VOL17_ISSUE1_JAN_MAR_2005 by SAN PUBLICATIONS

ðñùôïâÜèìéá

öñïíôßäá Ôüìïò 17, Ôåý÷ïò 1, ÉáíïõÜñéïò - ÌÜñôéïò 2005

õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 17, Ôåý÷ïò 1, ÉáíïõÜñéïò - ÌÜñôéïò 2005, Volume 17, Number 1, January - March 2005

Ôçò Óýíôáîçò 4

×. ×áôæüãëïõ, Ê.É. ÃïõñãïõëéÜíçò: Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá óôïõò ¸ëëçíåò áãñüôåò ÅñåõíçôéêÜ ¢ñèñá

×. ËõãéäÜêçò, Á. Æåñâüðïõëïò, ÖùôåéíÞ Ëáìðñéáíïý, Áéêáôåñßíç Ëõóßôóêá, Ã. Áðáæßäçò, Åõáíèßá ÊñáíéÜ, Á. Ìáñãéüëçò, ÓôÝëëá ÁñãõñéÜäïõ: ÖïéôçôÝò: Ìéá éäéáßôåñç ïìÜäá äéåñåýíçóçò ôçò ó÷Ýóçò óùìáôéêþí íïóçìÜôùí êáé øõ÷éêþí äéáôáñá÷þí É. Ôáñáíôßëçò: ÅðéäçìéïëïãéêÞ ìåëÝôç åðéðïëáóìïý ôåñçäüíáò óå 12÷ñïíïõò ìáèçôÝò çìéáóôéêþí ãõìíáóßùí óôï Íïìü Áñãïëßäáò Áíáóêüðçóç

Á. ÊïðáíÜêçò, Ð. ÄáóêáëÜêçò, ÃáñõöáëéÜ Ðáðáäïðïýëïõ: Ç ðíåõìïíßá åî õðåñåõáéóèçóßáò óÞìåñá êáé ðþò ôçí áíáãíùñßæïõìå P.J. Gupta: Primary care in ano-rectal conditions

Ã. Êõñéüðïõëïò: Ç ñýèìéóç ôçò öáñìáêåõôéêÞò áãïñÜò óôçí ÅëëÜäá. Ôõ÷áßåò óêÝøåéò ãéá ôçí åíáñìüíéóç ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò êáé ôùí ìç÷áíéóìþí ôçò áãïñÜò

Í. ÁíôùíÜêçò: Ðñüôáóç ìïíôÝëïõ HëåêôñïíéêÞò Óõíôáãïãñáößáò ãéá ôçí åëëçíéêÞ ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò: ÖáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç ÃñÜììá óôïí Åêäüôç

Í. ÃåùñãéÜííïò: Åðáíáðñïóäéïñßæïíôáò ôçí åðéêïéíùíßá ãéáôñïý-áóèåíÞ óôç óýã÷ñïíç åëëçíéêÞ öñïíôßäá õãåßáò ÍÝá Öéëßððåéï åñãáóôÞñé ôçò Ýñåõíáò

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

Áñéèìüò ¢äåéáò 451/91

ÊÙÄ. 3855

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ Ôá÷. Ãñáöåßï Ê. Ä. Áèçíþí

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

ÅéäéêÜ ¢ñèñá 31

ISSN 1105-7432

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

ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care

ÅÊÄÏÔÇÓ:

ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Ì. ×ïõñìïýæç 28 Ê. Ôïýìðá 544 53 Èåóóáëïíßêç Ôçë. (2310) 910342

Äéïéêçôéêü Óõìâïýëéï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Ðñüåäñïò ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Áíôéðñüåäñïò Á ×ñÞóôïò ËéoíÞò Áíôéðñüåäñïò Â Áíôþíçò Êáñüôóçò Ãåíéêüò ÃñáììáôÝáò-Ôáìßáò ÁèáíÜóéïò Óõìåùíßäçò Åéäéêüò ÃñáììáôÝáò ÓôÝëëá ÁñãõñéÜäïõ ÌÝëç ÁíÜñãõñïò Ìáñéüëçò Áíôþíçò Ìðáôßêáò Executive Board of the Greek Association of General Practitioners President Bodosakis-Prodromos Merkouris Vice-President A Christos Lionis Vice-President B Antonis Karotsis General Secretary Treasurer Athanasios Symeonidis Special Secretary Stella Argiriadou Members Anargiros Mariolis Antonis Batikas Ãñáììáôåßá Óýíôáîçò: Áíáóôáóßá Ñùìáíßäïõ Ôçë.: (2810) 394615, (28310) 25833 e-mail: tasrom@yahoo.co.uk Åêôýðùóç: ÔÅ×ÍÏÃÑÁÌÌÁ Ì. ÁõãÝñç 12, 153 43 Áã. ÐáñáóêåõÞ Ôçë.: 210.60.00.643, Fax: 210.6002295 E-mail: techn@hol.gr

ISSN 1105-7432

ÄéåõèõíôÞò Óýíôáîçò

Editor-in-Chief

×ñÞóôïò ËéïíÞò, AíáðëçñùôÞò ÊáèçãçôÞò ÔìÞìá ÉáôñéêÞò, ÐáíåðéóôÞìéï ÊñÞôçò Ô.È. 2208, ÇñÜêëåéï Ôçë. (2810) 394621, Fax. (2810) 394606 E-mail: lionis@galinos.med.uoc.gr

Christos Lionis, Ássociate Professor Faculty of Medicine, University of Crete P.O. Box 2208, Heraklio Tel.: +30 2810 394621, Fax: +30 2810 394606 E-mail: lionis@galinos.med.uoc.gr

ÁíáðëçñùôÝò Ä/íôÝò Óýíôáîçò

Associate Editors

Íßêïò ÁíôùíÜêçò (ÇñÜêëåéï) ÅëåõèÝñéïò Èçñáßïò (ÁèÞíá)

Nick Antonakis (Heraklio) Åleftherios Thireos (Athens)

Åðßêïõñïé Ä/íôÝò Óýíôáîçò

Assistant Editors

ÈùìÜò Áããåëüðïõëïò (Èåóóáëïíßêç) Ðáýëïò ÈåïäùñÜêçò (ÉùÜííéíá) Êïñíçëßá ÌáêñÞ (ÇñÜêëåéï) ÁíÜñãõñoò Ìáñéüëçò (ÁèÞíá)

Thomas Aggelopoulos (Thessaloniki) Pavlos Theodorakis (Ioannina) Kornilia Makri (Heraklio) Anargiros Mariolis (Athens)

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

Members of Editorial Board

ÓôÝëéïò ÅõáããÝëïõ (ÁèÞíá) ÃéÜííçò ÌïíÝäáò (KÝñêõñá) Íßêïò ÐáðáíéêïëÜïõ (ÊáñðåíÞóé) ÐçãÞ ÐåñäéêÜêç (´Áóôñïò) ÁèçíÜ Ôáôóéþíç (ÉùÜííéíá) ×ñýóá ×áôæüãëïõ (ËÜñéóá) Áíáóôáóßá ×ñéóôïöÝëç (Áëßáñôïò) ¸öç Öñáãêïýëç (ËÞìíïò)

Stelios Evagelou (Athens) Ioannis Monedas (Corfu) Nikos Papanikolau (Êarpenisi) Pigi Perdikaki (Astros) Atina Tatsioni (Ioannina) Chrysa Chatzoglou (Larissa) Anastasia Christofeli (Aliartos) Efi Fragouli (Limnos)

ÁíôáðïêñéôÝò Óýíôáîçò

Corresponding Editors

¸ëåíá ÅõáããåëÜêç (Êýðñïò) Èåïäþñá Æá÷áñéÜäïõ (Êýðñïò) Llukan Rrumbullaku (Áëâáíßá)

Elena Evaggelaki (Cyprus) Theodora Zaxariadou (Cyprus) Llukan Rrumbullaku (Álbania)

ÓõìâïõëåõôéêÞ ÅðéôñïðÞ

Advisory Board

Ð. ÂÜñäáò, ÊáèçãçôÞò Êáñäéïëïãßáò Ðáí/ìßïõ ÊñÞôçò Ì. Ãåßôïíá, Åðéê. ÊáèçãÞôñéá Äéïßêçóçò Õðçñ. Õãåßáò Ðáí/ìßïõ Èåóóáëßáò Å. Ãåëáóôïðïýëïõ, Åðßê. ÊáèçãçôÞò ÕãéåéíÞò Ðáí/ìßïõ Ðáôñþí Ä. ÃëÜñïò, ÊáèçãçôÞò ÉáôñéêÞò ÖõóéêÞò Ðáí/ìßïõ Éùáííßíùí Á. ÊáöÜôïò, ÊáèçãçôÞò ÐñïëçðôéêÞò ÉáôñéêÞò & ÄéáôñïöÞò Ðáí/ìßïõ ÊñÞôçò É. Êõñéüðïõëïò, ÊáèçãçôÞò Ïéêïíïìéêþí ôçò Õãåßáò ÅèíéêÞò Ó÷. Äçìüóéáò Õãåßáò Ä. Êùíóôáíôéíßäçò, Åðéê. ÊáèçãçôÞò ÕãéåéíÞò, ÐáíåðéóôÞìéï ÈñÜêçò Â. ÌáõñÝáò, ÊáèçãçôÞò Øõ÷éáôñéêÞò Ðáí/ìßïõ Éùáííßíùí M. ÓãÜíôæïò, ËÝêôïñáò Áíáôïìßáò Ðáí/ìßïõ Èåóóáëßáò K. Óéáìüðïõëïò, ÊáèçãçôÞò Íåöñïëïãßáò Ðáí/ìßïõ Éùáííßíùí Í. ÓéáöÜêáò, ÊáèçãçôÞò Ðíåõìïíïëïãßáò Ðáí/ìßïõ ÊñÞôçò K. Óïõëéþôçò ÄéäÜêôùñ Ïéêïíïìéêþí êáé ÐïëéôéêÞò Õãåßáò Ë. ÓðÜñïò, Ïìüôéìïò ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ Áèçíþí Á. ÖéëáëÞèçò, Áíáðë. ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ ÊñÞôçò Ã. ×ñéóôïäïýëïõ, ÊáèçãçôÞò Øõ÷éáôñéêÞò Ðáí/ìßïõ Áèçíþí

P. Vardas, Professor of Cardiology, University of Crete M. Geitona, Assistant Professor, University of Thessalia E. Gelastopoulou, Assistant Professor of Hygiene, University of Patras D. Glaros, Professor of Medical Physics, University of Ioannina A. Kafatos, Professor of Health Prevention and Nutrition, University of Crete D. Konstantinides, Assistant Professor of Hygiene, University of Thrace J. Kyriopoulos, Professor of Health Economics, National School of Public Health V. Mavreas, Professor of Phychiatry, University of Ioannina M. Sgantzos, Lector of Anatomy in University of Thessalia K. Siamopoulos, Professor of Nephrology, University of Ioannina N. Siafakas, Professor of Lung and Thorax, University of Crete K. Souliotis, PhD, Health Policy and Economics L. Sparos, Åmeritus Professor of Social Medicine, University of Athens A. Philalithis, Associate Professor of Social Medicine, University of Crete G. Christodoulou, Professor of Phychiatry, University of Athens

ðñùôïâÜèìéá

öñïíôßäá õãåßáò

ÐÅÑÉÅ×ÏÌÅÍÁ Tçò Óýíôáîçò ×. ×áôæüãëïõ, Ê.É. ÃïõñãïõëéÜíçò: Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá óôïõò ¸ëëçíåò áãñüôåò .............................................................. 4 ÅñåõíçôéêÜ ¢ñèñá ×. ËõãéäÜêçò, Á. Æåñâüðïõëïò, ÖùôåéíÞ Ëáìðñéáíïý, Áéêáôåñßíç Ëõóßôóêá, Ã. Áðáæßäçò, Åõáíèßá ÊñáíéÜ, Á. Ìáñãéüëçò, ÓôÝëëá ÁñãõñéÜäïõ: ÖïéôçôÝò: Ìéá éäéáßôåñç ïìÜäá äéåñåýíçóçò ôçò ó÷Ýóçò óùìáôéêþí íïóçìÜôùí êáé øõ÷éêþí äéáôáñá÷þí ....................................................................................................................................................................................................... 6 É. Ôáñáíôßëçò: ÅðéäçìéïëïãéêÞ ìåëÝôç åðéðïëáóìïý ôåñçäüíáò óå 12÷ñïíïõò ìáèçôÝò çìéáóôéêþí ãõìíáóßùí óôï Íïìü Áñãïëßäáò ................................................................................................................................................................................... 17 Áíáóêüðçóç Á. ÊïðáíÜêçò, Ð. ÄáóêáëÜêçò, ÃáñõöáëéÜ Ðáðáäïðïýëïõ: Ç ðíåõìïíßá åî õðåñåõáéóèçóßáò óÞìåñá êáé ðþò ôçí áíáãíùñßæïõìå ....................................................................................................................................................................................................................... 24 ÅéäéêÜ ¢ñèñá P.J. Gupta: Primary care in ano-rectal conditions ......................................................................................................................................................................... 31 Ã. Êõñéüðïõëïò: Ç ñýèìéóç ôçò öáñìáêåõôéêÞò áãïñÜò óôçí ÅëëÜäá. Ôõ÷áßåò óêÝøåéò ãéá ôçí åíáñìüíéóç ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò êáé ôùí ìç÷áíéóìþí ôçò áãïñÜò .................................................................................................................... 34 Í. ÁíôùíÜêçò: Ðñüôáóç ìïíôÝëïõ ÇëåêôñïíéêÞò Óõíôáãïãñáößáò ãéá ôçí åëëçíéêÞ ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò: ÖáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç .......................................................................................................................... 38 ÃñÜììá óôïí Åêäüôç Í. ÃåùñãéÜííïò: Åðáíáðñïóäéïñßæïíôáò ôçí åðéêïéíùíßá ãéáôñïý-áóèåíÞ óôç óýã÷ñïíç åëëçíéêÞ öñïíôßäá õãåßáò ................ 46 ÍÝá Öéëßððåéï åñãáóôÞñé Ýñåõíáò .................................................................................................................................................................................................................... 50

CONTENTS Editorial C. Chatzoglou, Ê.J. Gourgoulianis: Hypersensitivity pneumonitis in agricultural workers ...................................................................................... 4 Original Articles H. Lygidakis, A. Zervopoulos, Foteini Lamprianou, Aikaterini Lysitska, G. Apagidis, Evanthia Krania, A. Mariolis, Stella Argyriadou: Students: A particular examination group of the relation between physical diseases and Mental Disturbances .................................................................................................................................................................................................................................. 6 John Tarandilis: Epidemiological study of caries prevalence in twelve year-old pupils of semi urban secondary schools in the prefecture of Argolis ....................................................................................................................................................................................................... 17 Review A. Kopanakis, P. Daskalakis, Garifalia Papadopoulou: Hypersensitivity pneumonitis today’s diagnosis ..................................................... 24 Special Articles P.J. Gupta: Primary care in ano-rectal conditions ......................................................................................................................................................................... 31 John Kyriopoulos: Pharmaceuticals market regulation in Greece Random reflections on the harmonization of state intervention tools and market mechanisms ................................................................................................................................................................... 34 N. Antonakis: Proposal of an Electronic Prescription model for the Greek Primary Health Care: A pharmacoepidemiological approach ................................................................................................................................................................................................... 38 ÃñÜììá óôïí Åêäüôç N. Georgiannos: Redefining doctor-patient communication in modern Greek health care ................................................................................. 46 Íews Filippeio laboratory of research ................................................................................................................................................................................................................ 50

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ×áôæüãëïõ, Ê.É. ÃïõñãïõëéÜíçò

ÔÇÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 17, Number 1, 4-5, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 4-5, 2005

Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá óôïõò ¸ëëçíåò áãñüôåò ×. ×áôæüãëïõ1, Ê.É. ÃïõñãïõëéÜíçò2

Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá ãíùóôÞ åðßóçò êáé ùò åîùãåíÞò áëëåñãéêÞ êõøåëßôéäá óõìâáßíåé óå ìåãÜëç ðïéêéëßá åðáããåëìÜôùí, ìåôáîý ôùí ïðïßùí êáé ïé áãñüôåò. ÕðÜñ÷åé ìåãÜëç ðëçèþñá ïñãáíéêÞò óêüíçò öõôþí Þ æþùí êáé áñêåôÜ ÷çìéêÜ ôá ïðïßá ìðïñåß íá ðñïêáëÝóïõí ôç íüóï. Ç ðíåõìïíßá áðü õðåñåõáéóèçóßá åßíáé Ýíá åðßêáéñï èÝìá óôçí ÅëëÜäá áöïý óçìáíôéêü ðïóïóôü ôïõ ðëçèõóìïý ôçò ÷þñáò áðáó÷ïëåßôáé óôç ãåùñãßá êáé ôçí êôçíïôñïößá. Ôï 24% ôïõ ðëçèõóìïý ôçò ÅëëÜäáò ôï 2000 Þôáí áãñüôåò, åíþ ôï áíôßóôïé÷ï ðïóïóôü ôïõ çìéáóôéêïý ðëçèõóìïý Þôáí 14%. Ôï 25,7% ôùí çëéêéùìÝíùí ðÜíù áðü 65 åôþí æåé óå áãñïôéêÝò ðåñéï÷Ýò êáé ôï 17,3% óå çìéáóôéêÝò. Ðåñßðïõ 1:100000 ¸ëëçíåò áðáó÷ïëïýíôáé áðïêëåéóôéêÜ óôç ãåùñãßá, êôçíïôñïößá, äÜóç êáé áëéåßá, åíþ ôï ìåãáëýôåñï ðïóïóôü ôùí ìåôáíáóôþí óôçí ÅëëÜäá áðáó÷ïëïýíôáé óôç ãåùñãßá êáé óôçí êôçíïôñïößá.1 Ôá áíáðíåõóôéêÜ íïóÞìáôá åßíáé Ýíá êáëÜ áíáãíùñéóìÝíï ðñüâëçìá ìåôáîý ôùí áãñïôþí. Óýìöùíá ìå ìåëÝôåò, ïé áãñüôåò öáßíåôáé íá Ý÷ïõí õøçëüôåñç èíçóéìüôçôá êáé íïóçñüôçôá áðü åðéâåâáéùìÝíåò áíáðíåõóôéêÝò äéáôáñá÷Ýò, óå ó÷Ýóç ìå ôï ãåíéêü ðëçèõóìü êáé óå ó÷Ýóç ìå Üëëá åðáããÝëìáôá.2-5 Ç Ýêèåóç óå ðïëëáðëïýò ðáñÜãïíôåò åßíáé óõ÷íÞ êáé ç Ýêèåóç óå êÜðïéï ðáñÜãïíôá ìðïñåß íá ðñïêáëÝóåé ðåñéóóüôåñåò áðü ìßá äéáôáñá÷Ýò. Óôïõò ðáñÜãïíôåò êéíäýíïõ ãéá ðáèÞóåéò ôïõ áíáðíåõóôéêïý ðåñéëáìâÜíïíôáé ïé ïñãáíéêÝò êáé áíüñãáíåò óêüíåò, ÷çìéêÜ, áÝñéá êáé ëïéìïãüíïé ðáñÜãïíôåò.6 Ï åðéðïëá-

óìüò ôùí óõìðôùìÜôùí ôïõ áíáðíåõóôéêïý üðùò ï óõñéãìüò, ç äýóðíïéá êáé ï âÞ÷áò åßíáé õøçëüò (23-50%) óôïõò áãñüôåò.6 ÃåíéêÜ üìùò ôá óõìðôþìáôá áõôÜ åßíáé ìç åéäéêÜ êáé ìðïñåß íá óõíäÝïíôáé ìå ðåñéóóüôåñåò áðü ìßá åðáããåëìáôéêÝò áíáðíåõóôéêÝò äéáôáñá÷Ýò. Ïé ðéï óçìáíôéêÝò ðáèÞóåéò åßíáé ç ñéíßôéäá êáé ôï Üóèìá êáé ðáñüëï ðïõ åßíáé óõ÷íÝò óðÜíéá åßíáé èáíáôçöüñåò. Ôá ðéï óïâáñÜ áíáðíåõóôéêÜ íïóÞìáôá óôïõò áãñüôåò åßíáé ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá êáé ïé ëïéìþîåéò ôïõ áíáðíåõóôéêïý. Ôï ðéï óçìáíôéêü üìùò åßíáé üôé ïé áíáðíåõóôéêÝò ðáèÞóåéò ìðïñåß íá ðñïëçöèïýí ìå ôïí ðåñéïñéóìü ôçò Ýêèåóçò óôá õðåýèõíá ãéá ôç íüóï áíôéãüíá. Ï «ðíåýìïíáò» (Þ íüóïò) ôùí áãñïôþí (farmers lung) åßíáé Ýíáò áðü ôïõò ðéï óõ÷íïýò ôýðïõò ôçò ðíåõìïíßôéäáò áðü õðåñåõáéóèçóßá êáé ç ðñþôç ðåñéãñáöÞ ôçò êëéíéêÞò åéêüíáò Ýãéíå óå áóèåíåßò ðïõ åß÷áí åêôåèåß óå ìïõ÷ëéáóìÝíï Ü÷õñï áðü ôïí Campell ôï 1932.7 Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá ÷áñáêôçñßæåôáé áðü äéÜ÷õôç öëåãìïíÞ ôùí ìéêñþí áåñáãùãþí êáé ôïõ ðíåõìïíéêïý ðáñåã÷ýìáôïò, ðïõ ïöåßëåôáé óå ðáñáôåôáìÝíç åéóðíïÞ áíôéãüíùí áðü ôïí ðåñéâÜëëïíôá ÷þñï. Óôá áíôéãüíá áõôÜ ðåñéëáìâÜíåôáé Ýíáò åêôåôáìÝíïò áñéèìüò áðü ïñãáíéêÝò óêüíåò, üðùò æùéêÝò ðñùôåßíåò, ìýêçôåò, èåñìüöéëá âáêôÞñéá êáé äéÜöïñåò ÷áìçëïý ìïñéáêïý âÜñïõò ðôçôéêÝò êáé ìç ðôçôéêÝò ÷çìéêÝò ïõóßåò. ÌåñéêÝò áðü ôéò óõíÞèåéò ðçãÝò ðñïÝëåõóçò åßíáé ôï ìïõ÷ëéáóìÝíï Ü÷õñï, ôá äçìçôñéáêÜ, ç óêüíç îýëïõ, ç óêüíç áðü âåëáíéäéÜ, ï êÝäñïò êáé ï

Õðåýèõíç áëëçëïãñáößáò: ×. ×áôæüãëïõ, ÉáôñéêÞ Ó÷ïëÞ ËÜñéóáò, ÐáðáêõñéáæÞ 22, ÔÊ 41222, ËÜñéóá, Ôçë: 2410 565051, 565240, Fax: 2410 565064, Email: çhatz@med. uth.gr

ÃåíéêÞ Éáôñüò, ËÝêôïñáò Öõóéïëïãßáò, ÐáíåðéóôÞìéï Èåóóáëßáò, ÔìÞìá ÉáôñéêÞò, 2ÊáèçãçôÞò Ðíåõìïíïëïãßáò, ÐáíåðéóôçìéáêÞ ÐíåõìïíïëïãéêÞ ÊëéíéêÞ, Ðáíåðéóôçìéáêü Íïóïêïìåßï ËÜñéóáò

Ôüìïò 17, Ôåý÷ïò 1, 2005

×. ×áôæüãëïõ, Ê.É. ÃïõñãïõëéÜíçò

ðïëôüò ðåýêïõ êáé Ýëáôïõ, ôá öýëëá êáðíïý, ïé ðáðáãÜëïé, ôá ðåñéóôÝñéá, ïé êüôåò, ïé ãáëïðïýëåò, ôá óõóôÞìáôá êëéìáôéóìïý êáé ïé äåîáìåíÝò íåñïý. Ç êëéíéêÞ åéêüíá áëëÜ êáé ç ðïñåßá ôçò åîùãåíïýò áëëåñãéêÞò êõøåëéäßôéäáò ðïéêßëïõí êáé åßíáé äõíáôüí íá ïäçãÞóïõí óå ìç áíáóôñÝøéìç ðíåõìïíéêÞ âëÜâç. Ç åîÝëéîç ôçò íüóïõ åîáñôÜôáé áðü äéÜöïñïõò ðáñÜãïíôåò, üðùò ç ðïóüôçôá êáé ç äéÜñêåéá ôçò Ýêèåóçò óôï õðåýèõíï áíôéãüíï, ôï åßäïò ôçò åéóðíåüìåíçò óêüíçò êáé ç áíïóïëïãéêÞ áðÜíôçóç ôïõ áóèåíïýò. Ç äéáãíùóôéêÞ ðñïóÝããéóç ôçò ðíåõìïíßôéäáò áðü õðåñåõáéóèçóßá ðåñéëáìâÜíåé ôá áêüëïõèá: á) éóôïñéêü õðïôñïðéÜæïõóáò “Üôõðçò” ðíåõìïíßáò, â) æþá êáé êõñßùò ðôçíÜ óôï óðßôé Þ óôçí åñãáóßá áêüìá êáé üôáí ï áóèåíÞò áñíåßôáé ïðïéáäÞðïôå åðáöÞ ìå áõôÜ, ã) óõìðôþìáôá ðïõ åìöáíßóôçêáí ìåôÜ áðü ìåôáêüìéóç ôïõ áóèåíÞ óå íÝï óðßôé Þ ðåñéâÜëëïí åñãáóßáò, ä) ÷ñÞóç ðéóßíáò Þ óÜïõíáò, å) ðáñüìïéá óõìðôþìáôá óå Üëëïõò áóèåíåßò ïé ïðïßïé åãêáôÝëåéøáí ôï ðåñéâÜëëïí åñãáóßáò êáé óô) âåëôßùóç ôùí óõìðôùìÜôùí ìåôÜ áðü ôçí áðïìÜêñõíóç áðü ôçí ïéêßá Þ ôï ðåñéâÜëëïí åñãáóßáò.8 Ç äéÜãíùóç ðñÝðåé íá óôçñßæåôáé óôá ðáñáêÜôù: 1) éóôïñéêü Ýêèåóçò êáé áíåýñåóç èåôéêþí åéäéêþí áíôéóùìÜôùí (éæçìáôßíåò), 2) áíåýñåóç ëåìöïêõôôÜñùí óôïí ïññü óå ðïóïóôü ìåãáëýôåñï ôïõ 40%, 3) êëéíéêÞ åéêüíá óõìâáôÞ ìå ôçí ðáñïõóßá äéáìÝóïõ íïóÞìáôïò, 4) áîïíéêÞ ôïìïãñáößá èþñáêïò õøçëÞò åõêñßíåéáò ìå åõñÞìáôá èáìðïý ýáëïõ (groundglass) êáé ìéêñïïæéäéáêÝò óêéÜóåéò ìå êåíôñïëïâéþäç êáôáíïìÞ êáé 5) èåôéêÞ äïêéìáóßá ðñïêëÞóåùò Þ óõìâáôÜ ðáèïëïãïáíáôïìéêÜ åõñÞìáôá.9 Ç ðíåõìïíßôéäá áðü õðåñåõáéóèçóßá åßíáé óõ÷íü ðñüâëçìá óå ìéá áãñïôéêÞ ÷þñá üðùò ç ÅëëÜäá. Ï ãéáôñüò ôçò ÐñùôïâÜèìéáò Öñïíôß-

äáò Õãåßáò ðñÝðåé íá õðïøéÜæåôáé ôç íüóï óå êÜèå áóèåíÞ ìå óõìðôùìáôïëïãßá ëïßìùîçò ôïõ áíáðíåõóôéêïý ðïõ åðáíáëáìâÜíåôáé êáé ðéèáíüôáôá ç Ýíáñîç ôçò ó÷åôßæåôáé ìå óõãêåêñéìÝíï åñãáóéáêü ðåñéâÜëëïí. Ç áðïìÜêñõíóç áðü ôï ÷þñï åñãáóßáò ìðïñåß íá âïçèÞóåé óôç äéÜãíùóç áëëÜ êáé íá áíôéìåôùðßóåé áðïôåëåóìáôéêÜ ôï ðñüâëçìá.

Âéâëéïãñáößá 1. ÓéÜìðïò Ã. Ðëçèõóìüò êáé áíÜðôõîç óôçí ÅëëÜäá. ÅëëçíéêÞ Åôáéñåßá Äçìïãñáöéêþí Ìåëåôþí. Åêäüóåéò ÊïñöÞ, ÁèÞíá, 2003. 2. Heller RF, Kelson MC. Respiratory disease mortality in agricultural workers in eight member countries of the European Community. Int J Epidimiol, 6:170-4, 1982. 3. Office of Population Censuses and Surveys, Health & Safety Executive. Occupational Health Supplement. London: HMSO, 1995. 4. Toren K, Horte LG, Jarvholm B. Occupation and smoking adjusted mortality due to asthma among Swedish men. Br J Ind Med 48:323-6, 1991. 5. Health & Safety Commission. Health and Safety Statistics 2000/01. HSE Books, 2001. 6. Linaker C, Smedly J. Respiratory illness in agricultural workers. Occup Med, 52:451-9, 2002. 7. Campelt JA. Acute symptoms following work with hay. BMJ, 2:1143-4,1932. 8. ÊïðáíÜêçò Á, ÄáóêáëÜêçò Ð, Ðáðáäïðïýëïõ Ã. Ç ðíåõìïíßá åî õðåñåõáéóèçóßáò êáé ðùò ôçí áíôéìåôùðßæïõìå. ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò (õðü äçìïóßåõóç). 9. Selman Ì. Hypersensitivity pneumonitis. In: Schwarz M, King T, editors. Interstitial lung disease. BC Decker, 452-84, 2003.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ËõãéäÜêçò êáé óõí.

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 17, Number 1, 6-16, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 6-16, 2005

ÖïéôçôÝò: Ìéá éäéáßôåñç ïìÜäá äéåñåýíçóçò ôçò ó÷Ýóçò óùìáôéêþí íïóçìÜôùí êáé øõ÷éêþí äéáôáñá÷þí ×. ËõãéäÜêçò1, Á. Æåñâüðïõëïò1, ÖùôåéíÞ Ëáìðñéáíïý1, Áéêáôåñßíç Ëõóßôóêá1, Ã. Áðáæßäçò2, Åõáíèßá ÊñáíéÜ3, Á. Ìáñãéüëçò4, ÓôÝëëá ÁñãõñéÜäïõ2 Ðåñßëçøç ÅéóáãùãÞ: Åßíáé ãíùóôÞ ç ó÷Ýóç óùìáôéêþí íïóçìÜôùí, øõ÷éêþí äéáôáñá÷þí (Üã÷ïò, êáôÜèëéøç), êáèçìåñéíÞò ëåéôïõñãéêüôçôáò, êáðíßóìáôïò êáé áëêïüë. Ïé öïéôçôÝò åîåñ÷üìåíïé áðü ôçí åöçâåßá, áðïôåëïýí éäéáßôåñç ïìÜäá, áíôéìåôùðßæïíôáò ôçí áðïìÜêñõíóç áðü ôçí ïéêïãÝíåéá êáé ôçí êáèéÝñùóç åíüò íÝïõ óôñåóïãüíïõ ôñüðïõ æùÞò. Óêïðüò: Ç êáôáãñáöÞ øõ÷ïóùìáôéêþí êáôáóôÜóåùí, óå öïéôçôÝò áíþôåñùí êáé áíþôáôùí åêðáéäåõôéêþí éäñõìÜôùí ôçò ÅëëÜäáò êáé Éôáëßáò (Bologna), êáé ï ðéèáíüò óõó÷åôéóìüò ôïõò ìå ôï êÜðíéóìá, áëêïüë, êáé êáôáíÜëùóç öáñìÜêùí. Ðëçèõóìüò: 134 öïéôçôÝò éáôñéêÞò ôçò Bologna (UNIBO) (65 Üíäñåò, 69 ãõíáßêåò; ÌÏ=24,4 Ýôç sd=2,3, Ýôïò óðïõäþí 5,6 sd=1,6), 244 ôïõ Áñéóôïôåëåßïõ Ðáíåðéóôçìßïõ (ÁÐÈ) (113 Üíäñåò, 131 ãõíáßêåò; ÌÏ=21,9 sd=2,5, Ýôïò óðïõäþí 3,2 sd=1,4), 75 ôïõ ÔÅÉ ÊáâÜëáò (47 Üíäñåò, 28 ãõíáßêåò, ÌÏ=19,9 sd=1,4, Ýôïò óðïõäþí 2,2 sd=1,0), êáé 41 åíüò ÉÅÊ ÍïóçëåõôéêÞò Áèçíþí (6 Üíäñåò, 35 ãõíáßêåò, ÌÏ=23,6 sd=5,7, Ýôïò óðïõäþí 1,9 sd=0,1). ÌÝèïäïò: ÄïìçìÝíï åñùôçìáôïëüãéï ìå óôïé÷åßá äçìïãñáöéêÜ, ïéêïíïìéêÞò êáôÜóôáóçò, ÷ñüíéùí ðáèÞóåùí, êÜðíéóìá, êáôáíÜëùóç áëêïüë êáé öáñìÜêùí. Åðßóçò åöáñìïæüôáí ôï åñùôçìáôïëüãéï General Health Questionnaire-28 (GHQ-28) äéåñåõíþíôáò ôçí øõ÷éêÞ êáé óùìáôéêÞ õãåßá êáé ç Visual Analogical Scale (VAS) ãéá ôçí ðñïóùðéêÞ åêôßìçóç ôçò õãåßáò ôïõò. ÁðïôåëÝóìáôá: Ôï êáëýôåñï áðïôÝëåóìá óôç VAS êáé óôï óýíïëï ôïõ GHQ-28 ðáñïõóßáóáí ïé öïéôçôÝò ôïõ ÁÐÈ (ÌÏ=80,43 sd=13,53 êáé 19,69 sd=9,78). Ôï ÷åéñüôåñï óôç VAS ïé ôïõ ÉÅÊ Áèçíþí (ÌÏ=73,54 sd=15,78) êáé óôï GHQ-28 ïé öïéôçôÝò Éôáëßáò (ÌÏ=21,9 sd=10,9), ïé ïðïßïé öÜíçêå üôé êáôáíÜëùíáí ðåñéóóüôåñá áíôéåëêùôéêÜ (p <,001). Ç êáðíéóôéêÞ óõíÞèåéá ôùí öïéôçôþí ôåßíåé íá ó÷åôßæåôáé ìå ôçí êáôáíÜëùóç áëêïüë ãéá ôéò ïìÜäåò ÔÅÉ, UNIBO êáé ÁÐÈ (p <,05), êáé ìå ôï ÷áìçëüôåñï áðïôÝëåóìá óôç VAS ãéá ôïõò íÝïõò ôïõ ÔÅÉ êáé ÁÐÈ (p= ,032 êáé p <,001 áíôßóôïé÷á). ¢ã÷ïò êáé êáôÜèëéøç ìïéÜæïõí íá ó÷åôßæïíôáé ìå ôçí çëéêßá ôïõ ðáôÝñá, ôçí ôåëåõôáßá åðßóêåøç óå ãéáôñü êáé ôï äåßêôç ôçò VAS (p <,05). ÓõìðåñÜóìáôá: Ïé Ã/Ï ãéáôñïß ïöåßëïõí íá áó÷ïëçèïýí ìå ôçí õãåßá ôùí öïéôçôþí, åñìçíåýïíôáò ïñèÜ ôá óõìðôþìáôá ðéèáíÞò óùìáôïðïßçóçò, åðéôõã÷Üíïíôáò ôçí Ýãêáéñç áíß÷íåõóç-èåñáðåßá êáôáóôÜóåùí Üã÷ïõò êáé êáôÜèëéøçò.

ÖïéôçôÝò ÉáôñéêÞò Ó÷ïëÞò Ðáíåðéóôçìßïõ Bologna, Éôáëßá, 2ÊÝíôñï Õãåßáò ×ñõóïýðïëçò, ÅÊÁÂ Áèçíþí, 4ÊÝíôñï Õãåßáò Âýñùíá

ÅéóáãùãÞ Åßíáé ãíùóôÞ ç ó÷Ýóç ïñéóìÝíùí óùìáôéêþí íïóçìÜôùí, üðùò ôï åõåñÝèéóôï ðá÷ý Ýíôåñï, ç ÷ñüíéá êüðùóç, ç éíïìõáëãßá, ç çìéêñáíßá, ç äõóðåøßá ìç ïöåéëüìåíç óå Ýëêïò ê.ëð., ìå øõ÷éêÝò äéáôáñá÷Ýò êáé åéäéêüôåñá, óýìöùíá ìå ôçí êáôÜôáîç ôïõ ICD 10 êùäéêüò F40-F48, ìå ôéò ÍåõñùóéêÝò (ÍåõñùóéêÝò, óõíäåüìåíåò ìå ôï stress êáé óùìáôüìïñöåò äéáôáñá÷Ýò), ìå ôéò áã÷þäåéò Þ ôéò êáôáèëéðôéêÝò äéáôáñá÷Ýò, ICD 10 êùäéêüò F45 (Óùìáôüìïñöåò äéáôáñá÷Ýò).1-6 ÓõíÝðåéá áõôþí ôùí êáôáóôÜóåùí åßíáé ç óõ÷íÞ ÷ñÞóç ôùí õðçñåóéþí ôçò ÐÖÕ Þ ôùí åéäéêþí éáôñéêþí õðçñåóéþí, ðïõ óõíïäåýïíôáé áðü ðëçèþñá áñíçôéêþí Þ Üêáñðùí åðåìâÜóåùí. Óõ÷íÜ óõíåðÜãïíôáé ôçí êáôÜ÷ñçóç ïõóéþí, ICD 10 êùäéêüò F55 (ÊáôÜ÷ñçóç ïõóéþí ïé ïðïßåò äåí ðñïêáëïýí åîÜñôçóç), êáé äçìéïõñãïýí óùËÝîåéò êëåéäéÜ: ÕðÝñôáóç, õðåñôáóéêÞ êñßóç, êáôåðåßãïõóá, åðåßãïõóá ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÓôÝëëá ÁñãõñéÜäïõ, ÊÝíôñï Õãåßáò ×ñõóïýðïëçò, e-mail: stage@otenet.gr

Ôüìïò 17, Ôåý÷ïò 1, 2005

×. ËõãéäÜêçò êáé óõí.

Students: A particular examination group of the relation between physical diseases and mental disturbances H. Lygidakis, A. Zervopoulos, Foteini Lamprianou, Aikaterini Lysitska, G. Apagidis, Evanthia Krania, A. Mariolis, Stella Argyriadou Summary Introduction: The relation between physical diseases, mental disturbances, (stress, depression), everyday activity, smoking and alcohol is well known. Students make up this sensitive group, having to deal with the departure from their immediate family, and the beginning of a new stressful way of life. Aim: To record the phychosomatic incidents found in students of higher and highest Academic Institutions in Greece and Italy, and its possible connection with smoking, alcohol and drug consumption. Materials: 134 students from the medical school in Bologna (65 males, 69 females, mean 24.4 y/o sd=2.3; studying year 5.6 sd=1.6), 244 of the Aristotelion University in Thessaloniki (113 males, 131 females; mean 21.9 y/o sd=2.5; studying year 3.2 sd=1.4), 75 of the Technological Education Institution in Kavala (47 males, 28 females; mean 19.9 y/o sd=1.4; studying year 2.2 sd=1.0), and 41 of a private educational institution in Athens (6 males, 35 females, mean 23.6 y/o sd=5.7; studying year 1.9 sd=0.1). Methods: Questionnaire including demographic data: financial condition, chronic diseases, smoking, alcohol and drug consumption was given. The General Health Questionnaire-28 (GHQ-28) for the physical and mental health and the Visual Analytic Scale (VAS) for the personal estimation of their health were also applied. Results: The best results in VAS and in the total GHQ-28 were given by the students of AUTH (mean: 80.43 sd=13.53 and 19.69 sd=9.78). The worst result in VAS was given by the students of IEK in Athens (mean: 72.68 sd=15.81), while the worst in GHQ-28 by the students in Italy (mean: 21.9 sd=10.9). Smoking, alcohol consumption and worst results in VAS seem to be correlated in certain groups. Stress and depression seem to be also related with, the father's age, the last visit to the doctor visit and the results of VAS (p <.05). Conclusion: GPs should deal with students' health, explaining the possibility of somatization symptoms. Following early diagnosis, the cure of stress and depression should take place as soon as possible.

