VOL18_ISSUE2_APR_JUN_2006 by SAN PUBLICATIONS

ðñùôïâÜèìéá

öñïíôßäá Primary Health Care

Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 18, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2006, Volume 18, Number 2, April - June 2006

Ôçò Óýíôáîçò 62

L. Pisco: Main lines of action for reforming primary health care in Portugal

X. ËéïíÞò, Ê. ÌáêñÞ: Ôé äçµïóéåýåôáé óå áõôü ôï ôåý÷ïò ÅñåõíçôéêÝò Åñãáóßåò

Á. Áñâáíßôçò, Á. ÆõãïµáëÜò, Á. ÓêáñðÝëïò, È. ÌðåëÝæïò, Í. ÑáæÞò: Ç áîßá ôçò áíáãñáöÞò ôùí åµðïñéêþí ïíï-µá-óéþí öáñµÜêùí µå åëëçíéêÜ

Í. ÐëïõµÞò, Ó. ÅñçµÜêç, K. ÌáêñÞ, Á. ÖèåíÜêçò, Ã. ÖïõíôÜêçò, Ñ. ÐáôåëÞ, Å. Ôæþñôæçò, Å. ÊõâåñíçôÜêç, T. ÖéëáëÞèçò: Áíôéµåôþðéóç ôçò ðá÷õóáñêßáò µå ïµáäéêÞ èåñáðåßá óôçí ðñùôïâÜèµéá õãåßá: ÁðïôåëÝóµáôá äåêáïêôþ µçíþí èåñáðåõôéêÞò ðáñÝµâáóçò Áíáóêüðçóç

Á. ÆåúµðÝêçò, Ä.Â. ÐáíáãéùôÜêïò, ×. Ðßôóáâïò: Ï ñüëïò ôçò ïµïêõóôåÀíçò óôçí ðñüêëçóç êáñäéáããåéáêÞò íüóïõ ÁíáöïñÝò Ðåñéðôþóåùí

Å. ËáµðñïãéáííÜêçò, Á. ÂáóéëÜêç, Ê. ÌáêñÞ, Ã. AðïóôïëÜêçò, Á. ÖèåíÜêçò, Ê. ÌåiäÜíçò, Á. ÄåñµéôæÜêçò: Ðåñßðôùóç áóèåíïýò µå óýíäñïµï Marfan êáé ïîý äéá÷ùñéóµü ôçò áïñôÞò. ÄéáãíùóôéêÞ ðáñÝµâáóç óôçí ðñùôïâÜèµéá öñïíôßäá õãåßáò.

Ã. Ðáðáäüðïõëïò, Ä. Ìðñßµçò, Á. Ðñüêëïõ, Á. ÐåôñïõëÜêç, Á. ×ïõëÜêç, Ç. Óáëïýóôñïò: Áíáöõëáîßá óôçí ðñùôïâÜèµéá öñïíôßäá õãåßáò. Ìéá åðåßãïõóá êáôÜóôáóç ðïõ êáëåßôáé íá áíôéµåôùðßóåé Üµåóá ï ãåíéêüò ãéáôñüò

ÊÙÄ. 3855

ÃñÜµµáôá óôïí Åêäüôç 94

Æ. Ôóßµôóéïõ, Ó. Äçµïðïýëïõ, Ä. Âáóéëïðïýëïõ, Ó. ÁñãõñéÜäïõ, ×. ËéïíÞò: Ó÷Ýóç éáôñïý - áóèåíÞ êáé ðñùôïâÜèµéá öñïíôßäá õãåßáò: ÓêÝøåéò êáé ðáñáëëçëéóµïß µå áöïñµÞ ôç åðßóêåøç óôï Éåñü Êïéíüâéï Åõáããåëéóµïý ôçò Èåïôüêïõ

K. Hopayian: Ó÷üëéá óôï äçµïóéåõµÝíï Üñèñï "ÌåëÝôç ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ êáé µåôáâïëéêïý óõíäñüµïõ ó' Ýíá áãñïôéêü ðëçèõóµü ôïõ Íïµïý Á÷áÀáò áðü Ä. ËéÜíá êáé óõí. (Ôåý÷ïò Áðñéëßïõ - Éïõíßïõ 2005).

Lebanese Society of Family Medicine

Ä. Ãéáííüðïõëïò: ÓõµðåñÜóµáôá áðü ôçí ðñáãµáôïðïßçóç ôïõ óåµéíÜñéïõ äéáêïðÞò êáðíßóµáôïò, óôï ÊÜóôñï ÊõëëÞíçò 19-21 ÌáÀïõ 2006

Ì. ÁíäñÝïõ: ÅðéôñïðÞ ¸ñåõíáò ÅËÅÃÅÉÁ: "Öéëßððåéï" ÅñãáóôÞñéï ¸ñåõíáò

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

ÊÅÌÐ.ÁÈ.

ÍÝá áðü ôçí ÅËÅÃÅÉÁ

Áñéèìüò ¢äåéáò 451/91

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

Ôüìïò 18, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2006

õãåßáò

ÍÝåò åêäüóåéò 100

Å. Èçñáßïò: ËáúêÞ ÐáñáäïóéáêÞ ÉáôñéêÞ

101

Ðñïóå÷Þ óõíÝäñéá êáé óåµéíÜñéá

103

Ïäçãßåò ãéá ôïõò óõããñáöåßò

ISSN 1105-7432

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

ÅËÐÅÍ / PENRAZOL 2ç ÅÎÙÖÕËËÏÕ

ÅËÐÅÍ / ENTACT 3ç ÅÎÙÖÕËËÏÕ

WYETH / EFEXOR 4ç ÅÎÙÖÕËËÏÕ

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 ÄçìÞôñéïò ¸ëëçíáò Áíôéðñüåäñïò Â ÓôÝëëá ÁñãõñéÜäïõ Ãåíéêüò ÃñáììáôÝáò-Ôáìßáò ÁèáíÜóéïò Óõìåùíßäçò Åéäéêüò ÃñáììáôÝáò ÁíÜñãõñïò Ìáñéüëçò ÌÝëç Áíôþíçò Ìðáôßêáò Íéêüëáïò ÐáðáíéêïëÜïõ Executive Board of the Greek Association of General Practitioners President Bodosakis-Prodromos Merkouris Vice-President A Dimitrios Ellinas Vice-President B Stella Argiriadou General Secretary Treasurer Athanasios Symeonidis Special Secretary Antonis Batikas Members Anargiros Mariolis Nikolaos Papanikolaou 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 2810394621, Fax: +30 2810394606 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

Ðáýëïò ÈåïäùñÜêçò (ÉùÜííéíá) Êïñíçëßá ÌáêñÞ (ÇñÜêëåéï) ÁíÜñãõñoò Ìáñéüëçò (ÁèÞíá)

Pavlos Theodorakis (Ioannina) Kornilia Makri (Heraklio) Anargiros Mariolis (Athens)

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

Members of Editorial Board

ÈùìÜò Áããåëüðïõëïò (ÈÜóïò) ¢ëêçò Áëåâßæïò (ÁèÞíá) ÅëÝíç Ãåùñãáêßëá (ÁèÞíá) Íßêç Ãëýóôñá (ÆáãêëéâÝñé) Áéêáôåñßíç ÊÜâïõñá (Scotlant) ÑÝíá Ïéêïíïìßäïõ (ÄéáâáôÜ) Íßêïò ÐáðáíéêïëÜïõ (ÊáñðåíÞóé) ÂáããÝëçò Ðåôñïâßôóïò (Èåóóáëïíßêç) Íßêïò ÑïõóÜêçò (Ëéôü÷ùñï) ÊéêÞ Óôåöáíßäïõ (Óêýäñá) Ãéþñãïò Ôæáíßäçò (ÐÜñïò) ÅéñÞíç ×áôæïðïýëïõ (Èåóóáëïíßêç) Áíáóôáóßá ×ñéóôïöÝëç (Áëßáñôïò)

Thomas Aggelopoulos (Thessaloniki) Alkis Alevizos (Athens) Eleni Georgalika (Athens) Niki Glistra (Zagliveri) Ekaterini Kavoura (Scotlant) Rena Ikonomidou (Diavata) Nikos Papanikolau (Karpenisi) Vaggelis Petrovitsos (Thessaloniki) Nikos Rousakis (Litochoro) Kiki Stefanidou (Skidra) Giorgos Tzanidis (Paros) Irini Chatzopoulou (Thessaloniki) Anastasia Christofeli (Aliartos)

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. ÊáèçãÞôñéá 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 T. 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 Promotion 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 Psychiatry, University of Ioannina M. Sgantzos, Lecturer 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 Psychiatry, University of Athens

MERK - GENERICS

ÊÁÔÁ×ÙÑÇÓÇ

ðñùôïâÜèìéá

öñïíôßäá õãåßáò Primary Health Care

ÐÅÑÉÅ×ÏÌÅÍÁ Ôçò Óýíôáîçò L. Pisco: Main lines of action for reforming primary health care in Portugal....................................................................................................................................................................................63 X. ËéïíÞò, Ê. ÌáêñÞ: Ôé äçìïóéåýåôáé óå áõôü ôï ôåý÷ïò...........................................................................................................................................................................................................................67 ÅñåõíçôéêÝò Åñãáóßåò Á. Áñâáíßôçò, Á. ÆõãïìáëÜò, Á. ÓêáñðÝëïò, È. ÌðåëÝæïò, Í. ÑáæÞò: Ç áîßá ôçò áíáãñáöÞò ôùí åìðïñéêþí ïíïìáóéþí öáñìÜêùí ìå åëëçíéêÜ...............................68 Í. ÐëïõìÞò, Ó. ÅñçìÜêç, K. ÌáêñÞ, Á. ÖèåíÜêçò, Ã. ÖïõíôÜêçò, Ñ. ÐáôåëÞ, Å. Ôæþñôæçò, Å. ÊõâåñíçôÜêç, Á. ÖéëáëÞèçò: Áíôéìåôþðéóç ôçò ðá÷õóáñêßáò ìå ïìáäéêÞ èåñáðåßá óôçí ðñùôïâÜèìéá õãåßá: ÁðïôåëÝóìáôá äåêáïêôþ ìçíþí èåñáðåõôéêÞò ðáñÝìâáóçò............................................................................................................76 Áíáóêüðçóç Á. ÆåúìðÝêçò, Ä.Â. ÐáíáãéùôÜêïò, ×. Ðßôóáâïò: Ï ñüëïò ôçò ïìïêõóôåÀíçò óôçí ðñüêëçóç êáñäéáããåéáêÞò íüóïõ.............................................................................................82 ÁíáöïñÝò Ðåñéðôþóåùí Å. ËáìðñïãéáííÜêçò, Á. ÂáóéëÜêç, Ê. ÌáêñÞ, Ã. AðïóôïëÜêçò, Á. ÖèåíÜêçò, Ê. ÌåïäÜíçò, Á. ÄåñìéôæÜêçò: Ðåñßðôùóç áóèåíïýò ìå óýíäñïìï Marfan êáé ïîý äéá÷ùñéóìü ôçò áïñôÞò. ÄéáãíùóôéêÞ ðáñÝìâáóç óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò...........................................87 Ã. Ðáðáäüðïõëïò, Ä. Ìðñßìçò, Á. Ðñüêëïõ, Á. ÐåôñïõëÜêç, Á. ×ïõëÜêç, Ç. Óáëïýóôñïò: Áíáöõëáîßá óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò. Ìéá åðåßãïõóá êáôÜóôáóç ðïõ êáëåßôáé íá áíôéìåôùðßóåé Üìåóá ï ãåíéêüò ãéáôñüò.................................................................................................................................................................91 ÃñÜììáôá óôïí Åêäüôç Æ. Ôóßìôóéïõ, Ó. Äçìïðïýëïõ, Ä. Âáóéëïðïýëïõ, Ó. ÁñãõñéÜäïõ, ×. ËéïíÞò: Ó÷Ýóç éáôñïý - áóèåíÞ êáé ðñùôïâÜèìéá öñïíôßäá õãåßáò: ÓêÝøåéò êáé ðáñáëëçëéóìïß ìå áöïñìÞ ôç åðßóêåøç óôï Éåñü Êïéíüâéï Åõáããåëéóìïý ôçò Èåïôüêïõ..............................................................................................................................................95 K. Hopayian: Ó÷üëéá óôï äçìïóéåõìÝíï Üñèñï "ÌåëÝôç ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ êáé ìåôáâïëéêïý óõíäñüìïõ ó' Ýíá áãñïôéêü ðëçèõóìü ôïõ Íïìïý Á÷áÀáò áðü Ä. ËéÜíá êáé óõí. (Ôåý÷ïò Áðñéëßïõ - Éïõíßïõ 2005)..................................................................................................................................................................................96 Lebanese Society of Family Medicine ....................................................................................................................................................................................................................................................................97 ÍÝá áðü ôçí ÅËÅÃÅÉÁ Ä. Ãéáííüðïõëïò: ÓõìðåñÜóìáôá áðü ôçí ðñáãìáôïðïßçóç ôïõ óåìéíÜñéïõ äéáêïðÞò êáðíßóìáôïò, óôï ÊÜóôñï ÊõëëÞíçò 19-21 ÌáÀïõ 2006 ..................................98 Ì. ÁíäñÝïõ: ÅðéôñïðÞ ¸ñåõíáò ÅËÅÃÅÉÁ: “Öéëßððåéï” ÅñãáóôÞñéï ¸ñåõíáò ................................................................................................................................................................................99 ÍÝåò åêäüóåéò Å. Èçñáßïò: ËáúêÞ ÐáñáäïóéáêÞ ÉáôñéêÞ.............................................................................................................................................................................................................................................................100 Ðñïóå÷Þ óõíÝäñéá êáé óåìéíÜñéá ....................................................................................................................................................................................................................................... 102 Ïäçãßåò ãéá ôïõò óõããñáöåßò ............................................................................................................................................................................................................................................ 103

CONTENTS Editorial L. Pisco: Main lines of action for reforming Primary health care in Portugal...................................................................................................................................................................................63 C. Lionis, K. Makri: What's in this issue .................................................................................................................................................................................................................................................................67 Original Papers A. Arvanitis, A. Zygomalas, A. Skarpelos, T. Mpelezos, N. Razis: Advantages of writing the commercial names of drugs in greek .................................................................68 Í. Ploumis, S. Erimaki, K. Makri, Á. Fthenakis, G. Fountakis R. Pateli, Å. Tzortzis, Å. Kivernitaki, Á. Philalithis: Treatment of obesity within the Primary Care setting: Results of an 18-month therapeutic intervention.............................................................................................................................................................................................................................76 Review Á. Zeimbekis, D.B. Panagiotakos, C. Pitsavos: The importance of homocysteine in causing cardiovascular disease.................................................................................................82 Case Reports E. Lamprogiannakis, A. Vasilaki, K. Makri, G. Apostolakis, A. Fthenakis, K. Meidanis, A. Dermitzakis: Case of a patient with marfan syndrome and acute aortic dissection. diagnostic intervention in primary health care.............................................................................................................................................................................................................87 G. Papadopoulos, D. Brimis, A. Proklou, A. Petroulaki, A. Houlaki, H. Saloustros: Ánaphylaxis in primary health care. Án emergency state to be confronted by the general practitioners..........................................................................................................................................................................................................................................................................................91 Letters to the editor Z. Tsimtsiou S. Dimopoulou, D. Vasilopoulou, S. Argyriadou, C. Lionis: Issues on doctor - patient relationship after a visit to an Ordodox Monastery........................95 K. Hopayian: Commens on the puplished paper by D. Lianas. et al .......................................................................................................................................................................................................96 Lebanese Society of Family Medicine ....................................................................................................................................................................................................................................................................97 News from the Greek Association of General Practicioners D. Gianopoulos: Seminar of smoking association at Killini (May 2006)................................................................................................................................................................................................98 M. Adreou: Research Committee of ELEGEIA: The FILIPPIO workshop..............................................................................................................................................................................................99 New Editions E. Thireos: A new book: “Traditional Medicine”................................................................................................................................................................................................................................................100 Upcoming congresses and seminars ............................................................................................................................................................................................................................... 102 Instructions for the authors ................................................................................................................................................................................................................................................... 103

Luis Pisco

Ôüìïò 18, Ôåý÷ïò 2, 2006

ÔÇÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 18, Number 2, 63-66, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 63-66, 2006

Main lines of action for reforming primary health care in Portugal The goal of a Health System is to answer to the population’s health needs. Every effort must be made to hold principles of solidarity and justice, so that everyone can share the scientific and technological advancements that were put to the service of health and welfare. Most Western countries face the same problems in their health systems. The problems mentioned are invariably high costs, inefficiency and lack of quality. Portugal is no exception. Governments seek to organize health systems to improve distributive justice, efficiency, effectiveness and ability to solve the citizens problems. The determinant role of primary health care services in helping achieve these goals has been recognized. A recent study from the World Health Organization 1 concludes that the available evidence confirms that health systems that are strongly oriented to primary care obtain better health results for the population, more justice, adequate service use, higher user satisfaction and lower costs. A comparative study involving eleven countries has shown that the bigger the health system’s orientation to primary care, the higher the possibility of achieving good health results, at a lower cost, with a higher user satisfaction2. Another study in eighteen countries of the OECD analysing a period of thirty years has found similar results3. In the last 30 years the economic and social situation in Portugal has shown remarkable progress. The sustained and systematic improvement

of our health services in this period has been acknowledged. We currently have high quality health centres, hospitals, professionals and equipment. Our population is increasingly aware of its rights, increasingly demanding, and alert to the defence of its health. However, it was not always this way. We should not forget that for decades the major part of the population had no medical attention or a very fragile care system. Portugal has been an independent nation since 1143, a republic since 1910, a democracy since 1974 and joined the European Community in 1986. We have had community health centres since 1971 and a National Health Service since 1979. In the early 1970s, Portugal was one of the first European countries to adopt an integrated approach in primary health care through the development of an impressive health centre network. We currently have about 350 health centres and almost 2000 health units covering most of the national territory. This network, along with better maternity care at hospital level, has been deemed responsible for very significant advances in health status: in the late 1960s the Portuguese child mortality rate was in the 60 per 1000 range, by far the highest among the other 15 European Union countries4. Thirty years later it was 5.0 per 1000 representing a better ratio than Greece, Netherlands, Ireland, Luxembourg and the United Kingdom, and similar to Belgium, ranking ninth in the EU3. Despite the remarkable achievements in health policy, numerous challenges remain: in comparison to other OECD countries, the expenditure of the Portuguese health care sector is 63

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characterized by a high level of resources relative to the GDP, a low level of public per capita expenditure and high levels of pharmaceutical expenditure5. According to the OECD, the results in some areas of health policy, such as immunization policy, primary health care, care for diabetics, have seen significant achievements4. Also according to the OECD, despite the registered advancements, the health system still faces a number of challenges: health inequalities, the high level of private expenditure, a poor coordination between primary and secondary health care; these challenges still present important obstacles, and structural and cultural constraints. Most of them come from the bureaucratic structure that constrains family medicine at the National Health Service. Many health care reforms have been legislated, but so far never completely implemented. The health centres are a cultural, technical and institutional patrimony which is not only important to preserve but also to modernize and develop, since they continue to be the most efficient and accessible mean to protect and promote the population’s health. We are aware of its limitations and needs, the result of years of lack of investment. We realize the chronic lack of human resources, of which family doctors are only the most visible side. We lack family nurses, nutritionists, psychologists, social assistants, oral hygienists and the consulting of other medical experts, beside general and family medicine that allows us to raise our capacity to solve health problems that arrive daily to our offices. It is vital that more and larger investments are made in palliative care. There are good international examples of the advantages of cooperation between the several health professions and the main objective is to integrate the different professionals working together to strengthen primary health care6-8. Created by political decision in 1982, general practice the point of entry to the Portuguese NHS, is based in the concepts of comprehensiveness and continuity of care and has an emphasis on the person and the family. The community focus is variable across the country. The positive aspects are that we have a 64

Luis Pisco

good national coverage, well defined terms of reference, a well developed primary care culture, and excellent postgraduate training. Each person can choose his or her personal or family doctor within the NHS. The registration of the whole family to one family doctor is recommended and most people do this. Each doctor will have a defined patient list, usually ranging between 1500 and 2000 patients and the patient’s records are organized in family folders. The negative aspects are the very rigid, averse to change, civil service-driven system, a reversed distribution of health professionals, aging professionals with shortage of replacements and the professionals’ geographic distribution out of pace with demographic changes. Primary care is seen as second rate care and we have a salarybased payment system, with no incentives. In the current Government’s program it is explicitly stated that primary health care is the Health System’s central pillar and that Health Centres are the institutional base of primary health care. To make this vision come true, it is necessary to change the current primary health care scene, making it more accessible, more adequate to meet the needs and more efficient, in answer to, not only the citizens expectations, but also the professionals provision of better care to get better health. Restructuring is in progress in eight major areas: · Redesign and autonomy of the health centers The health center as a local health authority, management and financial autonomy, population coverage between 100.000 and 200.000, Family Health Units as the basis of care, allied health professions providing for all FHU, rationalization of acute and emergency care. · Implementation of Family Health Units Multiprofessional teams, self-organized, doctor’s patients lists as basis for practice population, maximum 8 GPs for 14.000 registered patients, mixed payment system (capitation / salary/objectives), financial and professional incentives and high access to care. · Restructuring of Public Health Services Shift from regulatory role to epidemiological

Luis Pisco

surveillance, geodemographic organization – 100.000-200.000, local health observatory. · Other dimensions of community intervention Reorganization of community intervention, enhancement of home care, enhancement of palliative care, implementation of mobile units in selected situations and implementation of family support networks. · Implementation of Local Health Units Enhancement of communication between health centers and hospitals and a trial of new organizational models. · Development of human resources Facilitate the admission of newly-graduated GPs, advertise the new system as to attract more nurses, facilitate mobility between practices, allow for part-time practice, reward activities such as tutoring, teaching and research and bring other health professions into the health centers · Development of health information systems Develop an integrated health information system covering all health centers and FHUs, create a data center allowing access to information anywhere in the country, create a network for data sharing among health professionals and communication with patients, implement guidelines and specification for software developers · Change and competency development Training for change management, continuing professional development of health professionals, involvement in undergraduate education and postgraduate training The initial phase, and the one with more public visibility, is the creation of Family Health Units (FHU), small multiprofessional teams, composed of 3 to 8 family doctors, an equal number of family nurses and administrative professionals, encompassing a population between 4000 and 14000 people. These teams will have technical, functional and organizational autonomy, and, very importantly, a retributive system that will reward merit, and is sensitive to productivity and accessibility, but also, and above all, quality. The FHU’s mission and responsibility, is to

Ôüìïò 18, Ôåý÷ïò 2, 2006

maintain and improve the health condition of the people that it envelops, through a general health care service, on a custom basis, with good accessibility and continuity. These are health care services based on proximity, of small dimensions, embedded in the community, of easy contact and friendly relations with their users. To reach this goal it is imperative, in the next few years to make an effort to requalify the existing structures, the current network of Health Centres and extensions, to build new structures, more adequate to the needs and closer to the people, but above all, to requalify the human resources in the current and future FHUs. It is imperative to debureaucratize and modernize, in an organized and planned way, the procedures in health centres and to provide incentives to change towards systematic identification of processes that can be simplified to the benefit of the citizens, increasing the efficiency and making better use of the time and work of the professionals. More organizational and management flexibility is needed, more teamwork, more autonomy and responsibilization, a new contractualization and evaluation culture, and an information system that answers to these needs. The big challenges to the health policy are conditioned by matters like demographic change and the aging of populations, the growing complexity of health care, the technological development, the increase in the citizens’ expectations and the financing problems, which condition not only the present, but also the future. The potential for transformation and innovation in our Health Services is still great with a necessity for permanent improvements in quality, with aim towards the fulfilment of needs and expectations and satisfies the population that uses them, as well as increasing the satisfaction of the health professionals and improvig organization and management. For that, we should consider was the motivations and needs, both of the ones receiving health care and the ones providing care. The Ministry Council, was created last October, in direct dependency of the Ministry of Health, the “Mission for the reform of Primary Health Care” (MCSP), with a mission’s structure for the guidance of the global launching project, 65

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coordination and tracking of the health centres’ reconfiguration strategy and the implementation of the family health units. The MCSP would like the reform of the Primary Health Care Services, to be seen, by the citizens and health professionals, as an enormous opportunity for improvement and never as a threat. In July 2006 we have so far 109 proposals for FHUs involving 2.137 professionals, 733 doctors, 726 nurses, 568 administrative staff and 110 other professionals, covering 1.295.860 patients. The previous average list size was 1531 patients and the average new list is 1768. The average FHU has around 12.000 patients, 7 doctors and 20 professionals in total. Until the end of the year we expect to have about 100 FHUs up and running. Most of the professionals that work in the health centres, as well as the citizens that use them, are perfectly aware of their problems and the reasons that determine them. They have lived the progresses and have suffered with mistakes and returns. They have grown weary of the contradictions between the political discourse favourable to the primary health care and the day-to-day practices. They are in the best situation to give positive contributions to the transformation of our Health Centres to the best. We are expecting everybody’s suggestions and criticisms. Luis Pisco Mission for the reform of Primary Health Care luispisco@mcsp.min-saude.pt www.mcsp.min-saude.pt

References 1. What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? WHO Regional Office for Europe’s Health Evidence Network (HEN) January 2004. 2. Starfield B. Primary care. Concept, evaluation and policy. New York, Oxford University Press, 1992. 3. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health services research, 2003, 38(3):831-865. 4. European Observatory of Health Systems and Policies. Health Care Systems in Transition. HiT summary: Portugal, 2004. 5. OECD health data 2004. Organization for Economic Co-operation and Development, Paris, 2004. 6. Barriers and Facilitators to Enhancing Interdisciplinary Collaboration in Primary Health Care. URL: http://www.eicp-acis.ca/en/resources/ pdfs/Barriers-and-Facilitators-to-EnhancingInterdisciplinary-Collaboration-in-Primary-HealthCare.pdf Accessed in 10th of July 2006. 7. Enhancing Interdisciplinary Collaboration in Primary Health Care in Canada. URL: http: //www.eicp-acis.ca/en/resources/pdfs/EnhancingInterdisciplinary-Collaboration-in-PrimaryHealth-Care-in-Canada.pdf Accessed in 10th of July 2006. 8. World Health Organization. Preparing a health care workforce for the 21st century: The challenge of chronic conditions. URL: http://www.who.int/ chronic_conditions/workforce_report/en/ Accessed in 10th of July 2006.

Ôüìïò 18, Ôåý÷ïò 2, 2006

ÔÇÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 18, Number 2, 67, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 67, 2006

Ôé äçìïóéåýåôáé óå áõôü ôï ôåý÷ïò Óôï ôåý÷ïò áõôü ç «ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò» áëëÜæåé óåëßäá êáé åãêáéíéÜæåé Ýíá íÝï ðåñéå÷üìåíï öéëïäïîþíôáò íá ðñïóåããßóåé ðñüôõðá óýã÷ñïíùí âéïúáôñéêþí ðåñéïäéêþí. Ç áëëáãÞ óõìðßðôåé ìå ôç íÝá óýíèåóç ôçò ÓõíôáêôéêÞò ôçò ÅðéôñïðÞò ôçí ïðïßá êïóìïýí ðïëëïß êáé ðïëëÜ õðïó÷üìåíïé íÝïé éáôñïß ãåíéêÞò éáôñéêÞò êáé åñåõíçôÝò áðü äéÜöïñåò ðåñéï÷Ýò ôçò ÷þñáò êáé ôïõ åîùôåñéêïý êáé ïé ïðïßïé ìáæß ìå ðñüóùðá ôçò ðñïçãïýìåíçò åðéôñïðÞò èá áðïôåëÝóïõí ôï éäáíéêü áìÜãáëìá ãéá ôçí áíÜäåéîç ôçò íÝáò ðñïïðôéêÞò ôïõ ðåñéïäéêïý. Ôï «íÝï» åðßóçò ôïõ ðåñéïäéêïý áíáäåéêíýåôáé ìå ïõóéáóôéêÝò áëëáãÝò óôï ðåñéå÷üìåíï ôïõ, ôï ïðïßï åö åîÞò èá öéëïîÝíåé äõï ôïõëÜ÷éóôïí Üñèñá óýíôáîçò, äõï åñåõíçôéêÜ Üñèñá, ìéá áíáóêüðçóç äõï áíáöïñÝò ðåñéðôþóåùí êáé ãñÜììáôá óôïí åêäüôç. Ç ðáñïõóßáóç íÝùí åêäüóåùí êáé ôùí íÝùí áðü ôç ãåíéêÞ éáôñéêÞ óå ÅëëÜäá êáé åîùôåñéêü èá áôïôåëÝóåé ïõóéáóôéêü ìÝñïò êÜèå ôåý÷ïõò. Tçí êáéíïýñéá ðñïóðÜèåéá óôá Üñèñá óýíôáîçò åãêáéíéÜæåé Ýíá óçìáíôéêü ðñüóùðï óôç óýã÷ñïíç éóôïñßá ôçò ÅõñùðáúêÞò ÃåíéêÞò ÉáôñéêÞò ê. Luis Pisco, ðñþçí ðñüåäñïò ôçò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò ôçò Ðïñôïãáëßáò, ìÝëïò óÞìåñá ôïõ Ä.Ó. ôçò WONCA Europe. Ï ê. Pisco óôï Üñèñï áõôü óýíôáîçò áíáöÝñåôáé óýíôïìá óôçí åîÝëéîç ôçò ÃåíéêÞò ÉáôñéêÞò êáé ôçò ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò óôçí Ðïñôïãáëßá êáé óôï ðñüãñáììá ìåôáññýèìéóçò ôçò êáéíïýñãéáò êõâÝñíçóçò óôç ÷þñá áõôÞ, êáèþò êáé óôéò 8 ìåßæïíåò ðåñéï÷Ýò ðïõ èá ðñÝðåé áõôÞ íá âáóéóôåß. Ôá åñåõíçôéêÜ Üñèñá áõôïý ôïõ ôåý÷ïõò ðñïÝñ÷ïíôáé áðü ìåëÝôåò ðïõ äéåîÞ÷èçóáí óå ÊÝíôñá Õãåßáò óôçí Ðåëïðüííçóï êáé ÊñÞôç êáé óõæçôïýí ôçí áîßá ôçò áíáãñáöÞò ôùí åìðïñéêþí ïíïìáóéþí óôá ÅëëçíéêÜ (Áñâáíßôçò êáé óõí., óåëßäåò 67-74) êáé óôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò

óôçí ÐÖÕ (Ðëïýìçò êáé óõí., óåëßäåò 75-80). ÁíåîÜñôçôá áðü ôïõò ìåèïäïëïãéêïýò ðåñéïñéóìïýò ðïõ óõíáíôïýí ïé ìåëÝôåò áõôÝò, ôá èÝìáôá ðïõ äéáðñáãìáôåýïíôáé ðáñïõóéÜæïõí õøçëü åíäéáöÝñïí êáé äéåõñýíïõí ôç óõæÞôçóç ãéá ôçí âåëôßùóç ôçò áðïôåëåóìáôéêüôçôáò óôç ÃåíéêÞ ÉáôñéêÞ êáé óôçí ÐÖÕ. Ïé ÆåìðÝêçò êáé óõí. (óåëßäåò 8185) óõæçôïýí ôï ñüëï ôçò ïìïêõóôåÀíçò óôçí ðñüêëçóç êáñäéáããåéáêÞò íüóïõ, Ýíá èÝìá ðïõ Ý÷åé óõæçôçèåß åõñýôåñá óôç âéâëéïãñáößá êáé öáßíåôáé íá ðñïóåëêýåé ôï åíäéáöÝñïí ôùí Éáôñþí ÃåíéêÞò ÉáôñéêÞò. Ôï ôåý÷ïò áõôü öéëüîåíåß åðßóçò äõï áíáöïñÝò ðåñéðôþóåùí ãéá ìéá áóèåíÞ ìå óýíäñïìï Ìatfan êáé ïîý äéá÷ùñéóìü ôçò áïñôÞò (ËáìðñïãéáííÜêçò êáé óõí, óåëßäåò 86-89) êáé ç Üëëç óå áóèåíÞ ìå áíáöõëáîßá (Ðáðáäüðïõëïò êáé óõí, óåëßäåò 90-93) óôçí ÐÖÕ. Óôá ãñÜììáôá ðñïò ôïí åêäüôç öéëïîåíåßôáé ìéá åðéóôïëÞ ðïõ äéáôõðþíåé óêÝøåéò êáé ðáñáëëçëéóìïýò ìå áöïñìÞ ìéá åðßóêåøç óôï Éåñü Êïéíüâéï Åõáããåëéóìïý ôçò Èåïôüêïõ óôçí Ïñìýëéá ×áëêéäéêÞò (Ôóßìôóéïõ êáé óõí, óåëßäá 94 êáé ìéá Üëëç ìéá ðïõ õðïãñÜöåé ï ê. Hopayian áðü ôï ÇíùìÝíï Âáóßëåéï êáé áöïñÜ ó÷üëéá êáé êñéôéêÞ óå äçìïóéåõìÝíï Üñèñï óôï ðåñéïäéêü ìáò (óåëßäá 95). Áêüìá äçìïóéåýåôáé åðéóôïëÞ ôçò Lebanese Society of Family Medicine ìå áíáöïñÜ óôá ôñáãéêÜ åðåéóüäéá ôïõ ËéâÜíïõ. ÔÝëïò ï ê. Èçñáßïò óå Üñèñï ôïõ ðáñïõóéÜæåé ôçí Ýêäïóç ðïõ óõíôüíéóå ï ê. ÑáæÞò êáé ç ïðïßá Ý÷åé ôßôëï «ËáúêÞ ÐáñáäïóéáêÞ ÉáôñéêÞ», Ýíá âéâëßï ìå åíäéáöÝñïí ãéá ôï ãéáôñü ðïõ åñãÜæåôáé óôçí Ð.Ö.Õ. ×ñÞóôïò Ëéüíçò ÄéåõèõíôÞò Óýíôáîçò Êïñíçëßá ÌÜêñç, Åðßêïõñç Äéåõèýíôñéá Óýíôáîçò 67

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Á. Áñâáíßôçò êáé óõí.

