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ðñùôïâÜèìéá Ôüìïò 16, Ôåý÷ïò 1, ÉáíïõÜñéïò - ÌÜñôéïò 2004

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 16, Ôåý÷ïò 1, ÉáíïõÜñéïò - ÌÜñôéïò 2004, Volume 16, Number 1, January - March 2004

Ôçò Óýíôáîçò 6

×. ËéïíÞò, Ì. Ìåñêïýñçò, Ã. ÌðÝëëïò: Ç áîéïëüãçóç ôçò åêðáßäåõóçò ôùí åéäéêåõïìÝíùí ãåíéêÞò éáôñéêÞò óôçí ÅëëÜäá: Áðü ôç ìáôéÜ ôïõ åîåôáóôÞ óôéò éáôñéêÝò åîåôÜóåéò ãéá ôç ëÞøç ôçò åéäéêüôçôáò ÅñåõíçôéêÜ ¢ñèñá

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Ã. Ôóá÷Üêç, Á. ÊñáóáíÜêç, Ê. Êïýôñá, Ì. Ôóéáëêïýôç, Í. ÁíôùíÜêçò: Ç ôñßôç çëéêßá êáé ïé õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óå ìéá áãñïôéêÞ ðåñéï÷Þ ôçò ÊñÞôçò Ã.Ó. Ôóßñïò, Ð. ÂïÀëá, Ä.Ê. Êáëïãåñüðïõëïò, Å. Ãåëáóôïðïýëïõ, Ê.É. ×ñõóáíèüðïõëïò: Áîéïëüãçóç ôçò ÷ñÞóçò ôïõ äéáäéêôýïõ áðü ôï éáôñéêü ðñïóùðéêü åíüò Ðáíåðéóôçìéáêïý Nïóïêïìåßïõ Â. Ôóïýíéáò, Ì. Ãåùñãüðïõëïò: Óõ÷íüôçôá åìöÜíéóçò ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ Áíáóêüðçóç

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Å.Ã. Öáâßïõ: Ç äéáöïñéêÞ äéÜãíùóç ôçò óéäçñïðåíéêÞò áíáéìßáò áðü ôçí åôåñüæõãç â èáëáóóáéìßá äéá ôùí åñõèñïêõôôáñéêþí äåéêôþí Åðßêáéñï ¢ñèñï

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Ð.Ì. ÄáíäïõëÜêçò: Ëåéôïõñãßá äçìïôéêïý íïóïêïìåßïõ áðïêáôÜóôáóçò õðåñçëßêùí óôçí Áããëßá Ã.É. Ôóßñïò, Ð.Å. ÂïÀëá, Ä.Ê. Êáëïãåñüðïõëïò, Á.É. Ôóßñïõ, Ã.Ä. ÌïõæÜêçò: Ç éáôñéêÞ ôå÷íïëïãßá óôéò áñ÷Ýò ôïõ 21ïõ áéþíá ÁíáöïñÜ ðåñßðôùóçò

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Á. ÂÞôáò: ÓðÜíéá åíôüðéóç ôïõ óôçèáã÷éêïý ðüíïõ óå áóèåíÞ ðïõ õðÝóôç ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ ÃñÜììá óôïí Åêäüôç

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Ó. ÁñãõñéÜäïõ, Á. Ìáñéüëçò: Êñßóåéò ðåñéëÞøåùí ôïõ 15ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò ÍÝá

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

ÐáíåðéóôÞìéï Áèçíþí: Ðñüãñáììá Ìåôáðôõ÷éáêþí Óðïõäþí óôçí "ÐñïáãùãÞ êáé ÁãùãÞ Õãåßáò"

Áñéèìüò ¢äåéáò 451/91

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ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ Ôá÷. Ãñáöåßï Ê. Ä. Áèçíþí

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

Óýíôïìç áíáöïñÜ 36

ISSN 1105-7432

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


ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care

ÅÊÄÏÔÇÓ:

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

Äéïéêçôéêü Óõìâïýëéï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Ðñüåäñïò ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Áíôéðñüåäñïò Á ×ñÞóôïò ËéoíÞò Áíôéðñüåäñïò  Áíôþíçò Êáñüôóçò Ãåíéêüò ÃñáììáôÝáò-Ôáìßáò ÁèáíÜóéïò Óõìåùíßäçò Åéäéêüò ÃñáììáôÝáò ÓôÝëëá ÁñãõñéÜäïõ ÌÝëç ÁíÜñãõñïò Ìáñéüëçò Áíôþíçò Ìðáôßêáò

ISSN 1105-7432

ÄéåõèõíôÞò Óýíôáîçò

Editor-in-Chief

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

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

ÁíáðëçñùôÝò Ä/íôÝò Óýíôáîçò

Associate Editors

Íßêïò ÁíôùíÜêçò (ÇñÜêëåéï) ÅëåõèÝñéïò Èçñáßïò (ÁèÞíá)

Nick Antonakis (Heraklio) Åleftherios Thireos (Athens)

Åðßêïõñïé Ä/íôÝò Óýíôáîçò

Assistant Editors

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

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

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

Members of Editorial Board

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

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

ÁíôáðïêñéôÝò Óýíôáîçò

Corresponding Editors

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

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

ÓõìâïõëåõôéêÞ ÅðéôñïðÞ

Advisory Board

Ð. ÂÜñäáò, ÊáèçãçôÞò Êáñäéïëïãßáò Ðáí/ìßïõ ÊñÞôçò

P. Vardas, Professor of University of Crete

Vice-President A Christos Lionis

Ä. ÃëÜñïò, ÊáèçãçôÞò ÉáôñéêÞò ÖõóéêÞò Ðáí/ìßïõ Éùáííßíùí

D. Glaros, Professor of University of Ioannina

Vice-President B Antonis Karotsis

É. Êõñéüðïõëïò, ÊáèçãçôÞò ÅèíéêÞò Ó÷ïëÞò Äçìüóéáò Õãåßáò

J. Kyriopoulos, Professor of National School of Public Health

Â. ÌáõñÝáò, ÊáèçãçôÞò Øõ÷éáôñéêÞò Ðáí/ìßïõ Éùáííßíùí

V. Mavreas, Professor of University of Ioannina

M. ÓãÜíôæïò, ËÝêôïñáò Áíáôïìßáò Ðáí/ìßïõ Èåóóáëßáò

M. Sgantzos, Lector of Anatomy in University of Thessalia

Special Secretary Stella Argiriadou

K. Óéáìüðïõëïò, ÊáèçãçôÞò Íåöñïëïãßáò Ðáí/ìßïõ Éùáííßíùí

K. Siamopoulos, Professor of University of Ioannina

Members Anargiros Mariolis Antonis Batikas

Í. ÓéáöÜêáò, ÊáèçãçôÞò Ðíåõìïíïëïãßáò Ðáí/ìßïõ ÊñÞôçò

N. Siafakas, Professor of University of Crete

K. Óïõëéþôçò ÄéäÜêôùñ Ïéêïíïìéêþí êáé ÐïëéôéêÞò Õãåßáò

K. Souliotis, PhD, Health Policy and Economics

Ë. ÓðÜñïò, ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ Áèçíþí

L. Sparos, Professor of University of Athens

Á. ÖéëáëÞèçò, Áíáðë. ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ ÊñÞôçò

A. Philalithis, Associate Professor of University of Crete

Ã. ×ñéóôïäïýëïõ, ÊáèçãçôÞò Øõ÷éáôñéêÞò Ðáí/ìßïõ Áèçíþí

G. Christodoulou, Professor of University of Athens

Executive Board of the Greek Association of General Practitioners President Bodosakis-Prodromos Merkouris

General Secretary Treasurer Athanasios Symeonidis

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


ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 16, Ôåý÷ïò 1, ÉáíïõÜñéïò - ÌÜñôéïò 2004, Volume 16, Number 1, January - March 2004

ÐÅÑÉÅ×ÏÌÅÍÁ Ôçò Óýíôáîçò ×. ËéïíÞò, Ì. Ìåñêïýñçò, Ã. ÌðÝëëïò: Ç áîéïëüãçóç ôçò åêðáßäåõóçò ôùí åéäéêåõïìÝíùí ãåíéêÞò éáôñéêÞò óôçí ÅëëÜäá: Áðü ôç ìáôéÜ ôïõ åîåôáóôÞ óôéò éáôñéêÝò åîåôÜóåéò ãéá ôç ëÞøç ôçò åéäéêüôçôáò ...................................................... 6 ÅñåõíçôéêÜ ¢ñèñá Ã. Ôóá÷Üêç, Á. ÊñáóáíÜêç, Ê. Êïýôñá, Ì. Ôóéáëêïýôç, Í. ÁíôùíÜêçò: Ç ôñßôç çëéêßá êáé ïé õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óå ìéá áãñïôéêÞ ðåñéï÷Þ ôçò ÊñÞôçò .............................................................................................................. 8 Ã.Ó. Ôóßñïò, Ð. ÂïÀëá, Ä.Ê. Êáëïãåñüðïõëïò, Å. Ãåëáóôïðïýëïõ, Ê.É. ×ñõóáíèüðïõëïò: Áîéïëüãçóç ôçò ÷ñÞóçò ôïõ äéáäéêôýïõ áðü ôï éáôñéêü ðñïóùðéêü åíüò Ðáíåðéóôçìéáêïý Íïóïêïìåßïõ ................................. 11 Â. Ôóïýíéáò, Ì. Ãåùñãüðïõëïò: Óõ÷íüôçôá åìöÜíéóçò ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ ........................................................................................................................................................................ 18 Áíáóêüðçóç Å.Ã. Öáâßïõ: Ç äéáöïñéêÞ äéÜãíùóç ôçò óéäçñïðåíéêÞò áíáéìßáò áðü ôçí åôåñüæõãç â èáëáóóáéìßá äéá ôùí åñõèñïêõôôáñéêþí äåéêôþí ............................................................................................................................................................................................. 23 Åðßêáéñï ¢ñèñï Ð.Ì. ÄáíäïõëÜêçò: Ëåéôïõñãßá äçìïôéêïý íïóïêïìåßïõ áðïêáôÜóôáóçò õðåñçëßêùí óôçí Áããëßá ................................................. 31 Óýíôïìç ÁíáöïñÜ Ã.É. Ôóßñïò, Ð.Å. ÂïÀëá, Ä.Ê. Êáëïãåñüðïõëïò, Á.É. Ôóßñïõ, Ã.Ä. ÌïõæÜêçò: Ç éáôñéêÞ ôå÷íïëïãßá óôéò áñ÷Ýò ôïõ 21ïõ áéþíá ........................................................................................................................................................................................................................................... 36 ÁíáöïñÜ Ðåñßðôùóçò Á. ÂÞôáò: ÓðÜíéá åíôüðéóç ôïõ óôçèáã÷éêïý ðüíïõ óå áóèåíÞ ðïõ õðÝóôç ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ .......................... 40 ÃñÜììá óôïí Åêäüôç Ó. ÁñãõñéÜäïõ, Á. Ìáñéüëçò: Êñßóåéò ðåñéëÞøåùí ôïõ 15ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò ...................................... 45 ÍÝá ÐáíåðéóôÞìéï Áèçíþí: Ðñüãñáììá Ìåôáðôõ÷éáêþí Óðïõäþí óôçí "ÐñïáãùãÞ êáé ÁãùãÞ Õãåßáò" ............................................. 47

CONTENTS Editorial Ch. Lionis, M. Merkouris, G. Bellos: Ôhe assessment of vocational trainig in General Practice in Greece .................................... 6 Original Papers G. Tsachaki, A. Krasanaki, K. Koutra, M. Tsialkouti, N. Antonakis: Primary Health Care services for elderly in a rural area ........................................................................................................................................................................................................................ 8 G. Tsiros, P. Voila, D. Kalogeropoulos, E. Jelastopulu, K. Chrisanthopoulos: Evaluation of using the Internet by physicians of a University Hospital ............................................................................................................... 11 B. Tsounias, M. Georgopoulou: Prevalence of oral lichen planus in patients with diabetes mellitus type ÉÉ ................................ 18 Reviews E.G. Faviou: The differentiation of iron deficiency from â-thalassemia trait by means of the erythrocytes indices ................................................................................................................................................................................................................. 23 Current Paper M. Dandoulakis: Function of a community hospital of rehabilitation of elder people in England ......................................................... 31 Brief Report G. Tsiros, P. Voila, D. Kalogeropoulos, A. Tsirou, G. Mouzakis: Medical technology in the beginning of 21st century ........... 36 Case Report A.G. Vitas: Extremely rare localization of the angina pectoris pain in patient who suffered from acute myocardial infarct ............................................................................................................................................................................ 40 Letter to the Editor S. Argiriadou, A. Mariolis: Assessment of abstracts submitted at the 15th Hellenic Congress of General Practice ............ 45 Íews University of Athens: A Postgraduate Programme on "Health Promotion and Education" ....................................................................... 47


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

×. ËéïíÞò êáé óõí.

THÓ ÓÕÍÔÁÎÇÓ ÅDITORIAL Primary Heatlh Care, Volume 16, Number 1, 6-7, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 6-7, 2004

Ç áîéïëüãçóç ôçò åêðáßäåõóçò ôùí åéäéêåõïìÝíùí ÃåíéêÞò ÉáôñéêÞò óôçí ÅëëÜäá: Áðü ôç ìáôéÜ ôïõ åîåôáóôÞ óôéò éáôñéêÝò åîåôÜóåéò ãéá ôç ëÞøç ôçò åéäéêüôçôáò ÁñêåôÞ óõæÞôçóç ãßíåôáé ãéá ôçí áðïôåëåóìáôéêüôçôá ôçò åðáããåëìáôéêÞò åéäßêåõóçò óôç ÃåíéêÞ ÉáôñéêÞ, êáé äéÜöïñá ó÷Þìáôá ïñãÜíùóçò ôçò áíáæçôïýíôáé. Ìéá óõóôçìáôéêÞ áîéïëüãçóç ìÝ÷ñé óÞìåñá äåí Ý÷åé ãßíåé êáé ç óçìåñéêÞ ðñïóÝããéóç ðñïóäïêÜ óôï íá óõìâÜëëåé óôï äéÜëïãï ðïõ Ý÷åé áíïßîåé ç ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò (ÅËÅÃÅÉÁ) êáé ç ÅðéôñïðÞ ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò ôïõ ÊÅÓÕ. Ç áîéïëüãçóç áõôÞ èá ìðïñïýóå íá åêôéìÞóåé ôçí áðïôåëåóìáôéêüôçôá ôçò åêðáßäåõóçò ìå âÜóç ôï åðßðåäï ôçò ãíþóçò ôùí åéäéêåõèÝíôùí, ôéò áðïêôçèåßóåò äåîéüôçôåò (skills) êáé åðáããåëìáôéêÝò áîßåò (values). Méá ôÝôïéá ìåèïäïëïãéêÞ ðñïóÝããéóç ðñïûðïèÝôåé Ýíá áðïäåêôü ïñéóìü ôçò ãåíéêÞò éáôñéêÞò êáé óáöÞ ðñïóäéïñéóôéêÜ ÷áñáêôçñéóôéêÜ êáé éêáíüôçôåò ôïõ ãéáôñïý ãåíéêÞò éáôñéêÞò. ¸íá ôÝôïéïò ïñéóìüò åßíáé óÞìåñá äéáèÝóéìïò êáé åßíáé áðïôÝëåóìá ìéáò ÅõñùðáúêÞò Ïìïöùíßáò (WONCA, Europe 2002)1. ¢ëëç ðñïûðüèåóç åßíáé ï ðñïóäéïñéóìüò ôùí "åðáñêþí" ãíþóåùí êáé êáôÜëëçëùí äåîéïôÞôùí ðïõ ðñÝðåé íá äéáèÝôåé ï ãéáôñüò ãåíéêÞò éáôñéêÞò ðïõ ìå ôç óåéñÜ ôçò ðáñáðÝìðåé óå åðéäçìéïëïãéêÜ ðñüôõðá ðïõ áíôéóôïé÷ïýí ü÷é ìüíï óå óõ÷íÜ êáé êïéíÜ ðñïâëÞìáôá ðïõ ï éáôñüò áõôÝò êáëåßôáé íá áíôéìåôùðßóåé áëëÜ êáé óôçí áðïôåëåóìáôéêüôçôá ôùí ðáñåìâÜóåùí ìå âÜóç ôç äéáèÝóéìç ìÝ÷ñé óÞìåñá ìáñôõñßá (evidence-based practice). Méá ðñþôç åìðåéñéêÞ êáé ðïéïôéêÞ ðñïóÝããéóç ôçò "åðÜñêåéáò" Þ áðïôåëåóìáôéêüôçôáò ôçò åðáããåëìáôéêÞò åêðáßäåõóçò óôç ãåíéêÞ éáôñéêÞ äåß÷íåé åëëåßììáôá ãíùóôéêÜ êáé áíåðÜñêåéåò óôá ðáñáêÜôù áíôéêåßìå6

íá Þ ðåäßá: • Åííïéïëïãéêüò ðñïóäéïñéóìüò ôçò ãåíéêÞò éáôñéêÞò êáé ôïõ ðåñéå÷ïìÝíïõ ôçò • ÄéáãíùóôéêÞ ðñïóÝããéóç ìå âÜóç ðéèáíüôçôåò • Äéáãíùóôéêïß êáé äéá÷ùñéóôéêïß áëãüñéèìïé ãéá ôá ðéï óõ÷íÜ íïóÞìáôá êáé ðñïâëÞìáôá õãåßáò, êáèþò êáé åðéóÞìùí áíáãíùñéóìÝíùí ìÝóá áðü äéáäéêáóßåò ïìïöùíßáò (consensus) êáôåõèõíôçñßùí ïäçãéþí. Ùò ðáñáäåßãìáôá áíáöÝñïíôáé ç äõóðåøßá, ïé øõ÷éêÝò äéáôáñá÷Ýò, áëëÜ êáé áêüìá ç ïîåßá áìõãäáëßôéäá. Áêüìç Ýëëåéøç åîïéêåßùóçò ôçò ÷ñÞóçò áðëþí äéáãíùóôéêþí êáé èåñáðåõôéêþí óõóêåõþí, áëëÜ êáé ôå÷íéêþí êáôÜëëçëùí óôç ÐÖÕ, êáé åäþ åðéãñáììáôéêÜ áíáöÝñïíôáé ç ÷ñÞóç ñïïìÝôñïõ, ç äéåíÝñãåéá ãåíéêÞò ïýñùí Þ ÷ñþóçò êáôÜ Gram. Eßíáé éäéáßôåñá öáíåñÞ ç áäõíáìßá ëÞøçò êëéíéêþí áðïöÜóåùí êáé öõóéêÜ äåí ãßíåôáé áíáöïñÜ óôéò äéáäéêáóßåò ìå âÜóç ôï äéáäýêôéï êáé ôéò äéåèíåßò âÜóåéò äåäïìÝíùí (üðùò Cochrane Library). Ç áðïõóßá äåîéïôÞôùí åðéêïéíùíßáò (communication skills) êáé ôçò áîéïëüãçóÞò ôçò (áðü ôïí áóèåíÞ Þ ôïí ßäéï éáôñü) ðéèáíÜ íá äéêáéïëïãïýíôáé áðü ôçí ðëÞñç áðïõóßá Ýêèåóçò êáé åîïéêåßùóçò ìå èÝìáôá ó÷åôéêÜ ìå ôç äéá÷åßñéóç ôçò ó÷Ýóçò éáôñïý-áóèåíïýò ôüóï óôï åðßðåäï ôçò ðñïðôõ÷éáêÞò üóï êáé ôçò åðáããåëìáôéêÞò åêðáßäåõóçò. Ç óõóôçìáôéêÞ áíáæÞôçóç ôçò âéâëéïãñáößáò ìÝóù ôïõ äéáäéêôýïõ åðßóçò ðñïóôßèåôáé óôá åë-


×. ËéïíÞò êáé óõí.

ëåßììáôá áðü ðëåõñÜò äåîéïôÞôùí ôùí åéäéêåõïìÝíùí ãåíéêÞò éáôñéêÞò êáé ãéá ôçí áðüêôçóç ôïõò äåí öáßíåôáé íá åðáñêïýí ïé äéáëÝîåéò óôï ìÞíá åêðáßäåõóçò ôïõò óôçí åðéäçìéïëïãßá, Ýñåõíá êáé óôáôéóôéêÞ. ×ñåéÜæåôáé óõóôçìáôéêÞ åñåõíçôéêÞ ðñïóðÜèåéá ãéá ôçí ðïóïôéêïðïßçóç üëùí ôùí ðáñáðÜíù êáé öõóéêÜ áíáíÝùóç ôïõ ðñïãñÜììáôïò åðáããåëìáôéêÞò åêðáßäåõóçò, åêðáßäåõóç åêðáéäåõôþí,

Ôüìïò 16, Ôåý÷ïò 1, 2004

êáôåõèýíóåéò ðïõ Þäç åñãÜæåôáé ç ÅðéôñïðÞ Åêðáßäåõóçò ôçò ÅËÅÃÅÉÁ êáé ç ÅðéôñïðÞ ÐÖÕ ôïõ ÊÅÓÕ. ×. ËéïíÞò Ì. Ìåñêïýñçò Ã. ÌðÝëëïò ÌÝëç ôçò ÅîåôáóôéêÞò ÅðéôñïðÞò ãéá ôçí åéäéêüôçôá ÃåíéêÞò ÉáôñéêÞò

7


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ôóá÷Üêç êáé óõí.

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 16, Number 1, 8-10, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 8-10, 2004

Ç ôñßôç çëéêßá êáé ïé õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, óå ìéá áãñïôéêÞ ðåñéï÷Þò ôçò ÊñÞôçò Ã. Ôóá÷Üêç1, Á. ÊñáóáíÜêç2, Ê. Êïýôñá3, M. Ôóéáëêïýôç4, Í. ÁíôùíÜêçò5

Ðåñßëçøç Óêïðüò ôçò ìåëÝôçò Þôáí ç êáôáãñáöÞ êáé êÜëõøç ôùí áíáãêþí óå õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò (ÐÖÕ) ôùí çëéêéùìÝíùí ìéáò áãñïôéêÞò ðåñéï÷Þò ôçò ÊñÞôçò. Ôï ðñüãñáììá áíáðôý÷èçêå óå ôñåéò öÜóåéò (ó÷åäéáóìïý, õëïðïßçóçò êáé áîéïëüãçóçò) êáé óå áõôü åíåðëÜêçóáí ïé ôïðéêïß öïñåßò ôçò ÐÖÕ êáé ç ÔïðéêÞ Áõôïäéïßêçóç. Ïé áñèñßôéäåò, ç õðÝñôáóç, ôá êáñäéáããåéáêÜ íïóÞìáôá êáé ï óáê÷áñþäçò äéáâÞôçò Þôáí ïé óõ÷íüôåñåò íüóïé ôùí çëéêéùìÝíùí, åíþ ç ïóôåïáñèñßôéäá ôïõ ãüíáôïò Þ/êáé ôïõ éó÷ßïõ, ôï ãÞñáò, ïé íåõñïëïãéêÝò íüóïé êáé ïé äéáôáñá÷Ýò ôùí áéóèçôçñßùí Þôáí ïé óõ÷íüôåñåò áéôßåò áíáðçñßáò óôçí ßäéá ïìÜäá ôïõ ðëçèõóìïý. Áñêåôïß áóèåíåßò Þôáí ðåñéïñéóìÝíïé óôï óðßôé êáé óõ÷íÜ ç ïéêïãÝíåéá ÷ñåéáæüôáí âïÞèåéá áðü åðáããåëìáôßá ãéá ôç öñïíôßäá ôïõ áóèåíÞ. Ç áíáìåíüìåíç áýîçóç ôïõ áñéèìïý ôùí çëéêéùìÝíùí óôçí åëëçíéêÞ ýðáéèñï óå óõíäõáóìü ìå ôçí áäõíáìßá õðïóôÞñéîçò ôïõò áðü ôá íåüôåñá Üôïìá ëüãù ìåôáíÜóôåõóçò ôïõò óå ðüëåéò, èá áëëÜîåé ôç æÞôçóç õðçñåóéþí õãåßáò óôçí ýðáéèñï êáé èá áðáéôÞóåé áëëáãÝò óôï ó÷åäéáóìü ôùí õðçñåóéþí õãåßáò ìå åìðëïêÞ êáé ôçò ÔïðéêÞò Áõôïäéïßêçóçò. 1

Iáôñüò ÃåíéêÞò ÉáôñéêÞò, Ðåñéöåñåéáêü éáôñåßï Ôõëßóïõ, 2Åéäéêåõüìåíç Éáôñüò, 3Êïéíùíéêüò Ëåéôïõñãüò, ÄÞìïò Ôõëßóïõ, ÁÔÅÉ ÊñÞôçò, 4Êïéíùíéêüò Ëåéôïõñãüò, ÄÞìïò Ôõëßóïõ, 5Éáôñüò ÃåíéêÞò ÉáôñéêÞò, ÄéäÜêôùñ Ðáíåðéóôçìßïõ ÊñÞôçò, Åð. Á´ ÅÓÕ. (ÄÞìïò Ôõëßóóïõ, ÊÝíôñï Õãåßáò Áíùãåßùí)

Primary Health Care services for elderly in a rural area G. Tsachaki, A. Krasanaki, K. Koutra, M. Tsialkouti, N. Antonakis Summary Aim of this study was the determination and provision of Primary Health Care (PHC) services for elderly, in a rural region of Crete. The program was developed in three phases (planning, implementation, and evaluation) and involved the local services of PHC and the local self-government. Arthritis, hypertension, other cardiovascular diseases and diabetes mellitus were the more illnesses of elderly. Osteoarthritis of the hip and/or knee, neurological diseases, and disturbances of sensory organs were the more frequent causes of disability in the same patients. Many elderly patients were limited in the house, and their families needed help from professional for the care of patient. The expected increase of the elderly in the rural areas of Greece, in combination with their weakness of support by the newer individuals (because their immigration in cities), will change the demand of PHC services in these areas, and will require changes in the planing of PHC services. These changes will demand participation of the local self-government. Key words: Primary health Care, elderly, health services, rural area.

8

ÅéóáãùãÞ Ç äçìïãñáöéêÞ ãÞñáíóç ôïõ ðëçèõóìïý ôçò åëëçíéêÞò õðáßèñïõ áëëÜæåé ôç óýíèåóç ôïõ ðëçèõóìïý, áëëÜ êáé ôç æÞôçóç ôùí õðçñåóéþí õãåßáò óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò (ÐÖÕ) ôçò ÷þñáò ìáò1. Ïé äçìïãñáöéêÝò áõôÝò áëëáãÝò Ý÷ïõí ôïíéóôåß áðü ðïëëïýò óõããñáöåßò áëëÜ ïé ðéèáíÝò óõíÝðåéåò ôùí áëëáãþí áõôþí óôç æÞôçóç õðçñåóéþí ÐÖÕ äåí Ý÷ïõí ìåëåôçèåß åðáñêþò. Ç äéåñåýíçóç ôùí ðáñáðÜíù áëëáãþí êáé ï ðñïóäéïñéóìüò ôùí íÝùí áíáãêþí ðïõ ðñïêýðôïõí åßíáé áðáñáßôçôåò ðñïûðïèÝóåéò, ãéá íá ãßíåé ï êáôÜëëçëïò ó÷åäéáóìüò ôùí õðçñåóéþí õãåßáò ðïõ èá êëçèïýí óýíôïìá íá ðñïóöÝñïõí ôá ÊÝíôñá Õãåßáò êáé ôá ÐåñéöåñåéáêÜ Éáôñåßá ôçò ÅëëÜäáò. Óôï ÄÞìï Ôõëßóïõ ôçò ÊñÞôçò äéåñåõíÞèçêáí ïé áíÜãêåò ôùí çëéêéùìÝíùí óå õðçñåóßåò õãåßáò ìå ìåèïäïëïãßá ðïõ åíÝðëåîå ôéò õðçñåóßåò ÐÖÕ ôçò ðåñéï÷Þò êáé ôçí ÔïËÝîåéò êëåéäéÜ: ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, çëéêéùìÝíïé, õðçñåóßåò õãåßáò, áãñïôéêÞ ðåñéï÷Þ ÕðïâëÞèçêå: 2 Éïõëßïõ 2003 ÅðáíõðïâëÞèçêå: 11 Óåðôåìâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Óåðôåìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: ÁíôùíÜêçò Íßêïò, Óåññþí 3, T.K. 71307 ÇñÜêëåéï, ÊñÞôç, Ôçë. (28340) 31208 Þ (2810) 330469 Þ êéí. 6945 075032, e-mail: antonakisnikos@yahoo.gr


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ã. Ôóá÷Üêç êáé óõí.

ðéêÞ Áõôïäéïßêçóç. Óêïðüò ôçò ìåëÝôçò Þôáí ç êáôáãñáöÞ êáé êÜëõøç ôùí áíáãêþí, óå õðçñåóßåò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò (ÐÖÕ), ôùí çëéêéùìÝíùí ìéáò áãñïôéêÞò ðåñéï÷Þò ôçò ÊñÞôçò.

Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïé Ç ðïñåßá ôïõ ðñïãñÜììáôïò ðåñéëáìâÜíåé ôñåéò öÜóåéò: ÖÜóç ðñïåôïéìáóßáò: Óôç öÜóç áõôÞ åðéäéþ÷èçêå ï óõíôïíéóìüò ôùí öïñÝùí ðïõ èá óõììåôåß÷áí óôï ðñüãñáììá. Ïé öïñåßò áõôïß Þôáí ïé öïñåßò ÐÖÕ êáé ïé õðçñåóßåò ôçò ÔïðéêÞò Áõôïäéïßêçóçò ôçò ðåñéï÷Þò. Áêïëïýèçóå õðïãñáöÞ ðñïãñáììáôéêÞò óýìâáóçò ìåôáîý ôùí åìðëåêüìåíùí öïñÝùí êáé ó÷åäéáóìüò ôïõ ðñïãñÜììáôïò (óôï÷ïèåóßá). ÖÜóç õëïðïßçóçò: Ðñïóäéïñßóôçêáí ïé çëéêéùìÝíïé ðïõ äéÝìåíáí ìüíéìá óôçí õðü ìåëÝôç ðåñéï÷Þ, ç ïðïßá áðïôåëåß äçìïôéêü äéáìÝñéóìá ôïõ ðñïáíáöåñèÝíôïò äÞìïõ. Óôçí ðåñéï÷Þ áõôÞ äéáìÝíïõí óõíïëéêÜ 1336 êÜôïéêïé óýìöùíá ìå ðñüóöáôç ôïðéêÞ áðïãñáöÞ ôùí ìïíßìùí êáôïßêùí. Ï ðñïóäéïñéóìüò ôùí çëéêéùìÝíùí Ýãéíå ìå åíçìÝñùóç êáé êáôáãñáöÞ “ðüñôá-ðüñôá” óå ïëüêëçñç ôçí ðåñéï÷Þ. Óôç óõíÝ÷åéá ïé çëéêéùìÝíïé ðïõ êáôáãñÜöçêáí, êëÞèçêáí íá óõìðëçñþóïõí äåëôßï óõììåôï÷Þò ôïõò óôï ðñüãñáììá, åðéóêÝöôçêáí ìå ñáíôåâïý ôéò ôïðéêÝò õðçñåóßåò ÐÖÕ êáé ôéò êïéíùíéêÝò õðçñåóßåò ôïõ ÄÞìïõ, äçìéïõñãÞèçêå öÜêåëïò õãåßáò, Ýãéíå êëéíéêüò êáé åñãáóôçñéáêüò Ýëåã÷ïò (üðïõ êñßèçêå áíáãêáßï) êáé Üñ÷éóå ç ðáñáêïëïýèçóç ôùí áôüìùí áõôþí êáé ç áíôéìåôþðéóç ôùí ðñïâëçìÜôùí õãåßáò êáé ôùí êïéíùíéêþí ðñïâëçìÜôùí ðïõ áíôéìåôþðéæáí. ÖÜóç áîéïëüãçóçò: ÁîéïëïãÞèçêáí ôá áðïôåëÝóìáôá ôïõ ðñïãñÜììáôïò êáé êáôáãñÜöçêå – ðáñïõóéÜóôçêå ç åìðåéñßá ôïõ Ýñãïõ. Ç êùäéêïðïßçóç ôçò éáôñéêÞò ðëçñïöïñßáò Ýãéíå ìå ôï óýóôçìá ICD-9 ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò2.

ÁðïôåëÝóìáôá Áðü ôïõò 1336 êáôïßêïõò ôçò ðåñéï÷Þò óôü÷ïò, ïé 212 (15,9%) Þôáí çëéêéùìÝíïé (çëéêßá >

65 åôþí). Áðü ôïõò 212 çëéêéùìÝíïõò, 74 Þôáí Üíäñåò êáé 138 ãõíáßêåò. ¼ëïé ïé çëéêéùìÝíïé óõììåôåß÷áí óôï ðñüãñáììá. 53 çëéêéùìÝíïé (25%) Þôáí ðåñéïñéóìÝíïé óôï óðßôé êáé åîáñôçìÝíïé áðü Üëëá Üôïìá. Êáíåßò çëéêéùìÝíïò äåí èåùñïýóå ôïí åáõôü ôïõ áðüëõôá áíåîÜñôçôï, åíþ 42 (19,8%) äåí åß÷áí êáìßá âïÞèåéá áðü Üëëï ðñüóùðï, ðáñüëï ðïõ ôçí ÷ñåéáæüôáí. Ï/Ç óýæõãïò âïçèïýóå ôïí çëéêéùìÝíï óå ðïóïóôü 34,9% ôïõ óõíüëïõ ôùí áóèåíþí, ôá ðáéäéÜ óå ðïóïóôü 30,7%, Üëëïé óõããåíåßò óå ðïóïóôü 7,6% êáé óå ðïóïóôü 5,7% âïçèïýóå ôïí çëéêéùìÝíï áðïêëåéóôéêÜ åðáããåëìáôßáò. Åðáããåëìáôßáò åìðëåêüôáí óôç öñïíôßäá 36 áóèåíþí (17%) óáí åîùôåñéêÞ õðïóôÞñéîç ôçò ïéêïãÝíåéáò. Áðü ôïõò 36 áõôïýò áóèåíåßò ïé 32 åß÷áí ÷Üóåé ôï/ôç óýíôñïöï ôïõò êáé ôç öñïíôßäá ôïõò åß÷áí ôá ðáéäéÜ ôïõò. ÁíÜãêç óõíå÷ïýò íïóçëåõôéêÞò öñïíôßäáò, åß÷áí 25 çëéêéùìÝíïé (11,8%). Óôç öñïíôßäá ôùí 21 áðü ôïõò çëéêéùìÝíïõò áõôïýò åìðëåêüôáí åðáããåëìáôßáò, åíþ ôçí áðïêëåéóôéêÞ åõèýíç ôïõ áóèåíÞ ôçí åß÷å åðáããåëìáôßáò óå 7 çëéêéùìÝíïõò. ÐåñéïäéêÜ ÷ñåéáæüôáí íïóçëåõôéêÞ öñïíôßäá 100 çëéêéùìÝíïé (47,2%), åíþ 84 (39,6%) äåí ÷ñåéáæüôáí íïóçëåõôéêÞ öñïíôßäá óôï óðßôé. Ðåñéóóüôåñïé áðü ôïõò ìéóïýò çëéêéùìÝíïõò Ýäùóáí ïñéáêü Þ ìéêñü óêïñ êáôÜ ôïí Ýëåã÷ï ôïõò ìå ôçí êëßìáêá Mini Mental State Examination (MMSE)3. Óôïí ðßíáêá 1 ðáñïõóéÜæïíôáé ïé óõ÷íüôåñåò íüóïé êáé ïé óõ÷íüôåñåò áéôßåò áíáðçñßáò ôùí çëéêéùìÝíùí ðïõ ðÞñáí ìÝñïò óôï ðñüãñáììá.

ÓõæÞôçóç Ï áñéèìüò ôùí áôüìùí ðïõ èá åßíáé ðåñéïñéóìÝíá óôï óðßôé ÷ùñßò õðïóôÞñéîç áðü ôçí ïéêïãÝíåéá, óôçí åëëçíéêÞ ýðáéèñï, áíáìÝíåôáé íá áõîçèåß ôá åðüìåíá ÷ñüíéá. ÂáóéêÞ áéôßá ôïõ öáéíïìÝíïõ áõôïý åßíáé ôï êýìá ôçò åóùôåñéêÞò ìåôáíÜóôåõóçò íÝùí áôüìùí, áðü ôçí ýðáéèñï ðñïò ôá áóôéêÜ êÝíôñá, ðïõ ðáñáôçñÞèçêå ôéò ôåëåõôáßåò äåêáåôßåò. Ïé ðáñáðÜíù áëëáãÝò ðïõ óõíôåëïýíôáé ìå ãñÞãïñï ñõèìü, ðñÝðåé íá ëçöèïýí óïâáñÜ õðüøç óôï ó÷åäéáóìü ôùí õðçñåóéþí õãåßáò ôçò õðáßèñïõ, äéáöïñåôéêÜ ðïëý óýíôïìá ïé õðçñåóßåò áõôÝò äåí èá ìðïñïýí íá áíôáðïêñéèïýí óôï ñüëï ôïõò1. 9


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ôóá÷Üêç êáé óõí.