ìáôéêÜ íïóÞìáôá (ëüãù ôùí ðáñåíåñãåéþí, üðùò ×ÍÁ, çëåêôñïëõôéêÝò äéáôáñá÷Ýò, ðñïâëÞìáôá óôï ãáóôñåíôåñéêü, ê.ëð.), ðåñéôôÝò åðáöÝò ìå éáôñéêü êáé ðáñáúáôñéêü ðñïóùðéêü ôçò ÐÖÕ, ðåñéôôÜ Ýîïäá, åðéâÜñõíóç ôùí ôáìåßùí. Ïé óõíèÞêåò áõôÝò Ý÷ïõí óáí óõíÝðåéá íá åðçñåÜæåôáé êáé ç êáèçìåñéíÞ ëåéôïõñãéêüôçôá ôùí áíèñþðùí. ÐáñÜëëçëá Ý÷åé ôåêìçñéùèåß ðëÝïí ç ó÷Ýóç ôïõò ìå ôçí êáðíéóôéêÞ óõíÞèåéá êáé ôç ÷ñÞóç áëêïüë. Ïé öïéôçôÝò åßíáé ãíùóôü üôé áðïôåëïýí ìéá éäéáßôåñç ðëçèõóìéáêÞ ïìÜäá, ðïõ áíôéìåôùðßæïõí ôçí ßäéá åðï÷Þ ðñïâëÞìáôá, üðùò áõôü ôçò áðïìÜêñõíóçò áðü ôï ïéêïãåíåéáêü ðåñéâÜëëïí, ôçí êáèéÝñùóç åíüò íÝïõ ôñüðïõ æùÞò, ìå ðëçèþñá áðü óôñåóïãüíïõò ðáñÜãïíôåò, êáé áõôÜ óôçí åðï÷Þ ðïõ ìüëéò åîÝñ÷ïíôáé áðü ôçí åöçâåßá.7-10 Óêïðüò ôçò åñãáóßáò åßíáé ç êáôáãñáöÞ øõ÷ïóùìáôéêþí êáôáóôÜóåùí óå öïéôçôÝò áíþôåñùí êáé áíþôáôùí åêðáéäåõôéêþí éäñõìÜôùí

ôçò ÅëëÜäáò êáé Éôáëßáò (Bologna), êáé ï ðéèáíüò óõó÷åôéóìüò ôïõò ìå ôï êÜðíéóìá, áëêïüë êáé êáôáíÜëùóç öáñìÜêùí.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò

Ç ìåëÝôç äéåîÞ÷èçêå ôï öèéíüðùñï ôïõ 2003 áðü ôåëåéüöïéôïõò ôçò ÉáôñéêÞò ôïõ Ðáíåðéóôçìßïõ ôçò Bologna (UNIBO), êáé áðü ãéáôñïýò Ã/Ï éáôñéêÞò ôùí Ê.Õ. ×ñõóïýðïëçò, Âýñùíá êáé ÅÊÁÂ Áèçíþí. Ï óõíïëéêüò ðëçèõóìüò ôçò ìåëÝôçò Þôáí 377 öïéôçôÝò (173 Üíäñåò, 204 ãõíáßêåò, ÌÏ çëéêßáò 22.6 Ýôç sd=3,29), ïé ïðïßïé ðñïÝñ÷ïíôáí áðü ôÝóóåñá áíþôåñá êáé áíþôáôá åêðáéäåõôéêÜ éäñýìáôá. Ðéï óõãêåêñéìÝíá, Ýëáâáí ìÝñïò 134 öïéôçôÝò éáôñéêÞò ôïõ UNIBO (65 Üíäñåò, 69 ãõíáßêåò, ÌÏ çëéêßáò 24,4 Ýôç sd=2,3, Ýôïò óðïõäþí 5,6 sd=1,6), 127 ôïõ Áñéóôïôåëåßïõ Ðáíåðéóôçìßïõ Èåóóáëïíßêçò (ÁÐÈ) (55 Üíäñåò êáé 72 ãõíáßêåò, ÌÏ çëéêßáò 21,9 Ýôç sd=2,5, Ýôïò óðïõäþí 3,2 sd=1,4), 75 ôïõ ÔÅÉ ÊáâÜëáò (47 Üíäñåò, 28 ãõíáßêåò, ÌÏ çëéêßáò 19,9 sd=1,4, Ýôïò óðïõäþí 2,2 sd=1,0), êáé 41 åíüò ÉÅÊ íïóçëåõôéêÞò Áèçíþí (6 Üíäñåò êáé 35 ãõíáßêåò ÌÏ çëéêßáò 23,6 sd=5,7, Ýôïò óðïõäþí 1,9 sd=0,1). Ãéá ôç ìåëÝôç ÷ñçóéìïðïéÞèçêå äïìçìÝíï åñùôçìáôïëüãéï ðïõ áðïôåëåßôï áðü ôñßá ìÝñç. Ôï ðñþôï ìÝñïò ðåñéåëÜìâáíå äçìïãñáöéêÜ óôïé÷åßá ãéá ôçí ïéêïãåíåéáêÞ êáé ôçí ïéêïíïìéêÞ -âÜóç ôïõ åðáããÝëìáôïò ôùí ãïíÝùí- êáôÜóôáóç ôùí öïéôçôþí. Óôï äåýôåñï ìÝñïò åñùôÞèçêáí ãéá ôï éáôñéêü ôïõò éóôïñéêü, ôçí ôåëåõôáßá åðßóêåøç óå ãéáôñü êáé ôçí êáôáíÜëùóç öáñìÜêùí ìå âÜóç ôï ICD-10 êùäéêüò F55, ðïõ ðåñéëáìâÜíåé: • ÁíôéêáôáèëéðôéêÜ (F55.0) • ÕðáêôéêÜ (F55.1) • ÁíáëãçôéêÜ (áóðéñßíç, ðáñáêåôáìüëç, öáéíáêåôßíç ê.ëð.) (F55.2) • Áíôéüîéíá (F55.3) • Âéôáìßíåò (F55.4) • ÓôåñïåéäÞ Þ ïñìüíåò (F55.5) 7

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

• ÅéäéêÜ öõôéêÜ öÜñìáêá, Þ öÜñìáêá ôçò ðñáêôéêÞò éáôñéêÞò (F55.6) • ¢ëëåò ïõóßåò ðïõ äåí ðñïêáëïýí åîÜñôçóç (üðùò äéïõñçôéêÜ, ÌÓÁÖ, áíôéåëêùôéêÜ ê.ëð.) (F55.8). Áêüìç, óôï åñùôçìáôïëüãéï óõìðåñéëáìâÜíïíôáí ç êáðíéóôéêÞ óõíÞèåéá (áñéèìüò ôóéãÜñùí êáé Ýôç êáðíßóìáôïò) êáé ç êáôáíÜëùóç áëêïüëçò (ðüóá ðïôÜ êáé ðüóåò öïñÝò ôçí åâäïìÜäá). ÊáôÜ ôçí åðåîåñãáóßá ôùí äåäïìÝíùí ÷ñçóéìïðïéÞèçêå ç óõíÜñôçóç Ýôç êáðíßóìáôïò (package year), ç ïðïßá äßíåôáé áðü ôïí ôýðï: (áñéèìüò ôóéãÜñùí ´ Ýôç êáðíßóìáôïò)/20. Ôï ôñßôï ìÝñïò áðïôåëåßôï áðü äýï êëßìáêåò. Ôç Visual Analogical Scale (VAS) ãéá ôç ìÝôñçóç ôçò ðñïóùðéêÞò åêôßìçóçò ôçò õãåßáò ôïõò, êáèþò êáé ôï General Health Questionnare-28 (GHQ-28) ãéá ôç äéåñåýíçóç ôçò øõ÷éêÞò êáé óùìáôéêÞò ôïõò õãåßáò. Ç VAS åßíáé ìéá ðïëý ÷ñÞóéìç êëßìáêá ãéá ôçí ðïóïôéêïðïßçóç ìç ìåôñÞóéìùí ìåãåèþí. ÓõíÞèùò áðïôåëåßôáé áðü Ýíá ÷Üñáêá ìå õðïäéáéñÝóåéò áðü 0-100 êáé Ýíá êÝíóïñá ãéá íá õðïäåéêíýåôáé áðü ôïí åîåôáæüìåíï ç ôéìÞ ðïõ ðéóôåýåé üôé ôïí áíôéðñïóùðåýåé. ×ñçóéìïðïéåßôáé áðü ôïõò åñåõíçôÝò óôç ìÝôñçóç ôïõ ðüíïõ, ôçò áðïôåëåóìáôéêüôçôáò ôùí áíáëãçôéêþí, ôçò Ýêöñáóçò ðñïóùðéêþí áðüøåùí ôïõ áóèåíÞ, üðùò ôçò õãåßáò, ôçò ðïéüôçôáò æùÞò ê.ëð. Ãéá ôç ìåëÝôç åêôõðþèçêå óôï åñùôçìáôïëüãéï êáé ïé öïéôçôÝò óçìåßùíáí ôï óçìåßï, ðïõ êáôÜ ôçí ÜðïøÞ ôïõò, ôïõò áíôéðñïóþðåõå. Õøçëüôåñåò ôéìÝò óôçí êëßìáêá óõíåðÜãïíôáí ìå ôçí êáëýôåñç ðñïóùðéêÞ Üðïøç ãéá ôçí õãåßá ôïõò. Ç åðéëïãÞ ôïõ GHQ 28 Ýãéíå, äéüôé åßíáé óôáèìéóìÝíï êáé óôéò äýï ÷þñåò êáé ÷ñçóéìïðïéåßôáé åõñÝùò óôçí ÐÖÕ.11 Ðñüêåéôáé ãéá Ýíá ÷ñÞóéìï åñãáëåßï ãéá ôç äéåñåýíçóç ôçò õãåßáò, êáèþò êáé ôùí åëáöñþí øõ÷ïðáèïëïãéêþí äéáôáñá÷þí, áðü ôï Ã/Ï ãéáôñü Þ ôïí øõ÷ßáôñï ðïõ áó÷ïëåßôáé óå äïìÝò ÐÖÕ,12,13 éäéáßôåñá üôáí åöáñìüæåôáé óõìðëçñùìáôéêÜ ìå Üëëá. Óõìðëçñþíåôáé áðü ôïí ßäéï ôïí åîåôáæüìåíï êáé ï ÷ñüíïò ïëïêëÞñùóÞò ôïõ Ý÷åé õðïëïãéóôåß óå 3 ëåðôÜ.14 ×ùñßæåôáé óå ôÝóóåñéò åíüôçôåò åñùôÞóåùí (õðïêëßìáêåò), áðü ôéò ïðïßåò ç ðñþôç (Á) áöïñÜ ôç óùìáôéêÞ õãåßá, ç äåýôåñç (B) ôï Üã÷ïò êáé ôçí áûðíßá, ç ôñßôç (C) ôç ëåéôïõñãéêüôçôá ôïõ áôüìïõ êáé ç ôÝôáñôç (D) ôç âáñéÜ êáôÜèëéøç. 8

×. ËõãéäÜêçò êáé óõí.

Ïé åðéëïãÝò ôùí áðáíôÞóåùí äéáâáèìßæïíôáé áðü: “Êáèüëïõ”, “¼ðùò óõíÞèùò”, “ÌÜëëïí ðåñéóóüôåñï áðü ü,ôé óõíÞèùò”, “Ðïëý ðåñéóóüôåñï áðü üôé óõíÞèùò”. Ãéá ôç âáèìïëüãçóç ôïõ GHQ-28 ÷ñçóéìïðïéïýíôáé äýï ìÝèïäïé. Ç ðñþôç, ç ìÝèïäïò äé÷ïôüìçóçò, ç ïðïßá åßíáé êáé ç åõñýôåñá ÷ñçóéìïðïéïýìåíç,15 âáèìïëïãåß ôéò äõï ðñþôåò áðáíôÞóåéò ìå 0, êáé ôéò äýï äåýôåñåò ìå 1. Ç äåýôåñç, ç ìÝèïäïò Lickert,16 âáèìïëïãåß áðü 0-3, êáé êåñäßæåé óå ðëçñïöïñßá Ýíáíôé ôçò ðñþôçò, éäéáßôåñá óôéò õðïêëßìáêåò ôïõ GHQ. ÅðïìÝíùò, õøçëüôåñåò ôéìÝò óôá áðïôåëÝóìáôá ôçò äïêéìáóßáò óõíåðÜãïíôáé ðáèïëïãéêÜ áðïôåëÝóìáôá. Óôç âáèìïëïãßá ôçò ìåëÝôçò ÷ñçóéìïðïéÞèçêå ç ìÝèïäïò Lickert. Ïé öïéôçôÝò ñùôÞèçêáí êáôÜ ôçí ðñïóÝëåõóÞ ôïõò óôï ìÜèçìá. Ôá äýï ðñþôá ìÝñç óõìðëçñþíïíôáí ìå ôç âïÞèåéá ôïõ åñåõíçôÞ, åíþ ôï ôåëåõôáßï åîïëïêëÞñïõ áðü ôïõò ßäéïõò, áöïý åß÷å äéåõêñéíéóôåß ðñïçãïõìÝíùò ç ÷ñÞóç ôçò VAS êáé üôé áõôÞ âáèìïëïãïýóå ôçí øõ÷éêÞ, áëëÜ êáé óùìáôéêÞ ôïõò õãåßá. Ç óôáôéóôéêÞ áíÜëõóç ôùí äåäïìÝíùí ðñáãìáôïðïéÞèçêå ìå SPSS ãéá Windows (Ýêäïóç 12.0). Ãéá ôçí óýãêñéóç ôùí ðïéïôéêþí ìåôáâëçôþí ÷ñçóéìïðïéÞèçêå ç ìÝèïäïò Pearson’s ÷2, åíþ ãéá ôéò ìÝóåò ôéìÝò áíáëüãùò, ôï Students t-test Þ ç áíÜëõóç äéáêýìáíóçò (ANOVA). ÐñïêåéìÝíïõ íá äéåñåõíçèïýí ïé ðáñÜãïíôåò ðïõ åðçñåÜæïõí ôï GHQ-28, ðñáãìáôïðïéÞèçêå ðáëéíäñïìéêÞ áíÜëõóç ìå ôç ìÝèïäï Stepwise, óôçí ïðïßá ùò åîáñôçìÝíç ìåôáâëçôÞ ÷ñçóéìïðïéÞèçêå ôï óõíïëéêü áðïôÝëåóìá ôïõ GHQ êáé óáí áíåîÜñôçôåò üëåò ïé õðüëïéðåò.

ÁðïôåëÝóìáôá Ç áíÜëõóç ôùí êïéíùíéêïïéêïíïìéêþí ðáñáãüíôùí ôïõ ðëçèõóìïý ìåëÝôçò Ýäåéîå óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò áíÜìåóá óôéò ôÝóóåñéò ïìÜäåò áíáöïñéêÜ óôïí ôüðï äéáìïíÞò ôùí ãïíÝùí (Ðßíáêáò É) êáé ôï åðÜããåëìÜ ôïõò (Ðßíáêáò ÉÉ). ¼ðùò öáßíåôáé óôïí ðñþôï ðßíáêá, ç êáôáíïìÞ ôïõ ôüðïõ äéáìïíÞò ôùí ãïíÝùí ãéá ôïõò öïéôçôÝò ôïõ ÁÐÈ êáé ôçò UNIBO åßíáé ðáñüìïéá êáé ôï ìåãáëýôåñï ðïóïóôü ôïõò ðñïÝñ÷å-

Ôüìïò 17, Ôåý÷ïò 1, 2005

×. ËõãéäÜêçò êáé óõí. Ðßíáêáò É. ÊáôáíïìÞ ôïõ ôüðïõ äéáìïíÞò ôùí ãïíÝùí áíÜ ïìÜäá ìåëÝôçò Ôüðïò ÄéáìïíÞò ÃïíÝùí

ÔÅÉ (Í)

Bologna (Í)

ÁÐÈ (Í)

ÉÅÊ (Í)

Óýíïëï (Í)

Ðüëç > 500.0000 Ðüëç 100.000 - 500.000 Ðüëç 25.000 - 100.000 Êùìüðïëç ×ùñéü Óýíïëï

19 4 10 19 23 75

45 25 38 18 8 134

43 20 34 17 13 127

28 2 5 5 1 41

135 51 87 59 45 377

÷2=66,408, p<,001 Ðßíáêáò ÉÉ. ÊáôáíïìÞ ôïõ åðáããÝëìáôïò ôùí ãïíéþí áíÜ ïìÜäá ìåëÝôçò ÅðÜããåëìá ÐáôÝñá

ÍïéêïêõñÜ Ãåùñãüò ÅñãÜôçò Åëåýè. Åðáããåëìáôßáò Äçìüóéïò ÕðÜëëçëïò Éäéùôéêüò ÕðÜëëçëïò Óõíôáîéïý÷ïò ¢ëëï Óýíïëï Ðëçèõóìïý ÌåëÝôçò

ÅðÜããåëìá ÌçôÝñáò

ÔÅÉ (Í)

UNIBO (Í)

ÁÐÈ (Í)

ÉÅÊ (Í)

Óýíïëï (Í)

ÔÅÉ (Í)

UNIBO (Í)

ÁÐÈ (Í)

ÉÅÊ (Í)

Óýíïëï (Í)

12 3 26 16 7 5 6 75

1 1 58 24 12 27 5 134

4 10 45 38 9 15 3 127

2 1 16 11 3 4 3 41

19 15 145 89 31 51 17 377

37 5 4 12 8 7 1 1 75

43 0 2 34 31 9 12 2 134

41 4 4 19 40 11 6 2 127

20 0 1 6 2 8 2 2 41

141 9 11 71 81 35 21 7 377

ÅðÜããåëìá ÐáôÝñá: ÷2= 49,892, p<,001, ÅðÜããåëìá ÌçôÝñáò: ÷2=52,324, p<,001

ôáé áðü ìåãáëïõðüëåéò Üíù ôùí 500.000 Þ ðüëåéò ôçò åðáñ÷ßáò ôùí 25.000 - 100.000 êáôïßêùí. Óôïõò ðßíáêåò ðïõ áêïëïõèïýí ðáñïõóéÜæïíôáé ïé äéáöïñÝò êáôáíÜëùóçò öáñìÜêùí óôéò ïìÜäåò (Ðßíáêáò ÉÉÉ), êáèþò êáé ç ðñáãìáôïðïéçèåßóá ôåëåõôáßá åðßóêåøç óå ãéáôñü (Ðßíáêáò IV). Áêïëïýèùò ðáñïõóéÜæïíôáé ïé ðáñÜìåôñïé ôçò êáðíéóôéêÞò óõíÞèåéáò êáé ôçò êáôáíÜëùóçò áëêïüë óôéò ïìÜäåò ôùí öïéôçôþí (Ðßíáêáò V). Áðü ôïí ðßíáêá ðáñáôçñåßôáé üôé ìüíï ï

ìÝóïò çìåñÞóéïò áñéèìüò êáôáíÜëùóçò ôóéãÜñùí êáé ï áñéèìüò ðïôçñéþí áëêïüë áíÜ çìÝñá äåí öáíåñþíïõí óôáôéóôéêÞ óçìáíôéêüôçôá. Ç áíÜëõóç ôïõ ôñßôïõ ìÝñïõò ôïõ åñùôçìáôïëïãßïõ áöïñïýóå ôç VAS êáé ôï GHQ-28, óôï ïðïßï åëÞöèçóáí õðüøç ðÝñáí ôïõ ôåëéêïý áðïôåëÝóìáôïò (GHQ Total), êáé ïé ôÝóóåñéò õðïêëßìáêåò ôïõ åñùôçìáôïëïãßïõ (GHQ Subscales). Ï áêüëïõèïò ðßíáêáò ðáñïõóéÜæåé ôïõò ìÝóïõò üñïõò ôùí áðïôåëåóìÜôùí óôéò äýï êëßìáêåò (Ðßíáêáò VI). Ï õøçëüôåñïò MO óôç VAS öáßíåôáé íá

Ðßíáêáò ÉÉÉ. ¾ðáñîç éáôñéêïý éóôïñéêïý, êáôáíÜëùóç óêåõáóìÜôùí êáé ïé äéáöïñÝò ôïõò áíÜ ïìÜäá

Éáôñéêü éóôïñéêü Âéôáìßíåò ÔïíùôéêÜ ÁíáëãçôéêÜ ÌÓÁÖ ÁíôéâéïôéêÜ ÁíôéåëêùôéêÜ Áã÷ïëõôéêÜ Óýíïëï Ðëçèõóìïý ÌåëÝôçò

ÔÅÉ (Í)

UNIBO (Í)

ÁÐÈ (Í)

ÉÅÊ (Í)

3 4 3 22 3 4 0 3 75

17 36 11 71 39 23 11 3 134

15 23 0 35 13 10 0 0 127

9 4 1 20 4 3 0 0 41

Óýíïëï (Í) 44 67 15 148 59 40 11 6 377

÷2

8,621 17,336 11,793 22,535 29,985 9,742 20,547 5,853

,035 ,001 ,008 ,000 ,000 ,021 ,000 ,119

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ËõãéäÜêçò êáé óõí.

Ðßíáêáò IV. Ôåëåõôáßá åðßóêåøç óå ãéáôñü áíÜ ïìÜäá Ôåëåõôáßá Åðßóêåøç óå Ãéáôñü

ÔÅÉ (Í)

UNIBO (Í)

ÁÐÈ (Í)

ÉÅÊ (Í)

Óýíïëï (Í)

£ 3ìçíï £ 6ìçíï £ 1 ×ñüíï > 1 ×ñüíï Óýíïëï

22 10 16 27 75

043 024 024 043 134

028 034 021 044 127

12 07 02 20 41

105 075 063 134 377

õðÜñ÷åé óôï ÁÐÈ êáé ï ÷áìçëüôåñïò óôï ÉÅÊ Áèçíþí (Ðßíáêáò 6). ÅðéðëÝïí ïé öïéôçôÝò ôïõ ÁÐÈ ðáñïõóéÜæïõí ôç ÷áìçëüôåñç âáèìïëïãßá óôéò A (óùìáôéêÞ) êáé D (êáôÜèëéøç) õðïêëßìáêåò ôïõ GHQ, êáèþò êáé óôï óõíïëéêü áðïôÝëåóìá. Ôï ÉÅÊ äåß÷íåé íá Ý÷åé ôéò ÷áìçëüôåñåò ôéìÝò óôéò õðïêëßìáêåò B (Üã÷ïò) êáé C (ëåéôïõñãéêüôçôá) êáé ôéò õøçëüôåñåò óôéò A êáé D. Ôï

UNIBO ôÝëïò, åìöÜíéóå ôéò õøçëüôåñåò ôéìÝò óôéò B êáé C, êáèþò êáé óôï óõíïëéêü áðïôÝëåóìá ôïõ GHQ. Óôïí ðßíáêá ðïõ áêïëïõèåß (Ðßíáêáò VII) åéóÜãåôáé ï áñéèìüò ôùí öïéôçôþí ìå öõóéïëïãéêÜ - ðáèïëïãéêÜ áðïôåëÝóìáôá óôï GHQ-28 êáé óôéò õðïêëßìáêÝò ôïõ. Óôçí ôåëåõôáßá ãñáììÞ ôïõ ãßíåôáé óýãêñéóç ôùí öõóéïëïãéêþí Þ ðáèïëïãéêþí ôéìþí ôïõ GHQ-28 ìå ôïõò áíôßóôïé÷ïõò ÌÏ ôçò VAS, ç äéáöïñÜ ôùí ïðïßùí åßíáé óôáôéóôéêþò óçìáíôéêÞ (p<,001). Óôçí ðåñáéôÝñù åðåîåñãáóßá ôùí áðïôåëåóìÜôùí öÜíçêå üôé ç VAS êáé ïé C êáé D õðïêëßìáêåò ôïõ GHQ-28 åß÷áí óôáôéóôéêÞ óçìáíôéêüôçôá óôéò ïìÜäåò (Ðßíáêáò VIII). Åí óõíå÷åßá ðñáãìáôïðïéÞèçêå ï óõó÷åôéóìüò ôçò êïéíùíéêïïéêïíïìéêÞò êáôÜóôáóçò ôïõ ðëçèõóìïý ìåëÝôçò (Ðßíáêáò IX) êáé ôçò êáôá-

Ðßíáêáò V. ÊáðíéóôéêÞ óõíÞèåéá êáé êáôáíÜëùóç áëêïüë áíÜ ïìÜäá ÔÅÉ ÊÜðíéóìá (Í) Íáé ¼÷é ÇìåñÞóéïò Áñéèìüò ÔóéãÜñùí Mean Sd ¸ôç Êáðíßóìáôïò Mean Sd ÐáêÝôá/Ýôïò Mean Sd Áëêïüë (Í) Íáé ¼÷é Áñéèìüò Ðïôçñéþí Áëêïüë ôçí êÜèå öïñÜ Mean Sd Åâäïìáäéáßá ÊáôáíÜëùóç Áëêïüë Mean Sd

UNIBO

ÁÐÈ

ÉÅÊ

Óýíïëï

29 46

62 72

66 61

30 11

187 190

20,10 7,53

20,35 10,48

19,59 8,53

22,00 6,51

20,31 8,79

3,83 1,65

6,05 2,13

4,47 1,80

6,70 4,47

5,25 2,69

4,19 3,41

6,43 4,02

4,54 2,70

7,69 5,86

5,62 4,07

57 18

76 58

101 26

21 20

255 122

2,12 1,40

1,78 ,96

2,05 1,32

1,95 1,91

1,98 1,30

2,25 1,42

2,49 1,92

2,67 1,84

1,10 ,30

2,39 1,75

Ðßíáêáò VI. ÌÝóïé üñïé áðïôåëåóìÜôùí ôùí VAS êáé GHQ áíÜ ïìÜäá ÔÅÉ Mean Sd VAS Subscale A Subscale B Subscale C Subscale D GHQ Total 10

79,47 5,25 6,32 6,77 2,83 21,17

17,18 3,72 4,73 3,41 4,30 13,68

UNIBO Mean Sd

ÁÐÈ Mean Sd

Mean

76,38 5,57 6,72 7,33 2,29 21,90

80,43 5,18 6,31 5,95 2,25 19,69

73,54 6,54 4,78 3,17 5,56 20,05

17,39 3,53 4,35 3,09 2,73 10,93

13,53 3,61 3,65 2,73 2,93 9,78

ÉÅÊ Sd 15,78 4,75 2,65 4,10 3,89 12,75

Óýíïëï Mean Sd 78,05 5,48 6,29 6,30 2,74 20,81

16,07 3,75 4,07 3,39 3,43 11,37

Ôüìïò 17, Ôåý÷ïò 1, 2005

×. ËõãéäÜêçò êáé óõí. Ðßíáêáò VII. ÖõóéïëïãéêÜ êáé ðáèïëïãéêÜ áðïôåëÝóìáôá óôï GHQ-28 áíÜ ïìÜäá ÔÅÉ (Í) Öõó. Ðáè. Subscale A Subscale B Subscale C Subscale D GHQ Total VAS Mean - GHQ Total

53 44 52 66 50 83,80

22 31 23 9 25 70,80

UNIBO (Í) Öõó. Ðáè.

ÁÐÈ (Í) Öõó. Ðáè.

82 77 87 120 75 84,55

92 81 96 113 85 83,47

52 57 47 14 59 66,00

Ðßíáêáò VIII. ÄéáöïñÝò ôùí ìåôáâëçôþí áíÜ ïìÜäá Mean Square VAS Subscale A Subscale B Subscale C Subscale D GHQ Total

693,470 20,663 39,298 191,769 128,032 117,406

2,721 1,475 2,395 19,104 11,796 ,907

35 46 31 14 42 74,29

ÉÅÊ (Í) Öõó. Ðáè. 26 22 36 35 27 75,00

Óýíïëï (Í) Öõó. Ðáè.

15 19 5 6 14 70,71

253 224 271 334 237 82,92

124 153 106 43 140 69,81

üôé ç ÷áìçëÞ VAS êáé ôï õøçëü GHQ-28 ó÷åôßæïíôáé ìå ôçí õøçëÞ êáôáíÜëùóç öáñìÜêùí ãéá ôï ÔÅÉ êáé ôï UNIBO. Ðáñáôçñåßôáé áêüìç ç áðïõóßá ôçò êáôçãïñßáò ôùí áíáëãçôéêþí, ôùí ïðïßùí ç êáôáíÜëùóç áí êáé äéÝöåñå óçìáíôéêÜ áíÜ ïìÜäá (p<,001), äåí Ýäåéîå ôåëéêÜ íá åðçñåÜæåé ôá áðïôåëÝóìáôá ôùí VAS êáé GHQ-28. Ç êáðíéóôéêÞ óõíÞèåéá ôùí öïéôçôþí ôåßíåé íá ó÷åôßæåôáé ìå ôçí êáôáíÜëùóç áëêïüë ãéá ôéò ïìÜäåò ÔÅÉ, UNIBO êáé ÁÐÈ (p<,05), êáé ìå ôï ÷áìçëüôåñï áðïôÝëåóìá óôç VAS ãéá ôïõò íÝïõò ôïõ ÔÅÉ êáé ÁÐÈ (p=,032 êáé p<,001 áíôßóôïé÷á). Ïé ìåôáâëçôÝò ðïõ äåß÷íåé íá åðçñåÜæïõí ôï äåßêôç package year ôùí êáðíéóôþí ðáñïõóéÜæïíôáé óôïí áêüëïõèï ðßíáêá (Ðßíáêáò XI). Ç çëéêßá, ï áñéèìüò ðïôçñéþí áëêïüë êáé ç

Sig. ,044 ,221 ,068 ,000 ,000 ,438

íÜëùóçò öáñìÜêùí (Ðßíáêáò X) ìå ôá áðïôåëÝóìáôá ôùí VAS êáé GHQ-28. Óôïí Ðßíáêá IX öáßíåôáé üôé ïé êïéíùíéêïïéêïíïìéêïß ðáñÜãïíôåò åðçñåÜæïõí ðåñéóóüôåñï ôá áðïôåëÝóìáôá ôçò VAS êáé ôïõ GHQ28 óôïõò öïéôçôÝò ôïõ ÁÐÈ, óõãêñéôéêÜ ìå ôéò Üëëåò ïìÜäåò. Áíôßóôïé÷á, óôïí Ðßíáêá X åðéóçìáßíåôáé

Ðßíáêáò IX. Óõó÷åôéóìüò êïéíùíéêÞò êáôÜóôáóçò ìå ôéò êëßìáêåò VAS êáé GHQ ÔÅÉ ÐáñÜãùí

VAS

GHQ

UNIBO ÐáñÜãùí ÅðÜããåëìá ÐáôÝñá

ÏéêïãåíåéáêÞ ÊáôÜóôáóç

,000

ÏéêïãåíåéáêÞ ÊáôÜóôáóç

p ,000

,008

ÁÐÈ ÐáñÜãùí ÅðÜããåëìá ÌçôÝñáò ÏéêïãåíåéáêÞ ÊáôÜóôáóç Áäåñöþí Çëéêßá ÐáôÝñá Çëéêßá ÌçôÝñáò Áñéèìüò Áäåñöþí Çëéêßá Áäåñöþí ÅðÜããåëìá Áäåñöþí OéêïãåíåéáêÞ KáôÜóôáóç Áäåñöþí

ÉÅÊ ÐáñÜãùí

ÅðÜããåëìá Áäåñöþí

,021

,000

,000 ,003 ,032 ,023 ,000 ,006

,004

Áîéïóçìåßùôá ÓçìáíôéêÜ: [ÉÅÊ] VAS – ÅðÜããåëìá ÌçôÝñáò: p=,071 [UNIBO] GHQ – Çëéêßá Áäåñöþí: p=,053 11

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ËõãéäÜêçò êáé óõí.

õðïêëßìáêá D ôïõ GHQ-28 öÜíçêå üôé åðéäñïýí ôï äåßêôç óôïõò íÝïõò ôïõ ÔÅÉ, åíþ ãéá áõôïýò ôïõ Ðáíåðéóôçìßïõ ôçò Bologna ï ìüíïò óôáôéóôéêÜ óçìáíôéêüò ðáñÜãùí ðáñáôçñÞèçêå üôé Þôáí ôï Ýôïò óðïõäþí. Ïé öïéôçôÝò ôïõ ÉÅÊ

ðáñïõóßáóáí óõó÷åôéóìü ìå ôéò õðïêëßìáêåò Á êáé D, êáèþò êáé ìå ôï óõíïëéêü áðïôÝëåóìá ôïõ GHQ-28, åíþ ôÝëïò ôï ÁÐÈ Ýäåéîå íá ìçí åðçñåÜæåôáé áðü êÜðïéá ìåôáâëçôÞ. ÔÝëïò, óôïí Ðßíáêá XII åðéóçìáßíïíôáé ôá

Ðßíáêáò X. Óõó÷åôéóìüò êáôáíÜëùóçò öáñìÜêùí ìå ôéò êëßìáêåò VAS êáé GHQ ÔÅÉ Åßäïò ÓêåõÜóìáôïò VAS GHQ

ÌÓÁÖ ÔïíùôéêÜ ÁíôéâéïôéêÜ Áã÷ïëõôéêÜ

UNIBO Åßäïò ÓêåõÜóìáôïò

p ,044 ,004 ,023 ,000

ÁíôéâéïôéêÜ Âéôáìßíåò ÁíôéåëêùôéêÜ Áã÷ïëõôéêÜ

ÁÐÈ Åßäïò ÓêåõÜóìáôïò

p ,032 ,049 ,001 ,000

ÉÅÊ Åßäïò ÓêåõÜóìáôïò

ÌÓÁÖ

,026

ÔïíùôéêÜ

p ,017

Áîéïóçìåßùôá Óçìáíôéêü: [ÔÅÉ] VAS – ÔïíùôéêÜ: p=,051 Ðßíáêáò XI. Óõó÷åôéóìüò äåßêôç ðáêÝôá/Ýôïò ìå Üëëåò ìåôáâëçôÝò ÌåôáâëçôÝò

ÔÅÉ Mean Square

UNIBO

ÁÐÈ

Sig.

Mean Square

Sig.

3,377

2,523

,042

3,477

1,147

,350

5,581 ,749

,738

49,460

1,865

,119

¸ôïò Óðïõäþí

,909

,692

,720

2,738

2,129

,019

1,855 ,887

,592

,017

,356

,967

Áñéèìüò Ðïôçñéþí Áëêïüë

4,593

3,165

,020

,637

,781

,720

1,777 ,796

,688

2,727

,390

,917

Åâäïìáäéáßá ÊáôáíÜëùóç Áëêïüë

1,626

1,564

,204

3,444

,661

,834

3,014 ,766

,718

,056

,286

,965

,711

,730

Çëéêßá

VAS

Mean Square

ÉÅÊ

Mean Square

469,351

1,547

,202

201,070

,926

,579 151,921 ,580

,891 238,750

GHQ: Subscale A

16,955

1,100

,412

15,238

1,588

,101 14,629 1,092

,388

41,547

2,941

,022

GHQ: Subscale B

22,517

1,171

,369

10,457

,688

,842 14,684 1,029

,446

9,679

1,666

,166

GHQ: Subscale C

17,212

1,477

,226

8,676

1,040

,453

9,705 ,879

,600

26,915

1,696

,158

GHQ: Subscale D

47,623

3,664

,008

6,507

,720

,810 14,044 1,271

,251

25,195

2,897

,023

281,144

1,807

,132

87,779

,941

,562 131,802 1,193

,306 278,506

2,492

,043

GHQ: Total

ÅîáñôçìÝíç ÌåôáâëçôÞ: ðáêÝôá/Ýôïò

Ðßíáêáò XII. ÁðïôåëÝóìáôá Multiple Regression Analysis óôï GHQ Total (Constant) VAS ÁíôéåëêùôéêÜ Ôåëåõôáßá Åðßóêåøç óå Ãéáôñü ÅðÜããåëìá ÐáôÝñá ÊáôáíÜëùóç Áëêïüë ÅîáñôçìÝíç ÌåôáâëçôÞ: GHQ Total 12

Std. Error

Sig.

73,909 -,327 -12,492 -1,316 ,954 -2,470

7,795 ,033 3,613 ,428 ,385 1,145

9,482 -9,951 -3,457 -3,073 2,477 -2,158

,000 ,000 ,001 ,002 ,014 ,032

×. ËõãéäÜêçò êáé óõí.

áðïôåëÝóìáôá ôçò ðáëéíäñïìéêÞò áíÜëõóçò ãéá ôï óýíïëï ôïõ ðëçèõóìïý ìåëÝôçò, óôçí ïðïßá åîáñôçìÝíç ìåôáâëçôÞ Þôáí ôï GHQ Total. Áðü ôçí áíÜëõóç öÜíçêå üôé ôï áðïôÝëåóìá ôïõ GHQ-28 åðçñåÜæåôáé áðü ôç ÷áìçëÞ ôéìÞ ôçò VAS, ôç ëÞøç áíôéåëêùôéêþí öáñìÜêùí, ôï óýíôïìï ÷ñïíéêü äéÜóôçìá åðßóêåøçò óå ãéáôñü, ôï åðÜããåëìá ôïõ ðáôÝñá êáé ôçí õøçëüôåñç êáôáíÜëùóç áëêïüë.

ÓõæÞôçóç Ðáñüôé ïé öïéôçôÝò áðïôåëïýí Ýíá ìåãÜëï ìÝñïò ôùí ÷ñçóôþí ôùí õðçñåóéþí õãåßáò, äåí õðÜñ÷ïõí ìåëÝôåò, ðïõ íá ðñïÝñ÷ïíôáé áðü Ê.Õ. ôçò ÅëëÜäáò, ó÷åôéêÝò ìå ôá ðñïâëÞìáôÜ ôïõò. Óôçí ðáñïýóá ìåëÝôç åíôïðßæïíôáé ïé åîÞò ìåèïäïëïãéêïß ðåñéïñéóìïß: ç áíïìïéïìïñößá ôïõ äåßãìáôïò, ôï ãåãïíüò üôé ïé óõíåíôåýîåéò óôçí êÜèå ïìÜäá äåí ðñáãìáôïðïéÞèçêáí áðü ôïõò ßäéïõò åñåõíçôÝò, êáé ôÝëïò ôï åñùôçìáôïëüãéï. Óôïõò óêïðïýò üìùò Þôáí íá ëçöèåß ìéá üóï ôï äõíáôüí ðëçñÝóôåñç åéêüíá ãéá ôçí øõ÷éêÞ õãåßá óôïõò öïéôçôÝò äéáöüñùí åêðáéäåõôéêþí éäñõìÜôùí, Ýóôù êáé åéò âÜñïò ôçò ïìïéïìïñößáò ôïõ äåßãìáôïò. Ôï GHQ-28 åßíáé Ýíá åý÷ñçóôï åñãáëåßï ãéá ôÝôïéåò ìåôñÞóåéò áí êáé ôá áðïôåëÝóìáôÜ ôïõ åðçñåÜæïíôáé áðü ðáñÜãïíôåò, üðùò ôï öýëï, ç çëéêßá, ï ÷ñüíéïò ðüíïò.17,18 Åðßóçò öáßíåôáé íá õðïëåßðåôáé óôçí êáôáãñáöÞ ôùí ÷ñüíéùí ðáèÞóåùí åðéêåíôñþíïíôáò óôéò ðñüóöáôåò, êáé åóôéÜæåôáé âáóéêÜ óôïí áõôïêôïíéêü éäåáóìü, ï ïðïßïò äåí åßíáé êáé ôï êõñéüôåñï ÷áñáêôçñéóôéêü ôçò Þðéáò êáôáèëéðôéêÞò äéáôáñá÷Þò. 12 Åíôïýôïéò, ÷ñçóéìïðïéïýìåíï óõìðëçñùìáôéêÜ ìå ôç VAS19,20 êáé ôá êñéôÞñéá ôïõ ICD10, áðïôåëåß Ýíá áñêåôÜ áîéüðéóôï åñãáëåßï ãéá ôÝôïéåò ìåëÝôåò. Óýìöùíá ìå ôéò ïäçãßåò ôïõ ICD-101 óôïí êùäéêü F55.0 ðåñéëáìâÜíïíôáé ôá áíôéêáôáèëéðôéêÜ, äçëáäÞ ôá ôñéêõêëéêÜ, ôåôáñôïêõêëéêÜ êáé ïé áíôáãùíéóôÝò ôçò ìïíïáìéíïîåéäÜóçò. Óôçí ðåñßðôùóç ôùí öïéôçôþí ðáñáôçñÞèçêå üôé ÷ñçóéìïðïéïýóáí áã÷ïëõôéêÜ, öáéíüìåíï ðïõ ÷áñáêôçñßæåé ôï ãåíéêü ðëçèõóìü, ï ïðïßïò óõ÷íÜ ÷ñçóéìïðïéåß âåíæïäéáæåðßíåò óôç èÝóç ôùí áíôéêáôáèëéðôéêþí.21 Ôï ãåãïíüò üìùò áõôü, ôïõò äéáöïñïðïéïýóå áðü ôïõò óêïðïýò ôçò ìåëÝôçò, ç ïðïßá áó÷ïëïýíôáí ìå ôçí “êáôÜ÷ñçóç ïõóéþí

Ôüìïò 17, Ôåý÷ïò 1, 2005

ðïõ äåí ðñïêáëïýí åîÜñôçóç”.1 ¸íá Üëëï öáéíüìåíï ðïõ ðáñáôçñÞèçêå ìå ôçí êáôÜôáîç ôùí öáñìÜêùí, Þôáí áõôü ìå êùäéêü F55.3 ðïõ áöïñïýóå ôá áíôéüîéíá. Êáé óôçí ðåñßðôùóç áõôÞ äéáêñßíåôáé óôï ãåíéêü ðëçèõóìü ôï öáéíüìåíï ôçò áíôéêáôÜóôáóçò ôùí áíôéüîéíùí ìå ñáíéôéäßíç Þ ðñáæüëåò. Ç êáôáíÜëùóç áõôþí ôùí öáñìÜêùí ðáñáôçñÞèçêå óôïõò öïéôçôÝò ôïõ UNIBO êáé ìÜëéóôá ÷ùñßò íá Ý÷åé ðñïçãçèåß êÜðïéïò Ýëåã÷ïò.22-24 Ôá áíáëãçôéêÜ ìå êùäéêü F55.2 Þôáí åðßóçò óçìåßï óôï ïðïßï õðÞñ÷å óýã÷õóç, äåäïìÝíïõ üôé ç íéìåóïõëßäç êáé ôï ôïëöåíáìéêü ïîý óõ÷íÜ õðïêáèéóôïýóáí áíáßôéá ôçí ðáñáêåôáìüëç êáé ôçí áóðéñßíç. 25-27 Ç êáôáíÜëùóç ôùí âéôáìéíþí ÷áñáêôÞñéæå ôá äõï ðáíåðéóôÞìéá, öáéíüìåíï ðïõ ðáñáôçñåßôáé óôïõò öïéôçôÝò,28-31 åíþ íÝïé ôïõ UNIBO ÷ñçóéìïðïéïýóáí êáé ôïíùôéêÜ, ãåãïíüò ðïõ ìáò áíáãÜãåé óå õðïèÝóåéò óùìáôïðïßçóçò -ðïëõöáñìáêßáò.32 ÔÝëïò, åßíáé åíôõðùóéáêÞ êáé ç êáôáíÜëùóç áíáëãçôéêþí êáé ÌÓÁÖ, ãåãïíüò ðïõ õðïäçëþíåé ðéèáíüôáôá ôçí áíÜãêç ôçò åöáñìïãÞò ìÝôñùí áäõíáìßáò ðñïìÞèåéÜò ôïõò Üíåõ éáôñéêÞò óõíôáãÞò.33 ÐñÜãìáôé ôï ðñüâëçìá ôçò åýêïëçò ðñïìÞèåéáò, ðïõ Ý÷åé óáí áðïôÝëåóìá ôçí ðïëõöáñìáêßá, èåùñåßôáé ðáãêüóìéï öáéíüìåíï êáé ìåëåôþíôáé ôñüðïé êáôáðïëÝìçóÞò ôïõ, óôïõò ïðïßïõò ï Ã/Ï ãéáôñüò Ý÷åé êïñõöáßï ñüëï.33,34 Ôá áíôéâéïôéêÜ Þôáí ç êáôçãïñßá, ðïõ ôåëéêþò êáôá÷ùñÞèçêå óôïí êùäéêü F55.8, üìùò ç ðáñïõóßá ôïõò ðéèáíþò íá äéêáéïëïãåßôáé ëüãù ôçò ãñßðçò êáôÜ ôçí åðï÷Þ ôçò äéåîáãùãÞò ôçò ìåëÝôçò. Ïé êïéíùíéêïïéêïíïìéêïß ðáñÜãïíôåò, üðùò Þôáí áíáìåíüìåíï, öÜíçêå íá åðçñåÜæïõí óå óçìáíôéêü âáèìü ôçí øõ÷ïóùìáôéêÞ õãåßá ôùí öïéôçôþí êáé éäéáßôåñá áõôþí ôïõ ÁÐÈ, ãåãïíüò ðïõ óõìöùíåß êáé ìå Üëëåò ìåëÝôåò.35 Ôá áðïôåëÝóìáôá ôçò óõ÷íüôçôáò ôùí éáôñéêþí åðéóêÝøåùí äåß÷íïõí üôé åêôüò ôïõ ÁÐÈ, óôïõò öïéôçôÝò ôùí õðïëïßðùí åêðáéäåõôéêþí éäñõìÜôùí êáôáãñÜöôçêáí óõ÷íÝò åðáöÝò ìå ôéò õðçñåóßåò õãåßáò óôï ôåëåõôáßï ôñßìçíï. Ôï ãåãïíüò áõôü ßóùò ìðïñåß íá áéôéïëïãçèåß ìå ôç ÷áìçëÞ âáèìïëïãßá óôç VAS, êáé ôçí õøçëÞ óôéò õðïêëßìáêåò A êáé D ôïõ ÉÅÊ, êáèþò êáé ôéò õøçëÝò ôéìÝò ôùí B êáé C, êáé óõíïëéêïý GHQ ôïõ UNIBO. Áêüìç, ç õøçëÞ êáôáíÜëùóç öáñìÜêùí öÜíçêå íá óõíäÝåôáé ìå ôï õøçëü óõíïëéêü GHQ êáé ôç ÷áìçëÞ VAS, ãåãïíüò ðïõ áðï13

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

äåéêíýåôáé êáé áðü Üëëåò ìåëÝôåò.19 Óýìöùíá ìå ôïõò Rohde P et al,36 ç êáðíéóôéêÞ óõíÞèåéá óôïõò íÝïõò åðçñåÜæåôáé áðü ðáñÜãïíôåò, üðùò êáðíéóôÞò ðáôÝñáò êáé ü÷é ìçôÝñá Þ óõããåíåßò, áíôéêïéíùíéêÞ óõìðåñéöïñÜ Þ øõ÷éêü íüóçìá ôïõ ðáôÝñá, ãåãïíüò ðïõ óôç ìåëÝôç ìáò äåí Þôáí äõíáôü íá äéåñåõíçèåß. ÐÜíôùò ôï êÜðíéóìá óôïõò íÝïõò óýìöùíá ìå ôç âéâëéïãñáößá óçìáßíåé áõîçìÝíï êßíäõíï åìöÜíéóçò ìåßæïíïò êáôÜèëéøçò.37-39 ÅðéðëÝïí, öáßíåôáé íá åßíáé óõíäåäåìÝíï ìå ôç ÷ñÞóç áëêïüë êáé ìÜëéóôá, óýìöùíá ìå ôïõò Novak A et al,40 íÝïé ðïõ äåí ðßíïõí, áëëÜ êáðíßæïõí, âñßóêïíôáé óå õøçëü êßíäõíï, ìåãáëýôåñï áðü ôïõò ìç êáðíéóôÝò, óôï ìÝëëïí íá îåêéíÞóïõí ôçí êáôáíÜëùóç áëêïüë. Óôçí ðáñïýóá ìåëÝôç ôï êÜðíéóìá êáé ôï áëêïüë öáßíåôáé íá ó÷åôßæïíôáé ìå ôç ÷áìçëÞ âáèìïëïãßá óôç VAS, ãåãïíüò ðïõ óõìöùíåß êáé ìå Üëëåò ìåëÝôåò. ÊáôÜ ôïõò Upadhyaya HP et al,41 ç ëåõêÞ öõëÞ, ç ìåãáëýôåñç çëéêßá, ç êáôÜèëéøç, ç ÷ñÞóç êÜííáâçò, áðïôåëïýí ðáñÜãïíôåò êéíäýíïõ óôïõò íÝïõò ãéá êÜðíéóìá. ÐÜíôùò ïé õøçëüôåñåò ôéìÝò ôïõ äåßêôç package year ôåßíïõí íá ó÷åôßæïíôáé ìå ôçí õøçëÞ âáèìïëïãßá ôçò õðïêëßìáêáò D, ôçò åíüôçôáò äçëáäÞ ôïõ GHQ ðïõ åßíáé åíäåéêôéêÞ êáôáèëéðôéêÞò äéáôáñá÷Þò. Ôï ãåãïíüò áõôü óõìöùíåß êáé ìå ôçí õðüëïéðç âéâëéïãñáößá êáé êáôáäåéêíýåé ôï óçìáíôéêü ñüëï ôïõ Ã/Ï ãéáôñïý óôç äéáêïðÞ ôïõ ãéá ôçí áðïöõãÞ ôùí âëáâåñþí óõíåðåéþí ôïõ.42,43 ÅðéðñïóèÝôùò, óçìáíôéêü åßíáé üôé ðåñßðïõ ï Ýíáò óôïõò ôñåéò öïéôçôÝò áðü üëá ôá åêðáéäåõôéêÜ éäñýìáôá Ý÷åé ðáèïëïãéêü áðïôÝëåóìá óôï GHQ-28. Åßíáé ãíùóôü üôé óå ìåëÝôåò üðùò ç ðáñïýóá, åíÝ÷åôáé ï êßíäõíïò ôïõ óöÜëìáôïò ôçò õðåñåêôßìçóçò, ãéá ôïí ðåñéïñéóìü üìùò ôïõ ïðïßïõ ÷ñçóéìïðïéÞèçêå ç ìÝèïäïò âáèìïëüãçóçò Lickert. Áõôü óçìáßíåé ßóùò ôçí áíÜãêç óõóôçìáôéêüôåñçò êáé åìðåñéóôáôùìÝíçò Ýñåõíáò áðü ôï Ã/Ï ãéáôñü ôùí ðéèáíþí áéôßùí ôïõ õøçëïý ðáèïëïãéêïý ðïóïóôïý óôï GHQ-28, êáé ôçí êáôáðïëÝìçóÞ ôïõò. Ç ðáëéíäñïìéêÞ áíÜëõóç äåß÷íåé ôçí åðßäñáóç óôï óõíïëéêü áðïôÝëåóìá ôïõ GHQ ðáñáãüíôùí, üðùò áõôü ôïõ åðáããÝëìáôïò ôïõ ðáôÝñá (ðïõ õðÜãåôáé óôïõò êïéíùíéêïïéêïíïìéêïýò), ôùí óõ÷íþí éáôñéêþí åðéóêÝøåùí (õøçëÞ ÷ñÞóç õðçñåóéþí õãåßáò), ôùí áíôéåëêùôéêþí (êáôÜ÷ñçóç öáñìÜêùí êáé ßóùò óùìáôïðïßçóç), ôçò ìåãáëý14

×. ËõãéäÜêçò êáé óõí.

