáéäéÜ ôçò ïìÜäáò Â êáôÜ ôç ÷ïñÞãçóç ôùí õãñþí óôï êÝíôñï õãåßáò. Óå áõôÜ ôá ðáéäéÜ åôÝèç iv ÷ïñÞãçóç õãñþí ãéá 4 þñåò (öÜóç áíáðëÞñùóçò). Ïé êáôåõèõíôÞñéåò ïäçãßåò ðñïâëÝðïõí üôé óå õðïôñïðÞ ôùí åìÝôùí ïé ðñïóðÜèåéåò ãéá per os åíõäÜôùóç óõíå÷ßæïíôáé ìå ôçí ßäéá äéáäéêáóßá áðü ôçí áñ÷Þ êáé ãéá äéÜóôçìá 8 ùñþí, åíþ õðÜñ÷åé Ýíäåéîç iv ÷ïñÞãçóçò óôá ðáéäéÜ ðïõ äåí êñáôïýí õãñÜ ëüãù óõíå÷éæüìåíùí åìÝôùí Þ üôáí äåí õðÜñ÷åé åðáñêÝò ðñïóùðéêü ãéá ÷ïñÞãçóç õãñþí per os. Óå êáíÝíá ðáéäß äåí åôÝèç ñéíïãáóôñéêüò êáèåôÞñáò ãéá ÷ïñÞãçóç õãñþí, ï ïðïßïò óõíéóôÜôáé áðü ðïëëïýò óõããñáöåßò óå ðáéäéÜ ìå åìÝôïõò ãéá ôçí áðïöõãÞ iv ÷ïñÞãçóçò Þ üôáí äåí õðÜñ÷åé ðñüóâáóç óå iv ÷ïñÞãçóç8. Ç õðåñï÷Þ ôçò ïìÜäáò Â ùò ðñïò ôçí iv ÷ïñÞãçóç õãñþí ïöåßëåôáé óå ðáñÜãïíôåò ðïõ Ý÷ïõí ó÷Ýóç ìå ôç öýóç ôçò åöçìåñßáò (áíáóöÜëåéá ãïíÝùí êáé èåñáðüíôùí, äõíçôéêÜ áíåðáñêÞò åðéôÞñçóç ôïõ ðáéäéïý áðü íïóçëåõôéêü êáé éáôñéêü ðñïóùðéêü). Óçìáíôéêü ñüëï åðßóçò êáôÝ÷ïõí ç þñá ðñïóÝëåõóçò ôïõ ðáéäéïý êáé ç áðüóôáóç ôçò êáôïéêßáò ôïõ áðü ôï êÝíôñï õãåßáò. Öáßíåôáé üôé ç iv åíõäÜôùóç ðñïôéìÞèçêå ðåñéóóüôåñï êáôÜ ôéò íõ÷ôåñéíÝò þñåò. ÅîÜëëïõ, ç per os åíõäÜôùóç óôï êÝíôñï õãåßáò ôéò íõ÷ôåñéíÝò þñåò åýñéóêå ôïõò ãïíåßò áëëÜ êáé ôï ðáéäß ìå ìåéùìÝíç óõììüñöùóç êáé óõíåñãáóßá. Óýìöùíá ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ðñÝðåé íá ìåôñþíôáé çëåêôñïëýôåò ðñéí êáé êáôÜ ôçí ðïñåßá ôçò iv åíõäÜôùóçò1. Óôç äéêÞ ìáò ìåëÝôç, óå êáíÝíá ðáéäß ôçò ïìÜäáò Â ðïõ Ýëáâå õãñÜ åíäïöëåâßùò äåí ìåôñÞèçêáí çëåêôñïëýôåò, áöïý äåí õðÞñ÷å ôÝôïéá äõíáôüôçôá êáôÜ ôçí åöçìåñßá. Ç iv ÷ïñÞãçóç üìùò äåí õðåñÝâç ðïôÝ ôéò 4 þñåò êáé ç åíõäÜôùóç óõíå÷éæüôáí per os ìüëéò ïé óõíèÞêåò ôï åðÝôñåðáí. Ôï åðüìåíï 24ùñï åðáíÞëèáí 3 ðáéäéÜ ôçò ïìÜäáò Á êáé 11 ðáéäéÜ ôçò ïìÜäáò Â (P=0,027). Ç äéáöïñÜ õðÝñ ôçò ïìÜäáò Â ïöåßëåôáé óôï üôé ëüãù ôçò áíïìïéïãÝíåéáò ôùí åöçìåñåõüíôùí éáôñþí üóïí áöïñÜ óôçí åìðåéñßá ôïõò óôá ðáéäéÜ, ïé ïäçãßåò ðïõ äßíïíôáí óôïõò ãïíåßò ãéá ôç öÜóç ôçò óõíôÞñçóçò äåí Þôáí ðÜíôïôå áíáëõôéêÝò (ðïëëÝò öïñÝò äåí åîçãåßôï áíáëõôéêÜ ôï ðïóü ôïõ ÷ïñçãïýìåíïõ äéáëýìáôïò ãéá êÜèå äéÜññïéá), áëëÜ ïýôå êáé ðÜíôá óùóôÝò (óýóôáóç ãéá áõ170

Ä. ÂÞíç êáé óõí

óôçñÝò äßáéôåò, ÷õìïýò Þ áíáøõêôéêÜ, áöáßñåóç ãÜëáêôïò áðü ôç äéáôñïöÞ) ôá ïðïßá åðéäåßíùíáí ôç äéÜññïéá Þ äåí áíáðëÞñùíáí óùóôÜ ôéò áðþëåéåò. Ïé óõóôÜóåéò ôùí äéåèíþí ïñãáíéóìþí ðñïâëÝðïõí ôçí åíùñßò åðáíáóßôéóç áìÝóùò ìåôÜ ôçí ïëïêëÞñùóç ôçò áíáðëÞñùóçò õãñþí ìå óýíèåôïõò õäáôÜíèñáêåò (ñýæé, ðáôÜôá, óéôÜñé, øùìß, áñáâüóéôïò), Üðá÷ï êñÝáò, ãéáïýñôé, öñïýôá, ëá÷áíéêÜ êáé ãÜëá ðëÞñåò, åíþ óõíå÷ßæåôáé ï ìçôñéêüò èçëáóìüò, åöüóïí ðñüêåéôáé ãéá èçëÜæïí âñÝöïò. Ôá áðëÜ óÜê÷áñá (÷õìïß, ôóÜé, áíáøõêôéêÜ) åðéäåéíþíïõí ôç äéÜññïéá5. ÊáíÝíá ðáéäß ôï ïðïßï åß÷å åíõäáôùèåß óôï êÝíôñï õãåßáò per os Þ iv êáé áðü ôéò 2 ïìÜäåò äåí åðáíÞëèå ìå õðïôñïðÞ óõìðôùìÜôùí. ÁíôéåìåôéêÜ ÷ïñçãÞèçêáí óå 9 ðáéäéÜ ôçò ïìÜäáò Â. Ç ÷ïñÞãçóç áíôéåìåôéêþí äåí óõíéóôÜôáé êáé ïé éáôñïß ðïõ êÜíïõí ÷ñÞóç ôÝôïéùí óêåõáóìÜôùí ðñÝðåé íá ãíùñßæïõí ôéò áíåðéèýìçôåò óïâáñÝò åíÝñãåéÝò ôïõò, üðùò áëëåñãéêÝò áíôéäñÜóåéò, êáôáóôïëÞ êáé åîùðõñáìéäéêÞ óõìðôùìáôïëïãßá1,7.

ÓõìðåñÜóìáôá Ó÷åäüí üëá ôá ðáéäéÜ ðïõ Ý÷ïõí åìÝôïõò êáé Þðéá Ýùò ìÝôñéá áöõäÜôùóç ìðïñïýí íá áíôéìåôùðéóèïýí ìå per os åíõäÜôùóç. Áðü ôç ìåëÝôç ìáò áîéïëïãÞèçêáí ç áíôéìåôþðéóç, ïé ðáñáëåßøåéò êáé ôá ëÜèç ìáò êáé ðñïêýðôåé üôé: 1) Ç per os åíõäÜôùóç åßíáé ôï ßäéï áðïôåëåóìáôéêÞ. 2) Ðñïôéìüôåñï åßíáé íá ÷ïñçãåßôáé óôï êÝíôñï õãåßáò õðü ôçí åðßâëåøç íïóçëåõôéêïý – éáôñéêïý ðñïóùðéêïý êáé íá äßíïíôáé óùóôÝò ïäçãßåò ãéá ôç öÜóç óõíôÞñçóçò. 3) Ç per os åíõäÜôùóç ìéêñþí áóèåíþí äåí ÷ñçóéìïðïéåßôáé áêüìç üðùò ðñÝðåé óôïí áíáðôõãìÝíï êüóìï3. Ç ðáñïýóá êáôÜóôáóç ìðïñåß íá âåëôéùèåß åÜí ðåñéóóüôåñïé éáôñïß ôçò ÐñùôïâÜèìéáò Öñïíôßäáò åîïéêåéùèïýí ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ãéá per os åíõäÜôùóç êáé åêðáéäåýóïõí/êáôåõèýíïõí óùóôÜ ôïõò ãïíåßò ôùí ìéêñþí áóèåíþí.

Âéâëéïãñáößá 1. Choice Study Group. Multicenter, randomized, double blind clinical trial to evaluate the efficacy and safety of a reduced osmolarity oral

Ä. ÂÞíç êáé óõí

rehydration salt solution in children with acute watery diarrhea. Pediatrics, 107:613-618, 2001. Duggan C, Lasche J, McCarty M, Mitchell K, Dershewitz R, Lerman SJ et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics, 104:3, e29, 1999. Avery M, Snyder J. Oral therapy for acute diarrhea. The underused simple solution. N Engl J Med, 323:891-894, 1990. Ìáôóáíéþôçò Í, ÊáñðÜèéïò È. ÐáéäéáôñéêÞ. Ôüìïò Á´. ÉáôñéêÝò åêäüóåéò Ëßôóáò, ÁèÞíá, 1995, óåë. 234. Provisional committee on quality improvement.

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Practice parameter: the management of acute gastroenteritis in young children. Pediatrics, 97:424-436, 1996. 6. Áäáìßäçò Ä, ÂáëÜóóç-ÁäÜì Å, Ñþìá-Ãéáííßêïõ Å. Ïîåßá ãáóôñåíôåñßôéäá: áîéïëüãçóç ôçò áíôéìåôþðéóçò óå ìïíÜäá ôñéôïâÜèìéáò ðåñßèáëøçò. Äåëôßï Á’ ÐáéäéáôñéêÞò ÊëéíéêÞò Ðáíåðéóôçìßïõ Áèçíþí, 40:35-44, 1993. 7. Goepp JG, Katz SA. Oral rehydration therapy. Am Fam Physician, 47:843-851, 1993. 8. Ármon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management [review]. Arch Dis Child, 85:132-142, 2001.

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ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 15, Number 4, 172-175, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 172-175, 2003

ÐñïáãùíéóôéêÞ éáôñéêÞ åîÝôáóç ðáéäéþí êé åöÞâùí Á. ÐáðïõôóéäÜêçò*

Ðåñßëçøç ÊÜèå ÷ñüíï ðïëëïß ãéáôñïß êáëïýíôáé íá åîåôÜóïõí ðáéäéÜ êáé Ýöçâïõò êáé íá áðïöáíèïýí ãéá ôçí áñôéìÝëåéá êáé ôçí êáôÜóôáóç ôçò õãåßáò ôïõò, ðñïêåéìÝíïõ áõôÜ íá îåêéíÞóïõí áèëçôéêÝò äñáóôçñéüôçôåò. Ç ðñïáãùíéóôéêÞ áõôÞ éáôñéêÞ áîéïëüãçóç ðñÝðåé íá åßíáé óýíôïìç, íá Ý÷åé ÷áìçëü êüóôïò áëëÜ ôáõôü÷ñïíá áðïôåëåóìáôéêÞ óôï íá áíáêáëýøåé ôá Üôïìá åêåßíá ðïõ äéáôñÝ÷ïõí êßíäõíï óôçí åíáó÷üëçóÞ ôïõò ìå ôïí áèëçôéóìü. Ç åîÝôáóç áõôÞ ðñÝðåé íá ãßíåôáé ôÝóóåñéò ìå Ýîé åâäïìÜäåò ðñéí ôçí Ýíáñîç ôçò áèëçôéêÞò ðåñéüäïõ êáé íá åðáíáëáìâÜíåôáé êÜèå Ýíá ìå ôñßá ÷ñüíéá Ôï éóôïñéêü åßíáé ôï ðéï óçìáíôéêü ìÝñïò ôçò ðñïáãùíéóôéêÞò áîéïëüãçóçò êáé ðñÝðåé íá åðéêåíôñþíåôáé óå ðñïçãïýìåíá êáñäéïáããåéáêÜ ðñïâëÞìáôá êáé óôï ïéêïãåíåéáêü éóôïñéêü èáíÜôïõ áðü êáñäéáããåéáêÜ áßôéá ðñéí ôçí çëéêßá ôùí ðåíÞíôá ÷ñüíùí. Áêïëïõèåß ãåíéêÞ öõóéêÞ åîÝôáóç ðïõ åðéêåíôñþíåôáé óôï ìÝñïò ôïõ óþìáôïò ðïõ Ý÷åé Üìåóç ó÷Ýóç ìå ôï õðïøÞöéï áãþíéóìá. ÅñãáóôçñéáêÝò åîåôÜóåéò äåí åßíáé ïðùóäÞðïôå áðáñáßôçôåò êáé ôá êñéôÞñéá áðïêëåéóìïý ðáéäéþí áðü ôá áèëÞìáôá åîáñôþíôáé êÜèå öïñÜ áðü ôá åõñÞìáôá áðü ôï éóôïñéêü, ôç öõóéêÞ åîÝôáóç êáé ôï õðïøÞöéï Üèëçìá.

Preparticipation screening of children and adolescents for sports A. Papoutsidakis Summary Every year many doctors are asked to perform preparticipation physical evaluations for children and adolescents involved in sports. That evaluation should be brief, cheap but at the same time effective enough to determine the athletes at risk. The evaluation should take place four to six weeks prior to initiation of sport and it should be repeated every one to three years. The medical history is the most important aspect of the evaluation and it should focus on any previous cardiovascular complications. A family history of cardiovascular death before the age of fifty and any other limiting medical problems. A general physical examination should be performed to focus on areas involved in sports participation. Laboratory tests are not usually neccessary. Disqualifying conditions may be determined based on the physical abnormality present and the amount of contact or energy involved in the sport to be played.

* Åéäéêåõüìåíïò ÏñèïðáéäéêÞò, ìåôáðôõ÷éáêüò öïéôçôÞò ÁèëçôéáôñéêÞò Ðáíåðéóôçìßïõ Bath, ÇíùìÝíï Âáóßëåéï

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¸íáò áðü ôïõò ëüãïõò ðïõ åðéóêÝðôïíôáé ôïí ãåíéêü ãéáôñü Þ ôïí ðáéäßáôñï ôá ðáéäéÜ êáé ïé Ýöçâïé åßíáé êáé ç óõìðëÞñùóç ôçò áèëçôéêÞò êÜñôáò õãåßáò ôïõò. Ïé áèëçôéêÝò áñ÷Ýò ôçò ÷þñáò ìáò áðáéôïýí áðü êÜèå ðáéäß ðñéí áðü ïðïéáäÞðïôå åðßóçìç áèëçôéêÞ óõììåôï÷Þ ôïõ íá Ý÷åé åîåôáóôåß áðü ãéáôñü ï ïðïßïò êáé õðïãñÜöåé ôç ó÷åôéêÞ êÜñôá õãåßáò. Ðïëëïß õðïóôçñßæïõí üôé ç óõìðëÞñùóç ôçò êÜñôáò õãåßáò åßíáé ðåñéôôÞ êáé ôï êüóôïò ðïõ áðáéôåßôáé, ãéá íá ãßíåé óùóôÜ üëïò ï ðñïáãùíéóôéêüò Ýëåã÷ïò, åßíáé ôÝôïéï ðïõ äåí Ý÷åé ôï áíôßóôïé÷ï üöåëïò üóïí áöïñÜ ôçí ðñüëçøç áéöíßäéùí èáíÜôùí, áöïý ç ìåãÜëç ðëåéïøçößá ôùí ðáéäéþí åßíáé õãéÞ.1 Ðáñ’ üëá áõôÜ ç ðñïáãùíéóôéêÞ åîÝôáóç êñßíåôáé áðáñáßôçôç1,2, ãéáôß åêôüò áðü ôçí äõíáôüôçôá ðïõ äßíåôáé óôï ãéáôñü ãéá Ýíáí êáëü éáôñéêü Ýëåã÷ï ôïõ ðáéäéïý, þóôå íá ðñïëÜâåé åðþäõíåò óõíÝðåéåò, äßíåôáé åðßóçò êáé ç ìåãÜëç åõêáéñßá, ãéá íá áíáðôõ÷èåß ËÝîåéò êëåéäéÜ: ðñïáãùíéóôéêÞ åîÝôáóç, áèëçôéóìüò, ðáéäéÜ, áéöíßäéïò èÜíáôïò áèëçôþí ÕðïâëÞèçêå: 10 Áõãïýóôïõ 2002 ÅðáíõðïâëÞèçêå: 11 Óåðôåìâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Óåðôåìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Áíôþíçò ÐáðïõôóéäÜêçò, ÔïìðÜæç 29, 74100 ÑÝèõìíï, ÊñÞôç, Ôçë.-Fax: (28310) 31593

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Á. ÐáðïõôóéäÜêçò

ó÷Ýóç åìðéóôïóýíçò ìåôáîý ãéáôñïý-áèëçôÞ. Áõôü ðñïäéáèÝôåé èåôéêÜ, ãéá íá îåêéíÞóåé ç éáôñéêÞ åíçìÝñùóç ôïõ áèëçôÞ ãéá äéÜöïñá èÝìáôá ðñüëçøçò: êÜðíéóìá, íáñêùôéêÜ êôë áêüìç êáé èÝìáôá óåîïõáëéêÞò áãùãÞò, æÞôçìá ðïëý óçìáíôéêü óôçí åöçâåßá.2 Ç âéâëéïãñáöéêÞ áíáæÞôçóç Ýãéíå ìå ôç ÷ñÞóç ôçò âÜóçò éáôñéêþí äåäïìÝíùí MEDLINE

áðü ôï 1980 ìÝ÷ñé óÞìåñá. ÁíáæçôÞèçêáí üëá ôá Üñèñá áíáóêüðçóçò ðïõ åß÷áí ó÷Ýóç ìå ôçí ðñïáãùíéóôéêÞ åîÝôáóç êáé ôïí áéöíßäéï áèëçôéêü èÜíáôï áðü ìåãÜëá êé Ýãêõñá éáôñéêÜ ðåñéïäéêÜ. Ôï áðïôÝëåóìá ôçò âéâëéïãñáöéêÞò áõôÞò áíáóêüðçóçò Þôáí íá êáôáëÞîïõìå óôçí êáôÜñôéóç ðßíáêá-áëãüñéèìïõ ãéá åýêïëç êáé ãñÞãïñç

Ðßíáêáò 1. ÖõóéêÞ áîéïëüãçóç áèëçôþí ðñïãíùóôéêÜ ÏÍÏÌÁ: ................................................................................................................................................................ ÁÃÏÑÉ/ÊÏÑÉÔÓÉ: ................................. ÇËÉÊÉÁ: ................................................................................... ÇÌÅÑÏÌÇÍÉÁ ÃÅÍÍÇÓÇÓ: ....................................................................................... ÄÉÅÕÈÕÍÓÇ: ............................................................................................................................................................................................................................. ÔÇËÅÖÙÍÏ: ............................................................................................................................................................................................................................. ÁÈËÇÌÁ: .................................................................................................................................................................................................................................... Ïäçãßåò: Ðáñáêáëþ äéáâÜóôå üëåò ôéò åñùôÞóåéò ðáñáêÜôù êáé áðáíôÞóôå üóï ðéï åéëéêñéíÜ ìðïñåßôå. Åßíáé óçìáíôéêü íá ðåñéëÜâåôå üëåò ôéò ãíùóôÝò óå óáò ðëçñïöïñßåò. Ïé ãïíåßò Þ êçäåìüíåò íá õðïãñÜøïõí óôï ôÝëïò. ÔñÝ÷ïõóá öáñìáêåõôéêÞ áãùãÞ: .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... 1. ¸÷åé êáíÝíáò áðü ôçí ïéêïãÝíåéÜ óïõ ðåèÜíåé îáöíéêÜ ðñéí ôçí çëéêßá ôùí 50;

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

2. ¸÷åéò ðïôÝ íéþóåé æáëÜäá ðñéí Þ êáôÜ ôç äéÜñêåéá ôçò Üóêçóçò;

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

3. ¸÷åéò Üóèìá Þ áëëåñãßåò;

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

4. ¸÷åéò ðïôÝ óðÜóåé êüêáëï, öïñÝóåé íÜñèçêá Þ ôñáõìáôßóåé êÜðïéá Üñèñùóç; (üðùò áóôñÜãáëï Þ ãüíáôï)

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

5. ¸÷åéò ðïôÝ ëéðïèõìÞóåé (äéÜóåéóç);

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

6. ¸÷åéò êÜðïéá ÷ñüíéá áññþóôéá Þ âëÝðåéò ôáêôéêÜ ãéáôñü;

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

7. ¸÷åéò ìÞðùò ìüíï Ýíá áðü ôá êáíïíéêÜ äéðëÜ üñãáíá; (üðùò ìÜôéá, íåöñÜ, ê.ëð.)

ÍÁÉ Ï×É ÅÎÇÃÇÓÇ

Ãéá ãõíáßêåò ìüíï: 8. Ðüóïí åôþí åß÷åò ôçí ðñþôç óïõ ðåñßïäï; 9. ¸÷åéò êáíïíéêÞ ðåñßïäï;

ÍÁÉ

Ï×É

¸÷ù ìåëåôÞóåé üëåò ôéò ðáñáðÜíù åñùôÞóåéò ìå ôï ãéï Þ ôçí êüñç ìïõ êáé äßíù ôçí Üäåéá óôï ðáéäß ìïõ íá óõíå÷ßóåé óôçí ðñïáãùíéóôéêÞ êëéíéêÞ åîÝôáóç êáé íá ëÜâåé ìÝñïò óå áèëÞìáôá.

ÕðïãñáöÞ ãïíÝá Þ êçäåìüíá:

Çìåñïìçíßá:

173

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÐáðïõôóéäÜêçò

ÖÕÓÉÊÇ ÅÎÅÔÁÓÇ Ãéáôñïß: Ðáñáêáëþ óõìðëçñþóôå üëåò ôéò ðáñáêÜôù ðëçñïöïñßåò. ¾øïò: ............................................... ¼ñáóç: (Ä) 20/ .......................... ÂÜñïò: .............................................. (Á) 20/ ........................................... Ðßåóç: ............................................... (Ó) 20/ ........................................... Äéüñèùóç ÍÁÉ/Ï×É ¼ñéá áñôçñéáêÞò ðßåóçò: 10-12 åôþí, >125/80 ¼ñéá ïðôéêÞò ïîýôçôáò: ÄéïñèùìÝíç Þ ìç 13-15 åôþí, >135/85 üñáóç êáëýôåñç áðü 20/50 êé áðü ôá äýï 16-18 åôþí, >140/90 ìÜôéá; ÊáñäéïðíåõìïíïëïãéêÞ åîÝôáóç: ÅîÞãçóç Ðíåýìïíåò Ðáëìïß ÊáñäéÜ

ÖõóéïëïãéêÜ

ÐáèïëïãéêÜ

ÅîÝôáóç ìõïóêåëåôéêïý: Áõ÷Ýíáò ¿ìïò Áãêþíáò Êáñðüò ×Ýñé ÌÝóç Ãüíáôï ÁóôñÜãáëïò Ðüäé ¢ëëï: (åîÝôáóç áíÜëïãç ìå ôï éóôïñéêü ôïõ áññþóôïõ)

ÓõíéóôÜôáé: 1. Äýíáôáé íá 2. Äýíáôáé íá 3. Äåí ìðïñåß 4. Äåí ìðïñåß

áóêçèåß áóêçèåß ìå ðñïûðïèÝóåéò: ìÝ÷ñé: ãéáôß:

ÕðïãñáöÞ ãéáôñïý:

Çìåñïìçíßá:

Äçìïóéåýåôáé êáôüðéí ãñáðôÞò Üäåéáò ôïõ åêäüôç ôïõ ðåñéïäéêïý The Journal of Family Practice, Vol. 41, No 1, 1995

ðñïáãùíéóôéêÞ åîÝôáóç ðáéäéþí (Ðßíáêáò 1)3. Åðßóçò åîÜãáìå ðïëëÜ ÷ñÞóéìá óõìðåñÜóìáôá ó÷åôéêÜ ìå ôïõò áðïêëåéóìïýò áðü áãùíßóìáôá áíÜëïãá ìå ôçí ðÜèçóç. Ç ðñïáãùíéóôéêÞ åîÝôáóç ðñÝðåé íá Ý÷åé ôïõò åîÞò óôü÷ïõò: · Íá ðñïóäéïñßóåé ôç ãåíéêÞ õãåßá ôïõ áèëçôÞ. · Íá äéåñåõíÞóåé ôéò óõíèÞêåò åêåßíåò, ïé ïðïßåò èá ìðïñïýóáí íá èÝóïõí óå êßíäõíï ôïõò áèëçôÝò. · Íá ðñïóäéïñßóåé ôï åðßðåäï ùñéìüôçôáò ôïõ 174

áèëçôÞ êáé íá åîåôÜóåé áí ç óõììåôï÷Þ ôïõ óôá óðïñ åíäåßêíõôáé Þ ü÷é. · Íá èåìåëéþóåé ìéá ó÷Ýóç ãéáôñïý-áóèåíÞ, ç ïðïßá óôï ìÝëëïí ìðïñåß íá áðïâåß ðïëý ÷ñÞóéìç. Åðéðñüóèåôá, áí åíôïðéóèåß êÜðïéï ðñüâëçìá êáôÜ ôç äéÜñêåéá ôçò åîÝôáóçò, ï ãéáôñüò ïöåßëåé íá ôï äéåñåõíÞóåé ðåñéóóüôåñï Þ íá ðáñáðÝìøåé óå êÜðïéïí ðéï åéäéêü. Åðßóçò, èá ðñÝðåé íá åßíáé óå èÝóç, óå ðåñßðôùóç êÜðïéáò ðÜèçóçò, íá ðñïôåßíåé åíáëëáêôéêü Üèëçìá ðéï áóöáëÝò ãéá ôï óõãêåêñéìÝíï áèëçôÞ. Õðïëïãßæåôáé

Ôüìïò 15, Ôåý÷ïò 4, 2003

Á. ÐáðïõôóéäÜêçò

üìùò üôé ôåëéêÜ ìüíï óôï 9,2% åíôïðßæåôáé êÜðïéá íÝá ðÜèçóç êáé ôåëéêÜ ìüíï óôï 1,2% èá óõóôçèåß ç áðï÷Þ áðü ôá áèëÞìáôá3. Ï êáëýôåñïò ÷ñüíïò ãéá ôçí ðñïáãùíéóôéêÞ åîÝôáóç åßíáé ôÝóóåñéò ìå Ýîé åâäïìÜäåò ðñéí ôçí Ýíáñîç ôçò áãùíéóôéêÞò ðåñéüäïõ3,4. Áõôü äßíåé áñêåôü ÷ñüíï óôçí ðåñßðôùóç ðïõ ðñïêýøåé êÜðïéï ðñüâëçìá ãéá ðåñáéôÝñù äéåñåýíçóç. ÃåíéêÜ, óõóôÞíåôáé ç åðáíÜëçøç ôçò åîÝôáóçò êÜèå Ýíá ìå ôñßá ÷ñüíéá ìå åôÞóéá áíáóêüðçóç ôïõ éóôïñéêïý ôïõ áèëçôÞ3. Áí âÝâáéá õðÜñ÷åé êÜðïéá áëëáãÞ óôçí ðïñåßá ôçò õãåßáò ôïõ áèëçôÞ, ôüôå êáèïñßæåôáé ç ðáñáêïëïýèçóç ôïõ áèëçôÞ êáôÜ ðåñßðôùóç. Ôï éóôïñéêü ôïõ áóèåíïýò åßíáé ôï ðéï óçìáíôéêü óôïé÷åßï êáôÜ ôç äéÜñêåéá ôçò ðñïáãùíéóôéêÞò åîÝôáóçò. Ôï 63-74% ôùí ðñïâëçìÜôùí ôïõ áèëçôÞ ìðïñïýí íá âãïõí óôçí åðéöÜíåéá ìå Ýíá êáëü éáôñéêü éóôïñéêü3. Ôï éóôïñéêü êáëü åßíáé íá Ý÷åé ìéá áðëÞ êáé óõóôçìáôïðïéçìÝíç ìïñöÞ üðùò áõôÞ ôïõ ðßíáêá 1. ÅðåéäÞ ôï 95% ôùí îáöíéêþí èáíÜôùí ôùí áèëçôþí êÜôù áðü ôçí çëéêßá ôùí 30 Ý÷åé ó÷Ýóç ìå ôï êáñäéáããåéáêü óýóôçìá3-6, èá ðñÝðåé íá äïèåß óôï éóôïñéêü ôïõ ðåñéóóüôåñç Ýìöáóç ìå êÜðïéåò ðéï åéäéêåõìÝíåò åñùôÞóåéò. Áêïëïõèåß âáóéêÞ êëéíéêÞ åîÝôáóç Åßíáé ìéá ãñÞãïñç óõíïðôéêÞ åîÝôáóç üëùí ôùí âáóéêþí óõóôçìÜôùí, óôçí ïðïßá ðåñéëáìâÜíåôáé ìéá ðïëý ãñÞãïñç åðéóêüðçóç ôùí áñèñþóåùí êáé ôùí êéíÞóåþí ôïõò. ÁíÜëïãá âÝâáéá ìå ôï õðïøÞöéá Üèëçìá èá ðñÝðåé óôç óõíÝ÷åéá íá åðéêåíôñùèåß óå êÜðïéï óõãêåêñéìÝíï ìÝñïò ôïõ óþìáôïò Þ óýóôçìá. ÅñãáóôçñéáêÝò åîåôÜóåéò ãéá õãéåßò áèëçôÝò äåí áðáéôïýíôáé ãéá ôçí ðñïáãùíéóôéêÞ åîÝôáóç2. Êñßíïíôáé áóýìöïñåò ïéêïíïìéêÜ êáé ôéò ðåñéóóüôåñåò öïñÝò áðëÜ åðéâåâáéþíïõí ãíùóôÝò êëéíéêÝò ïíôüôçôåò áðü ôï éóôïñéêü Þ ôçí êëéíéêÞ åîÝôáóç. ÕðÜñ÷ïõí êÜðïéåò êáôáóôÜóåéò ðïõ áðáéôïýí éäéáßôåñç ðñïóï÷Þ. Ôá êáñäéáããåéáêÜ åßíáé ôá ðéï óõ÷íÜ áßôéá áéöíßäéïõ áèëçôéêïý èáíÜôïõ3-6. ÐáñÜ ôï üôé ç öõóéêÞ åîÝôáóç ìðïñåß íá åßíáé ÷ùñßò ðáèïëïãéêÜ åõñÞìáôá, Ýíá óõóôïëéêü

öýóçìá, ôï ïðïßï ãßíåôáé åíôïíüôåñï ìåôÜ áðü ÷åéñéóìü Valsava, ðñÝðåé íá ìáò äßíåé ôï Ýíáõóìá ãéá ðáñáðïìðÞ óå ðéï äéåîïäéêÞ êáñäéïëïãéêÞ åêôßìçóç. Åðßóçò, áèëçôÝò ðïõ áíáöÝñïõí æÜëç êáôÜ ôç äéÜñêåéá Þ ìåôÜ ôçí Üóêçóç ðñÝðåé íá äéåñåõíçèïýí ðåñéóóüôåñï ãéá õðåñôñïöéêÞ êáñäéïìõïðÜèåéá, êáñäéáêÝò áññõèìßåò êáé áíùìáëßåò óôåöáíéáßùí áñôçñéþí3-6. ÁèëçôÝò óå åìðýñåôï êáôÜóôáóç èá ðñÝðåé íá áðïêëåéóôïýí áðü êÜèå Üèëçìá ìÝ÷ñé ôçí áðïäñïìÞ ôïõ ðõñåôïý3. Ôï Üóèìá äåí áðïôåëåß áðüëõôç Ýíäåéîç áðïêëåéóìïý áðü ôéò áèëçôéêÝò äñáóôçñéüôçôåò. ¢ëëùóôå ôï 10-15% ôùí áèëçôþí õøçëþí åðéäüóåùí Ý÷ïõí éóôïñéêü Üóèìáôïò. ÐñÝðåé ðÜíôùò áõôïß ïé áèëçôÝò íá ðáñáêïëïõèïýíôáé óõ÷íÜ êáé íá êáôáãñÜöïíôáé üëåò ïé ôõ÷üí áëëåñãßåò ôïõò ðïõ ôïõò ðñïêáëïýí âñïã÷üóðáóìï3. Áí õðÜñ÷ïõí êÜðïéåò êáôáóôÜóåéò, üðùò õøçëÞ áñôçñéáêÞ ðßåóç, ç éêáíüôçôá ãéá óõììåôï÷Þ óå êÜðïéï Üèëçìá èá ðñÝðåé íá óõíåîåôÜæåôáé ìå ôïí ôýðï ôïõ õðïøÞöéïõ áèëÞìáôïò. Ãéá ðáñÜäåéãìá, áèëçôÝò ìå õøçëÞ ðßåóç áðïêëåßïíôáé áðü áèëÞìáôá ðïõ áðáéôïýí éóïìåôñéêÞ Üóêçóç ôùí ìõþí üðùò ç Üñóç âáñþí3-6.