Ðßíáêáò 1. Ïé 10 óõ÷íüôåñåò íüóïé êáé ïé 10 óõ÷íüôåñåò áéôßåò áíáðçñßáò ôùí çëéêéùìÝíùí Íüóïò

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Áñèñßôéò ÕðÝñôáóç ÊáñäéáããåéáêÜ íïóÞìáôá (ðëçí õðÝñôáóçò êáé áããåéáêïý åãêåöáëéêïý åðåéóïäßïõ) Óáê÷áñþäçò ÄéáâÞôçò Øõ÷éêÞ íüóïò ×ñüíéá áðïöñáêôéêÞ ðíåõìïíïðÜèåéá Ïóôåïðüñùóç Íåïðëáóßåò Áããåéáêü åãêåöáëéêü åðåéóüäéï ºëéããïò

136 130

64,2 61,3

72 30 23

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Áéôßá áíáðçñßáò

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Ïóôåïáñèñßôéò ãüíáôïò Þ/êáé éó÷ßïõ ÃÞñáò ÍåõñïëïãéêÝò íüóïé Ôýöëùóç ×ñüíéá áðïöñáêôéêÞ ðíåõìïíïðÜèåéá Øõ÷éêÞ íüóïò ÑåõìáôïåéäÞò áñèñßôéò Ìåßùóç üñáóçò Êþöùóç ÁêñÜôåéá ïýñùí

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* Ðñüêåéôáé ãéá ôïí áñéèìü ôùí çëéêéùìÝíùí óôïõò ïðïßïõò êáôáãñÜöçêå ç íüóïò Þ ç áíáðçñßá

Ïé õðçñåóßåò óôï óðßôé, ç õðïóôÞñéîç ôçò ïéêïãÝíåéáò áðü ôéò õðçñåóßåò ÐÖÕ, ç êïéíùíéêÞ ìÝñéìíá êáé Üëëåò õðçñåóßåò, èá æçôïýíôáé üëï êáé ðåñéóóüôåñï óôçí ýðáéèñï. Ïé íüóïé öèïñÜò (ð.÷. ïóôåïáñèñßôéäåò) áëëÜ êáé ç öñïíôßäá ôùí óõ÷íþí íïóçìÜôùí ôùí çëéêéùìÝíùí (ð.÷. õðÝñôáóç êáé óáê÷áñþäçò äéáâÞôçò) èá ÷ñåéáóôïýí

10

óõóôçìáôéêÞ áíôéìåôþðéóç, âÜóåé êáôåõèõíôçñßùí ïäçãéþí êáé óõóôçìáôéêÞò ðáñáêïëïýèçóçò4. Ç ìåèïäïëïãßá ðïõ áêïëïýèçóå ç ìåëÝôç áõôÞ èåùñïýìå üôé ìðïñåß íá åöáñìïóôåß êáé óå Üëëåò ðåñéï÷Ýò (áóôéêÝò êáé áãñïôéêÝò) ìå óêïðü ôïí åìðëïõôéóìü ôçò õðÜñ÷ïõóáò ðëçñïöïñßáò ãéá ôá ðñïâëÞìáôá ôùí çëéêéùìÝíùí óÞìåñá óôçí ÅëëÜäá êáé ôï óùóôüôåñï ó÷åäéáóìü ôùí õðçñåóéþí ðïõ ôïõò õðïóôçñßæïõí. Ç óçìáíôéêÞ âïÞèåéá ðïõ ðñüóöåñáí óôç äéåîáãùãÞ ôïõ ðñïãñÜììáôïò ðïõ ðáñïõóéÜóáìå ïé õðçñåóßåò ôçò ÔïðéêÞò Áõôïäéïßêçóçò (ôüóï óôçí êáôáãñáöÞ, üóï êáé óôçí õðïóôÞñéîç ôùí çëéêéùìÝíùí), ìáò ïäçãåß óôï óõìðÝñáóìá üôé ïé õðçñåóßåò áõôÝò ìðïñïýí êáé ðñÝðåé íá ðáßîïõí âáóéêü ñüëï óôç öñïíôßäá ôùí çëéêéùìÝíùí.

Âéâëéïãñáößá 1. ËéïíÞò ×, Êïýôçò Á. Ðñüôáóç áíÜðôõîçò ôïõ åëëçíéêïý êÝíôñïõ õãåßáò. Ç åìðåéñßá áðü ôï ÊÝíôñï Õãåßáò Óðçëßïõ. ÉáôñéêÞ, 62:392-397, 1992. 2. Ðáãêüóìéïò Ïñãáíéóìüò Õãåßáò. Åã÷åéñßäéï äéåèíïýò óôáôéóôéêÞò ôáîéíïìÞóåùò ôùí íüóùí, êáêþóåùí êáé áéôéþí èáíÜôïõ. Õðïõñãåßï Óõíôïíéóìïý êáé Õðïõñãåßï Êïéíùíéêþí Õðçñåóéþí (åêä.), ôüì. É, óåë 717-760, ÁèÞíá 1980. 3. Folstein MF, Robins LN, Helzer JE. The MiniMental State Examination. Arch Gen Psychiatry, 40:812, 1983. 4. Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ, 320:1038-1043, 2000.


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ã.É. Ôóßñïò êáé óõí.

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 16, Number 1, 11-17, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 11-17, 2004

Áîéïëüãçóç ôçò ÷ñÞóçò ôïõ äéáäéêôýïõ áðü ôï éáôñéêü ðñïóùðéêü åíüò Ðáíåðéóôçìéáêïý Íïóïêïìåßïõ Ã.É. Ôóßñïò1, Ðáíáãéþôá Å. ÂïÀëá2, Ä.Ê. Êáëïãåñüðïõëïò1, Å. Ãåëáóôïðïýëïõ3, Ê.É. ×ñõóáíèüðïõëïò2

Ðåñßëçøç Óêïðüò: Ç áîéïëüãçóç ôçò ÷ñÞóçò ôïõ äéáäéêôýïõ ùò ðçãÞ éáôñéêÞò åíçìÝñùóçò áðü ôï éáôñéêü ðñïóùðéêü åíüò ðáíåðéóôçìéáêïý íïóïêïìåßïõ (Ð.Ã.Í. Ðáôñþí). Õëéêü êáé ÌÝèïäïò: Óõìðëçñþèçêå áíþíõìï åñùôçìáôïëüãéï áðü 123 éáôñïýò äéáöüñùí åéäéêïôÞôùí ôïõ Ð.Ã.Í.Ðáôñþí. ¸ãéíå áîéïëüãçóç êáé ïìáäïðïßçóç ôùí áðáíôÞóåùí ãéá óõãêñßóåéò, êáôÜ öýëï êáé ôïìÝá åéäéêüôçôáò. ÁðïôåëÝóìáôá: Óå óýíïëï 123 éáôñþí, ìåëåôÞèçêáí 65 (53%) Üíäñåò êáé 58 (47%) ãõíáßêåò, ìå äéÜìåóç çëéêßá 32 åôþí. ÁíÜ ôïìÝá, äéáêñßíïõìå 48 (39%) éáôñïýò óôïí Ðáèïëïãéêü, 35 (28%) óôïí ×åéñïõñãéêü, 24 (20%) óôïí Åñãáóôçñéáêü ôïìÝá êáé 16 (13%) Ãåíéêïýò éáôñïýò. Ç ÷ñÞóç ôïõ äéáäéêôýïõ áðü ôïõò ìåëåôçèÝíôåò éáôñïýò, êõìáßíåôáé ìåôáîý 58% (Åñãáóôçñéáêüò ôïìÝáò) êáé 77% (×åéñïõñãéêüò ôïìÝáò). ÁíáöïñéêÜ ìå ôï öýëï, ðáñáôçñåßôáé ìéá óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ ìåôáîý ôùí áíäñþí (83%) êáé ôùí ãõíáéêþí (60%, p=0,005), äéáðßóôùóç ðïõ óõìâáäßæåé ðáíåõñùðáúêÜ ìå ôçí õðåñï÷Þ ôùí áíäñþí ãåíéêÜ ùò ðñïò ôç ÷ñÞóç ôïõ äéáäéêôýïõ. ÓõìðåñÜóìáôá: Ç ÷ñÞóç ôïõ äéáäéêôýïõ áðü ôïõò éáôñïýò êáé éäéáßôåñá ôïõò Üíäñåò, åíüò ôñéôïâÜèìéïõ íïóçëåõôéêïý éäñýìáôïò, êáôáôÜóóåôáé óôéò êõñéüôåñåò ðçãÝò éáôñéêÞò åíçìÝñùóçò óôçí ðëåéïíüôçôá ôùí åéäéêïôÞôùí. Âáóéêü áñùãü ó’ áõôÞ ôç ðñïóðÜèåéá áðïôåëïýí, óôï ÷þñï ôïõ íïóïêïìåßïõ, ôüóï ôá óõóôçìáôéêÜ ðñïãñÜììáôá åêðáßäåõóçò óå Ç/Õ êáé internet, üóï êáé ï êáôÜëëçëïò åîïðëéóìüò ôïõ. Ç ôå÷íïëïãßá êáôÝ÷åé ðëÝïí êõñßáñ÷ï ñüëï óôï ÷þñï ôçò Üìåóçò ðëçñïöüñçóçò ôïõ éáôñïý, ðáñÝ÷ïíôÜò ôïõ ãíþóåéò ìå ôñüðï ðñïóéôü êáé åëêõóôéêü. Ç êáèçìåñéíÞ åîÝëéîç ôçò éáôñéêÞò Ýñåõíáò, êÜíåé åðéôáêôéêÞ ôçí áíÜãêç ôçò óõ÷íÞò åíçìÝñùóçò ôïõ óýã÷ñïíïõ éáôñïý, þóôå íá ðñïóöÝñåé óôïí áóèåíÞ ðëçñÝóôåñç êáèïäÞãçóç êáé áíôéìåôþðéóç.

1

Éáôñïß ÃåíéêÞò ÉáôñéêÞò, 2Éáôñïß ÐáèïëïãéêÞò ÊëéíéêÞò, 3ÅñãáóôÞñéï ÕãéåéíÞò, ÉáôñéêÞ Ó÷ïëÞ Ðáí/ìßïõ Ðáôñþí, Ðáíåðéóôçìéáêü Ãåíéêü Íïóïêïìåßï Ðáôñþí (Ð.Ã.Í.Ð.)

ÅéóáãùãÞ Ç êáèçìåñéíÞ åîÝëéîç ôçò éáôñéêÞò åðéóôÞìçò, ôüóï óôïí êëéíéêü üóï êáé óôïí åñãáóôçñéáêü ôïìÝá, åðéâÜëëåé ôç óõíå÷Þ åíçìÝñùóç ôïõ óýã÷ñïíïõ éáôñïý ãéá ôçí ðëçñÝóôåñç êáèïäÞãçóç ôùí áóèåíþí ôïõ êáé ôçí áðïôåëåóìáôéêüôåñç èåñáðåßá ôïõò. Äéáíýïíôáò ôïí 21ï áéþíá, ðáñáôçñïýìå óçìáíôéêÝò ôå÷íïëïãéêÝò åîåëßîåéò óôïí ÷þñï ôçò ÉáôñéêÞò. ÁõîÜíïíôáé åðïìÝíùò ïé áðáéôÞóåéò, ôüóï ôùí éáôñþí ãéá áðüêôçóç óýã÷ñïíçò êáé Üìåóçò ãíþóçò, üóï êáé ôùí áóèåíþí ãéá õðåýèõíç êáé áðïôåëåóìáôéêÞ ðñïò áõôïýò öñïíôßäá. Áñùãü áõôÞò ôçò ðñïóðÜèåéáò ôùí éáôñþí óÞìåñá áðïôåëåß áíáìöéóâÞôçôá ç óõíå÷éæüìåíç êáé óõóôçìáôéêÞ ðëçñïöüñçóÞ ôïõò, êõñßùò óôá ðëáßóéá ôçò åêðáßäåõóÞò ôïõò óå ôñéôïâÜèìéá íïóçëåõôéêÜ éäñýìáôá, óõíäåüìåíç Üìåóá ìå ôç âåëôßùóç ôçò ðïéüôçôáò ðáñï÷Þò õðçñåóéþí õãåßáò1. ËÝîåéò êëåéäéÜ: Ðáíåðéóôçìéáêü Íïóïêïìåßï, Äéáäßêôõï, ÉáôñéêÞ åíçìÝñùóç ÕðïâëÞèçêå: 2 Éïõëßïõ 2003 ÅðáíõðïâëÞèçêå: 11 Óåðôåìâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Óåðôåìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Ãåþñãéïò É. Ôóßñïò, Ãåíéêüò Éáôñüò, ÓïöïêëÝïõò 29, Ô.Ê. 26442, ÐÜôñá, Ôçë. (2610) 454.667, êéí. 6977 01 99 77, e-mail: geotsiro@otenet.gr 11


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã.É. Ôóßñïò êáé óõí.

Evaluation of using the Internet by physicians of a University Hospital G. Tsiros, P. Voila, D. Kalogeropoulos, E. Jelastopulu, K. Chrisanthopoulos Summary Aim: Evaluation of using the Internet as a source for medical information by physicians of a University Hospital (General University Hospital of Patras). Material and Method: 123 physicians of different specialties, employed in the General University Hospital of Patras, completed an anonymous questionnaire. The answers were categorized for comparisons by sex and specialization. Results: From 123 physicians (39% Internal Medicine, 28% Surgery, 20% Laboratory Medicine and 13% General Practitioners) the 65 (53%) were males and 58 (47%) females with a median age of 32 years. The use of Internet by the studied population varied between 58% for laboratory specialities and 77% for surgical specialities. There was a statistically significant difference (p=0,005) between males (83%) and females (60%) in using the Internet, a fact, which is in accordance with other studies regarding the preference of Internet by gender. Conclusions: The use of Internet by physicians and especially by males is one of the main sources for medical information in a tertiary medical institution. A great support in this effort are both the systematically carrying out of educational programs in PC and Internet use as well as the provision of suitable and satisfactory equipment in the hospital. The new technologies play an important role in providing actual information and knowledge to the physicians for their daily clinical work by an easy accessible and attractive way. Keywords: University Hospital, Internet, Medical information. General University Hospital of Patras

Óå ðïëëÜ íïóïêïìåßá ôçò ÷þñáò ìáò, åéäéêüôåñá ó’ áõôÜ ðïõ ðáñÝ÷ïõí åéäéêüôçôá óå íÝïõò éáôñïýò, åöáñìüæåôáé ìÝóù ôïõ åêðáéäåõôéêïý óõóôÞìáôïò åðéóôçìïíéêÞ åðéìüñöùóç – óå äéÜöïñåò ìïñöÝò – ìå óôü÷ï ôç óõíå÷Þ êáôÜñôéóç êáé åíçìÝñùóÞ ôïõò ãéá ôá íÝá åðéôåýãìáôá ôçò åðéóôÞìçò2. Ïé åöáñìïãÝò ôïõ äéáäéêôýïõ Ý÷ïõí äéåéóäýóåé óôï ÷þñï ôçò éáôñéêÞò, Ý÷ïíôáò åðéäåßîåé êáé áðïäåßîåé ôç äõíáôüôçôá ðñüóâáóçò êáé ðáñïõóßáóçò ðïëõìåóéêþí éáôñéêþí äåäïìÝíùí óôï ÷þñï ôçò ðåñßèáëøçò. ÅðçññåÜæåôáé Ýôóé, ç äéáäéêáóßá ëÞøçò éáôñéêþí áðïöÜóåùí êáé ç ðëçñïöïñéêÞ êáôáôÜóóåôáé ðáãêïóìßùò ùò Ýíá ìåôñßïõ êüóôïõò ðñïóâÜóéìï ðåñéâÜëëïí ãéá ôçí áíÜðôõîç êáé ðáñï÷Þ õðçñåóéþí åðéêïéíùíßáò. Ìå ôç ÷ñÞóç Þ÷ïõ êáé êéíïýìåíùí åéêüíùí (video), ìðïñïýí íá ðñïóïìïéùèïýí ðñáãìáôéêÜ ðåñéóôáôéêÜ êáé íá âåëôéóôïðïéçèåß ç äéáäéêáóßá ìÜèçóçò êáé åí ìÝñåé ôçò åêðáßäåõóçò. ÅêôéìÜôáé, üôé ïé éáôñéêÝò ðçãÝò ìÝóù ôïõ äéáäéêôýïõ ìðïñïýí íá áðïêôÞóïõí ðáãêüóìéá äéÜóôáóç êáé íá áíôåðåîÝëèïõí óôéò áõîçìÝíåò áðáéôÞóåéò ãéá éáôñéêÞ ðëçñïöüñçóç. Óôç óçìåñéíÞ åðï÷Þ, ç äéåñåýíçóç ôçò äõíáôüôçôáò ÷ñÞóçò “åñãáëåßùí” áíáæÞôçóçò êáé äéáóýíäåóçò éáôñéêþí ðïëõìåóéêþí äåäïìÝíùí ãéá ôç äéÜäïóç 12

åðéóôçìïíéêþí åðéôåõãìÜôùí êáé êëéíéêþí åñåõíþí, áðïôåëåß ðñüêëçóç. Ïé õðÜñ÷ïõóåò ìÝèïäïé – ðçãÝò áðïêüìéóçò ãíþóåùí, åíôüò êáé åêôüò íïóïêïìåßïõ, ðïéêßëëïõí, áñêåß íá äéáôßèåíôáé, åðéóçìáßíïíôáé êáé åöáñìüæïíôáé óùóôÜ. Áíáãêáßá öõóéêÜ êñßíåôáé ç ðñïóðÜèåéá, ç óõíåñãáóßá êáé ç èÝëçóç áðü ðëåõñÜò éáôñþí3,4. Óêïðüò ôçò åñãáóßáò áõôÞò Þôáí ç áîéïëüãçóç ôçò áðïäï÷Þò êáé ôçò ðñïóöïñÜò ôïõ äéáäéêôýïõ, óôç óõíå÷éæüìåíç éáôñéêÞ åêðáßäåõóç, áðü ôïõò éáôñïýò åíüò íïóïêïìåßïõ. ÅêôéìÞèçêå åðßóçò ç äõíáôüôçôá ðñüóâáóçò óôï äéáäßêôõï êáé ï âáèìüò áîéïðïßçóÞò ôïõ áðü ôïõò ßäéïõò éáôñïýò.

Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïé

Óôç ìåëÝôç óõììåôåß÷áí óõíïëéêÜ 123 éáôñïß äéáöüñùí åéäéêïôÞôùí, ïé ïðïßïé åñãÜæïíôáé óôï Ðáíåðéóôçìéáêü Ãåíéêü Íïóïêïìåßï Ðáôñþí (Ð.Ã.Í.Ð). Óõìðëçñþèçêå áíþíõìï åñùôçìáôïëüãéï (ÐáñÜñôçìá Á), åéäéêÜ äéáìïñöùìÝíï þóôå íá äéåñåõíçèïýí: · ÐáñÜãïíôåò ó÷åôéæüìåíïé ìå ôá áôïìéêÜ óôïé÷åßá ôïõ éáôñïý (öýëï, çëéêßá, åéäéêüôçôá), · Äõíáôüôçôá ðëçñïöüñçóçò ìÝóù ÷ñÞóçò äéáäéêôýïõ (internet) óôï ÷þñï ôïõ íïóïêïìåßïõ, · Ç êáôÜ ôçí êñßóç ôïõò ðéï åíäéáöÝñïõóá ðçãÞ éáôñéêÞò åíçìÝñùóçò, áíåîÜñôçôá åÜí ôç ÷ñçóéìïðïéïýí Þ ü÷é, · Ç ãåíéêÞ åêôßìçóç åðÜñêåéáò ÷ñÞóçò ôçò ðëçñïöïñéêÞò, åíôüò êáé åêôüò íïóïêïìåßïõ, óõíïäåõüìåíç áðü ðñïôÜóåéò – óõìðåñÜóìáôá. Áêïëïýèùò Ýãéíå áîéïëüãçóç êáé ïìáäïðïßçóç ôùí áðáíôÞóåùí ôïõ åñùôçìáôïëïãßïõ ãéá óýãêñéóç, êáôÜ öýëï êáé ôïìÝá åéäéêüôçôáò: Ðáèïëïãéêüò (Ð/È), ×åéñïõñãéêüò (×/Ê), Åñãáóôçñéáêüò (Åñã/êüò) êáé Ãåíéêïß éáôñïß (Ã.É.). Ç ðëåéïøçößá ôïõ äåßãìáôïò áöïñïýóå åéäéêåõüìåíïõò éáôñïýò. ¼ëá ôá óôïé÷åßá êáôá÷ùñÞèçêáí óå âÜóç äåäïìÝíùí (excel for windows 2000), üðïõ êáé åðåîåñãÜóôçêáí. Ç óõìðåñáóìáôïëïãéêÞ óôáôéóôéêÞ Ýãéíå ìå ÷2 êáé üëïé ïé óôáôéóôéêïß Ýëåã÷ïé


Ã.É. Ôóßñïò êáé óõí.

Þôáí áìößðëåõñïé ìå p<0,05 íá èåùñåßôáé óôáôéóôéêÜ óçìáíôéêü.

ÁðïôåëÝóìáôá Åðß óõíüëïõ 123 éáôñþí, ìåëåôÞèçêáí 65 (53%) Üíäñåò êáé 58 (47%) ãõíáßêåò ìå ëüãï öýëïõ Üíäñåò/ãõíáßêåò 10/9. Ôï åýñïò ôùí çëéêéþí ôùí ìåëåôçèÝíôùí éáôñþí êõìÜíèçêå ìåôáîý 25 êáé 48 åôþí, ìå äéÜìåóç çëéêßá 32 åôþí. ÁíÜ ôïìÝá, äéáêñßíïõìå 48 éáôñïýò óôïí Ðáèïëïãéêü, 35 óôïí ×åéñïõñãéêü, 24 óôïí Åñãáóôçñéáêü ôïìÝá êáé 16 Ãåíéêïýò Éáôñïýò (ÄéÜãñáììá 1). Óôï äéÜãñáììá 2 ðáñïõóéÜæåôáé ç ÷ñÞóç ôïõ äéáäéêôýïõ áíÜ éáôñéêü ôïìÝá, üðùò êáé ç ÷ñÞóç ôïõ áðü ôïõò éáôñïýò ÃåíéêÞò ÉáôñéêÞò. Ðáñüëï ðïõ ïé åñã/êïß éáôñïß öáßíåôáé íá ÷ñçóéìïðïéïýí ëéãüôåñï ôï äéáäßêôõï (59%), åíôïýôïéò äåí ðñïêýðôåé êáìéÜ óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óõ-

Ôüìïò 16, Ôåý÷ïò 1, 2004

ãêñéôéêÜ ìå ôïõò õðüëïéðïõò ôïìåßò åéäéêïôÞôùí. Óôï äéÜãñáììá 3 ðáñïõóéÜæåôáé ç ÷ñÞóç ôïõ äéáäéêôýïõ áðü ôïõò éáôñïýò áíÜ öýëï, ìå ôïõò Üíäñåò íá õðåñÝ÷ïõí ìå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ (p=0,005). Óôá äéáãñÜììáôá 4 êáé 5 ðáñïõóéÜæïíôáé ïé ðéï åíäéáöÝñïõóåò ðçãÝò éáôñéêÞò åíçìÝñùóçò êáôÜ ôçí êñßóç ôùí ìåëåôçèÝíôùí éáôñþí, áíåîÜñôçôá áí äýíáôáé íá ôéò ÷ñçóéìïðïéïýí Þ äåí Ý÷ïõí Üìåóç ðñüóâáóç ðñïò áõôÝò, áíÜ ôïìÝá åéäéêüôçôáò êáé áíÜ öýëï áíôßóôïé÷á. ÁíáöïñéêÜ ìå ôïõò éáôñïýò óôï Ð/È ôïìÝá êáé ôçí ðñïôßìçóç ôïõ äéáäéêôýïõ, ùò ôçí ðéï åíäéáöÝñïõóá ðçãÞ éáôñéêÞò åíçìÝñùóçò, õðÜñ÷åé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óõãêñéôéêÜ ìå ôá ðåñéïäéêÜ, ôá ðåñéóôáôéêÜ êáé ôç âéâëéïèÞêç (p<0,05). Åðßóçò êáé óôéò ×/Ê åéäéêüôçôåò õðÜñ÷åé áíÜëïãç óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ åðéðëÝïí êáé ìå ôá ìåôåêðáéäåõôéêÜ ìáèÞìáôá (p<0,05). ÃåíéêÜ üóïí áöïñÜ ôç ðñïôßìçóç ôïõ äéáäéêôýïõ, óýì-

ÄéÜãñáììá 3. ×ñÞóç ôïõ äéáäéêôýïõ áðü ôïõò éáôñïýò áíÜ öýëï (%).

ÄéÜãñáììá 1. ÌåëåôçèÝíôåò éáôñïß áíÜ ôïìÝá åéäéêüôçôáò (%).

ÄéÜãñáììá 2. ×ñÞóç äéáäéêôýïõ áíÜ ôïìÝá åéäéêüôçôáò.

ÄéÜãñáììá 4. Ïé ðïéï åíäéáöÝñïõóåò (áíåîáñôÞôùò ÷ñÞóçò) ðçãÝò éáôñéêÞò åíçìÝñùóçò áíÜ ôïìÝá åéäéêüôçôáò (%). 13


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÄéÜãñáììá 5. Ïé ðïéï åíäéáöÝñïõóåò (áíåîáñôÞôùò ÷ñÞóçò) ðçãÝò éáôñéêÞò åíçìÝñùóçò áðü ôïõò éáôñïýò áíÜ öýëï (%).

öùíá ìå ôçí êñßóç ôùí éáôñþí ùò ôçí ðéï åíäéáöÝñïõóá ðçãÞ éáôñéêÞò åíçìÝñùóçò, ìåôáîý Ð/È êáé Åñã/êþí åéäéêïôÞôùí, õðÜñ÷åé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ (p=0,02), åíþ ìåôáîý Ã.É. êáé ×/Ê åéäéêïôÞôùí, ç óôáôéóôéêÞ äéáöïñÜ åßíáé ïñéáêÞ (p=0,055). Ó÷åôéêÜ ìå ôï öýëï (äéÜãñáììá 5) êáé ôçí ðñïôßìçóç ôïõ äéáäéêôýïõ, ùò ôçí ðéï åíäéáöÝñïõóá ðçãÞ éáôñéêÞò åíçìÝñùóçò óýìöùíá ìå ôçí êñßóç ôùí éáôñþí, ôüóï óôïõò Üíäñåò üóï êáé óôéò ãõíáßêåò, õðÜñ÷åé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óõãêñéôéêÜ ìå ôá ðåñéïäéêÜ, ôá ðåñéóôáôéêÜ êáé ôç âéâëéïèÞêç (p<0,05).

ÓõæÞôçóç Ïé éáôñïß ôùí Åñã/êþí åéäéêïôÞôùí ÷ñçóéìïðïéïýí ëéãüôåñï ôï äéáäßêôõï (ôñåéò óôïõò ðÝíôå) ùò ìÝóï éáôñéêÞò ðëçñïöüñçóçò óõãêñéôéêÜ ìå ôïõò õðüëïéðïõò ôïìåßò åéäéêïôÞôùí, Ð/È, ×/ Ê êáé Ã.É. (ôñåéò óôïõò ôÝóóåñéò). Ïé Åñã/êÝò åéäéêüôçôåò (Áêôéíïëüãïé, Ìéêñïâéïëüãïé, ê.ëð.) åíçìåñþíïíôáé ðáñÜëëçëá áðü éáôñéêÜ ðåñéïäéêÜ, åðåéäÞ ç áðåéêüíéóç ÷ñçóéìïðïéåßôáé óáí êýñéá ìÝèïäïò Ýñåõíáò êáé åêðáßäåõóçò. Ôá ìÝóá áõôÜ ôïõò åðéôñÝðïõí íá ìåëåôïýí ÷ñïíéêÜ ðåñéóóüôåñï ìéá óõãêåêñéìÝíç åéêüíá (ð.÷. áêôéíïãñáößá, ìéêñïóêïðéêÞ åîÝôáóç) óõãêñéôéêÜ ìå Üëëá ìÝóá ðëçñïöüñçóçò. ÁíáöïñéêÜ ìå ôï öýëï, éäéáßôåñç ðñïôßìçóç óôçí ðëçñïöïñéêÞ ðáñáôçñåßôáé áðü ôïõò Üíäñåò éáôñïýò, äéáðßóôùóç ðïõ óõìâáäßæåé ðáíåõñùðáúêÜ ìå ôçí õðåñï÷Þ ôùí áíäñþí ãåíéêÜ ùò 14

Ã.É. Ôóßñïò êáé óõí.

ðñïò ôç ÷ñÞóç ôïõ äéáäõêôßïõ5. Óå áñêåôÜ ôñéôïâÜèìéá íïóçëåõôéêÜ éäñýìáôá ôçò ÷þñáò ïñãáíþíïíôáé óõóôçìáôéêÜ óåìéíÜñéá ðëçñïöïñéêÞò, ðïõ áðåõèýíïíôáé ó’ üëï ôï éáôñéêü ðñïóùðéêü, ìå áðþôåñï óôü÷ï ôï internet í’ áðïôåëÝóåé Ýíá éêáíü ìÝóï êÜëõøçò ôùí åíäéáöåñüíôùí ôïõ éáôñïý. ÅðéðëÝïí, óçìáíôéêÞ êñßíåôáé ç óôåëÝ÷ùóç êáé ï êáôÜëëçëïò åîïðëéóìüò ôùí íïóïêïìåßùí ìå çëåêôñïíéêïýò õðïëïãéóôÝò (Ç/Õ), ïé ïðïßïé äßäïõí Üìåóç ðñüóâáóç óôçí ôïðéêÞ Þ åõñýôåñç (åëëçíéêÞ & äéåèíÞ) éáôñéêÞ âéâëéïèÞêç6-8. Ïé éáôñéêÝò âéâëéïèÞêåò óÞìåñá, áðïóêïðïýí ü÷é ìüíï óôç äéáôÞñçóç óõëëïãþí âéâëßùí & åðéóôçìïíéêþí ðåñéïäéêþí, áëëÜ êáé ïðôéêïáêïõóôéêïý õëéêïý (êõñßùò áðü ôá CD-ROM ôçò Medline) ãéá ôçí êÜëõøç ôùí åêðáéäåõôéêþí êáé åñåõíçôéêþí áíáãêþí óôï ÷þñï ôçò õãåßáò9-11. Óå Ýíá ìüíï CD-ROM, ìðïñåß íá áðïèçêåõôåß êåßìåíï ðåñßðïõ 250.000 óåëßäùí ìåãÝèïõò Á4 Þ 25.000 Ýã÷ñùìåò åéêüíåò õøçëÞò áíÜëõóçò. ÓõããñÜììáôá 20 ïãêùäþí ôüìùí, ÷ùñïýí óÞìåñá, óå Ýíá ìüíï CD. Ìå ôç óõíå÷Þ åîÝëéîç ôçò ôå÷íïëïãßáò óýíôïìá, ôá íïýìåñá áõôÜ èá ðïëëáðëáóéáóôïýí. ÁíáìöéóâÞôçôá, ìå ôçí ðáñÜëëçëç åîÝëéîç ôçò ôå÷íïëïãßáò ôïõ äéáäéêôýïõ êáé ôùí Ç/Õ áíáäåéêíýïíôáé áñêåôÝò åöáñìïãÝò êáé äõíáôüôçôåò óôï ÷þñï ôçò éáôñéêÞò12. Ç Pub Med (MEDLARS online) åßíáé ç ðñþôç êáé ðéï ãíùóôÞ âéâëéïãñáöéêÞ âÜóç äåäïìÝíùí ôçò National Library of Medicine, ìå ðáãêïóìßùò äéáèÝóéìåò õðçñåóßåò13-15. ÓõãêñéôéêÜ ìå áíÜëïãåò ìåëÝôåò óå Íïóïêïìåßá ôçò ÁèÞíáò êáé ÐÜôñáò, åê ôïõ óõíüëïõ ôùí éáôñþí ðïõ óõììåôÝ÷ïõí óå åðéóôçìïíéêÝò áíáêïéíþóåéò, åíçìåñþíåôáé áðü ôï äéáäßêôõï ôï 83%, ôá ðåñéïäéêÜ ôï 74% êáé ôç âéâëéïèÞêç ôï 53%16. Óõíåðþò ôï internet èÝôåé Ýììåóá ôá èåìÝëéá Ýãêõñùí êáé ðïéïôéêþí éáôñéêþí äçìïóéåýóåùí ìå áðïôÝëåóìá, ôüóï ôçí ðñïáãùãÞ ôçò éáôñéêÞò ãíþóçò, üóï êáé ôçí áðáñ÷Þ ãéá íÝåò ìåëÝôåò êáé áíáêáëýøåéò êáèþò åðßóçò êáé ôçí åýñåóç êéíÞôñùí ãéá ôçí åðéóôçìïíéêÞ áíáæÞôçóç êáé åîÝëéîç óôï ÷þñï ôçò õãåßáò17,18. Ðïëëïß óõíÜäåëöïß ìáò åêöñÜæïõí ôçí åðéèõìßá óõóôçìáôéêÞò åíäïíïóïêïìåéáêÞò åíçìÝñùóçò ìÝóù internet óôá ðëáßóéá ôçò óõíå÷éæüìåíçò éáôñéêÞò åêðáßäåõóçò. Áõôü óõìâáßíåé, åßôå ëüãù ôïõ áõîçìÝíïõ - êáôÜ áõôïýò - êüóôïõò áðüêôçóçò Ç/Õ ãéá ðñïóùðéêÞ ÷ñÞóç, åßôå ëüãù


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ã.É. Ôóßñïò êáé óõí.

ôçò áíÜãêçò ãéá Ýãêáéñç êáé åìðåñéóôáôùìÝíç åíçìÝñùóç ôáõôü÷ñïíá ìå ôçí êáè’ çìÝñá éáôñéêÞ ðñÜîç. ÊáèçìåñéíÜ, ïé åéäéêåõüìåíïé éáôñïß åîáíôëïýí ôï ÷ñüíï ôïõò ðáñáëëÞëùò, óôçí ðåñßèáëøç ôùí áóèåíþí êáé óôç ãñáöåéïêñáôéêÞ äéåêðåñáßùóç ôùí êáèçêüíôùí ôïõò, êõñßùò ëüãù Ýëëåéøçò éáôñéêïý ðñïóùðéêïý. Åëá÷éóôïðïéïýíôáé ìå ôïí ôñüðï áõôü ïé äõíáôüôçôåò óõ÷íÞò ðñüóâáóçò óôï äéáäßêôõï, áíáéñþíôáò Ýôóé ôç óõóôçìáôéêÞ åðéóôçìïíéêÞ åðéìüñöùóç ìÝóù ôùí éáôñéêþí éóôïóåëßäùí. Ç ôå÷íïëïãßá ôïõ internet áðïôåëåß ôïí óçìáíôéêüôåñï óýììá÷ï üóïí áöïñÜ óôçí åíçìÝñùóç ôïõ éáôñïý, åöüóïí ôïõ ðáñÝ÷åé Üìåóç ðëçñïöüñçóç ìå ôñüðï ðñïóéôü êáé åëêõóôéêü, êÜíïíôáò åöéêôÞ ôç ÷ñÞóç êáé åíóùìÜôùóç óôçí ðëçñïöïñßá ôçò êéíïýìåíçò åéêüíáò êáé Þ÷ïõ19-22. ÁíåîáñôÞôùò ðÜíôùò ôùí ôõ÷üíôùí äõóêïëéþí áðüêôçóçò ðñïóùðéêïý Ç/Õ Þ äõíáôüôçôáò ðñüóâáóçò, ôï äéáäßêôõï ÷ñçóéìïðïéïýìåíï åíôüò êáé åêôüò íïóïêïìåßïõ, èåùñåßôáé ç ðéï åíäéáöÝñïõóá êáé óýã÷ñïíç ðçãÞ éáôñéêÞò åíçìÝñùóçò16,23.

æüìåíçò éáôñéêÞò åêðáßäåõóçò. ÓçìáíôéêÞ åðßóçò êñßíåôáé ç óôáäéáêÞ åðÝêôáóç ôùí åêðáéäåõôéêþí óåìéíáñßùí ðëçñïöïñéêÞò ó’ üëá ôá åðßðåäá ôçò éáôñéêÞò ðåñßèáëøçò, êáèþò êáé ç ðñïþèçóç óõíåñãáóßáò ìÝóù Ç/Õ ìåôáîý íïóçëåõôéêþí éäñõìÜôùí êáé åñåõíçôéêþí êÝíôñùí, ìå óôü÷ï ôüóï ôçí ðñïâïëÞ áðü êïéíïý ôïõ åðéóôçìïíéêïý ôïõò Ýñãïõ üóï êáé ôç âåëôßùóç ðáñï÷Þò õðçñåóéþí õãåßáò. Ç êáèçìåñéíÞ åîÝëéîç ôçò éáôñéêÞò Ýñåõíáò êÜíåé åðéôáêôéêÞ ôçí áíÜãêç ôçò óõ÷íÞò åíçìÝñùóçò ôïõ óýã÷ñïíïõ éáôñïý, þóôå íá ðñïóöÝñåé óôïí áóèåíÞ ðëçñÝóôåñç êáèïäÞãçóç êáé ðåñßèáëøç. Ç åðáñêÞò êáé âåëôéùìÝíç ãíþóç, ìÝóù ôçò óõíå÷éæüìåíçò åêðáßäåõóçò êáé Üìåóçò ðëçñïöüñçóçò, óôï÷åýåé óôçí ðñïâïëÞ ôïõ ðáñáãùãéêïý Ýñãïõ ôïõ éáôñïý êáé óõìâÜëëåé óôçí áíÜêôçóç ôçò åìðéóôïóýíçò ôïõ ùò ìÝëïõò ôçò êïéíùíßáò êáé óõìâïýëïõ ôçò åðß ðáíôüò åðéóôçôïý, þóôå íá áíáäåé÷èåß “ðÜíôùí Üîéïò” êáé áðïôåëåóìáôéêüò èåñÜðùí ü÷é ìüíï ôùí íüóùí áëëÜ êáé ôùí íïóïýíôùí.