ÅÑÅÕÍÇÔÉÊÇ EÑÃÁÓÉÁ ÏRIGINAL PAPER Primary Heatlh Care, Volume 18, Number 2, 68-75, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 68-75, 2006

Ç áîßá ôçò áíáãñáöÞò ôùí åìðïñéêþí ïíïìáóéþí öáñìÜêùí ìå åëëçíéêÜ Á. Áñâáíßôçò1, Á. ÆõãïìáëÜò1, Á. ÓêáñðÝëïò2, È. ÌðåëÝæïò3, Í. ÑáæÞò4 Ðåñßëçøç Óêïðüò ôçò ÝñåõíÜò ìáò åßíáé íá äåßîïõìå ôéò äõóìåíåßò åðéðôþóåéò ôçò îåíïìáíßáò óôçí áíáãñáöÞ ôùí ïíïìÜôùí ôùí öáñìÜêùí, åéäéêÜ óôçí ýðáéèñï. Óôü÷ïò ìáò åßíáé ç åõáéóèçôïðïßçóç ôùí éáôñþí, ôçò ðïëéôåßáò êáé ôùí öáñìáêïâéïìç÷áíéþí ãéá ôçí ôñïðïðïßçóç ôçò ãñáöÞò ôùí åìðïñéêþí ïíïìáóéþí ôùí öáñìÜêùí áðü Ëáôéíéêïýò üñïõò óå Åëëçíéêïýò, þóôå íá áðëïõóôåýóïõìå ôç æùÞ ôùí åêáôïììõñßùí ÅëëÞíùí ðïõ êáèçìåñéíÜ ÷ñçóéìïðïéïýí öÜñìáêá ÷ùñßò íá îÝñïõí ïýôå ôçí ïíïìáóßá ôïõò. ÐñÜãìáôé, ç óõíôñéðôéêÞ ðëåéïøçößá ôùí ðñïóåñ÷ïìÝíùí ãéá óõíôáãïãñÜöçóç öÝñíïõí ìáæß ôïõò ôá Üäåéá êïõôéÜ ôùí öáñìÜêùí, äéüôé, üðùò ëÝíå ïé ßäéïé, äåí ãíùñßæïõí íá ôá äéáâÜæïõí. Åðßóçò ðïëëïß áóèåíåßò ìðåñäåýïõí óõ÷íÜ ôéò óõóêåõáóßåò êáé ðñïóðáèïýí íá ôéò ðñïóäéïñßóïõí áðü ôá ÷ñþìáôá (ôá “êüêêéíá” Þ “êßôñéíá” ÷áðÜêéá ê.ï.ê.). 1⁄4ìùò éäéáßôåñç åíôýðùóç ðñïêáëåß ôï üôé ïé ßäéïé áóèåíåßò ðïëý ðéï åýêïëá èõìïýíôáé êáé îå÷ùñßæïõí ôá óêåõÜóìáôá ‘ÆéñôÝê’, ‘Íïïôñüð’, ‘Ñõèìïíüñì’ êáé ‘Óáëïóðßñ’, óôá ïðïßá áíáãñÜöåôáé ç ïíïìáóßá ìå åëëçíéêïýò ÷áñáêôÞñåò. Õëéêï êáé Ìåèïäïò: 1⁄4ëïé ïé ðñïóåñ÷üìåíïé áóèåíåßò ðïõ ëÜìâáíáí ïðïéáäÞðïôå ÷ñüíéá öáñìáêåõôéêÞ áãùãÞ óõìðëÞñùóáí áíþíõìï åñùôçìáôïëüãéï ìå åñùôÞóåéò ðïõ áöïñïýóáí óôçí çëéêßá, ôï ìïñöùôéêü åðßðåäï, ôï ðïéá öÜñìáêá ïé ßäéïé èõìïýíôáí üôé ëÜìâáíáí êáé ãéá ðïéá ðÜèçóç êáé ôï ðþò ïé ßäéïé ôá áîéïëïãïýóáí, åíþ óôï ôÝëïò åìåßò óçìåéþíáìå ôçí ðñáãìáôéêÞ öáñìáêåõôéêÞ áãùãÞ êáé ôéò áíôßóôïé÷åò ìå âÜóç ôç äéáâïýëåõóç êáé ôï âéâëéÜñéï õãåßáò äéáãíþóåéò. Ç Ýñåõíá äéÞñêçóå ôñåéò ìÞíåò êáé óõììåôåß÷áí 652 áóèåíåßò. ÓôáôéóôéêÞ åðåîåñãáóßá ôùí áðáíôÞóåùí Ýãéíå ìå ôï x2 test (conldence interval 95%). ÁðïôåëÝóìáôá: Áðü ôïõò 652 áóèåíåßò, ïé 132 (20,25%) ëÜìâáíáí Ýíá ôïõëÜ÷éóôïí áðü ôá ôÝóóåñá ðñïáíáöåñüìåíá óêåõÜóìáôá ‘ÆéñôÝê’, ‘Íïïôñüð’, ‘Ñõèìïíüñì’ êáé ‘Óáëïóðßñ’. Ôüóï óôï óýíïëï ôùí áóèåíþí, üóï êáé óôéò åðéìÝñïõò ïìÜäåò (çëéêßáò êáé ìïñöþóåùò), ôá óêåõÜóìáôá áõôÜ åìöÜíéóáí óõíôñéðôéêÞ õðåñï÷Þ óôçí áíáãíùñéóéìüôçôá (p <0,0001 óôï óýíïëï), óçìáíôéêÞ õðåñï÷Þ óôçí áíáãíþñéóç ôùí èåñáðåõôéêþí ôïõò éäéïôÞôùí (p <0,001 óôï óýíïëï) áëëÜ êáé óôçí êáôáîßùóç óôá ìÜôéá ôùí áóèåíþí (p<0,0005 óôï óýíïëï). ÓõìðåñÜóìáôá: Åßíáé óáöÝò üôé ç áíáãñáöÞ ôïõ åìðïñéêïý ïíüìáôïò åíüò öáñìÜêïõ ìå åëëçíéêïýò ÷áñáêôÞñåò, ðÝñá áðü ïðïéáäÞðïôå åèíéêÞ óêïðéìüôçôá, âïçèÜåé óçìáíôéêÜ óôçí áíáãíþñéóÞ ôïõ áðü ôïí ßäéï ôïí áóèåíÞ êáé åðïìÝíùò êáé óôçí êáôáîßùóÞ ôïõ. Áõôü áóöáëþò èá Ý÷åé èåôéêÝò åðéðôþóåéò óôç óõììüñöùóç ôïõ áóèåíïýò ìå ôç èåñáðåßá êáé åðïìÝíùò óôçí áðïôåëåóìáôéêüôçôÜ ôçò. Èá ðñÝðåé íá åãêáôáëåéöèåß åê ìÝñïõò ôùí öáñìáêåõôéêþí åôáéñåéþí ç óõíÞèåéá íá “âáöôßæïõí” ôá óêåõÜóìáôÜ ôïõò ìå ðáñÜîåíá îåíéêÜ ïíüìáôá, ôá ïðïßá áíôß íá åíôõðùóéÜæïõí ôïí êáôáíáëùôÞ, öáßíåôáé üôé ìÜëëïí ôïí áðïîåíþíïõí. Åßíáé ðñïôéìüôåñï, áêüìá êáé áðü ðëåõñÜò marketing, íá ðñïôéìïýí áðëïýóôåñåò ëÝîåéò, åé äõíáôüí ìå åëëçíéêÝò ñßæåò êáé íá ôéò áíáãñÜöïõí êáé ìå åëëçíéêïýò ÷áñáêôÞñåò óôéò óõóêåõáóßåò. Éáôñüò ÊÝíôñïõ Õãåßáò Êëåéôïñßáò, 2Ãåíéêüò Éáôñüò, ÅðéìåëçôÞò Â´ ÊÝíôñïõ Õãåßáò ÅñõìÜíèåéáò, 3Åéäéêåõüìåíïò ÃåíéêÞò ÉáôñéêÞò Ãåíéêïý Íïóïêïìåßïõ Ðáôñþí “Ï ¢ãéïò ÁíäñÝáò”, 4 Ãåíéêüò Éáôñüò, ÄéåõèõíôÞò ÊÝíôñïõ Õãåßáò Êëåéôïñßáò 1

ÅéóáãùãÞ Óôçí êáèçìåñéíÞ Üóêçóç ôïõ ëåéôïõñãÞìáôüò ìáò ðáñáôçñÞóáìå üôé ç óõíôñéðôéêÞ ðëåéïøçößá ôùí áóèåíþí ðïõ ðñïóÝñ÷ïíôáé ãéá óõíôáãïãñÜöçóç öÝñíïõí ìáæß ôïõò ôá Üäåéá êïõôéÜ ôùí öáñìÜêùí. Óôçí åñþôçóç ãéáôß äåí áíáöÝñïõí áðëÜ ôá ïíüìáôá ôùí óêåõáóìÜôùí, üëïé ó÷åäüí áðáíôïýí üôé äåí ãíùñßæïõí íá ôá äéáâÜæïõí. Åðßóçò ðïëëïß áóèåíåßò ìðåñäåýïõí óõ÷íÜ ôéò óõóêåõáóßåò êáé ðñïóðáèïýí íá ôéò ðñïóäéïñßóïõí ìå ÷ñþìáôá. Óôçí åñþôçóç “Ôé öÜñìáêá ðáßñíåôå;” áðáíôïýí “ôá ãáëÜæéá” Þ “ôá êüêêéíá” Þ “ôá êßôñéíá ÷áðÜêéá” ê.ï.ê. 1⁄4ìùò ìáò Ýêáíå éäéáßôåñç åíôýðùóç üôé ïé ßäéïé áóèåíåßò ðïëý ðéï åýêïëá èõìïýíôáé êáé îå÷ùñßæïõí ôá óêåõÜóìáôá “ÆéñôÝê”, “Íïïôñüð”, “Ñõèìïíüñì” êáé “Óáëïóðßñ” (óçìåéïýìåíá óõëëÞâäçí ùò 4Å óôï åîÞò), óôá ïðïßá áíáãñÜöåôáé ç ïíïìáóßá ìå åëëçíéêïýò ÷áñáêôÞñåò, ðáñüëï ðïõ ìåñéêÜ áðü áõôÜ åßíáé éäéáßôåñá åîåéäéËÝîåéò ÊëåéäéÜ (MesH Hellas): öÜñìáêï, ïíüìáôá, marketing, õðçñåóßåò õãåßáò ÕðïâëÞèçêå: 11 Éïõíßïõ 2004 ÅðáíõðïâëÞèçêå: 25 Éáíïõáñßïõ 2005 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 28 Éáíïõáñßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ÁíäñÝáò Ê. ÓêáñðÝëïò, Ãåíéêüò Éáôñüò, ÅðéìåëçôÞò Â´ ÊÝíôñïõ Õãåßáò ÅñõìÜíèåéáò Á÷áÀáò, Ä/íóç: Áèçíþí 8, Ê. ÏâñéÜ Ðáôñþí, Ô.Ê. 26500, ôçë.: (2610) 529977, 6979 778865, 26940 31301, Fax: (2610) 226400, 26940 31303, e-mail: ska@panafonet.gr

Á. Áñâáíßôçò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

Advantages of writing the commercial names of drugs in greek A. Arvanitis, A. Zygomalas, A. Skarpelos, T. Mpelezos, N. Razis Summary Aim The aim of our research is to show the negative elect of the habit of using foreign commercial names for drugs, especially in the countryside. Our objective is the sensitisation of the doctors, the state and the drug industries to consider changing the writing of the commercial names of the medicines with Greek characters instead of Latin. This will simplify the life of millions of Greeks that daily use drugs without knowing their name. Our motive was the observation that the patients can more easily remember and distinguish drugs like ‘ÆéñôÝê’, ‘Íïïôñüð’, ‘Ñõèìïíüñì’ and ‘Óáëïóðßñ’, whose names are written in Greek characters. Population study and Method: All the patients who receive chronic medical treatment answered to an anonymous questionnaire with questions that concerned the age, educational level, which medicines they remembered that they receive, and for which disease, and how they evaluate these drugs. After that, we wrote down their real prescription and the real diagnoses. The research lasted three months, and included 652 patients. Statistical analysis was made with x2 test (conldence interval 95%). Results: Among the 652 patients of the research, 132 (20.25%) received one at least from the four mentioned drugs ‘ÆéñôÝê’, ‘Íïïôñüð’, ‘Ñõèìïíüñì’ and ‘Óáëïóðßñ’. In the majority of patients in general and also in terms of age and education, those drugs presented overwhelming supremacy in case of recognition (p<0.0001 in the total), important supremacy in the knowledge of their therapeutic attributes (p<0.001 in the total) but also achieved higher marking by the patients (p<0.0005 in the total). Conclusions: It is safe to say that writing the commercial name of a medicine in Greek, beyond any national expediency, helps considerably its recognition by the patient and consequently the patient’s compliance with the treatment. This certainly will have positive elects in the electiveness of the treatment. Pharmaceutical Companies must abandon the habit to “baptize” drugs with strangely foreign names, which instead of impressing the consumer appear rather to confuse him/her. It is preferable, even from the side of marketing, to choose simpler words, if possible with Greek roots, and also to write them in Greek characters on the packaging. Key words: medicine, names, marketing of health services

êåõìÝíá. Ðïëý ÷áñáêôçñéóôéêü åßíáé ðåñéóôáôéêü üðïõ áóèåíÞò áíÝöåñå: “ÃéáôñÝ ìïõ ðáßñíù öÜñìáêá ãéá ôçí êáñäéÜ ìïõ, ôï áíáðíåõóôéêü ìïõ êáé ôï Ñõèìïíüñì”. ¹ôáí ôï ìïíáäéêü öÜñìáêï ðïõ ìðïñïýóå íá äéáâÜóåé, áðÜíôçóå åñùôçèåßò åê ôùí õóôÝñùí. 1⁄4ðùò Þôáí áíáìåíüìåíï, ç îåíïìáíßá ðïõ ãéá ðïëëÝò äåêáåôßåò åðéêñáôåß óôç ÷þñá ìáò, åðçñåÜæïíôáò êåßìåíá, åðéãñáöÝò áëëÜ êáé ôçí êáèïìéëïõìÝíç ãëþóóá, Ý÷åé ðëÞîåé ó÷åäüí ïëïêëçñùôéêÜ êáé ôéò åìðïñéêÝò ïíïìáóßåò ôùí öáñìÜêùí. Åßíáé ãíùóôü üôé ôá ðïóïóôÜ áíáëöáâçôéóìïý óôçí åëëçíéêÞ ýðáéèñï åßíáé õøçëÜ, ãåãïíüò ðïõ ó÷åôßæåôáé Üìåóá êáé ìå ôç ãÞñáíóç ôïõ ðëçèõóìïý óôéò ïñåéíÝò êáé äõóðñüóéôåò ðåñéï÷Ýò. ÅîÜëëïõ ï ìÝóïò üñïò çëéêßáò ôùí áóèåíþí ðïõ áíáæçôïýí õðçñåóßåò õãåßáò åßíáé áóöáëþò áõîçìÝíïò óå ó÷Ýóç ìå ôï ãåíéêü ðëçèõóìü. ÁðïôÝëåóìá üëùí áõôþí åßíáé ç ìåãÜëç äõóêïëßá ôùí áóèåíþí íá áíáãíùñßæïõí êáé íá èõìïýíôáé ôá

äéÜöïñá óêåõÜóìáôá ðïõ ëáìâÜíïõí, áêüìá êáé óå ÷ñüíéá âÜóç, ôç óôéãìÞ ðïõ äåí Ý÷ïõí êáìßá åîïéêåßùóç ìå ôï ëáôéíéêü áëöÜâçôï. Ôï ìåßæïí áõôü æÞôçìá áóöáëþò äõóêïëåýåé ôç æùÞ ôùí ðïëéôþí áõôÞò ôçò ÷þñáò, êõñßùò óôçí ýðáéèñï, áëëÜ êáé óôéò ðüëåéò. Óêïðüò ôçò ÝñåõíÜò ìáò åßíáé íá áíáäåßîïõìå ôéò äõóìåíåßò åðéðôþóåéò ôçò îåíïìáíßáò óôçí áíáãñáöÞ ôùí ïíïìÜôùí ôùí öáñìÜêùí, åéäéêÜ óôçí ýðáéèñï. Óôü÷ïò ìáò åßíáé ç åõáéóèçôïðïßçóç ôùí éáôñþí êáé ôùí Éáôñéêþí Óõëëüãùí ôçò ÷þñáò, ôçò Ðïëéôåßáò, áëëÜ êáé ôùí öáñìáêåõôéêþí åôáéñåéþí ãéá ôçí ôñïðïðïßçóç ôçò ãñáöÞò ôùí åìðïñéêþí ïíïìáóéþí ôùí öáñìÜêùí ìå ÅëëçíéêÜ, ôïõëÜ÷éóôïí óôç ìßá ðëåõñÜ ôïõ óêåõÜóìáôïò. Ðéóôåýïõìå ðùò Ýôóé èá áðëïõóôåõèåß ç æùÞ åêáôïììõñßùí ÅëëÞíùí ðïõ êáèçìåñéíÜ ÷ñçóéìïðïéïýí öÜñìáêá ÷ùñßò íá îÝñïõí ïýôå ôçí ïíïìáóßá ôïõò. Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïò

Ç Ýñåõíá Ýëáâå ÷þñá óôï ÊÝíôñï Õãåßáò Êëåéôïñßáò êáé óôá ÐåñéöåñåéáêÜ Éáôñåßá ÄÜöíçò êáé Ëåéâáñôæßïõ, ðåñéï÷Ýò ïñåéíÝò êáé áðïìáêñõóìÝíåò, ìå ðëçèõóìü ùò åðß ôï ðëåßóôïí áãñïôéêü – êôçíïôñïöéêü êáé õøçëïý ìÝóïõ üñïõ çëéêßáò. 1⁄4ëïé ïé ðñïóåñ÷üìåíïé áóèåíåßò ðïõ ëÜìâáíáí ïðïéáäÞðïôå ÷ñüíéá öáñìáêåõôéêÞ áãùãÞ (äéÜñêåéáò ðÜíù áðü Ýíá ìÞíá) óõìðëÞñùóáí åñùôçìáôïëüãéï (Ó÷Þìá I) ìå åñùôÞóåéò ðïõ áöïñïýóáí óôçí çëéêßá, ôï åðßðåäï åêðáßäåõóçò, ôï ðïéá öÜñìáêá ïé ßäéïé èõìïýíôáí üôé ëÜìâáíáí êáé ãéá ðïéá ðÜèçóç êáé ôï ðþò ïé ßäéïé ôá áîéïëïãïýóáí, âÜóåé êëßìáêáò ôåóóÜñùí âáèìþí. Óôï ôÝëïò åìåßò óçìåéþíáìå ôçí ðñáãìáôéêÞ öáñìáêåõôéêÞ áãùãÞ ôïõò êáé ôéò áíôßóôïé÷åò ìå âÜóç ôç äéáâïýëåõóç êáé ôï âéâëéÜñéï õãåßáò äéáãíþóåéò. Ôï åñùôçìáôïëüãéï Þôáí áíþíõìï, áëëÜ öñïíôßóáìå íá ñùôÜìå ôïõò áóèåíåßò åÜí ôï Ý÷ïõí Þäç óõìðëçñþóåé, þóôå íá áðïöåõ÷èïýí ïé äéðëÝò åããñáöÝò. Ïé áóèåíåßò ðïõ äåí Þîåñáí íá ãñÜöïõí Þ üóïé åß÷áí Üëëåò äõóêïëßåò (ð.÷. üñáóçò) óõìðëÞñùóáí ôï åñùôçìáôïëüãéï ìå ôç âïÞèåéÜ ìáò. Áêñéâåßò 69

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Áñâáíßôçò êáé óõí.

ÅÑÙÔÇÌÁÔÏËÏÃÉÏ Çìåñïìçíßá: ..................................... Á/á: .............................. 1. Öýëï: ¢ññåí ÈÞëõ 2. ¸ôïò ãåííÞóåùò: ........................... 3. Åêðáßäåõóç: ÁãñÜììáôïò/ç Óôïé÷åéþäçò ÄåõôåñïâÜèìéá ÔñéôïâÜèìéá 4. Ðïéá öÜñìáêá ëáìâÜíåôå óå ÷ñüíéá âÜóç (ãéá ðÜíù áðü 1 ìÞíá) êáé ãéá ðïéá ðÜèçóç; Ðþò áîéïëïãåßôå ôï êÜèå Ýíá áðü áõôÜ; ÏÍÏÌÁ ÖÁÑÌÁÊÏÕ

ÐÁÈÇÓÇ

ÓÕÌÐËÇÑÙÍÅÔÁÉ ÁÐÏ ÔÏÍ ÉÁÔÑÏ: 5. ÐñáãìáôéêÞ öáñìáêåõôéêÞ áãùãÞ (óêåýáóìá – íüóïò):

Ó÷Þìá 1. Ôï åñùôçìáôïëüãéï ôçò åñãáóßáò ìáò. 70

ÁÎÉÏËÏÃÇÓÇ: 1= ìÜëëïí êáêü 2= ìÝôñéï 3= êáëü 4= Üñéóôï

Á. Áñâáíßôçò êáé óõí.

èåùñÞèçêáí ïé ïíïìáóßåò ðïõ ìáò äüèçêáí, åßôå ãñáðôÜ åßôå ðñïöïñéêÜ, üôáí õðÞñ÷å êáíÝíá Þ Ýóôù Ýíá ëÜèïò öþíçìá óôçí ïíïìáóßá. Åðßóçò, óêåõÜóìáôá ðïõ áíáöÝñèçêáí áðü ôïõò áóèåíåßò ùò ÷ñïíßùò ëáìâáíüìåíá, áëëÜ äåí ðñïÝêõðôå áðü ôï âéâëéÜñéï õãåßáò óõíå÷üìåíç ëÞøç ãéá ðÜíù áðü Ýíá ìÞíá, áðïêëåßóôçêáí. ÁîéïëïãÞóáìå, ëïéðüí, ðïéá óêåõÜóìáôá áðü ôá áðïäåäåéãìÝíá ÷ñïíßùò ëáìâáíüìåíá èõìÞèçêå ï êÜèå áóèåíÞò ìå áêñßâåéá êáé ðïéá ü÷é. Åðßóçò, áðü áõôÜ ðïõ èõìÞèçêáí ïé áóèåíåßò óùóôÜ, áîéïëïãÞóáìå êáé ôï åÜí èõìÞèçêáí óùóôÜ êáé ôçí ðÜèçóç ãéá ôçí ïðïßá ôá ëÜìâáíáí êáé, ôÝëïò, ôç âáèìïëïãßá ðïõ ôïõò Ýäùóáí ïé áóèåíåßò. Ç Ýñåõíá äéÞñêçóå ôñåéò ìÞíåò (Áýãïõóôïò–Ïêôþâñéïò 2004) êáé óõììåôåß÷áí 652 áóèåíåßò. ÓôáôéóôéêÞ åðåîåñãáóßá ôùí áðáíôÞóåùí Ýãéíå ìå ôï x2 test (confidence interval 95%).

Ôüìïò 18, Ôåý÷ïò 2, 2006

ËÞøç óêåõáóìÜôùí · Ï áñéèìüò ôùí äéáöïñåôéêþí óêåõáóìÜôùí ðïõ ëáìâÜíïíôáí ÷ñïíßùò áðü üëïõò ôïõò áóèåíåßò, êáôÜ åìðïñéêÞ ïíïìáóßá, Þôáí 98. Ç êáôáíïìÞ ôïõ áñéèìïý ôùí óêåõáóìÜôùí ðïõ ëáìâÜíåé êÜèå áóèåíÞò öáßíåôáé óôïí ðßíáêá É êáé óôï Ó÷Þìá IV. · Ôï óêåýáóìá ÆéñôÝê ëáìâÜíåôáé ÷ñïíßùò áðü 18 áóèåíåßò (2,8%), ôï Íïïôñüð áðü 57 (8,7%), ôï Ñõèìïíüñì áðü 36 (5,6%) êáé ôï Óáëïóðßñ áðü 105 áóèåíåßò (16,1%). ¸íá ôïõëÜ÷éóôïí áðü ôá 4Å óêåõÜóìáôá ëáìâÜíïõí 132 áóèåíåßò (20,2%).

Áíáãíùñéóéìüôçôá êáé áíáãíþñéóç èåñáðåõôéêþí éäéïôÞôùí óêåõáóìÜôùí · Ôï 88% ôùí áóèåíþí ðïõ ëÜìâáíáí ôá óêåõÜ-

ÁðïôåëÝóìáôá Óýóôáóç ôïõ ðëçèõóìïý ôçò ìåëÝôçò (n=652): · Öýëï: 340 ãõíáßêåò, 312 Üíäñåò (Ó÷Þìá ÉÉ). · Çëéêßá: 38–94 åôþí, ìÝóç: 71,1 Ýôç (±SD= 9,2). · Åðßðåäï åêðáßäåõóçò: áãñÜììáôïé: 202, óôïé÷åéþäçò åêðáßäåõóç: 232, äåõôåñïâÜèìéá åêðáßäåõóç: 204, ôñéôïâÜèìéá: 14 (Ó÷Þìá ÉÉÉ). Ó÷Þìá III. ÊáôáíïìÞ ìïñöùôéêïý åðéðÝäïõ.

Ó÷Þìá ÉÉ. ÊáôáíïìÞ ôùí öýëùí.

Ó÷Þìá 4. ÊáôáíïìÞ ôïõ áñéèìïý ôùí óêåõáóìÜôùí.

Ðßíáêáò 1. ÊáôáíïìÞ ôïõ áñéèìïý êáé ôïõ ðëÞèïõò ôùí óêåõáóìÜôùí áñéèìüò óêåõáóìÜôùí 1 2 3 4 5 6 áñéèìüò áóèåíþí 57 116 134 116 106 64 ðïóïóôü 8,7% 17,8% 20,6% 17,8% 16,3% 9,8% ðëÞèïò óêåõáóìÜôùí 57 232 402 464 530 384

7 39 6,0% 273

8 16 2,5% 128

9 4 0,6% 93

Óýíïëï 652 100% 2506 71

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Áñâáíßôçò êáé óõí.

óìáôá 4Å èõìÞèçêáí óùóôÜ ôá ïíüìáôÜ ôïõò, åíþ ôï ðïóïóôü ôùí áóèåíþí ðïõ èõìÞèçêáí óùóôÜ ôá óêåõÜóìáôá ìå îåíüãëùóóç áíáãñáöÞ (óçìåéïýìåíá óôï åîÞò óõëëÞâäçí ùò ÓÎÁ) Þôáí 59,5% (p <0,0001). Ìåôáîý ôùí ÓÎÁ, ôï ðñþôï óå áíáãíùñéóéìüôçôá Þôáí ôï Zantac (65,6%). ÁíáëõôéêÜ ôá áðïôåëÝóìáôá ùò ðñïò ôçí áíáãíùñéóéìüôçôá ôùí óêåõáóìÜôùí öáßíïíôáé óôïí ðßíáêá II êáé óôï ó÷Þìá IV. · Áðü ôïõò áóèåíåßò ðïõ èõìÞèçêáí óùóôÜ ôá óêåõÜóìáôá 4Å, ðïóïóôü 93,7% áðÜíôçóáí óùóôÜ ùò ðñïò ôçí ðÜèçóç ãéá ôçí ïðïßá ôá ëáìâÜíïõí, åíþ ãéá ôá óêåõÜóìáôá ÓÎÁ ôï áíôßóôïé÷ï ðïóïóôü Þôáí 87,1% (p <0,001).

Ðßíáêáò II. Áíáãíùñéóéìüôçôá ôùí óêåõáóìÜôùí Óêåýáóìá Áñéèìüò áóèåíþí ðïõ ôá ëáìâÜíïõí ÆéñôÝê Íïïôñüð Ñõèìïíüñì Óáëïóðßñ 4Å Zantac ÓÎÁ

Ôï ðñþôï óå óùóôÝò áðáíôÞóåéò ùò ðñïò ôçí ðÜèçóç ãéá ôçí ïðïßá ëáìâÜíåôáé ìåôáîý ôùí ÓÎÁ Þôáí ôï Lipitor (87,5%), ãéá ôï ïðïßï óçìåéùôÝïí üôé ðáñáôçñÞèçêå áíáãíùñéóéìüôçôá 56/91 (61,5%). ÁíáëõôéêÜ ôá áðïôåëÝóìáôá ùò ðñïò ôçí áíáãíþñéóç ôùí èåñáðåõôéêþí éäéïôÞôùí ôùí óêåõáóìÜôùí öáßíïíôáé óôïí ðßíáêá III êáé óôï ó÷Þìá VI.

Áîéïëüãçóç óêåõáóìÜôùí áðü ôïõò áóèåíåßò ðïõ ôá èõìÞèçêáí óùóôÜ · 1⁄4ðùò öáßíåôáé óôï åñùôçìáôïëüãéï (Ó÷Þìá I), ç êëßìáêá âáèìïëüãçóçò ôùí óêåõáóìÜ-

Áñéèìüò áóèåíþí ðïõ ôá èõìÞèçêáí óùóôÜ

Ðïóïóôü

0014 0050 0029 0097 0190 0063 1362

77,8% 87,7% 80,1% 92,4% 88,0% 65,6% 59,5%

0018 0057 0036 0105 0216 0096 2290

100 80 60 40 20 0

ÆéñôÝê

Íïïôñüð Ñõèìïíüñì Óáëïóðßñ

4Å

Zantac

ÓÎÁ

p<0,0001

Ó÷Þìá V. ÐïóïóôÜ (%) áíáãíùñéóéìüôçôáò ôùí óêåõáóìÜôùí.

Ó÷Þìá VI. ÐïóïóôÜ (%) áíáãíþñéóçò èåñáðåõôéêþí éäéïôÞôùí ôùí óêåõáóìÜôùí.

Ðßíáêáò III. Áíáãíþñéóç èåñáðåõôéêþí éäéïôÞôùí ôùí óêåõáóìÜôùí Óêåýáóìá Áñéèìüò áóèåíþí Áñéèìüò áóèåíþí ðïõ ôá ëáìâÜíïõí êáé ðïõ èõìÞèçêáí óùóôÜ ôá èõìÞèçêáí óùóôÜ ôéò èåñáðåõôéêÝò ôïõò éäéüôçôåò ÆéñôÝê Íïïôñüð Ñõèìïíüñì Óáëïóðßñ 4Å Lipitor ÓÎÁ 72

0014 0050 0029 0097 0190 0056 1362

0013 0043 0027 0095 0178 0049 1186

Ðïóïóôü

92,9% 86% 93,1% 97,9% 93,7% 87,5% 87,1%

Á. Áñâáíßôçò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

ôùí ðïõ ÷ñçóéìïðïéÞóáìå ðåñéåëÜìâáíå 4 âáèìïýò: 1 âáèìüò = ìÜëëïí êáêü, 2 âáèìïß = ìÝôñéï, 3= êáëü êáé 4 âáèìïß = Üñéóôï. Ôá óêåõÜóìáôá 4Å óõãêÝíôñùóáí ìÝóç âáèìïëïãßá 3,64 âáèìþí, åíþ ôá ÓÎÁ 3,43 âáèìþí (p <0,0005). Ðñþôá óå âáèìïëïãßá ìåôáîý ôùí ÓÎÁ Þôáí ôá óêåõÜóìáôá Cozaar êáé Losec, ìå 3,71 âáèìïýò, ôá ïðïßá ùóôüóï óçìåßùóáí ó÷åôéêÜ ÷áìçëÞ áíáãíùñéóéìüôçôá: 14/26 (53,8%) êáé 17/36 (47,2%), áíôéóôïß÷ùò. ÁíáëõôéêÜ ôá áðïôåëÝóìáôá ùò ðñïò ôçí áîéïëüãçóç ôùí óêåõáóìÜôùí öáßíïíôáé óôïí ðßíáêá IV êáé óôï ó÷Þìá VII.

ÐáñáôçñÞóåéò ùò ðñïò ôï öýëï, ôçí çëéêßá êáé ôï åðßðåäï åêðáßäåõóçò (Ðßíáêáò V) · Ùò ðñïò ôçí áíáãíùñéóéìüôçôá ôùí óêåõáóìÜôùí äåí õðÞñîáí äéáöïñÝò ìåôáîý ôùí äýï öýëùí, ïýôå ùò ðñïò ôá 4Å, ïýôå ùò ðñïò ôá ÓÎÁ (p=ns). Êáé ôá ìåí êáé ôá äå ðáñïõóßáóáí åëáöñþò êáëýôåñç áíáãíùñéóé-

Ðßíáêáò IV. Áîéïëüãçóç ôùí óêåõáóìÜôùí Óêåýáóìá ÓõíïëéêÞ ÌÝóç âáèìïëïãßá âáèìïëïãßá ÆéñôÝê Íïïôñüð Ñõèìïíüñì Óáëïóðßñ 4Å Cozaar Losec ÓÎÁ

46/56 162/200 107/116 378/388 691/760 52/56 63/68 4667/5448

3,29/4 3,24/4 3,69/4 3,88/4 3,64/4 3,71/4 3,71/4 3,43/4

ìüôçôá ìåôáîý ôùí áóèåíþí 65 åôþí (p <0,05), ìå ôç óçìáíôéêÞ õðåñï÷Þ ôùí 4Å íá äéáôçñåßôáé, üðùò êáé óôï óýíïëï ôïõ äåßãìáôïò (p <0,0001). Åðßóçò êáëýôåñç áíáãíùñéóéìüôçôá ìåôáîý ôùí áóèåíþí äåõôåñïâÜèìéáò êáé ôñéôïâÜèìéáò åêðáßäåõóçò åìöÜíéóáí êáé ôá 4Å (p <0,05) êáé ôá ÓÎÁ (p <0,001), åíþ óôïõò áãñÜììáôïõò Þ óôïé÷åéþäïõò åêðáßäåõóçò áóèåíåßò ôá áíôßóôïé÷á ðïóïóôÜ Þôáí êÜðùò ÷áìçëüôåñá (p <0,025 – p <0,05). · Ùò ðñïò ôçí áíáãíþñéóç ôùí èåñáðåõôéêþí éäéïôÞôùí ôüóï ôùí 4Å üóï êáé ôùí ÓÎÁ óêåõáóìÜôùí äåí õðÞñîáí óôáôéóôéêþò óçìáíôéêÝò äéáöïñÝò, ïýôå ùò ðñïò ôï öýëï, ïýôå ùò ðñïò ôçí çëéêßá, ïýôå ùò ðñïò ôçí åêðáßäåõóç (p=ns). · Ç ðåñéóóüôåñï çëéêéùìÝíç ïìÜäá (>65 åôþí) Ýäùóå åëáöñþò ìåãáëýôåñç âáèìïëïãßá ôüóï óôá 4Å üóï êáé óôá ÓÎÁ óêåõÜóìáôá (p<0,05 êáé óôéò äýï êáôçãïñßåò). ¢ëëåò óçìáíôéêÝò äéáöïñÝò óôç âáèìïëïãßá ùò ðñïò ôï öýëï Þ ôçí åêðáßäåõóç äåí ðáñáôçñÞèçêáí (p=ns).

Ðïóïóôü 82,1% 81% 92,2% 97,4% 90,9% 92,9% 92,6% 85,7%

Ó÷Þìá VII. ÌÝóç áîéïëüãçóç ôùí óêåõáóìÜôùí (ìå Üñéóôá ôï 4).

Ðßíáêáò V. Ôá áðïôåëÝóìáôá áíÜ öýëï, çëéêßá êáé åðßðåäï åêðáßäåõóçò Áíáãíùñéóéìüôçôá Áíáãíþñéóç Èåñáðåõôéêþí ÉäéïôÞôùí 4Å ÓÎÁ 4Å ÓÎÁ Üíäñåò ãõíáßêåò 65 åôþí >65 åôþí AãñÜììáôïé Þ óôïé÷åéþäçò åêðáßäåõóç äåõôåñïâÜèìéá Þ ôñéôïâÜèìéá åêðáßäåõóç Óýíïëï

Âáèìïëïãßá 4Å

ÓÎÁ

99/111 91/105 72/75 118/141 123/157

668/1137 694/1153 503/786 859/1504 836/1487

90/99 88/91 68/72 110/118 115/123

582/668 604/694 424/503 762/859 738/836

344/396 347/364 269/288 422/472 441/492

2328/2672 2339/2776 1509/2012 3158/3436 2873/3344

67/69

526/803

63/67

448/526

250/268

1794/2104

190/216

1362/2290

178/190

1186/1362

691/760

4667/5448 73

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Áñâáíßôçò êáé óõí.