ôåñçò êáôáíÜëùóçò áëêïüë (ç êáôÜ÷ñçóç óõíÞèùò óõíäÝåôáé ìå ôçí êáôÜèëéøç), êáé ôçò ÷áìçëÞò VAS (÷áìçëÞ åêôßìçóç ôçò õãåßáò). Ðáñ´ üëï ðïõ ôá áðïôåëÝóìáôá áõôÜ áðïôåëïýí õðïèÝóåéò Þ åíäåßîåéò, ðïõ óáöþò ÷ñåéÜæïíôáé ìåãáëýôåñç êáé óõóôçìáôéêüôåñç äéåñåýíçóç, ç ðëåéïíüôçôá ôùí ðáñáãüíôùí åßíáé áíáóôñÝøéìïé êáé áðïôåëïýí áíôéêåßìåíá åíáó÷üëçóçò ôïõ Ã/Ï ãéáôñïý. ÅðïìÝíùò ï Ã/Ï ãéáôñüò áðü äéÜöïñá åðßðåäá ìðïñåß íá ðáñÝìâåé, áó÷ïëïýìåíïò ìå ôçí õãåßá ôùí öïéôçôþí, äßäïíôáò ïñèÞ åñìçíåßá óå óõìðôþìáôá ðéèáíÞò óùìáôïðïßçóçò Þ Üëëùí øõ÷ïóùìáôéêþí êáôáóôÜóåùí, þóôå ìå ôçí Ýãêáéñç áíß÷íåõóç êáé èåñáðåßá ôïõò, íá óõìâÜëåé óôçí áðïöõãÞ ôçò ìåßùóçò ôçò ðïéüôçôáò æùÞò, ôçò Üóêïðçò ÷ñÞóçò êáé ôùí õøçëþí êïóôþí ôùí õðçñåóéþí õãåßáò.

Âéâëéïãñáößá 1. ICD-10. Classification of mental and behavioral disorders: clinical description and diagnostic guidelines, World Health Organization 1992 (áðüäïóç óôá åëëçíéêÜ êáé åðéìÝëåéá: Ê. ÓôåöáíÞò, Ê. ÓïëäÜôïò, Â. ÌáõñÝáò) åêä. ÂÇÔÁ medical arts, ÁèÞíá, 1993; óåëßäá 246-247. 2. Morriss RK, Ahmed M, Wearden AJ, Mullis R, Strickland P, Appleby L, Campbell IT, Pearson D. The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome. J Affect Disord, 55:143-148, 1999. 3. Smith MS, Martin-Herz SP, Womack WM, Marsigan JL. Comparative study of anxiety, depression, somatization, functional disability, and illness attribution in adolescents with chronic fatigue or migraine. Pediatrics, 111:376-381, 2003. 4. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med, 65:528-533, 2003. 5. Mialet JP. From back pain to life-discontent. A holistic view of psychopathological contributions to pain Ann Med Interne (Paris), 154:219226, 2003. 6. Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management. Int J Methods Psychiatr Res, 12:34-43, 2003. Roy-Byrne PP. Generalized anxiety and mixed anxiety-depression: association with disability and health care utilization. J Clin Psychiatry,

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57(Suppl 7):86-91, 1996. 7. Nystrom M, Perasalo J, Salaspuro M. Mixed use of psychiatric drugs and alcohol by Finnish university students participating in a health screening: Scand J Prim Health Care, 12:276280, 1994. 8. Nystrom M. Positive and negative consequences of alcohol drinking among young university students in Finland. Br J Addict, 87:715-722, 1992. 9. Webb E, Ashton CH, Kelly P, Kamali F. Alcohol and drug use in UK university students. Lancet, 348:922-925, 1996. 10. Lanier CA, Nicholson T, Duncan. Drug use and mental well being among a sample of undergraduate and graduate college students. J Drug Educ, 31:239-248, 2001. 11. Garyfallos G, Karastergiou A, Adamopoulou A, Moutzoukis E, Alagiozidou E, Mala D, Garyfallos A. Greek version of the General Health Questionnaire: accuracy of translation and validity. Acta Psychiatr Scand, 84:371-378, 1991. 12. Hobi V, Gerhard U, Gutzwiller F. A report on experiences using Goldberg’s GHQ. Schweiz Rundsch Med Prax, 78:219-225, 1989. 13. Pariente P, Smith M. Detection of the anxiodepressive disorders in liaison psychiatry. Contribution of the General Health Questionnaire. Encephale, 16:459-464, 1990. 14. Goldberg D. Manual of the General Health Questionnaire. Windsor, Berk: NFER-Nelson, 1978. 15. Tennant C. The General Health Questionnaire: A valid index of psychological impairment in Australian populations. Medical Journal of Australia, 2:392-394, 1977. 16. Jun SH, Yoshio M, Toshihide T. Stability of Factor Structure and Correlation with Perceived Job Stress in General Health Questionnaire: a three-wave Survei over One Year in Japanese workers J Occup Health, 42:284-291, 2000. 17. Benjamin S, Morris S, McBeth J, Macfarlane GJ, Silman AJ. The association between chronic widespread pain and mental disorder: a population-based study. Arthritis Rheum, 43:561567, 2000. 18. Bandiera G, Regehr G. Reliability of a structured interview scoring instrument for a Canadian postgraduate emergency medicine training program Division of Emergency Medicine. Acad Emerg Med, 11:27-32, 2004. 19. Bandiera G, Regehr G. Evaluation of a structured application assessment instrument for assessing applications to Canadian postgraduate training programs in emergency medicine. Acad

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Emerg Med, 10:594-598, 2003. 20. Fones CS, Kua EH, Ng TP, Ko SM. Studying the mental health of a nation: a preliminary report on a population survey in Singapore. Singapore Med J, 39:251-255, 1998. 21. Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community. JAMA, 267:1478-1483, 1992. 22. Evans JM, McMahon AD, Steinke DT, McAlpine RR, Macdonald TM. Do H2-receptor antagonists cause acute pancreatitis? Pharmacoepidemiol Drug Saf, 7:383-388, 1998. 23. Carmona-Sanchez R, Suazo-Barahona J, Gonzalez A, Carmona-Sanchez L, Uscanga-Dominguez L. Use and abuse histamine H2 receptor blockers in hospitalized patients. Rev Gastroenterol Mex, 62:84-88, 1998. 24. Gullotta R, Ferraris L, Cortelezzi C, Minoli G, Prada A, Comin U, Rocca F, Ferrara A, Curzio M. Are we correctly using the inhibitors of gastric acid secretion and cytoprotective drugs? Results of a multicentre study. Ital J Gastroenterol Hepatol, 29:325-329, 1997. 25. Rodriguez JL, Jacobs DM, Zera RT, Van Camp JM, Muehlstedt SG, West MA, Bubrick MP. Academic practice groups: strategy for survival. Surgery, 128:505-512, 2000. 26. Ares JJ, Outt PE. Gastroprotective agents for the prevention of NSAID-induced gastropathy. Curr Pharm Des, 4:17-36, 1998. 27. Laure P, Lecerf T, Friser A, Binsinger C. Drugs, recreational drug use and attitudes towards doping of high school athletes. Int J Sports Med, 25:133-138, 2004. 28. dos Santos KM, Barros Filho Ade A. Beliefs on vitamin and consumption of vitamin supplements among university students in the city of Sao Paulo. Arch Latinoam Nutr, 52:241-248, 2002. 29. Krumbach CJ, Ellis DR, Driskell JA. A report of vitamin and mineral supplement use among university athletes in a division I institution. Int J Sport Nutr, 9:416-425, 1999. 30. Wilkinson JM, Simpson MD. Complementary therapy use by nursing, pharmacy and biomedical science students. au Nurs Health Sci, 3:1927, 2001. 31. Johnson RE, Hornbrook MC, Hooker RS, Woodson GT, Shneidman R. Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation. Pharmacoeconomics, 12:76-88, 1997. 32. Bond C, Hannaford P. Issues related to monitoring the safety of over-the-counter (OTC) 15

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

medicines. Drug Saf, 26:1065-1074, 2003. 33. Rosenthal MB, Berndt ER, Donohue JM, Frank RG, Epstein AM. Promotion of prescription drugs to consumers. N Engl J Med, 346:498505, 2002. 34. Laupacis A, Anderson G, O’Brien B. Drug policy: making effective drugs available without bankrupting the healthcare system. Healthc Pap, 3:12-30, 2002. 35. Carpio B, Brown B. The admissions process of a bachelor of science in nursing program: initial reliability and validity of the personal interview. Can J Nurs Res, 25:41-52, 1993. 36. Rohde P, Kahler CW, Lewinsohn PM, Brown RA. Psychiatric disorders, familial factors, and cigarette smoking: II. Associations with progression to daily smoking. Nicotine Tob Res, 6:119-132, 2004. 37. Armstrong TD, Costello EJ. Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol, 70:1224-1239, 2002. 38. Upadhyaya HP, Deas D, Brady KT, Kruesi M. Cigarette smoking and psychiatric comorbidity

×. ËõãéäÜêçò êáé óõí.

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in children and adolescents. J Am Acad Child Adolesc Psychiatry, 41:1294-1305, 2002. Glassman AH. Cigarette smoking: implications for psychiatric illness. Am J Psychiatry, 150:546553, 1993. Novak A, Burgess ES, Clark M, Zvolensky MJ, Brown RA. Anxiety sensitivity, self-reported motives for alcohol and nicotine use, and level of consumption. J Anxiety Disord, 17:165-180, 2003. Upadhyaya HP, Brady KT, Wharton M, Liao J. Psychiatric disorders and cigarette smoking among child and adolescent psychiatry inpatients. Am J Addict, 12:144-152, 2003. Brown RA, Lewinsohn PM, Seeley JR, Wagner EF. Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J Am Acad Child Adolesc Psychiatry, 35:16021610, 1996. Tan YM, Goh KL, Muhidayah R, Ooi CL, Salem O. Prevalence of irritable bowel syndrome in young adult Malaysians: a survey among medical students. J Gastroenterol Hepatol, 18: 1412-1416, 2003.

Ôüìïò 17, Ôåý÷ïò 1, 2005

É. Táñáíôßëçò

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 17, Number 1, 17-23, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 17-23, 2005

ÅðéäçìéïëïãéêÞ ìåëÝôç åðéðïëáóìïý ôåñçäüíáò óå 12÷ñïíïõò ìáèçôÝò çìéáóôéêþí ãõìíáóßùí óôï Íïìü Áñãïëßäáò I. Ôáñáíôßëçò1

Ðåñßëçøç Óêïðüò ôçò åñãáóßáò Þôáí: 1) ç åêôßìçóç ôïõ åðéðïëáóìïý ôçò ôåñçäüíáò óôïõò 12÷ñïíïõò ìáèçôÝò ôçò Á´ ôÜîçò ôùí çìéáóôéêþí Ãõìíáóßùí ôùí åðáñ÷éþí ¢ñãïõò êáé Íáõðëßïõ, 2) ç óýãêñéóç ôçò óôïìáôéêÞò êáôÜóôáóçò ìáèçôþí ìå Üìåóç ðñüóâáóç óå ïäïíôéáôñåßï ÊÝíôñïõ Õãåßáò, ìå áõôïýò ðïõ äåí Ý÷ïõí êáé 3) ç ðñïóðÜèåéá äéåñåýíçóçò ôçò óõììåôï÷Þò ôïõ ïäïíôéáôñåßïõ ôïõ K.Y. óôç óôïìáôéêÞ êáôÜóôáóç ôùí ìáèçôþí ôçò ðåñéï÷Þò åõèýíçò ôïõ êáé ôïõ åðáíáêáèïñéóìïý ôùí óôü÷ùí ôïõ üðïõ ÷ñåéáóôåß. Õëéêü êáé ìåèïäïëïãßá: ÅîåôÜóôçêáí 183 ìáèçôÝò áðü ôá 4 (äçìüóéá) ÃõìíÜóéá çìéáóôéêþí ðåñéï÷þí ôùí åðáñ÷éþí ¢ñãïõò êáé Íáõðëßïõ óôá ðëáßóéá ãåíéêüôåñïõ ðñïãñÜììáôïò ðñïëçðôéêÞò ÏäïíôéáôñéêÞò, óôç äéÜñêåéá ôïõ ó÷ïëéêïý Ýôïõò 2001-2002. Ç åîÝôáóç Ýãéíå áðü Ýíáí ïäïíôßáôñï ÷ñçóéìïðïéþíôáò ôï öõóéêü öùôéóìü, êÜôïðôñï êáé áìâëý áíé÷íåõôÞñá. Ç ìåèïäïëïãßá ôçò äéÜãíùóçò êáé áíáöïñÜò ôçò ôåñçäïíéêÞò åìðåéñßáò áêïëïýèçóå ôéò ïäçãßåò ôçò Ðáãêüóìéáò ÏñãÜíùóçò Õãåßáò (WHO)1. Ç êáôáãñáöÞ ôùí åõñçìÜôùí Ýãéíå óå áôïìéêÝò êáñôÝëåò êáé ïé ãïíåßò ôùí ìáèçôþí åéäïðïéÞèçêáí, ìå ëåðôïìåñåßò áôïìéêÝò åéäïðïéÞóåéò, ãéá ôá ðñïâëÞìáôá ôùí ðáéäéþí. Ôá óõìðåñÜóìáôá ìðïñïýí íá óõíïøéóôïýí óôá åîÞò: á) Ç ýðáñîç ôïõ ÊÝíôñïõ Õãåßáò óå ìéá ðåñéï÷Þ óõìâÜëëåé ìå ðïëëïýò ôñüðïõò (áãùãÞ õãåßáò, ðñïëçðôéêÜ ðñïãñÜììáôá, ðåñßèáëøç ÷ùñßò äéáêñßóåéò), óôç âåëôßùóç ôçò óôïìáôéêÞò õãåßáò óôçí ðåñéï÷Þ åõèýíçò ôïõ. â) Ç åðéäçìéïëïãéêÞ äéåñåýíçóç ôçò óôïìáôéêÞò êáôÜóôáóçò ôïõ ðëçèõóìïý êáé ôçò êáôáíïìÞò ôùí íïóçìÜôùí óôéò äéÜöïñåò çëéêßåò, åßíáé üñïò ãéá ôçí áîéïëüãçóç ôùí ðáñåìâÜóåþí êáé ôçí åîåéäßêåõóç êáé ôïí åðáíáêáèïñéóìü ôùí óôü÷ùí êÜèå ó÷ïëéêÞ ÷ñïíéÜ. ã) Ç ðñïëçðôéêÞ ðáñÝìâáóç ôïõ K.Y. ðñÝðåé íá åóôéÜóåé óôá ðáéäéÜ ôùí íçðéáãùãåßùí êáé ôçò Á´ ôÜîçò ôùí Äçìïôéêþí ó÷ïëåßùí óôçí ðåñéï÷Þ åõèýíçò ôïõ. ä) Ôá ÊÝíôñá Õãåßáò Ý÷ïõí ôçí åõèýíç ôùí ðáñåìâÜóåùí óå ðëçèõóìéáêü åðßðåäï áöïý ç ðïëéôåßá áäõíáôåß íá ó÷åäéÜóåé êáé åöáñìüóåé ïëïêëçñùìÝíá ðñïëçðôéêÜ ðñïãñÜììáôá.

Ïäïíôßáôñïò–ÌÄÅ óôç Äçìüóéá Õãåßá, ÅðéìåëçôÞò Á´, ÅÓÕ, ÊÝíôñï Õãåßáò Ëõãïõñéïý

ÅéóáãùãÞ Ç ôåñçäüíá åßíáé ç ðéï óõ÷íÞ áíèñþðéíç íüóïò. ÐñïóâÜëëåé ôïõò åíáóâåóôéùìÝíïõò éóôïýò ôùí äïíôéþí. Ç Ýíáñîç êáé ç åîÝëéîÞ ôçò åîáñôÜôáé áðü ôçí ðáñïõóßá ïäïíôéêÞò ìéêñïâéáêÞò ðëÜêáò, æÜ÷áñçò (êáé Üëëùí ïëéãïóáê÷áñéôþí) êáé ôÝëïò ïîåïðáñáãùãþí óôñåðôüêïêêùí (mutans êõñßùò) êáé ãáëáêôïâáêßëëùí. Èåùñåßôáé íüóïò ôïõ ðïëéôéóìïý ãéáôß ç óõ÷íüôçôÜ ôçò ìåãáëþíåé óýììåôñá ìå ôçí õëéêÞ ðñüïäï ðïõ åðéöÝñåé ç êïéíùíéêïïéêïíïìéêÞ åîÝëéîç. Åßíáé ÷ñüíéá áóèÝíåéá, ìå äõíáìéêÞ äéáäéêáóßá ðïõ êáèïñßæåôáé áðü ôçí áíèñþðéíç óõìðåñéöïñÜ. Ïé äáðÜíåò ðïõ ðñïêáëåß êáôÝ÷ïõí ôç äåýôåñç èÝóç, ìåôÜ áðü åêåßíåò ðïõ äéáôßèåíôáé ãéá ôç èåñáðåßá ôùí øõ÷éêþí íïóçìÜôùí.1 Óôç äéÜñêåéá ôùí äýï ôåëåõôáßùí äåêáåôéþí óå ðáéäéÜ (êáé åíÞëéêåò) óå ðïëëÝò ÷þñåò ôïõ áíáðôõãìÝíïõ êüóìïõ, óõìðåñéëáìâáíüìåíçò ôçò ÅëëÜäáò,2 ïé

ËÝîåéò êëåéäéÜ: Åðéðïëáóìüò ôåñçäüíáò, áíÜãêåò ðåñßèáëøçò, äåßêôçò SiC ÕðïâëÞèçêå: 25 Íïåìâñßïõ 2003 ÅðáíõðïâëÞèçêå: 8 Éïõíßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 27 Éïõíßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: Ôáñáíôßëçò É., ÅèíéêÞò Áíôßóôáóçò 11, 21200, ¢ñãïò, Ôçë.: (27510)20011 17

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. Táñáíôßëçò

Epidemiological study of caries prevalence in twelve year-old pupils of semi urban secondary schools in the prefecture of Argolis J. Tarandilis Summary The aim of this study has been the assessment of caries prevalence in twelve year-old pupils of the first classes in High schools of semi urban regions in the counties of Argos and Nafplion, as well as the comparison among those children who have access to a Health Center and those who have not. The study has included the assesment of the overall dental care provided by the Health Center and the redesigning of targets wherever needed. Within the framework of the general programme of Preventive Dentistry we proceeded as follows: One hundred and eighty three (183) pupils all from the 4 High Schools of the above mentioned regions were examined. The examination was conducted by the dentist who is submitting this study, who used the means of natural light or a light source, plain mouth mirrors and pointless explorers. The methodology, diagnosis and report on the findings was in accordance with the WHO criteria. The results of the examinations were recorded in individual files and the children’s parents were given detailed information on their children’s dental condition. The conclusions are summarized as follows: 1) Undoubtedly the role of a Health Center in the area is decisive in the improvement of dental Health within its grounds of responsibility. 2) The epidemiological probing into the dental condition of the population and the allocation of disorders to the corresponding age of the patient, is a prerequisite for a fair assesment of our yearly interventions. 3) The preventive intervention of the Health Center should focus on children of preschool age and the pupils of the first elementary classes. 4) The Health Centers have full responsibility for the provision of dental Health care to the population of their regions, since the State has not compiled and implemented complete preventive health programmes. Key words: Dental caries prevalence, Restorative treatment needs, Caries Index (SiC Index).

äåßêôåò ôïõ åðéðïëáóìïý ôçò ôåñçäüíáò ìåéþèçêáí èåáìáôéêÜ. Áéôßåò åßíáé: á) óå áôïìéêü åðßðåäï: ç áõîáíüìåíç óõíå÷þò ÷ñÞóç ôùí öèïñéïý÷ùí (ïäïíôüêñåìåò, óôïìáôïðëýìáôá, ôáìðëÝôåò öèïñßïõ), ç áëëáãÞ ôùí äéáéôçôéêþí óõíçèåéþí, ç ìåßùóç ôçò êáôáíÜëùóçò æÜ÷áñçò, ïé ðñüïäïé óôç óôïìáôéêÞ õãéåéíÞ êáé ðéèáíþò ôá áíôéâéïôéêÜ ðïõ ëáìâÜíïíôáé ãéá äéÜöïñåò Üëëåò áéôßåò.3 â) óå åðéóôçìïíéêü åðßðåäï: ç ðñüïäïò óôçí êáôáíüçóç ôçò äéáäéêáóßáò åîÝëéîçò ôçò ôåñçäüíáò êáé ç ïëïÝíá áõîáíüìåíç ðáñï÷Þ ðñïëçðôéêþí ïäïíôéáôñéêþí õðçñåóéþí (ôïðéêÞ åöáñìïãÞ öèïñéïý÷ùí, ðñïëçðôéêÝò åìöñÜîåéò). ã) óå êïéíùíéêü åðßðåäï: ôá ìáæéêÜ åêðáéäåõôéêÜ ðñïãñÜììáôá óôïìáôéêÞò õãåßáò (üðïõ ãßíïíôáé) êáé ç Üíïäïò ôïõ ìïñöùôéêïý åðéðÝäïõ. Óôç ÷þñá ìáò ôï êýñéï âÜñïò ôçò ðáñï÷Þò ÐñùôïâÜèìéáò ÏäïíôéáôñéêÞò Öñïíôßäáò Ý÷ïõí ôá ÊÝíôñá Õãåßáò. 18

Óêïðüò ôçò åñãáóßáò Þôáí: 1) ç åêôßìçóç ôïõ åðéðïëáóìïý ôçò ôåñçäüíáò óôïõò 12÷ñïíïõò ìáèçôÝò ôçò Á´ ôÜîçò ôùí çìéáóôéêþí Ãõìíáóßùí ôùí åðáñ÷éþí ¢ñãïõò êáé Íáõðëßïõ, 2) ç óýãêñéóç ôçò óôïìáôéêÞò êáôÜóôáóçò ìáèçôþí ìå Üìåóç ðñüóâáóç óå ïäïíôéáôñåßï ÊÝíôñïõ Õãåßáò, ìå áõôïýò ðïõ äåí Ý÷ïõí êáé 3) ç ðñïóðÜèåéá äéåñåýíçóçò ôçò óõììåôï÷Þò ôïõ ïäïíôéáôñåßïõ ôïõ K.Y. óôç óôïìáôéêÞ êáôÜóôáóç ôùí ìáèçôþí ôçò ðåñéï÷Þò åõèýíçò ôïõ êáé ôïõ åðáíáêáèïñéóìïý ôùí óôü÷ùí ôïõ üðïõ ÷ñåéáóôåß.

Ðëõèõóìüò ìåëÝôçò - ÌÝèïäïò

Ç åñãáóßá óôçñß÷ôçêå óôá óôïé÷åßá ðïõ óõëëÝîáìå êáôÜ ôçí ïäïíôïóôïìáôïëïãéêÞ åîÝôáóç ôùí 12÷ñïíùí ìáèçôþí ôçò Á´ Ãõìíáóßïõ ôùí 4 íÝùí Êáðïäéóôñéáêþí äÞìùí óôéò çìéáóôéêÝò ðåñéï÷Ýò ¢ñãïõò êáé Íáõðëßïõ. Significant ¼ëïé Ý÷ïõí ðáñüìïéï êïéíùíéêïïéêïíïìéêü åðßðåäï, ëåéôïõñãïýí óå êÜèå Ýíáí ðÜíù áðü Ýíá éäéùôéêÜ ïäïíôéáôñåßá, Ý÷ïõí ôçí ßäéá åýêïëç ðñüóâáóç óôá áóôéêÜ êÝíôñá ôïõ ¢ñãïõò êáé ôïõ Íáõðëßïõ. Ç äéáöïñÜ ôïõò åßíáé üôé ìüíï óôï äÞìï Áóêëçðéåßïõ ëåéôïõñãåß ôï ÊÝíôñï Õãåßáò Ëõãïõñéïý. Ç åîÝôáóç ôùí ìáèçôþí Ýãéíå áðü Ýíáí ïäïíôßáôñï, óôïõò ÷þñïõò ôùí ó÷ïëåßùí, óôéò ðñùéíÝò þñåò ëåéôïõñãßáò ôïõò ÷ñçóéìïðïéþíôáò ôï öõóéêü öùôéóìü, áìâëý áíé÷íåõôÞñá êáé êÜôïðôñï. Ïé ìáèçôÝò åéäïðïéÞèçêáí áðü ôïõò êáèçãçôÝò íá âïõñôóßóïõí ôá äüíôéá ôïõò ôï ðñùéíü ôçò åðßóêåøÞò ìáò. Ãéá ôçí êáôáãñáöÞ ôïõ åðéðïëáóìïý ôçò ôåñçäüíáò ÷ñçóéìïðïéÞèçêáí ïé äåßêôåò DMFT (Decayed, Missing, Filled Teeth) ãéá ôç ìüíéìç êáé dmft ãéá ôç íåïãéëÞ ïäïíôïöõÀá, óýìöùíá ìå ôéò ïäçãßåò ôïõ WHO.4 Ïé åðéìÝñïõò äåßêôåò DT êáé dt êáôáãñÜöïõí áñéèìçôéêÜ ôá ìüíéìá êáé íåïãéëÜ äüíôéá áíôßóôïé÷á ìå ôåñçäïíéêÝò ðñïóâïëÝò Ýùò ôï åðßðåäï ôçò ïäïíôßíçò Þ ìå ðñïóùñéíÜ óöñáãßóìáôá. Ïé äåßêôåò ÌT êáé mt áöïñïýí óôá åîáã÷èÝíôá åî´ áéôßáò ôçò ôåñçäüíáò ìüíéìá êáé íåïãéëÜ

Ôüìïò 17, Ôåý÷ïò 1, 2005

É. Táñáíôßëçò

äüíôéá (äåí óõìðåñéëáìâÜíïíôáé äçëáäÞ ôá äüíôéá ðïõ åîÞ÷èçêáí ãéá ïñèïäïíôéêïýò ëüãïõò, åêåßíá ðïõ åëëåßðïõí óõããåíþò Þ åîáéôßáò áôõ÷Þìáôïò êáé ôá íåïãéëÜ ìå öõóéïëïãéêÞ áðüðôùóç). Ïé äåßêôåò FT êáé ft ðñïóäéïñßæïõí ôá äüíôéá ìå Ýìöñáîç (÷ùñßò åíäåßîåéò åðáíáôåñçäïíéóìïý, ïðüôå ìåôñþíôáé óáí ôåñçäïíéóìÝíá) êáé óôåöÜíåò. Ïé äåßêôåò åßíáé ôá áñéèìçôéêÜ áèñïßóìáôá ôùí åðéìÝñïõò äåéêôþí. Ç êëßìáêá äéáâÜèìéóçò ôïõ DMFT ãéá ôïí ìüíéìï öñáãìü åßíáé áðü 032 (üóá ôá ìüíéìá äüíôéá) êáé ãéá ôïí dmft áðü 0-20.4 Ìå ôïõò äåßêôåò êáôáãñÜöåôáé ðëÞñùò ãéá êÜèå óôüìá ôï éóôïñéêü êáé ôá áðïôåëÝóìáôá ôçò íüóïõ. Óå ðëçèõóìéáêü åðßðåäï ïé ôéìÝò ôùí DMFT êáé dmft áðïôåëïýí ôïõò ìÝóïõò üñïõò ôïõ óõíüëïõ ôùí ôéìþí ôùí åðéìÝñïõò äåéêôþí DMFT êáé dmft åíüò åêÜóôïõ ôùí åîåôáóèÝíôùí áôüìùí. ¸íáò ðïëý óçìáíôéêüò äåßêôçò åßíáé ç åêáôïóôéáßá áíáëïãßá ôùí áôüìùí ÷ùñßò ôåñçäüíá. Åëåýèåñá ôåñçäüíáò åßíáé ôá óôüìáôá ôùí ðáéäéþí ìå DMFT=0 (üóùí Ý÷åé ïëïêëçñùèåß ç áëëáãÞ ôçò ïäïíôïöõÀáò) Þ DMFT=0 êáé dmft=0 (áí Ý÷ïõí áêüìá ìéêôü öñáãìü). Ùò äåßêôåò áíáãêþí ðåñßèáëøçò ôïõ Gluck ÷ñçóéìïðïéåßôáé ï D/D+F % (UTN) ãéá ôç ìüíéìç êáé ï d/d+f % (utn) ãéá ôç íåïãéëÞ ïäïíôïöõÀá, ãéá íá åêöñÜóïõí ôéò áíÜãêåò áðïêáôÜóôáóçò ôùí âëáâþí. O äåßêôçò SiC (Significant Caries Index) åßíáé ï ìÝóïò üñïò ôùí DMFT ôïõ åíüò ôñßôïõ ôùí ðáéäéþí ìå ôéò ìåãáëýôåñåò ôéìÝò (DMFT).5 ¸÷åé óêïðü íá åðéêåíôñþóåé ôçí ðñïóï÷Þ ìáò óôá ðáéäéÜ åêåßíùí ôùí ðåñéï÷þí ðïõ Ý÷ïõí ôéò ìåãáëýôåñåò áíÜãêåò ãéá ðåñßèáëøç.

H s Þ SD (standard deviation) åßíáé ç “óôáèåñÜ áðüêëéóç”, ìÝôñï ôçò äéáóðïñÜò ôùí ìåôñÞóåþí ìáò. Óôï äéÜóôçìá (x-s) Ýùò (x+s) ðåñß ôç ìÝóç ôéìÞ x ðåñéëáìâÜíåôáé ôï 68% ôùí ðáñáôçñÞóåùí êáé óôï äéÜóôçìá (x-2s) Ýùò (x+2s) ðåñéëáìâÜíåôáé ôï 95% ôùí ðáñáôçñÞóåùí.

ÁðïôåëÝóìáôá Áðü ôçí åðåîåñãáóßá ôùí óôïé÷åßùí ðñïÝêõøáí ïé ôéìÝò ôïõ ðßíáêá I ãéá ôïí ìüíéìï öñáãìü. Ôï DMFT êõìÜíèçêå áðü (÷±sd) 1,34±1,97 Ýùò 2±1,81, ï UÔÍ áðü 49–73%, ôá ðïóïóôÜ ìå DMFT=0 áðü 35,3–57,1% êáé ôá åëåýèåñá ôåñçäüíáò óôüìáôá áðü 29,4–54,3%. Óôï óýíïëï ôùí 12÷ñïíùí ìáèçôþí ôçò Á´ Ãõìíáóßïõ ôùí åðáñ÷éþí ¢ñãïõò êáé Íáõðëßïõ, ìå DMFT=0 âñÝèçêå ôï 48,5% êáé åëåýèåñï ôåñçäüíáò ôï 42%. ÄéáãñáììáôéêÜ ïé ìÝóïé üñïé ôùí DT êáé FT êáôÜ ó÷ïëåßï ðáñïõóéÜæïíôáé óôï ó÷Þìá I, ïé ìÝóïé üñïé ôùí DMFT óôï ó÷Þìá II êáé ïé UÔÍ öáßíïíôáé óôá ó÷Þìá III. Ôá óôïé÷åßá ðïõ áöïñïýí óôï íåïãéëü öñáãìü öáßíïíôáé óôï ðßíáêá II. Ôï dmft êõìÜíèçêå áðü 0,33 Ýùò 1,00 êáé ï utn áðü 67-90%. ÄéáãñáììáôéêÜ ïé ìÝóïé üñïé ôùí dmft ãéá ôç íåïãéëÞ ïäïíôïöõÀá êáôÜ ó÷ïëåßï öáßíïíôáé óôï ó÷Þìá IV. Åêôüò áðü ôïõò äåßêôåò åðéðïëáóìïý ôçò ôåñçäüíáò õðïëïãßóôçêáí åðßóçò ç êáôáíïìÞ óõ÷íïôÞôùí ôïõ DMFT êáé ï äåßêôçò SiC. Ôï DMFT ôïõ óõíüëïõ ôùí ìáèçôþí êáôáãñÜöçêå Ý÷ïíôáò åëÜ÷éóôç ôéìÞ 0 êáé ìÝãéóôç 14. ÔáîéíïìÞèçêå óå ôñåéò êáôçãïñßåò áíÜëïãá ìå ôç âáñýôçôÜ (Ýíôáóç) ôïõ: DMFT =0 (87

Ðßíáêáò I. ÌÝóåò ôéìÝò äåéêôþí DÔ, MÔ, FÔ, DMFT êáé ôõðéêÝò áðïêëßóåéò (SD) ôùí åîåôáæïìÝíùí ìáèçôþí êáôÜ ó÷ïëåßï. Äåßêôçò áíáãêþí ðåñßèáëøçò D/D+F % (UTN). ÌáèçôÝò ìå DMFT=0 êáé åëåýèåñïé ôåñçäüíáò. Äåßêôçò SiC. Á/Á

Ó÷ïëåßï

Áñéèìüò Ìáèçôþí

Áóêëçðéåßïõ (SD)

ÍÝáò Êßïõ (SD)

Áã. ÔñéÜäáò (SD)

Êïõôóïðïäßïõ (SD)

DÔ

MÔ

FÔ

0,67 0,02 0,69 (1,04) (0,15) (1,82) 1,04 0,04 0,67 (1,57) (0,20) (1,29) 1,35 0,18 0,47 (1,64) (0,51) (1,04) 0,71 0,06 0,57 (1,20) (0,33) (1,36)

DMFT

D/D+F %

DMFT=0

DMFT+ dmft=0

SiC

1,39 (2,04) 1,76 (2,13) 2,00 (1,81) 1,34 (1,97)

48,2%

41,2%

3,5

43,5%

39,1%

4,4

35,3%

29,4%

4,2

57,1%

54,3%

3,7

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. Táñáíôßëçò

èçêáí óôá ðáéäéÜ áõôÞò ôçò çëéêßáò óôï óýíïëï ôùí ó÷ïëåßùí ôùí åðáñ÷éþí ¢ñãïõò êáé Íáõðëßïõ. Ãéá ôïõò ðëçèõóìïýò ðïõ åîåôÜæïõìå ï SiC åß÷å ôéìÝò: Áóêëçðéåßï 3,5, ÍÝá Êßïò 4,4, Áã. ÔñéÜäá 4,2, Êïõôóïðüäé 3,7 (Ðßíáêáò I).

ÓõæÞôçóç Ó÷Þìá É. Ïé ìÝóïé üñïé ôùí DT êáé FT êáôÜ ó÷ïëåßï.

Ó÷Þìá ÉV. Ç ìÝóç ôéìÞ ôïõ dmft êáôÜ ó÷ïëåßï. Ó÷Þìá ÉÉ. Ç ìÝóç ôéìÞ ôïõ DMFT êáôÜ ó÷ïëåßï.

Ó÷Þìá ÉÉÉ. Ïé äåßêôåò áíáãêþí ðåñßèáëøçò ôùí ìïíßìùí (UÔÍ=D/ D+F %) êáôÜ ó÷ïëåßï.