Âéâëéïãñáößá 1. Ball RM. The sports preparticipation evaluation. N J Med, 88:629-33,1991. 2. Bratton R. Preparticipation screening of children for sports. Current recommendations. Sports Med, 24:300-7, 1997. 3. Rifat S, Ruffin M, Gorenflo D. Disqualifying criteria in a preparticipation sports evaluation. The Journal of Family Practice, 41:42-50,1995. 4. Franklin B, Fletcher G, Gordon N, et al. Cardiovascular evaluation of the athlete. Sports Med, 24:97-119, 1997. 5. Maron B. Cardiovascular risks to young persons on the athletic field. Ann Intern Med, 129:379-86, 1998. 6. Corrado D, Basso C, Schiavon M et al. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med, 339: 364-9, 1998.

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Å. Èçñáßïò êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ THE SECOND AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 15, Number 3, 176-183, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 3, 176-183, 2003

ËåéôïõñãéêÞ äéáóýíäåóç êáé óõíåñãáóßá ôïõ ðñïóùðéêïý ôùí ÊÝíôñùí Õãåßáò ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò Å. Èçñáßïò1, Í. ÃéáìáëÜêçò2, Å. Ëýêïõ2, Ì. Ðýëëç2, Ã. ÌðÝëïò1, ×. Ïéêïíïìïðïýëïõ2, Å. ÌùñáÀôçò1

Ðåñßëçøç Óêïðüò: Ç äéåñåýíçóç ôùí êñßóåùí êáé ôùí ðñïâëçìÜôùí ðïõ ðáñïõóéÜæïíôáé óôá ÊÝíôñá Õãåßáò (Ê.Õ.) ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò, ôùí ôñüðùí åðéêïéíùíßáò êáé ôùí áíôéäñÜóåùí ôùí åñãáæïìÝíùí, êáèþò êáé ôùí ðïëéôéêþí ðïõ åöáñìüæïõí ïé õðåýèõíïé ôùí Ê.Õ. ãéá ôçí åðßëõóÞ ôïõò. Õëéêü êáé ìÝèïäïò: Óôá åðôÜ Ê.Õ. ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò åóôÜëç Ýíá åñùôçìáôïëüãéï ãéá ôçí êáôáãñáöÞ óôïé÷åßùí ó÷åôéêþí ìå ôçí ïñãÜíùóç êáé ôç ëåéôïõñãßá ôùí Ê.Õ. êáé ÷ñçóéìïðïéÞèçêáí áêüìá äýï åñùôçìáôïëüãéá áðü áíÜëïãç Ýñåõíá: ôï ðñþôï áðåõèýíèçêå ó’ üëï ôï ðñïóùðéêü êáé óõíôÜ÷èçêå ìå óêïðü íá äéåñåõíçèåß ï ôñüðïò áíôéìåôþðéóçò åê ìÝñïõò ôçò äéïßêçóçò ôùí ðñïâëçìÜôùí êáé ôï äåýôåñï, ìå ôç ìïñöÞ äïìçìÝíçò óõíÝíôåõîçò, æçôÞèçêå íá áðáíôçèåß ìüíï áðü óôåëÝ÷ç ôùí Ê.Õ. Ôá åñåõíçôéêÜ åñùôÞìáôá ôá ïðïßá åôÝèçóáí Þôáí: á. Ðùò áóêåßôáé ç äéïßêçóç óôá Ê.Õ., â. ÕðÜñ÷åé óáöÞò ðñïóäéïñéóìüò ôïõ ñüëïõ ôïõ êÜèå åñãáæüìåíïõ óôá Ê.Õ., ã. ¸÷ïõí ôçí éêáíüôçôá ïé õöéóôÜìåíåò äéïéêçôéêÝò äïìÝò ôùí Ê.Õ. íá äéá÷åéñéóôïýí ôá ðñïâëÞìáôá ðïõ ðñïêýðôïõí óôçí êáèçìåñéíÞ ëåéôïõñãßá ôïõò. ÁðïôåëÝóìáôá: Áðü ôçí ðñþôç áíÜëõóç ôùí áðïôåëåóìÜôùí, ôï 70,1% ôùí åñãáæïìÝíùí óôá Ê.Õ. ãíùñßæåé ôçí ýðáñîç ïñãáíïãñÜììáôïò êáé ôç èÝóç ôïõò ó’ áõôü êáé ôï 74,8% äçëþíåé üôé ïé êáèçìåñéíÝò ôïõ äñáóôçñéüôçôåò åßíáé óáöþò êáèïñéóìÝíåò. Ôï 76,1% ãíùñßæåé ðïõ èá áðåõèõíèåß ãéá íá åðéëýóåé Ýíá ðñüâëçìá êáé ôï 65,8% ðïõ èá äéáâéâÜóåé ðáñáôçñÞóåéò Þ ðëçñïöïñßåò ôùí ïðïßùí èá ãßíåé áðïäÝêôçò, áí êáé ôï 84,3% ôï êÜíåé áðü äéêÞ ôïõ ðñùôïâïõëßá êáé ü÷é óõóôçìáôéêÜ. Ôï 82,4% ãíùñßæåé ðïéá åßíáé ôá ðéèáíÜ ðñïâëÞìáôá ðïõ ìðïñåß íá ðáñïõóéáóèïýí óôçí åñãáóßá ôïõ êáé ôï 54,2% ôçí ýðáñîç ó÷åäßïõ åðßëõóÞò ôïõò, áí êáé ôï 34,5% äçëþíåé üôé Ýíá ôÝôïéï ó÷Ýäéï Ý÷åé äïêéìáóôåß óôçí ðñÜîç. Ôá óõ÷íüôåñá ðñïâëÞìáôá ðïõ ðáñïõóéÜæïíôáé åßíáé ôå÷íéêÜ ðñïâëÞìáôá êáé äõóêïëßåò óõíåííüçóçò ìå áóèåíåßò ãéá ñáíôåâïý Þ ìå éáôñïýò. Óôï 57.1% ôùí Ê.Õ. ãßíïíôáé ðñïãñáììáôéóìÝíåò ôáêôéêÝò óõíáíôÞóåéò ôïõ ðñïóùðéêïý ãéá ôç óõæÞôçóç ôõ÷üí ðñïâëçìÜôùí. ÓõìðåñÜóìáôá: ÐáñÜ ôçí Ýëëåéøç åíüò èåóìïèåôçìÝíïõ ðëáéóßïõ êáé êáíüíùí ëåéôïõñãßáò ôùí Ê.Õ. êáé ôçí ìç áõôüíïìç êáé áõôïôåëÞ ëåéôïõñãßá ôïõò, ïé õöéóôÜìåíåò äéïéêçôéêÝò äïìÝò ó’ áõôÜ ìïéÜæïõí íá áíôáðïêñßíïíôáé ìÜëëïí éêáíïðïéçôéêÜ óôï ñüëï ôïõò, ðáñÜ ôá åðéìÝñïõò ðñïâëÞìáôá.

1 Â´ Ðåñéöåñåéáêü Óýóôçìá Õãåßáò & Ðñüíïéáò ÁôôéêÞò, 2Äéáðáíåðéóôçìéáêü-Äéáôìçìáôéêü Ìåôáðôõ÷éáêü ÔìÞìá ÏñãÜíùóçò & Äéïßêçóçò Õðçñåóéþí Õãåßáò Ðáíåðéóôçìßïõ Áèçíþí

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ÅéóáãùãÞ Ç äéïßêçóç (ìÜíáôæìåíô) áðïôåëåß ìéá áðü ôéò ðëÝïí óçìáíôéêÝò ðåñéï÷Ýò ôçò áíèñþðéíçò äñáóôçñéüôçôáò, áëëÜ êáé âáóéêÞ ëåéôïõñãßá ïðïéáóäÞðïôå êïéíùíßáò, ôçò ïðïßáò ç ýðáñîç âáóßæåôáé óôçí óõíåñãáóßá ðïëëþí ïñãáíéóìþí. Óçìáßíåé åðßôåõîç åðéäéùêüìåíùí áðïôåëåóìÜôùí ìå ôçí ðñïóðÜèåéá ðïëëþí áôüìùí1. Êáèïñéóôéêüò åäþ åßíáé êáé ï ñüëïò ôçò åðéêïéíùíßáò, ç ïðïßá âñßóêåôáé óôçí êáñäéÜ ôçò ïñãÜíùóçò êáé åßíáé Ýíá áðü ôá ðéï ïõóéáóôéêÜ óõóôáôéêÜ ôùí êáëþí ó÷Ýóåùí ôùí åñãáæïìÝíùí2. Ôéò ôåëåõôáßåò äåêáåôßåò, ïé Ýííïéåò “ïìÜäá õãåßáò” êáé “äéåðáããåëìáôéêÞ óõíåñãáóßá” áðïôåëïýí èÝìáôá Ýíôïíùí óõæçôÞóåùí ìåôáîý ôùí åðáããåëìáôéþí õãåßáò. Éäéáßôåñá ôç äåêáåôßá ËÝîåéò êëåéäéÜ: ÏìÜäá Õãåßáò, ÄéáëåéôïõñãéêÞ ÏìÜäá, Åðéêïéíùíßá Ðñïóùðéêïý, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, ÊÝíôñá Õãåßáò ÕðïâëÞèçêå: H åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÅëåõèÝñéïò Èçñáßïò, Âïõëãáñïêôüíïõ 8, Ëõêáâçôôüò, 114 71 ÁèÞíá, Tçë.: 6977079362, e-mail: ethireos@hol.gr

Å. Èçñáßïò êáé óõí.

Ôüìïò 15, Ôåý÷ïò 2, 2003

óôï ÷þñï ôçò õãåßáò, êáèþò áðïôåëïýí ìßá áðÜíôçóç óôçí áõîáíüìåíç ðïëõðëïêüôçôá, óôéò áíÜãêåò ôùí ïñãáíéóìþí ãéá åõÝëéêôåò äïìÝò êáé óôçí ïëïêëÞñùóç ôùí åðéìÝñïõò ëåéôïõñãéþí Summary Aim: To investigate the problems and the crisis that arise at the Health Centres êáé áðïöÜóåùí4. of B' Regional Health Care and Welfare System of Attica (Pe.S.Y.P.). To investiÔï æÞôçìá ôçò äéá÷åßñéóçò ôùí óõgate the way in which the personnel react to the problems, and the policies ãêñïýóåùí, ðïõ áíáðüöåõêôá áíáöýïimplemented by the administration of Pe. S.Y.P. to resolve these problems. Maíôáé óå ìéá óõíåñãáóßá, áðïôÝëåóå êáé terial and Method: A questionnaire was sent to the 7 Health Centres of B' áðïôåëåß Ýíá áêüìá æÞôçìá ðïõ áðáPe.S.Y.P. to collect information regarding the organisation and the operation of the Health Centres (H.C). An additional two questionnairs were used by similar ó÷ïëåß ôüóï ôá óôåëÝ÷ç ôçò äéïßêçóçò research. The purpose of the first questionnaire was to examine the manageüóï êáé ôá åðéìÝñïõò Üôïìá ðïõ óõìment when problems arise, and it was addressed to all the personnel. The ìåôÝ÷ïõí óå ïìÜäåò äéåðáããåëìáôéêÞò second one, in the form of an interview, was addressed to the H.C. executives. óõíåñãáóßáò. Óå Ýíáí ïñãáíéóìü ïé The queries posed for this study were: (a) How are the Health Centres adminóõãêñïýóåéò åßíáé áíáðüöåõêôåò êáistrated? (b) Is the role of every employee defined in detail? (c) Is the existing management of the Health Centres competent enough to deal with the problems èþò Ýñ÷ïíôáé óå åðáöÞ äéáöïñåôéêïß arising in the daily operation of the unit? Results: 70.1% of the H.C employees Üíèñùðïé, ìå äéáöïñåôéêÝò áîßåò, êïõëare aware of the existence of an organised administration and their position in ôïýñåò êáé åðßðåäá ìüñöùóçò. ÐáñÜëit. 74.8% say that their daily activities are accurately defined. 76.1% know who ëçëá, ìßá Üëëç óåéñÜ ðáñáãüíôùí to address in order to solve a problem and 65.8% where to forward recorded óõìâÜëëåé óôçí ýðáñîç êáé åîÜðëùóç observations and information, 84.3% act on initiative and not systematically. 82.4% are aware of the problems that may be present at their work and 54.2% ôùí óõãêñïýóåùí. Áõôïß åßíáé ç áëëçknow of the existence of a plan in times of crisis however only 37.5% testify to ëåîÜñôçóç ôùí êáèçêüíôùí, ïé áóõìthe application of such a plan. The most frequent problems that appear are âßâáóôïé óôü÷ïé, ç ÷ñÞóç áðåéëþí áðü usually technical, or confusion in the setting of rendevous dates. 51.1% of the ôïõò ðñïúóôáìÝíïõò, ç ðñïóùðéêüôçH.C scheduled meetings are called to deal with these problems. Conclusion: ôá êÜèå åñãáæüìåíïõ, ç êáôáíïìÞ ôùí Although a plan of action exists to deal with possible problems arising, it has never been used, and even though the existing management takes the initiative óðÜíéùí ðüñùí üôáí ôá Üôïìá Ý÷ïõí to deal with a crisis nothing is substantialy resolved. õøçëÝò ðñïóäïêßåò ãéá áíôáìïéâÞ, ç Key Words: health care team, functional interelation, primary health care, Health ìç áíáãíþñéóç5. Centres. Ïé êñßóåéò êáé ç äçìéïõñãßá ðñïâëçìÜôùí áðïôåëïýí ìüíéìç êáé óôáôïõ ’80, ìå öáíåñÝò ôéò åðéäñÜóåéò ôçò äéáêÞñõ- èåñÞ ðáñÜìåôñï óôï ÷þñï ôçò õãåßáò êáé ÷ñÞîçò ôçò Alma-Ata áëëÜ êáé ìåôáãåíÝóôåñùí ïäç- æïõí éäéáßôåñçò áíôéìåôþðéóçò êáé ìåëÝôçò6. Óêïãéþí ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò, üðùò ðüò ôçò åñãáóßáò åßíáé ç äéåñåýíçóç ôùí êñßóåùí ç èÝóðéóç ôïõ óôü÷ïõ “Õãåßá ãéá üëïõò ôï 2000” êáé ôùí ðñïâëçìÜôùí ðïõ ðáñïõóéÜæïíôáé óôá êáé ç ïäçãßá “Learning Together to Work To- ÊÝíôñá Õãåßáò ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò, ôùí gether in Health”, ç äñáóôçñéïðïßçóç ðñïò ôçí ôñüðùí åðéêïéíùíßáò êáé ôùí áíôéäñÜóåùí ôùí åñãáæïìÝíùí, êáèþò êáé ôùí ðïëéôéêþí ðïõ åöáñêáôåýèõíóç áõôÞ Þôáí åíôïíüôåñç3. Óôç äåêáåôßá ôïõ ‘90 ðáñáôçñÞèçêå äéåèíþò ìüæïõí ïé õðåýèõíïé ôùí Ê.Õ. ãéá ôçí åðßëõóÞ îáíÜ ìéá åðéêÝíôñùóç ôïõ åíäéáöÝñïíôïò ôùí ôïõò. åðáããåëìáôéþí õãåßáò áëëÜ êáé ôùí äéïéêçôéêþí óôåëå÷þí óôï èÝìá ôçò äéåðáããåëìáôéêÞò óõíåñãáóßáò, ôáõôü÷ñïíá åìöáíßæåôáé ìßá íÝá ðñïóÝã- Ðëçèõóìüò ìåëÝôçò – ÌÝèïäïò ãéóç ðïõ Ý÷åé ùò óôü÷ï ôçí åîïéêïíüìçóç ïéêïíïìéêþí êáé áíèñþðéíùí ðüñùí, åíþ ôáõôü÷ñïíá ÁöïñìÞ ãéá ôç óõãêåêñéìÝíç ìåëÝôç áðïôÝäßäíåé Ýìöáóç óôç âåëôßùóç ôçò ðïéüôçôáò ôùí ëåóå Ýíá åñùôçìáôïëüãéï ó÷åôéêü ìå ôçí ïñãÜðáñå÷ïìÝíùí õðçñåóéþí. íùóç êáé ôç ëåéôïõñãßá ôùí åðôÜ ÊÝíôñùí Õãåßáò Ùò äéáëåéôïõñãéêÝò ïìÜäåò ïñßæïíôáé ïé ïìÜ- (Êïñùðßïõ, Ìáñêüðïõëïõ, Ëáõñßïõ, ÓðÜôùí ÍÝáò äåò, ôùí ïðïßùí ôá ìÝëç ðñïÝñ÷ïíôáé áðü äéá- ÌÜêñçò, Êáðáíäñéôßïõ, ÂÜñçò) ðïõ áíÞêïõí óôçí öïñåôéêÜ ôìÞìáôá, äéåõèýíóåéò êáé éåñáñ÷éêÜ ôìÞ- ðåñéï÷Þ åõèýíçò ôïõ Â´ Ðåñéöåñåéáêïý ÓõóôÞìáìáôá åíüò ïñãáíéóìïý. ¸÷ïõí éäéáßôåñç óçìáóßá ôïò Õãåßáò êáé Ðñüíïéáò ôçò ÁôôéêÞò. ÓõãêåFunctional interelation and cooperation of the staff in seven Health Centres of Attika E. Thireos, N. Yiamalakis, H.. Lykou, M. Pylli, G. Belos, X. Oikonomopoulou, E. Moraitis

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å. Èçñáßïò êáé óõí.

íôñþèçêáí óôïé÷åßá ãéá ôç äéåôßá 2000-2001. Ìåôáîý ôùí åñùôÞóåùí ðïõ ôÝèçêáí óôï åñùôçìáôïëüãéï áõôü, æçôïýíôáí êáé óôïé÷åßá ó÷åôéêÜ ìå ôçí ãíþóç ôùí åñãáæïìÝíùí ãéá ôá õöéóôÜìåíá ïñãáíïãñÜììáôá ôùí Ê.Õ., êáèþò êáé åÜí ãßíïíôáí ðñïãñáììáôéóìÝíåò ôáêôéêÝò óõíáíôÞóåéò ôïõ ðñïóùðéêïý. ËáìâÜíïíôáò õðüøç ôéò áðáíôÞóåéò ôùí Ä/ íôþí ôùí Ê.Õ., äéáôõðþèçêáí ôá ðáñáêÜôù åñåõíçôéêÜ åñùôÞìáôá: 1. Ðþò áóêåßôáé ç äéïßêçóç óôá Ê.Õ; 2. ÕðÜñ÷åé óáöÞò ðñïóäéïñéóìüò ôïõ ñüëïõ ôïõ êÜèå åñãáæïìÝíïõ óôá Ê.Õ; 3. ¸÷ïõí ôçí éêáíüôçôá ïé õöéóôÜìåíåò äéïéêçôéêÝò äïìÝò ôùí Ê.Õ íá äéá÷åéñéóôïõí ðñïâëÞìáôá ðïõ ðñïêýðôïõí ìÝóá áðü áíôéðáñáèÝóåéò êáé áíôéðáëüôçôåò ôïõ ðñïóùðéêïý áëëÜ êáé ðñïâëÞìáôá ðïõ äçìéïõñãïýíôáé ìÝóá áðü ìç êáíïíéêÝò êáôáóôÜóåéò; Ãéá ôç óõãêåêñéìÝíç ìåëÝôç ç ìÝèïäïò ðïõ áêïëïõèÞèçêå ðåñéåëÜìâáíå ôç óõìðëÞñùóç áðü ôï ðñïóùðéêü ôùí Ê.Õ. äýï åñùôçìáôïëïãßùí: · åíüò äïìçìÝíïõ, ìå “êëåéóôÝò” åñùôÞóåéò, ðïõ áðåõèýíèçêå óå üëï ôï ðñïóùðéêü êáé óõíôÜ÷èçêå ìå óêïðü äéåñåõíçèåß ï ôñüðïò áíôéìåôþðéóçò åê ìÝñïõò ôçò äéïßêçóçò ôùí ðñïâëçìÜôùí (ÐáñÜñôçìá 1) êáé · åíüò ìå “áíïéêôÝò” åñùôÞóåéò, ìå ìïñöÞ äïìçìÝíçò óõíÝíôåõîçò êáé ôï ïðïßï æçôÞèçêå íá áðáíôçèåß áðü óôåëÝ÷ç ôùí ÊÝíôñùí Õãåßáò (ÐáñÜñôçìá 2). Ôá åñùôçìáôïëüãéá äåí Þôáí óôáèìéóìÝíá êáé åß÷áí ÷ñçóéìïðïéçèåß óå áíÜëïãç Ýñåõíá óôçí ÅëëÜäá7. Åðéðñüóèåôá, ùò åñãáëåßá óôç ìåëÝôç ìáò, ÷ñçóéìïðïéÞèçêáí ìßá óåéñÜ ÖÅÊ ó÷åôéêþí ìå ôçí ïñãÜíùóç êáé ëåéôïõñãßá ôùí ÊÝíôñùí Õãåßáò,

êáèþò êáé õðïõñãéêÝò áðïöÜóåéò ó÷åôéêÝò ìå ôá åðáããåëìáôéêÜ äéêáéþìáôá ôïõ ðñïóùðéêïý óå ïñãáíéóìïýò ðáñï÷Þò öñïíôßäáò õãåßáò. Óõãêåíôñþèçêáí ôá óôïé÷åßá, Ýãéíå ðåñéãñáöéêÞ óôáôéóôéêÞ åðåîåñãáóßá ôùí áðáíôÞóåùí ìå ôç ÷ñÞóç ôïõ ðñïãñÜììáôïò óôáôéóôéêÞò åðåîåñãáóßáò SPSS ver.10.0, ìå óêïðü ôçí åîáãùãÞ ðïóïôéêþí áðïôåëåóìÜôùí êáé óõìðåñáóìÜôùí ãéá ôçí õöéóôÜìåíç êáôÜóôáóç, êáèþò êáé ôçí äéáôýðùóç ðñïôÜóåùí êáé åöáñìüóéìùí ëýóåùí âáóéóìÝíùí óôá óõìðåñÜóìáôá áõôÜ.

ÁðïôåëÝóìáôá Óôçí ìåëÝôç óõììåôåß÷áí ôåëéêÜ ðÝíôå ÊÝíôñá Õãåßáò. ÁíáëõôéêÜ, áðü ôï ðñþôï åñùôìáôïëüãéï ðÞñáìå áðáíôÞóåéò áðü ðÝíôå Ê.Õ. êáé óõãêåêñéìÝíá ôá: Ê.Õ. Êïñùðßïõ (16 Ýíôõðá), Ê.Õ. ÂÜñçò (13 Ýíôõðá), Ê.Õ. Ëáõñßïõ (19 Ýíôõðá), Ê.Õ. Êáðáíäñéôßïõ (23 Ýíôõðá) êáé Ê.Õ. Ìáñêïðïýëïõ (38 Ýíôõðá). Åíþ, áðü ôï äåýôåñï åñùôçìáôïëüãéï ðÞñáìå áðáíôÞóåéò áðü ôÝóóåñá Ê.Õ.: Ê. Õ. Êïñùðßïõ (5 Ýíôõðá), Ê.Õ. ÂÜñçò (5 Ýíôõðá), Ê.Õ. Ëáõñßïõ (5 Ýíôõðá) êáé Ê.Õ. Êáðáíäñéôßïõ (5 Ýíôõðá). ÁðïôåëÝóìáôá áðü ôçí åðåîåñãáóßá ôùí áðáíôÞóåùí ôïõ 1ïõ åñùôçìáôïëïãßïõ (Ðßíáêáò 1-6): • Ôï 70,1% ôùí åñãáæïìÝíùí ãíùñßæåé ôçí ýðáñîç ïñãáíïãñÜììáôïò êáé ôç èÝóç ôïõò óå áõôü. • Ôï 74,8% äçëþíåé üôé ïé êáèçìåñéíÝò ôïõ äñáóôçñéüôçôåò åßíáé óáöþò êáèïñéóìÝíåò. • Ôï 76,1% ãíùñßæåé ðïõ èá áðåõèõíèåß ãéá íá ëýóåé Ýíá ðñüâëçìá • Ôï 72,6 % åíçìåñþíåé êÜðïéïí óõíåñãÜôç Þ

Ðßíáêáò É. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôïõ Ê.Õ. Ëáõñßïõ Åñ. Áð

Íáé (%)

1 2 3 4 5 6 7 8 9

57,9 47,4 78,9 84,2 78,9 – 89,5 52,6 26,7

178

19 19 19 19 19 15 19 19 15

Ï÷é Äåí áðÜíôçóáí Äåí ãíùñßæïõí ¢êõñç ÓõóôçìáôéêÜ Áðü äéêÞ óáò (%) (%) (%) áðÜíôçóç (%) êáôüðéí åíôïëÞò (%) ðñùôïâïõëßá (%) 42,10 52,60 05,30 15,80 21,10 – 10,50 47,40 60,00

– – 15,89 – – 06,70 – – 13,30

– – – – – – – – –

– – – – – 93,3 – – –

Ôüìïò 15, Ôåý÷ïò 2, 2003

Å. Èçñáßïò êáé óõí.

Ðßíáêáò ÉÉ. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôïõ Ê.Õ. Êïñùðßïõ Åñ. Áð

Íáé (%)

Ï÷é Äåí áðÜíôçóáí Äåí ãíùñßæïõí ¢êõñç ÓõóôçìáôéêÜ Áðü äéêÞ óáò (%) (%) (%) áðÜíôçóç (%) êáôüðéí åíôïëÞò (%) ðñùôïâïõëßá (%)

1 2 3 4 5 6 7 8 9

87,5 93,7 68,7 62,5 68,7 – 93,7 43,7 44,4

12,5 06,3 31,3 31,2 18,8 – 06,3 37,5 44,5

16 16 16 16 16 11 16 16 09

– – – 6,3 – – – 6,3 –

– – – – – – – – –

– – – – 12,5 – – 12,5 11,1

– – – – – – – – –

– – – – – 100 – – –

Ðßíáêáò ÉÉÉ. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôïõ Ê.Õ. Ìáñêïðïýëïõ Åñ. Áð 1 2 3 4 5 6 7 8 9

Íáé (%)

39 39 39 38 38 25 38 32 24

Ï÷é Äåí áðÜíôçóáí Äåí ãíùñßæïõí ¢êõñç ÓõóôçìáôéêÜ Áðü äéêÞ óáò (%) (%) (%) áðÜíôçóç (%) êáôüðéí åíôïëÞò (%) ðñùôïâïõëßá (%) 33,3 66,7 79,5 76,3 57,9 – 65,8 31,3 33,4

64,1 33,3 17,9 21,1 42,1 – 34,2 68,7 20,8

2,6 – – 2,6 – – – – –

– – 2,6 – – – – – –

– – – – – 12,0 – – 45,8

– – – – – 16 – – –

– – – – – 72 – – –

Ðßíáêáò ÉV. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôïõ Ê.Õ. Êáðáíäñéôßïõ Åñ. Áð 1 2 3 4 5 6 7 8 9

Íáé (%)

23 23 23 23 23 16 23 23 18

Ï÷é Äåí áðÜíôçóáí Äåí ãíùñßæïõí ¢êõñç ÓõóôçìáôéêÜ Áðü äéêÞ óáò (%) (%) (%) áðÜíôçóç (%) êáôüðéí åíôïëÞò (%) ðñùôïâïõëßá (%) 86,9 73,9 60,8 78,3 69,6 – 78,3 43,5 44,4

13,1 21,8 30,4 21,7 21,7 – 17,4 47,8 55,6

– 04,3 08,8 – 08,7 12,5 04,3 08,7 –

– – – – – – – – –

– – – – – 18,7 – – –

– – – – – 12,5 – – –

– – – – – 56,3 – – –

Ðßíáêáò V. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôïõ Ê.Õ. ÂÜñçò Åñ. Áð 1 2 3 4 5 6 7 8 9

13 13 13 13 13 07 13 13 13

Íáé (%) 084,6 092,3 092,3 061,5 053,8 – 084,6 100,0 038,5

Ï÷é Äåí áðÜíôçóáí Äåí ãíùñßæïõí ¢êõñç ÓõóôçìáôéêÜ Áðü äéêÞ óáò (%) (%) (%) áðÜíôçóç (%) êáôüðéí åíôïëÞò (%) ðñùôïâïõëßá (%) 15,4 07,7 07,7 38,5 46,2 – 15,4 – 46,2

– – – – – – – – 15,3

– – – – – – – – –

– – – – – 100 – – –

179

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å. Èçñáßïò êáé óõí.

