VOL17_ISSUE3_JUL_SEP_2005 by SAN PUBLICATIONS

ðñùôïâÜèìéá

öñïíôßäá Ôüìïò 17, Ôåý÷ïò 3, Iïýëéïò - ÓåðôÝìâñéïò 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 3, Éïýëéïò - ÓåðôÝìâñéïò 2005, Volume 17, Number 3, July - September 2005

Ôçò Óýíôáîçò 108

×. ËéïíÞò: Åíþðéïí äéëçììÜôùí: Ç ãåíéêÞ éáôñéêÞ ùò ðáñÜãùí âåëôßùóçò ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò ðïéüôçôáò óôç öñïíôßäá õãåßáò ÅñåõíçôéêÜ ¢ñèñá

110

Æ. Ðáðáñßæïõ, Í. ÔóáãêáñÜêçò, Å. ÐáðáäÜêçò, Å. ÄïõëãåñÜêçò, Å. ËáäïõêÜêç, ×. ÐáíéåñÜêçò, Ö. ËáäïìÝíïõ, Á. ÌðáôéóôÜêçò, Ð. ÄáóêáëÜêçò, Æ. ÔñïõëÜêç, Ñ. ÁëåîáíäñÜêç, N. ÄñáêùíÜêçò: ¸ëåã÷ïò ôçò åìâïëéáóôéêÞò êÜëõøçò óôá ðáéäéÜ çëéêßáò 3-15 åôþí óôçí ðåñéï÷Þ åõèýíçò ôïõ Ê.Õ. ×Üñáêá Íïìïý Çñáêëåßïõ

119

Á. Áñâáíßôçò, Á. ÓêáñðÝëïò, Ð. ÌáëéíäñÝôïò, ×. ×áëêéïðïýëïõ, Í. ÑáæÞò: ÌÝôñçóç ôçò áñôçñéáêÞò ðßåóçò: Áíáãêáéüôçôá êáé óêïðéìüôçôá áðü ôçí ðëåõñÜ ôùí ðñïóåñ÷üìåíùí óå Ðåñéöåñåéáêü Éáôñåßï ÁíáóêïðÞóåéò

127

Ö. Áñâáíßôç, Ä.Â. ÐáíáãéùôÜêïò, P. Kokkinos, ×ñ. Ðßôóáâïò: ÄéáôñïöÞ êáé áñôçñéáêÞ õðÝñôáóç: Ï ñüëïò ôçò ìåóïãåéáêÞò äéáôñïöÞò óôçí ðñüëçøç

139

I. ËÝíôæáò, Ó. Êïêêüñçò, Á. Áëåâßæïò, Ð. ÄáóêáëÜêçò, Á. ÊáìáñÜôïò, Á. Ìáñéüëçò: ÍÝïé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ: Äåßêôåò öëåãìïíÞò, èñüìâùóçò êáé ïîåéäùôéêïý stress ×. ÓêïõëÜêçò, Ã. Ëýêáò, Ì. Ðáîéíüò, É. ÔæÝëç, Í. Êüêêáëçò, Ð . Ìïó÷ïíôæüðïõëïò, Ä. ÂáëáãéÜííçò: ÖëåãìïíÝò êáé áðïóôÞìáôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò. Ðáñïõóßáóç äýï êëéíéêþí ðåñéðôþóåùí

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Á. Ìüíôç, Ã.Ê. Êïõâßäçò, È. Æäïýêïò: Óýíäñïìï Munchausen. ÐåñéãñáöÞ ðåñßðôùóçò óå ðáéäß 10 åôþí ÃñÜììá óôïí Åêäüôç

155

Í.×. Êïíäýëçò: Ðñüôáóç óõíåñãáóßáò ìå ôï ðåñéïäéêü "Ánnali Italiani di Chirurgia"

ÊÙÄ. 3855

ÅêðáéäåõôéêÜ ÐñïãñÜììáôá óôç ÃåíéêÞ ÉáôñéêÞ 156

Ãåíéêü Íïóïêïìåßï ËÜñéóáò

157

Ãåíéêü Íïóïêïìåßï Âüëïõ NÝåò Åêäüóåéò

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

Áñéèìüò ¢äåéáò 451/91

158

ÊÅÌÐ.ÁÈ.

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

ÁíáöïñÝò Ðåñéðôþóåùí 146

A. Máñéüëçò: "Ôï Ðåñéöåñåéáêü Éáôñåßï: Åã÷åéñßäéï ãéá ôïí Ãåíéêü/Ïéêïãåíåéáêü Éáôñü" ×ñÞóôïõ ËéïíÞ. ¸êäïóç: ÉáôñéêÝò Åêäüóåéò Ð.×. Ðáó÷áëßäç êáé Áêáäçìßáò ÃåíéêÞò ÉáôñéêÞò

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) Áéêáôåñßíç ÊÜâïõñá (Glasqow)

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

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 È. 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 Ôh. 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

MERK - GENERICS

ÊÁÔÁ×ÙÑÇÓÇ

ðñùôïâÜèìéá

öñïíôßäá õãåßáò

ÐÅÑÉÅ×ÏÌÅÍÁ Tçò Óýíôáîçò ×. ËéïíÞò: Åíþðéïí äéëçììÜôùí: Ç ãåíéêÞ éáôñéêÞ ùò ðáñÜãùí âåëôßùóçò ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò ðïéüôçôáò óôç öñïíôßäá õãåßáò ...................................................................................................................................... 108 ÅñåõíçôéêÜ ¢ñèñá Æ. Ðáðáñßæïõ, Í. ÔóáãêáñÜêçò, Å. ÐáðáäÜêçò, Å. ÄïõëãåñÜêçò, Å. ËáäïõêÜêç, ×. ÐáíéåñÜêçò, Ö. ËáäïìÝíïõ, Á. ÌðáôéóôÜêçò, Ð. ÄáóêáëÜêçò, Æ. ÔñïõëÜêç, Ñ. ÁëåîáíäñÜêç, N. ÄñáêùíÜêçò: ¸ëåã÷ïò ôçò åìâïëéáóôéêÞò êÜëõøçò óôá ðáéäéÜ çëéêßáò 3-15 åôþí óôçí ðåñéï÷Þ åõèýíçò ôïõ Ê.Õ. ×Üñáêá Íïìïý Çñáêëåßïõ .................................................... 110 Á. Áñâáíßôçò, Á. ÓêáñðÝëïò, Ð. ÌáëéíäñÝôïò, ×. ×áëêéïðïýëïõ, Í. ÑáæÞò: ÌÝôñçóç ôçò áñôçñéáêÞò ðßåóçò: Áíáãêáéüôçôá êáé óêïðéìüôçôá áðü ôçí ðëåõñÜ ôùí ðñïóåñ÷üìåíùí óå Ðåñéöåñåéáêü Éáôñåßï ......................................... 119 ÁíáóêïðÞóåéò Ö. Áñâáíßôç, Ä.Â. ÐáíáãéùôÜêïò, P. Kokkinos, ×ñ. Ðßôóáâïò: ÄéáôñïöÞ êáé áñôçñéáêÞ õðÝñôáóç: Ï ñüëïò ôçò ìåóïãåéáêÞò äéáôñïöÞò óôçí ðñüëçøç ........................................................................................................................................................... 127 I. ËÝíôæáò, Ó. Êïêêüñçò, Á. Áëåâßæïò, Ð. ÄáóêáëÜêçò, Á. ÊáìáñÜôïò, Á. Ìáñéüëçò: ÍÝïé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ: Äåßêôåò öëåãìïíÞò, èñüìâùóçò êáé ïîåéäùôéêïý stress ......................................................................................... 139 ÁíáöïñÝò Ðåñéðôþóåùí ×. ÓêïõëÜêçò, Ã. Ëýêáò, Ì. Ðáîéíüò, É. ÔæÝëç, Í. Êüêêáëçò, Ð. Ìïó÷ïíôæüðïõëïò, Ä. ÂáëáãéÜííçò: ÖëåãìïíÝò êáé áðïóôÞìáôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò. Ðáñïõóßáóç äýï êëéíéêþí ðåñéðôþóåùí ........................ 146 Á. Ìüíôç, Ã.Ê. Êïõâßäçò, È. Æäïýêïò: Óýíäñïìï Munchausen. ÐåñéãñáöÞ ðåñßðôùóçò óå ðáéäß 10 åôþí .................................... 151 ÃñÜììá óôïí Åêäüôç Í.×. Êïíäýëçò: Ðñüôáóç óõíåñãáóßáò ìå ôï ðåñéïäéêü "Ánnali Italiani di Chirurgia" ...................................................................................... 155 ÅêðáéäåõôéêÜ ðñïãñÜììáôá óôç ÃåíéêÞ ÉáôñéêÞ Ãåíéêü Íïóïêïìåßï ËÜñéóáò ...................................................................................................................................................................................................................... 156 Ãåíéêü Íïóïêïìåßï Âüëïõ .......................................................................................................................................................................................................................... 157 NÝåò Åêäüóåéò A. Máñéüëçò: "Ôï Ðåñéöåñåéáêü Éáôñåßï: Åã÷åéñßäéï ãéá ôïí Ãåíéêü/Ïéêïãåíåéáêü Éáôñü" ×ñÞóôïõ ËéïíÞ. ¸êäïóç: ÉáôñéêÝò Åêäüóåéò Ð.×. Ðáó÷áëßäç êáé Áêáäçìßáò ÃåíéêÞò ÉáôñéêÞò ........................................................................................................ 158

CONTENTS Editorial C. Lionis: In front of dilemmas: General Practice as a factor of clinical effectiveness and quality of care improvement ..... 108 Original Papers Z. Paparizou, Í. Tsagarakis, Å. Papadakis, Å. Doulgerakis, Å. Ladoukaki, H. Panierakis, F. Ladomenou, Á. Batistakis, Æ. Troulaki, R. Alexandraki, N. Drakonakis: Assessment of vaccine coverage of children aged 3-15 years in the area of clinical responsibility of the Harakas Health Centre, Heraklion, Crete ............................................... 110 A. Arvanitis, A. Skarpelos, P. Malindretos, C. Chalkiopoulou, N. Razis: Blood pressure measurement: necessity and expediency from the patients’ viewpoint ........................................................................................................................................................ 119 Reviews F. Árvaniti, D.Â. Panagiotakos, P. Kokkinos, C. Pitsavos: Nutrition and blood hypertension: The role of mediterrenean diet in prevention ........................................................................................................................................................................... 127 I. Lentzas, S. Kokkoris, A. Alevizos, P. Daskalakis, A. Kamaratos, A. Mariolis: Novel cardiovascular risk factors: inflammatory, thrombotic and oxidative stress markers ......................................................................................................................................................... 139 Cases Reports C. Skoulakis, G. Lykas, M. Paxinos, J. Tzeli, N. Kokkalis, P. Moschontzopoulos, D. Valagiannis: Infections and abscesses of mucopharyngeal space. Report of two clinical cases .......................................................................................... 146 A. Monti, G.K. Kouvidis, Th. Zdoukos: Munchausen syndrome: A case report of a 10-year-old child .................................................... 151 Letter to the Editor Í.C. Êondilis: A proposal for a collaboration with the Journal "Ánnali Italiani di Chirurgia" ......................................................................... 155 Educational cources for General Practice General Hospital of Larissa ...................................................................................................................................................................................................................... 156 General Hospital of Volos ........................................................................................................................................................................................................................... 157 New Editions A. Mariolis: "Remote and Rural Practice: A manual for General Practitioners/Family Physicians”. Christos Lionis, Publishers: P.C. Paschalidou and Academy of General Practice ................................................................................................ 158

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ËéïíÞò

ÔÇÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 17, Number 3, 108-109, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 108-109, 2005

Åíþðéïí äéëçììÜôùí: Ç ãåíéêÞ éáôñéêÞ ùò ðáñÜãùí âåëôßùóçò ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò ðïéüôçôáò óôç öñïíôßäá õãåßáò

Ôá æçôÞìáôá ôçò âåëôßùóçò ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò ðïéüôçôáò ôçò öñïíôßäáò õãåßáò Ý÷ïõí ðåñéëçöèåß áðü ÷ñüíéá óôçí áôæÝíôá ôùí ó÷åäéáóôþí ôùí õðçñåóéþí õãåßáò, êáèþò êáé óôéò äéáêçñýîåéò ôùí ðïëéôéêþí êïììÜôùí áëëÜ êáé ôçò äéåèíïýò âéâëéïãñáößáò. Ãéá ôçí ÅëëÜäá ôï èÝìá åîáêïëïõèåß íá åßíáé åðßêáéñï, áí êáé ç óõæÞôçóç óõ÷íÜ äåí åóôéÜæåôáé óôá æçôÞìáôá áõôÜ êáé ç ìåèïäïëïãéêÞ ðñïóÝããéóç ìïéÜæåé íá åßíáé äéáöïñåôéêÞ ìå áõôÞ ðïõ ÷ñçóéìïðïéåßôáé óôéò ÷þñåò ôçò ÄõôéêÞò êáé Âüñåéáò Åõñþðçò. Ç ãåíéêÞ éáôñéêÞ óôçí Åõñþðç Ýäåéîå íá åõáéóèçôïðïéåßôáé éäéáßôåñá óôçí áíÜãêç áëëáãÞò êáé Ýôóé äåí äßóôáóå íá ðñï÷ùñÞóåé óå Ýíáí íÝï ïñéóìü ôïõ ðåñéå÷ïìÝíïõ ôçò êáèþò êáé ôùí êåíôñéêþí éêáíïôÞôùí ôïõ éáôñïý ãåíéêÞò éáôñéêÞò (WONCA Europe 2002). Áí êáé ôï êåßìåíï áõôü Ý÷åé ìåôáöñáóèåß óôçí åëëçíéêÞ ãëþóóá (ôõðþíåôáé áðü ôçí ÅËÅÃÅÉÁ), åí ôïýôïéò õðÜñ÷åé áêüìç ìáêñýò äñüìïò ìÝ÷ñéò üôïõ áõôü ìåôïõóéùèåß óå óôñáôçãéêÞ, ðáñÜ ôéò ïõóéáóôéêÝò ðñïóðÜèåéåò ôçò ÅËÅÃÅÉÁ. Ôç âåëôßùóç ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò åß÷å ùò óôü÷ï êáé ç åéóáãùãÞ óôï óýóôçìá õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí ôùí óõìâïëáßùí ôùí ãåíéêþí éáôñþí. Åðßóçò, óôï ÇíùìÝíï Âáóßëåéï Ýíá êåßìåíï áñ÷þí ìå ôßôëï “Investing in General Practice: The New Medical Services Contact”, õéïèåôÞèçêå ìå øÞöéóìá áðü ôïõò ãåíéêïýò éáôñïýò ôïí Éïýíéï ôïõ 2003, êáé Ý÷åé ôåèåß óÞìåñá óå åöáñìïãÞ1,2. Ôï íÝï áõôü óõìâü108

ëáéï ðïõ ðåñéëáìâÜíåé üñïõò íïìéêïýò, ïéêïíïìéêïýò êáé ñõèìéóôéêïýò, êáèþò êáé êáèïäÞãçóç ãéá ôçí åöáñìïãÞ ôïõ, óôï÷åýåé êõñßùò óôç âåëôßùóç ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò êáé ôçò ðïéüôçôáò óå åðéëåãìÝíåò õðçñåóßåò õãåßáò ðïõ ÷áñáêôçñßæïíôáé ïõóéáóôéêÝò (essentials) Þ åðéðñüóèåôåò (additional). Óôï óõìâüëáéï áðïôõðþíåôáé ç åèíéêÞ óôñáôçãéêÞ êáé åðé÷åéñåßôáé ç éêáíïðïßçóç åèíéêþí Þ ôïðéêþí áíáãêþí, ìÝóù ìç÷áíéóìþí åíßó÷õóçò êéíÞôñùí ôùí ßäéùí ôùí ãåíéêþí éáôñþí, ôùí ïðïßùí ôïõò âáèìïýò åëåõèåñßáò óôç äéïßêçóç êáé ïñãÜíùóç äéåõñýíåé ðåñáéôÝñù. ØÞãìáôá ôÝôïéùí éäåþí óôçí êáèéÝñùóç óõìâïëáßùí ìå éáôñïýò Ð.Ö.Õ. êáé åðáããåëìáôßåò õãåßáò ðïõ åñãÜæïíôáé óôá ÊÝíôñá Õãåßáò, ìðïñïýìå íá áíé÷íåýóïõìå áðü ìéá åöáñìïãÞ óôçí ÊñÞôç ðïõ ðñüóöáôá äçìïóéåýèçêå3. Ç áðáñôßùóç (integration) ôïõ óõóôÞìáôïò õãåßáò óôç ÷þñá ìáò Þ ìå Üëëá ëüãéá ôçò áíÜðôõîçò ôçò ëåéôïõñãéêÞò äéáóýíäåóçò õðçñåóéþí êáé ìïíÜäùí óå Ýíá åëåã÷üìåíï êáé êáëÜ óõíôïíéóìÝíï äßêôõï, áðïôåëåß óõ÷íÞ áíáöïñÜ óôç äéåèíÞ âéâëéïãñáößá êáé ó’ áõôÞ áíáöåñüôáí êáé ç åðé÷åéñçèåßóá “ðåñéöåñéïðïßçóç” ôïõ óõóôÞìáôïò õãåßáò. ÐñïôÜóåéò ãéá ôç “ëåéôïõñãéêÞ áíáóõãêñüôçóç” ôïõ óõóôÞìáôïò óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, êõñßùò ìå ôçí åéóáãùãÞ ìéáò åðáñêïýò äÝóìçò õðçñåóéþí õãåßáò áðü ôïí ïéêïãåíåéáêü éáôñü, ìÝóù óõìâïëáßùí ìå ôïõò áóöáëéóôéêïýò ïñãáíéóìïýò, äéáôõðþèçêáí êáé äçìïóéåýèçêáí óôïí åëëçíéêü êáé îÝíï ôýðï4. Ï üñïò “äéêôýùóç”, ðïõ õðïäçëþíåé ôç ëåé-

Ôüìïò 17, Ôåý÷ïò 3, 2005

×. ËéïíÞò

ôïõñãßá ôïõ éáôñïý ãåíéêÞò éáôñéêÞò óå ïñãáíùìÝíá äßêôõá ãéá ôçí áíôéìåôþðéóç ÷ñïíßùí íïóçìÜôùí ìå ôç ÷ñÞóç standards êáé óõíôïíéóìÝíçò öñïíôßäáò, áðïôåëåß ìéá åðüìåíç ðñüêëçóç ãéá ôç ÃåíéêÞ ÉáôñéêÞ óôç ÷þñá ìáò. H äéêôýùóç áõôÞ óå åðßðåäï íïìïý áðïôåëåß áíôéêåßìåíï ðïõ óõíéóôÜôáé óôçí ðñüôáóç ôçò ïìÜäáò äéïßêçóçò Ýñãïõ ãéá ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ôïõ Õðïõñãåßïõ Õãåßáò êáé ÊïéíùíéêÞò Áëëçëåããýçò ðïõ óõíôüíéóå ï ðñüåäñïò ôçò ÅËÅÃÅÉÁ ê. Ì.Ð. Ìåñêïýñçò. Ïé ðñïêëÞóåéò ðïõ Ý÷åé íá áíôéìåôùðßóç ç ÃåíéêÞ ÉáôñéêÞ óôç ÷þñá ìáò åßíáé ðïëëÝò êáé ç ÅËÅÃÅÉÁ öáßíåôáé íá Ý÷åé ôç äõíáôüôçôá íá ïäçãÞóåé óå äéÝîïäï ôç óõæÞôçóç ãéá ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò êáé ôçí áðïôåëåóìáôéêüôçôÜ ôçò óôç ÷þñá ìáò.

Âéâëéïãñáößá 1. Investing General Practice: The New Medical Services Contract (http://www.bma.org.uk/ap.nsf/ content/NewGMScontract/Sfile/gpcont.pdf). 2. Investing in General Practice: The New Medical Services Contract – RCGP Summary (http:/ www.rcgp.org.uk/information/publications/summaries/summary03/INFO0003.doc). 3. Lionis C, Tsiraki M, Bardis V, Philalithis A. Seeking Quality Improvement in Primary Care in Crete, Greece: the first actions. Croatian Medical Journal, 45:599-603, 2004. 4. Souliotis K, Lionis C. Creating an Integrated Health Care System in Greece: A Primary Care Perspective. Journal of Medical System, 29:187196, 2005.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Æ. Ðáðáñßæïõ êáé óõí.

ÅÑÅÕÍÇÔÉÊÇ EÑÃÁÓÉÁ ÏRIGINAL PAPER Primary Heatlh Care, Volume 17, Number 3, 110-118, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 110-118, 2005

¸ëåã÷ïò ôçò åìâïëéáóôéêÞò êÜëõøçò óôá ðáéäéÜ çëéêßáò 3-15 åôþí óôçí ðåñéï÷Þ åõèýíçò ôïõ Ê.Õ. ×Üñáêá Íïìïý Çñáêëåßïõ Æ. Ðáðáñßæïõ2, Í. ÔóáãêáñÜêçò2, Å. ÐáðáäÜêçò1, Å. ÄïõëãåñÜêçò4, Å. ËáäïõêÜêç3, ×. ÐáíéåñÜêçò2, Ö. ËáäïìÝíïõ2, Á. ÌðáôéóôÜêçò2, Ð. ÄáóêáëÜêçò2, Æ. ÔñïõëÜêç4, Ñ. ÁëåîáíäñÜêç4, N. ÄñáêùíÜêçò5

Ðåñßëçøç Óôü÷ïé ôçò ðáñïýóáò åñãáóßáò Þôáí, ðñþôïí, íá êáôáãñáöïýí ïé õðï÷ñåùôéêïß êáé ðñïáéñåôéêïß åìâïëéáóìïß ðïõ Ý÷ïõí êÜíåé ôá ðáéäéÜ çëéêßáò 3 Ýùò êáé 15 åôþí, óôçí ðåñéï÷Þ åõèýíçò ôïõ Ê.Õ. ×Üñáêá, êáôÜ ôï ó÷ïëéêü Ýôïò 20032004. Äåýôåñïí, íá âñåèïýí, ôï ðïóïóôü ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí êáé ôá ðïóïóôÜ êÜëõøçò ÷ùñéóôÜ ãéá êÜèå ëïéìþäåò íüóçìá, ãéá ôï ïðïßï ãßíåôáé åìâüëéï. Ôñßôïí, íá ãßíåé öáíåñü ôï ãåãïíüò üôé ç ðáñïõóßá ôïõ ðáéäéáôñéêïý éáôñåßïõ óôç óõãêåêñéìÝíç ðåñéöÝñåéá åðçñÝáóå óçìáíôéêÜ ôçí åìâïëéáóôéêÞ êÜëõøç ôùí ðáéäéþí. Ãé’ áõôü ôï ëüãï Ýãéíå óýãêñéóç ôùí áðïôåëåóìÜôùí ìå áõôÜ ðáëáéüôåñçò åñãáóßáò, ç ïðïßá ðñáãìáôïðïéÞèçêå êáôÜ ôï ðñþôï Ýôïò ëåéôïõñãßáò ôïõ ðáéäéáôñéêïý éáôñåßïõ óôï Ê.Õ. ×Üñáêá. Áðü ôï óýíïëï ôùí 1110 ðáéäéþí óôçí Ýñåõíá óõììåôåß÷áí ôá 989 (89%). Ôá ðáéäéÜ ÷ùñßóôçêáí óå ôñåéò çëéêéáêÝò ïìÜäåò: íçðéáêÞò çëéêßáò (ðáéäéÜ 3-5 åôþí), ó÷ïëéêÞò (6-11 åôþí) êáé åöçâéêÞò (12-15 åôþí). ÂÜóåé ôïõ Åèíéêïý ÐñïãñÜììáôïò Åìâïëéáóìþí âñÝèçêå üôé 58,7% ôïõ óõíüëïõ ôùí ðáéäéþí Þôáí ðëÞñùò åìâïëéáóìÝíá, Ýíáíôé 9,5% êáôÜ ôï ðñþôï Ýôïò ëåéôïõñãßáò ôïõ ðáéäéáôñéêïý éáôñåßïõ (ôï 1996). Óôçí ðñþôç ïìÜäá 175/184 (95,1%) Þôáí ðëÞñùò åìâïëéáóìÝíá, Ýíáíôé 53,4% ôï 1996, óôç äåýôåñç 333/591 (56,3%) Ýíáíôé 8,4% êáé óôçí ôñßôç 73/214 (34,1%) Ýíáíôé 0,3% ôï 1996. Ôá ðïóïóôÜ êñßíïíôáé éäéáéôÝñùò éêáíïðïéçôéêÜ, áí ëÜâïõìå õðüøç êáé ôçí áëëáãÞ ôùí êñéôçñßùí ðïõ äåí åõíïïýí ìéá ôüóï èåáìáôéêÞ âåëôßùóç óôçí ðëÞñç, õðï÷ñåùôéêÞ, åìâïëéáóôéêÞ êÜëõøç. ¼óïí áöïñÜ êÜèå íüóï ÷ùñéóôÜ, óôçí ðñþôç ïìÜäá áîéïóçìåßùôç åßíáé ç äéáöïñÜ óôçí êÜëõøç ãéá ôçí çðáôßôéäá Â (97,8% Ýíáíôé 73,8% ôï 1996), åíþ óôç äåýôåñç õðÜñ÷åé óçìáíôéêÞ äéáöïñÜ óå üëåò ôéò íüóïõò, ìå ðéï åíôõðùóéáêÞ ôçò öõìáôßùóçò (90,7% Ýíáíôé 25,3%), ôçò çðáôßôéäáò Â (89,3% Ýíáíôé 60,7%) êáé ôùí äéöèåñßôéäáò-ôåôÜíïõ-êïêêýôç (ìå ìéá äéáöïñÜ ôçò ôÜîçò ôïõ 50%). Óôçí ôñßôç ïìÜäá, ôÝëïò, õðÞñîå óçìáíôéêÞ õðåñï÷Þ ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí ãéá ôç öõìáôßùóç (95,3% Ýíáíôé 51,8%) êáé ãéá äéöèåñßôéäá-ôÝôáíï-êïêêýôç (50,5% Ýíáíôé 28,3%-28,3%-10,6%, áíôßóôïé÷á ôï 1996).

ÅðéìåëçôÞò, Ðáéäßáôñïò Ê.Õ. ×Üñáêá, 2Áãñïôéêïß Éáôñïß, 3Åéäéêåõüìåíç ÃåíéêÞ Éáôñüò, 4ÅðéìåëçôÝò Ãåíéêïß Éáôñïß Ê.Õ. ×Üñáêá, 5ÄéåõèõíôÞò Ê.Õ. ×Üñáêá, Íïìüò Çñáêëåßïõ ÊñÞôçò

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ÅéóáãùãÞ Óêïðüò ôùí åìâïëßùí äåí åßíáé ìüíï ç åîÜëåéøç ôçò íüóïõ, áëëÜ êáé ç ðëÞñçò åîáöÜíéóç ôïõ áéôéïëïãéêïý ðáñÜãïíôá áõôÞò. Ôï ðñþôï âÞìá ôçò óýã÷ñïíçò éáôñéêÞò ðñïò ôçí êáèéÝñùóç ôïõ åìâïëéáóìïý óáí ôç óçìáíôéêüôåñç, ãéá ôçí åðï÷Þ åêåßíç, áðÜíôçóç óôá ëïéìþäç íïóÞìáôá, Ýãéíå ôï 1796, üôáí ï ãéáôñüò Edward Jennet îåêéíïýóå ôá ðåéñÜìáôá åìâïëéáóìïý. ÁõôÞ ç áðëÞ óêÝøç ôïõ éáôñïý íá ÷ñçóéìïðïéÞóåé ôïí éü ôçò åõëïãéÜò ôùí âïïåéäþí (óõããåíÞ ìå ôïí éü ôçò åõëïãéÜò) ãéá íá åðéôý÷åé áíïóßá áðÝíáíôé óôï èáíáôçöüñï éü ôçò åõëïãéÜò, áí êáé óôçí áñ÷Þ ðñïêÜëåóå ôéò åðéöõëÜîåéò ôïõ åðéóôçìïíéêïý êüóìïõ, Ýèåóå ôá èåìÝëéá ôçò ðñïëçðôéêÞò éáôñéêÞò êáé áðïôÝëåóå ìéá ëáìðñÞ áíáêÜëõøç1. Ç íÝá åðï÷Þ ôïõ åìâïëéáóìïý ËÝîåéò êëåéäéÜ: Åìâüëéï, êÜëõøç, ðáéäéÜ, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: 27 Ïêôùâñßïõ 2004 ÅðáíõðïâëÞèçêå: 14 Äåêåìâñßïõ 2004 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 2 Ìáñôßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ÅììáíïõÞë ÐáðáäÜêçò Äéåýèõíóç: Ôáãì. ÃéáêïõìÜêç 48, Ô.Ê. 71305 ÇñÜêëåéï ÊñÞôçò, Ôçë.: 6974500150, 2810-324803, e-mail: papadakisman@hygeianet.gr êáé papadaman@in.gr

Æ. Ðáðáñßæïõ êáé óõí.

Ôüìïò 17, Ôåý÷ïò 3, 2005

áíåðôõãìÝíåò ÷þñåò. Ðåñß ôá äþäåêá õðïøÞöéá, íåüôåñçò ãåíéÜò åìâüëéá, ãéá ôçí ðñüëçøç Üëëùí áóèåíåéþí, Ý÷ïõí ðåñÜóåé ôï äåýôåñï óôÜäéï êëéíéêþí äïêéìþí3,4. ¼ìùò, áêüìç êáé óÞìåñá ðåèáßíïõí äýï åêáôïììýñéá ðáéäéÜ ôï Summary ÷ñüíï, äéüôé äåí Ý÷ïõí åìâïëéáóôåß ìå The aims of this study were: first to record the obligatory and optional vaccinaôá Þäç áðü ðïëëþí åôþí õðÜñ÷ïíôá tion status of children aged 3-15 years in the area of clinical responsibility of åìâüëéá. ÁíåîÜñôçôá áðü ôïõò ðñïëçthe Health Center of Harakas for the school year 2003-2004. Second, to assess ðôéêïýò åìâïëéáóìïýò, åðéâÜëëåôáé the percentage of fully vaccinated children and the vaccine coverage for every preventable infectious disease, separately. Third, to show that the vaccine covóõíå÷Þò åðáãñýðíçóç ãéá ôçí áðïöõerage of the children was strongly influenced by the presence of the paediatric ãÞ åðáíåìöÜíéóçò ëïéìùäþí íïóçìÜdepartment by comparing the results of this study with those of an earlier one ôùí ðïõ åß÷áí ôåèåß õðü Ýëåã÷ï (äéconducted in the same area during the first year of operation of the paediatric öèåñßôéäá). department (1996). A total of 1110 schoolchildren, 989 (89%) participated in Ôï ðñïôåéíüìåíï Åèíéêü ÷ñïíïäéÜthis study. They were separated into three age groups: preschool children (3-5 years old), school aged children (6-11 years old) and adolescents (12-15 years ãñáììá åìâïëéáóìþí óôçí ÅëëÜäá, old). The findings indicate that 58.7% of the children were fully vaccinated ðñïóïìïéÜæåé ìå áñêåôÜ ÷ñïíïäéáãñÜìversus 9.5% in 1996, according to the National Vaccination Programme. In the ìáôá åõñùðáúêþí ÷ùñþí êáé áêïëïõfirst age group, 95.1% of children were fully vaccinated, versus 53.4% in 1996. èåß ôéò âáóéêÝò ïäçãßåò ôçò ÁìåñéêáíéIn the second group 56.3% were fully vaccinated versus 8.4% in 1996. In the êÞò ÐáéäéáôñéêÞò Áêáäçìßáò, ÷ùñßò third group 34.1% were fully vaccinated versus 0.3% in 1996. These percentages are completely satisfying, considering the changes in the criteria of obligaüìùò íá åßíáé áêñéâþò ßäéï ìå êáíÝíá. tory vaccination coverage. In the first group the vaccination coverage against Èá ðñÝðåé åäþ íá õðïãñáììéóèåß, üôé hepatitis B (97.8% vs. 73.8% in 1996) was noticeable, while in the second group äåí Ý÷åé ãßíåé äõíáôÞ ìéá ðáíåõñùthere was a significant difference in vaccination coverage for all diseases, ðáúêÞ óõìöùíßá ó÷åôéêÜ ìå ôï ÷ñïíïespecially for tuberculosis (90.7% vs. 25.3%), for hepatitis B (89.3% vs. 60.7%) äéÜãñáììá ôùí åìâïëéáóìþí. ¸ôóé, and for diphtheria-tetanus-pertussis (with a difference of almost 50%). In the third group, there was an important predominance of vaccination coverage êÜèå êñÜôïò åöáñìüæåé ôï äéêü ôïõ against tuberculosis (95.3% vs. 51.8%) and diphtheria-tetanus-pertussis (50.5% ðñüãñáììá, ðñïóáñìïóìÝíï êáôÜëëçvs. 28.3%-28.3%-10.6%, respectively, in 1996). ëá óôéò ôïðéêÝò õãåéïíïìéêÝò êáé êïéKey words: vaccine, coverage, children, primary care íùíéêÝò óõíèÞêåò, êáèþò êáé óôá íåüôåñá åðéäçìéïëïãéêÜ äåäïìÝíá. Ôï ðáéäéáôñéêü éáôñåßï óôï ÊÝíôñï Õãåßáò óõíå÷ßóôçêå êáôÜ ôïí 19ï áéþíá ìå ôçí åéóáãùãÞ ðïëëþí íÝùí åìâïëßùí ãéá ôïí Ýëåã÷ï ïñéóìÝ- (Ê.Õ.) ×Üñáêá ëåéôïõñãåß áðü ôï 1996 êáé äñáíùí éïãåíþí êáé âáêôçñéáêþí ëïéìþîåùí, áëëÜ óôçñéïðïéåßôáé ôüóï óôïí ôïìÝá ôçò ðñüëçøçò ç ìåãáëýôåñç ðñüïäïò óõíôåëÝóôçêå ôïí 20Ï áéþ- üóï êáé èåñáðåõôéêÜ. ÊáôÜ ôç äéÜñêåéá ôïõ ó÷ïíá2. Ðåñéóóüôåñïé áðü 70 äéáöïñåôéêïß ëïéìþ- ëéêïý Ýôïõò 1996-1997, Ýãéíå ðñïóðÜèåéá êáôáäåéò ðáñÜãïíôåò ðñïêáëïýí óõíÞèåéò áóèÝíåéåò ãñáöÞò ôùí åìâïëéáóìþí ðïõ åß÷áí êÜíåé, Ýùò óôïí Üíèñùðï. Ó÷åäüí ôï óýíïëï áõôþí Ý÷åé áðï- ôüôå, ôá ðáéäéÜ çëéêßáò 3-15 åôþí ôçò ðåñéï÷Þò ôåëÝóåé óôü÷ï ôçò áíÜðôõîçò åìâïëßùí. ÓÞìåñá, åõèýíçò ôïõ Ê.Õ.5. Ïé åìâïëéáóìïß áõôïß åß÷áí õðÜñ÷ïõí ðåñéóóüôåñá áðü 30 îå÷ùñéóôÜ åìâü- ãßíåé åßôå áðü ðáéäéÜôñïõò éäéþôåò, åßôå áðü éáëéá, åðßóçìá êáôáãåãñáììÝíá, áðü ôá ïðïßá ÷ñç- ôñïýò ôïõ Ê.Õ. êáé áãñïôéêïýò éáôñïýò ôçò ðåóéìïðïéïýíôáé, óõíÞèùò, ôá ìéóÜ, éäéáßôåñá óôéò ñéï÷Þò. Óêïðüò ôçò ðáñïýóáò åñãáóßáò Þôáí íá åêôéÓÕÍÔÏÌÏÃÑÁÖÉÅÓ ìçèåß ç åìâïëéáóôéêÞ êáôÜóôáóç ôùí ðáéäéþí Ê.Õ. ÊÝíôñï Õãåßáò çëéêßáò 3-15 åôþí ôçò ßäéáò ðåñéï÷Þò, êáôÜ ôï DTP Åìâüëéï äéöèåñßôéäáò, ôåôÜíïõ, êïêêýôç ó÷ïëéêü Ýôïò 2003-2004 êáé ç áðïôåëåóìáôéêüDT Åìâüëéï äéöèåñßôéäáò, ôåôÜíïõ (äéðëü) ôçôá ôçò äñáóôçñéïðïßçóçò ôïõ ðáéäéáôñéêïý éáTd Åìâüëéï äéöèåñßôéäáò, ôåôÜíïõ (äéðëü ôýðïõ åíçëßêïõ) OPV Åìâüëéï ðïëéïìõåëßôéäáò ÷ïñçãïýìåíï áðü ôï óôüìá ôñåßïõ óôïí ôïìÝá ôçò ðñüëçøçò êáé åõáéóèçôïIPV Åìâüëéï ðïëéïìõåëßôéäáò åíÝóéìï ðïßçóçò ôùí ãïíÝùí óôïí ôïìÝá áõôü, ìå âÜóç BCG Åìâüëéï öõìáôßùóçò ôç óýãêñéóç ôùí áðïôåëåóìÜôùí ìå áõôÜ ôçò MMR Åìâüëéï-ôñéäýíáìï-éëáñÜò, åñõèñÜò, ðáñùôßôéäáò ìåëÝôçò ôïõ ó÷ïëéêïý Ýôïõò 1996-19975. Ð.Ï.Õ. Ðáãêüóìéïò Ïñãáíéóìüò Õãåßáò Assessment of vaccine coverage of children aged 3-15 years in the area of clinical responsibility of the Harakas Health Centre, Heraklion, Crete Z. Paparizou, Í. Tsagarakis, Å. Papadakis, Å. Doulgerakis, Å. Ladoukaki, H. Panierakis, F. Ladomenou, Á. Batistakis, Æ. Troulaki, R. Alexandraki, N. Drakonakis

111

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÔÝëïò, óêïðüò Þôáí íá ôïíéóôåß ç áíáãêáéüôçôá ýðáñîçò åíüò ðáéäéáôñéêïý éáôñåßïõ óå êÜèå Ê.Õ., ìéá êáé ï ñüëïò ôïõ óôïí ôïìÝá ôçò ðñùôïãåíïýò ðñüëçøçò åßíáé êáèïñéóôéêüò.

Ðëçèõóìüò ÌåëÝôçò - ÌÝèïäïò Ç ìåëÝôç âáóßóôçêå óôçí êáôáãñáöÞ êáé åðåîåñãáóßá ôùí åìâïëéáóìþí áðü ôá áôïìéêÜ âéâëéÜñéá õãåßáò ôùí ðáéäéþí, ìéá êáé áõôÜ áðïôåëïýí ôç óçìáíôéêüôåñç ðçãÞ äåäïìÝíùí ðïõ áöïñïýí ôçí Üóêçóç ðñùôïâÜèìéáò öñïíôßäáò óôçí ðñïó÷ïëéêÞ êáé ôç ó÷ïëéêÞ çëéêßá, åöüóïí áõôÜ ôçñïýíôáé ôáêôéêÜ6. Ôï óýíïëï ôùí ó÷ïëéêþí ìïíÜäùí ôçò óõãêåêñéìÝíçò ðåñéöÝñåéáò áðïôåëåßôáé áðü 2 ðáéäéêïýò óôáèìïýò, 1 ðñïíÞðéï, 14 íçðéáãùãåßá, 22 äçìïôéêÜ ó÷ïëåßá êáé 5 ãõìíÜóéá. Ôï õëéêü áðïôÝëåóáí 989 âéâëéÜñéá õãåßáò ðáéäéþí çëéêßáò 3 Ýùò 15 åôþí, áðü Ýíá óýíïëï 1110 ðáéäéþí. Ôá ðáéäéÜ ÷ùñßóôçêáí óå ôñåéò çëéêéáêÝò ïìÜäåò: íçðéáêÞ çëéêßá (ðáéäéÜ 3-5 åôþí), ó÷ïëéêÞ çëéêßá (6-11 åôþí) êáé åöçâéêÞ çëéêßá (12-15 åôþí). Ãéá êÜèå çëéêéáêÞ ïìÜäá ôï õëéêü áðïôÝëåóáí, 184 âéâëéÜñéá áðü 219 ðáéäéÜ íçðéáêÞò çëéêßáò, 591 âéâëéÜñéá áðü 632 ðáéäéÜ ó÷ïëéêÞò êáé 214 âéâëéÜñéá áðü 259 ðáéäéÜ åöçâéêÞò çëéêßáò. Óôç óõíÝ÷åéá Ýãéíå êáôáãñáöÞ ôùí: ïíïìáôåðþíõìïõ, ðáôñþíõìïõ, çëéêßáò, öýëïõ, ôüðïõ äéáìïíÞò êáé ó÷ïëéêÞò ìïíÜäáò, êáèþò åðßóçò ôïõ áñéèìïý äüóåùí (üðïõ õðÞñ÷áí) ãéá ôá åìâüëéá: ôñéðëü (äéöèåñßôéäáò, ôåôÜíïõ, êïêêýôç, DTP), äéðëü (áðëü, DT Þ ôýðïõ åíçëßêïõ, Td), ðïëéïìõåëßôéäáò (OPV, IPV), öõìáôßùóçò (BCG), ôñéäýíáìï (éëáñÜò, åñõèñÜò, ðáñùôßôéäáò, MMR), ìïíïäýíáìá (éëáñÜò, ðáñùôßôéäáò, åñõèñÜò), çðáôßôéäáò Â, áéìüöéëïõ ôçò ãñßððçò ôýðïõ Â, ìçíéããéôéäüêïêêïõ (A Þ A+C), ãñßððçò êáé çðáôßôéäáò Á. Ãéá ôç óùóôÞ åêôßìçóç ôùí áðïôåëåóìÜôùí èá ðñÝðåé íá óçìåéùèåß üôé åëÞöèçóáí õðüøç ôá íÝá êñéôÞñéá ðëÞñïõò õðï÷ñåùôéêÞò åìâïëéáóôéêÞò êÜëõøçò âÜóåé ôïõ Åèíéêïý ÐñïãñÜììáôïò Åìâïëéáóìþí êáé ü÷é áõôÜ ôïõ 19965, ðïõ áðáéôïýóáí ëéãüôåñá åìâüëéá ãéá ôï ÷áñáêôçñéóìü åíüò ðáéäéïý ùò ðëÞñùò åìâïëéáóìÝíï, áíÜëïãá ðÜíôá êáé ìå ôçí çëéêßá ôïõ. Áõôü áöïñÜ ìüíï ôéò äýï ðñþôåò çëéêéáêÝò ïìÜäåò ðïõ ìåëåôÞèçêáí, äçëáäÞ ôéò çëéêßåò áðü 3-11 åôþí. 112

Æ. Ðáðáñßæïõ êáé óõí.