Âéâëéïãñáößá

ÓõìðåñÜóìáôá – ÐñïôÜóåéò Ç ÷ñÞóç éáôñéêþí éóôïóåëßäùí áð’ ôïõò éáôñïýò åíüò ôñéôïâÜèìéïõ íïóïêïìåßïõ êñßíåôáé ãåíéêÜ éêáíïðïéçôéêÞ, ìå âáóéêïýò áñùãïýò ôá óõóôçìáôéêÜ ðñïãñÜììáôá åêðáßäåõóçò óå Ç/Õ êáé internet áëëÜ êáé ôçí ýðáñîç êáôÜëëçëïõ åîïðëéóìïý. ÓõãêñéôéêÜ ìå ôï öýëï ÷ñçóéìïðïéåßôáé ðåñéóóüôåñï áð’ ôïõò Üíäñåò, óå ó÷Ýóç ìå ôçí åéäéêüôçôá ðáñáôçñåßôáé ëéãüôåñç ÷ñÞóç áðü ôïõò éáôñïýò ôïõ Åñã/êïý ôïìÝá. Ôï äéáäßêôõï èåùñåßôáé ç ðéï åíäéáöÝñïõóá ðçãÞ éáôñéêÞò åíçìÝñùóçò, áí êáé äåí êñßíåôáé ðÜíôïôå åöéêôÞ ç ÷ñÞóç ôïõ åíôüò íïóïêïìåßïõ, êõñßùò ëüãù öüñôïõ åñãáóßáò êáé Ýëëåéøçò ÷ñüíïõ. Ç ðëåéïøçößá ôùí ðñïôÜóåùí áðü ôïõò åñùôçèÝíôåò éáôñïýò ãéá ôç âåëôßùóç ôçò éáôñéêÞò ôïõò åíçìÝñùóçò ìÝóù äéáäéêôýïõ, óõíßóôáôáé: á) óôçí Üìåóç äõíáôüôçôá ðñüóâáóçò óôï internet åíôüò íïóïêïìåßïõ, â) óôïí ðñïãñáììáôéóìü åêðáéäåõôéêþí óåìéíáñßùí ìå ìåèüäïõò áíåýñåóçò – äéá÷åßñéóçò ðëçñïöïñéþí êáé ôáêôéêÞò åíçìÝñùóçò ãéá ðáñïõóßá íÝùí éáôñéêþí éóôïóåëßäùí êáé áíáêïéíþóåùí, óôá ðëáßóéá ôçò óõíå÷é-

1. Oermann MH, Lesley M, Kuefler SF. Using the Internet to teach consumers about quality care. Jt Comm J Qual Improv, 28:83-9, 2002. 2. Mullner RM. The Internet and healthcare: opportunities and challenges. J Med Syst, 26:4913, 2002. 3. Diaz JA, Griffith RA, Ng JJ, Reinert SE, Friedmann PD, Moulton AW. Patients’ use of the Internet for medical information. J Gen Intern Med, 17:180-5, 2002. 4. Nahas R, Evans MF. Good-quality medical advice on the Internet. Can Fam Physician, 47:567, 2001. 5. Jupiter Media Metrix at home panels, 2002 6. Risk A, Dzenowagis J. Review of internet health information quality initiatives. J Med Internet Res, 3:28, 2001 7. Purcell GP, Wilson P, Delamothe T. The quality of health information on the internet. BMJ, 324:557-8, 2002. 8. Karp S, Monroe AF. Quality of healthcare information on the Internet: caveat emptor still rules. Manag Care Q, 10:3-8, 2002. 9. Dorman SM. Health on the Net Foundation: advocating for quality health information. J Sch Health, 72:86, 2002. 15


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

10. Ruskin K. Information services and the Internet. J Clin Monit Comput, 15:419-20, 1999. 11. Liem SL. How reliable is medical-dental information on Internet? Ned Tijdschr Tandheelkd, 107:256, 2000. 12. ÁíôùíÜêçò Í, ËéïíÞò ×. ÅöáñìïãÝò ôùí çëåêôñïíéêþí õðïëïãéóôþí óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò êáé óôç ÃåíéêÞ/ÏéêïãåíåéáêÞ ÉáôñéêÞ. ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 9:213220, 1997. 13. Crocco AG, Villasis-Keever M, Jadad AR. Analysis of cases of harm associated with use of health information on the internet. JAMA, 287:2869-71, 2002. 14. Price SL, Hersh WR. Filtering Web pages for quality indicators: an empirical approach to finding high quality consumer health information on the World Wide Web. Proc AMIA Symp:9115, 1999. 15. Cline RJ, Haynes KM. Consumer health information seeking on the Internet: the state of the art. Health Educ Res, 16:671-92, 2001. 16. Ôóßñïò ÉÃ, ÂïÀëá ÅÐ, Êáëïãåñüðïõëïò ÊÄ êáé óõí. Áîéïëüãçóç ðçãþí éáôñéêÞò åíçìÝñùóçò. Ôüìïò ðåñéëÞøåùí 14ïõ ÐáíåëëÞíéïõ Óõíåäñßïõ

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ÃåíéêÞò ÉáôñéêÞò, óåë: 288, 2002. 17. Pergament D, Pergament E, Wonderlick A, Fiddler M. At the crossroads: the intersection of the Internet and clinical oncology. Oncology (Huntingt), 13:577-86, 1999. 18. Levi R. Risk of disinformation on the Internet. Quality labelling of medical websites is tested. Lakartidningen, 96:1737-40, 1999. 19. Faskunger J. Interactive health communication can improve the quality of health care. Lakartidningen, 99:1840-1, 2002. 20. Clark EJ. Health care web sites: are they reliable? J Med Syst, 26:519-28, 2002. 21. Walker J. Quality of midwifery care given throughout the world report of the Fourth International Homebirth Conference March 16, 17, 18 Amsterdam, The Netherlands. Midwifery, 16:161-4, 2000. 22. Wilson P. How to find the good and avoid the bad or ugly: a short guide to tools for rating quality of health information on the internet. BMJ, 324:598-602, 2002. 23. Marwick C. Ensuring ethical internet information. JAMA, 283:1677-8, 2000.


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ã.É. Ôóßñïò êáé óõí.

ÐáñÜñôçìá Á “Áîéïëüãçóç ôçò ÷ñÞóçò ôïõ äéáäéêôýïõ áðü ôï éáôñéêü ðñïóùðéêü åíüò ðáíåðéóôçìéáêïý íïóïêïìåßïõ”

ÅÑÙÔÇÌÁÔÏËÏÃÉÏ Ðáñáêáëþ óçìåéþóáôå ìå ìðëå óôõëü Ýíá X, ìåôÜ áðü ôçí áðÜíôçóç (óôá äåîéÜ) ðïõ åðéëÝîáôå Þ áðáíôÞóôå óõíïðôéêÜ óôéò áíôßóôïé÷åò åñùôÞóåéò. 1. Öýëï: ¢íäñáò Ãõíáßêá 2. Çëéêßá: .......................................................................................................................................................................................................... 3. Åéäéêüôçôá: ................................................................................................................................................................................................ 4. Éáôñüò:

Åéäéêåõüìåíïò

ÅéäéêåõìÝíïò

5. ×ñçóéìïðïéåßôå ôï äéáäßêôõï (internet) ùò ðçãÞ éáôñéêÞò åíçìÝñùóçò; ÍÁÉ Ï×É 6. Ðïéåò åßíáé êáôÜ ôç ãíþìç óáò ïé ðéï åíäéáöÝñïõóåò ðçãÝò éáôñéêÞò åíçìÝñùóçò, áíåîÜñôçôá áí Ý÷åôå äõíáôüôçôá Üìåóçò ðñüóâáóçò Þ ÷ñÞóçò ðñïò áõôÝò; (äõíáôüôçôá åðéëïãÞò ìßáò Þ êáé ðåñéóóüôåñùí áðáíôÞóåùí). á. ×ñÞóç Äéáäéêôýïõ â. Óõììåôï÷Þ óå ÓõíÝäñéá ã. ÌåôåêðáéäåõôéêÜ ÌáèÞìáôá ä. ÉáôñéêÜ ÐåñéïäéêÜ/¸íôõðá å. ÓõæÞôçóç Ðåñéóôáôéêþí óô. ×ñÞóç ÂéâëïèÞêçò 7. Ðþò êñßíåôå ôç äõíáôüôçôá ðñüóâáóçò óôï äéáäßêôõï ãéá ôçí éáôñéêÞ óáò ðëçñïöüñçóç åíôüò êáé åêôüò íïóïêïìåßïõ; 8. Ðïéá ç ãåíéêÞ óáò åêôßìçóç ãéá ôçí åðÜñêåéá åíçìÝñùóçò êáé åêðáßäåõóçò äéá÷åßñéóçò éáôñéêþí ðëçñïöïñéþí ìÝóù internet åíôüò íïóïêïìåßïõ; 9. Êñßíåôå ôçí áíáãêáéüôçôá âåëôßùóçò ôùí ðáñå÷üìåíùí ìÝóùí-äõíáôïôÞôùí ÷ñÞóçò ôçò ðëçñïöïñéêÞò óôá ðëáßóéá åêðáßäåõóçò êáé åíçìÝñùóÞò óáò; Ðïéåò ïé ðñïôÜóåéò óáò;

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Â. Ôóïýíéáò, Ì. Ãåùñãïðïýëïõ

ÅÑÅÕÍÇÔÉÊÏ ÁÑÈÑÏ ÏRIGINAL PAPER Primary Heatlh Care, Volume 16, Number 1, 18-22, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 18-22, 2004

Óõ÷íüôçôá åìöÜíéóçò ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ Â. Ôóïýíéáò1, Ì. Ãåùñãïðïýëïõ2

Ðåñßëçøç Ôá ðñïâëÞìáôá õãåßáò, ôá ïðïßá ó÷åôßæïíôáé ìå ôá ÷ñüíéá ìåôáâïëéêÜ íïóÞìáôá, åìöáíßæïõí áõîçìÝíï åíäéáöÝñïí, üóï ï ðëçèõóìüò ãçñÜóêåé. Ï óáê÷áñþäçò äéáâÞôçò (ôýðïõ ÉÉ) áðïôåëåß Ýíá áðü ôá ìåãáëýôåñá ðñïâëÞìáôá õãåßáò óå ðáãêüóìéá êëßìáêá. Ï ïìáëüò ëåé÷Þíáò åßíáé Ýíá ÷ñüíéï äåñìáôéêü íüóçìá, Üãíùóôçò áéôéïëïãßáò, ìå óõ÷íÝò óôïìáôïëïãéêÝò åêäçëþóåéò. ÌÝóá áðü ôç óõ÷íÞ åìöÜíéóç ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç (ôýðïõ ÉÉ) Ý÷åé óõó÷åôéóèåß ç ðáèïãÝíåéá ôùí äõï íïóçìÜôùí. Óêïðüò ôçò åñãáóßáò áõôÞò åßíáé ç ìåëÝôç ôçò óõ÷íüôçôáò ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç (ôýðïõ ÉÉ). ×ñçóéìïðïéÞèçêå äåßãìá 317 äéáâçôéêþí áóèåíþí (ôýðïõ ÉÉ) êáé ï éóÜñéèìïò ðëçèõóìüò õãéþí áôüìùí. Ôá åõñÞìáôá Ýäåéîáí ìéêñÞ äéáöïñÜ ðáó÷üíôùí áðü ïìáëü ëåé÷Þíá ôïõ óôüìáôïò ìåôáîý äéáâçôéêþí êáé õãéþí áôüìùí, ç ïðïßá äåí åðéâåâáéþèçêå óôáôéóôéêÜ. Áðü ôç óõæÞôçóç ðñïêýðôåé ôï óõìðÝñáóìá üôé áðáéôïýíôáé ðåñéóóüôåñï åîéäåéêåõìÝíåò óå äéáãíùóôéêÜ êñéôÞñéá ìåëÝôåò ãéá íá åðéâåâáéþóïõí ôçí êëéíéêÞ êáé ðáèïãåíåôéêÞ óõó÷Ýôéóç ôùí äõï íïóçìÜôùí. 1

ÄéåõèõíôÞò-Ïäïíôßáôñïò, 2ÅðéìåëÞôñéá-Âéïðáèïëüãïò, Ê.Õ. ÁôáëÜíôçò

Prevalence of oral lichen planus in patients with diabetes mellitus type ÉÉ B. Tsounias and M. Georgopoulou Summary Health problems associated with chronic metabolic diseases are becoming increasingly more prevalent as the average age of the population increases. Diabetes mellitus (type 2) represents one of the major chronic health problems facing the world today. Oral lichen planus is a common dermatological disease of unknown etiology and characteristic clinical manifestations from the skin and the oral mucosa. The purpose of this study was to examine patients with diabetes mellitus (type 2) for possible affected from oral Lichen planus. Three hundred and seventeen (317) patients with type II diabetes mellitus and the same number of controls were examined for the clinical evidences of oral lichen planus. Eleven patients with oral lichen planus were found for the diabetic group and seven patients for the control group. The rates between the two groups did not differ significantly and the results did not indicate an evident association of diabetes mellitus and oral lichen planus in this popular sample. Key words: Diabetes mellitus, Oral lichen planus, Metabolic diseases, Oral mucosa condition

18

ÅéóáãùãÞ Ï ïìáëüò ëåé÷Þíáò åßíáé ìéá ó÷åôéêÜ óõ÷íÞ, ÷ñüíéá êíçóìþäçò äåñìáôïðÜèåéá, ãíùóôÞ ðÜíù áðü 130 ÷ñüíéá. ×áñáêôçñßæåôáé áðü éþäåò – âëáôéäþäåò åîÜíèçìá êáé ç áéôéïëïãßá ôçò ðáñáìÝíåé Üãíùóôç1-3. Óôï âëåííïãüíï ôïõ óôüìáôïò ç óôïé÷åéþäçò êëéíéêÞ âëÜâç åßíáé ïé áñãõñüëåõêåò âëáôßäåò, ðïõ óõññÝïõí êáôÜ áèñïßóìáôá, ó÷çìáôßæïíôáò ãñáììþóåéò (Wickham’s strikes) ìå ìïñöÞ äáêôõëßùí Þ äéêôýïõ (äéêôõùôüò ôýðïò). Åêôüò ôçò êëáóóéêÞò áõôÞò ìïñöÞò ôïõ ïìáëïý ëåé÷Þíá õðÜñ÷åé êáé ç äéáâñùôéêÞ Þ åëêùôéêÞ ìïñöÞ ðïõ ÷áñáêôçñßæåôáé áðü ðïéêßëïõ ìåãÝèïõò êáé ó÷Þìáôïò äéáâñþóåéò Þ åëêþóåéò, óôçí ðåñéöÝñåéá ôùí ïðïßùí ðáñáôçñïýíôáé óõíÞèùò ïé ÷áñáêôçñéóôéêÝò ãñáììïåéäåßò âëáôßäåò. Åðßóçò ðéï óðÜíéåò åßíáé ç ðïìöïëõãþäçò – öõóáëéäþäçò, ç áôñïöéêÞ êáé ç õðåñôñïöéêÞ4-6. ËÝîåéò êëåéäéÜ: Óáê÷áñþäçò äéáâÞôçò, ïìáëüò ëåé÷Þíáò óôüìáôïò, ìåôáâïëéêÜ íïóÞìáôá, âëÜâåò âëåííïãüíïõ óôüìáôïò ÕðïâëÞèçêå: 5 Éáíïõáñßïõ 2004 ÅðáíõðïâëÞèçêå: 18 Ìáñôßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Ìáñôßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: Â. Ôóïýíéáò, Ê.Õ. ÁôáëÜíôçò, T.K. 35200 Öèéþôéäá, Ôçë.: (22330)23403, (22330)23404, Fax: (22330)23202


Â. Ôóïýíéáò, Ì. Ãåùñãïðïýëïõ

Ï ïìáëüò ëåé÷Þíáò åíôïðßæåôáé êõñßùò óôï âëåííïãüíï ôùí ðáñåéþí êáé áêïëïõèïýí ìå ìéêñüôåñç óõ÷íüôçôá ç ãëþóóá, ôá ÷åßëç, ç õðåñþá êáé ôï Ýäáöïò ôïõ óôüìáôïò, åíþ óôá ïýëá Ý÷åé ôç ìïñöÞ áðïöëïéùôéêÞò ïõëßôéäáò5,7. Ç óõíýðáñîç óôïìáôéêþí êáé äåñìáôéêþí âëáâþí ðïéêßëåé áðü ôï 25% Ýùò ôï 50% ôùí ðåñéðôþóåùí8. Ç äéÜñêåéá ôùí åêäçëþóåùí óôï óôüìá ðïéêßëåé áðü Ýíá ÷ñüíï óôï 28%, Ýíá Ýùò ðÝíôå ÷ñüíéá óôï 42%, ðÝíôå Ýùò äÝêá ÷ñüíéá óôï15%, êáé ðÜíù áðü äÝêá ÷ñüíéá óôï 15%, åíþ ôï íüóçìá åìöáíßæåôáé óå Üôïìá ìÝóçò çëéêßáò êáé ïé ãõíáßêåò åìöáíßæïõí ìéêñÞ õðåñï÷Þ5,6. Áí êáé ï ïìáëüò ëåé÷Þíáò Ý÷åé áñêåôÜ åõäéÜêñéôïõò êëéíéêïýò êáé éóôïðáèïëïãéêïýò ÷áñáêôÞñåò, ç ðáèïãÝíåéá ôïõ ðáñáìÝíåé Üãíùóôç4 åíþ ç öëåãìïíþäçò äéÞèçóç äåí åìöáíßæåé äéáöïñÝò ìåôáîý ôùí äéáöüñùí êëéíéêþí ìïñöþí ôïõ íïóÞìáôïò9. Óýã÷ñïíåò áðüøåéò ãéá ôçí ðáèïãÝíåéá ôïõ ïìáëïý ëåé÷Þíá4,10-12 åíï÷ïðïéïýí ôç óõììåôï÷Þ ôùí êõôôÜñùí Langerhans êáé ôùí êõôôáñïôïîéêþí Ô-4 ëåìöïêõôôÜñùí, ôá ïðïßá Ý÷ïõí ùò óôü÷ï ôá êýôôáñá ôçò âáóéêÞò óôéâÜäáò ôïõ åðéèçëßïõ. Ï ïìáëüò ëåé÷Þíáò ðéóôåýåôáé üôé ïöåßëåôáé óå óõíäõáóìü ãåíåôéêþí êáé ðåñéâáëëïíôéêþí ðáñáãüíôùí13,14 åíþ êáôÜ êáéñïýò Ý÷ïõí ãßíåé äéÜöïñåò óõó÷åôßóåéò ìå ôï stress Þ ãåíåôéêÜ íïóÞìáôá üðùò ïé ÷ñüíéåò çðáôïðÜèåéåò, ç õðÝñôáóç, ï óáê÷áñþäçò äéáâÞôçò, ç åëêþäçò êïëßôéäá êáé ôá êáêïÞèç íåïðëÜóìáôá15. Ï óáê÷áñþäçò äéáâÞôçò åßíáé Ýíá óýíèåôï ÷ñüíéï ìåôáâïëéêü íüóçìá, ôï ïðïßï ÷áñáêôçñßæåôáé áðü äéáôáñá÷Ýò óôï ìåôáâïëéóìü ôùí õäáôáíèñÜêùí, ôùí ëéðþí êáé ôùí ðñùôåúíþí16. Äéáêñßíïíôáé äõï ôýðïé: ï óáê÷áñþäçò äéáâÞôçò ôýðïõ É Þ éíóïõëéíïåîáñôþìåíïò óôïí ïðïßï õðÜñ÷åé áäõíáìßá ðáñáãùãÞò éíóïõëßíçò êáé ï ôýðïò ÉÉ Þ ìç éíóïõëéíïåîáñôþìåíïò, êáôÜ ôïí ïðïßï ôá êýôôáñá äåí áíôáðïêñßíïíôáé óôç äñÜóç ôçò éíóïõëßíçò17. Ï óáê÷áñþäçò äéáâÞôçò Ý÷åé óõó÷åôéóèåß êáôÜ êáéñïýò ìå äéÜöïñá íïóÞìáôá ôïõ âëåííïãüíïõ ôïõ óôüìáôïò, üðùò ç ìÝóç ñïìâïåéäÞò ãëùóóßôéäá, ç ãåùãñáöéêÞ ãëþóóá Þ øåõäïìåìâñáíþäçò ãëùóóßôéäá, ç óõã÷åéëßôéäá, ç óôïìáôïäõíßá, îçóôïóôïìßá, ï ïìáëüò ëåé÷Þíáò êáé ç êáôéíôßáóç18,19. Åðßóçò ç óõó÷Ýôéóç ìåôáîý óáê÷áñþäç äéáâÞôç êáé ðáñáãùãÞò – ñïÞò óÜëéïõ Ý÷åé ãßíåé

Ôüìïò 16, Ôåý÷ïò 1, 2004

áíôéêåßìåíï ìåëÝôçò áðü áñêåôïýò åñåõíçôÝò20. ÅðåéäÞ áðü ïñéóìÝíïõò åñåõíçôÝò ðéèáíïëïãåßôáé êÜðïéá óõó÷Ýôéóç ôùí ìåôáâïëéêþí äéáôáñá÷þí õäáôáíèñÜêùí – ðñùôåúíþí – ëéðþí, óôï óáê÷áñþäç äéáâÞôç ìå ôçí êáôáóôñïöÞ ôùí êõôôÜñùí ôïõ åðéèçëßïõ, ç ïðïßá ðáñáôçñåßôáé óôïí ïìáëü ëåé÷Þíá ôïõ óôüìáôïò, Ý÷ïõí ìåëåôÞóåé ôç óõíýðáñîç óáê÷áñþäç äéáâÞôç êáé ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò ìå áíôéêñïõüìåíá áðïôåëÝóìáôá21. Óêïðüò ôçò åñãáóßáò áõôÞò åßíáé íá ìåëåôçèåß ç óõ÷íüôçôá ýðáñîçò ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ óå óýãêñéóç ìå éóÜñéèìïõò õãéåßò ìÜñôõñåò.

Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïé ÊáôÜ ôç äéÜñêåéá ôçò Ýñåõíáò õðïâëÞèçêáí óå óôïìáôéêü Ýëåã÷ï 317 äéáâçôéêïß áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ, ïé ïðïßïé åðéóêÝöèçêáí ôï Âéïðáèïëïãéêü ÅñãáóôÞñéï ôïõ Ê.Õ. ÁôáëÜíôçò ãéá åñãáóôçñéáêü Ýëåã÷ï. Ç óôïìáôïëïãéêÞ åîÝôáóç ðñáãìáôïðïéïýíôáí ôçí åðïìÝíç çìÝñá ôçò áéìïëçøßáò, üôáí ðñïóÝñ÷ïíôáí ãéá ôçí ðáñáëáâÞ ôùí áðáíôÞóåùí, ïðüôå åß÷å äéáðéóôùèåß ôï åðßðåäï ãëõêüæçò ôïõ áßìáôïò (G>120 mg/dl). Ùò ìÜñôõñåò åîåôÜóèçêáí ßóïò áñéèìüò áôüìùí, ïé ïðïßïé áðü ôïí åñãáóôçñéáêü Ýëåã÷ï ðñïÝêõøå üôé äåí åß÷áí áõîçìÝíá åðßðåäá ãëõêüæçò, ïýôå óôï ðáñåëèüí åß÷áí åìöáíßóåé ôÝôïéá äéáôáñá÷Þ. Ïé äéáâçôéêïß áóèåíåßò åëÜìâáíáí áíôéäéáâçôéêÜ äéóêßá êáé áêïëïõèïýóáí êÜðïéá äéáéôçôéêÞ áãùãÞ. Ïõäåßò åê ôùí áóèåíþí åëÜìâáíå éíóïõëßíç. ÊáôÜ ôç ëÞøç ôïõ éóôïñéêïý åîáéñÝèçêáí åðßóçò üóïé åê ôùí áóèåíþí Þ ìáñôýñùí Ýðáó÷áí áðü êÜðïéï áëëåñãéêü íüóçìá Þ íüóçìá ôïõ êïëëáãüíïõ Þ Üëëï ìåôáâïëéêü íüóçìá. Ï êëéíéêüò óôïìáôïëïãéêüò Ýëåã÷ïò Ýãéíá óýìöùíá ìå ôá êñéôÞñéá ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò22 êáé ç äéÜãíùóç ôïõ ïìáëïý ëåé÷Þíá ôïõ âëåííïãüíïõ ôïõ óôüìáôïò Ýãéíå óýìöùíá ìå ôá êëéíéêÜ êñéôÞñéá8: á) ¾ðáñîç áñãõñüëåõêùí âëáôßäùí ðïõ äéáôÜóóïíôáí óå ëåðôÝò ãñáììþóåéò ðïõ ó÷çìÜôéæáí äáêôõëßïõò Þ äßêôõï â) ¼ðïõ õðÞñ÷áí äéáâñþóåéò Þ åëêþóåéò ðåñéöåñéêÜ õðÞñ÷áí áñãõñüëåõêåò âëáôßäåò ðïõ ó÷çìÜôéæáí ãñáììþóåéò áêôéíùôÜ.

19


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Â. Ôóïýíéáò, Ì. Ãåùñãïðïýëïõ

ÁðïôåëÝóìáôá Áðü ôïõò 317 äéáâçôéêïýò áóèåíåßò êáé ôïõò 317 ìÜñôõñåò, ïé 134 Þóáí Üññåíåò êáé ïé 183 èÞëåéò. ÁíáëõôéêÜ ôï öýëï êáé ç ïìÜäá çëéêßáò ôùí áóèåíþí êáé ôùí ìáñôýñùí öáßíïíôáé óôïí Ðßíáêá 1. Áðü ôïõò 317 äéáâçôéêïýò áóèåíåßò, ïé 11 Ýðáó÷áí áðü ïìáëü ëåé÷Þíá ôïõ óôüìáôïò, ðïóïóôü 3,5%, åíþ áðü ôïõò 317 ìÜñôõñåò Ýðáó÷áí áðü ïìáëü ëåé÷Þíá ôïõ óôüìáôïò 7, ðïóïóôü 2,2% (Ðßíáêáò 2). Áðü óôáôéóôéêÞ áíÜëõóç ôùí åõñçìÜôùí ìå ôï êñéôÞñéï ×2, ç äéáöïñÜ Þôáí ìç óôáôéóôéêÜ óçìáíôéêÞ (p >0,1). Ç äéÜñêåéá ôïõ óáê÷áñþäç äéáâÞôç, óå üóïõò Ýðáó÷áí áðü ïìáëü ëåé÷Þíá ôïõ óôüìáôïò öáßíåôáé óôïí Ðßíáêá 3, åíþ ïé êëéíéêÝò ìïñöÝò ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò öáßíïíôáé óôïí Ðßíáêá 4.

äüíá, íùäüôçôá, îçñïóôïìßá, áêñïññéæéêÜ áðïóôÞìáôá, óôïìáôïäõíßá êáé Üëëá16,18. Ðáëéüôåñåò åñåõíçôéêÝò åñãáóßåò Ý÷ïõí åíï÷ïðïéÞóåé ôéò äéáÐßíáêáò 2. Ôï öýëï êáé ç çëéêßá ôùí áóèåíþí ìå ïìáëü ëåé÷Þíá ôïõ óôüìáôïò Öýëï ¢ññåíåò ÈÞëåéò Óýíïëï

Äéáâçôéêïß

ÌÜñôõñåò

2 9 11

1 6 7

ÓõæÞôçóç Ïé óôïìáôéêÝò åêäçëþóåéò ôïõ óáê÷áñþäç äéáâÞôç ðåñéëáìâÜíïõí ðïéêßëåò ðáèïëïãéêÝò êáôáóôÜóåéò üðùò ðåñéïäïíôéêÜ íïóÞìáôá, ôåñç-

Ðßíáêáò 1. Ôï öýëï êáé ç çëéêßá áóèåíþí êáé ìáñôýñùí ÏìÜäåò çëéêéþí 30-39 40-49 50-59 60-69 70-79 80-89 90 ® Óýíïëï

20

Äéáâçôéêïß

ÌÜñôõñåò

Á

È

Á

È

1 2 11 61 53 5 1 134

2 3 18 89 61 7 3 183

1 15 57 60 1 134

1 1 24 94 58 4 1 183

Ðßíáêáò 3. Ç äéÜñêåéá ôïõ óáê÷áñþäç äéáâÞôç óôïõò áóèåíåßò ìå ïìáëü ëåé÷Þíá ÄéÜñêåéá (Ýôç) 0-1 1-5 5-10

Áñéèìüò áóèåíþí 4 5 2


Ôüìïò 16, Ôåý÷ïò 1, 2004

Â. Ôóïýíéáò, Ì. Ãåùñãïðïýëïõ Ðßíáêáò 4. Ïé êëéíéêïß ôýðïé ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óôïõò áóèåíåßò ôïõ äåßãìáôïò Ôýðïò ÄéêôõùôÞ ÄéáâñùôéêÞ ÅëêùôéêÞ Óýíïëï

Äéáâçôéêïß

ÌÜñôõñåò

4 7 11

4 3 7

êõìáßíïíôáé ìåôáîý ôùí ôéìþí 0,5%-0,7%22, 1%0%25, 4%-3%26, 2,9%-2,2%21. Ïé äéáöïñÝò áõôÝò ðéèáíüí íá ïöåßëïíôáé óå äéáöïñåôéêü ó÷åäéáóìü ôçò êÜèå åñãáóßáò, üðùò ïé çëéêßåò ôùí äéáâçôéêþí êáé ôùí ìáñôýñùí, ç áíáëïãßá äéáâçôéêþí êáé ìáñôýñùí, ôá äéáãíùóôéêÜ êñéôÞñéá ôïõ ïìáëïý ëåé÷Þíá êáé ç áîéïëüãçóç ôùí ëïéðþí óôïé÷åßùí áðü ôï éáôñéêü éóôïñéêü, üðùò ôá ëáìâáíüìåíá öÜñìáêá, åêôüò ôùí áíôéäéáâçôéêþí ê.ëð.15,18,21. Óôçí åñãáóßá áõôÞ ï áñéèìüò äéáâçôéêþí êáé ìáñôýñùí Þôáí ï ßäéïò êáé ãéá ôá äõï öýëá, üðùò ó÷åäüí ßäéïé Þôáí êáé ïé ðëçèõóìïß óôéò äéÜöïñåò ïìÜäåò çëéêéþí. Ïé äéáöïñÝò óôçí êëéíéêÞ ìïñöÞ ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò äåí öáßíåôáé íá åðçñåÜæïõí ôç óôáôéóôéêÞ äïêéìáóßá ãéáôß õðïêñýðôïõí ðáñüìïéá éóôïðáèïëïãéêÞ åéêüíá êáé ðáèïãåíåôéêü ìç÷áíéóìü9 åíþ äåí öáßíåôáé åðßóçò íá åðçñåÜæåôáé ç óõ÷íüôçôá åìöÜíéóçò ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò áðü ôç äéÜñêåéá ôïõ óáê÷áñþäç äéáâÞôç.

ÓõìðåñÜóìáôá ôáñá÷Ýò óôï ìåôáâïëéóìü ôùí õäáôáíèñÜêùí – ðñùôåúíþí êáé ëéðéäßùí óôçí ðáèïãÝíåéá ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò21,22, åíþ íåþôåñåò åñãáóßåò óõó÷åôßæïõí ôçí ðáèïãÝíåéá ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò ìå ôéò áíïóïëïãéêÝò äéáôáñá÷Ýò (áõôïáíïóßá) ïé ïðïßåò åíï÷ïðïéïýíôáé êáé óôïí óáê÷áñþäç äéáâÞôç23. ÔÝëïò ïñéóìÝíïé åñåõíçôÝò óõó÷åôßæïõí ôçí åìöÜíéóç ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò, óå ðáñüìïéåò ìå ëåé÷Þíá (ëåé÷çíïåéäåßò) åêäçëþóåéò óôï âëåííïãüíï ôïõ óôüìáôïò ìå ôç ëÞøç áíôéâéïôéêþí äéóêßùí áðü ôïõò äéáâçôéêïýò áóèåíåßò24. Ç éóôïëïãéêÞ üìùò ôåêìçñßùóç ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò êáôáññßðôåé áõôÞ ôçí õðüèåóç, åíþ ç äéáêïðÞ ôùí áíôéäéáâçôéêþí öáñìÜêùí ãéá áñêåôü äéÜóôçìá ïðüôå èá õðï÷ùñïýóáí ïé ëåé÷çíïåéäåßò åêäçëþóåéò (áí Þôáí) åßíáé áäýíáôç21. Óôçí ðáñïýóá åñãáóßá ðáñüôé ïé äéáâçôéêïß áóèåíåßò åìöÜíéóáí ìåãáëýôåñç óõ÷íüôçôá ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò (3,5%) óå ó÷Ýóç ìå ôïõò õãéåßò ìÜñôõñåò (2,2%) ç äéáöïñÜ áõôÞ äåí ôåêìçñéþèçêå óôáôéóôéêÜ ìå ôá êñéôÞñéï ×2 êáé ÷áñáêôçñßóôçêå ìç óôáôéóôéêÜ óçìáíôéêÞ. Óå ðáñüìïéåò åñãáóßåò Ý÷ïõí âñåèåß ðïóïóôÜ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò óå äéáâçôéêïýò êáé ìÜñôõñåò, ôá ïðïßá

Áðü ôç ìåëÜôç ôïõ äåßãìáôïò ôçò ðáñïýóáò åñãáóßáò äåí ðñïêýðôåé êÜðïéá óõó÷Ýôéóç ìåôáîý óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ êáé ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò. Ðåñåôáßñù ìåëÝôç ôïõ èÝìáôïò âáóéæüìåíç óå ãåíåôéêÝò, áíïóïëïãéêÝò êáé åíæõìéêÝò ðáñáìÝôñïõò, ìðïñåß íá äþóåé ðéï âÝâáéá óõìðåñÜóìáôá.

Âéâëéïãñáößá 1. ÊáðåôáíÜêçò É. ¸ã÷ñùìç Äåñìáôïëïãßá. Åêä Ãñ ÐáñéóéÜíïò, ÁèÞíá, 1987, óåë. 91-94. 2. Samman PD. Lichen Planus: a dermatologic centenary. Br J Derm, 81:306-7, 1969. 3. Óôñáôçãüò É êáé óõí. ÌáèÞìáôá ÄåñìáôïëïãßáòÁöñïäéóéïëïãßáò. Åêä. Ãñ. ÐáñéóéÜíïò, ÁèÞíá, 1987, óåë. 105-113. 4. Áããåëüðïõëïò Á, ÐáðáíéêïëÜïõ Ó, Áããåëïðïýëïõ Å. Óýã÷ñïíç óôïìáôéêÞ êáé ãíáèïðñïóùðéêÞ ðáèïëïãßá. Åêä Ëßôóáò, ÁèÞíá, 2000, óåë. 657661. 5. Ìáñêüðïõëïò Á, ÊáãéÜâçò É, Ðáëáéïëüãïõ Á, Ðáðáíáãéþôïõ Ð, Ôñéãùíßäçò Ã. Ïìáëüò ëåé÷Þíáò ôïõ óôüìáôïò. ÌåëÝôç 228 ðåñéðôþóåùí. Åëë Óôïì ×ñïíéêÜ, 33:107-111, 1989. 6. Axel T, Rundquist L. Oral Lichen planus – a 21


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demographic study. Community Dent Oral Epidemiol, 15:52-56, 1987. Silverman S, Gorsky M, Lozana-Nu F, Giannotti K. A prospective study of findings and management in 214 patients with oral lichen planus. Oral Surg Oral Med Oral Pathol, 72:665670, 1991. Andreasen JO. Oral Lichen planus. A clinical evaluation of 115 cases. Oral Surg, 25:31-42, 1968. Ôóïýíéáò Â. ÓõãêñéôéêÞ ìåëÝôç ôçò öëåãìïíþäïõò äéÞèçóçò ôïõ ïìáëïý ëåé÷Þíá ôïõ óôüìáôïò. Åëë Óôïì ×ñïíéêÜ, 25:113-118, 1981. Áëìðáíßäïõ-ÖáñìÜêç Å, Ìðïýñá Ð, ÊáãéÜâçò É, Ðáðáíáãéþôïõ Ð ÔóÜðáò É. ¸ëåã÷ïò áíïóïëïãéêþí ðáñáìÝôñùí óå 84 áóèåíåßò ìå ïìáëü ëåé÷Þíá ôïõ óôüìáôïò. Åëë Ð Óôïì Ãíáèïðñïóùð ×åéñ, 10:51-56, 1995. ÊáãéÜâçò É, Áëìðáíßäïõ-ÖáñìÜêç Å, ÌÜñãáñç Å, Ðáðáíáãéþôïõ Ð. Ç â2 ìéêñïóöáéñßíç óôïí ïìáëü ëåé÷Þíá ôïõ óôüìáôïò. Óôïìáôïëïãßá, 48: 32-34, 1991. Baudet-Pommel M, Janin-Mercier A, Sauteyrand P. Sequential immunopathologic study of oral lichen planus treated with tretinoin and etretinate. Oral Surg Oral Med Oral Pathol, 71: 197-202, 1991. ÊáëáôæÞò Á. Ï ïìáëüò ëåé÷Þíáò ôïõ óôüìáôïò ùò ðñïêáñêéíéêÞ êáôÜóôáóç. Åëë Óôïì ×ñïíéêÜ, 43:39-45, 1999. ÊáãéÜâçò É, Áëìðáíßäïõ-ÖáñìÜêç Å, Ðáðáíáãéþôïõ Ð, Ðïëõìåíßäçò Æ. ÁíÜëõóç ôùí HLA áíôéãüíùí óå áóèåíåßò ìå ïìáëü ëåé÷Þíá ôïõ óôüìáôïò. Åëë Óôïì ×ñïíéêÜ, 36:19-24, 1992. Scully C, Beyli M, Ferreiro MC, Ficarra G, Gill Y, Griffiths M, Holmstrup P, Mutlu S, Porter S, Wray D. Update on oral lichen planus: ethiopathogenesis and management. Critical Reviews in oral Biology & Medicine, 9:86122, 1998. Vernillo A. Diabetes mellitus: Relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 91:263-270, 2001.