Ðßíáêáò VI. ÁðáíôÞóåéò óôéò åñùôÞóåéò ôïõ ðñþôïõ åñùôçìáôïëïãßïõ áðü ôï ðñïóùðéêü ôùí ðÝíôå Ê.Õ. Åñ. 1 2 3 4 5 6 7 8 9

Áð

Íáé (%)

Ï÷é (%)

Äåí áðÜíôçóáí (%)

Äåí ãíùñßæïõí (%)

¢êõñç áðÜíôçóç(%)

ÓõóôçìáôéêÜ êáôüðéí åíôïëÞò(%)

70,1 74,8 76,1 72,6 65,8 – 82,5 54,2 37,5

29,4 24,4 18,5 25,7 30 – 16,7 40,3 45,4

0,51 0,8 4,9 1,7 1,7 3,8 0,8 3 5,7

– – 0,5 – – – – – –

– – – – 2,5 6,2 – 2,5 11,4

– – – – – 5,7 – – –

– – – – – 84,3 – – –

áíþôåñü ôïõ üôáí åðéëýåé ìüíïò ôïõ Ýíá ðñüâëçìá. • Ôï 65,8% ãíùñßæåé ðïõ èá äéáâéâÜóåé ôéò ðëçñïöïñßåò ôùí ïðïßùí ãßíåôáé áðïäÝêôçò, áí êáé ôï 84,3% ôï êÜíåé áðü äéêÞ ôïõ ðñùôïâïõëßá êáé ü÷é óõóôçìáôéêÜ. • Ôï 82,4% ãíùñßæåé ðïéá åßíáé ôá ðéèáíÜ ðñïâëÞìáôá ðïõ ìðïñåß íá ðáñïõóéáóôïýí óôçí åñãáóßá ôïõ. • Ôï 54,2% ãíùñßæåé ôçí ýðáñîç ó÷åäßïõ åðßëõóÞò ôïõò, áí êáé ìüíï ôï 37,5% äçëþíåé üôé Ý÷åé õðÜñîåé äïêéìÞ ôÝôïéïõ ó÷åäßïõ. • Ôá óõ÷íüôåñá ðñïâëÞìáôá ðïõ ðáñïõóéÜæïíôáé óõíÞèùò óôá Ê.Õ. öáßíïíôáé óôï Ó÷Þìá 1. ÓõìðåñÜóìáôá áðü ôçí áíÜëõóç ôùí áðáíôÞóåùí ôïõ 2ïõ åñùôçìáôïëïãßïõ: · Ï óõíçèÝóôåñïò ôñüðïò åðéêïéíùíßáò ôïõ ðñïóùðéêïý ôùí Ê.Õ. åßíáé ï ðñïöïñéêüò (Ó÷Þìá 2). · Ïé äéåíÝîåéò êáé ïé ôñéâÝò áíÜìåóá óôï ðñïóùðéêü ïöåßëïíôáé êõñßùò: I. Ðßåóç ëüãù ìåãÜëçò ðñïóÝëåõóçò áóèåíþí II. Äéáäéêáóßåò åëÝã÷ïõ ôùí õöéóôáìÝíùí áðü ôïõò áíùôÝñïõò ôïõò III. ÔñïðïðïéÞóåéò ðñïãñáììÜôùí IV. Óôéò äéïéêçôéêÝò & ïñãáíùôéêÝò äõóêïëßåò, üðùò: - ¸ëëåéøç ïñãáíïãñÜììáôïò êáé êáèçêïíôïëïãßïõ ðïõ ïäçãïýí óôçí áëëçëåðéêÜëõøç áñìïäéïôÞôùí êáé óôçí Ýëëåéøç óõíôïíéóìïý ôïõ ðñïóùðéêïý. - Ìç éóüôéìç ìåôá÷åßñéóç åñãáæïìÝíùí - Áýîçóç ãñáöåéïêñáôéêþí äéáäéêáóéþí · Ôï ðñïóùðéêü åêöñÜæåé ðáñÜðïíá êõñßùò ãéá ôïõò åîÞò ëüãïõò: 180

I. ×áìçëïß ìéóèïß II. ÁíåðÜñêåéá åîïðëéóìïý & áíáëùóßìùí III. ÁðáéôÞóåéò ãéá Üëëá êáèÞêïíôá IV. Ðßåóç ëüãù üãêïõ åñãáóßáò V. ÓõìðåñéöïñÜ ãéáôñþí & äéïéêçôéêþí VI. Êõêëéêü ùñÜñéï · ÕðÜñ÷ïõí äéåíÝîåéò ìåôáîý äéïéêçôéêïý êáé éáôñéêïý ðñïóùðéêïý ïé ïðïßåò ïöåßëïíôáé êõñßùò óôç ìç ôÞñçóç ôïõ ùñáñßïõ åê ìÝñïõò ôùí ãéáôñþí. · Ïé ðñïóôñéâÝò ìåôáîý ðñïóùðéêïý êáé áóèåíþí ïöåßëïíôáé: I. Óôçí áõîçìÝíï ÷ñüíï áíáìïíÞò ëüãù ìç ôÞñçóçò ôùí ñáíôåâïý êáé II. Óôçí Ýëëåéøç óùóôÞò ðëçñïöüñçóçò ôùí ðñïóåñ÷ïìÝíùí áðü ôá áóöáëéóôéêÜ ôïõò ôáìåßá. · Ç åöáñìïãÞ åíüò óõãêåêñéìÝíïõ ðëáéóßïõ ëåéôïõñãßáò êáé åðéêïéíùíßáò ôïõ ðñïóùðéêïý èá óõìâÜëåé: i. Óôïí óùóôü ðñïãñáììáôéóìü ôïõ ÷ñüíïõ & ôùí äñáóôçñéïôÞôùí ôïõ ðñïóùðéêïý, ii. Óôçí êáëýôåñç áðüäïóç ôùí åñãáæïìÝíùí, iii. Óôçí áðïôåëåóìáôéêüôåñç åîõðçñÝôçóç ôùí áóèåíþí, êáé ãåíéêÜ iv. Óôçí ðïéïôéêüôåñç ðáñï÷Þ õðçñåóéþí · Ïé õöéóôÜìåíåò äéïéêçôéêÝò äïìÝò ôùí Ê.Õ. áíáëáìâÜíïõí ðñùôïâïõëßåò ãéá ôç äéåõèÝôçóç ôùí êñßóåùí.

ÓõæÞôçóç Êåíôñéêüò èåóìüò óôç äéáäéêáóßá õëïðïßçóçò óôéò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò (Ð.Ö.Õ.) åßíáé ôï ÊÝíôñï Õãåßáò (Ê.Õ.). Ôï Ê.Õ äåí

Ôüìïò 15, Ôåý÷ïò 2, 2003

Å. Èçñáßïò êáé óõí.

óô

¼ðïõ: á) ÆçìéÜ/ âëÜâç óôá ìç÷áíÞìáôá êáé ãåíéêÜ ôå÷íéêÜ ðñïâëÞìáôá â) Äõóêïëßá óõíåííüçóçò ìå áóèåíåßò ãéá ñáíôåâïý ã) Äõóêïëßá óõíåííüçóçò ìå ãéáôñïýò ä) ÄéáêïðÝò çëåêôñéêïý ñåýìáôïò å) ÊáêÞ óõíåííüçóç ìåôáîý óõíáäÝëöùí óô) Öüñôïò åñãáóßáò æ) Áäõíáìßá öëåâïêÝíôçóçò ôïõ åîåôáæïìÝíïõ ç) Áëëåñãßá óôçí áêôéíïãñáöéêÞ ïõóßá áðü ôïí åîåôáæüìåíï Ó÷Þìá 1. ÐñïâëÞìáôá, êáôÜ óåéñÜ óçìáíôéêüôçôáò, ðïõ óõíÞèùò ðáñïõóéÜæïíôáé êáé ðñÝðåé íá áíôéìåôùðéóôïýí óôá Ê.Õ.

Ó÷Þìá 2. Ï óõíçèÝóôåñïò ôñüðïò åðéêïéíùíßáò ôïõ ðñïóùðéêïý ôùí Ê.Õ.

èåùñåßôáé áðëÜ êáé ìüíï Ýíá óõãêåêñéìÝíï êôßñéï. Ç ÝííïéÜ ôïõò åßíáé ðåñéóóüôåñï ëåéôïõñãéêÞ êáé ðåñéëáìâÜíåé ôï óýíïëï ôùí õðçñåóéþí êáé óõíôïíéóìÝíùí äñáóôçñéïôÞôùí ãéá ôçí ðëÞñç êÜëõøç ôùí áíáãêþí õãåßáò ìéáò óõãêåêñéìÝíçò ðåñéï÷Þò, ðïõ åßíáé êáé ç ðåñéï÷Þ åõèýíçò ôïõ. Óôï Üñèñï 14 ôïõ Í. 1397/83, êáèþò êáé óôïõò ìåôÝðåéôá íüìïõò, üðùò ï íüìïò 2071/92, ï 2194/ 94 êáé ï 2519/97, ôá Ê.Õ. ïñßæïíôáé ùò áðïêåíôñùìÝíåò ïñãáíéêÝò ìïíÜäåò ôùí Íïóïêïìåßùí

ôïõ Íïìïý. Óôá ÖÅÊ óýóôáóçò ôùí Ê.Õ. ðåñéÝ÷ïíôáé êáé ôá ïñãáíïãñÜììáôá ôïõò. Ôï ïñãáíüãñáììá åíüò öïñÝá åßíáé ìéá ëåéôïõñãéêÞ áðåéêüíéóç ôùí èÝóåùí åñãáóßáò êáé ôùí åðéóÞìùí ó÷Ýóåùí ðïõ Ý÷ïõí ïé èÝóåéò áõôÝò ìåôáîý óôéò. ÐáñïõóéÜæåôáé äçëáäÞ óå ìéá ãñáììéêÞ ìïñöÞ ç áëõóßäá åíôïëþí, ç êëßìáêá äéêáéïäïóßáò êáé éåñáñ÷ßáò ìÝóá óôïí ïñãáíéóìü, ïé ôïìåßò åõèýíçò ôïõ ðñïóùðéêïý êáé ôï ðïõ ëïãïäïôåß ï êáèÝíáò. ÅíäéáöÝñïí Ý÷åé åðßóçò ç Üôõðç (áíåðßóçìç) åðéêïéíùíßá, äçëáäÞ áõôÜ ðïõ äåí äåß÷íåé ôï ïñãáíüãñáììá êáèþò êáé ç åðéññÞ êáé åîïõóßá ðïõ áóêïýí äéÜöïñá ìÝëç ôïõ ïñãáíéóìïý, áíåîÜñôçôá áðü ôçí ôõðéêÞ ôïõò èÝóç Þ åîïõóßá. Ôï âáóéêü üìùò ðëåïíÝêôçìÜ ôïõ åßíáé üôé äßíåé ìéá Üìåóç êáé óáöÞ åéêüíá ôçò ôõðéêÞò (åðßóçìçò) äïìÞò êáé ôùí êáíáëéþí åîïõóßáò êáé åðéêïéíùíßáò. Áðü ôçí áíÜëõóç ôùí áðïôåëåóìÜôùí ôïõ ðñþôïõ åñùôçìáôïëïãßïõ ðñïÝêõøå üôé Ýíá áñêåôÜ ìåãÜëï ðïóïóôü (70,1%) ôùí åñãáæïìÝíùí óôá Ê.Õ. ãíùñßæåé ôçí ýðáñîç ïñãáíïãñÜììáôïò êáé ôç èÝóç ôïõò ó’ áõôü êáé Ýíá áíÜëïãï ðïóïóôü (74,8%) äçëþíåé üôé ïé êáèçìåñéíÝò ôïõ äñáóôçñéüôçôåò åßíáé óáöþò êáèïñéóìÝíåò. ¢ëëùóôå ãéá êÜðïéåò êáôçãïñßåò åñãáæïìÝíùí õðÜñ÷ïõí èåóìïèåôçìÝíá ìå ÐñïåäñéêÜ ÄéáôÜãìáôá ôá åðáããåëìáôéêÜ ôïõò äéêáéþìáôá. ¸íá ìåãÜëï ðïóïóôü öáßíåôáé íá ãíùñßæåé ðïõ èá áðåõèõíèåß ãéá íá åðéëýóåé Ýíá ðñüâëçìá êáé ðïõ èá äéáâéâÜóåé ðáñáôçñÞóåéò Þ ðëçñïöïñßåò ôùí ïðïßùí èá ãßíåé áðïäÝêôçò, áí êáé ïé ðåñéóóüôåñïé (84,4%) ôï êÜíïõí áðü äéêÞ ôïõò ðñùôïâïõëßá êáé ü÷é óõóôçìáôéêÜ. Ç ðëåéïíüôçôá ôùí åñãáæïìÝíùí (82,4%) ãíùñßæåé ðïéá åßíáé ôá ðéèáíÜ ðñïâëÞìáôá ðïõ ìðïñåß íá ðáñïõóéáóèïýí óôçí åñãáóßá ôïõ êáé ôçí ýðáñîç ó÷åäßïõ åðßëõóÞò ôïõò, áí êáé Ýíá ôÝôïéï ó÷Ýäéï äåí Ý÷åé äïêéìáóôåß óôçí ðñÜîç. Ôá óõ÷íüôåñá ðñïâëÞìáôá ðïõ ðáñïõóéÜæïíôáé åßíáé ôå÷íéêÜ ðñïâëÞìáôá êáé äõóêïëßåò óõíåííüçóçò ìå áóèåíåßò ãéá ñáíôåâïý Þ ìå éáôñïýò. Óýìöùíá ìå ôá áðïôåëÝóìáôá ìéáò áíôßóôïé÷çò Ýñåõíáò ðïõ äéåîÞ÷èç óå éäéùôéêü äéáãíùóôéêü êÝíôñï óôéò ÊñÞôçò7, Ýíá ðïëý ìéêñü ðïóïóôü (36%) ãíùñßæåé ôçí ýðáñîç ïñãáíïãñÜììáôïò, áí êáé ôï 64% äçëþíåé üôé ïé êáèçìåñéíÝò ôïõ äñáóôçñéüôçôåò åßíáé óáöþò êáèïñéóìÝíåò. Áí äçìéïõñãçèåß êÜðïéï óçìáíôéêü ðñüâëçìá ôï 64% ãíùñßæåé ðïõ èá áðåõèõíèåß ãéá íá ôï åðéëýóåé. 181

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

¸íá ìåãÜëï ðïóïóôü (82%) ôùí åñãáæïìÝíùí èá äéáâéâÜóåé ðáñáôçñÞóåéò Þ ðëçñïöïñßåò ôùí ïðïßùí èá ãßíåé áðïäÝêôçò, áí êáé ôï 64% ôï êÜíåé áðü äéêÞ ôïõ ðñùôïâïõëßá êáé ü÷é óõóôçìáôéêÜ. Åðßóçò ïé ðåñéóóüôåñïé åñãáæüìåíïé (91%) ãíùñßæïõí ðïéá åßíáé ôá ðéèáíÜ ðñïâëÞìáôá ðïõ ìðïñåß íá ðáñïõóéáóèïýí óôçí åñãáóßá ôïõò, êáèþò ôçí ýðáñîç ó÷åäßïõ åðßëõóÞò ôïõò, ôï ïðïßï Ý÷åé äïêéìáóèåß óôçí ðñÜîç. ÔÝëïò ôá óçìáíôéêüôåñá ðñïâëÞìáôá ðïõ ðáñïõóéÜæïíôáé êáé óå áõôÞí ôçí ðåñßðôùóç ìå áîéïëïãéêÞ óåéñÜ åßíáé êõñßùò ôå÷íéêÞò öýóåùò, ðñïâëÞìáôá åðéêïéíùíßáò ìå ôïõò áóèåíåßò Þ ôï ðñïóùðéêü, êáèþò êáé ç ìç ôÞñçóç ôùí ðñïãñáììÜôùí. Ôá âáóéêÜ óõìðåñÜóìáôá ðïõ ðñïÝêõøáí áðü ôçí áíÜëõóç ôïõ äåýôåñïõ åñùôçìáôïëïãßïõ åßíáé üôé êáô’ áñ÷Þí üóïí áöïñÜ ôçí åðéêïéíùíßá ìå ôï ðñïóùðéêü ãßíåôáé êõñßùò ìå ôç ÷ñÞóç ôïõ ðñïöïñéêïý ëüãïõ, åíþ óõãêåíôñþóåéò ôïõ ðñïóùðéêïý äåí ãßíïíôáé óõ÷íÜ. Ïé áíôéðáëüôçôåò êáé ïé ôñéâÝò ôïõ ðñïóùðéêïý ðñïêáëïýíôáé óõíÞèùò ëüãù áõîçìÝíïõ üãêïõ åñãáóßáò êáé ëüãù åëÝã÷ïõ ôùí õöéóôáìÝíùí áðü ôïõò áíùôÝñïõò ôïõò. ÐáñÜëëçëá ôï ðñïóùðéêü ðáñáðïíéÝôáé êõñßùò ãéá ÷áìçëÝò áìïéâÝò, áíåðÜñêåéá åîïðëéóìïý êáé áíáëùóßìùí êáé áðáéôÞóåéò ãéá Üëëá êáèÞêïíôá. Ïé äéåíÝîåéò ðïõ ðáñïõóéÜæïíôáé ìåôáîý ôïõ äéïéêçôéêïý êáé ôïõ éáôñéêïý ðñïóùðéêïý ïöåßëïíôáé êáôÜ âÜóç óôçí ìç ôÞñçóç ôùí ùñáñßùí áðü ôïõò ãéáôñïýò. Ïé ðñïóôñéâÝò ìå ôïõò áóèåíåßò ðçãÜæïõí áðü ôç ìç óùóôÞ ôÞñçóç ôùí ñáíôåâïý êáé áðü ôçí åëëéðÞ åíçìÝñùóç ôùí ðñïóåñ÷ïìÝíùí áðü ôá áóöáëéóôéêÜ ôïõò ôáìåßá. Äéáðéóôþèçêå üôé ôá ðñïâëÞìáôá ðïõ ðñïáíáöÝñèçêáí ðáñáìÝíïõí Üëõôá ðáñüëï ðïõ ôüóï ç äéïéêïýóá áñ÷Þ ôùí Ê.Õ. üóï êáé ôá åìðëåêüìåíá ìÝñç ëáìâÜíïõí ðñùôïâïõëßá ãéá ôçí åðßëõóÞ ôïõò. ÅðéóçìÜíèçêå ôÝëïò áðü ôïõò åñãáæïìÝíïõò üôé ç ýðáñîç åíüò óõãêåêñéìÝíïõ ðëáéóßïõ ëåéôïõñãßáò êáé åðéêïéíùíßáò ôïõ ðñïóùðéêïý èá âïçèÞóåé óôçí åýñõèìç ëåéôïõñãßá ôùí Ê.Õ. êáé óôçí áíáâÜèìéóç ôçò ðïéüôçôáò ôùí ðáñå÷üìåíùí õðçñåóéþí. ÓõãêñéôéêÜ ôþñá ìå ôçí Ýñåõíá ôùí ÊáöåôæÜêç Â. êáé ÌáõñéêÜêç Á.8, áí êáé ôï äåýôåñï åñùôçìáôïëüãéï ðïõ ÷ñçóéìïðïßçóáí Þôáí ìåñéêþò ôñïðïðïéçìÝíï, ðñïÝêõøå üôé ç ðñáêôéêÞ ôùí óõãêåíôñþóåùí ôùí åñãáæïìÝíùí, ìå óêïðü ôçí óõæÞôçóç åñãáóéáêþí èåìÜôùí, äåí áðïôåëåß óçìáíôéêü óôïé÷åßï åðéêïéíùíéáêÞò ðïëéôéêÞò. Ïé 182

Å. Èçñáßïò êáé óõí.

ôñéâÝò ôïõ ðñïóùðéêïý ïöåßëïíôáé êáé óå áõôÞí ôçí ðåñßðôùóç óôçí Ýíôáóç ôçò êáèçìåñéíÞò äïõëåéÜò êáé óôéò äéáäéêáóßåò åëÝã÷ïõ, åíþ ôï ðñïóùðéêü åêöñÜæåé ðáñÜðïíá ãéá ÷áìçëÝò áìïéâÝò êáé áðáéôÞóåéò ãéá Üëëá êáèÞêïíôá. ÔÝëïò, ïé äéåíÝîåéò ðïõ ðáñïõóéÜæïíôáé áíÜìåóá óå ãéáôñïýò êáé äéïéêçôéêïýò ïöåßëïíôáé óôï ùñÜñéï ôùí ãéáôñþí, åíþ ïé äéåíÝîåéò ìå óôéò áóèåíåßò ïöåßëïíôáé óôçí ìç ôÞñçóç ôùí ñáíôåâïý. Óå áõôü ôï óçìåßï èá ðñÝðåé íá åðéóçìÜíïõìå ôá ðñïâëÞìáôá ðïõ ðáñïõóéÜóôçêáí óôç óõëëïãÞ ôùí åñùôçìáôïëïãßùí. ÁõôÜ ïöåßëïíôáé óå Ýíá âáèìü óôçí íïïôñïðßá ðïõ åðéêñáôåß áêüìá óôá Ê.Õ., ôá ïðïßá ùò áðïêåíôñùìÝíåò ìïíÜäåò, äå óõíçèßæïõí íá åðéêïéíùíïýí ìå ôçí êåíôñéêÞ äéïßêçóç Þ óõíáíôïýí ðñïóêüììáôá ó‘ áõôÞí ôçí åðéêïéíùíßá. Åðéðñüóèåôá õðÞñîå êá÷õðïøßá ãéá ôï óêïðü ôçò Ýñåõíáò, ëüãù öüâïõ ôùí åñãáæïìÝíùí ãéá Ýëåã÷ï ôçò åñãáóßáò ôïõò êáé ü÷é ùò ðñïóðÜèåéáò ôçò êåíôñéêÞò äéïßêçóçò ãéá ðïéïôéêÞ áîéïëüãçóç ôüóï ôùí óõíèçêþí åñãáóßáò üóï êáé ôùí ðáñå÷ïìÝíùí õðçñåóéþí. Ëüãù áõîçìÝíïõ öüñôïõ åñãáóßáò ç óõìðëÞñùóç ôùí åñùôçìáôïëïãßùí Þôáí öáéíïìåíéêÜ ðñü÷åéñç, óõíåðþò ìðïñåß åýêïëá êáíåßò íá âãÜëåé óõìðåñÜóìáôá ãéá ôçí áîéïðéóôßá ôùí áðáíôÞóåùí. Óôá ðáñáðÜíù ðñÝðåé íá ðñïóèÝóïõìå üôé áðü ôç óýãêñéóç ôùí äýï åñùôçìáôïëïãßùí ðñïêýðôåé ìßá áíôßöáóç. Eíþ óýìöùíá ìå ôï ðñþôï åñùôçìáôïëüãéï – ðïõ áðåõèýíèçêå óå üëï ôï ðñïóùðéêü – ôï 70,1% ãíùñßæåé ôçí ýðáñîç ïñãáíïãñÜììáôïò êáé ôï 74,8% äçëþíåé üôé ïé áñìïäéüôçôÝò ôïõ åßíáé óáöþò êáèïñéóìÝíåò, ôá óôåëÝ÷ç óôï äåýôåñï åñùôçìáôïëüãéï äçëþíïõí üôé ïé óõãêñïýóåéò ðçãÜæïõí êáé áðü ôçí Ýëëåéøç ïñãáíïãñÜììáôïò êáé êáèçêïíôïëïãßïõ. Áõôü ìðïñåß íá ïöåßëåôáé óôï üôé åíþ ïé åñãáæüìåíïé ãíùñßæïõí èåùñçôéêÜ üôé õðÜñ÷åé ïñãáíüãñáììá êáé êáèçêïíôïëüãéï, ðñáêôéêÜ äåí ôï åöáñìüæïõí. ¢ëëùóôå, åêêñåìåß áêüìá ç Ýêäïóç ôçò ÕðïõñãéêÞò Áðüöáóçò ðïõ ðñïâëÝðåôáé áðü ôïí Í. 2194/94 ãéá ôçí óõãêñüôçóç ôùí õðçñåóéþí ôïõò óôá ðëáßóéá ôùí óõóôÜóåùí ôçò áðüöáóçò ôçò 15çò ïëïìÝëåéáò ôïõ ÊÅÓÕ8. Åíôýðùóç ôÝëïò, ðñïêÜëåóå ôï ãåãïíüò üôé ìßá ðçãÞ ðñïâëçìÜôùí óôï ÊÝíôñï Õãåßáò Ëáõñßïõ åßíáé ïé óõ÷íÝò äéáêïðÝò ñåýìáôïò, ðáñüëï ðïõ óôçí ðåñéï÷Þ åßíáé åãêáôåóôçìÝíïò õðïóôáèìüò óôéò Ä.Å.Ç. ÖõóéêÜ èá ðñÝðåé íá ëÜâïõìå õðüøç ôéò äõóìåíåßò êáéñéêÝò óõíèÞêåò ðïõ åðé-

Ôüìïò 15, Ôåý÷ïò 2, 2003

Å. Èçñáßïò êáé óõí.

êñáôïýóáí ôç ÷ñïíéêÞ ðåñßïäï ðïõ äéåîÞ÷èç ç Ýñåõíá áõôÞ, ïðüôå áíáäýèçêå ôï áßôçìá áðü ôï ðñïóùðéêü ãéá åãêáôÜóôáóç áõôüìáôçò ìáíäÜëùóçò óôçí åöåäñéêÞ ãåííÞôñéá, Ýëëåéøç êïéíÞ êáé óôá Üëëá Ê.Õ. Åßíáé ßóùò êïéíïôõðßá, áëëÜ ðñÝðåé íá ôïíéóôåß üôé ïé êñßóåéò êáé ç äçìéïõñãßá ðñïâëçìÜôùí ÷áñáêôçñßæïõí ôïí ôïìÝá óôéò õãåßáò. Áõôü åßíáé áíáìåíüìåíï êáèþò Üôïìá ìå äéáöïñåôéêü åðßðåäï ìüñöùóçò, êïõëôïýñáò êáé äéáöïñåôéêÝò öéëïäïîßåò åßíáé áíáãêáóìÝíïé íá óõíõðÜñ÷ïõí êáé íá óõíåñãáæïíôáé ãéá íá ðáñÜãïõí ôï éäéáßôåñï áãáèü ðïõ êáëåßôáé ÕÃÅÉÁ. ÌÝóá óå áõôü ôï ðëáßóéï ç åðéêïéíùíßá, ç óõíåñãáóßá êáé ç åíóõíåßäçôç äçìéïõñãßá ïìÜäáò ìå êïéíÝò åðéäéþîåéò áðïôåëåß åðéôáêôéêÞ áíÜãêç. Åðéðñüóèåôá, ç äéïßêçóç óôoõò ïñãáíéóìïý õãåßáò, ëüãù ôçò éäéáéôåñüôçôáò ðïõ Ý÷åé Ýíáò ôÝôïéïò ïñãáíéóìüò, ðñÝðåé åêôüò áðü ôéò ãíþóåéò, íá äéáèÝôåé êáé çãåôéêÜ ðñïóüíôá. Íá äéáèÝôåé ôçí éêáíüôçôá íá äéá÷åéñßæåôáé ôá ðñïâëÞìáôá ðïõ ðáñïõóéÜæïíôáé, íá ðñïóáñìüæåôáé óôéò óõíèÞêåò êáé íá áíôáðïêñßíåôáé óôéò áðáéôÞóåéò ôùí ðåñéóôÜóåùí. Ç åðßôåõîç ôùí óôü÷ùí ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò áðáéôåß ôçí áîéïðïßçóç ôïõ õðÜñ÷ïíôïò ðñïóùðéêïý êáé ôç äçìéïõñãßá íÝùí êáôçãïñéþí õãåéïíïìéêïý ðñïóùðéêïý. ¼óï áöïñÜ óôç ëåéôïõñãéêÞ äéáóýíäåóç ôïõ ðñïóùðéêïý, áðáñáßôçôç ðñïûðüèåóç èá Þôáí ï áíáó÷åäéáóìüò ôùí õðáñ÷üíôùí ïñãáíïãñáììÜôùí. Áðáñáßôçôïò åðßóçò èá Þôáí ï åðáíáó÷åäéáóìüò ôùí êáèçêïíôïëïãßùí ôùí åðéóôçìüíùí õãåßáò. ÔÝëïò, ç áíÜðôõîç ôçò åêðáßäåõóçò êáé ôçò Ýñåõíáò óôïí ôïìÝá ôçò äéåðáããåëìáôéêÞò óõíåñãáóßáò ìðïñåß íá äéáäñáìáôßóåé óçìáíôéêü ñüëï óôçí åýñõèìç ëåéôïõñãßá ôçò ïìÜäáò. Ç Ýñåõíá èá óõìâÜëëåé óôçí áíáêÜëõøç ôùí ãåíåóéïõñãþí

áéôéþí ôùí êñßóåùí, ôéò óõíèÞêåò êÜôù áðü ôéò ïðïßåò åìöáíßæïíôáé, êáèþò åðßóçò èá ôïíßóåé ôéò áäõíáìßåò ðïõ áíáäýïíôáé ìÝóá áðü ôïõò êüëðïõò ôçò äéåðáããåëìáôéêÞò óõíåñãáóßáò. Åõ÷áñéóôßåò: Ïé óõããñáöåßò åðéèõìïýí íá åõ÷áñéóôÞóïõí ôá ìÝëç ôçò åñåõíçôéêÞò ïìÜäáò ôïõ Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò (Ìáñßá ËéÜñïõ-åéäéêåõüìåíç ÃåíéêÞò ÉáôñéêÞò-Ê.Õ. Êáðáíäñéôßïõ, ðáôÝñá Ì. ÄáíäïõëÜêç-Ãåíéêü Éáôñü-Ä/íôÞ ÅÓÕÊ.Õ. ÂÜñçò, Çñþ Êñçôéêïý êáé ÍéêïëÝôôá ÊÜúôóç-íïóçëåýôñéåò-Ê.Õ. Ëáõñßïõ, ×. ÃéáííÜêç-äéïéêçôéêü-Ê.Õ. Ìáñêïðïýëïõ, ¢ñôåìéò ÔæéíéÝñç-ãñáììáôÝá Â´ Ðå.Ó.Õ.Ð. ÁôôéêÞò) ãéá ôçí ïõóéáóôéêÞ óõìâïëÞ ôïõò óôçí äéåîáãùãÞ ôçò ìåëÝôçò.