Óôçí ðñþôç ïìÜäá, ðëÞñùò åìâïëéáóìÝíá èåùñÞèçêáí ôá ðáéäéÜ ðïõ åß÷áí êÜíåé ôÝóóåñéò äüóåéò DTP, ôÝóóåñéò äüóåéò ðïëéïìõåëßôéäáò, ìßá äüóç MMR Þ ìéá äüóç áðü êÜèå ìïíïäýíáìï, ôñåéò äüóåéò çðáôßôéäáò Â êáé ôïõëÜ÷éóôïí ìßá äüóç ãéá ôïí áéìüöéëï ôçò ãñßððçò ôýðïõ Â (óôçí åñãáóßá ôïõ 1996 Ýíá ðëÞñùò åìâïëéáóìÝíï ðáéäß äåí ÷ñåéáæüôáí íá Ý÷åé êÜíåé äüóåéò åìâïëßïõ ôçò çðáôßôéäáò Â, ïýôå ôïõ áéìüöéëïõ). ¼óïí áöïñÜ ôéò íüóïõò éëáñÜ-åñõèñÜ-ðáñùôßôéäá èåùñÞèçêáí ðëÞñùò åìâïëéáóìÝíá êáé ôá ðáéäéÜ ðïõ áíÝöåñáí íüóçóç áðü éëáñÜ êáé åß÷áí êÜíåé ôá Üëëá äýï ìïíïäýíáìá, ôá ðáéäéÜ ðïõ áíÝöåñáí íüóçóç áðü åñõèñÜ êáé åß÷áí êÜíåé ôá Üëëá äýï ìïíïäýíáìá êáé ôá ðáéäéÜ ðïõ áíÝöåñáí íüóçóç áðü éëáñÜ êáé ðáñùôßôéäá êáé åß÷áí êÜíåé ôï Üëëï Ýíá ìïíïäýíáìï. Áêüìç, üóïí áöïñÜ ôçí ðïëéïìõåëßôéäá, ðëÞñùò åìâïëéáóìÝíá èåùñÞèçêáí êáé ôá ðáéäéÜ ðïõ åß÷áí êÜíåé äýï äüóåéò OPV êáé äýï äüóåéò IPV Þ ôñåéò äüóåéò OPV êáé ìßá IPV Þ ìßá OPV êáé ôñåéò IPV Þ ôÝóóåñéò ìüíï IPV. Óå áõôÝò ôéò êáôçãïñßåò óõíõðïëïãßóôçêáí êáé ïé ðñïçãïýìåíåò ðñïûðïèÝóåéò ãéá ôï ÷áñáêôçñéóìü åíüò ðáéäéïý ùò ‘ðëÞñùò åìâïëéáóìÝíï’. Óôç äåýôåñç ïìÜäá, ðëÞñùò åìâïëéáóìÝíá èåùñÞèçêáí ôá ðáéäéÜ ðïõ åß÷áí êÜíåé ðÝíôå äüóåéò DTP, ôïõëÜ÷éóôïí ðÝíôå äüóåéò ðïëéïìõåëßôéäáò, äýï äüóåéò MMR Þ ìéá äüóç áðü êÜèå ìïíïäýíáìï êáé ìßá äüóç MMR êáé ìßá äüóç ôïõ BCG, (óôçí åñãáóßá ôïõ 1996 Ýíá ðëÞñùò åìâïëéáóìÝíï ðáéäß äåí ÷ñåéáæüôáí íá Ý÷åé êÜíåé äýï áëëÜ ìßá äüóç MMR). ´Ïóïí áöïñÜ ôéò íüóïõò éëáñÜ-åñõèñÜ-ðáñùôßôéäá, ðëÞñùò åìâïëéáóìÝíá èåùñÞèçêáí êáé ôá ðáéäéÜ ðïõ áíôß ôïõ åíüò áðü ôá äýï MMR, åß÷áí ìßá íüóçóç êáé äõï ìïíïäýíáìá Þ äýï íïóÞóåéò êáé Ýíá ìïíïäýíáìï. Óôçí ôñßôç ïìÜäá, ðëÞñùò åìâïëéáóìÝíá èåùñÞèçêáí ôá ðáéäéÜ ðïõ åß÷áí êÜíåé üëá ôá åìâüëéá ðïõ áíáöÝñïíôáé óôç äåýôåñç ïìÜäá. Óôç óõíÝ÷åéá Ýãéíå Ýëåã÷ïò áí ôá ðáéäéÜ êÜèå ïìÜäáò êáé óõíïëéêÜ, Ý÷ïõí ðëÞñùò åìâïëéáóôåß ãéá êÜèå íüóï ÷ùñéóôÜ. Ïðüôå åêôüò ôùí ðáñáðÜíù ðñïûðïèÝóåùí ðïõ éó÷ýïõí áíÜëïãá ìå ôçí çëéêßá, ðëÞñùò åìâïëéáóìÝíï ãéá ôçí çðáôßôéäá Á èåùñÞèçêå Ýíá ðáéäß ðïõ Ý÷åé êÜíåé ìßá ôïõëÜ÷éóôïí äüóç áíåîáñôÞôùò çëéêßáò êáé ðëÞñùò åìâïëéáóìÝíï ãéá ôïí ìçíéããéôéäüêïêêï èåùñÞèçêå Ýíá ðáéäß ðïõ Ý÷åé êÜíåé ôïõëÜ÷éóôïí ìßá äüóç,

Æ. Ðáðáñßæïõ êáé óõí.

áíåîáñôÞôùò çëéêßáò. Åðßóçò, ãéá ôïí áéìüöéëï ôçò ãñßððçò ôýðïõ B, óôç äåýôåñç êáé óôçí ôñßôç ïìÜäá èåùñÞèçêå ðëÞñùò åìâïëéáóìÝíï Ýíá ðáéäß ðïõ Ý÷åé êÜíåé ôïõëÜ÷éóôïí ìßá äüóç (Ýùò êáé ôÝóóåñéò) êáé ãéá ôçí çðáôßôéäá Â ôïõëÜ÷éóôïí ôñåéò äüóåéò.

ÁðïôåëÝóìáôá Ôï óýíïëï ôùí âéâëéáñßùí õãåßáò ðïõ åîåôÜóôçêáí Þôáí 989 áðü Ýíá óýíïëï 1110 ðáéäéþí -ðïóïóôü óõììåôï÷Þò 89%, (áíôßóôïé÷á, êáôÜ ôçí åñãáóßá ôïõ 1996, ôá âéâëéÜñéá õãåßáò ðïõ åîåôÜóôçêáí Þôáí 1084 áðü Ýíá óýíïëï 1398 ðïóïóôü óõììåôï÷Þò 77,5%). Áðü áõôÜ ôá ðáéäéÜ, 502 (50,8%) Þôáí áãüñéá êáé 487 (49,2%) Þôáí êïñßôóéá. Ôçí ðñþôç ïìÜäá áðïôÝëåóáí 184 ðáéäéÜ çëéêßáò 3-5 åôþí, ôç äåýôåñç 591 ðáéäéÜ çëéêßáò 6-11 åôþí êáé ôçí ôñßôç 214 ðáéäéÜ çëéêßáò 1215 åôþí. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 581 ðáéäéÜ (58,7%) ðëÞñùò åìâïëéáóìÝíá, Ýíáíôé 9,5% ôï 1996 (Ó÷Þìá 1)5. Óôçí ðñþôç ïìÜäá 175/ 184 (95,1%) Þôáí ðëÞñùò åìâïëéáóìÝíá. Ìå âÜóç ôá êñéôÞñéá ôçò åñãáóßáò ôïõ 1996 ãéá ôçí ßäéá ïìÜäá, ðëÞñùò åìâïëéáóìÝíá åßíáé 178/184 (96,7% Ýíáíôé 53,4% ôï 1996)5. Óôç äåýôåñç ïìÜäá 333/591 (56,3%) âñÝèçêáí ðëÞñùò åìâïëéáóìÝíá. Ìå âÜóç ôá êñéôÞñéá ôçò åñãáóßáò ôïõ 1996 ãéá ôçí ßäéá ïìÜäá ðëÞñùò åìâïëéáóìÝíá åßíáé 400/591 (68% Ýíáíôé 8,4% ôï 1996)5. Óôçí ôñßôç ïìÜäá 73/214 (34,1%) Þôáí ðëÞñùò åìâïëéáóìÝíá, Ýíáíôé 0,3% ôï 19965 (Ó÷Þìá 2). Ôá áðïôåëÝóìáôá ôïõ åëÝã÷ïõ ôçò ðëÞñïõò åìâïëéáóôéêÞò êÜëõøçò ãéá êÜèå íüóï ÷ùñéóôÜ öáßíïíôáé ðáñáêÜôù (Ó÷Þìá 1): Äéöèåñßôéäá: Óôçí ðñþôç ïìÜäá âñÝèçêáí

Ó÷Þìá 1. ÓõíïëéêÞ êáôÜóôóç åìâïëéáóìþí (ãéá üëåò ôéò çëéêéáêÝò ïìÜäåò).

Ôüìïò 17, Ôåý÷ïò 3, 2005

181 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,4% Ýíáíôé 97,1% ôï 1996), óôç äåýôåñç ïìÜäá 455 (77% Ýíáíôé 26,9% ôï 1996) êáé óôçí ôñßôç ïìÜäá 108 (50,5% Ýíáíôé 28,3% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 744 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (75,3%). ÔÝôáíïò: Óôçí ðñþôç ïìÜäá âñÝèçêáí 181 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,4% Ýíáíôé 97,1% ôï 1996), óôç äåýôåñç ïìÜäá 455 (77% Ýíáíôé 26,9% ôï 1996) êáé óôçí ôñßôç ïìÜäá 108 (50,5% Ýíáíôé 28,3% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 744 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (75,2%). Êïêêýôçò: Óôçí ðñþôç ïìÜäá âñÝèçêáí 181 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,4% Ýíáíôé 96,1% ôï 1996), óôç äåýôåñç ïìÜäá 455 (77% Ýíáíôé 23,6% ôï 1996) êáé óôçí ôñßôç ïìÜäá 108 (50,5% Ýíáíôé 10,6% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 744 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (75,2%). Ðïëéïìõåëßôéäá: Óôçí ðñþôç ïìÜäá âñÝèçêáí 179 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (97,3% Ýíáíôé 97,1% ôï 1996), óôç äåýôåñç ïìÜäá 534 (90,3% Ýíáíôé 87,6% ôï 1996) êáé óôçí ôñßôç ïìÜäá 197 (92,1% Ýíáíôé 92,1% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 910 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (92%). ÉëáñÜ: Óôçí ðñþôç ïìÜäá âñÝèçêáí 182 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,9% Ýíáíôé 98,1% ôï 1996), óôç äåýôåñç ïìÜäá 584 (98,8% Ýíáíôé 80,8% ôï 1996) êáé óôçí ôñßôç ïìÜäá 138 (64,5% Ýíáíôé 7,1% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 904 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (91,4%). ÅñõèñÜ: Óôçí ðñþôç ïìÜäá âñÝèçêáí 181 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,4% Ýíáíôé 89,3% ôï 1996), óôç äåýôåñç ïìÜäá 581 (98,3% Ýíáíôé 76,5% ôï 1996) êáé óôçí ôñßôç ïìÜäá 138 (64,5% Ýíáíôé 6,3% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 900 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (91%).

Ó÷Þìá 2. ÐëÞñùåò åìâïëéáóìÝíá ðáéäéÜ êáôÜ ïìÜäåò. 113

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ðáñùôßôéäá: Óôçí ðñþôç ïìÜäá âñÝèçêáí 181 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (98,4% Ýíáíôé 89,3% ôï 1996), óôç äåýôåñç ïìÜäá 582 (98,5% Ýíáíôé 77,2% ôï 1996) êáé óôçí ôñßôç ïìÜäá 138 (64,5% Ýíáíôé 6% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 901 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (91,1%). Öõìáôßùóç: Óôçí ðñþôç ïìÜäá âñÝèçêáí 1 ðáéäß ðëÞñùò åìâïëéáóìÝíï (0,5%), óôç äåýôåñç ïìÜäá 536 (90,7% Ýíáíôé 25,3% ôï 1996)5 êáé óôçí ôñßôç ïìÜäá 204 (95,3% Ýíáíôé 51,8% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 741 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (74,9%). Çðáôßôéäá Â: Óôçí ðñþôç ïìÜäá âñÝèçêáí 180 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (97,8% Ýíáíôé 73,8% ôï 1996), óôç äåýôåñç ïìÜäá 528 (89,3% Ýíáíôé 60,7% ôï 1996) êáé óôçí ôñßôç ïìÜäá 172 (80,4% Ýíáíôé 42,8% ôï 1996)5. Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 880 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (89% Ýíáíôé 55,7% ôï 1996)5. Áéìüöéëïò ôçò ãñßððçò ôýðïõ Â: Óôçí ðñþôç ïìÜäá âñÝèçêáí 183 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (99,4%), óôç äåýôåñç ïìÜäá 392 (66,3%) êáé óôçí ôñßôç ïìÜäá 20 (9,4%). Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 595 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (60,2% Ýíáíôé 0% ôï 1996)5. Çðáôßôéäá Á: Óôçí ðñþôç ïìÜäá âñÝèçêáí 9 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (4,9%), óôç äåýôåñç ïìÜäá 18 (3%) êáé óôçí ôñßôç ïìÜäá 6 (2,8%). Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 33 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (3,3%). Ãñßððç: Óôçí ðñþôç ïìÜäá âñÝèçêáí 21 ðáéäéÜ ðïõ Ý÷ïõí êÜíåé ôïõëÜ÷éóôïí 1 äüóç åìâïëßïõ ãñßððçò, óôç äåýôåñç ïìÜäá 22 (3,7%) êáé óôçí ôñßôç ïìÜäá 6 (2,8%). Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 43 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (4,3%). Ìçíéããéôéäüêïêêïò: Óôçí ðñþôç ïìÜäá âñÝèçêáí 45 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (24,4%), óôç äåýôåñç ïìÜäá 126 (21,3%) êáé óôçí ôñßôç ïìÜäá 37 (17,3%). Óôï óýíïëï ôùí ðáéäéþí âñÝèçêáí 208 ðáéäéÜ ðëÞñùò åìâïëéáóìÝíá (21%).

ÓõæÞôçóç Ôá åìâüëéá áðïôåëïýí Ýíá áðü ôá óçìáíôéêüôåñá åðéôåýãìáôá ôçò âéïúáôñéêÞò Ýñåõíáò êáé ôå÷íïëïãßáò êáé óõãêáôáëÝãïíôáé ìåôáîý ôùí ðéï áðïôåëåóìáôéêþí ìÝôñùí ãéá ôçí ðñïóôáóßá ôçò 114

Æ. Ðáðáñßæïõ êáé óõí.

äçìüóéáò õãåßáò. Ôá ëïéìþäç íïóÞìáôá, üìùò, áðåéëïýí êáé óÞìåñá ôï áíèñþðéíï ãÝíïò êáé üðùò öáßíåôáé, èá åîáêïëïõèÞóïõí íá ôï áðåéëïýí, áêüìç êáé óå ÷þñåò õãåéïíïìéêÜ áíáðôõãìÝíåò (üðùò ç ÅëëÜäá), óå ðåñßðôùóç ðïõ áôïíÞóïõí ôá ìÝôñá ðñüëçøçò. ÐáñÜ ôçí åðéôõ÷ßá óôçí áíÜðôõîç êáé ôçí åöáñìïãÞ ôùí åìâïëéáóìþí, áóèÝíåéåò ðïõ åßíáé äõíáôü íá êáôáðïëåìçèïýí, óõíå÷ßæïõí íá õðÜñ÷ïõí, êõñßùò ëüãù ‘÷áìÝíùí åõêáéñéþí’ ôùí õðåýèõíùí ðáñï÷Þò öñïíôßäáò õãåßáò, ëüãù ‘áíôéåìâïëéáóôéêþí’ êéíÞóåùí ðïõ óõíôçñïýíôáé Þ åíéó÷ýïíôáé áðü áðïðñïóáíáôïëéóìÝíá ìÝóá åíçìÝñùóçò êáé áðü Üãíïéá ôùí ãïíÝùí7. Ðñüóöáôï ðáñÜäåéãìá ôï îÝóðáóìá åðéäçìßáò éëáñÜò óôçí ðåñéöÝñåéá ÏõáëéêÜëå, óôá áíáôïëéêÜ ôçò ËáúêÞò Äçìïêñáôßáò ôïõ Êïíãêü üðïõ ïé ‘Ãéáôñïß ×ùñßò Óýíïñá’ îåêßíçóáí óôéò 8 Ìáñôßïõ 2004 åðåßãïõóá åêóôñáôåßá åìâïëéáóìïý êáôÜ ôçò åðéäçìßáò8. Ðñéí ôçí åñìçíåßá ôùí áðïôåëåóìÜôùí èá ðñÝðåé íá ôïíéóôåß üôé ãéá ôç ìåëÝôç ÷ñçóéìïðïéÞèçêå ìßá ìåèïäïëïãßá åêôßìçóçò ôçò áíïóïðïßçóçò, âáóéæüìåíç óôéò ó÷ïëéêÝò ìïíÜäåò. ¸÷åé áðïäåé÷èåß óå ðáëáéüôåñç ìåëÝôç üôé ç óõãêåêñéìÝíç ìÝèïäïò åêôßìçóçò ôçò áíïóïðïßçóçò óôçí ðáéäéêÞ çëéêßá áðïôåëåß Ýíá áêñéâÝò êáé ïéêïíïìéêü åñãáëåßï áðïôßìçóçò ôçò åìâïëéáóôéêÞò êÜëõøçò9. ¸ãéíå åðåîåñãáóßá 989 áôïìéêþí âéâëéáñßùí õãåßáò ðáéäéïý, áðü üëåò ôéò ó÷ïëéêÝò êáé ðñïó÷ïëéêÝò ìïíÜäåò ôçò óõãêåêñéìÝíçò ðåñéöÝñåéáò (åêôüò ôùí Ëõêåßùí, ðïõ áöïñïýí Üëëç çëéêéáêÞ ïìÜäá), óôéò ïðïßåò åßíáé êáôáãåãñáììÝíá åðßóçìá 1110 ðáéäéÜ óõíïëéêÜ, äçëáäÞ åß÷áìå Ýíá ðïóïóôü óõììåôï÷Þò 89%, ãåãïíüò ðïõ êáèéóôÜ ðéï áîéüðéóôá ôá áðïôåëÝóìáôá (áíôßóôïé÷á, êáôÜ ôçí åñãáóßá ôïõ 1996, ôá âéâëéÜñéá õãåßáò ðïõ åîåôÜóôçêáí Þôáí 1084 áðü Ýíá óýíïëï 1398 - ðïóïóôü óõììåôï÷Þò 77,5%). ÅîÜëëïõ, ôá ðïóïóôÜ óõììåôï÷Þò Þôáí õøçëÜ êáé óôéò ôñåéò çëéêéáêÝò ïìÜäåò (84% ãéá ôç íçðéáêÞ çëéêßá, 94% ãéá ôá äçìïôéêÜ - ó÷ïëéêÞ çëéêßá êáé 83% ãéá ôá ãõìíÜóéá - åöçâéêÞ çëéêßá). Óôï óýíïëï ôùí ðáéäéþí âñÝèçêå üôé ôï 58,7% Ý÷åé åìâïëéáóôåß ðëÞñùò, üóïí áöïñÜ ôïõò õðï÷ñåùôéêïýò åìâïëéáóìïýò, áíÜëïãá ðÜíôá êáé ìå ôçí çëéêßá. Ôï 95,1% ôùí ðáéäéþí íçðéáêÞò çëéêßáò åßíáé ðëÞñùò åìâïëéáóìÝíá, åíþ ôï ðïóïóôü ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí ó÷ïëéêÞò çëéêßáò åßíáé 56,3% êáé åöçâéêÞò 34,1%, áíôßóôïé÷á. Ðáñáôçñåßôáé, üðùò êáé óå Üëëåò áíÜ

Æ. Ðáðáñßæïõ êáé óõí.

ôçí ÅëëÜäá åñãáóßåò10, üôé üóï ìåãáëýôåñç ç çëéêßá ôïõ ðáéäéïý, ôüóï áõîÜíåôáé êáé ç ðéèáíüôçôá íá ìçí åßíáé ðëÞñùò åìâïëéáóìÝíï. Áõôü ìðïñåß íá ïöåßëåôáé óôç ìåãáëýôåñç åõáéóèçôïðïßçóç ôùí ãïíÝùí üôáí ôá ðáéäéÜ ôïõò âñßóêïíôáé áêüìá óå ìéêñÞ çëéêßá, áëëÜ êáé óôç ìç åðáñêÞ åíçìÝñùóç êáé ôçí áðïõóßá ôùí êáôÜëëçëùí õðçñåóéþí ðñùôïâÜèìéáò öñïíôßäáò õãåßáò (üðùò ôï ðáéäéáôñéêü éáôñåßï). Ç ðáñïõóßá ôïõ ðáéäéáôñéêïý éáôñåßïõ óôï Ê.Õ. ôá ôåëåõôáßá ïêôþ ÷ñüíéá áíáìöéóâÞôçôá óõíÝâáëå óôç âåëôßùóç ôçò êáôÜóôáóçò åìâïëéáóìþí ôùí ðáéäéþí, áöïý åßíáé äåäïìÝíï üôé óôï ðáñáðÜíù ÷ñïíéêü äéÜóôçìá äåí õðÞñ÷å Üëëï ðáéäéáôñéêü éáôñåßï óôçí ðåñéï÷Þ (éäéþôçò, Üëëá áóöáëéóôéêÜ ôáìåßá - ÉÊÁ), ïé äå åìâïëéáóìïß ôùí ðáéäéþí óôï Ê.Õ. ãßíïíôáé áðïêëåéóôéêÜ áðü ôï ðáéäéáôñéêü éáôñåßï. Ôá ðáñáðÜíù ðïóïóôÜ ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí äåß÷íïõí üôé ç åíçìÝñùóç êáé ç ðáñÝìâáóç áðü ôçí ðëåõñÜ ôïõ ðáéäéáôñéêïý éáôñåßïõ, üóïí áöïñÜ ôïõò åìâïëéáóìïýò, ðñÝðåé íá ãßíåé ðéï åíôáôéêÞ åéäéêÜ ãéá ôç ó÷ïëéêÞ êáé åöçâéêÞ çëéêßá. Óôçí ðñþôç ïìÜäá ðïõ ìåëåôÞèçêå (3-5åôþí), ðñÝðåé íá áíáöåñèåß üôé óõìðåñéëÞöèçêáí ôá åìâüëéá ãéá ôçí çðáôßôéäá Â êáé ãéá ôïí áéìüöéëï ôçò ãñßððçò ôýðïõ Â ãéá ôçí åýñåóç ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí, êÜôé ðïõ äåí åß÷å ãßíåé óôçí ðñïçãïýìåíç åñãáóßá5. Óôéò ôåëåõôáßåò óõóôÜóåéò åìâïëéáóìþí êáèéåñþíåôáé êáé ôï åìâüëéï ãéá ôçí çðáôßôéäá B ôï íùñßôåñï ìåôÜ ôç ãÝííçóç11. Ç ÅèíéêÞ ÅðéôñïðÞ åìâïëéáóìþí êáé ç ÅëëçíéêÞ ÐáéäéáôñéêÞ Åôáéñåßá óõíéóôïýí ôá åìâüëéá çðáôßôéäáò Â êáé áéìüöéëïõ ôçò ãñßððçò íá ãßíïíôáé ìáæéêÜ óå üëá ôá âñÝöç. Ôï åìâüëéï ôïõ áéìüöéëïõ ôçò ãñßððçò ÷ïñçãåßôáé óå ðáéäéÜ ìÝ÷ñé 5 åôþí. Óå ðáéäéÜ ìåãáëýôåñá ôùí 14 ìçíþí ÷ïñçãåßôáé ìüíï ìßá äüóç. ¸ôóé, ôï ðïóïóôü ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí íçðéáêÞò çëéêßáò, ÷ùñßò áõôÜ ôá äýï åìâüëéá (êñéôÞñéá ôïõ 1996), èá Þôáí 96,7% Ýíáíôé 53,4% ôï 19965. Ç äéáöïñïðïßçóç áõôÞ ëüãù ôùí íÝùí óõóôÜóåùí ôïõ Åèíéêïý ÐñïãñÜììáôïò Åìâïëéáóìþí åîçãåß êáé ôï 99,4% ôùí ðëÞñùò åìâïëéáóìÝíùí ðáéäéþí ãéá ôïí áéìüöéëï Ýíáíôé ôïõ 0% ôïõ 1996 êáèþò êáé ôï 97,8% ôçò ðëÞñïõò êÜëõøçò ãéá ôçí çðáôßôéäá Â, Ýíáíôé ôïõ 73,8% ôïõ Ýôïõò 19965. Ôï ðñþôï óõæåõãìÝíï åìâüëéï ðïëõóáê÷áñßôç-ðñùôåÀíçò åßíáé ôï åìâüëéï ãéá ôïí áéìüöéëï

Ôüìïò 17, Ôåý÷ïò 3, 2005

ôçò ãñßððçò ôýðïõ Â, ôï ïðïßï åìðïäßæåé ôç ìåëëïíôéêÞ åìöÜíéóç áóèÝíåéáò óôï 95% ôïõëÜ÷éóôïí ôùí âñåöþí12. Ìåôáîý ôùí ðéï ðñüóöáôùí åðéôõ÷éþí óôá óõæåõãìÝíá åìâüëéá, ðïõ ðñïóôáôåýïõí ðåñéóóüôåñï áðü ôï 90% âñåöþí Þ ðáéäéþí áðü åðéèåôéêÝò íüóïõò, åíôÜóóåôáé êáé ôï óõæåõãìÝíï åìâüëéï ãéá ôç Neisseria meningitidis, ïñïôýðïõ C13, ìå åëÜ÷éóôåò ðáñåíÝñãåéåò. Áõôü óå óõíäõáóìü êáé ìå Üëëá óõæåõãìÝíá åìâüëéá ðïõ óôï÷åýïõí Üëëïõò óçìáíôéêïýò ïñïôýðïõò ìçíéããéôéäüêêïêïõ (Á, Y, W-135) êáé åßíáé õðü åîÝëéîç, èá Ý÷ïõí ôç äõíáôüôçôá åðéôõ÷ïýò áíôéìåôþðéóçò åðéäçìéþí êáé óðïñáäéêþí ðåñéðôþóåùí áóèÝíåéáò áðü ìçíéããéôéäüêêïêï14. Ôï áðïôÝëåóìá ôçò åìâïëéáóôéêÞò êÜëõøçò ôùí ðáéäéþí íçðéáêÞò çëéêßáò ãéá ôï ìçíéããéôéäüêïêêï óôçí ðáñïýóá åñãáóßá åßíáé åíèáññõíôéêü (24,4%). Åðßóçò, óýìöùíá ìå ðáëáéüôåñá äåäïìÝíá9,15,16, óôç íçðéáêÞ çëéêßá ôï ðñüâëçìá åóôéáæüôáí óôïí êïêêýôç êáé ôçí åñõèñÜ. Éäßùò ãéá ôçí åñõèñÜ, üðïõ óôç ÷þñá ìáò ðáñáôçñåßôáé Ýîáñóç óôéò åíÞëéêåò ãõíáßêåò, åß÷å äéáðéóôùèåß üôé ç êÜëõøç ôïõ ðáéäéêïý ðëçèõóìïý âñéóêüôáí óôï ÷áìçëüôåñï åðßðåäï óå óýãêñéóç ìå üëá ôá Üëëá åìâüëéá. Ôï ßäéï ðñüâëçìá åíôïðßæåôáé êáé óå áíáðôõóóüìåíåò ÷þñåò, ãåãïíüò ðïõ ôçò áðïäßäåé éäéáßôåñç óçìáóßá17. Tá åìâüëéá ãéá ôçí éëáñÜ, ôçí ðáñùôßôéäá êáé ôçí åñõèñÜ, ðïõ áðü ôï 1991 ðñïâëÝðïíôáé áðü ôï Åèíéêü Ðñüãñáììá Åìâïëéáóìþí, ðáñáêÜìöèçêáí ðñïêåéìÝíïõ íá äïèåß ðñïôåñáéüôçôá óå íÝá åìâüëéá üðùò ôçò çðáôßôéäáò Â. Aõôü èåùñåßôáé ùò ç âáóéêÞ áéôßá ãéá ôçí åìöÜíéóç åðéäçìéþí: Ôï 1993 åêäçëþèçêå óôç ÷þñá ìáò åðéäçìßá óõããåíïýò åñõèñÜò, ôï 1991 åðéäçìßá éëáñÜò, åíþ ôçí Üíïéîç ôïõ 1999, íÝá åðéäçìßá åñõèñÜò ìåôáîý áôüìùí áíáðáñáãùãéêÞò çëéêßáò. ÐÜíôùò, óýìöùíá ìå ôá ðñüóöáôá äåäïìÝíá ôçò óõãêåêñéìÝíçò ðåñéöÝñåéáò5, ç åìâïëéáóôéêÞ êÜëõøç ãéá éëáñÜ, åñõèñÜ êáé ðáñùôßôéäá ìåìïíùìÝíá, Þôáí êáé ðáñáìÝíåé óå õøçëÜ åðßðåäá óôç íçðéáêÞ çëéêßá, ìå óçìáíôéêÞ üìùò âåëôßùóç êõñßùò ãéá åñõèñÜ êáé ðáñùôßôéäá (áðü 89,3% ôï 1996 óå 98,4% óÞìåñá êáé ãéá ôéò äýï). ¼óïí áöïñÜ ôïí êïêêýôç, ôï 98,4% ôùí ðáéäéþí íçðéáêÞò çëéêßáò åßíáé ðëÞñùò åìâïëéáóìÝíá ôþñá Ýíáíôé ôïõ 96,1% ôï 19965. ¼óïí áöïñÜ ôç äåýôåñç ïìÜäá (6-11 åôþí), èá ðñÝðåé íá áíáöåñèåß üôé ï åìâïëéáóìüò ìå MMR åíôÜ÷èçêå óôï Åèíéêü Ðñüãñáììá Åìâïëéáóìþí ôï Ýôïò 1989 êáé Üñ÷éóå íá ãßíåôáé äù115

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ñåÜí óôá äçìüóéá åìâïëéáóôéêÜ êÝíôñá, ìå áðïôÝëåóìá êáôÜ ôç äéÜñêåéá ôçò äåêáåôßáò ôïõ ’90 ç åìâïëéáóôéêÞ êÜëõøç ôùí ìéêñþí ðáéäéþí íá áõîçèåß óçìáíôéêÜ. Ôï 1991 êáèéåñþèçêå êáé äåýôåñç äüóç MMR óôçí çëéêßá ôùí 11-12 åôþí, ç ïðïßá ôï 1999 ìåôáêéíÞèçêå óôçí çëéêßá ôùí 4-6 åôþí. Ïðüôå, åíþ áñ÷éêÜ ôï ðëÞñùò åìâïëéáóìÝíï ðáéäß ó÷ïëéêÞò çëéêßáò äåí åðéâáëëüôáí íá Ý÷åé êÜíåé äýï äüóåéò MMR, ôþñá ôá ðëÞñùò åìâïëéáóìÝíá ðáéäéÜ Þôáí áõôÜ ðïõ åß÷áí êáé ôéò äýï äüóåéò. ¸ôóé, âñÝèçêå üôé ôï 56,3% ôùí ðáéäéþí ó÷ïëéêÞò çëéêßáò Þôáí ðëÞñùò åìâïëéáóìÝíá, ìå äýï äüóåéò MMR. Áí óõìðåñéëçöèïýí êáé ôá ðáéäéÜ ìå ìßá äüóç MMR, ìüíï, óôï áôïìéêü âéâëéÜñéï õãåßáò ôïõò, ôüôå ôï 68% ôùí ðáéäéþí èá èåùñïýíôáí ðëÞñùò åìâïëéáóìÝíá. Ïé äéáöïñÝò üìùò åßíáé ìåãÜëåò êáé óôá õðüëïéðá ëïéìþäç íïóÞìáôá ãéá ôá ïðïßá ãßíïíôáé åìâüëéá óôç ó÷ïëéêÞ çëéêßá. Åêôüò ôçò óõãêñéôéêÞò äéáöïñÜò óôçí êÜëõøç ãéá éëáñÜ, åñõèñÜ êáé ðáñùôßôéäá, ðïõ åßíáé ôçò ôÜîçò ôùí 20 ðïóïóôéáßùí ìïíÜäùí óå ó÷Ýóç ìå ôï Ýôïò 19965, ðïëý ðåñéóóüôåñï åìöáíÞò åßíáé ç äéáöïñÜ óôçí êÜëõøç ãéá äéöèåñßôéäá, ôÝôáíï êáé êïêêýôç (äéáöïñÜ ôçò ôÜîçò ôïõ 50%), êÜôé ðïõ äåß÷íåé üôé ç Üðïøç ðïõ åðéêñáôïýóå ìÝ÷ñé óÞìåñá, üôé ç ôÝôáñôç êáé ç ðÝìðôç äüóç ôïõ DTP ðñïêáëïýí óïâáñÝò êáé ìüíéìåò âëÜâåò, Ý÷åé êáôáññéöèåß óýìöùíá êáé ìå ôá äåäïìÝíá ìáêñï÷ñüíéùí åñåõíþí. ÔÝëïò, êáé óå áõôÞ ôçí ïìÜäá åíèáññõíôéêü åßíáé ôï áðïôÝëåóìá åìâïëéáóìïý ãéá ôïí ìçíéããéôéäüêïêêï (21,3%), üðùò êáé óôçí ôñßôç ïìÜäá (17,3%). Ôéò ðáëáéüôåñåò áðüøåéò ãéá ôïí åìâïëéáóìü ãéá äéöèåñßôéäá-ôÝôáíï-êïêêýôç êáôáññßðôïõí êáé ôá áðïôåëÝóìáôá ôçò ôñßôçò ïìÜäáò, üðïõ ç êÜëõøç äéáöÝñåé áðü ôï 1996 óå ðïóïóôü 20% ãéá ôÝôáíï êáé äéöèåñßôéäá êáé 40% ãéá êïêêýôç. Êáé ç óçìáóßá ôçò äåýôåñçò äüóçò MMR öáßíåôáé íá Ýãéíå êáôáíïçôÞ êáé áðïäåêôÞ, ìéáò êáé ç äéáöïñÜ ðëÞñïõò åìâïëéáóôéêÞò êÜëõøçò ãéá êáèÝíá áðü ôá ðáñáðÜíù ëïéìþäç íïóÞìáôá, óå ó÷Ýóç ìå ôï ðñþôï Ýôïò ëåéôïõñãßáò ôïõ ðáéäéáôñéêïý éáôñåßïõ, öôÜíåé ôï 60%. ÅîÜëëïõ, ôá óçìåñéíÜ äåäïìÝíá ôçò ðåñéï÷Þò åõèýíçò ôïõ óõãêåêñéìÝíïõ Ê.Õ. äåí óõìöùíïýí ìå ðáëáéüôåñá ðáíåëëáäéêÜ äåäïìÝíá15,16, áðü üðïõ åß÷å ðñïêýøåé üôé Þôáí åëëéðÞò ï åìâïëéáóìüò óôá ðáéäéÜ ó÷ïëéêÞò êáé åöçâéêÞò çëéêßáò, êáèþò ìüíï 1 óôïõò 3 ìáèçôÝò ôçò Ã´ ãõìíáóßïõ åß÷áí ïëïêëç116

Æ. Ðáðáñßæïõ êáé óõí.

ñþóåé ôï åìâüëéï ãéá ôçí éëáñÜ, 1 óôïõò 4 ãéá ôçí ðáñùôßôéäá êáé 1 óôïõò 5 ãéá ôçí åñõèñÜ. ¸íá áðü ôá óçìáíôéêüôåñá ðñïâëÞìáôá ðïõ Ý÷åé åíôïðéóôåß óå Üëëåò ìåëÝôåò åßíáé ç åðáíåìöÜíéóç ‘îå÷áóìÝíùí’ áóèåíåéþí, üðùò ç öõìáôßùóç êáé ç ðïëéïìõåëßôéäá. Ìåñéêïß åðéóôÞìïíåò áðÝäùóáí ôçí åðéóôñïöÞ ôïõò óôçí Üêñéôç åéóáãùãÞ íÝùí åìâïëßùí. Ç óçìáóßá ôïõ åìâïëéáóìïý ãéá ðïëéïìõåëßôéäá öáßíåôáé íá Ý÷åé ãßíåé ðëÞñùò êáôáíïçôÞ óôç óõãêåêñéìÝíç ðåñéöÝñåéá ðïõ ìåëåôÞèçêå, áëëÜ êáé óå Üëëåò ðåñéï÷Ýò ôçò ÅëëÜäáò9 êáé ôá áðïôåëÝóìáôá óå üëåò ôéò çëéêéáêÝò ïìÜäåò ðëçóéÜæïõí ôï óôü÷ï ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò (Ð.Ï.Õ.) ãéá ôçí åêñßæùóç ôçò íüóïõ áðü ôïí ðëáíÞôç Ýùò ôï Ýôïò 2000. ¼óïí áöïñÜ ôç öõìáôßùóç, ï åìâïëéáóìüò åßíáé õðï÷ñåùôéêüò óå 64 ÷þñåò ôïõ êüóìïõ, áíÜìåóá óôéò ïðïßåò êáé ç ÅëëÜäá18,19. Óõíßóôáôáé íá ãßíåôáé õðï÷ñåùôéêÜ óå áêüìç Üëëåò 118 ÷þñåò. Óôçí ÅëëÜäá, åßíáé ãíùóôü üôé ìáæéêüò åìâïëéáóìüò Ýãéíå ãéá ðñþôç öïñÜ ôï 1985-1989, óå ðáéäéÜ 10-12 ÷ñüíùí óôá ðëáßóéá ôïõ áãþíá ðñüëçøçò ôçò öõìáôßùóçò. Ôï BCG äå öáßíåôáé íá ìåéþíåé ôá ðïóïóôÜ åîÜðëùóçò ôïõ âáêßëïõ óôïí ðëçèõóìü åðéäñÜ üìùò áðïöáóéóôéêÜ óôçí ðñüëçøç ôçò öõìáôéþäïõò ìçíéããßôéäáò (ðåñßðïõ 80%)20 êáé åßíáé ðåñéóóüôåñï áðïôåëåóìáôéêü óôçí ðñïóôáóßá Ýíáíôé áéìáôïãåíïýò åîÜðëùóçò ôçò öõìáôßùóçò êé ü÷é Ýíáíôé ôçò ðíåõìïíéêÞò óôçí ïðïßá êýñéï ðñïóôáôåõôéêü ñüëï ðáßæïõí ôá ðåñéâáëëïíôéêÜ ìõêïâáêôçñßäéá ôá ïðïßá ìå äéÜöïñïõò äñüìïõò áíïóïðïßçóçò ðñïóôáôåýïõí áðü ðíåõìïíéêÞ åîÜðëùóç ôçò íüóïõ21. ÓÞìåñá ðñïôåßíåôáé ç çëéêßá 5-6 åôþí ùò êáôÜëëçëç ãéá ôïí åìâïëéáóìü BCG, åêôüò åÜí õðÜñ÷ïõí åíäåßîåéò ðñùúìüôåñçò ÷ïñÞãçóÞò ôïõ, ç ïðïßá ìðïñåß íá ãßíåé êáé áðü ôéò ðñþôåò çìÝñåò ôçò æùÞò. Ìå âÜóç ôá ðáñáðÜíù, áíáìÝíïíôáí õøçëÜ ðïóïóôÜ êÜëõøçò óôç äåýôåñç êáé óôçí ôñßôç ïìÜäá êáé ü÷é óôçí ðñþôç. ÐñÜãìáôé, ôá ðïóïóôÜ êÜëõøçò ãéá ôç öõìáôßùóç Þôáí 90,7% óôá ðáéäéÜ ó÷ïëéêÞò çëéêßáò (6-11åôþí) êáé 95,3% óôá ðáéäéÜ åöçâéêÞò çëéêßáò (12-15 åôþí), ìå óçìáíôéêÞ âåëôßùóç óôá Þäç åíèáññõíôéêÜ áðïôåëÝóìáôá ôïõ 19965 (25,3% êáé 51,8%, áíôßóôïé÷á) åíþ Þôáí 0,5% óôá ðáéäéÜ íçðéáêÞò çëéêßáò. Óôï óçìåßï áõôü èá ðñÝðåé íá áíáöåñèåß üôé ôçí åõèýíç ãéá ôïí åìâïëéáóìü ôçò öõìáôßùóçò

Ôüìïò 17, Ôåý÷ïò 3, 2005

Æ. Ðáðáñßæïõ êáé óõí.

óôçí ðåñéï÷Þ ôïõ Ê.Õ. ×Üñáêá, öÝñåé ïìÜäá åñãáóßáò áðü ôï ðíåõìïíïëïãéêü ôìÞìá ôïõ ‘Âåíéæåëåßïõ’ Ãåíéêïý Íïóïêïìåßïõ Çñáêëåßïõ, óôçí ïðïßá ðñÝðåé íá áðïäïèïýí êáé ôá åýóçìá ãéá ôç óçìáíôéêÞ âåëôßùóç ôùí ðïóïóôþí êÜëõøçò ðïõ âñÝèçêáí óÞìåñá. ÔÝëïò, ôï åìâüëéï ãéá ôçí çðáôßôéäá B ÷ïñçãåßôáé óôéò çëéêßåò 2 ìçíþí, 3 ìçíþí êáé 8 ìçíþí Þ óå ó÷Þìá 0, 1, 6 ìÞíåò óå ìåãáëýôåñá âñÝöç, ðáéäéÜ, åöÞâïõò êáé íåáñïýò åíÞëéêåò, êáé ðñïêáëåß áíïóßá ðåñßðïõ äåêáåôïýò äéÜñêåéáò. Ï Ð.Ï.Õ. êáé ïé áñìüäéïé åðéóôçìïíéêïß öïñåßò óõíéóôïýí ôïí åìâïëéáóìü üëùí ôùí âñåöþí, ðáéäéþí êáé åöÞâùí. Áõôü Þäç åöáñìüæåôáé óå ðïëëÝò áíáðôõãìÝíåò üóï êáé áíáðôõóóüìåíåò ÷þñåò åèåëïíôéêÜ Þ êáé õðï÷ñåùôéêÜ. Óôçí ðáñïýóá ìåëÝôç âñÝèçêå üôé ôï 89% ôïõ óõíüëïõ ôùí ðáéäéþí Þôáí ðëÞñùò åìâïëéáóìÝíá, ìå ìåãáëýôåñç êÜëõøç üóï ç çëéêßá ðïõ ìåëåôÜôáé åßíáé ìéêñüôåñç (áðïôÝëåóìá ðáñüìïéï êáé ìå Üëëá áðü ôç âéâëéïãñáößá)9. Ç åìöÜíéóç ôïõ áíáóõíäõáóìÝíïõ åìâïëßïõ, ç óùóôÞ åíçìÝñùóç ôïõ êïéíïý áðü ôá ìÝóá ìáæéêÞò åíçìÝñùóçò êáé áðü ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò åßíáé ïé ðáñÜãïíôåò ðïõ óå ìåãÜëï âáèìü äéêáéïëïãïýí ôá ðñüóöáôá áðïôåëÝóìáôá. ÐáñÜ ôï óõíå÷Þ êáé ïìáäéêü åìâïëéáóìü ôùí íåïãÝííçôùí ðáéäéþí, ðïõ èá ìðïñïýóå íá ðåñéïñßóåé ôï åíäå÷üìåíï ìåôÜäïóçò ôïõ éïý, áõôü äåí èá óõìâåß ãéá äåêáåôßåò ÷ùñßò åðéôõ÷Þ åìâïëéáóìü ôùí åíçëßêùí õøçëïý êéíäýíïõ ãéá ëïßìùîç22. Ï åìâïëéáóìüò ãéá ôç ãñßððç êáé ôçí çðáôßôéäá A ðáñáìÝíåé, ùóôüóï, óå ÷áìçëÜ åðßðåäá ôüóï ãåíéêÜ üóï êáé óôçí ðåñéï÷Þ ðïõ ìåëåôÞèçêå (4,3% ãéá ôç ãñßððç êáé 3,3% ãéá ôçí çðáôßôéäá Á). Áõîáíüìåíç ÷ñÞóç ôïõ åìâïëßïõ ôçò ãñßððçò áíáìÝíåôáé óôï ìÝëëïí, êáèþò ï éüò áíáäåéêíýåôáé ùò ìåßæùí ðáñÜãïíôáò íïóçñüôçôáò23 êáé ïäçãåß óå õðåñâïëéêÝò íïóçëåßåò, éáôñéêÝò åðéóêÝøåéò êáé óõíôáãïãñáöÞóåéò, áêüìá êáé óå õãéÞ ðáéäéÜ, åéäéêÜ áõôÜ êÜôù ôùí 2 åôþí. Ç óýóôáóç Ýíôáîçò ôïõ åìâïëéáóìïý ãéá ôç ãñßððç óôï Åèíéêü Ðñüãñáììá Åìâïëéáóìþí ôùí ÷ùñþí êáé ç åõñåßá ÷ñÞóç ôïõ èá ðñÝðåé íá ëçöèåß óïâáñÜ õðüøç óôï ìÝëëïí. Ùóôüóï, óÞìåñá õðïóôçñßæåôáé ï ðáãêüóìéïò åìâïëéáóìüò óå âñÝöç çëéêßáò 6-23 ìçíþí, óå åðéëåãìÝíåò êáôçãïñßåò23,24. Ï åìâïëéáóìüò ãéá ôçí çðáôßôéäá Á óôçí ÅëëÜäá óõíéóôÜôáé ìüíï ãéá ïìÜäåò õøçëïý êéíäýíïõ, üðùò ôáîéäéþôåò óå ÷þñåò õøçëÞò åíäçìé-

êüôçôáò, ðñïóùðéêü âñåöïíçðéáêþí óôáèìþí êáé éäñõìÜôùí, ìåôáêéíïýìåíïé ðëçèõóìïß, ìåôáíÜóôåò áðü åíäçìéêÝò ÷þñåò êáé éáôñïíïóçëåõôéêü ðñïóùðéêü ìïíÜäùí ëïéìùäþí íïóçìÜôùí êáé ðáéäéáôñéêþí ôìçìÜôùí. Ôï ßäéï éó÷ýåé ðáãêïóìßùò, äçëáäÞ åðéëåãìÝíç åöáñìïãÞ áíÜëïãá ìå ôç ÷þñá êáé ôçí ðåñéï÷Þ êáé ãéá óõãêåêñéìÝíåò ïìÜäåò õøçëïý êéíäýíïõ25. Ç áõîáíüìåíç éêáíüôçôá ôïõ áíèñþðïõ íá åêìåôáëëåýåôáé ôçí ôå÷íïëïãßá ôùí åìâïëßùí, ôïí Ý÷åé ïäçãÞóåé óå ðåéñáìáôéêÜ óôÜäéá åýñåóçò åìâïëßùí ãéá ìåãÜëï áñéèìü íïóçìÜôùí, üðùò ïé áëëåñãßåò, ï êáñêßíïò êáé íåõñïåêöõëéóôéêÝò íüóïé26. “Óêïðüò ôïõ åìâïëéáóìïý äåí åßíáé ôüóï ç ðñïóôáóßá ôïõ åìâïëéáæüìåíïõ, üðùò ðïëëïß ðéóôåýïõí, üóï ç ðñïóôáóßá üëïõ ôïõ ðëçèõóìïý, ìå ôçí åêñßæùóç ôçò íüóïõ ðïõ áõôüò ôåëéêÜ åðéôõã÷Üíåé” ëÝåé ï ÔÜêçò Ðáíáãéùôüðïõëïò, åñåõíçôÞò ôïõ Éíóôéôïýôïõ Õãåßáò ôïõ Ðáéäéïý. Ç óýãêñéóç, åîÜëëïõ, ôùí ðñïãñáììÜôùí åìâïëéáóìïý ìå Üëëïõ åßäïõò ðáñåìâÜóåéò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò áðïäåéêíýåé üôé ôá åìâüëéá åßíáé óõ÷íÜ ìßá áðü ôéò êáëýôåñåò åðåíäýóåéò ôçò êïéíùíßáò óôïí ôïìÝá ôçò õãåßáò êáé óõìâÜëëïõí óçìáíôéêÜ óôçí åîáöÜíéóç ôùí ëïéìùäþí íüóùí. Ôåëåõôáßá ìåëÝôç áðïäåéêíýåé üôé ç êïéíùíßá ôïõ ÊáíáäÜ èá åðùöåëïýôáí áðü Ýíá ðëçñÝóôåñï ðñüãñáììá áíïóïðïßçóçò27. ÐáñÜëëçëá, üìùò, áðáéôåßôáé êáé ç ëÞøç õãåéïíïìéêþí ìÝôñùí, ç óõíå÷Þò õãåéïíïìéêÞ åðáãñýðíçóç, ç âåëôßùóç ôùí óõíèçêþí ôçò áôïìéêÞò õãéåéíÞò áðü ôïõò áñìüäéïõò öïñåßò êáé ç áãùãÞ õãåßáò ãéá ôç óôåíÞ óõíåñãáóßá ôïõ êïéíïý.