Â. Ôóïýíéáò, Ì. Ãåùñãïðïýëïõ

17. Murrah VA. Diabetes mellitus and associated oral manifestations: a review. J Oral Pathol, 14: 271-281, 1985. 18. Collin H-L, Niskanen L, Uusitupa M, Töyry J, Collin P, Koivisto A-M, Viinamäki H, Meurman J. Oral symptoms and signs in elderly patients with type 2 diabetes mellitus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 90: 299-305, 2000. 19. Guggenheimer J, Moore P, Rossie K, Myers D, Mongelluzzo M-B, Block H, Weyant R, Orchard T. Insulin-dependent diabetes mellitus and oral soft tissue pathologies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 89:563-576, 2000. 20. Moor P, Guggenheimer J, Etzel K, Weyant R, Orchard T. Type I diabetes mellitus, xerostomia and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 92:281291, 2001. 21. ÐÝôñïõ-ÁìåñéêÜíïõ ×, Ìáñêüðïõëïò Á, ÌðåëÜæç Ì, ÊáñáìÞôóïò Ä, Ðáðáíáãéþôïõ Ð. Åðéðïëáóìüò ôïõ óôïìáôéêïý ïìáëïý ëåé÷Þíá óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ. Åëë ÄéáâçôïëïãéêÜ ×ñïí, 9:118-122, 1996. 22. Borghelli RF, Pettinari IL, Chuchurru JA, Stirparo MA. Oral lichen planus in patients with diabetes. Oral Surg Oral Med Oral Pathol, 75: 498-500, 1993. 23. Lundstrom IM. Incidence of diabetes mellitus in patients with lichen planus. Int J Oral Surg, 12:147-152, 1983. 24. Boyd AS, Neldner KH. Lichen planus. J AM Acad Dermatol, 25:593-619, 1991. 25. Albrecht M, Banoczy J, Dinya E, Tamas G. Occurrence of oral leukoplakia and lichen planus in diabetes mellitus. J Oral Path Med, 21: 364-366, 1992. 26. Van Dis ML, Park ET. Prevalence of oral lichen planus in patients with diabetes mellitus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 79:696-700, 1995.


Ôüìïò 16, Ôåý÷ïò 1, 2004

E.Ã. ÖÜâéïõ

ANAÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 16, Number 1, 23-30, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 23-30, 2004

Ç äéáöïñéêÞ äéÜãíùóç ôçò óéäçñïðåíéêÞò áíáéìßáò áðü ôçí åôåñüæõãç â èáëáóóáéìßá äéá ôùí åñõèñïêõôôáñéêþí äåéêôþí ¸ëóá Ã. Öáâßïõ Ðåñßëçøç Õðïëïãßæåôáé üôé óôéò áíåðôõãìÝíåò ÷þñåò ôï êüóôïò ôùí êëéíéêïåñãáóôçñéáêþí åîåôÜóåùí áíÝñ÷åôáé óå 10% ôïõ ïëéêïý êüóôïõò öñïíôßäáò õãåßáò. ÓÞìåñá, ðåñéóóüôåñåò áðü ÷ßëéåò îå÷ùñéóôÝò äïêéìáóßåò åßíáé äéáèÝóéìåò óôïõò ãéáôñïýò êÜèå öïñÜ ðïõ Ýñ÷ïíôáé áíôéìÝôùðïé ìå ìßá éáôñéêÞ áðüöáóç. ÅðéðëÝïí, ï áñéèìüò ôïõò áõîÜíåé ìå ôÝôïéï ñõèìü ðïõ óõ÷íÜ åßíáé äýóêïëç ü÷é ìüíï ç áîéïëüãçóç ôïõò áëëÜ êáé áõôÞ êáèáõôÞ ç ÷ñÞóç ôïõò. Ç ðëÞñçò êáôáìÝôñçóç ôùí êõôôÜñùí ôïõ áßìáôïò ìå ôç âïÞèåéá áõôüìáôïõ áíáëõôÞ, ç ãåíéêÞ áßìáôïò äçëáäÞ, áðïôåëåß ôçí åñãáóôçñéáêÞ åîÝôáóç ìå ôç ìåãáëýôåñç æÞôçóç êáé ðéèáíüí ôï ìïíáäéêü äéáãíùóôéêü “åñãáëåßï” ðïõ äéáèÝôåé ï éáôñüò åíüò åîùôåñéêïý éáôñåßïõ Þ åíüò éäñýìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò ðñïêåéìÝíïõ íá äéåñåõíÞóåé ôá áßôéá áíáéìßáò áóèåíïýò ôïõ êáé åßôå íá ôïõ ÷ïñçãÞóåé ôçí êáôÜëëçëç èåñáðåõôéêÞ áãùãÞ åßôå íá ôïí ïäçãÞóåé óôïí åéäéêü áéìáôïëüãï. Óêïðüò ôïõ Üñèñïõ áõôïý åßíáé ç áíÜëõóç ôçò ÷ñçóôéêüôçôáò ôùí åñõèñïêõôôáñéêþí äåéêôþí MCV êáé RDW, üðùò áõôïß äßäïíôáé ìå ôç ãåíéêÞ áßìáôïò, óôïí áäñü äéá÷ùñéóìü ôçò åôåñüæõãçò â èáëáóóáéìßáò áðü ôç óéäçñïðåíéêÞ áíáéìßá, ôùí äýï óõ÷íïôÝñùí, äçëáäÞ, áéôéþí ìéêñïêõôôáñéêÞò õðü÷ñùìçò áíáéìßáò.

Âéïðáèïëüãïò, Ã.Í.Í.È.Á. “Ç Óùôçñßá”

Ç ãåíéêÞ áßìáôïò, ç åñãáóôçñéáêÞ åîÝôáóç ìå ôç ìåãáëýôåñç æÞôçóç, ìå ôçí åéóáãùãÞ ôùí óýã÷ñïíùí áõôüìáôùí áíáëõôþí Ý÷åé ñáãäáßá åîåëé÷èåß êáé ôáõôü÷ñïíá Ý÷åé áðïêôÞóåé éäéáßôåñç äéáãíùóôéêÞ áîßá ðáñÝ÷ïíôáò óôïí êëéíéêü éáôñü ðëçèþñá ðëçñïöïñéþí. Áíáìößâïëá, ùò ìïíáäéêü åñãáóôçñéáêü åýñçìá äåí ìðïñåß íá óôïé÷åéïèåôÞóåé ôç äéÜãíùóç êÜðïéïõ íïóÞìáôïò. Ùóôüóï, üôáí åñìçíåýïíôáé êáé áîéïëïãïýíôáé óùóôÜ üëåò ïé ôéìÝò ðïõ äßäïíôáé ìå ôïõò óýã÷ñïíïõò áõôüìáôïõò áíáëõôÝò ìðïñåß íá áðïôåëÝóåé ÷ñÞóéìï äéáãíùóôéêü åñãáëåßï óôá ÷Ýñéá ôïõ éáôñïý. Ç óùóôÞ, ëïéðüí, áîéïðïßçóç ôùí ðëçñïöïñéþí ðïõ ðáñÝ÷ïíôáé ìå ôç ãåíéêÞ áßìáôïò èá ìðïñïýóå íá áðïôñÝøåé ôçí áíþöåëç ÷ïñÞãçóç óéäÞñïõ, ðïõ óõíôáãïãñáöåßôáé óõ÷íüôáôá “åëáöñÜ ôç êáñäßá” óå áíáéìéêïýò áóèåíåßò. ÐñÜãìáôé, ç åõñåßá ÷ñÞóç ôùí áõôüìáôùí áíáëõôþí óôá åëëçíéêÜ íïóïêïìåßá óÞìåñá êáé ç äõíáôüôçôá áíÜëõóçò ìåãÜëïõ áñéèìïý äåéãìÜôùí ËÝîåéò êëåéäéÜ: åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá, óéäçñïðåíéêÞ áíáéìßá, åñõèñïêõôôáñéêïß äåßêôåò ÕðïâëÞèçêå: 20 ÌáÀïõ 2003 ÅðáíõðïâëÞèçêå: 14 Ïêôùâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 15 Íïåìâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Öáâßïõ ¸ëóá, Ôõñôáßïõ 11, Ð. ÖÜëçñï, T.K. 175 64, ÁèÞíá, Ôçë.: (210)9420247 Þ êéí. 6974 762427, e-mail: balt.n@mailbox.gr 23


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

E.Ã. ÖÜâéïõ

áíáéìßáò ôüóï óôçí êáèçìåñéíÞ éáôñéêÞ ðñáêôéêÞ üóï êáé óôçí êëéíéêÞ áéìáôïëïãßá.4,5 Ç âñåöéêÞ, ç ðñïó÷ïëéêÞ, ç åöçâéêÞ êáèþò êáé ç áíáðáñáSummary ãùãéêÞ çëéêßá áðïôåëïýí ôï öÜóìá It is estimated that in developed countries the cost of clinical lab tests amounts to 10% of the total cost of health care. Today there are more than 1.000 ôùí çëéêéþí üðïõ åìöáíßæåôáé ùò åðß differentiated tests which are available to physicians every time they are conôï ðëåßóôïí ç óéäçñïðåíéêÞ áíáéìßá. fronted with the task of making a medical decision regarding a particular case. Óýìöùíá ìå ôïí Ðáãêüóìéï ÏñãáíéOne disadvantage although is the rate at which new tests are being developed, óìü Õãåßáò (ÐÏÕ) ç åðßðôùóç ôçò for it is so rapid that their usefulness and their merit is often left unused. áíÝñ÷åôáé óôï 20-25% ôùí íåïãíþí, Nowadays a red blood cell count, as it is given by an automatic analyzer, is not only one of the most basic lab tests but it is also of great value, as it usually óôï 43% ôùí ðáéäéþí çëéêßáò Ýùò 4 represents the most direct means by which a physician is provided with either åôþí êáé óôï 37% ôùí ðáéäéþí çëéin his private practice or in a community medical center in order for him to êßáò áðü 5 Ýùò 12 åôþí.6 ÁðïôÝëåóìá search for the causes of anemia in his patient and to determine whether he will äå ôçò åììÞíïõ ñýóçò, êáôÜ ôçí áíáprescribe a particular mode of therapy or send his patient to a specialist ðáñáãùãéêÞ çëéêßá, åßíáé ôá ÷áìçëÜ preferably an hematologist. The purpose of this article is to analyze the usefulness of the erythrocyte indices MCV and RDW, as they are given by a red cell Ýùò áíýðáñêôá áðïèÝìáôá óéäÞñïõ count test, for it may prove to be a means by which we will be able to coarsely ðïõ åìöáíßæåé ôï 51% ôùí ãõíáéêþí.7 differentiate â thalassemia trait from iron deficiency. Ç óéäçñïðåíßá, ùò óõíïäü óôïéKey words: â-thalassemia minor, iron deficiency, erythrocytes indices. ÷åßï åíüò íïóÞìáôïò, áíáðôýóóåôáé üôáí ìåéùèïýí óçìáíôéêÜ ôá áðïèÝìáôá óéäÞñïõ óôéò áðïèÞêåò êáé áõôü ìðïñåß íá áßìáôïò óå ìéêñü ÷ñüíï êáé ìå åëÜ÷éóôï êüóôïò åðéôñÝðåé ôç ÷ñÞóç ôïõò ãéá ôïí ìáæéêü Ýëåã÷ï óõìâåß óå áíåðáñêÞ ðñüóëçøç óéäÞñïõ (íåïãíéöïñÝùí â ìåóïãåéáêÞò áíáéìßáò êáé ôïí åíôïðé- êÞ, ðáéäéêÞ çëéêßá, åöçâåßá, êýçóç, ãáëïõ÷ßá, õðïóéôéóìü), óå ìåéùìÝíç áðïññüöçóç óéäÞñïõ óìü óéäçñïðåíéêþí áóèåíþí. ¼ðùò åßíáé ãíùóôü äýï êýñéåò áéôßåò ìéêñï- (á÷ëùñõäñßá, ìåñéêÞ Þ ïëéêÞ ãáóôñåêôïìÞ, óýíêõôôáñéêÞò õðü÷ñùìçò áíáéìßáò åßíáé ç óéäçñï- äñïìá äõóáðïññüöçóçò), óå áðþëåéá áßìáôïò (÷åéðåíéêÞ áíáéìßá êáé ç åôåñüæõãç â èáëáóóáéìßá. Åíþ ç óéäçñïðåíéêÞ áíáéìßá êáé ç áíáéìßá ÷ñïíßáò ðÜèçóçò ðáñïõóéÜæåôáé óå üëïõò áíåîáéñÝôùò ôïõò ðëçèõóìïýò, ç â èáëáóóáéìßá áðáíôÜôáé óõ÷íüôåñá óôïõò Ìåóïãåéáêïýò ëáïýò (¸ëëçíåò, Éôáëïýò êáé Êõðñßïõò), ç á èáëáóóáéìßá óå ¸ã÷ñùìïõò (Áìåñéêáíïýò, Ôæáìáúêáíïýò êáé Íéãçñéáíïýò) êáé ÁóéÜôåò (Ôáúëáíäïýò êáé ÊéíÝæïõò), ç áéìïóöáéñéíïðÜèåéá Å åßíáé óõ÷íÞ óôç ÍïôéïáíáôïëéêÞ Áóßá êáé ôÝëïò ç óéäçñïâëáóôéêÞ áíáéìßá êáé ç áíáéìßá ðïõ ðñïêáëåßôáé áðü äçëçôçñßáóç ìå ìüëõâäï áðáíôþíôáé êõñßùò óå Üíäñåò êáé ðáéäéÜ áíôßóôïé÷á.1,2 ÊáôÜ ôçí åëëçíéêÞ ìõèïëïãßá ï ºöéêëïò, ãéïò ôïõ âáóéëéÜ ôçò ÈåóóáëéêÞò ÖõëÜêçò êáé èåßïò ôïõ ÉÜóïíá, èåñáðåýôçêå áðü áíéêáíüôçôá ðßíïíôáò ãéá ìÝñåò Ýíá ðïôü ðïõ ðáñáóêåýáóå ï ìÜíôçò ÌåëÜìðïäáò áðü ôç óêïõñéÜ ìá÷áéñéïý êáñöùìÝíïõ ãéá ÷ñüíéá óå éåñÞ âåëáíéäéÜ. Ç óéäçñïðåíßá, áêüìç êáé óÞìåñá, åßíáé ç ðéï óõ÷íÞ äéáôñïöéêÞ Ýëëåéøç êáé ðñïóâÜëëåé ðåñéóóüôåñá áðü 700 åêáôïììýñéá Üôïìá üëùí ôùí öõëåôéêþí êáé åèíéêþí ïìÜäùí, óå áíáðôõóóüìåíá êáé Ó÷Þìá 1. Êýêëïò äéáêßíçóçò ôïõ óéäÞñïõ óôïí ïñãáíéóìü. áíåðôõãìÝíá êñÜôç.3 Áðïôåëåß ôçí êýñéá áéôßá The differentiation of iron deficiency from â-thalassemia trait by means of the erythrocytes indices Elsa G. Faviou

24


Ôüìïò 16, Ôåý÷ïò 1, 2004

E.Ã. ÖÜâéïõ

ñïõñãéêÞ åðÝìâáóç, ôñáýìá, áéìïññïÀäåò, ëÞøç óáëéêõëéêþí, ðåðôéêü Ýëêïò, íåüðëáóìá, åëêþäç êïëßôéäá, áöáßìáîç, ôçëåáããåéåêôáóßá, äéáöñáãìáôïêÞëç, Ýììçíï ñýóç, áéìáôïõñßá, áéìüðôõóç, ê.á.), óå óõóóþñåõóç óéäÞñïõ óå åóôßåò áðü üðïõ äåí åßíáé åöéêôÞ ç êéíçôïðïßçóç ôïõ (éäéïðáèÞ ðíåõìïíéêÞ áéìïóéäÞñùóç) Þ ôÝëïò óå óõíäõáóìü ôùí ðáñáðÜíù áéôéþí.7 Ôï êåöÜëáéï ôçò âéï÷çìåßáò êáé ôçò öõóéïëïãßáò ôïõ óéäÞñïõ åßíáé ãíùóôü óå üëïõò áðü ôá öïéôçôéêÜ ÷ñüíéá óôçí ÉáôñéêÞ (ó÷Þìá 1). Ëüãù ôçò ðïëý ðåñéïñéóìÝíçò éêáíüôçôáò áðïññüöçóçò ôïõ óéäÞñïõ ðïõ ëáìâÜíïõìå ìå ôç äéáôñïöÞ ïé áðáéôÞóåéò ôïõ ïñãáíéóìïý óå áõôüí éêáíïðïéïýíôáé ìå åîáéñåôéêÜ ïéêïíïìéêÞ áíáêýêëùóç ôïõ åíåñãïý óéäÞñïõ. Ôï 60 Ýùò 70% ôïõ ïëéêïý óéäÞñïõ ôïõ ïñãáíéóìïý âñßóêåôáé óôçí áéìïóöáéñßíç. Ðïóïóôü ðåñßðïõ 10% ôïõ óéäÞñïõ âñßóêåôáé óôç ìõïóöáéñßíç, êõôü÷ñùìá, êáôáëÜóç êáé

õðåñïîåéäÜóç, åíþ ôï 20-30% âñßóêåôáé óôéò ðñùôåÀíåò ìåôáöïñÜò (ôñáíóöåñßíç) êáé åíáðïèÞêåõóçò ôïõ óéäÞñïõ (öåññéôßíç êáé áéìïóéäçñßíç) óôï Þðáñ, ôïí óðëÞíá êáé ôïí ìõåëü ôùí ïóôþí. Óôçí êëéíéêÞ äéÜãíùóç ç öåññéôßíç ðñÝðåé íá ðñïóäéïñßæåôáé ùò ç ðáñÜìåôñïò ðñþôçò åðéëïãÞò ãéá ôçí åêôßìçóç ôùí áðïèåìÜôùí óéäÞñïõ, üðùò ð.÷. óôçí ôáõôïðïßçóç ôçò áéôßáò ìéáò áíáéìßáò.7 Ç â èáëáóóáéìßá åßíáé ìéá ãåíåôéêÜ ìåôáâéâáæüìåíç áéìïóöáéñéíéêÞ äéáôáñá÷Þ ðïõ ÷áñáêôçñßæåôáé áðü åëáôôùìÝíç ðáñáãùãÞ â áëýóåùí ôçò áéìïóöáéñßíçò. Ðñïêáëåßôáé ùò åðß ôï ðëåßóôïí áðü óçìåéáêÝò ìåôáëëÜîåéò óôï â ãïíéäéáêü óýìðëåãìá êáé óðáíéüôåñá áðü åëëåßøåéò ôìçìÜôùí DNA. Ç áíôéññïðéóôéêÞ õðåñðëáóßá ôçò åñõèñÜò óåéñÜò ïäçãåß óå ðáñáãùãÞ áõîçìÝíïõ áñéèìïý åñõèñþí êõôôÜñùí ìå ìéêñüôåñï ìÝãåèïò êáé ìåéùìÝíç óõãêÝíôñùóç áéìïóöáéñßíçò. Óå ìåñéêÝò ðåñéï÷Ýò ôïõ êüóìïõ Ýùò êáé 30% ôïõ ðëçèõ-

Ó÷Þìá 2. Éóôüãñáììá åñõèñþí, ãõíáßêáò çëéêßáò 38 åôþí ìå óôßãìá â ìåóïãåéáêÞò áíáéìßáò, ìå ôï ÷áñáêôçñéóôéêü ó÷Þìá äßêçí “êüììáôïò”.

Ó÷Þìá 4. Éóôüãñáììá åñõèñþí, áíäñüò çëéêßáò 47 åôþí, ìå óéäçñïðåíéêÞ áíáéìßá.

(á)

(â)

Ó÷Þìá 3. (á): Çëåêôñïöüñçóç áéìïóöáéñßíçò ôçò áóèåíïýò (ó÷Þìá 2) ìå óôßãìá â ìåóïãåéáêÞò áíáéìßáò, (â): Çëåêôñïöüñçóç áéìïóöáéñßíçò ôïõ áóèåíÞ (ó÷Þìá 4) ìå óéäçñïðåíéêÞ áíáéìßá.

Ó÷Þìá 5. Äéêüñõöç êáé áðïðëáôõóìÝíç êáìðýëç êáôáíïìÞò åñõèñþí óå ãåíéêÞ áßìáôïò áóèåíÞ ìå óéäçñïðåíßá. 25


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

óìïý ðëÞôôåôáé áðü áõôÞí.1 Ôï óôßãìá â èáëáóóáéìßáò ðñáêôéêÜ áðáíôÜôáé óå üëåò ôéò åèíéêÝò ïìÜäåò, áí êáé óôïõò ëåõêïýò ôçò âüñåéáò Åõñþðçò åßíáé ðïëý óðÜíéï. Óôçí ÅëëÜäá êáé óôçí Éôáëßá, üðùò êáé óôéò ëïéðÝò ìåóïãåéáêÝò ÷þñåò, ç ìåãÜëç óõ÷íüôçôá ôïõ ãüíïõ óôïí ðëçèõóìü (20% ðåñßðïõ) ðñïôñÝðåé óå ìáæéêü Ýëåã÷ï åíôüðéóçò ôçò íüóïõ êáé áõôü ãéáôß áí êáé ç åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá óðÜíéá ðáñïõóéÜæåé óõìðôþìáôá, ç áíáãíþñéóç ôçò åßíáé óçìáíôéêÞ êáé ç ðñüëçøç ôçò áðïôåëåß ßóùò ôïí ìïíáäéêü ôñüðï áíôéìåôþðéóçò ôçò. Ç áäñÞ åðéóÞìáíóç ôùí öïñÝùí ìðïñåß íá ãßíåé ìå ôç ãåíéêÞ áßìáôïò.8,9 Ãéá ôç äéáöïñéêÞ äéÜãíùóç ôùí äýï áõôþí óõ÷íüôáôùí ðáèïëïãéêþí êáôáóôÜóåùí åß÷áí åðéíïçèåß óôï ðáñåëèüí äéÜöïñåò äéá÷ùñéóôéêÝò áíáëýóåéò êáé ôýðïé âáóéóìÝíïé óôïí óõíäõáóìü ôùí åñõèñïêõôôáñéêþí äåéêôþí, üðùò áõôïß äßäïíôáí áðü ôïõò áõôüìáôïõò áíáëõôÝò (ï äåßêôçò ôïõ Mentzer, ôïõ Shine, ôïõ England, ôïõ Green, ôïõ Srivastava, ôïõ Bessman, ôïõ Makri, ê.ë.ð).10-19 Ïé äïêéìáóìÝíåò, áõôÝò, ìÝèïäïé Ý÷ïõí ôåèåß ðëÝïí óôï ðåñéèþñéï ôïõëÜ÷éóôïí üóïí áöïñÜ ôïí áäñü äéá÷ùñéóìü ôçò åôåñüæõãçò â èáëáóóáéìßáò áðü ôç óéäçñïðåíéêÞ áíáéìßá. ÓÞìåñá, ï åñõèñïêõôôáñéêüò äåßêôçò MCV áðïôåëåß Ýíá áîéüðéóôï äåßêôç ðëçèõóìéêïý áñ÷éêïý åëÝã÷ïõ ôçò åôåñüæõãçò â ìåóïãåéáêÞò áíáéìßáò. ÐñÜãìáôé, ïé óýã÷ñïíïé çëåêôñïíéêïß áíáëõôÝò äßíïõí ôïí ìÝóï üãêï ôùí åñõèñïêõôôÜñùí (mean corpuscular volume, MCV) ìå áð’åõèåßáò ìÝôñçóç äéáéñþíôáò ôï Üèñïéóìá ôïõ üãêïõ ôùí åñõèñþí ìå ôïí áñéèìü ôùí ìåôñçìÝíùí åñõèñïêõôôÜñùí êáé åðïìÝíùò äåí õðïëïãßæåôáé ðëÝïí áðü ôç ó÷Ýóç MCV = Áéìáôïêñßôçò (%)/Åñõèñïêýôôáñá (åêáôïì./ìl) × 10. Êáô’ åðÝêôáóç, ôï MCV ðïõ ìåôñéÝôáé çëåêôñïíéêÜ äéáöÝñåé áðü åêåßíï ðïõ õðïëïãßæåôáé Ýììåóá ìå öõãïêÝíôñçóç ðïõ ùò ãíùóôüí åíÝ÷åé ôï óöÜëìá ôïõ ðáãéäåõìÝíïõ ðëÜóìáôïò (trapped plasma) óôç óôÞëç ôùí åñõèñþí áéìïóöáéñßùí. Óôéò ìéêñïêõôôáñéêÝò äå áíáéìßåò ðïõ ôï öáéíüìåíï áõôü åßíáé ðéï Ýíôïíï, ôï çëåêôñïíéêÜ ìåôñïýìåíï MCV åßíáé ìéêñüôåñï áðü åêåßíï ôçò öõãïêÝíôñçóçò ìå óõíÝðåéá íá ðáñïõóéÜæåé ìåãáëýôåñç äéá÷ùñéóôéêÞ éêáíüôçôá.20 ¸ôóé, ìå ôçí áíÜðôõîç ôùí çëåêôñïíéêþí áíáëõôþí ôï MCV Ý÷åé ãßíåé ìéá áîéüðéóôç êáé ðñáêôéêÞ åñãáóôçñéáêÞ äïêéìáóßá ãéá ôï áñ÷éêü 26

E.Ã. ÖÜâéïõ

screening ôùí öïñÝùí â ìåóïãåéáêÞò áíáéìßáò ãåãïíüò ðïõ Ý÷åé áíáöåñèåß åêôåíþò ôüóï óôç äéåèíÞ üóï êáé óôçí åëëçíéêÞ âéâëéïãñáößá.8,9,20,21 ÃåíéêÜ, óáí üñéï ãéá ôïí åíôïðéóìü ôùí åôåñïæõãùôþí ìåóïãåéáêÞò áíáéìßáò Ý÷oõí ÷ñçóéìïðïéçèåß ïé ôéìÝò MCV <79 êáé 80 fl.22 Ùóôüóï, äéÜöïñïé ìåëåôçôÝò ìå óêïðü íá áõîÞóïõí ôçí åéäéêüôçôá ôçò ìåèüäïõ ÷ùñßò íá åðçñåáóèåß ç åõáéóèçóßá ôçò Ýèåóáí ôï üñéï äéá÷ùñéóìïý óå ôéìÝò MCV ðïõ êõìáßíïíôáé áðü 70 Ýùò 75 fl.9,12,23-26 Åßíáé ãíùóôü üôé ôá ðåñéóóüôåñá Üôïìá ìå óôßãìá â èáëáóóáéìßáò Ý÷ïõí öõóéïëïãéêÞ Hb åíþ ìåñéêÜ ðáñïõóéÜæïõí Þðéá áíáéìßá, êõñßùò êáôÜ ôçí êýçóç Þ êáôÜ ôç äéÜñêåéá ëïéìþîåùí. Ïé åñõèñïêõôôáñéêïß äåßêôåò åßíáé ÷áñáêôçñéóôéêïß êáé ç äéÜãíùóç ôßèåôáé ðéï åýêïëá áðü áõôïýò ðáñÜ áðü ôç ìïñöïëïãßá ôïõ áßìáôïò. ¸ôóé, åíþ ç Hb êáé ï áéìáôïêñßôçò (Hct) ðáñïõóéÜæïíôáé öõóéïëïãéêïß Þ ðåñß ôá öõóéïëïãéêÜ üñéá, ï MCV êáé ç ìÝóç ðåñéåêôéêüôçôá áéìïóöáéñßíçò (mean corpuscular hemoglobin, MCH) ðïõ åêöñÜæåé ôï ìÝóï ðïóü áéìïóöáéñßíçò ðïõ ðåñéÝ÷åôáé áíÜ åñõèñïêýôôáñï êáé õðïëïãßæåôáé áðü ôç ó÷Ýóç MCH= Áéìïóöáéñßíç (g/dl)/Åñõèñïêýôôáñá (åêáôïì./ìl) × 10 åßíáé óõíÞèùò åëáôôùìÝíïé. ÂÝâáéá, áîßæåé íá ëå÷èåß üôé ç õðï÷ñùìßá åëÝã÷åôáé óõíÞèùò êáëýôåñá ìå ôçí åêôßìçóç ôçò ìÝóçò ðõêíüôçôáò áéìïóöáéñßíçò (mean corpuscular concentration, MCHC) ç ïðïßá åêöñÜæåé ôç ó÷Ýóç ôïõ âÜñïõò ôçò áíÜ åñõèñïêýôôáñï ðåñéå÷üìåíçò áéìïóöáéñßíçò ðñïò ôïí óõíïëéêü üãêï ôïõ åñõèñïêõôôÜñïõ. Åßíáé äçëáäÞ MCHC = Áéìïóöáéñßíç (g/dl)/Áéìáôïêñßôçò (%) × 100. Ùóôüóï, ïé äýï áõôïß äåßêôåò õðïäçëþíïõí äéáöïñåôéêÜ ôçí õðï÷ñùìßá. Ìå ôç MCH åêöñÜæåôáé êáëýôåñá ç õðï÷ñùìßá áí óõíõðÜñ÷åé ìéêñïêõôôÜñùóç, åíþ ìå ôç MCHC áí óõíõðÜñ÷åé ìáêñïêõôôÜñùóç.27 ¸ôóé, óôçí åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá ðïõ ÷áñáêôçñßæåôáé áðü ìéêñïêõôôÜñùóç êáé õðï÷ñùìßá, ðáñáôçñåßôáé ìåßùóç ìüíï ôçò MCH. Áõôü óõìâáßíåé ãéáôß óôçí åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá õðÜñ÷åé Ýíá ìéêñü ðïóü áéìïóöáéñßíçò ìÝóá óå Ýíá ìéêñü åñõèñïêýôôáñï, Ýôóé þóôå ç áíáëïãßá ôïõ ðïóïý ôçò áéìïóöáéñßíçò (âÜñïò) ðñïò ôï óýíïëï ôïõ åñõèñïêõôôÜñïõ (üãêïò) íá ìç äéáôáñÜóóåôáé. ÔÝëïò, ôï éóôüãñáììá ôùí åñõèñþí óôç â èáëáóóáéìßá Ý÷åé ôï ÷áñáêôçñéóôéêü ó÷Þìá äßêçí “êüììáôïò” (ó÷Þìá 2 êáé 3á). Ç óéäçñïðåíéêÞ áíáéìßá äéáãéãíþóêåôáé ìå


E.Ã. ÖÜâéïõ

äéÜöïñåò åñãáóôçñéáêÝò åîåôÜóåéò. Ôá áéìáôïëïãéêÜ åõñÞìáôÜ ôçò ðïéêßëïõí, ùóôüóï, áíÜëïãá ìå ôï óôÜäéï ôçò áíáéìßáò ðïõ âñßóêåôáé ï áóèåíÞò. Ôï Üäåéáóìá ôùí áðïèçêþí áðü ôï óßäçñï, áðïôåëåß ôï ðñþôï óôÜäéï óéäçñïðåíßáò êáé åßíáé ç ðñïêëéíéêÞ ìïñöÞ óéäçñïðåíéêÞò áíáéìßáò. Áêïëïõèåß ç åëÜôôùóç ôïõ áñéèìïý ôùí óéäçñïâëáóôþí ôïõ ìõåëïý ôùí ïóôþí, ç ðôþóç ôïõ óéäÞñïõ ôïõ ïñïý, ç åìöÜíéóç áíáéìßáò êáé ôÝëïò ç åëÜôôùóç ôïõ éóôéêïý óéäÞñïõ. Áñ÷éêÜ, ëïéðüí, åìöáíßæåôáé ïñèü÷ñùìç ïñèïêõôôáñéêÞ áíáéìßá êáé ç ìüíç ßóùò ìïñöïëïãéêÞ äéáôáñá÷Þ óôï ðåñéöåñéêü áßìá åßíáé ç áíéóïêõôôÜñùóç. Áñãüôåñá, ôá ìïñöïëïãéêÜ ÷áñáêôçñéóôéêÜ ôçò óôç ãåíéêÞ áßìáôïò èá åßíáé ç õðï÷ñùìßá, ç ìéêñïêõôôÜñùóç êáèþò åðßóçò ç áíéóïêõôôÜñùóç êáé ç ðïéêéëïêõôôÜñùóç (ó÷Þìá 4 êáé 3â).28 ÓõíÞèùò âÝâáéá, ïé ìïñöïëïãéêÝò ìåôáâïëÝò äåí åßíáé áîéüëïãåò ìÝ÷ñé íá ðÝóåé ç Hb êÜôù áðü 10-11 g/dl, ïðüôå åìöáíßæïíôáé ôá ÷áñáêôçñéóôéêÜ ôçò óéäçñïðåíßáò2 ðïõ åðéâåâáéþíïíôáé ìå ôç ìåßùóç ôçò Hb, ôùí åñõèñþí áéìïóöáéñßùí, ôïõ Hct êáé ôùí åñõèñïêõôôáñéêþí äåéêôþí (MCV, MCH êáé MCHC) áëëÜ êáé ìå ôá áíÜëïãá éóôïãñÜììáôá áðü ôïõò áõôüìáôïõò áíáëõôÝò áßìáôïò. Óôçí ðñþéìç öÜóç ôçò óéäçñïðåíßáò ôá åñõèñÜ áéìïóöáßñéá ìåñéêÝò öïñÝò áõîÜíïíôáé áíôß íá ìåéþíïíôáé, éäßùò óôá ðáéäéÜ.2 Óå Ýíáí áõôüìáôï áíáëõôÞ ôçò óåéñÜò Technicon H.1 ç ðéï ðñþéìç Ýíäåéîç åßíáé ç åìöÜíéóç åíüò ðëçèõóìïý õðü÷ñùìùí êõôôÜñùí. Ç ðôþóç, ðÜíôùò, ôïõ MCH êáé ôçò MCHC ðñïçãåßôáé ôçò ìåßùóçò ôïõ MCV.29 Ç ÷áìçëÞ MCHC åßíáé Ýíáò åõáßóèçôïò äåßêôçò óéäçñïðåíßáò üôáí õðïëïãßæåôáé áðü ôïí ìéêñïáéìáôïêñßôç êáé ôçí Hb Þ üôáí ìåôñéÝôáé ìå ôïõò óýã÷ñïíïõò áíáëõôÝò Technicon. ¼ôáí ç ìÝôñçóç ãßíåôáé ìå áíáëõôÝò ìåôáâïëÞò ôçò áíôßóôáóçò, üðùò åßíáé ïé óõóêåõÝò Coulter êáé Sysmex, ç MCHC åßíáé ðéï åéäéêüò äåßêôçò óéäçñïðåíßáò áëëÜ ü÷é ðïëý åõáßóèçôïò.2 Ùóôüóï, üôáí ç óéäçñïðåíéêÞ áíáéìßá åßíáé Þðéá ôá ðáñáðÜíù ÷áñáêôçñéóôéêÜ åßíáé üìïéá ìå áõôÜ äéáöüñùí ÷ñüíéùí ðáèÞóåùí ãåãïíüò ðïõ êÜíåé ôç äéÜêñéóç ôçò äýóêïëç.28 ¸ôóé ëïéðüí, ìüíï ç áíéóïêõôôÜñùóç åßíáé ðñþéìç ìïñöïëïãéêÞ áëëïßùóç óôç óéäçñïðåíéêÞ áíáéìßá, óõ÷íÜ äå åßíáé áíáãíùñßóéìç ðñéí åãêáôáóôáèåß óçìáíôéêÞ ìéêñïêõôôÜñùóç, õðï÷ñùìßá Þ áíáéìßá. Áíôßèåôá, óôç â ìåóïãåéáêÞ áíáéìßá ôåßíåé íá áðÝ÷åé Þ íá åßíáé åëáöñïý âáèìïý.1,28