Âéâëéïãñáößá 1. ËáíÜñá E. Äéïßêçóç Íïóçëåõôéêþí ÌïíÜäùí. ÁèÞíá, 1993. 2. Êáíåëëüðïõëïò X. ÁðïôåëåóìáôéêÞ Äéïßêçóç Áíèñùðßíùí Ðüñùí. ÁèÞíá, 1991, óåë. 279. 3. ÓáðïõíôæÞ-ÊñÝðéá Ä. ÏìÜäá Õãåßáò: ÄéáåðáããåëìáôéêÞ Óõíåñãáóßá, Óõãêñïýóåéò & Äéá÷åßñéóç Óõãêñïýóåùí. ÍïóçëåõôéêÞ, 1:75-81, 2001 4. ÌðïõñáíôÜò Ä. ÌÜíáôæìåíô: Èåùñçôéêü Õðüâáèñï – Óýã÷ñïíåò ÐñáêôéêÝò. Åêäüóåéò ÌðÝíïõ, 2002, óåë. 174-175. 5. Swansburg RJ. ÅéóáãùãÞ óôç íïóçëåõôéêÞ äéïßêçóç êáé çãåóßá, 1998, óåë. 636 6. Rocchiniali J, Titbury M. Clinical Leadership in Nursing. W. B. Saunders, 1998, óåë. 157 7. ÌáõñéêÜêçò Á., ÊáöåôæÜêçò Â. ËåéôïõñãéêÞ äéáóýíäåóç êáé óõíåñãáóßá ôïõ ðñïóùðéêïý óå ïñãáíéóìü õãåßáò. ÉáôñéêÜ ×ñïíéêÜ, 25:481-485, 2001 8. Õðïõñãåßï Õãåßáò êáé Ðñüíïéáò: Óêïðüò êáé ëåéôïõñãßá ôùí ÊÝíôñùí Õãåßáò, Ýããñáöï õð’ áñ. Á 3á/ïéê.6017/4.4.1990

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ä. Æþãáò êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ THE SECOND AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 15, Number 3, 184-193, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 3, 184-193, 2003

Åêôßìçóç ôçò áíáãêáéüôçôáò æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óå KÝíôñï ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò Ä. Æþãáò, Â. Æþãá, ×. Ôóéþëçò, Ó. Ðáíáãéùôßäïõ, É. ÔóéÜëéïò, Ê. Äéáìáíôüðïõëïò, Í. Åëåõèåñßïõ

Ðåñßëçøç Óêïðüò ôçò ìåëÝôçò åßíáé íá åêôéìçèåß ç áíáãêáéüôçôá ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí ðïõ æçôïýíôáé áðü ôïõò ãéáôñïýò åíüò êÝíôñïõ õãåßáò ãéá ðñïëçðôéêü Ýëåã÷ï êáé ãéá äéåñåýíçóç äýï êëéíéêþí áéôéÜóåùí: æÜëçò-éëßããïõ êáé êïéëéáêïý Üëãïõò. Õëéêü ôçò åñãáóßáò áðïôÝëåóå äåßãìá 5042 åîåôÜóåùí 442 áôüìùí ðïõ ðñáãìáôïðïéÞèçêáí óôï ìéêñïâéïëïãéêü åñãáóôÞñéï ôïõ Ê. Õãåßáò ÈÝñìçò áðü 1-11-02 Ýùò 31-12-02. Ôï õëéêü ôáîéíïìÞèçêå óå ôñåéò ïìÜäåò: åîåôÜóåéò ðñïëçðôéêïý åëÝã÷ïõ (ïìÜäá É), äéåñåýíçóçò æÜëçò-éëßããïõ (ïìÜäá ÉÉ), äéåñåýíçóçò êïéëéáêïý Üëãïõò (ïìÜäá ÉÉÉ). Ç åêôßìçóç ôçò áíáãêáéüôçôáò ôùí æçôïýìåíùí åîåôÜóåùí óôçñß÷èçêå: á) Óôçí åíáñìüíéóç ôùí æçôïýìåíùí åîåôÜóåùí ðñïò ôéò äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò. â) Óôç äéáãíùóôéêÞ áîßá ôçò æçôïýìåíçò åîÝôáóçò ãéá ôï óõãêåêñéìÝíï óýíäñïìï. ã) Óôç óõ÷íüôçôá ôùí æçôïýìåíùí åîåôÜóåùí êáé ôï ðïóïóôü èåôéêüôçôáò ôùí áðïôåëåóìÜôùí. Ôá áðïôåëÝóìáôá Ýäåéîáí üôé: á) Ôï 12% ôùí æçôïýìåíùí åîåôÜóåùí äåí óõíïäåýïíôáí áðü êëéíéêÝò ðëçñïöïñßåò. â) Ï ìÝóïò üñïò ôùí æçôïýìåíùí åîåôÜóåùí áíÜ Üôïìï Þôáí: óôçí ïìÜäá É 11,4, óôçí ïìÜäá ÉÉ 11,7, óôçí ïìÜäá ÉÉÉ 11,2. ã) Óôçí ïìÜäá É ìåôáîý ôùí Üëëùí æçôïýíôáí: ôñáíóáìéíÜóåò 80%, êñåáôéíßíç 72%, ÔÊÅ 40%, CPK35%, ã-GT 30%. Óôçí ïìÜäá ÉÉ : ôñáíóáìéíÜóåò 89%, êñåáôéíßíç 81%, ÔÊÅ 61%, ã-GT 46%, CPK 45%. Óôçí ïìÜäá ÉÉÉ: ÷ïëçóôåñßíç 61%, ã-GT 51%, CPK43%, óßäçñïò 25%. ä) Èåôéêü áðïôÝëåóìá ðáñïõóßáæå ôï 9,6% ôùí åîåôÜóåùí. Ôï ìåãáëýôåñï ìÝñïò ôïõ äéáìïñöþíïíôáí êáé óôéò ôñåéò ïìÜäåò áðü ôç ãåíéêÞ áßìáôïò, óÜê÷áñï êáé ÷ïëçóôåñßíç. ÓõìðåñáóìáôéêÜ ï êëéíéêüò ëüãïò öáßíåôáé íá ðáßæåé ìéêñü ñüëï óôçí åðéëïãÞ ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí. Ôï åßäïò êáé ï áñéèìüò ôùí æçôïýìåíùí åîåôÜóåùí äåí ó÷åôßæïíôáí ìå ôï âáèìü êáé ôçí åéäéêüôçôá ôïõ ðáñáããÝëïíôïò éáôñïý. Æçôåßôáé ìåãÜëïò áñéèìüò åîåôÜóåùí ôùí ïðïßùí ôï ðïóïóôü ôùí ðáèïëïãéêþí åõñçìÜôùí åßíáé óçìáíôéêÜ ÷áìçëü. Ç ðñáêôéêÞ áõôÞ åðéâáñýíåé ôï åñãáóôÞñéï êáé ðñïêáëåß ìåãÜëï ïéêïíïìéêü êüóôïò. ÅðéâÜëëåôáé óõììüñöùóç ôïõ ãéáôñïý ðñïò ôéò äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò, êáëýôåñç åêðáßäåõóç, ìåãáëýôåñç Ýìöáóç óôï éóôïñéêü êáé ôçí êëéíéêÞ åîÝôáóç

ÊÝíôñï Õãåßáò ÈÝñìçò, “ÉÐÐÏÊÑÁÔÅÉÏ” Ã.Í. Èåó/íßêçò

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ÅéóáãùãÞ ÌÝ÷ñé ðñüóöáôá ï ãéáôñüò ãéá íá ðñïóåããßóåé ôç äéÜãíùóç âáóéæüôáí êõñßùò óôç ëåðôïìåñåéáêÞ ëÞøç ôïõ éóôïñéêïý êáé ôç ó÷ïëáóôéêÞ êëéíéêÞ åîÝôáóç ôïõ áññþóôïõ. Áêïëïýèùò áí ôá ðñïêýðôïíôá åõñÞìáôá ôï åðÝâáëëáí êáôÝöåõãå óôç âïÞèåéá ôïõ åñãáóôçñßïõ áðü üðïõ æçôïýóå åðéëåêôéêÜ ïñéóìÝíåò åñãáóôçñéáêÝò åîåôÜóåéò ãéá íá åðéâåâáéþóåé ôç äéÜãíùóÞ ôïõ1. Ôá ôåëåõôáßá ÷ñüíéá ðïëëïß ãéáôñïß öáßíåôáé íá ìç äßíïõí ôçí ðñÝðïõóá âáñýôçôá óôï éóôïñéêü êáé ôçí áíôéêåéìåíéêÞ åîÝôáóç ôïõ áññþóôïõ êáé æçôïýí ìåãÜëï áñéèìü åñãáóôçñéáêþí åîåôÜóåùí ü÷é ôüóï ãéáôß ðéóôåýïõí óôç ÷ñçóéìüôçôÜ ôïõò üóï ãéá íá áðïöýãïõí ôõ÷üí êáôçãïñßåò ãéá ðñáãìáôéêÜ Þ õðïôéèÝìåíá óöÜëìáôá ËÝîåéò ÊëåéäéÜ: ÌéêñïâéïëïãéêÝò åîåôÜóåéò, åêôßìçóç, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ÕðïâëÞèçêå: ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: ÄçìÞôñéïò Æþãáò, Ðáñáóêåõïðïýëïõ 45, 55133 ÊáëáìáñéÜ Èåó/íßêçò Ôçë: (2310) 472372, 458681

Ôüìïò 15, Ôåý÷ïò 3, 2003

Ä. Æþãáò êáé óõí.

Evaluation of the necessity of lab tersts ordered in a primary care health centre D.V. Zogas, V.D. Zoga, Ch. D. Tsiolis, S.P. Panagiotidou, I.G. Tsialios, K.Z. Diamandopoulos, N.St. Eleftheriou Summary Aim: To evaluate the necessity of lab tests performed in a health centre for screening purposes and for the investigation of two clinical syndromes: dizziness-vertigo and abdominal pain. Material and Method: A sample of 5042 tests from 442 people was taken. The study was conducted over a 2 month period in Thermi Health Centre. The material was split into three groups: screening lab tests (group 1), investigation of dizziness-vertigo (group 2), investigation of abdominal pain (group 3). The factors considered were: (a) compliance with international guidelines (b) diagnostic value of tests ordered for the investigation of the above mentioned syndromes (c) frequency of tests ordered and percentage of positive findings. Results: 12% of the tests ordered were not accompanied by any clinical information. The mean number of tests ordered per person was: 11 in group 1, 12 in group 2 and 11 in group 3. These tests were ordered in group 1: transaminases 80%, creatinine 72%, ESR 40%, CPK 35%, gGT 30%. In group 2: transaminases 89%, creatinine 81%, ESR 61%, gGT 46%, CPK 45%. In group 3: cholesterol 61%, gGT51 %, CPK 43%, iron 25%. 9.6% of tests had positive results. CBC, glucose and cholesterol mainly contributed to this finding. Conclusions: The clinical role seems to play a minor role when ordering lab tests. The type and number of tests ordered were not related to the doctors experience and speciality. A large number of tests ordered gave significantly low positive findings. This way of testing is a burden to the lab and raises the financial cost. This makes it imperative that doctors comply with international guidlines, are better informed and place greater emphasis on the patients history and physical examination. Health Centre of Thermis, 'IPPOKRATIO' Thessaloniki General Hospital

êáé ðáñáëåßøåéò óôçí Üóêçóç ôïõ ëåéôïõñãÞìáôüò ôïõò. Ó’ áõôü Ý÷åé óõìâÜëåé åêôüò ôùí Üëëùí êáé ç ñáãäáßá åîÝëéîç óôïí ôïìÝá ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí, ôüóï óå áñéèìü êáé åîåéäßêåõóç üóï êáé óå ôá÷ýôçôá êáé åõêïëßá åêôÝëåóÞò ôïõò ìå ôïõò áõôüìáôïõò áéìáôïëïãéêïýò êáé âéï÷çìéêïýò áíáëõôÝò. Ç ôáêôéêÞ áõôÞ ôçò áëüãéóôçò êáé åí ðïëëïßò Üóêïðçò ÷ñÞóçò ôïõ åñãáóôçñßïõ åêôüò ôïõ üôé åðéâáñýíåé áäéêáéïëüãçôá ôï ïéêïíïìéêü êüóôïò ïäçãåß ðïëëÝò öïñÝò óå áäéÝîïäï Þ êáé óå ðëÜíç ôï ãéáôñü ðïõ äå äéáèÝôåé ôç ó÷åôéêÞ êëéíéêÞ åìðåéñßá ãéá ôç óùóôÞ åñìçíåßá ôùí áðïôåëåóìÜôùí ðïõ Ý÷åé óôá ÷Ýñéá ôïõ, áöïý Ýíá ìåãÜëï ìÝñïò áðü áõôÜ åßíáé êëéíéêÜ ìç áîéïëïãÞóéìá2-5. ÓõìðåñáóìáôéêÜ áõôü ðïõ ÷ñåéÜæåôáé ï êëéíéêüò ãéáôñüò êáé éäéáßôåñá ï ãéáôñüò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò (Ð.Ö.Õ.) ãéá íá åßíáé áðïôåëåóìáôéêüò óôï Ýñãï ôïõ åßíáé êõñßùò ôï êáëü éóôïñéêü, ç ðñïóåêôéêÞ êëéíéêÞ åîÝôáóç, ç óõíèåôéêÞ áîéïðïßçóç ôùí åõñçìÜôùí êáé ü÷é ïé ðïëëÝò áíáéôéïëüãçôåò êáé Üóêïðåò åñãáóôç-

ñéáêÝò åîåôÜóåéò. Óêïðüò ôçò åñãáóßáò áõôÞò Þôáí ç åêôßìçóç ôçò áíáãêáéüôçôáò ôùí æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí áðü ôïõò ãéáôñïýò ðïõ áóêïýí ôçí Ð.Ö.Õ. (ðáèïëüãïõò, ãåíéêÞò éáôñéêÞò, õðü÷ñåïõò õðçñåóßáò õðáßèñïõ) åíüò êÝíôñïõ õãåßáò ãéá ðñïëçðôéêü Ýëåã÷ï êáé ãéá ôç äéåñåýíçóç äýï óõíÞèùí êëéíéêþí áéôéÜóåùí ôçò æÜëçò-éëßããïõ êáé ôïõ êïéëéáêïý Üëãïõò.

Õëéêü êáé ìÝèïäïò

Ãéá ôï óêïðü áõôü ìåëåôÞèçêå Ýíá äåßãìá 5042 óõíÞèùí åîåôÜóåùí áßìáôïò êáé ïýñùí áðü Ýíá óýíïëï 16340 åîåôÜóåùí ðïõ ðñáãìáôïðïéÞèçêáí óôï ìéêñïâéïëïãéêü åñãáóôÞñéï ôïõ Ê. Õãåßáò ÈÝñìçò áðü 1-11-02 Ýùò 31-12-02 (40 åñãÜóéìåò çìÝñåò). Ïé åîåôÜóåéò ðåñéÝ÷ïíôáí óå 1079 ðáñáðåìðôéêÜ (áéìáôïëïãéêÜ, âéï÷çìéêÜ, ïýñùí) êáé åß÷áí åêäïèåß áðïêëåéóôéêÜ áðü ãéáôñïýò ðáèïëüãïõò, ãåíéêÞò éáôñéêÞò êáé õðü÷ñåïõò õðçñåóßáò õðáßèñïõ ôïõ êÝíôñïõ õãåßáò. Ç êáôáãñáöÞ ôùí óôïé÷åßùí Þôáí êáèçìåñéíÞ, ãéíüôáí óôï ÷þñï ôïõ ìéêñïâéïëïãéêïý åñãáóôçñßïõ êáé ðåñéëÜìâáíå: åßäç êáé áðïôåëÝóìáôá æçôïýìåíùí åîåôÜóåùí, êëéíéêÝò ðëçñïöïñßåò, öýëï êáé çëéêßá ðáñáðåìðïìÝíùí áôüìùí, âáèìü êáé åéäéêüôçôá ðáñáããÝëëïíôïò éáôñïý. Ïé åîåôÜóåéò áíÜëïãá ìå ôï óêïðü ðïõ åîõðçñåôïýóáí êáé ï ïðïßïò ðñïóäéïñéæüôáí áðü ôéò áíáãñáöüìåíåò óôá ðáñáðåìðôéêÜ êëéíéêÝò ðëçñïöïñßåò êáôáíÝìïíôáí óå ïìÜäåò. Ïé åîåôÜóåéò ðïõ áðïóêïðïýóáí óôïí ðñïëçðôéêü Ýëåã÷ï áðïôÝëåóáí ôçí ïìÜäá É, áõôÝò ðïõ áðïóêïðïýóáí óôç äéåñåýíçóç áôüìùí ðïõ ðñïóÝñ÷ïíôáí óôá éáôñåßá áéôéþìåíïé ãéá æÜëç-ßëéããï ôçí ïìÜäá ÉÉ êáé ãéá êïéëéáêü Üëãïò ôçí ïìÜäá ÉÉÉ. Ïé åîåôÜóåéò ðïõ äåí óõíïäåýïíôáí ìå êëéíéêÝò ðëçñïöïñßåò, åêåßíåò ðïõ áðïóêïðïýóáí óôïí ðåñéïäéêü Ýëåã÷ï áóèåíþí ìå ÷ñüíéá íïóÞìáôá êáé åêåßíåò ðïõ áðÝâëåðáí óôç äéåñåýíçóç Üëëùí êëéíéêþí åêäçëþóåùí åîáéñïýíôáí ôçò ìåëÝôçò. Ç åðéëïãÞ ôùí äýï óõãêåêñéìÝíùí êëéíéêþí áéôéÜóåùí ôçò æÜëçò-éëßããïõ êáé ôïõ êïéëéáêïý Üëãïõò Ýãéíå ãéáôß 185

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

åßíáé ðïëý óõ÷íÝò êáé áðïôåëïýí ìÝñïò ôçò óõìðôùìáôïëïãßáò ðëåßóôùí üóùí íïóçìÜôùí. ÌåôÜ ôçí êáôáãñáöÞ êáé ôáîéíüìçóç ôïõ õëéêïý óå ïìÜäåò ìåëåôÞèçêáí êáé áîéïëïãÞèçêáí: ç óõ÷íüôçôá, ôï åßäïò êáé ôá áðïôåëÝóìáôá ôùí åîåôÜóåùí (èåôéêÜ Þ áñíçôéêÜ) óå óõó÷åôéóìü ìå ôï óêïðü ãéá ôïí ïðïßï æçôïýíôáí, ôçí çëéêßá ôùí ðáñáðåìðïìÝíùí, ôçí åéäéêüôçôá êáé ôï âáèìü ôïõ ðáñáããÝëëïíôïò éáôñïý. ÈåôéêÜ èåùñÞèçêáí ôá áðïôåëÝóìáôá ôùí åîåôÜóåùí ôùí ïðïßùí ïé ôéìÝò áíåõñÝèçóáí åêôüò ôùí ôéìþí áíáöïñÜò ôïõ ìéêñïâéïëïãéêïý åñãáóôçñßïõ ôïõ Ê. Õãåßáò ÈÝñìçò. Ìç áíáãêáßåò ÷áñáêôçñßóèçêáí ïé åñãáóôçñéáêÝò åîåôÜóåéò, ç ÷ñçóéìüôçôá ôùí ïðïßùí äåí áðïäåéêíýåôáé ìå åðéäçìéïëïãéêÜ äåäïìÝíá óôçí ðåñßðôùóç ôïõ ðñïëçðôéêïý åëÝã÷ïõ êáé äå óõíéóôÜôáé ç ðñáãìáôïðïßçóÞ ôïõò óáí ñïõôßíá áðü äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò. Óôçí ðåñßðôùóç ôùí õðü äéåñåýíçóç êëéíéêþí óõíäñüìùí ìç áíáãêáßåò ÷áñáêôçñßóôçêáí ïé åîåôÜóåéò ôùí ïðïßùí ç èåôéêÞ Þ áñíçôéêÞ äéáãíùóôéêÞ áîßá åßíáé ìéêñÞ ãéá ôá óõãêåêñéìÝíá óýíäñïìá áöïý äå óõìâÜëëïõí óçìáíôéêÜ óôçí åðéâåâáßùóç Þ ôïí áðïêëåéóìü êÜðïéáò íüóïõ6-8. Ç êùäéêïðïßçóç ôùí äåäïìÝíùí ðïõ áöïñïýóáí ôéò êëéíéêÝò áéôéÜóåéò Ýãéíå ìå âÜóç ôï ÄéåèíÝò Óýóôçìá Ôáîéíüìçóçò Íüóùí, Êáêþóåùí êáé Áéôéþí ÈáíÜôïõ (ICD-9ç Áíáèåþñçóç). Ãéá ôç óôáôéóôéêÞ åðåîåñãáóßá ôùí áðïôåëåóìÜôùí ÷ñçóéìïðïéÞèçêáí ôï êñéôÞñéï ÷2 (óýãêñéóç èåôéêüôçôáò áðïôåëåóìÜôùí æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí ìåôáîý ôùí ïìÜäùí É, ÉÉ, ÉÉÉ ) êáé ôï êñéôÞñéï z êáé t (óýãêñéóç áñéèìïý æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí

Ä. Æþãáò êáé óõí.

óôéò ïìÜäåò ìåëÝôçò áíÜëïãá ìå ôçí åéäéêüôçôá êáé ôï âáèìü ôïõ ðáñáããÝëïíôïò éáôñïý).

ÁðïôåëÝóìáôá ÊáôÜ ôï ÷ñïíéêü äéÜóôçìá 1-11-02 Ýùò 3112-02 ðñáãìáôïðïéÞèçêáí óôï ìéêñïâéïëïãéêü åñãáóôÞñéï ôïõ Ê. Õãåßáò ÈÝñìçò 16340 åîåôÜóåéò. Áðü áõôÝò ìåëåôÞèçêáí êáé áîéïëïãÞèçêáí 5042 åîåôÜóåéò 442 áôüìùí, 199 áíäñþí êáé 243 ãõíáéêþí áöïý ðñþôá êáôáíåìÞèçêáí óå ïìÜäåò áíÜëïãá ìå ôï óêïðü æÞôçóÞò ôïõò. ÅîáéñÝèçêáí 7762 (47,5%) åîåôÜóåéò ïé ïðïßåò áðÝâëåðáí óôïí ðåñéïäéêü Ýëåã÷ï áóèåíþí ìå ÷ñüíéá íïóÞìáôá, 1620 (9,9%) ãéá äéåñåýíçóç Üëëùí êëéíéêþí åêäçëþóåùí êáé 1916 (11,7%) ïé ïðïßåò äåí óõíïäåýïíôáí ìå êëéíéêÝò ðëçñïöïñßåò (Ó÷Þìá I). Óôçí ïìÜäá É (ðñïëçðôéêüò Ýëåã÷ïò) óõìðåñéëÞöèçêáí 3709 åîåôÜóåéò 326 áôüìùí, çëéêßáò 19-85 åôþí (åíäéÜìåóç çëéêßá: 57,1 Ýôç ) áðü ôá ïðïßá 153 (46,9%) Þôáí Üíäñåò êáé 173 (53,1%) ãõíáßêåò. 104 (31,9%) áðü ôá ðáñáðÜíù Üôïìá åß÷áí ðáñáðåìöèåß áðü ðáèïëüãïõò, 216 (66,3%) áðü ãåíéêïýò ãéáôñïýò êáé 9 (13,4%) áðü ãéáôñïýò õðü÷ñåïõò õðçñåóßáò õðáßèñïõ. Óôçí ïìÜäá ÉÉ (äéåñåýíçóç æÜëçò-éëßããïõ) óõìðåñéëÞöèçêáí 784 åîåôÜóåéò 67 áôüìùí, çëéêßáò 17-75 åôþí (åíäéÜìåóç çëéêßá: 47,9 Ýôç) áðü ôá ïðïßá 22 (32,8%) Þôáí Üíäñåò êáé 45 (67,2%) ãõíáßêåò. 13 (19,4%) áðü ôá ðáñáðÜíù Üôïìá åß÷áí ðáñáðåìöèåß áðü ðáèïëüãïõò, 45(67,2%) áðü ãåíéêïýò ãéáôñïýò êáé 9 (13,4%) áðü ãéáôñïýò õðü÷ñåïõò õðçñåóßáò õðáßèñïõ.

Ó÷Þìá I. ÊáôáíïìÞ ìéêñïâéïëïãéêþí åîåôÜóåùí ðïõ ðñáãìáôïðïéÞèçêáí óôï ÊÝíôñï Yãåßáò ÈÝñìçò áðü1-11-02 Ýùò 31-12-02 áíÜëïãá ìå ôçí áéôßá ãéá ôçí ïðïßá æçôÞèçêáí. 186

Ôüìïò 15, Ôåý÷ïò 3, 2003

Ä. Æþãáò êáé óõí.

Óôçí ïìÜäá ÉÉÉ (äéåñåýíçóç êïéëéáêïý Üëãïõò) óõìðåñéëÞöèçêáí 549 åîåôÜóåéò 49 áôüìùí, çëéêßáò 14-81 åôþí (åíäéÜìåóç çëéêßá: 52,5Ýôç) áðü ôá ïðïßá 24 (49,0%) Þôáí Üíäñåò êáé 25 (51,0%) ãõíáßêåò. 21 (42,8%) áðü ôá ðáñáðÜíù Üôïìá åß÷áí ðáñáðåìöèåß áðü ðáèïëüãïõò, 26 (53,1%) áðü ãåíéêïýò ãéáôñïýò êáé 2 (4,1%) áðü ãéáôñïýò õðü÷ñåïõò õðçñåóßáò õðáßèñïõ (Ðßíáêáò I, II). Ç çëéêéáêÞ ïìÜäá óôçí ïðïßá ãßíïíôáí óõ÷íüôåñá åîåôÜóåéò óôçí ïìÜäá É êáé ãéá ôá äýï öýëá Þôáí áõôÞ ôùí 55-64 åôþí, óôçí ïìÜäá ÉÉ ãéá ôïõò Üíäñåò áõôÞ ôùí 65-74 åôþí êáé ãéá ôéò ãõíáßêåò ôùí 45-54 åôþí êáé óôçí ïìÜäá ÉÉÉ ãéá

ôïõò Üíäñåò áõôÞ ôùí 65-74 åôþí êáé ãéá ôéò ãõíáßêåò ôùí 45-54 åôþí (Ðßíáêáò III, Ó÷Þìá II, III, IV). Ï ìÝóïò üñïò åîåôÜóåùí ðïõ ðáñáããÝëëïíôáí áíÜ Üôïìï óôçí ïìÜäá É Þôáí 11,4 (åýñïò 6-20), óôçí ïìÜäá ÉÉ 11,7 (åýñïò 1-18), óôçí ïìÜäá ÉÉÉ 11,2 (åýñïò 1-19). Áðü ôéò 21 äéáöïñåôéêÝò êáôáìåôñçèåßóåò åîåôÜóåéò ïé ôñåéò óõ÷íüôåñá æçôçèåßóåò Þôáí óôçí ïìÜäá É ç ãåíéêÞ áßìáôïò 100%, ôï óÜê÷áñï áßìáôïò 99,7% êáé ïõñßá 99,7%. Óôçí ïìÜäá ÉÉ ç ãåíéêÞ áßìáôïò 100%, ôï óÜê÷áñï áßìáôïò 95,5%, ç ïõñßá 92,5%. Óôçí ïìÜäá ÉÉÉ ç ãåíéêÞ áßìáôïò 97,9%, ïé ôñáíóáìéíÜóåò 85,7%, ôï óÜê÷áñï áßìáôïò 83,7%. Óôçí ïìÜäá É äéáðéóôþíå-

Ðßíáêáò I. ÊáôáíïìÞ ðáñáðåìöèÝíôùí áôüìùí, ðáñáðåìðôéêþí, æçôïõìÝíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óôéò ïìÜäåò ìåëÝôçò ÏìÜäåò ìéêñïâéïëïãéêþí åñãáóôçñéáêþí åîåôÜóåùí

ÐáñáðåìöèÝíôá Üôïìá í (%)

ÐáñáðåìðôéêÜ í (%)

326 (73,7) 67 (15,2)

802 (74,3) 155 (14,4)

3709 (73,6) 784 (15,5)

49 (11,1)

122 (11,3)

549 (10,9)

442 (100,0)

1079 (100,0)

5042 (100,0)

É (Ðñïëçðôéêïý åëÝã÷ïõ) ÉÉ (Äéåñåýíçóç æÜëçò-éëßããïõ) 780,4* ÉÉÉ (Äéåñåýíçóç êïéëéáêïý Üëãïõò) 789,0* Óýíïëï

ÌéêñïâéïëïãéêÝò åîåôÜóåéò í (%)

* ICD-9

Ðßíáêáò II. ÄçìïãñáöéêÜ óôïé÷åßá ðáñáðåìöèÝíôùí ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò óôéò ïìÜäåò ìåëÝôçò ÐáñáðåìöèÝíôåò ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò

ÏÌÁÄÁ É (Ðñïëçðôéêüò Ýëåã÷ïò)

ÏÌÁÄÁ ÉÉ (ÆÜëç-ßëéããïò)

ÏÌÁÄÁ ÉÉÉ (Êïéëéáêü Üëãïò)

326 (73,7%) 153 (46,9%) 173 (53,1%) 19-85 åôþí 57,1 Ýôç

67 (15,2%) 22 (32,8%) 45 (67,2%) 17-75 åôþí 47,9 Ýôç

49 (11,1%) 24 (49,0%) 25 (51,0%) 14-81 åôþí 52,5 Ýôç

Óýíïëï ¢íäñåò Ãõíáßêåò çëéêßá åíäéÜìåóç çëéêßá

Ðßíáêáò III. ÊáôáíïìÞ ðáñáðåìöèÝíôùí áôüìùí ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò êáôÜ çëéêéáêÞ ïìÜäá êáé öýëï óôéò ïìÜäåò ìåëÝôçò ÇëéêéáêÞ ïìÜäá

15-24 25-34 35-44 45-54 55-64 65-74 75+ Óýíïëï

ÏÌÁÄÁ É (Ðñïëçðôéêüò Ýëåã÷ïò)

ÏÌÁÄÁ ÉÉ (ÆÜëç-ßëéããïò)

ÏÌÁÄÁ ÉÉÉ (Êïéëéáêü Üëãïò)

¢íäñåò í (%)

Ãõíáßêåò í (%)

¢íäñåò í (%)

Ãõíáßêåò í (%)

¢íäñåò í (%)

Ãõíáßêåò í (%)

1 (0,7) 6 (3,9) 5 (3,3) 32( 20,9) 65( 42,5) 36( 23,5) 8 (5,2) 153 (100,0)

4 (2,3) 11 (6,4) 14 (8,1) 30 (17,3) 77 (44,5) 32 (18,5) 5 (2,9) 173 (100,0)

1 (4,5) 5 (22,7) – 2 (9,1) 6 (27,3) 8 (36,4) – 22(100,0)

5 (11,1) 4 (8,9) 10 (22,2) 12 (26,7) 8 (17,8) 5 (11,1) 1 (2,2) 45 (100,0)

2 (8,3) 1 (4,2) 3 (12,5) 4 (16,7) 5 (20,8) 9 (37,5) – 24 (100,0)

4 (16,0) 2 (8,0) 2 (8,0) 6 (24,0) 3 ( 12,0) 5 (20,0) 3 (12,0) 25 (100,0) 187

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ó÷Þìá II. ÊáôáíïìÞ ðáñáðåìöèÝíôùí áôüìùí ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò êáôÜ çëéêéáêÞ ïìÜäá êáé öýëï (ïìÜäá É).

Ä. Æþãáò êáé óõí.

Ó÷Þìá III. ÊáôáíïìÞ ðáñáðåìöèÝíôùí áôüìùí ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò êáôÜ çëéêéáêÞ ïìÜäá êáé öýëï (ïìÜäá ÉÉ).

Ðßíáêáò IV. Ïé óõ÷íüôåñåò æçôçèåßóåò åîåôÜóåéò êáôÜ ôïí ðñïëçðôéêü Ýëåã÷ï (ïìÜäá É) êáé ç èåôéêüôçôÜ ôïõò (%) ÅîåôÜóåéò

ÏÌÁÄÁ É (Ðñïëçðôéêüò Ýëåã÷ïò) Æçôçèåßóåò í (%)

Ó÷Þìá IV. ÊáôáíïìÞ ðáñáðåìöèÝíôùí áôüìùí ãéá ìéêñïâéïëïãéêÝò åîåôÜóåéò êáôÜ çëéêéáêÞ ïìÜäá êáé öýëï (ïìÜäá ÉIÉ).

ôáé õøçëü ðïóïóôü æÞôçóçò ôñáíóáìéíáóþí 80,1%, êñåáôéíßíçò 71,8%, ÔÊÅ 39,9%, êñåáôéíïöùóöïêéíÜóçò (CPK) 34,7%, ã-ãëïõôáìõëïôñáíóöåñÜóçò ã-GT 30,4%. Óôçí ïìÜäá ÉÉ ôñáíóáìéíáóþí 89,5%, êñåáôéíßíçò 80,6%, ÔÊÅ 61,2%, ãGT 46,3%, CPK 44,8%. Óôçí ïìÜäá ÉÉÉ ÷ïëçóôåñßíçò 61,2%, ãGT 51%, CPK 42,8%, óéäÞñïõ 24,5% (Ðßíáêåò IV, V, VI). Ïé ðåñéóóüôåñåò åîåôÜóåéò óôçí ïìÜäá É æçôïýíôáí áðü ôïõò åðéìåëçôÝò Â, óôçí ïìÜäá ÉÉ áðü ôïõò åðéìåëçôÝò Á, óôçí ïìÜäá ÉÉÉ áðü ôïõò åðéìåëçôÝò Â ÷ùñßò ùóôüóï íá äéáðéóôþíïíôáé óçìáíôéêÝò áðïêëßóåéò ùò ðñïò ôá ðïóïóôÜ æÞôçóçò óôéò äéÜöïñåò âáèìßäåò (Ðßíáêáò VII). Óå ü,ôé áöïñÜ ôç óõ÷íüôçôá æÞôçóçò óå ó÷Ýóç ìå ôçí éáôñéêÞ åéäéêüôçôá ïé ðåñéóóüôåñåò åîåôÜóåéò óôçí ïìÜäá É æçôïýíôáé áðü ôïõò ãéáôñïýò ÷ùñßò åéäéêüôçôá, óôçí ïìÜäá ÉÉ êáé ÉÉÉ 188

ÃåíéêÞ áßìáôïò ÓÜê÷áñï áßìáôïò Ïõñßá ×ïëçóôåñßíç Ôñéãëõêåñßäéá HDL Ïõñéêü ïîý ÔñáíóáìéíÜóåò Êñåáôéíßíç ÃåíéêÞ ïýñùí Ô.Ê.Å. CPK ãGT Óßäçñïò ïñïý LDH ÁëêáëéêÞ öùóöáôÜóç

326 325 325 324 324 316 312 261 234 150 130 113 099 055 048 045

(100,0) 0(99,7) 0(99,7) 0(99,4) 0(99,4) 0(96,9) 0(95,7) 0(80,1) 0(71,8) 0(46,0) 0(39,9) 0(34,7) 0(30,4) 0(16,9) 0(14,7) 0(13,8)

ÈåôéêÝò í (%) 027 054 002 124 076 043 003 007 001 009 010 004 002 011

0(8,3) (16,6) 0(0,6) (38,3) (23,4) (13,6) 0(1,0) 0(2,7) 0(0,4) 0(6,0) 0(7,7) 0(3,5) 0(2,0) (20,0) – 001 0(2,2)

áðü ôïõò ðáèïëüãïõò, ÷ùñßò óçìáíôéêÝò áðïêëßóåéò ùò ðñïò ôá ðïóïóôÜ áíÜìåóá óôéò åéäéêüôçôåò (Ðßíáêáò VIII). Áðü ôï óýíïëï ôùí 5042 åîåôÜóåùí èåôéêÝò Þôáí ïé 523 (9,6%) (Ðßíáêáò IX). Óôá éóôïãñÜììáôá ôùí ó÷çìÜôùí V, VI, VII öáßíïíôáé ôá ðïóïóôÜ èåôéêüôçôáò êáé áñíçôéêüôçôáò ôùí óõ÷íüôåñá æçôïõìÝíùí åîåôÜóåùí óôçí êÜèå ïìÜäá ìåëÝôçò. Åðéóçìáßíåôáé ôï ÷áìçëü ðïóïóôü èåôéêüôçôáò ôùí åîåôÜóåùí êáé óôéò ôñåéò ïìÜäåò ìå åîáßñåóç üðùò Þôáí áíáìå-

Ôüìïò 15, Ôåý÷ïò 3, 2003

Ä. Æþãáò êáé óõí. Ðßíáêáò V. Ïé óõ÷íüôåñåò æçôçèåßóåò åîåôÜóåéò êáôÜ ôç äéåñåýíçóç ôçò æÜëçò-éëßããïõ (ïìÜäá ÉÉ) êáé ç èåôéêüôçôÜ ôïõò (%).