Âéâëéïãñáößá 1. ÉáôñéêÞ Ìéêñïâéïëïãßá êáé Áíïóïâéïëïãßá, Ðáðáðáíáãéþôïõ Ê. åêä. ÐáñáôçñçôÞò, 1991. 2. Hilleman MR. Vaccines in historic evolution and perspective: a narrative of vaccine discoveries. Vaccine, 18:1436–1447, 2000. 3. Ada G, Ramsay A. Vaccines, Vaccination and the Immune Response. Philadelphia, Lippincott-Raven, 1997. 4. Anonymous. The Jordan Report. Accelerated Development of Vaccines. Division of Microbiology and Infectious Diseases. Washington: National Institutes of Health, 2000. 5. ÐáðáäÜêçò Å, ÄñáêùíÜêçò Í, ÁëåîáíäñÜêç Ñ 117

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êáé óõí. ¸ëåã÷ïò åìâïëéáóìþí óôá ðáéäéÜ çëéêßáò 3-18 ÷ñüíùí, êáôÜ ôï ó÷ïëéêü Ýôïò 199697 ôçò ðåñéï÷Þò ôïõ ÊÝíôñïõ Õãåßáò ×Üñáêá Íïìïý Çñáêëåßïõ. ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 12:25-31, 2000. Ìáñáãêüò ×, ÂáëÜóç-ÁäÜì Å, ÌáíùëÜêçò Ã, ÌáíùëÜêç Á êáé óõí. ÂéâëéÜñéï Õãåßáò ôïõ Ðáéäéïý, ÅöáñìïãÞ êáé ÷ñçóéìüôçôá, ÉððïêñÜôçò, 1083-1089, 1982. Frenkel LD, Nielsen K. Immunization issues for the 21st century. Ann Allergy Asthma Immunol, 90:45-52, 2003. Äåëôßá Ôýðïõ ‘Ãéáôñþí ×ùñßò Óýíïñá’, 9 Ìáñôßïõ 2004. Rodewald LE, Roghmann KJ, Szilagyi PG, Winter NL, Campbell JR, Hamiston SG. The school-based immunization survey: an inexpensive tool for measuring vaccine coverage. Am J Public Health, 83:1749-1751, 1993. ÓÝñìðçò Á. ÊáôÜóôáóç åìâïëéáóìïý ôùí ìáèçôþí óôï ¢ñãïò Ïñåóôéêü êáôÜ ôï ó÷ïëéêü Ýôïò 2002-2003. ÐáéäéáôñéêÞ, 67:120-125, 2004. Middleton DB, Zimmerman RK, Mitchell KB. Vaccine schedules and procedures. J Fam Pract, 52:36-46, 2003. Ward JI, Zangwill KM. Haemophilus influenzae vaccines. Plotkin SA, Orenstein WA, eds. Vaccines, 3rd ed. Philadelphia, WB Saunders Co 183–221, 1999. Ramsay ME, Andrews N, Keezmarsk EB, Miller E. Efficacy of meningococcal serogroup C conjugate vaccine in teenagers and toddlers in England. Lancet, 357:195–196, 2001. Zimmer SM, Stephens DS. Meningococcal conjugate vaccines. Expert Opin Pharmacother, 5:855-863, 2004.

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15. ×áôæçìé÷áÞë Å, Ëåõèåñéþôïõ Ó êáé óõí. ÅöáñìïãÞ ôïõ åêôåôáìÝíïõ ðñïãñÜììáôïò áíïóïðïßçóçò áðü ôï ÊÝíôñï Õãåßáò Êïõöáëßùí. ÐáéäéáôñéêÞ, 60:603-612, 1997. 16. ËåéâáäÜò Í, ÄåëçóÜââáò Ì êáé óõí. ÊáôÜóôáóç åìâïëéáóìþí ìáèçôþí ó÷ïëéêÞò çëéêßáò ðåñéï÷Þò ÑáöÞíáò. ÐáéäéáôñéêÞ, 52:274-282, 1989. 17. Banatvala JE, Brown DW. Rubella. Lancet, 363:1127-1137, 2004. 18. BCG vaccination policies. Report of a WHO study Group. WHO Tech Ser, 652, Geneva WHO, 1980. 19. Fine P. BCG Vaccination against tuberculosis and leprosy. Br Med Bull, 44:691-703, 1988. 20. Schwoebel V, Hubert Â, Grosset J. Impact of BCG on tuberculous meningitis in France in 1990. The Lancet, 340:611, 1992. 21. Fraser D. Variation in protection by BCG. The Lancet, 347:333, 1996. 22. Alter MJ. Epidemiology and prevention of hepatitis B. Semin Liver Dis, 23:39-46, 2003. 23. Zangwill KM, Belshe RB. Safety and efficacy of trivalent inactivated influenza vaccine in young children: a summary for the new era of routine vaccination. Pediatr Infect Dis J, 23:189197, 2004. 24. Principi N, Esposito S. Are we ready for universal influenza vaccination in paediatrics? Lancet Infect Dis, 4:75-83, 2004. 25. MMWR Morb Mortal Wkly Rep, 48:1-37, 1999. 26. Ada G. Progress towards achieving new vaccine and vaccination goals. Intern Med J, 33: 297–304, 2003. 27. Chabot I, Goetghebeur MM, Gregoire JP. The societal value of universal childhood vaccination. Vaccine, 22:1992-2005, 2004.

Ôüìïò 17, Ôåý÷ïò 3, 2005

Á. Áñâáíßôçò êáé óõí.

ÅÑÅÕÍÇÔÉÊÇ EÑÃÁÓÉÁ ÏRIGINAL PAPER Primary Heatlh Care, Volume 17, Number 3, 119-126, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 119-126, 2005

ÌÝôñçóç ôçò áñôçñéáêÞò ðßåóçò: Áíáãêáéüôçôá êáé óêïðéìüôçôá áðü ôçí ðëåõñÜ ôùí ðñïóåñ÷üìåíùí óå Ðåñéöåñåéáêü Éáôñåßï Á. Áñâáíßôçò1, Á. ÓêáñðÝëïò2, Ð. ÌáëéíäñÝôïò3, ×ñéóôßíá ×áëêéïðïýëïõ4, Í. ÑáæÞò5

Ðåñßëçøç Óêïðüò: Ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò (ÁÐ) åßíáé áðü ôéò ðéï óõ÷íÝò éáôñéêÝò ðñÜîåéò óå Ýíá Ðåñéöåñåéáêü Éáôñåßï (ÐÉ) êáé ðïëëÝò öïñÝò æçôåßôáé áðü ôïí ßäéï ôïí ðñïóåñ÷üìåíï, áíåîÜñôçôá áðü ôçí áéôßá ðñïóÝëåõóÞò ôïõ. Óêïðüò ôçò ìåëÝôçò åßíáé ç åêôßìçóç ôïý ðüóï óõ÷íÜ êáé ãéá ðïéïõò ëüãïõò ïé ðñïóåñ÷üìåíïé óôï ÐÉ ÄÜöíçò Êáëáâñýôùí æçôïýí áðü ìüíïé ôïõò ôç ìÝôñçóç ôçò ÁÐ. Õëéêü êáé ÌÝèïäïò: Ãéá ôï äéÜóôçìá Áýãïõóôïò Ýùò êáé Ïêôþâñéïò 2004 êáôáãñÜøáìå ìåôáîý ôùí ðñïóåñ÷üìåíùí óôï ÐÉ ÄÜöíçò åêåßíïõò ðïõ äåí õðïâëÞèçêáí óå ìÝôñçóç ÁÐ êáé åêåßíïõò ðïõ æÞôçóáí ïé ßäéïé íá ìåôñçèïýí. ÓõãêåêñéìÝíá êáôáãñÜøáìå ôçí áéôßá ðñïóÝëåõóÞò ôïõò, ôï åÜí Ý÷ïõí éóôïñéêü áñôçñéáêÞò õðÝñôáóçò (ÁÕ) êáé ôï åÜí ìåôñÞèçêå ç ÁÐ Þ ü÷é. ÓõíïëéêÜ óôç ìåëÝôç óõìðåñéëÜâáìå 558 Üôïìá ìÝóçò çëéêßáò 64,8 åôþí (åëÜ÷éóôç: 21 åôþí ìÝãéóôç: 98 åôþí SD: ±12,36), 270 Üíäñåò êáé 288 ãõíáßêåò. Åðéäéþîáìå ðñïóùðéêÞ äéáâïýëåõóç ìå üëïõò ðñïêåéìÝíïõ íá ó÷çìáôßóïõìå óöáéñéêÞ ãíþìç ó÷åôéêÜ ìå ôï ðþò ïé ßäéïé áîéïëïãïýí ôçí éáôñéêÞ ðñÜîç ôçò ìÝôñçóçò ôçò ÁÐ. Ãéá ôç óôáôéóôéêÞ áíÜëõóç ÷ñçóéìïðïéÞèçêå ôï x2 test (confidence interval 95%). ÁðïôåëÝóìáôá: Ï ðëçèõóìüò ìáò ÷ùñßæåôáé óå ôñåéò ïìÜäåò: Á: áõôïß ðïõ äåí æÞôçóáí ìÝôñçóç ôçò ÁÐ (158 Üôïìá, 28,3%), Â: áõôïß ðïõ æÞôçóáí ìÝôñçóç êáé åß÷áí éóôïñéêü ÁÕ (244 Üôïìá, 43,7%) êáé Ã: áõôïß ðïõ æÞôçóáí ìÝôñçóç ÷ùñßò íá áíáöÝñïõí éóôïñéêü ÁÕ (156 Üôïìá, 28%). Ç óýóôáóç ôùí ôñéþí ïìÜäùí ùò ðñïò ôï öýëï êáé ôçí çëéêßá öáßíåôáé óôïí ðáñáêÜôù ðßíáêá. ÓçìåéùôÝïí üôé ç óýóôáóÞ ôïõò ùò ðñïò ôï ìïñöùôéêü åðßðåäï êáé ôçí áéôßá ðñïóÝëåõóçò äåí åìöáíßæåé êÜðïéï óôáôéóôéêþò óçìáíôéêü óôïé÷åßï. ÏìÜäá Óýíïëï Öýëï Çëéêßá (Ýôç) ¢íäñåò Ãõíáßêåò 0-65 >65 Á 158 (28,3%) 84 (31,1%) 74 (25,7%) 78 (50,6%) 80 (19,8%) Â 244 (43,7%) 104 (38,5%) 140 (48,6%) 26 (16,9%) 221 (54,7%) Ã 156 (28,0%) 82 (30,4%) 74 (25,7%) 50 (32,5%) 103 (25,5%) Óýíïëï 558 (100%) 270 (48,4%) 288 (51,6%) 154 (27,6%) 404 (72,4%) ÓõìðåñÜóìáôá: ¼ðùò åßíáé öõóéêü, óôçí ïìÜäá Á êõñéáñ÷ïýí ôá íåüôåñá Üôïìá (p<0.0005), ôá ïðïßá áäéáöïñïýí ðåñéóóüôåñï ãéá ôçí õãåßá ôïõò ãåíéêüôåñá. Ðïëëïß áðü áõôïýò ðñïóÝñ÷ïíôáé ãéá íá åîõðçñåôÞóïõí êÜðïéïí çëéêéùìÝíï (óõíôáãïãñáößá) êáé äçëþíïõí üôé åßíáé áðüëõôá õãéåßò êáé äåí èÝëïõí íá Ý÷ïõí êáìéÜ ó÷Ýóç ìå ôï ãéáôñü! Ç ïìÜäá Â ðåñéëáìâÜíåé åðéìåëåßò áóèåíåßò, ìå åðéêñÜôçóç ôùí ãõíáéêþí (P<0,025) êáé ôùí ðéï çëéêéùìÝíùí (P<0,0005). Ôï ðïóïóôü ôçò ïìÜäáò Ã öáßíåôáé áñêåôÜ õøçëü, éäßùò óôïõò 1

Éáôñüò, Ðåñéöåñåéáêïý Éáôñåßïõ ÄÜöíçò, 2Ãåíéêüò Éáôñüò, ÅðéìåëçôÞò Â´ ÊÝíôñïõ Õãåßáò ÅñõìÜíèåéáò, 3Éáôñüò ÍåöñïëïãéêÞò ÊëéíéêÞò Ð.Ã.Í. Á×ÅÐÁ Èåóóáëïíßêçò, 4Ðáéäßáôñïò, ÐÜôñá, 5Ãåíéêüò Éáôñüò, ÄéåõèõíôÞò ÊÝíôñïõ Õãåßáò Êëåéôïñßáò

ÅéóáãùãÞ Ôï 2003 äéÜöïñá óþìáôá åéäéêþí, üðùò ç ÅõñùðáúêÞ Åôáéñåßá ÕðÝñôáóçò - ÅõñùðáúêÞ Åôáéñåßá Êáñäéïëïãßáò, ç ÁìåñéêáíéêÞ ÅèíéêÞ ÅðéôñïðÞ ãéá ôçí ÕðÝñôáóç (JNC-7), ï Ðáãêüóìéïò Ïñãáíéóìüò Õãåßáò – ÄéåèíÞò Åôáéñåßá ÕðÝñôáóçò, ç ÂñåôáíéêÞ êáé ç ÊáíáäéêÞ Åôáéñåßá ÕðÝñôáóçò ê.Ü., äçìïóßåõóáí íÝåò êáôåõèõíôÞñéåò ïäçãßåò ãéá ôçí áñôçñéáêÞ õðÝñôáóç (ÁÕ). Ç óýíôáîç êáé äçìïóßåõóç áõôþí ôùí ïäçãéþí äéêáéïëïãåßôáé áðü ôçí ðñüóöáôç äçìïóßåõóç ðïëëþí óçìáíôéêþí ìåëåôþí. Áí êáé üëåò ïé êáôåõèõíôÞñéåò ïäçãßåò âáóßæïíôáé óôá ßäéá äåäïìÝíá, åßíáé åíäéáöÝñïí ôï üôé õðÜñ÷ïõí óçìáíôéêÝò äéáöïñÝò áíÜìåóÜ ôïõò, ð.÷. ìåôáîý ËÝîåéò êëåéäéÜ: Öáñìáêïèåñáðåßá, áñôçñéáêÞ õðÝñôáóç, åìðïñéêü üíïìá, marketing ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 17ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ, 4-8 ÌáÀïõ 2005) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 28 Éáíïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ÁíäñÝáò Ê. ÓêáñðÝëïò, Ãåíéêüò Éáôñüò, ÅðéìåëçôÞò Â´ ÊÝíôñïõ Õãåßáò ÅñõìÜíèåéáò Á÷áÀáò, Äéåýèõíóç: Áèçíþí 8, Ê. ÏâñéÜ Ðáôñþí, Ô.Ê. 26500, Ôçë.: (2610) 529977, 26940 31301, Êéíçôü: 6979 778865, Fax: (2610) 226400, 26940 31303, e-mail: ska@panafonet.gr 119

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Üíäñåò êáé óôç íåüôåñç çëéêéáêÞ ïìÜäá. Ôá Üôïìá áõôÜ æçôïýí ôç ìÝôñçóç ôçò ÁÐ áíåîáñôÞôùò ôïõ ãéá ðïéï ëüãï ðñïóÝñ÷ïíôáé óôï ÐÉ (óõíôáãïãñáößá, ðéóôïðïéçôéêÜ, íüóïò Üó÷åôç ìå ôçí ÁÐ ê.Ü.) Þ ðñïóÝñ÷ïíôáé áðïêëåéóôéêÜ ãéá ôç ìÝôñçóç ôçò ÁÐ. ÐïëëÝò öïñÝò åðéìÝíïõí íá ìåôñïýí ôçí ÁÐ ôïõò ðïëý óõ÷íÜ êáé ìå êÜèå åõêáéñßá. Ïé ðåñéóóüôåñïé åßíáé áñêåôÜ õãéåßò, áí êáé äåí ëåßðïõí êáé áóèåíåßò ðïõ ðÜó÷ïõí áðü óïâáñÝò íüóïõò (áêüìá êáé êáñêßíï). ¼ëïé ùóôüóï êáèçóõ÷Üæïíôáé ìå ôï íá ìåôñïýí ôçí ÁÐ êáé íá ôç âñßóêïõí öõóéïëïãéêÞ, èåùñþíôáò üôé áõôü áðïôåëåß äåßêôç õãåßáò (óõ÷íÜ ôïí ìïíáäéêü, áöïý áñíïýíôáé íá õðïâëçèïýí óå Üëëåò éáôñéêÝò åîåôÜóåéò!). ¼ëá ôá ðáñáðÜíù áíáäåéêíýïõí ôçí áíÜãêç ãéá åíôáôéêüôåñç åíçìÝñùóç ôïõ ðëçèõóìïý áðü ôïõò ëåéôïõñãïýò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôá ðëáßóéá ôçò ÁãùãÞò Õãåßáò, þóôå íá ãßíåôáé ïñèïëïãéêüôåñç êáé áðïäïôéêüôåñç ÷ñÞóç ôùí õðçñåóéþí õãåßáò ðñïò üöåëïò ôïõ ðëçèõóìïý. Blood pressure measurement: necessity and expediency from the patients’ viewpoint A. Arvanitis, A. Skarpelos, P. Malindretos, C. Chalkiopoulou, N. Razis Summary Aim: The measurement of arterial blood pressure (BP) is one of the most frequent medical actions in a Regional Surgery (RS) and the patients, regardless of the cause of attendance, ask many times for it. The aim of this study is to estimate how often and for what reasons do the patients ask the doctor to perform the medical action of BP measurement in the RS of Dafni Kalavrita. Material and Method: During the period from August to October 2004 we recorded among the patients in the RS of Dafni those who were not submitted in BP measurement and those who asked for it. We recorded their sex, age, educational status, the cause of attendance and whether they had had a history of arterial hypertension (AH). Our study included 558 individuals (mean age: 64.8 years; minimum: 21; maximum: 98; SD: ±12.36), 270 men and 288 women. We pursuit personal consultation with all the patients. In that way we tried to understand their opinion and evaluation of the medical action of BP measurement. For the statistical analysis we used the x 2 test (confidence interval 95%). Results: Our population was separated in three teams: A: individuals who did not ask for BP measurement (158 individuals, 28.3%). B: those who asked for BP measurement and had had a history of AH (244 individuals, 43.7%). C: those who asked for BP measurement and did not mention a history of AH (156 individuals, 28%). The distribution of the three teams as for the sex, the age, the educational status and the cause of attendance show some important statistical results. Conclusions: Naturally, younger individuals are prevalent in A team (p<0.0005). They are generally indifferent for their health. Many of them visit the RS in order to serve elderly people and declare that they are absolutely healthy and they do not wish for any medical check. B team includes assiduous patients, with prevalence of women (p<0.025) and elderly people (p<0.0005). The percentage of C team appears quite high. These individuals either ask for BP measurement independently of the reason they visit the RS (prescription, certificates, illness irrelevant with AH etc.) or they visit us exclusively for the measurement of BP. They often insist on having their BP measured regardless of the doctor’s opinion. Most of them are quite healthy, but patients suffering from serious illnesses (even cancer) are not rare, too. However, they are relieved when their BP is found normal, because they think that this is an indicator of health (often the sole indicator, since they deny to be submitted in other medical examinations!). From all the above we understand the need for more intensive briefing of the population, in terms of Health Education, by Primary Health Care officers. Thus the use of health services will become more rational and efficient, to the profit of the population. Key words: Blood pressure, hypertension, rural practice, primary care Health Center of Kleitoria

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Á. Áñâáíßôçò êáé óõí.

åõñùðáúêþí, áìåñéêáíéêþí êáé äéåèíþí ïäçãéþí. Ïé äéáöïñÝò áõôÝò ìðïñïýí íá áðïäïèïýí ü÷é ìüíï óå äéáöïñÝò óôïõò éäéáßôåñïõò ÷áñáêôÞñåò êÜèå ðåñéï÷Þò ùò ðñïò ôïõò ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ (åðéðïëáóìüò, ó÷åôéæüìåíïò êßíäõíïò, ðïóïóôÜ ñýèìéóçò), ôéò áíôéëÞøåéò êáé ôïí ôñüðï æùÞò, ôéò êïéíùíéêïïéêïíïìéêÝò óõíèÞêåò êáé ôéò äõíáôüôçôåò êáé ôç äïìÞ ôùí óõóôçìÜôùí äçìüóéáò õãåßáò, áëëÜ êáé óå äéáöïñÝò óôç öéëïóïößá, ôç íïïôñïðßá êáé ôéò áíôéëÞøåéò ìåôáîý ôùí óõããñáöéêþí ïìÜäùí. Ç áðïóðáóìáôéêÞ ðáñïõóßáóç äéáöïñåôéêþí êáôåõèõíôÞñéùí ïäçãéþí óå åêðáéäåõôéêÝò óõíáíôÞóåéò ïäçãåß ôïõò êëéíéêïýò ãéáôñïýò óå áâåâáéüôçôá Þ êáé óýã÷õóç ùò ðñïò ôçí åíäåäåéãìÝíç óôñáôçãéêÞ ðïõ ðñÝðåé íá åöáñìüóïõí óôïõò áññþóôïõò ôïõò óôçí ðñÜîç. Ç ÁÕ åßíáé åî ßóïõ óõ÷íÞ óôç ÷þñá ìáò üóï êáé óå Üëëåò áíåðôõãìÝíåò ÷þñåò êáé áöïñÜ ðåñßðïõ óôï 25% ôïõ ðëçèõóìïý ôùí åíçëßêùí. Ôá ðïóïóôÜ áíáãíþñéóçò, èåñáðåßáò êáé ñýèìéóçò ôçò õðÝñôáóçò óôç ÷þñá ìáò åßíáé ðáñüìïéá ìå áíôßóôïé÷á åñåõíþí óå ðëçèõóìïýò Üëëùí áíáðôõãìÝíùí ÷ùñþí. Ðïëëïß áãíïïýí üôé Ý÷ïõí áõîçìÝíç ðßåóç, áëëÜ êáé áðü áõôïýò ðïõ ôï ãíùñßæïõí ëßãïé åðéôõã÷Üíïõí éêáíïðïéçôéêÞ ñýèìéóç. Ôï ðïóïóôü êáëÞò ñýèìéóçò, ôüóï óôçí ÅëëÜäá üóï êáé óôï åîùôåñéêü äåí îåðåñíÜ ôï 2025%. Ç ÅëëÜäá äéáöÝñåé áðü Üëëåò ÅõñùðáúêÝò ÷þñåò ëüãù ôïõ ìéêñüôåñïõ êáñäéáããåéáêïý êéíäýíïõ (üðùò êáé ç Éôáëßá, ç Ãáëëßá, ç Éóðáíßá) êáé ôçò åõñåßáò åöáñìïãÞò ôùí ìåôñÞóåùí ôçò ðßåóçò óôï óðßôé Þ óôï öáñìáêåßï, êÜôé ðïõ ëåéôïõñãåß êáôÜ êÜðïéïí ôñüðï ùò åèíéêü ðñüãñáììá äéÜãíùóçò ôçò ÁÕ. Ôá ðáñáðÜíù äåß÷íïõí üôé õðÜñ÷ïõí ìåãÜëá ðåñéèþñéá ôüóï ãéá ôç ìåßùóç ôùí ðåñéðôþóåùí áäéÜãíùóôùí õðåñôáóéêþí óôç ÷þñá ìáò, üóï êáé ãéá ôçí áðïôåëåóìáôéêüôåñç áíôéìåôþðéóÞ ôïõò. Åßíáé ëïéðüí óêüðéìç ç ðñïóáñìïãÞ ôçò

Ôüìïò 17, Ôåý÷ïò 3, 2005

Á. Áñâáíßôçò êáé óõí.

óôñáôçãéêÞò áíôéìåôþðéóçò ôçò ÁÕ óôá éäéáßôåñá áõôÜ åèíéêÜ ÷áñáêôçñéóôéêÜ. Åêôüò ôùí ðñïáíáöåñèÝíôùí óôïé÷åßùí, ìéá áêüìá éäéáéôåñüôçôá öáßíåôáé üôé õðÜñ÷åé óôç ÷þñá ìáò êáé éäßùò óôéò ìç áóôéêÝò ðåñéï÷Ýò. ÐñÜãìáôé, ðáñáôçñÞóáìå üôé ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò (ÁÐ) åßíáé ßóùò ç óõ÷íüôåñá æçôïýìåíç éáôñéêÞ ðñÜîç óå Ýíá Ðåñéöåñåéáêü Éáôñåßï (ÐÉ) êáé ðïëëÝò öïñÝò æçôåßôáé áðü ôïí ßäéï ôïí ðñïóåñ÷üìåíï, áíåîÜñôçôá áðü ôçí áéôßá ðñïóÝëåõóÞò ôïõ. Óêïðüò ôçò ìåëÝôçò åßíáé ç åêôßìçóç ôïõ ðüóï óõ÷íÜ êáé ãéá ðïéïõò ëüãïõò (äçëáäÞ êÜôù áðü óõãêåêñéìÝíá êñéôÞñéá Þ ìå ôõ÷áßá åðéëïãÞ) ïé ðñïóåñ÷üìåíïé óôï ÐÉ ÄÜöíçò Êáëáâñýôùí æçôïýí áðü ìüíïé ôïõò ôç ìÝôñçóç ôçò ÁÐ. Åðßóçò èåëÞóáìå íá ðñïóäéïñßóïõìå êáé ôç óçìáóßá ðïõ äßíïõí ïé ßäéïé ïé ðïëßôåò (áóèåíåßò Þ ü÷é) óôçí éáôñéêÞ áõôÞ ðñÜîç. Åßíáé öáíåñü üôé ôá äåäïìÝíá áõôÜ èá ìðïñïýóáí íá ÷ñçóéìåýóïõí óôçí áêüìá êáëýôåñç ðñïóáñìïãÞ ôçò óôñáôçãéêÞò ðñüëçøçò, ðñþéìçò äéÜãíùóçò êáé áíôéìåôþðéóçò ôçò ÁÕ óôá éäéáßôåñá áõôÜ åèíéêÜ ìáò ÷áñáêôçñéóôéêÜ.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò Ç ÝñåõíÜ ìáò Ýëáâå ÷þñá óôï ÐÉ ÄÜöíçò, éáôñåßï ðïõ õðÜãåôáé óôï ÊÝíôñï Õãåßáò Êëåéôïñßáò (åðáñ÷ßá Êáëáâñýôùí, íïìüò Á÷áÀáò). Ðñüêåéôáé ãéá ðåñéï÷Þ ïñåéíÞ êáé áðïìáêñõóìÝíç, ìå ðëçèõóìü ùò åðß ôï ðëåßóôïí áãñïôéêü – êôçíïôñïöéêü, ó÷åôéêÜ ÷áìçëïý åðéðÝäïõ åêðáßäåõóçò êáé õøçëïý ìÝóïõ üñïõ çëéêßáò. Ãéá ôï ÷ñïíéêü äéÜóôçìá áðü ôïí Áýãïõóôï Ýùò êáé ôïí Ïêôþâñéï ôïõ 2004 êáôáãñÜøáìå ìåôáîý ôùí ðñïóåñ÷üìåíùí óôï ÐÉ ÄÜöíçò üëïõò åêåßíïõò ðïõ äåí õðïâëÞèçêáí óå ìÝôñçóç ÁÐ ìå éáôñéêÞ ðñùôïâïõëßá, äçëáäÞ åêåßíïõò ðïõ æÞôçóáí ïé ßäéïé íá ìåôñÞóïõìå ÁÐ. Åðßóçò êáôáãñÜøáìå êáé åêåß-

íïõò ðïõ äåí æÞôçóáí êÜôé ôÝôïéï, áëëÜ ïýôå êáé åìåßò êñßíáìå êÜôé ôÝôïéï áíáãêáßï. Áöïý áðïêëåßóáìå ôï åíäå÷üìåíï íá óõìðåñéëçöèåß êÜðïéïò óôç ìåëÝôç ãéá ðÜíù áðü ìßá öïñÜ, óçìåéþóáìå ôï öýëï, ôçí çëéêßá, ôï åðßðåäï åêðáßäåõóçò, ôçí áéôßá ðñïóÝëåõóÞò ôïõò êáé ôï åÜí Ý÷ïõí éóôïñéêü ÁÕ Þ ü÷é. ÓõíïëéêÜ óôç ìåëÝôç óõìðåñéëÜâáìå 558 Üôïìá ìÝóçò çëéêßáò 64,8 åôþí (åëÜ÷éóôç: 21 åôþí ìÝãéóôç: 98 åôþí óôáèåñÞ áðüêëéóç (SD): ±12,4 Ýôç). Åðéäéþîáìå ðñïóùðéêÞ äéáâïýëåõóç ìå üëïõò, áíáöÝñïíôáò åí ôÜ÷åé ðëçñïöïñßåò ãéá ôçí ìÝôñçóç ôçò ÁÐ: ôïí ôüðï, ôï ÷ñüíï êáé ôïí ôñüðï ðïõ ðñÝðåé íá ãßíåôáé ç éáôñéêÞ áõôÞ ðñÜîç, ôï ÷ñüíï ðïõ ðñÝðåé íá áöéåñþíåôáé êáé ôç óçìáóßá ðïõ Ý÷åé íá ìçí åßíáé ìïíïäéÜóôáôç êáé áðïìïíùìÝíç áõôÞ ç åîÝôáóç. Ìå ôïí ôñüðï áõôü ðñïóðáèÞóáìå íá ó÷çìáôßóïõìå óöáéñéêÞ ãíþìç ó÷åôéêÜ ìå ôï ðþò ïé ßäéïé áîéïëïãïýí ôçí éáôñéêÞ ðñÜîç ôçò ìÝôñçóçò ôçò ÁÐ, ðüóï óõ÷íÜ õðïâÜëëïíôáé ó’ áõôÞí, áðü ðïéïí êáé õðü ðïéåò óõíèÞêåò, åÜí åß÷áí ðïôÝ åìðåéñßá õøçëÞò ÁÐ êáé ðþò ôçí áíôéìåôþðéóáí êáé ðüóï åðéêßíäõíç ðéóôåýïõí üôé åßíáé ç íüóïò ôçò ÁÕ. ÔÝëïò ðñïóðáèÞóáìå íá ìÜèïõìå ôéò ðçãÝò åíçìÝñùóçò êÜèå ðñïóåñ÷ïìÝíïõ ó÷åôéêÜ ìå ôçí ÁÕ êáé ôç ìÝôñçóç ôçò ÁÐ. ×ùñßóáìå ôïí ðëçèõóìü ôçò ìåëÝôçò ìáò óå ôñåéò ïìÜäåò: ÏìÜäá Á: üóïé ðñïóÞëèáí óôï ÐÉ êáé äåí æÞôçóáí ìÝôñçóç ôçò ÁÐ (158 Üôïìá, 28,3%). ÏìÜäá Â: ïé ðñïóåñ÷üìåíïé ðïõ æÞôçóáí ìÝôñçóç ôçò ÁÐ êáé åß÷áí éóôïñéêü ÁÕ (244 Üôïìá, 43,7%). ÔÝëïò, ÏìÜäá Ã: üóïé ðñïóÞëèáí óôï ÐÉ êáé æÞôçóáí ìÝôñçóç ôçò ÁÐ ÷ùñßò íá áíáöÝñïõí éóôïñéêü ÁÕ (156 Üôïìá, 28%). Ç êáôáíïìÞ ôùí ôñéþí ïìÜäùí ùò ðñïò ôï öýëï, ôçí çëéêßá, ôçí áéôßá ðñïóÝëåõóçò êáé ôï åðßðåäï åêðáßäåõóçò öáßíåôáé óôïí Ðßíáêá 1. Ãéá ôç óôáôéóôéêÞ áíÜëõóç ÷ñçóéìïðïéÞèçêå ôï x2 test, êáé ìåôñÞèçêå ôï 95% äéÜóôçìá áîéïðéóôßáò.

Ðßíáêáò 1. ÊáôáíïìÞ ôïõ ðëçèõóìïý áíÜ ïìÜäá, êáé áíÜ öýëï, çëéêßá, áéôßá ðñïóÝëåõóçò êáé åðßðåäï åêðáßäåõóçò ÏìÜäá

Óýíïëï

Á Â Ã Óýíïëï

158 244 156 558

Öýëï ¢ññåí ÈÞëõ

Çëéêßá (Ýôç) 0-65 >65

84 104 82 270

78 26 50 154

74 140 74 288

80 221 103 404

Áéôßá ÐñïóÝëåõóçò Íüóïò Ó/Ã1 50 84 48 182

108 160 108 376

Åðßðåäï Åêðáßäåõóçò ÁÃÑ2 ÓÔ×3 Â´Â4 Ã´Â5 22 58 34 114

58 162 76 296

48 22 42 112

19 17 36

ÓõíôáãïãñÜöçóç, 2ÁãñÜììáôïé, 3Óôïé÷åéþäçò, 4ÄåõôåñïâÜèìéá, 5ÔñéôïâÜèìéá 121

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Áñâáíßôçò êáé óõí.

Ãõíáßêåò ¢íäñåò 48%

600 500

Óýíïëï ÏìÜäá Á ÏìÜäá Â ÏìÜäá Ã

400 300

52%

200 100 0

Ó÷Þìá 1. ÊáôáíïìÞ öýëùí.

¢ññåí

ÈÞëõ

Óýíïëï

Öýëï

Ó÷Þìá 5. ÊáôáíïìÞ öýëïõ êÜèå ïìÜäáò óå ó÷Ýóç ìå ôï óýíïëï ôïõ ðëçèõóìïý.

28% 600 500

0-65 >65

72%

Óýíïëï ÏìÜäá Á ÏìÜäá Â ÏìÜäá Ã

400 300 200

Ó÷Þìá 2. ÊáôáíïìÞ çëéêßáò.

100 0

33%

0-65

>65

Óýíïëï

Çëéêßá (Ýôç)

Ó÷Þìá 6. ÇëéêéáêÞ êáôáíïìÞ êÜèå ïìÜäáò óå ó÷Ýóç ìå ôï óýíïëï ôïõ ðëçèõóìïý. 600

Íüóïò

67%

Ó/Ã

Ó÷Þìá 3. ÊáôáíïìÞ áéôßáò ðñïóÝëåõóçò.

500

Óýíïëï ÏìÜäá Á ÏìÜäá Â ÏìÜäá Ã

400 300 200 100

20%

ÁãñÜììáôïò/ç Óôïé÷åéþäçò ÄåõôåñïâÜèìéá 54%

ÔñéôïâÜèìéá

Ó÷Þìá 4. ÊáôáíïìÞ åðéðÝäïõ åêðáßäåõóçò.

ÁðïôåëÝóìáôá Óôçí ïìÜäá Á (äçëáäÞ üóïé ðñïóÞëèáí óôï ÐÉ êáé äåí æÞôçóáí ìÝôñçóç ôçò ÁÐ) êõñéáñ÷ïýí ôá íåüôåñá Üôïìá (P <0,0005), ôá ïðïßá áäéáöïñïýí ðåñéóóüôåñï ãéá ôçí õãåßá ôïõò ãåíéêüôåñá (Ðßíáêáò 2). Ðïëëïß áðü áõôïýò ðñïóÞë122

Íüóïò

Ó/Ã

Óýíïëï Áéôßá ðñïóÝëåõóçò

Ó÷Þìá 7. ÊáôáíïìÞ ôçò áéôßáò ðñïóÝëåõóçò êÜèå ïìÜäáò óå ó÷Ýóç ìå ôï óýíïëï ôïõ ðëçèõóìïý.

èáí ãéá íá åîõðçñåôÞóïõí êÜðïéïí çëéêéùìÝíï (óõíôáãïãñáößá) êáé äçëþíáí üôé åßíáé áðüëõôá õãéåßò êáé äåí èÝëïõí íá Ý÷ïõí êáìéÜ ó÷Ýóç ìå ôï ãéáôñü! Ç ïìÜäá Á ðåñéëÜìâáíå óçìáíôéêÜ ëéãüôåñá Üôïìá ôñéôïâÜèìéáò åêðáßäåõóçò (Ñ <0,0005), áëëÜ ðåñéëáìâÜíåé óçìáíôéêÜ ðåñéóóüôåñá Üôïìá äåõôåñïâÜèìéáò åêðáßäåõóçò (Ñ <0,0005) (Ðßíáêáò 3). Ç åí ãÝíåé ðëçñïöüñçóÞ ôïõò ó÷åôéêÜ ìå ôç ìÝôñçóç ôçò ÁÐ êáé ôç íüóï ôçò ÁÕ åßíáé ðôù÷Þ êáé ðñïÝñ÷åôáé êõñßùò áðü óõããåíåßò êáé ãíùóôïýò êáé êáèüëïõ ó÷åäüí áðü åðáããåëìáôßåò õãåßáò. ¼ðùò öáßíåôáé óôïí Ðßíáêá 2 êáé 3 ïìÜäá Â (äçëáäÞ ïé ðñïóåñ÷üìåíïé ðïõ æÞôçóáí ìÝôñçóç ôçò ÁÐ êáé åß÷áí éóôïñéêü ÁÕ) ðåñéëÜìâáíå

Ôüìïò 17, Ôåý÷ïò 3, 2005

Á. Áñâáíßôçò êáé óõí. Áñéèìüò áôüìùí 0

Åðßðåäï åêðáßäåõóçò

100

200

300

400

500

600

ÁÃÑ

ÓÔ×

Óýíïëï ÏìÜäá Á ÏìÜäá Â ÏìÜäá Ã

Â´Â

Ã´Â

Óýíïëï

Ó÷Þìá 8. ÊáôáíïìÞ ôïõ åðéðÝäïõ åêðáßäåõóçò êÜèå ïìÜäáò óå ó÷Ýóç ìå ôï óýíïëï ôïõ ðëçèõóìïý.

Ðßíáêáò 2. ÊáôáíïìÞ ôïõ ðëçèõóìïý áíÜ ïìÜäá êáé çëéêßá. ÏìÜäá

Óýíïëï

Çëéêßá (Ýôç) 0-65

Á Â Ã Óýíïëï

158 (28,3%) 78 (50,6%) 244 (43,7%) 26 (16,9%) 156 (28%) 50 (32,5%) 558 (100%) 154 (100%)

>65 80 (19,8%) 221 (54,7%) 103 (25,5%) 404 (100%)

åðéìåëåßò áóèåíåßò, ìå åðéêñÜôçóç ôùí ãõíáéêþí (Ñ <0,025) êáé ôçò çëéêéáêÞò ïìÜäáò Üíù ôùí 65 åôþí (Ñ <0,0005). Óôçí ïìÜäá Â äåí ðáñáôçñÞèçêå õðåñï÷Þ ôùí áôüìùí õøçëïôÝñïõ åðéðÝäïõ åêðáßäåõóçò (ïýôå äåõôåñïâÜèìéáò, ïýôå ôñéôïâÜèìéáò, p <0,05) ùò öáßíåôáé óôïí Ðßíáêá 5. Ïöåßëïõìå íá óçìåéþóïõìå üôé ïé áóèåíåßò áõôïß åß÷áí åðßãíùóç ôçò áîßáò áõôÞò ôçò éáôñéêÞò ðñÜîçò, Ýñ÷ïíôáí óå ôáêôÜ ÷ñïíéêÜ äéáóôÞìáôá (óýìöùíá ìå ôéò ïäçãßåò ôïõ èåñÜðïíôá éáôñïý ôïõò), óçìåßùíáí ôéò ìåôñÞóåéò óå ÷áñôß ðïõ ðÜíôá åß÷áí ìáæß ôïõò êáé êÜèå öïñÜ ôï åðéäåßêíõáí óôï ãéáôñü æçôþíôáò êáé Ýíá ó÷üëéï ãéá ôçí ðáñïýóá ôïõò êáôÜóôáóç (äçëáäÞ áí õðÞñ÷å êÜðïéá äéáöïñïðïßçóç – ìåôáâïëÞ ê.Ü). Åðßóçò ðåñßìåíáí êÜðïéï ÷ñïíéêü äéÜóôçìá óôïí ðñïèÜëáìï ôïõ éáôñåßïõ ãéá íá îåêïõñáóôïýí Ýôóé þóôå íá ìçí åðçñåáóôåß ç åîÝôáóç áðü ôïí ðïäáñüäñïìï Þ áðü ôçí êïýñáóç êáé, üðùò Ýëåãáí, ãéá íá åãêëéìáôéóôïýí óôï ÷þñï ôïõ éáôñåßïõ. ÐáñÜë-

ëçëá üôáí ôïõò æçôïýóáìå íá îáíáìåôñÞóïõìå ôçí ÁÐ äýï êáé ôñåéò öïñÝò, Þôáí éäéáßôåñá õðïìïíåôéêïß óå üëï ôï ðñùôüêïëëï ôçò åîÝôáóçò. ÔÝëïò, ðñéí áêüìá ôïõò åíçìåñþóïõìå åìåßò, öÜíçêáí íá ãíùñßæïõí áñêåôÜ áðü ôá ðñÜãìáôá ðïõ ïé êáôåõèõíôÞñéåò ïäçãßåò áíáöÝñïõí, üðùò ãéá ôçí ðáñïõóßá Üëëùí ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ (äõóëéðéäáéìßá, êÜðíéóìá, äéáâÞôçò, ðá÷õóáñêßá) êáèþò êáé üôé óå áññþóôïõò õðü èåñáðåßá ãßíåôáé ìÝôñçóç êáé óå üñèéá èÝóç (éäßùò óôïõò äéáâçôéêïýò êáé ôïõò çëéêéùìÝíïõò) ãéá ôï åíäå÷üìåíï ïñèïóôáôéêÞò õðüôáóçò. Ç áñêåôÜ êáëÞ ðëçñïöüñçóÞ ôïõò ðñïÝñ÷åôáé ðåñéóóüôåñï áðü éáôñïýò êáé ëéãüôåñï áðü óõããåíåßò êáé ãíùóôïýò. Ôï ðïóïóôü ôçò ïìÜäáò Ã (äçëáäÞ üóùí ðñïóÝñ÷ïíôáí óôï ÐÉ êáé æçôïýóáí ìÝôñçóç ôçò ÁÐ ÷ùñßò íá áíáöÝñïõí éóôïñéêü ÁÕ) Þôáí õøçëü, éäßùò óôïõò Üíäñåò êáé óôç íåüôåñç çëéêéáêÞ ïìÜäá (áí êáé óôáôéóôéêþò áõôü äåí ôåêìçñéþíåôáé). Óôçí ïìÜäá Ã ðáñáôçñÞèçêå óçìáíôéêÜ áõîçìÝíï ðïóïóôü áôüìùí äåõôåñïâÜèìéáò åêðáßäåõóçò (Ñ <0,025), åíþ ôá Üôïìá óôïé÷åéþäïõò åêðáßäåõóçò õóôåñïýí (Ñ <0,0005) ùò öáßíåôáé óôïí Ðßíáêá 3. Ôá Üôïìá áõôÜ æçôïýí ôç ìÝôñçóç ôçò ÁÐ áíåîáñôÞôùò ôïõ ãéá ðïéï ëüãï ðñïóÝñ÷ïíôáé óôï ÐÉ (óõíôáãïãñáößá, ðéóôïðïéçôéêÜ, íüóïò Üó÷åôç ìå ôçí ÁÐ ê.Ü.) Þ ðñïóÝñ÷ïíôáé áðïêëåéóôéêÜ ãéá ôç ìÝôñçóç ôçò ÁÐ.