Ôüìïò 16, Ôåý÷ïò 1, 2004

Áðü ôïõò äéÜöïñïõò äåßêôåò ìÝôñçóçò ôçò áíéóïêõôôÜñùóçò ôùí åñõèñþí ï äåßêôçò ðïéêéëßáò ôùí åñõèñþí (coefficient of variation, CV) åßíáé ï ðëÝïí åõñÝùò ÷ñçóéìïðïéïýìåíïò êëéíéêÜ ãéáôß ðáñÝ÷åôáé åýêïëá áðü ôïí áõôüìáôï áíáëõôÞ ùò RDW (red cell distribution width). Ôï RDW áíáöÝñåôáé ùò óõíôåëåóôÞò Ýêöñáóçò åðß ôïéò % ôçò ðïéêéëßáò ôïõ üãêïõ ôùí åñõèñïêõôôÜñùí êáé äßíåôáé áðü ôïí ôýðï RDW = SD/ MCV × 100. [SD= åßíáé ç óôáèåñÞ áðüêëéóç ôùí üãêùí ôùí åñõèñïêõôôÜñùí]. Óôç óéäçñïðåíéêÞ áíáéìßá, ëïéðüí, ôï RDW áõîÜíåôáé ðñéí óõìâïýí Üëëåò ìïñöïëïãéêÝò áëëáãÝò óôçí åñõèñÜ óåéñÜ Þ ìåôáâïëÝò ôùí åñõèñïêõôôáñéêþí ðáñáìÝôñùí, ëüãù áíÜìåéîçò åíüò ìéêñïêõôôáñéêïý êáé åíüò ïñèïêõôôáñéêïý ðëçèõóìïý.2,30-32 Óôï éóôüãñáììá ç êáìðýëç êáôáíïìÞò åìöáíßæåôáé äéêüñõöç êáé áðïðëáôõóìÝíç óå áíôßèåóç ìå ôç öõóéïëïãéêÞ ç ïðïßá åßíáé ìïíïêüñõöç êáé ìå óôåíÞ âÜóç (ó÷Þìá 4 êáé 5).2,33 Èá ðñÝðåé, âÝâáéá, íá õðïãñáììßóïõìå üôé óôç óéäçñïðåíßá ïé ôéìÝò ôùí MCV êáé RDW åðáíÝñ÷ïíôáé óå öõóéïëïãéêÜ åðßðåäá äýï ìÞíåò ìåôÜ áðü êáôÜëëçëç èåñáðåßá.2,30,34-39 ÁõîçìÝíï RDW óçìåéþíåôáé êáé óå áíáéìßåò ðïõ ïöåßëïíôáé óå ÷ñüíéá íïóÞìáôá üðùò óå áéìïëõôéêÜ óýíäñïìá (ôï RDW áíôáíáêëÜ ôç äéêôõïåñõèñïêõôôÜñùóç ãé’áõôü êáé ìåôÜ ôç èåñáðåßá åðáíÝñ÷åôáé óôá öõóéïëïãéêÜ üñéá), óå Ýëëåéøç Â12 êáé öõëëéêïý ïîÝïò, óå ìåôáããéóèÝíôåò áóèåíåßò, óå áõôïÜíïóá íïóÞìáôá (ôï éóôüãñáììá ôùí åñõèñþí áðåéêïíßæåé Ýíá äéðëü ðëçèõóìü åñõèñïêõôôÜñùí), óôá íåïãíÜ, óå íåïðëáóßåò (áíïóïêáôáóôáëôéêÜ öÜñìáêá êáé ìõåëïôïîéêüôçôá) êáé óôç óöáéñïêõôôÜñùóç ÷ùñßò óðëçíåêôïìÞ (ìåôÜ ôç óðëçíåêôïìÞ ôï RDW åðáíÝñ÷åôáé óôá öõóéïëïãéêÜ åðßðåäá). Ï óõíäõáóìüò ðÜíôùò åíüò áõîçìÝíïõ RDW êáé ìéáò ÷áìçëÞò MCHC óå áíáëõôÝò ìåôáâïëÞò áíôßóôáóçò, ðïõ åßíáé ëéãüôåñï åõáßóèçôïé, áðïôåëåß éó÷õñÞ Ýíäåéîç õðÝñ ôçò óéäçñïðåíßáò, êáèþò áõôüò ï äåßêôçò åßíáé óõíÞèùò öõóéïëïãéêüò óôï óôßãìá êáé óôçí áíáéìßá ôçò ÷ñüíéáò íüóïõ. Óôéò åãêýïõò ç äéÜãíùóç ôïõ óôßãìáôïò êáèßóôáôáé ðéï äýóêïëç ãéá äýï ëüãïõò. Ðñþôïí ãéáôß ç áñáßùóç ôïõ áßìáôïò, ðïõ åßíáé öáéíüìåíï ôçò êýçóçò, ìåéþíåé ôçí Hb, ôá åñõèñïêýôôáñá, ôïí Hct êáé ç Üíïäïò ôïõ MCV ðïõ åðßóçò ðáñáôçñåßôáé óôç êýçóç óõíôåëåß óôï íá åßíáé ëéãüôåñï ÷áñáêôçñéóôéêïß ïé åñõèñïêõôôáñéêïß 27


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

äåßêôåò êáé äåýôåñïí ãéáôß óõíÞèùò óõíõðÜñ÷åé óéäçñïðåíßá ðïõ ðåñéðëÝêåé ôç äéáöïñïäéÜãíùóç.40 ÐñÜãìáôé, ç óéäçñïðåíéêÞ áíáéìßá ìðïñåß íá áðïêñýðôåé óõíõðÜñ÷ïõóá óôï ßäéï Üôïìï åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá êáé áõôü ãéáôß ç óéäçñïðåíßá ðñïêáëåß åëÜôôùóç ôçò HbÁ 2 ôüóï óôá öõóéïëïãéêÜ Üôïìá üóï êáé óôïõò öïñåßò ôïõ ðáèïëïãéêïý ãüíïõ. ¸ôóé óôïõò ôåëåõôáßïõò ç óõíÞèùò áõîçìÝíç Á2 áéìïóöáéñßíç ìðïñåß íá ðÝóåé óôá öõóéïëïãéêÜ åðßðåäá. Óôá Üôïìá áõôÜ ç ðáñáìïíÞ ôçò ìéêñïêõôôÜñùóçò êáé ôçò õðï÷ñùìßáò ìåôÜ ôç èåñáðåßá ÷ïñÞãçóçò óéäÞñïõ åðéâåâáéþíåé ôç óõíýðáñîç ôùí äýï áõôþí êáôáóôÜóåùí. Áðü ôïõò ðáñáðÜíù ëüãïõò êáèßóôáôáé åõíüçôï üôé ï ïéêïãåíåéáêüò éáôñüò ïöåßëåé Üìåóá ìå ôç äéÜãíùóç ôçò åãêõìïóýíçò íá óõóôÞíåé, ðÝñáí ôçò ãåíéêÞò áßìáôïò, åîÝôáóç óéäÞñïõ ïñïý êáé öåññéôßíçò, êáèþò êáé çëåêôñïöüñçóç áéìïóöáéñßíçò ôçò åãêýïõ. Óôçí ðåñßðôùóç äå, ðïõ âñåèåß óçìáíôéêÞ óéäçñïðåíßá êáé öõóéïëïãéêÞ çëåêôñïöüñçóç áéìïóöáéñßíçò èá ðñÝðåé õðï÷ñåùôéêÜ íá óõóôÞíåôáé çëåêôñïöüñçóç áéìïóöáéñßíçò ôïõ óõæýãïõ, áðïêáôÜóôáóç ôçò óéäçñïðåíßáò ôçò åãêýïõ êáé åðáíÜëçøç, åí óõíå÷åßá, ôçò çëåêôñïöüñçóçò áéìïóöáéñßíçò áõôÞò. Óôéò óðÜíéåò ðåñéðôþóåéò ðïõ äåí äýíáôáé íá ôåèåß äéÜãíùóç, ç áóèåíÞò ðñÝðåé íá ðáñáðÝìðåôáé, ôï óõíôïìüôåñï äõíáôü, óå áéìáôïëüãï.8,41,42 Ï Bessman43 ôï 1983 êáé ï Monson39 ôï 1986 ÷ñçóéìïðïßçóáí ôïõò åñõèñïêõôôáñéêïýò äåßêôåò MCV êáé RDW ùò êñéôÞñéá äéáöïñéêÞò äéÜãíùóçò ôùí áíáéìéþí óôïõò åíÞëéêåò êáé óôá ðáéäéÜ áíôßóôïé÷á. Õøçëüò áñéèìüò åñõèñïêõôôÜñùí ìå ÷áìçëü ÌCV êáé öõóéïëïãéêÞ Hb åßíáé ÷áñáêôçñéóôéêÜ ôïõ óôßãìáôïò â-èáëáóóáéìßáò, áëëÜ ðáñüìïéïé åñõèñïêõôôáñéêïß äåßêôåò ðáñáôçñïýíôáé êáé óå áóèåíåßò ìå ðïëõåñõèñáéìßá ðïõ åßíáé óéäçñïðåíéêïß. Ôï RDW óõíÞèùò åßíáé áõîçìÝíï óôç óéäçñïðåíßá, åíþ óôï óôßãìá åßíáé ðéï óõ÷íÜ öõóéïëïãéêü.43,44 Ôï MCV åßíáé ÷áìçëüôåñï óôïõò åôåñïæõãþôåò öïñåßò áðü üôé åßíáé óôïõò óéäçñïðåíéêïýò áóèåíåßò óå óõó÷Ýôéóç ìå ôïí áðüëõôï áñéèìü åñõèñþí êáé ôï RDW óôç óéäçñïðåíéêÞ áíáéìßá åðçñåÜæåôáé óôéò ðåñéóóüôåñåò ðåñéðôþóåéò ðñéí áðü êÜèå Üëëç ðáñÜìåôñï ôùí åñõèñïêõôôÜñùí. Ìéá áýîçóç ôïõ RDW öáßíåôáé íá åßíáé 90–100% åõáßóèçôç ãéá ôç óéäçñïðåíéêÞ áíáéìßá áëëÜ ìüíï 50–70% åéäéêÞ.28,45-47 Ç áýîçóç ôïõ RDW óå ìéá êáèüëá öõóéïëïãéêÞ ãåíéêÞ áßìáôïò óõ÷íÜ áíôéðñïóù28

E.Ã. ÖÜâéïõ

ðåýåé åßôå ðñþéìç Ýëëåéøç óéäÞñïõ åßôå Üëëç äéáéôçôéêÞ áéôßá.28 Ïé ôéìÝò 15–15,3% (ùò ìüíïõ äåßêôç äéá÷ùñéóìïý) öáßíåôáé íá äßíïõí ôá êáëýôåñá áðïôåëÝóìáôá ãéá ôç äéÜêñéóç ôçò óéäçñïðåíéêÞò áíáéìßáò áðü ôç â ìåóïãåéáêÞ áíáéìßá.48 Ðáñüëá áõôÜ, ç áêñéâÞò äéáöïñéêÞ äéÜãíùóç ìåôáîý öïñÝùí â ìåóïãåéáêÞò áíáéìßáò êáé óéäçñïðåíéêÞò áíáéìßáò âÜóåé ôùí åñõèñïêõôôáñéêþí äåéêôþí ðáñáìÝíåé äýóêïëç áí ü÷é áäýíáôç. Ç åõáéóèçóßá êáé ç åéäéêüôçôá ôùí åñõèñïêõôôáñéêþí äåéêôþí ãéá ôç óéäçñïðåíéêÞ áíáéìßá áõîÜíåôáé áîéïëïãþíôáò ôáõôü÷ñïíá ôéò ðáñáìÝôñïõò MCV, RDW, óõãêÝíôñùóç öåññéôßíçò óôïí ïñü êáé óéäçñïäåóìåõôéêÞ éêáíüôçôá ôïõ ïñïý. Ç áêñéâÞò äéáöïñéêÞ äéÜãíùóç èá ôåèåß ôåëéêÜ ìå ôçí çëåêôñïöüñçóç ôçò áéìïóöáéñßíçò, ôç âéïóýíèåóç ôçò Hb ìå óêïðü ôçí åêôßìçóç ôçò éóüññïðçò Þ ìç ðáñáãùãÞò á êáé â áëýóåùí, ôçí áíÜëõóç ôïõ DNA ìå ôç ÷ñÞóç ðåñéïñéóôéêþí åíæýìùí, ôïí ðñïóäéïñéóìü ôïõ óéäÞñïõ óôïí ïñü êáé ôçò óéäçñïäåóìåõôéêÞò éêáíüôçôáò ôïõ ïñïý. Áîßæåé íá óçìåéùèåß üôé ç ìÝèïäïò ôçò âéïóýíèåóçò ôçò áéìïóöáéñßíçò èÝôåé ôç äéÜãíùóç óôéò êëáóóéêÝò åôåñïæõãùôßåò ü÷é üìùò êáé óôéò åôåñïæõãùôßåò áðü óéùðçëïýò Þ Þðéïõò ãüíïõò.27 ÅðïìÝíùò ïé åñõèñïêõôôáñéêïß äåßêôåò ðáñÝ÷ïõí ÷ñÞóéìåò åíäåßîåéò ãéá ôçí ðéï ðéèáíÞ äéÜãíùóç áëëÜ ìüíï ïé åéäéêÝò åîåôÜóåéò ðïõ èá áêïëïõèÞóïõí èá ôåêìçñéþóïõí ôç äéÜãíùóç (üðùò ï ðñïãåííçôéêüò Ýëåã÷ïò óå ðåñéï÷Ýò ìå õøçëÞ åðßðôùóç ôçò â ìåóïãåéáêÞò áíáéìßáò). Ùóôüóï, åßíáé áðáñáßôçôï íá èåóðßóïõìå Ýíá óõãêåêñéìÝíï üñéï ãéá ðåñáéôÝñù áíÜëõóç þóôå íá áðïöýãïõìå ðïëý õøçëü ðïóïóôü áñíçôéêþí åîåôÜóåùí êáé ðïëý ÷áìçëÞ áðüäïóç èåôéêþí äéáãíþóåùí. Ç åîÝôáóç, ðÜíôùò, ôïõ MCV, êñéôÞñéï ìáæéêïý åëÝã÷ïõ ôùí öïñÝùí ôçò â ìåóïãåéáêÞò áíáéìßáò êáé ôïõ RDW, äåßêôçò áíéóïêõôôÜñùóçò, ôáõôü÷ñïíá üôáí áîéïëïãçèïýí óùóôÜ áðïôåëïýí ÷ñÞóéìï åñãáëåßï –åîÝôáóç äéáëïãÞò– óôç äéáöïñïäéÜãíùóç ôùí óïâáñþí áõôþí ðáèÞóåùí.

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507, 1989. 19. Ðáëáéïëüãïò Ã, ÐåñéóóÜêç Ã, ×ñïíïðïýëïõ Ã, Ãáñáíôæéþôç Á, Ëýôéíá Á, ËáäÜ Í êáé óõí. ÅìðåéñéêÞ äéá÷ùñéóôéêÞ óõíÜñôçóç ãéá äéáöïñéêÞ äéÜãíùóç ôçò ìåóïãåéáêÞò áíáéìßáò áðü ôç óéäçñïðåíéêÞ áíáéìßá. 19ï Åèíéêü ÓõíÝäñéï Ìéêñïâéïëïãßáò, 1ï ÐáíåëëÞíéï ÓõíÝäñéï ÉáôñéêÞò Âéïðáèïëïãßáò, Ôüìïò ÐåñéëÞøåùí óåë. 71, 2000. 20. Pearson HA, O’Brien RT, McIntoch S. Screening for thalassemia trait by electronic measurement of mean corpuscular volume. N Engl J Med 15; 288:351-3, 1973. 21. Bezman BW, Ritchey AK et al. Hematology of â-thalassemia trait–age–related development aspects and intrafamilial correlations. J Pediatr 97:901, 1980. 22. Óðõñïðïýëïõ-Êïôóéþíç ×, Ðáðáãåùñãßïõ Å, Ìðïýñáò Á, ÌðïóéíÜêïõ-Ðáðáèáíáóßïõ Å. Ç áîéïðéóôßá ôùí äåéêôþí MCV êáé RDW ãéá ôç äéáöïñéêÞ äéÜãíùóç åôåñïæõãùôþí â-ìåóïãåéáêÞò áíáéìßáò êáé óéäçñïðåíéêÞò áíáéìßáò. Äåëôßïí ÅëëçíéêÞò ÌéêñïâéïëïãéêÞò Åôáéñåßáò Ôüìïò 44:172-180, 1999. 23. Artaza JR, Carbia CD, Ceballo MF, Diaz NB. Red cell distribution width (RDW): its use in the characterization of microcytic and hypochromic anemias. Medicina 59:17-22, 1999. 24. Bessman JD, Feinstein DI. Quantitative anisocytosis as a discriminant between iron deficiency and thalassemia minor. Blood 53:28893, 1979. 25. Klee GG, Fairbanks VF, Pierre RV, O’Sullivan MB. Routine erythrocyte measurements in diagnosis of iron-deficiency anemia and thalassemia minor. Am J Clin Pathol 66:870-877, 1976. 26. Öáâßïõ Å, ÐáíôåëÜ Ï, Êùíóôáíôïðïýëïõ ×, ÊïõôæÜò Ó, ÃñçãïñÜôïõ ×, Èåïäùñïðïýëïõ Ä. Ç óçìáóßá ôçò óõó÷Ýôéóçò ôùí åñõèñïêõôôáñéêþí äåéêôþí MCV êáé RDW óôïí ðëçèõóìéáêü Ýëåã÷ï áóèåíþí ãéá åôåñüæõãç â ìåóïãåéáêÞ áíáéìßá êáé óéäçñïðåíéêÞ áíáéìßá. Äåëôßïí ÅëëçíéêÞò ÌéêñïâéïëïãéêÞò Åôáéñåßáò 46:633-642, 2001. 27. Çëéüðïõëïò Ã. Öõóéïëïãßá êáé öõóéïðáèïëïãßá ôïõ áßìáôïò êáé ôùí áéìïðïéçôéêþí ïñãÜíùí. 3ç Ýêäïóç, ÉáôñéêÝò åêäüóåéò Ðáó÷áëßäç, ÁèÞíá, 1993, Ôüìïò 1, óåë. 275. 28. Lee RG. Microcytosis and the anemias associated with impaired hemoglobin synthesis. In Wintrobe’s Clinical Hematology 9th edition, Lea & Febiger, Philadelphia, 1993, Vol 1:791-807. 29. Patton WN, Cave RJ, Harris RÉ. A study of changes in red cell volume and haemoglobin concentration during phlebotomy induced iron 29


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deficiency and iron repletion using the Technicon H1. Clin Lab Haematol 13:153-61, 1991. Bergin JJ. Evaluation of anemia. Getting the most out of the MCV, RDW, and other tests. Postgraduate Medicine Vol 77:253-269, 1985. Marsh WL, Bishop JW, Darcy TP. Evaluation of red cell volume distribution width (RDW). Hematol Pathol 1:117-23, 1987. Wintrobe’s Clinical Hematology 9th edition, Lea & Febiger, Philadelphia, 1993, Vol 1, p. 15. Oski FA. Differential diagnosis of anemia. In Nathan and Oski’s Hematology of infancy and childhood 4th edition, W. B. Saunders Company, Philadelphia, 1993, Vol 1, p.p. 346-353. Bessman JD. More on the RDW (letter). Am J Clin Pathol, 773, 1985. Sassier P, Olivero G. MCV and MCHC in a automatic blood cell analyzers (letter). Am J Clin Pathol 773-4, 1985. Dallman PR, Yip R, Oski FA. Iron deficiency and related nutritional anemias. In Nathan and Oski’s Hematology of infancy and childhood 4th edition, W. B. Saunders Company, Philadelphia, 1993, Vol 1, p.p. 413-50. Chen L, Wu Z. Study on the clinical diagnostic values of MCV and RDW to hemolytic anemia (abstract). Human Yi Ke Da Xue Xue Bao 23:203-205, 1998. Lea AC, Fielding J. Combined Vitamin B12 deficiency and beta-thalassaemia trait. Lancet 2:127, 1975. Monzon CM, Beaver BD, Dillon TD. Evaluation of erythrocyte disorders with mean corpuscular volume (MCV) and red cell distribu-

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tion width (RDW). Clinical Pediatrics 26:632638, 1987. Weatherall DJ, Clegg JB. The Thalassaemia syndromes. Oxford: Blackwell Scientific Publications, 1981. Wasi P, Disthasongchan P, Na-nakorn S. The effect of iron deficiency on the level of haemoglobin A2. J Lab Clin Med 71:85-9, 1968. Kattamis C, Lagos P, Metaxotou-Mavromati A, Matsaniotis N. Serum iron and unsaturated ironbinding capacity in the b-thalassaemia trait: their relation to the levels of haemoglobins A, A2, and F.: J Med Genet 9:154-159, 1972. Bessman JD, Gilmer PR, Gardner FH. Impoved classification of anemias by MCV and RDW. Am J Clin Pathol 80:322-326, 1983. Nathan and Oski’s. Hematology of infancy and childhood, 5th edition, W. B. Sounders Company, 1998, Vol I p.p. 380. Kaye FJ, Alter BP. Red cell size distribution analysis: a noninvasive evaluation of microcytosis. Blood 60:36a, 1982. Uchida T. Change in red blood cell distribution width with iron deficiency. Clin Lab Haematol 11:117-21, 1989. Cesana BM, Maiolo AT, Gidiulu AT, Damilano I, Massaro P, Poli EE. Relevance of red cell distribution width (RDW) in the differential diagnosis of microcytic anaemias. Clin Lab Haematol 13:141-51, 1991. Bessman JD, Gilmer PR, Gardner TH. Too early to put down RDW for discriminating iron deficiency and thalassemia (letter). Am J Clin Pathol 85:693, 1986.


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ð.Ì. ÄáíäïõëÜêçò

ÅÐÉÊÁÉÑÏ ÁÑÈÑÏ CURRENT PAPER Primary Heatlh Care, Volume 16, Number 1, 31-35, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 31-35, 2004

Ëåéôïõñãßá äçìïôéêïý íïóïêïìåßïõ áðïêáôÜóôáóçò õðåñçëßêùí óôçí Áããëßá Ð.Ì. ÄáíäïõëÜêçò1

Ðåñßëçøç Ç õãåéïíïìéêÞ öñïíôßäá êáé ðåñßèáëøç ôùí áôüìùí ôçò ôñßôçò çëéêßáò äçìéïõñãåß ðïëëÝò öïñÝò äéëÞììáôá óôïí ôñüðï ðåñáéôÝñù áíôéìåôþðéóçò ôùí. ÐïëëÝò öïñÝò åíþ Ý÷åé ôåëåéþóåé ï ðáñáêëéíéêüò Ýëåã÷ïò ôïõ áóèåíïýò êáé äåí õðÜñ÷åé ëüãïò ðáñáìïíÞò ôïõ óôï äåõôåñïâÜèìéï Þ ôñéôïâÜèìéï íïóïêïìåßï ç êáôÜóôáóç ôçò õãåßáò ôïõ äåí ôïõ åðéôñÝðåé íá ðÜåé óôï ãíùóôü ïéêïãåíåéáêü ôïõ ðåñéâÜëëïí Þ óå ïßêï åõãçñßáò. ¢ëëåò öïñÝò ï ãåíéêüò éáôñüò åõñßóêåôáé óå ïñéáêÝò êáôáóôÜóåéò üðïõ äåí åßíáé óßãïõñïò áí ï áóèåíÞò ìðïñåß íá ðáñáìåßíåé óôï óðßôé Þ íá ðÜåé óôï äåõôåñïâÜèìéï íïóïêïìåßï. Ôï äçìïôéêü íïóïêïìåßï áðïêáôáóôÜóåùò õðåñçëßêùí åßíáé ï óýíäåóìïò ìåôáîý äåõôåñïâÜèìéáò êáé ôñéôïâÜèìéáò ðåñßèáëøçò áðü ôç ìéá ìåñéÜ êáé ðåñßèáëøçò óôï óðßôé ç ïßêï åõãçñßáò áðü ôçí Üëëç. ÊáôÜ ôç äéÜñêåéá ôçò åðôÜìçíçò ðáñáìïíÞò ìïõ åéò ôï group practice, Townend Surgery óôçí ðüëç ôïõ Caterham óôï Surrey ôçò Áããëßáò, åß÷á ôçí åõêáéñåßá íá ðáñáêïëïõèÞóù ôç ëåéôïõñãßá ôïõ êïíôéíïý äçìïôéêïý íïóïêïìåßïõ, óôï ïðïßï åß÷áí äéêáßùìá åéóáãùãÞò ïé ãåíéêïß éáôñïß ôïõ áíáöåñèÝíôïò group practice. ÐåñéãñÜöåôáé ç ðñïóùðéêÞ åìðåéñßá ôïõ ãñÜöïíôïò êáé ãßíåôáé óýíôïìç âéâëéïãñáöéêÞ áíáóêüðçóç ãéá ôç ëåéôïõñãßá êáé ôç óçìáóßá ôùí äçìïôéêþí íïóïêïìåßùí óôï ÇíùìÝíï Âáóßëåéï óôéò áñ÷Ýò ôçò íÝáò ÷éëéåôßáò, ìåôÜ áðü 100 ÷ñüíéá óõíå÷ïýò ëåéôïõñãßáò. Ôïíßæïíôáé ôá ïéêïíïìéêÜ êáé êïéíùíéêÜ ïöÝëç ôùí ìïíÜäùí áõôþí êáé ç áíáãêáéüôçôá ãéá ôç ëåéôïõñãßá ôÝôïéùí íïóïêïìåßùí óôç ÷þñá ìáò.

1

ÄéåõèõíôÞò Ãåí. ÉáôñéêÞò, Ê. Õ. ÂÜñçò.

ÅéóáãùãÞ Ç áýîçóç ôïõ ãçñáóìÝíïõ ðëçèõóìïý óôéò áíåðôõãìÝíåò ÷þñåò óõíåðÜãåôáé áýîçóç ôçò æÞôçóçò ôùí õðçñåóéþí õãåßáò áðü ôïí ðëçèõóìü áõôü. Ç õãåéïíïìéêÞ ðåñßèáëøç êáé öñïíôßäá ôùí áôüìùí áõôþí äçìéïõñãåß ðïëëÝò öïñÝò äéëÞììáôá óôïí ÷åéñéóìü ôïõò. Óôá äåõôåñïâÜèìéá êáé ôñéôïâÜèìéá íïóïêïìåßá, ðïëëÝò öïñÝò äåí õðÜñ÷åé ëüãïò ðáñáìïíÞò ôïõò äéüôé ìðïñåß íá Ý÷åé ïëïêëçñùèåß ï åñãáóôçñéáêüò êáé ëïéðüò Ýëåã÷ïò êáé ç èåñáðåõôéêÞ áãùãÞ ðïõ ðñÝðåé íá ðáñÝ÷åôáé óôï íïóïêïìåßï ôçò êáôçãïñßáò áõôÞò. Áðü ôçí Üëëç äåí åßíáé óå èÝóç íá ðÜåé óôï óðßôé ôïõ, äéüôé ÷ñåéÜæåôáé áêüìá õøçëÞ íïóçëåõôéêÞ öñïíôßäá, ç ïðïßá äåí ìðïñåß íá ðáñáó÷åèåß áðü ôïõò óõããåíåßò. Ôï íïóïêïìåßï áðïêáôÜóôáóçò ôùí õðåñçëßêùí åßíáé ï óýíäåóìïò ìåôáîý äåõôåñïâÜèìéïõ íïóïêïìåßïõ êáé óðéôéïý Þ ïßêïõ åõãçñßáò. Óå ðñüóöáôç ìåëÝôç ðïõ Ýãéíå óôï ÇíùìÝíï ËÝîåéò êëåéäéÜ: äçìïôéêü íïóïêïìåßï, áðïêáôÜóôóç, ãåíéêÞ éáôñéêÞ, ïñãÜíùóç, äéïßêçóç, êÝíôñï õãåßáò ÕðïâëÞèçêå: 2 Áðñéëßïõ 1999 ÅðáíõðïâëÞèçêå: 8 Óåðôåìâñßïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 20 Ïêôùâñßïõ 2003 Õðåýèõíïò áëëçëïãñáößáò: Ð.Ì. ÄáíäïõëÜêçò, Âõäéáêßïõ 1, Ô.Ê. 16672 ÂÜñç, ÁôôéêÞò, Ôçë: (210) 8970526, e-mail: mdand2002@yahoo.co.uk 31


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ð.Ì. ÄáíäïõëÜêçò

óðßôé ôïõ, äéüôé ÷ñåéÜæåôáé ðåñáéôÝñù éáôñéêÞ áëëÜ êõñßùò íïóçëåõôéêÞ öñïíôßäá êáé áðïêáôÜóôáóç. Summary ÐïéïôéêÞ ìåëÝôç ðïõ Ýãéíå óôo Dealing with the care of elder patients many times you can’t decide what is the best for them. Sometimes although the secondary and tertiary care has nothing Ç.Â. óå ãåíéêïýò éáôñïýò ðïõ åß÷áí else to offer to them, the geriatric patient isn’t in the condition to go back to his äõíáôüôçôá íá ðáñáðÝìðïõí óå äçown home or even at a nursery home. There are also boundary cases at home ìïôéêÜ íïóïêïìåßá, åß÷å óêïðü íá when G.P. can’t decide if the patient must stay at home or has to be admitted ðñïóäéïñßóåé ôïõò ðáñÜãïíôåò ðïõ åðéat the secondary hospital. Community hospital is the link between secondary äñïýí óôçí ôåëéêÞ áðüöáóç ôïõ ãåíéand tertiary care and primary care. During my seven months study leave at the êïý Éáôñïý ãéá ôçí åéóáãùãÞ óôï íïTownend Surgery at Caterham-Surrey-U.K. I had the chance to attend the function of such a unit. The GPs from this surgery had admitting rights at the óïêïìåßï. ¼ôáí åðñüêåéôï ãéá êáèácommunity hospital of the area. The personal experience of such a unit is ñÜ ‘êïéíùíéêÝò’ åéóáãùãÝò ç áðüöáóç described and is made a brief systematic review of the role that these hospitals ãéá ôçí åéóáãùãÞ Þôáí åýêïëç êáé óáí have in the new NHS of U.K. at the beginning of the new millenium. We emphaìüíç ðñïûðüèåóç áðáéôïýóå ôçí ýðáñsize the economical and social benefits of such units and the necessity of îç ôïõ äçìïôéêïý íïóïêïìåßïõ, íïóçestablishment of such units in Greece. ëåõôéêïý ðñïóùðéêïý êáé ãåíéêïý éáKey words: community hospital, general practitioner hospital, organization & administration. ôñïý. ¼ôáí åðñüêåéôï ãéá ìéêôÞ ðåñßðôùóç ‘êïéíùíéêü-éáôñéêÞ’, ï êýñéïò Âáóßëåéï (Ç.Â.), ðñïóäéïñßóôçêáí óõíïëéêÜ 471 ðáñÜãùí ðïõ âÜñõíå óôçí áðüöáóç ôïõ ãåíéêïý äçìïôéêÜ íïóïêïìåßá (community hospitals). Ôï éáôñïý ãéá ôçí åéóáãùãÞ óôï êïíôéíü äåõôåñïóýíïëï ôùí êëéíþí Þôá 18579, ìå 20% ôùí Ãåíé- âÜèìéï ç óôï äçìïôéêü íïóïêïìåßï Þôáí ôï ðüóï êþí Éáôñþí (general practitioner), íá Ý÷ïõí äé- áéóèáíüôáí éêáíüò íá áíáëÜâåé ôçí éáôñéêÞ åõêáßùìá íá åéóáãÜãïõí áóèåíÞ óôá íïóïêïìåßá èýíç ãéá ôïí óõãêåêñéìÝíï Üññùóôï. Ïé áêüëïõáõôÜ. Áõôü óçìáßíåé üôé ï 1 óôïõò 5 áðü ôïõò èïé ôÝóóåñéò äéáöïñåôéêïß ôýðïé ‘êïéíùíéêü-éáÃåíéêïýò Éáôñïýò ôïõ Ç ÷ñçóéìïðïéïýí ôá íï- ôñéêþí’ åéóáãùãþí Ýãéíå äõíáôüí íá äéáðéóôùóïêïìåßá áõôÜ óôçí êáèçìåñéíÞ ôïõò ðñáêôéêÞ. èïýí, óôï öÜóìá ôùí áóèåíþí, ðïõ åß÷å áíÜãêç Óôéò áãñïôéêÝò ðåñéï÷Ýò ôï ðïóïóôü áõôü Þôáí 1 áðü êïéíùíéêÞ êáé ðáñÜëëçëá éáôñéêÞ öñïíôßäá. óôïõò 2 ãåíéêïýò éáôñïýò. Ç ðëåéïøçößá ôùí ÅéóáãùãÞ ãéá åêôßìçóç, óôáäéáêÞ åéóáãùãÞ ‘step íïóïêïìåßùí áõôþí ðáñÝ÷åé Ýíá ïëïêëçñùìÝíï down’ áðü ôï äåõôåñïâÜèìéï íïóïêïìåßï, åéóáäßêôõï áðïêáôÜóôáóçò çëéêéùìÝíùí êáé åîùôåñé- ãùãÞ áâåâáéüôçôáò ‘can’t cope’, êáé ðñïëçðôéêÞ êÜ éáôñåßá åéäéêþí éáôñþí áðü ôï êïíôéíü äåõôå- (anticipatory) åéóáãùãÞ. Måñéêïß ãåíéêïß éáôñïß ñïâÜèìéï íïóïêïìåßï. Ç óçìáóßá ôïõò ãéá ôçí áíáëÜìâáíáí ðéï äýóêïëåò éáôñéêÝò ðåñéðôþóåéò, ïëïêëçñùìÝíç ðáñï÷Þ õðçñåóéþí ÐÖÕ, óôçí áñ÷Þ ïé ïðïßåò ðáñÜëëçëá áðáéôïýóáí ìåãáëýôåñåò ôåôçò íÝáò ÷éëéåôßáò ôïíßæåôáé óôçí ðñüóöáôç áõôÞ ÷íéêÝò äåîéüôçôåò áðü ôï íïóçëåõôéêü ðñïóùðéêü ìåëÝôç1. Óôç óõíÝ÷åéá ðåñéãñÜöåôáé ç ðñïóùðé- üðùò áóèåíåßò ðïõ áðáéôïýóáí ðáñï÷åôåýóåéò åîéêÞ åìðåéñßá ôïõ ãñÜöïíôïò áðü ðáëáéüôåñç ðá- äñùìÜôùí, ìåôáããßóåéò, åíäïöëÝöéá ÷ïñÞãçóç õãñþí, êáé ÷çìåéïèåñáðåßåò, ðïõ Üëëïé ãåíéêïß ñáìïíÞ ôïõ óå group practice Ãåíéêþí Ïéêïãåéáôñïß äåí áíáëÜìâáíáí. ÉáôñéêÝò êáôáóôÜóåéò íåéáêþí Éáôñþí ôçò ùò Üíù ðåñéï÷Þò ôçò Ì. ôéò ïðïßåò ïé ãåíéêïß éáôñïß áéóèáíüôáí éêáíïß íá Âñåôáíßáò. áíáëÜâïõí Þôáí ëïéìþîåéò áíáðíåõóôéêïý, åðéäåßíùóç ×ÁÐ (÷ñüíéá áíáðíåõóôéêÞ ðíåõìïíïðÜèåéá), åðéäåßíùóç ôçò óôçèÜã÷çò óå çëéêéùìÝÐñïÝëåõóç áóèåíþí êáé áéôßåò åéóáãùãÞò íïõò êáé áóèåíåßò ôåëéêïý óôáäßïõ ïé ïðïßïé åßóôï äçìïôéêü íïóïêïìåßï ÷áí äõíáôüôçôá íá óôáèåñïðïéçèïýí2. Function of a community hospital of rehabilitation of elder people in England M. Dandoulakis

Ç ðñïÝëåõóç ôùí áóèåíþí áõôþí ìðïñåß íá åßíáé: 1. Áðü ôï Ãåíéêü Ïéêïãåíåéáêü Éáôñü, ï ïðïßïò ôïí åßäå óôï óðßôé ôïõ. 2. ¸÷åé åîéôÞñéï áðü ôï äåõôåñïâÜèìéï íïóïêïìåßï, ÷ùñßò íá åßíáé óå èÝóç íá ðÜåé óôï 32

¸îïäïò áðü ôï íïóïêïìåßï áðïêáôáóôÜóåùò ÌåôÜ ôçí Ýîïäü ôïõò áðü ôï íïóïêïìåßï áðïêáôáóôÜóåùò, èá ðÜíå áíÜëïãá ìå ôçí êáôÜóôáóç ôçò õãåßáò ôïõò, åßôå óôï óðßôé ôïõò õðü


Ð.Ì. ÄáíäïõëÜêçò

ôçí åðßâëåøç ôùí ðáéäéþí ôïõò, åßôå óå êÜðïéï ïßêï åõãçñßáò. Äåí åßíáé âÝâáéá ëßãåò ïé ðåñéðôþóåéò ðïõ áöïñïýí ðñïèáíÜôéåò êáôáóôÜóåéò êáé ðáñáìÝíïõí óôï íïóïêïìåßï ìÝ÷ñé íá êáôáëÞîïõí2.