ðáéäéÜ), DMFT =1-3 (64 ðáéäéÜ) êáé DMFT ³4 (32 ðáéäéÜ). Ç åêáôïóôéáßá áíáëïãßá ôùí ðáéäéþí ðïõ áíÞêïõí óå êÜèå äåßêôç åßíáé 47,5%, 35% êáé 17,5% áíôßóôïé÷á. To ðïóïóôü ôùí ðáéäéþí óå êÜèå êáôçãïñßá åßíáé óå áêïëïõèßá ìå ôá áíôßóôïé÷á ðïóïóôÜ (48,5-33,9-17,6) ðïõ âñÝ-

Ôï 1981 ç ÃåíéêÞ ÓõíÝëåõóç ôïõ WHO äéáêÞñõîå óáí ðáãêüóìéï óôü÷ï ãéá ôç óôïìáôéêÞ Õãåßá : ùò ôï Ýôïò 2000 ï ìÝóïò üñïò ôïõ DMFT ôùí 12÷ñïíùí Ýðñåðå íá ðÝóåé ðáãêüóìéá óôï 3 Þ ëéãüôåñï (2ïò óôü÷ïò). Ôá ó÷ïëåßá ðïõ åîåôÜæïõìå Ý÷ïõí ôéìÝò áðü 1,34 Ýùò 2 êáé óå óõíäõáóìü ìå ôéò åêáôïóôéáßåò áíáëïãßåò ôùí ìáèçôþí ðïõ åßíáé åëåýèåñïé ôåñçäüíáò (29,4% Ýùò 54,3%) áíÞêïõí óôç ÷áìçëÞ êëßìáêá åðéðïëáóìïý êáôÜ ôïí WHO1 (ðïõ ïñßæåôáé ùò: DMFT 1,2 Ýùò 2,6 êáé åëåýèåñá ôåñçäüíáò ðÜíù áðü 20%). Ç óýãêñéóç ìåôáîý ôïõò èåùñÞèçêå áíáãêáßá ãéá íá åëåã÷èåß áí õðÜñ÷ïõí óçìáíôéêÝò äéáöïñÝò ôùí ìÝóùí üñùí ôùí äåéêôþí ðïõ áöïñïýí óôç óôïìáôéêÞ êáôÜóôáóç ìáèçôþí çìéáóôéêïý Ãõìíáóßïõ ðåñéï÷Þò üðïõ ëåéôïõñãåß ÊÝíôñï Õãåßáò êáé ôùí õðïëïßðùí çìéáóôéêþí Ãõìíáóßùí êáé íá åêôéìçèåß ç óõíåéóöïñÜ ôïõ Ê.Õ. ó’ áõôü. ÐïëëÝò åñãáóßåò èÝëïõí ôçí ýðáñîç êáé ëåé-

Ðßíáêáò II. ÌÝóåò ôéìÝò äåéêôþí dt, mt, ft, dmft êáé ôõðéêÝò áðïêëßóåéò (SD) ôùí åîåôáæïìÝíùí ìáèçôþí êáôÜ ó÷ïëåßï. Äåßêôçò áíáãêþí ðåñßèáëøçò d/d+f % (utn) Á/Á

Ó÷ïëåßï

Áñéèìüò Ìáèçôþí

dmft

d/d+f %

Áóêëçðéåßïõ (SD)

ÍÝáò Êßïõ (SD)

Áãßáò ÔñéÜäáò (SD)

Êïõôóïðïäßïõ (SD)

0,04 (0,19) 0,00 (0,00) 0,00 (0,00) 0,00 (0,00)

0,07 (0,37) 0,08 (0,28) 0,33 (0,47) 0,10 (0,30)

0,89 (1,08) 0,33 (0,47) 1,00 (0,00) 0,60 (1,28)

0,79 (1,01) 0,25 (0,43) 0,67 (0,47) 0,50 (1,02)

68 67 80

É. Táñáíôßëçò

ôïõñãßá Ê.Õ. óå ìéá ðåñéï÷Þ êáôáëõôéêü ðáñÜãïíôá ãéá ôç óôïìáôéêÞ õãåßá ôïõ ìáèçôéêïý ðëçèõóìïý.6-8 Áðü ôïí ðßíáêá I öáßíåôáé üôé ôï ÃõìíÜóéï ôïõ Áóêëçðéåßïõ Ý÷åé DMFT (1,39) ìåãáëýôåñï ìüíï áðü áõôüí ôïõ Êïõôóïðïäßïõ (1,34). Êé áõôü óõìâáßíåé ìå ëéãüôåñá ôåñçäïíéóìÝíá äüíôéá óôá ðáéäéÜ ôïõ Áóêëçðéåßïõ (DÔ=0,67 Ýíáíôé 0,71 ôïõ Êïõôóïðïäßïõ), ëéãüôåñá åëëåßðïíôá (0,02 Ýíáíôé 0,06) êáé ðåñéóóüôåñá óöñáãéóìÝíá (0,69 êáé 0,57 áíôßóôïé÷á). Óôïí ðßíáêá II ç Í. Êßïò åìöáíßæåôáé ìå ôï ìéêñüôåñï dmft, åýñçìá ôõ÷áßï ðïõ óõíäÝåôáé ìå ôçí ðñùéìüôåñç áðüðôùóç ôùí íåïãéëþí, ðáñÜ ìå ïðïéïäÞðïôå Üëëï ðñïëçðôéêü Þ èåñáðåõôéêü ìÝôñï. Ó’ áõôü óõíçãïñåß êáé ôï áíáíôßóôïé÷á ìåãÜëï DMFT ôïõ ó÷ïëåßïõ, ðïõ ïöåßëåôáé óôç ìåãÜëç ôéìÞ ôïõ DT (Ðßíáêáò I). ÉóïññïðçìÝíç åßíáé ç ó÷Ýóç ôùí ôåñçäïíéóìÝíùí ðñïò ôá óöñáãéóìÝíá äüíôéá (0,67/ 0,69=0,97) ãéá ôï ÃõìíÜóéï Áóêëçðéåßïõ, ðáñüëï ðïõ äåß÷íåé üôé ãéá êÜèå Ýíá äüíôé ìå Ýìöñáîç ìáò äéáöåýãåé áêüìá Ýíá, ðïõ ïöåßëïõìå íá âñïýìå êáé íá áðïêáôáóôÞóïõìå ôçí áêåñáéüôçôÜ ôïõ. Óôá õðüëïéðá ÃõìíÜóéá ï ëüãïò DT/FT åßíáé 1,2 ãéá ôï Êïõôóïðüäé, óôç Í. Êßï 1,5 êáé óôçí Áã. ÔñéÜäá 2,9. ¢îéïò ðáñáôÞñçóçò áêüìá ãéá ôï ÃõìíÜóéï Áóêëçðéåßïõ åßíáé ï äåßêôçò áíáãêþí ðåñßèáëøçò (UTN) ãéá ôá ìüíéìá äüíôéá (Ðßíáêáò I) ï ïðïßïò åßíáé ìéêñüôåñïò üëùí (49%) êáé ï áíáêüëïõèá ìåãÜëïò utn (90%) ãéá ôá íåïãéëÜ (Ðßíáêáò II). ÐñÝðåé íá Ý÷ïõìå êáôÜ íïõ üôé äåßêôçò áíáãêþí ðåñßèáëøçò 50% óçìáßíåé üôé ãéá êÜèå äüíôé ìå Ýìöñáîç áíôéóôïé÷åß Ýíá äüíôé ôåñçäïíéóìÝíï ÷ùñßò èåñáðåßá êáé äåßêôçò 75% áíåâÜæåé ôçí áíôéóôïé÷ßá óå Ýíá ðñïò ôñßá áèåñÜðåõôá. Ï UTN ôïõ ÃõìíÜóéïõ Áóêëçðéåßïõ äåß÷íåé ôçí êáôáâïëÞ öéëüôéìçò ðñïóðÜèåéáò ãéá ôïí Ýëåã÷ï ôçò ôåñçäüíáò ôùí ìïíßìùí. Ï utn áíôßèåôá äåß÷íåé á) ôçí áðïôõ÷ßá ìáò ó’ áõôüí ôïí ôïìÝá äïõëåéÜò êáé ôéò åõèýíåò ìáò ãéá ìç Ýãêáéñåò ðáñåìâÜóåéò, â) ôçí Ýëëåéøç êáôáíüçóçò ôçò áíáãêáéüôçôáò ôçò ýðáñîçò êáé ôçò õãåßáò ôïõ íåïãéëïý öñáãìïý, ìÝ÷ñé ôç öõóéïëïãéêÞ áëëáãÞ ôïõ, áðü ãïíåßò êáé ìáèçôÝò, ã) ôçí ðñïôåñáéüôçôá ðïõ ðñÝðåé íá äïèåß óôçí ÁãùãÞ Õãåßáò. Ïé äÜóêáëïé óôá ó÷ïëåßá ìðïñïýí êáé ðñÝðåé íá ðáßîïõí óçìáíôéêü ñüëï óôïí ôïìÝá áõôü.

Ôüìïò 17, Ôåý÷ïò 1, 2005

Ïé ðñïóðÜèåéåò ôùí ïäïíôïãéáôñþí ôïõ Ê.Õ. ðñÝðåé íá åíôáèïýí, êáèþò ôï áðïôÝëåóìá åßíáé ðïëý ìáêñéÜ áðü ôï åðéèõìçôü. Ìéá íÝá áñ÷Þ ðñÝðåé íá ãßíåé ìå ôá ðáéäéÜ ôùí íçðéáãùãåßùí êáé ôçò ðñþôçò ôÜîçò ôùí Äçìïôéêþí ó÷ïëåßùí. ÁãùãÞ óôïìáôéêÞò õãåßáò, âïýñôóéóìá õðü åðéôÞñçóç, Üìåóç áðïêáôÜóôáóç ôùí ôåñçäïíéóìÝíùí íåïãéëþí, öèïñéþóåéò, ðáñï÷Þ åðéðëÝïí öèïñßïõ üðïõ ÷ñåéÜæåôáé êáé áñãüôåñá ðñïëçðôéêÝò åìöñÜîåéò åßíáé ïé ðñïôÜóåéò ðëÞèïõò óõããñáöÝùí ãéá ôï îåðÝñáóìá ôçò êáôÜóôáóçò. Ðåñéïäéêüò Ýëåã÷ïò èá äåß÷íåé êÜèå öïñÜ ôï ðïóïóôü ôçò åðéôõ÷ßáò ôçò ðáñÝìâáóçò. Óå Üëëåò çìéáóôéêÝò ðåñéï÷Ýò ìå Ïäïíôéáôñåßï óôá ÊÝíôñá Õãåßáò Ý÷ïõí áíáöåñèåß ãéá 12÷ñïíïõò ìáèçôÝò: Áðü ôï Ê.Õ. Êïõöáëßùí9 óôï íïìü Èåó/íßêçò ôï 1991 áíáöÝñèçêå DMFÔ 3,61 ãéá ôá áãüñéá êáé 4,78 ãéá ôá êïñßôóéá. Óôï Ê.Õ. ÍÝáò ÌÜêñçò8 ôï 1991-92 åß÷áìå óå 157 ðáéäéÜ DMFÔ=3,53 (±2,49) êáé äåßêôç áíáãêþí ðåñßèáëøçò ôùí ìïíßìùí äïíôéþí UÔÍ=49,22%. Åëåýèåñï ôåñçäüíáò Þôáí 16,56%. Ôï 1991-92 áðü ôï Ê.Õ. ÓéÜôéóôáò6 áíáöÝñèçóáí ãéá 73 äùäåêáåôåßò DMF 4,89 êáé UÔÍ 23,2%. Óôç ÓéÜôéóôá åðßóçò ôï 1992 óå Üëëç åñãá10 óßá óå 105 ðáéäéÜ õðïëïãßóôçêáí DMF=3,73 (±2,36) êáé dmf=1,50 (±1,65). ÂñÝèçêáí: UÔÍ= 23,3% êáé utn=64,3%. Ôï 1997-98 ôï Ê.Õ. Ó÷çìáôáñßïõ11 áíáöÝñåé ãéá ôéò çìéáóôéêÝò ðåñéï÷Ýò Ïéíüöõôùí êáé Ó÷çìáôáñßïõ óå 97 ðáéäéÜ: DMF=2,80 (±0,21), dmf=0,94 (±0,16), UÔÍ=77%, utn=77%, åëåýèåñï ôåñçäüíáò ôï 18% ôùí ðáéäéþí. Áðü ôï Ê.Õ. ×ñõóïýðïëçò ÊáâÜëáò7 óôç ó÷ïëéêÞ ÷ñïíéÜ 1998-99 áíáöÝñèçêáí ãéá ôçí êùìüðïëç: DMF=1,86 (±2,25), dmf=1,85 (±1,27), UÔÍ=47%, utn=63%. Ìå DMFÔ=0 âñÝèçêå ôï 32% ôùí ðáéäéþí êáé åëåýèåñï ôåñçäüíáò ôï 20%. Áðü ôçí êáôáíïìÞ ôùí óõ÷íïôÞôùí ôçò ôåñçäïíéêÞò ðñïóâïëÞò áíÜëïãá ìå ôç âáñýôçôá ôïõ äåßêôç DMFT, öáßíåôáé üôé áðü ôï óýíïëï ôùí ðáéäéþí ôï 82,5% Ý÷ïõí DMFT £3 êáé ôá õðüëïéðá 17,5% DMFT ³4 (ìå ôï DT êáôÜ êáíüíá õðåýèõíï), áðïäåéêíýïíôáò üôé ç ðñüëçøç ó´ áõôÜ ôá ðáéäéÜ åßíáé áíýðáñêôç êáé ç èåñáðåõôéêÞ áíôéìåôþðéóç äýóêïëç êáé åëëéðÞò. ¸ôóé Ýíáò íÝïò äåßêôçò ðñïôÜèçêå ôï 2000 ìå óêïðü íá åóôéÜóåé ôçí ðñïóï÷Þ ìáò óôá Üôï21

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ìá ìå ôïí õøçëüôåñï åðéðïëáóìü ôåñçäüíáò óå êÜèå ðëçèõóìü. Ç áíáãêáéüôçôÜ ôïõ ðñïÝêõøå áðü ôï ãåãïíüò üôé õðÜñ÷ïõí Üôïìá ìå õøçëü Þ ðïëý õøçëü DMFT åíþ ï ìÝóïò üñïò ôïõ DMFT óôïí ðëçèõóìü ìåéþíåôáé äñáóôéêÜ åîáéôßáò ôçò óõíå÷ïýò áýîçóçò ôùí åëåýèåñùí ôåñçäüíáò áôüìùí. ÏíïìÜóôçêå SiC Index áðü ôá áñ÷éêÜ ôùí Significant Caries Index.5 Ï íÝïò äåßêôçò åßíáé ï ìÝóïò üñïò ôïõ åíüò ôñßôïõ ôùí ìåãáëýôåñùí ôéìþí DMFT óôïí ðëçèõóìü ðïõ ìåëåôïýìå êÜèå öïñÜ. ÌÜëéóôá o Bratthall5 Ý÷åé èÝóåé Ýíá íÝï ðáãêüóìéï óôü÷ï ãéá ôç óôïìáôéêÞ õãåßá: ï äåßêôçò SiC ãéá ôïõò 12÷ñïíïõò óå åèíéêü åðßðåäï, Ýùò ôï Ýôïò 2015 íá åßíáé êÜôù áðü 3. ¼ôáí ìéá ÷þñá öôÜóåé åêåß, ðñÝðåé íá åðéêåíôñþíåé ôéò ðñïóðÜèåéåò óôéò ðåñéï÷Ýò ìå SiC ìåãáëýôåñï ôïõ 3. ¼ðùò öáßíåôáé áðü ôïí ðßíáêá I ïé ôéìÝò ôïõ SiC åßíáé üëåò õøçëÝò. Ï äåßêôçò SiC ãéá ôï Áóêëçðéåßï åßíáé ï ìéêñüôåñïò üëùí, äåßãìá üôé óôï Ê.Õ. Ý÷ïõí åëåýèåñç ðñüóâáóç, ÷ùñßò äéáêñßóåéò êáé áðïêëåéóìïýò ðáéäéÜ ÷áìçëïý êïéíùíéêï-ïéêïíïìéêïý åðéðÝäïõ êáé ðáéäéÜ ïéêïíïìéêþí ìåôáíáóôþí, êáôÜ ôåêìÞñéï õðåýèõíá ãéá ôçí Üíïäï ôïõ DÔ. Ç ÍÝá Êßïò êáé ç Áãßá ÔñéÜäá ðñÝðåé íá ðñïóå÷èïýí éäéáßôåñá. Êé áõôü ãéáôß áõôÜ ôá ðáéäéÜ óáí ìåëëïíôéêïß åíÞëéêåò èá ÷ñåéáóôïýí ðïëýðëïêá êáé ðïëõÝîïäá ó÷Þìáôá èåñáðåßáò êáé áðïêáôÜóôáóçò.7 Åßìáóôå áêüìá ìáêñéÜ áðü ôï óôü÷ï ôïõ 2015, áëëÜ êáé ôï 2015 åßíáé ìáêñéÜ áí äïõëÝøïõìå (üëïé ïé åìðëåêüìåíïé) óõóôçìáôéêÜ, ìå ó÷Ýäéï êáé óõíÝðåéá. Ïé äçìüóéåò õðçñåóßåò õãåßáò õðïôßèåôáé üôé áíáðôý÷èçêáí ãåùãñáöéêÜ ìå êñéôÞñéï ôçí êÜëõøç üëïõ ôïõ ðëçèõóìïý. Ôï Ê.Õ. Ëõãïõñéïý üìùò åßíáé ôï ìïíáäéêü ÊÝíôñï Õãåßáò óôéò åðáñ÷ßåò ¢ñãïõò êáé Íáõðëßïõ, ï ìüíïò äçìüóéïò öïñÝáò ðïõ ðñÝðåé íá õëïðïéÞóåé (êé áõôü ÷ùñßò âïÞèåéá Þ óõíåñãáóßá) ðñïãñÜììáôá ðñüëçøçò êáé áãùãÞò óôïìáôéêÞò õãåßáò óå ðëçèõóìü äåêÜäùí ÷éëéÜäùí ðïëéôþí, 11.077 ìáèçôþí ôçò ÐñùôïâÜèìéáò êáé ÄåõôåñïâÜèìéáò Åêðáßäåõóçò (5.149 êáé 5.928 áíôßóôïé÷á) êáé 1.160 íçðßùí. Ç åìðåéñßá ìáò äåß÷íåé üôé ç ýðáñîç êáé ëåéôïõñãßá ôùí Ïäïíôéáôñåßùí ôùí ÊÝíôñùí Õãåßáò ðáñÜ ôéò êáëÝò ðñïèÝóåéò êáé ôéò öéëüôéìåò ðñïóðÜèåéåò ôùí åñãáæïìÝíùí ó´ áõôÜ, äåí ëýíåé ìå ôïí ôñüðï êáé óôçí Ýêôáóç ðïõ èá ìðïñïýóå Þ èá Ýðñåðå, ôá ðñïâëÞìáôá ôçò óôïìáôéêÞò õãåßáò ôùí ðáéäéþí óôç ðåñéï÷Þ åõèýíçò ôïõò. 22

É. Táñáíôßëçò

Êé áõôü ãéáôß ï ïäïíôßáôñïò ôïõ ÊÕ ðñÝðåé íá áíôéðáëÝøåé: 1) Ôéò áäõíáìßåò ôïõ, ðïõ ó÷åôßæïíôáé ìå ôéò åëëåßøåéò ôçò ðñïðôõ÷éáêÞò ôïõ åêðáßäåõóçò êáé ôïí ðáñáäïóéáêü ðñïóáíáôïëéóìü ôçò Üóêçóçò ôçò ïäïíôéáôñéêÞò óôçí ðáñï÷Þ èåñáðåõôéêþí êáé åðáíïñèùôéêþí öñïíôßäùí12. 2) Ôç ìïéñïëáôñéêÞ áðïäï÷Þ ôçò ðáñïõóßáò ôçò ôåñçäüíáò áðü ãïíåßò êáé ìáèçôÝò. Ï ðüíïò åßíáé êõñßùò ôï êßíçôñï ãéá ôçí ðñþôç åðßóêåøç óôï ïäïíôéáôñåßï. 3) Ôçí áñíçôéêÞ óôÜóç ðïëëþí äéäáóêüíôùí óôçí ðñïëçðôéêÞ åîÝôáóç êáé óôá ðñïëçðôéêÜ ðñïãñÜììáôá þóôå íá ìç “äéáôáñá÷èåß ç åêðáéäåõôéêÞ äéáäéêáóßá”. 4) Ôçí Üãíïéá ôçò ðñáãìáôéêÞò Ýêôáóçò êáé êáôáíïìÞò ôçò ôåñçäüíáò, ìÝ÷ñéò üôïõ äçìéïõñãÞóåé (ìüíïò ôïõ) ìéá âÜóç äåäïìÝíùí, ðïõ èá ôïõ åðéôñÝøåé íá ðñïóáíáôïëßóåé êáé êáôáìåñßóåé ôéò öñïíôßäåò ôïõ.

ÓõìðåñÜóìáôá 1) Ç ýðáñîç êáé ëåéôïõñãßá Ê.Õ. óå ìéá ðåñéï÷Þ óõìâÜëëåé ìÝóá áðü ôçí áãùãÞ õãåßáò, ôá ðñïëçðôéêÜ ðñïãñÜììáôá êáé ôçí ðñïóöåñüìåíç ðåñßèáëøç ÷ùñßò äéáêñßóåéò, óôç âåëôßùóç ôïõ åðßðåäïõ óôïìáôéêÞò õãåßáò ôùí ìáèçôþí ôçò ðåñéï÷Þò ôïõ. 2) Ç äçìéïõñãßá ìéáò âÜóçò äåäïìÝíùí åßíáé áðáñáßôçôç ãéá ôïõò ïäïíôßáôñïõò ôïõ Ê.Õ. ãéá ôçí áîéïëüãçóç ôùí ðáñåìâÜóåùí, ôçí åîåéäßêåõóç êáé ôïí åðáíáêáèïñéóìü, êÜèå ó÷ïëéêÞ ÷ñïíéÜ, ôùí óôü÷ùí. 3) Ç ðñïëçðôéêÞ ðáñÝìâáóç ôïõ K.Y. ðñÝðåé íá åóôéÜóåé óôá ðáéäéÜ ôùí íçðéáãùãåßùí êáé ôçò Á´ ôÜîçò ôùí Äçìïôéêþí ó÷ïëåßùí óôç ðåñéï÷Þ åõèýíçò ôïõ. 4) Ç ðïëéôåßá óõíïëéêÜ áäõíáôåß íá ó÷åäéÜóåé êáé åöáñìüóåé ïëïêëçñùìÝíá ðñïëçðôéêÜ ðñïãñÜììáôá óå ðëçèõóìéáêü åðßðåäï, ãåãïíüò ðïõ áõîÜíåé ôçí åõèýíç ôùí ÊÝíôñùí Õãåßáò óôá ðëáßóéá ôçò ÐñùôïâÜèìéáò ÏäïíôéáôñéêÞò Öñïíôßäáò Õãåßáò.12

Âéâëéïãñáößá 1. ÊïõóôÝëëç Ì, ËÜããáò Ä. ÓôïìáôéêÞ õãåßá êáé

É. Táñáíôßëçò

ðáéäßáôñïò. ÐáéäéáôñéêÞ, 60:35-49, 1997. 2. Ôóéíßäïõ Ê, ÏõëÞò Ê É. Ç åîÝëéîç ôçò ôåñçäüíáò êáé ôùí ïäïíôéáôñéêþí áíáãêþí ôùí ðáéäéþí óôçí ÅëëÜäá ôçí ôåëåõôáßá åéêïóáåôßá (19751995). Ðáéäïäïíôßá, 9:143-50, 1995. 3. Gibbons R. The caries decline. A comment. Eur J Oral Sci, 104:424-25, 1996. 4. World Health Organization. Oral Health Surveys. Basic methods. 3nd Ed. Geneva: WHO, 1987. 5. Âratthall D. Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J, 50:378-84, 2000. 6. Ôïðßôóïãëïõ B, Éùáííßäïõ Â, Óéæéüðêïò Ê, ÈåïäïóéÜäïõ Å. Åðéðïëáóìüò ôåñçäüíáò óå ðáéäéÜ êáé åöÞâïõò (3 Ýùò 18 åôþí) ôçò ÓéÜôéóôáò Ìáêåäïíßáò êáôÜ ôï ÷ñïíéêü äéÜóôçìá 19881992. Ðáéäïäïíôßá, 8:171-82, 1994. 7. ÄåìåñôæÞ-Ïéêïíïìßäïõ Á, Ôïðßôóïãëïõ Â. Äéá÷ñïíéêÞ ïêôÜ÷ñïíç ðáñáêïëïýèçóç ôçò åðßðôùóçò ôçò ôåñçäüíáò óå ðáéäéÜ ôçò åðáñ÷ßáò ÍÝóôïõ ÊáâÜëáò êáôÜ ôá ó÷ïëéêÜ Ýôç 1992-1993

Ôüìïò 17, Ôåý÷ïò 1, 2005

ùò êáé 1999-2000. Ðáéäïäïíôßá, 16:82-90, 2002. 8. ÌùñáúôÜêç-ÔóÜìç Á, Êáìáñïýäç-ÑÝôóá Å. Ç ôåñçäüíá óôïí ðáéäéêü ðëçèõóìü ôçò ðåñéï÷Þò ôçò Í. ÌÜêñçò. 3 ÷ñüíéá ìåôÜ ôçí åöáñìïãÞ ïñãáíùìÝíçò ðáñÝìâáóçò. ÅëëçíéêÜ ÓôïìáôïëïãéêÜ ×ñïíéêÜ, 38:209-14, 1994. 9. Áìïýôæéá-Ôéìïëüãïõ Á. Åðéðïëáóìüò ôåñçäüíáò åöÞâùí Êïõöáëßùí íïìïý Èåó/íßêçò. Ïäïíôéáôñéêüò Áíáâáèìüò, Á:1-7, 1991. 10. Éùáííßäïõ Â, Ôïðßôóïãëïõ Â, Óéæéüðêïò Ê. Åðéðïëáóìüò ôåñçäüíáò êáé áíÜãêåò ðåñßèáëøçò ðáéäéþí çëéêßáò 6 êáé 12 åôþí óôï Íïìü ÊïæÜíçò ôçò Ìáêåäïíßáò. Ðáéäïäïíôßá, 8:183-92, 1994. 11. Öáíäñßäçò É, Äåëâåíáêéþôçò Ä. Åðéðïëáóìüò ôåñçäüíáò êáé áíÜãêåò ïäïíôéáôñéêÞò ðåñßèáëøçò ðáéäéþí çëéêßáò 6 êáé 12 åôþí óôçí áíáôïëéêÞ åðáñ÷ßá Èçâþí ôïõ Íïìïý Âïéùôßáò. Ðáéäïäïíôßá, 13:55-63, 1999. 12. ÊùëÝôóç-ÊïõíÜñç ×. Ç ðñùôïâÜèìéá öñïíôßäá õãåßáò óôçí ïäïíôéáôñéêÞ. Óôï: Ç ðñùôïâÜèìéá öñïíôßäá õãåßáò óôçí ÅëëÜäá. ÈåìÝëéï/Êïéíùíßá êáé Õãåßá, ÁèÞíá, 1996, ó. 135-48.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

A. ÊïðáíÜêçò êáé óõí

ÁÍÁÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 17, Number 1, 24-30, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 24-30, 2005

Ç ðíåõìïíßá åî õðåñåõáéóèçóßáò óÞìåñá êáé ðþò ôçí áíáãíùñßæïõìå Á. ÊïðáíÜêçò1, Ð. ÄáóêáëÜêçò2, ÃáñõöáëéÜ Ðáðáäïðïýëïõ3

Ðåñßëçøç Ç ðíåõìïíßá åî õðåñåõáéóèçóßáò Þ áëëéþò åîùãåíÞò áëëåñãéêÞ êõøåëéäßôéäá (ÅÁÊ) ðñïêáëåßôáé ìåôÜ áðü åðáíáëáìâáíüìåíç åéóðíïÞ ïñãáíéêþí áåñßùí Þ êüíåùí. ÐñïãåíÝóôåñá ç ÅÁÊ åß÷å èåùñçèåß óðÜíéá íüóïò, üìùò óÞìåñá äéáðéóôþíåôáé üôé åßíáé ðéï óõ÷íÞ áð´ üôé åß÷å áñ÷éêÜ åêôéìçèåß. ÁíÜëïãá ìå ôçí êëéíéêÞ åéêüíá ç íüóïò ÷áñáêôçñßæåôáé ùò ïîåßá, õðïîåßá êáé ÷ñüíéá. Ôá óõìðôþìáôá ôçò ïîåßáò íüóïõ åìöáíßæïíôáé 4 ìå 8 þñåò áðü ôçí Ýêèåóç óôï åíï÷ïðïéïýìåíï áíôéãüíï êáé ìïéÜæïõí ìå áõôÜ ôçò “ãñßððçò” ìå ðõñåôü, ñßãïò êáé êáêïõ÷ßá. Ôá êõñéüôåñá óõìðôþìáôá ôçò õðïîåßáò ìïñöÞò åßíáé ðñïïäåõôéêÜ åðéäåéíïýìåíç äýóðíïéá óôçí êüðùóç, åîÜíôëçóç, ðáñáãùãéêü âÞ÷á, áíïñåîßá, êáêïõ÷ßá êáé áðþëåéá âÜñïõò. ¼ôáí ç õðïîåßá ìïñöÞ äåí áíáãíùñéóôåß þóôå íá áíôéìåôùðéóôåß èåñáðåõôéêÜ, ôüôå ïäçãåßôáé óôç ÷ñüíéá ìïñöÞ. ÏñéóìÝíïé áðü ôïõò áóèåíåßò ìå ÷ñüíéá ÅÁÊ èá áíáðôýîïõí ìç áíáóôñÝøéìåò âëÜâåò óôïõò ðíåýìïíåò ëüãù äéÜìåóçò ðíåõìïíéêÞò ßíùóçò, ðïõ èá åðéöÝñåé äåîéÜ êáñäéáêÞ áíåðÜñêåéá óôá ðñï÷ùñçìÝíá óôÜäéá. Ç ðñüùñç äéÜãíùóç êáé Ýôóé ç áðïöõãÞ ôïõ áíôéãüíïõ ðïõ ðñïêáëåß ôç íüóï, åßíáé ðïëý óçìáíôéêÞ ãéá ôç èåñáðåßá. Óå üëåò ôéò ðåñéðôþóåéò ç öáñìáêåõôéêÞ èåñáðåßá ðåñéëáìâÜíåé ôá êïñôéêïóôåñïåéäÞ. Ç ðñüãíùóç ôçò íüóïõ äåí Ý÷åé áðïóáöçíéóôåß ðëÞñùò. Óôçí ïîåßá íüóï ç ßáóç åßíáé óõíÞèùò ðëÞñçò. Óôçí õðïîåßá ìïñöÞ ç áíáãíþñéóç ôçò íüóïõ åßíáé êñéôéêÞò óçìáóßáò. Óôç ÷ñüíéá ìïñöÞ ôçò ÅÁÊ ç áíáðíåõóôéêÞ áíåðÜñêåéá åßíáé óõíÞèçò åîÝëéîç, ÷ùñßò üìùò íá óõìâáßíåé ðÜíôïôå.

Ðíåõìïíïëüãïò-Åíôáôéêïëüãïò ÅðéìåëçôÞò Â´, Ãåíéêü Íïìáñ÷éáêü Íïóïêïìåßï ¸äåóóáò, 2Åéäéêåõüìåíïò ÃåíéêÞò ÉáôñéêÞò, Ã.Í.Á. ÉððïêñÜôåéï, 3Åéäéêåõüìåíç Âéïðáèïëïãßáò, Ð.Ã.Í.Á. Åëëçíéêïý Åñõèñïý Óôáõñïý

Ïñéóìüò Ðíåõìïíßá åî õðåñåõáéóèçóßáò Þ åîùãåíÞò áëëåñãéêÞ êõøåëéäßôéäá (ÅÁÊ) ïíïìÜæåôáé ç äéÜ÷õôç êïêêéùìáôþäçò ðíåõìïíéêÞ íüóïò, ðïõ ðñïóâÜëëåé ôüóï ôï äéÜìåóï éóôü ôïõ ðíåýìïíá üóï êáé ôïõò êõøåëéäéêïýò áåñï÷þñïõò êáé ç ïðïßá ïöåßëåôáé óôçí åðáíåéëçììÝíç åéóðíïÞ êáé åéäéêÞ åõáéóèçôïðïßçóç ôïõ ïñãáíéóìïý óå ðëÞèïò ïñãáíéêþí áåñßùí êáé êüíåùí êáèþò êáé óå ÷áìçëïý ìïñéáêïý âÜñïõò ÷çìéêþí áíôéãüíùí.1

Åðéäçìéïëïãßá Ìüíï Ýíá ìéêñü ðïóïóôü ôùí áôüìùí ðïõ Ý÷ïõí åêôåèåß óå ðáñÜãïíôåò êéíäýíïõ ãéá ðíåõìïíßá åî õðåñåõáéóèçóßáò áíáðôýóóïõí êëéíéêÜ óçìáíôéêÞ íüóï, åíþ öáßíåôáé üôé ïé ãåíåôéêïß ðáñÜãïíôåò ðáßæïõí óçìáËÝîåéò êëåéäéÜ: ÅîùãåíÞò áëëåñãéêÞ êõøåëéäßôéäá, åéóðíåüìåíåò ïñãáíéêÝò êüíåéò, ðíåõìïíéêÞ ßíùóç, êïñôéêïóôåñïåéäÞ ÕðïâëÞèçêå: 21 Ïêôùâñßïõ 2001 ÅðáíõðïâëÞèçêå: 17 Éáíïõáñßïõ 2005 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 20 Éáíïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: Áíôþíéïò ÊïðáíÜêçò, ÅêÜâçò 71, ÁèÞíá, ÃáëÜôóé ÔÊ 11146, ÔçëÝöùíï: 6974002594, Fax: (28420)61865, e-mail: antony_kop@yahoo.gr

A. ÊïðáíÜêçò êáé óõí

Ôüìïò 17, Ôåý÷ïò 1, 2005

ñåõáéóèçóßáò åîáñôÜôáé áðü ôçí éêáíüôçôá ôïõ åéóðíåüìåíïõ ïñãáíéêïý ðáñÜãïíôá íá äéåãåßñåé ôï áíïóïëïãéSummary êü óýóôçìá ôïõ îåíéóôïý, ôïí áñéèìü Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is a syndrome that results from repeated inhalation of finely dispersed antigens. êáé ôï ìÝãåèïò ôùí åéóðíåüìåíùí ïñPreviously considered a rare disease, HP may be more common than previously ãáíéêþí ìéêñïóùìáôßùí, êáèþò êáé ôçí estimated. Three clinically different presentations of HP have been described: êáôÜóôáóç ôïõ áíïóïëïãéêïý óõóôÞacute, subacute, and chronic. Symptoms of the acute disease occur 4 to 8 ìáôïò ôïõ ïñãáíéóìïý. ÌåãÜëá óùhours after exposure to the offending antigen and consist of the abrupt onset of ìáôßäéá Üíù ôùí 10ì áðïìáêñýíïíôáé a flu-like syndrome characterized by fever, chills, and malaise. The main of subacute HP symptoms are progressive dyspnea on exertion, fatigue, cough ìÝóù ôçò ñéíéêÞò êïéëüôçôáò ìå öéëwith mucoid sputum, anorexia, malaise, and weight loss. Unrecognized and ôñÜñéóìá êáé åíóöÞíùóç. O ðáñáðÜuntreated subacute HP may progress to chronic HP. A number of patients with íù ìç÷áíéóìüò ëåéôïõñãåß êáé óå óùchronic disease develop irreversible lung changes due to interstitial fibrosis that ìáôßäéá Üíù ôùí 2ì ìå ìåéùìÝíç progresses to right-sided heart failure. Early diagnosis and avoidance of antigen áðïôåëåóìáôéêüôçôá. Åíáðïôßèåíôáé exposure are key elements and the mainstay of treatment regimens. Corticosteroids are recommended in acute, severe, and progressive disease. Prognosis ôåëéêÜ óôéò êõøåëßäåò óùìáôßäéá äéáis incompletely understood. In the acute form, recovery is usually complete. In ìÝôñïõ 0,5-3ì äéÜ ìÝóù ôïõ ìç÷áíéthe subacute form recognition is crusial. In the chronic form progressive fucóìïý ôçò êáèéæÞóåùò. Ï ìç÷áíéóìüò tional deterioration to respiratory insufficiency is likely, but progression to endôçò äéá÷ýóåùò ëáìâÜíåé ìÝñïò óå óùstage disease is not a uniform finding. ìáôßäéá ìåãÝèïõò ìéêñüôåñïõ ôïõ 0,5ì, Key-words: Hypersensitivity pneumonitis, finely dispersed antigens, pulmonary ôá ðåñéóóüôåñá äåí åíáðïôßèåíôáé fibrosis, corticosteroids. êáèüëïõ áëëÜ ðáñáìÝíïõí óå åíáéþíôéêü ñüëï óôïí âáèìü ðïõ Ýíá Üôïìï êéíäõíåýåé ñçìá óôïí åêðíåüìåíï áÝñá2. íá íïóÞóåé. Ï ðíåýìïíáò ôùí áãñïôþí åßíáé ìéá Ðéèáíüôåñï åßíáé üôé áíôéäñÜóåéò õðåñåõáéáðü ôéò ðéï êïéíÝò ìïñöÝò ôçò ðíåõìïíßáò åî óèçóßáò ôýðïõ áíïóïóõìðëåãìÜôùí ó÷åôßæïíôáé õðåñåõáéóèçóßáò êáé áíåõñßóêåôáé óå ðïóïóôü 0,4 ìå ôçí ïîåßá ìïñöÞ ôçò íüóïõ, ç ïðïßá áêïëïõÝùò 7% ôïõ óõíüëïõ ôùí áãñïôþí.2 Ç åîÜðëùóç èåßôáé áðü ìç÷áíéóìïýò õðåñåõáéóèçóßáò êõôôáôçò íüóïõ ðïéêßëëåé áíÜëïãá ìå ôçí ðåñéï÷Þ êáé ñéêïý ôýðïõ, ðïõ ó÷åôßæïíôáé ìå ôç öëåãìïíÞ, ôï ôï êëßìá. ¸ôóé ï êßíäõíïò åßíáé 9% ãéá áãñüôåò ó÷çìáôéóìü êïêêéþìáôïò êáé ôç äéÜìåóç ßíùóç óå õãñÝò æþíåò êáé ìåéþíåôáé óôï 2% óôéò îçñü- ðïõ ðáñáôçñåßôáé óôçí õðïîåßá êáé ôç ÷ñüíéá ôåñåò ðåñéï÷Ýò.3 Ï áíáöåñüìåíïò êßíäõíïò åîÜ- ìïñöÞ ôçò íüóïõ.5 Áéôéïëïãéêïß ðáñÜãïíôåò - åíï÷ïðïéïýìåíá ðëùóçò ôçò íüóïõ óôïõò åêôñïöåßò ðôçíþí ðïéêßëëåé áêüìá ðåñéóóüôåñï áðü 20 Ýùò 20.000/ áíôéãüíá óôçí ðñüêëçóç ôçò ðíåõìïíßáò åî õðå100.000.1 ÐñÝðåé åðßóçò íá áíáöåñèåß üôé ç íü- ñåõáéóèçóßáò. óïò åìöáíßæåôáé ðéï óõ÷íÜ óôïõò åêôñïöåßò ðôçÃéá ôçí ðñüêëçóç ôçò íüóïõ åßíáé áðáñáßôçíþí ðáñÜ óôïõò áãñüôåò åðåéäÞ ç åðáöÞ ìå ôá ôï üðùò ðñïáíáöÝñèçêå íá õðÜñ÷åé åéäéêÞ ðñïáíôéãüíá ôùí ðôçíþí äåí åîáñôÜôáé ôüóï áðü äéÜèåóç ôïõ áôüìïõ êáé éêáíü áíôéãïíéêü åñÝèéôç ãåùãñáöéêÞ ôïðïèåóßá Þ ôéò êëéìáôïëïãéêÝò óìá. ÂáóéêÜ áíôéãüíá óÞìåñá èåùñïýíôáé ïé èåñóõíèÞêåò. ¸ôóé ç åðßðôùóç ôçò íüóïõ óôïõò áãñü- ìïöéëéêïß áêôéíïìýêçôåò ïé ïðïßïé áíáðôýóóïôåò åßíáé 8-540 áíÜ 100.000 áíÜ Ýôïò, åíþ óôïõò íôáé óôï ðåðéåóìÝíï ÷üñôï êáèþò êáé ïé áëâïõåêôñïöåßò ðåñéóôåñéþí ãßíåôáé 6.000-21.000 áíÜ ìßíåò êáé ïé ã-óöáéñßíåò ôùí åêêñéìÜôùí ôùí 100.000 áíÜ Ýôïò.4 ðôçíþí. Ïé óðüñïé ôùí èåñìïöéëéêþí áêôéíïìõêÞôùí åêêñßíïõí Ýíæõìá ôá ïðïßá ðñïêáëïýí ôç óÞøç ôùí ÷üñôùí. Áí ç áðïèÞêåõóç ôùí ÷üñôùí ãßíåé óå óõíèÞêåò õãñáóßáò êáé áíåðáñêïýò áåñéÐáèïãÝíåéá óìïý åõíïåßôáé ç áíÜðôõîç ôùí ìõêÞôùí. ÈåñìïÏ áêñéâÞò ðáèïãåíåôéêüò ìç÷áíéóìüò ôçò öéëéêïß áêôéíïìýêçôåò áíåõñßóêïíôáé åðßóçò óå íüóïõ åßíáé Üãíùóôïò êáé ðïëëÜ ðïõ Ý÷ïõí õðï- óõóôÞìáôá êëéìáôéóìïý, ðéóßíåò, êáé õãñáíôÞñåò.6 Ìéá Üëëç ïìÜäá õøçëïý êéíäýíïõ ãéá ôçí óôçñé÷èåß áðü ïñéóìÝíåò ìåëÝôåò, Ý÷ïõí áìöéóâçôçèåß áðü Üëëåò. Öáßíåôáé óõììåôÝ÷ïõí ðïëëïß áíÜðôõîç ðíåõìïíßáò åî õðåñåõáéóèçóßáò åßíáé ìç÷áíéóìïß. Ç áíÜðôõîç ôçò ðíåõìïíßáò åî õðå- ïé åêôñïöåßò ðôçíþí (êõñßùò ðåñéóôåñéþí) êáé Hypersensitivity pneumonitis today’s diagnosis A. Kopanakis, P. Daskalakis, Garifalia Papadopoulou

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ðïõëåñéêþí. Ôá åíï÷ïðïéïýìåíá áíôéãüíá, åßíáé Ýíá ìßãìá ðñùôåúíþí ðïõ âñßóêåôáé óôá åêêñßìáôá ôùí ðôçíþí êáé óôá ðåñéôôþìáôÜ ôïõò. Åðßóçò, ôá áíôéãüíá áõôÜ ìðïñåß íá âñåèïýí óå óôåãíùôÞñåò ñïý÷ùí, óå öùëéÝò ðôçíþí óå óðßôéá ïðüôå åõíïåßôáé ç áåñïãåíÞò ìåôÜäïóÞ ôïõò óôïí Üíèñùðï Þ áêüìç êáé óå ðïõðïõëÝíéá ìáîéëÜñéá. ¢ëëç êáôçãïñßá áíèñþðùí ðïõ åêôßèåíôáé óå êßíäõíï ãéá ôçí åìöÜíéóç ôçò íüóïõ, åßíáé ïé åñãÜôåò ðïõ áó÷ïëïýíôáé ìå ôçí åðåîåñãáóßá îýëïõ êáé ÷áñôéïý, áöïý ôá öõôÜ ôá äÝíôñá êáé ôá ðñïúüíôá ôïõò ìðïñåß íá áðïéêéóôïýí áðü åíï÷ïðïéïýìåíá áíôéãüíá. ÊÜôé áíÜëïãï óõìâáßíåé êáé ìå áõôïýò ðïõ åéóðíÝïõí ïñãáíéêÝò ïõóßåò ðïõ ÷ñçóéìïðïéïýíôáé óôçí êáôáóêåõÞ ðëáóôéêþí, óôéò äéÜöïñåò âáöÝò Þ óôç âéïìç÷áíßá çëåêôñïíéêþí. ÔÝëïò, óå êßíäõíï ãéá ôçí åìöÜíéóç ôçò íüóïõ, âñßóêïíôáé ïé áãñüôåò åéäéêÜ áõôïß ðïõ áó÷ïëïýíôáé ìå âïïåéäÞ, üðùò êáé ïé êôçíßáôñïé Þ ïé åêðáéäåõôÝò æþùí (Ðßíáêáò É).