123

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Áñâáíßôçò êáé óõí.

Ðßíáêáò 3. ÊáôáíïìÞ ôïõ ðëçèõóìïý áíÜ ïìÜäá êáé åðßðåäï åêðáßäåõóçò ÏìÜäá

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Åðßðåäï Åêðáßäåõóçò ÓÔ×** Â´Â***

ÁÃÑ* Á Â Ã Óýíïëï

158 (28,3%) 244 (43,7%) 156 (28%) 558 (100%)

22 (19,3%) 58 (50,9%) 34 (29,8%) 114 (100%)

58 162 76 296

(19,6%) (54,7%) (25,7%) (100%)

48 (42,9%) 22 (19,6%) 42 (37,5%) 112 (100%)

Ã´Â+ 19 (52,8%) 17 (47,2%) 36 (100%)

*ÁÃÑ: ÁãñÜììáôïé, **ÓÔ×: ÄçìïôéêÞò Åêðáßäåõóçò, ***Â´Â: ÄåõôåñïâÜèìéáò Åêðáßäåõóçò, +Ã´Â: ÔñéôïâÜèìéáò Åêðáßäåõóçò

ÓõæÞôçóç Áõôü èá áðïôåëïýóå Ýíáí ðïëý êáëü ôñüðï ðñþéìçò äéÜãíùóçò Þ êáé ðñüëçøçò ôçò ÁÕ óôïí ðëçèõóìü, áí ïé ðïëßôåò áõôïß åß÷áí ôç äéÜèåóç íá ìÜèïõí êáé íá åöáñìüóïõí ìåñéêÜ óçìáíôéêÜ ðñÜãìáôá ãéá ôçí éáôñéêÞ ðñÜîç ôçò ìÝôñçóçò ôçò ÁÐ êáé ãéá ôç íüóï ôçò ÁÕ. Äõóôõ÷þò üìùò, ïé ðåñéóóüôåñïé äåí Ý÷ïõí êáé ìÜëëïí äåí åðéèõìïýí íá Ý÷ïõí êáìßá ôÝôïéá åíçìÝñùóç. Ôï óå ôé åîõðçñåôåß ç ìÝôñçóç ôçò ÁÐ êáé ï ôñüðïò ðïõ ðñÝðåé íá ãßíåôáé ôïõò åßíáé Üãíùóôá. Ãéá ôï ëüãï áõôü äåí áêïëïõèïýí êÜðïéá óõãêåêñéìÝíç ìÝèïäï åðßóêåøçò óôï éáôñåßï (ð.÷. óõãêåêñéìÝíåò çìÝñåò Þ þñåò ôçò çìÝñáò, ðñéí Þ ìåôÜ ôï öáãçôü, üôáí åßíáé Þñåìïé Þ óõíáéóèçìáôéêÜ öïñôéóìÝíïé). Åðßóçò ðñïóåñ÷üìåíïé óôï éáôñåßï, ðïëëÝò öïñÝò âëÝðïíôáò üôé õðÜñ÷ïõí 2 Þ 3 Üôïìá óôç óåéñÜ ðñéí áðü áõôïýò, áðïöáóßæïõí íá ìçí ðåñéìÝíïõí ãéáôß âéÜæïíôáé “ãéá ôï êáöåíåßï”. ÐïëëÝò öïñÝò åðéìÝíïõí íá ìåôñïýí ôçí ÁÐ ôïõò ðïëý óõ÷íÜ êáé ìå êÜèå åõêáéñßá ÷ùñßò íá ãíùñßæïõí ôïõò ëüãïõò Þ åðåéäÞ áêïýí ôï ãåßôïíá êáé æçëåýïõí ðïõ êáé áõôïß äåí ÷ñçóéìïðïéïýí äùñåÜí ôéò õðçñåóßåò ðïõ ôïõò ðáñÝ÷åé ôï êñÜôïò (!) Ç åí ãÝíåé ðëçñïöüñçóÞ ôïõò ó÷åôéêÜ ìå ôç ìÝôñçóç ôçò ÁÐ êáé ôç íüóï ôçò ÁÕ ðñïÝñ÷åôáé êõñßùò áðü óõããåíåßò êáé ãíùóôïýò êáé ðïëý ëéãüôåñï áðü éáôñïýò. Ïé ðåñéóóüôåñïé åßíáé áñêåôÜ õãéåßò, áí êáé äåí ëåßðïõí êáé áóèåíåßò ðïõ ðÜó÷ïõí áðü óïâáñÝò íüóïõò (áêüìá êáé êáñêßíï). ¼ëïé ùóôüóï êáèçóõ÷Üæïíôáé ìå ôï íá ìåôñïýí ôçí ÁÐ êáé íá ôç âñßóêïõí öõóéïëïãéêÞ, èåùñþíôáò üôé áõôü áðïôåëåß äåßêôç õãåßáò. Ðïëëïß ìÜëéóôá èåùñïýí ôçí ÁÐ ùò ôïí ìïíáäéêü äåßêôç õãåßáò, áöïý áñíïýíôáé íá õðïâëçèïýí óå Üëëåò éáôñéêÝò åîåôÜóåéò! Áãíïïýí üôé ïé óõ÷íÝò ìåôñÞóåéò ðïõ áíáæçôïýí Ý÷ïõí áîßá, áëëÜ ðñÝðåé íá ãßíïíôáé óùóôÜ, ìå ðñïûðïèÝóåéò, ðñüãñáììá êáé éáôñéêÞ 124

ðáñáêïëïýèçóç. ¼ðùò öÜíçêå áðü ôç óõæÞôçóç ðïõ åß÷áìå ìáæß ôïõò, ðïëëÜ áðü ôá Üôïìá ôçò ïìÜäïò Ã åß÷áí êÜðïéá ðåñéóôáóéáêÞ åìðåéñßá õøçëÞò ÁÐ (ð.÷. 170/100 mmHg, óõíÞèùò óå ðåñéðôþóåéò Ýíôïíïõ Üã÷ïõò) êáé ðéóôåýïõí üôé ìå ôéò óõ÷íÝò ìåôñÞóåéò èá ðñïëÜâïõí êÜðïéá ðáñüìïéá êáôÜóôáóç, ç ïðïßá, êáôÜ ôç ãíþìç ôïõò, åßíáé åðéêßíäõíç êáé ÷ñåéÜæåôáé Üìåóç áíôéìåôþðéóç. Ôï ÷åéñüôåñï üìùò åßíáé üôé, äõóôõ÷þò üðùò öÜíçêå, ç ðëåéïøçößá ôùí áôüìùí áõôþí áíôéìåôþðéóå ôéò óõìâïõëÝò ìáò ãéá ôç óùóôÞ ðñüëçøç êáé áíôéìåôþðéóç ôçò ÁÕ (êáé êõñßùò ôùí ðåñéóôáóéáêþí áé÷ìþí õðÝñôáóçò) ìå äõóðéóôßá. Óýìöùíá ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò, ðñÝðåé íá Ý÷ïõìå õðüøç ìáò üôé ç áõîçìÝíç ÁÐ äåí ãßíåôáé áéóèçôÞ ïýôå ðñïêáëåß óõìðôþìáôá. Ôá óõìðôþìáôá, üôáí õðÜñ÷ïõí, ïöåßëïíôáé óôéò åðéðëïêÝò ôçò ðïõ óõíÞèùò åðÝñ÷ïíôáé ìåôÜ áðü ðïëëÜ ÷ñüíéá. ÅðïìÝíùò, ç äéÜãíùóç ôçò ÁÕ âáóßæåôáé áðïêëåéóôéêÜ óôç ìÝôñçóç ôçò ÁÐ. ÅðåéäÞ, ôüóï óå öõóéïëïãéêÜ üóï êáé óå õðåñôáóéêÜ Üôïìá, ç ÁÐ ðáñïõóéÜæåé ìåãÜëç ìåôáâëçôüôçôá, ãéá ôç äéÜãíùóç ôçò ÁÕ ðñÝðåé íá ðñïóäéïñéóôåß ç óõíÞèçò ÁÐ ôïõ áôüìïõ, ðñÜãìá ðïõ áðáéôåß ôçí ôÞñçóç ïñéóìÝíùí êáíüíùí. ÐáñáèÝôïõìå óõíïðôéêÜ ìåñéêïýò áðü ôïõò êõñéüôåñïõò: • Ç ìÝôñçóç ôçò ÁÐ óôï éáôñåßï ãßíåôáé ìå óôçèïóêïðéêÞ ôå÷íéêÞ êáé áîéüðéóôï ðéåóüìåôñï (õäñáñãõñéêü, ìåôáëëéêü Þ çëåêôñïíéêü) ôï ïðïßï ðñÝðåé íá åëÝã÷åôáé áíÜ åîÜìçíï. • Ïé äéáóôÜóåéò ôïõ áåñïèáëÜìïõ ôçò ðåñé÷åéñßäïò ðñÝðåé íá åßíáé áíÜëïãåò ìå ôçí ðåñßìåôñï ôïõ âñá÷ßïíá ôïõ áññþóôïõ (ôï ìÞêïò ôïõ áåñïèáëÜìïõ íá êáëýðôåé ôïõëÜ÷éóôïí 80% ôçò ðåñéìÝôñïõ ôïõ âñá÷ßïíá – ðåñé÷åéñßäá ìå áåñïèÜëáìï ìÞêïõò 30-35 cm åßíáé êáôÜëëçëç ãéá ôïõò ðåñéóóüôåñïõò).

Ôüìïò 17, Ôåý÷ïò 3, 2005

Á. Áñâáíßôçò êáé óõí.

• Ï åîåôáæüìåíïò ðñÝðåé íá êÜèåôáé Þñåìïò ãéá ìåñéêÜ ëåðôÜ, ìå ôï âñá÷ßïíá õðïóôçñéæüìåíï êáé ôçí ðåñé÷åéñßäá óôï ýøïò ôçò êáñäéÜò. Óôç óõíÝ÷åéá ãßíïíôáé 2-3 ìåôñÞóåéò ìå ìåóïäéÜóôçìá 1-2 ëåðôÜ. Ç áðïóõìðßåóç ôçò ðåñé÷åéñßäïò ãßíåôáé ìå ñõèìü 2 mmHg áíÜ äåõôåñüëåðôï. • Óå áññþóôïõò õðü èåñáðåßá ãßíåôáé ìÝôñçóç êáé óå üñèéá èÝóç (éäßùò óôïõò äéáâçôéêïýò êáé ôïõò çëéêéùìÝíïõò) ãéá ôï åíäå÷üìåíï ïñèïóôáôéêÞò õðüôáóçò. • Ãéá ôç äéÜãíùóç ôçò ÁÕ áðáéôïýíôáé óõíÞèùò åðáíåéëçììÝíåò ìåôñÞóåéò ôçò ÁÐ óå äéáäï÷éêÝò åðéóêÝøåéò. Óå ðåñéðôþóåéò áõîçìÝíçò ÁÐ óôçí ðñþôç åðßóêåøç, ç åðéâåâáßùóç áðáéôåß ìåôñÞóåéò óå ôïõëÜ÷éóôïí äýï áêüìá åðéóêÝøåéò ìå ìåóïäéáóôÞìáôá ôïõëÜ÷éóôïí ìßáò åâäïìÜäáò. • ÊáôÜ êáíüíá, ç äéÜãíùóç ôçò ÁÕ êáé ç áðüöáóç ãéá Ýíáñîç áíôéûðåñôáóéêÞò èåñáðåßáò äåí ðñÝðåé íá âáóßæïíôáé óå ìåôñÞóåéò ðïõ ãßíïíôáé óå ìßá ìïíáäéêÞ åðßóêåøç. Ìå åîáßñåóç ôéò ðåñéðôþóåéò åðåßãïõóáò ÁÕ, áêüìá êáé óå Üôïìá ìå ìåãÜëç áýîçóç ôçò ÁÐ (óõóôïëéêÞ/äéáóôïëéêÞ >180/110 mmHg), õðÜñ÷åé óõíÞèùò ðåñéèþñéï ìåñéêþí çìåñþí ãéá åðáíåêôßìçóç ôçò ÁÐ êáé áîéïëüãçóç ôïõ áññþóôïõ ðñéí åöáñìïóôåß èåñáðåßá. ¼óï ðéï êïíôÜ óôï üñéï ôùí 140/90 mmHg âñßóêåôáé ç ÁÐ, ôüóï ðéï ðïëëÝò åðéóêÝøåéò ÷ñåéÜæïíôáé ãéá ôçí åðéâåâáßùóç ôçò äéÜãíùóçò. • Ï êßíäõíïò ãéá êáñäéáããåéáêü íüóçìá äåí åîáñôÜôáé ìüíï áðü ôï åðßðåäï ôçò ÁÐ, áëëÜ êáé áðü ôçí ðáñïõóßá Üëëùí ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ (äõóëéðéäáéìßá, êÜðíéóìá, äéáâÞôçò, ðá÷õóáñêßá), âëÜâçò óôá üñãáíá – óôü÷ïõò (õðåñôñïößá áñéóôåñÞò êïéëßáò, áèçñùìÜôùóç êáñùôßäùí, ëåõêùìáôïõñßá) Þ åãêáôåóôçìÝíçò êáñäéáããåéáêÞò âëÜâçò (óôåöáíéáßá íüóïò, åãêåöáëéêü åðåéóüäéï, íåöñéêÞ âëÜâç, ðåñéöåñéêÞ áñôçñéïðÜèåéá). • ÁíÜëïãá ìå ôï óôÜäéï ôçò ÁÕ êáé ôç óõíýðáñîç Üëëùí ðáñáãüíôùí êéíäýíïõ ôá õðåñôáóéêÜ Üôïìá äéá÷ùñßæïíôáé óå óõíÞèïõò, ìéêñïý, ìÝóïõ Þ ìåãÜëïõ êáñäéáããåéáêïý êéíäýíïõ. Åßíáé åìöáíÝò üôé Üôïìá ßäéïõ óôáäßïõ ÁÕ ìðïñåß íá äéáôñÝ÷ïõí ðïëý äéáöïñåôéêü êßíäõíï (ìéêñü, ìÝóï Þ ìåãÜëï). Ï

ðñïóäéïñéóìüò ôïõ óõíïëéêïý êéíäýíïõ åßíáé áðáñáßôçôïò óå êÜèå Üññùóôï, ðñïêåéìÝíïõ íá áðïöáóéóôïýí ç Ýíáñîç êáé ï óôü÷ïò ôçò èåñáðåßáò. Ôá ðáñáðÜíù äõóôõ÷þò ü÷é ìüíï äåí åßíáé êáèüëïõ ãíùóôÜ óå ðïëëïýò áóèåíåßò, éäßùò óå áõôïýò ôçò ïìÜäáò Ã, áëëÜ óôç èÝóç ôïõò õðÜñ÷åé ìéá åíôåëþò äéáöïñåôéêÞ (êáé ëáíèáóìÝíç) áíôßëçøç êáé íïïôñïðßá. Äõóôõ÷þò öïâïýìáóôå üôé äåí åßíáé ãíùóôÜ êáé óå áñêåôïýò óõíáäÝëöïõò éáôñïýò, ìå áðïôÝëåóìá íá ãßíïíôáé ëáíèáóìÝíïé ÷åéñéóìïß óôï èÝìá ôçò ðñüëçøçò êáé áíôéìåôþðéóçò ôçò ÁÕ. Áðü ôá áðïôåëÝóìáôá ôçò ÝñåõíÜò ìáò áíáäåéêíýåôáé ìéá óçìáíôéêÞ ðôõ÷Þ ôïõ èÝìáôïò ôçò äéá÷åßñéóçò ôçò ÁÕ óôçí åðáñ÷ßá: ôï 56,3% (ïìÜäåò Á êáé Ã) ôùí ðïëéôþí ðïõ ÷ñçóéìïðïéïýí ôéò õðçñåóßåò õãåßáò Ý÷ïõí ëáíèáóìÝíç áíôßëçøç êáé óôÜóç áðÝíáíôé óôï èÝìá, áöïý åßôå äåí åíäéáöÝñïíôáé êáèüëïõ ãéá ôç ìÝôñçóç ôçò ÁÐ (ïìÜäá Á) åßôå ôçí áíôéìåôùðßæïõí ðåñéóôáóéáêÜ êáé ôçò äßíïõí ìéá áëëïéùìÝíç áîßá (ïìÜäá Ã). Ïé ãéáôñïß ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò ðñÝðåé íá êåñäßóïõí ôçí åìðéóôïóýíç ôùí ðïëéôþí, þóôå íá áõîçèåß ç áðïäï÷Þ ôüóï ôçò ðñïëçðôéêÞò éáôñéêÞò óôçí êïéíùíßá (ïìÜäá Á), üóï êáé ôçò âáóéóìÝíçò óå áðïäåßîåéò éáôñéêÞò (ïìÜäá Ã). Äõóôõ÷þò ç åêðáßäåõóç ðïõ ëáìâÜíïõí ôá åëëçíüðïõëá óôá ó÷ïëåßá (óôïé÷åéþäçò, äåõôåñïâÜèìéá Þ ôñéôïâÜèìéá) öáßíåôáé üôé äåí ðñïóöÝñåé ôßðïôá óôï èÝìá áõôü, áöïý óôá áðïôåëÝóìáôÜ ìáò äåí Ý÷åé óõãêåêñéìÝíåò èåôéêÝò åðéðôþóåéò. ¼ëá áõôÜ áíáäåéêíýïõí ôçí áíÜãêç ãéá åíôáôéêüôåñç êáé óõóôçìáôéêÞ åíçìÝñùóç ôïõ ðëçèõóìïý áðü ôïõò ëåéôïõñãïýò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôá ðëáßóéá ôçò ÁãùãÞò Õãåßáò, þóôå íá ãßíåôáé ïñèïëïãéêüôåñç êáé áðïäïôéêüôåñç ÷ñÞóç ôùí õðçñåóéþí õãåßáò ðñïò üöåëïò ôïõ ðëçèõóìïý. Âéâëéïãñáößá 1. ÅëëçíéêÞ Åôáéñåßá ÌåëÝôçò ôçò ÕðÝñôáóçò. ÐñáêôéêÝò ÊáôåõèõíôÞñéåò Ïäçãßåò ãéá ôçí ÕðÝñôáóç. ÁèÞíá 2005. 2. 2003 European Society of Hypertension – European Society of Cardiology Guidelines for the Management of Arterial Hypertension. J Hypertens, 21:1011-1053, 2003. 3. Seventh Report of the Joint National Commit125

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tee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42:1206-1252, 2003. 2003 World Health Organization – International Society of Hypertension Statement on Management of Hypertension. J Hypertens, 21:19831992, 2003. ÌïõíôïêáëÜêçò È, Á÷åßìáóôïò Á, ÂáñóáìÞò Å, Æáìðïýëçò ×, ÊáñáôæÜò Í, ÐáðáäïãéÜííçò Ä, Óôåñãßïõ Ã. ÓõóôÜóåéò ãéá ôç äéÜãíùóç êáé ôç èåñáðåßá ôçò õðÝñôáóçò áðü ôïí êëéíéêü ãéáôñü. Ðñüãñáììá “Õãåßá ãéá ôïí Ðïëßôç”. Ïäçãßåò ÏñèÞò ÊëéíéêÞò ÐñÜîçò êáé Öáñìáêïèåñáðåßáò. Õðïõñãåßï Õãåßáò êáé Ðñüíïéáò, 2000. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics, 114:555-576, 2004. Stergiou GS, Thomopoulou GC, Skeva II, Mountokalakis TD. Prevalence, awareness, treatment, and control of hypertension in Greece. The Didima study. Am J Hypertens, 12:959-965, 1999. He J, Whelton PK. Elevated systolic blood pressure as a risk factor for cardiovascular and renal disease. J Hypertens, 17:S7-S13, 1999. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet, 360:1903-1913, 2002. Conroy R, Pyorala K, Fitzgerald A, Sans S, Menotti A, De Backer G, et al on behalf of the

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Ôüìïò 17, Ôåý÷ïò 3, 2005

Ö. Áñâáíßôç êáé óõí.

ÁÍÁÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 17, Number 3, 127-138, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 127-138, 2005

ÄéáôñïöÞ êáé áñôçñéáêÞ õðÝñôáóç: Ï ñüëïò ôçò ìåóïãåéáêÞò äéáôñïöÞò óôçí ðñüëçøç Ö. Áñâáíßôç1, Ä.Â. ÐáíáãéùôÜêïò2, P. Kokkinos3, ×ñ. Ðßôóáâïò4

Ðåñßëçøç Ç äéáôñïöÞ áðïôåëåß Ýíáí áðü ôïõò óçìáíôéêüôåñïõò ðáñÜãïíôåò êéíäýíïõ ãéá êáñäéáããåéáêÝò ðáèÞóåéò êáé ó÷åôßæåôáé êáé ìå Üëëïõò ìåôáâïëéêïýò ðáñÜãïíôåò êéíäýíïõ üðùò åßíáé ï äéáâÞôçò, ç õøçëÞ áñôçñéáêÞ ðßåóç êáé ç ðá÷õóáñêßá. Ïé ðéï ðñüóöáôåò ïäçãßåò óõóôÞíïõí Ýëåã÷ï ôïõ óùìáôéêïý âÜñïõò, ìåßùóç ôçò ðñüóëçøçò ÷ëùñéïý÷ïõ íáôñßïõ, ðåñéïñéóìü ôçò êáôáíÜëùóçò ïéíïðíåýìáôïò êáé áýîçóç ôçò ðñüóëçøçò êáëßïõ êáé öõôéêþí éíþí ùò äéáôñïöéêÞ ðñïóÝããéóç óôçí ðñüëçøç êáé áíôéìåôþðéóç ôçò õðÝñôáóçò. Ç ìåãáëýôåñç ìåßùóç ôçò áñôçñéáêÞò ðßåóçò Ý÷åé ó÷åôéóèåß ìå ôçí ôñïðïðïßçóç ïëüêëçñçò ôçò äéáôñïöÞò êáé ü÷é ìåìïíùìÝíùí äéáôñïöéêþí óõóôáôéêþí. Ç ÌåóïãåéáêÞ äéáôñïöÞ Ý÷åé áðïäå÷èåß ùò ðñïóôáôåõôéêü äéáôñïöéêü ðñüôõðï åíÜíôéá óôç óôåöáíéáßá íüóï. Åêôüò áðü ôç õøçëÞ ðåñéåêôéêüôçôÜ ôçò óå ëá÷áíéêÜ êáé ëßðïò, êõñßùò ìïíïáêüñåóôï ëßðïò (ìå ôï åëáéüëáäï ùò êýñéá ðçãÞ), Ýíá Üëëï óçìáíôéêü óõóôáôéêü åßíáé ç õøçëÞ êáôáíÜëùóç öñïýôùí êáé ëá÷áíéêþí, ç ïðïßá åîáóöáëßæåé ôçí õøçëÞ ðñüóëçøç â-êáñïôÝíéïõ, âéôáìéíþí C êáé Å, ðïëõöáéíïëþí êáé ðïéêßëùí ìåôÜëëùí. ÁõôÜ åßíáé ôá óçìåßá êëåéäéÜ, üðùò Ý÷åé õðïäåé÷èåß, ðïõ åßíáé õðåýèõíá ãéá ôçí åõåñãåôéêÞ åðßäñáóç ôçò óõãêåêñéìÝíçò äéáôñïöÞò óôéò êáñäéïðÜèåéåò. Åðßóçò ç äßáéôá DASH (Dietary Approaches to Stop Hypertension) áðïäåéêíýåé üôé ìéá äßáéôá ðëïýóéá óå öñïýôá, ëá÷áíéêÜ, ãáëáêôïêïìéêÜ ÷áìçëÜ óå ëßðïò, öõôéêÝò ßíåò êáé ìÝôáëëá (áóâÝóôéï, êÜëéï, ìáãíÞóéï), Ý÷åé éó÷õñÞ áíôéõðåñôáóéêÞ åðßäñáóç. Ïé ìç öáñìáêåõôéêÝò ðáñåìâÜóåéò, üðùò åßíáé ç äéáôñïöÞ, áðïôåëïýí ðñüêëçóç óôçí ðñüëçøç ôçò õðÝñôáóçò.

1 ÊëéíéêÞ Äéáéôïëüãïò, ÂïõëÞ ôùí ÅëëÞíùí, 2ËÝêôïñáò ÂéïóôáôéóôéêÞò – Åðéäçìéïëïãßáò, ÔìÞìá ÅðéóôÞìçò Äéáéôïëïãßáò ÄéáôñïöÞò, ×áñïêüðåéï ÐáíåðéóôÞìéï, 3ÁíáðëçñùôÞò ÊáèçãçôÞò ÉáôñéêÞò, ÉáôñéêÞ Ó÷ïëÞ, Veterans Affairs Medical Center, Georgetown University, Washington DC, USA, 4ÁíáðëçñùôÞò ÊáèçãçôÞò Êáñäéïëïãßáò, ÉáôñéêÞ Ó÷ïëÞ, Ðáíåðéóôçìßïõ Áèçíþí

ÅéóáãùãÞ Ç ÷ñüíéá õðÝñôáóç áðïôåëåß Ýíáí áðü ôïõò êõñéüôåñïõò ðáñÜãïíôåò êéíäýíïõ áíÜðôõîçò êáñäéáããåéáêþí ðáèÞóåùí, üðùò óôåöáíéáßá íüóïò, áããåéáêü åãêåöáëéêü åðåéóüäéï êáé êáñäéáêÞ áíåðÜñêåéá, êáé óõíéóôÜ Ýíá áðü ôá ìåãáëýôåñá ðñïâëÞìáôá õãåßáò óôéò áíåðôõãìÝíåò ÷þñåò. Ï Ðáãêüóìéïò Ïñãáíéóìüò Õãåßáò áíáöÝñåé üôé ï áñéèìüò ôùí õðåñôáóéêþí áôüìùí ðáãêïóìßùò êõìáßíåôáé óôá 600 åêáôïììýñéá1. Áðü ôá Üôïìá áõôÜ ôá 3 åêáôïììýñéá áíáìÝíåôáé üôé èá ðåèÜíïõí ùò áðïôÝëåóìá ôçò õðÝñôáóçò åôçóßùò. Óôçí ÅëëÜäá ï åðéðïëáóìüò ôçò áñôçñéáêÞò õðÝñôáóçò õðïëïãßæåôáé íá åßíáé ãýñù óôï 38% óôïõò Üíäñåò êáé 24% óôéò ãõíáßêåò óýìöùíá ìå ðñüóöáôá óôïé÷åßá åðéäçìéïëïãéêþí ìåëåôþí2,3. ÃåíéêÜ, åêôéìÜôáé åðßóçò üôé ìüíï ôá ìéóÜ õðåñôáóéêÜ Üôïìá åßíáé åíÞìåñá ôçò êáôÜóôáóÞò ôïõò ËÝîåéò êëåéäéÜ: ÄéáôñïöÞ, áñôçñéáêÞ õðÝñôáóç, ìåóïãåéáêÞ äéáôñïöÞ, ðñüëçøç ÕðïâëÞèçêå: 15 Ïêôùâñßïõ 2004 ÅðáíõðïâëÞèçêå: 24 Íïåìâñßïõ 2004 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 21 Éáíïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ÄçìïóèÝíçò ÐáíáãéùôÜêïò, ËÝêôïñáò ÂéïóôáôéóôéêÞò Åðéäçìéïëïãßáò, ×áñïêüðåéï ÐáíåðéóôÞìéï, Äéåýèõíóç: ÈçóÝùò 70, Ô.Ê. 17671 ÁèÞíá, Ôçë.: (210) 9549332, e-mail: dbanag@hua.gr 127

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ö. Áñâáíßôç êáé óõí.

ðñüóëçøç ëßðïõò <35% ôçò åíÝñãåéáò12,13, óôç ÷áñáêôçñéóôéêÞ êñçôéêÞ ìåóïãåéáêÞ äéáôñïöÞ üðùò áõôÞ ðåñéãñÜöçêå óôç ÌåëÝôç ôùí 7 ×ùSummary Diet and nutrition have been extensively investigated as risk factors for major ñþí, ç óõíïëéêÞ ðñüóëçøç ëßðïõò Þôáí cardiovascular diseases and are also linked to other metabolic risk factors, like ðåñßðïõ ôï 40% ôçò åíÝñãåéáò áëëÜ diabetes, high blood pressure and obesity. Current guidelines recommend weigðáñÝìåíå ÷áìçëÞ ç ðñüóëçøç êïñåht control, reduced intake of sodium chloride, reduced alcohol consumption, and óìÝíùí ëéðáñþí ïîÝùí14. Ôçí ôåëåõpossibly increased dietary potassium and fibre as nutritional approaches to ôáßá äåêáåôßá Ýíáò ìåãÜëïò áñéèìüò prevent and treat hypertension. The most appealing reductions in blood pressure have been related to the modification of whole diets and not with the ìåëåôþí óõó÷åôßæåé ôç óõììüñöùóç óå administration of separated nutrient supplements. The Mediterranean diet has ìéá ìåóïãåéáêïý ôýðïõ äéáôñïöÞ ìå been postulated as a protective pattern against coronary heart disease. In ôç óõíïëéêÞ èíçóéìüôçôá, êáèþò åðßaddition to a high vegetable-fat content, mainly from monounsaturated fatty óçò êáé ôç óôåöáíéáßá íüóï êáé êÜacids (with olive oil as the main source), another major component of this ðïéåò ìïñöÝò êáñêßíïõ14-17. dietary pattern is the consumption of large quantities of fruit and vegetables that guarantee a high intake of b-carotene, vitamins C and E, polyphenols and Óôï óõãêåêñéìÝíï Üñèñï óõíïøßvarious important minerals. These key elements have been suggested to be æïíôáé ïé äéáôñïöéêÝò ïäçãßåò ãéá ôïí responsible for the beneficial effect of diet on cardiovascular disease. In additÝëåã÷ï ôçò áñôçñéáêÞò ðßåóçò, êáèþò ion the Dietary Approaches to Stop Hypertension (DASH) demonstrates that a åðßóçò ðáñïõóéÜæïíôáé åõñÞìáôá áðü diet rich in fruits, vegetables, low-fat dairy products, fibre and minerals (calcium, ìåëÝôåò ôá ïðïßá åêôéìïýí ôçí áðïôåpotassium, magnesium) produces a potent antihypertensive effect. Non-pharmacological interventions, like diet, seem extremely challenging in the prevention ëåóìáôéêüôçôá äéáéôçôéêþí ðñïóåããßof hypertension. óåùí, üðùò ãéá ðáñÜäåéãìá ç äßáéôá Key words: Nutrition, blood hypertention DASH (Dietary Approaches to Stop Hypertension) êáé ç ìåóïãåéáêÞ äéáêáé áðü áõôÜ ìüíï ïé ìéóïß âñßóêïíôáé õðü èåñá- ôñïöÞ óôï óýíïëü ôçò, óôçí ðñüëçøç ôçò ÷ñüðåßá. Åðéðñüóèåôá, ìüíï ôá ìéóÜ áðü ôá äéáãíù- íéáò õðÝñôáóçò. óìÝíá õðåñôáóéêÜ Üôïìá ðïõ âñßóêïíôáé õðü èåñáðåßá åðéôõã÷Üíïõí ôá åðéèõìçôÜ åðßðåäá áñôçñéáêÞò ðßåóçò. Óõíåðþò, óôçí êáëýôåñç ðå- Äßáéôá êáé õðÝñôáóç ñßðôùóç, ôï 12,5% ôïõ óõíüëïõ ôùí õðåñôáóéêþí åßíáé åðáñêþò åëåã÷üìåíï1-5. Óýã÷ñïíåò áðüÏé ðñüóöáôåò óõóôÜóåéò áðü ôï National øåéò õðïãñáììßæïõí üôé ç áëëáãÞ ôïõ ôñüðïõ High Blood Pressure Education Program óõóôÞæùÞò ìðïñåß íá óõíåéóöÝñåé äõíáìéêÜ óôçí ðñü- íïõí ðåñéïñéóìü ôïõ íáôñßïõ êáé ôçò ðñüóëçøçò ëçøç ôçò ÷ñüíéáò õðÝñôáóçò êáèþò åðßóçò êáé áëêïüë, êáèþò åðßóçò áýîçóç ôçò ðñüóëçøçò óôçí åðáíáöïñÜ, óå öõóéïëïãéêÜ åðßðåäá, ôçò êáëßïõ êáé ìáãíçóßïõ5. áõîçìÝíçò áñôçñéáêÞò ðßåóçò5. Ìåôáîý ôùí áëëáãþí óôïí ôñüðï æùÞò, ïé åõåñãåôéêÝò åðéäñÜóåéò ôçò äéáôñïöÞò óôçí õãåßá ÍÜôñéï ôïõ áíèñþðïõ Ý÷ïõí õðïäåé÷èåß óå áñêåôÝò ìåëÝôåò6-11. Ðéï óõãêåêñéìÝíá, ôï National High Blood Ï ðñþôïò óõó÷åôéóìüò ôïõ ÷ëùñéïý÷ïõ íáPressure Education Program óõóôÞíåé ìç öáñ- ôñßïõ ìå ôçí õðÝñôáóç Ýãéíå ðñéí áðü ðåñßðïõ ìáêåõôéêÞ ðáñÝìâáóç, üðùò ç õãéåéíÞ äéáôñïöÞ, 100 ÷ñüíéá üðïõ ðáñáôçñÞèçêå áýîçóç ôçò áñç áðþëåéá âÜñïõò êáé ç öõóéêÞ äñáóôçñéüôçôá, ôçñéáêÞò ðßåóçò ìå ôçí áýîçóç ôçò ðñüóëçøçò ãéá ôçí ðñùôïãåíÞ êáé äåõôåñïãåíÞ ðñüëçøç ôçò íáôñßïõ, åíþ ìåßùóÞ ôïõ ïäçãïýóå óå áíôßèåôï õðÝñôáóçò. Ôá ôåëåõôáßá ÷ñüíéá õðÜñ÷ïõí åðé- áðïôÝëåóìá18. ¸êôïôå ðïëëïß åñåõíçôÝò áó÷ïëÞóôçìïíéêÝò åíäåßîåéò üôé ç äéáôñïöÞ ç ïðïßá åß- èçêáí ìå ôçí ðñüóëçøç íáôñßïõ (Na) êáé êáôÝíáé ðëïýóéá óå öñïýôá, ëá÷áíéêÜ, üóðñéá, óéôç- ëçîáí óôï óõìðÝñáóìá üôé ç õðåñâïëéêÞ ðñüóëçñÜ ïëéêÞò áëÝóåùò, øÜñé, îçñïýò êáñðïýò êáé øç ðñïêáëåß õðÝñôáóç19. Ç áýîçóç óôçí áñôçãáëáêôïêïìéêÜ ðñïúüíôá ìå ÷áìçëÜ ëéðáñÜ, Ý÷åé ñéáêÞ ðßåóç åìöáíßæåôáé üôáí ôá Üôïìá ôá ïðïßá åõåñãåôéêÝò åðéäñÜóåéò óôçí õãåßá. ÐÜíôùò, áí áêïëïõèïýí äéáôñïöÞ ÷áìçëÞ óå Na êáé Ý÷ïõí êáé ïé ðñüóöáôåò ïäçãßåò óõóôÞíïõí óõíïëéêÞ öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç, ðñïóáñìüæïõí ôç Nutrition and blood hypertension: The role of mediterrenean diet in prevention F. Árvaniti, D.Â. Panagiotakos, P. Kokkinos, C. Pitsavos

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Ö. Áñâáíßôç êáé óõí.

æùÞ ôïõò óôïí äõôéêü ôñüðï æùÞò êáé áõîÜíïõí ôçí ðñüóëçøç Na20,21. ÐÜíôùò, óôéò óõãêåêñéìÝíåò ìåëÝôåò óõã÷õôéêïß ðáñÜãïíôåò, üðùò ìéêñüôåñï ðïóïóôü ðá÷õóáñêßáò, õøçëÜ åðßðåäá öõóéêÞò äñáóôçñéüôçôáò êáé ßóùò ëéãüôåñï ðéåóôéêüò ôñüðïò æùÞò, äåí ëÞöèçêáí õðüøç. Åðßóçò, äéÜöïñåò ðåéñáìáôéêÝò Ýñåõíåò õðïäåéêíýïõí üôé ï ðåñéïñéóìüò íáôñßïõ óå õðåñôáóéêïýò áóèåíåßò ìåéþíåé ôçí áñôçñéáêÞ ðßåóç22,23. Ìéá ìåëÝôç ðïõ ðñáãìáôïðïéÞèçêå õðÝäåéîå üôé ìéá äéáöïñÜ óôçí ðñüóëçøç íáôñßïõ ôçò ôÜîåùò ôùí 100 mmol áíÜ çìÝñá óõó÷åôßóôçêå ìå ìÝóç äéáöïñÜ óôç óõóôïëéêÞ ðßåóç êáôÜ 5 mmHg óå çëéêßåò áðü 15 Ýùò 19 åôþí êáé 10 mmHg óå çëéêßåò áðü 50 Ýùò 69 åôþí24. H ìåßùóç ôçò äéáóôïëéêÞò ðßåóçò áõîáíüôáí áíáëüãùò ôçò çëéêßáò êáé ó÷åôéæüôáí ìå ôçí áñ÷éêÞ áñôçñéáêÞ ðßåóç. Óôçí ßäéá ìåëÝôç åêôéìÞèçêå üôé ìéá óõíïëéêÞ ìåßùóç óôçí ðñüóëçøç áëáôéïý êáôÜ 50 mmol áíÜ çìÝñá èá ìðïñïýóå íá ïäçãÞóåé óå ìåßùóç êáôÜ 50% ôïõ áñéèìïý ôùí áôüìùí ðïõ áðáéôïýí áíôéõðåñôáóéêÞ èåñáðåßá, 22% ìåßùóç ôïõ áñéèìïý ôùí èáíÜôùí ðïõ ïöåßëïíôáé óå åãêåöáëéêÜ êáé 16% ìåßùóç ôïõ áñéèìïý ôùí èáíÜôùí áðü óôåöáíéáßá íüóï. Ìéá ìåãÜëç ìåëÝôç, ç INTERSALT, ìåëÝôçóå 10.000 åíÞëéêåò çëéêßáò 20-59 åôþí, áðü 52 êÝíôñá óå ïëüêëçñï ôïí êüóìï, êáé õðÝäåéîå üôé õðÜñ÷åé éó÷õñÞ óõó÷Ýôéóç ìåôáîý ôïõ ðñïóëáìâáíüìåíïõ Na êáé ôçò áñôçñéáêÞò ðßåóçò. Ðéï óõãêåêñéìÝíá ìéá äéáöïñïðïßçóç óôçí ðñüóëçøç ÷ëùñéïý÷ïõ íáôñßïõ êáôÜ 6 g, åß÷å ùò áðïôÝëåóìá ìåôáâïëÞ óôç óõóôïëéêÞ ðßåóç êáôÜ 3-6 mmHg25. Ìéá ôõ÷áéïðïéçìÝíç êëéíéêÞ Ýñåõíá, õðÝäåéîå üôé áóèåíåßò ìå õøçëÜ öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç, ïé ïðïßïé ðåñéüñéóáí óå ìÝôñéï âáèìü ôçí ðñüóëçøç íáôñßïõ ãéá 1,5 Ýùò 5 ÷ñüíéá åß÷áí ÷áìçëüôåñç áñôçñéáêÞ ðßåóç êáé ëéãüôåñá ðåñéóôáôéêÜ åìöÜíéóçò õðÝñôáóçò óå ó÷Ýóç ìå åêåßíïõò ïé ïðïßïé äåí ðñáãìáôïðïßçóáí áëëáãÞ óôçí ðñüóëçøç íáôñßïõ26. Áí êáé ôá åðéäçìéïëïãéêÜ êáé ðåéñáìáôéêÜ åõñÞìáôá õðïóôçñßæïõí ôï äõóìåíÞ ñüëï ôçò õðåñâïëéêÞò ðñüóëçøçò íáôñßïõ óôçí õðÝñôáóç, ìüíï ôï ìéóü ôïõ ðëçèõóìïý óôéò äõôéêÝò êïéíùíßåò (óôéò ïðïßåò åðéêñáôåß ç êáôáíÜëùóç íáôñßïõ) áíáðôýóóåé õðÝñôáóç. Ôï ãåãïíüò áõôü õðïäåéêíýåé üôé ïñéóìÝíïé ìðïñåß íá ðáñïõóéÜæïõí åõáéóèçóßá óôï íÜôñéï Þ üôé ç áðÝêêñéóç íáôñßïõ ìðïñåß íá åßíáé åëáôôùìÝíç27. ÌåéùìÝíç íåöñéêÞ áðÝêêñéóç íáôñßïõ öáßíåôáé íá ðáñïõóéÜæåôáé óå áñïõñáßïõò

Ôüìïò 17, Ôåý÷ïò 3, 2005

åõáßóèçôïõò óôï áëÜôé Þ óå áíåêôéêïýò óôçí õðåñôáóéêÞ äñÜóç ôçò áõîáíüìåíçò äéáéôçôéêÞò ðñüóëçøçò íáôñßïõ. Ðéï óõãêåêñéìÝíá, üôáí ï íåöñüò áðü Ýíáí áñïõñáßï ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç ìåôáìïó÷åýôçêå óå Ýíáí õðåñôáóéêü áñïõñáßï, ç áñôçñéáêÞ ðßåóç Ýðåóå óå öõóéïëïãéêÜ åðßðåäá. ÁíôéèÝôùò, üôáí Ýíáò áñïõñáßïò ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç Ýëáâå íåöñü áðü õðåñôáóéêü áñïõñáßï, ç áñôçñéáêÞ ðßåóç áõîÞèçêå28. Ç ìåéùìÝíç áðÝêêñéóç íáôñßïõ óå åðßðåäï óùëçíáñßùí ìðïñåß êáé áõôÞ íá óõíåéóöÝñåé óôçí áíÜðôõîç õðÝñôáóçò ìå äéÜöïñïõò ôñüðïõò. ÏñéóìÝíïé åñåõíçôÝò ðéóôåýïõí üôé ç êáôáêñÜôçóç íáôñßïõ ïäçãåß óå êáôáêñÜôçóç íåñïý áõîÜíïíôáò ôïí üãêï áßìáôïò. Ôï ãåãïíüò áõôü áõîÜíåé ôçí êáñäéáêÞ ðáñï÷Þ ìå áðïôÝëåóìá ôçí áõîçìÝíç áñôçñéáêÞ ðßåóç29. ¢ëëïé ðéóôåýïõí üôé ôï áõîçìÝíï íÜôñéï ìðïñåß íá áõîÞóåé ôç äñáóôçñéüôçôá ôïõ óõìðáèçôéêïý ç ïðïßá åíéó÷ýåé ôçí áããåéïóõóôïëÞ êáé ôåëéêÜ áíáðôýóóåôáé õðÝñôáóç30. ÐÜíôùò ï ñüëïò ôïõ íáôñßïõ óôçí ðáèïãÝíåóç ôçò õðÝñôáóçò Ý÷åé äçìéïõñãÞóåé áíôéðáñáèÝóåéò. Ðéï ðñüóöáôá óå ìéá ìåôá-áíÜëõóç ç ïðïßá ðåñéëÜìâáíå 56 ôõ÷áéïðïéçìÝíåò äïêéìÝò êëéíéêÝò ìåëÝôåò, ï Midgley êáé óõí. êáôÝëçîáí üôé ôï äéáéôçôéêü íÜôñéï ìðïñåß íá Ý÷åé ïñéóìÝíåò èåôéêÝò åðéäñÜóåéò óå õðåñôáóéêïýò çëéêßáò ðÜíù áðü 45 åôþí31. ÐÜíôùò õðÜñ÷åé ç Üðïøç üôé Üôïìá ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç äåí Ý÷ïõí üöåëïò áðü ôïí ðåñéïñéóìü ôçò ðñüóëçøçò íáôñßïõ, üóïí áöïñÜ ôçí ðåñáéôÝñù ìåßùóç ôçò áñôçñéáêÞò ðßåóçò. ÁõôÞ ç Üðïøç åíéó÷ýåôáé áðü ôá åõñÞìáôá ôçò ìåãáëýôåñçò Ýñåõíáò ðïõ Ý÷åé ðñáãìáôïðïéçèåß ãéá ôçí åêôßìçóç ôïõ ñüëïõ ôïõ ðåñéïñéóìïý íáôñßïõ óôïí Ýëåã÷ï ôçò áñôçñéáêÞò ðßåóçò êáé óôçí ðñüëçøç ôçò õðÝñôáóçò32. Áíôßèåôá, ìéá ðñüóöáôç ìåëÝôç, õðÝäåéîå üôé ìÝôñéá êáôáíÜëùóç íáôñßïõ (<2400 mg ôçí çìÝñá) ðåñéüñéóå ôïí êßíäõíï åìöÜíéóçò õðÝñôáóçò êáôÜ 30% óå Üôïìá ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç êáé 52% óå õðåñôáóéêÜ Üôïìá ÷ùñßò öáñìáêåõôéêÞ áãùãÞ33. Öáßíåôáé åðïìÝíùò üôé ôïõëÜ÷éóôï ùò ðñïò ôï ãåíéêü ðëçèõóìü ç óõíéóôþìåíç çìåñÞóéá ðñüóëçøç áëáôéïý ðñÝðåé íá êõìáßíåôáé óôá 5 g (áíþôåñç ðñüóëçøç) êáé íáôñßïõ <2400 mg34. ÕðÜñ÷ïõí âÝâáéá åñùôçìáôéêÜ ó÷åôéêÜ ìå ôéò óõóôÜóåéò óôï ãåíéêü ðëçèõóìü óå üôé áöïñÜ ôçí ðñüëçøç ôçò õðÝñôáóçò, ùóôüóï ùò ãåíéêÞ óýóôáóç éó÷ýåé ç áíáöåñüìåíç. Ìéá ôÝôïéá ðñüó129

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ëçøç ìðïñåß íá åðéôåõ÷èåß ìå áðïöõãÞ éäéáßôåñá áëáôéóìÝíùí ôñïöþí (áëëáíôéêÜ, ðáóôÜ) êáé ôñïöþí ìå óõíôçñçôéêÜ, ðåñéïñéóìü ÷ñÞóçò åðéôñáðÝæéïõ áëáôéïý, ìåßùóç ôçò êáôáíÜëùóçò ôùí åðåîåñãáóìÝíùí ôñïößìùí êáé ðñïôßìçóç ôùí öõóéêþí (öñÝóêá öñïýôá êáé ëá÷áíéêÜ).