ÄïìÞ êáé ëåéôïõñãßá íïóïêïìåßïõ áðïêáôáóôÜóåùò õðåñçëßêùí Ôï äõíáìéêü ôïõ äçìïôéêïý íïóïêïìåßïõ áðïêáôáóôÜóåùò åßíáé ùò áêïëïýèùò. Ï õðåýèõíïò éáôñüò ãéá ôïõò áóèåíåßò óå êáèçìåñéíÞ âÜóç åßíáé Ãåíéêüò/Ïéêïãåíåéáêüò Éáôñüò áðü ãåéôïíéêü éáôñåßï (surgery). Ï ïñéóìüò ðïõ äßíåé ôï Âáóéëéêü ÊïëÝãéï ôùí Ãåíéêþí Éáôñþí (RCGP), ãéá ôï äçìïôéêü íïóïêïìåßï åßíáé ï áêüëïõèïò. ‘...ôï íïóïêïìåßï üðïõ ç åéóáãùãÞ, ç öñïíôßäá êáé ç Ýîïäïò áðü ôï íïóïêïìåßï åßíáé êÜôù áðü ôïí Üìåóï Ýëåã÷ï ôïõ ãåíéêïý éáôñïý, ï ïðïßïò ðëçñþíåôáé ãéá ôéò õðçñåóßåò áõôÝò, áíÜëïãá ìå ôïí áñéèìü ôùí êëéíþí’. Ãéá ôï ëüãï áõôü ëÝãåôáé êáé íïóïêïìåßï ãåíéêþí éáôñþí. ÊÜèå çìÝñá ï Ãåíéêüò Éáôñüò êÜíåé åðßóêåøç óôïõò áóèåíåßò, ìáæß ìå ôï ðáñáúáôñéêü ðñïóùðéêü (íïóçëåýôñéåò, öõóéïèåñáðåýôñéåò ê.ëð.). ÕðÜñ÷åé åðßóçò õðåýèõíïò éáôñüò ìå åéäéêüôçôá ãçñéÜôñïõ, ï ïðïßïò áíÞêåé óôï êïíôéíü äåõôåñïâÜèìéï íïóïêïìåßï. Ï éáôñüò áõôüò åðéóêÝðôåôáé ôï Íïóïêïìåßï ìéá öïñÜ ôçí åâäïìÜäá. Åðßóçò õðÜñ÷åé ç äõíáôüôçôá íá æçôçèåß ç ãíþìç ôïõ åéäéêïý, áðü ôï ßäéï íïóïêïìåßï, üôáí ôç ÷ñåéáóôåß ï ãåíéêüò éáôñüò. Ãéá êÜèå áóèåíÞ õðÜñ÷åé öÜêåëïò ìå ðëÞñç éóôïñéêü, áíÜëïãï ìå åêåßíï ôïõ íïóïêïìåßïõ. Ôïí öÜêåëï áõôüí óõìðëçñþíåé åêåßíïò ï ãåíéêüò éáôñüò ðïõ Ý÷åé ðáñáðÝìøåé ôïí áóèåíÞ áðü ôï óðßôé ôïõ. Óôç óõíÝ÷åéá ðáñáêïëïõèåß ôçí ðïñåßá ôïõ êáé ìðïñåß íá æçôÞóåé ôç ãíþìç ôïõ åéäéêïý áðü ôïí íïóïêïìåßï. Ìå ôïí ôñüðï áõôü ôï íïóïêïìåßï áðïêáôáóôÜóåùò áðïôåëåß ôïí óýíäåóìï ôïõ óðéôéïý ìå ôï äåõôåñïâÜèìéï íïóïêïìåßï. Áíôéìåôùðßæïíôáé Ýôóé ïñéáêÝò êáôáóôÜóåéò äçëáäÞ óôéò ïðïßåò ï ãåíéêüò éáôñüò äåí åßíáé óßãïõñïò üôé ðñÝðåé íá ðÜíå óôï äåõôåñïâÜèìéï íïóïêïìåßï, ïé ïðïßåò üìùò äåí ìðïñïýí êáé íá ìåßíïõí êáé óôï óðßôé. Ï åñãáóôçñéáêüò åîïðëéóìüò ôïõ íïóïêïìåßïõ áõôïý åßíáé ìüíï ç äõíáôüôçôá äéåíÝñãåéáò áêôé-

Ôüìïò 16, Ôåý÷ïò 1, 2004

íïëïãéêþí åîåôÜóåùí. Ïé áéìáôïëïãéêÝò êáé âéï÷çìéêÝò åîåôÜóåéò ãßíïíôáé óôï äåõôåñïâÜèìéï íïóïêïìåßï, üðïõ óôÝëíåôáé ôï áßìá ìå õðçñåóéáêü áõôïêßíçôï. ÕðÜñ÷åé üìùò ðëïýóéï ðáñáúáôñéêü ðñïóùðéêü ìå íïóçëåýôñéåò, íïóçëåõôÝò, öõóéïèåñáðåõôÝò, êïéíùíéêïýò ëåéôïõñãïýò, ðñáêôéêÝò íïóïêüìåò êáé õðåýèõíåò ãéá ôçí êáèáñéüôçôá. ÊÜèå íïóçëåõôéêü ôìÞìá ëåéôïõñãåß áõôüíïìá, ìå äéêÞ ôïõ äéåõèýíïõóá, áëëÜ êáé óå óõíåñãáóßá ìåôáîý ôïõò êáé ìå ôï ãåíéêü éáôñü ï ïðïßïò êÜíåé êáèçìåñéíÜ åðßóêåøç óôïõò áóèåíåßò ôïõ íïóïêïìåßïõ. Ï éáôñüò åñãÜæåôáé ôáõôü÷ñïíá óôï group practice üðïõ áíÞêåé. Ìßá öïñÜ ôçí åâäïìÜäá êÜíåé åðßóêåøç ï ãçñßáôñïò. Ðñéí ãßíåé ç åðßóêåøç óôïõò áóèåíåßò ãßíåôáé óõíÜíôçóç üëùí üóùí åñãÜæïíôáé ìå ôïí ãçñßáôñï êáé ôï Ãåíéêü Éáôñü. Óõæçôåßôáé êÜèå ðåñßðôùóç ÷ùñéóôÜ êáé óõæçôþíôáé üëåò ïé ðôõ÷Ýò ôùí ðñïâëçìÜôùí ôïõ áóèåíïýò. ÁõôÜ âÝâáéá åêôüò ôá êáèáñÜ éáôñéêÜ åßíáé êáé ðñïâëÞìáôá êïéíùíéêÞò öýóåùò ìå êõñßáñ÷ï ôçí áðïêáôÜóôáóç ôùí çëéêéùìÝíùí áóèåíþí. ÕðÜñ÷ïõí óõããåíåßò íá äå÷ôïýí ôïí çëéêéùìÝíï; Åßíáé óå èÝóç íá ìåßíåé ï ãÝñïíôáò óôï óðßôé ç èá ðñÝðåé íá êáôåõèõíèåß óå êÜðïéïí ïßêï åõãçñßáò ìå õøçëÞ íïóçëåõôéêÞ öñïíôßäá; Åßíáé ìåñéêÜ áðü ôá åñùôÞìáôá ðïõ ðïëý óõ÷íÜ áðáó÷ïëïýí ôçí ïìÜäá. ¸íá óõ÷íü ðñüâëçìá ðïõ áíôéìåôùðßæåôáé åßíáé ôïõ áóèåíïýò ï ïðïßïò æïýóå ìéá öõóéïëïãéêÞ æùÞ ìÝ÷ñé ôçí åãêáôÜóôáóç åíüò áããåéáêïý åãêåöáëéêïý åðåéóïäßïõ (ÁÅÅ), êáé ôçí åðáêüëïõèç ðëÞñç ç ìåñéêÞ áíáðçñßá ìå áðïôÝëåóìá íá ìçí åßíáé ðéá äõíáôÞ ç áõôïåîõðçñÝôçóç óôï äéêü ôïõ óðßôé. Ç ðåñáéôÝñù áðïêáôÜóôáóç ôùí áíèñþðùí áõôþí, êñßíåôáé óå óõíåñãáóßá ìå ôïí ãÝñïíôá, ðïõ ðïëëÝò öïñÝò äåí åßíáé óå èÝóç íá êñßíåé óùóôÜ, ôçí ïéêïãÝíåéá ôïõ êáé ôçí ïìÜäá ôïõ íïóïêïìåßïõ áðïêáôáóôÜóåùò. Ãßíåôáé áðü üëïõò ðñïóðÜèåéá øõ÷ïëïãéêÞò õðïóôÞñéîçò ôïõ çëéêéùìÝíïõ, þóôå íá ìðïñÝóåé íá ðñïóáñìïóôåß óôç íÝá êáôÜóôáóç ôïõ. Ëüãù ôçò ïñãáíùìÝíçò áõôÞò ìïñöÞò óôçí áíôéìåôþðéóç ôùí áóèåíþí ìå ÁÅÅ, ôï äçìïôéêü íïóïêïìåßï áðïôåëåß ìéêôÞ ìïíÜäá ÁÅÅ, äçëáäÞ åêôßìçóçò êáé áðïêáôÜóôáóçò. ¸÷åé áðïäåé÷èåß ç åðßäñáóç ôùí ìïíÜäùí ÁÅÅ óôç ìåßùóç ôçò èíçôüôçôáò, íïóçñüôçôáò êáé ëåéôïõñãéêÞò áðïêáôÜóôáóçò ôùí áóèåíþí.

33


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÅîùôåñéêÜ éáôñåßá ôïõ íïóïêïìåßïõ áðïêáôÜóôáóçò ÅðåéäÞ ôï êïíôéíüôåñï ðåñéöåñåéáêü äåõôåñïâÜèìéï íïóïêïìåßï âñßóêåôáé óå êÜðïéá áðüóôáóç áðü ôçí ðåñéï÷Þ, ëåéôïõñãïýí åîùôåñéêÜ éáôñåßá åéäéêïôÞôùí ãéá ÷ñüíéïõò áóèåíåßò, óôï ïðïßï ðáñáðÝìðïõí ïé Ãåíéêïß Éáôñïß ôçò ðåñéï÷Þò. Ôá 312 (66%) áðü ôá íïóïêïìåßá ôçò ðñïáíáöåñèåßóçò ìåëÝôçò ðåñéåëÜìâáíáí åîùôåñéêÜ éáôñåßá åéäéêþí éáôñþí (consultants)1. Ìå ôïí ôñüðï áõôü ãßíåôáé åöéêôÞ ç ðïèçôÞ áðïóõìöüñçóç ôïõ íïóïêïìåßïõ ôüóï ôùí åîùôåñéêþí éáôñåßùí üóï êáé ôùí åóùôåñéêþí ôìçìÜôùí ôïõ.

Êüóôïò ëåéôïõñãßáò ¼ðùò ãßíåôáé áíôéëçðôü ôï êüóôïò ëåéôïõñãßáò ôïõ íïóïêïìåßïõ áðïêáôÜóôáóçò ðïõ ðåñéãñÜöïõìå, åßíáé ðïëý ìéêñüôåñï áðü ôï áíôßóôïé÷ï ôïõ äåõôåñïâÜèìéï, ëüãù Ýëëåéøçò åñãáóôçñßùí êáé éáôñéêïý ðñïóùðéêïý. Ôéò íõêôåñéíÝò þñåò êáé áñãßåò êáëýðôåôáé áðü ãåíéêü éáôñü ðïõ åöçìåñåýåé óôï êïíôéíü ÊÝíôñï Õãåßáò ãéá Ýêôáôá ðåñéóôáôéêÜ ôùí õðåñçëßêùí ðïõ èá ðáñïõóéáóôïýí.

ÐñïôÜóåéò ãéá åöáñìïãÞ óôá ÅëëçíéêÜ äåäïìÝíá Ç ëåéôïõñãßá ôÝôïéùí õãåéïíïìéêþí ìïíÜäùí áðïõóéÜæåé áðü ôïí Åëëçíéêü ÷þñï. Óå ðñüóöáôï Üñèñï óýíôáîçò áíáöÝñåôáé üôé ôï ìÝëëïí ôùí äçìïôéêþí íïóïêïìåßùí ìåôÜ áðü 100 ÷ñüíéá ëåéôïõñãßáò ôïõò ãéá ðñþôç öïñÜ äéáãñÜöåôáé ôüóï åëðéäïöüñï. Ïé ëüãïé ãé áõôü åßíáé ï åðáíáðñïóäéïñéóìüò ôïõ ñüëïõ ôçò ÐÖÕ, óôïí ïðïßï äßíåôáé ìåãÜëç óçìáóßá óôçí êÜëõøç áôüìùí ìå åéäéêÝò áíÜãêåò üðùò áíáðçñßåò, êáé óùìáôéêÝò áíéêáíüôçôåò. Åðßóçò ç ðñïóðÜèåéá áðïêÝíôñùóçò ôùí õðçñåóéþí õãåßáò óôï ÅÓÕ ôçò Ì. Âñåôáíßáò, óôçí ïðïßá ôï äçìïôéêü íïóïêïìåßï ìðïñåß íá ðáßîåé êõñßáñ÷ï ñüëï, óôï óõíôïíéóìü ôùí ôïðéêþí öïñÝùí ãéá ôçí åðéôõ÷Þ áíôéìåôþðéóç ôùí áôüìùí ìå åéäéêÝò áíÜãêåò, óôá ïðïßá ïé õðçñÞëéêåò áðïôåëïýí ôçí ðëåéïøçößá3. Ç ãÞñáíóç ôïõ ðëçèõóìïý Üëëáîå êáé ôçí åðéäçìéïëïãßá ôùí íïóçìÜôùí óôéò óýí÷ñïíåò 34

Ð.Ì. ÄáíäïõëÜêçò

êïéíùíßåò ôùí äõôéêþí ÷ùñþí óôéò ïðïßåò áíÞêåé êáé ç ÅëëÜäá. Ôá ÷ñüíéá íïóÞìáôá êáé ôá íïóÞìáôá öèïñÜò õðåñôåñïýí óôïõò çëéêéùìÝíïõò. Ôá íïóÞìáôá áõôÜ áðáéôïýí õøçëÞ íïóçëåõôéêÞ êáé öñïíôßäá áðïêáôÜóôáóçò, ç ïðïßá üìùò ðñÝðåé íá åßíáé ïñãáíùìÝíç. Ç áíÜãêç áõôÞ Ý÷åé åðéóçìáíèåß êáé ìå Üëëåò ìåëÝôåò4. Ôï ìÝãåèïò ôïõ ðñïâëÞìáôïò óôçí ÅëëÜäá öáßíåôáé áðü ôçí ðëçèþñá ôùí ïßêùí åõãçñßáò ðïõ õðÜñ÷ïõí óôçí ÅëëÜäá, êõñßùò óôá ìåãÜëá áóôéêÜ êÝíôñá, ôá áíôßóôïé÷á resentential êáé nursing home ðïõ õðÜñ÷ïõí óôï ÇíùìÝíï Âáóßëåéï. Åëëåßðåé üìùò ôåëåßùò ç åíäéÜìåóç áõôÞ ìïíÜäá ðáñï÷Þò õðçñåóéþí õãåßáò ç ïðïßá ìðïñåß íá äþóåé áðÜíôçóç êáé ëýóç óå ðïëëÜ áðü ôá ðñïâëÞìáôá ðïõ áíáêýðôïõí áðü ôç öñïíôßäá õãåßáò ôùí çëéêéùìÝíùí êáé åðßóçò íá ìåéþóåé ôï êüóôïò íïóçëåßáò. Èá åßíáé ï åíäéÜìåóïò êñßêïò ìåôáîý ðñùôïâÜèìéáò êáé äåõôåñïâÜèìéáò ðåñßèáëøçò, óôï ïðïßï èá ìðïñïýí íá êáôáöåýãïõí ôüóï ïé óõããåíåßò ôùí õðåñßëçêùí áóèåíþí, áëëÜ êáé ïé õðåýèõíïé ôùí ïßêùí åõãçñßáò êáé âÝâáéá ïé ãéáôñïß ðïõ áóêïýí ðñùôïâÜèìéá ðåñßèáëøç. Ç åõåëéîßá ôùí äçìïôéêþí íïóïêïìåßùí íá áíôáðïêñéèïýí óå ìåãÜëï öÜóìá êáôáóôÜóåùí êáé óõíèçêþí, ç åéäéêÞ ó÷Ýóç ìå ôéò ôïðéêÝò õðçñåóßåò õðïóôÞñéîçò, êÜíïõí áðïôåëåóìáôéêüôåñç ôçí áíÜññùóç êáé ôçí áðïêáôÜóôáóç ôùí çëéêéùìÝíùí áóèåíþí, óå óýãêñéóç ìå ôá äåõôåñïâÜèìéá íïóïêïìåßá. Åðßóçò õðåñôåñïýí áðü ôïõò ïßêïõò åõãçñåßáò, äéüôé óå ìåëÝôç ðïõ Ý÷åé ãßíåé óôç Ìåã. Âñåôáíßá ìüíï ôï 10% ôùí áóèåíþí êÜíïõí öõóéïèåñáðåßá, åíþ óå áíÜëïãç ðñïóðÜèåéá ðïõ Ýãéíå óôéò ÇÐÁ ãéá èåñáðåßá áðïêáôÜóôáóçò óå ïßêï åõãçñßáò, ôá áðïôåëÝóìáôá Þôáí ðôù÷Ü4. Óôï 1ï ÓõíÝäñéï Ìanagement (ÄåêÝìâñéïò 1999), ï ôüôå Õðïõñãüò Õãåßáò ÊáèçãçôÞò ê. Ê. ÓôåöáíÞò Ýëåãå üôé: ‘ôï íïóïêïìåßï äåí ìðïñåß ðáñÜ ìåëëïíôéêÜ íá åßíáé Ýíáò ÷þñïò ãéá õðçñåóßåò åðåßãïõóáò éáôñéêÞò, âáñéÜò ÷åéñïõñãéêÞò, ìïíÜäùí åíôáôéêÞò èåñáðåßáò. Ãéá üëåò ôéò Üëëåò ìïñöÝò ðåñßèáëøçò èá ðñÝðåé, êáôÜ êÜðïéï ôñüðï, íá äçìéïõñãçèïýí ðáñÜðëåõñåò äïìÝò. Êáé ôï åñþôçìá åßíáé, áí áõôÝò ïé äïìÝò èá ðñÝðåé íá áíáðôõ÷èïýí ùò ïìüêåíôñïé êýêëïé ãýñù áðü ôï Íïóïêïìåßï ç ðñÝðåé íá áðïôåëïýí îå÷ùñéóôÝò õðçñåóßåò’.5 Ï ðñïâëçìáôéóìüò ôïõ ÊáèçãçôÞ ê. ÓôåöáíÞ, óôç ìïñöÞ ðïõ ðñÝðåé íá Ý÷åé ôï óýí÷ñïíï


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ð.Ì. ÄáíäïõëÜêçò

èåñáðåõôÞñéï, ìðïñåß íá ðñïêáëÝóåé ôï Ýíáõóìá ãéá ðåñáéôÝñù ðñïâëçìáôéóìü êáé óõæÞôçóç áëëÜ êõñßùò ãéá Üìåóç ëÞøç ðïëéôéêþí áðïöÜóåùí ãéá ôç ëåéôïõñãßá ôÝôïéùí ìïíÜäùí óôçí ÅëëÜäá, ìå ôç ìåôáôñïðÞ õðáñ÷ïõóþí Þäç êôéñéáêþí ìïíÜäùí, óå ìïíÜäåò áðïêáôÜóôáóçò õðåñçëßêùí. Ìå ôç óõìâïëÞ ôùí ðáíåðéóôçìéáêþí öïñÝùí ÷ñåéÜæåôáé íá ðñïçãçèåß ìåëÝôç ôïõ êüóôïõò áðïôåëåóìáôéêüôçôáò ðïõ èá Ý÷åé ç ëåéôïõñãßá ôÝôïéùí ìïíÜäùí êáé åðßóçò ôïõ êïéíùíéêïý êüóôïõò ðïõ èá Ý÷åé óôéò ïéêïãÝíåéåò ôùí áóèåíþí áõôþí.

Âéâëéïãñáößá 1. Seamark D, Moore B, Trucker H, Church J, Seamark C. Community hospital for the new millenium. Br J of Gen Practice, 51:125-127, 2001. 2. Grant JA, Dowell J. A qualitative study of why general practitioners admit to community hospitals. Br J of Gen Practice, 52:628-634, 2002. 3. Meads G. Rediscovering community hospitals. Br J Gen Pract, 51:91-2, 2001. 4. Young J, Donalson K. Community hospitals and older people. Age and Ageing 30:7-10, 2001. 5. Ìé÷Üëçò Ä. Ç ìåôåîÝëéîç ôùí íïóïêïìåéáêþí ìïíÜäùí êáé ç áíÜðôõîç ôçò Ð.Ö.Õ. Ôá ÍÝá ôçò ¸íùóçò ôùí Ãåíéêþí/Ïéêïãåíåéáêþí Éáôñþí. 50:1&7, 2002.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã.É. Ôóßñïò êáé óõí.

ÓÕÍÔÏÌÇ ANAÖÏÑÁ BRIEF REPORT Primary Heatlh Care, Volume 16, Number 1, 36-39, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 36-39, 2004

Ç éáôñéêÞ ôå÷íïëïãßá óôéò áñ÷Ýò ôïõ 21ïõ áéþíá Ã.É. Ôóßñïò1, Ðáíáãéþôá Å. ÂïÀëá1, Ä.Ê. Êáëïãåñüðïõëïò1, Áíáóôáóßá É. Ôóßñïõ2, Ã.Ä. ÌïõæÜêçò3

Ðåñßëçøç H áíáöïñÜ ìáò óôï÷åýåé óôçí ðáñïõóßáóç óõóêåõþí õøçëÞò ôå÷íïëïãßáò, Üìåóçò ìåëëïíôéêÞò åöáñìïãÞò óôçí éáôñéêÞ äéÜãíùóç. ¸ãéíå åêôåíÞò áíáóêüðçóç ôçò ó÷åôéêÞò âéâëéïãñáößáò, éóôïóåëßäùí äéáäéêôýïõ ìå ëÝîåéò-êëåéäéÜ: éáôñéêÞ ôå÷íïëïãßá, åîåëßîåéò, äéáãíùóôéêÝò ìÝèïäïé, 21ïò áéþíáò. Ç ðñüïäïò ôùí ôå÷íïëïãéêþí åðéôåõãìÜôùí ðáñïõóéÜæåôáé ó’ üëåò ôéò éáôñéêÝò åéäéêüôçôåò ìå éäéáßôåñá üìùò áðïôåëÝóìáôá óôïõò ôïìåßò: ãåíåôéêÞ Ýñåõíá, áóýñìáôç åíäïóêüðçóç-ëÞøç éáôñéêþí ðëçñïöïñéþí ìÝóù ïèüíçò, ôñéóäéÜóôáôç áðåéêüíéóç ðáó÷üíôùí áíèñùðßíùí éóôþí/ïñãÜíùí êáé ëáðáñïóêïðéêÞ ÷åéñïõñãéêÞ ñïìðïôéêÞ. ÓõìðåñáóìáôéêÜ, ç ôå÷íïëïãßá Ý÷åé åöïäéÜóåé ôçí éáôñéêÞ ìå ðïéêéëßá èåñáðåõôéêþí ìÝóùí-åñãáëåßùí, êáëýðôïíôáò ôç äéáãíùóôéêÞèåñáðåõôéêÞ ðñïóðÝëáóç ó’ üëá ôá éáôñéêÜ åðßðåäá. 1

Éáôñïß Ðáíåðéóôçìéáêïý Ãåíéêïý Íïóïêïìåßïõ Ðáôñþí, 2ÖïéôÞôñéá ÉáôñéêÞò, 3Ãåíéêüò Éáôñüò

Medical technology in the beginning of 21st century G. Tsiros, P. Voila, D. Kalogeropoulos, A. Tsirou, G. Mouzakis Summary Our report aims to the presentation of high technology devices with direct application in medical diagnosis. It was done comprehensive review of the relative bibliography and sites of Internet using as keywords: medical technology, advancement, diagnostic methods and 21st century. The progress of the technological achievements is presented to all medical specialties but with specific result mainly in sectors: general research, wireless endoscopy-receipt of medical information through monitor, three-dimensional description of human suffering tissues/organs and robots in laparoscopic surgery. Deductively, technology has given to medicine a diversity of therapeutic means-tools grounded the diagnostic-therapeutic access in all medical levels. Keywords: Medical technology, Diagnostic methods, Progresses, 21st century. General University Hospital of Patras

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1. ÅéóáãùãÞ Óôá ðñþôá âÞìáôá ôçò éáôñéêÞò, ç äéÜãíùóç âáóéæüôáí ìüíï óôçí éêáíüôçôá ôïõ éáôñïý íá åíôïðßóåé êáé íá åñìçíåýóåé óùóôÜ ôá óõìðôþìáôá ìéáò íüóïõ. ¸ôóé ÷ñçóéìïðïéïýóå ôéò áéóèÞóåéò êáé ôçí åìðåéñßá ôïõ ìáæß ìå êÜðïéá áðëïúêÜ åñãáëåßá. Óôçí åðï÷Þ ìáò, ç ôå÷íïëïãéêÞ ðñüïäïò Ý÷åé èÝóåé óôç äéÜèåóç ôïõ éáôñïý óõóêåõÝò õøçëÞò ôå÷íïëïãßáò êáé ðïëëÝò óçìáíôéêÝò äéáãíùóôéêÝò ôå÷íéêÝò1. Óôçí áíáöïñÜ ìáò ðáñïõóéÜæïíôáé óýã÷ñïíåò äéáãíùóôéêÝò ìÝèïäïé, óõóêåõÝò õøçëÞò ôå÷íïëïãßáò - Üìåóçò ìåëëïíôéêÞò åöáñìïãÞò óôçí éáôñéêÞ äéÜãíùóç - ìå óôü÷ï ôçí åíçìÝñùóç ôùí éáôñþí ãéá ôéò ôå÷íïëïãéêÝò äõíáôüôçôåò êáé åîåëéêôéêÝò êáôåõèýíóåéò ðïõ áêïëïõèåß ç éáôñéêÞ åðéóôÞìç óôïí áéþíá ðïõ äéáíýïõìå. ¸ãéíå åêôåíÞò âéâëéïãñáöéêÞ áîéïëüãçóç/äéåñåýíçóç éóôïóåëßäùí ôïõ äéáäéêôýïõ ìå ëÝîåéò-êëåéäéÜ: éáôñéêÞ ôå÷íïëïãßá, ËÝîåéò êëåéäéÜ: éáôñéêÞ ôå÷íïëïãßá, äéáãíùóôéêÝò ìÝèïäïé, Åîåëßîåéò ÕðïâëÞèçêå: 20 ÌáÀïõ 2003 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 10 Öåâñïõáñßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: Ãåþñãéïò É. Ôóßñïò, Ãåíéêüò Éáôñüò, ÓïöïêëÝïõò 29, Ô.Ê. 26442, ÐÜôñá, Ôçë. (2610) 454.667, êéí. 6977 019977, e-mail: geotsiro@otenet.gr


Ã.É. Ôóßñïò êáé óõí.

åîåëßîåéò, äéáãíùóôéêÝò ìÝèïäïé, 21ïò áéþíáò.

2. Ôïìåßò éáôñéêþí ôå÷íïëïãéêþí åîåëßîåùí ÓÞìåñá ç ðñüïäïò ôùí ôå÷íïëïãéêþí åðéôåõãìÜôùí ðáñïõóéÜæåôáé ó’ üëåò ôéò éáôñéêÝò åéäéêüôçôåò, ìå éäéáßôåñá üìùò áðïôåëÝóìáôá óôïõò êÜôùèé ôÝóóåñéò ôïìåßò:

Ôüìïò 16, Ôåý÷ïò 1, 2004

ðïýò üðùò õðÝñç÷ïé, áîïíéêÞ (CT) êáé ìáãíçôéêÞ (MRI) ôïìïãñáößá ê.ëð. Ðñüóöáôá ìÜëéóôá ðáñïõóéÜóèçêå ôï óýóôçìá Cbyon Suite, ôï ïðïßï ÷ñçóéìïðïéþíôáò åéêüíåò ðïõ ëáìâÜíïíôáé ìå ðïéêßëåò ìåèüäïõò (CT, MRI), ôéò áíáóõíèÝôåé ôñéóäéÜóôáôá, äçìéïõñãþíôáò êáôÜ êÜðïéïí ôñüðï Ýíáí “åéêïíéêü áóèåíÞ” êáé ðñïóöÝñåé óôïí éáôñü ôçí äõíáôüôçôá íá ìåëåôÞóåé ìå áêñßâåéá ôçí áíáôïìßá êáé ôçí ðéèáíÞ ðáèïëïãßá ôïõ áóèåíïýò4.

ÃåíåôéêÞ Ýñåõíá ËáðáñïóêïðéêÞ ÷åéñïõñãéêÞ ñïìðïôéêÞ Ôï “éëéããéþäåò åðßôåõãìá”, ç ÷áñôïãñÜöçóç ôïõ áíèñþðéíïõ ãïíéäéþìáôïò (DNA), äüèçêå ìå ôçí åßóïäï ôïõ 21ïõ áéþíá óôçí äçìïóéüôçôá áðü äýï ôáõôï÷ñüíùò åðéóôçìïíéêÝò ïìÜäåò: á) Celera Genomics óôï åðéóôçìïíéêü ðåñéïäéêü ‘Science’ (www.aaas.org) êáé â) National Human Research Institute óôï ðåñéïäéêü ‘Nature’ (www.nature.com). Oé åðéóôÞìïíåò áíáêÜëõøáí, üôé ï Üíèñùðïò Ý÷åé ðïëý ëéãüôåñá ãïíßäéá áðü üóá ðßóôåõáí, ìüëéò 30.000. ÐïëëÜ ãïíßäéá åßíáé ßäéá ìå áõôÜ ôùí ìéêñïâßùí, äßíïíôáò êáôÜ óõíÝðåéá êÜðïéï “ïäçãü” ãéá ôá ãåíåôéêÜ ÷áñáêôçñéóôéêÜ ôïõ áôüìïõ êáé ìåëëïíôéêÝò äõíáôüôçôåò ãïíéäéáêÞò èåñáðåßáò áóèåíåéþí2.

Ôá ôåëåõôáßá ÷ñüíéá áíáäåéêíýïíôáé óôçí áßèïõóá ôïõ ÷åéñïõñãåßïõ ôá ñïìðïôéêÜ óõóôÞìáôá. Ï ëüãïò ãé’ áõôü, åßíáé ç áíÜãêç ôùí ÷åéñïõñãþí íá îåðåñÜóïõí ôïõò ðåñéïñéóìïýò ôçò åíäïóêïðéêÞò ÷åéñïõñãéêÞò, üðùò ç ìåéùìÝíç äõíáôüôçôá êéíÞóåùí, ïé êáôáóêåõáóôéêïß ðåñéïñéóìïß ôùí åñãáëåßùí, ç äéóäéÜóôáôç üñáóç ê.ëð., êáé íá ðñáãìáôïðïéÞóïõí åðåìâÜóåéò ðïõ äåí åßíáé åöéêôÝò ìå ôçí áðëÞ åíäïóêïðéêÞ ÷åéñïõñãéêÞ. Áðïôåëïýí õðïëïãéóôéêÝò óõóêåõÝò õøçëÞò éáôñéêÞò ôå÷íïëïãßáò êáé áêñßâåéáò ÷åéñéóìþí, áêüìá êáé óå ðåñéï÷Ýò éïíßæïõóáò áêôéíïâïëßáò5.

3. Óýã÷ñïíá éáôñéêÜ ôå÷íïëïãéêÜ åðéôåýãìáôá Áóýñìáôç åíäïóêüðçóç – ëÞøç éáôñéêþí ðëçñïöïñéþí ìÝóù ïèüíçò Ãéá ôçí åíäïóêüðçóç ôïõ ðåðôéêïý êáé éäßùò ôïõ -äýóêïëá ðñïóåããßóéìïõ- ëåðôïý åíôÝñïõ, õðÜñ÷ïõí ðñüóöáôåò ôåêìçñéùìÝíåò Ýñåõíåò êáé ìåëÝôåò (2nd Annual Conference on Capsule Endoscopy in Berlin, March, 2003) ãéá ôçí áðïôåëåóìáôéêüôçôá êáé áîéïðéóôßá ôùí “åíäïóêïðéêþí êáøïõëþí”. Áðåéêïíßæåôáé áóýñìáôá üëç ç äéáäñïìÞ ôïõ ãáóôñåíôåñéêïý óõóôÞìáôïò, ìÝóù åéäéêÞò ëÞøçò-ïèüíçò, “áíôéêáèéóôþíôáò” ôçí åðþäõíç ãáóôñïóêüðçóç-êïëïíïóêüðçóç3.

ÔñéóäéÜóôáôç áðåéêüíéóç ðáó÷üíôùí áíèñùðßíùí éóôþí/ ïñãÜíùí Åäþ êáé ÷ñüíéá ÷ñçóéìïðïéïýíôáé óõóôÞìáôá õøçëÞò ôå÷íïëïãßáò ãéá äéáãíùóôéêïýò óêï-

“Åíäåéêôéêïß” åêðñüóùðïé ôùí Üìåóùí ôå÷íïëïãéêþí äõíáôïôÞôùí êáé ðñïüäïõ ôçò éáôñéêÞò óôçí åðüìåíç 3åôßá, ìåôáîý Üëëùí åßíáé:

“e-medicine” (www.qinetiq.com): ÅðéóôÞìïíåò óôçí QinetiQ åñãÜæïíôáé ó’Ýíá åéêïíéêü(virtual) íïóïêïìåßï ðáñÝ÷ïíôáò óå áóèåíåßò éáôñéêÞ ðáñáêïëïýèçóç áðü ôçí ïéêßá ôïõò. Ïé áóèåíåßò, ëáìâÜíïõí virtual-äéóêßá (ìéêñïß ñáäéïìåôáäüôåò ìå ìéá áêßíäõíç âéïäéáóðþìåíç åðéêÜëõøç), ðïõ ðáñáìÝíïõí åíåñãïß ãéá 48 þñåò ìåôÜ ôï åîéôÞñéü ôïõò áðü ôï íïóïêïìåßï. ÁõôÜ ôá äéóêßá-ìüíéôïñ, äýíáíôáé íá èåñìïìåôñïýí ôï óþìá êáé íá ìåôáäßäïõí áóýñìáôá, ìÝóù ìéáò êÜñôáò GPRS Þ PDA (Personal Digital Assistant), ôá æùôéêÜ óçìåßá ôïõ áóèåíïýò óôïõò èåñÜðïíôåò éáôñïýò.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

“ÓôáèåñÞ ÷åéñïõñãéêÞ” (www.ri.cmu.edu): ÅñåõíçôÝò óôï Carnegie Mellon Robotics Institute áíÝðôõîáí åéäéêÜ ÷åéñïõñãéêÜ åñãáëåßá ðïõ “ìéìïýíôáé” ôéò êéíÞóåéò ôùí ÷åñéþí ìå áðüëõôç áêñßâåéá. Ïé áéóèçôÞñåò êßíçóçò óõíåñãÜæïíôáé ìå õðïëïãéóôÞ áíôáëëÜóóïíôáò ðëçñïöïñßåò êáé ðñáãìáôïðïéïýí áêñéâåßò ÷åéñéóìïýò ìå óôáèåñüôçôá, åëáôôþíïíôáò óôï Þìéóõ ôéò “Üèåëåò” ÷åéñïõñãéêÝò êéíÞóåéò.

“Life shirt-Äéáãíùóôéêü ãéëÝêï” (www.vivometrics.com): Ç Vivometrics êáôáóêåýáóå ôï “äéáãíùóôéêü ãéëÝêï”, ðïõ åëÝã÷åé ôá æùôéêÜ üñãáíá/óçìåßá (êáñäéÜ-ðíåýìïíåò ê.Ü.) ìå ìáãíçôéêÝò äñáóôçñéüôçôåò êáé Ýíá óýíïëï 40 äéáöïñåôéêþí ëåéôïõñãéþí ôïõ ïñãáíéóìïý. Ôï Lifeshirt åëÝã÷åé ôç öõóéêÞ êáôÜóôáóç ôïõ áôüìïõ (24 þñåò), äßíïíôáò ðëçñïöïñßåò óôïí èåñÜðïíôá éáôñü.

“Õðåñç÷ïãñÜöçìá 3D åìâñýïõ” (www.novint.com): ÅñåõíçôÝò óôç Novint ÷ñçóéìïðïéïýí ìéá óõóêåõÞ ðïõ åðéôñÝðåé ôçí ôñéóäéÜóôáôç (3D) åíäïìÞôñéá õðåñç÷ïãñáöéêÞ (U/S) áðåéêüíéóç ôïõ åìâñýïõ. Ôï õðåñç÷ïãñÜöçìá áõôü åßíáé ôï ßäéï áêßíäõíï üðùò êáé ôï óõìâáôéêü, ðñïóöÝñïíôáò óôïõò éáôñïýò ðåñéóóüôåñåò ðëçñïöïñßåò ãéá ôï Ýìâñõï êáé ôçí êáôÜóôáóç ôçò õãåßáò ôïõ.

“Video-KÜøïõëá” (www.givenimaging.com): Ç êÜøïõëá Ì2Á äéáóôÜóåùí 11X26 ÷éë., êéíåßôáé áíþäõíá óôï ãáóôñåíôåñéêü óùëÞíá, öÝñåé åíóùìáôùìÝíç ìéêñïêÜìåñá, ç ïðïßá åêðÝìðåé óÞìáôá ðïõ ìåôáôñÝðïíôáé óå åéêïíïìçíýìáôá ìÝóù åíüò áíáìåôáäüôç ðïõ âñßóêåôáé óå æþíç, ç ïðïßá äÝíåôáé óôï óôÞèïò ôïõ áóèåíïýò. Ç êÜøïõëá áðïâÜëëåôáé ìå ôá êüðñáíá áðü ôï áíèñþðéíï óþìá.

“Family doctor” (www.idsa.org): ÅðéóôÞìïíåò áðü ôï Samsung Researching Center áíÝðôõîáí ôçí éäÝá ôïõ “ïéêïãåíåéáêïý 38

Ã.É. Ôóßñïò êáé óõí.

éáôñïý”, ðïõ áíôéðñïóùðåýåôáé åí ìÝñåé áðü ìéá êÜøïõëá êáé ìßá ïèüíç (monitor). ÌåôÜ ôç ëÞøç ôçò êÜøïõëáò, êáôáãñÜöåôáé ç êáôÜóôáóç ôçò õãåßáò ôïõ áóèåíïýò êáé ôá áðïôåëÝóìáôá áíáãñÜöïíôáé óå ïèüíç ôïõ èåñÜðïíôïò éáôñïý.

“Doctor-chip” (www.brunel.ac.uk): Ðñüêåéôáé ãéá óõóêåõÞ (Brunel University) ðïõ ðñáãìáôïðïéåß ìéá Ýãêõñç êáé Ýãêáéñç åíáëëáêôéêÞ äéÜãíùóç áéìáôïëïãéêþí ðáèÞóåùí, ðñïóöÝñïíôáò åñãáóôçñéáêÞ åðåîåñãáóßá ôïõ DNA ì’ Ýíá “êõôôáñéêü ößëôñï” (chip).

“Power shoe-ÕðïâïÞèçóç âáäßóìáôïò”/SRI International (www.sri.com): ÅíóùìáôùìÝíïò ìç÷áíéóìüò óôï õðüäçìá áóèåíïýò, ðïõ õðïâïçèÜ óôï âÜäéóìá ìÝóù äéçëåêôñéêþí ðïëõìåñþí, ðáñÜãïíôáò ôçí áðáñáßôçôç åíÝñãåéá óôçí êßíçóç, áíôéêáèéóôþíôáò ôï “áðëü ìðáóôïýíé”.

“×åéñïõñãéêüò áéóèçôÞñáò”/Imperial College of London (www.ic.ac.uk): Eðéôõã÷Üíåé êáôáãñáöÞ ðëçñïöïñéþí – ‘Ýëåã÷ï åíôïëþí’ óôç äéÜñêåéá ìéáò ÷åéñïõñãéêÞò åðÝìâáóçò. Áðïóêïðåß óôçí Ýãêáéñç äéÜãíùóç êáé áðïóüâçóç ÷åéñïõñãéêþí ëáèþí, ãé’ áõôü êáé ðñïóïìïéÜæåôáé ìå ôï ìáýñï êïõôß (black box), áíÜëïãçò êáôáãñáöÞò ÷åéñéóìþí ôùí áåñïóêáöþí áð’ ôïõò ðéëüôïõò.