ÊëéíéêÝò åêäçëþóåéò ôçò ðíåõìïíßáò åî õðåñåõáéóèçóßáò Ç íüóïò áíÜëïãá ìå ôçí êëéíéêÞ åìöÜíéóç, ôç óõ÷íüôçôá, ôç äéÜñêåéá ôçò íüóçóçò êáé ôçí Ýêèåóç óôá ðéèáíÜ áíôéãüíá, ìðïñåß íá äéáêñéèåß óå 3 ìïñöÝò: Ôçí ïîåßá, ôçí õðïîåßá êáé ôç ÷ñüíéá ìïñöÞ. Ç ïîåßá ìïñöÞ åßíáé ôï áðïôÝëåóìá ôçò Ýêèåóçò ôïõ áôüìïõ óå õøçëÞ ðõêíüôçôá ôïõ áíôéãüíïõ êáé óå ðáñáôåôáìÝíï ÷ñïíéêü äéÜóôçìá. Åßíáé ç ðéï êïéíÞ êáé åýêïëá áíáãíùñßóéìç ìïñÐßíáêáò I. Éóôïñéêü ýðïðôï ãéá Ðíåõìïíßá åî õðåñåõáéóèçóßáò · Éóôïñéêü åðáíáëáìâáíüìåíùí åðåéóïäßùí Üôõðçò ðíåõìïíßáò. · Óõìðôþìáôá ðïõ åìöáíßæïíôáé ìåôÜ áðü ìßá íÝá åñãáóßá Þ ìåôáêüìéóç óå íÝï óðßôé. · Êáôïéêßäéá æþá óôï óðßôé (éäéáßôåñá ðôçíÜ) áêüìá êáé áí ï áóèåíÞò áñíåßôáé Üìåóç åðáöÞ ìå áõôÜ. · Éóôïñéêü äéáññïþí óôï óýóôçìá ýäñåõóçò óôï óðßôé Þ ôçí åñãáóßá. · ×ñÞóç óÜïõíáò Þ õäñïìáóÜæ Þ ðéóßíáò. · ¢ëëïé áóèåíåßò ìå ôá ßäéá óõìðôþìáôá óôïí ßäéï ÷þñï Þ åñãáóßá. · Ï áóèåíÞò áéóèÜíåôáé êáëýôåñá áöïý öýãåé áðü ôï óðßôé Þ ôçí åñãáóßá ôïõ (ð.÷. óå äéáêïðÝò). 26

A. ÊïðáíÜêçò êáé óõí

öÞ ôçò íüóïõ, áëëÜ ç óõìðôùìáôïëïãßá ôçò ìðïñåß íá ìéìçèåß ìéá éïãåíÞ Þ âáêôçñéáêÞ ëïßìùîç (üðùò ôç ìõêïðëáóìáôéêÞ ðíåõìïíßá) ìå áðïôÝëåóìá óõ÷íÜ ïé áóèåíåßò íá õðïâÜëëïíôáé óå áíôéâéïôéêÞ èåñáðåßá ÷ùñßò áðïôÝëåóìá.2 Ôá óõìðôþìáôá åìöáíßæïíôáé 4-8 þñåò ìåôÜ ôçí Ýêèåóç óôï áíôéãüíï. Ï áóèåíÞò ðáñïõóéÜæåé Ýíá áíÜëïãï “ãñßððçò” ìå ðõñåôü, ñßãïò êáé êáêïõ÷ßá. Ðáñáôçñïýíôáé åðßóçò êåöáëáëãßá, áñèñáëãßåò, åíþ áðü ôï áíáðíåõóôéêü óýóôçìá ðáñáôçñïýíôáé îçñüò âÞ÷áò, Üëãïò óôï èùñáêéêü ôïß÷ùìá, äýóðíïéá ÷ùñßò óõñéãìü êáé óðáíéüôåñá áéìüðôõóç. Ôá óõìðôþìáôá äéáñêïýí áðü ìåñéêÝò þñåò Ýùò 1-2 çìÝñåò êáé åðáíåìöáíßæïíôáé óå åðáíÝêèåóç ôïõ áôüìïõ óôï ßäéï áíôéãüíï. Áðü ôç öõóéêÞ åîÝôáóç ï éáôñüò èá äéáðéóôþóåé ôá÷ýðíïéá êáé ôåëïåéóðíåõóôéêïýò ôñßæïíôåò óôçí áêñüáóç. Ìåôáîý ôùí åðåéóïäßùí ôçò ïîåßáò ðíåõìïíßáò åî õðåñåõáéóèçóßáò ï áóèåíÞò åßíáé óõíÞèùò áóõìðôùìáôéêüò. Ç õðïîåßá ìïñöÞ åßíáé ôõðéêÞ óå Üôïìá ðïõ åêôñÝöïõí ðôçíÜ. ÁíáöÝñåôáé êáé ùò äéáëåßðïõóá ìïñöÞ ôçò íüóïõ. Ç íüóïò åìöáíßæåôáé ìåôÜ áðü ðáñáôåôáìÝíç åéóðíïÞ áíôéãüíùí, ðïõ ðñïÝñ÷ïíôáé áðü ôá åêêñßìáôá êáé ôá öôåñÜ ôùí ðôçíþí. ¸ôóé ðñïêýðôåé ìéá Üôõðç ìïñöÞ ôçò íüóïõ, ç ïðïßá ÷áñáêôçñßæåôáé áðü ðáñáãùãéêü âÞ÷á, äýóðíïéá, êáêïõ÷ßá. Ôá óõìðôþìáôá áõôÜ âáèìéáßá åðéäåéíþíïíôáé, ìå áðïôÝëåóìá ìåôÜ áðü åâäïìÜäåò Þ êáé ìÞíåò, ç äýóðíïéá êáé ï âÞ÷áò íá ãßíïíôáé åíôïíüôåñá, åíþ åìöáíßæåôáé áíïñåîßá êáé áðþëåéá âÜñïõò. Óôç öÜóç áõôÞ äåí ðáñáôçñåßôáé óõ÷íÜ åìöÜíéóç ðõñåôïý.1 Óôç öõóéêÞ åîÝôáóç äéáðéóôþíåôáé ôá÷ýðíïéá êáé óôçí áêñüáóç ôñßæïíôåò. Ç ÷ñüíéá ìïñöÞ ôçò íüóïõ åßíáé óõíÞèùò ôï áðïôÝëåóìá áäéÜãíùóôçò Þ áôåëþò èåñáðåõèåßóáò ïîåßáò Þ õðïîåßáò ðíåõìïíßáò åî õðåñåõáéóèçóßáò. Åßíáé ýðïõëç êáé åðéêßíäõíç ìïñöÞ, áöïý Ýíá ìåãÜëï ðïóïóôü ôùí áóèåíþí áõôþí ðáñïõóéÜæåé ìç áíáóôñÝøéìåò áëëïéþóåéò ëüãù äéÜìåóçò ßíùóçò. Ï áóèåíÞò åìöáíßæåôáé êáé åäþ ìå äýóðíïéá êõñßùò êáôÜ ôçí êüðùóç, âÞ÷á, êáé óõíïäü êáêïõ÷ßá êáé áðþëåéá âÜñïõò. Ìðïñåß åðßóçò íá ðáñáôçñçèïýí óçìåßá äåîéÜò êáñäéáêÞò áíåðÜñêåéáò êáé ðëçêôñïäáêôõëßá ðïõ áðïôåëïýí äåßêôç åðéäåßíùóçò ôçò íüóïõ.2 Óôç ÷ñüíéá ìïñöÞ ôçò íüóïõ ïé ôñßæïíôåò óõ÷íÜ áðïôåëïýí óôáèåñü åýñçìá. Ëüãù ôçò ýðïõëçò Ýíáñîçò ôçò íüóïõ, ç äéáöïñïäéÜãíùóç áðü Üëëá íïóÞ-

A. ÊïðáíÜêçò êáé óõí

ìáôá üðùò ç éäéïðáèÞò ðíåõìïíéêÞ ßíùóç åßíáé äýóêïëç.7 ÁêôéíïëïãéêÞ áðåéêüíéóç ôçò ðíåõìïíßáò åî õðåñåõáéóèçóßáò Ç áðëÞ áêôéíïãñáößá èþñáêïò äåí åßíáé äéáãíùóôéêÞ êáé ôá åõñÞìáôá ó’ áõôÞí ðïéêßëëïõí. Åßíáé ç ðéï óõ÷íÞ äéÜ÷õôç ðíåõìïíïðÜèåéá ðïõ åìöáíßæåôáé ìå öõóéïëïãéêÞ áêôéíïãñáößá èþñáêïò óå ðïóïóôü ðåñßðïõ 40%.8 Ó’ áõôïýò ôïõò áóèåíåßò ôá êïêêéþìáôá åßíáé ëßãá êáé ìéêñÜ êáé äå öáßíïíôáé óôçí áêôéíïãñáößá. Ôá åõñÞìáôá ôçò áêôéíïãñáößáò ðïéêßëëïõí áíÜëïãá ìå ôï óôÜäéï êáé ôç ìïñöÞ ôçò íüóïõ. Óôçí ïîåßá ìïñöÞ ôçò íüóïõ ç áêôéíïãñáößá ìðïñåß íá åßíáé öõóéïëïãéêÞ Þ íá ðáñïõóéÜæåé äéÜ÷õôåò óêéÜóåéò ôçò ìïñöÞò ôçò “èïëÞò õÜëïõ”. Ìðïñåß åðßóçò ç íüóïò íá åìöáíßæåôáé ìå ôç ìïñöÞ ðýêíùóçò Þ ïæéäéáêþí Þ äéêôõïæéäéáêþí óêéÜóåùí. Ôá åõñÞìáôá áõôÜ óõ÷íÜ áöïñïýí óôá ìÝóá êáé êáôþôåñá ðíåõìïíéêÜ ðåäßá (Åéêüíá 1). Óôçí õðïîåßá ìïñöÞ ôçò íüóïõ, ç áêôéíïãñáößá èþñáêïò áí äåí åßíáé öõóéïëïãéêÞ, èá äåßîåé ðáñüìïéåò áëëïéþóåéò ìå ôçí ïîåßá ìïñöÞ ðïõ áöïñïýí üìùò óõ÷íüôåñá óôá ìÝóá êáé áíþôåñá ðíåõìïíéêÜ ðåäßá (Åéêüíá 2). Ç áêôéíïãñáößá èþñáêïò óôç ÷ñüíéá ìïñöÞ ôçò íüóïõ, ÷áñáêôçñßæåôáé áðü óáöÞ äéêôõùôÞ áðåéêüíéóç, ç ïðïßá êáèþò åîåëßóóåôáé äßíåé ôç ÷áñáêôçñéóôéêÞ åéêüíá ôçò “ìåëéêçñÞèñáò”. ÁõôÝò ïé éíùôéêÝò áëëïéþóåéò ðáñáôçñïýíôáé óõ÷íüôåñá óôïõò áíþôåñïõò ëïâïýò êáé üðùò ðñïáíáöÝñèçêå ïìïéÜæïõí ìå ôá åõñÞìáôá óôçí áêôéíï-

Åéêüíá 1. Áêôéíïãñáößá èþñáêïò áóèåíïýò ìå ïîåßá ÅÁÊ: èïëåñüôçôá ðíåýìïíïò óôï äåîéü êÜôù ðíåõìïíéêü ðåäßï.

Ôüìïò 17, Ôåý÷ïò 1, 2005

ãñáößá ôùí áóèåíþí ìå éäéïðáèÞ ðíåõìïíéêÞ ßíùóç (Åéêüíá 3). Ôá áíùôÝñù åõñÞìáôá óôçí áêôéíïãñáößá èþñáêïò äå óõíïäåýïíôáé áðü õðåæùêïôéêÞ óõëëïãÞ (<10%) ïýôå áðü åìöáíÞ äéüãêùóç ôùí ëåìöáäÝíùí ôïõ ìåóïèùñáêßïõ. Ç áîïíéêÞ ôïìïãñáößá õøçëÞò åõêñßíåéáò (HRCT) áðïôåëåß ðïëý ðéï åõáßóèçôç ìÝèïäï áðü ôçí áðëÞ áêôéíïãñáößá èþñáêïò, óôçí áíåýñåóç ðáèïëïãéêþí åõñçìÜôùí. ¼ìùò, ðáñÜ ôï üôé ç HRCT óõíÝâáëå óôçí ïñèÞ äéÜãíùóç ôùí Þðéùí ìïñöþí ôçò íüóïõ, ðáñáôçñÞèçêå üìùò üôé áóèåíåßò ìå áðïäåäåéãìÝíç äéÜìåóç ðíåõìïíïðÜèåéá ìðïñåß íá åß÷áí öõóéïëïãéêÞ HRCT.8

Åéêüíá 2. Áêôéíïãñáößá èþñáêïò áóèåíïýò ìå õðïîåßá ÅÁÊ: èïëåñüôçôá, ïæßäéá êáé Þðéåò éíùôéêÝò áëëïéþóåéò óôá ìÝóá êáé êÜôù ðíåõìïíéêÜ ðåäßá.

Åéêüíá 3. Áêôéíïãñáößá èþñáêïò áóèåíïýò ìå ÷ñïíßá ÅÁÊ: äéêôõïæþäåéò óêéÜóåéò ìå åéêüíá ìåëéêçñÞèñáò óôá ìÝóá êáé éäéáßôåñá êÜôù ðíåõìïíéêÜ ðåäßá. 27

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Óôçí ïîåßá ìïñöÞ ôçò ðíåõìïíßáò åî õðåñåõáéóèçóßáò, ç HRCT åðéâåâáéþíåé ôçí ýðáñîç ôçò åéêüíáò ôçò “èïëÞò õÜëïõ” üôáí áõôÞ ðéèáíïëïãåßôáé óôçí áðëÞ áêôéíïãñáößá.8 Óôçí õðïîåßá ìïñöÞ ôçò íüóïõ ìðïñåß íá âñåèïýí ïæßäéá, åéêüíá “èïëÞò õÜëïõ”, ðáãßäåõóç áÝñá óôïõò ìéêñïýò áåñáãùãïýò (air trapping), åìöõóçìáôéêÝò ðåñéï÷Ýò Þ Þðéåò éíùôéêÝò áëëïéþóåéò.7 Ôá åõñÞìáôá áõôÜ âåëôéþíïíôáé åíôõðùóéáêÜ ìå ôçí áðïìÜêñõíóç ôïõ áôüìïõ áðü ôï áíôéãüíï êáé ôç ÷ïñÞãçóç êïñôéêïóôåñïåéäþí. ÔÝëïò óôç ÷ñüíéá ìïñöÞ äéáðéóôþíåôáé äéêôõïïæéäéáêÞ åéêüíá ðïõ ìðïñåß íá åîåëé÷èåß óå åéêüíá ìåëéêçñÞèñáò. Óõó÷åôßæïíôáò ôá ðáèïëïãïáíáôïìéêÜ åõñÞìáôá ìå ôá áêôéíïëïãéêÜ èåùñïýìå üôé ôá êïêêéþìáôá áíôéóôïé÷ïýí óå ðåñéï÷Ýò “èïëÞò õÜëïõ”, ïé ïæéäéáêÝò ðåñéï÷Ýò áíôéóôïé÷ïýí óå ðåñéï÷Ýò äéÜìåóçò ðíåõìïíßáò, êõôôáñéêÞò äéÞèçóçò ôùí âñïã÷éïëßùí êáé óå êïêêéþìáôá, åíþ ïé ðåñéï÷Ýò ìå ãñáììïåéäåßò óêéÜóåéò áíôéóôïé÷ïýí óå éíùôéêÝò ðåñéï÷Ýò.7,8 ÔÝëïò, ðñÝðåé íá áíáöåñèåß üôé ç áíåýñåóç åéêüíáò “èïëÞò õÜëïõ” êáé ïæéäßùí óçìáßíåé ìÜëëïí áíáóôñÝøéìåò áëëïéþóåéò (öëåãìïíÞ), åíþ ç áíåýñåóç åéêüíáò ãñáììïåéäþí óêéÜóåùí Þ ìåëéêçñÞèñáò óçìáßíåé ìÜëëïí ìç áíáóôñÝøéìåò áëëïéþóåéò (ßíùóç).

Äïêéìáóßåò ðíåõìïíéêÞò ëåéôïõñãßáò Ïé ëåéôïõñãéêÝò äïêéìáóßåò ôïõ ðíåýìïíá èá ìáò äåßîïõí áëëïéþóåéò ïé ïðïßåò äåí åßíáé ïýôå åéäéêÝò ïýôå äéáãíùóôéêÝò ãéá ôç íüóï. Ï áóèåíÞò ìå ðíåõìïíßá åî õðåñåõáéóèçóßáò ðáñïõóéÜæåé ðåñéïñéóôéêïý ôýðïõ áëëïéþóåéò óôïí Ýëåã÷ï ôçò áíáðíïÞò. Ç æùôéêÞ ÷ùñçôéêüôçôá (VC) ìåéþíåôáé åíþ ï õðïëåéðüìåíïò üãêïò (RV) äéáôçñåßôáé. Åðßóçò ï ëüãïò FEV1 (âßáéá åêðíåüìåíïò üãêïò óôï ðñþôï äåõôåñüëåðôï)/FVC (æùôéêÞ ÷ùñçôéêüôçôá óå âßáéç åêðíïÞ) ðáñáìÝíåé óå öõóéïëïãéêÜ åðßðåäá. Ïé áóèåíåßò ìå ÅÁÊ ðáñïõóéÜæïõí äéáôáñá÷Ýò óôçí áíôáëëáãÞ ôùí áåñßùí, ç ïðïßá ÷áñáêôçñßæåôáé áðü õðïîáéìßá ç ïðïßá óõíÞèùò ÷åéñïôåñåýåé êáôÜ ôç äéÜñêåéá ôçò Üóêçóçò, åíþ ç áñôçñéáêÞ ðßåóç ôïõ CO2 åßíáé öõóéïëïãéêÞ Þ åëáöñÜ áõîçìÝíç.9 Åäþ ðñÝðåé íá áíáöÝñïõìå üôé Ýíáò êáëüò êáé åõáßóèçôïò äåßêôçò ôçò äéáôáñá÷Þò ôçò ðíåõìïíéêÞò ëåéôïõñãßáò óå áóèåíåßò ìå ðíåõìïíßá åî õðåñåõáéóèçóßáò åßíáé ç ìåßùóç ôçò äéá÷õôéêÞò éêáíüôç28

A. ÊïðáíÜêçò êáé óõí

ôáò ãéá ôï ìïíïîåßäéï (DLCO). Ðáñáôçñåßôáé åðßóçò êÜðïéïò âáèìüò áðüöñáîçò ôùí ðåñéöåñéêþí áåñáãùãþí, üðùò áõôü öáßíåôáé áðü ôçí åëÜôôùóç ôçò ìÝãéóôçò êáé ôçò ìåóïåêðíåõóôéêÞò ñïÞò. Áõôü ìðïñåß íá ïöåßëåôáé óôç âñïã÷éïëßôéäá. Áðü ôçí Üëëç, Ýíáò óçìáíôéêüò áñéèìüò áóèåíþí ðáñïõóéÜæåé õðåñáíôéäñáóôéêïýò áåñáãùãïýò. ÔÝëïò ðñÝðåé íá áíáöåñèåß, üôé ï ëåéôïõñãéêüò Ýëåã÷ïò ôùí ðíåõìüíùí äåí ìðïñåß íá ÷ñçóéìåýóåé ùò ðñïãíùóôéêü óôïé÷åßï ôçò åîÝëéîçò ôçò íüóïõ, áöïý Ý÷åé áíáöåñèåß åõíïúêÞ åîÝëéîç ôçò íüóïõ óå áñêåôïýò áóèåíåßò ìå ðáèïëïãéêÞ óðéñïìÝôñçóç.

Åñãáóôçñéáêüò Ýëåã÷ïò ÓÞìåñá äåí õðÜñ÷ïõí åéäéêïß åñãáóôçñéáêïß äåßêôåò, ìå ôïõò ïðïßïõò èá ìðïñïýóå ìå áóöÜëåéá íá ôåèåß ç äéÜãíùóç ôçò íüóïõ Þ êáé íá ðáñáêïëïõèåßôáé ç ðïñåßá ôçò íüóïõ.

Âñïã÷ïêõøåëéäéêü Ýêðëõìá (BAL) Ç ôõðéêÞ åéêüíá ôïõ BAL (ðïõ ëáìâÜíåôáé ìÝóù âñïã÷ïóêüðçóçò), ôùí áóèåíþí ìå ðíåõìïíßáò åî õðåñåõáéóèçóßáò, åßíáé åêåßíç ôçò áýîçóçò ôïõ óõíïëéêïý áñéèìïý ôùí êõôôÜñùí ìå ÷áñáêôçñéóôéêÞ áýîçóç ôïõ ðïóïóôïý ôùí ëåìöïêõôôÜñùí (óõ÷íÜ >50% ôïõ óõíüëïõ ôùí êõôôÜñùí).10 Ç ðëåéïøçößá ôùí ëåìöïêõôôÜñùí ôïõ BAL åßíáé Ô-ëåìöïêýôôáñá. Ç áíÜëõóç ôùí öáéíïôýðùí ôçò åðéöÜíåéáò ôùí Ô-êõôôÜñùí äåß÷íåé åðéêñÜôçóç ôùí CD8 T-êõôôÜñùí êáé åëÜôôùóç ôçò ó÷Ýóçò CD4/CD8 óå ôéìÞ êÜôù ôïõ 1.10 Öáßíåôáé üôé ôï BAL åîáñôÜôáé áðü ôç ÷ñïíéêÞ óôéãìÞ ôçò åêôÝëåóçò ôçò åîÝôáóçò óå ó÷Ýóç ìå ôçí Ýêèåóç ôïõ áóèåíïýò óôï áíôéãüíï. ¢ìåóç åêôÝëåóç ôïõ BAL, åíôüò 24 ùñþí áðü ôç óôéãìÞ ôçò Ýêèåóçò, ïäçãåß óå áýîçóç ôùí ëåìöïêõôôÜñùí, ïõäåôåñïößëùí, çùóéíïößëùí êáé ìáóôïêõôôÜñùí. ÅêôÝëåóç ôïõ BAL ìåôÜ ôç 10ç ìÝñá åìöáíßæåé ôÜóç âáèìéáßáò åðáíüäïõ óôï öõóéïëïãéêü. Óõíåðþò ðñÝðåé íá åêôåëåßôáé ôï BAL ìÝóá óå 24-48 þñåò. Ç áîéïëüãçóÞ ôïõ åßíáé óçìáíôéêÞ ãéáôß ëåìöïêýôôáñá >50%, ìåßùóç ôïõ ëüãïõ CD4/CD8 êÜôù ôïõ 1, éóôïñéêü Ýêèåóçò óå Üôïìï ìå äýóðíïéá êáé áêñïáóôéêÜ åõñÞìáôá (ôñßæï-

Ôüìïò 17, Ôåý÷ïò 1, 2005

A. ÊïðáíÜêçò êáé óõí

íôåò), åßíáé åðáñêÞ ãéá ôç óôÞñéîç ôçò äéÜãíùóçò ôçò íüóïõ.10 Äïêéìáóßåò ðñüêëçóçò ÓçìáíôéêÞ áñùãÞ óôç äéÜãíùóç ðáñÝ÷åé ç åðáíÝêèåóç ôïõ áóèåíïýò óôï ðåñéâÜëëïí ìå ôï õðåýèõíï áíôéãüíï, ç ïðïßá ìðïñåß íá óõó÷åôéóôåß ìå óõãêåêñéìÝíá óõìðôþìáôá.11 Óõ÷íüôåñá ïé áóèåíåßò ìðïñåß íá ðáñïõóéÜóïõí ðõñåôü, êáêïõ÷ßá, ðïíïêÝöáëï, ôñßæïíôåò, ðåñéöåñéêÞ ïõäåôåñïöéëßá êáé ìåéùìÝíï FVC, óõìðôþìáôá ðïõ ðáñïõóéÜæïíôáé 8-12 þñåò ìåôÜ ôçí Ýêèåóç. Õðïîáéìßá êáé áêôéíïëïãéêÝò áíùìáëßåò ìðïñåß åðßóçò íá ðáñïõóéáóôïýí óå óïâáñÝò ðåñéðôþóåéò. Óõíåðþò, ï áóèåíÞò ðñÝðåé íá ðáñáêïëïõèåßôáé óôåíÜ ãéá ôïõëÜ÷éóôïí 24 þñåò. Ìéá Üëëç ìÝèïäïò ðñüêëçóçò åßíáé ç ðñïðáñáóêåõÞ ôùí ýðïðôùí áíôéãüíùí óå íïóïêïìåéáêü åðßðåäï, ç ïðïßá üìùò äåí ìðïñåß íá ÷ñçóéìïðïéçèåß åõñÝùò, áöåíüò ãéáôß ìðïñåß íá åðéöÝñåé ðñïïäåõôéêÞ íüóï êáé áöåôÝñïõ ãéáôß äåí åßíáé äéáèÝóéìá ðñïêáèïñéóìÝíá áíôéãüíá.11 Âéïøßá ðíåýìïíá ÉóôïðáèïëïãéêÞ åðéâåâáßùóç ôçò äéÜãíùóçò ôçò íüóïõ áðáéôåßôáé óå ðïëëÝò ðåñéðôþóåéò êáé ðñÝðåé íá åðé÷åéñåßôáé ìå äéáâñïã÷éêÞ âéïøßá ôïõ ðíåýìïíá (ìÝóù âñïã÷ïóêüðçóçò),12 åêôüò áðü ðñï÷ùñçìÝíåò ðåñéðôþóåéò üðïõ ôï ÷åéñïõñãéêü ðáñáóêåýáóìá ðáñÝ÷åé êáëýôåñåò ðëçñïöïñßåò. Åßíáé óçìáíôéêü íá ðëçñïöïñçèåß ï ðáèïëïãïáíáôüìïò ãéá ôçí õðïøßá ôçò ÅÁÊ, êáèüôé ôá åõñÞìáôá óõ÷íÜ åßíáé äõóäéÜêñéôá êáé ðñÝðåé íá åñìçíåõôïýí ìå âÜóç ôçí êëéíéêÞ åéêüíá ôïõ áóèåíïýò. Ç âéïøßá ðíåýìïíá ìðïñåß íá ìçí áñêåß ãéá ôç äéÜãíùóç êáè’ üôé ôá åõñÞìáôÜ ôçò áðáíôïýí êáé óå Üëëá íïóÞìáôá. ÄéáöïñéêÞ äéÜãíùóç Ç äéÜãíùóç ôçò ïîåßáò ðíåõìïíßáò åî õðåñåõáéóèçóßáò åßíáé óõ÷íÜ äýóêïëï íá ôåèåß êáé áðáéôåß õøçëü äåßêôç õðïøßáò. ×ùñßò óáöÝò éóôïñéêü Ýêèåóçò óå Ýíá åíï÷ïðïéïýìåíï ðáñÜãïíôá åßíáé ðïëý äýóêïëï íá äéáêñéèåß áðü ìéá ïîåßá ëïßìùîç ôïõ áíáðíåõóôéêïý, üðùò áðü ìéá Üôõðç ðíåõìïíßá ìõêïðëáóìáôéêÞ Þ éïãåíÞ.2 Åðßóçò

Ý÷åé áíáöåñèåß üôé áóèåíåßò ìå ïîåßá íüóï ìðïñåß íá åìöáíßóïõí áõîçìÝíïõò ôßôëïõò áíôéóùìÜôùí ãéá ôï ìõêüðëáóìá Þ ôïõò éïýò ôçò ãñßðçò. Ç äéáöïñéêÞ äéÜãíùóç ôçò õðïîåßáò ìïñöÞò ôçò íüóïõ ðåñéëáìâÜíåé ôéò êïêêéùìáôþäåéò öëåãìïíÝò ôïõ ðíåýìïíá üðùò ç öõìáôßùóç, êáèþò êáé ìç ëïéìþäåéò íüóïõò ôïõ ðíåýìïíá üðùò ç óáñêïåßäùóç. ÔÝëïò ç ÷ñüíéá ìïñöÞ ôçò íüóïõ ìðïñåß íá ìéìçèåß êÜèå äéÜìåóç ðíåõìïíïðÜèåéá êáèþò êáé ôçí éäéïðáèÞ ðíåõìïíéêÞ ßíùóç.13 Èåñáðåßá Ç Ýãêáéñç äéÜãíùóç ôçò íüóïõ êáé ç áðïöõãÞ ôçò Ýêèåóçò ôïõ áóèåíÞ óôï íïóçñü ðåñéâÜëëïí áðïôåëïýí êëåéäéÜ ãéá ôç èåñáðåõôéêÞ ðñïóÝããéóç áëëÜ êáé ãéá ôçí ðñüãíùóç ôçò íüóïõ.14 ¸÷åé áíáêïéíùèåß üìùò üôé ðïëëÜ Üôïìá áí êáé óõíå÷ßæïõí ôçí Ýêèåóç ôïõò óôï áíôéãüíï ðáñïõóßáóáí ýöåóç ôçò íüóïõ.15 Áõôü ìðïñåß íá åñìçíåýåôáé áðü ôï ãåãïíüò ôçò áðåõáéóèçôïðïßçóçò ôïõ ïñãáíéóìïý áðü ôç óõíå÷Þ Ýêèåóç óôï áíôéãüíï Þ ôçí áíÜðôõîç ôçò ëåãüìåíçò áíïóïëïãéêÞò áíï÷Þò. Ðáñüëá áõôÜ ðñÝðåé íá ãßíåôáé óýóôáóç óå áóèåíåßò ìå åîÝëéîç ôçò íüóïõ ãéá áðïöõãÞ ôïõ õðåýèõíïõ áíôéãüíïõ ìå ïðïéïäÞðïôå äõíáôü ôñüðï.16 Ðáñüìïéá ðñïâëÞìáôá ðáñïõóéÜæïíôáé êáé óôïõò åêôñïöåßò ðôçíþí ïé ïðïßïé óõ÷íÜ åßíáé áðñüèõìïé íá åãêáôáëåßøïõí ôá ðôçíÜ ôïõò. ¼ìùò áêüìá êáé áí áëëÜîïõí ðåñéâÜëëïí åñãáóßáò ç âåëôßùóç áðü ôç íüóï äåí åßíáé âÝâáéç, êáè’ üôé ôá áíôéãüíá ôùí ðôçíþí óôï óðßôé ðïõ äéáìÝíïõí ðáñáìÝíïõí óå õøçëÜ åðßðåäá êáé ãéá ðáñáôåôáìÝíï ÷ñïíéêü äéÜóôçìá ìåôÜ ôçí áðïìÜêñõíóç ôùí ðôçíþí. Ç ðñüëçøç ôçò åéóðíïÞò ôïõ áíôéãüíïõ ðåñéëáìâÜíåé ôá áêüëïõèá ìÝôñá14,17: • ÌÜóêåò ìå ößëôñï áðïññïöÞóåùò êüíåùò. • ÅðáñêÞ åîáåñéóìü ôïõ ÷þñïõ åñãáóßáò. • Ìç÷áíïðïßçóç ðïëëþí åñãáóéþí. Óôéò ðéï óïâáñÝò üìùò ìïñöÝò ôçò óõ÷íÜ áðáéôåßôáé ç èåñáðåßá ìå êïñôéêïóôåñïåéäÞ.1 Ç Ýíáñîç ôçò áãùãÞò ãßíåôáé óå äïóïëïãßá 1mg/ Kg âÜñïõò ðñåäíéæïëüíçò ãéá Ýíá ìÞíá. Ç äüóç óôç óõíÝ÷åéá ìåéþíåôáé óôá 10-15mg ôçí çìÝñá êáé äéáêüðôåôáé ðñïïäåõôéêÜ åßôå üôáí ï áóèåíÞò ðáñïõóéÜóåé ðëÞñç ßáóç Þ üôáí äåí ðáñïõóéÜóåé êáìßá êëéíéêÞ Þ åñãáóôçñéáêÞ âåëôßùóç. 29

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Óå ðåñßðôùóç õðïôñïðÞò üôáí ç êïñôéæüíç Ý÷åé äéáêïðåß Þ üôáí ìåéþíåôáé ç äüóç ôçò, åðáíá÷ïñçãåßôáé õøçëÞ äüóç êïñôéæüíçò Þ ïðïßá óôç óõíÝ÷åéá äéáêüðôåôáé âáèìéáßá. Ç ÷ïñÞãçóç åéóðíåüìåíùí êïñôéêïåéäþí äåí Ý÷åé áðïäåé÷èåß áðïôåëåóìáôéêÞ óôçí áíôéìåôþðéóç ôçò íüóïõ.18 Ðñüãíùóç êáé Åðéâßùóç Ðïëý óçìáíôéêÞ ãéá ôçí ðñüãíùóç êáé ôçí åîÝëéîç ôçò íüóïõ åßíáé ç Ýãêáéñç äéÜãíùóç êáé ç áðïöõãÞ ôçò Ýêèåóçò ôïõ áôüìïõ óôïí áëëåñãéïãüíï ðáñÜãïíôá. Ç ìáêñï÷ñüíéá ðïñåßá ôçò ðíåõìïíßáò åî õðåñåõáéóèçóßáò ðïéêßëëåé. Ç èíçôüôçôá ôçò ïîåßáò íüóïõ åßíáé <1%.19 ¸÷åé áíáöåñèåß üôé ç ÷ñüíéá íüóïò óå áóèåíåßò ìå íüóï ôùí åêôñïöÝùí ðôçíþí ïäçãåß óôï èÜíáôï óå ðïóïóôü 25% åíôüò ðåíôáåôßáò áðü ôçí Ýíáñîç ôçò íüóïõ.20 Ç ðáñïõóßá åéêüíáò ìåëéêçñÞèñáò óôçí áêôéíïãñáößá èþñáêïò êáé ðëçêôñïäáêôõëßáò êáôÜ ôç ãåíéêÞ åîÝôáóç áðïôåëïýí äåßêôåò óïâáñÞò ìïñöÞò ôçò íüóïõ êáé êáêÞò ðñüãíùóçò.21

Âéâëéïãñáößá 1. Pabst S, Weisser B, Vetter H, Grohe Ch. Extrinsic allergic alveolitis. Schweiz Rundsch Med Prax 93:643-8, 2004. 2. Hendrick DJ. Extrinsic allergic alveolitis in practice. Practitioner 248:268-73, 2004. 3. Grant IW, Blyth W, Wardrop VE, et al. Prevalence of farmer’s lung in Scotland: a pilot survey. Br Med J, 1:530-4, 1972. 4. Malmberg, P, Rask-Andersen, A, Hoglund, S, et al. Incidence of organic dust toxic syndrome and allergic alveolitis in Swedish farmers. Int Arch Allergy Appl Immunol, 87:47-54, 1988. 5. Cormier Y, Lacasse Y. Keys to the diagnosis of hypersensitivity pneumonitis: The role of serum precipitins, lung biopsy, and high-resolution computed tomography. Clin Pulm Med, 3:72-78, 1996. 6. Rose CS, Martyny JW, Newman LS, et al. “Lifeguard lung”: Endemic granulomatous pneumonitis in an indoor swimming pool. Am J Public Health, 88:1795-800, 1998. 7. Lynch DA, Newell JD, Logan PM, et al. Can CT distinguish idiopathic pulmonary fibrosis from hypersensitivity pneumonitis? AJR Am J Roentgenol, 165:807-11, 1995. 30

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8. Cormier Y, Brown M, Worthy S, et al. Highresolution computed tomographic characteristics in acute farmer’s lung and in its follow-up. Eur Respir J, 16:56–60, 2000. 9. Du Wayne Schmidt C, Jensen RL, Christensen LT, et al. Longitudinal pulmonary function changes in pigeon breeders. Chest, 93:359–63, 1988. 10. Costabel U, Guzman J. Bronchoalveolar lavage in interstitial lung disease. Curr Opin Pulm Med, 7:255-61, 2001. 11. Ohtani Y, Kojima K, Sumi Y, et al. Inhalation provocation tests in chronic bird Fancier’s lung. Chest. 118:1382-9, 2000. 12. Ìåñìßãêçò ×, Ìåñìßãêçò Ä, ÊïðáíÜêçò Á. Äéáâñïã÷éêÞ âéïøßá ðíåýìïíïò. ¸êäïóç ôçò ÅëëçíéêÞò ÐíåõìïíïëïãéêÞò Åôáéñåßáò, ÄéÜ÷õôåò ÄéÜìåóåò ÐíåõìïíïðÜèåéåò, ÐåñéïäéêÝò Åêäüóåéò ôçò ÅëëçíéêÞò ÐíåõìïíïëïãéêÞò Åôáéñåßáò, ÁèÞíá, 167-180, 2003. 13. ÊïðáíÜêçò Áíô, Ðáóóáëßäïõ Å, Ìåñìýãêçò ×, ÊáóôáíÜêçò Å, Ðïëõ÷ñïíüðïõëïò Â. Äýóðíïéá óôçí êüðùóç óå áóèåíÞ ìå äéáìÝóïõ ôýðïõ óêéÜóåéò Üìöù. Ðíåýìùí, 16:342-347, 2003. 14. ÊïðáíÜêçò Á, ÐáôåíôáëÜêçò Ì. Ôé íåþôåñï óôç èåñáðåßá ôùí äéÜ÷õôùí åðáããåëìáôéêþí íïóçìÜôùí. Ðíåýìùí 15:103-105, 2002. 15. Bourke SJ, Banham SW, Carter R, et al. Longitudinal course of extrinsic allergic alveolitis in pigeon breeders. Thorax 1989; 44:415–8. 16. Cormier Y, Belanger J. Long-term physiologic outcome after acute farmer’s lung. Chest, 87:796–800, 1985. 17. Kusaka H, Ogasawara H, Munakata M, et al. Two-year follow up on the protective value of dust masks against farmer’s lung disease. Intern Med, 32:106–11, 1993. 18. Ramírez A, Sansores R, Chapela R, et al. Inhaled beclomethasone versus oral prednisone. A clinical trial in patients with hypersensitivity pneumonitis. Am J Respir Crit Care Med, 151:A605, 1995. 19. Kokkarinen J, Tukiainen H, Terho EO. Mortality due to farmer’s lung in Finland. Chest, 106:509–12, 1994. 20. Pérez-Padilla R, Salas J, Chapela R, et al. Mortality in Mexican patients with chronic pigeon breeders lung compared to those with usual interstitial pneumonia. Am Rev Respir Dis, 148:49–53, 1993. 21. Erkinjuntti-Pekkanen R, Rytkonen H, Kokkarinen JI, et al. Long-term risk of emphysema in patients with farmer’s lung and matched control farmers. Am J Respir Crit Care Med, 158:662–5, 1998.

P.J. Gupta

Ôüìïò 16, Ôåý÷ïò 4, 2004

EIÄIKO ÁÑÈÑÏ SPECIAL ARTICLE Primary Heatlh Care, Volume 17, Number 1, 31-33, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 31-33, 2005

Primary care in ano-rectal conditions Pravin J. Gupta

Ðåñßëçøç Ïé ðáèÞóåéò ôïõ ïñèïðñùêôéêïý óùëÞíá åßíáé óõíÞèåéò êáé óõ÷íÜ ïé ãéáôñïß ôçò Ð.Ö.Õ. Ýñ÷ïíôáé áíôéìÝôùðïé ìå äýóêïëåò åñùôÞóåéò ó÷åôéêÜ ìå ôçí êáëýôåñç äõíáôÞ áíôéìåôþðéóç ôùí óõìðôùìÜôùí ôïõò. Óôï åéäéêü áõôü Üñèñï ðåñéãñÜöïíôáé ìå ðñáêôéêü ôñüðï, ç óõìðôùìáôïëïãßá êáé ç èåñáðåõôéêÞ áíôéìåôþðéóç áõôþí ôùí êáôáóôÜóåùí.

M.S., Consulting Proctologist, Gupta Nursing Home, INDIA,

Primary care in ano-rectal conditions P.J. Gupta Summary This article aims to present some aspects of the pharmaceutical market in Greece. Specifically, the paper focuses on the impact of excessive state intervention in the health care market and pharmaceutical pricing. It is concluded that there is a need to include clinical and socioeconomic evaluation criteria, and introduce price referencing for pharmaceuticals, in the battery of state intervention tools and market regulation in order to promote efficiency and cost control policies.

Diseases of the rectum and anus are common phenomena. As doctors of first contact, primary care physicians frequently face with difficult questions concerning the optimum management of ano-rectal symptoms1. This brief perspective attempts to offer a practical approach to the management of a variety of the ano-rectal diseases. Symptomatology of ano-rectal pathologies 1. Anal Pain 2. Bleeding per rectum 3. Pus discharge from and around anus 4. Prolapse 5. Anal pruritus 6. Presence of swelling or lump in or around anus 7. Passage of mucus per rectum 8. Constipation or fecal obstruction 9. Frequency of stool 10. Difficulty in passing stool 11. Incontinence to flatus or feces. Investigating a case of ano-rectal

Key words: Ano-rectal conditions, treatment, primary health care ËÝîåéò êëåéäéÜ: ðáèÞóåéò ïñèïðñùêôéêïý óùëÞíá, èåñáðåßá, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: 25 Aõãïýóôïõ 2004 ÅðáíõðïâëÞèçêå: 5 Öåâñïõáñßïõ 2005 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 15 Öåâñïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: Pravin J. Gupta, M.S., Consulting Proctologist, Gupta Nursing Home, D/9, Laxminagar, NAGPUR- 440022, INDIA, Phone: +49 712 2231047, Fax: +49 712 2547837, e-mail: drpjg_npg@sancharnet.in 31

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

lesion- the patient’s history, inspection, and palpation of the anorectum remain the basic, essential features of diagnosis. Anoscopy [proctoscopy] remains the mainstay in detection of anal pathologies. When a more proximal lesion is suspected, a sigmoidoscopy or colonoscopy along with biopsy is needed2.

Treatment of ano-rectal diseases Family physicians could manage most of the common anorectal disorders they encounter in office practice. Most cases could be treated by conservative medical treatment (e.g., dietary changes, sitz bath, analgesics, antibiotics, stool softeners, hemorrhoidal creams and suppositories) or non-surgical procedures. Acute anal fissures are superficial and are usually multiple. They respond well to conservative therapies like warm sitz bath, application of various ‘hemorrhoidal’ creams, analgesics, and dietary modifications. Proper anal hygiene and correction of chronic constipation or diarrhea are essential to prevent recurrence of fissures. Chronic anal fissures require some sort of internal sphincter manipulation. Such manipulation could be either surgical or non-surgical. Surgery remains the option to be offered to patients with relapse or therapeutic failure of the pharmacological treatment already undergone. It has been estimated that 50% of the population develops hemorrhoids by the age of 50 years. Although, not constituting an etiological treatment of the disease, conservative treatment do have a role in relieving the symptoms of hemorrhoids and associated complaints. In case of failure with these therapies, instrumental treatment like infrared coagulation, rubber band ligation, radiofrequency ablation or Doppler assisted hemorrhoidal artery ligation can always be offered to the patients. Surgery remains the choice of treatment in advanced disease3. Medical treatment of hemorrhoids includes control of constipation using bran, mucilage, lactulose or bulk forming laxatives. Increasing daily intake of fibers, avoidance of colonic stimulants like coffee, tea and spices, use of fla32

P.J. Gupta

vonoid derivatives [Diosmin] and Calcium Dobisilate, and use of hemorrhoidal creams, ointments and suppositories. The anorectal area is susceptible to several infectious and inflammatory processes. Abscesses often have their origin in an infection in the anal glands. The suppurative process then tracks through the various planes in the anorectal region. The infection can present at the anal verge as a perianal abscess. These abscesses could easily be drained in the office under local anesthesia. Patients with fistulas are generally referred to a specialist for treatment. Pilonidal abscess could be drained under local anesthesia in the office. Rectal prolapse could be either mucosal or full thickness [Procedentia]. Treatment in both the situations is through surgical intervention. A child presenting with bleeding per rectum and protrusion of ‘something’ from the anus may have a juvenile rectal polyp. A full-length colonoscopy helps in ruling out possible lesions higher up before going for its removal. Malignancy of the ano-rectum could manifest in many different symptoms or may be incidentally found during rectal examination. Most anal cancers respond well to treatment with combined chemotherapy and pelvic radiation. Colorectal cancers always need a surgical treatment. Condylomas present as warty growths in or around the anus. These warts can produce pruritus, soiling, bleeding and may be a constant source of irritation. Various office procedures available for their treatment include- Application of 85% Trichloroacetic acid, Cryotherapy, Oral interferon and flurouracil, radiofrequency ablation, laser removal, electrodessication or surgical removal. Ulcerative colitis or Crohn’s disease can involve the rectal area, presenting with rectal discomfort, tenesmus, rectal discharge, and constipation/increased frequency of stool. A fulllength colonoscopy and biopsy is needed to establish the diagnosis. Medical treatment often proves beneficial in most of the patients. Drugs like Sulphasalazine, 5-Aminosalicylic acid and corticosteriods have often been found effective. External anal tags may cause symptoms like itching, anxiety, or hygienic problems. They can

Ôüìïò 16, Ôåý÷ïò 4, 2004

P.J. Gupta

be removed under local anesthesia. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or presence of foreign bodies. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears. Constipation is a symptom, which is not measurable scientifically. The approach for the treatment of constipation is multimodal. Increase in the dietary fiber intake and use of bulking agents like Ispaghula [psyllium], methylcellulose, bran, karaya gum, and similar preparations are useful in facilitation of the defecatory process. Lactulose, sorbitol, and lactilol have minimum known side effects and are considered safe in pregnancy and in children. Senna, bisacodyl, sodium picosulphate, and magnesium salts should be used with caution. Low doses of polyethylene glycol and sodium phosphate could be used for intermittent lavage of the bowel. Drugs like Cisapride, Mosapride, Itiopride, and Docusates are known to improve intestinal motility and could be prescribed for a prescribed duration. Proctitis is usually caused by sexually transmitted infections that could be treated with antibiotics. Pruritus ani due to fungal infections and hygiene problems are amenable to simple treatments. Thrombosed external hemorrhoids could be opened and drained. Perirectal or ischiorectal abscesses require incision and drainage, sometimes under general anesthesia. Con-

stipation is common in children, which in turn may result in anal fissures4. Such fissures should be treated using stool softeners like lactulose, use of anesthetic ointment and maintenance of local hygiene. It is estimated that almost 1/3rd of pregnant women develop anal fissures and thrombosed external hemorrhoids after delivery5. Managing constipation during and after gestation can minimize most of the ano-rectal lesions and their symptomatic outcome. Anal fissure during the antepartum period should possibly be dealt with a conservative approach.