ÓõìðåñÜóìáôá – ÓõæÞôçóç

ìéáò åêðáßäåõóçò (4Å: p <0,05, ÓÎÁ: p <0,001 – Ðßíáêáò 5). ÅíäéáöÝñïí ðáñïõóéÜæåé ç åõíïúêüôåñç óôÜóç ôçò ðåñéóóüôåñï çëéêéùìÝíçò ïìÜäáò (>65 åôþí) áðÝíáíôé óå üëá ôá óêåõÜóìáôá, áöïý Ýäùóå åëáöñþò ìåãáëýôåñç âáèìïëïãßá ôüóï óôá 4Å üóï êáé óôá ÓÎÁ (p<0,05 êáé óôéò äýï êáôçãïñßåò – ðßíáêáò 5). Áõôü ðñïöáíþò ïöåßëåôáé óôç ìåãáëýôåñç åîÜñôçóç áðü ôá öÜñìáêá ðïõ áíáðôýóóïõí ïé çëéêéùìÝíïé. Åßíáé óáöÝò üôé ç áíáãñáöÞ ôïõ åìðïñéêïý ïíüìáôïò åíüò óêåõÜóìáôïò ìå åëëçíéêïýò ÷áñáêôÞñåò, ðÝñá áðü ïðïéáäÞðïôå åèíéêÞ óêïðéìüôçôá, âïçèÜåé óçìáíôéêÜ óôçí áíáãíþñéóÞ ôïõ áðü ôïí ßäéï ôïí áóèåíÞ êáé åðïìÝíùò êáé óôçí óùóôüôåñç ÷ñÞóç ôïõ êáé óôçí êáôáîßùóÞ ôïõ. Áõôü áóöáëþò èá Ý÷åé èåôéêÝò åðéðôþóåéò óôç óõììüñöùóç ôïõ áóèåíïýò ìå ôç èåñáðåßá êáé åðïìÝíùò óôçí áðïôåëåóìáôéêüôçôá ôçò èåñáðåßáò. Èá ðñÝðåé ëïéðüí íá åãêáôáëåéöèåß åê ìÝñïõò ôùí öáñìáêåõôéêþí åôáéñåéþí ç óõíÞèåéá íá “âáöôßæïõí” ôá óêåõÜóìáôÜ ôïõò ìå ðáñÜîåíá îåíéêÜ ïíüìáôá, ôá ïðïßá áíôß íá åíôõðùóéÜæïõí ôïí êáôáíáëùôÞ, öáßíåôáé üôé ìÜëëïí ôïí áðïîåíþíïõí. Åßíáé ðñïôéìüôåñï, áêüìá êáé áðü ðëåõñÜò marketing, íá ðñïôéìïýí áðëïýóôåñåò êáé åõêïëïìíçìüíåõôåò ëÝîåéò, åé äõíáôüí ìå åëëçíéêÝò ñßæåò êáé íá ôéò áíáãñÜöïõí êáé ìå åëëçíéêïýò ÷áñáêôÞñåò óôéò óõóêåõáóßåò. Êáé áõôü ðñÝðåé íá ãßíåé ãéá Ýíáí áêüìá åðéðñüóèåôï ëüãï: óôçí ðåñßðôùóç ôùí öáñìÜêùí äåí ðáßæåé ôüóï óçìáíôéêü ñüëï ç ïíïìáóßá Þ ôï ó÷Ýäéï êáé ôï ÷ñþìá ôïõ êïõôéïý þóôå íá ôá äéáëÝîåé ï áóèåíÞò, ìéáò êáé ôá öÜñìáêá äåí âñßóêïíôáé óå êÜðïéï ñÜöé super market þóôå íá ÷ñåéÜæïíôáé êÜðïéåò éäéáéôåñüôçôåò ãéá íá “ôñáâÞîïõí ôï ìÜôé”, üðùò ãßíåôáé óôá ôñüöéìá êáé óôá Üëëá åßäç êáèçìåñéíÞò êáôáíÜëùóçò. Ôá öÜñìáêá óõíôáãïãñáöïýíôáé áðü ôïí èåñÜðïíôá éáôñü êáé ÷ïñçãïýíôáé óõãêåêñéìÝíá ãéá êÜèå ðÜèçóç, ÷ùñßò ï áóèåíÞò íá Ý÷åé ðñùôïâïõëßá óôçí åðéëïãÞ ôïõò, ðáñÜ ìüíï óôç óùóôÞ êáôáíÜëùóÞ ôïõò. Êáé åäþ áêñéâþò åßíáé ôï óçìåßï üðïõ ç åëëçíéêÞ áíáãñáöÞ ôçò ïíïìáóßáò ôùí óêåõáóìÜôùí ìðïñåß íá âïçèÞóåé. Ôï ðñüâëçìá ôçò îåíïìáíßáò óôç ÷þñá ìáò åßíáé áñêåôÜ ðáëáéü, áëëÜ öáßíåôáé üôé óôéò ìÝñåò ìáò, ìå ôçí åêñçêôéêÞ áíÜðôõîç ôçò ðëçñïöïñéêÞò êáé ôùí ðáãêïóìßùí çëåêôñïíéêþí ìÝóùí ìáæéêÞò åíçìÝñùóçò, Ý÷åé åðéäåéíùèåß. ÅêáôïíôÜäåò îÝíåò ëÝîåéò, éäßùò áããëéêÝò – áìåñéêÜíéêåò, åéóÜãïíôáé

Ôá áðïôåëÝóìáôá ôçò Ýñåõíáò áðïäåéêíýïõí îåêÜèáñá ôç óçìáíôéêÜ áõîçìÝíç áíáãíùñéóéìüôçôá ôùí óêåõáóìÜôùí ìå åëëçíéêÞ áíáãñáöÞ (p <0.0001 – Ó÷Þìá 5). Åíäåéêôéêü åßíáé üôé Ýíá ðáëéü êáé êáôáîéùìÝíï óêåýáóìá üðùò ôï Zantac óçìåßùóå ìéêñüôåñç áíáãíùñéóéìüôçôá óå ó÷Ýóç ìå ôá ðåñéóóüôåñá ôùí 4Å. Ïé áóèåíåßò ëïéðüí ëáìâÜíïõí ôá 4Å ãíùñßæïíôáò ôï üíïìÜ ôïõò, ðñÜãìá ðïõ ôïõò äéåõêïëýíåé óå ðñáêôéêÜ æçôÞìáôá (óõíôáãïãñáößá, ðñïìÞèåéá áðü ôï öáñìáêåßï ê.Ü.), áëëÜ ïäçãåß óôçí áíáãíþñéóç êáé ôùí èåñáðåõôéêþí ôïõò éäéïôÞôùí. ÐñÜãìáôé, ïé áóèåíåßò ðïõ èõìÞèçêáí ãéá ðïéá ðÜèçóç ëáìâÜíïõí ôá óêåõÜóìáôá 4Å Þôáí óçìáíôéêÜ ðåñéóóüôåñïé óå ó÷Ýóç ìå ôïõò õðüëïéðïõò (p <0,001 – Ó÷Þìá 6). Áõôü Ý÷åé éäéáßôåñç óçìáóßá, áí áíáëïãéóôïýìå üôé ôï óêåýáóìá “Óáëïóðßñ”, ôï ïðïßï ëáìâÜíåôáé áðü ìåãÜëç ìåñßäá ôùí áóèåíþí, Ý÷åé áñêåôÜ åîåéäéêåõìÝíåò èåñáðåõôéêÝò åíäåßîåéò (óçìåéùôÝïí üôé ïé åíäåßîåéò áíáëãçôéêïý êáé áíôéðõñåôéêïý äåí õðÞñ÷áí óôç óõíôáãïãñáößá ôïõ êáé äåí Ýãéíáí äåêôÝò). ÅîÜëëïõ ôï óêåýáóìá Lipitor ðïõ ðñþôåõóå óôçí êáôçãïñßá áõôÞ ìåôáîý ôùí ÓÎÁ Ý÷åé ðïëý óõãêåêñéìÝíç êáé åõñÝùò ãíùóôÞ Ýíäåéîç, óôçí ïðïßá óáöþò ðáñáðÝìðåé ç ïíïìáóßá ôïõ. Ôï ìåãáëýôåñï ßóùò åíäéáöÝñïí ìåôáîý ôùí áðïôåëåóìÜôùí ôçò Ýñåõíáò ðáñïõóéÜæåé ç áîéïëüãçóç ôùí óêåõáóìÜôùí áðü ôïõò áóèåíåßò. Áðïäåéêíýåôáé üôé ïé áóèåíåßò âáèìïëüãçóáí ôá óêåõÜóìáôá 4Å ìå óçìáíôéêÜ ìåãáëýôåñï âáèìü óå ó÷Ýóç ìå ôá ÓÎÁ (p <0,0005 – Ó÷Þìá 7). Èá ðñÝðåé åäþ íá óçìåéþóïõìå üôé óêåõÜóìáôá üðùò ôï Losec êáé ôï Cozaar ðïõ óõãêÝíôñùóáí êáé áõôÜ õøçëÞ âáèìïëïãßá, áëëÜ êáé ðëÞèïò Üëëùí óêåõáóìÜôùí, Ý÷ïõí óáöþò ðéï Üìåóç, áíáêïõöéóôéêÞ êáé Üñá áíáãíùñßóéìç áðü ôïí áóèåíÞ äñÜóç óå ó÷Ýóç êõñßùò ìå ôï Óáëïóðßñ êáé ôï Íïïôñüð, áëëÜ êáé ó÷Ýóç ìå ôá ÆéñôÝê êáé Ñõèìïíüñì. Ðáñ’ üëá áõôÜ, ôá 4Å ðñïçãÞèçêáí Ýíáíôé ôçò ïìÜäáò üëùí ôùí õðïëïßðùí óêåõáóìÜôùí (ÓÎÁ). Ôá áðïôåëÝóìáôÜ ìáò äåí ðáñïõóßáóáí éäéáßôåñåò äéáöïñïðïéÞóåéò ùò ðñïò ôï öýëï, ôçí çëéêßá êáé ôï åðßðåäï åêðáßäåõóçò. Áíáìåíüìåíï Þôáí üëá ôá óêåõÜóìáôá íá ðáñïõóéÜóïõí åëáöñþò êáëýôåñç áíáãíùñéóéìüôçôá ìåôáîý ôùí íåïôÝñùí áóèåíþí (p<0,05 – ðßíáêáò 5) êáé ìåôáîý ôùí áóèåíþí äåõôåñïâÜèìéáò êáé ôñéôïâÜè74

Á. Áñâáíßôçò êáé óõí.

ìáæß ìå ôá äéÜöïñá ðñïúüíôá êáé åðéâÜëëïíôáé óôéò äéÜöïñåò åêöÜíóåéò ôçò æùÞò ìáò áðü ôï åìðïñéêü êõñßùò êýêëùìá, ìå áðïôÝëåóìá íá ÷ñçóéìïðïéïýíôáé êáèçìåñéíÜ áðü üëïõò ó÷åäüí ôïõò ¸ëëçíåò åíôåëþò áâáóÜíéóôá, áíåîÝëåãêôá êáé áõèáßñåôá ôéò ðåñéóóüôåñåò öïñÝò. Êáé üóïí áöïñÜ óôéò îÝíåò ëÝîåéò ïé ïðïßåò áíáöÝñïíôáé óå áíôéêåßìåíá ðïõ åßíáé åðéôåýãìáôá ôçò ôå÷íïëïãßáò Üëëùí ëáþí, åýëïãï èá Þôáí íá ôá ïíïìÜóïõí ìå ìéá ëÝîç áðü ôç äéêÞ ôïõò ãëþóóá, áöïý ôá åðéíüçóáí Þ ôá åöåýñáí åêåßíïé. Êáé áöïý ìåôá÷åéñéæüìáóôå ôá áíôéêåßìåíá áõôÜ åìåßò ïé ¸ëëçíåò, ëïãéêü åßíáé – éäßùò üôáí äåí õðÜñ÷åé ç áíôßóôïé÷ç åëëçíéêÞ ëÝîç – íá ÷ñçóéìïðïéïýìå ôçí îÝíç ëÝîç. Ùóôüóï õðÜñ÷åé ðëÞèïò åëëçíéêþí ëÝîåùí ðïõ ôáéñéÜæïõí áðüëõôá óå ôÝôïéá íÝá áíôéêåßìåíá êáé åðéôåýãìáôá ôçò ôå÷íïëïãßáò ôéò ïðïßåò åëÜ÷éóôïé ¸ëëçíåò ÷ñçóéìïðïéïýí. Óôçí åðéóôçìïíéêÞ ìÜëéóôá ãëþóóá êáé åéäéêÜ óôçí åðéóôÞìç ôçò éáôñéêÞò êáé öáñìáêåõôéêÞò ÷ñçóéìïðïéïýíôáé ðáãêïóìßùò ëÝîåéò åëëçíéêÞò ñßæáò ìå “áããëüôñïðåò” äéáöïñïðïéÞóåéò êáé áíáãñáöÞ ìå ëáôéíéêïýò ÷áñáêôÞñåò ð.÷. êëáñéèñïìõêßíç  klarithromycin  klaricid. Ï “åîåëëçíéóìüò” ôùí (“åîáìåñéêáíéóìÝíùí” åëëçíéêþí!) ïíïìáóéþí áõôþí èá Þôáí åýêïëïò êáé åßíáé áðïñßáò Üîéïí ãéáôß äåí Ý÷åé Þäç ãßíåé. ¸íá Üëëï êùìéêïôñáãéêü ãåãïíüò åßíáé üôé ðïëëïß ðáíåðéóôçìéáêïß äÜóêáëïé áðåõèõíüìåíïé óôïõò öïéôçôÝò êáé óôçí åðéóôçìïíéêÞ êïéíüôçôá, óå áíèñþðïõò äçëáäÞ ðïõ èá Ýðñåðå íá åìðíÝïõí êáé íá ðáñáäåéãìáôßæïõí, ðïëëÝò öïñÝò áðïöåýãïõí ôéò åëëçíéêÝò ëÝîåéò ëÝãïíôáò ð.÷. ðùò “ï ôÜäå Ýãñáøå ôï paper”, “ï editor ôïõ äåßíá ðåñéïäéêïý”, “ôï paper ðÝñáóå áðü review” ê.ëð. Ôé ùèåß ëïéðüí üëïõò áõôïýò íá ÷ñçóéìï-

Ôüìïò 18, Ôåý÷ïò 2, 2006

ðïéïýí îÝíåò ëÝîåéò êáé ïíïìáóßåò; ÁëëÜ ôé ùèåß êáé üëïõò åìÜò ôïõò õðïëïßðïõò íá ðñïôåßíïõìå êáé íá áãïñÜæïõìå ôá óõãêåêñéìÝíá ðñïúüíôá êáé íá ðáñáêïëïõèïýìå áäéáìáñôýñçôá üëá ôá êáôÜ óõññïÞí åãêëÞìáôá êáôÜ ôçò åëëçíéêÞò; Ç Üêñéôç õéïèÝôçóç áðü ðëåõñÜò ìáò ôüóùí ëÝîåùí ôçò óçìåñéíÞò “ðáãêïóìéïðïéçìÝíçò” ãëþóóáò ïäçãåß óôï ãëùóóéêü ìáò áêñùôçñéáóìü êáé öõóéêÜ óôçí ðïëéôéóìéêÞ ìáò áöõäÜôùóç. 1⁄4ðùò óçìåéþíåé ï ÓáñÜíôïò É. ÊáñãÜêïò (Áëáëßá, Þôïé ôï óýã÷ñïíï ãëùóóéêü µáò ðáíüñáµá, ÁèÞíá: Gutenberg, 1985) “ôï åëëçíüðïõëï, µïëïíüôé åßíáé êëçñïíüµïò ôïõ µåãáëýôåñïõ ãëùóóéêïý èçóáõñïý, ÷ñçóéµïðïéåß êÜðïõ ëéãüôåñï áðü 1000 ëÝîåéò, üóåò äçëáäÞ êé ï êôçíïôñüöïò ãéá íá óõíåííïçèåß µå ôï êïðÜäé ôïõ, ç êñßóç, ðïõ åíõðÜñ÷åé óôç ãëùóóéêÞ, äçëáäÞ óôçí êáèáñÜ åêöñáóôéêÞ ðëåõñÜ ôçò íåïåëëçíéêÞò ðïëéôéóìéêÞò æùÞò, ãßíåôáé åíôïíüôåñç áðü ôï ãåãïíüò üôé ó’ Ýíá ðïëõóÞìáíôï ãëùóóéêü ðñüâëçìá êáé óõãêåêñéìÝíá óå ìéá åðÝëáóç åíüò îåíéêïý ôñüðïõ Ýêöñáóçò êáé óêÝøçò, åìåßò áíôéðáñáèÝôïõìå ìéá ãëùóóéêÞ áäñÜíåéá, ìéá ãëùóóéêÞ áíáéóèçóßá”. Äõóôõ÷þò, áõôÞ ç ãëùóóéêÞ áäñÜíåéá ÷áñáêôçñßæåé åí ðïëëïßò êáé ôç ëåãïìÝíç “ðïëéôéêÞ êáé ðíåõìáôéêÞ çãåóßá” ôïõ ôüðïõ. ÊáôáëÞãïõìå ëïéðüí óôï óõìðÝñáóìá üôé ìéá õãéÞò “åðáíÜóôáóç” êáôÜ ôçò îåíïìáíßáò ðñÝðåé íá îåêéíÞóåé áðü ôïí ßäéï ôï ëáü ðïõ êéíäõíåýåé áðü áõôÞí. Áõôüò áêñéâþò åßíáé êáé ï óêïðüò ôçò åñãáóßáò ìáò: íá áêïõóôåß ìéá öùíÞ áöýðíéóçò, êõñßùò ðñïò ôïõò óõíáäÝëöïõò éáôñïýò, þóôå ïé ßäéïé íá æçôÞóïõí ôçí áëëáãÞ ôïõ êáèåóôþôïò áíáãñáöÞò ôùí ïíïìáóéþí ôùí öáñìÜêùí, ðñïò üöåëïò ðÜíôïôå ôùí áóèåíþí ôïõò.

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Í. ÐëïõìÞò êáé óõí.

ÅÑÅÕÍÇÔÉÊÇ EÑÃÁÓÉÁ ÏRIGINAL PAPER Primary Heatlh Care, Volume 18, Number 2, 76-81, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 76-81, 2006

Áíôéìåôþðéóç ôçò ðá÷õóáñêßáò ìå ïìáäéêÞ èåñáðåßá óôçí ðñùôïâÜèìéá õãåßá: ÁðïôåëÝóìáôá äåêáïêôþ ìçíþí èåñáðåõôéêÞò ðáñÝìâáóçò Í. ÐëïõìÞò1, Ó. ÅñçìÜêç2, K. ÌáêñÞ1, Á. ÖèåíÜêçò1, Ã. ÖïõíôÜêçò1, Ñ. ÐáôåëÞ1, Å. Ôæþñôæçò1 Å. ÊõâåñíçôÜêç3, Á. ÖéëáëÞèçò4

Ðåñßëçøç Óêïðüò: Ç ðá÷õóáñêßá åßíáé ìßá íüóïò ìå áõîáíüìåíç åðßðôùóç óôç óýã÷ñïíç êïéíùíßá, êáé áðïôåëåß ôç âÜóç ðëåßóôùí ðñïâëçìÜôùí õãåßáò (ð.÷. õðÝñôáóç, óáê÷áñþäçò äéáâÞôçò). Óêïðüò ôçò óõãêåêñéìÝíçò ìåëÝôçò åßíáé ï Ýëåã÷ïò ôçò áðïôåëåóìáôéêüôçôáò ìéáò óõíäõáóìÝíçò ðñïóÝããéóçò ãéá ôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò óôá ðëáßóéá ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò. Õëéêü êáé ÌÝèïäïò: Óôç ìåëÝôç áõôÞ Ýëáâáí åèåëïíôéêÜ ìÝñïò 23 áóèåíåßò (22 ãõíáßêåò êáé Ýíáò Üíäñáò) çëéêßáò 23 Ýùò 65 åôþí (ìÝóç ôéìÞ 45 Ýôç). Äåêáôñåßò Þôáí õðÝñâáñïé (Äåßêôçò ÌÜæáò Óþìáôïò (ÄÌÓ) 27 Ýùò 29.9 kg/ m2) êáé 10 Þôáí ðá÷ýóáñêïé (ÄÌÓ>30 kg/ m2). Óå üëïõò ôïõò áóèåíåßò æçôÞèçêå éáôñéêü éóôïñéêü êáé Ýãéíå ðëÞñçò öõóéêÞ åîÝôáóç êáé åñãáóôçñéáêüò Ýëåã÷ïò. Óôïõò áóèåíåßò äüèçêå äéáéôïëüãéï, êáé áãùãÞ ìå ïñëéóôÜôç Þ óéìðïõôñáìßíç. 1⁄4ëïé ïé áóèåíåßò ìåôåß÷áí óå åâäïìáäéáßåò óõíåäñßåò ïìáäéêÞò èåñáðåßáò, ïé ïðïßåò ðåñéëÜìâáíáí æýãéóìá êáé åíèÜññõíóç ãéá ôç óõíÝ÷éóç ôùí ðñïóðáèåéþí ôïõò. ÁðïôåëÝóìáôá: Ôï áñ÷éêü âÜñïò ôùí áóèåíþí êõìáéíüôáí áðü 80.0 Ýùò 113.0 kg (ìÝóç ôéìÞ 89.3 kg). Ï ÄÌÓ Þôáí ìåôáîý 27.0 êáé 34.2 kg/m2 (ìÝóç ôéìÞ 29.5 kg/m2). 1⁄4ëïé ïé áóèåíåßò ðáñÝìåéíáí óôç ìåëÝôç ãéá äåêáïêôþ ìÞíåò. Óôï ôÝëïò ôïõ ðñþôïõ åîáìÞíïõ, ïé áóèåíåßò åìöÜíéóáí áðþëåéá âÜñïõò êáôÜ ìÝóï üñï 6.1 kg (p<0.001). Óôï ôÝëïò ôïõ äåýôåñïõ åîáìÞíïõ, ïé áóèåíåßò Ý÷áóáí åðéðëÝïí 4.0 kg (p<0.001) êáôÜ ìÝóï üñï. Óôï ôÝëïò ôïõ ôñßôïõ åîáìÞíïõ ôï âÜñïò ôùí áóèåíþí ðáñÝìåéíå óôáèåñü (ìÝóç áðþëåéá âÜñïõò 0.3 kg, p>0.75). Äåí ðáñáôçñÞèçêáí ðáñåíÝñãåéåò áðü ôç öáñìáêåõôéêÞ áãùãÞ. ÓõìðåñÜóìáôá: Ç ïìáäéêÞ èåñáðåßá óå óõíäõáóìü ìå äßáéôá êáé öáñìáêåõôéêÞ áãùãÞ åßíáé áðïôåëåóìáôéêÞ óôç ìåßùóç ôïõ óùìáôéêïý âÜñïõò. Áõôüò ï óõíäõáóìüò ðñïóåããßóåùí åßíáé åöéêôüò óôá ðëáßóéá ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò.

ÅðéìåëçôÝò Â ÃåíéêÞò ÉáôñéêÞò, Ê.Õ. Êáóôåëëßïõ, 2Åñã. Öõóéïëïãßáò, Ôì. ÉáôñéêÞò Ðáí/ìßïõ. ÊñÞôçò, 3Äéåõèýíôñéá Ê.Õ. Êáóôåëëßïõ, 4Áí. Êáè. ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ ÊñÞôçò 1

ÅéóáãùãÞ Ç ðá÷õóáñêßá åßíáé ìéá áðü ôéò óõ÷íüôåñåò áóèÝíåéåò ôïõ óýã÷ñïíïõ ôñüðïõ æùÞò, ç åðßðôùóÞ ôçò ìÜëéóôá áõîÜíåôáé ìå ñõèìü åðéäçìßáò óå üëåò ôéò çëéêéáêÝò ïìÜäåò1,2. Ùò ÷ñüíéá íüóïò, áðïôåëåß ôç âÜóç ðÜíù óôçí ïðïßá áíáðôýóóåôáé ðëçèþñá óõíïäþí íïóçìÜôùí, üðùò åßíáé ï óáê÷áñþäçò äéáâÞôçò ôýðïõ ÉÉ, ç õðÝñôáóç, ç õðåñëéðéäáéìßá, êáé ôåëéêÜ ç êáñäéáããåéáêÞ íüóïò3,4, áëëÜ êáé ðáèÞóåéò áíáðíåõóôéêïý (ð.÷. õðíéêÞ Üðíïéá) êáé ïñéóìÝíïé ôýðïé êáñêßíïõ. ¸÷åé õðïëïãéóôåß üôé ç ðá÷õóáñêßá åßíáé óçìáíôéêÞ áéôßá åëÜôôùóçò ôïõ ðñïóäüêéìïõ åðéâßùóçò, ðïõ áöïñÜ êõñßùò ôá íåüôåñá ôìÞìáôá ôïõ ðëçèõóìïý, êáé ùò åê ôïýôïõ Ý÷åé ôåñÜóôéï êïéíùíéêïïéêïíïìéêü êüóôïò5. ËÝîåéò êëåéäéÜ (MeSH Hellas): ðá÷õóáñêßá, ïìáäéêÞ èåñáðåßá, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ, 30 Áðñéëßïõ 4 ÌáÀïõ 2003) êáé Ýëáâå Ýðáéíï áðü ôçí åðéôñïðÞ êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáííùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: Íéêüëáïò ÐëïõìÞò Ä/íóç: Ð.É. Ë. ×åñóïíÞóïõ ×åñóüíçóïò Çñáêëåßïõ ÊñÞôçò, Ôçë: (28970) 22042, Fax: (28970) 22014 e-mail: nick_ploumis@hotmail.com

Í. ÐëïõìÞò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

Treatment of obesity within the Primary Care Setting: Results of an 18-month therapeutic intervention Í. Ploumis, S. Erimaki, K. Makri, Á. Fthenakis, G. Fountakis R. Pateli, Å. Tzortzis, Å. Kivernitaki, Á. Philalithis Summary Aim: Obesity is a modern illness of increasing incidence in our societies, and constitutes the basis of major health problems (e.g. hypertension, diabetes mellitus). The aim of this study is to assess the efficacy of a combined approach for the treatment of obesity within the Primary Care Setting. Population study Method: Twenty three patients (22 women and 1 man) aged 23 to 65 years (mean age 45 years) participated voluntarily in this study. Thirteen of them were overweight (Body Mass Index (BMI) 27 to 29.9 kg/m2) and 10 obese (BMI 30 kg/m2). All patients gave a detailed medical history, received a complete physical examination and laboratory tests. Specific dietary instructions, as well as treatment with orlistat or sibutramine were administered to the patients. All patients participated in weekly courses of group therapy, which included measurement of their weight, and were encouraged to continue their efforts. Results: The baseline weight of patients was between 80.0 and 113.0 kg (mean 89.3 kg). The BMI was between 27.0 and 34.2 kg/m2 (mean 29.5 kg/m2). All patients remained in the study for 18 months. By the end of the first semester, patients lost an average weight of 6.1 kg ((p<0.001). Patients continued to lose weight; by the end of the second semester, the mean weight loss was 4.0 kg (p<0.001). The weight of the patients remained stable over the third semester (mean weight loss of 0.3 kg, p>0.75). No major side effects from pharmacological treatment were observed. Conclusions: Group therapy combined with diet and pharmacological treatment is an effective approach to the management of obesity. This combination is feasible within the Primary Care Setting. Key words: obesity, therapy, primary helth care

Ìïëïíüôé öáßíåôáé üôé ï Ýëåã÷ïò ôçò ðá÷õóáñêßáò áðáéôåß ãåíéêüôåñç ðñïóÝããéóç ôïõ ðëçèõóìïý, ìå óôñáôçãéêÝò ðáñüìïéåò ìå áõôÝò ãéá ôç äéáêïðÞ ôïõ êáðíßóìáôïò6, ç áýîçóç ôçò åðßðôùóçò ôçò ðá÷õóáñêßáò áëëÜ êáé ï êßíäõíïò óïâáñþí åðéðëïêþí ðïõ åìöáíßæïõí ïé ðá÷ýóáñêïé áóèåíåßò, êáèéóôïýí åðéôáêôéêÞ ôçí éáôñéêÞ ðáñÝìâáóç, éäßùò óôá ðëáßóéá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. Óôü÷ïò ìéáò ôÝôïéáò ðáñÝìâáóçò åßíáé áöåíüò ç áðþëåéá âÜñïõò êáé ç äéáôÞñçóÞ ôïõ óå õãéÞ åðßðåäá, áöåôÝñïõ äå ç åëÜôôùóç ôçò åðßðôùóçò ôùí åðéðëïêþí ôçò ðá÷õóáñêßáò. Ç óõíçèÝóôåñç ðñáêôéêÞ üìùò åßíáé ç áíôéìåôþðéóç ôùí óõíåðåéþí êáé ü÷é ôïõ ðñïâëÞìáôïò ôçò ðá÷õóáñêßáò, ç óçìáóßá ôïõ ïðïßïõ õðïâáèìßæåôáé ðïëëÝò öïñÝò áðü ôïõò ßäéïõò ôïõò éáôñïýò7,8. Ïé ëüãïé ãéá áõôü åßíáé ðïéêßëïé, üðùò ç Ýëëåéøç ÷ñüíïõ åîáéôßáò ìåãÜëïõ áñéèìïý áóèåíþí, ç Üãíïéá ôïõ ðñïâëÞìáôïò, ïé óôåñåüôõðåò áíôéëÞøåéò ãéá ôï ÷áñáêôÞñá ôùí ðá÷ýóáñêùí êáé ç ðåðïßèçóç üôé ç íüóïò áõôÞ åßíáé áèåñÜðåõôç6,9. ÅðéðëÝïí, áñêåôïß áðü ôïõò éáôñïýò äåí åßíáé åðáñêþò åêðáéäåõìÝíïé óå ÷åéñéóìïýò ìå óôü÷ï ôçí êéíçôïðïßçóç ôùí áóèåíþí ôïõò, ðñïêåéìÝíïõ ïé ôåëåõôáßïé íá áëëÜîïõí ôéò óõíÞèåéÝò ôïõò ó÷åôéêÜ

ìå ôçí ðñüóëçøç ôñïöÞò. Óôçí ðñïóðÜèåéá åðßëõóçò ìåñéêþí áðü ôá ðñïáíáöåñèÝíôá ðñïâëÞìáôá óôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò Ý÷åé ÷ñçóéìïðïéçèåß áðü äéÜöïñïõò åñåõíçôÝò ç ôå÷íéêÞ ôçò ïìáäéêÞò èåñáðåßáò, ìå åíèáññõíôéêÜ áðïôåëÝóìáôá üóïí áöïñÜ ôçí åëÜôôùóç ôïõ âÜñïõò êáé ôç äéáôÞñçóÞ ôïõ óå öõóéïëïãéêÜ åðßðåäá ãéá ìáêñý ÷ñïíéêü äéÜóôçìá10. Ï óêïðüò ôçò ìåëÝôçò áõôÞò åßíáé ç áîéïëüãçóç ôçò ïìáäéêÞò èåñáðåßáò óôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò êáé óôç äéáôÞñçóç öõóéïëïãéêïý âÜñïõò, óôá ðëáßóéá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. Ç ðáñïýóá åñãáóßá åßíáé óõìðëçñùìÝíç ðáñïõóßáóç ðñïçãïýìåíçò11. Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïò

Óôç ìåëÝôç áõôÞ Ýëáâáí ìÝñïò 23 áóèåíåßò (22 ãõíáßêåò êáé Ýíáò Üíäñáò) çëéêßáò 23 Ýùò 65 åôþí (ìÝóç ôéìÞ 45 Ýôç, ôõðéêÞ áðüêëéóç 11,2 Ýôç). Äåêáôñåßò Þôáí õðÝñâáñïé (ÄÌÓ 27 Ýùò 29,9 kg/m2) êáé 10 Þôáí ðá÷ýóáñêïé (ÄÌÓ >30 kg/m2). Ïé áóèåíåßò áõôïß åðéóêÝðôïíôáí ãéá äéÜöïñïõò ëüãïõò ôï Ð.É. ×åñóïíÞóïõ, êáé áðïöÜóéóáí åèåëïíôéêÜ íá ëÜâïõí ìÝñïò, êáôüðéí áíôáðüêñéóÞò ôïõò óå áíáêïßíùóç ðïõ åß÷å áíáñôçèåß óå äéÜöïñá óçìåßá ôçò áßèïõóáò áíáìïíÞò ôïõ Éáôñåßïõ. Óå üëïõò ôïõò áóèåíåßò Ýãéíå åíçìÝñùóç ó÷åôéêÜ ìå ôá ìÝóá êáé ôïõò óôü÷ïõò ôçò èåñáðåõôéêÞò ðáñÝìâáóçò. Óôïõò áóèåíåßò áõôïýò Ýãéíå ëÞøç ðëÞñïõò éáôñéêïý éóôïñéêïý, ç ïðïßá ðåñéëÜìâáíå ðëçñïöïñßåò ó÷åôéêÜ ìå ôï âÜñïò ôïõò óôçí ðáéäéêÞ êáé åöçâéêÞ çëéêßá. Éäéáßôåñç Ýìöáóç äüèçêå óôçí êáôáãñáöÞ üëùí ôùí ðñïçãïýìåíùí ðñïóðáèåéþí ôùí áóèåíþí íá ÷Üóïõí âÜñïò, åßôå ìå äßáéôá êáé ãõìíáóôéêÞ åßôå ìå ëÞøç öáñìáêåõôéêÞò áãùãÞò. Óå êÜèå áóèåíÞ Ýãéíå ðëÞñçò öõóéêÞ åîÝôáóç êáèþò êáé åñãáóôçñéáêüò Ýëåã÷ïò, ðïõ ðåñéëÜìâáíå ðñïóäéïñéóìü ëéðéäßùí êáé èõñåïåéäéêþí ïñìïíþí. Óå åðüìåíç åðßóêåøç óôï éáôñåßï êáé ìåôÜ áðü æýãéóìá, ãéá êÜèå áóèåíÞ êáèïñßóôçêáí ñåáëéóôéêïß óôü÷ïé áíáöïñéêÜ ìå ôçí áðþëåéá âÜñïõò (óõíÞèùò ìåôáîý 5 Ýùò 15 77

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

% ôïõ áñ÷éêïý âÜñïõò). Áêïëïýèùò, óå êÜèå áóèåíÞ äüèçêáí óõãêåêñéìÝíåò äéáéôçôéêÝò ïäçãßåò2, ïé ïðïßåò ðåñéëÜìâáíáí ìåßùóç ôùí ðñïóëáìâáíüìåíùí èåñìßäùí çìåñçóßùò êáôÜ 10-30%, ôçò êáôáíÜëùóçò ôñïöþí ðëïýóéùí óå ëéðáñÜ, áýîçóç êáôáíÜëùóçò éíþí êáé áðïöõãÞ «ôóéìðïëïãÞìáôïò». Óå üëïõò ôïõò áóèåíåßò óõóôÞèçêå ç ëåðôïìåñÞò êáôáãñáöÞ, óå ìïñöÞ çìåñïëïãßïõ, ôçò çìåñÞóéáò ðñüóëçøçò ôñïöÞò. ÖáñìáêåõôéêÞ áãùãÞ ÷ïñçãÞèçêå óôïõò áóèåíåßò, ìå êñéôÞñéï ôï ÄÌÓ áëëÜ êáé ôçí ýðáñîç êáñäéáããåéáêþí ðáñáãüíôùí êéíäýíïõ. ¸ôóé, 20 áóèåíåßò Ýëáâáí áñ÷éêÜ áãùãÞ ìå ïñëéóôÜôç (120 mg ôñåéò öïñÝò çìåñçóßùò). ÅííÝá áðü áõôïýò ôïõò áóèåíåßò ðïõ äåí áíôáðïêñßèçêáí áñ÷éêÜ óôç èåñáðåßá ìå ïñëéóôÜôç Ýëáâáí áãùãÞ ìå óéìðïõôñáìßíç óå äüóç 10 mg çìåñçóßùò. Ôñåéò áóèåíåßò äåí Ýëáâáí êáìßá öáñìáêåõôéêÞ áãùãÞ ãéá ôç ìåßùóç ôïõ âÜñïõò. Ðñïò áýîçóç ôçò åíåñãåéáêÞò êáôáíÜëùóçò êáé ôçò ìõéêÞò ìÜæáò ìå áíôßóôïé÷ç åëÜôôùóç ôïõ ðïóïóôïý ëßðïõò ïþìáôïò, óôïõò áóèåíåßò ÷ïñçãÞèçêáí ðñïãñÜììáôá Üóêçóçò, ôá ïðïßá ðåñéëÜìâáíáí ôüóï ðñïãñáììáôéóìÝíç Üóêçóç (ð.÷. 30-min âÜäéóç 3 öïñÝò ôçí åâäïìÜäá), üóï êáé áýîçóç ôçò ãåíéêüôåñçò óùìáôéêÞò äñáóôçñéüôçôáò (ð.÷. óýóôáóç íá ÷ñçóéìïðïéïýí óêÜëåò áíôß ãéá áóáíóÝñ). Ôá áðïôåëÝóìáôá ôçò Üóêçóçò óôï âáóéêü ñõèìü ìåôáâïëéóìïý, ôçí áðþëåéá âÜñïõò êáé ôç äéáôÞñçóÞ ôçò12, áëëÜ êáé óôç ãåíéêüôåñç êáôÜóôáóç õãåßáò êáé ôçí øõ÷ïëïãéêÞ êáôÜóôáóç ôùí áóèåíþí åßíáé ãíùóôÜ13,14. ÔÝëïò, ãéá ìåãáëýôåñç óôÞñéîç ôùí áóèåíþí óôçí ðñïóðÜèåéá áðþëåéáò âÜñïõò, äéïñãáíþèçêáí åâäïìáäéáßåò óõíåäñßåò ïìáäéêÞò èåñáðåßáò äéÜñêåéáò ìßáò þñáò10. Óå áõôÝò ôéò óõíåäñßåò ïé áóèåíåßò æõãßæïíôáí, áíÝëõáí ôç óõìðåñéöïñÜ ôïõò ùò ðñïò ôç ëÞøç ôñïöÞò, êáé åíèáññýíïíôáí óôç óõíÝ÷éóç ôçò ðñïóðÜèåéÜò ôïõò.