ÊÜëéï ÅõñÞìáôá áðü ðëçèõóìéáêÝò ìåëÝôåò õðïäåéêíýïõí ìéá áíôßóôñïöç óõó÷Ýôéóç ìåôáîý ôçò ðñüóëçøçò êáëßïõ êáé ôçò áñôçñéáêÞò ðßåóçò. Ç ÷áìçëÞ ðñüóëçøç êáëßïõ ìðïñåß íá ïäçãÞóåé óå áýîçóç ôçò áñôçñéáêÞò ðßåóçò35-38. Ïé óõó÷åôßóåéò áõôÝò öáßíåôáé íá åßíáé ðéï éó÷õñÝò óå áóèåíåßò ïé ïðïßïé ðñïóëáìâÜíïõí õøçëÝò ðïóüôçôåò íáôñßïõ. ¸íáò óçìáíôéêüò áñéèìüò åñåõíçôþí êáôÝëçîå óôï óõìðÝñáóìá üôé ç áýîçóç ôçò ðñüóëçøçò êáëßïõ åß÷å ùò áðïôÝëåóìá ôç ìåßùóç ôùí åðéðÝäùí ôçò óõóôïëéêÞò ðßåóçò êáôÜ 5,9 mmHg êáé ôçò äéáóôïëéêÞò êáôÜ 3,4 mmHg40. ¢ëëåò ìåëÝôåò áíáöÝñïõí üôé ï óçìáíôéêüò ðåñéïñéóìüò, ãéá ìéêñü ÷ñïíéêü äéÜóôçìá, ôçò ðñüóëçøçò êáëßïõ åß÷å ùò áðïôÝëåóìá ôç äçìéïõñãßá åõáéóèçóßáò óôï áëÜôé óå íïñìïôáóéêÜ Üôïìá39, êáèþò åðßóçò ìåßùóç ôçò áñôçñéáêÞò ðßåóçò ìåôÜ áðü óõìðëÞñùìá êáëßïõ óôç äéáôñïöÞ, óå õðåñôáóéêÜ Üôïìá40. Ðéèáíïß ìç÷áíéóìïß óýìöùíá ìå ôïõò ïðïßïõò ç õøçëÞ ðñüóëçøç êáëßïõ ìåéþíåé ôçí áñôçñéáêÞ ðßåóç åßíáé: á) áýîçóç ôçò áðÝêêñéóçò íáôñßïõ, â) áíáóôïëÞ ôçò Ýêêñéóçò ñåíßíçò, ã) áíôáãùíéóìüò ôçò áããåéóõóðáóôéêÞò äñÜóçò ôçò áããåéïôåíóßíçò ÉÉ êáé áããåéïäéáóôïëÞ, ä) áýîçóç ôçò åíäïèçëéïåîáñôþìåíçò áããåéïäéáóôïëÞò, å) ìåßùóç ôçò ðáñáãùãÞò èñïìâïîÜíçò (áããåéïóõóðáóôéêÞ ïõóßá) êáé óô) áýîçóç ôçò ðáñáãùãÞò êáëéäßíçò ðïõ ðñïêáëåß áããåéïäéáóôïëÞ41. Ãåíéêüôåñá ìéá äéáôñïöÞ ðëïýóéá óå öñïýôá êáé ëá÷áíéêÜ åßíáé ðñïôéìüôåñç áðü óõìðëçñþìáôá ëüãù ôïõ üôé ïé ôñïöÝò ðåñéÝ÷ïõí êáé Üëëá óõóôáôéêÜ, üðùò áóâÝóôéï, âéôáìßíåò êáé ìáãíÞóéï, ôá ïðïßá åßíáé ðéèáíü íá Ý÷ïõí åõåñãåôéêÞ åðßäñáóç óôçí áñôçñéáêÞ ðßåóç. Ôá óõìðëçñþìáôá êáëßïõ ìðïñåß íá Ý÷ïõí áñíçôéêÝò åðéðôþóåéò óå ïñéóìÝíïõò áóèåíåßò üðùò åßíáé ïé äéáâçôéêïß Þ ôá Üôïìá ìå íåöñéêÞ áíåðÜñêåéá. H çìåñÞóéá ðñüóëçøç ôïõ êáëßïõ ðñÝðåé íá êõìáßíåôáé áðü 3 Ýùò 3,5 g ìå ôáõôü÷ñïíï ðåñéïñéóìü íáôñßïõ. Ç ðïóüôçôá áõôÞ ðñÝðåé íá ðñïÝñ÷åôáé 130

Ö. Áñâáíßôç êáé óõí.

áðü öñÝóêá öñïýôá êáé ëá÷áíéêÜ ôá ïðïßá ðåñéÝ÷ïõí ìåãÜëåò ðïóüôçôåò êáëßïõ.

ÌáãíÞóéï Ëßãåò åðéäçìéïëïãéêÝò ìåëÝôåò Ý÷ïõí äåßîåé ìéá áñíçôéêÞ óõó÷Ýôéóç ìåôáîý ôçò áñôçñéáêÞò ðßåóçò êáé ôçò äéáéôçôéêÞò ðñüóëçøçò ìáãíçóßïõ. ÐÜíôùò ïé êáëÜ ó÷åäéáóìÝíåò ôõ÷áéïðïéçìÝíåò ìåëÝôåò åßíáé åëÜ÷éóôåò êáé ôá åõñÞìáôÜ ôïõò áëëçëïóõãêñïõüìåíá42-45. ÁðïôåëÝóìáôá ìåëåôþí äåß÷íïõí üôé ï ðåñéïñéóìüò ìðïñåß íá óõìâáßíåé ìüíï óå áóèåíåßò ìå ÷áìçëÜ åðßðåäá ìáãíçóßïõ44,45. Ðñüóöáôá óôïé÷åßá õðïäåéêíýïõí üôé ïé åíäïêõôôáñéêÝò óõãêåíôñþóåéò ôïõ ìáãíçóßïõ ìðïñåß íá áðïôåëïýí ôï êëåéäß ãéá ôç äéáôÞñçóç öõóéïëïãéêïý ôüíïõ ôùí áããåßùí êáé ôçò áðïññüöçóçò ãëõêüæçò ðïõ åîáñôÜôáé áðü ôçí éíóïõëßíç45. Ç ìåßùóç ôïõ åíäïêõôôÜñéïõ ìáãíçóßïõ ìðïñåß íá åîçãåß ôç ó÷Ýóç ìåôáîý áíôßóôáóçò ôçò éíóïõëßíçò êáé õðÝñôáóçò. Ïé ðéèáíïß ìç÷áíéóìïß äñÜóçò ôïõ ìáãíçóßïõ åßíáé: á) ìåßùóç ôïõ áããåéáêïý ôüíïõ, ðéèáíüôáôá ìåéþíïíôáò ôçí ðñüóëçøç áóâåóôßïõ áðü ôá êýôôáñá êáé â) åíåñãïðïßçóç ôçò ðáñáãùãÞò ðñïóôáãëáíäßíçò-É2 (áããåéïäéáóôáëôéêÞ ïõóßá)41. Åîáéôßáò ôùí áíåðáñêþí äåäïìÝíùí äåí õðÜñ÷ïõí óõãêåêñéìÝíåò óõóôÜóåéò ãéá ôçí ðñüóëçøç ìáãíçóßïõ.

ÁóâÝóôéï ÁðïôåëÝóìáôá áðü åðéäçìéïëïãéêÝò ìåëÝôåò õðïäåéêíýïõí ôïí áõîçìÝíï åðéðïëáóìü ôçò õðÝñôáóçò óå ó÷Ýóç ìå ôç ìåéùìÝíç äéáéôçôéêÞ ðñüóëçøç áóâåóôßïõ46. Ç èåùñçôéêÞ âÜóç ãéá ôï ñüëï ôïõ áóâåóôßïõ óôçí ðáèïãÝíåóç ôçò õðÝñôáóçò óôçñßæåôáé óôïí êåíôñéêü ñüëï ðïõ äéáäñáìáôßæåé ôï áóâÝóôéï óôç ñýèìéóç ôçò óõóôïëÞò ôùí ëåßùí ìõúêþí éíþí ôùí áããåßùí. Ïé áëëáãÝò óôç óõóôïëÞ ôùí ëåßùí ìõúêþí éíþí åßíáé áðïôÝëåóìá áíùìáëéþí óôï ìåôáâïëéóìü ôïõ áóâåóôßïõ êáé ôï ãåãïíüò áõôü ìðïñåß íá áõîÞóåé ôçí ðåñéöåñéêÞ áíôßóôáóç ìå áðïôÝëåóìá ôçí áýîçóç ôçò áñôçñéáêÞò ðßåóçò. Åðéðñüóèåôá, ïé ðåñéóóüôåñåò, áëëÜ ü÷é üëåò, ïé ìåëÝôåò ðáñáôÞñçóáí ìåßùóç óôçí áñôçñéáêÞ ðßåóç óå õðåñôáóéêïýò áóèåíåßò ðïõ ëÜìâáíáí óõìðëçñþìáôá áóâåóôßïõ47,48. Äýï ðñüóöáôåò ìåôá-áíáëýóåéò áðü ôõ÷áéïðïéçìÝíåò êëé-

Ôüìïò 17, Ôåý÷ïò 3, 2005

Ö. Áñâáíßôç êáé óõí.

íéêÝò äïêéìÝò óõìðëçñùìÜôùí áóâåóôßïõ õðÝäåéîáí ìéêñÞ, áëëÜ óôáèåñÞ, ìåßùóç ôçò áñôçñéáêÞò ðßåóçò óå Üôïìá ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç êáé õðåñôáóéêïýò áóèåíåßò ðïõ áýîçóáí ôçí ðñüóëçøç áóâåóôßïõ49,50. ÐÜíôùò, ç ìÝôñéá ìåßùóç ôçò óõóôïëéêÞò ðßåóçò ðñïóäéïñßóôçêå óå áõôÝò ôéò äýï ìåôá-áíáëýóåéò áëëÜ äåí äéêáéïëïãÞèçêå ç ÷ñÞóç óõìðëçñùìÜôùí áóâåóôßïõ óôïí Ýëåã÷ï ôçò ðßåóçò óå õðåñôáóéêïýò áóèåíåßò. ¢ëëåò ìåëÝôåò Ýäåéîáí üôé ìÝóç çìåñÞóéá ðñüóëçøç áóâåóôßïõ (êïíôÜ óôá 1000 mg) ïäÞãçóå óå ìåßùóç ôçò óõóôïëéêÞò ðßåóçò êáôÜ 1,44 mmHg, åíþ äåí åðçñÝáóå Þ ìåßùóå ôç äéáóôïëéêÞ ðßåóç êáôÜ 0,84 mmHg51. Áí êáé õðÜñ÷ïõí êáé áíôßèåôåò áðüøåéò ïé ïðïßåò èåùñïýí üôé ç åðßäñáóç ôïõ áóâåóôßïõ óôç ñýèìéóç ôçò õðÝñôáóçò åßíáé ó÷åäüí áìåëçôÝá52,53, óå ãåíéêÝò ãñáììÝò èåùñåßôáé üôé ç êáôáíÜëùóç áóâåóôßïõ óå ðïóüôçôåò áíÜëïãá ìå ôç óõíéóôþìåíç ãéá ôï öýëï êáé ôçí çëéêßá, åßíáé äõíáôü íá ìåéþóåé ôá åðßðåäá ôçò áñôçñéáêÞò ðßåóçò54. ÃåíéêÜ, ç ðñüóëçøç áóâåóôßïõ óå ðïóüôçôåò ðïõ óõóôÞíïíôáé ãéá ôïí ãåíéêü ðëçèõóìü, êáé ðñïåñ÷üìåíåò áðü ôñüöéìá, åßíáé åõåñãåôéêÞ ãéá ðïéêßëïõò ëüãïõò, üðùò ãéá ðáñÜäåéãìá ðñüëçøç ôçò ïóôåïðüñùóçò. Åðéðñüóèåôá, ç ìåëÝôç DASH Ýäåéîå üôé ìéá äéáôñïöÞ ðëïýóéá óå ãáëáêôïêïìéêÜ ðñïúüíôá ÷áìçëþí ëéðáñþí ó÷åôßæåôáé ìå ìåßùóç ôçò áñôçñéáêÞò ðßåóçò ôüóï óå Üôïìá ìå öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç üóï êáé óå õðåñôáóéêÜ Üôïìá9.

Ïéíüðíåõìá Ôá åðéäçìéïëïãéêÜ åõñÞìáôá Ý÷ïõí äçìéïõñãÞóåé óýã÷õóç ó÷åôéêÜ ìå ôçí êáôáíÜëùóç ïéíïðíåõìáôùäþí ðïôþí êáé ôçí áñôçñéáêÞ ðßåóç. Óå ìéá ìåëÝôç, ôá Üôïìá ôá ïðïßá êáôáíÜëùíáí ïéíïðíåõìáôþäç ðïôÜ êáèçìåñéíÜ åß÷áí õøçëüôåñç áñôçñéáêÞ ðßåóç óå ó÷Ýóç ìå Üôïìá ôá ïðïßá Ýðéíáí ðïëý ìüíï ôá óáââáôïêýñéáêá55. Óå ìéá Üëëç ìåëÝôç, ðáñáôçñÞèçêå ìéá ó÷Ýóç óå ó÷Þìá J ìåôáîý ôçò êáôáíÜëùóçò ïéíïðíåõìáôùäþí ðïôþí êáé ôçò áñôçñéáêÞò ðßåóçò êáèþò åðßóçò êáé ìå ôïí êßíäõíï êáñäéáããåéáêþí íïóçìÜôùí56,57. ÅõñÞìáôá áðü ôõ÷áéïðïéçìÝíåò êëéíéêÝò ìåëÝôåò õðïóôçñßæïõí éó÷õñÜ ìéá áéôéïëïãéêÞ ó÷Ýóç ìåôáîý ìÝôñéáò êáôáíÜëùóçò ïéíïðíåõìáôùäþí ðïôþí êáé ÷áìçëÞò áñôçñéáêÞò ðßåóçò58,59. Ç 6ç áíáöïñÜ áðü ôï Joint National Committee on

Prevention Detection and Treatment of High Blood Pressure èåùñåß ôçí õðåñâïëéêÞ êáôáíÜëùóç ïéíïðíåõìáôùäþí ðïôþí êßíäõíï ãéá õðÝñôáóç êáé åãêåöáëéêü åðåéóüäéï, åíþ åßíáé äõíáôü íá ðñïêáëÝóåé áíôßóôáóç óôçí áíôéõðåñôáóéêÞ èåñáðåßá5. ÅêôéìÜôáé üôé ç õðÝñôáóç ïöåéëüìåíç óôá ïéíïðíåõìáôþäç ðïôÜ ìðïñåß íá áðïôåëåß ôï 30% ôùí ðåñéðôþóåùí ôçò õðÝñôáóçò60. Ôï ãåãïíüò áõôü êáé åðéðñüóèåôá ç õøçëÞ åðéêñÜôçóç ôçò êáôáíÜëùóçò ïéíïðíåõìáôùäþí ðïôþí óå ïñéóìÝíïõò ëáïýò êáèéóôïýí ôçí êáôáíÜëùóç ïéíïðíåýìáôïò Ýíáí óçìáíôéêü áëëÜ ôñïðïðïéÞóéìï ðáñÜãïíôá êéíäýíïõ ãéá õðÝñôáóç. Ãéá ôï ëüãï áõôü êÜèå ðñïóðÜèåéá áëëáãÞò ôïõ ôñüðïõ æùÞò ìå óêïðü ôçí ðñüëçøç êáé èåñáðåßá ôçò õðÝñôáóçò èá ðñÝðåé íá ðåñéëáìâÜíåé áðï÷Þ Þ ðåñéïñéóìü ôçò êáôáíÜëùóçò ïéíïðíåýìáôïò. Ïé óõóôÜóåéò ðïõ éó÷ýïõí óÞìåñá ó÷åôéêÜ ìå ôçí êáôáíÜëùóç ïéíïðíåõìáôùäþí ðïôþí åßíáé Ýùò 30 ml áéèáíüëçò ãéá ôïõò Üíäñåò êáé 15 ml ãéá ôéò ãõíáßêåò. Ç óõãêåêñéìÝíç óýóôáóç ìåôáöñÜæåôáé óå ëéãüôåñï áðü 720 ml ìðßñá Þ 300 ml êñáóß Þ 60 ml ïõßóêé ãéá ôïõò Üíäñåò êáé ïé ìéóÝò ðïóüôçôåò ãéá ôéò ãõíáßêåò61.

ÄéáéôçôéêÝò áëëáãÝò Ç ÌåóïãåéáêÞ ÄéáôñïöÞ ÌåëÝôåò ðáñáôÞñçóçò õðïäåéêíýïõí ÷áìçëüôåñç áñôçñéáêÞ ðßåóç óå ÷ïñôïöÜãïõò óõãêñéíüìåíïé ìå ìç ÷ïñôïöÜãïõò êáé óå åêåßíïõò ôùí ïðïßùí ç äéáôñïöÞ åßíáé ðëïýóéá óå ìÝôáëëá êáé öõôéêÝò ßíåò62,63. ÐÜíôùò ðñÝðåé íá åðéóçìáíèåß üôé ïé öõôïöáãéêÝò äßáéôåò äåí åßíáé ðñáêôéêÝò ãéá ôçí ðëåéïíüôçôá ôùí áíèñþðùí. Ìéá åíáëëáêôéêÞ ôçò öõôïöáãéêÞò äßáéôáò åßíáé ç ìåóïãåéáêÞ äéáôñïöÞ64-71. Ôï åëáéüëáäï åßíáé ôï âáóéêüôåñï ÷áñáêôçñéóôéêü áõôÞò ôçò äéáôñïöÞò, ü÷é ìüíï åðåéäÞ Ý÷åé áñêåôÝò åõåñãåôéêÝò åðéäñÜóåéò, áëëÜ åðéôñÝðåé åðßóçò ôçí êáôáíÜëùóç ìåãÜëùí ðïóïôÞôùí ëá÷áíéêþí ìå ôç ìïñöÞ óáëÜôáò êáé ïóðñßùí ìå ôç ìïñöÞ ìáãåéñåìÝíïõ öáãçôïý. ¢ëëá âáóéêÜ óõóôáôéêÜ ôçò ìåóïãåéáêÞò äéáôñïöÞò åßíáé ôï óéôÜñé, ïé åëéÝò, ôá óôáöýëéá êáé ðïéêßëá ðáñÜãùãá áõôþí. Áõôïý ôïõ åßäïõò ç ðáñáäïóéáêÞ äéáôñïöÞ ðåñéÝ÷åé 9 óôïé÷åßá: õøçëÞ êáôáíÜëùóç åëáéïëÜäïõ, ïóðñßùí, äçìçôñéáêþí, öñïýôùí, ëá÷áíéêþí, ìÝôñéá Ýùò õøçëÞ êáôáíÜëùóç øá131

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ñéïý, ìÝôñéá êáôáíÜëùóç êñáóéïý, ãáëáêôïêïìéêþí ðñïúüíôùí (êõñßùò ôõñß êáé ãéáïýñôé) êáé ÷áìçëÞ êáôáíÜëùóç êñÝáôïò êáé õðïêáôÜóôáôùí áõôïý. Åðéðñüóèåôá, áí êáé ç ðñüóëçøç ãÜëáôïò åßíáé ìÝôñéá, ç êáôáíÜëùóç ôõñéïý êáé ãéáïõñôéïý åßíáé ó÷åôéêÜ õøçëÞ. Ôï áëêïüë êáôáíáëþíåôáé óå ìÝôñéåò ðïóüôçôåò êáé ó÷åäüí óå êÜèå ãåýìá. Ç óõãêåêñéìÝíç äßáéôá ÷áñáêôçñßæåôáé áðü ÷áìçëÞ ðåñéåêôéêüôçôá óå êïñåóìÝíï ëßðïò (ëéãüôåñï áðü ôï 9% ôçò óõíïëéêÞò åíÝñãåéáò), ìå ôç óõíïëéêÞ ðñüóëçøç ëßðïõò íá ðïéêßëåé áðü 30% Ýùò 40% ôçò óõíïëéêÞò ðñïóëáìâáíüìåíçò åíÝñãåéáò áíáëüãùò ôçí ðåñéï÷Þ. Åðéðñüóèåôá ç áíáëïãßá ôùí ìïíïáêüñåóôùí ðñïò ôá êïñåóìÝíá ëßðç êõìáßíåôáé ãýñù óôï 2. Ç õøçëÞ ðåñéåêôéêüôçôá ôçò äéáôñïöÞò óå ëá÷áíéêÜ, öñÝóêá öñïýôá êáé äçìçôñéáêÜ êáé ç êáèçìåñéíÞ ÷ñÞóç åëáéïëÜäïõ ùò êýñéá ðçãÞ ëßðïõò áëëÜ ôüóç þóôå íá äéáôçñåßôáé Ýíá öõóéïëïãéêü óùìáôéêü âÜñïò áðïôåëïýí åããýçóç ãéá åðáñêÞ ðñüóëçøç â-êáñïôÝíéïõ, âéôáìßíçò C, ôïêïöåñïëþí, ìïíïáêüñåóôùí ëéðáñþí ïîÝùí, á-ëéíïëåíéêïý ïîÝïò, ðïéêéëßá ìåôÜëëùí êáé ðïëëþí Üëëùí ðéèáíÜ åõåñãåôéêþí ïõóéþí üðùò åßíáé ïé ðïëõöáéíüëåò êáé ïé áíèïêõáíßíåò. Ç ìåóïãåéáêÞ äéáôñïöÞ áíáðáñßóôáôáé óôç ìïñöÞ ìéáò ðõñáìßäáò óôç âÜóç ôçò ïðïßáò áíáöÝñïíôáé ôñüöéìá ôá ïðïßá ðñÝðåé íá êáôáíáëþíïíôáé ðéï óõ÷íÜ êáé óôçí êïñõöÞ ôñüöéìá ôá ïðïßá ðñÝðåé íá êáôáíáëþíïíôáé óðÜíéá (Åéêüíá 1). Ôá åðéäçìéïëïãéêÜ äåäïìÝíá ðïõ áöïñïýí ôç èíçóéìüôçôá äåß÷íïõí üôé êÜôé áóõíÞèéóôï öáßíåôáé åðçñåÜæåé ôï åðßðåäï õãåßáò ôùí ìåóïãåéáêþí ëáþí. Áí êáé ïé åñìçíåßåò ôùí äåäïìÝíùí åìðåñéÝ÷ïõí äõóêïëßåò, ìéá êáëÞ åîÞãçóç ôçò ÷áìçëÞò èíçôüôçôáò áðü êáñäéáããåéáêÜ óôï ìåóïãåéáêü ðëçèõóìü åßíáé ç äéáôñïöÞ ôïõò üðùò õðïäåéêíýåôáé áðü ôïõò åñåõíçôÝò ôçò ÌåëÝôçò ôùí 7 ×ùñþí14. Ðéï óõãêåêñéìÝíá ïé åñåõíçôÝò ôçò ìåëÝôçò (âáóéæüìåíïé óå 2 åëëçíéêïýò ðëçèõóìïýò ôçò ÊÝñêõñáò êáé ôçò ÊñÞôçò) áðïêÜëõøáí ôïí ðñïóôáôåõôéêü ñüëï ôçò ìåóïãåéáêÞò äéáôñïöÞò åíÜíôéá óôçí áèçñïóêëÞñùóç, êõñßùò ëüãù ôçò ìåßùóçò ôçò áñôçñéáêÞò ðßåóçò êáé ôïõ äåßêôç ìÜæáò óþìáôïò. ÁñêåôÜ ÷ñüíéá áñãüôåñá ïé åñåõíçôÝò ôçò ìåëÝôçò CARDIO2000, ìåëÝôçóáí Ýíá äåßãìá áðü 2000 áóèåíåßò ìÝóçò çëéêßáò ìå Ýíá ðñþôï åðåéóüäéï åìöñÜãìáôïò ôïõ ìõïêáñäßïõ Þ áóôáèÞ óôçèÜã÷ç êáé åîïìïéùìÝíïõò áíÜ öýëï êáé çëéêßá áðü äéÜöïñåò ðåñéï÷Ýò ôçò 132

Ö. Áñâáíßôç êáé óõí.

ÅëëÜäïò72. Ç ìåóïãåéáêÞ äéáôñïöÞ ó÷åôßóôçêå ìå ìåßùóç 7% ìå 10% ôïõ êéíäýíïõ ãéá óôåöáíéáßá íüóï óå èåñáðåõìÝíïõò, ìç èåñáðåõìÝíïõò Þ ìç åëåã÷üìåíïõò õðåñôáóéêïýò áóèåíåßò. Ðñüóöáôá, óå ìéá ìåãÜëç ðñïïðôéêÞ Ýñåõíá ç ïðïßá óõìðåñéëÜìâáíå 22043 Üôïìá ìÝóçò êáé ìåãáëýôåñçò çëéêßáò áðü ôçí ÅëëÜäá, ç Ôñé÷ïðïýëïõ êáé óõí. (áðü ôçí ìåëÝôç EPIC óôïí åëëçíéêü ðëçèõóìü) áíÝöåñáí üôé ìéá áíôßóôñïöç ó÷Ýóç ìå ìåãáëýôåñç õéïèÝôçóç óôç ìåóïãåéáêÞ äéáôñïöÞ ðáñáôçñÞèçêå ãéá èáíÜôïõò ïöåéëüìåíïõò óå óôåöáíéáßá íüóï, ëáìâÜíïíôáò õðüøç ôï öýëï, ôï êÜðíéóìá, ôï ìïñöùôéêü åðßðåäï, ôï äåßêôç ìÜæáò óþìáôïò êáé ôï åðßðåäï öõóéêÞò äñáóôçñéüôçôáò69. Ï Martinez-Gonzalez êáé óõí., óå ìéá ìåëÝôç áóèåíþí - ìáñôýñùí ç ïðïßá ðåñéëÜìâáíå 350 áóèåíåßò êáé õãéåßò ìÜñôõñåò, áíÝöåñáí üôé üóï õøçëüôåñï Þôáí ôï óêïñ ôçò ìåóïãåéáêÞò äéáôñïöÞò ôüóï ìéêñüôåñåò Þôáí ïé ðéèáíüôçôåò ãéá Ýìöñáãìá ôïõ ìõïêáñäßïõ, êõñßùò ëüãù ôçò ìåßùóçò ôçò áñôçñéáêÞò ðßåóçò16. Ï Schroder êáé óõí. ìåëåôþíôáò Ýíáí ìåóïãåéáêü ðëçèõóìü áðü ôçí Éóðáíßá, ôüíéóáí ôçí óçìáóßá ôçò äéáôñïöÞò êáé ôçò óõíïëéêÞò ðñüóëçøçò íáôñßïõ ùò ìç öáñìáêåõôéêÞ ðñïóÝããéóç óôçí ðñüëçøç êáé áíôéìåôþðéóç ôçò õðÝñôáóçò33. Ï Álonso êáé óõí. óå ìéá óõã÷ñïíéêÞ Ýñåõíá ìå 4393 óõììåôÝ÷ïíôåò áðü ôçí Éóðáíßá, ðáñáôÞñçóáí üôé ç õøçëÞ êáôáíÜëùóç öñïýôùí êáé ëá÷áíéêþí Þôáí áíôßóôñïöá óõó÷åôéóìÝíç ìå ôá åðßðåäá ôçò áñôçñéáêÞò ðßåóçò óå Ýíáí ðëçèõóìü ìå áõîçìÝíç êáôáíÜëùóç ëßðïõò. Ðéï óõãêåêñéìÝíá, óõãêñßíïíôáò åêåßíïõò ìå ôçí õøçëüôåñç êáôáíÜëùóç öñïýôùí êáé ëá÷áíéêþí ìå ôá Üôïìá ìå ôç ÷áìçëüôåñç êáôáíÜëùóç ï ó÷åôéêüò ëüãïò ðéèáíïôÞôùí ãéá õðÝñôáóç Þôáí 0,23 (áðü 0,10 Ýùò 0,55)73. Ï Ruiz-Guiterrez êáé óõí. ìåëÝôçóå ìåôáîý Üëëùí ôéò åðéäñÜóåéò áðü ìéá äßáéôá ðëïýóéá óå ìïíïáêüñåóôá ëéðáñÜ ïîÝá, ðñïåñ÷üìåíá áðü çëéÝëáéï êáé åëáéüëáäï, óôçí áñôçñéáêÞ ðßåóç óå õðåñôáóéêÝò ãõíáßêåò. ÐáñáôçñÞèçêå ìéá óçìáíôéêÞ ìåßùóç óôá åðßðåäá óõóôïëéêÞò êáé äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò ìåôÜ áðü ðñüóëçøç åëáéïëÜäïõ74. ÔåëéêÜ, ìåñéêÜ ÷ñüíéá ðñéí ï Strazzulo êáé óõí. ðáñáôÞñçóáí üôé ìåßùóç ôçò ðñüóëçøçò êïñåóìÝíïõ ëßðïõò óå óõíäõáóìü ìå ìÝôñéá áëëáãÞ óôçí áíáëïãßá ðïëõáêüñåóôùí êáé êïñåóìÝíùí ëéðþí ôçò äéáôñïöÞò, ìåßùóå óçìáíôéêÜ ôá åðßðåäá áñôçñéáêÞò ðßåóçò75. Ðñüóöáôá ç Ôñé÷ïðïýëïõ êáé óõí.76, áðü ôçí åëëçíéêÞ êïïñôÞ ôçò ìåëÝôçò ÅÐÉÊ,

Ö. Áñâáíßôç êáé óõí.

Ôüìïò 17, Ôåý÷ïò 3, 2005

Ó÷Þìá 1. Ç ðáñáäïóéáêÞ ìåóïãåéáêÞ ðõñáìßäá.

Ýäåéîå üôé ç ìåóïãåéáêÞ äéáôñïöÞ óõó÷åôéæüôáí áíôéóôñüöùò áíÜëïãá ìå ôéò ôéìÝò óõóôïëéêÞò êáé äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò óå äåßãìá 20343 áíäñþí êáé ãõíáéêþí áðü üëç ôç ÷þñá.

Åðßóçò ï Perona êáé óõí. ¸äåéîáí üôé ç êáôáíÜëùóç åëáéïëÜäïõ ìåßùóå ôç óõóôïëéêÞ áñôçñéáêÞ ðßåóç óå çëéêéùìÝíïõò õðåñôáóéêïýò áóèåíåßò õðü öáñìáêåõôéêÞ áãùãÞ77. 133

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Ç ìåóïãåéáêÞ äéáôñïöÞ åßíáé ÷áìçëÞ óå êïñåóìÝíï ëßðïò, õøçëÞ óå ðïëõáêüñåóôá ëéðáñÜ ïîÝá, ðñïåñ÷üìåíá êõñßùò áðü ôï åëáéüëáäï, õøçëÞ óå óýíèåôïõò õäáôÜíèñáêåò (üóðñéá) êáé õøçëÞ óå öõôéêÝò ßíåò, êõñßùò áðü öñïýôá êáé ëá÷áíéêÜ. Ç óõíïëéêÞ ðåñéåêôéêüôçôá óå ëßðïò åßíáé õøçëÞ, ðåñßðïõ óôï 40% ôçò óõíïëéêÞò åíåñãåéáêÞò ðñüóëçøçò, áëëÜ ç áíáëïãßá ìïíïáêüñåóôùí ðñïò êïñåóìÝíá ëßðç êõìáßíåôáé ãýñù óôï 2. Ç õøçëÞ ðåñéåêôéêüôçôá óå öñïýôá, ëá÷áíéêÜ, äçìçôñéáêÜ êáé åëáéüëáäï åããõþíôáé ôçí õøçëÞ ðñüóëçøç â-êáñïôÝíéïõ, âéôáìßíçò C êáé Å, ðïëõöáéíïëþí êáé ðïëëþí ìåôÜëëùí. ÁõôÜ ôá é÷íïóôïé÷åßá, Ý÷åé öáíåß üôé Ý÷ïõí ðïéêßëåò åõåñãåôéêÝò åðéäñÜóåéò óôçí áíèñþðéíç õãåßá êáé éäéáßôåñá óôá êáñäéáããåéáêÜ íïóÞìáôá77. Ç Óéìïðïýëïõ åðßóçò, Ý÷åé äåßîåé üôé ç ìåóïãåéáêÞ äéáôñïöÞ åìðåñéÝ÷åé Ýíá óçìáíôéêü áñéèìü ðñïóôáôåõôéêþí ïõóéþí üðùò åßíáé ôï óåëÞíéï, ç ãëïõôáèåéüíç, ìéá éóïññïðçìÝíç áíáëïãßá (ù-6):(ù-3) ëéðáñþí ïîÝùí, õøçëÞ ðïóüôçôá öõôéêþí éíþí, áíôéïîåéäùôéêÜ (éäéáßôåñá ñåóâåñáôñüëç áðü ôá óôáöýëéá, ôá öõóôßêéá êáé ôï êñáóß êáé ðïëõöáéíüëåò áðü ôï åëáéüëáäï) êáèþò åðßóçò âéôáìßíåò Å êáé C, ôá ïðïßá ó÷åôßæïíôáé ìå ìåéùìÝíï êßíäõíï õðÝñôáóçò, óôåöáíéáßáò íüóïõ êáé êáñêßíïõ65.

Ç äßáéôá DASH (The Dietary Approaches to Stop Hypertension) H ìåëÝôç DASH õðïóôçñßæåé ìéá äéáéôçôéêÞ ðáñÝìâáóç ðáñüìïéá ìå åêåßíç ôçò ìåóïãåéáêÞò äéáôñïöÞò9. Ç óõãêåêñéìÝíç ìåëÝôç óõìðåñéëÜìâáíå 495 åíÞëéêåò ìå óõóôïëéêÞ ðßåóç ìéêñüôåñç áðü 160 mmHg êáé äéáóôïëéêÞ áðü 80 Ýùò 90 mmHg. Áñ÷éêÜ, ôá Üôïìá áêïëïýèçóáí äßáéôá ìå ÷áìçëÞ ðåñéåêôéêüôçôá óå öñïýôá, ëá÷áíéêÜ êáé ãáëáêôïêïìéêÜ ðñïúüíôá êáé öõóéïëïãéêü ëßðïò (äßáéôá åëÝã÷ïõ). ¸ðåéôá ôá ßäéá Üôïìá áêïëïýèçóáí äßáéôá ðëïýóéá óå öñïýôá êáé ëá÷áíéêÜ Þ ìéá “óõíäõáóìÝíç” äßáéôá ðëïýóéá óå öñïýôá, ëá÷áíéêÜ êáé ãáëáêôïêïìéêÜ ðñïúüíôá ìå ÷áìçëÜ ëéðáñÜ êáé ðåñéïñéóìÝíç óå êïñåóìÝíï êáé ïëéêü ëßðïò. Ï óêïðüò ôçò ìåëÝôçò Þôáí íá åêôéìÞóåé åÜí ìéá äßáéôá ðëïýóéá óå öñïýôá, ëá÷áíéêÜ, ãáëáêôïêïìéêÜ ÷áìçëþí ëéðáñþí êáé

134

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ôï íÜôñéï íá ðáñáìÝíåé óôáèåñü, ìðïñåß íá ìåéþóåé ôçí áñôçñéáêÞ ðßåóç. Ôá äåäïìÝíá ôçò áíÜëõóçò Ýäåéîáí üôé ç “óõíäõáóìÝíç” äßáéôá ó÷åôßóôçêå ìå ìåßùóç ôçò óõóôïëéêÞò êáé äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò êáôÜ 5,5 êáé 3,0 mmHg áíôßóôïé÷á óå ó÷Ýóç ìå ôç äßáéôá åëÝã÷ïõ (Ñ<0,001), åíþ ç äßáéôá ìå ôá öñïýôá êáé ôá ëá÷áíéêÜ ìåßùóå ôç óõóôïëéêÞ ðßåóç êáôÜ 2,8 mmHg ðåñéóóüôåñï (Ñ<0,001) êáé ôç äéáóôïëéêÞ êáôÜ 1,1 mmHg ðåñéóóüôåñï óå ó÷Ýóç ìå ôç äßáéôá åëÝã÷ïõ (Ñ<0,07). Åðéðñüóèåôá, ìåôáîý ôùí 133 áóèåíþí ìå õðÝñôáóç ç “óõíäõáóìÝíç” äßáéôá åëÜôôùóå ôç óõóôïëéêÞ êáé äéáóôïëéêÞ áñôçñéáêÞ ðßåóç êáôÜ 11,4 êáé 5,5 mmHg áíôßóôïé÷á ðåñéóóüôåñï óå ó÷Ýóç ìå ôç äßáéôá åëÝã÷ïõ (Ñ<0,001 ãéá ôï êáèÝíá), åíþ ìåôáîý ôùí 326 áôüìùí ÷ùñßò õðÝñôáóç ç ìåßùóç Þôáí 3,5 mmHg (Ñ<0,001) êáé 2,1 mmHg (Ñ=0,003)9. Óå ìéá Üëëç ìåëÝôç ï Svetkey êáé óõí. õðÝâáëå óå åíÞëéêåò ìå óõóôïëéêÞ êáé äéáóôïëéêÞ áñôçñéáêÞ ðßåóç ìåôáîý 120-159 êáé 80-95 mmHg áíôßóôïé÷á, ôç “óõíäõáóìÝíç” äßáéôá DASH Þ ôçí ôõðéêÞ ÁìåñéêáíéêÞ äßáéôá (äßáéôá åëÝã÷ïõ), êáôáíáëþíïíôáò ôñåéò äéáöïñåôéêÝò ðñïóëÞøåéò íáôñßïõ (õøçëÞ=142 mmol/d, ìÝôñéá=107 mmol/d, êáé ÷áìçëÞ 65 mmol/d) ãéá 30 çìÝñåò79. Ïé åñåõíçôÝò ðáñáôÞñçóáí üôé ôá ìåãáëýôåñá ïöÝëç áñôçñéáêÞò ðßåóçò åðéôåý÷èçêáí ìå ôç óõíäõáóìÝíç äßáéôá DASH/÷áìçëÞ ðñüóëçøç óå íÜôñéï. Ç áñôçñéáêÞ ðßåóç Ýãéíå öõóéïëïãéêÞ Þ éäáíéêÞ óôï 71% ôùí áôüìùí ðïõ êáôáíÜëùíáí ôç äßáéôá åëÝã÷ïõ/÷áìçëÞ óå íÜôñéï êáé óôï 77% ôùí áôüìùí ðïõ êáôáíÜëùíáí ôç äßáéôá DASH/÷áìçëÞ óå íÜôñéï. Ï Svetkey êáôÝëçîå óôï üôé ç äßáéôá DASH óå óõíäõáóìü ìå ôïí ðåñéïñéóìü ôçò ðñüóëçøçò íáôñßïõ âåëôéþíåé ôçí áñôçñéáêÞ ðßåóç. ¼ëåò áõôÝò ïé ìåëÝôåò õðïäåéêíýïõí éó÷õñÜ üôé ç åóôßáóç ôùí äéáôñïöéêþí áëëáãþí ãéá ôïí Ýëåã÷ï ôçò áñôçñéáêÞò ðßåóçò äåí èá ðñÝðåé íá ãßíåé óå Ýíá èñåðôéêü óõóôáôéêü. ¼ðùò ðñïêýðôåé áðü ôá ðñïçãïýìåíá óôïé÷åßá åßíáé áñêåôïß ïé äéáôñïöéêïß ðáñÜãïíôåò ïé ïðïßïé óõìâÜëëïõí óôç ñýèìéóç ôçò áñôçñéáêÞò ðßåóçò. Ç äßáéôá ç ïðïßá óõóôÞíåôáé óôï ãåíéêü ðëçèõóìü åßíáé ÷áìçëÞ óå êïñåóìÝíï ëßðïò, ðëïýóéá óå öñïýôá êáé ëá÷áíéêÜ êáé åðáñêÞ ðñüóëçøç áóâåóôßïõ, ìáãíçóßïõ êáé êáëßïõ.

Ôüìïò 17, Ôåý÷ïò 3, 2005

Ö. Áñâáíßôç êáé óõí.