References 1. Janicke DM, Pundt MR. Anorectal disorders. Emerg Med Clin North Am, 14:757-788, 1996. 2. Kamm MA. Diagnostic, pharmacological, surgical, and behavioral developments in benign anorectal disease. Eur J Surg Suppl, 582:119123, 1998. 3. Orlay G. Haemorrhoids – a review. Aust Fam Physician, 32:523-526, 2003. 4. Youssef NN, Di Lorenzo C. Childhood constipation: evaluation and treatment. J Clin Gastroenterol, 33:199-205, 2001. 5. Abramowitz L, Batallan A. Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum. Gynecol Obstet Fertil, 31:546-549, 2003.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Êõñéüðïõëïò

ÅÉÄÉÊÏ ÁÑÈÑÏ SPECIAL ARTICLE Primary Heatlh Care, Volume 17, Number 1, 34-37, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 34-37, 2005

Ç ñýèìéóç ôçò öáñìáêåõôéêÞò áãïñÜò óôçí ÅëëÜäá. Ôõ÷áßåò óêÝøåéò ãéá ôçí åíáñìüíéóç ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò êáé ôùí ìç÷áíéóìþí ôçò áãïñÜò Ã. Êõñéüðïõëïò1 Ðåñßëçøç Óôï Üñèñï áõôü, ðáñïõóéÜæïíôáé ìåñéêÝò ðëåõñÝò ôçò öáñìáêåõôéêÞò áãïñÜò óôçí ÅëëÜäá. Åéäéêüôåñá, ôï êåßìåíï åóôéÜæåôáé óôéò åðéðôþóåéò ôçò õðåñâïëéêÞò êñáôéêÞò ðáñÝìâáóçò óôçí õãåéïíïìéêÞ áãïñÜ êáé óôéò ôéìÝò ôùí öáñìÜêùí. Ùò óõìðÝñáóìá óõíÜãåôáé üôé åßíáé áíáãêáßï íá åéóá÷èïýí êñéôÞñéá êëéíéêÞò êáé êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò êáé íá åéóá÷èïýí ôéìÝò áíáöïñÜò óôá öáñìáêåõôéêÜ ðñïúüíôá êáé íá õðÜñ÷åé óýæåõîç ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò êáé ôùí ñõèìßóåùí ôçò áãïñÜò, þóôå íá ðñïÜãåôáé ç áðïäïôéêÞ ÷ñÞóç ôùí ðüñùí êáé ï Ýëåã÷ïò ôïõ êüóôïõò.

ÊáèçãçôÞò Ïéêïíïìéêþí ôçò Õãåßáò êáé Ðñüåäñïò ôçò Federation for International Cooperation of Health Services and Systems Research Centers (FICOSSER)

Pharmaceuticals market regulation in Greece Random reflections on the harmonization of state intervention tools and market mechanisms J. Kyriopoulos Summary This article aims to present some aspects of the pharmaceutical market in Greece. Specifically, the paper focuses on the impact of excessive state intervention in the health care market and pharmaceutical pricing. It is concluded that there is a need to include clinical and socioeconomic evaluation criteria, and introduce price referencing for pharmaceuticals, in the battery of state intervention tools and market regulation in order to promote efficiency and cost control policies. Key words: Pharmaceutical, State intervention, Socioeconomic evaluation, Pricing, Market

ÅéóáãùãÞ Åßíáé ãíùóôü üôé ïé õãåéïíïìéêÝò áãïñÝò (êáôÜ óõíÝðåéá êáé ç öáñìáêåõôéêÞ áãïñÜ) ÷áñáêôçñßæïíôáé áðü ôçí áðïõóßá åðáñêïýò ðëçñïöüñçóçò ôùí ÷ñçóôþí, åíþ ç áãïñÜ ôïõ öáñìÜêïõ åìöáíßæåé åðßóçò Ýíôïíåò ìïíïðùëéáêÝò ôÜóåéò óå åêôåôáìÝíá ðåäßá åöáñìïãÞò åîáéôßáò ôçò êáôï÷ýñùóçò ôçò åõñåóéôå÷íßáò êáé áðü ôçí ðáñïõóßá ôçò áóöÜëéóçò, ç ïðïßá åõèýíåôáé ãéá ôçí Ýëëåéøç åõáéóèçóßáò ùò ðñïò ôéò ôéìÝò, ÷áñáêôçñéóôéêÜ ôá onoia åðéôåßíïõí ôéò óôñåâëþóåéò êáé èåìåëéþíïõí ôçí áíÜãêç êñáôéêÞò ðáñÝìâáóçò. Áîßæåé íá óçìåéùèåß üôé ç áãïñÜ ÷áñáêôçñßæåôáé åðßóçò áðü êÜðïéï âáèìü Üãíïéáò ôùí ðñïìçèåõôþí êáé êõñßùò ôùí óõíôáãïãñÜöùí ãéáôñþí åîáéôßáò ôçò äõó÷Ýñåéáò äéá÷åßñéóçò ìåãÜëïõ ðëÞèïõò êëéíéêþí (äéáãíùóôéêþí êáé èåñáðåõôéêþí) ðëçñïöïñéþí.

ËÝîåéò êëåéäéÜ: ÖÜñìáêá, ÊñáôéêÞ ÐáñÝìâáóç, ÊïéíùíéêïïéêïíïìéêÞ Áîéïëüãçóç, Ôéìïëüãçóç, ÁãïñÜ. ÕðïâëÞèçêå: 19 Éïõëßïõ 2004 ÅðáíõðïâëÞèçêå: 6 Ïêôùâñßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 18 Ïêôùâñßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: Ã. Êõñéüðïõëïò, ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, Ôçë.: (210) 6435328, Fax: (210) 6449571, e-mail: usph-kyr@ath-forthnet.gr

Ã. Êõñéüðïõëïò

Áí êáé ç áíáãêáéüôçôá åìðëïêÞò ôïõ êñÜôïõò åßíáé ðïëéôéêÜ íïìéìïðïéçìÝíç êáé åðéóôçìïíéêÜ ôåêìçñéùìÝíç óå äéåèíÞ êëßìáêá, åíôïýôïéò Ý÷åé áðïäåé÷èåß åìðåéñéêÜ üôé ç êáôÜ÷ñçóç ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò äéáìÝóïõ ôçò åéóáãùãÞò áíïñèüëïãùí Þ/êáé õðåñâïëéêþí öñáãìþí åéóüäïõ óôçí áãïñÜ ôùí öáñìáêåõôéêþí ðñïúüíôùí (äéáäéêáóßåò Ýãêñéóçò, ôéìïëüãçóçò, Ýíôáîçò óôïí êáôÜëïãï óõíôáãïãñáöïýìåíùí öáñìÜêùí) êáé ç ðñïóðÜèåéá ôå÷íçôÞò êáèÞëùóçò ôùí ôéìþí ìðïñåß íá õðçñåôïýí âñá÷õðñüèåóìïõò óôü÷ïõò ôçò äçìïóéïíïìéêÞò ðïëéôéêÞò, áëëÜ ôåëéêþò ðïëëáðëáóéÜæïõí ôéò óôñåâëþóåéò êáé áðïìáêñýíïõí áðü ôïõò åðéèõìçôïýò óôü÷ïõò ôçò õãåéïíïìéêÞò ðïëéôéêÞò êáé ôçí ðñïóðÜèåéá åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôùí äáðáíþí. Åßíáé ðáóßäçëï üôé ç äéáôýðùóç áõôÞ Ý÷åé åðéâåâáéùèåß ìå êáôçãïñçìáôéêü ôñüðï áðü ôéò åîåëßîåéò óôç öáñìáêåõôéêÞ ðïëéôéêÞ êáôÜ ôç äéÜñêåéá ôùí ôåëåõôáßùí åôþí.1 Ôá öáéíüìåíá áõôÜ ðåñéïñßæïõí ôçí ôåêìçñéùìÝíç (ùò åê ôïýôïõ ðñáãìáôéêþò åëåýèåñç) óõíôáãïãñÜöçóç êáé äåí óÝâïíôáé ôéò ðñïôéìÞóåéò ôùí êáôáíáëùôþí, ðñÜãìá ôï ïðïßï ðñïêáëåß óôçí áóêïýìåíç õãåéïíïìéêÞ ðïëéôéêÞ ðïëëáðëÝò áññõèìßåò êáé äåí äéáóöáëßæåé ôçí åðéèõìçôÞ åðßôåõîç ôçò èåñáðåõôéêÞò áðïôåëåóìáôéêüôçôáò, ôçò áðïäïôéêÞò ÷ñÞóçò ôùí óðÜíéùí õãåéïíïìéêþí ðüñùí êáé óå ìåñéêÝò ðåñéðôþóåéò ôçò éóüôçôáò óôçí ðñüóâáóç ôùí êáôÜëëçëùí öáñìáêåõôéêþí ðñïúüíôùí. Õðü ôï ðñßóìá áõôü ôá æçôÞìáôá, ôá ïðïßá èßãïíôáé óôï êåßìåíï áõôü ó÷åôéêÜ ìå ôç öáñìáêåõôéêÞ ðïëéôéêÞ äåí áöïñïýí ðåñéïñéóôéêÜ óå åðéóôçìïíéêÝò êáé ôå÷íéêÝò ñõèìßóåéò áëëÜ óôçí êïéíùíéêÞ ðñïóðÜèåéá ãéá óõíå÷Þ âåëôßùóç ôçò öñïíôßäáò õãåßáò êáé ôçò áðïôåëåóìáôéêüôçôáò ôçò éáôñéêÞò ðñáêôéêÞò êáé ùò åê ôïýôïõ óõíéóôïýí ìåßæïí êïéíùíéêü, õãåéïíïìéêü êáé ðïëéôéêü èÝìá. Óôï êåßìåíï áõôü åðé÷åéñåßôáé ç åðéãñáììáôéêÞ ðñïóÝããéóç ôùí åðéðôþóåùí, ôéò ïðïßåò åðéöÝñåé ç áíïñèüëïãç êáé õðåñâÜëëïõóá êñáôéêÞ ðáñÝìâáóç êáé ç äõóáñìïíßá ìå ôç ÷ñçóéìïðïßçóç åñãáëåßùí ôçò áãïñÜò êáé åéäéêüôåñá (á) ç åðéâïëÞ áíáéôéïëüãçôùí öñáãìþí åéóüäïõ óôçí áãïñÜ, (â) ç ëïãéóôéêÞ-êïóôïëïãéêÞ äéáìüñöùóç ôùí ôéìþí êáé (ã) ç áðïõóßá áíáæÞôçóçò êáôÜëëçëùí êáé óõíäõáóôéêþí ôå÷íéêþí êáé ìåèüäùí ñýèìéóçò ôçò áãïñÜò.

Ôüìïò 17, Ôåý÷ïò 1, 2005

Ïé áíïñèüëïãïé öñáãìïß åéóüäïõ óôçí áãïñÜ åíéó÷ýïõí ôéò ìïíïðùëéáêÝò ôÜóåéò êáé åðéôåßíïõí ôéò óôñåâëþóåéò Ôá åìðüäéá åéóüäïõ óôçí áãïñÜ åêäçëþíïíôáé áöåíüò ìå ôçí ðåñßðëïêç áíïñèüëïãç êáé ÷ñïíïâüñá äéáäéêáóßá Ýãêñéóçò êáé áäåéïäüôçóçò êáé áöåôÝñïõ ìå ôçí õéïèÝôçóç áíôéåðéóôçìïíéêþí êáé áìöéëåãüìåíùí ìåèüäùí êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò (üðùò ôï êñéôÞñéï ôïõ êüóôïõò çìåñÞóéáò èåñáðåßáò) ó÷åôéêÜ ìå ôçí åéóáãùãÞ óôïí åãêåêñéìÝíï êáôÜëïãï óõíôáãïãñáöçìÝíùí öáñìÜêùí. Ìå ôçí Ýííïéá áõôÞ äéáìïñöþíåôáé ìéá êáôÜóôáóç ãéá ôçí åéóáãùãÞ Þ ôïí áðïêëåéóìü öáñìáêåõôéêþí ðñïúüíôùí, ç ïðïßá äåí õðáêïýåé óå åðéóôçìïíéêÜ êñéôÞñéá, åíéó÷ýåé ôéò ìïíïðùëéáêÝò ôÜóåéò óå ìåãÜëåò ðåñéï÷Ýò ôçò öáñìáêåõôéêÞò áãïñÜò êáé äåí óõìâÜëëåé óôçí ðñïáãùãÞ ôùí áíáãêáßùí ðïëéôéêþí åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôùí äáðáíþí. ÅðéðñïóèÝôùò, ïé õöéóôÜìåíïé äéïéêçôéêïß öñáãìïß óôç óõíôáãïãñÜöçóç óå óõíäõáóìü ìå ôçí ðåñßðëïêç åëåãêôéêÞ äéáäéêáóßá óôç äéáíïìÞ ôùí öáñìÜêùí ðñïò ôïõò ÷ñÞóôåò áõîÜíïõí ôï êüóôïò ôïõ ÷ñüíïõ êáé ðñïôñÝðïõí áíáðüöåõêôá óôçí õøçëÞ éäéùôéêÞ äáðÜíç, äçëáäÞ óôç ìåñéêÞ áêýñùóç ôçò áóöáëéóôéêÞò êÜëõøçò êáé ôç ìåôáöïñÜ ôïõ ÷ñçìáôïäïôéêïý âÜñïõò óôá íïéêïêõñéÜ, ìå áðïôÝëåóìá ôï ðñáãìáôéêü ðïóïóôü óõíáóöÜëéóçò (äçëáäÞ ôï óýíïëï ôùí éäéùôéêþí ðëçñùìþí) íá êõìáßíåôáé óå õøçëÜ åðßðåäá ôá ôåëåõôáßá ÷ñüíéá.2 Ç Üñóç ôùí áíïñèüëïãùí êáé ãñáöåéïêñáôéêþí öñáãìþí åéóáãùãÞò öáñìÜêùí óôçí áãïñÜ êáé ôùí åìðïäßùí äéáíïìÞò ðñïò ôïõò ÷ñÞóôåò ìðïñåß íá óõìâÜëëåé óôçí åëá÷éóôïðïßçóç ôùí õöéóôáìÝíùí ìïíïðùëéáêþí ôÜóåùí. Ôá âáóéêÜ êñéôÞñéá ôá ïðïßá ðñÝðåé íá ôçñïýíôáé, óôéò ó÷åôéêÝò äéáäéêáóßåò, åßíáé, ðëçí ôùí êëáóéêþí öáñìáêïëïãéêþí êñéôçñßùí (áóöÜëåéá êáé äñáóôéêüôçôá ôïõ öáñìÜêïõ), ôá êñéôÞñéá ôçò éáôñéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò.3 ÄåäïìÝíïõ üôé ôï ìåãáëýôåñï ðëÞèïò ôùí öáñìáêåõôéêþí ðñïúüíôùí õößóôáíôáé ìéá äéáäéêáóßá áîéïëüãçóçò óå äéåèíÝò åðßðåäï, ç ïðïßá âáóßæåôáé óå ôåêìÞñéá, êáé ùò åê ôïýôïõ ÷áñáêôçñßæïíôáé áðü õøçëÞ ðïéüôçôá4, ç äçìéïõñãßá ìéáò âÜóçò äåäïìÝíùí ìå êáôåõèõíôÞñéåò ïäçãßåò 35

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ãéá èåñáðåõôéêÞ ôåêìçñßùóç êáé êáíüíåò ïñèÞò óõíôáãïãñÜöçóçò êáé ç áíÜðôõîç õðïäïìÞò ãéá ôçí åêôÝëåóç ìåëåôþí âéïúóïäõíáìßáò ìðïñåß íá óõìâÜëëåé óôçí åðéóôçìïíéêÞ áîéïëüãçóç ãéá ôçí åéóáãùãÞ óôçí áãïñÜ ãåíïóÞìùí öáñìÜêùí ôçò åã÷þñéáò ðáñáãùãÞò Ç áãíüçóç ôùí åðéóôçìïíéêþí êñéôçñßùí êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò (ó÷Ýóç ïéêïíïìéêïý êüóôïõò êáé éáôñéêÞò áðïôåëåóìáôéêüôçôáò), ç ïðïßá ÷áñáêôçñßæåé óôáèåñÜ ôçí ôñÝ÷ïõóá öáñìáêåõôéêÞ ðïëéôéêÞ óôç ÷þñá ìáò, åëá÷éóôïðïéåß ôï õãåéïíïìéêü üöåëïò êáé äåí óõìâÜëëåé, üðùò Þäç óçìåéþèçêå óôçí ðñïþèçóç ôùí áíáãêáßùí ðïëéôéêþí åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôùí äáðáíþí.3 ÊáôÜ óõíÝðåéá, ç åíèÜññõíóç åêôÝëåóçò êëéíéêþí äïêéìþí êáé óõììåôï÷Þò óå ðïëõêåíôñéêÝò äéåèíåßò ìåëÝôåò êáé áíáëýóåùí êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò ãéá ôç äéåñåýíçóç ôçò ó÷Ýóçò êüóôïõò-áðïôåëåóìáôéêüôçôáò ïöåßëïõí íá áðïôåëÝóïõí âáóéêÜ óôïé÷åßá ôçò ðïëéôéêÞò ãéá ôçí åßóïäï ôùí öáñìáêåõôéêþí ðñïúüíôùí óôçí áãïñÜ êáé ðñïò ôïýôï ïé õãåéïíïìéêÝò õðçñåóßåò êáé ïé åðáããåëìáôßåò õãåßáò åßíáé áíáãêáßï íá åíèáññõíèïýí êáé íá õðïóôçñé÷èïýí ðñïò áõôÞ ôçí êáôåýèõíóç. Ç åðéóôçìïíéêÞ êñéôéêÞ ôïõ õöéóôÜìåíïõ êáôáëüãïõ óõíôáãïãñáöïý ìåíþí öáñìÜêùí óõíéóôÜ ìéá ðñïóÝããéóç, ç ïðïßá åäñÜæåôáé óôçí áìöéëåãüìåíç ÷ñÞóç ôïõ êáôáëüãïõ êáé óôçí ðáñáâßáóç ôùí åðéóôçìïíéêþí êñéôçñßùí ôçò êïéíùíéêïïéêïíïìéêÞò áîéïëüãçóçò, ç ïðïßá åß÷å ùò áðïôÝëåóìá êõñßùò ôçí áíáäéáíïìÞ ôùí ìåñéäßùí ôçò áãïñÜò, ìå êñáôéêÞ ðáñÝìâáóç ðáñÜ ôç äéáóöÜëéóç ôçò ðïéüôçôáò ôçò öñïíôßäáò êáé ôçí ðñïþèçóç ðïëéôéêþí åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôùí äáðáíþí. Ùò åê ôïýôïõ, ç óõãêñüôçóç èåôéêïý Þ/êáé áñíçôéêïý êáôáëüãïõ óõíôáãïãñáöçìÝíùí öáñìÜêùí, ùò åñãáëåßïõ åéóáãùãÞò Þ áðüññéøçò áðü ôçí áóöáëéóìÝíç áãïñÜ, ïöåßëåé íá Ý÷åé õðïóôçñéêôéêü êáé åíäåéêôéêü ÷áñáêôÞñá ãéá ôç óõíôáãïãñÜöçóç êáé íá ìç âáóßæåôáé óå ëïãéóôéêÜ êñéôÞñéá (êüóôïò çìåñÞóéáò èåñáðåßáò) áëëÜ óôï óõíïëéêü êüóôïò áíôéìåôþðéóçò ôçò áññþóôéáò êáé óôçí êïéíùíéêïïéêïíïìéêÞ áîéïëüãçóç áðïôßìçóçò ôçò ó÷Ýóçò êüóôïõò-áðïôåëåóìáôéêüôçôáò. Ç ìåèïäïëïãßá áõôÞ äåí ðñÝðåé íá ðåñéïñßæåôáé óôçí “áíôáãùíéóôéêÞ” óýãêñéóç ìåôáîý öáñìáêåõôéêþí èåñáðåéþí áëëÜ êáé óå ó÷Ýóç ìå 36

Ã. Êõñéüðïõëïò

Üëëåò êëéíéêÝò êáé ôå÷íïëïãéêÝò èåñáðåõôéêÝò ðáñåìâÜóåéò. Åí êáôáêëåßäé, ç åéóáãùãÞ ôùí ôå÷íéêþí êáé ôùí ìåèüäùí áõôþí áðïôåëåß ôçí ðñïûðüèåóç ãéá ôçí áíÜðôõîç ðïëéôéêþí õãåßáò êáé äéá÷åßñéóçò ôçò áóèÝíåéáò, ìå âÜóç ôá åðéóôçìïíéêÜ ôåêìÞñéá. ÏéêïíïìéêÞ versus ëïãéóôéêÞ ðñïóÝããéóç ãéá ôç äéáìüñöùóç ôùí ôéìþí Ç ðáñÝìâáóç óôéò ôéìÝò êáé ç ôå÷íçôÞ êáèÞëùóç ùèåß üðùò áðïäåß÷èçêå ðñáêôéêÜ, êáôÜ ôá ôåëåõôáßá ÷ñüíéá, óôçí áðüóõñóç êáé áíôéêáôÜóôáóç áðïôåëåóìáôéêþí öáñìÜêùí ìéêñïý ó÷åôéêÜ êüóôïõò êáé óôç ìåãÝèõíóç ôùí ðáñÜëëçëùí åîáãùãþí.1 ÓõìðåñáóìáôéêÜ, ç ðïëéôéêÞ áõôÞ åíï÷ïðïéåßôáé åðßóçò ãéá ôçí Ýîïäï áðü ôçí áãïñÜ ÷ñÞóéìùí öáñìáêåõôéêþí ðñïúüíôùí êáé ùò åê ôïýôïõ ðåñéïñßæåé ôéò åðéëïãÝò ôùí ãéáôñþí êáé ôùí ÷ñçóôþí, ðñïêáëåß õøçëÜ ðïóïóôÜ óõíáóöÜëéóçò êáé ïäçãåß óå áðïôõ÷ßá ôéò ðïëéôéêÝò åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôùí äáðáíþí. ÊáôÜ óõíÝðåéá ç áíáãêáéüôçôá åéóáãùãÞò íÝùí ôå÷íéêþí êáé åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò óôéò ôéìÝò ãéá ôç ñýèìéóç ôçò öáñìáêåõôéêÞò áãïñÜò åßíáé áíáãêáßá. Ç äéáìüñöùóç ôùí ôéìþí äåí ìðïñåß íá åêöñÜæåé ôç ëïãéóôéêÞ ó÷Ýóç, ç ïðïßá âáóßæåôáé óôï êüóôïò êáé ôï åðéôñåðôü êÝñäïò áëëÜ ôç ó÷Ýóç ðñïóöïñÜò êáé æÞôçóçò óå óõó÷Ýôéóç ìå ôéò áíôáãùíéóôéêÝò èåñáðåßåò êáé ôéò ôéìÝò ôùí õðïêáôÜóôáôùí ðñïúüíôùí, Ýôóé þóôå íá åíéó÷ýïíôáé ïé ôÜóåéò õðïêáôÜóôáóçò ìåôáîý öáñìÜêùí êáé Üëëùí èåñáðåõôéêþí êáé ôå÷íïëïãéêþí ðáñåìâÜóåùí, ìå óêïðü ôç ìåãéóôïðïßçóç ôïõ õãåéïíïìéêïý ïöÝëïõò êáé ôçí áðïäïôéêÞ ÷ñÞóç ôùí óðÜíéùí ðüñùí. Ïé ôéìÝò, ïé ïðïßåò äéáìïñöþíïíôáé ìå áõôÜ ôá êñéôÞñéá ïöåßëïõí íá óõãêñïôïýí ôçí ôéìÞ áíáöïñÜò, äçëáäÞ ôçí Üñéóôç ôéìÞ ãéá ôç âÝëôéóôç ó÷Ýóç êüóôïõò-áðïôåëÝóìáôïò êáôÜ äéáãíùóôéêÞ êáé èåñáðåõôéêÞ êáôçãïñßá, åðß ôçò ïðïßáò êáèïñßæïíôáé ùò óõíïäåõôéêÜ åñãáëåßá ôï ðïóïóôü óõíáóöÜëéóçò (óõììåôï÷Þ óôï êüóôïò) êáé ïé áóöáëéóôéêÝò ôéìÝò. Åßíáé áíáãêáßï íá åîåôáóèåß, óôç ìåóïðñüèåóìç ðñïïðôéêÞ ç êáèéÝñùóç óôü÷ïõ äáðÜíçò áíÜ öýëï, çëéêßá äéáãíùóôéêÞ êáôçãïñßá êáé âáñýôçôá íüóïõ ãéá ôçí åíäå÷üìåíç åéóáãùãÞ èåôéêþí êéíÞôñùí ïñèÞò êáé ëåëïãéóìÝíçò ÷ñÞóçò ôùí öáñìÜêùí ìå ðéèáíÞ èåóìïèÝôçóç áñíçôéêïý óõíáóöáëßóôñïõ. Óôá ðëáßóéá áõôÜ,

Ôüìïò 17, Ôåý÷ïò 1, 2005

Ã. Êõñéüðïõëïò

Ýíá óýóôçìá öáñìáêïåðéäçìéïëïãéêÞò ðáñáôÞñçóçò ìðïñåß íá óõìâÜëëåé óôçí ïñèïëïãéêïðïßçóç ôùí äéáðñáãìáôåýóåùí ìåôáîý ôùí ðáñáãüíôùí ôçò öáñìáêåõôéêÞò áãïñÜò êáé ôç äéáìüñöùóç ðïëéôéêþí âáóéóìÝíùí óå ôåêìÞñéá. Ç óõíáóöÜëéóç, üðùò äåß÷èçêå áðü åñåõíçôéêÜ êáé åìðåéñéêÜ áðïôåëÝóìáôá, áðïôåëåß ó÷åäüí ôï ìïíáäéêü åõ÷åñÝò åñãáëåßï åëÝã÷ïõ ôïõ êüóôïõò êáé óõãêñÜôçóçò ôçò äáðÜíçò, áëëÜ âåâáßùò ÷ñåéÜæåôáé ïñèïëïãéêïðïßçóç, ðñÜãìá ôï ïðïßï óçìáßíåé üôé ïöåßëåé íá êéíåßôáé óå åõñåßá êëßìáêá êáé íá åßíáé áíÜëïãç ôïõ åéóïäÞìáôïò (ìå åîáßñåóç ôùí öôù÷þí, ôùí áíÝñãùí êáé åíäå÷ïìÝíùò Üëëùí åéäéêþí êáôçãïñéþí) êáé áíôéóôñüöùò áíÜëïãç ôçò áíÜãêçò (ìå õðïóôÞñéîç ôùí ÷ñïíßùò ðáó÷üíôùí Þ áóèåíþí ïé ïðïßïé ÷ñÞæïõí èåñáðåéþí, ïé ïðïßåò ïäçãïýí óå êáôáóôñïöéêÝò äáðÜíåò). Ï åðáíáðñïóäéïñéóìüò ôùí ôéìþí (åíäå÷ïìÝíùò óôáäéáêÜ) åßíáé åýëïãï íá ïäçãÞóåé óå áõîÞóåéò ôùí åã÷ùñßùí Þ/êáé ôùí ðáëáéþí öáñìÜêùí Þ áêüìá Üëëùí öáñìÜêùí ìå åðéðôþóåéò, ïé ïðïßåò ìðïñåß íá áíôéìåôùðéóèïýí ìå Üëëá óõíïäåõôéêÜ ìÝôñá. ¸íáò ìç÷áíéóìüò åðéóôñïöÞò ðëçñùìþí ãéá ðáñÜäåéãìá áðü ôéò åðé÷åéñÞóåéò ðñïò ôá áóöáëéóôéêÜ ôáìåßá äéáóöáëßæåé ôç óõãêñÜôçóç ôùí äáðáíþí êáé áðïöåýãåé óå êÜðïéï âáèìü ôéò óôñåâëþóåéò (ðáñÜëëçëåò åîáãùãÝò, áñíçôéêÞ åðéäüôçóç åã÷þñéáò âéïìç÷áíßáò) áðü ôéò ðáñåíÝñãåéåò ôçò êáôÜ÷ñçóçò ôùí åñãáëåßùí êñáôéêÞò ðáñÝìâáóçò óôéò ôéìÝò. Ç áíáèåþñçóç ôùí ôéìþí åßíáé áíáãêáßï íá ðñïóáíáôïëéóèåß åðßóçò óå äéáìüñöùóç áíôáãùíéóôéêþí óõíèçêþí þóôå ôá ïõóéùäþò üìïéá ðñïúüíôá íá ìçí áðïêëåßïíôáé åììÝóùò. Ç ðáñÝìâáóç áõôÞ ìðïñåß ðñïóèÝôùò íá óõìâÜëëåé óôçí õðïóôÞñéîç ôçò åã÷þñéáò ðáñáãùãÞò êáé ôçí áýîçóç ôçò áðáó÷üëçóçò óôïí ôïìÝá áõôü. Áîßæåé íá åðéóçìáíèåß üôé ç åéóáãùãÞ åíüò óõóôÞìáôïò ôéìþí óôçí áãïñÜ ôïõ öáñìÜêïõ äåí óõíäÝåôáé áíáãêáóôéêÜ ìå æçôÞìáôá óõëëïãéêÞò áëëçëåããýçò êáé êïéíùíéêÞò äéêáéïóýíçò äéáìÝóïõ ôïõ óõóôÞìáôïò ÷ñçìáôïäüôçóçò, èÝìá ôï onoio åßíáé éäåïëïãéêÞò êáé ðïëéôéêÞò öýóçò. Åðßìåôñï Ç ðñïáãùãÞ áõôþí ôùí ôå÷íéêþí êáé ìåèüäùí ðñïûðïèÝôåé óçìáíôéêÝò áëëáãÝò óôç öáñìáêåõôéêÞ ðïëéôéêÞ êáèþò åðßóçò êáé óïâáñÝò

åðåíäýóåéò óôï áíèñþðéíï êåöÜëáéï. Ìå Üëëá ëüãéá, ðñïáðáéôåß ìéá Üëëç êïõëôïýñá ãéá ôçí õãåéïíïìéêÞ ðïëéôéêÞ. Ïé åðéóçìÜíóåéò áõôÝò, ðéèáíþò áðáéôïýí ôç óõãêñüôçóç åíüò óôáèåñïý ðëáéóßïõ äéáâïõëåýóåùí êáé äéáðñáãìáôåýóåùí ãéá ôéò ñõèìßóåéò ôçò áãïñÜò, óôï ïðïßï åßíáé áíáãêáßï íá ìåôÝ÷ïõí üëïé ïé åôáßñïé ôïõ öáñìáêåõôéêïý ôïìÝá. ÐáñÜ ôï ãåãïíüò üôé - óå óõãêñéôéêÞ âÜóçç áãïñÜ ôïõ öáñìÜêïõ ñõèìßæåôáé åõ÷åñÝóôåñá áðü ôéò Üëëåò õãåéïíïìéêÝò áãïñÝò, åíôïýôïéò Ý÷åé õðïóôåß ðïëëáðëÝò óôñåâëþóåéò åîáéôßáò ôçò êáôÜ÷ñçóçò ôùí åñãáëåßùí êñáôéêïý ðáñåìâáôéóìïý, üðùò Þäç óçìåéþèçêå. Åßíáé âÝâáéï, üôé ç ðïëéôéêÞ áõôÞ Ý÷åé ìüíïí âñá÷õðñüèåóìá áðïôåëÝóìáôá êáé óå êÜèå ðåñßðôùóç Ý÷åé õðåñâåß ôá üñéá ôçò. Ùò åê ôïýôïõ Ýíá ìåßãìá êáôÜëëçëùí ìåèüäùí êñáôéêÞò ðáñÝìâáóçò êáé äéáìüñöùóçò ôéìþí (÷ñÞìáôïò êáé ÷ñüíïõ) åßíáé áíáãêáßï íá åéóá÷èåß þóôå íá õðçñåôïýíôáé ôá êñéôÞñéá ôçò (êïéíùíéêÞò) éóüôçôáò, ôçò (éáôñéêÞò) áðïôåëåóìáôéêüôçôáò êáé ôçò (ïéêïíïìéêÞò) áðïäïôéêüôçôáò ìå óêïðü ôç ìåãéóôïðïßçóç ôïõ êïéíùíéêïý êáé õãåéïíïìéêïý ïöÝëïõò. Âéâëéïãñáößá 1. Êõñéüðïõëïò Ã, Ãåßôïíá M. H áãïñÜ ôïõ ÖáñìÜêïõ óôçí ÅëëÜäá: ÐïëéôéêÝò, ÏéêïíïìéêÝò êáé ÕãåéïíïìéêÝò Óõíéóôþóåò, óôï: Ãåßôïíá Ì., Êõñéüðïõëïò Ã. (åðéìÝëåéá), ÐïëéôéêÞ êáé Ïéêïíïìßá ôïõ ÖáñìÜêïõ óôçí ÅëëÜäá, ÈåìÝëéï, ÁèÞíá, 1999, óåë. 19-47. 2. Kyriopoulos J, Geitona M, Karalis G. Hidden Economy, Private Spending and Informal Copayment in Health Care; the Role of Medical Manpower in Greece, in: Beazoglou T., Heffley D., Kyriopoulos J., (eds) Human Resources Supply and Cost Containment in the Health Systems, FICOSSER, Exandas Publishers, Athens, 1997, p.p. 269-282. 3. Ãåßôïíá Ì, Êõñéüðïõëïò Ã. ÊñéôÞñéá êáé Ôå÷íéêÝò ÖáñìáêïïéêïíïìéêÞò Áîéïëüãçóçò, óôï: Ãåßôïíá Ì., Êõñéüðïõëïò Ã. (åðéìÝëåéá). ÐïëéôéêÞ êáé Ïéêïíïìßá ôïõ ÖáñìÜêïõ óôçí ÅëëÜäá, ÈåìÝëéï, ÁèÞíá, 1999, óåë. 193-208. 4. Beazoglou T, Kyriopoulos J. Quality and Controlling Cost of Health Care: the Case of Pharmaceuticals in USA and Greece, in: Kyriopoulos J. (ed). Health Systems in the World; from Evidence to Policy, Papazisis Publishers, Athens, 2004, p.p. 737-753. 37

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Í. ÁíôùíÜêçò

ÅÉÄÉÊÏ ÁÑÈÑÏ SPECIAL ARTICLE Primary Heatlh Care, Volume 17, Number 1, 38-45, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 38-45, 2005

Ðñüôáóç ìïíôÝëïõ ÇëåêôñïíéêÞò Óõíôáãïãñáößáò ãéá ôçí åëëçíéêÞ ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò: ÖáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç Í. ÁíôùíÜêçò1 Ðåñßëçøç Ï óçìåñéíüò ôñüðïò Ýêäïóçò êáé äéáêßíçóçò ôùí éáôñéêþí óõíôáãþí óôç ÷þñá ìáò äçìéïõñãåß óçìáíôéêÜ ðñïâëÞìáôá êáé äåí óõìâÜëåé óôç óõãêÝíôñùóç ðëçñïöïñßáò ðïõ èá ìðïñïýóå íá âïçèÞóåé óôç óùóôüôåñç, áðïôåëåóìáôéêüôåñç êáé ïéêïíïìéêüôåñç ÷ñÞóç ôùí öáñìÜêùí, áëëÜ êáé óôçí ðáñáêïëïýèçóç óçìáíôéêþí ðáñáìÝôñùí ôçò äçìüóéáò õãåßáò. Óôç äçìïóßåõóç áõôÞ ðñïôåßíåôáé ìïíôÝëï ÇëåêôñïíéêÞò Óõíôáãïãñáößáò êáé ÖáñìáêïåðéäçìéïëïãéêÞò åðåîåñãáóßáò ôùí óõíôáãþí, êáôÜëëçëï ãéá ôçí åëëçíéêÞ ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. Ï ó÷åäéáóìüò ôïõ ìïíôÝëïõ óôçñß÷èçêå óå äåäïìÝíá áðü ôç äéåèíÞ âéâëéïãñáößá, áëëÜ êáé óå åìðåéñßá êáé Ýñåõíá óôï ÷þñï áõôü. Ðñïôåßíåôáé ç äçìéïõñãßá åíéáßáò çëåêôñïíéêÞò öüñìáò óõíôáãïëïãßïõ, ðïõ èá äéáèÝôåé äéáóõíäÝóåéò ìå ÷ñÞóéìåò âÜóåéò äåäïìÝíùí, èá äéáèÝôåé áõôïìáôéóìïýò êáé èá óõíäÝåôáé ìÝóù äéêôýïõ ìå öáñìáêåßá êáé êÝíôñá åðåîåñãáóßáò äåäïìÝíùí (ÊÝíôñá Öáñìáêïåðéäçìéïëïãßáò). ÐáñÜ ôéò óçìáíôéêÝò äõóêïëßåò áíÜðôõîçò, óôÜèìéóçò êáé äéÜäïóçò ôïõ óõóôÞìáôïò, ôá áíáìåíüìåíá ïöÝëç ðéóôåýåôáé üôé èá áíôéññïðßóïõí ãñÞãïñá êáé èåáìáôéêÜ ôá ðñïâëÞìáôá êáé ôï êüóôïò. Ç åðåîåñãáóßá ôùí äåäïìÝíùí ðïõ èá óõãêåíôñþíïíôáé èá ìðïñåß íá áíáãíùñßæåé ôá÷ýôáôá êáé íá ðáñáêïëïõèåß åðéäçìéêÝò åîÜñóåéò, áëëáãÝò äåéêôþí íïóçñüôçôáò, ðåñéðôþóåéò áêáôÜëëçëçò ÷ñÞóçò ôùí öáñìÜêùí, ðåñéðôþóåéò áêñéâÞò óõíôáãïãñáößáò, ðáñÜíïìåò äñáóôçñéüôçôåò óôï ÷þñï ôïõ öáñìÜêïõ êáé ðïëëÝò Üëëåò ðáñáìÝôñïõò. Èá åßíáé äõíáôÞ (åêôüò ôùí Üëëùí) ç åðéôÞñçóç êáé ç ðñïáãùãÞ ôçò äçìüóéáò õãåßáò. Ôï óýóôçìá èá ìðïñåß åðßóçò íá ðñïâëÝøåé ôçí åîÝëéîç ðïëëþí áðü ôéò ðáñáìÝôñïõò áõôÝò âïçèþíôáò Ýôóé áðïôåëåóìáôéêÜ óôï ó÷åäéáóìü õðçñåóéþí õãåßáò. Ôá óõóùñåõìÝíá ðñïâëÞìáôá óôï ÷þñï ôïõ öáñìÜêïõ êáé ïé óýã÷ñïíåò ôÜóåéò óôá ðñïçãìÝíá óõóôÞìáôá õãåßáò ôçò Åõñþðçò äåß÷íïõí ðùò ìéá ôÝôïéá áíôéìåôþðéóç ôïõ èÝìáôïò åßíáé ìïíüäñïìïò ãéá ôçí ÅëëÜäá.

ÄéäÜêôùñ Ðáíåðéóôçìßïõ ÊñÞôçò, Éáôñüò ÃåíéêÞò ÉáôñéêÞò, ÊÝíôñï Õãåßáò Áíùãåßùí, ÐÅÓÕÐ ÊñÞôçò

ÅéóáãùãÞ - Ïñéóìïß Óýìöùíá ìå ôçí ÁMCP (Academy of Managed Care Pharmacy, U.S.A.), ÇëåêôñïíéêÞ Óõíôáãïãñáößá (Ç.Ó.) åßíáé ç äçìéïõñãßá, áðïèÞêåõóç êáé ìåôáöïñÜ ìå çëåêôñïíéêÜ ìÝóá (ð.÷. çëåêôñïíéêïýò õðïëïãéóôÝò, äßêôõá õðïëïãéóôþí ê.ëð.) ðëçñïöïñßáò ðïõ ó÷åôßæåôáé ìå éáôñéêÝò óõíôáãÝò. Óôïí ðáñáðÜíù ïñéóìü äåí ðåñéëáìâÜíåôáé ç ìåôáöïñÜ ðëçñïöïñßáò ìå ôçëåïìïéïôõðßá (fax) Þ ôçëåöùíéêÞ óõíäéÜëåîç.1 Ç ñáãäáßá áíÜðôõîç ôçò öáñìáêïèåñáðåßáò êáôÜ ôéò ôåëåõôáßåò äåêáåôßåò, ïé óçìáíôéêÝò äáðÜíåò óôïí ÷þñï áõôü, ç áýîçóç ôïõ åðéðïëáóìïý ôùí ëáèþí óôç ÷ñÞóç ôùí öáñìÜêùí êáé ðïëëïß Üëëïé ðáñÜãïíôåò êáèéóôïýí áíáãêáßá óÞìåñá ôç ÷ñÞóç Ç.Ó. óå ðñïçãìÝíá óõóôÞìáôá õãåßáò. Ïé ìåëÝôåò êüóôïõò–ùöÝëåéáò áðü ôçí åöáñìïãÞ ôÝôïéùí ìïíôÝëùí äéáêßíçóçò ôçò ðëçñïöïñßáò ôùí éáôñéêþí óõíôáãþí åßíáé åíèáññõíôéêÝò.2,3

ËÝîåéò êëåéäéÜ: ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Óõíôáãïãñáößá, Öáñìáêïåðéäçìéïëïãßá, Äçìüóéá Õãåßá ÕðïâëÞèçêå: 22 Íïåìâñßïõ 2004 ÅðáíõðïâëÞèçêå: 31 Äåêåìâñßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 18 Éáíïõáñßïõ 2005 Aëëçëïãñáößá: ÁíôùíÜêçò Íßêïò, Óåññþí 3, 713 07 ÇñÜêëåéï, ÊñÞôç, Ôçë.: (2810)330469, 28340 31208, 69450 75032, e-mail: antonakisnikos@yahoo.gr

Ôüìïò 17, Ôåý÷ïò 1, 2005

Í. ÁíôùíÜêçò

Proposal of an Electronic Prescription model for the Greek Primary Health Care: A pharmacoepidemiological approach N. Antonakis Summary The current way of writing and distribution of prescriptions in Greece creates important problems and it does not help in the collection of information that could support the proper, effective and inexpensive use of medicines, as well as the follow-up of some important parameters of public health. In this publication a model for electronic prescription and pharmacoepidemiological analysis of the prescriptions, suitable for the Greek Primary Care, is presented. The planning of this system was supported in the literature, but also in experience and medical research in Greek Primary Care. It is proposed the creation of single electronic prescription form that will be connected with useful databases. It will also allocate automatisms and will be connected, via network, with the pharmacies and centers for data analysis (Centers of Pharmacoepidemiology). Despite the difficulties of growth, evaluation and distribution of system, the expected benefits can equalize the difficulties and the cost. The data analysis centers might rapidly recognize and watch epidemic outbreaks, changes of morbidity rates, cases of inappropriate use of medicines, cases of expensive prescription, illegal prescribing activities and a lot of other parameters. Thus, the monitoring and the promotion of public health will be the possible. The system might also forecast changes of this parameters, helping thus effectively in the planning of health services. The problems associated with the drug therapy and the modern tendencies in the advanced health systems of Europe show that such solution is one-way road for Greece. Key Words: Primary Health Care, Prescription, Pharmacoepidemiology, Public Health

Ç Ç.Ó. åßíáé óçìáíôéêü åñãáëåßï ãéá ìéá, ó÷åôéêÜ, íÝá åðéóôÞìç óôïí éáôñéêü ÷þñï, ôç Öáñìáêïåðéäçìéïëïãßá.4 Ç Öáñìáêïåðéäçìéïëïãßá ëåéôïõñãåß óáí ãÝöõñá áíÜìåóá óôç Öáñìáêïëïãßá êáé ôçí Åðéäçìéïëïãßá êáé ìåëåôÜ ôç ÷ñÞóç êáé ôá áðïôåëÝóìáôá ôùí öáñìÜêùí óå ìåãÜëïõò ðëçèõóìïýò.5 Ç óõíôáãïãñáößá åßíáé ç óõ÷íüôåñç èåñáðåõôéêÞ ðñÜîç óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò (Ð.Ö.Õ.)6 êáé ç ðáñáêïëïýèçóç ôçò ìå öáñìáêïåðéäçìéïëïãéêÝò ìåèüäïõò ìðïñåß íá ðñïóöÝñåé ðïëëÜ óôç óùóôüôåñç ïñãÜíùóç ôùí õðçñåóéþí õãåßáò ôïõ ÷þñïõ áõôïý êáé óôç ëÞøç åðéóôçìïíéêÜ èåìåëéùìÝíùí äéïéêçôéêþí áðïöÜóåùí.2,3 Ãéá ôçí Ç.Ó. óôçí Ð.Ö.Õ. Ý÷ïõí ðñïôáèåß êáé åöáñìïóôåß áñêåôÜ ìïíôÝëá ðïõ åìöáíßæïõí óçìáíôéêÝò äéáöïñÝò ìåôáîý ôïõò. Ãéá ôç äçìéïõñãßá ôùí ìïíôÝëùí áõôþí ëáìâÜíïíôáé ðÜíôá õðüøç ïé ôïðéêÝò óõíèÞêåò êáé ç ãåíéêüôåñç ïñãÜíùóç ôïõ óõóôÞìáôïò õãåßáò.7 Óôç äçìïóßåõóç áõôÞ ðñïôåßíåôáé Ýíá ìïíôÝëï Ç.Ó. ðïõ åêôéìÜôáé üôé åßíáé êáôÜëëçëï ãéá ôçí åëëçíéêÞ Ð.Ö.Õ. Ðñïôåßíïíôáé åðßóçò ôñüðïé áîéïðïßçóçò ôïõ ìïíôÝëïõ áõôïý ãéá ôçí åðéôÞñçóç êáé ðñïáãùãÞ ôçò äçìüóéáò õãåßáò ìÝóù ôùí ðëçñïöïñéþí ðïõ èá áðïèçêåýïíôáé óôï

óýóôçìá êáé èá áíáëýïíôáé óå åéäéêÜ êÝíôñá.