ÓôáôéóôéêÞ áíÜëõóç Ãéá ôç óôáôéóôéêÞ áíÜëõóç ôùí äåäïìÝíùí ÷ñçóéìïðïéÞèçêå ôï ðñüãñáììá SPSS v12.0. H êáíïíéêüôçôá ôùí óõíå÷þí ìåôáâëçôþí åëÝã÷èçêå ìå ôï ôåóô Kolmogorov-Smirnov. Ç óýãêñéóç ôùí ôéìþí ôïõ âÜñïõò êáé ôïõ ÄÌÓ óôéò äéÜöïñåò ÷ñïíéêÝò óôéãìÝò Ýãéíå ìå ôç ìÝèïäï ANOVA ãéá åðáíáëáì78

Í. ÐëïõìÞò êáé óõí.

âáíüìåíåò ìåôñÞóåéò (repeated measures ANOVA). Ï âáèìüò óçìáíôéêüôçôáò (ìåôÜ äéüñèùóç êáôÜ Bonferroni) ïñßóôçêå óôï 0.05 (P<0.05). ÁðïôåëÝóìáôá Ôï âÜñïò ôùí áóèåíþí êáôÜ ôçí åßóïäü ôïõò óôç ìåëÝôç êõìáéíüôáí áðü 80 Ýùò 113 kg (ìÝóç ôéìÞ 89.3 kg êáé ôõðéêÞ áðüêëéóç 7.7 kg, åíþ ï ÄÌÓ Þôáí ìåôáîý 27 êáé 34 kg/m2 (ìÝóç ôéìÞ 29.5 kg/m2 êáé ôõðéêÞ áðüêëéóç 2.0 kg/m2). Áðü ôï éóôïñéêü ôùí áóèåíþí ðñïÝêõøå üôé ïé 15/23 Þôáí ðá÷ýóáñêïé êáôÜ ôçí ðáéäéêÞ Þ/êáé åöçâéêÞ çëéêßá. 1⁄4ëïé ïé áóèåíåßò åß÷áí ðñïóðáèÞóåé óôï ðáñåëèüí íá ÷Üóïõí âÜñïò, êõñßùò ìå äßáéôá. ÊáôÜ ìÝóï üñï áíáöÝñïíôáí 3 ðñïóðÜèåéåò, ïé ïðïßåò üìùò êáôÝëçãáí óå íÝá áýîçóç âÜñïõò. 1⁄4óïí áöïñÜ ôç óõíýðáñîç Üëëùí êáôáóôÜóåùí ðïõ áõîÜíïõí ôïí êáñäéáããåéáêü êßíäõíï, äéáðéóôþèçêå üôé 7 áóèåíåßò åß÷áí åðéðëÝïí õðåñ÷ïëçóôåñïëáéìßá, êáé ëÜìâáíáí áãùãÞ ìå óôáôßíåò, 6 åìöÜíéæáí õðÝñôáóç åíþ 3 Ýðáó÷áí áðü óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ. ÊáðíéóôÝò Þôáí 7 áóèåíåßò êáé ïéêïãåíåéáêü éóôïñéêü êáñäéáããåéáêÞò íüóïõ åß÷áí 6 áóèåíåßò. Ôá ÷áñáêôçñéóôéêÜ ôùí áóèåíþí óõíïøßæïíôáé óôïí ðßíáêá É. Ç ïìáäéêÞ èåñáðåßá ôùí õðÝñâáñùí êáé ðá÷ýóáñêùí áõôþí áóèåíþí óõíäõáóìÝíç ìå äßáéôá êáé öáñìáêåõôéêÞ áãùãÞ åß÷å óáí óõíÝðåéá ôçí áðþëåéá âÜñïõò, ç ïðïßá Þôáí åìöáíÞò óôïõò ðåñéóóüôåñïõò áðü áõôïýò Þäç áðü ôïõò ðñþôïõò ôñåéò ìÞíåò. ¸îé ìÞíåò ìåôÜ ôçí Ýíáñîç ôïõ ðñïãñÜììáôïò, ïé áóèåíåßò åß÷áí ÷Üóåé êáôÜ ìÝóï üñï 6.1 kg (95% äéÜóôçìá åìðéóôïóýíçò 5.4-6.8). Ç áðþëåéá áõôÞ Þôáí óôáôéóôéêÜ óçìáíôéêÞ (p< 0.001). Ç áðþëåéá âÜñïõò óõíå÷ßóôçêå êáé êáôÜ ôï äåýôåñï åîÜìçíï ôïõ ðñïãñÜììáôïò, Þôáí üìùò ìéêñüôåñç (ìÝóïò üñïò 4.0 kg, 95% äéÜóôçìá åìðéóôïóýíçò 3.2-4.7, p< 0.001). Ìå Üëëá ëüãéá, ï ñõèìüò áðþëåéáò âÜñïõò Þôáí ìéêñüôåñïò óôï äåýôåñï åîÜìçíï ôïõ ðñïãñÜììáôïò. Óôï ôÝëïò ôïõ ôñßôïõ åîáìÞíïõ ôïõ ðñïãñÜììáôïò, ðáñáôçñÞèçêå ìéêñÞ áðþëåéá âÜñïõò, ç ïðïßá äåí Þôáí óôáôéóôéêÜ óçìáíôéêÞ (ìÝóç áðþëåéá âÜñïõò 0.3 kg, p> 0.75), äçëáäÞ ïé áóèåíåßò äéáôçñÞèçêáí óôá åðßðåäá ôïõ åëáôôùìÝíïõ ôïõò âÜñïõò.

Í. ÐëïõìÞò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

Ðßíáêáò I. Óýíïøç ôùí ÷áñáêôçñéóôéêþí ôùí áóèåíþí ðïõ Ýëáâáí ìÝñïò óôç ìåëÝôç. Á: Üíäñåò, Ã: ãõíáßêåò, ÂÓ: âÜñïò óþìáôïò, ÓÄ : óáê÷áñþäçò äéáâÞôçò, Ïéê. Éóô.: Ïéêïãåíåéáêü éóôïñéêü êáñäéáããåéáêÞò íüóïõ A/á öýëï/ ÂÓ ÄÌÓ ÕðÝñôáóç Õðåñ÷ïçëéêßá åéóüäïõ åéóüäïõ ëçóôåñï(Ýôç) (kg) ëáéìßá

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Ã/43 Ã/39 Ã/48 Ã/56 Ã/52 Ã/37 Ã/48 Ã/56 Ã/47 Ã/41 Ã/30 Ã/53 Ã/41 Ã/28 Ã/54 Ã/39 Ã/65 Ã/23 Ã/46 Ã/58 Ã/35 Ã/32 Á/62

101 89 92 93 83 90 81 82 85 97 81 91 90 90 88,5 85 88 86 80 99,5 83 86 113

32.5 30.1 31.0 31.3 28.7 29.9 27.2 27.4 27.6 32.0 27.0 30.0 29.9 30.1 30.0 29.0 29.5 28.0 27.2 32.1 27.1 27.5 34.2

ÓÄ

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ÊÜðíéóìá Ïéê. Éóô.

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Êáô´ áíôéóôïé÷ßá, ï ÄÌÓ ôùí áóèåíþí óôï ðÝñáò ôïõ ðñþôïõ åîáìÞíïõ åëáôôþèçêå êáôÜ 2.02 kg/m2 (95% äéÜóôçìá åìðéóôïóýíçò 1.8-2.2). Ç åëÜôôùóç áõôÞ Þôáí óôáôéóôéêÜ óçìáíôéêÞ (p< 0.001). Óôï ðÝñáò ôïõ äåýôåñïõ åîáìÞíïõ ç åëÜôôùóç Þôáí ìéêñüôåñç, áëëÜ ðáñÝìåíå óôáôéóôéêÜ óçìáíôéêÞ (ìÝóïò üñïò 0.52 kg/m2, 95% äéÜóôçìá åìðéóôïóýíçò 0.05-0.98, p<0.01), åíþ óôï ðÝñáò ôïõ ôñßôïõ åîáìÞíïõ ï ÄÌÓ äåí ðáñïõóßáóå ïõóéáóôéêÞ ìåôáâïëÞ (ìÝóç åëÜôôùóç 0.11 kg/m2, p>0.75). Óôéò Åéê. I êáé 2 áðåéêïíßæïíôáé áíôßóôïé÷á ç áðþëåéá âÜñïõò êáé ç åëÜôôùóç ôïõ ÄÌÓ êáôÜ ôç äéÜñêåéá ôïõ ðñïãñÜììáôïò áõôïý. Ç åëÜôôùóç ôïõ âÜñïõò ôùí áóèåíþí åðÝäñáóå êáé óå Üëëïõò ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ. ¸ôóé, óå 7 áóèåíåßò ðïõ ëÜìâáíáí áãùãÞ ìå óôáôßíåò ãéá ôçí õðåñ÷ïëçóôåñïëáéìßá ôïõò, ìåéþèçêå ç äüóç ôçò óôáôßíçò êáôÜ 50%. Ïé ðáñåíÝñãåéåò ðïõ ðáñáôçñÞèçêáí áðü ôç öáñìáêåõôéêÞ áãùãÞ Þôáí Þðéåò êáé áöïñïýóáí ãáóôñåíôåñéêÝò äéáôáñá÷Ýò ëüãù ëÞøçò ïñëéóôÜôçò. Ïõäåßò åê ôùí áóèåíþí äéÝêïøå ôç öáñìáêåõôéêÞ áãùãÞ ëüãù åìöÜíéóçò ðáñåíåñãåéþí.

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ÖáñìáêåõôéêÞ áãùãÞ ãéá ôçí ðá÷õóáñêßá ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç / óéìðïõôñáìßíç 1⁄4÷é ÏñëéóôÜôç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç ÏñëéóôÜôç ÏñëéóôÜôç / óéìðïõôñáìßíç 1⁄4÷é ÏñëéóôÜôç 1⁄4÷é ÏñëéóôÜôç ÏñëéóôÜôç

Åéêüíá I. ÂÜñïò óþìáôïò ôùí áóèåíþí (ìÝóç ôéìÞ, êáé áêñüôáôá) êáôÜ ôçí Ýíáñîç ôïõ ðñïãñÜììáôïò (ÂÓ 0), êáé ìåôÜ áðü 6 (ÂÓ 6), 12 (ÂÓ 12)êáé 18 (ÂÓ 18) ìÞíåò. Ïé áóôåñßóêïé õðïäçëþíïõí óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò óõãêñéôéêÜ ìå ôï ÂÓ0. Ïé êýêëïé õðïäçëþíïõí óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò óå ó÷Ýóç ìå ôï ÂÓ 6.

ÓõæÞôçóç Ôï êýñéï åýñçìá ôçò ìåëÝôçò åßíáé üôé ç ðá÷õóáñêßá ìðïñåß íá áíôéìåôùðéóôåß áðïôåëåóìáôéêÜ ìå ôçí åöáñìïãÞ ïìáäéêÞò èåñáðåßáò óôá ðëáßóéá 79

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Åéêüíá II. Äåßêôçò ìÜæáò óþìáôïò (ÄÌÓ) ôùí áóèåíþí (ìÝóç ôéìÞ, êáé áêñüôáôá) êáôÜ ôçí Ýíáñîç ôïõ ðñïãñÜììáôïò (ÄÌÓ0), êáé ìåôÜ áðü 6 (ÄÌÓ6), 12 (ÄÌÓ12) êáé 18 (ÄÌÓ18) ìÞíåò. Ïé áóôåñßóêïé õðïäçëþíïõí óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò óõãêñéôéêÜ ìå ôï ÄÌÓ0. Ïé êýêëïé õðïäçëþíïõí óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò óå ó÷Ýóç ìå ôï ÄÌÓ6.

ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. Óå äéÜöïñåò ðñüóöáôåò ìåëÝôåò Ý÷åé äåé÷èåß üôé ç ïìáäéêÞ èåñáðåßá õðåñÝ÷åé ôçò áôïìéêÞò óôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò. ¸ôóé, ìéá ôõ÷áéïðïéçìÝíç ìåëÝôç 75 ðá÷ýóáñêùí Ýäåéîå üôé ïé áóèåíåßò åêåßíïé ðïõ ðÞñáí ìÝñïò óå óõíåäñßåò ïìáäéêÞò èåñáðåßáò Ý÷áóáí ðåñéóóüôåñï âÜñïò óå ó÷Ýóç ìå åêåßíïõò ðïõ áíôéìåôùðßóôçêáí óå áôïìéêÞ âÜóç10. ¢ëëç ôõ÷áéïðïéçìÝíç ìåëÝôç ìðüñåóå íá äåßîåé ôçí õðåñï÷Þ ôçò ïìáäéêÞò èåñáðåßáò ôçò ðá÷õóáñêßáò óå ó÷Ýóç ìå ôçí áôïìéêÞ üóïí áöïñÜ ôçí åëÜôôùóç ôïõ âÜñïõò áëëÜ êáé ôç ìåßùóç ôùí ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ 15. ÔÝëïò, áíáóêüðçóç ôçò âéâëéïãñáößáò ó÷åôéêÞò ìå ôá ìáêñï÷ñüíéá (÷ñïíéêü äéÜóôçìá ðáñáêïëïýèçóçò ìåãáëýôåñï ôùí 3 åôþí) áðïôåëÝóìáôá äßáéôáò óôçí åëÜôôùóç ôïõ óùìáôéêïý âÜñïõò Ýäåéîå üôé ðá÷ýóáñêïé ðïõ áíôéìåôùðßóôçêáí ìå äßáéôá óå óõíäõáóìü ìå ïìáäéêÞ èåñáðåßá åß÷áí ìåãáëýôåñåò ðéèáíüôçôåò íá äéáôçñÞóïõí ôï ÷áìçëüôåñï âÜñïò ôïõò óå ó÷Ýóç ìå áõôïýò ðïõ Ýêáíáí ìüíï äßáéôá16. Ç ðáñïýóá ìåëÝôç, óå óõìöùíßá ìå ôá ðñïáíáöåñèÝíôá, äåß÷íåé üôé ç ïìáäéêÞ èåñáðåßá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ìðïñåß íá óôçñßîåé ôïõò ðá÷ýóáñêïõò áóèåíåßò óôçí ðñïóðÜèåéÜ ôïõò íá ÷Üóïõí âÜñïò ìå äéÜöïñïõò ôñüðïõò. 80

Í. ÐëïõìÞò êáé óõí.

Êáôáñ÷Þí, ïé åâäïìáäéáßåò óõíåäñßåò ïìáäéêÞò èåñáðåßáò ëåéôïýñãçóáí ùò Üìéëëá ãéá ôïõò áóèåíåßò, ïé ïðïßïé åðéæçôïýóáí ôçí åðéâñÜâåõóç ãéá ôçí áðþëåéá âÜñïõò ðïõ åß÷áí åðéôý÷åé. Óõæçôïýóáí ôéò ðáñåêôñïðÝò ôçò ðñïçãïýìåíçò åâäïìÜäïò êáé åíèáññýíïíôáí ãéá ôçí õéïèÝôçóç õãéåéíþí äéáôñïöéêþí óõíçèåéþí. Ï óõíôïíéóìüò ìå åíåñãçôéêü ôñüðï áðü ôïí Éáôñü åìøý÷ùíå ôïõò áóèåíåßò êáé åíßó÷õå ôï ðíåýìá ïìáäéêüôçôáò êáé óõíåñãáóßáò. Ç ðñüóâáóç ôùí áóèåíþí Þôáí åýêïëç, ìéá êáé üëåò ïé ðáñåìâÜóåéò ãßíïíôáí êïíôÜ óôïí ôüðï êáôïéêßáò ôïõò, ìå áðïôÝëåóìá ôçí áðïöõãÞ ìåãÜëùí ìåôáêéíÞóåùí ðñïò ôçí ðüëç. Åäþ ðñÝðåé íá ôïíéóôåß üôé ç åëÜôôùóç ôïõ âÜñïõò åß÷å åðßóçò óçìáíôéêÞ åðßäñáóç óôçí øõ÷éêÞ êáôÜóôáóç ôùí áóèåíþí13,14. 1⁄4ëïé ïé ìåôÝ÷ïíôåò áíÝöåñáí óçìáíôéêÞ éêáíïðïßçóç áðü ôç óõììåôï÷Þ ôïõò óôï ðñüãñáììá êáé ðáñáäÝ÷ïíôáí üôé éäéáßôåñá ÷ñÞóéìç Þôáí ç êáôáãñáöÞ çìåñïëïãßïõ, ç ïðïßá ôïõò âïÞèçóå íá áíáãíùñßóïõí ôéò äéáôñïöéêÝò ôïõò óõíÞèåéåò êáé óôç óõíÝ÷åéá íá ôéò ôñïðïðïéÞóïõí. Óôï óçìåßï áõôü ðñÝðåé íá ôïíéóôåß ç ðïëý ìéêñÞ óõììåôï÷Þ ôùí áíäñþí óôç ìåëÝôç, ðáñÜ ôï ãåãïíüò üôé ç ðá÷õóáñêßá áöïñÜ ôá äýï öýëá. Ðéèáíþò áõôü íá ïöåßëåôáé óôç ãåíéêüôåñç áíôßëçøç üôé ç ðá÷õóáñêßá åßíáé êõñßùò áéóèçôéêü ðñüâëçìá, ðïõ áöïñÜ êõñßùò ôéò ãõíáßêåò. Áõôü ïäçãåß Ýíá óçìáíôéêü áñéèìü ðá÷ýóáñêùí óôïí áõôü-áðïêëåéóìü ôïõ áðü ïðïéáäÞðïôå èåñáðåõôéêÞ ðáñÝìâáóç, ìå âëáâåñÝò óõíÝðåéåò óôç ãåíéêüôåñç êáôÜóôáóç ôçò õãåßáò ôïõò. ÅðïìÝíùò, ç áíôéìåôþðéóç ôçò ðá÷õóáñêßáò ðñÝðåé íá ðåñéëáìâÜíåé êáé ãåíéêüôåñç ðáñÝìâáóç óôçí êïéíüôçôá, ìå óôü÷ï ôçí åõáéóèçôïðïßçóç ôïõ ðëçèõóìïý ôüóï ãéá ôïõò êéíäýíïõò ôçò ðá÷õóáñêßáò üóï êáé ãéá ôá ïöÝëç áðü ôçí áíôéìåôþðéóÞ ôçò6. Ôá ôåëåõôáßá ÷ñüíéá Ý÷åé äïèåß ìåãÜëç óçìáóßá óôçí áíôéìåôþðéóç ôçò ðá÷õóáñêßáò óôá ðëáßóéá ìéáò ãåíéêüôåñçò ðñïóðÜèåéáò åëÜôôùóçò ôçò íïóçñüôçôáò êáé èíçôüôçôáò áðü êáñäéáããåéáêÜ íïóÞìáôá 6,17. Ðñïò ôçí êáôåýèõíóç áõôÞ äéÜöïñåò ìåëÝôåò Ý÷ïõí äåßîåé óçìáíôéêÞ åëÜôôùóç ôùí åðéðÝäùí áñôçñéáêÞò ðßåóçò êáé óáê÷Üñïõ áßìáôïò, êáèþò êáé âåëôßùóç ôïõ ëéðéäáéìéêïý ðñïößë óå ðá÷ýóáñêïõò ðïõ Ý÷áóáí âÜñïò 18-20. Óôç äéêÞ ìáò óåéñÜ áóèåíþí ðáñáôçñÞèçêå óçìáíôéêÞ âåëôßùóç ôïõ ëéðéäáéìéêïý ðñïößë ôùí áóèåíþí. Aõôü åßíáé Ýììåóï óõìðÝñáóìá, ðïõ ðñïêýðôåé áðü ôçí åëÜôôùóç ôçò äïóïëïãßáò óôáôßíçò ðïõ ëÜìâáíáí ïé

Í. ÐëïõìÞò êáé óõí.

áóèåíåßò áõôïß. ¸íáò ëüãïò ðïõ äåí ðáñáôçñÞèçêå óçìáíôéêÞ åðßäñáóç ôçò åëÜôôùóçò âÜñïõò óôçí áñôçñéáêÞ ðßåóç êáé ôï óÜê÷áñï åßíáé ôï ó÷åôéêÜ ìéêñü ìÝãåèïò ôïõ äåßãìáôüò ìáò. Èá ìðïñïýóå åðßóçò áõôü íá ïöåßëåôáé óôï ãåãïíüò üôé ï ìÝóïò ÄÌÓ ôùí áôüìùí ðïõ Ýëáâáí ìÝñïò óôç ìåëÝôç äåí Þôáí ôüóï õøçëüò. ÔÝëïò, áðü ôçí åñãáóßá áõôÞ öáßíåôáé ðùò Ýíá Üëëï ðëåïíÝêôçìá ôçò ïìáäéêÞò èåñáðåßáò åßíáé üôé ï Ãåíéêüò Éáôñüò óôï ðåñéâÜëëïí ôïõ Ðåñéöåñåéáêïý Éáôñåßïõ, ðáñÜ ôç ìåãÜëç ðßåóç ÷ñüíïõ ðïõ äÝ÷åôáé, ìðïñïýóå íá ðáñáêïëïõèÞóåé êáé íá âïçèÞóåé Ýíá ìåãÜëï áñéèìü áóèåíþí ãéá ìåãÜëï ÷ñïíéêü äéÜóôçìá. Åßíáé ãåíéêÜ ðáñáäåêôü, ôüóï áðü ìåëÝôåò üóï êáé áðü ôçí êëéíéêÞ åìðåéñßá ðïõ óõóóùñåýåôáé, üôé ç ðá÷õóáñêßá åßíáé ìéá ÷ñüíéá íüóïò, ìå ìáêñï÷ñüíéá ðïñåßá êáé óõ÷íÝò õðïôñïðÝò, êáé åðïìÝíùò ðñÝðåé íá áíôéìåôùðßæåôáé ìå ôïí áíÜëïãï ôñüðï 21. Áõôü óçìáßíåé üôé ïé ðá÷ýóáñêïé áóèåíåßò ðñÝðåé íá ðáñáìÝíïõí óå ðáñáêïëïýèçóç áêüìá êáé áí ìåôÜ áðü ðáñÝìâáóç ôï âÜñïò ôïõò Ý÷åé ìåéùèåß. Ç ïìáäéêÞ èåñáðåßá êÜíåé äõíáôÞ ôÝôïéá ìáêñï÷ñüíéá ðáñáêïëïýèçóç.

Ôüìïò 18, Ôåý÷ïò 2, 2006

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Âéâëéïãñáößá 1. Flegal KÌ, Carroll MD, Ogden CI, Johnson CI. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 288:1723-7, 2003. 2. National Institutes of Health, National Heart, Lung and Blood Institute. Association for the study of Obesity: The Practical Guide, Identification, Evaluation and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institutes of Health, 2000. 3. National Task Force on the Prevention and Treatment of Obesity. Overweight, obesity, and health risk. Arch Intern Med 160:898-904, 2000. 4. Rippe JM. The case for medical management of obesity: a call for increased physician involvement. Obes Res Suppl 1:23S-33S, 1998. 5. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 289:187-93, 2003. 6. Noel PH and Pugh JA. Management of overweight and obese adults. BMJ 325:757-61, 2002. 7. Grizzard T. Undertreatment of obesity. JAMA 288:2177, 2002. 8. Sciamanna CN, Tate DF, Lang W, Wing RR. Who reports receiving advice to lose weight? Results

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from a multistate survey. Arch Intern Med160: 2334-9, 2000. Foster GD, Wadden TA, Makris AP, Davidson D, Sanderson RS, Allison DB, Kessler A. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 11:1168-77, 2003. Renjilian DA, Perri MG, Nezu AM, McKelvey WF, Shermer RL, Anton SD. Individual versus group therapy for obesity: effects of matching participants to their treatment preferences. J Consult Clin Psychol 2001, 69:717-21, 2001. Plumis N, Tzortzis E, Sakka I, Philalithis A. A combined approach for the treatment of obesity within primary care setting. Int J Obesity 28s1, 144, 2004. Rippe JM and Hess S. The role of physical activity in the prevention and management of obesity. J Am Diet Assoc 98:S31-8, 1998. He XZ and Baker DW. Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age. Am J Public Health 94:1567-73, 2004. McInnis KJ, Franklin BA, Rippe JM. Counseling for physical activity in overweight and obese patients. Am Fam Physician 67:1249-56, 2003. Dzator JA, Hendrie D, Burke V, Gianguilio N, Gillam HF, Beilin LJ, Houghton S. A randomized trial of interactive group sessions achieved greater improvements in nutrition and physical activity at a tiny increase in cost. J Clin Epidemiol 57: 610-9, 2004. Ayyad C and Andersen T. Long-term efficacy of dietary treatment of obesity: a systematic review of studies published between 1931 and 1999. Obes Rev 1:113-9, 2000. Orzano AJ and Scott JG. Diagnosis and treatment of obesity in adults: an applied evidencebased review. J Am Board Fam Pract 17:359-69, 2004. Derosa G, Cicero AF, Murdolo G, Ciccarelli L, Fogari R (2004). Comparison of metabolic effects of orlistat and sibutramine treatment in Type 2 diabetic obese patients. Diabetes Nutr Metab 17: 222-9, 2004. Derosa G, Cicero AF, Murdolo G, Piccinni MN, Fogari E, Bertone G, Ciccarelli L, Fogari R. Efficacy and safety comparative evaluation of orlistat and sibutramine treatment in hypertensive obese patients. Diabetes Obes Metab 7:47-55, 2005. Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 16: 397-415, 1992. Hill JO. Dealing with obesity as a chronic disease. Obes Res Suppl 1:34S-38S, 1998 81

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÆåúìðÝêçò êáé óõí.

ÁÍÁÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 18, Number 2, 82-86, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 82-86, 2006

Ï ñüëïò ôçò ïìïêõóôåÀíçò óôçí ðñüêëçóç êáñäéáããåéáêÞò íüóïõ Á. ÆåúìðÝêçò1, Ä.Â. ÐáíáãéùôÜêïò2, ×. Ðßôóáâïò3

Ðåñßëçøç Ç óõãêÝíôñùóç ïìïêõóôåÀíçò èåùñåßôáé áðü ðïëëïýò åñåõíçôÝò ùò áíåîÜñôçôïò ðáñÜãïíôáò êéíäýíïõ ãéá êáñäéáããåéáêÜ íïóÞìáôá ìÝóù äéáöüñùí ìç÷áíéóìþí. Åéäéêüôåñá, ç óõììåôï÷Þ ôçò óå ìç÷áíéóìïýò ðïõ ðñïêáëïýí èñüìâùóç Ý÷åé áðïäåé÷èåß óå ðïëëÝò ìåëÝôåò. ¢ëëåò ìåëÝôåò êáôÝëçîáí óôï üôé áõîçìÝíç óõãêÝíôñùóç ïìïêõóôåÀíçò óôï ðëÜóìá åíéó÷ýåé óçìáíôéêÜ ôïí êßíäõíï ðïõ ó÷åôßæåôáé ìå êëáóóéêïýò ðáñÜãïíôåò êéíäýíïõ üðùò ôï êÜðíéóìá, ç õðÝñôáóç êáé ç õðåñëéðéäáéìßá. Ùóôüóï õðÜñ÷ïõí åõñÞìáôá ðïõ åßôå äåí åðéâåâáéþíïõí åßôå äåí áíáãíùñßæïõí ôç óçìáóßá ôçò ïìïêõóôåÀíçò óôçí ðñüêëçóç óôåöáíéáßáò íüóïõ, åíþ ðñüóöáôåò ìåëÝôåò ôçí èåùñïýí ùò áðïôÝëåóìá ðáñÜ áéôßá ôçò áñôçñéïóêëÞñõíóçò. Åðßóçò Ý÷åé õðïóôçñé÷ôåß üôé êÜðïéá èñåðôéêÜ óõóôáôéêÜ, üðùò ôï öõëéêü ïîý, ìåéþíïõí óçìáíôéêÜ ôçí ïëéêÞ ïìïêõóôåÀíç ôïõ ðëÜóìáôïò. Ùóôüóï ðáñáìÝíåé Üãíùóôï áí Ý÷ïõí ôçí ßäéá åðßäñáóç êáé óôïí êßíäõíï ãéá óôåöáíéáßá íüóï. ÅðéðëÝïí, ïé óõãêåíôñþóåéò ïìïêõóôåÀíçò êáèïñßæïíôáé êáé áðü ãåíåôéêïýò ðáñÜãïíôåò. Öáßíåôáé üôé ðñïò ôï ðáñüí ç ðñïóï÷Þ ìáò èá ðñÝðåé íá åóôéáóôåß óå äéÜöïñïõò ðáñÜãïíôåò, üðùò ç äéáôñïöÞ êáé ôï êÜðíéóìá, êáèþò êáé óå Üëëïõò êáèéåñùìÝíïõò ðáñÜãïíôåò êéíäýíïõ óôá Üôïìá ìå õøçëÝò óõãêåíôñþóåéò ïìïêõóôåÀíçò.

Ãåíéêüò Éáôñüò, 2ËÝêôïñáò ÂéïóôáôéóôéêÞò – Åðéäçìéïëïãßáò, ÔìÞìá ÅðéóôÞìçò Äéáéôïëïãßáò-ÄéáôñïöÞò, ×áñïêüðåéï ÐáíåðéóôÞìéï ÁèÞíáò, 3Áí. ÊáèçãçôÞò Ðáí/êÞò ÊáñäéïëïãéêÞò ÊëéíéêÞò ÉððïêñÜôåéïõ Ã.Í.Á., Åðéóôçìïíéêü ÊÝíôñï: Ðáí/êÞ ÊáñäéïëïãéêÞ ÊëéíéêÞ É.Ã.Í.Á, ÉáôñéêÞ Ó÷ïëÞ Ðáíåðéóôçìßïõ ÁèÞíáò 1

ÅéóáãùãÞ Óôçí ðñïóðÜèåéá ãéá êáëýôåñç êáôáíüçóç, åñìçíåßá êáé áíôéìåôþðéóç ôçò êáñäéáããåéáêÞò íüóïõ Ý÷ïõí áíáöåñèåß äéÜöïñïé ðáñÜãïíôåò. Åêôüò áðü ôïõò êëáóéêïýò üðùò ç áñôçñéáêÞ õðÝñôáóç, ï óáê÷áñþäçò äéáâÞôçò, ïé äõóëéðéäáéìßåò, ôï êÜðíéóìá áíáöÝñïíôáé åðßóçò ðáñÜãïíôåò üðùò ôï öýëï, ç çëéêßá, ôï êëçñïíïìéêü éóôïñéêü. Ôá ôåëåõôáßá ÷ñüíéá åëÝã÷ïíôáé êáé Üëëïé ðáñÜãïíôåò üðùò ç ðá÷õóáñêßá, ç êáôáíÜëùóç áëêïüë, äéÜöïñïé øõ÷ïêïéíùíéêïß êáé èñïìâùôéêïß ðáñÜãïíôåò, äåßêôåò öëåãìïíÞò, ç ïìïêõóôåÀíç (Hcy) êáé Üëëïé. ÐáñÜãïíôåò üðùò ç ïìïêõóôåÀíç ãéá ôïõò ïðïßïõò ôá äåäïìÝíá åßíáé áêüìç õðü óõæÞôçóç ïíïìÜæïíôáé íÝïé Þ áíáäõüìåíïé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ. Ç éóôïñßá ôçò ïìïêõóôåÀíçò îåêéíÜ ðñéí áðü 30 ðåñßðïõ ÷ñüíéá üôáí ï McCulley1 ðáñáôçñþíôáò óå íåêñïôïìéêü õëéêü ðáéäéþí ìå éóôïñéêü ïìïêõóôéíïõñßáò èñüìâùóç áñôçñéþí,

ËÝîåéò êëåéäéÜ (MeSH Hellas): êáñäéáããåéáêÜ íïóÞìáôá, êáñäéáããåéáêïß ðáñÜãïíôåò ïìïêõóôåÀíç. ÕðïâëÞèçêå: 4 Ïêôùâñßïõ 2004 ÅðáíõðïâëÞèçêå: 21 Éáíïõáñßïõ 2005 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 9 Ìáñôßïõ 2005 Õðåýèõíïò áëëçëïãñáößáò: ¢êçò ÆåúìðÝêçò, Ä/íóç: Éêáñßáò 30, ÔÊ 12132 ÐåñéóôÝñé, ÁèÞíá, ôçë.: (210) 5776671, 6944829404, e-mail: akis12132@yahoo.com

Á. ÆåúìðÝêçò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

The importance of homocysteine in causing cardiovascular disease Á. Zeimbekis, D.B. Panagiotakos, C. Pitsavos

Óýã÷ñïíá äåäïìÝíá

ÓÞìåñá õðÜñ÷åé ðëÞèïò äåäïìÝíùí4 áðü ìåëÝôåò óå ðåéñáìáôüæùá ðïõ áðïêáëýðôïõí ðéèáíïýò ìç÷áíéóìïýò ìå ôïõò ïðïßïõò äñá ç õðåñïìïêõóôåúíáéìßá ìå ðéï ðéèáíü áõôüí ôçò èñüìâùóçò. ÐáñÜëëçëá ç ãíþóç üôé ôá åðßðåäá ôùí âéôáìéíþí Â6 êáé Â12 ìåéþíïõí ôá åðßðåäá ïìïêõóôåÀíçò ïäçãåß óå Ýñåõíåò ðáñÝìâáóçò ìå ÷ïñÞãçóç âéôáìéíþí óå åðéëåãìÝíåò ïìÜäåò áóèåíþí. Ôáõôü÷ñïíá ðñïêýðôïõí ìåëÝôåò ðïõ áìöéóâçôïýí Þ êáé áðïññßðôïõí ôï ñüëï ôçò ïìïêõóôåÀíçò, õðïóôçñßæïíôáò üôé ç áýîçóç ôçò óå êáñäéáããåéáêïýò áóèåíåßò äåí áðïôåëåß áßôéï áëëÜ åßíáé áðïôÝëåóìá ôçò áèçñïóêëÞñõíóçò. Åßíáé ãåãïíüò üôé êõñßùò ïé ìåëÝôåò áóèåíþí-ìáñôýñùí Ýäåéîáí èåôéêÞ óõó÷Ýôéóç ìåôáîý ïìïêõóôåÀíçò êáé áèçñïóêëÞñùóçò, åíþ ïé ðñïïðôéêÝò ìåëÝôåò Ýäùóáí áíôéêñïõüìåíá áðïôåëÝóìáôá. ÐáñÜëëçëá õðÜñ÷ïõí ìåëÝôåò ðïõ åíôüðéóáí áõîçìÝíï êßíäõíï ìüíï óå åéäéêÝò ïìÜäåò áôüìùí êáé ìåôÜ áðü óýíôïìá ÷ñïíéêÜ äéáóôÞìáôá ðáñáêïëïýèçóçò êáé ÷ùñßò íá ëáìâÜíïíôáé õðüøç ðéèáíïß óõã÷õôéêïß ðáñÜãïíôåò5-7. ¸ôóé ìåëÝôåò üðùò ç Mobile Clinic Health Examination Survey8 ç British Regional Heart Study9 ç ìåëÝôç Gaerphilly10 êáé ç British United Provident Association Study11 Ýäåéîáí áíôéêñïõüìåíá áðïôåëÝóìáôá ó÷åôéêÜ ìå ôï ñüëï ôçò ïìïêõóôåÀíçò. ÁíáöÝñåôáé üôé áõôü ìðïñåß íá ïöåßëåôáé åßôå óå äéáöïñÝò óôç äïìÞ ôùí ìåëåôþí áõôþí åßôå óå äéáöïñÝò êáé êëçñïíïìéêÝò éäéïìïñößåò óôïõò õðü ìåëÝôç ðëçèõóìïýò. Áðü ôçí Üëëç ìåñéÜ ç Ýëëåéøç èåôéêÞò óõó÷Ýôéóçò ìðïñåß íá ïöåßëåôáé êáé óå Ýëëåéøç áîéïðéóôßáò ôùí ìåèüäùí ðïõ ÷ñçóéìïðïéïýíôáé ãéá ôç ìÝôñçóç ôçò ïìïêõóôåÀíçò12.