ÓõìðÝñáóìá Ç äéáôñïöÞ äéáäñáìáôßæåé ðïëý óçìáíôéêü ñüëï óôçí åìöÜíéóç ðáñáãüíôùí ãéá êáñäéáããåéáêÝò ðáèÞóåéò üðùò ç õðÝñôáóç êáé ó÷åôßæåôáé êáé ìå Üëëïõò ìåôáâïëéêïýò ðáñÜãïíôåò êéíäýíïõ üðùò åßíáé ï äéáâÞôçò, ç õøçëÞ áñôçñéáêÞ ðßåóç êáé ç ðá÷õóáñêßá. Åßíáé ðéá áðïäåäåéãìÝíï üôé ç ðñüóëçøç öñïýôùí êáé ëá÷áíéêþí, åëáéïëÜäïõ, öõôéêþí éíþí êáé ç ìÝôñéá êáôáíÜëùóç áëêïüë áðïôåëïýí ðñïóôáôåõôéêïýò ðáñÜãïíôåò åíÜíôéá óôçí õðÝñôáóç. ÕðÜñ÷ïõí åðáñêåßò ãíþóåéò ïé ïðïßåò óõóôÞíïõí üôé ôÝôïéïõ åßäïõò äßáéôåò üðùò åßíáé ç DASH êáé ç ìåóïãåéáêÞ äéáôñïöÞ, ìðïñïýí íá ìåéþóïõí ôïí êßíäõíï ôçò õðÝñôáóçò êáé êáôÜ óõíÝðåéá ôçò óôåöáíéáßáò íüóïõ. Ï De Lorgeril êáé ï Salen áíáöÝñïõí üôé ç êáñäéïðñïóôáôåõôéêÞ äñÜóç ôçò ìåóïãåéáêÞò äéáôñïöÞò êáé ç ãáóôñïíïìéêÞ áðüëáõóç ðïõ ðáñÝ÷åé, ôçí êáèéóôïýí åîáéñåôéêÜ åëêõóôéêÞ ãéá ôïõò óêïðïýò ôçò äçìüóéáò õãåßáò78. ÐÜíôùò, ïñéóìÝíïé åñåõíçôÝò ðéóôåýïõí üôé ïé åðéäñÜóåéò ôçò óõãêåêñéìÝíçò äéáôñïöÞò óôçí áíèñþðéíç õãåßá ìðïñïýí íá åîçãçèïýí âÜóåé ãåùãñáöéêþí, êïéíùíéêþí êáé äéáöïñþí óôçí êïõëôïýñá ìåôáîý ôùí ëáþí, åíþ Üëëïé õðïóôçñßæïõí üôé áõôÞ ç ðáñáäïóéáêÞ äéáôñïöÞ åßíáé äýóêïëï íá áöïìïéùèåß áðü Üëëïõò ëáïýò åîáéôßáò ôùí äéáöïñþí óôçí êïõëôïýñá êáé ôéò ðåñéâáëëïíôéêÝò óõíèÞêåò80. Ç Ôñé÷ïðïýëïõ êáé óõí. ðéóôåýïõí üôé ç ìåóïãåéáêÞ äéáôñïöÞ ìðïñåß åýêïëá íá âñåé Ýäáöïò êáé óå Üëëåò ÷þñåò, êáèþò ìðïñåß íá ãßíåé ÷ñÞóç ðïéêéëßáò ôñïößìùí þóôå íá åðéôåõ÷èåß áýîçóç ôçò ðñüóëçøçò ìïíïáêüñåóôùí ëéðáñþí ïîÝùí êáé êáôÜ óõíÝðåéá íá åðéôåõ÷èïýí ôá ßäéá áðïôåëÝóìáôá óôï åðßðåäï õãåßáò ôùí áíèñþðùí81. ÓõìðåñáóìáôéêÜ, ïé ìç öáñìáêåõôéêÝò ðáñåìâÜóåéò, üðùò åßíáé ç äéáôñïöÞ, áðïôåëïýí ðñüêëçóç óôçí ðñüëçøç ôçò õðÝñôáóçò.

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41. Kotchen TA, Kotchen JM. Nutrition, diet and hypertension. In: Modern nutrition in health and disease. Shils ME, Olson JA, Shike M, Ross AC (Eds). Lippincott, Williams & Wilkins, 9th edition, 1999. 42. Joffres MR, Reed DM, Yano K. Relation of magnesium intake and other dietary factors to blood pressure; the Honolulu heart study. Am J Clin Nutr, 45:469-475, 1987. 43. Toshima H, Koga Y, Blackburn H. (Eds) Lessons from the Seven Countries Study. In Dontas A. CVD Risk factors and Trends in Greece. Springer Verlag Tokyo, 1994. 44. Saito K, Hattori K, Omatsu T, et al. Effects of oral magnesium on blood pressure and red cell sodium transport in patients receiving long-term thiazide diuretics for hypertension. Am J Hypertens, 1:71S-74S, 1988. 45. Ma J, Folsom AR, Melnick SL, et al. Associations of serum and dietary magnesium with cardiovascular disease, hypertension, diabetes, insulin, and carotic arterial wall thickness: the ARIC Study. Atherosclerosis Risk in Communities Study. J Clin Epidemiol, 48:927-40, 1995. 46. Cappuccio FP, Elliott P, Allender PS, Pryer J, Follman DA, Cutler JA. Epidemiologic association between dietary calcium intake and blood pressure: a meta-analysis of published data. Am J Epidemiol, 142:935-945, 1995. 47. The effects of non-pharmacologic interventions on blood pressure of persons with high normal levels. JAMA, 267:1213-1220, 1992. 48. Morris CD, McCarron DA. Effect of calcium supplementation in an older population with mildly increased blood pressure. Am J Hypertens, 5:230-237, 1992. 49. Allender PS, Cutler JA, Follmann D, et al. Dietary calcium and blood pressure: A meta-analysis of randomized clinical trials. Ann Intern Med, 124:825-831, 1996. 50. Bucher HC, Cook RJ, Guyatt GH, et al. Effects of dietary calcium supplementation on blood pressure: A meta-analysis of randomized controlled trials. JAMA, 275:1016-1022, 1996. 51. Griffith L, Guayatt G, Cook R, et al. The influence of dietary and nondietary calcium supplementation on blood pressure. An updated metaanalysis of randomized controlled trials. Am J Hypertension, 12:84-92, 1999. 52. Resnick L. Therapeutic implications of calcium intake in hypertension. More analysis, a little progress and a different approach. Am J Hypertension, 12:82-83, 1999. 53. Cappuccio F. The “calcium antihypertension

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theory”. Am J Hypertension, 12:93-95, 1999. 54. McCarron D. Role of adequate dietary calcium intake in the prevention and management of salt-sensitive hypertension. Am J Clin Nutr, 65:712S-716S, 1997. 55. Gruchow HW, Sbocinski KA, Barboriak JJ. Alcohol nutrient intake and hypertension in US adults JAMA, 253:1567-1572, 1985. 56. Klatsky AL, Friedman GD, Siegeland AB, et al. Alcohol consumption and blood pressure. N Engl J Med, 296:1194, 1977. 57. Panagiotakos DB, Pitsavos C, Chrysohoou C, Stefanadis C, Toutouzas P. Risk stratification of coronary heart disease in Greece: final results from the CARDIO2000 Epidemiological Study. Prev Med, 35:548-556, 2002. 58. Puddey IB, Beilin LJ, Vandongen R, Rouse IL, Rogers P. Evidence for a direct effect of alcohol consumption on blood pressure in normotensive men. A randomized controlled Trial. Hypertension, 7:707-713, 1985. 59. Ueshima H, Mikawa K, Baba S, et al. Effect of reduced alcohol consumption on blood pressure in untreated hypertensive men. Hypertension, 21:248-252, 1993. 60. Maheswaran R, Beevers M, Beevers DG. Effectiveness of advice to reduce alcohol consumption in hypertensive patients. Hypertension, 19:79-84, 1992. 61. Anon. Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Int Med, 157:2413-46, 1997. 62. Rouse IL, Beilin LJ, Armstrong BK, Vandongen R. Blood pressure -lowering effects of vegetarian diet: controlled trial in normotensive subjects. Lancet, 1:5-10, 1983. 63. Margetts BM, Beilin LJ, Vandongen R, Armstrong BK. Vegetarian diet in mild hypertension: a randomized controlled trial. BMJ, 293:1468-1471, 1986. 64. Keys A. Mediterranean diet and public health: personal reflections. Am J Clin Nutr, 61:1321S1323S, 1995. 65. Simopoulos AP. The Mediterranean diets: What is so special about the diet of Greece? The scientific evidence. J Nutr, 131:3065S-3073S, 2001. 66. Panagiotakos DB, Pitsavos C, Chrysohoou C, et al. The role of traditional Mediterranean-type of diet and lifestyle, in the development of acute coronary syndromes: preliminary results from cardio2000 study. C Eur J Pub Health, 12; 7-1, 2002. 137

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67. Willett WC, Sacks F, Trichopoulou A, et al. Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr, 61:1402S1406S, 1995. 68. Pitsavos C, Panagiotakos DB, Chrysohoou C, et al. The adoption of Mediterranean diet attenuates the development of acute coronary syndromes in people with the metabolic syndrome. Nutr J, 3:9, 2003. 69. Trichopoulou A, Costacou T, Bamia C, et al. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med, 348:2599-2608, 2003. 70. Assmann G, de Basker G, Bagnara S, et al. International Consensus statement on olive oil and the Mediterranean diet: implications for health in Europe. Eur J Cancer Prev, 6:418421, 1997. 71. Trichopoulou A, Vasilopoulou E. Mediterranean diet and longevity. Br J Nutr 84:S205-209, 2000. 72. Pitsavos C, Panagiotakos DB, Chrysohoou C, et al. The effect of the combination of Mediterranean diet and leisure time physical activity on the risk of developing acute coronary syndromes, in hypertensive subjects. J Hum Hypert, 16:517– 524, 2002. 73. Alonso A, de la Fuente C, Martin-Arnau AM, de Irala J, Martinez JA, Martinez-Gonzalez MA. Fruit and vegetable consumption is inversely associated with blood pressure in a Mediterranean population with a high vegetable-fat intake: the Seguimiento Universidad de Navarra (SUN) Study. Br J Nutr, 92:311-319, 2004. 74. Ruiz-Gutierrez V, Muriana FJG, Guerrero A.

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I. ËÝíôæáò êáé óõí.

ÁÍÁÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 17, Number 3, 139-145, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 139-145, 2005

ÍÝïé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ: Äåßêôåò öëåãìïíÞò, èñüìâùóçò êáé ïîåéäùôéêïý stress I. ËÝíôæáò1, Ó. Êïêêüñçò2, Á. Áëåâßæïò1, Ð. ÄáóêáëÜêçò1, Á. ÊáìáñÜôïò2, Á. Ìáñéüëçò1

Ðåñßëçøç ÌÝ÷ñé ðñüóöáôá ãíùñßæáìå üôé ðáñÜãïíôåò êéíäýíïõ ãéá êáñäéáããåéáêÞ íüóï Þôáí ôï êÜðíéóìá, ç äõóëéðéäáéìßá, ï óáê÷áñþäçò äéáâÞôçò, ç áñôçñéáêÞ õðÝñôáóç êáé ôï èåôéêü ïéêïãåíåéáêü éóôïñéêü. ¼ìùò, ôçí ôåëåõôáßá êõñßùò äåêáåôßá Ý÷ïõí áíáãíùñéóèåß íåüôåñïé ðáñÜãïíôåò êéíäýíïõ, üðùò ïé äåßêôåò öëåãìïíÞò, èñüìâùóçò êáé ïîåéäùôéêïý stress. ¸ôóé, åõñÞìáôá óõóôçìáôéêÞò öëåãìïíÞò ôáõôïðïéïýí áóèåíåßò ìå áõîçìÝíï êßíäõíï ìåëëïíôéêþí óôåöáíéáßùí óõìâáìÜôùí, ðåñéëáìâÜíïíôáò åêåßíïõò ðïõ äåí åß÷áí ðñïçãïýìåíï éóôïñéêü, êáèþò åðßóçò êáé áõôïýò ìå óôáèåñÜ êáé áóôáèÞ óôåöáíéáßá óýíäñïìá. Åðßóçò, ìåëÝôåò Ý÷ïõí äåßîåé üôé ïé åíåñãïðïéçìÝíïé äåßêôåò ðÞîçò êáé éíùäüëõóçò åßíáé áõîçìÝíïé óå Üôïìá ìå áõîçìÝíï êßíäõíï ãéá óôåöáíéáßá íüóï. ÔÝëïò, ðñüóöáôåò ìåëÝôåò Ýäåéîáí üôé õðÜñ÷åé óáöÞò ó÷Ýóç áéôßïõ – áðïôåëÝóìáôïò ìåôáîý ôçò ïîåßäùóçò ôçò LDL êáé ôçò áèçñïóêëÞñõíóçò.

ÊÝíôñï Õãåßáò Âýñùíá, 2Â´ Ðáèïëïãéêü ÔìÞìá, ‘ÔæÜíåéï’ Íïóïêïìåßï ÐåéñáéÜ

Novel cardiovascular risk factors: inflammatory, thrombotic and oxidative stress markers I. Lentzas, S. Kokkoris, A. Alevizos, P. Daskalakis, A. Kamaratos, A. Mariolis Summary Until recently smoking, dyslipidemia, diabetes mellitus, arterial hypertension and positive family history were the only known cardiovascular risk factors. However, during the last decade novel risk factors have been recognized such as inflammatory, thrombotic and oxidative stress markers. Therefore evidence of systemic inflammation can be used to identify patients at increased risk of future coronary events, including those with no previous history as well as those with stable and unstable coronary syndromes. Several studies have shown that the activated coagulative and fibrinolytic factors are increased in patients with high risk for coronary heart diseases. Furthermore, recent studies have shown that there is a causative relationship between LDL oxidation and atherosclerosis. Key words: cardiovascular disease, inflammation, marker, thrombosis, oxidative stress

ÅéóáãùãÞ Ôá ôåëåõôáßá ÷ñüíéá üëï êáé ðåñéóóüôåñïé åñåõíçôÝò áó÷ïëïýíôáé ìå ôçí áíáêÜëõøç íÝùí ðáñáãüíôùí êéíäýíïõ ãéá êáñäéáããåéáêÞ íüóï, ç ïðïßá áðïôåëåß ìáêñÜí ôçí ðéï óõ÷íÞ áéôßá èáíÜôïõ ðáãêïóìßùò. Ïé ðáñáäïóéáêÝò áðüøåéò ãéá ôçí ðáèïãÝíåóç ôùí ïîÝùí óôåöáíéáßùí óõíäñüìùí áëëÜæïõí. ÌÝ÷ñé ðñüóöáôá ãíùñßæáìå ìüíï ôïõò ëåãüìåíïõò ‘ðáñáäïóéáêïýò’ ðáñÜãïíôåò êéíäýíïõ ãéá êáñäéáããåéáêÞ íüóï üðùò ð.÷. ôï êÜðíéóìá, ç äõóëéðéäáéìßá, ï óáê÷áñþäçò äéáâÞôçò, ç áñôçñéáêÞ õðÝñôáóç êáé ôï èåôéêü ïéêïãåíåéáêü éóôïñéêü. ¼ìùò, ôçí ôåëåõôáßá êõñßùò äåêáåôßá Ý÷ïõí áíáãíùñéóèåß íåüôåñïé ðáñÜãïíôåò êéíäýíïõ, üðùò ïé äåßêôåò öëåãìïíÞò, èñüìâùóçò êáé ïîåéäùôéêïý stress. Ç ðáñïýóá åñãáóßá ðñïóðáèåß íá áíáóêïðÞóåé ôá ôåëåõôáßá äåäïìÝíá óôïí ôïìÝá áõôü.

ËÝîåéò ÊëåéäéÜ: êáñäéáããåéáêÜ íïóÞìáôá, äåßêôåò, öëåãìïíÞ, èñüìâùóç, ïîåéäùôéêü stress ÕðïâëÞèçêå: 29 Éïõëßïõ 2004 ÅðáíõðïâëÞèçêå: 18 Íïåìâñßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 21 Éáíïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ÁíÜñãõñïò Ìáñéüëçò Äéåýèõíóç: ÊïñõôóÜò 3, Âýñùíáò, T.K. 16231 ÁèÞíá, Ôçë: (210)7608051-52, Fax: (210)7608053, e-mail: kyvyrona1@hippocratio.gr 139

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Äåßêôåò öëåãìïíÞò ¸íáò ìåãÜëïò áñéèìüò åñãáóéþí óõíäÝåé ôçí õðåñ÷ïëçóôåñïëáéìßá ìå ôçí áèçñïãÝíåóç. ¼ìùò, ìüíï ðñüóöáôá Ý÷ïõìå áíôéëçöèåß üôé öëåãìïíþäåéò ìç÷áíéóìïß óõíäÝïõí ôç äõóëéðéäáéìßá ìå ôï ó÷çìáôéóìü ôïõ áèçñþìáôïò. Ç ðñüóëçøç ëåõêïêõôôÜñùí êáé ç Ýêöñáóç ðñïöëåãìïíùäþí êõôôïêéíþí ÷áñáêôçñßæïõí ôçí ðñþéìç áèçñïãÝíåóç, åíþ ç äõóëåéôïõñãßá ôùí ìåóïëáâçôþí ôçò öëåãìïíÞò åëáôôþíïõí ôï ó÷çìáôéóìü ôïõ áèçñþìáôïò óôïõò åðßìõò. Åðßóçò, öëåãìïíþäåéò äéáäéêáóßåò åðÜãïõí ôç èñüìâùóç, ìßá üøéìç áëëÜ äñáìáôéêÞ åðéðëïêÞ ôçò áèçñïóêëÞñõíóçò õðåýèõíç ãéá åìöñÜãìáôá ìõïêáñäßïõ êáé ðïëëÜ åãêåöáëéêÜ åðåéóüäéá. Ç íÝá áíôßëçøç ôïõ ñüëïõ ôçò öëåãìïíÞò óôçí áèçñïóêëÞñõíóç ðáñÝ÷åé Ýíá ìç÷áíéêü ðñüôõðï ãéá ôçí êáôáíüçóç ôùí êëéíéêþí åõåñãåôçìÜôùí ôùí õðïëéðéäáéìéêþí èåñáðåéþí. Ç ôáõôïðïßçóç ôùí åíåñãïðïéçôþí ôçò öëåãìïíÞò êáé ç áðïêÜëõøç ôùí ëåðôïìåñåéþí ôùí öëåãìïíùäþí äéáäéêáóéþí ìðïñåß ôåëéêÜ íá ìáò ðáñÝ÷ïõí íÝïõò èåñáðåõôéêïýò óôü÷ïõò1. Ïé ðáñáäïóéáêÝò áðüøåéò ãéá ôçí ðáèïãÝíåóç ôùí ïîÝùí óôåöáíéáßùí óõíäñüìùí áëëÜæïõí. Ïé âëÜâåò õøçëïý êéíäýíïõ äåí åßíáé áíáãêáóôéêÜ ïé áããåéïãñáöéêÜ ìåãÜëåò óôåíþóåéò, áëëÜ ìÜëëïí ïé áóôáèåßò, åðéññåðåßò âëÜâåò ðïõ Ý÷ïõí ìåãÜëïõò ðõñÞíåò áðü ëéðßäéá êáé ëåðôÜ éíþäç êáëýììáôá. Ç áóôÜèåéá ôçò ðëÜêáò ó÷åôßæåôáé óôåíÜ ìå ôçí áíÜðôõîç öëåãìïíÞò ìÝóá óôïí Ýóù ÷éôþíá. Ôá ïîÝá óôåöáíéáßá óýíäñïìá óõíÞèùò ðñïêýðôïõí áðü ñÞîç ìßáò åðéññåðïýò áèçñïóêëçñçíôéêÞò ðëÜêáò ðïõ óõíäÝåôáé ìå ôç öëåãìïíþäç äéáäéêáóßá. Ç óôáèåñïðïßçóç ôùí ðëáêþí ðáñÜ ïé äéáäåñìéêÝò Þ ïé ÷åéñïõñãéêÝò ôå÷íéêÝò áðïôåëåß Ýíá íÝï èåñáðåõôéêü óôü÷ï. Ç ìåßùóç ôùí ëéðéäßùí ìðïñåß íá óôáèåñïðïéÞóåé ôéò âëÜâåò ìåôñéÜæïíôáò ôç öëåãìïíþäç áðÜíôçóç2. Ç ðáñáôÞñçóç üôé ó÷åäüí ôá ìéóÜ åìöñÜãìáôá ôïõ ìõïêáñäßïõ êáé åãêåöáëéêÜ åðåéóüäéá óõìâáßíïõí óå Üôïìá ÷ùñßò õøçëÜ åðßðåäá LDL ÷ïëçóôåñüëçò Ý÷åé ðõñïäïôÞóåé ôç ìåëÝôç ðáñáãüíôùí Üëëùí ðëçí ôçò õðåñëéðéäáéìßáò ðïõ óõìâÜëëïõí óôçí áíÜðôõîç áèçñïóêëÞñõíóçò. ¸íá áõîáíüìåíï óýíïëï áðü åõñÞìáôá äåß÷íåé üôé ç öëåãìïíÞ ðáßæåé ïõóéáóôéêü ñüëï óôçí áíÜðôõîç êáé ôç ñÞîç ôçò ðëÜêáò3. Ðñüóöáôá äåäïìÝíá äåß÷íïõí üôé ç óõóôç140

I. ËÝíôæáò êáé óõí.

ìáôéêÞ öëåãìïíÞ åßíáé Ýíáò éó÷õñüò ðñïãíùóôéêüò äåßêôçò êáñäéáããåéáêþí óõìâáìÜôùí 4, ï ïðïßïò Ý÷åé ïõóéáóôéêÜ åíéó÷ýóåé ôçí éêáíüôçôÜ ìáò íá ôáîéíïìïýìå ôïõò áóèåíåßò áíÜëïãá ìå ôïí êßíäõíï áíÜðôõîçò êÜðïéïõ åðåéóïäßïõ. Áêüìá êáé ìç öëåãìïíþäåéò íÝïé äåßêôåò êéíäýíïõ, üðùò ç ïìïêõóôåÀíç, ìðïñåß íá áõîÞóïõí ôïí êáñäéáããåéáêü êßíäõíï ìÝóù åíåñãïðïßçóçò ìåóïëáâçôþí öëåãìïíÞò5. Ç ðëåéïøçößá ôùí êáñäéáããåéáêþí óõìâáìÜôùí óõìâáßíåé óå èÝóåéò ìç óçìáíôéêÞò óôåíþóåùò, êáèþò ç öëåãìïíÞ ìðïñåß íá ïäçãÞóåé óå áóôÜèåéá êáé ñÞîç áõôþí ôùí ìéêñüôåñùí áèçñïóêëçñùôéêþí ðëáêþí, ïé ïðïßåò åßíáé ìåãáëýôåñåò óå áñéèìü áðü üôé ïé ìåãÜëåò ðëÜêåò ðïõ ìåéþíïõí ôçí ôá÷ýôçôá áéìáôéêÞò ñïÞò. ÐñÜãìáôé, ç Üìåóç åðéóêüðçóç öëåãìïíùäþí êõôôÜñùí ìÝóá óôéò ðëÜêåò åßíáé Ýíáò ðñïãíùóôéêüò ðáñÜãïíôáò ôçò áóôáèïýò óôåöáíéáßáò íüóïõ6. Ç ðçãÞ ôçò öëåãìïíÞò åßíáé áâÝâáéç. ÄéÜöïñïé öëåãìïíþäåéò ðáñÜãïíôåò Ý÷ïõí ðñïôáèåß ùò åíåñãïðïéçôÝò áõôÞò ôçò öëåãìïíþäïõò äéåñãáóßáò, üðùò ëïéìþîåéò áðü ìéêñïïñãáíéóìïýò êáé ïðïéïóäÞðïôå Üëëïò ðáñÜãïíôáò ðïõ ìðïñåß íá ïäçãÞóåé óå ôñáõìáôéóìü ôïõ åíäïèçëßïõ, üðùò õðåñãëõêáéìßá, êÜðíéóìá, ïîåéäùìÝíç LDH ÷ïëçóôåñüëç, åëåýèåñåò ñßæåò, Þ ïîý stress óôï áããåßï áðü õðÝñôáóç. Ãåíåôéêïß ðáñÜãïíôåò ìðïñïýí åðßóçò íá äéáäñáìáôßóïõí êáèïñéóôéêü ñüëï óôï âáèìü Þ ôç äéÜñêåéá ôçò öëåãìïíþäïõò áðÜíôçóçò áðü Üôïìï óå Üôïìï. ¼ìùò, áõôÝò ïé ãåíåôéêÝò åðéäñÜóåéò äåí Ý÷ïõí îåêáèáñéóôåß ðëÞñùò. ÌåôÜ áðü õðïîßá, õðåñïîõãüíùóç, õðåñéþäç áêôéíïâïëßá, âáêôçñéáêÞ Þ éïãåíÞ ëïßìùîç Þ Ýêèåóç óôçí áããåéïôåíóßíç ÉÉ, åëåõèåñþíåôáé ï ìåôáãñáöéêüò ðáñÜãïíôáò nuclear factor kappa B (NF-KB), ëåéôïõñãþíôáò ùò Ýíáò áðü ôïõò ðñùéìüôåñïõò åíåñãïðïéçôÝò ôïõ êáôáññÜêôç ôçò öëåãìïíÞò.7 Áõôüò ï ðáñÜãïíôáò ðáßæåé êáèïñéóôéêü ñüëï óôçí Ýíáñîç ìåôáãñáöÞò ãïíéäßùí êõôïêéíþí (ð.÷. TNF-a), ÷çìåéïôáêôéêþí ðáñáãüíôùí (ð.÷. monocyte attractant protein-1) êáé ìïñßùí ðñïóêüëëçóçò. Ïé ÷çìåéïôáêôéêïß ðáñÜãïíôåò Ýëêïõí ìïíïêýôôáñá áðü ôï áßìá êáé ôá ìüñéá ðñïóêüëëçóçò “óõëëáìâÜíïõí” ôá ìïíïêýôôáñá óôçí åðéöÜíåéá ôïõ åíäïèçëßïõ, åðéôñÝðïíôáò óôá ìïíïêýôôáñá íá äéáðåñÜóïõí ôï åíäïèçëéáêü öñÜãìá êáé íá ãßíïõí ìáêñïöÜãá. Ç åßóïäïò ôùí ìïíïêõôôÜñùí ìÝóá óôï áããåéáêü ôïß÷ùìá åßíáé ôï êëåéäß ãéá ôçí áíÜðôõîç

I. ËÝíôæáò êáé óõí.

ôçò áèçñïóêëÞñõíóçò, êáèþò ôï ìðëïêÜñéóìá ôçò ìåôáíÜóôåõóçò ôùí ìïíïêõôôÜñùí Ý÷åé âåëôéþóåé ôçí áèçñïóêëÞñõíóç óå ìïíôÝëá ðåéñáìáôüæùùí8. ¼ôáí ôá ìïíïêýôôáñá âñåèïýí ìÝóá óôï áããåéáêü ôïß÷ùìá ðáñÜãïõí êõôïêßíåò (IL-1, IL-6 êáé TNF-á) êáé åíåñãïðïéïýí ìå áõôü ôïí ôñüðï ôïí êáôáññÜêôç ôçò öëåãìïíÞò. Åðßóçò, áðåëåõèåñþíïíôáé ìåôáëëïðñùôåúíÜóåò åðÜãïíôáò ôïí ðïëëáðëáóéáóìü ôùí ëåßùí ìõúêþí êõôôÜñùí êáé ôç ëÞøç LDL áðü áõôÜ ôá êýôôáñá þóôå íá ìåôáôñáðïýí óå áöñþäç êýôôáñá. Ìå ôç óõíå÷Þ ëÞøç ëéðïðñùôåúíþí, ìßá ëéðþäçò ãñÜììùóç ìðïñåß íá åîåëé÷èåß óå ìßá ìåãÜëç áèçñùóêëçñùôéêÞ ðëÜêá. Ôï áèÞñùìá êáëýðôåôáé êáé ðñïóôáôåýåôáé áðü Ýíá éíþäåò êÜëõììá, ôï ïðïßï âñßóêåôáé óå éóïññïðßá, ç ïðïßá êáèïñßæåôáé áðü ôçí åíáðüèåóç êïëëáãüíïõ (ìÝóù ôùí ëåßùí ìõúêþí êõôôÜñùí) êáé ôçí áðïäüìçóç ôïõ êïëëáãüíïõ (ìÝóù IL-6, TNF-á êáé ìåôáëëïðñùôåúíáóþí). Ó÷Üóç Þ ñÞîç ôçò ðëÜêáò ìðïñåß íá óõìâåß üôáí áõôÞ ç éóïññïðßá äéáôáñÜóóåôáé áðü áõîçìÝíç öëåãìïíÞ ïäçãþíôáò óôç ëÝðôõíóç ôïõ éíþäïõò êáëýììáôïò. Ç ñÞîç ôçò ðëÜêáò åêèÝôåé Üêñùò èñïìâïãåíåßò ïõóßåò óôï áßìá, ïäçãþíôáò óå ôïðéêü ó÷çìáôéóìü èñüìâïõ. Åðßóçò, öëåãìïíþäåéò êõôïêßíåò ïäçãïýí óå åíåñãïðïßçóç ôùí áéìïðåôáëßùí êáé Ýêöñáóç ôùí ìïñßùí P-selectin êáé CD40 óôçí åðéöÜíåéÜ ôïõò, áõîÜíïíôáò ìå áõôü ôïí ôñüðï ôç ìåôáîý ôïõò óõãêüëëçóç9. ¸ôóé, Ýíáò ìåãÜëïò áñéèìüò ðáñáãüíôùí ìðïñåß íá ðñïêáëÝóåé ôçí Ýíáñîç ìßá ðïëýðëïêçò öëåãìïíþäïõò äéåñãáóßáò ç ïðïßá ïäçãåß óôï ó÷çìáôéóìü, áíÜðôõîç êáé áðïóôáèåñïðïßçóç ôçò áèçñùìáôéêÞò ðëÜêáò êáé óôç óõíÝ÷åéá óôï ó÷çìáôéóìü èñüìâïõ ìå óõíÝðåéá ôçí åìöÜíéóç ïîÝùí éó÷áéìéêþí óôåöáíéáßùí óõíäñüìùí Þ åìöñÜãìáôïò ôïõ ìõïêáñäßïõ. Ïé êõôïêßíåò, åðßóçò, óçìáôïäïôïýí ôçí ðáñáãùãÞ ðñùôåúíþí ïîåßáò öÜóçò, üðùò éíùäïãüíï, áìõëïåéäÝò Á êáé CRP, ïé ïðïßåò ðáñÜãïíôáé áñ÷éêÜ óôï Þðáñ. Áõôïß åßíáé óõóôçìáôéêïß äåßêôåò öëåãìïíÞò êáé åßíáé ðéï åýêïëï íá ìåôñçèïýí áðü üôé Üëëïé ðáñÜãïíôåò üðùò ïé éíôåñëåõêßíåò åîáéôßáò ìéêñüôåñçò çìåñÞóéáò äéáêýìáíóçò. Ôá åðßðåäá ôïõ éíùäïãüíïõ åßíáé åí ìÝñåé ãåíåôéêþò êáèïñéóìÝíá, áëëÜ áõîÜíïõí ìå ôçí çëéêßá, ôï äéáâÞôç, ôçí LDL ÷ïëçóôåñüëç, ôçí ðá÷õóáñêßá, ôçí åììçíüðáõóç êáé ôïí áñéèìü ëåõêþí áéìïóöáéñßùí10. Óôç ìåëÝôç Framingham11,

Ôüìïò 17, Ôåý÷ïò 3, 2005

ó÷åäüí 50% ôïõ êáñäéáããåéáêïý êéíäýíïõ ðïõ ó÷åôéæüôáí ìå ôï êÜðíéóìá áðïäüèçêå óôï áõîçìÝíï éíùäïãüíï êáé ìßá ìåôá-áíÜëõóç Ýäåéîå üôé ôá áíþôåñá åðßðåäá ôïõ éíùäïãüíïõ ïäçãïýóáí óå ó÷åôéêü êßíäõíï ôçò ôÜîçò ôïõ 1,8 ãéá êáñäéáããåéáêÜ óõìâÜìáôá12. Ôï éíùäïãüíï öáßíåôáé üôé áõîÜíåé ôïí êßíäõíï ìÝóù ôçò åðáãùãÞò ôçò óõíÜèñïéóçò ôùí áéìïðåôáëßùí êáé ôïõ ðïëëáðëáóéáóìïý ôùí ëåßùí ìõúêþí êõôôÜñùí13. Ôï áìõëïåéäÝò Á ôïõ ïñïý åßíáé ìßá ëéðïðñùôåÀíç ðïõ ó÷åôßæåôáé ìå ôç ëåéôïõñãßá ôçò HDL ÷ïëçóôåñüëçò. Ôá åðßðåäÜ ôïõ åßíáé ìåôñßùò áõîçìÝíá óå óôåöáíéáßïõò áóèåíåßò óõãêñéíüìåíá ìå õãéþí áôüìùí êáé åßíáé 5 öïñÝò õøçëüôåñá ìåôÜ áðü ìåôáìüó÷åõóç êáñäéÜò14. Åðßóçò, ôï áìõëïåéäÝò Á, Þôáí ðñïãíùóôéêüò ðáñÜãïíôáò èíçôüôçôáò óå áóèåíåßò ìå áóôáèÞ óôçèÜã÷ç15 êáé ìåôÜ ìåôáìüó÷åõóç êáñäéÜò. ÐáñáìÝíåé áóáöÝò åÜí ôï áìõëïåéäÝò åßíáé ðñïóôáôåõôéêü Þ åðéâëáâÝò, êáèþò áíáóôÝëëåé ôïí ðïëëáðëáóéáóìü ôùí åíäïèçëéáêþí êõôôÜñùí êáé ôç óõíÜèñïéóç ôùí áéìïðåôáëßùí16, áëëÜ ìåéþíåé ôá åðßðåäá ôçò HDL ÷ïëçóôåñüëçò17. ÐïëëÜ Üëëá ðáñÜãùãá ôïõ êáôáññÜêôç ôçò öëåãìïíÞò Ý÷ïõí áðïäåé÷èåß üôé åßíáé äåßêôåò óôåöáíéáßùí Þ êáñäéáããåéáêþí óõìâáìÜôùí, ðåñéëáìâÜíïíôáò ôï D-dimer18, ôçí IL-619, ôïí åíåñãïðïéçôÞ ôïõ ðëáóìéíïãüíïõ20, êõôôáñéêÜ ìüñéá ðñïóêüëëçóçò21, ôïí TNF-á22, ôç öùóöïëéðÜóç Á223, ôïí áñéèìü ôùí ëåõêþí áéìïóöáéñßùí12 êáé ôç ó÷åôéæüìåíç ìå ôçí åãêõìïóýíç ìåôáëëïðñùôåúíÜóç ôïõ ðëÜóìáôïò, ðñùôåÀíç Á24. ¼ìùò, ç õøçëÞò åõáéóèçóßáò CRP (hs-CRP) åßíáé Ýíáò ðéï éó÷õñüò ðñïãíùóôéêüò äåßêôçò ãéá óôåöáíéáßá íüóï25 Þ ìåëëïíôéêÜ êáñäéáããåéáêÜ óõìâÜìáôá26 áðü üôé ïé ðåñéóóüôåñïé öëåãìïíþäåéò äåßêôåò, ðåñéëáìâáíïìÝíïõ ôïõ éíùäïãüíïõ êáé ôïõ áìõëïåéäïýò Á. ¸ôóé, ç CRP Ý÷åé áíáäåé÷èåß óáí ï ðéï ÷ñÞóéìïò öëåãìïíþäçò äåßêôçò ãéá ôçí åêôßìçóç ôïõ êáñäéáããåéáêïý êéíäýíïõ: åßíáé åõñÝùò ìåëåôçìÝíç, ôá áðïôåëÝóìáôÜ ôçò åßíáé åðáíáëÞøéìá êáé åßíáé ó÷åôéêÜ öèçíÞ åîÝôáóç êáé åõñÝùò äéáäåäïìÝíç. ÐïëëÝò ìåëÝôåò Ý÷ïõí äåßîåé ôçí éêáíüôçôá ôçò hs-CRP íá áðïôåëåß ðñïãíùóôéêü äåßêôç ãéá ìåëëïíôéêÜ êáñäéáããåéáêÜ óõìâÜìáôá êáé óå ðñùôïðáèÝò27,28 êáé äåõôåñïðáèÝò åðßðåäï29. Óáí áðëü test áðü ìüíï ôïõ, åßíáé ðéï éó÷õñüò ðñïãíùóôéêüò äåßêôçò áðü üôé ïé ðáñáäïóéáêïß ðáñÜãïíôåò êéíäýíïõ, üðùò ôï êëÜóìá ïëéêÞò/HDL ÷ïëçóôåñüëç, ï äéáâÞ141

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôçò30, ç óõìöïñçôéêÞ êáñäéáêÞ áíåðÜñêåéá Þ ôï êÜðíéóìá.

Äåßêôåò Èñüìâùóçò ÅíåñãïðïéçìÝíïé äåßêôåò ðÞîçò êáé éíùäüëõóçò åßíáé áõîçìÝíïé óå Üôïìá ìå áõîçìÝíï êßíäõíï ãéá óôåöáíéáßá íüóï êáé Üëëåò äéáôáñá÷Ýò ôïõ ìç÷áíéóìïý ðÞîåùò – ìßá êáôÜóôáóç ðïõ åßíáé ãíùóôÞ ùò ðñïèñïìâùôéêÞ êáôÜóôáóç31. Ç åíåñãïðïßçóç ôùí ìç÷áíéóìþí ðÞîçò êáé éíùäüëõóçò êáèïñßæåôáé óå Ýíá óçìáíôéêü âáèìü áðü ãåíåôéêïýò ðáñÜãïíôåò. Ôá ãïíßäéá ðïõ åðçñåÜæïõí ôçí åíåñãïðïßçóç ôçò áéìüóôáóçò åßíáé ðéèáíü íá áðïôåëïýí óçìáíôéêü óõóôáôéêü ôçò óõíïëéêÞò ðñïäéÜèåóçò ãéá èñüìâùóç óôï ãåíéêü ðëçèõóìü31. Ç åñãáóôçñéáêÞ åêôßìçóç ôçò âéïëïãßáò ôçò ðÞîçò êáé ôùí áéìïðåôáëßùí Ý÷åé ðáñáäïóéáêÜ åðéêåíôñùèåß óôéò áíùìáëßåò, óõããåíåßò Þ åðßêôçôåò, ðïõ ìáò âïçèïýí íá êáôáíïÞóïõìå ôéò äéáôáñá÷Ýò ôçò áéìüóôáóçò, ôéò áíåîÞãçôåò áéìïññáãßåò êáé ôç öáñìáêïëïãéêÞ ôéôëïðïßçóç ôùí ïõóéþí ðïõ ðñïïñßæïíôáé ãéá ôçí áíáóôïëÞ ôïõ ìç÷áíéóìïý ôçò èñüìâùóçò. ÅðåéäÞ ç áñôçñéïóêëçñõíôéêÞ áããåéáêÞ íüóïò ó÷åôßæåôáé ìå ôï ìç÷áíéóìü ôçò ðÞîçò êáé õðÜñ÷åé óáöÞò ó÷Ýóç ìåôáîý ôçò áèçñïóêëÞñùóçò, ôçò öëåãìïíÞò êáé ôçò èñüìâùóçò, ç áíÜðôõîç äåéêôþí ðïõ Ý÷ïõí ðáèïöõóéïëïãéêÞ, ðñïãíùóôéêÞ êáé èåñáðåõôéêÞ ó÷Ýóç Ý÷åé áñ÷ßóåé íá ðáßñíåé óçìáíôéêÝò äéáóôÜóåéò32. Óýìöùíá ìå ôïí Giannitsis et al, ç ðÞîç ôïõ áßìáôïò ó÷åôßæåôáé ìå ôç óïâáñüôçôá ôçò óôåöáíéáßáò íüóïõ êáé ïé áéìïóôáôéêïß äåßêôåò ôçò åíåñãïðïßçóçò ôçò èñïìâßíçò (åðßðåäá ðëÜóìáôïò ôùí êëáóìÜôùí ðñïèñïìâßíçò F1+2, óýìðëåãìá èñïìâßíçò – áíôéèñïìâßíçò ÉÉÉ) áðïôåëïýí ÷ñÞóéìï åñãáëåßï ãéá ôçí ôáõôïðïßçóç áóèåíþí ìå ëáíèÜíïõóá õðåñðçêôéêÞ êáôÜóôáóç ðïõ Ý÷ïõí ìåãáëýôåñç ðñïäéÜèåóç íá õðïóôïýí èñüìâùóç ôùí óôåöáíéáßùí áñôçñéþí33. Åðßóçò, ïé ðáñáðÜíù äåßêôåò äåí ó÷åôßæïíôáé ìå ôçí ðáñïõóßá áñôçñéáêÞò íüóïõ, áëëÜ ôá áõîçìÝíá åðßðåäá áõôþí åßíáé áðáñáßôçôá ãéá ôç èåôéêÞ óõó÷Ýôéóç ìåôáîý ôùí åðéðÝäùí D-Dimer êáé ôçò áñôçñéáêÞò íüóïõ34. ÁõîçìÝíá åðßðåäá D-Dimer éíþäïõò åßíáé åíäåéêôéêÜ ôçò õðåñðçêôéêÞò êáôÜóôáóçò êáé 142

I. ËÝíôæáò êáé óõí.

ó÷åôßæïíôáé éó÷õñÜ êáé áíåîÜñôçôá ìå ôçí ðáñïõóßá óôåöáíéáßáò íüóïõ óå áóèåíåßò ìå óôáèåñÞ óôçèÜã÷ç. ÁõôÜ ôá áðïôåëÝóìáôá õðïóôçñßæïõí ôçí õðüèåóç ôçò óõíåéóöïñÜò ôïõ åíäáããåéáêïý éíþäïõò óôçí áèçñïèñïìâoãÝííåóç35. ÁõîçìÝíá åðßðåäá Üëëùí áéìïóôáôéêþí äåéêôþí, üðùò ï ðáñÜãïíôáò ×ÉÉ36, ï ðáñÜãïíôáò ×É, ç ðñïêáëëéêñåÀíç, ôï õøçëïý ìïñéáêïý âÜñïõò êéíéíïãüíï37, ç oìïêõóôåÀíç38 êáé ôï éíùäïðåðôßäéï Á (FPA)39, ìðïñåß íá ðáßæïõí óçìáíôéêü ñüëï óôçí ðáèïãÝíåóç ôçò óôåöáíéáßáò íüóïõ. Ç äéáôáñáãìÝíç ëåéôïõñãßá ôçò éíùäüëõóçò åîáéôßáò áõîçìÝíùí åðéðÝäùí óôï ðëÜóìá ôïõ áíáóôïëÝá åíåñãïðïßçóçò ôïõ ðëáóìéíïãüíïõ (ÑÁÉ-1) Þ ôïõ éóôéêïý åíåñãïðïéçôÞ ôïõ ðëáóìéíïãüíïõ (tPA) óõó÷åôßæåôáé ìå ôçí áíÜðôõîç åìöñÜãìáôïò ôïõ ìõïêáñäßïõ óå áóèåíåßò ìå Ýêäçëç óôåöáíéáßá íüóï40.