Ðßíáêáò VI. Ïé óõ÷íüôåñåò æçôçèåßóåò åîåôÜóåéò êáôÜ ôç äéåñåýíçóç ôïõ êïéëéáêïý Üëãïõò (ïìÜäá ÉÉÉ) êáé ç èåôéêüôçôÜ ôïõò (%).

ÅîåôÜóåéò

ÏÌÁÄÁ ÉÉ (ÆÜëç-ßëéããïò) Æçôçèåßóåò í (%)

ÃåíéêÞ áßìáôïò ÓÜê÷áñï áßìáôïò Ïõñßá ÔñáíóáìéíÜóåò ×ïëçóôåñßíç Ôñéãëõêåñßäéá HDL Êñåáôéíßíç Ïõñéêü ïîý Ô.Ê.Å. ãGT CPK Óßäçñïò ïñïý ÃåíéêÞ ïýñùí LDH ÁëêáëéêÞ öùóöáôÜóç

67 64 62 60 59 59 55 54 54 41 31 30 28 23 14 10

(100,0) 0(95,5) 0(92,5) 0(89,5) 0(88,0) 0(88,0) 0(82,1) 0(80,6) 0(80,6) 0(61,2) 0(46,3) 0(44,8) 0(41,8) 0(34,3) 0(20,9) 0(14,9)

ÏÌÁÄÁ ÉÉÉ (Êïéëéáêü Üëãïò)

ÈåôéêÝò í (%) 18 (26,9) 12 (18,7) – 04 0(6,6) 19 (32,2) 10 (16,9) 05 0(9,1) – 01 0(1,8) 05 (12,2) 01 0(3,2) 01 0(3,3) 10 (35,7) 05 (21,7) – 01 (10,0)

Æçôçèåßóåò í (%) ÃåíéêÞ áßìáôïò ÔñáíóáìéíÜóåò ÓÜê÷áñï áßìáôïò Ïõñßá Ô.Ê.Å. Êñåáôéíßíç Ïõñéêü ïîý ×ïëçóôåñßíç Ôñéãëõêåñßäéá ÃåíéêÞ ïýñùí ãGT HDL CPK ÁìõëÜóç LDH Óßäçñïò ïñïý

48 42 41 41 37 36 34 30 30 30 25 24 21 16 16 12

(97,9) (85,7) (83,7) (83,7) (75,5) (73,5) (69,4) (61,2) (61,2) (61,2) (51,0) (49,0) (42,8) (32,6) (32,6) (24,5)

ÈåôéêÝò í (%) 06 (12,5) 05 (11,9) 08 (19,5) – 03 0(8,1) – – 12 (40,0) 08 (26,7) 07 (23,3) 02 0(8,0) 02 0(8,3) 01 0(4,8) 01 0(6,2) – 01 0(8,3)

Ðßíáêáò VII. ÊáôáíïìÞ æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óå óõó÷åôéóìü ìå ôï âáèìü ôïõ ðáñáããÝëëïíôïò éáôñïý. Âáèìüò ðáñáããÝëëïíôïò éáôñïý

Õðü÷ñåïò õðçñåóßáò õðáßèñïõ ÅðéìåëçôÞò Â´ ÅðéìåëçôÞò Á´ Áí/ôçò Ä/íôÞò, ÄéåõèõíôÞò Óýíïëï

ÏÌÁÄÁ É (Ðñïëçðôéêüò Ýëåã÷ïò)

ÏÌÁÄÁ ÉÉ (ÆÜëç-ßëéããïò)

ÏÌÁÄÁ ÉÉÉ (Êïéëéáêü Üëãïò)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

006

0072 (12,0)

103 (11,4)

023 (11,5)

124 071 125

1602 (12,9) 0733 (10,3) 1302 (10,4)

19 25 14

218 (11,5) 303 (12,1) 160 (11,4)

12 10 25

155 (12,9) 108 (10,8) 263 (10,5)

326

3709

784

549

Ðßíáêáò VIII. ÊáôáíïìÞ æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óå óõó÷åôéóìü ìå ôçí åéäéêüôçôá ôïõ ðáñáããÝëëïíôïò éáôñïý. Åéäéêüôçôá ðáñáããÝëëïíôïò éáôñïý

Ðáèïëüãïò Ãåíéêüò Éáôñüò ×ùñßò Åéäéêüôçôá Óýíïëï

ÏÌÁÄÁ É (Ðñïëçðôéêüò Ýëåã÷ïò)

ÏÌÁÄÁ ÉÉ (ÆÜëç-ßëéããïò)

ÏÌÁÄÁ ÉÉÉ (Êïéëéáêü Üëãïò)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

ÐáñáðåìöèÝíôá Üôïìá í

Æçôïýìåíåò ÅîåôÜóåéò í (%)

104 216 006 326

1154 (11,1) 2483 (11,5) 0072 (12,0) 3709

13 45 09 67

165 (12,7) 516 (11,5) 103 (11,4) 784

21 26 02 49

245 (11,7) 281 (10,8) 023 (11,5) 549 189

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

íüìåíï ôçò ãåíéêÞò áßìáôïò, ôïõ óáê÷Üñïõ êáé ôçò ÷ïëçóôåñßíçò ôùí ïðïßùí ôï ðïóïóôü óõììåôï÷Þò óôï óýíïëï ôçò èåôéêüôçôáò óôçí ïìÜäá É Þôáí 86,6%, óôçí ïìÜäá ÉÉ 69,6% êáé óôçí ïìÜäá ÉÉÉ 63,1%.

ÓõæÞôçóç Ç óõìâïëÞ ôùí åñãáóôçñéáêþí ìéêñïâéïëïãéêþí åîåôÜóåùí ôüóï êáôÜ ôçí ðñüëçøç üóï êáé êáôÜ ôçí åðßëõóç ôùí äéáöüñùí äéáãíùóôéêþí ðñïâëçìÜôùí åßíáé óçìáíôéêÞ êáé áäéáìöéóâÞôçôç áñêåß ç æÞôçóÞ ôïõò íá åßíáé ïñèïëïãéêÞ êáé íá âáóßæåôáé óå áíáãíùñéóìÝíåò äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò (guidelines)6-11. Ìå ôçí ðáñïýóá ìåëÝôç åðé÷åéñåßôáé íá åêôéìçèåß ç áíáãêáéüôçôá ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí ðïõ æçôïýíôáé áðü ôïõò ãéáôñïýò ôïõ êÝíôñïõ õãåßáò ãéá ðñïëçðôéêü Ýëåã÷ï êáé ôç äéåñåýíçóç áóèåíþí ðïõ ðñïóÝñ÷ïíôáé óôá éáôñåßá áéôéþìåíïé æÜëç-ßëéããï êáé êïéëéáêü Üëãïò. Áðü ôç ìåëÝôç êáé áîéïëüãçóç 5042 ðñáãìáôïðïéçèåéóþí åîåôÜóåùí êáé ôùí áíôßóôïé÷ùí áðïôåëåóìÜôùí ôïõò ðñïêýðôïõí ôá êÜôùèé: Óå óçìáíôéêü áñéèìü ìéêñïâéïëïãéêþí ðáñáðåìðôéêþí äåí áíáöÝñåôáé ï ëüãïò ãéá ôïí ïðïßï æçôïýíôáé ïé åîåôÜóåéò. Ìéá ðáñÜëåéøç óçìáíôéêÞ äåäïìÝíïõ üôé ïé ðáñå÷üìåíåò êëéíéêÝò ðëçñïöïñßåò áðïôåëïýí ÷ñçóéìüôáôï óôïé÷åßï åéäéêÜ

Ä. Æþãáò êáé óõí.

óôéò ðåñéðôþóåéò êáôÜ ôéò ïðïßåò Ýíá ðáèïëïãéêü áðïôÝëåóìá ÷ñåéÜæåôáé åðáíÝëåã÷ï ãéá áðïêëåéóìü ðéèáíïý åñãáóôçñéáêïý ëÜèïõò. Ôá Üôïìá ôçò ìÝóçò êáé ìåãÜëçò çëéêßáò õðïâÜëëïíôáé óõ÷íüôåñá óå åîåôÜóåéò ôüóï ãéá ëüãïõò ðñüëçøçò üóï êáé ãéá ëüãïõò äéåñåýíçóçò äéáöüñùí êëéíéêþí åêäçëþóåùí. Åýñçìá áíáìåíüìåíï áöïý óôéò çëéêßåò áõôÝò áõîÜíåé ï äåßêôçò íïóçñüôçôáò ãéá ðïëëÜ íïóÞìáôá êáèþò êáé ç åõáéóèçôïðïßçóç ãýñù áðü âáóéêÜ èÝìáôá õãåßáò. Ï ìÝóïò üñïò ôùí æçôïýìåíùí ìéêñïâéïëïãéêþí åîåôÜóåùí áíÜ Üôïìï åßíáé 11,4. Ï áíôßóôïé÷ïò ìÝóïò üñïò óå äýï ó÷åôéêÝò ìåëÝôåò ôïõ 199312 êáé 199813 Þôáí 3,2 êáé 3,8 åîåôÜóåéò áíôßóôïé÷á ÷ùñßò üìùò íá äéåõêñéíßæåôáé óå áõôÝò ïýôå ç åéäéêüôçôá ôùí ðáñáðåìðüíôùí éáôñþí ïýôå ï ëüãïò æÞôçóÞò ôïõò þóôå íá ãßíåé áêñéâÞò óýãêñéóç. ÁíåîÜñôçôá áðü áõôü åêôéìïýìå ðùò ï æçôïýìåíïò áñéèìüò åîåôÜóåùí üðùò áõôüò ðñïêýðôåé áðü ôá åõñÞìáôá ôçò ìåëÝôçò ìáò åßíáé ðïëý ìåãáëýôåñïò áðü áõôüí ðïõ áðáéôåßôáé ãéá Ýíáí áðëü ðñïëçðôéêü Ýëåã÷ï Þ ãéá ôç äéåñåýíçóç óõíÞèùí êëéíéêþí óõíäñüìùí, üðùò áõôÜ ôçò ìåëÝôçò. Ï êëéíéêüò ëüãïò ðáñáããåëßáò ìéêñïâéïëïãéêþí åîåôÜóåùí äå öáßíåôáé íá åðçñåÜæåé éäéáßôåñá ôï åßäïò áõôþí ðïõ åðéëÝãïíôáé áöïý åîåôÜóåéò üðùò ôï óÜê÷áñï, ç ÷ïëçóôåñßíç, ôï ïõñéêü ïîý, ïé ôñáíóáìéíÜóåò, ç CPK æçôïýíôáé ðåñßðïõ

Ó÷Þìá V. ÐïóïóôÜ èåôéêüôçôáò êáé áñíçôéêüôçôáò ôùí óõ÷íüôåñá æçôïõìÝíùí ìéêñïâéïëïãéêþí åîåôÜóåùí êáôÜ ôïí ðñïëçðôéêü Ýëåã÷ï (ïìÜäá É). 190

Ä. Æþãáò êáé óõí.

ìå ôçí ßäéá óõ÷íüôçôá ôüóï êáôÜ ôïí ðñïëçðôéêü Ýëåã÷ï üóï êáé êáôÜ ôç äéåñåýíçóç äõï äéáöïñåôéêþí êëéíéêþí óõíäñüìùí, üðùò áõôÜ ôçò ìåëÝôçò (Ðßíáêåò ÉV, V, VI êáé Ó÷Þìá VIII). Èåôéêü (ðáèïëïãéêü) áðïôÝëåóìá ðáñïõóéÜæåé ôï 9,6% ôïõ óõíüëïõ ôùí åêôåëïýìåíùí åîåôÜóåùí. Ôï 3,2% ôïõ ðñïáíáöåñüìåíïõ ðïóïóôïý áöïñÜ áðïôåëÝóìáôá ïñéáêÜ èåôéêÜ. Èá ðñÝðåé óôï óçìåßï áõôü íá õðïãñáììßóïõìå üôé ç äéáìüñöùóç ôïõ ðïóïóôïý êáôÜ ôï ìåãáëýôåñï

Ôüìïò 15, Ôåý÷ïò 3, 2003

ìÝñïò ôïõ ïöåßëåôáé óôá èåôéêÜ áðïôåëÝóìáôá ôñéþí ìüíï åîåôÜóåùí, ôçò ãåíéêÞò áßìáôïò, ôïõ óáê÷Üñïõ êáé ôçò ÷ïëçóôåñßíçò. Óõãêñßíïíôáò ôéò èåôéêüôçôåò ìåôáîý ôùí ïìÜäùí É êáé ÉÉ óå ü,ôé áöïñÜ ôéò åîåôÜóåéò óáê÷Üñïõ, ÷ïëçóôåñßíçò êáé ôñáíóáìéíáóþí ðñïêýðôåé üôé äåí õðÜñ÷åé óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ ìåôáîý ôùí äýï ïìÜäùí. Óõãêñßíïíôáò ôéò èåôéêüôçôåò ìåôáîý ôùí ïìÜäùí É êáé ÉÉÉ ðñïêýðôåé üôé ãéá ôï óÜê÷áñï êáé ôç ÷ïëçóôåñßíç äåí õðÜñ÷åé óôáôéóôéêþò óç-

Ó÷Þìá VII. ÐïóïóôÜ èåôéêüôçôáò êáé áñíçôéêüôçôáò ôùí óõ÷íüôåñá æçôïõìÝíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óôç äéåñåýíçóç êïéëéáêïý Üëãïõò (ïìÜäá ÉÉI).

Ó÷Þìá VI. ÐïóïóôÜ èåôéêüôçôáò êáé áñíçôéêüôçôáò ôùí óõ÷íüôåñá æçôïõìÝíùí ìéêñïâéïëïãéêþí åîåôÜóåùí êáôÜ ôç äéåñåýíçóç æÜëçòéëßããïõ (ïìÜäá ÉÉ). 191

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ìáíôéêÞ äéáöïñÜ, åíþ ãéá ôéò ôñáíóáìéíÜóåò ðñïêýðôåé üôé áõôÝò åßíáé ðåñéóóüôåñï èåôéêÝò óôçí ïìÜäá ÉÉÉ (óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ ãéá p=0,02). ÂÝâáéá ôï ÷áìçëü ðïóïóôü èåôéêþí åñãáóôçñéáêþí åîåôÜóåùí äåí åßíáé åýêïëï íá ó÷ïëéáóèåß ãéáôß áñêåôÝò öïñÝò ôï áñíçôéêü (åíôüò öõóéïëïãéêþí ïñßùí) áðïôÝëåóìá åßíáé åîßóïõ óçìáíôéêü åêåß üðïõ ÷ñåéÜæåôáé íá áðïêëåéóôåß Ýíá íüóçìá êáé íá äéåõêïëõíèåß ç äéáöïñéêÞ äéÜãíùóç. Óõãêñßíïíôáò ôïí áñéèìü ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí ðïõ æçôïýí ïé ãéáôñïß áíÜëïãá ìå ôçí åéäéêüôçôÜ ôïõò (ãåíéêïß ãéáôñïß-ðáèïëüãïé) âñÝèçêå üôé äåí õðÜñ÷åé óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ óå êáìéÜ áðü ôéò ìåëåôïýìåíåò ïìÜäåò. Óõãêñßíïíôáò ôïí áñéèìü ôùí åîåôÜóåùí ðïõ æçôïýí ïé ãéáôñïß áíÜëïãá ìå ôï âáèìü ôïõò (åðéìåëçôÝò Â', Á', êáé Áíáðë. Ä/íôñéåò-Ä/íôÝò) âñÝèçêå üôé õðÜñ÷åé óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ óôçí ïìÜäá É (ðñïëçðôéêüò Ýëåã÷ïò), üðïõ ïé åðéìåëçôÝò Â æçôïýí ðåñéóóüôåñåò åñãáóôçñéáêÝò åîåôÜóåéò áðü ôïõò åðéìåëçôÝò Á (ãéá p <1x10-9), åíþ ãéá ôéò õðüëïéðåò ïìÜäåò (ÉÉ êáé ÉÉÉ) äåí õðÜñ÷åé óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ. Áðü ôá ðáñáðÜíù åêôéìïýìå üôé ç æÞôçóç ôùí åîåôÜóåùí, ìå áóÞìáíôåò äéáöïñÝò ùò ðñïò ôï âáèìü êáé ôçí åéäéêüôçôá ôùí ãéáôñþí, äåí áêïëïõèåß ôéò áíáãíùñéóìÝíåò êáôåõèõíôÞñéåò ïäçãßåò6-8,11 Þ ôéò ðñáãìáôéêÝò äéáãíùóôéêÝò áíÜãêåò áëëÜ Ýíá ôõðïðïéçìÝíï ùò åðß ôï ðëåßóôïí êïéíü äéåñåõíçôéêü ðñùôüêïëëï ßóùò áðü ëüãïõò åëëéðïýò åêðáßäåõóçò, áíáóöÜëåéáò, åîÜñôçóçò áðü ôï åñãáóôÞñéï.14 Ï êáôáéãéóìüò ôïõ áóèåíïýò ìå ðïëëÝò êáé ðñï ðÜíôùí ìç áíáãêáßåò åîåôÜóåéò äåí åßíáé âÝâáéá áðïêëåéóôéêüôçôá ôçò Ð.Ö.Õ. Åßíáé ðñáêôéêÞ ðïõ åöáñìüæåôáé ó’ üëåò ôéò âáèìßäåò ôïõ óõóôÞìáôïò õãåßáò ü÷é ìüíï ôçò ÷þñáò ìáò áëëÜ êáé Üëëùí ðñïçãìÝíùí ÷ùñþí ôïõ åîùôåñéêïý. Óôéò ÇÐÁ äáðáíþíôáé åôçóßùò ðåñéóóüôåñá áðü 30 äéó. äïëÜñéá ãéá ðñïåã÷åéñçôéêÝò åîåôÜóåéò 60% ôùí ïðïßùí üðùò Ýäåéîáí ó÷åôéêÝò ìåëÝôåò äåí Þôáí áíáãêáßåò15-17. ÔÝëïò ðñÝðåé íá ôïíéóôåß ãéá ìéá áêüìç öïñÜ üôé óå êÜèå ðåñßðôùóç ç êëéíéêÞ åîÝôáóç ôïõ áóèåíïýò ðñïÝ÷åé ïðïéáóäÞðïôå åñãáóôçñéáêÞò åîåôÜóåùò ðáñÜ ôçí ïìïëïãïõìÝíç ðñüïäï ôçò åñãáóôçñéáêÞò éáôñéêÞò.

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ÓõìðåñÜóìáôá - ÐñïôÜóåéò Ï êëéíéêüò ëüãïò öáßíåôáé íá ðáßæåé äåõôåñåýïíôá ñüëï, ðëçí åëá÷ßóôùí ðåñéðôþóåùí üðùò Ýäåéîáí ôá áðïôåëÝóìáôá ôçò ìåëÝôçò, óôçí åðéëïãÞ ôùí ìéêñïâéïëïãéêþí åîåôÜóåùí. Ç óõ÷íüôçôá êáé ôï åßäïò ôùí æçôïýìåíùí åîåôÜóåùí äå óõíäÝåôáé ìå ôï âáèìü êáé ôçí åéäéêüôçôá ôïõ ðáñáããÝëëïíôïò éáôñïý. Æçôåßôáé ìåãÜëïò áñéèìüò åîåôÜóåùí ôùí ïðïßùí ôï ðïóïóôü ôùí ðáèïëïãéêþí åõñçìÜôùí åßíáé óçìáíôéêÜ ÷áìçëü. Ï èåñÜðùí éáôñüò äåß÷íåé íá ìç óôï÷åýåé óôï ðñüâëçìá, áëëÜ áíáëßóêåôáé óå Üóêïðåò êáé Üóôï÷åò åîåôÜóåéò (ìç áíáãêáßåò). Ç ðñáêôéêÞ áõôÞ åêôüò ôïõ üôé ìðïñåß íá ïäçãÞóåé óå áäéÝîïäï Þ êáé óå ðëÜíç ôï ãéáôñü áðü ëáíèáóìÝíç åñìçíåßá ôùí áðïôåëåóìÜôùí2,18, åðéâáñýíåé ôï åñãáóôÞñéï êáé ðñïêáëåß ìåãÜëï ïéêïíïìéêü êüóôïò äõóáíÜëïãï ðñïò ôï ðñïóöåñüìåíï üöåëïò19-21. Ãé’ áõôü åðéâÜëëåôáé óõììüñöùóç ôïõ ãéáôñïý êáé éäéáßôåñá ôïõ ãéáôñïý ôçò Ð.Ö.Õ ðñïò ôéò äéåèíåßò êáôåõèõíôÞñéåò ïäçãßåò, êáëýôåñç åêðáßäåõóç, ìåãáëýôåñç Ýìöáóç óôï éóôïñéêü êáé ôçí êëéíéêÞ åîÝôáóç22,11,24. Ãéáôß åßíáé ÷ñÝïò üëùí ü÷é ìüíï íá åðéóçìáßíïõìå ìéá êáôÜóôáóç, áëëÜ êáé íá ðñïóðáèïýìå åðùöåëþò íá ôç ìåôáâÜëëïõìå. Åõ÷áñéóôïýìå èåñìÜ ôï ìéêñïâéïëüãï ôïõ Ê.Õãåßáò ÈÝñìçò ê. Äéáìáíôüðïõëï ÆÞóç êáé ôéò ðáñáóêåõÜóôñéåò ôïõ åñãáóôçñßïõ ê.ê. Êáìðåñßäïõ ¢ííá, Êáñõðßäïõ ÅëÝíç êáé Ôóéêïý Ìáñßá ãéá ôçí ðïëýôéìç âïÞèåéÜ ôïõò óôçí ðñáãìáôïðïßçóç áõôÞò ôçò åñãáóßáò.

Âéâëéïãñáößá 1. ÁñáðÜêçò Ã. ÊëéíéêÞ óçìåéïëïãßá. ÁèÞíá 1976. 2. Lofgren RP. Áñ÷Ýò ôçò ðñïëçðôéêÞò éáôñéêÞò êáé åðéëïãÞ åñãáóôçñéáêïý åëÝã÷ïõ. Áðü ôï âéâëßï ôçò S. Mladenovic, M.D. Secrets ÃåíéêÞò ÉáôñéêÞò. ÊëéíéêÜ ðñïâëÞìáôá êáé ç áíôéìåôþðéóÞ ôïõò. ÉáôñéêÝò åêäüóåéò Ð. Ðáó÷áëßäçò, 2ç Ýêäïóç. 3. Ëïõêüðïõëïò Ä. Áîéïëüãçóç åñãáóôçñéáêþí åîåôÜóåùí. ÉáôñéêÝò åêäüóåéò Ð. Ðáó÷áëßäçò, ÁèÞíá 1994. 4. ÌïõíôïêáëÜêçò È. ÄéáöïñéêÞ äéÜãíùóç åðß ôç âÜóåé ôùí êõñßùí êëéíéêþí åêäçëþóåùí. Åðéóôçìïíéêáß åêäüóåéò Ã. ÐáñéóéÜíïò, ÁèÞíá 1977.

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5. Roiren MF, More preoperative assessment by physician and less by laboratory tests. N Engl J Med, 342:204-205, 2000. 6. American Association for Clinical Chemistry. Website: www.labtestsonline.org 7. AAFP Clinical Recomendation, Periodic Health Examinations: Clinical Care and Reasearch, 2003 American Academy of family physicians www.aafp.org 8. Guidelines ÃåíéêÞò ÉáôñéêÞò. ÅðéìÝëåéá-ðñïóèÞêåò åëëçíéêÞò Ýêäïóçò, ËéïíÞò ×ñÞóôïò, Ñïâßèçò ÅììáíïõÞë. ÉáôñéêÝò åêäüóåéò Ð.×. Ðáó÷áëßäçò. 9. Æçëßäçò ×, ÖéëáëÞèçò ÁÅ, Âëá÷ïíéêïëÞò É. Ç ÷ñÞóç õðçñåóéþí õãåßáò óå Ýíá ôìÞìá åðåéãüíôùí ðåñéóôáôéêþí. Materia Medica Greca, 1992, 20. 10. Murtagh J. ÃåíéêÞ éáôñéêÞ. ÉáôñéêÝò åêäüóåéò Ð. Ðáó÷áëßäçò, 2002, óåë. 89-107. 11. Manual of Family Practice, Robert Taylor, MD, Little, Brown and Company, 15-23, 1997. 12. ÃåùñíôáìéëÞò Á, ÄéâÜñç Ä, Óåìåñôæßäçò ×, Ðáðáäçìçôñßïõ Á. ×ñÞóç ôïõ ìéêñïâéïëïãéêïý åñãáóôçñßïõ êáé ç êáôáíÜëùóç õðçñåóéþí ó’ Ýíá Ê.Õ. Áíáêïßíùóç 5ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò, 1993. 13. ¸ëëçíáò Ä, Áíèïðïýëïõ Å, Âïõñâïõôóéþôïõ Â, Ôá÷ôóÞ Ì, Ðáðáíáóôáóßïõ Ó, Æåðåéñßäçò Ë, Êáêáñßíïõ Å. ×ñÞóç õðçñåóéþí ôïõ ìéêñïâéïëïãéêïý åñãáóôçñßïõ. Aíáêïßíùóç 10ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò 1998. 14. Ãáñäßêáò Ê. Íá êáôáñãÞóïõìå ôçí ðáèïëïãßá;

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Åðéèåþñçóç õãåßáò, ÉáíïõÜñéïò-ÖåâñïõÜñéïò 1993. Marcello PW, Robert PL, et al. ‘Routine’ preoperative studies. Surg. CI NA, 76:11-21, 1996. Kaplan EB, et al. The usefulness of preoperative laboratory screening. JAMA, 253:3576-81, 1985. Macario A, Roizen MF, Thistet RA, et al. Reassessment of preoperative laboratory testing has changed the test ordering patterns of physicians. Surg Gynecal Obstet, 560, 75:539-547, 1992. Roiren MF. Preoperative evaluation. In: Anesthesia 5th Ed. PCL, 2000, p.p. 824-883. Fried C. Equality and Rights in Medical Care. Hastings Center Report, Feb. 1986. Gillon R. Ethics, Economics and general practice. In: Mooney G, Mc Guire A, Medical Ethics and Economics in Health Care. Oxford University Press, 1988. Abel Smith B: Cost Containment in health care, London, Benford Square Press, 1984. Ìáñêáíôþíçò Ë. ¸ìöáóç óôçí êëéíéêÞ åîÝôáóç: ÉáôñéêÜ áíÜëåêôá, Ôüìïò Á, 14:265-266, 2001. Simon Ch, Everutt H, Birtwistle B, et al. In: Oxford Handbook of General Practice. Oxford University Press, 2000, p.p. 80-83. Essentials of Family Medicine, 3rd Edition, Philip Sloane, MD, Lippincott, Williams and Wilkins, 1998, p.p. 157-179.

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ÁNAÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 15, Number 4, 194-203, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 194-203, 2003

Ï ñüëïò ôùí ãåíïóÞìùí öáñìÜêùí óôéò ÷þñåò ôïõ Ï.Ï.Ó.Á. êáé óôçí ÅëëÜäá Î. ÁëáôóÜêç, Ê. Óïõëéþôçò, Ã. Êõñéüðïõëïò

Ðåñßëçøç Óôçí ðáñïýóá åñãáóßá åðé÷åéñåßôáé ç óõãêñéôéêÞ ðáñïõóßáóç ôçò ó÷Ýóçò ìåôáîý ôùí ðñùôüôõðùí êáé ôùí ãåíïóÞìùí öáñìÜêùí, üðùò áõôÞ ðñïêýðôåé áðü ôç äéåèíÞ êáé åëëçíéêÞ âéâëéïãñáößá. Ìå óêïðü ôçí ðáñïõóßáóç ôùí ïéêïíïìéêþí äåäïìÝíùí ôá ïðïßá äéáìïñöþíïõí ôç èÝóç ôùí ãåíïóÞìùí ôüóï óôéò ÷þñåò ôïõ Ïñãáíéóìïý ÏéêïíïìéêÞò Óõíåñãáóßáò êáé ÁíÜðôõîçò (Ï.Ï.Ó.Á.), üóï êáé óôçí åã÷þñéá áãïñÜ, êñßèçêå óêüðéìï íá åîåôáóôåß åííïéïëïãéêÜ ï üñïò “ãåíüóçìá” ðñïêåéìÝíïõ íá ãßíåé óáöÞò ç äéáöïñïðïßçóç ôùí üñùí ðïõ ÷ñçóéìïðïéïýíôáé óôç öáñìáêåõôéêÞ áãïñÜ êáé óôéò äéáäéêáóßåò ðáñáãùãÞò ãåíïóÞìùí öáñìÜêùí. ÅðéðëÝïí, ãßíåôáé ìéá ðñïóðÜèåéá êáôáãñáöÞò ôçò äéåèíïýò åìðåéñßáò óå óýãêñéóç ìå ôçí åëëçíéêÞ áãïñÜ óå ü,ôé áöïñÜ ôïí ïéêïíïìéêü ñüëï ðïõ äéáäñáìáôßæïõí ôá ãåíüóçìá êáèþò êáé ôùí ðïëéôéêþí ðïõ åðçñåÜæïõí ôç æÞôçóÞ ôïõò. Ôï Üñèñï êáôáëÞãåé óôçí åêôßìçóç ôçò ìåëëïíôéêÞò èÝóçò ôùí ãåíïóÞìùí üðùò áõôÞ äéáöáßíåôáé áðü ôçí åéêüíá ôçò áãïñÜò öáñìÜêùí êáé ôçí åöáñìïæüìåíç öáñìáêåõôéêÞ ðïëéôéêÞ ôüóï óôç ÷þñá ìáò üóï êáé äéåèíþò. ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, ÔïìÝáò Ïéêïíïìéêþí ôçò Õãåßáò

The role of Generics in the member countries of the Organisation of Economic Coperation and Development and in Greece J. Alatsaki, K. Souliotis, J. Kyriopoulos Summary Aim: To define a comparative presence between the brand name and generic drugs, as resulted from international and Greek bibliography. Taking into consideration the financial facts that shape the market share of generics in the Organisation of Economic Coperation and Development (OECD)as well as in the local market, it was necessary to have a clear definition of the term generics. There had to be a differentiation of the meanings used in the pharmaceutical industry, as well as for the product lines of generic drugs. Due to the fact that the local pharmaceutical industry is mainly based on the production of generic drugs, the study attempts to define the registration of the international experience in comparison with the Greek industry, as regards the role that generics play in economics and the policies which affect their demand. The study concluded a long term estimate of the generics market shares as seen from a national and international aspect by the ph!armaceutical industry and pharmaceutical policy. National School of Public Health, Department of Health Economics

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ÅéóáãùãÞ - óêïðüò Ç óêïðéìüôçôá ôùí ðïëéôéêþí åëÝã÷ïõ ôçò öáñìáêåõôéêÞò äáðÜíçò óôéò ðåñéóóüôåñåò ÷þñåò êáé ç ðåñéïñéóìÝíç åðéôõ÷ßá ôùí óõóôçìÜôùí åëÝã÷ïõ ôùí ôéìþí ôùí öáñìÜêùí, ïäÞãçóå óôçí êáèéÝñùóç åíáëëáêôéêþí ôñüðùí ðåñéóôïëÞò ôùí öáñìáêåõôéêþí äáðáíþí1. Ìéá åõñÝùò äéáäåäïìÝíç ðïëéôéêÞ óôéò Ç.Ð.Á. áëëÜ êáé óôéò ÷þñåò ôçò ÅõñùðáúêÞò ¸íùóçò ðñïò ôçí êáôåýèõíóç áõôÞ, áöïñÜ óôçí åíèÜññõíóç ôçò ÷ñÞóçò ãåíïóÞìùí, ôá ïðïßá èåùñïýíôáé üôé åíôåßíïõí ôïí áíôáãùíéóìü, åíèáññýíïõí ôçí Ýñåõíá ãéá íÝá öÜñìáêá - ðåñéïñßæïíôáò ôá ìïíïðùëéáêÜ êÝñäç ôùí ðñùôüôõðùí éäéïóêåõáóìÜôùí - êáé âÝâáéá óõìâÜëëïõí óôç óõãêñÜôçóç ôçò öáñìáêåõôéêÞò äáðÜíçò2. Åßíáé åíäåéêôéêü üôé óôéò Ç.Ð.Á., äåäïìÝíïõ êáé ôïõ åõíïúêïý íïìïèåôéêïý ðåñéâÜëëïíôïò, ôá ãåíüóçìá öÜñìáêá áíôéðñïóùðåýïõí ìåñßäéï ìåãáëýôåñï ôïõ 40% ôçò áãïñÜò, åíþ óôçí ËÝîåéò êëåéäéÜ: öáñìáêåõôéêÞ ðåñßèáëøç, ãåíüóçìá, öáñìáêåõôéêÞ äáðÜíç ÕðïâëÞèçêå: 26 Máñôßïõ 2003 ÅðáíõðïâëÞèçêå: 24 Éïõíßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 20 Áõãïýóôïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: ÊõñéÜêïò Óïõëéþôçò, 28çò Ïêôùâñßïõ 5, 124 61 ×áúäÜñé, ÁèÞíá, Tçë. (210) 9419369, Fax: (210) 9493118

Î. ÁëáôóÜêç êáé óõí.