Ç óçìåñéíÞ êáôÜóôáóç óôçí ÅëëÜäá

Ç óõíôáãïãñáößá óôçí ÅëëÜäá ãßíåôáé óÞìåñá ìå ôç ÷ñÞóç Ýíôõðùí óõíôáãïëïãßùí ðïõ êáôÝ÷åé ï áóèåíÞò Þ ï éáôñüò. Ôá óõíôáãïëüãéá áõôÜ ôåßíïõí íá ðÜñïõí åíéáßá ìïñöÞ ôá ôåëåõôáßá ÷ñüíéá. Ãéá ôçí Ýêäïóç ìéáò áðëÞò óõíôáãÞò (÷ùñßò óõíïäåõôéêÜ Ýããñáöá) ìå Ýíá ìüíï öÜñìáêï, ï éáôñüò ðñÝðåé íá óõìðëçñþóåé ðåñßðïõ 16 ÷åéñüãñáöá ðåäßá. Ï ôñüðïò óõìðëÞñùóçò êáé ðñïþèçóçò ôùí Ýíôõðùí óõíôáãþí ðïõ åêäßäïíôáé åßíáé éäéáßôåñá ðïëýðëïêïò. Ï éáôñüò ðñÝðåé íá óõíôáãïãñáöåß öÜñìáêá áðü ëßóôá ðïõ Ý÷åé åêäþóåé ôï Õðïõñãåßï Õãåßáò åíþ äéêáéïýôáé íá óõíôáãïãñáöÞóåé êáé öÜñìáêá ðïõ äåí ðåñéëáìâÜíïíôáé óôç ëßóôá áõôÞ, åöüóïí áéôéïëïãÞóåé ôçí áíáãêáéüôçôá ôçò óõíôáãïãñÜöçóçò áõôÞò ìå åéäéêÞ Ýíôõðç ãíùìÜôåõóç. ÐñÝðåé íá óçìåéþíåé ôá ðïóïóôü óõììåôï÷Þò ôùí áóèåíþí óôç äáðÜíç ôùí öáñìÜêùí, ç ïðïßá ðïéêßëåé áíÜëïãá ìå ôç äéÜãíùóç êáé ôïí áóöáëéóôéêü öïñÝá. ÐñÝðåé áêüìç íá óõìðëçñþíåé åéäéêÞ Ýíôõðç öüñìá ãéá ôá óêåõÜóìáôá ðïõ åìðßðôïõí óôïí íüìï ðåñß íáñêùôéêþí ïõóéþí êáé åéäéêÞ Ýíôõðç öüñìá ãéá ôá áíôéìéêñïâéáêÜ öÜñìáêá ôçò êáôçãïñßáò ôùí Êéíïëïíþí. Ãéá ôçí êáôçãïñßá áõôÞ ðñÝðåé íá åðéóõíÜðôåé êáé áíôéâéüãñáììá (ü÷é ðÜíôá). ÏñéóìÝíåò áðü ôéò óõíôáãÝò (ìå äéáöïñåôéêÜ êñéôÞñéá) ðñÝðåé íá åëåã÷èïýí áðü åëåãêôÞ éáôñü êáé óôç óõíÝ÷åéá íá åêôåëåóôïýí áðü ôïí Öáñìáêïðïéü. ÊáìéÜ äéáäéêáóßá áðü ôéò ðáñáðÜíù äåí åßíáé ìç÷áíïãñáöçìÝíç óÞìåñá. ÐñÝðåé íá óçìåéùèåß üôé ôï óýóôçìá Ýêäïóçò êáé äéáêßíçóçò ôùí óõíôáãþí ðáñïõóéÜóôçêå áðëïõóôåõìÝíá, áöïý äåí áíáöÝñèçêáí ðïëëÝò Üëëåò ðáñÜìåôñïé, üðùò ôá äéáöïñåôéêÜ äéêáéþìáôá óõíôáãïãñáößáò ôùí éáôñþí áíÜëïãá ìå ôçí åéäéêüôçôá êáé ôï åðßðåäï åêðáßäåõóçò, ç äõíáôüôçôá êÜðïéïõ éáôñïý íá óõíôáãïãñáöåß âáóéæüìåíïò óå ãíùìÜôåõóç Üëëïõ éáôñïý ê.ëð. Ç óõíôáãïãñáößá óôçí åëëçíéêÞ Ð.Ö.Õ. Ý÷åé 39

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Í. ÁíôùíÜêçò

ìåëåôçèåß åëÜ÷éóôá. Öáßíåôáé üìùò ðùò ôá ðñïâëÞìáôá ðïõ õðÜñ÷ïõí åßíáé, óå ãåíéêÝò ãñáììÝò, áíÜëïãá ìå áõôÜ ðïõ Ý÷ïõí êáôáãñáöåß óå Üëëåò åõñùðáúêÝò (êáé ìÜëéóôá ìåóïãåéáêÝò) ÷þñåò. Ôá ðñïâëÞìáôá áõôÜ ó÷åôßæïíôáé ìå ôçí ðïëõðëïêüôçôá ôçò åëëçíéêÞò íïìïèåóßáò, ôéò õøçëÝò äáðÜíåò ãéá öáñìáêïèåñáðåßá, ôá óõ÷íÜ ëÜèç óôç ÷ñÞóç ôùí öáñìÜêùí êáé ôçí áðïññüöçóç áíèñþðéíùí ðüñùí ôçò Ð.Ö.Õ. óå ðïëýðëïêåò óõíôáãïãñáöéêÝò äéáäéêáóßåò. Ïé óçìåñéíÝò äéáäéêáóßåò óõíôáãïãñÜöçóçò óôçí ÅëëÜäá äåí åßíáé éêáíÝò íá äçìéïõñãÞóïõí ôéò áðáñáßôçôåò åêåßíåò âÜóåéò äåäïìÝíùí ðïõ èá åßíáé äõíáôüí ÷ñçóéìïðïéçèïýí ãéá ôçí åðéôÞñçóç êáé ðñïáãùãÞ ôçò äçìüóéáò õãåßáò êáé ôç ëÞøç äéïéêçôéêþí áðïöÜóåùí óôï ÷þñï ôçò õãåßáò8.

Ìåèïäïëïãßá ó÷åäéáóìïý ôïõ ìïíôÝëïõ ðïõ ðñïôåßíåôáé ¸ãéíå áíáóêüðçóç ôçò åëëçíéêÞò êáé îåíüãëùóóçò âéâëéïãñáößáò êáé ìåëåôÞèçêáí ôá ìïíôÝëá Ç.Ó. ðïõ Ý÷ïõí åöáñìïóôåß óå åõñùðáúêÝò êõñßùò ÷þñåò, áëëÜ êáé óôéò Ç.Ð.Á, üðùò êáé ç ÷ñÞóç ôùí ìïíôÝëùí áõôþí ãéá ôçí åðéôÞñçóç êáé ðñïáãùãÞ ôçò äçìüóéáò õãåßáò. Ç ðñüôáóç ðïõ áêïëïõèåß åßíáé ðñïúüí óõíèåôéêÞò åñãáóßáò ðïõ óôçñß÷èçêå óôçí ðñïáíáöåñèåßóá âéâëéïãñá-

ÌïíÜäá ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò (Ýêäïóç, áðïèÞêåõóç, áðïóôïëÞ ôçò óõíôáãÞò)

ößá, áëëÜ êáé óå ðñïçãïýìåíç åìðåéñßá êáé åñåõíçôéêÞ åñãáóßá, óå áíÜëïãá èÝìáôá, óôçí åëëçíéêÞ Ð.Ö.Õ.

Ôï ðñïôåéíüìåíï ìïíôÝëï Ç.Ó. ãéá ôçí åëëçíéêÞ Ð.Ö.Õ. (óõíïðôéêÞ - áðëïõóôåõìÝíç ðáñïõóßáóç) Ôï ìïíôÝëï ðïõ ðñïôåßíåôáé ðåñéëáìâÜíåé óõíäõáóìü Ç.Ó. êáé öáñìáêïåðéäçìéïëïãéêÞò áíÜëõóçò ôùí äåäïìÝíùí ðïõ èá óõãêåíôñþíïíôáé. Ðéï óõãêåêñéìÝíá ðåñéëáìâÜíåé çëåêôñïíéêÞ Ýêäïóç êáé äéáêßíçóç óõíôáãþí áðü ôéò ìïíÜäáò ôçò Ð.Ö.Õ. ðñïò ôá öáñìáêåßá êáé åéäéêÜ êÝíôñá óõíïëéêÞò åðåîåñãáóßáò ôçò ðëçñïöïñßáò ðïõ ðñïôåßíåôáé íá ïíïìáóôïýí ÊÝíôñá Öáñìáêïåðéäçìéïëïãßáò (Ê.Ö.). Ç óýíäåóç ôùí ìïíÜäùí Ð.Ö.Õ., ôùí öáñìáêåßùí êáé ôïõ Ê.Ö. èá åßíáé áìößäñïìç (Åéêüíá 1). Ôá åðéìÝñïõò ôìÞìáôá ôïõ ðáñáðÜíù ìïíôÝëïõ èá åßíáé ôá áêüëïõèá: Åíéáßá çëåêôñïíéêÞ öüñìá éáôñéêÞò óõíôáãÞò (Åéêüíá 2). Ìå ôïí üñï áõôü ðñïôåßíåôáé ç äçìéïõñãßá áðëïý êáé åý÷ñçóôïõ ëïãéóìéêïý, âáóéóìÝíïõ óôçí åíéáßá Ýíôõðç öüñìá ðïõ ðñïùèåßôáé óÞìåñá áðü ôá áóöáëéóôéêÜ ôáìåßá. Ôï ëïãéóìéêü èá ðáñÝ÷åé óôïí éáôñü ôéò ðëçñïöïñßåò ðïõ ôïõ åßíáé áðáñáßôçôåò ãéá ôç óõìðëÞñùóç ôçò çëåêôñïíéêÞò áõôÞò öüñìáò (ëßóôá óõíôáãï-

Öáñìáêåßï (åêôÝëåóç, áðïèÞêåõóç, áðïóôïëÞ ôçò óõíôáãÞò)

ÁóèåíÞò (öáñìáêïèåñáðåßá)

ÓõíäÝóåéò ìÝóù äéêôýïõ

¢ëëåò ìïíÜäåò Ð.Ö.Õ. ¢ëëá öáñìáêåßá ÊÝíôñï Öáñìáêïåðéäçìéïëïãßáò (Ýíá áíÜ ðåñéöÝñåéá)

Åéêüíá É. Ó÷çìáôéêÞ êáé áðëïõóôåõìÝíç ðáñïõóßáóç ôïõ ðñïôåéíüìåíïõ ìïíôÝëïõ. 40

Ôüìïò 17, Ôåý÷ïò 1, 2005

Í. ÁíôùíÜêçò

Çëåêôñïíéêüò éáôñéêüò öÜêåëïò ÂÜóç äåäïìÝíùí óõíôáãþí ðïõ åêäßäïíôáé

ÊáôåõèõíôÞñéåò ïäçãßåò ÖáñìáêïëïãéêÝò ðëçñïöïñßåò Åíéáßá çëåêôñïíéêÞ öüñìá óõíôáãïëïãßïõ

Äéáäßêôõï ÂÜóç äåäïìÝíùí öáñìÜêùí åëëçíéêÞò áãïñÜò (ð.÷. åèíéêü óõíôáãïëüãéï)

Öáñìáêåßï ÊÝíôñï Öáñìáêïåðéäçìéïëïãßáò ê.ë.ð.

Åéêüíá 2. ÌåñéêÝò áðü ôéò äéáóõíäÝóåéò ôçò ðñïôåéíüìåíçò çëåêôñïíéêÞò öüñìáò óõíôáãïëïãßïõ.

ãñáöïýìåíùí öáñìÜêùí, ëßóôá öáñìÜêùí ðïõ åìðßðôïõí óôïí íüìï ðåñß íáñêùôéêþí, ðïóïóôÜ óõììåôï÷Þò ôïõ áóèåíïýò óôç äáðÜíç, íïìïèåóßá ê.ëð.). Èá ðáñÝ÷åé åðßóçò ðëçñïöïñßåò öáñìáêïëïãßáò ãéá ôá óõíôáãïãñáöïýìåíá öÜñìáêá, þóôå íá ìðïñåß ï éáôñüò íá áíáôñÝîåé óå áõôÝò åýêïëá, üðùò êáé ðëçñïöïñßåò ãéá ôçí áîßá ôïõ öáñìÜêïõ, þóôå íá ìðïñåß íá åðéëÝîåé ôï ïéêïíïìéêüôåñï èåñáðåõôéêü ó÷Þìá ãéá ôïí áóèåíÞ ôïõ. ÓõíäÝóåéò ìå ó÷åôéêïýò ôüðïõò ôïõ äéáäéêôýïõ ìðïñåß íá åßíáé ÷ñÞóéìåò. Ç çëåêôñïíéêÞ óõíôáãÞ èá áñ÷åéïèåôåßôáé áõôüìáôá óôïí çëåêôñïíéêü éáôñéêü öÜêåëï ôïõ áóèåíÞ (åÜí õðÜñ÷åé), áëëÜ êáé óå çëåêôñïíéêÞ âÜóç äåäïìÝíùí ôùí óõíôáãþí ðïõ åêäßäïíôáé. Ôá ðåäßá ôçò óõíôáãÞò ðïõ èá áðïèçêåýïíôáé óôç âÜóç áõôÞ ìðïñåß íá åßíáé åðéëåãìÝíá (ð.÷. èá åßíáé äõíáôüí íá ìçí áðïèçêåýïíôáé ôá ðñïóùðéêÜ óôïé÷åßá ôïõ áóèåíÞ). Ïé âÜóåéò áõôÝò èá áðïóôÝëëïíôáé óôï Ê.Ö. Ôá ðåäßá ôçò åíéáßáò çëåêôñïíéêÞò öüñìáò éáôñéêÞò óõíôáãÞò ðïõ ðñïôåßíåôáé êáé ïé äõíáôüôçôåò áõôüìáôçò óõìðëÞñùóçò ðáñïõóéÜæïíôáé óôïí ðßíáêá 1. ÌåôÜ ôçí ðñþôç êáôá÷þñçóç ôïõ áóèåíÞ, ï éáôñüò èá ðñÝðåé íá óõìðëçñþíåé ìüíï 6 Þ 7 ðåäßá ãéá ôçí Ýêäïóç óõíôáãÞò ìå Ýíá öÜñìáêï. ÊÜèå åðéðëÝïí öÜñìáêï èá áðáéôåß ôç óõìðëÞñùóç 3-4 áêüìç ðåäßùí. Ç êùäéêïðïßçóç åßíáé áðáñáßôçôç ãéá äýï ìüíï ðáñáìÝôñïõò (äéÜãíùóç êáé öÜñìáêï) êáé ìðïñåß íá ãßíåôáé áõôüìáôá (Ðßíáêá É). Ôï ëïãéóìéêü åßíáé äõíáôüí íá õðåíèõìßæåé óôïí éáôñü ôá óõíïäåõôéêÜ Ýããñáöá ðïõ èá ðñÝ-

ðåé íá óõìðëçñþóåé (ð.÷. ãíùìÜôåõóç áíáíôéêáôÜóôáôïõ öáñìÜêïõ), áíÜëïãá ìå ôï öÜñìáêï ðïõ óõíôáãïãñáöåß. Ôá Ýããñáöá áõôÜ èá åßíáé åðßóçò çëåêôñïíéêÜ êáé ôá óôïé÷åßá ôïõ áóèåíÞ êáé ôïõ öáñìÜêïõ èá óõìðëçñþíïíôáé óå áõôÜ áõôüìáôá áðü ôç óõíôáãÞ. Ôá ðïóïóôÜ óõììåôï÷Þò ôïõ áóèåíÞ óôç äáðÜíç èá óõìðëçñþíïíôáé åðßóçò áõôüìáôá, áíÜëïãá ìå ôç äéÜãíùóç êáé ôï óêåýáóìá ðïõ èá áíáãñÜöåôáé. ÁóõìâáôüôçÐßíáêáò I. Ôá ðñïôåéíüìåíá ðåäßá ôïõ åíéáßïõ çëåêôñïíéêïý óõíôáãïëïãßïõ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Êùäéêüò áóèåíïýò Áóöáëéóôéêüò öïñÝáò* ÕãåéïíïìéêÞ ìïíÜäá ðïõ åêäßäåé ôç óõíôáãÞ** Ïíïìáôåðþíõìï áóèåíïýò* Äéåýèõíóç êáôïéêßáò* ÔçëÝöùíï* ÄéÜãíùóç (åðéëïãÞ áðü êñåìÜìåíç ëßóôá) Êùäéêüò äéÜãíùóçò (ICD Þ ICPC)** Êùäéêüò õãåéïíïìéêÞò ìïíÜäáò** Öýëï áóèåíïýò* Çìåñïìçíßá** ÖÜñìáêï (åðéëïãÞ áðü êñåìÜìåíç ëßóôá) Êùäéêüò öáñìÜêïõ (ATC Þ ICPC-drugs)** Ðïóüôçôá Äïóïëïãßá (åðéëïãÞ áðü êñåìÜìåíç ëßóôá) Ïäçãßåò Ðïóïóôü óõììåôï÷Þò ôïõ áóèåíïýò óôç äáðÜíç** ÇëåêôñïíéêÞ õðïãñáöÞ

* Óõìðëçñþíïíôáé áõôüìáôá áðü ôï ëïãéóìéêü, ìå ôçí ðñïûðüèåóç üôé Ý÷ïõí êáôá÷ùñçèåß ðáëáéüôåñá óå Üëëç óõíôáãÞ Þ óôïí çëåêôñïíéêü öÜêåëï ôïõ áóèåíÞ. ** Óõìðëçñþíïíôáé áõôüìáôá áðü ôï ëïãéóìéêü. Ï éáôñüò Ý÷åé äõíáôüôçôá äéüñèùóçò.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôåò êáé âëáâåñÝò áëëçëåðéäñÜóåéò öáñìÜêùí ðïõ áíáãñÜöïíôáé ìáæß óôçí ßäéá óõíôáãÞ åßíáé äõíáôüí íá åðéóçìáßíïíôáé áðü ôï ëïãéóìéêü (ð.÷. áíáãñáöÞ ìç óôåñïåéäïýò áíôéöëåãìïíþäïõò öáñìÜêïõ ìáæß ìå êïõìáñéíéêü áíôéðçêôéêü). Åßíáé äõíáôüí åðßóçò íá õðåíèõìßæïíôáé óôïí éáôñü ïäçãßåò ðïõ ðñÝðåé íá äþóåé óôïí áóèåíÞ (ð.÷. ðñïãñáììáôéóìüò åëÝã÷ïõ ôñáíóáìéíáóþí üôáí óõíôáãïãñáöåßôáé óôáôßíç). ÊÝíôñï Öáñìáêïåðéäçìéïëïãßáò. Ôï êÝíôñï áõôü èá åßíáé óõíäåìÝíï ìå üëåò ôéò ìïíÜäåò ðïõ åìðëÝêïíôáé óôç äéáêßíçóç éáôñéêþí óõíôáãþí êáé ïé âÜóåéò äåäïìÝíùí ðïõ èá äÝ÷åôáé èá åðåîåñãÜæïíôáé óå áõôü, ìåìïíùìÝíá êáé óõíïëéêÜ. Ïé óôáôéóôéêÝò áíáëýóåéò ðïõ èá ãßíïíôáé èá åßíáé ðåñéãñáöéêÝò êáé óõìðåñáóìáôïëïãéêÝò. ÏñéóìÝíåò óôáôéóôéêÝò áíáëýóåéò èá ãßíïíôáé áõôüìáôá áðü åéäéêü ëïãéóìéêü, ïñéóìÝíåò èá ãßíïíôáé óáí ñïõôßíá áðü ôï ðñïóùðéêü ôùí Ê.Ö. ìå ôç âïÞèåéá óôáôéóôéêþí ðáêÝôùí åõñåßáò ÷ñÞóçò êáé ïñéóìÝíåò èá ãßíïíôáé óå åéäéêÝò ìüíï ðåñéðôþóåéò ìå ôç ÷ñÞóç ôùí ßäéùí ðáêÝôùí. Ôá áðïôåëÝóìáôá ôùí áíáëýóåùí åßíáé äõíáôüí íá åêäßäïíôáé óå çëåêôñïíéêÞ åöçìåñßäá ôïõ Ê.Ö. óôï äéáäéêôýïõ. Óôá óõìðåñÜóìáôá ôçò åðåîåñãáóßáò èá ìðïñåß íá Ý÷åé ðñüóâáóç êÜèå ìïíÜäá ðïõ ðñïìçèåýåé ìå äåäïìÝíá ôï êÝíôñï (áìößäñïìç óýíäåóç), áëëÜ êáé êÜèå Üëëïò åðßóçìïò öïñÝáò ðïõ èá ÷ñåéÜæåôáé ðëçñïöïñßåò. Ôá äéêáéþìáôá ðñüóâáóçò, óå ïñéóìÝíá ôïõëÜ÷éóôïí áðïôåëÝóìáôá áíáëýóåùí, èá ðáñá÷ùñïýíôáé ìå åéäéêïýò êùäéêïýò ãéá ëüãïõò ôÞñçóçò ôïõ áðïññÞôïõ. Õðïëïãßæåôáé üôé áñêåß Ýíá Ê.Ö. áíÜ ÐåñéöÝñåéá ôçò ÅëëçíéêÞò ÅðéêñÜôåéáò, ðïõ èá óôåãÜæåôáé óå ÷þñï åíüò ãñáöåßïõ êáé èá óôåëå÷þíåôáé áðü Ýíáí åéäéêÜ åêðáéäåõìÝíï õðÜëëçëï. Ç óõíïëéêÞ åðåîåñãáóßá ôùí äåäïìÝíùí üëùí ôùí Ê.Ö. èá åßíáé åðßóçò ÷ñÞóéìç. Äéáêßíçóç ôùí óõíôáãþí (Åéêüíá 1). Ï áðëïýóôåñïò ôñüðïò ðñïþèçóçò ôçò óõíôáãÞò óôï öáñìáêåßï åßíáé ç åêôýðùóç ôçò êáé ç ðáñÜäïóç ôçò áðü ôïí áóèåíÞ óôï öáñìáêïðïéü. Ç äéáêßíçóç áõôÞ ìðïñåß íá ãßíåôáé êáé ìÝóù ôïõ äéáäéêôýïõ (Ý÷åé åöáñìïóôåß ìå åðéôõ÷ßá óå áñêåôÝò ÷þñåò).9 Ç ðñïþèçóç ôùí âÜóåùí äåäïìÝíùí ðñïò ôï Ê.Ö. ìðïñåß íá ãßíåôáé åýêïëá ìå ðïëëïýò ôñüðïõò (åããñáöÞ óå CD-ROM Þ DVD, áðïóôïëÞ ìÝóù äéáäéêôýïõ ê.ëð.). Ç áðïóôïëÞ ìÝóù äéáäéêôýïõ åßíáé ç ëýóç ðïõ ðñïôåßíåôáé êáé ìðïñåß íá ãßíåôáé áõôüìáôá Þ ìå åéäéêÞ åíôïëÞ ôïõ ÷ñÞóôç. 42

Í. ÁíôùíÜêçò

Áíáìåíüìåíá ðñïâëÞìáôá áðü ôç ëåéôïõñãßá ôïõ ðñïôåéíüìåíïõ ìïíôÝëïõ Ðñüâëçìá áðïññÞôïõ ðñïóùðéêþí äåäïìÝíùí êáé áóöÜëåéáò ôùí ðëçñïöïñéþí áðü áëëïßùóç Þ áðþëåéá. Ôï èÝìá áõôü åßíáé ãåíéêüôåñï êáé áöïñÜ êÜèå åßäïõò ÷åéñéóìü éáôñéêÞò ðëçñïöïñßáò (÷åéñüãñáöçò êáé øçöéáêÞò). Ãéá ôçí áóöÜëåéá ôçò äéáêßíçóçò ôùí çëåêôñïíéêþí äåäïìÝíùí Ý÷ïõí ãßíåé áîéüëïãåò ðñïóðÜèåéåò óå ðïëëÝò ÷þñåò (êáé óôç ÷þñá ìáò) êáé ôá áðïôåëÝóìáôá åßíáé åíèáññõíôéêÜ.10 Ðñüâëçìá êüóôïõò. Ôï êüóôïò åßíáé óçìáíôéêü, áëëÜ öáßíåôáé íá áíôéññïðåßôáé áðü ôá ïöÝëç êáé ìÜëéóôá âñá÷õðñüèåóìá.3 Ðñüâëçìá áíåðÜñêåéáò ãíþóåùí ÷åéñéóìïý Çëåêôñïíéêþí Õðïëïãéóôþí áðü ôï õãåéïíïìéêü ðñïóùðéêü. Âñá÷õ÷ñüíéá ðñïãñÜììáôá åêðáßäåõóçò ðéèáíüí íá åßíáé áíáãêáßá. ÍïìéêÜ ðñïâëÞìáôá. Ç ÅëëçíéêÞ íïìïèåóßá ðñÝðåé íá áëëÜîåé óå ó÷Ýóç ìå ôç óõíôáãïãñáößá êáé ôá áóöáëéóôéêÜ ôáìåßá ðñÝðåé íá óõììïñöùèïýí êáé íá åõèõãñáììéóôïýí óôç íÝá ðñáãìáôéêüôçôá.

Áíáìåíüìåíá ïöÝëç áðü ôç ëåéôïõñãßá ôïõ ðñïôåéíüìåíïõ ìïíôÝëïõ Áðëïýóôåõóç ôùí äéáäéêáóéþí – åîïéêïíüìçóç áíèñþðéíùí ðüñùí. Ç äéáäéêáóßá óõìðëÞñùóçò ôùí óõíïäåõôéêþí åããñÜöùí ôçò óõíôáãÞò (åéäéêü óõíôáãïëüãéï íüìïõ ðåñß íáñêùôéêþí ïõóéþí, ãíùìáôåýóåéò áíáíôéêáôÜóôáôùí öáñìÜêùí ê.ëð.) èá óõìðëçñþíïíôáé áõôüìáôá êáé ìüíïí üôáí ðñïâëÝðåôáé áðü ôç íïìïèåóßá êáé ï éáôñüò èá ðñÝðåé áðëÜ íá ôá õðïãñÜøåé çëåêôñïíéêÜ. Ôá óôïé÷åßá ôïõ áóèåíÞ (ð.÷. ïíïìáôåðþíõìï, áñéèìüò ìçôñþïõ ê.ëð.) åßíáé äõíáôüí íá åéóÜãïíôáé áõôüìáôá óôçí çëåêôñïíéêÞ óõíôáãÞ áðü ôïí çëåêôñïíéêü öÜêåëï Þ ðñïçãïýìåíç óõíôáãÞ. Óõóóþñåõóç ðïëýôéìçò éáôñéêÞò ðëçñïöïñßáò (âë. ðáñáêÜôù: öáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç). Óùóôüôåñç, áóöáëÝóôåñç êáé ïéêïíïìéêüôåñç ÷ñÞóç ôùí öáñìÜêùí. Ï éáôñüò èá Ý÷åé óôç äéÜèåóç ôïõ ðåñéóóüôåñåò ðëçñïöïñßåò (ð.÷. öáñìáêïëïãéêÝò ðëçñïöïñßåò, ôéìÝò öáñìÜêùí ê.ëð.) ãéá íá ðåôý÷åé ôïõò ðáñáðÜíù óôü÷ïõò. ÐëÞñç Ýëåã÷ï ôçò äéáêßíçóçò ôùí öáñìÜ-

Ôüìïò 17, Ôåý÷ïò 1, 2005

Í. ÁíôùíÜêçò

êùí (âë. ðáñáêÜôù: öáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç). Äõíáôüôçôá åëÝã÷ïõ êáé ðáñÝìâáóçò óå ðåñéðôþóåéò áêáôÜëëçëçò ÷ñÞóçò ôùí öáñìÜêùí (âë. ðáñáêÜôù: öáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç).

ÖáñìáêïåðéäçìéïëïãéêÞ ðñïóÝããéóç: ÅðéôÞñçóç êáé ðñïáãùãÞ ôçò õãåßáò Ç Öáñìáêïåðéäçìéïëïãßá ìðïñåß íá ðåñéãñÜöåé, íá åîçãåß, íá åðéôçñåß êáé íá ðñïâëÝðåé ôçí åîÝëéîç ðáñáìÝôñùí ðïõ ó÷åôßæïíôáé ìå ôç äçìüóéá õãåßá, üðùò ïé åðéäçìéêÝò åîÜñóåéò, ïé åìâïëéáóìïß êáé ïé äåßêôåò èíçóéìüôçôáò êáé íïóçñüôçôáò, óå ïñéóìÝíï ÷þñï, ÷ñüíï êáé ðëçèõóìü.11-16 Óå ðïëëÝò ðåñéðôþóåéò ç óõëëïãÞ, áðïóôïëÞ êáé åðåîåñãáóßá ôùí óôïé÷åßùí ìðïñåß íá ãßíåôáé áõôüìáôá áðü äßêôõï çëåêôñïíéêþí õðïëïãéóôþí êáé íá åêäßäåôáé, åðßóçò áõôüìáôá, “óÞìá óõíáãåñìïý” ãéá åðéêßíäõíåò ðáñåêêëßóåéò ôùí ðáñáìÝôñùí áõôþí. ÔÝôïéá óõóôÞìáôá Ý÷ïõí Þäç ÷ñçóéìïðïéçèåß ãéá ôçí Üìåóç áíáãíþñéóç åîÜñóåùí ëïéìùäþí íïóçìÜôùí ðïõ ïöåßëïíôáé óå ôñïìïêñáôéêÝò åíÝñãåéåò (ð.÷. êñïýóìáôá Üíèñáêá). ¸íá ôÝôïéï áõôüìáôï óýóôçìá ÷ñçóéìïðïéÞèçêå êáôÜ ôç äéåîáãùãÞ ôùí ÷åéìåñéíþí Ïëõìðéáêþí Áãþíùí óôéò Ç.Ð.Á. ôï Ýôïò 2002. Ôï óýóôçìá áõôü åöÜñìïæå, áíÜ 4ùñï, áëãüñéèìï ðïõ ìðïñïýóå íá åêäþóåé “óÞìá óõíáãåñìïý” ãéá Ýîáñóç êÜðïéïõ íïóÞìáôïò.17,18 Óôçí êáèçìåñéíÞ ñïõôßíá ðáñáêïëïýèçóçò ðáñáìÝôñùí äçìüóéáò õãåßáò, ïé áíÜãêåò äåí åßíáé ðÜíôá ôüóï åðéôáêôéêÝò êáé åðåßãïõóåò üðùò óôçí ðåñßðôùóç êéíäýíïõ ôñïìïêñáôéêÞò åðßèåóçò ìå âéïëïãéêÜ üðëá, óôï ÷þñï äéåîáãùãÞò Ïëõìðéáêþí Áãþíùí. Ôï óýóôçìá Ç.Ó. ðïõ ðñïôåßíåôáé ðáñáðÜíù, ðÝñá áðü ôá ðñïáíáöåñèÝíôá ïöÝëç, ìðïñåß íá óõìâÜëåé áðïöáóéóôéêÜ êáé óôá ðïëëÜ óçìåßá ðïõ ó÷åôßæïíôáé ìå ôïí åõñýôåñï ÷þñï ôçò äçìüóéáò õãåßáò. Ôá óçìáíôéêüôåñá áðü áõôÜ åßíáé ôá áêüëïõèá: 1. Ðñþéìç áíáãíþñéóç, ðáñáêïëïýèçóç êáé äéåõêüëõíóç ðáñÝìâáóçò, óå ðåñéðôþóåéò åðéäçìéêþí åîÜñóåùí ëïéìùäþí íïóçìÜôùí. Ãéá ðáñÜäåéãìá, ç áõîçìÝíç óõíôáãïãñÜöçóç áíôéäéáññïúêþí öáñìÜêùí, ìðïñåß íá áíáãíùñßóåé ôá÷ýôáôá ôçí Ýîáñóç êñïõóìÜôùí ãáóôñåíôåñßôéäáò êáé íá åíôïðßóåé ôïðéêÜ ôï

ðñüâëçìá. Ìðïñåß åðßóçò íá ôï ðáñáêïëïõèÞóåé ÷ñïíïôïðéêÜ.19 Ðñþéìç áíáãíþñéóç, ðáñáêïëïýèçóç êáé äéåõêüëõíóç ðáñÝìâáóçò, óå ðåñéðôþóåéò áëëáãþí óôïõò äåßêôåò íïóçñüôçôáò ìç ëïéìùäþí íïóçìÜôùí. Ãéá ðáñÜäåéãìá, ç ÷ñüíéá ðáñáêïëïýèçóç ôçò óõíôáãïãñÜöçóçò öáñìÜêùí ðïõ ðñïïñßæïíôáé ãéá ôçí áíôéìåôþðéóç áëëåñãéþí ìðïñåß íá êáôáãñÜøåé ôçí ôïðï÷ñïíéêÞ êáôáíïìÞ ôùí êáôáóôÜóåùí áõôþí, íá äþóåé ðëçñïöïñßåò ãéá ôç âáñýôçôá êáé ôï åßäïò ôïõò êáé íá âïçèÞóåé óôçí áíôéìåôþðéóç ôïõò. Ôá óôïé÷åßá áðü ôç Öáñìáêïåðéäçìéïëïãßá ìðïñïýí íá óõíäõáóôïýí ìå Üëëá óôïé÷åßá, üðùò ïé ìåôñÞóåéò ôçò ñýðáíóçò ôçò áôìüóöáéñáò êáé íá ðñïêýøïõí ÷ñÞóéìá óõìðåñÜóìáôá ãéá ðáñÝìâáóç.16 Ðñüãíùóç ãéá ôçí åîÝëéîç äéáöüñùí ðáñáìÝôñùí (ð.÷. äáðÜíåò öáñìáêïèåñáðåßáò, äåßêôåò íïóçñüôçôáò, äåßêôåò æÞôçóçò õðçñåóéþí õãåßáò ê.ëð.). Ãéá ðáñÜäåéãìá, õðÜñ÷åé ç äõíáôüôçôá ðñüâëåøçò ôïõ áíáìåíüìåíïõ äåßêôç íïóçëåõôéêÞò êßíçóçò (hospitalisation) Þ ôïõ äåßêôç åéäéêÞò èíçóéìüôçôáò áðü ÷ñüíéá íïóÞìáôá.16,20 Ðñþéìç áíáãíþñéóç êáé ðáñÝìâáóç óå ðåñéðôþóåéò áêáôÜëëçëçò ÷ñÞóçò ôùí öáñìÜêùí óå ïñéóìÝíç ðåñéï÷Þ. Ãéá ðáñÜäåéãìá, ç êáôáãñáöÞ õðåñâïëéêÞò ÷ñÞóçò áíôéìéêñïâéáêþí öáñìÜêùí óå êÜðïéá ìéêñÞ ðåñéï÷Þ (Ýíá ÷ùñéü), óå óõíäõáóìü ìå ôç ãíþóç üôé óå ïëüêëçñç ôçí õðü ðáñáêïëïýèçóç ðåñéöÝñåéá õðÜñ÷åé Ýîáñóç éïãåíïýò ëïßìùîçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò, èá âïçèÞóåé ôïí éáôñü ôïõ Ðåñéöåñåéáêïý Éáôñåßïõ ôïõ óõãêåêñéìÝíïõ ÷ùñéïý íá áíôéëçöèåß ôï äéáãíùóôéêü ôïõ ëÜèïò êáé ôç ëÜèïò ÷ñÞóç ôùí áíôéìéêñïâéáêþí öáñìÜêùí. Ðñþéìç áíáãíþñéóç êáé ðáñÝìâáóç óå ðåñßðôùóç áíåðéèýìçôùí åíåñãåéþí öáñìÜêùí (öáñìáêïåðáãñýðíçóç). Ãéá ðáñÜäåéãìá, áí äéáðéóôùèåß áýîçóç óôç óõíôáãïãñÜöçóç öáñìÜêùí ãéá ôçí áíôéìåôþðéóç áôïðéêþí äåñìáôéêþí åîáíèçìÜôùí ðáñÜëëçëç êáé óôáôéóôéêÜ óõó÷åôéæüìåíç ìå ôç óõíôáãïãñÜöçóç íÝïõ óêåõÜóìáôïò, ðéèáíüí ç áéôßá ôùí åîáíèçìÜôùí íá åßíáé ôï íÝï öÜñìáêï.15 Áíáãíþñéóç áêáôÜëëçëùí èåñáðåõôéêþí ó÷çìÜôùí êáé ðáñÝìâáóç. Ãéá ðáñÜäåéãìá, óôï Ê.Ö. åßíáé äõíáôüí íá ãßíåôáé áõôüìáôç åðé43

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ëïãÞ ôùí óõíôáãþí ôùí çëéêéùìÝíùí ðïõ ðëçñïýí êñéôÞñéá áêáôÜëëçëçò óõíôáãïãñáößáò (ð.÷. êñéôÞñéá ôïõ Beers)21 êáé íá åöéóôÜôáé ç ðñïóï÷Þ ôùí éáôñþí. 7. Áíáãíþñéóç ðåñéðôþóåùí êáôåõèõíüìåíçò óõíôáãïãñáößáò Þ ðáñÜíïìçò óõíôáãïãñáöéêÞò äñáóôçñéüôçôáò. Ãéá ðáñÜäåéãìá, åÜí Ýíáò Þ ðåñéóóüôåñïé áóèåíåßò, ëáìâÜíïõí ðïóüôçôåò öáñìÜêùí ðïëý ìåãáëýôåñåò áðü ôéò áíþôåñåò ðïóüôçôåò ðïõ óõíéóôþíôáé áðü ôç Öáñìáêïëïãßá, ðéèáíüí íá õðÜñ÷åé ðáñÜíïìç äñáóôçñéüôçôá. Ôï Ê.Ö. èá ìðïñåß åðßóçò íá åíôïðßæåé ðåñéðôþóåéò ðáñáðïßçóçò ôùí óõíôáãþí, ìå óýãêñéóç ôùí äåäïìÝíùí áðü äéáöïñåôéêÝò öÜóåéò ôçò äéáêßíçóçò ôùí óõíôáãþí. Ïé ðáñáðÜíù äéáäéêáóßåò åßíáé äõíáôüí íá åßíáé áõôüìáôåò. 8. Áíáãíþñéóç ðåñéðôþóåùí áêñéâÞò óõíôáãïãñáößáò. Ãéá ðáñÜäåéãìá, èá åßíáé äõíáôüí íá ãßíåé áõôüìáôç áíß÷íåõóç óõóôçìáôéêÞò óõíôáãïãñÜöçóçò áêñéâþí óêåõáóìÜôùí, åíþ õðÜñ÷ïõí óôçí áãïñÜ öôçíüôåñá êáé åîßóïõ áðïôåëåóìáôéêÜ óêåõÜóìáôá. 9. Áíáãíþñéóç ðåñéðôþóåùí óôéò ïðïßåò äåí áêïëïõèïýíôáé ïé êáíüíåò ïñèÞò óõíôáãïãñáößáò. Ãéá ðáñÜäåéãìá, èá ìðïñïýí íá åíôïðéóôïýí áõôüìáôá ðåñéðôþóåéò óõíôáãïãñáößáò öáñìÜêùí ðïõ ðñïïñßæïíôáé ãéá âñá÷õ÷ñüíéá ìüíï ÷ïñÞãçóç êáé üìùò ÷ïñçãïýíôáé ãéá ìåãÜëï ÷ñïíéêü äéÜóôçìá. 10.ÓõìâïëÞ óôçí ðåñéãñáöÞ ôçò öõóéêÞò éóôïñßáò ôùí íïóçìÜôùí. Ãéá ðáñÜäåéãìá, ç ðáñáêïëïýèçóç ôçò öáñìáêïèåñáðåßáò ôùí äéáâçôéêþí áóèåíþí ìðïñåß íá óõìâÜëåé óôç äéáìüñöùóç åéêüíáò ãéá ôç öõóéêÞ éóôïñßá ôçò íüóïõ óå óõãêåêñéìÝíç ðåñéï÷Þ. 11.ÊáôáãñáöÞ ôùí óõ÷íüôåñùí äéáãíþóåùí êáé ôùí óõ÷íüôåñá ÷ñçóéìïðïéïýìåíùí öáñìÜêùí óå ïñéóìÝíç ðåñéï÷Þ. Ç ãíþóç áõôÞ ìðïñåß íá âïçèÞóåé ôç äéáãíùóôéêÞ äéáäéêáóßá (èåþñçìá Bayes), ôï ó÷åäéáóìü ôùí õðçñåóéþí õãåßáò êáé ôçí ïñãÜíùóç ôçò óõíå÷ïýò åêðáßäåõóçò ôùí éáôñþí.8

Åãêõñüôçôá ¼ðùò åßíáé öõóéêü ç õëïðïßçóç åíüò ìïíôÝ-

Í. ÁíôùíÜêçò

ëïõ ìå ôéò ðñïäéáãñáöÝò ðïõ áíáöÝñáìå, áðáéôåß äïêéìáóôéêÞ åöáñìïãÞ êáé ðñïóáñìïãÝò ðñéí áðü ôçí ôåëéêÞ åöáñìïãÞ ôïõ. Ç äõíáôüôçôá ôïõ íá áíáãíùñßæåé óùóôÜ ôéò êáôáóôÜóåéò ðïõ ðñïáíáöÝñáìå (Åãêõñüôçôá) ðñÝðåé íá èåìåëéþíåôáé ìå éêáíïðïéçôéêÝò ôéìÝò Åõáéóèçóßáò êáé Åéäéêüôçôáò Þ áêüìç êáëëßôåñá ìå ROC áíáëýóåéò.17,22

ÓõìðåñÜóìáôá Óõíåêôéìþíôáò ðïëëïýò ðáñÜãïíôåò ôçò óýã÷ñïíçò Ð.Ö.Õ. óôçí ÅëëÜäá, üðùò ç ðñïóðÜèåéá ìç÷áíïñãÜíùóçò ðïëëþí ìïíÜäùí Ð.Ö.Õ., ç ÷ñçìáôïäüôçóç áðü ôï êñÜôïò ôçò ìç÷áíïñãÜíùóçò ôùí öáñìáêåßùí, ç ïëïÝíá êáé ìåãáëýôåñç åîïéêåßùóç ôùí õãåéïíïìéêþí ìå ôïõò çëåêôñïíéêïýò õðïëïãéóôÝò, ôï ïëïÝíá áõîáíüìåíï êüóôïò ôçò öáñìáêïèåñáðåßáò, ôï ïéêïíïìéêü ðñüâëçìá ôùí áóöáëéóôéêþí ôáìåßùí êáé ôéò ôÜóåéò ðïõ åðéêñáôïýí óå üëá ôá ðñïçãìÝíá óõóôÞìáôá õãåßáò ôçò Åõñþðçò, ìðïñïýìå íá óõìðåñÜíïõìå üôé ç ëýóç ôçò Ç.Ó. åßíáé åöáñìüóéìç êáé áðáñáßôçôç ãéá ôç ÷þñá ìáò. Ôï ìïíôÝëï Ç.Ó. ðïõ ðñïôåßíåôáé óôç äçìïóßåõóç áõôÞ ðåñéëáìâÜíåé âáóéêÝò áëëÜ óõãêåêñéìÝíåò êáôåõèýíóåéò ãéá ôç ëýóç ôïõ ðñïâëÞìáôïò. Åðßóçò ÷ñçóéìïðïéåß ôç ëýóç áõôÞ ìå óêïðü íá ùöåëçèåß ïëüêëçñï ôï óýóôçìá õãåßáò. Ïé äõóêïëßåò ðïõ ðñÝðåé íá îåðåñáóôïýí èá åßíáé óçìáíôéêÝò (ð.÷. áëëáãÞ óôç ñïõôßíá ìïíÜäùí Ð.Ö.Õ. êáé öáñìáêåßùí, äçìéïõñãßá Ê.Ö.), üìùò ôá èåôéêÜ áðïôåëÝóìáôá öáßíåôáé üôé ìðïñïýí íá áíôéññïðßóïõí Üìåóá êáé èåáìáôéêÜ ôéò äõóêïëßåò áõôÝò. Ç áíÜðôõîç åíüò ìïíôÝëïõ, üðùò ôï ðñïôåéíüìåíï, áðáéôåß óçìáíôéêïýò ïéêïíïìéêïýò êáé áíèñþðéíïõò ðüñïõò êáé êõñßùò áðáéôåß ÷ñüíï ãéá ôçí áíÜðôõîç, óôÜèìéóç, ðéëïôéêÞ åöáñìïãÞ êáé åõñåßá äéÜäïóç ôïõ. ÊÜèå âéáóôéêÞ êáé áðïóðáóìáôéêÞ ëýóç ìðïñåß íá õðïíïìåýóåé ôç óùóôÞ êáé óõíïëéêÞ áíôéìåôþðéóç ôïõ ðñïâëÞìáôïò. Öáßíåôáé üôé ìå ôçí áíÜðôõîç åíüò ôÝôïéïõ óõóôÞìáôïò åßíáé äõíáôüí íá êáëõöèïýí ðïëëÜ áðü ôá êåíÜ ðïõ õðÜñ÷ïõí óÞìåñá óôçí ðáñáêïëïýèçóç åðéäçìéïëïãéêþí ðáñáìÝôñùí óôç ÷þñá ìáò. Öáßíåôáé åðßóçò üôé ìðïñïýí íá âåëôéùèïýí óçìáíôéêÜ ïé ðáñå÷üìåíåò õðçñåóßåò õãåßáò.