Summary Homocysteine levels are now considered by some investigators as an independent risk factor of cardiovascular disease through many and various mechanisms. Specifically, its participation in mechanisms of thrombosis has been documented in many studies. Moreover, other studies suggest that an elevated plasma total homocysteine concentration substantially increases the risk associated with some conventional cardiovascular risk factors like smoking, hypertension and hyperlipidemia. However, there are finding that do not really confirm or recognize homocysteine importance in actually causing coronary artery disease, while recent studies have considered homocysteine more as a result than a cause of arteriosclerosis. Also, it has been suggested that nutrient components, like folic acid, reliably reduce plasma total homocysteine, but whether this reduces coronary risk is unknown. In addition, genetic factors seem to modulate total plasma homocysteine levels, too. It seems that, for the present, careful attention to several factors, like diet, smoking, as well as other conventional risk factors in individuals with a raised plasma total homocysteine level is warranted. Key-words: cardiovascular, agents, homocysteine

äéáôýðùóå ôçí õðüèåóç üôé ç õøçëÞ óõãêÝíôñùóç ïìïêõóôåÀíçò óôï ðëÜóìá-ç ïðïßá ÷áñáêôçñßæåé ôçí ïìïêõóôéíïõñßá- ìðïñåß íá ðñïêáëÝóåé áñôçñéïóêëÞñùóç. Ç õðüèåóç áõôÞ Ýìåéíå ùò óêÝøç ìÝ÷ñé ôç äåêáåôßá ôïõ ’90 ïðüôå åìöáíßæïíôáé Ýñåõíåò ðïõ õðïóôçñßæïõí ôçí õðüèåóç ôïõ McCulley êáé óõìðåñáßíïõí üôé ç áõîçìÝíç ïìïêõóôåÀíç ðëÜóìáôïò áðïôåëåß éó÷õñü êáé áíåîÜñôçôï ðáñÜãïíôá êáñäéáããåéáêïý êéíäýíïõ. Ìéá ðñþôç óçìáíôéêÞ ðñïïðôéêÞ ìåëÝôç ðïõ ìåëÝôçóå ôç ó÷Ýóç õðåñïìïêõóôåúíáéìßáò êáé ôï êßíäõíï óôåöáíéáßáò íüóïõ åßíáé ç Physicians Health Study2. ÐåñéÝëáâå 14.916 Üíäñåò, Áìåñéêáíïýò ãéáôñïýò, çëéêßáò 40-84 åôþí, ÷ùñßò ðñïçãïýìåíï êáñäéïëïãéêü éóôïñéêü, ðïõ ðáñáêïëïõèÞèçêáí åðß ðåíôáåôßá. Óôç äéÜñêåéá áõôÞ 271 Üôïìá õðÝóôçóáí Ýìöñáãìá ìõïêáñäßïõ êáé ôá äåßãìáôá áßìáôïò ôïõò ðïõ ðñïûðÞñ÷áí, áðü ôçí Ýíáñîç ôçò ìåëÝôçò, áíáëýèçêáí êáé óõãêñßèçêáí ìå áíÜëïãïõò ìÜñôõñåò. Ïé áóèåíåßò äéáðéóôþèçêå íá åìöáíßæïõí óõ÷íüôåñá áñôçñéáêÞ õðÝñôáóç, óáê÷áñþäç äéáâÞôç, õðåñ÷ïëçóôåñïëáéìßá êáé õðåñïìïêõóôåúíáéìßá. ÁíÜëïãá åõñÞìáôá óõíáíôÜìå êáé óôç ìåëÝôç British United Provident Association Study ìå 21.520 Üôïìá3. Óå 229 Üíäñåò ðïõ áðåâßùóáí áðü éó÷áéìéêÞ êáñäéïðÜèåéá óôç äéÜñêåéá ôçò ðáñáêïëïýèçóçò, ÷ùñßò ðñïçãïýìåíï éóôïñéêü, âñÝèçêáí õøçëüôåñá åðßðåäá Hcy óå ó÷Ýóç ìå áíôßóôïé÷ïõò ìÜñôõñåò.

Ìåôáâïëéóìüò ïìïêõóôåÀíçò Ç ïìïêõóôåÀíç åßíáé èåéïý÷ï áìéíïîý -ìç áðáñáßôçôï- ðïõ ó÷çìáôßæåôáé êáôÜ ôïí ìåôáâïëéóìü ôçò ìåèåéïíßíçò. Óôç óõíÝ÷åéá ìðïñåß íá áêïëïõèÞóåé: • Åðáíáìåèõëßùóç: ìåôáâïëßæåôáé óå ìåèåéïíßíç. 83

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

• Äéáóïõëöõëßùóç: ãßíåôáé õäñüëõóç ðñïò ãëïõôáèåéüíç êáé Üëëåò èåéïý÷åò åíþóåéò ðïõ áðïâÜëëïíôáé ìå ôá ïýñá. ÔéìÝò ïìïêõóôåÀíçò ðëÜóìáôïò Ïé áðïäåêôÝò ôéìÝò ôçò óôï ðëÜóìá êõìáßíïíôáé ìåôáîý 5-15 mmol/L óå êáôÜóôáóç íçóôåßáò13. Ï Kang êáé óõí.14 üñéóáí ôçí õðåñïìïêõóôåúíáéìßá ùò: • Þðéá (óõãêÝíôñùóç 15-30 mmol/L), • ìÝôñéá (óõãêÝíôñùóç 30-100 mmol/L), • âáñéÜ (óõãêÝíôñùóç >100 mmol/L). Áßôéá áýîçóçò ôçò ïìïêõóôåÀíçò Ôá áßôéá áýîçóçò ôùí ôéìþí ôçò ïìïêõóôåÀíçò äéáêñßíïíôáé óå: Á. ÃåíåôéêÜ. ÓõããåíÞò áíåðÜñêåéá åíæýìùí ôïõ ìåôáâïëéóìïý, ìåôáëëÜîåéò. Â. ÄéáôñïöéêÜ. ÄéáôñïöéêÞ áíåðÜñêåéá âéôáìéíþí B6, B12, öõëéêïý ïîÝïò. Åðßóçò, Üëëåò êáôáóôÜóåéò Þ ÷áñáêôçñéóôéêÜ ðïõ óõíäÝïíôáé ìå õðåñïìïêõóôåúíáéìßá åßíáé: • Öýëï (Üññåíåò) • Çëéêßá (ÌåãÜëç çëéêßá) • ÊÜðíéóìá • ÁñôçñéáêÞ ÕðÝñôáóç • ×ñüíéá íåöñéêÞ áíåðÜñêåéá • Õðïèõñåïåéäéóìüò • Ðá÷õóáñêßá • Áëêïüë • ÊáêïÞèçò áíáéìßá • Ca ìáóôïý, ùïèçêþí, ðáãêñÝáôïò • Ïîåßá ËåìöïãåíÞò Ëåõ÷áéìßá • ÌåèïôñåîÜôç, öõíõíôïÀíç, èåïöõëëßíç, ðõñéäïîßíç ê.ëð. ÅëëçíéêÜ äåäïìÝíá Áí êáé ç Ýñåõíá óôç ÷þñá ìáò åßíáé ãíùóôü üôé õóôåñåß óå åðßðåäï ìåãÜëùí åðéäçìéïëïãéêþí ìåëåôþí, õðÜñ÷ïõí åíäéáöÝñïíôá êáé ðñüóöáôá äåäïìÝíá ãéá ôçí ïìïêõóôåÀíç. Ç ìåëÝôç ÁÔÔÉÊÇ15,16 åßíáé ìéá ðñïïðôéêÞ ìåëÝôç âáóéóìÝíç óôïí ðëçèõóìü óôçí ïðïßá óõììåôåß÷áí ðåñßðïõ 3.000 Üíäñåò êáé ãõíáßêåò áðü ôçí åõñýôåñç ðåñéï÷Þ 84

Á. ÆåúìðÝêçò êáé óõí.

ôùí Áèçíþí. Óôç ìåëÝôç áõôÞ äéáðéóôþóáìå üôé ôá åðßðåäá ïìïêõóôåÀíçò Þôáí óçìáíôéêÜ õøçëüôåñá óôïõò êáðíéóôÝò óå óýãêñéóç ìå áõôÜ ôùí ðñþçí Þ ôùí ìç êáðíéóôþí (13,5±4,5 Ýíáíôé 12,8±3,2 Ýíáíôé 12,1±3,1 mmol/L, P<0,01) åíþ âñÝèçêå üôé Ý÷ïõí ó÷Ýóç êáé ìå ôï öýëï (Üíäñåò: 12,9±4,5 Ýíáíôé ãõíáéêþí: 10,4±3,1 mmol/L, Ñ<0.01). Åðßóçò ç óõãêÝíôñùóç ïìïêõóôåÀíçò áõîÜíåé ìå ôçí çëéêßá (+10% áíÜ 10 ÷ñüíéá, P<0,05) êáé ìå ôçí áýîçóç ôïõ äåßêôç óùìáôéêÞò ìÜæáò (+4% áíÜ 5-Kg/m2, P<0,05). Áêüìç, Üôïìá ìå áõîçìÝíç ôçí áñôçñéáêÞ ðßåóç ôïõ áßìáôïò ðáñïõóéÜæïõí áõîçìÝíåò ôéìÝò ïìïêõóôåÀíçò. ÈåôéêÞ óõó÷Ýôéóç âñÝèçêå åðßóçò ìåôáîý ôçò Apo-B êáé ôçò ïìïêõóôåÀíçò (+7% áíÜ 20-mg/dl áýîçóç óôçí Apo-B, P<0,001) êáé ôçò ïëéêÞò ÷ïëçóôåñüëçò ìå ôçí ïìïêõóôåÀíç (+2% áíÜ 20-mg/dl áýîçóç óôçí ïëéêÞ ÷ïëçóôåñüëç, P<0,05). ÅíäéáöÝñïõóá åßíáé ìéá ðñüóöáôç ðåñéãñáöéêÞ ìåëÝôç áðü ôç ðåñéï÷Þ ôçò ÊñÞôçò, ìå äåßãìá 854 áôüìùí ôïõ åíÞëéêïõ ðëçèõóìïý. Ôá êýñéá åõñÞìáôá ôçò ìåëÝôçò åßíáé üôé ç ìÝóç ôéìÞ Hcy âñÝèçêå ßóç ìå 13,3 mmol/lt åíþ áõôÞ óõó÷åôßóôçêå èåôéêÜ ìå ôçí çëéêßá, ôï öýëï, ôç óõóôïëéêÞ áñôçñéáêÞ ðßåóç êáé áñíçôéêÜ ìå ôïí áñéèìü ôùí ôóéãÜñùí, ôï öõëéêü ïîý, ôéò âéôáìßíåò Â1 êáé Â6, ôçí ðá÷õóáñêßá, ôçí ïëéêÞ êáé LDL-÷ïëçóôåñüëç. Íá óçìåéùèåß üôé ïé ßäéïé ïé óõããñáöåßò åðéöõëÜóóïíôáé ãéá ôçí áíôéðñïóùðåõôéêüôçôá ôïõ äåßãìáôïò ôïõò êáèþò áðïôåëåßôáé êõñßùò áðü ðñïóùðéêü Íïóïêïìåßïõ, öïéôçôÝò/öïéôÞôñéåò, êáôïßêïõò óõãêåêñéìÝíçò áãñïôéêÞò ðåñéï÷Þò êáé åðéæþíôåò çëéêéùìÝíïõò áðü ôç ìåëÝôç ôùí ÅðôÜ ×ùñþí17. ÓõìðÝñáóìá ÐïëëÝò ðñïïðôéêÝò ìåëÝôåò áëëÜ êõñßùò ìåëÝôåò áóèåíþí-ìáñôýñùí Ý÷ïõí äåßîåé üôé ìßá ìåôñßùò õøçëÞ óõãêÝíôñùóç ïìïêõóôåÀíçò áðïôåëåß áíåîÜñôçôï ðáñÜãïíôá êéíäýíïõ ãéá êáñäéáããåéáêÜ íïóÞìáôá. Ïé óõãêåíôñþóåéò ïìïêõóôåÀíçò åßíáé õøçëüôåñåò óå áóèåíåßò ìå íïóÞìáôá ôùí ðåñéöåñåéáêþí áããåßùí, ôùí åãêåöáëéêþí áããåßùí êáé óôåöáíéáßá íüóï óå ó÷Ýóç ìå õãéåßò. Ç ïìïêõóôåÀíç åõíïåß ôçí áñôçñéïóêëÞñõíóç ìÝóù ðïéêßëùí ìç÷áíéóìþí. Ùóôüóï, äåí åßíáé áêüìç îåêÜèáñï áí ç ßäéá ç ïìïêõóôåÀíç Þ Ýíáò ìåôáâïëßôçò ôçò Þ êÜðïéïò óõìðáñÜãïíôáò ôçò åõèýíåôáé ðñùôßóôùò ãéá ôçí áèçñùìáôéêÞ

Á. ÆåúìðÝêçò êáé óõí.

åðßäñáóç óôïí ïñãáíéóìü. Ðñéí íá åöáñìïóôåß ï ðñïëçðôéêüò Ýëåã÷ïò ãéá äåõôåñïãåíÞ Þ êáé ðñùôïãåíÞ ðñüëçøç, èá ðñÝðåé íá ðñïêýøïõí áóöáëÞ óõìðåñÜóìáôá ôçò áðïôåëåóìáôéêüôçôáò ìéáò èåñáðåõôéêÞò ðáñÝìâáóçò. Ç ëÞøç âéôáìéíþí ùò óõìðëçñþìáôá äéáôñïöÞò äåß÷íåé íá ìåéþíåé Þ êáé íá åðáíáöÝñåé óôá öõóéïëïãéêÜ åðßðåäá ôç óõãêÝíôñùóç ïìïêõóôåÀíçò óôéò ðåñéóóüôåñåò ðåñéðôþóåéò. Ùóôüóï, ãéá íá êáèïñéóôåß ç åðßäñáóç ôçò ëÞøçò âéôáìéíþí óôç íïóçñüôçôá êáé èíçóéìüôçôá áðü êáñäéáããåéáêÜ íïóÞìáôá áðáéôïýíôáé ðñïïðôéêÝò êáé ôõ÷áéïðïéçìÝíåò (ìå óêïðü ôçí áýîçóç ôçò óôáôéóôéêÞò áîßáò ôùí áðïôåëåóìÜôùí) êëéíéêÝò äïêéìÝò18. ÌÝ÷ñé íá ðñïêýøïõí óõìðåñÜóìáôá áðü ôéò ìåëÝôåò ðáñÝìâáóçò êáé ßóùò óáöåßò êáôåõèõíôÞñéåò ïäçãßåò ãéá ôïí Ýëåã÷ï ôçò õðåñïìïêõóôåÀíáéìßáò, áðü äéåèíþò áíáãíùñéóìÝíïõò Éáôñéêïýò öïñåßò, ïé ãéáôñïß ðïõ áóêïýí ÐñïëçðôéêÞ ÉáôñéêÞ êáé êýñéá ïé Ãåíéêïß Éáôñïß èá ðñÝðåé íá óõóôÞíïõí Ýëåã÷ï êáé èåñáðåßá üëùí ôùí êáèéåñùìÝíùí ðáñáãüíôùí êáñäéáããåéáêïý êéíäýíïõ êáé íá ôïíßæïõí åðßóçò ôçí áíÜãêç ãéá õéïèÝôçóç ÌåóïãåéáêÞò ÄéáôñïöÞò, ç ïðïßá êáèþò åßíáé ðëïýóéá óå âéôáìßíç êáé öõëéêü áðïôåëåß Ýíá áóöáëÝò ðñïëçðôéêü ìÝôñï åëÜôôùóçò ôçò ïìïêõóôåÀíçò ðáñÝ÷ïíôáò ðñïóôáóßá áðü ôçí êáñäéáããåéáêÞ íüóï19. Âéâëéïãñáößá 1. McCully KS. Vascular pathology of homocysteinemia: implications for the pathogenesis of arteriosclerosis. Am J Pathol 56:111-28, 1969. 2. Stampfer MJ, Malinow MR, Willett WC, Newcomer LM, Upson B, Ullmann D, Tishler PV, Hennekens CHA. prospective study of plasma homocysteine and risk of myocardial infarction in US physicians. J Am Med Assoc, 268:877-881, 1992. 3. Wald NJ, Watt HC, Law MR, Weir DG, McPartlin J, Scott JM. Homocysteine and ischemic heart disease: results of a prospective study with implications regarding prevention. Arch Intern Med, 158:862-867, 1998. 4. Knekt P, Reunanen A, Alfthan G, Heliovaara M, Rissanen H, Marniemi J, Aromaa A. Hyperhomocystenemia. A risk factor or a consequence of coronary heart disease? Arch Intern Med 161: 1589-1594, 2001. 5. Stehower CD, Weijenberg MP, Van den Berg M, Jacobs C, Feskens EJ, Kromhout D. Serum

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reactive protein, white cell blood count, serum amyloid A, and fibrinogen) in healthy subjects. Am J Cardiol, 91:368-70, 2003. 17. ×áôæÞò ×, ÌðåñôóéÜò Ã, ËéíáñäÜêçò Ì, Scott J, ÊáöÜôïò Á. Ðñïóäéïñéóìüò åðéðÝäùí ïëéêÞò ïìïêõóôåÀíçò, öõëéêïý ïîÝùò êáé âéôáìßíçò Â12 ïñïý óå õãéÞ åíÞëéêï ðëçèõóìü ôçò ÊñÞôçò. ÉáôñéêÞ, 85:293-304, 2004. 18. Kuller LH, Evans RW. Homocysteine, Vitamins

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Ôüìïò 18, Ôåý÷ïò 2, 2006

ÁÍÁÖÏÑÁ ÐÅÑÉÐÔÙÓÇÓ CASE REPORT Primary Heatlh Care, Volume 18, Number 2, 87-90, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 87-90, 2006

Ðåñßðôùóç áóèåíïýò ìå óýíäñïìï Marfan êáé ïîý äéá÷ùñéóìü ôçò áïñôÞò. ÄéáãíùóôéêÞ ðáñÝìâáóç óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò Å. ËáìðñïãéáííÜêçò1, Á. ÂáóéëÜêç2, Ê. ÌáêñÞ2, Ã. AðïóôïëÜêçò1, Á. ÖèåíÜêçò3, Ê. ÌåïäÜíçò1, Á. ÄåñìéôæÜêçò1

Ðåñßëçøç ÐáñïõóéÜæåôáé ðåñßðôùóç áóèåíïýò ìå óýíäñïìï Marfan êáé ïîý äéá÷ùñéóìü ôçò áïñôÞò, ç ïðïßá ðñïóÞëèå óôï ÊÝíôñï Õãåßáò (Ê.Õ.) ôçò ðåñéï÷Þò ôçò ìå Üôõðá óõìðôþìáôá üðùò ôÜóç ãéá ëéðïèõìßá êáé èùñáêéêü Üëãïò. Ï öáéíüôõðïò ôçò áóèåíïýò, íåáñÞ, øçëÞ ìå áñá÷íïäáêôõëßá, óêáöïåéäÞ êáé óôåíü èþñáêá, Ýèåóå ôçí õðïøßá óôïí ãéáôñü ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò ãéá ôçí ýðáñîç ôïõ óõíäñüìïõ êáé ãéá ôï åßäïò ôïõ ïîÝïò óõìâÜìáôïò. Ç óõ÷íüôçôá ôïõ ó. Marfan óôï ãåíéêü ðëçèõóìü õðïëïãßæåôáé óôéò 1/10.000 áíåîÜñôçôá áðü åèíéêüôçôá, öýëëï êáé öõëÞ. Åßíáé ç ðéï óõ÷íÞ êëçñïíïìéêÞ äéáôáñá÷Þ ôïõ óõíäåôéêïý éóôïý. Ç ìÝóç çëéêßá Ýíáñîçò ôùí óõìðôùìÜôùí åßíáé ç äåýôåñç Þ ç ôñßôç äåêáåôßá ôçò æùÞò éäéáßôåñá üóïí áöïñÜ ôéò äéáôáñá÷Ýò ôçò áïñôÞò. H äéÜãíùóç Ýãéíå áñ÷éêÜ áðü ôïí ãéáôñü ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, óôç óõíÝ÷åéá ç áóèåíÞò ìåôáöÝñèçêå óôï åöçìåñåýïí íïóïêïìåßï êáé áðü åêåß óå êáñäéï÷åéñïõñãéêü êÝíôñï üðïõ õðïâëÞèçêå óå áíôéêáôÜóôáóç ôçò áíéïýóáò áïñôÞò. Óôï åðüìåíï äéÜóôçìá åíôïðßóèçêáí Üëëá ôñßá ìÝëç ôçò ïéêïãÝíåéáò ìå ó. Marfan ôá ïðïßá áíôéìåôùðßóèçêáí ìå öáñìáêåõôéêÞ áãùãÞ (ôá äýï) êáé ÷åéñïõñãéêÜ ôï ôñßôï.

ÊáñäéïëïãéêÞ ÊëéíéêÞ, ÂåíéæÝëåéï Íïóïêïìåßï Çñáêëåßïõ, 2Ðåñéöåñéêü Éáôñåßï Åðéóêüðçò Çñáêëåßïõ 3ÊÝíôñï Õãåßáò Êáóôåëëßïõ Çñáêëåßïõ 1

ÅéóáãùãÞ Ôï Óýíäñïìï Marfan (ÓÌ) áðïôåëåß ôçí ðéï óõ÷íÞ êëçñïíïìéêÞ äéáôáñá÷Þ ôïõ óõíäåôéêïý éóôïý 1. ÌåôáâéâÜæåôáé ìå ôïí áõôïóùìáôéêü åðéêñáôïýíôá ÷áñáêôÞñá. ×áñáêôçñßæåôáé áðü ìõïóêåëåôéêÝò áíùìáëßåò, åêäçëþóåéò áðü ôïõò ïöèáëìïýò, ôï êåíôñéêü íåõñéêü óýóôçìá, ôï äÝñìá, ôïõò ðíåýìïíåò êáé ôï êáñäéáããåéáêü óýóôçìá (áíåýñõóìá èùñáêéêÞò áïñôÞò, ðñüðôùóç ìéôñïåéäïýò êáé ôñéãëþ÷éíïò âáëâßäáò ê.á)2. Ôá ÷áñáêôçñéóôéêÜ éóôïëïãéêÜ åõñÞìáôá ôïõ óõíäñüìïõ åßíáé o êáôáêåñìáôéóìüò êáé ç áðïäéïñãÜíùóç ôùí åëáóôéêþí éíþí ôïõ ìÝóïõ ÷éôþíá ôçò áïñôÞò3. Ç óõ÷íüôçôá ôïõ óôï ãåíéêü ðëçèõóìü õðïëïãßæåôáé óôéò 1/10.000 áíåîÜñôçôá áðü åèíéêüôçôá, öýëï êáé öõëÞ4. Ç ìÝóç çëéêßá Ýíáñîçò ôùí óõìðôùìÜôùí ËÝîåéò êëåéäéÜ: ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, óýíäñïìï Marfan, äéá÷ùñéóôéêü áíåýñõóìá áïñôÞò. ÕðïâëÞèçêå: 10 ÌáÀïõ 2006 ÅðáíõðïâëÞèçêå: 25 ÌáÀïõ 2006 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 1 Éïõíßïõ 2006 Õðåýèõíïò áëëçëïãñáößáò: ËáìðñïãéáííÜêçò ÅììáíïõÞë, Éáôñüò Êáñäéïëüãïò, Ä/íóÞ Äõññá÷ßïõ 12, ÔÊ 71307, ÇñÜêëåéï, ÊñÞôç. ôçë.: (2810) 211674, 6942065063, e-mail: mlamprog@yahoo.gr 87

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Case of a patient with marfan syndrome and acute aortic dissection. diagnostic intervention in primary health care. E. Lamprogiannakis1, A. Vasilaki2, K. Makri2, G. Apostolakis1, A. Fthenakis2, K. Meidanis1, A. Dermitzakis1

Å. ËáìðñïãéáííÜêçò êáé óõí.

ÐåñéãñáöÞ ðåñßðôùóçò

Ç áóèåíÞò 24 åôþí ðñïóÞëèå óôï ÊÝíôñï Õãåßáò (Êáóôåëëßïõ) êáôÜ ôç äéÜñêåéá ôçò åöçìåñßáò, áíáöÝñïíôáò Summary We report a case of a female patient with Marfan syndrome and acute aortic ðñï ìéáò þñáò åðåéóüäéï èùñáêéêïý dissection. She arrived in the Health Center with atypical symptoms of tendency Üëãïõò äéÜñêåéáò ðåñßðïõ 10 ëåðôþí, for syncope and thoracic pain. She was young, tall, with arachnodaktyly, skaóõíïäåõüìåíï áðü áéìùäßá Üíù Üêñùí phoid, narrow thorax, with a loud diastolic aortic murmur, so placed suspicion êáé èÜìâïò üñáóçò. ÊáôÜ ôçí ðñïóÝin the doctor of the primary health care for the existence of the syndrome and ëåõóç ôçò Þôáí áóõìðôùìáôéêÞ. Åß÷å for the type of the acute event. The frequency of the syndrome in the general population is calculated in the 1/10.000 independent of nationality, gender and åëåýèåñï áôïìéêü áíáìíçóôéêü êáé race. It is the most frequent hereditary disturbance of connective tissue. The äåí ëÜìâáíå êÜðïéá öáñìáêåõôéêÞ median age of the beginning of symptoms is the second or third decade of life, áãùãÞ. Áðü ôçí êëéíéêÞ åîÝôáóç particularly with regard to the disturbances of aorta. The diagnosis came initially äéáðéóôþèçêáí ôá áêüëïõèá: ìåãÜëï from the doctor of the primary health care, then the patient was transported to áíÜóôçìá ìå ýøïò 1,90 m êáé âÜñïò the being on duty hospital and from there in a heart surgery center. There she underwent in replacement of ascending aorta. Later, three other three members 70 Kgr, ìáêñéÜ Üêñá, ëåðôüò êïñìüò, of the family with Marfans syndrome where identied two of which were dealt with áñá÷íïäá÷ôõëßá, åëáöñÜ êýöùóç, óêápharmacologically the third surgically. öïåéäÞò êáé óôåíüò èþñáêáò, åðßóçò Key Words: primary health care, syndrome, aneurysm dissectig. åß÷å ìõùðßá. ÁñôçñéáêÞ Ðßåóç: 120/70 mmHg, êáñäéáêÞ óõ÷íüôçôá 90/min, ñõèìéêïß êáñäéáêïß ôüíïé, Ýíôïíï (4/6) 1 Cardiologic Clinic, Venizelion Hospital, Heraklion, Crete. 2Community Clinic Of Episkopi äéáóôïëéêü öýóçìá êõñßùò óôçí åóôßá - Health Center Kastelliu Heraklion ôçò áïñôéêÞò âáëâßäáò, öõóéïëïãéêü áíáðíåõóôéêü øéèýñéóìá êáé çëåêôñïåßíáé ç äåýôåñç Þ ç ôñßôç äåêáåôßá ôçò æùÞò éäé- êáñäéïãñÜöçìá ìå öëåâïêïìâéêü ñõèìü ÷ùñßò áßôåñá üóïí áöïñÜ ôéò äéáôáñá÷Ýò ôçò áïñôÞò5. åéäéêÝò áëëïéþóåéò. Åêôüò áðü ôçí åðéññÝðåéá ðñïò ôïí ó÷çÁðü ôç ïéêïãåíåéáêü éóôïñéêü ðñïÝêõøå üôé ìáôéóìü áíåõñõóìÜôùí ôçò èùñáêéêÞò áïñôÞò ç áóèåíÞò åß÷å Ýíáí äßäõìï áäåëöü ýøïõò 1.95 ïé áóèåíåßò ìå ÓÌ äéáôñÝ÷ïõí õøçëü êßíäõíï m êáé âÜñïõò 75 Kgr êáé Ýíáí áêüìá çëéêßáò äéá÷ùñéóìïý Þ ñÞîçò ôçò áïñôÞò – éäßùò ôïõ åã- 25 åôþí ìå ðáñüìïéåò óêåëåôéêÝò áíùìáëßåò êáé ãýò ôìÞìáôïò áõôÞò – óå ó÷åôéêÜ ìéêñÞ çëéêßá6. ìåãÜëï áíÜóôçìá (ýøïò 1.95 m, âÜñïò 77 Kgr). ÐñáãìáôéêÜ ôï ÓÌ åõèýíåôáé ãéá ôï 6 – 9% üëùí Áðü ôïõò ãïíåßò ï ðáôÝñáò, 63 åôþí, åß÷å Ýíôïíç ôùí ðåñéðôþóåùí äéá÷ùñéóìïý ôçò áïñôÞò7,8. ðáñáìüñöùóç ôïõ èùñáêéêïý êëùâïý, Þôáí øçëüò ÐáñïõóéÜæïõìå ôçí ðåñßðôùóç íåáñÞò ãõíáß- (1,87 m) êáé ëåðôüò (73 Kgr) åíþ ç ìçôÝñá äåí êáò 24 åôþí ìå ÓÌ, ðïõ äéáãíþóèçêå ãéá ðñþôç ðáñïõóßáæå ðáñüìïéåò äéáôáñá÷Ýò. Ç ðáñïõóßá öïñÜ áðü ôï ãéáôñü ôçò ðñùôïâÜèìéáò öñïíôßäáò áõôïý ôïõ öáéíïôýðïõ óôçí áóèåíÞ óå óõíäõáóìü õãåßáò üôáí õðÝóôç ïîý äéá÷ùñéóìü ôçò áïñôÞò ìå ôï ïéêïãåíåéáêü éóôïñéêü, Ýêáíå ôç äéÜãíùóç êáé ïäÞãçóå óôç äéÜãíùóç ôïõ óõíäñüìïõ êáé ôïõ ÓÌ ó÷åäüí âÝâáéç, åíþ ç óõìðôùìáôïëïãßá óå Üëëá ôñßá ìÝëç ôçò ïéêïãÝíåéáò ôçò ôá ïðïßá ôçò óå óõíäõáóìü ìå ôá êëéíéêÜ åõñÞìáôá Ýèåóå ðáñüôé Þôáí åíÞëéêá ðáñÝìåíáí åðßóçò áäéÜãíù- áìÝóùò óôïí åöçìåñåýïíôá ãåíéêü éáôñü ôç óïâáóôá ùò ôüôå. ñÞ õðïøßá ôïõ ïîÝïò äéá÷ùñéóìïý ôçò áïñôÞò. Óêïðüò ôçò åñãáóßáò áõôÞò åßíáé, ìå ôçí Ç áóèåíÞò ìåôáöÝñèçêå óôï åöçìåñåýùí åõêáéñßá ôçò ðáñïõóßáóçò ôïõ ðåñéóôáôéêïý íá íïóïêïìåßï üðïõ õðïâëÞèçêå óå õðåñç÷ïêáñäéïôïíßóåé ðüóï êáèïñéóôéêüò åßíáé ï ñüëïò ôïõ ãéá- ãñÜöçìá ôï ïðïßï áðåêÜëõøå: äéÜôáóç áïñôéêÞò ôñïý ôçò ðñùôïâÜèìéáò õãåßáò, óôç äéÜãíùóç, ñßæáò, áíåõñõóìáôéêÞ äéÜôáóç áïñôÞò äéáìÝôñïõ áíôéìåôþðéóç áëëÜ êáé óôç äéá÷åßñéóç ðáñüìïéùí 5,5 cm ìå ìÝôñéá ðñïò óïâáñÞ áíåðÜñêåéá êáé ðåñéóôáôéêþí ìå ôç ðáñÝìâáóç ôïõ óôçí ïéêïãÝ- êõìáôéóìü ôïõ êñçìíïý ôïõ Ýóù ÷éôþíá ôçò óôïí íåéá êáé óôçí êïéíüôçôá. áõëü ôïõ áããåßïõ, ìå äéá÷ùñéóìü ôïõ áëçèïýò áðü ôï øåõäÞ áõëü. Ôï åýñçìá áõôü èåùñåßôáé äéáãíùóôéêü ôïõ ïîÝïò äéá÷ùñéóìïý ôçò ÁïñôÞò. 88

Å. ËáìðñïãéáííÜêçò êáé óõí.