Åõñþðç, ïé ÷þñåò ìå ôï õøçëüôåñï áíôßóôïé÷ï ðïóïóôü åßíáé ç Ãåñìáíßá (38,8%), ç Äáíßá (37,5%) êáé ç Öéíëáíäßá (32%)3. Óôçí ÅëëÜäá, ç óõæÞôçóç ãéá ôçí ðñïþèçóç ôùí ãåíïóÞìùí óõíäÝåôáé ìå ôï ðñüâëçìá ôçò áýîçóçò ôçò öáñìáêåõôéêÞò äáðÜíçò, êõñßùò äéüôé ôá ôåëåõôáßá ìÝôñá ðåñéïñéóìïý ôùí ôéìþí êáé åéóáãùãÞò èåôéêïý êáôáëüãïõ óõíôáãïãñÜöçóçò, áðïäåß÷ôçêáí áíåðáñêÞ óå ó÷Ýóç ìå ôïí åðéäéùêüìåíï óôü÷ï1. Áíôßèåôá, ìåôÜ ôï 1998 ç öáñìáêåõôéêÞ äáðÜíç áõîÜíåôáé êáé áðïññïöÜ ôï 15,8% ôçò äçìüóéáò êáé ôï 15,3% ôçò éäéùôéêÞò äáðÜíçò õãåßáò4, ìå áðïôÝëåóìá ïé ðñïôÜóåéò ãéá ôçí áíôéìåôþðéóç ôïõ öáéíïìÝíïõ íá õðåñâáßíïõí ôéò êëáóóéêÝò ðñïóåããßóåéò ïé ïðïßåò ðñïÝâëåðáí åéóáãùãÞ èåôéêÞò Þ áñíçôéêÞò ëßóôáò, èÝóðéóç ïñïöÞò óôç óõíôáãïãñÜöçóç, äéåýñõíóç ôçò óõììåôï÷Þò ôïõ ÷ñÞóôç êáé Ýëåã÷ï ôùí ôéìþí êáé íá ðñïóáíáôïëßæïíôáé ðñïò ôçí åíßó÷õóç ôùí ãåíïóÞìùí, ôá ïðïßá óôç ÷þñá ìáò áíôéðñïóùðåýïõí ìüëéò ôï 10% ôçò áãïñÜò. Óêïðüò ôïõ Üñèñïõ åßíáé êáô´ áñ÷Þí ç áðïóáöÞíéóç ôçò Ýííïéáò ôùí ãåíïóÞìùí öáñìÜêùí, ç ïñéïèÝôçóç ôïõ ñüëïõ ôïõò óôç äéåèíÞ áëëÜ êáé ôçí åã÷þñéá öáñìáêåõôéêÞ áãïñÜ êáé ç åêôßìçóç ôùí ðñïïðôéêþí - êáé ôïõ ðñïóäïêþìåíïõ ïöÝëïõò - ùò ðñïò ôçí õéïèÝôçóç ðïëéôéêþí åíèÜññõíóçò ôçò ÷ñÞóçò ôïõò óôç ÷þñá ìáò.

ÅííïéïëïãéêÞ ðñïóÝããéóç Ï üñïò ãåíüóçìá (generics) ÷áñáêôçñßæåé öÜñìáêá ôùí ïðïßùí Ý÷åé ëÞîåé ç ðñïóôáóßá ðíåõìáôéêÞò éäéïêôçóßáò. Ôá ãåíüóçìá êáôáóêåõÜæïíôáé ôüóï áðü äéáöïñåôéêïýò ðáñáãùãïýò óå ó÷Ýóç ìå áõôïýò ôùí áõèåíôéêþí ðñïúüíôùí üóï êáé áðü ôïõò ßäéïõò. ÊáôÜ ìéá Üëëç åñìçíåßá, ãåíüóçìï èåùñåßôáé Ýíá öÜñìáêï ôïõ ïðïßïõ ç äñáóôéêÞ ïõóßá äåí ðñïóôáôåýåôáé ùò ðíåõìáôéêÞ éäéïêôçóßá êáé êõêëïöïñåß ìå äéáöïñåôéêÞ åìðïñéêÞ ïíïìáóßá áðü áõôÞ ôùí ðñùôüôõðùí öáñìáêåõôéêþí ðñïúüíôùí5. Ôá ãåíüóçìá öÜñìáêá, äéáêñßíïíôáé óå áõôÜ ôá ïðïßá Ý÷ïõí åìðïñéêÞ ïíïìáóßá (branded generics) êáé óå áõôÜ ôùí ïðïßùí ç ôáõôïðïßçóç ãßíåôáé ìå ôç ÷ñÞóç Äéåèíïýò Êïéíü÷ñçóôçò Ïíïìáóßáò (International Non-proprietary Name), äåí Ý÷ïõí åìðïñéêü óÞìá Þ Ý÷ïõí åí ìÝñåé âéïúóïäõíáìßá ìå Þ ÷ùñßò ôï üíïìá ôïõ ðáñáãùãïý6,2.

Ôüìïò 15, Ôåý÷ïò 4, 2003

Ìéá Üëëç óçìáíôéêÞ äéÜêñéóç, åßíáé áõôÞ ìåôáîý ôùí áìéãþò ãåíïóÞìùí (generic medicines) êáé ôùí áíôéãñÜöùí (copy products), ôá ïðïßá óõíáíôþíôáé óõíÞèùò óå ÷þñåò ìå áíáðïôåëåóìáôéêÞ Þ êáé áíýðáñêôç ðñïóôáóßá åõñåóéôå÷íßáò ãéá ÷çìéêÜ óõóôáôéêÜ êáé åðïìÝíùò êáé ãéá ôéò äñáóôéêÝò ïõóßåò ôùí öáñìÜêùí. Ç äéáöïñÜ åðïìÝíùò åíüò ãåíïóÞìïõ êáé åíüò áíôéãñÜöïõ, Ýãêåéôáé óôï üôé ôï ìåí ðñþôï áíôéãñÜöåé Ýíá áõèåíôéêü ôïõ ïðïßïõ ç ðåñßïäïò ðñïóôáóßáò ôçò åõñåóéôå÷íßáò Ý÷åé ëÞîåé, åíþ ôï äåýôåñï áíôéãñÜöåé Ýíá áõèåíôéêü, ôïõ ïðïßïõ ç ðñïóôáóßá åðéâÜëëåôáé áðü ôç íïìïèåóßá7. Åðßóçò, èá ðñÝðåé íá ãßíåé óáöÞò äéá÷ùñéóìüò ìåôáîý ôùí åííïéþí “õðïêáôÜóôáóç” êáé “èåñáðåõôéêÞ õðïêáôÜóôáóç”. Ç ðñþôç Ýííïéá áíáöÝñåôáé óå ðåñéðôþóåéò óôéò ïðïßåò ï öáñìáêïðïéüò ÷ïñçãåß óôïí ÷ñÞóôç öáñìáêåõôéêü ðñïúüí äéáöïñåôéêü áð’ áõôü ðïõ Ý÷åé óõíôáãïãñáöÞóåé ï ãéáôñüò, åíþ ç äåýôåñç, óå õðïêáôÜóôáóç öáñìÜêïõ, ôïõ ïðïßïõ ç ÷çìéêÞ óýíèåóç åßíáé äéáöïñåôéêÞ áðü áõôÞ ðïõ Ý÷åé óõíôáãïãñáöÞóåé ï ãéáôñüò.

Ç óêïðéìüôçôá ôçò ðáñáãùãÞò ãåíïóÞìùí Áðü ôç óôéãìÞ ðïõ ï êÜôï÷ïò ôçò åõñåóéôå÷íßáò ôùí ðñùôüôõðùí öáñìÜêùí, Ý÷åé áîéïðïéÞóåé ôá ïöÝëç ôïõ äéêáéþìáôïò ôçò ðíåõìáôéêÞò éäéïêôçóßáò êáé ôçò áðïêëåéóôéêÞò äéÜèåóçò óôçí áãïñÜ ãéá óõãêåêñéìÝíï äéÜóôçìá óýìöùíá ìå ôç ó÷åôéêÞ íïìïèåóßá, åßíáé ðéèáíÞ, åðéôñåðôÞ êáé åíäå÷ïìÝíùò èåìéôÞ, ç ðáñáãùãÞ êáé ðñïþèçóç ãåíïóÞìùí áðü Üëëåò åôáéñåßåò Þ áêüìç êáé áðü ôçí ßäéá, ç ïðïßá ìðïñåß íá ðáñÜãåé êáé íá êõêëïöïñåß ãåíüóçìá Þ íá åîáãïñÜæåé åôáéñåßá ãåíïóÞìùí. Ïé åôáéñåßåò áõôÝò äåí åðùìßæïíôáé êüóôïò ãéá ðñùôüôõðç Ýñåõíá êáé áíÜðôõîç öáñìÜêùí, óå áíôßèåóç ìå ôïõò ðáñáãùãïýò áõèåíôéêþí ðñïúüíôùí, ïé ïðïßïé êáëïýíôáé íá áðïóâÝóïõí ôï åðåíäõèÝí êåöÜëáéï åíôüò ôïõ ÷ñïíéêïý ðëáéóßïõ óôï ïðïßï ç ïõóßá Ý÷åé ôçí áðïêëåéóôéêüôçôá óôçí áãïñÜ, êáèïñßæïíôáò ôéìÝò õøçëüôåñåò ôïõ ïñéáêïý êüóôïõò ðáñáãùãÞò (Ramsey Pricing). Ç åßóïäïò ôùí ãåíïóÞìùí óôçí áãïñÜ, ìðïñåß íá ðñïêáëÝóåé ìåßùóç ôùí ôéìþí ãéá ôá ðñùôüôõðá ðñïúüíôá åîáéôßáò ôùí áíôáãùíéóôéêþí óõíèçêþí, äéüôé ôá ãåíüóçìá ÷ñçóéìïðïéïýí ôçí 195

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ßäéá äñáóôéêÞ ïõóßá êáé ùò åê ôïýôïõ åßíáé âéïúóïäýíáìá, ìïëïíüôé äåí åßíáé áðáñáßôçôá ðáíïìïéüôõðá ìå ôá åðþíõìá áõèåíôéêÜ. Ç äéáöïñÜ ôïõò óõíßóôáôáé óôï üôé åíþ ðåñéÝ÷ïõí ôçí ßäéá ðïóüôçôá áðü ôç óõãêåêñéìÝíç äñáóôéêÞ ïõóßá, åßíáé ðïëý ðéèáíü íá äéáöÝñïõí óôá Ýêäï÷á ðïõ ðåñéÝ÷ïõí. ¸ôóé, ïé ôéìÝò ôïõò êáëýðôïõí ôï êüóôïò ðáñáãùãÞò êáé äéáíïìÞò êáé ïé ðáñáãùãïß ôïõò, äåí ÷ñåéÜæåôáé íá åðåíäýóïõí ôìÞìá ôùí åóüäùí ôïõò ãéá Ýñåõíá êáé áíÜðôõîç - ìå ïñéóìÝíåò åîáéñÝóåéò ãåíoóÞìùí ìå åìðïñéêÞ ïíïìáóßá (branded generics), üðïõ äéáôßèåíôáé ðüñïé ãéá Ýñåõíá êáé áíÜðôõîç. Ç åéóáãùãÞ ôïõ áíôáãùíéóìïý óôçí áãïñÜ öáñìÜêùí ìÝóù ôùí åðþíõìùí ãåíüóçìùí ðñïúüíôùí Ýôóé þóôå íá áíôáãùíéóôïýí óå åðßðåäï ôéìþí ôüóï ìå ôá áõèåíôéêÜ üóï êáé ìåôáîý ôïõò, åîáñôÜôáé óå ìåãÜëï âáèìü áðü ôéò åðéëïãÝò êáé ôéò ðéÝóåéò ôùí áóöáëéóôéêþí ôáìåßùí êáé ôùí êáôáíáëùôþí. Áðü ôçí Üëëç, áðáéôåßôáé ç áíôáðüêñéóç åê ìÝñïõò ôçò áãïñÜò, Ýôóé þóôå ïé ðáñáãùãïß ãåíïóÞìùí íá Ý÷ïõí êßíçôñï íá åðåíäýïõí ðüñïõò ãéá ôçí ðáñáãùãÞ ðñïúüíôùí ðïõ èá áíôáãùíßæïíôáé ôá Þäç êáèéåñùìÝíá. Ìßá óõìðåñéöïñÜ ç ïðïßá Ý÷åé Þäç ðáñáôçñçèåß óôçí áãïñÜ, áöïñÜ óôç óôáäéáêÞ ðñïþèçóç ôïõ ïíüìáôïò ôçò åôáéñåßáò óáí åìðïñéêü óÞìá, ìå ôçí ðáñÜëëçëç äéáêßíçóç óêåõáóìÜôùí ÷ùñßò åìðïñéêü óÞìá (INN). ÁíåîáñôÞôùò ðÜíôùò ôïõ ôñüðïõ áíÜðôõîçò ôçò ó÷åôéêÞò åðé÷åéñçìáôéêÞò äñáóôçñéüôçôáò, ç ýðáñîç áíôáãùíéóìïý ôùí ãåíüóçìùí ðñïúüíôùí ìå åôáéñéêü óÞìá êáé ôùí ÉÍÍ ðñïúüíôùí ìå ôá áõèåíôéêÜ, åíôåßíåé ôïí áíôáãùíéóìü óôçí áãïñÜ, êõñßùò ëüãù ôçò ðßåóçò ôçí ïðïßá áóêåß óôï åðßðåäï ôùí ôéìþí. ÅíäåéêôéêÜ áíáöÝñåôáé üôé óôçí ÅëëÜäá ç ôéìÞ ôùí ãåíüóçìùí öáñìÜêùí êáèïñßæåôáé áãïñáíïìéêÜ êáé åßíáé 20% ÷áìçëüôåñç ôçò áíôßóôïé÷çò ôùí ðñùôüôõðùí öáñìÜêùí. Óýìöùíá ëïéðüí ìå ôá ðñïáíáöåñèÝíôá, ï ïéêïíïìéêüò ñüëïò ôùí öáñìÜêùí ôá ïðïßá Ý÷ïõí êáôï÷õñùèåß ùò êáéíïôüìá óå ó÷Ýóç ìå ôá ãåíüóçìá, óõíßóôáôáé óôï ãåãïíüò üôé ç ðñïóôáóßá ôçò åõñåóéôå÷íßáò, ðñïùèåß ôçí ïéêïíïìéêÞ áíôáìïéâÞ ÷ùñßò ôçí ïðïßá ïé öáñìáêåõôéêÝò åôáéñåßåò ðïõ óôçñßæïíôáé óôçí Ýñåõíá äåí èá ìðïñïýóáí íá êáéíïôïìÞóïõí, åíþ ïé êáôáóêåõáóôÝò ãåíïóÞìùí ðåñíïýí óôïõò êáôáíáëùôÝò ôá ðëåïíåêôÞìáôá ôùí êáëÜ äïêéìáóìÝíùí öáñìÜ196

Î. ÁëáôóÜêç êáé óõí.

êùí óå ÷áìçëüôåñåò ôéìÝò, ìå áðïôÝëåóìá íá ðñïêýðôïõí óçìáíôéêÝò áðïôáìéåýóåéò ãéá ôïõò ôåëéêïýò ðëçñùôÝò, êáèþò êáé ãéá ôéò êåíôñéêÝò äéïéêÞóåéò ôùí ôáìåßùí, áëëÜ êáé ôïõ êñÜôïõò8,9. Ï ïéêïíïìéêüò ëïéðüí ñüëïò ôùí ãåíïóÞìùí, ôüóï ôùí åðùíýìùí üóï êáé áõôþí ÷ùñßò åìðïñéêÞ ïíïìáóßá, ðñïêýðôåé áðü ôç äéáöïñÜ ìåôáîý ôçò êÜëõøçò ôïõ êüóôïõò ðáñáãùãÞò êáé äéáíïìÞò êáé ôçò åðßôåõîçò éêáíïý êÝñäïõò, ôï ïðïßï èá áíôéóôáèìßóåé ôï õøçëü ñßóêï ôçò êáéíïôïìßáò êáé èá óôçñßæåé ôç ìåëëïíôéêÞ Ýñåõíá êáé áíÜðôõîç. Ç áýîçóç ëïéðüí ôïõ ñõèìïý ðáñáãùãÞò ãåíïóÞìùí, åíéó÷ýåé ôïí áíôáãùíéóìü êáé åðéðëÝïí óõìâÜëëåé óôç ìåßùóç ôïõ åðéðÝäïõ ôùí ôéìþí ôùí öáñìÜêùí, ç ïðïßá ðñïêýðôåé áðü áõôüìáôåò ëåéôïõñãßåò êáé õðü êáèåóôþò áíôáãùíéóôéêÞò ëåéôïõñãßáò ôçò áãïñÜò êáé ü÷é áðü ðåñéïñéóôéêÝò êñáôéêÝò ðáñåìâÜóåéò ôùí ïðïßùí ç áðïôåëåóìáôéêüôçôá åßíáé ðñïóùñéíÞ10-12.

Ç äéåèíÞò åìðåéñßá ôçò áãïñÜò ãåíïóÞìùí Ç äéáöïñïðïßçóç ôùí ìåñéäßùí óõììåôï÷Þò ôùí ãåíïóÞìùí óôéò äéÜöïñåò áãïñÝò ôïõ Ïñãáíéóìïý ÏéêïíïìéêÞò Óõíåñãáóßáò êáé ÁíÜðôõîçò (Ï.Ï.Ó.Á.) ãéá ôá óõíôáãïãñáöïýìåíá öÜñìáêá, êáôáãñÜöåôáé áíáëõôéêÜ óôïí Ðßíáêá I, óýìöùíá ìå ôá óôïé÷åßá ôïõ ïðïßïõ ï óôáèìéóìÝíïò ìÝóïò üñïò óõììåôï÷Þò ôùí ãåíïóÞìùí óå ðïóïóôÜ ãéá ôá Ýôç 1996-1997 åßíáé 11%. Óôçí ÅõñùðáúêÞ ¸íùóç, ï áíôßóôïé÷ïò ìÝóïò üñïò (óå áîßåò) Þôáí ãéá ôï åí ëüãù ÷ñïíéêü äéÜóôçìá 15%, ìå ôï ìåñßäéï ôùí ãåíïóÞìùí íá åßíáé ôï õøçëüôåñï óôç Ãåñìáíßá (39%), óôç Äáíßá (38%) êáé óôç Öéëáíäßá (32%) êáé ÷áìçëüôåñï óôçí Éóðáíßá, óôç Ãáëëßá (2%), óôçí Ðïñôïãáëßá, óôçí Éôáëßá (3%) êáé óôç Óïõçäßá (4%). Óôçí Ðïñôïãáëßá êáé óôçí Éóðáíßá, ôï ìåñßäéï ôùí “áìéãþò” ãåíïóÞìùí üðùò ïñßæïíôáé ó’ áõôÞ ôçí åñãáóßá ðáñáìÝíïõí áêüìç ÷áìçëÜ êáé ôï ìåñßäéï ôùí áíôéãñÜöùí ðñïúüíôùí, ôá ïðïßá üðùò ðñïáíáöÝñèçêå åéóÝñ÷ïíôáé óôçí áãïñÜ ðñéí åêðíåýóåé ç ðåñßïäïò ðíåõìáôéêÞò ðñïóôáóßáò, åßíáé áíôéóôïß÷ùò õøçëÜ. Áõôü óõìâáßíåé äéüôé åíþ óôçí ÅõñùðáúêÞ ¸íùóç ðñéí ôï 1992 ç ðåñßïäïò ðíåõìáôéêÞò ðñïóôáóßáò åðéôñåðüôáí ìüíï ãéá ÷çìéêÝò ìåèüäïõò êáé ü÷é ãéá ÷çìéêÜ ðñïúüíôá, ìå ôïí íüìï ðïõ ôÝèçêå óå éó÷ý ôï 1992 êáé áöïñÜ óôçí ðñïóôáóßá ôùí ìåèüäùí,

Ôüìïò 15, Ôåý÷ïò 4, 2003

Î. ÁëáôóÜêç êáé óõí.

Ðßíáêáò I. ÐùëÞóåéò ãåíïóÞìùí óôéò ÷þñåò ôïõ Ï.Ï.Ó.Á. óå áîßá 1996, 1997 ôéìÝò ðáñáãþãùí (óå ECU) ×þñá

¼ëá ôá óõíôáã/öïýìåíá öÜñìáêá (óå ECU)

Åðþíõìá Ãåíüóçìá ÷ùñßò ¼ëá ôá Åðþíõìá Ãåíüóçìá ¼ëá ôá ãåíüóçìá åôáéñéêü üíïìá ãåíüóçìá ãåíüóçìá ÷ùñßò åôáéñéêü ãåíüóçìá (óå ECU) (óå ECU) (óå ECU) ìåñßäéï % üíïìá % %

Å.Å Áõóôñßá ÂÝëãéï Äáíßá Öéëáíäßá Ãáëëßá Ãåñìáíßá ÅëëÜäá Éñëáíäßá Éôáëßá Ëïõîåìâïýñãï Ïëëáíäßá Ðïñôïãáëßá Éóðáíßá Óïõçäßá Áããëßá Óýíïëï

1,090 1,749 429 903 12,137 13,311 1,222 284 6,663 55 1,830 1,199 4,363 1,509 6,072 52,817

267

87 24

95 103 161 289 290 5,165 154 36 200

111

241 34 0,33 63 1,318 8,149

172 24

35 7

461

10 0,2

9 6 38 32 2 39 13 13 3

ÓôáèìéóìÝíïò ìÝóïò

13 3 0 4 22 15

208 31

38 26

8 8

45 34

131

592 41

49 3

657

173

871

ÓôáèìéóìÝíïò ìÝóïò

155

460

79 615 3,966

¢ëëåò åõñùðáúêÝò ÷þñåò Ôóå÷ßá Ïõããáñßá Éóëáíäßá Íïñâçãßá Ðïëùíßá Åëâåôßá Ôïõñêßá Óýíïëï

563 459 90 774 1,211 1,530 756 5385

¢ëëåò ÷þñåò ôïõ Ï.Ï.Ó.Á. Áõóôñáëßá ÊáíáäÜò Éáðùíßá ÊïñÝá Ìåîéêü ÍÝá Æçëáíäßá Ç.Ð.Á Óýíïëï

1,589 4,231 49,578 5,483 1,420 301 58,303 120,904

5131 6,186

1283 1,743

6,413 11,135

9 2 ÓôáèìéóìÝíïò ìÝóïò

11 10

Ãåíéêü Óýíïëï

179,106

7,110

2,027

20,453

ÓôáèìéóìÝíïò ìÝóïò

5 15 8 11

ÐçãÞ: NERA (1998)14

åîáóöáëßóôçêå ç áðáñáßôçôç ðñïóôáóßá ãéá ôá ðñùôüôõðá öÜñìáêá, þóôå íá ðåñéïñéóôåß ç áíôéãñáöÞ ôùí äñáóôéêþí ïõóéþí. Ç åðßäñáóç üìùò ôïõ íüìïõ áõôïý äåí Þôáí ôï ßäéï áðïôåëåóìáôéêÞ ãéá ôéò äýï ðáñáðÜíù ÷þñåò, äéüôé ï íüìïò äåí åß÷å áíáäñïìéêÞ éó÷ý. Óôéò Üëëåò ÷þñåò åêôüò ÅõñùðáúêÞò ¸íùóçò ï óôáèìéóìÝíïò ìÝóïò üñïò ôïõ ìåñéäßïõ ôùí ãåíïóÞìùí åßíáé 30%, áëëÜ ôá äåäïìÝíá èåùñïýíôáé ðëáóìáôéêÜ ãéá ôçí Ïõããáñßá êáé ôçí Ðïëùíßá, óôéò ïðïßåò ç äéÜêñéóç ìåôáîý ãåíïóÞìùí êáé áíôéãñÜöùí ðñïúüíôùí Þôáí áóáöÞò ðñéí

ôçí êáôï÷ýñùóç ôçò åõñåóéôå÷íßáò (patent) ôùí ðñïúüíôùí, ìå áðïôÝëåóìá ôçí êõêëïöïñßá ðëçèþñáò áíôéãñÜöùí óôéò áãïñÝò áõôÝò. Ãéá ôéò ìç åõñùðáúêÝò ÷þñåò – ìÝëç ôïõ Ï.Ï.Ó.Á., ï óôáèìéóìÝíïò ìÝóïò üñïò êõìáßíåôáé óôï 10%, ìå ôï õøçëüôåñï ðïóïóôü íá åìöáíßæåôáé óôïí ÊáíáäÜ (15%) êáé ôçí ÁìåñéêÞ (11%)13. Ïé ðåñéóóüôåñåò ÷þñåò ôïõ Ï.Ï.Ó.Á., Ý÷ïõí õéïèåôÞóåé ðïëéôéêÝò ìÝóù ôùí ïðïßùí åðé÷åéñåßôáé ç åíßó÷õóç ôçò ðáñáãùãÞò êáé êáôáíÜëùóçò ãåíïóÞìùí. Ãéá ðáñÜäåéãìá: á) ÐáñÝ÷ïõí óôïõò ãéáôñïýò ïéêïíïìéêÜ êáé 197

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Üëëá êßíçôñá ãéá ôç óõíôáãïãñÜöçóç ãåíïóÞìùí. â) ÐáñÝ÷ïõí óôïõò öáñìáêïðïéïýò ïéêïíïìéêÜ êáé ìç ïéêïíïìéêÜ êßíçôñá, þóôå íá åêôåëïýí óõíôáãÝò õðïêáèéóôþíôáò Ýíá öÜñìáêï ìå Ýíá Üëëï ôï ïðïßï Ý÷åé ôï ßäéï Þ ïõóéùäþò üìïéï äñáóôéêü óõóôáôéêü. ã) ÐáñÝ÷ïõí óôïõò öáñìáêïðïéïýò ïéêïíïìéêÜ êáé ìç ïéêïíïìéêÜ êßíçôñá, þóôå íá åêôåëïýí óõíôáãÝò õðïêáèéóôþíôáò Ýíá öÜñìáêï ìå Ýíá Üëëï öèçíüôåñï ôï ïðïßï äåí Ý÷åé ôçí ßäéá äñáóôéêÞ ïõóßá (èåñáðåõôéêÞ õðïêáôÜóôáóç). ä) Ðñïóðáèïýí íá Ý÷ïõí ôïí Ýëåã÷ï ôùí ôéìþí ôüóï ãéá ôïõò ðáñáãùãïýò ãåíïóÞìùí üóï êáé ãéá ôïõò ðáñáãùãïýò ðïõ óôçñßæïíôáé óôçí Ýñåõíá. å) ×ñçóéìïðïéïýí óõóôÞìáôá áðïæçìéþóåùí ìå óêïðü íá åðçñåÜóïõí ôç æÞôçóç ãåíïóÞìùí. óô) Ðñïùèïýí åðßóçìá ôç ÷ñÞóç ãåíüóçìùí ìÝóù ôçò äéáöÞìéóçò áõôþí áðåõèõíüìåíïé óôïõò óõíôáãïãñÜöïõò áëëÜ êáé óôïõò êáôáíáëùôÝò. æ) ÅðéôñÝðïõí Þ äåí áíáãíùñßæïõí ôï äéêáßùìá óôïõò êáôáíáëùôÝò íá äÝ÷ïíôáé ãåíüóçìá Þ èåñáðåõôéêÜ õðïêáôÜóôáôá. ç) Äßíïõí êßíçôñá êáé áíôéêßíçôñá ôá ïðïßá áöïñïýí óôéò óõììåôï÷Ýò ôùí áóöáëéóìÝíùí Ýôóé þóôå íá êÜíïõí ôïõò êáôáíáëùôÝò-áóöáëéóìÝíïõò åõáßóèçôïõò óôéò ôéìÝò êáé íá äåß÷íïõí ðñïôßìçóç óôá öôçíüôåñá öÜñìáêá. è) Êáèéåñþíïõí ðëÜíá åñãáóßáò Ýôóé þóôå íá åðéôñÝðïõí ôçí áíÜðôõîç ãåíïóÞìùí ðñïúüíôùí ðñéí íá åêðíåýóåé ç ðåñßïäïò ðñïóôáóßáò ôùí áõèåíôéêþí êáé êáéíïôüìùí öáñìÜêùí Ýôóé þóôå íá êõêëïöïñÞóïõí áìÝóùò ìåôÜ ôç ëÞîç áõôÞò (bolar type provisions). Óôïí ðßíáêá II, êáôáãñÜöïíôáé ïé ôå÷íéêÝò êáé ïé ìÝèïäïé ïé ïðïßåò äéáðéóôþèçêáí óå äéÜöïñåò ÷þñåò ôïõ ÏÏÓÁ, áðü ôç NERA (National Economic Research Associates)14 ç ïðïßá äéåñåýíçóå ôç óõó÷Ýôéóç ìåôáîý ôïõ áñéèìïý ôùí ðïëéôéêþí ðñïáãùãÞò ôçò ÷ñÞóçò ãåíïóÞìùí êáé ôïõ âáèìïý äéåßóäõóçò ôùí ôåëåõôáßùí óôéò äéÜöïñåò áãïñÝò. Ç ðïóïôéêÞ áõôÞ ðñïóÝããéóç, äåí ïäçãåß óå óáöåßò óõó÷åôßóåéò, åðéâåâáéþíåé üìùò ôçí õðüèåóç üôé ïé éäéáßôåñåò ðïëéôéêÝò êÜèå êñÜôïõò êáé ï ôñüðïò ìå ôïí ïðïßï êÜèå öïñÜ åðéëÝãåôáé íá åöáñìïóôïýí, áðïôåëïýí ïõóéáóôéêïýò ðáñÜãïíôåò äéåßóäõóçò ôùí ãåíïóÞìùí13,15,16. 198

Î. ÁëáôóÜêç êáé óõí.

Ïé Üìåóá åìðëåêüìåíïé óôç óõíôáãïãñÜöçóç öáñìÜêùí åßíáé ï ãéáôñüò, ï öáñìáêïðïéüò êáé ï áóèåíÞò, êáèþò êáé ï åêÜóôïôå áóöáëéóôéêüò öïñÝáò ï ïðïßïò áíáëáìâÜíåé ôçí ðëçñùìÞ åíüò ìåãÜëïõ ôìÞìáôïò ôçò ôéìÞò ôïõò. Ï óçìáíôéêüôåñïò ëüãïò ôçò õðïêáôÜóôáóçò, áöïñÜ óôç äÝóìåõóç üóï ôï äõíáôüí ëéãüôåñùí áðü ôïõò äçìüóéïõò äéáèÝóéìïõò ðüñïõò, êáèþò êáé óôç ìåßùóç ôçò óõí-ðëçñùìÞò ôùí ÷ñçóôþí. ¢ëëïé ëüãïé ðïõ áíáöÝñïíôáé åßíáé ç åíßó÷õóç ôïõ áíôáãùíéóìïý óôéò åèíéêÝò áãïñÝò öáñìÜêùí, ç áýîçóç ôçò ïñèïëïãéêÞò öáñìáêåõôéêÞò ÷ñÞóçò êáé ç åíèÜññõíóç ôçò åã÷þñéáò âéïìç÷áíéêÞò ðáñáãùãÞò ãåíïóÞìùí17-19.