Í. ÁíôùíÜêçò

Âéâëéïãñáößá 1. Academy of Managed Care Pharmacy: http:// www.amcp.org 2. Lipton HL, Miller RH, Wimbush JJ. Electronic prescribing: ready for prime time? J Healthc Inf Manag, 17:72-79, 2003. 3. Corley ST. Electronic prescribing: a review of costs and benefits. Top Health Inf Manage, 24:29-38, 2003. 4. Sayer GP, McGeechan K, Kemp A, Bhasele A, Hom F, Hendrie L, Swan L, Scahill S. The General Practice Research Network: the capabilities of an electronic patient management system for longitudinal patient data. Pharmacoepidemiol Drug Saf, 12:483-489, 2003. 5. International Society for Pharmacoepidemiology: http://www.pharmacoepi.org/aboutpe.cfm. 6. Stanton LA, Peterson GM, Rumble RH, Cooper GM, Polack AE. Drug-related admissions to an Australian hospital. J Clin Pharm Ther, 19:341–347, 1994. 7. Buehler JW, Hopkins RS, Overhage JM, Sosin DM, Tong V. CDC Working Group. Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR Recomm Rep, 53:1-11, 2004. 8. ÁíôùíÜêçò N, ÐëïõìÞò Í, ÓáñéäÜêçò Ì, ÌáêñÞ Ê, ÖéëéððÜêç Ì, ËéïíÞò ×. Ç óõíôáãïãñáößá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. ÉÉÉ. Ç ðñïäñïìéêÞ ìåëÝôç ôïõ ÊÝíôñïõ Õãåßáò Áíùãåßùí Áñ÷åßá ÅëëçíéêÞò ÉáôñéêÞò, 18:379-388, 2001. 9. Bessell TL, Silagy CA, Anderson JN, Hiller JE, Sansom LN. Quality of global e-pharmacies: can we safeguard consumers? Eur J Clin Pharmacol, 58:567-572, 2002. 10. Stamatiou Y, Skipenes E, Henrikson E, Stathiakis N, Sikianakis A, Charalampous E, Antonakis N, Stolen K, Den Brader F, Lund MS, Papadaki K, Valvis G. The CORAS approach for model-based risk management applied to a telemedicine service. Stud Health Technol inform, 95:206-211, 2003. 11. Porta MS, Hartzema AG. The contribution of epidemiology to the study of drugs. Drug Intell Clin Pharm, 21:741-747, 1987.

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12. Fillenbaum GG, Horner RD, Hanlon JT, Landerman LR, Dawson DV, Cohen HJ. Factors predicting change in prescription and nonprescription drug use in a community-residing black and white elderly population. J Clin Epidemiol, 49:587-93, 1996. 13. Alvarez-Requejo A, Porta M. Pharmacoepidemiology in practice. Current status and future trends. Drug Saf, 13:1-7, 1995. 14. Andremont A, Brun-Buisson C, Struelens M. Evaluating and predicting the ecologic impact of antibiotics. Clin Microbiol Infect, 5(Suppl 7):1-6, 2001. 15. Leufkens HG. The role of pharmacoepidemiology in pharmacovigilance: rational drug use in pregnancy. Pharmacoepidemiol Drug Saf, 8(Suppl 1):55-61, 1999. 16. Johnson RE, Hornbrook MC, Nichols GA. Replicating the chronic disease score (CDS) from automated pharmacy data. J Clin Epidemiol, 47:1191-1199, 1994. 17. Zhang J, Tsui FC, Wagner MM, Hogan WR. Detection of outbreaks from time series data using wavelet transform. AMIA Annu Symp Proc, 748-752, 2003. 18. Gesteland PH, Gardner RM, Tsui FC, Espino JU, Rolfs RT, James BC, Chapman WW, Moore AW, Wagner MM. Automated syndromic surveillance for the 2002 Winter Olympics. J Am Med Inform Assoc, 10:547-554, 2003. 19. Miller JR, Mikol Y. Surveillance for diarrheal disease in New York City. J Urban Health, 76:388–390, 1999. 20. Von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol, 45:197-203, 1992. 21. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med, 163:27162724, 2003. 22. Altman DG. Some common problems in medical research. Én: Practical statistics for medical research. Chapman & Hall (eds), London 1997, p.p. 396-419.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Í. ÃåùñãéÜííïò

ÃÑÁÌÌÁ ÓÔÏÍ ÅÊÄÏÔÇ LETTER TO THE EDITOR Primary Heatlh Care, Volume 17, Number 1, 46-49, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 46-49, 2005

Åðáíáðñïóäéïñßæïíôáò ôçí åðéêïéíùíßá ãéáôñïý-áóèåíÞ óôç óýã÷ñïíç åëëçíéêÞ öñïíôßäá õãåßáò

“...öáßíåôáé ó÷åäüí óßãïõñï ðùò, üôáí üëïé ïé ãéáôñïß äéáèÝóïõí ëßãï ÷ñüíï ãéá íá áíáðôýîïõí äåîéüôçôåò åðéêïéíùíßáò, ôá ðñÜãìáôá èá åîåëé÷èïýí ðñïò ôï êáëýôåñï... ïé áóèåíåßò èá åßíáé ðéï éêáíïðïéçìÝíïé áðü ôçí ðáñå÷üìåíç öñïíôßäá, ôï ßäéï êáé ïé ãéáôñïß... ç ðïéüôçôá ôçò öñïíôßäáò èá áíáâáèìéóôåß êáé ïé ðåñéðôþóåéò éáôñéêïý ëÜèïõò èá åëá÷éóôïðïéçèïýí... Ç áðáéôïýìåíç êßíçóç åßíáé íá ðåßóïõìå êÜâå ãéáôñü... ðñïêåéìÝíïõ íá ìÜèåé íá åðéêïéíùíåß... èá ìðïñïýóå íá îåêéíÞóåé ìéá ôÝôïéá äéáäéêáóßá õéïèåôþíôáò ôç ÷ñÞóç äýï ìüíï åñùôÞóåùí óå êÜèå åðáöÞ ôïõ ìå áóèåíÞ... ç ðñþôç óôçí áñ÷Þ êÜèå óõæÞôçóçò “ðþò ìðïñþ íá óáò âïçèÞóù;” êáé ç äåýôåñç ìå ôçí ïëïêëÞñùóç ôçò “Ý÷åôå êÜðïéåò åñùôÞóåéò Þ ó÷üëéá;”... William Campbell Felch1 ÁãáðçôÝ ê. ÄéåõèõíôÞ Óýíôáîçò, Ðïëéôéóìéêïß êáé êïéíùíéêïß ðáñÜãïíôåò åðéäñïýí óôç ó÷Ýóç ãéáôñïý - áóèåíÞ êáé ç áðïôåëåóìáôéêüôçôá ôçò åðçñåÜæåôáé óçìáíôéêÜ áðü ôïí ôñüðï óõììåôï÷Þò ôïõ áóèåíÞ óôç èåñáðåõôéêÞ äéáäéêáóßá. Ôï ðáôåñíáëéóôéêü ðñüôõðï, ðïõ êõñéÜñ÷çóå Ýùò ôá ìÝóá ôïõ 20ïõ áéþíá, ðåñéüñéæå ôçí åõèýíç ôïõ áóèåíÞ óôçí áðëÞ “óõììüñöùóç” ôïõ óôéò “åíôïëÝò” ôïõ ãéáôñïý, óôåñþíôáò ôç ó÷Ýóç áðü ôç ãüíéìç åðéêïéíùíéáêÞ áëëçëåðßäñáóç. Ôï ðñüôõðï áõôü èåùñåßôáé óÞìåñá áíáðïôåëåóìáôéêü.2 Óýã÷ñïíá âéïøõ÷ïêïéíùíéêÜ ðñüôõðá åóôéÜæïõí óôçí åíôüðéóç ôùí áíôéëÞøåùí ôïõ áóèåíÞ 46

ãéá ôç íüóï êáé ôéò ðñïåêôÜóåéò ôçò, óôçí áìïéâáßá êáôáíüçóç ôùí éäéáéôåñïôÞôùí ãéáôñïý êáé áóèåíÞ, óôçí áëëçëïûðïóôÞñéîç êáé ôçí áíáãíþñéóç ôïõ êïéíïý åäÜöïõò, ðÜíù óôï ïðïßï ïéêïäïìåßôáé, ìå åìðéóôïóýíç êáé áêñßâåéá, ìéá áðïôåëåóìáôéêÞ èåñáðåõôéêÞ ó÷Ýóç. ÔÝôïéá ðñüôõðá èåùñïýíôáé ùò ôá ðëÝïí êáôÜëëçëá ãéá ôç äéá÷åßñéóç ÷ñüíéùí íïóçìÜôùí êáé ôçí ðñïáãùãÞ ôçò áãùãÞò õãåßáò óôï ðëáßóéï ôçò êïéíüôçôáò êáé èá ðñÝðåé íá åðéäéþêïíôáé üôáí ïé óõíèÞêåò ôï åðéôñÝðïõí. Ï ãéáôñüò êáëåßôáé íá ðáñïôñýíåé êáé íá åêðáéäåýåé ôïí áóèåíÞ íá óõììåôÝ÷åé åíåñãçôéêÜ óôç èåñáðåõôéêÞ äéáäéêáóßá, äåäïìÝíïõ ðùò ìéá ôÝôïéá óõíåéäçôïðïéçìÝíç óõììåôï÷Þ ðñïÜãåé êáëýôåñá êëéíéêÜ áðïôåëÝóìáôá.3 Ùò ôç äåêáåôßá ôïõ 1970, ç ãíþóç ôçò éáôñéêÞò ôå÷íéêÞò, ôçò öõóéêÞò åîÝôáóçò êáé ôçò åðßëõóçò éáôñéêþí ðñïâëçìÜôùí, áðïôåëïýóáí ôá âáóéêÜ êñéôÞñéá ãéá ôçí êñßóç ôçò åðéóôçìïíéêÞò éêáíüôçôáò ôïõ ãéáôñïý. ÓÞìåñá, ç äéåèíÞò âéâëéïãñáößá áíáãíùñßæåé ôçí éêáíüôçôá åðéêïéíùíßáò ôïõ ãéáôñïý ùò âáóéêÞ êëéíéêÞ äåîéüôçôá áðïëýôùò áðáñáßôçôç ãéá ôçí áíÜðôõîç ìéáò ëåéôïõñãéêÞò ó÷Ýóçò ãéáôñïý-áóèåíÞ êáèþò ç åðéêïéíùíßá èåùñåßôáé êïìâéêüò ðáñÜãïíôáò áðïôåëåóìáôéêüôçôáò óå êÜèå åðßðåäï ðáñï÷Þò öñïíôßäáò õãåßáò.2 Ïé ãéáôñïß ðïõ äéáèÝôïõí äåîéüôçôåò åðéêïéíùíßáò áíôéëáìâÜíïíôáé ôá÷ýôåñá êáé ðéï Ýãêõñá ôï ðñüâëçìá ôïõ áóèåíÞ, ôïõ ðáñÝ÷ïõí êáëýôåñç øõ÷ïëïãéêÞ õðïóôÞñéîç êáé ìåãáëýôåñç éêáíïðïßçóç êáé ðñïÜãïíôáò, ôáõôü÷ñïíá, ôçí åìðéóôïóýíç êáé ôçí õãåßá, âéþíïõí ïé ßäéïé ëéãüôåñï åñãáóéáêü Üã÷ïò êáé ìåãáëýôåñç åðáããåëìáôéêÞ

Í. ÃåùñãéÜííïò

éêáíïðïßçóç.4 Åßíáé áíáìåíüìåíï ï ãéáôñüò êáé ï áóèåíÞò íá áíôéëáìâÜíïíôáé ôçí “áóèÝíåéá” ìå äéáöïñåôéêü ôñüðï. Ï ãéáôñüò ïöåßëåé íá êáôáíïÞóåé ôçí Üðïøç ôïõ áóèåíÞ êáé íá êáôáóôÞóåé óáöÝò ðùò êÜèå óêÝøç, óõìâïõëÞ Þ áðüöáóç ðïõ áöïñÜ ôç äéá÷åßñéóç ôçò íüóïõ ôïõ êáé ôéò ðéèáíÝò ðñïåêôÜóåéò ôçò èá ôåêìçñéùèåß ìå âÜóç áõôü ôï åðßôåõãìá. Áðáñáßôçôï åöüäéï óå ìéá ôÝôïéá ðñïóðÜèåéá áðïôåëåß ç åðéêïéíùíßá, ç ïðïßá êáèßóôáôáé áðïôåëåóìáôéêÞ üôáí ïé åìðëåêüìåíïé êáôáöÝñïõí íá áðïäþóïõí ôçí ßäéá åñìçíåßá êáé ôçí ßäéá óçìáíôéêüôçôá óå êÜèå ðëçñïöïñßá ðïõ åêöñÜæåôáé ëåêôéêÜ Þ ìç ëåêôéêÜ. 2 Ç âåëôßùóç ôçò åðéêïéíùíßáò, äåí áíáöÝñåôáé ãåíéêÜ óå øõ÷ïêïéíùíéêÝò ðáñáìÝôñïõò öñïíôßäáò, áëëÜ óôçí áíÜðôõîç óõãêåêñéìÝíùí, ðïéïôéêÜ êáé ðïóïôéêÜ, äåîéïôÞôùí ôïõ ãéáôñïý, êáôÜ ôñüðï éêáíü íá âåëôéþóåé, ìå áêñßâåéá êáé áðïäïôéêüôçôá, ôç öõóéêÞ Ýêâáóç êáé ôï áðïôÝëåóìá ôçò íüóïõ êáé íá ðñïÜãåé ôçí õðïóôÞñéîç, ôç óõíåñãáóßá êáé ôç óõíôñïöéêüôçôá ãéáôñïýáóèåíÞ. Ç áðïôåëåóìáôéêÞ åðéêïéíùíßá ëåéôïõñãåß ìå äõíáìéêÞ, ó÷åäéáóìü êáé ðñïãñáììáôéóìü ùò ðñïò ôï åðéäéùêüìåíï áðïôÝëåóìá, åîáóöáëßæïíôáò áëëçëåðßäñáóç êáé áíôáëëáãÞ ôùí ðëçñïöïñéþí, êáôÜ ôñüðï ðïõ åëá÷éóôïðïéåß êÜèå ðåñéôôü áßóèçìá áâåâáéüôçôáò.2 Óôçí ðñïóðÜèåéá âåëôßùóçò Þ áíÜðôõîçò ôùí åðéêïéíùíéáêþí äåîéïôÞôùí, áäéáìöéóâÞôçôïò èåùñåßôáé óÞìåñá ï ñüëïò ôçò åêðáßäåõóçò. ÌåëÝôç 180 åñåõíçôéêþí åñãáóéþí ìå áíôéêåßìåíï ôç ó÷åôéêÞ åêðáßäåõóç, ðïõ ðñáãìáôïðïéÞèçêå ãéá ôçí ¸íùóç ÉáôñéêÞò Åêðáßäåõóçò ôçò Åõñþðçò, êáôÝëçîå óôï óõìðÝñáóìá ðùò ïé äåîéüôçôåò åðéêïéíùíßáò åßíáé äéäÜîéìåò óå ãéáôñïýò êÜèå åðéðÝäïõ åêðáßäåõóçò áëëÜ êáé êÜèå éáôñéêïý ðåäßïõ.5 Ïé ìÝèïäïé åêðáßäåõóçò óôçí åðéêïéíùíßá åßíáé õðáñêôÝò. Áðáñáßôçôá óôÜäéá áðïôåëïýí ç åíôüðéóç ôçò áíáãêáéüôçôáò ãéá åðéêïéíùíéáêÞ âåëôßùóç, ï ðñïóäéïñéóìüò êáé ðåñéãñáöÞ ôùí äåîéïôÞôùí, ç ðáñáôÞñçóç êáé ÷ñÞóç ôïõò óôçí ðñÜîç, ç åîÜóêçóç êáé âåëôéóôïðïßçóç ôïõò.2 Ïñãáíþóåéò õðïóôÞñéîçò áóèåíþí, éäéùôéêïß êáé êñáôéêïß öïñåßò õðçñåóéþí õãåßáò êáé åðåíäõôÝò åóôéÜæïõí ôï åíäéáöÝñïí ôïõò, åõñÝùò áíÜ ôçí õöÞëéï, óå ìåèüäïõò âåëôßùóçò ôçò åðéêïéíùíßáò. Óõíå÷þò áõîáíüìåíç Ýìöáóç áíôéêáôïðôñßæåôáé óå äéåèíåßò äéáêçñýîåéò ïìïöùíßáò åéäéêþí

Ôüìïò 17, Ôåý÷ïò 1, 2005

åðéóôçìüíùí, êáôåõèõíôÞñéåò ïäçãßåò êáé åðáããåëìáôéêÜ äåäïìÝíá Üóêçóçò êáé åêðáßäåõóçò óôçí éáôñéêÞ,6,7 ðïõ ðñïâÜëïõí ôçí åöáñìïãÞ åêðáéäåõôéêþí ðñïãñáììÜôùí âåëôßùóçò ôùí äåîéïôÞôùí åðéêïéíùíßáò ùò ìßá åê ôùí âáóéêþí ðáñáìÝôñùí ãéá ôçí ïñãÜíùóç åðéôõ÷çìÝíçò åêðáßäåõóçò ôùí ãéáôñþí êáé ôùí öïéôçôþí éáôñéêÞò,3,9 èåùñþíôáò áäéáìöéóâÞôçôï ðùò ç õøçëÞ ðïéüôçôá óôçí Üóêçóç ôçò éáôñéêÞò åðéóôÞìçò ðñïûðïèÝôåé ôçí áíáâÜèìéóç ôçò ðïéüôçôáò óôçí åðéêïéíùíßá. Ç åêðáßäåõóç óôçí åðéêïéíùíßá áðïêôÜ ïõóéáóôéêü íüçìá áí Ý÷åé ùò ôåëéêü óôü÷ï ôçí åöáñìïãÞ óôçí éáôñéêÞ ðñáêôéêÞ. Ç ãíþóç äåí ìðïñåß íá ìåôáôñáðåß áõôüìáôá óå ðñáêôéêÞ. Áíáãêáßá êñßíåôáé ç óõóôçìáôéêÞ ôáîéíüìçóç ôùí äåîéïôÞôùí ðïõ ðñÝðåé íá äéäá÷èïýí, ç ðáñáôÞñçóç ôïõò óôçí ðñÜîç, ç åöáñìïãÞ êáé åîÜóêçóç ôïõò, ç äéáñêÞò åðáíåêôßìçóç êáé åðáíáðñïóäéïñéóìüò ôïõò êáé ç åðáíáôñïöïäüôçóç ôùí åêðáéäåõïìÝíùí. Ç êáôáíüçóç, ç áíÜðôõîç, ç âåëôßùóç êáé ç äéäáóêáëßá ôùí äåîéïôÞôùí åðéêïéíùíßáò åßíáé Ýñãï ìáêñïðñüèåóìï. Ç ôåëåéüôçôá åßíáé áðñïóäéüñéóôç êáé èá ðñÝðåé íá ðáñáìÝíåé ï äéáñêÞò åðéäéùêüìåíïò óôü÷ïò.2 Ç åìðåéñßá óôçí éáôñéêÞ ôÝ÷íç, ùò áðïêëåéóôéêüò êáèïäçãçôÞò âåëôßùóçò ôçò åðéêïéíùíßáò, èåùñåßôáé óÞìåñá áíáîéüðéóôïò äÜóêáëïò. Ç ðåßñá áðïôåëåß ôïí êýñéï õðïóôçñéêôÞ ôçò óõíÞèåéáò êáé ôåßíåé íá ìç äéá÷ùñßæåé êáé íá ìçí åðéëÝãåé åõêñéíþò ìåôáîý êáëþí êáé êáêþí óõíçèåéþí.2 Ôá ðñïãñÜììáôá åêðáßäåõóçò ôùí öïéôçôþí éáôñéêÞò ðïõ áðïöïéôïýí áðü ôéò åëëçíéêÝò éáôñéêÝò ó÷ïëÝò, óõíÞèùò óôåñïýíôáé ìåèïäéêÞò åêðáéäåõôéêÞò ðñïóÝããéóçò ôïõ áíôéêåéìÝíïõ ôçò åðéêïéíùíßáò. Óõ÷íÜ ïé åêðáéäåõôÝò åóôéÜæïõí óôç äéáäéêáóßá ôçò äéÜãíùóçò êáé ôçò åðßëõóçò éáôñéêþí ðñïâëçìÜôùí, ðáñáìåñßæïíôáò ìéá ðñïóÝããéóç åðéêåíôñùìÝíç óôïí áóèåíÞ. ÓôáäéáêÜ ïé åêðáéäåõüìåíïé ôáõôßæïõí ôçí Ýííïéá ôçò áðïôåëåóìáôéêÞò åðéêïéíùíßáò ìå åêåßíç ôçò åðéôõ÷çìÝíçò åðßëõóçò éáôñéêþí ðñïâëçìÜôùí. Ôá êïìâéêÜ óçìåßá åðéêïéíùíßáò óðÜíéá áíáëýïíôáé óôçí êáèçìåñéíÞ åêðáéäåõôéêÞ ðñáêôéêÞ, ïé åêðáéäåõüìåíïé óðÜíéá ëáìâÜíïõí áíôéêåéìåíéêÞ êñéôéêÞ, åíþ ç áîßá ôçò áõôïáîéïëüãçóçò áìöéóâçôåßôáé, áöïý äýóêïëá ìðïñåß êáíåßò íá óõíåéäçôïðïéÞóåé êáé íá êñßíåé ôç äéêÞ ôïõ éêáíüôçôá’åðéêïéíùíßáò.2 Ï åëëçíéêÝò ôýðïò, üëï êáé ðéï óõ÷íÜ, öéëï47

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

îåíåß êáôáããåëßåò áóèåíþí, ùò Ýêöñáóç óõíÞèùò äõóáñÝóêåéáò áðü óõãêåêñéìÝíåò óôÜóåéò êáé óõìðåñéöïñÝò ôùí ãéáôñþí, åíþ ôáõôü÷ñïíá âñßóêåôáé óå åîÝëéîç ç ðñïóðÜèåéá ãéá ëåéôïõñãéêÞ ìåôáññýèìéóç êáé áíáâÜèìéóç ôïõ óõóôÞìáôïò õãåßáò ôçò ÷þñáò. ÐáñÜ ôï ãåãïíüò ðùò ç äéïãêïýìåíç äõóáñÝóêåéá ôùí áóèåíþí èá ìðïñïýóå íá áðïäïèåß åí ìÝñåé óå áëëáãÝò ðïõ åðÞëèáí óôçí êïéíùíéêÞ ïñãÜíùóç, ôçí åîÝëéîç ôçò éáôñéêÞò åðéóôÞìçò êáé ôïõ óõóôÞìáôïò õãåßáò ôçò ÷þñáò ìáò, ç Ýíôáîç åêðáéäåõôéêþí ðñïãñáììÜôùí ìå áíôéêåßìåíï ôçí åðéêïéíùíßá óôéò åëëçíéêÝò éáôñéêÝò ó÷ïëÝò êñßíåôáé áíáãêáßá ãéá ôçí áíáâÜèìéóç ôçò ðïéüôçôáò óå êÜèå åðßðåäï êáé ðåäßï ðáñï÷Þò éáôñéêÞò öñïíôßäáò. Ôï ÔìÞìá ÉáôñéêÞò ôçò Ó÷ïëÞò Åðéóôçìþí Õãåßáò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò Ý÷åé áíáðôýîåé êáé ðåñéëÜâåé ïñãáíùìÝíç êáé ìåèïäéêÞ åêðáßäåõóç óå èÝìáôá ó÷Ýóçò ãéáôñïý-áóèåíÞ óôï ðñïðôõ÷éáêü ðñüãñáììá óðïõäþí ôïõ ôïìÝá ÊïéíùíéêÞò ÉáôñéêÞò, ìå åðéóôçìïíéêü õðåýèõíï ôïí Áí. Êáè. ê. ËéïíÞ.3 Óôçí ÉáôñéêÞ Ó÷ïëÞ ôïõ Ðáíåðéóôçìßïõ Éùáííßíùí, ï Åð. Êáè. ê. ÕöáíôÞò êáé ï Êáè. ê. ÌáõñÝáò, ðñïùèïýí ôï ó÷åäéáóìü êáé Ýíôáîç åêðáéäåõôéêþí ðáñåìâÜóåùí ìå óôü÷ï ôçí âåëôßùóç ôùí åðéêïéíùíéáêþí äåîéïôÞôùí ôùí öïéôçôþí óôï ðñïðôõ÷éáêü ðñüãñáììá óðïõäþí ôïõ ÔìÞìáôïò Øõ÷éáôñéêÞò (ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò êáé Øõ÷éêÞò Õãåßáò), üðïõ Þäç åêðïíåßôáé ó÷åôéêÞ äéäáêôïñéêÞ äéáôñéâÞ êáé Ýñåõíá. Ðñüóöáôá åãêáéíéÜóèçêå ç óõíåñãáóßá ìåëþí ÄÅÐ êáé åñåõíçôþí ôùí áíôéóôïß÷ùí ôïìÝùí ôùí äýï Ðáíåðéóôçìßùí, áëëÜ êáé áíôßóôïé÷ùí ôïìÝùí Åõñùðáúêþí Ðáíåðéóôçìßùí ìå óôü÷ï ôçí áîéïðïßçóç ôçò õðÜñ÷ïõóáò åìðåéñßáò êáé ôï óõíôïíéóìü ôùí ðñïóðáèåéþí ãéá áíáâÜèìéóç ôçò éáôñéêÞò åêðáßäåõóçò óôï áíôéêåßìåíï ôçò åðéêïéíùíßáò êáé ôçò ó÷Ýóçò ãéáôñïý-áóèåíÞ. Ç âåëôßùóç ôùí äåîéïôÞôùí åðéêïéíùíßáò êñßíåôáé óçìáíôéêÞ ãéá ôïõò ãéáôñïýò êÜèå åéäéêüôçôáò, èåùñåßôáé ùóôüóï áíáãêáßá ãéá ôçí åäñáßùóç êáé áíÜðôõîç ôùí ó÷Ýóåùí ôïõ Ãåíéêïý Ïéêïãåíåéáêïý Ãéáôñïý ìå ôïõò áóèåíåßò ôïõ êáé ôçí êïéíüôçôá, ðñïêåéìÝíïõ íá åðéôåëÝóåé ôï óýíïëï ôùí éäéáßôåñùí êáèçêüíôùí ôïõ.10 Ç ÅõñùðáúêÞ Áêáäçìßá Åêðáéäåõôþí ÃåíéêÞò ÉáôñéêÞò, ðåñéëáìâÜíåé ôçí åðéêïéíùíßá ãéáôñïý-áóèåíÞ óôá âáóéêÜ ðåäßá êáèÞêïíôïò ôïõ Ãåíéêïý Ïéêïãåíåéáêïý Ãéáôñïý, ðåñéãñÜöåé ôç âéïøõ÷ï48

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êïéíùíéêÞ/ïëéóôéêÞ ðñïóÝããéóç ôïõ áóèåíÞ ùò éäéáßôåñï ÷áñáêôçñéóôéêü ôçò åéäéêüôçôáò êáé õðïãñáììßæåé ôï êáèÞêïí áíÜðôõîçò ðïéïôéêþí åêðáéäåõôéêþí êáé åñåõíçôéêþí ðñïãñáììÜôùí óôï ðåäßï áõôü.11 Ç ÉáôñéêÞ Ó÷ïëÞ ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò Ý÷åé áíáãíùñßóåé Þäç ôç ÃåíéêÞ/ ÏéêïãåíåéáêÞ ÉáôñéêÞ ùò áêáäçìáúêü áíôéêåßìåíï åêðáßäåõóçò ôùí öïéôçôþí éáôñéêÞò, åíþ ìÝëç ÄÅÐ êáé åñåõíçôÝò ôïõ Ðáíåðéóôçìßïõ Éùáííßíùí, åñãÜæïíôáé ðñïò áõôÞ ôçí êáôåýèõíóç. Ï áíáó÷åäéáóìüò ôçò åêðáßäåõóçò ôùí öïéôçôþí éáôñéêÞò êáé ôùí ãåíéêþí/ïéêïãåíåéáêþí ãéáôñþí, ìå Üîïíá ôçí ïëéóôéêÞ ðñïóÝããéóç ôïõ áóèåíÞ, óå óõíäõáóìü ìå ôçí áíáãíþñéóç ôçò ÃåíéêÞò/ÏéêïãåíåéáêÞò ÉáôñéêÞò ùò áêáäçìáúêïý áíôéêåéìÝíïõ Ýñåõíáò êáé åêðáßäåõóçò, áðïôåëïýí áðáñáßôçôåò ðñïûðïèÝóåéò ãéá ôçí áíáâÜèìéóç ôçò ðïéüôçôáò óôï ÷þñï ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò êáé áíáìÝíåôáé íá óõíåéóöÝñïõí óçìáíôéêÜ óôçí áðïôåëåóìáôéêÞ ìåôáññýèìéóç ôïõ óõóôÞìáôïò õãåßáò ôçò ÷þñáò. Í. ÃåùñãéÜííïò ÔìÞìá Øõ÷éáôñéêÞò, ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò êáé Øõ÷éêÞò Õãåßáò, ÉáôñéêÞ Ó÷ïëÞ Ðáíåðéóôçìßïõ Éùáííßíùí

Âéâëéïãñáößá 1. Felch WC. The secret(s) of Good Patient Care - Thoughts On Medicine In The 21th Century. PRAEGER. London, 1996. 2. Kurtz SM. Doctor-Patient Communication: Principles and Practices. Can J Neurol Sei, 29(Suppl 2):23-29, 2002. 3. ËéïíÞò ×., Ñïâßèçò Å. Ó÷Ýóç éáôñïý - áóèåíïýò. Ðñüãñáììá ÐñïìçèÝáò. ÇñÜêëåéï 2001. 4. Maquire P, Piteeathly C. Key communication skills and how to acquire them. BMJ, 325:697700, 2002. 5. Aspegren K. BEDE Guide No2: Teaching and learning communication skills in medicine-a review with quality grading of articles. Medical Teacher, 21:563-570, 1999. 6. Association of American Medical Colleges. Medical School Objectives Project, Report III. Contemporary Issues in Medicine: Communication in Medicine. Washington, DC: Association of American Medical Colleges, 1999.

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7. General Medical Council. Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education. London, U.K.: General Medical Council 1993. 8. Parker G. On our selection: predictors of medical school success. Medical Journal of Australia, 158:747-751, 1993. 9. Laidlaw TS, MacLeod H, Kaufman DM, Langille DB, Sargeant J. Implementing a communication skills program in medical school: needs assessment and program change. Med Educ,

36:115-24, 2002. 10. Täte P, Foulkes J, Neighbour R, Campion P, Field S. Assessing physicians’ interpersonal skills via videotaped encounters: a new approach for the Royal College of General Practitioners Membership Examination. J Health Conun, 4:143-52, 1999. 11. EURACT. European definition of General Practice/Family Medicine - The European definitions 2002.www.euract.org

European Section of the International Journal of Rural and Remote Health ü Ôï íÝï äéåèíÝò çëåêôñïíéêü ðåñéïäéêü ãéá ôïõò õãåéïíïìéêïýò ðïõ åñãÜæïíôáé óå áãñïôéêÝò ðåñéï÷Ýò ü Ôï åðßóçìï ðåñéïäéêü ôïõ EURIPA Åðéóêåöèåßôå ôï óôç äéåýèõíóç http://rrh.deakin.edu.au êáé åããñáöåßôå äùñåÜí

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÍÝá

ÍÅÁ NEWS Primary Heatlh Care, Volume 17, Number 1, 50-51, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 1, 50-51, 2005

Öéëßððåéï åñãáóôÞñé ôçò Ýñåõíáò Óôï ôÝëïò ôïõ Ìáñôßïõ ðñáãìáôïðïéÞèçêáí óôá Øáêïýäéá ×áëêéäéêÞò ï 1ïò êýêëïò ôïõ óåìéíáñßïõ "Öéëßððåéï åñãáóôÞñé ôçò Ýñåõíáò" ðïõ ïñãáíþèçêå áðü ôçí EðéôñïðÞ ¸ñåõíáò ôçò ÅËÅÃÅÉÁ. ÕëïðïéÞèçêå Ýôóé ôï üñáìá ôçò EðéôñïðÞò ¸ñåõíáò, íá ìåôáöÝñåé ôéò åìðåéñßåò ôçò áðü ôéò óõíáíôÞóåéò ôçò EGPRN. Óõììåôåß÷áí 26 ãåíéêïß ãéáôñïß, åéäéêåõüìåíïé êáé åéäéêåõìÝíïé áðü üëç ôçí ÅëëÜäá ôùí ïðïßùí ç åðéëïãÞ ëüãù ôçò ìåãÜëçò áíôáðüêñéóçò, Ýãéíå ìå âÜóç ôï âéïãñáöéêü ôïõò. Ôï óåìéíÜñéï äéÞñêçóå ôñåéò çìÝñåò, Þäç ÷áñáêôçñßóôçêå åðéôõ÷Ýò áðü ôïõò óõììåôÝ÷ïíôåò êáé ïé åêðáéäåõôÝò ×ñ. ËéïíÞò, Ä. Êïýâåëáò, Ì.

ÊáëïåéäÜò êáé ç ÓôÝëëá ÁñãõñéÜäïõ, ðñïóðÜèçóáí ìå ôïí êáëýôåñï ôñüðï íá ôïõò åéóÜãïõí óôçí Ýñåõíá êáé ôç ìåèïäïëïãßá ôçò. Ðáñüíôåò êáè’ üëç ôç äéÜñêåéá ôïõ óåìéíáñßïõ ïé êïò Ì. Ìåñêïýñçò êáé êïò Á. Óõìåùíßäçò ðïõ óôÞñéîáí ôçí ðñïóðÜèåéá ôçò åðéôñïðÞò Ýñåõíáò. Ç åðéôõ÷ßá èá êñéèåß óôï âÜèïò ôïõ ÷ñüíïõ, áò åëðßóïõìå üìùò ç ðñïóðÜèåéá áõôÞ íá áíèßóåé, íá êáèéåñùèåß êáé íá óõìâÜëëåé óôçí áíáâÜèìéóç ôçò ÃåíéêÞò/ÏéêïãåíåéáêÞò ÉáôñéêÞò óôçí ÅëëÜäá. ×áñéôßíç Ìåëéóóïðïýëïõ Ãåíéêüò Éáôñüò Ê.Õ. ×ñõóïýðïëçò

Ôüìïò 17, Ôåý÷ïò 1, 2005

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ATHENS - September 10 & 11, 2005

8th international conference Primary Care Diabetes EUROPE PRELIMINARY PROGRAMME

ABSTRACTS: Abstracts can be sent in for the poster exhibition by mail or email to the secretariat (address details on the back) or on-line via our website www.pcdeurope.org. Please send in your abstract indicating aims, intervention method, results and conclusion. A poster prize will be awarded for the best poster. PLEASE NOTE that as of this year only those accepted abstracts will be published and exhibited of which the first author is a fully registered participant, present at the poster exhibition during break times! Abstract submission deadline is JUNE 15, 2005.

LOCATION: The Divani Caravel Hotel, 2 Vas. Alexandrou Avenue, 16121 Athens, Greece. Phone: 00210 7207000, info@divanisedivanicaravel.gr, http://www.divanis.gr

CONFERENCE LANGUAGE: The offical conference language is English, all presentations and publications will be done in English.

PRIMARY CARE DIABETES STUDY GROUP, PRESENTING ON SUNDAY Aim The aim of the Study Group on Primary Care Research in Diabetology is to increase the amount and the quality of research in primary diabetes care and to facilitate international contacts and motivate young scientists to perform research in primary as well as shared care settings.

Position The EASD Study Group on Primary Care Research in Diabetology intends to be the formal European study group for diabetes research in primary care. Members of the study group also form the 'research branch' of Primary Care Diabetes Europe. ww.pcdeurope.org) Following the first meeting in Athens 2005 the EASD Executive Committee, Council and General Assembly will be asked to accept the creation of the new EASD Study Group. Up to now 18 general practitioners from 11 European countries have become a member of the group. Further information can be obtained from the secretariat Paula Laterveer, details below.

SATURDAY SEPTEMBER 10, 2005 12:00 Chairman Introduction & Welcome Eugene Hughes, UK 12:15 The Mediterranean Perspective of Diabetes and Primary Care, Kamles Khunti (UK) 12:45 The EU Perspective of Diabetes and Primary Care, Christos Lionis (Greece) 13:15 From Obesity to Diabetes, Alain Golay (Switzerland) 14:00 Coffee break 14:30 Short presentation from abstracts and poster prize 2004, Martina Kelly (Ireland) 15:30 Behavioural Medicine, Lena Insulander (Sweden) 16:15 Patient Education, Ghislaine Hochberg (France) 17:00 Poster time and Welcome Reception

SUNDAY SEPTEMBER 11, 2005 09:15 Welcome + Summary Day 1, Eugene Hughes (UK) 09:30 Research in Primary Care in Europe, Guy Rutten (Netherlands) 09.40 Four Presentations from the Study Group: - The Spanish Primary Care Research Network, Xavier Cos (Spain) - PAtH Questionnaire: Attitudes of GPs to the diagnosis and management of IGT: the PAtH (Practitioners' Attitudes to Hyperglycaemia) Questionnaire, Philip Evans (UK) - Diabetes and increased risk of infections, Kees Gorter (Netherlands) - The First attempt to use Metaplans for Education of Medical Students, General Practitioners and Nurses, Lika Tsutskiridze (Georgia) 11:00 Coffee break 11:30 Four Presentations from the Study Group: - A community intervention promoting physical activity reduced weight gain and beneficially affected cardiovascular risk factors in a low-income urban district. Results from The Romsas in Motion study, Anna Karen Jenum (Norway) - Barriers of the Primary Care diabetes Management in Hungary, Imre Rurik (Hungary) - Diabetes amongst immigrants in Sweden, Per Wandell (Sweden) - Sustainability of diabetes care in primary care, David Whitford (Ireland) 13.30 PCDE report and closure 13:30 Lunch with a View 51

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, 2) ÅíçìåñùôéêÜ Üñèñá, 3) Óýíôïìá Üñèñá (óýíôïìåò äçìïóéåýóåéò) Ýêôáóçò ìÝ÷ñé 7 óåëßäåò ìå ðñüóöáôåò ü÷é Üíù áðü 5 âéâëéïãñáöéêÝò ðçãÝò, 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 óå ÷Üñôéíç êáé çëåêôñïíéêÞ ìïñöÞ, êáé èá õðïâÜëëïíôáé óå äýï áíôßôõðá óôç äéåýèõíóç ôïõ ÄéåõèõíôÞ Óýíôáîçò: - ÐáíåðéóôÞìéï ÊñÞôçò (õðüøç AíáðëçñùôÞ ÊáèçãçôÞ ×. ËéïíÞ), ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò, Ô.È. 1393, ÇñÜêëåéï ÊñÞôçò. Êáèþò êáé óôï e-mail: tasrom@yahoo.com.uk 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.