Ïé êáñäéáêÝò êïéëüôçôåò åß÷áí öõóéïëïãéêü ìÝãåèïò ìå êáëÞ ëåéôïõñãéêüôçôá ôçò áñéóôåñÞò Êïéëßáò. Ç äéÜãíùóç åðéâåâáéþèçêå ìå áîïíéêÞ ôïìïãñáößá ìå óêéáãñáöéêü. Ç áóèåíÞò ìåôáöÝñèçêå åðåéãüíôùò óå êáñäéï÷åéñïõñãéêü êÝíôñï üðïõ õðïâëÞèçêå óå áíôéêáôÜóôáóç ôçò áíéïýóáò áïñôÞò ìå óõíèåôéêü óùëçíùôü ìüó÷åõìá ìå äéáôÞñçóç ôçò öõóéêÞò áïñôéêÞò âáëâßäáò. ÔÝèçêå óå öáñìáêåõôéêÞ áãùãÞ ìå êïõìáñéíéêÜ áíôéðçêôéêÜ, áíáóôïëÝá ôïõ Ìåôáôñåðôéêüõ Åíæýìïõ (á-ÌÅÁ) êáé â-ÁíáóôïëÝá. Ðáñáêïëïõèåßôáé Ýêôïôå ãéá 5, Ýôç êëéíéêÜ, õðåñç÷ïêáñäéïãñáöéêÜ êáé ìå ìáãíçôéêÞ ôïìïãñáößá. Åßíáé áóõìðôùìáôéêÞ, üìùò ðáñïõóéÜæåé ìéêñïý âáèìïý áíåðÜñêåéá áïñôÞò. Ôá õðüëïéðá ìÝëç ôçò ïéêïãÝíåéáò åêëÞèçóáí óôï Ê.Õ üðïõ õðïâëÞèçêáí óå ëåðôïìåñÞ êëéíéêÞ åîÝôáóç, ÇÊÃ êáé áêôéíïãñáößá èþñáêïò. Ïé ìõïóêåëåôéêÝò áíùìáëßåò ðïõ äéáðéóôþèçêáí óõíçãïñïýóáí óôç äéÜãíùóç ôïõ ÓÌ óôïí ðáôÝñá êáé óôïõò áäåëöïýò ôçò, êÜôé ôï ïðïßï äåí ãíþñéæáí ùò ôüôå. 1⁄4ëïé ðáñáðÝìöèçêáí ãéá õðåñç÷ïêáñäéïãñÜöçìá êáé êáñäéïëïãéêÞ åîÝôáóç ðïõ åðéâåâáßùóáí ôçí ðáñáðÜíù äéÜãíùóç. Óôïí ðáôÝñá áðïêáëýöèçêå åõìÝãåèåò áíåýñõóìá áïñôÞò (äéáìÝôñïõ 5,5 cm) ìå óïâáñÞ áíåðÜñêåéáò ôçò âáëâßäáò. Óôç óõíÝ÷åéá êáé áõôüò õðïâëÞèçêå óå áíôéêáôÜóôáóç ôçò áíéïýóáò áïñôÞò êáé ôçò áïñôéêÞò âáëâßäáò ìå âáëâéäïöüñï óõíèåôéêü ìüó÷åõìá. Áðü ôç ðáñáêïëïýèçóç ôïõ ùò óÞìåñá åßíáé áóõìðôùìáôéêüò ìå êáëÞ ëåéôïõñãßá ôçò ìç÷áíéêÞò âáëâßäáò êáé ôçò áñéóôåñÞò êïéëßáò. Óôïõò áäåëöïýò ôçò äéáðéóôþèçêå Þðéá äéÜôáóç ôçò áïñôÞò (4,2–4,4 cm) ìå Þðéá áóâÝóôùóç êáé Ýêêåíôñç óýãêëåéóç ôçò áïñôéêÞò âáëâßäáò, ðñüðôùóç ìéôñïåéäïýò êáé ôñéãëþ÷éíïò âáëâßäáò, êáé êáëÞ ëåéôïõñãéêüôçôá ôçò áñéóôåñÞò êïéëßáò. Áõôïß ôÝèçêáí óå öáñìáêåõôéêÞ áãùãÞ ìå á-ÌÅÁ êáé â-ÁíáóôïëÝá, ðáñáêïëïõèïýíôáé ôáêôéêÜ êáé ðáñáìÝíïõí áóõìôùìáôéêïß ùò óÞìåñá. ÓõæÞôçóç Ç ðéï óõ÷íÞ (35%) êáñäéïáããåéáêÞ áíùìáëßá óôï ÓÌ, ç ïðïßá êáé ðáñáôçñÞèçêå óôïõò áäåëöïýò ôçò áóèåíïýò, åßíáé ç ðñüðôùóç ìéôñïåéäïýò âáëâßäáò ðïõ ìðïñåß íá ïäçãÞóåé óå óïâáñÞ áíåðÜñêåéá ôçò. Áêïëïõèïýí óå óõ÷íüôçôá åìöÜíéóçò ç ðñïïäåõôéêÞ äéÜôáóç ôùí êüëðùí

Ôüìïò 18, Ôåý÷ïò 2, 2006

ôïõ Valsava ðïõ ðñïêáëåß áíåðÜñêåéá áïñôÞò (15%-44%), ç äéÜôáóç ôçò áïñôéêÞò ñßæáò êáé ôïõ åããýò ôìÞìáôïò ôçò áíéïýóáò áïñôÞò9-11 (áíåýñõóìá áïñôÞò). Ç ôåëåõôáßá áõôÞ äéáôáñá÷Þ, óå ìåãáëýôåñï Þ ìéêñüôåñï âáèìü, õðÞñ÷å óå üëá ôá ìÝëç, ìå öáéíüôõðï ÓÌ, ôçò ïéêïãÝíåéáò ôçò. Ç ðéï óõ÷íÞ êáé õðåýèõíç ãéá ðñþéìç èíçôüôçôá åðéðëïêÞ, åßíáé ç ñÞîç Þ ï äéá÷ùñéóìüò ôïõ áïñôéêïý áíåõñýóìáôïò ðïõ åßíáé óõíÞèùò ôýðïõ Á óôç ôáîéíüìçóç ôïõ Stanford Þ ôýðïõ É óôç ôáîéíüìçóç ôïõ DeBakey12,13. Ç èíçóéìüôçôá êáé óôéò äýï ðåñéðôþóåéò åßíáé õøçëÞ, ùò êáé 50%, ÷ùñßò Üìåóç ÷åéñïõñãéêÞ èåñáðåßá5,13. Äåí ðáñïõóéÜæïõí üëåò ïé ðåñéðôþóåéò äéá÷ùñéóìïý ôï ôõðéêü äéáó÷éóôéêü èùñáêéêü Üëãïò ìå áíôáíÜêëáóç óôç ñÜ÷ç. ÏñéóìÝíïé åêôåôáìÝíïé äéá÷ùñéóìïß óôï ÓÌ Ý÷ïõí óõìâåß ÷ùñßò ðüíï14. ÁóèåíÞò, íåáñüò, øçëüò, ìýùðáò ìå Üôõðá åíï÷ëÞìáôá, üðùò ôÜóç ðñïò ëéðïèõìßá, èùñáêéêü Þ êïéëéáêü Üëãïò, Þ öýóçìá áïñôéêÞò áíåðÜñêåéáò èá ðñÝðåé íá äçìéïõñãåß Üìåóá ôçí õðïøßá óôïí ãéáôñü ãéá áóèåíÞ ìå ÓÌ. Ïé Þäç äéáãíùóìÝíïé áóèåíåßò ðñÝðåé íá åíçìåñþíïíôáé ãéá ôá óõìðôþìáôá ôïõ äéá÷ùñéóìïý ôçò áïñôÞò. Åðßóçò ïé óõããåíåßò ôïõò ðñÝðåé íá õðïâÜëëïíôáé óå ëåðôïìåñÞ Ýëåã÷ï ãéá ôõ÷üí áðïêÜëõøç ôïõ ÓÌ êáé óå áõôïýò üðùò êáé Ýãéíå óôç ïéêïãÝíåéá ðïõ åîåôÜæïõìå. Ç èåñáðåßá ôïõ äéá÷ùñéóìïý ôçò áïñôÞò åßíáé ç åðåßãïõóá ÷åéñïõñãéêÞ áíôéêáôÜóôáóç ôçò áíéïýóáò áïñôÞò ìå óõíèåôéêü ìüó÷åõìá âáëâéäïöüñï Þ ìç. Óôç óõíÝ÷åéá ç ôáêôéêÞ ðáñáêïëïýèçóç êáé ìå ìáãíçôéêÞ ôïìïãñáößá åßíáé áðáñáßôçôç, åðåéäÞ ç äéÜìåôñïò êÜèå ôìÞìáôïò ôçò áïñôÞò Ý÷åé ôçí ôÜóç íá áõîÜíåôáé ìå ôç ðÜñïäï ôïõ ÷ñüíïõ, êÜôé ðïõ åßíáé äõíáôüí íá áðáéôÞóåé íÝá ÷åéñïõñãéêÞ åðÝìâáóç12,15,16. Áêñïãùíéáßïò ëßèïò óôç êáñäéïëïãéêÞ áíôéìåôþðéóç ôïõ ÓÌ åßíáé ç ôáêôéêÞ ç÷ïêáñäéïãñáöéêÞ ðáñáêïëïýèçóç ôùí ìåôáâïëþí ôçò äéáìÝôñïõ ôçò áïñôÞò, ç ìåßùóç ôçò óõóôïëéêÞò áñôçñéáêÞò ðßåóçò êáé ç ÷ïñÞãçóç â-áðïêëåéóôþí óå áñíçôéêÝò éíüôñïðåò äüóåéò, (óôü÷ïò êáñäéáêÞò óõ÷íüôçôáò çñåìßáò <70) ìå óêïðü ôç ìåßùóç ôïõ ñõèìïý äéÜôáóçò ôçò áïñôÞò êáé ôïõ êéíäýíïõ äéá÷ùñéóìïý17. Åðßóçò ãéá ôïí ßäéï ëüãï ðñÝðåé íá áðïöåýãåôáé ç éóïìåôñéêÞ (áíáåñüâéá) Üóêçóç êáèþò êáé ç Üóêçóç óå ìÝãéóôï åðßðåäï åíþ åßíáé áðáñáßôçôç ç ðñïöýëáîç êáôÜ ôçò åíäïêáñäßôéäáò óå êÜèå ïäïíôéáôñéêÞ Þ Üëëç åðåìâáôéêÞ ðñÜîç. Ç ðñïãñáììáôéóìÝíç ÷åéñïõñãéêÞ åðÝìâáóç óõíéóôÜôáé 89

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

óå áíåõñýóìáôá ôçò áïñôÞò áðü 5 – 5.5 cm óå äéÜìåôñï, áêüìá êáé óå áóõìðôùìáôéêïýò áóèåíåßò ìå ÓÌ, üðùò Þôáí ï ðáôÝñáò ôçò áóèåíïýò, ëüãù ôïõ õøçëïý êéíäýíïõ ñÞîçò Þ äéá÷ùñéóìïý5,6,13. Ïé ãõíáßêåò ìå ÓÌ Ý÷ïõí äýï ðñïâëÞìáôá ó÷åôéæüìåíá ìå ôçí åãêõìïóýíç. Ôï ðñþôï åßíáé ï êßíäõíïò 50% ìåôáâßâáóçò ôçò íüóïõ óôï êÜèå ðáéäß êáé ôï äåýôåñï åßíáé ï êßíäõíïò äéá÷ùñéóìïý éäßùò êáôÜ ôï ôåëåõôáßï ôñßìçíï ôçò êýçóçò, ôïí ôïêåôü êáé ôïí ðñþôï ìÞíá ôçò ëï÷åßáò. Ãõíáßêåò ìå äéÜôáóç áïñôÞò Üíù ôùí 4 cm ðñÝðåé íá óõìâïõëåýïíôáé íá áðïöåýãïõí ôçí åãêõìïóýíç18,19. O ãåíéêüò ãéáôñüò ìðïñåß íá ðáßîåé êáèïñéóôéêü ñüëï óôçí Ýãêáéñç äéÜãíùóç ôùí áóèåíþí ìå ÓÌ, óôç ôáêôéêÞ ðáñáêïëïýèçóç ôïõò êáé óôç ñýèìéóç ôçò öáñìáêåõôéêÞò áãùãÞò ãéá ôçí åðßôåõîç ôùí óôü÷ùí ôçò ÁÐ êáé ÊÓ, ìåéþíïíôáò Ýôóé ôç èíçóéìüôçôá ðïõ ïöåßëåôáé óôéò åðéðëïêÝò ôïõ. Åðßóçò óçìáíôéêüò åßíáé ï ñüëïò ôïõ óôçí áíß÷íåõóç ðáñüìïéùí áäéÜãíùóôùí ðåñéóôáôéêþí óôçí êïéíüôçôá êáèþò óôçí åíçìÝñùóç êáé êáèïäÞãçóç ôùí áóèåíþí ìå Þäç äéáãíùóìÝíï óýíäñïìï ãéá ôá óõìðôþìáôá ôùí åðéðëïêþí ôïõ áëëÜ êáé ãéá ôç ìåôáâïëÞ ôïõ ôñüðïõ æùÞò ôïõò.

Å. ËáìðñïãéáííÜêçò êáé óõí.

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Âéâëéïãñáößá 1. Fleisher KJ, Nousari HC, Anhalt CJ, Stone CD, Lascinger JC. immunohistochemical abnormalities of fibrilin in cardiovascular tissues in Marfan’s syndrome. Ann Thorac Surg, 63: 1012-7.1997. 2. Judge DP, Dietz HC. Marfan syndrome. Lancet, 366: 1965-76, 2005. 3. Ramirz F, Dietz HC. Therapy insight: aortic aneurysm and dissection in Marfan’s syndrome. Nat Clin Pract Cardiov Med, 1:31-6, 2004. 4. Cameron DE, Vricella LA. Semin. Valve-sparing aortic root replacement in Marfan syndrome. Thorac Cardiovasc Surg Pediatr Card Surg, 103111, 2005. 5. Gillnov AM, Zeher KJ, Redmond JM, et al. Cardiac operation in children with Marfan’s syndrome: indications and results. Ann. Thorac. Surg, 64: 1140-5, 2005. 6. Ohtsubo S, Itoh T. Sudden death and cardiovascular complications in Marfan syndrome: impact of surgical intervention. Nippon Rinsho. Jul; 63(7): 1201-6 2005. 7. Schmidt MA, Ensing GJ, Michels VV, Carter GA, Hagler DJ, Feldt RH. Autosomal dominant 90

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supravalvular aortic stenosis: Large three-generation family. Am J Med Genet., 32:384, 1989. Curran MW, Atkinson DL, Ewart AK, Morris CA, Leppert MF Keating MT: The elastin gene is disrupted by a translocation associated with supravalvular aortic stenosis. Cell, 73:159, 1993. Van Karnebeek CD, Naeff MS, Mulder FJ, Hennekam RC, Offringa M. Natural history of cardiovascular manifestations in Marfan syndrome. Arch Dis Child 84:129-137 2001. Marsalese D. L., Moodie D.S., Vacant M., Lytle BW, Gill CC, Sterba R, Cosgrone PM, Passalacqua M, Goomastic M, Kovacs A: Marfan’s syndrome: Natural history and long-term followup of cardiovascular involvement. J Am Coll Cardiol, 14:422, 1989. Child J.S., Perloff J.K., and Kaplan S. The heart of the matter: Cardiovascular involvement in Marfan’s syndrome. J. Am. Coll. Cardiol. 14:429, 1989. Milewicz D, Dietz H. Miller C. Treatment of Aortic Disease in patients with Marfan syndrome. Circulation, 111:e150-e157, 2005. Yoshinaga M, Oku S, Nagai E. A case of Marfan syndrome in adolescent with aortic dissection: should the recommendation for surgical intervention be changed? Ped Cardiol 20: 431-4, 1999. Gott VL, Cameron DE, Pyeritz RE, Cill MA, Greene PS, Stone CD, Alejo DE, McKusick IA: Composite graft repair of Marfan aneurysm of the ascending aorta: Results in 150 patients. J. Cardiovasc Surg 9:482, 1994. Scaefer S, Peshock RM, Malloy GR, Katz J, Parkey RW, Willerson JT: Nuclear magnetic resonance imaging in Marfan’s syndrome. J. Am. Coll. Cardiol, 9:70, 1987. Soulen RL, Fishman E., Pyeritz RE, Zernauri EA, Pessar ML: Evaluation of the Marfan syndrome: MR imaging versus CT. Radiology, 165: 697, 1987. Rossi-Foulkes R, Roman MJ,Rosen SE, KramerFox R, Ehlers KH, O;Loughlin JE, Davis JG, Devereux RB: Phenotypic features and impact of beta-blocker or calcium antagonist therapy on aortic lumen size in the Marfan syndrome. Am J Cardiol, 83:1364-1368, 1999. Lind J, Wallenburg HC: The Marfan syndrome and pregnancy: a retrospective study in Dutch population. Eur J Obstet Gynecol Reprod Biol, 98: 28-35, 2001. Rossiter JP, Morales AJ, Repke JT, Murphy EA, Pyeritz RE: prospective longitudinal evaluation of pregnancy in the Marfan syndrome. Am J Obstet. Gynecol 173:1599, 1995.

Ã. Ðáðáäüðïõëïò êáé óõí.

Ôüìïò 18, Ôåý÷ïò 2, 2006

ÁÍÁÖÏÑÁ ÐÅÑÉÐÔÙÓÇÓ CASE REPORT Primary Heatlh Care, Volume 18, Number 2, 91-94, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 91-94, 2006

Áíáöõëáîßá óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò: Ìéá åðåßãïõóá êáôÜóôáóç ðïõ êáëåßôáé íá áíôéìåôùðßóåé Üìåóá ï ãåíéêüò ãéáôñüò Ã. Ðáðáäüðïõëïò1, Ä. Ìðñßìçò1, Á. Ðñüêëïõ2, Á. ÐåôñïõëÜêç2, Á. ×ïõëÜêç2, Ç. Óáëïýóôñüò2

Ðåñßëçøç Ç áíáöõëáîßá êáé ç áíáöõëáêôïåéäÞò áíôßäñáóç öáßíåôáé üôé áõîÜíïõí ôá ôåëåõôáßá ÷ñüíéá ðáãêïóìßùò. Ôá êýñéá áßôéá óôïõò åíÞëéêåò åßíáé ôá öÜñìáêá, ôá ôñïöéêÜ áëëåñãéïãüíá êáé ôá äÞãìáôá åíôüìùí, åíþ óôá ðáéäéÜ êõñßùò ïé ôñïöÝò. Óå äéÜóôçìá ôñéþí ìçíþí ðñïóÞëèáí óôï éáôñåßï åðåéãüíôùí ðåñéóôáôéêþí ôïõ ÊÝíôñïõ Õãåßáò ×Üñáêá ðÝíôå áóèåíåßò ìå áíáöõëáîßá Ý÷ïíôáò äéáöïñåôéêÞ êëéíéêÞ åéêüíá êÜèå öïñÜ. Ç áíáöõëáîßá åßíáé óõ÷íÜ äýóêïëç óôç äéÜãíùóç ôçò êáé ðñÝðåé íá äéáöïñïäéáãíùóôåß áðü ôï Üóèìá, ôï êáñäéáêü åðåéóüäéï, ôçí êñßóç ðáíéêïý êáé ôçí ðáñáóõìðáèçôéêïôïíßá. Ç áäñåíáëßíç åßíáé ôï öÜñìáêï åêëïãÞò ãéá ôçí èåñáðåßá ôçò áíáöõëáîßáò êáé ü÷é ç êïñôéæüíç üðùò ëáíèáóìÝíá ãéáôñïß êáé áóèåíåßò íïìßæïõí. Åðßóçò áðáñáßôçôç èåùñåßôáé êáé ç ìåôáèåñáðåõôéêÞ äéá÷åßñéóç ôïõ áóèåíïýò, ìå ôçí áíåýñåóç ôïõ õðåýèõíïõ áëëåñãéïãüíïõ, êáèþò êáé ôç ÷ñÞóç ôçò ðñïãåìéóìÝíçò óýñéããáò áäñåíáëßíçò áðü ôïí áóèåíÞ óå ìåëëïíôéêÜ åðåéóüäéá. Ï Ãåíéêüò Éáôñüò ìðïñåß íá ðáßîåé ðïëý óðïõäáßï ñüëï óôçí ïîåßá áíôéìåôþðéóç ôçò áíáöõëáîßáò, üðùò êáé óôçí åêðáßäåõóç êáé ôçí åíçìÝñùóç ôùí áóèåíþí ãéá ôïí ôñüðï êáé ôïí ÷ñüíï ÷ñÞóçò ôçò ðñïãåìéóìÝíçò óýñéããáò áäñåíáëßíçò.

Ãåíéêïß Éáôñïß, 2Áãñïôéêïß Éáôñïß

ÅéóáãùãÞ Ìå ôïí üñï áíáöõëáîßá åííïïýìå ìéá âáñéÜ óõóôçìáôéêÞ áëëåñãéêÞ áíôßäñáóç ôïõ áíèñþðéíïõ ïñãáíéóìïý.1,2 Äåí õðÜñ÷åé ðáãêïóìßùò áðïäåêôüò ïñéóìüò ãéá ôçí áíáöõëáîßá äåäïìÝíïõ üôé åìðåñéÝ÷åé äéáöïñåôéêÞ óõìðôùìáôïëïãßá êáé äéáöïñåôéêïýò ìç÷áíéóìïýò ðïõ ôçí ðñïêáëïýí1. ¸íáò êáëüò ïñéóìüò åßíáé üôé áõôÞ ðñïûðïèÝôåé ôçí ýðáñîç ôçò ìéáò ç êáé ôùí äýï óïâáñþí áêïëïýèùí êáôáóôÜóåùí: áíáðíåõóôéêÞò äõó÷Ýñåéáò ðïõ íá ðñïêáëåßôáé áðü ôçí áðüöñáîç ôïõ áíþôåñïõ áíáðíåõóôéêïý (ïßäçìá ëÜñõããá) Þ ôïõ êáôþôåñïõ áíáðíåõóôéêïý (âñïã÷üóðáóìïò) êáé õðüôáóçò ðïõ åêäçëþíåôáé óáí ëéðïèõìéêü åðåéóüäéï, shock Þ áðþëåéá óõíåßäçóçò1. Ç ýðáñîç åîáíèÞìáôïò, Ýîáøçò, Üã÷ïõò, êáôáâïëÞò Þ æÜëçò åßíáé óõíÞèåéò.1 Ðáñüëï ðïõ ç áíáöõëáîßá äåí ËÝîåéò êëåéäéÜ: ÐñùôïâÜèìéá öñïíôßäá õãåßáò, áíáöõëáîßá, shock ÕðïâëÞèçêå: 14 Óåðôåìâñßïõ 2005 ÅðáíõðïâëÞèçêå: 12 Äåêåìâñßïõ 2005 ¸ãéíå äåêôÞ äéá äçìïóßåõóç: 14 Ìáñôßïõ 2006 Õðåýèõíïò áëëçëïãñáößáò: Ðáðáäüðïõëïò Ãéþñãïò. Ä/íóç: Ðáñíáóóïý 7, ÔÊ 71303 ÇñÜêëåéï ÊñÞôçò, e-mail: gpapado@otenet.g

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ðáðáäüðïõëïò êáé óõí.

Ï Ýíáò áóèåíÞò ðáñïõóßáæå ìåßùóç ôçò áñôçñéáêÞò ðßåóçò (70/40 mmHg), áðþëåéá ïýñùí, Þôáí Ýíôïíá äéåãåñôéêüò êáé åß÷å ðôþóç ôïõ åðéðÝSummary äïõ óõíåßäçóçò. Ç êáñäéáêÞ ôïõ ëåéOver the last few years anaphylaxis and anaphylactoid reaction seem to have increased worldwide. The main causes for anaphylaxis in adults are medications, ôïõñãßá äåí ðáñïõóßáæå ðáèïëïãéêÜ food antigens and insect bites. In children food antigens are the main causes. In a óçìåßá ðÝñáí áðü ìéá áíôáíáêëáóôéêÞ period of three months five cases of anaphylaxis were treated in the emergency öëåâïêïìâéêÞ ôá÷õêáñäßá. Ôï éáôñéêü section of Harakas Health Centre. All five cases had different clinical signs and ôïõ éóôïñéêü Þôáí åëåýèåñï. ¸ãéíå symptoms. Anaphylaxis is difficult to diagnose and other causes of the same sympëÞøç ôñé÷ïåéäéêïý áßìáôïò ãéá Ýëåã÷ï toms have to be excluded like bronchial asthma, panic attack with hyperventilation, cardiac and vasovagal episodes. Adrenalin is the main medication used to treat ôçò ãëõêüæçò áöïý ôÝèçêå ç õðïøßá acute anaphylaxis and not corticosteroids, as most physicians and patients think. ðéèáíÞò õðïãëõêáéìßáò ï ïðïßïò Þôáí We also consider essential the post-therapeutic management with recognition of áñíçôéêüò. Áöïý Ýãéíå õðïóôÞñéîç ôùí the responsible antigen and the usage of a pre-filled injection of adrenaline by the âáóéêþí ôïõ ëåéôïõñãéþí (áíáðíåõóôépatient. Primary Care physicians have to be capable of recognising and treating êïý êáé êõêëïöïñéêïý óõóôÞìáôïò) acute anaphylaxis and managing patients after the acute episode. ìåôáöÝñèçêå óôï äåõôåñïâÜèìéï íïKey words: primary health care, anaphylaxis, shock óïêïìåßï ïõóéáóôéêÜ áäéÜãíùóôïò. Ç äéÜãíùóç ôïõ áíáöõëáêôéêïý shock åßíáé Ýíá óõ÷íü ðñüâëçìá öáßíåôáé üôé ôçí ôåëåõ- Ýãéíå åêåß ôçí åðüìåíç çìÝñá. ôáßá äåêáåôßá õðÜñ÷åé ìéá áýîçóç óôçí óõ÷íüôçôá Ï äåýôåñïò áóèåíÞò ìåôáöÝñèçêå óôï ÊÝáóèåíþí ðïõ áíôéìåôùðßæïíôáé óôçí ðñùôïâÜèìéá íôñï Õãåßáò ìå õðüôáóç (80/50 mmHg), ìåãÜëç Þ äåõôåñïâÜèìéá öñïíôßäá õãåßáò ìå óõìðôþìáôá ðôþóç ôïõ åðéðÝäïõ óõíåßäçóçò, Ýíôïíç åñõèñüáíáöõëáîßáò1,2. ôçôá êïñìïý ìå ïéäÞìáôá èçëþí, ðñïóþðïõ êáé Ôá óõ÷íüôåñá áßôéá ðïõ ðñïêáëïýí áíáöõëá- âëåöÜñùí, êíéäùôéêü åîÜíèçìá êïñìïý êáé ìåîßá åßíáé ôá öÜñìáêá êáé êõñßùò ôá áíôéâéïôéêÜ, ãÜëç áíáðíåõóôéêÞ äõó÷Ýñåéá áðü ôï êáôþôåñï ïé ôñïöÝò êõñßùò îçñïß êáñðïß, øÜñé, ãÜëá, áõãÜ áíáðíåõóôéêü ìå âñïã÷üóðáóìï (wheezing).Ôï êáé ôá äÞãìáôá åíôüìùí3. çëåêôñïêáñäéïãñÜöçìá ôïõ ðáñïõóßáæå êÜðïéåò Ï ãéáôñüò ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåß- ìïíÞñçò Ýêôáêôåò óõóôïëÝò êáé ï êïñåóìüò ôïõ áò ðñÝðåé íá åßíáé åîïéêåéùìÝíïò ìå ôçí êëéíéêÞ ïîõãüíïõ Þôáí ìåéùìÝíïò óôï 87%. Ëüãù ôçò åéêüíá ôçò áíáöõëáîßáò, íá åßíáé óå èÝóç íá ôçí êëéíéêÞò ôïõ åéêüíáò ôÝèçêå Üìåóá ç õðïøßá äéáöïñïäéáãíþóåé áðü Üëëåò êáôáóôÜóåéò êáé íá áëëåñãéêÞò áíôßäñáóçò êáé ï áóèåíÞò áíôéìåôùìðïñåß íá ðáñÝìâåé Üìåóá ãéá ôçí áíôéìåôþðéóç ðßóôçêå Üìåóá ìå õðïóôÞñéîç ôçò áíáðíïÞò ôïõ ôçò. êáé ÷ïñÞãçóç â-äéåãÝñôç êáé âïõäåóïíßäçò ìå íåöåëïðïéçôÞ, êáèþò êáé åíäïìõéêÞ ÷ïñÞãçóç áäñåíáëßíçò. Ôáõôü÷ñïíá õðïóôçñß÷ôçêå êáé ç ÐåñéãñáöÞ Ðåñßðôùóçò êõêëïöïñßá ôïõ ìå ÷ïñÞãçóç êñõóôáëëïåéäþí äéáëõìÜôùí. Ïé äýï Üëëïé áóèåíåßò ðáñïõóßáæáí Ýíôïíï Óå äéÜóôçìá 3 ìçíþí, áðü áñ÷Ýò ÌáÀïõ Ýùò ôÝëïò Éïõëßïõ, ðñïóÞëèáí óôï ÊÝíôñï Õãåßáò åéóðíåõóôéêü óõñéãìü (stridor) áðü Ýíôïíï ïßäçìá ×Üñáêá óå þñá åöçìåñßáò, 5 áóèåíåßò ìå êëéíéêÞ ëÜñõããá êáé óôáöõëÞò, ïßäçìá âëåöÜñùí, äéÜ÷õôç åéêüíá áíáöõëáîßáò. Ïé áóèåíåßò Þôáí üëïé Üíôñåò åñõèñüôçôá êáé Þôáí íïñìïôáóéêïß. Ç êáñäéáêÞ ìå ìÝóï üñï çëéêßáò 55 åôþí. Ïé äýï ìüíï áðü ëåéôïõñãßá ôïõò äåí ðáñïõóßáæå ðáèïëïãéêÜ óçáõôïýò åß÷áí éóôïñéêü áëëåñãéêÞò áíôßäñáóçò óôï ìåßá åíþ ï êïñåóìüò ôïõ ïîõãüíïõ Þôáí 82% óôïí ðáñåëèüí. Åðßóçò áõôïß ïé äýï áóèåíåßò åß÷áí Ýíá áóèåíÞ êáé 85% óôïí Üëëï. Êáé óå áõôïýò êáé áéôéïëïãéêü ðáñÜãïíôá ãéá ôçí åìöÜíéóç ôçò ôïõò áóèåíåßò áðü ôçí êëéíéêÞ åéêüíá åôÝèç ç áíáöõëáîßáò. Ï Ýíáò åß÷å åðáöÞ ìå êñüôùíá êáé õðïøßá ôçò áíáöõëáîßáò êáé áíôéìåôùðßóôçêå ï Üëëïò åß÷å äÞãìá åíôüìïõ. Óôïõò õðüëïéðïõò Üìåóá ìå õðïóôÞñéîç ôçò áíáðíåõóôéêÞò ôïõò ôñåéò ï áéôéïëïãéêüò ðáñÜãïíôáò Þôáí Üãíùóôïò. ëåéôïõñãßáò, åíäïìõéêÞò ÷ïñÞãçóçò áäñåíáëßíçò Ç êëéíéêÞ åéêüíá Þôáí äéáöïñåôéêÞ êáé óôïõò êáé åíäïöëÝâéá ÷ïñÞãçóç õãñþí, õäñïêïñôéæüíçò êáé áíôééóôáìéíéêþí. ðÝíôå áóèåíåßò. Ánaphylaxis in primary health care. Án emergency state to be confronted by the general practitioners G. Papadopoulos, D. Brimis, A. Proklou, A. Petroulaki, A. Houlaki, H. Saloustros

Ã. Ðáðáäüðïõëïò êáé óõí.