Ç áãïñÜ öáñìÜêùí êáé ï ñüëïò ôùí ãåíïóÞìùí óôçí ÅëëÜäá Óýìöùíá ìå ôéò ðñïâëÝøåéò ôçò International Marketing Services (IMS - Health), ç ðáãêüóìéá öáñìáêåõôéêÞ áãïñÜ áíáìÝíåôáé íá áíáðôõ÷èåß ôá åðüìåíá ðÝíôå ÷ñüíéá ìå åôÞóéï ñõèìü 8,4%. Ôï ãåãïíüò áõôü áðïäßäåôáé êõñßùò óôçí áýîçóç ôïõ ðñïóäüêéìïõ åðéâßùóçò êáé óôçí áíáêÜëõøç íÝùí, õøçëÞò ôå÷íïëïãßáò èåñáðåéþí. Óå óõíäõáóìü ìå ôéò ðñïóðÜèåéåò ôùí êõâåñíÞóåùí óôéò ðåñéóóüôåñåò ÷þñåò íá óõãêñáôÞóïõí ôçí áýîçóç ôùí äáðáíþí õãåßáò, äçìéïõñãåßôáé Ýíá ðåñéâÜëëïí ëåéôïõñãßáò âáóéóìÝíï óôç ó÷Ýóç êüóôïõò/áðïôåëåóìáôéêüôçôáò, ç ïðïßá ïäçãåß ôç öáñìáêïâéïìç÷áíßá óôçí áíÜðôõîç êáéíïôüìùí ðñïúüíôùí ôùí ïðïßùí ç áõîçìÝíç áðïôåëåóìáôéêüôçôá èá ðñÝðåé íá äéêáéïëïãåß ôï åðéðëÝïí êüóôïò20. Óôçí ÅëëÜäá ôçí ôåëåõôáßá 15åôßá ç åã÷þñéá öáñìáêïâéïìç÷áíßá ÷áñáêôçñßæåôáé áðü ïñéæüíôéá äéÜñèñùóç óôçí ðáñáãùãÞ ôçò. Áõôü ðñáêôéêÜ óçìáßíåé üôé åíþ ðáñÜãåé Üëëá öáñìáêåõôéêÜ ðñïúüíôá (êáëëõíôéêÜ êáé ïñïýò), äåí ðáñÜãåé ðñþôåò ýëåò öáñìÜêùí. Ç Ýëëåéøç êáèåôïðïßçóçò óôçí ðáñáãùãÞ ïöåßëåôáé óôçí áíõðáñîßá öáñìáêåõôéêÞò Ýñåõíáò. ÓÞìåñá óôçí ÅëëÜäá, óôï ÷þñï ôïõ öáñìÜêïõ äñáóôçñéïðïéïýíôáé 189 åðé÷åéñÞóåéò óå åôáéñéêÞ ìïñöÞ (corporate) åíþ ïé äéêáéïý÷ïé óÞìáôïò áíÝñ÷ïíôáé óå 28720,21. Ç ìÝóç åôÞóéá áðáó÷üëçóç óôç öáñìáêïâéïìç÷áíßá ðáñïõóéÜæåé êÜìøç ìåôÜ ôï 1991, ãåãïíüò ôï ïðïßï óõíäÝåôáé ìå ôç óôñïöÞ ôçò áãïñÜò óå Ýôïéìá åéóáãüìåíá ðñïúüíôá. Óýìöù-

Ôüìïò 15, Ôåý÷ïò 4, 2003

Î. ÁëáôóÜêç êáé óõí.

Ðßíáêáò II. Ðåñßëçøç ôùí åðéëåãìÝíùí åèíéêþí ãéá ôçí ðñïþèçóç ôçò ÷ñÞóçò ôùí ãåíïóÞìùí

Áõóôñßá

ÂÝëãéï

Äáíßá

Öéëáíäßá

Ãáëëßá

Ãåñìáíßá

ÅëëÜäá

Éñëáíäßá

Éôáëßá

Ëïõîåìâïýñãï

Ïëëáíäßá

Ðïñôïãáëßá

Éóðáíßá

Óïõçäßá

Âñåôáíßá

ÅõñùðáúêÞ ¸íùóç

ÅðéôñÝðåôáé ç õðïêáôÜóôáóç ãåíïóÞìùí

ÅðéôñÝðåôáé ç èåñáðåõôéêÞ õðïêáôÜóôáóç

ÐïëéôéêÝò

ÅðéôñÝðåôáé óôïõò êáôáíáëùôÝò íá áñíïýíôáé ôçí õðïêáôÜóôáóç ãåíïóÞìùí

ÏéêïíïìéêÜ êßíçôñá óôïõò ãéáôñïýò

Ìç-Üóêçóç ïéêïíïìéêÞò åðéññïÞò óôïõò ãéáôñïýò

ÏéêïíïìéêÜ êßíçôñá óôïõò öáñìáêïðïéïýò

Ìç-Üóêçóç ïéêïíïìéêÞò åðéññïÞò óôïõò öáñìáêïðïéïýò

ÅîåéäéêåõìÝíï óýóôçìá áðïæçìéþóåùí ãéá ôá ãåíüóçìá Åðßóçìç äçìïóéïðïßçóç ôçò ðñïôßìçóçò ãåíïóÞìùí

Áñéèìüò èåôéêþí áðáíôÞóåùí

Éóëáíäßá

Íïñâçãßá

Ðïëùíßá

Åëâåôßá

Ôïõñêßá

Áõóôñáëßá

ÊáíáäÜ

Éáðùíßá

Ìåîéêü

Í. Æçëáíäßá

Ç.Ð.Á

ÅðéôñÝðåôáé ç õðïêáôÜóôáóç ãåíïóÞìùí

ÅðéôñÝðåôáé ç èåñáðåõôéêÞ õðïêáôÜóôáóç

ÅðéôñÝðåôáé óôïõò êáôáíáëùôÝò íá áñíïýíôáé ôçí õðïêáôÜóôáóç ãåíïóÞìùí

ÏéêïíïìéêÜ êßíçôñá óôïõò ãéáôñïýò

Ìç-Üóêçóç ïéêïíïìéêÞò åðéññïÞò óôïõò ãéáôñïýò

ÏéêïíïìéêÜ êßíçôñá óôïõò öáñìáêïðïéïýò

Ìç-Üóêçóç ïéêïíïìéêÞò åðéññïÞò óôïõò öáñìáêïðïéïýò

ÅîåéäéêåõìÝíï óýóôçìá áðïæçìéþóåùí ãéá ôá ãåíüóçìá

ÊïñÝá

ÐïëéôéêÝò

Ïõããáñßá

¢ëëåò ×þñåò ôïõ Ï.Ï.Ó.Á.

Ôóå÷ßá

¢ëëåò ÅõñùðáúêÝò ×þñåò

Åðßóçìç äçìïóéïðïßçóç ôçò ðñïôßìçóçò ãåíïóÞìùí

Áñéèìüò èåôéêþí áðáíôÞóåùí

1 = ÍÁÉ 0 = Ï×É ÐçãÞ: NERA (1998)14

Êåíü = äåí õðÜñ÷åé ðëçñïöïñßá.

199

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

íá ìå ðñüóöáôá óôïé÷åßá ôïõ Éíóôéôïýôïõ ÖáñìáêåõôéêÞò ¸ñåõíáò êáé Ôå÷íïëïãßáò (É.Ö.Å.Ô.), ôï ìåãáëýôåñï ôìÞìá ôçò áãïñÜò öáñìÜêùí áðü ôï 1995 êáé ìåôÜ êáôáëáìâÜíïõí ôá åéóáãüìåíá öÜñìáêá, ôá ïðïßá ðáñïõóßáóáí ðïëý ãñÞãïñïõò ñõèìïýò áýîçóçò, áðü 45,3% ôçò áãïñÜò ôï 1995 óå 57% ôï 2000. Ç ðôþóç ôïõ ìåñéäßïõ ôùí ðáñáãüìåíùí óôçí ÅëëÜäá öáñìÜêùí áðïäßäåôáé óôïí ôñüðï êáèïñéóìïý ôùí ôéìþí ôïõò, ï ïðïßïò åõíïåß ôçí åéóáãùãÞ öáñìÜêùí. ÓõãêåêñéìÝíá, ôá åéóáãüìåíá ôéìïëïãïýíôáé ìå âÜóç ôç ÷áìçëüôåñç ex-factory ôéìÞ ôçò Åõñþðçò êáé ôá åã÷ùñßùò ðáñáãüìåíá/ óõóêåõáæüìåíá âÜóåé êïóôïëïãéêþí óôïé÷åßùí áðü ôï Õðïõñãåßï ÁíÜðôõîçò. Ìå ôïí ôñüðï áõôü, ôá åã÷ùñßùò ðáñáãüìåíá ðáßñíïõí ôéìÞ ôéò ðåñéóóüôåñåò öïñÝò ÷áìçëüôåñç êáé áðü ôç ÷áìçëüôåñç ôçò Åõñþðçò. Ç ðñáêôéêÞ áõôÞ Ý÷åé ùò áðïôÝëåóìá íá õðïêáèßóôáíôáé êáôÜ ôç óõíôáãïãñÜöçóç ôá öèçíÜ êáé äïêéìáóìÝíá öÜñìáêá áðü áêñéâÜ ðáñüìïéáò áðïôåëåóìáôéêüôçôáò, ãåãïíüò ôï ïðïßï ïäçãåß óôçí áðüóõñóç ôùí öèçíþí öáñìÜêùí áðü ôçí áãïñÜ, ëüãù áäõíáìßáò áíôáðüêñéóçò óôéò áðáéôÞóåéò ôïõ áõîáíüìåíïõ áíôáãùíéóìïý20. Õðü áõôÝò ôéò óõíèÞêåò, ï ÷þñïò ôçò öáñìáêïâéïìç÷áíßáò óôçí ÅëëÜäá ìåôáâÜëëåôáé êáé ôç èÝóç ôçò âéïìç÷áíßáò êáôáëáìâÜíåé ç åìðïñßá, åíþ åêôéìÜôáé üôé óå ëßãá ÷ñüíéá ï êëÜäïò èá óõññéêíùèåß óçìáíôéêÜ. Ôá ôåëåõôáßá ÷ñüíéá âÝâáéá, Ý÷ïõí ëçöèåß ìéá óåéñÜ áðü ìÝôñá óôçí ðñïóðÜèåéá åíßó÷õóçò ôçò åëëçíéêÞò öáñìáêïâéïìç÷áíßáò, üðùò: • ÊáôáñãÞèçêáí ïé íïìïèåôéêÝò åðéâáñýíóåéò õðÝñ ôñßôùí (ÔÓÁÕ, Ôáìåßï ÅðéêïõñéêÞò ÁóöÜëéóçò ÕðáëëÞëùí Öáñìáêåõôéêþí Åðé÷åéñÞóåùí - ÔÅÁÕÖÅ êáé ÅÏÖ). • ÊáôáñãÞèçêå ôï êÝñäïò ôïõ åéóáãùãÝá, ðïõ õðÞñ÷å óôçí ôéìÞ ôïõ åéóáãüìåíïõ öáñìÜêïõ êáé Þôáí ôçò ôÜîçò ôïõ 12%. • Ìåéþèçêå ôï ðïóïóôü êÝñäïõò ôïõ åã÷þñéïõ öáñìáêïâéïìç÷Üíïõ êáôÜ 35% äçëáäÞ áðü 12,5% ðÞãå óôï 8,5%. Ï õðïëïãéóìüò ôùí êåñäþí ôïõ ÷ïíäñåìðüñïõ êáé ôïõ öáñìáêïðïéïý Ýãéíå óå ìéêñüôåñç âÜóç ëüãù êáôÜñãçóçò ôùí åéóöïñþí õðÝñ ôñßôùí. • Ï êáèïñéóìüò ôçò ôéìÞò ôùí åéóáãüìåíùí öáñìÜêùí ãßíåôáé ðëÝïí ìå âÜóç ôç öèçíüôåñç ôéìÞ ôçò Åõñþðçò, åíþ ìÝ÷ñé ðñüóöáôá ãéíüôáí ìå âÜóç ôï ìÝóï üñï ôùí ôñéþí 200

Î. ÁëáôóÜêç êáé óõí.

öèçíüôåñùí ÷ùñþí. • Ãéá íá åãêñéèåß ôéìÞ óå íÝï öÜñìáêï óôçí ÅëëÜäá èá ðñÝðåé íá êõêëïöïñåß ôïõëÜ÷éóôïí óå ìßá åõñùðáúêÞ ÷þñá. • ËÞöèçêáí åéäéêÜ ìÝôñá ãéá ôá ðáñáóêåõáæüìåíá óôçí ÅëëÜäá öÜñìáêá. ÓõãêåêñéìÝíá, üôáí ìéá õöéóôÜìåíç ìïíÜäá ðñáãìáôïðïéåß íÝåò åðåíäýóåéò, áõôü ëáìâÜíåôáé õðüøç óôçí ôéìÞ ôïõ íÝïõ öáñìÜêïõ êáé åíéó÷ýåôáé ç ôéìÞ ôïõ íÝïõ ðáñáóêåõáæüìåíïõ óôç ÷þñá öáñìÜêïõ. • Êáèïñéóìüò ïñßïõ áðáãüñåõóçò óôéò äáðÜíåò ðñïþèçóçò óôï 5% åðß ôïõ óõíïëéêïý ôæßñïõ, Ýôóé þóôå íá áðïöåýãåôáé ç êáôÜ÷ñçóç óôç äéáöÞìéóç. • Äçìéïõñãßá åíéáßáò, ãéá üëá ôá áóöáëéóôéêÜ ôáìåßá, èåôéêÞò ëßóôáò óõíôáãïãñáöïýìåíùí öáñìÜêùí êáé åê ôçò ïðïßáò ðñïêýðôåé ï óáöÞò äéá÷ùñéóìüò ôïõò áðü ôá ìç óõíôáãïãñáöïýìåíá öÜñìáêá, äçëáäÞ áõôÜ ðïõ ÷ïñçãïýíôáé ÷ùñßò éáôñéêÞ óõíôáãÞ. Óôï óçìåßï áõôü ðñÝðåé íá áíáöåñèåß üôé ôá ðáñáðÜíù ìÝôñá Ý÷ïõí õðïóôåß áõóôçñÞ êñéôéêÞ áðü áñêåôïýò ìåëåôçôÝò, ïé ïðïßïé èåùñïýí üôé ìðïñïýí íá áðïöÝñïõí áðïôåëÝóìáôá ìüíï óå âñá÷õðñüèåóìç âÜóç22,23. Óå ü,ôé áöïñÜ ôá ãåíüóçìá öÜñìáêá, áõôÜ Ýêáíáí ôçí åìöÜíéóÞ ôïõò óôç ÷þñá ìáò, óôá ìÝóá ôçò äåêáåôßáò ôïõ ’60. Ôçí ðåñßïäï åêåßíç êáé ìÝ÷ñé ôá ôÝëç ôçò äåêáåôßáò ôïõ ’70, ï áñìüäéïò Ïñãáíéóìüò ãéá ôçí Ýãêñéóç Üäåéáò êõêëïöïñßáò ôùí öáñìÜêùí óôçí ÅëëÜäá Þôáí ôï ÊÝíôñï ¸ñåõíáò êáé ¸ãêñéóçò ÖáñìÜêùí (Ê.Å.Å.Ö). Ôï Ê.Å.Å.Ö. ÷ïñçãïýóå ôçí Üäåéá óå êÜðïéïõò öïñåßò åêôüò ôùí öáñìáêåõôéêþí åôáéñåéþí (ð.÷. óôïõò öáñìáêïðïéïýò) íá ÷ñçóéìïðïéïýí ôçí ôå÷íïãíùóßá êáé ôï åìðïñéêü óÞìá åíüò öáñìÜêïõ êáé íá ôï ðáñÜãïõí óå Üëëåò ðáñáãùãéêÝò ìïíÜäåò. Ìå ôïí ôñüðï áõôü, åðéêñÜôçóáí ôá ãåíüóçìá óôçí ÅëëÜäá ìå ôïí üñï öÜñìáêá “öáóüí” ôá ïðïßá üìùò, ëüãù ôçò ðñáêôéêÞò ôïõ Ê.Å.Å.Ö. íá åëÝã÷åé ôá öÜñìáêá ìüíï êáôÜ ôçí áñ÷Þ ôçò åéóüäïõ ôïõò óôçí êáôáíÜëùóç, äåí êáôüñèùóáí íá êåñäßóïõí ôçí åìðéóôïóýíç ôïõ ìåãáëýôåñïõ ìÝñïõò ôüóï ôùí åðáããåëìáôéþí õãåßáò üóï êáé ôùí ÷ñçóôþí. Áðü ôï 1983 ôç èÝóç ôïõ Ê.Å.Å.Ö. ðÞñå ï Åëëçíéêüò Ïñãáíéóìüò ÖáñìÜêùí (Å.Ï.Ö), ìå áñìïäéüôçôá íá áðïöáóßæåé ôçí Ýãêñéóç, áðüññéøç, áíáíÝùóç, ôñïðïðïßçóç, áíáóôïëÞ Þ êáé áíÜ-

Ôüìïò 15, Ôåý÷ïò 4, 2003

Î. ÁëáôóÜêç êáé óõí.

êëçóç ôùí áäåéþí êõêëïöïñßáò ôùí öáñìÜêùí áöïý ðñþôá äéåíåñãÞóåé ôéò áðáéôïýìåíåò êëéíéêÝò, åñãáóôçñéáêÝò êáé Üëëåò ìåëÝôåò - êáé íá ëáìâÜíåé Üìåóá ìÝôñá üôáí áðïäåéêíýåôáé áðü ôéò ðáñáðÜíù ìåëÝôåò üôé êéíäõíåýåé ç Äçìüóéá Õãåßá. ÐáñÜëëçëá éäñýåôáé ç ÅèíéêÞ Öáñìáêïâéïìç÷áíßá, ìå óêïðü ôçí ðáñáãùãÞ (ãåíïóÞìùí ìå áõóôçñÝò ðïéïôéêÝò ðñïäéáãñáöÝò), ôçí åéóáãùãÞ êáé äéÜèåóç öáñìáêåõôéêþí êáé ëïéðþí åéäþí áñìïäéüôçôáò ôïõ Å.Ï.Ö., ôïí åöïäéáóìü ôçò åóùôåñéêÞò áãïñÜò êáé ôçí åîáãùãÞ ôùí ðñïúüíôùí ôçò (Í 1316/83). ¼ìùò ç ÅèíéêÞ Öáñìáêïâéïìç÷áíßá äÝ÷åôáé Ýíôïíç åðßèåóç ëßãá ÷ñüíéá áñãüôåñá, ü÷é ìüíï áðü ôéò ðïëõåèíéêÝò öáñìáêïâéïìç÷áíßåò, ïé ïðïßåò åäñåýïõí óôçí ÅëëÜäá êáé ôùí ïðïßùí ôá ïéêïíïìéêÜ óõìöÝñïíôá èßãïíôáé Üìåóá, áëëÜ êáé áðü ôïõò ãéáôñïýò, ïé ïðïßïé èåùñïýí üôé ôïõò áöáéñåßôáé åììÝóùò ôï äéêáßùìá íá ëåéôïõñãïýí áõôüíïìá êáé áõôïâïýëùò24. Ï äõíçôéêüò üìùò ñüëïò ôùí ãåíïóÞìùí öáñìÜêùí óôç ÷þñá ìáò ðáñáìÝíåé êáé åíéó÷ýåôáé áðü ôï üôé ç öáñìáêåõôéêÞ äáðÜíç óçìåéþíåé ôá ôåëåõôáßá ÷ñüíéá óçìáíôéêÞ áýîçóç, áðü 1.220 åêáô. ôï 1995 óå 1.846 åêáô. ôï 2000, ìå ôï ìåñßäéï óõììåôï÷Þò ôçò éäéùôéêÞò äáðÜíçò íá åßíáé éäéáßôåñá õøçëü (38,4% ôï 2000). Ñáãäáßá áýîçóç åðßóçò ðáñïõóéÜæïõí ïé ðáñÜëëçëåò åîáãùãÝò, ïé ïðïßåò õðåñâáßíïõí ðëÝïí ôá 293 åêáô. åôçóßùò25. Ç áýîçóç ôçò öáñìáêåõôéêÞò äáðÜíçò, ïöåßëåôáé óå ìåãÜëï âáèìü óôçí áðïõóßá ïëïêëçñùìÝíçò ðïëéôéêÞò ãéá ôï öÜñìáêï - äåí õðÜñ÷åé åíéáßï êÝíôñï ëÞøçò áðïöÜóåùí êáé áðáéôåßôáé óõíáñìïäéüôçôá ðïëëþí Õðïõñãåßùí - óôçí Ýëëåéøç äõíáôüôçôáò åëÝã÷ïõ ôçò óõíôáãïãñáößáò ôùí ãéáôñþí êáé ôçò åêôÝëåóçò ôùí óõíôáãþí áðü ôïõò öáñìáêïðïéïýò ëüãù ôçò Ýëëåéøçò ìç÷áíïãñÜöçóçò, óôçí áðïõóßá ñõèìßóåùí ìÝóù ôùí ïðïßùí íá êáèïñßæïíôáé êáé íá åëÝã÷ïíôáé ïé äáðÜíåò ðñïþèçóçò ôùí öáñìÜêùí êáé óôçí Ýëëåéøç ïäçãéþí ïñèÞò óõíôáãïãñÜöçóçò êáé èåñáðåõôéêþí ðñùôïêüëëùí. ÓõìðåñáóìáôéêÜ, ôüóï ãéá ôïí Ýëåã÷ï ôçò öáñìáêåõôéêÞò äáðÜíçò, üóï êáé ãéá ôçí åíäõíÜìùóç ôçò åã÷þñéáò öáñìáêïâéïìç÷áíßáò êáé ôçí åíßó÷õóç ôçò ðáñáãùãÞò ãåíïóÞìùí, åßíáé áðáñáßôçôï íá ëçöèïýí ìÝôñá üðùò26,27: • Äçìéïõñãßá åíéáßïõ êÝíôñïõ ëÞøçò áðïöÜóåùí ãéá ôç öáñìáêåõôéêÞ ðïëéôéêÞ êáé Üñóç ôçò óõíáñìïäéüôçôáò ðïëëþí Õðïõñãåßùí, ç

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ïðïßá åíï÷ïðïéåßôáé óå ìåãÜëï âáèìü ãéá ôç ìÝ÷ñé óÞìåñá Ýëëåéøç áðïôåëåóìáôéêüôçôáò. ×ïñÞãçóç óôïõò ãéáôñïýò ïäçãéþí ïñèÞò óõíôáãïãñÜöçóçò Þ èåñáðåõôéêþí ðñùôïêüëëùí, ïé ïðïßåò èá åßíáé óýìöùíåò ìå ôéò éó÷ýïõóåò óôéò ðåñéóóüôåñåò åõñùðáúêÝò ÷þñåò, Ýôóé þóôå íá ðñïôåßíïõí öÜñìáêá êáôÜ ðñïôåñáéüôçôá êáé êáôÜ ðåñßðôùóç ìå êñéôÞñéï ôç ó÷Ýóç êüóôïõò – áðïôåëåóìáôéêüôçôáò. Áîéïðïßçóç ôùí äïìþí ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò êáé åéóáãùãÞ êéíÞôñùí óôïõò ãéáôñïýò ãéá ôç óõíôáãïãñÜöçóç ãåíïóÞìùí. Äçìéïõñãßá óõóôÞìáôïò ìç÷áíïãñÜöçóçò ìå óêïðü ôïí Ýëåã÷ï ôçò óõíôáãïãñáößáò ôùí ãéáôñþí êáèþò êáé ôçò åêôÝëåóçò ôùí óõíôáãþí áðü ôï öáñìáêïðïéü. Êáèïñéóìüò óõãêåêñéìÝíïõ ðñïûðïëïãéóìïý ãéá ôïõò ãéáôñïýò, Ýôóé þóôå íá “áíáãêÜæïíôáé” íá óõíôáãïãñáöïýí ðåñéóóüôåñá ãåíüóçìá ôá ïðïßá åßíáé öèçíüôåñá áðü ôá ðñùôüôõðá. Óýóôáóç åéäéêþí åðéôñïðþí ïé ïðïßåò èá áðïöáóßæïõí ôçí Ýíôáîç åíüò öáñìÜêïõ óôç èåôéêÞ ëßóôá, ìå êñéôÞñéï ôç ó÷Ýóç ôçò èåñáðåõôéêÞò áîßáò ìå ôï êüóôïò ôïõ. ÐëÞñçò åíçìÝñùóç ôïõ êïéíïý ãéá ôá öÜñìáêá (êüóôïò – áðïôåëåóìáôéêüôçôá).

ÓõìðåñÜóìáôá Ïé åîåëßîåéò ôçò ôåëåõôáßáò äåêáåôßáò óå üôé áöïñÜ ôç öáñìáêåõôéêÞ äáðÜíç óôç ÷þñá ìáò, êáôáäåéêíýïõí ôçí áíáãêáéüôçôá ó÷åäéáóìïý êáé õéïèÝôçóçò åíáëëáêôéêþí ðïëéôéêþí, ðñïò ôçí êáôåýèõíóç ôçò ìåßùóçò ôçò äáðÜíçò êáé åíßó÷õóçò ôçò åã÷þñéáò âéïìç÷áíßáò. Ç åíèÜññõíóç ÷ñÞóçò ãåíüóçìùí öáñìÜêùí êáé ç åíßó÷õóç ðáñáãùãÞò áõôþí, èá ìðïñïýóå íá óõìâÜëëåé ïõóéáóôéêÜ ðñïò ôçí åðßôåõîç ôùí óôü÷ùí áõôþí, êÜôé ôï ïðïßï Ý÷åé åðéâåâáéùèåß êáé áðü ôç äéåèíÞ åìðåéñßá28,29. Ç åðéôõ÷ßá ôïõ üëïõ åã÷åéñÞìáôïò, ðñïûðïèÝôåé ôçí ïõóéáóôéêÞ óôÞñéîç ìéáò ôÝôïéáò ðïëéôéêÞò ðñïþèçóçò ôùí ãåíïóÞìùí, ìå ðñáêôéêÝò ïé ïðïßåò Ý÷ïõí Þäç åöáñìïóèåß äéåèíþò üðùò ãéá ðáñÜäåéãìá ç èÝóðéóç êõìáéíüìåíùí ðåñéèùñßùí êÝñäïõò ãéá ôïõò öáñìáêïðïéïýò, ç õðï201

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

÷ñÝùóç ôùí öáñìáêáðïèçêþí êáé ôùí êñáôéêþí íïóïêïìåßùí íá ðñïôéìïýí ãåíüóçìá öÜñìáêá êáôÜ ôç äéåíÝñãåéá ôùí ïéêåßùí äéáãùíéóìþí ôïõò êáé ç äéåõêüëõíóç ôçò ðñüóâáóçò ôùí ãéáôñþí êáé ôùí öáñìáêïðïéþí óôçí ðëçñïöüñçóç ãéá ôá èåñáðåõôéêÜ éóïäýíáìá öÜñìáêá. ÅðéðëÝïí, ç ðñïþèçóç ôçò óõíôáãïãñÜöçóçò ãåíïóÞìùí, óõíäÝåôáé ìå ôçí åíßó÷õóç êáé ôçí áíáäéïñãÜíùóç ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, ç ïðïßá óôï âáèìü êáôÜ ôïí ïðïßï èá áðïôåëÝóåé êïìâéêü óçìåßï óôç ëåéôïõñãßá ôïõ óõóôÞìáôïò õãåßáò, åíäõíáìþíåé ôéò ðñïûðïèÝóåéò ôïõ åëÝã÷ïõ ôçò óõíôáãïãñÜöçóçò, áëëÜ êáé ôïõ ðåñéïñéóìïý ôçò öáñìáêåõôéêÞò äáðÜíçò. Ç ðñïþèçóç ìÜëéóôá ôçò óõæçôïýìåíçò ðñáêôéêÞò ôçò áíáãñáöÞò ôçò äñáóôéêÞò ïõóßáò êáôÜ ôç óõíôáãïãñÜöçóç öáñìÜêùí, áíáìÝíåôáé íá ðñïóäþóåé ìåãáëýôåñç äéáöÜíåéá óôéò ó÷Ýóåéò ôùí ãéáôñþí ìå ôç öáñìáêåõôéêÞ áãïñÜ. Óå êÜèå ðåñßðôùóç, äåäïìÝíïõ üôé ïé ãéáôñïß áðïôåëïýí ôï âáóéêü ñõèìéóôÞ ôçò êáôáíÜëùóçò öáñìÜêùí - ôüóï óôçí ðïóïôéêÞ üóï êáé óôçí ðïéïôéêÞ ôïõò äéÜóôáóç - ç åðéôõ÷ßá ìéáò ðïëéôéêÞò ðïõ áðïóêïðåß óôçí ðñïþèçóç ôçò óõíôáãïãñÜöçóçò ãåíïóÞìùí êáé óôïí ðåñéïñéóìü ôçò öáñìáêåõôéêÞò äáðÜíçò, áðáéôåß ôçí åéóáãùãÞ åëåã÷üìåíùí êéíÞôñùí ãéá ôïõò åêöñáóôÝò ôçò æÞôçóçò, äçëáäÞ êáôÜ êýñéï ëüãï ôïõò ãéáôñïýò êáé äåõôåñåõüíôùò ôïõò öáñìáêïðïéïýò, óýìöùíá êáé ìå ôç äéåèíÞ ðñáêôéêÞ (Ðßíáêáò II). ÔÝëïò, õðÝñ ôçò ðñïþèçóçò ôùí ãåíïóÞìùí öáñìÜêùí èá ìðïñïýóáí íá ëåéôïõñãÞóïõí êáé ìéá óåéñÜ áðü Ýììåóåò ðáñåìâÜóåéò óôïí ôñüðï ðáñï÷Þò êáé ÷ñçìáôïäüôçóçò ôçò öáñìáêåõôéêÞò öñïíôßäáò, üðùò ãéá ðáñÜäåéãìá ç åðéâïëÞ ïñßùí óôç óõíôáãïãñÜöçóç ôùí éáôñþí - ñýèìéóç ç ïðïßá èá ùèïýóå ôïõò ãéáôñïýò íá óõíôáãïãñáöïýí öèçíüôåñá öÜñìáêá - Þ ç õðï÷ñÝùóç ãéá óõíôáãïãñÜöçóç óõãêåêñéìÝíïõ ðïóïóôïý ãåíïóÞìùí åðß ôçò óõíïëéêÞò óõíôáãïãñáößáò.