“Åã÷åüìåíç ìç÷áíéêÞ éóôþí” (web.mit.edu): Ìç÷áíéêïß âéïúáôñéêÞò óôï John Hopkins University, ôåëåéïðïéïýí ìéá íÝá èåñáðåßá ðïõ áíôéêáèéóôÜ ôçí åã÷åßñçóç áñèñïðëáóôéêÞò: ôçí åã÷åüìåíç ìç÷áíéêÞ éóôþí. Åã÷Ýïõí óôéò áñèñþóåéò ìåßãìáôá ðïëõìåñþí, êõôôÜñùí êáé ðáñáãüíôùí áõîÞóåùò, ðïõ óôåñåïðïéïýíôáé êáé äçìéïõñãïýí õãéÞ éóôü. Ç Ýã÷õóç áíáäåéêíýåôáé óôç öèçíüôåñç êáé åõêïëüôåñç ìÝèïäï ãéá ôïõò áóèåíåßò. Ç åöáñìïãÞ ôçò áíáìÝíåôáé ìÝóá óôçí åðüìåíç 10åôßá (ìå óýñéããåò êáé ü÷é åìöõôåýìáôá), êáé


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ã.É. Ôóßñïò êáé óõí.

áðþôåñá óå Üëëá üñãáíá ð.÷. êáñäéÜ, Þðáñ.

“ÌïñéáêÞ áðåéêüíéóç” (web.mit.edu): ÅñåõíçôéêÝò ïìÜäåò óå üëï ôïí êüóìï ÷ñçóéìïðïéïýí ôå÷íéêÝò: ìáãíçôéêÝò, ðõñçíéêÝò êáé ïðôéêÞò áðåéêüíéóçò, ìåëåôþíôáò ôçí áëëçëåðßäñáóç ôùí ìïñßùí (ãïíßäéá, ðñùôåÀíåò) ðïõ áðïôåëïýí ôç âÜóç âéïëïãéêþí äéáäéêáóéþí. Óôï Massachusetts General Hospital åëðßæïõí íá ìðïñïýí íá äéáðéóôþíïõí ôéò áéôßåò ìéáò áóèÝíåéáò, üðùò ï êáñêßíïò, êáé ôçí ðéèáíüôçôá åìöÜíéóÞò ôïõò ðïëý ðñéí åêäçëùèïýí óõìðôþìáôá. ÊëéíéêÝò äïêéìÝò Ý÷ïõí Þäç áñ÷ßóåé êáé óå 10 ÷ñüíéá ç ìïñéáêÞ áðåéêüíéóç èá áíôéêáôáóôÞóåé âéïøßåò, ìáóôïãñáößåò êáé Üëëåò äéáãíùóôéêÝò ìåèüäïõò. Ïé ôå÷íéêÝò × & ×É êáôáãñÜöïíôáé áð’ ôï ÌÉÔ (Massachusetts-Institute of Technology) ì’ åöáñìïãÞ åíôüò 10åôßáò.

ËáðáñïóêïðéêÞ ÷åéñïõñãéêÞò ñïìðïôéêÞ” Óôçí ðñÜîç, ôá ñïìðïôéêÜ óõóôÞìáôá ðïõ åßíáé äéáèÝóéìá ãéá åìðïñéêÞ åíäïóêïðéêÞ ÷ñÞóç, åßíáé ðåñéïñéóìÝíá ìå êõñéüôåñïõò åêðñïóþðïõò: á) ZEUS: ÔñéóäéÜóôáôç áðåéêüíéóç ôïõ ÷åéñïõñãéêïý ðåäßïõ, êßíçóç âñá÷ßïíá-åíäïóêïðßïõ ìÝóù öùíçôéêþí åíôïëþí ôïõ ÷åéñïõñãïý, â) HERMES, AEROSOP, daVinci, Socrates, NeyroMate6.

4. ÓõìðåñÜóìáôá ¼ëåò áõôÝò ïé óýã÷ñïíåò ôå÷íéêÝò óôï÷åýïõí óå ìéêñüôåñåò ÷åéñïõñãéêÝò ôïìÝò, ôá÷åßá áíÜññùóç, áíþäõíåò åðåìâÜóåéò, êáëýôåñá áðïôåëÝóìáôá êáé Ýãêáéñç ðñüëçøç íïóçìÜôùí. Êáèþò ç ôå÷íïëïãßá èá åîåëßóóåôáé êáé ôá óõóôÞìáôá èá ãßíïíôáé ìéêñüôåñá, åëáöñýôåñá, ôá÷ýôåñá, åý÷ñçóôá êáé öèçíüôåñá, èá Ý÷ïõí üëï êáé ðåñéóóüôåñåò åöáñìïãÝò ôüóï óå åñåõíçôéêü üóï êáé óå ðñáêôéêü åðßðåäï, óõìâÜëëïíôáò óôç äéáôÞñçóç êáé ôçí âåëôßùóç ôçò ðïéüôçôáò æùÞò. ÂÝâáéá, ôá éáôñéêÜ åîåëéêôéêÜ óõóôÞìáôá êáé

óõóêåõÝò ó÷åäéÜæïíôáé ãéá íá óõíåñãÜæïíôáé êáé íá âïçèïýí ôïí éáôñü, áõîÜíïíôáò ôéò äõíáôüôçôÝò ôïõ, êáé ü÷é ãéá íá ôïí áíôéêáôáóôÞóïõí, üðùò äéáöáßíåôáé ôïõëÜ÷éóôïí óôï Üìåóï ìÝëëïí. Ïé åîåëéêôéêÝò êáôåõèýíóåéò êáé ôá åðéôåýãìáôá ôçò éáôñéêÞò ôå÷íïëïãßáò äåí ðñÝðåé íá áðïôåëïýí ãíùóôéêü áíôéêåßìåíï ôùí åðéìÝñïõò êáé ó÷åôéêþí ùò ðñïò ôçí åîÝëéîç åéäéêïôÞôùí, áëëÜ íá áðïôåëïýí áíôéêåßìåíï ãíþóçò ãéá üëï ôïí éáôñéêü êëÜäï. Óõíåðþò, ðñïóöÝñåôáé ìéá óöáéñéêÞ åðéóôçìïíéêÞ åíçìÝñùóç, ôüóï ôùí éäßùí ôùí åðéóôçìüíùí, üóï êáé ôùí óõíáíèñþðïõò ôïõò. Ïé åîåëßîåéò ìåôáöÝñïíôáé ìå ôñüðï áíáëõôéêü êáé ðïëëÝò öïñÝò åëðéäïöüñï, üóïí áöïñÜ áóèÝíåéåò ðïõ äåí áíôéìåôùðßæïíôáé áðïôåëåóìáôéêÜ ìå ôéò Þäç õðÜñ÷ïõóåò ôå÷íéêÝò. ¼ëïé ïé éáôñïß, ïöåßëïõìå íá åßìáóôå åíÞìåñïé ãéá ôéò ðñïüäïõò óôï ÷þñï ôçò õãåßáò, þóôå íá óôçñßîïõìå áõôÝò ôéò ðñïóðÜèåéåò ãéá ìéá ðéï “áíèñþðéíç ðëåõñÜ” ôçò éáôñéêÞò, áêïëïõèþíôáò öõóéêÜ ôåêìçñéùìÝíåò ìåëÝôåò êáé ôçí êáôÜëëçëç åêðáßäåõóç.

Âéâëéïãñáößá 1. Olsen JE. The technicalization of medicine in the 19th century. Dan Medicinhist Arbog, 18798, 2001. 2. Service RF. Genetics and Medicine: Recruiting Genes, Proteins for a Revolution in Diagnostics. Science, 300:236-9, 2003. 3. Yu M. M2A capsule endoscopy. A breakthrough diagnostic tool for small intestine imaging. Gastroenterol Nurs, 25:24-7, 2002. 4. Omar MI, Sohail S. Recent applications of Ultrasound technology. J Coll Physicians Surg Pak, 13:125-6, 2003. 5. ÁñôåëÜñçò Ó. Ç ÷ñÞóç ôçò ìïíôÝñíáò ôå÷íïëïãßáò óôç ÷åéñïõñãéêÞ. Ôüìïò Ðñáêôéêþí 5ïõ Ðáìðåëïðïííçóéáêïý Óõíåäñßïõ, ÐÜôñá, 2002, Ôüìïò 7, óåë. 12-16. 6. Óôñáôïýëéáò Ê. ËáðáñïóêïðéêÞ ×åéñïõñãéêÞ: ôï ðáñüí êáé ôï ìÝëëïí. ÉáôñéêÞ ôïõ óÞìåñá, 33:914, 2002.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á.Ã. ÂÞôáò

ÁÍÁÖÏÑÁ ÐÅÑÉÐÔÙÓÇÓ CASE REPORT Primary Heatlh Care, Volume 16, Number 1, 40-44, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 40-44, 2004

ÓðÜíéá åíôüðéóç ôïõ óôçèáã÷éêïý ðüíïõ óå áóèåíÞ ðïõ õðÝóôç ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ A.Ã. ÂÞôáò

Ðåñßëçøç Óêïðüò ôçò ðáñïýóáò åñãáóßáò (case report) åßíáé ç ðáñïõóßáóç óðÜíéïõ ðåñéóôáôéêïý, ìå áóõíÞèéóôç åíôüðéóç ôùí êñßóåùí ôïõ óôçèáã÷éêïý ðüíïõ, óå ãõíáßêá 48 åôþí ðïõ õðÝóôç ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ (OEM). Ï ðüíïò Þôáí åíôïðéóìÝíïò óôï äåîéü þìï ÷ùñßò Ýôåñç óõìðôùìáôïëïãßá. Ôüóï ôï áôïìéêü üóï êáé ôï ïéêïãåíåéáêü éóôïñéêü ôçò áóèåíïýò Þôáí åëåýèåñï. Ç åãêáôÜóôáóç ôïõ OEM Ýãéíå ìå óõíïëéêÜ ôñåéò êñßóåéò ïîÝïò Üëãïõò, åíôïðéóìÝíåò óôï äåîéü þìï, åíþ õðÞñ÷å êáé óáöÞò êéñêÜäéá ðåñéïäéêüôçôá ôùí éó÷áéìéêþí êñßóåùí. Ôïíßæåôáé üôé ïé Ãåíéêïß Éáôñïß ðñÝðåé íá ãíùñßæïõí åíäåëå÷þò üëá ôá éó÷áéìéêÜ óõìðôþìáôá ôçò êáñäéÜò, âåëôéþíïíôáò Ýôóé, áöåíüò ôïí ÷ñüíï áíôßäñáóçò êáé áöåôÝñïõ ôçí ðñüãíùóç ôïõ ïîÝïò éó÷áéìéêïý åðåéóïäßïõ. Åéäéêüò Ãåíéêüò Éáôñüò

Extremely rare localization of the angina pectoris pain in woman who suffered from acute myocardial infarct Athanasios G. Vitas Summary The aim of this study was the presentation a case of a middle-aged woman who suffered from acute myocardial infarct (AMI) and extremely rare localization of the preceding pain. The pain was localized at the right shoulder and was not accompanied by any other symptom. From her personal anamnesis came out that she suffered from mild arterial hypertension, lasting two years, which was successfully controlled with a combination of ACE inhibitors and diuretics. Her family anamnesis was free. The habitation of AMI did not become one crisis of pain but with more crises that had also circadian rhythm (periodicity). Also, agitated the results of other study’s that recorded and deliberated the symptoms of event of AMI, the profit of precocious diagnosis and the level of knowledge of symptoms from patients, individuals with high risk and the Doctors. General Practitioner

40

ÅéóáãùãÞ ÐáñÜ ôá åíôõðùóéáêÜ Üëìáôá óôç äéÜãíùóç êáé áíôéìåôþðéóç ôïõ ïîÝïò åìöñÜãìáôïò ôïõ ìõïêáñäßïõ (OEM), êáôÜ ôéò ôñåéò ôåëåõôáßåò äåêáåôßåò, óõíå÷ßæåé íá ðáñáìÝíåé êýñéï ðñüâëçìá ãéá ôç äçìüóéá õãåßá óôï âéïìç÷áíïðïéçìÝíï êüóìï. Áðü ôï óýíïëï ôùí áôüìùí ðïõ åéóÜãïíôáé óôéò óôåöáíéáßåò ìïíÜäåò ìå ðéèáíü OEM, ç äéÜãíùóç åðéâåâáéþíåôáé ôåëéêÜ ìüíï óôï 30-50% ôùí áóèåíþí. Ðáñüôé ç óõ÷íüôçôá ôïõ èáíÜôïõ áðü OEM Ý÷åé ìåéùèåß êáôÜ 30% ðåñßðïõ ôçí ôåëåõôáßá äåêáåôßá, åîáêïëïõèåß íá åßíáé èáíáôçöüñï óôï Ýíá ôñßôï ôùí áóèåíþí. Ðåñßðïõ ôï 50% ôùí èáíÜôùí ðïõ ó÷åôßæïíôáé ìå OEM óõìâáßíïõí ôçí ðñþôç þñá áðü ôçí Ýíáñîç ôùí óõìðôùìÜôùí êáé áðïäßäïíôáé óå áññõèìßåò, óõ÷íüôåñá óå êïéëéáêÞ ìáñìáñõãÞ.1 Ç åãêáôÜóôáóç åíüò OEM ãßíåôáé ìå ìßá Þ ðåñéóóüôåñåò êñßóåéò óôéò ïðïßåò óõíçèÝóôåñá åðéêñáôåß ï ðüíïò. ¼ôáí ïé êñßóåéò åßíáé ðåñéóóüôåËÝîåéò êëåéäéÜ: Ðáíåðéóôçìéáêü Íïóïêïìåßï, Äéáäßêôõï, ÉáôñéêÞ åíçìÝñùóç ÕðïâëÞèçêå: 16 Éáíïõáñßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 5 Ìáñôßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: ÁèáíÜóéïò ÂÞôáò, Íáõáñßíïõ 7, Ô.Ê. 66100, ÄñÜìá, Ôçë.: (25210) 32009, e-mail: athanasiosvitas@yahoo.gr


Ôüìïò 16, Ôåý÷ïò 1, 2004

Á.Ã. ÂÞôáò

ñåò, ç ïëïêëÞñùóç ôïõ åìöñÜãìáôïò ãßíåôáé óõ÷íÜ óå ëßãåò çìÝñåò êáé ü÷é ôçí ðñþôç çìÝñá, üðùò óõìâáßíåé êáôÜ êáíüíá åÜí ôï ïîý Ýìöñáãìá åãêáôáóôáèåß óå ìéá êñßóç.2 ÐáñÜ ôéò ðñüóöáôåò ðñïüäïõò óôçí åñãáóôçñéáêÞ äéÜãíùóç ôïõ OEM, ôï éóôïñéêü åîáêïëïõèåß íá Ý÷åé ïõóéþäç óçìáóßá ãéá ôç äéÜãíùóç ôïõ. Óôá ôÝëç ôçò ðñïçãïýìåíçò äåêáåôßáò ï Hearse äéáôýðùóå ôçí Üðïøç “... åßíáé åêðëçêôéêü üôé ç êñßóéìç ó÷Ýóç ðïõ õößóôáôáé ìåôáîý ôçò äéÜñêåéáò ôùí óõìðôùìÜôùí, ôçò Ýêôáóçò ôçò éó÷áéìßáò êáé ôçò ôåëéêÞò Ýêâáóçò, ìÜëëïí äåí Ý÷ïõí êáëÜ ðñïóäéïñéóôåß”. Óêïðüò ôçò ðáñïýóáò åñãáóßáò åßíáé ç ðáñïõóßáóç åíäéáöÝñïíôïò ðåñéóôáôéêïý, ìéáò åíÞëéêçò ãõíáßêáò ìå óðÜíéá åíôüðéóç ôïõ ðáñáôåôáìÝíïõ óôçèáã÷éêïý ðüíïõ, ç ïðïßá ôåëéêÜ õðÝóôç OEM.

ÐåñéãñáöÞ ôçò ðåñßðôùóçò Ãõíáßêá 48 åôþí, ðåñéï-åììçíïðáõóéáêÞ êáé ìå äåßêôç ìÜæáò óþìáôïò 28,7 êáôÝöõãå óôéò 19:00ì.ì. óå ãíùóôü ôçò, éäéþôç Ïñèïðåäéêü Éáôñü, áíáöÝñïíôáò Þðéï, “ðéåóôéêü”, óõíå÷Ýò Üëãïò, åíôïðéóìÝíï óôï äåîéü þìï áðü 5ùñïõ. ×ùñßò Ýôåñç óõìðôùìáôïëïãßá. Åß÷å ðñïçãçèåß (½ þñá ðñéí ôçí åãêáôÜóôáóç ôïõ ðüíïõ) ìåóçìåñéáíü ãåýìá êáé ìÝôñéá ïéíïðïóßá. Áðü åñùôÞóåéò ðïõ áöïñïýóáí ôï áôïìéêü ôçò éóôïñéêü, ðñïÝêõøå ìéá ìÝôñéáò âáñýôçôáò áñôçñéáêÞ õðÝñôáóç áðü 2åôßáò, ôçí ïðïßá ñýèìéæå åðáñêþò ìå óõíäõáóìü áíáóôïëÝùí ôïõ ìåôáôñåðôéêïý åíæýìïõ ôçò áããåéïôåíóßíçò êáé äéïõñçôéêïý. Ôï ïéêïãåíåéáêü ôçò éóôïñéêü Þôáí åëåýèåñï. Áðü ôçí êëéíéêÞ åîÝôáóç äéáðéóôþèçêå öõóéïëïãéêÞ èåñìïêñáóßá óþìáôïò (36,7°C), åíþ ï ðüíïò ìåôáâáëëüôáí åëÜ÷éóôá ìå ôéò åíåñãçôéêÝò, ôéò ðáèçôéêÝò êéíÞóåéò Þ ôçí ðëÞîç. ÄéåíåñãÞèçêå áêôéíïëïãéêüò Ýëåã÷ïò ôïõ äåîéïý þìïõ, ôçò óýóôïé÷çò ùìïêëåéäéêÞò Üñèñùóçò êáé ôïõ èþñáêá,

÷ùñßò íá âñåèïýí ðáèïëïãéêÜ óôïé÷åßá. Óôç óõíÝ÷åéá ôçò Ýãéíå ìéá åíäïìõúêÞ Ýíåóç ìå Diclofenac 75mg êáé Thiocolchicoside 4mg. Åßêïóé ëåðôÜ áñãüôåñá, áíÝöåñå óáöÞ âåëôßùóç ôçò Ýíôáóçò ôïõ ðüíïõ êáé æÞôçóå íá áðÝëèåé. Ôçò ÷ïñçãÞèçêå éáôñéêÞ óõíôáãÞ, ðïõ óõãêñïôïýóáí ìç óôåñïåéäÞ áíôéöëåãìïíþäç êáé ìõï÷áëáñùôéêÜ (per os) öÜñìáêá, åíþ ôçò äüèçêáí êáé ïäçãßåò ãéá åðáíåîÝôáóç. ¸ìåéíå åëåýèåñç óõìðôùìÜôùí ìÝ÷ñé ôéò ðñþôåò ðñùéíÝò þñåò ôçò åðïìÝíçò çìÝñáò, üôáí ëüãù õðïôñïðÞò ôïõ Üëãïõò, åðéóêÝöôçêå íùñßò ôï ðñùß (éäßá âïýëçóç) éäéþôç Éáôñü Êáñäéïëüãï. Ç öýóç ôïõ ðüíïõ Þôáí áêñéâþò ç ßäéá. ÌåôÜ ôç ëåðôïìåñÞ ëÞøç éóôïñéêïý, ôçò äéåíåñãÞèçêå êëéíéêÞ åîÝôáóç êáôÜ ôçí ïðïßá äéáðéóôþèçêáí öõóéïëïãéêÞ áéìïäõíáìéêÞ êáôÜóôáóç (áñôçñéáêÞ ðßåóç 135/85mmHg), öõóéïëïãéêü áíáðíåõóôéêü øéèýñéóìá êáé êáñäéáêïß ôüíïé (Si—Sa åõêñéíåßò). Óôï çëåêôñïêáñäéïãñÜöçìá (ÇÊÃ) ðïõ áêïëïýèçóå, êáôáãñÜöçêå öõóéïëïãéêüò öëåâïêïìâéêüò ñõèìüò (68/min, èåôéêÜ Ñ óôçí Ð êáé áñíçôéêÜ óôçí aVR), ï Üîïíáò ôïõ QRS Þôáí öõóéïëïãéêüò. ÌåôÜ ôï ðÝñáò ôçò åîÝôáóçò áíÝöåñå âåëôßùóç ôïõ Üëãïõò, ðïõ ç ßäéá ôçí áðÝäùóå óôç (ðñùéíÞ) ëÞøç ôùí áíáëãçôéêþí. Óôç óõíÝ÷åéá, êáôüðéí õðïäåßîåùò ôïõ Êáñäéïëüãïõ Éáôñïý êáé åíþ ç áóèåíÞò ðáñÝìåíå áóõìðôùìáôéêÞ, äéåíåñãÞèçêáí ïé ðáñáêÜôù åñãáóôçñéáêÝò åîåôÜóåéò áßìáôïò: Ht, WBC, CRP, ÓÜê÷áñï, Ïõñßá, Ïõñéêü ïîý, SGOT, LDH, CPK, CPK-MB. Ôá áðïôåëÝóìáôá áðÝâçóáí áðüëõôá öõóéïëïãéêÜ. Ï èåñÜðùí éáôñüò ôçò óõíÝóôçóå ðñïãñáììáôéóìÝíç äïêéìáóßá êüðùóçò ìåôÜ ôï ðÝñáò ëßãùí çìåñþí êáé Ýöõãå áðü ôï Éáôñåßï óôéò 11:30 ð.ì. Ìßá þñá áñãüôåñá åðÝóôñåøå åê íÝïõ, ðáñáðïíïýìåíç ãéá íÝá õðïôñïðÞ ôïõ ðüíïõ áðü 14 þñáò, ìå åíôüðéóç êáé ðÜëé óôï äåîéü þìï. Ôçò Ýãéíå ÇÊà ðïõ áõôÞ ôç öïñÜ Ýäåé÷íå áíÜóðáóç ôïõ äéáóôÞìáôïò S-T óôéò áðáãùãÝò Ð, ÐÉ êáé aVF, ìå óáöÞ åéêüíá êáôüðôñïõ. Åéêüíåò É, ÉÉ, III. Äéáêïìßóôçêå åðåéãüíôùò óå ÊáñäéïëïãéêÞ

Åéêüíá 1. 41


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á.Ã. ÂÞôáò

Åéêüíá 2.

Åéêüíá 3.

ÊëéíéêÞ, áð’ üðïõ êáé åîÞëèå 10 ìÝñåò áñãüôåñá ìå ôç äéÜãíùóç “ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ/ êáôùôÝñïõ ôïé÷þìáôïò”. ÌåôÜ óáñÜíôá çìÝñåò ôçò Ýãéíå óôåöáíéïãñáöéêüò Ýëåã÷ïò üðïõ äéáðéóôþèçêå “íüóïò äýï áããåßùí”.

ÓõæÞôçóç H ðñþôç áíôéêåéìåíéêÞ ðåñéãñáöÞ ôùí ãíùñéóìÜôùí ôïõ óôçèáã÷éêïý ðüíïõ Ýãéíå óôá ôÝëç ôïõ 18ïõ áéþíá áðü ôïí William Heberden êáé äåí Ý÷åé îåðåñáóôåß ìÝ÷ñé óÞìåñá. Ï ðüíïò ôïõ OEM ðïéêßëåé óå Ýíôáóç, óôïõò ðåñéóóüôåñïõò áóèåíåßò åßíáé óïâáñüò êáé óå ïñéóìÝíåò ðåñéðôþóåéò áöüñçôïò. ÓõíÞèùò äéáñêåß ðåñéóóüôåñï áðü 30 min êáé óõ÷íÜ åðß þñåò. Ôï åíü÷ëçìá ðåñéãñÜöåôáé ùò óõóöéãêôéêü, óõíèëéðôéêü, êáôáðéåóôéêü Þ óõìðéåóôéêü, Üëãïò. Óõ÷íÜ ï áóèåíÞò ðáñáðïíåßôáé ãéá áßóèçìá ìåãÜëïõ âÜñïõò Þ óýíèëéøçò óôï óôÞèïò. Åíþ ôï åíü÷ëçìá ðåñéãñÜöåôáé ùò ðíßîéìï, óößîéìï Þ âáñýò ðüíïò, ìðïñåß åðßóçò íá ÷áñáêôçñéóôåß ùò óïõâëéÜ, ìá÷áéñéÜ, áìâëýò ðüíïò Þ êáõóáëãßá. Ôï Üëãïò åßíáé óõíÞèùò ïðéóèïóôåñíéêü ìå óõ÷íÞ åðÝêôáóç êáé óôéò äýï ðëåõñÝò ôïõ ðñü42

óèéïõ èùñáêéêïý ôïé÷þìáôïò, êáôÜ ðñïôßìçóç ôçí áñéóôåñÞ. Ãßíåôáé íá áêôéíïâïëåß óôï ùëÝíéï ÷åßëïò ôïõ áñéóôåñïý Üíù Üêñïõ, ðñïêáëþíôáò áßóèçìá áéìùäßáò óôïí áñéóôåñü êáñðü, ôçí áñéóôåñÞ Üêñá ÷åßñá êáé ôïõò äáêôýëïõò. ÏñéóìÝíïé áóèåíåßò áéóèÜíïíôáé ìüíï áìâëý ðüíï Þ áéìùäßá ôùí êáñðþí óå óõíäõáóìü ìå óïâáñü ïðéóèïóôåñíéêü Þ ðñïêÜñäéï åíü÷ëçìá. Óå ìåñéêÝò ðåñéðôþóåéò áóèåíþí, ï ðüíïò ôïõ OEM áñ÷ßæåé áðü ôï åðéãÜóôñéï êáé ìéìåßôáé ðïéêéëßá êïéëéáêþí êáôáóôÜóåùí, ãåãïíüò ðïõ ïäçãåß óõ÷íÜ óå ëáíèáóìÝíç äéÜãíùóç ôïõ OEM ùò “äõóðåøßá”. Óôïõò äéáâçôéêïýò ãßíåôáé íá áðïõóéÜæïõí ôá ðáñáðÜíù óõìðôþìáôá (âïõâÜ åìöñÜãìáôá), Þ íá áíáöÝñïõí ìüíï äýóðíïéá. Óå ïñéóìÝíïõò áóèåíåßò, éäßùò óôïõò çëéêéùìÝíïõò, ôï OEM óõ÷íÜ åêäçëþíåôáé ìå óõìðôþìáôá ïîåßáò áíåðÜñêåéáò ôçò áñéóôåñÜò êïéëßáò. ÓðÜíéá, ï ðüíïò ôïõ OEM ìðïñåß íá áêôéíïâïëåß óôïí ôñÜ÷çëï, ôéò óéáãüíåò, ôç ìåóïðëÜôéá ÷þñá Þ ôïõò þìïõò, êáôÜ ðñïôßìçóç ðÜëé óôçí áñéóôåñÞ ðëåõñÜ.4'5 Ôá óõìðôþìáôá áõôÜ óõíïäåýïíôáé óõíÞèùò áðü åößäñùóç, áäõíáìßá, öüâï êáé óôï 50% ôùí ðåñéðôþóåùí ìå äéáôïé÷ùìáôéêü OEM, áðü íáõôßá êáé åìåôïýò.6


Ôüìïò 16, Ôåý÷ïò 1, 2004

Á.Ã. ÂÞôáò

Ðïëëïß åñåõíçôÝò, êõñßùò áðü ôï ÷þñï ôçò ðñùôïâÜèìéáò ðåñßèáëøçò, óõììåñéæüìåíïé ôçí Üðïøç üôé ôï éóôïñéêü êáé ç êëéíéêÞ åéêüíá Ý÷ïõí ìåßæïíá óçìáóßá óôç äéÜãíùóç êáé êáôÜ óõíÝðåéá êáé óôçí ðñüãíùóç ôïõ OEM, åêðüíçóáí êáôÜ êáéñïýò äéÜöïñåò áíáäñïìéêÝò ìåëÝôåò óå ìéá ðñïóðÜèåéá ðëçñÝóôåñçò êáé ôá÷ýôåñçò äéáãíùóôéêÜ ðñïóÝããéóçò, ôïõ ïîÝïò éó÷áéìéêïý ðüíïõ ôçò êáñäéÜò. Ìéá áíôéðñïóùðåõôéêÞ ìåëÝôç, ç REACT, äéåíåñãÞèçêå óå 20 êïéíüôçôåò êáé áöïñïýóå 1.294 óõíåíôåýîåéò áóèåíþí, ïé ïðïßïé õðÝóôçóáí OEM êáôÜ ôç ÷ñïíéêÞ ðåñßïäï 1997-1999 êáé åðÝæçóáí. Ôï êýñéï óýìðôùìá áõôþí Þôáí ï èùñáêéêüò ðüíïò 89,7% êáé áêïëïõèïýóáí ïé áéìùäßåò 67,3% êáé ç äýóðíïéá 50,8%. ¢ëëåò åíôïðßóåéò ôïõ ðüíïõ (åêôüò ôïõ èþñáêá), Þôáí ôá Üíù Üêñá (24,2%), ôï åðéãÜóôñéï (18,7%), ç ðëÜôç (14,5%), ï ôñÜ÷çëïò (8,2%), ç êÜôù ãíÜèïò (6,7%) êáé ïé þìïé (5,1%). Ïé óðÜíéåò åíôïðßóåéò ôïõ éó÷áéìéêïý Üëãïõò (ôñÜ÷çëïò, êÜôù ãíÜèïò, þìïé), óçìåéùíüôáí óå óõíäõáóìü êáé ìå Üëëá óõìðôþìáôá (åößäñùóç, áäõíáìßá, åìåôü).7 Ç áíÜëõóç åíüò ìåãÜëïõ áñéèìïý áóèåíþí ðïõ íïóçëåýôçêáí ìå OEM êáé åîåôÜóôçêáí óôá ðëáßóéá ôçò ìåëÝôçò MILIS (Multicenter Investigation of Limitation of Infarct Size), áðïêÜëõøå óáöÞ êéñêÜäéá ðåñéïäéêüôçôá üóïí áöïñÜ ôçí þñá Ýíáñîçò ôïõ OEM, ìå ìÝãéóôç åðßðôùóç ôùí óõìâáìÜôùí ìåôáîý 6 ð.ì. êáé 12:00 ôï ìåóçìÝñé. Ïé êéñêÜäéïé ñõèìïß åðçñåÜæïõí ðïëëÝò öõóéïëïãéêÝò êáé âéï÷çìéêÝò ðáñáìÝôñïõò. Ïé ðñþôåò ðñùéíÝò þñåò óõíäÝïíôáé ìå áõîÞóåéò ôùí êáôå÷ïëáìéíþí óôï ðëÜóìá êáé ìå áýîçóç ôçò óõãêïëëçôéêüôçôáò ôùí áéìïðåôáëßùí.8 Ìéá Üëëç ðïëý ðñüóöáôç ìåëÝôç, ðïõ áðÝâëåðå óôçí åëá÷éóôïðïßçóç ôïõ ÷ñüíïõ äéÜãíùóçò Þ ôçò óïâáñÞò õðüíïéáò åíüò ïîÝïò éó÷áéìéêïý åðåéóïäßïõ êáé ðïõ âáóéæüôáí áðïêëåéóôéêÜ óôá áðïôåëÝóìáôá ôçò ìåëÝôçò REACT, Ýäåéîå üôé ç åðáñêÞò ãíþóç ôçò óõ÷íüôçôáò åêäÞëùóçò ôùí óõìðôùìÜôùí ôïõ OEM, áíÜ ôéò ïìÜäåò ðëçèõóìïý, ìåéþíåé óçìáíôéêÜ ôï ÷ñüíï “áíôßäñáóçò”, åîáóöáëßæïíôáò Ýôóé, ôá÷ýôåñç áíôéìåôþðéóç áëëÜ êáé èåáìáôéêÞ âåëôßùóç ôçò ðñüãíùóçò.9 ÐïëëÝò åñãáóßåò Ý÷ïõí ôåêìçñéþóåé ìéá óçìáíôéêÜ êáëýôåñç åîÝëéîç ôçò Ýêâáóçò ôïõ OEM óå áóèåíåßò ðïõ æÞôçóáí éáôñéêÞ âïÞèåéá áìÝóùò ìåôÜ ôçí åéóâïëÞ ôùí óõìðôùìÜôùí, óõãêñéôéêÜ

ìå åêåßíïõò ðïõ êáèõóôÝñçóáí õðïôéìþíôáò ôçí êëéíéêÞ ôïõò óõìðôùìáôïëïãßá. Ìå âÜóç áõôÜ ôá äåäïìÝíá, îåêßíçóå óôï Monash ôçò Áõóôñáëßáò, áðü Ãåíéêïýò Éáôñïýò, ìéá óôñáôçãéêÞ êáôáãñáöÞò ôçò ãíþóçò ôùí óõìðôùìÜôùí åêäÞëùóçò ôïõ OEM, åíþ áêïëïýèçóå êáé ó÷åôéêÞ åíçìÝñùóç, óå 1.486 Üôïìá ðïõ ÷áñáêôçñßóôçêáí “õøçëïý êéíäýíïõ”. Áíáëýïíôáò ôá äåäïìÝíá ï Smith K. êáé ïé óõíåñãÜôåò ôïõ, Ýêðëçêôïé äéáðßóôùóáí üôé ìüíï ôï 4,2% ôïõ äåßãìáôïò ãíþñéæå ïñèÜ ôïõëÜ÷éóôïí ðÝíôå âáóéêÜ óõìðôþìáôá, åíþ ôï 4,1% äåí ìðüñåóå íá áíáöÝñåé êáíÝíá áðïëýôùò óýìðôùìá.10 Ìßá Üëëç ìåëÝôç ðïõ Ýãéíå óôéò ÇíùìÝíåò Ðïëéôåßåò ôçò ÁìåñéêÞò, ìå ôõ÷áßá ôïðïãñáöéêÞ êáôáíïìÞ, áíé÷íåýïíôáò ôéò ãíþóåéò ôùí éáôñþí êáé õðïëïãßæïíôáò ôáõôü÷ñïíá ôçí ôá÷ýôçôá áíáãíþñéóçò êáé äéá÷åßñéóçò ôïõ OEM, êáôÜ ôçí ïîåßá öÜóç, Ýäåéîå üôé ïé íïóïêïìåéáêïß éáôñïß åßíáé êÜðùò áðëçñïöüñçôïé üóïí áöïñÜ ôùí åìðåéñéêþí óôïé÷åßùí, ðïõ ó÷åôßæïíôáé ìå ôï æùôéêÞò óçìáóßáò ðñüâëçìá ôçò êáèõóôÝñçóçò (âñáäýôçôá ðñþôçò áíôßäñáóçò).11 Óõíïøßæïíôáò, èá ðñÝðåé íá ôïíéóôåß ãéá áêüìç ìéá öïñÜ, ï áðïöáóéóôéêüò ñüëïò ôùí ëåéôïõñãþí ðïõ áóêïýí ðñùôïâÜèìéá ðåñßèáëøç. Ï Ãåíéêüò Éáôñüò Ý÷ïíôáò åíäåëå÷Þ ãíþóç ôùí éó÷áéìéêþí óõìðôùìÜôùí ôçò êáñäéÜò êáé ìå õøçëü áßóèçìá åõèýíçò, èá áðïöáóßæåé ðñþôïò ãéá ôïí ôñüðï “áíôßäñáóçò”, ßóùò êáôÜ ôçí êñéóéìüôåñç öÜóç ôïõ ïîÝïò éó÷áéìéêïý óõíäñüìïõ. Áðü ôï åí ëüãù ðåñéóôáôéêü (case report), áîßæåé íá èõìÜôáé êáíåßò üôé: 1. Ç åãêáôÜóôáóç ôïõ OEM Ýãéíå ü÷é ìå ìßá áëëÜ ìå ðåñéóóüôåñåò êñßóåéò ïîÝïò Üëãïõò. 2. Áðü ôç ÷ñïíéêÞ ðåñéãñáöÞ Ýíáñîçò ôùí åðåéóïäßùí ðüíïõ, äéáðéóôþíåôáé åýêïëá, ìéá óáöÞò êéñêÜäéá ðåñéïäéêüôçôá ôùí éó÷áéìéêþí êñßóåùí. 3. Ï ðüíïò óôï äåîéü þìï (áêüìá êáé üôáí åßíáé ôï ìüíï óýìðôùìá), èá ðñÝðåé, åêôüò ôùí Üëëùí ðéèáíþí íïóçñþí êáôáóôÜóåùí, íá åãåßñåé êáé ôçí õðïøßá ôçò ìõïêáñäéáêÞò éó÷áéìßáò. Âéâëéïãñáößá 1. Braunwald Å. Heart Disease. Acute Myocardîal Infarctîon. 5th Ed. Philadelphia, 1997, óåë. 15331642. 43


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

2. Ôïýôïõæáò Ð. Êáñäéïëïãßá. Óôåöáíéáßá Íüóïò. 3ç ¸êä. ÁèÞíá, 1997, óåë. 327-334. 3. Lionel H. The Heart, Physiology and Metabolism. Acute Myocardial Infarction. 2nd Ed. New York, 1991, óåë. 537-560. 4. Óáââüðïõëïò Ã. ÌåôåêðáéäåõôéêÜ ÌáèÞìáôá Êáñäéïëïãßáò. Ôï ÐñïêÜñäéï ¢ëãïò óôï Åîùôåñéêü Éáôñåßï. Èåóóáëïíßêç, 413-417, 1999. 5. Muller R, Gould L, Betu R. Painless Myocardial Infarction in Elderly. Am Heart J, 199:200202, 1990. 6. Ingram D, Fulton R, Portal R. Vomiting as a Diagnostic Aid in Acute Ischemie Cardiac Pain. BMJ, 281:631-636, 1990. 7. Goff DC Jr, Sellers DE, McGovem PG, Meischke H, Goldberg RJ, Bittner V, Hedges JR, AIIender PS, Nichaman MZ. Knowledge of heart attack symptoms in a population survey in the united States: The REACT Trial. Rapid Early Action for Coronary Treatment. Arch Intern Med, 21:2329-2338, 1999. 8. Muller J, Stone P, Tun Z. Circadian Variation

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in the Frequency of Onset of Acute Myocardial Infarction. N Engl J Med, 313:1315-1319, 1985. 9. Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, Meischke H, Goldberg RJ, Luepker RV, Raczynski JM, Cooper L, Mann C. Knowledge of heart attack symptoms in 20 US communities. Results from the rapid early action for coronary treatment community trial. Prev Med 38:85-93, 2003. 10. Smith Ê, Cameron P, Meyer A, McNeil J. Knowledge of heart attack symptoms in a community survey of Victoria. Emerg Med (Fremantle). 3:255-60, 2002. 11. Zapka J, Estabrook B, Gilliland J, Leviton L, Meischke H, Melville S, Taylor J, Daya M, Laing B, Meshack A, Reyna R, Robbins M, Hand M, Finnegan J. Health care providers’ perspectives on patient delay for seeking care for symptoms of acute myocardial infarction. Health Educ Behav, 5:714-33, 1999.