Ï ðÝìðôïò áóèåíÞò ìåôáöÝñèçêå óôï ÊÝíôñï Õãåßáò ìå ðôþóç ôïõ åðéðÝäïõ óõíåßäçóçò, äéÜ÷õôç åñõèñüôçôá, ïßäçìá ðñïóþðïõ, áðþëåéá ïýñùí êáé âñïã÷üóðáóìï. Áñ÷éêÜ Þôáí íïñìïôáóéêüò (130/85 mmHg) áëëÜ åíôüò ðÝíôå ëåðôþí ðåñßðïõ ç áñôçñéáêÞ ôïõ ðßåóç Ýðåóå óçìáíôéêÜ (70/45 mmHg). Ï êïñåóìüò ôïõ ïîõãüíïõ Þôáí 80% êáé ç êáñäéáêÞ ôïõ ëåéôïõñãßá äåí åß÷å åðçñåáóôåß. Áíôéìåôùðßóôçêå ìå õðïóôÞñéîç ôïõ áíáðíåõóôéêïý êáé ôïõ êõêëïöïñéêïý óõóôÞìáôïò êáé åíäïìõéêÞ ÷ïñÞãçóç áäñåíáëßíçò, ÷ïñÞãçóç â-äéåãÝñôç êáé âïõäåóïíßäçò ìå íåöåëïðïéçôÞ êáèþò êáé åíäïöëÝâéá ÷ïñÞãçóç õäñïêïñôéæüíçò êáé áíôééóôáìéíéêþí. Óå êáíÝíá áðü ôïõò áóèåíåßò äåí åðçñåÜóôçêå ç êáñäéáêÞ ëåéôïõñãßá óçìáíôéêÜ. Ç áíôéìåôþðéóç üëùí ôùí áóèåíþí Ýãéíå ìå âÜóç ôéò äéåèíåßò ïäçãßåò ãéá ôçí èåñáðåßá ôçò áíáöõëáîßáò1,2,4. Ïé áóèåíåßò áíôáðïêñßèçêáí åðéôõ÷þò, ìå äñáóôéêÞ ýöåóç ôçò óõìðôùìáôïëïãßáò êáé âåëôßùóç ôçò êëéíéêÞò ôïõò êáôÜóôáóçò êáé ìåôáöÝñèçêáí óå äåõôåñïâÜèìéï íïóïêïìåßï ðñïò ðáñáêïëïýèçóç êáé ßóùò ðåñáéôÝñù áíôéìåôþðéóç. ÓõæÞôçóç 1⁄4ðùò áíáöÝñèçêå ðáñáðÜíù ôá ðåñéóôáôéêÜ áíáöõëáîßáò öáßíåôáé üôé áõîÜíïõí äéåèíþò ôá ôåëåõôáßá ÷ñüíéá. Ðéèáíïß ðáñÜãïíôåò ãé´áõôü öáßíïíôáé íá åßíáé ç ãåíéêüôåñç áýîçóç ôùí áëëåñãéêþí êáôáóôÜóåùí ôïõ ðëçèõóìïý êáé ßóùò ç áõîáíüìåíç Ýêèåóç óå äéÜöïñá áíôéãüíá2,5. Óôá áßôéá ôçò áíáöõëáîßáò óôïõò åíÞëéêåò öáßíåôáé üôé ðñþôç èÝóç êáôÝ÷ïõí ôá öÜñìáêá êõñßùò áíôéâéïôéêÜ (ðåíéêéëëßíç, êåöáëïóðïñßíåò, ôñéìåèïðñßìç – óïõëöïìåèïîáæüëç), áóðéñßíç êáé ìç óôåñïåéäÞ áíôéöëåãìïíþäç. Äåýôåñç èÝóç êáôÝ÷ïõí ïé ôñïöéêÝò áëëåñãßåò êáé ôñßôç ôá äÞãìáôá åíôüìùí. Óå Ýíá ìåãÜëï ðïóïóôü äåí áíáãíùñßæåôáé áëëåñãéïãüíïò ðáñÜãïíôáò. Óôá ðáéäéÜ ïé ôñïöéêÝò áëëåñãßåò êáôÝ÷ïõí ôçí ðñþôç èÝóç, áêïëïõèïýí ôá öÜñìáêá êáé ôá äÞãìáôá åíôüìùí4,6. Óå äýï áóèåíåßò ðïõ áíôéìåôùðßóáìå áíáãíùñßóôçêå áëëåñãéïãüíïò ðáñÜãïíôáò êáé Þôáí êáé óôïõò äýï äÞãìá Þ åðáöÞ ìå Ýíôïìá. Óôïõò õðüëïéðïõò ôñåéò ôá áßôéá äåí áíáãíùñßóôçêáí. Ç áíôéìåôþðéóç ôçò áíáöõëáîßáò Ýãéíå

Ôüìïò 18, Ôåý÷ïò 2, 2006

áñ÷éêÜ ìå åíäïìõéêÞ ÷ïñÞãçóç áäñåíáëßíçò, ìå óõíå÷üìåíï monitoring ôçò êáñäéáêÞò ëåéôïõñãßáò, ôçò áñôçñéáêÞò ðßåóçò êáé ôïõ êïñåóìïý ïîõãüíïõ. Óå Ýíáí ìüíï áóèåíÞ áðü ôïõò ôÝóóåñéò ðïõ ÷ïñçãÞèçêå áñ÷éêÜ áäñåíáëßíç ÷ñåéÜóôçêå ç åðáíÜëçøç ôçò äüóçò ìåôÜ 15 ëåðôÜ ëüãù ìç âåëôßùóçò ôçò óõìðôùìáôïëïãßáò. Ó´áõôïýò ðïõ ðáñïõóßáæáí âñïã÷üóðáóìï ÷ïñçãÞèçêå â-äéåãÝñôçò ìáæß ìå êïñôéêïóôåñïåéäÞ ìå íåöåëïðïéçôÞ êáé åíäïöëÝâéá õäñïêïñôéæüíç êáé áíôééóôáìéíéêÜ. Óå üëïõò ôïõò áóèåíåßò ç âåëôßùóç ôçò êëéíéêÞò åéêüíáò Þôáí äñáóôéêÞ åíôüò 30 ëåðôþí åêôüò áðü Ýíáí üðïõ ôï ïßäçìá óôáöõëÞò ðáñÝìåéíå êáé êáôÜ ôçí ìåôáöïñÜ ôïõ óôï äåõôåñïâÜèìéï íïóïêïìåßï ÷ùñßò üìùò íá ðáñïõóéÜæåé áíáðíåõóôéêÞ äõó÷Ýñåéá. Åßíáé áðáñáßôçôï åäþ íá õðïãñáììéóôåß üôé ç ðáñáðïìðÞ ôïõ áóèåíïýò óôï íïóïêïìåßï ðáñÜ ôçí ýöåóç ç åîáöÜíéóç ôùí óõìðôùìÜôùí êñßíåôáé áðáñáßôçôç. Ï áóèåíÞò ðñÝðåé íá ðáñáêïëïõèåßôáé ôïõëÜ÷éóôïí ãéá äþäåêá þñåò óå íïóïêïìåßï ëüãù ôïõ êéíäýíïõ åìöÜíéóçò ôçò áëëåñãéêÞò áíôßäñáóçò äåýôåñçò öÜóçò2,6. Óå Ýíá áóèåíÞ ðïõ áíôéìåôùðßóôçêå óôï ÊÝíôñï Õãåßáò, ç äéÜãíùóç ôçò áíáöõëáîßáò äéÝöõãå ëüãù ôçò Üôõðçò êëéíéêÞò åéêüíáò. Ôéò ðéï ðïëëÝò öïñÝò ç êëéíéêÞ äéÜãíùóç ôçò áíáöõëáîßáò åßíáé ðïëý äýóêïëç êáé ðñÝðåé íá äéáöïñïäéáãíùóôåß áðü âñïã÷éêü Üóèìá, êáñäéáêü åðåéóüäéï, êñßóç ðáíéêïý êáé ðáñáóõìðáèçôéêïôïíßá1,2,6. 1⁄4óïí áíáöïñÜ ôçí äéáöïñïäéÜãíùóç áðü ôï âñïã÷éêü Üóèìá óôçí ÷ñÞóç â-äéåãÝñôç äåí õðÜñ÷åé äñáóôéêÞ âåëôßùóç ôçò áíáðíåõóôéêÞò ëåéôïõñãßáò óôçí ðåñßðôùóç áíáöõëáîßáò ðáñÜ ìüíï ìåñéêÞ áíôáðüêñéóç ó´áõôÞ. Åðßóçò óôçí ðåñßðôùóç ðáñáóõìðáèçôéêïôïíßáò üôáí ï áóèåíÞò ðáñáìåßíåé êáôáêåêëéìÝíïò õðÜñ÷åé âåëôßùóç ôùí óõìðôùìÜôùí ðñÜãìá ðïõ äåí óõìâáßíåé óôçí áíáöõëáîßá. Ç áäñåíáëßíç åßíáé ôï öÜñìáêï åêëïãÞò ãéá êÜèå áíáöõëáêôéêÞ áíôßäñáóç êáé åßíáé ôï öÜñìáêï ðïõ èá óþóåé ôç æùÞ ôïõ áóèåíÞ. Áíôßèåôá ôá áíôééóôáìéíéêÜ êáé ôá êïñôéêïóôåñïåéäÞ ðáñüëï ðïõ Ý÷ïõí ôïí ñüëï ôïõò óôç èåñáðåßá ôçò áíáöõëáîßáò äåí èåùñïýíôáé ðñþôçò ãñáììÞò öÜñìáêá êáé äåí åßíáé áõôÜ ðïõ èá óþóïõí ôç æùÞ ôïõ2-6. Ç êëéíéêÞ åìðåéñßá Ý÷åé äåßîåé üôé ðïëëïß áóèåíåßò ìå áíáöõëáîßá äåí ëáìâÜíïõí ðÜíôá 93

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôçí óùóôÞ èåñáðåßá. Öáßíåôáé üôé ç áäñåíáëßíç äåí ÷ñçóéìïðïéåßôáé óõ÷íÜ áðü ôïõò ãéáôñïýò, ðïõ ðñïôéìïýí ôá êïñôéêïóôåñïåéäÞ êáé ôá áíôééóôáìéíéêÜ öÜñìáêá. Åðßóçò öáßíåôáé üôé áí ôçí ÷ñçóéìïðïéÞóïõí ðñïôéìïýí ôçí õðïäüñéá ÷ïñÞãçóç áíôß ôçò åíäïìõéêÞò ðïõ óõíéóôÜôáé ðáãêïóìßùò1-6. ÌåëÝôç óôçí Åõñþðç Ýäåéîå üôé óå 274 áóèåíåßò ìå áíáöõëáîßá ìüíï ïé 40 Ýëáâáí áãùãÞ ìå áäñåíáëßíç êáôÜ ôçí óôéãìÞ ôïõ åðåéóïäßïõ3. Åßíáé óõ÷íü öáéíüìåíï ïé áóèåíåßò ìå áíáöõëáîßá ìåôÜ ôçí áíôéìåôþðéóç ôïõò, åßôå áðü ãéáôñïýò ôéò ðñùôïâÜèìéáò öñïíôßäáò, åßôå êáé áðü ôï äåõôåñïâÜèìéï íïóïêïìåßï, íá öåýãïõí ÷ùñßò ðåñáéôÝñù ïäçãßåò6-8. Åßíáé ÷áñáêôçñéóôéêü üôé êáé ïé äõï áóèåíåßò áðü áõôïýò ðïõ áíôéìåôùðßóáìå êáé åß÷áí ðñïçãïýìåíï åðåéóüäéï óôï ðáñåëèüí, ï Ýíáò åß÷å ðÜíôá ìáæß ôïõ êïñôéêïóôåñïåéäÝò óáí öÜñìáêï ðñüëçøçò ðéèáíÞò áíáöõëáêôéêÞò áíôßäñáóçò åíþ ï Üëëïò ôßðïôá. Ç äéá÷åßñéóç ôïõ áóèåíïýò ìåôÜ áðü Ýíá ïîý åðåéóüäéï áíáöõëáîßáò ðåñéëáìâÜíåé ôçí áðïìüíùóç ôïõ áëëåñãéïãüíïõ (áí äåí åßíáé ãíùóôü) êáé ôçí áðïöõãÞ ôïõ áðü ôïí áóèåíÞ óôï ìÝëëïí üóï áõôü åßíáé äõíáôüí. ¸ôóé ï ãåíéêüò éáôñüò ðñÝðåé íá ðáñáðÝìðåé ôïí áóèåíÞ óå êÜðïéï áëëåñãéïëüãï ðñïêåéìÝíïõ íá áíáãíùñéóôåß ôï õðåýèõíï áíôéãüíï, ðáñüëï ðïõ áñêåôÝò öïñÝò áõôü äåí áíáãíùñßæåôáé6. Åðßóçò, áóèåíåßò ðïõ Ý÷ïõí éóôïñéêü áíáöõëáîßáò ðñÝðåé ðÜíôïôå íá Ý÷ïõí ìáæß ôïõò ðñïãåìéóìÝíåò óýñéããåò áäñåíáëßíçò êáé ü÷é êïñôéæüíç, üðùò åóöáëìÝíá íïìßæïõí ðïëëïß áóèåíåßò ìå ôÝôïéï éóôïñéêü. Åäþ ï ãåíéêüò ãéáôñüò ìðïñåß íá ðáßîåé óðïõäáßï ñüëï ìå ôï íá åêðáéäåýóåé ôïí áóèåíÞ íá áíáãíùñßæåé ôá óõìðôþìáôá ôçò áíáöõëáîßáò ìüíïò ôïõ êáé íá ôïõ õðïäåßîåé ôïí

Ã. Ðáðáäüðïõëïò êáé óõí.

ôñüðï ðïõ èá êÜíåé ôçí Ýíåóç ãñÞãïñá ÷ùñßò íá ÷áèåß ðïëýôéìïò ÷ñüíïò. Åßíáé ÷áñáêôçñéóôéêü óå ìéá Ýñåõíá óôï ÇíùìÝíï Âáóßëåéï óå ðåíÞíôá ãåíéêïýò ãéáôñïýò ìüíï Ýíáò Þîåñå ðüôå êáé ðþò íá ÷ñçóéìïðïéÞóåé ôçí ðñïãåìéóìÝíç óýñéããá áäñåíáëßíçò8. Ï ãåíéêüò ãéáôñüò ëïéðüí ðÝñá áðü ôçí Üìåóç áíôéìåôþðéóç ôïõ åðåéóïäßïõ ôçò áíáöõëáîßáò ðñÝðåé íá ðáñÝìâåé êáé óôçí ðñüëçøç ôùí ìåëëïíôéêþí åðåéóïäßùí ìå ïäçãßåò ðñïò ôïí áóèåíÞ ãéá áðïöõãÞ ôïõ áëëåñãéïãüíïõ áí áõôü åßíáé äõíáôü êáèþò êáé ìå ôçí åêðáßäåõóç ôïõ ãéá ôïí óùóôü ôñüðï êáé ÷ñüíï ÷ïñÞãçóçò ôçò ðñïãåìéóìÝíçò óýñéããáò áäñåíáëßíçò.

Âéâëéïãñáößá 1. Anaphylaxis and cardiopulmonary resuscitation guideline for health care professionals in the primary care trust. NHS Greater Glasgow November 2004, pp 3-14. 2. The emergency Medical Treatment of anaphylactic reactions for first Medical responders. Resuscitation Council UK, 2005 pp 1-11. 3. S. Acero, A. I. Tabar. Anaphylaxis: etiological diagnosis. Allerg. Immunol Clin 14:133-7, 1999. 4. Anaphylaxis Policy. Eastebourne Downs NHS Primary Care Trust, 2005, pp 1-10. 5. Sukhmeet Singh Panesar, Samantha Walker. Primary care management of Anaphylaxis. Prim Care Respir J 12:124-6, 2003. 6. Anaphylaxis. the GP perspective. Austr Family Physician, 31:807-9, 2003. 7. Pamela W Ewan. ABC of allergies. Anaphylaxis. BMJ, 316:1442-5, 1998. 8. Dickinson E. Patients and doctors lack knowledge about adrenaline injections. BMJ, 327:1328, 2003.

Ôüìïò 18, Ôåý÷ïò 2, 2006

ÃÑÁÌÌÁÔÁ ÓÔÏÍ ÅÊÄÏÔÇ LETTERS TO THE EDITOR Primary Heatlh Care, Volume 18, Number 2, 95-97, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 95-97, 2006

Ó÷Ýóç éáôñïý - áóèåíÞ êáé ðñùôïâÜèìéá öñïíôßäá õãåßáò: ÓêÝøåéò êáé ðáñáëëçëéóìïß ìå áöïñìÞ ôç åðßóêåøç óôï Éåñü Êïéíüâéï Åõáããåëéóìïý ôçò Èåïôüêïõ óôçí Ïñìýëéá ×áëêéäéêÞò ÁãáðçôÝ ê. ÄéåõèõíôÞ Óýíôáîçò, Ìå ôçí åõêáéñßá ôïõ 2ïõ Öéëßððåéïõ Åñãáóôçñßïõ ¸ñåõíáò, ìéá ïìÜäá óõììåôå÷üíôùí áðïöÜóéóå íá åðéóêåöôåß ôï Éåñü Êïéíüâéï Åõáããåëéóìïý ôçò Èåïôüêïõ óôçí Ïñìýëéá ×áëêéäéêÞò. Ç åðßóêåøç áõôÞ Ýäùóå ôçí åõêáéñßá ãéá ðáñáëëçëéóìïýò ìå ôç ó÷Ýóç éáôñïý-áóèåíÞ, Ýíá èÝìá ðïõ áêüìç äå óõíáíôÜôáé åõñýôáôá óôçí åëëçíéêÞ âéâëéïãñáößá. Óôï ãñÜììá áõôü ðáñïõóéÜæåôáé ç åìðåéñßá ôçò åðßóêåøçò ìå áíáöïñÝò óôç ó÷Ýóç éáôñïý-áóèåíÞ. Ç åðßóêåøç óôï ðñïóöÜôùò áíåãåñèÝí ôìÞìá ôïõ Ìïíáóôçñéïý, ìáò áðïêÜëõøå Ýíáí ÷þñï õøçëÞò áéóèçôéêÞò. Ç ðñïóáñìïãÞ ôçò åêêëçóßáò óôï êáôÜëëçëï ðåñéâÜëëïí ðïõ áðáéôåßôáé ãéá ôçí åðéêïéíùíßá ìå ôï èåßï, ìáò õðåíèýìéóå ôçí áíáãêáéüôçôá ìéáò êáôÜëëçëçò áñ÷éôåêôïíéêÞò ôïõ éáôñåßïõ ðïõ èá äéåõêïëýíåé ôçí åðéêïéíùíßá ôïõ áóèåíÞ ìå ôïí éáôñü1. Ç óõëëïãÞ ôïõ õëéêïý êáé ï ó÷åäéáóìüò ôïõ íáïý áêïýóáìå üôé âáóßóôçêáí óå óõóôçìáôéêÞ ìåëÝôç âéâëßùí ôçò éåñÜò ðáñÜäïóçò, äéáäéêáóßá ðïõ ìáò õðåíèýìéóå âáóéêÝò áñ÷Ýò ôçò ìåèïäïëïãßáò Ýñåõíáò, áíáöïñéêÜ ìå ôç óõóôçìáôéêÞ áíáæÞôçóç ôçò ðëçñïöïñßáò ðñéí ôçí ëÞøç ìéáò åñåõíçôéêÞò Þ êáé êëéíéêÞò-óðáíéüôåñá- áðüöáóçò. ÅíäéáöÝñïí ðñïêÜëåóå ç ðáñáôÞñçóç ìéáò ìïíá÷Þò, ç ïðïßá õðïãñÜììéóå ôçí áäõíáìßá íá áíôáðïêñéèïýí ïé óýã÷ñïíïé éåñåßò óôéò áõîçìÝíåò áíÜãêåò ðïõ áõôïß áíôéìåôùðßæïõí, ìå áðïôÝëåóìá óõ÷íÜ íá ìçí ãíùñßæïõí ôï ðïßìíéï ôïõò. Ç ðáñáôÞñçóç áõôÞ èýìéóå ôçí Ýëëåéøç óõíÝ÷åéáò óôç öñïíôßäá, âáóéêü ÷áñáêôçñéóôéêü ôçò åéäéêüôçôáò ôçò ÃåíéêÞò ÉáôñéêÞò2. Ç ëÝîç «äéáêïíßá», ðïõ áêïýóáìå íá ðåñéãñÜöåé ôçí ðñïóöïñÜ ôùí ìïíá÷þí óôïí Üíèñùðï, öÝñíåé áâßáóôá óôï ìõáëü ôïí «éåñáðïóôïëéêü ñüëï» ðïõ áíáöÝñåé ï Balint óõ÷íÜ óôá âéâëßá ôïõ, ðåñéãñÜöïíôáò ôï Ýñãï ôïõ ãåíéêïý éáôñïý óôá ðëáßóéá ôçò Üóêçóçò ôçò éáôñéêÞò ìå åðßêåíôñï ôïí áóèåíÞ3. Ï ãåíéêüò éáôñüò ïöåßëåé íá äéåñåõíÜ ôüóï ôçí êáèáñÜ éáôñéêÞ-áíôéêåéìåíé-

êÞ äéÜóôáóç ôçò íüóïõ, üóï êáé ôçí õðïêåéìåíéêÞ ôçò (áóèÝíåéá), üðùò ôçí âéþíåé ï áóèåíÞò. ÊáôÜ ôïí McCormic ôï íá áíáêáëýøåéò ôïí áóèåíÞ ðïõ ðÜó÷åé áðü ìßá íüóï åßíáé ôï ßäéï óçìáíôéêü ìå ôï íá áíáêáëýøåéò ôçí íüóï ðïõ Ý÷åé ðñïóâÜëëåé ôïí áóèåíÞ4. Ï Baron Ý÷åé ðåñéãñÜøåé áõôÞ ôçí áíÜãêç ëÝãïíôáò üôé «ïé Üíèñùðïé äåí Ýñ÷ïíôáé áðëÜ ãéá ìéá äéÜãíùóç êáé èåñáðåßá^ Ýñ÷ïíôáé ãéá íá ãßíïõí êáëÜ, íá åðáíáêôÞóïõí ôçí áßóèçóç ôçò õãåßáò êáé íá åðéóôÝøïõí ãåìÜôïé åíÝñãåéá óôéò êáèçìåñéíÝò ôïõò äñáóôçñéüôçôåò»5. ¸ôóé ï ãåíéêüò éáôñüò áíáìÝíåôáé íá áíôéëçöèåß ôá ðñáãìáôéêÜ áßôéá ðñïóÝëåõóçò ôïõ áóèåíÞ ôïõ, íá ðñïôåßíåé èåñáðåõôéêÝò ðñïôÜóåéò ðïõ åíáñìïíßæïíôáé ìå ôéò áíÜãêåò êáé ôïí ôñüðï æùÞò ôïõ, áëëÜ êáé íá ðñïâåß óå ïõóéáóôéêÝò ðñïëçðôéêÝò ðáñåìâÜóåéò. Óôï ôÝëïò ôçò åðßóêåøçò ìáò, ç ðñÜîç ôçò ìïíá÷Þò íá ìáò óõíïäåýóåé ìÝ÷ñé ôçí Ýîïäï, ðáñáëëçëßóôçêå ìå ôçí õðï÷ñÝùóç ôïõ éáôñïý íá óõíïäåýåé ôïí áóèåíÞ ôïõ ìÝ÷ñé ôçí Ýîïäï ôïõ éáôñåßïõ ôïõ, ïõóéáóôéêü ìÝñïò ôçò áðïôåëåóìáôéêÞò åðéêïéíùíßáò ìå ôïí áóèåíÞ. Ç åðßóêåøç áõôÞ ìáò õðåíèýìéóå áêüìç üôé ç áíáæÞôçóç ôïõ áíèñþðïõ ðßóù áðü ôïí áóèåíÞ åßíáé áðáñáßôçôç ãéá íá ôåèïýí ôá èåìÝëéá ìéáò éó÷õñÞò, ìáêñï÷ñüíéáò, áíèñþðéíçò ó÷Ýóçò ìåôáîý éáôñïý êáé áóèåíÞ, áîéïðïéþíôáò Ýôóé óôï Ýðáêñï ôï «öÜñìáêï: éáôñüò»1. Åõ÷áñéóôßåò: åõ÷áñéóôïýìå ôéò ìïíá÷Ýò ôïí Éåñïý Êïéíïâßïõ Åõáããåëéóìïý ôçò Èåïôüêïõ óôçí Ïñìýëéá ×áëêéäéêÞò ãéá ôç èåñìÞ õðïäï÷Þ êáé ôçí áðáñÜìéëëç öéëïîåíßá ôïõò. Ìå åêôßìçóç. Æ. Ôóßìôóéïõ Ó. Äçìïðïýëïõ, Ä. Âáóéëïðïýëïõ, Ó. ÁñãõñéÜäïõ, ×. Ëéüíçò: 95

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Âéâëéïãñáößá 1. Blum RH. The Office Call. In: The Management of the Doctor-Patient Relationship. Mc GrawHill Book Company, Inc., New York, Torondo, London,150-69, 1960. 2. The European Definition of General Practice/ Family Medicine. Wonca Europe, 2002. (http://

www.woncaeurope.org) 3. Balint, M. The doctor, his patient and the illness. London: Pitman Medical, 1964. 4. McConnic, J. Death of the personal doctor. Lancet, 348: 667-8, 1996. 5. Baron, R.J. Bridging clinical distance: an empathie rediscovery of the known. J Med Philos, 6: 5-23, 1981.

Metabolic syndrome is common but caution is needed in choice and interpretation of statistics Dear Editor, I read the paper by Lianas D, Skarpleios A, Arvanitis A, Razis N. (Metabolic Syndrome And Cardiovascular Risk In Remote And Mountainous Greek Population) that illustrated in the Primary Health Care, March 2005 issue1. The authors stated that their aim was, to estimate the relation of MS (metabolic syndrome) with specific cardiovascular risk factors in the population of a rural region of Achaia. Taking the records of 505 adults, they analysed the frequency of MS in each group with one of the following risk factors: diabetics, the obese, hypertensives, the over-45s in men and over-55s in women, hypercholesterolaemics, and men versus women. Table 1 shows an impressive set of significant results. The authors conclude that the importance of these findings lies in the fact that MS patients have a greater risk of cardiovascular disease than would be expected from summing the risks of each factor. I would like to sound a note of caution regarding the choice of analysis and the interpretation of these results. MS is defined as the presence of at least three features from: serum triglycerides „ 150mg/dL, HDL cholesterol <40mg/dL in men and <50mg/dL in women, BP„130/85, waist circumference > 102 cm in men and >88 cm in women, and a fasting blood glucose >110 mg/dL.

The MS group already possessed three or more of the features that they were being tested against. Therefore, a chi-square test of the presence of MS and the risk factors selected by the authors amounts to a test of the risk factors against themselves. A significant result is, therefore, inevitable but not meaningful or useful. I do believe that the authors have made two important findings. Firstly, they add to the body of literature which shows that cardiovascular risk factors tend to be associated (which is, after all, what the metabolic syndrome means). Secondly, they have pointed to an alarmingly high prevalence in a rural region. This raises serious concerns about the implications for public health. Reference Lianas D, Skarplelos A, Arvanitis A, Razis N. Metabolic Syndrome And Cardiovascular Risk In Remote And Mountainous Greek Population. Primary Health Care, 17:57-63, 2005.

Dr Kevork Hopayian, MD, FRCGP Hon Senior Lecturer School of Medicine University of East Anglia

Ôüìïò 18, Ôåý÷ïò 2, 2006

Lebanese Society of Family Medicine

July 24,2006 Dear colleagues, Many Lebanese condemn violence in achieving “political” goals”. The majority of physicians in Lebanon believe in peaceful civil means of solving any conflict. We also believe that the overwhelming majority of people on this planet share the same basic views: those of love, peace, equity, human rights and the pursuit of happiness. It is sad that the whole world has not learned that war does not solve conflicts but rather perpetuate them endlessly. For almost 2 weeks, bridges and roads in our country were bombarded making transportation of the wounded; carrying medical supplies, food and fuel impossible by road. Trucks that carry basic supplies to stranded populations are hit by the Israeli planes. A convoy of humanitarian aids including ambulances was targeted by US made planes. A factory that produces serum and another that produces dairy products were also

hit by the “Israeli Defense Forces”. Red Cross teams were shot at and several members were badly wounded. In this message, We are not urging you to take sides or to change your convictions, not that you will (Nietzsche correctly said that “convictions are more dangerous enemies of truth than lies”); we only want you to know that this war is too barbaric and indiscriminate and has to be stopped now. While the US and Israeli governments are dragging their feet to allow military gains, a whole nation is being slaughtered after two Israeli soldiers were abducted. Act now and let your government know that endorsing a war is inhumane. Sincerely, On behalf of the Lebanese Society of Family Medicine Bassem Saab, MD President

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ä. Ãéáííüðïõëïò

ÍÅÁ ÁÐÏ ÔÇÍ ÅËÅÃÅÉÁ NEWS FROM THE GREEK ASSOCIATION OF GENERAL PRACTICIONERS Primary Heatlh Care, Volume 18, Number 2, 98-99, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 98-99, 2006

ÓõìðåñÜóìáôá áðü ôçí ðñáãìáôïðïßçóç ôïõ Óåìéíáñßïõ ÄéáêïðÞò Êáðíßóìáôïò, 19-21 ÌáÀïõ 2006 óôï ÊÜóôñï ÊõëëÞíçò Óôéò 19, 20 êáé 21 ÌáÀïõ 2006 óôï ÊÜóôñï ÊõëëÞíçò, ðñáãìáôïðïéÞèçêå, áðü ôï Ðåñéöåñåéáêü ÔìÞìá ÄõôéêÞò ÅëëÜäáò ôçò ÅË.Å.ÃÅ.ÉÁ, ôï ÓåìéíÜñéï ìå èÝìá: «Ôå÷íéêÝò ÄéáêïðÞò Êáðíßóìáôïò óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò». Óôï ÓåìéíÜñéï óõììåôåß÷áí óõíïëéêÜ 22 Éáôñïß ÃåíéêÞò ÉáôñéêÞò áðü üëç ôçí ÅëëÜäá. Óôçí ïìÜäá ôùí åêðáéäåõôþí óõììåôåß÷áí Ãåíéêïß Éáôñïß, Ðíåõìïíïëüãïé êáé Øõ÷ïëüãïé ìå åìðåéñßá óôçí ëåéôïõñãßá Éáôñåßùí ÄéáêïðÞò Êáðíßóìáôïò. Áðü ôçí ðëåõñÜ ôùí óõíåñãáæüìåíùí åðéóôçìüíùí Üëëùí åéäéêïôÞôùí óçìáíôéêÞ Þôáí ç ðáñïõóßá ôïõ ê. ÐáôåíôáëÜêç Ìé÷Üëç, Ðíåõìïíïëüãïõ, ÄéåõèõíôÞ Åðáããåëìáôéêþí Íüóùí èþñáêïò Óéóìáíüãëåéïõ Íïóïêïìåßïõ ÁôôéêÞò, ôçò ê Ôóáñïõ÷Ü Áéìéëßáò, Ðíåõìïíïëüãïõ, ÅðéìåëÞôñéáò Í.Í.È. «Ç ÓÙÔÇÑÉÁ», ôçò ê. ÔñáêáäÜ Ãåùñãßáò êáé ôçò ê. ÔóéáìÞôá Ìáñßáò, Ðíåõìïíïëüãùí, Åðéìåëçôþí Ð.Ã.Í. Ðáôñþí, êáé ôçò ê. ÊùëÝôôç ÁããåëéêÞò, Øõ÷ïëüãïõ, Õðåýèõíçò ÓõìâïõëåõôéêÞò Õðçñåóßáò Ðáíåðéóôçìßïõ Èåóóáëßáò. ÐñïóêåêëçìÝíïò Þôáí åðßóçò ï Ðñüåäñïò ôïõ Äéåèíïýò Äéêôýïõ “Intemtional Primary Care Respiratory Group” Dr Anders Ostrem, Íïñâçãüò, Ãåíéêüò Éáôñüò, ï ïðïßïò ðñáãìáôïðïßçóå êáé ôçí åíáñêôÞñéá äéÜëåîç ìå èÝìá «Ç ÅõñùðáúêÞ Åìðåéñßá áðü ôçí ëåéôïõñãßá Éáôñåßùí ÄéáêïðÞò Êáðíßóìáôïò óôçí ÐÖÕ.». Ï ê. Ostrem ôüíéóå ôï óçìáíôéêü ñüëï ôïõ Ãåíéêïý/ Ïéêïãåíåéáêïý Éáôñïý óôçí äéá÷åßñéóç ôçò áóèåíþí åîáñôþìåíùí áðü ôçí íéêïôßíç, ùò åíüò áðü ôïõò óçìáíôéêüôåñïõò ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ. 1⁄4ëïé ïé åéóçãçôÝò åðéóÞìáíáí ôçí éäéáéôåñüôçôá ôçò ðñïóÝããéóçò ôïõ êáðíéóôÞ óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò êáé ôïí ñüëï ôïõ Ãåíéêïý/ Ïéêïãåíåéáêïý Éáôñïý ùò Óõìâïýëïõ Õãåßáò. Ç óõíå÷Þò åðáöÞ ôïõ ãéáôñïý 98

ìå ôïí ßäéï ôïí áóèåíÞ, áëëÜ êáé ôá ìÝëç ôçò ïéêïãÝíåéáò ôïõ, öÝñíåé ôïí ãéáôñü ôçò ïéêïãÝíåéáò óå ìéá ðéï ðëåïíåêôéêÞ èÝóç þóôå íá äéá÷åéñßæåôáé êáé íá áíôéìåôùðßæåé áðïôåëåóìáôéêüôåñá êÜèå ðáñÜãïíôá êéíäýíïõ êáé éäéáßôåñá áõôüí ôçò åîÜñôçóçò áðü ôçí íéêïôßíç. èá ðñÝðåé åðßóçò íá óçìåéùèåß üôé Þôáí óçìáíôéêÞ ç åíåñãÞò óõììåôï÷Þ êáé ôï Ýíôïíï åíäéáöÝñïí üëùí ôùí óõììåôå÷üíôùí êáè‘ üëç ôçí äéÜñêåéá ôïõ ðñïãñÜììáôïò ìå ôçí äéáôýðùóç åýóôï÷ùí åñùôÞóåùí êáé ðáñáãùãéêþí óõæçôÞóåùí. ÊáôÜ ôçí ðñáêôéêÞ Üóêçóç ïé åêðáéäåõüìåíïé ÷ùñéóìÝíïé óå ìéêñÝò ïìÜäåò óõììåôåß÷áí óå åéêïíéêÜ óåíÜñéá ãéáôñïý-áóèåíïýò õðü ôçí åðßâëåøç ôùí åêðáéäåõôþí. ÊáôÜ ôçí äéáäéêáóßá áîéïëüãçóçò ôïõ ðñïãñÜììáôïò ïé óõììåôÝ÷ïíôåò áíáöÝñèçêáí ìå èåôéêÜ ó÷üëéá óôï ìåãáëýôåñï áñéèìü ôùí äéáëÝîåùí êáèþò êáé óôï åðßðåäï êáôÜñôéóçò êáé ìåôáäïôéêüôçôáò ôùí ðåñéóóïôÝñùí ïìéëçôþí, åíþ äéáôõðþèçêáí ðñïôÜóåéò ó÷åôéêÜ ìå ôçí áýîçóç ôïõ ÷ñüíïõ ôïõ ðñïãñÜììáôïò. ÔÝëïò üëïé ïé óõììåôÝ÷ïíôåò, êáôÜ ôçí äéáìüñöùóç óõìðåñáóìÜôùí êáôÝëçîáí óôá ðáñáêÜôù: • Äçìéïõñãßá Äéêôýïõ Éáôñåßùí ÄéáêïðÞò Êáðíßóìáôïò ãéá éáôñïýò ÃåíéêÞò ÉáôñéêÞò ïé ïðïßïé äéá÷åéñßæïíôáé êáðíéóôÝò. ¸íá êïéíü ðñùôüêïëëï êáôáãñáöÞò êáé ðáñáêïëïýèçóçò áóèåíþí èá áðïóôÝëëåôáé óå êÜèå íÝï ìÝëïò ôïõ Äéêôýïõ, åíþ óçìáíôéêÝò ðëçñïöïñßåò êáé ó÷åôéêÞ âéâëéïãñáöéêÞ åíçìÝñùóç èá õðÜñ÷åé áðü ôçí 1ç Éïýëç 2006 óôçí éóôïóåëßäá ôçò ÅË.Å.ÃÅ.ÉÁ. • Äçìéïõñãßá Forum ãéá éáôñïýò ÃåíéêÞò ÉáôñéêÞò óýíôïìá èá äçìéïõñãçèåß óôçí éóôïóåëßäá ôçò ÅðáããåëìáôéêÞò ¸íùóçò

Ä. Ãéáííüðïõëïò

ÃåíéêÞò ÉáôñéêÞò (www.enosigi.gr). üðïõ ïé åíäéáöåñüìåíïé éáôñïß èá Ý÷ïõí ôçí åõêáéñßá íá áíôáëëÜóóïõí åìðåéñßåò êáé íá åêèÝôïõí ðñïâëçìáôéóìïýò üóïí áöïñÜ ôçí äéá÷åßñéóç áóèåíþí åîáñôçìÝíùí áðü ôçí íéêïôßíç.