Äåßêôåò ïîåéäùôéêïý stress Ôá êýôôáñá óõíå÷þò ðáñÜãïõí åëåýèåñåò ñßæåò êáé äñáóôéêÝò ìïñöÝò ïîõãüíïõ ùò ìÝñïò ôùí ìåôáâïëéêþí äéåñãáóéþí ôïõò. ÁõôÝò ïé åëåýèåñåò ñßæåò åîïõäåôåñþíïíôáé áðü Ýíá ðïëýðëïêï áíôéïîåéäùôéêü áìõíôéêü óýóôçìá áðïôåëïýìåíï áðü Ýíæõìá, üðùò ç êáôáëÜóç, ç äéóìïõôÜóç ôïõ óïõðåñïîåéäßïõ, ç õðåñïîåéäÜóç ôçò ãëïõôáèåéüíçò êáé ìåãÜëïò áñéèìüò ìç åíæõìáôéêþí áíôéïîåéäùôéêþí, üðùò ïé âéôáìßíåò Á, Å êáé C, ç ãëïõôáèåéüíç, ç ïõìðéêéíüíç êáé ôá öëáâïíïåéäÞ. Ïîåéäùôéêü stress óõìâáßíåé üôáí õðÜñ÷åé áíéóïññïðßá ìåôáîý ôçò ðáñáãùãÞò åëåõèÝñùí ñéæþí êáé ôçò áíôéïîåéäùôéêÞò éêáíüôçôáò. Áõôü, ìðïñåß íá ïöåßëåôáé åßôå óôçí áõîçìÝíç ðáñáãùãÞ åëåõèÝñùí ñéæþí óôïí ïñãáíéóìü åßôå óôçí áðþëåéá ôùí öõóéïëïãéêþí áíôéïîåéäùôéêþí ìç÷áíéóìþí. Ôï ïîåéäùôéêü stress Ý÷åé ó÷åôéóèåß ìå ôçí ðñüêëçóç êáñäéáããåéáêþí íüóùí41-43. Ï ñüëïò ôùí áíôéïîåéäùôéêþí óôçí ðñùôïðáèÞ êáé äåõôåñïðáèÞ ðñüëçøç ôçò óôåöáíéáßáò íüóïõ âñßóêåôáé õðü ìåëÝôç. ÐáñÜ ôï üôé åðéäçìéïëïãéêÜ äåäïìÝíá äåß÷íïõí üôé ôá áíôéïîåéäùôéêÜ ìðïñåß íá ìåéþóïõí ôïí êáñäéáããåéáêü êßíäõíï, ôá áðïôåëÝóìáôá ôùí êëéíéêþí ìåëåôþí äåí ôï åðéâåâáéþíïõí44. Öáßíåôáé üôé õðÜñ÷åé óáöÞò ó÷Ýóç áéôßïõ – áðïôåëÝóìáôïò ìåôáîý ôçò ïîåßäùóçò ôçò LDL êáé ôçò áèçñïóêëÞñõíóçò45. Ç áèçñïóêëÞñõíóç

I. ËÝíôæáò êáé óõí.

åßíáé ìßá ðïëõðáñáãïíôéêÞ íüóïò êáé ç LDL ïîåéäþíåôáé áðü üëá ôá êýôôáñá ôïõ áñôçñéáêïý ôïé÷þìáôïò êáôÜ ôç äéÜñêåéá ôçò áíÜðôõîçò ôçò áèçñïóêëÞñõíóçò ìÝóù ðåñéóóüôåñùí áðü Ýíá ìç÷áíéóìþí. Ïé ðïéêßëïé ìç÷áíéóìïß ïîåßäùóçò ôçò LDL ðáñÜãïõí áñêåôÜ ðñïúüíôá õðåñïîåßäùóçò ëéðéäßùí, üðùò éóïðñïóôÜíéá áðü áñá÷éäïíéêü ïîý, åéêïóéðåíôáíïúêÜ ïîÝá, ïîõóôåñüëåò áðü ìç åóôåñïðïéçìÝíç êáé åóôåñïðïéçìÝíç ÷ïëçóôåñüëç, õäñüîõ ëéðáñÜ ïîÝá, õðåñïîåßäéá ëéðéäßùí êáé áëäåàäåò. ¸ôóé, ìßá áðëÞ ìÝôñçóç ëéðéäéáêÞò õðåñïîåßäùóçò åßíáé ðéèáíü íá ìçí åßíáé åðáñêÞò ùò äåßêôçò êáñäéáããåéáêïý êéíäýíïõ êáé ãé’ áõôü õðÜñ÷åé áíÜãêç ãéá ìåôñÞóåéò ðåñéóóüôåñùí äåéêôþí. Ìåñéêïß áðü ôïõò ðéï óõ÷íÜ ÷ñçóéìïðïéçìÝíïõò äåßêôåò ïîåéäùôéêïý stress, åßíáé ôá õðåñïîåßäéá ôùí ëéðéäßùí ôïõ ðëÜóìáôïò46, ç äéóìïõôÜóç ôïõ óïõðåñïîåéäßïõ óôá åñõèñïêýôôáñá, ç õðåñïîåéäÜóç ôçò ãëïõôáèåéüíçò óôï áßìá, ç ìáëïíäéáëäåàäç, ç ïëéêÞ áíôéïîåéäùôéêÞ éêáíüôçôá ôïõ ðëÜóìáôïò êáé ôá åðßðåäá 8-epi-PG F2á óôá ïýñá47.

ÓõìðÝñáóìá ÓõìðåñáóìáôéêÜ, èá ìðïñïýóáìå íá ðïýìå üôé ôçí ôåëåõôáßá äåêáåôßá êõñßùò, ç Ýñåõíá óôï ðåäßï ôùí êáñäéáããåéáêþí íïóçìÜôùí Ý÷åé óôñáöåß óôçí áíß÷íåõóç íÝùí ðáñáãüíôùí ìå ðñïãíùóôéêÞ óçìáóßá. ÕðÜñ÷åé ìåãÜëç ðéèáíüôçôá ïé íÝïé áõôïß äåßêôåò óå ëßãá ÷ñüíéá íá ãßíïõí åîåôÜóåéò ñïõôßíáò, ïé ïðïßåò èá Ý÷ïõí éó÷õñÞ ðñïâëåðôéêÞ éó÷ý ãéá ôçí åìöÜíéóç ìåëëïíôéêþí êáñäéáããåéáêþí óõìâáìÜôùí óôï ãåíéêü ðëçèõóìü. Ðéóôåýïõìå ëïéðüí üôé ïé Ãåíéêïß Éáôñïß, ïé ïðïßïé åßíáé ïé âáóéêïß ëåéôïõñãïß ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, ðñÝðåé íá åßíáé åíçìåñùìÝíïé ãéá ôéò íÝåò áõôÝò åîåëßîåéò óôïí ôïìÝá ôçò ðñüëçøçò ôçò êáñäéáããåéáêÞò íüóïõ.

Âéâëéïãñáößá 1. Libby P. Inflammation in atherosclerosis. Nature, 420:868-874, 2002. 2. Libby P. Coronary artery injury and the biology of atherosclerosis: inflammation, thrombosis, and stabilization. Am J Cardiol, 86:3J-8J, 2000. 3. Ridker PM. Connecting, the role of C-reactive protein and statins in cardiovascular disease.

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ÁÍÁÖÏÑÁ ÐÅÑÉÐÔÙÓÇÓ CASE REPORT Primary Heatlh Care, Volume 17, Number 3, 146-150, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 146-150, 2005

ÖëåãìïíÝò êáé áðïóôÞìáôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò. Ðáñïõóßáóç äýï êëéíéêþí ðåñéðôþóåùí ×. ÓêïõëÜêçò1, Ã. Ëýêáò2, Ì. Ðáîéíüò3, É. ÔæÝëç3, Í. Êüêêáëçò4, Ð. Ìïó÷ïíôæüðïõëïò5, Ä. ÂáëáãéÜííçò6 Ðåñßëçøç ÅéóáãùãÞ: Ôá áðïóôÞìáôá ôïõ ôñá÷Þëïõ åßíáé óõíÞèùò óïâáñÝò êáôáóôÜóåéò. Ãéá ôç óùóôÞ áíôéìåôþðéóÞ ôïõò ÷ñåéÜæåôáé óùóôÞ áíôéâéïôéêÞ êÜëõøç êáé óõ÷íÜ ÷åéñïõñãéêÞ äéÜíïéîç êáé ðáñï÷Ýôåõóç. Ôï âëåííïãïíïöáñõããéêü (ÂÖÄ) åßíáé Ýíá áðü ôá äéáóôÞìáôá ôïõ ôñá÷Þëïõ êáé ðñïóäéïñßæåôáé ìåôáîý âëåííïãüíïõ ôïõ öÜñõããá êáé óôïìáôïöáñõããéêÞò ðåñéôïíßáò. Ôá áðïóôÞìáôá ðïõ åíôïðßæïíôáé óôï äéÜóôçìá áõôü óõíÞèùò äéáíïßãïíôáé áðü ìüíá ôïõò ðñïò ôïí öÜñõããá. Áóèåíåßò: ÐáñïõóéÜæåôáé ç åìðåéñßá áðü ôçí áíôéìåôþðéóç 2 áóèåíþí ìå áðïóôÞìáôá óôï âëåííïãïíïöáñõããéêü äéÜóôçìá (ÂÖÄ). ÁðïôåëÝóìáôá: Ïé áóèåíåßò Þñèáí ìå óïâáñÞ äõóêáôáðïóßá ÷ùñßò åêóåóçìáóìÝíç ôñá÷çëéêÞ äéüãêùóç. ÊáôÜ ôçí åîÝôáóç ðáñïõóßáæáí ðñïâïëÞ ôïõ ðëÜãéïõ öáñõããéêïý ôïé÷þìáôïò, åíäïáõëéêÜ, ðñïò ôç ìÝóç ãñáììÞ. Ìå ôç âïÞèåéá ôçò õðïëïãéóôéêÞò ôïìïãñáößáò åíôïðßóôçêå ç ðáñïõóßá áðïóôÞìáôïò óôï ÂÖÄ. Óôéò ðåñéðôþóåéò ôçò ìåëÝôçò, ìåôÜ áðü óõíôçñçôéêÞ áãùãÞ 1-4 çìåñþí, åß÷áìå áõôüìáôç äéÜíïéîç ôïõ áðïóôÞìáôïò ðñïò ôïí áõëü ôïõ öÜñõããá. Ïé áóèåíåßò èåñáðåýèçêáí ÷ùñßò åðéðëïêÝò êáé åîÞëèáí óå 7-8 ìÝñåò. ÓõìðÝñáóìá: Ôá áðïóôÞìáôá ôïõ ÂÖÄ óõíÞèùò ìðïñïýí íá èåñáðåõèïýí ìå óõíôçñçôéêÞ áãùãÞ ÷ùñßò ÷åéñïõñãéêÞ åðÝìâáóç.

1,5

Ùôïñéíïëáñõããïëüãïò, ÅðéìåëçôÞò Á´, 2Åéäéêåõüìåíïò ÃåíéêÞò ÉáôñéêÞò, 3Åéäéêåõüìåíïé Ùôïñéíïëáñõããïëïãßáò, 4Ùôïñéíïëáñõããïëüãïò, Áí. ÄéåõèõíôÞò, 6Ùôïñéíïëáñõããïëüãïò, ÄéåõèõíôÞò, ÙÑË ÊëéíéêÞ Ãåíéêïý Íïìáñ÷éáêïý Íïóïêïìåßïõ Âüëïõ

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ÅéóáãùãÞ Ïé öëåãìïíþäåéò åîåñãáóßåò ôïõ áíþôåñïõ áíáðíåõóôéêïý óõóôÞìáôïò áðoôåëïýí ìßá ìåãÜëç ïìÜäá ðáèïëïãéêþí êáôáóôÜóåùí, ôéò ïðïßåò óõ÷íÜ êáëåßôáé íá äéáãíþóåé êáé íá áíôéìåôùðßóåé ï ãéáôñüò. ÐåñéëáìâÜíïõí ôéò åðéöáíåéáêÝò öëåãìïíÝò ôïõ âëåííïãüíïõ (öáñõããßôéäá, áìõãäáëßôéäá, ê.ëð.), ôéò öëåãìïíÝò ôùí êïéëïôÞôùí ôçò ðåñéï÷Þò (éãìïñßôéäá, ùôßôéäá) êáé ôéò öëåãìïíÝò êáé ôá áðïóôÞìáôá ðïõ åíôïðßæïíôáé óôá åí ôù âÜèåé áíáôïìéêÜ ìüñéá ôïõ ôñá÷Þëïõ1. Åíþ ïé öëåãìïíþäåéò åîåñãáóßåò ôïõ âëåííïãüíïõ ôïõ öÜñõããá êáé ôùí êïéëïôÞôùí, áíôéìåôùðßæïíôáé éêáíïðïéçôéêÜ ìå óõíôçñçôéêÞ áíôéâéïôéêÞ áãùãÞ êáé Ý÷ïõí óõíÞèùò êáëÞ Ýêâáóç ÷ùñßò åðéðëïêÝò, ïé åí ôù âÜèåé öëåãìïíÝò ôïõ ôñá÷Þëïõ åßíáé óïâáñüôåñåò êáé ðéï åðéêßíäõíåò êáôáóôÜóåéò. Ç åðéêéíäõíüôçôÜ ôïõò ïöåßëåôáé óôï üôé ìðïñåß íá åðåêôáèïýí ó÷åôéêÜ ËÝîåéò ÊëåéäéÜ: áðüóôçìá, öëåãìïíÞ, ôñÜ÷çëïò, âëåííïãüíïò, ãåíéêüò éáôñüò ÕðïâëÞèçêå: 9 Äåêåìâñßïõ 2003 ÅðáíõðïâëÞèçêå: 27 Éïõëßïõ 2004 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 1 Óåðôåìâñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ×áñÜëáìðïò ÓêïõëÜêçò, Ùôïñéíïëáñõããïëüãïò. Äéåýèõíóç: ÄçìçôñéÜäïò 287, Ô.Ê. 38222, Âüëïò, Ôçë.: (24210)36112, e-mail: skulakis@Hotmail.com êáé skulakis@otenet.gr

×. ÓêïõëÜêçò êáé óõí.

Ôüìïò 17, Ôåý÷ïò 3, 2005

âñÜã÷ïò öùíÞò êáé Þðéá óõìðôùìáôïëïãßá ëïßìùîçò ôïõ áíþôåñïõ áíáðíåõóôéêïý, áðü ôñéçìÝñïõ ÷ùñßò íá Ý÷åé ðÜñåé êÜðïéá öáñìáêåõôéêÞ áãùãÞ. Áðü ôï éóôïñéêü äåí áíáöÝñèçêå Summary Objective: Neck abscesses are serious conditions, their management includes êÜðïéïò ðñüóöáôïò ôñáõìáôéóìüò ôïõ administration of antibiotics and often surgical intervention and drainage. The öÜñõããá. Óçìåéþíåôáé üôé ç áóèåíÞò pharyngeal mucosal space (PMS) lies between the pharyngeal mucosa and the äåí åß÷å õðïâëçèåß óå áìõãäáëåêôïìÞ middle layer (buccopharyngeal fascia) of deep cervical fascia. Abscesses of óôï ðáñåëèüí. ÊáôÜ ôçí êëéíéêÞ åîÝthis space usually drained spontaneously to the pharynx. Patients: We present ôáóç äéáðéóôþèçêå ðñïâïëÞ ôïõ ôïéour experience in the management of 2 patients with abscesses of the PMS. Results: The patients presented with dysphagia, without any marked neck ÷þìáôïò ôïõ õðïöÜñõããá áñéóôåñÜ swelling. On examination the lateral pharyngeal wall protruded toward the midlêáèþò êáé ðéï ïßäçìá óôç ãëùóóéêÞ ine. CT scan revealed the presence of PMS. Ôhe patients were managed åðéöÜíåéá ôçò åðéãëùôôßäáò. Ç áóèåconservatively and spontaneous drainage resulted toward the pharyngeal lumen íÞò åß÷å èåñìïêñáóßá 37,8° C, ÔÊÅ between the first and fourth day. There were no complications and both patients 45mm ôçí 1ç þñá êáé ç ãåíéêÞ áßìáwere discharged after 7-8 days. Conclusion: Abscesses of the PMS can be managed conservatively without surgical intervention. ôïò Ýäåéîå 20.900 ëåõêÜ/uL (83% ðïKey words: abscesses, inflammation, cervix, mucous membrane, general pracëõìïñöïðýñçíá, 8,4% ëåìöïêýôôáñá). titioner Óôçí áîïíéêÞ ôïìïãñáößá äéáðéóôþèçêå ðáñïõóßá áðïóôÞìáôïò óôï âëåíGeneral Hospital of Volos íïãïíïöáñõããéêü äéÜóôçìá áñéóôåñÜ, ìåãÝèïõò 3cm x 2cm (Eéêüíá 1). H åýêïëá óå æùôéêÜ áíáôïìéêÜ ìüñéá ôçò ðåñéï- áóèåíÞò ôÝèçêå óå áãùãÞ ìå êåöáëïóðïñßíç 2çò ÷Þò2. ¸ôóé, Ýíá åí ôù âÜèåé ôñá÷çëéêü áðüóôçìá ãåíéÜò, ìåôñïíéäáæüëç, êáèþò êáé ìå ãáñãáñéìðïñåß íá åðåêôáèåß êáé íá ðñïêáëÝóåé äéÜâñù- óìïýò ìå æåóôü áëáôüíåñï. ÊáôÜ ôçí ôñßôç çìÝñá óç ôçò êáñùôßäáò áñôçñßáò, ïðüôå ôßèåôáé óå ìåôÜ ôçí åéóáãùãÞ ôï áðüóôçìá äéáíïß÷ôçêå áõÜìåóï êßíäõíï ç æùÞ ôïõ ðÜó÷ïíôïò. ôüìáôá êáé ç áóèåíÞò åîÞëèå óå êáëÞ êáôÜóôáÃéá ôç óùóôÞ áíôéìåôþðéóç ôùí áðïóôçìÜ- óç, áðýñåôç, ôçí üãäïç çìÝñá ôçò íïóçëåßáò ôçò. ôùí ôïõ ôñá÷Þëïõ ÷ñåéÜæåôáé ü÷é ìüíï óùóôÞ Ðåñßðôùóç 2: Ãõíáßêá çëéêßáò 51 åôþí ðñïáíôéâéïôéêÞ êÜëõøç, áëëÜ ðïëý óõ÷íÜ êáé ÷åé- óÞëèå ìå Ýíôïíç äõóêáôáðïóßá áðü äéçìÝñïõ. Äåí ñïõñãéêÞ äéÜíïéîç êáé ðáñï÷Ýôåõóç. Ç êáëÞ ãíþóç åß÷å éóôïñéêü ðñüóöáôçò ëïßìùîçò ôïõ áíùôÝñïõ ôçò áíáôïìßáò ôùí äéáóôçìÜôùí ôçò ðåñéï÷Þò áíáðíåõóôéêïý åíþ ìßá ìÝñá ðñéí áðü ôçí ÝíáñâïçèÜ óôç óùóôÞ åêôßìçóç ôïõ åíôïðéóìïý ôçò îç ôùí óõìðôùìÜôùí áíÝöåñå Ýíá ìéêñü ôñáõèÝóçò ôùí áðïóôçìÜôùí êáé áðïôåëåß óçìáíôéêü ìáôéóìü óôïí öÜñõããá êáôÜ ôçí êáôÜðïóç. Áðü âÞìá ãéá ôç óùóôÞ áíôéìåôþðéóÞ ôïõò1,2. ôï áôïìéêü éóôïñéêü ôçò áíÝöåñå áìõãäáëåêôïìÞ Mßá éäéáßôåñç êáôçãïñßá ôñá÷çëéêþí áðï- óå çëéêßá 5 åôþí. Ç êëéíéêÞ åîÝôáóç áíÝäåéîå óôçìÜôùí åßíáé ôá áðïóôÞìáôá ðïõ åíôïðßæï- ðñïâïëÞ êáé åñõèñüôçôá ôïõ ðëÜãéïõ öáñõããéíôáé óôï âëåííïãïíïöáñõããéêü äéÜóôçìá (ÂÖÄ), êïý ôïé÷þìáôïò áñéóôåñÜ. Ç ðñïâïëÞ îåêéíïýóå Ýíá äéÜóôçìá ðïõ ðñïóäéïñßæåôáé ìåôáîý ôïõ 0,5-1cm êÜôù áðü ôïí êÜôù ðüëï ôçò óýóôïé÷çò âëåííïãüíïõ ôïõ öÜñõããá êáé ôçò óôïìáôïöá- áìõãäáëÞò êáé Ýöôáíå ìÝ÷ñé ôï óýóôïé÷ï ãëùóñõããéêÞò ðåñéôïíßáò (Âuccopharyngeal fascia). Ôá óïåðéãëùôôéäéêü âïèñßï. Ïé öùíçôéêÝò ÷ïñäÝò êáé áðïóôÞìáôá áõôÜ ðáñüôé áöïñïýí åí ôù âÜèåé ïé áñõôáéíïåéäåßò ÷üíäñïé äåí åìöÜíéæáí ðáèïëïáíáôïìéêÝò äïìÝò, êáôÜ êáíüíá äéáíïßãïíôáé áðü ãéêÜ åõñÞìáôá. Äåí âñÝèçêáí óçìåßá ôñáõìáôéìüíá ôïõò ðñïò ôïí öÜñõããá êáé åðïìÝíùò äåí óìïý óôïí âëåííïãüíï ôïõ öÜñõããá. Ç áóèåíÞò áðáéôïýí ÷åéñïõñãéêÞ åðÝìâáóç3. åß÷å èåñìïêñáóßá 38,5°C, 17.000 ëåõêÜ (81% ðïëõìïñöïðýñçíá, 11% ëåìöïêýôôáñá) êáé ÔÊÅ 35 mm ôçí 1ç þñá. Ï õðüëïéðïò åñãáóôçñéáêüò Ýëåã÷ïò Þôáí öõóéïëïãéêüò. Óôïí Ýëåã÷ï ìå áîïÁíáöïñÜ ðåñéðôþóåùí íéêÞ ôïìïãñáößá âñÝèçêå õðüðõêíç ðåñéï÷Þ óôï Ðåñßðôùóç 1: Ãõíáßêá çëéêßáò 71 åôþí ðñï- áñéóôåñü ôìÞìá ôïõ âëåííïãïíïöáñõããéêïý äéáóÞëèå óôï íïóïóïêïìåßï ìå äõóêáôáðïóßá, Þðéï óôÞìáôïò, ÷áñáêôçñéóôéêÞ öëåãìïíþäïõò åîåñãáInfections and abscesses of mucopharyngeal space. Report of two clinical cases Skoulakis C., Lykas G., Paxinos M., Tzeli J., Kokkalis N., Moschontzopoulos P., Valagiannis D.

147

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

óßáò (Eéêüíá 2). ÔÝèçêå óå áãùãÞ ìå êëéíäáìõêßíç 600mg áíÜ 8 þñåò ß.í., ìå ôéêáñóéëëßíç-êëáâïõëáíéêü 3,2 gr áíÜ 8 þñåò ß.í., êáèþò êáé ìå ãáñãáñéóìïýò ìå æåóôü áëáôüíåñï. Ôçí åðüìåíç ìÝñá ç êáôÜóôáóç ôçò áóèåíïýò Þôáí óôáèåñÞ ìå ìéêñÞ êÜìøç ôïõ ðõñåôïý (38,1° C). Äýï çìÝñåò ìåôÜ ôçí åéóáãùãÞ ç áóèåíÞò áíÝöåñå õðïêåéìåíéêÞ âåëôßùóç êáé ôçí áßóèçóç üôé êáôÜðéíå êÜðïéá ïõóßá ãëïéþäïõò õöÞò (ðýïí). ÊáôÜ ôçí

Åéêüíá 1. Åéêüíá áîïíéêÞò ôïìïãñáößáò üðïõ áðåéêïíßæåôáé ìéêñÞ áðïóôçìáôéêÞ êïéëüôçôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò óôï ýøïò ôïõ õïåéäïýò ïóôïý (Ç 1ç ðåñßðôùóç).

Åéêüíá 2. Åéêüíá áîïíéêÞò ôïìïãñáößáò üðïõ áðåéêïíßæåôáé öëÝãìùí ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò (Ç 2ç ðåñßðôùóç). 148

×. ÓêïõëÜêçò êáé óõí.

åîÝôáóç âñÝèçêå ìéêñÞ ïðÞ óôï âëåííïãüíï, áðü üðïõ Þôáí öáíåñÞ ç Ýîïäïò ðýïõ, óå áðüóôáóç 2-3 cm êÜôù áðü ôïí êÜôù ðüëï ôçò áñéóôåñÞò áìõãäáëÞò. Ç êáëëéÝñãåéá ðïõ åëÞöèç áðü ôçí ðåñéï÷Þ Þôáí óôåßñá. Ç áóèåíÞò åîÞëèå 7 ìÝñåò ìåôÜ ôçí åéóáãùãÞ ôçò óå êáëÞ êáôÜóôáóç.

ÓõæÞôçóç Ôï âëåííïãïíïöáñõããéêü äéÜóôçìá (ÂÖÄ) åßíáé Ýíá åðßìçêåò äéÜóôçìá ðïõ ðåñéâÜëëåé ôïí áõëü ôïõ öÜñõããá. Åêôåßíåôáé áðü ôç âÜóç ôïõ êñáíßïõ ìÝ÷ñé ôïí êñéêïåéäÞ ÷üíäñï ôïõ ëÜñõããá. Óå åãêÜñóéá äéáôïìÞ ïñéïèåôåßôáé áðü ôïí âëåííïãüíï ôïõ öÜñõããá êáé áðü ôç óôïìáôïöáñõããéêÞ ðåñéôïíßá (Buccopharyngeal fascia), ç ïðïßá åßíáé ôìÞìá ôïõ ìåóáßïõ ðåôÜëïõ ôçò åí ôù âÜèåé ôñá÷çëéêÞò ðåñéôïíßáò. ÄçëáäÞ ðñï÷ùñþíôáò áðü ôïí áõëü ôïõ öÜñõããá ðñïò ôá Ýîù, ìåôÜ ôï âëåííïãüíï õðÜñ÷åé ÷áëáñüò óõíäåôéêüò éóôüò êáé óôç óõíÝ÷åéá Ýíá ìõúêü óôñþìá, ï óöéãêôÞñáò ôïõ öÜñõããá, ï ïðïßïò åßíáé óôåñåÜ ðñïóêïëëçìÝíïò óôï ôåëåõôáßï óôïé÷åßï ôïõ äéáóôÞìáôïò ðïõ åßíáé ç óôïìáôïöáñõããéêÞ ðåñéôïíßá. ¸ôóé ìåôáîý âëåííïãüíïõ ôïõ öÜñõããá êáé óöéãêôÞñá ôïõ öÜñõããá ï ÷áëáñüò óõíäåôéêüò éóôüò ðïõ õðÜñ÷åé, äçìéïõñãåß ìéá ÷áëáñÞ óýíäåóç ìåôáîý ôïõ âëåííïãüíïõ êáé ôïõ óöéãêôÞñá Ýôóé þóôå íá õðïâïçèïýíôáé ïé êáôáðïôéêÝò êéíÞóåéò. Áõôüò ï ÷þñïò åßíáé ïõóéáóôéêÜ ôï âëåííïãïíïöáñõããéêü äéÜóôçìá (ÂÖÄ). Åêôüò áðü ôá óôïé÷åßá ðïõ áíáöÝñèçêáí õðÜñ÷åé óôçí ðåñéï÷Þ êáé áñêåôüò ëåìöïåðéèçëéáêüò éóôüò, êáèþò êáé ìéêñïß óéåëïãüíïé áäÝíåò3,4. Ðñï÷ùñþíôáò áðü ôïí áõëü ôïõ öÜñõããá ðñïò ôï äÝñìá, ìåôÜ ôï ÂÖÄ âñßóêïíôáé ôá äéáóôÞìáôá ðïõ Ý÷ïõí óáí Ýóù üñéï ôç óôïìáôïöáñõããéêÞ ðåñéôïíßá êáé áõôÜ åßíáé ôï ïðéóèïöáñõããéêü êáé ôï ðëÜãéï öáñõããéêü äéÜóôçìá. Ç åðéêïéíùíßá ôïõ ÂÖÄ ìå ôá äéáóôÞìáôá áõôÜ åßíáé äýóêïëç ãéáôß ôá ÷ùñßæåé ôï éó÷õñü ìõïðåñéôïíáúêü óôñþìá ðïõ äçìéïõñãåßôáé áðü ôï óöéãêôÞñá ôïõ öÜñõããá êáé ôç óôïìáôïöáñõããéêÞ ðåñéôïíßá. Ç áíÜðôõîç áðïóôÞìáôïò óôï ÂÖÄ ïöåßëåôáé óå öëåãìïíÝò ôïõ âëåííïãüíïõ ôïõ öÜñõããá ðïõ åðåêôåßíïíôáé êáôÜ óõíÝ÷åéá éóôïý. Åðßóçò ôá ðåñéáìõãäáëéêÜ áðïóôÞìáôá, éäéáßôåñá áõôÜ ðïõ åíôïðßæïíôáé óôïí êÜôù ðüëï, ìðïñåß íá

×. ÓêïõëÜêçò êáé óõí.

åðåêôáèïýí óôï äéÜóôçìá áõôü, áöïý ï ðåñéáìõãäáëéêüò ÷þñïò åõñßóêåôáé óôá ðÜíù üñéá ôïõ äéáóôÞìáôïò. ÅîÜëëïõ, ôñáõìáôéóìïß ôïõ âëåííïãüíïõ ìðïñåß íá åìâïëßóïõí ìéêñüâéá áðü ôï âëåííïãüíï óôï äéÜóôçìá áõôü, êáé íá äçìéïõñãçèåß áðüóôçìá. Ç åðÝêôáóç ôïõ áðïóôÞìáôïò åíôüò ôïõ äéáóôÞìáôïò ãßíåôáé êáôÜ êáíüíá ðñïò ôá êÜôù, áöåíüò ëüãù ôçò âáñýôçôáò êáé áöåôÝñïõ ãéáôß Ýôóé ôï ïäçãïýí ïé ðåñéóôáëôéêÝò (êáôáðïôéêÝò) êéíÞóåéò ôïõ óöéãêôÞñá ôïõ öÜñõããá. ¼ôáí ôï áðüóôçìá öôÜóåé ìÝ÷ñé ôá êÜôù üñéá ôïõ äéáóôÞìáôïò -óôïí êñéêïåéäÞ ÷üíäñï- Ý÷ïõìå ôçí åìöÜíéóç ïéäÞìáôïò óôïí áñõôáéíïåéäÞ ÷üíäñï êáé óôç ãëùóóéêÞ åðéöÜíåéá ôçò åðéãëùôôßäáò. ÐñÝðåé íá óçìåéùèåß üôé ëüãù ôçò ðßåóçò ðïõ åîáóêåß ï óöéãêôÞñáò óôï áðüóôçìá êáôÜ ôç äéÜñêåéá ôçò êáôáðïôéêÞò êßíçóçò åìöáíßæåôáé Ýíôïíïò ðüíïò êáé äõóêáôáðïóßá. Áõôü üìùò åßíáé èåôéêü üóïí áöïñÜ ôçí Ýêâáóç ôçò ðÜèçóçò ãéáôß ìå ôç óõíå÷Þ ðßåóç ðïõ äÝ÷åôáé áðü ôïí ìõ, ôåëéêÜ ôï áðüóôçìá äéáíïßãåôáé ìüíï ôïõ ðñïò ôçí åõÝíäïôç ðëåõñÜ ôïõ âëåííïãüíïõ ôïõ öÜñõããá. Ôï êýñéï óýìðôùìá ôùí áóèåíþí ìå áðüóôçìá óôï ÂÖÄ åßíáé, üðùò áíáöÝñèçêå, ç äõóêáôáðïóßá. Ìðïñåß åðßóçò íá åìöáíéóèïýí Þðéåò áëëïéþóåéò óôç ÷ñïéÜ ôçò öùíÞò ðïõ ìðïñåß íá ðñïÝñ÷ïíôáé åßôå áðü ôçí ðñïâïëÞ ôïõ áðïóôÞìáôïò óôïí áõëü ôïõ õðïöÜñõããá åßôå áðü ôçí áíÜðôõîç ïéäÞìáôïò óôçí ðåñéï÷Þ ôùí áñõôáéíïåéäþí êáé ôçò åðéãëùôôßäïò. Ç ðáñïõóßá ôñéóìïý êáôÜ êáíüíá áðïõóéÜæåé åêôüò ôùí ðåñéðôþóåùí ðïõ ôï áðüóôçìá åðåêôåßíåôáé êáé óå Üëëá äéáóôÞìáôá. Áðü ôá ãåíéêüôåñá óçìåßá ôçò öëåãìïíÞò, ìðïñåß íá Ý÷ïõìå Þðéá ðõñåôéêÞ êßíçóç, ëåõêïêõôôÜñùóç êáé áýîçóç ôçò ÔÊÅ óå åðßðåäá ðïõ ÷áñáêôçñßæïõí ôçí åíôïðéóìÝíç öëåãìïíÞ. Ïé ìéêñïâéáêïß ðáñÜãïíôåò ðïõ åõèýíïíôáé ãéá ôç äçìéïõñãßá áõôþí ôùí áðïóôçìÜôùí óõó÷åôßæåôáé ìå ôç ÷ëùñßäá ôçò ðåñéï÷Þò. Ç êëéíéêÞ õðïøßá ôïõ áðïóôÞìáôïò, ÷ñåéÜæåôáé ïðùóäÞðïôå áðåéêïíéóôéêÞ åðéâåâáßùóç. Ç ðéï êáôÜëëçëç åîÝôáóç ãéá íá ãßíåé áõôü, åßíáé ï Ýëåã÷ïò ìå CÔ. ÊáôÜ ôçí åîÝôáóç ìå õðåñç÷ïãñÜöï åßíáé äýóêïëï íá ðñïóäéïñéóôåß ôï äéÜóôçìá ðïõ âñßóêåôáé ôï áðüóôçìá åíþ ç ÌRÉ åßíáé áêñéâÞ åîÝôáóç6-8. Åöüóïí åðéâåâáéùèåß üôé ôï áðüóôçìá åíôïðßæåôáé óôï ÂÖÄ ï áóèåíÞò ðñÝðåé íá ôåèåß óå óõíôçñçôéêÞ áãùãÞ êáé ðáñáêïëïýèçóç. ÓõíÞèùò ôï áðüóôçìá äéáíïßãåôáé áõôüìáôá óå ëßãåò

Ôüìïò 17, Ôåý÷ïò 3, 2005

ìÝñåò ìåôÜ ôçí Ýíáñîç ôçò áãùãÞò9,10. Óôéò áóèåíåßò ôçò ðáñïýóáò ìåëÝôçò åß÷áìå áõôüìáôç äéÜíïéîç óå 1-4 ìÝñåò áðü ôçí åéóáãùãÞ ôïõò. ÐñÝðåé íá óçìåéùèåß üôé óôç äåýôåñç ðåñßðôùóç ðïõ ðåñéãñÜöåôáé, åðåéäÞ ç áîïíéêÞ ôïìïãñáößá Ýãéíå ó÷åôéêÜ íùñßò, ðñïöáíþò äåí åß÷å ó÷çìáôéóôåß áêüìá ôï áðüóôçìá ãé’ áõôü öÜíçêå ìüíï öëåãìïíÞ ôïõ äéáóôÞìáôïò, ç ïðïßá üìùò Ýãéíå áðüóôçìá ðïõ äéáíïß÷ôçêå áõôüìáôá óôïí áõëü ôïõ öÜñõããá, üðùò öÜíçêå áðü ôçí åîÝôáóç ôçò áóèåíïýò. Áí ôþñá ï áóèåíÞò äåí âåëôéþíåôáé êáé ðáñïõóéÜæåé óçìåßá êáé óõìðôþìáôá åîåëéóóüìåíçò öëåãìïíÞò Þ Ý÷åé êáé Üëëïõò åðéâáñõíôéêïýò ðáñÜãïíôåò (óáê÷áñþäçò äéáâÞôçò, áíïóïêáôáóôïëÞ ê.ëð.) ï ãéáôñüò èá ðñÝðåé íá óêåöôåß ôï åíäå÷üìåíï íá ðáñÝìâåé ÷åéñïõñãéêÜ äéáíïßãïíôáò ôï áðüóôçìá2,10. ÃåíéêÜ èá ðñÝðåé èá ðñÝðåé íá óçìåéùèåß üôé ôá áðïóôÞìáôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò áíÞêïõí óôá åí ôù âÜèåé áðïóôÞìáôá ôïõ ôñá÷Þëïõ áîéïëïãþíôáò ôá ìå âÜóåé ôçí åíôüðéóÞ ôïõò. ¼ìùò äéáöÝñïõí óçìáíôéêÜ áðü ôá õðüëïéðá üóïí áöïñÜ ôçí áíôéìåôþðéóÞ ôïõò, ç ïðïßá êáôÜ êáíüíá åßíáé óõíôçñçôéêÞ. Áêüìá äéáöÝñïõí óôï üôé åíþ óôá Üëëá áðïóôÞìáôá ôùí åí ôù âÜèåé äéáóôçìÜôùí, åßíáé ó÷åôéêÜ åýêïëç ç åîÜðëùóç ôçò öëåãìïíÞò áðü ôï Ýíá äéÜóôçìá óôï Üëëï, ãéá ôï ÂÖÄ äåí éó÷ýåé ôï ßäéï ãéáôß äéá÷ùñßæåôáé áðü ôá Üëëá ìå ôç âëåííïãïíïöáñõããéêÞ ðåñéôïíßá ðïõ åßíáé éó÷õñÞ, åíþ Ý÷åé åýêïëç äéÝîïäï ðñïò ôçí ðëåõñÜ ôïõ ó÷åôéêÜ åõÝíäïôïõ âëåííïãüíïõ ôïõ öÜñõããá. Ç áõôüìáôç äéÜíïéîç ðñïò ôïí öÜñõããá óõíÞèùò äåí åíÝ÷åé êéíäýíïõò åéóñüöçóçò ãéáôß ôï óçìåßï ôçò äéÜíïéîçò åßíáé óõíÞèùò ìéêñü êáé ç Ýîïäïò ôïõ ðýïõ óôáäéáêÞ10. ¼ðùò áíáöÝñèçêå ôá áðïóôÞìáôá ôïõ ÂÖÄ áíÞêïõí óôá åí ôù âÜèåé áðïóôÞìáôá ôïõ ôñá÷Þëïõ ãéá ôá ïðïßá åßíáé ãíùóôü üôé ïé åìðëåêüìåíïé ìéêñïâéáêïß ðáñÜãïíôåò åßíáé ðåñéóóüôåñïé áðü Ýíáí, åíþ ç áðïìüíùóç êáé ôáõôïðïßçóç ôïõò åßíáé óõíÞèùò äýóêïëç ãéáôß üôáí äéááíïé÷èïýí ôá áðïóôÞìáôá áõôÜ êáé ëçöèåß êáëëéÝñãåéá êáôÜ êáíüíá Ý÷åé ÷ïñçãçèåß íùñßôåñá áíôéâßùóç. Ìå ôç óêÝøç ôçò ðïëõìéêñïâéáêÞò öëåãìïíÞò êáé ôùí áíáåñüâéùí óõíèçêþí óôïõò åí ôù âÜèåé éóôïýò, èåùñåßôáé óùóôü ç áíôéâéïôéêÞ èåñáðåßá ðïõ ÷ïñçãåßôáé óôïí áóèåíÞ íá äñáóôéêÞ ãéá ôïõò êïéíïýò êüêêïõò ðïõ åßíáé ôá óõ÷íü149

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôåñá åìðëåêüìåíá ìéêñüâéá, ãéá ôá áñíçôéêÜ êáôÜ Gram ìéêñüâéá áëëÜ êáé ãéá ôá áíáåñüâéá ìéêñüâéá2,11. Ç ãíþóç áõôÞò ôçò éäéáßôåñçò íïóïëïãéêÞò ïíôüôçôáò áðü ôïí ãåíéêü ãéáôñü åßíáé ðïëý ÷ñÞóéìç ãéáôß üðùò áíáöÝñèçêå êáôÜ êáíüíá ï áóèåíÞò èåñáðåýåôáé ìå óõíôçñçôéêÜ ìÝóá. ¸ôóé åöüóïí ôåèåß ç äéÜãíùóç ï èåñÜðùí éáôñüò ìðïñåß íá åßíáé ï ãåíéêüò ãéáôñüò ìå óýìâïõëï ôïí Ùôïñéíïëáñõããïëüãï. ÓõìðÝñáóìá Ï áóèåíÞò ðïõ ðñïóÝñ÷åôáé ìå Ýíôïíç äõóêáôáðïóßá ÷ùñßò ôñéóìü ìå öáéíüìåíá äýóðíïéáò êáé åìöáíßæåé Ýíôïíç åõáéóèçóßá óôçí øçëÜöçóç êáé ìåôáêßíçóç ôïõ óêåëåôïý ôïõ ëÜñõããá êáèþò êáé ðñïâïëÞ ôïõ âëåííïãüíïõ ôïõ öáñõããéêïý ôïé÷þìáôïò ÷ùñßò åîùôåñéêÞ äéüãêùóç, åßíáé ðïëý ðéèáíüí íá Ý÷åé áðüóôçìá óôï âëåííïãïíïöáñõããéêü äéÜóôçìá. Ç åðéâåâáßùóç ôçò äéÜãíùóçò ãßíåôáé ìå CÔ. Ç óõíôçñçôéêÞ áíôéìåôþðéóç ôïõ áóèåíïýò ìå IV áíôéâéïôéêÞ áãùãÞ åîáóöáëßæåé óõíÞèùò êáëÞ ðñüãíùóç, áöïý óôéò ðåñéóóüôåñåò ðåñéðôþóåéò ç áðïóôçìáôéêÞ êïéëüôçôá äéáíïßãåôáé áõôüìáôá ðñïò ôïí áõëü ôïõ öÜñõããá Þ ôïõ õðïöÜñõããá ÷ùñßò íá áðáéôåßôáé ÷åéñïõñãéêÞ äéÜíïéîç. Ç ðáñïõóßáóç ôùí èåñáðåõôéêþí ÷åéñéóìþí ìå ôïõò ïðïßïõò áíôéìåôùðßæïíôáé ôá áðïóôÞìáôá ôïõ âëåííïãïíïöáñõããéêïý äéáóôÞìáôïò Ý÷åé ùò óêïðü íá áíáäåßîåé ôéò äõíáôüôçôåò ðïõ Ý÷åé óÞìåñá ï éáôñüò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò ãéá ðáñï÷Þ áðïôåëåóìáôéêÞò èåñáðåßáò óå êëéíéêÝò ïíôüôçôåò ðïõ ðáëáéüôåñá áðïôåëïýóáí áðïêëåéóôéêü ðåäßï ôïõ åéäéêïý. Âéâëéïãñáößá 1. Chen MK, Wen YS, Chang CC, et al. Predisposing factors of life threatening deep neck

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infection: logistic regression analysis of 214 cases. J Otolaryngol, 27:141-144, 1998. Johnson JT. Abscess and deep space infection of the head and neck. Infect Dis Clin North, Am 6:705-717, 1992. Parker GD, Hamsberger HR, Jacobs JM. The Pharyngeal Mucosal Space. Semin Ultr CT MR, 11:460-475, 1990. Harnsberger HR. The parapharyngeal and pharyngeal mucosal space, in Hamsberger HR (ed): Handbook of head and neck imaging. St. Louis, MO, Mosby-Year Book, 1995, 29-45. Dalley RW, Robertson WD, Oliverio PJ, Zinreich SJ. Overview of diagnostic imaging of the head and neck, in Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE (eds): Otolaryngology-Head & Neck Surgery. Ed 3, Vol 1, St. Louis, MO, Mosby, 1998, 25-83. Forsgren J, Rynnel-Dagoo B, Samnelson A. The microbe, in Johnson JT, Yu VT (eds). Infection diseases and antimicrobial therapy of Ears, Nose and Throat. Philadelphia, PA, WB Saunders Co, 1997, 9-17. Pichichero ME. Group A Beta hemolytic streptococcal tonsillopharyngitis, in Johnson JT, Yu VT (eds). Infection diseases and antimicrobial therapy of Ears, Nose and Throat. Philadelphia, PA, WB Saunders Co, 1997, 402-422. Brook I. The clinical microbiology of Waldeyer’s ring. Otolaryngol Clin North Am, 20:259272, 1987. Forrest LA, Weed HG. Deep Neck Infection, in Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE (eds): Otolaryngology-Head & Neck Surgery. Ed 3, Vol 3, St. Louis, MO, Mosby, 1998, 1700-1706. Skoulakis Ch, Papadakis Ch, Bizakis J, Nikolidakis A, Manios A, Helidonis E. Abscess of the pharyngeal mucosal space. An unusual location. J Otolaryngol, 32:121-4, 2003. Bizakis J, Segas J, Skoulakis Ch, Voloudakis A, Velegrakis G, Christodoulou P, Helidonis E. Retropharyngoesophageal abscess associated with a swallowed bone. Am J Otolaryngol, 14:354-7, 1993.

Ôüìïò 17, Ôåý÷ïò 3, 2005

Ê. Ìüíôç êáé óõí.

ÁÍÁÖÏÑÁ ÐÅÑÉÐÔÙÓÇÓ CASE REPORT Primary Heatlh Care, Volume 17, Number 3, 151-154, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 151-154, 2005

Óýíäñïìï Munchausen. ÐåñéãñáöÞ ðåñßðôùóçò óå ðáéäß 10 åôþí Á. Ìüíôç1, Ã.Ê. Êïõâßäçò2, È. Æäïýêïò3

Ðåñßëçøç ÐåñéãñÜöïõìå ðåñßðôùóç óõíäñüìïõ Ìunchausen óå áãüñé 10 åôþí, ôï ïðïßï õðïêñéíüôáí óõìðôþìáôá êáé êáôáóêåýáæå óçìåßá ïõñïëéèßáóçò. Åêôüò áðü ôïí éó÷õñéóìü ðüíïõ óôçí êïéëéÜ êáé ôç íåöñéêÞ ÷þñá, éäéáßôåñá ðñéí ôçí ïýñçóç, åß÷å åðéíïÞóåé Ýíá ôñüðï íá ðáñïõóéÜæåé ìéêñïóêïðéêïýò ëßèïõò ùò ðñïúüí ôçí ïýñçóÞò ôïõ. Tï ðáéäß õðïâëÞèçêå óå ðëåéÜäá åîåôÜóåùí êáé ðåñéöÝñèçêå óå ðïëëïýò ãéáôñïýò êáé äéáãíùóôéêÜ êÝíôñá, áêüìç êáé ìåôÜ ôçí áíáêïßíùóç ôùí óõìðåñáóìÜôùí ìáò, ôá ïðïßá ç ìçôÝñá ôïõ äåí áðïäÝ÷èçêå. Óõæçôïýìå êáé áíáóêïðïýìå ôï óýíäñïìï êáé ôç óðáíéüôçôÜ ôïõ óôçí ðáéäéêÞ çëéêßá, ìå áíáöïñÝò óôïí éäéáßôåñï ñüëï ôçò ìçôÝñáò êáé ôçò ïéêïãåíåéáêÞò ðáèïëïãßáò.