Ôüìïò 16, Ôåý÷ïò 1, 2004

Ó. ÁñãõñéÜäïõ, Á. Ìáñéüëçò

ÃÑÁÌÌÁ ÓÔÏÍ ÅÊÄÏÔÇ LETTER TO THE EDITOR Primary Heatlh Care, Volume 16, Number 1, 45-46, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 45-46, 2004

Kñßóåéò ðåñéëÞøåùí ôïõ 15ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò ÁãáðçôÝ ê. ÄéåõèõíôÞ Óýíôáîçò, ÁíÜìåóá óôá êñéôÞñéá áîéïëüãçóçò ôùí ãéáôñþí, åßíáé ôï åðéóôçìïíéêü êáé åêðáéäåõôéêü Ýñãï ôïõò, ðïõ ãéá ôï ôåëåõôáßï ìÜëéóôá êñßíïíôáé îå÷ùñéóôÜ, ùò åêðáéäåõüìåíïé êáé ùò åêðáéäåõôÝò. Ðñüêåéôáé ãéá êñéôÞñéá ðïõ óõíäÝïíôáé Üìåóá, ðïõ ïñéóìÝíåò öïñÝò áëëçëåðéêáëýðôïíôáé, êáé óõ÷íüôáôá ôï Ýíá áðïôåëåß óõíÝ÷åéá ôïõ Üëëïõ. ÓõíÞèùò óôçí áñ÷Þ ôçò åðáããåëìáôéêÞò ðïñåßáò ôïõ ãéáôñïý, ç óõììåôï÷Þ óôéò åðéóôçìïíéêÝò äñáóôçñéüôçôåò åßíáé áõôÞ ôïõ åêðáéäåõüìåíïõ, åíþ óôç óõíÝ÷åéá ëáìâÜíåé êáé ñüëïõò åñåõíçôÞ êáé åêðáéäåõôÞ. Áí êáé ç ó÷Ýóç áõôþí ôùí êñéôçñßùí (åêðáßäåõóç-Ýñåõíá) ìå ôçí éáôñéêÞ åðéóôÞìç, èåùñåßôáé Üññçêôç, ïé áðáñáßôçôåò ôå÷íéêÝò ôïõò (ìåèïäïëïãßá óôçí Ýñåõíá, óõããñáöÞ, äéäáóêáëßá, ðáñïõóßáóç) äåí ðåñéëáìâÜíïíôáé óôç äéäáêôÝá ýëç ôçò ðáíåðéóôçìéáêÞò öïßôçóçò. Ï ôñüðïò óõããñáöÞò êáé ðáñïõóßáóçò ìéáò éáôñéêÞò åñãáóßáò åßíáé óõãêåêñéìÝíïò, äéÝðåôáé áðü êáíüíåò ðïõ ç ÜãíïéÜ ôïõò ðïëëÝò öïñÝò áðïôåëåß áßôéï áðüññéøçò áîéüëïãùí ðéèáíþò, åñãáóéþí. Ç èÝóðéóç êñéôçñßùí ãéá ôçí áîéïëüãçóç ìéáò éáôñéêÞò åñãáóßáò åßíáé áðáñáßôçôç ãéá ôçí ðïóïôéêïðïßçóç ôçò ðïéüôçôáò ôçò. ÁõôÜ ôá êñéôÞñéá ðñÝðåé íá Ý÷ïõí ôá åîÞò ÷áñáêôçñéóôéêÜ: ðñÝðåé íá åßíáé åõñÝùò áðïäåêôÜ, íá åßíáé óõãêåêñéìÝíá, ïñéïèåôçìÝíá êáé óáöÞ, þóôå íá äéåõêïëýíïõí ôïí êñéôÞ óôçí áîéïëüãçóç ôùí åñãáóéþí. Ïé ðåñéëÞøåéò ðïõ õðïâÜëëïíôáé óôï ÐáíåëÕðåýèõíïò áëëçëïãñáößáò: Ó. ÁñãõñéÜäïõ ÊÝíôñï Õãåßáò ×ñõóïýðïëçò ÊáâÜëáò, e-mail: stage@otenet.gr

ëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò, üðùò ãßíåôáé êáé óôá ðåñéóóüôåñá óõíÝäñéá, áêïëïõèïýí óõãêåêñéìÝíá êñéôÞñéá âáèìïëüãçóçò êáé ìÜëéóôá üìïéá ì’ áõôÜ ðïõ õéïèåôïýíôáé êáé áðü ôçí European General Practitioners Research Network (EGPRN), ðïõ áðïôåëåß ôçí ÅõñùðáúêÞ Ýêöñáóç ôçò Ýñåõíáò, óôç ÃåíéêÞ ÉáôñéêÞ. ÁíáöïñéêÜ ìå ôéò ðåñéëÞøåéò ðïõ õðïâëÞèçêáí óôï 150 ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò, êñßèçêáí áðü ïìÜäá Ãåíéêþí Éáôñþí, ìÝëç ôùí Åðéôñïðþí ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò (ÅËÅÃÅÉÁ), ðïõ åîÝôáóáí êÜèå ðåñßëçøç, óýìöùíá ìå ôá ðáñáêÜôù êñéôÞñéá áîéïëüãçóçò (åß÷áí ôåèåß áðü ôçí ÅðéôñïðÞ ¸ñåõíáò ôçò ÅËÅÃÅÉÁ): 1. Áõèåíôéêüôçôá (åßíáé ç ðåñéï÷Þ Ýñåõíáò áõèåíôéêÞ;). 2. ÓáöÞ äéáôýðùóç ôïõ óêïðïý êáé ôùí åñùôçìÜôùí ðïõ ç åñãáóßá êáëåßôáé íá áðáíôÞóåé. 3. ÓõíÜöåéá ìå ôç ÃåíéêÞ ÉáôñéêÞ. 4. Óçìáóßá êáé óðïõäáéüôçôá ôçò åñãáóßáò ãéá ôç ÃåíéêÞ ÉáôñéêÞ. 5. Ðáñïõóßáóç äåäïìÝíùí (áíôéóôïé÷ßá ôùí áðïôåëåóìÜôùí ìå ôï óêïðü êáé ôçí ìÝèïäï). 6. ÓõæÞôçóç êáé óõìðåñÜóìáôá. 7. ÃåíéêÞ åéêüíá ôçò ðáñïõóßáóçò ôçò åñãáóßáò. Óå êÜèå ðåäßï áðü ôá ðáñáðÜíù ç âáèìïëüãçóç åßíáé: 4=Üñéóôç, 3=ðïëý êáëÞ, 2=ìÝôñéá, 1=ðôù÷Þ. Ôï óýíïëï ôùí åñãáóéþí ðïõ õðïâëÞèçêáí ãéá êñßóç Þôáí 551: · ÐñïöïñéêÝò Áíáêïéíþóåéò: 324 + 56 (óõìðëçñùìáôéêü ôåý÷ïò)= 380 · ÁíáñôçìÝíåò Áíáêïéíþóåéò (Posters): 79 + 45


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

12 (óõìðëçñùìáôéêü ôåý÷ïò)= 91 · Åñãáóßåò ðïõ äåí åãêñßèçêáí= 80. · Óýíïëï åñãáóéþí ðïõ Ýãéíáí áðïäåêôÝò ãéá ðáñïõóßáóç óôï óõíÝäñéï= 471. Ôï Üñéóôá óôç âáèìïëüãçóç Þôáí ôï 28, åíþ ôï üñéï ãéá ôçí ðñüêñéóç ôùí ðñïöïñéêþí áíáêïéíþóåùí Þôáí ôï 18. Ãéá ôéò åñãáóßåò ðïõ óõãêÝíôñùíáí âáèìïëïãßá áðü 12-18, ï ôñüðïò ðáñïõóßáóçò Þôáí áõôüò ôçò áíáñôçìÝíçò áíáêïßíùóçò. Ïé ëüãïé áõôÞò ôçò áðüöáóçò Þôáí ïé åîÞò: • Ãéá íá äïèåß ç åõêáéñßá óå íÝïõò åñåõíçôÝò íá ðáñïõóéÜóïõí ôï Ýñãï ôïõò. • ÅðåéäÞ ï ÷ñüíïò ãéá ôçí åðéôñïðÞ ôùí poster åßíáé ðåñéóóüôåñïò áðü üôé óôéò ðñïöïñéêÝò áíáêïéíþóåéò, þóôå íá ó÷ïëéáóôïýí ïé åñãáóßåò ðïéï áíáëõôéêÜ. • ¼ôáí ïé óõããñáöåßò ôùí ðåñéëÞøåùí äåí áêïëïýèçóáí áðüëõôá ôïõò êáíüíåò óõããñáöÞò Þ ðáñïõóßáæáí ëÜèç óôïí ôñüðï äéáôýðùóçò, ðáñïõóßáóçò óôïé÷åßùí ê.ëð., áëëÜ öáíÝñùíáí üôé åß÷å ãßíåé óçìáíôéêÞ ðñïóðÜèåéá. Åðßóçò ùò áíáñôçìÝíç áíáêïßíùóç ðáñïõóéáæüôáí ïé åñãáóßåò, ðïõ áðü ôçí áñ÷Þ ïé óõããñáöåßò ôïõò äÞëùíáí åðéèõìßá áõôïý ôïõ ôñüðïõ ðáñïõóßáóçò ôçò åñãáóßáò ôïõò. Ç áíáëõôéêÞ âáèìïëïãßá ôùí åñãáóéþí ðïõ äåí Ýãéíáí áðïäåêôÝò ãéá ðáñïõóßáóç óôï 15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ðáñïõóéÜæåôáé óôïí Ðßíáêá É. Áðü ôïí ðßíáêá öáßíåôáé üôé Ýìöáóç äéíüôáí óôï êñéôÞñéï (4) äçëáäÞ ôç óçìáóßá êáé óðïõäáéüôçôá ôçò åñãáóßáò ãéá ôç ÃåíéêÞ ÉáôñéêÞ, óôï êñéôÞñéï (7), ôï ðüóï êáëÞ Þôáí ç ãåíéêÞ åéêüíá ôçò, ãåãïíüò ðïõ áíáãÜãåé óôéò ôå÷íéêÝò óõããñáöÞò ìéáò ðåñßëçøçò, óôá êñéôÞñéá (6) êáé (5) ðïõ åßíáé áðïôÝëåóìá åíüò êáëÜ ó÷åäéáóìÝíïõ ðñùôïêüëëïõ, ìéáò êáëÞò åðåîåñãáóßáò ôùí óôïé÷åßùí, ðïõ èá ïäçãÞóïõí âÝâáéá êáé óå óùóôÜ êáé áóöáëÞ óõìðåñÜóìáôá. Óôï ðáñáêÜôù ó÷Þìá öáßíåôáé êáé ç äéáóðïñÜ ôçò âáèìïëïãßáò áíÜ êñéôÞñéï. Áðü ôï ó÷Þìá 1 ðáñáôçñåßôáé üôé ï ìåãáëýôåñïò áñéèìüò ôùí åñãáóéþí ðïõ äåí åãêñßèçêáí âáèìïëïãÞèçêáí óôá êñéôÞñéá ìå 1 êáé 2.

46

Ó. ÁñãõñéÜäïõ, Á. Ìáñéüëçò Ðßíáêáò. Âáèìïëïãßá åñãáóéþí ðïõ äåí Ýãéíáí áðïäåêôÝò 4* 3* 2*

1*

1. Áõèåíôéêüôçôá

3

8

29

40

2. ÓáöÞ äéáôýðùóç ôïõ óêïðïý êáé ôùí åñùôçìÜôùí ðïõ ç åñãáóßá êáëåßôáé íá áðáíôÞóåé

1

4

26

49

3. ÓõíÜöåéá ìå ôç ÃåíéêÞ ÉáôñéêÞ

0

4

22

54

4. Óçìáóßá êáé óðïõäáéüôçôá ôçò åñãáóßáò ãéá ôç Ã/É

0

2

10

68

5. Ðáñïõóßáóç äåäïìÝíùí

0

6

19

55

6. ÓõæÞôçóç êáé óõìðåñÜóìáôá

0

5

18

57

7. ÃåíéêÞ åéêüíá ôçò ðáñïõóßáóçò ôçò åñãáóßáò

0

1

18

61

*4=Üñéóôç, 3=ðïëý êáëÞ, 2=ìÝôñéá, 1=öôù÷Þ

ÓõìðåñáóìáôéêÜ áðü ôá ðáñáðÜíù äéáöáßíåôáé ç áíÜãêç åêðáßäåõóçò ôùí Ãåíéêþí Éáôñþí áöåíüò óôç ìåèïäïëïãßá ôçò Ýñåõíáò, áöåôÝñïõ óôïí ôñüðï óõããñáöÞò êáé ðáñïõóßáóçò ôïõ åñåõíçôéêïý ôïõò Ýñãïõ. Ðñïôåßíåôáé ç äéïñãÜíùóç åêðáéäåõôéêþí çìåñßäùí áðü ôçí ÅðéôñïðÞ ¸ñåõíáò ôçò ÅËÅÃÅÉÁ óå óõíåñãáóßá ìå ôá ÐåñéöåñåéáêÜ ÔìÞìáôá ôçò, ó÷åôéêÜ ìå ôç ìåèïäïëïãßá Ýñåõíáò êáé ôïõò ôñüðïõò óõããñáöÞò ìéáò åñåõíçôéêÞò åñãáóßáò.

Ó÷Þìá 1. Ó÷çìáôéêÞ ðáñÜóôáóç ôçò âáèìïëïãßáò áíÜ êñéôÞñéï.

Ó. ÁñãçñéÜäïõ Ðñüåäñïò ÅðéôñïðÞò ¸ñåõíáò Á. Ìáñéüëçò ÌÝëïò ÅðéôñïðÞò Åêðáßäåõóçò


Ôüìïò 15, Ôåý÷ïò 3, 2003

ÍÝá

NEA NEWS Primary Heatlh Care, Volume 16, Number 1, 47-48, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 1, 47-48, 2004

ÅÈÍÉÊÏ ÊÁÉ ÊÁÐÏÄÉÓÔÑÉÁÊÏ ÐÁÍÅÐÉÓÔÇÌÉÏ ÁÈÇÍÙÍ ÉÁÔÑÉÊÇ Ó×ÏËÇ ÔÌÇÌÁ ÖÉËÏÓÏÖÉÁÓ, ÐÁÉÄÁÃÙÃÉÊÇÓ & ØÕ×ÏËÏÃÉÁÓ ÓÅ ÓÕÌÐÑÁÎÇ ÌÅ ÔÏ ÔÅÉ ÁÈÇÍÙÍ ÔÌÇÌÁ ÅÐÉÓÊÅÐÔÙÍ/ÔÑÉÙÍ ÕÃÅÉÁÓ ÔÌÇÌÁ ÄÇÌÏÓÉÁÓ ÕÃÉÅÉÍÇÓ

ÌÅÔÁÐÔÕ×ÉÁÊÏ ÐÑÏÃÑÁÌÌÁ ÓÐÏÕÄÙÍ ÓÔÇÍ "ÐÑÏÁÃÙÃÇ ÊÁÉ ÁÃÙÃÇ ÕÃÅÉÁÓ" ÓÕÃ×ÑÇÌÁÔÏÄÏÔÏÕÌÅÍÏ ÁÐÏ ÔÏ ÊÏÉÍÏÔÉÊÏ ÐËÁÉÓÉÏ ÓÔÇÑÉÎÇÓ ÐÑÏÓÊËÇÓÇ ÕðïâïëÞò áéôÞóåùí õðïøçößùí ìåôáðôõ÷éáêþí öïéôçôþí/ôñéþí ãéá ôï áêáä. Ýôïò 2004-2005

Ç ÉáôñéêÞ Ó÷ïëÞ ôïõ Ðáí/ìßïõ Áèçíþí óå óõíåñãáóßá ìå ôï ÔìÞìá Öéëïóïößáò, ÐáéäáãùãéêÞò & Øõ÷ïëïãßáò ôïõ Ðáí/ìßïõ Áèçíþí êáé óå óýìðñáîç ìå ôá ÔìÞìáôá Åðéóêåðôþí/ôñéþí Õãåßáò êáé Äçìüóéáò ÕãéåéíÞò ôïõ ÔÅÉ Áèçíþí, áíáêïéíþíåé ôç ëåéôïõñãßá ôïõ ÐñïãñÜììáôïò Ìåôáðôõ÷éáêþí Óðïõäþí äéÜñêåéáò äýï åôþí, ôï ïðïßï ïäçãåß óôçí áðïíïìÞ Ìåôáðôõ÷éáêïý Ôßôëïõ Óðïõäþí (ÌÄÅ-Master) óôçí "ÐñïáãùãÞ êáé ÁãùãÞ Õãåßáò". Ôï ðñüãñáììá áñ÷ßæåé ôïí Ïêôþâñéï ôïõ 2004, ðåñéëáìâÜíåé ôÝóóåñá äéäáêôéêÜ åîÜìçíá ãéá ôçí ïëïêëÞñùóç ôïõ ÌÄÅ êáé åßíáé ðëÞñïõò áðáó÷üëçóçò. Óôï Ð.Ì.Ó. ãßíïíôáé äåêôïß, åöüóïí ðëçñïýí ôéò áðáñáßôçôåò ðñïûðïèÝóåéò ãéá ôçí åðéôõ÷Þ ðáñáêïëïýèçóç ôùí ìáèçìÜôùí, ðôõ÷éïý÷ïé ôùí ÁÅÉ áðü 1) ÐáíåðéóôÞìéá ôçò çìåäáðÞò Þ áíôßóôïé÷ùí ôìçìÜôùí ôçò áëëïäáðÞò ôùí ðáñáêÜôù ôìçìÜôùí: IáôñéêÞò, OäïíôéáôñéêÞò, ÖÐØ, Ðáéäáãùãéêþí, Øõ÷ïëïãßáò, Êïéíùíéïëïãßáò, ÌÌÅ, ÍïóçëåõôéêÞò, êáé áðü 2) ÔÅÉ ôùí ðáñáêÜôù ôìçìÜôùí: Åðéóêåðôþíôñéþí Õãåßáò, Äçìüóéáò ÕãéåéíÞò, ÍïóçëåõôéêÞò,

ÊïéíùíéêÞò Åñãáóßáò, ÌáéåõôéêÞò, Âñåöïíçðéïêïìßáò êáèþò êáé ðôõ÷éïý÷ïé ëïéðþí óõíáöþí ôìçìÜôùí Ðáíåðéóôçìßùí êáé ÔÅÉ. Ï áñéèìüò ôùí åéóáêôÝùí åßíáé 20 êáô' áíþôáôï üñéï. Ç ðïëý êáëÞ ãíþóç ôçò ÁããëéêÞò ãëþóóáò áðïôåëåß âáóéêÞ ðñïûðüèåóç ãéá ôçí áîéïëüãçóç ôùí õðïøçößùí. Ç åããñáöÞ óôï Ð.Ì.Ó. óõíåðÜãåôáé óõììåôï÷Þ óôéò ëåéôïõñãéêÝò äáðÜíåò ôïõ ðñïãñÜììáôïò ýøïõò 2000 Euros åôçóßùò. ×ïñçãåßôáé ðåñéïñéóìÝíïò áñéèìüò õðïôñïöéþí ìå âÜóç ôçí áêáäçìáúêÞ åðßäïóç óôï ÐÌÓ.

Ðëçñïöïñßåò Ïé åíäéáöåñüìåíïé, áöïý åíçìåñùèïýí ãéá ôïõò óôü÷ïõò, ôï áíôéêåßìåíï, ôç äïìÞ êáé ôç ëåéôïõñãßá ôïõ Ð.Ì.Ó. áðü ôç ãñáììáôåßá ôïõ ÊÝíôñïõ Ìåëåôþí Õðçñåóéþí Õãåßáò, ÅñãáóôÞñéï ÕãéåéíÞò êáé Åðéäçìéïëïãßáò ôçò ÉáôñéêÞò Ó÷ïëÞò ôïõ Ðáíåðéóôçìßïõ Áèçíþí, êá. ×. Âëá÷ïðïýëïõ, ôçë. 210-748 2015, chsr@med.uoa.gr, Áëåîáíäñïõðüëåùò 25, 115 27, ÁèÞíá 47


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

èá ðñÝðåé íá õðïâÜëïõí áðü 10/5/04 Ýùò êáé 10/6/04 óôç Ãñáììáôåßá Ìåôáðôõ÷éáêþí ÐñïãñáììÜôùí ôçò ÉáôñéêÞò Ó÷ïëÞò ôïõ Ðáíåðéóôçìßïõ Áèçíþí, êá. Ì. Íéêïëïýôóïõ, ôçë. 210746 2002-3, ÌéêñÜò Áóßáò 75, Ãïõäß, ôá ðáñáêÜôù äéêáéïëïãçôéêÜ: 1. Áßôçóç Õðïøçöéüôçôáò óå åéäéêü Ýíôõðï, ôï ïðïßï ìðïñïýí íá ðñïìçèåõôïýí áðü ôéò ðáñáðÜíù ãñáììáôåßåò. 2. Âéïãñáöéêü Óçìåßùìá. 3. ÅðéêõñùìÝíï áíôßãñáöï ðôõ÷ßïõ/ùí Þ Ýãêõñá áðïäåéêôéêÜ óôïé÷åßá üôé áíáìÝíåôáé ç áðïöïßôçóç ôïõò ìÝ÷ñé ôéò 15 Ïêôùâñßïõ 2004. Ïé ôåëåéüöïéôïé/åò ðñÝðåé íá õðïâÜëïõí åðéêõñùìÝíï áíôßãñáöï ôçò ìÝ÷ñé ôüôå âáèìïëïãßáò ôïõ êáé õðåýèõíç äÞëùóç üôé áðïäÝ÷ïíôáé ç ôõ÷üí åðéëïãÞ ôïõò íá ãßíåé õðü ôçí áßñåóç áðüêôçóç ôïõ ðôõ÷ßïõ ôïõò ìÝ÷ñé ôéò 15 Ïêôùâñßïõ, 2004 êáé ôçò Ýêäïóçò ôïõ ó÷åôéêïý åðéêõñùìÝíïõ åããñÜöïõ ìÝóá óôïõò ôñåéò åðüìåíïõò ìÞíåò.

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4. Ðéóôïðïéçôéêü áíáëõôéêÞò âáèìïëïãßáò ðñïðôõ÷éáêþí (Þ êáé ìåôáðôõ÷éáêþí) ìáèçìÜôùí. 5. Áíáãíþñéóç ôßôëïõ óðïõäþí áðü ôï ÄÉÊÁÔÓÁ ãéá üóïõò Ý÷ïõí ôßôëïõò óðïõäþí áðü ÁÅÉ ôçò áëëïäáðÞò. 6. Áðïäåéêôéêü ÁããëéêÞò ãëþóóáò. Óå ðåñßðôùóç ðïõ ï/ç õðïøÞöéïò/á äåí Ý÷åé åðáñêÝò ðéóôïðïéçôéêü, ç ãíþóç ôçò áããëéêÞò èá äéáðéóôþíåôáé ìå åîÝôáóç. 7. Äýï óõóôáôéêÝò åðéóôïëÝò. 8. ÁðïäåéêôéêÜ åðáããåëìáôéêÞò åìðåéñßáò (åÜí õðÜñ÷ïõí). Ç åðéëïãÞ ôùí ìåôáðôõ÷éáêþí öïéôçôþí èá ãßíåé áðü åðéôñïðÞ ìå âÜóç ôá áíùôÝñù äéêáéïëïãçôéêÜ êáé óõíåíôåýîåéò ôùí õðïøçößùí, ïé ïðïßåò èá ãßíïõí áðü 10/6/04 Ýùò 25/6/04, ìåôÜ áðü ôçëåöùíéêÞ óõíåííüçóç. ÁèÞíá, 1/5/2004 Ï Åðéóôçìïíéêüò Õðåýèõíïò ôïõ ÐÌÓ Áíáð. ÊáèçãçôÞò Ã. Ôïýíôáò


ÏÄÇÃÉÅÓ ÃÉÁ ÔÏÕÓ ÓÕÃÃÑÁÖÅÉÓ INSTRUCTIONS FOR THE AUTHORS Ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äÝ÷åôáé ãéá äçìïóßåõóç êåßìåíá Åðéóôçìüíùí Õãåßáò, ôá ïðïßá êáôáôÜóóïíôáé óôéò åîÞò êáôçãïñßåò: 1) ÅñåõíçôéêÝò åñãáóßåò Þ áíáóêïðÞóåéò (óýíôïìåò äçìïóéåýóåéò) Ýêôáóçò ìÝ÷ñé 7 óåëßäåò ìå ðñüóöáôåò ü÷é Üíù áðü 5 âéâëéïãñáöéêÝò ðçãÝò, 2) ÅíçìåñùôéêÜ Üñèñá, 3) Óýíôïìá Üñèñá, 4) ÁíáöïñÝò ðåñéðôþóåùí, 5) ÐáñïõóéÜóåéò ÊÝíôñùí Õãåßáò. ¸íá óýíïëï êåéìÝíùí, ðïõ áöïñïýí Ýíá óõãêåêñéìÝíï ãíùóôéêü ôïìÝá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ìðïñåß íá óõãêñïôåß ÁöéÝñùìá. Åêôüò ôùí êåéìÝíùí ðïõ áíáöÝñïíôáé óôéò ðáñáðÜíù êáôçãïñßåò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé Üñèñá ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò, êáèþò êáé êåßìåíá ðïõ áðïóêïðïýí óôçí ðáñïõóßáóç, ó÷ïëéáóìü êáé êñéôéêÞ áîéïëüãçóç óõãêåêñéìÝíùí ãåãïíüôùí, Üñèñùí êáé åêäüóåùí ó÷åôéêþí ìå ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, óôçí ÅëëÜäá êáé óôï åîùôåñéêü. Ôçí åõèýíç ôçò óõããñáöÞò ôùí Üñèñùí áõôþí Þ êåéìÝíùí Ý÷ïõí ìüíï ôá ìÝëç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò Þ åðéóôÞìïíåò ìåôÜ áðü åéäéêÞ ðñüóêëçóç. Åðßóçò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé ãñÜììáôá ðïõ áðåõèýíïíôáé óôç ÓõíôáêôéêÞ ÅðéôñïðÞ, ôá ïðïßá áíáöÝñïíôáé óå ðáñáôçñÞóåéò, êëéíéêÝò êáé åñåõíçôéêÝò åìðåéñßåò Þ ó÷ïëéÜæïõí ôç äéåèíÞ êáé åëëçíéêÞ âéâëéïãñáößá. Ôçí åõèýíç ãéá ôç äçìïóßåõóç ôùí êåéìÝíùí áõôþí Ý÷åé ï ÄéåõèõíôÞò Óýíôáîçò êáé ç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ïé åñåõíçôéêÝò åñãáóßåò, ôá åíçìåñùôéêÜ Üñèñá, ïé óýíôïìåò äçìïóéåýóåéò êáé ïé áíáöïñÝò ðåñéóôáôéêþí ãßíïíôáé äåêôÜ ãéá äçìïóßåõóç ìüíï ìåôÜ áðü èåôéêÞ êñßóç ôïõò áðü åðéóôÞìïíåò-êñéôÝò ìå ôïõò ïðïßïõò óõíåñãÜæåôáé ôï ðåñéïäéêü. ÊÜèå êåßìåíï ðïõ áðïóôÝëëåôáé óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äéáâéâÜæåôáé óôïõò êñéôÝò, ÷ùñßò íá ãíùóôïðïéïýíôáé ôá ïíüìáôá ôùí óõããñáöÝùí. Ôá ó÷üëéá êáé ïé ðáñáôçñÞóåéò ôùí êñéôþí óôç óõíÝ÷åéá, ìå ôçí åõèýíç ôçò Ãñáììáôåßáò Óýíôáîçò ôïõ ðåñéïäéêïý, åðéóôñÝöïíôáé óôïõò óõããñáöåßò, ðñïêåéìÝíïõ áõôïß íá ðñïóáñìüóïõí áíÜëïãá ôï êåßìåíü ôïõò ðñéí ôç äçìïóßåõóç. Óå ðåñßðôùóç áóõìöùíßáò ôùí êñéôþí, ôï êåßìåíï èá áîéïëïãåßôáé áðü ôçí ßäéá ôç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ôá ïíüìáôá üëùí ôùí åðéóôçìüíùí ðïõ äéåôÝëåóáí êñéôÝò èá äçìïóéåýïíôáé óå åéäéêÞ óåëßäá óôï ôåëåõôáßï ôåý÷ïò êÜèå ÷ñüíïõ. Ôá êåßìåíá, ôá ïðïßá äÝ÷åôáé ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò", èá ðñÝðåé íá áêïëïõèïýí ôéò ðáñáêÜôù ðñïäéáãñáöÝò. • Íá åßíáé ãñáììÝíá óôçí åðßóçìç äçìïôéêÞ ãëþóóá êáé ìå ôï ìïíïôïíéêü óýóôçìá, äáêôõëïãñáöçìÝíá óôç ìéá üøç ôçò óåëßäáò, óå äéðëü äéÜóôçìá êáé ìå ëåõêü ðåñéèþñéï 3 åêáôïóôþí óå üëåò ôéò ðëåõñÝò ôïõò. • Ç ðñþôç óåëßäá ôïõ êåéìÝíïõ ðñÝðåé íá ðåñéëáìâÜíåé: á) ôïí ôßôëï (ìå ðåæÜ ãñÜììáôá), â) ôá ïíüìáôá ôùí óõããñáöÝùí (ìå êåöáëáßá ãñÜììáôá åíþ áíáãñÜöïíôáé ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá ðëÞñç åðþíõìá ìå áñéèìçôéêïýò åêèÝôåò ïé ïðïßïé óå õðïóçìåßùóç ðáñïõóéÜæïõí ôçí éäéüôçôá ôïõ êÜèå óõããñáöÝá), ã) ôï åðéóôçìïíéêü êÝíôñï óôï ïðïßï Ýãéíå ç åñãáóßá, ä) 3-5 ðñüóèåôïõò üñïõò ó÷åôéêÜ ìå ôï èÝìá êáé ïé ïðïßïé åßíáé õéïèåôçìÝíïé áðü ôï Medical Subject Headings (Bethesda Md, 1966), å) ôç äéåýèõíóç êáé ôï ôçëÝöùíï åíüò áðü ôïõò óõããñáöåßò, ï ïðïßïò èá åßíáé õðåýèõíïò ãéá ôçí áëëçëïãñáößá ìå ôï ðåñéïäéêü. • Óå îå÷ùñéóôÞ äåýôåñç óåëßäá ðñÝðåé íá ãñÜöåôáé ç åëëçíéêÞ ðåñßëçøç ôïõ êåéìÝíïõ (ðñïçãåßôáé ç Ýíäåéîç ÐÅÑÉËÇØÇ), ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. • ÌåôÜ ôï êåßìåíï óå îå÷ùñéóôÞ óåëßäá èá ðñÝðåé íá ãñÜöåôáé ç áããëéêÞ ðåñßëçøç ôïõ êåéìÝíïõ, ç ïðïßá äå èá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. Ðñïçãïýíôáé ç ëÝîç SUMMARY, ç áããëéêÞ ìåôÜöñáóç ôïõ ôßôëïõ, ïé ëÝîåéò PRIMARY HEALTH CARE... êáé ôá ïíüìáôá ôùí óõããñáöÝùí ÷ùñßò ôßôëï Þ éäéüôçôá. • Ïé âéâëéïãñáöéêÝò ðáñáðïìðÝò, åëëçíéêÝò êáé îÝíåò, óôï êåßìåíï èá ðñÝðåé íá åßíáé ðñüóöáôåò, áðü áíáãíùñéóìÝíá ðåñéïäéêÜ Þ óõããñÜììáôá, íá åßíáé áñéèìçìÝíåò êáé í’ áíôáðïêñßíïíôáé óôï âéâëéïãñáöéêü êáôÜëïãï, ï ïðïßïò èá ðñÝðåé íá ãñÜöåôáé óå îå÷ùñéóôÞ óåëßäá ìåôÜ ôï ãñÜøéìï ôçò áããëéêÞò ðåñßëçøçò. Óôï âéâëéïãñáöéêü êáôÜëïãï ïé ðáñáðïìðÝò èá ðñÝðåé í’ áêïëïõèïýí ôç óåéñÜ ìå ôçí ïðïßá ðáñïõóéÜóôçêáí óôï êåßìåíï. ÊáèåìéÜ áðü áõôÝò èá ðñÝðåé íá ðåñéÝ÷åé óôç óåéñÜ ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá åðþíõìá ôùí óõããñáöÝùí, ôïí ôßôëï ôçò åñãáóßáò, ôï üíïìá ôïõ ðåñéïäéêïý óýìöùíá ìå ôï óýóôçìá ôçò WHOCISO/R4), ôïí ôüìï, ôçí ðñþôç êáé ôçí ôåëåõôáßá óåëßäá ôïõ Üñèñïõ, êáèþò êáé ôï Ýôïò äçìïóßåõóçò. ¼ôáí ðñüêåéôáé ãéá óõããñÜììáôá Þ ìïíïãñáößåò, åêôüò áðü ôïõò óõããñáöåßò, ôï Ýôïò Ýêäïóçò êáé ôïí ôßôëï, ðñÝðåé íá ãñÜöïíôáé êáé ï áñéèìüò êáé ôá óôïé÷åßá Ýêäïóçò (åêäïôéêüò ïßêïò, ðüëç). (õðüäåéãìá âéâëéïãñáößáò: Biziagos E, Moschandrea J, Kouroumalis ÅÁ. Prevalence of hepatitis  and C markers in volunteer blood donors in Crete. A 5-year study. J Viral Hepat, 6:243-8, 1999.). • Ïé ðßíáêåò êáé ôá ó÷Þìáôá áêïëïõèïýí ôï âéâëéïãñáöéêü êáôÜëïãï êáé èá ðñÝðåé íá ðáñïõóéÜæïíôáé óå ÷ùñéóôÝò óåëßäåò, íá öÝñïõí ëáôéíéêÞ áñßèìçóç, ç ïðïßá èá ðñÝðåé í’ áíôáðïêñßíåôáé óôéò ðáñáðïìðÝò ôïõ êåéìÝíïõ, êáèþò êáé ôéò áðáñáßôçôåò åðåîçãÞóåéò. • 'Ïëá ôá êåßìåíá èá ðñÝðåé íá õðïâÜëëïíôáé êáôÜ ðñïôßìçóç ìå êåéìåíïãñÜöï word óå äýï áíôßôõðá êáé íá áðïóôÝëëïíôáé óôç äéåýèõíóç ôïõ ÄéåõèõíôÞ Óýíôáîçò: - ÐáíåðéóôÞìéï ÊñÞôçò (õðüøç AíáðëçñùôÞ ÊáèçãçôÞ ×. ËéïíÞ), ÔïìÝáò ÊïéíùíéêÞò ÉáôñéêÞò, Ô.È. 1393, ÇñÜêëåéï ÊñÞôçò. Ïé óõããñáöåßò ìðïñïýí íá õðïâÜëëïõí ôá êåßìåíÜ ôïõò êáé óå çëåêôñïíéêÞ ìïñöÞ óôç äéåýèõíóç: primcare@fammed.med.uoc.gr Ïé óõããñáöåßò èá ðñÝðåé íá äåóìåýïíôáé óôçí åðéóôïëÞ ôïõò üôé ç åñãáóßá äåí Ý÷åé õðïâëçèåß Þ äåí Ý÷åé äçìïóéåõèåß åí üëù Þ åí ìÝñåé óå Üëëï ðåñéïäéêü, üôé üëïé ïé óõããñáöåßò åßíáé óýìöùíïé ìå ôçí áðïóôïëÞ ôçò êáé óå ðåñßðôùóç áðïäï÷Þò ôçò ãéá äçìïóßåõóç, ôá óõããñáöéêÜ äéêáéþìáôá åê÷ùñïýíôáé óôï ðåñéïäéêü. Ç ÓõíôáêôéêÞ ÅðéôñïðÞ äéáôçñåß ôï äéêáßùìá áðïóýñóåùò ìéáò åñãáóßáò åöüóïí áõôÞ Ý÷åé óôáëåß êáé ó' Üëëï ðåñéïäéêü. 49

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