Âéâëéïãñáößá 1. Óïõëéþôçò Ê, Êõñéüðïõëïò Ã. Åîåëßîåéò óôçí ÁãïñÜ ôïõ ÖáñìÜêïõ óôçí ÅëëÜäá, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 13:10-16, 2001. 2. Íéêïëáêïðïýëïõ-ÓôåöÜíïõ Ç. ÐïëéôéêÝò ÖáñìÜêïõ óôçí ÅõñùðáúêÞ ¸íùóç. Ï Åêóõã÷ñïíéóìüò ôïõ Ñõèìéóôéêïý Ðëáéóßïõ, ÐáðáæÞóçò, ÁèÞíá, 2002, óåë. 124-129. 202

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3. Wittner P. European Generics Markets. Countries, Companies and Trends, Informa Pharmaceuticals, London, 2000. 4. Óïõëéþôçò Ê. ÁíÜëõóç ôùí Äáðáíþí Õãåßáò óôçí ÅëëÜäá 1989-1998. ÌåèïäïëïãéêÝò Äéåõêñéíßóåéò êáé Äéáðéóôþóåéò ãéá ôï Óýóôçìá Õãåßáò. Óôï: Êõñéüðïõëïò Ã., Óïõëéþôçò Ê. Ïé ÄáðÜíåò Õãåßáò óôçí ÅëëÜäá. ÌåèïäïëïãéêÜ ÐñïâëÞìáôá óôç ÌÝôñçóç êáé ÓõíÝðåéåò ãéá ôéò ÐïëéôéêÝò Õãåßáò, Åêä. ÐáðáæÞóçò, ÁèÞíá, 2002, óåë. 65-77. 5. European Generic Medicines Association. www.egagenerics.com, 2002. 6. Edell D. Generic vs Brand Name Drugs: What's The Real Difference?, 2000, p. 13. 7. Kanavos P, Golna C. The WTO and Patents. The Impact on the Pharmaceutical Industry, Informa Pharmaceuticals, London, 2000. 8. Haney C. PC EXPO. Where generics can win over brand names, IDG News Service/Hong Kong Bureau, 1999, p. 23. 9. Health Committee. Generic Market was manipulated, The Pharmaceutical Journal, London, 2000, 264:5. 10. Managing Drug Supply. The Selection, Procurement, Distribution and Use of Pharmaceuticals, West Hartford, Conn., Kumarian Press, 1997. 11. Senior I, Ribbert J, Shindler A, De Souza N. Definition of Generic, n/e/r/a, Policy relating to generics medicines. In: the OECD, London, 1998a, p.p. 3:15-17. 12. Meyer M, Chan K, Boltons S. Generic warfarin: implications for patient care-another view. Pharmacotherapy, 1998, 18:884-886. 13. Senior I, Ribbert J, Shindler A, De Souza N. Share of Generics. In: Prescribed Medicines within the OECD: Public Health and Economic Issues, Consumption of Generics by Volume and Value n/e/r/a, Policy relating to generics medicines in the OECD, London, 1998b, p.p. 19-20. 14. NERA. Policy Relating to Generic Medicine in the OECD, 1998. 15. Murphy JE. Generic Substitution and Optimal Patient Care, JAMA, New York, Arch Intern Med, 1999, 159:429-433. 16. De Parle N. Evaluation and Management Services Guidelines. JAMA, 2000, 283:23. 17. Kessler D, Rose JL, Temple RJ, Schapiro R, Griffin JP. Therapeutic-Class Wars: Drug Promotion in a Competitive Marketplace. The New England Journal of Medicine, 1994, 331:13501354. 18. Benahan BF, Kolassa EM. A physician survey

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Ã.I. Ôóßñïò, Ä.Ê. Êáëïãåñüðïõëïò

ÃÑÁÌÌÁ ÓÔÏÍ ÅÊÄÏÔÇ LETTER TO THE EDITOR Primary Heatlh Care, Volume 15, Number 4, 204-205, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 204-205, 2003

ÊïéíÝò äõóëåéôïõñãßåò óôçí åêðáßäåõóç ôùí Ãåíéêþí/ Ïéêïãåíåéáêþí Éáôñþí ÅëëÜäïò êáé ÌåãÜëçò Âñåôáíßáò

AãáðçôÝ ê. ÄéåõèõíôÞ Óýíôáîçò, Óêïðüò ôçò åðéóôïëÞò ìáò áõôÞò åßíáé ç áíÜäåéîç ôùí äõóëåéôïõñãéþí åêðáßäåõóçò ôùí Ãåíéêþí/Ïéêïãåíåéáêþí Éáôñþí (Ã./Ï.É.) ôçò ÌåãÜëçò Âñåôáíßáò, ùò åöáëôÞñéï óõíå÷ïýò ðñïóðÜèåéáò áíáâÜèìéóçò ôçò åêðáßäåõóçò óôçí ÃåíéêÞ ÉáôñéêÞ áðü ôïõò ¸ëëçíåò óõíáäÝëöïõò ôïõò. Ç óõóôçìáôéêÞ åéäßêåõóç ôùí Ã./Ï.É. îåêßíçóå óôç ÷þñá ìáò ðåñßðïõ ðñéí 17 ÷ñüíéá. Ç éäéáéôåñüôçôá üìùò áõôÞò ôçò åéäéêüôçôáò, ðïõ êõñßùò óõíïøßæåôáé óôï ìåãÜëï rotation (15 óçìåßá), áðáéôåß óõíå÷Þ âåëôßùóç ôùí ðñïãñáììÜôùí åêðáßäåõóçò. Ïé åéäéêåõüìåíïé Ã./Ï.É., Ý÷ïõí êáèïñéóôéêü ñüëï óôç äéáäéêáóßá ôçò åêðáßäåõóçò ôïõò êáé èá ðñÝðåé íá áîéïðïéïýí êÜèå äõíáôüôçôá âåëôßùóçò óå Üìåóç óõíåñãáóßá ìå ôï ÓõíôïíéóôÞ Åêðáßäåõóçò1. Áí êáé ï èåóìüò ôïõ Ã./Ï.É. óôá ðåñéóóüôåñá ðñïçãìÝíá êñÜôç áðïôåëåß ôï “êýôôáñï” ôçò ÐñùôïâÜèìéáò Ðåñßèáëøçò, åíôïýôïéò óå ÷þñåò ìå éäéáßôåñá áíáðôõãìÝíï ôï Óýóôçìá Õãåßáò, üðùò ç ÌåãÜëç Âñåôáíßá, áíáöÝñïíôáé äõóëåéôïõñãßåò óôçí åêðáßäåõóÞ ôùí Ã./Ï.É., ðïõ óå ìåãÜëï ðïóïóôü ðñïóåããßæïõí ôéò áíôßóôïé÷åò ôùí ÅëëÞíùí óõíáäÝëöùí ôïõò. Óýìöùíá ìå Ýñåõíá ðïõ äçìïóéåýôçêå ôïí ÌÜéï 2003 áðü ôïí Âñåôáíéêü Éáôñéêü Óýëëïãï (ÂÌÁ), ïé Ã./Ï.É., óõ÷íÜ áéóèÜíïíôáé ùò Éáôñïß “äåýôåñçò êáôçãïñßáò” üóïí áöïñÜ ôçí åêðáßäåõóÞ ôïõò2. Óôçí Ýñåõíá ðïõ Ýãéíå áðü ôçí ÅðéôñïðÞ Ãåíéêþí Éáôñþí ôïõ Âñåôáíéêïý Éáôñéêïý Óõëëü204

ãïõ êáé áöïñïýóå ôçí åêðáßäåõóç ôùí Ã./Ï.É., áíáöÝñïíôáé ïé áðüøåéò êáé ïé åìðåéñßåò 160 åéäéêåõüìåíùí éáôñþí (54% Üíäñåò, 56% ãõíáßêåò). Óýìöùíá ìå ôá áðïôåëÝóìáôá, ïé ìéóïß áðü ôïõò óõììåôÝ÷ïíôåò ðéóôåýïõí ðùò ôï ãåãïíüò üôé åßíáé åêðáéäåõüìåíïé (åéäéêåõüìåíïé) Ã./Ï.É., åðçññåÜæåé ôçí êáôÜëëçëç åêðáßäåõóç ðïõ ëáìâÜíïõí, åíþ åðôÜ óôïõò äÝêá áíáöÝñïõí Ýíáí “áñíçôéóìü” áðü ôá áíôßóôïé÷á ôìÞìáôá óôá ïðïßá åêðáéäåýïíôáí. Åðßóçò, áí êáé óõíïëéêÜ ç ðëåéïøçößá ôùí íÝùí Éáôñþí åßíáé åõ÷áñéóôçìÝíç áðü ôçí ðñáêôéêÞ óôï íïóïêïìåßï, ôï Ýíá ôÝôáñôï Þôáí ïõäÝôåñï êáé Ýíáò óôïõò äÝêá Þôáí äõóáñåóôçìÝíïò. Áðü ôïõò óõììåôÝ÷ïíôåò óôçí Ýñåõíá, ïé ïðïßïé åêðáéäåýïíôáí óôçí åðåßãïõóá éáôñéêÞ, ìüíï ôï Ýíá ôñßôï áõôþí êáôÜöåñå íá ëÜâåé Üäåéá ãéá ôç ðáñáêïëïýèçóç åéäéêþí óåìéíáñßùí ðïõ õðüêåéíôáé óôçí åêðáßäåõóç óôï ôìÞìá åðåéãüíôùí. Ôï óçìáíôéêüôåñï æÞôçìá ôùí ðåñéóóüôåñùí ìåëåôçèÝíôùí éáôñþí, Þôáí ç åîáóöÜëéóç êáôÜëëçëçò åêðáßäåõóçò ðïõ íá ó÷åôßæåôáé êáé íá ðñïÜãåé ôç èÝóç ôïõ Ã./Ï.É. üóïí áöïñÜ ôç ìåëëïíôéêÞ ôïõò êáñéÝñá. Ïé óçìáíôéêüôåñåò ðñïôÜóåéò ãéá ôïí ôñüðï ìå ôïí ïðïßï ìðïñïýí íá âåëôéùèïýí ïé åêðáéååìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Ãåþñãéïò É. Ôóßñïò, ÓïöïêëÝïõò 29, Ô.Ê: 26442, ÐÜôñá, Ôçë. (2610) 454667, êéí. (6977) 01 99 77, Å-mail: geotsiro@otenet.gr

Ôüìïò 15, Ôåý÷ïò 4, 2003

Ã.I. Ôóßñïò, Ä.Ê. Êáëïãåñüðïõëïò

äåõôéêÝò èÝóåéò óôá íïóïêïìåßá Þôáí: á. Ðåñéóóüôåñá åêðáéäåõôéêÜ ìáèÞìáôá ãéá ôïõò Ã./Ï.É. â. ÐëçñÝóôåñç êáé ôáêôéêÞ óõíåñãáóßá ìå Éáôñïýò Üëëùí åéäéêïôÞôùí, þóôå íá äéáöáßíåôáé ðéï êáèáñÜ ç ó÷Ýóç ôçò åñãáóßáò ôïõ Ã./Ï.É. ìå ôï íïóïêïìåßï ãåíéêÜ. ã. Ðåñéóóüôåñïò åëåýèåñïò ÷ñüíïò ãéá ôçí åêðáßäåõóç ôùí Ãåíéêþí Éáôñþí. ä. Ðåñéóóüôåñç äéäáóêáëßá êáé “õðïóôÞñéîç” áðü ôï åéäéêåõìÝíï éáôñéêü ðñïóùðéêü. å. Ðåñéóóüôåñç åêðáßäåõóç óôçí ÊïéíùíéêÞ ÉáôñéêÞ. óô. Ìåãáëýôåñç ðñáêôéêÞ åîÜóêçóç óå íïóïêïìåßá, þóôå íá åíóùìáôþíåôáé ðåñéóóüôåñï ï Ã./Ï.É. óå êÜèå åéäéêüôçôá. Áðü ôá áíùôÝñù óôïé÷åßá ðñïêýðôåé, üôé êáé ïé åéäéêåõüìåíïé Ã./Ï.É. ôçò ÌåãÜëçò Âñåôáíßáò, ðÝñáí ôùí Üëëùí ðñïâëçìÜôùí åêðáßäåõóçò ðïõ áíôéìåôùðßæïõí êáôÜ ôçí åéäßêåõóç, óå ðïëëÝò ðåñéðôþóåéò äåí áíôéìåôùðßæïíôáé ùò åéäéêåõüìåíïé ôïõ áíôßóôïé÷ïõ íïóïêïìåßïõ-êëéíéêþí áëëÜ ùò “äéåñ÷üìåíïé”. Ôï ãåãïíüò áõôü óå êáìéÜ ðåñßðôùóç äå èá ðñÝðåé íá áðïôåëåß “ðáñçãïñçôéêü óôïé÷åßï” ãéá ôïõò ¸ëëçíåò óõíáäÝëöïõò ôïõò (åöüóïí ðáñáôçñåßôáé óå ÅõñùðáúêÞ ÷þñá ìå éäéáßôåñá áíáðôõãìÝíï ôï Óýóôçìá Õãåßáò), áëëÜ áíôßèåôá “ïñüóçìï” óõíå÷ïýò ðñïóðÜèåéáò áíáâÜèìéóçò ôçò åéäéêüôçôÜò ôïõò, åöüóïí ç êáôáîßùóç ôçò ÃåíéêÞò ÉáôñéêÞò Ý÷åé íá õðåñíéêÞóåé áñêåôÜ åìðüäéá áêüìá. Áðáñáßôçôç ðñïûðüèåóç ãéá ôç óùóôÞ åêðáßäåõóç ôùí åéäéêåõïìÝíùí óôçí ÃåíéêÞ ÉáôñéêÞ åßíáé ç åöáñìïãÞ (êáé ç óõíå÷Þ âåëôßùóç) åíüò

ðñïãñÜììáôïò èåùñçôéêÞò êáôÜñôéóçò êáé ðñáêôéêÞò Üóêçóçò ðïõ èá åßíáé åéäéêÜ åðåîåñãáóìÝíï êáôÜ ãíùóôéêü áíôéêåßìåíï åêðáßäåõóçò êáé ðñïóáñìïóìÝíï óõíïëéêÜ óôéò áíÜãêåò, ôïõò óôü÷ïõò êáé ôéò äñáóôçñéüôçôåò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò êáé Ðåñßèáëøçò3. Ç áíáâÜèìéóç êáé êáôáîßùóç ôçò ÃåíéêÞò ÉáôñéêÞò åßíáé Ýñãï êáé õðï÷ñÝùóç êáé ôïõ êÜèå åéäéêåõüìåíïõ Ã./Ï.É., ðïõ ìå ôç ðïéïôéêÞ äïõëåéÜ ôïõ, ôçí åðáñêÞ ãíþóç ôïõ ñüëïõ ôïõ óôçí ðáñï÷Þ õðçñåóéþí õãåßáò, áëëÜ êáé ìå ôçí åíåñãü óõììåôï÷Þ ôïõ óôçí åêðáßäåõóç êáé óôç Ýñåõíá èÝôåé èåìåëéþäåéò ðáñÜãïíôåò ãéá ôçí áíÜðôõîç ôçò ÃåíéêÞò ÉáôñéêÞò4,5. Ã.I. Ôóßñïò, Ä.Ê. Êáëïãåñüðïõëïò

Âéâëéïãñáößá 1. Ìé÷Üëçò Ä. 1ç ÓõíÜíôçóç Óõíôïíéóôþí ÃåíéêÞò ÉáôñéêÞò. Ôá ÍÝá ôçò ¸íùóçò ôùí Ãåíéêþí/ Ïéêïãåíåéáêþí Éáôñþí, ôåý÷ïò 24, óåë. 1, 2000. 2. British Medical Association (BMA). http:// www.bma.org.uk. Press release – Don’t treat us as second class doctors, 8 May 2003. 3. ÃïëåìÜôçò ×.Â. ÅêôåëåóôéêÞ ÅðéôñïðÞ ÊÅ.Ó.Õ. ÐñïâëÞìáôá Åéäéêåõüìåíùí Ãåíéêþí Éáôñþí. Ôá ÍÝá ôçò ¸íùóçò ôùí Ãåíéêþí/Ïéêïãåíåéáêþí Éáôñþí, ôåý÷ïò 47, óåë. 5, 2002. 4. Óõìåùíßäçò Á. Ç óõíÝíôåõîç ôïõ ìÞíá. Ôá ÍÝá ôçò ¸íùóçò ôùí Ãåíéêþí/Ïéêïãåíåéáêþí Éáôñþí, ôåý÷ïò 4, óåë. 6, 1998. 5. ËéïíÞò ×. Êñßóç óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò – Ñçôïñåßá Þ ðñáãìáôéêüôçôá; ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 15:8-9, 2003.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

I. Mouzas

ÍÅÊÑÏËÏÃÉÁ MEMORIES Primary Heatlh Care, Volume 15, Number 4, 206-207, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 4, 206-207, 2003

Memories of Giannis Vlachonikolis, a brilliant thinker by I Mouzas*

It was with deep shock and sadness that we learned of the sudden and untimely death of Giannis Vlachonikolis. Our friend left us too soon. We must all be aware m instances like this that many memories fade away, especially those moments many of us have shared personally with Giannis. Now came a time as the shock and sorrow have lessened to commemorate the life of this special colleague who shared his life with our lives. We lost a friend and brilliant thinker and we wish to commemorate him. Giannis Vlachonikolis, Professor of Biostatistics at the Medical Faculty of the Crete University, was generously and effectively dedicated to the advancement of the study of cancer and chronic disease from the point of view of the biostatistician. He was responsible for several Research programs in Statistics, Epidemiology, Cancer Studies and Computer Applications. He performed methodological research in statistical and mathematical applications in collaborative multidisciplinary projects for cancer and chronic disease, especially in Medicine, Epidemiology, Biology, and Psychiatry. One of his most important achievements is the establishment of a population-based cancer registry in Crete that served as an exemplary regional cancer registry and prototype in strategic planning of such registries. He was a founding member of the Gastroenterology Registry of Crohn's and Colitis Study Group (GRECCO on Crete). And, of course, he has been for many years an Assistant Professor of Gastroenterology, School of Medicine, University of Crete

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active member and "official statistician" of the EC IBD Group. He has been known to all of us as a provocative thinker, an always-participative mind and a kind person. He deserves the gratitude of our Group for his generous and effective dedication to the advancement of our common cause. Giannis Vlachonikolis with wife Yvonne and son Giorgi formed a lucky family. Their warmth and hospitality made a lasting impression to colleagues from Greece that had spent a post graduation time in Oxford. Underlying his impulsive manner there was a strong intelligence, precise and logical, but pleasant and not arrogant. It is not often that an individual of such an extraordinary intellect comes into our lives. He had the gift and the inspiration to conceive an original, abstract idea and to evaluate it till its last logical consequences. I remember very well the superb way Giannis guided my young colleague Athanassios Pallis and myself last summer, through long discussions and debates till late in the night, into the concepts of statistical analysis in order to further evaluate old and construct new and valid quality of life instruments. The result of this highly didactic for me interaction was the paper that appeared in the August issue of the Journal of Gastroenterology, titled "Improved validation of the Inflammatory Bowel Disease Questionnaire and development of a short form for Greek patients". This paper that was accepted without modifications is an exceptional "tour de force" of the brilliant mathematical mind of Giannis. Last summer the disease of Giannis, a pro-

I. Mouzas

gressive disease of the motor neuron, amyatrophic lateral sclerosis, had reached a steady level and he needed only some little help in the sense of being given a drive to the Biostatistics Laboratory of the Medical Faculty in Heraklion and back home. He was a beloved guest of mine for the 10 or so days that usually lasted his occupation with his Crete duties. The time of his stay in Crete was shorter and shorter and the interval longer as time was passing by and movement restriction was progressing. His view of the world and people gradually was been modifying. He was more and more interested in individual details of every day life, in other people's concerns and fears, discussing with more or less well known colleagues and peers. They were talking with him, telling him their personal concerns, their personal pain and disease experiences. He used to expose to me in our conversations how his new situation activated a change in himself in terms of coming closer to people he already knew and how he was getting a solidarity and interrelated view of the human condition. We used now to talk about philosophical issues still with mathematics and medicine and we had relaxed intervals playing chess. He enjoyed helping my little daughter with algebra and physics. At the beginning of spring

Ôüìïò 15, Ôåý÷ïò 4, 2003

2003 the disease took a quickly deteriorating course that restrained him from using initially the one and later both hands. I had myself at this time a personal experience of being ill (a coronary by pass operation after a heart infarct). In this way, I could better appreciate the brave way Giannis was dealing with his illness and the inevitable end. I was deeply impressed by the human and honest suffering of my friend and felt that I moved closer to a broader conception of the world. For all this, I am grateful to my friend. Dear friends of our EC IBD Group, let's take a brake while our lives run at a high speed. Let's consider what is most important, what is the order of priorities we want in our life. Let the loss of our friend Giannis make us more thoughtful about taking the time to appreciate the unique value of each person we interact with, both professionally and personally. The memory of his life and work will long remain an inspiration in the future. "As we mourn a dear one gone. And the tears unbidden come, While we bow our heads in grief. Comfort Lord ! Bring sweet Relief !!'

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ÏÄÇÃÉÅÓ ÃÉÁ ÔÏÕÓ ÓÕÃÃÑÁÖÅÉÓ INSTRUCTIONS FOR THE AUTHORS Ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äÝ÷åôáé ãéá äçìïóßåõóç êåßìåíá Åðéóôçìüíùí Õãåßáò, ôá ïðïßá êáôáôÜóóïíôáé óôéò åîÞò êáôçãïñßåò: 1) ÅñåõíçôéêÝò åñãáóßåò Þ áíáóêïðÞóåéò (óýíôïìåò äçìïóéåýóåéò) Ýêôáóçò ìÝ÷ñé 7 óåëßäåò ìå ðñüóöáôåò ü÷é Üíù áðü 5 âéâëéïãñáöéêÝò ðçãÝò, 2) ÅíçìåñùôéêÜ Üñèñá, 3) Óýíôïìá Üñèñá, 4) ÁíáöïñÝò ðåñéðôþóåùí, 5) ÐáñïõóéÜóåéò ÊÝíôñùí Õãåßáò. ¸íá óýíïëï êåéìÝíùí, ðïõ áöïñïýí Ýíá óõãêåêñéìÝíï ãíùóôéêü ôïìÝá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ìðïñåß íá óõãêñïôåß ÁöéÝñùìá. Åêôüò ôùí êåéìÝíùí ðïõ áíáöÝñïíôáé óôéò ðáñáðÜíù êáôçãïñßåò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé Üñèñá ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò, êáèþò êáé êåßìåíá ðïõ áðïóêïðïýí óôçí ðáñïõóßáóç, ó÷ïëéáóìü êáé êñéôéêÞ áîéïëüãçóç óõãêåêñéìÝíùí ãåãïíüôùí, Üñèñùí êáé åêäüóåùí ó÷åôéêþí ìå ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, óôçí ÅëëÜäá êáé óôï åîùôåñéêü. Ôçí åõèýíç ôçò óõããñáöÞò ôùí Üñèñùí áõôþí Þ êåéìÝíùí Ý÷ïõí ìüíï ôá ìÝëç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò Þ åðéóôÞìïíåò ìåôÜ áðü åéäéêÞ ðñüóêëçóç. Åðßóçò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé ãñÜììáôá ðïõ áðåõèýíïíôáé óôç ÓõíôáêôéêÞ ÅðéôñïðÞ, ôá ïðïßá áíáöÝñïíôáé óå ðáñáôçñÞóåéò, êëéíéêÝò êáé åñåõíçôéêÝò åìðåéñßåò Þ ó÷ïëéÜæïõí ôç äéåèíÞ êáé åëëçíéêÞ âéâëéïãñáößá. Ôçí åõèýíç ãéá ôç äçìïóßåõóç ôùí êåéìÝíùí áõôþí Ý÷åé ï ÄéåõèõíôÞò Óýíôáîçò êáé ç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ïé åñåõíçôéêÝò åñãáóßåò, ôá åíçìåñùôéêÜ Üñèñá, ïé óýíôïìåò äçìïóéåýóåéò êáé ïé áíáöïñÝò ðåñéóôáôéêþí ãßíïíôáé äåêôÜ ãéá äçìïóßåõóç ìüíï ìåôÜ áðü èåôéêÞ êñßóç ôïõò áðü åðéóôÞìïíåò-êñéôÝò ìå ôïõò ïðïßïõò óõíåñãÜæåôáé ôï ðåñéïäéêü. ÊÜèå êåßìåíï ðïõ áðïóôÝëëåôáé óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äéáâéâÜæåôáé óôïõò êñéôÝò, ÷ùñßò íá ãíùóôïðïéïýíôáé ôá ïíüìáôá ôùí óõããñáöÝùí. Ôá ó÷üëéá êáé ïé ðáñáôçñÞóåéò ôùí êñéôþí óôç óõíÝ÷åéá, ìå ôçí åõèýíç ôçò Ãñáììáôåßáò Óýíôáîçò ôïõ ðåñéïäéêïý, åðéóôñÝöïíôáé óôïõò óõããñáöåßò, ðñïêåéìÝíïõ áõôïß íá ðñïóáñìüóïõí áíÜëïãá ôï êåßìåíü ôïõò ðñéí ôç äçìïóßåõóç. Óå ðåñßðôùóç áóõìöùíßáò ôùí êñéôþí, ôï êåßìåíï èá áîéïëïãåßôáé áðü ôçí ßäéá ôç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ôá ïíüìáôá üëùí ôùí åðéóôçìüíùí ðïõ äéåôÝëåóáí êñéôÝò èá äçìïóéåýïíôáé óå åéäéêÞ óåëßäá óôï ôåëåõôáßï ôåý÷ïò êÜèå ÷ñüíïõ. Ôá êåßìåíá, ôá ïðïßá äÝ÷åôáé ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò", èá ðñÝðåé íá áêïëïõèïýí ôéò ðáñáêÜôù ðñïäéáãñáöÝò. • Íá åßíáé ãñáììÝíá óôçí åðßóçìç äçìïôéêÞ ãëþóóá êáé ìå ôï ìïíïôïíéêü óýóôçìá, äáêôõëïãñáöçìÝíá óôç ìéá üøç ôçò óåëßäáò, óå äéðëü äéÜóôçìá êáé ìå ëåõêü ðåñéèþñéï 3 åêáôïóôþí óå üëåò ôéò ðëåõñÝò ôïõò. • Ç ðñþôç óåëßäá ôïõ êåéìÝíïõ ðñÝðåé íá ðåñéëáìâÜíåé: á) ôïí ôßôëï (ìå ðåæÜ ãñÜììáôá), â) ôá ïíüìáôá ôùí óõããñáöÝùí (ìå êåöáëáßá ãñÜììáôá åíþ áíáãñÜöïíôáé ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá ðëÞñç åðþíõìá ìå áñéèìçôéêïýò åêèÝôåò ïé ïðïßïé óå õðïóçìåßùóç ðáñïõóéÜæïõí ôçí éäéüôçôá ôïõ êÜèå óõããñáöÝá), ã) ôï åðéóôçìïíéêü êÝíôñï óôï ïðïßï Ýãéíå ç åñãáóßá, ä) 3-5 ðñüóèåôïõò üñïõò ó÷åôéêÜ ìå ôï èÝìá êáé ïé ïðïßïé åßíáé õéïèåôçìÝíïé áðü ôï Medical Subject Headings (Bethesda Md, 1966), å) ôç äéåýèõíóç êáé ôï ôçëÝöùíï åíüò áðü ôïõò óõããñáöåßò, ï ïðïßïò èá åßíáé õðåýèõíïò ãéá ôçí áëëçëïãñáößá ìå ôï ðåñéïäéêü. • Óå îå÷ùñéóôÞ äåýôåñç óåëßäá ðñÝðåé íá ãñÜöåôáé ç åëëçíéêÞ ðåñßëçøç ôïõ êåéìÝíïõ (ðñïçãåßôáé ç Ýíäåéîç ÐÅÑÉËÇØÇ), ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. • ÌåôÜ ôï êåßìåíï óå îå÷ùñéóôÞ óåëßäá èá ðñÝðåé íá ãñÜöåôáé ç áããëéêÞ ðåñßëçøç ôïõ êåéìÝíïõ, ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. Ðñïçãïýíôáé ç ëÝîç SUMMARY, ç áããëéêÞ ìåôÜöñáóç ôïõ ôßôëïõ, ïé ëÝîåéò PRIMARY HEALTH CARE... êáé ôá ïíüìáôá ôùí óõããñáöÝùí ÷ùñßò ôßôëï Þ éäéüôçôá. • Ïé âéâëéïãñáöéêÝò ðáñáðïìðÝò, åëëçíéêÝò êáé îÝíåò, óôï êåßìåíï èá ðñÝðåé íá åßíáé ðñüóöáôåò, áðü áíáãíùñéóìÝíá ðåñéïäéêÜ Þ óõããñÜììáôá, íá åßíáé áñéèìçìÝíåò êáé í’ áíôáðïêñßíïíôáé óôï âéâëéïãñáöéêü êáôÜëïãï, ï ïðïßïò èá ðñÝðåé íá ãñÜöåôáé óå îå÷ùñéóôÞ óåëßäá ìåôÜ ôï ãñÜøéìï ôçò áããëéêÞò ðåñßëçøçò. Óôï âéâëéïãñáöéêü êáôÜëïãï ïé ðáñáðïìðÝò èá ðñÝðåé í’ áêïëïõèïýí ôç óåéñÜ ìå ôçí ïðïßá ðáñïõóéÜóôçêáí óôï êåßìåíï. ÊáèåìéÜ áðü áõôÝò èá ðñÝðåé íá ðåñéÝ÷åé óôç óåéñÜ ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá åðþíõìá ôùí óõããñáöÝùí, ôïí ôßôëï ôçò åñãáóßáò, ôï üíïìá ôïõ ðåñéïäéêïý óýìöùíá ìå ôï óýóôçìá ôçò WHOCISO/R4), ôïí ôüìï, ôçí ðñþôç êáé ôçí ôåëåõôáßá óåëßäá ôïõ Üñèñïõ, êáèþò êáé ôï Ýôïò äçìïóßåõóçò. ¼ôáí ðñüêåéôáé ãéá óõããñÜììáôá Þ ìïíïãñáößåò, åêôüò áðü ôïõò óõããñáöåßò, ôï Ýôïò Ýêäïóçò êáé ôïí ôßôëï, ðñÝðåé íá ãñÜöïíôáé êáé ï áñéèìüò êáé ôá óôïé÷åßá Ýêäïóçò (åêäïôéêüò ïßêïò, ðüëç). (õðüäåéãìá âéâëéïãñáößáò: Biziagos E, Moschandrea J, Kouroumalis ÅÁ. Prevalence of hepatitis Â and C markers in volunteer blood donors in Crete. A 5-year study. J Viral Hepat, 6:243-8, 1999.). • Ïé ðßíáêåò êáé ôá ó÷Þìáôá áêïëïõèïýí ôï âéâëéïãñáöéêü êáôÜëïãï êáé èá ðñÝðåé íá ðáñïõóéÜæïíôáé óå ÷ùñéóôÝò óåëßäåò, íá öÝñïõí ëáôéíéêÞ áñßèìçóç, ç ïðïßá èá ðñÝðåé í’ áíôáðïêñßíåôáé óôéò ðáñáðïìðÝò ôïõ êåéìÝíïõ, êáèþò êáé ôéò áðáñáßôçôåò åðåîçãÞóåéò. • 'Ïëá ôá êåßìåíá èá ðñÝðåé íá õðïâÜëëïíôáé êáôÜ ðñïôßìçóç ìå êåéìåíïãñÜöï word óå äýï áíôßôõðá êáé íá áðïóôÝëëïíôáé óôç äéåýèõíóç ôïõ ÄéåõèõíôÞ Óýíôáîçò: - ÐáíåðéóôÞìéï ÊñÞôçò (õðüøç AíáðëçñùôÞ ÊáèçãçôÞ ×. ËéïíÞ), ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò, Ô.È. 1393, ÇñÜêëåéï ÊñÞôçò. Ïé óõããñáöåßò ìðïñïýí íá õðïâÜëëïõí ôá êåßìåíÜ ôïõò êáé óå çëåêôñïíéêÞ ìïñöÞ óôç äéåýèõíóç: primcare@fammed.med.uoc.gr Ïé óõããñáöåßò èá ðñÝðåé íá äåóìåýïíôáé óôçí åðéóôïëÞ ôïõò üôé ç åñãáóßá äåí Ý÷åé õðïâëçèåß Þ äåí Ý÷åé äçìïóéåõèåß åí üëù Þ åí ìÝñåé óå Üëëï ðåñéïäéêü, üôé üëïé ïé óõããñáöåßò åßíáé óýìöùíïé ìå ôçí áðïóôïëÞ ôçò êáé óå ðåñßðôùóç áðïäï÷Þò ôçò ãéá äçìïóßåõóç, ôá óõããñáöéêÜ äéêáéþìáôá åê÷ùñïýíôáé óôï ðåñéïäéêü. Ç ÓõíôáêôéêÞ ÅðéôñïðÞ äéáôçñåß ôï äéêáßùìá áðïóýñóåùò ìéáò åñãáóßáò åöüóïí áõôÞ Ý÷åé óôáëåß êáé ó' Üëëï ðåñéïäéêü.