Ôüìïò 18, Ôåý÷ïò 2, 2006

ÄçìÞôñçò Ãéáííüðïõëïò Ãåíéêüò Éáôñüò Å.Á´ -Áí. ÄéåõèõíôÞò Ê.Õ. ÂÜñäáò-Çëåßáò ÅðéóôçìïíéêÜ Õðåýèõíïò ôïõ Óåìéíáñßïõ E-mail: digianop@otenet.gr

ÅðéôñïðÞ ¸ñåõíáò ÅËÅÃÅÉÁ: “Öéëßððåéï” ÅñãáóôÞñéï ¸ñåõíáò Óôá Øáêïýäéá ×áëêéäéêÞò, ðñáãìáôïðïéÞèçêå áðü ôéò 30 Ìáñôßïõ ùò ôéò 2 Áðñéëßïõ 2006 ôï äåýôåñï ÓåìéíÜñéï ôçò ÅðéôñïðÞò ¸ñåõíáò ôçò ÅËÅÃÅÉÁ, ôï Öéëßððåéï ÅñãáóôÞñé ôçò ¸ñåõíáò, ìå èÝìá: «Áðü ôçí äéáôýðùóç ôïí åñåõíçôéêïý åñùôÞìáôïò óôï ó÷åäéáóìü». Ç Ðñüåäñïò ôçò åðéôñïðÞò ¸ñåõíáò ê. Dr ÓôÝëëá ÁñãõñéÜäïõ, Áíáðë. Ä/íôñéá ôïõ ÊÕ ×ñõóïýðïëçò ÊáâÜëáò, øõ÷Þ êáé åìðíåýóôñéá ôïõ Öéëßððåéïõ Åñãáóôçñßïõ ôçò ¸ñåõíáò óõíÝâáëëå ôá ìÝãéóôá óôçí Üøïãç, ùò ôçí ðáñáìéêñÞ ëåðôïìÝñåéá, äéïñãÜíùóç ôçò åêäÞëùóçò áõôÞò. Ïé åñãáóßåò ôïõ Óåìéíáñßïõ îåêßíçóáí ìå ôï ÷áéñåôéóìü ôïõ ÐñïÝäñïõ ôçò ÅËÅÃÅÉÁ Ìåñêïýñç ÌðïäïóÜêç ðïõ ìå ôïí ÷åéìáññþäç êáé ïõóéþäç ëüãï ôïõ ãéá ôçí Ýñåõíá êáé ôçí ÃåíéêÞ ÉáôñéêÞ óõíåðÞñå ãéá ìéá áêüìç öïñÜ ôï áêñïáôÞñéï ôïõ, åíþ ôç óêõôÜëç ðÞñå óôç óõíÝ÷åéá ï ê. ÄçìÞôñçò ¸ëëçíáò, Ä/íôÞò ÊÕ Ðñßíïõ ÊáâÜëáò, Ãåíéêüò ÓõíôïíéóôÞò åêðáßäåõóçò åéäéêåõïìÝíùí ÃåíéêÞò ÉáôñéêÞò Áíáô. Ìáêåäïíßáò & ÈñÜêçò ìå ôçí éäéáßôåñá åíäéáöÝñïõóá ðáñïõóßáóç ôïõ. Óôéò åðüìåíåò çìÝñåò ïé ïìéëçôÝò Þôáí ïé ê. Dr ÓôÝëëá ÁñãõñéÜäïõ, ï ê. ÄçìÞôñçò Êïýâåëáò ÁíáðëçñùôÞò ÊáèçãçôÞò Öáñìáêïëïãßáò Á.Ð.È.,

ï ê. Ìé÷Üëçò ÊáëïåéäÜò Ãåíéêüò Éáôñüò/ ÊïéíùíéêÞò ÉáôñéêÞò, ìÝëïò ôçò åðéôñïðÞò ¸ñåõíáò ôçò ÅËÅÃÅÉÁ, êáèþò êáé ï ê. ×ñÞóôïò ËéïíÞò ÁíáðëçñùôÞò ÊáèçãçôÞò ÊïéíùíéêÞò êáé ÏéêïãåíåéáêÞò ÉáôñéêÞò Ðáíåðéóôçìßïõ ÊñÞôçò êáé Áíôéðñüåäñïò ôçò ÅËÅÃÅÉÁ. 1⁄4ëïé ïé åêðáéäåõôÝò êáôÜöåñáí ìÝóá áðü Ýíá ðñüôõðï ìïíôÝëï äéäáóêáëßáò ôçò èåùñßáò ìÝóù áóêÞóåùí íá êáëýøïõí ðëÞñùò ôá èåìáôéêÜ áíôéêåßìåíá ôïõ åñãáóôçñßïõ ðïõ Þôáí: ïé ìÝèïäïé Ýñåõíáò, ç ðáñáôÞñçóç êáé ç äéáôýðùóç ôïõ åñåõíçôéêïý åñùôÞìáôïò, ç óõóôçìáôéêÞ áíáóêüðçóç êáé áðïôßìçóç ôçò âéâëéïãñáößáò êáé ç äéáìüñöùóç ôçò åñåõíçôéêÞò ðñüôáóçò. Ïé óõììåôÝ÷ïíôåò - 25 Ãåíéêïß Éáôñïß åéäéêïß êáé åéäéêåõüìåíïé - áðü üëç ôçí ÅëëÜäá åîÞñáí ôï õøçëü åðßðåäï ôùí ðáñïõóéÜóåùí åíþ åõ÷Þ üëùí Þôáí íá âñåèïýìå óýíôïìá ãéá íá ðáñáêïëïõèÞóïõìå ôïí Â’ Êýêëï ôïõ óåìéíáñßïõ. ÁíäñÝïõ ÌÜñèá Ãåíéêüò Éáôñüò, ÅðéìåëÞôñéá Â´ ÊÕ Óôáõñïýðïëçò ÎÜíèçò, ÌÝëïò ôïõ Ðåñéö. ÔìÞìáôïò Áíáô. Ìáêåäïíßáò & ÈñÜêçò ôçò ÅËÅÃÅÉÁ

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å. Èçñáßïò

ÍÅÅÓ ÅÊÄÏÓÅÉÓ NEW EDITIONS Primary Heatlh Care, Volume 18, Number 2, 100-101, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 100-101, 2006

ËáúêÞ ÐáñáäïóéáêÞ ÉáôñéêÞ

ÓõíôïíéóôÞò ¸êäïóçò: Í. ÑáæÞò ×ïñçãßá Ýêäïóçò: Êáëëéìáíïðïýëåéï Åêêëçóéáóôéêü Äéáêïíéêü ÊÝíôñï Êáëáâñýôùí, Á÷áÀá 2006

Áí, óå üëåò ôéò áíèñþðéíåò êïéíùíßåò, ïé ðßóôåéò êáé ïé ðñáêôéêÝò ó÷åôéêÜ ìå ôç íüóï êáé ôçí õãåßá êáôÝ÷ïõí óçìáíôéêÞ èÝóç óôïí áíèñþðéíï ðïëéôéóìü, üðïõ óõ÷íÜ ç íüóïò êáé ç õãåßá áðïôåëïýí ìÝñïò ôçò ãåíéêÞò êïóìïëïãéêÞò åñìçíåßáò ðïõ åíïðïéåß üëåò ôéò ðëåõñÝò ôçò áíèñþðéíçò æùÞò (áôõ÷Þìáôá, äéáðñïóùðéêÝò óõãêñïýóåéò, öõóéêÝò êáôáóôñïöÝò, êáôáóôñïöÝò ôçò óïäåéÜò, áðþëåéåò, õãåßá, åõæùßá êëð). Áí, ç ÷ñÞóç ôùí öõôþí ãéá öáñìáêåõôéêïýò 100

óêïðïýò åßíáé ôüóï ðáëéÜ üóï êáé ï ðïëéôéóìüò êáé ðïëëÜ áðü ôá âüôáíá ðïõ áíáöÝñïíôáé óå áñ÷áßåò óõíôáãÝò Ý÷ïõí ÷ñçóéìïðïéçèåß óôçí ðáñáãùãÞ öáñìÜêùí ãéá ôçí êáôáðïëÝìçóç ðïéêßëùí áóèåíåéþí (êáñäéïôïíùôéêü-äéãïîßíç, áíôéðáñêéíóïíéêü-ëåâïíôüðá, õðáêôéêü-öýëëá óÝííçò êáé ðïëëÜ Üëëá), åíþ êÜðïéåò áðü ôéò åìðåéñéêÝò óõíôáãÝò ðïõ ÷ñçóéìïðïéÞèçêáí ãéá ÷ñüíéá óôçí áíôéìåôþðéóç óõãêåêñéìÝíùí íüóùí Þ óõìðôùìÜôùí, áíáãíùñéóìÝíåò áðü ôïí ðëçèõóìü ùò áðïôåëåóìáôéêÝò, Ý÷ïõí áðïäåßîåé ôçí áðïôåëåóìáôéêüôçôÜ ôïõò ìå ôçí åðéóôçìïíéêÞ Ýñåõíá. Áí, Ýíá óçìáíôéêü æÞôçìá ó÷åôéêÜ ìå ôçí ëáúêÞ ðáñáäïóéáêÞ éáôñéêÞ åßíáé ç ðñïóâáóéìüôçôá óå áõôÞí, áðü ãåùãñáöéêÞò, ðïëéôéóôéêÞò êáé ïéêïíïìéêÞò ðëåõñÜò, ôùí ðéï åõÜëùôùí ðëçèõóìþí, üôáí ç ðñüóâáóç óôçí óýã÷ñïíç éáôñéêÞ óõ÷íÜ äåí åßíáé åöéêôÞ ãé’ áõôïýò, åíþ áðü ôçí Üëëç ðëåõñÜ, ç åêñçêôéêÞ áíÜðôõîç êáé äéÜäïóç äéáöüñùí ìïñöþí ðáñáäïóéáêÞò éáôñéêÞò ðñïêáëåß áíçóõ÷ßá óôéò åõñùðáúêÝò êïéíùíßåò êáé ôá óõóôÞìáôá õãåßáò, ìéáò êáé ëßãá åßíáé ãíùóôÜ ãéá ôçí áðïôåëåóìáôéêüôçôá ôùí ðñïôåéíïìÝíùí èåñáðåéþí êáé áêüìá ëéãüôåñá ãéá ôéò áíåðéèýìçôåò åíÝñãåéÝò ôïõò. Áí, ç óýã÷ñïíç éáôñéêÞ ïöåßëåé íá êáôáíïÞóåé ðåñéóóüôåñï ôá åíäïãåíÞ óôïé÷åßá ôïõ êÜèå ðïëéôéóìïý ãéá íá ìðïñÝóåé íá âïçèÞóåé ôïõò áíèñþðïõò ðïõ ôï Ý÷ïõí áíÜãêç êáé ç áîßá ôçò ãíþóçò ôçò êïõëôïýñáò ôïõ «Üëëïõ» áðïêôÜ éäéáßôåñç óçìáóßá óÞìåñá ìå ôçí áõîáíüìåíç êéíçôéêüôçôá ôùí ðëçèõóìþí. Ôüôå, ç ðñüóöáôç Ýêäïóç 200 ðåñßðïõ óåëßäùí ìå ôïí ôßôëï «ËáúêÞ ÐáñáäïóéáêÞ ÉáôñéêÞ», áðïôÝëåóìá ôçò áîéÝðáéíçò, åðßðïíçò êáé óõóôç-

Å. Èçñáßïò

ìáôéêÞò ðñïóðÜèåéáò ôïõ óõíáäÝëöïõ ê. Íßêïõ ÑáæÞ êáé ôùí óõíåñãáôþí ôïõ, Ý÷åé ôç äéêÞ ôçò îå÷ùñéóôÞ óçìáóßá. Åðéäéþêåé íá áíáäåßîåé ôçí ðïëéôéóôéêÞ êëçñïíïìéÜ óå èÝìáôá ðïõ áöïñïýí ôç ÷ñÞóç âïôÜíùí êáé ðáñáóêåõáóìÜôùí ãéá èåñáðåõôéêïýò óêïðïýò, Ý÷ïíôáò ùò ðñùôáãùíéóôÞ ôïí … ëáúêü Üíèñùðï êáé ôá ãéáôñïóüöéá ôïõ, ðïõ ãéá áéþíåò ðñüóöåñáí ìéá ëýóç óôá ðñïâëÞìáôá õãåßáò ôùí óõíáíèñþðùí ìáò óå ðåñéï÷Ýò êáé åðï÷Ýò üðïõ ï ãéáôñüò äåí ìðïñïýóå íá óõíäñÜìåé. Óôï ðñþôï êåöÜëáéï ôïõ âéâëßïõ ãßíåôáé ìéá óõíïðôéêÞ áëëÜ åîáéñåôéêÜ åíäéáöÝñïõóá éóôïñéêÞ áíáäñïìÞ óôç ÷ñÞóç ôùí âïôÜíùí êáé ôç èåñáðåõôéêÞ éáôñéêÞ áíÜ ôïõò áéþíåò, áðü ôçí åëëçíéêÞ ìõèïëïãßá ìÝ÷ñé ôá óýã÷ñïíá ÷ñüíéá ôçò éóôïñßáò ìáò, ìå ãïçôåõôéêÝò áíáöïñÝò óå áíôéðñïóùðåõôéêÜ Ýñãá åëëÞíùí ëïãïôå÷íþí. Óôá åðüìåíá äåêáåðôÜ êåöÜëáéá ôïõ âéâëßïõ ãéíüìáóôå êïéíùíïß ôçò ãíþóçò êáé ôçò ëáúêÞò óïößáò ðïõ Ýñ÷åôáé áðü ôá âÜèç ôùí áéþíùí ìÝóá áðü ôçí êáôáãñáöÞ óõíçèåéþí êáé ðñáêôéêþí ôùí ðñïãüíùí ìáò ó÷åôéêþí ìå ðáñáäïóéáêÝò èåñáðåõôéêÝò ôå÷íéêÝò, ðïõ Ýöôáóáí óôéò ìÝñåò ìáò ìÝóá áðü áöçãÞóåéò ãåñïíôüôåñùí óõìðïëéôþí áðü äéÜöïñåò ðåñéï÷Ýò ôçò Á÷áÀáò. Ç êåíôñéêÞ èåþñçóç ôçò áíèñùðïëïãßáò óôç äçìüóéá õãåßá áöïñÜ óôï üôé ïé Ýííïéåò õãåßá áññþóôéá-èåñáðåßá åßíáé äéáðñïóùðéêÜ öáéíüìåíá ðïëéôéóìéêÜ êáèïñéóìÝíá êáé ùò ôÝôïéá èá ðñÝðåé íá áíôéìåôùðßæïíôáé, ôüóï óå èåùñçôéêü üóï êáé óå ðñáêôéêü åðßðåäï. Ç äå åèíïãñáöéêÞ Ýñåõíá Ý÷åé áíáäåßîåé óçìáíôéêÝò äéáöïñÝò áíÜìåóá óôç âéïúáôñéêÞ åðéóôÞìç (üðïõ ç êëéíéêÞ ðñáêôéêÞ óôï÷åýåé óôïí åíôïðéóìü ôçò óùìáôéêÞò Þ øõ÷éêÞò äõóëåéôïõñãßáò Þ âëÜâçò êáé ôçí åðáêüëïõèç èåñáðåõôéêÞ ðáñÝìâáóç óôç äéáäéêáóßá ôçò óùìá-

Ôüìïò 18, Ôåý÷ïò 2, 2006

ôéêÞò áóèÝíåéáò) êáé ôçí ðáñáäïóéáêÞ Þ åíáëëáêôéêÞ éáôñéêÞ (ðïõ óôï÷åýåé óôïí åíôïðéóìü ôçò óçìáßíïõóáò åìðåéñßáò êáé ôçò ðñáãìáôéêüôçôáò ôçò áññþóôéáò óôçí êáèçìåñéíÞ æùÞ ôïõ áôüìïõ êáé ÷ñçóéìïðïéåß ðëçñïöïñßåò ðïõ áðïêáëýðôïõí ôï íüçìá ôçò áññþóôéáò ãéá ôç äéÜãíùóç, ìå ôïí Üññùóôï íá áíôéìåôùðßæåôáé ùò ïëüôçôá êáé ìå óêïðü ôç èåñáðåßá ôùí äõóëåéôïõñãéêþí äéáóôÜóåùí ôçò åìðåéñßáò ôçò áññþóôéáò). ¸íá óçìáíôéêü æÞôçìá ãéá ôç äïõëåéÜ ôùí ëåéôïõñãþí ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ç ïðïßá åìðåñéÝ÷åé ìéá ïëéóôéêÞ ïðôéêÞ êáé äéåðéóôçìïíéêÞ ðñïóÝããéóç ãéá ôçí õãåßá, åßíáé ç äõíáôüôçôá êáôáíüçóçò ôùí ðïéêßëùí ìïñöþí êáé ôñüðùí Ýêöñáóçò ôçò éäéáéôåñüôçôáò êáé ôçò äéáöïñåôéêüôçôáò ôùí õðïêåéìåíéêþí êáé êïéíùíéêþí åìðåéñéþí ôçò õãåßáò êáé ôçò áññþóôéáò, ðÝñá áðü ôá óôåíÜ üñéá ôïõ íïóïêïìåßïõ êáé ôùí õðçñåóéþí õãåßáò, óôçí êïéíùíéêÞ ðáñáãùãÞ ôçò õãåßáò óôï ðëáßóéï ôçò êïéíüôçôáò. Óôçí êáôåýèõíóç áõôÞ ç ðáñïýóá Ýêäïóç êáôáèÝôåé ôç äéêÞ ôçò óõìâïëÞ, üôáí ìÜëéóôá óôá ðñþôá áðïôåëÝóìáôá ìéáò ðñüóöáôçò ìåëÝôçò ðåäßïõ, ðïõ áðïôåëåß ìÝñïò ôïõ åñåõíçôéêïý Ýñãïõ ìå ôßôëï “Traditional Medicine Across European and Asian Cultures” (TMEA – ASIA IT&C Programme) ìå ôç óõììåôï÷Þ ôçò ×åéñïõñãéêÞò ÊëéíéêÞò ôïõ ÔìÞìáôïò ÍïóçëåõôéêÞò ôïõ Êáðïäéóôñéáêïý Ðáíåðéóôçìßïõ Áèçíþí (ÓõíôïíéóôÞò ï ÊáèçãçôÞò ê. Ã. ÌðïíÜôóïò), áíáöÝñåôáé, üôé Ýíáò, ü÷é åõêáôáöñüíçôïò, áñéèìüò éáôñþí Ð.Ö.Õ. ÷ñçóéìïðïéåß Þ óõíéóôÜ ôç ÷ñÞóç ðáñáäïóéáêþí óõíôáãþí ãéá ôç èåñáðåßá óõìðôùìÜôùí üðùò ç äéÜññïéá, ï ðõñåôüò êáé ï ðïíïêÝöáëïò. ÅëåõèÝñéïò Èçñáßïò ÁíáðëçñùôÞò ÄéåõèõíôÞò Óýíôáîçò

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Ôüìïò 18, Ôåý÷ïò 2, 2006

ÅÊÐÁÉÄÅÕÔÉÊÁ ÌÁÈÇÌÁÔÁ ÓÔÇ ÃÅÍÉÊÇ ÉÁÔÑÉÊÇ EDUCATIONAL COURSES FOR GENERAL PRACTICE Primary Heatlh Care, Volume 18, Number 2, 101, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 101, 2006

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÐÑÏÓÅ×Ç ÓÕÍÅÄÑÉÁ ÊÁÉ ÓÅÌÉÍÁÑÉÁ UPCOMING CONGRESSES AND SEMINARS Primary Heatlh Care, Volume 18, Number 2, 102, 2006 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 18, Ôåý÷ïò 2, 102, 2006

Çìåñïìçíßá ÅëëçíéêÜ ÓõíÝäñéá 21-24 Óåðôåìâñßïõ

28-30 Óåðôåìâñßïõ

28 Óåðôåìâñßïõ – 1 Ïêôùâñßïõ

7 Ïêôùâñßïõ

9-12 Íïåìâñßïõ

13-16 Íïåìâñßïõ

ÄéåèíÞ ÓõíÝäñéá 27–30 Áõãïýóôïõ

23-24 Óåðôåìâñßïõ

ÅêäÞëùóç - Ðëçñïöïñßåò 2ï Ðáìðåëïðïííçóéáêü Óõìðüóéï ÃåíéêÞò ÉáôñéêÞò - ÅËÅÃÅÉÁ (ÔìÞìá ÐåëïðïííÞóïõ) ÊáëáìÜôá, Îåíïäï÷åßï Elite Ðëçñïöïñßåò: www.elegeia.gr 8ï ÐáíåëëÞíéï ÓõíÝäñéï Management Õðçñåóéþí Õãåßáò & ÊïéíùíéêÞò Öñïíôßäáò ÅñÝôñéá, Îåíïäï÷åßï Eretria Village Ðëçñïöïñßåò: www.mediforce.gr 18ï ÅôÞóéï ÐáíåëëÞíéï ÓõíÝäñéï ÊïéíùíéêÞò ÐáéäéáôñéêÞò ìå èÝìá: “Ðáéäß, Õãåßá êáé Ðïëéôéóìüò” – ÅëëçíéêÞ Åôáéñåßá ÊïéíùíéêÞò ÐáéäéáôñéêÞò & ÐñïáãùãÞò ôçò Õãåßáò ÇñÜêëåéï, ÔìÞìá ÉáôñéêÞò Ðáíåðéóôçìßïõ ÊñÞôçò Ðëçñïöïñßåò: www.socped.gr ×ñüíéá ÍïóÞìáôá óôçí Ð.Ö.Õ. Áðü ôç èåùñßá óôçí ðñÜîç Óõíåäñéáêü ÊÝíôñï Èåóóáëïíßêçò “POLIS” Ðëçñïöïñßåò: www.elegeia.gr 13ï ÐáãêñÞôéï Éáôñéêü ÓõíÝäñéï ÇñÜêëåéï, Îåíïäï÷åßï Candia Maris Ðëçñïöïñßåò: pagritiosinedrio2006@mikatravel.com 2ï ÐáíåëëÞíéï ÓõíÝäñéï ãéá ôç Äéïßêçóç, ôá ÏéêïíïìéêÜ êáé ôéò ÐïëéôéêÝò Õãåßáò ìå èÝìá “ÔåêìçñéùìÝíç Öñïíôßäá Õãåßáò êáé ÕãåéïíïìéêÞ Ìåôáññýèìéóç” ÁèÞíá, Îåíïäï÷åßï Hilton Ðëçñïöïñßåò: www.healthcongress.g WONCA EUROPE 2006 – 12th Regional Conference “Towards Medical Renaissance: bridging the gap between biology and Humanities” Florence, Italy Ðëçñïöïñßåò: www.woncaeurope2006.org EURACT 2nd Annual Meeting of GP/FM Teachers in Europe “Assessment in

FP/GP”

19-22 Ïêôùâñßïõ

Kranjska Gora, Slovenia Ðëçñïöïñßåò: www.drmed.org EGPRN Meeting “Community Orientation in Primary Care” ÊáâÜëá, Îåíïäï÷åßï Lucy Ðëçñïöïñßåò: www.egprn.org & http://www.egprn-kavala.eu

5-9 Íïåìâñßïõ

15th WONCA Asia Pacific Regional Conference “Happy and Healthy Family” Bangkok, Singapore

23-25 Íïåìâñßïõ

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Ðëçñïöïñßåò: www.thaifammed.org EQuiP Conference “The impact of Health System Reform on quality in GP/FM” Barcelona, Spain Ðëçñïöïñßåò: www.equip.ch

ÏÄÇÃÉÅÓ ÃÉÁ ÔÏÕÓ ÓÕÃÃÑÁÖÅÉÓ INSTRUCTIONS FOR THE AUTHORS Ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äÝ÷åôáé ãéá äçìïóßåõóç êåßìåíá Åðéóôçìüíùí Õãåßáò, ôá ïðïßá êáôáôÜóóïíôáé óôéò åîÞò êáôçãïñßåò: 1) ÅñåõíçôéêÝò åñãáóßåò Þ áíáóêïðÞóåéò, 2) ÅíçìåñùôéêÜ Üñèñá, 3) Óýíôïìá Üñèñá (óýíôïìåò äçìïóéåýóåéò) Ýêôáóçò ìÝ÷ñé 7 óåëßäåò ìå ðñüóöáôåò ü÷é Üíù áðü 5 âéâëéïãñáöéêÝò ðçãÝò, 4) ÁíáöïñÝò ðåñéðôþóåùí, 5) ÐáñïõóéÜóåéò ÊÝíôñùí Õãåßáò. ¸íá óýíïëï êåéìÝíùí, ðïõ áöïñïýí Ýíá óõãêåêñéìÝíï ãíùóôéêü ôïìÝá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ìðïñåß íá óõãêñïôåß ÁöéÝñùìá. Åêôüò ôùí êåéìÝíùí ðïõ áíáöÝñïíôáé óôéò ðáñáðÜíù êáôçãïñßåò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé Üñèñá ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò, êáèþò êáé êåßìåíá ðïõ áðïóêïðïýí óôçí ðáñïõóßáóç, ó÷ïëéáóìü êáé êñéôéêÞ áîéïëüãçóç óõãêåêñéìÝíùí ãåãïíüôùí, Üñèñùí êáé åêäüóåùí ó÷åôéêþí ìå ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, óôçí ÅëëÜäá êáé óôï åîùôåñéêü. Ôçí åõèýíç ôçò óõããñáöÞò ôùí Üñèñùí áõôþí Þ êåéìÝíùí Ý÷ïõí ìüíï ôá ìÝëç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò Þ åðéóôÞìïíåò ìåôÜ áðü åéäéêÞ ðñüóêëçóç. Åðßóçò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé ãñÜììáôá ðïõ áðåõèýíïíôáé óôç ÓõíôáêôéêÞ ÅðéôñïðÞ, ôá ïðïßá áíáöÝñïíôáé óå ðáñáôçñÞóåéò, êëéíéêÝò êáé åñåõíçôéêÝò åìðåéñßåò Þ ó÷ïëéÜæïõí ôç äéåèíÞ êáé åëëçíéêÞ âéâëéïãñáößá. Ôçí åõèýíç ãéá ôç äçìïóßåõóç ôùí êåéìÝíùí áõôþí Ý÷åé ï ÄéåõèõíôÞò Óýíôáîçò êáé ç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ïé åñåõíçôéêÝò åñãáóßåò, ôá åíçìåñùôéêÜ Üñèñá, ïé óýíôïìåò äçìïóéåýóåéò êáé ïé áíáöïñÝò ðåñéóôáôéêþí ãßíïíôáé äåêôÜ ãéá äçìïóßåõóç ìüíï ìåôÜ áðü èåôéêÞ êñßóç ôïõò áðü åðéóôÞìïíåò-êñéôÝò ìå ôïõò ïðïßïõò óõíåñãÜæåôáé ôï ðåñéïäéêü. ÊÜèå êåßìåíï ðïõ áðïóôÝëëåôáé óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äéáâéâÜæåôáé óôïõò êñéôÝò, ÷ùñßò íá ãíùóôïðïéïýíôáé ôá ïíüìáôá ôùí óõããñáöÝùí. Ôá ó÷üëéá êáé ïé ðáñáôçñÞóåéò ôùí êñéôþí óôç óõíÝ÷åéá, ìå ôçí åõèýíç ôçò Ãñáììáôåßáò Óýíôáîçò ôïõ ðåñéïäéêïý, åðéóôñÝöïíôáé óôïõò óõããñáöåßò, ðñïêåéìÝíïõ áõôïß íá ðñïóáñìüóïõí áíÜëïãá ôï êåßìåíü ôïõò ðñéí ôç äçìïóßåõóç. Óå ðåñßðôùóç áóõìöùíßáò ôùí êñéôþí, ôï êåßìåíï èá áîéïëïãåßôáé áðü ôçí ßäéá ôç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ôá ïíüìáôá üëùí ôùí åðéóôçìüíùí ðïõ äéåôÝëåóáí êñéôÝò èá äçìïóéåýïíôáé óå åéäéêÞ óåëßäá óôï ôåëåõôáßï ôåý÷ïò êÜèå ÷ñüíïõ. Ôá êåßìåíá, ôá ïðïßá äÝ÷åôáé ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò", èá ðñÝðåé íá áêïëïõèïýí ôéò ðáñáêÜôù ðñïäéáãñáöÝò. • Íá åßíáé ãñáììÝíá óôçí åðßóçìç äçìïôéêÞ ãëþóóá êáé ìå ôï ìïíïôïíéêü óýóôçìá, äáêôõëïãñáöçìÝíá óôç ìéá üøç ôçò óåëßäáò, óå äéðëü äéÜóôçìá êáé ìå ëåõêü ðåñéèþñéï 3 åêáôïóôþí óå üëåò ôéò ðëåõñÝò ôïõò. • Ç ðñþôç óåëßäá ôïõ êåéìÝíïõ ðñÝðåé íá ðåñéëáìâÜíåé: á) ôïí ôßôëï (ìå ðåæÜ ãñÜììáôá), â) ôá ïíüìáôá ôùí óõããñáöÝùí (ìå êåöáëáßá ãñÜììáôá åíþ áíáãñÜöïíôáé ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá ðëÞñç åðþíõìá ìå áñéèìçôéêïýò åêèÝôåò ïé ïðïßïé óå õðïóçìåßùóç ðáñïõóéÜæïõí ôçí éäéüôçôá ôïõ êÜèå óõããñáöÝá), ã) ôï åðéóôçìïíéêü êÝíôñï óôï ïðïßï Ýãéíå ç åñãáóßá, ä) 3-5 ðñüóèåôïõò üñïõò ó÷åôéêÜ ìå ôï èÝìá êáé ïé ïðïßïé åßíáé õéïèåôçìÝíïé áðü ôï Medical Subject Headings (Bethesda Md, 1966), å) ôç äéåýèõíóç êáé ôï ôçëÝöùíï åíüò áðü ôïõò óõããñáöåßò, ï ïðïßïò èá åßíáé õðåýèõíïò ãéá ôçí áëëçëïãñáößá ìå ôï ðåñéïäéêü. • Óå îå÷ùñéóôÞ äåýôåñç óåëßäá ðñÝðåé íá ãñÜöåôáé ç åëëçíéêÞ ðåñßëçøç ôïõ êåéìÝíïõ (ðñïçãåßôáé ç Ýíäåéîç ÐÅÑÉËÇØÇ), ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. • ÌåôÜ ôï êåßìåíï óå îå÷ùñéóôÞ óåëßäá èá ðñÝðåé íá ãñÜöåôáé ç áããëéêÞ ðåñßëçøç ôïõ êåéìÝíïõ, ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. Ðñïçãïýíôáé ç ëÝîç SUMMARY, ç áããëéêÞ ìåôÜöñáóç ôïõ ôßôëïõ, ïé ëÝîåéò PRIMARY HEALTH CARE... êáé ôá ïíüìáôá ôùí óõããñáöÝùí ÷ùñßò ôßôëï Þ éäéüôçôá. • Ïé âéâëéïãñáöéêÝò ðáñáðïìðÝò, åëëçíéêÝò êáé îÝíåò, óôï êåßìåíï èá ðñÝðåé íá åßíáé ðñüóöáôåò, áðü áíáãíùñéóìÝíá ðåñéïäéêÜ Þ óõããñÜììáôá, íá åßíáé áñéèìçìÝíåò êáé í’ áíôáðïêñßíïíôáé óôï âéâëéïãñáöéêü êáôÜëïãï, ï ïðïßïò èá ðñÝðåé íá ãñÜöåôáé óå îå÷ùñéóôÞ óåëßäá ìåôÜ ôï ãñÜøéìï ôçò áããëéêÞò ðåñßëçøçò. Óôï âéâëéïãñáöéêü êáôÜëïãï ïé ðáñáðïìðÝò èá ðñÝðåé í’ áêïëïõèïýí ôç óåéñÜ ìå ôçí ïðïßá ðáñïõóéÜóôçêáí óôï êåßìåíï. ÊáèåìéÜ áðü áõôÝò èá ðñÝðåé íá ðåñéÝ÷åé óôç óåéñÜ ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá åðþíõìá ôùí óõããñáöÝùí, ôïí ôßôëï ôçò åñãáóßáò, ôï üíïìá ôïõ ðåñéïäéêïý óýìöùíá ìå ôï óýóôçìá ôçò WHOCISO/R4), ôïí ôüìï, ôçí ðñþôç êáé ôçí ôåëåõôáßá óåëßäá ôïõ Üñèñïõ, êáèþò êáé ôï Ýôïò äçìïóßåõóçò. 1⁄4ôáí ðñüêåéôáé ãéá óõããñÜììáôá Þ ìïíïãñáößåò, åêôüò áðü ôïõò óõããñáöåßò, ôï Ýôïò Ýêäïóçò êáé ôïí ôßôëï, ðñÝðåé íá ãñÜöïíôáé êáé ï áñéèìüò êáé ôá óôïé÷åßá Ýêäïóçò (åêäïôéêüò ïßêïò, ðüëç). (õðüäåéãìá âéâëéïãñáößáò: Biziagos E, Moschandrea J, Kouroumalis ÅÁ. Prevalence of hepatitis Â and C markers in volunteer blood donors in Crete. A 5-year study. J Viral Hepat, 6:243-8, 1999.). • Ïé ðßíáêåò êáé ôá ó÷Þìáôá áêïëïõèïýí ôï âéâëéïãñáöéêü êáôÜëïãï êáé èá ðñÝðåé íá ðáñïõóéÜæïíôáé óå ÷ùñéóôÝò óåëßäåò, íá öÝñïõí ëáôéíéêÞ áñßèìçóç, ç ïðïßá èá ðñÝðåé í’ áíôáðïêñßíåôáé óôéò ðáñáðïìðÝò ôïõ êåéìÝíïõ, êáèþò êáé ôéò áðáñáßôçôåò åðåîçãÞóåéò. • 'Ïëá ôá êåßìåíá èá ðñÝðåé íá õðïâÜëëïíôáé óå ÷Üñôéíç êáé çëåêôñïíéêÞ ìïñöÞ, êáé èá õðïâÜëëïíôáé óå äýï áíôßôõðá óôç äéåýèõíóç ôïõ ÄéåõèõíôÞ Óýíôáîçò: - ÐáíåðéóôÞìéï ÊñÞôçò (õðüøç AíáðëçñùôÞ ÊáèçãçôÞ ×. ËéïíÞ), ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò, Ô.È. 1393, ÇñÜêëåéï ÊñÞôçò. Êáèþò êáé óôï e-mail: tasrom@yahoo.com.uk Ïé óõããñáöåßò èá ðñÝðåé íá äåóìåýïíôáé óôçí åðéóôïëÞ ôïõò üôé ç åñãáóßá äåí Ý÷åé õðïâëçèåß Þ äåí Ý÷åé äçìïóéåõèåß åí üëù Þ åí ìÝñåé óå Üëëï ðåñéïäéêü, üôé üëïé ïé óõããñáöåßò åßíáé óýìöùíïé ìå ôçí áðïóôïëÞ ôçò êáé óå ðåñßðôùóç áðïäï÷Þò ôçò ãéá äçìïóßåõóç, ôá óõããñáöéêÜ äéêáéþìáôá åê÷ùñïýíôáé óôï ðåñéïäéêü. Ç ÓõíôáêôéêÞ ÅðéôñïðÞ äéáôçñåß ôï äéêáßùìá áðïóýñóåùò ìéáò åñãáóßáò åöüóïí áõôÞ Ý÷åé óôáëåß êáé ó' Üëëï ðåñéïäéêü. 103

Ðáñáããåëßá áíáôýðùí

Ïé áíáãíþóôåò ôçò "ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò", Ãåíéêïß Ãéáôñïß, ïé ïðïßïé åðéèõìïýí íá Ý÷ïõí óå áíÜôõðá êÜðïéï Þ êÜðïéá áðü ôá äçìïóéåõüìåíá óôï ôåý÷ïò Üñèñá, ìðïñïýí íá ðáñáãÝëëïõí ôïí áñéèìü ôùí áíôéôýðùí óôï "Ôå÷íüãñáììá" (ç äéåýèõíóç êáé ôá ôçëÝöùíá äçìïóéåýïíôáé óôï êÜôù ìÝñïò äåîéÜ ôïõ ðßíáêá). Ïé ôéìÝò ãéá êÜèå áñéèìü áíôéôýðùí ðáñáôßèåíôáé óôïí êáôùôÝñù ðßíáêá.

ÁíÜôõðá

Óåëßäåò/Êüóôïò

50 áíÜôõðá

4/44,00 EÕÑÙ

8/74,00 EÕÑÙ

16/118,00 EÕÑÙ

100 áíÜôõðá

4/50,00 EÕÑÙ

8/88,00 EÕÑÙ

16/174,00 EÕÑÙ

200 áíÜôõðá

4/60,00 EÕÑÙ

8/118,00 EÕÑÙ

16/177,00 EÕÑÙ

500 áíÜôõðá

4/88,00 EÕÑÙ

8/147,00 EÕÑÙ

16/235,00 EÕÑÙ

"Ôå÷íüãñáììá" ÌÜñêïõ ÁõãÝñç 12 - 153 43 Áã. ÐáñáóêåõÞ Ôçë.: 210.60.00.643, Fax: 210.60.02.295 e-mail: techn@hol.gr

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