Ðáéäßáôñïò, 2Áêôéíïëüãïò, 3Ãåíéêüò ãéáôñüò, Ãåíéêü Íïóïêïìåßï-ÊÝíôñï Õãåßáò Éêáñßáò

Munchausen syndrome: A case report of a 10-year-old child Catherine Monti, G.K. Kouvidis, Th. Zdoukos Summary We report a case of Munchausen syndrome in a 10-year-old boy, who feigned symptoms and signs of urolithiasis. Apart from back and abdominal pain, especially before urination, he fabricated a pattern of “voiding stones”, presenting tiny soil stones as a product of his urine. He underwent numerous procedures and investigations and his mother did not cooperate with us when our conclusion was reported. We discuss and review the syndrome and its rarity in childhood, with reference to the specific role of the mother and the family pathology. Êey words: Munchausen syndrome, malingering, urinary calculi

ÅéóáãùãÞ Ôï óýíäñïìï Ìunchausen (Ìõí÷Üïõæåí) åßíáé ìéá Øõ÷éáôñéêÞ äéáôáñá÷Þ êáôÜ ôçí ïðïßá Ýíáò áóèåíÞò õðïäýåôáé óõìðôþìáôá Þ êáé “êáôáóêåõÜæåé” áíôéêåéìåíéêÜ åõñÞìáôá êÜðïéáò Þ êÜðïéùí íüóùí, ìå êýñéï êßíçôñï ôïí ßäéï ôï ñüëï ôïõ áóèåíïýò ìå íüóï ðïõ “äåí äéáãéãíþóêåôáé” Þ “äåí èåñáðåýåôáé”.1 Óýìöùíá ìå ôá áêñéâÞ äéáãíùóôéêÜ êñéôÞñéá ï üñïò ðåñéãñÜöåé ìéá áðü ôéò ìïñöÝò ôùí “ðñïóðïéçôþí-ôå÷íçôþí” äéáôáñá÷þí, áðü ôéò ïðïßåò äéáöÝñåé óôç óïâáñüôçôá êáé ôçí ðñüãíùóç. Óõ÷íÜ üìùò óôç âéâëéïãñáößá õðü ôïí üñï “óýíäñïìï Munchausen” ðåñéãñÜöåôáé ôï óýíïëï áõôþí ôùí äéáôáñá÷þí. Áêñéâåßò áñéèìçôéêÝò óôáôéóôéêÝò åðßðôùóçò äåí Ý÷ïõí êáôáãñáöåß. Ôï óýíäñïìï Munchausen áíáöÝñåôáé óõíÞèùò óå Üíôñåò ìå øõ÷ïðáèïëïãéêÞ ðñïóùðéêüôçôá, åíþ ïé ðñïóðïéçôÝò äéáôáñá÷Ýò áöïñïýí óõíÞèùò óå ãõíáßêåò ìå åõ÷Üñéóôç êïéíùíéêÞ óõìðåñéöïñÜ. ¼óïí áöïñÜ óôá ðáéäéÜ, ËÝîåéò êëåéäéÜ: óýíäñïìï Munchausen, ðñïóðïßçóç, ïõñïðïéçôéêïý óõóôÞìáôïò ëßèïé ÕðïâëÞèçêå: 26 MáÀïõ 2004 ÅðáíõðïâëÞèçêå: 16 Íïåìâñßïõ 2004 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 18 Íïåìâñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: Ìüíôç Êáôåñßíá, Äéåýèõíóç: Ãñçãïñßïõ Å´ 15, Ô.Ê. 55133, ÊáëáìáñéÜ, Èåóóáëïíßêç, Ôçë.: (2310)480513 (ïéêßá), 6947573333 (êéíçôü), e-mail: monthcon@ika.forthnet.gr 151

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

óðáíéüôáôá áíáöÝñïíôáé ôá ßäéá ùò “äñÜóôåò”2-6, åíþ ðïëý óõ÷íÜ ðåñéãñÜöïíôáé ðåñéóôáôéêÜ üðïõ åíÞëéêåò êáôáóêåõÜæïõí óõìðôþìáôá óå ðáéäéÜ, êáêïðïéþíôáò ôá Ýììåóá Þ Üìåóá (óýíäñïìï “Ìõí÷Üïõæåí äé’ áíôéðñïóþðïõ” -Munchausen by proxy)7,8. H áíôéìåôþðéóç áöïñÜ óõìâïõëåõôéêÞ-øõ÷ïèåñáðåßá. Ç ðñüãíùóç ãåíéêÜ åßíáé êáëýôåñç óôéò áðëÝò ðåñéðôþóåéò ðñïóðïßçóçò åíþ óôéò ðåñéðôþóåéò ôïõ “êëáóéêïý” óõíäñüìïõ áíáöÝñïíôáé öôù÷Ü áðïôåëÝóìáôá1,9. ÌÝñïò ôçò èåñáðåßáò åßíáé áóöáëþò êáé ç áíôéìåôþðéóç ôùí âëáâþí ðïõ ðñïêáëïýí ïé áóèåíåßò óôïí åáõôü ôïõò. ÐåñéãñÜöïõìå ìéá ðåñßðôùóç åêäÞëùóçò óõíäñüìïõ Munchausen óå áãüñé 10 åôþí ìå óõìðôþìáôá êáé óçìåßá áðü ôï ïõñïðïéçôéêü.

ÐåñéãñáöÞ ðåñßðôùóçò Áãüñé çëéêßáò 10 åôþí, ðñïóêïìßóôçêå áðü ôç ìçôÝñá ôïõ óôá ÅîùôåñéêÜ Éáôñåßá ôçò ÐáéäéáôñéêÞò ÊëéíéêÞò ôïõ Íïóïêïìåßïõ ìáò ãéá Üôõðá êïéëéáêÜ Üëãç êáé Üëãïò óôïí äåîéü ïõñçôÞñá êáôÜ ôçí ïýñçóç. Åðñüêåéôï ãéá öõóéïëïãéêü óùìáôïìåôñéêÜ êáé øõ÷ïêéíçôéêÜ ðáéäß, ôï ïðïßï ëüãù ðáñüìïéùí óõìðôùìÜôùí ðñéí áðü Ýíá ÷ñüíï åß÷å õðïâëçèåß óå åêôåôáìÝíï Ýëåã÷ï óå ÐáíåðéóôçìéáêÞ ÐáéäéáôñéêÞ ÊëéíéêÞ, ïðüôå êáé åß÷å áðïêëåéóèåß ìéá ðëåéÜäá ðéèáíþí äéáôáñá÷þí (ëïéìþîåéò, áéìïóöáéñéíïðÜèåéåò, öëåãìïíþäçò íüóïò ôïõ åíôÝñïõ, ïõñïëéèßáóç Þ áóâåóôéïõñßá, ñåõìáôéêÜ íïóÞìáôá, ôñïöéêÝò äõóáíåîßåò, ÷åéñïõñãéêÝò êáôáóôÜóåéò). Áðü ôï ïéêïãåíåéáêü éóôïñéêü õðÞñ÷å èåßïò ìå íåöñïëéèßáóç. Ìïíáäéêü åýñçìá ôçò êëéíéêÞò åîÝôáóçò Þôáí Ýíá áìößâïëï óçìåßï Jordano. Ï åñãáóôçñéáêüò Ýëåã÷ïò (ãåíéêÞ áßìáôïò, CRP, TÊÅ, ôñáíóáìéíÜóåò, ïõñßá, ãëõêüæç, ãåíéêÞ êáé êáëëéÝñãåéá ïýñùí) ï ïðïßïò äéåõñýíèçêå ôéò åðüìåíåò çìÝñåò ëüãù åðéìïíÞò ôïõ Üëãïõò, (ìÝôñçóç Ca ïýñùí êáé Ca/êñåáôéíßíç ïýñùí, áðëÞ ÍÏÊ, õðåñç÷ïãñÜöçìá ïõñïðïéçôéêïý êáé êïéëéÜò) áðÝâç áñíçôéêüò. Êáèçóõ÷Üóáìå ôç ìçôÝñá êáé óõóôÞóáìå áíáìïíÞ. Ôçí åðüìåíç åâäïìÜäá ôï ðáéäß ðñïóêïìßóôçêå åðåéãüíôùò ìáæß ìå äåßãìá ïýñùí ôïõ, ìÝóá 152

Ê. Ìüíôç êáé óõí.

óôï ïðïßï ðåñéÝ÷ïíôáí 4 ëßèïé ìåãÝèïõò ðåñßðïõ 3 ÷éëéïóôþí, óêëçñÞò óýóôáóçò êáé äéáöïñåôéêþí ÷ñùìÜôùí. Ôï ðáéäß Þôáí óå Üñéóôç ãåíéêÞ êáôÜóôáóç êáé óôá ïýñá äåí âñÝèçêå êáíÝíá ß÷íïò áßìáôïò. Ïé ëßèïé åóôÜëçóáí ãéá Ýëåã÷ï. Ìå áðüöáóç ôçò ìçôÝñáò Ýãéíå åéóáãùãÞ óå Ðáí/ìéáêÞ ÊëéíéêÞ üðïõ êáé ðñïóêïìßóôçêáí íÝïé ëßèïé áðü ïõñÞóåéò óôï óðßôé, åíþ êáôÜ ôç íïóçëåßá ôïõ ôï ðáéäß äåí áðÝâáëå êáíÝíáí. Ï Ýëåã÷ïò áðÝâç åê íÝïõ áñíçôéêüò. Ïé ëßèïé âñÝèçêáí üëïé áêôéíïóêéåñïß, áóõìâßâáóôïé ìå ôéò áñíçôéêÝò áêôéíïãñáößåò. Áðü ôçí åéäéêüôåñç áíÜëõóç ìå êñõóôáëëïãñáößá ðñïÝêõøå üôé åðñüêåéôï ãéá áðëÜ ìéêñïóêïðéêÜ ÷áëßêéá ôïõ åäÜöïõò... Ôï ðáéäß åðáíÞëèå óôï Íïóïêïìåßï ôïõ íçóéïý ìå íÝïõò ðáñüìïéïõò ëßèïõò áðü ïýñçóç ðïõ ç ìçôÝñá ìáñôõñïýóå üôé ôçí åß÷å ç ßäéá ðáñáêïëïõèÞóåé. Ôï áðïôÝëåóìá ãéá ôç óýóôáóç ôùí ëßèùí Þôáí êáôÜ ôç ãíþìç ôçò áíáîéüðéóôï. Ðñïôåßíáìå íÝá åéóáãùãÞ ãéá íá âñïýìå ôïí ÷ñüíï íá ðñïóåããßóïõìå ìå ôçí áðáéôïýìåíç ëåðôüôçôá ôï èÝìá, óôçí êáôåýèõíóç ôçò øõ÷éáôñéêÞò óõìâïõëÞò. Ç åéóáãùãÞ äåí Ýãéíå äåêôÞ êáé óôïí ìÞíá ðïõ áêïëïýèçóå ôï ðáéäß ðåñéöÝñèçêå óå áñêåôïýò åîùôåñéêïýò ãéáôñïýò áðü ôïõò ïðïßïõò êÜðïéïé ôï ðáñÝðåìøáí ãéá íÝåò áðåéêïíéóôéêÝò åîåôÜóåéò (õðÝñç÷ï êáé óðéíèçñïãñÜöçìá íåöñþí, ðõåëïãñáößá, áîïíéêÞ êïéëßáò) ÷ùñßò íá ðñïêýøïõí ðáèïëïãéêÜ åõñÞìáôá. ÊáëÝóáìå ôç ìçôÝñá ãéá ìéá áíáëõôéêüôåñç óõæÞôçóç, óôçí ïðïßá üìùò áõôÞ äåí ðñïóÞëèå ðïôÝ. Áð’ ü,ôé ãíùñßæïõìå, ôï ðáéäß äåí ðáñïõóßáóå îáíÜ ðáñüìïéá óõìðôþìáôá.

ÓõæÞôçóç Ôï óýíäñïìï Munchausen ðåñéãñÜöçêå ôï 1951 óôo ðåñéïäéêü Lancet áðü ôïí Richard Asher êáé âáðôßóôçêå áðü ôïí ßäéï ìå ôï üíïìá ôïõ Ãåñìáíïý âáñþíïõ Munchausen, åíüò ðñáãìáôéêïý ðñïóþðïõ ôïõ 18ïõ áéþíá, äéÜóçìïõ ùò “ìåãÜëïõ ðáñáìõèÜ” ëüãù ôùí áðßóôåõôùí áöçãÞóåþí ôïõ ãéá ôéò óôñáôéùôéêÝò ôïõ ðåñéðÝôåéåò. Ç ÷áñáêôçñéóôéêÞ ôñéÜäá ôïõ óõíäñüìïõ óõíßóôáôáé óå ðñïóðïßçóç íüóïõ, ðáèïëïãéêÜ øåýäç êáé ðåñéöïñÜ áðü ãéáôñü óå ãéáôñü1. Ï áóèåíÞò ðñïóðïéåßôáé óõìðôþìáôá Þ êáé ðñïêáëåß áíÜëïãá öõóéêÜ óçìåßá êáé ðáèïëïãéêÜ åñ-

Ê. Ìüíôç êáé óõí.

ãáóôçñéáêÜ åõñÞìáôá ìå ìïíáäéêü êßíçôñï íá ðáßîåé ôïí ñüëï ôïõ áóèåíïýò. Óýìöùíá ìå ôá Øõ÷éáôñéêÜ äéáãíùóôéêÜ êñéôÞñéá DMS-IV ôï “êëáóéêü” óýíäñïìï Ìunchausen áöïñÜ êáôÜ êáíüíá óå åíÞëéêåò Üíäñåò ìå øõ÷ïðáèïëïãéêÞ ðñïóùðéêüôçôá êáé äéáêñßíåôáé áðü ôéò “ôå÷íçôÝò-ðñïóðïéçôÝò äéáôáñá÷Ýò” (factitious disorders) ðïõ åêäçëþíïõí êõñßùò ãõíáßêåò ìå åõ÷Üñéóôç êáé êïéíùíéêÞ óõìðåñéöïñÜ ìå êßíçôñï ôçí ðñïóÝëêõóç ôïõ åíäéáöÝñïíôïò1,10. H äéÜêñéóÞ ôùí êáôáóôÜóåùí áõôþí äåí åßíáé ðÜíôá óáöÞò êáé óôç âéâëéïãñáößá óõ÷íÜ ðåñéãñÜöïíôáé åíéáßá åßôå ìå ôïí Ýíáí åßôå ìå ôïí Üëëïí üñï, óõíçèÝóôåñá ùò “ó. Ìunchausen”. Ïé äéáôáñá÷Ýò áõôÝò óðÜíéá áöïñïýí óå åöÞâïõò êáé áêüìç óðáíéüôåñá óå ìéêñÜ ðáéäéÜ, üðùò åßíáé ç äéêÞ ìáò ðåñßðôùóç (áðü ôçí Ýñåõíá óôï PubÌed11, åðß óõíüëïõ 2125 ðåñéðôþóåùí ìüíïí ïé 4 Þôáí ðáéäéÜ Ýùò êáé 12 åôþí2-6, ïé áíáöïñÝò óå åöÞâïõò Üíù ôùí 15 åôþí ðëçèáßíïõí üóï ç çëéêßá ìåãáëþíåé). Óôçí ÐáéäéáôñéêÞ óõ÷íÝò åßíáé ïé áíáöïñÝò ðåñéðôþóåùí “Munchausen by proxy” (äé’ áíôéðñïóþðïõ)7, üðïõ ï äñÜóôçò åßíáé ãïíÝáò (óõíÞèùò ç ìçôÝñá) Þ Üëëï ðñüóùðï ðïõ öñïíôßæåé ôï ðáéäß, áêüìç êáé íïóçëåõôéêü ðñïóùðéêü8. ÐåñéãñÜöçêå ãéá ðñþôç öïñÜ ôï 1970 áðü ôïí Meadow êáé Ý÷åé êåíôñßóåé óõ÷íÜ êáé ôï äçìïóéïãñáöéêü åíäéáöÝñïí. Ó’ áõôÝò ôéò ðåñéðôþóåéò ôï ðáéäß åßíáé èýìá êáêïðïßçóçò, ìåñéêÝò öïñÝò óïâáñüôáôçò Ýùò êáé ìïéñáßáò. Óðáíéüôåñá áíáöÝñïíôáé ìçôÝñåò ðïõ “äéäÜóêïõí” ôá ðáéäéÜ íá õðïäýïíôáé äéÜöïñá óõìðôþìáôá, ðñïêáëþíôáò ìéá ðåñéðëïêüôåñç êáôÜóôáóç2. Ôï óýíäñïìï Munchausen óõ÷íÜ åßíáé äýóêïëï íá äéáãíùóèåß áñ÷éêÜ, ðñÝðåé üìùò íá ôï õðïðôåõüìáóôå üôáí ðáñáôçñïýìå “áóõíÝðåéåò” óôï éóôïñéêü ôïõ áóèåíïýò Þ áóõìöùíßá ìåôáîý ôùí óõìðôùìÜôùí ìå ôá áíôéêåéìåíéêÜ åõñÞìáôá. Óôçí ðåñßðôùóÞ ìáò, ãëáöõñÞ Þôáí ç ðëÞñçò áðïõóßá áéìáôïõñßáò êáèþò êáé ç ãåíéêÞ êáôÜóôáóç ôïõ ðáéäéïý ðïõ óå êáìßá ðåñßðôùóç åß÷å ôçí åéêüíá ðÜó÷ïíôïò áðü êïëéêïåéäÝò Üëãïò. Ïöåßëïõìå íá äéáêñßíïõìå ôï óýíäñïìï áðü ôçí áðëÞ õðïêñéóßá óôçí ïðïßá õðÜñ÷åé ðñïöáíÝò åðéäéùêüìåíï Üìåóï üöåëïò (ð.÷. áðïæçìßùóç Þ áðïöõãÞ ðïéíÞò), êáèþò êáé áðü ôçí áíôßäñáóç óùìáôïðïßçóçò (“ìåôáôñïðÞò”) øõ÷éêïý stress, üðïõ ôá óõìðôþìáôá ìðïñåß íá åßíáé éáôñéêþò áíåîÞãçôá áëëÜ ï áóèåíÞò äåí õðïêñßíåôáé óõíåéäçôÜ1.

Ôüìïò 17, Ôåý÷ïò 3, 2005

Ç ãêÜìá ôùí ôå÷íçôþí óõìðôùìÜôùí êáé óçìåßùí ðïõ åðéíïïýí ïé áóèåíåßò åßíáé åõñýôáôç, ìå éäéáßôåñá åõöÜíôáóôá “áíôéêåéìåíéêÜ” óçìåßá êáé åñãáóôçñéáêÜ åõñÞìáôá. ÅíäåéêôéêÜ ìüíïí áíáöÝñïõìå êÜðïéá áðü áõôÜ: ðõñåôüò, áéìáôïõñßá, ðñùôåúíïõñßá, áéìüðôõóç, äåñìáôéêÝò âëÜâåò, äýóðíïéá, ðáñáëýóåéò, óðáóìïß, õðïäüñéï åìöýóçìá, ðåñéêïã÷éêü ïßäçìá, óêüðéìç ëÞøç öáñìÜêùí ãéá ðñüêëçóç áíåðéèýìçôùí åíåñãåéþí (óõ÷íÞ ç õðïãëõêáéìßá)12 ê.ëð. Óôçí ðåñßðôùóÞ ìáò ç åðéíüçóç ôïõ ðáéäéïý âáóéæüôáí êõñßùò óå ìßìçóç ôùí óõìðôùìÜôùí ôïõ èåßïõ ôïõ, ôïí ïðïßï ìÜëéóôá “åêìåôáëëåõüôáí” ùò ðëçñïöïñßá, ãíùñßæïíôáò ôçí áîéïëüãçóÞ ôçò ùò èåôéêü ïéêïãåíåéáêü éóôïñéêü. Ïé åðéíïÞóåéò ôùí áóèåíþí äåí âëÜðôïõí ðÜíôá ôïí åáõôü ôïõò (ð.÷. ÷ñÞóç áßìáôïò æþïõ), óõ÷íÜ üìùò áõôo-êáêïðïéïýíôáé åêèÝôïíôáò óå êßíäõíï áêüìç êáé ôç æùÞ ôïõò. Ó’ áõôÝò ôéò ðåñéðôþóåéò ç Ýãêáéñç äéÜãíùóç åßíáé êñßóéìç. Óôçí ðåñßðôùóÞ ìáò, áð’ ü,ôé óõìðåñáßíïõìå, ôï ðáéäß áðïèÞêåõå ôïõò ëßèïõò ðñéí ôçí ïýñçóç óôçí áêñïðïóèßá Þ ôï Ýîù óôüìéï ôçò ïõñÞèñáò, ÷ùñßò íá ðñïêáëåß âëÜâç. Óå áíÜëïãåò ðåñéðôþóåéò óôç âéâëéïãñáößá óõíáíôïýìå áóèåíåßò ðïõ áõôï-êáêïðïéïýíôáé åéóÜãïíôáò Ýùò ôçí êýóôç äéÜöïñá õëéêÜ ðïõ èá “ïõñÞóïõí”13. ÐïëëÝò öïñÝò, ëüãù äéáãíùóôéêïý áäéÝîïäïõ ãßíïíôáé Ü÷ñçóôåò êáé âëáâåñÝò åðåìâÜóåéò (ð.÷. íåöñåêôïìÞ, åñåõíçôéêÞ ëáðáñïôïìßá ê.ëð.). Óôç äéêÞ ìáò ðåñßðôùóç, ç óõíÝ÷éóç ôçò ðåñéöïñÜò ôïõ ðáéäéïý óå äéÜöïñïõò ãéáôñïýò êáé äéáãíùóôéêÜ êÝíôñá, ôï åîÝèåóå óå ìåãÜëç äüóç áêôéíïâïëßáò. Ç èåñáðåßá ôïõ óõíäñüìïõ ðåñéëáìâÜíåé êáô’ áñ÷Þí ôçí Üìåóç áíôéìåôþðéóç ôùí ïñãáíéêþí âëáâþí ðïõ ðéèáíÜ Ý÷åé ðñïêáëÝóåé ï áóèåíÞò óôïí åáõôü ôïõ êáé ôç äéáêïðÞ ôùí ðåñéôôþí äéáãíùóôéêþí äéáäéêáóéþí. Ï áóèåíÞò ðñÝðåé íá áíôéìåôùðßæåôáé ìå óõìðÜèåéá, ÷ùñßò åðéôßìçóç êáé íá ôïõ ðáñÝ÷åôáé øõ÷éáôñéêÞ åêôßìçóç êáé óõìâïõëÞ. Óôçí ðåñßðôùóÞ ìáò Þôáí ðñïöáíÞò ç áíÜãêç øõ÷éáôñéêÞò óõìâïõëåõôéêÞò ìå óôü÷ï ü÷é ìüíï ôï ðáéäß áëëÜ êáé üëç ôçí ïéêïãÝíåéá. ¼óïí áöïñÜ óôï ðáéäß, åêôüò áðü ôçí ðñï Ýôïõò áíÜëïãç ðåñéöïñÜ ôïõ, åß÷å ðáñáôçñçèåß åðßóçò ìéá “áôõ÷çìáôïèçñéêÞ” óõìðåñéöïñÜ (ôñåéò åéóáãùãÝò óôï Íïóïêïìåßï ìåôÜ áðü ðôþóç áðü ýøïò, äýï ìåôÜ áðü äÜãêùìá óêýëïõ). ¼óïí áöïñÜ äå 153

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óôçí ïéêïãÝíåéá, ç ìçôÝñá öáéíüôáí íá óõììåôÝ÷åé ìå êÜðïéïí ôñüðï ðïõ ìáò èõìßæåé ôï óýíäñïìï “äé’ áíôéðñïóþðïõ”: ÁñíÞèçêå ôá “êáëÜ íÝá” ðùò ôï ðáéäß äåí Ý÷åé ïñãáíéêü ðñüâëçìá, õðÝâáëå ç ßäéá åîåôÜóåéò ðïõ “Ýðñåðå íá ãßíïõí ãéá íá êáèçóõ÷áóôåß”, ðáñåß÷å ðïëëÜ ðñïíüìéá óôï ðáéäß ìÝóá óôï óðßôé êáé âñéóêüôáí óå Ýíôïíç áíôéðáñÜèåóç ìå ôïí ðáôÝñá ï ïðïßïò äåí ðßóôåõå êáé äåí óõíüäåõóå ðïôÝ ôï ðáéäß, ïýôå Þëèå óå åíçìåñùôéêÞ åðáöÞ ìå ôïõò ãéáôñïýò. Äõóôõ÷þò øõ÷éáôñéêÞ ðáñÝìâáóç ôåëéêÜ äåí ðñáãìáôïðïéÞèçêå ëüãù ôçò áñíçôéêÞò óôÜóçò ôçò ìçôÝñáò êáèþò êáé ôçò ðëÞñïõò áðïõóßáò áíÜëïãùí õðçñåóéþí óôï íçóß. ÁíáöïñÝò óôçí åìðåéñßá áðü ôç èåñáðåßá áõôþí ôùí äéáôáñá÷þí äåí õðÜñ÷ïõí åðáñêåßò9. Ç ðñüãíùóç ÷áñáêôçñßæåôáé ãåíéêÜ öôù÷Þ ãéá ôï “êëáóéêü” ó. Munchausen, åíþ ðéï åíèáññõíôéêÜ åßíáé ôá ðñÜãìáôá óôéò ôå÷íçôÝò äéáôáñá÷Ýò, üðïõ óõíÞèùò ìåôÜ ôçí áðïêÜëõøÞ ôïõò ïé áóèåíåßò áí êáé áñíïýíôáé ôéò åíÝñãåéÝò ôïõò êáé äåí äÝ÷ïíôáé øõ÷éáôñéêÞ ðáñáêïëïýèçóç, ôñïðïðïéïýí ðÜíôùò ôç óõìðåñéöïñÜ ôïõò. Óôçí ðåñßðôùóÞ ìáò, ôá óõìðôþìáôá õðï÷þñçóáí ìåôÜ ôéò ôåëåõôáßåò áðåéêïíéóôéêÝò åîåôÜóåéò ðïõ áíáöÝñèçêáí. Âéâëéïãñáößá 1. Turner J, Reid S. Munchausen’s syndrome. Lancet, 359:346-349, 2002. 2. Croft RD, Jervis M. Munchausen’s syndrome

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in a 4 year old. Arch Dis Child, 64:740-741, 1989. 3. Rinaldi S, Dello Strologo L, Montecchi F, Rizzoni G. Relapsing gross hematuria in Mynchausen syndrome. Pediatr Nephrol, 7:202-203, 1993. 4. Bjornson CL, Kirk VG. Munchausen’s syndrome presenting as hemoptysis in a 12-year old girl. Can Respir J, 8:439-442, 2001. 5. Gidwani G. Management quandary. Intermittent copious discharge in a premenarchal girl. J Pediatr Adolesc Gynecol, 14:187-188, 2001. 6. Abrol RP, Heck A, Gleckel L, Rosner F. Selfinduced hematuria. J Natl Med Assoc, 82:127128, 1990. 7. Feldman MD, Brown RM. Munchausen by proxy in an international context. Child Abuse Negl, 26:509-524, 2002. 8. Repper J. Munchausen syndrome by proxy in health care workers. J Adv Nurs, 21:299-304, 1995. 9. Plassmann R. Inpatient and outpatient longterm psychotherapy of patients suffering from factitious disorders. Psychother Psychosom, 62:96-107, 1994. 10. Chew BH, Pace KT, Honey RJ. Munchausen syndrome presenting as gross hematuria in two women. Urology, 59:601, 2002. 11. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi, üñïé áíåýñåóçò: Munchausen OR factitious disorders. 12. Roy M, Roy A. Factitious hypoglycemia An 11-year follow up. Psychosomatics, 36:64-65, 1995. 13. Heimbach D, Bruhl P. Munchausen’s syndrome in urology. Int Urol Nephrol, 27:539-545, 1995.

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Xñ. Êïíäýëçò

ÃÑÁÌÌÁ ÓÔÏÍ ÅÊÄÏÔÇ LETTER TO THE EDITOR Primary Heatlh Care, Volume 17, Number 3, 155, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 155, 2005

Ðñüôáóç óõíåñãáóßáò ôïõ ðåñéïäéêïý "Ánnali Italiani di Chirurgia"

Áîéüôéìå Êýñéå ÄéåõèõíôÜ Óýíôáîçò, Ìå ìåãÜëç õðåñçöÜíåéá åßìáé óôçí åõ÷Üñéóôç èÝóç íá áíáêïéíþóù óôïí êüóìï ôçò ÃåíéêÞò ÉáôñéêÞò ôç äõíáôüôçôá ðïõ Ý÷ïõìå ãéá áðoóôïëÞ óå Ýãêñéôï ðåñéïäéêü ôçò ãåßôïíïò ÷þñáò Éôáëßáò, åðéóôçìïíéêþí ìáò Üñèñùí. Ôï ðåñéïäéêü ïíïìÜæåôáé “Ánnali Italiani di Chirurgia” êáé åßíáé ôï åðßóçìï ðåñéïäéêü ôçò ÉôáëéêÞò Åôáéñåßáò Ôñáýìáôïò êáé Åðåßãïíôïò êáé ôçò ÉôáëéêÞò Åôáéñåßáò Ðáíåðéóôçìéáêþí ×åéñïõñãþí. Åðßóçò åßíáé êáôá÷ùñçìÝíï óôï Index Medicus, Medlars, Medline, Pubmed, Cumulative Contents Index êáé óôï ðñüãñáììá “Ôhe Genuine Article” ôïõ É.S.I. óôï Medlars êáé Medline, ôï âñßóêåé êáíåßò óôç äéåýèõíóç: http:medscape.com/ misc/formmedline.ht (Search Medline). To ðåñéïäéêü åßíáé äéìçíéáßï. Ï ÊáèçãçôÞò êáé Åêäüôçò ôïõ ðåñéïäéêïý, Prof. Nicola Picardi, ëüãù áñßóôçò óõíåñãáóßáò ìïõ ìáæß ôïõ áðü ôá öïéôçôéêÜ ìïõ êéüëáò ÷ñüíéá êáôÜ ìåãÜëç ìïõ ôéìÞ, ìå üñéóå ùò corrispondent ôïõ ðåñéïäéêïý óôçí ÅëëÜäá. Óôá Üñèñá ïé óõããñáöåßò äåí ðñÝðåé íá åßíáé ðÜíù áðü 6 (óôá Case Reports ü÷é ðÜíù

áðü 3). ÅíäéáöÝñïõí èÝìáôá ãåíéêÞò ÷åéñïõñãéêÞò, ôñáýìáôïò êáé ëïéðüí ÷åéñïõñãéêþí åéäéêïôÞôùí. ÅíäéáöÝñïõí íÝåò ôå÷íéêÝò, áðåéêïíéóôéêÝò ìÝèïäïé, Review, Case Reports, ÁíáóêïðÞóåéò, ÔñïðïðïéÞóåéò ðáëáéþí ôå÷íéêþí ê.ëð. åðßóçìåò ãëþóóåò ôïõ ðåñéïäéêïý åßíáé ôá áããëéêÜ êáé ôá éôáëéêÜ (ôá áããëéêÜ ìÜò óõìöÝñïõí ãéá äõíáôüôçôá sitetion). Åðßóçò ðñÝðåé íá ìïõ óôáëåß ìéá ðåñßëçøç óôá åëëçíéêÜ ãéá íá ãßíåé ìéá ìåôÜöñáóÞ ôçò áðü åìÝíá óôá éôáëéêÜ óôçí ðåñßðôùóç ðïõ èá ôï óôåßëïõìå óôá áããëéêÜ, ìéá ðåñßëçøç óôá áããëéêÜ óôçí ðåñßðôùóç ðïõ èá ôï óôåßëïõìå óôá éôáëéêÜ. Êñßíù åíäéáöÝñïõóá ôç äõíáôüôçôá áñèñïãñáößáò óå Ýíá ôüóï Ýãêñéôï ðåñéïäéêü êáé èá ðáñáêáëïýóá ôïõò üðïéïõò åíäéáöåñüìåíïõò ãéá ïðïéáäÞðïôå Üëëç ðëçñïöïñßá íá ìå êáëïýí óôï 6936 678777, íá ãñÜöïõí óôï e-mail ìïõ kondilisnicdoc@pathfinder.gr Ìå ôéìÞ Êïíäýëçò ×ñ. Íéêüëáïò Åêðáéäåõüìåíïò ÃåíéêÞòÏéêïãåíåéáêÞò ÉáôñéêÞò Ãåíéêü Íïóïêïìåßï Íéêáßáò “¢ãéïò ÐáíôåëåÞìùí”

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ÍÝá

ÅÊÐÁÉÄÅÕÔÉÊÁ ÌÁÈÇÌÁÔÁ ÓÔÇ ÃÅÍÉÊÇ ÉÁÔÑÉÊÇ EDUCATIONAL COURSES FOR GENERAL PRACTICE Primary Heatlh Care, Volume 17, Number 3, 156-157, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 156-157, 2005

Ôá ðáñáêÜôù ðñïãñÜììáôá óõíå÷éæüìåíçò åêðáßäåõóçò ãéá åéäéêåõüìåíïõò ãåíéêÞò éáôñéêÞò äéåíåñãÞèçêáí óôá ãåíéêÜ íïóïêïìåßá ËÜñéóáò êáé Âüëïõ, êáé äçìïóéåýïíôáé ãéá íá êáôáäåß-

îïõí ôçí ïõóéáóôéêÞ åñãáóßá ðïõ ãßíåôáé óå ÐåñéöåñåéáêÜ Íïóïêïìåßá ôçò ÷þñáò ìáò ãéá ôçí åêðáßäåõóç ôùí åéäéêåõïìÝíùí óôçí åéäéêüôçôá ôçò ÃåíéêÞò ÉáôñéêÞò.

Ã Å Í É ÊÏ Í ÏÓ Ï ÊÏ Ì Å É Ï Â Ï ËÏÕ ÅÊÐÁÉÄÅÕÔÉÊÏ ÐÑÏÃÑÁÌÌÁ ÅÉÄÉÊÅÕÏÌÅÍÙÍ ÓÔÇ ÃÅÍÉÊÇ ÉÁÔÑÉÊÇ ÊÁÉ ÓÕÍÅ×ÉÆÏÌÅÍÇ ÉÁÔÑÉÊÇ ÅÊÐÁÉÄÅÕÓÇ ÓåðôÝìâñéïò 2004 – Éïýíéïò 2005 ÁìöéèÝáôñï Ãåíéêïý Íïóïêïìåßïõ ËÜñéóáò, ¿ñá 12:00-13:00 ÕÐÅÕÈÕÍÏÉ:

ÊáèçãçôÞò Ê. ÃïõñãïõëéÜíçò, Ä/íôÞò ÐíåõìïíïëïãéêÞò ÊëéíéêÞò Ð.Ã.Í. ËÜñéóáò, ÓõíôïíéóôÞò Åêðáßäåõóçò ÃåíéêÞò ÉáôñéêÞò Á. ÓáìáíôÜ, Ä/íôñéá Äåñìáôïëïãéêïý ÔìÞìáôïò Ã.Í. ËÜñéóáò, Áíáðëçñþôñéá Óõíôïíßóôñéá Åêðáßäåõóçò ÃåíéêÞò ÉáôñéêÞò

ÐÅÌÐÔÇ 30-9-04 ÐÅÌÐÔÇ 14-10-04 ÔÑÉÔÇ 2-11-04 ÐÅÌÐÔÇ 2-12-04 ÐÅÌÐÔÇ 13-1-05 ÐÅÌÐÔÇ 3-2-05 ÐÅÌÐÔÇ 3-3-05 ÐÅÌÐÔÇ 7-4-05

ÐÅÌÐÔÇ 5-5-05

ÐÅÌÐÔÇ 2-6-05 156

ÐñïóÝããéóç áóèåíïýò ìå áíáéìßá Å. Ìðïõñïíßêïõ, Åðéì. Â´ Áéìáôïëïãéêïý Ã.Í.Ë. Ïîåßá êïéëßá É. ÐñÜðáò, Åðéì. Á´ ×åéñïõñãéêÞò ÊëéíéêÞò Ã.Í.Ë. ÄéáöïñéêÞ äéÜãíùóç ôñá÷çëéêþí - ðñïóùðéêþí öëåãìïíþí Å. ÓåñÝôç, Åðéì. Á´ Ïäïíôéáôñéêïý ÔìÞìáôïò Ã.Í.Ë. Éïãåíåßò Çðáôßôéäåò Â êáé C áðü ôçí ïðôéêÞ ãùíßá ôïõ Ãåíéêïý Éáôñïý Ì. ×áôæçôÜêç, Áíáðëçñþôñéá Ä/íôñéá ÊÝíôñïõ Áéìïäïóßáò Ã.Í.Ë. ÄéáãíùóôéêÞ ðñïóÝããéóç áóèåíïýò ìå õðÝñôáóç Ê. Êáñáêïýóçò, Åðéì. Â´ ÐáèïëïãéêÞò ÊëéíéêÞò Ã.Í.Ë. Ìáóôüò - Êëéíéêï-åñãáóôçñéáêÞ ÄéÜãíùóç - Ðñüëçøç Å. ÊëÝôá, Åðéì. Á´ Áêôéíïëïãéêïý ÔìÞìáôïò Ã.Í.Ë. Åðåßãïíôá ðåñéóôáôéêÜ óôçí ÐáéäéáôñéêÞ Ã. Âáíéþôç, Áíáðëçñþôñéá Ä/íôñéá ÐáéäéáôñéêÞò ÊëéíéêÞò Ã.Í.Ë. ÖõóéïëïãéêÞ áêôéíïãñáößá èþñáêá êáé åðßäåéîç ÷áñáêôçñéóôéêþí ðáèïëïãéêþí áêôéíïãñáöéþí Ã. ÌðáëÞò, Åðéì. Á´ Áêôéíïëïãéêïý ÔìÞìáôïò Ã.Í.Ë. ÐñïóÝããéóç áóèåíþí ìå êïéíÜ íåõñïëïãéêÜ ðñïâëÞìáôá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò Ó. ÑÜëëç, Åðéì. Á´ Áêôéíïëïãéêïý ÔìÞìáôïò Ã.Í.Ë. ÄéáöïñéêÞ äéÜãíùóç éïãåíþí åîáíèçìÜôùí ðáéäéêÞò çëéêßáò Á. ÓáñìáíôÜ, Áíáðëçñþôñéá Ä/íôñéá Äåñìáôïëïãéêïý ÔìÞìáôïò Ã.Í.Ë.

Ôüìïò 17, Ôåý÷ïò 3, 2005

ÍÝá

Á×ÉËËÏÐÏÕËÅÉÏ Ã.Í. ÂÏËÏÕ ÅÊÐÁÉÄÅÕÔÉÊÏ ÐÑÏÃÑÁÌÌÁ ÃÅÍÉÊÇÓ ÉÁÔÑÉÊÇÓ 2004-2005 Ïêôþâñéïò 2004 – ÌÜéïò 2005 ìöéèÝáôñï Ãåíéêïý Íïóïêïìåßïõ Âüëïõ, ¿ñá 13:00-14:00 ÁöïñÜ ðñïãñáììáôéóìÝíåò ÄéáëÝîåéò ðïõ èá ãßíïíôáé óôï ÁìöéèÝáôñï ôïõ Íïóïêïìåßïõ êÜèå ÐÝìðôç êáé þñá 13.00-14.00 óôéò áêüëïõèåò çìåñïìçíßåò.

ÐáñÜëëçëá èá ïñãáíùèåß äéÞìåñï áðïãåõìáôéíü êëéíéêü öñïíôéóôÞñéï ãéá ôçí áíôéìåôþðéóç ôïõ Ó. ÄéáâÞôç óå çìåñïìçíßá ðïõ èá áíáêïéíùèåß, ìå ôç óõììåôï÷Þ ôùí åéäéêåõïìÝíùí êáé ìå õðåýèõíï ôçí Åíäïêñéíïëüãï ê. ÊÜóç Ã. (áñ÷Ýò ôïõ 2005).

157

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

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ÍÅÅÓ ÅÊÄÏÓÅÉÓ ÍÅW EDITIONS Primary Heatlh Care, Volume 17, Number 3, 158, 2005 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 17, Ôåý÷ïò 3, 518, 2005

"To Ðåñéöåñåéáêü Éáôñåßï: Åã÷åéñßäéï ãéá ôïí Ãåíéêü/Ïéêïãåíåéáêü Éáôñü" ×ñÞóôïò ËéïíÞò ¸êäïóç: ÉáôñéêÝò Åêäüóåéò Ð.×. Ðáó÷áëßäçò êáé Áêáäçìßá ÃåíéêÞò ÉáôñéêÞò, 2006

Ðñüóöáôá êõêëïöüñçóå ôï âéâëßï ìå ôßôëï: "Ôï Ðåñéöåñåéáêü Éáôñåßï: Åã÷åéñßäéï ãéá ôïí Ãåíéêü/Ïéêïãåíåéáêü Éáôñü" áðïôåëþíôáò êáé ôçí ðñþôç Ýêäïóç ôçò Áêáäçìßáò ÃåíéêÞò ÉáôñéêÞò. Ôçí Ýìðíåõóç êáé åðéìÝëåéá ôïõ åß÷å ï Áí. ÊáèçãçôÞò ÊïéíùíéêÞò êáé ÏéêïãåíåéáêÞò Éáôñé158

êÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò ê. ×. ËéïíÞò öéëïäïîþíôáò íá êáëýøåé Ýíá êåíü óôçí åëëçíéêÞ âéâëéïãñáößá. Ôçí ðáñïýóá Ýêäïóç ðñïëïãßæïõí ï Áí. ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò ê. Ô. ÖéëáëÞèçò êáé ï Ðñüåäñïò ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò ê. ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò êáé ôï åðßìåôñï ôçò Ý÷åé ãßíåé áðü ôïí ÊáèçãçôÞ Ïéêïíïìéêþí Õãåßáò ôçò ÅèíéêÞò Ó÷ïëÞò Äçìüóéáò Õãåßáò ê. É. Êõñéüðïõëï. Åßêïóé äýï óõããñáöåßò ìïéñÜæïíôáé ôéò ãíþóåéò êáé ôçí åìðåéñßá ôïõò óõìâÜëëïíôáò ìå ôïí êáëýôåñï ôñüðï óôç óõããñáöÞ êåöáëáßùí ôïõ âéâëßïõ. Áðïôåëåßôáé áðü 3 ìÝñç: ÌÝñïò (É): "Ç ïñãÜíùóç ôïõ Ðåñéöåñåéáêïý Éáôñåßïõ êáé ç óýíäåóç ìå ôçí êïéíüôçôá". ÌÝñïò (ÉÉ): "Ïé õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôï Ðåñéöåñåéáêü Éáôñåßï" ÌÝñïò (ÉÉÉ): "Ç Ýñåõíá óôï Ðåñéöåñåéáêü Éáôñåßï". Ôï âéâëßï áðåõèýíåôáé óå Éáôñïýò ÃåíéêÞò ÉáôñéêÞò ðïõ åñãÜæïíôáé óå ÐåñéöåñåéáêÜ Éáôñåßá, ÊÝíôñá Õãåßáò êáèþò êáé óå Éáôñïýò õðü÷ñåïõò õðçñåóßáò õðáßèñïõ, ÖïéôçôÝò ÉáôñéêÞò, êáèþò êáé óå Üëëïõò Åðáããåëìáôßåò Õãåßáò. Ïé 279 óåëßäåò ôïõ âéâëßïõ åßìáé óßãïõñïò üôé èá áðïôåëÝóïõí Ýíá åõ÷Üñéóôï ôáîßäé óôïí áíáãíþóôç êáé Ýíá ÷ñÞóéìï åñãáëåßï óôçí êáè' çìÝñá êëéíéêÞ ðñÜîç óå üóïõò óõíáäÝëöïõò åñãÜæïíôáé óôï ÷þñï ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. Dr. ÁíÜñãõñïò Ä. Ìáñéüëçò Åðéóôçìïíéêüò Õðåýèõíïò Ê.Õ. Âýñùíá